Lin Haoliang, Wang Dongyan, Li Hui, Wu Chuling, Zhang Fengqian, Lin Zhongqiu, Yao Tingting
Department of Gynecological Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China.
Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China.
Front Oncol. 2022 Aug 11;12:952480. doi: 10.3389/fonc.2022.952480. eCollection 2022.
Cervical cancer with nodal involvement beyond the pelvis was considered as distant nodal metastasis in the previous International Federation of Gynecology and Obstetrics staging system. With the improvement of cancer-directed therapies, some of these patients can receive curative treatment. Classifying them as distant metastasis may result in underestimation of their prognosis as well as undertreatment. However, limited research has been conducted on the survival and treatment pattern in distant lymphatic metastatic cervical cancer.
To investigate the survival, treatment pattern, and treatment outcome of patients with cervical cancer metastasized to distant lymph nodes (DLN) beyond the pelvis.
Patients with stage III-IV cervical cancer from 1988 to 2016 were identified using the Surveillance, Epidemiology, and End Results program. The cancer cause-specific survival (CSS) was analyzed using the Kaplan-Meier method, log-rank test, multivariable Cox proportional hazard regression, subgroup analysis, and propensity score-matched analysis.
Of 17783 patients with stage III-IV cervical cancer, patients with distant nodal disease beyond the pelvis (n=1883; included para-aortic lymph nodes metastasis) had superior survival compared to those with pelvic organ invasion or with distant organ(s) metastasis (5-year CSS, 32.3%, 26.3%, and 11.5%, respectively; adjusted <0.001). The T stage significantly affected the survival of patients with positive DLN (5-year CSS for T1, T2, and T3: 47.3%, 37.0%, and 19.8%, respectively, adjusted <0.01). For patients with positive DLN, combination radiotherapy (external beam radiotherapy [EBRT] with brachytherapy) prolonged CSS compared to EBRT alone (5-year CSS, 38.0% vs 21.7%; propensity score-adjusted HR, 0.60; 95% CI 0.51-0.72; <0.001). Despite the superiority of combination radiotherapy, EBRT was the most frequently used treatment after 2004 (483/1214, 39.8%), while the utilization of combination radiotherapy declined from 37.8% (253/669) during 1988 through 2003 to 25.2% (306/1214) during 2004 through 2016.
Patients with cervical cancer metastasized to DLN have favorable survival compared to those with pelvic organ invasion or with distant organ(s) metastasis. Their prognosis is significantly affected by local tumor burden and local treatment. Adequate and aggressive local radiotherapy, such as image-guided brachytherapy, can be considered for these patients to achieve better outcomes.
在既往国际妇产科联盟（International Federation of Gynecology and Obstetrics）分期系统中，伴有盆腔以外淋巴结转移的宫颈癌被视为远处淋巴结转移。随着针对癌症治疗方法的改进，其中一些患者可以接受根治性治疗。将他们归类为远处转移可能会导致对其预后的低估以及治疗不足。然而，关于远处淋巴转移宫颈癌的生存情况和治疗模式的研究有限。
探讨盆腔以外远处淋巴结转移（DLN）的宫颈癌患者的生存情况、治疗模式和治疗结局。
利用监测、流行病学和最终结果（Surveillance, Epidemiology, and End Results）计划识别1988年至2016年的III-IV期宫颈癌患者。采用Kaplan-Meier法、对数秩检验、多变量Cox比例风险回归、亚组分析和倾向评分匹配分析对癌症特异性生存（CSS）进行分析。
在17783例III-IV期宫颈癌患者中，盆腔以外有远处淋巴结疾病的患者（n = 1883；包括腹主动脉旁淋巴结转移）的生存率高于有盆腔器官侵犯或远处器官转移的患者（5年CSS分别为32.3%、26.3%和11.5%；校正P<0.001）。T分期显著影响DLN阳性患者的生存（T1、T2和T3的5年CSS分别为47.3%、37.0%和19.8%，校正P<0.01）。对于DLN阳性患者，与单纯体外照射放疗（EBRT）相比，联合放疗（体外照射放疗[EBRT]加近距离放疗）可延长CSS（5年CSS，38.0%对21.7%；倾向评分校正风险比，0.60；95%可信区间0.51-0.72；P<0.001）。尽管联合放疗具有优势，但2004年后EBRT是最常用的治疗方法（483/1214，39.8%），而联合放疗的使用率从1988年至2003年期间的37.8%（253/669）降至2004年至2016年期间的25.2%（306/1214）。
与有盆腔器官侵犯或远处器官转移的患者相比，发生DLN转移的宫颈癌患者具有较好的生存率。他们的预后受局部肿瘤负荷和局部治疗的显著影响。对于这些患者，可以考虑采用充分且积极的局部放疗，如图像引导近距离放疗，以获得更好的治疗效果。
