鼻咽癌外照射加腔内近距离超分割推量照射的远期疗效分析

背景与目的:鼻咽癌的后装治疗一般采用鼻咽腔内治疗的方法进行推量照射,适用于局部早期鼻咽癌.福建省肿瘤医院率先开展鼻咽旁插植技术,无颅底破坏的局部晚期鼻咽癌采用后装治疗推量照射.本文分析腔内后装推量照射的远期疗效,探讨常规外照射的合适剂量配合后程超分割后装推量照射的临床价值.方法:1998年1月～2002年12月体外照射加腔内后装超分割推量放射治疗鼻咽癌患者352例,体外常规放射治疗50～70 Gy后进行腔内近距离超分割推量照射,外照射后咽旁间隙肿瘤残留者配合咽旁区插植放疗.采用个体化鼻咽腔内施源器,超分割照射每次2.5～3.0 Gy,2次/天,间隔6 h,总剂量5～32 Gy,中位剂量17 Gy.结果:本组l、2、3、5年生存率分别为97.0%、91.3%、87.6%、84.7%.总体5年生存率Ⅰ、Ⅱ期88.2%,Ⅲ、Ⅳ期79.2%(log-rank检验,P=0.016);总体局控率Ⅰ、Ⅱ期94.1%,Ⅲ、Ⅳ期91.7%(log-rank检验,P＞0.05).后组颅神经损伤32例(9.4%).结论:鼻咽腔内后装联合咽旁间隙捅植近距离放射治疗鼻咽癌取得良好的局控率和生存率,局部晚期鼻咽癌取得与早期鼻咽癌类似的局控率,咽旁间隙受累者咽旁插植增加颈动脉鞘区照射剂量,后组颅神经损伤发生率较高.     

鼻咽癌后装腔内放疗个体化施源器剂量学分析

目的:评估热塑面罩固定鼻咽个体化施源器剂量的准确性及其应用价值.方法:选择10例后装放疗患者,分别制作鼻咽个体化施源器并使用面罩固定.每次治疗前均行CT扫描,并在计划系统中重建出施源器位置,获取铱源驻留位点坐标,通过与计划CT比较,计算出施源器位移偏差,进而评估后装治疗剂量的准确性.结果:非面罩固定最远端源驻留位点(P1)平均偏差在X、Y、Z三个方向为(1.62士0.24)、(2.32士0.22)和(2.50士0.28)mm,近端(P5)为(1.13±0.11)、(1.22±0.20)和(1.80±0.15)mm.经面罩固定后个体化施源器最远端源驻留位点(P1)平均位移则分别为(0.82±0.06)、(0.70±0.07)和(0.94±0.08) mm,近端(P5)为(0.70士0.02)、(0.46土0.01)和(0.60土0.03)mm.面罩固定施源器位移偏差导致的感兴趣点(源旁2 cm)剂量误差＜1.2％.结论:使用热塑面罩固定个体化施源器剂量准确,适合鼻咽癌腔内后装治疗.     

鼻咽旁区插植配合体外放射治疗鼻咽癌

目的探讨鼻咽旁区插植近距离放射治疗技术在鼻咽癌治疗中的作用。方法初治鼻咽癌患者体外照射56～70Gy（T2期56～60Gy,T3期66～70Gy）后复查CT或MRI发现鼻咽旁区残留病例67例,以腔内+鼻咽旁区插植放射治疗增量,咽旁区在模拟机引导下插入1～4根施源管,采用荷兰核通公司生产的192Ir高剂量率近距离治疗机,放射剂量2.5～4.0Gy/次,2次/d,间隔>6h,总剂量12～20Gy,3～4?d完成。插植组与同期的类似病例（67例）配对进行研究。结果鼻咽旁区插植组和对照组的3年生存率分别为92.4%,84.5%（P>0.05);3年无局部复发生存率分别为97.0%、76.4%（P<0.05);3年无远地转移生存率分别为76.6%、69.1%（P>0.05)。鼻咽旁区插植组的晚期放射反应如口干、张口困难发生率均低于对照组。结论鼻咽旁区插植放射治疗可以显著提高鼻咽癌咽旁区残留的局部控制率,拓宽了鼻咽癌近距离放射治疗的适应证,是一种有效的补充治疗手段。     

