【作者】 姬巍；

【导师】 王绿化； 杨伟志； 冯勤付；

【作者基本信息】 中国协和医科大学 ， 肿瘤学， 2008， 博士

【摘要】 第一部分:血浆细胞因子联合DVH参数预测NSCLC放射性肺损伤目的评价非小细胞肺癌(NSCLC)胸部放疗前及照射40～50Gy时血浆中TGF-β、IL-6、VEGF及ACE含量变化与放射性肺炎(RP)的发生及生存预后的关系。材料与方法2004年2月至2007年4月共131例非小细胞肺癌患者按治疗常规给予放疗或(和)化疗;男131例,女20例,中位年龄60岁(26～81岁)。放疗前、照射40～50Gy时采血冻存,采用酶联免疫吸附法检测血液中TGF-β、IL-6、VEGF及ACE含量。放射性肺炎根据CTCAE 3.0标准评价,评价终点为=2级放射性肺炎。结果中位随访时间24.7个月,有23例病人发生了2级以上RP,发生率17.6%。放疗前、放疗40-50Gy时血浆中VEGF、IL-6含量以及其在放疗期间的变化与RP无明显相关性。发生RP组患者的疗中TGF-β含量明显高于未发生肺炎者(4.52ng/ml与3.29ng/ml,P=0.027),而血浆ACE含量明显低于未发生肺炎者(384.72ng/ml与479.72ng/ml,P=0.043),放疗中TGF-β升高者RP发生率明显高于降低者(39.4%与14.3%,P=0.017)。发生RP组的健肺MLD、健肺V10、健肺V15、健肺V20分别高于未发生肺炎组(1576cGy与1028 cGy、43%与33%、34%与21%、27%与15%,P＜0.05)。多因素分析显示TGF-β升高是发生RP的独立风险因素。当放疗至40-50Gy时TGF-β升高者且血浆ACE含量在347ng/ml以下,是RP发生的最高风险组,发生RP达77.8%。全组124例Ⅲ-Ⅳ期进行生存分析,中位随访时间24.1个月,3年生存率为31%,3年无进展生存率为33%,中位生存时间为17.7个月,中位无进展时间为14.3个月。单因素分析显示放疗前KPS低于80分、体重下降超过5%、放疗剂量在60Gy以下、放疗中TGF-β升高影响总生存和无进展生存。COX多因素分析:体重下降、放疗剂量和血浆TGF-β含量在放疗中的变化是独立的预后指标;KPS评分在80分以下、体重下降超过5%和放疗中TGF-β升高都是影响无进展生存的独立因素。结论(1)在NSCLC进行3DCRT时,健肺MLD、健肺V10、健肺V15和健肺V20是影响放射性肺炎发生的重要DVH参数;放疗中血浆细胞因子ACE含量低于347 ng/ml、放疗中血浆细胞因子TGF-β含量升高是放射性肺炎发生的独立预测指标。(2)放疗前KPS低于80分、体重下降超过5%、放疗剂量在60Gy以下、放疗中血浆细胞因子TGF-β含量升高是NSCLC预后的重要影响因素;放疗中血浆细胞因子TGF-β含量升高是影响NSCLC总生存、无进展生存的独立的预后指标。第二部分:NSCLC术后3DCRT疗效及肺损伤相关因素研究目的分析非小细胞肺癌(NSCLC)术后接受三维适形放射治疗(3DCRT)的疗效及放射性肺炎(RP)的风险因素分析。材料与方法2002年11月～2006年3月90例非小细胞肺癌术后接受3DCRT,中位年龄58岁。全组90例中有70例(77.8%)接受肺叶切除,接受全肺切除的20例(22.2%)。R0切除占67.8%(61/90),R1和R2切除共29例(32.2%)。84例根据病理情况接受了术后辅助放疗,术后辅助放疗中位60Gy(40-70Gy)。术后38例患者接受中位3周期的辅助化疗。放射性肺炎根据CTCAE 3.0标准评价,评价终点为=2级放射性肺炎。比较健肺、患肺和全肺接受照射的相对体积和绝对体积,并进行ROC曲线分析。结果84例术后辅助放疗的进行生存和失败模式分析。存活病人中位随访37.7个月,中位生存时间48个月,1、2、3、4年生存率分别为90.3%、72.6%、58.6%和43.9%。接受R0切除的48例N2病例的3年、4年生存率分别为65.2%和46.6%。有治疗失败模式可分析资料的81例中43例(53.1%)出现复发转移,其中胸内复发和锁骨上转移低于远地转移的。单因素分析显示性别、年龄、体重下降、肿瘤大小、病理类型和分期并不影响预后。接受R1、R2切除的预后较差,R0切除与R1+R2切除的3年生存率分别为64.3%和35.7%(P=0.047)。全组90例进行放射性肺炎风险分析,9例患者出现有症状的RP,全组RP发生率为10%,接受全肺切除的患者中无RP发生,其中2级7例,3级2例,经抗炎、激素和对症处理后好转。性别、年龄、肿瘤发生部位、病理类型、T或N分期、术前和放疗前肺功能不是放射性肺炎的危险因素。术后辅助化疗有增加放射性肺炎发生的趋势,但没有统计学差异,放疗总剂量、照射范围、在两组病例中没有差异,双肺MLD、双肺V5-V25、健肺MLD、健肺V5-V40、患肺MLD、患肺V5-V35在发生放射性肺炎组均高于没有发生肺炎组,双肺V30、V35和患肺V40在两组间的差异有统计学意义,P值分别为0.030、0.007、0.047;患侧肺组织在接受15Gy～40Gy照射体积和双肺接受30Gy～35Gy照射体积上也要明显高于未发生放射性肺炎组。根据V30大小及放射性肺炎发生率进行ROC(receiver operating characteristic curve)分析发现曲线下面积为0.757,P=0.020,以患侧肺接受30Gy照射的体积340 cm~3作为分界点(cut-off),RP发生率分别为29.2%和2.5%,P=0.003。以此值预测放射性肺炎的发生,其敏感性为88%,特异性为70%。结论(1)对NSCLC术后放疗采用3DCRT的新技术有较好的疗效,放疗相关毒性发生率较低,术后放疗是安全的。(2)对于术后接受放疗的NSCLC,应尽量减少患肺的高剂量区的照射体积和双肺V30和V35,将患肺接受30Gy照射的体积控制在340 cm~3以下。(3)对于全肺切除的患者,单肺V20限制在10%以下,接受术后放疗是安全可行的。第三部分:吡非尼酮防治放射性肺损伤的实验研究目的观察吡非尼酮对放射引起的肺损伤的预防和治疗的机理。材料与方法将体重25g左右的10-12周近交系BalB/C雄性小鼠,随机分为空白对照组(Control,C组)、单纯照射组(Radiation,R组)、单纯吡非尼酮组(Pirfenidone P组)和吡非尼酮加照射组(Pirfenidone+Radiation P+R组),共四组。采用6MV-X射线,单次照射小鼠全胸部1200cGy。吡非尼酮200mg/kg,灌胃给药。每只小鼠每天给药0.5ml。于照射前3天给药,吡非尼酮和生理盐水共连续给药12周。于照射后第1-6月每月取材,进行设定指标的观察:血浆TGF-β含量测定、肺泡灌洗液巨噬细胞计数、Masson三色染色后进行肺纤维化评分、碱水解法测定肺组织羟脯氨酸含量。结果在6个月观察期内,四组小鼠活动、放疗区域脱毛现象、体重等无明显差别。与单纯照射组相比,吡非尼酮+照射组的小鼠肺泡灌洗液巨噬细胞聚集在照射后第4月时减少76%第5月时减少62%。血浆TGF-β含量第3-5月有降低的趋势。肺羟脯氨酸含量在第4和5月分别减少21%和24%。照射后小鼠肺纤维化病变多位于气道旁、血管周及肺泡间隔内,呈多灶性或弥漫性改变,吡非尼酮可以使第4、5、6个月肺泡间隔内的弥漫性病变明显改善。结论药物吡非尼酮可以减轻近交系BalB/C雄性小鼠放射性肺损伤,是通过抑制肺泡中巨噬细胞聚集、减少肺组织胶原含量从而改善照射后肺纤维化。吡非尼酮对BalB/C小鼠具有放射防护作用。更多还原

