立体定向放射治疗局部进展期胰腺癌的临床研究
发布时间：2018-11-28 12:16
【摘要】：目的1、应用四维CT(4D-CT)测量胰腺肿瘤在三维方向上随呼吸运动的位移,并分析其相关的影响因素,为胰腺肿瘤的立体定向放射治疗制定精确的内靶区提供参考依据。2、评价采用射波刀(Cyber Knife#174;)立体定向放射手术平台治疗局部进展期胰腺癌患者的有效性和安全性。方法1、选择10例拟接受射波刀治疗的胰腺肿瘤患者,采用B超、CT、超声内镜引导下穿刺植入或术中植入的方法将至少1枚纯金标记(Fiducial)植入胰腺肿瘤体内,并行4D-CT扫描。经4D工作站分析处理,得到从0-90%共十个序列的呼吸时相。通过Pinnacle治疗计划系统勾画金标轮廓,并自动确定金标的质心(Centroid)位置。记录质心位置在各呼吸时相的三维空间坐标,并计算其在L-R(Left-Right side)、A-P(Anterior-Posterior side)和S-I(Superior-Inferior side)方向上随呼吸运动的范围。同时采集10例患者的性别、年龄、身高、体重、肿瘤位置和肿瘤体积等临床参数,采用多元线性回归模型分析其与胰腺肿瘤位移的相关性,从而找出胰腺肿瘤运动的相关影响因素。2、回顾性分析2006.10-2014.9期间接受射波刀立体定向放射手术平台治疗的59例局部进展期胰腺癌患者的疗效。中位肿瘤体积为27.1ml(13.0-125.1 ml),中位处方剂量为45Gy(35-50 Gy),中位分割次数为5次(3-8次)。采用RECIST标准评价治疗区域的变化,采用Kaplan-Meier曲线计算总生存期(OS)和无局部进展生存率(FFLP)。结果:1、10例患者中男性5例,女性5例。中位年龄66岁(28-76岁),中位身高167.5cm(158-180 cm),平均体重61.4kg(49-74kg)。病灶位于胰头者6例,胰体尾者4例。肿瘤体积平均值为50.81ml(9.63-125.15ml)。测量结果显示10例患者金标的质心点在L-R、A-P和S-I方向上随呼吸运动的位移分别为0.16±0.09cm(0.06-0.29cm)、0.31±0.12cm(0.13-0.47cm)和0.72±0.25cm(0.31-1.16cm),其中S-I方向上的位移明显大于L-R和A-P方向(P0.001)。其移动距离与患者年龄、身高、体重、肿瘤位置无关,但S-I方向的位移与肿瘤体积的大小密切相关,体积超过50ml的胰腺肿瘤在S-I方向的运动幅度明显小于体积在50ml以下的肿瘤(P0.05)。2、59例局部进展期胰腺癌患者的中位随访时间为10.9个月(3.2-48.7个月),目前仍生存患者的中位随访期为15.6个月(3.9-37.6个月)。中位生存期为12.5个月,1年和2年的生存率分别为53.9%和35.1%。采用以CT为基础的评价方式,1年的无局部进展生存率(Freedom From Local Progression,FFLP)为90.8%。治疗后2周的疼痛缓解率为92.5%。1-2级急性和晚期胃肠道反应出现在61%的患者。1例患者出现3级晚期胃肠道反应,表现为肠道的不全梗阻,无4级及以上胃肠道副反应发生。结论:1、胰腺肿瘤的运动主要受呼吸运动影响,且在S-I方向的移动距离最大,在确定内靶区时应主要考虑在S-I方向的外扩。肿瘤体积可能是影响其呼吸运动幅度的主要影响因素2、采用射波刀立体定向放射手术平台治疗局部进展期胰腺癌可以获得很好的临床疗效,且并发症很小。
[Abstract]:Objective 1. To measure the displacement of pancreatic tumors with respiration in three dimensional direction by using four dimensional CT (4D-CT), and to analyze the related factors. To provide reference for stereotactic radiotherapy of pancreatic neoplasms to establish accurate internal target areas. 2. To evaluate the application of Cyber Knife#174; in the evaluation of pancreatic neoplasms by stereotactic radiotherapy. The efficacy and safety of stereotactic radiosurgery platform in the treatment of locally advanced pancreatic cancer. Methods 1. Ten patients with pancreatic neoplasms undergoing radiosurgery were enrolled in this study. At least one gold labeled (Fiducial) was implanted into the pancreatic tumor by B-ultrasound and CT, ultrasound guided puncture or intraoperative implantation. Parallel 4D-CT scanning. After 4 D workstation analysis, 10 sequence respiratory phases from 0 to 90% were obtained. The outline of gold mark is drawn by Pinnacle therapy plan system, and the center of mass (Centroid) position of gold mark is automatically determined. The position of the center of mass was recorded in the three-dimensional coordinates of each breathing phase, and the range of movement with the respiration in the direction of L-R (Left-Right side), A-P (Anterior-Posterior side) and S-I (Superior-Inferior side) was calculated. The clinical parameters such as sex, age, height, weight, tumor location and tumor volume were collected from 10 patients, and the correlation between tumor displacement and pancreatic tumor displacement was analyzed by multivariate linear regression model. In order to find out the related factors of pancreatic tumor movement. 