胰腺癌放疗对胃、十二指肠黏膜损伤的胃镜观察31例

Gastric or duodenal injury induced by radiotherapy for pancreatic carcinoma:An analysis of 31 cases

目的:探讨胰腺癌放疗导致胃、十二指肠黏膜放射性损伤及其影响因素.方法:收集我院胰腺癌放疗后行胃镜检查的31例患者,临床症状根据RTOG/EORTC进行分期,胃镜观察采用内镜分级分为Ⅰ级-Ⅳ级,所有病例均行内镜下组织病理学活检.对胰腺癌放疗导致的胃、十二指肠黏膜放射性损伤的影响因素进行统计学分析.结果:临床症状观察主要以腹胀、恶心、呕吐、腹痛、出血等急性期胃肠道反应为主.胃镜观察:Ⅰ级胃、十二指肠黏膜正常4例;Ⅱ级轻度胃、十二指肠黏膜炎6例;Ⅲ级糜烂性胃炎3例;Ⅳ级病变包括:单纯胃溃疡6例,胃溃疡伴胃窦变形1例;单纯十二指肠溃疡5例,吻合口溃疡1例,十二指肠溃疡合并狭窄4例.所有病例均经胃镜下组织病理学活检,符合炎症或溃疡性改变.-刀、3-D、TOMO3种不同放疗技术对比结果显示:-刀对比3-D总病变率(80.0%vs80.0%,P>0.0167);-刀对比TOMO总病变率(80.0%vs72.7%,P>0.0167);3-D对比TO M O总病变率(80.0%v s72.7%,P>0.0167).-刀不同放疗剂量对比,总病变率为(90%vs100%vs100%),3组结果分别比较P<0.0167.放疗前手术组16例,非手术组15例,总病变率(87.5%vs66.7%,P>0.05).同步GEM化疗9例,非同步化疗22例,总病变率(66.7%vs91.9%,P>0.05).预防应用胃肠黏膜保护药物16例,未预防应用胃肠黏膜保护药物15例,总病变率为(68.7%vs100%,P<0.05).放疗期间使用氨磷汀14例,未使用氨磷汀17例,总病变率为(85.7%vs82.4%,P>0.05).有慢性合并症患者14例,无慢性合并症患者17例,总病变率为(78.6%vs76.5%,P>0.05).结论:本研究胃镜观察结果显示胰腺癌放疗后胃、十二指肠黏膜放射性损伤发生率高,病变以胃黏膜糜烂、溃疡,十二指肠黏膜溃疡、狭窄等中重度病变为主.对影响放射性胃、十二指肠黏膜损伤因素分析显示:随着放疗剂量的增加,胃、十二指肠黏膜损伤加重;预防使用胃肠黏膜保护药物可以减少放射性胃、十二指肠黏膜损伤的病变率,差异有统计学意义;但不同放疗技术、是否应用氨磷汀、是否有腹部手术史、是否有慢性合并症对放射性胃、十二指肠黏膜放射性损伤病变率比较无统计学差异.

AIM： To observe gastric or duodenal mucosal injury induced by radiotherapy in patients with pancreatic carcinoma and to analyze possible influencing factors. METHODS： Thirty-one patients with pancreatic carcinoma who underwent gastroscopy after ra- diotherapy were included. Their clinical symp- toms were graded according to RTOG/EORTC. Gastroscopic findings were graded as Ⅰ -Ⅳ. All patients underwent endoscopic biopsy for his- topathological examination. Factors influencing radiotherapy-induced gastric or duodenal mu- cosal injury were analyzed. RESULTS： Main clinical symptoms included abdominal distension, anorexia, acid reflux, nau- sea, vomiting, and abdominal pain. Endoscopic analysis indicated that 4 cases were classified asgrade I （no gastric or duodenal mucosa injury）, 6 cases as gradeⅡ （mild gastric or duodenal muco- sitis）, 3 cases as grade III （erosive gastritis）, and 17 cases as grade Ⅳ （ including 6 with gastric ulcer, Ⅰwith gastric ulcer and gastric antral deforma- tion, 5 with duodenal ulcer, Ⅰ with anastomotic ulcer, and 4 with duodenal ulcer and narrowing）. Endoscopic biopsy and histopathological analysis proved that all cases had inflammatory or ulcer- ative changes. The rates of detection of gastric or duodenal mucosa injury by 7-ray, 3-D, TOMO or gastroscopy were： 7-ray therapy vs 3-D （80.0% vs 80.0%, P 〉 0.0167）, 7-ray therapy vs TOMO （80.0% vs 72.7%, P 〉 0.0167）, and 3-D vs TOMO （80.0% vs 72.7%, P 〉 0.0167）. When 7-ray radiotheraphy dose was 51 Gy （10 cases）, 48 Gy （3 cases） and 45 Gy （2 cases）, the rates of gastric or duodenal mu- cosal injury were 90%, 100% and 100%, respec- tively. The rate of gastric or duodenal mucosal in- jury did not differ significantly between patients who underwent surgery （n= 16） and those who did not undergo （n = 15） （87.5% vs 66.7%, P 〉 0.05）, between patients receiving concurrent chemora- diotherapy （n = 9） and those not receiving （n = 22） （66.7% vs 91.9%, P 〉 0.05）, between those receiv- ing amifostine during radiotherapy （n= 10） and not receiving （n = 15） （85.7% vs 82.4%, P 〉 0.05）, or between patients having co-morbidities （e.g., diabetes mellitus, hypertension, or inflammatory bowel disease） （n =14） and those not having （n = 17） （78.6% vs 76.5%, P 〉 0.05）. In contrast, the rate of gastric or duodenal mucosal injury differed significantly between patients given gastrointesti- nal mucosal protective agents during radiothera- py （n = 16） and those not given （n = 15） （68.7% vs 100%, P 〈 0.05）. CONCLUSION： Gastroscopy is a preferred mo- dality for the detection of gastric or duodenal injury induced by radiotherapy in patients with pancreatic carcinoma. High radiation dose is associated with a higher incidence of gastric or duodenal mucosal injury. The use of gastric or duodenal mucosal protective agents is a favorable factor for radiotherapy-induced gastric or duo- denal mucosal injury. Radiotherapy techniques, amifostine, abdominal surgery or chronic com-plicafions have no significant impact on gastric or duodenum injury induced by radiation.