螺旋断层放疗于食管癌之运用课件

1、螺旋断层放疗于食管癌之运用Tomotherapy for esophageal cancer Department of Radiation OncologyFar Eastern Memorial Hospital, Taiwan 2大綱台灣Tomo放療設備現況Tomo facitilities in Taiwan 台灣食管癌流行病學Epidymiology of esophageal cancer in Taiwan 傳統食管癌放療的心臟併發症Cardiac morbidities after RT of esophageal cancer 螺旋斷層放療的心臟保護治療計劃Heart spa

2、ring tomotherapy for esophageal cancer 總結Conclusion Department of Radiation OncologyFar Eastern Memorial Hospital, Taiwan 3台灣Tomo放療設備現況Tomo facitilities in Taiwan 台灣食管癌流行病學Epidymiology of esophageal cancer in Taiwan 傳統食管癌放療的心臟併發症Cardiac morbidities after RT of esophageal cancer 螺旋斷層放療的心臟保護治療計劃Heart

3、sparing tomotherapy for esophageal cancer 總結Conclusion 大綱4亚洲第一家拥有两部Tomo的医院Tomo Facility in Asia (as of 2015-06)CountryJapanChinaKoreaTaiwanHKAstraliaTomo No4630212055Population(million)127.3135750.2223.377.18823.13MalysiaPhilipinesSingaporeThailand Myanmar4321129.7298.395.39967.0153.26CountryTomo No

4、Population(million)5亞東醫院放射治療現況放射治療開始於2001/10/24每日治療病患約90人放射治療時間: 7:30am 9:30pm 90% 以上皆使用IMRT/IGRTTomo HI-ART2008-7-302006-12-12Tomo HDElekta Versa HD2015-10-12Department of Radiation OncologyFar Eastern Memorial Hospital, Taiwan 6亚东螺旋断层放疗 创新研发提升品质世界首例, 2012全皮肤螺旋断层放射治疗HITS假體研究Biomed Res Int. 2013:108

5、794 世界首例報告Biomed Res Int. 2013:717589 世界首創, 2014 左乳癌挡块设计螺旋刀治疗假體研究Biomed Res Int. 2014:741326亞洲首例, 2008全骨髓放射治疗TMI 與傳統治療方式之比較: Biomed Res Int. 2013;2013:321762. 亞洲首例報告: Technol Cancer Res Treat.2009 Feb;8(1):29-38. 世界首創, 2015食管癌螺旋刀扇形挡块设计假體研究Biomed Res Int. 2015:9595048螺旋断层放疗-亚洲区顶尖教学训练中心馬來西亞瑪麗亞山醫院馬來西亞王

6、子醫院復旦大學附設醫院香港伊利沙伯醫院2009年2015年新加坡、馬來西亞、菲律賓、香港、上海復旦、湖南岳陽與四川重慶共19 人次荣获SNQ国家品质标章与香港伊莉莎白医院感谢状台湾区唯一螺旋断层放疗教学训练中心Department of Radiation OncologyFar Eastern Memorial Hospital, Taiwan +二元气动多叶准直器连续式旋转放射连续式治疗床前进=250 cm/s leaf speed0.3% leaf transmissionEliminates field matching treat up to 160cm volumeThousand

7、s of radiation beamlets9Tomo治疗原理Department of Radiation OncologyFar Eastern Memorial Hospital, Taiwan 10台灣Tomo放療設備現況Tomo facitilities in Taiwan 台灣食管癌流行病學Epidymiology of esophageal cancer in Taiwan 傳統食管癌放療的心臟併發症Cardiac morbidities after RT of esophageal cancer 螺旋斷層放療的心臟保護治療計劃Heart sparing tomotherapy

8、 for esophageal cancer 總結Conclusion 大綱8th most common cancer worldwide456,000 new cases in 20126th most common cause of cancer death400,000 deathsM/F: 2.4:1mortality : incidence: 0.88高死亡率的全球十大癌病 -食管癌WHO, 2012全球男性食管癌发生率地图男57歲,女62歲年齡標準化發生率14.5 vs. 0.8 / 10万人2348人 vs. 148人男女比= 18 : 1菸酒檳高危險男發生率排第6死亡率排第5

9、Taiwan Cancer Registry,2013好发组织病理型态东西有别SCC(%)AdenoCa (%)Unspecified (%)Black89.47.12.8Chinese77.814.83.7Japanese69.727.3-Hispanic white45.847.93.2Non-hispanic white4350.52.9Taiwan Cancer Registry,2013Taiwan (2013)- SCC: Adeno = 92.5 : 3.5Lambert et al. Endoscopy 2007;39:550-555National Department of

10、 Health, Taiwan, ROC. 1972-2012. Cancer Registry Annual Report每十萬人口死亡率 (男性)台湾男性常见癌病死亡率历年变化趋式台灣頭頸癌患者食道鏡檢同時發現鳞状上皮异型增生或食管癌機率高FEMH, 129 H&N cancer patients23.3% (30 pts) synchronous esophageal neoplasia11 low-grade intraepithelial neoplasia14 high-grade intraepithelial neoplasia12 invasive carcinoma sta

11、ge IA:IB:IIA:IIIA=3:5:1:315.5% modified treatment strategy NNS (number needed to screen) = 6.45 (1/15.5%, 95% CI= 4.60-10.90)Chung CS et al. BMC Gastroenterology 2013Chung CS et al. Sci Rep 2016hypopharyngeal Cawhite-light endoscopy.narrow-band imagingNBI,magnifyingendoscopyLugol-unstained areaEndos

