淋巴结转移灶切除术影响ⅢC期子宫内膜癌患者的生存

Objective. Surgical staging of endometrial cancer identifies those patients with microscopic metastatic disease most likely to benefit from adjuvant therapy and may also confer therapeutic benefit. Our objective was to compare survival of patients who underwent resection of grossly positive lymph nodes (LN) to those with microscopically positive LN. Methods. Patients had stage IIIC endometrial cancer with pelvic and/or aortic LN metastases and underwent surgery between 1973 and 2002. Exclusion criteria included pre-surgical radiation and second primary cancer. Survival was analyzed using Kaplan-Meier method and Cox proportional hazards model. Results. Mean age of 96 patients with stage IIIC endometrial cancer was 64. There were 45 cases with microscopic LN involvement and 51 with grossly enlarged LN. Overall, 41%had disease in aortic LN, which in 18%represented isolated aortic LN metastasis. Adjuvant therapies were given to 92%of patients (85%radiotherapy, 10%chemotherapy, 10%progestins). Among those with grossly involved LN, 86%were completely resected. Five-year disease-specific survival (DSS) was 63%in 45 patients with microscopic metastatic disease compared to 50%in 44 patients with grossly positive LN completely resected and 43%in 7 with residual macroscopic disease. In multivariable analyses, gross nodal disease not debulked (HR = 6.85, P = 0.009), serosal/adnexal involvement (HR = 2.24, P = 0.036), diagnosis prior to 1989 (HR = 4.33, P < 0.001),older age (HR = 1.09, P < 0.001), and >2 positive lymph nodes (HR = 3.12, P = 0.007) were associated with lower DSS. Conclusion. Grossly involved LN can often be completely resected in patients with stage IIIC endometrial cancer. These retrospective data provide evidence suggestive of a therapeutic benefit for lymphadenectomy in endometrial cancer.

盆腔淋巴结计数是FIGO分期Ⅰ期和Ⅱ期高危组织学类型子宫内膜癌患者的重要预后因子

Objective.: To determine whether pelvic lymph node count is associated with patterns of recurrence or survival in patients with FIGO stage I and II endometrial cancer. Methods.: Single institution retrospective study of 467 patients with FIGO stage I and II endometrial cancer treated with primary surgery including lymph node dissection. Analysis included pelvic lymph node count, histology, stage, age, race, BMI, year of surgery, depth of myometrial invasion, and adjuvant radiation. Kaplan-Meier life-tables were used to calculate survival; the Cox proportional hazards model was used to identify prognostic factors independently associated with survival. Results.: Mean pelvic lymph node count was 12.6(SD±8). Distant recurrence was associated with decreased pelvic lymph node count, high-risk histology, and postoperative pelvic radiation. Pelvic lymph node countwas not associated with survival by univariate analysis, however, overall(OS) and progression-free(PFS) survival were significantly better with pelvic lymph node counts ≥12 among women with high-risk histology(P< 0.001), but not among women with low-risk histology. Multivariable Cox proportional hazards regression identified increasing age, non-Caucasian race, and high-risk histology as independent negative prognostic factors for both OS and PFI. Among patients with high-risk histology, pelvic lymph node count remained an independent prognostic factor for both overall(OS) and progression-free survival(PFS) in the model, with hazard ratios of 0.28 and 0.29, respectively, when ≥12 pelvic lymph nodes were identi-fied. Pelvic lymph node count had no association with OS or PFS in women with low-risk histology. Conclusion.: Pelvic lymph node count ≥12 is an important prognostic variable in patients with FIGO stage I and II endometrial cancer who have high-risk histology. Most likely, the association of survival and lymph node count in this group is the result of improved staging among patients with higher pelvic lymph node counts.

盆腔根治性手术后采用腹直肌肌皮瓣和腹直肌鞘皮瓣重建阴道:皮瓣相关发病率的比较

Purpose. To compare flap-specific complications of rectus abdominis myocutane ous (RAM) and myoperitoneal (RAMP)-flap neovagina reconstructions performed con currently with radical pelvic procedures. Materials and methods. Retrospective s ingle institution chart review of all patients with RAM or RAMP flap neovaginal reconstructions performed on a Gynecologic Oncology service, 1988-2003. Analysi s for associations with flap-specific morbidity was performed. Results. Neovagi nal reconstructions comprised 32 RAM and 7 RAMP flaps. Twenty-two (69%) RAM pa tients underwent total pelvic exenteration compared to 1 (14%) RAMP patient (P < 0.013). Overall, 33 (85%) of the patient population had previously been treat ed with radiation. Flap-specific complications developed in 12 (32%) RAM versu s 4 (57%) of the RAMP patients (P > 0.1). Donor site complications and incision al hernias were increased in RAMP patients (both P < 0.03), with trends for incr easing risk of vaginal stricture/stenosis and superficial wound sepa-rations (b oth P < 0.1). Complete vaginal stenosis developed in only 1 (3%) RAM versus 3 ( 43%) RAMP patients. Furthermore, 3 RAMP patients developed complete stenosis wh en the vaginal defect was circumferential and involved > 65%of the vagina while this did not occur in 22 similar RAM patients (P < 0.0005). Only patients with partial longitudinal defects maintained vaginal patency after RAMP flap. Fifteen (58%)-of 26 patients surviving >12 months reported coitus, with no significan t difference between the groups. Conclusions. When there is circumferential loss of the upper 2/3 of the vagina. RAMP flaps are not suitable for neovaginal reco nstruction after radical pelvic surgery because of an increased risk of vaginal stenosis compared to RAM flaps. Patients with partial longitudinal vaginal defec ts, however, may have successful neovaginal reconstruction with RAMP flaps.