RU2719935C2 - Method for interstitial, high-power brachytherapy of locally advanced small pelvis tumors having a lateral invasion of a small pelvis wall - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to oncology, radiation therapy and surgery. Perform high-power brachytherapy with 192Ir radiation source on afterloading system. After the surgical intervention of the pelvic organs, introducers of 6Fr diameter are installed on a tumor bed intraoperatively under vision control. It is brought out through separate punctures on anterior abdominal wall or perineum and sutures are fixed to patient's skin. Spasemaker or an expander is placed in a small pelvis cavity in the irradiation field, a laparotomic wound is closed, and after stabilization of the patient's condition on 1st-8th day, the target is delineated and the radiation field is planned taking into account the size, localization and risk organs. Position of the introducers is taken as a coordinate system x, y, z, after which high-power brachytherapy is performed with a radiation source of 192Ir in a single boost dose of 5 Gy once a day daily for five days on the afterloading system.

EFFECT: method provides higher clinical effectiveness in locally advanced pelvic tumors with lateral invasion, the method is well tolerated, accompanied by moderate, recoverable toxic reactions.

1 cl, 5 dwg, 1 tbl, 1 ex

Description

The invention relates to medicine, namely to oncology, radiation therapy and surgery, and can be used in the treatment of locally advanced pelvic tumors having lateral invasion into the pelvic wall.

The proportion of malignant tumors of the pelvic organs in the structure of oncological morbidity in Western Europe is 1/5 of all localizations. Malignant tumors of the pelvic localization in the structure of the oncological morbidity of the population of the Russian Federation account for more than 25%. These include cervical cancer, uterine cancer, colorectal cancer, bladder cancer, sarcoma, and prostate cancer. In the overall structure of cancer incidence, cervical cancer is 5.3%, or 21.27 per 100,000 population, occupying 6th place, and among the organs of the reproductive system - third (14%) after breast cancer (54.5%) and endometrium (19 , 3%). The incidence of colorectal cancer, rectosigmoid colon, anus is 18.69 per 100,000 population. Moreover, every third cancer patient by the time the diagnosis is established, the process is locally prevalent, and this indicator has remained unchanged for several decades. Tumors localized in the pelvis are characterized by early invasion of the surrounding organs, with distant metastasis occurring much later.

Currently, methods have been developed for extensive resections of locally distributed pelvic tumors, good results have been achieved in reducing early postoperative mortality, and reducing the incidence of postoperative complications.

The unsolved problem is the treatment of patients with a microscopically and macroscopically positive edge of the resection.

Currently, for locally advanced tumor lesions of the pelvic organs, the following treatment options are used:

- surgical treatment, palliative polychemotherapy (median overall survival of 6 months);

- surgical treatment + interstitial high-power brachytherapy (Alektiar KM, Zelefsky MJ, and Paty PB, et al (2000) High-dose-rate intraoperative brachytherapy for recurrent colorectal cancer. Int J Radiat Oncol Biol Phys 48 (1) 219-26). The addition of intraoperative brachytherapy to cytoreductive surgical treatment in 27 patients with recurrent endometrial cancer led to a 2-year relapse-free survival in 78% of patients versus 67% when intraoperative brachytherapy was not used;

- surgical treatment + remote radiation therapy in the postoperative period.

One of the new treatment options for locally advanced tumors of the pelvic organs is high-power brachytherapy of locally distributed tumors of the pelvis and has undoubted advantages over other types of treatment. Unlike competing technologies, this technique is applicable for a positive edge of tumor resection R1 (urgent histological examination of a removed preparation), R2, possibly in complex areas: proximity of large vessels, adjacent risk organs, providing a sharp gradient of the absorbed therapeutic dose between the target and unaffected tissue . This method is applicable in patients with multi-stage complex treatment, including patients who have previously undergone external radiation therapy, including chemotherapy and local tumor control.

