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처방선량 및 치료기법별 치료성적 분석 결과에 기반한 자궁경부암 환자의 최적 방사선치료 스케쥴

Other Titles
 Optimum Radiotherapy Schedule for Uterine Cervical Cancer based-on the Detailed Information of Dose Fractionation and Radiotherapy Technique 
 조재호  ;  김현창  ;  서창옥  ;  이창걸  ;  금기창  ;  조남훈  ;  이익재  ;  심수정  ;  서양권  ;  성진실  ;  김귀언 
 Journal of the Korean Society for Therapeutic Radiology and Oncology, Vol.23(3) : 143-156, 2005 
Journal Title
Journal of the Korean Society for Therapeutic Radiology and Oncology(대한방사선종양학회지)
Issue Date
Cervix cancer ; Fractionation ; High dose rate brachytherapy
Cervix cancer ; Fractionation ; High dose rate brachytherapy
Background: The best dose-fractionation regimen of the definitive radiotherapy for cervix cancer remains to be clearly determined. It seems to be partially attributed to the complexity of the affecting factors and the lack of detailed information on external and intra-cavitary fractionation. To find optimal practice guidelines, our experiences of the combination of external beam radiotherapy (EBRT) and high-dose-rate intracavitary brachytherapy (HDR-ICBT) were reviewed with detailed information of the various treatment parameters obtained from a large cohort of women treated homogeneously at a single institute.

Materials and Methods: The subjects were 743 cervical cancer patients (Stage IB 198, IIA 77, IIB 364, IIIA 7, IIIB 89 and IVA 8) treated by radiotherapy alone, between 1990 and 1996. A total external beam radiotherapy (EBRT) dose of 23.4~59.4 Gy (Median 45.0) was delivered to the whole pelvis. High-dose-rate intracavitary brachytherapy (HDR-ICBT) was also performed using various fractionation schemes. A Midline block (MLB) was initiated after the delivery of 14.4~43.2 Gy (Median 36.0) of EBRT in 495 patients, while in the other 248 patients EBRT could not be used due to slow tumor regression or the huge initial bulk of tumor. The point A, actual bladder & rectal doses were individually assessed in all patients. The biologically effective dose (BED) to the tumor (α/β=10) and late-responding tissues (α/β=3) for both EBRT and HDR-ICBT were calculated. The total BED values to point A, the actual bladder and rectal reference points were the summation of the EBRT and HDR-ICBT. In addition to all the details on dose-fractionation, the other factors (i.e. the overall treatment time, physicians preference) that can affect the schedule of the definitive radiotherapy were also thoroughly analyzed. The association between MD-BED Gy3 and the risk of complication was assessed using serial multiple logistic regression models. The associations between R-BED Gy3 and rectal complications and between V-BED Gy3 and bladder complications were assessed using multiple logistic regression models after adjustment for age, stage, tumor size and treatment duration. Serial Coxs proportional hazard regression models were used to estimate the relative risks of recurrence due to MD-BED Gy10, and the treatment duration.

Results: The overall complication rate for RTOG Grades 1~4 toxicities was 33.1%. The 5-year actuarial pelvic control rate for all 743 patients was 83%. The midline cumulative BED dose, which is the sum of external midline BED and HDR-ICBT point A BED, ranged from 62.0 to 121.9 Gy10 (median 93.0) for tumors and from 93.6 to 187.3 Gy3 (median 137.6) for late responding tissues. The median cumulative values of actual rectal (R-BED Gy3) and bladder point BED (V-BED Gy3) were 118.7 Gy3 (range 48.8~265.2) and 126.1 Gy3 (range: 54.9~267.5), respectively. MD-BED Gy3 showed a good correlation with rectal (p=0.003), but not with bladder complications (p=0.095). R-BED Gy3 had a very strong association (p=<0.0001), and was more predictive of rectal complications than A-BED Gy3. B-BED Gy3 also showed significance in the prediction of bladder complications in a trend test (p=0.0298). No statistically significant dose-response relationship for pelvic control was observed. The  Sandwich  and  Continuous  techniques, which differ according to when the ICR was inserted during the EBRT and due to the physicians preference, showed no differences in the local control and complication rates; there were also no differences in the 3 vs. 5 Gy fraction size of HDR-ICBT.

Conclusion: The main reasons optimal dose-fractionation guidelines are not easily established is due to the absence of a dose-response relationship for tumor control as a result of the high-dose gradient of HDR-ICBT, individual differences in tumor responses to radiation therapy and the complexity of affecting factors. Therefore, in our opinion, there is a necessity for individualized tailored therapy, along with general guidelines, in the definitive radiation treatment for cervix cancer. This study also demonstrated the strong predictive value of actual rectal and bladder reference dosing therefore, vaginal gauze packing might be very important. To maintain the BED dose to less than the threshold resulting in complication, early midline shielding, the HDR-ICBT total dose and fractional dose reduction should be considered.
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1. College of Medicine (의과대학) > Dept. of Orthopedic Surgery (정형외과학교실) > 1. Journal Papers
1. College of Medicine (의과대학) > Dept. of Pathology (병리학교실) > 1. Journal Papers
1. College of Medicine (의과대학) > Dept. of Preventive Medicine (예방의학교실) > 1. Journal Papers
1. College of Medicine (의과대학) > Dept. of Radiation Oncology (방사선종양학교실) > 1. Journal Papers
Yonsei Authors
Keum, Ki Chang(금기창) ORCID logo https://orcid.org/0000-0003-4123-7998
Kim, Gwi Eon(김귀언)
Kim, Hyeon Chang(김현창) ORCID logo https://orcid.org/0000-0001-7867-1240
Suh, Chang Ok(서창옥)
Seong, Jin Sil(성진실) ORCID logo https://orcid.org/0000-0003-1794-5951
Shim, Su Jung(심수정)
Lee, Ik Jae(이익재) ORCID logo https://orcid.org/0000-0001-7165-3373
Lee, Chang Geol(이창걸) ORCID logo https://orcid.org/0000-0002-8702-881X
Cho, Nam Hoon(조남훈) ORCID logo https://orcid.org/0000-0002-0045-6441
Cho, Jae Ho(조재호) ORCID logo https://orcid.org/0000-0001-9966-5157
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