국한성 두경부 대세포성(Diffuse Large Cell) 림프종의 적정 방사선 조사선량

The Optimal Radiation Dose in Localized Head and Neck Diffuse Large Cell Lymphoma

  • 금웅섭 (연세대학교 의과대학 방사선종양학교실) ;
  • 서창옥 (연세대학교 의과대학 방사선종양학교실) ;
  • 김용배 (연세대학교 의과대학 방사선종양학교실) ;
  • 심수정 (연세대학교 의과대학 방사선종양학교실) ;
  • 표홍렬 (연세대학교 의과대학 방사선종양학교실) ;
  • 노재경 (연세대학교 의과대학 연세암센터) ;
  • 정현철 (연세대학교 의과대학 연세암센터) ;
  • 김귀언 (연세대학교 의과대학 방사선종양학교실)
  • Koom Woong Sub (Department of Radiation Oncolgy, Yonsei University College of Medicine) ;
  • Suh Chang Ok (Department of Radiation Oncolgy, Yonsei University College of Medicine) ;
  • Kim Yong Bae (Department of Radiation Oncolgy, Yonsei University College of Medicine) ;
  • Shim Su Jung (Department of Radiation Oncolgy, Yonsei University College of Medicine) ;
  • Pyo Hongryull (Department of Radiation Oncolgy, Yonsei University College of Medicine) ;
  • Roh Jae Kyung (Yonsei Cancer Center, Yonsei University College of Medicine) ;
  • Chung Hyun Cheol (Yonsei Cancer Center, Yonsei University College of Medicine) ;
  • Kim Gwi Eon (Department of Radiation Oncolgy, Yonsei University College of Medicine)
  • 발행 : 2002.12.01

초록

목적 : 두경부에 국한된 1기, 2기 대세포성(diffuse large cell) 비호치킨 림프종의 항암화학방사선 병용요법 시 방사선 조사영역 내의 재발을 예방하기 위한 적정 방사선 조사선량을 알아보고자 하였다. 대상 및 방법 : 1985년 5월부터 1998년 12월까지 국한성 두경부 대세포성 림프종으로 항암화학요법 후 방사선치료를 받은 53명을 대상으로 하였다. 나이는 13세부터 69세까지였으며 중앙값은 49세였다. 남녀 비는 1.65대 1이었고 1기, 2기 환자가 각각 27명, 26명이었다. 종양 크기별로 5 cm 미만이 30명, 5 cm 이상이 23명이었다. 원발부위는 경부림프절 22명, 편도 20명, 비인두 4명, 설기저부 3명, 부비동 2명, 후두 1명, 연구개 1명이었다. 항암화학요법은 1명을 제외하고 3회 이상 시행되었으며 방사선치료는 48명이 원발부위와 경부임파선을, 5명이 원발부위만 치료하였다. 생존율, 무병생존율, 조사영역 내 무재발생존율과 방사선 조사선량에 따른 방사선 조사영역 내에서의 재발빈도를 조사하였다. 결과 : 항암화학요법 후 44명$(83\%)$이 완전관해 되었고 연이은 방사선치료 후 53명 모두 완전관해 되었다. 12명$(23\%)$이 재발하였고 그중 2명은 방사선 조사영역 내 재발이었고 방사선 조사영역 바깥 재발은 11명으로 복강 및 골반내 림프절이 가장 많았다. 방사선 조사선량 별 조사영역 내 재발은 $30\~35\;Gy$에서 7명 중 1명, $35\~40\;Gy$에서 16명중 1명이었고 40 Gy 이상에서는 재발이 없었다. 방사선 조사영역 내 재발에 유의한 예후인자는 없었으나 5 cm 이상인 종양에서 재발하였고 5 cm 미만인 종양은 30 Gy에서도 재발하지 않았다. 10 년 방사선 조사영역내 무재발 생존율, 무병생존율, 전체생존율은 각각 $96\%,\;76\%,\;75\%$였다. 결론 : 국한성 두경부 대세포성 림프종에서 항암화학방사선 병용요법 시 종양의 크기가 5 cm 미만인 경우에는 30Gy의 방사선 조사선량으로도 국소제어를 할 수 있다. 따라서 방사선치료에 따르는 구강건조증을 최소화시킬 수 있을 것이다. 5 cm 이상의 종양에서는 30 Gy 이상의 방사선 조사 선량이 필요하리라 생각된다.

