本文選題：自適應(yīng)放療 + 宮頸癌��； 參考：《廣西醫(yī)科大學(xué)》2014年碩士論文

【摘要】：目的：研究宮頸癌術(shù)前自適應(yīng)調(diào)強(qiáng)放療在靶區(qū)與危及器官體積、位移、劑量學(xué)的特點(diǎn),并對(duì)自適應(yīng)放療在治療術(shù)前宮頸癌近期療效、毒副作用方面進(jìn)行初步評(píng)價(jià),從而了解自適應(yīng)放療技術(shù)在宮頸癌放療方面的優(yōu)勢(shì)。 材料及方法：對(duì)21例IB2-IIIB期(FIGO2009分期)術(shù)前放化療的宮頸癌患者進(jìn)行每周CT定位,在MIM maestro軟件上進(jìn)行靶區(qū)和危及器官的勾畫,制定普通調(diào)強(qiáng)放療計(jì)劃及后續(xù)自適應(yīng)放療計(jì)劃,所有計(jì)劃PGTV靶區(qū)處方劑量為53Gy,2.12Gy/次／天,PCTV靶區(qū)處方劑量為45Gy,1.8Gy/次／天,5次／周,危及器官勾畫參照RTOG盆腔危及器官勾畫指南,限量參照QUANTEC標(biāo)準(zhǔn)。收集并統(tǒng)計(jì)各周CT靶區(qū)及危及器官的體積、位移,通過(guò)CBCT在骨性配準(zhǔn)及灰度配準(zhǔn)模式下對(duì)患者治療期間擺位誤差進(jìn)行統(tǒng)計(jì)分析,得出擺位誤差并計(jì)算外擴(kuò)邊界。初次定位圖像通過(guò)MM形變?nèi)诤现列露ㄎ粓D像,初始放療計(jì)劃因此得以在新CT上計(jì)算實(shí)際劑量,將新計(jì)劃通實(shí)際劑量融合得到累加劑量。通過(guò)配伍組設(shè)計(jì)的方差分析研究修改計(jì)劃前后靶區(qū)、危及器官的劑量學(xué)改變,根據(jù)RECSIT1.1標(biāo)準(zhǔn)及RTOG急性放射損傷標(biāo)準(zhǔn)對(duì)自適應(yīng)放療近期療效和毒副作用進(jìn)行評(píng)價(jià)。 結(jié)果：1、腫瘤及危及器官體積情況：腫瘤治療后平均體積明顯縮小,總體積平均縮小37.09%,其中第2周縮小比例較其他周明顯(p=0.003),但腫瘤變化情況個(gè)體差異較大。腫瘤最大徑、治療前腫瘤體積、治療前血紅蛋白水平、腫瘤分期與腫瘤體積變化比例無(wú)相關(guān)關(guān)系。膀胱初次定位平均體積為(270.93±129.44)cc,直腸初次定位平均體積為39.3cc (14.42-97.7cc),腸袋初次定位平均體積為：948.12cc (473.21-1615.38cc),治療期間膀胱、直腸、腸袋變化體積絕對(duì)值平均為(88.15±74.26) cc、9.12cc (4.12-17.16cc)、101.40cc (35.84-131.32cc),分析初始CT及各周CT危及器官的體積平均值,差異無(wú)統(tǒng)計(jì)學(xué)意義。 2、位移情況：宮頸質(zhì)心在左右、上下、前后方向位移為(1.8±0.6) mm,(3.1±1.9) mm,(4.9±2.3) mm。膀胱質(zhì)心在左右、上下、前后方向位移分別為(2.6±1.8) mm、(19.5±8.3)mm、(9.1±3.4)mm。直腸在左右、上下、前后方向位移分別為(3.2±1.5) mm、(6.0±3.3) mm、(9.4±5.8)mm。分析宮頸質(zhì)心位移同膀胱體積、直腸體積變化關(guān)系無(wú)統(tǒng)計(jì)學(xué)意義。宮頸前壁位移同膀胱后壁位移、宮頸后壁位移同直腸前壁位移具有相關(guān)性(r=0.282、r=0.481),差異有統(tǒng)計(jì)學(xué)意義。3、擺位誤差與外擴(kuò)邊界：骨性配準(zhǔn)模式下的擺位誤差在左右、上下、前后方向均值為(0.02±0.248) cm,(0.11±0.989)cm,(-0.06±0.32) cm;灰度配準(zhǔn)模式下的擺位誤差在左右、上下、前后方向均值為(0.01±0.186) cm,(0.14±0.814)cm,(0.02±0.41) cm。三個(gè)方向上不同配準(zhǔn)模式得出擺位誤差的差異無(wú)統(tǒng)計(jì)學(xué)意義(p值均0.05)。