单纯放疗与辅助放化疗治疗淋巴结阳性的外阴鳞癌手术患者临床疗效对比

Comparison of clinical efficacy between radiotherapy alone and adjuvant chemoradiotherapy in the surgical treatment of vulvar squamous cell carcinoma with positive lymph nodes

目的比较单纯放疗与辅助放化疗治疗淋巴结阳性的外阴鳞癌手术患者的临床疗效。方法从美国监测、流行病学和结果数据库(SEER)中获取2004年至2015年诊断为女性外阴恶性肿瘤的患者作为研究对象,其随访截至时间为2018年11月30日。通过筛选获得病理确诊淋巴结阳性的外阴鳞状细胞癌术后患者共907例,分析淋巴结转移的外阴鳞癌患者的临床特征及预后影响因素。按术后辅助治疗的方式,将患者分为辅助放疗联合化疗组(CRT)及辅助放疗组(RT),应用稳健逆概率处理加权,对比两组的临床特征及癌症特异性生存预后。结果淋巴结转移的外阴鳞癌手术患者的中位确诊年龄为67岁(21~95岁),中位癌症特异性生存期(CSS)为34个月,多因素Cox回归分析显示,年龄(HR=1.03,95%CI为1.03~1.04,P<0.001),FIGO分期Ⅳ期(HR=1.85,95%CI:1.06~3.23,P=0.029),2枚阳性淋巴结(HR=1.31,95%CI:1.03~1.67,P=0.03),3枚阳性淋巴结(HR=1.61,95%CI:1.19~2.19,P=0.002),4枚及以上阳性淋巴结(HR=2.76,95%CI:2.07~3.67,P<0.001),淋巴结转移未知(HR=1.63,95%CI:1.19~2.23,P=0.002),放疗(HR=0.74,95%CI:0.60~0.91,P=0.004),化疗(HR=0.71,95%CI:0.57~0.87,P=0.001)是其CSS的独立预后因素。RT及CRT患者的亚组分析显示,年龄≥60岁、区域性病灶、低分化或未分化、FIGOⅢ~Ⅳ期,T分期为T2~T3期,N分期为N1~N2期,M分期为M0期,肿瘤大小≥2 cm,具有3个及以上的淋巴结转移,或淋巴结转移未知的患者可从辅助放化疗中获得更高的CSS收益。CRT组较RT组具有更高的癌症特异性生存率(P=0.003),经稳健逆概率加权后,中位生存期分别为6.92年及3.58年(P=0.0337)。结论淋巴结转移的外阴鳞状细胞癌手术患者,采用辅助放疗联合化疗,可获得比辅助放疗更优的癌症特异性生存预后,这可为临床选择更佳的外阴癌术后维持治疗提供借鉴。

Objective To compare the clinical efficacy of radiotherapy alone and adjuvant chemoradiotherapy in patients with lymph node positive vulvar squamous cell carcinoma after surgery.Methods The cases from the US Surveillance,Epidemiology and End Result(SEER)Database who were diagnosed with female vulvar cancer between 2004 and 2015 were analyzed.The followed-up was ended on November 30 of 2018.The clinical features and prognostic variables of 907 individuals with vulvar squamous cell carcinoma and lymph node metastases were examined.The patients were divided into CRT group(receiving adjuvant Chemoradiotherapy)and RT group(receiving adjuvant radiotherapy).Stabilized inverse probability of treatment weighting(SIPTW)was used to compare the clinical traits and cancer-specific survival(CSS)of the two groups.Results The median cancer-specific survival was 34 months,while the median age at diagnosis of vulvar squamous cell carcinoma with lymph node metastases was 67 years(range 21-95 years).Multivariate Cox regression analysis showed that age(HR=1.03,95%CI:1.03-1.04,P<0.001),FIGO stageⅣ(HR=1.85,95%CI:1.06-3.23,P=0.029),two positive lymph nodes(HR=1.31,95%CI:1.03-1.67,P=0.03),three positive lymph nodes(HR=1.61,95%CI:1.19-2.19,P=0.002),four or more positive lymph node(HR=2.76,95%CI:2.07-3.67,P<0.001),unknown of lymph node metastases(HR=1.63,95%CI:1.19-2.23,P=0.002),radiotherapy(HR=0.74,95%CI:0.60-0.91,P=0.004),chemotherapy(HR=0.71,95%CI:0.57-0.87,P=0.001)were independent prognostic factors for CSS.A subgroup analysis revealed that patients with characteristics such as advanced age(≥60 years),regional lesions,poorly or undifferentiated tumors,FIGOⅢandⅣ,T2 and T3 staging,N1 and N 2 staging,M0 staging,tumors larger than 2 cm,3 or more lymph node metastases,and unknown lymph node metastases may benefit more from chemoradiotherapy in terms of CSS.The cancer-specific survival rate of CRT group was greater than that of RT group(P=0.003).And the median survival time was 6.92 years and 3.58 years after stabilized inverse probability weighting(P=0.0337).Conclusions Adjuvant radiotherapy combined with chemotherapy improves the cancer-specific survival prognosis for surgical patients with vulvar squamous cell carcinoma and lymph node metastases.