高雄榮民總醫院放射腫瘤部

高雄榮民總醫院

子宮頸癌放射治療政策及執行程序 (2016年第一版)

修訂日期(2016/08/03)

(2017/07/26)

(2018/06/13)

(2019/02/22)

(2020/06/03)

本版與上版的差異:

前言

1.1.2新增IB2

1.1.3新增IB3

前言

子宮頸癌的治療指引以子宮頸癌多專科團隊訂定的治療準則為依據。以下僅就子宮頸癌治療時放射治療的適應症、治療技術、治療劑量、以及正常組織的劑量限制來說明子宮頸癌放射治療政策及執行程序。

子宮頸癌之放射治療政策(strategy)及執行程序

1. 放射治療的適應症

1. 1. 治癒性放射治療(definitive curative radiotherapy alone)：包括全骨盆腔體外放射治療(whole pelvis external beams radiation therapy) 及腔內近接治療(intracavitory radiotherapy, ICRT或 intracavitory brachytherapy, ICBT) 或組織插種近接治療(interstitial brachytherapy, ISBT)

1. 1. 1. 不宜或不願手術治療早期子宮頸癌(不考慮生育者) (IA1 with LVSI, IA2)

      2. 不宜或不願手術治療早期子宮頸癌(FIGO IB1, IB2或IIA1)可考慮合併以cisplatin為主之化學治療。

      3. 不宜或不願手術治療FIGO IB3,或IIA2子宮頸癌，合併以cisplatin為主之化學治療。

      4. FIGO IIB以上較晚期之子宮頸癌，合併以cisplatin為主之化學治療。

   2. 術後輔助性放射治療(postoperative adjuvant radiotherapy)：包括全骨盆腔體外放射治療及陰道內近接放射治療(intravaginal radiotherapy, IVRT or intravaginal brachytherapy, IVBT)

1.2.1手術治療後，根據Sedlis criteria行體外放射治療

1.2.2同步化放療(任一項或以上者)

(1)子宮頸旁組織受侵犯(parametrial invasion)

(2)手術切除邊緣發現癌細胞(positive surgical margin)

(3)骨盆腔淋巴腺轉移(positive pelvic nodes)

1.2.3 術後positive or close vaginal mucosal surgical margins，可考慮追加IVRT

2. 固定模具製作及定位：

2.1若臨床需要可考慮靜脈顯影劑注射以增加腫瘤與血管等組織之辨識

2.2為減少小腸之照射，需喝水脹膀胱。建議於定位前20~30分鐘前排空膀胱，並喝約300cc開水後脹尿至少 15 分鐘，喝水量及脹尿程度以病患能忍耐之舒適度為主。

2.3採治療姿勢﹝仰臥、雙手置於胸前﹞，病患腳部擺放在腳踝固定器(ankle fix device)上，必要時以真空氣墊(vacuum pillow)固定姿勢

2.4每3-5 毫米擷取一張電腦斷層影像

2.5以雷射光於病人腹部、身體兩側劃上等中心(isocenter)記號

2.6將影像傳送至電腦治療計劃系統(radiation treatment plan, RTP system)

3. 靶體積定義(Target Volume Definition)

3.1標靶體積(Gross Target Volume, GTV): 電腦斷層，磁振照影或正子攝影影像，可量測的病灶(measurable gross lesions seen at CT scan, MRI or PET/CT)

3.2臨床標靶體積(Clinical Target Volume, CTV):

3. 2. 1. 總髂骨血管(common iliac vessels)

      2. 外髂骨血管(external iliac vessels)

      3. 內髂骨血管(internal iliac vessels)

      4. 薦骨前區(presacral region)

4. 放射治療計畫規劃(Radiation Therapy Planning)及放射治療劑量:

4. 1. 強度調控放射治療(Intensity-modulated Radiotherapy, IMRT)或體積弧形調控放射治療(Volumetric Arc Therapy, VMAT),治療範圍：common iliac, external iliac, internal iliac, obturator and presacral nodes; cervix, parametrium and upper third vagina

   2. 劑量處方 (dose prescription)：

每分次1.8-2.0Gy，每週五分次，五週總劑量為45-50Gy(1.8-2.0 fraction dose,5 fractions per week, total dose 45-50 Gy over 5 weeks)

4.3轉移淋巴結(gross adenopathy):

針對無法手術切除之轉移淋巴結(gross adenopathy)，給予總劑量45-50Gy。

4.4子宮旁追治照野(parametrial boost fields):

4.4.1當主腫瘤龐大時(bulky primary tumor)，在全骨盆腔體外放射治療給予總劑量45-50 Gy後，可考慮給予5.4-9.0 Gy 之子宮旁追加治療

