本文選題：腹式根治性宮頸切除術(shù) + 腹式根治性子宮切除術(shù)�。� 參考：《復(fù)旦大學(xué)》2014年博士論文

【摘要】：第一部分 早期宮頸癌患者行腹式根治性宮頸切除術(shù)與全子宮切除術(shù)手術(shù)范圍比對目的：研究對早期宮頸癌患者行腹式根治性宮頸切除術(shù)(Abdominal Radical Trachelectomy, ART)與腹式根治性全子宮切除術(shù)(Abdominal Radical Hysterectomy, ARH),其手術(shù)方式及范圍的差異。方法：前瞻性納入自2012年8月到2013年8月間,我院IA1期伴淋巴脈管浸潤及IA2期、IB1期上皮性宮頸癌患者156例,依照其個(gè)人手術(shù)意愿分為腹式根治性宮頸切除組47例及腹式根治性全子宮切除術(shù)組109例患者,術(shù)中對新鮮未行福爾馬淋固定的標(biāo)本進(jìn)行平輔固定,并由同一位醫(yī)生測量各標(biāo)本兩側(cè)宮旁組織的長度、高度,膀胱宮頸韌帶和宮骶韌帶長度,以及3、6、9和12點(diǎn)陰道切除長度。應(yīng)用χ2檢驗(yàn)或Fish精確概率方檢驗(yàn)方法對標(biāo)本各韌帶手術(shù)范圍進(jìn)行比對,分析兩種手術(shù)方式手術(shù)范圍的差異性。結(jié)果：ART組患者中位年齡為32歲(20-41歲),與ARH組患者相比年紀(jì)較輕,51歲(32-80歲),p0.001；在ART與ARH組中,大部分患者病理診斷為鱗癌,37例(72.3%)與79例(72.5%),以FIGO分期IB1期為主,分別為34例(75.6%)與90例(82.6%)。兩組雙側(cè)宮旁平均長度分別為44.08±17.52mm和44.96±20.77 mm(p=0.432),平均宮旁平均高度分別為25.74±5.24mm和26.09±5.11mm(p=0.361)。兩組平均膀胱宮頸韌帶長度分別為3.85±1.76mm和4.01±2.06mm(p=0.647),平均宮骶韌帶長度分別為13.30±4.86mm和12.88±4.51mm(p=0.605)。除此之外,兩組陰道3、6、9及12點(diǎn)處切除長度均不存在統(tǒng)計(jì)學(xué)差異。結(jié)論：早期宮頸癌患者行經(jīng)腹根治性宮頸切除術(shù)與傳統(tǒng)的經(jīng)腹根治性全子宮切除術(shù)相比,可切除同樣范圍的宮旁組織及韌帶長度。第二部分 早期宮頸癌患者宮旁淋巴結(jié)檢出及其臨床意義目的：采用創(chuàng)新的三段式宮旁淋巴結(jié)檢出方法,對比經(jīng)腹根治性宮頸切除術(shù)與經(jīng)腹根治性全子宮切除術(shù)宮旁淋巴結(jié)檢出率的差異,明確宮旁淋巴結(jié)檢出的意義及其與ART手術(shù)的關(guān)系。方法：前瞻性采集自2012年8月到2013年8月間,我院IA1期伴淋巴脈管浸潤及IA2期、IB1期患上皮性宮頸癌156名患者的術(shù)后新鮮標(biāo)本,依照其最初手術(shù)方式將標(biāo)本為ART組及ARH組,并通過三段取材法分別對兩組標(biāo)本的左右主韌帶、子宮膀胱韌帶及宮骶韌帶進(jìn)行分段取材,行脫水處理石蠟包埋HE染色后,鏡下檢查并記錄各段組織中淋巴結(jié)數(shù)目、大小及其與宮旁組織內(nèi)血管的關(guān)系。對于最終病理報(bào)告提示伴宮旁淋巴結(jié)轉(zhuǎn)移的患者,給予紫杉醇(PTX)+卡鉑(CBP)6個(gè)周期化療。采用χ2檢驗(yàn)或Fish精確概率方檢驗(yàn)方法進(jìn)行統(tǒng)計(jì)學(xué)檢驗(yàn)。結(jié)果：ART組中47例患者共檢出86枚宮旁淋巴結(jié),ARH組109例患者共檢出341枚宮旁淋巴結(jié)。兩組的宮旁淋巴結(jié)檢出率分別為80.85%和96.33%。其中,大部分宮旁淋巴結(jié)位于宮旁組織內(nèi)區(qū),分別為63/86枚(73.26%)和222/341枚(65.10%)。膀胱宮頸韌帶與宮骶韌帶也存在少量宮旁淋巴結(jié)。兩組中位宮旁淋巴結(jié)檢出數(shù)分別為2枚和3枚,p=0.04。在盆腔淋巴結(jié)陰性患者中,兩組宮旁淋巴結(jié)轉(zhuǎn)移率分別為6.67%和6.06%,在盆腔淋巴結(jié)陽性患者中,宮旁淋巴結(jié)轉(zhuǎn)移率為100%和66.67%�；颊咂骄S訪時(shí)間分別為9.6個(gè)月與9.8個(gè)月,未出現(xiàn)復(fù)發(fā)或死亡病例。結(jié)論：宮頸周圍均存在宮旁淋巴結(jié)分布,且闊韌帶中可能存在宮旁淋巴結(jié)與子宮動脈上行支伴行。三段取材法行宮旁淋巴結(jié)檢測,檢出率較高。且陽性宮旁淋巴結(jié)的檢出可指導(dǎo)早期宮頸癌患者行術(shù)后輔助治療,降低術(shù)后復(fù)發(fā)風(fēng)險(xiǎn)。第三部分腹式根治性宮頸切除術(shù)宮頸切緣安全性的評估目的：采用創(chuàng)新的術(shù)中宮頸上切緣全安性取材方法,對經(jīng)腹根治性宮頸切除術(shù)標(biāo)本宮頸離斷面的上切緣進(jìn)行安全評估,以在術(shù)中確保患者保育生育功能的可行性。方法：前瞻性采集自2012年8月到2013年10月,我院IA1期伴淋巴脈管浸潤及IA2期、IB1期53名行經(jīng)腹根治性宮頸切除術(shù)患者的新鮮宮頸標(biāo)本。自宮頸與宮體離斷后,送術(shù)中快速冰凍病理,采用創(chuàng)新取材方法檢測距宮頸手術(shù)上切緣10mm處腫瘤累及與否。若發(fā)現(xiàn)腫瘤累及,術(shù)中采取宮頸補(bǔ)充切除術(shù)后,行二次取材。對于二次取材不理想的標(biāo)本,改行根治性子宮切除術(shù)。根據(jù)患者術(shù)后石蠟最終病理結(jié)果,伴中高危復(fù)發(fā)危險(xiǎn)因素者,給予PTX+CBP方案3-6個(gè)周期化療。結(jié)果：53例患者,中位年齡32歲(20-41歲),術(shù)中剖視標(biāo)本20例(37.74%)無肉眼腫瘤形態(tài),11例(20.75%)非特異型病灶,22例(41.51%)為明顯腫塊,三類形態(tài)初次切緣累及率分別為5.00%,36.36%以及18.19%。9例患者首次取材腫瘤累及,二次取材后7例(77.78%)患者補(bǔ)充切緣未見腫瘤累及,ART手術(shù)的成功率為94.34%。15例(28.30%)患者接受術(shù)后輔助治療,中位隨訪時(shí)間為9.5個(gè)月(2個(gè)月-17個(gè)月),未出現(xiàn)復(fù)發(fā)或死亡病例結(jié)論：術(shù)中快速冰凍上切緣取材范圍擬定為10mm可行,且該上切緣取材方式易操作、耗時(shí)短、且安全可靠,可廣泛應(yīng)用。
