调强适形放射治疗联合TACE对直肠癌肝转移的预后分析

Prognostic analysis of intensity modulated radiotherapy combined with TACE for hepatic metastasis of rectal cancer

目的探究直肠癌肝转移患者应用调强适形放射治疗联合经肝动脉化疗栓塞术(TACE)治疗的生存预后。方法选择2019年4月至2020年4月在河北中石油中心医院诊治的120例直肠癌肝转移患者,其中男性70例,女性50例;年龄44~67岁,平均年龄55.63岁(标准差8.56岁);身体质量指数(BMI)19.34~25.89 kg/m^(2),平均BMI 22.20 kg/m^(2)(标准差1.80 kg/m^(2));直肠癌分化程度低分化49例,高分化71例;肝转移瘤最大直径0.78~5.65 cm,中位最大直径3 cm(1~5 cm);肿瘤数目1~4个,平均肿瘤数目2.14个(标准差0.59个);生存质量(QOL)问卷-结直肠癌38项(QLQ-CR38)评分(35~45)分,平均QOL 40.33分(标准差3.03分);TNM分期Ⅰ期73例,Ⅱ期47例;Child-Pugh分级A级68例,B级52例;直肠腺癌48例,鳞腺癌72例;门静脉或下腔静脉癌栓28例;卡氏(KPS)评分69~87分,平均KPS评分77.50分(标准差7.33分)。通过随机数字表法分为两组,即对照组60例患者接受TACE治疗方案,研究组60例患者接受调强适形放射治疗联合TACE治疗。对两组患者的治疗效果进行比较分析,比较两组患者治疗前后的肝功能情况、QOL,并记录患者的不良反应情况,对患者进行3年随访,记录各时间段的生存率。结果对照组患者的治疗有效率为50.00%(30/60),低于研究组治疗有效率[76.67%(46/60)](P<0.05)。经治疗后两组凝血酶原时间(PT)、白蛋白(ALB)水平降低,但组间差异无统计学意义(P>0.05)。两组天门冬氨酸氨基转移酶(AST)、丙氨酸氨基转移酶(ALT)水平均较治疗前升高,且研究组高于对照组[(244.26±112.10)U/L vs(90.25±12.45)U/L、(255.12±56.54)U/L vs(90.45±15.26)U/L。P<0.05]。治疗后KPS和QLQ-CR38量表评分均升高且研究组高于对照组[(89.98±4.56)分vs(82.11±3.46)分、(72.41±4.18)分vs(64.56±3.16)分。P<0.05]。在研究组中,正常肝脏、脊髓、胃部、左肾、右肾的平均受量均显著高于对照组[(19.26±5.11)Gy vs(16.26±6.15)Gy、(8.36±2.12)Gy vs(1.23±0.54)Gy、(0.52±0.18)%vs(0.31±0.12)%、(4.88±0.51)%vs(2.12±0.12)%、(8.11±9.11)%vs(4.15±1.03)%。P<0.05]。然而,两组胃肠道反应、肝功能损伤、肾功能损伤、骨髓抑制、周围神经毒性等不良反应发生率比较,差异无统计学意义(P>0.05)。此外,研究组1年及2年生存率均优于对照组(86.67%vs 68.33%、71.67%vs 53.33%。P<0.05);但3年生存率组间比较,差异无统计学意义(P>0.05)。结论对于直肠癌肝转移患者,应用调强适形放射治疗联合TACE治疗可以改善治疗有效率,提高患者1年和2年生存率,改善患者QOL,对患者的生存预后产生积极影响,但对患者治疗短期内的肝功能有一定损害。

Objective To explore the survival prognosis of rectal cancer patients with liver metastasis performed intensity modulated radiotherapy(IMRT)combined with transcatheter arterial chemoembolization(TACE).Methods From April 2019 to April 2020,a total of 120 rectal cancer patients with liver metastasis were enrolled,which included 70 males and 50 females,aged 44-67 years old with average age of 55.63 years old(standard deviation 8.56 years old);body mass index(BMI)was 19.34-25.89 kg/m^(2)with mean BMI of 22.20 kg/m^(2)(standard deviation 1.80 kg/m^(2));49 cases of poorly differentiated rectal cancer and 71 of highly differentiated rectal cancer;maximum diameter of liver metastases was 0.78-5.65 cm with median maximum diameter of 3 cm(1-5 cm);numbers of tumor was 1-4 with mean numbers of 2.14(standard deviation 0.59);score of quality of life(QOL)questionnaire-colorectal cancer 38(QLQ-CR38)was 35-45 with mean score of 40.33(standard deviation 3.03 scores);73 cases of TNM stageⅠand 47 of stageⅡ.According to Child-Pugh classification,there were 68 cases of grade A and 52 of grade B.There were 48 cases of rectal adenocarcinoma and 72 of squamous adenocarcinoma;28 cases of portal vein or inferior vena cava tumor thrombus;the Karnofsky Performance Status(KPS)score was 69-87 with mean score of 77.50(standard deviation 7.33 scores).All of them were divided into control group(n=60,performed TACE)and study group(n=60,performed IMRT combined with TACE)by random number table method.The therapeutic effects of 2 groups were compared and analyzed,the liver function and QOL before and after treatment were compared between 2 groups,and the adverse reactions were recorded.All of them were followed up for 3-year to record survival rates at each time point.Results The effective rate of treatment in control group[50.00%(30/60)]was significantly lower than that in study group[76.67%(46/60)](P<0.05).After treatment,the levels of prothrombin time(PT)and albumin(ALB)in 2 groups were both decreased,but there was no significant difference between 2 groups(P>0.05).The levels of aspartate aminotransferase(AST)and alanine aminotransferase(ALT)in 2 groups were higher than those before treatment,and study group was remarkably significantly higher than control group[(244.26±112.10)U/L vs(90.25±12.45)U/L,(255.12±56.54)U/L vs(90.45±15.26)U/L.P<0.05].After treatment,KPS and QLQ-CR38 scale scores were increased,and study group was significantly higher than control group[(89.98±4.56)scores vs(82.11±3.46)scores,(72.41±4.18)scores vs(64.56±3.16)scores.P<0.05].The mean dose of normal liver,spinal cord,stomach,left kidney and right kidney in study group were significantly higher than those in control group[(19.26±5.11)Gy vs(16.26±6.15)Gy,(8.36±2.12)Gy vs(1.23±0.54)Gy,(0.52±0.18)%vs(0.31±0.12)%,(4.88±0.51)%vs(2.12±0.12)%,(8.11±9.11)%vs(4.15±1.03)%.P<0.05].There was no significant difference in incidence of adverse reactions such as gastrointestinal reaction,liver function injury,renal function injury,bone marrow suppression and peripheral neurotoxicity between 2 groups(P>0.05).In addition,the survival rates of 1-year and 2-year after operation in study group were better than in control group(86.67%vs 68.33%,71.67%vs 53.33%.P<0.05);but there was no significant difference in 3-year survival rate between 2 groups(P>0.05).Conclusion It is demonstrated that IMRT combined with TACE in patients with liver metastasis of rectal cancer could improve treatment efficiency,increase 1-year and 2-year survival rate and QOL,and have positive impact on survival prognosis of patients,but show certain damage to liver function in short term of treatment.