McMeekin D S, Lashbrook D, Gold M, Johnson G, Walker J L, Mannel R
Department of Obstetrics-Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73190, USA.
Gynecol Oncol. 2001 May;81(2):273-8. doi: 10.1006/gyno.2001.6157.
The aim of this study was to analyze FIGO Stage IIIc endometrial cancer (EC) patients to better define clinicopathologic associations, patterns of failure, and survival.
Charts were abstracted from EC patients with lymph node metastasis from 1989 to 1998. Data on clinicopathologic variables, adjuvant treatment, site of first recurrence, and survival were collected. Associations between variables were tested by chi(2) and Wilcoxon rank sums. Survival analyses were performed by the Kaplan-Meier method, and multiple regression analysis was done by the Cox proportional hazards model.
From 607 EC patients evaluated, 47 (8%) were identified with FIGO Stage IIIc disease. All 47 underwent hysterectomy and pelvic lymph node (PLN) sampling, and 42/47 had para-aortic lymph node (PALN) sampling. Stage IIIc disease was defined by positive PLN alone in 38%, positive PLN and PALN in 41%, and positive PALN alone in 17%. Twelve of 47 also had positive peritoneal cytology and/or adnexal metastases. Grade III tumors were present in 56% and >50% myometrial invasion in 61%. No association between depth of invasion (DOI) and grade was seen, however. Nearly 1/3 of cases had papillary serous or clear cell histology. Postoperative adjuvant treatment included whole abdominal radiation (36%), pelvic radiation with (19%) and without (17%) extended field, chemotherapy (17%), and oral progestins (11%). The 3-year and 5-year survival estimates for all patients were 77 and 65%, respectively. At a median follow-up of 37 months, 5 patients are alive with disease, and 10 are dead of disease. A distant site of first recurrence was most common (21%), followed by pelvic failure (9%). Only 1 patient has had an abdominal recurrence. Univariate predictors of survival included age, DOI, and extranodal disease, but not grade, histology, or PALN involvement. For the 12 patients with nodal disease and positive cytology and/or adnexa, 3-year survival was 39% versus 93% for those patients without evidence of extranodal disease. In a multivariate analysis only DOI was an independent predictor of survival (P = 0.03).
Once lymph node involvement occurs, the importance of additional extranodal disease increases. Consideration of substaging Stage IIIc patients based on positive adnexa or cytology is supported by the data. The extent which adjuvant treatments contributed to the 77% 3-year survival remains to be defined. The patterns of failure suggest a possible role for combined modalities in future treatments.
本研究旨在分析国际妇产科联盟（FIGO）Ⅲc期子宫内膜癌（EC）患者，以更好地明确临床病理关联、复发模式和生存率。
从1989年至1998年有淋巴结转移的EC患者病历中提取信息。收集临床病理变量、辅助治疗、首次复发部位和生存的数据。变量之间的关联通过卡方检验和Wilcoxon秩和检验进行。生存分析采用Kaplan-Meier方法，多因素回归分析采用Cox比例风险模型。
在评估的607例EC患者中，47例（8%）被确定为FIGOⅢc期疾病。所有47例均接受了子宫切除术和盆腔淋巴结（PLN）取样，47例中有42例进行了腹主动脉旁淋巴结（PALN）取样。Ⅲc期疾病单独PLN阳性的占38%，PLN和PALN均阳性的占41%，单独PALN阳性的占17%。47例中有12例同时有阳性腹膜细胞学检查和/或附件转移。56%为Ⅲ级肿瘤，61%肌层浸润>50%。然而，未发现浸润深度（DOI）与分级之间存在关联。近1/3的病例为乳头状浆液性或透明细胞组织学类型。术后辅助治疗包括全腹放疗（36%）、盆腔扩大野放疗（19%）和非扩大野放疗（17%）、化疗（17%）和口服孕激素（11%）。所有患者的3年和5年生存率估计分别为77%和65%。中位随访37个月时，5例患者带瘤存活，10例患者死于疾病。远处首次复发最常见（21%），其次是盆腔复发（9%）。只有1例患者有腹部复发。生存的单因素预测因素包括年龄、DOI和淋巴结外疾病，但不包括分级、组织学类型或PALN受累情况。对于12例有淋巴结疾病且细胞学检查和/或附件阳性的患者，3年生存率为39%，而无淋巴结外疾病证据的患者为93%。多因素分析中，只有DOI是生存的独立预测因素（P = 0.03）。
一旦发生淋巴结受累，额外的淋巴结外疾病的重要性增加。数据支持根据附件或细胞学阳性对Ⅲc期患者进行进一步分期。辅助治疗对77%的3年生存率的贡献程度仍有待确定。复发模式提示联合治疗方式在未来治疗中可能发挥作用。
