立体定向放疗与常规放疗结合治疗高分级脑胶质瘤

目的采用立体定向放疗与常规放疗结合治疗高分级脑胶质瘤,分析其疗效,探讨其影响预后的因素.方法自1998年12月至2005年1月用立体定向放疗与常规放疗结合的方法治疗高分级脑胶质瘤106例.立体定向放疗针对GTV追加剂量,每次5～7Gy,共计5～7次,常规放疗主要针对亚临床病变,一般剂量为50Gy.寿命表法统计生存率.结果本组病例1、3年生存率分别为66.2%和27.0%.Ⅲ级胶质瘤较Ⅳ级的患者预后好,预后与年龄、肿瘤部位和治疗剂量等其他因素无关.结论立体定向放疗加常规放疗治疗高分级脑胶质瘤既发挥了放射物理剂量分布的优点,又符合放射生物学原则,较以往治疗提高了患者的生存机会.     

立体定向放射治疗脑干区肿瘤适应证及疗效分析

目的探讨立体定向放疗治疗(stereotactic radiotherapy,SRT)脑干区肿瘤适应证、方法及临床疗效。方法应用立体定向放疗治疗(SRT)脑干区肿瘤21例;其中胶质瘤9例、血管瘤4例、转移瘤4例、胶质瘤手术后残留4例。治疗方法采用如下3种方案:1外照射加SRT追量,包括8例高级别胶质瘤(3~4)和2例转移瘤。在外照射量30~36Gy基础上,SRT追量18~30Gy。2低级别胶质瘤(1~2)术后残留及复发,共7例。SRT靶区剂量40~45Gy,分8~12次、每天一次。3良性肿瘤的4例;分别为动静脉瘤(AVM s)及血管瘤(CA)2例。靶区剂量35~40Gy,分4~6次,隔天治疗。结果治疗后12个月生存率20例,临床症状近期好转率20例,死亡1例。立体定向放射治疗脑干肿瘤2年生存率达85.7%。结论立体定向放射治疗脑干区肿瘤安全有效:病灶剂量、分割治疗方式及适应证选择是关键。     

恶性胶质瘤外照射加X刀推量治疗模式的探讨

目的恶性胶质瘤是预后极差的常见颅内恶性肿瘤，本研究报告恶性胶质瘤外照射加X刀推量的治疗模式的疗效。方法对15例确诊为恶性胶质瘤的患者进行了外照射加X刀推量的治疗。外照射50Gy／25F／5W后，紧接着用X刀推量7～10Gy。结果治疗后近期效果满意，无严重神经功能障碍并发症。3例患者分别死于X刀后4、5、11月，余均健在。全组仅1例在治疗后3月出现脑水肿，给予对症治疗后缓解。余患者无严重的放射反应。结论恶性胶质瘤外照射加X刀推量的治疗模式是可行的．疗效较好。     

不能手术的脑肿瘤患者分次立体定向放射治疗研究

目的探讨不能手术的脑肿瘤患者采用分次立体定向放射治疗(fractionated stereotactic radiotherapy,FSRT)的价值。方法采用X线FSRT法治疗15例不能手术的脑肿瘤患者。所有病例根据临床表现及MRI和/或CT确诊。其中4例采用单纯立体定向放射治疗,11例采用立体定向放射治疗 常规放射治疗。常规外照射剂量30.0~52.0 Gy。FSRT准直器2.5~5.0 cm,靶体积0.9~39.6 cm3,分次剂量5.0~15.0 Gy,总剂量15.0~50.0 Gy。1个靶中心参考剂量线为70%~90%,2个靶中心参考剂量线为50%。采用4~6个弧非共面等中心旋转照射。结果治疗后生存期2~105个月,中位生存期30.8个月。急性神经毒性反应较轻,各有2、1、1例出现Ⅰ、Ⅱ、Ⅲ级晚期神经损伤,无Ⅳ级晚期神经损伤。结论对于不能手术的脑肿瘤患者行X线FSRT是安全有效的。     

小儿脑胶质瘤术后残留灶立体定向适形放射治疗

目的评价小儿脑胶质瘤术后残留灶的立体定向适形放射治疗的疗效。方法对28例有残留灶患者采用6MVX线多角度适形放疗,总剂量45～55Gy。结果6个月、1年、2年生存率分别为100%、92%、82%,未发现放射性脑损伤。结论立体定向适形放疗小儿脑胶质瘤术后残留,是一种安全、有效的方法。     

