307例ⅰb～ⅱa期宮頸鱗癌患者的臨床及預(yù)后分析

1、河北醫(yī)科大學(xué)學(xué)位論文使用授權(quán)及知識(shí)產(chǎn)權(quán)歸屬承諾本學(xué)位論文在導(dǎo)師（或指導(dǎo)小組）的指導(dǎo)下，由本人獨(dú)立完成。本學(xué) 位論文研究所獲得的研究成果，其知識(shí)產(chǎn)權(quán)歸河北醫(yī)科大學(xué)所有。河北醫(yī) 科大學(xué)有權(quán)對(duì)本學(xué)位論文進(jìn)行交流、公開(kāi)和使用。凡發(fā)表與學(xué)位論文主要 內(nèi)容相關(guān)的論文，第一署名單位為河北醫(yī)科大學(xué)，試驗(yàn)材料、原始數(shù)據(jù)、 申報(bào)的專利等知識(shí)產(chǎn)權(quán)均歸河北醫(yī)科大學(xué)所有。否則，承擔(dān)相應(yīng)的法律責(zé)任。研究生簽名：風(fēng)麗駆導(dǎo)師簽章:.河北醫(yī)科大學(xué)研究生學(xué)位論文獨(dú)創(chuàng)性聲明本論文是在導(dǎo)師指導(dǎo)下進(jìn)行的研究工作及取得的研究成果，除了文中 特別加以標(biāo)注等內(nèi)容外，文中不包含其他人已發(fā)表或撰寫(xiě)的研究成果，指 導(dǎo)教師對(duì)此進(jìn)行了審定。本論文由本

2、人獨(dú)立撰寫(xiě)，文責(zé)自負(fù)。研究生簽名：閥內(nèi)筱導(dǎo)師簽章:ws!i中文摘要1英文摘要4英文縮寫(xiě)8研究論文307例i biia期宮頸鱗癌患者的臨床及預(yù)后分析前言9材料與方法9結(jié)果11附圖14附表17討論25結(jié)論29參考文獻(xiàn)30綜述早期宮頸癌預(yù)后相關(guān)影響因素的研究進(jìn)展33致謝 43個(gè)人簡(jiǎn)歷 44307例i bia期宮頸鱗癌患者的臨床及預(yù)后分析摘 要目的：通過(guò)回顧與隨訪307例初治為手術(shù)的i biia期宮頸鱗癌病例, 分析臨床特點(diǎn)、臨床病理因素及治療方式對(duì)預(yù)后的影響，同時(shí)針對(duì)公認(rèn)的 宮頸癌預(yù)后影響因素淋巴結(jié)轉(zhuǎn)移，分析盆腔淋巴結(jié)轉(zhuǎn)移危險(xiǎn)因素，為改 善我院宮頸鱗癌患者預(yù)后提供依據(jù)。方法：對(duì)河北醫(yī)科大學(xué)第四醫(yī)院于

3、2008年7月至2011年12月收治 的初治為我院手術(shù)，并經(jīng)術(shù)后病理證實(shí)的i biia期（按照f(shuō)igo 2009 年分期）宮頸鱗癌439例，查閱病歷并隨訪調(diào)查，選取臨床及隨訪資料完 整的307例入組本研究。307例患者均符合以下納入標(biāo)準(zhǔn)：初治為在我 院行手術(shù)治療；臨床分期為i biia期；術(shù)后病理證實(shí)為宮頸鱗癌; 臨床及隨訪資料完整；不合并有其他惡性腫瘤；死亡患者均是宮頸 癌引起的死亡。分析患者因素（年齡、絕經(jīng)狀態(tài)、分娩次數(shù)），腫瘤的臨 床病理參數(shù)（臨床分期、腫塊直徑、腫瘤形態(tài)、組織分化、肌層浸潤(rùn)深度、 脈管瘤栓、淋巴結(jié)轉(zhuǎn)移、手術(shù)切緣、宮頸內(nèi)口）及治療方式對(duì)預(yù)后的影響， 以及分析盆腔淋巴結(jié)轉(zhuǎn)移

4、危險(xiǎn)因素。釆用單因素及多因素分析的方法研究各因素與i biia期宮頸鱗癌 患者預(yù)后的影響：采用spss 21.0統(tǒng)計(jì)軟件。計(jì)數(shù)資料釆用於檢驗(yàn)，預(yù)后 的單因素分析采用kaplan-meier方法、log-rank對(duì)數(shù)等級(jí)檢驗(yàn)方法，cox 回歸模型進(jìn)行多因素分析，以p<0.05作為差別顯著性判斷標(biāo)準(zhǔn)。結(jié)果：1年齡本組307例患者，發(fā)病年齡25歲71歲，中位年齡48歲，平均年齡 55 歲 o 年齡035 歲患者 26 例（8.5%）, >35 歲 281 例（91.5%）,其中 41-45 歲患者66例x21.5%）, 46-50歲患者（21.2%）。資料顯示41-45歲為發(fā)病 的高峰年

