就“点评：子宫恶性肿瘤的前哨淋巴结检测——更少即更多”一文的回复信
Letter to the Editor

就“点评：子宫恶性肿瘤的前哨淋巴结检测——更少即更多”一文的回复信

Jan Persson1, Oscar Lührs1,2, Celine Lönnerfors1

1Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Skåne University Hospital and Lund University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology, Lund, Sweden; 2Department of Obstetrics and Gynecology, Kristianstad Central Hospital, Kristianstad, Sweden

Correspondence to: Jan Persson, MD. Professor, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Skåne University Hospital and Lund University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology, 22185 Lund, Sweden. Email: jan.persson@med.lu.se.

Response to: Siesto G. Sentinel node mapping for uterine cancer: is less always more. Gynecol Pelvic Med 2020;3:1.

Received: 12 May 2020; Accepted: 30 May 2020; Published: 25 June 2020.

doi: 10.21037/gpm-2020-03

关于对Lührs等作者发表的“吲哚青绿和Tc-99纳米胶体结合并不能提高早期宫颈癌前哨淋巴结的检出率”一文的评论回应(前点评文章可见“子宫恶性肿瘤的前哨淋巴结检测：更少即更多”)。

很感激大家会对我们的文章感兴趣。我们非常同意Siesto医生的观点，即要保证手术与肿瘤安全性的前哨淋巴结手术(SLN)不仅需要高双侧检出率，而且对于检测盆腔淋巴结转移也需要接近100%的灵敏度。正如原文中强调的，要做到这一点，严格遵守基于解剖学的手术方案以及高水平的外科专业知识是关键[1,2]。这一点在对比子宫内膜癌中检测SLN的两项最大前瞻性研究(SHREC研究和FIRS研究，双边映射分别为95%和52%[3,4])时得到了明确的证明。在SHREC研究中，所有的手术都由五名外科医生进行，他们在机器人手术和SLN检测方面都有着丰富的经验；而在FIRES研究中的16名外科医生中，只有两名之前有过机器人SLN测绘的经验。

假设SLN对检测盆腔淋巴结转移的灵敏度接近100%，那么与全盆腔淋巴结切除术相比，SLN有几个优点，如减少围手术期发病率和淋巴并发症，后者已被证明对患者的生活质量有很大影响。此外，超声切除和免疫组织化学评估提高了转移检测率，从而改善了肿瘤学结果。由于机器人手术和开放手术之间的内在差异，特别是在视觉质量和图像放大方面，我们不相信将吲哚青绿与机器人辅助手术结合使用对SLN进行研究所得出的敏感性和安全性数据可以转移到开放手术上。

Melamed等的LACC研究和SEER研究的结果都表明，与开放手术相比，宫颈癌微创手术(MIS)后的肿瘤学结果较差[5,6]。虽然对于目前所报道的微创手术带来的较差结果背后的可能机制没有明确显然的解释，但大家对微创手术已然有了愈渐重要的关注。

因为84%的微创手术都是在腹腔镜下进行的，因此LACC研究并没有提供机器人根治性子宫切除术的相关数据。在SEER研究的1，225项微创手术中，79.8%是应用机器人进行的，这些手术都是在2010至2013年间进行，即也是美国引入机器人手术的时期。此外，该1，225项微创手术在357个中心(与Melamed医生有交流)进行的事实也表明了在一些中心，微创手术/机器人手术的平均病例量非常低。由此也不免会让人得出在低容量中心实施创新的手术方法会导致较差结果的假设。我们认为，在诠释结果时，与引入新方法相关的组织与研究的时间应该纳入考虑之中。

