放射治疗在肺癌多学科综合治疗中的应用

21世纪初，肺癌将成为支配全球癌症流行的总趋势，今后30年中将成为中国居民的主要死因，手术，放疗和化疗是肿瘤治疗的三大支柱，放射治疗（简称放疗）是肺癌现代治疗中的重要手段，本文对单纯放疗（特殊情况下的放疗）以及放疗与手术，化疗的多学科综合治疗疗效进行了对比和归纳，笔者想念随着放疗设备的不断更新换代，以及多种照射技术和多学科综合治疗方法的迅速发展，必将进一步提高肺癌放疗的疗效。     

前列腺癌的放射治疗进展

前列腺癌局部根治性放射治疗包括外照射、内照射放疗等。近几年，三维适形放疗（3-dimentional conformal radiotherapy）、调强放疗（intensity modulated radiotherapy）、运用质子的调强放疗（intensity modulated protontherapy）、超声引导的经会阴粒子植人等治疗技术在临床逐渐取代传统放疗；最新的影像引导的放射治疗（image guide radiotherapy）以及生物靶区等概念已在临床开始应用。我们综述了前列腺癌体内、外照射技术的发展，着重介绍调强放疗。     

肿瘤放射治疗技术进展

20世纪90年代以来,随着放射物理技术、计算机技术和医学影像技术的迅猛发展,放射治疗技术已取得了长足进展。三维适形放疗、调强放疗、容积旋转调强放疗和螺旋断层放疗等先进放射治疗技术层出不穷,大幅提高了肿瘤靶区的物理适形度和治疗效率。但在肿瘤的放射治疗临床实践中仍然存在若干急需解决的问题。近年来,以生物引导放射治疗、图像引导放射治疗、剂量引导放射治疗和放射影像组学为代表的新技术,推动着放射治疗向以"精确定位"、"精确计划"和"精确治疗"为终极目标的"三精放疗"时代迈进。     

垂体瘤的放射治疗

在垂体瘤的治疗中 ,放射治疗作为一种有效的治疗手段起着举足轻重的作用。 1932年Ｃｕｓｈｉｎｇ采用放射技术照射脑垂体治疗Ｃｕｓｈｉｎｇ病取得了一定的疗效。伴随着手术和药物治疗的进步 ,放射治疗技术也在不断发展[1] 。近 2 0年来 ,在常规放射治疗垂体瘤的基础上 ,计算机技术在放射医学临床领域的应用使垂体瘤放疗技术日趋精确 ,既往所引起的放疗并发症得到了有效的控制和改善 ,特别是立体定向放射治疗的开展使单独应用该技术就能对垂体瘤得到满意的治疗。放射治疗方法应根据患者的具体病情而定 ,目前有多种方式可供不同条件的医疗单…     

原发性肝癌的放射治疗

原发性肝癌(primary hepatocellular carcinoma,PHC)是我国常见的一种恶性肿瘤, 其病理类型中以肝细胞癌最多见. 放射治疗是一种常用的有效的治疗手段. 本文主要从肝癌放疗敏感性、放疗技术的发展等方面对PHC的放射治疗作一综述, 旨在说明PHC的放射治疗在减少放射性肝损伤等方以取得了可喜的成绩, 且仍有较大发展空间.     

肿瘤病人放疗的护理心得

放疗是肿瘤治疗中重要手段之一，但放疗同时，会出现许多局部及全身损害。因此，对放射治疗的病人不仅要做好放疗前、中、后的护理，也要做好对放射治疗所产生副反应的观察及护理工作。     

自适应放射治疗的研究进展

近年来,肿瘤放射治疗技术发展迅猛,由初期的粗放二维（常规照射）治疗模式,进展到三维适形放疗（3D-CRT）,再到三维调强放疗（IMRT）,进而发展到多维（如四维CT和图像引导放疗）,放疗已经进入了精确治疗的时代。精确治疗意味着在提高肿瘤剂量的同时,有效保护正常组织,从而提高患者的生存质量。自适应放射治疗（ART）是在3D-CRT和IMRT的基础上发展而来的新技术。本文就ART的研究进展作一综述。     

X-刀、γ-刀和三维适形放射治疗

随着科学技术的进步，尤其是电子计算机的飞速，发展国内外放射治疗的发展已有了长足的进步。X-刀、γ-刀和适形放疗技术日臻成熟。现就近10年来立体定向放射治疗的应用情况综述如下。     

精准放射治疗技术在直肠癌的临床应用

精准放射治疗技术在直肠癌综合治疗中占据重要地位,当前的主流技术为调强放射治疗技术(intensity modulated radiotherapy,IMRT).体位固定技术、图像引导技术及治疗中患者直肠和膀胱的充盈情况一定程度上直接影响直肠癌放射治疗的精准度和治疗效果.直肠癌放疗的不良反应对患者的生存质量有较大影响,正确合理地选择放射治疗技术有助于提高直肠癌放射治疗实施的精准性,降低周围正常组织的受照剂量,提高直肠癌肿瘤的局部控制率.本文就直肠癌精准放疗技术在临床中的运用和如何进一步提高其准确性做一综述.     

