1、国内食管癌照射范围, 局部照射野 传统野 钡片肿瘤部位、病变长度和食管轴向 常规野 钡片所见加CT扫描 根据肿瘤实际范围 三维立体适形照射野(不规则野) 精确放疗调强照射野(多子野叠加，同期推量预防和治疗) 图像引导生物信息调强(靶区内剂量的不均匀化),照射野的具体范围与勾画,RTOG 85-01 (鳞癌占82%)放化组 锁骨上区到食管胃结合部 （下1/3段食管癌不照射锁骨上区) 30Gy/15F后缩野到原肿瘤上下各 外放5cm再加20Gy/10F 总剂量50Gy单放组 原肿瘤上下各外放5cm 达50Gy/25F （胸上、中段食管癌照射锁骨上区) 缩野至病变上下各外放5cm 再加14Gy /7
2、F 总剂量64Gy,生存或 单放组 放化疗结合组首次失败 随机62例 随机61例（90年前) 非随机69例(90后) 1年生存(%) 34% (21/62) 52%(32/61) 62%(43/69)3年生存(%) 0 30%(18/61) 18%(26/69)5年生存(%) 0 26%(14/61) 14%(10/69)中位生存 12.2个月 14.1个月 16.7个月疾病未控率(%) 37%(23/62) 25%(15/61) 28%(19/69)局部区域失败(%) 16%(10/62) 13%(8/61) 20%(14/69)单纯远转移(%) 15%( 6/62) 8%(5/61) 16
3、%(11/69)局部+区域+远转(%) 15%(9/62) 8%(5/61) 10%(7/69),照射野的具体范围与结果,RTOG 85-01长期结果,低剂量组 肿瘤上下外放5cm、前后左右外放2cm照射 50.4 Gy （颈段癌包锁骨上区，电子线补量 下段包腹腔干淋巴结区）高剂量组 前程同上达50.4Gy 后程缩野后为肿瘤上下各外放2cm 前后左右外放仍为2cm 总剂量64.8Gy,照射野的具体范围与勾画,RTOG 94-05 （二维放疗）,照射野的具体范围与结果,218例可供分析，高、低剂量组各109例，鳞癌占87%和84%中位随访16.4个月，生存者中位随访29.5个月治疗相关死亡高剂量
4、组和低组分别为10%(11 例) 和2%11例死亡者中，7例发生在50.4Gy过程中 3例在高剂量加量中 1例在结束64.8Gy后9个月瘘形成,RTOG 94-05 长期结果,高剂量组109例 低剂量组109例中位生存期 13.0个月 18.1个月2年生存率 39% 40%局部区域失败+未控 50% 55%远转移 9% 16% 全部无差别, 食管壁内“多源性”病灶 iller 1/7的病例在主病灶2cm外可见继发病灶 Pradoura 间隔5cm多源性癌达16% Reboud 多源性食管病变达35% 淋巴结转移 “跳跃式”转移,关于食管癌多原发的研究,食管癌的生物学特点： “跳跃性”,52例食
5、管癌术后亚临床病灶分布,亚临床病灶 单纯近端 单纯远端 上下两端均有 总发生率(%)多中心起源 7例 3例 5例 15/52(28.9)重度不典型增生 11例 11例 6例 28/52(53.9)食管壁内浸润 12例 10例 19例 41/52(78.9),CTV纵向外放标准探讨,史鸿云 祝淑钗 翟福山 中华放射肿瘤学杂志2006;15(4):280-284,多中心起源、壁内浸润和跳跃性转移均可发生在距主瘤部位较远的食管壁上,CTV纵向外放标准探讨,这也是胸外科医生要保证手术边界的安全性 必须要切除较长的正常食管组织的主要原因,马国伟，中华肿瘤杂志，2003，25(5): 472474 史鸿云
6、，中华放射肿瘤学杂志，2006，15(4)：280284 Nishimaki T, World J Surg, 1996,20(1):3237 Lam KY, Clinc Pathol,1996,49(2):124129,食管癌生物学特点 淋巴结“跳跃式”转移,Details of recurrence sites after elective nodal irradiation (ENI) using 3D-conformal radiotherapy (3D-CRT) combined with chemotherapy for thoracic esophageal squamous c
7、ell carcinoma A retrospective analysis Hideomi Yamashita, Kae Okuma, Reiko Wakui, Shino Kobayashi-Shibata, Kuni Ohtomo, Keiichi Nakagawa Department of Radiology, University of Tokyo Hospital, Hongo, Bunkyo-ku, Tokyo, JapanRadiotherapy and Oncology. 2011，98 ： 255260,Details of recurrence sites after
8、elective nodal irradiation (ENI) using 3D-conformal radiotherapy (3D-CRT) combined with chemotherapy for thoracic esophageal squamous cell carcinoma A retrospective analysis (Japan),2000.6-2009.7 126例鳞癌 中位年龄67岁 全部3DCRT 疗前均PET 病变部位 胸上/胸中/胸下 29/53/44例 中位长度7.0cm 临床分期 T1/T2/T3/T4 28/18/54/26例 N0/N1 50/7
