髓母細(xì)胞瘤的放射治療課件

髓母細(xì)胞瘤的放射治療

髓母細(xì)胞瘤的放射治療概述來源：胚胎殘留的未分化的原始髓樣上皮細(xì)胞。部位：第四腦室頂上的小腦蚓部。發(fā)病率：2.1/10萬/年，占兒童顱內(nèi)惡性腫瘤的15~20%。疾病特點：惡性程度高。

①生長極其迅速；②手術(shù)難以完整切除；③腫瘤細(xì)胞易沿腦脊液播散（16~46%）。髓母細(xì)胞瘤的放射治療臨床表現(xiàn)顱內(nèi)壓增高：頭痛、嘔吐、視神經(jīng)乳頭水腫小腦損害：軀干性共濟(jì)失調(diào)為主其它：復(fù)視、面癱、強迫頭位、頭顱增大、病理反射陽性、嗆咳、小腦危象、蛛網(wǎng)膜下腔出血脊髓轉(zhuǎn)移灶癥狀：背部或雙下肢痛、進(jìn)行性加重的截癱或四肢癱髓母細(xì)胞瘤的放射治療分級StageRiskstagingsystemStageChang'sMstagingsystemLow-riskLocalizeddiseaseatthetimeofdiagnosisM0NoevidenceofgrosssubarachnoidorGroupAge>3yearshematogenousmetastasisTotaltumorresectionorsubtotalwithresidualtumor<1.5cm3

High-riskDisseminateddiseaseatthetimeofdiagnosisM1MicroscopictumorcellsfoundinGroupcerebrospinalfluidAge≤3years

M2GrossnoduleseedingseeninthecerebellarorcerebralsubarachnoidspaceorinthethirdorlateralventriclesSubtotaltumorresectionwitharesidualtumorM3Grossnoduleseedinginthespinal

≥1.5cm3subarachnoidspacemetastasisM4Extraneural髓母細(xì)胞瘤的放射治療治療方案標(biāo)準(zhǔn)治療方案(“Philadelphiaprotocol”)手術(shù)放療：術(shù)后28天內(nèi)開始?；?VCP)：放療中VCR1.5mg/m2/w，共8周；放療后6周開始CCNU75mg/m2DDP75mg/m2VCR1.5mg/m2/w×3w，每6周一個周期，共8個周期。髓母細(xì)胞瘤的放射治療放療劑量低危組：CSI23.4Gy/13f+后顱窩加量至54Gy高危組：CSI36Gy/20f+后顱窩加量至54Gy髓母細(xì)胞瘤的放射治療放療技術(shù)常規(guī)分割CSI+Boosttoposteriorfossa超分割CSI+BoosttoposteriorfossaSRTBoosttoposteriorfossa髓母細(xì)胞瘤的放射治療Craniospinalirradiation(CSI):methods俯臥位，雙手置于體側(cè)頭部兩側(cè)對穿野照射全腦及上段頸髓單后野照射脊髓各野皮膚間隔1cm每照射10Gy移動一次射野以減少各野間交叉高劑量6MV-X線照射劑量(DT)：23.4Gy~36Gy,1.8Gy/f髓母細(xì)胞瘤的放射治療髓母細(xì)胞瘤的放射治療Craniospinalirradiation(CSI):doseradiotherapyalone

（5-yearEFS）

Chemotherapy+（5-yearEFS）

standardradiotherapy

reduced-doseradiotherapy60%±7.8%

41%±8%75%±7%

69%±8%Prospectiverandomisedtrialofchemotherapygivenbeforeradiotherapyinchildhoodmedulloblastoma:InternationalSocietyofPaediatricOncology(SIOP)andthe(German)SocietyofPaediatricOncology(GPO)—SIOPII.

