1、螺旋断层放疗于食管癌之运用Tomotherapy for esophageal cancer Department of Radiation OncologyFar Eastern Memorial Hospital,Taiwan 2大綱l台灣Tomo放療設備現況Tomo facitilities in Taiwan l台灣食管癌流行病學Epidymiology of esophageal cancer in Taiwan l傳統食管癌放療的心臟併發症Cardiac morbidities after RT of esophageal cancer l螺旋斷層放療的心臟保護治療計劃Heart
2、sparing tomotherapy for esophageal cancer l總結Conclusion Department of Radiation OncologyFar Eastern Memorial Hospital,Taiwan 3l台灣Tomo放療設備現況Tomo facitilities in Taiwan l台灣食管癌流行病學Epidymiology of esophageal cancer in Taiwan l傳統食管癌放療的心臟併發症Cardiac morbidities after RT of esophageal cancer l螺旋斷層放療的心臟保護治療計
3、劃Heart sparing tomotherapy for esophageal cancer l總結Conclusion 大綱4亚洲第一家拥有两部Tomo的医院Tomo Facility in Asia(as of 2015-06)CountryJapanChinaKoreaTaiwanHKAstraliaTomo No4630212055Population(million)127.3135750.2223.377.18823.13MalysiaPhilipinesSingaporeThailand Myanmar4321129.7298.395.39967.0153.26Country
4、Tomo NoPopulation(million)5亞東醫院放射治療現況n放射治療開始於2001/10/24n每日治療病患約90人n放射治療時間:7:30am 9:30pmn 90%以上皆使用IMRT/IGRTTomo HI-ART2008-7-302006-12-12Tomo HDElekta Versa HD2015-10-12Department of Radiation OncologyFar Eastern Memorial Hospital,Taiwan 6亚东螺旋断层放疗 创新研发提升品质世界首例,2012全皮肤螺旋断层放射治疗HITSl 假體研究Biomed Res Int.
5、2013:108794 l 世界首例報告Biomed Res Int.2013:717589 世界首創,2014 左乳癌挡块设计螺旋刀治疗假體研究Biomed Res Int.2014:741326亞洲首例,2008全骨髓放射治疗TMI l 與傳統治療方式之比較:Biomed Res Int.2013;2013:321762.l亞洲首例報告:Technol Cancer Res Treat.2009 Feb;8(1):29-38.世界首創,2015食管癌螺旋刀扇形挡块设计假體研究Biomed Res Int.2015:9595048螺旋断层放疗-亚洲区顶尖教学训练中心馬來西亞瑪麗亞山醫院馬來西
6、亞王子醫院復旦大學附設醫院香港伊利沙伯醫院2009年年2015年年新加坡、馬來西亞、菲律賓、香港、上海復旦、湖南岳陽與四川重慶共新加坡、馬來西亞、菲律賓、香港、上海復旦、湖南岳陽與四川重慶共19 人次人次荣获SNQ国家品质标章与香港伊莉莎白医院感谢状台湾区唯一螺旋断层放疗教学训练中心Department of Radiation OncologyFar Eastern Memorial Hospital,Taiwan 二元气动多叶准直器连续式旋转放射连续式治疗床前进250 cm/s leaf speed0.3%leaf transmissionEliminates field matching
7、 treat up to 160cm volumeThousands of radiation beamlets9Tomo治疗原理Department of Radiation OncologyFar Eastern Memorial Hospital,Taiwan 10l台灣Tomo放療設備現況Tomo facitilities in Taiwan l台灣食管癌流行病學Epidymiology of esophageal cancer in Taiwan l傳統食管癌放療的心臟併發症Cardiac morbidities after RT of esophageal cancer l螺旋斷層
8、放療的心臟保護治療計劃Heart sparing tomotherapy for esophageal cancer l總結Conclusion 大綱8th most common cancer worldwide456,000 new cases in 20126th most common cause of cancer death400,000 deathsM/F:2.4:1mortality:incidence:0.88高死亡率的全球十大癌病-食管癌WHO,2012全球男性食管癌发生率地图男男5757歲歲,女女6262歲歲年齡標準化發生率年齡標準化發生率14.5 vs.0.8 /101
9、4.5 vs.0.8 /10万万人人23482348人人 vs.148 vs.148人人男女比男女比=18:1=18:1菸酒檳高危險菸酒檳高危險男發生率排第男發生率排第6 6死亡率排第死亡率排第5 5Taiwan Cancer Registry,2013好发组织病理型态东西有别SCC(%)AdenoCa(%)Unspecified(%)Black89.47.12.8Chinese77.814.83.7Japanese69.727.3-Hispanic white45.847.93.2Non-hispanic white4350.52.9Taiwan Cancer Registry,2013Ta
