局部晚期鼻咽癌调强放疗脑干限量可以超过54Gy-105例斜坡受侵鼻咽癌脑干剂量统计及三年随访分析

发布时间：2018-11-10 14:24

【摘要】：目的:斜坡是距离脑干最近的骨性结构,同时也是局部晚期鼻咽癌颅底骨质中常见的受侵部位。在接受根治性放疗的患者中,斜坡受侵可能导致脑干的剂量超过2010年鼻咽癌调强放疗专家共识推荐的最大剂量54Gy限值。本研究回顾性分析四川省肿瘤医院鼻咽癌斜坡受侵患者脑干的照射剂量和长期随访结果,同时分析斜坡受侵情况、照射剂量与脑干剂量之间的关系,为将来临床中遇到类似患者提供治疗决策方面的参考。方法:收集2011年1月至2012年12月四川省肿瘤医院斜坡受侵、接受根治性放化疗的鼻咽癌患者105例,根据第七版UICC/AJCC分期系统分期,其中T3期37例,T4期68例,年龄21-72岁,中位年龄47岁。统计全部患者脑干剂量,同时将其中77例患者在Eclipse治疗计划系统上复原出放疗计划,重新勾画全斜坡及受侵斜坡靶区,记录受侵斜坡部位及受侵斜坡体积大小,测量全斜坡距绝对脑干的最短距离和受侵斜坡距绝对脑干的最短距离。采用Kaplan—Meier方法计算生存期,寿命表法计算生存率,log-rank方法计算可能影响预后的单因素分析,C0X风险比例模型计算影响预后的多因素分析。分析脑干剂量的影响因素,采用卡方检验进行单因素分析,logistic风险回归模型进行多因素分析。P0.05为差异有统计学意义。结果:中位随访时间44月,随访期间局部区域复发8例、远处转移14例、死亡16例,其中复发死亡者3例,转移死亡者4例,1例死于其他恶性肿瘤,2例死于肿瘤相关并发症,6例死亡原因不明。3年的总生存率、局部区域无复发生存率、无远处转移生存率、无疾病进展生存率分别是88.6%;94.9%;86.3%;77.0%。斜坡照射的累积剂量(D95)为20.56Gy-72.23Gy,中位剂量为60.32Gy;受侵斜坡体积为0.5cm3-18.6cm3,中位体积为4.2cm3,累积剂量(D95)为61.67Gy-81.68Gy,中位剂量为72.77Gy,真实脑干的最大剂量为44.29Gy-72.05Gy,中位剂量为56.4Gy,超过54Gy的有72/105(46/77)例,超过60Gy的有26/105(11/77)例,2/77例脑干的1%体积剂量(D01)大于60Gy,72/77例D1cc在54Gy以下;外放1mm后,1cc剂量为37.86Gy-65.68Gy,中位剂量为51.59Gy,超过60Gy的有3/77例,超过66Gy的有0例,9/77例脑干的D01大于60Gy;外放2mm后,1cc剂量为41.10Gy-68.40Gy,中位剂量为54.63Gy,超过60Gy的有12/77例,超过66Gy的有1/77例,22/77例脑干的D01大于60Gy。本组患者中,由于脑干剂量限值充分放宽,受侵斜坡的D95仅有7例未达到66Gy,D90则全部达到66Gy以上,在预后因素分析中,受侵斜坡的剂量和脑干剂量都不是影响生存的预后因素。在影响脑干剂量的多因素分析中,斜坡全层受侵及受侵斜坡D95剂量较高可能导致脑干剂量较高(P0.05)。结论:从本回顾性研究结果看,对脑干Dmax限制可以适当放宽到60Gy以上,D1cc尽量限制在54Gy以下,可以比较安全地给予原发灶包括受侵斜坡66Gy以上的根治剂量。本组患者三年局控率接近95%,疗效较为满意。
[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.
【学位授予单位】：西南医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R739.63

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