髓母细胞瘤的放射治疗课件

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。

①生长极其迅速；②手术难以完整切除；③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+BoosttoposteriorfossaSRTBoosttoposteriorfossaCraniospinalirradiation(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/fCraniospinalirradiation(CSI):doseradiotherapyalone

（5-yearEFS）

Chemotherapy+（5-yearEFS）

standardradiotherapy

reduced-doseradiotherapy60%±7.8%

41%±8%75%±7%

69%±8%Prospectiverandomisedtrialofchemotherapygivenbeforeradiotherapyinchildhoodmedulloblastoma:InternationalSocietyofPaediatricOncology(SIOP)andthe(German)SocietyofPaediatricOncology(GPO)—SIOPII.

MedPediatrOncol25:166-178,1995

23.4GyCSI对智力的影响(POG-8631)JournalofClinicalOncology,Vol16,No5,pp.1723–28,1998超分割放疗Twice-dailyl-Gyfractionswereadministeredseparatedby4-6h.放疗剂量和射野同常规分割SRTBoosttoposteriorfossaPOSTERIORFOSSABOOSTINMEDULLOBLASTOMA: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

Hypothyroidp值年龄1

<5岁7/7(100%)<0.001

5~10岁9/15(60%)>10岁2/10(20%)照射剂量123.4Gy+CT10/12(83%)<0.025

36Gy+CT6/10(60%)36Gy2/10(20%)照射方法2常规分割21/34(62%)=0.02超分割2/14(14%)1.HYPOTHYROIDISMINCHILDRENWITHMEDULLOBLASTOMA:ACOMPARISONOF3600AND2340cGYCRANIOSPINALRADIOTHERAPYInt.J.RadiationOncologyBiol.Phys.,Vol.53,No.3,pp.543–547,20022.ThyroidDysfunctionasaLateEffectinSurvivorsofPediatricMedulloblastoma/PrimitiveNeuroectodermalTumorsAComparisonofHyperfractionatedversusConventionalRadiotherapy

Cancer1997;80:798–804.认知障碍

IQ(pointdeclineperyear)23.4Gy(CSI)+后颅窝加量5.236Gy(CSI)+后颅窝加量3.923.4Gy(CSI)+瘤床加量2.4MODELINGRADIATIONDOSIMETRYTOPREDICTCOGNITIVEOUTCOMESINPEDIATRICPATIENTSWITHCNSEMBRYONALTUMORSINCLUDINGMEDULLOBLASTOMAInt.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）。Risk-adaptedcraniospinalradiotherapyfollowedbyhigh-dosechemotherapyandstem-cellrescueinchildrenwithnewlydiagnosedmedulloblastoma(StJudeMedulloblastoma-96):long-termresultsfromaprospective,multicentretrial

Vol7October2006手术+放/化疗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.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手术切除范围TimingofRadiationinChildrenWithMedulloblastoma/PNETPediatrBloodCancer2007;48:416–422后颅窝BEDTimingofRadiationinChildrenWithMedulloblastoma/PNETPediatrBloodCancer2007;48:416–422Risk-adaptedcraniospinalradiotherapyfollowedbyhigh-dosechemotherapyandstem-cellrescueinchildrenwithnewlydiagnosedmedulloblastoma(StJudeMedulloblastoma-96):long-termresultsfromaprospective,multicentretrial