髓母細胞瘤的放射治療髓母細胞瘤的放射治療曹嫣娜1優(yōu)秀課件概述概述來源：胚胎殘留的未分化的原始髓樣上皮細胞。部位：第四腦室頂上的小腦蚓部。發(fā)病率：2.1/10萬/年，占兒童顱內(nèi)惡性腫瘤的1520%。疾病特點：惡性程度高。生長極其迅速；手術難以完整切除；腫瘤細胞易沿腦脊液播散（1646%）。2優(yōu)秀課件臨床表現(xiàn)臨床表現(xiàn)顱內(nèi)壓增高：頭痛、嘔吐、視神經(jīng)乳頭水腫小腦損害：軀干性共濟失調(diào)為主其它：復視、面癱、強迫頭位、頭顱增大、病理反射陽性、嗆咳、小腦危象、蛛網(wǎng)膜下腔出血脊髓轉(zhuǎn)移灶癥狀：背部或雙下肢痛、進行性加重的截癱或四肢癱3優(yōu)秀課件分級分級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 Extraneural4優(yōu)秀課件治療方案標準治療方案(“Philadelphia protocol”)手術放療：術后28天內(nèi)開始。化療(VCP)：放療中VCR1.5mg/m2/w，共8周；放療后6周開始CCNU75mg/m2 DDP75mg/m2 VCR1.5mg/m2/w3w，每6周一個周期，共8個周期。5優(yōu)秀課件放療劑量低危組：CSI 23.4Gy/13f+后顱窩加量至 54Gy高危組：CSI 36Gy/20f+后顱窩加量至54Gy6優(yōu)秀課件放療技術常規(guī)分割CSI+Boost to posterior fossa 超分割CSI+Boost to posterior fossa SRT Boost to posterior fossa7優(yōu)秀課件Craniospinal irradiation(CSI):methods俯臥位，雙手置于體側(cè)頭部兩側(cè)對穿野照射全腦及上段頸髓單后野照射脊髓各野皮膚間隔1cm每照射10Gy移動一次射野以減少各野間交叉高劑量6MV-X線照射劑量(DT)：23.4Gy36Gy,1.8Gy/f8優(yōu)秀課件9優(yōu)秀課件Craniospinal 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 10優(yōu)秀課件23.4GyCSI的療效Risk-adapted craniospinal radiotherapy followed by high-dose chemotherapy and Risk-adapted craniospinal radiotherapy followed by high-dose chemotherapy and stem-cell rescue in children with newly diagnosed medulloblastoma(St Jude stem-cell rescue in children with newly diagnosed medulloblastoma(St Jude Medulloblastoma-96):long-term results from a prospective,multicentre trialMedulloblastoma-96):long-term results from a prospective,multicentre trial http:/oncology.the Vol 7 October 2006Vol 7 October 200611優(yōu)秀課件23.4GyCSI對智力的影響(POG-8631)Journal of Clinical Oncology,Vol 16,No 5,pp.172328,199812優(yōu)秀課件CSI:cranial-spinal 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)13優(yōu)秀課件超分割放療Twice-daily l-Gy fractions were administered separated by 4-6 h.放療劑量和射野同常規(guī)分割14優(yōu)秀課件SRT 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 15優(yōu)秀課件放療反應急性反應：骨髓抑制、腦水腫等；遠期副作用：甲低認知障礙其它：聽力減退、骨骼發(fā)育障礙、周圍組織損傷繼發(fā)第二惡性腫瘤等。16優(yōu)秀課件甲低 Hypothyroid p值值年齡1 5歲 7/7(100%)10歲 2/10(20%)照射劑量123.4Gy+CT 10/12(83%)3歲、低危者(CSF-)、BED超過50Gy、放療持續(xù)時間小于50天提示預后較好；低劑量CSI(23.4Gy)/低劑量CSI+化療/HFRT有助于減輕低?；颊哌h期并發(fā)癥但并不能增加治愈率；術后應立即開始放療，一般不推薦放療前化療；根據(jù)危險性分級選擇放療劑量和化療方案。34優(yōu)秀課件謝謝！謝謝！35優(yōu)秀課件