Radiation Oncology Journal

The Korean Society for Radiation Oncology (대한방사선종양학회)
권호 표지

Rectal Complication Following Radical Radiotherapy in Carcinoma of the Uterine Cervix

자궁경부암에서 근치적 방사선치료 후의 직장 합병증

  • Kim Won-Dong (Department of Radiation Oncology and Medical Research Institute, College of Medicine, Chungbuk National University) ;
  • Park Woo-Yoon (Department of Radiation Oncology and Medical Research Institute, College of Medicine, Chungbuk National University)
  • 김원동 (충북대학교 의과대학 방사선종양학교실, 의학연구소) ;
  • 박우윤 (충북대학교 의과대학 방사선종양학교실, 의학연구소)
  • Published : 2006.03.01
Download PDF
⟨ Previous Next ⟩

Abstract

Puroose: This study evaluated the late rectal complications in cervix cancer patients following treatment with external beam radiotherapy (EBRT) and high dose rate intracavitary radiation (HDR ICR). The factors affecting the risk of developing late rectal complications and its incidence were analyzed and discussed. Materials and Methods: The records of 105 patients with cervix cancer who were treated with radical radiotherapy using HDR ICR between July, 1995 and December, 2001 were retrospectively reviewed. The median dose of EBRT was 50.4Gy $(41.4{\sim}56.4 Gy)$ with a daily fraction size of 1.8Gy. A total of $5{\sim}7$ (median: 6) fractions of HDR ICR were given twice weekly with a fraction size of $4{\sim}5 Gy$ (median: 4Gy) to A point using an Ir (Iridium)-192 source. The median dose of ICR was 24 Gy $(20{\sim}35 Gy)$. During HDR ICR, the rectal dose was measured in vivo by a semiconductor dosimeter. The median follow-up period was 32 months, ranging from 5 to 84 months. Results: Of the 105 patients, 12 patients (11%) developed late rectal complications: 7 patients with grade 1 or 2, 4 patients with grade 3 and 1 patient with grade 4. Rectal bleeding was the most frequent chief complaint. The complications usually began to occur $5{\sim}32$ (median: 12) months after the completion of radiotherapy. Multivariate analysis revealed that the measured cumulative rectal BED over 115 Gy3 (Deq over 69 Gy) and the depth (D) of a 5 Gy isodose volume more than 50 mm were the independent predictors for late rectal complications. Conclusion: With evaluating the cumulative rectal BED and the depth of a 5 Gy isodose volume as predictors, we can individualize treatment planning to reduce the probability of late rectal complications.

목적 : 자궁경부암의 치료에 있어서 고선량률 강내치료를 포함하는 근치적 방사선치료는 매우 중요한 역할을 담당한다. 저자는 근치적 방사선치료 후 발생하는 만성 직장 합병증의 빈도와 이에 연관된 여러 치료요인들을 분석함으로써 합병증과 관련된 예후인자를 파악하고자 하였다. 대상 및 방법 : 1995 년 7월부터 2001 년 12월까지 자궁경부암으로 진단받고 근치적 방사선치료로 외부 방사선치료 와 고선량률 강내치료를 모두 받은 환자 105 명을 대상으로 하였다. 외부 방사선치료의 총 방사선량 중앙값은 50.4Gy $(41.4{\sim}56.4 Gy)$이고 고선량률 강내치료는 이리듐 (Iridium)-192를 이용하여 A point에 $ 4{\sim}5Gy$ ( 중앙값 4Gy), 분할 횟수는 $5{\sim}7$회 ( 중앙값 6 회 )로 주 2회 조사하여 총 $20{\sim}35 Gy$ ( 중앙값 24 Gy) 를 조사하였다. 강내치료 도중 반도체 선량계를 이용하여 직장선량을 직접 측정하였다. 환자의 중앙 추적기간은 32 개월 ($5{\sim}84$ 개월 ) 이었다. 결과 : 만성 직장 합병증은 12명 (11%)에서 관찰되었다. 7명은 grade 1, 2, 4 명은 grade 3, 1 명은 grade 4 였다. 이들은 모두 직장출혈이 주 증상이었다. 직장 합병증이 발생하기까지의 기간은 방사선치료 종료 후 $5{\sim}32$ 개월 ( 중앙값 12 개월 )이었다. 다변량 분석상 측정 누적 직장 BED $(Gy_3)$ 가 $115 Gy_3$ (Deq 로는 69 Gy) 를 넘는 경우, 5 Gy 등선량 체적길이 (D)가 50mm가 넘는 경우에는 통계적으로 유의하게 만성 직장 합병증의 가능성이 증가하였다. 결론 : 자궁경부암에서 고선량률 강내치료시 반도체 선랑계를 이용한 측정 누적 직장 BED 와 5 Gy 등선량 체적 갚 이를 계산함으로써 만성 직장 합병증을 예측하고 그 가능성을 줄일 수 있을 것이다.

