Intensity Modulated Whole Pelvic Radiotherapy in Patients with Cervix Cancer: Analysis of Acute Toxicity

자궁경부암 환자에서 전골반 강도변조방사선치료에 의한 급성부작용

  • Choi, Young-Min (Departments of Radiation Oncology, School of Medicine, Dong-A University) ;
  • Lee, Hyung-Sik (Departments of Radiation Oncology, School of Medicine, Dong-A University) ;
  • Hur, Won-Joo (Departments of Radiation Oncology, School of Medicine, Dong-A University) ;
  • Cha, Moon-Seok (Departments of Obstetrics and Gynecology, School of Medicine, Dong-A University) ;
  • Kim, Hyun-Ho (Departments of Obstetrics and Gynecology, School of Medicine, Dong-A University)
  • 최영민 (동아대학교 의과대학 방사선종양학교실) ;
  • 이형식 (동아대학교 의과대학 방사선종양학교실) ;
  • 허원주 (동아대학교 의과대학 방사선종양학교실) ;
  • 차문석 (동아대학교 의과대학 산부인과학교실) ;
  • 김현호 (동아대학교 의과대학 산부인과학교실)
  • Published : 2006.12.31

Abstract

$\underline{Purpose}$: To evaluate acute toxicities in cervix cancer patients receiving intensity modulated whole pelvic radiation therapy (IM-WPRT). $\underline{Materials\;and\;Methods}$: Between August 2004 and April 2006, 17 patients who underwent IM-WPRT were analysed. An intravenous contrast agent was used for radiotherapy planning computed tomography (CT). The central clinical target volume (CTV) included the primary tumor, uterus, vagina, and parametrium. The nodal CTV was defined as the lymph nodes larger than 1 cm seen on CT and the contrased-enhanced pelvic vessels. The planning target volume (PTV) was the 1-cm expanded volume around the central CTV, except for a 5-mm expansion from the posterior vagina, and the nodal PTV was defined as the nodal CTV plus a 1.5 cm margin. IM-WPRT was prescribed to deliver a dose of 50 Gy to more than 95% of the PTV. Acute toxicity was assessed with common toxicity criteria up to 60 days after radiotherapy. $\underline{Results}$: Grade 1 nausea developed in 10 (58.9%) patients, and grade 1 and 2 diarrhea developed in 11 (64.7%) and 1 (5.9%) patients, respectively. No grade 3 or higher gastrointestinal toxicity was seen. Leukopenia, anemia, and thrombocytopenia occurred in 15 (88.2%). 7 (41.2%), and 2 (11.8%) patients, respectively, as hematologic toxicities. Grade 3 leukopenia developed in 2 patients who were treated with concurrent chemoradiotherapy. $\underline{Conclusion}$: IM-WPRT can be a useful treatment for cervix cancer patients with decreased severe acute toxicities and a resultant improved compliance to whole pelvic irradiation.

목 적: 자궁경부암으로 전골반 강도변조방사선치료를 받은 환자들에서 급성부작용을 조사하고자 하였다. 대상 및 방법: 2004년 8월부터 2006년 4월까지 동아대병원에서 자궁경부암으로 전골반 강도변조방사선치료를 받은 17명의 환자를 대상하였다. 정맥 조영제를 이용하여 방사선치료계획용 전산화단층촬영을 하였다. 중심부위 임상표적체적(clinical target volume, CTV)에는 원발병소, 자궁, 질, 자궁방조직 등을 포함하였고, 림프절 CTV는 1 cm 이상의 림프절과 조영제로 확인된 골반부위 혈관으로 정하였다. 계획용표적체적(planning target volume, PTV)은 중심부위 CTV로부터 1 cm 여유를 추가한 용적으로 정하였는데, 질의 후면으로부터는 5 mm의 여유를 추가하였다. 그리고 림프절 CTV로부터 1.5 cm 여유를 추가하여 PTV에 포함시켰다. PTV의 95% 이상에 50 Gy의 방사선이 조사되도록 강도변조방사선치료를 계획하였다. 방사선치료 후 60일 동안의 급성부작용을 공통독성기준(common toxicity criteria)을 이용하여 평가하였다. 결 과: 급성 위장관부작용으로 1도의 오심, 1도 및 2도의 설사가 각각 10 (58.9%), 11 (64.7%), 1 (5.9%)명에서 각각 발생되었으나, 3도 이상의 부작용은 없었다. 혈액학적 부작용으로는 백혈구감소증, 빈혈, 혈소판감소증 등이 각각 15 (88.2%), 7 (41.2%), 2 (11.8%)명에서 발생되었으나, 3도 이상의 부작용은 백혈구감소증에서만 2명(11.8%)에서 발생되었다. 3도의 백혈구감소증이 발생된 환자들은 화학요법과 방사선치료를 병용하였다. 결 론: 자궁경부암에 대한 전골반 방사선치료에 강도변조방사선치료를 이용함으로써 중등도 이상의 급성부작용을 감소시켜 치료에 대한 환자의 내성을 증가시킬 것으로 생각된다.

