宫颈癌靶区勾画原则

子宫颈癌IMRT靶区设计原则四川省肿瘤医院放疗科谭燕SichuanCancerHospital,Chengdu610041P.R.ChinaTel:[phone]提纲背景分析UCCIMRT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Lymphaticdrainagepattern.Adaptedfrom:PlentlAA,FriedmanEA(1971)LymphaticsystemOfthefemalegenitalia.Saunders,Philadelphia,p832009年FIGO新分期的特点StageIIAissubdividedintostageIIA1andIIA2(4vs.4cm)Microinvasiveandinvasiveadenocarcinomashouldbestagedassquamouscellcarcinomaofthecervix.TheuseofMRI/CT/PET-CTscanningisencouragedFIGO依然是UCC分期标准，但是随着现代影像技术的介入，涉及到1/4IB,1/2IIA-IIB,2/3IIIA,和90%的IIIB病人的临床分期发生改变；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:AveretteHE,FordJHJ,DudanRCetal(1994)Stagingofcervicalcancer.ClinObstetGynecol18:215–232;EifelPJ(1994)Problemswiththeclinicalstagingofcarcinomaofthecervix.SeminRadiatOncol4:1–8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-bulkyIB,andearly-stageIIAtumors：RT与手术疗效等同•≥IB2：RT+cisplatin-basedchemo•RT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）盆腔引流区转移腹主动脉旁转移淋巴结转移与预后•Volume25.number24augest202007,JOURNALofCLINICALONCOLOGY腹主动脉旁照射与预后A,B:Exampleoftreatmentplanwithintensitymodulatedradiationtherapyforirradiationofpara-aorticlymphnodes.C:Dose-volumehistogram(DVH)illustratingsparingofleftkidneyandsmallintestine(Plan7Asolidline;Plan78Bdashedline).CTV,clinicaltargetvolume.(FromGrigsbyPW,SinghAK,SiegelBA,etal.Lymphnodecontrolincervicalcancer.IntJRadiatOncolBiolPhys2004;59:637–638,withpermission.)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DiagrammaticrepresentationofGTVandCTVforthree-dimensionaltreatmentplanningincarcinomaofuterinecervix.Coronal(A,C)andtransverse(B,D)sectionsforlimited(A,B)andadvanced(C,D)disease(grayzonesinleftparametrium).CTV,clinicaltargetvolume;GTV,grosstumorvolume.(FromPotterR,Haie-MederC,LimbergenEV,etal.Recommendationsfromgynaecological(GYN)GECESTROworkinggroup(II):Conceptsandtermsin3Dimagebasedtreatmentplanningincervixbrachytherapy-3Ddosevolumeparametersandaspectsof3Dimage-basedanatomy,radiationphysics,radiobiology.RadiotherOncol2006;78:67–77,with我院IMRT补偿3D-OHDR靶区示意图IMRT治疗与器官内运动Thepre-treatmentCTV(red)andCTVatalatertimepoint(lightblue)overlaidononescan.ThePTVaroundthepre-treatmentCTVisalsoshown(darkblue).(a)CTtransversalslice;(b)CTsagittalslice;(c)MRItransversalslice;(d)MRIsagittalslice.IMRT治疗中靶区运动情况Thepre-treatmentGTV(red)andfourGTVsatlatertimepoints(week1:yellow,2:lightblue,3:green,4:magenta).ThegenericPTVisshownaroundthepretreatmentGTV(darkblue);(b)analogousfortheCTV.IMRT治疗肿瘤消退与器官运动sagittalviewoftwopatientsattwodifferenttimepoints.PatientAshowsalmostnochangeinpositionoftheCTV(A;pre-treatmentbladdervolume35cc,A;week1bladdervolume124cc).PatientBshowsasubstantialchangeinorientationoftheuterus(B;pre-treatmentbladdervolume117cc,B;week4bladdervolume49cc).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IIB10例IIIB10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X4周总计240次CT4DCT/次IMRT总计80次单次IMRT照射过程中靶区动度变化左右上下前后左右上下前后均数（㎜）1.41.61.7均数（㎜）1.41.61.7标准差（㎜）1.21.31.3标准差（㎜）1.21.31.3最大值（㎜）4.63.45.13.75.73.8最大值（㎜）4.63.45.13.75.73.8左右上下前后均数（mm）1.81.92.0标准差（mm）1.31.61.5最大值（mm）5.03.98.34.56.64.5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左右上下前后均数（mm）3.93.87.9标准差（mm）3.84.06.8最大值（mm）12.79.216.110.424.019.1左右上下前后均数（mm）6.59.514.2标准差（mm）4.86.610.5最大值(mm）15.614.425.820.436.431.5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:limitbladderandrectalpointsto70%ofpointAdosewithHDR.JLDR:limitrectalpoint70Gyandbladderpoint75Gy.JLimituppervaginalmucosa120Gy,midvaginalmucosa80–90Gy,andlowervaginalmucosa60–70Gy.Vaginaldoses50–60Gycausesignificantfibrosisandstenosis.JOvarianfailurewith5–10Gyandsterilizationwith2–3Gy.JLimituterus100Gy,ureters75Gy,andfemoralheads50Gy.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Ⅲb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Ⅲb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生化、B超、ECG、ECT、胸片、血Rt、免疫学基本正常MRI（Ⅲb期）ART入院EBRT结束ICRT结束IMRTCompensated3D-OHDR累积剂量(BEDa/B=10)：GTV(宫颈病灶)D90＞85GyCTV1(阴道)D90=70~80GyCTV1(宫体)D90=70~78GyCTVln(盆腔+腹主动脉旁）D90=45GyBoost-Volume(宫旁)D90=60~70GyGTVln(…)D90=60Gy累积OAR剂量Bladder2cc=71.0Gy1cc=73.4GyRectum2cc=69.0Gy1cc=71.3Gy