根據(jù)Van herk邊界公式計(jì)算出骨配準(zhǔn)模式下CTV-PTV邊界分別為：左右方向2.24mm、上下方向9.67mm、前后方向3.74mm�；叶扰錅�(zhǔn)模式下CTV-PTV邊界分別為：左右方向1.55mm、上下方向9.20mm、前后方向3.37mm。 4、靶區(qū)劑量學(xué)的變化：如果未修改計(jì)劃,PGTV的V53、V58.3、V49.29、 D50、CI水平,PCTV的V45、CI水平較原計(jì)劃水平下降,差異有統(tǒng)計(jì)學(xué)意義(p值均0.05),修改計(jì)劃后,PGTV的V53、D50、CI水平、PCTV的V45、CI水平有提高,差異有顯著性(p值均0.05)。 5、危及器官劑量學(xué)變化：如果未修改計(jì)劃,膀胱V40、膀胱V50、直腸V40、直腸V50、腸袋V40、腸袋V45絕對(duì)體積、腸袋Dmean升高,差異有統(tǒng)計(jì)學(xué)意義(p均0.05)；修改計(jì)劃后膀胱V40、膀胱V50、直腸V50、直腸Dmean、腸袋V40、腸袋V45絕對(duì)體積下降,差異有統(tǒng)計(jì)學(xué)意義(p均0.05)。股骨頭V50、V30、Dmean,骨髓V10、V20、Dmean劑量學(xué)差異在修改計(jì)劃前后的差異無(wú)統(tǒng)計(jì)學(xué)意義。6、毒副作用及近期療效：所有患者治療期間1-2級(jí)胃腸道毒性發(fā)生率約61.9%,3-4級(jí)胃腸道毒性發(fā)生率約4.7%；1-2級(jí)血液學(xué)(白細(xì)胞)毒性發(fā)生率約52.4%,3-4級(jí)血液學(xué)(白細(xì)胞)毒性發(fā)生率約23.8%。所有病例治療后影像學(xué)PR率61.9%,14例患者進(jìn)行了手術(shù),術(shù)后病理CR率42.85%,分析病理CR與影像PR、腫瘤初始體積、最大徑、治療前血紅蛋白水平的相關(guān)性無(wú)統(tǒng)計(jì)學(xué)意義。 結(jié)論：1.宮頸癌術(shù)前放化療期間,腫瘤消退在第2周比較顯著,但具有較大個(gè)體差異性,消退情況同初始腫瘤體積、最大徑無(wú)明顯相關(guān)性； 2.即使有一定準(zhǔn)備條件,膀胱、直腸體積在放療期間仍有較大差異,膀胱后壁與宮頸前壁位移弱相關(guān),直腸前壁與宮頸后壁位移中度相關(guān)；3.骨性配準(zhǔn)及灰度配準(zhǔn)模式下測(cè)量的擺位誤差無(wú)明顯差異,骨性配準(zhǔn)模式下CTV-PTV外擴(kuò)邊界為：左右方向2.24mm、上下方向9.67mm、前后方向3.74mm。灰度配準(zhǔn)模式下CTV-PTV外擴(kuò)邊界為：左右方向1.55mm、上下方向9.20mm、前后方向3.37mm。4.宮頸癌術(shù)前自適應(yīng)調(diào)強(qiáng)放療能提高靶區(qū)覆蓋率及適形度；5.宮頸癌術(shù)前自適應(yīng)調(diào)強(qiáng)放療能在一定劑量水平上降低膀胱、直腸、腸袋的受照劑量。6.宮頸癌術(shù)前自適應(yīng)調(diào)強(qiáng)放療近期療效確切,毒副反應(yīng)不高。
[Abstract]:Objective: To study the characteristics of the volume, displacement and dosimetry of adaptive intensity modulated radiation therapy for cervical cancer in the target area and endanger organs, and to evaluate the short-term effect and side effects of adaptive radiotherapy in the treatment of cervical cancer before treatment, and to understand the advantages of adaptive radiotherapy in the radiotherapy of cervical cancer.
