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局部晚期宫颈癌的标准治疗方法是外照射联合近距离放射治疗(放疗)[1-2]。宫颈癌的近距离放疗包括单纯腔内治疗和腔内联合组织间插植治疗(简称腔内+插植治疗),其中单纯腔内治疗即传统的宫腔管+卵圆体治疗方式,由于创伤小,施源器位置比较固定,临床应用较广泛;腔内+插植治疗即采用宫腔管联合插植针的治疗方式,因其可灵活调整插植针的数量、位置和进针深度,可最大限度地实现对靶区的处方剂量覆盖并有效保护危及器官(organ at risk,OAR)[3]。笔者发现2种治疗方式的疗效与患者肿瘤靶体积的大小有着直接关系,但对于不同体积的肿瘤选用何种后装治疗技术却鲜有文献详细报道。本研究主要针对不同高危临床靶体积(high risk-clinical target volume,HR-CTV)中单纯腔内治疗与腔内+插植治疗的剂量学差异进行探讨,并通过对比分析总结出HR-CTV可能存在的阈值,为临床后装治疗技术的选择提供参考。
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由表1可知,当HR-CTV≤40 cm3时,单纯腔内治疗组靶区剂量(D90、 D100)和靶区覆盖度(V100)均优于腔内+插植治疗组(均P<0.05),而当70 cm3<HR-CTV≤80 cm3及HR-CTV>80 cm3时,腔内+插植治疗组的D90、 D100、V100均显著大于单纯腔内治疗组(均P<0.01);在40 cm3<HR-CTV≤50 cm3、50 cm3<HR-CTV≤60 cm3、60 cm3<HR-CTV≤70 cm3时,2组间D90、 D100、V100的差异均无统计学意义(均P>0.01)。单纯腔内治疗组的靶区高量(D50、V150、V200)在各体积范围内均高于腔内+插植治疗组,其中HR-CTV≤60 cm3时,2组间的差异均有统计学意义(均P<0.05),而当HR-CTV>60 cm3时,2组的靶区高量相近,且差异均无统计学意义(均P>0.05)。与单纯腔内治疗组比较,HR-CTV>40 cm3时,腔内+插植治疗组则显著提高了靶区CI,且差异均有统计学意义(均P<0.05)。单纯腔内治疗和腔内+插值治疗宫颈癌患者的剂量分布比较如图1所示。
靶区剂量学参数 体积范围(cm3) 单纯腔内治疗组
(n=45)腔内+插植治疗组
(n=55)t值 P值 D90(cGy) HR-CTV≤40 597.6±29.7 543.5±46.5 2.826 0.012 40<HR-CTV≤50 560.3±41.3 584.2±42.6 −0.837 0.410 50<HR-CTV≤60 563.1±51.3 572.3±31.2 −0.751 0.451 60<HR-CTV≤70 556.2±46.5 573.6±32.4 −1.759 0.087 70<HR-CTV≤80 492.4±43.6 577.8±38.6 −4.963 <0.001 HR-CTV>80 475.6±28.5 557.8±28.8 −5.976 <0.001 D100(cGy) HR-CTV≤40 366.7±47.5 310.5±38.2 2.951 0.010 40<HR-CTV≤50 306.2±36.4 337.6±61.4 −1.416 0.191 50<HR-CTV≤60 297.6±50.5 319.3±51.8 −1.485 0.161 60<HR-CTV≤70 295.6±36.1 322.4±37.5 −1.322 0.194 70<HR-CTV≤80 259.6±42.7 348.7±57.8 −4.675 <0.001 HR-CTV>80 259.4±36.4 316.1±46.3 −3.642 0.002 V100(%) HR-CTV≤40 89.9±3.1 83.1±5.8 3.128 0.005 40<HR-CTV≤50 87.7±3.7 88.5±5.3 0.710 0.524 50<HR-CTV≤60 86.3±5.1 87.0±4.5 −0.227 0.811 60<HR-CTV≤70 85.6±4.3 86.5±4.1 −0.684 0.533 70<HR-CTV≤80 80.9±3.8 86.1±4.0 −3.779 0.001 HR-CTV>80 78.5±4.9 85.3±3.4 −3.486 0.003 D50(cGy) HR-CTV≤40 993.2±51.2 880.3±60.1 3.771 0.002 40<HR-CTV≤50 971.6±22.2 912.6±31.2 4.534 0.001 50<HR-CTV≤60 942.1±58.7 879.2±49.7 2.556 0.018 60<HR-CTV≤70 938.6±59.2 911.3±60.3 1.524 0.139 70<HR-CTV≤80 914.2±40.3 906.7±65.2 0.613 0.547 HR-CTV>80 902.2±61.8 873.6±45.6 1.245 0.195 V150(%) HR-CTV≤40 57.9±4.1 49.0±5.9 3.545 0.003 40<HR-CTV≤50 56.2±3.1 52.3±3.1 2.477 0.020 50<HR-CTV≤60 54.5±5.7 49.2±6.2 2.934 0.008 60<HR-CTV≤70 53.6±4.1 51.3±4.8 1.262 0.213 70<HR-CTV≤80 51.2±3.5 50.0±5.1 0.752 0.459 HR-CTV>80 