2. The curative effect of 59 patients with locally advanced pancreatic cancer treated with radiosurgery platform during the period from June 10 to April 2014.9 was analyzed retrospectively. The median tumor volume was 27.1ml (13.0-125.1 ml),) and the median prescription dose was 45Gy (35-50 Gy),). The median fraction was 5 times (3-8 times). RECIST criteria were used to evaluate the changes in the treatment area, and Kaplan-Meier curve was used to calculate the total survival time (OS) and the local progression free survival rate (FFLP). Results: 1 among 10 patients, 5 were male and 5 were female. The median age was 66 years (28-76 years) and the median height 167.5cm (158-180 cm), mean weight 61.4kg (49-74kg). The lesions were located in the head of pancreas in 6 cases and in the body and tail of pancreas in 4 cases. The mean volume of tumor was 50.81ml (9.63-125.15ml). The results showed that the displacement of the centroid points with respiration in the direction of L-RN A-P and S-I was 0.16 卤0.09cm (0.06-0.29cm), respectively. The displacement in the S-I direction was significantly higher than that in the L-R and A-P directions (P0.001), and 0.31 卤0.12cm (0.13-0.47cm) and 0.72 卤0.25cm (0.31-1.16cm). The distance of movement was not related to the patient's age, height, weight, tumor location, but the displacement of the S-I direction was closely related to the size of the tumor. The amplitude of motion in S-I direction of pancreatic tumors over 50ml was significantly smaller than that in tumors below 50ml (P0.05). The median follow-up time of 259 patients with locally advanced pancreatic cancer was 10.9 months (3.2-48.7 months). The median follow-up period was 15.6 months (3.9-37.6 months). The median survival time was 12.5 months and the 1-and 2-year survival rates were 53.9% and 35.1% respectively. The 1-year local progressive survival rate (Freedom From Local Progression,FFLP) based on CT was 90.8. Two weeks after treatment, the pain relief rate was 92.5 grade and grade 1-2 acute and late gastrointestinal reactions occurred in 61% of the patients. One patient developed grade 3 late gastrointestinal reaction, which was characterized by incomplete intestinal obstruction. No side effects occurred in grade 4 or above. Conclusion: 1. The movement of pancreatic tumor is mainly affected by respiratory movement, and the movement distance in S-I direction is the largest, so the extension in S-I direction should be considered in determining the inner target area. The volume of tumor may be the main factor affecting the amplitude of respiratory movement. 2. The treatment of local advanced pancreatic cancer with wave knife stereotactic radiosurgery platform can obtain a good clinical effect, and the complications are very small.
