前列腺癌靶区勾画

1、前列腺癌靶区勾画中国医科院肿瘤医院第一页，共五十三页。前列腺癌发病率和死亡率国别发病率死亡率美国23万（95.1/10万）3万中国7/10万(城市8.51/10万)2.72/10万第二页，共五十三页。GroupMSKCC (T1-T2 1819)Cleveland Clinic Foundation(localized prostate cancer 1682) Cases7-year bRFS Cases8-year bRFS Brachy73374%EBRT34077%628 70%,RP 74679%1054 72%P =0.1P0.05Radiother Oncol. 2004 Apr

2、;71(1):29-33. J Clin Oncol. 2002 Aug 15;20(16):3376-85. 第三页，共五十三页。对于局限期前列腺癌，根治性前列腺切除与放射治疗疗效相当第四页，共五十三页。解 剖第五页，共五十三页。AnatomyYellow: Peripheral gland Blue: Transitional zoneRed: Central glandGreen: Anterior fibromuscular zone第六页，共五十三页。前列腺癌的靶区包括范围前列腺精囊腺盆腔淋巴引流区第七页，共五十三页。前列腺及包膜受侵情况第八页，共五十三页。CTV in Prosta

3、te CancerCTV=prostate (+SV) +LN 第九页，共五十三页。Extracapsular Extension associated with PSA , GS, and T stagesP = : 3/2(PSA) + (Gleason score 3) x10Partins TablesRoach III. J Urol 150: 1923-24, 1993第十页，共五十三页。Wang L, Radiology 2004Extracapsular Extension MSKCC： RP术后，185/712 (26%) 中位包膜外扩展距离2 mm0.5-12 mm平均包膜

4、外扩展距离2.93 mmSD 2.3 mm第十一页，共五十三页。勾画前列腺CTV时，幷不必刻意外扩很大边界第十二页，共五十三页。精囊腺受侵情况第十三页，共五十三页。SV involvementKestin et al IJROBP 2002William Beaumont ： RP术后，51/344，81 SV+ 中位SV长度 3.5 cm0.7 8.5 cm中位SV侵犯长度1.0 cm ( 7% 1.0 Cm1% 2.0 Cm）0.23.8 cm第十四页，共五十三页。SV+ associated with PSA , GS, and T stagesLow RiskIntermediate

5、RiskHigh Risk1 high-risk2 high-risk3 high-risk1%15%15%32%58%27%Kestin et al IJROBP 2002第十五页，共五十三页。SV involvementKestin et al IJROBP 2002第十六页，共五十三页。When treating the SV for prostate cancer, only the proximal 2.0 2.5 cm be included within the CTVKestin et al IJROBP 2002第十七页，共五十三页。 SV invasionP= (PSA)

6、+ (Gleason score 6) x10Partins TablesRoach III. J Urol 150: 1923-24, 1993第十八页，共五十三页。前列腺癌淋巴引流第十九页，共五十三页。18 patients with pathologically proven lymph node metastases 69Nodal Locationlymph node metastases (N)ParaAortic14Common iliac13Ext Iliac29Int Iliac11Perirectal2Total69Shih et al IJROBP Nov 2005Mas

7、sachusetts General Hospital第二十页，共五十三页。第二十一页，共五十三页。Prostate Cancer Nodal SpreadStep wise from pelvis to abdomenNodal metastases more likely with:Increasing T stageIncreasing PSAIncreasing GS第二十二页，共五十三页。LNM%= 2/3(PSA) + (Gs 6)x10Partins TablesRoach III. J Urol 150: 1923-24, 1993第二十三页，共五十三页。External il

8、iac lymph nodes Internal iliac lymph nodes Obturator groupPerirectal LNPart of the common iliac nodesS1-3 pre-sacral lymph nodes Para Aortic (optional)Prostate Cancer pelvic nodal irradiation第二十四页，共五十三页。MSKCC 前列腺癌放疗指南结合2022.2 NCCN指南第二十五页，共五十三页。Clinical Target VolumeRisk Group Low-RiskIntermediate-Ri

9、skHigh-RiskT1T2aPSA 10 ng/mL GS 20 ng/mL GS 810CTVProstate OnlyProstate +2-2.5Cm SVProstate + 2-2.5Cm SV + Nodal regions (when risk of involvement 15%)第二十六页，共五十三页。Risk stratification and treatment recommendationLow riskIntermediate riskHigh riskT1T2aPSA 10 ng/mL GS 20 ng/mL GS 8103DCRT/IMRT= 70 Gy3D