3D打印个体化施源器鼻咽癌腔内后装治疗应用初探

目的 初步探讨3D打印个体化施源器在鼻咽癌腔内后装放疗中应用的可行性。方法对1例rT1期复发鼻咽癌及1例T2期残留鼻咽癌患者进行定位CT扫描,传输至3D图像处理软件获得鼻咽腔几何轮廓参数,并设计管道走位使其靠近肿瘤区(rGTV)。按设计参数,使用3D打印机制造出个体化腔内施源器。用类似后鼻孔填塞技术将施源器置入鼻咽腔内。在施源器预设的管道中,插入后装施源管及假源,再次行定位CT并传入3D后装计划系统。勾画靶区和危及器官,设计优化治疗计划,完成首次治疗后取出施源器。再次治疗前复查定位CT并观察假源位置是否准确。结果 施源器置入鼻咽腔后能与鼻咽壁完全贴合,并且自行固定无须额外的固定措施。治疗中多次复查CT并与计划CT比较假源位置误差≤1mm,患者治疗全程无明显不适。优化后三维治疗方案100%剂量曲线包全rGTV,脑干、脊髓最大剂量<30%。复发患者给予处方剂量40Gy分8次4周完成,残留患者12Gy分2次1周完成。2例患者后装治疗后3个月复查肿瘤均全消。结论 使用3D打印技术制作的个体化鼻咽腔内施源器具有自行固定、位置准确、重复性好、患者耐受良好的优点,近期疗效确切,值得进一步研究。     

3D打印个体化施源器鼻咽癌腔内后装治疗应用初探

目的 初步探讨3D打印个体化施源器在鼻咽癌腔内后装放疗中应用的可行性。方法对1例rT1期复发鼻咽癌及1例T2期残留鼻咽癌患者进行定位CT扫描,传输至3D图像处理软件获得鼻咽腔几何轮廓参数,并设计管道走位使其靠近肿瘤区(rGTV)。按设计参数,使用3D打印机制造出个体化腔内施源器。用类似后鼻孔填塞技术将施源器置入鼻咽腔内。在施源器预设的管道中,插入后装施源管及假源,再次行定位CT并传入3D后装计划系统。勾画靶区和危及器官,设计优化治疗计划,完成首次治疗后取出施源器。再次治疗前复查定位CT并观察假源位置是否准确。结果 施源器置入鼻咽腔后能与鼻咽壁完全贴合,并且自行固定无须额外的固定措施。治疗中多次复查CT并与计划CT比较假源位置误差≤1mm,患者治疗全程无明显不适。优化后三维治疗方案100%剂量曲线包全rGTV,脑干、脊髓最大剂量<30%。复发患者给予处方剂量40Gy分8次4周完成,残留患者12Gy分2次1周完成。2例患者后装治疗后3个月复查肿瘤均全消。结论 使用3D打印技术制作的个体化鼻咽腔内施源器具有自行固定、位置准确、重复性好、患者耐受良好的优点,近期疗效确切,值得进一步研究。     

鼻咽癌腔内加咽旁间隙插植组织间照射的剂量优化

鼻咽癌咽旁间隙插植技术是近年来发展起来的一种近距离放射疗法 ,对于鼻咽咽旁区部分受累的病变可以进行组织间插植照射 ,它是对鼻咽腔内放射治疗技术的补充 ,拓宽了鼻咽癌后装治疗的适应证 ,临床上已取得较好效果。笔者探讨这一技术的剂量优化方法 ,并应用定量指标与规则的插植治疗进行比较、评估。一、材料和方法鼻咽癌咽旁间隙组织间插植照射的靶区主要包括鼻咽粘膜、受侵的粘膜下肌肉组织、部分咽旁间隙。由于鼻咽部特殊的解剖结构及周围器官的限制 ,插植治疗不可能依照巴黎系统的布针原则 ,即平行、等距、等长来安排施源管 ,只能采用多…     

