肿瘤相关因子在肿瘤综合治疗中的意义

肿瘤的综合治疗是公认的一个大原则 ,但不同条件的医院、不同水平的医生所选的治疗方法和顺序的不当 ,极大地限制了综合治疗原则在临床上的正确使用和普及。为此 ,我们进行了肿瘤相关因子 (CFT)导向下综合治疗与常规综合治疗癌症的疗效对比研究 ,以探讨 CFT在肿瘤综合治疗中的意义。资料与方法1.1　一般资料　随机选取 2 0 0 1年 1月— 2 0 0 2年 11月在我院肿瘤科住院的经CT、病理确诊的初治癌症患者 12 0例 ,男 98例 ,女 2 2例 ,年龄最大 74岁 ,最小18岁 ,平均年龄 5 8岁 ;涉及病种 14种 ,其中肺癌 6 0例 ,胃癌 14例 ,肝癌 12例 ,食管…     

手术治疗在乳腺癌综合治疗中的地位

 非手术治疗技术的进展使乳腺癌局部和全身控制的效果进一步提高,但是手术治疗仍具有重要作用。早期乳腺癌可选择保乳治疗（部分可选择经乳晕切口的保乳术）、保留皮肤的乳房切除加即刻再造或改良根治术等个体化治疗。局部晚期的乳腺癌可先行新辅助治疗,然后行外科手术治疗。复发、转移乳腺癌的手术治疗对于控制局部症状、改善生活质量具有重要意义,最近的研究还表明可以带来生存获益。目前乳腺癌治疗策略仍然是以外科手术为主的综合治疗,无论从提高生存率还是改善生活质量方面来看,外科手术在乳腺癌的多学科治疗中仍占据核心地位。     

肿瘤放射治疗研究新进展

放射治疗是肿瘤治疗最主要的手段之一,在肿瘤的综合治疗中占有举足轻重的地位。在过去的几十年中,影像学、物理学及计算机技术的进步都极大地促进了放射治疗的飞速发展。目前,以精确定位、精确计划、精确治疗为核心的精确放疗（precision radiotherapy, PT）技术已经打破了传统的经验式的常规治疗模式,成为一种新的“常规”放疗,从而促使放射治疗进入精确放疗的时代。     

功能性成像在肿瘤放射治疗中的应用

近十多年来，随着计算机技术、放射物理学、分子生物学、功能影像学等学科的快速发展以及各门学科的全方位有机结合，放疗已经从简单的二维的普通照射发展为立体定向三维适形放射治疗、调强放射治疗等精确放射治疗技术。如何在这些精确放疗技术中准确确定肿瘤靶区将直接影响肿瘤的疗效和正常组织器官的保护。目前，靶区的确定以X-ray片、CT等解剖影像技术为基础，而SPECT、MRS、PET等功能性影像技术的发展不但将对这些经典靶区的确定发挥主要作用。而且由于这些技术可以显示组织的功能代谢状态乃至分子水平的变化，使体外检测肿瘤的放射敏感性成为可能。     

放疗在输尿管上皮肿瘤中的治疗地位

输尿管恶性肿瘤发生率较低，仅占。肾及尿道上皮恶性肿瘤的5％-7％。90％的输尿管恶性肿瘤为移行细胞癌，10％为其他类型的恶性肿瘤如鳞癌、腺癌、未分化癌、小细胞癌等，其中以鳞癌的局部侵犯率及复发率较高。     

肿瘤综合治疗

据世界卫生组织统计,45％的肿瘤可以治愈（以5年生存率计算）．其中22％依靠手术治愈,18％依靠放射治疗治愈．5740依靠化疗治愈。虽然手术治疗和放射治疗对肿瘤的治愈比例较高,但是单一的治疗手段所收到的效果,远远不如采用两种或两种以上方式治疗的效果要好。这种采用两种或两种以上方式治疗的在医学上称为肿瘤的综合治疗。     

