介入化疗加放疗治疗中晚期宫颈癌的临床研究

宫颈癌是最常见的妇科恶性肿瘤,外科手术仅适于早期患者,中晚期宫颈癌传统治疗方法以放射治疗为主,其有效率较为有限。为进一步提高疗效,1998年3月～1999年5月我们对40例晚期宫颈癌应用介入化疗加放疗,并与同期单纯放疗的40例进行对比,现报告如下。     

非根治剂量的体外照射配合腔内放疗加根治术治疗宫颈癌

目的 总结分析外照射配合腔内放疗加根治术治疗Ⅰb-Ⅲa期宫期癌的5年生存率和晚期并发症。方法 106例宫颈癌均行广泛性子宫切除和盆腔淋巴结清除术,其中78例行术前放疗（体外加腔内放疗,下同）,16例采用腔内放疗＋手术,12例术后放疗。外照射采用^60Co治疗机,给予合盆或盆腔四野照射,B点剂量术前放疗者为25－30Gy,术后放疗者为40－50Gy;腔内放疗采用^192Ir高剂量率后装机,A点剂量6－18Gy。结果 （1）5年生存率：Ⅰb-Ⅲa期术前放疗组为78.2%（61／78）,腔内＋手术组为68.8%（11／16）,术后放疗组为33.3%（4／12）。术前放疗组与术后放疗组相比,差异有显著性（P＜0.05）。术前放疗组中,Ⅱ期患者的5年生存率(77.6%,45／58）高于术后放疗组（1／4,P＜0.05）。（2）主要并发症：多为放射性直肠炎和膀胱炎。术前放疗组、腔内放疗＋手术组和术后放疗组的并发症发生率分别为34.6%(27/78）、31.3%（5／16）和33.3%(4/12),差异无显著性（P＞0.05）。结论 非根治量的体外照射配合腔内放疗加根治术治疗宫颈癌,可提高Ⅰb-Ⅲa期患者总的5年生存率和Ⅱ期患者的5年生存率,晚期并发症发生率差异无显著性。     

宫颈癌根治术后三维适形放疗的临床价值

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,internal and external iliac 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 Ⅱb 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.     

手术与手术联合放化疗对70例喉癌患者的临床效果比较

目的分析研究经手术与手术联合放化疗治疗70例喉癌患者中的临床效果比较及远期并发症。方法选取喉癌患者70例,随机分成对照组和观察组2组,各35例,对照组仅行手术切除,试验组行手术+放化疗治疗,分析比较2组的临床效果及远期并发症情况。结果观察组35例喉癌患者中Ⅰ、Ⅱ、Ⅲ、Ⅳ期患者术后5年生存率分别为90.91%、61.54%、44.44%、0,与对照组(83.33%、58.33%、44.44%、0)相比无显著性差异,临床总有效率远远高于对照组,差异具有统计学意义(P<0.05),且观察组5年总生存率(60.00%)与对照组(62.86%)较接近,P>0.05。观察组复发转移总发生率为34.28%,与对照组(37.14%)相比无统计学差异,P>0.05。观察组术后2例喉腔狭窄、3例肺部感染、3切口感染、2例皮下气肿、1例第二原发恶性肿瘤(食管癌),对照组术后2例喉腔狭窄、4例肺部感染、2切口感染、3例皮下气肿、2例第二原发恶性肿瘤(食管癌),两组对比无统计学差异,P>0.05。观察组术后的总满意度(74.28%)与对照组(77.14%)接近,不存在统计学差异(P>0.05)。结论针对于喉癌患者,采用手术疗法与手术联合放化疗治疗的术后生存率、复发转移情况无明显差异,两种方式的并发症并无显著不同,但针对不同患者可采取相应放化疗进行延缓病情发展,本研究对临床上研究喉癌治疗具有参考价值。     

Changes in Prevalence and Clinical Characteristics of Cervical Cancer in the People's Republic of China: A Study of 10,012 Cases From a Nationwide Working Group

Purpose.

About one-third of the world''s total annual new cervical cancer cases are found in the People''s Republic of China. We investigate the prevalence and clinical characteristics of cervical cancer cases in the People''s Republic of China over the past decade.