48.9±5.7 47.9±4.8 0.717 0.494 V200(%) HR-CTV≤40 36.8±2.3 29.8±4.1 3.927 0.001 40<HR-CTV≤50 34.8±1.9 30.8±3.1 3.626 0.002 50<HR-CTV≤60 34.2±3.8 29.6±4.1 3.027 0.007 60<HR-CTV≤70 33.1±3.8 31.5±4.1 1.753 0.088 70<HR-CTV≤80 32.3±2.9 30.6±4.0 1.918 0.069 HR-CTV>80 30.8±4.9 28.8±4.2 1.417 0.182 CI HR-CTV≤40 0.66±0.07 0.62±0.04 0.186 0.851 40<HR-CTV≤50 0.59±0.05 0.67±0.03 −2.590 0.018 50<HR-CTV≤60 0.61±0.07 0.71±0.03 −4.577 <0.001 60<HR-CTV≤70 0.62±0.05 0.69±0.06 −3.144 0.006 70<HR-CTV≤80 0.57±0.04 0.71±0.05 −6.872 <0.001 HR-CTV>80 0.56±0.06 0.71±0.06 −6.298 <0.001 注:D50、D90、D100 分别表示50%、90%、100%靶体积接受的最低照射剂量;V100、V150、V200 分别表示100%、150%、200%处方剂量包绕靶区的体积百分比。HR-CTV为高危临床靶体积;CI为靶区适形指数 表 1 单纯腔内治疗组和腔内+插植治疗组在宫颈癌患者HR-CTV各体积范围的靶区剂量学参数的比较(
±s)$ \bar{x} $ Table 1. Comparison of target dosimetry parameters in various volume ranges of high risk-clinical target volume between intracavitary therapy group and intracavitary/interstitial therapy group in patients with cervical cancer (
±s)$ \bar{x} $ 图 1 Ⅰ b2 期宫颈癌患者(女性,51岁)高危临床靶体积≤40 cm3的单纯腔内治疗(A)和腔内+插植治疗(B) 的等剂量分布图
Figure 1. Comparison of isodose line distribution between intracavitary therapy (A) and intracavitary/interstitial therapy (B) within high risk-clinical target volume≤40 cm3 in a patient (female, 51 years old) with cervical cancer of stage Ⅰ b2
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由表2可知,单纯腔内治疗组和腔内+插植治疗组在HR-CTV≤40 cm3、40 cm3<HR-CTV≤50 cm3、50 cm3<HR-CTV≤60 cm3和60 cm3<HR-CTV≤70 cm3时,直肠D2 cm3剂量间的差异均无统计学意义(均P>0.05),但当HR-CTV>70 cm3时,腔内+插植治疗组的直肠D2 cm3剂量要比单纯腔内治疗组降低20 cGy以上,且差异均有统计学意义(均P<0.05)。膀胱的D2 cm3剂量在HR-CTV≤60 cm3时,2组的差异均无统计学意义(均P>0.05),但当HR-CTV>60 cm3时,单纯腔内治疗组的膀胱D2 cm3剂量随靶区体积增大有升高的趋势,且显著高于腔内+插植治疗组,且差异均有统计学意义(均P<0.05)。2种治疗技术在各体积范围内小肠、乙状结肠的D2 cm3均相近,且差异均无统计学意义(均P>0.05)。
危及器官 体积范围(cm3) 单纯腔内治疗组(n=45) 腔内+插植治疗组(n=55) t值 P值 直肠 HR-CTV≤40 408.1±4.8 405.9±4.2 0.258 0.756 40<HR-CTV≤50 406.1±10.2 409.6±6.6 −1.003 0.378 50<HR-CTV≤60 412.7±9.8 411.2±10.5 0.677 0.512 60<HR-CTV≤70 411.1±15.2 405.8±12.5 −0.733 0.459 70<HR-CTV≤80 431.2±9.5 402.4±3.1 2.745 0.011 HR-CTV>80 438.7±14.2 405.8±2.3 −3.293 0.002 膀胱 HR-CTV≤40 485.3±21.5 462.8±28.5 1.871 0.080 40<HR-CTV≤50 501.3±35.2 484.6±32.5 1.078 0.301 50<HR-CTV≤60 484.2±31.8 471.3±36.4 1.374 0.135 60<HR-CTV≤70 495.4±30.2 461.3±35.2 2.234 0.031 70<HR-CTV≤80 507.1±34.5 481.2±22.1 2.924 0.009 HR-CTV>80 514.5±40.3 481.2±27.3 3.782 0.002 乙状结肠 HR-CTV≤40 253.4±129.1 272.1±109.8 −0.335 0.742 40<HR-CTV≤50 305.8±35.9 