9、6 M0/M1a/M1b 91/5/30 / 22/31/38/35 (metastatic sites of M1b were lower cervical, supra-clavicular or celiac LNs) 化疗方案 all patients received chemotherapy concurrently two cycles 5-fluorouracil 800 mg/m2/day, days 14 & days 2932 nedaplatin 80 mg/m2, day 1 & day 29 同期后再2 two cycles same dose chemothera
10、py,Radiotherapy and Oncology. 2011，98 ： 255260,Definition regional LN by AJCC is mediastinal and perigastric LN excluding celiac LN. Definition of M1a region is cervical LNs in the upper thoracic, none in the middle thoracic, and celiac LNs in the lower thoracic esophagus,Details of recurrence sites
11、 after elective nodal irradiation (ENI) using 3D-conformal radiotherapy (3D-CRT) combined with chemotherapy for thoracic esophageal squamous cell carcinoma A retrospective analysis (Japan),GTV included primary tumor and LN 1 cm in short axis by CT or PET CTV was defined as the whole thoracic esophag
12、us (from the supraclavicular fossae to the esophagogastric junction) including GTV plus 5 mm margin CTV comprised up to M1a LNs and regional LNs including positive LNs PTV adding margins 510 mm to the respective CTVs Mean lung D20 Gy V20 20%. Spinal cord dose 0.05,Details of recurrence sites after e
13、lective nodal irradiation (ENI) using 3D-conformal radiotherapy (3D-CRT) combined with chemotherapy for thoracic esophageal squamous cell carcinoma A retrospective analysis (Japan),large radiation fields used in this study was the fundamentaladherence to the first radiation field used in RTOG 85-01
14、and the results of most surgical series in Japan have indicated a survival benefit of prophylactic 3-field LN dissection for SqCC in the thoracic esophagus,Details of recurrence sites after elective nodal irradiation (ENI) using 3D-conformal radiotherapy (3D-CRT) combined with chemotherapy for thora
15、cic esophageal squamous cell carcinoma A retrospective analysis (Japan),ConclussionThis study suggest that ENI was effective for preventing regional nodal failure in CRT for esophageal SqCCmore local recurrences were detected in the upper thanin the middle and lower thoracic carcinomas,Retrospective
16、 Analysis of Outcome Differences in Preoperative Concurrent Chemoradiation With or Without Elective Nodal Irradiation for Esophageal Squamous Cell Carcinoma Feng-Ming Hsu, M.D. Jang-Ming Lee, M.D., Ph.D , Pei-Ming Huang, M.D. Chia-Chi Lin, M.D., Ph.D. Chih-Hung Hsu, M.D., Ph.D. Yu-Chieh Tsai, M.D. Y
