Kamada T, Saitou H, Takamura A, Nojima T, Okushiba S I
Division of Radiation Medicine, Research Center of Charged Particle Therapy, National Institute of Radiological Sciences, Chiba, Japan.
Int J Radiat Oncol Biol Phys. 1996 Mar 1;34(4):767-74. doi: 10.1016/0360-3016(95)02132-9.
To determine the feasibility of high dose radiotherapy and to evaluate its role in the management of extrahepatic bile duct (EHBD) cancer.
Between 1983 and 1991, 145 consecutive patients with EHBD cancer were treated by low dose rate intraluminal 192Ir irradiation (ILRT) either alone or in combination with external beam radiotherapy (EBRT). Among the primarily irradiated, 77 patients unsuitable for surgical resection, 54 were enrolled in radical radiotherapy, and 23 received palliative radiotherapy. Fifty-nine received postoperative radiotherapy, and the remaining 9 preoperative radiotherapy. The mean radiation dose was 67.8 Gy, ranging from 10 to 135 Gy. Intraluminal 192Ir irradiation was indicated in 103 patients, and 85 of them were combined with EBRT. Expandable metallic biliary endoprosthesis (EMBE) was used in 32 primarily irradiated patients (31 radical and 1 palliative radiotherapy) after the completion of radiotherapy.
The 1-, 3-, and 5-year actuarial survival rates for all 145 patients were 55%, 18%, and 10%, for the 54 patients treated by radical radiotherapy (mean 83.1 Gy), 56%, 13%, and 6% [median survival time (MST) 12.4 months], and for the 59 patients receiving postoperative radiotherapy (mean 61.6 Gy), 73%, 31%, and 18% (MST 21.5 months), respectively. Expandable metallic biliary endoprosthesis was useful for the early establishment of an internal bile passage in radically irradiated patients and MST of 14.9 months in these 31 patients was significantly longer than that of 9.3 months in the remaining 23 patients without EMBE placement (p < 0.05). Eighteen patients whose surgical margins were positive in the hepatic side bile duct(s) showed significantly better survival compared with 15 patients whose surgical margins were positive in the adjacent structure(s) (44% vs. 0% survival at 3 years, p < 0.001). No survival benefit was obtained in patients given palliative or preoperative radiotherapy. Gastroduodenal complications increased in those receiving doses of 90 Gy or more, and serious biliary bleeding was experienced in three preoperatively irradiated patients. Complications in other patients was tolerable.
High-dose radiotherapy, consisting of ILRT and EBRT, appears to be feasible in the management of EHBD cancer, and it offers a survival advantage for patients not suited for surgical resection and patients with positive margins in the resected end of the hepatic side bile duct. Expandable metallic biliary endoprosthesis assists the internal bile flow and may lengthen survival after high dose radiotherapy.
确定高剂量放疗的可行性，并评估其在肝外胆管（EHBD）癌治疗中的作用。
1983年至1991年间，145例连续的EHBD癌患者接受了低剂量率腔内192Ir照射（ILRT），单独或联合外照射放疗（EBRT）。在主要接受照射的患者中，77例不适合手术切除，54例接受根治性放疗，23例接受姑息性放疗。59例接受术后放疗，其余9例接受术前放疗。平均放疗剂量为67.8 Gy，范围为10至135 Gy。103例患者采用了腔内192Ir照射，其中85例联合了EBRT。32例主要接受照射的患者（31例根治性放疗和1例姑息性放疗）在放疗完成后使用了可扩张金属胆管内支架（EMBE）。
145例患者的1年、3年和5年精算生存率分别为55%、18%和10%；54例接受根治性放疗的患者（平均83.1 Gy）为56%、13%和6%[中位生存时间（MST）12.4个月]；59例接受术后放疗的患者（平均61.6 Gy）为73%、31%和18%（MST 21.5个月）。可扩张金属胆管内支架有助于在接受根治性放疗的患者中早期建立内胆汁通道，这31例患者的MST为14.9个月，显著长于其余23例未放置EMBE的患者的9.3个月（p<0.05）。18例肝侧胆管手术切缘阳性的患者与15例相邻结构手术切缘阳性的患者相比，生存率显著更高（3年生存率分别为44%和0%，p<0.001）。接受姑息性或术前放疗的患者未获得生存益处。接受90 Gy或更高剂量的患者胃十二指肠并发症增加，3例术前接受照射的患者发生了严重胆出血。其他患者的并发症可耐受。
由ILRT和EBRT组成的高剂量放疗在EHBD癌的治疗中似乎是可行的，对于不适合手术切除的患者以及肝侧胆管切除端切缘阳性的患者具有生存优势。可扩张金属胆管内支架有助于内胆汁流动，并可能延长高剂量放疗后的生存期。
