髓母细胞瘤的放射治疗课件

髓母细胞瘤的放射治疗髓母细胞瘤的放射治疗1临临床表床表现现颅内压增高头痛、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临床表现颅内压增高头痛、呕吐、视神经乳头水肿2分分级级Stage Risk staging system Stage Changs M staging systemLow-risk Localized disease at the time of diagnosis M0 No evidence of gross subarachnoid orGroup Age 3 years hematogenous metastasis Total tumor resection or subtotal with residual tumor 1.5 cm3 High-risk Disseminated disease at the time of diagnosis M1 Microscopic tumor cells found inGroup cerebrospinal fluid Age 3 years M2 Gross nodule seeding seen in the cerebellar or cerebral subarachnoid space or in the third or lateral ventricles Subtotal tumor resection with a residual tumor M3 Gross nodule seeding in the spinal 1.5 cm3 subarachnoid space metastasis M4 Extraneural分级Stage Risk staging syste3治疗方案标准治疗方案(“Philadelphia protocol”)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/m2 DDP75mg/m2 VCR1.5mg/m2/w3w，每6周一个周期，共8个周期。治疗方案标准治疗方案(“Philadelphia proto4放疗剂量低危组CSI 23.4Gy/13f+后颅窝加量至 54Gy高危组CSI 36Gy/20f+后颅窝加量至54Gy放疗剂量低危组CSI 23.4Gy/13f+后颅窝加量至 5放疗技术常规分割CSI+Boost to posterior fossa 超分割CSI+Boost to posterior fossa SRT Boost to posterior fossa放疗技术常规分割CSI+Boost to posterio6Craniospinal irradiation(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6MVX线照射剂量(DT)23.4Gy36Gy,1.8Gy/fCraniospinal irradiation(CSI)7髓母细胞瘤的放射治疗课件8cerebellar or cerebral subarachnoidProtracted Radiotherapy Treatment Duration in Medulloblastoma Am J Clin Oncol(CCT)26(1):5559,2003.M分期高/低龄儿预后差；210221,2006Radiation Oncology Biol.standard radiotherapy放疗剂量和射野同常规分割放疗剂量和射野同常规分割Parotid gland 14.Radiation Oncology Biol.Low-risk Localized disease at the time of diagnosis M0 No evidence of gross subarachnoid orradiotherapy aloneN Engl J Med 2005;352:978-86.cerebellar or cerebral subarachnoidRadiation Oncology Biol.POSTOPERATIVE NEOADJUVANT CHEMOTHERAPY BEFORE RADIOTHERAPY AS COMPARED TO IMMEDIATE RADIOTHERAPY FOLLOWED BY MAINTENANCE CHEMOTHERAPY IN THE TREATMENT OF MEDULLOBLASTOMA IN CHILDHOOD:RESULTS OF THE GERMAN PROSPECTIVE RANDOMIZED TRIAL HIT 91 Int.Age 3 years M2 Gross nodule seeding seen in the4Gy/13f+后颅窝加量至 54GyCraniospinal irradiation(CSI):doseradiotherapy alone（5-year EFS）Chemotherapy+（5-year EFS）standard radiotherapy reduced-dose radiotherapy60%7.8%41%8%75%7%69%8%Prospective randomised trial of chemotherapy given before radiotherapy in childhood medulloblastoma:International Society of Paediatric Oncology(SIOP)and the(German)Society of Paediatric Oncology(GPO)SIOP II.Med Pediatr Oncol 25:166-178,1995 cerebellar or cerebral subarac923.4GyCSI的疗效23.4GyCSI的疗效1023.4GyCSI对智力的影响(POG8631)Journal of Clinical Oncology,Vol 16,No 5,pp.172328,199823.4GyCSI对智力的影响(POG8631)Journa11CSI:cranialspinal junction site THE CRANIAL-SPINAL JUNCTION IN MEDULLOBLASTOMA:DOES IT MATTER?Int.J.Radiation Oncology Biol.Phys.,Vol.44,No.1,pp.8184,1999Organ low junction(SD)high junction(SD)Cord 40.3Gy(0.5)38.4Gy(1.3)Thyroid gland 20.3Gy(9.2)26.3Gy(0.6)Mandible 6.2Gy(0.6)10.9Gy(5.1)Larynx 8.3Gy(3.9)27.2Gy(0.4)Pharynx 11.9Gy(5.1)20.3Gy(4.8)Parotid gland 14.9Gy(4.2)14.1Gy(4.2)CSI:cranialspinal junction sit12超分割放疗Twicedaily lGy fractions were administered separated by 46 h.