脑转移瘤立体定向放射治疗进展

MRI在脑转移瘤的诊断、治疗以及随访中有重要作用。原发灶状况、脑转移瘤的体积、立体定向放疗前后是否加全脑放疗、一般状况评分、回归分割分析(RPA)分级、是否存在颅外转移等是影响脑转移瘤治疗效果的主要因素。单纯立体定向放疗逐渐成为脑转移瘤治疗的主流．分次立体定向放疗在脑转移瘤治疗中的作用尚未完全明确。     

脑转移瘤立体定向放射治疗进展

MRI在脑转移瘤的诊断、治疗以及随访中有重要作用。原发灶状况、脑转移瘤的体积、立体定向放疗前后是否加全脑放疗、一般状况评分、回归分割分析(RPA)分级、是否存在颅外转移等是影响脑转移瘤治疗效果的主要因素。单纯立体定向放疗逐渐成为脑转移瘤治疗的主流,分次立体定向放疗在脑转移瘤治疗中的作用尚未完全明确。     

肝转移瘤立体定向适形放疗63例

立体定向适形放疗(Stereothechic conformal radiotherapy,SCRT)已广泛应用于临床[1],1997年8月~2003年5月,笔者对本院63例肝转移瘤患者共计121个病灶实施SCRT,并对其近期疗效及相关因素进行回顾性分析。1对象和方法1.1对象肝转移瘤63例,共计121个转移灶;男42例,女21例;年龄43~78岁,平均60.5岁。结肠癌术后14例,直肠癌术后12例,胃癌术后11例,肺癌9例,头颈部恶性肿瘤8例,乳腺癌6例,其他3例;病理学类型:鳞癌15例,腺癌38例,软组织恶性肿瘤8例,其他2例;低分化13例36个病灶,中高分化50例85个病灶,3个转移灶11例,2个转移灶35例,单发转移17例。…     

松果体瘤立体定向近距离放疗中MRI的应用

探讨ＭＲＩ在松果体瘤颅脑立体定向术下近距离内放疗（ＳＩＲＢＴ）中的应用。方法：在ＭＲＩ指导下对４例松果体瘤实施ＳＩＲＢＴ。肿瘤平均直径为３．８ｃｍ。利用ＭＲ确定肿瘤的边界、空间几何分布、贯穿肿瘤生长长轴的理想穿刺道、等剂量曲线、肿瘤治疗后的变化情况以实现动态内放疗。结果：后装管留置与术前计划符合。在内放疗中肿瘤迅速缩小需要相应缩小等剂量曲线。内放疗后肿瘤平均缩小为８５％（７８％～９６％）。所有病人均发生肿瘤内出血。结论：作者认为ＭＲＩ在ＳＩＲＢＴ中发挥重要作用，即：确定理想的插植治疗方案，内放疗剂量的设置以及实现动态内放疗。     

伽玛刀立体定向放疗结合全脑照射治疗脑转移瘤临床效果分析

目的 分析立体定向放疗结合全脑照射治疗脑转移瘤的疗效和预后,同时观察服用替莫唑胺(TMZ)与放疗结合对患者生存率的影响。方法 脑转移瘤患者52例,按照治疗方法不同分为2组,一组为全脑照射(WBRT)+立体定向放疗(SRT,伽玛刀),共35例,一组为单纯SRT,共17例。全脑放疗分次剂量为1.8~3.0 Gy/次,1 次/d,5 次/周,总剂量D_T30~40 Gy,WBRT+SRT组全脑后伽玛刀补量采用45%~75%等剂量曲线包绕PTV,边缘剂量12~15 Gy,中心剂量20~30 Gy。单纯SRT组分次立体定向放疗采用45%~75%等剂量曲线包绕PTV,边缘剂量36~40 Gy,中心剂量70~80 Gy。随访1~2年。所选52例患者中有20例患者放疗期间及放疗后服用替莫唑胺胶囊,同步化疗组化疗方案为:口服替莫唑胺75 mg/m²,1次/d,直至放疗结束,放疗结束后再服用3~6个月,剂量改为150 mg/m²。结果 放射治疗后1~3个月,复查CT/MRI显示总有效率(CR+PR)为84.62%,WBRT+SRT组有效率为88.57%,SRT组有效率为76.47%;肿瘤的6个月及1年的局部控制率分别为92.10%和85.20%。WBRT+SRT组的平均生存期13.2个月,中位生存期11个月;6个月生存率为71.40%,12个月生存率为54.30%,18个月生存率为14.30%。SRT组的平均生存期10.2个月,中位生存期9个月;6个月生存率为41.20%,12个月生存率为23.50%,18个月生存率为5.88%。替莫唑胺+放疗与单纯放疗的6个月、12个月及18个月生存率分别为80.00%和56.30%、60.00%和37.50%、10.00%和12.50%。结论 WBRT+SRT治疗脑转移瘤总体上优于单纯SRT治疗。放疗+TMZ联合治疗与单纯放疗相比,替莫唑胺在放疗过程中服用可提高患者生存率,不良反应无显著增加。     

