三维适形放疗联合化疗治疗局部晚期和术后复发性直肠癌

目的：探讨局部晚期和术后复发性直肠癌三维适形放射治疗（3D—CR）联合化疗的临床疗效。方法：30例局部晚期和术后复发性直肠癌采用常规放射治疗至40Gy，再予后程适形放疗加化疗。适形放疗25Gy-30Gy，肿瘤总量65Gy-70Gy；化疗采用奥沙利铂130mg／m^2，d1，亚叶酸钙100mg／m^2，d1-5,5-氟脲嘧啶500mg／m^2，d1-5。结果：患者有效率为90％；12、24、36月生存率分别为83．3％，60％，40％；12、24、36月局部控制率分别为90％，83．3％，56．7％。胃肠道反应、骨髓抑制、放射性直肠炎、放射性膀胱炎为主要副反应，多为1—2级。结论：三维适形放疗联合化疗可提高局部晚期和术后复发性直肠癌的控制率和生存率。     

直肠癌五野调强放疗与传统适形放疗剂量学研究

目的：研究五野调强技术（ＩＭＲＴ）与三维适形（３ＤＣＲＴ）技术治疗直肠癌肿瘤靶区和危及器官照射剂量的区别。方法：回顾性分析１５例直肠癌患者的放疗资料,其中７例为术前放疗,８例为术后放疗。在每位患者的模拟定位ＣＴ上分别勾画肿瘤靶区及小肠、膀胱、股骨头等危及器官（ＯＡＲ）,并分别进行３ＤＣＲＴ和ＩＭＲＴ计划设计,要求处方剂量至少覆盖９５％的计划靶体积。应用适形指数（ＣＩ）和均匀指数（ＨＩ）评价肿瘤靶区剂量的分布,应用Ｄｘ％（接受高量照射的ｘ％的体积所受到的最低剂量）和平均剂量评价ＯＡＲ受照射剂量。两个计划剂量分布的差别采用配对ｔ检验比较。结果：在ＩＭＲＴ和３ＤＣＲＴ计划中,ＣＩ分别为０.９４和０.８７（Ｐ＝０.０００）;ＨＩ分别为１.１３和１.１７（P＝０.００１）;小肠Ｄ３０％分别为１９.６７Ｇｙ和２５.２０Ｇｙ,Ｄ５０％分别为１５.１３Ｇｙ和２２.２０Ｇｙ,平均剂量分别为１８.８１Ｇｙ和２２.８９Ｇｙ（Ｐ均为０.０００）;膀胱的Ｄ３０％分别为３４.２０Ｇｙ和４４.６７Ｇｙ,Ｄ５０％分别为２４.８０Ｇｙ和３５.０７Ｇｙ,平均剂量分别为２８.７０Ｇｙ和３５.６８Ｇｙ（Ｐ均为０.０００）;股骨头Ｄ５％分别为４０.６０Ｇｙ和４０.４７Ｇｙ(P＝０.９３６）,平均剂量分别为３０.１４Ｇｙ和２５.５７Ｇｙ（Ｐ＝０.００１）。结论：ＩＭＲＴ在靶区剂量均匀性和适形度方面均优于３ＤＣＲＴ计划,对正常组织的保护也存在明显的优势。     

直肠癌术后调强放疗和三维适形放疗剂量学比较研究

目的比较研究直肠癌术后调强放疗（IMRT）和三维适形放疗（3DCRT）时靶区及其周围危及器官受照剂量的差异。方法随机选择6例直肠癌术后患者,进行CT扫描、靶区和危及器官的勾画,用三维治疗计划系统进行3DCRT和IMRT计划设计,并对结果进行比较分析。结果IMRT计划PTV的均匀性（1．09±0．02）和适形度（0．81±0．08）均优于3DCRT计划（1．17±0．01,0．66±0．05）,差异具有统计学意义（P〈0．05）。IMRT与3DCRT相比,在50Gy的高剂量区,膀胱的V50下降了10％,小肠的V50下降了4％,差异具有统计学意义（P〈0．05）,而左、右股骨头的差异无统计学意义。结论在直肠癌术后放疗中,IMRT技术较3DCRT技术有剂量学方面的优越性。     

