| Cervical cancer is a kind of malignant tumor which seriously harms women's health and affects the quality of life of women.85% of the incidence of the disease is concentrated in developing countries. Some patients need radiotherapy after surgery.At present, there are two ways to treat this part of the patient's radiotherapy with external irradiation and brachytherapy therapy.The increase in the dose of conventional radiotherapy greatly increases the side effects of the bladder and rectum.At present, the most used is in vitro intensity modulated radiation therapy (radiotherapy intensity-modulated, IMRT).IMRT is a linear accelerator or cobalt-60 treatment machine uniform dose (rate) output of the field of the process.This treatment must meet two conditions:in the direction of irradiation, the shape of the field must be consistent with the shape of the lesion (target area); shot in the output dose rate of every point must be adjusted according to the requirements of the way.The treatment greatly reduces the amount of the surrounding organs to be threatened, and improves the treatment target area dose. A large number of studies suggest that the local control effect of cervical cancer can be improved. Brachytherapy is a kind of the applicator placed in the specified location, and then the radiation source applicator radiotherapy through the catheter into the lead tank, radiation source returns automatically after the end of treatment. With the application of cervical cancer brachytherapy applicator into the uterine cavity and (or) the vagina. Since the day of treatment for cervical cancer has become one of the basic treatment for cervical cancer. At present, the treatment of cervical cancer after surgery is mainly IMRT technology, target area, including the pelvic lymphatic vessel drainage area and vaginal stump.Add or do not add a small amount of brachytherapy. IMRT target area only radiation pelvic lymph vessel drainage area, the vaginal stump after the treatment to prevent the recurrence of the study is still relatively small. The purpose of this study was to retrospectively analyzed the effect of combined chemotherapy plus IMRT alone or IMRT+brachytherapy for postoperative cervical cancer,to evaluate the application of IMRT and brachytherapy in the treatment of cervical cancer after radical hysterectomy.[Objective]:Observe the efficacy?prognosis?toxicity and function of hanging ovarian underwent IMRT+chemotherapy (control group) and IMRT+ brachytherapy+chemotherapy (observation group) after radical hysterectomy. Evaluate the clinical application value of MRT+brachytherapy+chemotherapy.[Method] A retrospective analysis of the effect of IMRT or IMRT+ brachytherapy of 58 patients with cervical cancer after surgery in our hospital (Tumor Hospital of Shandong province) from March 2009 to March 2011 was performed. The range of age is from 28 to 60 years old, the median age is 42.8 years old. There are 51 cases of squamous cell carcinoma,6 cases of adenocarcinoma,1 cases of adenosquamous carcinoma,14 cases of stage I,44 stage II cases. Clinical stage was-IIa2 stage Ibl, all underwent radical surgery, the operation was extensive hysterectomy and pelvic lymph node dissection, a total of 10 cases of 40 years old patients with ovarian preservation.Postoperative patients who had the following risk factors were supplemented with radiotherapy and chemotherapy, including:positive tumor resection margin; uterine involvement; lymph node metastasis.Or have the following risk factors more than 2 items:tumor 4cm, cervical stromal invasion depth, 1/2, cancer embolus.After surgery, no naked tumor residual, no residual swelling lymph nodes, concurrent Taxol+CBP chemotherapy.In the risk factors of recurrence, the common iliac lymph node metastasis and/or the abdominal aortic lymph node metastasis of pelvic lymph node metastasis,2, the need to increase the area of the abdominal aortic lymph nodes in the drainage area, including the extension of the field of radiotherapy.Therefore, the target area of radiotherapy is not consistent, so not included in the study. IMRT using enhanced CT angiography. Scan the upper bound to the lower part of the lower abdomen. CT scanning layer thickness is 5mm, scanning window width is 350Hu, the window is 50Hu.Image was transferred to Pinnacle3 V8.0 AD AC planning system of the physical room, using 6MV X ray,7 fields intensity modulated radiation therapy. Prescription dose:45Gy-50Gy 2.0Gy/ 95%PTV/25f.Target area was delineated by gynecology and oncology doctors and imaging doctors, the treatment plan was completed by physical divisions. The radiotherapy range included vaginal stump upper and lower total 4cm (vaginal stump upper and lower 2cm), common iliac, internal and external iliac, and adjacent lymph nodes. The prevention of radiation dose was 45Gy-50Gy.Target delineation according to the document 0418 announced in 2008 by the Radiation Therapy Oncology Group(RTOG) of American about the radiotherapy of CTV cervical cancer or endometrial cancer postoperative delineation of prospective clinical trials.CT delineation include the scope of the pelvic lymphatic drainage area and vaginal stump. The stump of the upper bound for the stump on the edge of 2cm, the lower bound for the stump of the lower edge of 2cm. Before and after the community is more complex, because vaginal stump is very close to the posterior wall of bladder and