髓母细胞瘤的放射治疗.ppt

髓母细胞瘤的放射治疗 曹嫣娜 概述 来源 胚胎残留的未分化的原始髓样上皮细胞 部位 第四脑室顶上的小脑蚓部 发病率 2 1 10万 年 占儿童颅内恶性肿瘤的15 20 疾病特点 恶性程度高 生长极其迅速 手术难以完整切除 肿瘤细胞易沿脑脊液播散 16 46 临床表现 颅内压增高 头痛 呕吐 视神经乳头水肿小脑损害 躯干性共济失调为主其它 复视 面瘫 强迫头位 头颅增大 病理反射阳性 呛咳 小脑危象 蛛网膜下腔出血脊髓转移灶症状 背部或双下肢痛 进行性加重的截瘫或四肢瘫 分级 治疗方案 标准治疗方案 Philadelphiaprotocol 手术放疗 术后28天内开始 化疗 VCP 放疗中VCR1 5mg m2 w 共8周 放疗后6周开始CCNU75mg m2DDP75mg m2VCR1 5mg m2 w 3w 每6周一个周期 共8个周期 放疗剂量 低危组 CSI23 4Gy 13f 后颅窝加量至54Gy高危组 CSI36Gy 20f 后颅窝加量至54Gy 放疗技术 常规分割CSI Boosttoposteriorfossa超分割CSI BoosttoposteriorfossaSRTBoosttoposteriorfossa Craniospinalirradiation CSI methods 俯卧位 双手置于体侧头部两侧对穿野照射全脑及上段颈髓单后野照射脊髓各野皮肤间隔1cm每照射10Gy移动一次射野以减少各野间交叉高剂量6MV X线照射剂量 DT 23 4Gy 36Gy 1 8Gy f Craniospinalirradiation CSI dose Prospectiverandomisedtrialofchemotherapygivenbeforeradiotherapyinchildhoodmedulloblastoma InternationalSocietyofPaediatricOncology SIOP andthe German SocietyofPaediatricOncology GPO SIOPII MedPediatrOncol25 166 178 1995 23 4GyCSI的疗效 Risk adaptedcraniospinalradiotherapyfollowedbyhigh dosechemotherapyandstem cellrescueinchildrenwithnewlydiagnosedmedulloblastoma StJudeMedulloblastoma 96 long termresultsfromaprospective multicentretrialVol7October2006 23 4GyCSI对智力的影响 POG 8631 JournalofClinicalOncology Vol16 No5 pp 1723 28 1998 CSI cranial spinaljunctionsite THECRANIAL SPINALJUNCTIONINMEDULLOBLASTOMA DOESITMATTER Int J RadiationOncologyBiol Phys Vol 44 No 1 pp 81 84 1999 超分割放疗 Twice dailyl Gyfractionswereadministeredseparatedby4 6h 放疗剂量和射野同常规分割 SRTBoosttoposteriorfossa POSTERIORFOSSABOOSTINMEDULLOBLASTOMA ANANALYSISOFDOSETOSURROUNDINGSTRUCTURESUSING3 DIMENSIONAL CONFORMAL RADIOTHERAPYInt J RadiationOncologyBiol Phys Vol 46 No 2 pp 281 286 2000 放疗反应 急性反应 骨髓抑制 脑水肿等 远期副作用 甲低认知障碍其它 听力减退 骨骼发育障碍 周围组织损伤继发第二恶性肿瘤等 甲低 1 HYPOTHYROIDISMINCHILDRENWITHMEDULLOBLASTOMA ACOMPARISONOF3600AND2340cGYCRANIOSPINALRADIOTHERAPYInt J RadiationOncologyBiol Phys Vol 53 No 3 pp 543 547 20022 ThyroidDysfunctionasaLateEffectinSurvivorsofPediatricMedulloblastoma PrimitiveNeuroectodermalTumorsAComparisonofHyperfractionatedversusConventionalRadiotherapyCancer1997 80 798 804 认知障碍 MODELINGRADIATIONDOSIMETRYTOPREDICTCOGNITIVEOUTCOMESINPEDIATRICPATIENTSWITHCNSEMBRYONALTUMORSINCLUDINGMEDULLOBLASTOMAInt J RadiationOncologyBiol Phys Vol 65 No 1 pp 210 221 2006 影响因素包括 受照射时年龄 小于3岁差 照射范围 全脑差于部分脑照射 照射剂量 低剂量较好 特别是后颅窝最大剂量 肿瘤部位 