鼻咽癌三维适形放疗的初步观察
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摘要
目的：初步评价三维适形放疗技术在鼻咽癌治疗中的剂量分布优势
及临床应用价值。
方法：自2001年6月至2002年12月，采用三维适形放疗技术治疗
鼻咽癌15例。首程治疗8例，均为局部晚期患者，再程治疗7例。初程
患者，缩野时针对鼻咽原发病灶采用适形放疗技术，照射10-40Gy，鼻咽
部总量70-76Gy／35-38次／7-7.6周。复发再程治疗患者采用全程适形，总
量56-66Gy／28-33次／5.6-6.6周。以CT图象为基础，结合MRI图象勾画
靶区，大体肿瘤体积(gross tumor volume,GTV)四周扩0.5-1.0cm形
成计划靶体积(planning target volume,PTV)。设计5个共面或非共面
野。
结果：根据靶区剂量适形度、DVH(dose-volume histogram,DVH)
曲线、危及器官所受剂量进行常规与适形放疗计划的比较。适形放疗90％
等剂量曲线与靶区更适形，靶区外等剂量线迅速跌落；视交叉垂体区、
腮腺区的受量明显减少；脑组织(不包括脑干)高剂量区的受量亦减少。
由于无逆向设计及调强技术，在保护脑干、上段颈髓时适形放疗无明显优
势。MRI在判别颅底骨质破坏、颅内受侵方面较CT优越。全组患者耐
受性良好，未出现严重的口腔反应。近期疗效首程治疗100％(8／8)；再
鼻咽癌三维适形放疗的初步观察中文提要
程治疗86%(6/7)。随访时间5一21个月，局控率1佣%，87%(l 3/15)患
者生存。
结论:三维适形放疗技术治疗鼻咽癌具有明显的剂量分布优势。用
于局部晚期及复发鼻咽癌局部控制率较高。对远期疗效和放疗后毒副反
应有待积累资料再作进一步评价。MRI在明确病变范围、诊断复发、辅
助勾画靶区方面有重要的作用。
Objective: To investigate the superiority of the dose distribution and the clinical value of three-dimensional radiation therapy (3DCRT) for the boost treatment of primary nasopharyngeal carcinoma (NPC) or the salvage treatment of locally recurrent NPC.
Methods: From June 2001 to December 2002,15 NPC patients treated with 3DCRT.8 primary NPC patients with locally advanced disease used for the boost treatment with a dose of 10-40Gy,the overall dose was 70-76Gy/35-38F /7-7.6weeks; 7 patients with locally recurrent NPC used for the salvage treatment,the dose was 56-66Gy/28-33F/5.6-6.6weeks. According to CT and MRI images to delineate the target ,the gross tumor volume(GTV) was enlarged 5-10mm circumferentialy to form the planning target volume (PTV).5 static conformal portals were delivered with coplanar or non-coplanar irradiation technique.
Results: The plans of 3DCRT were compared with the conventional plans in respect to dose conformalilty,dose-volume histogram(DVH) and dose to the organs at risk.90% iso-dose curve was more suitable to the target in 3DCRT,iso-dose curves outside the target decreased steeply. In the area of
parotid glands,pituitary gland and optic chiasma,the dose received decreased significantly.In the high dose area,the dose to the brain also decreased. Without inverse planning and intensity-modulated radiation therapy (IMRT), 3DCRT had no advantage in protecting brain stem and spinal cord. MRI was superior to CT in differentiating the lesions of skull base.All patients had good tolerance,the acute oral side effect was slight.The short-term effectiveness was 100% and 86% respectively.In the 5-21 months' follow-up period,there was no regional failure.
Conclusion: 3DCRT is effective and feasible to the treatment of NPC,with good responses and no serious side effect.The long-term survival and possible specific side effect,however, need further investigation.MRI is helpful to delineate tumor volume and find tumor recurrence.