17、ung-Chie Lee, M.D., Ph.D. Jason Chia-Hsien Cheng, M.D., Ph.DDepartment of Oncology, Department of Surgery ，National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, TaiwanInt.J. Radiat. Oncol.Biol.Physi. 2011, 81(4):593599,Retrospective Analysis of Outcome Differen
18、ces in Preoperative Concurrent Chemoradiation With or Without Elective Nodal Irradiation for Esophageal Squamous Cell Carcinoma (Taiwan),回顾分析118例鳞癌 1997年AJCC分期和 术前同期放化疗 放疗剂量中位值36Gy 后行根治性切除 ENI 73例62%（锁骨上预防 54例和腹腔引流区预防19例） IFI 45例38% 56例 57%接受同期化疗（紫杉醇+顺铂，2周期） 随访远处淋巴结转移包括(M1a 和M1b) 中位随访期38个月,材料,Retros
19、pective Analysis of Outcome Differences in Preoperative Concurrent Chemoradiation With or Without Elective Nodal Irradiation for Esophageal Squamous Cell Carcinoma (Taiwan),ENI组73例 IFI组45例 P值围手术期死亡率 0.483级心肺毒副反应 0.44M1a 3年复发率 3% 11% 0.05孤立远LNM(M1a+M1b) 10% 14% 0.293年总生存率 45% 52% 0.313年无进展生存率 45% 43%
20、 0.89病理淋巴结转移系总生存的独立影响因素 HR=1.78 P=0.045,结果,结论 ENI 降低了M1a复发率但未改善生存，淋巴结转移系影响因素,Radiotherapy and Oncology. 2009,92: 266269,Elective nodal irradiation (ENI) in definitive chemoradiotherapy(CRT) for squamous cell carcinoma of the thoracic esophagus,Masakatsu Onozawa a, Keiji Nihei a, Satoshi Ishikura c,
21、Keiko Minashi b, Tomonori Yano b, Manabu Muto b, Atsushi Ohtsu b, Takashi Ogino a.,1999.22001.4 102例可分析的鳞癌 接受根治性放化同期 化疗方案 DDP 40mg/m2 d1,d8 5-Fu 400mg/m2/d d1-5,d8-12 每5周重复, 疗中用2周期 疗后剂量 DDP 80mg/m2 d1, 5-Fu 800mg/m2/d d1-5, 每4周重复放疗方案 CT诊断LNM为长径1cm 范围 胸上段包括锁骨上, 胸下段包括腹腔在ENI野内 前后两野对穿 40Gy/20F/4W 休息2周后给
22、予后程放疗 斜野或多野 20Gy/10F/2W CTV包括原发瘤和转移淋巴结,上下外放3cm PTV包括原发瘤和转移淋巴结和区域淋巴结, 放11.5cm,所有病人中位随访17个月(3-62) 存活者 中位随访41个月(9-62)放化疗后获CR 62例占59% 其中40例生存 20例复发转移3年总生存率43%,失败模式 局部失败即原发瘤复发累及淋巴结复发即原有转移的远处失败即除原发瘤和区域LNM外选择淋巴结复发即在 ENI野内的,Radiotherapy and Oncology. 2009,92: 266269,Elective nodal irradiation (ENI) in defin
23、itive chemoradiotherapy (CRT) for squamous cell carcinoma of the thoracic esophagus,Elective nodal irradiation (ENI) in definitive chemoradiotherapy (CRT) for squamous cell carcinoma of the thoracic esophagus,In CRT for esophageal SCC ENI is effective for preventing regional nodal failureFurther eva
24、luation of whether ENI leads to an improved overall survival is needed,结 论,Radiotherapy and Oncology. 2009,92: 266269,Elective lymph node irradiation late course accelerated hyper-fractionated radiotherapy plus concurrent cisplatin- based chemotherapy for esophageal squamous cell carcinoma: a phase
25、II study Dongqing Wang, Jiali Yang, Jingyu Zhu, Baosheng Li, Limin Zhai， Mingping Sun, Heyi Gong, Tao Zhou, Yumei Wei, Wei Huang, Zhongtang Wang, Hongsheng Li and Zicheng ZhangDepartment of Radiation Oncology, Shandong Cancer Hospital, Shandong Academy of Medical Sciences, Jinan, China Radiation Onc