立体定向放疗应用于肺寡转移灶的疗效与预后

目的 分析立体定向放射治疗（stereotactic body radiation therapy,SBRT）应用于肺寡转移灶的疗效与预后。方法 回顾性分析2012-2018年本院SBRT肺寡转移患者104例临床资料,2015年12月前的患者采用调强放疗（intensity modulated radiation therapy,IMRT）技术行立体定向放射治疗,2015年12月后的患者采用螺旋断层放疗（helical tomotherapy,HT）技术行立体定向放射治疗,用Kaplan-Meier方法计算局部控制（local control,LC）、无进展生存期（progression-free survival,PFS）及总生存（overall survival,OS）,Cox回归模型进行单因素与多因素分析,NCICTCAE V4.0标准评价放疗的不良反应。结果 1、2、3年的LC分别为86.6%、75.9%、72.3%,PFS分别为40.9%、28.4%、22.1%,OS分别为75.9%、53.2%、43.53%,中位OS为26.6个月。多因素分析显示原发肿瘤的病理类型、肺部结节的体积及SBRT治疗前癌胚抗原水平（carcino-embryonic antigen,CEA）为LC的独立预后因素（χ²=28.66,P<0.05）,SBRT后的进展方式为OS的独立预后因素（χ²=40.01,P<0.05）,HT-SBRT与IMRT-SBRT的LC及OS差异无统计学意义（P>0.05）;治疗的主要不良反应为放射性肺炎（25例,24.04%）,2级及以上放射性肺炎的发生率不超过7%。结论 SBRT应用于肺寡转移灶的治疗局部控制率高,不良反应可接受,HT-SBRT与IMRT-SBRT的疗效相当,不良反应差异无统计学意义,可广泛应用于临床。     

有无均整器模式下脊柱转移瘤立体定向放疗计划的剂量学比较

目的 比较 6 MV X射线无均整器模式(FFF)和均整器模式(FF)下,脊柱转移瘤立体定向放疗(SBRT)计划的剂量学差异。方法 选取9例入组患者共12处脊柱转移灶分别设计FFF-SBRT和FF-SBRT计划,比较两组计划的靶区、危及器官和正常组织剂量体积直方图(DVH)、靶区适形度(CI)、机器跳数和治疗时间的差别。结果 两种模式下的计划均能满足临床治疗需要。靶区、危及器官、正常组织剂量分布相似。FFF-SBRT计划的机器跳数明显高于FF-SBRT计划(t=-5.20,P<0.01),实际治疗时间相当于FF-SBRT计划的1/2(t=17.27,P<0.01)。结论 两种模式均能满足临床治疗需求,FFF-SBRT计划的治疗时间更短,效率更高。临床试验注册中国临床试验注册中心,ChiCTR-TRC-14004281。     

立体定向放射治疗脑转移瘤疗效分析

目的 分析立体定向放射疗法(SRT)治疗脑转移瘤的临床疗效。方法 回顾性分析66例脑转移瘤全脑放射治疗(WBRT)追加SRT和26例脑转移瘤单纯SRT的结果,分析两者在Karnofsky评分、颅内肿瘤复发率、一年生存率等方面的状况。结果 WBRT+SRT组在颅内肿瘤复发率(13.3%和42.2%)、中位复发时间(10.5个月和4.2个月)、中位生存期(13.0个月和6.5个月)与单纯SRT组相比有显著性差异(P<0.05),但在Karnofsky评分、治疗有效率、一年生存率、死亡率的差异均无统计学意义。结论 WBRT+SRT能明显改善患者的生存质量,降低肿瘤颅内复发率,是脑转移瘤的一种理想局部治疗手段。     