及临床应用价值。
方法：自2001年6月至2002年12月，采用三维适形放疗技术治疗
鼻咽癌15例。首程治疗8例，均为局部晚期患者，再程治疗7例。初程
患者，缩野时针对鼻咽原发病灶采用适形放疗技术，照射10-40Gy，鼻咽
部总量70-76Gy／35-38次／7-7.6周。复发再程治疗患者采用全程适形，总
量56-66Gy／28-33次／5.6-6.6周。以CT图象为基础，结合MRI图象勾画
靶区，大体肿瘤体积(gross tumor volume,GTV)四周扩0.5-1.0cm形
成计划靶体积(planning target volume,PTV)。设计5个共面或非共面
野。
结果：根据靶区剂量适形度、DVH(dose-volume histogram,DVH)
曲线、危及器官所受剂量进行常规与适形放疗计划的比较。适形放疗90％
等剂量曲线与靶区更适形，靶区外等剂量线迅速跌落；视交叉垂体区、
腮腺区的受量明显减少；脑组织(不包括脑干)高剂量区的受量亦减少。
由于无逆向设计及调强技术，在保护脑干、上段颈髓时适形放疗无明显优
势。MRI在判别颅底骨质破坏、颅内受侵方面较CT优越。全组患者耐
受性良好，未出现严重的口腔反应。近期疗效首程治疗100％(8／8)；再
鼻咽癌三维适形放疗的初步观察中文提要
程治疗86%(6/7)。随访时间5一21个月，局控率1佣%，87%(l 3/15)患
者生存。
结论:三维适形放疗技术治疗鼻咽癌具有明显的剂量分布优势。用
于局部晚期及复发鼻咽癌局部控制率较高。对远期疗效和放疗后毒副反
应有待积累资料再作进一步评价。MRI在明确病变范围、诊断复发、辅
助勾画靶区方面有重要的作用。
Objective: To investigate the superiority of the dose distribution and the clinical value of three-dimensional radiation therapy (3DCRT) for the boost treatment of primary nasopharyngeal carcinoma (NPC) or the salvage treatment of locally recurrent NPC.
Methods: From June 2001 to December 2002,15 NPC patients treated with 3DCRT.8 primary NPC patients with locally advanced disease used for the boost treatment with a dose of 10-40Gy,the overall dose was 70-76Gy/35-38F /7-7.6weeks; 7 patients with locally recurrent NPC used for the salvage treatment,the dose was 56-66Gy/28-33F/5.6-6.6weeks. According to CT and MRI images to delineate the target ,the gross tumor volume(GTV) was enlarged 5-10mm circumferentialy to form the planning target volume (PTV).5 static conformal portals were delivered with coplanar or non-coplanar irradiation technique.
Results: The plans of 3DCRT were compared with the conventional plans in respect to dose conformalilty,dose-volume histogram(DVH) and dose to the organs at risk.90% iso-dose curve was more suitable to the target in 3DCRT,iso-dose curves outside the target decreased steeply. In the area of
parotid glands,pituitary gland and optic chiasma,the dose received decreased significantly.In the high dose area,the dose to the brain also decreased. Without inverse planning and intensity-modulated radiation therapy (IMRT), 3DCRT had no advantage in protecting brain stem and spinal cord. MRI was superior to CT in differentiating the lesions of skull base.All patients had good tolerance,the acute oral side effect was slight.The short-term effectiveness was 100% and 86% respectively.In the 5-21 months' follow-up period,there was no regional failure.
Conclusion: 3DCRT is effective and feasible to the treatment of NPC,with good responses and no serious side effect.The long-term survival and possible specific side effect,however, need further investigation.MRI is helpful to delineate tumor volume and find tumor recurrence.
引文
1 谷铣之，殷蔚伯，刘泰福，等主编．肿瘤放射治疗学．北京：北京医科大学、中国协和医科大学联合出版社，1993：468—477．
2 汤钊猷主编．现代肿瘤学．上海：上海医科大学出版社，1993：608。
3 刘泰福主编．现代放射肿瘤学．上海：复旦大学出版社，上海医科大学出版社，2001：555-562．
4 Xia P, Fu KK,Wong GW, et al. Comparision of treatment plans involving intensity-modulated radiotherapy for nasopharyngeal carcinoma[J]. Int J Radiat Oncol Biol Phys,2000,48(2):329-337.
