Uloga stereotaksične radioterapije u lečenju metastaza u jetri kolorektalnog karcinoma
Sažetak
Kolorektalni karcinom je treći najčešći maligni tumor i drugi po učestalosti uzrok smrtnosti od malignih oboljenja u svetu. U Srbiji u 2020. godini je dijagnostikovano 5900 novih slučajeva i oko 3300 umrlih od ove bolesti. Najčešća lokalizacija metastatske bolesti je jetra. Ukoliko je procenjena mogućnost kompletne resekcije metastatske promene u jetri hirurgija je metoda izbora. Činjenica da su metastaze u jetri resektabilne u 10-20% slučajeva ostavlja mogućnost za primenu drugih modaliteta lečenja. Alternativu hirurgiji u lokalnom lečenju neresektabilnih metastaza u jetri predstavljaju stereotaksična radioterapija (SBRT), intersticijalna i intraluminalna brahiterapija, transkateterska arterijska hemoembolizacija, regionalna hemioterapija kroz hepatičnu arteriju, radioembolizacija primenom mikrosfera sa itrijumom-90, radiofrekventna i hemijska ablacija, krioablacija i ablacija mikrotalasima. Kandidati za SBRT metastaza u jetri su pacijenti sa neresektabilnom bolešću u jetri ili pacijenti kod kojih zbog prisutnih komorbiditeta nije moguće sprovesti hirurško lečenje, uz zadovoljavajuću funkciju okolnog nezahvaćenog parenhima jetre. Kontrola respiracijom uzrokovanih promena položaja tumora podrazumeva primenu različitih tehnika kao što su infracrveni markeri, tehnika zadržavanja daha, abdominalna kompresija, respiratorni tracking i respiratorni gating. Uređaji na kojima se sprovodi SBRT obuhvataju sajber nož, aparat za tomoterapiju i modifikovani linearlni akcelerator, kojim je omogućena rigorozna kontrola preciznosti sprovođenja zračne terapije i eksalacija doze zračenja. Različiti režimi frakcionisanja su u upotrebi, od primene doze u jednoj frakciji do hipofrakcionisanih režima, sa najčešćim aplikovanjem doze u opsegu od 30-60 Gy u 3 frakcije. Nizak procenat komplikacija SBRT metastaza u jetri se pripisuje pažljivom planiranju i preskripciji doze kao i izborom adekvatnog režima frakcinisanja. Rezultati dosadašnjih istraživanja ukazuju da aplikovanje visokih doza zračenja doprinosi visokom procentu lokalnog odgovora, ali sa druge strane ostavlja mogućnost progresije bolesti izvan granica ciljnog volumena. Uz adekvatnu selekciju pacijenata sa neresektibilnim metastatskim promenama u jetri primena savremenih tehnika zračne terapije, posebno u kombinaciji sa efikasnim modalitetima sistemskog lečenja, može doprineti boljoj lokalnoj kontroli i produženju preživljavanja.
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