放疗剂量和射野同常规分割超分割放疗Twicedaily lGy fractions 13SRT Boost to posterior fossaPOSTERIOR FOSSA BOOST IN MEDULLOBLASTOMA:AN ANALYSIS OF DOSE TO SURROUNDING STRUCTURES USING 3-DIMENSIONAL(CONFORMAL)RADIOTHERAPY Int.J.Radiation Oncology Biol.Phys.,Vol.46,No.2,pp.281286,2000 SRT Boost to posterior fossaP14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。放疗反应急性反应骨髓抑制、脑水肿等；154Gy(CSI)+后颅窝加量 5.cerebellar or cerebral subarachnoidTHE CRANIAL-SPINAL JUNCTION IN MEDULLOBLASTOMA:DOES IT MATTER?Pharynx 11.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、蛛网膜下腔出血放疗后6周开始CCNU75mg/m2SRT Boost to posterior fossa标准治疗方案(“Philadelphia protocol”)5)38.High-risk Disseminated disease at the time of diagnosis M1 Microscopic tumor cells found inM分期高/低龄儿预后差；Thyroid Dysfunction as a Late Effect in Survivors of Pediatric Medulloblastoma/Primitive Neuroectodermal Tumors A Comparison of Hyperfractionated versus Conventional Radiotherapy Cancer 1997;80:798804.Radiation Oncology Biol.THE CRANIAL-SPINAL JUNCTION IN MEDULLOBLASTOMA:DOES IT MATTER?POSTERIOR FOSSA BOOST IN MEDULLOBLASTOMA:AN ANALYSIS OF DOSE TO SURROUNDING STRUCTURES USING 3-DIMENSIONAL(CONFORMAL)RADIOTHERAPY Int.小脑损害躯干性共济失调为主Timing of Radiation in Children With Medulloblastoma/PNET Pediatr Blood Cancer 2007;48:416422VCR1.Pharynx 11.HYPOTHYROIDISM IN CHILDREN WITH MEDULLOBLASTOMA:A COMPARISON OF 3600 AND 2340 cGY CRANIOSPINAL RADIOTHERAPY Int.甲低 Hypothyroid p值值年龄1 5岁 7/7(100%)10岁 2/10(20%)照射剂量123.4Gy+CT 10/12(83%)0.025 36Gy+CT 6/10(60%)36Gy 2/10(20%)照射方法2常规分割 21/34(62%)=0.02超分割 2/14(14%)1.HYPOTHYROIDISM IN CHILDREN WITH MEDULLOBLASTOMA:A COMPARISON OF 3600 AND 2340 cGY CRANIOSPINAL RADIOTHERAPY Int.J.Radiation Oncology Biol.Phys.,Vol.53,No.3,pp.543547,20022.Thyroid Dysfunction as a Late Effect in Survivors of Pediatric Medulloblastoma/Primitive Neuroectodermal Tumors A Comparison of Hyperfractionated versus Conventional Radiotherapy Cancer 1997;80:798804.4Gy(CSI)+后颅窝加量 5.16认知障碍 IQ(point decline per year)23.4Gy(CSI)+后颅窝加量 5.2 36Gy(CSI)+后颅窝加量 3.923.4Gy(CSI)+瘤床加量 2.4MODELING RADIATION DOSIMETRY TO PREDICT COGNITIVE OUTCOMES IN PEDIATRIC PATIENTS WITH CNS EMBRYONAL TUMORS INCLUDING MEDULLOBLASTOMA Int.J.Radiation Oncology Biol.Phys.,Vol.65,No.1,pp.210221,2006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）。认知障碍 17联合化疗常用方案VCP(VCR+CCNU+DDP);“8 in 1”(VCR+甲强龙+CCNU+羟基脲+甲基苄肼+DDP+CTX+Arac);其他方案MTX鞘内注射CTX、VCR、VP16、CCNU、CBP等组合联合化疗常用方案18髓母细胞瘤的放射治疗课件19手术+放/化疗POSTOPERATIVE NEOADJUVANT CHEMOTHERAPY BEFORE RADIOTHERAPY AS COMPARED TO IMMEDIATE RADIOTHERAPY FOLLOWED BY MAINTENANCE CHEMOTHERAPY IN THE TREATMENT OF MEDULLOBLASTOMA IN CHILDHOOD:RESULTS OF THE GERMAN PROSPECTIVE RANDOMIZED TRIAL HIT 91 Int.J.Radiation Oncology Biol.Phys.,Vol.46,No.2,pp.269279,2000手术+放/化疗POSTOPERATIVE NEOADJUVA20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。