食管癌外照射加腔内放射治疗的临床分析

目的:分析高剂量率后装腔内放疗在食管癌放射治疗中的应用价值。方法:回顾性分析1999年3 月至2005年12月在天津医科大学附属肿瘤医院接受放射治疗的食管癌患者的临床资料。符合条件的患者共89例。其中单纯外照射组62例,外照射联合腔内放疗组（联合照射组）27例,有42例患者接受了序贯或同步化疗。将患者分为单纯外照射组和外照射联合腔内放疗组进行分析,单纯外照射多为前后两野对穿照射40Gy后缩野避开脊髓加量,腔内放疗多在外照射结束后1 周内开始,一般4～7Gy/次,每周1 次,共2～3 次。部分患者接受了化疗,常用化疗方案为顺铂加氟脲嘧啶方案。应用完全缓解率和治疗后进食改善率评价近期疗效,应用无局部复发生存率（LRFS）及总生存率（OS）评价远期疗效。统计分析采用χ2检验比较两组间有效率及进食改善率的差别,Kaplan-Meier 计算两组的OS及LRFS,Log-Rank比较两组间OS及LRFS的差别。结果:全组生存患者中位随访时间34个月,至最后随访之日63例患者死亡。单纯外照射组与联合照射组的完全缓解率分别为10%及29%（P=0.049）;进食改善率分别为67.7% 和74.1%（P=0.795）;5 年无局部复发生存率分别为24% 和36%（P=0.332）;5 年总生存率分别为18% 和21%（P=0.401）。 肿瘤长度≤5cm及>5cm组联合放疗与单纯放疗的5 年生存率分别为42% 、36%（P=0.045）及16% 、14%（P=0.685）。 结论:后装腔内放疗联合外照射可提高近期疗效及较小病灶（肿瘤长度≤5cm）患者的生存率。      

体外加腔内照射与单纯外照射治疗宫颈癌的远期疗效观察

 目的分析体外加腔内照射（Ａ组）与单纯外照射（Ｂ组）治疗宫颈癌的远期疗效。方法　外照射加１９２Ｉｒ高剂量率后装腔内放疗治疗宫颈癌４５例，并与同期单纯外照射宫颈癌４５例进行比较。结果　Ⅱ期Ａ组和Ｂ组５年生存率分别为９０％　和６３．６％（Ｐ＜０．０５），局部复发率分别为２０％和５０％（Ｐ＜０．０５）；Ⅲ期Ａ组和Ｂ组５年生存率分别为６８％　和４３．５　％　（Ｐ＜０．０５），局部复发率分别为２８％　和６５．２％（Ｐ＜０．０１）。鳞癌和腺癌的５年生存率分别为６７．９％和３３．３％（Ｐ＜０．０５）。结论宫颈癌的５年生存率及局部控制率体外加腔内放射治疗明显优于单纯外照射，鳞癌优于腺癌。     

外照射放疗联合腔内近距离放疗治疗食管癌的系统评价

目的:评价外照射联合腔内近距离放疗(观察组)与单纯外照射放疗(对照组)治疗食管癌的疗效和安全性.方法:通过计算机检索CBMdisc、VIP、CNKI、Cochrane Library、Pubmed和Embase等数据库和手工检索8种主要中文肿瘤学期刊,收集有关外照射联合腔内近距离放疗与单纯外照射放疗治疗食管癌的随机和半随机对照试验.采用RevMan 4.2.10进行统计学分析.结果:共收集到14个已发表的随机对照试验,1 400例患者,方法学质量评价均为C级.Meta分析结果显示,近期有效率,1和3年生存率明显高于单纯外照射放疗,局部复发率在观察组降低,P值分别为0.03、＜0.000 01、0.005和0.02;两组5年生存率及远处转移率相似,P值分别为0.29和0.43;观察组放射性食管炎、出血、良性食管狭窄的发生率高于对照组,P值分别为0.04、0.002和0.03.两组食管穿孔和食管溃疡的发生率差异无统计学意义,P值分别为0.77和0.20;放射性肺炎发生率对照组高于观察组,P=0.000 5.结论:与观察组相比,治疗组近期、1和3年生存率提高,局部复发降低;但远期生存率及远处转移率无改善;治疗组不良反应发生率增加.     

