专家共识:子宫颈癌年轻患者保留生育功能如何抉择?

2021-08-23 Sunny MedSci原创

为推进和规范早期子宫颈癌的 FSS,专家讨论制订本了共识。

 1987 年 Dargent 创立广泛子宫颈切除术(RT) 以来,早期子宫颈癌年轻患者的保留生育功 能手术 ( FSS) 快速发展,已经形成以 Dargent 术式——腹腔镜辅助经阴道广泛子宫颈切除 术( LAVRT/VRT) 为经典,开腹广泛子宫颈切除术( ART) 、腹腔镜广泛子宫颈切除术 ( LRT) 、机器人辅助腹腔镜广泛子宫颈切除术( RRT) 等多种手术路径的RT并存,以子宫颈锥切术和单纯子宫颈切除术( ST) 等非根治性 FSS为补充的新格局,使早期子宫颈癌年轻患者在治愈肿瘤的基础上达成生育目的。

为推进和规范早期子宫颈癌的 FSS,专家讨论制订本了共识,旨在指导临床实践,以期在不影响肿瘤学结局的前提下,降低 FSS 手术失败率,改善术后妊娠率,提高活产率。现为您整理要点如下:

FSS的手术适应证

由于子宫颈上段浸润者FSS失败率和不良产科结局均明显升高,肿瘤直径>2cm并且对NACT 反应差是术后复发的高危因素,胃型腺癌和恶性腺瘤等非人乳头瘤病毒 ( HPV) 相关性宫颈恶性肿瘤本身预后极差,为保证FSS的安全性和改善术后产科结局,本共识推荐FSS 适应证标准如下。

患者方面:①具有强烈的保留生育器官和功能的愿望; ②生育期年龄段,卵巢功能评估具备生育潜力; ③不能承受FSS和术后妊娠过程,或患有不宜妊娠的疾病,以及围产期母体并发症高风险者,均不适合FSS; ④对选择 FSS 的理由、手术方式和途径、可能的并发症、术后肿瘤结局、术后妊娠期并发症及其监测和妊娠结局等相关问题充分知情同意。

肿瘤方面: ①肿瘤局限于子宫颈,最大直径≤2 cm,宫颈间质浸润深度<1/2,肿瘤距宫颈内口≥1.5cm; ②肿瘤直径 2- 4 cm者可考虑 ART,或进行 1-3 疗程NACT,评估肿瘤缩小至≤2 cm 后实施FSS; ③神经内分泌小细胞癌、胃型腺癌和恶性腺瘤不适合FSS; ④盆腔淋巴结无转移。

医生方面:具备FSS精细化管理与质量控制能力和方案、手术技能以及平台条件。(证据等级: ⅡA 级)

FSS术前评估

本共识推荐,PET / ceMRI是早期宫颈癌年轻患者FSS术前肿瘤影像学评估的最佳选择。鉴于国内此设备较少,临床应用数据有限,首选推荐MRI增强扫描 +PET /CT方案,MRI增强扫描作为最低标准方案。(证据等级: ⅡA 级)

FSS术式的选择

FSS 术式选择首要取决于肿瘤分期,当肿瘤学结局相同时,则应关注生育结局的优劣。不同期别宫颈癌,FSS 时宫颈肿瘤切除和淋巴结转移评估方法选择如下: ( 证据等级: ⅡA 级)

FSS 宫颈肿瘤切除有经阴道和经腹两种途径,ⅠA期首选经阴道途径( 宫颈锥切术、ST或VRT) ,术后肿瘤学和妊娠结局俱佳; ⅠB1期肿瘤首选与 B型广泛子宫切除术范围相当的VRT,术后妊娠结局较ART更佳,低危病例选择ST和宫颈锥切术者早产率显著降低; 与 C 型广泛子宫切除术范围相当的ART、LRT或RRT更适合ⅠB2期直接手术者。PLND途径取决于宫颈肿瘤切除途径,选择经阴道途径切除宫颈肿瘤者,腹腔镜PLND更微创,盆腹腔脏器干扰少,对术后妊娠率的影响更小。

