Mayer Arpád, Nemeskéri Csaba, Petneházi Csaba, Borgulya Gábor, Varga Szilvia, Naszály Attila
Center of Oncoradiology, Uzsoki Hospital, Budapest, Hungary.
Strahlenther Onkol. 2004 Apr;180(4):209-15. doi: 10.1007/s00066-004-1122-8.
Comprehensive literature on cervical cancer demonstrates, even today, the need for optimization of the timing of external-beam radiotherapy (EBRT) and high-dose-rate brachytherapy (HDR-BT) in the treatment of stage IIA/B-IIIB cervical carcinoma.
210 patients with carcinoma of the cervix were treated in the Municipal Center of Oncoradiology between January 1991 and December 1996 (FIGO IIA: n = 10, FIGO IIB: n = 113, and FIGO IIIB: n = 87). Two regimens were compared: sequential radiation therapy (SRT) with 4 x 8 Gy HDR-BT to point A followed by EBRT, and continuous radiation therapy (CRT) in which 5 x 6 Gy HDR-BT to point A, one session per week, was integrated into the EBRT. A total dose of 68-70 Gy to point A and 52-54 Gy to point B was given in EBRT with SRT, five fractions per week were applied. Four fractions per week were applied in CRT, i. e., no EBRT was performed on the day of HDR-BT. Total doses to points A and B were identical in both regimens. Overall treatment time (OTT) amounted to 56 days for SRT and 35 days for CRT. Median follow-up time was 3.4 (2.5-4.2) years.
Progression-free 5-year-survival (PFS) was 71% in the CRT and 56% in the SRT group. Nevertheless, this difference was not statistically significant (p = 1.00), and the same was found in a subgroup analysis of the different tumor stages, showing, however, an unequivocal trend. Late bladder and rectal injuries occurred in 13% and 25%, respectively. Late rectal injuries were significantly more frequent with SRT than CRT (35 patients in the SRT and 18 patients in the CRT group; p = 0.037). This was due to the higher doses per fraction of HDR-BT in the SRT group. No difference was found regarding late bladder injuries (p = 0.837).
For the patients included in this study, no advantage has been found so far in using CRT, i. e., shortening the OTT by weekly integration of HDR-BT into EBRT. Nevertheless, an obvious trend exists. The dose of 8 Gy per fraction of HDR-BT in the SRT regimen was obviously too high. To achieve a significant improvement in local control and disease-free survival (DFS) as well as overall survival (OS), the combination with modern chemotherapy regimens and regional deep hyperthermia may rather be the treatment option.
关于宫颈癌的综合文献表明，即使在今天，在IIA/B-IIIB期宫颈癌的治疗中，仍需要优化外照射放疗（EBRT）和高剂量率近距离放疗（HDR-BT）的时间安排。
1991年1月至1996年12月期间，210例宫颈癌患者在市肿瘤放射治疗中心接受治疗（国际妇产科联盟（FIGO）IIA期：n = 10，FIGO IIB期：n = 113，FIGO IIIB期：n = 87）。比较了两种治疗方案：序贯放疗（SRT），即先对A点进行4次8 Gy的HDR-BT，然后进行EBRT；以及连续放疗（CRT），即在EBRT中每周一次对A点进行5次6 Gy的HDR-BT。SRT的EBRT中，A点总剂量为68 - 70 Gy，B点总剂量为52 - 54 Gy，每周照射5次。CRT每周照射4次，即在HDR-BT当天不进行EBRT。两种方案中A点和B点的总剂量相同。SRT的总治疗时间（OTT）为56天，CRT为35天。中位随访时间为3.4（2.5 - 4.2）年。
CRT组的5年无进展生存率（PFS）为71%，SRT组为56%。然而，这种差异无统计学意义（p = 1.00），在不同肿瘤分期的亚组分析中也得到相同结果，不过显示出明确的趋势。晚期膀胱和直肠损伤分别发生在13%和25%的患者中。SRT组晚期直肠损伤明显比CRT组更频繁（SRT组35例，CRT组18例；p = 0.037）。这是由于SRT组HDR-BT每次分割剂量更高。晚期膀胱损伤方面未发现差异（p = 0.837）。
对于本研究纳入的患者，目前尚未发现将HDR-BT每周整合到EBRT中以缩短OTT的CRT方案具有优势。然而，存在明显趋势。SRT方案中HDR-BT每次8 Gy的剂量明显过高。为了在局部控制、无病生存期（DFS）以及总生存期（OS）方面取得显著改善，联合现代化疗方案和区域深部热疗可能是更好的治疗选择。
