嗜神经侵袭对早期子宫颈癌患者预后的影响

Evidence of perineural invasion on early-stage cervical cancer and prognostic significance

目的：探讨嗜神经侵袭（PNI）在早期（Ⅰa2～Ⅱb期）子宫颈癌患者中的发生情况及对预后的影响。方法选择2007年1月至2012年12月，在四川省肿瘤医院妇瘤科接受子宫广泛性切除＋盆腔（或加腹主动脉旁）淋巴结切除术，病理诊断为早期子宫颈癌的238例患者，镜下观察子宫颈及宫旁组织是否存在PNI现象，明确早期子宫颈癌患者不同临床病理指标与PNI发生的关系，并分析影响患者预后的因素。结果238例早期子宫颈癌患者中，发生PNI 22例，发生率为9.2%（22/238）。其中，Ⅰa2～Ⅱa2期210例，发生PNI 18例，发生率为8.6%（18/210）；Ⅱb期28例，发生PNI 4例，发生率为14.3%（4/28），两者PNI发生率比较，差异无统计学意义（P=0.261）。早期子宫颈癌患者PNI的发生与肿瘤直径、间质浸润深度、宫旁浸润、淋巴脉管间隙浸润、淋巴结转移明显相关（〈0.05）；而与年龄、临床分期、病理类型、病理分级以及手术切缘是否阳性无关（P〉0.05）。单因素生存分析显示，早期子宫颈癌患者的无瘤生存时间（DFS）与肿瘤直径、间质浸润深度、宫旁浸润、淋巴脉管间隙浸润、淋巴结转移、手术切缘阳性、PNI明显相关（〈0.05），而其总生存时间（OS）与间质浸润深度、宫旁浸润、手术切缘阳性、PNI明显相关（〈0.05）；在早期子宫颈癌患者中，PNI阳性患者的DFS和OS较PNI阴性患者均明显缩短，分别比较，差异均有统计学意义（P=0.002，P=0.008）。多因素生存分析显示，宫旁浸润、间质浸润深度是影响患者DFS和OS的独立因素（〈0.05），淋巴结转移仅是影响患者DFS的独立因素（P=0.024）；而PNI不是影响患者DFS或OS的独立因素（P〉0.05）。结论早期子宫颈癌存在PNI现象，PNI的发生与肿瘤直径、间质浸润深度、宫旁浸润、淋巴脉管间隙浸润、淋巴结转移明显相关，是影响患者DFS和OS的不良因素，可作为早期子宫颈癌术后选择辅助性放化疗的一个指标。

Objective To evaluate the incidence and significance of perineural invasion （PNI） in cervical cancer. Methods Retrospective chart review of patients with cervical cancer （stages Ⅰa2-Ⅱb） who underwent radical hysterectomy and pelvic lymphadenectomy from 2007 to 2012. To evaluate the incidence and significance of PNI in cervical and uterine tissues by microscopic examination. Results A total of 238 patients were included, 9.2% （22/238） patients with PNI in the cervical stroma. Patients with PNI were more likely to have adverse histopathologic features, including lymphoma vascular space invasion, parametrical invasion, depth of invasion, tomor size and lymph nodes metastases （all 〈0.05）. PNI were independent of age, international federation of gynecology and obstetrics （FIGO） stage, histopathology type and grade, and positive vaginal margin （all P〉0.05）. Patients with PNI had shorter disease-free and overall survival （P=0.002 and P=0.008, respectively）. On multivariate analysis, risk factors for recurrence and death included parametrical invasion and depth of invasion （〈0.05）. Similarly, risk factors for recurrence included lymph nodes metastases （P=0.024）. However, PNI was not identified as an independent risk factor for either recurrence or death （P〉0.05）. Conclusions PNI exists in early cervical cancer. PNI is associated with tumor size, depth of invasion, parametrical invasion, lymphoma vascular space invasion and lymph nodes metastases. PNI represente a decreasing disease-free and overall survival in patients with early-stage cervical cancer, and is independently associated with multiple high-risk factors, which be informed management decisions regarding adjuvant therapy.