改善生活质量的宫颈癌手术的临床与循证医学研究

【作者】 陈艳丽；

【导师】 李力；

【作者基本信息】 广西医科大学 ， 肿瘤学， 2010， 硕士

【摘要】 腹腔镜下根治性子宫切除加盆腔淋巴结切除对早期宫颈癌患者预后和生活质量的影响目的：探讨腹腔镜下根治性全子宫切除+盆腔淋巴结切除术(Laparoscopic radical hysterectomy and pelvic lymphadenectomy LRH+LPL)治疗早期宫颈的疗效及其对患者生活质量的影响。方法：回顾性分析2002年2月至2008年12月31日因诊断为宫颈癌在广西医科大学附属肿瘤医院妇瘤科住院行手术治疗患者(FIGO分期为：Ⅰb-Ⅱa期)的临床资料。依据手术方式的不同分为研究组(腹腔镜下根治性全子宫切除+盆腔淋巴结切除术),对照组(开腹根治性全子宫切除+盆腔淋巴结切除术)。比较两种手术方式的：手术时间、术中出血量、盆腔淋巴结切除数量、术中及术后并发症、总生存率、无瘤生存率及治疗后的生活质量,并采用Cox比例风险模型分析影响患者预后的因素。结果：腹腔镜手术组共有31例患者,除了有两例中转开腹手术其他病例都成功地完成了LRH+LPL;开腹手术组有85例患者。腹腔镜组的手术时间明显增加(260.07±76.67min VS 215.33±51.12min P=0.007),术后排气时间明显减少(42.88±18.66h VS 68.99±66.7h P=0.0001),术中出血量、盆腔淋巴结切除数无明显差异。中位随访时间是42months (6-84月),腹腔镜组与开腹组各有3例和10例患者失访。两组比较5年生存率、5年无瘤生存率差异无统计学意义。复发率比较无差异(24.86%VS21.55%,P>0.05),病死率比较无差异(10.34%VS 11.58%,P>0.05)。患者的生活质量调查结果差别无统计学意义。结论：LRH+LPL与传统的开腹根治性全子宫切除+盆腔淋巴结切除手术治疗早期宫颈癌能达到同样的效果,如果手术者对腔镜操作熟练可以选择腹腔镜手术替代传统的开腹手术治疗早期宫颈癌。但目前还未见有临床随机对照试验的数据结果报道,需要开展多中心的大型的临床随机对照试验研究来证实。腹腔镜下根治性全子宫切除加盆腔淋巴结切除对早期宫颈癌患者预后影响的Meta分析目的评价腹腔镜下根治性全子宫切除术+盆腔淋巴结切除术(Laparoscopic radical hysterectomy and pelvic lymphadenectomy LRH+LPL)治疗早期宫颈癌的疗效。方法电子检索Cochrane图书馆,Medline、EMBASE、Pubmed、CBMdisc数据库,收集符合纳入标准的文献,提取资料、评价纳入研究的方法学质量,并提取有效数据进行了Meta分。结果符合纳入标准的8篇文章,无前瞻性随机对照研究(RCT),3篇为前瞻性非随机对照试验,5个为回顾性病例对照研究,与传统的开腹根治性子宫切除术(radical abdominal hysterectomy)组相比,腹腔镜下根治性子宫切除术+盆腔淋巴结切除术(Laparoscopic radical hysterectomy and pelvic lymphadenectomy LRH+LPL)组具有术中出血量少、住院时间短、术后肠道排气时间短,术后并发症少等优点,而在复发率和术中并发症发生率上则无显著差异性。结论腹腔镜下根治性子宫切除术+盆腔淋巴结切除术是安全可行的,它能缩短住院时间,减少术中出血量,降低术后并发症的发生率,不增加手术后的复发率和术中并发症的发生率。但由于纳入的文献的质量较低,这将会影响结果的可靠性。需要大样本的随机双盲对照试验的研究结果来进一步证实。根治性子宫颈切除术治疗早期宫颈癌的临床分析目的分析根治性子宫颈切除术治疗早期宫颈癌的临床效果。方法回顾性分析2002年11月至2009年9月,广西医科大学附属肿瘤医院10例早期宫颈癌患者行根治性宫颈切除术的临床资料。结果9例患者成功实施了根治性宫颈切除术,一例患者因术中盆腔淋巴结快速冰冻病理检查提示：转移性癌,改行根治性全子宫切除术。平均年龄为30岁(25～38岁),5例未生育,4例已有子女,但所有患者均要求保留生育功能。国际妇产科联盟(FIGO)分期为：4例Ⅰb1期,5例Ⅰa期；病例类型均为鳞癌。8例是在腹腔镜下淋巴清扫,腹腔镜辅助阴式根治性宫颈切除术,1例患者行开腹根治性宫颈切除术+盆腔淋巴结清扫术。一例术中发生髂外静脉撕裂,术后有静脉血栓形成。随诊期间无病例复发。1例患者术后行辅助妊娠成功但妊娠3+月时流产。结论对早期宫颈癌患者施行根治性宫颈切除术的保留生育功能的治疗是可行的。根治性宫颈切除治疗早期宫颈癌临床价值的循证评价目的评价根治性宫颈切除术(保留患者生育功能)治疗早期年轻宫颈癌的临床价值。方法采用系统评价的方法,对2000年1月至2009年12月国内外公开发表的有关根治性宫颈切除术(保留患者生育功能)治疗早期年轻宫颈癌的所有文献进行复习,从而评价根治性宫颈切除术治疗早期宫颈癌的临床价值。结果共19篇文献纳入本研究,复发率0%-9.8%,平均为4.7%；死亡率为0%-4.2%,平均死亡率为1%；术后妊娠率为46.1%,足月产185例,占37.3%,早产97例,占21%,流产188例,占40.6%,其中早期流产114例,占全部流产病例的60.6%。晚期流产74例,占全部流产病例的39.4%。结论宫颈根治切除术是安全可行的,能满足患者的生育要求。严格执行手术指征,宫颈根治切除术不增加复发率。需要临床随机对照试验的研究结果来进一步验证。不同的治疗方式对ⅡB期宫颈癌患者预后和生活质量的影响目的：研究不同治疗方式治疗ⅡB期宫颈癌患者的临床价值及疗效。方法：回顾性分析2000年01月01日至2007年12月31日在广西医科大学附属肿瘤医院妇瘤科住院治疗的Ⅱb期宫颈癌的病例资料158例,根据不同的治疗方法将其分成(1)单纯放射治疗组33例；(2)同步放化疗组,28例；(3)新辅助化疗+手术组28例；(4)新辅助放化疗同步+手术组24例；(5)新辅助化疗或新辅助放化疗同步+手术+术后巩固放化疗组45例,比较各组患者的5年生存率、5年无瘤生存率,及生活质量。结果：各组比较5年生存率、5年无瘤生存率有差异,第5组患者的5年生存率、5年无瘤生存率最低。各组比较生活质量有差异,第1组及第2组的生活质量较低。结论：新辅助化疗后行根治性全子宫切除+盆腔淋巴结切除术是否可用于治疗Ⅱb期宫颈癌尚有异议。新辅助化疗治疗局部晚期宫颈癌的临床疗效的Meta分析目的评价新辅助化疗治疗局部晚期宫颈癌的临床疗效。方法电子检索Cochrane图书馆,Medline、EMBASE、Pubmed、CBMdisc数据库,收集符合纳入标准的文献,提取资料、评价纳入研究的方法学质量,并提取有效数据进行了Meta分析。结果符合纳入标准的共5篇文章,4篇为前瞻性随机对照试验,1篇为回顾性病例对照研究。新辅助化疗对局部晚期宫颈癌的5年生存率没有影响,提高了局部晚期宫颈癌的5年无瘤生存率,降低了术后淋巴结的转移率及宫旁的浸润率。结论新辅助化疗可用于治疗局部晚期宫颈癌,可降低术后宫旁浸润率及淋巴结转移率。但纳入的研究少且都为小样本的研究,因此新辅助化疗对局部晚期宫颈癌的疗效有待进一步大样本、高质量的多中心的随机双盲对照试验加以证实。更多还原

