192Ir在经介入近距离放疗的临床应用

探经介入途径的近距离放射治疗是利用介入放射技术开展的高精度近距离放射治疗,¹⁹²Ir作为一种最常用的放射源,在胆管内的近距离放疗以治疗恶性阻塞性黄疸（MOJ）的作用已被应用于临床,临床研究也已经证实了血管内放射治疗能使血管成形术后再狭窄得到很好的抑制,并能保持血管内支架通畅。本文就¹⁹²Ir在血管和胆道的近距离腔内放疗机制、临床应用加以综述。     

金属内支架胆管引流与放射治疗结合治疗肝外胆管癌

目的回顾性分析局部晚期肝外胆管癌金属内支架胆管引流结合放射治疗的疗效。方法1996年1月至2002年9月收治17例不能手术切除肝外胆管癌患者,先接受金属支架行胆管引流,3例治疗1周内失访,其余14例单纯近距离放疗(近距离照射组,n=5)或外照射(外照射组,n=9,其中包括2例近距离 外照射)。Ir192高剂量率近距离放疗在金属内支架置入当天或隔天治疗。外照射的中位剂量48Gy(14～66Gy),2Gy/次。结果经金属内支架置入结合放疗后,10例黄疸患者中8例黄疸消褪,近距离和外照射对缓解黄疸症状无显著差别。全组中位生存期12个月(5～35个月),1、2年生存率分别为40.8%和8.2%。近距离治疗组与体外照射组的中位生存期、1、2年生存率分别为8个月、40.0%、20.2%和12个月、40.0%、13.3%(χ2=1.10,P=0.29)。结论金属内支架胆管引流结合放射治疗可以显著缓解黄疸症状,高剂量放射治疗可以进一步提高长期生存。     

放射治疗在肝门部胆管癌综合治疗中的作用

肝门部胆管癌是少见的恶性肿瘤。根治性手术是肝门部胆管癌患者获得长期生存的惟一预后因素,但手术切除率很低,术后放射治疗可以提高姑息切除者的局部控制率和长期生存率。绝大多数肝门部胆管癌患者就诊时为不可切除的晚期肿瘤,并伴有不同程度的胆道梗阻症状,各种胆汁引流术可以有效地缓解胆道梗阻,但并不能延长生存期。回顾性临床分析结果表明,在胆汁引流基础上的放射治疗可以进一步缓解症状,延长生存期。放疗方式可以分为单纯外照射、外照射结合腔内放疗以及新的放射技术的应用。有效的肝门部胆管癌综合治疗手段还有待于前瞻性、随机对照的临床试验。     

介入影像医学技术在晚期肝门胆管癌姑息治疗中的应用价值

目的探讨超声引导及数字减影血管造影(DSA)下经皮经肝胆道金属支架植入术在晚期肝门胆管癌伴有梗阻性黄疸治疗中的应用价值。方法回顾性分析2011年1月—2013年1月我院普外中心60例晚期肝门胆管癌伴有恶性梗阻性黄疸及肝功能严重损害患者,先行超声引导下经皮经肝胆道穿刺引流术(PTC),再在DSA下经PTC窦道植入胆道金属支架,将外引流转变为生理性内引流,以改善肝功能。结果 60例患者术前血清总胆红素(386±95)μmol/L,术后第10天,血清总胆红素下降到(189±68)μmol/L(P<0.05),碱性磷酸酶(AKP)与γ-谷氨酰转肽酶(γ-GT)也较术前明显下降(P<0.05),出现并发症7例(11.7%)。结论超声及DSA介导经皮经肝胆道内置引流术是一种治疗晚期肝门胆管癌伴恶性梗阻性黄疸的有效方法,具有安全、简便、经济、可重复等优点。     

