宮頸癌靶區(qū)勾畫原則

1、子宮頸癌IMRT靶區(qū)設(shè)計原則,四川省腫瘤醫(yī)院放療科譚燕Sichuan Cancer Hospital,Chengdu 610041 P.R.ChinaTel:(028)85420332,,提綱,背景分析UCC IMRT 設(shè)計原則IMRT治療與器官內(nèi)運動IMRT 劑量補償?shù)?D-OHDR病例介紹,,,子宮頸癌轉(zhuǎn)移模式及轉(zhuǎn)移幾率,,Lymphatic drainage pattern. Adapted from: Plentl

2、 AA, Friedman EA (1971)Lymphatic system Of the female genitalia. Saunders, Philadelphia, p 83,2009年FIGO,,,,新分期的特點,Stage IIA is subdivided into stage IIA1 and IIA2 (4 cm)Microinvasive and invasive adenocarcinoma should

3、 be staged assquamous cell carcinoma of the cervix.The use of MRI/CT /PET-CTscanning is encouragedFIGO 依然是UCC分期標準，但是隨著現(xiàn)代影像技術(shù)的介入，涉及到1/4 IB, 1/2 IIA-IIB, 2/3 IIIA,和 90% 的IIIB 病人的臨床分期發(fā)生改變；上調(diào)26% IB, 40% IIA, 50% IIB, 66%

4、IIIA,和 75% IIIB 期。 FIGO 僅可用于把握治療原則，而不能用于指導具體治療策略！！(Sources: Averette HE, Ford JHJ, Dudan RC et al(1994) Staging of cervical cancer. Clin Obstet Gynecol 18:215–232; Eifel PJ(1994) Problems with the clinical stag

5、ing of carcinoma of the cervix. Sem inRadiat Oncol 4:1–8,,治療策略選擇,,中華婦瘤專委會指南：IA： 手術(shù)IB1-IIA：手術(shù)+術(shù)后放化療IIB-IVA：放化聯(lián)合治療,IA,non-bulky IB, and early-stage IIA tumors ：RT與手術(shù) 療效等同≥ IB2 ：RT+cisplatin-based chemoRT 適用于所有

6、期別NCCN2010：鉑類一線方案,子宮頸癌IMRT（EBRT）設(shè)計原則,基本原則：提高靶區(qū)劑量覆蓋及劑量均勻度，減少OAR劑量實現(xiàn)途徑：認識原發(fā)灶浸潤范圍（局部大小、宮旁、陰道、直腸、膀胱、M?）評價淋巴引流區(qū)與轉(zhuǎn)移其他個體化相關(guān)預(yù)后因素評價（CBC、年齡、免疫狀態(tài)、合并疾病、 依從性、耐受能力）,,盆腔引流區(qū)轉(zhuǎn)移,,,腹主動脈旁轉(zhuǎn)移,,

7、淋巴結(jié)轉(zhuǎn)移與預(yù)后,,Volume 25.number 24 augest 20 2007,JOURNAL of CLINICALONCOLOGY,腹主動脈旁照射與預(yù)后,,,A,B: Example of treatment plan with intensity modulated radiation therapy for irradiation of para-aortic lymph nodes. C: Dose-volume h

8、istogram (DVH) illustrating sparing of left kidney and small intestine (Plan 7A solid line; Plan 78B dashed line). CTV, clinical target volume. (From Grigsby PW, Singh AK, Siegel BA, et al. Lymph node control in cervical

9、 cancer. Int J Radiat Oncol Biol Phys 2004;59:637–638,with permission.),子宮頸癌靶區(qū)勾畫,CT/MRI/PET宮頸、宮體、陰道、宮旁分開勾畫局部病灶不同，靶區(qū)設(shè)計不同（下1/3陰道）腹主動脈旁淋巴結(jié)轉(zhuǎn)移（根治和術(shù)后一樣重要）髂總及髂外、內(nèi)，閉孔及骶前，下腹部淋巴引流區(qū)；陰道旁及韌帶前1/3IIIB期:均應(yīng)包括腹主動脈旁淋巴引流區(qū)陰道下1/3受浸:應(yīng)考慮

