（醫(yī)學(xué)課件）髓母細(xì)胞瘤的放射治療.ppt

1、髓母細(xì)胞瘤的放射治療,1,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1520%。 疾病特點：惡性程度高。 生長極其迅速； 手術(shù)難以完整切除； 腫瘤細(xì)胞易沿腦脊液播散（1646,2,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,3,分級,4,治療方案,標(biāo)準(zhǔn)治療方案(“Philadelphia protocol”) 手術(shù) 放療：術(shù)后28天

2、內(nèi)開始。 化療(VCP)：放療中VCR1.5mg/m2/w，共8周； 放療后6周開始CCNU75mg/m2 DDP75mg/m2 VCR1.5mg/m2/w3w， 每6周一個周期，共8個周期,5,放療劑量,低危組：CSI 23.4Gy/13f+后顱窩加量至 54Gy 高危組：CSI 36Gy/20f+后顱窩加量至54Gy,6,放療技術(shù),常規(guī)分割CSI+ Boost to posterior fossa 超分割CSI+ Boost to posterior fossa SRT Boost to posterior fossa,7,Craniospinal irradiation (CSI):me

3、thods,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)：23.4Gy36Gy, 1.8Gy/f,8,9,Craniospinal irradiation (CSI):dose,Prospective randomised trial of chemotherapy given before radiotherapy in childhood medulloblastoma: International Society of Paediatric Oncology (

4、SIOP) and the (German) Society of Paediatric Oncology (GPO)SIOP II. Med Pediatr Oncol 25:166-178, 1995,10,23.4GyCSI的療效,Risk-adapted craniospinal radiotherapy followed by high-dose chemotherapy and stem-cell rescue in children with newly diagnosed medulloblastoma (St Jude Medulloblastoma-96): long-te

5、rm results from a prospective, multicentre trial http:/oncology.the Vol 7 October 2006,11,23.4GyCSI對智力的影響(POG-8631,Journal of Clinical Oncology, Vol 16, No 5, pp. 172328, 1998,12,CSI:cranial-spinal junction site,THE CRANIAL-SPINAL JUNCTION IN MEDULLOBLASTOMA: DOES IT MATTER? Int. J. Radiation Oncolo

6、gy Biol. Phys., Vol. 44, No. 1, pp. 8184, 1999,13,超分割放療,Twice-daily l-Gy fractions were administered separated by 4-6 h. 放療劑量和射野同常規(guī)分割,14,SRT Boost to posterior fossa,POSTERIOR FOSSA BOOST IN MEDULLOBLASTOMA: AN ANALYSIS OF DOSE TO SURROUNDING STRUCTURES USING 3-DIMENSIONAL (CONFORMAL) RADIOTHERAPY I

7、nt. J. Radiation Oncology Biol. Phys., Vol. 46, No. 2, pp. 281286, 2000,15,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,16,甲低,1.HYPOTHYROIDISM IN CHILDREN WITH MEDULLOBLASTOMA: A COMPARISON OF 3600 AND 2340 cGY CRANIOSPINAL RADIOTHERAPY Int. J. Radiation Oncology Biol. Phys., V

8、ol. 53, No. 3, pp. 543547, 2002 2. Thyroid Dysfunction as a Late Effect in Survivors of Pediatric Medulloblastoma /Primitive Neuroectodermal Tumors A Comparison of Hyperfractionated versus Conventional Radiotherapy Cancer 1997;80:798804,17,認(rèn)知障礙,MODELING RADIATION DOSIMETRY TO PREDICT COGNITIVE OUTCO

9、MES IN PEDIATRIC PATIENTS WITH CNS EMBRYONAL TUMORS INCLUDING MEDULLOBLASTOMA Int. J. Radiation Oncology Biol. Phys., Vol. 65, No. 1, pp. 210221, 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,18,聯(lián)合化療,常用方案： VCP(VCR+CCNU+DDP); “8 in 1” (VCR+甲強龍+CCNU+羥基脲+甲基芐肼+ DDP+CTX+Ara

10、-c); 其他方案： MTX鞘內(nèi)注射 CTX、VCR、VP-16、CCNU、CBP等組合,19,Risk-adapted craniospinal radiotherapy followed by high-dose chemotherapy and stem-cell rescue in children with newly diagnosed medulloblastoma (St Jude Medulloblastoma-96): long-term results from a prospective, multicentre trial http:/oncology.the Vol

11、 7 October 2006,20,手術(shù)+放/化療,POSTOPERATIVE NEOADJUVANT CHEMOTHERAPY BEFORE RADIOTHERAPY AS COMPARED TO IMMEDIATE RADIOTHERAPY FOLLOWED BY MAINTENANCE CHEMOTHERAPY IN THE TREATMENT OF MEDULLOBLASTOMA IN CHILDHOOD: RESULTS OF THE GERMAN PROSPECTIVE RANDOMIZED TRIAL HIT 91 Int. J. Radiation Oncology Biol

12、. Phys., Vol. 46, No. 2, pp. 269279, 2000,21,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,POSTOPERATIVE NEOADJUVANT CHEMOTHERAPY BEFORE RADIOTHERAPY AS COMPARED TO IMMEDIATE RADIOTHERAPY FOLLOWED BY MAINTENANCE CHEMOTHERAPY IN THE TREATMENT OF MEDULLOBLASTOMA IN CHILDHOOD: R

13、ESULTS OF THE GERMAN PROSPECTIVE RANDOMIZED TRIAL HIT 91 Int. J. Radiation Oncology Biol. Phys., Vol. 46, No. 2, pp. 269279, 2000,22,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,23,手術(shù)+化療-結(jié)果,Treatment of Early Childhood Medulloblastoma by Postoperative Chemotherapy Alone N Engl J Med 2005;352:978-86,24,影響預(yù)后的因素,年齡

14、臨床分級 術(shù)式 后顱窩生物有效劑量（BED） 放療持續(xù)時間,25,On multivariate analysis, age 3 years, M0 status, 50 Gy PFB dose, radiotherapy treatment duration 50 days, and use of chemotherapy correlated with better freedom from progression and posterior fossa control rates.Protracted Radiotherapy Treatment Duration in Medullob

15、lastoma Am J Clin Oncol (CCT) 26(1): 5559, 2003,影響因素的多變量分析,26,On multivariate analysis, age 3 years, M0 status, 50 Gy PFB dose, radiotherapy treatment duration 50 days, and use of chemotherapy correlated with better freedom from progression and posterior fossa control rates.Protracted Radiotherapy T

16、reatment Duration in Medulloblastoma Am J Clin Oncol (CCT) 26(1): 5559, 2003,影響因素的多變量分析,27,年齡,Timing of Radiation in Children With Medulloblastoma/PNET Pediatr Blood Cancer 2007;48:416422,28,CSF cytology,Timing of Radiation in Children With Medulloblastoma/PNET Pediatr Blood Cancer 2007;48:416422,29

17、,手術(shù)切除范圍,Timing of Radiation in Children With Medulloblastoma/PNET Pediatr Blood Cancer 2007;48:416422,30,后顱窩BED,Timing of Radiation in Children With Medulloblastoma/PNET Pediatr Blood Cancer 2007;48:416422,31,Risk-adapted craniospinal radiotherapy followed by high-dose chemotherapy and stem-cell rescue in children with newly diagnosed medulloblastoma (St Jude Medulloblastoma-96): long-term results from a prospective, multicentre trial http:/ Vol 7 October 2006,病理及免疫組化類型,32,放療持續(xù)時間,Pro