常规加调强适形推量放疗联合化疗治疗术后胶质肉瘤

目的探讨胶质肉瘤术后常规加调强适形(IMRT)推量放疗联合化疗的疗效。方法回顾性分析7例胶质肉瘤术后应用常规加IMRT推量放疗联合化疗病人的治疗经验。放疗总剂量为60Gy,其中常规放疗40Gy,后程IMRT20Gy。均行化疗,其中采用替莫唑胺方案3例,司莫司汀加替尼泊苷方案4例。结果本组急性治疗反应均为1～2级,治疗后均出现局部进展,中位局部进展时间为放疗开始后12.0个月,平均进展时间为13.7个月。并发脑内播散和肺转移1例。中位生存时间18.0个月,平均生存时间20.5个月。结论术后常规加IMRT推量放疗联合化疗治疗胶质肉瘤,病人对治疗反应可以耐受,生存时间略长于文献报道。     

术后射波刀立体定向放疗联合化疗治疗高级别胶质瘤研究

目的分析高级别胶质瘤术后射波刀立体定向放射治疗、普通直线加速器同步放射治疗加化学治疗的临床疗效。方法将31例高级别胶质瘤患者分为射波刀立体定向放疗(射波刀)组16例、普通直线加速器放射治疗同步加化学治疗(普放)组15例。射波刀组用立体定向放疗技术,放疗剂量11.3Gy/天,连续3天,总剂量33.9Gy;普放组用调强放疗技术,2Gy/天·次,30次,总剂量60Gy,周一~周五治疗,期间连用替莫唑胺42天。两组均在放疗后用替莫唑胺辅助化疗6个疗程。用Kaplan-Meier法和COX模型进行生存分析。结果随访36~47(中位41)个月,射波刀组和普放组中位生存时间分别是15.55、14.7个月,1、2、3年生存率分别为56.3%、43.8%、37.5%及53.4%、40.2%、40.2%。两组对比,生存无明显差异(P0.05)。结论高级别胶质瘤术后,采用射波刀立体定向放射治疗或者普通直线加速器同步放射治疗加化疗,后续联合辅助化疗,两者疗效无明显差别。     

高级别脑胶质瘤术后低分割同期推量调强放疗的初步研究

目的探讨高级别脑胶质瘤术后采用低分割同期推量调强放疗的临床疗效、安全性及预后影响因素。方法 2013年8月至2016年3月期间我科共治疗术后病理证实为高级别脑胶质细胞瘤的患者37例,术后放疗统一采用低分割同期推量调强放疗方式,放疗期间同步口服替莫唑胺化疗,放疗后4 w开始行辅助替莫唑胺化疗共6个周期。结果 1年、2年、3年总生存率分别为81.1%、77.4%、62.1%,其中Ⅳ级分别为63.2%、56.1%、42.1%;1年、2年、3年无疾病进展生存率分别为71.0%、64.5%、38.7%,其中Ⅳ级分别为57.4%、50.2%、25.1%,Ⅲ级1年、2年无疾病进展生存率分别为83.3%、64.5%。单因素分析显示,年龄、病理分级、是否同步替莫唑胺与总生存率(overall survival,OS)相关。多因素分析提示,是否同步替莫唑胺、病理分级与OS相关。全组患者无4级以上急性不良反应,多为1~2级,经对症处理均可缓解。结论低分割同步推量调强放疗方式治疗高级别脑胶质瘤能够获得理想的近期临床疗效,且不良反应耐受度好,是一种有效的治疗方式。患者年龄、病理分级、是否同步替莫唑胺是重要的预后因素。     