直肠癌术前三维适形放疗和五野调强放疗的剂量学比较研究

目的:探讨直肠癌术前三维适形放疗(3D-CRT)和五野调强放射治疗(5F-IMRT)计划的剂量学特点,及其术前放疗较佳的放疗技术.方法:对27例拟行术前放疗的直肠癌患者进行3D-CRT和IMRT 2套治疗计划设计,比较2种放疗计划的靶区剂量学特点以及小肠、膀胱和双侧股骨头等正常组织的受照射剂量及体积.结果:5F-IMRT计划中适形指数(CI)为(0.805±0.050),大于3D-CRT(0.698±0.060),P＜0.001;2种计划的GTV均匀指数(HI)值均非常接近1,差异无统计学意义;5F-IMRT计划中HICTV和HIPTV值均分别小于3D-CRT计划,P＜0.05.5F-IMRT计划中小肠D5、Dmin和Dmax与3D-CRT相应参数差异无统计学意义,但Dmean低于3D-CRT,P＜0.05;5F-IMRT计划中小肠V30高于3D-CRT,而V50则前者低于后者,差距也有统计学意义,P=0.041.类似的结果也见于膀胱.5F-IMRT计划中左、右股骨头Dmin和Dmax均低于3D-CRT,V40也明显小于3D-CRT,P＜0.05.结论:直肠癌术前放疗5F-IMRT计划剂量分布适形性及均匀性明显优于3D-CRT,且能更好地保护直肠周边邻近的正常组织器官.     

直肠癌盆腔常规放疗与三维适形放疗的剂量学研究

目的比较直肠癌盆腔常规放疗和三维适形放疗（3DCRT）对治疗靶区及盆腔正常组织和器官的影响。方法对36例接受3DCRT的直肠癌患者CT定位图像资料进行研究,在连续的CT图像上分别勾画出肿瘤临床靶区（CTV）和危及组织、器官（大小肠、膀胱、盆腔骨、股骨头颈）,用三维治疗计划模拟出2种三维治疗方式（3、4个野计划）和3种常规治疗方式（2、3、4个野计划）,即3D-3、3D4、2D-2、2D-3、2D4治疗计划。通过剂量-体积直方图（DVH）的分析来评价这5种治疗方式对CTV和危及组织、器官的影响。结果5种治疗方式的D95、V95都达到97%以上,3D治疗的适形指数（CI）明显大于2D治疗,剂量不均匀指数（DI）4个野方式要明显小于3个野方式。3D-3与2D-3、3D-4与2D-4相比大小肠受照平均剂量分别要减少28．5%和25．7%,差异有统计学意义。在45 Gy高剂量区3D-3与2D-2、3D-3与2D-3和3D4与2D4相比分别要减少80．8%、51．1%和54．7%的大小肠受照体积。对盆腔骨和膀胱的影响,无论是平均受照剂量还是35、45 Gy的高剂量受照体积3D方式均要明显优于2D方式,且差异有统计学意义。对股骨头颈的影响3D方式明显优于2D方式。结论尽管直肠癌盆腔常规放疗和3DCRT对靶区CTV的影响差别不大,但对盆腔正常组织和器官的影响却有明显不同,3DCRT更能有效地保护正常组织和器官。     

三维适形放射治疗对脑瘤患者肿瘤标志物和基质金属蛋白酶的影响

目的探讨三维适形放射治疗(3D-CRT)对脑瘤患者肿瘤标志物和基质金属蛋白酶(MMP)相关指标的影响。方法选取2014年2月至2015年10月间青岛市胶州中心医院收治的68例脑瘤患者,采用随机数字表法分为对照组和观察组,每组34例。对照组患者采用手术治疗和常规化疗,观察组患者在对照组基础上行3D-CRT,比较两组患者总有效率、治疗前后肿瘤标志物和MMP相关指标。结果观察组患者中,脑胶质瘤患者总有效率为85.0%,其他脑瘤患者总有效率为78.6%,全组患者总有效率82.4%,高于对照组患者的50.0%、35.7%和44.1%,差异有统计学意义(P<0.05)。观察组患者治疗后不同时间肿瘤标志物和MMP相关指标水平均低于对照组患者,差异均有统计学意义(均P<0.05)。结论 3D-CRT对脑瘤患者的治疗效果较好,对患者肿瘤标志物和MMP相关指标的表达也有较好的控制作用。     

三维适形放疗结合奥沙利铂为主的化疗治疗晚期直肠癌

目的 探讨三维适形放疗（3DCRT）结合奥沙利铂为主化疗治疗局部晚期和术后复发直肠癌的临床疗效。方法 66例局部晚期和术后复发直肠癌均在常规放疗44Gy后进入3DCRT，采用3DCRT结合奥沙利铂、氟尿嘧啶、亚叶酸钙同步化疗（综合组）34例，单独应用3DCRT（对照组）32例。综合组同步放化疗结束3～4周后，再巩固化疗2～3个周期。结果 综合组和对照组疼痛缓解率分别为97％和84％（P〉0．05）；有效率（CR＋PR）分别为91％和84％（P〉0．05）；2年局部控制率与局部无进展率之和分别为71％和66％（P〉0．05）；2年生存率分别为65％和38％（P〈0．01）；2年远处转移率分别为35％和63％（P〈0．01）。在毒副反应方面两个组相似（P〉0．05）。结论 三维适形放疗结合奥沙利铂为主化疗治疗局部晚期和术后复发直肠癌可明显减少远处转移率和提高2年生存率，且毒副反应可以耐受。     

