肺癌术后的靶区勾画

肺癌术后的靶区勾画肺癌术后靶区照那里肺癌术后靶区的验证射线的基本剂量学123辐射防护概述4肺癌术后靶区的勾画图谱一、概述1998年的PORT荟萃分析的局限性数据采集：年代早、时间跨度大、数据变异大。分期：手术，淋巴结分期等信息不完善导致两组不均衡患者选择：N0多，N2。放疗设备：60C0较多，加速器未广泛应用于该研究中。放疗技术：单野照射；侧野照射；后野挡脊髓等研究设计：部分存在一定问题，不同研究间样本量差异大。术后化疗：辅助化疗未普及，远处转移的死亡掩盖了局部的作用。ClinCancerRes.2005Radiotherapyandoncology2013目的：评价术后放疗的时机。方法：术后早放疗指与化疗同步或先放疗。晚放疗指二周期化疗后放疗。二、肺癌术后靶区照那里术后预防照射淋巴引流区－－－－引流规律术后预防照射易复发部位－－－－复发表型照那里肺癌淋巴引流途径A：右肺上尖段和后段。B：右肺中叶和右肺上叶背段。C：右肺下叶基底段。D-G：左肺引流的四条途径。D：通过主动脉弓下淋巴结，然后向近端沿迷走神经引流至斜角肌淋巴结或沿喉返神经引流至纵隔淋巴结。E：沿膈神经引流至斜角肌淋巴结。F：沿主支气管引流至气管旁淋巴结。G：沿主支气管下方引流至隆突下淋巴结。TheorSurg1990;5:19肺癌各区域淋巴结转移概率CancerRadioth2001;6:725-36淋巴结右上右中右下左上左下左肺右肺1L0.0320.0130.0110.2020.0490.1250.0191R0.2340.1570.0660.0500.0580.0540.1522L0.0180.0470.0210.1400.0880.1140.0292R0.2700.1870.1840.0550.0810.0680.2144L0.0180.0470.0210.1500.1220.1360.0294R0.2340.1750.1900.0450.0710.0580.20050.0000.0000.0000.0950.0700.0820.00060.0000.0000.0000.050.0.0500.0500.00070.1530.1530.2900.1660.2460.2060.1998L0.0000.0000.0000.0050.0300.0170.0008R0.0050.0050.0050.0000.0000.0000.0059L0.0000.0000.0000.0050.0050.0050.0009R0.0050.0050.0200.0000.0000.0000.01010L0.0000.0000.0000.1500.1200.1350.00010R0.1370.1050.0870.0120.0310.0220.10911L0.0000.0000.0000.5000.5950.5480.00011R0.4100.4550.5500.0000.0000.0000.472CancerRadioth2001,5(6):725-36淋巴结右上右中右下左上左下左肺右肺1L0.0320.0130.0110.2020.0490.1250.0191R0.2340.1570.0660.0500.0580.0540.1522L0.0180.0470.0210.1400.0880.1140.0292R0.2700.1870.1840.0550.0810.0680.2144L0.0180.0470.0210.1500.1220.1360.0294R0.2340.1750.1900.0450.0710.0580.20050.0000.0000.0000.0950.0700.0820.00060.0000.0000.0000.050.0.0500.0500.00070.1530.1530.2900.1660.2460.2060.1998L0.0000.0000.0000.0050.0300.0170.0008R0.0050.0050.0050.0000.0000.0000.0059L0.0000.0000.0000.0050.0050.0050.0009R0.0050.0050.0200.0000.0000