12、copic submucosal dissection SCC invading the lamina propriaMost locally advancedesophagus cancersT1bN+ or T2-T4aJAMA.1999, RTOG8501 NEJM 2012, Lancet Oncolog, 2015 , Cross TrialJCO, 2009Cancer 2002, IJROBP ;1999ABCDEDepartment of Radiation OncologyFar Eastern Memorial Hospital, Taiwan 17台灣Tomo放療設備現況

13、Tomo facitilities in Taiwan 台灣食管癌流行病學Epidymiology of esophageal cancer in Taiwan 傳統食管癌放療的心臟併發症Cardiac morbidities after RT of esophageal cancer 螺旋斷層放療的心臟保護治療計劃Heart sparing tomotherapy for esophageal cancer 總結Conclusion 大綱放射線加速小鼠动脉粥样硬化病变的发展並造成出血傾向Stewart A, et al. American Journal of Pathology, 2006

14、14Gy照射區Female, 22wk, 0 Gy Female, 22wk, 14 Gy Ionizing Radiation Accelerates the Development of Atherosclerotic Lesions in ApoE/ Mice and Predisposes to an Inflammatory Plaque Phenotype Prone to HemorrhageWeintraub NL, et al. J Am Coll Cardiol. 2010辐射引起血管损伤和纤维化的机制NF-B = nuclear factor-kappa B.Thromb

15、in is a key link between downregulated TM and radiation-induced vascular and intestinal fibrosisWang J, et al. World J Gastroenterol, 2007放疗引发迟发性心脏损伤Congestive heart failureIschemiaCoronary artery diseaseValvular diseaseMyocardial infarctionCardiac death霍奇金淋巴瘤的传统放疗明显造成心脏损伤242 times above baselineCar

16、diac morbidity/mortalityCourtesy of Andrea K Ng, MD 左侧乳癌放疗要避免心脏照射2013調強與3D混合放療心臟劑量15.6GyTomo6.9Gy 3D 心臟劑量16.4GyFEMH experience吾23QUANTECLungThresholdToxicityMean lung dose7 Gy5 % symptomatic pneumonitis13 Gy10 % symptomatic pneumonitis20 Gy20 % symptomatic pneumonitis24 Gy30 % symptomatic pneumoniti

17、sV20 30 Gy 20 % symptomatic pneumonitisHeartMean heart dose 26 Gy 15 % pericarditisV25 10 % 1 % cardiac mortalityV30 46 % 15 % pericarditisSpinal cordMaximum dose50 Gy0.2 % myelopathy60 Gy6 % myelopathyInt J Radiat Oncol Biol Phys. 2010心肺脊髓的处方剂量限制临床正常组织效应量化分析(QUANTEC)Years after diagnosis Overall Su

18、rvival IMRT 3DCRT p=0.009 Long-term outcomeCCRT, Eso Ca MDACC Experience Lin et. al., IJROBP 2012 Lin et. al., IJROBP 2012 3DCRT的患者死于心脏疾病的机率比IMRT组高-MDACC食管癌长期存活者曾接受放疗死于心脏病的机率比未放疗组高Gharzai L, et al. PLoS ONE , 2016OR 1.23, 95% CI 1.031.47HR 1.96, 95% CI 1.4662.624SEER dataDepartment of Radiation Onco

19、logyFar Eastern Memorial Hospital, Taiwan 27台灣Tomo放療設備現況Tomo facitilities in Taiwan 台灣食管癌流行病學Epidymiology of esophageal cancer in Taiwan 傳統食管癌放療的心臟併發症Cardiac morbidities after RT of esophageal cancer 螺旋斷層放療的心臟保護治療計劃Heart sparing tomotherapy for esophageal cancer 總結Conclusion 大綱Courtesy of Yi-Jen Che

20、n, M.D., Ph.D食管癌放化疗中其体积可能缩小藉由Tomo每日MVCT可尽早修改治疗计画3DCRTProtonDose distributions and dosevolume histograms Makishima H, et al. J Radiat Res, 2015250-MeV 40Gy/20fx + 20Gy/0fxIMRT, Proton and 3D Conformal Radiotherapy (3D-CRT) for Reducing Perioperative Cardiopulmonary Complications in Esophageal Cancer

21、Patients-3DCRTIMRTProton Ling TC, et al. Cancers 2014Loma LindaLing TC, et al. Cancers 2014亚东同步放化疗于中晚期食管癌之研究2007 - 2012, 67 pts, cT2-4N0-3M0IMRT (N=33) vs. Tomo (N=34)more 5-FU alone, oral Ufur in IMRTmore Taxol, cetuximab in TomoOSDFSLCDMFS1y : 61.4% v.s. 76.5%2y : 39.8% v.s. 68.8%Tomo並未增加放射性肺炎发生率I

22、MRT v.s. Tomo (without Fan-Shaped Complete Block) 21.2% (Gr 1:5, Gr 3:2) vs. 2.9% (Gr 1:1), p=0.027Mean lung dose : 15.1 Gy vs. 15.4 Gy, P=0.520, 15, 10, 5 ?TomoIMRT扇形全档块（Fan-Shaped Complete Block）于食管癌螺旋断层放疗治疗计划之运用：假体研究35BioMed Research International. 2015 食管癌Tomo有無使用扇形全档块(FSCB)劑量分佈之比較FSCBFSCBNo FSC

23、B下段食管癌Tomo使用扇形全档块(FSCB)治疗计划之比較Material & MethodsRetrospective review of RT treatment plannings (RTPs)- year : 20072015inclusion: 19 RTPs of lower-third thoracic EC patients treated by Tomoexclusion: skip lesions (tumor/lymph node)Dose: normalize to 50 Gy / 25 fractionsnon-block, FSCB, fan angle, homogeneous index, dosimetric quality for organs at risk (lung, heart, spinal cord)PatientEnrollmentRadiotherapyplanning