[Abstract]:Part 1: comparison of the scope of abdominal radical hysterectomy and hysterectomy in early cervical cancer patients: To study the operation of radical hysterectomy (Abdominal Radical Trachelectomy, ART) and radical hysterectomy (Abdominal Radical Hysterectomy, ARH) for early cervical cancer patients, and the operation of radical hysterectomy (Abdominal, ARH) Methods and range differences. Methods: from August 2012 to August 2013, 156 patients with lymphatic vascular invasion and IA2, IB1 stage IB1 cervical cancer were prospectively divided into 47 cases of abdominal radical hysterectomy group and 109 cases of radical hysterectomy in the group of abdominal radical hysterectomy according to their personal operation. The length, height, the height, the length of the uterine cervix, the length of the uterine cervix ligament and the sacral ligament were measured by the same doctor and the length of the uterine cervix and the sacral ligament were measured by the same doctor, and the length of the 3,6,9 and 12 points of the vaginal excision were measured. The operation range of the ligaments of the specimens was compared by the x 2 test or the Fish accurate probability square test. Two Results: the median age of the ART group was 32 years (20-41 years old). Compared with the ARH group, the age was lighter, 51 years (32-80 years), and p0.001. In the ART and ARH group, most of the patients were diagnosed as squamous cell carcinoma, 37 (72.3%) and 79 (72.5%), and 34 (75.6%) and 90 (82.6%) respectively in the IB1 stage of FIGO staging. The average paracesal length of the two groups were 44.08 + 17.52mm and 44.96 + 20.77 mm (p=0.432) respectively. The average paracesal average height was 25.74 + 5.24mm and 26.09 + 5.11mm (p=0.361) respectively. The average length of the cervical ligaments in the two groups were 3.85 + 1.76mm and 4.01 + 2.06mm (p=0.647) respectively. The average length of the flat uterine sacral ligament was 13.30 + 4.86mm and 12.88 + 4.51mm (P), respectively (P). =0.605). Besides this, there is no statistical difference between the two groups of vaginal 3,6,9 and 12 points. Conclusion: early cervical cancer patients with radical hysterectomy and traditional radical hysterectomy can excise the same range of paracerval tissue and ligament length. Second early cervical cancer patients, Gong Panglin Detection and clinical significance Objective: To compare the difference of the detection rate between the paramiceral lymph nodes by radical hysterectomy and radical hysterectomy by a new three segment paramiceral lymph node detection method, and to clarify the significance of the detection of the paramiceral lymph nodes and the relationship with the ART operation. Method: prospective acquisition from August 2012 By August 2013, the fresh specimens of 156 patients with lymphoid vascular invasion and IA2 stage IA1 and IB1 stage of epithelial cervical cancer were collected in group ART and ARH according to their initial operation, and the left and right ligaments of the two groups, the bladder ligaments and the sacral ligaments in the two groups were taken apart by three segments. After the water treated paraffin embedded HE staining, the number, size and relation to the blood vessels in the para Palal tissues were examined and recorded under the microscope. 