国际淋巴瘤放射治疗协作组(ILROG)现代放射治疗靶区勾画及剂量指南——结内NHL

本指南反映了ILROG指导委员会在NHL现代放疗时代的共识,阐述了缩小照射野、降低剂量的作用,并且整合了现代三维计划图像技术和先进的放疗技术。在现代治疗条件下,应采用包含全身化疗在内的综合治疗。本指南明确定义了ISRT的CTV范围。对于惰性NHL,单纯放疗常作为根治手段,因此应考虑更大的照射野。为了既实现肿瘤LC这一主要目标,又降低正常组织损伤的风险,IMRT、呼吸门控、IGRT、四维图像等先进治疗技术都应使用于临床。     

早期霍奇金淋巴瘤化疗后受累野照射对疗效和长期毒副作用的影响

 扩大野放疗可以治愈早期霍奇金淋巴瘤（HL）。为了减少远期毒副作用,近10～20年来开展了系列综合治疗的随机对照研究。对于早期经典HL,化疗和放疗综合治疗较单纯放疗或单纯化疗均可明显改善长期无瘤生存率。目前已有部分研究证实受累野照射和较低照射剂量可以明显降低长期并发症,早期HL的标准治疗是短疗程化疗加受累野放疗。     

晚期肺癌常规放射治疗的剂量评估

目的对于晚期中心型非小细胞肺癌的放射治疗,常规放射治疗通常采用前后两野对穿照射,肿瘤量达到4 000cGy后,改为斜野或侧野水平照射,使肿瘤剂量达到6 000cGy.本文通过比较常规放疗和两维适形放疗对肺部肿瘤患者的剂量分布的不同,定性和定量地对常规放射治疗进行评估.方法选择经病理学或细胞学确诊的肺部恶性肿瘤,肿瘤局部晚期,位置居中无法手术的患者.为每位患者设计两种治疗计划,常规治疗计划和两维适形治疗计划.结果通过近20例患者的比较,以其中1例患者为例进行量化分析.常规放射照射的照射野均比两维适形放射治疗的照射野大,但是常规放射治疗的前野和后野并没有将整个肿瘤靶区包括.约有2cm×3cm的肿瘤在照射野以外.对于同一位患者,对于两维适形放射治疗中,100%的等剂量线包绕了PTV的98.8%;68%的等剂量线则完全地包绕了PTV.而常规野治疗计划,100%的等剂量线包绕了PTV的98.5%,42%的等剂量线才能100%地将PTV包绕.两维适形放射治疗使脊髓接受4 000cGy剂量的体积由80%下降到6.8%;两肺接受2 000cGy剂量的体积均下降5%左右.结论对于晚期中心型非小细胞肺癌的放射治疗,与常规放射治疗相比,适形放射治疗可以大幅度地降低周围危及器官所接受的剂量,但危及器官的受照射体积和剂量仍然较高.要避免放射性肺炎的发生可以通过缩野加量或逆向调强照射技术来达到.     

放射治疗肿瘤新进展

近年来，在高科技发展带动下，适形治疗技术迅速成熟，高传能线密度，临床应用日益活跃。可以预言，这些治疗手段革命性突破将在下个世纪成为癌症的标准治疗方法之一。一、适形治疗适形治疗是一种放射治疗技术。适形，即高放射剂量区（照射野）形态与肿瘤（靶区）形态一致。由于靶区是立体的，且又是用放射线治疗，故称三维适形放射治疗。当靶区体积较小，单次大剂量照射就可达到局部控制目的，该照射方式称为放射外科，其代表产品是伽玛刀。当要求造形治疗靶区内及靶表面剂量分布均匀，则每个照射野内剂量须能按要求调整，并使靶区高剂量，…     

鼻咽癌常规放疗中电子线L形野照射技术应用研究

 目的　探索一种能更好地解决鼻咽癌常规放疗中射野之间衔接问题的新方法。方法　使用三维计划系统模拟鼻咽癌2D-适形放疗（CRT）或3D-CRT治疗中电子线L形野照射技术与常规放疗颈后电子线野照射技术的布野方法,进行剂量学分布比较。结果　电子线L形野照射技术与颈后电子线野照射技术的靶区剂量超过6000 cGy的包绕体积都达到95 %以上,满足临床上肿瘤治疗的剂量需要,但颈后电子线野照射技术出现明显的剂量热点,最高剂量可达8900 cGy,电子线L形野照射技术的最高剂量达7200 cGy。电子线L形野照射技术的喉部高剂量范围比颈后电子线野照射技术小,前者喉部剂量超过6500 cGy的体积为19.64 %,后者为31.95 %。结论　电子线L形野照射技术在照射野之间衔接和剂量分布方面都具有较好的优势,值得临床推广应用。     

