Method for radiation therapy at lymphogranulomatosis

FIELD: medicine.

SUBSTANCE: the innovation deals with irradiating lymphatic collector, that is: at the first stage it is necessary to perform irradiation for the whole volume of affected lymph collector at total focal dose being 26 Gy, at the second stage one should carry out irradiation at collector's areas depending upon the degree of their destruction at decreasing the size of fields: for the area of residual lymph nodes remained after polychemotherapy - up to the total focal dose being 44 Gy, for the area of massively affected lymph nodes in case of total effect after polychemotherapy - up to 36 Gy, for the area of moderately affected lymph nodes in case of total effect after polychemotherapy - up to 30 Gy. The method enables to decrease the number of complications and local relapses, shorten terms for therapy, improve values for patients' survival rate at decreasing total integral dose of irradiation.

EFFECT: higher efficiency of radiation therapy.

2 ex

 

The present invention relates to medicine, namely to methods of radiation treatment of Hodgkin's disease and can be used in any Oncology (radiology) institution.

Various methods of radiation therapy of Hodgkin's disease. In the mid-20th century method of radical program of radiation therapy was introduced Peters V. .Kaplan first applied medical accelerator in radiation treatment of patients with locally advanced stages of Hodgkin's disease and exposure in the amount of radical programs using high total focal dose (40-44 Gy).

In the last decade in Russia and abroad is most often used (sub)total lymphatic irradiation collectors, in which the irradiation undergo lymphatic collectors above the diaphragm, paraaortal region and spleen. Use another method of radiation therapy - cropropamide (mantle) exposure in which exposure is subject only to the lymph collectors above the diaphragm.

However, this method of radiation therapy of Hodgkin's disease has a number of disadvantages. If it is applied to the radiation is exposed to the entire lymphatic collector, regardless of the extent of his defeat. This leads to unnecessary irradiation of individual zones within the lymphatic collector, and further to the formation of bol is e expressed postradiation complications in patients with Hodgkin's disease. It is known that in the structure of mortality in patients cured of Hodgkin's disease, in the first place are cardio-pulmonary complications. The overall reduction in integral dose in radiation therapy should reduce their number, to reduce the mortality rates from this complications, to improve the quality of life of patients.

At the same time, the radiation therapy with a selective reduction of the irradiated volume and the tabulation of small fields need total focal dose to the affected area should lead to a reduction in local recurrence and improve survival rates.

This method of radiation therapy corresponds to a name - radiation therapy with a gradual reduction in the irradiated fields.

To reduce the number of late complications and improve patient outcomes, reduce costs by reducing the duration of treatment to the patient during irradiation of lymph collectors radiation therapy to the entire lymphatic region with a single focal dose of 2 Gy and a total focal dose of 26 Gy, further reducing margins on the remaining lymph nodes to the total focal dose of 44 Gy, in the area of massively affected lymph nodes in the presence of the full effect after chemotherapy - up to 36 Grams, on an area of moderately affected lymph nodes in the presence of the full effect after the of polihimioterpii - up to 30 Gr. When irradiated contralateral lymph collectors radiation therapy to the entire lymphatic region with a single focal dose of 2 Gy and a total focal dose of 26 Gy.

The method is as follows. The patient performed a detailed clinical and instrumental examination, including history taking, physical examination, ECG, functional tests, x-rays and a CT scan of the chest, ultrasound examination of the abdominal cavity and peripheral lymph nodes, laboratory tests. Set the stage of the disease, the major risk factors of adverse prognosis. The diagnosis is confirmed by histological examination. The functional status of the patient is assessed by the Karnofsky scale. After this, the patient is assigned to the 4th course of chemotherapy. Upon reaching the full effect or partial effect, at least 70% regression of tumor tissue, the chemotherapy is completed. After conducted a three-week break in treatment. Before radiation therapy, the patient is control tests (restaurovani), including the same amount of research and compulsory CT study for preglacial topometry. Estimated weight effects from the drug treatment. Reviewed functional the initial status of the patient on the Karnofsky scale. After this the patient depending on the degree of regression of the tumor tissue is prescribed radiation therapy. On the whole lymphatic collector (cervical-supraclavicular-submandibular, axillary, hilar, paranormally with spleen) for 13 sessions brought the total focal dose of 26 Gy. Further reduction of the margins on the remaining lymph nodes (eg, supraclavicular area to the left instead of the cervical-supraclavicular-submandibular or the root zone to the right instead of intrathoracic) to the total focal dose of 44 Gy, in the area of massively affected lymph nodes in the presence of the full effect after chemotherapy (for example, the upper mediastinal area instead of intrathoracic) - up to 36 Grams, on an area of moderately affected lymph nodes in the presence of the full effect after chemotherapy (for example, lower-paraaortal area instead paraaortal with spleen) 30 Gr.

At the first stage are exposed to the reservoir above the diaphragm. Restaurovani is carried out between stages of radiation therapy, and includes examination, ECG, x-rays of the chest, ultrasound examination of the abdominal cavity, laboratory tests. The second stage is irradiated paraaortal region and spleen. This comprehensive treatment program is complete, and the patient is released under dynamic observation. In further conducted counter the global assessment of patients with common intervals.

