Long term experience with 3D image guided brachytherapy and clinical outcome in cervical cancer patients
Long term experience with 3D image guided brachytherapy and clinical outcome in cervical cancer patients
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DOI：
10.1016/j.radonc.2016.04.016
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发表时间：
2016-09-01
影响因子：
5.7
通讯作者：
Van Limbergen, Erik
中科院分区：
文献类型：
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作者：
Ribeiro, Ivone;Janssen, Hilde;Van Limbergen, Erik
背景与目的：报告我们10年来使用脉冲剂量率（PDR）近距离放射治疗（BT）联合放化疗和MRI（或CT在9例选定患者中）引导近距离放射治疗宫颈癌患者的经验和学习曲线。方法和材料：连续170例FIGO IB-IVB期宫颈癌患者（无主动脉旁淋巴结区以外的转移） 2002 年至 2012 年间，这些患者在我们研究所接受治疗。患者接受外照射放射治疗（诊断时对淋巴结呈阳性的淋巴结加强治疗）+/- 化疗，然后进行脉冲或低剂量率近距离放射治疗加强治疗。 MRI（或 CT）图像是用施源器在原位拍摄的。前 16 名患者根据基于 X 射线的计划进行治疗，并在 MRI 上进行了优化。根据 GEC-ESTRO 建议，对高危 CTV、中危 CTV、膀胱、直肠和乙状结肠进行回顾性轮廓绘制。在所有其他患者中，在通过 MRI（或 CT）描绘目标体积和有风险的器官后优化治疗计划。通过应用线性二次模型将剂量转换为 2 Gy 的等效剂量 (EQD2)。患者的中位年龄为 55 岁（范围 16-88 岁）。 41% 患有 III 期或 IV 期疾病。在 170 名患者中，91 名患者在诊断时影像学显示有转移性淋巴结（62 名患者盆腔淋巴结受累，29 名主动脉旁淋巴结受累）。在 27 名 (16%) 患者中，腔内技术与间质近距离放射治疗相结合。结果：整个患者组高风险 CTV 的平均 D90 和 D100 分别为 84.8 +/- 8.36 Gy 和 67.5 +/- 6.29 Gy。 IR CTV 的平均 D90 和 D100 值为 68.7 +/- 5.5 Gy 和 56.5 +/- 6.25 Gy。两个患者组之间都存在重要的学习曲线，前 16 名患者的平均 D90 增加了 75.8 Gy，而第二组患者的平均 D90 增加了 85.8 Gy。与此同时，膀胱和乙状结肠2 cm(3)的平均剂量分别从86.1 Gy减少到82.7 Gy，从70 Gy减少到61.7 Gy。中位随访时间为 37 个月（范围 2-136 个月），所有患者的局部控制率为 96%，区域控制（盆腔和主动脉旁）率为 81%，粗无病生存率为 55%。 5 年总生存率为 65%。目标体积的较高剂量导致局部控制率从前 16 名患者的 88% 提高到第二组患者的 97%。关于晚期毒性，21 名患者 (12%) 出现 3-4 级晚期发病。直肠、泌尿道、乙状结肠和阴道的发病率分别为 5%、6%、2% 和 5%。发现直肠 D2 cm(3) >65 Gy 与 3 级晚期发病率之间存在相关性 (p = 0.006)。结论：虽然大多数患者表现为局部晚期癌症，但仍取得了良好的局部和区域控制率。直肠、泌尿道、乙状结肠和阴道3-4级发病率分别为5%、6%、2%和5%。发现直肠 D2 cm(3) >65 Gy 与 >3 级晚期发病率之间存在相关性 (p = 0.006)。 (C) 2016 Elsevier Ireland Ltd. 保留所有权利。
Background and purpose: To report our 10 years' experience and learning curve of the treatment of cervical cancer patients with chemo radiotherapy and MRI (or CT in 9 selected patients) guided brachytherapy using pulsed dose rate (PDR) brachytherapy (BT).Methods and materials: Hundred and seventy consecutive patients with cervical cancer FIGO stage IB-IVB (without metastases beyond the para-aortic nodal region) were treated in our institute between 2002 and 2012. Patients received external beam radiotherapy (nodal boost to the lymph nodes positive at diagnosis) +/- chemotherapy followed by a pulsed or low dose rate brachytherapy boost. MRI (or CT) images were taken with the applicator in situ. The first 16 patients were treated according to X-ray-based plans, optimized on MRI. High-risk CTV, intermediate-risk CTV, bladder, rectum and sigmoid were retrospectively contoured according to the GEC-ESTRO recommendations. In all other patients, treatment plans were optimized after delineation of the target volumes and organs at risk at MRI (or CT). Doses were converted to the equivalent dose in 2 Gy (EQD2) by applying the linear quadratic model. The median age of the patients was 55 years (range 16-88). 41% had stage III or IV disease. Of the 170 patients, 91 patients had on imaging metastatic lymph nodes at diagnosis (62 patients pelvic lymph node involvement and 29 para-aortic). In 27 (16%) patients the intracavitary technique was combined with interstitial brachytherapy.Results: The mean D90 and D100 for the high-risk CTV were 84.8 +/- 8.36 Gy and 67.5 +/- 6.29 Gy for the entire patient group. Mean D90 and D100 values for the IR CTV were 68.7 +/- 5.5 Gy and 56.5 +/- 6.25 Gy. There was an important learning curve between both patient groups, with an increase in mean D90 of 75.8 Gy for the first 16 patients compared to 85.8 Gy for the second group. At the same time, the mean dose to 2 cm(3) of bladder and sigmoid decreased from 86.1 Gy to 82.7 Gy and from 70 Gy to 61.7 Gy, respectively. At a median follow-up of 37 months (range 2-136 months), local control rate for all patients was 96%, the regional control (pelvic and para-aortic) rate 81% and crude disease free survival rate 55%. The overall survival at 5 years is 65%. The higher dose to the target volume resulted in an increase in local control from 88% in the first 16 patients compared to 97% in the second patient group. Regarding late toxicity, 21 patients (12%) presented grade 3-4 late morbidity. Rectal, urinary, sigmoid and vaginal morbidity was 5%, 6%, 2% and 5%, respectively. A correlation between rectal D2 cm(3) >65 Gy and grade >3 late morbidity was found (p = 0.006).Conclusion: Although the majority of the patients presented with locally advanced carcinoma, excellent local and regional control rates were achieved. Rectal, urinary, sigmoid and vaginal grade 3-4 morbidity was 5%, 6%, 2% and 5%, respectively. A correlation between rectal D2 cm(3) >65 Gy and grade >3 late morbidity was found (p = 0.006). (C) 2016 Elsevier Ireland Ltd. All rights reserved.