宫颈癌的预防和治疗

子宫颈癌是人体最常见的肿瘤之一,不但在女性生殖器官肿瘤中占首位,而且是女性各种恶性肿瘤中最多见,根据29个省、市、自治区回顾调查我国宫颈癌死亡率占癌症死亡率的第四位,占女性癌的第二位。

Intensity-modulated radiation therapy with concurrent chemotherapy for locally advanced cervical and upper thoracic esophageal cancer

AIM： To evaluate the dosimetry, efficacy and toxicity of intensity-modulated radiation therapy （IMRT） and concurrent chemotherapy for patients with locally advanced cervical and upper thoracic esophageal cancer. METHODS： A retrospective study was performed on 7 patients who were definitively treated with IMRT and concurrent chemotherapy. Patients who did not receive IMRT radiation and concurrent chemotherapy were not included in this analysis. IMRT plans were evaluated to assess the tumor coverage and normal tissue avoidance. Treatment response was evaluated and toxicities were assessed. RESULTS： Five- to nine-beam IMRT were used to deliver a total dose of 59.4-66 Gy （median： 64.8 Gy） to the primary tumor with 6-MV photons. The minimum dose received by the planning tumor volume （PTV） of the gross tumor volume boost was 91.2%-98.2% of the prescription dose （standard deviation [SD]： 3.7%-5.7%）. The minimum dose received by the PTV Of the clinical tumor volume was 93.8%-104.8% （SD： 4.3%-11.1%） of the prescribed dose. With a median follow-up of 15 rno （range： 3-21 too）, all 6 evaluable patients achieved complete response. Of them, 2 developed local recurrences and 2 had distant metastases, 3 survived with no evidence of disease. After treatment, 2 patients developed esophageal stricture requiring frequent dilation and 1 patient developed tracheal-esophageal fistula. CONCLUSION： Concurrent IMRT and chemotherapy resulted in an excellent early response in patients with locally advanced cervical and upper thoracic esophageal cancer. However, local and distant recurrence and toxicity remain to be a problem. Innovative approaches are needed to improve the outcome.

Clinical study of paclitaxel plus cisplatin in the treatment of recurrent cervical cancer

Objective: To observe the efficacy and toxicities of paclitaxel plus cisplatin in the treatment of recurrent cervical cancer. Methods: Twenty-three patients with a diagnosis of recurrent cervical cancer were eligible. Three-weekly chemo- therapy regimen consisted of paclitaxel 135–150 mg/m2 infusion for 3 h on day 1, cisplatin 25 mg/m2 infusion on day 1 to 3. All patients received at least two cycles treatment. Results: The response rates was 47.8%, including CR 2 cases (8.7%), PR 9 cases (39.1%). The major toxicity included neutropenia, nausea vomiting, arthralgia, myalgia and alopecia. Conclusion: Paclitaxel combined with cisplatin is an effective therapy with acceptable adverse reactions for recurrent cervical cancer.

Molecular mechanism of Skp2 in promoting cervical cancer HeLa cell proliferation

Objective: To explore the impact of s-phase kinase-associated protein 2 (Skp2) on cervical cancer cell proliferation and the relationship between Skp2 and expression of cell regulation factors and transcription factors. Methods: RNAi technology was used to silence Skp2 gene in HeLa cells. After interference, RT-PCR was used for detection of Skp-2 mRNA, and Western blotting and flow cytometry were used for protein expression analysis. Results: siRNA significantly inhibited HeLa cell proliferation (P<0.05) and increased HeLa apoptosis, and G1/G0 phase cells were increased significantly (P<0.01). Skp2 siRNA transfected HeLa cells effectively reduced Skp2 protein levels, while p27 and p-p53 protein levels were increased significantly. RT-PCR results showed that after interference Skp2 mRNA, c-myc mRNA and cyclin A mRNA expressions decreased significantly compared with those in control group (P<0.01), and p27mRNA expression level was significantly higher (P<0.01). Conclusion: The change of Skp2 expression affects the expression of the cell cycle protein, thus affecting proliferation and apoptosis of HeLa cells. Skp2 protein plays an important role in the progression of cervical cancer; yet the specific mechanism still needs further study.

