早期非小细胞肺癌SBRT培训班培训课件.ppt

1、LDCT：1.5%Control：0.3%1 1早期非小细胞肺癌早期非小细胞肺癌SBRTSBRT培训班培训班11/5/202211/5/2022Stereotactic 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

2、时肿瘤的个体化测定图像采集、治疗计划和施照时肿瘤的运动并进行针对性的计划制定与实施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通过在线及离线图像引导确保精确施照 最重要的是，在最重要的是，在2 2周内通过周内通过3-83-8次治疗给予超高生次治疗给予超高生物剂量的照射物剂量的照射2 2早期非小细胞肺癌早期非小细胞肺癌SBRTSBRT培训班培训班11/5/202211/5/2022不可手术早期不可手术早期NSCLCNSCLC的的SBRTSBRT3 3早期非小细胞肺癌早期非小细胞肺癌SBRTSBRT培训班培训班11/5/202211/5/2022SABR for Inope

3、rable NSCLCJ Thorac Oncol.2015;10:8728824 4早期非小细胞肺癌早期非小细胞肺癌SBRTSBRT培训班培训班11/5/202211/5/2022SBRT vs Proton vs Heavy Ion RTGrutters et al,Radio Oncol,2009SBRT is significantly better than 3DCRT in OS and DFSSBRT is as good as Proton and Heavy Ion.5 5早期非小细胞肺癌早期非小细胞肺癌SBRTSBRT培训班培训班11/5/202211/5/2022 NSC

4、LC-病理 T1，T2(2cm from tracheo-bronchial tree)T5cm,N0M0Objective:To select the better of the 2 SBRT regimens by comparing them at 1 year(yr.)post SBRT:protocol-specified adverse events;primary tumor controlInt J Radiat Oncol Biol Phys.2015 Nov 15;93(4):757-64.15早期非小细胞肺癌早期非小细胞肺癌SBRT培训班培训班11/5/202216早期非

5、小细胞肺癌早期非小细胞肺癌SBRT培训班培训班11/5/2022The true rate of not experiencing a psAE is 83%.期外周型期外周型NSCLCNSCLC 34Gy 34Gy1 1次次vs.12Gyvs.12Gy4 4次次（RTOG0915RTOG0915，期研究）期研究）N=39N=45结论：结论：34Gy34Gy组组1 1年不良反应发生率和局部控制率满足研究终点年不良反应发生率和局部控制率满足研究终点要求，建议要求，建议III III 试验中采用。试验中采用。17早期非小细胞肺癌早期非小细胞肺癌SBRT培训班培训班11/5/2022期外周型期外周型

6、NSCLCNSCLC两种两种SBRTSBRT方案疗效比较的长方案疗效比较的长期随访数据（期随访数据（RTOG0915RTOG0915，期研究）期研究）18早期非小细胞肺癌早期非小细胞肺癌SBRT培训班培训班11/5/2022期外周型期外周型NSCLCNSCLC两种两种SBRTSBRT方案疗效比较的长方案疗效比较的长期随访数据（期随访数据（RTOG0915RTOG0915，期研究）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：不良反应：3 3级及以上不良反应发生率较之前结果没有明显变化。级及以上不良反应发生率较之前结果没有明显变化。1

7、9早期非小细胞肺癌早期非小细胞肺癌SBRT培训班培训班11/5/2022周围型周围型/中心型肺癌（中心型肺癌（SBRTSBRT）Central tumors tumors located 2 cm from the trachea,mainstem bronchus,main bronchi or esophagus tumors located 3 complications with 3 Fx 20Gy(P .004)Decline pulmonary function tests pneumonias pleural effusions apnea skin reactionTimmer

8、man,et al.J Clin Oncol,2006;24:4833-4839.2121早期非小细胞肺癌早期非小细胞肺癌SBRTSBRT培训班培训班11/5/202211/5/2022SABR Toxicity of central lung tumor MDACC2005.2-2011.5101Pts,T1-2N0M0(n=82);isolated lung-parenchyma recurrent lesions(n=19)50Gy/4f;or 70Gy/10fMedian Follow-up 30.3m(40.5m for survivor)NO Grade 4 Toxcity Tox