Example 1. Patient K., 31, outpatient map 1485/02. The patient performed a detailed clinical and instrumental examination, including history taking, physical examination, ECG, functional tests, x-rays and a CT scan of the chest, ultrasound examination of the abdominal cavity and peripheral lymph nodes, laboratory tests. Installed IIIAS stage of the disease. Diagnosed defeat ten lymph zones: supraclavicular lymph nodes on both sides of (massive), mediastinal lymph nodes and the root of the right lung (moderate), axillary to the right (solid), paraaortal (massive), iliac (right-solid, left - moderate), spleen (moderate). Symptoms of intoxication was not. Of the risk factors of poor prognosis of the disease was observed defeat intrathoracic lymph nodes and spleen, ten of the affected areas, 5 of which were massively affected. The diagnosis is confirmed by histological examination - scleronomic variant of chlamydia. The functional status of the patient according to the Karnofsky scale was 80%. From April 5 to July 2002 patients received 4 courses of chemotherapy scheme CEA/ABVD with complete regression of all affected lymph collectors, confirmed control clinical and instrumental examination. Lane is considered the functional status of the patient on a scale Karnofsky - 100%. Achieved complete remission. The program of chemotherapy was completed. The patient since August 2002 initiated a program of radiation therapy with a gradual reduction fields. The first stage was exposed to the reservoir above the diaphragm. Cervical-supraclavicular-submandibular region was irradiated with 2 opposing fields sizes 22×18 cm with a single focal dose of 2 Gy, the total focal dose of 26 Gy. Further, the size of the field is reduced to 20×8 cm (60% by area) and the total focal dose increased to 36 Gy to the supraclavicular nodes. The axillary region was irradiated with 2 opposing fields sizes 10×15 cm with a single focal dose of 2 Gy, the total focal dose of 26 Gy to the left and 36 Gy to the right. The mediastinum and the roots of the lungs (thoracic area) was irradiated with two opposite curly fields sizes 13×15 cm with a single focal dose of 2 Gy, the total focal dose of 26 Gy. Further, the size of the fields is reduced to 9×12 cm (45% by area) and the total focal dose increased to 30 Gy to the upper mediastinum and the right root. Three weeks after the end of the first phase of radiation therapy, after a brief clinical and instrumental examination, which diagnosed a complete remission conducted stage 2 of radiotherapy paraaortal region and spleen with two opposite curly fields size 19×19 cm with a single focal dose of 2 Gy, the total focal dose 26gr prototype engine. Further, the size of the fields is reduced to 19×12 cm (37% by area) and the total focal dose increased to 30 Gy to ohne-paraaortal and spleen, and ohne-paraaortal fields 8×10 cm (78% by area) to 36 Gy. Three weeks after completing the second stage of radiation therapy, after a brief clinical and instrumental examination, which diagnosed a complete remission, held the 3rd stage of radiotherapy iliac region with two opposite curly fields sizes 17×14 cm with a single focal dose of 2 Gy, the total focal dose of 26 Gy. Further, the size of the fields is reduced to 6×14 cm (75% by area) and the total focal dose increased to 30 Gy to the right iliac, and inguinal - fields 10×14 cm to 26 Gr. The treatment was finished on December 27, 2002, and the patient was released under dynamic observation. In General, compared to the standard radical program of radiation therapy, the volume of the irradiated areas decreased by approximately 30%, which led to a significant reduction in integral dose for the entire course of radiation therapy.

Example 2. Patient G., aged 23, outpatient map 6615/98. The patient performed a detailed clinical and instrumental examination, including history taking, physical examination, ECG, functional tests, x-rays and a CT scan of the chest, ultrasound examination of the abdominal cavity and peripheral lim is oticheskih nodes, laboratory analyses. Set IV stage of the disease. Diagnosed defeat three lymph zones: supraclavicular lymph nodes on the left (solid), mediastinum (moderate), axillary right (moderate). Marked symptoms of intoxication - profuse night sweats and weight loss of more than 10%. Of the risk factors of poor prognosis of the disease was observed In-phase and the presence of massively affected areas. The diagnosis is confirmed by histological examination - scleronomic variant of chlamydia. The functional status of the patient according to the Karnofsky scale was 90%. From 7 December to March 2002 patients received 4 courses of chemotherapy scheme CHOPP/ABVD with partial regression of metastatic lymph collectors, confirmed control clinical and instrumental examination (residual node in the left supraclavicular and mediastinal, the degree of regression of the tumor mass more than 90%). Revised functional status of the patient according to the Karnofsky scale is 100%. Achieved partial remission. The program of chemotherapy was completed. The patient since April 1999 commenced a program of radiation therapy with a gradual reduction fields. The first stage was exposed to the reservoir above the diaphragm. Cervical-supraclavicular-submandibular region was irradiated with 2 opposing fields sizes 22×16 cm pay Chasovoy dose of 2 Gy, total focal dose of 30 Gy. Further, the size of the fields is reduced to 7×9 cm (78% by area) and the total focal dose increased up to 44 Gy. The axillary region was irradiated with 2 opposing fields sizes 9×14 cm with a single focal dose of 2 Gy, the total focal dose of 30 Gy to the left and 44 Gy to the right. The mediastinum and the roots of the lungs (thoracic area) was irradiated with two opposite curly fields sizes 12×14 cm with a single focal dose of 2 Gy, the total focal dose of 30 Gy. Further, the size of the fields is reduced to 7×9 cm (63% by area) and the total focal dose increased up to 44 Gy only on the upper mediastinum. Three weeks after the end of the first phase of radiation therapy after a brief clinical and instrumental examination, which diagnosed a complete remission conducted stage 2 of radiotherapy paraaortal region and spleen with two opposite curly fields sizes 17×19 cm with a single focal dose of 2 Gy, the total focal dose of 30 Gy. Treatment completed 3 September 1999, and the patient was released under dynamic observation. In General, compared to the standard radical program of radiation therapy, the volume of the irradiated areas decreased by approximately 25%, which resulted in a significant reduction of the integral dose for the entire course of radiation therapy. In further conducted regular follow-up examination. Lastly the e - in December 2002. Diagnosed 4 years of complete remission. In October 2002, the patient gave birth to a healthy child.