Purpose : To determine the optimal radiation dose in a localized non-Hodgkin's lymphoma of the head and neck in the treatment setting for combined chemoradiotherapy. Materials an Methods :Fifty-three patients with stage I and II diffuse large ceil non-Hodgkin's lymphoma of the head and neck, who were treated with combined chemoradiotherapy between 1985 and 1998 were retrospectively reviewed. The median age was 49 years, and the male-to-female ratio was approximately 1.6. Twenty-seven patients had stage 1 disease and 26 had stage II. Twenty-three patients had bulky tumors $(\geq5\;cm)$ and 30 had non-bulky tumors (<5 cm). The primary tumors arose mainly from an extranodal organ $(70\%)$, most cases involving Waldeyer's ring $(90\%)$. All patients except one were initially treated with $3\~6$ cycles of chemotherapy, which was followed by radiotherapy. Radiation was delivered either to the primary tumor area alone $(9\%)$ or to the primary tumor area plus the bilateral neck nodes $(91\%)$ with a minimum dose of 30 Gy $(range\;30\~60\;Gy)$. The failure patterns according to the radiation field were analyzed, and the relationship between the dose and the in-field recurrence was evaluated. Results : The 10-year overall survival and the 10-year disease free survival rates were similar at $75\%\;and\;76\%$, respectively. A complete response (CR) after chemotherapy was achieved in 44 patients $(83\%)$. Subsequent radiotherapy showed a CR in all patients. Twelve patients $(23\%)$ had a relapse of the lymphoma after the initial treatment. Two of these patients had a recurrence inside the radiation field. No clear dose response relationship was observed and no significant prognostic factors for the in-field recurrences were identified because of the small number of in-field recurrences. However, for patients with tumors <5 cm in diameter, there were no in-field recurrences after a radiation dose 30 Gy. The 2 in-field recurrences encountered occurred in patients with a tumor $\geq5\;cm$. Conclusion .A dose of 30 Gy is sufficient for local control in patients with a non-bulky (<5 cm), localized, diffuse large cell non-Hodgkin's lymphoma when combined with chemotherapy. An additional boost dose in the primary site is recommended for patients with bulky tumors $(\geq5\;cm)$.

