调强放射治疗致鼻咽癌放射性颞叶坏死的剂量—体积及临床研究

发布时间：2018-02-25 05:30

本文关键词： 鼻咽癌放射性颞叶坏死调强放射治疗　出处：《广西医科大学》2014年硕士论文　论文类型：学位论文

【摘要】：目的：本研究通过回顾性分析研究鼻咽癌调强放射治疗（Intensity-modulated radiation therapy，IMRT）后放射性颞叶坏死（Radiation induced temporal lobe necrosis，RITLN）与颞叶的剂量-体积关系以及临床特点，研究鼻咽癌放射治疗中颞叶的剂量、其他相关因素与放射性颞叶坏死的关系；探索放射治疗中颞叶耐受剂量的体积指标和相应的耐受剂量，明确放射性颞叶坏死的发生规律，为鼻咽癌调强放射治疗中颞叶的保护提供确切的限制剂量-体积标准。探索自适应放疗(adaptive radiation therapy, ART)在降低局部晚期鼻咽癌放射性颞叶坏死中的作用。方法：收集四川省肿瘤医院2004年1月-2009年1月IMRT初治性根治的鼻咽癌病例共695例，通过随访核磁共振成像（MagneticResonance Imaging，MRI）诊断RITLN。统计入选患者的一般情况（性别、年龄、T分期、糖尿病、高血压、烟酒史、血脂水平）、治疗情况（化疗、靶向治疗、是否自适应放疗）和颞叶剂量进行分析。颞叶剂量分别统计双侧颞叶D0.1cc（0.1立方厘米接受的最大剂量）、D0.5cc、D1cc、D2cc、D3cc、D5cc、D10cc、D15cc、D20cc、Dmean（平均剂量）、Dmax（最大剂量）。分析颞叶坏死与颞叶剂量的关系，筛选预测颞叶坏死剂量-体积的合适指标以及相应的颞叶限制剂量。分析调强放疗中患者的一般情况、治疗情况和放疗剂量、分次剂量、计划次数等因素中RITLN的影响因素。结果：695例入选病例中，共59例以MRI确诊为RITLN，全组总的RITLN发生率为8.49%。发生坏死的颞叶剂量均明显高于未坏死的颞叶剂量（p0.05）。坏死病灶均位于原计划的高剂量区域。通过受试者工作特征曲线（ROC曲线）分析，结果显示Dmax、D0.1cc、D0.5cc、D1cc、D2cc、D3cc、D5cc、D10cc、D15cc、D20cc、Dmean中曲线下面积随体积增大呈先增后减的趋势，D2cc的曲线下面积最大（0.856）。各个剂量-体积指标进行多因素分析显示D2cc是颞叶坏死的独立影响指标。5年内颞叶RITLN的发生率5%（TD5/5，Tolerance dose）的等效生物剂量为（biological effective dose，BED）D2cc60.31Gy（95%CI：59.09Gy，61.54Gy），TD50/5为76.85Gy（95%CI：75.74Gy，78.22Gy）。局部晚期鼻咽癌患者采用非ART和ART时颞叶的剂量（D2cc）分别为：T3期患者非ART和ART的颞叶剂量（D2cc）分别为67.1±7.2Gy和62.3±6.6Gy，P=0.000；T4期患者非ART和ART计划的颞叶剂量（D2cc）分别为69.4±7.7Gy和65.5±6.9Gy，，P=0.001。局部晚期鼻咽癌非ART的颞叶剂量明显高于ART，P=0.000， T3期非ART和ART的RITLN发生率分别为13.7%和5.8%，P=0.037。T4期程计划和ART的RITLN发生率分别为21.8%和11.7%，P=0.038。局部晚期鼻咽癌ART的RITLN发生率明显低于非ART计划的发生率。非ART与ART的5年局部控制率为：T3期的非ART和ART患者的5年局控率分别为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与ART的局控率无统计差异。对纳入病例的性别、年龄、病理类型、糖尿病、高血压、吸烟史、饮史酒、胆固醇、甘油三脂、化疗、靶向治疗、颞叶剂量（D2cc）、是否ART、单次剂量进行单因素分析显示颞叶剂量（P0.001）、T分期（P=0.0000.05）、同步化疗（P=0.002），糖尿病（P=0.027）、单次剂量是否2Gy（P=0.000）、是否行ART（P=0.036）有统计意义。多因素分析结果显示颞叶剂量（P0.001）、T分期（P0.001）、单次剂量是否≥2Gy（P0.001）、同步化疗（P=0.009）、是否行ART（P=0.021）是RITLN的独立影响因素，其OR值分别为3.463、4.023、3.963、2.976、0.339。结论：RITLN的发生与颞叶的照射剂量和对应体积关系密切，RITLN主要因颞叶接受较高的放疗剂量；颞叶的D2cc的等效生物剂量60.31Gy可作为颞叶TD5/5的限制剂量；局部晚期鼻咽癌可通过ART降低颞叶剂量，减少RITLN的发生；另外肿瘤T分期、颞叶的剂量D2cc≥2Gy、同步化疗也是RITLN的独立危险因素。
[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.

【学位授予单位】：广西医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R739.63

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