全国肿瘤放射治疗技术进展暨肿瘤规范化综合治疗研讨班会议通知

由北京医学会放射肿瘤学分会主办的第八届全国肿瘤放疗技术进展研讨班暨大连大学附属中山医院主办的第四届国家级继续教育项目——肿瘤规范化综合治疗研讨班,将于2014年6月12—14日在大连市举办。     

近距离治疗在鼻咽癌放射治疗中的地位

 近距离治疗(BrachytheraPy)是放射治疗学中与远距离治疗(Teletherapy)相呼应的一大分枝, 其照射技术有五大类; 腔内(Intracavitary)、管内(In-troluminal)、组织间插入(Interstitial Implantation)、术中(Introoperative)和敷贴(mould)治疗。     

放射治疗基本原理在头颈部肿瘤综合治疗的应用

放射治疗基本原理在头颈部肿瘤综合治疗的应用ＬｅｓｔｅｒＪＰｅｔｅｒｓｅｔａｌ．ＩｎｔＪＲａｄｉａｔＯｎｃｏｌＢｉｏｌＰｈｙｓ，１９９７，３９：８３１．２０余年来，放射生物学研究得出的一些原理对放射肿瘤学的发展产生了重要的影响。其中包括：（１）单次照射...     

肿瘤相关巨噬细胞在肿瘤放射治疗中的研究进展

肿瘤相关巨噬细胞（TAM）是肿瘤组织中数量最多的免疫细胞之一。TAM为一个表型可塑的异质性细胞群体,能调控肿瘤增殖、转移及耐药等表型,已成为抗肿瘤治疗的新靶点。放射治疗是恶性肿瘤的基本治疗手段之一,研究发现放射治疗对TAM的表型和功能有显著影响,而TAM也可反过来调控肿瘤放疗疗效。本文就TAM在肿瘤放疗中的研究进展作一综述。     

子宫颈癌俯卧位调强放射治疗摆位误差分析

目的研究子宫颈癌俯卧位调强放射治疗的摆位误差大小,为子宫颈癌调强放疗计划设计临床靶区体积（CTV）外放计划靶区体积（PTV）时提供参考数据。方法选取行俯卧位调强放射治疗的子宫颈癌患者6例,所有病例治疗时身下垫有孔泡沫板,热塑成形固定膜固定。连续5d治疗时用电子射野影像装置（EPID）拍射正侧位验证片各1张,共60张验证片,通过配准数字化重建图像（DRR）和EPID拍摄的验证片的骨性解剖结构,计算平移和旋转误差。结果平移误差：左右方向为（3．1±1．8）mm、头脚方向为（3．9±3．3）mm、腹背方向为（4．2±2．6）mm;旋转误差冠状面为（0．8±0．9）°、矢状面为（1．2±1）°。结论对于子宫颈癌俯卧位调强放射治疗,CTV到PTV的外放应为左右7．1mm、腹背10．8mm、头脚10.4mm,在患者身体上做摆位的标记线有助于减少摆位误差。     

Importance of the time interval between surgery and postoperative radiation therapy in the combined management of head & neck cancer

Twenty-two patients with advanced carcinomas of various head and neck sites were treated with surgical resection followed by elective postoperative radiation therapy. No patient had gross residual or recurrent disease at the time radiation therapy was started. The time interval from surgery to the start of radiation therapy varied from two and one half weeks to sixteen weeks; the median was seven weeks. Doses of radiation varied from 4500 rad to 5400 rad in five to five and one half weeks.One patient was lost to follow-up. Of the remaining twenty-one patients ten were alive with no evidence of disease (NED) at two to four years (48 %). We observed that 7 of 10 (70 %) of patients whose radiation therapy was started within seven weeks after surgery, were alive free of disease; however, only 3 of 11 (27 %) of those in whom there was a delay of seven weeks or more survived free of disease. Furthermore, in the former group there were virtually no local or regional recurrences, regardless of the stage of the disease, while in the latter group the incidence of local or regional recurrences was 64 %.These data suggest that delay in the start of postoperative radiation therapy, even in the absense of gross recurrent tumor, might adversely affect the results of combined surgical and radiotherapeutic management of head and neck cancers.     