5、齡，其次是46-50歲患者。2絕經(jīng)狀態(tài)與分娩次數(shù)本組資料未絕經(jīng)患者247例（80.5%）,絕經(jīng)60例（19.5%）；分娩次 數(shù)s2次220例，占71.7%,分娩次數(shù)>2次87例，占283%0結(jié)果顯示 宮頸鱗癌在未絕經(jīng)及分娩次數(shù)0次女性中發(fā)病率高。3臨床表現(xiàn)本組307例中，以接觸性陰道出血就診159例，占51.8%,陰道不規(guī) 則出血122例，占39.7%,陰道排液53例，占173%,顯示接觸性陰道 出血為主要癥狀。4 生存率（overall survival, os）全組患者總生存時(shí)間277個(gè)月，中位生存時(shí)間39個(gè)月，死亡25例， 3年總生存率為91.9%, 5年總生存率89.2%o單因素

6、分析各因素對(duì)預(yù)后的影響，結(jié)果顯示：淋巴結(jié)轉(zhuǎn)移、脈管瘤栓 （lvsi）、宮頸內(nèi)口是否受侵是預(yù)后的影響因素（pv0.05）。年齡、絕經(jīng) 狀態(tài)、分娩次數(shù)、臨床分期、腫塊直徑、腫瘤形態(tài)、組織分化、肌層浸潤(rùn) 深度、手術(shù)切緣、治療方式與i biia期宮頸鱗癌預(yù)后無(wú)關(guān)（p>0.05）。多因素分析淋巴結(jié)轉(zhuǎn)移、脈管瘤栓（lvsi）、宮頸內(nèi)口是否受侵對(duì)預(yù) 后的影響，結(jié)果顯示：淋巴結(jié)轉(zhuǎn)移和lvsi是i b-1ia期宮頸鱗癌患者預(yù) 后獨(dú)立影響因素（pv0.05）,宮頸內(nèi)口是否受侵統(tǒng)計(jì)學(xué)無(wú)顯著性差異（p >0.05 ）o5 術(shù)后無(wú)病生存時(shí)間（disease-free survival, dfs）本資料中，復(fù)

7、發(fā)40例，2年總復(fù)發(fā)率9.8%, 3年總復(fù)發(fā)率13.0%, 5 年總復(fù)發(fā)率10.8%o單因素分析顯示：淋巴結(jié)轉(zhuǎn)移、脈管瘤栓（lvsi）、宮頸內(nèi)口是否受 侵是無(wú)進(jìn)展生存時(shí)間的影響因素（pv0.05）。年齡、絕經(jīng)狀態(tài)、分娩次數(shù)、 臨床分期、腫塊直徑、腫瘤形態(tài)、組織分化、肌層浸潤(rùn)深度、手術(shù)切緣、 治療方式與術(shù)后復(fù)發(fā)無(wú)關(guān)（p>0.05）。應(yīng)用cox回歸模型對(duì)淋巴結(jié)轉(zhuǎn)移、lvsi、宮頸內(nèi)口是否受侵對(duì)術(shù)后 dfs的影響進(jìn)行分析，結(jié)果顯示淋巴結(jié)轉(zhuǎn)移、lvsi是影響i biia期宮 頸鱗癌術(shù)后無(wú)病生存的獨(dú)立預(yù)后影響因素（pv0.05）,存在淋巴結(jié)轉(zhuǎn)移及 lvsi的患者術(shù)后復(fù)發(fā)風(fēng)險(xiǎn)高。6淋巴結(jié)轉(zhuǎn)移相關(guān)危險(xiǎn)

8、因素分析lvsi、宮頸內(nèi)口是否受侵、臨床分期差異有顯著性（pv0.05）,而年 齡、絕經(jīng)狀態(tài)、分娩次數(shù)、手術(shù)切緣、組織分化、肌層浸潤(rùn)深度、腫塊直 徑差異無(wú)統(tǒng)計(jì)學(xué)意義（p>0.05）°結(jié)論:1本組病例中41s年齡35歲患者66例占21.5%,提示41、年齡s45 歲患者宮頸鱗癌發(fā)病率較高。2本組病例中，未絕經(jīng)患者占80.5%,分娩次數(shù)s2次患者占7l7%, 顯示i biia期宮頸鱗癌多發(fā)生于未絕經(jīng)女性，分娩次數(shù)02次患者的發(fā) 病率高。3本組資料中，以接觸性陰道岀血就診159例，占51.8%,提示接觸 性陰道出血為主要癥狀。4淋巴結(jié)轉(zhuǎn)移、脈管瘤栓（lvsi）、宮頸內(nèi)口是否受侵是預(yù)后