【Abstract】 PartⅠ:Combination of Serum Cytokine with lung DVH for Prediction Radiation PneumonitisPurpose:To study the relationship between level of plasma transform growth factor bata(TGF-beta),interleukin(IL-6),angiotensin-converting enzyme(ACE),vascular endothelial growth factor(VEGF),dose volume histogram(DVH) and radiation pneumonitis(RP).Materials and Methods:The records of all patients with lung cancer treated with radiotherapy(RT) with curative intent from February 2004 to April 2007.A total of 131 patients were identified.Blood samples were collected and measured with enzyme-linked immunosorbent assay(ELISA).TGF-beta,IL-6, VEGF and ACE measurements obtained before RT(Pre-RT) and when RT dose reached 40-50Gy(during-RT).The endpoint of the study was the development of=grade 2 RP(National Cancer Institute common toxicity criteria 3.0).Results:The Median follow-up time for the alive patients is 24.7 months.The incidence of=grade 2 RP was 17.6%.Between the RP and non-RP group, there was no difference in Pre- or during- RT level of VEGF,IL-6.In those patient whose TGF-βlevel during- RT was higher than the pre- RT baseline, RP occurred more frequently than in patients whose TGF-βlevel during- RT was less than the baseline value(39.4%vs 14.3%,P=0.017).We observed TGF-βlevel was higher and ACE level was lower in RP group than in the non-RP group,during-RT respectively(4.52ng/ml vs 3.29ng/ml,P=0.027 and 384.72ng/ml vs 479.72ng/ml,P=0.043).In RP group,patients are received higher contra-lateral lung MLD,contra-lateral lung V10,contra-lateral lung V15, contra-lateral lung V20(1576cGy vs1028 cGy、43%vs 33%、34%vs 21%、27%vs 15%,P＜0.05).On multivariate analysis,a persistent elevation of plasma TGF-βabove the baseline concentration during- RT was an independent risk factor for the occurrence of RP(P=0.005).Total 124 patients of the stageⅢ～Ⅳentered the survival analysis;median follow time was 24.1 months.The 1-y,2-y,3-y overall survival was 70.0%,40.0%,30.8%.1-y,2-y, 3-y progress free survival time was 52.8%,38.7%,32.7%.The median survival time was 17.7 months and the median progress free time was 14.3 months.On univariate analysis,KPS less than 80,weight loss more than 5%,radiation dose less than 60Gy,elevated plasma TGF-βlevel during- RT were risk factors for overall survival time and progress free survival time.On COX multivariate analysis,weight loss,radiation dose and the elevated TGF-βlevel were independent risk factors for overall survival.KPS less than 80,weight loss more than 5%and the elevated TGF-βlevel were independent risk factors for progress free survival.Conclusions:(1) The DVH parameter contra-lateral lung MLD,contra-lateral lung V10, contra-lateral lung V15,contra-lateral lung V20 are important risk factors in NSCLC patients who received 3DCRT.The ACE level lower than 347 ng/ml, an elevated plasma TGF-βlevel during- RT are independent risk factor for RP.