局部晚期宫颈癌患者晚期胃肠道并发症的严重程度和持续性：来自 EMBRACE-I 的经验教训及对未来的启示。
Severity and Persistency of Late Gastrointestinal Morbidity in Locally Advanced Cervical Cancer: Lessons Learned From EMBRACE-I and Implications for the Future.
机构信息
Department of Oncology, Aarhus University Hospital, Aarhus, Denmark.
Department of Oncology, Aarhus University Hospital, Aarhus, Denmark.
出版信息
Int J Radiat Oncol Biol Phys. 2022 Mar 1;112(3):681-693. doi: 10.1016/j.ijrobp.2021.09.055. Epub 2021 Oct 20.
PURPOSE
The purpose was to evaluate patient- and treatment-related risk factors for physician-assessed and patient-reported gastrointestinal (GI) symptoms after radio(chemo)therapy and image guided adaptive brachytherapy in locally advanced cervical cancer.
METHODS AND MATERIALS
Of 1416 patients from the EMBRACE-I study, 1199 and 1002 were prospectively evaluated using physician-assessed (Common Terminology Criteria for Adverse Events [CTCAE]) and patient-reported (European Organization for Research and Treatment of Cancer [EORTC]) GI symptoms, respectively. CTCAE severe grade (grade [G] ≥3) events were pooled according to the location in the GI tract (anus/rectum, sigmoid, and colon/small bowel). CTCAE G ≥2 and EORTC "very much" and "quite a bit" plus "very much" scores (≥ "quite a bit") were analyzed for individual symptoms with Cox regression. Logistic regression was used for persistent G ≥1 and EORTC ≥ "quite a bit" symptoms, defined if present in at least half of follow-ups.
RESULTS
The incidence of G ≥3 events was 2.8%, 1.8%, and 2.3% for G ≥3 anus/rectum, sigmoid, and colon/small bowel events, respectively. Among G ≥2 symptoms, diarrhea and flatulence were the most prevalent (8.5% and 9.9%, respectively). Among patient-related factors, baseline morbidity, increasing age, smoking status, and low body mass index were associated with GI symptoms to varying degrees. Among treatment-related factors, rectum D and the International Commission on Radiation Units and Measurements recto-vaginal reference point (ICRU RV-RP) correlated with G ≥3 anus/rectum events and moderate/persistent diarrhea, proctitis, bleeding, abdominal cramps, and difficulty in bowel control. Bowel D correlated with G ≥3 sigmoid and colon/small bowel events and moderate/persistent diarrhea and flatulence. For external beam radiation therapy (EBRT), prescription dose correlated with G ≥3 anus/rectum, diarrhea, and difficulty in bowel control. Patients with large lymph-node boost (V57Gy) were at higher risk for G ≥3 sigmoid events, moderate/persistent diarrhea, proctitis, and cramps.
CONCLUSIONS
The analysis showed that both EBRT and image guided adaptive brachytherapy contribute to GI symptoms after locally advanced cervical cancer treatment. Rectum D, ICRU RV-RP , and bowel D are risk factors for GI morbidity. The risk for various symptoms was lower with an EBRT prescription of 45 Gy than 50 Gy and increased with larger V57Gy.
目的
评估局部晚期宫颈癌患者在接受放射（化疗）和图像引导自适应近距离放疗后，医生评估和患者报告的胃肠道（GI）症状与患者和治疗相关的风险因素。
方法和材料
在 EMBRACE-I 研究的 1416 名患者中，1199 名和 1002 名患者分别前瞻性地使用医生评估（不良事件通用术语标准 [CTCAE]）和患者报告（欧洲癌症研究与治疗组织 [EORTC]）GI 症状进行评估。根据 GI 道的位置（肛门/直肠、乙状结肠和结肠/小肠）将 CTCAE 严重程度（G）≥3 级事件进行汇总。使用 Cox 回归分析了单独症状的 CTCAE G≥2 和 EORTC“非常”和“相当多”加“非常”评分（≥“相当多”）。对于至少一半随访中存在的持续性 G≥1 和 EORTC≥“相当多”的症状，使用逻辑回归进行分析。
结果
G≥3 级肛门/直肠、乙状结肠和结肠/小肠事件的发生率分别为 2.8%、1.8%和 2.3%。在 G≥2 症状中，腹泻和腹胀最为常见（分别为 8.5%和 9.9%）。在患者相关因素中，基线发病率、年龄增长、吸烟状况和低体重指数与 GI 症状的严重程度呈不同程度的相关。在治疗相关因素中，直肠 D 和国际辐射单位和测量委员会直肠-阴道参考点（ICRU RV-RP）与 G≥3 级肛门/直肠事件以及中度/持续性腹泻、直肠炎、出血、腹痛和排便控制困难相关。肠道 D 与 G≥3 级乙状结肠和结肠/小肠事件以及中度/持续性腹泻和腹胀相关。对于外照射放疗（EBRT），处方剂量与 G≥3 级肛门/直肠、腹泻和排便控制困难相关。接受大淋巴结（V57Gy）加量的患者发生 G≥3 级乙状结肠事件、中度/持续性腹泻、直肠炎和痉挛的风险更高。
结论
该分析表明，局部晚期宫颈癌治疗后，EBRT 和图像引导自适应近距离放疗均会导致胃肠道症状。直肠 D、ICRU RV-RP 和肠道 D 是胃肠道发病率的危险因素。EBRT 处方剂量为 45 Gy 时，各种症状的风险低于 50 Gy，而 V57Gy 越大，风险越高。
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