9、icity%G1G2G3Chest wall pain1813RP111.9ASTRO 2014 ASTRO 2014 2222早期非小细胞肺癌早期非小细胞肺癌SBRTSBRT培训班培训班11/5/202211/5/2022中心型肺癌中心型肺癌SBRTSBRT剂量剂量Indiana U/RTOG:60Gy/3f（毒性过高）MDACC:50Gy/4fRTOG0813:50-60Gy/5fVUMC“Risk adapted”:60Gy/3f,5f,or 8f2323早期非小细胞肺癌早期非小细胞肺癌SBRTSBRT培训班培训班11/5/202211/5/2022早期非小细胞肺癌早期非小细胞肺癌SBR

10、TSBRT的剂量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2424早期非小细胞肺癌早期非小细胞肺癌SBRTSBRT培训班培训班11/5/202211/5/2022可手术早期可手术早期NSCLCNSCLC的的SBRTSBRT探索探索2525早期非小细胞肺癌早期非小细胞肺癌SBRTSBRT培训班培训班11/5/202211/5/2022SBRT for Operable Stage I NSCLCJ Thorac Oncol.2015;10:87

11、28822626早期非小细胞肺癌早期非小细胞肺癌SBRTSBRT培训班培训班11/5/202211/5/2022SBRT Versus Surgery Matched Studies 2-year OS2-year LC2-year CSSZheng(Kong),Int J Radiat Oncol Biol Phys.2014;90(3):603-112727早期非小细胞肺癌早期非小细胞肺癌SBRTSBRT培训班培训班11/5/202211/5/2022Stereotactic Body Radiation Therapy Versus Surgery for Early Lung Canc

12、er Among US Veterans4,069 patients(veterans)with biopsy-proven clinical stage I non-small cell lung cancer diagnosed between 2006 and 2015 449 SBRT,2,986 lobectomy,634 sublobar resectionHigher cancer-specific mortality for SBRT compared with lobectomy(subdistribution hazard ratio 1.45,95%confidence

13、interval:1.09 to 1.94,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.2017Ann Thorac Surg.20172828早期非小细胞肺癌早期非小细胞肺癌SBRTSBRT培训班培训班11/5/202211/5/2022SBRT in Early Stage NSCLCRandomized Trials2

14、013 CLOSED Due to Poor Recruitment 2011 CLOSED Due to Poor Recruitment 2013 CLOSED Due to Poor Recruitment 2929早期非小细胞肺癌早期非小细胞肺癌SBRTSBRT培训班培训班11/5/202211/5/20223030早期非小细胞肺癌早期非小细胞肺癌SBRTSBRT培训班培训班11/5/202211/5/20223131早期非小细胞肺癌早期非小细胞肺癌SBRTSBRT培训班培训班11/5/202211/5/2022争议与展望p2项入组失败的pooled analysisp随访时间短（SA

15、BR组40.2月/手术组35.4月）均未达到中位总生存p手术组不良反应高pSABR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）3232早期非小细胞肺癌早期非小细胞肺癌SBRTSBRT培训班培训班11/5/202211/5/2022Ongoing trailsOngoing trailsRTOG 3502VALORSABRTooth3333早期非小细胞肺癌早期非小细胞肺癌SBRTSBRT培训班培训班11/5/202211/5/2022RTOG Foundation 3502RTOG Foundation 3502POSTILVPOSTILV:A Randomized

16、 Trial in A Randomized Trial in P Patients atients with with OOperable perable StStage age I I Non-Small Cell Non-Small Cell L Lung ung Cancer:Radical Resection Cancer:Radical Resection V Vs Ablative s Ablative Stereotactic RadiotherapyStereotactic RadiotherapyStudy TeamRadiation oncologist PIs:J Yu

17、(L Xing);FM KongSurgeon Co-Chairs:Y Wu/J He/W Mao/G Chen;A Chang/M Orringer/T DAmicoRadiation Co-Chairs:L Wang/X Fu;Z Liao/J ChangPhysicist PIs:J Dai/Y Yin;F Yin/Y Xiao/J YueFirst 5 selected participating Sites3434早期非小细胞肺癌早期非小细胞肺癌SBRTSBRT培训班培训班11/5/202211/5/2022Schema of RTOG Foundation Schema of RT