康复新液保留灌肠治疗中老年宫颈癌放射性直肠炎28例

宫颈癌(Cervical carcinoma)是老年妇女最常见的恶性生殖器官肿瘤,也是严重威胁妇女健康的一种疾病.放疗及手术是官颈癌有效的治疗手段,临床上根据病期及肿瘤大小或病人的意愿选择治疗方法;但无论早期还是中、晚期,放射治疗均是很好的治疗方法.放射治疗包括体外照射和腔内后装治疗.放射治疗的副作用包括急性放射炎和远期后遗症.直肠炎是很常见的一种急性放射反应,主要临床表现为腹痛、腹泻及里急后重等.这些反应严重影响患者的生活质量和对放疗的接受程度,有的甚至被迫停止放疗.本研究应用康复新液治疗由放疗引起的直肠炎,试图找到治疗或减轻宫颈癌放疗引起的直肠炎的更加有效的方法.     

Technical advances in external radiotherapy for hepatocellular carcinoma

Radiotherapy techniques have substantially improved in the last two decades. After the introduction of 3-dimensional conformal radiotherapy, radiotherapy has been increasingly used for the treatment of hepatocellular carcinoma(HCC). Currently, more advanced techniques, including intensity-modulated radiotherapy(IMRT), stereotactic ablative body radiotherapy(SABR), and charged particle therapy, are used for the treatment of HCC. IMRT can escalate the tumor dose while sparing the normal tissue even though the tumor is large or located near critical organs. SABR can deliver a very high radiation dose to small HCCs in a few fractions, leading to high local control rates of 84%-100%. Various advanced imaging modalities are used for radiotherapy planning and delivery to improve the precision of radiotherapy. These advanced techniques enable the delivery of high dose radiotherapy for early to advanced HCCs without increasing the radiation-induced toxicities. However, as there have been no effective tools for the prediction of the response to radiotherapy or recurrences within or outside the radiation field, future studies should focus on selecting the patients who will benefit from radiotherapy.     

Radiotherapy and radiosurgery for Cushing's disease

Patients with residual or recurrent Cushing's disease receive external beam radiotherapy (RT) with the aim of achieving long-term tumour control and normalization of elevated hormone levels. Treatment is given either as conventional radiotherapy using conformal techniques or as stereotactic radiotherapy, which is either used as fractionated treatment (SCRT) or as single fraction radiosurgery (SRS). We describe the technical aspects of treatment and report a systematic review of the published literature on the efficacy and toxicity of conventional RT, SCRT and SRS. There are no studies directly comparing the different radiation techniques and the reported results are inevitably of selected patients by investigators with interest in the treatment tested. Nevertheless the review of the published literature suggests better hormone and tumour control rates after fractionated irradiation compared to single fraction radiosurgery. Hypopituitarism represents the most commonly reported late complication of radiotherapy seen after all treatments. Although the incidence of other late effects is low, the risk of radiation injury to normal neural structures is higher with single fraction compared to fractionated treatment. Stereotactic techniques offer more localized irradiation compared with conventional radiotherapy, however longer follow-up is necessary to confirm the potential reduction of long-term radiation toxicity of fractionated SCRT compared to conventional RT. On the basis of the available literature, fractionated conventional and stereotactic radiotherapy offer effective treatment for Cushing's disease not controlled with surgery alone. The lower efficacy and higher toxicity of single fraction treatment suggest that SRS is not the appropriate therapy for the majority of patients with Cushing's disease.     

