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ENGLISH ABSTRACT
腹腔镜与开腹行子宫广泛性切除术治疗Ⅰa2～Ⅱa2期子宫颈癌的可行性及肿瘤结局的配对队列研究
王伟
尚春亮
黄佳明
陈淑琴
沈慧敏
姚书忠
作者及单位信息
·
DOI： 10.3760/cma.j.issn.0529-567X.2015.12.004
Long-term oncological outcomes after laparoscopic versus abdominal radical hysterectomy in stage Ⅰ a2- Ⅱ a2 cervical cancer: a matched cohort study
Wang Wei
Shang Chunliang
Huang Jiaming
Chen Shuqin
Shen Huimin
Yao Shuzhong
Authors Info & Affiliations
Wang Wei
Department of Obstetrics and Gynecology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510000, China
Shang Chunliang
Huang Jiaming
Chen Shuqin
Shen Huimin
Yao Shuzhong
·
DOI： 10.3760/cma.j.issn.0529-567X.2015.12.004
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摘要

目的探讨腹腔镜下行子宫广泛性切除术（LRH）与开腹行子宫广泛性切除术（ARH）治疗Ⅰa2～Ⅱa2期子宫颈癌的手术可行性及远期肿瘤结局。

方法收集2005年1月至2013年8月在中山大学附属第一医院接受LRH+淋巴结切除术（LND）的Ⅰa2～Ⅱa2期子宫颈癌患者372例（LRH组）作为观察对象，以同期接受ARH+LND的Ⅰa2～Ⅱa2期子宫颈癌患者434例（ARH组）作为对照。依据已知的子宫颈癌复发危险因素（包括肿瘤直径、淋巴脉管间隙受累、子宫颈间质浸润、淋巴结转移、宫旁浸润、切缘浸润）对两组患者进行匹配，获得203对病例组（即LRH组和ARH组各203例），对两组患者的手术相关指标、术中和术后并发症、复发和生存情况进行比较，并对影响患者预后的因素进行单因素和多因素生存分析；进一步对影响预后的独立危险因素进行分层，比较不同分层中两组患者的预后。

结果（1）手术相关指标：LRH组、ARH组患者的手术时间分别为（239±44）、（270±42）min，术中出血量分别为（210±129）、（428±320）ml，术后肠道功能恢复时间分别为（2.0±0.8）、（3.0±1.6）d，术后住院时间分别为（11±6）、（13±6）d，两组间分别比较，差异均有统计学意义（ P<0.01）。（2）术中和术后并发症：LRH组、ARH组术中并发症的发生率分别为6.4%（13/203）、6.9%（14/203），两组比较，差异无统计学意义（ P=1.000）。LRH组、ARH组术后并发症（除外膀胱功能障碍）的发生率分别为9.4%（19/203）、20.2%（41/203），两组比较，差异有统计学意义（ P=0.002）；膀胱功能障碍的发生率分别为36.5%（74/203）、37.4%（76/203），两组比较，差异无统计学意义（ P=0.910）。（3）复发与生存情况：LRH组、ARH组的复发率分别为7.9%（16/203）、9.4%（19/203），两组比较，差异无统计学意义（ P=0.850）。LRH组、ARH组患者的5年无复发生存率分别为92.1％和91.1%，5年总生存率分别为93.7％和96.1%，两组分别比较，差异均无统计学意义（ P=0.790， P=0.900）。（4）预后影响因素分析：单因素生存分析显示，肿瘤直径、临床分期、术后辅助治疗、淋巴脉管间隙受累、子宫颈间质浸润、宫旁浸润、盆腔淋巴结转移、腹主动脉旁淋巴结转移明显影响子宫颈癌患者的预后（ P<0.01）；而年龄、体质指数、手术方式、病理类型、病理分级对子宫颈癌患者的预后无明显影响（ P>0.05）。多因素生存分析显示，肿瘤直径、盆腔淋巴结转移、腹主动脉旁淋巴结转移是影响子宫颈癌患者预后的独立危险因素（ P<0.01）。进一步对影响子宫颈癌患者预后的独立危险因素进行分层分析显示，在肿瘤直径>4 cm、盆腔淋巴结转移阳性、腹主动脉旁淋巴结转移阳性的子宫颈癌患者中，LRH组与ARH组患者的5年无复发生存率和5年总生存率分别比较，差异均无统计学意义（ P>0.05）。

结论LRH+LND治疗Ⅰa2～Ⅱa2期子宫颈癌具有手术可行性及肿瘤学安全性，可作为ARH+LND的替代手术方式。

宫颈肿瘤;子宫切除术;腹腔镜检查;队列研究
ABSTRACT

ObjectiveTo investigate the long- term oncological outcomes of laparoscopic radical hysterectomy (LRH) plus lymph node dissection (LND) and abdominal radical hysterectomy (ARH) plus LND for patients with stage Ⅰa2-Ⅱa2 cervical cancer.