Keywords

References

  1. Shigematsu Y. Nishiyama K. Masaki N. et al. Treatment of carcinoma of the uterine cervix by remotely controlled afterloading intracavitary radiotherapy with high-dose rate: a comparative study with a low-dose rate system. Int J Radiat Oncol Biol Phys 1983;9:351-356 https://doi.org/10.1016/0360-3016(83)90295-X
  2. Hareyama M. Sakata K. Oouchi A. et al. High dose rate versus low dose rate intracavitary therapy for carcinoma of the uterine cervix: a randomized trial. Cancer 2002;94:117-124 https://doi.org/10.1002/cncr.10207
  3. Clark BG. Souhami L. Roman TN. et al. The prediction of late rectal complications in patients treated with high dose rate brachytherapy for carcinoma of the cervix. Int J Radiat Oncol Biol Phys 1997;38:989-993 https://doi.org/10.1016/S0360-3016(97)00074-6
  4. Ogino I. Kitamura T. Okamoto N. et al. Late rectal complication following high dose rate intracavitary brachytherapy in cancer of the cervix. Int J Radiat Oncol Biol Phys 1995;31: 725-734 https://doi.org/10.1016/0360-3016(94)00547-8
  5. Crook JM. Esche BA. Chaplain G. et al. Dose-volume analysis and the prevention of radiation sequelae in cervical cancer. Radiother Oncol 1987;8:321-332 https://doi.org/10.1016/S0167-8140(87)80182-2
  6. LENT/SOMA scales for all anatomic sites. In J Radiat Oncol Biol Phys 1995;31:1049-1091 https://doi.org/10.1016/0360-3016(95)90159-0
  7. International Commission on Radiation Units and Measurements. Report 38. Dose and volume specification for reporting intracavitary therapy in gynecology. Washington, DC: International Commission on Radiation Units and Measurements; Bethesda. 1985
  8. Huh SJ. Lim DH. Ahn YC. et al. Comparison between in vivo dosimetry and barium contrast tachnique for prediction of rectal complications in high dose rate intracavitary radiotherapy in cervix cancer patients. Strahlenther Onkol 2003;3:191-196
  9. Inoue T. Harada K. Hata K. et al. A modified dose monitoring system in remote afterloading therapy of carcinoma of the uterine cervix using semi-conductor dosimeter. Strahlentherapie 1981;157:400-404
  10. Teshima T. Chatani M. Hata K. et al. High dose rate intracavitary therapy for carcinoma of the uterine cervix: II. Risk factors for rectal complication. Int J Radiat Oncol Biol Phys 1988;14:281-286 https://doi.org/10.1016/0360-3016(88)90433-6
  11. Deshpande DD. Shrivastav SK. Pradhan AS. et al. Dosimetry of intracavitary applications in carcinoma of the cervix: rectal dose analysis. Radiother Oncol 1997;42:163-166 https://doi.org/10.1016/S0167-8140(96)01841-5
  12. Choi P, Teo P. Foo W, et al. High-dose-rate remote afterloading irradiation of carcinoma of the cervix in Hong Kong: unexpectedly high complication rate. Clin Oncol 1992;4:186-191 https://doi.org/10.1016/S0936-6555(05)81087-8
  13. Lee JE. Huh SJ. Park W. et al. Prediction of late rectal complication following high dose rate intracavitary brachytherapy in cancer of the uterine cervix. J Korean Soc Thera Radio Oncol 2003;21:276-282
  14. Cheng JC. Peng LC. Chen YH. Huang DY. Wu JK, Jian JJ. Unique role of proximal rectal dose in late rectal complications for patients with cervical cancer undergoing high-dose-rate intracavitary brachytherapy. Int J Radiat Oncol Biol Phys 2003;57:1010-1018 https://doi.org/10.1016/S0360-3016(03)00721-1
