鼻腔鼻窦畸胎癌肉瘤的调强放射治疗

鼻腔鼻窦畸胎癌肉瘤的调强放射治疗第1页/共30页TreatmentofsinonasalteratocarcinosarcomausingIMRT第2页/共30页Introduction

CaseDiscussion第3页/共30页casediscussionintroductionSNTCS

sino

nasal

terato

carcino

sarcoma

<

80

casesreported第4页/共30页casediscussionintroductionHistoryVencentJ.HyamsDirectoroftheOtolaryngicPathologybranchoftheArmedForcesInstituteofPathology，1968-1984

Teratoidcarcinosarcoma?Mixedmesodermaltumour?Malignantteratomaandblastomas?1984第5页/共30页casediscussionintroductionCharacteristicsT1-weightedMRrevealsasofttissuefillingtheleftethmoidsinus,asuniformlyhighsignal(*),andeffusion(whitearrowhead)intheleftsphenoidsinus.Takasaki,K.,2006Epithelialglandularcarcinoma(atright)andosteosarcomacomponent(atleft).(hematoxylin-eosin,originalmagnification

x40).

Smith,S.L.,2008Endoscopicexaminationshowingaleftsinonasaltumorintheleftmiddleturbinate.M,middleturbinate;S,nasalseptum.Su,Y.Y.,2010CBA第6页/共30页TreatmentcasediscussionintroductionPatientsgenerallypresentwithlocallyadvanced-stagediseasethehighlymalignant,aggressivebiologicalbehaviorthepresenceofairfilledparanasalspacespermitssilentgrowth

DistantmetastasisofSNTCSisunusualandthemostcommoncauseoftreatmentfailureislocalrecurrenceSurgicalexcision

andpostoperativeradiotherapyhasbecomethemost

widelyacceptedtherapeuticplan第7页/共30页Introduction

CaseDiscussion第8页/共30页HPIintroductiondiscussioncase42-year-oldmanTwoweekshistoryofprogressiveleftnasalobstructionandintermittentnasalbleedingNasalexaminationshowedamoderatelyfirm,reddish-purplemassintheleftmeatusBiopsyofthetumorrevealedaheterogeneousadmixtureofepithelialandmesenchymalelements,suggestingSNTCSTeratocarcinosarcomaTeratocarcinosarcomaconsistsoftwocomponents,epithelialandmesenchymal(hematoxylin-eosin,originalmagnification×200)第9页/共30页cT3N0M0MRIintroductiondiscussioncaseMRIrevealedasofttissuefillingtheleft

meatus,

maxillary

andethmoidsinus,andeffusionintheleftmaxillarysinus第10页/共30页introductiondiscussioncaseAnteriorcraniofacialresectionIMRTGTVincludedtheresidualgrossdiseaseinthenasalcavityandparanasalsinusCTV-60includestheGTVwitha5~10mmmargin,thewholenasalcavityandtheinvolvedparanasalsinusCTV-54

high-risklocalstructures(includingthewholenasopharynx,lowerhalfofsphenoidsinus,etal)lymphaticregions(includingipsilaterallymphnodelevelsIB,II,IIIandVA)A3-mmmarginwasaddedtoproducePTVsPTV-66wasprescribedto66Gywith2.2Gy/fractionPTV-60wasprescribedto60Gywith2.0Gy/fractionPTV-54wasprescribedto54Gywith1.8Gy/fractionTreatment第11页/共30页Follow-upintroductiondiscussioncaseNow3.5yearshavepassedsincetheirradiationtherapyNoseveredry-eyesyndrome,andothersevereradiation-inducedoculartoxicitieshappenedNoevidenceofrecurrenceormetastasis第12页/共30页Introduction

CaseDiscussion第13页/共30页Shoulders?introductioncasediscussion第14页/共30页SinonasaltumorsFrontalSinusMaxillarySinusEthmoidSinusSpenoidSinus1234Challenge!introductioncasediscussion第15页/共30页IMRTintroductioncasediscussion3-beamconventional2D6-beamconventional3Dconformal7-beamIMRTAdosimetrycomparisonbetween(a)a3-beamconventional2Dtreatment,(b)a6-beamconventional3DconformalRTtreatment,and(c)a7-beamIMRTtreatment.ThePTVisrepresentedbythesolidredline.The100%and70%oftheprescriptiondoseareshownbythegreenandredcolour-washedareas.AbetterdoseconformitytothePTVcanbeachievedintheIMRTtreatment.第16页/共30页GhentExperienceintroductioncasediscussion2009Madani,I.,2009第17页/共30页Dose–volumeConstraintsintroductioncasediscussionMadani,I.,2009第18页/共30页VisualPathway

DoseintroductioncasediscussionMadani,I.,2009第19页/共30页AcuteToxicityintroductioncasediscussionMadani,I.,2009第20页/共30页StudiesReportedintroductioncasediscussionMadani,I.,2009第21页/共30页CTVDelineationintroductioncasediscussion第22页/共30页ImplementationStrategy2001introductioncasediscussionClaus,F.,2001第23页/共30页introductioncasediscussion“Compartment-relatedCTVDefinition”InthoseregionswhereGTVwasflankedbyintactbone,nomarginwasaddedInthoseregionswhereGTVinvadedcompartmentsenclosedbybone,likeotherparanasalsinuses,orextendeduptotheirostia,thewholecompartmentwasincludedintheCTVcontoursInthoseregionswhereGTVinvadedradiologicallydefinedspacesknowntoresistpoorlyinvasionbymalignanttumors(e.g.,masticatororparapharyngealspaces),theentirespacewasaddedClaus,F.,2001第24页/共30页CervicalLymphNodesDuthoy,W.,2005introductioncasediscussion2005第25页/共30页LNRecurrenceDuthoy,W.,2005Ethmoidsinus/Ad:7%

(14/194)Maxillary

sinus/SCC:12%(33/274)introductioncasediscussioncase第26页/共30页2006introductioncasediscussionCTVDelineationcont’第27页/共30页CTVDelineationcont’“Indeed,inabsenceofunambiguousinformationon