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1、脑胶质瘤术后放疗及靶区勾画原则,中山大学肿瘤防治中心放疗科,脑胶质瘤的发病概况,成人最常见的颅内原发肿瘤约占脑肿瘤的35%60%近年发病率呈逐渐上升趋势,脑胶质瘤的病理分类,共分为四大类:星形细胞肿瘤少突胶质细胞肿瘤混合性胶质细胞肿瘤室管膜肿瘤,脑胶质瘤的WHO分级,根据细胞异型性、核分裂、血管增生及坏死程度分级低级别胶质瘤(Low-grade glioma,LGG):WHO级高级别胶质瘤(High-grade glioma,HGG): WHO III级,脑胶质瘤的术后放疗原则脑胶质瘤放疗靶区的勾画原则,脑胶质瘤的术后放疗原则脑胶质瘤放疗靶区的勾画原则,低级别胶质瘤的术后放疗原则高级别胶质瘤的
2、术后放疗原则(略),术后放疗的争议较大,主要集中在以下两个方面:术后放疗的时间问题:术后早期放疗还是疾病进展时?术后放疗的剂量问题,1.术后放疗的时间问题,EORTC22845 Trial,EORTC22845 III期临床随机研究目的:评价LGG术后患者早期放疗与延迟治疗的长期疗效,van den Bent M J, Afra D, de Witte O, et al. Long-term efficacy of early versus delayed radiotherapy for low- grade astrocytoma and oligodendroglioma in adul
3、ts: the EORTC 22845 randomised trial J. Lancet, 2005,366(9490):985- 990.,van den Bent M J, Afra D, de Witte O, et al. Long-term efficacy of early versus delayed radiotherapy for low- grade astrocytoma and oligodendroglioma in adults: the EORTC 22845 randomised trial J. Lancet, 2005,366(9490):985- 99
4、0.,方案设计,研究结果(1),中位生存期早期放疗组:7.4年延迟治疗组:7.2年,van den Bent M J, Afra D, de Witte O, et al. Long-term efficacy of early versus delayed radiotherapy for low- grade astrocytoma and oligodendroglioma in adults: the EORTC 22845 randomised trial J. Lancet, 2005,366(9490):985- 990.,研究结果(2),中位无进展生存期早期放疗组:5.3年延迟
5、治疗组:3.5年,van den Bent M J, Afra D, de Witte O, et al. Long-term efficacy of early versus delayed radiotherapy for low- grade astrocytoma and oligodendroglioma in adults: the EORTC 22845 randomised trial J. Lancet, 2005,366(9490):985- 990.,结 论,尽管早期放疗与延迟治疗OS无差别,但可延长PFS对年老、局部神经功能缺陷、高颅内压或认知力下降的患者,应早期放疗对
6、于年轻(45岁)、临床仅表现为癫痫、预后良好的患者,可采用“wait and see”策略,van den Bent M J, Afra D, de Witte O, et al. Long-term efficacy of early versus delayed radiotherapy for low- grade astrocytoma and oligodendroglioma in adults: the EORTC 22845 randomised trial J. Lancet, 2005,366(9490):985- 990.,术后放疗剂量的问题,EORTC 22844 Tr
7、ialNCCTG/RTOG/ECOG Study,术后放疗剂量的问题,EORTC 22844 TrialNCCTG/RTOG/ECOG Study,研究方法及目的,期前瞻性临床随机研究共379例LGG术后患者分低剂量组(45Gy/25次)和高剂量组(59.4Gy/33次)研究低级别胶质瘤术后放疗的剂量效应关系,Karim A B, Maat B, Hatlevoll R, et al. A randomized trial on dose - response in radiation therapy of low-grade cerebral glioma: European Organiz
8、ation for Re-search and Treatment of Cancer (EORTC) Study 22844.J. Int J Radiat Oncol Biol Phys, 1996, 36:549- 556.,研究结果(1):生存情况,中位随访期74个月5年总生存率:低剂量组:58%高剂量组:59%5年无进展生存率:低剂量组:47%高剂量组:50%,Karim A B, Maat B, Hatlevoll R, et al. A randomized trial on dose - response in radiation therapy of low-grade ce
