43例鼻咽癌的调强适形放射治疗体会

目的介绍调强适形放射(IMRT)治疗鼻咽癌的效果。方法对43例初治或复发鼻咽癌患者给予IMRT,将照射靶体积划分为鼻咽大体肿瘤体积(GTVnx)、颈部大体肿瘤体积(GTVnd)、临床靶体积1(CTV1)、临床靶体积2(CTV2)。处方剂量GTVnx68Gy~74Gy,GTVnd60Gy~66Gy,CTV160Gy,CTV254Gy;共30次。34例接受放化综合治疗,9例接受单纯放疗。结果GTVnx、GTVnd、CTV1、CTV2的平均剂量分别为72.40Gy、67.83Gy、60.25Gy和64.85Gy。中位随访期9个月,局部无进展生存率100%;1例放疗后4月出现肝和肺转移。结论IMRT技术对初治或复发鼻咽癌病例均可获得理想的剂量分布,正常组织得到很好的保护,毒副反应可以耐受,临床疗效令人满意。     

鼻咽癌调强放疗初步结果

目的:探讨鼻咽癌三维适形调强放射治疗(intensity-modulatedradiotherapy,IMRT)的初步疗效。方法:对91例经病理确诊的鼻咽低分化鳞癌患者进行调强放疗。处方剂量分别为GTV(鼻咽部和颈部淋巴结肿瘤靶区)66~70Gy,CTV1(临床靶区)60~62Gy,CTV2和CTVn(颈部淋巴结区域)54~56Gy。11例患者IMRT结束后有局部残留,1例采用IMRT追量照射10Gy/4次,其余给予鼻咽腔内后装追量照射9~15Gy/3~5次。分析疗效及放射治疗毒性。结果:中位随访时间12个月,1和2年生存率为97·1%和97·1%,局控率为97·1%和92·5%。急性放射反应多为Ⅰ度和Ⅱ度以口干和放射性口腔炎为主,分别占72·5%和58·2%。远期放射反应表现为不同程度的口干和听力下降,占患者的39·6%和17·6%。GTV、CTV1及CTV2的平均剂量分别为70·6、67·9和65·0Gy;5%体积的正常器官受照射剂量的平均值为:脑干41·4Gy,脊髓35·4Gy,左腮腺46·5Gy,右腮腺51·8Gy。结论:调强放疗能使得鼻咽癌各靶区得到很好的剂量分布,提高了初治鼻咽癌的局部控制率,明显减轻了急性放射反应。鼻咽癌IMRT处方剂量70Gy以上,CTV2预防照射的范围有待于进一步探讨。     

鼻咽癌调强适形放疗复发病例分析

目的：分析探讨鼻咽癌调强适形放疗（IMRT）后复发的原因。方法：初治鼻咽癌患者211例中,Ⅰ期3例,Ⅱ期44例,Ⅲ期96例,ⅣA期68例;Ⅰ、Ⅱ期行单纯根治性放疗,Ⅲ、ⅣA期化放综合治疗。鼻咽和上颈部采用IMRT技术,将鼻咽的靶体积划分为鼻咽大体肿瘤体积（GTV-T）、临床靶体积1（CTV1）和临床靶体积2（CTV2）;颈部的靶体积划分为颈部大体肿瘤体积（GTV-N）和上颈部淋巴引流区靶体积（CTV-N）。GTV-T、GTV-N、CTV1和CTV2、CTV-N的处方剂量分别为66-68Gy、60-68Gy、60-62Gy和54-56Gy,共（30-31）次/（6-6.2）周。下颈及锁骨上区常规切线照射。结果：211例患者中鼻咽复发2例,上颈部复发1例,鼻咽和颈部同时复发1例,近期复发率1.9%;鼻咽复发部位均在GTV-T内,1例上颈部复发于GTV-N内,1例上颈部复发因GTV-N脱靶于CTV-N内;2例分别于首程放疗后19和20个月死亡,2例健在。结论：IMRT对鼻咽癌能获得理想的局部控制,但仍存在复发问题。对鼻咽肿瘤的最佳照射剂量存在个体差异,照射剂量不足、乏氧细胞多、治疗中断以及对靶区认识不足等可能是导致复发的主要原因。     

