宫颈癌不同根治性放疗技术剂量学研究

目的:比较不同根治性放疗技术对腹膜后淋巴结转移的宫颈癌患者放疗靶区及危险器官剂量学的差异,为临床提供剂量学参考.方法:选取10例腹膜后淋巴结转移拟行根治性放疗的宫颈癌患者,分别制订常规盆腔4野盒式照射+腹主动脉旁淋巴引流区适形照射计划(常规放疗组)和调强放疗计划(IMRT组),比较两者靶区及危险器官受量.结果:IMRT计划PTV适形度优于常规放疗计划,差异具有统计学意义,P＜0.05.与常规计划相比,IMRT计划的膀胱Ds0下降11％,直肠D50下降13％,小肠D50下降20％,脊髓D1cc受照剂量下降16％.结论:对于腹膜后淋巴结转移行根治性放疗的宫颈癌患者来说,IMRT计划较常规盆腔4野照射+腹主动脉旁淋巴引流区5野适形照射计划有明显的剂量学优势.     

延伸野IMRT对宫颈癌预后研究进展

近几十年精确放疗技术发展迅速,IMRT在妇科恶性肿瘤中的应用也逐渐增加。研究表明在晚期宫颈癌患者中有很高的隐匿性腹主动脉旁淋巴结转移的发生率,而盆腔和腹主动脉旁淋巴结状态是宫颈癌患者重要预后影响因素。既往预防性延伸野常规放疗存在严重胃肠道副反应,联合同步化疗也存在争议。现有研究对于转移性盆腔及腹主动脉旁淋巴结的最佳放疗剂量也未达成共识。本文主要分析预防性延伸野IMRT联合同步化疗对宫颈癌患者预后影响和淋巴结阳性区域剂量效应关系。     

局部晚期宫颈癌的放化疗研究进展

宫颈癌为常见的女性生殖系统恶性肿瘤,半数患者就诊时已为局部晚期。调强放疗和三维后装放疗在剂量学和放射生物效应方面优于传统放疗,成为局部晚期宫颈癌(LACC)放疗的主流。LACC单纯放疗的效果较差,而放化疗综合治疗可以明显提高疗效。目前同步以铂类为基础的放化疗为LACC的标准治疗模式,但诱导化疗、辅助化疗的价值及其与同步放化疗的不同组合模式的价值有待明确。对放疗资源受限的区域,术前新辅助化疗可能是一种有效的补充治疗。调强同步放化疗时,盆腔延伸野预防性放疗的价值有待明确。正电子发射断层显像术(PET)/计算机体层摄影(CT)对腹主动脉旁淋巴结情况有较高的影像判读价值,有助于外科手术评估时个体化治疗方案的确定。本文就LACC放疗、化疗的研究进展作一综述。     

预防性EFRT应用于晚期宫颈癌的研究进展

宫颈癌是妇科常见恶性肿瘤,其发病率和死亡率在女性恶性肿瘤中居第四位。淋巴结转移是其最主要的转移方式,也是宫颈癌的重要独立预后不良因素。考虑到腹主动脉旁淋巴结转移的漏诊率较高,及宫颈癌治疗后腹主动脉旁淋巴结转移导致的治疗失败率较高,近年来有临床医生将预防性延伸野放疗应用于Ⅲ B及Ⅲ c1宫颈癌患者的治...     