9、和dfs 的影響因素。多因素分析顯示淋巴結(jié)轉(zhuǎn)移和lvsi是i biia期宮頸鱗癌 患者預(yù)后和dfs的獨(dú)立影響因素，術(shù)后病理有此類危險(xiǎn)因素的患者應(yīng)予 以重視。5 lvsi.宮頸內(nèi)口是否受侵、臨床分期是淋巴結(jié)轉(zhuǎn)移的危險(xiǎn)因素。6 ibiia期無(wú)高危因素并強(qiáng)烈要求保留卵巢功能的年輕患者，可 考慮保留卵巢，但應(yīng)充分告知卵巢轉(zhuǎn)移的風(fēng)險(xiǎn)。7術(shù)后無(wú)治療，單純化療、單純放療、放療+化療對(duì)i biia期宮頸 鱗癌患者預(yù)后無(wú)影響。關(guān)鍵詞：宮頸鱗癌，治療,dfs,預(yù)后，淋巴結(jié)轉(zhuǎn)移clinical and prognostic analysis of 307 cases of cervical squamous cel

10、l carcinomaabstractobjective:307 cases of patients who underwent radical surgery for stage i b- iia cervical squamous cell carcinoma were retrospectively followed and analyzed the clinical features, pathological, treatments, prognosis and relapses- lymph node metastasis is accepted established as th

11、e prognosis factor of cervical squamous cell carcinoma which is also analyzed the relationship with other factors. the aim of this study is to provide basis for improving survival rates and prognostic of cervical carcinoma.methods: a retrospective analysis and a follow-up of 307 patients with figo s

12、tage i b- ii a cervical squamous cell carcinoma diagnosed by surgery at the fourth affiliated hospital of hebei medical university from july 2008 to december 2011 were conducted, selected from 439 cases. they were all in accordance with the following five criteria, first, all patients underwent radi

13、cal operation of cervical carcinoma at the fourth affiliated hospital of hebei medical university; second, figo stage i b- ii a; third, they were all proved by pathology after surgery; fourth, clinical and follow-up data were relatively complete; fifth, they had no other tumors; sixth, all dead pati

14、ents were caused by cervical cancer. patients factors(age, menstruation, reproductive history), clinical data of tumor(figo stage, diameter and shape of tumor, tumor differentiation, depth of tumor invasion, lymph vascular space invasion, lymph node metastasis, operative margin, internal orifice of

15、the uterus) 、treatment and the relationship between lymph node metastasis and other factors were included in this study.spss21.0 was used for statistical analysis. the enumeration data used%2 test, single factor analysis of prognosis used kaplan-meier survival analysis and log rank test. the multiva

16、riate analysis of significant factors use the cox regression model, and the significance judge standard was pv0.05.results:1 ageamong the 307 patients, the current study showed the age was 2571 years old, and the median age was 48 years old, while the average age was 55 years old. the number of pati

17、ents whose age was not large than 35 years old was 26 (8.5%), and large than 35 years old was 281 (91.5%). and the number of patients between 41 and 45 years old was 66 (21.5%), while the number of patients between 46 and 50 years old was 65(21.5%). the data showed that patients between 41 and 45 ye

18、ars old had the largest morbidity and the second was between 46 and 50 years old-2 menopause and reproductive historythe number of non-menopause females was 247 ( 80.5% ) , and menopause was 60 (19.5%) the number of patients who gave birth to no more than 2 times was 220 (71.7%), and more than 2 tim

19、es was 87 (28.3%).this result showed cervical squamous cell carcinoma often occurs to non-menopause females and females reproductive history was no more than 2 times.3 clinical manifestation and signsthe number of patients whose manifestation was contact bleeding was 159(51.78%), abnormal vaginal bl

20、eeding 122 (39.7%), abnormal vaginal discharge 53 (17.3%), and it showed contact bleeding was more-seen symptoms.4 survival ratethe survival time distributed from 2 months to 77 months, and the median time was 39 months. there were 25 patients died 5 years, while the three overall survival rate was

21、91-9% and the five year overall survival rate was 89.2%lymph vascular space invasion(lvsi), lymph node metastasis and internal orifice of the uterus influenced the prognosis of 1 b- ii a cervical squamous cell carcinoma by single factor analysis(p<0>05). age, menopause, reproductive history, f

22、igo stage, diameter and shape of tumor, tumor differentiation, depth of tumor invasion, operative margin and treatment had no influence on the prognosis of 1 b ii a cervical squamous cell carcinoma(p>0.05).use the cox regression model to analyze the effect of lymph vascular space invasion, lymph

