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Lower Uterine Segment Involvement as a Predictor for Poor Prognosis in Patients Receiving Adjuvant Radiotherapy for Stage I Endometrial Carcinoma
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摘要:
目的 探讨子宫下段受累对Ⅰ期子宫内膜癌术后放疗患者的预后作用。 方法 回顾性分析1999年1月至2012年12月在北京协和医院进行术后放疗的Ⅰ期子宫内膜癌患者265例, 中位年龄53岁, 病理类型主要为子宫内膜样腺癌(226例, 85.3%)。根据病理结果是否有子宫下段受累分为两组:子宫下段受累组和子宫下段未受累组, 比较两组患者的预后因素和临床治疗结果, 并对其中的高危和高中危患者进行亚组分析。主要研究终点包括总生存率、无进展生存率、局部区域复发率、远处转移率和治疗失败率。使用Kaplan-Meier法统计生存率, 不同组间生存率的比较使用Log-rank检验, 使用Cox比例风险回归模型进行预后因素分析。 结果 所有Ⅰ期内膜癌患者的5年总生存率和无进展生存率分别为92.8%和89.7%, 5年局部区域复发率、远处转移率和治疗失败率分别为4.5%、6.4%和7.8%。单因素分析显示, 子宫下段受累是影响总生存率和无进展生存率的相关因素(P=0.015, 0.035)。Cox比例风险回归模型显示, 子宫下段受累组患者的总生存率和无进展生存率更低(P=0.041, RR=0.346, 95% CI:0.125~0.959; P=0.041, RR=0.411, 95% CI:0.175~0.963)。亚组单因素分析显示, 在高危和高中危患者中, 子宫下段受累是影响治疗失败率的相关因素(P=0.034)。 结论 子宫下段受累可能是影响Ⅰ期内膜癌辅助放疗患者总生存率和无进展生存率的不良预后因素; 在高危和高中危患者中, 子宫下段受累主要与治疗失败的发生相关。 Abstract:Objective To explore the effect of lower uterine segment involvement (LUSI) in predicting the prognosis of stage Ⅰ endometrial carcinoma patients treated with postoperative radiotherapy. Methods The data of a total of 265 patients with stage Ⅰ endometrial carcinoma treated with hysterectomy and adjuvant radiotherapy between January 1999 and December 2012 were retrospectively analyzed. The median age of the cohort was 53 years. The most common pathological type was endometrioid adenocarcinoma (226/265, 85.3%). The patients were divided into two groups according to the presence of LUSI:LUSI group and non-LUSI group. The prognostic factors and treatment outcomes were compared between the two groups, subgroup analysis was conducted in the high-risk and high-intermediate-risk patients in the two groups. Primary outcomes were overall survival (OS), progression-free survival (PFS), loco-regional recurrence (LR), distant metastasis (DM), and treatment failure (TF). The survival rates were calculated using the Kaplan-Meier method. The survival rates between different groups were compared using the Log-rank test. Prognostic factors for survival were analyzed using a Cox proportional hazards regression model. Results The 5-year OS and PFS for all the patients were 92.8% and 89.7%, respectively; the 5-year LR, DM, and TF were 4.5%, 6.4%, and 7.8%, respectively. Univariate analysis revealed that LUSI was a significant predictor of OS and PFS (P=0.015, 0.035). Cox proportional hazard model demonstrated a significantly decreased OS and PFS in the LUSI group compared with the non-LUSI group(P=0.041, RR=0.346, 95% CI:0.125-0.959; P=0.041, RR=0.411, 95% CI:0.175-0.963). Subgroup univariate analysis showed that for high-risk and high-intermediate-risk patients, LUSI was a significant predictor of TF (P=0.034). Conclusions LUSI may be a significant predictor of reduced OS and PFS in patients with stage Ⅰ endometrial carcinoma treated with adjuvant radiotherapy. In addition, LUSI may be associated with treatment failure in high-risk and high-intermediate-risk patients. -
表 1 子宫下段受累组与子宫下段未受累组患者的临床病理特征及预后因素分布[例（%）]
临床病理特征 子宫下段
受累组
(n=83)子宫下段
未受累组
(n=182)χ2 P 年龄（岁） 40.081 0.000 ＜60 59(71.1) 116(63.7) ≥60 24(28.9) 66(36.3) 放疗前贫血 3.322 0.068 无 70(84.3) 167(91.8) 有 13(15.7) 15(8.2) 肌层浸润 9.502 0.002 浅肌层 57(68.7) 88(48.4) 深肌层 26(31.3) 94(51.6) 组织学分级 0.998 0.318 G1~2 70(84.3) 144(79.1) G3 13(15.7) 38(20.9) 淋巴脉管间隙侵犯 1.214 0.270 无 78(94.0) 168(92.3) 有 5(6.0) 14(7.7) 手术方式 2.025 0.155 全子宫双附件切除术 59(71.1) 113(62.1) 全子宫双附件切除+
淋巴结切除或活检24(28.9) 69(37.9) 放疗方式 9.615 0.002 内照射 45(54.2) 62(34.1) 外照射/外+内照射 38(45.8) 120(65.9) 化疗 0.457 0.499 无 73(88.0) 165(90.7) 有 10(12.0) 17(9.3) 内分泌治疗 1.949 0.163 无 80(96.4) 180(98.9) 有 3(3.6) 2(1.1) 
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表 2 高危和高中危患者中子宫下段受累组与子宫下段未受累组的临床病理特征及预后因素分布[例（%）]
临床病理特征 子宫下段
受累组
(n=39)子宫下段
未受累组
(n=56)χ2 P 年龄（岁） 52.429 0.000 ＜60 18(46.2) 14(25.0) ≥60 21(53.8) 42(75.0) 放疗前贫血 0.936 0.333 无 33(84.6) 51(91.1) 有 6(15.4) 5(8.9) 肌层浸润 5.324 0.021 浅肌层 17(43.6) 12(21.4) 深肌层 22(56.4) 44(78.6) 组织学分级 5.324 0.021 G1~2 27(69.2) 29(51.8) G3 12(30.8) 27(48.2) 淋巴脉管间隙侵犯 1.617 0.203 无 34(87.2) 43(76.8) 有 5(12.8) 13(23.2) 手术方式 1.149 0.284 全子宫双附件切除术 8(20.5) 17(30.4) 全子宫双附件切除+
淋巴结切除或活检31(79.5) 39(69.6) 放疗方式 2.906 0.888 内照射 17(43.6) 15(26.8) 外照射/外+内照射 22(56.4) 41(73.2) 化疗 0.000 0.991 无 32(82.1) 46(82.1) 有 7(17.9) 10(17.9)
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