第一临床医学院知识库

目的：探讨新辅助化疗对于局部晚期宫颈癌患者的临床疗效以指导本地区患者的治疗。
方法:本文回顾性分析了兰州大学第一医院妇产科自2013年01月至2017年12月病理诊断为宫颈癌，妇科检查及影像学检查支持临床分期为IB2、IIA2期患者240例，按是否行新辅助化疗分为观察组和对照组，观察组为新辅助化疗+手术治疗，给予2周期静脉化疗（紫杉醇/多西他赛+顺铂），化疗结束后评估疗效，行开腹/腹腔镜广泛性子宫切除术，对照组直接行开腹/腹腔镜广泛性子宫切除术，比较观察组与对照组同种术式不同影响因素及相同影响因素不同术式下术中出血、淋巴结切除个数、尿管拔除时间、肛门排气时间差异，及两组淋巴脉管侵犯、淋巴结阳性、宫旁浸润及肿瘤标记物等指标，同时对研究对象进行电话随访，分析复发病例特征。
结果：在总共纳入研究的240例患者临床资料中，年龄范围为24-75岁，平均年龄是：47.83±9.34岁，40-50岁者最多，占总病例数的47.9%。其中，高学历者（中专及以上）仅有35例（14.58%）；BMI在18.5-27.9者居多（87.90%），临床分期IB2期157例（65.40%），IIA2期83例（35.60%）；病理类型中，鳞癌共228例(95%)，非鳞癌12例(5%)；分化程度中，中分化197例（82.10%），高分化及低分化共43例（17.90%）；分组比较中，观察组中分化者97例（78.20%），鳞癌118例（95%），IB2期80例（64.50%）；行新辅助化疗后比较组内不同观察指标的阳性率，分化程度及临床分期对化疗有效率无显著差异（P＞0.05）；而病理类型比较中，鳞癌的化疗有效率显著高于非鳞癌组（P＜0.05）；两组CA125及SCC-Ag阳性率比较中，观察组在治疗后显著低于治疗前，差异有统计学意义（P＜0.05）；在观察组内对肿瘤治疗有效性的病例进行分析，完全缓解2例（1.60%），部分缓解85例(68.60%)，有效率为70.20%；分别行开腹/腹腔镜广泛子宫切除术，相同术式下术中出血、术后住院天数、淋巴结检出个数、通气时间均无明显差异（P＞0.05），但腹腔镜组新辅助化疗后患者尿管拔除时间较直接手术组明显缩短（P＜0.05）；相同影响因素不同术式下，除外术后并发症，其他各观察指标比较中，腹腔镜组明显优于开腹组（P＜0.05），其中腹腔镜组有4例术中行保留自主神经的子宫广泛切除术，2例术前行双J管植入；两组中术后并发症发生率相近（P＞0.05），无统计学意义，但腹腔镜组9例并发症中，发热6例，膀胱漏2例，而开腹组11例中，刀口愈合不良6例，发热4例；对比术后病理检查：观察组在宫旁侵犯、脉管转移、淋巴结阳性及肌层浸润深度中较对照组阳性率低（P＜0.05），差异有统计学意义。在5年电话随访中，共随访到233人，平均随访时间观察组22.64±14.08月，对照组24.66±13.53月，两组中平均复发时间分别为14.00±2.45月、10. 50±2.80月，复发率分别为10.20%、19.10%，无瘤生存期观察组较对照组时间长（P＜0.05），差异有统计学意义。两组中，均有2例患者死亡，5年内生存率无明显差异（P＞0.05）。
结论：新辅助化疗能明显缩小肿瘤体积，有效降低SCC-Ag、CA125、淋巴结阳性、脉管转移、宫旁浸润率的阳性率，并显著延长无瘤生存期，但对远期生存率无显著影响。

Objective: To investigate the clinical efficacy of neoadjuvant chemotherapy in patients with locally advanced cervical cancer to guide the treatment of patients in this region.        