23、node metastasis and internal orifice of the uterus to survival, and the result showed lymph vascular space invasion and lymph node metastasis were statistically independent factors (p<0.05).5 disease-free survival ratethere were 40 cases recurrence, the overall 2 year recurrence rate was 9.8%, th

24、e 3 year recurrence rate 13.0% and the 5 year recurrence rate was 10.8%.single analysis: lymph vascular space invasion, lymph node metastasis and internal orifice of the uterus influenced the dfs of i b ii a cervical squamous cell carcinoma (po.05). age, menopause, reproductive history, figo stage,

25、diameter and shape of tumor, tumor differentiation, depth of tumor invasion, operative margin and treatment had no influence on the recurrence of i b iia cervical squamous cell carcinoma(p>005).use the cox regression model to analyze the effect of lymph vascular space invasion, lymph node metasta

26、sis and internal orifice of the uterus to dfs, and the result showed lymph vascular space invasion and lymph node metastasis were statistically independent factors (p<0.05). the relapse risk of patients with lymph vascular space invasion and lymph node metastasis was higher than patients without

27、them.6 risk factor of lymph node metastasislvsi, internal orifice of the uterus, figo stage had statistically difference (p<005), while age, menopause, reproductive history, operative margin, tumor differentiation, depth of tumor invasion, and diameter of tumor had no influence on the lymph node

28、metastasis of i b- iia cervical squamous cell carcinoma(p>0.05).conclusion:1 the number of patients between 41 and 45 years old was 66 (21.5%), which showed that patients between 41 and 45 years old had the largest morbidity.2 the number of non-menopause females was 247 (80.5%), and patients who

29、gave birth to no more than 2 times was 220 (71.7%). this result showed cervical squamous cell carcinoma often occurs to non-menopause females and females reproductive history was no more than 2 times.3 the number of patients whose manifestation was contact bleeding was 159(51.78%), and it showed con

30、tact bleeding was more-seen symptoms.4 lymph vascular space invasion, lymph node metastasis and internal orifice of the uterus influenced the survival and dfs of i b ii a cervical squamous cell carcinoma, but lymph vascular space invasion and lymph node metastasis were statistically independent fact

31、ors. we should pay attention to these patients with such risk factors.5 lvsi, internal orifice of the uterus, figo stage were the risk factors of lymph node metastasis of i b- iia cervical squamous cell carcinoma.6 the early stage( i b ii a) young patients, who had none risk factors,could reserve ov

32、aries.at the same time, they should be informed the risk of the ovary metastasis.7 different ways of treatment of i b- ii a cervical squamous cell carcinoma did not affect the prognosis.key words: cervical squamous cell carcinoma, treatment, dfs, prognosis, lymph node metastasis英文縮寫(xiě)英文縮寫(xiě)英文全稱中文名稱figof

33、ederation intemational of gynecology and obstetrics國(guó)際婦產(chǎn)科聯(lián)盟spssstatistical package forsocial science社會(huì)科學(xué)統(tǒng)計(jì)軟件包dfsdisease-free survival無(wú)病生存率osoverall survival總生存率coxcox regression analysiscox回歸分析lvsilymph vascular space invasion脈管瘤栓307例i biia期宮頸鱗癌患者的臨床及預(yù)后分析前 言宮頸癌是婦科常見(jiàn)惡性腫瘤，在全球女性惡性腫瘤中占第二位，在發(fā) 展中國(guó)家居首位，在女性生

34、殖道惡性腫瘤中占第一位。who報(bào)道，近30 年來(lái)五大洲不論高發(fā)地區(qū)或低發(fā)地區(qū)宮頸癌的發(fā)病率普遍呈下降趨勢(shì)。特 別在發(fā)達(dá)國(guó)家中宮頸癌的發(fā)病率己下降了約30%,但全球每年仍新增宮頸 癌患者40多萬(wàn)，80%在發(fā)展中國(guó)家，而我國(guó)每年新發(fā)病例約占全世界的 1/3o隨著近年來(lái)宮頸癌早期篩查及診療技術(shù)的不斷進(jìn)步，手術(shù)方法的完 善，治療方案的合理化，很多宮頸癌患者在早期能夠得到及時(shí)的診斷并治 療，然而仍有部分患者存在宮頸癌治療后的復(fù)發(fā)和轉(zhuǎn)移，甚至死亡。因此 如何篩選出復(fù)發(fā)轉(zhuǎn)移的危險(xiǎn)因素，并針對(duì)合并該危險(xiǎn)因素的患者制定個(gè)體 化的治療方案，提高生存率，降低復(fù)發(fā)死亡率，是臨床急需解決的問(wèn)題。本研究釆用回顧性分析，通