外照射同期配合腔内近距离照射治疗中晚期食管癌疗效观察

目的:观察外照射同期配合腔内放疗治疗中晚期食管癌的疗效及不良反应.方法:160例食管癌患者随机分为外照射加腔内放疗组(治疗组)80例、单纯外照射组(对照组)80例.治疗组:外照射开始同期腔内照射,每周先外照射4次,1.8-2Gy/次,后腔内照射1次,5Gy/次,共4-5次,腔内照射当天不做外照射;对照组:采用常规分割单纯外照射,1.8-2Gy/次,5次/周.结果:两组的1、2和3年生存率分别为88.8%、61.3%、30.0%和57.5%、45.0%、23.8%,1、2年生存率两组有统计学差异(P＜0.05).治疗组和对照组急性放射性食管炎的发生率分别为33.8%(27/80)和18.8%(15/80)(P＜0.05),但Ⅲ级及以上的食管炎发生率相当,晚期并发症无增加.结论:外照射同期加腔内照射治疗食管癌疗效优于单纯外照射.此方法对控制原发灶、减少复发和转移、提高生存率有一定临床意义.     

食管癌体外照射加腔内~（192）铱治疗疗效分析

食管癌外照射加腔内后装治疗４０例与单纯外照射６０例。腔内治疗在外照射肿瘤量５０－６０Ｇｙ后进行，４－６Ｇｙ／次周，治疗２－３次，总量６０－６５Ｇｙ。单纯外照射总量也达６０－６５Ｇｙ／６－７周。外照射加腔内组ＣＲ７５％、ＰＲ２２．５％、ＮＲ２．５％，一年生存率８０％。单纯外照射组分别为４３％，５２％，５％，５６．７％。提示外照射加腔内治疗能提高食管癌的生存率及生存质量。腔内治疗在食管癌的根治性放疗中成为不可缺少的手段。     

外照射同期配合腔内近距离照射治疗中晚期食管癌疗效观察

目的：观察外照射同期配合腔内放疗治疗中晚期食管癌的疗效及不良反应。方法：160例食管癌患者随机分为外照射加腔内放疗组（治疗组）80例、单纯外照射组（对照组）80例。治疗组：外照射开始同期腔内照射,每周先外照射4次,1．8—2Gy／次,后腔内照射1次,5Gy／次,共4—5次,腔内照射当天不做外照射;对照组：采用常规分割单纯外照射,1．8—2Gy／次,5次／周。结果：两组的1、2和3年生存率分别为88．8％、61．3％、30．0％和57．5％、45．0％、23．8％,1、2年生存率两组有统计学差异（P〈0．05）。治疗组和对照组急性放射性食管炎的发生率分别为33．8％（27／80）和18．8％（15／80）（P〈0．05）,但Ⅲ级及以上的食管炎发生率相当,晚期并发症无增加。结论：外照射同期加腔内照射治疗食管癌疗效优于单纯外照射。此方法对控制原发灶、减少复发和转移、提高生存率有一定临床意义。     

外照射结合腔内放疗中晚期食管癌102例疗效观察

探讨食管癌外照射加腔内放疗的临床价值。 1995年 1～ 1995年 12月将 10 2例经病理证实的食管癌患者 ,随机分为外照射加腔内放疗组 (综合组 )、单纯外照射组 (对照组 ) ,各 5 1例。 6MVX线外照射 ,综合组外照射剂量 6 0Gy 6周 ,补充腔内治疗 2次 ,剂量 10～ 12Gy ;对照组外照射剂量 6 5～ 70Gy 6～ 7周。结果 :综合组的 1、2、3、4、5年生存率分别为 72 5 %、42 0 %、2 8 5 %、2 0 4%、14 2 % ,对照组的 1、2、3、4、5年生存率分别为 5 2 9%、33 3%、2 1 5 %、15 6 %、11 7% ,仅 1年生存率差异有显著性 (P <0 0 5 ) ;因局部复发或未控而死者综合组为 5 0 9% ,对照组为 6 8 6 % ,差异有显著性 (P <0 0 5 ) ;食管溃疡、瘘和狭窄的发生率两组差异无显著性 (P >0 0 5 )。初步研究结果提示 ,外照射结合腔内放疗可提高食管癌的局部控制率和 1年生存率     

内外照射加卡铂化疗治疗食管癌的前瞻性随机分组研究

目的;评价内外照结合加卡铂化疗综合治疗中晚期食管癌的远期疗效和并发症。方法：１９９３年８月至１９９４年５月,对１２９例地前瞻性随机分组研究。全部病例病理证实,随访均满４年,随访率９８．５％。Ａ组３３例单纯外照射总量６０Ｇｙ／３０次／６周。Ｂ组３２例先常规外照射肿瘤量达３８Ｇｙ／１９次时,开始腔内照射,结束时外照总量５０Ｇｙ／５．５周,腔内一１５－１６Ｇｙ／３次／３周,Ｃ组３１例放疗同Ｂ组,仅在第１     