【Abstract】 THE IMPACT ON PROGNOSIS AND QUALITY OF LIFE OF LAPAROSCOPIC RADICAL HYSTERECTOMY WITH PELVIC LYMPHADENECTOMY IN TREATMENT EARLY CERVICAL CANCEROBJECTIVE:To evaluate the clinical effect of laparoscopic-assisted radical hysterectomy (LARH) and pelvic lymphadenectomy in management of early invasive cervical carcinomaMETHODS:Retrospective the consecutive cases with FIGO Ib-IIa cervical cancer from February 2002 to December 2008 were documented, including 31 patients underwent LRH+LPL, and 85 patients underwent ARH+APL as control group. The clinic data of perioperative periods、survival rate and quality of life were compared between groups.RESULTS:All laparoscopic procedures were completed successfully except 2 cases converted to laparotomy. In laparoscopy group the operating time increased significantly (260.07±76.67min VS 215.33±51.12min P=0.007), and the recovery time of bowel decreased significantly (42.88±18.66h VS 68.99±66.7h P=0.0001). No significant difference was found between groups on the blood loss during operation and numbers of the pelvic lymph nodes resected.The median follow-up was 42 months (range 6 to 84 months). Three and ten cases lost to follow-up in laparoscopy and laparotomy group, respectively. The recurrence rate (24.86% VS 21.55%,P>0.05) and the mortality rate (10.34% VS 11.58%, P>0.05) between groups was similar.There was no significant difference between groups in the five-year overall survival rate and the 5-year disease free survival rate.The quality of life between groups was similar. CONCLUSION:Our data demonstrated that cervical cancer could be treated successfully with LRH+LPL with similar clinical effect to ARH+APL. LRH+LPL is a safe and effective alternative to conventional abdominal surgery for stage Ib-IIa cervical cancer, and should be used if the surgeon is sufficiently trained. Its clinical value should be confirmed by multicenter randomized clinic trials. THE IMPACT ON PROGNOSIS AND QUALITY OF LIFE OF LAPAROSCOPIC RADICAL HYSTERECTOMY WITH PELVIC LYMPHADENECTOMY IN TREATMENT EARLY CERVICAL CANCER:A META ANALYSISOBJECTIVE:To evaluate the clinical effects of laparoscopic-assisted radical hysterectomy(LARH) and pelvic lymphadenectomy(LPL) METHODS:The following electronic databases were searched:CBMdisc、Medline、Pubmed、EMBASE、Cochrane Library.All eligible documents were assessed for quality.All data were performed by a Meta-analysis. RESULTS:There were 8 documents met the inclusion