18、OG Foundation Study 3502Study 3502Phase II Randomized StudyPhase II Randomized StudyPrimary 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.3535早期非小细胞

19、肺癌早期非小细胞肺癌SBRTSBRT培训班培训班11/5/202211/5/2022早期非小细胞肺癌早期非小细胞肺癌SBRTSBRT复发后的挽救性治疗复发后的挽救性治疗36早期非小细胞肺癌早期非小细胞肺癌SBRT培训班培训班11/5/2022Salvaging Local-Regional Recurrence after Stereotactic Ablative Radiotherapy(SABR)for Early-Stage NSCLCPresented By Eric Brooks at 2017 ASCO Annual Meeting37早期非小细胞肺癌早期非小细胞肺癌SBRT培训

20、班培训班11/5/2022MethodsPresented By Eric Brooks at 2017 ASCO Annual Meeting38早期非小细胞肺癌早期非小细胞肺癌SBRT培训班培训班11/5/2022Slide 18Presented By Eric Brooks at 2017 ASCO Annual Meeting39早期非小细胞肺癌早期非小细胞肺癌SBRT培训班培训班11/5/2022Slide 29Presented By Eric Brooks at 2017 ASCO Annual Meeting40早期非小细胞肺癌早期非小细胞肺癌SBRT培训班培训班11/5/2

21、022Benefit of Salvage TreatmentPresented By Eric Brooks at 2017 ASCO Annual Meeting41早期非小细胞肺癌早期非小细胞肺癌SBRT培训班培训班11/5/2022Effect of Salvage on SurvivalPresented By Eric Brooks at 2017 ASCO Annual Meeting42早期非小细胞肺癌早期非小细胞肺癌SBRT培训班培训班11/5/2022Slide 48Presented By Eric Brooks at 2017 ASCO Annual Meeting43

22、早期非小细胞肺癌早期非小细胞肺癌SBRT培训班培训班11/5/2022Slide 56Presented By Eric Brooks at 2017 ASCO Annual Meeting44早期非小细胞肺癌早期非小细胞肺癌SBRT培训班培训班11/5/2022ConclusionsPresented By Eric Brooks at 2017 ASCO Annual Meeting45早期非小细胞肺癌早期非小细胞肺癌SBRT培训班培训班11/5/2022SBRTSBRT的质量保证与控制的质量保证与控制 4646早期非小细胞肺癌早期非小细胞肺癌SBRTSBRT培训班培训班11/5/2022

23、11/5/2022SBRTSBRT的特点的特点对医师、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4747早期非小细胞肺癌早期非小细胞肺癌SBRTSBRT培训班培训班11/5/202211/5/2022QA&QCQA&QC的进步的进步肿瘤的放射治疗与设备的QA&QC密切相关（AAPM TG-40）精确放疗对QA&QC制定了较高的标准（GB/T19046-2003，AAPM TG-142）SBRT对QA&QC提出了更高层次的挑战性要求（TG-101）4848早期非小细胞肺癌早期非小细胞肺癌SBRTSBR

24、T培训班培训班11/5/202211/5/2022常规常规QA/QCQA/QC详细而规范的日常QA流程及记录治疗申请单、治疗记录单防护措施及出具的报告剂量刻度及计算方法和规范加速器/TPS验收和 commissioning报告CT-ED表TPS的QA规范和报告图像引导使用规范4949早期非小细胞肺癌早期非小细胞肺癌SBRTSBRT培训班培训班11/5/202211/5/2022End-to-EndEnd-to-End测试测试肺模体点剂量验证二维矩阵验证胶片验证5050早期非小细胞肺癌早期非小细胞肺癌SBRTSBRT培训班培训班11/5/202211/5/2022加速器与TPS模型的一致性模体摆

25、位的精确性计划照射的精确性专用模体照射（专用模体照射（RTOGRTOG）5151早期非小细胞肺癌早期非小细胞肺癌SBRTSBRT培训班培训班11/5/202211/5/2022实际病例介绍实际病例介绍模拟定位模拟定位采用常用体位：仰卧、双手上举握柄、真空垫固定（立体定向放疗固定框架板）扫描范围：自环甲膜至12th胸椎，层厚3mm使用4DCT图像以获取ITV。如果靶区在任意方向动度超过15mm，应当使用诸如腹部压块、ABC、Gating等技术限制运动，减少照射范围需要获取平扫（非强化）3DCT，以用于计划设计和剂量计算如果有必要，可进行PET/CT模拟定位5252早期非小细胞肺癌早期非小细胞肺癌

