Zola P, Fuso L, Mazzola S, Piovano E, Perotto S, Gadducci A, Galletto L, Landoni F, Maggino T, Raspagliesi F, Sartori E, Scambia G
Department of Gynecology and Obstetrics, University of Turin, Turin, Italy.
Gynecol Oncol. 2007 Oct;107(1 Suppl 1):S150-4. doi: 10.1016/j.ygyno.2007.07.028. Epub 2007 Sep 14.
The aim of this study was to evaluate how much clinical surveillance performed by follow-up scheduled appointments may correctly identify asymptomatic recurrences and describe the pattern of relapse detected by procedures.
The records of 327 consecutive women with recurrent cervical cancer treated from 1980 to 2005 were retrospectively collected in 8 Italian Institutions. Primary disease and recurrence data were picked up: diagnosis, type of treatment, FIGO stage, tumour grade, histology, clinical lesion size, number of localizations and site of relapse, presence of symptoms and primary method of detection, the type of treatment of recurrence and follow-up data, such as appointment date, clinical status and procedure performed. A multivariate analysis was carried out using the Cox proportional hazards regression model. Survival curves were calculated using the Kaplan-Meier technique. Survival differences were evaluated by the log-rank test.
Sixty-seven out of 327 patients (20.5%) had a local recurrence on vaginal vault, 120 (36.7%) in central pelvis, 31 (9.5%) in pelvic wall, 16 cases (4.9%) in lymph nodes. Seventy-nine patients (24.2%) showed a distant relapse while 14 (4.3%) developed both a distant and local relapse. Among patients with distant relapses 39 (49.4%) had lung metastasis, 41 (51.9%) an hepatic recurrence, 4 (5.1%) a bone relapse. Among distant sites 32 out of 79 patients (40.5%) had single relapse and 46 (58.2%) had multiple localizations. The site of relapse influenced survival since patients with vaginal vault recurrences lived significantly longer than patients with recurrences in other sites. Ninety-seven (29.7%) patients were symptomatic and anticipated the scheduled visit, 66 (20.2%) reported their symptoms during the follow-up visit and 164 (50.1%) were asymptomatic and the diagnostic path was introduced by a planned visit or exam. Between asymptomatic patients the first procedure was clinical visit for 85 patients out of 164 patients (51.8%), imaging for 60 patients (36.6%), both clinical visit and imaging for 14 (8.5%) and cytology for 5 (3%, Pap smear test). The median OS of symptomatic patients was 37 months versus 109 months of asymptomatic patients (Log rank, p=0.00001). The median survival since recurrence was 9 months for symptomatic patients and median was not reached for asymptomatic patients (p<0.0001). The median disease-free interval was 24 months for asymptomatic patients vs. 36 months for symptomatic patients (p=0.03).
Our study helps demonstrate the great need of prospective cost-effectiveness studies which are lacking at the present time.
本研究旨在评估通过定期随访预约进行的临床监测能够正确识别无症状复发的程度，并描述通过相关程序检测到的复发模式。
回顾性收集了1980年至2005年期间在意大利8家机构接受治疗的327例复发性宫颈癌连续病例的记录。收集了原发性疾病和复发数据：诊断、治疗类型、国际妇产科联盟（FIGO）分期、肿瘤分级、组织学、临床病变大小、复发部位数量和部位、症状的存在情况和主要检测方法、复发的治疗类型以及随访数据，如预约日期、临床状态和所进行的程序。使用Cox比例风险回归模型进行多变量分析。采用Kaplan-Meier技术计算生存曲线。通过对数秩检验评估生存差异。
327例患者中，67例（20.5%）阴道穹窿局部复发，120例（36.7%）盆腔中部复发，31例（9.5%）盆腔壁复发，16例（4.9%）淋巴结复发。79例患者（24.2%）出现远处复发，14例（4.3%）同时出现远处和局部复发。在远处复发的患者中，39例（49.4%）有肺转移，41例（51.9%）肝复发，4例（5.1%）骨复发。在远处部位中，79例患者中有32例（40.5%）单发复发，46例（58.2%）多发。复发部位影响生存，因为阴道穹窿复发的患者比其他部位复发的患者存活时间显著更长。97例（29.7%）患者有症状并提前预约就诊，66例（20.2%）在随访就诊时报告了症状，164例（50.1%）无症状，诊断途径是通过计划就诊或检查。在无症状患者中，164例患者中有85例（51.8%）的首次程序是临床就诊，60例（36.6%）是影像学检查，14例（8.5%）是临床就诊和影像学检查，5例（3%，巴氏涂片检查）是细胞学检查。有症状患者的中位总生存期为37个月，无症状患者为109个月（对数秩检验，p = 0.00001）。有症状患者复发后的中位生存期为9个月，无症状患者未达到中位生存期（p < 0.0001）。无症状患者的中位无病间期为24个月，有症状患者为36个月（p = 0.03）。
我们的研究有助于证明目前缺乏前瞻性成本效益研究的迫切需求。
