1 主持人 四川大学华西第二医院妇科主任,潘小玲教授 2 病例汇报人四川大学华西第二医院妇科梅玲主治医师3 病例摘要患者,32 岁,G8 P2 +5 ,顺产 1 次,2016 年因"中央型前置胎盘"行剖宫产手术 1 次,现育有两个孩子. 2012年因右侧输卵管妊娠行经腹输卵管妊娠病灶清除术 1次,人工流产4次.末次月经2018年5月1日,停经38 d当地医院彩超提示子宫稍大,肌壁回声均匀,宫内查见孕囊样回声,大小约0.9 cm ×0.8 cm ×0.9 cm,内未见确切卵黄囊及胎芽,诊断宫内早孕.停经第41 d给予米非司酮联合米索前列醇药物流产,服药后阴道有少量流血,无妊娠组织排出. 2018 年6 月28 日复查彩超提示子宫大小9.1 cm×4.2 cm,宫腔下份可见不规则液性暗区,大小约 4.7 cm ×1.2 cm ×2.6 cm,壁较厚,回声增强,内可见卵黄囊回声,似可见少许胎芽,未见确切原始心管波动,孕囊周围查见约1.9 cm ×0.5 cm 液性暗区,子宫前壁下段肌层部分区域菲薄,最薄处约0.12 cm,且与孕囊分界欠清,当地医院考虑"切口妊娠",将患者转至上级医院.当地上级医院行超声声学造影提示宫腔内见孕囊回声,内可见卵黄囊,直径1.1 cm,孕囊位于原切口处并深入肌层内,增强早期子宫前壁原切口处见长5.1 cm,深2.4 cm 快速不均匀高增强区域,原切口区域未见正常宫壁,膀胱壁未见明显受侵. 6 月29 日血人绒

The aim of the present study is to identify the prognostic factors of overall survival and examine the effects of adjuvant chemotherapy and radiotherapy on the overall survival in neuroendocrine carcinoma of the uterine cervix (NECUC) patients.Forty-eight surgically treated patients were retrospectively recruited and clinicopathologic characteristics and treatments were reviewed. Kaplan-Meier product-limit method and Cox proportional-hazards regression were utilized for univariate and multivariate analyses.The median follow-up time was 20.6 months and the median overall survival was 30.7 months. The estimated 2-year and 5-year overall survival rates were 57.5% and 31.3%, respectively. Forty patients had ≤ stage IIA disease and 8 had >IIA disease. Univariate analysis identified the clinical stage ≤ IIA (P = 0.042), tumor size ≤ 4 cm (P = 0.005), negative lymph nodes metastasis (P < 0.001), depth of stromal invasion ≤ 1/2 (P = 0.001), negative parametrial involvement (P = 0.004), and weak staining of synaptophysin (P = 0.037), and chromogranin (P = 0.011) as the prognostic factors for an improved overall survival, while chemotherapy and radiotherapy were not prognostic factors in the whole cohort. However, surgery combined with chemotherapy and radiotherapy produced a survival advantage over surgery alone in patients with large tumors (P = 0.006). The combination of surgery and chemotherapy (with or without radiotherapy) did not show any significant difference in overall survival for small tumors (P = 0.816), compared with no chemotherapy (with or without radiotherapy). In addition, radiotherapy for tumors with squamous cell carcinoma or adenocarcinoma components achieved a better survival (P = 0.01), and there was a tendency of an unfavorable survival for radiotherapy in homogeneous carcinoma (P = 0.099). Tumor size was an independent prognostic factor in the multivariate analysis (HR: 12.724, 95% CI: 1.697-95.423, P = 0.013).In conclusion, clinicopathologic features significantly influence a NECUC patient's outcome. Tumor size and tumor histology can influence the effect of adjuvant chemotherapy and radiotherapy on overall survival. We recommend that platinum-based adjuvant chemotherapy should be used in all cases, while radiotherapy should be reserved for the selected NECUC patients whose tumors have mixed histology.