一种新型可调充气式鼻咽后装施源器的研制和应用

背景与目的：鼻咽腔内近距离放疗施源器(以下简称施源器)在鼻咽腔内近距离放疗中起重要作用,直接影响治疗的效果。我们研制了一种新型施源器。方法：新型施源器用医用乳胶材料制成,在距施源器前端15mm处置一气囊,气囊边缘与管轴相切,紧贴于管壁一侧,令充气时管轴反向拱形隆起贴近治疗部位。使用时经中鼻道达后壁,通过旋转施源器可调节施源器方向和位置,经注气孔注入空气并固定。治疗前需复核定位证实。结果：共治疗221例鼻咽癌,初治病例中鼻咽肿物消退率92．6％,复发病例鼻咽肿物全部消退,鼻咽前壁或后壁粘膜坏死5例,鼻甲水肿及后鼻道粘连8例。结论：本施源器具有安全可靠,操作方便,患者无痛苦,剂量分布理想,固定性较好等优点。在治疗中出现鼻咽粘膜坏死可能与初期使用时单次剂量过高有关。     

鼻咽部后装放疗模具施源器的设计制作和临床应用

鼻咽部后装放疗模具施源器的设计制作和临床应用陈南江廖天禄李杭姜桂林张其昆我们于１９９２年１月引进深圳威达医疗器械公司生产的ＷＤ－ＨＤＲ１８型高剂量率近距离遥控后装放射治疗机，用于腔内后装放疗配合外放射治疗鼻咽癌３８例，共８６人次，局部肿瘤退缩满意，观...     

鼻咽癌腔内及咽旁间隙插植近距离放射治疗的护理

放射治疗是治疗鼻咽癌的主要方法，对经足量外照射后残余肿瘤及放疗后咽旁间隙残留或复发病例可应用腔内及咽旁插植的方法进行治疗。通过对654例鼻咽癌患者进行腔内及咽旁间隙插植放疗，加强心理护理及治疗前、中、后护理，保证治疗过程顺利进行，完成治疗计划，提高放疗疗效。     

鼻咽癌后装治疗鼻咽模施源器的制作方法

鼻咽癌后装治疗鼻咽模施源器的制作方法卢杰用后装治疗机进行鼻咽癌腔内照射时，需施源器作源的定位。本文介绍的是由我科设计并已在临床中使用的鼻咽模施源器的制作工艺及方法。１鼻咽模施源器的制作方法１．１依据鼻咽部Ｘ光片、ＣＴ片，以及尸体解剖上取得的鼻咽腔石膏...     

局限性残留、复发鼻咽癌的鼻内镜进路救援性外科治疗

背景与目的:对于放疗后鼻咽局限性残留、复发鼻咽癌,二程放疗可以使部分患者得到长期局部控制,但其放射性后遗症也相当严重:而救援性外科手术在取得相仿甚至更优疗效的同时,避免了这些放射性后遗症.然而,传统开放式手术进路创伤大,术野欠清晰,难以按肿瘤外科原则进行连续、整块切除.本研究旨在探索一种新的微创性鼻内镜进路的复发鼻咽癌外科治疗方法.方法:从2004年9月至2007年1月,25例放疗后鼻咽局限性残留或复发鼻咽癌患者在中山大学肿瘤防治中心进行经鼻内镜鼻咽切除术,将鼻咽肿瘤和足够的安全边缘连续、整块切除.观察其疗效和并发症.结果:25例患者均在鼻内镜进路下按肿瘤外科手术原则进行根治性整块切除,仅1例切缘阳性,鼻咽创面愈合良好,均未追加术后放疗.中位随访时间13个月(3～31个月),1例原位残留,3例术后原位复发,无远处转移和死亡.1年总生存率100%,无局部复发生存率达86.0%.无张口、吞咽、发音困难和其他手术并发症发生,无围手术期死亡.结论:鼻内镜进路鼻咽癌救援手术能充分暴露鼻咽以及咽旁间隙浅部,能将鼻咽残留、复发病灶按肿瘤外科原则进行连续、整块根治性切除,并发症少而轻,近期疗效满意.     

47例鼻咽癌外照射配合咽旁间隙插植后装治疗的研究

目的:探讨外照射配合咽旁间隙插植治疗鼻咽癌的价值。方法:初治的鼻咽癌患者常规行外照射68～70Gy后复查CT或MRI,有咽旁间隙残留的98例,随机分成2组。一组行咽旁间隙插植后装补量(插植组),共47例。插植的方法是在模拟定位机引导下,经颌下插入1～3根施源管至咽旁区。后装机采用核通公司生产的192Ir高剂量率近距离治疗机,补量12～15Gy/4～6次/2～3d(2次/d,2.5～4Gy/次,每次间隔>6h);另一组行耳后野补量12～14Gy(对照组),共51例。结果:插植组与对照组3年总生存率及3年无远处转移生存率,差异无显著意义(P>0.05);3年无局部复发生存率,插植组显著高于对照组(P<0.05);晚期放射反应中的口干及张口受限等,插植组显著低于对照组(P<0.05)。结论:做为鼻咽癌咽旁间隙的补量,咽旁间隙插植后装治疗可显著提高咽旁间隙区残留的局部控制率,且晚期放射反应显著低于耳后野补量照射,具有较理想的临床应用价值。     