(2) Pre- RT KPS less than 80,weight loss more than 5%,radiation dose less than 60Gy,elevated plasma TGF-βlevel during- RT are important risk factors for overall survival of the NSCLC patients.An elevated plasma TGF-βlevel during- RT are independent risk factor for overall survival and progress free survival. PartⅡ:Prognosis and RP Risk Factors for NSCLC who received Post-Operative 3-Dimensional Conformal RadiothrapyPurpose:The purpose of this study is to evaluate the prognosis and relationship between lung dosimetric parameters and the risk of symptomatic radiation pneumonitis(RP) in patients with non-small cell lung cancer(NSCLC) who received postoperative radiotherapy.Materials and Methods:From November 2002 November to March 2006 March,ninety patients with NSCLC who received postoperative 3-dimentinal conformal radiotherapy were included in this study.Seventy(78%) of them underwent lobectomy,and 20(22%) underwent pneumonectomy.Eighty-four received adjuvant radiotherapy according to the pathological status.X-ray with energy of 6MV was used for all patients.The median radiation dose was 60Gy with fraction size of 2Gy.Thirty-eight patients(42.2%) received median 3 cycles adjuvant chemotherapy.The percentage of the whole lung volume (Vp-dose) and the ipsilateral absolute lung volume(Vipsi-dose) which received more than a specific dose of irradiation were generated for every patient.The endpoint was grade 2 and above radiation pneumonitis based on CTC AE 3.0. The relation between the dosimetric factors and RP was also analyzed with receiver operating characteristic(ROC) curves.Results:Eighty-four patients who received adjuvant post-operative radiotherapy were analyzed for overall survival and treatment failure mode. Median follow-up was 37.7 months for survivors.The overall median survival time was 48 months.The overall 1-,2-,3- 4-year survival rate was 90.3%, 72.6%,58.6%and 43.9%respectively.The 3-,4-year overall survival rate of the forty-eight patients who received completely resection was 65.2%and 46.6%respectively.Eight-one patients had the data of the failure mode,53.1% (43/81) who had treated failure,the recurrence the in-thoracic and superclavicular was far less than the distant metastasis.On univariate analysis for all patients,sex,age,weight loss,tumor size,pathology and stage were not prognostic.R1/R2 resection was associated with significantly worse survival. The 3-year overall survival rate of the R0 and R1+R2 dissection was 64.3% and 35.7%respectively(P=0.047).Ninety patients were analyzed for radiation pneumonitis.Nine patients(10%) developed RP(grade 2 in 7 cases,and grade 3 in 2 cases),and all of them were in the lobectomy group.No RP was observed in patients who received pneumonectomy.The sex,age,tumor location,pathological type,T or N stage,Pulmonary function test were not the risk factors for RP.Adjuvant chemotherapy had a trend to increase the RP rate. The total dose and the field size had no different in the two groups.The all lung MLD,all lung V5-V25,contra-lateral MLD,contra-lateral V5-V40,ipsi-lateral MLD,ipsi-lateral V5-V35 were much higher with RP group than in those without RP.The area under curve in receiver operating characteristic curves based