criteria. There were no RCTS,three prospective non-randomized controlled trials and five retrospective case-control studies. Comparing to ARH+APL, LARH+LPL has several advantages.Such as decreasing the recovery time of bowel, the blood loss during operation, postoperative hospital stays and complications of postoperation. But the recurrence rate and complications of intraoperation between LARH+LPL and ARH+APL was similar. CONCLUSION:LRH+LPL is a safe and effective alternative to conventional abdominal surgery for stage Ib-Ⅱa cervical cancer.Beause the quality of all the included documents are low, the conclusion is needed to further assessed by rigorously designeds, randomed, double-blind,controlled trialsTHE CLINICAL EFFECT OF RADICAL TRACHELECTOMY IN TREATMENT EARLY SATAGE CERVICAL CARCINOMAOBJECTIVE:To investigate the feassibility and effect of radical trachelectomy in treating women with early cervical cancer who desired to maintain fertility. METHODS: Retrospective The consecutive cases with early stage cervical cancer from December 2002 to February 2009 were documented, including 10 patients underwent radical trachelectomy.Subjects were selected for this treatment on the basis of favorable cervical tumors and a desire to maintain fertility. RESULTS:9 women underwent this procedure successfully. One patients converted to radical hysterectomy,because lymph nodes are positive.Mean age was 30years(range 25 to 38 years),Mean operative time was 200 mins(range 150 to365 mins), with a mean blood loss of 330 ml(range 250 to 800 ml). There were one intra-operative and one post-operative complication. With an average following up of 24 months(range 2 to 84 months), there have been no recurrences and no deaths. One woman has becomed pregnant with the help of artificial fertilization CONCLUSIONS: Radical trachelectomy is possible to preserve fertility in the treatment of patients with early cervical cancer, but treatment indication should be considered carefully.THE CLINICAL EFFECT OF RADICAL TRACHELECTOMY IN TREATMENT EARLY SATAGE CERVICAL CARCINOMA: A SYSTEMATIC REVIEWOBJECTIVE:To evaluate the feassibility and effect of radical trachelectomy in treating women with early cervical cancer who desired to maintain fertility. METHODS:The following electronic databases were searched:CBMdis、Medline、Pubmed、EMBASE、Cochrane Library. RESULTS:There were 19 documents met the inclusion criteria.The recurrence rate was 0%-9.8%,the mean recurrence rate was 4.7%. The death rate was 0%-4.2%, the mean death rate was 1%. The pregnancy rate was 46.1%,while 40.6% of these pregnancies were lost during the first and second trimesters. The rate of first trimester loss was60.6%, while second trimester loss was 39.4%. Furthermore, overall preterm deliveries (<37 weeks) occurred