Keywords

References

  1. Yeoh E, Horowitz M, Russo A, et al. A retrospective study of the effects of pelvic irradiation for carcinoma of the cervix on gastrointestinal function. Int J Radiat Oncol Biol Phys 1993; 26:229-237 https://doi.org/10.1016/0360-3016(93)90202-7
  2. Snijders-Keilholz A, Griffioen G, Davelaar J, Trimbos JB, Leer JW. Vitamin B12 malabsorption after irradiation for gynaecological tumours. Anticancer Res 1993;13:1877-1881
  3. Beer WH, Fan A, Halsted CH. Clinical and nutritional implications of radiation enteritis. Am J Clin Nutr 1985;41:85-91 https://doi.org/10.1093/ajcn/41.1.85
  4. Ellis RE. The distribution of active bone marrow in the adult. Phys Med Biol 1961;5:255-258 https://doi.org/10.1088/0031-9155/5/3/302
  5. Mauch P, Constine L, Greenberger J, et al. Hematopoietic stem cell compartment: acute and late effects of radiation therapy and chemotherapy. Int J Radiat Oncol Biol Phys 1995; 31:1319-1339 https://doi.org/10.1016/0360-3016(94)00430-S
  6. Keys HM, Bundy BN, Stehman FB, et al. Cisplatin, radiation, and adjuvant hysterectomy compared with radiation and adjuvant hysterectomy for bulky stage IB cervical carcinoma. N Engl J Med 1999;340:1154-1161 https://doi.org/10.1056/NEJM199904153401503
  7. Peters WA III, Liu PY, Barrett RJ II, et al. Concurrent chemotherapy and pelvic radiation therapy compared with pelvic radiation therapy alone as adjuvant therapy after radical surgery in high-risk early-stage cancer of the cervix. J Clin Oncol 2000;18:1606-1613 https://doi.org/10.1200/JCO.2000.18.8.1606
  8. Whitney CW, Sause W, Bundy BN, et al. Randomized comparison of fluorouracil plus cisplatin versus hydroxyurea as an adjunct to radiation therapy in stage IIB-IVA carcinoma of the cervix with negative para-aortic lymph nodes: a Gynecologic Oncology Group and Southwest Oncology Group study. J Clin Oncol 1999;17:1339-1348 https://doi.org/10.1200/JCO.1999.17.5.1339
  9. Rose PG, Bundy BN, Watkins EB, et al. Concurrent cisplatin-based radiotherapy and chemotherapy for locally advanced cervical cancer. N Engl J Med 1999;340:1144-1153 https://doi.org/10.1056/NEJM199904153401502
  10. Roeske JC, Lujan A, Rotmensch J, Waggoner SE, Yamada D, Mundt AJ. Intensity-modulated whole pelvic radiation therapy in patients with gynecologic malignancies. Int J Radiat Oncol Biol Phys 2000;48:1613-1621 https://doi.org/10.1016/S0360-3016(00)00771-9
  11. Portelance L, Chao KS, Grigsby PW, Bennet H, Low D. Intensity-modulated radiation therapy (IMRT) reduces small bowel, rectum, and bladder doses in patients with cervical cancer receiving pelvic and para-aortic irradiation. Int J Radiat Oncol Biol Phys 2001;51:261-266 https://doi.org/10.1016/S0360-3016(01)01664-9
  12. Heron DE, Gerszten K, Selvaraj RN, et al. Conventional 3D conformal versus intensity-modulated radiotherapy for the adjuvant treatment of gynecologic malignancies: a comparative dosimetric study of dose-volume histograms small star, filled. Gynecol Oncol 2003;91:39-45 https://doi.org/10.1016/S0090-8258(03)00461-X
  13. van de Bunt L, van der Heide UA, Ketelaars M, de Kort GA, Jurgenliemk-Schulz IM. Conventional, conformal, and intensity-modulated radiation therapy treatment planning of external beam radiotherapy for cervical cancer: the impact of tumor regression. Int J Radiat Oncol Biol Phys 2006;64:189-196 https://doi.org/10.1016/j.ijrobp.2005.04.025
  14. Georg P, Georg D, Hillbrand M, Kirisits C, Potter R. Factors influencing bowel sparing in intensity modulated whole pelvic radiotherapy for gynaecological malignancies. Radiother Oncol 2006;80:19-26 https://doi.org/10.1016/j.radonc.2006.04.014
  15. Lujan AE, Mundt AJ, Yamada SD, Rotmensch J, Roeske JC. Intensity-modulated radiotherapy as a means of reducing dose to bone marrow in gynecologic patients receiving whole pelvic radiotherapy. Int J Radiat Oncol Biol Phys 2003; 57:516-521 https://doi.org/10.1016/S0360-3016(03)00521-2
  16. Roeske JC, Lujan A, Reba RC, et al. Incorporation of SPECT bone marrow imaging into intensity modulated whole- pelvic radiation therapy treatment planning for gynecologic malignancies. Radiother Oncol 2005;77:11-17 https://doi.org/10.1016/j.radonc.2005.06.017
  17. Brixey CJ, Roeske JC, Lujan AE, Yamada SD, Rotmensch J, Mundt AJ. Impact of intensity-modulated radiotherapy on acute hematologic toxicity in women with gynecologic malignancies. Int J Radiat Oncol Biol Phys 2002;54: 1388-1396 https://doi.org/10.1016/S0360-3016(02)03801-4
  18. Mundt AJ, Lujan AE, Rotmensch J, et al. Intensity- modulated whole pelvic radiotherapy in women with gynecologic malignancies. Int J Radiat Oncol Biol Phys 2002;52:1330-1337 https://doi.org/10.1016/S0360-3016(01)02785-7