本文選題：宮頸癌 + 螺旋斷層放療��； 參考：《南方醫(yī)科大學(xué)》2017年碩士論文

【摘要】：目的分析宮頸癌放療中腫瘤變化及膀胱、直腸充盈狀態(tài)等諸因素對靶區(qū)和危及器官(OAR)實(shí)際劑量的影響,為臨床提供幫助。方法選取2013年9月至2015年6月于陸軍總醫(yī)院(原北京軍區(qū)總醫(yī)院)行螺旋斷層放療(Tomotherapy)宮頸癌患者20例�；颊哐雠P位,熱塑體膜固定后于CT模擬定位機(jī)下定位,將定位圖像傳至Pinnacle 9.2系統(tǒng),分別勾畫腫瘤(GTV)、臨床靶區(qū)(CTV)、計劃靶區(qū)(PTV)以及OAR,再將勾畫后的CT圖像傳至Tomotherapy治療計劃系統(tǒng)4.1.2.2進(jìn)行計劃設(shè)計。計劃完成并驗證通過后開始放療。每次治療前均行兆伏級CT(MVCT)掃描,并將MVCT重建后與定位的千伏級CT(KVCT)圖像進(jìn)行自動、手動配準(zhǔn),以校正擺位誤差。選取每5次放療中的第1、3次MVCT圖像與定位時的KVCT圖像,在Tomotherapy自適應(yīng)模塊中重新計算劑量分布,得到對應(yīng)單次實(shí)際受照射劑量。將對應(yīng)的融合CT圖像以及單次劑量分布傳輸至形變軟件(MIM 6.5)中進(jìn)行劑量疊加,得到總受照射劑量。在每5次的第1、3次MVCT圖像上,參考初始計劃的靶區(qū),以相同的原則重新勾畫靶區(qū)和OAR,觀察分次照射間靶區(qū)與OAR體積、位置變化分別對靶區(qū)、OAR實(shí)際劑量的影響;將各分次的MVCT及靶區(qū)、總受照射劑量疊加成的計劃稱為Plan-2,初始計劃稱為Plan-1,在DVH上比較Plan-1和Plan-2靶區(qū)、OAR劑量分布情況。采用SPSS20.0軟件進(jìn)行數(shù)據(jù)處理。結(jié)果1靶區(qū)1.1腫瘤變化對靶區(qū)位置的影響1.1.1 GTV體積與照射劑量的關(guān)系隨照射劑量增加,腫瘤體積逐漸縮小,以10～40 Gy縮小顯著,平均每10 Gy縮小10%以上,40 Gy后退縮速度減緩(表1)。1.1.2 GTV中心位置與照射劑量的關(guān)系隨照射劑量增加,腫瘤體積縮小,GTV中心位置也發(fā)生相應(yīng)變化,但變化范圍不大。10～40 Gy照射腫瘤縮小最明顯時的平均位置變化是0.55～0.56 cm,其中前后方向位移中位值為0.38 cm,頭腳方向為0.27 cm,左右方向為0.22 cm。均無統(tǒng)計學(xué)意義(P0.05)(表2)。1.1.3子宮中心位置與照射劑量的關(guān)系照射劑量10Gy后,子宮前后和頭腳方向的中心位置變化逐漸增大,在前后方向位移中位值為0.55 cm,頭腳方向為0.60 cm(P=0.000,0.077),左右方向變化不明顯為0.22cm(P=0.564)(表3)。1.1.4 CTV中心位置與照射劑量的關(guān)系在治療過程中,CTV中心位置變化與照射劑量無關(guān)(表4)。1.2位置變化對靶區(qū)劑量的影響Plan-2中GTV和子宮的D98及D2與Plan-1相比均無差異,Dmean分別高于Plan-1 1.45%和 1.60%(P=0.002,0.002),D95分別高于 Plan-1 1.48%和 1.34%(P=0.058,0.073);CTVD95、Dmean及D2與 Plan-1相比均無差異,D98、V95%低于 Plan-1,降低比例分別為 7.69%、2.59%(P=0.002,0.001)(表 5)。95%處方劑量覆蓋CTV體積為97.36%±1.85%,中位漏照百分比2.01%(0.46～5.99%),中位漏照體積為18.67cm3(2.52～45.77cm3),漏照部位主要位于子宮前部及髂總淋巴引流區(qū)上部(圖a,b)。1.3 OAR充盈狀態(tài)對靶區(qū)的影響1.3.1膀胱充盈狀態(tài)對CTV中心位置的影響膀胱體積與計劃體積相差≤300 cm3或體積相差之比≤40%時,對CTV中心位置影響不大;但當(dāng)膀胱體積與計劃體積相差300 cm3或體積相差之比40%時,CTV的前后、頭腳方向位移較大(P=0.034,0.032或0.013,0.001),但對左右方向無明顯影響(表6)。1.3.2膀胱充盈狀態(tài)對CTV劑量的影響當(dāng)膀胱體積與計劃體積相差300 cm3或體積相差之比40%時,CTV Dmin明顯降低(P=0.004,0.000),但對CTV Dmax、Dmean無明顯影響(P0.05)(表7)。1.3.3直腸充盈狀態(tài)對CTV中心位置的影響直腸體積差異絕對值及其差異比對CTV中心位置影響未顯示出統(tǒng)計學(xué)差異(P0.05)(表 8)。1.3.4直腸充盈狀態(tài)對CTV劑量的影響直腸體積差異絕對值及其差異比對CTV的Dmax、Dmean及Dmin影響均未顯示出統(tǒng)計學(xué)差異(P0.05)(表9)。2 OAR2.1腫瘤變化對OAR中心位置和劑量的影響2.1.1腫瘤變化對膀胱中心位置和劑量的影響隨照射劑量增加,腫瘤縮小,對膀胱的中心位置無明顯影響(表10);但治療過程中,膀胱的V45、V50分別較計劃的Plan-1降低了 21.16%、33.02%(P=0.035,0.004),而 V30、V40、Dmean無顯著差異(P0.05)(表 11)。2.1.2腫瘤變化對直腸中心位置和劑量的影響隨照射劑量增加,腫瘤體積縮小,直腸中心位置無明顯變化(表12);但Plan-2 較計劃的 Plan-1,直腸 V50、Dmean分別增高 48.48%、20.25%(P=0.049,0.000),而 V30、V40、V45 則無顯著差異(P0.05)(表 13)。2.2 OAR充盈狀態(tài)對膀胱和直腸受照劑量的影響2.2.1膀胱2.2.1.1分次治療中膀胱的充盈狀態(tài)在分次治療中膀胱的充盈狀態(tài)差異很大,與照射劑量無明顯關(guān)系(表14)。2.2.1.2膀胱充盈狀態(tài)對膀胱受照劑量的影響膀胱體積差異絕對值及差異比對膀胱Dmax、Dmin、Dmean、V30、V40、V45及V50影響未見明顯規(guī)律(P0.05)(表15)。2.2.2直腸2.2.2.1分次治療中直腸的充盈狀態(tài)在治療過程中直腸的充盈狀態(tài)普遍較前增大,與照射劑量無明顯關(guān)系(表16)。2.2.2.2直腸充盈狀態(tài)對直腸受照劑量的影響直腸體積差異絕對值及差異比對直腸Dmin、Dmax、Dmean影響無明顯差異(P0.05),但直腸體積差異大于30cm3時使其V30、V40、V45、V50增大,或直腸體積差異比大于30%時使其V40、V45、V50增大(P0.05)(表17)。結(jié)論1、宮頸癌Tomotherapy調(diào)強(qiáng)放療中,隨腫瘤縮小,子宮位置有不同程度的變化,引起靶區(qū)劑量變化,主要表現(xiàn)為子宮前傾造成部分靶區(qū)漏照,但漏照體積較小。在圖像引導(dǎo)下,CTV外擴(kuò)5 mm可以滿足靶區(qū)劑量要求。2、膀胱的充盈變化在300 cm3或40%以內(nèi)時,對靶區(qū)的劑量影響不大,所以放療期間不必苛求病人嚴(yán)格的憋尿,適度充盈即可。3、直腸的充盈狀態(tài)對靶區(qū)劑量無明顯影響,但當(dāng)直腸體積變化30 cm3或30%時使直腸受照劑量明顯增加,建議治療前排空直腸,減少損傷的發(fā)生。
[Abstract]:Objective to analyze the effects of tumor changes, bladder, filling state and other factors on the actual dose of target area and endanger organ (OAR) in the radiotherapy of cervical cancer. Methods 20 cases of cervical cancer were selected from September 2013 to June 2015 in Army General Hospital (General Hospital of Beijing Military Region). Patients with cervical cancer were treated with spiral fault radiotherapy (Tomotherapy). In the supine position, the thermoplastic film was fixed under the CT positioning machine. The location image was passed to the Pinnacle 9.2 system. The tumor (GTV), the clinical target area (CTV), the