Ⅲc期卵巢上皮性癌“卷地毯”式肿瘤细胞减灭术的技术要点与安全性分析

Technical essentials and safety analysis of “rolling carpet” cytoreduction surgery in stage Ⅲc epithelial ovarian cancer

目的探讨Ⅲc期卵巢上皮性癌(卵巢癌)患者行包含广泛性腹膜切除的肿瘤细胞减灭术("卷地毯"式CRS)的技术要点与安全性。方法收集2017年12月—2019年12月四川省肿瘤医院妇科肿瘤中心行"卷地毯"式CRS的Ⅲc期卵巢癌患者30例("卷地毯"式CRS组),总结"卷地毯"式CRS的手术技术要点,即将腹膜外间隙作为卵巢癌手术的切入路径,从盆腔腹膜外间隙开始游离盆腔内肿瘤,将盆腔内的原发肿瘤灶及壁层腹膜上所有种植转移灶或可疑潜在的转移灶一并彻底切除;选择同期行传统肿瘤细胞减灭术(CRS)的Ⅲc期卵巢癌患者30例(传统CRS组)作为对照。回顾性分析两组患者的临床病理特点,并通过比较两组间手术相关指标、手术并发症发生情况,评估"卷地毯"式CRS的可行性与安全性。结果(1)临床病理特点:"卷地毯"式CRS组、传统CRS组患者的年龄分别为(55.4±9.6)、(54.6±9.5)岁,两组比较,差异无统计学意义(P>0.05);两组患者的病理类型、病理分级、新辅助化疗(NACT)、美国东部肿瘤协作组体力状况评分(ECOG-PS评分)、腹膜癌瘤指数(PCI)分别比较,差异均无统计学意义(P均>0.05)。(2)手术相关指标:"卷地毯"式CRS组30例患者均施行了理想的CRS,30例(100%)患者的肿瘤细胞减灭完整度评分(CC评分)均为CC-0分(即术后无肉眼残留灶,达到理想的CRS),传统CRS组30例患者中,23例(77%)患者为CC-0分,5例(17%)为CC-1分,2例(7%)为CC-2分,两组CC评分比较,差异有统计学意义(P=0.011);"卷地毯"式CRS组、传统CRS组的中位手术时间分别为315 min(252~446 min)、268 min(215~372 min),中位术中出血量分别为589 ml(300~900 ml)、450 ml(250~800 ml),中位ICU住院时间分别为2 d(1~7 d)、1 d(0~5 d),中位总住院时间分别为14 d(9~17 d)、12 d(7~15 d),两组间上述指标分别比较,差异均无统计学意义(P均>0.05)。(3)手术并发症:"卷地毯"式CRS组、传统CRS组术后分别有5例(17%)、3例(10%)患者发生了Clavien?Dindo分级为Ⅰ~Ⅱ级的并发症,两组比较,差异无统计学意义(P>0.05)。两组患者中均无需要再次手术者,围手术期无一例患者死亡。结论在有盆腹膜种植转移的Ⅲc期卵巢癌患者中行"卷地毯"式CRS是安全、可行的,可达到理想的CRS,且具有可以接受的围手术期并发症发生率,无围手术期死亡患者。

Objective To introduce the technical essentials of cytoreduction surgery(CRS)with extensive peritonectomy(“rolling carpet”surgery)in stageⅢc epithelial ovarian cancer(EOC)and evaluate the feasibility and safety of the operation by analyzing the incidence of surgical complications and perioperative mortality.Methods From December 2017 to December 2019,30 patients with stage IIIc EOC who underwent“rolled carpet”CRS and 30 patients who underwent traditional CRS at the same period in Sichuan Cancer Hospital were collected.To summarize the key points of“rolled carpet”CRS operation technology,i.e.the extraperitoneal space was the cut path of ovarian cancer operation,and the tumor in the pelvic cavity was dissociated from the extraperitoneal space of the pelvic cavity.The tumor in the pelvic cavity and all the implants or potential metastases on the parietal peritoneum were removed completely.The clinical and pathological characteristics between the two groups were analyzed retrospectively,and the feasibility and safety of“rolling carpet”CRS were evaluated by comparing the operation related indexes and the occurrence of surgical complications between the two groups.Results(1)Clinicopathological features:the age of patients in“rolling carpet”CRS group and traditional CRS group were respectively(55.4±9.6)and(54.6±9.5)years,and the median peritoneal cancer index(PCI)was 12(range,4-24)and 10(range,5-18),respectively.There were no statistical significance between the two groups(all P>0.05).(2)Operation related indexes:in the“rolled carpet”CRS group,all patients(100%,30/30)were performed optimal CRS,reaching completeness of cytoreduction score(CC score),named CC-0 score,and there was no visible residual lesion after operation.While,in the traditional CRS group,23 patients(77%,23/30)reached CC-0 score,5 cases(17%,6/30)reached CC-1 score,2 cases(7%,2/30)reached CC-2 score,and there were statistical significance between the two groups(P=0.011).The median surgical time was 315 minutes(range,252-446 minutes)vs 268 minutes(range,215-372 minutes),the median intraoperative blood loss was 589 ml(range,300-900 ml)vs 450 ml(range,250-800 ml),the median ICU hospital stay time was 2 days(range,1-7 days)vs 1 day(range,0-5 days),the median total hospital stay time was 14 days(range,9-17 days)vs 12 days(range,7-15 days).There were no statistical significance between the two groups(all P>0.05).(3)Surgical complications:there were respectively 5 cases(17%,5/30)and 3 cases(10%,3/30)complications with Clavien-Dindo gradingⅠ-Ⅱ,which was significant no difference between the“rolled carpet”CRS group and the traditional CRS groups(P>0.05).No re-operations were needed and the operative mortality was 0.Conclusion It is safe and feasible to perform“rolled carpet”CRS in patients with advanced stageⅢc EOC with peritoneum implantation and metastasis,which could achieve optimal CRS,and has an acceptable incidence of perioperative complications,no perioperative death.