Bean Lisa M, Ward Kristy K, Plaxe Steven C, McHale Michael T
Division of Gynecologic Oncology, Department of Reproductive Medicine, University of California San Diego, Moores Cancer Center, La Jolla, CA.
Division of Gynecologic Oncology, Department of Reproductive Medicine, University of California San Diego, Moores Cancer Center, La Jolla, CA; Division of Gynecologic Oncology, University of Florida Jacksonville, Jacksonville, FL.
Am J Obstet Gynecol. 2017 Sep;217(3):332.e1-332.e6. doi: 10.1016/j.ajog.2017.05.021. Epub 2017 May 15.
Treatment for early-invasive adenocarcinoma of the cervix remains controversial. Although data have shown similar survival rates to those seen with squamous cell carcinoma, conservative options for patients with microinvasive adenocarcinoma have not been as widely accepted. Despite comparable survival outcomes, patients with early-invasive adenocarcinoma are still routinely subjected to more radical surgical techniques than their equivalently staged squamous cell counterparts.
The objective of the study was to evaluate how less radical surgery has an impact on 5 year survival in patients with microinvasive adenocarcinoma of the cervix.
The Surveillance, Epidemiology, and End Results database was queried from 1988 through 2010 to perform a retrospective analysis of women with International Federation of Gynecology and Obstetrics stage IA1 or IA2 cervical carcinoma. Five year survival by procedure type (local excision, simple hysterectomy, or radical hysterectomy) was determined for each cell type (squamous or adenocarcinoma), as was lymph node status.
Among 1567 patients with cervical adenocarcinoma, 5 year survival was 97.3% (confidence interval, 95.8-98.2%) for stage IA1 disease and 98.3% (confidence interval, 96.5%, 99.2%) for stage IA2. For comparison, the 5-year survival rates for 5,749 patients with stage IAI or lA2 squamous cell carcinoma were 96.7% (confidence interval, 96.0-97.3%) and 95.6% (confidence interval, 94.4-96.5%), respectively. For stage IA1 ACA, survival was 96.6%, 98.4% and 96.5% following excision, hysterectomy and radical hysterectomy, respectively. For stage IA2 ACA, survival rates were 100%, 96.9% and 99.4%, respectively. There was no statistical difference in survival between patients having either cell type undergoing local excision (P = .26), simple hysterectomy (P = .08), or radical hysterectomy (P = .87). We also found no statistically significant difference in survival among patients with adenocarcinoma compared by treatment type (local excision compared with simple hysterectomy [P = .64]; local excision compared with radical hysterectomy [P = .82]; or simple hysterectomy compared with radical hysterectomy [P = .70]). Among patients with adenocarcinoma, 0.97% had positive pelvic lymph nodes, none had positive aortic lymph nodes, and 91.85% had confirmed negative lymph nodes. For squamous cell carcinoma, 0.72% of patients had positive pelvic lymph nodes and 0.10% had positive aortic lymph nodes.
There was no significant difference in survival when patients were compared by cell type or procedure, suggesting that survival of patients with microinvasive adenocarcinoma is not improved by utilizing more invasive surgical methods. Regardless of histology, the frequency of nodal involvement was very low among both groups, supporting an overall excellent prognosis for all patients with microinvasive disease. We submit these data as evidence that preoperative planning of more conservative techniques is appropriate, not just for those with squamous histology or who desire future fertility, but for all patients with microinvasive cervical disease.
早期浸润性宫颈癌的治疗仍存在争议。尽管数据显示其生存率与鳞状细胞癌相似，但对于微浸润腺癌患者的保守治疗方案尚未得到广泛认可。尽管生存结果相当，但早期浸润性腺癌患者仍比同等分期的鳞状细胞癌患者常规接受更激进的手术技术。
本研究的目的是评估较保守的手术对宫颈微浸润腺癌患者5年生存率的影响。
查询1988年至2010年的监测、流行病学和最终结果数据库，对国际妇产科联盟IA1或IA2期宫颈癌女性进行回顾性分析。确定每种细胞类型（鳞状或腺癌）按手术类型（局部切除、单纯子宫切除术或根治性子宫切除术）的5年生存率以及淋巴结状态。
在1567例宫颈腺癌患者中，IA1期疾病的5年生存率为97.3%（置信区间，95.8 - 98.2%），IA2期为98.3%（置信区间，96.5%，99.2%）。作为对比，5749例IA1或IA2期鳞状细胞癌患者的5年生存率分别为96.7%（置信区间，96.0 - 97.3%）和95.6%（置信区间，94.4 - 96.5%）。对于IA1期腺癌患者，局部切除、子宫切除和根治性子宫切除后的生存率分别为96.6%、98.4%和96.5%。对于IA2期腺癌患者，生存率分别为100%、96.9%和99.4%。两种细胞类型的患者进行局部切除（P = 0.26）、单纯子宫切除（P = 0.08）或根治性子宫切除（P = 0.87）时，生存率无统计学差异。我们还发现，按治疗类型比较腺癌患者生存率时无统计学显著差异（局部切除与单纯子宫切除比较[P = 0.64]；局部切除与根治性子宫切除比较[P = 0.82]；或单纯子宫切除与根治性子宫切除比较[P = 0.70]）。在腺癌患者中，0.97%盆腔淋巴结阳性，无主动脉淋巴结阳性，91.85%淋巴结确认阴性。对于鳞状细胞癌，0.72%的患者盆腔淋巴结阳性，0.10%的患者主动脉淋巴结阳性。
按细胞类型或手术方式比较患者时，生存率无显著差异，这表明采用更具侵入性的手术方法并不能提高微浸润腺癌患者的生存率。无论组织学类型如何，两组中淋巴结受累的频率都非常低，这支持了所有微浸润疾病患者总体预后良好的观点。我们提交这些数据作为证据，证明更保守技术的术前规划是合适的，不仅适用于鳞状组织学类型的患者或希望保留生育能力的患者，也适用于所有宫颈微浸润疾病患者。
