1、子宫颈癌IMRT靶区设计原则,四川省肿瘤医院放疗科谭燕Sichuan Cancer Hospital,Chengdu 610041 P.R.ChinaTel:(028)85420332,提纲,背景分析UCC IMRT 设计原则IMRT治疗与器官内运动IMRT 剂量补偿的3D-OHDR病例介绍,子宫颈癌转移模式及转移几率,Lymphatic drainage pattern. Adapted from: Plentl AA, Friedman EA (1971)Lymphatic system Of the female genitalia. Saunders, Philadelphia, p
2、83,2009年FIGO,新分期的特点,Stage IIA is subdivided into stage IIA1 and IIA2 (4 cm)Microinvasive and invasive adenocarcinoma should be staged assquamous cell carcinoma of the cervix.The use of MRI/CT /PET-CTscanning is encouragedFIGO 依然是UCC分期标准，但是随着现代影像技术的介入，涉及到1/4 IB, 1/2 IIA-IIB, 2/3 IIIA,和 90% 的IIIB 病人的临
3、床分期发生改变；上调26% IB, 40% IIA, 50% IIB, 66% IIIA,和 75% IIIB 期。 FIGO 仅可用于把握治疗原则，而不能用于指导具体治疗策略！(Sources: Averette HE, Ford JHJ, Dudan RC et al(1994) Staging of cervical cancer. Clin Obstet Gynecol 18:215232; Eifel PJ(1994) Problems with the clinical staging of carcinoma of the cervix. Sem inRadiat Oncol 4
4、:18,治疗策略选择,中华妇瘤专委会指南：IA： 手术IB1-IIA：手术+术后放化疗IIB-IVA：放化联合治疗,IA,non-bulky IB, and early-stage IIA tumors ：RT与手术 疗效等同 IB2 ：RT+cisplatin-based chemoRT 适用于所有期别NCCN2010：铂类一线方案,子宫颈癌IMRT（EBRT）设计原则,基本原则：提高靶区剂量覆盖及剂量均匀度，减少OAR剂量实现途径：认识原发灶浸润范围（局部大小、宫旁、阴道、直肠、膀胱、M?）评价淋巴引流区与转移其他个体化相关预后因素评价（CBC、年龄、免疫状态、合并疾病、 依从性、耐受能力
5、）,盆腔引流区转移,腹主动脉旁转移,淋巴结转移与预后,Volume 25.number 24 augest 20 2007,JOURNAL of CLINICALONCOLOGY,腹主动脉旁照射与预后,A,B: Example of treatment plan with intensity modulated radiation therapy for irradiation of para-aortic lymph nodes. C: Dose-volume histogram (DVH) illustrating sparing of left kidney and small inte
6、stine (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 cancer. Int J Radiat Oncol Biol Phys 2004;59:637638,with permission.),子宫颈癌靶区勾画,CT/MRI/PET宫颈、宫体、阴道、宫旁分开勾画局部病灶不同，靶区设计不同（下1/3阴道）腹主动脉旁淋巴结转移（根治和术后一样重
7、要）髂总及髂外、内，闭孔及骶前，下腹部淋巴引流区；阴道旁及韧带前1/3IIIB期:均应包括腹主动脉旁淋巴引流区阴道下1/3受浸:应考虑腹股沟区引流淋巴区预防,RTOG 靶区定义,RTOG 剂量指南,精细勾画,我院靶区示意图,子宫颈癌术后靶区定义（RTOG）,腔内近距离靶区定义,Diagrammatic representation of GTV and CTV for three-dimensional treatmentplanning in carcinoma of uterine cervix. Coronal (A,C) and transverse (B,D) sections fo
8、r 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 gynaecological (GYN) GEC ESTRO working group (II): Concepts and terms in 3D imagebased treatment p
9、lanning in cervix brachytherapy-3D dose volume parameters and aspects of 3D image-based anatomy, radiation physics, radiobiology. Radiother Oncol 2006;78:6777,with,我院IMRT补偿3D-OHDR靶区示意图,IMRT治疗与器官内运动,The pre-treatment CTV (red) and CTV at a later time point (light blue) overlaid on one scan. The PTV a
10、round the pre-treatment CTV is also shown (dark blue). (a) CT transversal slice; (b) CT sagittal slice; (c) MRI transversal slice; (d) MRI sagittal slice.,IMRT治疗中靶区运动情况,The pre-treatment GTV (red) and four GTVs at later time points (week 1: yellow, 2: light blue, 3: green, 4: magenta). The genericPT
11、V is shown around the pretreatment GTV (dark blue); (b) analogous for the CTV.,IMRT治疗肿瘤消退与器官运动,sagittal view of two patients at two different time points. Patient A shows almost no change in position of the CTV (A; pre-treatment bladder volume 35 cc, A; week1 bladder volume 124 cc). Patient B shows
12、a substantial change in orientation of the uterus (B; pre-treatmentbladder volume 117 cc, B; week 4 bladder volume 49 cc). Bowel, green; rectum, yellow; bladder, pink; GTV, red; CTV, blue,膀胱充盈状态对靶区影响,直肠充盈状态对靶区的影响,我院对IMRT过程中内运动研究,IIB 10例 IIIB 10例入组：15min/次 IMRT 采集3次离线16排CT 总计60每周第1天(15min/次IMRT)采集3次X
13、 4周 总计 240次CT4DCT/次IMRT 总计80次,单次IMRT照射过程中靶区动度变化,单次IMRT照射过程中宫体动度变化,单次IMRT照射过程中宫颈动度变化,分次IMRT照射间靶区动度变化,分次IMRT照射间宫颈动度变化,分次IMRT照射间宫体动度变化,OAR剂量限制,HDR: limit bladder and rectal points to 5060 Gy cause significant fibrosis and stenosis.J Ovarian failure with 510 Gy and sterilization with 23 Gy.J Limit uteru
14、s 100 Gy, ureters 75 Gy, and femoral heads 50 Gy.,病例,患者中年女性，起病缓，病程较长绝经2年，下腹部胀痛4+月，腰背部疼痛伴间断阴道流血溢液3+月西藏军区总医院病理：角化型鳞癌（2012.5.22）入院妇检分期 b 期（FIGO，2009）无高血压、糖尿病、肝炎、结核等合并疾病,病例,患者中年女性，起病缓，病程较长绝经2年，下腹部胀痛4+月，腰背部疼痛伴间断阴道流血溢液3+月西藏军区总医院病理：角化型鳞癌（2012.5.22）入院妇检分期 b 期（FIGO，2009）无高血压、糖尿病、肝炎、结核等合并疾病,入院检查,入院体检心肺腹未及明显异常
15、生化、B超、ECG、ECT、胸片、血Rt、免疫学 基本正常MRI （ b 期）,ART,入院,EBRT结束,ICRT结束,IMRT Compensated 3D-OHDR,累积剂量(BED a/B=10)： GTV(宫颈病灶) D9085Gy CTV1(阴道) D90=7080Gy CTV1(宫体) D90=7078Gy CTVln(盆腔+腹主动脉旁）D90=45Gy Boost-Volume(宫旁) D90=6070Gy GTVln() D90=60Gy,累积OAR剂量 Bladder 2cc= 71.0Gy 1cc= 73.4Gy Rectum 2cc= 69.0Gy 1cc= 71.3Gy,end,
