局部晚期非小细胞肺癌同步加量调强放疗的回顾性分析

Simultaneously integrated boost intensity-modulated radiotherapy for locally advanced non-smallcell lung cancer：A retrospective study of 78 patients

目的 分析采用同步加量调强放疗（SIB-IMRT）技术治疗局部晚期非小细胞肺癌（NSCLC）的疗效及安全性.方法 回顾分析2008年1月至2011年6月在我院胸部放疗科行SIB-IMRT治疗的局部晚期NSCLC 78例,其中,ⅢA期45例,ⅢB期33例.处方剂量为PTV 50.4 ～64.0 Gy/28 ～33次,单次剂量为1.8～2.1 Gy；IGTV为60.0 ～ 74.3 Gy/28 ～ 33次,单次剂量为2.0～2.5 Gy.主要观察指标为总有效率（ORR）、局部控制率（LCR）、总生存率（OS）、无疾病进展生存率（PFS）及3级及以上食管和肺损伤.结果 78例患者均按计划完成根治性放疗,IGTV剂量≥60 Gy.67例（85.9％）患者接受以顺铂或卡铂为基础的第三代细胞毒药物两药联合方案化疗,其中17例（21.8％）为同步放化疗,50例（64.1％）为序贯放化疗.全组ORR为69.2％,其中CR 11例（14.1％）,PR 43例（55.1％）,SD 22例（28.2％）,PD 2例（2.6％）.截至2012年10月,失访6例,随访率92.3％.72例可随访患者中已死亡50例,22例存活.1、2、3年局部控制率分别为88.4％、54.7％、28.6％,中位PFS为15.3个月（2.3 ～46.8个月）,中位OS为27.3个月（5.8 ～49.3个月）.1、2、3年无进展生存率分别为50.7％、27.6％、21.1％；1、2、3年总生存率分别为87.5％、56.6％、30.3％.在同步放化疗与非同步放化疗亚组中,中位OS分别为32.8个月和24.1个月,1、2、3年总生存率分别为94.7％、73.7％、47.3％和83.0％、50.5％、23.9％（x2=3.946,P＜0.05）.全组共发生急性放射性食管损伤59例（75.6％）,治疗相关性肺损伤（TRP）21例（26.9％）,其中3级及以上放射性食管损伤19例（24.4％）,3级及以上放射性肺损伤9例（11.5％）.随访1年后,2例（2.6％）出现晚期3级肺损伤,食管无3级及以上晚期不良反应.结论 SIB-IMRT照射技术治疗局部晚期NSCLC疗效确切,安全性良好,值得临床进一步开展大样本前瞻性随机对照研究.

Objective To evaluate the clinical efficacy and toxicity of simultaneously integrated boost intensity-modulated radiotherapy （SIB-IMRT） for patients with locally advanced non-small cell lung cancer （NSCLC）. Methods Patients with NSCLC who received SIB-IMRT from January 2008 to June 2011 in our hospital were retrospeetively analyzed. Among the 78 patients, 45 patients had clinical stage IIIA disease, 33 patients III~ disease. The SIB-IMRT plans were designed to deliver 50.4 -64.0 Gy in 28 - 33 fraetions （ 1.8 - 2. 1 Gy/fraction） to PTV while simultaneously delivering 60. 0 - 74. 3 Gy in 28 - 33 fractions （2.0 - 2.5 Gy/fraction） to IGTV. The primary endpoint was overall survival （OS）. The secondary endpoints were overall response rate （ORR）, local control rate （LCR）, progression-free survival （PFS） , adverse events （AEs）. Results All patients completed definitive radiotherapy and 67 （85.9%） patients received platinum-based doublet ehemotherapy. Among them, 17 （21.8%） reeeivedconcurrent chemoradiation, other 50 （ 64.1% ） received sequential chemoradiation. The ORR was 69. 2% （54/78） , with CR 11（14.1% ） , PR 43（55.1% ） , SD 22（28.2% ） , PD 2（2. 6% ）. The follow-up rate was 92.3%. Among 72 patients who were followed up, 50 were dead, 22 were alive. 1,2,3-year LCR were 88.4% ,54.7% ,28.6%. Median OS and PFS were 27.3 months （5.8 -49.3 months）, 15.3 months （2.3-46.8 months）,respectively. 1,2,3-year OS and PFS were 87.5%,50.7%,56.6%,27.6%, 30.3% and 21.1% , respectively. There was a statistically significant difference in OS between the sub- group arms with concurrent chemoradiation or non-concurrent chemoradiation （X2 = 3. 946, P 〈 O. 05 ）. Nineteen （24. 4% ） patients experienced acute grade 3 esophagitis and 9 （ 11.5% ） experienced acute grade≥3 treatment-related pneumonitis （TRP）. There were 2 （2. 6% ） late grade 3 pulmonary toxicity after 1 -year follow-up. No late grade ≥ 3 esophageal toxicity was observed. Conclusions It is safe and workable to use SIB-IMRT to treat patients with NSCLC. More prospective clinical studies are warranted.