目的 探讨腹腔镜和开腹手术治疗老年女性输卵管卵巢良性肿瘤的安全性和有效性.方法 统计161例年龄≥70岁患有附件良性肿瘤的老年女性,回顾分析其开腹和腹腔镜手术治疗的相关临床资料.结果 与腹腔镜组比较,开腹组手术持续时间、麻醉时间、拔除尿管时间、肛门排气时间,住院时间显著延长,术中失血量明显增多(均P<0.05),开腹组术后镇痛药使用次数、抗生素使用时间延长,伤口非甲级愈合、术后体温≥38℃的发生率明显增高(P<0.05);两组住院费用无统计学差异(P>0.05);两组术中收缩压、舒张压波动均值、术中收缩压>160 mmHg和<90 mmHg、术中心动过速、心动过缓的发生率无统计学差异(P>0.05).腹腔镜组无中转开腹病例,两组均无严重低血压,心力衰竭、心律失常、心肌梗死、脑血管意外等术中并发症发生,两组术后感染等并发症发生率无统计学差异(P>0.05).两组各发生1例术后少尿,使用速尿后缓解.结论 输卵管卵巢良性肿瘤的老年女性,在充分评估一般情况且控制血压、血糖后,且未患有严重心肺疾病可耐受传统手术者,腹腔镜手术可以作为一个比较优先的考虑,同时对性质不明的老年妇科肿瘤患者可选择腹腔镜做探查手术.

目的:通过回顾性分析行广泛性子宫切除术加盆腔淋巴结切除术的早期宫颈癌患者的临床及病理特征,探讨选择低危早期宫颈癌患者的条件.方法:收集2006年1月至2011年12月在我院行广泛性子宫切除术+盆腔淋巴结切除术治疗的652例早期宫颈癌患者的临床、手术和手术后病理资料,并进行回顾性分析.结果:肿瘤直径＞2 cm、肿瘤中低分化、淋巴血管间隙浸润(LVSI)阳性、肿瘤浸润间质≥1/2全层、子宫下段受累是早期宫颈癌患者淋巴结转移的危险因素;LVSI阳性是其独立危险因素(OR=4.77,P=0.000).肿瘤直径＞2 cm的早期宫颈癌患者发生肿瘤浸润间质≥1/2全层、LVSI阳性、淋巴结转移、子宫下段受累、肿瘤中低分化的发生率更高.在肿瘤直径≤2 cm的早期宫颈癌患者中,当肿瘤浸润间质≥1/2全层时,淋巴结转移、LVSI阳性、子宫下段受累、肿瘤中低分化的发生率更高.结论:肿瘤大小和肿瘤浸润间质深度是选择低危早期宫颈癌患者的重要因素.

目的:探讨宫颈残端癌的临床病理特点,为临床诊治及预防提供参考.方法:收集31例宫颈残端癌患者的临床病理资料并进行回顾性分析,采用PCR-反向点杂交法检测人乳头瘤病毒(HPV),寿命表法计算生存率.结果:31例患者平均47.77±7.64岁;临床表现以阴道不规则流血为主,共16例(51.61％);子宫次全切除原因以子宫肌瘤为主,共21例(67.74％).入院后检测HPV阳性率83.87％ (26/31),高危型HPV阳性率77.42％(24/31),且其中6例子宫次全切除术前与宫颈残端癌术前的高危型HPV感染情况一致.31例患者均采用手术治疗,术后补充放化疗20例.术后病理检查示原位癌累腺2例,浸润性鳞癌22例,腺癌6例,腺鳞癌1例.31例患者随访时间6 ～ 96个月,5年生存率78.20％.结论:宫颈残端癌的临床表现与一般宫颈癌相似,病理类型以鳞癌为主.HPV感染率高于正常人群.高危型HPV的检测、慎重选择子宫次全切除术以及子宫次全切除术后的严密随访对预防宫颈残端癌的发生尤为重要.

