血液系统恶性肿瘤合并中枢神经系统侵犯行干细胞移植前行颅脊髓照射：光子或质子治疗后的有效性和毒性。
Craniospinal irradiation prior to stem cell transplant for hematologic malignancies with CNS involvement: Effectiveness and toxicity after photon or proton treatment.
机构信息
Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
Department of University of Tennessee Health Science Center, Memphis, Tennessee.
出版信息
Pract Radiat Oncol. 2017 Nov-Dec;7(6):e401-e408. doi: 10.1016/j.prro.2017.05.002. Epub 2017 May 10.
PURPOSE/OBJECTIVE(S): Craniospinal irradiation (CSI) improves local control of leukemia/lymphoma with central nervous system (CNS) involvement; however, for adult patients anticipating stem cell transplant (SCT), cumulative treatment toxicity is a major concern. We evaluated toxicities and outcomes for patients receiving proton or photon CSI before SCT.
METHODS AND MATERIALS
We identified 37 consecutive leukemia/lymphoma patients with CNS involvement who received CSI before SCT at our institution. Photon versus proton toxicities during CSI, transplant, and through 100 days posttransplant were compared using Fisher exact and Wilcoxon rank sum tests. Long-term neurotoxicity, disease response, and overall survival were analyzed.
RESULTS
Thirty-seven patients (23 photon, 14 proton) underwent CSI for CNS involvement of acute lymphoblastic leukemia (49%), acute myeloblastic leukemia (22%), chronic lymphocytic leukemia (3%), chronic myelocytic leukemia (14%), lymphoma (11%), and myeloma (3%). CSI was used for consolidation (30 patients, 81%) and gross disease treatment (7 patients, 19%). Median radiation dose (interquartile range) was 24 Gy (23.4-24) for photons and 21.8 Gy (21.3-23.6) for protons (P = .03). Proton CSI was associated with lower rates of Radiation Therapy Oncology Group grade 1-3 mucositis during CSI (7% vs 44%, P = .03): 1 grade 3 with protons versus 5 grade 1, 3 grade 2, and 2 grade 3 with photons. During CSI, other toxicities (infection, gastrointestinal symptoms) did not differ. Allogeneic stem cell transplant (SCT) was used in 95% of patients, with 53% of patients in remission before SCT. Myeloablative conditioning was used for 76%. During SCT admission and 100 days post-SCT, toxicities did not differ by CSI technique. Successful engraftment occurred in 95% of patients (P = .67). Progression or death occurred for 47% of patients, with only 1 CNS relapse.
CONCLUSION
In our cohort, CSI offered excellent local control for CNS-involved hematologic malignancies in the pre-SCT setting. Acute mucositis occurred less frequently with proton CSI with comparable peritransplant/long-term toxicity profile, suggesting the need to further explore the benefit/toxicity profile of this technique.
目的
颅脊髓照射（CSI）可提高中枢神经系统（CNS）受累白血病/淋巴瘤的局部控制率；然而，对于接受干细胞移植（SCT）的成年患者，累积治疗毒性是一个主要关注点。我们评估了在 SCT 前接受质子或光子 CSI 的患者的毒性和结局。
方法和材料
我们在本机构确定了 37 例连续 CNS 受累白血病/淋巴瘤患者，他们在 SCT 前接受了 CSI。使用 Fisher 精确检验和 Wilcoxon 秩和检验比较 CSI、移植期间和移植后 100 天的光子与质子毒性。分析长期神经毒性、疾病反应和总生存率。
结果
37 例患者（23 例光子，14 例质子）因急性淋巴细胞白血病（49%）、急性髓细胞白血病（22%）、慢性淋巴细胞白血病（3%）、慢性髓细胞白血病（14%）、淋巴瘤（11%）和骨髓瘤（3%）接受了 CSI。CSI 用于巩固治疗（30 例，81%）和大体疾病治疗（7 例，19%）。光子的中位放疗剂量（四分位间距）为 24 Gy（23.4-24），质子为 21.8 Gy（21.3-23.6）（P =.03）。质子 CSI 与 CSI 期间较低的放射治疗肿瘤学组 1-3 级粘膜炎发生率相关（7%对 44%，P =.03）：质子有 1 例 3 级，光子有 5 例 1 级，3 例 2 级和 2 例 3 级。在 CSI 期间，其他毒性（感染、胃肠道症状）没有差异。95%的患者接受了同种异体干细胞移植（SCT），53%的患者在 SCT 前处于缓解期。76%的患者采用了清髓性预处理。在 SCT 住院期间和 SCT 后 100 天，CSI 技术的毒性没有差异。95%的患者成功植入（P =.67）。47%的患者发生进展或死亡，仅有 1 例 CNS 复发。
结论
在我们的队列中，CSI 在 SCT 前为 CNS 受累血液系统恶性肿瘤提供了极好的局部控制。质子 CSI 发生急性粘膜炎的频率较低，移植期/长期毒性谱相似，表明需要进一步探索该技术的获益/毒性谱。
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