乳腺癌保乳术后三种放疗技术剂量学评价

目的：比较乳腺癌保乳术后常规放疗（CR）、三维适形（3D-CRT）放疗、调强适形（IMRT）放疗靶区剂量均匀性、危及器官受照体积等方面的差异。方法：随机选择10例乳腺癌患者,为每例患者设计上述三种照射技术的治疗计划。处方剂量为50Gy/25次。所有计划都使95%靶区体积达到处方剂量要求。根据积分剂量体积直方图（DVH）比较靶区受量和相关正常器官受量的差异和剂量分布。结果：CR、3D-CRT、IMRT靶区均匀性指数分别为1.16±0.03、1.15±0.03和1.14±0.02（P=0.279）,适形度指数分别为0.61±0.05、0.65±0.06和0.69±0.06（P=0.025）;三种放疗技术中患侧肺V30分别为19.39±3.09、15.53.±3.98、15.68±4.38（P=0.057）,V20分别为22.26±3.52、18.87±4.24、20.68±4.52（P=0.202）,V10分别为26.68±3.72、23.96±4.76、34.27±14.02（P=0.039）,V5分别为33.71±3.70、31.66±5.49、49.81±24.25（P=0.018）;对侧乳腺V3分别为3.31±3.74、2.37±3.11、14.24±3.81（P=0.007）;心脏V5分别为19.99±17.22、13.77±11.10、38.42±29.95（P=0.037）。结论：与CR相比,3D-CRT和IMRT能够改善靶区均匀性和适形度,并降低患侧肺的高剂量受照体积,但IMRT同时增加了患侧肺、对侧乳腺、心脏低剂量受照体积。     

早期乳腺癌保乳术后的放疗时机

早期乳腺癌保留乳房手术加放疗的疗效与根治术相同。对术后放疗时机的问题有一些回顾性和随机性研究,但无明确结论,近期的一些随机研究尚需要长期随访。总的来说,对于无需术后化疗的病人应尽早放疗,建议手术放疗间隔最好不超过8周。术后放疗、化疗顺序对疗效无显著影响,先放疗或先化疗均可以。对于腋窝淋巴结转移数较多的远地转移高危病人,术后可先做辅助化疗,但放疗不应延迟到术后7个月以后。如果手术切缘阳性,放疗应尽早开始。同步放化疗可以在不延迟放化疗的基础上提高局部疗效,但疗效提高有限,同时会增加急性和晚期毒副作用,不宜作为常规治疗。特殊病人需要使用时,应选择有效低毒的化疗方案,以降低治疗带来的急性毒副作用和晚期并发症。缩短放疗总时间对需要化疗的病人可以缩短手术到化疗的时间间隔,目前可行的方式有大分割放疗和乳腺瘤床同步补量技术。缩短放疗总时间是否能对疗效改善有影响,有待于临床资料证实。     

高压氧治疗高原地区乳腺癌术后放疗不良反应的疗效

目的:探讨高压氧疗对高海拔地区乳腺癌患者保乳术后放疗不良反应的疗效.方法:44例女性乳腺癌保乳手术后行局部放疗后皮肤红斑、色素沉着、水肿、疼痛等不良反应的患者,其中32例给予每周5次的高压氧治疗,每次以240 kPa的压力吸入纯氧90分钟;12例拒绝高压氧疗者作为对照组.接受高压氧治疗的患者采用LENT-SOMA标准进行治疗前、后评估,并针对每个患者制定个体化治疗护理措施.结果:接受个体化高压氧治疗护理的32例患者局部皮肤恢复接近正常,疼痛、水肿、红斑评分显著低于对照组(P<0.001),其中7例患者自觉症状彻底消失,仅纤维化和毛细血管扩张近期改变不明显.而对照组12例患者症状持续存在.结论:高压氧对于高原缺氧地区乳腺癌保乳术后放疗的不良反应具有明显缓解作用.     