The Analysis of High-Risk Molecular Markers for Cervical Cancer Patients under Thirty-Five

OBJECTIVE To explore molecular markers for cervical cancer in female patients below thirty-five years of age, so that the markers may be used to formulate a prognosis and to provide some useful targets for improving therapy. METHODS Pathological data were collected from 64 cervical cancer patients under the age of 35 from June, 1995 to June, 2000 in our institution. The data were retrospectively analyzed as a study group, and compared to data obtained from 90 cervical cancer cases over the age of 35 as controls who underwent treatment during the same time period. Immuno-histochemical and quantified image analyses were conducted to look for differences between the two groups in expression of survivin, p27, CD44v6, MMP-2 and TIMP-2. RESULTS The overall 5-year survival rate (65.6%) of the study group was significantly lower (P<0.05) compared to the control group (84.4%). The expression of survivin, MMP -2 and CD44v6 was much higher in the younger study group compared to the older control group, but TIMP-2 displayed higher expression in the control group (P<0.05). There was no significant difference in p27 expression between the two groups (P>0.05). CONCLUSION Young women patients with cervical cancer have a poorer prognosis compared to old women. Our study reveals that survivin, MMP-2, TIMP-2 and CD44v6 expression have a correlation with shorter 5-year survival. Improvement in the prognosis for young cervical cancer patients can be expected using biomedical therapy which targets these molecular markers.

Expression and Clinical Significance of HMGB1 and RAGE in Cervical Carcinoma

OBJECTIVE To study the expression level and clinical significance of HMGB1 and RAGE in cervical squamous epithelial carcinoma. METHODS Real time quantitative polymerase chain reaction （qRT-PCR） was employed to examine the expression of HMGB1 （high mobility group box protein1）, and RAGE （receptor for advanced glycation endproducts） in 60 cervical squamous epithelial carcinomas （CSEC）, their paraneoplastic tissues （PS） and 30 normal cervix tissues （NCS）. RESULTS The expression of HMGB1 in the CSEC samples and PS was similar （P〉0.05）, but higher compared to NCS （P〈0.05）. Overexpression of HMGB1 in the CESC tissues was significantly correlated with the tumor （P〈0.05）, and the presence of metastasis （P〈0.01）, but not correlated with the tumor diameter or tumor grade.RAGE expression was not significantly different among these tissue types, and showed no significant correlation with the the tumor stage, diameter or grade. But there was a significant positive correlation between RAGE expression and CSEC metastasis. CONCLUSION The results suggest that HMGB1 may be related to the proliferation, progression and metastasis of CSEC. The relationship of HMGBI/RAGE may be of importance for CSEC metastasis. HMGB1 presents a new potential gene target for prevention and treatment of CSEC. Study of HMGBI/RAGE expression will offer an experimental foundation for understanding the pathogenesis of CSES.

Overexpression of p53 Gene in Esophageal and Cervical Cancer and the Relationship with Radiotherapy Effects

Objective :To investigate the relationship between p53 -protein overexpression in esophageal and cervical squamous cell cancer and their clinical radiosensitivity. Methods: The immuno-histochemical assays were done for 52 cases with esophageal and cervical squamous cell cancer. The relationship between the assay results and short-term radiotherapy was investigated. Results: p53 overexpression was 52. 38% and 35. 48% respectively, in esophageal cancer and cervical cancer; p53 over-expression in high differentiated squamous cell cancer was lower than those in moderate and poor differentiated cases(P<0. 05). There was no relationship between p53 overexpression and stages(P> 0. 05). In the cases of cervical cancer, p53 overexpression had the less short-term effect(P< 0. 05), and In esophageal cancers, there was no relationship with radiotherapy effect(P>0. 05). Conclusion:This study suggests that y53 gene lias the certain relationship with tumor radiosensitivity.

