宫颈癌图像引导三维近距离后装治疗中国专家共识

近年来宫颈癌三维近距离治疗(BT)技术在中国得到快速发展。与二维技术相比,宫颈癌图像引导的三维BT技术可以提高局控率、生存率。三维BT要求用体积剂量参数评价治疗靶区及危及器官受量,探索体积剂量参数与局控率、并发症发生率之间关系。BT开始时肿瘤残留体积及形状与局控率有明确相关性,应当结合MRI、超声、妇科检查结果,综合判断残留肿瘤体积。腔内联合组织间插植技术可以改善靶区剂量分布。严格遵守靶区勾画、体积剂量原则以及质控要求。为规范其应用,中华医学会放射治疗学分会近距离治疗学组、中国医师协会放射肿瘤分会妇科肿瘤学组、中国抗癌协会近距离治疗专委会结合中国国情联合制定此专家共识。     

宫颈癌近距离腔内放疗二维治疗技术规范中国专家共识

近距离治疗是宫颈癌根治性放疗中必不可少的一部分,目前国内应用最多仍是二维近距离后装技术。为规范宫颈癌近距离腔内放疗二维治疗技术的应用与开展,中华医学会放射肿瘤治疗分会近距离治疗学组、中国医师协会放射肿瘤分会妇科肿瘤学组、中国抗癌协会近距离治疗专委会联合制定此专家共识。     

Chinese expert consensus on standardized application of two-dimensional brachytherapy for cervical cancer

Brachytherapy is an essential part of radical radiotherapy for cervical cancer. At present, two-dimensional brachytherapy is the most frequently adopted approach in China. To standardize the application and implementation of two-dimensional brachytherapy for cervical cancer, the expert consensus was jointly formulated by Brachytherapy Group of China Society for Radiation Oncology (CSTRO), Gynecological Oncology Group of Chinese Association for Therapeutic Radiation Oncologists (CATRO) and Brachytherapy Special Committee of Chinese Anti-Cancer Association (CACA).     

局部晚期宫颈癌后装腔内联合组织间插植剂量学及临床疗效分析

目的 研究后装腔内/组织间插植近距离治疗(IC/ISBT)与传统后装腔内近距离治疗(ICBT)相比较的剂量学差异及其近期疗效。方法 45例局部晚期宫颈癌患者采用IC/ISBT及ICBT方法进行后装近距离治疗,分别对两种治疗方法的A点(A1、A2)、D90%、D100%以及膀胱、结肠、直肠、小肠受量进行计算,同时观察近期疗效。结果 IC/ISBT比ICBT放疗A点剂量显著提升(P<0.05);并且IC/ISBT的D90%、D100%也均明显高于ICBT (P<0.05)。外照射后残存肿瘤直径≥3cm时,IC/ISBT比ICBT可获得较高的靶区剂量提升(P<0.05)。IC/ISBT与ICBT的膀胱、直肠、结肠、小肠D2cm³、D0.1cm³相近(P>0.05)。疗后1、3、6个月的近期疗效IC/ISBT与ICBT相近(P>0.05)。结论 局部晚期宫颈癌(残存肿瘤直径≥3cm)后装近距离治疗中IC/ISBT在不增加危及器官受量及降低近期疗效前提下显著地提高了靶区、A点剂量,具有明显剂量学优势。     

Analysis of dosimetry and clinical efficacy of intracavitary/interstitial brachytherapy in locally advanced cervical cancer

Objective To study the dosimetric differences and short-term efficacy between intracavitary/interstitial brachytherapy (IC/ISBT) and conventional intracavitary brachytherapy (ICBT). Methods Forty-five patients with locally advanced cervical cancer were treated with IC/ISBT and ICBT. Points A (A1,A2), D90%, D100%, organs at risk, and the doses of bladder, colon, rectum and small intestine were calculated and the short-term efficacy was observed between two groups. Results Point A dose was significantly improved in IC/ISBT compared with ICBT (P<0.05). The D90% and D100% in IC/ISBT were significantly higher than those in ICBT (both P<0.05). After brachytherapy, IC/ISBT could obtain a significantly larger increase in target dose when residual tumor diameter was ≥3 cm compared with ICBT (P<0.05). The D2cm³ and D0.1cm³ of bladder, rectum, colon and small intestine did not significantly differ between IC/ISBT and ICBT (all P>0.05). The 1-,3-and 6-month clinical efficacy did not significantly differ between two technologies (all P>0.05). Conclusion During brachytherapy for locally advanced cervical cancer (residual tumor diameter ≥3 cm), IC/ISBT significantly increases the doses of target area and point A without increasing the dose of organs at risk or lowering the short-term clinical efficacy, which has significant dosimetric advantages.     

