射波刀临床应用初步体会(附2例临床报道)

目的 阐述射波刀(Cyberknife)临床应用的初步体会.方法 应用射波刀治疗的18例28个靶区不同种类和部位肿瘤病人中2例典型病例进行讨论.结果 初步应用表明射波刀由机器人投射、实时影像追踪定位、红光二极管同步追踪摄像机等6个子系统组成的.射波刀是全新的放射外科设备,它开创性地应用非等中心、非共面、非聚焦的"三非"放疗模式,在靶区外半球面上有100个结点,1200条射束可供计划系统选择.应用骨骼结构作为参考框架实时影像追踪定位,确保了治疗精准度在亚毫米水平;采用大剂量单次或2～5低分次放疗模式治疗全身各部位肿瘤.本组随访8～12周,症状和体征均有好转,按RTOG急性放射损伤分级标准0级.结论 射波刀是兼容放射外科和放射治疗的新一代设备,属于全新的放疗模式,拓展了放射外科治疗全身肿瘤领域.     

射波刀无框架立体定向放射治疗的临床经验及技巧(附33例分析)

目的探讨射波刀(Cyberknife)无框架立体定向放射治疗的定位经验及技巧。方法回顾性分析33例行射波刀治疗病人的临床资料,共计46个靶区154分次。结果本组摆位和定位过程简捷、精确,治疗顺利。随访2～5个月,症状和体征均有好转,MR检查未见放射性脑水肿发生,按肿瘤放射治疗协作组(RTOG)急性放射损伤分级标准为0级。结论射波刀定位方式具有无框架、无创、精度高、摆位简捷和实时图像引导追踪等优点。     

射波刀分次治疗鞍区和鞍旁肿瘤的初步研究

目的总结射波刀分次治疗鞍区或鞍旁肿瘤的疗效。方法回顾性分析30例术后残留、复发或不适合手术的鞍区或鞍旁肿瘤的临床资料,其中垂体瘤8例,脑膜瘤9例,颅咽管瘤、海绵窦血管瘤和三叉神经鞘瘤各4例,脊索瘤1例。均应用射波刀分次治疗,照射肿瘤的周边剂量15～24 Gy,平均19 Gy;中心剂量23～35 Gy,平均29 Gy;等剂量曲线62%～70%,平均67%。结果术后视力障碍改善3例,无变化2例;眼球运动障碍改善4例,无变化1例;面部麻木改善3例,未改善2例,无新增脑神经受损症状。随访12～27个月,平均17个月;复查MRI显示:肿瘤缩小21例,保持原有大小9例。结论射波刀分次治疗鞍区或鞍旁肿瘤初步疗效满意,可提高脑神经对射线的耐受剂量,长期疗效有待进一步随访。     

射波刀治疗听神经瘤的初步结果

目的 总结射波刀分次治疗听神经瘤的初步结果和设计治疗计划技巧.方法 应用射波刀分次治疗29例听神经瘤.肿瘤平均最大直径为31 mm.肿瘤平均体积为13.2 cm3 (0.3～36.0 cm3).设计治疗计划时,将射线束控制在150～ 200条之间,使治疗计划有良好的适形性,同时提高肿瘤内高剂量区范围.2例巨大肿瘤照射4次,3例小肿瘤照射2次,其余24例照射3次.平均随访时间21个月.结果 1例巨大肿瘤患者在治疗后10个月死亡,其余28例肿瘤中,6例缩小50％以上,15例缩小20％,7例肿瘤无变化.13例保持原有有效听力,1例听力明显下降,1例听力从无效改善为有效,其余患者为无效听力.无面瘫,3例患者出现脑积水,1例出现脑干水肿,治疗后水肿消失.结论 射波刀分次治疗听神经瘤的初步疗效满意,不良反应较轻;为高龄、不适合手术、部分肿瘤较大的听神经瘤患者提供又一治疗手段,但长期疗效和不良反应有待进一步随访.     

