肺癌个体化放疗指南PPT推荐.ppt
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YuJ.MetalCTNPV=86.5;
PET/CTNPV=90.6%CTNPV=86.5;
PET/CTNPV=90.6%GrillsSetal.JClinOncol.2010GrillsSetal.JClinOncol.2010局部失败几率:
局部失败几率:
4-5%4-5%;
Wedge:
21-26%Wedge:
21-26%区域失败几率:
区域失败几率:
0-5%;
18-22%0-5%;
18-22%局部加区域为:
局部加区域为:
5-10%;
29-33%5-10%;
29-33%中国资料中国资料:
不行预防时区域失败率不行预防时区域失败率5%100BED100;
(;
(取决于增殖与乏氧取决于增殖与乏氧)DailyVerification&
QA:
3Dor4D/On-lineKVorMVDailyVerification&
3Dor4D/On-lineKVorMVIGRTIGRT误差权重:
常规分割误差权重:
常规分割-2/60Gy=3.3%-2/60Gy=3.3%;
立体定向立体定向-12/48Gy=25%-12/48Gy=25%OrganOrganMotionControlMotionControl:
ABC/Gating/4D-:
ABC/Gating/4D-CT/Planning/DeliveryCT/Planning/Delivery较小手术更能提高局控率:
原因在于其靶区外放的范围同样得较小手术更能提高局控率:
原因在于其靶区外放的范围同样得到合理照射,而手术无法做到到合理照射,而手术无法做到(RuttenIJROBP2006)(RuttenIJROBP2006)CompactDoseDeposition&
OARCompactDoseDeposition&
OARPulmonaryVeinPulmonaryVeinBronchusBronchusEsophagusEsophagusCordCordSkinSkinChestwallChestwallLungLungSo.AllofthelungCaforthetrialmustbeinthisperipheralzone!
PhaseIDoseResponseforLocalControlPhaseIDoseResponseforLocalControlCurrentRTOGSBRTStudiesCurrentRTOGSBRTStudiesMedicalinoperableperipheral:
Medicalinoperableperipheral:
Peripherallesion:
48Gyin4fxsPeripherallesion:
48Gyin4fxsCentrallesion:
Centrallesion:
PhaseIdoseescalation:
50Gyin5fxsPhaseIdoseescalation:
50Gyin5fxsOperable&
peripherallesion:
Operable&
54-60Gyin3Fxs54-60Gyin3FxsAblativeDose:
BEDAblativeDose:
BED100Gy100GyRTOG0236:
BEDRTOG0236:
BED54Gyin3FxtoGTV+5-10mm151Gy54Gyin3FxtoGTV+5-10mm151GyTootoxicforcentrallesionTootoxicforcentrallesionJCOG0403:
JCOG0403:
48Gyin4FxtoI/C(40GytoPTV)106Gy48Gyin4FxtoI/C(40GytoPTV)106GyHighrecurrenceforT2HighrecurrenceforT2MDACC:
MDACC:
50Gyin4FxtoPTV(GTV+11mm)113Gy50Gyin4FxtoPTV(GTV+11mm)113GyAround54GytoGTVAround54GytoGTVKeep35-40GyoffcriticalnormaltissuesKeep35-40GyoffcriticalnormaltissuesOptimalSBRTRegimen?
OptimalSBRTRegimen?
pVUUniversity:
Risk-AdaptedSBRT60GyVUUniversity:
Risk-AdaptedSBRT60GyIdeallocation:
20GyIdeallocation:
20Gy3fx3fxVeryPeripheral:
12GyVeryPeripheral:
12Gy5fx5fxCentrallocated:
7.5Centrallocated:
7.58fx8fxpLocalrelapsein7of219patientsLocalrelapsein7of219patients2/129forT1and5/90forT22/129forT1and5/90forT2SBRTvs3DCRTvsHeavyIonRT肺癌个体化肺癌个体化放疗思考放疗思考肺癌放疗模式转化肺癌放疗模式转化AdvancesofRadiationOncologyAdvancesofRadiationOncology经验医学经验医学个体医学个体医学循证医学循证医学失败与尝试失败与尝试结果难重复结果难重复循证是治疗之本循证是治疗之本即快速应用信息即快速应用信息为量体裁衣为量体裁衣可最大优化可最大优化疗效疗效常规常规RTRT追求追求损伤损伤个体化追求个体化追求疗效疗效损伤损伤最佳平衡最大优化WilliamOslerWilliamOsler(1849-1919)(1849-1919)假如假如个体个体之间没有之间没有如此大的不同,医学就如此大的不同,医学就仅仅是科学而不是艺术仅仅是科学而不是艺术18921892年提出个体化医学年提出个体化医学放疗是医学和艺术放疗是医学和艺术的完美结合,不能量化的完美结合,不能量化本人对放射治疗的见解本人对放射治疗的见解肺癌异质性对放疗的挑战肺癌异质性对放疗的挑战比较比较解剖与功能影像引导放疗解剖与功能影像引导放疗GTVPTVAnatomicalImageGuidedIMRTorIGRTBiologicalImageGuidedRT=BGRT,DosePaintingPTV-LowDoseGTV-ConventionalDosehGTV-HigherDoseDosehomogeneitypreferredWholeorganirradiationrequiredDoseinhomogeneitypreferredProliferatingTV,PGTVDoseinthetargetisuniformedDoseinthetargetisuniformedProliferationAppotosisCellularImageCellularImageMolecularMolecularImageImageEGFR,P53,VEGFHypoxiaCellDensityTissueImageTissueImageTissueImageTissueImageMolecularImageMolecularImage影响个体化放疗差异的因素影响个体化放疗差异的因素RTResponseRTResponseRadiosensitivityRadiosensitivityAgeAgeGenderGenderPerformanceStatusPerformanceStatusStagingStagingPatho