Combined treatment with interstitial hyperthermia and interstitial radiotherapy in an animal tumor model

An interstitial hyperthermia system operating at 27 MHz has been developed at the Dr. Daniel den Hoed Cancer Center. To test this system in combination with interstitial radiotherapy and to study the interactions of interstitial radiotherapy and interstitial hyperthermia, animal experiments were performed using rhabdomyosarcoma type R1 transplanted in the flanks of female Wag/Rij rats. Using the 27 MHz system, it appeared feasible to obtain hyperthermic temperatures. In this experiment a thermal dose of 44 degrees C for 30 minutes was delivered by controlling the temperature at the periphery of the tumor to 44 degrees C. The interstitial heating applicators were inserted in four standard afterloading catheters implanted with a fixed spacing of 7 mm; the same catheters were used for the radioactive sources for interstitial radiotherapy treatment following the interstitial hyperthermia sessions. Interstitial radiotherapy was given by means of four Ir192 wires with an average activity of 4.5.10(7) Bq/cm. Minimum tumor doses of 20 to 115 Gy with a mean dose rate of 47 cGy/hour were applied. Interstitial hyperthermia alone resulted in a growth delay (GD1) of 6 +/- 2 days without significant reduction of tumor volume. The 50% tumor cure dose after interstitial radiotherapy alone was 95 +/- 9 Gy. Combination of interstitial hyperthermia and interstitial radiotherapy resulted in reduction of the 50% tumor cure dose to 48 +/- 13 Gy. The dose-effect data for cure for these modalities are compared to existing data for external irradiation and external hyperthermia in the same tumor model. It was found that the addition of hyperthermia to different modes of irradiation, that is, either to single dose or protracted radiotherapy, results in a common level of radiosensitivity through impaired repair of sublethal damage. This study demonstrates the feasibility of the 27 MHz heating system in achieving hyperthermic temperatures; in the combined modality experiments a thermal enhancement factor of 2.0 +/- 0.3 (mean +/- standard deviation) was observed.     

The role of brachytherapy in early-stage nasopharyngeal carcinoma

To present the treatment results and assess the optimal radiation dose and the role of brachytherapy in early stage nasopharyngeal cancer (NPC).

One hundred eighty-three patients with Stage I and II (American Joint Committee on Cancer Staging System, 1987) NPC completed the planned radiotherapy in our institution from 1979 to 1991. In 133 patients, radiotherapy was given to the nasopharynx by external beam to 64.8–68.4 Gy. Further boost was done by high dose rate (HDR) brachytherapy for 5–16.5 Gy in one to three fractions. For the remaining 50 patients, a course of external radiotherapy to the nasopharynx for 68.4–72 Gy was given to nasopharynx. Age (>40 or not) sex, neck boost or not, brachytherapy, and irradiation dose were analyzed to determine significant factors that influence the probabilities of local control and actuarial survival.

The 5-year disease-specific survival was 85.8% and local control was 83%. Only the brachytherapy and irradiation dose significantly affected the results. The use of the brachytherapy had significant impact on overall survival and local control. Furthermore, we compared the prognostic effect of various radiation dosage among Group I of 50 patients (<72.5 Gy, no brachytherapy, excluding four patients who received brachytherapy), Group II of 71 patients (72.5–75 Gy; one to two fractions of brachytherapy), and Group III of 58 patients (>75 Gy; three fractions of brachytherapy). Five-year disease-specific survival rates of Group I, Group II, and Group III were 77, 95.5, and 82.4%, respectively. Five-year local control rates were: 73.7, 93.9, and 79.5%. We found that the Group II had the best actuarial survival and local control rate (log-rank test, p < 0.05). Most patients receiving brachytherapy encountered foul odor because of nasopharynx crust; 12 of them had palate or sphenoid sinus floor perforation or nasopharynx necrosis. None of the patients without brachytherapy experienced the same complications.

