术后化疗对有高危因素的早期子宫内膜癌患者预后的影响

目的 探讨术后化疗对有高危因素的早期(Ⅰ、Ⅱ期)子宫内膜癌患者预后的影响.方法 选择1994年1月-2007年6月间,北京大学第一医院妇产科收治的66例有高危因素的早期子宫内膜癌且术后均辅以化疗的患者(化疗组),40例相同期别及相同高危因素但术后未予化疗者作为对照组,Kaplan-Meier法计算两组患者的5年累积生存率,并进行比较;对有高危因素的早期子宫内膜癌患者的预后影响因素进行单因素及多因素分析.结果化疗组患者的5年累积生存率为94%,对照组为81%,化疗组明显高于对照组(P<0.05).单因素分析显示,化疗组中≥4个疗程患者的5年累积生存率为100%,<4个疗程患者的5年累积生存率为86%,两者比较,差异有统计学意义(P<0.05);而不同年龄、手术病理分期、病理类型、病理分化程度及术后有无放疗、术后化疗后是否联合放疗、有无孕激素治疗患者间比较,差异均无统计学意义(P>0.05).多因素分析显示,术后化疗是影响有高危因素的早期子宫内膜癌患者预后的独立因素(P<0.05).结论术后化疗可改善有高危因素的早期子宫内膜癌患者的预后,且疗程数应≥4个,但因例数较少,需通过前瞻性随机对照研究的进一步证实.     

Adjuvant chemotherapy as treatment of high-risk stage I and II endometrial cancer

OBJECTIVE: This study was performed to define the subgroups of patients who benefit from postoperative adjuvant chemotherapy in stage I and II endometrial carcinoma. METHODS: A retrospective review of 170 International Federation of Gynecology and Obstetrics (FIGO) stage I and II endometrial carcinoma patients treated between 1988 and 2000 at Niigata University Hospital was performed. All patients underwent surgery, of which 41 patients underwent adjuvant chemotherapy, consisting of intravenous cisplatin, doxorubicin, and cyclophosphamide. Multivariate analysis was performed for the prognostic factors and actuarial techniques were used for the survival and recurrence rates. RESULTS: The patients were divided into low-risk and high-risk groups based on the number of prognostic factors (tumor grade G3, outer half myometrial invasion, lymph-vascular space involvement (LVSI), and cervical invasion). The 5-year disease-free survival and the 5-year overall survival for the low-risk group were 97.4%, and 100%, respectively, which were significantly better than 77.4% and 88.1% for the high-risk group (P < 0.0001, P < 0.0001), respectively. Among high-risk group patients, the 5-year disease-free survival and the 5-year overall survival were 88.5% and 95.2% in 26 patients treated with adjuvant chemotherapy, and 50.0% and 62.5% in eight cases who underwent only surgery (P = 0.0150, P = 0.0226). Disease recurrence occurred in 7 (20.6%) of 34 high-risk group patients. Four of seven recurrences occurred in patients who did not receive postoperative chemotherapy, in which all four were distant failure. In the remaining three patients who were in the CAP group, two had vaginal wall recurrence and only one had pulmonary recurrence. Three recurrences were also observed in the 133 low-risk group patients. Only isolated vaginal wall recurrence occurred in three patients without adjuvant chemotherapy after the initial surgery. CONCLUSIONS: There is possibility that postoperative adjuvant CAP may be omitted in surgical stage I or II endometrial cancer patients with 0 or 1 prognostic factor. The high-risk group of patients should be treated with postoperative adjuvant CAP to decrease distant failure and improve prognosis.     

Outcome of patients with early ovarian cancer undergoing three courses of adjuvant chemotherapy following complete surgical staging

We conducted the present study to determine the outcome of patients with early ovarian cancer who underwent three courses of adjuvant chemotherapy after complete surgical staging. One hundred consecutive patients with stage I-II epithelial ovarian cancer who had undergone complete surgical staging and received three courses of platinum-based chemotherapy were entered in this study. Twenty-one patients were low risk, defined as stage IA-B, grade 1 and histologic types except for clear cell adenocarcinoma, and remaining 79 were high risk. All patients with stage IA or IB, whatever histologic type and histopathologic grade, were alive without disease. The 5-year survival rate was 89.4% for patients with stage IC and 76.2% for those with stage II. The 5-year survival rate for low- and high-risk patients was 100% and 89.4%, respectively. The survival rate for grade 1 was significantly better than that for grade 2 or 3. Multivariate analysis revealed that histologic grade was an independent prognostic factor in stage IC-II ovarian cancer. The outcome of patients with early ovarian cancer undergoing three courses of chemotherapy after complete surgical staging was favorable even in high-risk patients.     

