鼻腔鼻窦畸胎癌肉瘤的调强放射治疗

Cancer Center, Wuhan Union HospitalGang PENGTreatment of sinonasal teratocarcinosarcoma using IMRTChangsha August 20, 2010 Introduction Case Discussion case discussionintroductionSNTCSsino nasal terato carcino sarcoma 80 cases reported case discussionintroductionHistoryVencent J. HyamsDirector of the Otolaryngic Pathology branch of the Armed Forces Institute of Pathology， 1968-1984 Teratoid carcinosarcoma ? Mixed mesodermal tumour ? Malignant teratoma and blastomas ?1984case discussionintroductionCharacteristicsT1-weighted MR reveals a soft tissue filling the left ethmoid sinus, as uniformly high signal (*), and effusion (white arrowhead) in the left sphenoid sinus. Takasaki, K.,2006Epithelial glandular carcinoma (at right) and osteosarcoma component (at left). (hematoxylin-eosin, original magnification x40). Smith, S. L.,2008Endoscopic examination showing a left sinonasal tumor in the left middle turbinate. M, middle turbinate; S, nasal septum. Su, Y. Y., 2010CBATreatmentcase discussionintroduction1. Patients generally present with locally advanced-stage disease the highly malignant, aggressive biological behavior the presence of air filled paranasal spaces permits silent growth 2. Distant metastasis of SNTCS is unusual and the most common cause of treatment failure is local recurrence3. Surgical excision and postoperative radiotherapy has become the most widely accepted therapeutic plan Introduction Case Discussion HPIintroduction discussioncase 42-year-old man Two weeks history of progressive left nasal obstruction and intermittent nasal bleeding Nasal examination showed a moderately firm, reddish-purple mass in the left meatus Biopsy of the tumor revealed a heterogeneous admixture of epithelial and mesenchymal elements, suggesting SNTCSTeratocarcinosarcoma Teratocarcinosarcoma consists of two components, epithelial and mesenchymal (hematoxylin-eosin, original magnification 200)cT3N0M0MRIintroduction discussioncaseMRI revealed a soft tissue filling the left meatus, maxillary and ethmoid sinus, and effusion in the left maxillary sinusintroduction discussioncasep Anterior craniofacial resectionp IMRT GTV included the residual gross disease in the nasal cavity and paranasal sinus CTV-60 includes the GTV with a 510 mm margin, the whole nasal cavity and the involved paranasal sinus CTV-54 a) high-risk local structures (including the whole nasopharynx, lower half of sphenoid sinus, et al)b) lymphatic regions (including ipsilateral lymph node levels IB, II, III and VA) A 3-mm margin was added to produce PTVsa) PTV-66 was prescribed to 66 Gy with 2.2 Gy/fractionb) PTV-60 was prescribed to 60 Gy with 2.0 Gy/fractionc) PTV-54 was prescribed to 54 Gy with 1.8 Gy/fractionTreatmentFollow-upintroduction discussioncase1. Now 3.5 years have passed since the irradiation therapy2. No severe dry-eye syndrome, and other severe radiation-induced ocular toxicities happened3. No evidence of recurrence or metastasis Introduction Case Discussion Shoulders ?introduction case discussionSinonasal tumors1. Frontal Sinus2. Maxillary Sinus3. Ethmoid Sinus4. Spenoid Sinus1234Challenge !introduction case discussionIMRTintroduction case discussion3-beam conventional 2D 6-beam conventional 3D conformal 7-beam IMRTA dosimetry comparison between (a) a 3-beam conventional 2D treatment, (b) a 6-beam conventional 3D conformal RT treatment, and (c) a 7-beam IMRT treatment. The PTV is represented by the solid red line. The 100% and 70% of the prescription dose are shown by the green and red colour-washed areas. A better dose conformity to the PTV can be achieved in the IMRT treatment. Ghent Experienceintroduction case discussion2009Madani, I., 2009Dosevolume Constraintsintroduction case discussionMadani, I., 2009Visual Pathway Doseintroduction case discussionMadani, I., 2009Acute Toxicityintroduction case discussionMadani, I., 2009Studies Reportedintroduction case discussionMadani, I., 2009CTV Delineationintroduction case discussionImplementation Strategy2001introduction case discussionClaus, F.,2001introduction case discussion“Compartment-related CTV Definition”1. In those regions where GTV was flanked by intact bone, no margin was added In those regions where GTV invaded compartments enclosed by bone, like other paranasal sinuses, or extended up to their ostia, the whole compartment was included in the CTV contours1. In those regions where GTV invaded radiologically defined spaces known to resist poorly invasion by malignant tumors (e.g., masticator or parapharyngeal spaces), the entire space was added Claus, F.,2001Cervical Lymph NodesDuthoy, W.,2005introduction case discussion2005LN RecurrenceDuthoy, W.,2005Ethmoid sinus / Ad : 7% (14/194)Maxillary sinus / SCC: 12% (33/274)introduction case discussioncase2006introduction case discussionCTV Delineation contCTV Delineation cont“ Indeed, in absence of unambiguous information on the surgical procedure and comprehensive report of the pathological analysis, a too selective selection and delineation of the CTV may lead to an unacceptable high rate of loco-regional recurrences ”Vincent Gregoire, 2006It will not be inappropriate to be generous in target volume delineatio