Hepatoma-derived growth factor expression as a prognostic marker in cervical cancer

AIM： To examine the association of hepatoma-derived growth factor （HDGF） expression with the prognosis of patients with cervical cancer of the uterus （CC）. METHODS： HDGF is a unique nuclear growth factor, and it may play an important role in the development and progression of carcinoma. HDGF expression in 88 CC patients aged 23 to 76 years （median, 54 years） was analyzed by immunohistochemistry. A rabbit polyclonal antibody against the C-terminal amino acids （aa 231-240） of the human HDGF sequence was used as primary antibody at a dilution of 1：5000. This specific anti-HDGF antibody was purified using C-terminal peptide-conjugated Sepharose columns. Staining of endothelial cells in the noncancerous areas of each specimen was used as an internal positive control. Samples with more than 80% of tumor cells showing positive immunoreactivity in both the nucleus and cytoplasm were regarded as HDGF index level 2,more than 80% positive immunoreactivity in either the nucleus or cytoplasm as level 1, and less than 80% in both the nucleus and cytoplasm as level 0. The chi-square test and Fisher’s exact probability test were used to examine the relationship between HDGF expression and clinicopathologic parameters, and statistical significance was examined by the log-rank test. Multivariate analysis of factors related to survival was performed using Cox’s proportional hazards regression model. Statistical signifcance was set at P 〈 0.05. RESULTS： The five-year overall survival rate was 82.9%. Fourteen patients died due to tumors, nine of whom had tumor recurrence at 2-21 mo （median, 10 mo） after surgery. Tumor recurrence in five patients was determined at the time of the patients’ deaths. Nineteen cases were regarded as HDGF index level 0, 11 as level 1, and 58 as level 2. Patients with level 2 expression showed higher rates of histological classification of keratinized squamous cell carcinomaand adenosquamous carcinoma （44.8% of level 2 patients and 13.3% in levels 0 and 1）, deep invasion （pT2-4 in 65.5% of level 2 patients, and 30.0% in levels 0 and 1）, the presence of lymphatic invasion （50.0% in level 2, and 20.0% in levels 0 and 1）, and the presence of lymph node metastasis （37.9% in level 2, and 6.7% in levels 0 and 1）. Patients with an HDGF index of level 2 CC showed poorer 5-year overall survival rates than those with level 0 or 1 CC （74.0% and 100%, respectively, P = 0.0036）. Univariate analysis revealed that histological classification （P = 0.04）, depth of tumor invasion （P = 0.0001）, vascular invasion （P = 0.004）, and lymph node metastasis （ P = 0.0001） were significant factors affecting overall survival in addition to HDGF expression. Multivariate analysis revealed HDGF expression level and lymph node metastasis as independent prognostic factors for overall survival （P = 0.0148 and P = 0.0197, respectively）. The prognostic signifcance of HDGF was further analyzed in pT1 andsignifcance of HDGF was further analyzed in pT1 and pT2-4 patient groups, respectively. Among patients with pT1 CC, one the 39 analyzed patients died during the study, and no difference was observed among patients with HDGF index level 0, 1, or 2 CC. However, prognostic signifcance of the HDGF index was observed in the pT2-4 patient group, in which the mortality rates of patients with HDGF index level 2 CC and those with level 0 or 1 CC signifcantly differed （P = 0.0463）. CONCLUSION： The HDGF expression level is of prognostic signifcance in CC.

