子宫内膜癌手术治疗相关问题

Important perspectives on the surgical treatment of endometrial cancer

关键词:  子宫内膜癌  手术分期  淋巴结清扫

Key words:  endometrial cancer  surgical staging  lymphadenectomy

摘要:

子宫内膜癌初诊时70%为临床早期，治疗首选手术，手术原则为全子宫、双附件切除及手术分期。淋巴结切除范围和年轻患者保留卵巢的安全性问题一直是关注焦点，目前推荐根据术前评估和术中所见决定手术分期的程度。研究显示诊断时认为病变局限于子宫的患者中约10%伴有淋巴结转移，而化疗可使Ⅲ期病人获益，因此通过有经验的妇科肿瘤医生术前和术中评估识别高危因素，决定是否行淋巴结切除以及何种程度的淋巴结切除，可避免不必要的系统性淋巴结切除。盆腔淋巴结切除是手术分期的重要组成部分，但低危型病例可省略系统性淋巴结切除，而高危型子宫内膜癌的分期应包括肠系膜下动脉和肾血管水平的腹主动脉旁淋巴结的评估。对于局限于子宫的病变也可以前哨淋巴结界定淋巴结切除的范围，对于年轻的低危型子宫内膜癌患者保留卵巢是可行的。

Abstract:

As Endometrial Cancers (EMC) are mostly detected in the early stage (in about 70% of the EMC patients), surgery is generally the optimal treatment. The operation usually involves total hysterectomy, bilateral salpingo-oophorectomy and surgical staging. In this field, many studies have focused on two essential aspects: thoroughness of lymph node desection and safety of ovary preservation among young patients. It is now recommended that staging of patients should be determined from preoperative evaluation and surgical findings. Studies indicate that among patients with the tumor strictly confined to the uterus-FIGO stage I, 10% of them are found to be lymph nodes positive-actually FIGO stage III. And these patients could benefit from the post-operative chemotherapy. Thus, an experienced gynecological oncologist would identify the risk factors before and within the operation, make the decision if the patient should receive lymphadenectomy or to which extent that the lymphadenectomy should be performed. Consequently, some systemic lymph node desection could be avoided. Pelvic lymphadenectomy is an important part of surgical staging. For low-risk patients, systemic lymphadenectomy is not required. For high-risk patients, however, extended lymphadenectomy should be performed, including para-aortic lymph nodes at the level of inferior mesenteric artery and renal vessels. For patients with their lesion confined to the uterus, the thoroughness of lymphadenectomy could be based on sentinel lymph node mapping. Besides, ovary conservation is an optional choice for young patients with little risk factors.