ORIGINAL ARTICLE Korean J Obstet Gynecol 2012;55(12):913-919 http://dx.doi.org/10.5468/kjog.2012.55.12.913 pissn 2233-5188 eissn 2233-5196 PROGNOSIS OF STAGE IIB CERVICAL CANCER AMONG TREATMENT REGIMENS: RADICAL HYSTERECTOMY VS. NEOADJUVANT CHEMOTHERAPY FOLLOWED BY RADICAL HYSTERECTOMY VS. CONCURRENT CHEMORADIOTHERAPY Young Ju Woo, MD 1, Jung Mi Byun, MD 2, Dae Hoon Jeong, MD 2,3, Young Nam Kim, MD 2,3, Su Seon Kim, MD 2, Young Jin Seo, MD 2, Moon Su Sung, MD 2, Kyoung Bok Lee, MD 2, Ki Tae Kim, MD 2,3 1 Department of Obstetrics and Gynecology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon; 2 Department of Obstetrics and Gynecology, Busan Paik Hospital, Inje University College of Medicine; 3 Paik Institute for Clinical Research, Inje University, Busan, Korea Objective We aimed to compare the prognosis of patients with stage IIB cervical cancer treated with radical hysterectomy alone, with neoadjuvant chemotherapy followed by radical hysterectomy, and with concurrent chemoradiation therapy (CCRT). Methods From January 2000 to December 2006, 104 patients with cervical cancer IIB were diagnosed and managed with radical hysterectomy alone, neoadjuvant chemotherapy followed by radical hysterectomy, and CCRT. The outcomes of patients in terms of the 5-year disease-free survival, overall survival, and recurrence rates were compared. Results Of 86 eligible patients, 20 were treated with radical hysterectomy alone, 43 with neoadjuvant chemotherapy, and 23 with CCRT. Neoadjuvant chemotherapy with radical hysterectomy was performed in young (P<0.001) and radical hysterectomy alone was performed in the patients with a large tumor size (P<0.001). Among the 3 groups, distant metastasis was the lowest in the neoadjuvant chemotherapy group (P=0.014). Between the neoadjuvant chemotherapy group and radical hysterectomy alone group, radical hysterectomy alone group showed a larger tumor size (>4 cm) (P=0.0459) and more extensive lympho-vascular involvement (P=0.0158) in pathologic finding. Conclusion No significant differences in the 5-year disease-free and overall survival rates were observed among the 3 groups. However, the neoadjuvant chemotherapy group