Bone marrow-sparing intensity-modulated radiotherapy for postoperative treatment of cervical cancer

Objective： The aim of this study was to compare bone marrow-sparing intensity-modulated radiotherapy （IMRT） with IMRT without entering pelvic bone marrow as a planning constraint in the treatment of cervical cancer after hysterectomy. Methods： For a cohort of 10 patients, bone marrow-sparing IMRT and routine IMRT planning were designed. The prescribed dose was 45 Gy/1.8 Gy/25f, 95% of the planning target volume received this dose. Doses were computed with a commercially available treatment planning system （TPS） using convolution/superimposition （CS） algorithm. Plans were compared according to dose-volume histogram （DVH） analysis in terms of planning target volume （PTV） homogeneity and conformity indices （HI and CI） as well as organs at risk （OARs） dose and volume parameters. Results： Bone marrow-sparing IMRT had an vantages over routine IMRT in terms of CI, but inferior to the latter for HI. Compared with routine IMRT, V5, Vl0, V20, V30, V40 of pelvic bone marrow of bone marrow-sparing IMRT reduced by 1.81%, 8.61%, 31.81%, 29.50%, 28.29%, respectively. No statistically significant differences were observed between bone marrow-sparing IMRT and routine IMRT in terms of small bowel, bladder and rectum. Conclusion： For patients with cervical cancer after hysterectomy, bone marrowsparing IMRT reduced the pelvic bone marrow volume irradiated at all dose levels and might be conducive to preventing the occurrence of acute bone marrow toxicity.

Transfection with the ribozyme targeting HPVE6 mRNA results in growth inhibition of E6-expressing cervical carcinoma cells

Objective: To acquire a ribozyme against the E6 gene of human papillomaviruses type 16 (HPV16E6) and investigate its effects on the phenotypes and gene expression of cervical cancer cell line. Methods: Anti-HPV16E6 ribozyme (HRz) was designed by computer programs and its activity identified by cleavage experiment in vitro before its transfection via lipofectin into CaSKi cells with the empty eucaryotic expression plasmid transfection of the cells also performed, the resultant cells designated as CaSKi-R, CaSKi-P respectively. The morphology and the soft agar forming ability were studied in CaSKi cells and the transfected cells, and the expression of E6, proliferating cell nuclear antigen (PCNA) and C-erbB-2 genes assayed by flow cytometry. The tumorgenicity of each cell line was evaluated in nude mice receiving inoculations of CaSKi, CaSKi-R and CaSKi-P cells separately, while in one group, both CaSKi and CaSKi-R cells were inoculated on different sides of the mice. Results: HRz was able to cleave HPV16E6 mRNA in a site-specific manner and could be expressed stably in transfected CaSKi cells. Northern blot analysis showed that E6 mRNA was less in CaSKi-R than in CaSKi cells, and no significant difference in the morphology and growth rate was observed between CaSKi and CaSKi-P cells, but the growth rate CaSKi-R was lowered. The colony-forming rate of CaSKi-P in soft agar was similar to that of CaSKi cells, while that of CaSKi-R was decreased. Flow cytometry showed that anti-HPV16E6 ribozyme reduced the expression of E6, PCNA and C-erbB-2 genes in CaSKi-R cells, but not in CaSKi-P cells. The tumorgenicity of CaSKi-R in nude mice was decreased compared with CaSKi cells. Conclusion: HRz can partially reverse the malignant phenotype of CaSKi cells, possibly due to decreased E6 gene expression, and the consequent decrease of PCNA and C-erbB-2 gene expressions.

