發(fā)布時間：2018-11-10 14:24

【摘要】：目的:斜坡是距離腦干最近的骨性結(jié)構(gòu),同時也是局部晚期鼻咽癌顱底骨質(zhì)中常見的受侵部位。在接受根治性放療的患者中,斜坡受侵可能導(dǎo)致腦干的劑量超過2010年鼻咽癌調(diào)強放療專家共識推薦的最大劑量54Gy限值。本研究回顧性分析四川省腫瘤醫(yī)院鼻咽癌斜坡受侵患者腦干的照射劑量和長期隨訪結(jié)果,同時分析斜坡受侵情況、照射劑量與腦干劑量之間的關(guān)系,為將來臨床中遇到類似患者提供治療決策方面的參考。方法:收集2011年1月至2012年12月四川省腫瘤醫(yī)院斜坡受侵、接受根治性放化療的鼻咽癌患者105例,根據(jù)第七版UICC/AJCC分期系統(tǒng)分期,其中T3期37例,T4期68例,年齡21-72歲,中位年齡47歲。統(tǒng)計全部患者腦干劑量,同時將其中77例患者在Eclipse治療計劃系統(tǒng)上復(fù)原出放療計劃,重新勾畫全斜坡及受侵斜坡靶區(qū),記錄受侵斜坡部位及受侵斜坡體積大小,測量全斜坡距絕對腦干的最短距離和受侵斜坡距絕對腦干的最短距離。采用Kaplan—Meier方法計算生存期,壽命表法計算生存率,log-rank方法計算可能影響預(yù)后的單因素分析,C0X風(fēng)險比例模型計算影響預(yù)后的多因素分析。分析腦干劑量的影響因素,采用卡方檢驗進(jìn)行單因素分析,logistic風(fēng)險回歸模型進(jìn)行多因素分析。P0.05為差異有統(tǒng)計學(xué)意義。結(jié)果:中位隨訪時間44月,隨訪期間局部區(qū)域復(fù)發(fā)8例、遠(yuǎn)處轉(zhuǎn)移14例、死亡16例,其中復(fù)發(fā)死亡者3例,轉(zhuǎn)移死亡者4例,1例死于其他惡性腫瘤,2例死于腫瘤相關(guān)并發(fā)癥,6例死亡原因不明。3年的總生存率、局部區(qū)域無復(fù)發(fā)生存率、無遠(yuǎn)處轉(zhuǎn)移生存率、無疾病進(jìn)展生存率分別是88.6%;94.9%;86.3%;77.0%。斜坡照射的累積劑量(D95)為20.56Gy-72.23Gy,中位劑量為60.32Gy;受侵斜坡體積為0.5cm3-18.6cm3,中位體積為4.2cm3,累積劑量(D95)為61.67Gy-81.68Gy,中位劑量為72.77Gy,真實腦干的最大劑量為44.29Gy-72.05Gy,中位劑量為56.4Gy,超過54Gy的有72/105(46/77)例,超過60Gy的有26/105(11/77)例,2/77例腦干的1%體積劑量(D01)大于60Gy,72/77例D1cc在54Gy以下;外放1mm后,1cc劑量為37.86Gy-65.68Gy,中位劑量為51.59Gy,超過60Gy的有3/77例,超過66Gy的有0例,9/77例腦干的D01大于60Gy;外放2mm后,1cc劑量為41.10Gy-68.40Gy,中位劑量為54.63Gy,超過60Gy的有12/77例,超過66Gy的有1/77例,22/77例腦干的D01大于60Gy。本組患者中,由于腦干劑量限值充分放寬,受侵斜坡的D95僅有7例未達(dá)到66Gy,D90則全部達(dá)到66Gy以上,在預(yù)后因素分析中,受侵斜坡的劑量和腦干劑量都不是影響生存的預(yù)后因素。在影響腦干劑量的多因素分析中,斜坡全層受侵及受侵斜坡D95劑量較高可能導(dǎo)致腦干劑量較高(P0.05)。結(jié)論:從本回顧性研究結(jié)果看,對腦干Dmax限制可以適當(dāng)放寬到60Gy以上,D1cc盡量限制在54Gy以下,可以比較安全地給予原發(fā)灶包括受侵斜坡66Gy以上的根治劑量。本組患者三年局控率接近95%,療效較為滿意。
[Abstract]:Objective: Clivus is the closest bone structure to the brain stem and is also a common site in the skull base of locally advanced nasopharyngeal carcinoma (NPC). In patients undergoing radical radiotherapy, Clivus invasion may result in brain stem doses exceeding the maximum dose 54Gy limit recommended by experts in 2010 for intensity-modulated radiotherapy of nasopharyngeal carcinoma (NPC). In this study, we retrospectively analyzed the radiation dose and long-term follow-up results of patients with Clivus invading nasopharyngeal carcinoma (NPC) in Sichuan Cancer Hospital. At the same time, we analyzed the invasion of Clivus and the relationship between the dose of irradiation and the dose of brainstem. To provide a reference for future clinical treatment of similar patients. Methods: from January 2011 to December 2012, 105 patients with nasopharyngeal carcinoma (NPC) who underwent radical radiotherapy and chemotherapy in Sichuan Cancer Hospital were collected. According to the seventh UICC/AJCC staging system, there were 37 cases of T3 stage and 68 cases of T4 stage, aged 21-72 years. The median age is 47 years. The brain stem dose of all the patients was counted, and 77 of them were restored to the radiotherapy plan on the Eclipse treatment plan system. The whole slope and the target area of the invading slope were redrawn, and the invading slope position and the volume of the invaded slope were recorded. The shortest distance