showed lower distant metastasis, smaller tumor size, and less extensive lympho-vascular involvement than the other 2 groups. Accordingly, unnecessary adjuvant therapy could be avoided. These results imply that neoadjuvant chemotherapy could improve the prognosis of patients with cervical cancer IIB. Keywords: Cervical cancer; Neoadjuvant chemotherapy; Radical hysterectomy; Concurrent chemoradiation therapy; Survival 자궁경부암은파파니콜로바른표본검사법으로인해전암병변의조기진단이가능해지고, 진단된전암병변의치료가효과적으로시행되어짐으로써전세계적으로발생률이감소하고있는여성암이다 [1]. 우리나라의경우, 한국중앙암등록사업연례보고서에따르면 2002년 3,979건의자궁경부암이발생한이후, 2009년에는 3,733건의발생을보이며매년감소추세를보이고있다 [2]. 보건복지부에서보고한통계자료에따르면지난 2005년-2009 년암생존율에대한국제비교에서한국은 5년생존율이 80.3% 로미국의 70.2% 보다무려 10% 나높다 [3]. 이는암으로진단된후에도적절한치료를받아사망률역시감소하고있음을의미한다. 그러나, 자궁경부암환자의전체적인사망률은 Received: 2012.6.27. Revised: 2012.9.5. Accepted: 2012.10.9. Corresponding author: Ki Tae Kim, MD Department of Obstetrics and Gynecology, Busan Paik Hospital, Inje University College of Medicine, 75 Bokji-ro, Busanjin-gu, Busan 614-735, Korea Tel: +82-51-890-6374 Fax: +82-51-897-6380 E-mail: hellojungmi@hanmail.net This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/ by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright 2012. Korean Society of Obstetrics and Gynecology WWW.KJOG.ORG 913
KJOG Vol. 55, No. 12, 2012 점차감소하고있지만, 자궁경부암으로진단된 1/3 환자가자궁경부암으로인해사망하게되며, 발병당시 stage IIb 이상으로진행된상태에서진단된경우가 31.2% 로높은빈도를차지하고있어광범위한조기검진의필요성은물론진행된상태의자궁경부암의치료법에대한개발이필요하다 [4]. 현재까지알려진자궁경부암의치료는초기병기에서는크게수술혹은방사선요법이주된것이나국소적으로진행된자궁경부암의치료는방사선요법뿐만아니라화학요법이개발되면서이들의조합으로생존율을향상시키는노력이시도되고있다. 그러나기존치료법들의효과에대한명확한비교연구가없어표준요법의선택에있어서혼란이많고, 각기관마다나름대로의적응증으로치료를하고있는실정이다. 1999년이전에는재발의고위험예후인자를가지고있거나종양의크기가크거나질상부로침습되어있는자궁경부암의경우근치자궁절제술이나방사선요법을시행하였다 [5]. 하지만국소적으로진행된자궁경부암의치료성적은수술적요법과방사선요법만을받았을때, 치료실패율이나재발률이높고예후가좋지않았다 [6,7]. 1999년미국의 National Cancer Institute 에서는 국소적으로진행된자궁경부암이나재발의고위험예후인자를가진환자즉기존의방사선요법의대상이되는자궁경부암환자에대하여 platinum 제제를기본으로한화학요법의병행이고려되어야한다 고공표하였다 [8]. 이들연구에서는동시항암화학방사선치료를받은경우, 원격재발이낮은것으로보고되어투여된항암제의역할이국소적인방사선감수성증강제의역할뿐만아니라미세전이부위에대한치료효과도있을것으로보고하였다. 또한 2001년과 2008년에시행된메타분석을통해동시항암화학방사선요법에대한효과가더욱지지되었다 [9,10]. 그이후동시항암화학방사선요법은국소적으로진행또는재발된자궁경부암그리고수술후재발의고위험예후인자를가진초기자궁경부암환자에서표준적인치료요법으로적용되고있다. 하지만동시항암화학방사선요법의경우, 고식적인방사선요법에비하여장독석이나골수억제부작용과같은급성부작용의증가및치료비용의증가같은단점도있으므로대상환자의선정에신중을기하여야한다 [11]. 