Is there a survival benefit to adjuvant radiotherapy in high-risk surgical stage I endometrial cancer?

OBJECTIVE: The aim of this study was to examine the effects of therapeutic modalities on survival of stage I endometrial cancer and also to evaluate the surgical morbidity and the prognostic importance of surgicopathological variables. METHODS: A hundred and ninety-six stage I endometrial cancer patients treated at Hacettepe University Hospital between 1982 and 1997 were included. After initial diagnosis all patients underwent surgical procedures including peritoneal cytology, infracolic omentectomy, total abdominal hysterectomy, bilateral salphingoopherectomy, and complete pelvic-paraaortic lymphadenectomy. The mean age at initial diagnosis was 56 years (SD = 9.9 years) and the patients were followed 3-18 years (median, 8 years). All patients had endometrioid carcinoma. Stage IC and/or grade 3 tumors were considered high-risk factors and by this definition 147 (75%) patients were low risk and 49 (25%) patients were high risk. Forty-nine percent of high-risk patients received adjuvant radiotherapy compared with 3.5% of patients in the low-risk group. RESULTS: The 10-year disease-free and overall survival rates of the entire group were 97 and 98%, respectively. Ten-year overall survival rate for the low-risk group was 100% compared with 94% for patients with high-risk features (P = 0.002). The 10-year disease-free survival rate in the high-risk group was 96% for 24 patients who received adjuvant radiotherapy versus 92% for 25 patients who did not receive adjuvant therapy (P = 0.53). Only high grade was a significant predictor of poor survival (P = 0.0004). Overall surgical morbidity rate was 8.1% without mortality related to surgery. CONCLUSIONS: Surgical staging achieved excellent survival for stage I endometrial cancer patients without incurring untoward morbidity and mortality. No survival advantage of adjuvant radiotherapy was detected even for high-risk patients, so we suggest the use of radiotherapy may be reserved for relapse.     

Postoperative adjuvant therapy in early invasive cervical cancer patients with histopathologic high-risk factors

Abstract. Park TK, Kim SN, Kwon JY, Mo HJ. Postoperative adjuvant therapy in early invasive cervical cancer patients with histopathologic high-risk factors.
The purpose of this study is to evaluate the efficacy of postoperative adjuvant therapy in preventing treatment failure after primary treatment with surgery in early invasive cervical cancer patients associated with the following histopathologic high-risk factors: lymph node metastasis (either macroscopic or microscopic), parametrial extension, lymphovascular permeation and depth of invasion 10 mm.
Postoperative adjuvant concurrent chemoradiotherapy (PCCRT), postoperative adjuvant chemotherapy (PCT), or postoperative adjuvant radiotherapy (PRT) alone was administered to the 80 early invasive cervical cancers with at least one of the high-risk factors. Each of 61 patients received three to six cycles of chemotherapy at intervals of approximately 3 weeks. Twenty three patients were treated with PCCRT, 38 patients were treated with PCT alone, and 19 patients received PRT.
The 5-year survival rates of patients with macroscopic lymph node metastasis were 66.7% and 35.7% in PCCRT and PRT, respectively. With microscopic lymph node metastasis, the 5-year survival rates were 83.3%, 60.0%, and 70.1% in PCCRT, PCT, and PRT, respectively. With parametrial extension, the 5-year survival rate was 58.1% in PCCRT. The 5-year survival rates of patients with lymphovascular permeation were 100%, 90.9%, and 66.7% in PCCRT, PCT, and PRT, respectively. With depth of invasion 10 mm, the 5-year survival rates were 100% and 91.3%, in PCCRT and PCT, respectively.
PCCRT appears to be superior to PRT or PCT alone in early invasive cervical cancer patients with histopathologic high-risk factors.     