立体定向分次放疗联合全脑放射治疗脑转移瘤疗效分析

目的 分析X刀分次立体定向放疗(FSRT)联合全脑照射(WBRT)治疗脑转移瘤疗效。方法 回顾性分析51例脑转移瘤FSRT+WBRT和35例脑转移瘤单纯WBRT的结果,比较分析两者有效率、生存率的差异。结果 FSRT+WBRT、WBRT组完全缓解率分别为49%、26%(P<0.05),中位生存期分别为(11.0±1.5)、(6.5±0.5)个月(P<0.05),18个月生存率分别为24%、9%(P<0.05)。两组有效率(8%、71%,P>0.05)和6、12个月生存率(63%、41%,51%、23%,P>0.05)相似。 结论 X刀FSRT联合WBRT治疗脑转移瘤损伤小、安全、延长生存期,疗效优于单纯全颅放疗。     

立体定向分次放疗联合全脑放射治疗脑转移瘤疗效分析

Objective To evaluate efficiency of brain metastases tumor using X-knife under farctionational stereotactie radiotherapy (FSRT) combine with whole brain radiotherapy (WBRT). Methods Retrospective comparing 51 patients treated by FSRT plus WBRT (FSRT + WBRT group) with 35 patients treated by WBRT alone (WBRT group) on the effecting rate and survival rate. Results The completeness response rate was 49 % and 26 % (P < 0.05) in FSRT + WBRT and WBRT groups, respectively. The effecting rate was 80 % and 71 % (P 0.05) in FSRT + WBRT and WBRT groups, respectively. The middle survival time was (11.0 ± 1.5) months and (6.5 ± 0.5) months (P < 0.05) in FSRT + WBRT and WBRT groups, respeetivley. The 0.5-, 1.0- and 1.5-years survival rate was 63 % and 41 % (P 0.05), 51 % and 23 % (P 0.05) and 24 % and 9 % (P < 0.05) in FSRT + WBRT and WBRT groups, respectively. Conclusions The method with FSRT plus WBRT in the treatment of brain metastases tumor is safe and relieved focal symptom of patients quickly with lesser injury on normal tissue and the survival time be prolonged, it has better therapeutic effects than WBRT alone for treating brain metastases tumor.     

由SABR再论放射敏感性

随着现代放射治疗技术进步,放疗已由过去二维时代进入三维和四维时代,治疗精度大幅度提高,分割模式也发生了深刻变革。从传统放射治疗发展到以三维适形放射治疗（3D-CRT）和调强放射治疗（IMRT）为代表的聚焦照射,提高了肿瘤靶区剂量,减少了正常组织的损伤。同时随着影像引导技术进步,治疗机与影像引导结合,每次治疗前通过影像扫描技术获得肿瘤靶区位置信息,或用4D影像引导技术精确地将射线投射到目标靶点,达到立体定向体部放射治疗（stereotactic body radiation therapy,SBRT）/立体定向消融放疗（stereotactic ablative radiotherapy,SABR）的目的,放射治疗完全进入精准、高效和低毒时代。高剂量、大分割照射已经取得令人信服和可喜的疗效,传统放射生物学理论已无法解释这种照射模式抗肿瘤细胞作用机制。传统放疗认为,肿瘤有敏感与不敏感之分,但是,进入SABR时代,肿瘤对其治疗均反应良好,放射治疗学迫切需要建立新的放射生物学学说和体系,在传统放射生物学理论基础上,更好地阐明新技术原理、作用机制,并建立与传统放射生物学内在联系,为临床普及和推广消融放疗技术奠定理论基础。     

