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LinusT.Chuang,MD利纳斯庄医学博士Mt.SinaiSchoolofMedicine西奈山医学院RadicalTrachelectomy

forEarlyCervicalCancer

早期宫颈癌根治性子宫颈切除术CervicalCancer

宫颈癌Secondmostcommonfemalecancer在女性癌症中位居第二Incidence:500,000发病率:500,000Death:270,000病死率:270,000Standardtreatments:标准治疗Radicalhysterectomy宫颈癌根治术Chemo-radiationtherapy化学-放射治疗Incidence发病率SEERCancerStatisticsReview1975–2005

Age(年龄)%<200.220-3414.935-4426.245-5423.555-6415.865-7410.475-846.685+2.541%RadicalHysterectomy宫颈癌根治术StageIB1andIIAcervicalcancer宫颈癌IB1及IIAApproaches方法:Abdominal+lymphadenectomy

经腹+淋巴结切除术Vaginal+laparoscopically

lymphadenectomy经阴道+腹腔镜淋巴结切除术Laparoscopic+lymphadenectomy腹腔镜+淋巴结切除术Laparoscopic-assistedrobotic+lymphadenectomy机器人腹腔镜+淋巴结切除术SensitivityandSpecificityofImagingStudiesforPelvicNodesinCervicalCancers

宫颈癌盆腔淋巴结影像学的敏感性与特异性研究ChildersJGynecologicOncology47,38(1992)Imagingtechnique影像学技术Sensitivity敏感性Specificity特异性Accuracy符合率False(—)假阴性False+假阳性Lymphangiography淋巴造影25-66%82-91%69-85%32%10%CTscan60-80%86-100%76-89%13%21%MRIscan60%91%84%*CTscan:positivepredictivevalue:60%,negativepredictivevalue:91%CT扫描:阳性预测价值60%,阴性91%PETScanEvaluationof

LocallyAdvancedCervicalCancer

PET扫描在原发晚期宫颈中的评估Author(作者)Samplesize(n)标本量Methodchosen(PETvs.PET/CT)方法选择Sensitivity敏感性Specificity特异性Roseetal.22PET75%92%Linetal.50PET85.7%94.4%Choietal.22PET/CT57.6%92.6%Loftetal.119PET/CT100%99%Yehetal.42PET83.3%96.7%16PET/CT75%50%Yildirimetal.RadicalHysterectomy

宫颈癌根治术FertilitySparingSurgery

保留生育功能手术FertilitySparingSurgery

保留生育功能手术VaginalRadicalTrachelectomy(VRT)

经阴道根治性子宫颈切除术Author(s)作者Year年Country国别Schauta1902AustriaDargent1994FranceShepherd1998EnglandRoyandPlante1998CanadaVRT

经阴道根治性子宫颈切除术Thevaginalmucosaisinjectedtoseparatetheplanesofdissection.阴道粘膜注射分离

SonodaY,Abu-Rustum

NR.Gynecol

Oncol.2007Feb;104(2Suppl1):50-5.

VRTThevaginalmucosaisincised.Theouterlayerisincisedcompletelyonlyanteriorlyandposteriorly.Thelateralincisionsareshallow.阴道粘膜切开.阴道前后壁粘膜外层全部切开,两侧则稍浅.VRTThevaginalmucosaisfoldedoverthecervix.

阴道粘膜折叠与宫颈VRTTheposteriorculdesacisentered.进入阴道后穹窿VRTThepararectalspaceisopenedtoisolatetheuterosacralligaments.

打开直肠旁间隙,分离宫骶韧带VRTTheuterosacralligamentisdivided.分离宫骶韧带VRTThevesicouterinespaceisdevelopedwithsharpdissection.锐性分离膀胱子宫间隙VRTTheparavesicalspaceisopened.打开膀胱旁间隙VRTThekneeoftheuretercanbepalpatedinthebladderpillar.在膀胱支柱处可以触到输尿管膝

VRTThebladderpillarcanbedividedtoallowformoredescensus.分离膀胱支柱可以使其更加下降VRTTwoclampsareusedtodividetheparametriumoncetheureterisassuredtobeaway.确定输尿管已经分走后,用两把钳子分离宫旁

VRTThecervicouterinebranchoftheuterinearteryisdivided.分离子宫动脉子宫宫颈分枝

VRTAmputatingthecervix.切除宫颈VRTAcerclageisplacedtohelpsupportthecervix.环扎术帮助支持宫颈VRTFinalreconstructionofvaginatoresidualcervix.

