肺癌放療標準課件

UpdateinRadiotherapyforNon-SmallCellLungCancer

CancerInstitute&Hospital,ChineseAcademyofMedicalSciences

LuhuaWangRadiotherapyforNSCLCDefinitiveradiotherapyforearlystagenon-smallcelllungcancerDefinitiveradiotherapyforlocallyadvancedstagenon-smallcelllungcancerAdvancedtechnologyinradiotherapyimprovedthetreatmentresultsNormaltissueisproperlyprotectedDefinitiveRadiotherapyforEarlyStageNSCLCOutcomesAfterStereotacticLungRadiotherapy

orWedgeResection

forStageINon–Small-CellLungCancerSRBT(n=55)WedgeResection(n=69)PPulmonaryFunction（FEV-1）1.39(0.86-2.37)1.31(0.52-3.0)NSCharlsoncomorbidityindex3(1-4)4(3-6)<0.01Age74(69-78)78(55-89)<0.01StageT1-T2T1-T2NSGreatestdimensionGTV:2.3(1-5.3)Specimen：1.7(0.4-4.7)-Positivemediastinalnodes0(PET,Mediastinoscopy)0(Surgery)NSChemotherapy16%10%NSGrillsetal:JCO2010doi:10.1200/JCO.2009.26.5157OutcomesAfterStereotacticLungRadiotherapy

orWedgeResection

forStageINon–Small-CellLungCancerGrillsetal:JCO2010doi:10.1200/JCO.2009.26.5157LRRRLRRDMFFFOSCSSAllpatientsn=124SBRT44919777293WedgeResection20182721658794P.06.37.01.53ExcludeT4andnohistologicalinformationn=110SBRT50515807092WedgeResection24182922618593P.05.07.02.62OutcomesAfterStereotacticLungRadiotherapy

orWedgeResection

forStageINon–Small-CellLungCancerAuthorsPtsMFUTRRorLRDMOSCSSGinsberg,19951225417-6175Landreneau,1997422924-5838*602416-6538*Sienel,2007495416--67Sienel,200856451618-713145556-48Keenan,200454271196274El-Sherif,20062073171540-Lee,200335516304761Voynov,2005110414818-Birdas,200641255-54-27250---*localfailure142514---OutcomesofLocalResection

forStageINon–Small-CellLungCancerMountain*JCOG*JNCCH*StageIAStageIB67%57%80%63%74%53%STI**90%

84%*Surgery**StereotacticIrradiationComparisonof5-YrOverallSurvivalBetweenSurgery&STISurvivalcurvesofoperableptsirradiated

withBEDof100GyormoreaccordingtoStagestageIA(n=47)stageIB(n=16)p=0.2OverallSurvivalTime(years)SummaryofJapaneseStudiesOnishiH,ASCO2004SBRThasbeenbecomingstandardtreatmentforinoperablestageINSCLCHowaboutoperablestageINSCLC?DefinitiveRadiotherapyforEarlyStageNSCLCQuestion:CanwegiveathoroughstaginginChina?CantheclinicalearlystagePtsbegivenathoroughStaging?PET/CTscanning,howmanypercentcanitbeusedinyourclinicalearlystagepatients?Mediastinoscopy,Isitacceptedandwidelyusedbyourthoracicsurgeon,ANDourpatientsEBUS,whatdoesitmean,“ifappropriable”?Withoutappropriatestaging,Howdowetreatourpatients?So,beforewegetnewevidence,surgerystillisthestandardcareforoperableearlystagepatients.DefinitiveConcurrentChemo-Radiotherapy

forLocallyAndvancedNSCLCConcurrentChemo-Radiotherapyplaysmoreimportantroles☆☆☆☆DefinitiveConcurrentChemo-Radiotherapy

forLocallyAdvancedNSCLC☆☆0255075100012345TimeafterrandomizationSurvivalP-value(log-rank):0.038

Dead/Total

MSTSeq50 163/199 14.6mo.Con1 147/200 17.1mo.RTOG9410:

ConcurrentvsSequentialChemo-Radiotherapy

forStageIIINSCLCFormHChoyButHowManyPatientswithLocallyAdvancedNSCLCCanAcceptConcurrentChemo-radiotherapy?Ruysscher,D.D.etal.AnnOncol200920:98-102;PercentagepatientseligibleforconcurrenttherapyDatafromCancerHospitalofCAMS