基于容积旋转弧形调强放疗技术的肝癌立体定向放疗方案评估与位置误差分析

目的 基于容积旋转弧形调强放疗（VMAT）技术,对肝癌立体定向放疗（SABR）方案进行评估,并结合图像引导技术及呼吸管理技术,分析执行中患者位置误差。方法 回顾性分析接受基于VMAT技术的SABR治疗并配合自主深呼气末屏气技术（vDEBH）进行呼吸管理的15例肝癌患者。VMAT计划采用2个部分弧,对治疗方案评估剂量参数,比较VMAT与调强放疗技术（IMRT）的计划质量差异。所有优化方案均经质量保证（QA）验证,包括点剂量和面剂量验证、机器跳数（MU）和出束时间记录。每次治疗时,锥形束CT（CBCT）影像采集2次,包括治疗前1次评估两次治疗间误差和治疗结束后1次评估当次治疗内位移。结果 VMAT和IMRT优化方案的各剂量学参数均满足临床治疗要求,差异无统计学意义（P>0.05）;相比IMRT,VMAT方案的平均MU降低了28.1%（t=3.064,P<0.05）,且治疗时间缩短了31.6%（t=2.278,P<0.05）。CBCT图像引导结果显示,采用vDEBH技术可有效减少当次治疗内的位置误差,各方向上的偏移均控制在可容许范围内（<3 mm）。结论 基于VMAT技术的肝癌SABR治疗计划在靶区体积剂量分布和正常组织受量等剂量学表现与IMRT技术相当,可行性良好且在治疗效率方面优势明显。     

应用自行研制的运动模体研究呼吸状态改变对立体定向门控放疗的影响

目的 评价患者呼吸状态的改变对实时位置监测系统(RPM)引导下自由呼吸立体定向门控放疗影响。方法 通过自行研制运动模体模拟患者治疗过程中出现基线偏移,呼吸频率改变,呼气末延时、吸气末延时,以及不规则呼吸情况,并分析三维适形、固定野动态调强、单弧旋转调强3组计划各状态变化与模体中心小球位置(L)及电离室受照剂量的相关性。结果 自研模体的摆位重复性和测量稳定性良好。L与基线偏移呈现正相关(r=0.99,P＜0.01)。基线偏移小于摆位误差时,剂量变化在4%以内,相对较小,超出后受照剂量快速下降并呈现负相关(r= -0.95,P＜0.01),偏移超出与不超出摆位误差时所测得的受照剂量,差异具有统计学意义(Z= -3.06,P<0.01)。3组计划受基线偏移的影响率差异无统计学意义(P>0.05)。呼吸频率改变对 L 和剂量影响较小。吸气末延迟和呼气末延迟都导致3组计划剂量下降,最大达-1.74%,同时吸气末延迟相对呼气末延迟影响更大,差异具有统计学意义(Z= -2.67,P<0.01),但延迟时间长短对剂量的影响率没有明显相关性(P＞0.05),3组计划受波形改变的影响率差异无统计学意义(P＞0.05)。不规则呼吸对剂量影响较大,3组计划重复测量6次受照剂量分别为三维适形(709.68±180.00)cGy;固定野动态调强(751.40±127.16)cGy;单弧旋转调强(750.00±185.60)cGy,均小于处方剂量,一致性欠佳。结论 患者呼吸状态改变会导致剂量下降,基线偏移超出摆位误差阈值或者波形变异较大出现不规则呼吸时更甚,且与放疗技术不相关。     

常规放疗结合后程立体定向放射治疗老年非小细胞肺癌患者的预后分析

目的观察老年非小细胞肺癌立体定向放疗疗效,并探讨其预后因子。方法128例老年非小细胞肺癌患者行常规放疗结合立体定向放疗,定期随访。结果全组患者1年生存率65.72%,单因素分析表明肿瘤体积、肿瘤剂量、卡氏评分影响近期结果,多因素分析仅肿瘤体积和肿瘤剂量为近期疗效预后因子,与生存期有关的预后因素为近期疗效、肿瘤剂量、临床分期。结论立体定向放疗可延长生存时间,对Ⅲ期患者,肿瘤剂量提高至72Gy是安全的。     

Prediction of clinical outcome after stereotactic body radiotherapy for non-small cell lung cancer using diffusion-weighted MRI and F-FDG PET

Purpose/objectives

To evaluate the use of diffusion-weighted magnetic resonance imaging (DW-MRI) and ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography (PET) for predicting disease progression (DP) among patients with non-small cell lung carcinoma (NSCLC) treated with stereotactic body radiotherapy (SBRT).