35、過(guò)分析307例i biia期宮頸鱗癌患者 的臨床資料，結(jié)合隨訪觀察患者生存復(fù)發(fā)情況，旨在找岀影響患者預(yù)后的 影響因素，并分析盆腔淋巴結(jié)轉(zhuǎn)移的危險(xiǎn)因素，提高宮頸癌的診療水平, 改善患者預(yù)后。材料與方法1研究對(duì)象選取2008年7月至2011年12月河北醫(yī)科大學(xué)第四醫(yī)院收治的初治 為我院手術(shù)，并經(jīng)術(shù)后病理證實(shí)的1 biia期宮頸鱗癌患者307例，對(duì)臨床病理資料及隨訪資料進(jìn)行回顧性分析。按照國(guó)際婦產(chǎn)科聯(lián)盟（2009年figo）的臨床分期標(biāo)準(zhǔn)，本組307例分期：i b1期175例，i b2期67 例，iia1期50例,iia2期15例。所有病例嚴(yán)格遵循以下納入標(biāo)準(zhǔn)：初治為在我院行手術(shù)治療；臨床分期為i

36、all a期；術(shù)后病理證實(shí)為宮頸鱗癌；臨床及隨訪資料完整；不合并有其他惡性腫瘤；死亡患者均是宮頸癌引起的死亡。2研究方法2.1臨床資料河北醫(yī)科大學(xué)第四醫(yī)院于2008年7月至2011年12月收治的i bii a期宮頸鱗癌患者307例，初治均為在我院手術(shù)。所有患者均由兩名以上 有經(jīng)驗(yàn)的婦科主任醫(yī)師進(jìn)行婦科檢查，確定臨床分期，術(shù)前檢查血、尿常 規(guī)、肝腎功能、宮頸癌二項(xiàng)、胸片、心電圖、婦科b超，部分患者行全 腹ct檢查。對(duì)可疑膀胱、直腸受侵的患者行膀胱鏡或腸鏡檢查。詳細(xì)記 錄病例資料，包括年齡、病史、婚育史、月經(jīng)史、家族史、臨床表現(xiàn)、輔 助檢查（hpv）、宮頸活檢結(jié)果、治療方法（手術(shù)及術(shù)后治療）、病理

37、結(jié)果、 腫瘤復(fù)發(fā)情況、腫瘤復(fù)發(fā)后治療及生存情況。腫塊直徑及腫瘤形態(tài)根據(jù)婦科檢查結(jié)果、婦科b超及手術(shù)記錄的相 關(guān)描述確定；臨床分期嚴(yán)格按照國(guó)際婦產(chǎn)科聯(lián)盟（2009年figo）的臨床分 期標(biāo)準(zhǔn)；組織分化依據(jù)who組織學(xué)分級(jí)標(biāo)準(zhǔn)劃分，即i級(jí)（髙度分化）, n級(jí)（中度分化）,iii級(jí)（低度分化），本研究將iii級(jí)歸為ii級(jí)，ii-m 級(jí)歸為111級(jí)；腫瘤病理因素（組織分化、淋巴結(jié)轉(zhuǎn)移、lvsi、肌層浸潤(rùn) 深度、手術(shù)切緣、宮頸內(nèi)口）嚴(yán)格依據(jù)術(shù)后病理檢查報(bào)告。307例患者臨 床病例資料見(jiàn)tabled2.2隨訪治療完成后1個(gè)月首次復(fù)查，2年內(nèi)每36個(gè)月復(fù)查1次，第3年每 半年1次，以后每年1次。復(fù)查內(nèi)容包括

38、婦科檢查，宮頸細(xì)胞學(xué)檢查，婦 科b超，宮頸癌二項(xiàng)。所有病例都采用電話隨訪，隨訪時(shí)間以手術(shù)日期 至末次隨訪之日計(jì)算。本組病例隨訪截止日期為2015年1月15日。總生存時(shí)間是指從患者接受手術(shù)當(dāng)日到末次隨訪時(shí)間或研究對(duì)象死 亡的這段時(shí)間。無(wú)病生存時(shí)間是指患者從接受手術(shù)當(dāng)日到治療失敗時(shí)間 （治療失敗可分為：局部、區(qū)域和遠(yuǎn)處）。復(fù)發(fā)的診斷：主要通過(guò)病理診 斷，腫瘤再次岀現(xiàn)部位的活檢及穿刺病理證實(shí)；其次為臨床診斷發(fā)生遠(yuǎn)處 肺、骨轉(zhuǎn)移無(wú)法獲得病理診斷，可依靠癥狀、體征及輔助檢查進(jìn)行診斷。 3分析指標(biāo)回顧性分析患者因素（年齡、絕經(jīng)狀態(tài)、分娩次數(shù)），腫瘤的臨床病 理參數(shù)（臨床分期、腫塊直徑、腫瘤形態(tài)、組織分化、