Comparison of different treatment regimens for ⅠB2 and ⅡA2 cervical cancer

Objective： The aim of this study was to explore the difference of long-term prognosis of different treatment regimens in patients with stage IB2, IIA2 cervical Cancer. Methods： From August 1995 to September 2005, radical hysterectomy was chosen as primary treatment regimen for 122 patients （group A）, 85 patients underwent radical hysterectomy after ef- fective neoadjuvant therapy （group B）, and 98 patients received surgery after ineffective preoperative therapy （group C）. All patients received postoperative therapy. Results： Atotal of 305 patients were analyzed. The maximum diameter of tumor was largest in group B, while the pathological risk factors （cervical infiltration, positive surgical margins） were in the lowest propor- tion. The 5-year mortality rate and relapse rate of group B were the highest, and the overall survival （OS） and progression-free survival （PFS） were the shortest （P 〈 0.05）. No significant difference of long-term survival was found in group C and group A. No difference was found in the surgical of three groups. Large tumor more than 5.5 cm had higher effective ratio of treatment than those 5.5 cm or less. Patients received effective preoperative radiotherapy had better long-term prognosis than those received chemotherapy or radiochemotherapy. Conclusion： neoadjuvant treatment using for patients with IB2, IIA2 cervical cancer is effective in reducing risk factors of pathological, but it could not improve the long-term survival. The indications of adjuvant therapy after surgery should be reconsidered. Those tumors of diameter 5.5 cm or less response poor to neoadjuvant treatment, and no improvement of survival was found, so direct surgical treatment is suggested for these patients. Radiotherapy is a better choice of preoperative treatment.

Clinical Report on Californium-252 Neutron Intraluminal Brachytherapy Combined with External Irradiation for Cervical Carcinoma Treatment

OBJECTIVE To observe the curative effects and complications of californium-252 （^252Cf） neutron intraluminal brachytherapy （IBT） combined with external irradiation （El） for treatment of cervical carcinoma.METHODS From December 2000 to December 2004, 128 cases of cer vical carcinoma staged into IIA-IIIB according to the International Federation of Gynecology and Obstetrics （FIGO） standards were treated with ^252Cf neutron IBT using 8-10 Gy per fraction, once a week. The total dose at reference A point was 36-40 Gy in 4-5 fractions. From the second day after ^252Cf neutron IBT treatment, the whole pelvic cavity was treated with ^60Co y-ray El, applying 2 Gy per fraction, 4 times per week. After 20-25Gy of El, the center of the whole pelvic field was blocked with 4 cm of lead in width. The total dose of El was 45-50 Gy.RESULTS The short-term therapeutic effects were CR 95.3% and PR 4.7%. The 3 and 5-year local control rates were 93.5% and 87.9%. The overall 3-year survival rate was 87.5% and for Stages Ⅱ and Ⅲ , 90.9% and 81.5% respectively; the overall 5-year survival rate was 70% and for Stages II and III, 76.2% and 61% respectively. The rate of radiation complications was 4.7% for radiation cystitis, 7.8% for radiation proctitis, 6.3% for vagina contracture and adhesion and 5.5% for protracted radiation proctitis.CONCLUSION An combination of ^252Cf neutron IBT with El for treatment of cervical carcinoma can be well-tolerated by cervical carcinoma patients. The rate of local tumor control is high and radiation complications are few.

Clinical study on radiotherapy combined with surgical treatment of 162 patients with cervical cancer

Objective： To compare the 5-year survival rates and complications of internal and external irradiation therapy combined with operation in patients with Ⅱ-Ⅲ period of cervical cancer. Methods： 162 cervical cancer patients after the whole palace resection pelvic lymphadenectomy were divided into three groups, and then accepted radiotherapy. The first group with 91 cases was accepted internal and external irradiation therapy before operation; the second group with 37 cases was given internal irradiation therapy before operation; the third group with 34 cases was given routine postoperative radiotherapy. External irradiation used ^60Co irradiation or a linear accelerator, to the whole basin, and the irradiation dose of ＂B＂ point in preoperative radiotherapy was 26-30 Gy, in postoperative radiotherapy was 46-50 Gy; intraluminal brachytherapy used ^192lr, the dose of ＂A＂ point was 5-15 Gy. Results： The 5-year survival rate of preoperative combined radiotherapy group was 78.0% （71/91）, preoperative intracavitary radiotherapy group 64.9% （24/37）, and postoperative radiotherapy group 35.3% （12/34）. Comparing the 5-year survival rates of the preoperative combined and postoperative irradiation groups, there was significant difference （P 〈 0.05）. The major complications were radioactive proctitis and cystitis, the complication incidences of three groups were 35.2% （32/91）, 32.4% （12/37）, 38.2% （13/34）, respectively, and the differences were not statistically significant （P 〉 0.05）. Conclusion： The intraluminal brachytherapy plus external irradiation can significantly increase the 5-year survival rate of patients with Ⅱa-Ⅲa stages, and the incidence of complications was not significant difference.

