不同新辅助治疗方式在局部晚期子宫颈癌的临床应用及评价

The Clinical Application and Evaluation of Different Neoadjuvant Therapy in Local Advanced Cervical Cancer

目的:探讨不同新辅助治疗方式在局部晚期子宫颈癌(LACC)中的临床应用效果。方法:回顾性分析甘肃省妇幼保健院2010~2013年接受住院手术治疗的LACC 260例(鳞癌236例,腺癌12例,腺鳞癌12例)患者的临床资料,根据治疗方式分为新辅助化疗联合腔内后装放疗组82例(NACT+BT组)、单纯新辅助化疗组77例(NACT组)、仅行根治性手术组101例(RH组),通过术后病理危险因素、术后辅助放射治疗率、无进展生存率(PFS)、总生存率(OS)及Cox多因素分析方法来评价不同新辅助治疗方式的临床意义。结果:①与NACT组比较,NACT+BT组能够显著缩小局部肿瘤体积(89.02%vs 76.62%,P<0.05)。②NACT+BT组的深肌层浸润率、宫旁侵犯阳性率、脉管内癌栓阳性率均明显低于RH组(P<0.05),其深肌层浸润率也低于NACT组(P<0.05);NACT组的脉管内癌栓阳性率低于RH组(P<0.05)。NACT+BT组术后补充放疗率(30.49%)低于NCAT组(66.23%)和RH组(79.21%),差异有统计学意义(P<0.05)。③NACT+BT组的5年PFS(90.95%)显著高于RH组(79.23%),差异有统计学意义(P<0.05);3组5年OS比较,差异无统计学意义(P>0.05)。④Cox多因素分析显示淋巴结转移阳性(HR4.79,P<0.01)、手术切缘阳性(HR4.38,P=0.04)和NACT+BT治疗方式(HR0.24,P=0.03)是影响LACC 5年PFS的独立因素;淋巴结转移阳性(HR6.47,P<0.01)是影响5年OS的独立因素。结论:单纯新辅助化疗可以控制病理中危因素,但没有降低术后辅助放疗率以及改善生存结局。而新辅助化疗联合腔内后装放疗可更好地减少术后病理危险因素,降低术后辅助放疗比率,延长PFS,具有较好的临床应用价值。

Objective:To explore the clinical application effect of neoadjuvant therapy in local advanced cervical cancer(LACC).Methods:Retrospective analysis of clinical data was performed in 260 patients with LACC and received surgical treatment in Maternal and Child Care Hospital of Gansu Province from 2010 to 2013,including 236 cases with squamous cell carcinoma,12 cases with adenocarcinoma and 12 cases with adenosquamous carcinoma.These patients were divided into direct surgical group(RH group,n=101),neoadjuvant chemotherapy group(NACT group,n=77)and adjuvant chemotherapy combined with brachytherapy group(NACT+BT group,n=82).The clinical efficacy of neoadjuvant therapy was evaluated by postoperative pathological risk factor,postoperative adjuvant radiation therapy rate,PFS,OS and Cox multi-factor analysis.Results:①Compared with that in NACT group(76.62%),the local tumor volume was significantly reduced in NACT+BT group(89.02%)(P<0.05).②The occurrence of deep stromal invasion,parametrial extension,intravascular tumor thrombus was significant decreased in NACT+BT group compared with that in RH group(P<0.05).The rate of deep stromal invasion in NACT+BT group was lower that in NACT group(P<0.05).The occurrence of intravascular tumor thrombus was lower in NACT group compared with RH group(P<0.05).The rate of postoperative adjuvant pelvic radiotherapy was significant decreased in NACT+BT group(30.49%)compared with NCAT group(66.23%)and RH group(79.21%)(P<0.05).③The 5-year PFS of the NACT+BT group(90.95%)was significantly higher than that of the RH group(79.23%).The difference was statistically significant(P<0.05).There was no significant difference in 5-year OS among the three groups(P>0.05).④Cox multivariate analysis showed that lymph node metastasis(HR 4.79,P<0.01),positive surgical margin(HR 4.38,P=0.04)and NACT+BT(HR 0.24,P=0.03)were independent factors affecting LACC 5-year PFS.Lymph node metastasis was an independent factor affecting 5-year OS(HR 6.47,P<0.01).Conclusions:Neoadjuvant chemotherapy could control the pathological risk factors with little effect in reducing the post-operative adjuvant radiotherapy rate or improving the survival outcome.Neoadjuvant chemotherapy combined with brachytherapy could reduce postoperative pathological risk factors and the ratio of postoperative adjuvant radiotherapy,as well as prolong PFS.The combined therapy may be with better clinical application value.