患者1 女性,14岁。因“不规则阴道流血半年,宫颈肿瘤切除术后19 d”于2014-03-09入本院。病史采集：G0 P0,既往月经周期为28~30 d,经期4 d,LMP：2014-01-20,半年前出现阴道不规则流血,淋漓不尽,当地医院 CT 检查结果示盆腔包块,于2014-02-10于重庆医科大学附属永川医院行剖腹探查术,发现肿瘤来源于宫颈,大小约为12 cm×8 cm×6 cm,脱出于阴道中,形似葡萄状,色灰白、质软,部分组织出血、坏死,伴恶臭。赘生物蒂部较宽,与宫颈分界不清。于是改行经阴道宫颈肿瘤切除术。术后组织病理检查结果示：宫颈葡萄状 横 纹 肌 肉 瘤。患者病理切片至本院会诊示：宫颈腺肉瘤(adenosarcoma,AS)伴肉瘤成分过度生长；肉瘤成分：子宫内膜间质肉瘤(约70%)、软骨肉瘤(约20%)、横纹肌肉瘤(约10%)。2014-03-10于本院再次切除2个宫颈赘生物,蒂部宽,直径分别约为4 cm 和3 cm。术后组织病理检查结果示：AS。术后予以异环磷酰胺、表柔比星、顺铂(IAP)方案化疗3个疗程。2014-06-04再次行子宫次广泛切除术+双附件切除术+盆腔淋巴结清扫术+腹主动脉旁淋巴结取样。剖视子宫示：宫颈中度糜烂,宫颈管见2 cm×2 cm 手术瘢痕。术后组织病理检查结果示：AS(肉瘤成分为子宫内膜间质肉瘤、软骨肉瘤、横纹肌肉瘤),肌层浸润深度<1/2；淋巴结未见肿瘤转移(0/25)；切缘呈阴性。术后再次予以 IAP 方案化疗1个疗程,患者因经济因素,未继续化疗,现患者存活,情况稳定,无复发转移,目前仍处于随访中。

Objective To study the clinical characteristics and treatment strategies of the ovarian benign tumor with ascites or pleural effusion (Meigs syndrome),and combined with literatures reviewed. Methods Retrospective analyses were conducted on 14 cases with Meigs syndrome in West China Second University Hospital of Sichuan University from April 2011 to August 2013.Prognosis was conducted by telephone,and literatures were reviewed.SPSS 17.0 software was used to make correlation analysis between the amount of ascites,tumors diameters and serum CA125 expressions.The study protocol was approved by the Ethical Review Board of Investigation in Human Being of West China Second University Hospital,Sichuan University. Informed consent was obtained from all participants. Results The 14 patients with Meigs′syndrome were from 20 to 79 years old and the mean age was (54.4±13.7)years old.Among them,there were 9 patients combined with pelvis and abdominal mass,3 patients with abdominal pain and distension,2 patients with cough and short breath.Besides,there were 4 patients with serum CA125 levels increased and 2 patients with pleural effusion before surgery.Among them,2 patients received ovarian tumor resection,7 patients received unilateral adnexectomy and 2 patients received bilateral adnexectomy and 3 patients with hysterectomy plus bilateral adnexectomy.Postoperative histopathology result showed that there were 7 cases with fibroma of ovary,5 cases with fibrothecoma and 2 cases with papillary cystadenoma.There was positive correlation between ascites volumes and tumors diameters (r=0. 535,P=0.048),while there was no correlation between ascites volumes and values of serum CA125 (r=0. 319,P=0.266),and there was positive correlation between tumors diameters and values of serum CA125 (r= 0 .6 2 5 ,P = 0 .0 2 7 ).Conclusions Meigs syndrome is a rare clinical disease and is apt to be misdiagnosed as tuberculosis,hepatitis or chest and abdominal malignant tumor,definite diagnosis is only made through histopathology,and tumor resection leads to favorable prognosis.The ascites volumes of Meigs syndrome positively correlates with tumors diameters, supporting the hypothesis of tumor compression.