Methods: This article retrospectively analyzed the results of the pathological diagnosis of cervical cancer in the Department of Obstetrics and Gynecology of the First Hospital of Lanzhou University from January 2013 to December 2017. Gynecologic examination and imaging studies supported 240 patients with stage IB2 and IIA2 clinical stages. Neoadjuvant chemotherapy was divided into observation group and control group. The observation group was neoadjuvant chemotherapy+surgical treatment. Two cycles of intravenous chemotherapy (paclitaxel/docetaxel and cisplatin) were given. After the end of chemotherapy, the efficacy was evaluated and laparotomy was performed. Extensive hysterectomy, the control group performed open laparoscopic/abdominal laparoscopic hysterectomy, and compared the same influencing factors and the same influencing factors between the observation group and the control group. , Urinary catheter removal time, anal exhaust time difference, and two groups of lymphatic vessel invasion, lymph node positive, parametrial infiltration and tumor markers and other indicators, at the same time the subjects were followed up by telephone to analyze the characteristics of recurrent cases.       
 Results: Among the 240 patients included in the study, the age range was 24-75 years and the average age was 47.83±9.34. The 40-50-year-old had the most, accounting for 47.9% of the total number of cases. Among them, highly educated ,there were only 35 (14.58%) of them (Secondary school and above), the majority (87.90%) of BMI were 18.5-27.9, 157 (65.40%) of clinical stage IB2, and 83 (35.60%) of stage IIA2. There were 228 (95%) squamous cell carcinomas, 12 (5%) non-squamous cell carcinomas, 197 (82.10%) moderately differentiated, and 43 (17.90%) well differentiated and poorly differentiated. Among the observational group, 97 (78.20%) were differentiated, 118 (95%) were squamous cell carcinomas, and 80 (64.50%) were IB2 stage patients. After neoadjuvant chemotherapy, the positive rate of different observations in the group, differentiation and clinical There was no significant difference in staging efficiency of chemotherapy (P>0.05), but in the comparison of pathological types, the chemotherapy efficiency of squamous cell carcinoma was significantly higher than that of non-squamous cell carcinoma group (P<0.05). The positive rates of CA125 and SCC-Ag in the two groups were compared.  After treatment, the observational group was significantly lower than before treatment (P<0.05). In the observation group, the efficacy of tumor treatment was analyzed. Two cases (1.60%) were completely relieved and 85 cases were partially relieved. (68.60%), the effective rate is 70.20%. There were no significant differences in endoscopic hemorrhage, intraoperative blood loss, postoperative hospital stay, number of lymph nodes detected, and ventilation time (P>0.05), but catheter removal was performed after neoadjuvant chemotherapy in the laparoscopic group. The time was significantly shorter than that of the direct surgery group (P<0.05). The same influencing factors were different under the different surgical methods, except for postoperative complications. Compared with other observational indexes, the laparoscopic group was significantly superior to  the open group (P<0.05). Laparoscopic groupThere were 4 cases of extensive uterectomy with autonomic nerves reserved and 2 cases of double J tube implantation before surgery. The incidence of postoperative complications was similar between the two groups (P>0.05). There was no statistical significance, but laparoscopic group In 9 cases of complications, fever was found in 6 cases and bladder leakage in 2 cases. In the open group, 11 cases had poor knife healing and 4 fever. Compared with postoperative pathological examination, the positive rate of the observational group in the parametrial invasion, vasculature metastasis, lymph node positive and muscle infiltration depth was lower than the control group (P<0.05), the difference was statistically significant. During the 5-year telephone follow-up, a total of 233 people were followed up. The average follow-up time was 22.64±14.08 months in the observational group and 24.66±13.53 months in the control group. The average recurrence time in the two groups was 14.00±2.45 months and 10.50±2.80 months, respectively. The recurrence rates were 10.20% and 19.10%, respectively, and the observation period in the tumor-free survival group was longer than that in the control group (P<0.05). The difference was statistically significant. In both groups, there were 2 patients died and there was no significant difference in survival rate within 5 years (P>0.05).
Conclusions: Neoadjuvant chemotherapy can significantly reduce tumor volume, effectively reduce the positive rate of SCC-Ag, CA125, lymph node positive, vasculature metastasis, parametrial  infiltration rate, and significantly prolong the disease-free urvival period, but no significant  effect on long-term survival  rate influences.