局部晚期宫颈癌3D-IGABT时膀胱不同充盈体积对靶区及危及器官的影响

梅烦; 李杰慧; 杜燕军; 胡丽丽; 田雪; 洪卫; 刘雯; 李凤虎

doi:10.3760/cma.j.cn121381-202503019-00600

局部晚期宫颈癌3D-IGABT时膀胱不同充盈体积对靶区及危及器官的影响

Effects of different bladder filling volumes on target areas and organs at risk during three-dimensional image-guided adaptive brachytherapy for locally advanced cervical cancer

摘要

摘要:
目的探讨局部晚期宫颈癌三维图像引导自适应近距离放射治疗（3D-IGABT）时膀胱不同充盈体积对靶区及危及器官的影响。
方法选取2020年11月至2022年3月于贵州医科大学附属肿瘤医院就诊的153例未手术局部晚期宫颈癌患者进行前瞻性研究，患者年龄（55.4±4.3）岁。所有患者共接受526例次（以下用n表示例次）3D-IGABT。采用随机数字表法将所有患者按膀胱注入含造影剂生理盐水体积（即膀胱充盈体积）分为2组：50~70 ml组（n=266）、80~100 ml组（n=260）。再以高危临床靶区（HR-CTV）体积中位数35.85 cm³为界，将HR-CTV体积≥35.85 cm³的患者分为50~70 ml组（n=123）与80~100 ml组（n=140）；将HR-CTV体积<35.85 cm³的患者分为50~70 ml组（n=143）与80~100 ml组（n=120）。参照国际辐射单位与测量委员会第89号报告勾画残存大体肿瘤体积（GTV_res）、HR-CTV以及膀胱、直肠、乙状结肠和小肠等危及器官。采用Oncentra MasterPlan 3.2治疗计划系统制定治疗计划，分别记录GTV_res和HR-CTV的体积、剂量，以及危及器官1 cm³体积在施源器附近接受高剂量区照射的剂量（简称\rmD_1\;\rmc\rmm^3 ）、2 cm³体积在施源器附近接受高剂量区照射的剂量（简称\rmD_2\;\rmc\rmm^3 ）。组间比较采用独立样本t检验或非参数秩和检验。
结果 50~70 ml组（n=266、123、143）与80~100 ml组（n=260、140、120）比较，GTV_res和HR-CTV的体积、剂量的差异均无统计学意义（Z=−1.96~−0.02，均P>0.05）。50~70 ml组（n=266）与80~100 ml组（n=260）比较，50~70 ml组（n=266）膀胱的\rmD_2\;\rmc\rmm^3 、\rmD_1\;\rmc\rmm^3 明显降低，差异均有统计学意义280.40（259.53, 303.41） cGy对297.88（272.10, 320.87） cGy、304.65（281.61, 330.33） cGy对319.49（295.19, 348.97） cGy，Z=−5.40、−4.83，均P<0.001）；50~70 ml组（n=266）乙状结肠的\rmD_2\;\rmc\rmm^3 、\rmD_1\;\rmc\rmm^3 明显增高，差异均有统计学意义204.36（165.19, 240.71） cGy对188.89（152.56, 229.53） cGy、245.33（186.42, 260.81） cGy对210.31（174.02, 250.12） cGy，Z=−2.24、−1.67，均P<0.05）。50~70 ml组（n=123）与80~100 ml组（n=140）比较，50~70 ml组（n=123）膀胱的\rmD_2\;\rmc\rmm^3 、\rmD_1\;\rmc\rmm^3 均明显降低，差异均有统计学意义（282.10±31.27） cGy对（297.22±29.05） cGy、（304.57±34.98） cGy对（320.58±31.45） cGy，t=−4.04、−3.88，均P<0.001）。50~70 ml组（n=143）与80~100 ml组（n=120）比较，50~70 ml组（n=143）膀胱的\rmD_2\;\rmc\rmm^3 、\rmD_1\;\rmc\rmm^3 均明显降低，差异均有统计学意义（279.93±33.70） cGy对（296.45±34.15） cGy、（306.14±38.27） cGy对（322.15±37.79） cGy，t=−3.93、−3.40，均P<0.05）；80~100 ml组（n=120）乙状结肠的\rmD_2\;\rmc\rmm^3 、\rmD_1\;\rmc\rmm^3 均明显降低，差异均有统计学意义（173.93±53.16） cGy对（191.81±59.53） cGy、（202.44±54.67） cGy对（220.01±61.38） cGy，t=−2.83、−1.21，均P<0.05）。
结论行3D-IGABT的局部晚期宫颈癌患者，当HR-CTV体积≥35.85 cm³时，推荐采用50~70 ml膀胱充盈体积，该方案在保证GTV_res、HR-CTV剂量的同时，有助于降低膀胱受照剂量；当HR-CTV体积<35.85 cm³时，为保护膀胱宜选择50~70 ml膀胱充盈体积，而为保护乙状结肠则建议选择80~100 ml膀胱充盈体积。

