老年胃癌术后放化疗胰腺所受剂量对内外分泌功能的影响

The effect of pancreatic radiation dose on endocrine and exocrine function in elderly patients with gastric cancer undergoing postoperative radiotherapy

目的观察胃癌术后行辅助同步放化疗患者的内外分泌功能指标在治疗前后的变化,结合胰腺的放疗剂量体积相关数据,分析老年胃癌术后放疗患者胰腺放疗相关损伤与胰腺受照剂量体积的相关性。方法前瞻性分析2017年3月-2019年7月在复旦大学附属华东医院接受胃癌根治术后辅助放化疗老年患者胰腺放疗相关损伤与胰腺受照剂量的相关性。收集患者的一般临床资料,通过检测其治疗前后的血液学指标(胰岛素、C肽、糖化白蛋白、糖化血红蛋白、淀粉酶、脂肪酶等),了解放疗对患者胰腺相关功能的损伤。同时在制定放疗计划时,勾划正常组织胰腺,并记录DVH数据(如胰腺V5、V10、V15、V20、V25、V30、V35、V40、V45),平均胰腺受照剂量;最高及最低胰腺受照剂量等,与胰腺功能损伤进行统计学相关分析。结果30例符合条件的患者中,中位年龄65岁;中位随访时间18个月,1和2年生存率分别为90%,75%;放疗后3个月,胰岛素、C肽、淀粉酶、脂肪酶较放疗前基线水平均出现了下降(P<0.05)。淀粉酶、脂肪酶于放疗后6个月与放疗后3个月相比,仍然持续下降,差异具有统计学意义(P<0.05)。经ROC曲线分析显示,胰腺V45预测价值(AUC=0.864,95%Cl0.716~0.992,P=0.001),切点值(cut-off)为V45<50%(敏感性84.6%,特异性82.4%)。结论胃癌术后老年患者在施行同步放化疗后,出现不同程度的胰腺内外分泌功能的下降,所以应当将胰腺设为危及器官,并加以剂量限制,我们推荐V45<50%,该参考值能够降低胰腺放疗相关的损伤风险。

Objective To observe the changes of internal and external secretory function in patients with gastric cancer undergoing adjuvant concurrent chemoradiotherapy before and after treatment,and analyze the correlation between radiationrelated injury of pancreas and radiation dose of pancreas in elderly patients with gastric cancer after surgery.Methods The correlation between pancreatic radiation-related injury and pancreatic radiation dose in elderly patients receiving adjuvant chemoradiotherapy after radical gastrectomy in our hospital from March 2017 to July 2019 was analyzed.The general clinical data of the patients were collected,and the hematological indexes(insulin,C-peptide,glycosylated albumin,glycosylated hemoglobin,amylase,lipase,etc.)before and after treatment were detected to determine the damage of pancreatic related functions caused by radiotherapy.In the planning of radiotherapy,the normal tissues including pancreas was delineated,and the DVH data(such as pancreas V5,V10,V15,V20,V25,V30,V35,V40,V45)were recorded,and the correlation between the average pancreatic radiation dose,maximum and minimum pancreatic radiation dose and pancreatic function injury was analyzed.Results Among the 30 eligible patients,the median age was 65 years;the median follow-up time was 18 months,and the 1-and 2-year survival rates were 90%and 75%,respectively.Three months after radiotherapy,the levels of insulin,C-peptide,amylase and lipase decreased compared with baseline levels before radiotherapy(P<0.05);Amylase and lipase decreased continuously in 6 months after radiotherapy compared with 3 months after radiotherapy(P<0.05).ROC curve analysis showed that the predictive value of pancreatic V45(AUC=0.864,95%Cl 0.716-0.992,P=0.001),and the cut-off value was V45<50%(sensitivity 84.6%,specificity 82.4%).Conclusion In elderly patients with gastric cancer,there are varying degrees of decline in pancreatic internal and external secretion function after concurrent chemoradiotherapy,so the pancreas should be set as a dangerous organ,and the radiation dose should be limited.We recommend V45<50%,which can reduce the risk of pancreatic radiation-related injury.