from the total Clivus to the absolute brainstem and the shortest distance from the invading Clivus to the absolute brainstem were measured. Survival time was calculated by Kaplan-Meier method, survival rate was calculated by life table method, univariate analysis was calculated by log-rank method and multivariate analysis was calculated by C0X risk ratio model. The influencing factors of brainstem dose were analyzed, the single factor analysis was carried out by chi-square test, and the multivariate analysis was carried out by logistic risk regression model. The difference was statistically significant (P0.05). Results: the median follow-up time was 44 months. During the follow-up period, 8 cases of local regional recurrence, 14 cases of distant metastasis, 16 cases of death, including 3 cases of recurrent death, 4 cases of metastatic death, 1 case died of other malignant tumors. 2 cases died of tumor-related complications, and 6 cases died of unknown cause. The overall survival rate of 3 years, local area no recurrence survival rate, non distant metastasis survival rate, non disease progression survival rate were 88. 6% respectively. 94.9 and 86.3s about 77.0. The cumulative dose (D95) of slope irradiation was 20.56Gy-72.23 Gy and the median dose was 60.32 Gy. The invading slope volume was 0.5cm 3-18.6cm 3, the median volume was 4.2 cm 3, the cumulative dose (D95) was 61.67Gy-81.68 Gy, the median dose was 72.77 Gy, the maximum dose of real brain stem was 44.29Gy-72.05 Gy, and the median dose was 56.4 Gy. There were 72 / 105 (46 / 77) cases that exceeded 54Gy, 26 / 105 (11 / 77) over 60Gy, 1% volume dose (D01) of brain stem (D01) > 60 Gy / 72 / 77 (D1cc) below 54Gy in 2 / 77 cases. After 1mm, the dose of 1cc was 37.86Gy-65.68 Gy, the median dose was 51.59 Gy, 3 / 77 cases exceeded 60Gy, 0 cases exceeded 66Gy, and D01 of brain stem in 9 / 77 cases was greater than 60 Gy. After 2mm, the dose of 1cc was 41.10Gy-68.40 Gy, and the median dose was 54.63 Gy. There were 12 / 77 cases that exceeded 60Gy, 77 cases exceeded 66Gy (1 / 77), and 22 / 77 cases of brain stem D01 were more than 60 Gy. In this group, the brainstem dose limit was fully relaxed, and only 7 patients with invading Clivus D95 did not reach 66 Gy D90, all of them were above 66Gy. In the analysis of prognostic factors, Neither the invading Clivus dose nor the brainstem dose are prognostic factors for survival. In the multivariate analysis of brain stem dose, the higher D95 dose of the whole Clivus layer and the invading Clivus may lead to the higher dose of the brain stem (P0.05). Conclusion: according to the results of this retrospective study, the limitation of brainstem Dmax can be relaxed to more than 60Gy, and the limit of D1cc to 54Gy is lower than that of 54Gy. It is safe to give the radical dose of the primary focus, including the invading Clivus 66Gy. The local control rate of 3 years was close to 95 and the curative effect was satisfactory.
【學(xué)位授予單位】：西南醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R739.63

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