81例局部晚期鼻咽癌放疗的临床研究

目的观察3种不同治疗方案对局部晚期鼻咽癌的临床疗效、急性反应和晚期损伤。方法初治鼻咽癌81例,其中Ⅲ期50例,ⅣA期31例。单纯放疗组（RT）30例,常规放疗加化疗组（RT＋CT）33例,调强放疗加化疗组18例（IMRT＋CT）。常规放疗鼻咽部剂量70～76 Gy,肿大淋巴结60～65 Gy,颈部预防剂量50 Gy;调强放疗设鼻咽大体肿瘤为GTV（nx）、颈部阳性淋巴结GTV（nd）、高危临床靶体积CTV1和低危临床靶体积CTV2。处方剂量分别为GTV（nx） 70．6～76．6 Gy分31～33次、GTV（nd） 61．6～70．6 Gy分28～33次、CTV1 60 Gy分28次、CTV2 53．2 Gy分28次,化疗方案包括诱导、同期与辅助。生存率用Kaplan-Meier法计算,Logrank检验,RTOG或EORTC标准评价急性反应和晚期损伤。结果中位随访时间21．5个月,全组2和3年局部区域无进展、无远处转移生存率、总生存率分别为90%、85%、86%和83%、83%、83%;RT组分别为63%、82%、65%和52%、76%、60%;RT ＋CT组分别为76%、83%、77%和73%、83%、60%;IMRT＋CT组分别为100%、94%、100%和89%、94%、100%。RT组与RT＋CT组生存差异无统计学意义（X^2=0．53,P=0．473）,RT组与IMRT＋CT组生存差异有统计学意义（X^2=7．42,P=0．007）,RT＋CT组与IMRT＋CT组生存比较差异有统计学意义（X^2=5．06,P=0．028）。全组多数患者仅表现为1～2级急性反应和0～1级晚期损伤,RT组1例出现放射性脑病。放疗后1年中重度口干发生率RT组和RT＋CT组总计92%,而IMRT＋CT组仅表现为轻度口干。结论IMRT加化疗对局部晚期鼻咽癌患者可获得理想的局部区域控制和总生存率;IMRT可明显减轻放疗引发的口干。     

鼻咽癌调强放疗的剂量学研究

 【摘要】目的 分析鼻咽癌调强放疗各个靶区和周围正常组织器官的剂量学特点。方法 2005年1月-2006年6月住院的30例初治鼻咽癌进行调强放疗，将鼻咽和颈部的靶体积勾画为鼻咽大体肿瘤体积（GTVnx）、颈部大体肿瘤体积(GTVnd)、临床靶体积1（CTV1）和临床靶体积2(CTV2)，处方剂量分别为70、66、60、60Gy/30F，鼻咽和上颈部靶体积采用IMRT技术照射、下颈部靶体积采用下颈前野常规照射。研究GTV、CTV的最大、最小、平均剂量和颞叶、脑干、脊髓、视神经、晶体、眼球的最大受照剂量及腮腺、颞下颌关节的50%体积受照剂量。结果 GTVnx的最大、最小、平均剂量（均值）分别为79.2、59.5、71.9Gy, GTVnd的最大、最小、平均剂量分别为77.1、63.6、72.1Gy，CTV1、CTV2的最小剂量分别为47.6、49.7Gy，颞叶、脑干、脊髓、视神经、晶体、眼球的最大受照剂量及腮腺、颞下颌关节的50%体积受照剂量63.2、48.6、44.7、59.3、6.9、25.9Gy和34.0、36.3Gy。结论 调强放疗可以使各个靶区得到足够的、均匀的剂量分布，周围正常组织器官得到较好的保护，但是要注意CTV的低剂量区。鼻咽癌调强放疗剂量分布优于常规放疗。     

