早期子宮內膜癌術后放療效果的系統評價_《中國循證醫學雜志》

作者：

魏冬梅 ¹ , 梅玲 ¹ ,  方芳 ¹ , 吳泰相 ² , 劉關鍵 ²

1.四川大學華西附屬二院婦科（成都 610041）；2.四川大學華西醫院中國循證醫學中心（成都 610041）;

關鍵詞：

輔助性放療子宮內膜癌系統評價隨機對照試驗 Meta 分析

DOI：

10.7507/1672-2531.20090086

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目的　系統評價術后放療對早期子宮內膜癌的有效性、安全性及成本- 效果。
方法　電子檢索Cochrane 圖書館、MEDLINE、EMbase、CancerLit、CBMdisc、VIP、萬方學位論文數據庫、CNKI，并輔以手工檢索。檢索時間截至2007 年3 月，收集子宮內膜癌（EC）術后放療的隨機對照試驗（RCT）。由兩名研究者按Cochrane 系統評價方法，獨立選擇試驗，提取資料、評價納入研究的方法學質量，并提取有效數據進行Meta 分析。
結果　共納入7 個RCT，包括2 084 例患者，其中5 個為術后放療（盆腔和/ 或陰道）與術后非放療比較，包括1 254 例患者；1 個為陰道放療不同劑量間的比較（2.5 Gy vs 5.0 Gy），包括290 例患者；1 個為兩種放療方式的比較（陰道＋盆腔 vs 陰道），包括540 例患者。Meta 分析結果顯示：⑴ 手術 vs 手術＋放療：① 手術 vs 手術＋盆腔放療：5、8、10 年局部復發率
及5、8 年總體復發率，手術+ 盆腔放療組低于單純手術組；兩組5、8 年遠處復發率及5、8、10 年總體生存率差異無統計學意義；10 年遠處復發率手術+ 盆腔放療組高于單純手術組；兩組10 年總體復發率差異無統計學意義；②手術 vs 手術＋陰道放療：5、10 年總體生存率及5、10 年無瘤生存率，兩組差異無統計學意義。⑵ 手術＋內分泌治療 vs 手術＋盆腔放療：兩組局部及遠處復發率、總體生存率及無瘤生存率（ lt;2 年）差異均無統計學意義。⑶ 術后陰道放療兩種不同劑量（2.5 Gy vs 5.0 Gy）的比較：5 年復發率（局部、遠處、總體）及5 年總體生存率、毒性反應，兩組差異均無統計學意義。⑷ 手術＋陰道放療 vs 手術＋陰道放療＋盆腔放療：5 年局部復發率聯合放療組低于單獨陰道放療組，5 年遠處復發率聯合放療組高于單獨陰道放療組，5 年總體生存率兩組無統計學差異。⑸成本- 效果分析：術后放療比復發后放療雖增加了成本但卻提高了總體生存率，術后高劑量近距離放療成本- 效果價值較好。
結論　術后放療對于子宮內膜癌Ⅰ期患者，能有效降低其局部復發率，但對遠處復發率、總體生存率、無瘤生存率
無明顯改善，療效和單純手術效果相似；放療的副作用較單純手術大。因各試驗納入研究人群不完全一致，且亞組
分析發現內膜癌的死因絕大多數并非由子宮內膜癌本身或治療引起，而是死于其合并癥，故放療對子宮內膜癌患
者的總體生存率、無瘤生存率的效果有待進一步大樣本、高質量的多中心隨機雙盲對照試驗加以證實。

引用本文： 魏冬梅,梅玲,方芳,吳泰相,劉關鍵. 早期子宮內膜癌術后放療效果的系統評價. 中國循證醫學雜志, 2009, 09(4): 465-475. doi: 10.7507/1672-2531.20090086 復制