9、rebral glioma: European Organization for Re-search and Treatment of Cancer (EORTC) Study 22844.J. Int J Radiat Oncol Biol Phys, 1996, 36:549- 556.,研究结果(2):毒性反应,急性反应轻微,两组间未见统计学差异未见明确的放射性脑坏死晚期毒性及生活质量两组间未见差异,Karim A B, Maat B, Hatlevoll R, et al. A randomized trial on dose - response in radiation thera
10、py of low-grade cerebral glioma: European Organization for Re-search and Treatment of Cancer (EORTC) Study 22844.J. Int J Radiat Oncol Biol Phys, 1996, 36:549- 556.,术后放疗剂量的问题,EORTC 22844 TrialNCCTG/RTOG/ECOG Study,术后放疗剂量的问题,EORTC 22844 TrialNCCTG/RTOG/ECOG Study,研究方法及目的,203例LGG术后患者分低剂量组(50.4Gy/28次)和
11、高剂量组(64.8Gy/36次)对比两组间的生存及毒性,Shaw E, Arusell R, Scheithauer B, et al. Prospective randomized trial of low- versus high- dose radiation ther-apy in adults with supratentorial low- grade glioma: ini-tial report of a North Central Cancer Treatment Group/Radiation Therapy Oncology Group/Eastern Cooperati
12、ve Oncology Group study J. J Clin Oncol, 2002, 20:2267- 2276.,研究结果(1):生存期及TTP,5年生存率:Low-dose RT组:72%High-dose RT组:65%,Shaw E, Arusell R, Scheithauer B, et al. Prospective randomized trial of low- versus high- dose radiation ther-apy in adults with supratentorial low- grade glioma: ini-tial report of
13、 a North Central Cancer Treatment Group/Radiation Therapy Oncology Group/Eastern Cooperative Oncology Group study J. J Clin Oncol, 2002, 20:2267- 2276.,中位肿瘤进展时间(TTP):Low-dose RT组 vs High-dose RT组无显著差异(p=0.65),研究结果(2):毒性反应,严重CNS放射毒性发生率:Low-dose RT组 6% vs High-dose RT组 10%,Shaw E, Arusell R, Scheithau
14、er B, et al. Prospective randomized trial of low- versus high- dose radiation ther-apy in adults with supratentorial low- grade glioma: ini-tial report of a North Central Cancer Treatment Group/Radiation Therapy Oncology Group/Eastern Cooperative Oncology Group study J. J Clin Oncol, 2002, 20:2267-
15、2276.,结 论,以上两个研究均表明:高剂量放疗对延长患者生存期无益可能加重放疗的毒性反应,小 结,完全切除的LGG患者(毛细胞型除外):年龄40岁且无高危因素者可观察,否则应早期放疗未完全切除的LGG患者:年轻、症状稳定或可控者可观察或放疗;年老、局部神经功能缺陷、高颅内压或认知力下降的患者,应早期放疗放疗的推荐放疗剂量为45Gy54Gy,1.82.0Gy/次,脑胶质瘤的术后放疗原则脑胶质瘤放疗靶区的勾画原则,脑胶质瘤放疗靶区的勾画原则,已实现了由全脑或全中枢放疗到局部野放疗的转变逐渐转向功能影像与传统解剖影像相结合的模式,高级别胶质瘤靶区勾画原则,包括间变性少突胶质瘤、间变性星形细胞瘤和
16、胶质母细胞瘤影像学资料:参考手术前、后MRI靶区定义:靶区剂量:CTV:5460Gy,1.82.0Gy/次,GTV:术后MRI强化区+瘤床 CTV:GTV+23cm(包全MRI T2W水肿区) PTV:CTV+0.5cm 须注意包全解剖学易受侵犯区域,如胼胝体,瘤床+23cm为CTV1,若CTV1250cm3,照射至4650Gy时,可缩野至瘤床外1cm(CTV2),推量至60Gy,低级别胶质瘤靶区勾画原则,包括星形细胞瘤和少突胶质瘤影像学资料:参考手术前、后MRI靶区定义:靶区剂量:CTV:4554Gy,1.82.0Gy/次,GTV:MRI T2W或FLAIR异常高信号区CTV:GTV+12cmPTV:CTV+0.5cm,室管膜肿瘤,包括室管膜瘤和间变性室管膜瘤CSF检查:术后23周影像学资料:参照手术前、后颅脑+全脊髓MRI放疗原则:局部野放疗:MRI及CSF检查脊髓均阴性者全中枢+局部野放疗:MRI或CSF检查阳性者,