磁共振纤维束成像指导的靶区勾画对483例脑胶质瘤放疗疗效的影响

目的:分析483例在我科完成胶质瘤调强放疗患者的长期随访数据，评价磁共振颅内纤维束成像技术联合调强放疗对胶质瘤局部控制和预后的影响。方法:回顾性分析483例已完成调强放疗并随访1年以上的胶质瘤患者的病理类型、放疗靶区勾画方法和剂量、放疗后病灶控制和生存情况。结果:WHO Ⅱ级胶质瘤96例，WHO Ⅲ级胶质瘤148例，WHO Ⅳ级胶质瘤239例。放疗靶区（GTV和CTV）依据传统磁共振T1加权、T2加权图像和磁共振纤维束成像显示病灶及邻近颅内纤维束的关系确定。放疗后89.0%患者头痛、头晕明显减轻，88.2%患者单侧肢体无力明显减轻（从2级恢复到4级）。头颅增强MRI提示64.2%患者颅内局部病灶缩小、水肿减轻，30.0%患者病灶稳定在术后大小。放疗后6月85.1%患者生活质量评分（KPS评分）从60或70分上升到90或100分。放疗后部分缓解（PR）64.2%，稳定（SD）30.0%，进展（PD）5.8%。WHO Ⅱ级胶质瘤1年平均OS 76.0%，2年平均OS 71.6%，3年平均OS 64.9%，5年平均OS 61.5%。WHO Ⅲ级胶质瘤1年平均OS 80.4%，2年平均OS 75.0%，3年平均OS 67.5%，5年平均OS 55.0%。WHO Ⅳ级胶质瘤1年平均OS 48.1%，2年平均OS 35.8%，3年平均OS 31.5%。放疗后1年19.9%患者有轻-中度记忆力下降；1.0%认知功能明显下降。结论:磁共振颅内纤维束成像技术联合调强放疗可有效照射胶质瘤远处浸润的亚临床病灶区，尤其是对未达全切和手术后再次复发的胶质瘤患者起到局部控制肿瘤、改善生存质量、延长生存期的作用。然而磁共振纤维束成像技术指导靶区对胶质瘤患者放疗疗效的长期影响尚需更多的病例及更长的时间研究。

The effect of diffusion tensor tractography guided target delineation on efficacy after intensity modulation radiotherapy in 483 cases of glioma

Objective:To analyse the data of 483 cases of glioma who fulfilled the intensity modulation radiation therapy and followed up at least for 1 year in our center，to evaluate the effect of MR diffusion tensor tractography combined with intensity modulation radiation therapy on local control and prognosis.Methods:Retrospectively investigate the pathology，radiotherapy target delineation，radiation dose，local lesion control and survival in this study.Results:There were 96 WHO II grade glioma cases，148 WHO III and 239 WHO IV grade glioma cases.The gross target volume and clinic target volume were delineated by relationship between lesion and intracranial fasciculus on conventional MRI (T1WI，T2WI)and MR diffusion tensor tractography imaging.The results of follow-up showed that the headache and dizziness alleviated in 89.0% cases，unilateral limbs fatigue significantly alleviated in 88.2% cases (from grade 2 to grade 4).The results of brain MRI displayed that local lesions shrink and edema lessened in 64.2% cases，and lesion size stabled in 30.0% cases.The Karnofsky score was increased from 60 or 70 scores to 90 or 100 scores in 85.1% cases at 6 months after radiation.The partial remission (PR) was 64.2%.Stable disease (SD) was 30.0%，and progression of disease (PD) was 5.8%.The mean OS was 76.0% after 1 year，71.6% after 2 years，64.9% after 3 years and 61.5% after 5 years respectively in WHO II grade.The mean OS was 80.4% after 1 year，75.0% after 2 years，67.5% after 3 years and 55.0% after 5 years respectively in WHO III grade.The mean OS was 48.1% after 1 year，35.8% after 2 years and 31.5% after 3 years respectively in WHO IV grade.There was slighter to moderately memory loss in 19.9% cases and cognitive function impairment in 1.0% cases 1 year after radiation.Conclusion:Diffusion tensor tractography magnetic resonance imaging combined with intensity modulation radiation therapy could efficiently eliminate distant infiltrative sub-clinical foci，especially in partial tumors resection and relapse cases.It resulted in a good local control，improving life quality and extending life span.However，the long term impact of diffusion tensor tractography guided target delineation on the efficiency of radiation therapy on glioma needs more cases and more time.