Materials/methods

Fifteen patients with histologically confirmed stage I NSCLC who underwent pre-treatment DW-MRI and PET and were treated with SBRT were enrolled. The mean apparent diffusion coefficient (ADC) value and maximum standardised uptake value (SUV_max) were measured at the target lesion and evaluated for correlations with DP.

Results

The median pre-treatment ADC value was 1.04 × 10⁻³ (range 0.83–1.29 × 10⁻³) mm²/s, and the median pre-treatment SUV_max was 9.9 (range 1.6–30). There was no correlation between the ADC value and SUV_max. The group with the lower ADC value (≤1.05 × 10⁻³ mm²/s) and that with a higher SUV_max (≥7.9) tended to have poor DP, but neither trend was statistically significant (p = 0.09 and 0.32, respectively). The combination of the ADC value and SUV_max was a statistically significant predictor of DP (p = 0.036).

Conclusion

A low ADC value on pre-treatment DW-MRI and a high SUV_max may be associated with poor DP in NSCLC patients treated with SBRT. Using both values in combination was a better predictor.     

A preliminary experience of moderate-intensity stereotactic body radiation therapy for ultra-central lung tumor

Abstract

Purpose: Administration of stereotactic body radiation therapy (SBRT) to ultra-central (UC) lung tumors, generally defined as those abutting the proximal bronchial trees, is difficult due to concerns about serious toxicities. Therefore, our institution has performed moderate-intensity SBRT.

Patients and methods: Patients with UC tumors underwent SBRT at a dose of 50–60?Gy in 10 fractions, with D_max in the target volume not exceeding 110% of the prescribed dose. The primary outcomes were tumor response and overall survival (OS).

Results: From January 2017 to September 2018, we treated eight patients who had been diagnosed with UC tumors. The median follow-up time was 8.6 months (range: 2.7–14.9). Five of the eight patients (62.5%) showed a complete response (CR), two (25%) had a partial response (PR), and one (12.5%) had stable disease (SD); the response and disease control rates were 87.5% and 100%, respectively. Seven patients were alive with no evidence of disease or with controlled disease until the last follow-ups, except for one patient who died due to a non-RT cause at 3 months after SBRT. One patient experienced grade 2 esophageal pain and another had grade 1 cough. No grade 3 or higher toxicities were reported.

Conclusion: Moderate-intensity SBRT might aid in achieving good control of UC tumors without excessive toxicities. Future studies involving larger numbers of patients and longer follow-up times are warranted to confirm the efficacy and feasibility.     

胸腔镜肺叶切除术与立体定向放疗治疗早期非小细胞肺癌的疗效比较

目的 比较胸腔镜（VATS）肺叶切除术与立体定向放疗（SBRT）治疗早期非小细胞肺癌（NSCLC）患者的疗效。方法 回顾性分析了2012年1月至2016年12月在浙江省肿瘤医院接受VATS肺叶切除术或SBRT的早期NSCLC患者。根据年龄、性别、卡氏评分（KPS）、查尔森合并症指数（CCI）、肺功能和肿瘤直径对两种治疗患者进行倾向评分匹配（PSM）。对两组符合要求的病例总生存率（OS）、癌症特异性生存率（CSS）、局部控制率（LRC）和无病生存率（DFS）进行对比分析。结果 共纳入567例符合要求病例,其中VATS肺叶切除术458例,SBRT 109例。经倾向评分匹配后,每组分别纳入52例患者。中位随访时间44个月。手术组3年和5年的总生存率分别为94.2%和91.6%,SBRT组分别为88.6%和79.9%（P=0.097）。手术组和SBRT组的5年CSS差异无统计学意义（91.6% vs. 83.7%,P=0.270）。两组3年和5年期LRC相当（94.0%和85.9% vs.93.5%和93.5%,P=0.621）。两队列间5年DFS的差异无统计学意义（80.5% vs.79.0%,P=0.624）。手术组中,有5例患者（10%）出现≥ 3级治疗不良反应。1例患者术后30 d内因严重肺部感染导致的败血症死亡。SBRT组中,1例患者发生3级放射性肺炎,无4级或5级治疗相关不良反应。结论 SBRT或可作为代替VATS肺叶切除术治疗Ⅰ~Ⅱ期非小细胞肺癌的一种选择,但尚需进行随机试验进一步评估。     