外照射结合腔内放疗中晚期食管癌102例疗效观察

探讨食管癌外照射加腔内放疗的临床价值。1995年1－1995年12月将102例经病理证实的食管癌患者，随机分为外照射加腔内放疗组（综合组）、单纯外照射组（对照组），各51例。6MV X线外照射，综合组外照射剂量60Gy 6周，补充腔内治疗2次，剂量10－12Gy；对照组外照射剂量65－70Gy 6－7周。结果：综合组的1、2、3、4、5年生存率分别为72．5％、42．0％、28．5％、20．4％、14．2％，对照组的1、2、3、4、5年生存率分别为52．9％、33．3％、21．5％、15．6％、11．7％，仅1年生存率差异有显著性（P＜0．05）；因局部复发或未控而死者综合组为50．9％，对照组为68．6％，差异有显著性（P＜0．05）；食管溃疡、瘘和狭窄的发生率两组差异无显著性（P＞0．05）。初步研究结果提示，外照射结合腔内放疗可提高食管癌的局部控制率和1年生存率。     

外照射加腔内近距离放射治疗鼻咽癌的临床观察

我院放疗科自1992年4月～1994年4月外照射加腔内距离放射治疗鼻咽癌70例,均经病理证实。首程治疗60例,鼻咽复发癌再程治疗10例。本组(结合组)与同期单纯外照射组的1、2、3年生存率没有明显统计学差异。两组中的鼻咽复发癌再程放疗的1、2、3年生存情况亦没有明显统计学差异。放疗后复发情况:结合组的鼻咽腔内复发率明显低于单纯外照射组,但其颅底与咽旁间隙的复发率,两组没有明显差异。采用腔内近距离放疗病人的鼻咽粘膜反应较单纯外照射重,鼻咽复发癌腔内放疗后易出现鼻咽出血。给我们的提示是:对鼻咽腔周围病变,外照射致局部控制没有把握时,不宜盲目行腔内近距离放疗。一般情况下,腔内近距离放疗只是腔内加量放疗,做为外照射的补充治疗,剂量不宜过高。     

Radical external radiotherapy for prostatic carcinoma

From 1965 through 1974, 88 patients with Stage B or C prostatic carcinoma were treated with radical megavoltage therapy. Treatment technique was small field arc alone for Stage B and 4 field box whole pelvis irradiation to 4400 or 5000 rad with small field rotational boost for Stage C. All were at risk for 5 years and 30 for 10 years or more. None of the 14 Stage B patients have died of cancer, although one is living with metastases. In Stage C (74 patients) uncorrected actuarial survival was 55% ± 5.8 (5 year) and 28% ± 6.5 (10 year). When corrected for intercurrent deaths, survival was 65 % ± 5.8 (5 year) and 37 % ± 8.1. Survival curves for those patients receiving 6000–6900 rad were not significantly different from those receiving 7000 rad or more. Local control may be better in the latter group, 82.7% (43/52) versus 71.4% (20/28), although this is, not significant. Thirty-one percent of local failures appeared after 5 years. Whole pelvis dose of 5000 rad was associated with a higher 5 and 10 year survival than 4400 rad but the difference was not statistically significant. Comparison between groups treated with radiation alone, versus radiation plus a simultaneous hormonal therapy showed no significant differences in survival, local control or complications. A group of 20 patients who failed hormonal therapy and were then irradiated did less well. Complications were generally mild, but early in the series 2 patients receiving 7500 rad developed ano-rectal necrosis; one of these patients died. More common problems were urethral stricture (12 % ) and ano-rectal stenosis (10%). Changes in technique in 1971 drastically reduced the subsequent complications. The failure of whole pelvic irradiation to improve on the 10 year results of local treatment is discussed.     

Relocatable frame for stereotactic external beam radiotherapy

A non-invasive head fixation system is described which is accurately relocatable and enables the transfer of stereotactic positions between a variety of radiodiagnostic images and therapeutic procedures. The system can be simply and repeatedly applied for planning stereotactic radiation therapy from one or more diagnostic images and for repeated treatment with a conventional linear accelerator. In addition, the long-term effects of therapy can be objectively monitored by relocating the frame and repeating images in an identical way, months or years later.     