乳腺癌保乳术后大分割放疗的不良反应研究进展

研究表明保乳术后大分割放疗与常规分割放疗相比,疗效相当且未增加不良反应,目前已成为全乳照射的优选方案。早期乳腺癌综合治疗后局部复发率低、生存时间长,放疗相关的不良反应是临床关注的焦点。而大分割放疗时代许多不良反应相关的危险因素尚不明确,有待进一步研究。本文就乳腺癌保乳术后大分割放疗的不良反应展开综述。     

乳腺癌行保乳术后放疗体位固定的研究

保乳术由于乳腺大部分或全部保留,放疗时应该用^60Co或高能X线切线照射,使乳腺及胸壁得到均匀的高剂量照射而不引起肺的放射损伤^[1]。这就要求放疗体位既要重复性好,又要稳定性高。现就我院的临床乳腺癌保乳术后放疗体位固定情况进行比较分析。     

乳腺癌保乳术后放疗疗效和美观效果

目的　观察乳腺癌保乳术后放疗的疗效和美观效果。方法　保乳术后全乳外照射和瘤床加量共10 9例,79例除应用高剂量率插植技术[T1期肿瘤用单排插植,针距为1.5cm ,T2期以上肿瘤用双排或三排插植;针距间单次剂量(DB) 10～12Gy ,靶区周边剂量为85 %DB]外,其中4 8例还经组织间插植加量放疗;30例除采用电子线常规外照射15Gy外,其中2 7例还经电子线外照加量放疗。全乳照射应用6MV直线加速器,采用双切线半野照射技术,靶区剂量为4 5～5 2Gy(平均4 8.6Gy)。采用医生评分与患者问卷方法评价美观效果。结果　5年生存率为93.8% ,局部复发率为6 .5 %。全组无放射性溃疡发生,5例出现位于插植针孔周围急性皮肤炎症。在经临床随访体检的75例中,医生打分和患者自评满意度为优的比例分别占87%和81% (P >0 .0 5 )。两组满意度医生总评为优的患者比例分别为81.2 %和85 .2 % (P >0 .0 5 )。结论　乳腺癌保乳术后放疗可降低术后复发率,并发症少。不同的瘤床加量放疗方法不影响美观满意度。     

乳腺癌保乳术后大分割放疗的进展

早期乳腺癌保乳术联合辅助放疗可以达到与改良根治术相同的疗效,但是保乳术后辅助放疗的剂量和分割方式多种多样,一般认为辅助放疗的标准剂量和分割方式是50Gy/25F.近年来,越来越多的研究表明,保乳术后大分割放疗(如42.5Gy/16F或者40Gy/15F)可达到与常规分割方式相同的效果,且不会明显增加不良反应.此外,大分...     

腺癌保乳术后调强放疗与三维适形放疗的疗效比较

目的 比较乳腺癌保乳术后调强放疗(IMRT)与三维适形放疗(3D-CRT)的疗效、不良反应及对基质金属蛋白酶-9(MMP-9)和基质金属蛋白酶组织抑制剂-1(TIMP-1)的影响.方法 选择96例接受乳腺癌保乳术的女性患者,按照随机数字表法将患者随机分为对照组和观察组,每组各48例.对照组予以3D-RCT,观察组予以IMRT,处方剂量均为50 Gy/25次.比较两组的照射剂量、不良反应、美容效果及治疗前后的血清MMP-9和TIMP-1水平.结果 观察组计划靶区(PTV)的V105%、V110%及V115%明显低于对照组(P﹤0.01),观察组患侧肺脏及左侧病灶者心脏接受的照射剂量明显低于对照组(P﹤0.01);观察组的皮肤反应率为12.5%(6/48),低于对照组的29.2%(14/48),差异有统计学意义(P﹤0.05);观察组美容优良率为97.9%(47/48),高于对照组的83.3%(40/48),差异有统计学意义(P﹤0.05).放疗后,两组患者的MMP-9及MMP-9/TIMP-1均较本组治疗前降低,但组间比较差异无统计学意义(P﹥0.05).结论 与3D-CRT相比,IMRT的PTV适形度和剂量均匀性较好,可降低危及器官的受照剂量,皮肤反应较少且美容效果好,值得临床推广.     

