【作者】 王涛；

【导师】 程光惠；

【作者基本信息】 吉林大学 ， 临床医学硕士（专业学位）， 2025， 硕士

【摘要】 目的:本研究将探讨在局部晚期宫颈癌(LACC)患者行外照射(EBRT)±同期含铂类化疗+磁共振成像引导的自适应近距离放疗(MR-IGABT)治疗模式中IR-CTV的剂量-体积参数与临床预后之间的剂量效应关系。材料和方法:回顾性分析我中心2016年2月至2019年11月间共62例LACC患者的临床资料,主要入组条件为ⅠB3、ⅡA1、ⅡA2、ⅡB、ⅢA、ⅢB、ⅢC1、ⅢC2、ⅣA期(2018 FIGO分期),所有患者均采用EBRT±同期含铂类化疗+MR-IGABT方案,其中EBRT的剂量范围为45-50.4Gy,1.8-2Gy/f,对部分具有淋巴结转移的患者淋巴结推量至55-60Gy。采用的EBRT技术包括三维适形放射治疗(3D-CRT)、调强放射治疗(IMRT)、容积旋转调强放疗(VMAT)。BT的剂量范围为25-28Gy/4f、27Gy/3f、33Gy/5f,所有患者的BT均于本中心在MRI引导下实施,主要方式包括单纯腔内近距离治疗(ICBT)、组织间插植近距离放疗(ISBT)或IC/ISBT及徒手插植。对患者的年龄、总治疗时间(OTT)、疾病分期、病理类型、诊断时淋巴结转移状态、是否行同期化疗、EBRT技术、BT方式、BT完成时以及完成后3个月时的局部肿瘤缓解情况;第一次BT时GTV体积(GTVres VBT1)及第一次 BT 时 HR-CTV 的体积(HR-CTV VBT1);GTVres 的平均体积(GTVres Vmean)、HR-CTV 的平均体积(HR-CTV Vmean)、IR-CTV 的平均体积(IR-CTV Vmean);GTVres、HR-CTV及IR-CTV的剂量-体积参数D98、D90、D50进行统计分析。采用Kaplan-Meier和单变量及多变量COX回归分析分析5年局部控制率(LC)、总生存率(OS)、无进展生存率(PFS)。采用probit模型评估IR-CTV的体积参数和剂量-体积参数与5年LC、OS、PFS之间的关系。结果:1.共分析62例患者,中位年龄为54(29-79)岁,其中IB3期2人、ⅡA1期1人、ⅡA2期7人、ⅡB期28人、ⅢB期5人、ⅢC1期12人、ⅢC2期1人、IVA期6人。中位OTT为62(49-141)天,27.4%的患者于其他机构完成EBRT后继续于我中心接受BT,导致该部分患者的OTT相对较长。分别有11.3%、80.6%、21.0%的患者分别接受了新辅助化疗、同步化疗和辅助化疗。88.7%的患者病理类型为鳞癌,其余患者均为腺癌。分别有12.9%、87.1%、43.5%的患者分别接受了 ICBT、ISBT或IC/ISBT及徒手插植。中位随访时间为56.2(5.9-86.7)个月,BT完成时以及完成后3个月时的局部肿瘤完全缓解率分别达到了 56.5%和83.9%,共14例患者死亡,但有4例死于非肿瘤因素,5年LC、OS和PFS分别为69.4%、69.4%和 67.7%。单变量 COX 回归分析显示 GTVres VBT1、HR-CTV VBT1、GTVres Vmean、HR-CTVVmean、IR-CTVVmean、GTVres D90、GTVres D98、HR-CTV D50、HR-CTV D90、HR-CTV D98、BT完成后3个月时的局部肿瘤缓解情况与5年LC、OS和PFS密切相关,结果具有统计学意义(P<0.05),而肿瘤分期对与5年LC和OS密切相关,结果具有统计学意义(P<0.05),此外IR-CTV的剂量-体积参数与LACC患者的5年预后未见显著相关。进一步的多变量COX回归分析显示 IR-CTV Vmean是影响 5 年 LC(P=0.05)、OS(P=0.032)和 PFS(P=0.015)的独立预测因素。probit概率模型显示对于接受MR-IGABT的LACC患者,IR-CTV Vmean分别小于 35.1、35.1、44.8cm3 时,患者的 5 年 LC、OS 和 PFS 可达到90%以上。结论:1.接受 MR-IGABT 的 LACC 患者的 IR-CTV D50、D90 和 D98 与其 5 年 LC、OS和PFS未见显著相关性。2.接受MR-IGABT的LACC患者的IR-CTV Vmean是影响其5年LC、OS和PFS的独立预测因素。3.接受MR-IGABT的LACC患者的IR-CTV Vmean小于35.1cm3时,其5年LC、OS和PFS均可达到90%。更多还原