【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】：R735.9
本文编号：2362797
[Abstract]:Objective 1. To measure the displacement of pancreatic tumors with respiration in three dimensional direction by using four dimensional CT (4D-CT), and to analyze the related factors. To provide reference for stereotactic radiotherapy of pancreatic neoplasms to establish accurate internal target areas. 2. To evaluate the application of Cyber Knife#174; in the evaluation of pancreatic neoplasms by stereotactic radiotherapy. The efficacy and safety of stereotactic radiosurgery platform in the treatment of locally advanced pancreatic cancer. Methods 1. Ten patients with pancreatic neoplasms undergoing radiosurgery were enrolled in this study. At least one gold labeled (Fiducial) was implanted into the pancreatic tumor by B-ultrasound and CT, ultrasound guided puncture or intraoperative implantation. Parallel 4D-CT scanning. After 4 D workstation analysis, 10 sequence respiratory phases from 0 to 90% were obtained. The outline of gold mark is drawn by Pinnacle therapy plan system, and the center of mass (Centroid) position of gold mark is automatically determined. The position of the center of mass was recorded in the three-dimensional coordinates of each breathing phase, and the range of movement with the respiration in the direction of L-R (Left-Right side), A-P (Anterior-Posterior side) and S-I (Superior-Inferior side) was calculated. The clinical parameters such as sex, age, height, weight, tumor location and tumor volume were collected from 10 patients, and the correlation between tumor displacement and pancreatic tumor displacement was analyzed by multivariate linear regression model. In order to find out the related factors of pancreatic tumor movement. 2. The curative effect of 59 patients with locally advanced pancreatic cancer treated with radiosurgery platform during the period from June 10 to April 2014.9 was analyzed retrospectively. The median tumor volume was 27.1ml (13.0-125.1 ml),) and the median prescription dose was 45Gy (35-50 Gy),). The median fraction was 5 times (3-8 times). RECIST criteria were used to evaluate the changes in the treatment area, and Kaplan-Meier curve was used to calculate the total survival time (OS) and the local progression free survival rate (FFLP). Results: 1 among 10 patients, 5 were male and 5 were female. The median age was 66 years (28-76 years) and the median height 167.5cm (158-180 cm), mean weight 61.4kg (49-74kg). The lesions were located in the head of pancreas in 6 cases and in the body and tail of pancreas in 4 cases. The mean volume of tumor was 50.81ml (9.63-125.15ml). The results showed that the displacement of the centroid points with respiration in the direction of L-RN A-P and S-I was 0.16 卤0.09cm (0.06-0.29cm), respectively. The displacement in the S-I direction was significantly higher than that in the L-R and A-P directions (P0.001), and 0.31 卤0.12cm (0.13-0.47cm) and 0.72 卤0.25cm (0.31-1.16cm). The distance of movement was not related to the patient's age, height, weight, tumor location, but the displacement of the S-I direction was closely related to the size of the tumor. The amplitude of motion in S-I direction of pancreatic tumors over 50ml was significantly smaller than that in tumors below 50ml (P0.05). The median follow-up time of 259 patients with locally advanced pancreatic cancer was 10.9 months (3.2-48.7 months). The median follow-up period was 15.6 months (3.9-37.6 months). The median survival time was 12.5 months and the 1-and 2-year survival rates were 53.9% and 35.1% respectively. The 1-year local progressive survival rate (Freedom From Local Progression,FFLP) based on CT was 90.8. Two weeks after treatment, the pain relief rate was 92.5 grade and grade 1-2 acute and late gastrointestinal reactions occurred in 61% of the patients. One patient developed grade 3 late gastrointestinal reaction, which was characterized by incomplete intestinal obstruction. No side effects occurred in grade 4 or above. Conclusion: 1. The movement of pancreatic tumor is mainly affected by respiratory movement, and the movement distance in S-I direction is the largest, so the extension in S-I direction should be considered in determining the inner target area. The volume of tumor may be the main factor affecting the amplitude of respiratory movement. 2. The treatment of local advanced pancreatic cancer with wave knife stereotactic radiosurgery platform can obtain a good clinical effect, and the complications are very small.
【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】：R735.9
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