小细胞肺癌个体化放射治疗方案的优化

发布时间：2018-05-29 15:32

本文选题：小细胞肺癌 + 放射治疗　；参考：《天津医科大学》2015年博士论文

【摘要】：研究目的:同步放化疗是局限期小细胞肺癌的标准治疗手段,但许多病人由于身体原因或病灶范过大等原因没能直接接受同步放化疗,同步放化疗的放疗最佳剂量及靶区等都还存在争论,部分由于各种原因接受手术治疗的病人术后是否也还要接受放化疗,此类病人的放疗原则与未做手术者是否有区别等等也有待于进一步研究。本研究的目的主要有以下两个方面:1)小细胞肺癌的个体化放疗研究,探讨诱导化疗后疗效是否对放疗时机产生影响、锁骨上淋巴引流区预防照射的适应症及靶区勾画、术后病人胸部放疗及脑预防照射的指征等;2)小细胞肺癌病人放疗技术的优化:胸部放疗时降低预防照射区照射剂量的可行性研究。研究内容与方法:研究内容和方法分为以下两大部分:1)非手术病人的病历资料分析:回顾性分析我院接受根治性放射治疗的局限期小细胞肺癌患者临床病历资料,根据2-3周期后诱导化疗后疗效分为有效组和无效组,根据2-3个周期后即开始放疗还是4个周期以后开始放疗分为早放疗组和晚放疗组,分析诱导化疗不同疗效及不同放疗时机总生存期及无进展生存期的不同;将接受三维适形放疗病人的计划重新导入计划系统,在定位CT图像上分析锁骨上淋巴结转移的规律及风险因素;分析我院接受降低预防照射区域剂量(大体肿瘤靶区剂量60Gy/30次,总计划靶区54Gy/30次,SIR-IMRT)与常规放射治疗(总计划靶区60Gy/30次,C-IMRT)病人资料,分析比较两组病人的局部复发率、总生存率及治疗相关毒副作用的差异。2)手术病人的病历资料分析:分析我院因各种原因接受手术治疗的小细胞肺癌病例资料,分析比较不同分期及治疗情况下有无术后放疗的生存期差异;分析术后有脑转移随访资料的患者,比较疾病分期、术前术后辅助治疗等因素对脑转移发生率的影响研究结果:1)诱导化疗后疗效对放疗时机的影响:早放疗组和晚放疗组的中位OS分别为37.8个月和24.9个月(P=0.052),中位PFS分别为19.4个月和13.8个月(P=0.003)。亚组分析发现,2-3周期诱导化疗后有效的患者,早放疗组和晚放疗组的中位OS分别为40.7个月和24.9个月(P=0.009),PFS分别为23.3个月和13.3个月(P=0.001);诱导化疗后无效的患者的中位OS分别为20.8个月和19.7个月(P=0.484),中位PFS分别为11.1个月和14.3个月(P=0.949)。2)锁骨上淋巴引流区转移的风险因素及转移模式:118例上纵隔阳性病人中有77例(65.3%)发现锁骨上淋巴结转移,而121例上纵隔阴性病人中只有6例(5.0%)发现锁骨上淋巴结转移(P=0.000)。95.2%的锁骨上淋巴结转移累及喉返神经旁淋巴结下区(Ⅰ区)与颈内静脉旁淋巴结区(Ⅲ区),I、III区阴性而出现其他区域转移的病例只有4.8%。3)小细胞肺癌术后的胸部放疗和脑预防照射:对于有肺门及纵隔淋巴结转移病人,术后胸部放疗与未放疗的中位生存期分别为66.7月和34.6月(p=0.016),术后病理分期N0患者行胸部放疗者和未行放疗者的中位生存期分别为37.3月和96.8月(P=0.561)。全组病人3年脑转移发生率20.6%。术后I、II、III期患者3年脑转移发生率分别为6.3%、28.2%、29.0%(P=0.026)。多因素回归分析显示术后病理分期(P=0.002)及手术切除情况(P=0.020)是影响脑转移的独立预后因素。4)小细胞肺癌降低预防照射区剂量的研究:有137例病人符合入组条件,72例病人接受了SIR-IMRT,65例病人接受了C-IMRT,经倾向评分配对分析后两组各有42例病人进入分析。两组的3年生存率分别为51.0%和45.0%(P=0.066),3年无局部区域复发生存率分别为71.2%和39.2%(P=0.119)。两组病人3级以上放射性肺损伤发生率分别为4.8%和11.9%。3级以上食管损伤发生率亦分别为4.8%和11.9%。结论:局限期小细胞肺癌2-3周期诱导化疗后应该尽快开始放疗,尤其是对于化疗后有效的病人;对于有上纵膈淋巴结转移的病人,需要行锁骨上区预防性照射;小细胞肺癌术后病人如果有淋巴结转移,应该接受胸部放疗,同时接受脑预防照射;小细胞肺癌降低预防区照射剂量可以降低毒副作用,而不会影响放疗疗效。
[Abstract]:Objective: synchronous radiotherapy is the standard treatment for small cell lung cancer in limited period, but many patients have not been able to receive synchronous radiotherapy directly due to physical causes or large lesions, and the optimal dose and target area of radiotherapy in synchronous radiotherapy and chemotherapy are still controversial. The purpose of this study is two aspects: 1) the study of individualized radiotherapy for small cell lung cancer, whether the effect of induced chemotherapy on the timing of radiotherapy, and the prefusion of supraclavicular lymphatic drainage area Indications of anti irradiation and target area mapping, the indication of chest radiotherapy and cerebral prophylaxis for postoperative patients, etc.; 2) optimization of radiotherapy technology in small cell lung cancer patients: feasibility study on reducing radiation dose in radiation prevention area during chest radiotherapy. Research contents and methods are divided into two parts: 1) the medical records of non operative patients. Data analysis: retrospective analysis of clinical records of patients with localized small cell lung cancer in our hospital after radical radiation therapy. According to the 2-3 cycle after induction chemotherapy, the curative effect was divided into effective and ineffective groups. According to the 2-3 cycles after the radiotherapy or after 4 cycles, the radiotherapy group and the late radiotherapy group were divided into early radiotherapy group and late radiotherapy group, and the inducement was analyzed. The difference in the total survival and the progression free survival period of different therapeutic effects and different radiotherapy opportunities; the plan system was re introduced for the patients receiving three-dimensional conformal radiotherapy to analyze the regularity and risk factors of the supraclavicular lymph node metastasis in the positioning CT image. 