5 Hsiung CY, Yorke ED,Chui CS,et al. Intensity-modulated radiotherapy versus conventional three-dimensional conformal radiotherapy for boost or salvage treatment of nasopharyngeal careinoma[J]. Int J Radiat Oncol Biol Phys,2002,53(3):638-647.
6 Hunt MA,Zelefsky MJ,Woiden S,et al. Treatment planning and delivery of intensity-modulated radiation therapy for primary nasopharynx cancer[J], Int J Radiat Oncol Biol Phys,2001,49(3):623-632.
7 Suitanem K,Shu HK,Xia P, et al. Three-dimensional intensity-modulated radiotherapy in the treatment of nasopharyngeal carcinoma: the University of California-San Francisco experience[J], Int J Radiat Oncol Biol Phys,2000,48(3):711-722.
8 Pugachev A,Li JG,Boyer AL,et al. Role of beam orientation optimization in intensity-modulated radiation therapy[J], Int J Radiat Oncol Biol Phys,2001,50(2):551-560.
9 Chong VFH, Fan YF. Skull base erosion in nasopharyngeal carcinoma[J]. Clin Radiol,1996, 51:625-631.
10 龙晚生，汤积耀，罗学毛．鼻咽癌侵犯前中颅窝的MRI表现[J]．中华放射学杂志，1999，33(2)：122-124．
11 Som PM. Sinonasal tumors and inflammatory tissues:differentiation with MR
imaging[J]. Radiology, 1988:803.
12 Chong VF, Fan Y. Detection of recurrent nasopharyngeal carcinoma:MR imaging versus CT[J]. Radiology, 1997,202(2):463-470.
13 Rasch C,Keus R, Pameijer FA,et al. The potential impact of CT-MRI matching on tumor volumn delineation in advanced head and neck cancer[J], Int J Radiat Oncol Biol Phys,1997, 39(4):841-848.
14 Nishioka T, Shiga T, Shirato H, et al. Image fusion between 18FDG-PET and MRI/CT for radiotherapy planning of oropharyngeal and nasopharyngeal carcinomas[J], Int J Radiat Oncol Biol Phys,2002,53(4):1051-1057.
15 Kim GE,Lim J,Park HC,et al. A feasibility study using three-dimensional conformal boost technique in locally advanced carcinoma of the nasopharynx[J]. Acta Oncol, 2001,40(5):582-587.
16 周根发，王传亭，刘鹏．鼻咽癌常规放疗与并用适形照射近期疗效分析[J]．华北煤炭医学院学报，2002，4(2)：155—156．
17 Levendag PC,Lagerwaard FJ,de Pan C,et al. High-dose,high-precision treatment options for boosting cancer of the nasopharynx[J]. Radiother Oncol,2002,63(1):67-74.
18 Wolden SL,Zelefsky MJ,Hunt MA,et al. Failure of a 3D conformal boost to improve radiotherapy for nasopharyngeal carcinoma[J], Int J Radiat Oncol Biol Phys,2001, 49(5): 1229-1234.
19 郑小康，马骏，陈龙华．局部复发鼻咽癌三维适形放疗初步观察[J]．癌症，2001，20(2)：175—179．
20 林少俊，潘建基，吴君心．鼻咽癌局部复发适形放疗近期疗效分析[J]．癌症，2001，20(2)：171～174．
21 Chang JT, See LC,Liao CT, et al. Locally recurrent nasopharyngeal carcinoma[J]. Radiother Oncol,2000,54(2): 135-142.
22 Ling CC, Humm J, Larson S, et al. Towards multidimensional radiotherapy (MD-CRT): biological imaging and biological conformality[J], Int J Radiat Oncol Biol Phys,2000,47(3):551-560.