早期宫颈癌髂总淋巴结转移相关因素及预后临床分析

目的 探讨Ⅰ B1～ⅡA2期宫颈癌髂总淋巴结转移的相关因素及预后,为指导临床治疗提供依据.方法 回顾性分析1997-06 12-2013-06-30山东省肿瘤医院收治的行广泛子宫切除+盆腔淋巴清除术284例Ⅰ B1～ⅡA2期宫颈癌患者的临床病理资料.结果 在284例患者中有盆腔淋巴结转移82例,转移率为28.9％.其中髂总淋巴结转移率为5.3％(15/284),腹主动脉旁淋巴结转移率为2.8％(8/284).单因素分析显示,淋巴血管间隙浸润、盆腔其他淋巴结转移是髂总淋巴结转移的危险因素,P＜0.05.多因素分析显示,盆腔其他淋巴结转移为髂总淋巴结转移的独立危险因素,OR=35.41,P=0.001.髂总淋巴结阳性患者5年总生存率为21.2％.多因素分析显示,淋巴血管间隙浸润(OR=2.6,P=0.01)及腹主动脉旁淋巴结转移(OR=9.3,P＜0.01)均为早期宫颈癌髂总淋巴结转移患者5年生存率的独立影响因素.结论 早期宫颈癌髂总淋巴结转移率较低,盆腔其他淋巴结转移是其独立高危因素,而且髂总淋巴结转移患者预后较差.若术后病理显示髂总淋巴结转移患者,在补充放化疗时,建议采用调强适形放疗,同时建议其靶区勾画的范围上界达到腹主动脉旁.     

宫颈癌术后容积旋转调强治疗与三维适形调强放疗的临床研究

目的 评估宫颈癌术后盆腔放疗中开展容积旋转调强治疗(VMAT)与三维适形调强放疗(IMRT)的近期疗效及不良反应.方法 选取30例宫颈癌术后盆腔肿瘤床及淋巴引流区预防性放射治疗的患者,其中15例接受了VMAT治疗,15例患者接受了IMRT治疗.放疗采用每周5次,每日1次,每次1.8Gy.盆腔预防性放疗处方剂量为45Gy.根据RTOG评定指标评价放射治疗反应.结果 至末次随访时间,VMAT组4例复发,IMRT组5例复发.骨髓抑制反应VMAT组11例,IMRT组12例.全部患者中,均未出现3级及以上胃肠道早期反应及泌尿道早期反应.结论 对宫颈癌术后应用容积旋转调强技术及固定野调强技术进行照射治疗,两者在不良反应及复发率上无明显差别.     

睾丸精原细胞瘤124例临床分析

目的探讨睾丸精原细胞瘤的治疗和预后之间的关系。方法回顾性分析山东省肿瘤防治研究院１９６３年７月～１９９５年１１月收治的精原细胞瘤患者１２４例,其中,Ⅰ期精原细胞瘤患者仅做精索高位结扎睾丸切除加髂－腹主动脉旁淋巴引流区放射治疗;Ⅱ、Ⅲ期精原细胞瘤术后给予放疗及有计划地加用辅助性化疗。结果Ⅰ、Ⅱ、Ⅲ期精原细胞瘤５年生存率分别为９５．９％、７０．４％、和０。结论Ⅰ期精原细胞瘤患者仅做精索高位结扎睾丸切除加髂－腹主动脉旁淋巴引流区放射治疗可以治愈;而对Ⅱ、Ⅲ期病例单用睾丸切除加淋巴引流区放射治疗是不够的,为改善Ⅱ、Ⅲ期精原细胞瘤患者的预后,在预防性／根治性照射后,有计划的加用辅助性化疗是必要的。     

宫颈癌盆腔淋巴结靶区的勾画研究进展

宫颈癌发病率仅次于乳腺癌，居全世界女性恶性肿瘤的第二位。全世界每年约有20多万妇女死于宫颈癌。放射治疗在宫颈癌的治疗中居于重要地位，而全盆腔放疗一直都是根治性放疗或术后放疗的标准野，并且在一些具有高危因素的患者，还需要进行延伸野照射。照射野通常包括原发肿瘤部位，盆腔淋巴引流区及腹膜后淋巴引流区，同时包括小肠、直肠、膀胱、肾等正常器官。     

