前列腺癌靶区勾画.ppt

1、前列腺癌靶区勾画,中国医科院肿瘤医院,前列腺癌发病率和死亡率,Radiother Oncol. 2004 Apr;71(1):29-33.,J Clin Oncol. 2002 Aug 15;20(16):3376-85.,对于局限期前列腺癌，根治性前列腺切除与放射治疗疗效相当,解 剖,Anatomy,Yellow: Peripheral gland Blue: Transitional zone Red: Central gland Green: Anterior fibromuscular zone,前列腺癌的靶区包括范围,前列腺 精囊腺 盆腔淋巴引流区,前列腺及包膜受侵情况,CTV in

2、 Prostate Cancer,CTV=prostate (+SV) +LN ,Extracapsular Extension associated with PSA , GS, and T stages,P = : 3/2(PSA) + (Gleason score 3) x10 Partins Tables,Roach III. J Urol 150: 1923-24, 1993,Wang L, Radiology 2004,Extracapsular Extension,勾画前列腺CTV时，幷不必刻意外扩很大边界,精囊腺受侵情况,SV involvement,Kestin et al

3、IJROBP 2002,SV+ associated with PSA , GS, and T stages,Kestin et al IJROBP 2002,SV involvement,Kestin et al IJROBP 2002,When treating the SV for prostate cancer, only the proximal 2.0 2.5 cm be included within the CTV,Kestin et al IJROBP 2002,SV invasion,P= (PSA) + (Gleason score 6) x10 Partins Tabl

4、es,Roach III. J Urol 150: 1923-24, 1993,前列腺癌淋巴引流,18 patients with pathologically proven lymph node metastases 69,Shih et al IJROBP Nov 2005,Massachusetts General Hospital,Prostate Cancer Nodal Spread,Step wise from pelvis to abdomen Nodal metastases more likely with: Increasing T stage Increasing PS

5、A Increasing GS,LNM%= 2/3(PSA) + (Gs 6)x10 Partins Tables,Roach III. J Urol 150: 1923-24, 1993,External iliac lymph nodes Internal iliac lymph nodes Obturator group Perirectal LN Part of the common iliac nodes S1-3 pre-sacral lymph nodes Para Aortic (optional),Prostate Cancer pelvic nodal irradiatio

6、n,MSKCC 前列腺癌放疗指南,结合2009.2 NCCN指南,Clinical Target Volume,Risk stratification and treatment recommendation,Simulation,CT Scan: from bottom of SI joints to 1.5 cm below the level of ischial tuberosities. Maximal slice thickness of 5 mm Patient set-up: be treated in the supine position. Immobilization:

7、employ immobilization system that keeps random and systematic errors to acceptable limits,Bladder：size should not vary between simulation and treatments. (e.g. bladder to be emptied 1 h prior to sim/treatment, patient to drink 500cc water soon thereafter) Rectum: Instruct patients to evacuate their

8、bowels prior to planning and treatment.,Contouring:,Prostate apex: situated above the urogenital diaphragm. 5mm above the bulbospongiosus Contour base of SV only, if no clinical SV involvement. Rectal wall: from 1 cm above to 1 cm below the PTV. Consider contouring the whole length of the rectum. Co

9、ntour external bladder wall from its apex to the dome. femoral heads: from the inferior margin of PTV to the superior lip of acetabulum.,靶区勾画规定：,CTV = GTV PTV = CTV + 1 cm margin，向后方向仅外放0.5 cm以减少直肠照射。,缩 野,from PTV1 volume to PTV2 volume between 46 and 60 Gy.,Dose constraints,rectum 50 Gy 50% 70 Gy 2

10、0% the bladder 55 Gy 50% 70 Gy 30% femoral heads 35 Gy 100% 45 Gy 60% 60 Gy 30% RTOG: 5% 50Gy Small Bowel: 0% 52Gy; V505% Large Bowel: 0% 55Gy; V5010%,Verification,Isocentre check using AP and lateral films be acquired at least weekly during treatment.,前列腺和精囊腺的CTV,包含盆腔淋巴结预防照射的前列腺癌靶区勾画,RTOG GU REACH

11、CONSENSUS ON PELVICLYMPH NODE,the pelvic lymph node volumes to be irradiated include: distal common iliac, presacral lymph nodes (S1-S3) external iliac lymph nodes internal iliac lymph nodes obturator lymph nodes,IJROBP, 2008,RTOG GU REACH CONSENSUS ON PELVICLYMPH NODE,CTVs include the vessels (arte

12、ry and vein) and a 7-mm radial margin carve out bowel, bladder, bone, and muscle. Volumes from the L5/S1 interspace to the superior aspect of the pubic bone.,IJROBP, 2008,L5/S1水平包全髂总骶前淋巴结,IJROBP, 2008,1.5 Cm,0.7 Cm,S1-S3水平包全髂内外和骶前淋巴结 Carve out小肠、膀胱、肌肉和骨等,IJROBP, 2008,S3以下包全髂内外淋巴结 骶前淋巴结终止于梨状肌出现层面,IJR

13、OBP, 2008,髂外淋巴结一直要勾画至股骨头顶端层 即腹股沟韧带处（髂外A与股A分界处,IJROBP, 2008,闭孔淋巴结要勾画至耻骨联合上缘水平,IJROBP, 2008,我们科勾画情况,References,RTOG GU RADIATION ONCOLOGY SPECIALISTS REACH CONSENSUS ON PELVIC LYMPH NODE VOLUMES FOR HIGH-RISK PROSTATE CANCER. Int. J. Radiation Oncology Biol. Phys., 2008 EAU guidelines on prostate cancer Mapping of nodal disease in locally advanced prostate cancer: Re