.0000.01010L0.0000.0000.0000.1500.1200.1350.00010R0.1370.1050.0870.0120.0310.0220.10911L0.0000.0000.0000.5000.5950.5480.00011R0.4100.4550.5500.0000.0000.0000.472肺癌各区域淋巴结转移概率各层淋巴结阳性患者百分数StrahlentherOnkol2002;178:199–208＃5（主肺动脉窗)转移4.2％（3/72)＃6（主动脉弓旁）转移1.4％（1/72）PET显示第5，6组纵隔淋巴结转移情况（72例右肺癌）Subclavicularfossa,supravicularfossa,contralateralhilum,N3,N8少见JTO,2016术后放疗靶区确定左肺肺癌：残端，2R、2L、4R、4L、5、6、7和10-11L右肺肺癌：残端，2R、4R、7和10-11R三、肺癌术后靶区的验证Redjournal2014右侧肺癌（47个复发部位）：最常见：#2R(26%),#10R(19%),#4R(19%),#7(15%)8个(17%)照射野外复发部位,与野内淋巴结同时出现左侧肺癌（65个复发部位）：最常见：#4R(22%),#7(20%),#4L(14%),#6(12%),#10L(12%),#5(11%)均位于PORTCTV照射野内54例首次局部区域复发(250例)48(89%)例野内6(11%)例野内、野外同时复发6例野外复发患者特点：原发灶位于右侧肺癌均与野内复发同存大部分同时伴器官转移或SLN转移Loc.PatternofLRFRUL#2R,#4R,#4L,#7RUL#2R,#3a,#6,SLNRUL#2R,#3a,SLNRLL#2R,#5,#6,brainandlungmetastasesRLL#2R,#4R,#5,brain,lungandadrenalmetastasesRUL#2R,#4R,#5,#7,SLN,vertebralmetastasis方法：53例A组患者:除包括GTV外，还包括患侧肺门和纵，下界达到支气管隆突下3cm,上界为胸腔出口。如果病变累及对侧肺门或锁骨上淋巴结，则加照受累及的区域。B组患者：包括GTV外和术后病理证实淋巴结受累及的区域。四、肺癌术后靶区的勾画图谱肺癌术后放疗靶区定义右侧肺癌术后CTV：上界：胸骨切迹下界：隆突下3cm(包括7)左界：气管左侧右界：支气管残端、右肺门、4R、2R。左侧肺癌术后CTV：上界：胸骨切迹下界：隆突下3cm(包括7)左界：支气管残端、左肺门、5、6、4L、2L。右界：4R、2R。病例1：左上肺腺癌手术方式：左上肺肺叶切除术+纵隔淋巴结清扫术后诊断：左上肺腺癌pT2aN2M0IIIa期放疗指征：R0术后有N2靶区CTV范围：见靶区定义。皮肤皮肤左肺左肺气管右肺脊髓右肺CTV食管气管脊髓食管皮肤皮肤左肺左肺气管右肺脊髓右肺CTV食管气管脊髓食管CTV皮肤皮肤左肺左肺气管右肺脊髓右肺CTV食管脊髓食管CTV气管皮肤皮肤左肺左肺右肺脊髓右肺CTV食管脊髓食管CTV气管气管皮肤皮肤左肺左肺右肺脊髓右肺CTV食管脊髓食管CTV气管气管皮肤皮肤左肺左肺右肺脊髓右肺CTV脊髓CTV食管食管皮肤皮肤左肺左肺右肺脊髓右肺CTV脊髓CTV皮肤皮肤左肺左肺右肺脊髓右肺脊髓CTV心脏食管食管病例2：右下肺腺癌手术方式：右下肺肺叶切除术+纵隔淋巴结清扫术后诊断：右下肺腺癌pT2aN2M0IIIa期放疗指征：R0术后有N2靶区CTV范围：见靶区定义。皮肤皮肤左肺左肺右肺脊髓右肺脊髓食管气管食管气管CTV皮肤皮肤左肺左肺右肺脊髓右肺脊髓食管气管食管气管CTVCTV皮肤皮肤左肺左肺右肺脊髓右肺脊髓食管气管食管气管CTVCTV皮肤皮肤左肺左肺右肺脊髓右肺脊髓食管气管食管气管CTVCTV皮肤皮肤左肺左肺右肺脊髓右肺脊髓食管气管食管气管CTVCTV皮肤皮肤左肺左肺右肺脊髓右肺脊髓食管气管食管CTVCTV皮肤皮肤左肺左肺右肺脊髓右肺脊髓食管食管CTVCTV皮肤皮肤左肺左肺右肺脊髓右肺脊髓食管食管CTVCTV心脏皮肤皮肤左肺左肺右肺脊髓右肺脊髓食管食管CTV心脏心脏谢谢！