颈胸交界区食管癌放射治疗中设野方法的研究

目的：比较颈胸交界区食管癌放射治疗中不同射野与楔形板应用的技术。方法：采用美国CMS公司XiO V4．1．1三维治疗计划系统（TPS），比较颈胸交界区食管癌在不同治疗计划中等剂量曲线、剂量体积直方图（DVH）及其他评价指标的优劣。结果：采用先前后对穿照射（适形野或马褂野）及后程两前斜野加楔形板治疗技术的剂量分布较仅应用两前斜野加楔形板治疗技术等剂量曲线分布均匀，肺受量减小。运用马褂野较用适形野的照射方式剂量分布更加均匀且满足锁骨上淋巴结区预防照射要求；楔形板常规应用技术（仅厚端相对避免内野高剂量）的靶区剂量分布较其在三维治疗计划系统的应用技术均匀性明显不足。结论：放射治疗技术和楔形板在颈胸交界区食管癌放射治疗中的应用应做到个体化，对锁骨上淋巴结区需预防照射的患者，应采用先前后对穿照射（适形野或马褂野）加后程两前斜野及楔形板治疗技术，对锁骨上淋巴结区不需预防照射的患者，则可以用前两斜野加楔形板治疗技术。     

常规加三维适形放射治疗晚期浸润型胸腺瘤的分析

目的 探讨常规加三维适形放射治疗晚期浸润型胸腺瘤的疗效.方法 15例均为无法切除的晚期胸腺瘤,采用常规加三维立体适形放射治疗技术.常规放疗采用6MV X线前后野对穿照射瘤体,前后野剂量比为2∶1,射野包括瘤体外1～2cm.2Gy/次,1次/d,5次/周,放疗剂量DT 20Gy时予胸部CT复查,根据肿瘤缩小情况适当调整照射野,总剂量DT 32～36Gy.改为三维适形放疗,用6MV X线设一个等中心3～5个照射野,通过剂量体积直方图进行优化.单次周边剂量为2Gy,1次/d,5次/周,放疗剂量DT 30～36Gy左右,使总剂量达到Dt66～70Gy,42～50d内完成.结果 无法手术切除的浸润型胸腺瘤,经常规加三维适形放射治疗后,肿瘤可得到控制,5年生存率可提高到66.7%.结论 对晚期浸润型胸腺瘤(Ⅲ、Ⅳ期),用高能X线给予常规体外加三维适形放疗,减少正常组织、器官放疗剂量,提高肿瘤放疗剂量,仍有获得长期生存的可能.     

三维适形放射治疗计划照射野位置的模拟验证

目的:验证三维适形放疗(3dimentional conformal radiotherapy,3DCRT)计划的照射野精度。方法:应用放射治疗模拟定位机对372例三维适形放疗计划的照射野进行治疗过程模拟,观察其与实际预照射目标的吻合性及铅模质量。结果:在治疗模拟中发现三维适形放疗计划照射野和铅模存在一定误差,最大误差2.1cm,最小误差0.3cm,误差率为5.1%(19/372)。结论:应用放射治疗模拟定位机对三维适形放疗计划照射野精度验证,方法简便,及时纠正了各种误差,可推广使用。     

前列腺癌的适形和调强适形放疗

适形和调强适形放射治疗已经广泛地应用于治疗前列腺癌.适形放疗或调强适形放疗技术能够提高靶区的照射剂量,改善前列腺癌的无生化失败生存率和总生存率.调强适形技术可使高剂量分布区与靶区三维形状的适合度大大提高,显著减少周围正常组织和器官的受照射体积,在照射剂量提高的同时并未增加直肠和膀胱的毒性反应.适形和调强适形放疗的治疗体位宜选择仰卧位.临床靶区需要包括整个前列腺.对于有高危因素的病人临床靶区还需要包括精囊和盆腔淋巴结.     

图像引导放射治疗研究及其发展

三维适形放疗和调强放疗系通过高度适形照射减少正常组织受照体积,改进剂量分布,以达到较高的治疗增益比。但是,放疗过程中的一些不确定性因素影响肿瘤实际照射剂量的分布,造成肿瘤脱靶和（或）危及器官损伤增加。其一,肿瘤和周围正常器官组织的位移,包括治疗间位移和治疗中位移。治疗间位移主要指靠近消化系统和泌尿系统的器官,随着胃肠道、膀胱的状态及患者体重的改变有不同程度位移。     

