本文關(guān)鍵詞： 鼻咽癌 放射性顳葉壞死 調(diào)強(qiáng)放射治療　出處：《廣西醫(yī)科大學(xué)》2014年碩士論文　論文類型：學(xué)位論文

【摘要】：目的：本研究通過回顧性分析研究鼻咽癌調(diào)強(qiáng)放射治療（Intensity-modulated radiation therapy，IMRT）后放射性顳葉壞死（Radiation induced temporal lobe necrosis，RITLN）與顳葉的劑量-體積關(guān)系以及臨床特點(diǎn)，研究鼻咽癌放射治療中顳葉的劑量、其他相關(guān)因素與放射性顳葉壞死的關(guān)系；探索放射治療中顳葉耐受劑量的體積指標(biāo)和相應(yīng)的耐受劑量，明確放射性顳葉壞死的發(fā)生規(guī)律，為鼻咽癌調(diào)強(qiáng)放射治療中顳葉的保護(hù)提供確切的限制劑量-體積標(biāo)準(zhǔn)。探索自適應(yīng)放療(adaptive radiation therapy, ART)在降低局部晚期鼻咽癌放射性顳葉壞死中的作用。 方法：收集四川省腫瘤醫(yī)院2004年1月-2009年1月IMRT初治性根治的鼻咽癌病例共695例，通過隨訪核磁共振成像（MagneticResonance Imaging，MRI）診斷RITLN。統(tǒng)計(jì)入選患者的一般情況（性別、年齡、T分期、糖尿病、高血壓、煙酒史、血脂水平）、治療情況（化療、靶向治療、是否自適應(yīng)放療）和顳葉劑量進(jìn)行分析。顳葉劑量分別統(tǒng)計(jì)雙側(cè)顳葉D0.1cc（0.1立方厘米接受的最大劑量）、D0.5cc、D1cc、D2cc、D3cc、D5cc、D10cc、D15cc、D20cc、Dmean（平均劑量）、Dmax（最大劑量）。分析顳葉壞死與顳葉劑量的關(guān)系，篩選預(yù)測顳葉壞死劑量-體積的合適指標(biāo)以及相應(yīng)的顳葉限制劑量。分析調(diào)強(qiáng)放療中患者的一般情況、治療情況和放療劑量、分次劑量、計(jì)劃次數(shù)等因素中RITLN的影響因素。 結(jié)果：695例入選病例中，共59例以MRI確診為RITLN，全組總的RITLN發(fā)生率為8.49%。發(fā)生壞死的顳葉劑量均明顯高于未壞死的顳葉劑量（p0.05）。壞死病灶均位于原計(jì)劃的高劑量區(qū)域。通過受試者工作特征曲線（ROC曲線）分析，結(jié)果顯示Dmax、D0.1cc、D0.5cc、D1cc、D2cc、D3cc、D5cc、D10cc、D15cc、D20cc、Dmean中曲線下面積隨體積增大呈先增后減的趨勢，D2cc的曲線下面積最大（0.856）。各個(gè)劑量-體積指標(biāo)進(jìn)行多因素分析顯示D2cc是顳葉壞死的獨(dú)立影響指標(biāo)。5年內(nèi)顳葉RITLN的發(fā)生率5%（TD5/5，Tolerance dose）的等效生物劑量為（biological effective dose，BED）D2cc60.31Gy（95%CI：59.09Gy，61.54Gy），TD50/5為76.85Gy（95%CI：75.74Gy，78.22Gy）。 局部晚期鼻咽癌患者采用非ART和ART時(shí)顳葉的劑量（D2cc）分別為：T3期患者非ART和ART的顳葉劑量（D2cc）分別為67.1±7.2Gy和62.3±6.6Gy，P=0.000；T4期患者非ART和ART計(jì)劃的顳葉劑量（D2cc）分別為69.4±7.7Gy和65.5±6.9Gy，，P=0.001。局部晚期鼻咽癌非ART的顳葉劑量明顯高于ART，P=0.000， T3期非ART和ART的RITLN發(fā)生率分別為13.7%和5.8%，P=0.037。T4期程計(jì)劃和ART的RITLN發(fā)生率分別為21.8%和11.7%，P=0.038。局部晚期鼻咽癌ART的RITLN發(fā)生率明顯低于非ART計(jì)劃的發(fā)生率。非ART與ART的5年局部控制率為：T3期的非ART和ART患者的5年局控率分別為94.5%和94.3%，P=0.933，T4期的5年局控率92.1%和93.2%，P=0.78。在局部晚期鼻咽癌中非ART與ART的局控率無統(tǒng)計(jì)差異。 對納入病例的性別、年齡、病理類型、糖尿病、高血壓、吸煙史、飲史酒、膽固醇、甘油三脂、化療、靶向治療、顳葉劑量（D2cc）、是否ART、單次劑量進(jìn)行單因素分析顯示顳葉劑量（P0.001）、T分期（P=0.0000.05）、同步化療（P=0.002），糖尿�。≒=0.027）、單次劑量是否2Gy（P=0.000）、是否行ART（P=0.036）有統(tǒng)計(jì)意義。多因素分析結(jié)果顯示顳葉劑量（P0.001）、T分期（P0.001）、單次劑量是否≥2Gy（P0.001）、同步化療（P=0.009）、是否行ART（P=0.021）是RITLN的獨(dú)立影響因素，其OR值分別為3.463、4.023、3.963、2.976、0.339。 結(jié)論：RITLN的發(fā)生與顳葉的照射劑量和對應(yīng)體積關(guān)系密切，RITLN主要因顳葉接受較高的放療劑量；顳葉的D2cc的等效生物劑量60.31Gy可作為顳葉TD5/5的限制劑量；局部晚期鼻咽癌可通過ART降低顳葉劑量，減少RITLN的發(fā)生；另外腫瘤T分期、顳葉的劑量D2cc≥2Gy、同步化療也是RITLN的獨(dú)立危險(xiǎn)因素。
[Abstract]:Objective: This study was retrospective analysis of nasopharyngeal carcinoma intensity-modulated radiation therapy (Intensity-modulated radiation, therapy, IMRT) after radioactive temporal lobe necrosis (Radiation induced temporal lobe necrosis, RITLN) and temporal lobe dose volume relationship and clinical characteristics, the research of temporal lobe radiation therapy of nasopharyngeal carcinoma in the dose related factors and radiation temporal lobe necrosis; explore temporal lobe volume index of tolerance dose in radiotherapy and the corresponding tolerated dose, clear radioactive temporal lobe necrosis occurrence, provide limited protection for the exact dose of nasopharyngeal carcinoma IMRT in the treatment of temporal lobe volume. Adaptive radiotherapy (adaptive radiation exploration therapy, ART) in reducing the local advanced nasopharyngeal carcinoma radioactive temporal lobe necrosis in rats.
Methods: from January 2004 January -2009 year in Sichuan province cancer hospital IMRT nasopharyngeal carcinoma cases radical were 695 Cases, the follow-up magnetic resonance imaging (MagneticResonance, Imaging, MRI) in general statistical diagnosis of RITLN. enrolled patients (gender, age, T stage, diabetes, hypertension, smoking and alcohol use, blood lipid level, treatment) situation (chemotherapy, targeted therapy, whether adaptive radiotherapy) and temporal lobe dose were analyzed. The temporal lobe dose statistics were bilateral temporal lobe (D0.1cc 0.1 cubic centimeters accept the maximum dose), D0.5cc, D1cc, D2cc, D3cc, D5cc, D10cc, D15cc, D20cc, Dmean (average dose), Dmax (maximum dose). Analysis of the relationship between temporal lobe necrosis and temporal lobe dose screening, prediction of temporal lobe necrosis dose volume index and the corresponding right temporal lobe dose limiting. Analysis of the general condition of the patient in radiotherapy, and radiotherapy dose, divided dose, time plan Factors affecting the number of factors such as RITLN.