2 汤钊猷主编．现代肿瘤学．上海：上海医科大学出版社，1993：608。
3 刘泰福主编．现代放射肿瘤学．上海：复旦大学出版社，上海医科大学出版社，2001：555-562．
4 Xia P, Fu KK,Wong GW, et al. Comparision of treatment plans involving intensity-modulated radiotherapy for nasopharyngeal carcinoma[J]. Int J Radiat Oncol Biol Phys,2000,48(2):329-337.
5 Hsiung CY, Yorke ED,Chui CS,et al. Intensity-modulated radiotherapy versus conventional three-dimensional conformal radiotherapy for boost or salvage treatment of nasopharyngeal careinoma[J]. Int J Radiat Oncol Biol Phys,2002,53(3):638-647.
6 Hunt MA,Zelefsky MJ,Woiden S,et al. Treatment planning and delivery of intensity-modulated radiation therapy for primary nasopharynx cancer[J], Int J Radiat Oncol Biol Phys,2001,49(3):623-632.
7 Suitanem K,Shu HK,Xia P, et al. Three-dimensional intensity-modulated radiotherapy in the treatment of nasopharyngeal carcinoma: the University of California-San Francisco experience[J], Int J Radiat Oncol Biol Phys,2000,48(3):711-722.
8 Pugachev A,Li JG,Boyer AL,et al. Role of beam orientation optimization in intensity-modulated radiation therapy[J], Int J Radiat Oncol Biol Phys,2001,50(2):551-560.
9 Chong VFH, Fan YF. Skull base erosion in nasopharyngeal carcinoma[J]. Clin Radiol,1996, 51:625-631.
10 龙晚生，汤积耀，罗学毛．鼻咽癌侵犯前中颅窝的MRI表现[J]．中华放射学杂志，1999，33(2)：122-124．
11 Som PM. Sinonasal tumors and inflammatory tissues:differentiation with MR
imaging[J]. Radiology, 1988:803.
12 Chong VF, Fan Y. Detection of recurrent nasopharyngeal carcinoma:MR imaging versus CT[J]. Radiology, 1997,202(2):463-470.
13 Rasch C,Keus R, Pameijer FA,et al. The potential impact of CT-MRI matching on tumor volumn delineation in advanced head and neck cancer[J], Int J Radiat Oncol Biol Phys,1997, 39(4):841-848.
14 Nishioka T, Shiga T, Shirato H, et al. Image fusion between 18FDG-PET and MRI/CT for radiotherapy planning of oropharyngeal and nasopharyngeal carcinomas[J], Int J Radiat Oncol Biol Phys,2002,53(4):1051-1057.
15 Kim GE,Lim J,Park HC,et al. A feasibility study using three-dimensional conformal boost technique in locally advanced carcinoma of the nasopharynx[J]. Acta Oncol, 2001,40(5):582-587.
16 周根发，王传亭，刘鹏．鼻咽癌常规放疗与并用适形照射近期疗效分析[J]．华北煤炭医学院学报，2002，4(2)：155—156．
17 Levendag PC,Lagerwaard FJ,de Pan C,et al. High-dose,high-precision treatment options for boosting cancer of the nasopharynx[J]. Radiother Oncol,2002,63(1):67-74.
18 Wolden SL,Zelefsky MJ,Hunt MA,et al. Failure of a 3D conformal boost to improve radiotherapy for nasopharyngeal carcinoma[J], Int J Radiat Oncol Biol Phys,2001, 49(5): 1229-1234.
19 郑小康，马骏，陈龙华．局部复发鼻咽癌三维适形放疗初步观察[J]．癌症，2001，20(2)：175—179．
20 林少俊，潘建基，吴君心．鼻咽癌局部复发适形放疗近期疗效分析[J]．癌症，2001，20(2)：171～174．
21 Chang JT, See LC,Liao CT, et al. Locally recurrent nasopharyngeal carcinoma[J]. Radiother Oncol,2000,54(2): 135-142.
22 Ling CC, Humm J, Larson S, et al. Towards multidimensional radiotherapy (MD-CRT): biological imaging and biological conformality[J], Int J Radiat Oncol Biol Phys,2000,47(3):551-560.