Importance of PET/CT Scan Use in Planning Radiation Therapy for Lymphoma

Background: Radiation therapy is a key part of the combined modality treatment for Hodgkin’s lymphoma(HL) and non-Hodgkin’s lymphoma (NHL), which can achieve locoregional control of disease. The 3D-conformalradiation oncology can be extended-field (EFRT), involved-field (IFRT) and involved node (INRT). Newtechniques have resulted in a smaller radiation field and lower dose for critical organs such as lung heart andbreast. Materials and Methods: In our research, we made a virtual simulation for one patient who was treatedin four different radiotherapeutic techniques: mantle field (MFRT), EFRT, IFRT and INRT. After delineatiionwe compared dose-volume histograms for each technique. The fusion of CT for planning radiotherapy withthe initial PET/CT was made using Softver Xio 4.6 in the Focal program. The dose for all four techniques was36Gy. Results: Our results support the use of PET/CT in radiation therapy planning. With IFRT and INRT,the burden on the organs at risk is less than with MFRT and EFRT. On the other hand, the dose distributionin the target volume is much better with the latter. Conclusions: The aim of modern radiotherapy of HL andNHL is to reduce the intensity of treatment and therefore PET/CT should be used to reduce and not increasethe amount of tissue receiving radiation.     

Role of Radiation Therapy in the Treatment of Hodgkin Lymphoma

Radiation therapy has historically been the pillar of curative treatment for Hodgkin lymphoma (HL). With improved efficacy of systemic therapy and the ever-increasing recognition of treatment-related morbidity in long-term survivors, the role of radiotherapy has evolved significantly. Modern combined modality therapy (CMT) with multi-agent chemotherapy followed by involved site radiation therapy (ISRT) to initially involved sites of disease remains the gold standard for the majority of patients with HL. Reduction of long-term treatment-related toxicity has become the major driver in clinical trial design for early-stage HL while improved disease-specific survival remains the goal in patients with more advanced and unfavorable disease. This review will address the data supporting the use of radiotherapy in HL as well as specific methods for reducing late toxicity from radiotherapy.     

国际淋巴瘤放射治疗协作组(ILROG)现代放射治疗照射野与剂量指南——结外淋巴瘤(ENL)

ENL约占NHL总数的1/3。放疗常用于初始治疗(尤其是惰性结外淋巴瘤)、系统治疗后的巩固治疗、挽救性治疗以及姑息治疗。由于ENL临床表现多种多样,可以累及全身各器官,病理亚型丰富,给常规临床诊疗以及开展前瞻性和回顾性研究带来诸多困难。不同中心或医生使用的放疗方法亦不尽相同。迄今,ENL的放疗缺乏相关指南。本文中ILROG专家们统一了ENL治疗原则,同时阐述了常见ENL的模拟定位、靶区定义和计划制定,并详尽介绍了放疗靶区勾画方法。本文应用的ISRT新原则,与之前发表的HL和结内NHL指南相同。本文靶区基于ICRU文件,与实体肿瘤相同。此外,本文根据组织分型、解剖结构、治疗目的以及放疗前可能应用的其他治疗模式,为不同器官淋巴瘤放疗给予特殊推荐。     

Cost-Effectiveness of PET Directed Versus Combined Modality Therapy for Early-Stage Favorable Hodgkin's Lymphoma

IntroductionThe standard of care for early-stage Hodgkin Lymphoma (HL) is combined modality therapy (CMT) consisting of chemotherapy and involved site radiation therapy (ISRT). Recent treatment de-escalation trials have assessed the impact of omitting radiation with the use of positron emission tomography (PET) and have suggested a detriment in progression free survival (PFS) for patients who do not receive radiation therapy (RT) but similar overall survival. The purpose of this study was to compare the cost-effectiveness of PET-directed therapy versus standard of care CMT.MethodsThis study used a cost-effectiveness Markov model simulating 5 year outcomes for 1 million patients with early-stage HL treated with either PET-directed therapy consisting of 2 cycles of ABVD chemotherapy ± ISRT or CMT consisting of 2 cycles of ABVD + ISRT. Patients progressed to no evidence of disease, progression of disease (PD), or death. Patients with PD underwent salvage therapy with high dose chemotherapy and stem cell transplant (HDC-SCT). The primary outcome measured was the incremental cost-effectiveness ratio. Deterministic sensitivity analyses were performed.ResultsWe found that PET-directed therapy and CMT strategies were associated with costs of $47,362 and $41,167, respectively. The CMT strategy was equally as effective as the PET-directed therapy strategy with QALYs of 3.4. On 1-way sensitivity analyses, the model was most sensitive to CMT and HDC-SCT costs. Two-way sensitivity analyses showed the model was sensitive to the relative costs of these treatments.ConclusionFor patients with early-stage HL, CMT is the cost-effective strategy as compared with PET-directed therapy.     