anterior wall of rectal. The larger irradiation volume including bladder and rectum, the more side effects will happen, but small target volume lead to miss the target area, so the target edge is 7mm far away from vaginal stump. PTV for the outline of the CTV target area is the expansion of 10mm of CTV. The expansion of PTV is the result of the comprehensive consideration of the position errors and the displacement of the organs. The purpose is to balance the missing regions and the reduction of the serious complications of the normal tissue. Expand the PTV irradiation can effectively prevent the miss, but on the other hand will cause the irradiated volume of organs increased, thereby increasing the side effect of radiotherapy. CTV includes common iliac, iliac, external iliac, and obturator lymph drainage of presacral region in the iliac, total peripheral plus 7 mm boundary, sacral 10mm area, basin side wall region of 18mm nCTV in the region. The target area in IMRT+brachytherapy group was not included the target area of the vaginal stump. The brachytherapy machine is Rongli integration brachytherapy machine of domestic.With the integration of the characteristics of the post installed, the simulation system, video transmission system, brachytherapy planning system, system integration, to achieve the applicator placement, positioning, data processing, radiotherapy planning after the treatment process once completed. To further improve the accuracy of the treatment. Patients before treatment keep bladder filling, lithotomy position. Patients lying on the therapeutic bed, with 75% iodophor disinfection of the vulva, vagina, urethra, exposure vaginal stump with speculum and iodine disinfection. The vagina of dual source applicator is inserted into the top of the vagina stump. Respectively, to shoot the pelvic side of the X-ray film. Set the X axis through the vaginal applicator dual line, Y axis perpendicular to the X axis of the human body coronal line in the direction. Perpendicular to the Y, the X axis through the intersection of the XY axis of the human body sagittal line for the Z axis. According to the ICRU38 report set the rectal dose reference point (R) for the axis of the vaginal container and the posterior wall of the vagina after the intersection of 0.5cm, that is, the coordinate system (0.5,0.5,-0.5). Set the point corresponding to the rectal reference point for the bladder reference point (0.5,0.5,0.5).For dose point (1,1,0) located in the vaginal stump above 1cm, the body of coronal vaginal stump axis at lcm, to the dose of 500cGyx5 times-500cGyx6 times per week during radiotherapy, washing vaginal 1 time a day during radiotherapy.We suppose IMRT therapy only as the control group (30 cases), IMRT+ brachytherapy as observation group (28 cases), recent adverse reactions,3 years and 5 years ovrall survival rate,3 years progression free survival rate, long-term complications and ovarian function status of the two groups were abserved and analyzed with SPSS22.0 software.[Results] According to the drawing function of survival Kaplan Meier method, two groups of survival function was compared with log-rank, B-IMRT group and S-IMRT+brachytherapy group survival rate was 96.67%(29/30) and 100%(28/28) after 3 year, was 90%(27/30) and 92.85%(26/28) after 5 year. No statistically significant difference of tumor recurrence was showed between two groups. Most recurrence happened in 3 years after treatment, DFS was 80%(24/30) and 82.14% (23/28) in B-IMRT group and S-IMRT+brachytherapy group after 3 years. Between two groups, P=0.828. Hematological toxicity was similar in the two groups, and the rank sum test was carried out on the decrease of WBC, platelet and hemoglobin.Respectively Z=0.860, P=0.390:Z=0.033, P=0.974:Z=0.331, P=0.740. There was no statistically difference between the two groups. The differences between the two groups of acute small intestine, acute large intestine is significantly, Z=2.055, P=0.040:Z=2.115, P=0.034. Comparison of late radiation injury of small intestine large intestine and bladder between B-IMRT group and S-IMRT+brachytherapy group:there is significant difference between them,Z=1.976, P=0.048:Z=2.228, P=0.026:Z=2.107, P=0.035. Two groups of ovarian preservation patients with serum FSH and E2 level had no difference before and after radiotherapy and chemotherapy, the P values were 0.460,0.649,0.652,0.686. FSH and E2 changed markedly before and after radiotherapy and chemotherapy in the same group and there is statistics significance in two group. P= 0.003,0.024 in B-IMRT group,P=0.014,0.003 in S-IMRT+brachytherapy group. Keeping ovarian function failed after treatment of the two groups..[Conclusion]1. There is no significant difference between B-IMRT group and S-IMRT+ brachytherapy group about OS in 3 and 5 years and DFS in 3 years, suggesting that the effect of the two treatments were similar.2. Compared with B-IMRT group and S-IMRT+brachytherapy group, the side effect of small intestine, large intestine and bladder in S-IMRT+brachytherapy group was less than that in B-IMRT group.Prompt S-IMRT+brachytherapy group has certain advantage than B-IMRT group.3. Ovarian function was rapidly failure after treatment in the two groups with ovary retained. Suggesting retaining ovarian is useless in cervical cancer patients with postoperative radiotherapy and chemotherapy. |
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