335.4±49.6 −0.320 0.755 50<HR-CTV≤60 269.8±79.4 302.1±108.3 −1.507 0.143 60<HR-CTV≤70 254.5±71.0 283.1±66.1 −1.247 0.220 70<HR-CTV≤80 289.3±79.8 302.1±90.9 −1.266 0.215 HR-CTV>80 285.1±71.1 302.4±81.6 −0.533 0.598 小肠 HR-CTV≤40 232.6±52.5 246.4±49.8 −1.046 0.340 40<HR-CTV≤50 253.6±41.5 268.9±52.7 −0.833 0.411 50<HR-CTV≤60 278.7±60.1 272.5±70.5 1.027 0.330 60<HR-CTV≤70 287.8±53.2 273.7±38.7 0.524 0.605 70<HR-CTV≤80 276.4±44.6 280.7±51.7 0.517 0.614 HR-CTV>80 287.8±61.2 272.1±53.5 −0.556 0.583 注:HR-CTV为高危临床靶体积。D2 cm3表示2 cm3的危及器官体积接受的最低照射剂量 表 2 单纯腔内治疗组和腔内+插植治疗组在宫颈癌患者HR-CTV各体积范围的危及器官剂量(D2 cm3)的比较(
±s,cGy)$ \bar{x} $ Table 2. Comparison of organ at risk dose (D2 cm3) in various volume ranges of high risk-clinical target volume between intracavitary therapy group and intracavitary/interstitial therapy group in patients with cervical caner (
±s, cGy)$ \bar{x} $
不同HR-CTV下单纯腔内治疗与腔内联合组织间插植治疗在宫颈癌三维后装治疗中的对比研究
Comparative study of intracavitary therapy and combined intracavitary/interstitial therapy in different HR-CTV in three-dimensional brachytherapy for cervical cancer
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摘要:
目的 研究不同高危临床靶体积(HR-CTV)下单纯腔内治疗与腔内联合组织间插植(腔内+插植)治疗技术在宫颈癌三维后装治疗中的剂量学差异,并探讨HR-CTV是否存在阈值。 方法 回顾性分析2019年10月至2021年2月于广西医科大学第四附属医院接受根治性放疗的100例中晚期宫颈癌患者的临床资料,年龄35~63岁,中位年龄51岁。根据后装治疗技术不同将患者分为单纯腔内治疗组(45例)、腔内+插植治疗组(55例)。按患者每个计划的HR-CTV大小分为6个体积范围进行分析,即HR-CTV≤40 cm3、40 cm3<HR-CTV≤50 cm3、50 cm3<HR-CTV≤60 cm3、60 cm3<HR-CTV≤70 cm3、70 cm3<HR-CTV≤80 cm3、HR-CTV>80 cm3。 采用独立样本t检验比较2种后装治疗技术在不同体积范围内的靶区和危及器官(OAR)的剂量学参数。 结果 当HR-CTV≤40 cm3时,单纯腔内治疗组的靶区剂量(D90、D100)、靶区覆盖度(V100)及靶区高量(D50、V150、V200)均高于腔内+插植治疗组,且差异均有统计学意义(t=2.826~3.927,均P<0.05),但靶区适形指数(CI)、OAR膀胱和直肠D2 cm3(2 cm3的OAR体积接受的最低照射剂量)的差异均无统计学意义(t=0.186、1.871、0.258,均P>0.05)。当70 cm3<HR-CTV≤80 cm3和HR-CTV>80 cm3时,腔内+插植治疗组的靶区剂量(D90、D100)、靶区覆盖度(V100)、CI、OAR直肠和膀胱D2 cm3剂量均显著优于单纯腔内治疗组,且差异均有统计学意义(t=−6.872~3.782,均P<0.05),而2种治疗技术的靶区高量(D50、V150、V200)相近,差异无统计学意义(t=0.613~1.918,均P>0.05)。当40 cm3<HR-CTV≤70 cm3时,2组的靶区剂量(D90、D100)、靶区覆盖度(V100 )以及直肠D2 cm3的差异均无统计学意义(t=−1.759~0.710,均P>0.05),但腔内+插植治疗组的CI显著优于单纯腔内治疗组,且差异均有统计学意义(t=−2.590、−4.577、−3.144,均P<0.05)。 结论 对于小体积靶区(≤40 cm3),单纯腔内治疗技术在不增加OAR剂量的情况下能更好地提高靶区剂量和靶区内高剂量体积;当靶区体积较大特别是>70 cm3时,腔内+插植治疗技术能在显著提高靶区处方剂量和适形度的同时更好地保护OAR。 -
关键词:
- 宫颈肿瘤 /
- 三维后装治疗 /
- 腔内治疗 /
- 组织间插植治疗 /
- 高危临床靶体积;剂量学