乳腺癌保乳术后调强放疗摆位误差的剂量学研究

目的：研究乳腺癌保乳术后调强放疗摆位误差对靶区内剂量的影响。方法：使用电子射野影像系统（EPID）,在治疗初及治疗中对10例乳腺癌保乳术后病人调强放疗时所拍摄的60幅射野图像,与计划系统生成的标准射野数字重建（DRR）图像进行比较,测量每一位病人的平均摆位误差数值。比较初次调强放射治疗计划（对照组）和参考误差后制定的调强放射治疗计划（试验组）二者靶区剂量体积直方图差异。结果：10例患者摆位误差在左右（X）和头脚（Y）及前后（Z）的平均移动偏差分别为（0．8±1．3）mm、（3．2±2．5）mm、（1．8±1．5）mm。对照组、试验组中CTV的D95分别为4992cGy±38cGy、4916cGy±113cGy,V105％分别为24．2±18．6、31．8±24．3;V110% 0．12±0．4、1．8±1．3。结论：乳腺癌保乳术后调强放疗PTV外放5mm是可行的。     

乳腺癌保乳术后调强放疗摆位误差的剂量学研究

目的:研究乳腺癌保乳术后调强放疗摆位误差对靶区内剂量的影响.方法:使用电子射野影像系统(EPID),在治疗初及治疗中对10例乳腺癌保乳术后病人调强放疗时所拍摄的60幅射野图像,与计划系统生成的标准射野数字重建(DRR)图像进行比较,测量每一位病人的平均摆位误差数值.比较初次调强放射治疗计划( 对照组)和参考误差后制定的调强放射治疗计划(试验组)二者靶区剂量体积直方图差异.结果:10例患者摆位误差在左右(X)和头脚(Y)及前后(Z)的平均移动偏差分别为(0.8±1.3)mm、(3.2±2.5)mm、(1.8±1.5)mm.对照组、试验组中CTV的D95分别为4992cGy±38cGy、4916cGy±113cGy,V105%分别为24.2±18.6、31.8±24.3;V110%0.12±0.4 、1.8±1.3.结论:乳腺癌保乳术后调强放疗PTV外放5mm是可行的.     

Pulmonary complications following different radiotherapy techniques for breast cancer, and the association to irradiated lung volume and dose

Purpose. This study investigates the incidence of short-term pulmonary complications following radiotherapy (RT) for breast cancer (BC) with different treatment techniques/incidentally irradiated lung volumes and the importance of confounding factors on RT-induced pulmonary complications.Patients and methods. Prospectively, 475 patients with BC were followed for pulmonary complications 1, 4 and 7 months post-RT. Mean lung dose volume histograms (MDVH) were constructed and compared for the different RT-techniques. Among a subset of the mastectomized patients treated with loco-regional (LR-) RT, who had undergone complete three-dimensional (3-D) dose planning (n= 43), MDVH for asymptomatic patients was compared with MDVH for patients experiencing both radiological and clinical pulmonary side-effects.Results. Moderate pulmonary complications, that is requiring treatment with corticosteroids, were rare following local RT ( < 1%), but were diagnosed among 11% of the patients treated with LR-RT. A correlation between increasing irradiated lung volumes at the > 20 Gy-level (V₂₀), based on MDVH for the RT-techniques, and pulmonary complications was found (P < 0.001). Furthermore, increasing age and reduced pre-RT functional level were independently associated with a higher rate of pulmonary complications (P = 0.005 and P = 0.018). Among the subgroup of mastectomized patients treated with LR-RT, who had undergone complete 3-D dose planning, a difference in mean V₂₀ was found between patients experiencing both clinical and radiological pulmonary side-effects compared to patients experiencing neither of the two side-effects (P = 0.007).Conclusion. Moderate pulmonary complications following local RT for BC are rare. The incidence of short-term moderate pulmonary complications in LR-RT is, however, clinically significant and to define quality assurance guidelines for these RT-techniques, 3-D RT planning can be used.     