NACT预处理

ⅠB2期宫颈癌经过 1-3疗程NACT后,多数肿瘤能够缩小至<2 cm甚至完全缓解(CR) ,为实施FSS创造了条件。NACT方案选择以顺铂为基础的联合化疗,如紫杉醇联合顺铂(TP) 、5-FU 联合顺铂( FP) 、博来霉素联合长春新碱和顺铂( BVP) 等。肿瘤直径2-6cm 的早期宫颈癌NACT后肿瘤缩小至<2 cm时,LRT、ART或VRT均安全可行,其中VRT术后妊娠结局更佳,NACT反应差、腺癌和( 或) LVSI阳性是术后复发的高危因素。肿瘤达到或接近CR者也可选择ST或扩大宫颈锥切术,但应慎重。肿瘤直径<2 cm的ⅠB1期宫颈癌患者 NACT后行VRT+ 宫颈环扎术,肿瘤学和妊娠结局尤佳。

ⅠB1期宫颈癌通常直接行 FSS,无需NACT; 拟选择宫颈锥切术或ST等非根治性FSS者,推荐 1-3疗程NACT后肿瘤达到或接近CR后手术。ⅠB2期可直接行C型ART,拟选择其他途径RT者需先行NACT,待肿瘤缩小至<2 cm 或CR后实施 FSS;2-3疗程NACT后肿瘤稳定/进展或肿瘤直径仍>2 cm者,建议放弃FSS。实施NACT前,应完成妇科检查和肿瘤影像学评估,符合适应证标准者推荐先行PLND,排除淋巴结转移后再行NACT。(证据等级: ⅡB)

盆腔淋巴结病理学评估

本共识建议适于VRT、ST或宫颈锥切术等经阴道途径切除宫颈肿瘤者,系统性PLND后等待石蜡病理结果;也可选择SLN示踪活检术,完整切除SLN冰冻病理检查。(证据等级: ⅡB)

推荐病理学超分期作为SLN常规病理检查。(证据等级: ⅡB)

本共识推荐,当SLN示踪活检术双侧显影SLN冰冻病理检查淋巴结转移阴性时,推荐采用 SLN病理学超分期联合细胞角蛋白免疫组化或OSNA检测等新技术进一步评估; 单侧或双侧 SLN未显影者,推荐系统性PLND送石蜡病理检查评估。(证据等级: ⅡB)

宫颈环扎术时机的选择

FSS患者是否行宫颈环扎术,取决于残留宫颈长度和宫颈机能状态。肿瘤学和妊娠结局良好,宫颈环扎术并非必要。而VRT、ART或LRT,宫颈和宫旁组织切除范围广,残留宫颈上段或部分子宫峡部组织难以维持宫颈机能,推荐RT术中常规行宫颈环扎术,可有效预防足月前胎膜早破(pPROM) 所致晚期流产和早产。RT术中经阴道宫颈环扎术困难者可选择经腹或腹腔镜途径; 残留宫颈长度≥1.5cm 者宫颈机能不全几率较低,无需宫颈环扎术; RT术中未能行宫颈环扎术者,推荐于自然受孕或辅助生殖技术助孕前和孕早期评估宫颈长度和机能状况,孕期仍需继续监测; 宫颈机能不全者,非孕期或孕早期经腹或腹腔镜宫颈环扎术也有良好的预防效果; 已发生 pPROM者,紧急经腹宫颈环扎术后严密管控宫缩和预防感染也有较好疗效,但难免流产率较高。宫颈环扎术应在宫颈内口水平环扎,并将环扎带 /线置于腹膜外,以 6.0-6.5号扩宫棒顺利通过宫颈管为宜。(证据等级: ⅡB)

子宫动脉保留

本共识推荐,FSS 术中尽可能保留子宫动脉。(证据等级: ⅡA)

术中附加性疾病及处理

FSS术中应一并处理可能影响术后妊娠的疾病,恢复正常解剖,预防术后盆腹腔粘连形成等。子宫内膜异位症、较大( ≥5 cm) 或影响宫腔形态的子宫肌瘤、子宫内膜息肉、宫腔粘连、子宫中隔、卵巢良性肿瘤、卵巢冠囊肿、输卵管粘连积水和梗阻、盆腔炎性疾病等均可能影响FSS的妊娠和生育结局,可于PLND时予以附加性处理; 多囊卵巢综合征者不推荐卵巢楔形切除或打孔术,防止卵巢不可逆损伤或功能衰退; 术中意外发现的卵巢和(或) 输卵管、子宫内膜以及盆腹腔其他脏器恶性或低度恶性肿瘤,推荐按相应肿瘤的诊治指南规范处理,对于此类多原发肿瘤建议终止 FSS。(证据等级: ⅡB)

