影像引导宫颈癌三维腔内放疗的临床初步观察

Clinical preliminary observation on image-guided brachytherapy for cervical cancer

背景与目的：放射治疗是宫颈癌的主要治疗方法。通过分析苏州大学附属第一医院放疗科收治的31例初治宫颈癌患者三维腔内放疗的剂量体积直方图（dose—volumehistogram，DVH）剂量分布和临床结果，观察影像引导宫颈癌三维后装放疗患者的近期疗效及放射反应。方法：选取2013年5月-2014年12月在苏州大学附属第一医院放疗科行根治性放疗的31例初治宫颈癌患者，FIGO期为IIa-Ⅳ期。每例患者接受4~6次CT引导下的三维后装放疗，单次高危临床靶区（highrisk—clinicaltargetvolume，HR—CTV）给予400-600cGy处方剂量，31例患者共计153次施源器置入，采用192Ir高剂量率后装治疗机实施腔内放疗。分析内外照射的HR-CTVD90、膀胱D2cc、乙状结肠D2cc、直肠DO．icc和直肠D2cc，采用EQD2进行剂量计算。按照RTOG／EORTC放射反应评分标准和RECIST1．1评价标准分析放射反应和近期疗效。结果：膀胱、直肠、乙状结肠均无3级及以上急性或慢性放射反应。2例患者发生后期直肠出血（2级），经止血和灌肠等对症处理后症状改善。放疗后1-3个月完全缓解率（completeremission，CR）为93．55％（29／31），1年局部控制率（10calcontrolrate，LCR）为93．55％（29／31），1年无进展生存率（progression—freesurvival，PFS）为90．32％（28／31）。结论：cT引导的三维腔内放疗联合外照射治疗局部晚期宫颈癌，定位精确，靶区剂量充足，危及器官的受照剂量可见、可控、可信，提高了患者的治疗耐受性，避免了重度放射反应的发生，大大提高了患者治疗后的生活质量，值得推广应用。

Background and purpose： The radiation therapy is the main treatment of cervical cancer. In order to investigate the efficacy and toxicity of the 3D image-guided brachytherapy for cervical cancer, we analyzed dose-volume histogram （DVH） dose distribution and clinical data from 31 cases of cervical cancer treated with three dimensional brachytherapy. Methods： From May. 2013 to Dec. 2014, 31 cervical cancer cases with FIGO stage lI a-IV received comprehensive treatment in our department. High risk-clinical target volume （HR-CTV） was 400- 600 cGy per fraction, and totally 4-6 fractions for each patient. A total of 152 times 3D-CT guided brachytherapy was performed with 192Ir high-dose-rate afterloader. We calculated the doses with EQD2 and analyzed the data on HR- CTV D90, bladder D2cc, sigmoid D2cc, rectum DO. lcc and rectum D2cc of both the external-beam radiotherapy and CT-guided brachytherapy. The efficacy and toxicity were evaluated by RTOG/EORTC and RECIST （version 1.1） guideline. Results： There was no third degree reaction occurring on bladder, rectum or sigmoid. Two patients developed second degree chronic rectal bleeding 3 months after the completion of radiotherapy which were well controlled by medications. The tumor complete remission rate （CR） was 93.55% （29/31） 1-3 months after the treatment. Local control rate （LCR） rate was 93.55% （29/31） one year after the treatment, whereas disease-free survival rate （DFS） was 90.32% （28/31）. Conclusion： The 3D CT-guided brachytherapy combined with external radiation for locally advanced cervical cancer showed positioning accuracy with an adequate dose distribution to the target area. The treatment made the OR dose visible, controllable and credible. It improved the treatment of patients with increased tolerance and avoided the severe radiation reactions. Thus, the combination therapy may greatly improve the quality of life for patients, and ought to be promoted.