수술혹은방사선요법전에신보강화학요법을시행하는이론적근거는미세전이를차단하고, 종양크기감소로인한약물치료후수술혹은방사선요법을용이하게할수있다는것이다 [12]. 동시항암화학방사선요법에비하여독성이적을수있고, 효과가있을경우수술이불가능했던환자를가능하게하여완치가능성을높일수있다는장점을가진다 [13]. 하지만치료일정이길어짐에따라근치적치료가늦어질수있고, 환자들의순응도가감소할수있다는점, 항암제의독성에의한합병증이발생할수있고화학요법제에저항성을가지는암세포들로재빠르게종괴가재구성될수있다는단점도가지고있다 [14,15]. 진행된자궁경부암에서동시항암화학방사선요법이표준치료가된이후신보강화학요법이생존율을더높였다는연구결과가현재까지는없지만, 보고된바에따르면 22%-44% 의완전관해율을보이며림프절전이를줄이고 2-3년무병생존율을증가시키는것으로알려져있다 [16]. 현재진행된국소병변을가진침윤성자궁경부암치료로 cisplatin 을기본으로한신보강화학요법의반응률은 67%-91% 로다양하게보고되고있다 [12,16]. 본연구에서는자궁경부암 IIB로진단된후일차치료로근치자궁절제술을시행받은환자, 신보강화학요법시행후근치자궁절제술을받은환자및동시항암화학방사선요법을받은환자들의 5년생존율및무병생존율을비교하고예후를분석하여진행된자궁경부암환자에서보다나은치료에대한근거를제시하고자하였다. 연구대상및방법 2000년 1월 1일부터 2006년 12월 31일까지인제대학교부산백병원산부인과에서자궁경부암 International Federation of Obstetrics and Gynecology (FIGO) 병기 IIB로진단받은 104명환자들중에서근치자궁절제술을받은환자, 신보강화학요법시행후수술한환자및동시항암화학방사선요법을받은환자들을대상으로의무기록을참고하여후향적분석을하였다. FIGO 병기결정을위하여부인과적골반진찰및기타이학적진찰, 병리조직학적검사, 흉부방사선촬영, 신우조영술, 방광경검사, 직장경검사, 보조적으로컴퓨터단층촬영 (computed tomography, CT) scan이나자기공명영상 (magnetic resonance imaging, MRI) 촬영을한후이상의소견을종합하여 FIGO 분류기준에따라병기를결정하였다. 신보강화학요법과동시항암화학방사선요법에서항암제는 3주간격으로 3회투여를하였으며, 항암약제는 cisplatin 과 5-FU를사용하였다. 항암화학요법에대한반응정도는세계보건기구 (World Health Organization, WHO) 기준을사용하였으며 4주이상간격으로두번측정시육안적으로병변이소실되는경우를완전관해 (complete remission, CR), 병변의면적이 50% 이상감소되는경우를부분관해 (partial remission, PR), 병변의면적이 50% 이하의변화를보이는경우를안정군 (stable disease, SD), 25% 이상증가하거나새로운병변이출현한경우를진행병변 (progressive disease, PD) 으로정하였고, 완전관해및부분관해를보인경우를항암제반응군으로간주하였고, 안정군및진행병변의경우를항암제비반응군으로간주하였다. 항암제투여전후 2번에걸쳐일반혈액검사와간기능및신기능검사를시행하여항암제에의한독성을평가하였다. 추적조사는치료종결후첫 2 년간은 3개월간격, 그후 3년간은 6개월간격그이후로는 6개월-1 년간격으로실시하였으며내원시마다부인과진찰및질세포진검사를시행하였고, 병기결정을위한기초검사시 CT나 MRI를시행했던경우, 1년마다 CT나 MRI 혹은양전자컴퓨터단층촬영 (positron emission tomography-computed tomography, PET-CT) 을시행하여결과를관찰하였다. 전체생존은환자가처음치료받은후사망하였거나마지막생존여부가확인된시점까지로하였고, 무병생존은일차치료를받은후국소재발혹은원격전이가없는시점까지로정의하였다. 일차치료로근치자궁절제술을받은환자, 신보강화학요법후근치자궁절제술을받은환자및동시항암화학방사선요법을받은환자들의 914 WWW.KJOG.ORG