初治鼻咽癌调强放疗布野及联合化疗的临床研究

[目的]研究鼻咽癌调强放射治疗(IMRT)的投照方式、近期临床疗效,以及单纯放疗和放、化疗结合的耐受性。[方法]2003年12月￣2005年12月157例初治鼻咽癌患者鼻咽和全颈及锁骨上全程实施前7野IMRT。鼻咽大体肿瘤体积(GTV1)、颈部大体肿瘤体积(GTV2)、临床靶体积1(CTV1)和临床靶体积2(CTV2)处方剂量分别为70Gy、66Gy、60Gy、50Gy,共32分次。88例患者行联合化疗。采用Kaplan-Meier法进行生存分析,RTOG标准评价急性反应和晚期损伤。[结果]治疗计划结果显示,靶区内GTV1、GTV2、CTV1和CTV2的平均剂量分别为70.5Gy、67.0Gy、60.1Gy和51.2Gy。中位随访时间16个月,1、2年局部区域无进展和无远处转移生存率及总生存率分别为97.4%、94.9%和93.6%、89.4%及96.4%、92.7%。放化综合治疗组的口咽、黏膜反应及血液系统毒性明显高于单纯放疗组。患者近期毒副反应均可以耐受,口干症状随着治疗后时间的延长逐渐减轻。[结论]IMRT使靶体积照射剂量提高,而周围器官受照剂量降低,对初治鼻咽癌可获得理想的局部区域控制,放化综合治疗对控制远处转移有一定价值。     

117例鼻咽癌适形调强放射治疗的预后研究

 目的　分析初治鼻咽癌根治性调强放射治疗（IMRT）的预后。方法　2005年1至11月初诊鼻咽癌患者117例进入分析,其中男81例,女36例,中位年龄42岁（18～76岁）。按照1992年福州鼻咽癌分期标准：Ⅰ期11例、Ⅱ期15例、Ⅲ期54例、ⅣA期37例,IMRT计划与实施由PEACOCK系统完成。鼻咽肿瘤体积（GTVnx）处方剂量68 Gy,颈部转移淋巴结（GTVnd）60～66 Gy,临床靶体积1（CTV1）60 Gy,临床靶体积2（CTV2）54 Gy。结果　全组随访10.5～59.5个月,中位随访期48个月,3、5年总生存率分别为95.7 %和89.7 %,无进展生存率分别为91.5 %和87.2 %,局部区域控制率分别为94.0 %和91.5 %。单因素分析显示治疗前Karnofsky评分、T分期、1992年福州分期、治疗前血小板和治疗后尿酸水平等因素均影响患者的生存时间,多因素分析显示T分期是影响患者生存时间的独立因素。结论　根治性IMRT显著延长了初治鼻咽癌患者的生存时间,T分期是影响患者生存时间的独立预后因素。     

复发鼻咽癌调强放疗的剂量学探讨

目的:分析和评价复发鼻咽癌调强放疗(IMRT)的剂量学特点.方法:30例局部、区域复发的鼻咽癌患者使用IMRT的再程放疗,其中7例同时伴有颈淋巴结转移.根据1992年福州分期标准进行再分期,Ⅰ、Ⅱ、Ⅲ、Ⅳ期分别为7、7、4、12例. 鼻咽大体肿瘤体积(GTV)处方剂量为58.80-78.76Gy,分次剂量2.0-2.92Gy.结果:治疗计划GTV的中位体积为37.46cm3(14.30-227.52 cm3),覆盖鼻咽GTVD95的平均剂量为62.56Gy,GTVV95的平均体积为98.69%;靶区内GTV、CTV1和CTV2的平均剂量分别为65.82Gy、54.02Gy和50.20Gy;GTV的平均分割剂量为2.28Gy(2.0-2.92Gy).结论:IMRT能较好覆盖肿瘤靶区而降低邻近敏感器官剂量.     

局部晚期鼻咽癌73例放化疗综合治疗的临床研究

目的:回顾性分析两种不同的放化疗综合治疗方案对局部晚期鼻咽癌的临床疗效、急性反应和晚期损伤。方法:初治鼻咽癌患者73例,分为常规放疗加化疗综合治疗组(RT CT)42例和调强放疗加化疗组(IMRT CT)31例。常规放疗鼻咽部剂量70～76Gy,肿大淋巴结60～65Gy,颈部预防剂量50Gy;调强放疗设鼻咽部大体肿瘤为GTVnx、颈部阳性淋巴结GTVnd、高危临床靶体积CTV1和低危临床靶体积CTV2。处方剂量分别为GTVnx(70.6～76.6)Gy/(31～33)f、GTVnd(61.6～70.6)Gy/(28～33)f、CTV156Gy/28f、CTV2(50.4～53.2)Gy/28f,化疗方案包括诱导、同期与辅助。结果:中位随访时间20个月,全组2年和3年的局部区域无复发率、无远处转移生存率及总生存率分别为83.3%、90.9%、86.2%和78.9%、89.5%、84.3%;(RT CT)组分别为70.0%、85.0%、77.6%和70.0%、80.6%、60.4%;(IMRT CT)组分别为88.9%、95.5%、100%和88.9%、95.5%、100%。Log-rank生存比较显示,(RT CT)组与(IMRT CT)组的局部区域无复发率与总生存率比较差异有统计学意义,P值分别为0.045和0.021。结论:IM-RT加化疗对局部晚期鼻咽癌可获得理想的局部区域控制和总生存率。     