, Frank Seefelda,

. Radiotherapy and Oncology 79 (2006) 298-303).An analysis of world literature in recent years shows the promise of this trend (Alektiar KM, Zelefsky MJ, and Paty PB, et al (2000) High-dose-rate intraoperative brachytherapy for recurrent colorectal cancer. Int J Radiat Oncol Biol Phys 48 (1) 219-26 Awtrey CS, Cadungog MG, Leitao MM, Alektiar KM, Aghajanian C, Hummer AJ, et al. Surgical resection of recurrent endometrial carcinoma. Gynecol Oncol. 2006; 102: 480-88. Doi: 10.1016 / j.ygyno. 2006.01. 007. Gemignani ML, Alektiar KM, and Leitao M, et al (2001) Radical surgical resection and high-dose intraoperative radiation therapy (HDR-IORT) in patients with recurrent gynecologic cancers Int J Radiat Oncol Biol Phys 50 (3) 687- 94. A dosimetric analysis of interstitial intensity modulated implantsfor pelvic recurrences, base of tongue and orbita tumors with specific references to the ICRU-58. Frank-Andre 'Sieberta, Thilo Borna, Stefanie

Frank Seefelda,

. Radiotherapy and Oncology 79 (2006) 298-303).

As a prototype of the present invention, a method for stereotactic remote radiation therapy of pelvic tumor lesions (Stereotactic body radiation therapy in patients with pelvic recurrence from rectal carcinoma. Japanese journal of clinical oncology Volume: 38 ISSN: 1465-3621 ISO Abbreviation: Jpn. J. Clin. Oncol. Publication Date: 2008 Oct 2008-10-10 Completed Date: 2008-11-13). The treatment method is presented by a course of remote radiation therapy in a single focal dose of 16 Gy.

The disadvantage of this method is the limitation of the method with tumor foci more than 4 cm and the lack of direct visual control of the target.

The technical result of the invention is the development of a method for irradiating directly the tumor tissue of the pelvic wall, which should lead to significant damage to the tumor and should increase the percentage of partial and complete regression of the tumor tissue, local tumor control.

The specified technical result in the implementation of the invention is achieved due to the fact that, as well as in the known method, high-power brachytherapy is performed with a ¹⁹² Ir radiation source on the afterlooding system.

A feature of the proposed method is that after resectional surgery of the pelvic organs, on the bed of the tumor, intraoperatively under control of vision, introducers with a diameter of 6Fr are installed, they are brought out through separate punctures on the anterior abdominal wall or perineum and fixed to the patient’s skin with sutures, the pelvic cavity is placed in the irradiation field by a spasemaker, or an expander, the laparotomy wound is sutured and after stabilization of the patient’s condition from 1-8 days, the target is contoured and the field is planned irradiation taking into account the size, localization and risk organs, the position of the introducers is taken as the x, y, z coordinate system, after which high-power brachytherapy with a source of radiation of ¹⁹² Ir is carried out in a single focal dose of 5 Gy 1 time per day for five days on the afterlooking system.

The invention is illustrated by a detailed description, clinical example and illustrations, which depict:

FIG. 1 - Spiral computed tomography (CT) of patient F., before brachytherapy.

FIG. 2 - Intraoperative photo, established introducers.

FIG. 3 - Positioning of the device to protect the small intestine from possible contact with the introducers.

FIG. 4 - SKT marking of radiation fields before brachytherapy.

FIG. 5 - CT of the abdominal cavity of the patient after 3 months, there is no tumor tissue in the area of brachytherapy.

The method is as follows.

The surgical stage of treatment is performed: pelvic tumor is removed, if necessary, resection and removal of adjacent organs. With a histologically or macroscopically positive edge of the resection, the presence of residual tumor tissue is established, under visual control, the introducers on the bed of the removed tumor are fixed with threads to the pelvic wall and through separate punctures they are brought out to the front abdominal wall, or through punctures in the perineum, after which they are fixed to the skin.

In the postoperative period, to stabilize the state, MRI, CT of the abdominal cavity, and pelvis are performed to determine the size and densitometric characteristics of the tumor tissue.

The technique of high-power brachytherapy (BMBT) for pelvic tumor lesions consists of the following steps.

