Effect of Postoperative Three-dimensional Conformal/Intensity Modulated Radiotherapy Combined with Chemotherapy versus Chemotherapy Alone on Locally Advanced Rectal Carcinoma
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摘要: 目的 比较直肠癌术后三维适形/调强放疗联合化疗与术后单纯化疗的疗效及不良反应。方法 回顾性分析直肠癌根治术患者226例，其中辅助化疗组116例，辅助放化疗组110例。辅助放化疗组采用三维适形放疗88例，调强放疗22例。剂量范围45～54 Gy，中位剂量50 Gy。全组患者化疗周期数为2～8周期，中位4周期。观察患者不良反应，比较三维适形/调强放疗联合化疗与单纯术后化疗两组不同辅助治疗模式对局部复发率、总生存率（OS）及无病生存率（DFS）的影响。结果 术后放化组1、2、3年局部复发率分别为3.8%、10.5%、10.5%，明显低于术后化疗组的15.5%、29.7%、33.2%（P=0.001），术后放化组与术后化疗组1、2、3年OS分别为94.2%、76%、70.7%和95.6%、68.4%、53.5%，组间差异接近统计学意义（P=0.059），1、2、3 年DFS组间差异无统计学意义（P=0.608）。术后放化组的胃肠道、血液学不良反应发生率分别为78.2%和64.5%，高于术后化疗组的41.4%和30.2%（P=0.000；P=0.000）。亚组分析显示Ⅱ期患者术后放化组和术后化疗组1、2、3年OS、DFS差异均无统计学意义（P=0.810；P=0.067）。Ⅲ期患者术后放化组的1、2、3年OS高于术后化疗组，差异有统计学意义（P=0.047），DFS与术后化疗组比较差异无统计学意义（P=0.201）。术后放化组中20.9%患者出现放射性肠炎；10%患者出现放射性膀胱炎。无3级以上不良反应发生。结论 直肠癌术后三维适形/调强放疗联合化疗可显著降低局部复发率，提高Ⅲ期直肠癌患者总生存率。放化联合治疗组血液学及胃肠道不良反应高于术后单纯化疗，但患者耐受性较好。盆腔照射采用三维适形或调强放疗技术，在提高局控率的同时可较常规放疗显著降低放射性膀胱炎和放射性肠炎的发生率和发生程度。Abstract: Objective To evaluate the effect and toxicity of postoperative three-dimensional conformal/intensity modulated radiotherapy combined with chemotherapy and chemotherapy alone on locally advanced rectal carcinoma. Methods A total of 226 patients with locally advanced rectal carcinoma who had undergone radical mesorectal excision were retrospectively analyzed, including 116 patients with postoperative adjuvant chemotherapy (Group A) and 110 patients with adjuvant chemoradiotherapy (Group B). All chemotherapy were from 2 cycles to 8 cycles, a median of 4 cycles. There were 88 patients who had been treated by three-dimensional conformal radiotherapy and 22 patients were treated by intensity modulated radiotherapy. A median dose of radiation was 50 Gy (45-54) Gy]. The toxicity, local recurrent rates, overall survival rates, and disease-free survival rates between the two groups were analyzed statistically. Results 1-, 2-, 3-year local recurrent rates were 15.5%,29.7%,33.2% in Group A and 3.8%, 10.5%, 10.5% in Group B (P=0.001).1-,2-,3-year overall survival rates were 95.6%,68.4%,53.5% in Group A and 94.2%,76%,70.7% in Group B.The differences between two groups were close to statistical significance (P=0.059). 1-, 2-, 3-year disease-free survival rates in two groups were not statistically signifi cant (P=0.608). The incidence of gastrointestinal and hematological toxicity were higher in Group B than those in Group A（78.2% vs. 41.4%, P=0.000; and 64.5% vs. 30.2%, P=0.000）. The differences of 1-, 2-, 3-year overall survival rates and disease-free survival rates were not statistically signifi cant between Group B and Group A in stage Ⅱ patients (P=0.810 and P=0.067）. 1-, 2-, 3-year overall survival rates in Group B was higher than those in Group A in stage Ⅲ patients (P=0.047). As for disease-free survival rates, there were no signifi cant difference between two Groups (P=0.201). Radiation enteritis occurred in 20.9% of patients and radiocystitis occurred in 10% patients in Group B. No patient got toxicity in grade Ⅲ and more. Conclusion Postoperative threedimensional conformal/ intensity modulated radiotherapy combined with chemotherapy could decrease local recurrent rate obviously, and increase overall survival rate for locally advanced rectal carcinoma patients in stage Ⅲ. Hematological and gastrointestinal toxicity in adjuvant chemoradiotherapy group was higher than those in chemotherapy alone group, but all patients could tolerate the treatment well. Compared with conventional radiotheraphy, three-dimensional conformal/ IMRT could decrease the incidence of radiocystitis and radiation enteritis.
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