26、SBRTSBRT培训班培训班11/5/202211/5/2022靶区勾画靶区勾画在4DCT每个时相肺窗上勾画GTV10个时相的GTV融合成ITV并移植到平扫3DCT上ITV外放5mm生成PTV如果靶区运动幅度小于5mm，可由GTV外扩10mm生成PTV5353早期非小细胞肺癌早期非小细胞肺癌SBRTSBRT培训班培训班11/5/202211/5/2022危及器官危及器官5454早期非小细胞肺癌早期非小细胞肺癌SBRTSBRT培训班培训班11/5/202211/5/2022三、实际病例介绍5555早期非小细胞肺癌早期非小细胞肺癌SBRTSBRT培训班培训班11/5/202211/5/2022计划

27、设计计划设计按照推荐，使用3D-CRT技术。设定大于10个非共面射野,其中3个非共面野由于靶区位置较偏，适当调整ISO位置，以防止机架碰撞（尤其是存在非共射野）5656早期非小细胞肺癌早期非小细胞肺癌SBRTSBRT培训班培训班11/5/202211/5/2022山 东 省 肿 瘤 医 院山东省肿瘤防治研究院AccuRay CyberKnifeAccuRay CyberKnifeOrthogonal kV imaging,Orthogonal kV imaging,couchElektaVarianIGRT Tools for SBRTIGRT Tools for SBRTMV and kV

28、radiographs,kV Cone Beam CTMV and kV radiographs,kV Cone Beam CTTomotherapyTomotherapyHelical scan,low MV imagingHelical scan,low MV imagingsource;detectors optimized forsource;detectors optimized forlow-dose imaginglow-dose imagingConventional CT acquiredConventional CT acquiredwith patient on trea

29、tmentwith patient on treatment real-time trackingreal-time trackingMV Cone Beam CTMV Cone Beam CTUses treatment beam;Uses treatment beam;modified EPID reducesmodified EPID reducesimaging doseimaging dose Gantry-mounted kV source,2 EPIDsGantry-mounted kV source,2 EPIDs kV and MV planar imaging;kV flu

30、oroscopy kV and MV planar imaging;kV fluoroscopy kVCBCT kVCBCTHiArtSiemensExacTracCT-in-RoomNovalis 5757早期非小细胞肺癌早期非小细胞肺癌SBRTSBRT培训班培训班11/5/202211/5/2022治疗前位置校正CBCT手动按肿瘤配准手动按肿瘤配准5858早期非小细胞肺癌早期非小细胞肺癌SBRTSBRT培训班培训班11/5/202211/5/2022KVKV正侧位正侧位2D2D图像验证图像验证5959早期非小细胞肺癌早期非小细胞肺癌SBRTSBRT培训班培训班11/5/202211/5/2

31、022山 东 省 肿 瘤 医 院山东省肿瘤防治研究院立体定向治疗立体定向治疗SBRTSBRT精确射线施照精确射线施照Hitting the TargetHitting the Target精确靶区勾画精确靶区勾画Finding the TargetFinding the Target立体定向放疗瓶颈立体定向放疗瓶颈 Break Bottlenecks of SBRTBreak Bottlenecks of SBRTTo give higher dose to the tumorsTo give higher dose to the tumorsTo avoid surrounding crit

32、ical organsTo avoid surrounding critical organsOrgan Motion ControlOrgan Motion Control IGRT and Verification IGRT and VerificationDefinition of GTVp/n;Definition of GTVp/n;CTVp/n CTVp/n&PTV Margin PTV Margin6060早期非小细胞肺癌早期非小细胞肺癌SBRTSBRT培训班培训班11/5/202211/5/2022山 东 省 肿 瘤 医 院山东省肿瘤防治研究院谢 谢！山东省肿瘤医院放疗十病区（胸部放疗）电话：0531-67626819/15553181309Email：6161早期非小细胞肺癌早期非小细胞肺癌SBRTSBRT培训班培训班11/5/202211/5/2022