患者,女性,48岁,因"经期延长,经量增多1年"于2011年5月31日入华西第二医院,2d后在全麻下行经腹子宫全切术,术后第2天患者在入厕解小便后端坐床旁休息时出现面色苍白,随之意识丧失,不伴抽搐及大小便失禁,双肺呼吸音清,右下肺呼吸音低,无明显干湿哕音,四肢冰冷.立即给氧、心电监护及输液处理后,血压、血氧饱和度上升不理想,给予紧急气管插管并呼吸机辅助呼吸,多巴胺升压,同时急诊行床旁心电图,示窦性心动过速,电轴不偏,ST段改变,Ⅲ导联较入院时加深,呈SIQⅢTⅢ表现,胸片示左下肺与心影重叠区密度增高,心影偏大,左侧膈面和左侧肋膈角模糊显示不清,患者于12:55分转入ICU继续治疗,多科会诊后考虑:晕厥伴低血压:急性肺栓塞?与患者及家属充分沟通后给予溶栓抗凝治疗,尿激酶100万U静脉滴注,1次/2h,监测DIC、ECG、血气、血常规,于APTT＜ 80 s或低于正常上限2倍后给予抗凝:肝素4000 U负荷,之后以18 U/(kg·h)维持,使APTT在1.5 ～2.3倍,同时给予监测血小板计数,避免HITT的发生,次日11:40,心电监护示HR 70～80次/min,血氧饱和度97％,Bp 115/70 mm Hg(1 mm Hg=0.133 kPa),四肢暖干,双侧瞳孔等大等圆,双肺呼吸音清晰,未闻及干湿性哕音,双下肢不肿,华西医院呼吸内科医师会诊后指出,至此患者急性大面积肺栓塞的诊断成立,继续给予抗凝治疗,同时给予纠正贫血、控制血压及抗炎治疗.完善心脏超声心动图、双侧下肢动静脉彩超及腹主动脉彩超等检查均未见明显异常,2周后患者病情平稳出院.随访2年,未有复发.

Objectives To investigate the association between toll-like receptor 9 ( TLR9 ) single nucleotide polymorphisms (SNPs) and human papillomavirus (HPV) infection among Chinese Han women with cervical cancer. Methods TLR9 –1486 and 2848 SNPs were investigated in patients with cervical cancer and controls using polymerase chain reaction (PCR)-restriction fragment length polymorphism. HPV16 E6 and E7 infections were assessed using PCR. Results Of 120 patients with cervical cancer and 100 controls, there was a significant association between TLR9 2848 SNP and cervical cancer risk, but there was no such association with TLR9 –1486 SNP. Frequency of the TLR9 2848 GA genotype was significantly higher in patients with cervical cancer than in controls. There was no statistically significant between-group difference in presence of HPV16 infection. Presence of HPV infection with TLR9 2848 (rs352140) GA/AA genotype increased the risk of cervical cancer 13.8-fold compared with the GG genotype. Conclusions The TLR9 2848 G/A polymorphism in Chinese Han women was associated with increased risk of cervical cancer in the presence of HPV16 infection. Further studies are necessary to uncover the functional aspect of this TLR9 2848 polymorphism. Keywords Toll-like receptor 9 (TLR9) , gene polymorphism , rs352140 , single nucleotide polymorphism (SNP) , Human papillomavirus (HPV) , cervical cancer

Objectives To investigate the association between toll-like receptor 9 ( TLR9) single nucleotide polymorphisms (SNPs) and human papillomavirus (HPV) infection among Chinese Han women with cervical cancer. Methods TLR9 –1486 and 2848 SNPs were investigated in patients with cervical cancer and controls using polymerase chain reaction (PCR)-restriction fragment length polymorphism. HPV16 E6 and E7 infections were assessed using PCR. Results Of 120 patients with cervical cancer and 100 controls, there was a significant association between TLR9 2848 SNP and cervical cancer risk, but there was no such association with TLR9 –1486 SNP. Frequency of the TLR9 2848 GA genotype was significantly higher in patients with cervical cancer than in controls. There was no statistically significant between-group difference in presence of HPV16 infection. Presence of HPV infection with TLR9 2848 (rs352140) GA/AA genotype increased the risk of cervical cancer 13.8-fold compared with the GG genotype. Conclusions The TLR9 2848 G/A polymorphism in Chinese Han women was associated with increased risk of cervical cancer in the presence of HPV16 infection. Further studies are necessary to uncover the functional aspect of this TLR9 2848 polymorphism.

Objective To investigate the relationship between chronic cervicitis and gene polymorphism of human β-defensin-1(HBD-1) and toll-like receptor(TLR).Methods Cervical epithelial cells were collected from 150 outpatients with chronic cervicitis(chronic cervicitis group) and 100 normal women(control group) in West China Second Hospital of Sichuan University.After DNA extraction from cervical epithelial cells,single nucleotide polymorphism(SNP) was detected by polymerase chain reaction and restriction fragment length polymorphism(PCR-RFLP).Results Both the frequencies of CG genotype and G allele in HBD-1 exon-44C/G were higher in the chronic cervicitis group than in the normal group(P<0.05),while the genotypes and allele frequencies in the exons of HBD-1-52 G/A and-20G/A showed no significant difference between the two groups(P>0.05).The gene polymorphism of TLR2 Arg753Gln,TLR4 Asp299Gly and TLR4 Thr399Ile showed no significant difference between the two groups(P>0.05).Conclusion Chronic cervicitis is associated with high frequencies of G allele and C/G genotype in-44C/G of β-defensin-1 rather than the gene polymorphism of HBD-1-52G/A,HBD-1-20G/A,TLR2 Arg753Gln,TLR4 Asp299Gly and TLR4 Thr399Ile.