MedPediatrOncol25:166-178,1995

髓母細(xì)胞瘤的放射治療23.4GyCSI的療效Risk-adaptedcraniospinalradiotherapyfollowedbyhigh-dosechemotherapyandstem-cellrescueinchildrenwithnewlydiagnosedmedulloblastoma(StJudeMedulloblastoma-96):long-termresultsfromaprospective,multicentretrial

Vol7October2006髓母細(xì)胞瘤的放射治療23.4GyCSI對智力的影響(POG-8631)JournalofClinicalOncology,Vol16,No5,pp.1723–28,1998髓母細(xì)胞瘤的放射治療CSI:cranial-spinaljunctionsite

THECRANIAL-SPINALJUNCTIONINMEDULLOBLASTOMA:DOESITMATTER?

Int.J.RadiationOncologyBiol.Phys.,Vol.44,No.1,pp.81–84,1999Organlowjunction(SD)highjunction(SD)Cord40.3Gy(0.5)38.4Gy(1.3)Thyroidgland20.3Gy(9.2)26.3Gy(0.6)Mandible6.2Gy(0.6)10.9Gy(5.1)Larynx8.3Gy(3.9)27.2Gy(0.4)Pharynx11.9Gy(5.1)20.3Gy(4.8)Parotidgland14.9Gy(4.2)14.1Gy(4.2)髓母細(xì)胞瘤的放射治療超分割放療Twice-dailyl-Gyfractionswereadministeredseparatedby4-6h.放療劑量和射野同常規(guī)分割髓母細(xì)胞瘤的放射治療SRTBoosttoposteriorfossaPOSTERIORFOSSABOOSTINMEDULLOBLASTOMA:ANANALYSISOFDOSETOSURROUNDINGSTRUCTURESUSING3-DIMENSIONAL(CONFORMAL)RADIOTHERAPYInt.J.RadiationOncologyBiol.Phys.,Vol.46,No.2,pp.281–286,2000髓母細(xì)胞瘤的放射治療放療反應(yīng)急性反應(yīng)：骨髓抑制、腦水腫等；遠(yuǎn)期副作用：甲低認(rèn)知障礙其它：聽力減退、骨骼發(fā)育障礙、周圍組織損傷繼發(fā)第二惡性腫瘤等。髓母細(xì)胞瘤的放射治療甲低

Hypothyroidp值年齡1

<5歲7/7(100%)<0.001

5~10歲9/15(60%)>10歲2/10(20%)照射劑量123.4Gy+CT10/12(83%)<0.025

36Gy+CT6/10(60%)36Gy2/10(20%)照射方法2常規(guī)分割21/34(62%)=0.02超分割2/14(14%)1.HYPOTHYROIDISMINCHILDRENWITHMEDULLOBLASTOMA:ACOMPARISONOF3600AND2340cGYCRANIOSPINALRADIOTHERAPYInt.J.RadiationOncologyBiol.Phys.,Vol.53,No.3,pp.543–547,20022.ThyroidDysfunctionasaLateEffectinSurvivorsofPediatricMedulloblastoma/PrimitiveNeuroectodermalTumorsAComparisonofHyperfractionatedversusConventionalRadiotherapy

Cancer1997;80:798–804.髓母細(xì)胞瘤的放射治療認(rèn)知障礙

IQ(pointdeclineperyear)23.4Gy(CSI)+后顱窩加量5.236Gy(CSI)+后顱窩加量3.923.4Gy(CSI)+瘤床加量2.4MODELINGRADIATIONDOSIMETRYTOPREDICTCOGNITIVEOUTCOMESINPEDIATRICPATIENTSWITHCNSEMBRYONALTUMORSINCLUDINGMEDULLOBLASTOMAInt.J.RadiationOncologyBiol.Phys.,Vol.65,No.1,pp.210–221,2006影響因素包括：受照射時年齡（小于3歲差）、照射范圍（全腦差于部分腦照射）、照射劑量(低劑量較好）特別是后顱窩最大劑量、腫瘤部位（幕上好于后顱窩）。髓母細(xì)胞瘤的放射治療聯(lián)合化療常用方案：VCP(VCR+CCNU+DDP);“8in1”(VCR+甲強龍+CCNU+羥基脲+甲基芐肼+DDP+CTX+Ara-c);其他方案：MTX鞘內(nèi)注射CTX、VCR、VP-16、CCNU、CBP等組合髓母細(xì)胞瘤的放射治療Risk-adaptedcraniospinalradiotherapyfollowedbyhigh-dosechemotherapyandstem-cellrescueinchildrenwithnewlydiagnosedmedulloblastoma(StJudeMedulloblastoma-96):long-termresultsfromaprospective,multicentretrial