Young Ju Woo, et al. The treatment of cervical cancer IIB 임상병리학적인인자, 5 년무병생존율및전체생존율과재발률을비 교하여각치료에대한예후를비교분석하였다. 통계학적인분석은 MedCalc 프로그램 (ver. 11, Medcalc Software, Mariake, Belgium) 을이용하여임상병리학적인인자및재발유무는 Student s t-test 와 chi-square test 로비교하고 5 년무병생존및전체 생존율은 Kaplan-Meier 방법으로계산하여 Log-rank test 로검증하였 으며 P 값이 0.05 미만인경우를통계적으로유의한것으로하였다. 결과 2000 년 1 월 1 일부터 2006 년 12 월 31 일까지만 7 년간인제대학교 부산백병원산부인과에서자궁경부암병기 IIB 로진단받은 104 명중, 방사선요법만시행받은환자 (10 명 ), 복식전자궁절제술후추가치료받 은환자 (2 명 ), 화학요법만받은환자 (1 명 ), 타병원에서근치자궁절제술 을시행받고화학요법만받은환자 (1 명 ), 진단만받고치료를거부한 환자 (2 명 ) 및자궁경부암으로동시항암화학방사선요법중위장관기질 종양 (gastrointestinal stromal tumor, GIST) 이발견되고위장관기질종양 의재발로사망한경우 (1 명 ), 1 차동시항암화학방사선요법후추적관 찰되지않았던경우 (1 명 ) 를포함한 18 명을제외한 86 명의환자를대상 으로실험하였다. 이들중근치자궁절제술은 20 명 (23.3%), 신보강화학 요법후근치자궁절제술을받은환자는 43 명 (50%), 동시항암화학방 사선요법은 23 명 (26.7%) 이시행받았고, 신보강화학요법을 1 회시행받 은후급성신부전및간부전이발생하여내과적치료후근치자궁절제 술을받았던환자 1 예의경우일차치료로근치자궁절제술을시행받은 군으로분류하였으며, 동시항암화학방사선요법을받은환자중 1 차 치료후골수억제에의한 grade 4 백혈구감소 [17] 로인한패혈증쇼 크로사망한 1 예가있었다. 1. 각치료군의임상적특징및경과전체 86 명환자의평균연령은 53.4 ±11.1 세였고, 이들중근치전자 궁절제술을받았던 20 명의평균연령은 53 ±11.5 세, 신보강화학요법을 받은후근치자궁절제술을받은환자 43 명의평균연령은 48.8 ± 8.6 세, 동시항암화학방사선요법을받았던 23 명의평균연령은 62.8 ± 9.2 세로 동시항암화학방사선요법을받았던환자들의평균연령이통계적으로 유의하게높았다 (P<0.001). 각군의육안및방사선검사로확인된종 양크기를비교해보면, 근치자궁절제술을시행받은군의종양크기는 5.9 ± 3.4 cm, 신보강화학요법을받은군의평균종양크기는 3.9 ± 1.3 cm, 동시항암화학방사선요법을받은군의평균종양크기는 3.3 ± 1.4 cm 으로근치자궁절제술을시행받은군의종양크기가신보강화학요법 이나동시항암화학방사선요법을받은군에서의종양크기보다컸다 (P <0.001). 각치료군의자궁경부암의세포조직학적소견을비교해보 면신보강화학요법을받은군에서는편평상피세포가 37 명 (86%) 에서 발견되었고, 근치자궁절제술및동시항암화학방사선요법을받았던군 에서는모든환자에서편평상피세포가발견되었으나통계적으로의미 있는차이는없었다 (Table 1). 2. 근치자궁절제술을시행받은군과신보강화학요법후근치자궁절제술을시행받은군의수술및조직학적결과비교신보강화학요법후근치자궁절제술을시행받은군의평균재원기간 은 22.1 ± 9.9 일로근치자궁절제술을받은환자들의평균재원기간인 18.1 ± 6.3 일보다길었고 (P = 0.036), 림프절절제술을시행하여획득한 림프절의수는근치자궁절제술을시행한군에서통계적으로유의하게 더많았다 (P<0.001). 그외수술시간이나출혈양등은통계적으로의 미있는차이는없었다. 조직학적소견에서종양의크기가 4 cm 이상 인경우, 신보강화학요법을시행한군에서 11 명 (25.6%), 근치자궁절 제술을시행한군에서 11 명 (55%) 으로신보강화학요법을받은군에서 의종양크기가작았고 (P = 0.0459), 림프혈관강침윤이신보강화학요법 을받았던군보다근치자궁절제술을받은군에서더많이발견되었다 (20.9% vs. 55%, P = 0.0158) (Table 2). 3. 각치료에따른재발률과 5 년무병생존율및전체생존율의비교각치료군에따른재발률에대한비교에서는통계적으로유의한차 이는없었으나재발부위를비교해보았을때, 근치자궁절제술을받고 재발한 8 명중 2 명 (25%) 은국소재발, 6 명 (75%) 은원격재발을하였 고, 신보강화학요법을받은후재발한 16 명중 9 명 (56.2%) 이국소재 Table 1. Patient characteristics Characteristic NAC (n=43) RAH (n=20) CCRT (n=23) P-value Age (yr) 48.8 ± 8.6 53.0 ± 11.5 62.8 ± 9.2 <0.001 BMI (kg/m 2 ) 22.5 ± 3.4 22.8 ± 3.9 22.8 ± 4.2 0.315 Tumor size (cm) 3.9 ± 1.28 5.9 ± 3.37 3.3 ± 1.4 <0.001 Histology 0.168 Squamous cell carcinoma 37 (86.0) 20 (100) 23 (100) Adenocarcinoma 4 (9.3) 0 0 Adenosquamous cell carcinoma 2 (4.7) 0 0 Values are presented as mean ± standard deviation or number (%). NAC, neoadjuvant chemotherapy; RAH, radical abdominal hysterectomy; CCRT, concurrent chemoradiotherapy; BMI, body mass index. WWW.KJOG.ORG 915
