SiewertⅡ、Ⅲ型食管胃结合部腺癌术前受累野照射同期化疗可行性分析

doi:10.3760/cma.j.issn.1004-4221.2017.11.006

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摘要

目的探讨局部进展期SiewertⅡ、Ⅲ型食管胃结合部腺癌(AEG)术前受累野照射同期化疗的可行性。方法前瞻性纳入局部进展期SiewertⅡ、Ⅲ型AEG患者45例,术前行XELOX方案化疗2个周期,同期受累野IMRT 45 Gy分25次,5 次/周,6~8周后手术切除。CT模拟定位前胃体水充盈800~1000 ml,以厚度>5 mm管壁勾画GTV-t,上沿食管方向外扩2.0 cm,下沿胃体方向外扩1.5~2.0 cm,轴向外扩0.8 cm为CTV-t;GTV-nd依据CT/MRI等影像学检查结果进行勾画;CTV-nd仅包括GTV-nd和淋巴结转移受累区域;外扩0.8~1.0 cm定义为PTV。通过分析术后病理结果及放疗不良反应探讨靶区勾画方式的可行性。结果 45例患者均完成术前同期放化疗和手术治疗,完成同期2个周期化疗者39例,1个周期者6例。R0切除率为96%,pCR率为22%。肿瘤退缩分级0、1、2、3级分别10、17、15、3例。淋巴结转移率为38%(17/45),淋巴结转移度为4.33%(46/1062)。术后病理T、N降期24、26例,术后T3—T4期所占比例较疗前降低51%,术后淋巴结阳性者所占比例较疗前降低42%(P=0.000、0.000)。放射性食管炎/胃炎发生率为44%,其中1、2、3级发生率分别为18%、22%、4%,急性放射性肺炎发生率为7%,均为1、2级。围手术期治疗相关病死1例。结论 SiewertⅡ、Ⅲ型局部进展期AEG患者术前XELOX方案化疗2个周期联合45 Gy同期放疗可以实现较高的pCR率,可有效降低淋巴结转移率,实现降期并增加根治性手术的R0切除率。该

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	王军
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关键词 ：食管胃结合部腺癌/放射疗法, 食管胃结合部腺癌/化学疗法, 受累野照射, 可行性

Abstract：

Objective To analyze the feasibility of intensity-modulated radiation therapy (IMRT) with concurrent chemotherapy in patients with locally advanced Siewert type Ⅱ and Ⅲ adenocarcinoma of the esophagogastric junction (AEG). Methods A prospective study was performed on 45 patients with locally advanced Siewert type Ⅱ and Ⅲ AEG. These patients received two cycles of XELOX chemotherapy and concurrent IMRT to the involved field (45 Gy/25 f, 5 f/week) for 6 to 8 weeks before surgical resection. The patients ingested 800 to 1000 ml water to distend the stomach before computed tomography (CT) scan. The gross tumor volume of the primary tumor (GTV-t) was delineated on the CT image with a stomach wall thickness of>5 mm. GTV-t was expanded by a 2.0 cm margin along the esophagus, a 1.5-2.0 cm margin along the stomach, and a 0.8 cm margin axially outward to generate the clinical target volume of the primary tumor (CTV-t). GTV-lymph node (GTV-nd) was delineated based on CT/magnetic resonance imaging scan. CTV-nd only included GTV-nd and the involved lymph nodes. Planning target volume was generated by expanding the CTV by 0.8 to 1.0 cm. The feasibility of target volume delineation was explored by analyzing postoperative pathological examination Resutls and radiotherapy toxicities. Resutls All the 45 patients completed preoperative concurrent chemoradiotherapy and surgery, with two cycles of chemotherapy in 39 patients and one cycle in 6 patients. The rates of R0 resection and pathological complete response (pCR) were 95.6%(43/45) and 22.2%(10/45), respectively. There were 10(22.2%), 17(37.8%), 15(33.3%), and 3(6.7%) patients with tumor regression grades 0, 1, 2, 3, respectively. The rate of lymph node metastasis was 37.8%(17/45), and the lymph node ratio was 4.33%(46/1062). The postoperative pathological examination showed that T and N downstaging after surgery was observed in 24 and 26 patients, respectively;the proportions of patients with T3-T4 tumors and positive lymph nodes after surgery declined by 51.1%(P=0.000) and 42.2%(P=0.000), respectively. The overall incidence of radiation esophagitis/gastritis was 44.4%(20/45), and the incidence rates of grade 1, 2, and 3 radiation esophagitis/gastritis were 18%, 22%, and 4%, respectively. The incidence of acute radiation pneumonitis was 6.7%(3/45), all in grades 1 and 2. There was one perioperative treatment-related death. Conclutions Two cycles of XELOX chemotherapy combined with concurrent 45 Gy radiotherapy before surgery in patients with locally advanced Siewert type Ⅱ and Ⅲ AEG can achieve a relatively high pCR rate, effectively reduce the lymph node metastasis rate, achieve downstaging, and increase R0 resection rate. This regimen has many good advantages, including low incidence of acute toxicities, good tolerability, and acceptable rate of perioperative treatment-related deaths. The target volume delineation involving metastatic lymph nodes is feasible.

Key words： Esophagogastric junction adenocarcinoma/radiotherapy Esophagogastric junction adenocarcinoma/chemotherapy Involved-field irradiation,feasibility

收稿日期: 2017-02-24

基金资助:

河北省医学适用技术跟踪项目(GL201633);2016年度中国癌症基金会北京希望马拉松基金(LC2016W10)

引用本文:

王军,赵群,黄欣等. SiewertⅡ、Ⅲ型食管胃结合部腺癌术前受累野照射同期化疗可行性分析[J]. 中华放射肿瘤学杂志, 2017, 26(11): 1269-1275.

Wang Jun,Zhao Qun,Huang Xin et al. Feasibility of intensity-modulated radiation therapy with concurrent chemotherapy in patients with Siewert type Ⅱ and Ⅲ adenocarcinoma of the esophagogastric junction before surgery[J]. Chinese Journal of Radiation Oncology, 2017, 26(11): 1269-1275.

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