The optimal radiotherapy dose to the nasopharnyx area in early stage NPC may be within 72.5 to 75 Gy by our treatment protocol. A dose of more than 75 Gy did not have significant local control or survival advantage. The use of brachytherapy to elevate radiation dose had significant local control and survival benefit for early stage NPC patients, but the fractionation size should be decreased to reduce the complications.     

鼻咽癌IMRT放射性溃疡临床及剂量因素分析

目的 通过分析鼻咽癌初程IMRT后发生鼻咽溃疡的临床特点、预后及放疗剂量学等资料,了解与放射性鼻咽溃疡发生的相关因素。方法 回顾分析2001—2013年接受初程IMRT的鼻咽癌患者共1217例,结合临床症状、腔镜、MRI及病理(除外局部复发)诊断放射性鼻咽溃疡共21例,总结其临床特点、预后情况,并复阅其放疗计划进行剂量学评估。结果 21例放射性溃疡患者中男17例、女4例;T₂期1例、T₃期3例、T₄期17例。GTV_nx中位数83 cm³,除1例T₂期病变PGTV_nx处方剂量为69.96 Gy外,余20例处方剂量为73.92 Gy。鼻咽溃疡发生时间为放疗结束后1.8~21.9个月(中位数6.2个月),鼻咽部大出血发生率为48%(10/21)。21例患者中6例溃疡愈合,15例持续不愈,其中8例死亡(鼻咽大出血4例、恶液质及伴多器官功能衰竭3例、多发骨转移1例)。     

Nasopharyngeal carcinoma treated by radical radiotherapy alone: Ten-year experience of a single institution

PURPOSE: To report on our experience in the treatment of nasopharyngeal carcinoma (NPC) by radical radiotherapy alone in our institution during the last decade. METHODS AND MATERIALS: From January 1990 to May 1999, 905 NPC patients were treated and were studied retrospectively. Radical radiotherapy was given to this cohort by conventional technique in a routine dose of 70-72 Gy to the primary tumor and metastatic lymph nodes. In case of residual primary lesion, a boost dose of 8-24 Gy was delivered by either 192Ir afterloading brachytherapy, fractionated stereotactic radiotherapy, conformal radiotherapy, or small external-beam fields. RESULTS: The 5-year and 10-year local-regional control, overall survival, and disease-free survival rates were 81.7% and 76.7%, 76.1% and 66.5%, 58.4% and 52.1%, respectively. In case of residual primary lesions after a dose of 70-72 Gy of conventional external-beam radiotherapy (EBRT), an additional boost was able to achieve a local control of 80.8%, similar to that obtained with primary lesions that completely disappeared at 70-72 Gy (82.6%, p = 0.892). CONCLUSIONS: The treatment results of radical EBRT followed by a boost dose to the residual primary tumor for nasopharyngeal carcinoma in our institution are promising.     

Ⅰ/Ⅱ期鼻咽癌外照射后残留后装推量的疗效分析

  目的  研究Ⅰ/Ⅱ期鼻咽癌常规外照射后2天内鼻咽纤维镜下可疑残留者使用后装推量是否可以改善疗效。  方法  根据福州92分期分为Ⅰ/Ⅱ期的患者281例, 经首程常规根治量放疗完成后2天内, 影像学检查提示可疑残留病灶的患者35例行后装治疗作为联合照射组, 选取根治量放疗后完全缓解未推量的作为对照组(单纯外照射组)246例, 联合照射组采用后装推量10~12Gy/2F/6~8D。  结果  两组患者治疗后的5年生存情况联合照射组鼻咽癌复发1例, 死亡2例, Ⅰ、Ⅱ期鼻咽癌的5年总的生存率分别为100%、92.3%。单纯外照射组鼻咽复发17例, 死亡41例, Ⅰ、Ⅱ期鼻咽癌患者的5年总的生存率分别为90.1%和80.6%(P=0.042), 联合照射组鼻咽5年局控率为97.1%, 单纯外照射组鼻咽局控率为93.3%(P=0.036), 两组毒副作用均可耐受。  结论  对早期鼻咽癌常规外照射后影像学可疑残留者, 及早行后装推量治疗可以提高局控率及生存率, 患者可耐受。