The optimal radiation volume after first-line chemotherapy in Hodgkin lymphoma

Radiation therapy has evolved from extended-field radiation therapy (EFRT) to involved-field radiation therapy (IFRT), reducing toxicity while maintaining high cure rates. Recent publications recommend a further reduction to involved-nodal radiation therapy (INRT); however, this has not been clinically validated. The need for irradiation or optimal radiation volume after chemotherapy are not defined. The treatment results of 296 Hodgkin's disease patients receiving ABVD or BEACOPP-21 chemotherapy with consequent EFRT demonstrate CR/PR > or = 80% and 99% local disease control rate. Beam therapy with EFRT is possible to use if dose levels don't exceed 30 Gy. Higher doses demands reduction of volume of radiating target. In our opinion the optimum program of beam therapy involves 2 stages with maximal possible dose level EFRT followed by additional INRT. Those approaches offer perspectives for Hodgkin's disease treatment.     

Involved-node radiotherapy (INRT) in patients with early Hodgkin lymphoma: concepts and guidelines.

BACKGROUND AND PURPOSE: To describe new concepts for radiation fields in patients with early stage Hodgkin lymphoma treated with a combined modality. PATIENTS AND MATERIALS: Patients receiving combined modality therapy with at least 2 or 3 cycles of chemotherapy prior to radiotherapy. Pre- and postchemotherapy cervical and thoracic CT scans are mandatory and should be performed, whenever possible, in the treatment position with the use of image fusion capabilities. A pre-chemotherapy PET scan is strongly recommended to increase the detection of involved lymph nodes. RESULTS: Radiation fields are designed to irradiate the initially involved lymph nodes exclusively and to encompass their initial volume. In some cases, radiation fields are slightly modified to avoid unnecessary irradiation of muscles or organs at risk. CONCLUSIONS: The concept of involved-node radiotherapy (INRT) described here is the first attempt to reduce the size of radiation fields compared to the classic involved fields used in adult patients. Proper implementation of INRT requires adequate training and an efficient prospective or early retrospective quality assurance program.     

霍奇金淋巴瘤现代治疗的远期不良反应

 源于20世纪60年代的扩大野和次全淋巴结区的放射治疗是第一个治愈早期霍奇金淋巴瘤的手段。但机体正常组织在接受大剂量照射后产生包括心脏疾病及二次肿瘤在内的许多远期不良反应,其中接受40～45 Gy的扩大野或斗篷野照射的患者30年内心脏疾病及二次肿瘤的累计发生率约30 %,因此改善预后与减少治疗的不良反应成为霍奇金淋巴瘤治疗的主要目标。目前受累野及受累淋巴结区的放射治疗均能减少照射的总剂量及正常组织的受照射量,同时效应依赖性治疗策略使患者在减量治疗或强化治疗中最大获益。加强远期不良反应的筛查有利于早期干预减少其临床后果,治疗不良反应相关的基因研究是目前研究的热点。     

Reduction of the treated volume to involved node radiation therapy as part of combined modality treatment for early stage aggressive non-Hodgkin’s lymphoma

Background and purpose

This retrospective study investigated whether focused involved node radiation therapy (INRT) can safely replace involved field RT (IFRT) in patients with early stage aggressive NHL.

Patients and methods

We included 258 patients with stage I/II aggressive NHL who received combined modality treatment (87%) or primary RT alone (13%). RT consisted of a total dose of 30–40 Gy in 15–20 fractions IFRT or INRT. We compared survival, relapse pattern, radiation-related toxicity and quality of life for both RT techniques.

Results

Type of RT was not related to the outcome in either the uni- or multivariate survival analysis. Relapses developed in 59 of 252 patients (23%) of which 47 (80%) were documented as distant recurrence only. Failure of the INRT technique was noted in one patient. There was no significant difference in acute radiation-related toxicity between RT-groups but IFRT showed a significantly higher incidence of higher grade toxicities. Patients treated with INRT had a significantly better physical functioning and global quality of life compared to the IFRT group.

Conclusions

Given the retrospective nature of this study, no solid conclusions can be drawn. However, in view of the equivalent efficacy and more favorable toxicity profile, the replacement of IFRT by INRT in combination with chemo-(immuno)-therapy looks very attractive for patients with early stage aggressive NHL.     

Managing liver metastases with conformal radiation therapy

A subgroup of liver metastases, especially those emanating from colorectal carcinoma, may be cured. Surgical excision is accepted as the mainstay of treatment for these malignancies; unfortunately, however, the majority of patients presents with advanced unresectable hepatic involvement and have no standard treatment option available. Radiation therapy (RT) has not played a significant role in managing liver metastases, because the liver has little tolerance to radiation. In patients with good hepatic function, however, very-high-dose RT may be used safely and effectively if a small volume of the liver (< 25%) is irradiated. In particular, RT, and especially three-dimensional conformal RT (3D-CRT), may be used to manage medically unfit patients or those with an unresectable metastatic liver lesion. This review discusses existing literature on use of various types of RT, including whole-liver irradiation, partial hepatic irradiation with 3D-CRT, and hypofractionated high-dose irradiation with stereotactic body RT, and future directions for this treatment modality.