Clinical outcome of stereotactic body radiotherapy of 54 Gy in nine fractions for patients with localized lung tumor using a custom-made immobilization system

Purpose The aim of this study was to investigate the clinical outcome of stereotactic body radiotherapy (SBRT) of 54 Gy in nine fractions for patients with localized lung tumor using a custom-made immobilization system. Methods and materials The subjects were 19 patients who had localized lung tumor (11 primaries, 8 metastases) between May 2003 and October 2005. Treatment was conducted on 19 lung tumors by fixed multiple noncoplanar conformal beams with a standard linear accelerator. The isocentric dose was 54 Gy in nine fractions. The median overall treatment time was 15 days (range 11–22 days). All patients were immobilized by a thermo-shell and a custom-made headrest during the treatment. Results The crude local tumor control rate was 95% during the follow-up of 9.4–39.5 (median 17.7) months. In-field recurrence was noted in only one patient at the last follow-up. The Kaplan-Meier overall survival rate at 2 years was 89.5%. Grade 1 radiation pneumonia and grade 1 radiation fibrosis were observed in 12 of the 19 patients. Treatment-related severe early and late complications were not observed in this series. Conclusion The stereotactic body radiotherapy of 54 Gy in nine fractions achieved acceptable tumor control without any severe complications. The results suggest that SBRT can be one of the alternatives for patients with localized lung tumors. Part of this work was presented at the 65th annual meeting of the Japan Radiological Society, April 2006     

Experimental stereotactic irradiation of normal rabbit lung: computed tomographic analysis of radiation injury and the histopathological features

Purpose The aim of this study was to establish an animal experimental model of pulmonary stereotactic irradiation and clarify the morphological patterns of pulmonary radiation injury with computed tomography and the histopathological features. Materials and methods Tiny spherical regions in the lungs of seven anesthetized rabbits were irradiated stereotactically with a single fractional dose of 21–60 Gy. Subsequently, the irradiated lungs were observed biweekly with computed tomography (CT) for 24 weeks. Radiation injury of the lung was examined histopathologically in one specimen. Results Localized hypodense changes were observed 7–15 weeks after irradiation in three rabbits irradiated with 60 Gy, and the findings persisted beyond that time. The electron density ratios in the lung fields obtained from the CT images were shown to be decreasing, corresponding to the hypodensity changes. No clear increased density opacity was observed in any rabbit in the 60-Gy irradiated group. Severe localized fibrotic change was observed in the histopathological specimens. Conclusion Specific localized hypodensity changes were found in only three rabbits irradiated with 60 Gy, the highest dose we employed.     

伽玛刀立体定向放疗早期非小细胞肺癌疗效及生存质量分析

目的 探讨伽玛刀立体定向放射治疗早期非小细胞肺癌患者的疗效及生存质量分析.方法 20例非手术治疗的早期非小细胞肺癌患者,中位年龄76岁.Ⅰ期患者10例,Ⅱ期10例.根据患者的具体状况,给予伽玛刀分次立体定向放疗(SBRT)3～6 Gy×8～15次,2～3周完成,采用50％等剂量曲线包绕95％以上PTV,边缘剂量39 ～ 56 Gy,中心剂量78 ～ 112 Gy.在入院后、治疗结束后1、3、6和12个月至病情进展或者死亡,根据EORTC QLQ-LC43中相关变量对患者进行系统评价,比较放疗前后生存质量变化.结果 中位随访时间为24个月.20例患者治疗后6个月有效率为80％,原发病灶完全缓解率为35％.1、2、3年局部控制率分别为100％、95％、95％;l、2、3年总生存率分别为95％、80％、50％;1、2、3年无进展生存率为85％、64％、33％.3年失败率为20％,5％为PTV内进展.治疗期间无3级及以上急性不良反应发生,15％的患者出现1～2级放射性肺炎.年龄、性别、有无病理诊断等临床因素与患者生存相关性较弱(P＞0.05).生存质量中情绪功能明显改善,差异有统计学意义(P＜0.05);呼吸困难和咳嗽有不同程度改善,躯体功能、疲倦、食欲减退和失眠无加重,差异均无统计学意义.结论 SBRT对于老年患者取得了良好的结果,局部控制率高,不良反应作用小,生存率尚可,能明显改善情绪功能及患者生存质量.