Treatment results of adjuvant chemotherapy after radical hysterectomy for intermediate- and high-risk stage IB-IIA cervical cancer

OBJECTIVE: To determine the effectiveness of chemotherapy alone as postoperative adjuvant therapy for intermediate- and high-risk cervical cancer. METHODS: The study group comprised of 65 consecutive patients with stage IB or IIA squamous cell or adenosquamous cervical cancer who were initially treated with radical hysterectomy and pelvic lymphadenectomy between 1993 and 2002. Tumors were of intermediate-risk (stromal invasion > 50%, n = 30) or high-risk (positive surgical margin, parametrial invasion, and/or lymph node involvement, n = 35). In all cases, chemotherapy was administered adjuvantly: three courses of bleomycin, vincristine, mitomycin, and cisplatin for intermediate-risk cases and five courses for high-risk cases. Disease-free survival and complications of the combined therapy were investigated. RESULTS: Estimated 5-year disease-free survival was 93.3% for the 30 patients with intermediate-risk tumors (100% for those with squamous cell carcinoma and 71.4% for those with adenosquamous carcinoma) and 85.7% for the 35 patients with high-risk tumors (89.3% for those with squamous cell carcinoma and 71.4% for those with adenosquamous carcinoma). The incidence of locoregional recurrence was 3.3% in the intermediate-risk group and 8.6% in the high-risk group. Side effects of chemotherapy and complications of the combined therapy were within acceptable limits. No patient had severe bleomycin-related pulmonary toxicity. Only 1.5% of patients developed small bowel obstruction, which was cured by conservative therapy. CONCLUSIONS: The treatment results suggest the potential role of adjuvant chemotherapy alone for patients with cervical cancer.     

Patterns and outcomes of chemotherapy for elderly patients with stage II ovarian cancer: a population-based study

BACKGROUND: The optimal treatment for patients with stage II ovarian cancer is controversial, although most experts recommend adjuvant chemotherapy. The purpose of this study was to assess the patterns of use of chemotherapy in women with stage II ovarian cancer, and to compare the survival of treated and untreated patients aged 65+ years in a population-based sample. METHODS: Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database of cancers diagnosed in approximately 14% of the U.S. population, we identified women who were diagnosed with stage II ovarian cancer between 1992 and 1996, survived >or=120 days beyond diagnosis, and were >or=65 years of age. Multivariate regression was used to compare those treated to those not treated with chemotherapy. Cox proportional hazards regression models were used to analyze patient survival. RESULTS: Of 236 women with stage II ovarian cancer, 160 (67.8%) received chemotherapy, and 118 (50%) received platinum-based regimens. Younger patients and those with higher-grade tumors were more likely to receive chemotherapy. The adjusted hazards ratio for mortality associated with any chemotherapy use was 0.67 (95% CI, 0.45-0.98), corresponding to an increase in median survival from 28 months to 35 months (P < 0.0001). CONCLUSIONS: This observational study found that most patients aged >or=65 years and diagnosed with stage II ovarian cancer between 1992 and 1996 were treated with chemotherapy. Grade and younger age were the most significant predictors of treatment, and treatment was associated with a 5-year mortality reduction of 33%. These findings are not definitive, but they may provide some guidance in the absence of randomized trials of adjuvant chemotherapy for older women with stage II ovarian cancer.     

Lymph-vascular space invasion and number of positive para-aortic node groups predict survival in node-positive patients with endometrial cancer

OBJECTIVE: The aim of this study was to determine pathologic variables associated with disease-specific survival of node-positive patients with endometrial carcinoma treated with combination of surgery including pelvic and para-aortic lymphadenectomy and adjuvant chemotherapy. METHODS: Survival of 55 node-positive endometrial carcinoma patients prospectively treated with surgery and adjuvant chemotherapy between 1982 and 2002 at Hokkaido University Hospital was compared to various histopathologic variables. All patients underwent primary surgical treatment including pelvic and para-aortic lymphadenectomy followed by adjuvant chemotherapy consisting of intravenous cisplatin, doxorubicin, and cyclophosphamide. Survival analyses were performed by the Kaplan-Meier curves and the log-rank test. Independent prognostic factors were determined by multivariate Cox regression analysis using a forward stepwise selection. RESULTS: Among 303 consecutive endometrial cancer patients treated during the period of this study, 55 patients (18.2%), including 44 without peritoneal metastasis (FIGO stage IIIc) and 11 with peritoneal metastasis (FIGO stage IV), were found to have retroperitoneal lymph node metastasis. Multivariate Cox regression analysis revealed that peritoneal metastasis and lymph-vascular space invasion (LVSI) were independently related to poor survival in node-positive endometrial carcinoma. The estimated 5-year survival rate of stage IIIc patients with or without moderate/prominent LVSI was 50.9% and 93.3%, respectively with statistically significant difference (P=0.0024). The estimated 5-year survival rate of stage IV patients was 20.0%. Prognosis of stage IIIc patients could be stratified into three groups by the number of positive para-aortic node (PAN) with an estimated 5-year survival rate of 86.4% for no positive PAN (n = 23), 60.4% for one positive PAN (n = 13), and 20.0% for > or = 2 positive PAN (n = 8). The difference of survival rate between no or one positive PAN and > or = 2 positive PAN was statistically significant (P = 0.0007 for no positive PAN vs > or = 2 positive PAN, P = 0.0319 for one positive PAN vs > or = 2 positive PAN). Multivariate analysis including number of positive PAN groups showed that LVSI, number of positive PAN groups were independent prognostic factors for survival. Survival of patients with stage IIIc disease could be stratified into three groups by combination of LVSI and number of positive PAN groups with an estimated 5-year survival rate of 93.3% for no or one positive PAN group with nil or minimal LVSI, 62.6% for no or one positive PAN group with intermediate or prominent LVSI, and 20.0% for > or = 2 positive PAN groups irrespective of LVSI (P = 0.0002 for no or one positive PAN group with nil or minimal LVSI vs > or = 2 positive PAN groups, P = 0.0223 for no or one positive PAN group with nil or minimal LVSI vs no or one positive PAN group with intermediate or prominent LVSI, P = 0.0388 for no or one positive PAN group with intermediate or prominent LVSI vs > or = 2 positive PAN groups). CONCLUSIONS: LVSI and number of positive PAN groups were independent prognostic factors for stage IIIc endometrial cancer patients. Postoperative therapy and follow-up modality need to be individualized according to LVSI and the number of positive PAN for stage IIIc patients. New molecular markers to predict the prognosis of endometrial cancer patients preoperatively should be found for individualization of treatment. New chemotherapy regimen including taxane needs to be considered as an adjuvant therapy for patients with node-positive endometrial cancer.     

