放疗的晚期后遗症——放射肿瘤学中技术和理念创新的影响。
Late Sequelae of Radiotherapy—The Effect of Technical and Conceptual Innovations in Radiation Oncology.
出版信息
Dtsch Arztebl Int. 2021 Mar 26;118(12):205-211. doi: 10.3238/arztebl.m2021.0024.
BACKGROUND
Approximately half of all patients with tumors need radiotherapy. Long-term survivors may suffer from late sequelae of the treatment. The existing radiotherapeutic techniques are being refined so that radiation can be applied more precisely, with the goal of limiting the radiation exposure of normal tissue and reducing late sequelae.
METHODS
This review is based on the findings of a selective search in PubMed for publications on late sequelae of conventional percutaneous radiotherapy, January 2000 to May 2020. Late sequelae affecting the central nervous system, lungs, and heart and the development of second tumors are presented, and radiobiological mechanisms and the relevant technical and conceptual considerations are discussed.
RESULTS
The current standard of treatment involves the use of linear accelerators, intensity-modulated radiotherapy (IMRT), image-guided and respiratory-gated radiotherapy, and the integration of positron emission tomography combined with computed tomography (PET-CT) in radiation treatment planning. Cardiotoxicity has been reduced with regard to the risk of coronary heart disease after radiotherapy for Hodgkin's lymphoma (hazard ratio [HR] 0.44 [0.23; 0.85]). It was also found that the rate of radiation- induced pneumonitis dropped from 7.9% with conformal treatment to 3.5% with IMRT in a phase III lung cancer trial. It is hoped that neurocognitive functional impairment will be reduced by hippocampal avoidance in modern treatment planning: an initial phase III trial yielded a hazard ratio of 0.74 [0.58; 0.94]. It is estimated that 8% of second solid tumors in adults are induced by radiotherapy (3 additional tumors per 1000 patients at 10 years).
CONCLUSION
Special challenges for research in this field arise from the long latency of radiation sequelae and the need for largescale, well-documented patient collectives in order to discern dose-effect relationships, and take account of cofactors, when the overall number of events is small. It is hoped that further technical and conceptual advances will be made in the areas of adaptive radiotherapy, proton and heavy-ion therapy, and personalized therapy.
背景
大约一半的肿瘤患者需要接受放疗。长期存活者可能会遭受治疗的晚期后遗症。现有的放射治疗技术正在不断完善，以便更精确地应用放射线，从而限制正常组织的辐射暴露并减少晚期后遗症。
方法
本综述基于对 2000 年 1 月至 2020 年 5 月在 PubMed 上发表的关于常规经皮放疗的晚期后遗症的选择性搜索结果。介绍了影响中枢神经系统、肺和心脏的晚期后遗症以及第二肿瘤的发生，并讨论了放射生物学机制以及相关的技术和概念性考虑。
结果
目前的治疗标准包括使用线性加速器、强度调制放疗（IMRT）、图像引导和呼吸门控放疗，以及将正电子发射断层扫描与计算机断层扫描（PET-CT）相结合用于放射治疗计划。霍奇金淋巴瘤放疗后冠心病风险降低（危险比 [HR] 0.44 [0.23；0.85]），降低了心脏毒性。在一项 III 期肺癌试验中，与适形治疗相比，IMRT 使放射性肺炎的发生率从 7.9%降至 3.5%。人们希望通过现代治疗计划中的海马回避来减少神经认知功能障碍：一项初步的 III 期试验得出的危险比为 0.74 [0.58；0.94]。据估计，成人中 8%的第二实体肿瘤是放疗诱导的（10 年内每 1000 例患者增加 3 例肿瘤）。
结论
该领域研究的特殊挑战源于辐射后遗症的潜伏期长，需要大规模、有记录的患者群体，以便在事件总数较少的情况下辨别剂量-效应关系，并考虑协变量。希望在自适应放疗、质子和重离子治疗以及个体化治疗等领域取得进一步的技术和概念进展。
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