宫颈癌体外自适应放疗

放疗已经成为宫颈癌的主要治疗手段之一,近年来在体外精确放疗技术治疗期间,器官运动、摆位误差、解剖学变化等因素可能导致实际接受剂量与初始计划不一致,从而造成靶区剂量不足及危及器官受照剂量过多。自适应放疗（ ART）可根据治疗过程中所得到的位置、体积、剂量等参数的反馈信息,利用图像引导及个体化建模等方法对后续治疗计划进行相应的优化和调整,从而在提高局部控制率的同时降低放疗不良反应的发生率。     

Dose-rate effects in external beam radiotherapy redux

Recent developments in external beam radiotherapy, both in technical advances and in clinical approaches, have prompted renewed discussions on the potential influence of dose-rate on radio-response in certain treatment scenarios. We consider the multiple factors that influence the dose-rate effect, e.g. radical recombination, the kinetics of sublethal damage repair for tumors and normal tissues, the difference in α/β ratio for early and late reacting tissues, and perform a comprehensive literature review. Based on radiobiological considerations and the linear-quadratic (LQ) model we estimate the influence of overall treatment time on radio-response for specific clinical situations. As the influence of dose-rate applies to both the tumor and normal tissues, in oligo-fractionated treatment using large doses per fraction, the influence of delivery prolongation is likely important, with late reacting normal tissues being generally more sensitive to the dose-rate effect than tumors and early reacting tissues. In conventional fractionated treatment using 1.8-2 Gy per fraction and treatment times of 2-10 min, the influence of dose-rate is relatively small. Lastly, the dose-rate effect in external beam radiotherapy is governed by the overall beam-on-time, not by the average linac dose-rate, nor by the instantaneous dose-rate within individual linac pulses which could be as high as 3 × 10⁶ MU/min.     

Hypothyroidism after external radiotherapy. Fifteen cases]

Hypothyroidism frequency is estimated to be between 10 and 45% after radiotherapy alone, and 40 to 67% after radiotherapy associated with thyroidectomy. This hypothyroidism is infraclinical in 60% of the cases. Our study concerned 15 cases of hypothyroidism after external radiotherapy delivered between and 1991 and 1999. An irradiation of the cervical, cerebral and thorax regions was indicated for different types of cancers. Larynx carcinoma epidermoid was the most frequent cancer (seven cases); the radiation treatment used cobalt 60 with conventional fractionation, i.e., 2 Gy per treatment, five treatments a week. In nine cases, the hypothyroidism was discovered during a systematic examination; it was clinically evident in the six remaining cases. Hypothyroidism appeared after an irradiation dose average of 50 Gy (extremes 30-65 Gy). The average duration of the irradiation was about 7 weeks and the hypothyroidism appeared in a mean 22 months. In all cases, the substituting treatment was initiated with a favorable progression. Faced with the risk of hypothyroidism, it is necessary to check patients who have undergone external irradiation of the neck.     

Comparison of mammographic findings after intraoperative radiotherapy or external beam whole breast radiotherapy

Background

The TARGIT (TARGeted Intraoperative Radiotherapy) trial was designed to compare local recurrence and complication rates in breast cancer patients, prospectively randomised to either EBRT (external beam whole breast radiotherapy) or a single dose of IORT (intraoperative radiotherapy). The aim of our study was to compare follow-up mammographic findings, ultrasound and biopsy rates in each group.

Methods

Follow-up imaging and breast biopsies of women from one centre participating in the TARGIT-A trial were independently reviewed by two radiologists blinded to the radiotherapy treatment received.

Results

The cohort consisted of 141 patients (EBRT n = 80/IORT n = 61). There was no significant difference in the patient or disease characteristics of the two groups. The number of follow-up mammograms and length of follow-up was similar (EBRT/IORT n = 2.0/2.4; 4.3yr/5.1yr; p = 0.386 χ² test). There were no significant differences in mammographic scar or calcification appearances of the post-operative site. Generalised increase in breast density and skin thickening were more common in the EBRT compared to the IORT group (p = 0.002; p = 0.030, χ² test respectively). A trend towards additional ultrasound at follow-up was observed in the IORT group (15 of 61 [24.6%] versus 11 of 80 [13.8%]), however this was not statistically significant (p = 0.100 χ² test). No disease recurrence was demonstrated on any of the breast biopsies taken. Only one biopsy was reported as fat necrosis in the IORT group.

Conclusions

Mammographic changes were more common following EBRT, although more additional follow-up ultrasounds were performed in the IORT group. IORT is not detrimental to subsequent radiological follow up.     