Primary choriocarcinoma of uterine cervix treated by uterine artery drug pouring and embolism: one case report

Primary choriocarcinoma of the uterine cervix (PCC) is an extremely rare disease. The conventional treatment of PCC is a combination of hysterectomy and chemotherapy. We present one rare case proved by cervical biopsy. The patient was an 36-year-old Chinese woman with irregular vaginal bleeding for 60 days. A cervical tumoral mass was seen in the pelvic examination and biopsy revealed active hyperplasia of trophoblastic cell. Because of massive vaginal haemorrhage, the patient accepted uterine artery drug pouring and embolism emergently. This management had gained a satisfactory effect. Thus, Uterine artery drug pouring and embolism is one new and effective weapon for PCC, which can preserve the patient’s productive ability.

A dosimetric evaluation of flattening filter-free volumetric modulated arc therapy for postoperative treatment of cervical cancer

Objective The aim of the study was to compare flattening filter-free(FFF) beams and conventional flattening filter(FF) beams in volumetric modulated arc therapy(VMAT) for cervical cancer after surgery, through a retrospective planning study.Methods VMAT plans of FFF beams and normal FF beams were designed for a cohort of 15 patients. The prescribed dose was 45 Gy to 1.8 Gy per fraction, and at least 95% of the planning target volume received this dose. Doses were computed with a commercially available treatment planning system using a Monte Carlo(MC) algorithm. Plans were compared according to dose-volume histogram analysis in terms of planning target volume homogeneity and conformity indices(HI and CI), as well as organs at risk(OAR) dose and volume parameters. Results FFF-VMAT was similar to FF-VMAT in terms of CI, but inferior to FF-VMAT considering HI. No statistically differences were observed between FFF-VMAT and FF-VMAT in following organ at risks including pelvic bone marrow, small bowel, bladder, rectum, and normal tissue(NT)..Conclusion For patients with cervical cancer after hysterectomy, the FFF beam achieved target and OAR dose distribution similar to that of the FF beam. Reduction of beam-on time in cervical cancer is beneficial.

Clinical observation of three-dimensional conformal radiotherapy(3D-CRT) with concurrent chemotherapy in treatment of recurrent cervical cancers

Objective： The aim of the study was to explore the efficacy of three-dimensional conformal radiotherapy （3D- CRT） combined with TP concurrent chemotherapy in treatment of recurrent cervical cancers. Methods： From May 2005 to May 2009, 36 patients with recurrent cervical cancer were treated by 3D-CRT of 60-66 Gy and TP （docetaxel 70 mg/m^2, d1; cisplatin 20 mg/m^2, dl-d3; 21 days per cycle, totally 2 cycles） concurrent chemotherapy. Results： All of the patients had finished the 3D-CRT, the total response rate, complete response rate and partial response rate were 80.0% （28/35）, 45.7% （16/35）, and 34.3% （12/35）, respectively. The pain-alleviation rate was 91.4% （32/35）. The hemorrhage control rate was 94.3% （33/35）. The median overall survival was 21.2 months. The 1-, 2- and 3-year survival rates were 54.3%, 37.1% and 22.8%, respectively. The life qualities of the patients were improved, without any treatment related death. Conclusion： Radiotherapy is effective and well-tolerated for recurrent cervical cancers, and it can promote regional control of the disease and prolong survival time.

