Definitive radiotherapy for carcinoma of the vagina: Outcome and prognostic factors
Definitive radiotherapy for carcinoma of the vagina: Outcome and prognostic factors
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DOI：
10.1016/0360-3016(95)02394-1
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发表时间：
1996-07-15
影响因子：
7
通讯作者：
Delclos, L
中科院分区：
文献类型：
--
作者：
Chyle, V;Zagars, GK;Delclos, L
目的：原发性阴道癌是一种少见的肿瘤。由于长期的兴趣在这种疾病在我们的机构有相当数量的患者患有这种疾病已经积累，并进行了这项回顾性审查，以确定疾病的结果，以划定显着的预后因素，并提供治疗指南。本文回顾性分析了1953年至1991年间接受放射治疗的301例阴道癌患者（鳞状细胞癌271例，腺癌30例）。结局的预后因素使用单变量和多变量技术评估（局部控制、盆腔控制、转移复发、生存和并发症）。结果：使用国际妇产科联合会（FIGO）系统对患者疾病进行分期，分期分布如下：0，37（12%）; I，65（22%）; II，122（40%）; IU，60例（20%）; IVA，17例（6%）。治疗根据阶段而不同，近距离放射治疗主要用于早期疾病，但外部光束对更晚期的疾病起着突出的作用。原位病变患者接受单纯近距离放射治疗或经阴道正电压照射。对于I期，25例仅使用近距离放射治疗，38例使用外照射和近距离放射治疗，2例仅使用经阴道治疗。对于II期，20例仅使用近距离放射治疗，66例使用外照射和近距离放射治疗，36例仅使用外照射。对于III期，15例患者使用外部和近距离放射治疗，45例患者仅使用外部治疗。2例IVA期患者仅接受近距离放射治疗，10例接受外照射和近距离放射治疗联合治疗，6例仅接受外照射。总剂量范围为10 - 154戈伊（平均值74.7戈伊，中位数70.0戈伊），但只有18例（6%）接受的剂量低于55戈伊。中位随访13年时，5、10、15、20和25年生存率分别为60%、49%、38%、29%和23%。超过5年的生存率相对于一般人群中年龄匹配的女性为50%至65%。5年、10年和15年时的精算局部复发率分别为23%、26%和26%。5年、10年和15年时的盆腔复发率分别为26%、30%和31%，转移率分别为15%、18%和18%。腺癌（非透明细胞）是一种比鳞状细胞癌严重得多的疾病。鳞状细胞癌局部控制的主要决定因素是肿瘤体积（以厘米为单位的大小或FIGO分期）、肿瘤部位（上部病变比其他病变好）和肿瘤周围位置（累及后壁的病变更差）。肿瘤体积是转移复发的重要决定因素，但未能实现局部控制也是转移的独立重要决定因素。首次复发后的挽救治疗并不常见，复发后5年的生存率仅为12%。39例患者发生严重并发症，20年的精确发生率为19%。结论：阴道癌是一个巨大的治疗挑战。就其预后因素而言，该疾病是异质性的。非透明细胞腺癌预后极差，应与鳞状细胞癌相鉴别。外照射和近距离放射治疗在治疗中起着至关重要的作用，大多数原位以外的疾病患者在近距离放射治疗前应接受重要的外照射。
Purpose: Primary carcinoma of the vagina is an uncommon tumor. Because of the long-standing interest in this disease at our institution a substantial number of patients with this disease has been accumulated, and this retrospective review was performed to define disease outcome, to delineate significant prognostic factors, and to provide treatment guidelines.Methods and Materials: This was a retrospective review of 301 patients with vaginal carcinoma (271 with squamous cell and 30 with adenocarcinoma) who received definitive radiotherapy between 1953 and 1991. Prognostic factors for outcome (local control, pelvic control, metastatic relapse, survival, and complications) were evaluated using univariate and multivariate techniques.Results: Patients disease was staged using the International Federation of Gynecology and Obstetrics (FIGO) system, and stages were distributed as follows: 0, 37 (12%); I, 65 (22%); II, 122 (40%); IU, 60 (20%); and, IVA, 17 (6%). Treatment varied according to stage, with brachytherapy predominating for early disease but external beam playing a prominent role for more advanced disease. Patients with in situ disease received brachytherapy alone or transvaginal orthovoltage irradiation. For Stage I, brachytherapy alone was used in 25, external beam and brachytherapy in 38, and transvaginal alone in 2. For Stage II, brachytherapy alone was used in 20, external and brachytherapy in 66, and external irradiation alone in 36. For Stage III, external and brachytherapy was used in 15, and external alone in 45. Two patients,vith Stage IVA received brachytherapy alone, 10 received a combination of external and brachytherapy, and 6 received external irradiation alone. Total doses ranged from 10 to 154 Gy (mean 74.7 Gy, median 70.0 Gy), but only 18 (6%) received less than 55 Gy. At a median follow-up of 13 years, the 5-, 10-, 15-, 20-, and 25-year survival rates were 60%, 49%, 38%, 29%, and 23%, respectively. Beyond 5 years the survival rates relative to those for age-matched females in the general population were between 50 and 65%. Actuarial local recurrence rates were 23%, 26%, and 26% at 5, 10, and 15 years. Actuarial pelvic relapse rates were 26%, 30%, and 31% at 5, 10, and 15 years, and metastatic rates at those times were 15%, 18%, and 18%. Adenocarcinoma (nonclear cell) was a significantly worse disease than squamous cell carcinoma. The major determinants of local control for squamous carcinoma were tumor bulk (specified by size in centimeters, or by FIGO stage), tumor site (upper lesions faring better than others), and tumor circumferential location (lesions involving the posterior wall faring worse). Tumor hulk was an important determinant of metastatic relapse, but failure to achieve local control was also an independently significant determinant of metastases. Salvage after first relapse was uncommon and the survival rate at 5 years after relapse was only 12%. Serious complications occurred in 39 patients with an actuarial incidence of 19% at 20 years.Conclusion: Vaginal carcinoma poses a formidable therapeutic challenge. The disease is heterogeneous with respect to its prognostic factors. Nonclear cell adenocarcinoma has an extremely poor prognosis and should be distinguished from squamous carcinoma. Both external beam and brachytherapy play crucial roles in management and most patients with disease beyond in situ should receive a significant component of external irradiation prior to brachytherapy.