同步放化疗对伴有盆腹腔淋巴结转移的宫颈癌患者疗效分析

目的 研究同步放化疗是否提高根治术后伴有盆腹腔淋巴结转移宫颈癌患者的生存。方法 收集2008-2011年间188例行宫颈癌根治术且术后病理伴有盆腹腔淋巴结转移的患者的临床资料,分析同步放化疗的疗效。结果 全组46例患者出现复发转移,单纯放疗组后腹膜、髂总及盆腔非髂总转移者的复发转移分别为4、5、11例(57.1%、55.6%、28.2%);同步放化疗组相应的复发转移分别为5、5、16例(62.5%、25%、15.2%)。与单纯放疗相比,同步放化疗能够明显改善盆腔非髂总、髂总淋巴结转移者的5年生存率(非髂总88.6%∶76.9%,P=0.003;髂总80.0%∶44.4%,P=0.041),而不能改善腹主动脉旁淋巴结转移者的5年生存率(50.0%∶42.9%,P=0.973)。淋巴结转移的部位及同步放化疗是总生存率的影响因素(后腹膜比盆腔非髂总HR=4.259,95%CI=1.700~10.671,P=0.002;髂总比盆腔非髂总HR=2.985,95%CI=1.290~6.907,P=0.011;同步放化疗比放疗:HR=0.439,95%CI=0.218~0.885,P=0.021)。结论 同步放化疗能改善盆腔淋巴结转移患者的生存,但不能改善腹主动脉旁淋巴结转移患者的生存。     

Ia2-Ⅱa期宫颈癌术后盆腔小野放化疗取代盆腔标准野放疗的临床探究

目的:观察采用盆腔小野放化疗与盆腔标准野放疗治疗Ia2-Ⅱa期术后宫颈癌患者的生存率及不良反应。方法:选取2009年7月至2012年7月之间行广泛全子宫切除+盆腔淋巴结清扫后的Ia2-Ⅱa期且具有肿瘤复发中危因素行术后治疗的宫颈癌患者,随机分为两组:盆腔小野放化疗组、盆腔标准野放疗组。比较两组患者的生存率及不良反应。结果:采用盆腔小野放化疗组、标准放疗组的4年生存率分别为97.6%、92.9%,两组间比较差异无统计学意义（P＞0.05）。但在不良反应方面,盆腔小野放化疗组的直肠反应及泌尿道反应明显低于标准野放疗组,差异具有统计学意义（P＜0.05）。结论:盆腔小野放化疗组与盆腔标准野放疗组的4年生存率未见明显差异,因此采用盆腔小野放化疗对行根治性手术的Ia2-Ⅱa期宫颈癌患者中具有中度预后不良危险因素的患者是可行的,且采用盆腔小野放化疗的不良反应较标准放疗组明显低、患者生活质量明显提高。     

Cervical cancer: combined modality therapy

Prospective, randomized studies conducted over the past 10 years have changed the management of patients with advanced cervical cancer. The reviewed studies evaluated the use of surgery, irradiation, and chemotherapy in patients with various stages of cervical carcinoma in the absence and presence of high-risk factors for recurrence. A study by the Radiation Therapy Oncology Group (RTOG) compared pelvic with pelvic plus prophylactic para-aortic irradiation in patients with stages IB (> 4 cm), IIA, and IIB cervical cancer. The 10-year survival advantage was 11% for patients treated with prophylactic para-aortic irradiation. A follow-up study compared pelvic plus prophylactic para-aortic irradiation and brachytherapy with pelvic irradiation, brachytherapy, and chemotherapy with cisplatin and 5-FU in patients with IB-to IVA-stage cervical cancer. Overall and disease-free survivals were significantly improved in patients receiving chemotherapy. In patients with a prevalence of stage IIB and III, the Gynecologic Oncology Group (GOG) demonstrated that treatment with hydroxyurea alone was inferior to cisplatin or cisplatin, 5-FU, and hydroxy-urea in patients treated concurrently with pelvic irradiation and brachytherapy, and the GOG adopted irradiation and weekly cisplatin as standard therapy. Further GOG studies suggest that irradiation and weekly cisplatin chemotherapy without hysterectomy is the optimal treatment for patients with stage IB cervical cancer. High-risk factors for recurrence include tumor size, depth of tumor invasion, lymphovascular space involvement, and lymph node involvement. Prospective, randomized studies conducted by the GOG evaluated the effectiveness of various treatments in patients with high-risk factors. In one study that did not use chemotherapy, the recurrence-free interval was about 10% better for stage IB patients receiving postoperative irradiation after radical hysterectomy and pelvic lymphadenectomy compared with those who received no further therapy. Patients with Stages IB and IIA disease who, following radical hysterectomy and lymph node dissection, are identified as having positive pelvic lymph nodes and positive parametrial involvement, are at higher risk for recurrence and death than the high-risk group described above. An intergroup study conducted by the GOG, RTOG, and Southwest Oncology Group compared postoperative pelvic irradiation alone with postoperative pelvic irradiation plus concurrent chemotherapy in this group of patients. Overall and progression-free survivals were superior for patients receiving chemotherapy, and their greatest survival occurred in patients who received 3 or 4 chemotherapy cycles compared with 1 or 2 cycles or no chemotherapy. These findings are summarized with respect to their implications fortreatment of patients with advanced cervical cancer.     

