Grigsby P W, Herzog T J
Mallinckrodt Institute of Radiology, Box 8224, Washington University Medical Center, 4939 Children's Place, Suite 5500, St. Louis, MO 63110, USA.
Clin Obstet Gynecol. 2001 Sep;44(3):531-7. doi: 10.1097/00003081-200109000-00008.
After the logic of evidence-based medicine, there are several conclusions to be reached from these recent prospective, randomized phase III clinical trials. Patients with stages IB2 and IIA cervical carcinoma, although technically manageable, should be treated with external pelvic irradiation and brachytherapy and weekly (cisplatin 40 mg/m2 x 6 wk), if it is suspected that the likelihood of positive lymph nodes or margins requiring adjuvant treatment after radical surgery would be significant. In those patients in whom the risks of either positive margins or lymph nodes are low, either radical surgery or radiation are equally efficacious options. A recent report that surveyed the Surveillance, Epidemiology, and End Results program database suggested that there may be a survival advantage for surgical intent-to-treat patients compared with the radiation intent-to-treat patients for tumors 4 cm or smaller in patients with stage IB and IIA cervical cancers. Certainly, toxicity criteria for these patients in terms of long-term problems need to be further examined. For those patients who undergo a radical hysterectomy and lymph node dissection, postoperative irradiation is indicated if high-risk factors such as large tumor size, lymph vascular space invasion, and deep stromal invasion are identified. Patients who are found to have positive lymph nodes, positive parametrial invasion, or positive margins at the time of hysterectomy should receive postoperative irradiation with chemotherapy. All other patients with more advanced clinical stages of cervical carcinoma should be treated with external pelvic irradiation, brachytherapy, and concurrent chemotherapy. Based on the results of the randomized studies, there appears to be no role for either hydroxyurea or fluorouracil. The chemotherapy agent of choice, at present, is cisplatin administered concurrently with irradiation at a dose of 40 mg/m2 weekly for 6 weeks. Concurrent chemotherapy should be avoided in patients with a poor performance status and other severe comorbidities, and these patients should be treated with irradiation alone. Further refinement of treatment for those patients who require combined chemo/radiation versus those with comorbidities such that combination chemotherapy is actually too toxic must be defined.
根据循证医学的逻辑，从这些近期的前瞻性、随机III期临床试验中可以得出几个结论。IB2期和IIA期宫颈癌患者，尽管在技术上可以处理，但如果怀疑阳性淋巴结或切缘在根治性手术后需要辅助治疗的可能性很大，则应接受盆腔外照射、近距离放疗和每周一次（顺铂40mg/m²×6周）的治疗。对于那些切缘或淋巴结阳性风险较低的患者，根治性手术或放疗都是同样有效的选择。最近一项对监测、流行病学和最终结果计划数据库的调查显示，对于IB期和IIA期宫颈癌中肿瘤直径4cm或更小的患者，手术意向性治疗患者可能比放疗意向性治疗患者有生存优势。当然，这些患者在长期问题方面的毒性标准需要进一步研究。对于那些接受根治性子宫切除术和淋巴结清扫术的患者，如果发现有高危因素，如肿瘤体积大、淋巴血管间隙浸润和深层间质浸润，则需要术后放疗。在子宫切除时发现有阳性淋巴结、阳性宫旁浸润或阳性切缘的患者应接受术后放疗加化疗。所有其他临床分期较晚的宫颈癌患者应接受盆腔外照射、近距离放疗和同步化疗。根据随机研究的结果，羟基脲或氟尿嘧啶似乎都没有作用。目前，首选的化疗药物是顺铂，与放疗同步给药，剂量为每周40mg/m²，共6周。对于身体状况差和有其他严重合并症的患者，应避免同步化疗，这些患者应仅接受放疗。对于那些需要联合化疗/放疗的患者与那些合并症患者，由于联合化疗毒性过大，必须进一步明确治疗方案。