分次立体放疗和放射外科治疗颅内肿瘤对照分析

目的　探讨分次立体放疗和放射外科治疗颅内肿瘤的临床疗效和并发症。方法　采用立体定向系统和三维治疗计划 ,对随机分为两组的病例进行治疗 ,采用分次立体放疗 (FSRT) 92例 ,次数为 3～ 10次 ,每次剂量为 3～ 10Gy ,总剂量为 36～ 5 2Gy ,边缘剂量曲线为 6 5 %～ 90 %;放射外科治疗 (SRS) 10 7例 ,采用单次治疗 ,每次剂量为 18～ 2 8Gy ,边缘剂量曲线为 6 0 %～ 90 %。结果　经过 2～ 4年随访 ,FSRT组总有效率 81.5 %(75 / 92 ) ,SRS组总有效率 6 9.2 %(74/ 10 7) ,两组对照疗效无显著差异。两组对胶质瘤的治疗进行对照分析 ,FSRT组CR +PR为83.7%(36 / 43) ,SRS为 5 6 .3%(2 7/ 48) ,两组经 χ2 检验有显著差异 (P <0 .0 1)。两组治疗后出现的并发症主要为脑水肿、神经功能受损和放射性脑坏死。FSRT组出现脑水肿有 2 5例 ,SRS组 6 7例 ,两组对照有显著差异 (P <0 .0 0 1) ;FSRT组出现神经功能受损有 5例 ,SRS组 17例 ,两组对照有显著差异 (P <0 .0 0 1) ;FSRT组出现放射性脑坏死有 2例 ,SRS组有 9例。结论　分次立体放射治疗与放射外科治疗颅内肿瘤均有较好疗效 ,分次立体放射治疗后并发症较少 ,对胶质瘤的治疗采用分次方法可能更好。     

调强放疗联合替莫唑胺治疗丘脑胶质瘤

目的探讨调强放疗(IMRT)联合替莫唑胺(TMZ)化疗治疗丘脑胶质瘤的疗效,分析影响预后的因素。方法回顾性分析2005年1月~2010年12月联合放化疗治疗的25例丘脑胶质瘤。所有病例治疗前均行立体定向活检明确病理诊断,其中低级别胶质瘤(WHOⅡ级)11例,高级别胶质瘤(WHOⅢ~Ⅴ级)14例。记录治疗反应,计算总体生存率(OS)和无疾病进展生存率(PFS),并应用COX回归模型进行多因素预后分析。结果本组病例急性治疗反应多为Ⅰ~Ⅱ级,没有Ⅲ级以上的反应。同期放化疗结束时,中位KPS上升20。6个月、1年和2年的OS分别为84.0%、52.0%和22.2%,PFS分别为76.0%、33.0%和19.8%,中位生存时间为13.0个月(95%CI 9.5~16.5),中位无进展生存时间9.0个月(95%CI6.9~11.1)。多因素分析显示,性别、年龄、病程以及放疗前KPS与预后无显著关系,病理级别与预后显著相关。结论调强放疗联合TMZ化疗治疗丘脑胶质瘤的急性反应小,患者能够耐受,近期疗效有改善,但长期疗效仍不理想。     

Conventional external radiotherapy in the management of clivus chordomas with overt residual disease

Cranial chordomas are uncommon tumors accounting for less than 1% of all intracranial neoplasms. Although they are slowly growing, rarely metastasising tumors, cranial chordomas are challenging to treat due to their critical location, invasive nature and aggressive recurrence. The aim of this retrospective study was to evaluate the role of conventional irradiation in the treatment of clival chordomas with overt residual disease after incomplete surgery. Between January 1979 and December 1997, 18 patients with histologically confirmed clival chordoma were treated with radiotherapy. Median age at the time of diagnosis was 32 years. The mean duration of the symptoms before diagnosis was 33.9 months. Median tumor diameter at initial presentation was 5 cm (range, 3–7 cm). The type of surgical procedure was subtotal excision in 11 patients and biopsy in 7. Radiation treatment was delivered with megavoltage units, and total doses between 50 Gy and 64 Gy (median, 60 Gy) were administered with conventional daily fractions. One patient received additional 12.50 Gy with linear accelerator-based stereotactic radiosurgery after subtotal excision and external irradiation. The mean follow-up time was 43.2 months. Overall survival at 5 years was 35%. Eleven patients showed progression after radiotherapy. The median time to progression after radiotherapy was 40.8 months (38.4–43.2) with a 5-year progression-free survival of 23%. Five patients (29.4%) showed symptomatic relief after radiotherapy while persistent symptoms were recorded for 6 patients. Incomplete surgery and conventional external radiotherapy with a dose of around 60 Gy seem to be inadequate in the treatment of clival chordomas. Received: 31 March 2000 / Accepted in revised form: 11 July 2000     