FDG-PET lymph node staging and survival of patients with FIGO stage IIIb cervical carcinoma

PURPOSE: To evaluate the outcome of patients with International Federation of Gynecology and Obstetrics (FIGO) clinical Stage IIIb cervical carcinoma as a function of site of initial regional lymph node metastasis as detected by 2[18F]fluoro-2-deoxy-D-glucose (FDG)-positron emission tomography (PET). METHODS AND MATERIALS: Forty-seven patients with FIGO Stage IIIb cervical cancer were evaluated before therapy with whole-body FDG-PET. Most patients were treated with external beam irradiation, intracavitary brachytherapy, and weekly cisplatin for six cycles. Overall and cause-specific survival rates were calculated by the Kaplan-Meier method. RESULTS: The pretreatment whole-body FDG-PET demonstrated that all patients had FDG uptake in the cervix. Of 47 patients, 13 (28%) had no evidence of lymph node metastasis, 20 (43%) had metastasis to pelvic lymph nodes only, 7 (15%) had pelvic and para-aortic lymph node metastases, and 7 (15%) had metastases to pelvic, para-aortic, and supraclavicular lymph nodes. The 3-year estimate of cause-specific survival was 73% for those with no lymph node metastasis, 58% for those with only pelvic lymph node metastasis, 29% for those with pelvic and para-aortic lymph node metastases, and 0% for those with pelvic, para-aortic, and supraclavicular lymph node metastasis (p = 0.0005). CONCLUSION: The cause-specific survival for patients with FIGO Stage IIIb carcinoma is highly dependent on the extent of lymph node metastasis as demonstrated by whole-body FDG-PET.     

Is prophylactic para-aortic irradiation worthwhile in the treatment of advanced cervical carcinoma? Results of a controlled clinical trial of the EORTC radiotherapy group

From November 1977 to July 1981, 441 patients with cervical carcinoma were randomized between pelvic irradiation and pelvic and para-aortic irradiation. Included were patients with stage I and IIB with proximal vaginal and/or parametrial involvement with positive pelvic lymph nodes either on lymphangiogram or at surgery, and stage IIB with distal vaginal and/or parametrial involvement and III regardless of pelvic node status on lymphangiogram. Patients with clinically or surgically involved para-aortic nodes were not included. The external beam dose to the para-aortic area was fixed at 45 Gy. There was no statistically significant difference between the two treatment arms in terms of local control, overall distant metastases and survival with no evidence of disease (NED), although the incidence of para-aortic metastases and distant metastases without tumor at pelvic sites was significantly higher in patients receiving pelvic irradiation alone (pelvic group). The 4-year NED survival rate was 51%. The incidence of severe digestive complications was significantly higher in patients receiving para-aortic irradiation (para-aortic group). Routine para-aortic irradiation for all high risk patients with cervical carcinoma is of limited value, but patients with a high probability of local control can benefit from extended field irradiation, despite an increase in severe digestive complications.     