经皮肝穿胆管内金属支架置入联合伽玛刀立体定向放射治疗肝门部胆管癌

目的探讨经皮肝穿胆管内金属支架置入联合伽玛刀立体定向放射治疗肝门部胆管癌的疗效及安全性。方法 2005年10月—2007年1月对不愿意手术或不能手术治疗的21例肝门部胆管癌患者,给予经皮肝穿胆管内金属支架置入联合伽玛刀立体定向放射治疗。肿瘤边缘剂量4～8Gy/次,隔日1次,总剂量为40～60 Gy,10～20 d完成。结果患者行经皮肝穿胆管内支架置入术后,血总胆红素及直接胆红素水平均有显著下降。治疗后1~3月复查,1例出现再梗阻,其余血胆红素水平基本上接近正常。肿瘤病灶CR 2例,PR 14例,PD 1例,SD 3例,总有效率(CR+PR)为80%。胆道支架植入术中及术后,出现血压下降4例,放疗不良反应以消化道反应多见,均为I~II度。患者中位生存期为14.5月,1、2年生存率分别为47.6%、14.2%。结论经皮肝穿胆管内支架置入术联合伽玛刀立体定向放射治疗是肝门部胆管癌的一种有效方法,并发症及不良反应少。     

125I粒子近距离治疗在局部晚期腮腺腺样囊性癌的应用

目的单纯应用¹²⁵I放射性粒子组织间植入治疗局部晚期腮腺腺样囊性癌,评估疗效并分析相关预后因素,为局部晚期腮腺腺样囊性癌的治疗提供临床参考。方法回顾性纳入2007年8月至2018年1月于北京大学口腔医院接受单纯应用¹²⁵I放射性粒子植入治疗的局部晚期腮腺腺样囊性癌患者,分析其总生存率(OS)、无进展生存率(PFS)和局部控制率(LCR)及相关影响因素,并观察近、远期放射不良反应情况。结果本组病例共16例(cT4bN0M0),女性患者占多数(11/16,68.7%),中位年龄55.4岁。随访8~104个月(中位时间41.5个月),1、3、5年LCR分别为93.7%、80%、68.7%,1、3、5年OS分别为86.7%、72%、54%;1、3、5年PFS分别为74%、53%、18.9%。9例(56.2%)患者出现不同部位器官转移,以颅内转移、肺转移常见;其中6例术前伴有颅底骨质侵犯者出现多器官转移,肿瘤侵犯颈动脉是影响远处转移的危险因素(HR=12,P=0.045)。共有8例(8/16,50%)患者出现不同程度远期放射性不良反应。结论单纯应用¹²⁵I放射性粒子植入治疗局部晚期腮腺腺样囊性癌的5年局部控制率为68.7%,肿瘤侵犯颅底骨质、包绕颈动脉是其预后不佳与发生多器官远处转移的主要因素。     

晚期胰腺癌介入治疗临床操作指南（试行）（第六版）

<正>一晚期胰腺癌的定义胰腺癌是常见消化系统恶性肿瘤之一。它在最常见癌症中排名第14位,也是目前世界范围内癌症死亡的第7大原因^[1]。根据Globocan最新的统计预测,2020年大约有466000例患者死于胰腺癌^[2]。胰腺癌的也常适用AJCC的TNM分期,如表1所示：临床上多用是否可以手术切除对胰腺癌进行分期：可切除胰腺癌,交界性可切除胰腺癌（可能手术切除,也可能不能手术切除）、局部晚期胰腺癌（不可手术切除）、转移性/晚期胰腺癌（不可手术切除）。所有诊断出来的胰腺癌中,只有不到15%是可能手术的,85%以上都不可手术切除。     

腹腔镜超声在机器人辅助肝门部胆管癌切除术中的应用

目的初步探讨腹腔镜超声在机器人辅助肝门部胆管癌切除术中的应用价值。资料与方法对23例患者行腹腔镜超声引导机器人辅助肝门部胆管癌切除术,术中常规应用腹腔镜超声检查了解肿瘤与周围主要组织的解剖关系,确定肿瘤分期和手术方式,精确引导肿瘤切除,对手术过程和术后情况进行分析总结并与同期18例行开腹根治性切除术患者进行比较。结果 18例患者在腹腔镜超声引导下顺利完成根治性切除术,根治性切除率为78.26(18/23),5例患者在术中腹腔镜超声下发现未预期病变,使其改变手术方式。本组患者手术成功率为100(23/23),手术方式改变率为21.73(5/23),RO切除(病理证实切缘无癌细胞)率为94.44(17/18)优于同期开腹根治性手术切除组61.11(11/18)。无围手术期死亡病例。结论腹腔镜超声在机器人辅助肝门部胆管癌切除术中能指导选择手术方式,并能提高肝门部胆管癌的根治性切除率。     