Consensus guidelines for delineation of clinical target volume for intensity-modulated pelvic radiotherapy in postoperative treatment of endometrial and cervical cancer

PURPOSE: To develop an atlas of the clinical target volume (CTV) definitions for postoperative radiotherapy of endometrial and cervical cancer to be used for planning pelvic intensity-modulated radiotherapy. METHODS AND MATERIALS: The Radiation Therapy Oncology Group led an international collaboration of cooperative groups in the development of the atlas. The groups included the Radiation Therapy Oncology Group, Gynecologic Oncology Group, National Cancer Institute of Canada, European Society of Therapeutic Radiology and Oncology, and American College of Radiology Imaging Network. The members of the group were asked by questionnaire to define the areas that were to be included in the CTV and to outline theses areas on individual computed tomography images. The initial formulation of the group began in late 2004 and culminated with a formal consensus conference in June 2005. RESULTS: The committee achieved a consensus CTV definition for postoperative therapy for endometrial and cervical cancer. The CTV should include the common, external, and internal iliac lymph node regions. The upper 3.0 cm of the vagina and paravaginal soft tissue lateral to the vagina should also be included. For patients with cervical cancer, or endometrial cancer with cervical stromal invasion, it is also recommended that the CTV include the presacral lymph node region. CONCLUSION: This report serves as an international template for the definition of the CTV for postoperative intensity-modulated radiotherapy for endometrial and cervical cancer.     

CT引导徒手腔内联合插植自适应后装与传统A点后装治疗宫颈癌剂量比较

目的 探讨CT引导徒手腔内联合插植实现影像引导自适应后装(IGABT)相较于传统A点二维后装(CP)剂量学优势,明确其在宫颈癌治疗中的价值。方法 选取在中山大学肿瘤医院行全量放疗的宫颈癌患者 26例,每例患者行4次后装治疗。治疗时先徒手置入宫腔管及2根插植针,后增加插植针数量并调整方向、深度,分别行CT扫描获得2套图像。勾画高危临床靶区(HRCTV),A点和危及器官(直肠、膀胱及乙状结肠)。在2套图像上分别行CP和IGABT计划设计,并配对t检验、Wilcoxon检验两者剂量参数差异。结果 以CP计划的覆盖指数(CI)进行分组,A组(CI≥0.90)包含20个CP和对应IGABT计划,B组(CI<0.90)包含84个CP和对应IGABT计划。A组的HRCTV体积及肿瘤直径明显小于B组(46.7cm³∶62.1cm³,P<0.001及3.1cm∶4.4cm,P<0.0001)。IGABT显著提高所有及B组D90%及覆盖指数,降低膀胱剂量,减少A组乙状结肠剂量,并改善剂量适形度及均匀性。结论 IGABT能提高靶区覆盖、剂量适形度和均匀性,保护危及器官,且对肿瘤较大的患者仍有优势。     

Dosimetric comparison between CT-guided free-hand intracavity/interstitial adaptive brachytherapy and conventional point-A brachytherapy in the treatment of cervical cancer

Objective To analyze the dosimetric differences between CT-guided free-hand intracavity/interstitial brachytherapy[image-guided adaptive brachytherapy (IGABT)] and conventional point-A plan (CP) in the treatment of cervical cancer. Methods Twenty-six cervical cancer patients who received four cycles of IGABT in Sun Yat-sen University Cancer Center were enrolled in this study. Two sets of CT images were obtained before and after applicator adjustment to aid in the design of CP and IGABT plans. The high-risk clinical target volume (HRCTV), point A, and organs at risk (bladder, rectum, and sigmoid colon) were defined on CT images. CP and IGABT plans were designed on CT images. Parameter differences between CP and IGABT plans were analyzed with paired t-test and Wilcoxon test. Results According to the coverage index (CI) of CP, plans were divided into two groups:in group A (CI≥0.90), 20 CP and corresponding IGABT plans were included, and 84 CP and corresponding IGABT plans in group B (CI<0.90). The mean volume of HRCTV and mean tumor diameter in group A were significantly smaller than those in group B (46.7 cm³ vs. 62.1 cm³, P<0.001 and 3.1 cm vs. 4.4 cm, P<0.001). Compared with CP, IGABT significantly improved the value of D90% in all plans and group B, whereas lowered the bladder dose. IGABT also reduced the dose of sigmoid colon in group A. IGABT significantly improved conformal index and dose homogeneity index. Conclusions IGABT can significantly improve the target coverage, conformal index and dose homogeneity index, protect organs at risk. Compared with CP, IGABT has advantages in the treatment of patients with bulky tumor.     