Materials and methods: 21 cases of IB2-IIIB (FIGO2009 staging) preoperative radiotherapy and chemotherapy of cervical cancer patients were given a weekly CT location, the target area and endanger organs were outlined on MIM Maestro software. The general intensity modulated radiation therapy plan and subsequent adaptive radiotherapy plan were made. All the planned PGTV target area prescriptions were 53Gy, 2.12Gy/ times / day, PCTV target area. The prescription dose is 45Gy, 1.8Gy/ times / day, 5 times / week, endanger organs and draw reference to RTOG pelvic organ delineation guide, limited reference to QUANTEC standard. The volume and displacement of CT target area and endanger organ in each week are collected and counted, and the position error of the patients during the treatment of bone registration and gray registration is statistically analyzed by CBCT. The initial positioning image is fused to the new location image through the MM deformation. The initial radiotherapy plan is able to calculate the actual dose on the new CT. The new plan is combined with the actual dose to get the cumulative dose. The target area before and after the modification plan is studied through the variance analysis designed by the compatibility group. The dosimetry of the organs is endangered. According to RECSIT1.1 standard and RTOG acute radiation injury standard, we evaluated the short-term efficacy and side effects of adaptive radiotherapy.
Results: 1, tumor and endanger organ volume: the average volume of the tumor was obviously reduced and the total volume decreased by 37.09%, and the proportion of the second weeks was smaller than that of other Zhou Mingxian (p=0.003), but the individual difference was larger. The maximum diameter of the tumor, the volume of the tumor before treatment, the level of hemoglobin before treatment, the stage of tumor and the tumor body. The average volume of primary location of the bladder was (270.93 + 129.44) CC, the average volume of the primary location of the rectum was 39.3cc (14.42-97.7cc), the average volume of the initial location of the intestinal bag was 948.12cc (473.21-1615.38cc). The mean value of the changes of the volume of the bladder, rectum and intestinal bag was (88.15 + 74.26) CC, 9.12cc (4.12-17.1) during the treatment. 6cc) and 101.40cc (35.84-131.32cc). There was no significant difference in the average volume of CT and CT in each week.
2, displacement situation: the cervical center of mass was left and right, up and down, the displacement of the anterior and posterior direction was (1.8 + 0.6) mm, (3.1 + 1.9) mm, and (4.9 + 2.3) mm. of the bladder center of mass, and up and down, the displacement was (2.6 + 1.8) mm, (19.5 + 8.3) mm and (9.1 + 3.4) mm. rectum in left and right, up and down, respectively mm, mm, mm. The relationship between the displacement of the cervix and the volume of the bladder and the volume of the rectum was not statistically significant. The displacement of the anterior wall of the cervix with the displacement of the posterior wall of the bladder, the displacement of the posterior wall of the cervix and the displacement of the anterior wall of the rectum (r=0.282, r=0.481) were statistically significant, and the difference was statistically significant, and the pendulum error and the exodiffused boundary were left and right in the pattern of bone registration. Up and down, the mean value of the front and rear directions is (0.02 + 0.248) cm, (0.11 + 0.989) cm and (-0.06 + 0.32) cm, and the pendulum position error in gray registration mode is about, up and down, the mean value of the direction is (0.01 + 0.186) cm, (0.14 + 0.814) cm, (0.02 + 0.41) cm., and the difference of the pendulum error is not statistically significant (P value 0.05) according to the different registration modes. The Van herk boundary formula calculates that the CTV-PTV boundary in the bone registration mode is respectively: the left and right 2.24mm, the upper and lower direction 9.67mm, and the 3.74mm. gray registration mode in the front and back direction 3.74mm., respectively, the left and right 1.55mm, the upper and lower 9.20mm, and the back and back 3.37mm..