早期子宫颈癌淋巴结转移34例临床观察

目的探讨早期子宫颈癌术后淋巴结转移同步放疗、化疗与预后关系。方法回顾性分析34例早期子宫颈癌术后淋巴结转移的患者,全部行广泛性子宫切除＋盆腔淋巴结清扫术。其中Ⅰa期5例,Ⅰb期16例,Ⅱa期13例;术前放疗、化疗13例,术后全部行同步放疗、化疗;单个淋巴结转移26例,2个或2个以上淋巴结转移8例。结果淋巴结转移率22.1%（34/154）,34例淋巴结转移患者全部行术后同步放疗、化疗,5年生存率82.4%。转移淋巴结直径〈2cm者,5年生存率86.7%;转移性淋巴结直径≥2cm者,5年生存率57.9%;1个淋巴结转移至1级组患者,5年生存率76.6%;转移至2级组患者,5年生存率45.0%。结论淋巴结转移是影响子宫颈癌预后的重要因素,而术后对有淋巴结转移患者行同步放疗、化疗,可有效地提高5年生存率。     

Indocyanine green guidance for combined robotic pelvic and para-aortic sentinel node mapping in cervical cancer

BackgroundIndocyanine green (ICG) for pelvic sentinel lymph node (SLN) mapping is well established in endometrial cancer (Persson et al., 2019 Jul). However, the application for para-aortic SLNs is less reported; and the detection rate of para-aortic SLNs, mainly after cervical injection of ICG, varies between 14% and 71% (Rossi et al., 2013 Nov; Kim et al., 2020 Mar; Gallotta et al., 2019 Mar). One recent report differentiates between lower and upper para-aortic SLNs in endometrial cancer (Kim et al., 2020 Mar). Here we describe a technique using ICG for identifying pelvic SLNs, lower and upper para-aortic SLNs in cervical cancer.VideoA 46-year old female presented with high grade cervical dysplasia/carcinoma in situ on cervical smear. Cervical cone biopsy revealed a grade two squamous cell carcinoma (depth of invasion 6.8mm, width 20.8mm). Clinically she was staged as an early FIGO-stage IB2 cervical cancer. NMR revealed bilaterally enlarged iliac lymph nodes. Additional PET-CT revealed FDG-uptake in the enlarged pelvic lymph nodes. In view of the imaging findings a staging Robotic pelvic and para-aortic SLN procedure was planned, prior to select the primary treatment (radical hysterectomy or chemo-radiation). ICG was injected into the cervical stroma, and a robotic pelvic and para-aortic SLN dissection (using Firefly System ®, Intuitive Surgical Inc.) was initiated 15 minutes and 35 minutes, respectively, after cervical injection.ResultsThis video demonstrates the application of ICG for mapping bilateral primary pelvic SLNs, secondary and tertiary para-aortic SLNs in the lower and upper para-aortic region respectively, in cervical cancer. Pathology revealed one metastatic pelvic SLN on the left side, other four pelvic SLNs were negative; both the secondary/lower (n = 3) and tertiary/upper (n = 5) para-aortic SLNs were negative, as well as the non-SLNs (n = 8).ConclusionThe application of ICG for para-aortic SLN mapping should further be investigated and validated in staging surgically locally advanced cervical cancer and those with suspicious lymph nodes on imaging.     

The role of para-aortic lymphadenectomy in endometrial cancer

Endometrial cancer (EC) is the most common malignancy of the female reproductive tract and the fourth most common cancer overall. Approximately 20 % of patients with EC harbor disease outside the uterus, and 10 % of patients initially diagnosed with cancer confined to the uterus are found to have lymph node metastases. Para-aortic lymph node involvement occurs in approximately 7–8 % of EC patients overall and in about 50 % of patients with positive pelvic nodes. Metastases to the para-aortic lymph nodes are associated with poor prognosis. Factors associated with para-aortic lymph node dissemination include advanced stage, high histological grade, deep myometrial invasion, cervical involvement, lymphovascular space involvement, and the presence of pelvic lymph node metastases. Approximately 77 % of patients with para-aortic nodal involvement are found to have metastases above the level of the inferior mesenteric artery. Systematic pelvic and para-aortic lymphadenectomy with dissection optimally carried out to the renal vessels is important in high-risk patients in order to identify nodes present at distant sites, particularly above the inferior mesenteric artery (IMA). While the definitive management of EC varies widely across the gynecological oncology community, there is a consensus that patients at risk for lymphatic metastases (high and intermediate risk) who are targeted with systematic lymphadenectomy may have an improved prognosis. Well-designed prospective studies evaluating the therapeutic role of systematic lymphadenectomy in EC are needed. Herein, we describe the role of para-aortic lymphadenectomy in the surgical staging of EC emphasizing its prerequisites, extent, and diagnostic and potential therapeutic advantages.     

