【摘要】：背景與目的卵巢惡性腫瘤是女性生殖器官常見的三大惡性腫瘤之一,病死率居婦科惡性腫瘤首位。上皮性卵巢癌是卵巢惡性腫瘤中最常見的類型。上皮性卵巢癌的治療原則為以手術(shù)為主、化療為輔的綜合治療。盡管經(jīng)過了徹底的手術(shù)治療以及完整規(guī)范的化療,仍有50%-80%的上皮性卵巢癌患者出現(xiàn)復發(fā),晚期患者5年生存率徘徊于30%-40%。國際婦產(chǎn)科聯(lián)盟手術(shù)-病理分期是公認的影響卵巢癌預后的重要因素,而淋巴結(jié)是否轉(zhuǎn)移是手術(shù)-病理分期的重要因素。早期上皮性卵巢癌盆腔淋巴結(jié)轉(zhuǎn)率為5%-14%,腹主動脈旁淋巴結(jié)轉(zhuǎn)移率為4%-12%；晚期上皮性卵巢癌盆腔淋巴結(jié)轉(zhuǎn)移率達50%以上,腹主動脈旁淋巴結(jié)轉(zhuǎn)移率為17%。但是關(guān)于上皮性卵巢癌是否需要行腹膜后淋巴結(jié)清掃術(shù)尤其是腹主動脈旁淋巴結(jié)清掃術(shù)目前仍然存在著爭議。據(jù)文獻報道,全世界范圍內(nèi)只有10%-30%的卵巢癌患者行全面的分期手術(shù)。本文主要的目的是探討淋巴結(jié)轉(zhuǎn)移以及淋巴結(jié)清掃范圍對上皮性卵巢癌復發(fā)及生存率的影響,以及上皮性卵巢癌淋巴結(jié)發(fā)生轉(zhuǎn)移的危險因素,以期為上皮性卵巢癌的手術(shù)治療提供理論依據(jù)。方法1.回顧性分析2012年01月01日-2015年11月30日期間于鄭州大學第二附屬醫(yī)院行腹膜后淋巴結(jié)清掃術(shù)的104例上皮性卵巢癌患者的臨床病理資料。根據(jù)淋巴結(jié)清掃范圍分為兩組：①盆腔淋巴結(jié)清掃組37例；②盆腔+腹主動脈旁淋巴結(jié)清掃組67例�？偨Y(jié)上皮性卵巢癌盆腔淋巴結(jié)和腹主動脈旁淋巴結(jié)的轉(zhuǎn)移率以及轉(zhuǎn)移的腹主動脈旁淋巴結(jié)的分布情況；對患者進行隨訪,分析淋巴結(jié)轉(zhuǎn)移以及淋巴結(jié)清掃范圍對上皮性卵巢癌復發(fā)及生存率的影響,并行單因素和多因素分析了解影響上皮性卵巢癌盆腔淋巴結(jié)轉(zhuǎn)移和腹主動脈旁淋巴結(jié)轉(zhuǎn)移的相關(guān)因素。2.統(tǒng)計方法應用SPSS21.0軟件進行統(tǒng)計學分析,計量資料比較采用t檢驗,計數(shù)資料比較采用x2檢驗,Kaplan-Meier法計算生存率,生存率的比較采用Log-rank檢驗,多因素分析采用非條件logistic回歸分析,α=0.05為檢驗水準。結(jié)果1.淋巴結(jié)轉(zhuǎn)移率及淋巴結(jié)轉(zhuǎn)移相關(guān)因素：104例病例中共有46例發(fā)生腹膜后淋巴結(jié)轉(zhuǎn)移,轉(zhuǎn)移率為44.23%(46/104)。41例發(fā)生盆腔淋巴結(jié)轉(zhuǎn)移,轉(zhuǎn)移率為39.42%(41/104)；24例發(fā)生腹主動脈旁淋巴結(jié)轉(zhuǎn)移,轉(zhuǎn)移率為35.82%(24/67)。盆腔+腹主動脈旁淋巴結(jié)清掃組中7例僅有盆腔淋巴結(jié)轉(zhuǎn)移,轉(zhuǎn)移率為10.45%(7/67)；5例僅有腹主動脈旁淋巴結(jié)轉(zhuǎn)移,轉(zhuǎn)移率為7.46%(5/67)；19例盆腔及腹主動脈旁淋巴結(jié)均有轉(zhuǎn)移,轉(zhuǎn)移率為28.36%(19/67)。單因素分析結(jié)果顯示臨床分期、病理類型、組織學分化是上皮性卵巢癌盆腔淋巴結(jié)轉(zhuǎn)移的危險因素,臨床分期和盆腔淋巴結(jié)轉(zhuǎn)移是上皮性卵巢癌腹主動脈旁淋巴結(jié)轉(zhuǎn)移的危險因素。多因素分析結(jié)果顯示臨床分期是上皮性卵巢癌盆腔淋巴結(jié)轉(zhuǎn)移的獨立危險因素,盆腔淋巴結(jié)轉(zhuǎn)移是上皮性卵巢癌腹主動脈旁淋巴結(jié)轉(zhuǎn)移的獨立危險因素。2.淋巴結(jié)切除數(shù)量及陽性淋巴結(jié)數(shù)量與淋巴結(jié)清掃范圍的關(guān)系：盆腔淋巴結(jié)清掃組和盆腔+腹主動脈旁淋巴結(jié)清掃組淋巴結(jié)平均切除個數(shù)分別為(19.56±6.14)個和(39.55±15.59)個。隨著淋巴結(jié)清掃范圍的擴大,切除的淋巴結(jié)數(shù)量增多(P0.05)。盆腔淋巴結(jié)清掃組和盆腔+腹主動脈旁淋巴結(jié)清掃組平均陽性淋巴結(jié)個數(shù)分別為(9.09±4.63)個和(32.93±18.10)個。隨著淋巴結(jié)清掃范圍的擴大,陽性淋巴結(jié)切除數(shù)量增加(P0.05)。3.復主動脈旁淋巴結(jié)轉(zhuǎn)移好發(fā)區(qū)域：左腎靜脈水平和腹主動脈旁與下腔靜脈間是淋巴結(jié)轉(zhuǎn)移率最高的區(qū)域,轉(zhuǎn)移率為42.31%(11/26)。4.臨床分期與手術(shù)-病理分期相符率：8例肉眼病灶局限于卵巢或盆腔者因淋巴結(jié)轉(zhuǎn)移而導致期別上升,占17.39%(8/46)。其中5例行盆腔+腹主動脈旁淋巴結(jié)清掃術(shù),1例僅有腹主動脈旁淋巴結(jié)轉(zhuǎn)移,4例盆腔淋巴結(jié)及腹主動脈旁淋巴結(jié)均有轉(zhuǎn)移,5例均有左腎靜脈水平淋巴結(jié)轉(zhuǎn)移。5.復發(fā)率及無瘤生存期：104例病例中有41例發(fā)生復發(fā),總復發(fā)率為39.42%(41/104)。淋巴結(jié)轉(zhuǎn)移者和淋巴結(jié)無轉(zhuǎn)移者復發(fā)率分別為60.87%(28/46)和22.41%(13/58),淋巴結(jié)轉(zhuǎn)移者復發(fā)率較淋巴結(jié)無轉(zhuǎn)移者高(P0.05)。淋巴結(jié)轉(zhuǎn)移者和淋巴結(jié)無轉(zhuǎn)移者平均無瘤生存期分別為(23±1.963)個月和(32±1.643)個月,淋巴結(jié)轉(zhuǎn)移者無瘤生存期較淋巴結(jié)無轉(zhuǎn)移者短(P0.05)。盆腔淋巴結(jié)清掃組和盆腔+腹主動脈旁淋巴結(jié)清掃組復發(fā)率分別為54.05%(20/37)和31.34%(21/67),盆腔+腹主動脈旁淋巴結(jié)清掃組復發(fā)率較盆腔淋巴結(jié)清掃組低(P0.05)。盆腔淋巴結(jié)清掃組中位無瘤生存期為20個月,盆腔+腹主動脈旁淋巴結(jié)清掃組中位無瘤生存期為39個月,盆腔+腹主動脈旁淋巴結(jié)清掃組無瘤生存期較盆腔淋巴結(jié)清掃組長(P0.05)。結(jié)論1.盆腔+腹主動脈旁淋巴結(jié)清掃術(shù)可以明確上皮性卵巢癌的分期,降低復發(fā)率,延長無瘤生存率；2.上皮性卵巢癌需要行盆腔+腹主動脈旁淋巴結(jié)清掃術(shù),因左腎靜脈下淋巴結(jié)轉(zhuǎn)移率高,淋巴結(jié)清掃范圍應達到左腎靜脈水平。3.臨床期別晚、漿液性癌、低分化是上皮性卵巢癌淋巴結(jié)轉(zhuǎn)移的高危因素,該部分患者尤其需要行盆腔+腹主動脈旁淋巴結(jié)清掃術(shù)。