39、肌層浸潤(rùn)深度、lvsi、 淋巴結(jié)轉(zhuǎn)移、手術(shù)切緣、宮頸內(nèi)口）及治療方式對(duì)預(yù)后的影響，以及各因 素與盆腔淋巴結(jié)轉(zhuǎn)移的關(guān)系，尋找患者預(yù)后及復(fù)發(fā)的危險(xiǎn)因素。4統(tǒng)計(jì)分析本研究釆用spss21.0統(tǒng)計(jì)軟件對(duì)資料進(jìn)行統(tǒng)計(jì)分析。對(duì)于隨訪期間 因其他原因死亡病例，末次隨訪仍存活、未復(fù)發(fā)的病例，統(tǒng)計(jì)學(xué)分析時(shí)按照截尾數(shù)據(jù)處理。計(jì)數(shù)資料釆用%2檢驗(yàn)，預(yù)后的單因素分析釆用kaplan-meier方法、log rank對(duì)數(shù)等級(jí)檢驗(yàn)方法，并繪制生存曲線。單因 素分析對(duì)于生存率及無(wú)病生存率(disease-free survival, dfs)有統(tǒng)計(jì)學(xué)意義的因素，用cox回歸模型進(jìn)行多因素分析，以po.05作為差別顯著性判斷

40、標(biāo)準(zhǔn)。1年齡本組307例患者，發(fā)病年齡25歲71歲，中位年齡48歲，平均年齡 55歲。年齡s5歲患者26例(8.5%), >35歲281例(91.5%),其中41-45 歲患者66例(21.5%), 46-50歲患者(21.2%)。資料顯示41-45歲為發(fā)病 的高峰年齡，其次是4650歲患者。見(jiàn)table!. 2。2絕經(jīng)狀態(tài)與分娩史本組資料未絕經(jīng)患者247例(80.5%),絕經(jīng)60例(19.5%)；分娩次 數(shù)立次220例，占71.7%,分娩次數(shù)>2次87例，占28.3%。結(jié)果顯示宮頸鱗癌在未絕經(jīng)及分娩次數(shù)立次女性中發(fā)病率高。不同年齡段分娩次數(shù)的比較，差異有統(tǒng)計(jì)學(xué)意義。見(jiàn)table!

41、. 3。3臨床表現(xiàn)本組307例中，以接觸性陰道出血就診159例，占51.8%,陰道不規(guī)則出血122例，占39.7%,陰道排液53例，占17.3%,白帶異常17例,無(wú)癥狀14例，腰酸腹墜11例，顯示接觸性陰道出血為主要癥狀。4術(shù)前診斷本組307例患者，293例宮頸活檢確診，6例因活檢提示鱗狀上皮重 度不典型增生累及腺體行宮頸錐切術(shù)確診，5例因液基細(xì)胞學(xué)檢查可見(jiàn)非典型鱗狀細(xì)胞(ascus)行l(wèi)eep術(shù)確診，3例術(shù)前活檢提示透明細(xì)胞癌。查閱到56例患者行人乳頭瘤病毒(humanpapillomavirus, hpv)檢測(cè),hpv陽(yáng)性患者46例，感染率為82.1%。5腫瘤臨床特點(diǎn)5.1本研究中腫塊直徑

42、s4cm者226例(73.6%),腫塊直徑4cm者81例 (26.4%),腫塊直徑w4cm患者所占比例高。見(jiàn)tablet o5.2 臨床分期 i bl 期 175 例(57.0%), ib2 期 67 例(21.8%), iia1 期50 例(163%), iia2 期 15 例。見(jiàn) tablel5.3腫瘤形態(tài):外生型189例(61.6%),其他類型118例(38.4%),結(jié)果顯示，腫瘤形態(tài)以外生型為主。見(jiàn)tabled6腫瘤病理特點(diǎn)本組資料中，高、中分化宮頸鱗癌151例(49.2%),中低分化或低分化156例(50.8%),結(jié)果顯示中低分化或低分化宮頸鱗癌發(fā)病率高；肌層浸潤(rùn)深度3/2患者136