After the resection phase of the surgical intervention, special introducers are installed on the tumor bed for high-power brachytherapy with a diameter of 6Fr. The number of introducers is selected individually, taking into account the size and shape of the residual tumor. After installation, the introducers through separate punctures on the anterior abdominal wall, or perineum, are brought out and fixed to the patient's skin with sutures. A spasemaker or an expander for mamoplasty is placed in the pelvic cavity to prevent small loops of the small intestine from entering the irradiation field. The laparotomy wound is sutured. The patient is transferred to the intensive care unit. After stabilization of the patient from the 1st to the 8th day, the patient is transported to the canyon for brachytherapy. At this time, specialists conduct contouring of the target and planning the radiation field at the workstation (for example, BrachyVision, Varian Medical Systems, Charlottesville, VA, USA) taking into account the size, location and risk organs. The position of the introducers is taken as the coordinate system (x, y, z). For each introducer within the boundaries of the tumor, a system of reference points encodes. High-power brachytherapy is carried out with a radiation source of ¹⁹² Ir. The exposure of the radiation source can be carried out along the entire introducer in the required time interval, taking into account the planning. Spend 5 sessions of 5 Gy daily for 5 days.

When planning high-power brachytherapy, the recommendations for QUANTEC radiation therapy are taken into account (see table).

Such a high dose is justified by the difference in the rate of restoration of sublethal damage to tumor and normal cells, the leveling of the oxygen effect, which makes it possible to enhance the damaging effect of radiation on the tumor while reducing damage to healthy tissues.

Thus, the proposed method allows you to summarize a high focal dose with maximum damage to the tumor and preservation of intact tissues, which is fundamentally important, given the need to maximize the preservation of neighboring organs and structures by an unaffected tumor.

Clinical example.

Example 1. Patient F., 40 years old. Diagnosis: Cervical cancer pT4N1M0, stage IVA. 3 courses of chemotherapy according to the Taksakad scheme, carboplatin. Disease progression. Continued tumor growth. Surgical treatment from 11/01/17 (anterior infralevatory evisceration of the pelvis with urine diversion according to Bricker). Progression of the disease continued tumor growth (Fig. 1).

In February 2018, an operation was performed: Advanced combined removal of recurrent tumors of the small pelvis and abdominal cavity with low anterior resection of the rectum, resection of the anterior abdominal wall, and paraaortic lymphatic dissection. Installation of introducers for brachytherapy (Fig. 2). Established protection of the small intestine from possible contact with the introducers (Fig. 3). We performed SKT marking of the radiation fields before brachytherapy (Fig. 4). The formation of a single-barrel colostomy. Brachytherapy was performed. With CT of the abdominal cavity after 3 months, there is no tumor tissue in the area of brachytherapy (Fig. 5).

Using the proposed method in the clinic can improve the treatment of locally advanced pelvic tumors having lateral invasion into the wall of the pelvis due to the introduction of high-power brachytherapy, for 5 sessions in the immediate vicinity of critical structures, with different sizes of foci. The proposed method of treatment is an easily reproducible method, well tolerated by patients, accompanied by moderate, controlled toxic reactions.

Claims (1)

   A method for interstitial, high-power brachytherapy of locally advanced pelvic tumors having lateral invasion into the wall of the small pelvis, including high-power brachytherapy with a 192Ir radiation source on the afterlooding system, characterized in that, after resection of the pelvic organs, on the tumor bed, intraoperatively under control vision, set introducers with a diameter of 6Fr, out through separate punctures on the anterior abdominal wall or perineum and fix they are sutured to the patient’s skin, a spasemaker is placed in the pelvic cavity, or the expander, the laparotomy wound is sutured and after stabilization of the patient’s condition from 1-8 days, the target is contoured and the radiation field is planned taking into account the size, localization and risk organs, the position of the introducers they take it for the x, y, z coordinate system, after which they perform high-power brachytherapy with a 192Ir radiation source in a single focal dose of 5 Gy once a day for five days on the afterlooking system.

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