胸部肿瘤三维适形放疗剂量造影剂影响的研究

目的:探讨CT造影剂对胸部肿瘤三维适形放疗剂量的影响.方法:共有40例患者入组,其中食管癌患者34例,肺癌患者6例,中位年龄62岁.在相同扫描条件下分别行CT平扫及增强扫描.在图像融合状态下,分别勾画大体靶区(GTV)、临床靶区(CTV)、计划靶区(PTV)以及危及器官,以平扫图像为基础图像进行剂量计算和计划优化,PTV边缘剂量1.8～2.0 Gy/次,总量45～66 Gy,并以此计划进行治疗.利用计划系统图像融合的功能,将在平扫图像(C-)上勾画的靶区及照射野设计复制到增强图像上,在增强图像(C+)上重新进行剂量计算;分别比较C+和C-图像中相对应的单次治疗照射野MU的不同(按照2 Gy/次计算),肿瘤中心点的剂量、肿瘤边缘点的CT值及剂量的不同;并进行统计学分析.结果:40例患者共有205个照射野,其平扫及增强图像射野MU分别为284.55±63.64和283.00±63.21,P=0.120;肿瘤中心点的剂量分别为平扫(45.219 5±9.561 4) Gy、增强(45.211 7±9.614 5)Gy,P=0.772;肿瘤边缘点的剂量分别为平扫(43.837 2±9.304 9)Gy、增强(42.904 5±9.164 5)Gy,P=0.001;边缘点的CT值分别为平扫(140.83±40.55) HU、增强(39.20±20.82) HU,P=0.00.结论:采用适当的扫描条件,对于胸部肿瘤,可以采用直接增强扫描的方式进行CT定位,使用CT增强扫描对放疗计划的优化影响不明显.     

局部复发鼻咽癌三维适形放疗初步观察

目的:探索三维适形放疗(3demensionalconformalradiationtherapy3DCRT)技术在局部复发鼻咽癌再程放疗中的应用。方法:1998年4月～1999年10月,采用3DCRT技术治疗局部复发鼻咽癌26例。其中低分化鳞癌25例,低分化腺癌1例。按92’福州分期标准再分期:T1N0M04例,T2N0M08例,T3N0M09例,T4N0M05例。密集肿瘤区(grosstumorvolumeGTV)最大径1.0～5.0cm(平均3.1cm)。全组病例均采用每次5～7个固定适形野照射,计划靶区(planningtargetvolumePTV)平均最大剂量、最小剂量、平均剂量分别为104.1±1.3%、92.1±2.8%、99.2.±1.7%。时间-剂量-分次处方:65～70Gy/26～28次,共5～5.5周。随访8～26个月,中位随访时间17个月。结果:再程放疗后随访期内靶区边缘复发2例,颈淋巴结复发3例,远处转移2例,死亡4例。随访期内肿瘤局部控制率88.5%(23/26),84.6%(22/26)患者生存,76.9%(20/26)无瘤生存。再程放疗所致急性放射反应少而轻。累计后遗症发生率19.2%(5/26),放射性功能损害发生率15.4%4/26。结论:三维适形放疗技术用于局部复发鼻咽癌具有明显的剂量分布优势。初步临床观察结果表明,这一放疗新技术用于局部复发鼻咽癌肿瘤局部控制率高、放射反应和后遗症较少,远期疗效和后遗症尚有待观察。     

105例体部肿瘤三维适形放疗

目的 分析三维立体适形放射治疗体部恶性肿瘤的近期疗效.方法 对105例体部恶性肿瘤采用全身三维立体定向适形放射治疗固定系统固定,然后经螺旋CT定位扫描,拓能3D-TPS设计治疗计划,医科达直线加速器实施计划.每次2.5～4 Gy,1次/d,DT 20～50 Gy.结果 CR 51例,PR 41例,CP PR 87.6%(92/105),NC 9例,PD 4例.结论 三维立体适形放射治疗恶性肿瘤可以得到较好的近期疗效,值得推广应用.     