Abstract:Objective To study the dosimetric differences between intracavitary therapy and combined intracavitary/interstitial therapy in three-dimensional brachytherapy for cervical cancer at different high-risk clinical target volumes (HR-CTV) and to explore whether HR-CTV has a threshold value. Methods The clinical data of 100 patients with advanced cervical cancer who received radical radiotherapy in the Fourth Affiliated Hospital of Guangxi Medical University from October 2019 to February 2021 were retrospectively analyzed. The age range was 35–63 years, with a median age of 51 years. According to different brachytherapy techniques, the patients were divided into two groups: intracavitary therapy group (45 cases) and intracavitary/interstitial therapy group (55 cases). According to the size of HR-CTV of each plan of a patient, the volume interval of 10 cm3 was used and divided into six volume ranges for analysis, namely, HR-CTV≤40 cm3, 40 cm3<HR-CTV≤50 cm3, 50 cm3<HR-CTV≤60 cm3, 60 cm3<HR-CTV≤70 cm3, 70 cm3<HR-CTV≤80 cm3, HR-CTV>80 cm3. Independent sample t-test was used in comparing the target dose (D90 and D100), target coverage (V100), target high dose (D50, V150, and V200), target conformity index (CI), and D2 cm3 of organ at risks (OAR) (bladder, rectum, sigmoid colon, and small intestine) of the two brachytherapy techniques in various volume ranges. Results When HR-CTV≤40 cm3, the target dose (D90 and D100), target coverage (V100), and high dose of target (D50, V150, and V200) in the intracavitary group were higher than those in the intracavitary/interstitial therapy group, and the differences were statistically significant(t=2.826–3.927, all P<0.05), but no significant difference in CI and D2 cm3 (mininum radiation dose received by the OAR volume of 2 cm3) of the bladder and rectum (t=0.186, 1.871, 0.258; all P>0.05). When 70 cm3<HR-CTV≤80 cm3 and HR-CTV>80 cm3, the target dose (D90 and D100), target coverage (V100), and CI and D2 cm3 of rectum and bladder in the intracavitary/interstitial group were significantly better, and the differences were statistically significant(t=−6.872–3.782, all P<0.05), while the high dose in target (D50, V150, and V200) of the two techniques was similar, and the differences were statistically significant (t=0.613–1.918, all P>0.05). When 40 cm3<HR-CTV≤70 cm3, no significant differences in target dose (D90, D100), target coverage (V100), and D2 cm3 of rectum were found between the two groups (t=−1.759–0.710, all P>0.05), but the CI of intracavitary/interstitial group was