肢体和浅表躯干软组织肉瘤患者手术和围手术期 HDR 近距离放疗后的剂量体积直方图限制。
Dose volume histogram constraints in patients with soft tissue sarcomas of the extremities and the superficial trunk treated with surgery and perioperative HDR brachytherapy.
机构信息
Departments of Orthopedic Surgery, Clínica Universidad de Navarra, Pamplona, Spain; Department of Solid Tumors and Biomarkers, Center for Applied Medical Research, Pamplona, Spain.
Departments of Oncology, Clínica Universidad de Navarra, Pamplona, Spain; Department of Solid Tumors and Biomarkers, Center for Applied Medical Research, Pamplona, Spain.
出版信息
Radiother Oncol. 2022 May;170:159-164. doi: 10.1016/j.radonc.2022.02.025. Epub 2022 Feb 25.
BACKGROUND
Wound healing complications (WHC), osteoradionecrosis (ORN), and nerve damage (ND) are common adverse effects in adult patients with soft tissue sarcomas of the extremities and the superficial trunk treated with surgery and perioperative high dose rate brachytherapy (PHDRB) alone or combined with external beam radiotherapy (EBRT).
RATIONALE
Analysis of the treatment factors contributing to these complications can potentially minimize their occurrence and severity.
PATIENTS
A total of 169 patients enrolled in two parallel prospective studies were included in this analysis. Previously Unirradiated cases (Group 1; n = 139) were treated with surgical resection, 16-24 Gy of PHDRB and 45 Gy of EBRT. Adjuvant chemotherapy was given to selected patients with high-grade tumors. Previously irradiated cases (Group 2; n = 30) were treated with surgical resection and 32-40 Gy of PHDRB without further EBRT.
METHODS
Patient factors, tumor factors, surgical factors, PHDRB factors and EBRT factors were analyzed using Cox univariate and multivariate analysis.
RESULTS
In Previously Unirradiated cases, WHC, ORN and ND occurred in 38.8%, 5.0% and 19.4%. Multivariate analysis indicated that WHC increased with CTV size (p = 0.02) and CTV Physical dose (p = 0.02). ORN increased with Bone EQD2 ≥ 67 Gy(p = 0.01) and ND was more frequent in patients with TVDVH-based dose (tissue volume encompassed by the 100% isodose) ≥ 84 Gy (p < 0.01). In Previously Irradiated cases, WHC, ORN and ND occurred in 63.3%, 3.3% and 23.3%. Multivariate analysis showed that WHC was more frequent in patients with SkinLifetime EQD2 ≥ 84 Gy (p = 0.01) and ND was more frequent after CTV Physical Doses ≥ 40 Gy (p < 0.01).
CONCLUSIONS
WHC in Previously Unirradiated patients can be minimized by using a more conservative CTV definition together with a meticulous implant technique and planning aimed to minimize hyperdose CTV areas. In Previously Irradiated patients WHC may be mimimized considering Lifetime EQD2 Skin doses. ORN can be reduced by using the Bone EQD2 constraint. ND occurs more frequently in patients with large tumors receiving high treated volume doses, but no specific constraints can be recommended due to the lack of peripheral nerve definition during brachytherapy planning.
背景
在接受手术和围手术期高剂量率近距离放射治疗（PHDRB）单独或联合外部束放射治疗（EBRT）治疗的四肢和浅表躯干软组织肉瘤的成年患者中，常见的不良影响是伤口愈合并发症（WHC）、放射性骨坏死（ORN）和神经损伤（ND）。
理由
分析导致这些并发症的治疗因素有可能将其发生和严重程度降至最低。
患者
本分析共纳入了两项平行前瞻性研究中的 169 名患者。以前未接受过放疗的病例（第 1 组；n=139）接受手术切除、16-24Gy PHDRB 和 45Gy EBRT。选择高分级肿瘤的患者给予辅助化疗。以前接受过放疗的病例（第 2 组；n=30）接受手术切除和 32-40Gy PHDRB，不再进行 EBRT。
方法
使用 Cox 单变量和多变量分析对患者因素、肿瘤因素、手术因素、PHDRB 因素和 EBRT 因素进行分析。
结果
在以前未接受过放疗的病例中，WHC、ORN 和 ND 的发生率分别为 38.8%、5.0%和 19.4%。多变量分析表明，WHC 随 CTV 大小增加（p=0.02）和 CTV 物理剂量增加（p=0.02）而增加。ORN 随 Bone EQD2≥67Gy 增加（p=0.01）而增加，ND 更常见于 TVDVH 基于剂量（组织体积被 100%等剂量线包围）≥84Gy 的患者（p<0.01）。在以前接受过放疗的病例中，WHC、ORN 和 ND 的发生率分别为 63.3%、3.3%和 23.3%。多变量分析表明，WHC 更常见于皮肤 Lifetime EQD2≥84Gy 的患者（p=0.01），ND 更常见于 CTV 物理剂量≥40Gy 的患者（p<0.01）。
结论
对于以前未接受过放疗的患者，通过使用更保守的 CTV 定义以及精心设计的植入技术和计划，最大限度地减少高剂量 CTV 区域，可以最大限度地减少 WHC。对于以前接受过放疗的患者，可以通过考虑皮肤 Lifetime EQD2 剂量来最大限度地减少 WHC。ORN 可以通过使用 Bone EQD2 限制来降低。在接受高剂量治疗体积剂量的大肿瘤患者中，ND 更常见，但由于在近距离放射治疗计划中缺乏周围神经定义，因此无法推荐特定的限制。
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