食管癌治疗新进展课件

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,食管癌治疗现状和进展,食管癌治疗现状和进展,中国高发,男性高发,食管癌是地域性疾病,5,年生存率,美国,16%,欧洲,10%,Parkin et al.CA Cancer J Clin,，,2005,Jemal et al.CA Cancer J Clin,，,2011,陈万青。中华肿瘤学杂志,2009,代敏，等。中华流行病学杂志,2012,全球,年新发病例,2002,年,:46.2,万，第,8,位,2008,年,:48.2,万,全球,年死亡病例,2002,年：,38.6,万，第,6,位,2008,年：,40.68,万,中国,年新发病例,2004,年：,23.7,万，第,4,位,2008,年：,25.9,万，第,5,位,中国,年新死亡例,2004,年：,19.0,万，第,4,位,2008,年：,17.6,万，第,4,位,中国高发5年生存率Parkin et al.CA Can,王占伟。博士论文,王占伟。博士论文,男性发病率排位：,4,位（,1983,）,9,位（,2004,）,近,20,年食管癌流行病趋势：,中国和其他高发地区 食管癌发病率都下降,鳞癌和腺癌比例不变（,95%,：,5%,）,美国等非高发地区,鳞癌发病率下降，腺癌发病率升高（,50%vs 50%,）,男性发病率排位：4位（1983）9位（2004,食管癌治疗新进展课件,放化疗,+,手术,放化疗,手术,放化疗+手术,食管癌治疗新进展课件,食管鳞癌放疗临床的研究,放疗适应症：放化疗,vs,放化疗,+,手术,放疗技术改进：,3DCRT/IMRT,化疗方案优化,(,同期放疗时,):PTX-based vs PF,食管鳞癌放疗临床的研究放疗适应症：放化疗 vs 放化疗+手术,食管癌的同期放化疗,同期放化疗优于单纯放疗，并有好长期疗效,同期放化疗,=,放化疗,+,手术,食管癌的同期放化疗同期放化疗优于单纯放疗，并有好长期疗效,RT+CT(,随机，,61,例,),RT+CT,非随机，,69,例,RT,，,62,例,Cooper JS,JAMA,1999,RT 50Gy+4,程,PF,RT 60Gy,RT+CT(随机，61例)RT+CT非随机，69例RT，62,末次随访,2010.12,存活,17,例,中位随访,138,月（,126-152,月）,December 2010,and the median follow-up time was 24 months(1 month to 128 months)for all patients,and 138 months(126 months to 152 months)for those alive.At last follow-up visit there were 9 patients alive in LCAF,and 8 patients alive in LCAF+CT.Ninety-four patients died.Median survival times were 25 months for LCAF and 32 month for LCAF+CT(p=0.653).,5,年,8,年,10,年,OS,111,例,:34%27%22%,LCAF,：,28%21%19%,LCAF_CT:40%29%23%,（,p=0.653,）,Zhao KL,redjournal,2005,Liu M(Zhao KL),Radiat Oncol.,2012,末次随访2010.12 December 2010,食管癌治疗新进展课件,17,例存活者生活质量评估,生活质量,长期存活者的数目,(%),饮食,普食,13(76%),软食,3(18%),半流质,1(6%),咳嗽,无,13(76%),1,级,4,（,24%,）,2,级,0,3,级,0,咯血,无,16(94%),有,2(6%),KPS,90,15(88%),70-80,2,（,12%,）,17例存活者生活质量评估生活质量长期存活者的数目(%)饮食普,FFCD 9102,入组标准：,T3N0-1M0,，胸段食管癌,鳞癌,89%,Bedenne L,，,et al.JCO,2007,FFCD 9102入组标准：T3N0-1M0，胸段食管癌,食管癌治疗新进展课件,随机分组病例,实际治疗病例,随机分组病例实际治疗病例,结论：,放化疗有效者，手术提高局部控制率，没有提高生存率。,结论：放化疗有效者，手术提高局部控制率，没有提高生存率。,放化疗无效者，再手术提高了疗效,*,p 0.05,Stahl,JCO 2005,放化疗无效者，再手术提高了疗效*p 0.05Stahl,CRT,后,CR,者疗效好，但再加,S,无提高疗效,88CRT+S,75CRT,CRT,前后,(S,前,)PET,SUV3,：,CR,JCO 2010,28,4714,CRT后CR者疗效好，但再加S无提高疗效88CRT+SJCO,放化疗,=,放化疗,+,手术,放化疗,CR,者，挽救性手术没有提高疗效,放化疗残留者，挽救性手术提高疗效,放化疗=放化疗+手术,3DCRT/IMRT,照射野：精确诊断，精确治疗,副反应、局部控制率和疗效,3DCRT/IMRT照射野：精确诊断，精确治疗,照射野的勾画,RTOG 85-01,锁骨上区到食管胃结合部照射,50 Gy,（下,1/3,段食管癌不照射锁骨上区），缩野时包括肿瘤上下外放,5cm,。