Method.

A total of 10,012 hospitalized patients with cervical cancer from regions nationwide were enrolled from 2000 to 2009. Demographic and clinical characteristics, therapeutic strategies, and outcomes were analyzed.

Results.

The mean age at diagnosis of all cervical cancer patients was 44.7 ± 9.5 years, which is 5–10 years younger than mean ages reported before 2000 in the People''s Republic of China. The age distribution showed 16.0% of patients were ≤35 years old, 41.7% were 35–45 years old, and 41.7% were >45 years old. Early stage diagnoses were most prevalent: 57.3% were stage I, 33.9% were stage II, and 4.3% were stage III or IV. Most patients (83.9%) were treated with surgery, and only 9.5% had radiotherapy alone. Among 8,405 patients treated with surgery, 68.6% received adjuvant treatments, including chemotherapy (20.9%), radiotherapy (26.0%), and chemoradiotherapy (21.9%). Among stage IA patients, 16.0% were treated with corpus uteri preservation. The proportion of ovarian preservation was 42.0%.

Conclusions.

Cervical cancer cases in the People''s Republic of China show increasing prevalence in young patients and at early stages. In the past 10 years, surgery has become the dominant treatment and is increasingly combined with adjuvant chemotherapy for patients with stages I and II. Conservative surgical approaches are reasonable options for genital organ preservation in selected patients.     

中、晚期宫颈癌43例同步放疗、化疗的临床疗效观察

目的　探讨同步放疗、化疗治疗中晚期宫颈癌的疗效及毒副作用。方法　将病理确诊的Ⅱb期～Ⅳ期宫颈癌 43例作为研究组 (A组 ) ,DDP 5 0mg/m2 合并水化 ,第 1天 ;5 Fu 75 0mg/m2 ,静脉点滴 ,第 2～ 5天 ;4周重复 1次 ,共 2～ 4次。同时行根治性放疗 ,60 Co体外照射 ,总剂量为 45～ 5 0Gy ,腔内后装采用192 Ir后装机 ,A点 7Gy/周 ,总剂量为 3 5～ 42Gy。以同期收治、条件相同行单纯放疗的 40例宫颈癌患者为对照组 (B组 )。观察近期疗效、3年生存率及放疗、化疗并发症。结果　放疗 3个月后 2组有效率分别为 93 .0 % (A组 )和 72 .5 % (B组 ) ,有显著性差异 (P <0 .0 5 )。A组 3年生存率 (83 .7% )明显高于B组 (62 .5 % ) ,P <0 .0 5。A组局部复发率、远处转移率明显低于B组。同步放疗、化疗组有较明显的骨髓抑制、消化道反应 ,但均能耐受。放疗远期并发症不增加。结论　同步放疗、化疗能明显提高中晚期宫颈癌患者的生存率 ,DDP 5 Fu的应用是安全可行的 ,但远期疗效需进一步观察     

Equivalent survival in patients with advanced stage IB–II and III–IVA cervical cancer treated by adjuvant surgery following chemoradiotherapy

Objectives

To evaluate survival in patients with advanced cervical cancer who underwent surgery after concurrent chemoradiotherapy.

Methods

One hundred and forty-four patients with biopsy-proven stage IB–IVA cervical cancer underwent adjuvant surgery after concurrent chemoradiotherapy. Surgical resection was classified as curative (no evidence of remaining disease after surgery) or palliative (remaining disease after surgery). Endpoints were pelvic control, overall survival (OS) and disease-free survival (DFS) at 5 and 10 years. Analysis included tumour FIGO stage, type of surgery (curative versus palliative), pelvic control, response to chemoradiotherapy and lymphatic status.

