乳腺导管原位癌术后辅助放疗

 保乳术已成为导管原位癌(DCIS)最常见的治疗手段,术后放疗可降低其复发风险。然而,对于DCIS放疗的照射范围、可不行术后放疗低危人群的选择、部分乳腺加速放疗（APBI）在DCIS中的作用等还存在争议。然而,多数研究均显示DCIS保乳术患者均能从术后放疗中获益。进一步的前瞻性研究主要证实低危组的DCIS患者是否可以安全地省去术后放疗。对单纯保乳术后患者的长期随访结果显示,除有禁忌症的患者外,放疗成为保乳术后所有患者的常规治疗方式。     

乳腺癌保乳术后放疗反应及美容效果

乳腺癌保乳术后放疗是保乳综合治疗的重要组成部分,对早期乳腺癌施行保乳手术结合放疗已得到广泛认可.现代放疗技术包括三维适形放疗(3D-CRT)和调强放疗(IMRT)等在保乳治疗中得到合理应用.放射反应和美容效果是评价保乳术后放疗的重要因素.不同放疗技术产生的放射反应和美容效果不同并各有其特点.     

乳腺癌保乳术后加速部分乳腺照射的靶区确定

目前,保乳治疗已经成为Ⅰ、Ⅱ期乳腺癌的主要治疗方式.保乳术后放疗的目的主要是提高局部肿瘤控制率和乳房保全率.一直以来,全乳房照射加瘤床补量的放疗模式是乳腺癌保乳术后放疗的常规选择,因为这种放疗模式明显降低了局部肿瘤复发率.大量研究证明,保乳术后复发绝大多数发生在瘤床及其附近区域,因此单纯针对瘤床的部分乳腺照射（partial breast irradiation,PBI）成为近期乳腺癌放疗研究的热点.PBI的剂量分割方式通常为加速分割,因此亦可称其为加速部分乳腺照射（accelerated partial breast irradiation,APBI）.以下重点综述APBI的靶区确定.     

乳腺癌保乳术后放射治疗的发展与现状

放射治疗在乳腺癌的治疗过程中发挥着重要的作用.乳腺癌术后放疗可以降低复发率和死亡率,提高总生存率.保乳术结合放疗对于乳腺癌的治疗发展具有重要的意义.全文对乳腺癌保乳术后放射治疗的发展与现状作一综述.     

乳腺癌保乳术后大分割全乳照射研究现状

目前保乳治疗已成为早期乳腺癌的首选治疗方式,而放疗则是乳腺癌保乳治疗的重要组成部分。但常规分割全乳放疗疗程超过6周,过长的疗程成为部分患者放弃保乳治疗的原因,也使部分接受保乳手术患者放弃术后放疗,而且成为放化疗顺序安排纠结因素之一。     

乳腺癌保乳术后放疗进展

保乳治疗目前已是早期乳腺癌的首选治疗方式,而放疗则是乳腺癌保乳治疗的重要组成部分.近年来,保乳术后放疗在多个方面取得了不同程度进展,如腋淋巴结1～3个转移者区域淋巴引流区放疗取舍、放疗对远期生存影响的再认识、保乳治疗后乳房内复发模式的明确、导管原位癌保乳术后放疗地位的确定、调强放疗的剂量学优势与皮肤保护、影像引导放疗在保乳治疗中的应用、部分乳腺照射的现状与亟待解决的问题、新辅助化疗后保乳治疗者的放疗选择等,下面分别加以综述.     

早期乳腺癌患者行乳腺癌根治术和保乳术后放疗的生存比较

目的 探讨乳腺癌根治术和保乳术后放疗对早期乳腺癌患者生存情况的影响.方法 选择早期乳腺癌379例,分为根治术组(341例)和保乳术后放疗组(38例).分别观察两组患者的Karnofsky评分和复发情况.结果 随访5年时保乳术后放疗组患者Karnofsky评分显著高于根治术组(P＜0.05);保乳术后放疗组患者1、3、5...     

乳腺癌保乳术中近距离瘤床放疗的临床应用评估

目的:探讨早期乳腺癌保乳术中采用近距离瘤床放疗取代常规术后全乳放疗后瘤床加量外照射的安全性和可行性.方法:共入组30例患者,其中15例早期乳腺癌患者接受保乳术中近距离瘤床放疗,术后常规行全乳放疗;另选择15例早期乳腺癌患者作为配对,接受保乳手术及术后全乳和瘤床加量放疗.比较2组患者术后24～48 h残腔引流量、切口Ⅰ期愈合率、术后住院天数和乳房外形满意度.结果:研究组与对照组的术后24～48 h残腔引流量、切口Ⅰ期愈合率、平均住院天数及辅助化疗开始时间的差异均无统计学意义(P＞0.05).2组患者的短期随访结果显示,均能保持满意的乳房外形.结论:早期乳腺癌保乳术中近距离瘤床放疗具有较好的安全性和临床可操作性.     