Para-aortic node biopsy in staging women with cervical, ovarian and endometrial carcinoma: a review.

In women with gynecologic malignancies the para-aortic lymph nodes are not routinely treated. However, pretherapy surgical staging has now disclosed an incidence of para-aortic node metastasis of 10.3% for presumed stage I and II ovarian cancer, 8.0% for stage I endometrial carcinoma, and 23.5% for stage II, III, and IV cervical cancer. Prospective trials to evaluate therapy directed to the para-aortic nodes in women with early ovarian and endometrial carcinoma have not been carried out. Moreover, the results of high dose irradiation to biopsy proven metastasis to the aortic lymph nodes from cervical cancer has resulted in only 11.9% survival without recurrence at two years.     

中晚期宫颈癌腹主动脉旁淋巴结转移治疗的临床研究

目的:研究中晚期（Ⅱb-Ⅲb期）宫颈癌腹主动脉旁淋巴结(PALN)转移采用手术和放疗治疗的疗效。方法:选择中晚期（Ⅱb-Ⅲb期）腹主动脉旁淋巴结转移的宫颈癌患者76例,观察组43例,行腹主动脉旁淋巴结清扫术,术后行同步放化学治疗。对照组33例,行宫颈癌同步放化学治疗。分析与患者3年生存率有关的临床病理因素,探讨影响患者预后的因素。结果:手术分期、病理分级、SCCA水平、局部肿瘤大小、腹主动脉旁淋巴结大小、治疗方法与患者的3年生存率有关。多因素分析表明影响患者生存期的因素是分期、分级、局部肿瘤大小、腹主动脉旁淋巴结大小、治疗方法。结论:中晚期宫颈癌腹主动脉旁淋巴结转移,行腹主动脉旁淋巴结切除并辅以术后延伸放疗联合同期化疗,对于病人治疗有重要意义。     

Extended field irradiation in the treatment of patients with cervical carcinoma involving biopsy proven para-aortic nodes

Between November 1974 and November 1979, 15 patients with cervical carcinoma were treated with extended field irradiation for biopsy proven para-aortic lymph node (PALN) metastases. Treatment consisted of pelvic and para-aortic irradiation at a daily dose of 180 to 200 rad per day, delivering 4000 to 6000 rad to the pelvis and 4000 to 5000 rad to the para-aortic nodes. One or two intracavitary insertions each delivered an additional 2000 to 3500 rad to point A. The three year actual disease free survival for the 12 patients with Stage I and II disease was 50%. All six survivors remain alive without evidence of disease for 41 to 93 months, with a mean and median follow-up of 65 months. All patients dying of disease did so within 26 months, all but one dying within one year. All patients with Stage III and IV are dead of disease. Pelvic disease was controlled in 11 of 12 patients with Stage I or II disease, and in one of the three patients with Stage III and IV disease. There was no clinical indication of failure in the PALN in any patient. Nine patients failed with disseminated disease. Three of 15 patients (20%) suffered serious treatment-related complications. Two of these were attributed to the pelvic irradiation, with one patient requiring a colostomy. Thus, complications resulting from the extended field irradiation were seen in only one patient (6.7%). There was no treatment related mortality. Extended field irradiation can lead to a 50% survival in patients with Stage I and II cervical carcinoma and PALN metastases, a survival comparable to that reported in patients with involved pelvic nodes.