邢力刚-早期非小细胞肺癌SBRT-201803培训班

1、2018.03 济南,早期非小细胞肺癌立体定向放射治疗临床应用,早期非小细胞肺癌立体定向放疗技术培训班（第一届） 1st training course of sbrt for early-stage nsclc,ldct：1.5% control：0.3%,stereotactic body radiation therapy (sbrt)stereotactic ablative radiotherapy (sabr),体位固定重复性高，避免治疗间患者运动对治疗精确性的影响 剂量分布高度适形，高剂量区覆盖肿瘤，周围正常组织剂量迅速下降以保护正常组织 个体化测定图像采集、治疗计划和施照时肿瘤

2、的运动并进行针对性的计划制定与实施 通过在线及离线图像引导确保精确施照 最重要的是，在2周内通过3-8次治疗给予超高生物剂量的照射,不可手术早期nsclc的sbrt,sabr for inoperable nsclc,j thorac oncol. 2015;10: 872882,sbrt vs proton vs heavy ion rt,nsclc-病理 t1，t2(5cm)n0，m0 因其他医学问题不适合手术 未采用其他治疗 不做距离支气管树2cm之内的,2004.5-2006.10 59人参加，55人可评估 62%女性，中位年龄72岁 t1，44人，t2，11人 中位随访4年（7.2y

3、，最长）,rtog 0236,疗效与失败模式,5年dfs和os分别是26%和40% 5年原发灶复发率仅7% 区域复发率（肺门和纵膈）：3年13%，5年38% 远处失败、同一肺叶和区域淋巴结复发是主要的失败模式 未观察到严重的长期毒性,周围型肺癌 sabr的剂量,karolinska/nordic: 45gy/3f kyoto u/jcog: 48gy/4f indiana u/rtog: 60gy/3f rtog0915: 48gy/4f vs 34gy/1f,japanese multi-center study,onishi et al. jto 2007,bed =100 gy had

4、better tumor control.,sbrt 剂量思考,肿瘤体积与sbrt剂量,期外周型nsclc两种sbrt方案疗效比较的长期随访数据（rtog0915，期研究）,patient population: biopsy-proven nsclc, medically inoperable peripheral lung tumors (as defined by rtog 0236, i.e., 2cm from tracheo- bronchial tree) t5cm, n0m0 objective: to select the better of the 2 sbrt regim

5、ens by comparing them at 1 year (yr.) post sbrt: protocol-specified adverse events; primary tumor control,int j radiat oncol biol phys. 2015 nov 15;93(4):757-64.,the true rate of not experiencing a psae is 83%.,期外周型nsclc 34gy1次vs. 12gy4次（rtog0915，期研究）,n=39,n=45,结论： 34gy组1年不良反应发生率和局部控制率满足研究终点要求，建议iii

6、 试验中采用。,期外周型nsclc两种sbrt方案疗效比较的长期随访数据（rtog0915，期研究）,期外周型nsclc两种sbrt方案疗效比较的长期随访数据（rtog0915，期研究）,arm 1( 34gy1次):39例；arm 2(12gy4次):45例。中位随访3.8年。,不良反应： 3级及以上不良反应发生率较之前结果没有明显变化。,周围型/中心型肺癌（sbrt）,central tumors tumors located 2 cm from the trachea, mainstem bronchus, main bronchi or esophagus tumors located

7、 6 mm from the heart tumors located in the mediastinum.,sabr dose for central lung tumor,how about the sbrt treatment of central lung tumors? how about the complications timmerman, j clin oncol 2006 local control: 67/70 (95% for 24 months) 11 fold increase in g3 complications with 3 fx 20gy (p .004)

8、,decline pulmonary function tests pneumonias pleural effusions apnea skin reaction,timmerman,et al. j clin oncol,2006; 24:4833-4839.,sabr toxicity of central lung tumor mdacc,2005.2-2011.5 101pts, t1-2n0m0(n=82); isolated lung-parenchyma recurrent lesions (n=19) 50gy/4f; or 70gy/10f median follow-up