化疗联合放射治疗在局部晚期鼻咽癌中的应用效果观察

目的 探究局部晚期鼻咽癌患者治疗中采用化疗联合放射治疗的效果。方法 选择2019年5月-2021年5月进行治疗的124例晚期鼻咽癌患者作为研究对象。根据治疗方案不同分组,对照组62例进行单纯放射治疗,试验组62例进行化疗联合放射治疗。比较近期疗效、远期疗效、血清指标、免疫指标、不良反应。结果 试验组近期疗效比对照组好,差异有统计学意义(P<0.05)。试验组无远处转移生存率64.52%比对照组59.68%高,但差异无统计学意义(P>0.05)。治疗前,两组血清正五聚蛋白3(pentraxin 3,PTX3)、转移相关蛋白1(metastasis associated protein 1,MTA1)水平进行组间比较,差异无统计学意义(P>0.05)。治疗后,两组患者PTX3水平比治疗前降低、MTA1水平比治疗前降低,差异有统计学意义(P<0.05)。同时试验组治疗后PTX3水平与MTA1水平均比对照组低,差异有统计学意义(P<0.05)。治疗前,两组免疫指标CD3⁺、CD4⁺/CD8⁺、CD1...     

高位胆管梗阻的介入治疗和近期疗效分析

目的回顾性分析高位梗阻性黄疸患者介入治疗方法及近期疗效。方法100例接受经皮肝穿刺胆汁引流或胆道支架置入治疗的高位梗阻性黄疸患者,其中胆管癌39例,转移瘤22例,肝移植后胆管病变18例,原发性肝癌15例,胆囊癌6例。测定术前,术后3～7d、8～14d血胆红素水平并进行显著性检验。结果79例行单纯外引流或内外引流,21例行胆道支架置入术,所用支架4种31枚。术前血清胆红素含量与术后3～7d胆红素水平差别有显著性(P<0.05),与术后8～14d胆红素水平比较有非常显著的差异(P<0.01)。结论介入治疗高位梗阻性黄疸方法简单、近期疗效满意。     

192Ir高剂量率近距离放疗在结直肠癌术后复发肺内寡转移治疗的初步应用

目的 初步探讨运用近距离放射治疗结直肠癌术后复发肺内寡转移患者的临床疗效,评估其可行性。方法 回顾性收集河北省沧州中西医结合医院自2013年5月至2017年10月入院的结直肠癌术后肺内寡转移患者的病例,10例患者共15个病灶,采用CT引导下¹⁹²Ir高剂量率近距离放射治疗肺部转移病灶。应用定位CT扫描图像,将插植针置入肿瘤,在CT引导下调整插植针至合适位置,将插植完成后图像传至计划系统,勾画靶区和危及器官,进行三维重建,制定放疗计划,计划通过后实施治疗,采用单次放疗,剂量20 Gy。结果 10例患者均顺利完成治疗,1级不良事件发生率30%,其中1例为轻度咳嗽,2例为痰中带血,无严重不良事件发生。治疗后1年肿瘤局部控制率（LC）为93.3%,其中1例患者治疗6个月后局部进展,再次实施近距离放射治疗,中位无进展生存期（PFS）为8.5个月,中位总生存（OS）为14.7个月。结论 对于无法手术的结直肠癌术后复发肺内寡转移患者来说,近距离放射治疗是一种可选择的安全可行的治疗方式,短期内可重复治疗,不良反应小,肿瘤局部控制率佳。     

瓦里安高剂量率铱源剂量学参数的蒙特卡罗模拟研究

目的 采用美国医学物理师学会（AAPM）和欧洲放射治疗和肿瘤学会（ESTRO）推荐的蒙特卡罗方法对瓦里安GammaMed Plus HDR ¹⁹²Ir源的剂量学参数进行模拟研究。方法 基于EGSnrc蒙特卡罗软件,建立该型号¹⁹²Ir源精确的计算模型。采用公式推导、双线性插值及单位转换等方法,分别得到了单位活度空气比释动能强度、剂量率常数、径向剂量函数以及各向异性函数,并将结果与文献报道数据进行分析比较。结果 研究得到的单位活度空气比释动能强度为9.781×10^-8 U/Bq,剂量率参数为1.113 cGy·h^-1·U^-1,与文献报道的相差在0.4%以内。本研究的径向剂量函数、各向异性函数与文献数据能较好吻合。结论 基于EGSnrc蒙特卡罗软件能对¹⁹²Ir源剂量学特性进行定量研究,这将为进一步研究后装剂量分布,精确评价临床放疗剂量提供理论依据。     