围手术期并发症预防和处理

宫颈管狭窄是 RT 术后常见并发症,主要表现为术后闭经和宫腔经血潴留,可继发宫腔和输卵管积血或积脓、盆腔感染和不孕等。FSS 后宫颈管狭窄者,辅助生殖技术助孕比例明显增加; 经阴道宫颈扩张术后宫颈管狭窄可得以改善。(证据等级: ⅡB)

FSS后妊娠相关问题

存在不孕因素者,推荐术后3个月启动辅助生殖技术助孕。无不孕因素者,推荐给予至少 6 个月自然受孕机会,其间可监测排卵、指导同房; 6 个月后仍未受孕或出现新的不孕因素者,

应积极纠正不孕因素或采用辅助生殖技术助孕,包括宫内人工授精( IUI) 和体外受精胚胎移植( IVF-ET)等。(证据等级: Ⅲ)

孕期早产监测及处理

FSS 术后成功妊娠者,随着妊娠的进展,残留宫颈可能逐渐扩张缩短,孕期需适时监测残留宫颈长度和宫颈内口扩张度,监测宫颈黏液胎儿纤连蛋白水平变化。未行宫颈环扎者,必要时行预防性或紧急经腹宫颈环扎术; 术后严密监控感染及子宫收缩,包括阴道局部和全身感染监测、阴道局部清洁消毒、全身抗生素治疗、抑制宫缩,以及胎儿纤连蛋白联合经阴道超声行早产监测等。其他孕期监测同正常孕妇。(证据等级: ⅡB)

终止妊娠的选择

FSS 术后宫颈瘢痕坚韧或已行宫颈环扎术者宫颈扩张困难,预计新生儿不能存活者应酌情切除宫颈瘢痕或取出环扎线 /带,避免剖宫取胎术; 未行宫颈环扎术且无宫颈瘢痕坚韧者可能因宫颈扩张过快或急产发生软产道裂伤和大出血,严重者可致子宫破裂和阔韧带血肿,部分患者可能发生失血性休克。发生急产时,新生儿严重产伤或感染时有发生,需高度警惕和预防,必要时需预防性注射破伤风抗毒素。FSS 术后预期新生儿能够存活者,无论是否宫颈环扎和宫颈瘢痕坚韧,推荐剖宫产终止妊娠。(证据等级: Ⅲ)

参考资料:

熊光武,张师前,郭红燕,李蓉,刘开江,刘青,马晓欣,王刚,王颖梅,向阳.早期子宫颈癌保留生育功能手术的中国专家共识[J].中国微创外科杂志,2021,21(08):673-679.