宫颈癌IMRT与BT联合应用研究进展

BT是宫颈癌根治性放疗的重要组成部分。随着放疗技术不断发展,对于盆腔体外IMRT后残存肿瘤体积大、伴有宫旁浸润的宫颈癌患者,有学者提出了BT同步IMRT的治疗技术。本文回顾近年来IMRT与BT综合应用在宫颈癌治疗中的研究进展。     

MRI引导下的宫颈癌三维后装治疗进展

宫颈癌是造成全球女性肿瘤患者死亡的主要原因之一,放疗是宫颈癌的主要治疗手段,而后装治疗是宫颈癌放疗不可缺少的组成部分,外照射联合后装治疗适用于无远处转移的各期初治或复发宫颈癌患者。MRI具有良好的软组织分辨率,在精确靶区范围、保护OAR以及改善患者临床结局等方面有着独特优势;近来许多研究证实了MRI引导下的宫颈癌三维后装的可行性及优越性。本文主要从相关MR成像技术、施源器选择、靶区勾画与评估以及MRI引导下的三维后装治疗所带来的临床效应等方面进行阐述。     

2016年原发性肝癌放疗共识

随着技术进步,放疗对原发性肝癌的有效性和安全性都在不断提高,但国内至今仍无相关共识。因此,肝癌放疗的相关协会,包括中华医学会放射肿瘤学分会、中国生物医学工程学会精确放疗分会肝癌学组与消化系统肿瘤专家委员会、中国研究型医院学会放射肿瘤学分会肝癌学组共同讨论,最终形成原发性肝癌放疗共识。主要内容包括:对早中期肝癌患者,如不能进行手术切除或射频消融可考虑局部放疗,特别是SBRT;对中晚期肝癌患者,放疗可以和TACE或肝动脉灌注化疗或全身药物治疗联合,以提高治疗效果;对于晚期伴有远处转移的肝癌患者,放疗可以作为姑息减征手段,提高患者生活质量,延长生存期。虽然放疗是肝癌有效治疗手段之一,但仍需前瞻、随机、对照的Ⅲ期研究,以获得更高级别的临床证据,进一步确立放疗在肝癌治疗中的地位。     

Image-based brachytherapy for cervical cancer

Cervical cancer is the third most common cancer in women worldwide; definitive radiation therapy and concurrent chemotherapy is the accepted standard of care for patients with node positive or locally advanced tumors > 4 cm. Brachytherapy is an important part of definitive radiotherapy shown to improve overall survival. While results for two-dimensional X-ray based brachytherapy have been good in terms of local control especially for early stage disease, unexplained toxicities and treatment failures remain. Improvements in brachytherapy planning have more recently paved the way for three-dimensional image-based brachytherapy with volumetric optimization which increases tumor control, reduces toxicity, and helps predict outcomes. Advantages of image-based brachytherapy include: improved tumor coverage (especially for large volume disease), decreased dose to critical organs (especially for small cervix), confirmation of applicator placement, and accounting for sigmoid colon dose. A number of modalities for image-based brachytherapy have emerged including: magnetic resonance imaging (MRI), computed tomography (CT), CT-MRI hybrid, and ultrasound with respective benefits and outcomes data. For practical application of image-based brachytherapy the Groupe Europeen de Curietherapie-European Society for Therapeutic Radiology and Oncology Working Group and American Brachytherapy Society working group guideline serve as invaluable tools, additionally here-in we outline our institutional clinical integration of these guidelines. While the body of literature supporting image-based brachytherapy continues to evolve a number of uncertainties and challenges remain including: applicator reconstruction, increasing resource/cost demands, mobile four-dimensional targets and organs-at-risk, and accurate contouring of “grey zones” to avoid marginal miss. Ongoing studies, including the prospective EMBRACE (an international study of MRI-guided brachytherapy in locally advanced cervical cancer) trial, along with continued improvements in imaging, contouring, quality assurance, physics, and brachytherapy delivery promise to perpetuate the advancement of image-based brachytherapy to optimize outcomes for cervical cancer patients.     

ICRU89号报告解析之临床篇——宫颈癌自适应近距离放疗靶区勾画

宫颈癌根治性放疗中,近距离放疗发挥了非常重要的作用。宫颈癌近距离放疗ICRU89号报告,在三维近距离治疗基础上引入时间的概念,正式提出自适应(4D)近距离放疗。本文在ICRU89号报告的基础上查阅相关资料,结合本中心经验,针对文中靶区勾画相关章节进行分析、归纳、总结,希望能帮助同行理解和掌握。     