Adjuvant radiation therapy for rectal cancer

Since 1976, 104 patients with rectal cancer have been treated with a new approach of combined pre- and postoperative radiation. All patients were given 500 rad preoperative irradiation on the day of or the day before surgery. Surgery in the majority of patients was an abdominal perineal resection. The disease was then staged pathologically according to Astler-Coller's modification of Duke's staging. Patients with early stage cancer (Stages A and B1) were followed with no further therapy. Patients with poor prognostic characteristics (Stages B2, C1, C2) were given postoperative pelvic irradiation (4500 rad in 5 weeks). Twenty-nine patients were found to have Stage A or B1 cancer and were followed with no further therapy. Of these 29 patients, 1 patient developed recurrence and one has died of metastatic disease. The excellent survival of patients with early tumors indicates that minimizing the role of adjuvant therapy in this group has not been detrimental to their survival. Fifteen were found to have liver metastases at laparotomy and had just a colostomy and palliative therapy. Sixty patients had Stage B2 and C disease. Thirty-one received postoperative irradiation as per protocol. Twenty-nine patients did not receive postoperative irradiation for a variety of reasons. Follow-up ranges from 1 to 7 years in these patients. Of the 29 patients with Stage B2 and C disease who should have but did not receive postoperative radiation, 10 patients (34%) have developed a recurrence in the pelvis, and 5 other patients (17%) have developed metastatic disease. Of 31 patients who received postoperative irradiation, only 2 patients (6%) developed a local recurrence and 4 patients (13%) have developed distant metastases. Survival at 3 years was 80% for patients receiving the combined treatment, as compared to 42% for those not receiving the postoperative part of the treatment protocol.     

三维适形放疗治疗直肠癌术后复发病例临床观察

目的：观察三维适形放疗治疗直肠癌术后复发病例的疗效。方法：选择直肠癌术后复发患者54例接受三维适形放疗，其中低分化腺癌4例，中分化腺癌37例，高分化腺癌7例，粘液腺癌6例。放疗总剂量在60－72GY／22－24F／每周4－5次，其毒性作用用血液学、生化试验、胃肠道和泌尿系统反应进行评价。观察有无放射性肠淡症状，监测血细胞。每3月复查MRCT1次，二年生每6月复查MR或CT1次。结果：迄2000年12月25日止共随访54例，随访到53例（98.1%），失访1例（1.9%）；中位随访时间为15.4个月，平均访时间为14.3个月（3－30个月）。疗效判定标准：按WHO制订标准，完全缓解5例，占9.3%；部分缓解27例，占50.0%。稳定15例，占27.8%；进展6例占11.1%。有效率为59.3%。一年生存率61.1%（33/54），症状缓解率92.6%（50／54）。放射性肠炎发生率约为5.6%。均未出现白细胞减少和肝、肾功能降低与尿频、尿急、尿痛和血尿。结论：三维适形放射治疗直肠癌术后复发患者具有明显的剂量分布优势，局部控制率和症状缓解率高，放射性肠炎发生率低。     

Development of an irradiation method of intraoperative radiation therapy for curatively resected rectal cancer

Background. Intraoperative radiation therapy (IORT) has been performed to prevent local recurrence of rectal cancer only when positive margins are suspected. To further reduce local recurrence, we attempted to develop a new IORT irradiation method in which electron beam irradiation is administered as uniformly as possible to the intrapelvic dissection surfaces. Methods. Low anterior resection and abdominoperineal resection were performed in one male and one female cadaver. Electron beam irradiation was administered by four different methods, and absorbed doses were measured at 15 sites within the pelvis. We also attempted to measure absorbed doses at nine sites within the pelvis in 14 patients treated with IORT. Results. The cadaver study revealed low absorbed doses in the lateral walls of the pelvis when a single irradiation was delivered from the anterior. When the lateral walls of the pelvis were irradiated twice, once each time on the right and left, the absorbed doses were low in the central pelvis and presacrum. Relatively high absorbed doses were achieved in all of these areas by a technique that combined these two methods. Adequate absorbed doses were not achieved by a single irradiation administered from the perineum. Conclusion. This study suggests that electron beam irradiation administered three times to the dissected surfaces in the pelvis after resection of rectal cancer (i.e., to the central pelvis and presacrum from the anterior, and to the left and right lateral walls of the pelvis) is the most suitable method for achieving adequate absorbed doses. Received: May 6, 1998 / Accepted: December 15, 1998     

Advances in combined radiation therapy for the management of rectal cancer

Significant advances have been made in the use of adjuvant radiation for patients with localized rectal cancer. Recent progress in adjuvant postoperative radiation regimens relates to the integration of systemic therapy into radiation, as well as redefining the techniques and sequences for both modalities. The adjuvant radiation management approach in both North America and Europe has been shifting towards preoperative adjuvant therapy to promote sphincter-preserving surgery and to decrease acute and late toxicity. Although 5-fluorouracil-based chemotherapy in combination with radiation remains the standard adjuvant therapy for rectal cancer, the integration of novel chemotherapeutic agents and biologic modulators remains an active area of investigation.     

