Radiation Oncology Journal

The Korean Society for Radiation Oncology (대한방사선종양학회)
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The Results of Postoperative Radiation Therapy for Perihilar Cholangiocarcinoma

간문부 담도암에서 수술 후 방사선 치료의 결과

  • Lee, Yu-Sun (Departments of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine) ;
  • Park, Jae-Won (Departments of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine) ;
  • Park, Jin-Hong (Departments of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine) ;
  • Choi, Eun-Kyung (Departments of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine) ;
  • Ahn, Seung-Do (Departments of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine) ;
  • Lee, Sang-Wook (Departments of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine) ;
  • Song, Si-Yeol (Departments of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine) ;
  • Lee, Sung-Gyu (Departments of General Surgery, Asan Medical Center, University of Ulsan College of Medicine) ;
  • Hwang, Shin (Departments of General Surgery, Asan Medical Center, University of Ulsan College of Medicine) ;
  • Lee, Young-Joo (Departments of General Surgery, Asan Medical Center, University of Ulsan College of Medicine) ;
  • Park, Kwang-Min (Departments of General Surgery, Asan Medical Center, University of Ulsan College of Medicine) ;
  • Kim, Ki-Hun (Departments of General Surgery, Asan Medical Center, University of Ulsan College of Medicine) ;
  • Ahn, Chul-Soo (Departments of General Surgery, Asan Medical Center, University of Ulsan College of Medicine) ;
  • Moon, Deok-Bog (Departments of General Surgery, Asan Medical Center, University of Ulsan College of Medicine) ;
  • Chang, Heung-Moon (Departments of Medical Oncology, Asan Medical Center, University of Ulsan College of Medicine) ;
  • Ryu, Min-Hee (Departments of Medical Oncology, Asan Medical Center, University of Ulsan College of Medicine) ;
  • Kim, Tae-Won (Department of Medical Oncology, Asan Medical Center, University of Ulsan College of Medicine) ;
  • Lee, Jae-Lyun (Department of Medical Oncology, Asan Medical Center, University of Ulsan College of Medicine) ;
  • Kim, Jong-Hoon (Departments of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine)
  • 이유선 (울산대학교 의과대학 서울아산병원 방사선종양학교실) ;
  • 박재원 (울산대학교 의과대학 서울아산병원 방사선종양학교실) ;
  • 박진홍 (울산대학교 의과대학 서울아산병원 방사선종양학교실) ;
  • 최은경 (울산대학교 의과대학 서울아산병원 방사선종양학교실) ;
  • 안승도 (울산대학교 의과대학 서울아산병원 방사선종양학교실) ;
  • 이상욱 (울산대학교 의과대학 서울아산병원 방사선종양학교실) ;
  • 송시열 (울산대학교 의과대학 서울아산병원 방사선종양학교실) ;
  • 이승규 (울산대학교 의과대학 서울아산병원 일반외과학교실) ;
  • 황신 (울산대학교 의과대학 서울아산병원 일반외과학교실) ;
  • 이영주 (울산대학교 의과대학 서울아산병원 일반외과학교실) ;
  • 박광민 (울산대학교 의과대학 서울아산병원 일반외과학교실) ;
  • 김기훈 (울산대학교 의과대학 서울아산병원 일반외과학교실) ;
  • 안철수 (울산대학교 의과대학 서울아산병원 일반외과학교실) ;
  • 문덕복 (울산대학교 의과대학 서울아산병원 일반외과학교실) ;
  • 장흥문 (울산대학교 의과대학 서울아산병원 종양내과학교실) ;
  • 류민희 (울산대학교 의과대학 서울아산병원 종양내과학교실) ;
  • 김태원 (울산대학교 의과대학 서울아산병원 종양내과학교실) ;
  • 이재련 (울산대학교 의과대학 서울아산병원 종양내과학교실) ;
  • 김종훈 (울산대학교 의과대학 서울아산병원 방사선종양학교실)
  • Received : 2009.06.03
  • Accepted : 2009.10.15
  • Published : 2009.12.31
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Abstract