Vol7October2006髓母細(xì)胞瘤的放射治療手術(shù)+放/化療POSTOPERATIVENEOADJUVANTCHEMOTHERAPYBEFORERADIOTHERAPYASCOMPAREDTOIMMEDIATERADIOTHERAPYFOLLOWEDBYMAINTENANCECHEMOTHERAPYINTHETREATMENTOFMEDULLOBLASTOMAINCHILDHOOD:RESULTSOFTHEGERMANPROSPECTIVERANDOMIZEDTRIALHIT’91Int.J.RadiationOncologyBiol.Phys.,Vol.46,No.2,pp.269–279,2000髓母細(xì)胞瘤的放射治療維持化療對6歲以上低危組更有效；新輔助化療增加放療的骨髓抑制從而延長治療時間；M分期高/低齡兒預(yù)后差；手術(shù)是否有殘留對預(yù)后無明顯影響。POSTOPERATIVENEOADJUVANTCHEMOTHERAPYBEFORERADIOTHERAPYASCOMPAREDTOIMMEDIATERADIOTHERAPYFOLLOWEDBYMAINTENANCECHEMOTHERAPYINTHETREATMENTOFMEDULLOBLASTOMAINCHILDHOOD:RESULTSOFTHEGERMANPROSPECTIVERANDOMIZEDTRIALHIT’91Int.J.RadiationOncologyBiol.Phys.,Vol.46,No.2,pp.269–279,2000髓母細(xì)胞瘤的放射治療手術(shù)+化療--方案適用于低齡兒童、無手術(shù)殘留、無轉(zhuǎn)移病灶患者髓母細(xì)胞瘤的放射治療手術(shù)+化療--結(jié)果TreatmentofEarlyChildhoodMedulloblastomabyPostoperativeChemotherapyAloneNEnglJMed2005;352:978-86.髓母細(xì)胞瘤的放射治療影響預(yù)后的因素年齡臨床分級術(shù)式后顱窩生物有效劑量（BED）放療持續(xù)時間髓母細(xì)胞瘤的放射治療Onmultivariateanalysis,age3years,M0status,50GyPFBdose,radiotherapytreatmentduration50days,anduseofchemotherapycorrelatedwithbetterfreedomfromprogressionandposteriorfossacontrolrates.

ProtractedRadiotherapyTreatmentDurationinMedulloblastomaAmJClinOncol(CCT)26(1):55–59,2003.影響因素的多變量分析髓母細(xì)胞瘤的放射治療Onmultivariateanalysis,age3years,M0status,50GyPFBdose,radiotherapytreatmentduration50days,anduseofchemotherapycorrelatedwithbetterfreedomfromprogressionandposteriorfossacontrolrates.

ProtractedRadiotherapyTreatmentDurationinMedulloblastomaAmJClinOncol(CCT)26(1):55–59,2003.影響因素的多變量分析髓母細(xì)胞瘤的放射治療年齡TimingofRadiationinChildrenWithMedulloblastoma/PNETPediatrBloodCancer2007;48:416–422髓母細(xì)胞瘤的放射治療CSFcytologyTimingofRadiationinChildrenWithMedulloblastoma/PNETPediatrBloodCancer2007;48:416–422髓母細(xì)胞瘤的放射治療手術(shù)切除范圍TimingofRadiationinChildrenWithMedulloblastoma/PNETPediatrBloodCancer2007;48:416–422髓母細(xì)胞瘤的放射治療后顱窩BEDTimingofRadiationinChildrenWithMedulloblastoma/PNETPediatrBloodCancer2007;48:416–4