Comparison of high-dose rate prostate brachytherapy dose distributions with iridium-192, ytterbium-169, and thulium-170 sources

Purpose

Recent studies have identified that among different available radionuclides, the dose characteristics and shielding properties of ytterbium-169 (¹⁶⁹Yb) and thulium-170 (¹⁷⁰Tm) may suit high-dose rate (HDR) brachytherapy needs. The purpose of this work was to compare clinically optimized dose distributions using proposed ¹⁶⁹Yb and ¹⁷⁰Tm HDR sources with the clinical dose distribution from a standard microSelectron V2 HDR iridium-192 (¹⁹²Ir) brachytherapy source (Nucletron B.V., Veenendaal, The Netherlands).

Methods and materials

CT-based treatment plans of 10 patients having prostate volumes ranging from 17 to 92 cm³ were studied retrospectively. Clinical treatment of these patients involved 16 catheters and a microSelectron V2 HDR ¹⁹²Ir source. All dose plans were generated with inverse planning simulated annealing optimization algorithm. Dose objectives used for the ¹⁹²Ir radionuclide source were used for the other two radionuclides. The dose objective parameters were adjusted to obtain the same clinical target (prostate) volume coverage as the original ¹⁹²Ir radionuclide plan. A complete set of dosimetric indices was used to compare the plans from different radionuclides. A pairwise statistical analysis was also performed.

Results and conclusions

All the dose distributions optimized with specific ¹⁹²Ir, ¹⁶⁹Yb, and ¹⁷⁰Tm sources satisfied the standard clinical criteria for HDR prostate implants, such as those for the Radiation Therapy Oncology Group clinical trial 0321, for combined HDR and external beam treatment for prostate adenocarcinoma. For equivalent clinical target volume dose coverage, the specific ¹⁶⁹Yb and ¹⁷⁰Tm sources resulted in a statistically significant dose reduction to organs at risk compared with microSelectron V2 HDR ¹⁹²Ir source. This study indicates that a ¹⁷⁰Tm or ¹⁶⁹Yb radionuclide source may be an alternative to the ¹⁹²Ir radionuclide sources in HDR brachytherapy.     

125I放射性粒子治疗复发性腮腺癌24例临床分析

目的 探讨应用¹²⁵I放射性粒子组织间植入近距离放疗在腮腺区复发恶性肿瘤的临床应用及疗效。方法 回顾性分析2006年至2013年,就诊于北京大学口腔医院,经放射性¹²⁵I粒子组织间植入治疗的24例复发腮腺腺源性恶性肿瘤患者的临床资料,所有患者均为临床Ⅳ期。定期随访,观察并分析局部控制率,生存率及不良反应。结果 24例复发肿瘤患者,随访时间4至59个月。6例局部控制失败,10例患者死亡。患者1年、3年生存率分别为74.8%和39.3%,1年、3年无进展生存率分别为74.8%和31.5%,1年、3年局部控制率分别为82.0%和69.4%。无3级以上放射性损伤。结论 单纯放射性¹²⁵I粒子组织间植入治疗,对于无法手术切除的复发腮腺恶性肿瘤患者,为可选治疗方式,局部控制率较好。     

Clinical outcomes of high-dose-rate brachytherapy and external beam radiotherapy in the management of clinically localized prostate cancer

