肿瘤综合治疗进展2学习课件

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1、 精确的靶区勾画精确的靶区勾画 Target Delineation 照射靶区与边界的研究照射靶区与边界的研究 Individual & AdaptiveIndividual & Adaptivep我们所需要的是病人的我们所需要的是病人的 个体化的靶区或边界个体化的靶区或边界- patient-specific margins p而不是群体化的病人的 靶区或边界-population specific marginsp靶区或边界应当要包括物理靶区或边界生物靶区或边界影像影像/手术手术/病理体积与病理体积与GTV勾画勾画 Yu et al; Int. J Rad Oncol Bio Phys 2

2、009Yu et al; Int. J Rad Oncol Bio Phys 2009外科标本最大径外科标本最大径病理标本最大径病理标本最大径 实际标本最大径实际标本最大径 CT纵隔窗大小纵隔窗大小 CT肺窗大小肺窗大小 PET-CT大小大小由病理科医生所勾画的肿瘤镜下边界，画线的右边是肿瘤外界肿瘤组织正常肺泡结构正常肺泡结构放大倍数放大倍数4040病理医生勾画好肿瘤边界后的病理医生勾画好肿瘤边界后的HEHE切片切片CT, FDG PET & PET/CT与病理最大径的与病理最大径的比较比较 Measurement of Biggest Tumor Measurement of Biggest

3、 Tumor DimensionDimension CT size(cm) PET size(cm) PET/CT size(cm) Pathology size(cm)X axis(n=4.3) 5.511.36 4.921.20 5.071.28 5.201.22Y axis(n=4.3) 5.581.60 5.141.48 5.181.50 5.271.61Z axis(n=4.3) 5.671.39 5.341.25 5.401.25 5.501.37 No significant difference, P0.05; Yu.Europ Journal of Radiology 200

4、8病理体积与病理体积与PET/CT影像体积的比较研究影像体积的比较研究CT & FDG PET-CT for NSCLC N-Stage Pathology ResultsCT StagePET-CT StageN-StageNumberN-StageNumberN-StageNumberN049N0N1N229(40%) 614N0N1N241(75%)53N148N0N1N21026(55%)12N0N1N2139(80%)8N225N0N1N29313(50%)N0N1N25218(75%)Diagnostic values of Diagnostic values of FLT VS

5、FDGFLT VS FDG for for lymph node Detection in NSCLClymph node Detection in NSCLC pNstagePt N FLT PET/CT FDG PET/CTSensiSpeciAccuPPVNPVSensiSpeciAccuPPVNPVpN0139696010084840100pN11268978793858876806692pN2660978492828073756287PPV：positive predict value；NPV：negative predict valueNSCLC原发灶镜下侵袭范围原发灶镜下侵袭范围

6、中华肿瘤杂志中华肿瘤杂志2004年第年第9期期病理类型病理类型 X X轴轴 Y Y轴轴 Z Z轴轴 平均值平均值 95%CTV 腺癌腺癌 1.801.10 2.862.48 2.171.58 2.181.80 7mm 鳞癌鳞癌 1.370.97 1.451.03 1.141.26 1.331.09 5mm P值值 0.18 0.017 0.035 0.001临床靶区的设定临床靶区的设定取决于病理和靶取决于病理和靶区边界失败频度区边界失败频度患者男性患者男性, ,73岁岁, ,PET-CT示示左下肺占位左下肺占位, ,平均平均SUV=20.3 最大最大SUV=30.2术后病理为低分化鳞癌术后病理

7、为低分化鳞癌最大显微镜下浸润范围最大显微镜下浸润范围 -Microextension, ME为为6.0mm FDG-PET-SUV用于用于CTV扩充区扩充区前瞻性前瞻性研究研究 Prospective Study of CTV-Margin by PET-SUV SUV & MTV与肿瘤镜下浸润范围关系与肿瘤镜下浸润范围关系2009 ASTRO Oral Presentation-Chicago P=0.008P0.00139例例NSCLC ME平均值为平均值为 4.61mm2.71mm肿瘤最大肿瘤最大SUV的平均值为的平均值为 7.242.41肿瘤代谢体积的平均值为肿瘤代谢体积的平均值为 4

8、0.62cm333.66cm3Phase III Trial: ENI vs IFI; Yu, ASCO-Phase III Trial: ENI vs IFI; Yu, ASCO-20062006STDSTDF FIFIFStage III NSCLC: ChT/RT; 200 Pts RandomizedStage III NSCLC: ChT/RT; 200 Pts RandomizedParameterParameter2Yr LF2Yr LF1Yr OS1Yr OS2Yr OS2Yr OS3Yr OS3Yr OSENI4959.725.619.2IFRT4167.238.727.3P