키워드

참고문헌

  1. GIick JH, Kim K, EarIe J. An ECOG randomized phase III trial of CHOP vs CHOP plus radiotherapy for intermediate grade early stage non-Hodgkin's Iymphoma (abst). Proc Am Soc Clin Oncol 1995;14:391
  2. MiIIer TP, DahIberg S, Cassady JR, et aI. Chemotherapy alona compared with chemotherapy plus radiotherapy for Iocalized intermediate- and high-grade non-Hodgkin's Iymphoma. N Engl J Med 1998;399:21-26
  3. Kamath SS, Marcus RB, Lynch JW, MendenhaII NP. The impact of radiotherapy dose and other treatment-related and clinical factors on in-fild control in stage I and II non-Hodgkin's Iymphoma. Int J Radat Oncol Biol Phys 1999;44:563-568 https://doi.org/10.1016/S0360-3016(99)00051-6
  4. FuIIer LM, Krasin MJ, VeIasquez WS, et aI. Significance of tumor size and radistion dose to local control in stage I-III diffuse Iarge cell lymphoma treated with CHOP-Bleo and radiation. Int J Radat Oncol Biol Phys 1995;31:3-11 https://doi.org/10.1016/0360-3016(94)00343-J
  5. Kaminski MS, CoIeman CN, CoIby TV, et aI. Factors predicting survival in aduIts with stage I and II large-cell lymphoma treated with primary radiation therapy. Ann Intern Med 1986;104:747-756
  6. Landberg TG, Hakansson LG, MoIIer TR, et aI. CVP-remission-maintenance in stage I or II non-Hodgkin's lymphomas: preliminary results of a randomized study. Cancer 1979;44:831-838 https://doi.org/10.1002/1097-0142(197909)44:3<831::AID-CNCR2820440307>3.0.CO;2-S
  7. Levitt SH, BIoomfieId CD, Frizzera G, Lee C. Curative radiotherapy for locaIized diffuse histiocytic lymphoma. Cancer Treat Rep 1980;64:175-177
  8. Sweet DL, Kinzie J, Gaeke ME, Golomb HM, Ferguson DL, UItmann JE. Survival of patients with localized diffuse histiocytic lymphoma. Blood 1981;58:1218-1223
  9. Bonadonna G, Bajetta E, Lattuada A, et aI. CVP versus BACOP chemotherapy sequentially combined with irradiation in stage I-II diffuse non-Hodgkin's lymphomas. In : Jones SE, Salmon SE, eds. Adjuvant therapy of cancer IV. Orlando, Fla. : Grune & Stratton, 1984;661-668
  10. Nissen NI, ErsboII J, Hansen HS, et aI. A randomized study of radiotherapy versus radiotherapy plus chemotherapy in stage I-II non-Hodgkin's lymphomas. Cancer 1983;52:1-7 https://doi.org/10.1002/1097-0142(19830701)52:1<1::AID-CNCR2820520102>3.0.CO;2-M
  11. Hoppe R. The role of radiation therapy in the management of the non-Hodgkin's lymphomas. Cancer 1985;55:2176-2178 https://doi.org/10.1002/1097-0142(19850501)55:9+<2176::AID-CNCR2820551421>3.0.CO;2-L
  12. HaIIahan D, Farah R, Vokes E, et aI. The patterns of failure in patients with pathological stage I and II diffuse histiocytic lymphoma treated radiotherapy alone. Int J Radiat Oncol Bil Phys 1989;17:767-771 https://doi.org/10.1016/0360-3016(89)90064-3
  13. Levitt SH, Lee C, BIoomfieId CD, Frizzera G. The role of radiation therapy in the treatment of early stage large cell lymphoma. Hematol Oncol 1985;3:33-37 https://doi.org/10.1002/hon.2900030105
  14. MiIIer TP, Jones SE. Chemotherapy of localized histiocytic lymphoma. Lancet 1979;1:358-360
  15. CabaniIIas F, Bodey GP, Freireich EJ. Management with chemotherapy only of stage I and II malignant lymphoma of aggressive histologic types. Cancer 1980;46:2356-2359 https://doi.org/10.1002/1097-0142(19801201)46:11<2356::AID-CNCR2820461107>3.0.CO;2-X
  16. Connors JM, KIimo P, Fairey RN, Voss N. Brief chemotherapy and involved field radiation therapy for Iimited-stage, histologically aggressive lymphoma. Ann Intern Med 1987;107:25-30
  17. Longo DL, GIatstein E, Duffey PL, et aI. Treatment of Iocalized aggressive lymphomas with combination chemotherapy followed by involved-field radiation therapy. J Clin Oncol 1989;7:1295-1302
  18. MiIIer TP, Jones SE. Initial chemotherapy for clinically locaIized lymphomas of unfavorable histology. Blood 1983;62:413-418
  19. Nathu RM, MendenhaII PN, AImasri NM, Lynch JM. Non-Hodgkin's lymphoma of the head and neck: a 30-year experience at the university of florida. Head and Neck 1999;21:247-254 https://doi.org/10.1002/(SICI)1097-0347(199905)21:3<247::AID-HED10>3.0.CO;2-6
  20. Tsujii H. Quantitative dose-response anaIysis of salivary function following radiotherapy using sequential RI-sialo-graphy. Int J Radiat Oncol Biol Phys 1985;11:1603-1612 https://doi.org/10.1016/0360-3016(85)90212-3
  21. Han Liem I, VaIdes OImos RA, BaIm AJM, et aI. Evidence for early and persistent impairment of salivary gland excretion after irradiation of head and neck tumours. Eur J Nucl Med 1996;23:1485-1490 https://doi.org/10.1007/BF01254473
  22. Franzen L, Funegard U, Ericson T, et aI. Parotid gland function during and following radiotherapy of malgncies in the head and neck, a consecutive study of saIivary flow and patient discomfort. Eur J Cancer 1992;28:457-462 https://doi.org/10.1016/S0959-8049(05)80076-0
  23. Liu RP, FIeming TJ, Toth BB, et aI. SaIivary flow rates in patients with head and neck cancer 0.5 to 25 years after radiotherapy. Oral Surg Oral Med Oral Pathol 1986;61:243-245
  24. Dreizen S, Brown LR, DaIy TE, et aI. Prevention of xero-stomia-related dental caries in irradiated cancer patient. J Dent Res 1977;56:99-104 https://doi.org/10.1177/00220345770560022101
  25. Kosuda S, Satoh M, Yamamoto F, Uematsu M, Kusano S. Assessment of salivary gland dysfunction following chemoradiotherapy using quantitive saIivary gland scintigraphy. Int J Radiat Oncol Biol Phys 1999;45:379-384