早期乳腺癌保乳术后的放射治疗

术后放疗是早期乳腺癌保乳治疗的重要组成部分.早期乳腺癌保乳术后放疗时机、照射范围、剂量、方式等是放疗的重要环节,对生存率、局部控制率、美容效果有重要影响.     

保乳术后瘤床放疗的研究进展

早期乳腺癌术后单纯瘤床放疗是指保乳术后在较短时间内完成对瘤床的照射.主要有近距离治疗和适形放疗两种治疗方式,其中对近距离治疗的研究较多.目前保乳术后单纯瘤床放疗仍为试验性研究.     

胸部肿瘤调强放疗后动态心电图异常的临床分析

目的:分析胸部肿瘤调强放疗后动态心电图异常,观察调强放疗对患者心脏的影响。方法:选取从2012年3月到2013年3月收治的需要接受调强放疗的胸部肿瘤患者共109例为观察组,同时选择110例采用常规放疗的胸部肿瘤患者作为对照组。对比观察两组患者接受放疗后,患者心电图的异常情况。同时观察调强放疗患者动态心电图治疗前、治疗后以及治疗半年后的异常情况。结果:对比观察组和对照组在治疗前、治疗后以及治疗半年后出现异常心电图的发生率。两组患者在治疗结束后其异常动态心电图发生率均出现明显升高,并且对照组明显要高于观察组患者。患者在治疗后出现动态心电图异常对比治疗前有显著增加,治疗前和治疗结束两组数据对比有统计学差异。治疗前和治疗结束半年后患者出现窦性心律失常、偶发房室性心律失常以及频发房室性心律失常的发生率对比,治疗结束后的发生率明显要高于治疗前。不同治疗方案对比异常心电图各项指标没有统计学差异。结论:调强放疗对胸部肿瘤患者的心脏毒性主要集中在放疗的早期,在放疗结束后心脏毒性会相对减少。对比常规放疗方法,调强放疗对于患者心脏毒性要相对较少。     

Randomised trial of standard 2D radiotherapy (RT) versus intensity modulated radiotherapy (IMRT) in patients prescribed breast radiotherapy.

BACKGROUND: Radiation dose distributions created by two dimensional (2D) treatment planning are responsible for partial volumes receiving >107% of the prescribed dose in a proportion of patients prescribed whole breast radiotherapy after tumour excision of early breast cancer. These may contribute to clinically significant late radiation adverse effects. AIM: To test three dimensional (3D) intensity modulated radiotherapy (IMRT) against 2D dosimetry using standard wedge compensators in terms of late adverse effects after whole breast radiotherapy. METHODS: Three hundred and six women prescribed whole breast radiotherapy after tumour excision for early stage cancer were randomised to 3D IMRT (test arm) or 2D radiotherapy delivered using standard wedge compensators (control arm). All patients were treated with 6 or 10MV photons to a dose of 50Gy in 25 fractions to 100% in 5 weeks followed by an electron boost to the tumour bed of 11.1Gy in 5 fractions to 100%. The primary endpoint was change in breast appearance scored from serial photographs taken before radiotherapy and at 1, 2 and 5 years follow up. Secondary endpoints included patient self-assessments of breast discomfort, breast hardness, quality of life and physician assessments of breast induration. Analysis was by intention to treat. RESULTS: 240 (79%) patients with 5-year photographs were available for analysis. Change in breast appearance was identified in 71/122 (58%) allocated standard 2D treatment compared to only 47/118 (40%) patients allocated 3D IMRT. The control arm patients were 1.7 times more likely to have a change in breast appearance than the IMRT arm patients after adjustment for year of photographic assessment (95% confidence interval 1.2-2.5, p=0.008). Significantly fewer patients in the 3D IMRT group developed palpable induration assessed clinically in the centre of the breast, pectoral fold, infra-mammary fold and at the boost site. No significant differences between treatment groups were found in patient reported breast discomfort, breast hardness or quality of life. CONCLUSION: This analysis suggests that minimisation of unwanted radiation dose inhomogeneity in the breast reduces late adverse effects. Incidence of change in breast appearance was statistically significantly higher in patients in the standard 2D treatment arm compared with the IMRT arm. A beneficial effect on quality of life remains to be demonstrated.     