KJOG Vol. 55, No. 12, 2012 Table 2. Comparison of surgico pathologic outcomes Variables NAC (%) (n=43) RAH (%) (n=20) P-value Admission days (day) 22.1 ± 9.9 18.1 ± 6.31 0.036 Operation time (min) 197.1 ± 42.7 189.9 ± 47.3 0.565 Blood loss (ml) 867.4 ± 296.6 895.0 ± 305.2 0.846 Foley catheter keeping days (day) 14.1 ± 5.4 13.1 ± 4.1 0.4474 Drainage catheter keeping days (day) 10.3 ± 3.5 11.2 ± 3.7 0.721 Node count 22.3 ± 7.6 31.7 ± 14.6 <0.001 Pathologic findings Tumor size ( 4 cm) 11 (25.6) 11 (55.0) 0.0459 Deep cervical invasion 36 (84.7) 20 (100) 0.1380 Lymph node metastasis 19 (43.2) 12 (60.0) 0.3692 Parametrial invasion 9 (20.9) 6 (30.0) 0.059 LVSI 9 (20.9) 11 (55.0) 0.0158 Positive vaginal resection margin 7 (16.3) 2 (10.0) 0.7824 Adjuvant therapy 26 (60.5) 17 (85.0) 0.0976 Values are presented as mean ± standard deviation or number (%). NAC, neoadjuvant chemotherapy; RAH, radical abdominal hysterectomy; LVSI, lymphovascular space invasion. Table 3. Comparison of clinical courses Variables NAC (n=43) RAH (n=20) CCRT (n=23) P-value Recurrence 16 (37.2) 8 (40) 9 (39.1) 0.9749 Sites of recurrence 0.0140 Local 9 (56.2) 2 (25) 0 (0) Distant 7 (43.8) 6 (75) 9 (100) No. of death 15 (34.9) 5 (25) 8 (34.8) 0.7125 5YSR (%) 67.5 80.0 65.4 0.8035 DFS (mo) 73.01 (3-134) 57.87 (0-123) 58.44 (0-118) 0.261 Values are presented as number (%). NAC, neoadjuvant chemotherapy; RAH, radical abdominal hysterectomy; CCRT, concurrent chemoradiotherapy; 5YSR, 5-year survival rate; DFS, diseasefree survival. 발을하였고, 7명 (43.8%) 은원격재발을하였으며, 동시화학방사선요법을받은후재발한 9명모두가원격재발을보여신보강화학요법을받은환자일수록다른치료군에비해원격재발이낮았다 (P = 0.0140) (Table 3). 평균추적관찰기간은 74.6개월 (1.5-134.3 개월 ) 이었으며, 전체환자중 28명 (32.6%) 이사망하였다. 근치자궁절제술을시행받은환자중 5명 (25%), 신보강화학요법을받은환자중 15명 (34.9%), 동시항암화학방사선요법을받은환자중 8명 (34.8%) 이사망하였다. 