Murphy Kevin T, Rotmensch Jacob, Yamada S Diane, Mundt Arno J
Department of Radiation and Cellular Oncology, University of Chicago, Chicago, IL 60637, USA.
Int J Radiat Oncol Biol Phys. 2003 Apr 1;55(5):1272-6. doi: 10.1016/s0360-3016(02)04404-8.
To evaluate the outcome and patterns of failure in women with uterine clear-cell carcinoma and discuss implications for adjuvant radiation therapy (RT).
Between 1980 and 2000, 686 endometrial carcinoma patients underwent primary surgery at our institution. Thirty-eight women (5.5%) had clear-cell tumors (18 clear-cell only, 8 clear-cell + adenocarcinoma, and 12 clear-cell + other unfavorable histologies [10 papillary serous, 1 uterine sarcoma, 1 both]). All underwent surgery and assessment of peritoneal cytology. None received preoperative RT. Pelvic and para-aortic node samplings were performed in 26 and 17 patients, respectively. FIGO stages were as follows: 3 IA, 4 IB, 5 IC, 4 IIA, 6 IIB, 8 IIIA, 2 IIIB, 3 IIIC, and 6 IV. Adjuvant therapies included the following: 5 none, 22 RT (13 pelvic RT, 2 vaginal brachytherapy, 7 both), 11 chemotherapy (8 alone, 3 after pelvic RT), and 3 hormones. No patient received whole-abdominal RT or para-aortic RT. Median follow-up was 36.5 months.
The 5-year actuarial disease-free survival of the entire group was 38.5%. No correlation was seen between relapse and stage, myometrial invasion, cytology, cervical extension, or involvement of extrauterine sites. Patients with clear +/- adenocarcinoma histology had a similar 5-year disease-free survival (38.8% vs. 38.7%, p = 0.95) compared with those with clear-cell + other unfavorable histologies. Sixteen patients relapsed (42%). Eight failed in the pelvis (5 vagina, 3 lateral pelvis). There were no pelvic failures in the group of 22 patients who received adjuvant RT, whereas in the group of 16 women who did not, 8 (50%) relapsed in the pelvis (p < 0.0001). Corresponding pelvic failure rates in the Stage IA-IIB patients with and without RT were 0/16 (0%) and 5/6 (83%) (p < 0.0001). Six patients (16%) failed in the para-aortic nodes and 2 (5%) in the abdomen. Only 1 (2%) patient developed an isolated abdominal failure (This patient had a mixed clear-cell/papillary serous tumor). Of the 26 women with clear-cell +/- adenocarcinoma histology, only 1 (3.8%) relapsed in the abdomen. Nine patients (24%) relapsed in distant sites, primarily the lungs and bone.
Clear-cell carcinoma comprises a small percentage of endometrial cancers, frequently presents as a mixed histology, and has a poor overall outcome. Unlike papillary serous tumors, clear-cell carcinoma does not seem to have a high propensity for abdominal failure. Our results thus do not support the routine use of whole-abdominal RT in these patients. Future protocols should focus instead on combinations of locoregional RT and chemotherapy to reduce the risk of local and systemic recurrence.
评估子宫透明细胞癌女性患者的治疗结果和失败模式，并探讨辅助放疗（RT）的意义。
1980年至2000年间，686例子宫内膜癌患者在本机构接受了初次手术。38例女性（5.5%）患有透明细胞瘤（18例仅为透明细胞癌，8例透明细胞癌+腺癌，12例透明细胞癌+其他不良组织学类型[10例乳头状浆液性癌，1例子宫肉瘤，1例两者皆有]）。所有患者均接受了手术及腹膜细胞学评估。无一例接受术前放疗。分别对26例和17例患者进行了盆腔和腹主动脉旁淋巴结取样。国际妇产科联盟（FIGO）分期如下：3例IA期，4例IB期，5例IC期，4例IIA期，6例IIB期，8例IIIA期，2例IIIB期，3例IIIC期，6例IV期。辅助治疗包括：5例未接受辅助治疗，22例接受放疗（13例盆腔放疗，2例阴道近距离放疗，7例两者皆有），11例接受化疗（8例单纯化疗，3例在盆腔放疗后化疗），3例接受激素治疗。无一例患者接受全腹放疗或腹主动脉旁放疗。中位随访时间为36.5个月。
整个组的5年无病生存率为38.5%。复发与分期、肌层浸润、细胞学、宫颈受累或子宫外部位受累之间未见相关性。透明细胞癌伴/不伴腺癌组织学类型的患者5年无病生存率相似（38.8%对38.7%，p = 0.95），与透明细胞癌+其他不良组织学类型的患者相比。16例患者复发（42%）。8例在盆腔复发（5例阴道，3例盆腔侧壁）。接受辅助放疗的22例患者组中无盆腔复发，而未接受放疗的16例女性组中，8例（50%）在盆腔复发（p < 0.0001）。IA-IIB期接受和未接受放疗患者相应的盆腔复发率分别为0/16（0%）和5/6（83%）（p < 0.0001）。6例患者（16%）在腹主动脉旁淋巴结复发，2例（5%）在腹部复发。仅1例（2%）患者出现孤立性腹部复发（该患者为透明细胞/乳头状浆液性混合肿瘤）。在26例透明细胞癌伴/不伴腺癌组织学类型的女性中，仅1例（3.8%）在腹部复发。9例患者（24%）在远处部位复发，主要为肺和骨。
透明细胞癌占子宫内膜癌的比例较小，常表现为混合组织学类型，总体预后较差。与乳头状浆液性肿瘤不同，透明细胞癌似乎没有较高的腹部复发倾向。因此，我们的结果不支持在这些患者中常规使用全腹放疗。未来的方案应侧重于局部区域放疗和化疗的联合应用，以降低局部和全身复发的风险。
