內(nèi)科學課件-食管癌

1、Esophageal Cancer食 管 癌 Esophageal carcinoma is an extremely deadly disease, and in spite of major advances in cancer treatment, prognosis is poor.食管癌是原發(fā)于食管粘膜上皮的惡性腫瘤，以局部侵犯為主，是我國常見惡性腫瘤之一，尤其好發(fā)于中老年。其典型癥狀為進行性吞咽困難，診斷以內(nèi)鏡病理檢查最可靠，鋇餐攝影、CT、MR有助于確定病變范圍，治療方法以手術、故療為主，單純放射治療后總體5年生存率10左右，單純手術的5年生存率30左右；I期食管癌的生存率(無論

2、放射治療或手術)可高達90。放療失敗病例中，未控和復發(fā)者占84.9，遠地轉移僅占4.5。EPIDEMIOLOGY 1980年調(diào)查表明我國食管癌男、女合計粗死亡率為16.710萬，僅次于胃癌居第二，男性食管癌發(fā)病率為21.010萬，亦男性腫瘤中位居第二，女性發(fā)病率12.310萬，位居第三。世界每年新發(fā)食管痛病例約為31.04萬，我國約占16.72萬。近年來我國食管癌發(fā)病率有下降趨勢。從全球來看食管癌發(fā)病率很不平衡，伊朗黑海地區(qū)男性發(fā)病率為165.5/10萬，女性為195.3/10萬，拉丁美洲發(fā)病率約為10-1510萬，歐美國家的發(fā)病率較低。食管癌的好發(fā)年齡為50-69歲占全部病例60以上，35歲

3、之前很少，70歲之后逐漸下降。19901992年我國抽樣地區(qū)62種腫瘤的粗死亡率（1/10萬）與死亡構成（%）節(jié)選ETIOLOGY食管癌的病因與生活習慣、物理化學刺激、局部粘模損傷、環(huán)境及遺傳因素有關。酸菜、霉變食物含有大量黃曲留素、亞硝胺。動物實驗證明霉變食物能誘發(fā)大鼠食管、前胃鱗癌；酗酒嗜煙者發(fā)病率是煙酒不沾者的156倍；喜食燙粥、燙茶者發(fā)病率亦明顯增高；我國高發(fā)現(xiàn)場多缺微量元素銅；食管癌高發(fā)區(qū)多為貧困、營養(yǎng)不良地區(qū)；食管癌具有顯著的家族聚集現(xiàn)象表明其遺傳性。高發(fā)區(qū)可出現(xiàn)連續(xù)3代或3代以上的家族性食管癌患者，如伊朗北部某一村莊14例食管癌中有13人是一對夫妻的后裔。另一跡象為高發(fā)區(qū)居民遷移

4、至低發(fā)區(qū)后，仍保持上百年的高發(fā)趨勢。TOPOGRAPHIC ANATOMY The esophagus is a thin-walled, hollow tube. The normal esophagus is lined with stratified keratinized squamous epithelium, which extends from the cricoid cartilage inferiorly to the gastroesophageal junction. There are four layers to the esophagus. The innermos

5、t layer consists of epithelium, followed by the inner circular muscle layer, the outer longitudinal muscle layer, and an adventitia. No serosa is present. There are many methods of subdividing the esophagus.The American Joint Committee on Cancer (AJCC) divides the esophagus into four regions: cervic

6、al, upper thoracic, mid-thoracic, and lower thoracic.Cervical oesophagus: This commences at the lower border of the cricoid cartilage and ends at the thoracic inlet (suprasternal notch), approximately 18cm from the upper incisor teeth.Intrathoracic oesophagusi. The upper thoracic portion: extending

7、from the thoracic inlet to the level of the tracheal bifurcation, approximately 24cm from the upper incisor teethii. The mid-thoracic portion (C15.4) is the proximal half of the oesophagus between the tracheal bifurcation and the oesophagogastric junction. The lower level is approximately 32cm from

8、the upper incisor teeth.iii. The lower thoracic portion (C15.5), approximately 8cm in length (includes abdominal oesophagus), is the distal half of the oesophagus between the tracheal bifurcation and the oesophagogastric junction. The lower level is approximately 40cm from the upper incisor teeth.18

