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摘要:
放射治疗是乳腺癌的重要治疗手段，由于左乳与心脏位置毗邻，设计照射野时常不能完全避开心脏。乳腺癌放射治疗增加了患缺血性心脏病、心包炎和瓣膜病的风险。年轻、高体重指数（body mass index, BMI）、肿瘤位于中央象限和胸骨旁区域与心脏受到高剂量辐射有关。放疗心脏毒性与放疗技术有很大关系，对于左乳切除术后放疗，多野调强适形放疗（IMRT）能够平衡靶区覆盖和正常组织受量，而左乳保乳术后放疗，采用双弧度容积旋转调强（VMAT）较多野IMRT更具优势。相比全乳照射，加速部分乳腺照射能够显著降低心脏剂量；而对于需要照射区域淋巴结的患者，采用容积旋转调强或螺旋断层放疗在减少心脏受量方面则显示出优势。相比自由呼吸，深吸气屏气放疗能够显著减少心脏和冠状动脉左前降支剂量；尤其是对于胸壁+区域淋巴结（包括内如淋巴结）放疗的患者采用深吸气屏气（deep inspiration breath hold, DIBH）放疗获益更多，而对于保乳术后仍为大乳腺的患者，采用俯卧位能减少心脏毒性。另外，左乳放疗期间同步曲妥珠单抗靶向治疗、芳香化酶抑制剂（aromatase inhibitors, AI）会影响心脏事件的发生。基于上述因素，在给左侧乳腺癌患者制定放疗计划时，应结合患者年龄、BMI、原发肿瘤位置、体型、术后乳腺大小、是否需要区域淋巴结照射，根据现有放疗设备，给予最优的放疗方案，同时减少增加心脏毒性的同步治疗，从而最大程度减少治疗导致的心脏不良反应。
Abstract:Radiotherapy (RT) is an important treatment for breast cancer. As the left breast is adjacent to heart, heart irradiation cannot be completely avoided. Radiotherapy on breast cancer increases the risk of ischemic heart disease, pericarditis and valvular disease. Tumor location and treatment choices influence cardiac dose with complex interactions. Radiation technology plays an important role in cardiac toxicity of radiotherapy. Multi-field IMRT may be the optimal one which can balance PTV coverage and organ at risk sparing for left-sided breast cancer after mastectomy; as to the patients after breast-conserving surgery irradiation, volumetric-modulated arc therapy (VMAT) offer certain dosimetric advantages over fixed-field IMRT plans. Compared with whole breast irradiation, partial breast irradiation shows a significant reduction in radiation dose for the heart. As to lymph node-positive left-sided breast cancer patients, VMAT or tomotherapy retains target homogeneity and coverage and allows maximum doses to organs at risk to be reduced; deep inspiration breath hold results in a significant reduction in radiation dose to the heart and left anterior descending coronary artery compared with an free breathing, especially for the patients who need to irradiate chest wall and regional lymph node; and for some patients with large breast after surgery, prone setup can significantly reduce the amount of heart volume. Moreover, left-sided radiotherapy concurrent with trastuzumab or AI increases the cardiac toxicity risk. In conclusion, left-sided breast radiotherapy plan needs to consider patients' age, BMI, primary tumor location, size, postoperative breast size, whether need regional lymph node radiation; giving the optimal radiotherapy plan according to the existing radiation therapy equipment, at the same time, reducing the synchronous cardiac toxicity increasing treatment, so as to minimize cardiac adverse event.
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Key words:
- Breast cancer /
- Radiotherapy /
- Cardiac toxicity
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