- 期刊
子宮頸癌放射治療的結果及直腸後遺症的分析（新光醫院的五年經驗）
Result of Radiotherapy in the Treatment of Uterine Cervical Cancer and Analysis of Late Rectal Complications (Five Years Experience at SKMH)
摘要
目的：子宮頸癌是目前台灣婦女發生率最高的癌症，本研究主要在檢討新光醫院五年來放射線治療子宮頸癌的初步結果，並分析因治療而引發之直腸副作用的可能因素而改善將來的治療計劃。 材料與方法：從1992年9月至1994年12月，共有109位子宮頸癌病人在新光醫院完成放射線治療，放射線治療包括遠隔治療與子宮腔內近接治療。開始的治療範圍涵蓋整個子宮，陰道及下腹腔淋巴腺，經照射40 Gy至44 Gy後，依腫瘤期別縮小範圍至兩側的子宮旁組微(parametrium)子宮腔內治療次數3次，間隔一周，每次給予參考點A (point A) 72 Gy的劑量，針對年紀較大及直腸累積放射劑量較高的病患則依情況調整point A劑量至5 Gy或6 Gy。109位病息中有102例(FIGO stage lb-lla 24人，llb 48人，llla-ll1b26人，1Va-b 4人)接受追跌檢查而進入分析。結果：102位病患經過30至54個月的追蹤檢查（中位值39個月），至1997年12月底止，仍存活者共有65人（其中一人已有遠處轉移）,37人已死亡，其中8人死於局部復發，16人死於遠處轉移，1人死局部復發合併遠處轉移，3人死於治療所引發的後遣症，9人死於其它疾病。三年存活率與下腹腔腫瘤控制率分別為lb-lla 95%/95%, llb 84%/92%, llla-lllb50%/78%，Ⅳ 25%/50%)。針對86位存活時問超過一年的病患進行大腸後遺症的分析，其結果顯示共有26人(30.2%)發生直腸後遺症（RTOG grade I 14人，grade II 18人，grade III-IV 4人），經分析後發現FIGO stage IIb-IV，直腸放射劑量（遠隔治療+所有近接治療的ICRU直腸劑量）大於65 Gy，以及總治療時問超過70天者為高危險群。 結論：研究結果顯示stage IIIa-IIIb病患的治療結果仍須進一步加以改善。因有18例(17.6%)的病息發生遠處轉移，應評估選定高危險的病人進行化學治療之臨床研究。以目前近接治療的方式，約有30%會發生不同程度的放射線直腸炎，未來應繼續分析引發直腸後遣症的因素，在不影響治療結果的前提下，由治療計劃的調整，進而減少後遣症發生的機率。
並列摘要
Introduction: Cancer of the uterine cervix is the most prevalent female cancer in Taiwan. Our study is to analyse the treatment outcome of cervical cancer in the past five years at Shin Kong Memorial Hospital. In order to refine future treatment protocol, the possible risk factors of late rectal complications will also be analysed. Materials & Methods: From September 1992 to December 1994, 109 patients with uterine cervical cancer completed planned radiotherapy (RT) at Shin Kong Memorial Hospital. Treatment consisted of external beam RT followed by HDR (high dose rate) intracavitary brachytherapy. After external RT dose of 40~44 Gy to whole pelvis, bilateral parametrium of stage (IIb cases were further boosted to 54~58 Gy with central shielding. Intracavitary brachytherapy consisted of three to four insertions with intervals of one week. The prescribed dose of each insertion was 7.2 Ely to point A, while in some circumstances (old age or high cumulative rectal dose), point A dose had been modified to 5-6 Gy. One hundred and two cases (24 Iv-IIa, 48 IIb, 26 IIIa-b, 4 IVa) received follow-up and were enrolled for the study. Results: After 30 to 54 months of follow-up (median 39 months), 65 cases was alive (one was noted to have distant metastasis), 37 cases died of disease (8 for local reurrence, 16 for distant metastasis, one for both), 3 cases died of complication, while 9 cases were dead due to intercurrent disease. The 3-year cause-specific survival and local control rates are 95%/95% for Ib-IIa, 84%/92% for IIb, 50%/78% for IIIa-b, 25%/50% for stage IV, respectively. A total of 86 cases who survived more than one year were further analysed to define the risk factors of late gastrointestinal complication. Twenty-six patients (30.2%) was noted to have late rectal sequale (RTOG gradeI 14, gradeI 8, gradeIII-IV 4), while four cases (4.6%) developed ileus. Logistic regression analysis demonstrated a high risk of late rectal sequale in those who were stage IIb-IV cases, total rectal dose (external RT+total ICRU rectal dose)＞65 Gy, and overall treatment time＞70 days. Conclusion: Our current study show the treatment outcome of Figo IIIa-tub cases is not satisfactory. Because 18 patients (17.6%) were noted to have distant metastases, it might be recommended to select high risk patients to undergo adjuvant chemotherapy. With our present tratment proctocol, there will be about 30% of cases to have different extent of radiation proctitis. We will continue to analyse possible risk factors of late rectal complications and promote the therapeutic gain of HDR brachytherapy based treatment planning.