Exploiting sensitization windows of opportunity in hyper and hypo-fractionated radiation therapy

In contrast to the conventional radiotherapy/chemoradiotherapy paradigms used in the treatment of majority of cancer types, this review will describe two areas of radiobiology, hyperfractionated and hypofractionated radiation therapy, for cancer treatment focusing on application of novel concepts underlying these treatment modalities. The initial part of the review discusses the phenomenon of hyper-radiation sensitivity (HRS) at lower doses (0.1 to 0.6 Gy), describing the underlying mechanisms and how this could enhance the effects of chemotherapy, particularly, in hyperfractionated settings. The second part examines the radiobiological/physiological mechanisms underlying the effects of high-dose hypofractionated radiation therapy that can be exploited for tumor cure. These include abscopal/bystander effects, activation of immune system, endothelial cell death and effect of hypoxia with re-oxygenation. These biological properties along with targeted dose delivery and distribution to reduce normal tissue toxicity may make high-dose hypofractionation more effective than conventional radiation therapy for treatment of advanced cancers. The novel radiation physics based methods that take into consideration the tumor volume to be irradiated and normal tissue avoidance/tolerance can further improve treatment outcome and post-treatment quality of life. In conclusion, there is enough evidence to further explore novel avenues to exploit biological mechanisms from hyper-fractionation by enhancing the efficacy of chemotherapy and hypo-fractionated radiation therapy that could enhance tumor control and use imaging and technological advances to reduce toxicity.KEYWORDS : Low Doses Fractionated Radiation Therapy (LDFRT), hyper-radiation sensitivity (HRS), induced radiation resistance (IRR), hyperfractionation, chemopotentiation, stereotactic body radiation therapy (SBRT), stereotactic ablative radiosurgery (SARS), stereotactic ablative radiotherapy (SABR), stereotactic radiosurgery (SRS), spatially fractionated GRID radiotherapy (SFGRT), lattice     

2013年美国放射肿瘤学会年会肝脏肿瘤放射治疗研究进展荟萃

随着放射治疗技术的进步,肝脏肿瘤放射治疗疗效的提高,放射治疗为不能手术治疗的患者提供了新的选择。介绍了2013年第55届美国放射肿瘤学会(ASTRO)关于肝脏肿瘤放射治疗方面的进展,主要为立体定向放射治疗(SBRT)治疗肝肿瘤的疗效及毒副作用。未来放射治疗在肝脏肿瘤治疗中的地位将会日益凸显。现将本届会议的主要研究报道分类整理如下。     

Management of nonfunctioning pituitary tumors: radiotherapy

External beam radiotherapy (RT) is an essential part of the management of intracranial tumors and has been used in treating pituitary adenomas for more than five decades. It has been demonstrated that conventional RT for postoperative residual or progressive nonfunctioning pituitary adenomas (NFAs) present an excellent long-term local tumor control, although its use has been limited because of the potential late toxicity related to radiation treatments. Recent advances in radiation techniques have led to more accurate treatments, rendering obsolete many commonly held views of the “old” radiotherapy. New techniques include intensity modulated radiotherapy, volumetric-modulated arc therapy, and stereotactic techniques, either stereotactic radiosurgery or fractionated stereotactic radiotherapy. New techniques allow the delivering of higher radiation doses to the target with rapid dose fall-off in the surrounding normal tissues, and potentially limiting the long term toxicity of radiation. In this review, we present a critical analysis of the most recent available literature on the use of radiation in patients with NFAs, focusing particularly on the efficacy and safety of radiation stereotactic techniques.     

Intraoperative radiotherapy for treatment of locally advanced and recurrent esophageal and gastric adenocarcinomas

Intraoperative radiotherapy (IORT) allows delivery of radiotherapy doses in excess of those typically deliverable with conventional external beam radiotherapy. IORT has potential utility in clinical situations, such as treatment of esophageal and gastric malignancies, in which the radiation tolerance of normal organs limits the dose that can be given with conventional radiotherapy techniques. We reviewed the records of 50 patients who received IORT for locally advanced primary or recurrent gastric or esophageal adenocarcinomas deemed unresectable for cure. IORT was given as a single fraction of electron beam radiotherapy (10-25 Gy) after maximal tumor resection: R0 in 42%, R1 in 46%, and R2 in 12%. Forty-eight patients also received external beam radiotherapy (8-55 Gy), 46 received radiosensitizing chemotherapy, and nine received systemic chemotherapy after radiotherapy. Outcomes were estimated with Kaplan-Meier analysis. Median survival was 1.6 years. Overall survival at 1, 2, and 3 years was 70%, 40%, and 27%. Of 42 patients who died, 37 died from cancer progression and three from multifactorial treatment toxicity. Median survival for patients with recurrent disease versus primary disease was 3.0 years versus 1.3 years (P < 0.05), with a delay of metastatic failure in patients with recurrent tumors (P = 0.06). At 3 years, distant metastatic failure was 79%, local failure was 10%, and regional failure was 15%. IORT for locally advanced primary or recurrent gastric malignancies effectively decreases the risk of local failure. For patients with isolated local recurrences, IORT may be effective salvage therapy. However, more effective systemic therapy is needed as a component of treatment.     