Abstract:
Objective To investigate the effects of different bladder filling volumes on target areas and organs at risk during three-dimensional image-guided adaptive brachytherapy (3D-IGABT) for locally advanced cervical cancer.
Methods A prospective study was conducted involving 153 non-surgical locally advanced cervical cancer patients treated at the Affiliated Cancer Hospital of Guizhou Medical University from November 2020 to March 2022, with a mean age of (55.4±4.3) years. All patients collectively underwent a total of 526 sessions (hereafter denoted as n) of 3D-IGABT. Using random number table method, all patients were divided into two groups in accordance with the volume of saline containing contrast agent instilled into the bladder (bladder filling volumes): 50–70 ml group (n=266) and 80–100 ml group (n=260). Then, using a median volume of 35.85 cm³ for the high-risk clinical target volume (HR-CTV) as the cut-off value, patients with HR-CTV≥35.85 cm³ were divided into 50–70 ml group (n=123) and 80–100 ml group (n=140); patients with HR-CTV<35.85 cm³ were divided into 50–70 ml group (n=143) and 80–100 ml group (n=120). In reference to the International Commission on Radiation Units and Measurements No.89 report, residual gross tumor volume (GTV_res); HR-CTV; and organs at risk, such as bladder, rectum, sigmoid colon, and small intestine, were delineated. Treatment plans were developed using the Oncentra MasterPlan 3.2 treatment planning system. The volumes and doses of GTV_res and HR-CTV, the dose received by 1 cm³ volume of organs at risk near the applicator in high-dose region (\rmD_1\;\rmc\rmm^3 ), and the dose received by 2 cm³ volume near the applicator in high-dose region (\rmD_2\;\rmc\rmm^3 ) were recorded. Intergroup comparisons were performed using independent sample t-test or nonparametric rank-sum test.
Results Comparison between the 50–70 ml group (n=266, 123, 143) and the 80–100 ml group (n=260, 140, 120) showed no statistically significant difference in the volume or dose of GTV_res and HR-CTV (Z=−1.96 to −0.02, all P>0.05). Comparison between the 50–70 ml group (n=266) and the 80–100 ml group (n=260), 50–70 ml group (n=266) revealed a significant reduction in bladder \rmD_2\;\rmc\rmm^3 and \rmD_1\;\rmc\rmm^3 , with statistically significant differences ((280.40 (259.53, 303.41) cGy vs. 297.88 (272.10, 320.87) cGy, 304.65 (281.61, 330.33) cGy vs. 319.49 (295.19, 348.97) cGy, Z=−5.40, −4.83, both P<0.001); 50–70 ml group (n=266) sigmoid colon \rmD_2\;\rmc\rmm^3 and \rmD_1\;\rmc\rmm^3 were significant increases, and the differences were statistically significant ((204.36 (165.19, 240.71) cGy vs. 188.89 (152.56, 229.53) cGy, 245.33 (186.42, 260.81) cGy vs. 210.31 (174.02, 250.12) cGy, Z=−2.24, −1.67, both P<0.05). Comparison between the 50–70 ml group (n=123) and the 80–100 ml group (n=140), showed that the bladder \rmD_2\;\rmc\rmm^3 and \rmD_1\;\rmc\rmm^3 of the 50–70 ml group (n=123) were significantly reduced, and the differences were statistically significant ((282.10±31.27) cGy vs. (297.22±29.05) cGy, (304.57±34.98) cGy vs. (320.58±31.45) cGy, t=−4.04, −3.88, both P<0.001). Comparison between the 50–70 ml group (n=143) and the 80–100 ml group (n=120) showed that the 50–70 ml group (n=143) had significantly reduced bladder \rmD_2\;\rmc\rmm^3 and \rmD_1\;\rmc\rmm^3 , with statistically significant differences ((279.93±33.70) cGy vs. (296.45±34.15) cGy, (306.14±38.27) cGy vs. (322.15±37.79) cGy, t=−3.93, −3.40, both P<0.05). Meanwhile, the 80–100 ml group (n=120) demonstrated a significant reduction in sigmoid colon \rmD_2\;\rmc\rmm^3 and \rmD_1\;\rmc\rmm^3 , and the differences were statistically significant ( (173.93±53.16) cGy vs. (191.81±59.53) cGy, (202.44±54.67) cGy vs. (220.01±61.38) cGy, t=−2.83, −1.21, both P<0.05).
Conclusions Among patients with locally advanced cervical cancer receiving 3D-IGABT, when HR-CTV≥35.85 cm³, bladder filling volume of 50–70 ml is recommended. This plan ensures the doses of GTV_res and HR-CTV and helps reduce the radiation dose to the bladder. When HR-CTV<35.85 cm³, bladder filling volumes of 50–70 and 80–100 ml are preferable to protect the bladder and the sigmoid colon, respectively.

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