立体定向放射外科治疗脑转移瘤的临床进展

立体定向放射外科治疗脑转移瘤近年的研究进展迅速,该技术治疗脑转移瘤已经取得较为满意的疗效。本文从脑转移瘤的适应证、智能射波刀的应用及近年治疗结果几个方面综述立体定向放射外科治疗脑转移瘤目前的进展。     

射波刀治疗海绵窦巨大海绵状血管瘤临床研究

目的探讨射波刀治疗海绵窦巨大海绵状血管瘤的有效性和安全性。方法共7例经影像学诊断的海绵窦巨大海绵状血管瘤患者,血管瘤体积11.86~70.12 cm3,中位值23.30 cm3,予射波刀分次治疗,计划靶区剂量归一70%~80%,照射剂量21 Gy/3次(5例)、25 Gy/5次(1例)和30 Gy/3次(1例),照射野109~155个,靶区体积覆盖95%以上。分别于术后即刻和随访时评价手术疗效和安全性。结果术后随访6~18个月(平均9.37个月),临床症状均有所改善。术后仅1例出现放射性脑水肿,予甘露醇和地塞米松治疗后缓解。复查MRI显示,血管瘤体积6.75~28.35 cm3,中位值10.50 cm3,较术前缩小(Z=-2.366,P=0.018)。结论射波刀是治疗海绵窦巨大海绵状血管瘤的有效方法。对于不宜行传统手术切除和放射治疗的患者,建议首选射波刀治疗。     

射波刀分次治疗海绵窦血管瘤的初步结果

目的 总结射波刀分次治疗海绵窦血管瘤( CSH)的初步经验.方法 应用射波刀治疗海绵窦血管瘤20例,肿瘤最大径为23.0～67.0 mm,平均42.0 mm.肿瘤平均体积为25.4 cm3.1例肿瘤照射1次,3例照射2次,其余16例肿瘤照射3次,周边剂量分别为13 Gy/1次;17.8～19.0 Gy/2次;18.4 ～21.0 Gy/3次.随访时间为7-36个月(平均15个月).结果 5例巨大肿瘤射波刀治疗后有轻微的症状加重,需要脱水治疗.所有患者均未出现新的脑神经受损症状.4例视力受影响者治疗后6个月改善,12例其他脑神经受损者症状改善或恢复正常.4例肿瘤缩小90％以上,9例缩小50％以上,4例缩小30％左右,1例未缩小,2例未复查MRI,但是症状改善.结论 射波刀治疗CSH的不良反应轻,初步疗效满意.对大型或巨大CSH,射波刀分次照射可成为其主要治疗手段之一.     

射波刀立体定向放射治疗脊髓动静脉畸形(附2例报道)

目的 观察用射波刀立体定向放射治疗脊髓动静脉畸形的疗效.方法 对1例Rosemblum分型Ⅱ型脊髓动静脉畸形病人用射波刀进行治疗,放射总剂量25 Gy,每次5 Gy,1次/日,连续5日(25Gy/5f);对1例Ⅲ型者,采用21Gy/2f.治疗前1例行脊髓血管造影检查明确诊断,1例行手术探查明确诊断.治疗前、后定期行脊髓MRI检查,以评估治疗的影像学效果.使用阿米诺夫量表评估治疗前、后脊髓功能的改变.使用脊髓急性放射毒性分级表评估脊髓放射毒性.结果 治疗后行10个月、6个月随访,MRI复查脊髓内脊髓动静脉畸形异常信号消失,阿米诺夫量表总分由7分、8分,降至1、0分,均临床显效;而脊髓急性毒性在随访期内均为0级.结论 射波刀立体定向放射治疗对Ⅱ型和Ⅲ型脊髓动静脉畸形有效,但长期疗效及脊髓毒性反应尚待观察.     

