Perez C A, Grigsby P W, Camel H M, Galakatos A E, Mutch D, Lockett M A
Radiation Oncology Center, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO.
Int J Radiat Oncol Biol Phys. 1995 Feb 15;31(4):703-16. doi: 10.1016/0360-3016(94)00523-0.
Definitive radiation therapy alone or combined with surgery in carcinoma of the uterine cervix yields comparable tumor control and survival in Stages I and IIA when patients are adequately treated with either modality. Our 30-year institutional experience is described.
This is a nonrandomized comparison of treatment results of 415 patients with Stage IB, 137 with Stage IIA, and 340 with Stage IIB carcinoma of the uterine cervix treated with irradiation alone and 197 with Stage IB, 44 with Stage IIA, and 65 with limited Stage IIB treated with pre- or postoperative irradiation and surgery. Irradiation alone consisted of a combination of external beam therapy and intracavitary insertions to deliver doses of 70 to 85 Gy to point A for patients with Stages IB and IIA disease and 80 to 90 Gy for patients with bulky or Stage IIB tumors. For patients treated with irradiation and surgery, various combinations of external beam and intracavitary therapy were used to deliver 60 to 75 Gy to point A. Surgical procedures consisted of radical hysterectomy with or without lymph node dissection in 130 patients with Stage IB, 28 patients with Stage IIA, and 10 patients with limited Stage IIB. Fifty-seven patients had total abdominal or conservative hysterectomy with or without lymph node dissection, and 3 had vaginal hysterectomy. In addition, 51 patients with Stage IIB tumors underwent pelvic lymphadenectomy after definitive irradiation.
The 5-year cause-specific survival (CSS) rates for patients with Stage IB nonbulky tumors treated with irradiation alone or irradiation combined with surgery were 90 and 85%, respectively, and the 10-year survival rate was 84% with either modality. In patients with bulky tumors (> 5 cm), the 5-year CSS rates were 61% with irradiation alone and 63% with irradiation plus surgery; at 10 years the rates were 61 and 68%, respectively (p = 0.5). For those with Stage IIA nonbulky tumors, the 5-year CSS rates were 75% with irradiation alone and 83% with combined irradiation and surgery, and 10-year CSS rates were 66 and 71%, respectively. In patients with Stage IIA bulky tumors, the 5-year CSS rates were 69% with irradiation alone and 60% with irradiation plus surgery, and at 10 years, 69 and 44%, respectively (p = 0.05). In patients with Stage IIB nonbulky tumors treated with irradiation alone or combined with surgery, the 5- and 10-year CCS rates were 72 and 65%, respectively; the corresponding survival rates with bulky tumors or bilateral parametrial involvement were 56 and 50%. Incidence of pelvic failures, alone or with distant metastasis, for Stage IB was 10% (43 out of 415) with irradiation alone and 14% (28 of 197) with irradiation plus surgery; for Stage IIA, 17% (23 out of 137) with irradiation alone and 20% (9 our of 44) with irradiation plus surgery; and for Stage IIB, 23% (88 out of 391) with irradiation alone and 29% (4 out of 14) with irradiation plus surgery. Grade 3 sequelae were comparable in both groups (irradiation alone, 5% to 11%; irradiation combined with surgery, 8% to 12%); the differences are not statistically significant. The most frequent major sequelae in 892 patients receiving irradiation only were rectovaginal fistula (13 cases, 1.5%), proctitis (10, 1.1%), small bowel obstruction (16, 1.8%), ureteral stricture (16, 1.8%), and vesicovaginal fistula (8, 0.9%). In 306 patients treated with irradiation plus surgery, the most commonly recorded major sequelae were small bowel obstruction/perforation (13 cases, 4.2%), ureteral stricture (8, 2.6%), vesicovaginal fistula (5, 1.6%), and rectovaginal fistula (4, 1.3%).
Irradiation alone or combined with surgery yields comparable pelvic tumor control, survival, and morbidity in patients with Stage IB, IIA, and limited IIB carcinoma of the uterine cervix.
对于Ⅰ期和ⅡA期子宫颈癌患者，单纯根治性放疗或放疗联合手术，若两种治疗方式应用得当，则肿瘤控制效果和生存率相当。本文介绍了我们机构30年的经验。
这是一项非随机对照研究，比较单纯放疗与放疗联合手术的治疗结果。单纯放疗组有415例ⅠB期、137例ⅡA期和340例ⅡB期子宫颈癌患者；放疗联合手术组有197例ⅠB期、44例ⅡA期和65例局限期ⅡB期患者。单纯放疗采用外照射和腔内照射相结合的方式，给予ⅠB期和ⅡA期疾病患者A点剂量70至85 Gy，给予肿瘤体积大或ⅡB期患者A点剂量80至90 Gy。对于放疗联合手术的患者，采用外照射和腔内照射的不同组合给予A点剂量60至75 Gy。手术方式包括：130例ⅠB期、28例ⅡA期和10例局限期ⅡB期患者行根治性子宫切除术，可选择是否行淋巴结清扫；57例患者行全腹或保守性子宫切除术，可选择是否行淋巴结清扫；3例患者行阴道子宫切除术。此外，51例ⅡB期肿瘤患者在根治性放疗后行盆腔淋巴结清扫术。
对于非体积大的ⅠB期肿瘤患者，单纯放疗和放疗联合手术的5年疾病特异性生存率（CSS）分别为90%和85%，两种治疗方式的10年生存率均为84%。对于体积大的肿瘤（>5 cm）患者，单纯放疗的5年CSS率为61%，放疗加手术的5年CSS率为63%；10年时，相应的生存率分别为61%和68%（p = 0.5）。对于非体积大的ⅡA期肿瘤患者，单纯放疗的5年CSS率为75%，放疗联合手术的5年CSS率为83%，10年CSS率分别为66%和71%。对于体积大的ⅡA期肿瘤患者，单纯放疗的5年CSS率为69%，放疗加手术的5年CSS率为60%，10年时分别为69%和44%（p = 0.05）。对于非体积大的ⅡB期肿瘤患者，单纯放疗或放疗联合手术的5年和10年CSS率分别为72%和65%；对于体积大的肿瘤或双侧宫旁受累患者，相应的生存率分别为56%和50%。ⅠB期患者单纯放疗或放疗联合手术时盆腔失败（单独或合并远处转移）的发生率分别为10%（415例中的43例）和14%（197例中的28例）；ⅡA期患者分别为17%（137例中的23例）和20%（44例中的�例）；ⅡB期患者分别为23%（391例中的88例）和29%（14例中的4例）。两组3级后遗症发生率相当（单纯放疗为5%至11%；放疗联合手术为8%至12%）；差异无统计学意义。在仅接受放疗的892例患者中，最常见的主要后遗症为直肠阴道瘘（13例，1.5%）、直肠炎（10例，1.1%）、小肠梗阻（16例，1.8%）、输尿管狭窄（16例，1.8%）和膀胱阴道瘘（8例，0.9%）。在接受放疗加手术的306例患者中，最常记录的主要后遗症为小肠梗阻/穿孔（13例，4.2%）、输尿管狭窄（8例，2.6%）、膀胱阴道瘘（5例，1.6%）和直肠阴道瘘（4例，1.3%）。
对于ⅠB期、ⅡA期和局限期ⅡB期子宫颈癌患者，单纯放疗或放疗联合手术在盆腔肿瘤控制、生存率和并发症方面效果相当。
