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Early Clinical Results of Whole Breast Irradiation with Helical Tomotherapy or Fixed-field Intensity-modulated Radiation Therapy
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摘要:
目的 研究早期乳腺癌保乳术后应用螺旋断层调强放疗(helical tomotherapy, HT)和固定野调强放疗(fixed-field intensity-modulated radiotherapy, FF-IMRT)的近期疗效和早期临床反应。 方法 2012年9月至2013年3月本院使用HT(HT组)和FF-IMRT(FF-IMRT组)进行保乳术后全乳放疗的早期乳腺癌患者共24例, 每组12例, 术后病理分期0~ⅡB期, 全乳放疗剂量46~50 Gy/23~25次。其中接受化疗者11例(45.8%), 接受内分泌治疗者18例(75%)。对两组靶区及危及器官剂量分布进行评估, 对放疗毒性反应及美容效果进行评价。 结果 与FF-IMRT组相比, HT组的计划靶区(planning target volume, PTV)105%、PTV110%高剂量区减少(P=0.000, P=0.023), 靶区的均匀性和适形度改善(P=0.003, P=0.002)。患侧肺的V5、V20、Dmean(P=0.002, P=0.001, P=0.000), 双肺的V5、V20、Dmean(P=0.010, P=0.002, P=0.009)及心脏的V5、V20(P=0.033, P=0.030)等受量降低。HT组出现Ⅰ、Ⅱ级放射性皮炎者分别有10例(83.3%)、2例(16.7%), FF-IMRT组出现Ⅰ、Ⅱ级放射性皮炎者分别有11例(91.7%)、1例(8.3%); 所有患者均未出现放射性肺炎。HT组患者美容效果为满意者12例(100%), FF-IMRT组美容效果为满意者11例(91.7%)。两组患者的近期不良反应和美容效果评价差异均无统计学意义。 结论 应用HT与FF-IMRT技术进行保乳术后全乳放疗, 可获得满意的近期临床效果, 长期治疗效果还有待进一步随诊观察。 Abstract:Objective To observe the early therapeutic effects, toxicities and cosmetic results of whole breast radiotherapy with helical tomotherapy (HT) or fixed-field intensity-modulated radiotherapy (FF-IMRT) in patients with early-stage breast cancer after breast-conserving surgery. Methods From September 2012 to March 2013, 24 patients with stage 0-ⅡB breast cancer after breast-conserving surgery were observed. HT and FF-IMRT were applied in 12 patients after breast-conserving surgery, respectively. The radiotherapy schedule was 46-50 Gy/23-25 fractions to the whole breast with a boost to the tumor bed to 60 Gy.Eleven patients (45.8%) received chemotherapy and 18 patients(75%)received endocrine therapy.The targets and the organs-at-risk were evaluated. Toxic and cosmetic results were observed. Results Planning target volume(PTV)105% and PTV 110% were significantly less for HT than FF-IMRT (P=0.000, P=0.023). Homogeneity index (P=0.003) and conformity index(P=0.002) were better for HT than FF-IMRT. HT achieved significant decrease in 5 Gy (P=0.002), 20 Gy (P=0.001), and mean dose (P=0.000) for ipsilateral lung. Similar results were obtained for both lungs and heart(all P < 0.05). In the HT group, 10 patients developed grade 1 radiation dermatitis and 2 developed grade 2 radiation dermatitis; in the FF-IMRT group, 11 developed grade 1 radiation dermatitis and 1 developed grade 2 radiation dermatitis. No radiation pneumonitis was