最后将阴道重建于剩余宫颈VRTAbdominalRadicalTrachelectomy(ART)

经腹根治性子宫颈切除术SmithJR,BoyleDC,CorlessDJ,UngarL,LawsonAD,DelPrioreG,McCallJM,LindsayI,BridgesJE.BrJObstet

Gynaecol.1997Oct;104(10):1196-200.Abu-RustumN,SonodaYpopularizedtheprocedureEligibilityCriteriaforART

ART适合标准Confirmedinvasivecervicalcancer:squamous,adenocarcinoma,oradenosquamous浸润性宫颈癌:鳞癌,腺癌,腺鳞癌FIGOStageIA2toIB1分期IA2及IB1

Age<

45

yearsandstrongdesiretopreservefertility小于45岁并有强烈的保留生育功能的欲望Noclinicalevidenceofimpairedfertility没有生育功能受损的临床依据Lesionsize≤

4

cm病灶≤

4

cmChestX-raywithnoevidenceofmetastasis.PreoperativeMRIofpelvis

+

abdomen,orappropriateimagingprotocol胸片及术前盆腹腔MRI证实没有转移4–6

weekspostconizationwithadequateresolutionofacuteinflammation4-6周前锥切结果为急性炎症Abu-RustumNetal.Gynecol

Oncol.2008Nov;111(2):261-4.AbdominalRadicalTrachelectomy(ART)

经腹根治性子宫颈切除术Theuterusismanipulatedbyclampsontheroundligamentsavoidingtheutero-ovarianpedicles.利用钳子钳夹圆韧带控制子宫避开子宫卵巢椎弓根ARTTheuterinevesselsarethenligatedanddivided.

结扎离断子宫血管Theparametriaandparacolposwithuterinevesselsaremobilizedmediallywiththespecimen.

适当松解宫旁与宫颈旁血管Acompleteureterolysisisperformed.输尿管松解术Theposteriorculdesacperitoneumisincisedandtheuterosacralligamentdivided.打开后穹窿腹膜并分离宫骶韧带Theparametriaandparacolposaredivided.

宫旁与宫颈旁的分离ARTAftercompletelyseparatingtheparametria,ligatingtheuterinevesselsattheiroriginsandcompletingtheureterolysis,ananteriorcolotomyisperformedfacilitatedbyavaginalcylinder.完全分离宫旁,断扎子宫血管及输尿管松解术后,经阴道的结肠前部切开就易于进行ARTAWertheimclampcanbeusedtodeterminethevaginalresectionmargin.Wertheim钳用于确定阴道切开的边缘ARTClampsareplacedattheleveloftheinternalos.

钳子置于宫颈内口Usingaknife,theradicaltrachelectomyiscompletedbyseparatingthefundusfromtheisthmusorupperendocervixatapproximately5

mmbelowtheleveloftheinternalos.在宫颈内口下方5mm处分离并切除宫颈ARTEndometrialandupperendocervicalcurettageaswellasashavemarginontheremainingtissueissentforfrozen-section.内膜和颈管内刮宫及残余部分边缘快速病理Frozensectionisobtainedontheendocervicalmargin.取颈管内边缘部分做冰冻Frozensectionisobtainedcircumferentiallyonthevaginalcuff.阴道周缘部分做冰冻ARTApermanentcerclagewith#0Ethibondisplacedandtheknottiedposteriorly.

0号线环扎后部ARTReconstructionoftheuterinecorpustouppervaginaafterthecerclageisplaced.

环扎后将阴道顶端重建于宫颈ARTTheuterinefundusisreattachedtothevaginalapexwith6to8interrupted#2-0absorbablesutures.子宫体与阴道顶重新间断缝合

ARTThereconstructedfunduswithremainingbloodsupplyfromtheintactutero-ovarianligaments—uterineserosawithoutevidenceoffundalischemia.

在没有基底部局部缺血的证据时，重建宫体和卵巢固有韧带与子宫浆膜的血供RoboticRadicalTrachelectomy(RRT)

机器人根治性子宫颈切除术ChuangLetal,Fertility-sparingRobotic-assistedRadicalTrachelectomyandBilateralPelvicLymphadenectomyinEarly-stageCervicalCancerJournalofMinimallyInvasiveGynecology,Vol15,Issue6,2008,Pages767-770.BurnettA,Roboticradicaltrachelectomyandpelviclymphadenectomyinearlycervicalcancer,Gynecol.Oncol.112(2009),p.S8.SixcasesreportedIntraoperativeMarginAssessment

术中切缘的评估TheperipheralsofttissueincludingtheparametriaisinkedgreenwhiletheLUS/ECmarginsareinkedblue.周边疏松组织及宫旁染成绿色而LUS/EC边缘染成蓝色Insomecases,thetumorwillappearinthefrozensectionat<

5

mmfromthemargin.部分病例中冰冻中肿瘤距切缘<

5

mmInthesecases,theLUSmarginisrevised.在这些病例中，LUS切缘需修正

IsmiilN,etalGynecol

Oncol.2009Apr;113(1):42-6.IntraoperativeMarginAssessment

术中边缘的评估Themarginwasreportedasnegativein123,suspiciousin3andpositivein6cases.据报道123例为阴性，3例可疑阳性，6例阳性Itwasrevisedin16cases(6positive,2suspiciousand8negativebut<

5

mm).16例重新修改边缘（6例阳性，2例可疑阳性，8例阴性FinalmarginassessmentagreedwiththeFSdiagnosisin130(98.5%).FS诊断为最终切缘评估Nofalsenegativeintraoperativeassessmentwasfound.术中评估没有假阴性IsmiilN,etalGynecol