The efficiency of treatment in patients with uterine-confined endometrial cancer

AIM: To present our experience regarding the efficiency of treatment in patients with uterine-confined endometrial cancer. PATIENTS AND METHODS: 775 patients with uterine-confined endometrial cancer (UCEC) were treated between July 1985 and June 2000 in the Krakow Branch of Sklodowska Memorial Institute. RESULTS: Among the 775 patients, 5-year disease-free survival was observed in 82.8% patients; 96% patients with low risk of disease recurrence, 93.6% patients with intermediate risk and 78.3% patients with high risk survived five years with no evidence of disease. In the group with a high-risk disease recurrence rate, 5-year disease-free survival was statistically higher among patients treated with adjuvant brachytherapy plus external beam radiotherapy (EBRT) in comparison to patients treated with adjuvant brachytherapy (BRT) alone (82.4% vs 72.1%). CONCLUSIONS: The recommended treatment in patients with high and moderate differentiation of UCEC with FIGO Stage IA is surgery alone. Surgery with adjuvant EBRT in the group of patients with intermediate risk of cancer recurrence allows over 90% of patients to be cured. In the group of patients with a high risk of disease recurrence adjuvant BRT with EBRT is statistically more efficient in comparison to BRT alone.     

Borderline ovarian tumors

Ninety-four patients with borderline ovarian tumors were retrospectively analyzed for clinical features, treatments, and survival characteristics. There were 46 patients with FIGO stage IA cancer, 7 with stage IB, 20 with stage IC, 4 with stage IIB, 5 with stage IIC, 5 with stage IIIA, 3 with stage IIIB, and 4 with stage IIIC tumors. Seventy patients had at least a total abdominal hysterectomy and bilateral salpingo-oophorectomy, 20 patients had conservative surgery including unilateral salpingo-oophorectomy or ovarian cystectomy, and 4 patients had bilateral salpingo-oophorectomy. Fifteen patients with stage I disease received adjuvant melphalan therapy and 2 received external beam radiation for concomitant gynecologic cancers; 7 with stage II tumors received adjuvant melphalan therapy and 1 received external beam radiation; and 5 with stage III tumors received melphalan therapy and 6 patients received cisplatin-based combination chemotherapy. Follow-up ranged from 1 to 117 months, with a median of 33.5 months. Eighty-seven patients were alive. Seven patients died, two of disease. The overall 5-year survival rate was 83.0%; those treated with adjuvant therapy had a 79.5% survival, whereas the others had 84.6% survival. Second-look surgery was performed in 10 patients; six results were negative after melphalan therapy, one was negative after cisplatin combination therapy, and one was negative after no adjuvant treatment. Two patients had positive second-look surgery, one with stage IIIC disease treated with a cisplatin combination and the other with stage IC disease treated with melphalan. This review did not demonstrate that patients with borderline ovarian tumors benefited from adjuvant therapy.     