43、例(44.3%),肌層浸潤(rùn)深度1/2患者171例(55.7%),肌層浸潤(rùn)深度1/2宮頸鱗癌發(fā)病率高；手術(shù)切緣陽(yáng)性10例, 手術(shù)切緣陰性297例。有脈管瘤栓49例(16.0%),無(wú)脈管瘤栓258例(84.0%)；無(wú)淋巴結(jié)轉(zhuǎn)移者259例(84.4%), 02個(gè)者28例，2個(gè)者20 例；宮頸內(nèi)口陰性患者194例(63.2%),陽(yáng)性113例(36.8%)。見(jiàn)tablel。 7治療本研究307例i b-iia期宮頸鱗癌均行手術(shù)治療，手術(shù)范圍：a： 廣泛子宮雙附件切除術(shù)+盆腔淋巴結(jié)切除術(shù)167例(53.4%), b：廣泛子 宮單附件切除術(shù)+盆腔淋巴結(jié)切除術(shù)7例，c：廣泛子宮切除術(shù)+盆腔淋巴 結(jié)切除術(shù)127

44、例(41.4%)； d：次廣泛子宮雙附件切除術(shù)+盆腔淋巴結(jié)切 除術(shù)4例，e：次廣泛子宮單附件切除術(shù)+盆腔淋巴結(jié)切除術(shù)1例，f：次 廣泛子宮切除術(shù)+盆腔淋巴結(jié)切除術(shù)1例。其中136例保留卵巢，171例 未保留卵巢，23例行腹主動(dòng)脈旁淋巴結(jié)切除術(shù)，術(shù)后病理均未見(jiàn)陽(yáng)性淋 巴結(jié)。我院對(duì)于合并至少一項(xiàng)高危因素(盆腔淋巴結(jié)轉(zhuǎn)移、宮旁組織浸潤(rùn)、 手術(shù)切緣陽(yáng)性)或兩項(xiàng)中危因素(宮頸深肌浸潤(rùn)、脈管瘤栓、腫瘤直徑較 大)的患者，術(shù)后輔以放化療。本組307例患者中，單純手術(shù)72例(23.5%), 術(shù)后單純放療12例，單純化療107例(34.9%),放化療聯(lián)合治療116例 (37.8%)。放射治療主要包括體外調(diào)強(qiáng)照射

45、、腔內(nèi)后裝照射，化療方案主 要為ip方案(紫杉醇、順鉗)、tc方案(紫杉醇、卡鈕)和pf方案(奧 沙利鉗、替加氟)，根據(jù)患者意愿及治療需要，療程分別為16個(gè)。本資料顯示i biia期宮頸鱗癌患者的治療以手術(shù)+聯(lián)合放化療為主，其次為手術(shù)+單純化療，術(shù)后單純放療者最少。見(jiàn)tablel8總體療效&1術(shù)后生存率患者總生存時(shí)間是指從患者接受手術(shù)當(dāng)日到末次隨訪時(shí)間或該研究 對(duì)象死亡的這段時(shí)間。全組患者總生存時(shí)間2力個(gè)月，中位生存時(shí)間39 個(gè)月，至隨訪截止，共有25例患者死亡，3年總生存率為91.9%, 5年總生存率89.2%o8.2術(shù)后無(wú)病生存時(shí)間無(wú)病生存時(shí)間是指患者從接受手術(shù)當(dāng)日到治療失敗時(shí)間（

46、治療失敗可 分為：局部、區(qū)域和遠(yuǎn)處）。本資料中，復(fù)發(fā)40例，其中局部復(fù)發(fā)（陰道 殘端、陰道）8例，區(qū)域復(fù)發(fā)（盆腔淋巴結(jié)、膀胱、直腸、乙狀結(jié)腸）12 例，遠(yuǎn)處轉(zhuǎn)移（肺、肝、骨、鎖骨上淋巴結(jié)）20例。2年總復(fù)發(fā)率9.8%, 3年總復(fù)發(fā)率13.0%, 5年總復(fù)發(fā)率10.8%o9宮頸鱗癌預(yù)后影響因素分析將可能影響宮頸鱗癌預(yù)后的13項(xiàng)變量用kaplan-meier法進(jìn)行單因素 分析，結(jié)果顯示：淋巴結(jié)轉(zhuǎn)移、脈管瘤栓（lvsi）、宮頸內(nèi)口是否受侵對(duì) os和dfs有顯著影響（pv0.05）。年齡、絕經(jīng)狀態(tài)、分娩次數(shù)、臨床分 期、腫塊直徑、腫瘤形態(tài)、組織分化、肌層浸潤(rùn)深度、手術(shù)切緣、治療方 式與預(yù)后無(wú)關(guān)（p&g

