前程加卡铂后程野中野加速超分割放射治疗食管癌90例临床观察

目的探讨前程加卡铂后程野中野加速超分割放射治疗食管癌的疗效。材料与方法自１９９１年１０月至１９９３年６月对９０例食管癌病人随机分常规放射治疗组（常规组）和前程加卡铂后程野中野加速超分割放疗组（前化后超组）各４５例。两组临床资料相近，具备可比性。常规组每周照５次，每次２Ｇｙ，总量６０～７０Ｇｙ；前化后超组前３周放疗同常规组，配合卡铂每周两次，每次１００ｍｇ，总量６００ｍｇ。第４，５周在原照射野中设小野（同病变长度），每次１．５Ｇｙ，每周５次，上午照大野，下午照小野，总量５周６５Ｇｙ，其中大野５周５０Ｇｙ，小野后两周１５Ｇｙ。结果放疗结束时Ｘ线改善前化后超组病灶全消和消失１／２以上８６．７％（３９／４５），常规组５７．８％（２６／４５）（Ｐ＜０．０１）。１，２，３，４年生存率分别为７５．６％、５３．３％、４２．２％、３３．３％和５５．６％、３１．１％、２０．０％、１５．６％。前化后超组明显好于常规组（Ｐ＜０．０５）。结论前程配合卡铂后程大野套小野加速超分割放射治疗能显著提高食管癌１，２，３，４年生存率，病人能顺利完成疗程。     

后程加速超分割放射治疗食管癌的技术与结果

１９８８年４月至１９９０年４月对８５例食管鳞癌进行常规分割和后程加速超分割放疗随机前瞻研究。常规分割组４２例，每周￣６０Ｃｏ放射５次，每次１．８Ｇｙ，总疗程７．６周照射６８．４Ｇｙ。后程加速超分割组４３例，放射前程为常规分割，每次１．８Ｇｙ。４．６周照射２３次共４１．４Ｇｙ，然后缩野，每周照射５天，每天２次，每次１．５Ｇｙ，间隔４小时以上，１．８周照射１８次共２７Ｇｙ，总疗程６．４周，总剂量６８．４Ｇｙ。后程加速超分割放疗组１、２、３年食管局部病灶控制率和生存率分别为６９．０％，６１．９％，５９．５％和７２．１％，５５．８％，４１．９％。常规分割组分别为３９．０％，３１．７％，２９．３％和４７．６的，２６．２％，１９．０％。后程加速超分割放疗组的局部控制率和生存率明显高于常规分割放疗组。     

术前加速放疗与常规放疗治疗晚期食管癌的比较

术前放疗联合手术治疗８０例晚期食管癌。术前加速放疗４０例和术前常规放疗４０例。全纵隔照射，加速组４０Ｇｙ／２０次／２周，常规组４０Ｇｙ／２０次／４周。两组放疗后３～４周行食管癌根治术。手术切除率：加速组１００％，常规组９７．５％。术后病理，中、重度放疗反应：加速组９０％，常规组６２．５％，Ｐ＜０．０５。１、２、３年生存率：加速组９０％，７７．５％和６２．５％，常规组７７．５％，５７．５的和４０％，３年生存率两组统计学有差异，Ｐ＜０．０５。     

后程加速超分割放射治疗食管癌的长期疗效

目的评价后程加速超分割放射治疗食管癌的长期疗效及放射反应和并发症。材料与方法１９８８年４月至１９９０年４月，８５例食管鳞癌随机分为２组：常规分割放射组４２例，每天１．８Ｇｙ，每周５次，总剂量６８．４Ｇｙ，总疗程７～８周；后期加速超分割放射组４３例，前２／３病程放射方法伺常规放射组，４～５周内照射４１．４Ｇｙ／２３次，然后缩野进行加速分割照射，每日２次，每次１．５Ｇｙ，间隔４～６小时，总疗程６．４周，总剂量６８．４Ｇｙ／４１次，所有病例均采用６０Ｃｏ远距离外照射，，结果５年实际生存率和原发肿瘤局控率，与常规分割组比较，后程加速超分割组明显提高，分别为３２．６％比１４．３％和５５．８％比２６．２％。复发中位时间，后程加速超分割组为８个月，明显长于常规分割组的４个月（ｐ＝０．０３），后程加速超分割组急性放射反应明显高于常规分割组，但患考能耐受，全部顺利完成疗程，后期放射损伤２组无显著差别。结论本组较少病例研究的初步结果显示食管癌后程加速超分别放射的疗效优于常规分割放射，患者能很好耐受后程加速超分割放射治疗方案。     

