全肺及患侧肺正常肺组织高、低剂量区肺体积预测急性放射性肺炎的价值

摘要

目的:观察非小细胞肺癌根治性放疗患者急性放射性肺炎发生情况,探讨全肺及患侧肺正常肺组织高、低剂量区肺体积对急性放射性肺炎的预测价值.方法:2013年8月至2015年11月收治的经病理证实行根治性放疗的非小细胞肺癌患者174例.放疗剂量60 ～ 70 Gy,≤64 Gy 97例,＞64 Gy 77例.化疗方案为紫衫类联合铂类一线方案,同期放化疗19例,序贯放化疗155例.利用剂量体积直方图计算正常肺V5 ～ V30、MLD、V5ipsi(肿瘤同侧肺V5)～V30ipsi、MLDipsi.根据CTC 4.0标准评估肺损伤.对急性放射性肺炎进行卡方检验、Logistic因素分析及受试者工作特征曲线分析.结果:174例患者中发生≥2级急性放射性肺炎26例(14.94％),3级11例(6.32％),4级2例(1.15％).单因素分析同期放化疗、COPD、V5 ～ V30、MLD、V5ipsi～V30ipsi、MLDipsi均与≥2级急性放射性肺炎相关,多因素Logistic回归分析V5、V20ipsi、MLD是与≥2级ARP发生相关的独立危险因素.ROC曲线分析V5、V20ipsi、MLD界值分别为62.38％、47.14％、16.85 Gy.根据V5、V20ipsi值对174例患者筛选入组,B组V5＜62％+ V20ipsi≥47％,C组V5≥62％+ V20ipsi＜47％,D组V5≥62％+ V20ipsi≥47％.C、D两组卡方检验差异具有统计学意义.结论:剂量学参数V5、V20ipsi、MLD与急性放射性肺炎发生相关,与V5相比,限制V20ipsi不超过界值可能会更有效降低急性放射性肺炎发生率.%Objective To observe the incidence of acute radiation pneumonitis (ARP) in patients with nonsmall cell lung cancer treated by three-dimensional conformation radiotherapy or intersity-modulated radiation therapy,and investigate the predictive value of high dose volume and low dose volume of the total and ipsilateral lung on ARP.Methods 174 patients with non-small-cell lung cancer verified by pathology who received radical radiotherapy in our hospital from Aug 2013 to Nov 2015 were screened.Radioactive dose was 60 Gy-70 Gy,with 97 patients' dose of 60-64 Gy and 77 patients' dose of 65-70 Gy.Chemotherapy was done by paclitaxel + pentium first line treatment.155 patients were treated with radiotherapy alone and 19 with radiotherapy combined with chemotherapy.The V5～ V30,MLD (mean lung dose),V5ipis ～ V30ipsi,MLDipsi were calculated from the dose volume histogram system.The ARP was evaluated according to Common Toxicity Criteria 4.0 (CTC4.0).Univafiate and nultivariate analysis and receiver operating characteristic (ROC) curves were performed to assess the correlated factors of ARP.Results Of 174 patients,26 patients (14.94％) developed radioactive pneumonia at grade 2,11 patients (6.32％) at grade 3,2 patients (1.15％) at grade 4.The correlative factors included the radiochemotherapy regimen (sequential chemotherapy to radiotherapy or concurrent radiochemotherapy),V5,V10,V20,V30,MLD of the total lung and ipsilateral lung according to univariate analysis.Multivariate analysis of all the factors mentioned above showed the V5,V20ipsi and MLD were the independent predictive factors associated with ARP.ROC analysis indicated that the cut-off point of V5,V20ipsi,MLD were 62.38％,47.14％and 16.85Gy respectively.According to the V5,V20ipsi value,174 patients were divided into three groups:B group V5＜62％+V20ipsi≥47％,C group V5≥62％+V20ipsi＜47％,D group V5≥62％+V20ipsi≥47％.The chisquare test between the C group and D group has statistical significance.Conclusion V5,V20ipsi,and MLD are the independent risk factors of ARP.Compared with V5,limiting V20ipsi threshold is more likely to result in ARP.