MethodsA retrospective review of stage Ⅰa2- Ⅱ a2 cervical cancer patients who underwent LRH + LND ( n=372) and ARH + LND ( n=434) at the First Affiliated Hospital of Sun Yat- sen University from Jan. 2005 to Aug. 2013 was performed. Individual patient matching was performed by the risk factors for recurrence [tumor size, lymph vascular space invasion (LVSI), depth of cervical stromal invasion, lymph node metastasis, parametrial involvement, and resection margin involvement] between two groups. After matched, a total of 203 patient pairs (LRH- ARH) were enrolled. The survival data, surgery data, intraoperative and postoperative complications were compared between the two groups. To assess the prognosis factors, the univariate and multivariate Cox's proportional hazards model analysis were conducted. Stratified analysis was performed based on the independent prognosis factors to investigate the survival data between the two surgery groups.

Results(1) Surgery data: The operating time [(239±44) vs (270±42) minutes], estimated blood loss [(210±129) vs (428±320) ml], the duration of bowel motility return [(2.0±0.8) vs (3.0±1.6) days] and hospital stay [(11±6) vs (13±6) days] in the LRH group were significantly shorter than those in ARH group (all P<0.01). (2) Intraoperative and postoperative complications: The intraoperative complications rate was similar betweentwo groups [6.4%(13/203) vs 6.9%(14/203), P=1.000]. The rate of postoperative complications (excluded bladder dysfunction) in the LRH group were significantly lower than those in the ARH group [9.4% (19/203) vs 20.2% (41/203), P=0.002]. While there was no significant difference in the rates of bladder dysfunction between two groups [36.5% (74/203) vs 37.4% (76/203), P=0.910]. (3) Recurrence and survival data: There was no significant difference in the recurrence rates between the LRH group and ARH groups [7.9% (16/203) vs 9.4% (19/203), P=0.850]. There were similar 5- year recurrence- free survival (RFS; 92.1% vs 91.1%, P=0.790) and 5- year overall survival (OS; 93.7% vs 96.1%, P=0.900). (4) Prognosis factor: In univariate analysis, the results showed that tumor size, International Federation of Gynecology and Obstetrics (FIGO) stage, adjuvant therapy, LVSI, stromal invasion, parametrium invasion, pelvic lymph node metastasis, and para-aortic lymph node metastasis were significantly associated with poor prognosis (all P<0.01). However, age, body mass index (BMI), surgery type, histological type, grade were not significantly associated with poor prognosis (all P>0.05). The multivariate analysis results, showed that tumor size, pelvic lymph node metastasis,and para- aortic lymph node metastasis were significantly associated with poor prognosis (all P<0.01). Stratified analysis showed that, even in patients with tumor size >4 cm, pelvic lymph node metastasis positive, and para-aortic lymph node metastasis positive in all subgroups, there were not significant difference for the estimated 5-year RFS and 5-year OS between LRH and ARH group (all P>0.05).

ConclusionFor patients with stage Ⅰa2-Ⅱa2 cervical cancer, LRH plus lymph node dissection is an oncologically safe and surgical feasible alternative to ARH.

Uterine cervical neoplasms;Hysterectomy;Laparoscopy;Cohort studies
Yao Shuzhong, Email: mocdef.3ab61yflzsy
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引用本文

王伟,尚春亮,黄佳明,等. 腹腔镜与开腹行子宫广泛性切除术治疗Ⅰa2～Ⅱa2期子宫颈癌的可行性及肿瘤结局的配对队列研究[J]. 中华妇产科杂志,2015,50(12)：894-901.

DOI:10.3760/cma.j.issn.0529-567X.2015.12.004

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在发展中国家，子宫颈癌是女性第二大恶性肿瘤，超过90％的子宫颈癌死亡患者发生在发展中国家 [ 1 ]。开腹行子宫广泛性切除术（abdominal radical hysterectomy，ARH）＋淋巴结切除术（lymph node dissection，LND）被认为是早期子宫颈癌的标准手术治疗方式 [ 2 ]。在过去的20年中，腹腔镜下行子宫广泛性切除术（laparoscopic radical hysterectomy，LRH）发展迅速，被认为是ARH的潜在替代手术方式 [ 3 , 4 ]。在LRH作为早期子宫颈癌一线手术治疗方式前，需考量LRH的手术安全性、可行性及远期肿瘤结局（即肿瘤学安全性），并与"金标准"手术方式——ARH进行比较分析。国内、外已有多个研究证实了LRH用于早期子宫颈癌手术治疗的安全性及可行性 [ 5 , 6 , 7 , 8 , 9 , 10 , 11 ]。然而，有关LRH治疗早期子宫颈癌的远期肿瘤结局的研究却鲜有报道，缺乏能够证实LRH与ARH远期肿瘤结局一致性的一级证据。本研究目的是在匹配子宫颈癌复发危险因素的情况下，比较分析LRH与ARH用于治疗Ⅰa2～Ⅱa2期子宫颈癌的手术可行性及远期肿瘤结局，为LRH用于治疗Ⅰa2～Ⅱa2期子宫颈癌提供临床依据。
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备注信息
A
姚书忠，Email： mocdef.3ab61yflzsy
B
广东省自然科学基金 (S2013010015448)
中山大学临床研究5010项目 (2007010)
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