The current status of intensity-modulated radiation therapy in the treatment of nasopharyngeal carcinoma

Radiation therapy is the mainstay of treatment in nasopharyngeal carcinoma, alone or in combination with chemotherapy. In the early stage, it can be managed by radiotherapy alone. For locally advanced-stage disease, several meta-analyses have demonstrated the role of concurrent chemoradiotherapy. Conventional radiation therapy results in significant side effects, particular xerostomia, leading to poor quality of life. With the maturity of intensity-modulated radiation therapy in the recent 10 years, more and more evidences have shown the advantages of intensity-modulated radiation therapy over conventional radiation therapy, regarding the local-regional control, survival rate and quality of life. This article reviews the utilization of intensity-modulated radiation therapy in the management of nasopharyngeal carcinoma with respect to its technical advantages, clinical outcome, critical organ sparing and quality of life, and the dilemma in target delineation. In particular, an issue of treatment-related dysphagia will also be discussed.     

The position and volume of the small bowel during adjuvant radiation therapy for rectal cancer

Purpose: The rate of small bowel toxicity from adjuvant pelvic radiation therapy (RT) for rectal cancer has been reported to be lower for patients treated preoperatively (Preop). This was probably due to a lesser volume of irradiated small bowel; however, studies of postoperative treatment reported that patients with an abdominoperineal resection (APR), who likely have the largest volume of small bowel in the pelvis, had less acute and chronic toxicity than those with a low anterior resection (LAR). In this study, three-dimensional treatment planning techniques were used to characterize the position and volume of small bowel in the pelvis and compare these to repeat studies obtained during the typical 5-week course of treatment to attempt to explain the above observations.

Methods and Materials: Treatment planning CT scans were obtained in 30 patients with rectal cancer (10 Preop, 10 LAR, 10 APR), including 12 patients with weekly CT scans during RT (65 scans). The position of the small bowel was measured by the distance to the nearest small bowel from the bones of the posterior pelvis and by the volume of small bowel within four anatomically defined regions of the pelvis. The motion of the small bowel was expressed as the standard deviation of the small bowel position measured with both the distance and the volume in the 12 patients with repeat studies.

Results: Contrast-containing small bowel was found an average 2.9 cm more anterior than small bowel without contrast below the sacral promontory. The position of the small bowel in Preop patients was significantly more anterior (p ≤ 0.01) with less volume (p ≤ 0.04) in the pelvis than postoperatively treated patients. The small bowel was also more anterior for patients with an LAR vs. APR (p ≤ 0.03) but with similar volume in all pelvic regions. Small bowel motion, expressed as the standard deviation of the distance from the bones of the posterior pelvis to the closest small bowel, was 2.9 cm, 1.4 cm, and 0.2 cm for the Preop, LAR, and APR group, respectively. The LAR group had a considerable degree of motion in the posterior pelvis. Increased bladder volume was associated with reduced small bowel volumes, although this benefit decreased during treatment.

Conclusion: Because treatment planning CT scans can detect small bowel that does not contain contrast, they may be more accurate than the traditional small bowel series. The Preop patients had significantly less pelvic small bowel supporting the clinical observation of better tolerance to therapy. The higher small bowel toxicity reported for LAR vs. APR patients may be explained by the greater variability of both the position and volume of the small bowel in the posterior pelvis for LAR patients. This finding suggests that a single planning study may not be accurate for the block design used for boost treatment of LAR patients. Bladder-filling techniques were useful for Preop and LAR but not APR patients, and decreased in benefit over time. This study suggested that treatment planning CT scans were more useful than a small bowel series and that more than one treatment planning CT may be obtained in any patient receiving > 45 Gy for rectal cancer. However, further research will be necessary to determine the optimal timing and total number of repeat studies.     