Survival of women after breast conserving surgery for early stage breast cancer

Background. Increasing numbers of older women with breast cancer are receiving breast-conserving surgery (BCS). However, substantial numbers of them are not receiving either axillary dissection or adjuvant irradiation. Objective. To determine whether failure to perform axillary dissection or irradiation is associated with decreased survival in women with early-stage breast cancer. Method. We studied 26,290 women aged 25 in 1988-1993 from the surveillance, epidemiology, and end results (SEER) data and 5,328 women aged 65 in 1991-1993 from SEER-Medicare linked data, who had early-stage breast cancer and received BCS. Results. Twenty seven percent of women aged 25 receiving BCS did not receive axillary dissection, most of whom (74%) were age 65. Women receiving BCS with axillary dissection had lower 7-year breast cancer-specific mortality than did those without dissection (hazard ratio=0.53, 95% confidence interval: 0.44–0.63). We found an interaction between receipt of axillary dissection and radiotherapy on survival of older women after BCS. Women who received either axillary dissection or radiotherapy experienced similar survivals to those who received both axillary dissection and radiation, while women who received neither treatment experienced poorer survival (hazard ratio=1.76, 1.23–2.52), after controlling for demographics, tumor size and comorbidity. Conclusions. Women who receive neither axillary dissection nor radiation therapy after BCS experience an increased risk of death from breast cancer. The lack of improvement in the past two decades in survival of older women with breast cancer may be explained in part by the increasing use of treatments that do not address potential tumor in axillary nodes.     

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。     

Lactation following conservation surgery and radiotherapy for breast cancer

A 38-year-old woman with early stage invasive breast cancer was treated with wide excision of the tumor, axillary lymph node dissection, and breast irradiation. Three years later, she gave birth to a normal baby. She attempted breast feeding and had full lactation from the untreated breast. The irradiated breast underwent only minor changes during pregnancy and postpartum but produced small amounts of colostrum and milk for 2 weeks postpartum. There are only a few reports of lactation after breast irradiation. These cases are reviewed, and possible factors affecting breast function after radiotherapy are discussed. Because of scant information available regarding its safety for the infant, nursing from the irradiated breast is not recommended.     

乳腺癌保乳术后全乳野中野适形调强放射治疗技术

目的：探讨乳腺癌保乳术后全乳野中野适形调强照射技术方法,并与常规全乳切线野照射技术进行剂量学对比。方法：选取22例早期乳腺癌保乳术后患者在CT模拟机下对乳腺部位行薄层定位扫描,将定位图像传输至治疗计划系统进行全乳野中野计划设计：在全乳两切线适形野的基础上挡去高剂量区部分,另设计2—4个小跳数射野以降低靶区最高剂量和调整高剂量区的范围及所在位置。处方剂量50Gy／25次,要求95％的靶区接受处方剂量;然后利用其CT模拟定位资料按照常规切线野射野方法在治疗计划上模拟常规切线野治疗计划,对野中野计划和常规射野计划进行靶区适形性、靶区均匀性和危及器官受量的比较。结果：野中野适形调强放射治疗技术的适形度、均匀性优于常规切线野照射,靶区内超过110％处方剂量的体积明显小于常规切线野技术。减少了肺组织V20的体积,降低了心脏的平均剂量和受照体积。结论：乳腺癌保乳术后全乳野中野适形调强放射治疗技术是一种有益的全乳照射技术。     

Short-course radiotherapy for the whole breast after breast conserving surgery

Short-course radiotherapy for the whole breast after breast conserving surgery is an alternative to conventional fractionation schedules for radiotherapy. This method shortens the treatment period by increasing the daily fraction dose from 2 to 2.5 Gy or more, and is already being used in Canada and parts of Europe as a more convenient treatment for breast cancer patients than conventional long-term radiotherapy. An important randomized trial in Canada found that there were no statistical differences in efficacy or adverse effects between conventional radiotherapy and short-course radiotherapy. However, that trial included only breast cancer patients with the most favorable prognoses and excluded patients who had carcinoma involving the inked margin of excision. In that trial, additional boost irradiation to the lumpectomy site was not used, and only 11% of patients were treated with systemic chemotherapy. It is also possible that irradiation using large fraction doses cause more severe late toxicities in normal breast tissue than conventional fraction irradiation. Therefore, while short-course radiotherapy may also prove more convenient, further clinical studies should be performed to confirm the feasibility of the new method for Japanese women, before being put into general clinical use in Japan. The present paper is a review of short-course radiotherapy for the whole breast after breast conserving surgery.     