significantly better than that of the intracavitary group, and the differences were statistically significant (t=−2.590, −4.577, −3.144; all P<0.05). Conclusions For a small volume target (≤40 cm3), intracavitary therapy alone can better increase the dose of target and high dose volume in a target area without increasing the dose of OAR. When the target volume is large (>70 cm3), combined intracavitary/interstitial therapy can significantly improve the prescribed dose and conformity of the target while protecting the OAR. -
图 1 Ⅰ b2 期宫颈癌患者(女性,51岁)高危临床靶体积≤40 cm3的单纯腔内治疗(A)和腔内+插植治疗(B) 的等剂量分布图
Figure 1. Comparison of isodose line distribution between intracavitary therapy (A) and intracavitary/interstitial therapy (B) within high risk-clinical target volume≤40 cm3 in a patient (female, 51 years old) with cervical cancer of stage Ⅰ b2
表 1 单纯腔内治疗组和腔内+插植治疗组在宫颈癌患者HR-CTV各体积范围的靶区剂量学参数的比较(
±s)$ \bar{x} $ Table 1. Comparison of target dosimetry parameters in various volume ranges of high risk-clinical target volume between intracavitary therapy group and intracavitary/interstitial therapy group in patients with cervical cancer (
±s)$ \bar{x} $ 靶区剂量学参数 体积范围(cm3) 单纯腔内治疗组
(n=45)腔内+插植治疗组
(n=55)t值 P值 D90(cGy) HR-CTV≤40 597.6±29.7 543.5±46.5 2.826 0.012 40<HR-CTV≤50 560.3±41.3 584.2±42.6 −0.837 0.410 50<HR-CTV≤60 563.1±51.3 572.3±31.2 −0.751 0.451 60<HR-CTV≤70 556.2±46.5 573.6±32.4 −1.759 0.087 70<HR-CTV≤80 492.4±43.6 577.8±38.6 −4.963 <0.001 HR-CTV>80 475.6±28.5 557.8±28.8 −5.976 <0.001 D100(cGy) HR-CTV≤40 366.7±47.5 310.5±38.2 2.951 0.010 40<HR-CTV≤50 306.2±36.4 337.6±61.4 −1.416 0.191 50<HR-CTV≤60 297.6±50.5 319.3±51.8 −1.485 0.161 60<HR-CTV≤70 295.6±36.1 322.4±37.5 −1.322 0.194 70<HR-CTV≤80 259.6±42.7 348.7±57.8 −4.675 <0.001 HR-CTV>80 259.4±36.4 316.1±46.3 −3.642 0.002 V100(%) HR-CTV≤40 89.9±3.1 83.1±5.8 3.128 0.005 40<HR-CTV≤50 87.7±3.7 88.5±5.3 0.710 0.524 50<HR-CTV≤60 86.3±5.1 87.0±4.5 −0.227 0.811 60<HR-CTV≤70 85.6±4.3 86.5±4.1 −0.684 0.533 70<HR-CTV≤80 80.9±3.8 86.1±4.0 −3.779 0.001 HR-CTV>80 78.5±4.9 85.3±3.4 −3.486 0.003 D50(cGy) HR-CTV≤40 993.2±51.2 880.3±60.1 3.771 0.002 40<HR-CTV≤50 971.6±22.2 912.6±31.2 4.534 0.001 50<HR-CTV≤60 942.1±58.7 879.2±49.7 2.556 0.018 60<HR-CTV≤70 938.6±59.2 911.3±60.3 1.524 0.139 70<HR-CTV≤80 914.2±40.3 906.7±65.2 0.613 0.547 HR-CTV>80 902.2±61.8 873.6±45.6 1.245 0.195 V150(%) HR-CTV≤40 57.9±4.1 49.0±5.9 3.545 0.003 40<HR-CTV≤50 56.2±3.1 52.3±3.1 2.477 0.020 