9、=0.048RTOG-0617及及NCCN引证引证III期期NSCLC建议累及野照射建议累及野照射 关于肿瘤的预防照射关于肿瘤的预防照射Elective Node Irradiation,ENIp如果我们控制那些可见病灶如果我们控制那些可见病灶(GTV) 都很困难的话都很困难的话; ;p那我们何必要去做没有任何意义那我们何必要去做没有任何意义的的 预防性照射呢？预防性照射呢？ But As We Know ThatBut As We Know That: :Are esophageal cancers likein USA and in China Are esophageal cancers

10、 likein USA and in China Horses of a different color and different functions?Horses of a different color and different functions? 治疗结果治疗结果-Treatment ResultsParameters Overall survival Progression free survival Follow time 1 yr3yr5yr 1 yr 3yr 5yrSurgery group88.6%56.2%34.7% 73.3%39.7%20.6%RT group93.

11、3%61.5%36.9% 75.9%43.7%23.1%Overall Survival Surgery group vs RT groupOverall SurvivalmonthsProgression-Free Survival in Surgery group vs RT group为何需要放化疗联合靶向为何需要放化疗联合靶向Why Cetuximab+CCRTWhy Cetuximab+CCRTpWe really need better results for CancerspEncouraging results in the lab researchIn Vitro: Cell

12、 CultureIn Vivo: Animal StudypEncouraging results in the clinic researchHead and neck cancerM-Colo-rectal CancerPreliminary data for NSCLC 西妥昔单抗西妥昔单抗 + 紫杉醇紫杉醇+ 顺铂顺铂+ 同步放疗同步放疗 ( 400/250mg/m2 ) (45mg/m2) (20mg/m2) ( 59.4Gy )主要评价：临床缓解率主要评价：临床缓解率 颈段颈段+ 胸中上胸中上段段 食管鳞癌食管鳞癌（44例例）次要评价：安全性次要评价：安全性/生存率生存率 其他评价

13、：其他评价：K-RAS基因检测基因检测EXCEL-0901 ProtocleW 2W 3 Cetuximab (400mg/250mg/m2)W 4W 5W 6W 7W 1 Cisplatin (20mg/m2)3DCRT (1.8 Gy X 33 fractions)Paclitaxel (45mg/m2)苯海拉明 (50 mg ) 地塞米松 (5-10 mg ) W 8 PD153035食管癌食管癌EGFR显显像像XXX,男性男性, 64岁岁, 胸上段食管鳞癌胸上段食管鳞癌, SUVmax=1.68, T/NT=2.8 治疗前和中食管钡餐对比治疗前和中食管钡餐对比治疗前治疗前放疗放疗23.

14、4Gy/13次次由病理科医生所勾画的肿瘤镜下边界，画线的右边是肿瘤外界肿瘤组织正常肺泡结构正常肺泡结构放大倍数放大倍数4040病理医生勾画好肿瘤边界后的病理医生勾画好肿瘤边界后的HEHE切片切片Diagnostic values of Diagnostic values of FLT VS FDGFLT VS FDG for for lymph node Detection in NSCLClymph node Detection in NSCLC pNstagePt N FLT PET/CT FDG PET/CTSensiSpeciAccuPPVNPVSensiSpeciAccuPPVNPV

15、pN0139696010084840100pN11268978793858876806692pN2660978492828073756287PPV：positive predict value；NPV：negative predict value SUV & MTV与肿瘤镜下浸润范围关系与肿瘤镜下浸润范围关系2009 ASTRO Oral Presentation-Chicago P=0.008P0.00139例例NSCLC ME平均值为平均值为 4.61mm2.71mm肿瘤最大肿瘤最大SUV的平均值为的平均值为 7.242.41肿瘤代谢体积的平均值为肿瘤代谢体积的平均值为 40.62cm33

16、3.66cm3But As We Know ThatBut As We Know That: :Are esophageal cancers likein USA and in China Are esophageal cancers likein USA and in China Horses of a different color and different functions?Horses of a different color and different functions?Overall Survival Surgery group vs RT groupOverall SurvivalmonthsW 2W 3 Cetuximab (400mg/250mg/m2)W 4W 5W 6W 7W 1 Cisplatin (20mg/m2)3DCRT (1.8 Gy X 33 fractions)Paclitaxel (45mg/m2)苯海拉明 (50 mg ) 地塞米松 (5-10 mg ) W 8