Atlan D, Touboul E, Deniaud-Alexandre E, Lefranc J P, Ganansia V, Bernard A, Antoine J M, Jannet D, Lhuillier P E, Uzan M, Genestie C, Antoine M, Jamali M, Milliez J, Uzan S, Blondon J
Oncologie-radiothérapie, hôpital Tenon, 4 rue de la Chine, 75020 Paris, France.
Cancer Radiother. 2002 Jun;6(4):217-37. doi: 10.1016/s1278-3218(02)00198-1.
To identify prognostic factors and treatment toxicity in a series of operable stages IB and II cervical carcinomas.
Between May 1972 and January 1994, 414 patients (pts) with cervical carcinoma staged according to the 1995 FIGO staging system underwent radical hysterectomy with (n = 380) or without (n = 34) bilateral pelvic lymph node dissection. Lateral ovarian transposition to preserve ovarian function was performed on 12 pts. The methods of radiation therapy (RT) were not randomised and depended on the usual practices of the surgical teams. Group I: 168 pts received postoperative RT (64 pts received vaginal brachytherapy alone [mean total dose (MD): 50 Gy], 93 pts had external beam pelvis RT (EBPRT) [MD: 45 Gy over 5 weeks] followed by vaginal brachytherapy [MD: 20 Gy], and 11 pts had EBPRT alone [MD: 50 Gy over 6 weeks]. Group II: 246 pts received preoperative utero-vaginal brachytherapy [MD: 65 Gy], and 32 of theses 246 pts also received postoperative EBPRT [MD: 45 Gy over 5 weeks] delivered to the parametric and the pelvic lymph nodes with a midline pelvic shield. The mean follow-up was 106 months.
The 10-year disease-free survival (DFS) rate was 80%. From 75 recurrences, 35 were isolated locoregional. Multivariate analysis showed that independent factors decreasing the probability of DFS were: both exo and endocervical tumour site (p = 0.047), lymph-vascular space invasion (p = 0.041), age < or = 51 yr (p = 0.013), 1995 FIGO staging system (stage IB1 vs stage IIA, p = 0.004, stage IB1 vs stage IB2, p = 0.0009, and stage IB1 vs stage IIB with 1/3 proximal parametrical infiltration, p = 0.00002), and histological pelvic involved lymph nodes (p = 0.00009). Methods of adjuvant RT did not influence the probability of DFS (group I vs group II, p = 0.10). The postoperative complication rate was 10.2% in group I and 8.9% in group II (p = 0.7) but the postoperative urethral complication rate necessitating surgical intervention with reimplantation was lower in group I than in group II (0.6% vs 2.3%, respectively, p = 0.03). The 10-year rate for grade 3 and 4 late radiation complications according to the LENT-SOMA scoring system was 10.4%. EPRT significantly increased the 10-year rate for grade 3 and 4 late radiation complications (yes vs no: 22% vs 7%, respectively, p = 0.0002).
In our series, the methods of adjuvant RT (primary surgery vs preoperative uterovaginal brachytherapy) do not seem to influence the prognosis of the stage IB, IIA, and IIB (with 1/3 proximal parametrical involvement only) cervical carcinomas. The postoperative EPRT applied according to histopathological risk factors after surgical treatment increases the risk of late radiation complications.
确定一系列可手术的ⅠB期和Ⅱ期宫颈癌的预后因素及治疗毒性。
1972年5月至1994年1月期间，414例根据1995年国际妇产科联盟（FIGO）分期系统分期的宫颈癌患者接受了根治性子宫切除术，其中380例进行了双侧盆腔淋巴结清扫，34例未进行。12例患者进行了侧方卵巢移位以保留卵巢功能。放射治疗（RT）方法未随机分组，取决于手术团队的常规做法。第一组：168例患者接受术后放疗（64例仅接受阴道近距离放疗[平均总剂量（MD）：50 Gy]，93例接受盆腔外照射放疗（EBPRT）[5周内MD：45 Gy]，随后接受阴道近距离放疗[MD：20 Gy]，11例仅接受EBPRT[6周内MD：50 Gy]）。第二组：246例患者接受术前子宫 - 阴道近距离放疗[MD：65 Gy]，这246例患者中有32例还接受了术后EBPRT[5周内MD：45 Gy]，照射范围包括宫旁组织和盆腔淋巴结，采用中线盆腔屏蔽。平均随访时间为106个月。
10年无病生存率（DFS）为80%。在75例复发患者中，35例为孤立性局部复发。多因素分析显示，降低DFS概率的独立因素为：宫颈外口和宫颈管内肿瘤部位（p = 0.047）、淋巴血管间隙浸润（p = 0.041）、年龄≤51岁（p = 0.013）、1995年FIGO分期系统（ⅠB1期与ⅡA期，p = 0.004；ⅠB1期与ⅠB2期，p = 0.0009；ⅠB1期与ⅡB期且有1/3近端宫旁浸润，p = 0.00002）以及组织学上盆腔受累淋巴结（p = 0.00009）。辅助放疗方法不影响DFS概率（第一组与第二组，p = 0.10）。第一组术后并发症发生率为10.2%，第二组为8.9%（p = 0.7），但第一组术后需要手术干预并重新植入的尿道并发症发生率低于第二组（分别为0.6%和2.3%，p = 0.03）。根据LENT - SOMA评分系统，10年3级和4级晚期放疗并发症发生率为10.4%。EBPRT显著增加了10年3级和4级晚期放疗并发症发生率（是与否：分别为22%和7%，p = 0.0002）。
在我们的研究系列中，辅助放疗方法（初次手术与术前子宫 - 阴道近距离放疗）似乎不影响ⅠB期、ⅡA期和ⅡB期（仅1/3近端宫旁受累）宫颈癌的预后。手术治疗后根据组织病理学危险因素应用术后EBPRT会增加晚期放疗并发症的风险。
