vestimИзвестия Национальной академии наук Беларуси. Серия медицинских наукProceedings of the National Academy of Sciences of Belarus, Medical series1814-60232524-2350The Republican Unitary Enterprise Publishing House "Belaruskaya Navuka"vestim-208Research ArticleКЛИНИЧЕСКАЯ И ЭКСПЕРИМЕНТАЛЬНАЯ МЕДИЦИНАCLINICAL AND EXPERIMENTAL MEDICINEВыбор метода лечения рака эндометрия низкого рискаChoice of the treatment method of low-risk endometrial cancerМавричевС. А.MavrichevS. A.mavrichev_@tut.byКрасныйС. А.KrasnyS. A.noemail@neicon.ruРеспубликанский научно-практический центр онкологии и медицинской радиологии им. Н. Н. АлександроваN. N. Alexandrov National Cancer Centre of Belarus201506062016041222Copyright © Мавричев С.А., Красный С.А., 20162016Мавричев С.А., Красный С.А.Mavrichev S.A., Krasny S.A.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://vestimed.belnauka.by/jour/article/view/208

До настоящего времени нет четкого представления о необходимости лучевой терапии (ЛТ) при лечении пациенток, страдающих раком эндометрия (РЭ) низкого риска. К низкому риску относят эндометриоидную аденокарцино-му IAG1-2 стадии. Представлены результаты хирургического (ХЛ) и комбинированного лечения (КЛ) женщин с РЭ низкого риска за период c 2006 по 2010 г. В группе с КЛ наиболее часто используемыми схемами лечения были три варианта: 1) предоперационная брахитерапия (ПБТ) + операция в объеме гистерэктомии с билатеральной сальпин-го-оофорэктомией (ХС), 2) ПБТ + ХС + послеоперационная дистанционная ЛТ (ДЛТ), 3) ХС + ДЛТ. ПБТ проводилась однократно накануне операции в разовой очаговой дозе 13,5 Гр, ДЛТ - обычными фракциями по 2 Гр до суммарной очаговой дозы 40-44 Гр. Общая 5-летняя выживаемость составила при КЛ 90,6 %, при ХЛ - 87,8 %, уточненная - 94,6 и 94,5 % соответственно (р > 0,05). В плане общей и уточненной выживаемости при РЭ IAG1 и IAG2 стадий без инвазии в миометрий статистически значимых различий между КЛ и ХЛ не получено (р > 0,05). Показатели общей выживаемости при РЭ IAG1 стадии с инвазией в миометрий до 1/2 его толщины имели статически значимые различия ( р = 0,001), показатели уточненной выживаемости не получены (р > 0,05). При РЭ IAG2 стадии с нивазией в миометрий до 1/2 общая и уточненная выживаемость оказалась статистически значимо выше при КЛ, чем при ХЛ (р = 0,00004 и р = 0,002). Лучшую эффективность продемонстрировали методики КЛ с ПБТ и/без послеоперационной ДЛТ по сравнению с ХЛ и методиками КЛ. В отношении ЛТ при РЭ низкого риска необходим дифференцированный подход. Рекомендуется полностью отказаться от ЛТ при РЭ IAG1-2 стадии без инвазии в миометрий и по возможности воздерживаться от ЛТ при РЭ IAG1 стадии с инвазией в миометрий до 1/2. При РЭ IAG2 стадии нет оснований полностью отказываться от ЛТ. Необходимы дальнейшие исследования роли ЛТ при РЭ IAG1-2 стадии с инвазией в миометрий до 1/2.

So far, the issue of radiotherapy (RT) employment in the management of stage I low-risk endometrial cancer (EC) patients remains controversial. Stage IA, grade 1-2 endometrioid adenocarcinoma is qualified as low-risk. The paper presents the outcomes of surgical (ST) and combination treatment (CT) of low-risk EC patients between 2006 and 2010. There were three most commonly used treatment options in the CT group: 1) preoperative brachytherapy (PBT) plus surgery, its magnitude being hysterectomy with bilateral salpingo-oophorectomy (HS) (1239 patents); 2) PBT + HS + postoperative external-beam RT (ERT) (1051); 3) HS + ERT (429). A single PBT was performed on the day before surgery at a single target dose of 13.5 Gy, ERT was carried out with conventional fractions of 2 Gy up to a total target dose of 40-44 Gy. Overall 5-year survival with CT was 90.6 %, ST - 87.8 %, cancer-specific survival was 94.6 % and 94.5 %, respectively (р > 0.05). No statistically significant differences between CT and ST (р > 0.05) were found in overall and cancer-specific survivals for stage IAG1 EC without myometrium invasion and for stage IAG2 EC without myometrium invasion. Statistically significant differences in overall survival (р = 0.001) were documented for stage IAG1 EC with myometrium invasion up to 1/2 of its thickness; however, they were not observed in cancer-specific survival (р > 0.05). Overall and cancer-specific survivals for stage IAG2 EC with myometrium invasion up to 1/2 of its thickness appeared to be significantly higher with CT than with ST (р = 0.00004 and р = 0.002). The highest efficacy was attained using CT with PBT and/without postoperative ERT, compared with ST and other CT options. A differentiated approach to RT is needed for low-risk EC. RT is recommended to be completely rejected for stage IAG1-2 EC without myometrium invasion. It is possible to refrain from using RT for stage IAG1 EC with myometrium invasion up to 1/2 of its thickness. There are no reasons to completely reject RT for stage IAG2 EC. Further research is needed to assess the role of RT for stage IAG1-2 EC with myometrium invasion up to 1/2 of its thickness.