10、腹股溝區(qū)引流淋巴區(qū)預(yù)防,,RTOG 靶區(qū)定義,,,RTOG 劑量指南,精細勾畫,,我院靶區(qū)示意圖,子宮頸癌術(shù)后靶區(qū)定義（RTOG）,,腔內(nèi)近距離靶區(qū)定義,,Diagrammatic representation of GTV and CTV for three-dimensional treatmentplanning in carcinoma of uterine cervix. Coronal (A,C) and transvers

11、e (B,D) sections for limited (A,B) and advanced (C,D) disease (gray zones in left parametrium). CTV, clinical target volume;GTV, gross tumor volume. (From Potter R, Haie-Meder C, Limbergen EV, et al. Recommendations from

12、 gynaecological (GYN) GEC ESTRO working group (II): Concepts and terms in 3D imagebased treatment planning in cervix brachytherapy-3D dose volume parameters and aspects of 3D image-based anatomy, radiation physics, radio

13、biology. Radiother Oncol 2006;78:67–77,with,我院IMRT補償3D-OHDR靶區(qū)示意圖,,,IMRT治療與器官內(nèi)運動,The pre-treatment CTV (red) and CTV at a later time point (light blue) overlaid on one scan. The PTV around the pre-treatment CTV is also sh

14、own (dark blue). (a) CT transversal slice; (b) CT sagittal slice; (c) MRI transversal slice; (d) MRI sagittal slice.,IMRT治療中靶區(qū)運動情況,The pre-treatment GTV (red) and four GTVs at later time points (week 1: yellow, 2: li

15、ght blue, 3: green, 4: magenta). The genericPTV is shown around the pretreatment GTV (dark blue); (b) analogous for the CTV.,IMRT治療腫瘤消退與器官運動,sagittal view of two patients at two different time points. Patient A shows al

16、most no change in position of the CTV (A; pre-treatment bladder volume 35 cc, A; week1 bladder volume 124 cc). Patient B shows a substantial change in orientation of the uterus (B; pre-treatmentbladder volume 117 cc, B;

17、 week 4 bladder volume 49 cc). Bowel, green; rectum, yellow; bladder, pink; GTV, red; CTV, blue,膀胱充盈狀態(tài)對靶區(qū)影響,直腸充盈狀態(tài)對靶區(qū)的影響,我院對IMRT過程中內(nèi)運動研究,IIB 10例 IIIB 10例入組：15min/次 IMRT 采集3次離線16排CT 總計60每周第1天(15min/次IMRT)采集3次X 4周 總

18、計 240次CT4DCT/次IMRT 總計80次,單次IMRT照射過程中靶區(qū)動度變化,單次IMRT照射過程中宮體動度變化,單次IMRT照射過程中宮頸動度變化,分次IMRT照射間靶區(qū)動度變化,分次IMRT照射間宮頸動度變化,分次IMRT照射間宮體動度變化,OAR劑量限制,HDR: limit bladder and rectal points to 50–60 Gy cause significant fibrosis and sten

19、osis.J Ovarian failure with 5–10 Gy and sterilization with 2–3 Gy.J Limit uterus <100 Gy, ureters <75 Gy, and femoral heads <50 Gy.,,病例,患者中年女性，起病緩，病程較長絕經(jīng)2年，下腹部脹痛4+月，腰背部疼痛伴間斷陰道流血溢液3+月西藏軍區(qū)總醫(yī)院病理：角化型鱗癌（2012.5.22

20、）入院婦檢分期 Ⅲb 期（FIGO，2009）無高血壓、糖尿病、肝炎、結(jié)核等合并疾病,病例,患者中年女性，起病緩，病程較長絕經(jīng)2年，下腹部脹痛4+月，腰背部疼痛伴間斷陰道流血溢液3+月西藏軍區(qū)總醫(yī)院病理：角化型鱗癌（2012.5.22）入院婦檢分期 Ⅲb 期（FIGO，2009）無高血壓、糖尿病、肝炎、結(jié)核等合并疾病,入院檢查,入院體檢心肺腹未及明顯異常生化、B超、ECG、ECT、胸片、血Rt、免疫學 基本正常MRI （

21、 Ⅲb 期）,ART,,入院,EBRT結(jié)束,ICRT結(jié)束,,,IMRT Compensated 3D-OHDR,累積劑量(BED a/B=10)： GTV(宮頸病灶) D90＞85Gy CTV1(陰道) D90=70~80Gy CTV1(宮體) D90=70~78Gy CTVln(盆腔+腹主動脈旁）