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  3. [GetPortalCommentsPageByObjectIdResponse(id=1845868, encodeId=c7a9184586818, content=<a href='/topic/show?id=5d2f206482e' target=_blank style='color:#2F92EE;'>#专家共识#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=44, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=20648, encryptionId=5d2f206482e, topicName=专家共识)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=568152, createdName=snowpeakxu, createdTime=Sun Feb 20 20:26:49 CST 2022, time=2022-02-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2006702, encodeId=25442006e025b, content=<a href='/topic/show?id=199d452095f' target=_blank style='color:#2F92EE;'>#子宫颈#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=39, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=45209, encryptionId=199d452095f, topicName=子宫颈)], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTKjqGDO7icVKUiaT7urgwXvnvzWtp0fMFU46Xfib8oavFKygiaWtibXReS6ZUh3PImsNicGAwTO5HXxoicnA/132, createdBy=ee262500130, createdName=ms7474195563676018, createdTime=Mon Jan 17 23:26:49 CST 2022, time=2022-01-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1282867, encodeId=56a6128286ec7, content=<a href='/topic/show?id=53f24521227' target=_blank style='color:#2F92EE;'>#子宫颈癌#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=45212, encryptionId=53f24521227, topicName=子宫颈癌)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=6411176, createdName=mfx799, createdTime=Wed Aug 25 07:26:49 CST 2021, time=2021-08-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1408294, encodeId=7f5914082940c, content=<a href='/topic/show?id=92194628826' target=_blank style='color:#2F92EE;'>#宫颈#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=45, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=46288, encryptionId=92194628826, topicName=宫颈)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=11102737131, createdName=一闲, createdTime=Wed Aug 25 07:26:49 CST 2021, time=2021-08-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1525710, encodeId=edba1525e1074, content=<a href='/topic/show?id=e96e489842a' target=_blank style='color:#2F92EE;'>#年轻患者#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=49, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=48984, encryptionId=e96e489842a, topicName=年轻患者)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=aab511654279, createdName=minzju5056, createdTime=Wed Aug 25 07:26:49 CST 2021, time=2021-08-25, status=1, ipAttribution=)]
  4. [GetPortalCommentsPageByObjectIdResponse(id=1845868, encodeId=c7a9184586818, content=<a href='/topic/show?id=5d2f206482e' target=_blank style='color:#2F92EE;'>#专家共识#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=44, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=20648, encryptionId=5d2f206482e, topicName=专家共识)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=568152, createdName=snowpeakxu, createdTime=Sun Feb 20 20:26:49 CST 2022, time=2022-02-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2006702, encodeId=25442006e025b, content=<a href='/topic/show?id=199d452095f' target=_blank style='color:#2F92EE;'>#子宫颈#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=39, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=45209, encryptionId=199d452095f, topicName=子宫颈)], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTKjqGDO7icVKUiaT7urgwXvnvzWtp0fMFU46Xfib8oavFKygiaWtibXReS6ZUh3PImsNicGAwTO5HXxoicnA/132, createdBy=ee262500130, createdName=ms7474195563676018, createdTime=Mon Jan 17 23:26:49 CST 2022, time=2022-01-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1282867, encodeId=56a6128286ec7, content=<a href='/topic/show?id=53f24521227' target=_blank style='color:#2F92EE;'>#子宫颈癌#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=45212, encryptionId=53f24521227, topicName=子宫颈癌)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=6411176, createdName=mfx799, createdTime=Wed Aug 25 07:26:49 CST 2021, time=2021-08-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1408294, encodeId=7f5914082940c, content=<a href='/topic/show?id=92194628826' target=_blank style='color:#2F92EE;'>#宫颈#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=45, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=46288, encryptionId=92194628826, topicName=宫颈)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=11102737131, createdName=一闲, createdTime=Wed Aug 25 07:26:49 CST 2021, time=2021-08-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1525710, encodeId=edba1525e1074, content=<a href='/topic/show?id=e96e489842a' target=_blank style='color:#2F92EE;'>#年轻患者#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=49, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=48984, encryptionId=e96e489842a, topicName=年轻患者)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=aab511654279, createdName=minzju5056, createdTime=Wed Aug 25 07:26:49 CST 2021, time=2021-08-25, status=1, ipAttribution=)]
    2021-08-25 一闲
  5. [GetPortalCommentsPageByObjectIdResponse(id=1845868, encodeId=c7a9184586818, content=<a href='/topic/show?id=5d2f206482e' target=_blank style='color:#2F92EE;'>#专家共识#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=44, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=20648, encryptionId=5d2f206482e, topicName=专家共识)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=568152, createdName=snowpeakxu, createdTime=Sun Feb 20 20:26:49 CST 2022, time=2022-02-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2006702, encodeId=25442006e025b, content=<a href='/topic/show?id=199d452095f' target=_blank style='color:#2F92EE;'>#子宫颈#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=39, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=45209, encryptionId=199d452095f, topicName=子宫颈)], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTKjqGDO7icVKUiaT7urgwXvnvzWtp0fMFU46Xfib8oavFKygiaWtibXReS6ZUh3PImsNicGAwTO5HXxoicnA/132, createdBy=ee262500130, createdName=ms7474195563676018, createdTime=Mon Jan 17 23:26:49 CST 2022, time=2022-01-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1282867, encodeId=56a6128286ec7, content=<a href='/topic/show?id=53f24521227' target=_blank style='color:#2F92EE;'>#子宫颈癌#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=45212, encryptionId=53f24521227, topicName=子宫颈癌)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=6411176, createdName=mfx799, createdTime=Wed Aug 25 07:26:49 CST 2021, time=2021-08-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1408294, encodeId=7f5914082940c, content=<a href='/topic/show?id=92194628826' target=_blank style='color:#2F92EE;'>#宫颈#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=45, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=46288, encryptionId=92194628826, topicName=宫颈)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=11102737131, createdName=一闲, createdTime=Wed Aug 25 07:26:49 CST 2021, time=2021-08-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1525710, encodeId=edba1525e1074, content=<a href='/topic/show?id=e96e489842a' target=_blank style='color:#2F92EE;'>#年轻患者#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=49, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=48984, encryptionId=e96e489842a, topicName=年轻患者)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=aab511654279, createdName=minzju5056, createdTime=Wed Aug 25 07:26:49 CST 2021, time=2021-08-25, status=1, ipAttribution=)]