Comparisonofcomorbidityperage(1)VariablesGroups＜70歲≥70歲PvalueNo.（%）No.（%）ComorbidityYes78(24.5)76(43.7)0.000No241(75.5)98(56.3）493of527withdocumentedinformationofcomorbiditiy,2000-2006Charlsoncomorbidityindex（CCI)Definitionofcomorbidity：1、ChronicObstructivePulmonaryDisease

（COPD）2、CardiovascularDiseases：MyocardialIschemia、MyocardialInfarction、AnginaPectoris、CoronaryArteryBypassGraftSurgery3、PeripheralArteryDisease：IntermittentClaudication（Raynaud’sdisease）、AbdominalAorticAneurysm、SurgicalIntervention4、CerebralVascularDiseases：HemiplegiaaccordingtoCerebralVascularAccidents5、OtherDiseases：severeRheumatoidArthritis、RenalDiseases：Glomerulonephritis，Pyelonephritis；GastrointestinalDiseases：GastricUlcer，Gastrectomy，Colitis；HepaticDiseases：Cirrhosis，Heptitis；Confusion；ChronicInfectionExclusionCriteria：othermalignanttumors，Hypertension，Diabetes，andsomeAutoimmuneDiseases（Sarcoidosis，Wegenergranulomatosis，SystemicLupusErythematosus

）arenotconsideredascomorbiditiesPercentageofPtseligibleforconcurrentchemoradiotherapyDefinecriteriaofeligibility⑴Age<75⑵FollowCCIcriteria：ptwithseverecomorbidity0%10%20%30%40%50%60%70%80%90%100%0-5960-6970-7475+AgeDistributioneligibleineligibleTreatmentFeaturesVariables分組＜70≥70PvalueNo.（%）No.（%）TotalDose(Gy)50～60Gy849(24.3)

35(21.9)0.34060Gy186(50.7)92(57.5)＞60Gy92(25.1)33(20.6)ModalityRTalone121(33.0)120(75.0)0.000ConcurrentCRT113(30.8)8(5)SequentialCRT133(36.2)32(20)TechniquesRegularRT191(52.0)83(51.9)1.0003DCRT176(48.0)77(48.1)Interactionofageandsystemictreatment(chemotherapy)WithoutchemotherapyWithchemotherapyP=0.625P=0.013≥70＜70NewradiationtechniquesimprovedtreatmentresultsImage-GuidedRadiationDelivery

IGRT

40pairsofleavesMLCKV-levelX-raytubeKV-levelArrayDetector

MV-levelArrayDetector

BetterlocationforpatientpositionBetterlocationfortumorAccurateirradiationtotargetvolumeControltumormovinginbreath4-DirectionCTimagingtechniqueinspirationSpiralinitiationPhaseFrominspiraiontoexhalationEndofexhalationexhalationBreathcurveBedpositionFromexhalation

toinspiraionFrominspiraiontoexhalationUseofadvancedradiationtechnologieshavetranslatedintoimprovementofsurvivalInt.J.RadiationOncologyBiol.Phys.,Vol.66,No.1,pp.108–116,20063Dvs2DinMEDICALLYINOPERABLESTAGEINON–SMALL-CELLLUNGCANCER(a)Overallsurvival(b)Disease-specificsurvivalInt.J.RadiationOncologyBiol.Phys.,Vol.66,No.1,pp.108–116,20063Dvs2DinMEDICALLYINOPERABLESTAGEINON–SMALL-CELLLUNGCANCERLocal-regionalcontrolInfluenceofTechnologicAdvancesonOutcomesinPatientsWithUnresectable,LocallyAdvancedNon–Small-CellLungCancerReceivingConcomitantChemoradiotherapyZhongxingX.Liao

M.D.*,

,

,RitsukoR.KomakiM.D.*,etal.InternationalJournalofRadiationOncology*Biology*Physics

Volume76,Issue3,1March2010,Pages775-781

Conclusions

1、Treatmentwith4DCT/IMRTwasatleastasgoodasthatwith3DCRTintermsoftheratesoffreedomfromLRPandDM.

2、TherewasasignificantreductionintoxicityandasignificantimprovementinOS.3DCRTvs2DinNSCLC

Cance