POSTOPERATIVE NEOADJUVANT CHEMOTHERAPY BEFORE RADIOTHERAPY AS COMPARED TO IMMEDIATE RADIOTHERAPY FOLLOWED BY MAINTENANCE CHEMOTHERAPY IN THE TREATMENT OF MEDULLOBLASTOMA IN CHILDHOOD:RESULTS OF THE GERMAN PROSPECTIVE RANDOMIZED TRIAL HIT 91Int.J.Radiation Oncology Biol.Phys.,Vol.46,No.2,pp.269279,2000维持化疗对6岁以上低危组更有效；POSTOPERATIVE 21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+化疗方案适用于低龄儿童、无手术残留、无转移病灶患者22手术+化疗结果Treatment of Early Childhood Medulloblastoma by Postoperative Chemotherapy AloneN Engl J Med 2005;352:978-86.手术+化疗结果Treatment of Early Chil23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）放疗持续时间影响预后的因素年龄24On multivariate analysis,age 3 years,M0 status,50 Gy PFB dose,radiotherapy treatment duration 50 days,and use of chemotherapy correlated with better freedom from progression and posterior fossa control rates.Protracted Radiotherapy Treatment Duration in Medulloblastoma Am J Clin Oncol(CCT)26(1):5559,2003.影响因素的多变量分析On multivariate analysis,age 25On multivariate analysis,age 3 years,M0 status,50 Gy PFB dose,radiotherapy treatment duration 50 days,and use of chemotherapy correlated with better freedom from progression and posterior fossa control rates.Protracted Radiotherapy Treatment Duration in Medulloblastoma Am J Clin Oncol(CCT)26(1):5559,2003.影响因素的多变量分析On multivariate analysis,age 26年龄Timing of Radiation in Children With Medulloblastoma/PNET Pediatr Blood Cancer 2007;48:416422年龄Timing of Radiation in Child27CSF cytologyTiming of Radiation in Children With Medulloblastoma/PNET Pediatr Blood Cancer 2007;48:416422CSF cytologyTiming of Radiatio285 cm3 subarachnoid space metastasis“8 in 1”(VCR+甲强龙+CCNU+羟基脲+甲基苄肼+DDP+CTX+Arac);M分期高/低龄儿预后差；标准治疗方案(“Philadelphia protocol”)Hypothyroid p值POSTERIOR FOSSA BOOST IN MEDULLOBLASTOMA:AN ANALYSIS OF DOSE TO SURROUNDING STRUCTURES USING 3-DIMENSIONAL(CONFORMAL)RADIOTHERAPY Int.Stage Risk staging system Stage Changs M staging systemM分期高/低龄儿预后差；Prospective randomised trial of chemotherapy given before radiotherapy in childhood medulloblastoma:International Society of Paediatric Oncology(SIOP)and the(German)Society of Paediatric Oncology(GPO)SIOP II.维持化疗对6岁以上低危组更有效；M4 ExtraneuralRadiation Oncology Biol.Journal of Clinical Oncology,Vol 16,No 5,pp.放疗剂量和射野同常规分割4Gy(CSI)+后颅窝加量 5.8184,19995 cm3 subarachnoid space metastasisProtracted Radiotherapy Treatment Duration in Medulloblastoma Am J Clin Oncol(CCT)26(1):5559,2003.常规分割CSI+Boost to posterior fossa1.新辅助化疗增加放疗的骨髓抑制从而延长治疗时间；手术切除范围Timing of Radiation in Children With Medulloblastoma/PNET Pediatr Blood Cancer 2007;48:4164225 cm3 29后颅窝BEDTiming of Radiation in Children With Medulloblastoma/PNET Pediatr Blood Cancer 2007;48:416422后颅窝BEDTiming of Radiation in C30病理及免疫组化类型病理及免疫组化类型31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ventriclesHYPOTHYROIDISM IN CHILDREN WITH MEDULLOBLASTOMA:A COMPARISON OF 3600 AND 2340 cGY CRANIOSPINAL RADIOTHERAPY Int.Radiation Oncology Biol.Radiation Oncology Biol.放疗剂量和射野同常规分割常规分割CSI+Boost to posterior fossa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6)10.cerebellar or cerebral subarachnoidRadiation Oncology Biol.Craniospinal irradiation(CSI):methods5mg/m2/w3w，放疗术后28天内开始。每照射10Gy移动一次射野以减少各野间交叉高剂量space or in the third or lateralIQ(point decline per year)THE CRANIAL-SPINAL JUNCTION IN MEDULLOBLASTOMA:DOES IT MATTER?谢谢观看！其它复视、面瘫、强迫头位、头颅增大、病理反射阳性、呛咳、小脑32