乳腺癌改良根治术后内乳电子线大分割照射剂量学评估和急性不良反应、近期疗效

doi:10.3760/cma.j.cn113030-20210401-00136

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摘要目的探讨乳腺癌改良根治术后内乳电子线大分割照射剂量学特征及急性不良反应、近期疗效。方法选择2018—2020年收治 155例乳腺癌改良根治术后患者,Ⅲ期 137例(88.4%),Ⅱ期 18例(11.6%)。所有患者均接受规范的化疗、内分泌治疗和抗Her2靶向治疗。按第1、2、3肋间将内乳临床靶体积(CTVim)分为3个亚区(CTVim1、CTVim2、CTVim3),同时勾画锁骨上下区形成计划靶体积(PTVsc)。胸壁CTV和CTVim采用 6~15MeV电子线照射43.5Gy分15次,3周完成。PTVsc采用6MV X线二维放疗或三维放疗43.5Gy分15次,3周完成。评估内乳、PTVsc及肺、心脏、左前降支(LAD)和右冠脉(RA)的剂量学特征,分析急性不良反应、近期疗效。结果 CTVim的 Dmean为(43.3±2.6)Gy,D95%为(30.5±8.3)Gy,V90%为(85.0±10.5)%,V80%为(91.0±7.4)%。CTVim1的相应参数值显著低于CTVim2和CTVim3(均 P<0.001)。体质指数对内乳剂量无影响(P>0.05)。三维放疗比二维放疗技术显著增加CTVim的 Dmean[(43.4±2.6)Gy∶(41.4±2.3)Gy,P=0.021]和PTVsc的热点体积[V110%:(26.7±17.5) cm³∶(12.5±8.4) cm³,P=0.018;V120%:(6.1±5.3) cm³∶(2.0±2.6) cm³,P=0.023]。患肺 Dmean为(9.8±1.9)Gy,V20Gy为(19.7±4.7)%。全组患者心脏 Dmean为(3.3±1.7)Gy,左乳腺癌为(4.7±1.4)Gy,右乳腺癌为(2.6±1.2)Gy。左乳腺癌患者LADDmean为(13.9±4.9)Gy,右乳腺癌患者RADmean为(7.5±3.7)Gy。≥2级急性放射性皮炎、放射性食管炎、放射性肺炎发生率分别为19.3%、4.5%、2.6%。中位随访20.5个月(9.9~41.8个月),2例胸壁复发,2例区域淋巴结复发,6例远处转移,死亡 1例。结论乳腺癌改良根治术后内乳电子线大分割照射时肺、心、冠脉剂量较低,患者急性不良反应轻且发生率低。但第1肋间的内乳剂量偏低,虽然近期随访疗效较好但需要长期随访。

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	张媛媛
	张婷婷
	唐玉
	景灏
	房辉
	宋永文
	陈波
	唐源
	金晶
	刘跃平
	卢宁宁
	亓姝楠
	李宁
	李晔雄
	王淑莲

关键词 ：乳腺肿瘤/改良根治术, 内乳/术后电子线照射,大分割, 二维放射疗法, 三维放射疗法, 治疗结果

Abstract：Objective To investigate the dosimetric characteristics, acute toxicity and short-term efficacy of postmastectomy hypofractionated internal mammary (IM) chain irradiation with electrons in patients with high-risk breast cancer. Methods A total of 155 patients with breast cancer who underwent modified mastectomy between November 2018 and January 2020 were selected. Among them, 137(88.4%) patients were classified as stage Ⅲ and 18(11.6%) as stage Ⅱ. All patients received standard chemotherapy, endocrine therapy and anti-Her2 targeted therapy. CTVim was divided into three subregions:CTVim1, CTVim2 and CTVim3, which represented the first, second and third intercostal IM, respectively. The planning target volume of subraclavicular region (PTVsc) was delineated. CTVcw and CTVim were irradiated with 6-15MeV electron at 43.5Gy in 15 fractions over 3 weeks. Moreover, PTVsc was irradiated with 6MV X-ray at 43.5Gy in 15 fractions over 3 weeks using two-dimensional radiotherapy (2DRT) or three-dimensional radiotherapy (3DRT). The dosimetric characteristics of CTVim, PTVsc, lung, heart, left anterior descending coronary artery (LAD) and right coronary artery (RA) were evaluated, and the acute toxicity and short-term efficacy were analyzed. Results The mean dose (Dmean) of CTVim was (43.3±2.6)Gy, D95% was (30.5±8.3)Gy, V90% was (85.0±10.5)% and V80% was (91.0±7.4)%, respectively. The corresponding parameters of CTVim1 were significantly lower than those of CTVim2 and CTVim3(allP<0.001). Body mass index exerted no significant effect on IM dose (P>0.05). Compared with 2DRT, 3DRT for SC significantly increased theDmean of CTVim[(43.4±2.6)Gy vs.(41.4±2.3)Gy,P=0.021], and the hot spot within PTVsc[V110%:(26.7±17.5) cm³ vs.(12.5±8.4) cm³,P=0.018; V120%:(6.1±5.3) cm³ vs.(2.0±2.6) cm³,P=0.023]. TheDmean of the ipsilateral lung was (9.8±1.9)Gy, and V20Gy was (19.7±4.7)%. TheDmean of heart was (3.3±1.7)Gy in the whole group,(4.7±1.4)Gy for the left-sided breast cancer and (2.6±1.2)Gy for the right-sided breast cancer, respectively. TheDmean of LAD for the left-sided breast cancer was (13.9±4.9)Gy. TheDmean of RA for the right-sided breast cancer was (7.5±3.7)Gy. The incidence rates of ≥ grade 2 acute radiation dermatitis, esophagitis and pneumonitis were 19.3%, 4.5% and 2.6%, respectively. With a median follow-up time of 20.5 months (range:9.9-41.8 months), 2 cases of chest wall recurrence, 2 regional lymph node recurrence, 6distant metastases and 1death were reported. Conclusions When hypofractionated internal mammary chain is irradiated by electrons after mastectomy, the doses to the lung, heart and coronary artery are low, and the acute toxicities are mild. However, the dose to CTVim1 is inadequate. Although short-term efficacy is high, long-term follow-up is warranted.

Key words： Breast neoplasm/mastectomy Internal mammary chain/postoperative electron irradiation, hypofractionation Two-dimensional radiotherapy Three-dimensional radiotherapy Treatment outcome

收稿日期: 2021-04-01

基金资助:中国癌症基金会北京马拉松院所联合攻关课题(LC2019L02)

通讯作者: 王淑莲,Email:wsl20040118@yahoo.com

引用本文:

张媛媛,张婷婷,唐玉等. 乳腺癌改良根治术后内乳电子线大分割照射剂量学评估和急性不良反应、近期疗效[J]. 中华放射肿瘤学杂志, 2021, 30(11): 1122-1128.

Zhang Yuanyuan,Zhang Tingting,Tang Yu et al. Dosimetric evaluation, acute toxicity and short-term efficacy of postmastectomy hypofractionated internal mammary chain irradiation with electrons[J]. Chinese Journal of Radiation Oncology, 2021, 30(11): 1122-1128.

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http://journal12.magtechjournal.com/Jweb_fszlx/CN/10.3760/cma.j.cn113030-20210401-00136 或 http://journal12.magtechjournal.com/Jweb_fszlx/CN/Y2021/V30/I11/1122

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