Intensity-modulated radiation therapy for the treatment of nonanaplastic thyroid cancer

PURPOSE: Intensity-modulated radiation therapy (IMRT) enables highly conformal treatment for thyroid cancer (TC). In this study, we review outcomes/toxicity in a series of TC patients treated with IMRT. METHODS AND MATERIALS: Between July 2001 and January 2004, 20 nonanaplastic TC patients underwent IMRT. Mean age was 55. There were 3 T2 and 17 T4 patients. Sixteen patients had N1 disease. Seven patients had metastases before RT. Fifteen underwent surgery before RT. Radioactive iodine (RAI) and chemotherapy were used in 70% and 40%, respectively. Median total RT dose was 63 Gy. RESULTS: With two local failures, 2-year local progression-free rate was 85%. There were six deaths, with a 2-year overall survival rate of 60%. For patients with M0 disease, the 2-year distant metastases-free rate was 46%. The worst acute mucositis and pharyngitis was Grade 3 (n = 7 and 3, respectively). Two patients had Grade 3 acute skin toxicity and 2 had Grade 3 acute laryngeal toxicity. No significant radiation-related late effects were reported. CONCLUSIONS: IMRT for TC is feasible and effective in appropriately selected cases. Acute toxicity is manageable with proactive clinical care. Ideal planning target volume doses have yet to be determined. Additional patients and long-term follow-up are needed to confirm these preliminary findings and to clarify late toxicities.     

A phase II trial for the optimisation of treatment position in the radiation therapy of prostate cancer

BACKGROUND: Patient immobilisation and position are important contributors to the reproducibility and accuracy of radiation therapy. In addition the choice of position can alter the external contour of the treated area and has the potential to alter the spatial relationship between internal organs. The published literature demonstrates variation in the use of the prone and supine position for prostate cancer radiation therapy. Previous investigators using different protocols for patient preparation, imaging and target volume definition have demonstrated changes in the calculated therapeutic ratio comparing the two positions. We did not use rigid immobilisation, laxatives, rectal catheters or bladder voiding and assessed if in the prone position would cause a reduction of the dose to the rectum. We performed a prospective comparison of the two positions in 26 patients to determine if the differences in the spatial relation between the rectum and the planning target volume (PTV) would impact on dose-volume histograms to organs at risk (OAR). We also determined if any such improvement might permit dose escalation. MATERIALS AND METHODS: Twenty-six patients with clinically localized prostate cancer consented to participate in this study. All patients underwent a planning CT scan in both the prone and supine treatment positions. The PTV and OAR were drawn on each set of scans by one of the investigators. The PTV included the prostate and seminal vesicles with a 1cm margin except posteriorly where this margin was reduced to 5mm. The outer circumference of the bladder, rectal wall, small bowel (when present) was drawn along with femoral heads. 3D conformal treatment plans were computed using Helax TMS version 6.1B. A 3-field treatment technique was employed with energy of 10/15 MV. The prescribed dose was 70 Gy and the PTV was encompassed by the 95% isodose and the maximum dose was always less than 107%. Cumulative dose-volume histograms were calculated for the PTV, rectum, bladder, femoral heads and small bowel (when present). These non-uniform histograms for both the prone and supine treatment positions were transformed into uniform ones using the effective volume method [Kutcher J, Burman C. Calculation of probability factors for non-uniform normal tissue irradiation: the effective volume method. Med Phys 1987;14:487]. RESULTS: Twenty-one of the 26 (80%) patients had a lower effective volume of rectum irradiated if the prone instead of the supine treatment position was used. The median value of the effective volume in the supine treatment position was 31.74 Gy while the median value in the prone position was 22.48 Gy. The dose escalation was applied to the patients in the prone treatment position until the effective volume for the rectum was the same as that in the supine position. The range of dose escalation possible for these patients was 0.1-7.9 Gy. These patients could potentially have the dose escalated from the prescribed dose of 70 Gy for the supine position without any increase in side effects. For the five patients where no potential benefit was found when changing treatment position, only two patients displayed a significant (>1 Gy) advantage for the supine treatment position. Twenty-one of the 26 patients also showed an advantage for the prone treatment position in relation to bladder dose. CONCLUSION: The use of the prone position reduced the dose to the unprepared rectum and unvoided bladder in the majority of cases. It should be considered particularly in cases where large posterior seminal vesicles cause significant overlap between the planning target volume and the rectum.     

