Wang Weiping, Zhou Yuncan, Wang Dunhuang, Hu Ke, Zhang Fuquan
Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
Front Oncol. 2020 Oct 2;10:579410. doi: 10.3389/fonc.2020.579410. eCollection 2020.
Currently, the standard radiation field for locally advanced cervical cancer patients without evidence of para-aortic lymph node (PALN) metastasis is the pelvis. Due to the low accuracy of imaging in the diagnosis of PALN metastasis and the high incidence of PALN failure after pelvic radiotherapy, prophylactic pelvic and para-aortic irradiation, also called extended-field irradiation (EFI), is performed for patients with cervical cancer. In the era of concurrent chemoradiotherapy, randomized controlled trials are limited, and whether patients with cervical cancer can benefit from prophylactic EFI is still controversial. With conformal or intensity-modulated radiation therapy, patients tolerate prophylactic EFI very well. The severe toxicities of prophylactic EFI are not significantly higher than those of pelvic radiotherapy. We recommend delivering prophylactic EFI to cervical cancer patients with common iliac lymph nodes metastasis. Clinical trials are needed to investigate whether patients with ≥3 positive pelvic lymph nodes and FIGO stage IIIB disease can benefit from prophylactic EFI. According to the distribution of PALNs, it is reasonable to use the renal vein as the upper border of the radiation therapy field for patients treated with prophylactic EFI. The clinical target volume expansion of the node from the vessel should be smaller in the right para-caval region than in the left lateral para-aortic region. The right para-caval region above L2 or L3 may be omitted from the PALN target volume to reduce the dose to the duodenum. More clinical trials on prophylactic EFI in cervical cancer are needed.
目前，对于无腹主动脉旁淋巴结（PALN）转移证据的局部晚期宫颈癌患者，标准放射野是盆腔。由于PALN转移诊断中影像学检查准确性较低，且盆腔放疗后PALN失败发生率较高，因此对宫颈癌患者进行预防性盆腔和腹主动脉旁照射，即扩大野照射（EFI）。在同步放化疗时代，随机对照试验有限，宫颈癌患者是否能从预防性EFI中获益仍存在争议。采用适形或调强放射治疗时，患者对预防性EFI耐受性良好。预防性EFI的严重毒性并不显著高于盆腔放疗。我们建议对有髂总淋巴结转移的宫颈癌患者进行预防性EFI。需要开展临床试验来研究盆腔淋巴结≥3枚阳性且国际妇产科联盟（FIGO）分期为IIIB期的患者是否能从预防性EFI中获益。根据PALN的分布情况，对于接受预防性EFI治疗的患者，将肾静脉作为放疗野的上界是合理的。在腔静脉右侧区域，淋巴结从血管的临床靶体积扩展应小于腹主动脉左侧旁区域。为减少十二指肠受量，可将L2或L3以上的腔静脉右侧区域从PALN靶体积中省略。宫颈癌预防性EFI还需要更多的临床试验。