医用射频治疗仪及其组织效应和临床应用

自1983年我们应用自行研制的附有控温装置及侧射式毁损探针射频治疗仪治疗三叉神经痛、癫痫、顽痛等疾病,临床实践表明该系统性能安全,可靠。本文简单介绍该治疗仪的组成、性能特点,实验观察及临床应用体会。     

应用射频温控热凝仪治疗面肌抽搐

1986～1987年利用 ZB～301射频温控热凝仪共治疗顽固性面肌抽搐患者52例,追踪观察疗效,3个月复发3例,半年后复发14例,有效率73%。     

经硬膜下入路显微手术切除大型海绵窦血管瘤

目的探讨大型海绵窦血管瘤(cavernous sinus hemangiomas,CSH)的影像学表现及治疗方式。方法对经手术术后病理证实的4例大型CSH的影像学及临床资料进行回顾性分析,并复习相关文献。4例患者均做头颅MRI、头颅CTA扫描,后经硬膜下入路行显微外科手术治疗。结果病变在头颅MRI上呈等T1、边缘锐利的短T2表现、FLAIR高信号,增强后快速均匀强化或延迟欠均匀强化(最终达到均匀强化),肿瘤不同程度向中颅窝、鞍区、鞍上生长;头颅CTA显示肿瘤无明显供血动脉,但周边细小血管丰富;4例患者均只做到部分切除。术中平均失血3425 ml,术后3例出现颅神经功能障碍。结论根据头颅MRI特征性表现基本能诊断CSH,相比显微手术潜在的风险,射波刀放疗效果显著,可能会逐步成为本病的首选治疗方式。     

Cost-effectiveness analysis for trigeminal neuralgia: Cyberknife vs microvascular decompression

BACKGROUND/AIMS: We present the preliminary results of a cost-effectiveness analysis of cyberknife radiosurgery (CKR) versus microvascular decompression (MVD) for patients with medically unresponsive trigeminal neuralgia. METHODS: Direct healthcare costs from hospital's perspective attributable to CKR and MVD were collected. Pain level caused by trigeminal neuralgia was measured through the Barrow Neurological Institute pain intensity scoring criteria, at admission and after an average of 6 months follow-up. RESULTS: 20 patients for both arms were enrolled, for a total of 40 patients. The two procedures resulted equally effective at 6 month follow-up, with different resources consumption: CKR reducing hospital costs by an average of 34% per patient. The robustness of these results was confirmed in appropriate sensitivity analyses. CONCLUSION: CKR resulted to be a cost-saving alternative compared with the surgical intervention.     

Surgical management of primary tumors of the cervical spine: surgical considerations and avoidance of complications

Abstract

Objective:

Primary cervical spinal tumors are rare tumors of the spine and are associated with significant morbidity and mortality. Such tumors include multiple myeloma, chordomas, giant cell tumors, hemangiomas, osteosarcomas, chondrosarcomas, synovial sarcomas, aneurysmal bone cysts (ABC), hemangiomas, eosinophilic granulomas, osteoid osteomas, and osteoblastomas. We review the surgical decision-making process and identify critical key steps for surgical complication avoidance. We also present case illustrations demonstrating such pathological diagnoses and surgical treatments performed.

Methods:

We retrospectively review the literature regarding the most common primary cervical spinal tumors that have undergone surgical resection with or without adjuvant treatment.

Results:

En bloc resection of primary cervical tumors resulted in significantly increased progression-free survival and overall survival. From the limited data, adjuvant treatment with proton-beam therapy for chordomas has potential benefit. Neo-adjuvant chemotherapy for Ewing’s sarcoma and osteogenic sarcoma has shown some promise, with en bloc resection demonstrating stronger benefit for osteogenic sarcoma.

Discussion:

En bloc resection for primary spinal tumors has proven to be the standard of care in spinal oncology. Adjuvant and neo-adjuvant treatments such as chemotherapy and radiotherapy variants (conventional, proton beam, cyberknife) need to be studied further in most primary tumor types to become standard of care. Chordoma management is more widely studied with en bloc resection and adjuvant proton-beam therapy demonstrating improved progression-free survival and overall survival. Surgical management and adjuvant treatment strategies are case dependent, depending on tumor histology, patient neurological examination, prior surgeries at that level, and prior adjuvant treatment.     