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15.	Morrow CP, Bundy BN, Kurman RJ, et al. Relationship between surgical-pathological risk factors and outcome in clinical stage 1 and II carcinoma of the endometrium: a Gynecologic Oncology Group study. Gynecol Oncol, 1991, 40: 55-65.
16.	Kadar N, Malfetano JH, Homesley HD. Determinants of survival of surgically staged patients with endometrial carcinoma histologically confined to the uterus: implications for therapy. Obstel Gynecol, 1992, 80: 655-659.
17.	Creutzberg CL, van Putten WL, Koper PC, et al. Surgery and post operative radiot herapy versus surgery alone for patient s wit h stage1 endomet rial carcinoma: multicent re randomised trial. PORTEC Study Group. Post Operative Radiation Therapy in Endomet rial Carcinoma. Lancet, 2000, 355(9213): 1404-1411.
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19.	Scholten AN, van Put ten WL, Beerman H, et al. Postoperative radiot herapy for stage 1 endomet rial carcinoma: longterm outcome of the randomized PORTEC trial with central pathology review. Int J Radiat Oncol Biol Phys, 2005, 63(3): 834-838.
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25.	Garzetti GG, Ciavattini A, Muzzioli M, et al. The relationship of clinicalpathological status and adjuvant treatment with natural killer cell activity in stage I and II endometrial carcinoma. Acta Obstet Gynecol Scand, 1994, 73: 652-657.
26.	Dede M, Yenen MC, Goktolga U, et al. Is adjuvant therapy necessary for peritoneal cytology-positive surgical-pathologic Stage I endometrial cancer? Preliminary results. European Journal of Gynaecological Oncology, 2004, 25(5): 591-593.
27.	Creutzberg CL, van Putten WL, Koper PC, et al. The morbidity of treatment for patients with Stage I endometrial cancer: results from a randomized trial. Int J Radiat Oncol Biol Phys, 2001, 51(5): 1246-1255.
28.	Fanning J, Hoffman ML, Andrews SJ, et al. Cost-effectiveness analysis of the treatment for intermediate risk endometrial cancer: postoperativebrachy therapy versus observation. Gynecol Oncol, 2004, 93: 632-636.
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31.	-704.

