Chao K S, Leung W M, Grigsby P W, Mutch D G, Herzog T, Perez C A
Radiation Oncology Center, Mallinckrodt Institute of Radiology, St. Louis, MO 63110, USA.
Int J Radiat Oncol Biol Phys. 1998 Mar 15;40(5):1095-100. doi: 10.1016/s0360-3016(97)00899-7.
There are two criteria for the diagnosis of Stage IIIB cervical cancer in the FIGO staging system: tumor fixation to the pelvic side wall and/or the presence of hydronephrosis due to tumor. However, we often encounter hydronephrosis without tumor fixed to the pelvic side wall or the level of ureteral obstruction not corresponding to the main tumor mass in the pelvis. The clinical implication of these phenomena remains unclear. We investigated the Stage IIIB population treated at the Mallinckrodt Institute of Radiology and hypothesized that, if hydronephrosis presents without tumor fixation to the pelvic side wall or if the level of ureteral obstruction is above the main pelvic tumor mass, it most likely resulted from external compression of ureter(s) by enlarged lymph nodes and, consequently, a worse outcome is expected.
From 1959 to 1989, there were 297 patients with Stage IIIB cervical cancer who received definitive radiation therapy at the Mallinckrodt Institute of Radiology and were assessable for the presence of hydronephrosis and the level of ureteral obstruction. There were 281 patients who presented with tumor fixed to the pelvic side wall, and 62 of them were associated with concurrent hydronephrosis. An additional 16 patients presented with hydronephrosis without tumor fixation to the pelvic side wall. Among these 78 documented cases of hydronephrosis, the level of ureteral obstruction was above the true pelvis in 39 patients, and below the true pelvis in the other 39. Radiation therapy was individualized according to tumor extension and configuration; para-aortic lymph nodes were not routinely treated except in patients with clinical evidence of nodal metastasis.
The progression-free survival (PFS) at 5 years was 35% in 62 patients with hydronephrosis and tumor fixed to the pelvic side wall vs. 43% in 213 patients with tumor fixed to the pelvic side wall only (p=0.12). However, PFS at 5 years decreased to 23% in 16 patients who presented with hydronephrosis without tumor fixation to the pelvic side wall (p < 0.001). When the level of ureteral obstruction was investigated, 5-year PFS was 39% vs. 22%, respectively, for the obstruction below vs. above the true pelvis (p=0.02). The majority of patients with ureteral obstruction above the true pelvis died of distant metastasis.
The additional presence of hydronephrosis did not significantly worsen the PFS among Stage IIIB patients with tumor fixation to the pelvic side wall. However, hydronephrosis without tumor extending to the pelvic side wall or the level of ureteral obstruction above the true pelvis was associated with poor outcome due to a significant increase in distant failure. We propose that this population be separated from current Stage IIIB classification.
国际妇产科联盟（FIGO）分期系统中，IIIB期宫颈癌的诊断有两条标准：肿瘤固定于盆腔侧壁和/或因肿瘤导致肾积水。然而，我们经常遇到肾积水但肿瘤未固定于盆腔侧壁，或输尿管梗阻水平与盆腔内主要肿瘤块不对应的情况。这些现象的临床意义仍不明确。我们对马林克罗特放射研究所治疗的IIIB期患者群体进行了研究，并假设，如果肾积水伴有肿瘤未固定于盆腔侧壁，或输尿管梗阻水平高于盆腔内主要肿瘤块，很可能是肿大淋巴结对输尿管的外部压迫所致，因此预期预后较差。
1959年至1989年，有297例IIIB期宫颈癌患者在马林克罗特放射研究所接受了根治性放疗，且可评估肾积水情况和输尿管梗阻水平。有281例患者肿瘤固定于盆腔侧壁，其中62例同时伴有肾积水。另有16例患者肾积水但肿瘤未固定于盆腔侧壁。在这78例有记录的肾积水病例中，39例患者输尿管梗阻水平高于真骨盆，另外39例低于真骨盆。放疗根据肿瘤范围和形态个体化进行；除非有临床证据表明有淋巴结转移，腹主动脉旁淋巴结一般不常规治疗。
62例肾积水且肿瘤固定于盆腔侧壁的患者5年无进展生存率（PFS）为35%，而仅肿瘤固定于盆腔侧壁的213例患者为43%（p = 0.12）。然而，16例肾积水但肿瘤未固定于盆腔侧壁的患者5年PFS降至23%（p < 0.001）。当研究输尿管梗阻水平时，梗阻低于真骨盆的患者5年PFS为39%，高于真骨盆的为22%（p = 0.02）。大多数输尿管梗阻水平高于真骨盆的患者死于远处转移。
对于肿瘤固定于盆腔侧壁的IIIB期患者，额外存在肾积水并未显著恶化其PFS。然而，肾积水但肿瘤未延伸至盆腔侧壁或输尿管梗阻水平高于真骨盆与远处转移显著增加导致的预后不良相关。我们建议将这部分患者从当前的IIIB期分类中区分出来。