Adjuvant therapy in pancreatic cancer: Phase I trial of radiation dose escalation with concurrent full-dose gemcitabine

PURPOSE: To evaluate the clinical significance of the interval between surgery and postoperative radiotherapy (RT) for patients with soft tissue sarcoma. METHODS AND MATERIALS: The records of 799 patients who underwent postoperative RT for soft tissue sarcoma between 1960 and 2000 were retrospectively reviewed. Univariate and multivariate analyses were used to evaluate the potential impact of the timing of postoperative RT on the rate of local control (LC). RESULTS: The actuarial overall LC rate was 79% at 10 years and 78% at 15 years. Univariate analysis indicated that the factors associated with an inferior 10-year LC rate were positive resection margins (p <0.0001); treatment for recurrent disease (p <0.0001); primary location in the head and neck or deep trunk (p <0.0001); age >64 years (p <0.0001); histopathologic subtype of malignant fibrous histiocytoma, neurogenic sarcoma, or epithelioid sarcoma (p = 0.01); tumor size >10 cm (p = 0.02); postoperative radiation dose <64 Gy (p = 0.03); and high histologic grade (p = 0.05). On multivariate analysis, all these factors remained statistically significant, except for high histologic grade and large size. A delay between surgery and the start of RT of >30 days was associated with a decreased 10-year LC rate, but this association was not statistically significant (76% vs. 83%, p = 0.07). The potential association between RT delay and inferior LC could be explained by an imbalance in the distribution of other prognostic factors. CONCLUSION: The interval between surgery and RT did not significantly impact the 10-year LC rate. These findings indicate that an RT delay should not be viewed as an independent adverse factor for LC and that treatment intensification may not be necessary for patients in whom a treatment delay has already occurred.     

The role of radiation therapy in the treatment of small cell undifferentiated bronchogenic cancer.

The current enthusiasm for polychemotherapy in small cell undifferentiated bronchogenic carcinoma obscures the necessity for primary control by radiation therapy. One hundred and sixty-three patients with this diagnosis were treated in the periods 1965-67 (56) and 1974-76 (107). In the earlier period patients received radiation alone or radiation plus single-agent chemotherapy. In the latter period, all patients were treated with multiple-agent chemotherapy in addition to radiation therapy. Median survival time was extended approx. 4 weeks for the latter group of patients at the cost of much morbidity and occasional lethality. In the patients that were autopsied from both series, only 5/30 were free of disease within the treatment portals and all had received more than 4000 rad tumor dose regardless of adjuvant therapy. A total of 14 autopsies were performed on patients treated by chemo-immunotherapy alone during the 1974-76 period. All of these revealed disease in the primary site and mediastinum although some had no evidence of distant metastasis. Tumor volume is sufficiently large within the primary site and regional lymphatics that presently available chemoimmunotherapy without high dose irradiation is unlikely to sterilize loco-regional disease. Elective radiation to the whole brain was administered to 25 patients and only 3 developed cerebral metastases. Of the remaining 82 patients who were treated concurrently, 25 developed cerebral metastasis and then received radiation therapy to the whole brain, 10 of these patients subsequently died.     