Chibuike O Chigbu, MD, Series EditorTrends in cervical cancer screening in developing countries

Developing countries suffer the highest burden of cervical cancers but have the lowest resources. Effective cervical cytology screening programme, along with a network of diagnostic and therapeutic colposcopy centres, like developed countries, is almost impossible to be reproduced in developing countries. Visual inspection methods [e.g., Visual inspection with Lugol's iodine(VILI) and Visual Inspection with Acetic Acid(VIA)] which are cheaper, require less expertise and have the advantage of possible treatment in one setting have been shown to be effective alternatives. The sensitivity to detect CIN2+, by VIA and VILI, have been shown to be 80% and 91% respectively, with a specificity rate of 92% and 85% respectively. Screening by human papillomavirus(HPV) testing has high sensitivity(96.4%) but low specificity(94.1%) to detect CIN2+, when compared to Pap Smear(sensitivity, 55.4% and specificity, 96.8%). A single lifetime HPV testing in a large unscreened population has been shown to significantlyreduce cervical cancer incidence and mortality when compared to cervical cytology, VIA or no screening. HPV testing of self-collected vaginal specimens also helps to overcome religious and socio-cultural barriers towards pelvic examination amongst women in developing countries. Current HPV testing methods are expensive, skill/infrastructure demanding and takes time to produce results. A cheaper HPV test, called careH PV?, which is able to provide results within 2.5 h and requires minimal skill/infrastructure to operate, was designed for use in developing countries. One stop screen and treat facilities using VIA or rapid HPV testing, and cryotherapy, can overcome non-compliance to follow-up which is a major issue in developing countries. Cure rates of 81.4% for CIN1, 71.4% for CIN2 and 68.0% for CIN3 at 6 mo after treatment have been reported. Incorporating telemedicine with cervicography of VIA or VILI or even telecolposcopy, has great potential in cervical cancer screening, especially in countries with vast geographical areas.

Clinical value of three-dimensional conformal radiation therapy for postoperation cervix cancer

Objective： To observe the clinical value of three dimensional conformal radiation therapy （3D-CRT） followed by radical surgery and discuss the best radiation technique for cervical cancer patients after radical hysterectomy. Methods： From February 2003 to June 2006, 115 stage Ⅰ-Ⅲa uterus cervix cancer patients received postoperation radiotherapy in our department after radical surgery. They were randomly divided into two groups. There were 81 patients in 3D-CRT group and 74 patients in traditional radiation group. According to FIGO, there were 45 in stage Ⅰ, 77 in stage Ⅰa, 31 in stage Ⅱb, 2 in stage Ⅲa. Pathological examination confirmed that 148 cases had squamous carcinoma and 7 cases had adenocarcinoma. The target volume included supravaginal portion, the cervical stump, paracervical tissue, common iliac lymph nodes, intemal and extemal lilac lymph nodes, obturator and sacral lymph nodes. For 3D-CRT group we designed four-field or two-fields rotating irradiation in the left-right and the anterior-posterior direction. For traditional radiation group we designed two-field, anterior-posterior, at opposed lateral directions. The radiation dose ranged from 48-50 Gy. Stage lib patients with a cervical stump recurrence received postoperative boost radiation by 8-10 Gy. Results： There were no significant difference in 0.5-year, 1-year, 1.5-year, 2-year local control rate between 3D-CRT group and traditional radiation group （P 〉 0.05）. The occurrence of early and late complications was significant lower in 3D-CRT group than that in traditional radiation group （P 〈 0.05）. There was significant difference in gastrointestinal reaction and urinary system reaction between the two groups （P 〈 0.05）. In postoperation radiotherapy 3D-CRT was superior compared with traditional two-field radiation at opposed lateral direction. Conclusion： 3D-CRT is superior compared with traditional radiation. Four-field rotating irradiation in 3D-CRT has advantages of dose focusing, even dose distribution and cause less side effects and complications. The side-field and cervical stump-targeted boost irradiation are apparent advantages of 3D-CRT.