<正>子宫内膜异位症(endometriosis,EM)是育龄妇女的常见病,发病率约15%,临床上以痛经、盆腔痛和不孕为主要表现。EM虽属良性病变,但其表现与恶性肿瘤的生物学行为类似,并有一定比例的异位子宫内膜发生组织学改变,成为癌瘤。EM恶变主要发生在卵巢,病理类型多为子宫内膜样癌或透明细胞癌,卵巢外异位内膜恶变及恶变的其他病理组织学类型较少。现报道1例在位子宫内膜及卵巢外异位内膜同时恶变,并结合文献复习,探讨其临床病理特点、诊断以及治疗。

目的 探讨死亡相关蛋白激酶(DAPK)和鼠双微体(MDM2)蛋白在正常卵巢组织、卵巢良性上皮性肿瘤、卵巢交界性上皮性肿瘤、卵巢上皮性癌组织中的表达及其与相关临床病理特征间的关系.方法 应用免疫组化SP法检测30例正常卵巢组织、30例卵巢良性上皮性肿瘤、30例卵巢交界性上皮性肿瘤和60例卵巢上皮性癌组织中DAPK蛋白和MDM2蛋白的表达情况.结果 DAPK和MDM2蛋白在正常卵巢组织、卵巢良性上皮性肿瘤、卵巢交界性上皮性肿瘤和卵巢上皮性癌中阳性表达率分别为100.00%(30/30)、93.33%(28/30)、50.00%(15/30)、35.00%(21/60)和16.67%(5/30)、23.33%(7/301)、66.67%(25/30)、78.33%(47/60),组间差异均有统计学意义(x2值分别为27.52、33.40,P均<0.05).DAPK蛋白阳性表达与淋巴结转移、腹水生成、FIGO分期密切相关(x2值分别为15.84、33.47、10.55,P均<0.05),但在病理类型、组织学分级、年龄方面差异无统计学意义(x2值分别为5.11、3.46、0.41,P均>0.05).MDM2蛋白阳性表达与患者年龄有关(x2=5.19,P<0.05),与淋巴结转移、腹水生成、临床分期、病理类型、组织学分级等无关(x2值分别为0.14、0.64、4.54、0.83、1.02,P均>0.05).在卵巢上皮性癌组织中,DAPK和MDM2表达呈显著负相关(r=-0.33,P<0.05).结论 DAPK和MDM2在卵巢上皮性癌的发生、发展中有重要作用.两者可作为判断卵巢上皮性癌生物学行为和预后的参考指标及卵巢上皮性癌基因治疗的新靶点.

DNA错配修复(mismatch repair,MMR)基因是人体细胞中存在的一种能识别并修复DNA碱基错配的安全保障系统。近来研究发现,MMR基因缺陷可增加子宫内膜癌发病风险,与子宫内膜癌发生、发展及不良预后有关。本文综述MMR基因与子宫内膜癌相关性研究进展。

DNA错配修复(mismatch repair,MMR)基因是人体细胞中存在的一种能识别并修复DNA碱基错配的安全保障系统。近来研究发现,MMR基因缺陷会降低整个基因组的稳定性,最终导致肿瘤发生。本文对MMR基因与妇科三大恶性肿瘤的相关性研究进展作一综述。

Objective:To detect the effect of hemoglobin on E.coli vaginal infection in rats.Methods: After establishing rat model of persistent vaginal infection with E.coli,the rats were randomized into the experimental group and the control group.The experimental group was administered intravaginally with hemoglobin.The histologically pathological section and the organ index of uterine and vagina were observed,then the indicator changes of each group before and after treatment were analyzed.Results: With statistical analysis of the organ index of rat uterine cervix and vagina,there were no difference between the hemoglobin group(the experimental group) and the control group(P>0.05).The comparison between the matrix control group(no treatment after infection) with the former two groups,there was significant difference(P<0.05).The organ index of the matrix control group increased significant.Conclusion: Hemoglobin might relieve the inflammation of E.coli vaginal infection in rats.