Ⅰ、Ⅱ期乳腺癌保乳术后的三维适形调强放射治疗

目的对Ⅰ、Ⅱ期乳腺癌施行保乳术后的病人进行根治性三维适形调强放射治疗,提高局部控制率,减轻放疗副作用,提高了生存质量.方法2004年4月～2004年10月的11例接受过标准保存乳房手术的Ⅰ、Ⅱ期乳腺癌病人,均为女性,年龄31～46岁,平均34.7岁.术前触诊肿瘤大小为6mm～30mm,术后病理结果为:单纯癌4例、浸润性导管癌5例、高分化管状腺癌1例、中分化腺癌1例.手术后三个月内接受三维适形调强放射治疗.乳房切线照射剂量47～50Gy/24～31次,局部电子线补量10～15Gy/5～8次.结果全部病人顺利完成全程放疗,最长1例接受放疗后已经2年半,局部及全身未见复发征象,乳房外观形状良好,放疗反应轻微.结论通过对Ⅰ、Ⅱ期乳腺癌病人进行三维适形调强放射治疗,达到了提高病人的生存质量,提高肿瘤控制率的目的.     

Intraoperative radiation therapy

The modern use of intraoperative radiation therapy (IORT) was initiated by the studies of Abe and colleagues at the University of Kyoto. This work stimulated significant laboratory and clinical investigation into the use of IORT throughout Japan, Europe, and the United States. Because of this experience, single high doses of irradiation can be safely delivered to a tumor volume in appropriate clinical situations. Most importantly, this high dose of additional radiation treatment yields improved local control of selected tumors. Treatment programs of external beam radiation therapy, surgical resection, and IORT for patients with locally advanced primary and recurrent rectal carcinoma and retroperitoneal sarcoma have yielded excellent local control and higher survival rates. The future of IORT will be in the successful integration of this therapy into multimodality treatment programs of chemotherapy, external beam irradiation, and surgery for locally advanced malignancies. Received: August 20, 2001     

直肠癌的新辅助治疗

近年来,直肠癌发病率逐年上升,随着新辅助治疗的提出与应用,直肠癌的疗效得到提升,引起国内外学者的关注。新辅助治疗包括术前放疗、术前化疗和术前同步放化疗。其中术前放疗方式可分为短程放疗和常规放疗,通过比较T降期率、保肛率、完全缓解率等指标,对两种方式的临床效果进行了评价。尽管单纯术前化疗的经验还不够丰富,但其仍在降低肿瘤分期等方面具有优势。目前,临床应用最多的为术前同步放化疗,且国内外学者均认为该方式在治疗直肠癌时具有明显优势,同时,三维放疗技术可使靶区分布更为均匀,对病灶治疗更为精准。但直肠癌的新辅助治疗在国内却尚未广泛应用于临床,对其临床效果的确定仍需进一步的理论支持,本文就直肠癌的新辅助治疗做一综述。     

三维适形放疗同步吉西他滨化疗治疗中晚期胰腺癌的疗效观察

目的:回顾性分析三维适形放射疗法(three dimensional-conformal radiotherapy,3DCRT)同步吉西他滨化疗治疗中晚期胰腺癌的疗效和安全性。方法:收集2005年6月-2010年6月接受3DCRT同步吉西他滨化疗的32例Ⅲ～Ⅳ期初治中晚期胰腺癌患者的临床资料。从放疗第1周起同步化疗,吉西他滨500～750mg/m2d1静脉滴注,每周1次,直至放疗结束。6MV X线50.0～50.4Gy,1.8～2.0Gy/次,1次/d,每周5d。结果:32例患者均全部完成放疗计划,8例患者按计划完成放化疗。完全缓解1例(3.1%)、部分缓解8例(25.0%)、疾病稳定15例(46.9%)、疾病进展8例(25.0%),总有效率为28.1%(9/32),疼痛缓解率达75.9%(22/29)。中位生存时间为10.6个月,1年生存率为20.4%,2年生存率为0%。主要不良反应为白细胞减少(62.5%)、血小板减少(59.4%)、恶心和呕吐(81.2%)和肝功能损害(78.1%),未发生4级不良反应。结论:3DCRT同步吉西他滨化疗治疗中晚期胰腺癌显示出较好的疗效,可明显提高患者的生活质量,延长患者的生存期,且不良反应可耐受。