頭頸部腫瘤放療靶區(qū)勾畫原則2015-08-01

頭頸部鱗癌放療靶區(qū)勾畫原則中山大學(xué)腫瘤防治中心放療科鄧美玲頭頸部鱗癌的發(fā)病概況頭頸部鱗癌的發(fā)病概況期放療在頭頸部鱗癌中的作用放療在頭頸部鱗癌中的作用在早期患者，單純放療可取得與手術(shù)相同的療效，且可保全功能在局部晚期患者，聯(lián)合化療可作為非手術(shù)治療的標(biāo)準(zhǔn)治療手段可提高局部晚期頭頸部鱗癌術(shù)后患者的局部控制率和生存期常規(guī)二維放療的缺陷常規(guī)二維放療的缺陷嚴(yán)重晚期損傷發(fā)生率高局部區(qū)域控制率及生存期有待提高局部晚期患者局部控制率約為50%~70%，DFS僅30%~40%局部區(qū)域復(fù)發(fā)為最主要的失敗模式2級(jí)以上口干的發(fā)生率明顯下60~90%7~20%5~15%0~2%15~50%6%IMRT在頭頸鱗癌治療中的優(yōu)勢(shì)及挑戰(zhàn) 1/頸部淋巴結(jié)的影像學(xué)分區(qū)2頭頸鱗癌頸部淋巴結(jié)轉(zhuǎn)移規(guī)律3靶區(qū)的定義4靶區(qū)勾畫示例 1/頸部淋巴結(jié)的影像學(xué)分區(qū)2頭頸鱗癌頸部淋巴結(jié)轉(zhuǎn)移規(guī)律3靶區(qū)的定義4靶區(qū)勾畫示例A：C1下緣水平B：C3上緣水平C：C4中間水平D：C6下緣水平E：C7下緣水平F：T1中間水平GregoireV,LevendagP,AngKK,etal.CT-baseddelineationoflymphnodelevelsandrelatedCTVsinthenode-negativeguidelines.RadiotherOncol2003;69:227-36.對(duì)淋巴結(jié)分區(qū)共識(shí)的更新A：C1上緣水平B：C2下緣水平C：C4中間水平D：C6下緣水平E：T1中間水平F：T2上緣水平 1/頸部淋巴結(jié)的影像學(xué)分區(qū)2頭頸鱗癌頸部淋巴結(jié)轉(zhuǎn)移規(guī)律3靶區(qū)的定義4靶區(qū)勾畫示例GrégoireV,CocheE,CosnardG,etal.Selectionanddelineationoflymphnodetargetvolumesinheadandneckconformalradiotherapy.Proposalforstandardizingterminologyandprocedurebasedonthesurgicalexperience.RadiotherOncol.2000;56(2):135-50.GrégoireV,CocheE,CosnardG,etal.Selectionanddelineationoflymphnodetargetvolumesinheadandneckconformalradiotherapy.Proposalforstandardizingterminologyandprocedurebasedonthesurgicalexperience.RadiotherOncol.2000;56(2):135-50.GrégoireV,CocheE,CosnardG,etal.Selectionanddelineationoflymphnodetargetvolumesinheadandneckconformalradiotherapy.Proposalforstandardizingterminologyandprocedurebasedonthesurgicalexperience.RadiotherOncol.2000;56(2):135-50.GrégoireV,CocheE,CosnardG,etal.Selectionanddelineationoflymphnodetargetvolumesinheadandneckconformalradiotherapy.Proposalforstandardizingterminologyandprocedurebasedonthesurgicalexperience.RadiotherOncol.2000;56(2):135-50.病理證實(shí)的咽后淋巴結(jié)轉(zhuǎn)移率病理證實(shí)的咽后淋巴結(jié)轉(zhuǎn)移率GrégoireV,CocheE,CosnardG,etal.Selectionanddelineationoflymphnodetargetvolumesinheadandneckconformalradiotherapy.Proposalforstandardizingterminologyandprocedurebasedonthesurgicalexperience.RadiotherOncol.2000;56(2):135-50.CT和MR發(fā)現(xiàn)陽性咽后淋巴結(jié)的敏感性（CT:83%,MR:100%）及特異性高臨床診斷的咽后