[恶性卵巢肿瘤保留生育功能手术的结果]

Univ.-Frauenklinik Freiburg i. Br., Abt. Frauenheilkunde u. Geburtshilfe I mit Poliklinik.

Zentralbl Gynakol. 1996;118(6):317-21.

Indication for fertility preserving surgery results from the patient's age, the histologic tumor type and the stage of the ovarian malignancy. Approximately 80-85 % of these lesions are ovarian cancers. 10-15 % tumors with low malignant potential (LMP) and approx. 5 % germ cell tumors. Of the ovarian cancers approx. 15 % of LMP tumors 50 %, and of germ cell tumors more than 90 % occur in patients below 40 years of age, in which fertility preserving surgery might be considered. An adequate operative staging permits a conservative procedure for ovarian cancers stage Ia. Due to the good prognosis of LMP-tumors (10 year survival, all stages, approx. 90 %) and the low rate of recurrences after conservative surgery of 6.8 % (10/147), a fertility preserving operation is feasible in select cases also in more advanced stages than Ia. In cases of germ cell tumors, which in the majority of cases are unilateral, even if the tumor extends beyond the ovaries, an adnexectomy will suffice. A successful chemotherapy, e.g. with bleomycin, etoposid, and cisplatin leads to remission rates of > 90 %. The reduced number of patients treated according to the above criteria in 90 % had a normal menstrual cycle after surgery and chemotherapy. Besides numerous case reports on successful pregnancies, there are also reports in literature on results in larger patients groups. Thus it has been reported that of 99 patients with an ovarian cancer stage I. 56 underwent conservative surgery. Child-bearing desire, present in 17 of these women, could be fulfilled in all cases (Colombo et al. 1995). Bianci and coworkers also described successful pregnancies (14/48) after conservative treatment of tumors of LMP. Numerous case reports have been published showing that after fertility preserving surgery of germ cell tumors pregnancies may also be successful. Since especially in ovarian cancers recurrences may occur at a later time, a hysterectomy with removal of the contralateral adnexa is suggested after complete family planning or when the patient enters the menopause. The possibilities offered by in vitro-fertilization have theoretically enlarged the spectrum of fertility preserving surgery. Thus, individual authors propose the conservation of the uterus after bilateral ovarectomy-keeping the option of a pregnancy by oocyte donation open for the patient. As further alternative conservation of a restovary after removal of the uterus and one adnexa is discussed. In these cases the patient's oocytes are preserved for feasible in vitro-fertilization in a "substitute" mother. Results of such fertility preserving procedures have not yet been published.

保留生育功能手术的指征取决于患者年龄、组织学肿瘤类型以及卵巢恶性肿瘤的分期。这些病变中约80 - 85%为卵巢癌，10 - 15%为低恶性潜能（LMP）肿瘤，约5%为生殖细胞肿瘤。在卵巢癌中，约15%的LMP肿瘤、50%的生殖细胞肿瘤发生于40岁以下患者，对于这些患者可考虑保留生育功能手术。充分的手术分期可为Ia期卵巢癌患者施行保守手术。由于LMP肿瘤预后良好（所有分期10年生存率约90%），且保守手术后复发率低（6.8%，10/147），在Ia期以上的某些病例中，保留生育功能手术也是可行的。对于生殖细胞肿瘤，多数情况下为单侧，即使肿瘤超出卵巢范围，附件切除术也足够了。成功的化疗，如使用博来霉素、依托泊苷和顺铂，缓解率>90%。按照上述标准治疗的患者中，90%术后经化疗月经周期正常。除了众多成功妊娠的病例报告外，文献中也有关于较大患者群体结果的报道。据报道，99例I期卵巢癌患者中，56例行保守手术。其中17名有生育意愿的女性，均成功实现生育（科伦坡等人，1995年）。比安奇及其同事也描述了LMP肿瘤保守治疗后成功妊娠的情况（14/48）。大量病例报告表明，生殖细胞肿瘤保留生育功能手术后妊娠也可能成功。由于尤其是卵巢癌可能在后期复发，建议在完成计划生育或患者进入绝经期后行子宫切除术并切除对侧附件。体外受精提供的可能性理论上扩大了保留生育功能手术的范围。因此，个别作者提议在双侧卵巢切除术后保留子宫——为患者保留通过卵母细胞捐赠实现妊娠的选择。作为进一步的替代方案，讨论了子宫和一侧附件切除术后保留残余卵巢的情况。在这些情况下，患者的卵母细胞被保存下来，以便在“替代”母亲体内进行可行的体外受精。此类保留生育功能手术的结果尚未发表。