Malignant neoplasms of the uterus following radiation therapy for cervical carcinoma: a clinical study of 47 cases

Objective： To study the characteristics and clinical features of uterine neoplasms developed after radiation therapy for cervical carcinoma. Methods： Clinical data of 47 cases of uterine neoplasms occurred following radiation therapy for cervical carcinoma were retrospectively reviewed. Results： The median age at uterine neoplasms diagnosis was 62 years （range： 38-77 years）, and the median latency period from initial therapy to development of uterine neoplasms was 14 years （range： 5-35 years）. Thirty of 47 cases were endometrial carcinoma, of which 3 were uterine papillary serous carcinoma （UPSC）. Seventeen of 47 patients were uterine sarcoma, all of those were carcinosarcoma. The distribution by stage, grade, and histology of 30 cases of endometrial carcinoma was as follows： stage Ⅰb, 1 case; stage Ⅰc, 2 cases; stage Ⅱ, 6; stage Ⅲa, 4; stage Ⅲb, 2; stage Ⅲc, 11; stage Ⅳ, 4 cases; grade 1, two cases; grade 2, nine; grade 3 （include 3 UPSC patients）, seventeen; unknown grade, two; endometriod, 27; UPSC, 3 cases; 7 of 30 cases of endometrial carcinoma had recurrences （23.3%）, at median time to recurrence was 24 months, and their median survival time was 26 months. The overall 3- and 5-year survival rates were 60% and 38%, respectively. Of the 17 cases of uterine sarcoma, the median survival was 10 months, 6 patients occurred recurrence （35.9%）, at a median time to recurrence was 9 months, and their median survival was 6 months. The overall 3- and 5-year survival rates were 12% and 0, respectively. Conclusion： The main uterine neoplasms development after radiation therapy for cervical carcinoma is endometrial carcinomas, of which there is a preponderance of high-risk histological subtypes and a poor prognosis. Most of the uterine sarcomas occurred following radiation therapy for cervical carcinoma are carcinosarcomas and the prognosis is very poor.

Clinical study of three dimensional conformal radiotherapy combined with intracavitary brachytherapy in the treatment of cervical cancer

Objective: The aim of our study was to evaluate the outcome and complications of cervical cancer patients undergoing conventional intracavitary brachytherapy (ICBT) treated with 3D-conformal radiotherapy (3DCRT). Methods: Sixty cervical cancer patients were divided randomly into the conformal group and the conventional group. Thirty patients treated with 3D-conformal radiotherapy in the 3DCRT group, when the whole pelvic received DT 40 Gy, a planning CT scan of each patient was obtained and the second 3DCRT therapy plan was taken. Then, continued to irradiate to 50 Gy. At last, 3DCRT was boosted at local involved volumes to the total dose of 60 Gy. When 3DCRT was combined with intracavitary brachytherapy, the dose of brachytherapy to point A was 30 Gy/5 fractions. In the conventional group, after a total tumor dose of 40 Gy was delivered by the whole pelvic irradiation, the four-field technique was used to irradiate the total pelvic and regional nodes (median dose of 10 Gy), and the involved volumes were boosted to 60 Gy and the dose of brachytherapy to point A was 30 Gy-36 Gy/5-6 fractions. Moreover, both groups were combined with intracavitary brachytherapy respectively. Results: The 1, 2, 3-year survival rates for the 3DCRT group and the conventional group were 96.7%, 93.3%, 90.0% and 86.6%, 76.7%, 70% respectively (P = 0.04, P = 0.02 and P = 0.02). There was a statistically significant difference between the two groups. Compared to the two groups each other in toxic effects, except for the I-II grade rectal and bladder reaction and pelvic fibrosis which was lower in the 3DCRT group (P = 0. 007, P = 0. 006 and P = 0. 015), the side effects were similar and well tolerated in two groups. Conclusion: The all-course 3DCRT combined with intracavitary brachytherapy can be considered as an effective and feasible approach to cervical cancer and may significantly improve the survival rate and reduce the late toxicity. This new role for 3DCRT merits need further evaluation with large patient numbers and longer follows up.