Results

Tumour FIGO stages were IB–II in 91 cases and III–IVA in 53 cases. Surgery was curative in 127 cases. Pelvic control was achieved in 114 patients and was equivalent in stage IB–II and III–IVA patients. So far, 60 patients have died. The 5-year OS and DFS rates were, respectively, 57.6% [95% CI: 49.1–67.5] and 65% [95% CI: 56.2–75]. OS was significantly affected by the type of surgery (p < 2.10⁻¹⁶), the presence of tumoural residue (p = 0.002) and the pelvic lymphatic status (p < 0.001). DFS was affected by the pelvic (p = 0.02) and para-aortic lymphatic status (p = 0.009). No significant difference was observed between OS and DFS in stage IB–II and III–IVA patients, whereas a macroscopic tumoural residue was observed in, respectively, 30.9 and 52.2% of cases (p = 0.022).

Conclusion

Survival rates were equivalent between patients with IB–II and III–IVA cervical cancer, suggesting that adjuvant surgery following chemoradiotherapy may improve local control.     

两种化疗方案在宫颈癌同步放化疗中的疗效及副反应对比分析

目的对宫颈癌同步放化疗中的两种化疗方案进行对比研究,探讨更佳化疗方案。方法将我院2004~2005年收治的238例行宫颈癌同步放化疗的患者随机分为BIP方案组(133例)和PF方案组(105例),对他们的2年生存率和毒副反应进行对比研究。结果BIP方案组2年生存率76.7%（102/133）,2年无进展生存率70.7%（94/133）;PF方案组2年生存率63.8%（67/105）,2年无进展生存率57.1%（60/105）。两组比较,差异有统计学意义（P＜0.05）。近期毒副反应评价,BIP方案组Ⅲ~Ⅳ度骨髓抑制发生率显著高于PF方案组（P＜0.05）,远期毒副反应评价经比较差异无统计学意义。结论在宫颈癌同步放化疗的化疗方案中,BIP方案在生存率方面优于PF方案,但骨髓抑制较为严重,在远期毒副反应方面两种化疗方案差异无统计学意义。     

宫颈癌辅助性化疗的探讨

自1989年5月至1996年1月采用改良VBP方案作为宫颈局部肿瘤是巨块型（＞4cm）宫颈癌病例的第一线治疗共48人，142个疗程，无致命性毒性反应，获得了85％以上的有效率，完全缓解达45％，使48例原本只能放疗的患者有41例得以手术根治，而且手术切缘无残瘤。手术标本的病理学评价Ⅲ,Ⅳ级者占鳞癌病例的54％，占临床反应者的63％。淋巴结阳性率为12．1％。辅助化疗组5年生存率79.1％，对照组仅50.8％（P＜0.005）。     

Contribution of surgery in patients with bulky residual disease after chemoradiation for advanced cervical carcinoma.

AIM: To report the outcome of 30 patients who underwent surgery after concomitant chemoradiation for locally advanced cervical cancer with residual disease > or = 2 cm. METHODS: From 1988 to 2004, 143 patients with FIGO stage IB2-IVA cervical cancer underwent surgery after concurrent chemoradiotherapy. Among them, 30 had a residual cervical tumour > or = 2 cm prior to surgery. Surgery consisted in a simple or radical hysterectomy (n=15) or in a pelvic exenteration (n=15). Endpoints were recurrence and distant metastasis rates, overall survival (OS) and disease-free survival (DFS) at 3 and 5 years. Analysis included FIGO stage, response to chemoradiation, para-aortic lymphatic status or type of surgery: palliative (remaining disease after surgery) or curative (no evidence of remaining disease after surgery). RESULTS: Surgery has been only palliative in 11 cases. Pelvic recurrences occurred in 8 patients after a median interval of 8.8 months. Distant metastases occurred in 8 patients after a median interval of 13 months. So far, 16 patients have died (53.3%). The 3-year and 5-year OS rates are 64.9% and 55.6%, respectively, for the 19 patients who had a curative surgery. The DFS rate is 50.8% at 3 and 5 years in this latter group. Overall 12 patients (40%) are alive and free of disease after a median follow-up of 32.5 months. CONCLUSIONS: Adjuvant surgery may improve the outcome of patients with bulky residual tumour after chemoradiation for locally advanced cervical cancer, allowing a 5-year OS of 55.6% after curative intervention.     