胸部放疗在广泛期小细胞肺癌治疗中的价值

目的 探讨胸部放疗在广泛期小细胞肺癌中的应用价值及对患者预后的影响.方法 回顾性分析154例广泛期小细胞肺癌患者的临床资料,化放疗组89例,化疗组65例.放疗采用常规分割1.8～2.0 Gy/次,1次/d,总剂量为40～60 Gy,化疗采用EP方案(顺铂+依托泊甙)、CE方案(卡铂+依托泊甙)或者CAO方案(环磷酰胺+阿霉素+长春新碱).结果 全组中位生存时间为13.7个月,2年和5年生存率分别为27.9%和8.1%,其中化放疗组分别为17.2个月、36.0%和10.1%,化疗组分别为9.3个月、16.9%和4.6%,两组生存率差异有统计学意义(P=0.001).全组中位无进展生存时间为8.0个月,2年和5年无进展生存率分别为13.6%和8.2%,其中化放疗组分别为10.0个月、17.4%和10.5%,化疗组分别为6.2个月、9.8%和4.9%.两组无进展生存率差异有统计学意义(P＜0.001).化放疗组胸内复发率为29.6%(21/89),化疗组胸内复发率为70.0%(42/65),差异有统计学意义(P=0.000).结论 胸部放疗能降低广泛期小细胞肺癌局部失败的发生率,延长患者的总生存时间和无进展生存时间.

Abstract：

Objective To evaluate the effect of thoracic radiation therapy(TRT) on patients with extensive stage small-cell lung cancer(SCLC). Methods One hundred and fifty-four patients with extensive stage SCLC treated in our department between January 2003 and December 2006 were enrolled in this study.Eighty nine patients received chemotherapy and thoracic radiation therapy(ChT/TRT),and 65 patients were treated with chemotherapy alone(ChT without TRT).The chemotherapy was CE(carboplatin and etoposide),PE(cisplatin and etoposide) or CAO(CTX,ADM and VCR) regimens.The total dose of thoracic irradiation was 40-60 Gy with 1.8-2.0 Gy per fraction. Results For the whole group,the median survival time(MST) was 13.7 months,the 2-year and 5-year overall survival rates were 27.9% and 8.1%,respectively.The MST,overall survival rates at 2 years and 5 years in the ChT/TRT group and ChT without TRT group were 17.2 months,36.0%,10.1% and 9.3 months,16.9%,4.6%,respectively(P =0.001).The median progression-free survival(PFS) for all patients was 8.0 months,the 2-year and 5-year PFS were 13.6% and 8.2%,respectively.The median PFS,2-year and 5-year PFS in the ChT/TRT group and ChT without TRT group were 10.0 months,17.4%,10.5% and 6.2 months,9.8%,4.9%,respectively(P ＜0.001).The incidence of intra-thoracic local failure was 29.6% in the ChT/TRT group and 70.0% in the ChT/without TRT group(P = 0.000). Conclusions Chemotherapy plus thoracic radiation therapy can improve the overall survival,progress free survival and reduce local regional failure rate in patients with extensive stage SCLC compared with that by chemotherapy alone.     

贲门癌调强适形放疗的剂量学研究

目的 用三维治疗计划系统评价调强放疗技术(IMRT)、三维适形技术(3D-CRT)和常规放疗技术在贲门癌应用上的剂量学差异.方法 回顾分析10例贲门癌患者的CT定位图像,利用三维治疗计划系统分别制作IMRT、3D-CRT和模拟常规计划,给予处方剂量4500 cGy.利用剂量体积直方图(DVH图)比较靶区以及危及器官的受照剂量.结果 3D-CRT和IMRT计划与常规计划相比,临床靶区(PTV)的平均剂量均明显提高(P＜0.05),IMRT计划与3D-CRT计划相比,大体肿瘤体积(GTV)的平均剂量增加更加明显(P＜0.05).3D-CRT计划与常规计划相比,在不增加肝脏平均剂量的情况下,减少了受照体积的百分数.IMRT和3D-CRT计划均可明显降低脊髓和心脏的最大受照剂量(P＜0.05),IMRT计划比3D-CRT计划更加减少了脊髓最大受照剂量(P＜0.05).结论 在贲门癌的放射治疗计划剂量分布中,IMRT优于3D-CRT和常规放疗技术.