髓母細胞瘤的放射治療詳解演示文稿

髓母細胞瘤的放射治療詳解演示文稿當前1頁，總共30頁。優(yōu)選髓母細胞瘤的放射治療當前2頁，總共30頁。臨床表現(xiàn)顱內壓增高：頭痛、嘔吐、視神經乳頭水腫小腦損害：軀干性共濟失調為主其它：復視、面癱、強迫頭位、頭顱增大、病理反射陽性、嗆咳、小腦危象、蛛網膜下腔出血脊髓轉移灶癥狀：背部或雙下肢痛、進行性加重的截癱或四肢癱當前3頁，總共30頁。分級StageRiskstagingsystemStageChang'sMstagingsystemLow-riskLocalizeddiseaseatthetimeofdiagnosisM0NoevidenceofgrosssubarachnoidorGroupAge>3yearshematogenousmetastasisTotaltumorresectionorsubtotalwithresidualtumor<1.5cm3

High-riskDisseminateddiseaseatthetimeofdiagnosisM1MicroscopictumorcellsfoundinGroupcerebrospinalfluidAge≤3years

M2GrossnoduleseedingseeninthecerebellarorcerebralsubarachnoidspaceorinthethirdorlateralventriclesSubtotaltumorresectionwitharesidualtumorM3Grossnoduleseedinginthespinal

≥1.5cm3subarachnoidspacemetastasisM4Extraneural當前4頁，總共30頁。治療方案標準治療方案(“Philadelphiaprotocol”)手術放療：術后28天內開始。化療(VCP)：放療中VCR1.5mg/m2/w，共8周；放療后6周開始CCNU75mg/m2DDP75mg/m2VCR1.5mg/m2/w×3w，每6周一個周期，共8個周期。當前5頁，總共30頁。放療劑量低危組：CSI23.4Gy/13f+后顱窩加量至54Gy高危組：CSI36Gy/20f+后顱窩加量至54Gy當前6頁，總共30頁。放療技術常規(guī)分割CSI+Boosttoposteriorfossa超分割CSI+BoosttoposteriorfossaSRTBoosttoposteriorfossa當前7頁，總共30頁。Craniospinalirradiation(CSI):methods俯臥位，雙手置于體側頭部兩側對穿野照射全腦及上段頸髓單后野照射脊髓各野皮膚間隔1cm每照射10Gy移動一次射野以減少各野間交叉高劑量6MV-X線照射劑量(DT)：23.4Gy~36Gy,1.8Gy/f當前8頁，總共30頁。當前9頁，總共30頁。Craniospinalirradiation(CSI):doseradiotherapyalone

（5-yearEFS）

Chemotherapy+（5-yearEFS）

standardradiotherapy

reduced-doseradiotherapy60%±7.8%

41%±8%75%±7%

69%±8%Prospectiverandomisedtrialofchemotherapygivenbeforeradiotherapyinchildhoodmedulloblastoma:InternationalSocietyofPaediatricOncology(SIOP)andthe(German)SocietyofPaediatricOncology(GPO)—SIOPII.MedPediatrOncol25:166-178,1995

當前10頁，總共30頁。23.4GyCSI的療效Risk-adaptedcraniospinalradiotherapyfollowedbyhigh-dosechemotherapyandstem-cellrescueinchildrenwithnewlydiagnosedmedulloblastoma(StJudeMedulloblastoma-96):long-termresultsfromaprospective,multicentretrial

Vol7October2006當前11頁，總共30頁。23.4GyCSI對智力的影響(POG-8631)JournalofClinicalOncology,Vol16,No5,pp.1723–28,1998當前12頁，總共30頁。CSI:cranial-spinaljunctionsite

THECRANIAL-SPINALJUNCTIONINMEDULLOBLASTOMA:DOESITMATTER?

Int.J.RadiationOncologyBiol.Phys.,Vol.44,No.1,pp.81–84,1999Organlowjunction(SD)highjunction(SD)Cord40.3Gy(0.5)38.4Gy(1.3)Thyroidgland20.3Gy(9.2)26.3Gy(0.6)Mandible6.2Gy(0.6)10.9Gy(5.1)Larynx8.3Gy(3.9)27.2Gy(0.4)Pharynx11.9Gy(5.1)20.3Gy(4.8)Parotidgland14.9Gy(4.2)14.1Gy(4.2)當前13頁，總共30頁。超分割放療Twice-dailyl-Gyfractionswereadministeredseparatedby4-6h.放療劑量和射野同常規(guī)分割當前14頁，總共30頁。SRTBoosttoposteriorfossaPOSTERIORFOSSABOOSTINMEDULLOBLASTOMA:ANANALYSISOFDOSETOSURROUNDINGSTRUCTURESUSING3-DIMENSIONAL(CONFORMAL)RADIOTHERAPYInt.J.RadiationOncologyBiol.Phys.,Vol.46,No.2,pp.281–286,2000當前15頁，總共30頁。放療反應急性反應：骨髓抑制、腦水腫等；遠期副作用：甲低認知障礙其它：聽力減退、骨骼發(fā)育障礙、周圍組織損傷繼發(fā)第二惡性腫瘤等。當前16頁，總共30頁。甲低