子宫颈癌患者术后生存情况及其影响因素

 目的　探讨影响子宫颈癌患者术后生存的影响因素。方法　对1976年3月至1999年6月手术治疗的365例子宫颈癌患者临床资料和随访结果进行回顾性分析。采用Kaplan-Meier法计算累积生存率,用Log-Rank法比较各因素不同水平生存分布的差异。在单因素分析的基础上,进一步应用COX回归模型进行预后因素分析。结果　全组子宫颈癌术后患者5、10、15、20年累积生存率分别为88 %、83 %、81 %、80 %。Log-Rank分析结果显示,不同年龄、分期水平间生存差异有统计学意义（χ2＝19.738,P＜0.01;χ2＝36.672,P＜0.01）。随年龄和分期的升高,患者生存率均降低。术式、放疗不同水平间生存差异无统计学意义（均P＞0.05）。COX模型多因素分析表明,年龄、分期是影响预后的独立因素（均P＜0.01）。结论　年龄、分期是影响子宫颈癌预后的因素,早期治疗对子宫颈癌患者预后有重要意义,应提高早期发现率和早诊率。     

手术为主的综合疗法治疗小细胞肺癌

目的：探索以手术为主的综合疗法对小细胞肺癌的适应症，方法及临床效果。方法：回顾性总结分析845例小细胞肺癌治疗的临床资料：其中573例广泛期病变采用化疗或（和）放疗；局限期病变272例：单纯化（放）疗50例：先手术后化疗48例；先化疗后手术再化或（和）放疗174例；比较分析、评价不同方法的疗效。结果：广泛期病变1、2、3年生存率分别为13．0％、6．8％、0；局限期病变：化疗组和手术后化疗组1、3、5年生存率分别为74、2％、31．2％、4-3％和75％、46、6％、31．9％．二组间1年生存率无显著性差异（P〉0．05），3、5年的生存率差异显著（P〈0.05）；而先化疗、后手术、术后化（放）疗组1、3、5、10年生存率分别为88.4％、58．9％、46、5％、11．5％，明显优于前两组（P〈0.05）；术前所用化疗方案与周期对生存时间无明显影响。术式包括肺叶切除、全肺切除、支气管（肺动脉）袖式切除重建，肺叶和全肺切除的5、10年生存率明显优于袖式切除．肺叶切除优于全肺及袖式切除。颅内、肝脏或骨髓转移仍为影响本组小细胞肺癌长期生存的主要原因。结论：小细胞肺癌对化疗、放疗均敏感，广泛期病变无手术适应症，应采用以化（放）疗为主的保守治疗。而局限期小细胞肺癌则应积极选用以手术为主、辅助术前、术后化（放）疗的综合方法，可获得较为满意、甚至长期生存的临床效果.     

扩大根治术用于中晚期胆囊癌的疗效及安全性分析

目的 探讨扩大根治术用于治疗中晚期胆囊癌的疗效及安全性.方法 将60例中晚期胆囊癌患者根据手术方式的不同分为标准根治术13例,扩大根治术20例,姑息性手术19例,剖腹探查术8例.观察不同术式的并发症.采用电话和门诊随访2年,比较不同术式患者的1年和2年生存率.结果 标准根治术、扩大根治术、姑息性手术和剖腹探查术的并发症发生率分别为7.7%、20.0%、10.5%和0.0%.Ⅲ期、Ⅳ期患者的的中位生存时间分别为6个月和5个月.Ⅲ期、Ⅳ期患者的1年和2年生存率分别为30.8%、15.4%,6.4%、4.3%.不同分期的胆囊癌患者生存率比较,差异无统计学意义(χ2=0.255,P=0.133).扩大根治术患者Ⅲ期和Ⅳ期的中位生存时间为12个月和10个月.在Ⅲ、Ⅳ期胆囊癌患者中,行不同术式患者生存率之间差异有统计学意义(χ2=10.036,P=0.018;χ2=15.829,P=0.001).结论 胆囊癌扩大根治术治疗中晚期胆囊癌可显著延长患者术后生存时间,但并发症发生率较高.临床上施行胆囊癌扩大根治术治疗中晚期胆囊癌时应严格遵循手术适应证.