PurposeTo report prostate-specific antigen (PSA) relapse-free survival and treatment-related toxicity outcomes after combining high-dose-rate (HDR) brachytherapy with external beam radiotherapy (EBRT) for patients with clinically localized prostate cancer.Methods and MaterialsBetween 1998 and 2009, 229 patients were treated with HDR brachytherapy followed 3 weeks later by supplemental EBRT. The HDR brachytherapy boost consisted of three fractions of ¹⁹²Ir (5.5–7.5 Gy per fraction), and EBRT consisted of intensity-modulated radiotherapy delivering an additional 45.0–50.4 Gy directed to the prostate gland and seminal vesicles. Median follow-up was 61 months.ResultsSeven-year PSA relapse-free survival for low-, intermediate-, and high-risk patients were 95%, 90%, and 57%, respectively (p < 0.001). Among high-risk patients treated with biological equivalent doses in excess of 190 Gy, 7-year PSA relapse-free survival was 81%. In multivariate analysis, Gleason scores of ≥8 predicted for increased risk of biochemical failure, whereas the use of short-term neoadjuvant androgen deprivation therapy did not influence tumor-control outcomes even among intermediate- or high-risk patients. Seven-year incidence of distant metastases for low-, intermediate-, and high-risk patients were 5%, 3%, and 17%, respectively. Seven-year incidence of late Grade 2 and 3 genitourinary toxicities were 22.1% and 4.9%, respectively and the 7-year incidence of Grade 2 and 3 gastrointestinal toxicities were 1% and 0.4%, respectively.ConclusionHDR prostate brachytherapy in conjunction with supplemental EBRT results in excellent biochemical relapse-free survival rates with a low incidence of severe late genitourinary or gastrointestinal toxicities. The use of short-term neoadjuvant androgen deprivation did not influence long-term biochemical tumor control in this cohort.     

妇科肿瘤后装逆向调强放疗的初步临床研究

目的 评价后装逆向调强放疗技术在妇科肿瘤治疗中的临床价值。方法 选取20例Ⅰ~Ⅲ期宫颈癌患者,采用随机数字表和余数分组的方法分为A、B两组,各10例。A组病例行后装逆向调强放疗,B组病例行三维适形后装放疗。分析两组患者的靶区剂量分布、危及器官受量、放疗并发症及近期疗效。 结果 A组靶区剂量均匀度指数（HI）为52.43±0.45,好于B组的46.37±1.45（t=0.92,P<0.05）;A组直肠、膀胱最大受量D_max分别比B组低37%、35%（t=1.34、1.39,P<0.05）,A组75%处方剂量的直肠、膀胱受照体积V₇₅约为B组的1/2（t=1.23、1.13,P<0.05）;A组局部控制率96%好于B组的 93%（t=1.25,P<0.05）。结论 后装逆向调强放疗优于三维适形后装放疗,值得在妇科肿瘤治疗中广泛应用。     

American Brachytherapy Society–Groupe Européen de Curiethérapie–European Society of Therapeutic Radiation Oncology (ABS-GEC-ESTRO) consensus statement for penile brachytherapy

PurposeTo develop a consensus statement between the American Brachytherapy Society (ABS) and Groupe Européen de Curiethérapie/European Society for Therapeutic Radiation and Oncology (GEC-ESTRO) for the use of brachytherapy in the primary management of carcinoma of the penis.Methods and MaterialsThe American Brachytherapy Society and Groupe Européen de Curiethérapie/European Society for Therapeutic Radiation and Oncology convened a group of expert practitioners and physicists to develop a statement for the use of ¹⁹²Ir in low-dose-rate (LDR), pulse-dose-rate, and high-dose-rate (HDR) brachytherapy for penile cancer.ResultsDecades of brachytherapy experience with LDR ¹⁹²Ir wire and pulse-dose-rate ¹⁹²Ir sources for this rare malignancy indicate a penile preservation rate of 70% at 10 years postimplant. Chief morbidities remain stenosis of the urethral meatus and soft tissue ulceration at the primary site. Nonhealing ulceration can be successfully managed with various measures including hyperbaric oxygen treatment. HDR brachytherapy implant procedures are technically similar to LDR. The optimal HDR dose and fractionation schemes are being developed.ConclusionsThe good tumor control rates, acceptable morbidity, and functional organ preservation warrant recommendation of brachytherapy as the initial treatment for invasive T1, T2, and selected T3 penile cancers.     