Purpose: The aim of this study was to evaluate the results of postoperative radiotherapy in a case of perihilar cholagiocarcinoma by analyzing overall survival rate, patterns of failure, prognostic factors for overall survival, and toxicity. Materials and Methods: Between January 1998 and March 2008, 38 patients with perihilar cholangiocarcinoma underwent a surgical resection and adjuvant radiotherapy. The median patient age was 59 years (range, 28 to 72 years), which included 23 men and 15 women. The extent of surgery was complete resection in 9 patients, microscopically positive margins in 25 patients, and a subtotal resection in 4 patients. The tumor bed and regional lymphatics initially received 45 Gy or 50 Gy, but was subsequently boosted to a total dose of 59.4 Gy or 60 Gy in incompletely resected patients. The median radiotherapy dose was 59.4 Gy. Concurrent chemotherapy was administered in 30 patients. The median follow-up period was 14 months (range, 6 to 45 months). Results: The 3-year overall survival and 3-year progression free survival rates were 30% and 8%, respectively. The median survival time was 28 months. A multivariate analysis showed that differentiation was the only significant factor for overall survival. The 3-year overall survival was 34% in R0 patients and 20% in R1 patients. No statistically significant differences in survival were found between the 2 groups (p=0.3067). The first site of failure was local in 18 patients (47%). No patient experienced grade 3 or higher acute toxicity and duodenal bleeding developed in 2 patients. Conclusion: Our results suggest that adjuvant RT might be a significant factor in patients with a positive margin following a radical resection. However, there was still a high locoregional recurrence rate following surgery and postoperative radiotherapy. Further study is necessary to enhance the effect of the adjuvant radiotherapy.

목 적: 수술 후 방사선치료를 시행한 간문부 담도암 환자를 대상으로 생존율, 재발양상, 예후 인자, 치료 부작용을 분석하여 방사선 치료의 결과를 알아보고자 하였다. 대상 및 방법: 98년 1월부터 2008년 3월까지 서울아산병원에서 근치적 또는 고식적 절제술 후 방사선 치료를 시행 받은 총 39명의 환자 중 총 방사선 조사량이 30 Gy 이상이었던 38명의 환자를 대상으로 후향적으로 분석하였다. 대상 환자들의 연령은 28~72세(중앙 연령, 59세)였으며, 남자가 23명 여자가 15명이었다. Eastern Cooperative Oncology Group (ECOG) 활동도는 모두 2 이하였다. AJCC에 따른 병리적 병기 1기, 2기는 각각 15명(40%), 23명 (60%)이었다. 수술은 완전 절제가 시행된 경우는 9명(24%), 절제연 양성인 경우는 29명(76%)이었다. 동시 항암화학요법은 30명(79%)에서 시행되었다. 방사선치료는 원발 종양이 있던 부위와 주변 림프절에 조사하였으며, 1회 선량은 1.8 Gy 또는 2 Gy로, 총 방사선량은 35~61 Gy (중앙값, 59.4 Gy)였다. 대상 환자들의 추적 관찰 기간은 6~45개월(중앙값, 14개월)이었다. 대상 환자의 생존율 분석은 Kaplan-Meier 법, 예후 인자 분석은 log-rank 법을 사용하였다. 결 과: 전체 환자의 3년 생존율은 30%, 3년 무진행 생존율은 8%이었으며, 중앙생존기간은 28개월이었다. 생존율에 유의하게 영향을 준 예후 인자는 종양의 분화도(p=0.003)였고, 무진행 생존율에 유의하게 영향을 준 예후 인자는 혈관-림프 침범(p=0.0307), 종양의 분화도(p=0.0245), 수술 후 CA 19-9 (p=0.0172)이었다. 완전 절제가 시행된 환자 9명의 3년 생존율은 34%로서 불완전 절제가 시행된 환자 29명의 20%보다 높았으나 유의한 차이는 보이지 않았다(p=0.3067). 최초 재발 양상은 국소 재발 18명(47%), 원격전이는 16명(42%)이었다. 치료에 연관된 EORTC Grade 3 이상의 급성 부작용은 관찰되지 않았으며, 만성 부작용으로는 십이지장 궤양에 의한 출혈이 2명(5.1%)에서 발생하였다. 결 론: 본 연구에서는 완전 절제가 시행된 경우와 절제연 양성인 경우에서의 생존율이 유의한 차이를 보이지 않아 방사선 치료의 국소재발 억제 효과가 있었을 가능성을 시사하였으나, 환자수가 적고 수술 단독군과의 비교가 이루어지지 않아 결론을 내리기는 어려웠다. 게다가 완전 절제 수술 후 방사선 치료를 시행한 군에서도 높은 국소 재발률을 보여, 향후 항암제와의 병용치료 및 정밀 방사선 치료 등을 통한 국소 제어율을 높이기 위한 연구가 필요하다.

Keywords

References

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