Permanent I-125 brain stem implants in children

Between 1988 and 1997, 28 children have had iodine-125 implants for CNS tumors performed in our institution. Ten had stereotactic implantation in the brain stem region, and nine had the diagnosis of brain stem glioma (8 diffuse pontine, 1 midbrain tumor). Their ages ranged from 1.8 to 12 years. All patients had histological confirmation of malignancy (7 high-grade glioma, 2 low-grade glioma, 1 PNET). Diffuse pontine glioma patients received external beam radiation (50 Gy) followed by a fractionated stereotactic boost of 3 Gy×4 fractions. After 4–6 weeks, patients were reevaluated for stereotactic interstitial I-125 therapy. The planned implant dose was 82.9 Gy to the enhancing tumor (4 cGy per h). Preliminary results indicated that no surgical complications were associated with the catheter placement. Four patients have died (7–9 months from diagnosis) and four patients remain alive (5–38 months from diagnosis, median 10 months). Two autopsies confirmed the presence of progressive glioblastoma multiforme and intralesional necrosis. In one patient who received an implant alone for midbrain LGA, necrosis without tumor was found on biopsy after 36 months. He was successfully treated with hyperbaric oxygen therapy. The implementation of permanent I-125 implants appears to have a role in the management of pediatric CNS malignancy. This study confirms the results of previous reports regarding the safety of stereotactic interstitial brachytherapy in the brain stem. Tumor control for patients with high-grade brain stem glioma remains poor even with high focal radiation doses. Received: 10 May 1998     

Local control of high-grade gliomas with limited volume irradiation versus whole brain irradiation

INTRODUCTION: To evaluate the role of limited field radiation therapy in the management of high-grade gliomas and glioblastoma multiforme (GBM). MATERIAL AND METHODS: From July '96 to January '98, 50 newly diagnosed patients of high-grade gliomas (Grade III and IV) and glioblastoma multiforme who underwent surgery in the form of partial, sub-total or near-total excision as the primary treatment were enrolled in this study. The patients were randomized to receive two different postoperative external radiation protocols, Study Group A: Localized field external radiotherapy 50 Gy/25#/5 wks followed by Boost 10 Gy/5#/1 wk, Control Group B: Whole brain external radiotherapy 40 Gy/20#/4 wks followed by Boost 20 Gy/10#/2 wks by localized field. RESULTS: 20/25 (80%) patients in the study group and 14/25 (56%) patients in the control group showed improvement in their Karnofsky Performance Status (KPS). Thus a significant difference in the performance status was noted in favor of limited field irradiation. No significant difference in the local response was seen between the two groups after radiotherapy. Six months progression-free survival of the study group was 44% as compared to 26% in the control group. Six months overall survival was 66.67% in the study group and 50.72% in the control group (P<0.01). Maximum recurrences were noticed within 2 cm of the original tumor margin in both the groups. CONCLUSIONS: Although local control and survival of the patient in both the groups were same, performance status definitely improved in patients treated with localized field irradiation only.     

Role of stereotactic radiosurgery and fractionated stereotactic radiotherapy in the management of intracranial ependymoma

Ependymoma accounts for 5-10% of all childhood CNS tumors and less than 5% of intracranial tumors in adults. Ependymomas typically have a sharp tumor-brain parenchyma interface and this characteristic lends itself well to stereotactic radiation delivery. Data on the use of stereotactic radiosurgery (SRS) and fractionated stereotactic radiotherapy (FSRT) for ependymoma in various settings have emerged over the past 10 years. SRS has been used in recurrent disease and as a boost after external beam radiation therapy. FSRT has been used in pediatric brain tumors and can potentially limit the long-term toxicities associated with radiation therapy by reducing the amount of normal brain parenchyma treated. Long-term follow-up is needed to determine the long-term efficacy and toxicities associated with these treatment modalities.     