改良髂内动脉化疗联合放疗治疗Ⅲ～Ⅳa期子宫颈癌32例

目的探讨改良髂内动脉化疗联合放疗治疗Ⅲ～Ⅳa期宫颈癌的疗效。方法回顾分析2005年5月至2009年8月在广东省茂名农垦医院妇产科、肿瘤放疗科住院治疗70例Ⅲ～Ⅳa期子宫颈癌患者的完整资料,其中行改良髂内动脉化疗术联合放疗（介入+放疗,A组）患者32例,单纯放疗（B组）患者38例。A组患者采用Seldinger技术穿刺右股动脉,先行右子宫动脉化疗栓塞术;再超选至左髂内动脉化疗,保留导管连续化疗3 d;化疗药有顺铂、氟尿嘧啶。放疗用直线加速器远距离外照射+¹⁹²Ir高剂量率腔内放疗。B组只进行外照射和腔内放疗,剂量稍增减。结果 1年生存率比较,A组为78.1%,高于B组（55.3%,P<0.05）;3年生存率比较,A组为59.4%,高于B组34.2%（P<0.05）;两组1、3年生存率比较差异有统计学意义;5年生存率两组比较差异无统计学意义（P>0.05）。两组放疗并发症发生率比较,差异无统计学意义（P>0.05）。结论改良髂内动脉化疗术联合放疗对Ⅲ～Ⅳa期宫颈癌的近期疗效较单纯放疗为好,生存质量较高;两组5年生存率比较则差异无统计学意义。     

Radiation recall reaction with docetaxel administration after accelerated partial breast irradiation with electronic brachytherapy

PurposeAccelerated partial breast irradiation (APBI) offers several advantages over whole breast irradiation. Electronic brachytherapy may further reduce barriers to breast conserving therapy by making APBI more available. However, its toxicity profile is not well characterized.Methods and MaterialsA 60-year-old woman was treated with APBI using Axxent (Xoft, Sunnyvale, CA) electronic brachytherapy. One month after APBI, a cycle of docetaxel and cyclophosphamide was given. Within 3 weeks, the patient developed an ulcerative radiation recall reaction in the skin overlying the lumpectomy cavity. To investigate this toxicity, the skin dose from electronic brachytherapy was compared with the dose that would have been delivered by an iridium-192 (¹⁹²Ir) source. Additionally, a dose equivalent was estimated by adjusting for the increased relative biologic effectiveness (RBE) of low energy photons generated by the electronic source.ResultsUsing electronic brachytherapy, the skin dose was 537 cGy per fraction compared with 470 cGy for an ¹⁹²Ir source. Given an RBE for a 40 kV source of 1.28 compared with ¹⁹²Ir, the equivalent dose at the skin for an electronic source was 687 cGy-equivalents, a 46% increase.ConclusionsWe present a case of an ulcerative radiation recall reaction in a patient receiving APBI with electronic brachytherapy followed by chemotherapy. Our analysis shows that the use of electronic brachytherapy resulted in the deposition of significantly higher equivalent dose at the skin compared with ¹⁹²Ir. These findings suggest that standard guidelines (e.g., surface-to-skin distance) that apply to ¹⁹²Ir-based balloon brachytherapy may not be applicable to electronic brachytherapy.     

Brachytherapy and percutaneous stenting in the treatment of cholangiocarcinoma: a prospective randomised study

PURPOSE: To evaluate the effect of radiation therapy including intraluminal brachytherapy with iridium-192 on survival of patients with malignant biliary strictures (cholangiocarcinoma, histologically improved) treated with metallic stent in a prospective randomised study. METHOD AND MATERIALS: In the prospective randomised study, 21 patients with cholangiocarcinoma were treated with implantation of percutaneous stents followed with intraluminal Ir-192 brachytherapy (mean dose 30 Gy) and external radiotherapy (mean dose 50 Gy) and 21 patients were treated only with stents insertion. We did not find any statistically significant differences in age and tumor localization between these two groups of patients. RESULTS: All the patients died. In the group of patients treated with brachytherapy and with stent implantation, the mean survival time was 387.9 days. In the group of patients treated only with stent insertion the mean survival was 298 days. In effort to eliminate possible effect of external radiotherapy we treated the control group of eight patients with cholangiocarcinoma by stent insertion and brachytherapy only. CONCLUSION: Our results show that combined radiation therapy could extend the survival in the patients with cholangiocarcinoma obstruction.