Results: 695 Cases, a total of 59 cases with MRI were diagnosed as RITLN, the total incidence rate of RITLN in the temporal lobe dose of 8.49%. necrosis were significantly higher than that of temporal lobe dose not necrosis (P0.05). The high dose area necrotic lesions were located in the original plan. The receiver operating characteristic curve (ROC curve) analysis, the result shows that Dmax, D0.1cc, D0.5cc, D1cc, D2cc, D3cc, D5cc, D10cc, D15cc, D20cc, Dmean in the area under the curve first increased and then decreased with the increase in size, the area under the D2cc curve of the maximum (0.856). The dose volume index of multivariate analysis showed that D2cc is the independent effect of temporal lobe necrosis index.5 of medial temporal lobe in the incidence of RITLN was 5% (TD5/5, Tolerance dose) the equivalent biological dose (biological effective dose, BED) D2cc60.31Gy (95%CI:59.09Gy, 61.54Gy), TD50/5 76.85Gy (95%CI: 75.74Gy 78.22Gy).
Patients with locally advanced nasopharyngeal carcinoma by ART and ART when the temporal lobe dose (D2cc) respectively: temporal lobe dose in patients with non ART and ART T3 (D2cc) were 67.1 + 7.2Gy and 62.3 + 6.6Gy, P=0.000; temporal lobe dose in patients with non ART and ART plan T4 (D2cc) were 69.4 + 7.7Gy and 65.5 + 6.9Gy, temporal lobe dose ART P=0.001. locally advanced nasopharyngeal carcinoma was significantly higher than that of ART, P=0.000, T3 and ART RITLN non ART incidence rates were 13.7% and 5.8%, P=0.037.T4 period plan and ART RITLN rate was 21.8% and 11.7%, P=0.038. for locally advanced nasopharyngeal carcinoma. The incidence rate of RITLN ART the incidence rate was significantly lower than that of non ART. The 5 year local control rate of ART for non ART and non ART stage T3 and ART patients 5 year local control rates were 94.5% and 94.3%, P=0.933, T4 period of 5 years and 92.1% local control rate of 93.2%, P=0.78. in locally advanced nasopharyngeal carcinoma and non ART the local control rate without ART Statistical differences.
The cases included gender, age, pathological type, diabetes, hypertension, smoking history, drinking wine, cholesterol, glycerin three greases, chemotherapy, targeted therapy, temporal lobe dose (D2cc), ART, single factor analysis showed that a single dose of temporal lobe dose (P0.001), T stage (P=0.0000.05) concurrent chemotherapy, (P=0.002), diabetes mellitus (P=0.027), a single dose of 2Gy (P=0.000), ART (P=0.036) is statistically significant. Multivariate analysis showed that temporal lobe dose (P0.001), T stage (P0.001), single dose is more than 2Gy (P0.001), chemotherapy (P=0.009) and whether or not ART (P=0.021) was the independent factor of RITLN, OR = 3.463,4.023,3.963,2.976,0.339.
Conclusion: the radiation dose and the corresponding volume related to the occurrence of temporal lobe RITLN closely RITLN, mainly due to the temporal lobe receiving higher radiation doses; biological effective dose of the temporal lobe in 60.31Gy D2cc can be used as the dose limiting TD5/5 temporal lobe; locally advanced nasopharyngeal carcinoma can reduce the temporal lobe dose by ART, reduce the incidence of RITLN; in addition T stage of the tumor, the temporal lobe dose of D2cc is larger than 2Gy, the independent risk factors of concurrent chemotherapy is RITLN.

【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)】：R739.63

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