Zhang Qing, Fu Shen, Liu Taifu, Peng Lihua, Huang Guofeng, Lu Jiade J
Department of Radiation Oncology, 6th Hospital of Jiao Tong University, Shanghai, People's Republic of China.
Urol Oncol. 2009 Jan-Feb;27(1):14-20. doi: 10.1016/j.urolonc.2007.07.019. Epub 2008 Jan 14.
Surgery is the mainstay treatment for transitional cell carcinoma (TCC) of the ureter; however, local recurrence remains a common cause of treatment failure for locally advanced disease after surgery, and the benefit of adjuvant radiotherapy has not been completely determined. The objective of this analysis was to evaluate the outcome of postsurgical high dose radiotherapy consisting of intraoperative electron beam radiotherapy (IOERT) and external beam radiotherapy (EBRT) in locally advanced transitional cell carcinoma of the ureter.
Seventeen patients with pathologically diagnosed TCC of ureter were treated with nephroureterectomy and adjuvant radiation consisted of IOERT and EBRT according to an institutional research protocol. The dose of IOERT ranged between 10 to 20 Gy (median 14 Gy). Conventional EBRT given with the total dose ranged between 36 and 45 Gy (median 42 Gy). Chemotherapy was utilized in 10 of the 17 patients at the discretion of their primary oncologist.
The median follow-up for all patients was 48 months (range, 10-91 months). The overall survivals of the entire group of patients at 1, 3, and 5 years were 82%, 65%, and 46%, respectively. The estimated locoregional control rates at 1, 3, and 5 year were 82%, 64%, and 51%, respectively. Depth of invasion (pT), histological grade, and presence of residual disease were significant prognostic factors in univariate analysis. Multivariate analysis revealed that independent prognostic factors for survival included histological grade (grade 1 + 2 vs. grade 3 + 4; P = 0.03) and presence of residual disease after surgery (R0 vs. R1 or R2 resection; P = 0.053). Acute and long-term adverse effects rated grade 3 or higher were seen in 4 and 2 patients, respectively. No grade 5 toxicity occurred.
IOERT and EBRT following surgery produced a 51% local control and 46% overall survival rate for locally advanced TCC of ureter at 5 years of follow-up, with acceptable rates of acute and late toxicity. Adjuvant IOERT appears to permit dose escalation safely in patients who received conventional adjuvant EBRT and chemotherapy. This strategy deserves to be optimized and then tested in a prospective trial to learn if it can further improve outcome.
手术是输尿管移行细胞癌（TCC）的主要治疗方法；然而，局部复发仍是手术治疗局部晚期疾病失败的常见原因，辅助放疗的益处尚未完全确定。本分析的目的是评估术中电子束放疗（IOERT）和外照射放疗（EBRT）组成的术后高剂量放疗在局部晚期输尿管移行细胞癌中的疗效。
17例经病理诊断为输尿管TCC的患者接受了肾输尿管切除术，并根据机构研究方案接受了由IOERT和EBRT组成的辅助放疗。IOERT剂量范围为10至20 Gy（中位剂量14 Gy）。常规EBRT的总剂量范围为36至45 Gy（中位剂量42 Gy）。17例患者中有10例由其主治肿瘤内科医生酌情使用了化疗。
所有患者的中位随访时间为48个月（范围10 - 91个月）。整个患者组1年、3年和5年的总生存率分别为82%、65%和46%。1年、3年和5年的局部区域控制率估计分别为82%、64%和51%。在单因素分析中，浸润深度（pT）、组织学分级和残留疾病的存在是显著的预后因素。多因素分析显示，生存的独立预后因素包括组织学分级（1 + 2级与3 + 4级；P = 0.03）和术后残留疾病的存在（R0切除与R1或R2切除；P = 0.053）。分别有4例和2例患者出现3级或更高等级的急性和长期不良反应。未发生5级毒性反应。
术后IOERT和EBRT在5年随访时对局部晚期输尿管TCC产生了51%的局部控制率和46%的总生存率，急性和晚期毒性发生率可接受。辅助IOERT似乎允许在接受常规辅助EBRT和化疗的患者中安全地提高剂量。该策略值得优化，然后在前瞻性试验中进行测试，以了解其是否能进一步改善疗效。