9、cm24cm32cm40cmLymphatic Drainage The esophagus has an extensive, dual, longitudinal interconnecting system of lymphatics. The lymphatic channels in the mucosa and submucosa communicate with the lymphatic channels in the muscle layers extending through the esophagus. As a result of this system, lymph

10、 can travel the entire length of the esophagus before draining into the lymph nodes, and thus the entire esophagus is at risk for lymphatic metastasis. Up to 8 cm of normal tissue can exist between gross tumor and micrometastases “skip areas” because of the extensive lymphatic network. 美國RTOG 淋巴結分類方

11、法為實現(xiàn)食管癌淋巴結分期的標化，美國RTOG在廣泛應用的肺癌區(qū)域淋巴引流圖（NARUKE等首先報告）的基礎上，簡單得增加了幾站淋巴結增加的淋巴結包括：橫膈淋巴結（15站，位于橫膈的后方）、賁門旁淋巴結（16站，毗鄰胃食道結合部）、胃左淋巴結（17站，沿胃左動脈分布）、肝總動脈（18站，沿肝總動脈分布）、脾動脈淋巴結（19站，沿脾動脈分布）和腹腔淋巴結（20站，腹腔動脈根部淋巴結）氣管分叉以上的食管旁淋巴結歸于3P，以下的歸于8組淋巴結，后者可再分為8M（位于氣管分叉與肺下靜脈下緣之間）和8L（位于肺下靜脈與胃食道結合部之間）；膈食道韌帶下緣是分隔下食管旁淋巴結（8L）與賁門旁淋巴結的解剖標志B

12、ABA 1997，CASSON 1994，KORST1998食管癌淋巴結轉移的方式食管癌的淋巴結轉移包括沿食管長軸方向和向食道周圍轉移兩種方式，食管的粘膜下淋巴管網(wǎng)豐富，這樣沿食管長軸方向遠離原發(fā)灶的淋巴結很容易發(fā)生轉移。食管有兩套縱向相互交通的淋巴系統(tǒng)，由于食管這一特殊的淋巴管網(wǎng)系統(tǒng)，淋巴液在注入到淋巴結以前可以穿越整個食道，淋巴腺恰好位于上皮層的基底膜下方，注入固有層和粘膜肌層，淋巴腺穿透肌層注入到區(qū)域淋巴結或直接注入胸導管。 淋巴引流的研究HAAGENSEN（1972）通過在食管粘膜和粘膜下層注射藍顏料的方法，對食管的淋巴引流進行了系統(tǒng)的研究，檢測切除標本淋巴引流藍顏料的范圍，發(fā)現(xiàn)與食管

13、環(huán)周引流相比，縱向引流的變化很大（自由度高），并注意到下段食管大部分引流到腹腔干區(qū)域的膈下淋巴結、胃左動脈周圍的淋巴結和左膈下動脈周圍的淋巴結。TANABE等（1986）利用內(nèi)鏡技術將锝標記的淶膠體注入到42例食管癌患者的食道壁上，手術后用閃爍計數(shù)法測量，發(fā)現(xiàn)：盡管也有引流到腹部的情況，但胸上段和胸中段食管主要向頸和上縱隔引流；而胸下段食管主要引流到腹部。 FIGURE 46.2. Positive lymph node distribution according to the location of the primary tumor. PATHOLOGYTABLE 46.4. PATHO

14、LOGIC CLASSIFICATION OF MALIGNANT ESOPHAGEAL TUMORSSquamous cell carcinoma and adenocarcinoma account for 95% of all esophageal tumors.Adenocarcinoma is the other major cell type and is becoming increasingly common, especially among white men . The reasons for this increase are not entirely clear. N

15、onepithelial tumors of the esophagus are rare. Metastases to the esophagus do occur. The most common source is the breast, but other reported sites include the pharynx, tonsil, larynx, lung, stomach, liver, kidney, prostate, testis, bone, and skin.病理學形態(tài)早期食管癌是指局限于粘膜或粘膜下層，尚未侵犯肌層，無淋巴結和遠地轉移的癌。隱伏型(充血型)糜爛