환자의예후인자를고려하지않은상태에서치료법에의거하여 Kaplan- Meier method 를통해계산한 5년무병생존율은근치자궁절제술을시행받은군, 신보강화학요법을시행받고수술한군, 동시항암화학방사선요법을받은군에서각각 63.6%, 65.1%, 63.6% 로차이는없었으며 (P = 0.92) (Fig. 1A), 5년전체생존율역시세군간차이는없었다 (80.0%, 67.4%, 65.2%, P=0.85) (Fig. 1B). 고찰 자궁경부암의치료는암의원발병소와잠재적인전파부위를제거하는것으로크게외과적절제, 방사선요법혹은동시항암화학방사선요법으로나뉘어져있다. 치료방법을선택함에있어가장중요한인자는임상적병기로일반적으로병기 IA-IIA 의조기암에서는환자의상태나조건을고려하여수술또는방사선요법중의하나를선택하여적용하며예후는양호하나일단자궁방결합조직 (parametrial tissue) 또는골반림프절전이시에는치료방법에상관없이예후는불량하다. 병기 916 WWW.KJOG.ORG
Young Ju Woo, et al. The treatment of cervical cancer IIB A Disease-free survival B 100 100 Overall survival Survival probability (%) 80 60 40 20 0 Primary treatment NAC RAH CCRT 0 10 20 30 40 50 60 Time (mo) Log-rank test P = 0.9157 Survival probability (%) 80 60 40 20 0 Primary treatment NAC RAH CCRT 0 10 20 30 40 50 60 Time (mo) Log-rank test P = 0.8035 Fig. 1. (A) Disease-free survival rate by treatment group. (B) Overall survival rate by treatment group. NAC, neoadjuvant chemotherapy; RAH, radical hysterectomy; CCRT, concurrent chemoradiotherapy. IIB-IVA 의진행된암에서는수술시절제범위가넓어지고, 누공, 요관손상등의유병률도증가되며오히려수술로인한합병증의발생이증가하므로수술적치료의적응이되지않으며그효과도다른치료법에비해좋지않으므로방사선치료를적용해왔다 [18-20]. FIGO 임상병기 IB, IIA 에서임파절전이가없을경우수술또는방사선치료후 5년생존율은 80%-90% 이고 [21], 국소적으로전이하였거나림프절의전이가있는경우 5년생존율이약 30%-50% 감소한다 [22,23]. FIGO 병기 IIB 환자의경우 5년생존율이 35%-65%, IIIB 환자에서는 35%, 병기 IVa 환자에서는 10%-15% 에불과하며 1950년대이후치료결과에따른개선이보이지않고있다 [24]. 국소적으로진행된침윤성자궁경부암이나자궁경부병변이크거나자궁방결합조직의침윤이의심스러운경우, 수술적요법과방사선요법으로는만족할만한치료성적을거둘수없어보다효과적인치료방법의필요성이요구되고있다 [25,26]. 신보강화학요법은종양에대한혈액공급을원활하고저항성이없는상태에서항암제를투여함으로써효과를높일수있으며, 환자의전신상태가양호한시기에치료함으로써심각한독성발생의가능성을줄일수있다 [13]. 또한 53%-94% 의높은반응률을보이며, 10%-13.8% 의조직학적인완치율을보인다 [27]. 이와는대조적으로 Rabinovich 등 [28] 은신보강화학요법을받은환자와받지않은환자양쪽에서치료실패율이비슷하며항암제를사용하여도원격전이된암세포를효과적으로치료할수없었고, 방사선치료영역밖에서의재발을막을수없었다고보고하였다. 하지만자궁경부병변의크기가커서수술이불가능했던환자를대상으로신보강화학요법후반응을보인환자모두에서근치자궁절제술이가능했으며 3년무병생존율이병기 IB-IIA, IIB, III 에서각각 100%, 81%, 66% 로나타나서재발의고위험인자를가진환자의수술전항암치료의효용성에대해서보고되고있다 [29]. 본연구에서는자궁경부암IIB 환자의일차치료로근치자궁절제술, 신보강항암요법시행후근치자궁절제술시행한군및동시항암화학방사선요법을시행했던군간의생존율및재발률을비교하여국소로진행된자궁경부암의치료에보다효과적인방법을모색하고자하였다. 다른치료군보다동시항암화학방사선요법을받았던환자들의평균 연령이통계적으로유의하게높았다. 이는연령이높을수록수술에대 한합병증이증가할수있고그로인한사망률이증가될가능성이있 으므로동시항암화학방사선요법을많이시행하였고, 젊은연령일수록 난소의기능을보존하기위해술전항암요법을시행하므로추가방사 선요법을피해보고자하였기때문인것으로생각된다. 하지만일차치 료로근치자궁절제술을시행받은환자, 수술전신보강화학요법을시 행받은환자및동시항암화학방사선요법을받은환자들의 5 년생존율 및무병생존율비교하였을때, 세군간생존율에는차이가없었고치 료후추적관찰중재발률에대한차이도없었다. 