体外延伸野调强加腔内放疗联合化疗治疗子宫颈癌腹主动脉旁淋巴结转移的临床研究

Extended-field intensity modulated radiation therapy and intra-cavitary brachytherapy combined with chemotherapy for stage Ⅰb1-Ⅳa cervical cancer with positive para-aortic lymph nodes

【摘要】目的探讨体外延伸野调强加腔内放疗联合化疗治疗子宫颈癌腹主动脉旁淋巴结转移的疗效及副反应。方法回顾性分析2009年1月一2011年12月于复旦大学附属肿瘤医院治疗的46例Ⅰb1期-Ⅳa期（包括Ⅰb1期1例、Ⅱb期8例、Ⅲa期2例、Ⅲb期33例、1Va期2例）子宫颈癌腹主动脉旁淋巴结转移患者的临床资料。46例子宫颈癌患者均予体外延伸野调强加腔内放疗联合化疗，具体方法为：采用体外延伸野调强放疗，延伸野剂量为50．4Gy，1．8Gy／次，共28次，对转移淋巴结、宫旁加量者加量6．0～8．0Gy，外照射5周后补充腔内放疗，A点剂量为20．0～30．0Gy，5．0Gy／次，共4～6次；在放疗前、放疗中、放疗后分别给予1、2、3个疗程紫杉醇＋卡铂方案的化疗。随访时间为15～50个月（中位随访时间为27个月），观察患者的治疗完成情况、生存情况和近、远期并发症的发生情况。结果（1）治疗完成情况：完成放疗总时间为47～71d，中位完成放疗时间为53d；26例患者腹主动脉旁淋巴结加量放疗，37例患者接受盆腔肿大淋巴结或宫旁加量放疗。化疗的总疗程数为189个，每例患者平均4．1个（2～6个）。（2）生存情况：患者的3年总生存率为61．2％，3年无瘤生存率为46．2％。21例（46％，21／46）患者复发，中位复发时间为16个月（9～35个月）。（3）近、远期并发症：急性放、化疗反应：38例（83％，38／46）患者出现Ⅰ～Ⅲ级胃肠道反应，其中Ⅲ级胃肠道反应2例（4％，2／46）；46例（100％，46／46）患者均出现不同程度的骨髓抑制，其中Ⅲ～Ⅳ度骨髓抑制18例（39％，18／46）；27例（59％，27／46）患者出现Ⅰ级泌尿道反应。晚期放疗反应：21例（46％，21／46）患者出现Ⅰ-Ⅳ级放射性肠炎，其中Ⅲ-Ⅳ级放射性肠炎3例（7％，3／46）；4例（9％，4／46）患者出现Ⅱ级放射性膀胱炎。结论体外延伸野调强加腔内放疗联合化疗治疗子宫颈癌腹主动脉旁淋巴结转移患者能获得满意的3年总生存率，且患者的耐受性较好。

Objective To investigate the treatment effects and toxicities of extended-field intensity modulated radiation therapy （EF-IMRT） and intra-eavitary braehytherapy combined with chemotherapy for stage Ⅰb1-Ⅳa cervical cancer with positive para-aortic lymph nodes. Methods A total of 46 stageⅠb1-Ⅳa cervical cancer patients with positive para-aortic lymph nodes treated at Fudan University Shanghai Cancer Center between 2009 and 2011 were reviewed. Neoadjuvant, concomitant and adjuvant chemotherapy with paelitaxel and carboplatin were administrated for one cycle before radiation therapy, two cycles during radiation therapy or three cycles after radiation therapy. All patients received EF-IMRT and intra-cavitary brachytherapy. The positive lymph nodes received an additional boost dose. Results All patients received EF-IMRT to 50. 4 Gy （ 1.8 Gy per fraction）. Twenty-six patients was treated with boost dose of 6. 0 -8.0 Gy in 2.0 Gy per fraction to positive para-aortic lymph nodes. Thirty-seven patients received a positive para- aortic lymph nodes boost or（and） parametrial boost. All patient also received a high-dose-rate intra-cavitary brachytherapy at the point ＂A＂ dose of 20. 0 - 30. 0 Gy in 5.0 Gy per fraction. Total chemotherapy cycles were 189, and the average patient received 4. 1 courses. Two cases （4% , 2/46） experienced grade m gastrointestinal toxicities, no patients suffered grade IV gastrointestinal toxicities. Fifteen cases （33%, 15/46） experienced grade m hematological toxicities, and 3 （7%, 3/46 ） experienced grade IV hematological toxieities. Late grade Ⅲ -Ⅳ toxicity was seen in 3 cases （7% ,3/46）. The 3 year progression- free survival rate was 46. 2% , and the 3 years overall survival rate was 61.2%. Conclusion EF-IMRT and intra-cavitary brachytherapy combined with chemotherapy is safe and effective for stage Ⅰb1-Ⅳa cervical cancer with positive para-aortic lymph nodes.