observed in all patients. Twelve patients in HT group and 11 patients in FF-IMRT group developed satisfactory cosmetic results (P > 0.05). Conclusions Whole breast radiotherapy with HT or FF-IMRT for patients with early-stage breast cancer after breast-conserving surgery can achieve good therapeutic effectiveness, with satisfactory cosmetic results and acceptable toxicities, although the long-term clinical benefits need further observations. -
表 1 患者一般临床资料
组别 中位年龄
(岁)病灶所在乳腺[例(%)] TNM分期[例(%)] 病理类型[例(%)] 腋窝淋巴结[例(%)] 内分泌治疗[例(%)] 放化疗时序[例(%)] 左侧 右侧 0 1A ⅡA ⅡB 浸润性导管癌 黏液腺癌 浸润性导管癌
合并导管内癌其他浸润性癌 导管内癌 未手术 前哨淋巴结
活检清扫术 有 无 单纯放疗 化疗+放疗 放疗+化疗 化疗+放疗+化疗 FF-IMRT组(n=12) 39(23~53) 8(66.7) 4(33.3) 2(16.7) 7(58.3) 2(16.7) 1(8.3) 5(41.7) 1(8.3) 3(25) 1(8.3) 2(16.7) 1(8.3) 3(25) 8(66.7) 9(75) 3(25) 8(66.7) 2(16.7) 2(16.7) 0 HT组(n=12) 46(38~58) 6(50) 6(50) 4(33.3) 7(58.3) 0 1(8.3) 5(41.7) 1(8.3) 2(16.7) 1(8.3) 3(25) 2(16.7) 3(25) 7(58.3) 9(75) 3(25) 5(41.7) 0 6(50) 1(8.3) 所有患者(n=24) 43(23~58) 14(58.7) 10(41.3) 6(25) 14(58.3) 2(8.3) 2(8.3) 10(41.7) 2(8.3) 5(20.8) 2(8.3) 5(20.8) 3(12.5) 6(25) 15(62.5) 18(75) 6(25) 13(54.2) 2(8.3) 8(33.3) 1(4) 
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表 2 两组患者剂量分布比较(x±s)
组别 PTV(cm3) PTV95%(%) PTV100%(%) PTV105%(%) PTV110%(%) Dmean(Gy) Dmax(Gy) HI CI FF-IMRT组 530.53±429.41 98.92±0.89 93.70±2.91 71.83±8.73 8.36±10.51 49.97±2.11 52.41±2.17 0.13±0.01 0.76±0.06 HT组 544.02±112.96 98.85±0.65 95.47±0.23 43.8±15.77 0.53±0.64 48.73±1.61 52.47±1.79 0.11±0.02 0.84±0.03 t值 -0.092 0.168 -2.06 5.35 2.65 1.49 -0.065 3.72 -4.09 P值 0.928 0.870 0.060 0.000 0.023 0.164 0.950 0.003 0.002 PTV：计划靶区；Dmean：平均剂量；Dmax：最大剂量；HI：均匀性指数；CI：适形度指数
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表 3 两组患者正常器官受量比较(x±s)
部位 V5(%) V20(%) Dmean(Gy) Dmax(Gy) 患侧肺 FF-IMRT组 22.77±4.93 12.35±3.22 6.79±1.57 49.04±2.55 HT组 16.12±2.75 7.30±1.46 4.34±0.64 49.05±1.75 t值 3.970 4.750 5.010 -0.007 P值 0.002 0.001 0.000 0.994 双肺 FF-IMRT组 11.28±3.27 6.12±1.98 3.34±0.95 49.05±2.55 HT组 8.20±1.50 3.68±0.66 2.50±0.32 49.05±1.75 t值 3.100 4.190 3.160 -0.007 P值 0.010 0.002 0.009 0.994 心脏 FF-IMRT组 9.14±3.53 3.88±2.15 3.10±1.23 47.38±1.52 HT组 4.48±1.93 0.94±0.48 1.83±0.42 45.02±1.72 t值 3.190 3.310 2.360 2.710 P值 0.033 0.030 0.078 0.054 健侧乳腺 FF-IMRT组 - - 0.28±0.12 1.77±0.54 HT组 - - 1.31±0.39 4.10±1.23 t值 - - -7.720 -5.200 P值 - - 0.000 0.000 健侧肺 FF-IMRT组 - - 0.11±0.10 1.75±0.73 HT组 - - 0.61±0.17 4.10±1.23 t值 - - -8.090 -7.250 P值 - - 0.000 0.000
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