Intraoperative and conformal external-beam radiation therapy in patients with locally advanced pancreatic carcinoma; results from a feasibility phase II study

BACKGROUND/AIMS: Chemoradiation therapy is widely indicated to patients with locally advanced pancreatic carcinoma, though the capability of radiotherapy alone is not assessed enough. The purpose of this study is to clarify the efficacy and safety of a more intensive radiotherapy for those patients. METHODOLOGY: Fifteen patients were enrolled in a feasible phase II study of treatment with intraoperative radiation therapy (25 Gy), followed by conformal external-beam radiation therapy (40 Gy in 20 fractions, 5 times/week). The antitumor effect was evaluated on the early phase of dynamic computed tomography image. RESULTS: The full irradiation dose was feasible in 12 of 15 patients. The overall response rate was 40% (1 complete and 5 partial responses). Grade 3 toxicity was observed in 2 patients (13%) with nausea/vomiting or anorexia. One patient developed gastric ulcer and died of gastrointestinal bleeding 12 months after intraoperative radiation therapy. The median survival time was 11.1 months, and the 2-year survival rates were 13%. Survival for more than 2 years was observed in 2 of the 6 responders. CONCLUSIONS: The above radiotherapy is considered to be active for the locally advanced pancreatic cancer with acceptable toxicity, when the gastrointestinal tract is excluded from the radiation field. This should be further assessed in late phase II studies involving a large number of patients.     

Morbidities of adjuvant chemotherapy and radiotherapy for resectable rectal cancer

PURPOSE: Although adjuvant chemoradiotherapy may improve outcomes after surgery for high-risk rectal cancer, its toxicities are not well documented. This is a review of complications associated with adjuvant therapy in randomized, controlled trials. METHODS: A MEDLINE and literature search was performed for randomized, controlled trials of adjuvant therapy for rectal cancer. Modalities of adjuvant therapy evaluated included preoperative radiotherapy, preoperative chemoradiotherapy, postoperative radiotherapy, and postoperative chemoradiotherapy. All documented complications were analyzed, including any effect on pelvic floor function and quality of life. RESULTS: Short-term (acute) complications of preoperative radiotherapy include lethargy, nausea, diarrhea, and skin erythema or desquamation. These acute effects develop to some degree in most patients during treatment but are usually self-limiting. With preoperative radiotherapy the incidence of perineal wound infection increases from 10 to 20 percent. The acute toxicities after postoperative radiotherapy for rectal cancer occur in 4 to 48 percent of cases, and serious toxicities, requiring hospitalization or surgical intervention, occur in 3 to 10 percent of cases. Postoperative radiotherapy is associated with more complications than preoperative radiotherapy. The main problems with postoperative radiotherapy are small-bowel obstruction (5–10 percent), delay in starting radiotherapy caused by delayed wound healing (6 percent) and postoperative fatigue (14 percent), and toxicities precluding completion of adjuvant therapy (49–97 percent). The morbidity and mortality of both preoperative and postoperative radiotherapy are higher in elderly patients and when two-portal rather than three-portal or four-portal radiation technique is used. Meticulous radiation technique is important, and multiple fields of irradiation are mandatory. After combined adjuvant chemotherapy and radiotherapy acute hematologic and gastrointestinal toxic effects are frequent (5–50 percent). Delayed radiation toxicities include radiation enteritis (4 percent), small-bowel obstruction (5 percent), and rectal stricture (5 percent). Pelvic floor function and quality of life have not been well evaluated in randomized, controlled trials. CONCLUSION: Adjuvant therapy for rectal cancer has considerable adverse effects. Adverse effects on bowel and sphincter function and quality of life have not been defined.Dr. Ooi is supported in part by the Irene and Margaret Stewardson Charitable Trusts.     

Progress in radiation therapy and integration in Tenon hospital (AP-HP) of new advances in routine practices of radiotherapy for non-small-cell lung cancer

Much progress has been made in recent years in administration modalities for external radiotherapy of non-small-cell lung carcinoma. Three-dimensional conformal radiotherapy with or without intensity modulation, with respiratory gated radio-therapy (4D radiotherapy), and image-guided radiotherapy (IGRT) can be considered as a third revolution in radiation therapy after total dose fractionation and the development of megavoltage radiation therapy equipment. We describe progress in the three-dimensional radiotherapy technique and the integration of this technique in the department of Radiation Oncology at Tenon hospital (AP-HP).