初治鼻咽癌调强适形放疗近期临床观察

目的研究调强放射治疗(IMRT)对初治鼻咽癌的疗效以及对正常组织的保护和毒性反应。方法对24例鼻咽癌初治患者鼻咽和全颈及锁骨上全程实施IMRT,肿瘤靶区授予处方剂量68~70Gy。对于Ⅲ和Ⅳ期患者,在IMRT同时,结合患者淋巴结转移及一般情况给予PDD+5-Fu±THP-ADM方案化疗1~2周期。结果治疗计划结果显示,覆盖鼻咽GTV1D95的平均剂量为70.48Gy,GTV1V95的平均体积为98.46%;靶区内GTV1、GTV2、CTV1和CTV2的平均剂量分别为70.48Gy、66.98Gy、60.10Gy和51.18Gy。本组有2例、16例、5例和1例患者分别出现0、1、2和3级的皮肤急性放射性反应;有4例、6例、13例和1例患者分别出现1、2、3和4级的口腔粘膜急性放射性反应;其中1例合并联合化疗患者因严重口腔粘膜炎中断放疗1周。其他合并化疗患者在化疗后均出现不同程度的骨髓抑制,经对症处理均未影响正常放射治疗。本组患者中位随访期13个月。无1例出现局部复发或远处转移。结论IMRT在初治早期或晚期鼻咽癌病例均可获得理想的剂量分布,正常组织得到很好的保护,毒副反应可以耐受,临床疗效令人满意。     

Organ motion in image-guided radiotherapy: lessons from real-time tumor-tracking radiotherapy

External radiotherapy using imaging technology for patient setup is often called image-guided radiotherapy (IGRT). The most important problem to solve in IGRT is organ motion. Four-dimensional radiotherapy (4DRT), in which the accuracy of localization is improved – not only in space but also in time – in comparison to 3DRT, is required in IGRT. Real-time tumor-tracking radiotherapy (RTRT) has been shown to be feasible for performing 4DRT with the aid of a fiducial marker near the tumor. Lung, liver, prostate, spinal/paraspinal, gynecological, head and neck, esophagus, and pancreas tumors are now ready for dose escalation studies using RTRT.     

国产威达（WD－H·D·R18）后装腔内治疗机的临床应用（附380例疗效观察）

我院自１９９２年６月至１９９３年６月使用广东威达（ＷＤ·Ｈ·Ｄ·Ｒ·１８型）后装腔内治疗机，施行腔内放疗、组织间插植、术中置管和表面敷贴放疗等方法，治疗各种癌瘤共３８０例，其近期疗效为：完全消失７９．７４％（３０３／３８０）部分消失：１４．７４％（５６／３８０）无效：５．５３％（２１／３８０）；总有效率：９４．４８％（３５９／３８０）。全组随诊时间为１－１２个月。结合临床应用的若干问题对该机作出初步评价。     

2019年中国大陆地区放疗人员和设备基本情况调查研究

[目的]了解我国大陆地区放疗人才及设备情况。[方法]2019年4月10日至9月20日期间,中华医学会放射肿瘤治疗学分会通过线上问卷的形式进行了全国第九次行业调查,调查2018年度全国各个医院从事放疗的人员、设备、技术、年放疗人次以及主要放疗病种等数据。[结果]本次问卷回收率100%,所有放疗单位数据通过各省医学会再次确认。中国大陆地区放疗单位1463家。从事放疗的工作人员共29096人,其中放疗医师14575人、物理师4172人、技师8940人、维修师1409人。共有直线加速器2021台(含进口和国产),钴60远距离治疗机66台,近距离治疗机339台,质子重离子机5台,常规模拟机1453台,CT模拟机355台。能开展二维放疗1002家,三维适形放疗1272家,静态调强放疗1121家,Rapid Arc145家,容积旋转调强放疗279家,立体定向放射治疗297家,近距离治疗273家,全身X线治疗75家,全身电子线治疗73家,Tomo治疗38家,质子/重离子治疗5家。病床数97836张(含综合医院肿瘤科病床),放疗年治疗人数1259602人。[结论]中国大陆地区放疗单位数目缓慢增长,放疗从业人员较前稍减少,开展放疗新技术单位逐年增加,全国每百万人口放疗设备(加速器+钴60)仅1.5,仍低于WHO的要求。     