planned target area (PTV) and the OAR, and then the outlined CT images were passed to the Tomotherapy treatment plan system 4.1.2.2 to be planned. After the completion and verification, the radiotherapy was completed and the radiotherapy started after the radiotherapy. The memevolt CT (MVCT) scan is performed before each treatment, and the mv level CT (KVCT) image of the MVCT is reconstructed automatically to correct the pendulum position error. The 1,3 time MVCT image and the positioning KVCT image in every 5 radiotherapy are selected and the dose distribution is recalculated in the Tomotherapy self adaptation module, and the corresponding single practice is obtained. The corresponding fusion CT image and the single dose distribution were transferred to the deformation software (MIM 6.5) for dose superposition, and the total irradiated dose was obtained. On every 5 1,3 MVCT images, the target area and OAR were redrawn with the same principle as the same principle. The volume of the target area between the fractional irradiation and the OAR volume was observed, and the position change was observed. The effect on the target area and the actual dose of OAR respectively; the plan to superimpose the total irradiated doses of each sub MVCT and target area is called Plan-2, the initial plan is called Plan-1, the target area of Plan-1 and Plan-2 is compared with the DVH, the distribution of OAR dose is compared with the SPSS20.0 software. Results the effect of the 1.1 tumor change on the target area in the 1 target area is 1.. 1.1 the relationship between the volume of 1.1 and the dose of radiation increased with the dose of irradiation, the volume of the tumor gradually narrowed, the decrease of the volume of the tumor was 10~40 Gy, the average of each 10 Gy was reduced by more than 10%, and the rate of contraction was slowed down after 40 Gy (Table 1) the relationship between the center position of.1.1.2 and the dose of radiation increased with the dose of irradiation, the volume of the tumor was reduced, and the location of the GTV center also changed correspondingly. The changes in the range of.10 to 40 Gy irradiated tumor were 0.55 to 0.56 cm, which was 0.38 cm, the head and foot direction was 0.27 cm, and the left and right direction was 0.22 cm. (P0.05) (P0.05) (Table 2) the relationship between the center of the uterus and the dose of irradiation, after the dose 10Gy, before the uterus, the uterus was in front of the uterus. The change of the center position of the post and head direction is gradually increased, the position value of the front and back displacement is 0.55 cm, the head and foot is 0.60 cm (P=0.000,0.077). The change of the left and right direction is not obviously 0.22cm (P=0.564) (P=0.564) (Table 3).1.1.4 CTV center position and the irradiation dose. The change of CTV center position is independent of the irradiation dose (Table 4).1.2 during the treatment process. The effect of position change on target area dose in Plan-2, GTV and D98 and D2 of uterus were no difference compared with Plan-1, Dmean was higher than Plan-1 1.45% and 1.60% (P=0.002,0.002), D95 higher than Plan-1 1.48% and 1.34% (P=0.058,0.073), respectively. 2.59% (P=0.002,0.001) (Table 5) (Table 5).95% prescription dose coverage CTV volume 97.36% + 1.85%, median leakage percentage 2.01% (0.46 to 5.99%), median leakage volume of 18.67cm3 (2.52 to 45.77cm3), leakage location is mainly located in the front of the uterus and the upper iliac lymphatic drainage area (a, B).1.3 OAR filling state of the target area of the target area of the bladder filling state When the difference of bladder volume and planned volume is less than 300 cm3 or the ratio of volume difference is less than 40%, the position of the CTV center has little effect on the position of CTV center, but when the difference between the volume of the bladder and the planned volume is 