加速超分割放射治疗食管癌的临床初步观察

为了观察加速超分割放射治疗食管癌的耐受性和临床效果，作者自１９９２年１０月至１９９３年５月，将４０例胸段食管鳞癌病人随机分为加速超分割放射治疗组（２０例）和常规放射治疗组（２０例）。常规组１．８Ｇｙ／次，总量７０．２Ｇｙ，３９次，５５天。加速超分割组分为二个阶段：第一阶段１．１Ｇｙ／次，２次／日，间隔至少６小时，总剂量为３０．８Ｇｙ，２８次，２０天；第二阶段３次／日，１．１Ｇｙ／次，间隔４～６小时，总量３３Ｇｙ，３０次，１４天。两阶段总量６３．８Ｇｙ，５８次，３４天。近期疗效分析，加速超分割组ＣＲ５０％，常规组ＣＲ３０％。ＣＲ＋ＰＲ分别为９０％和９５％。预计治疗增益因子１．１３。急性反应主要为Ⅰｏ和Ⅱｏ食管炎，加速超分割组（１８／２０）发生率明显高于常规组（４／２０），但患者均能耐受。３年随访率为１００％，超分割组３年生存率４０％（８／２０），常规组２０％（４／２０），Ｐ＜０．０１，有非常显著性差异。初步结果显示加速超分割放射治疗食管癌，可望提高生存率，病人能耐受，作者认为此方案是可行的。     

247例中段食管癌不同处方剂量肺校正后生存率分析

目的：探讨中段食管癌放疗最佳剂量。方法：６０钴外照射中段食管癌２４７例，对处方量６５Ｇｙ组和７５Ｇｙ组拟行肺校正后靶区剂量分别为７２．５Ｇｙ和８５．５Ｇｙ。结果：肺校正后７２．５Ｇｙ组５年、８年、１０年、１３年生存率分别为１２．２％（１４／１１４）、７．９％（９／１１４）、５．２％（６／１１４）、１．８％（２／１１４）。８５．５Ｇｙ组５年、８年、１０年、１３年生存率分别为７．２％（９／１２５）、２．４％（３／１２５）、０．８％（１／１２５）、０（０／１２５）。两组对比７２．５Ｇｙ组明显高于８５．５Ｇｙ组（Ｐ＜０．００５）。结论：食管癌放疗行肺校正是必要的，校正后靶区剂量７２．５Ｇｙ左右，我们认为是根治性放疗最佳剂量。     

98例食管癌加速超分割放疗的临床研究

目的：评价加速超分割放射治疗食管癌的疗效。方法：从１９９０年１０月至１９９２年５月我们对９８例经病理证实为食管鳞癌的患者进行了研究。随机分为常规组和加速超分割组。常规组：１８０～２００ｃＧｙ／次，５次／周，总量６０００～７０００ｃＧｙ／６～７周；加速超分割组：１５０ｃＧｙ／次，２次／日，间隔６小时以上，总量５４００ｃＧｙ／３．５周。两组患者均采用６０Ｃｏ远距离外照射。结果：常规组１，３，５年生存率分别为４６％（２３／５０）、２０％（１０／５０）、１２％（６／５０）；加速超分割组１，３，５年生存率分别为７０．８％（３４／４８）、３９．６％（１９／４８）、２９．２％（１４／４８），加速超分割组明显优于常规组（Ｐ＜０．０５），而两组放疗反应和并发症无明显差异。结论：我们的初步研究显示：加速超分割放疗能明显提高食管癌患者的生存率，但不增加放疗反应及并发症。     