Clinical aspects of intensity-modulated radiotherapy in the treatment of breast cancer

In recent years, interest has grown throughout the radiotherapy community in investigation and clinical application of intensity-modulated radiation therapy (IMRT) for adjuvant treatment of breast cancer. IMRT removes the usual reliance on flat (or uniform-intensity) radiation fields, and instead replaces that simple paradigm with a variable-intensity pattern that is usually determined with the aid of a computerized optimization algorithm. The main goal of much IMRT and optimization work is the delivery of more conformal plans to the patient. Thus, IMRT has the potential to improve target coverage and reduce inhomogeneities observed within the breast (and regional lymph nodes) that are obtained with standard plans. Furthermore, IMRT may be able to reduce doses delivered to the heart and lungs, and may potentially minimize further the probability of complications from radiotherapy.     

Intensity-modulated Radiotherapy in the Treatment of Breast Cancer

Intensity-modulated radiotherapy (IMRT) is a newer method of radiotherapy that uses beams with multiple intensity levels for any single beam, allowing concave dose distributions and tighter margins than those possible using conventional radiotherapy. IMRT is ideal for treating complex treatment volumes and avoiding close proximity organs at risk that may be dose limiting and provides increased tumour control through an escalated dose and reduces normal tissue complications through organ at risk sparing. Given the potential advantages of IMRT and the availability of IMRT-enabled treatment planning systems and linear accelerators, IMRT has been introduced in a number of disease sites. This systematic review examined the evidence for IMRT in the treatment of breast cancer to quantify the potential benefits of this new technology and to make recommendations for radiation treatment programmes considering adopting this technique. Providing that avoidance of acute adverse effects associated with radiation is an outcome of interest, then IMRT is recommended over tangential radiotherapy after breast-conserving surgery, based on a review of six published reports including 2012 patients. There were insufficient data to recommend IMRT over standard tangential radiotherapy for reasons of oncological outcomes or late toxicity. Future research should focus on studies with longer follow-up and provide data on late toxicity and disease recurrence rates.     

Radiothérapie conformationnelle avec modulation d’intensité dans les cancers du sein : intérêt,limitations, modalités techniques

Intensity modulated radiotherapy (IMRT) is a technique allowing dose escalation and normal tissue sparing for various cancer types. For breast cancer, the main goals when using IMRT were to improve dose homogeneity within the breast and to enhance coverage of complex target volumes. Nonetheless, better heart and lung protections are achievable with IMRT as compared to standard irradiation for difficult cases. Three prospective randomized controlled trials of IMRT versus standard treatment showed that a better breast homogeneity can translate into better overall cosmetic results. Dosimetric and clinical studies seem to indicate a benefit of IMRT for lymph nodes irradiation, bilateral treatment, left breast and chest wall radiotherapy, or accelerated partial breast irradiation. The multiple technical IMRT solutions available tend to indicate a widespread use for breast irradiation. Nevertheless, indications for breast IMRT should be personalized and selected according to the expected benefit for each individual.     

降低乳腺癌放疗心脏损伤相关治疗措施的研究进展

乳腺癌放疗后患者长期受到心脏损伤的影响,心脏损伤涉及很多结构,包括冠状动脉、心肌、传导系统、心包及瓣膜等。这些损伤增加了放射相关性心脏病的风险,从而影响患者的远期生存率和生活质量。随着现代放射治疗技术、物理学及其他各项技术的发展,乳腺癌患者放射治疗后发生心脏损伤的几率明显降低。本文针对降低乳癌患者放疗心脏损伤的各项技术及治疗措施（包括乳腺托架定位及俯卧位放疗、3DCRT及IMRT放射治疗、呼吸门控技术、大分割放疗、加速部分乳腺放疗及质子治疗等）做一综述。     

胸部肿瘤患者调强放疗后动态心电图变化的临床对比研究

目的:探讨胸部肿瘤患者在不同时间段、不同类型肿瘤、不同治疗方法下调强放疗动态心电图变化情况。方法:选取2010年4月-2013年4月95例胸部肿瘤患者为研究对象,按照肿瘤类型分成肺癌组35例,乳腺癌组29例,食管癌组31例;按照治疗方法分成单纯放疗组26例,同步放化组34例,序贯放化组35例,分别在治疗前、治疗后和治疗结束6个月后观察动态心电图变化情况。结果:治疗后和治疗前在偶发室（房）性心律失常、ST-T段改变动态心电图异常发生率上比较差异有统计学意义（P＜0.05）,而治疗结束6个月后和治疗前在偶发室（房）性心律失常、ST-T段改变动态心电图异常发生率比较差异无统计学意义（P＞0.05）。不同治疗方法和不同肿瘤类型上治疗前动态心电图各项指标比较差异无统计学意义（P＞0.05）;治疗后各项指标比较差异也无统计学意义（P＞0.05）。结论:调强放射治疗后胸部肿瘤患者动态心电图改变多在早期出现,且为可逆性。调强放射治疗精确性保证了不同类型胸部肿瘤放疗后动态心电图改变无显著差异性。     