Stereotactic radiotherapy for cerebral metastases using CyberKnife

During recent decade development of frameless techniques of fixation enabled introduction of stereotactic radiation therapy in metastatic brain lesions and made possible irradiation of large foci involving or proximal to eloquent and critical brain areas. This paper focuses on comparative analysis of effectiveness of hypofractionation (HRST) and radiosurgery (SRS) using CyberKnife system in cerebral metastases. Since November 2009 till June 2011 54 patients with cerebral metastases were treated using CyberKnife system. Age of patients ranged between 25 and 77 years (mean 54 years). 16 patients received radiosurgical treatment (mean total dose was 22.5-35 Gy, number of fractions varied from 2 to 7, mean volume of irradiation was 22.69 cm3) and 8 patients were treated by HRST with RS of selected foci (mean total dose reached 23 and 30 Gy, mean volume of irradiation was 1.02 cm3 and 11.19 cm3, respectively). Indices of overall regression and stabilization of disease for HRST and SRS groups were 81% and 79%, respectively. With mean follow-up period of 12.3 (1-16.1) months median survival for SRS and HRST reached 6.38 (1-15.8) and 6.2 (0.2-16.1) months and median recurrence-free survival was 3.6 (1-13.6) and 5.5 (2-14.2) months, respectively. Obtained results confirmed biological advantages of fractionated stereotactic radiotherapy of large cerebral tumors in comparison with radiosurgery. Prospective studies with rigid criteria of inclusion are required to determine optimal dose/volume/fractionation interrelations in stereotactic radiation treatment of cerebral metastases.     

The value of stereotactic biopsy and percutaneous radiation in therapy of glioblastoma multiforme]

The concept of cytoreductive surgery in the treatment of glioblastoma multiforme is controversial. A retrospective study was carried out between 1986 and 1991 to analyze the results of stereotactic biopsy followed by supportive treatment (n = 49), incomplete radiation therapy (less than 40 Gy, n = 26), and complete radiation therapy (greater than or equal to 40 Gy, n = 58) and to compare with those of resection plus irradiation described in the literature. The patients treated with supportive care and an incomplete course of irradiation had a median survival of less than 8 weeks. For the patients who completed the radiation therapy the median survival was 32 weeks. In patients with midline shift the Karnofsky scores worsened more often during the course of radiation therapy, or therapy had to be terminated prematurely. The most important prognostic determinant was the patient's age. A comparison of survival rates in our series with those reported by other authors for patients who received tumor resection with subsequent irradiation yielded no significant difference. This would appear to cast doubt on the concept of cytoreductive surgery. The treatment of choice for patients with glioblastoma multiforme is at present radiation therapy. There is no question about the necessity of decompressive surgery whenever it is required to perform radiation therapy for severe space-occupying lesions and when it can be performed without causing new neurological deficits.     

Radiation therapy in the management of pediatric craniopharyngiomas—a review

Craniopharyngiomas are benign suprasellar tumors that arise from epithelial remnants of the Rathkes pouch. The two standard treatment options are primary total resection or limited surgery followed by external beam radiation. The 10- and 20-year progression-free survival rates following limited surgery and radiation therapy are superior to those achieved by primary surgery alone. The side effect profiles for these two treatment approaches are different. Following total resection there is a very high incidence of panhypopituitarism requiring lifelong multiple hormone replacement therapy. The other side effects include potential damage to adjacent structures such as optic chiasm, vasculature and hypothalamus. Following limited surgery and radiation therapy the incidence of endocrine deficits is significantly lower compared to radical surgery, as is the risk of neurovascular and hypothalamic injury. Optic neuropathy and brain necrosis are rare in modern radiation therapy series. Second malignant neoplasms, although rare, can occur. In children with recurrent craniopharyngiomas following radical surgery, the recommended salvage treatment is radiation therapy, as further surgical attempts at salvage are associated with high relapse rates and increased morbidity and mortality. There have been significant technological advances in the field of radiation treatment planning and delivery that have great potential for reducing the incidence of long-term irradiation sequelae in the developing brain. The general availability of megavoltage linear accelerators and modern radiotherapy innovations such as three-dimensional conformal radiation treatment (3D CRT), stereotactic radiosurgery (SRS), stereotactic radiotherapy (SRT), and intensity modulated radiation therapy (IMRT) should further limit the rate of complications and improve cure rates in children with primary or recurrent craniopharyngioma.     

