胰腺癌螺旋断层放疗后胃、十二指肠损伤的预测因素分析

Gastroduodenal complications after tomotherapy in patients with pancreatic cancer： endoscopic findings and risk factors

目的 探讨胰腺癌患者螺旋断层放疗（TOMO）后致胃、十二指肠放射性损伤的内镜下表现，并寻找预测因素。方法 收集2010年2月至2015年5月在中国空军总医院放疗科行TOMO的胰腺癌患者70例，放疗前、后均行内镜检查，描述内镜下放射性胃、十二指肠损伤，对致胃、十二指肠放射性溃疡影响因素进行统计学分析。结果 放疗后行内镜检查的中位时间为1个月，内镜结果显示放射性胃、十二指肠炎症41例（58.6%）；放射性胃、十二指肠溃疡30例（42.9%），活动性出血7例（10.0%），放射性溃疡并瘢痕造成局部狭窄3例（4.3%），新发胃潴留6例（8.6%），新发胃底静脉曲张4例（5.7%）。临床因素手术减黄、放疗防护（氨磷汀）与胃放射性溃疡的发生有关（χ^2=4.186，P=0.041；χ^2=5.679，P=0.017）；常见不良反应事件评价标准（CTCAE）评分≥2与十二指肠放射性溃疡的发生有关（χ^2=3.960，P=0.047）。受试者工作特征（ROC）曲线分析表明，胃平均剂量＞13.39 Gy、≤13.39 Gy时溃疡的发生率分别为25.0%、9.1%，曲线下面积（AUC）=0.740，P=0.048。结论 胰腺癌TOMO后胃肠道损伤普遍存在，手术减黄是放射性胃溃疡的保护因素，平均剂量＞13.39 Gy是放射性胃溃疡的剂量预测指标，建议TOMO后早期行内镜检查。

Objective To investigate the risk factors and patterns of radiation induced gastroduodenal complications in patients with pancreatic cancer following tomotherapy （TOMO） using endoscopy. Methods Patients with pancreatic cancer who were treated TOMO in Air Force General Hospital from February 2010 to May 2015 were collected. All patients underwent endoscopic examination before and after radiotherapy. The radiation injuries were observed, and factors influencing radiationinduced gastroduodenal complications were analyzed. Results The median time of gastroscopy after radiotherapy was 1 month, radiation gastritis and duodenitis were 41 cases （58.6%）, radiation gastric and duodenal ulcers were 30 cases （42.9%）, and hemorrhage 7 cases （10.0%）, scar formation 3 cases （4.3%）, 6 cases （8.6%） had newly developed gastric retention, and 4 cases （5.7%） had newly developed gastric varix. Univariate analysis showed that relieving jaundice and radiation protection （amifostine） were associated with the development of radiation gastric ulcers （χ^2=4.186, P=0.041; χ^2=5.679, P=0.017）. Conmon terminology criteria for adverse events （CTCAE）≥2 was associated with the development of radiation duodenal ulcers （χ^2=3.960, P=0.047）. Mean dose （Dmean） 〉13.39 Gy and Dmean≤13.39 Gy gastric ulcers rates were 25.0% and 9.1%, respectively （AUC=0.740, P=0.048）. Conclusion The TOMO induced gastroduodenal injury in patients with pancreatic cancer is frequent. Relieving jaundice is the protection of radiation gastric ulcer. Dmean〉13.39 Gy is independent predictive factors for radiation gastric ulcers. Patients after TOMO should be examined by endoscopy early.