9、 30.3m(40.5m for survivor),no grade 4 toxcity,astro 2014,中心型肺癌sbrt剂量,indiana u/rtog: 60gy/3f （毒性过高） mdacc: 50gy/4f rtog0813: 50-60gy/5f vumc “risk adapted”: 60gy/3f,5f, or 8f,早期非小细胞肺癌sbrt的剂量,早期非小细胞肺癌sbrt的剂量不应低于bed 100gy 小于3厘米肿瘤，中高剂量的（bed 100-150gy）应该足够 大于3厘米肿瘤，具体剂量有待进一步确定 中央型肿瘤要充分考虑正常组织损伤,可手术早期nsclc

10、的sbrt探索,sbrt for operable stage i nsclc,j thorac oncol. 2015;10: 872882,sbrt versus surgery matched studies,2-year os,2-year lc,2-year css,zheng (kong), int j radiat oncol biol phys. 2014;90(3):603-11,stereotactic body radiation therapy versus surgery for early lung cancer among us veterans,4,069 pa

11、tients (veterans) with biopsy-proven clinical stage i non-small cell lung cancer diagnosed between 2006 and 2015 449 sbrt, 2,986 lobectomy, 634 sublobar resection higher cancer-specific mortality for sbrt compared with lobectomy (subdistribution hazard ratio 1.45, 95% confidence interval: 1.09 to 1.

12、94, p = 0.01) no survival difference between sbrt and sublobar resection (subdistribution hazard ratio 1.25, 95% confidence interval: 0.93 to 1.68, p = 0.15),ann thorac surg. 2017,sbrt in early stage nsclcrandomized trials,2013 closed due to poor recruitment,2011 closed due to poor recruitment,2013

13、closed due to poor recruitment,争议与展望,2项入组失败的pooled analysis 随访时间短（sabr组40.2月/手术组35.4月） 均未达到中位总生存 手术组不良反应高 sabr组8例（26%）无病理诊断，手术组6例（22%）术前无病理（1例手术良性）,ongoing trails,rtog 3502 valor sabrtooth,rtog foundation 3502postilv: a randomized trial in patients with operable stage i non-small cell lung cancer: r

14、adical resection vs ablative stereotactic radiotherapy,study team radiation oncologist pis: j yu (l xing); fm kong surgeon co-chairs: y wu/j he/w mao/g chen; a chang/m orringer/t damico radiation co-chairs: l wang/x fu; z liao/j chang physicist pis: j dai/y yin; f yin/y xiao/j yue ,first 5 selected

15、participating sites,schema of rtog foundation study 3502phase ii randomized study,primary endpoint: 2 year local regional tumor control, freedom from local-regional recurrence after rods and freedom from progression of local primary tumor and disease occurrence at nodal regions after sbrt.,早期非小细胞肺癌s

16、brt复发后的挽救性治疗,salvaging local-regional recurrence after stereotactic ablative radiotherapy (sabr) for early-stage nsclc,presented by eric brooks at 2017 asco annual meeting,methods,presented by eric brooks at 2017 asco annual meeting,slide 18,presented by eric brooks at 2017 asco annual meeting,slide

17、 29,presented by eric brooks at 2017 asco annual meeting,benefit of salvage treatment,presented by eric brooks at 2017 asco annual meeting,effect of salvage on survival,presented by eric brooks at 2017 asco annual meeting,slide 48,presented by eric brooks at 2017 asco annual meeting,slide 56,present

18、ed by eric brooks at 2017 asco annual meeting,conclusions,presented by eric brooks at 2017 asco annual meeting,sbrt的质量保证与控制,sbrt的特点,对医师、物理师、技师提出更苛刻的要求 模拟定位、体位固定-可重复性 呼吸运动-有效管理、控制 靶区勾画-精确细致 计划制定-控制剂量限值 计划执行-精确谨慎,qa detectors optimized for low-dose imaging,conventional ct acquired with patient on treatment real-time tracking,mv cone beam ct uses treatment beam; modified epid reduces imaging dose, gantry-mounted kv source, 2 epids kv and mv planar imaging; kv fluoroscopy kvcbct,hiart,siemens,exactrac,ct-in-room,novalis,治疗前位置校正,cbct手动按肿瘤配准,kv正侧位2d图像验证,立体定向治疗 sbrt,精确射线施