  15. Cunningham DE. Stryker JA. Velkley DE. et al. Routine clinical estimation of rectal, rectosigmoidal, and bladder doses from intracavitary brachytherapy in the treatment of carcinoma of the cervix. Int J Radiat Oncol Biol Phys 1981;7:653-660 https://doi.org/10.1016/0360-3016(81)90381-3
  16. Kakinohana Y. Toita T, Ogawa K. et al. Comparison of calculated, and measured rectal doses in HDR brachytherapy with Ir-192 source. Nippon Igaku Hoshasen Gakkai Zasshi 1997;57:265-270
  17. Stuecklschweiger GF, Arian-Schad KS, Poier E. et al. Bladder and rectal dose of gynecologic high-dose-rate implants: comparison of orthogonal radiographic measurements with in vivo and CT -assisted measurements. Radiology 1991;181:889-894 https://doi.org/10.1148/radiology.181.3.1947116
  18. Petereit DG. Pearcey R. Literature analysis of high dose rate brachytherapy fractionation schedules in the treatment of cervical cancer: is there an optimal fractionation schedule? Int J Radiat Oncol Biol Phys 1999;43:359-366 https://doi.org/10.1016/S0360-3016(98)00387-3
  19. Pourquier H. Dubois JB. Delard R. Cancer of the uterine cervix: dosimetric guidelines for prevention of late rectal and rectosigmoid complications as a result of radiotherapeutic treatment. Int J Radiat Oncol Biol Phys 1982;8:1887-1895 https://doi.org/10.1016/0360-3016(82)90446-1
  20. Clark BG, Souhami L. Roman TN. et al. Rectal complications in patients with carcinoma of the cervix treated with concomitant clsplatin and external beam irradiation with high dose rate brachytherapy: a dosimetric analysis. Int J Radiat Oncol Biol Phys 1994;28:1243-1250 https://doi.org/10.1016/0360-3016(94)90501-0
  21. Toita T. Kakinohana Y. Ogawa K. et al. Combination external beam radiotherapy and high-dose-rate intracavitary brachytherapy for uterine cervical cancer: analysis of dose and fractionation schedule. Int J Radiat Oncol Biol Phys 2003;56:1344-1353 https://doi.org/10.1016/S0360-3016(03)00288-8
  22. Lee SW. Suh CO, Chung EJ, Kim GE. Dose optimization of fractionated external radiation and high-dose-rate intracavitary brachytherapy for FIGO stage IB uterine cervical carcinoma. Int J Radiat Oncol Biol Phys 2002;52:1338-1344 https://doi.org/10.1016/S0360-3016(01)02821-8
  23. Hyun KT, Choi J. Park SY. et al. Dosimetric parameters that predict late rectal complications after curative radiotherapy in patients with uterine cervical carcinoma. Cancer 2005;104:1304-1311 https://doi.org/10.1002/cncr.21292
  24. Rubin P, Constine LS, Williams JP. Late effects of cancer treatment: Radiation and drug toxicity. In: Perez CA, Brady LW, eds. Principles and practice of radiation oncology. 3rd ed. Philadelphia, PA: Lippincott-Raven Co. 1998:155-212
  25. Sakata K, Nasakura H. Oouchi A, et al. High-dose-rate intracavitary brachytherapy: results of analyses of late rectal complications. Int J Radiat Oncol Biol Phys 2002;54:1369-1376 https://doi.org/10.1016/S0360-3016(02)03055-9
  26. Van Lancker M, Storme G. Prediction of severe late complications in fractionated, high dose-rate brachytherapy in gynecological applications. Int J Radiat Oncol Biol Phys 1991;20:1125-1129 https://doi.org/10.1016/0360-3016(91)90214-O