后装腔内联合组织间插植在ⅢB期宫颈癌中剂量学及疗效分析

目的 比较基于CT图像引导下单纯后装腔内近距离治疗(ICBT)与腔内联合组织间插植治疗(IC+ISBT)两种后装方式治疗ⅢB期宫颈癌的剂量学及疗效。方法 回顾性分析2014年6月至2017年2月于吉林省肿瘤医院放疗四科治疗的宫颈癌ⅢB期患者93例的临床资料,根据近距离治疗前妇科检查和盆腔MRI检查的结果确定肿瘤残留大小和宫旁浸润情况,分为ICBT组与IC+ISBT组。比较两种后装治疗方式的D90%、D100%、V100%以及膀胱、直肠D2cm³, 观察近、远期疗效。结果 中位随访时间为60个月。所有患者5年局部控制率、无远处转移生存率、总生存率分别为83%、71%、68%。与ICBT组相比,IC+ISBT组高危临床靶体积D90%均>85Gy,两组间差异无统计学意义(P=0.188),但膀胱和直肠D2cm³剂量分别显著降低7、8Gy (P值均<0.01),且无远处转移生存率显著提高(P=0.009)。高危临床靶体积>60cm³ 5年局部控制率在IC+ISBT组显著提高(P=0.029)。结论 后装腔内联合组织间插植治疗ⅢB期宫颈癌能够保证靶区覆盖的同时,显著降低远处转移发生率和危及器官受量,并显著提高大体积肿瘤的局部控制率。     

Imaging-guided brachytherapy for locally advanced cervical cancer: the main process and common techniques

Brachytherapy (BT) delivers integrated boost doses to the central tumor while sparing the surrounding organs at risk (OARs) efficiently. It’s a mandatory treatment component for locally advanced cervical cancer (LACC) because it results in excellent overall survival and local control compared with other dose boosting modalities. Currently, BT is undergoing a transition from 2-dimensional (2D) to 3-dimensional (3D) treatment planning. Imaging-guided BT (IGBT) employing computed tomography (CT) or magnetic resonance imaging (MRI) can provide exact individual delineation of target and OARs meanwhile prescribe the dose to the target volume instead of “point A” for X-ray-based BT. There are three main techniques for BT: intracavitary (IC), interstitial (IS), and intracavitary/interstitial (IC/IS) combination. The applicator choice depends on the specific tumor extension. The real-time transabdominal ultrasound (US)-guided applicator placement technique is strongly recommended to ensure ideal applicator positioning. MRI is the ideal standard imaging for BT owing to its superior soft tissue visualization than CT. However, CT-based BT is more often performed because of the availability. In developing countries, US-based BT can be adopted. For treatment planning, the applicator reconstruction is easier on CT than on MRI, because the applicator image is more clearly visible. Individual treatment planning should be performed for every single applicator insertion to ensure dose accuracy. In this review article, we explain the main clinical process and common techniques, including the applicator choice and placement, imaging techniques, target delineation, and treatment planning; asthose will help to improve the efficiency of 3D BT.     

中国非小细胞肺癌放射治疗临床指南(2020版)

随着先进技术的迅速发展,放射治疗已进入精确放疗时代,精确放疗显著提高了肿瘤控制效果、降低了不良反应,对非小细胞肺癌(NSCLC)不同期别均发挥着重要作用。近年来,靶向治疗、免疫治疗等新疗法取得了突破性进展,为患者带来了生存获益。中华医学会放射肿瘤治疗学分会、中国医师协会放射肿瘤治疗医师分会、中国抗癌协会放射治疗专业委员会和中国临床肿瘤学会肿瘤放疗专家委员会联合组织相关专家,在NSCLC现有医学证据基础上,结合专家意见制订了《中国非小细胞肺癌放射治疗临床指南(2020版)》,内容主要包括概述、诊断、早中晚期治疗原则、放疗技术和随访等,以期为中国临床医生和患者提供针对放疗的NSCLC循证医学指南,指导临床实践。     

新型冠状病毒病(COVID-19)疫情期间恶性肿瘤高剂量率近距离治疗推荐

目前国内新型冠状病毒病疫情总体呈现散发状态,防范疫情任务仍然艰巨。近距离治疗(BT)在肿瘤患者治疗中起着重要的作用,在部分恶性肿瘤放疗过程中,BT不能被替代也不可过度延迟。而对于疫情期间BT推荐或指导的相关报道较少。本文总结国内外可检索到的较少几篇关于疫情期间BT的推荐,结合吉林大学中日联谊医院放射治疗科在前期疫情期间的工作经验,希望可以给同行们提供疫情期间恶性肿瘤高剂量率BT的参考。     

Recommendations on high-dose-rate rachytherapy for malignant tumors during COVID-19 epidemic

InChina, COVID-19 epidemic is currently showing a sporadic state, and the task of epidemic prevention is still arduous. Brachytherapy (BT) plays a critical role in the treatment of cancer. For some cancer receiving radiotherapy, use of BT can not be replaced or excessively delayed. Nevertheless, the recommendations or guidelines regarding the application of BT during COVID-19 epidemic have been rarely reported. In this article, a few recommendations on the application of BT during COVID-19 epidemic were retrieved and the work experience of Department of Radiation Oncology, China-Japan Union Hospital of Jilin University in the early epidemic period was summarized, aiming to provide relevant reference for the use of high-dose-rate BT for malignant tumor patients during COVID-19 epidemic.