[Abstract]:BACKGROUND AND OBJECTIVE Ovarian malignancies are one of the three most common malignancies in female genital organs, with the highest mortality in gynecological malignancies. Epithelial ovarian cancer is the most common type of ovarian malignancies. The principle of treatment for epithelial ovarian cancer is a combination of surgery and chemotherapy. 50% to 80% of patients with epithelial ovarian cancer recurred after chemotherapy and the 5-year survival rate of patients with advanced ovarian cancer hovered between 30% and 40%. Pelvic lymph node metastasis rate was 5% - 14%, para-aortic lymph node metastasis rate was 4% - 12%; pelvic lymph node metastasis rate of advanced epithelial ovarian cancer was more than 50%, para-aortic lymph node metastasis rate was 17%. But whether retroperitoneal lymph node dissection, especially para-aortic lymph node dissection, was necessary for epithelial ovarian cancer There is still controversy. According to the literature, only 10-30% of the patients with ovarian cancer in the world have undergone comprehensive staging surgery. Methods 1. The clinical and pathological data of 104 patients with epithelial ovarian cancer who underwent retroperitoneal lymphadenectomy in the Second Affiliated Hospital of Zhengzhou University from January 1, 2012 to November 30, 2015 were retrospectively analyzed. Thirty-seven patients were treated with palpation and 67 patients were treated with pelvic and para-abdominal aortic lymph node dissection.The metastasis rates of pelvic and para-abdominal aortic lymph nodes and the distribution of metastatic para-abdominal aortic lymph nodes in epithelial ovarian cancer were summarized. Relapse and survival rate, and single factor and multifactor analysis of the impact of epithelial ovarian cancer pelvic lymph node metastasis and para-abdominal aortic lymph node metastasis related factors. 2. Statistical methods SPSS21.0 software for statistical analysis, statistical data comparison using t test, statistical data comparison using x2 test, Kaplan-Meier method The survival rate was calculated by Log-rank test, and the unconditional logistic regression analysis was used for multivariate analysis. Results 1. Lymph node metastasis rate and related factors of lymph node metastasis: Of 104 cases, 46 cases had retroperitoneal lymph node metastasis, and the metastasis rate was 44.23% (46/104). 41 cases had pelvic lymph node metastasis. Metastasis rate was 39.42% (41 / 104); para-aortic lymph node metastasis was found in 24 cases (35.82% (24 / 67); pelvic lymph node metastasis was found in 7 cases (10.45% (7 / 67); para-aortic lymph node metastasis was found in 5 cases (7.46%); pelvic lymph node metastasis was found in 19 cases (5 / 67). The metastasis rate was 28.36%(19/67). Univariate analysis showed that clinical stage, pathological type and histological differentiation were risk factors for pelvic lymph node metastasis in epithelial ovarian cancer. Clinical stage and pelvic lymph node metastasis were risk factors for pelvic lymph node