在斯堪的纳维亚半岛，妇科癌症手术集中在有限的几个三级转诊中心，由于手术的罕见性，根治性子宫切除术会更为集中安排在中心内。几乎所有的宫颈癌微创手术都是应用机器人进行的。瑞典和丹麦进行的两项全国性大规模研究结果均未能显示出在LACC和SEER研究[7,8]中所显示的开放性手术与微创手术在复发率和存活率方面的差异。因此，只要有一个负责任的护理组织和足够的手术量，我们相信宫颈癌机器人根治性子宫切除术是有用武之地的。然而，这应该在额外的随机试验中进一步研究，例如正在进行的RACC试验[9]。

尽管如此，我们仍然必须认真对待与特定入路相关的不良结果的潜在风险，必须寻找并排除与不良结果相关的可能外科因素。而在讨论宫颈癌手术的未来时，我们应把为微创外科服务的SLN优势以及这些优势能否应用于开放手术纳入考虑。

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Gynecology and Pelvic Medicine. The article did not undergo external peer review.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gpm.amegroups.org/article/view/10.21037/gpm-2020-03/coif). JP reported other from Intuitive surgical (Honoraria received for site visits and proctoring), outside the submitted work. CL reported other from Intuitive surgical (Honoraria received for lectures), outside the submitted work. OL has no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

  1. Geppert B, Lönnerfors C, Bollino M, et al. A study on uterine lymphatic anatomy for standardization of pelvic sentinel lymph node detection in endometrial cancer. Gynecol Oncol 2017;145:256-61. [Crossref] [PubMed]
  2. Persson J, Geppert B, Lönnerfors C, et al. Description of a reproducible anatomically based surgical algorithm for detection of pelvic sentinel lymph nodes in endometrial cancer. Gynecol Oncol 2017;147:120-5. [Crossref] [PubMed]
  3. Persson J, Salehi S, Bollino M, et al. Pelvic Sentinel lymph node detection in High-Risk Endometrial Cancer (SHREC-trial)-the final step towards a paradigm shift in surgical staging. Eur J Cancer 2019;116:77-85. [Crossref] [PubMed]
  4. Rossi EC, Kowalski LD, Scalici J, et al. A comparison of sentinel lymph node biopsy to lymphadenectomy for endometrial cancer staging (FIRES trial): a multicentre, prospective, cohort study. Lancet Oncol 2017;18:384-92. [Crossref] [PubMed]
  5. Ramirez PT, Frumovitz M, Pareja R, et al. Minimally invasive versus abdominal radical hysterectomy for cervical cancer. N Engl J Med 2018;379:1895-904. [Crossref] [PubMed]
  6. Melamed A, Margul DJ, Chen L, et al. Survival after minimally invasive radical hysterectomy for early-stage cervical cancer. N Engl J Med 2018;379:1905-14. [Crossref] [PubMed]
  7. Alfonzo E, Wallin E, Ekdahl L, et al. No survival difference between robotic and open radical hysterectomy for women with early-stage cervical cancer: results from a nationwide population-based cohort study. Eur J Cancer 2019;116:169-77. [Crossref] [PubMed]
  8. Jørgensen SL, Mogensen O, Wu C, et al. Nationwide introduction of minimally invasive robotic surgery for early-stage endometrial cancer and its association with severe complications. JAMA Surg 2019;154:530-8. [Crossref] [PubMed]
  9. Falconer H, Palsdottir K, Stalberg K, et al. Robot-assisted approach to cervical cancer (RACC): an international multi-center, open-label randomized controlled trial. Int J Gynecol Cancer 2019;29:1072-6. [Crossref] [PubMed]
译者介绍

王纯菲。2019级专业型硕士，本科毕业于南京医科大学。在医学的求实领域中，以“博学至精，明德至善”要求自己，用饱满的热情和责任心探寻医学真谛！（更新时间：2021/11/17）

（本译文仅供学术交流，实际内容请以英文原文为准。）

doi: 10.21037/gpm-2020-03
Cite this article as: Persson J, Lührs O, Lönnerfors C. Response to editorial commentary by G. Siesto “Seninel node mapping in uterine cancer: is less always more”. Gynecol Pelvic Med 2020;3:14.

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