淋巴結(jié)轉(zhuǎn)移率咽后淋巴結(jié)轉(zhuǎn)移多見于口咽（咽壁和軟腭）、喉咽和鼻咽癌N0期鼻咽或咽壁癌，咽后淋巴結(jié)轉(zhuǎn)移即高達(dá)16%~40%，N+期發(fā)生率更高GrégoireV,CocheE,CosnardG,etal.Selectionanddelineationoflymphnodetargetvolumesinheadandneckconformalradiotherapy.Proposalforstandardizingterminologyandprocedurebasedonthesurgicalexperience.RadiotherOncol.2000;56(2):135-50.對(duì)側(cè)淋巴結(jié)轉(zhuǎn)移幾率及分布區(qū)域與原發(fā)灶相關(guān)頭頸部鱗癌對(duì)側(cè)淋巴結(jié)轉(zhuǎn)移規(guī)律如：軟腭癌、舌根癌、咽壁癌、喉癌）。即使對(duì)側(cè)有轉(zhuǎn)移，亦較同側(cè)低對(duì)側(cè)淋巴結(jié)分布規(guī)律與同側(cè)相同GrégoireV,CocheE,CosnardG,etal.Selectionanddelineationoflymphnodetargetvolumesinheadandneckconformalradiotherapy.Proposalforstandardizingterminologyandprocedurebasedonthesurgicalexperience.RadiotherOncol.2000;56(2):135-50.VIVI區(qū)淋巴結(jié)轉(zhuǎn)移率VI區(qū)淋巴結(jié)包括氣管旁、氣管前、環(huán)狀軟骨前、甲狀軟骨周圍以及喉返神經(jīng)路徑的淋巴結(jié)掃標(biāo)本病理為陰性，仍有10%患者可出現(xiàn)單獨(dú)VI區(qū)淋巴結(jié)轉(zhuǎn)移在CTV內(nèi)GrégoireV,CocheE,CosnardG,etal.Selectionanddelineationoflymphnodetargetvolumesinheadandneckconformalradiotherapy.Proposalforstandardizingterminologyandprocedurebasedonthesurgicalexperience.RadiotherOncol.2000;56(2):135-50.TimonCV,TonerM,ConlonBJ:Paratracheallymphnodeinvolvementinadvancedcancerofthelarynx,hypopharynx,andcervicalesophagus.Laryngoscope2003,113:1595-1599.。。跳躍轉(zhuǎn)移（skipmetastases）GrégoireV,CocheE,CosnardG,etal.Selectionanddelineationoflymphnodetargetvolumesinheadandneckconformalradiotherapy.Proposalforstandardizingterminologyandprocedurebasedonthesurgicalexperience.RadiotherOncol.2000;56(2):135-50.ByersRM,WeberRS,AndrewsT,etal.Frequencyandtherapeuticimplicationsof“skipmetastases”intheneckfromsquamouscarcinomaoftheoraltongue.HeadNeck1997,19:14-19.發(fā)現(xiàn)，兩者呈明顯相關(guān)性。淋巴結(jié)包膜外侵犯（ECE）的概率GhadjarP,Schreiber-FacklamH,Gr?terR,etal.Quantitativeanalysisofextracapsularextensionofmetastaticlymphnodesanditssignificanceinradiotherapyplanninginheadandnecksquamouscellcarcinoma.IntJRadiatOncolBiolPhys.2010;76(4):1127-32.00ECE定量分析GhadjarP等對(duì)轉(zhuǎn)移淋巴結(jié)包膜外侵犯（ECE）進(jìn)行定量分析后因此認(rèn)為GTVnd外擴(kuò)1cm即可包全ECE的范圍GhadjarP,Schreiber-FacklamH,Gr?terR,etal.Quantitativeanalysisofextracapsularextensionofmetastaticlymphnodesanditssignificanceinradiotherapyplanninginheadandnecksquamouscellcarcinoma.IntJRadiatOncolBiolPhys.2010;76(4):1127-32.