신보강화학요법의반응률은 65.1% 로기존의보고에비해높은편은 아니었으나항암제에반응이없었던군에서재발률이높았으며 (25% vs. 60%) 이는통계적으로경계성의의미를가지며개체수가증가할 때보다의미있는결과를보일것으로기대된다 (P = 0.053). 신보강화 학요법을받은환자군에서원격재발이적었고 (P = 0.014), 재발의예 후인자와관련된조직학적소견상신보강화학요법을시행받은군에서 종양의크기가더작았고, 림프혈관강침윤이통계적으로유의한차이 를나타내며적었다 (P = 0.046, 0.016). 따라서수술전신보강화학요법 을시행할경우, 원격재발을감소시키며조직학적예후인자들을호전 시킴으로불필요한추가치료를피할수있도록하였다. 하지만본연구 가후향적고찰이며대상수가적고각치료에대한합병증유무에대 한정확한정보가부족하였던한계점을가지고있으므로향후보다넓 은규모의연구를통해상기치료에대한비교가입증되는것이필요하 다고생각된다. References 1. Jemal A, Siegel R, Ward E, Murray T, Xu J, Thun MJ. Cancer statistics, 2007. CA Cancer J Clin 2007;57:43-66. 2. Ministry of Health, Welfare and Family Affairs. Annual report of cancer incidence (2007), cancer prevalence (2007) and WWW.KJOG.ORG 917
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Young Ju Woo, et al. The treatment of cervical cancer IIB cal hysterectomy. Gynecol Oncol 2001;82:88-93. 28. Rabinovich MG, Focaccia G, Ferreyra R, Elem Y, Leone BA, Vallejo CT. Neoadjuvant chemotherapy for cervical carcinoma. Obstet Gynecol 1991;78:685-8. 29. Panici PB, Scambia G, Baiocchi G, Greggi S, Ragusa G, Gallo A, et al. Neoadjuvant chemotherapy and radical surgery in locally advanced cervical cancer. Prognostic factors for response and survival. Cancer 1991;67:372-9. 자궁경부암병기 IIB 환자에서치료법에따른예후비교 : 근치자궁절제술, 신보강화학요법후근치자궁절제술및동시화학방사선요법의예후를비교한후향적연구 1 성균관대학교삼성창원병원산부인과, 2 인제대학교의과대학부산백병원산부인과학교실, 3 백인제기념임상의학연구소 우영주 1, 변정미 2, 정대훈 2,3, 김영남 2,3, 김수선 2, 서영진 2, 성문수 2, 이경복 2, 김기태 2,3 목적자궁경부암병기 IIB인환자들에서근치자궁절제술, 신보강화학요법후근치자궁절제술및동시화학방사선요법을시행받은군간의예후를비교하였다. 연구방법 2000년 1월부터 2006년 12월까지인제대학교부산백병원산부인과에서자궁경부암 IIB로진단된 104명의환자에서근치자궁절제술, 신보강화학요법후근치자궁절제술및동시항암화학방사선요법을시행받은군간의 5년무병생존율및전체생존율과재발률을비교하여각각치료에대한예후를분석하였다. 결과근치자궁절제술을시행받은 20명, 신보강화학요법을시행한후근치자궁절제술을시행받은 43명, 동시항암화학방사선요법을시행받은 23명을포함하여총 86명을대상으로분석하였다. 연령이낮을수록 (P<0.001) 신보강화학요법이시행되었고, 종양크기가클수록신보강화학요법이나동시화학방사선요법보다는근치자궁절제술이시행되었다 (P<0.001). 세군중신보강화학요법을받은군에서원격재발이의미있게낮았다 (P = 0.014). 근치자궁절제술만시행한군과신보강화학요법후근치자궁절제술을한군을비교하였을때, 근치자궁절제술을한군의조직학적소견에서중등도위험인자인 4 cm 이상인종양크기와림프혈관강침윤이통계적으로의미있게증가하였다 (P = 0.0459, 0.0158). 결론세군간 5년무병생존율및전체생존율에차이는없었으나신보강화학요법은원격전이를낮추고, 종양의크기와림프혈관강침윤을감소시켜불필요한추가치료를피할수있도록하였다. 중심단어 : 자궁경부암, 신보강화학요법, 근치자궁절제술, 동시항암화학방사선요법, 생존 WWW.KJOG.ORG 919