肺癌的放射治疗与其副作用

肺癌的放射治療與其副作用上饶市肿瘤医院金明根INTRODUCTIONS•肺癌是胸腔腫瘤最多的癌症•肺癌高居臺灣男性與女性癌病的第二與第四位•吸煙者罹患此癌症的機會為非吸煙者的二十倍以上•治癒早期肺癌的機會遠比中晚期高INCIDENCE•InUSA,approximately96,300newmalepatientsand79,800femalediagnosedannuallyinUSA.•Drainageoflymphatics肺癌吸煙與肺癌•35歲男性每天吸25支以上在75歲以前會有13%機會罹患肺癌，10%冠狀動脈疾病•吸煙量、時間、開始年齡、吸入深淺、焦油含量、尼古丁量、二手煙等•職業：石棉、鉻、鎳、砷、氡、芳香族烴等肺癌飲食與肺癌•胡蘿蔔素、維生素C,E、及硒等有減少游離基的作用•遺傳：3p21肺癌鳞状上皮癌(squamouscellcarcinoma)腺癌(adenocarcinoma)30-40%肺癌大細胞癌(largecellcarcinoma)10-15%小細胞癌(smallcellcarcinoma)15-25%,oatcellcarcinoma肺癌症狀•咳嗽(75%)、痰中帶血(40%)、胸痛(40%)、氣喘(40%)、體重減輕、厭食、虛弱等等特殊症狀•左肺腫瘤:聲音沙啞•右肺腫瘤:SVCsyndrome•肺尖腫瘤:手臂麻診斷及期別病史及身體檢查痰細胞學檢查80%近端腫瘤，20%遠端或較小腫瘤影像檢查chestx-ray,CTscan,MRI,bonescan,支氣管鏡檢查2nd,3rdsubsegmentaldivision,診斷及期別縱隔腔鏡檢查superiormediastinalLNs正子攝影(PET)IAT1N0M0IBT2N0M0IIAT1N1M0IIBT2N1M0IIIAT1-2N2M0,T3N0-2M0IIIBT1-3N3M0,T4N0-3M0肺癌的治療StageI-II手術/放射治療StageIIIA手術/放射治療/化療StageIIIB化療=放射治療Non-smallcelllungcancer•Resectabletumor:about20%Surgery:stageI(T1-2N0)53-70%at5yrsstageII(T1-2N1)48-56%stageIII(T3N0-1,N2)0-33%Mortality:2.7%,complication13%AdjuvantTreatment•Theroleofpost-opXRTLocalrecurrencep=0.188Unresectabletumors•DefinitiveRadiationTherapyChemo-radiotherapyforLocalAdvancedStageIIINSCLCFrenchtrial:inductionC/T3cyclesvindestine,lomustine,cisplatin,cyclophosp0.02Chemo-radiotherapyforLocalAdvancedStageIIINSCLCEORTC:concurrentcisplatinsplitcourseofRTSmallCellCarcinoma•Highgrowthfraction,widelydisseminated•Sensitivetomanychemtherapeuticagents•Surgery:10%oflimitedsmallcellca.•Smallcellca.:DFS&LCSC/Talonevs.C/T+XRTTheRoleofRadiotherapyforLimitedSmallCellLungCancerRadiationTherapyTechniquesPID:8139350,lungCTV:CTV-rSumplanRadiationToleranceofNormalTissueinChestAffectingfactors•Intrinsicradiosensitivityofnormaltissues•Totalgivendose•Doseperfraction•VolumebeenirradiatedRadiotherapyRelatedReactionand/orComplicationsAcuteReactions•0-6months•Reversible!LateReactions•6months•Irreversible!!RadiationToleranceofNormalTissueinChestTotalGivenDose•Lung:7to9.3Gyinsinglefractions18to22Gywholelung(2Gy)25GyanyportionoflungRadiationToleranceofLungImmediateeffect•Latentperiod:1to3months•TypeIIpneumocytereleaseofsurfactant•Endothelialdamage:exudationandfluidaccumulatesininterstitialspacesRadiationToleranceofLungLateeffect•Latentperiod:3to7months•Sclerosisofalveolarwall,vasculitis,interstitialfibrosis,lossofpulmonaryvolume,&pleuralthickeningRadiationToleranceofLungPredisposingfactors•Chemotherapy:bleomycin,450units•InterferonsManagementofRadiationPneumonitis•Inevitableconsequenceofaggressiveradiotherapy•Toavoidtheun-necessarilylung•Mostpatientsarenosymptoms•Corticosteroids:reliefsymptomRadiationToleranceofTracheaandBronchiTotalGivenDose•Tracheaandbronchi:50-60Gyin2GyperfractionsRadiationToleranceofTracheaandBronchiTracheaandbronchi•Microscopicfindings:epitheliumthickensandgobletcellsincrease•Irritatecough:decreaseinciliaryfunctionanddrynessRadiationToleranceofEsophagusTotalGivenDose•Esophagus:50-60Gyin2GyperfractionsRadiationToleranceofEsophagusEsophagus•Acuteeffect:dysphagia,epitheliallosssubsides1-2weeksaftercessationofirradiationRadiationToleranceofEsophagusEsophagus•Lateeffect:5%3monthsto2yearsmuscularis:fibrosisstricture:rareTreatmentofRadiationEsophagitis•Inevitableconsequenceofaggressiveradiotherapy•95%ofpatients:selflimited•Softfood,MucainesuspensionRadiationToleranceofHeartHeart•AcutePericarditispericardialeffusion,cardiactamponade50%selflimited40Gy/4weeks,50Gy/5weeksRadiationToleranceofHeartHeart•ChronicPericarditislatentperiod:6mstoyearsmyocardialandendocardialfibrosisnotcorrelatedwithacutepericarditis