前列腺癌的外照射放疗进展

外照射放疗作为前列腺癌的主要治疗手段之一,随着放疗技术的进步、靶区认识的统一,已进入精确放疗时代.高剂量放疗的准确实施,使前列腺癌的疗效显著提高.而影像引导的放射治疗、质子放疗和低分割放疗则是疗效进一步提高的研究方向.     

In vivo dosimetry during external photon beam radiotherapy

In this critical review of the current practice of patient dose verification, we first demonstrate that a high accuracy (about 1-2%, 1 SD) can be obtained. Accurate in vivo dosimetry is possible if diodes and thermoluminescence dosimeters (TLDs), the main detector types in use for in vivo dosimetry, are carefully calibrated and the factors influencing their sensitivity are taken into account. Various methods and philosophies for applying patient dose verification are then evaluated: the measurement of each field for each fraction of each patient, a limited number of checks for all patients, or measurements of specific patient groups, for example, during total body irradiation (TBI) or conformal radiotherapy. The experience of a number of centers is then presented, providing information on the various types of errors detected by in vivo dosimetry, including their frequency and magnitude. From the results of recent studies it can be concluded that in centers having modern equipment with verification systems as well as comprehensive quality assurance (QA) programs, a systematic error larger than 5% in dose delivery is still present for 0.5-1% of the patient treatments. In other studies, a frequency of 3-10% of errors was observed for specific patient groups or when no verification system was present at the accelerator. These results were balanced against the additional manpower and other resources required for such a QA program. It could be concluded that patient dose verification should be an essential part of a QA program in a radiotherapy department, and plays a complementary role to treatment-sheet double checking. As the radiotherapy community makes the transition from the conventional two-dimensional (2D) to three-dimensional (3D) conformal and intensity modulated dose delivery, it is recommended that new treatment techniques be checked systematically for a few patients, and to perform in vivo dosimetry a few times for each patient for situations where errors in dose delivery should be minimized.     

Class solutions for conformal external beam prostate radiotherapy

PURPOSE: To determine a class solution coplanar plan from comparisons of three-field (3F), four-field (4F), and six-field (6F) plans in conformal non-intensity-modulated prostate radiotherapy. METHODS AND MATERIALS: Doses to two clinical target volumes, prostate only (PO) and prostate plus seminal vesicles (PSV) were evaluated in each of 10 patients using a variety of 3F, 4F, and 6F plans with a planning target volume margin of 10 mm. All plans were prescribed to 64 and 74 Gy. The class solution plan for each of 3F, 4F, and 6F was chosen from a variety of symmetrical and asymmetrical field arrangements that had been previously assessed. The class solution plans, 3F (0, 90, 270 degrees ), 4F (35, 90, 270, 325 degrees ), and 6F (50/lat/25) were compared with reference plans: 3F (0, 120, 240 degrees ), 4F (0, 90, 180, 270 degrees ), and 6F (55, 90, 125, 235, 270, 305 degrees ). Rectal volumes irradiated to greater than 50% (V(50)), 80% (V(80)), and 90% (V(90)) of the prescribed dose, normal tissue complication probabilities (NTCP) for rectum, bladder, and femoral heads (FH), and tumor control probabilities (TCP) were assessed. FH tolerance was set at 52 Gy to 10% volume. RESULTS: The field arrangement that gave the lowest irradiated rectal volume with acceptable bladder and FH doses was a 3F (0, 90, 270 degrees ) class solution plan. This plan gave a reduction in rectal V(80) of 1.2-12.4% for the PO group and 2.3-23.8% for the PSV group compared with the other plans. The reduction in rectal V(90) was 0.2-11.9% for the PO group and 1.5-23.3% for the PSV group using the 3F (0, 90, 270 degrees ) plan. This plan provided one of the lowest rectal NTCPs, but the difference was not significant when compared with the 4F class solution plan. When target volumes with 10-mm margins remain unchanged to 74 Gy, the irradiated rectal volumes for all plans were higher and rectal NTCPs can be trebled. CONCLUSION: The use of appropriate beam arrangements can provide a class solution plan using only 3 fields compared with 4 or 6 fields for the parameters considered. Both 3F (0, 90, 270 degrees ) and 4F (35, 90, 270, 325 degrees ) plans can be used as a class solution plan. Other practical issues that may influence the choice of class solution include delivery time with smaller number of fields, ease of verification, the use of 10-mm multileaf collimation vs. conformal blocks, and field shape fitting limitations when using dynamic wedges.