Burghardt E, Haas J, Girardi F
Baillieres Clin Obstet Gynaecol. 1988 Dec;2(4):879-88. doi: 10.1016/s0950-3552(98)80015-1.
The first sharp improvement in the operative treatment of cervical cancer was the shifting of the plane of resection away from the tumour into the parametria. This permitted resection of the primary cancer with a margin of healthy tissue. Systematic studies of excised parametrial tissue, carried out around the turn of the century, showed four types of parametrial involvement: continuous, discontinuous, carcinomatosis of the parametrial lymphatics, and parametrial lymph node involvement. It is well known that histologically demonstrated parametrial involvement often contradicts the clinical stage. So-called staging laparotomies are meant to address this problem but they, too, are inadequate since most parametrial cancer deposits are microscopic and cannot be palpated. In our own studies of totally extirpated parametria, contiguous cancer spread into the parametria never exceeded 10 mm, not even in the largest still-operable tumours. Thus the theory of contiguous, direct cancer spread to the pelvic wall is wrong. Parametrial involvement usually occurred as cancer deposits in the rarely mentioned parametrial lymph nodes. Parametrial involvement correlates better with the size of the primary tumour, expressed as the tumour-cervix quotient, than with the clinical stage. The smallest tumours, without showing continuous parametrial involvement, had a 3.4% incidence of positive nodes. Thirty-five per cent of the patients with the largest tumours had positive parametrial nodes. Parametrial lymph nodes were found in 280 (78%) of 359 surgical specimens processed as giant sections. Sixty-three patients (22.5%) had positive parametrial nodes. The nodes at the pelvic wall were involved in 80% of the patients with positive parametrial nodes. The five-year survival rate was 84% if the parametria were free of disease, but it dropped to 53% with any type of parametrial involvement. Survival rates did not differ much if only the parametrial nodes or only the pelvic nodes were positive (56% and 66%, respectively). However, if both groups were positive survival dropped to 43.1%. Positive parametrial nodes can be located anywhere in the parametrium; therefore, surgery must remove the entire structure. It remains to be seen whether an exception can be made for small Stage Ib tumours, or if lymphadenectomy can be omitted in these patients. If so, radical vaginal surgery may be the treatment of choice.
宫颈癌手术治疗的首个显著进展是将切除平面从肿瘤处转移至宫旁组织。这使得能够在切除原发性癌时保留一定边缘的健康组织。在世纪之交开展的对切除的宫旁组织的系统研究显示，宫旁受累有四种类型：连续型、间断型、宫旁淋巴管癌病以及宫旁淋巴结受累。众所周知，组织学证实的宫旁受累情况常常与临床分期不符。所谓的分期剖腹术旨在解决这一问题，但同样也并不充分，因为大多数宫旁癌灶是微小的，无法触及。在我们自己对完全切除的宫旁组织的研究中，即使是在最大的仍可手术切除的肿瘤中，癌灶向宫旁组织的连续扩散也从未超过10毫米。因此，癌灶连续、直接扩散至盆腔壁的理论是错误的。宫旁受累通常表现为在很少被提及的宫旁淋巴结中的癌灶。宫旁受累与以肿瘤-宫颈比值表示的原发性肿瘤大小的相关性，要比与临床分期的相关性更好。最小的肿瘤，即使未显示宫旁连续受累，其淋巴结阳性发生率为3.4%。最大肿瘤的患者中有35%宫旁淋巴结阳性。在作为大体切片处理的359个手术标本中，发现了280个（78%）宫旁淋巴结。63名患者（22.5%）宫旁淋巴结阳性。宫旁淋巴结阳性的患者中，80%盆腔壁淋巴结受累。如果宫旁组织没有病变，五年生存率为84%，但如果存在任何类型的宫旁受累，五年生存率则降至53%。如果仅宫旁淋巴结阳性或仅盆腔淋巴结阳性，生存率差异不大（分别为56%和66%）。然而，如果两组淋巴结均阳性，生存率则降至43.1%。阳性宫旁淋巴结可位于宫旁组织的任何部位；因此，手术必须切除整个宫旁组织。对于小的Ib期肿瘤是否可以例外，或者这些患者是否可以省略淋巴结切除术，仍有待观察。如果可以，根治性阴道手术可能是首选治疗方法。