幕上好于后颅窝 联合化疗 常用方案 VCP VCR CCNU DDP 8in1 VCR 甲强龙 CCNU 羟基脲 甲基苄肼 DDP CTX Ara c 其他方案 MTX鞘内注射CTX VCR VP 16 CCNU CBP等组合 Risk adaptedcraniospinalradiotherapyfollowedbyhigh dosechemotherapyandstem cellrescueinchildrenwithnewlydiagnosedmedulloblastoma StJudeMedulloblastoma 96 long termresultsfromaprospective multicentretrialVol7October2006 手术 放 化疗 POSTOPERATIVENEOADJUVANTCHEMOTHERAPYBEFORERADIOTHERAPYASCOMPAREDTOIMMEDIATERADIOTHERAPYFOLLOWEDBYMAINTENANCECHEMOTHERAPYINTHETREATMENTOFMEDULLOBLASTOMAINCHILDHOOD RESULTSOFTHEGERMANPROSPECTIVERANDOMIZEDTRIALHIT 91Int J RadiationOncologyBiol Phys Vol 46 No 2 pp 269 279 2000 维持化疗对6岁以上低危组更有效 新辅助化疗增加放疗的骨髓抑制从而延长治疗时间 M分期高 低龄儿预后差 手术是否有残留对预后无明显影响 POSTOPERATIVENEOADJUVANTCHEMOTHERAPYBEFORERADIOTHERAPYASCOMPAREDTOIMMEDIATERADIOTHERAPYFOLLOWEDBYMAINTENANCECHEMOTHERAPYINTHETREATMENTOFMEDULLOBLASTOMAINCHILDHOOD RESULTSOFTHEGERMANPROSPECTIVERANDOMIZEDTRIALHIT 91Int J RadiationOncologyBiol Phys Vol 46 No 2 pp 269 279 2000 手术 化疗 方案 适用于低龄儿童 无手术残留 无转移病灶患者 手术 化疗 结果 TreatmentofEarlyChildhoodMedulloblastomabyPostoperativeChemotherapyAloneNEnglJMed2005 352 978 86 影响预后的因素 年龄临床分级术式后颅窝生物有效剂量 BED 放疗持续时间 Onmultivariateanalysis age3years M0status 50GyPFBdose radiotherapytreatmentduration50days anduseofchemotherapycorrelatedwithbetterfreedomfromprogressionandposteriorfossacontrolrates ProtractedRadiotherapyTreatmentDurationinMedulloblastomaAmJClinOncol CCT 26 1 55 59 2003 影响因素的多变量分析 Onmultivariateanalysis age3years M0status 50GyPFBdose radiotherapytreatmentduration50days anduseofchemotherapycorrelatedwithbetterfreedomfromprogressionandposteriorfossacontrolrates ProtractedRadiotherapyTreatmentDurationinMedulloblastomaAmJClinOncol CCT 26 1 55 59 2003 影响因素的多变量分析 年龄 TimingofRadiationinChildrenWithMedulloblastoma PNETPediatrBloodCancer2007 48 416 422 CSFcytology TimingofRadiationinChildrenWithMedulloblastoma PNETPediatrBloodCancer2007 48 416 422 手术切除范围 TimingofRadiationinChildrenWithMedulloblastoma PNETPediatrBloodCancer2007 48 416 422 后颅窝BED TimingofRadiationinChildrenWithMedulloblastoma PNETPediatrBloodCancer2007 48 416 422 Risk adaptedcraniospinalradiotherapyfollowedbyhigh dosechemotherapyandstem cellrescueinchildrenwithnewlydiagnosedmedulloblastoma StJudeMedulloblastoma 96 long termresultsfromaprospective multicentretrialVol7October2006 病理及免疫组化类型 放疗持续时间 Protracte