子宫肌壁间妊娠又称子宫浆膜面妊娠[1],是一种罕见的异位妊娠,指受精卵在子宫壁肌层着床,生长发育,不是种植在子宫内,而是四周完全被子宫肌层环绕,与子宫腔不通,与输卵管也不相通.

目的:探讨复发性卵巢恶性肿瘤再次手术的临床价值及可行性。方法:回顾性分析1995年3月至2004年6月共111例复发性卵巢恶性肿瘤行再次手术治疗患者的临床及随访资料。根据病理类型分为上皮性卵巢癌组和其他类型癌组,根据复发距初次手术的时间分为＞6个月复发组和≤6个月复发组,再根据再次手术中所见复发转移灶数目分为单病灶组和多病灶组,最后根据再次手术后化疗的次数分为≥6个疗程组、＜6个疗程组和未化疗组。观察再次手术中满意减灭术和手术并发症的例数,分析术后生存率。各组数据比较采用χ~2检验。结果:上皮性卵巢癌组和其他类型癌组中获得满意减灭术例数分别为70例和2例（χ~2=5.91,P＜0.05）;初次手术后＞6个月复发组和≤6个月复发组获得满意减灭术例数分别为45例和27例（χ~2=0.39,P＞0.05）;单病灶组和多病灶组获得满意减灭术例数分别为51例和21例（χ~2=25.73,P＜0.05）。术后并发症主要为术中出血＞1000mL、肠梗阻、肠瘘、切口感染、尿路感染等,总发生率为22.5%,单病灶组和多病灶组手术并发症比较无统计学意义（χ~2=3.81,P＞0.05）。予以术后补救化疗后,≥6个疗程组、＜6个疗程组和未化疗组术后中位生存期分别是12个月、9个月和2个月。术后1～5年生存率分别为83.7%、69.5%、58.6%、42.3%、29.2%。结论:对于单个复发病灶及初次手术后＞6个月复发的上皮性卵巢癌患者实施再次手术是可行的,术后予以补救化疗可提高治疗的有效性,延长生存时间。

Objective:To investigate the effect of rSIFN-co,consensus Interferon(Infergen),IFNα-2b(Interferon α-2b)and chemotherapeutics on cervical cancer cell line Caski in vitro.Methods:After Caski cervical cancer cells were cultured in vitro with rSIFN-co、Infergen、IFNα-2b and cisplatin(DDP)at the concentration of 0.156 μg/ml、0.625 μg/ml、2.5 μg/ml and 10 μg/ml respectively for 72 hours,cell proliferation was mensurated by MTT assay,cell inhibition rate was calculated.Then after Caski cervical cancer cells were treated with rSIFN-co、Infergen、IFNα-2b and DDP at the concentration of 0.156 μg/ml、0.625 μg/ml、2.5 μg/ml for 72 hours,cell apoptosis was determined by flow cytometry.Results:rSIFN-co、Infergen、IFNα-2b and DDP could induce inhibition and apoptosis of Caski cells.The inhibition and apoptosis of Caski cells which had been induced by rSIFN-co and DDP were better than which had been induced by Infergen and IFNα-2b at the same concentration,and DDP was more better than rSIFN-co.Conclusions:rSIFN-co has antineoplastic effect by inhibiting proliferation and inducing apoptosis in Caski cervical cancer cell in vitro.The effect is inferior to DDP,but better than the same type interferon and general type I interferon.

Objective:To investigate the technique and approach of surgical treatment of cervical stump carcinoma and improve the surgical technology.Methods:A retrospective analysis of 22 cases having cervical stump carcinoma as treated surgically was performed from 2005.5 to 2007.11.Results:All patients underwent Wertheim-Meigs surgery,16 cases in association with radiotherapy or chemotherapy.The total tumor removal rate reached 100%,no mortality,and only in three patients the bladder was injured.All cases recovered well.Conclusion:It is high risk to operate on cervical stump carcinoma.Selecting appropriate operative method and skillfully using the operative techniques are the keys to get good therapeutic efficacy.