on the relationship between incidence of RP and the value of Vipsi-dose was 0.757(P=0.020).Using Vipsi-30 of 340cm~3 as a cut-off to predict RP,the sensitivity and the specificity were 88%and 70%,respectivly.The incidence of RP was 2.5%in patients with Vipsi-30＜340cm3 compared with 29.2%in patients with a Vipsi-30＞340cm3(P=0.003).Conclusions:It was safe for patients with NSCLC to receive postoperative 3DCRT if irradiation dose to lung tissue was well defined.The absolute volume of ipsilateral lung received more than 30 Gy after lobectomy was significantly correlated with the risk of RP.The volume should be less than 340cm~3. Patients with pneumonectomy received modern 3DCRT are safe when the whole lung V20 less than 10%. PartⅢ:Effects of pirfenidone on prevention of radiation-induced lung toxicity-Results of animal experimentPurpose:Pirfenidone(5-methyl-1-phenyl-2-(1H)-pyridone),is a novel experimental drug used as anti-fibrotic agent.This study was undertaken to investigate the effect of pirfenidone on prevention of radiation-induced lung toxicity.Materials and Methods:Male BALB/C mice were randomized into 4 groups: Control(group C);Radiation alone(group R);Pirfenidone alone(group P); Radiation+Pirfenidone(group R+P).Either sham irradiation(groups C and P)or single fraction of 12Gy to whole thorax(groups R and R+P) were given to the animals.The animals were fed with control diet or same diet plus 0.5% Pirfenidone from 3 days prior to irradiation to 12 weeks after irradiation.The animals(6-8 mice per group) were sacrificed 1,2,3,4,5,6 months after irradiation.Bronchoalveolar lavage fluid(BALF) from the right lungs was collected for detection of cell counting,and the left lungs were collected for hydroxyproline measurement or fixed for Masson trichrome staining.The plasm transforming growth factorβ(TGF-β) was measured with ELISA method. T test and Chi square were used for statistical analysis.Results:Macrophages in BALF were dramatically increased in the R and R+P groups at 4,5,and 6 months after irradiaiton,but the number of macrophages were lower in group R than in group R+P(18.51×10~4/ml vs 4.50×10~4/ml P= 0.005;60.61×10~4/ml vs 23.05×10~4/ml P=0.046;46.24×10~4/ml vs 35.00×10~4/ml P=0.305).Plasma TGF-βlevel in group R+P was lower comparing to that in group R at 3,4 and 5 months after irradiation,but not statistically significant (3.48 pg/ml vs 5.03 pg/ml P=0.223;3.82pg/ml vs 5.31 pg/ml P=0.666; 3.31pg/ml vs 4.27pg/ml P=0.310).Total lung hydroxyproline content,an index of fibrosis,was gradually increased with time in both group R and group R+P. But the level in R+P group were 21%,24%lower comparing to group R at 4 and 5 months(86.1μg/lung vs 67.7μg/lung P=0.007;104.1μg/lung vs 79.2μg/lung P=0.001).Based on Masson trichrome staining,we found that pirfenidone can ameliorate the severity of lung fibrosis at 4,5 and 6 months after irradiation,the mean fibrosis score was higher in group R than in group R+P(47.50 vs 20.30 P=0.003;47.91 vs 29.15 P=0.039;42.50 vs 19.46 P= 0.000).Conclusions:Pirfenidone has a protective effect on radiation-induced lung toxicity in mice.更多还原