metastasis in epithelial ovarian cancer. Results showed that clinical stage was an independent risk factor for pelvic lymph node metastasis in epithelial ovarian cancer, and pelvic lymph node metastasis was an independent risk factor for para-abdominal aortic lymph node metastasis in epithelial ovarian cancer. The average number of lymph nodes resected in para-aortic lymph node dissection group was (19.56+6.14) and (39.55+15.59). With the enlargement of lymph node dissection range, the number of resected lymph nodes increased (P 0.05). The average number of positive lymph nodes in pelvic lymph node dissection group and pelvic+para-aortic lymph node dissection group were (9.09+4.63) and (9.09+4.63) respectively. With the enlargement of lymph node dissection range, the number of positive lymph node resection increased (P 0.05). 3. Prevalent area of multiple paraaortic lymph node metastasis: Level of left renal vein and para-abdominal aorta and inferior vena cava were the areas with the highest lymph node metastasis rate (42.31% (11/26). 4. Clinical stage and surgical-pathological stage The coincidence rate was 17.39% (8/46) in 8 cases with gross foci confined to the ovary or pelvic cavity. 5 cases underwent pelvic + abdominal paraaortic lymphadenectomy, 1 case had abdominal paraaortic lymph node metastasis, 4 cases had pelvic lymph node metastasis and 5 cases had left renal vein level lymph node metastasis. Metastasis. 5. Recurrence rate and tumor-free survival: 41 of 104 cases had recurrence, the total recurrence rate was 39.42%(41/104). The recurrence rates of lymph node metastasis and non-metastasis were 60.87%(28/46) and 22.41%(13/58), respectively. The recurrence rate of lymph node metastasis was higher than that of non-metastasis (P 0.05). The mean tumor-free survival time was (23 + 1.963) months and (32 + 1.643) months, respectively. The tumor-free survival time of patients with lymph node metastasis was shorter than that of patients without lymph node metastasis (P 0.05). The recurrence rates of pelvic lymph node dissection group and pelvic + para-aortic lymph node dissection group were 54.05% (20/37) and 31.34% (21/67), respectively. The median tumor-free survival was 20 months in pelvic lymph node dissection group, 39 months in pelvic + para-aortic lymph node dissection group, and longer in pelvic + para-aortic lymph node dissection group than in pelvic lymph node dissection group (P 0.05). Palpation dissection can determine the stage of epithelial ovarian cancer, reduce the recurrence rate, prolong the tumor-free survival rate; 2. epithelial ovarian cancer needs pelvic + abdominal para-aortic lymph node dissection, because the left renal vein lymph node metastasis rate is high, lymph node dissection should reach the level of the left renal vein. 3. clinical stage late, serous cancer, low differentiation is Epithelial ovarian cancer is a high risk factor for lymph node metastasis. Pelvic + para-aortic lymphadenectomy is especially necessary in this group of patients.
【學位授予單位】：鄭州大學
【學位級別】：碩士
【學位授予年份】：2016
【分類號】：R737.31

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