ReferencesОкеанов, А. Е. Статистика онкологических заболеваний / А. Е. Океанов, П. И. Моисеев, Л. Ф. Левин; под ред. О. Г. Суконко. - Минск, 2014. - 382 с.Океанов, А. Е. Статистика онкологических заболеваний / А. Е. Океанов, П. И. Моисеев, Л. Ф. Левин; под ред. О. Г. Суконко. - Минск, 2014. - 382 с.Malkasian, G. D. Carcinoma of the endometrium: effect of stage and grade on survival / G. D. Malkasian // Cancer. -1978. - Vol. 41, N 3. - P. 996-1001.Malkasian, G. D. Carcinoma of the endometrium: effect of stage and grade on survival / G. D. Malkasian // Cancer. -1978. - Vol. 41, N 3. - P. 996-1001.Greutzberg, C. Perspectives in gynecologic oncology: 6th Eur. congr. / C. Greutzberg. - Nice, 2009. - P. 49-60.Greutzberg, C. Perspectives in gynecologic oncology: 6th Eur. congr. / C. Greutzberg. - Nice, 2009. - P. 49-60.Sobin, L. H. TNM classification of malignant tumours / L. H. Sobin, M. K. Gospodarowich, Ch. Wittekind. - 7th ed. -Wiley-Blackwell, 2009. - P. 212-216.Sobin, L. H. TNM classification of malignant tumours / L. H. Sobin, M. K. Gospodarowich, Ch. Wittekind. - 7th ed. -Wiley-Blackwell, 2009. - P. 212-216.Fanning, J. Treatment for early endometrial cancer. Cost-effectiveness analysis / J. Fanning // J. Repr. Med. - 1999. -Vol. 44, N 8. - P. 719-723.Fanning, J. Treatment for early endometrial cancer. Cost-effectiveness analysis / J. Fanning // J. Repr. Med. - 1999. -Vol. 44, N 8. - P. 719-723.Lymph node dissection in the surgical management of stage I endometrial carcinomas / D. Querleu [et al.] // Gynecol. Obstet. Fertil. - 2003. - Vol. 31, N 12. - P. 1004-1012.Lymph node dissection in the surgical management of stage I endometrial carcinomas / D. Querleu [et al.] // Gynecol. Obstet. Fertil. - 2003. - Vol. 31, N 12. - P. 1004-1012.Surgical staging in endometrial cancer: clinical-pathologic findings of a prospective study / R. C. Boronow [et al.] // Obstet. Gynecol. - 1984. - Vol. 63. - P. 825-832.Surgical staging in endometrial cancer: clinical-pathologic findings of a prospective study / R. C. Boronow [et al.] // Obstet. Gynecol. - 1984. - Vol. 63. - P. 825-832.Therapeutic role of lymph node resection in endometrioid corpus cancer: a study of 12,333 patients / J. K. Chan [et al.] // Cancer. - 2006. - Vol. 107, N 8. - P. 1823-1830.Therapeutic role of lymph node resection in endometrioid corpus cancer: a study of 12,333 patients / J. K. Chan [et al.] // Cancer. - 2006. - Vol. 107, N 8. - P. 1823-1830.Efficacy of systematic pelvic lymphadenectomy in endometrial cancer (MRC ASTEC trial): a randomized study / H. Kitchener [et al.] // Lancet. - 2009. - Vol. 373, N 9658. - P. 125-136.Efficacy of systematic pelvic lymphadenectomy in endometrial cancer (MRC ASTEC trial): a randomized study / H. Kitchener [et al.] // Lancet. - 2009. - Vol. 373, N 9658. - P. 125-136.Systematic pelvic lymphadenectomy vs. no lymphadenectomy in early-stage endometrial carcinoma: randomized clinical trial / Panici P. Benedetti [et al.] // J. Natl. Cancer Inst. - 2008. - Vol. 100, N 23. - P. 1660-1661.Systematic pelvic lymphadenectomy vs. no lymphadenectomy in early-stage endometrial carcinoma: randomized clinical trial / Panici P. Benedetti [et al.] // J. Natl. Cancer Inst. - 2008. - Vol. 100, N 23. - P. 1660-1661.Lymphadenectomy for the management of endometrial cancer / K. May [et al.] // Cochrane Database Syst. Rev. -2010. - CD 0077585.Lymphadenectomy for the management of endometrial cancer / K. May [et al.] // Cochrane Database Syst. Rev. -2010. - CD 0077585.Low-risk corpus cancer: is lymphadenectomy or radiotherapy necessary? / A. Mariani [et al.] // Am. J. Obstet. Gynecol. - 2000. - Vol. 182, N 6. - P. 1506-1519.Low-risk corpus cancer: is lymphadenectomy or radiotherapy