16、型斑塊型乳頭型中晚期食管癌的病理類型 中晚期食管癌占臨床放療工作所治療全部食管癌病例的95以上。食管鱗癌分為髓質(zhì)型、潰瘍型、蕈傘型、縮窄型、腔內(nèi)型，幾十年的臨床實踐證明該分型對于放射診斷、臨床治療都有重要意義。NATURAL HISTORY AND PATTERNS OF SPREADSquamous cell carcinoma is characterized by the development of extensive local growth and lymph node metastases. 直接浸潤:Because the esophagus has no serosa, di

17、rect invasion of contiguous structures occurs very early.上段食管癌可侵犯下咽、喉、氣管、喉返神經(jīng)等；中段食管癌可侵犯氣管、支氣管、隆突、肺門、無名靜脈、奇靜脈、胸導管、胸主動脈等；下段食管癌可侵犯下肺靜脈、心包、賁門等。嚴重者可致食管氣管瘺、食管支氣管瘺、食管主動脈瘺，繼發(fā)感染、出血等引起死亡。外侵嚴重常常增加手術切除的難度。CLINICAL PRESENTATION 早期食管癌(1)吞咽硬咽感最常見，出現(xiàn)率約50.6 % -63%。(2)胸骨后疼痛：糜爛型患者更多見，主要為沉悶疼、燒灼痛或針刺痛，多因吞咽粗糙硬食、熱食或刺激嚨物誘發(fā)或

18、加重。而在進食軟食、溫食、流質(zhì)時較輕，疼痛主要與粘膜糜爛、淺潰瘍受食物刺激所致，故部位多與病變部位一致。(3)胸骨后悶膿不適。(4)食管內(nèi)異物感，部位與病變部位一致。(5)咽喉緊縮不適，與食管引起的咽部腺體分泌減少及食管收縮有關。(6)食物通過緩慢并有滯留感。中、晚期食管癌吞咽困難，是中晚期食管癌常見的典型痞狀，也是23病人的首發(fā)癥狀。嘔吐沫狀粘掖：吐出的液體呈蛋清樣，夾雜泡沫，食物殘渣，偶見脫落腫瘤組織。 疼痛，是常見癥狀之一，位于前胸或后背，疼痛部位常與病變部位一致；為鈍病、隱痛、灼痛或刺痛，重者影響進食及睡眠。聲音嘶?。撼槟[瘤直接侵犯或轉移淋巴結壓迫喉返神經(jīng)引起聲帶麻痹所致。嗆咳：為吞

19、咽功能障礙，食管內(nèi)容物返流進入氣管或食管氣管痞、食管支氣管瘦所致。其他DIAGNOSTIC WORK-UP病史+體格檢查（H&P）鋇餐造影(可選擇的)如果可能，食管鏡可使上消化道的病變形象化血象,SMA-12,胸/腹CT掃描對于沒有明確的遠處轉移（M1）的腫瘤，如果腫瘤在隆突水平或位于隆突之上，則應行支氣管鏡檢查超聲內(nèi)鏡(EUS) ，如沒有明確的遠處轉移如有必要可行穿刺細胞學檢查若沒有明確的遠處轉移且腫瘤位于賁門,腹腔鏡是可以選擇的可疑的轉移病灶應得到活檢病理的證實history and physical examination Esophagogastroduodenoscopy to vi

20、sualize entire upper GI tract, if possibleBarium swallow (optional)CBC, SMA-12, Chest/abdominal CT If tumor is at or above the carina with no evidence of M1 disease, do bronchoscopyIf no evidence of M1 disease and tumor is at GE junction, laparoscopy is optional Suspicion of metastatic cancer confir

21、med by biopsyEndoscopic ultrasound (EUS), if no evidence of M1 disease, with FNA if indicatedPET/CT scan if no evidence of M1 diseaseendoscopyAlthough the esophagogram may be used to define lesion extent, endoscopy is the key diagnostic procedure and of vital importance accurately to diagnose and de

22、fine the lesion.During flexible endoscopy, biopsies and brushings should be taken on the primary site and any areas suspected of containing satellite or submucosal spread. Examination with panendoscopy of the oral cavity, pharynx, larynx, and tracheobronchial tree should also be performed at the tim