Clinician's guide to prostate IMRT plan assessment and optimisation

Intensity-modulated radiotherapy (IMRT) offers dosimetric benefit for irregularly shaped treatment volumes compared to three-dimensional conformal approaches. Some groups advocate IMRT as the standard of care for prostate radiotherapy. For clinicians, assessment of an IMRT plan can introduce new opportunities and challenges. Although a standard IMRT plan may be deemed acceptable by meeting pre-set dose constraints, further optimisation may yield a superior treatment plan by further reducing dose to critical structures or improving target volume homogeneity. The aim of this article is to present aspects of IMRT planning relevant to clinicians to aid in plan critiquing.     

Evaluation of a Novel Field-placement Algorithm for Locoregional Breast Cancer Radiotherapy Including the Internal Mammary Chain

Aims

Irradiation of the internal mammary chain (IMC) is increasing following recently published data, but the need for formal delineation of lymph node volumes is slowing implementation in some healthcare settings. A field-placement algorithm for irradiating locoregional lymph nodes including the IMC could reduce the resource impact of introducing irradiation of the IMC. This study describes the development and evaluation of such an algorithm.

非小细胞肺癌3D-CRT与IMRT立体定向放疗剂量学比较

目的:研究三维适形(3D-CRT)和逆向调强(IMRT)两种计划方式在进行早期非小细胞肺癌(NSCLC)立体定向放射治疗(SBRT)的剂量学差异。方法:选取接受放射治疗的早期NSCLC患者12例,分别采用3D-CRT和IMRT技术设计SBRT治疗计划。比较两种计划方式下PTV的相关剂量学参数(CI、HI、D1%、D99%),肺、胸壁、心脏及脊髓的剂量学参数(Vx、Dmean、Dmax),以及加速器的机器跳数、治疗时间等差异。结果:在PTV相关参数比较中,3D-CRT计划的CI、HI以及D1%均差于IMRT,差异有统计学意义,P<0.05;但是两者的D99%差异无统计学意义,P>0.05。在危及器官受量的比较中,3D-CRT与IMRT计划的患侧肺V5～V40、健侧肺V5～V15、双侧肺V5～V40、胸壁V5～V40、Dmean、心脏V20～V40、Dmean及脊髓Dmax的差异均无统计学意义,P>0.05。3D-CRT计划的机器跳数及治疗时间较IMRT计划分别减少了53%和78%,P<0.05。在绝对剂量体积比较中,3D-CRT的V60～V75及V45～V60均大于IMRT,V20～V45小于IMRT,差异均无统计学意义,P>0.05。结论:IMRT计划在早期NSCLC行SBRT治疗中不具有明显的剂量学优势。考虑到IMRT实施过程的复杂性和不确定性,早期NSCLC行SBRT治疗时3D-CRT可作为首选。     

The Long and the Short of it: the Role of Short-course Radiotherapy in the Neoadjuvant Management of Rectal Cancer

Total mesorectal excision is the cornerstone of treatment for rectal cancer. Multiple randomised trials have shown a reduction in local recurrence rates with the addition of preoperative radiotherapy, either as a 1-week hypofractionated short-course (SCRT) or a conventionally fractionated long-course (LCRT) schedule with concurrent chemotherapy. There is also increasing interest in the addition of neoadjuvant chemotherapy to radiotherapy with the aim of improving disease-free survival. The relative use of SCRT and LCRT varies considerably across the world. This is reflected in, and is probably driven in part by, disparity between international guideline recommendations. In addition, different approaches to treatment may exist both between and within countries, with variation related to patient, disease and treatment centre and financial factors. In this review, we will specifically focus on the use of SCRT for the treatment of rectal cancer. We will discuss the literature base and current guidelines, highlighting the challenges and controversies in clinical application of this evidence. We will also discuss potential future applications of SCRT, including its role in optimisation and intensification of treatment for rectal cancer.     