Hypothyroidp值年齡1

<5歲7/7(100%)<0.001

5~10歲9/15(60%)>10歲2/10(20%)照射劑量123.4Gy+CT10/12(83%)<0.025

36Gy+CT6/10(60%)36Gy2/10(20%)照射方法2常規(guī)分割21/34(62%)=0.02超分割2/14(14%)1.HYPOTHYROIDISMINCHILDRENWITHMEDULLOBLASTOMA:ACOMPARISONOF3600AND2340cGYCRANIOSPINALRADIOTHERAPYInt.J.RadiationOncologyBiol.Phys.,Vol.53,No.3,pp.543–547,20022.ThyroidDysfunctionasaLateEffectinSurvivorsofPediatricMedulloblastoma/PrimitiveNeuroectodermalTumorsAComparisonofHyperfractionatedversusConventionalRadiotherapy

Cancer1997;80:798–804.當前17頁，總共30頁。認知障礙

IQ(pointdeclineperyear)23.4Gy(CSI)+后顱窩加量5.236Gy(CSI)+后顱窩加量3.923.4Gy(CSI)+瘤床加量2.4MODELINGRADIATIONDOSIMETRYTOPREDICTCOGNITIVEOUTCOMESINPEDIATRICPATIENTSWITHCNSEMBRYONALTUMORSINCLUDINGMEDULLOBLASTOMAInt.J.RadiationOncologyBiol.Phys.,Vol.65,No.1,pp.210–221,2006影響因素包括：受照射時年齡（小于3歲差）、照射范圍（全腦差于部分腦照射）、照射劑量(低劑量較好）特別是后顱窩最大劑量、腫瘤部位（幕上好于后顱窩）。當前18頁，總共30頁。聯(lián)合化療常用方案：VCP(VCR+CCNU+DDP);“8in1”(VCR+甲強龍+CCNU+羥基脲+甲基芐肼+DDP+CTX+Ara-c);其他方案：MTX鞘內注射CTX、VCR、VP-16、CCNU、CBP等組合當前19頁，總共30頁。Risk-adaptedcraniospinalradiotherapyfollowedbyhigh-dosechemotherapyandstem-cellrescueinchildrenwithnewlydiagnosedmedulloblastoma(StJudeMedulloblastoma-96):long-termresultsfromaprospective,multicentretrial

Vol7October2006當前20頁，總共30頁。手術+放/化療POSTOPERATIVENEOADJUVANTCHEMOTHERAPYBEFORERADIOTHERAPYASCOMPAREDTOIMMEDIATERADIOTHERAPYFOLLOWEDBYMAINTENANCECHEMOTHERAPYINTHETREATMENTOFMEDULLOBLASTOMAINCHILDHOOD:RESULTSOFTHEGERMANPROSPECTIVERANDOMIZEDTRIALHIT’91Int.J.RadiationOncologyBiol.Phys.,Vol.46,No.2,pp.269–279,2000當前21頁，總共30頁。維持化療對6歲以上低危組更有效；新輔助化療增加放療的骨髓抑制從而延長治療時間；M分期高/低齡兒預后差；手術是否有殘留對預后無明顯影響。POSTOPERATIVENEOADJUVANTCHEMOTHERAPYBEFORERADIOTHERAPYASCOMPAREDTOIMMEDIATERADIOTHERAPYFOLLOWEDBYMAINTENANCECHEMOTHERAPYINTHETREATMENTOFMEDULLOBLASTOMAINCHILDHOOD:RESULTSOFTHEGERMANPROSPECTIVERANDOMIZEDTRIALHIT’91Int.J.RadiationOncologyBiol.Phys.,Vol.46,No.2,pp.269–279,2000當前22頁，總共30頁。手術+化療--方案適用于低齡兒童、無手術殘留、無轉移病灶患者當前23頁，總共30頁。手術+化療--結果TreatmentofEarlyChildhoodMedulloblastomabyPostoperativeChemotherapyAloneNEnglJMed2005;352:978-86.當前24頁，總共30頁。影響預后的因素年齡臨床分級術式后顱窩生物有效劑量（BED）放療持續(xù)時間當前25頁，總共30頁。Onmultivariateanalysis,age3years,M0status,50GyPFBdose,radiotherapytreatmentduration50days,anduseofchemotherapycorrelatedwithbetterfreedomfromprogressionandposteriorfossacontro