47、t;0.05）o 見(jiàn) figl、fig.2、fig.3、fig.4、fig.5、fig.6, tablel o對(duì)于單因素分析中有統(tǒng)計(jì)學(xué)意義的各因素進(jìn)行cox風(fēng)險(xiǎn)回歸分析， 結(jié)果顯示淋巴結(jié)轉(zhuǎn)移、lvsi是影響術(shù)后os和dfs的獨(dú)立預(yù)后影響因素 （pv0.05）,存在淋巴結(jié)轉(zhuǎn)移及l(fā)vsi的患者術(shù)后復(fù)發(fā)風(fēng)險(xiǎn)高，預(yù)后差。 見(jiàn) table4> 5。10淋巴結(jié)轉(zhuǎn)移相關(guān)危險(xiǎn)因素lvsl宮頸內(nèi)口是否受侵、年齡、臨床分期差異有顯著性（pv0.05）, 而絕經(jīng)狀態(tài)、分娩次數(shù)、手術(shù)切緣、組織分化、肌層浸潤(rùn)深度、腫塊直徑 差異無(wú)統(tǒng)計(jì)學(xué)意義（p>0.05）o結(jié)果顯示evsl宮頸內(nèi)口受侵、臨床分 期高是淋巴結(jié)

48、轉(zhuǎn)移的危險(xiǎn)因素,存在這些淋巴結(jié)轉(zhuǎn)移風(fēng)險(xiǎn)的患者應(yīng)引起重 視。見(jiàn) table6ool tvvi<0x40«090it存時(shí)何oe-生稈函徴l(shuí)vsiswtijw1 prttih 艾 呃koo-v:祝忙/r漁tt生存懇散fig.l survival rate in patients with different status of lvsi淋12結(jié)儀“工刖h個(gè)'葉>,個(gè)餐總枳生存»t(itv>vox40coeofig.2 survival rate in patients with different status of pelviclymphnode me

49、tastasis玄處內(nèi)口 bttwttrm茨 ihtl 火r.6-4-r0-o o c o o累枳生布函c(生祁時(shí)樹(shù)fig>3 survival rate in patients with different status of internal orifice ofcervical1r枚生存函eofr-or生存屈釵lvsi一wtt:'ihlr-stt夫 盹1火fig.4 dfs in patients with different status of lvsi10*>*2個(gè)>tr汪轉(zhuǎn)&女 st-bim*64- o o 忍枳o(hù)o-o2040eoeoorfig.

50、5 dfs in patients with different status of pelvic lymph node metastasis生存甬敕mimcjsinn uni 失 尉*韻火-4- o o t機(jī)生存器o&-i0無(wú)進(jìn)嚴(yán)住存ih樹(shù)fig.6 dfs in patients with diflerent status of internal orifice of cervical附 表tablel clinical data of 307 patients and kaplan-meier analysis臨床病理特 征nn%osdfs咒2值p宏值p年齡（歲）0.064>

51、;0.050.068>0.05w35268.5>3528191.5絕經(jīng)狀態(tài)0.018>0.050.019>0.05未絕經(jīng)24780.5絕經(jīng)6019.5分娩次數(shù)3.086>0.054.233>0.05w2次22071.7>2次872&3臨床分期3.069>0.050.244>0.05ib117557.0ib26721.8iia15016.311a2154.9腫塊直徑0.404>0.050.455>0.05w422673.6>48126.4組織分化0.096>0.053.750>0.05i級(jí)，ii級(jí)1514

52、9.2ii - iii級(jí)或15650.8iii級(jí)肌層浸潤(rùn)深3.069>0.050.578>0.05度w1/213644.3>1/217155.7臨床病理特 征nn%osdfs咒2值p址值p手術(shù)切緣2.293>0.050.578>0.05陽(yáng)性29796.7陰性103.3淋巴結(jié)轉(zhuǎn)移35.639<0.0541.483<0.05無(wú)25984.4w2個(gè)289.1>2個(gè)206.5lvsi22.732<0.0528.322<0.05陰性25884.0陽(yáng)性4916.0宮頸內(nèi)口6.829<0.055.166<0.05陰性19463.2陽(yáng)性1

53、1336.8術(shù)后治療2.3368>0.054.234>0.05無(wú)7223.5單純放療123.9單純化療10734.9聯(lián)合放化療11637.7保留卵巢0.953>0.050.127>0.05無(wú)1刀55.7有13644.3腫瘤形態(tài)0.366>0.050.999>0.05外生型18961.6其他類型1183&4table2 age-related distribution of 307 patients年齡段（歲）nn%5268.536-404715.341-456621.546-506521.251-555116.656-60309.8>60227

54、.1table3 reproductive history of different 況ge年齡（歲）分娩次數(shù)次>2次p<352240.00036-40434414559746-50471851-55262556-601614>60715table4 independent effective factor on survival rate by cox hazard modelvariable（刪！：）b（回歸系se（標(biāo)準(zhǔn)wald（統(tǒng)計(jì)ft）df（自由度）sig（p值）exp（相對(duì)危險(xiǎn)度）95%ci（可信區(qū)間）lowerupper淋巴結(jié)轉(zhuǎn)移8.8382.01902個(gè)1.542.5298.0571.004.2140