50<HR-CTV≤60 54.5±5.7 49.2±6.2 2.934 0.008 60<HR-CTV≤70 53.6±4.1 51.3±4.8 1.262 0.213 70<HR-CTV≤80 51.2±3.5 50.0±5.1 0.752 0.459 HR-CTV>80 48.9±5.7 47.9±4.8 0.717 0.494 V200(%) HR-CTV≤40 36.8±2.3 29.8±4.1 3.927 0.001 40<HR-CTV≤50 34.8±1.9 30.8±3.1 3.626 0.002 50<HR-CTV≤60 34.2±3.8 29.6±4.1 3.027 0.007 60<HR-CTV≤70 33.1±3.8 31.5±4.1 1.753 0.088 70<HR-CTV≤80 32.3±2.9 30.6±4.0 1.918 0.069 HR-CTV>80 30.8±4.9 28.8±4.2 1.417 0.182 CI HR-CTV≤40 0.66±0.07 0.62±0.04 0.186 0.851 40<HR-CTV≤50 0.59±0.05 0.67±0.03 −2.590 0.018 50<HR-CTV≤60 0.61±0.07 0.71±0.03 −4.577 <0.001 60<HR-CTV≤70 0.62±0.05 0.69±0.06 −3.144 0.006 70<HR-CTV≤80 0.57±0.04 0.71±0.05 −6.872 <0.001 HR-CTV>80 0.56±0.06 0.71±0.06 −6.298 <0.001 注:D50、D90、D100 分别表示50%、90%、100%靶体积接受的最低照射剂量;V100、V150、V200 分别表示100%、150%、200%处方剂量包绕靶区的体积百分比。HR-CTV为高危临床靶体积;CI为靶区适形指数 表 2 单纯腔内治疗组和腔内+插植治疗组在宫颈癌患者HR-CTV各体积范围的危及器官剂量(D2 cm3)的比较(
±s,cGy)$ \bar{x} $ Table 2. Comparison of organ at risk dose (D2 cm3) in various volume ranges of high risk-clinical target volume between intracavitary therapy group and intracavitary/interstitial therapy group in patients with cervical caner (
±s, cGy)$ \bar{x} $ 危及器官 体积范围(cm3) 单纯腔内治疗组(n=45) 腔内+插植治疗组(n=55) t值 P值 直肠 HR-CTV≤40 408.1±4.8 405.9±4.2 0.258 0.756 40<HR-CTV≤50 406.1±10.2 409.6±6.6 −1.003 0.378 50<HR-CTV≤60 412.7±9.8 411.2±10.5 0.677 0.512 60<HR-CTV≤70 411.1±15.2 405.8±12.5 −0.733 0.459 70<HR-CTV≤80 431.2±9.5 402.4±3.1 2.745 0.011 HR-CTV>80 438.7±14.2 405.8±2.3 −3.293 0.002 膀胱 HR-CTV≤40 485.3±21.5 462.8±28.5 1.871 0.080 40<HR-CTV≤50 501.3±35.2 484.6±32.5 1.078 0.301 50<HR-CTV≤60 484.2±31.8 471.3±36.4 1.374 0.135 60<HR-CTV≤70 495.4±30.2 461.3±35.2 2.234 0.031 70<HR-CTV≤80 507.1±34.5 481.2±22.1 2.924 0.009 HR-CTV>80 514.5±40.3 481.2±27.3 3.782 0.002 乙状结肠 HR-CTV≤40 253.4±129.1 272.1±109.8 −0.335 0.742 40<HR-CTV≤50 305.8±35.9 335.4±49.6 −0.320 0.755 50<HR-CTV≤60 269.8±79.4 302.1±108.3 −1.507 0.143 60<HR-CTV≤70 254.5±71.0 283.1±66.1 −1.247 0.220 70<HR-CTV≤80 289.3±79.8 302.1±90.9 −1.266 0.215 HR-CTV>80 285.1±71.1 302.4±81.6 −0.533 0.598 小肠 HR-CTV≤40 232.6±52.5 246.4±49.8 −1.046 0.340 40<HR-CTV≤50 253.6±41.5 268.9±52.7 −0.833 0.411 50<HR-CTV≤60 278.7±60.1 272.5±70.5 1.027 0.330 60<HR-CTV≤70 287.8±53.2 273.7±38.7 0.524 0.605 70<HR-CTV≤80 276.4±44.6 280.7±51.7 0.517 0.614 HR-CTV>80 287.8±61.2 272.1±53.5 −0.556 0.583 注:HR-CTV为高危临床靶体积。D2 cm3表示2 cm3的危及器官体积接受的最低照射剂量 -
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