【Abstract】 Purpose:This study investigates the dose-response relationships between Intermediate-risk clinical target volume(IR-CTV)dose-volume parameters and clinical outcomes in patients with locally advanced cervical cancer(LACC)undergoing a combined treatment regimen of external beam radiotherapy(EBRT)with or without concurrent platinum-based chemotherapy,followed by magnetic resonance imaging-guided adaptive brachytherapy(MR-IGABT).Material/Method(s):A retrospective analysis was conducted on the clinical data of 62 patients with LACC treated at our center from February 2016 to November 2019.The main inclusion criteria were stages ⅠB3,ⅡA1,ⅡA2,ⅡB,ⅢA,ⅢB,ⅢC1,ⅢC2,and IVA according to the 2018 FIGO staging system.All patients were treated with EBRT ±concurrent platinum-based chemotherapy+MR-IGABT.The dose range for EBRT was 45-50.4 Gy,with 1.8-2 Gy per fraction.For patients with lymph node metastasis,the lymph node boost dose was increased to 55-60 Gy.The EBRT techniques employed included Three-dimensional Conformal Radiotherapy(3D-CRT),Intensity Modulated Radiotherapy(IMRT),and Volume Modulated Arc Therapy(VMAT).The BT dose ranges were 25-28 Gy/4 fractions,27 Gy/3 fractions,and 33 Gy/5 fractions.All BT procedures were performed at our center under MRI guidance,primarily using Intracavitary Brachytherapy(ICBT),Interstitial Brachytherapy(ISBT),or a combination of IC/ISBT and freehand implantation.The following factors were statistically analyzed:patient age,Overall Treatment Time(OTT),disease stage,pathological type,lymph node metastasis status at diagnosis,whether concurrent chemotherapy was administered,EBRT technique,BT method,local tumor response at the completion of BT and 3 months post-BT,GTV volume at the first BT(GTVres VBT1),HR-CTV volume at the first BT(HR-CTV VBT1),GTVres Vmean,HR-CTV Vmean,IR-CTV Vmean,and dose-volume parameters D98,D90,and D50 for GTVres,HR-CTV,and IR-CTV.Kaplan-Meier and univariate and multivariate COX regression analyses were used to assess the 5-year Local Control(LC),Overall survival(OS),and Progression-Free survival(PFS).The probit model was used to evaluate the relationship between IR-CTV volume parameters,dose-volume parameters,and 5-year LC,OS,and PFS.Results:A total of 62 patients were analyzed,with a median age of 54(29-79)years.The distribution of disease stages was as follows:2 patients with IB3,1 with ⅡA1,7 withⅡA2,28 with ⅡB,5 with ⅢB,12 with ⅢC1,1 with ⅢC2,and 6 with IVA.The OTT was 62(49-141)days.Notably,27.4%of the patients completed EBRT at other institutions before continuing with BT at our center,resulting in relatively longer OTT for these patients.Additionally,11.3%,80.6%,and 21.0%of the patients received neoadjuvant chemotherapy,concurrent chemotherapy,and adjuvant chemotherapy,respectively.The pathological type was squamous cell carcinoma in 88.7%of the patients,with the remaining cases being adenocarcinoma.In terms of BT methods,12.9%received ICBT,87.1%received ISBT or a combination of IC/ISBT,and freehand implantation was performed in 43.5%of the cases.The median follow-up time was 56.2(5.9-86.7)months.The complete local tumor response rates at the completion of BT and 3 months post-BT were 56.5%and 83.9%,respectively.A total of 14 patients died,but 4 of these deaths were due to non-cancer-related causes.The 5-year LC,OS,and PFS rates were 69.4%,69.4%,and 67.7%,respectively.Univariate COX regression analysis revealed that GTVres VBT1,HR-CTV VBT1,GTVres Vmean,HR-CTV Vmean,IR-CTV Vmean,GTVres D90,GTVres D98,HR-CTV D50,HR-CTV D90,HR-CTV D98,and local tumor response at 3 months post-BT were significantly associated with 5-year LC,OS,and PFS(P<0.05).Additionally,tumor stage was significantly correlated with 5-year LC and OS(P<0.05).However,no significant correlation was observed between IR-CTV dose-volume parameters and 5-year prognosis in LACC patients.Further multivariate COX regression analysis identified IR-CTV Vmean as an independent predictive factor for 5-year LC(P=0.05),OS(P=0.032),and PFS(P=0.015).The probit probability model indicates that for LACC patients undergoing MR-IGABT,when the IR-CTV Vmean is less than 35.1 cm3,35.1 cm3,and 44.8 cm3 respectively,the 5-year LC,OS,and PFS rates of the patients can exceed 90%.Conclusion:1.No significant correlations were observed between the IR-CTV D50,D90,and D98 values and the 5-year LC,OS,and PFS rates in LACC patients who underwent MR-IGABT.2.The IR-CTV Vmean emerged as an independent predictor of 5-year LC,OS,and PFS in LACC patients treated with MR-IGABT.3.When the IR-CTV Vmean was less than 35.1 cm3 in LACC patients receiving MR-IGABT,the 5-year LC,OS,and PFS rates all reached 90%.更多还原