The survival of inoperable breast cancer treated with radiotherapy and radiotherapy followed by mastectomy

Forty-five patients with locally advanced breast carcinoma were treated by radiotherapy. Twelve of them became operable and were operated. After 3 and 4 years in comparable clinical stage the rate of metastases in the nonoperated group was 78.6% and in the operated 75%. The survival after 3 and 4 years in comparable clinical stages was similar. In more advanced stages the survival was worse. Considering the trauma of mastectomy and the similar survival obtained in our material, an international trial should be performed to decide whether inoperable breast cancer becoming operable after radiotherapy should be operated.     

Impact of chemotherapy dose-density on radiotherapy dose-intensity after breast conserving surgery

Purpose:To evaluate if chemotherapy (CT) dose-intensificationjeopardizes radiotherapy (RT) dose-intensity (DI). Patients and methods:From 1992 to 1997, 247 stage I–IIbreast cancer patients, treated with conserving surgery, were treated at theNational Cancer Institute of Genoa in a randomized study comparing the sameCEF regimen delivered every two weeks (CEF14) or three weeks (CEF21). RT wasapplied to the residual breast at a total dose of 50 Gy in five weeks.Allowance was made for treatment at 2.3 Gy per fraction in order to compensatefor gaps (hypofractionation). Radiotherapy DI was expressed as the averagetotal dose received each week, i.e., weekly dose-rate (WDR). Theeffect of various tumour, treatment and patient-related factors on theendpoint (a delivered WDR of RT < 9.5 Gy) was investigated by univariateanalysis. Factors found to have P-value 0.20 were entered inmultivariate analysis. Results:All but three patients (244 of 247, 98.8%)received a cumulative total dose of RT within ±10% of thatplanned. Moreover, most of them (197 of 247, 79.8%) received an averageWDR of 9.5 Gy/wk. With univariate analysis the probability of WDR < 9.5Gy/wk significantly correlated with age, menopausal status, concomitantadministration of RT and CT, and white blood cell toxicity. Moreover, apositive effect on WDR was found in patients treated at 2.3 Gy per fraction.The type of treatment (CEF14 vs. CEF21) did not affect the probability of WDR< 9.5 Gy/wk. With multivariate analysis, age (55 vs. >55 years, RR= 3.99, 95% CI: 1.89–8.42, P= 0.0003), RT fractionation(conventional vs. hypofractionation, RR = 0.32, 95% CI:0.15–0.68, P= 0.017) and WBC toxicity (none vs. some, RR =1.54, 95% CI: 1.06–2.22,P = 0.027) wereindependent predictors of WDR < 9.5 Gy. Regarding the CT-RT overlap,patients receiving more than two cycles of chemotherapy during radiotherapyhad an increased risk of RT delay compared to other patients (RR = 3.74,95% CI: 1.44–9.48, P= 0.0063). Conclusions:There is no evidence of a direct effect of CTdose-density on dose-intensity of RT. However, the concomitant use of CT andRT reduces the possibility of giving a full dose-intensity of RT.     

Cancer risk after radiotherapy for breast cancer

Among women with breast cancer, we compared the relative and absolute rates of subsequent cancers in 1541 women treated with radiotherapy (RT) to 4570 women not so treated (NRT), using all registered in the Swiss Vaud Cancer Registry in the period between 1978 and 1998, and followed up to December 2002. Standardised incidence ratios (SIRs) and the corresponding 95% confidence intervals (CIs) were based on age- and calendar year-specific incidence rates in the Vaud general population. There were 11 lung cancers in RT (SIR = 1.40; 95% CI: 0.70-2.51) and 17 in NRT women (SIR = 0.76; 95% CI: 0.44-1.22), 72 contralateral breast cancers in RT (SIR = 1.85; 95% CI: 1.45-2.33) and 150 in NRT women (SIR = 1.38; 95% CI: 1.16-1.61), and 90 other neoplasms in RT (SIR = 1.37; 95% CI: 1.10-1.68) and 224 in NRT women (SIR = 1.05; 95% CI: 0.91-1.19). Overall, there were 173 second neoplasms in RT women (SIR = 1.54, 95% CI: 1.32-1.78) and 391 among NRT women (SIR = 1.13, 95% CI: 1.02-1.25). The estimates were significantly heterogeneous. After 15 years, 20% of RT cases vs 16% of NRT cases had developed a second neoplasm. The appreciable excess risk of subsequent neoplasms after RT for breast cancer must be weighed against the approximately 5% reduction of breast cancer mortality at 15 years after RT.