,复旦大学肿瘤医院,GTV:,可见肿瘤,CTV:GTV+,上下,3cm,正常食管,PTV:CTV1,周围放1,cm,DT=60-70Gy,NCCN 2009V2,GTV:,可见肿瘤,PTV:GTV,上下,5cm,四周,1.5-2CM,(,隆突以上包括双锁骨上,下段包括腹部淋巴结,),靶区勾画变迁,照射野的勾画 RTOG 85-01复旦大学肿瘤医院NCC,研究 治疗 病例数,放疗 化疗,2y 3y 5y,RTOG8501,放疗,62 64Gy 10%0%0%,放化疗,61 50Gy DDP+5Fu 36%30%25%,放化疗,69 50Gy,DDP+5Fu 35%27%,RTOG9405,放化疗,109 50.4 DDP+5-Fu 40%33%,放化疗,109 64.8 DDP+5-Fu 31%25%,RTOG,食管不同野照射的疗效比较,N Engl J Med 1992;326:1593,J Clin Oncol.1997;15:277,J Clin Oncol 2002,20(5):1167,上下,5cm,四周,2cm,全纵隔 全食管 双锁上,研究 治疗 病例数 放疗,累积野适形放疗的研究（我院经验）,Esophageal SCC confirmed by cytology or histology,T1-4N0-1M0 lesions(UICC),KPS 70,No prior therapy,No evidence of esophageal perforation or deep ulceration to mediastinum,No massive esophageal bleeding,Normal hepatic,renal and bone marrow functions;,No previous malignance history.,Zhao KL,Int J Radiat Oncol Biol Phys,.2010;76:446.,入组条件,(53,例,),累积野适形放疗的研究（我院经验）Esophageal SCC,靶区勾画方法,GTV:,可见肿瘤,CTV1:GTV+,上下,3cm,正常食管,PTV1:CTV1,前后左右上下放1,cm,CTV2:GTV+,上下,1cm,正常食管,PTV2:CTV2,前后左右上下放,1cm,PTV1=41.4Gy.PTV2=68.4Gy,靶区勾画方法GTV:可见肿瘤,The median follow-up was 40.6 months(range,20.2-48.6 months)in the 21 survivors.,The median follow-up for the 32 dead patients was 17.7 months(range,3.5-43.6 months),The median follow-up was 4,Acute toxicity,Late toxicity,Grade 1,Grade 2,Grade 3,Grade 4-5,Grade 1,Grade 2,Grade 3,Grade 4-5,Esophagus,21,10,2,2,2,1,Lung/trachea,12,3,3,6,2,Heart,Skin,Neurologic,Maximum severity reported per patient,33(62.3%),13(23.6%),5(9.1%),0,8(14.5%),6(10.9%),3(5.5%),0,Toxicity,Acute toxicityLate toxicityGra,Fig1.,1-,2-and 3-year,；,77%,56%,and 41%,Fig1.1-,2-and 3-year；77%,5,作者,年份,病例数,局控率（,%,）,生存率（,%,）,1,年,3,年,5,年,1,年,3,年,5,年,施学辉,1999,2D,43,67,58,56,72,42,34,赵快乐,2004,2D,201,77,58,56,73,34,26,汪洋,2002,2D,52,81,57,80,41,赵快乐,2005,2D,57,72,63,59,77,39,28,赵快乐,2010,3D,53,83,62,78,41,食管癌后加速放疗：,2D vs 3DCRT,的比较,Shi XH et al Radioth Oncol 1999,51:21,Zhao KL et al、I J ROBP.2004,60:123,Wang Y et al.IJROBP.2002.54:131,Zhao KL et al、,W J Gastro 2003;9:1374,Zhao KL et al.IJROBP.2005,62:1014,作者年份病例数局控率（%）生存率（%）1年3年5年1年3年5,治疗失败模式,26%(14,例,),无瘤生存,74%(39,例,),治疗失败,44%,（,17,）野内复发,41%,（,16,）远处转移,8%,（,3,）野外区域,LN,复发,2.5%,（,1,）死亡原因不明,5%,（,2,）远处,m+,局部,R,治疗失败模式26%(14例)无瘤生存74%(39例)治疗失败,放疗前,放疗前,CT,同复发,PET,融合,复发,PET,Zhao KL,Int J Radiat Oncol Biol Phys,.2010;76(2):446-51.,放疗前放疗前CT同复发PET融合复发PETZhao KL,英国,wales,大学：局部照射就足够,145,例,50Gy+3-4,周期化疗,GTV,：,（,CT,和,EUS,）,CTV:,GTV,上下,2cm,GTV,前后左右,1cm,PTV:,CTV,上下,1cm,CTV,前后左右,0.5cm,不淋巴结预防,Button MR et al.red journal.2009,73:818,中位生存：,15,月,照射野内失败：,55,例 远处转移（或合并局部复发）：,27,例