Reduction of radiotherapy-induced late complications in early breast cancer: the role of intensity-modulated radiation therapy and partial breast irradiation. Part II--Radiotherapy strategies to reduce radiation-induced late effects

Radiotherapy after conservation surgery has been proven to decrease local relapse and death from breast cancer, and is now firmly established in the management of early breast carcinoma. Currently, the challenge is to optimise the therapeutic ratio by minimising treatment-related morbidity, while maintaining or improving local control and survival. The second part of this review examines the role of two approaches: intensity-modulated radiation therapy (IMRT) and partial breast irradiation, as means of improving the therapeutic ratio. Discussion of IMRT includes both inverse- and forward-planned methods: the breast usually requires minimal modulation to improve dose homogeneity, and therefore lends itself to simpler forward-planned IMRT techniques; whereas inverse-planned IMRT may be useful in selected cases. There are many dosimetry studies reporting the superiority of IMRT over conventional breast radiotherapy, but there is still a paucity of clinical data regarding patient benefit from these techniques. A critical literature review of clinical partial breast radiotherapy studies focuses on the influence of irradiated breast volume, dose and fractionation, and patient selection on normal tissue side-effects and local control. Clinical reports of partial breast irradiation show several encouraging, but some concerning results about local recurrence rates. Therefore, mature results from randomised trials comparing partial breast irradiation with whole-breast radiotherapy are required. Accurate localisation of the tumour bed and application of appropriate clinical target volumes and planning target volumes are discussed in detail, as these concepts are fundamental for partial breast irradiation.     

早期乳腺癌保乳术后4种放疗技术的剂量参数比较

目的：比较早期乳腺癌保乳术后常规切线野（TW）、野中野调强（FIF - IMRT）、切线逆向调强（T -IMRT）和容积调强（VMAT）4种放射治疗技术的靶区和危及器官的剂量参数。方法：15例左侧早期（pT1-2 N0 M0）乳腺癌患者保乳术后接受放疗。CT 模拟定位扫描后勾画靶区和危及器官,在同一患者 CT 影像上分别做 TW、FIF - IMRT、T - IMRT 和 VMAT 4种治疗计划设计。PTV 剂量为50Gy,V47.5≥95%。4种计划的剂量限制相同。在剂量-体积直方图中读取4种计划靶区剂量的分布参数,心脏、双侧肺脏及对侧乳腺受照剂量和体积,对各参数的均数进行比较,并比较4组平均机器跳数差异。结果：4种计划都满足 V47.5≥95%。VMAT 与 T - IMRT、FIF - IMRT 和 TW 计划相比,明显提高了靶区适行指数（CI,P ﹤0.05）。VMAT、T - IMRT和 FIF - IMRT 与 TW 相比,明显改善了靶区均匀性指数（HI,P ﹤0.05）。VMAT 增加了危及器官（心脏和同侧肺脏）V 5、V10和 V20的受照射体积,但是没有增加﹥ V30的照射体积。VMAT 明显增加了右侧乳腺和右侧肺脏照射剂量（P ﹤0.05）,T - IMRT 和 FIF - IMRT 明显降低了右侧乳腺和右侧肺脏照射剂量（P ﹤0.05）。VMAT 与T - IMRT、FIF - IMRT 和 TW 相比,明显增加了机器跳数（P ﹤0.05）。结论：早期乳腺癌保乳术后放射治疗4种计划比较,VMAT 明显提高了靶区的适行性和均匀性,增加了正常组织的受照射剂量和机器跳数,延长了治疗时间。T - IMRT 和 FIF - IMRT 也提高了靶区的适行性和均匀性,降低了正常组织的受照射剂量。     

VMAT和IMRT在早期右侧乳腺癌保乳术后放射治疗中的比较剂量学研究

目的:比较三种放射治疗计划对右侧乳腺癌保乳术后放射治疗的剂量学差异。方法:选择11名早期右侧乳腺癌保乳术后的患者,采用处方剂量5000 cGy,分别设计2FIMRT、4FIMRT和2arcVMAT三种计划。使用剂量体积直方图(dose volume histogram,DVH)来分析PTV和OARs的每个评估指标。结果:VMAT和IMRT为所有患者实现了整个乳房的良好的剂量均匀性。VMAT计划比两个IMRT计划有更好的HI,并减少了V107。在乳腺体积>503 mm^3的患者中,2arcVMAT具有更好的HI。2FIMRT在OARs,包括心脏,左、右肺,对侧乳腺,食管,脊髓和肝脏,对比4FIMRT和2arcVMAT,受照射剂量更低,差异具有统计学意义。结论:这三种计划可以满足右侧乳腺癌术后放疗的临床剂量要求,综合靶区剂量分布及OARs进行评分,整体考虑使用2FIMRT可能比其他两种计划具有临床优势。