4.4.2治療照野之上緣位於骶髂關節(SI joint)上一公分處，外緣及下緣與全骨盆腔前後照野相同

4.4.3中線遮擋膀胱及直腸，寬度約4-5公分

4.5 Extended field radiotherapy:

4.5.1手術後發現主動脈旁淋巴腺(Para- aortic lymph nodes)有轉移時，應考慮接受放射線治療。總劑量為45-50 Gy，每分次劑量 1.8 或 2.0Gy，每週五分次，共五週(45-50 Gy/25 fractions/5 weeks)。

4.5.2治療範圍為全骨盆腔照射範圍(whole pelvis irradiated field)向上延伸至renal vessels or T12/L1 level。

4.6腔內近接放射治療 (intracavitory radiotherapy, ICRT or

intracavitory brachytherapy, ICBT)

4.6.1採高劑量率後荷式近接治療(high-dose-rate after loading

brachytherapy)

4.6.2 IB1-IVA之子宮頸癌，先給予45-50Gy(含子宮旁追治照野)之體外全骨盆放射治療。

4.6.3 Point A 或標靶劑量(dose of point A or target volume):一週二分次，每分次5.5-6Gy 共5分次

4.7手術後之陰道內近接放射治療 (intravaginal radiotherapy, IVRT or intravaginal brachytherapy, IVBT)

4.7.1 positive or close vaginal mucosal surgical margins: 作為體外放射治療後的加強治療，治療劑量為陰道黏膜下五毫米(5mm)每分次(fraction) 5.5Gy(Gy)，一週二分次，總共2分次或陰道黏膜每分次(fraction) 6Gy，一週二分次，總共3分次

4.8 組織插種近接治療(interstitial brachytherapy, ISBT)

4.8.1組織插種近接治療劑量為參考點或參考體積每分次(fraction) 5-9Gy(Gy)，一天一~二分次，總共2-6分次

5. 危急器官 (Organ at Risk)及劑量限制(Dose Constraints)

5.1 小腸：Dmax≦50 Gy

5.2 直腸：Dmax≦60 Gy;V50<50%,V60<40%

5.3 膀胱: Dmax≦65;V65<50%

5.4 股骨頭:Dmax≦50

Reference:

1. NCCN clinical practice guidelines for cervical cancer, 2020 version 1

2. American Joint Committee on Cancer(AJCC), seventh edition.

3. FIGO Committee on Gynecologic Oncology, revised FIGO staging for cervix, Int J Gynaecol Obstet 2009.

4. Randomized study of radical surgery versus radiotherapy for stage Ib-IIa cervical cancer, Landoni F et al.

5. Phase III Comparison of Pelvic Irradiation with Concurrent CDDP/5-FU vs Pelvic and Para-Aortic Irradiation without Chemotherapy in Patients with High-Risk Carcinoma of the Cervix, RTOG 90-01.

6. Phase III Randomized Trial of Radiosensitization with HU vs HU/5-FU/CDDP vs CDDP in Patients with Stage IIB/III/IVA Cervical Cancer with Negative Para-Aortic Nodes. GOG 120

7. A randomized trial of pelvic radiation therapy versus no further therapy in selected patients with stage IB carcinoma of the cervix after radical hysterectomy and pelvic lymphadenectomy: Intergroup 0107/SWOG 8797/GOG 109

8. Phase III Randomized Comparison of Radiotherapy with vs without Continuous-Infusion 5-FU/Bolus CDDP Following Radical Hysterectomy and Node Dissection in High-Risk Patients with Stages IA2, IB, and IIA Carcinoma of the Cervix SWOG-8797, GOG-109, RTOG-9112, INT-0107

8. Radiation Oncology: An Evidenced-Based Approach, J. J. Lu and L. W. Brady (Eds.)

9. Liu WS, Yen SH, Chang CH, Yang KM, Wu YP, Chen KY. Determination of the appropriate fraction number and size of the HDR brachytherapy for cervical cancer. Gynecol Oncol. 1996 Feb;60(2):295-300.

10. Chung-Man-Leung, Yu-Chang Hu, Chien-Hsun Chen, Ching-Hsiung Chang. Postoperative Radiation Therapy in Patients with Pathologic Risks of Stage Ib to IIa cervical carcinoma. Therapeutic Radiology and Oncology Vol. 11, No.2, p.71-79, June 2004

11. Po-Chun Chen, Wen-Shan Liu, Chien-Hsun Chen, Ching-Hsiung Chang. Prognostic factors after adjuvant radiotherapy in cervical cancers: a retrospective study Therapeutic Radiology and Oncology Vol. 20, No. 2, 89-96, June 2013