10、iwan(2013)-SCC:Adeno=92.5:3.5Lambert et al.Endoscopy 2007;39:550-555National Department of Health,Taiwan,ROC.1972-2012.Cancer Registry Annual Report-5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 45.0 50.0 19881990199219941996199820002002200420062008201020122014口腔、口咽及下口腔、口咽及下咽癌咽癌肺癌肺癌食道癌食道癌胃癌胃癌肝及肝內膽管癌肝及肝內膽管癌
11、結腸直腸癌結腸直腸癌膽囊及膽道癌膽囊及膽道癌攝護腺癌攝護腺癌胰臟癌胰臟癌非何杰金淋巴癌非何杰金淋巴癌 每十萬人口死亡率每十萬人口死亡率 (男性男性)台湾男性常见癌病死亡率历年变化趋式鳞状上皮异型增生或食管癌機率高FEMH,129 H&N cancer patientssynchronous esophageal neoplasia11 low-grade intraepithelial neoplasia14 high-grade intraepithelial neoplasia12 invasive carcinoma stage IA:IB:IIA:IIIA=3:5:1:3 modifi
12、ed treatment strategy NNS(number needed to screen)=6.45(1/15.5%,95%CI=4.60-10.90)Chung CS et al.BMC Gastroenterology 2013Chung CS et al.Sci Rep 2016hypopharyngeal Cawhite-light endoscopy.narrow-band imagingNBI,magnifyingendoscopyLugol-unstained areaEndoscopic submucosal dissection SCC invading the l
13、amina propriaMost locally advancedesophagus cancersT1bN+or T2-T4aJAMA.1999,RTOG8501 NEJM 2012,Lancet Oncolog,2015,Cross TrialJCO,2009Cancer 2002,IJROBP;1999ABCDEDepartment of Radiation OncologyFar Eastern Memorial Hospital,Taiwan 17l台灣Tomo放療設備現況Tomo facitilities in Taiwan l台灣食管癌流行病學Epidymiology of e
14、sophageal cancer in Taiwan l傳統食管癌放療的心臟併發症Cardiac morbidities after RT of esophageal cancer l螺旋斷層放療的心臟保護治療計劃Heart sparing tomotherapy for esophageal cancer l總結Conclusion 大綱放射線加速小鼠动脉粥样硬化病变的发展並造成出血傾向Stewart A,et al.American Journal of Pathology,200614Gy照射區Female,22wk,0 Gy Female,22wk,14 Gy Ionizing Rad
15、iation Accelerates the Development of Atherosclerotic Lesions in ApoE/Mice and Predisposes to an Inflammatory Plaque Phenotype Prone to HemorrhageWeintraub NL,et al.J Am Coll Cardiol.2010辐射引起血管损伤和纤维化的机制NF-B=nuclear factor-kappa B.Thrombin is a key link between downregulated TM and radiation-induced
16、vascular and intestinal fibrosisWang J,et al.World J Gastroenterol,2007放疗引发迟发性心脏损伤 Congestive heart failure Ischemia Coronary artery disease Valvular disease Myocardial infarction Cardiac death霍奇金淋巴瘤的传统放疗明显造成心脏损伤242 times above baselineCardiac morbidity/mortalityCourtesy of Andrea K Ng,MD 左侧乳癌放疗要避免心
17、脏照射2013調強與調強與3D混合放療混合放療心臟劑量心臟劑量15.6GyTomo6.9Gy 3D 心臟劑量心臟劑量16.4GyFEMH experience吾23QUANTECLungThresholdToxicityMean lung dose7 Gy5%symptomatic pneumonitis13 Gy10%symptomatic pneumonitis20 Gy20%symptomatic pneumonitis24 Gy30%symptomatic pneumonitisV20 30 Gy 20%symptomatic pneumonitisHeartMean heart do
18、se 26 Gy 15%pericarditisV25 10%1%cardiac mortalityV30 46%15%pericarditisSpinal cordMaximum dose50 Gy0.2%myelopathy60 Gy6%myelopathyInt J Radiat Oncol Biol Phys.2010心肺脊髓的处方剂量限制临床正常组织效应量化分析(QUANTEC)Years after diagnosis Overall Survival IMRT 3DCRT p=0.009 Long-term outcomeCCRT,Eso Ca MDACC Experience
