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子宫颈癌是全球范围内女性第二大恶性肿瘤[1],其严重威胁女性生命健康。目前临床治疗手段主要为手术和放疗。其中腹腔镜手术因其微创、术中出血少、术后恢复快、切口小等优势在妇科肿瘤手术中迅速发展[2]。然而,2018年新英格兰杂志的2篇研究报道称相比腹腔镜及机器人手术,开腹宫颈癌根治术具有更好的肿瘤学结局[3-4],多数学者认为这可能与术中举宫器的使用有关[5]。近年来研究发现,D2-40能特异性识别淋巴管内皮细胞的M2A癌胚膜抗原[6],用于肿瘤组织中淋巴管的计数。CD34是常特异性微血管标记分子。在本研究中,我们通过免疫组织化学染色检测CD34标记MVD、D2-40标记MLVD及脉管癌栓阳性率,探讨腹腔镜宫颈癌根治术中举宫器的应用与脉管癌栓阳性率的相关性。为了得出更准确的结论,我们运用倾向性得分匹配(propensity score matching,PSM)分析,以缩小组间差距。
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依据纳排标准共纳入109例符合标准的早期宫颈癌病人,其中举宫法组73例,免举宫法36例。在未进行PSM前,2组病人在BMI、术前SCC、临床分期方面差异均有统计学意义(P < 0.05)(见表 1)。
分组 n 年龄/岁 BMI/(kg/m2) 手术时间/min 术中失血量/mL CA125/(U/mL) SCC/(ng/mL) HPV16/18感染 临床分期 组织学类型 阴道切除
长度/cmⅠB1 ⅠB2 ⅠB3 ⅡA1 ⅡA2 鳞癌 非鳞癌 举宫法组 73 51.03±7.36 24.61±1.56 239.15±32.34 163.24±28.23 39.55±38.17 5.93±6.81 61 14 45 4 9 1 62 11 2.84±0.45 免举宫法组 36 50.64±7.47 23.78±1.80 243.72±27.90 159.97±20.10 41.22±24.44 3.63±2.70 30 7 13 6 8 2 31 5 2.85±0.37 t — 0.43 2.31 0.77 1.85 0.55 2.04 0.22* 7.41* 0.03* 0.67 P — >0.05 < 0.05 >0.05 >0.05 >0.05 < 0.05 >0.05 < 0.05 >0.05 >0.05 *示χ2值 表 1 2组病人匹配前的临床病理资料基线表
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经过1∶1匹配后,共46例病人匹配成功,举宫法组23例,免举宫法组23例。PSM分析后2组间的10个混杂因素差异均无统计学意义(P>0.05)(见表 2)。
分组 n 年龄/岁 BMI/(kg/m2) 手术时间/min 术中失血量/mL CA125/(U/mL) SCC/(ng/mL) HPV16/18感染 临床分期 组织学类型 阴道切除长度/cm ⅠB1 ⅠB2 ⅠB3 ⅡA1 ⅡA2 鳞癌 非鳞癌 举宫法组 23 49.44±6.15 24.20±1.56 237.22±32.71 154.44±27.05 34.17±15.76 3.76±4.99 20 5 13 2 2 1 26 1 2.84±0.49 免举宫法组 23 50.63±7.42 23.88±1.88 239.63±25.23 155.37±18.50 36.31±16.14 3.74±2.93 21 4 10 3 5 1 27 0 2.86±0.38 t — 0.64 0.67 0.30 0.15 0.49 0.10 1.00* 2.27* 1.02* 0.58 P — >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 *示χ2值 表 2 2组病人匹配后的临床病理资料基线表
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腹腔镜宫颈癌根治术举宫法与免举宫法病人的癌组织和癌旁组织免疫组化结果显示,脉管计数与脉管癌栓阳性率差异均无统计学意义(P>0.05)(见表 3、4)。
分组 n MVD计数/个 MLVD计数/个 癌组织 癌旁组织 癌组织 癌旁组织 举宫法组 23 20.59±4.56 15.44±1.87 4.04±1.22 4.24±1.74 免举宫法组 23 21.22±3.42 15.81±1.73 3.85±0.82 4.19±2.52 t — 0.47 0.76 0.65 1.48 P — >0.05 >0.05 >0.05 >0.05 表 3 2组宫颈癌病人癌组织和癌旁组织脉管计数比较(x±s)
分组 n MVD癌栓阳性率/% MLVD癌栓阳性率/% 癌组织 癌旁组织 癌组织 癌旁组织 举宫法组 23 4.35±1.01 5.62±0.91 4.28±3.60 5.41±2.17 免举宫法组 23 4.00±1.36 5.79±1.07 4.33±2.86 5.37±2.45 t — 1.08 0.65 0.45 0.33 P — >0.05 >0.05 >0.05 >0.05 表 4 2组宫颈癌病人癌组织和癌旁组织脉管癌栓阳性率比较(x±s)
基于倾向性得分匹配分析举宫器在腹腔镜宫颈癌根治术中对脉管癌栓阳性率的影响
Effect of uterine manipulator on the positive rate of vascular tumor thrombus in laparoscopic radical cervical cancer surgery based on propensity score matching
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摘要:
目的探讨腹腔镜宫颈癌根治术中举宫器的应用对脉管癌栓阳性率的影响。 方法纳入2018年11月至2021年3月接受腹腔镜子宫根治性切除术举宫法或免举宫法治疗宫颈癌的病人的临床资料,经过纳排标准筛选后纳入109例有效病人,其中举宫法组73例,免举宫法组36例,利用倾向性得分匹配,按1∶1进行配对后通过平衡病人组间差异。免疫组织化学法检测入组标本中CD34标记微血管密度(microvessel density,MVD)、D2-40标记微淋巴管密度(microlymphatic vessel density,MLVD)及脉管癌栓阳性率,分析2种手术方法对脉管癌栓阳性率的影响。 结果经倾向性得分匹配后,2组各纳入23例病人,2组癌组织和癌旁组织脉管计数与脉管癌栓阳性率差异均无统计学意义(P>0.05)。 结论在腹腔镜宫颈癌根治术中,术中有无举宫器的使用对癌和癌旁组织脉管阳性率无影响,使用举宫器安全可行。 Abstract:ObjectiveTo investigate the effect of uterine manipulator on the positive rate of vascular tumor thrombus in laparoscopic radical hysterectomy for cervical cancer. MethodsThe clinical data of patients with cervical cancer who underwent laparoscopic radical hysterectomy in our hospital from November 2018 to March 2021 were included.After the screening by inclusion and exclusion criteria, 109 effective patients were included, including 73 cases in the uterine manipulator group and 36 cases in the non-uterine manipulator group.Using propensity score matching as 1:1, the difference was balanced between patient groups.Immunohistochemical method was used to detect the CD34 labeled microvessel density (MVD), D2-40 labeled microlymphatic vessel density (MLVD) and the positive rate of vascular tumor thrombus.The effects of the two surgical methods on the positive rate of vascular tumor thrombus were analyzed. ResultsAfter propensity score matching, 23 patients were included in each group.There was no significant difference in vessel count and positive rate of vessel tumor thrombus in cancer tissues and adjacent tissues between the two groups (P>0.05). ConclusionsIn laparoscopic radical hysterectomy for cervical cancer, whether or not to use a uterine manipulator during the operation has no effect on the positive rate of vessels in cancer and adjacent tissues, and it is safe and feasible to use a uterine manipulator. -
表 1 2组病人匹配前的临床病理资料基线表
分组 n 年龄/岁 BMI/(kg/m2) 手术时间/min 术中失血量/mL CA125/(U/mL) SCC/(ng/mL) HPV16/18感染 临床分期 组织学类型 阴道切除
长度/cmⅠB1 ⅠB2 ⅠB3 ⅡA1 ⅡA2 鳞癌 非鳞癌 举宫法组 73 51.03±7.36 24.61±1.56 239.15±32.34 163.24±28.23 39.55±38.17 5.93±6.81 61 14 45 4 9 1 62 11 2.84±0.45 免举宫法组 36 50.64±7.47 23.78±1.80 243.72±27.90 159.97±20.10 41.22±24.44 3.63±2.70 30 7 13 6 8 2 31 5 2.85±0.37 t — 0.43 2.31 0.77 1.85 0.55 2.04 0.22* 7.41* 0.03* 0.67 P — >0.05 < 0.05 >0.05 >0.05 >0.05 < 0.05 >0.05 < 0.05 >0.05 >0.05 *示χ2值 表 2 2组病人匹配后的临床病理资料基线表
分组 n 年龄/岁 BMI/(kg/m2) 手术时间/min 术中失血量/mL CA125/(U/mL) SCC/(ng/mL) HPV16/18感染 临床分期 组织学类型 阴道切除长度/cm ⅠB1 ⅠB2 ⅠB3 ⅡA1 ⅡA2 鳞癌 非鳞癌 举宫法组 23 49.44±6.15 24.20±1.56 237.22±32.71 154.44±27.05 34.17±15.76 3.76±4.99 20 5 13 2 2 1 26 1 2.84±0.49 免举宫法组 23 50.63±7.42 23.88±1.88 239.63±25.23 155.37±18.50 36.31±16.14 3.74±2.93 21 4 10 3 5 1 27 0 2.86±0.38 t — 0.64 0.67 0.30 0.15 0.49 0.10 1.00* 2.27* 1.02* 0.58 P — >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 *示χ2值 表 3 2组宫颈癌病人癌组织和癌旁组织脉管计数比较(x±s)
分组 n MVD计数/个 MLVD计数/个 癌组织 癌旁组织 癌组织 癌旁组织 举宫法组 23 20.59±4.56 15.44±1.87 4.04±1.22 4.24±1.74 免举宫法组 23 21.22±3.42 15.81±1.73 3.85±0.82 4.19±2.52 t — 0.47 0.76 0.65 1.48 P — >0.05 >0.05 >0.05 >0.05 表 4 2组宫颈癌病人癌组织和癌旁组织脉管癌栓阳性率比较(x±s)
分组 n MVD癌栓阳性率/% MLVD癌栓阳性率/% 癌组织 癌旁组织 癌组织 癌旁组织 举宫法组 23 4.35±1.01 5.62±0.91 4.28±3.60 5.41±2.17 免举宫法组 23 4.00±1.36 5.79±1.07 4.33±2.86 5.37±2.45 t — 1.08 0.65 0.45 0.33 P — >0.05 >0.05 >0.05 >0.05 -
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