300 cm3 or the ratio of volume to volume is 40%, the head and foot direction is larger (P =0.034,0.032 or 0.013,0.001) before and after CTV, but it is not clear to the left and right direction. Effect (Table 6) the effect of.1.3.2 bladder filling state on the dose of CTV, when the difference of bladder volume and planned volume was 300 cm3 or volume ratio 40%, CTV Dmin decreased significantly (P=0.004,0.000), but CTV Dmax, Dmean had no obvious effect (P0.05) (P0.05) (7).1.3.3 rectum filling state affecting the absolute value of the rectal volume difference in the location of the CTV center and the absolute value of the rectal volume difference and The effect of difference ratio on the location of CTV center did not show significant difference (P0.05) (Table 8) the effect of.1.3.4 rectal filling state on the dose of the rectum on the dose of CTV, the difference of the absolute value of the rectal volume difference and its difference was not statistically significant (P0.05) (P0.05) (P0.05) (P0.05) (P0.05) (P0.05) (P0.05) (P0.05) (Table 9) the effect of the change of.2 OAR2.1 on the location and dose of the OAR Center The effect of tumor changes on the central position and dose of the bladder increased with the dose of irradiation, and the tumor was reduced, and the central position of the bladder was not significantly affected (table 10). But during the treatment, the V45 and V50 of the bladder decreased by 21.16%, 33.02% (P=0.035,0.004), respectively, while V30, V40, and Dmean were not significantly different (Table 11).2.1.2 tumor changes The effect of the rectal center position and dose increased with the dose of irradiation, the tumor volume reduced and the rectal center position was not significantly changed (Table 12), but Plan-2 was 48.48%, 20.25% (P=0.049,0.000), respectively, compared with planned Plan-1, rectal V50 and Dmean, while V30, V40, V45 were not significantly different (table 13).2.2 OAR filling state of the bladder and rectum The effect of dose on the filling state of bladder in 2.2.1 2.2.1.1 fractionated bladder is very different during the fractionated treatment, and there is no significant relationship with the dose of irradiation (table 14) the absolute and difference ratio of bladder volume in the bladder filling state of the bladder affects the bladder volume difference and difference ratio in bladder Dmax, Dmin, Dmean, V30, V40, V45, and V50 shadows. No obvious regularity (P0.05) (table 15) (table 15).2.2.2 rectal filling state during the rectal 2.2.2.1 fractionation in the treatment process, the filling state of rectum was generally higher in the treatment process, and there was no significant relationship with the dose of irradiation (table 16) the effect of rectal volume difference on rectal volume difference absolute value and difference ratio on rectal Dmin, Dmax, Dmean had no significant difference (P0.05), but when the volume difference of rectum was greater than that of 30cm3, its V30, V40, V45, V50 increased, or the volume difference of the rectum was greater than 30% (P0.05) (P0.05) (Table 17). Conclusion 1, in the intensive radiation radiotherapy of cervical cancer, the uterine position changes with different degrees, leading to the change in the dose of the target area. The leakage of some target area was caused by the exversion of the uterus, but the volume of the leakage was small. Under the guidance of the image, CTV expanded 5 mm to meet the target dose.2. When the filling of the bladder was within 300 cm3 or 40%, the dose had little influence on the target area. The condition has no obvious effect on the dose of the target area, but when the volume of the rectum changes 30 cm3 or 30%, the dose of the rectum is obviously increased. It is suggested that the rectum be emptied before treatment to reduce the injury.
【學(xué)位授予單位】：南方醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R737.33

