Eble M J, Wulf J, van Kampen M, Weischedel U, Wannenmacher M
Abteilung Klinische Radiologie, Radiologischen Universitätsklinik Heidelberg.
Strahlenther Onkol. 1995 Feb;171(2):77-86.
Prognosis in patients with resected rectal carcinomas is correlated to local tumor control. Percutaneous (EBRT) and intraoperative boost irradiation (IORT) can improve local control. The aim of this study was to analyse the role of locally restricted dose escalation and the possibility to integrate IORT in a multi-modality adjuvant treatment approach.
A total of 128 and 71 patients with primary and recurrent disease were eligible for analysis. More than 60% of patients suffered from a stage III carcinoma. Between 26.3 and 38.8% of patients revealed lymphangiosis carcinomatosa in pathohistological examination. A dose of 40.2 Gy was applied using multiple field techniques. Either a percutaneous boost dose of 18.3 Gy or an intraoperative boost dose of 12.1 Gy was given in 97 and 62 patients. 40 patients with non-resectable recurrent carcinomas were treated with radiotherapy alone. In respectively 67.4% and 52.6% of IORT patients (primary and recurrent) a simultaneous chemotherapy was given, whereas only 16.5% and 8.3% of patients with EBRT alone had additional chemotherapy.
Five-year overall survival was 64% and 41% in stage II and III (T2-3) carcinomas. All patients with stage III (T4) carcinomas died within 3 years. Overall the local failure rate was correlated to tumor stage (12.7 to 19.7%) and lymphangiosis carcinomatosa (12.5 vs. 22.9%). In patients with radiotherapy alone, local failure rate decreased with increasing irradiation dose (32%/40 to 48 Gy, 25%/49 to 56 Gy, 20.5%/57 to 66 Gy 0%/40.2 Gy + IORT). The overall 2-year survival was significantly improved after IORT and IORT plus simultaneous chemotherapy in both primary and recurrent disease. Perioperative morbidity was not increased. The toxicity of the multi-modality approach with IORT was low and acceptable.
The local tumor control in rectal carcinoma after radiotherapy was dose dependent, IORT could be integrated in an adjuvant multi-modality treatment concept, without increasing morbidity. Local failure rate could be markedly reduced.
接受直肠切除术患者的预后与局部肿瘤控制相关。经皮（体外放射治疗，EBRT）和术中追加照射（IORT）可改善局部控制。本研究的目的是分析局部剂量递增的作用以及在多模式辅助治疗方法中整合IORT的可能性。
共有128例原发性疾病患者和71例复发性疾病患者符合分析条件。超过60%的患者患有III期癌症。在病理组织学检查中，26.3%至38.8%的患者出现癌性淋巴管炎。采用多野技术给予40.2 Gy的剂量。97例和62例患者分别接受了18.3 Gy的经皮追加剂量或12.1 Gy的术中追加剂量。40例不可切除的复发性癌患者仅接受了放射治疗。在IORT患者（原发性和复发性）中，分别有67.4%和52.6%的患者同时接受了化疗，而仅接受EBRT的患者中分别只有16.5%和8.3%接受了额外化疗。
II期和III期（T2 - 3）癌患者的5年总生存率分别为64%和41%。所有III期（T4）癌患者均在3年内死亡。总体而言，局部失败率与肿瘤分期（12.7%至19.7%）和癌性淋巴管炎（12.5%对22.9%）相关。在仅接受放射治疗的患者中，局部失败率随照射剂量增加而降低（40至48 Gy为32%，49至56 Gy为25%，57至66 Gy为20.5%，40.2 Gy + IORT为0%）。在原发性和复发性疾病中，IORT以及IORT联合同步化疗后的总体2年生存率均显著提高。围手术期发病率未增加。IORT多模式治疗方法的毒性较低且可接受。
放射治疗后直肠癌的局部肿瘤控制取决于剂量，IORT可整合到辅助多模式治疗概念中，而不增加发病率。局部失败率可显著降低。