necessary? / A. Mariani [et al.] // Am. J. Obstet. Gynecol. - 2000. - Vol. 182, N 6. - P. 1506-1519.Postoperative external irradiation and prognostic parameters in stage I endometrial carcinoma: clinical and histopathologic study of 540 patients / J. Aalders [et al.] // Obstet. Gynecol. - 1980. - Vol. 56, N 4. - P. 419-427.Postoperative external irradiation and prognostic parameters in stage I endometrial carcinoma: clinical and histopathologic study of 540 patients / J. Aalders [et al.] // Obstet. Gynecol. - 1980. - Vol. 56, N 4. - P. 419-427.A phase III trial of surgery with or without adjunctive external pelvic radiation therapy in intermediate risk endometrial adenocarcinoma: a Gynecology Oncology Group study / H. M. Keys [et al.] // Gynecol. Oncol. - 2004. - Vol. 62. - P. 744-751.A phase III trial of surgery with or without adjunctive external pelvic radiation therapy in intermediate risk endometrial adenocarcinoma: a Gynecology Oncology Group study / H. M. Keys [et al.] // Gynecol. Oncol. - 2004. - Vol. 62. - P. 744-751.A phase III randomized study of surgery vs surgery plus adjunctive radiation therapy in intermediate risk endometrial adenocarcinoma (GOG 99) / J. A. Roberts [et al.] // Gynecol. Oncol. - 1998. - Vol. 68. - P. 135.A phase III randomized study of surgery vs surgery plus adjunctive radiation therapy in intermediate risk endometrial adenocarcinoma (GOG 99) / J. A. Roberts [et al.] // Gynecol. Oncol. - 1998. - Vol. 68. - P. 135.For the PORTEC Study Group (post-operative radiation therapy in endometrial carcinoma). Surgery and postoperative radiotherapy versus surgery alone for patients with stage-I endometrial carcinoma: multicentre randomized trial / C. L. Greutsberg [et al.] // Lancet. - 2000. - Vol. 355 (9213). - P. 1404-1411.For the PORTEC Study Group (post-operative radiation therapy in endometrial carcinoma). Surgery and postoperative radiotherapy versus surgery alone for patients with stage-I endometrial carcinoma: multicentre randomized trial / C. L. Greutsberg [et al.] // Lancet. - 2000. - Vol. 355 (9213). - P. 1404-1411.Adjuvant radiotherapy in women with stage I endometrial cancer: a systematic rev. / H. Lukka [et al.] // Gynecol. Oncol. - 2006. - Vol. 102, N 2. - P. 361-368.Adjuvant radiotherapy in women with stage I endometrial cancer: a systematic rev. / H. Lukka [et al.] // Gynecol. Oncol. - 2006. - Vol. 102, N 2. - P. 361-368.Ten-year data on 138 patients with endometrial carcinoma and postoperative vaginal brachytherapy alone: no need for external-beam radiotherapy in low and intermediate risk patients / B. Roper [et al.] // Gynecol. Oncol. - 2007. - Vol. 107, N 3. - P. 541-548.Ten-year data on 138 patients with endometrial carcinoma and postoperative vaginal brachytherapy alone: no need for external-beam radiotherapy in low and intermediate risk patients / B. Roper [et al.] // Gynecol. Oncol. - 2007. - Vol. 107, N 3. - P. 541-548.Endometrial cancer: A review and current management strategies: Part II / SGO Clinical Practice Endometrial Cancer Working Group; for the Society of Gynecologic Oncology Clinical Practice Committee / W. M. Burke [et al.] // Gynecol. Oncol. - 2014. - Vol. 134, N 2. - P. 393-402.Endometrial cancer: A review and current management strategies: Part II / SGO Clinical Practice Endometrial Cancer Working Group; for the Society of Gynecologic Oncology Clinical Practice Committee / W. M. Burke [et al.] // Gynecol. Oncol. - 2014. - Vol. 134, N 2. - P. 393-402.Uterine neoplasms. NCCN clinical practice guidelines in oncology. Version 2. - 2015. - P. 85.Uterine neoplasms. NCCN clinical practice guidelines in oncology. Version 2. - 2015. - P. 85.

The authors declare that there are no conflicts of interest present.