10、CRT/IMRT = 76 Gy3DCRT/IMRT 76 Gy +neoadjuvant and adjuvant ADT第二十七页，共五十三页。SimulationCT Scan: from bottom of SI joints to 1.5 cm below the level of ischial tuberosities. Maximal slice thickness of 5 mmPatient set-up: be treated in the supine position. Immobilization: employ immobilization system that

11、 keeps random and systematic errors to acceptable limits第二十八页，共五十三页。Bladder：size should not vary between simulation and treatments. (e.g. bladder to be emptied 1 h prior to sim/treatment, patient to drink 500cc water soon thereafter) Rectum: Instruct patients to evacuate their bowels prior to planni

12、ng and treatment. 第二十九页，共五十三页。Contouring:Prostate apex: situated above the urogenital diaphragm. 5mm above the bulbospongiosus Contour base of SV only, if no clinical SV involvement. Rectal wall: from 1 cm above to 1 cm below the PTV. Consider contouring the whole length of the rectum.Contour extern

13、al bladder wall from its apex to the dome.femoral heads: from the inferior margin of PTV to the superior lip of acetabulum.第三十页，共五十三页。靶区勾画规定：CTV = GTVPTV = CTV + 1 cm margin，向前方向仅外放0.5 cm以减少直肠照射。 第三十一页，共五十三页。缩 野from PTV1 volume to PTV2 volume between 46 and 60 Gy.第三十二页，共五十三页。Dose constraints rectum5

14、0 Gy 50%70 Gy 20%the bladder55 Gy 50%70 Gy 30%femoral heads 35 Gy 100%45 Gy 60%60 Gy 30%RTOG: 5% 50GySmall Bowel: 0% 52Gy; V505%Large Bowel: 0% 55Gy; V5010%第三十三页，共五十三页。VerificationIsocentre check using AP and lateral films be acquired at least weekly during treatment. 第三十四页，共五十三页。前列腺和精囊腺的CTV第三十五页，共五

15、十三页。第三十六页，共五十三页。第三十七页，共五十三页。第三十八页，共五十三页。第三十九页，共五十三页。第四十页，共五十三页。包含盆腔淋巴结预防照射的前列腺癌靶区勾画第四十一页，共五十三页。RTOG GU REACH CONSENSUS ON PELVICLYMPH NODEthe pelvic lymph node volumes to be irradiated include: distal common iliac, presacral lymph nodes (S1-S3) external iliac lymph nodes internal iliac lymph nodesob

16、turator lymph nodesIJROBP, 2022第四十二页，共五十三页。RTOG GU REACH CONSENSUS ON PELVICLYMPH NODECTVs include the vessels (artery and vein) and a 7-mm radial margin carve out bowel, bladder, bone, and muscle. Volumes from the L5/S1 interspace to the superior aspect of the pubic bone.IJROBP, 2022第四十三页，共五十三页。L5/

17、S1水平包全髂总骶前淋巴结IJROBP, 20221.5 Cm0.7 Cm第四十四页，共五十三页。S1-S3水平包全髂内外和骶前淋巴结Carve out小肠、膀胱、肌肉和骨等IJROBP, 2022第四十五页，共五十三页。S3以下包全髂内外淋巴结骶前淋巴结终止于梨状肌出现层面IJROBP, 2022第四十六页，共五十三页。髂外淋巴结一直要勾画至股骨头顶端层即腹股沟韧带处髂外A与股A分界处IJROBP, 2022第四十七页，共五十三页。 闭孔淋巴结要勾画至耻骨联合上缘水平 IJROBP, 2022第四十八页，共五十三页。我们科勾画情况第四十九页，共五十三页。第五十页，共五十三页。Referenc

18、esRTOG GU RADIATION ONCOLOGY SPECIALISTS REACH CONSENSUS ON PELVIC LYMPH NODE VOLUMES FOR HIGH-RISK PROSTATE CANCER. Int. J. Radiation Oncology Biol. Phys., 2022EAU guidelines on prostate cancerMapping of nodal disease in locally advanced prostate cancer: Rething the clinical target volume for pelvic nodal irradiation based on vascular rather than bony ana