【參考文獻(xiàn)】

相關(guān)期刊論文 前10條

1 丁嘉佩;袁君;朱紅;吳蘇日娜;嚴(yán)思奇;馬覺;;錐形束CT評價根治性宮頸癌調(diào)強(qiáng)放療患者腫瘤臨床靶區(qū)運(yùn)動度的研究[J];臨床腫瘤學(xué)雜志;2016年04期

2 劉云;余嫻;肖何;胡南;王閣;;體質(zhì)量指數(shù)對圖像引導(dǎo)宮頸癌放射治療擺位誤差的影響[J];第三軍醫(yī)大學(xué)學(xué)報;2016年04期

3 王陸州;徐細(xì)明;;基于錐形束CT的宮頸癌患者放療擺位誤差分析[J];中國醫(yī)療設(shè)備;2015年11期

4 李奕彤;王雅棣;張富利;許衛(wèi)東;姚波;陳點(diǎn)點(diǎn);路娜;;宮頸癌調(diào)強(qiáng)放療中靶區(qū)變化與劑量分析[J];中華放射醫(yī)學(xué)與防護(hù)雜志;2015年10期

5 張基永;林珠;吳麗麗;彭遜;;圖像引導(dǎo)自適應(yīng)放療在宮頸癌治療中的應(yīng)用[J];山東醫(yī)藥;2015年27期

6 曹倩倩;朱麗紅;王俊杰;曲昂;姚麗紅;周舜;姜樹坤;孫海濤;林蕾;趙田地;李旭;王巍;廖安燕;;6D治療床對原發(fā)宮頸癌放療擺位誤差及靶區(qū)邊界的影響[J];中華醫(yī)學(xué)雜志;2015年09期

7 綦向;;圖像引導(dǎo)下的宮頸癌自適應(yīng)調(diào)強(qiáng)放射治療[J];中醫(yī)臨床研究;2014年27期

8 龐皓文;邱杰;孫帥;楊波;管秋;張福泉;;宮頸癌調(diào)強(qiáng)放療中直腸體積與位置變化及對吸收劑量影響[J];中華放射腫瘤學(xué)雜志;2012年03期

9 王多明;秦永輝;古麗娜·庫爾班;候友翔;王若崢;;宮頸癌在圖像引導(dǎo)調(diào)強(qiáng)放療中擺位誤差的分析[J];新疆醫(yī)科大學(xué)學(xué)報;2012年03期

10 戴建榮;胡逸民;;圖像引導(dǎo)放療的實(shí)現(xiàn)方式[J];中華放射腫瘤學(xué)雜志;2006年02期

，

本文編號：2052540