6 cyclical treatments of paclitaxel (PTX) + carboplatin (CBP) were given to the patients with paranathial lymph node metastases. X 2 test or Fish accurate probability square test was used. Results: in group ART, 86 paravesical lymph nodes were detected in 47 patients and 341 paravesal lymph nodes were detected in 109 patients in group ARH. The detection rates of para Palal lymph nodes in the two groups were 80.85% and 96.33%. respectively. Most para Palal lymph nodes were located in the intravesical intravesical region, 63 /86 (73.26%) and 222/341 (65.10%). There were also a small number of paracauterous lymph nodes in the ligaments and the uterine sacral ligaments. The median paracert lymph nodes in the two groups were 2 and 3 respectively. Among the patients with pelvic lymph node negative, two groups of paracauterous lymph node metastases were 6.67% and 6.06%, respectively. In the patients with pelvic lymph node positive, the rate of paracert lymph node metastasis was 100% and 66.67%. in the patients with pelvic lymph node positive. There were no recurrences or deaths in 9.6 months and 9.8 months, respectively. Conclusion: there were paracleal lymph nodes around the cervix, and there might be paracleal lymph nodes and ascending branches of uterine artery in the broad ligament. The detection rate of paracleal lymph nodes in the three segments was higher. The detection of positive paracleal lymph nodes could guide the early uterine. Cervical cancer patients were treated with postoperative adjuvant therapy to reduce the risk of postoperative recurrence. Evaluation of the safety of cervical margin of the third part of the abdominal radical hysterectomy. Methods: from August 2012 to October 2013, we prospectively collected 53 fresh cervical specimens with lymphatic vascular infiltration, IA2 phase, and IB1 period, and 53 patients undergoing radical hysterectomy at stage IB1. 10mm tumor involvement in cervix surgery. If the tumor is involved, two times after the resection of the cervix in the operation. For the two times, the radical hysterectomy is performed. According to the final pathological results of paraffin and the risk factors for high risk of recurrence, 3-6 cycles of the PTX+CBP scheme are given. Results: in 53 patients, the median age was 32 years (20-41 years old), 20 cases (37.74%) had no naked eye tumor, 11 cases (20.75%) non specific, 22 (41.51%) as obvious mass, three primary cutting edge involvement rate 5% respectively, 36.36% and 18.19%.9 patients for the first time. There was no tumor involvement in the patients. The success rate of ART operation was 94.34%.15 (28.30%) patients receiving postoperative adjuvant treatment. The median follow-up time was 9.5 months (2 months -17 months). No recurrence or death case was concluded: the range of rapid frozen upper edge selection in the operation was 10mm feasible, and the cutting edge method was easy to operate. It is short, safe and reliable, and can be widely used.
【學(xué)位授予單位】：復(fù)旦大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2014
【分類號】：R737.33

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