筋膜外全子宫切除术加盆腔淋巴清扫术治疗早期宫颈癌可行性研究

The feasibility of extrafascial hysterectomy and laparoscopic pelvic lymphadenectomy as the treatment of early stage cervical cancer

目的探讨筋膜外全子宫切除术加盆腔淋巴清扫术治疗早期宫颈癌（Ⅰa2～Ⅰb1期）的可行性。方法选择2008年6月至2010年6月在山东省青岛市市立医院行手术治疗的47例早期宫颈癌（Ⅰa2～Ⅰb1期）患者，先行腹腔镜下盆腔淋巴清扫术，术中行冰冻病理检查，如盆腔淋巴结阳性，则按传统手术方式行腹腔镜下腹主动脉旁淋巴清扫或取样＋广泛性子宫切除术：如盆腔淋巴结阴性，则行腹腔镜下筋膜外全子宫切除术。所有患者术后如经病理证实有脉管间隙受侵、间质浸润深、盆腔淋巴结转移、宫旁组织阳性或手术切缘阳性，则加用放化疗。术后均严密随访。结果参与随访的42例患者中，1例Ⅰb1期低分化、病灶直径〉2cm的鳞癌患者术中冰冻提示（右侧）闭孔淋巴结有癌组织浸润，行腹腔镜下腹主动脉旁淋巴清扫＋广泛性子宫切除术。其余41倒患者均行腹腔镜下筋膜外全子宫切除术。1例Ⅰb1期低分化、病灶直径〉2cm的腺癌患者，术后病理诊断提示有脉管浸润。未发现宫旁浸润及手术切缘阳性的病例。盆腔淋巴结阳性、脉管浸润的2例患者术后进行了放化疗。平均随访60～84（71．33±7．77）个月，1例出现复发及可疑肺转移；行广泛性子宫切除术的1例患者术后5年复查发现鳞状上皮癌抗原升高，但未发现复发及转移灶，其余患者未发现复发及转移。结论早期宫颈癌（Ⅰa2～Ⅰb1期）患者在盆腔淋巴结无转移的情况下行筋膜外全子宫切除术加盆腔淋巴清扫术可能可行。

Objective To evaluate the feasibility of extrafascial hysterectomy instead of radical hysterectomy as the treatment of early stage （stage Ⅰ a2- Ⅰ b1）cervical cancer.Methods 47 cases with early stage（ stage Ⅰ a2- Ⅰ b1）eervical cancer accepted laparoscopic pelvic lymphadenectomy. Patients with negative pelvic lymphatic nodes accepted laparoscopic extrafascial hysterectomy, and patients with positive pelvic lymphatic nodes accepted laparoscopic radical hysterectomy and para aortic lymph node sampling or dissection. Those with high risk factors ,such as lymph-vascular space invasion,deep interstitial infiltration, positive pelvic lymphatic nodes,parametrial involvement or Positive surgical margin,accepted radiotherapy and chemotherapy.All the cases were followed up. Results 42 patients were followed up till now,and 1 patient with Poorly differentiated squamous carcinoma of stage Ⅰ b1 was confirmed positive obturator lymph nodes accepted Laparoscopic radical hysterectomy and para aortic lymph node dissection. The other 41 patients acceped extrafascial hysterectomy. 1 patient with Poorly differentiated adenocarcinoma of stage I b 1 was confirmed lymph-vascular space invasion. Not found parametrial involvement or positive surgical margin.The 2 cases with positive obturator lymph nodes or lymph- vascular space invasion accepted radiotherapy and chemotherapy. A 60-84 （71.33±7.77）months follow-up revealed one recurrence and 1 case with increase of SCC-Ag,but not found the focus. Conclusion In selected and informed patients,extrafascial hysterectomy and pelvic lymphadenectomy seems to be feasible for patients of early stage （stage Ⅰ a2- Ⅰ b1）cervical caner.