肿瘤切除程度及术后放、化疗对脑胶质瘤疗效影响的临床研究

目的探讨肿瘤切除程度的不同及术后不同辅助治疗方法对脑胶质瘤疗效的影响。方法对319例临床资料完整的脑胶质瘤患者进行回顾性研究，分别从肿瘤切除程度及术后辅助治疗方法两个方面探讨对低分级胶质瘤和高分级胶质瘤治疗效果的影响。根据随访结果确定1、3、5年生存率，采用Х^2检验对组间生存率差异进行比较分析。结果低分级胶质瘤患者：肿瘤全切组与未全切组1、3、5年生存率差异无显著性意义；术后早期放疗组较延期放疗组1年生存率差异无显著性意义，3、5年生存率降低。其差异有显著性意义。高分级胶质瘤患者：肿瘤全切组较未全切组1、3、5年生存率高。其差异有显著性意义；术后放、化联合治疗组较单纯放疗组1、3、5年生存率高。其差异有显著性意义。结论手术治疗脑胶质瘤。对于低分级胶质瘤应在保留重要神经功能的前提下切除肿瘤，高分级胶质瘤应尽可能扩大切除；低分级胶质瘤术后应延期行放疗，以肿瘤复发或生长增快时为宜，高分级胶质瘤术后采用放、化联合治疗较单纯放疗更为有效。     

92例高级别胶质瘤患者术后生存分析

目的探讨影响高级别胶质瘤术后生存的因素。方法对2014年1月至2016年8月首诊确定为高级别胶质瘤(WHO III-IV级)的92例患者采用Kaplan-Meier法分析生存率,Log-rank检验进行单因素分析,Cox回归模型进行多因素分析。结果中位生存期为15个月,中位无进展生存期为8个月,肿瘤全切率为72. 83%,1年、2年、3年、4年的生存率分别为56. 5%,35. 9%,30. 4%,25. 4%。Log-rank单因素分析表明高级别胶质瘤预后与年龄、术前生活质量评分、肿瘤大小、数目、是否累及多个皮层脑叶或者运动功能区、切除程度、病理级别、异柠檬酸脱氢酶基因是否突变、O-6-甲基鸟嘌呤DNA甲基转移酶基因启动子是否甲基化、Ki 67指数、术后是否进行放疗和/或化疗以及所进行的放化疗的方式、复发后是否积极治疗相关(P 0. 05)。引入检验水准(α=0. 01),COX多因素分析表明年龄、肿瘤切除程度、术后是否进行放疗和/或化疗是影响高级别胶质瘤预后的独立危险因素(P 0. 01)。结论发病年龄65岁、肿瘤全切除、术后进行同步放化疗和辅助化疗的高级别胶质瘤患者预后较好。     

放、化疗同步治疗高级别胶质瘤

目的比较单纯放疗与放疗加替莫唑胺（放疗同时和放疗后给药）治疗高级别胶质瘤的局控率、生存率及不良反应。方法对52例首次术后的问变性星形及胶质母细胞瘤随机分为接受单纯放疗（分次照射局部放疗，2Gy／d，5d／w，共持续6W，总剂量60Gy）、放疗加每天持续的替莫唑胺治疗（75mg／m^2／d），7d／w，从放疗开始到放疗结束）以及6个周期的替莫唑胺辅助治疗（150～200mg／m^2，治疗5d，每28d为一个疗程）。每组26例。主要研究目标为整体生存率。结果放疗加替莫唑胺（RT—TMZ）组与单纯放疗（RT）组总有效率（CR＋PR）分别为76．9％和50．0％；6个月无进展生存率分别为73．1％和46．2％；中位无进展生存期分别为8．8个月和6．2个月（P〈0．05）。1年累积局部复发率分别为42．3％和76．9％；1年无复发生存率分别为57．7％和23．1％，1年生存率分别为65．4％和30．8％（P〈0．05）。RT—TMZ组常见不良反应是恶心，呕吐，白细胞和血小板下降，但仅限于Ⅰ～Ⅱ度。结论两组相比在提高局控率、延缓肿瘤复发与提高患者无瘤生存期方面RT—TMZ组要优于RT组，而不良反应方面两组反应均较轻微，所以放疗加替莫唑胺治疗新确诊的间变性星形及胶质母细胞瘤有效并能够明显提高生存率而毒副作用小。