30 times, the total plan target area 54Gy/30, SIR-IMRT) and conventional radiotherapy (total plan target area 60Gy/30 times, C-IMRT) patient data, analysis and comparison of the local recurrence rate, total survival rate and the difference of the side effects of treatment related to the treatment of the two groups of patients.2) the analysis of the medical records of the patients in the operation: analysis of the small cell lung of our hospital for various reasons for various reasons. Cancer case data, analysis and comparison of different stages and treatment with or without postoperative radiotherapy difference of survival; analysis of postoperative follow-up data of patients with brain metastases, comparison of disease staging, preoperative and postoperative adjuvant therapy and other factors on the incidence of brain metastasis: 1) the effect of chemotherapy after chemotherapy on the timing of radiotherapy: early radiotherapy group and The median OS of the late radiotherapy group was 37.8 months and 24.9 months (P=0.052), and the median PFS was 19.4 months and 13.8 months respectively (P=0.003). The subgroup analysis found that the middle OS of the early radiotherapy group and the late radiotherapy group was 40.7 months and 24.9 months respectively (P=0.009), and the PFS was 23.3 and 13.3 months respectively (P=0.001). The median OS of ineffective patients after induction chemotherapy was 20.8 months and 19.7 months (P=0.484), the median PFS was 11.1 months and 14.3 months (P=0.949).2), the risk factors for the metastasis of the supraclavicular lymphatic drainage area and the transfer mode: 77 of the 118 upper mediastinal positive patients (65.3%) found the supraclavicular lymph node metastasis, while 121 were negative in the mediastinum. Only 6 cases (5%) found the supraclavicular lymph node metastases (P=0.000).95.2%'s supraclavicular lymph node metastasis involving the subregion of the paravicular lymph node (area I) and the adjacent lymph nodes of the internal jugular vein (zone III). The cases of I, III negative and other regional metastasis were only 4.8%.3) the chest radiotherapy and cerebral prophylactic irradiation after the operation of small cell lung cancer: For patients with pulmonary and mediastinal lymph node metastases, the median survival period of postoperative chest radiotherapy and non radiotherapy was 66.7 months and 34.6 months respectively (p=0.016). The median survival period of the postoperative pathological staging N0 patients with chest radiotherapy and non radiotherapy were 37.3 months and 96.8 months respectively (P=0.561). The 3 year incidence of brain metastases in the whole group was I, II, II after the operation of 20.6%.. The incidence of brain metastases in 3 years of I patients was 6.3%, 28.2%, and 29% (P=0.026). Multivariate regression analysis showed that postoperative pathological staging (P=0.002) and surgical excision (P=0.020) were independent prognostic factors of brain metastases.4) small cell lung cancer decreased the dose of prophylactic irradiation area: 137 patients met the conditions of entry, 72 patients accepted SIR-IMRT, 65 patients received C-IMRT, and 42 patients in each of the two groups entered the analysis after the tendency score matching analysis. The 3 year survival rates of the two groups were 51% and 45% (P=0.066), and the local regional recurrent survival rates were 71.2% and 39.2% (P=0.119), respectively. The incidence of upper radioactive lung injury in the two group was respectively 4.8% and 11.9%.3, respectively. The incidence of the above esophageal injury is also 4.8% and 11.9%., respectively: the 2-3 cycles of localized small cell lung cancer should be treated as soon as possible after chemotherapy, especially for patients who are effective after chemotherapy; for patients with upper mediastinal lymph node metastases, prophylactic irradiation is required; patients with small cell lung cancer have lymph nodes if they have lymph nodes. Metastasis should be treated with chest radiotherapy and cerebral prophylaxis. Small cell lung cancer reduces the dose of the prevention area to reduce toxic and side effects without affecting the effect of radiotherapy.
【学位授予单位】：天津医科大学
【学位级别】：博士
【学位授予年份】：2015
【分类号】：R734.2

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