The method of radiation therapy with a gradual reduction of the field, as a second stage of treatment after chemotherapy applied in 96 patients with Hodgkin's disease (study group). The control group consisted of 166 patients with complex treatment, which used the standard radical program of radiation therapy. The method of radiation therapy with a gradual reduction of fields allowed in 89.6% of patients locally to increase the total focal dose to the mediastinum and significantly reduce total focal dose on the root area of the lymph nodes (p=0.0001). In General, due to the application of the method of radiation therapy with a gradual reduction of the field, the volume of the irradiated areas is reduced by about 20-30%, which reduces the total integral of the absorbed dose for the entire course of radiation therapy 1.2-1.4 times.

Disease-free survival.

Significant differences in the rate of relapse-free survival obtained at 3-6 years after the end of treatment (p=0,010-0,022). In future years, despite the lack of veracity, noted more than 10% differences in survival rates (10-year - 92 and 79%), which indicates the advantage of this method of radiation therapy with a gradual reduction of the fields.

Overall survival.

Reliable difference the Oia indicator overall survival was registered 3 years (p=0,019). Marked deterioration in survival in the group of standard radiation therapy for 5-7 years (p=0,053-0,099). In General, about 10% differences in survival rates (10-year - 86 and 77%), talk about the advantage of this method of radiation therapy with a gradual reduction of the fields.

Total tumor specific survival.

Significant differences on this indicator registered for 5 and 6 year (p=0,016-0,022). Marked deterioration in survival in the group of standard radiation therapy for 3, 4, 7, 8 years (p=0,072-0,093). In General, approximately 8-15% of the differences in the rate of tumor specific survival 5 years (10-year - 99 and 86%) say about the advantage of this method of radiation therapy with a gradual reduction of the fields.

Obtained a significant reduction in the number of local recurrence in the mediastinum and cervical-supraclavicular region after the application of the method of radiation therapy with a gradual reduction of the field (p=0,037). Reduction of local recurrence in the primary group can be associated with the local election results desired total focal dose radiation therapy with a gradual reduction of the field after careful Restavracija disease.

Complications.

In General, severe complications (respiratory failure III degree, circulatory insufficiency II-III degree, expressed pericard is s, death from acute heart failure or myocardial infarction) was observed in 1 patient primary and 10 control groups (1 and 6%, p=0.05).

Nelimpoblastny acute leukemia and secondary malignant tumors.

Significant differences in the groups were not found (1 and 0.6%, p<1,0). Acute leukemia and cancer was diagnosed in one patient and control group. The patient's primary group with acute leukemia in currently alive, the rest died from opportunistic diseases.

The proposed method of radiation therapy of Hodgkin's disease has improved the results of survival and local recurrence, reduce the number of complications from the cardio-pulmonary system.

The proposed method is available in all Oncology (radiology) offices, does not require special training - this opens up broad prospects for its use in medical practice.

Literature

1. Kaplan H. The radical radiotherapy of regionally localized Hodgkin's disease // Radiology. - 1962. - v.78. - p.553-561.

2. Longo D.L., Glatstein E., Duffey P.L., et all. Alternating MOPP and ABVD chemotherapy plus mantle-field radiation therapy in patients with massive mediastinal Hodgkin's disease // J. Clin. Oncol. - 1997. - v.l5. - N.11. - P.3338-3346.

The method of radiation therapy of Hodgkin's disease involving the irradiation of lymph collector, characterized in that the first stage of a patient irradiation on the entire volume affected simpaticheskogo collector total focal dose of 26 Gy, in the second phase, carried out the irradiation zone of the collector depending on the extent of their involvement with the reduction of the margins: on the residual area after the chemotherapy of lymph nodes to the total focal dose of 44 Gy, in the area of massively affected lymph nodes in the presence of the full effect after chemotherapy - up to 36 Grams, on an area of moderately affected lymph nodes in the presence of the full effect after chemotherapy to 30 Gr.



 

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