23、e of esophagoscopy because of the high incidence of second tumors in the head and neck and upper airway.CT Computed tomography (CT) of the thorax can demonstrate extramucosal extension of disease, and should be extended below the diaphragm to include the liver, upper abdominal nodes, and adrenals. T

24、he CT scan may not adequately assess periesophageal lymph node involvement or accurately show the true length of the primary tumor. EUS To assess periesophageal lymph node involvement and the transmural extent of disease, endoscopic ultrasonography (EUS) should be performed. EUS provides an accuracy

25、 of 85% for tumor invasion (T stage) compared with surgical pathology, and 75% for the assessment of lymph node metastases. esophagus (ICD-O C15) STAGE:TNM Classification of Malignant TumoursT Primary Tumour TX. Primary tumour cannot be assessed T0. No evidence of primary tumour Tis. Carcinoma in si

26、tu T1. Tumour invades lamina propria or submucosa T2. Tumour invades muscularis propria T3. Tumour invades adventitia T4. Tumour invades adjacent structures N Regional Lymph Nodes NX. Regional lymph nodes cannot be assessed N0. No regional lymph node metastasis N1. Regional lymph node metastasis Cer

27、vical oesophagus: Scalene Internal jugular Upper and lower cervical Perioesophageal SupraclavicularIntrathoracic oesophagusupper, middle, and lower Upper perioesophageal (above the azygous vein) Subcarinal Lower perioesophageal (below the azygous vein) Mediastinal Perigastric, except coeliacM Distan

28、t Metastasis MX. Distant metastasis cannot be assessed M0. No distant metastasis M1. Distant metastasis For tumours of lower thoracic oesophagus M1a. Metastasis in coeliac lymph nodes M1b. Other distant metastasis For tumours of upper thoracic oesophagus M1a. Metastasis in cervical lymph nodes M1b.

29、Other distant metastasis For tumours of mid-thoracic oesphagus M1a. Not applicable M1b. Non-regional lymph node or other distant metastasis Summary ：Oesophagus T1 Lamina propria, submucosaT2 Muscularis propriaT3 AdventitiaT4 Adjacent structuresN1 RegionalM1Distant metastasisTumour of lower thoracic

30、oesophagusM1aCoeliac nodesM1bOther distant metastasisTumour of upper thoracic oesophagusM1a Cervical nodesM1b Other distant metastasisTumour of mid-thoracic oesophagusM1b Distant metastasis including non-regional lymph nodesGENERAL MANAGEMENT 食管癌的治療方法有手術、放療、化療、熱療、中醫(yī)、中藥等。目前以手術、故療和綜合治療應用較多，對于特定病人確定治療方

31、案時，應根據(jù)分期、病理類型、病變部位、全身情況等因素，制定全而的合理的治療方案。其基本原則：0-期宜根治，期以上應以姑息為主，姑息治療應以放療為主。上段首選放療，這是因為上段食管癌故療效果與手術相同，而上段食管附近大血管豐富，手術危險性大。下段首選手術，中段則視具體情況而定，浸潤型區(qū)域淋巴結轉移者宜旨選手術。重視綜合治療。SurgeryCurative surgery of the thoracic esophagus involves a subtotal or total esophagectomy, and is usually performed for lesions of the

32、gastroesophageal junction and the lower third of the thoracic esophagus. Esophagectomy can be accomplished by a number of techniques, including a transhiatal esophagectomy (THE), a right thoracotomy (Ivor-Lewis), a left thoracotomy, or radical esophagectomy. Squamous cell carcinoma of the cervical e

33、sophagus presents a very difficult situation. If surgery is performed, it usually requires removal of portions of the pharynx, the entire larynx and thyroid gland, and the proximal esophagus. Radical neck dissections are also carried out. For this reason, radiation therapy to this portion of the eso

34、phagus is preferable. Survival is essentially the same as with surgery, but irradiation does not cause the major functional impairments or the high morbidity and mortality rates of surgery. The 5-year survival after an R0 resection is 15% to 20%, and the median survival after R0 resectionis approxim