Stage III endometrial cancer: analysis of prognostic factors and failure patterns after adjuvant chemotherapy

OBJECTIVE: This study was performed to assess the prognostic factors and patterns of recurrence in stage III endometrial carcinoma treated with surgery and adjuvant chemotherapy. METHODS: A retrospective review of 61 stage III endometrial carcinoma patients treated between 1988 and 1998 at Niigata University Hospital was performed. All patients underwent surgery, followed by adjuvant chemotherapy consisting of intravenous cisplatin, doxorubicin, and cyclophosphamide. Multivariate analysis was performed for the prognostic factors and actuarial techniques were used for the survival and recurrence rates. RESULTS: The 5-year disease-free survival was 78.6%. Multivariate analysis revealed deep myometrial invasion and lymph-vascular space involvement correlated significantly with disease-free survival. Based on these two factors, the patients could be divided into low-risk and high-risk groups. The 5-year disease-free survival for the low-risk group was 100%, which was significantly better than the 59.1% for the high-risk group. Disease recurrence occurred in 13 of 30 high-risk patients, and there was no recurrence in the 31 low-risk patients. Looking at the patterns of recurrence for the high-risk group by lymph node metastasis, 5 recurrences were locoregional, 1 was locoregional/distant, and 1 was distant in 16 node-positive high-risk patients. In 14 node-negative patients, 5 had distant and 1 had locoregional/distant recurrences. CONCLUSIONS: The locoregional failure in the node-positive high-risk group deserves further attention. For improvement of locoregional control, it may be worthwhile to consider new strategies. The role of new adjuvant chemotherapy should be investigated to control distant failure in node-negative high-risk patients.     

Management of endometrial cancer with suspected cervical involvement

The 1989 International Federation of Gynecology and Obstetrics (FIGO) staging system for endometrial cancer cells for operative assessment of the extent of uterine disease, grade, and sites of metastasis before assigning a stage to the cancer. In the current study, 70 endometrial cancer patients with suspected cervical involvement based on a positive endocervical curettage or punch biopsy were treated with initial surgery followed by tailored radiation or chemotherapy. Only 37% of the patients had operative findings consistent with the preoperative suspicion of stage II disease. Postoperative therapy was determined by the extent of cervical involvement, depth of myometrial invasion, cell type, tumor grade, and the presence and location of extra-uterine disease. Based upon these parameters, 21 patients were believed to have low risk for pelvic recurrence and received no adjuvant therapy (90% 5-year survival); 38 patients received postoperative pelvic radiation because of high-risk factors for pelvic recurrence or pelvic nodal involvement (65% 5-year survival); and 11 patients received chemotherapy and/or extended radiation because of extrapelvic disease (no 5-year survivors). The approach outlined supports initial surgery for cases of endometrial cancer with suspected cervical involvement. This approach permits accurate surgical staging under the new FIGO system, avoids radiotherapy in many patients whose disease is less extensive than suspected preoperatively, and can accomplish good local control with limited morbidity.     

Clinical outcome of primary gastric lymphoma treated with chemotherapy alone or surgery followed by chemotherapy.

BACKGROUND: The role of surgical resection in the treatment of primary gastric lymphoma (PGL) remains unclear. This retrospective study evaluated the clinical outcome of PGL treated with chemotherapy alone or surgery followed by chemotherapy. METHODS: During 1986-2003, 59 patients with PGL (other than mucosa-associated lymphoid tissue type lymphoma) were identified from hospital files. The medical records, pathologic sections, radiographic images and treatment modalities of these patients were reviewed. Patients were categorized into localized (stage IE and IIE-1) and advanced (stage IIE-2 or beyond) stage groups. Survival was estimated by the Kaplan-Meier method. RESULTS: The study included 55 patients who received treatment at the same institute. Among them, 32 had localized PGL (15 stage IE, 17 stage IIE-1) and 23 had advanced disease. The median survival of the localized stage group was not reached during a mean follow-up of 168.1 +/- 16.7 months (95% confidence interval [CI], 135.4-200.8 months), while that of the advanced stage group was 33.0 +/- 6.8 months (95% CI, 19.7-46.5; p < 0.001, log-rank test). Among patients with localized PGL, the 5-year overall survival rate of those receiving chemotherapy alone (n = 19) or combination therapy (surgery followed by chemotherapy, n = 13) was 73.4% and 87.5%, respectively (p = 0.229). The 5-year disease-free survival was 68.4% and 84.6%, respectively (p = 0.540). However, post-chemotherapy life-threatening hemorrhage occurred in five of the 32 patients (15.6%) in the localized stage group: four in the chemotherapy-alone group, and one in the combination therapy group, all of whom had failed to achieve complete response. CONCLUSION: The clinical outcome of localized PGL treated by chemotherapy alone is similar to that treated by surgery followed by chemotherapy in terms of tumor response, disease-free survival and overall survival, suggesting that surgery be reserved for those with residual tumors after chemotherapy.     