in 21% of these pregnancies. CONCLUSIONS:Radical trachelectomy appears safe when performed by sufficient surgery.lt can satisfy the patients’ needs to preserve the fertility. The conclusion is needed to further assessed by rigorously designeds, randomed, double-blind,controlled trialsTHE IMPACT ON PROGNOSIS AND LIFE QUALITY ALL KINDS OF TREATMENTS IN TREATING CERVICAL CANCER (STAGEⅡB)OBJECTIVE:To investigate the clinical effect of all kinds of treatments treated for FIGO stageⅡb cervical cancer.METHODS:Retrospective The consecutive 158 cases with FIGO stageⅡb cervical cancer from Janurarye 2000 to December 2007were documented, including 33patients underwent exclusive radiotherapy、28patients underwent concurrent chemoradiation、28 patients underwent neoadjuvant chemotherapy (NACT) and radical surgery(RS)、24 patients underwent neoadjuvant concurrent chemoradiation and radical surgery、45 patients underwent neoadjuvant chemotherapy or neoadjuvant concurrent chemoradiation and radical surgery and adjuvant chemoradiation. The 5-year over-all survival rate、5-year disease free survival rate and quality of life were compared among groups.RESULTS:There was significant difference among groups in the five-year overall survival rate、the 5-year disease free survival rate and quality of life. The overall 5-year survival rate of neoadjuvant chemotherapy or neoadjuvant concurrent chemoradiation and radical surgery and adjuvant chemoradiation group is the lowest.The quality of life of both exclusive radiotherapy and concurrent chemoradiation groups are the lowest.CONCLUSIONS:Neoadjuvant chemotherapy (NACT) and radical surgery(RS) could be useded to treat the FIGO stageⅡb cervical cancer.Although it didn’t improve the survival rate,yet it improved the quality of life. NEOADJUVANT CHEMOTHERAPY AND RADICAL SURGERY TREATMENT THE LOCALLY ADVANCED CANCER:A MATA ANALYSISOBJECTIVE:To evaluate the clinical effects of neoadjuvant chemotherapy (NACT) and radical surgery(RS) in locally advanced cervical cancer METHODS:The following electronic databases were searched:CBMdisc、Medline、Pubmed、EMBASE、Cochrane Library.All eligible documents were assessed for quality.All data were performed by a Meta-analysis.Neoadjuvant chemotherapy (NACT) and radical surgery(RS) didn’t increase the 5-year survival rate,but increased the 5-year disease-free survival rate and decreased lymph node metastasis and parameter metastasis. CONCLUSION:Neoadjuvant chemotherapy (NACT) and radical surgery could be chosen to treat the locally advanced cervical cancer.It increased the 5-year disease-free survival rate and decreased lymph node metastasis and parameter metastasis. But the conclusion is needed to further assessed by rigorously designeds, randomed, double-blind,controlled trials.更多还原