26、ology 2013, 8:108,Elective lymph node irradiation late course accelerated hyper-fractionated radiotherapy plus concurrent cisplatin based chemotherapy for esophageal squamous cell carcinoma: a phase II study,2004.1-2011.11 68例AJCC分期-a 食管鳞癌 回顾性分析 中位年龄63岁(40-75) KPS80 颈段/胸上/胸中/胸下 8/24/27/9/a 分期为14/32/
27、22 比例为 20.6% 、47.1% 、32.3% 2周期以DDP基础同期化疗 DDP+5-Fu 20例 占29.4% DDP+Capecitabine 12例 占17.5% DDP+ pemetrexed 32例 占47.1%,临床材料,Elective lymph node irradiation late course accelerated hyper-fractionated radiotherapy plus concurrent cisplatin based chemotherapy for esophageal squamous cell carcinoma: a phas
28、e II study,放疗方案,GTVp+GTVn GTVp 上下各外放5cm ,轴向外放1cm 前程PTV1 GTVn 上下和轴向均外放0.8cm 高危淋巴引流区HRLNR 均匀外放0.8cm 处方剂量40Gy/20F/4W GTVp 上下各外放3cm ,轴向外放1cm 后程PTV2 GTVn 上下和轴向均外放0.8cm 不再照射高危淋巴引流区HRLNR 19.6Gy/14F/1.4W 1.4Gy/F 2F/d 间隔6h 前后两程总剂量 59.6Gy/34F/5.4W,Elective lymph node irradiation late course accelerated hyper-
29、fractionated radiotherapy plus concurrent cisplatin based chemotherapy for esophageal squamous cell carcinoma: a phase II study,Elective lymph node irradiation late course accelerated hyper-fractionated radiotherapy plus concurrent cisplatin based chemotherapy for esophageal squamous cell carcinoma:
30、 a phase II study,Elective lymph node irradiation late course accelerated hyper-fractionated radiotherapy plus concurrent cisplatin based chemotherapy for esophageal squamous cell carcinoma: a phase II study,Elective lymph node irradiation late course accelerated hyper-fractionated radiotherapy plus
31、 concurrent cisplatin based chemotherapy for esophageal squamous cell carcinoma: a phase II study,Elective lymph node irradiation late course accelerated hyper-fractionated radiotherapy plus concurrent cisplatin based chemotherapy for esophageal squamous cell carcinoma: a phase II study,中位 随访18.5个月
32、中位生存34.4个月 1年 3年 5年 P值总生存率 75.5% 46.5% 22.7%期和期总生存率 78.6% 49.4% 39.9% 0.671a期总生存率 68.3% 41.0% 15.4%,治疗结果,首次失败局部复发 20.6% 局部+区域失败者29.4%(20/68) 区域失败 17.6% 远处转移 19.1%3级急性食管炎和白细胞下降 26.4%(18/68)和32.4%(22/68)3级晚期损伤：食管狭窄1例，肺纤维化1例， 5例死于晚期并发症(消化道出血3例，瘘2例),临床资料1 2005.1-2010.12 食管癌患者219例接受放疗 男144例,女75例,中位年龄67岁(4089 岁)2 根据是否采用淋巴引流区放疗分为 预防野组114例，累及野组105例 3 临床分期采用 2009 年中国非手术治疗食管 专家小组提出的 非手术治疗食管癌临床分期标准,入组条件1 病理或细胞学证实的食管癌患者 2 进流食或半流食,卡氏评分70分 3 不合并严重内科疾病 4 无食管出血、穿孔等征象 5 可行根治性放射治疗初治患者 6 CT检查未发现远处转移者,食管鳞癌根治性放化疗淋巴引流区预防照射的比较研究,
