Division of Interventional Radiology, Stanford University School of Medicine, Stanford, California 94305-5642, USA.
Int J Radiat Oncol Biol Phys. 2013 Oct 1;87(2):323-9. doi: 10.1016/j.ijrobp.2013.05.041. Epub 2013 Jul 9.
Previous external beam radiation therapy (EBRT) is theoretically contraindicated for yttrium-90 ((90)Y) radioembolization (RE) because the liver has a lifetime tolerance to radiation before becoming vulnerable to radiation-induced liver disease. We analyzed the safety of RE as salvage treatment in patients who had previously undergone EBRT.
Between June 2004 and December 2010, a total of 31 patients who had previously undergone EBRT were treated with RE. Three-dimensional treatment planning with dose-volume histogram (DVH) analysis of the liver was used to calculate the EBRT liver dose. Liver-related toxicities including RE-induced liver disease (REILD) were reviewed and classified according to Common Terminology Criteria for Adverse Events version 4.02.
The mean EBRT and RE liver doses were 4.40 Gy (range, 0-23.13 Gy) and 57.9 Gy (range, 27.0-125.9 Gy), respectively. Patients who experienced hepatotoxicity (≥grade2; n=12) had higher EBRT mean liver doses (7.96 ± 8.55 Gy vs 1.62 ± 3.39 Gy; P=.037), the only independent predictor in multivariate analysis. DVH analysis showed that the fraction of liver exposed to ≥30 Gy (V30) was the strongest predictor of hepatotoxicity (10.14% ± 12.75% vs 0.84% ± 3.24%; P=.006). All patients with V30 >13% experienced hepatotoxicity. Fatal REILD (n=2) occurred at the 2 highest EBRT mean liver doses (20.9 Gy and 23.1 Gy) but also at the highest cumulative liver doses (91.8 Gy and 149 Gy).
Prior exposure of the liver to EBRT may lead to increased liver toxicity after RE treatment, depending on fractional liver exposure and dose level. The V30 was the strongest predictor of toxicity. RE appears to be safe for the treatment of hepatic malignancies only in patients who have had limited hepatic exposure to prior EBRT.
理论上，钇-90((90)Y)放射性栓塞术(RE)不适合之前接受过外部束放射治疗(EBRT)的患者，因为肝脏在易发生放射性肝损伤之前，有一个终身的辐射耐受量。我们分析了之前接受过 EBRT 的患者接受 RE 作为挽救治疗的安全性。
在 2004 年 6 月至 2010 年 12 月期间，共有 31 名之前接受过 EBRT 的患者接受了 RE 治疗。使用三维治疗计划和剂量体积直方图(DVH)分析肝脏，以计算 EBRT 肝脏剂量。根据不良事件通用术语标准 4.02 版，回顾并分类了与肝脏相关的毒性，包括 REILD。
EBRT 和 RE 肝脏剂量的平均值分别为 4.40 Gy(范围，0-23.13 Gy)和 57.9 Gy(范围，27.0-125.9 Gy)。发生肝毒性(≥2 级;n=12)的患者 EBRT 肝脏剂量更高(7.96±8.55 Gy 比 1.62±3.39 Gy;p=0.037)，这是多变量分析中的唯一独立预测因子。DVH 分析表明，暴露于≥30 Gy 的肝脏分数(V30)是肝毒性的最强预测因子(10.14%±12.75%比 0.84%±3.24%;p=0.006)。所有 V30>13%的患者均发生肝毒性。2 例致命性 REILD(分别为 20.9 Gy 和 23.1 Gy)发生在 EBRT 肝脏剂量最高的情况下，但也发生在累积肝脏剂量最高的情况下(91.8 Gy 和 149 Gy)。
之前肝脏接受 EBRT 照射可能会导致 RE 治疗后肝脏毒性增加，具体取决于肝部分暴露和剂量水平。V30 是毒性的最强预测因子。只有在之前 EBRT 对肝脏暴露有限的患者中，RE 似乎才是治疗肝恶性肿瘤的安全方法。