35、ately 18 months;no difference in survival was observed between groups treated with either surgery alone or induction therapy followed by surgery.Figure 29.1-6Thoracoscopic view and dissection of intrathoracic esophagusFigure 29.1-7Standard, two-field, and three-field lymphadenectomy.Radiation Therap

36、yCurative irradiation with EBRT for esophageal cancer also requires careful patient selection. In general, patients with stage I or II disease are amenable to radiation therapy. If tumors appear to infiltrate the tracheobronchial tree, with impending fistula development, or if the adventitia of the

37、aorta is involved with impending rupture, the daily dose should be reduced from the conventional 1.8 or 2 Gy per fraction to 1.5 Gy. This may prevent rapid tumor regression with consequent fistula formation or vessel rupture. Several historical series have reported results of using external beam rad

38、iation therapy (RT) alone.Most of these series includedpatients with unfavorable features, such as clinical T4 cancer.Overall, the 5-year survival rate for patients treated with conventional doses of RT alone is 0% to 10%. Shi and colleagues reported a 33% 5-year survival rate with the use of late-c

39、ourse ccelerated fractionation to a total dose of 68.4 Gy. However, in the Radiation Therapy Oncology Group (RTOG) 85-01 trial, in which patients in the RT-alone arm received 64 Gy at 2 Gy/d with conventional techniques, all patients died of cancer by 3 years. Therefore, the panel recommends that RT

40、 alone should generally be reserved for palliation or for patients who are medically unable to receive chemotherapy.RT with concurrent chemotherapyRTOG 85-01 trial reported by Herskovic et al and others. Patients: squamous cell carcinoma.4 cycles of 5-fluorouracil (5-FU) and cisplatin. RT (50 Gy at

41、2 Gy/d) was given concurrent with day 1 of chemotherapy. control arm: RT alone, a higher dose (64 Gy) combined modality therapy had a significant improvement in both median survival (14 versus 9 months) and 5- year survival (27% versus 0%). the 8-year survival was 22%.The incidence of local failure

42、as the first site of failure (defined as local persistence plus recurrence) was also lower in the combined modality arm (47% versus 65%).combined modality therapyRTOG85-01/94-05：同時放化療vs.單純放療5y OS 27% vs. 0%;8y OS 22%FFCD9102:入組445例（T3-4N0-1M0），Concurrent PF 2 Cycles + RT 后評估，259例有效者，隨機分為：手術及化療3 療程。結

43、果：2y OS 34% vs 40%; MS 18m vs 19m 德國對70歲以上的隨機研究結果與FFCD9102相似Palliative Treatment Palliative treatment is chosen only for the relief of symptoms of esophageal carcinoma, especially dysphagia .Palliative irradiation can be used to control the primary disease as well as distant metastasis. Resolution o

44、f symptoms, especially pain and dysphagia, can be accomplished in as much as 80%.RADIATION THERAPY TECHNIQUES FIGURE 46.4. Radiation therapy techniques for esophageal cancer. A: Anteroposterior/posteroanterior opposed dose distribution for mid-thoracic lesion. B: Three-field dose distribution for mi

45、d-thoracic lesion.conventional irradiationFIGURE 46.6. A: Initial simulation film with portal drawn for a thoracic esophageal lesion. B: Portal film. FIGURE 46.7. A: Simulation film. B: Portal film. Anterior oblique field used to treat tumor in the lower third of the thoracic esophagus. Anteroposter

46、ior and posteroanterior portals were used to deliver 42 Gy to the midplane of the thorax. An additional 18 Gy was delivered with oblique fields, sparing the spinal cord. The patient was treated with 18-MV photons.胸中段食管癌三野照射劑量分布Doses of Radiation 原發(fā)灶放療總劑量60-70Gy為宜，低于60cy或高于70Gy生存率均會受到影響；淋巴引流區(qū)的預防照射劑量一