19、Lin et.al.,IJROBP 2012 Lin et.al.,IJROBP 2012 3DCRT的患者死于心脏疾病的机率比IMRT组高-MDACC食管癌长期存活者曾接受放疗死于心脏病的机率比未放疗组高Gharzai L,et al.PLoS ONE,2016OR 1.23,95%CI 1.031.47HR 1.96,95%CI 1.4662.624SEER dataDepartment of Radiation OncologyFar Eastern Memorial Hospital,Taiwan 27l台灣Tomo放療設備現況Tomo facitilities in Taiwan l
20、台灣食管癌流行病學Epidymiology of esophageal cancer in Taiwan l傳統食管癌放療的心臟併發症Cardiac morbidities after RT of esophageal cancer l螺旋斷層放療的心臟保護治療計劃Heart sparing tomotherapy for esophageal cancer l總結Conclusion 大綱Tumor Regression00.20.40.60.811.21.41.60246Weeks From 1st Tx DayFraction Regression#2#3#4AverageFitting
21、Courtesy of Yi-Jen Chen,M.D.,Ph.D食管癌放化疗中其体积可能缩小藉由Tomo每日MVCT可尽早修改治疗计画3DCRTProtonDose distributions and dosevolume histograms Makishima H,et al.J Radiat Res,2015250-MeV 40Gy/20fx+20Gy/0fxIMRT,Proton and 3D Conformal Radiotherapy(3D-CRT)for Reducing Perioperative Cardiopulmonary Complications in Esopha
22、geal Cancer Patients-3DCRTIMRTProton Ling TC,et al.Cancers 2014Loma LindaLing TC,et al.Cancers 2014亚东同步放化疗于中晚期食管癌之研究2007-2012,67 pts,cT2-4N0-3M0IMRT(N=33)vs.Tomo(N=34)more 5-FU alone,oral Ufur in IMRTmore Taxol,cetuximab in TomoOSDFSLCDMFS1y :61.4%v.s.76.5%2y :39.8%v.s.68.8%Tomo並未增加放射性肺炎发生率IMRT v.s.
23、Tomo(without Fan-Shaped Complete Block)21.2%(Gr 1:5,Gr 3:2)vs.2.9%(Gr 1:1),p=0.027Mean lung dose:15.1 Gy vs.15.4 Gy,P=0.520,15,10,5?TomoIMRT扇形全档块（Fan-Shaped Complete Block）于食管癌螺旋断层放疗治疗计划之运用：假体研究35BioMed Research International.2015 食管癌Tomo有無使用扇形全档块(FSCB)劑量分佈之比較FSCBFSCBFSCBNo FSCBNo FSCB下段食管癌Tomo使用扇形全
24、档块(FSCB)治疗计划之比較Material&Methodsl Retrospective review of RT treatment plannings(RTPs)-year:20072015-inclusion:19 RTPs of lower-third thoracic EC patients treated by Tomo-exclusion:skip lesions(tumor/lymph node)l Dose:normalize to 50 Gy/25 fractionsl non-block,FSCB,fan angle,homogeneous index,dosimet
25、ric quality for organs at risk(lung,heart,spinal cord)PatientEnrollmentRadiotherapyplanning systemDosimetricanalysisNon-block/FSCB38Dose Volume Histogram Lung(mean lung dose,V20,V15,V10,V5)Heart(mean heart dose,V40,V30,V20,V10,V5)Spinal cord(maximum dose)PTV(HI:homogeneous index)Homogeneous index(HI
26、):ratio of minimum dose received in 5%and 95%of the PTV.D95D5heartSpinal cordWhole lungPTVV2010總 結Long-term benefits of RT may be diminished by cardiac toxicity.Tomo achieves better conformity and unifomity;also reduce dose of OAR esp heartNarrow-FSCB plans of Tomo obtained significant lower mean heart dose for lower esophageal cancer.Heart-sparing RT could be considered for some locally advanced diseasepotentially curative intent,longer life expectancy,prior heart/lung disease,prior cardiac toxic agents,patients expectation,etc)
