Perez C A, Michalski J, Brown K C, Lockett M A
Radiation Oncology Center, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO USA.
Int J Radiat Oncol Biol Phys. 1996 Oct 1;36(3):573-84. doi: 10.1016/s0360-3016(96)00378-1.
A great deal of controversy exists regarding the potential benefit of pelvic lymph node irradiation compared with treatment to the prostate only in patients with localized prostate cancer. Despite numerous reports, including a randomized study, this issue has not been completely elucidated.
A total of 963 patients with histologically proven localized adenocarcinoma of the prostate treated with definitive radiation therapy alone were analyzed. Median follow-up was 6.5 years (minimum: 2 years, maximum: 22 years). Pelvic lymph nodes received 40 to 55 Gy with anteroposterior/posteroanterior and sometimes lateral stationary portals in 1.8 Gy daily fractions; an additional dose was delivered to the prostate with 120 degrees bilateral are rotation to complete doses of 65 to 68 Gy for Stage A2 and B tumors and 68 to 71 Gy for Stage C tumors. The same total doses were delivered with smaller fields when the prostate only was treated.
In Stage A2 (T1b,c) the 10-year clinical pelvic failure rate was 16% regardless of the volume irradiated or tumor differentiation. With Stage B (T2) well- or moderately differentiated tumors, the 10-year pelvic failure rates were 22% when pelvic lymph nodes were irradiated and 32% when prostate only was irradiated (p = 0.41). With Stage A2 (T1b,c) and B (T2) poorly differentiated tumors, the 10-year pelvic failure rates were 32% and 7%, respectively (p = 0.72). With clinical stage C (T3) well-differentiated tumors treated with 50 to 55 Gy to pelvic lymph nodes, the pelvic failure rate was 22% compared with 37% in those receiving 40 to 45 Gy (p < or = 0.07). A significant reduction in pelvic failures was noted with Stage C poorly differentiated tumors when the pelvic lymph nodes received doses higher than 50 Gy (23%) compared with lower doses (46%) (p < or = 0.01). Volume or doses of irradiation did not influence incidence of distant metastases in any stage or tumor differentiation group. Disease-free survival did not correlate with volume treated in any clinical stage or tumor differentiation group. In 317 patients on whom pretreatment prostate-specific antigen levels were available, there is a suggestion that those treated to the pelvic lymph nodes had a higher chemical disease-free survival than those receiving prostate irradiation only. Follow-up is short, and differences are not statistically significant in any of the groups. Morbidity of therapy was slightly higher in patients treated to the pelvic lymph nodes, but in Stages A2 (T1b,c) and B (T2) differences are not statistically significant (4 to 6%). Stage C patients treated to the pelvic lymph nodes with 50 Gy had a 12% incidence of Grade 2 rectosigmoid morbidity compared with 6% in those treated with 40 Gy (p = 0.26).
In this retrospective analysis, pelvic lymph node irradiation did not influence local/pelvic tumor control, incidence of distant metastases, or disease-free survival in patients with clinical Stage A2 (T1b,c) or B (T2) localized carcinoma of the prostate. In patients with Stage C (T3) disease, irradiation of the pelvic lymph nodes with doses of 50 to 55 Gy resulted in a lower incidence of pelvic recurrences and improved disease-free survival. Morbidity of therapy was acceptable, although patients with Stage C disease had a somewhat higher incidence of Grade 2 rectosigmoid morbidity. Pelvic lymph node irradiation is being elucidated in properly designed prospective, randomized protocols.
对于局限性前列腺癌患者，与仅治疗前列腺相比，盆腔淋巴结照射的潜在益处存在大量争议。尽管有许多报道，包括一项随机研究，但这个问题尚未完全阐明。
对总共963例经组织学证实为局限性前列腺腺癌且仅接受根治性放射治疗的患者进行分析。中位随访时间为6.5年（最短：2年，最长：22年）。盆腔淋巴结接受40至55 Gy照射，采用前后/后前野，有时加侧野，每日分次剂量为1.8 Gy；前列腺额外接受双侧120度弧形旋转照射，A2期和B期肿瘤总剂量达65至68 Gy，C期肿瘤总剂量达68至71 Gy。仅治疗前列腺时，用较小野给予相同总剂量。
在A2期（T1b,c），无论照射体积或肿瘤分化程度如何，10年临床盆腔失败率为16%。对于B期（T2）高分化或中分化肿瘤，照射盆腔淋巴结时10年盆腔失败率为22%，仅照射前列腺时为32%（p = 0.41）。对于A2期（T1b,c）和B期（T2）低分化肿瘤，10年盆腔失败率分别为32%和7%（p = 0.72）。对于临床C期（T3）高分化肿瘤，盆腔淋巴结接受50至55 Gy照射时，盆腔失败率为22%，而接受40至45 Gy照射者为37%（p≤0.07）。当盆腔淋巴结接受高于50 Gy剂量照射时，C期低分化肿瘤盆腔失败率显著降低（23%），低于该剂量时为46%（p≤0.01）。照射体积或剂量不影响任何分期或肿瘤分化组的远处转移发生率。无病生存率与任何临床分期或肿瘤分化组的治疗体积均无相关性。在317例有治疗前前列腺特异性抗原水平数据的患者中，提示照射盆腔淋巴结者的生化无病生存率高于仅接受前列腺照射者。随访时间短，各组差异均无统计学意义。盆腔淋巴结照射患者的治疗并发症发生率略高，但在A2期（T1b,c）和B期（T2）差异无统计学意义（4%至6%）。盆腔淋巴结接受50 Gy照射的C期患者乙状结肠直肠2级并发症发生率为12%，接受40 Gy照射者为6%（p = 0.26）。
在这项回顾性分析中，盆腔淋巴结照射不影响临床A2期（T1b,c）或B期（T2）局限性前列腺癌患者的局部/盆腔肿瘤控制、远处转移发生率或无病生存率。对于C期（T3）疾病患者，盆腔淋巴结照射剂量为50至55 Gy可降低盆腔复发率并改善无病生存率。治疗并发症发生率可接受，尽管C期疾病患者乙状结肠直肠2级并发症发生率略高。正在通过设计合理的前瞻性随机方案进一步阐明盆腔淋巴结照射的作用。
