Zelefsky M J, Nori D, Shiu M H, Brennan M F
Memorial Sloan-Kettering Cancer Center, New York, NY 10021.
Int J Radiat Oncol Biol Phys. 1990 Oct;19(4):913-8. doi: 10.1016/0360-3016(90)90012-9.
While there is debate in the literature concerning the tolerance of neurovascular structures to external beam radiation, the tolerance of these tissues to interstitial radiation has never been established. To evaluate the dose of radiation and its effect on early and late toxicity of neurovascular structures, a retrospective review of our experience was undertaken. Between 1975 and 1987, 299 patients with extremity sarcomas underwent limb-sparing surgery and tumor bed Iridium-192 interstitial implantation at Memorial Sloan-Kettering Cancer Center. Forty-five patients (15%) of this group were found to have locally advanced tumors involving major neurovascular structures. Of these patients, 64% had high grade lesions. Eleven percent had evidence of gross residual disease on these structures, and an additional 58% had microscopic residual disease at or close to the margins of resection. After loading catheters were placed directly upon the neurovascular structures in the exposed tumor bed and a median dose of 4400 cGy was delivered to the target volume. Eight patients had previous radiation to the treated field and 13 patients received postoperative radiation. With a median follow-up of 4 years, the 5-year actuarial disease-free survival was 69% and the 5-year actuarial freedom from in-field failure was 79%. The 5-year actuarial incidence of distant metastases was 30%. Eighty-four percent of the patients maintained long-term preservation of limb function without the need for amputation. Four patients (9%) ultimately developed evidence of radiation neuritis 6-20 months post therapy. All four patients had received additional radiation with cumulative doses exceeding 9000 cGy to the neurovascular bundle. We conclude that combined surgical resection and interstitial radiation for locally advanced sarcomas with neurovascular involvement can provide excellent local control with preservation of limb and neurovascular function without significant toxicity.
虽然文献中对于神经血管结构对体外束辐射的耐受性存在争议，但这些组织对间质辐射的耐受性尚未确定。为了评估辐射剂量及其对神经血管结构早期和晚期毒性的影响，我们对自身经验进行了回顾性研究。1975年至1987年间，299例肢体肉瘤患者在纪念斯隆凯特琳癌症中心接受了保肢手术及肿瘤床铱-192间质植入。该组中有45例患者（15%）被发现局部晚期肿瘤累及主要神经血管结构。在这些患者中，64%为高级别病变。11%的患者在这些结构上有肉眼可见的残留病灶，另外58%在切除边缘或附近有镜下残留病灶。将加载导管直接置于暴露肿瘤床的神经血管结构上，靶体积接受的中位剂量为4400 cGy。8例患者先前已接受过治疗区域的放疗，13例患者接受了术后放疗。中位随访4年，5年无病生存率为69%，5年局部无复发生存率为79%。远处转移的5年精算发生率为30%。84%的患者长期保持肢体功能，无需截肢。4例患者（9%）在治疗后6 - 20个月最终出现放射性神经炎的证据。所有4例患者均接受了额外放疗，神经血管束累积剂量超过9000 cGy。我们得出结论，对于累及神经血管的局部晚期肉瘤，联合手术切除和间质放疗可提供良好的局部控制，同时保留肢体和神经血管功能，且无明显毒性。