Intracranial meningiomas: diagnosis and treatment

Meningiomas are extra-axial CNS tumors which have a female predominance and occur in middle-to-late adult life. Most meningiomas (90%) are benign, 6% are atypical and a small proportion (2%) are malignant. Most patients diagnosed with a meningioma undergo surgical resection to relieve neurological symptoms. Complete surgical resection is often curative. For most incompletely resected or recurrent tumors not previously irradiated, radiotherapy is administered. Radiotherapy may be administered as either conventional external beam irradiation or stereotactically by linear accelerator, gamma knife or cyberknife radiosurgery. Advocates of stereotactic radiotherapy have suggested this therapy in lieu of surgery particularly in poor surgical risk patients, patients with meningiomas in eloquent or surgically inaccessible locations and in patients of advanced age. When the meningioma is unresectable or all other treatments (e.g., surgery and radiotherapy) have failed, hormonal chemotherapy may be considered. Notwithstanding limited data, hydroxyurea has been modestly successful in patients with recurrent meningiomas.     

The combined DEX-CRH test in treatment course and long-term outcome of major depression

Neuroendocrine studies strongly suggest that the hypothalamic-pituitary-adrenocortical (HPA) system plays a crucial role in the development and course of depression. The interaction between the disease process and HPA system function in long-term course, however, is unclear. Since improvement of HPA system deterioration has been demonstrated to be associated with treatment response, the question has arisen whether the course of therapy response as reflected by, for example, early improvement or response (after 1 or 2 weeks of therapy) is also based on HPA system dysfunction and whether the course of HPA regulation during treatment is only a state marker or has additional predictive implications for long-term outcome. In order to elucidate these questions a long-term study was carried out to investigate whether HPA system disturbance is associated (1) with the course of treatment response, predominantly early treatment response, during acute depression and (2) with the long-term course of depression, i.e. number of episodes. Twenty patients with affective disorders who participated in earlier controlled antidepressant treatment studies over 6 weeks were enrolled in an exploratory follow-up study. Using the combined DEX/CRH test it was demonstrated that (1) early improvement, early treatment response and beneficial treatment outcome after 6 weeks were associated with a lower HPA system activity and that (2) in long-term course of depression the HPA system deterioration increases in parallel with the number of previous episodes. These findings suggest that HPA system alterations are closely related to treatment response and long-term outcome of depression.     

颈内动脉系统超急性期脑梗死不同时间窗动、静脉溶栓的对比分析

目的 关注颈内动脉系统超急性期脑梗死的溶栓治疗,探讨起病3～6 h动脉溶栓与3 h内静脉溶栓的疗效差异并比较其安全性.方法 选择发病6 h内的颈内动脉系统超急性脑梗死患者66例,其中38例起病3 h内的患者予静脉溶栓治疗(采用重组组织型纤溶酶原激活剂(rt-PA)0.9 mg/kg静脉溶栓),28例起病3～6 h的患者予动脉溶栓治疗(经股动脉穿刺,经微导管对梗死部位接触性给予rt-PA,总量为0.6 mg/kg).对两组患者治疗前和治疗后2 h、24 h、7 d的神经功能缺损程度评分(NIHSS)以及治疗前和治疗后7 d、90 d的Barthel指数(BI)进行比较,并记录两组的不良事件.结果两组治疗后2 h、24 h、7 d的NIHSS评分与治疗后7 d、90 d的BI评分均较治疗前有明显改善,差异有统计学意义(P<0.05);各时间点NIHSS评分与BI评分在动脉溶栓组与静脉溶栓组之间比较差异无统计学意义(P>0.05);两组不良事件发生率相当.结论 对于颈内动脉系统超急性期脑梗死,3 h内予静脉溶栓具有与3～6 h动脉溶栓相当的疗效,且未增加出血、死亡等不良事件的发生率.在具备介入治疗条件的单位,针对3～6 h起病的合并大动脉病变的急性脑梗死患者,动脉溶栓治疗可能是理想的治疗策略.     

腰大池持续引流在创伤性蛛网膜下隙出血中的应用

住院治疗的104例蛛网膜下隙出血患者随机分为常规治疗组和Medtronic EDM系统持续外引流组。治疗24h后,分别对两组患者脑积水发生率、头痛持续时间、意识障碍持续时间、颅内压和红细胞计数恢复至正常水平的时间等指标进行比较,差异均有统计学意义(P<0.05或P<0.01)。表明采用Medtronic EDM系统行腰大池持续外引流术治疗蛛网膜下隙出血有效。