勾畫CTVnd的共識(shí)*淋巴引流區(qū)（圖D）GregoireV,LevendagP,AngKK,etal.CT-baseddelineationoflymphnodelevelsandrelatedCTVsinthenode-negativeneck:DAHANCA,EORTC,GORTEC,NCIC,RTOGconsensusguidelines.RadiotherOncol2003;69:227-36.GrégoireV,EisbruchA,HamoirM,etal.ProposalforthedelineationofthenodalCTVinthenode-positiveandthepost-operativeneck.RadiotherOncol.2006;79(1):15-20.CCABDDGrégoireV,AngK,BudachW，etal.Delineationofthenecknodelevelsforheadandnecktumors:guidelines.RadiotherOncol.2014頸部靶區(qū)選擇性治療的建議頸部靶區(qū)選擇性治療的建議浸潤深度、腫瘤分級(jí)以及其隱匿性轉(zhuǎn)移的概率擇性治療應(yīng)治療VorwerkH,HessCF.Guidelinesfordelineationoflymphaticclinicaltargetvolumesforhighconformalradiotherapy:headandneckregion.WeissMH,HarrisonLB,IsaacsRS.UseofdecisionanalysisinplanningamanagementstrategyforthestageN0neck.Arch.Otolaryngol.HeadNeckSurg.1994;120:699±702.GrégoireGrégoireV,CocheE,CosnardG,etal.SelectionanddelineationofN0-1及N2b期淋巴區(qū)域選擇性治療的建議lymphnodetargetvolumesinheadandneckconformalradiotherapy.Proposalforstandardizingterminologyandprocedurebasedonthesurgicalexperience.RadiotherOncol.2000;56(2):135-50.VorwerkH,HessCF.VorwerkH,HessCF. 1/頸部淋巴結(jié)的影像學(xué)分區(qū)2頭頸鱗癌頸部淋巴結(jié)轉(zhuǎn)移規(guī)律3靶區(qū)的定義4靶區(qū)勾畫示例根治性放療靶區(qū)定義GTVpGTVp和GTVnd的定義參考體格檢查、內(nèi)窺鏡、CT、MRI或PET/CT進(jìn)行綜合考慮體檢及不同影像學(xué)對(duì)GTVp的影響ThiagarajanA,CariaN,Sch?derH,etal.TargetvolumedelineationinChaoKS,WippoldFJ,AngKK，etal.M.D.AndersonConsensusGuidelinesforHeadandNeckTargetVolumeDeterminationandDelineation.IntJRadiatOncolBiolPhys.2004;60(1):S496-S497.骨質(zhì)處可作適當(dāng)調(diào)整（DT:59.4Gy/33次）CTV3：即CTV2外的淋巴引流區(qū)，同側(cè)、對(duì)側(cè)ChaoKS,WippoldFJ,AngKK，etal.M.D.AndersonConsensusGuidelinesforHeadandNeckTargetVolumeDeterminationandDelineation.IntJRadiatOncolBiolPhys.2004;60(1):S496-S497.根治性放療靶區(qū)示例根治性放療靶區(qū)示例CTV1CTV1：包括GTVp和GTVnd外擴(kuò)5-10mm范圍（DT:70Gy/30次）CTV2：含顯微鏡下微轉(zhuǎn)移灶的高危區(qū)域，包括原發(fā)灶CTV2和淋巴引原發(fā)灶CTV2：毗鄰CTV1的具高危腫瘤浸潤的正常組織，主要取決于原發(fā)腫瘤部位以及可能侵犯的范圍。例如：舌根癌和扁桃體癌，原發(fā)灶喉淋巴引流區(qū)CTV2：受累淋巴區(qū)域上、下1~2cm的范圍及未受累的高危淋巴引流區(qū)。主要取決于原發(fā)腫瘤部位、T分期和受累淋巴結(jié)情況。未受累的高危淋巴引流區(qū)通常指出現(xiàn)鏡下轉(zhuǎn)移可能性超過15%~20%的區(qū)域。YaoM,DornfeldK