食管癌内外放射治疗剂量与疗效关系的随机前瞻研究

目的研究内外放射剂量和放射治疗中食管Ｘ线片变化对中晚期食管癌局部控制和生存率的影响。方法１４６例食管鳞癌病人随机分外照射５０Ｇｙ、外照射７０Ｇｙ、外照射５０Ｇｙ＋腔内照射６Ｇｙ、外照射５０Ｇｙ＋腔内照射１２Ｇｙ,２分次４个组,分析各剂量组生存率和外放射４０Ｇｙ时Ｘ线片变化与生存率的关系;并观察５９例食管癌病人术前放射治疗剂量与切除标本病理反应的关系。结果（１）各组病人的１,２,３年生存率差异无显著意义;（２）外照射４０Ｇｙ时的食管Ｘ线片变化与预后有关。外照射４０Ｇｙ时Ｘ线片为１,２级者和３,４级者,中位生存期分别为２３个月和１２个月;１,２,３年累积生存率分别为７３．７％,５６．４％,３３．３％和４８．９％,２２．３％,１３．０％,Ｐ＝０．０００２６;（３）术前放射４０～４９Ｇｙ与５０～７０Ｇｙ比较,标本无癌率分别为３２．２％和３９．３％,差异无显著意义。结论不论是外照射还是腔内照射,在本研究采用的剂量范围内,高剂量并不能提高中晚期食管癌放射治疗效果。外照射４０Ｇｙ时食管Ｘ线片变化可作为估计放射治疗预后的指标。     

超分割放射治疗局部晚期非小细胞肺癌的临床研究

目的探讨超分割放疗在晚期非小细胞肺癌治疗中的作用。方法超分割组：１２Ｇｙ／次，每日２次，间隔至少６ｈ，Ｄｒ７２Ｇｙ／６ｗ。常规组：２Ｇｙ／次，每天１次，Ｄｒ６４Ｇｙ／６４ｗ共３２次。两组均５ｄ／ｗ。结果超分割组和常规组总有效率分别为６４０％（１８／２８）和５７１％（１６／２８），无显著性差异（Ｐ＞００５）。随访３年，超分割组和常规组的一年、二年和三年生存率及局部控制率分别为６７９％、３２１％、２１４％和６４３％、４２９％、２８６％；４６４％、１７９％、１０７％和４２９％、２５０％、１７９％；均有显著性差异（Ｐ＜００５）。两组放射性食管炎和肺炎的发生率分别为５３６％、７１％和３２１％、１７９％，无显著性差异（Ｐ＞００５）。结论超分割放射治疗局部晚期非小细胞肺癌，反应轻微，患者均可耐受；并有提高肿瘤局部控制率和改善长期生存率的作用，疗效优于单纯常规放疗。     

鼻咽癌超分割放疗临床研究

１９９２年５月至１９９３年１０月将６２例鼻咽癌病人随机分为常规放疗组和超分割放疗组。常规放疗组每日１次，１．８～２．０Ｇｙ／次，每周五次，总量６８～７０Ｇｙ／３４～３７次／７～７．４周。超分割放疗组１．１Ｇｙ／次，每日２次，间隔≥６～８小时，总量７４～７７Ｇｙ／６６～７０次／７周。急性粘膜反应超分割放疗组重于常规放疗组（Ｐ＜０．０５），经系统口咽处理病人可以耐受，放疗结束后６个月，临床与ＣＴ检查鼻咽肿瘤退缩率两组基本相同。两年生存率和无瘤生存率，常规放疗组分别为８３．９％和７４．２％。超分割放疗组分别为９０．３％和８３．９％（Ｐ＞０．０５），近期疗效超分割组略优于常规放疗组，放疗后主要后遗症（张口困难、口干、放射性龋齿等）超分割组明显轻于常规放疗组（Ｐ＜０．０５）。     

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。     

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.     

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.