1. Eitan R, Saenz CC, Venkatraman ES, et al. Pilot study prospectively evaluating the use of the measurement of preoperative sonographic endometrial thickness postmenopausal patients with endometrial cancer. Menopause, 2005, 12 (1): 27-30.
2. Purdie DM, Green AC. Epidemiology of endometrial cancer: best practice and research. Clin Obstet Gynaecol, 2001, 15: 341-354.
3. Jeffrey JF, Krepart GV, Lotocki RJ. Papillary serous adenocarcinoma of the endometrium. Obstet Gynecol, 1986, 67(5): 670-674.
4. Dunton CJ, Balsara G, McFarland M, et al. Uterine papillary serous carcinoma: a review. Obstet Gynecol Surv, 1991, 46(2): 97-102.
5. 吳鳴, 郎景和, 郭麗娜. 子宮內膜癌的特殊類型——子宮乳頭狀漿液性癌. 中華婦產科雜志, 1996, 31(1): 3-7.
6. Sherman AL. Progesterone caproate in the treatment of endometnal cancer. Obstet Gynecal, 1992, 28: 309.
7. 吳鳴, 沈鏗, 郎景和. 子宮內膜癌206 例臨床分析. 中華婦產科雜志. 2002, 37: 620.
8. Abeler VM, Kjorstad KE. Clear cell carcinoma of the endometrium: A histo - pathological and clinical study of 97 cases. Gynecol Oncol, 1991, 40: 207.
9. Abeler VM, Kjorstad KE. Endometrial squamous cell carcinoma: Report of three cases and review of the literature. Gynecol Oncol, 1990, 36: 21.
10. Creasman WT, Odicino F, Maisonneuve P, et al. Carcinoma of the corpus uteri. Int J Gynaecol Obstet, 2003, 83(Suppl 1): 79-118.
11. Martinez AA, Stitt JA, Speiser BL, et al. Clinical applications of brachytherapy Ⅱ: high2dose2rate. In: Perez CA, Brady LW, eds. Principles and practice of radiation oncology. 3rd ed. Philadelphia Lippincott-Raven, 1998. 5732576.
12. 中華醫學會婦產科學會, 中華婦產科雜志編輯委員會. 婦科常見惡性腫瘤診斷治療規范(草案) . 中華婦產科雜志, 1998, 33:.
13. Ball HG, Elkadry EA. Endometrial cancer: current concepts and management. Surg Oncol Clin N Am, 1998, 7: 271-284.
14. Creasman WT, Morrow CP, Bundy BN, et al. Surgical pathologic spread patterns of endometrial cancer, A Gynecologic Oncology Group Study. Cancer, 1987, 60(suppl.8): 2035-2041.
15. Morrow CP, Bundy BN, Kurman RJ, et al. Relationship between surgical-pathological risk factors and outcome in clinical stage 1 and II carcinoma of the endometrium: a Gynecologic Oncology Group study. Gynecol Oncol, 1991, 40: 55-65.
16. Kadar N, Malfetano JH, Homesley HD. Determinants of survival of surgically staged patients with endometrial carcinoma histologically confined to the uterus: implications for therapy. Obstel Gynecol, 1992, 80: 655-659.
17. Creutzberg CL, van Putten WL, Koper PC, et al. Surgery and post operative radiot herapy versus surgery alone for patient s wit h stage1 endomet rial carcinoma: multicent re randomised trial. PORTEC Study Group. Post Operative Radiation Therapy in Endomet rial Carcinoma. Lancet, 2000, 355(9213): 1404-1411.
18. Creutzberg CL, van Putten WL, Koper PC, et al. Survival after relapse in patient s wit h endometrial cancer: result s from a randomized trial. Gynecol Oncol, 2003, 89: 201-209.
19. Scholten AN, van Put ten WL, Beerman H, et al. Postoperative radiot herapy for stage 1 endomet rial carcinoma: longterm outcome of the randomized PORTEC trial with central pathology review. Int J Radiat Oncol Biol Phys, 2005, 63(3): 834-838.
20. Keys HM, Roberts JA, Brunetto VL, et al. A phase Ⅲt rial of surgery with or without adjuvant external pelvic radiation t herapy in intermediate risk endomet rial adenomcarcinoma: a GOG study. Gynecol Oncol, 2004, 92: 744-775.
21. Aalders J, Abeler V, Kolstad P, et al. Postoperative external irradiation and prognostic parameters in stage I endometrial carcinoma: clinical and histopathologic study of 540 patients. Obstet Gynecol, 1980, 56: 419-427 (Level II-2).
22. Higgins JPT, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions 4.2.4 [updated March 2005]. In: The Cochrane Library, Issue 2, 2005.
23. Sorbe B, Straumits A, Karlsson L. Intravaginal high-dose-rate brachytherapy for stage I endometrial cancer: a randomized study of two dose-per-fraction levels. Int J Radiat Oncol Biol Phys, 2005, 62(5): 1385-1389.
24. Piver MS, Yazigi R, Blumenson L, et al. A prospective trial comparing hysterectomy, hyspterectomy plus vaginal radium, and uterine radium plus hysterectomy in stage I endometrial carcinoma. Obstet Gynecol, 1979, 54: 85-99.
25. Garzetti GG, Ciavattini A, Muzzioli M, et al. The relationship of clinicalpathological status and adjuvant treatment with natural killer cell activity in stage I and II endometrial carcinoma. Acta Obstet Gynecol Scand, 1994, 73: 652-657.
26. Dede M, Yenen MC, Goktolga U, et al. Is adjuvant therapy necessary for peritoneal cytology-positive surgical-pathologic Stage I endometrial cancer? Preliminary results. European Journal of Gynaecological Oncology, 2004, 25(5): 591-593.
27. Creutzberg CL, van Putten WL, Koper PC, et al. The morbidity of treatment for patients with Stage I endometrial cancer: results from a randomized trial. Int J Radiat Oncol Biol Phys, 2001, 51(5): 1246-1255.
28. Fanning J, Hoffman ML, Andrews SJ, et al. Cost-effectiveness analysis of the treatment for intermediate risk endometrial cancer: postoperativebrachy therapy versus observation. Gynecol Oncol, 2004, 93: 632-636.
29. Ashih H, Gustilo-Ashby T, Myers ER, et al. Cost-effectiveness of treatment of early stage endometrial cancer. Gynecol Oncol, 1999, 74(2): 208-216.
30. Laupacis A, Feeny D, Detsky AS, et al. How attractive does a new technology have to be to warrant adoption and utilization? Tentative guidelines for using clinical and economic evaluation. Can Med Assoc, 1992, 146: 473-481.
31. -704.

《中國循證醫學雜志》

早期子宮內膜癌術后放療效果的系統評價

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《中國循證醫學雜志》

早期子宮內膜癌術后放療效果的系統評價

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