47、般為50Gy。照射方式：原發(fā)灶采用一前垂直野，二后斜野的三野交叉法，三野劑量比為1:1:1。劑量分割：以常規(guī)分割為主。術前放療劑量一般為40Gy。術后放療劑量一般為50Gy常規(guī)放療失敗原因 局部失敗 7080% 轉移 20% 尸檢轉移 50%食管癌三維適形及調(diào)強放射治療 3D conformal therapy and intensity-modulated radiation therapy3DCRT的優(yōu)勢常規(guī)三野/擴大野/3DCRT計劃分析常規(guī)模擬機定位中心與3DCRT計劃中心的位置在X、Y、Z軸方向上的差異分別為3.7mm、9.6mm和6.4mm常規(guī)野的處方劑量60Gy時，60Gy所包含

48、的GTV為36.6%，CTV為27%；擴大野則分別為38%和33%；3DCRT的CTV則為95%。三種方法100%GTV的劑量分別為44、57和62Gy正常組織：雙肺V20三者分別為22.9%、31.2%、20.1%；脊髓Dmax則分別為38.69、45.37、9.11Gy結論：3DCRT能更好的包括腫瘤，且正常組織也得到更好的保護常規(guī)放療設野時以食管腔為中心，經(jīng)典的照射野大小 (前寬6.0 cm，后斜野5.0 cm)80%90%的等劑量曲線不能包全腫瘤管腔為中心常規(guī)野擴大照射野，前寬8.0 cm，后斜野6.0 cm，80%90%的等劑量曲線仍不能包全腫瘤管腔為中心擴大野3D-CRT3DCRT

49、 vs IMRTDVH1.適應癥：(1) 拒絕手術或以心肺疾患等不能手術患者,(2) CT顯示沒有明顯腫大/轉移淋巴結者(一) 較早期食管癌（臨床IIIA期N0）三維適形 # 單一放射治療 # 較早期食管癌（臨床IIIA期）單一放射治療 2. 食管癌放射治療靶區(qū)定義：勾畫靶區(qū)的標準：GTV：以影像學（如食管造影片）和內(nèi)窺鏡（食管鏡和或腔內(nèi)超聲）可見的腫瘤長度。CT片（縱隔窗和肺窗）顯示原發(fā)腫瘤的（左右前后）大小為GTV CTV1: 在GTV左右前后方向均放0.5-0.8cm (平面)，外放后將解剖屏障包括做調(diào)整。PTV1：CTV1+0.3cmCTV2：包括預防照射的淋巴引流區(qū)上段：鎖骨上淋巴引

50、流區(qū)、食管旁、2區(qū)、4區(qū)、5區(qū)、7區(qū)中段：食管旁、2區(qū)、4區(qū)、5區(qū)、7區(qū)的淋巴引流區(qū)。下段：食管旁、4區(qū)、5區(qū)、7區(qū)和胃左、賁門周圍的淋巴引流區(qū)）病變上下(在GTV上下方向)各外放3cm5cm。PTV2：在CTV基礎上各外放0.5-0.7cm。三維適形 # 單一放射治療 # 較早期食管癌（臨床IIIA期）3. 放療劑量： 95PTV 60Gy/30次（2Gy次）+ 選擇性腔內(nèi)放療。 或 95%PTV2 50Gy/25次/5周+ 95%PTV1 20Gy10次。三維適形 # 單一放射治療 # 較早期食管癌（臨床IIIA期）(二)中晚期食管癌 （原發(fā)腫瘤較大(T3)和或CT掃描片顯示腫大淋巴結II

51、b-） 三維適形 # 單一放射治療 # 中晚期食管癌1. 勾畫靶區(qū)的標準 GTV：以影像學（如食管造影片）和內(nèi)窺鏡（食管鏡和或腔內(nèi)超聲）可見的腫瘤長度。CT片（縱隔窗和肺窗）顯示原發(fā)腫瘤的（左右前后）大小為GTV 和CT片顯示腫大淋巴結（如腫大淋巴結遠離原發(fā)病灶或和觸診可確定的轉移淋巴結部位如鎖骨上淋巴結，氣管旁淋巴結為GTVnd。CTV：包括GTV和GTVnd預防照射的淋巴引流區(qū)（各段食管癌靶區(qū)勾畫的標準與CTV2相同）PTV：在CTV基礎上各外放0.5cm。 三維適形 # 單一放射治療 # 中晚期食管癌單一放射治療 # 中晚期食管癌2. 放療劑量單一放療劑量：95PTV 6070Gy303