Stage IIIC endometrioid corpus cancer includes distinct subgroups

OBJECTIVE: Because stage IIIC corpus cancer is a heterogeneous substage, the outcomes of patients with stage IIIC disease were assessed according to the extent of extrauterine disease. METHODS: From 1984 through 1993, 51 patients with surgical stage IIIC corpus cancer were treated at our institution; 5 patients had tumors with nonendometrioid histologic features and were excluded from the analyses. Of the 46 patients with endometrioid carcinoma, 22 had lymph nodes as the only site of extrauterine disease (stage IIIC(0)) and 24 also had peritoneal cytologic, uterine serosal, adnexal, or vaginal involvement or a combination of these (stage IIIC(ab)). The mean number of lymph nodes removed was 18 pelvic and 8 aortic nodes. Median follow-up for surviving patients was 84 months. RESULTS: Patients with stage IIIC(0) cancer had a 5-year cause-specific survival (CSS) of 72% and a 5-year recurrence-free survival (RFS) of 68%, and those with stage IIIC(ab) had a CSS of 33% and an RFS of 25% (P < 0.01). Of the 22 patients with stage IIIC(0) endometrioid cancer, 21 had adjuvant radiotherapy (1 also received chemotherapy) and 1 was not treated. Relapse occurred in 7 (32%) patients, with only 1 having an initial failure component outside the node-bearing areas (lung). Of the 24 patients with stage IIIC(ab) cancer, 16 received adjuvant radiotherapy (1 had concomitant chemotherapy), 2 had chemotherapy, 4 had hormonal therapy, and 2 were not treated. We observed 16 recurrences (67%). Of the 14 patients with known initial sites of failure, 9 had an extranodal failure component. CONCLUSION: Assessment of CSS, RFS, and sites of relapse suggests that FIGO surgical stage IIIC endometrioid corpus cancer includes two distinct and readily separable subgroups: (1) stage IIIC(0), nodal involvement only, and (2) stage IIIC(ab), nodal plus cytologic, uterine serosal, adnexal, or vaginal involvement, or a combination of these. Our results also suggest that different treatment strategies are needed for these subgroups.     

The importance of adjuvant chemotherapy and pelvic radiotherapy in high-risk early stage endometrial carcinoma

Objective

To determine the impact of a policy change in which women with high-risk early stage endometrioid endometrial cancer (EEC) received adjuvant chemoradiotherapy.

Methods

This is a population-based retrospective cohort study of British Columbia Cancer Registry patients diagnosed from 2008 to 2012 with high-risk early stage EEC, who received adjuvant chemoradiotherapy after primary surgery. High-risk early stage was defined as the presence of two or more high-risk uterine factors: grade 3 tumor, more than 50% myometrial invasion, and/or cervical stromal involvement. Adjuvant therapy consisted of 3 or 4 cycles of carboplatin and paclitaxel chemotherapy, followed by pelvic radiotherapy. Sites and rate of recurrence were compared to a historical cohort diagnosed from 2005 to 2008 in which none of the patients received adjuvant chemoradiotherapy. Five-year progression-free and overall survival rates were calculated.

Results

The study includes 55 patients. All patients except for 2 received at least 3 cycles of chemotherapy. All patients received pelvic radiotherapy except for 2 who received brachytherapy only. Median follow-up was 27 months (7–56 months). Four patients (7.3%) recurred, including three with distant recurrence only and one with both a pelvic and paraaortic nodal recurrence. The historical cohort had a 29.4% recurrence rate, and therefore the hazard ratio for recurrence was 0.27 (95% CI 0.02–4.11). Five-year progression-free and overall survival rates were 88.6% and 97.3%, respectively.

Conclusion

Patients with high-risk early stage endometrial carcinoma treated with adjuvant chemoradiotherapy have a low rate of recurrence compared to those not receiving such therapy.     