A Randomised Phase II Clinical Trial Comparing the Deliverability and Acute Toxicity of Wide Tangent versus Volumetric Modulated Arc Therapy to the Breast and Internal Mammary Chain

AimsInclusion of the internal mammary chain in the radiotherapy target volume (IMC-RT) improves disease-free and overall survival in higher risk breast cancer patients, but increases radiation doses to heart and lungs. Dosimetric data show that either modified wide-tangential fields (WT) or volumetric modulated arc therapy (VMAT) together with [AQ1]voluntary deep inspiration breath hold (vDIBH) keep mean heart doses below 4 Gy in most patients. However, the impact on departmental resources has not yet been documented. This phase II clinical trial compared the time taken to deliver IMC-RT using either WT and vDIBH or VMAT and vDIBH, together with planning time, dosimetry, set-up reproducibility and toxicity.Materials and methodsLeft-sided breast cancer patients requiring IMC-RT were randomised to receive either WT(vDIBH) or VMAT radiotherapy. The primary outcome was treatment time, powered to detect a minimum difference of 75 min (5 min/fraction) between techniques. The population mean displacement, systematic error and random error for cone beam computed tomography chest wall matches in three directions of movement were calculated. Target volume and organ at risk doses were compared between groups. Side-effects, including skin (Radiation Therapy Oncology Group), lung and oesophageal toxicity (Common Terminology Criteria for Adverse Events v 4.03) rates, were compared between the groups over 3 months. Patient-reported outcome measures, including shoulder toxicity at baseline, 6 months and 1 year, were compared.ResultsTwenty-one patients were recruited from a single UK centre between February 2017 and January 2018. The mean (standard deviation) total treatment time per fraction for VMAT treatments was 13.2 min (1.7 min) compared with 28.1 min (3.3 min) for WT(vDIBH). There were no statistically significant differences in patient set-up errors in between groups. The average mean heart dose for WT(vDIBH) was 2.6 Gy compared with 3.4 Gy for VMAT(vDIBH) (P = 0.13). The mean ipsilateral lung V_17Gy was 32.8% in the WT(vDIBH) group versus 34.4% in the VMAT group (P = 0.2). The humeral head (mean dose 16.8 Gy versus 2.8 Gy), oesophagus (maximum dose 37.3 Gy versus 20.1 Gy) and thyroid (mean dose 22.0 Gy versus 11.2 Gy) all received a statistically significantly higher dose in the VMAT group. There were no statistically significant differences in skin, lung or oesophageal toxicity within 3 months of treatment. Patient-reported outcomes of shoulder toxicity, pain, fatigue, breathlessness and breast symptoms were similar between groups at 1 year.ConclusionVMAT(vDIBH) and WT(vDIBH) are feasible options for locoregional breast radiotherapy including the IMC. VMAT improves nodal coverage and delivers treatment more quickly, resulting in less breath holds for the patient. This is at the cost of increased dose to some non-target tissues. The latter does not appear to translate into increased toxicity in this small study.     

Radiothérapie adaptative : stratégies et bénéfices selon les localisations tumorales

Adaptive radiotherapy (ART) is a complexe image-guided radiotherapy modality that comprises multiple planning to account for anatomical variations occurring during irradiation. Schematically, two strategies of RTA can be distinguished and combined according to tumor locations. One or more replanning can be proposed to correct systematic variations such as tumor shrinkage. A library of treatment plans with day-to-day plan selection from cone-beam CT imaging can also be proposed to correct random variations such as uterine motion or bladder/rectum volume changes. Because of strong anatomical variations occurring during irradiation, RTA appears therefore particularly justified in head and neck, lung, bladder, cervical and rectum and pancreas tumors, and to a lesser extent for prostate tumors and other digestive tumors. For these tumor locations, ART provides a fairly clear dosimetric benefit but a clinical benefit not yet formally demonstrated. ART cannot be proposed in a routine practice but must be evaluated medico-economically in the context of prospective trials. A rigorous quality control must be associated.