52、5次（2Gy次）推薦中晚期食管癌進行同步放化療，建議方案:PDD 25-30mgm35天，5-Fu 450-500mg/m5天（推薦靜脈連續(xù)輸注），28天為一周期2周期，13月后鞏固化療34周期 同步放化療時的放療劑量：95PTV 60Gy30次（2Gy次）術后放射治療 三維適形 # 術后放射治療食管癌三維適形及調(diào)強放射治療(一)完全切除手術后（根治性手術）1. IIa（T2-3N0M0淋巴結陰性組）患者：推薦進行術后預防性放射治療三維適形 # 術后放射治療 # 根治性手術后 # IIa勾畫靶區(qū)的標準 1).胸上段(CTV)：上界: 環(huán)甲膜水平，下界: 隆突下3cm，包括吻合口、食管旁、氣管旁

53、、下頸、鎖骨上、2區(qū)、4區(qū)、5區(qū)、7區(qū)等相應淋巴引流區(qū)。三維適形 # 術后放射治療 # 根治性手術后 # IIa2).胸中段 CTV：上界為胸1椎體的上緣包括鎖骨頭水平氣管周圍的淋巴結, 包括相應縱隔的淋巴引流區(qū)（如食管旁、氣管旁、下頸、鎖骨上、2區(qū)、4區(qū)、5 區(qū)、7區(qū)等相應淋巴引流區(qū)（見圖），下界為瘤床下緣23cm。PTV：在CTV基礎上均放0.5cm。3)處方劑量：95PTV Dt 5460Gy2730次5.4周6周 三維適形 # 術后放射治療 # 根治性手術后 # IIa2. IIb（N1）III期（該期患者推薦放療化療同時進行）： 三維適形 # 術后放射治療 # 根治性手術后 # II

54、b-III期1) 上段食管癌CTV：與淋巴結陰性組相同，上界: 環(huán)甲膜水平，下界: 隆突下3-4cm，包括吻合口、食管旁、氣管旁、鎖骨上、2區(qū)、4區(qū)、5區(qū)、7區(qū)等相應淋巴引流區(qū)。 2) 中下段食管癌（CTV）：CTV：原發(fā)病變的長度病變上下各外放5cm+相應淋巴引流區(qū)。（按此標準勾畫靶區(qū)時，中段食管癌患者的上界建議設在T1上緣，便于包括2區(qū)的淋巴引流區(qū)）PTV：在CTV基礎上均放0.5cm。三維適形 # 術后放射治療 # 根治性手術后 # IIb-III期3) 處方劑量：95PTV Dt 54 60Gy27次30次（2Gy次）。靶體積內(nèi)的劑量均勻度為95105的等劑量線范圍內(nèi)，PTV：9310

55、7。4)推薦化療方案：PDD5Fu，化療劑量同單一放療,28天為一周期,共2周期。13月后，進行34周期的鞏固化療。） 三維適形 # 術后放射治療 # 根治性手術后 # IIb-III期(二) 姑息手術：所有肉眼不凈或病理不凈者都應行術后放射治療三維適形 # 術后放射治療 #姑息手術后術后放射治療 食管癌三維適形及調(diào)強放射治療適形放射治療計劃實施及流程：胸部CT掃描，勾畫腫瘤靶體積（必須參照食管造影和食管鏡檢的結果勾畫靶區(qū)），上級醫(yī)生確定并認可治療靶區(qū)由物理師設計三維適形野，物理主任核對并認可治療計劃副主任以上的醫(yī)師認可治療計劃CT模擬校位，由醫(yī)師物理師加速器技術人員共同在加速器校對，科查房同

56、意治療計劃三維治療計劃實施。完成三維計劃到治療時間：在一周內(nèi)完成。 正常組織限制劑量 1.肺平均劑量13Gy，兩肺V2030%，兩肺V3020。2.脊髓劑量：平均劑量9Gy-21Gy和0體積劑量45Gy6周。3.心臟：V4050Brachytherapy In addition to EBRT, intracavitary therapy can be used as part of a curative or palliative treatment plan. The advantage of brachytherapy is the exploitation of the inverse square law and quick dose fall-off, thus sparing surrounding tissues, and the radioact