淋巴结转移的Ⅰb 1～Ⅱb期子宫颈癌患者手术后的综合治疗及预后分析

目的研究淋巴结转移的Ⅰb1～Ⅱb期宫颈癌患者广泛性子宫切除加盆腔淋巴结切除术后综合治疗的方式和预后。方法选取1990年1月至2003年6月复旦大学附属肿瘤医院接受手术治疗的Ⅰb1～Ⅱb期淋巴结转移的宫颈癌患者215例。所有患者均接受了广泛性子宫切除加盆腔淋巴结切除术。根据术后治疗情况将患者分为4组：放疗加化疗组（107例）、放疗组（45例）、化疗组（22例）和无辅助治疗组（41例）。通过比较4组患者的临床病理资料,对患者预后及可能影响预后的有关因素进行分析。结果放疗加化疗组、化疗组、放疗组和无辅助治疗组患者的3年无瘤生存率分别为60．7％、53．5％、47．4％和36．0％,放疗加化疗组患者的3年无瘤生存率显著高于无辅助治疗组,两组比较,差异有统计学意义（P=0．001）,而化疗组、放疗组的3年无瘤生存率分别与无辅助治疗组比较,差异无统计学意义（P值分别为0．060和0．159）。放疗加化疗组、化疗组、放疗组和无辅助治疗组患者的盆腔复发率分别为7．5％、22．7％、26．7％和34．1％,远处转移率分别为16．8％、18．2％、15．6％和22．0％,复发合并转移率分别为4．7％、0、4．4％和7．3％。放疗加化疗组盆腔复发率显著低于其余3组,与其余3组比较,差异有统计学意义（P〈0．01）,而远处转移率、复发合并转移率与其余3组比较,差异无统计学意义（P〉0．05）。多因素分析显示,肿瘤直径、病理类型、淋巴结转移数目和术后辅助治疗是影响淋巴结转移的宫颈癌患者预后的重要因素（P〈0．05）。结论淋巴结转移的宫颈癌患者根治性手术后辅助放、化疗能提高3年无瘤生存率,降低盆腔复发率。     

Radical hysterectomy followed by tailored postoperative therapy in the treatment of stage IB2 cervical cancer: feasibility and indications for adjuvant therapy

OBJECTIVE: To determine the outcome, complications and likelihood of requiring adjuvant therapy of patients with stage IB2 cervical cancer treated with primary radical hysterectomy and lymph node dissection. METHODS: Clinical and pathologic data between 1985 and 1999 were reviewed. Associations between clinical and pathologic variables were tested using the Fisher's exact test. Survival was estimated using the Kaplan-Meier method with significance being calculated using the Log Rank test. RESULTS: Six hundred radical hysterectomies were performed during the study period. Fifty-eight of these women (9.6% of all radical hysterectomies) were diagnosed with FIGO stage IB2 cancers. Sixteen patients (28%) had positive pelvic lymph nodes. Forty-six patients (79%) had invasion involving the outer 1/3 of the cervical stroma, six had positive vaginal margins while five had occult parametrial extension. After retrospective review of the histopathologic data from this case series, criteria from two recently published prospective multicenter Gynecologic Oncology Group (GOG) trials were applied to this data set. According to criteria established by GOG protocol 92, 30 (52%) patients should have theoretically received adjuvant pelvic radiation while 21 (36%) would have qualified for adjuvant chemotherapy and radiation according to the results of GOG protocol 109. In actual fact, only 35 patients (60%) received adjuvant radiotherapy and one received adjuvant chemo-radiation. Severe toxicity was unusual with two developing urinary fistulae and one having a pulmonary embolism. Despite the lack of adjuvant therapy in most cases, only 21 women (38%) recurred of whom 11 failed on the pelvic wall, with an estimated 5-year survival of 62.1%. CONCLUSIONS: Radical hysterectomy and tailored adjuvant radiation therapy in stage IB2 cervical cancer is feasible. Even without the liberal use of adjuvant therapy, survival in this high-risk group compares favorably to primary chemotherapy and radiation. According to recently published randomized clinical trials, most patients should receive adjuvant postoperative therapy. The benefits of this multimodality approach require randomized study.     