Oncol.2009Apr;113(1):42-6.ParametrialLengths

宫旁长度EinsteinMH,etalGynecol

Oncol.2009Jan;112(1):73-7.PathologicResults病理结果VRT(n

=

28)ART(n

=

15)PvalueMediangrosslength(cm)平均总长度1.45(0.73–1.63)3.97(2.7–5.36)0.01Medianhistologiclength(cm)平均组织学长度1.07(0.89–1.25)1.51(1.36–1.77)≤

0.0001Patientswithparametriallymphnodesdetected患者宫旁淋巴结0(0%)8(57.3%)0.0002RHvsVRT/ART

RH与VRT/ART的对比Nostatisticaldifferencesbetweenthetwogroups两组间无明显差异mediannumberoflymphnodesremoved(26vs28)平均淋巴结清除数量nodepositiverate(15vs8%)淋巴结阳性率The5-yearrecurrencefreesurvivalrate:5年复发及生存率96%(fortheRTgroupcomparedto86%fortheRHgroupP

=

NSDiazJPetalGynecol

Oncol.2008Nov;111(2):255-60.ARTMediantimeintheoperatingroomwas298

min(range,180–425).平均手术时间298分钟Medianestimatedbloodlosswas250

ml(range,50–700).平均出血量估计250mlMedianhospitalstaywas4

days(range,3–6).平均住院日4天（3-6天）Norecurrence.无复发Abu-RustumNR,etalGynecol

Oncol.2008Nov;111(2):261-4.CytologicFindingsafterRT

RT后细胞学检查结果Anendometrialcomponentwasidentifiedin131ofthecases(59%).131例鉴定出有内膜成分(59%)Twenty-eightcaseswerediagnosedasabnormal.28例诊断异常Thebiopsiesconfirmedthepresenceofalesioninonly4of25biopsies25例活检中4例证实目前有病变3low-gradesquamousintraepitheliallesions3例低度鳞状上皮内瘤变1adenosquamouscarcinoma1例腺鳞癌Allcasesdiagnosedasatypicalglandularcellsrepresentedtubal

metaplasia,loweruterinesegmentglandularcells,orendometrialstromalcells.所有病理诊断的非典型腺细胞代表输卵管组织化生,子宫下段腺细胞或子宫内膜基质细胞FeratovicR,etalCancer.2008Feb25;114(1):1-6.CytologicFindingsafterRT

RT后细胞学检查结果Loweruterinesegmentglandularcells.子宫下段腺细胞Endometrialstromalcells.子宫内膜基质细胞Tubal

metaplasia.输卵管化生FeratovicR,etalCancer.2008Feb25;114(1):1-6.FertilityPreservingSurgery

保留生育功能手术Over900caseshavebeenperformed.实施了900多例手术Mosthavebeencarriedoutvaginally(radicalvaginaltrachelectomyandlaparoscopicpelvicnodedissection).大部分经阴道手术(根治性阴道宫颈切除术及腹腔镜盆腔淋巴结切除)Asmallernumberhavebeenperformedabdominally.与开腹手术数量相仿

Over300pregnanciesreportedwith196livebirths.据报道超过300例怀孕,196例活产10%significantprematurityratewithbirthpriorto32weeks.32周前的早产率10%31recurrences(4%),and16deaths(2%).31例复发,16例死亡MillikenDA,ShepherdJH.Curr

Opin

Oncol.2008Sep;20(5):575-80.PhaseIItrialofneoadjuvant

paclitaxelandcisplatininuterinecervicalcancer

宫颈癌中辅助顺铂与紫杉醇的II期试验StageIB2toIIB分期IB2到IIBPaclitaxel60mg/m2followedbycisplatin60mg/m2every10daysandforthreecourses.紫杉醇60mg/m2

随后顺铂60mg/m2

每10天一疗程,共3疗程43patientswereenrolledinthisstudyandallofthemweregivenanoperation.43例患者接受试验并接受手术Hematologictoxicitywasseenin17patients.Butmostofthemwereanemiaandtherewasnograde3or4.17例患者出现血液毒性.但大部分是贫血Grade1neurotoxicitiesdevelopedin29patientsandallofthemwereperipheralneurotoxicity.29例出现神经毒性,全部为外周神经毒性ParkDC,etalGyn

Oncol92(1):59-63,2004PhaseIItrialofneoadjuvant

paclitaxelandcisplatininuterinecervicalcancer

宫颈癌中辅助顺铂与紫杉醇的II期试验

ParkDC,etalGyn

Oncol92(1):59-63,2004ARTinFirst10Patients

前10个采用ART的患者Tenpatientsunderwentradicalabdominaltrachelectomy.10例患者采用根治性宫颈切除术Twopatientsachievedpregnancy:2人怀孕1twindelivery1例双胞胎1patienthad2pregnancies.1例怀孕两次Twopatientsexperiencedcervicalstenosiswithregularmensesandthesame2patientspassedtheirabdominal