4, the change in dosimetry in the target area: if the plan is not modified, PGTV's V53, V58.3, V49.29, D50, CI level, PCTV V45, CI level is lower than the original plan level, and the difference is statistically significant (P value is 0.05).
5, endanger the changes in dosimetry: bladder V40, bladder V50, rectal V40, rectal V50, intestinal bag V40, intestinal bag V45 absolute volume, intestinal bag Dmean increased, the difference was statistically significant (P 0.05), and modified planned bladder V40, bladder V50, rectum V50, rectal Dmean, intestinal bag, intestinal bag absolute volume decreased, the difference was statistically significant Meaning (P 0.05). The difference between V50, V30, Dmean, bone marrow V10, V20, Dmean was not statistically significant.6, side effects, and short-term efficacy before and after the modification plan: the incidence of gastrointestinal toxicity at level 1-2 was about 61.9% during the treatment of all patients, and the incidence of grade 3-4 gastrointestinal toxicity was about 4.7%; the incidence of grade 1-2 Hematology (leukocyte) toxicity was about 4.7% 52.4%, the incidence of grade 3-4 Hematology (leukocyte) toxicity was about 23.8%. in all cases, the rate of PR was 61.9%, and 14 patients underwent surgery. The postoperative pathological CR rate was 42.85%. The pathological CR and image PR were analyzed. The initial volume, the maximum diameter of the tumor, and the correlation of the hemoglobin level before treatment were not statistically significant.
Conclusion: 1. during the preoperative and postoperative radiotherapy and chemotherapy of cervical cancer, the tumor regression was significant in second weeks, but there was a larger individual difference. The regression was not significantly correlated with the initial tumor volume and the maximum diameter.
2. even with certain preparation conditions, the volume of the bladder and rectum still vary considerably during the radiotherapy. The posterior wall of the bladder is weakly related to the displacement of the anterior wall of the cervix, the anterior wall of the rectum is moderately related to the displacement of the posterior wall of the cervix, and there is no obvious difference in the displacement error measured in 3. bone registration and gray registration mode, and the CTV-PTV external expansion boundary under the bone registration mode is left: left The right direction 2.24mm, the upper and lower direction 9.67mm, the front and back direction 3.74mm. gray registration mode, the CTV-PTV external expansion boundary is: the left and right 1.55mm, the upper and lower direction 9.20mm, the anterior and back direction 3.37mm.4. cervical cancer preoperative adaptive intensity modulated radiotherapy can improve the target area coverage and conformal degree; 5. the preoperative adaptive intensity modulated radiation therapy of cervical cancer can be at a certain dose level Reducing the dose of bladder, rectum and intestinal pouch.6. the effect of preoperative intensity modulated radiation therapy on cervical cancer is definite and the toxic side effects are not high.
【學(xué)位授予單位】：廣西醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2014
【分類號(hào)】：R737.33

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相關(guān)期刊論文 前1條

1 楊海松;聶曉歷;劉利彬;陳寶錄;;不同匹配方式對(duì)宮頸癌圖像引導(dǎo)放射治療擺位誤差的影響[J];福建醫(yī)藥雜志;2012年02期

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