Long-term follow-up of patients with advanced ovarian cancers treated with intermittent administration of combination chemotherapy with cisplatin, doxorubicin and cyclophosphamide

Despite high primary response rates with cisplatin-based combination chemotherapy, the overall survival rate for advanced ovarian cancers remains dismal. We designed a new systematic treatment approach with a combination chemotherapy consisting of cisplatin, doxorubicin and cyclophosphamide (cyclic PAC chemotherapy), with the aim of improving survival rates with minimal disturbance of quality of life. Cyclic PAC chemotherapy is a three-step chemotherapy with three courses of the PAC regimen in each step. A total of nine courses with a 3-month drug-free period between each step were administered over a 15-month period to patients with clinical stage IC-IV ovarian cancer who had undergone cytoreductive surgery. Forty-eight patients with stage IC-IV disease (34 patients with stage III and IV disease) were treated with cyclic PAC chemotherapy. Thirty-four patients with stage IC-IV disease (23 patients with stage III and IV disease) were treated by a brief course of PAC chemotherapy. Long-term survival and toxicity were evaluated for both treatment groups. Cyclic PAC chemotherapy improved the overall outcome of patients (66.6% 3-year and 56.5% 5-year survival rates) compared to brief PAC (41.2% 3-year and 23.5% 5-year survival rates) ( P < 0.01). The outcome of patients with stage III-IV ovarian cancer of the cyclic PAC group (52.6% 3-year and 37.2% 5-year survival rates) was also superior to that of the brief PAC group (21.7% 3-year and 8.7% 5-year survival rates). Generally, the treatment was well tolerated. The toxicity was similar in both groups, although myelosuppresion and neurotoxicity were rather prominent in the cyclic PAC group. Cyclic PAC chemotherapy may lead to improved survival in advanced ovarian cancer, and merits further investigation in a randomized study.     

A prospective population-based management program including primary surgery and postoperative risk assessment by means of DNA ploidy and histopathology. Adjuvant radiotherapy is not necessary for the majority of patients with FIGO stage I–II endometrial cancer

A management program for FIGO stage I-II nonserous, nonclear-cell adenocarcinomas was evaluated. Histopathology and DNA ploidy were used to estimate postoperatively the risk of progression or death of disease and to tailor treatment. The patient material was a population-based consecutive cohort of all women with endometrial cancer in the Southern Swedish Health Care Region diagnosed between June 1993 and June 1996 (n = 553). Of these, 335 were eligible for the management program. Patients estimated to be at low risk were treated by surgery only, while high-risk patients also received vaginal brachytherapy. A large low-risk group consisting of 84% (n = 283) of the patients with an estimated disease-specific 5-year survival of 96% (95% CI = 93-98%) was identified. The high-risk group (n = 52, 16%) showed a worse outcome with an 80% 5-year disease-specific survival (95% CI = 65-89%). The difference in survival between the groups was highly significant (P < 0.0001). Half of the progressions were distant in the high-risk group. Although there is a clear indication for adjuvant therapy for this group, locoregional radiotherapy could be expected to fail in cases with distant progression. Thus, effective systemic treatments need to be developed. Low-risk patients, constituting the majority (84%) of the patients, can be safely treated by surgery only.     

Postoperative adjuvant concurrent chemoradiotherapy improves survival rates for high-risk, early stage cervical cancer patients

OBJECTIVE: This study was undertaken to evaluate the efficacy of postoperative concurrent chemoradiotherapy (CCRT) and to investigate the recurrence and survival rates after adjuvant CCRT in high-risk early cervical cancer (stages IA2, IB, IIA) patients who were treated by radical hysterectomy and pelvic lymphadenectomy. METHODS: From July 1994 to June 2001, we retrospectively reviewed the medical records of 151 patients who had undergone radical abdominal hysterectomy with pelvic lymphadenectomy and paraaortic lymph nodes dissection at Ajou University Hospital for early cervical cancer (stages IA2, IB, IIA). CCRT was performed in 30 patients with high-risk factors such as positive pelvic lymph nodes, parametrial involvement, or positive surgical margins. Adjuvant chemotherapy consisted of cisplatin (70 mg/m(2) on day 1) and 5-fluorouracil (5-FU; 1000 mg/m(2) on days 2-5) for four cycles every 4 weeks beginning 2-3 weeks after surgery. Pelvic radiotherapy was started concurrently at the second and third cycle of chemotherapy. We also analyzed the recurrence pattern and survival rates of 114 patients (control group) who received no adjuvant therapy after surgery. The mean follow-up period was 49 months (24-98 months). RESULTS: There were recurrences in three patients after CCRT (10%) and in five patients in the control group (4.4%). The actuarial 5-year overall survival rates for patients in CCRT and control group were 96.7% vs. 97.7%, respectively. The progression-free survival rates were 88.7% for the high-risk group and 95.4% for the non-high-risk group. CONCLUSIONS: This study confirms good local control and 5-year overall and progression-free survival rates in high-risk cervical cancer patients after CCRT, which is comparable with the results of the control group. Our results indicate that adjuvant concurrent chemoradiotherapy seems to be effective in stages IA2-IIA cervical cancer patients with high-risk factors.