【作者】 刘蕊；

【导师】 宋磊；

【作者基本信息】 中国人民解放军军医进修学院 ， 妇产科， 2004， 硕士

【摘要】 目的：探讨PVM(卡铂、长春新碱、丝裂霉素)方案超选择性子宫动脉化疗栓塞(transarterial chemoembolization，TACE)治疗中晚期宫颈癌的疗效及临床意义；评价术前化疗后行广泛子宫切除+盆腔淋巴结清扫术的可行性。 方法：收集2001年7月至2004年4月在我院行动脉化疗栓塞的中晚期宫颈癌患者(Ⅱb期-Ⅳa期)25例，包括Ⅱb期17例，Ⅲ期5例，Ⅳa期3例。有3例(Ⅲ期2例，Ⅳa期1例)曾在外院行少量放射治疗，临床症状无变化，其余22例入院前未行任何治疗，即为先期化疗。治疗前已明确病理诊断，鳞癌19例，腺癌5例，透明细胞癌1例。治疗为PVM方案(卡铂CBP400mg-600mg，长春新碱VCR2mg，丝裂霉素MMC16mg)，采用超选择双侧子宫动脉灌注法，化疗后用明胶海绵和聚乙烯醇(PVA)微粒栓塞，经用1-2个疗程后，行手术治疗。观察子宫动脉化疗栓塞的近期疗效、副反应及影响化疗疗效的因素；评价化疗后广泛子宫切除+盆腔淋巴结清扫术的可行性，术后并发症及影响预后的不良因素。 结果：25例患者1例完全缓解，19例部分缓解，3例病情无变化，2例病情进展。动脉化疗栓塞的总体缓解率为80％，先期化疗的总体缓解率为90.9％，既往行放疗的3例患者，病情均无缓解。肿瘤分期对化疗缓解率的影响有统计学意义(P=0.0289)，肿瘤分化程度对化疗缓解军国州罗笋院硕1学位论文率的影响无统计学显著差异(P=0 .32)，肿瘤分期与肿瘤大小的交互作用对化疗缓解率的影响有统计学差异(P=0 .0259)。未放疗的22例患者获得了广泛子宫切除+盆腔淋巴结清扫术的机会。术中出血量、手术时间、术后住院日、术后膀肤功能恢复时间与同期行相同术式的Ib及lla期宫颈癌患者比较无显著性差异，术中、术后未发生严重并发症。22例手术的患者病理回报断端均无癌细胞，3例宫旁浸润，6例脉管内有癌栓，8例有淋巴结转移，其中1例完全缓解的患者术后病理未见癌细胞。 结论:动脉化疗栓塞是治疗中晚期宫颈癌安全有效的辅助方法。PVM方案动脉化疗临床总体缓解率高，毒副作用小，对宫颈鳞癌及腺癌均有效，对宫颈腺癌中残留副中肾管来源的透明细胞癌1例疗效不明显。肿瘤分期对化疗缓解率有影响，肿瘤分化程度对化疗缓解率无影响，肿瘤大小可能通过影响分期从而影响化疗缓解率。TACE可以提高局部治疗作用，缩小肿瘤的体积和浸润范围，使原来无法手术的患者有可能获得切除病灶的机会;不增加广泛子宫切除术及盆腔淋巴结清扫术的术中困难程度及术后并发症。术后病理提示动脉化疗栓塞可以改善影响预后的不良因素。介入治疗的理想疗效加上及时彻底的手术，有较明显的近期疗效，对远期疗效及生存率的影响，仍需大量临床病例及长期随访验证。更多还原

【Abstract】 Purpose To study the curative effect of the treatment for metaphase or advanced cervical carcinoma with chemoembolization of uterine arteries by a combination of carboplatin, vincristin, mitomycin and its clinical significance. To evaluate feasibility of radical hysterectomy and pelvic lymphadenectomy after neoadjuvant chemotherapy(NAC). Methods From Jul 2001 to Apr 2004,25 patients(IIb-IVa) were entered in this study. Stage was II b in 17, III in 5, IVa in 3. Twenty-one cases were untreated before admission while 3 cases were treated with radiotherapy. All patients’ pathological diagnosis were definite before chemoembolization as 19 cases in squamous carcinoma, 5 cases in adenocarcinoma and 1 case in clear cell carcinoma. Treatment was consisted of: PVM regime (carboplatin 400mg-600mg, vincristin 2mg, mitomycin 16mg ) transarterial infusion bilateral uterine arteries, then transcatheter arterial embolization(TAE) with gelfoam and polyvinyl alcohol broken pieces for one or two courses followed by radical hysterectomy. Observed the recent efficacy and toxicity of transarterial chemoembolization(TACE).Evaluated intra-operative and postoperative complications of radical hysterectomy and pelvic lymphadenectomy after NAC.Results Of the 25 evaluable patients who completed TACE, overall clinical response was noted in twenty patients(80%) including one completeresponse and nineteen partial response. Three patients had stable disease and two had progression disease. Overall response was noted 90.9% in the patients with NAC. The response to chemotherapy related to clinical stages significantly(P=0.0289), but not to grade of differentiation (P=0.32) - There was significant interaction between clinical stages and tumor volume (P=0.0289) . The 22 patients underwent radical hysterectomy and pelvic lymphadenectomy four weeks following neoadjuvant chemotherapy. Three cases who had been treated with radiotherapy had no clinical response. The median blood loss, operating time, the length of postoperative hospital stay and bladder rehabilitation time for radical hysterectomy and pelvic lymphadenectomy in patients with metaphase or advanced cervical carcinoma were similar to those in patients with stages I b and II a disease. No intra-operative or immediate postoperative complications were observed. There were not any cancer-cells in all stumps, but pathologic examination of surgical specimens revealed parametrial infiltration in 3 of the 22 patients, vascular invasion in 6 cases, lymph nodes metastasis in 8 cases. Conlusion These results suggest that NACE is safe and effective treatment technic without severe complications for therapy of metaphase or advanced cervical carcinoma. PVM regime yields a high response rate with acceptable toxicity. It is effective for squamous carcinoma and adenocarcinoma except clear cell carcinoma. The response to chemotherapy relates to clinical stages, but not to grade of differentiation. Tumor volume affects the response to chemotherapy by the influence of the clinical stages. NACE is able to increase local therapeutic effects and to diminish effectivelythe primary tumor and invasive coverage to decrease staging and improve the operability in patients with metaphase or advanced cervical carcinoma. Intra-operative and postoperative complications of radical hysterectomy and pelvic lymphadenectomy after neoadjuvant chemotherapy are not raised. Pathologic examination of surgical specimens revealed the improvement of prognosis of these patients. The high rate of optimal responses and operation might impact positively on survival, but only a longer follow-up period with allow objective assessment of this impact.更多还原