1、前列腺癌靶区勾画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前列腺癌发病率和死亡率国别国别发病率发病率死亡率死亡率美国美国23万万（95.1/10万）万）3万万中国中国7/10万万(城市城市8.51/10万万)2.72/10万万GroupMSKCC(T1-T2 1819)Cleveland Clinic Foundation(localized prostate cancer 1682)Cases7-year bRFS Cases8-year bRFS Brachy73374%EBRT34077%628 70%,RP 74679%1054 72%P=0.1P0.05Radiothe
2、r 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除与放射治疗疗效相当解解 剖剖AnatomyYellow:Peripheral gland Blue:Transitional zoneRed:Central glandGreen:Anterior fibromuscular zone前列腺癌的靶区包括范围前列腺癌的靶区包括范围 前列腺前列腺 精囊腺精囊腺 盆腔淋巴引流区盆腔淋巴引流区前列腺及包膜受侵情况前列腺及包膜受侵
3、情况CTV in Prostate Cancer CTV=prostate (+SV)+LN Extracapsular Extension associated with PSA,GS,and T stages P=:3/2(PSA)+(Gleason score 3)x10 Partins TablesRoach III.J Urol 150:1923-24,1993Wang L,Radiology 2004Extracapsular Extension MSKCC：RP术后，术后，185/712(26%)中位包膜外中位包膜外扩展距离扩展距离2 mm0.5-12 mm平均包膜外平均包膜外扩
4、展距离扩展距离2.93 mmSD 2.3 mm 勾画前列腺勾画前列腺CTV时，幷不必刻意外扩很时，幷不必刻意外扩很大边界大边界精囊腺受侵情况精囊腺受侵情况SV involvementKestin et al IJROBP 2002William Beaumont：RP术后，术后，51/344，81 SV+中位中位SV长度长度 3.5 cm0.7 8.5 cm中位中位SV侵犯长侵犯长度度1.0 cm(7%1.0 Cm1%2.0 Cm）0.23.8 cmSV+associated with PSA,GS,and T stagesLow RiskIntermediate RiskHigh Risk1
5、 high-risk2 high-risk3 high-risk1%15%15%32%58%27%Kestin et al IJROBP 2002SV involvementKestin et al IJROBP 2002 When treating the SV for prostate cancer,only the proximal 2.0 2.5 cm be included within the CTVKestin et al IJROBP 2002 SV invasion P=(PSA)+(Gleason score 6)x10 Partins TablesRoach III.J
6、Urol 150:1923-24,1993前列腺癌淋巴引流前列腺癌淋巴引流18 patients with pathologically proven lymph node metastases 69Nodal Locationlymph node metastases(N)ParaAortic14Common iliac13Ext Iliac29Int Iliac11Perirectal2Total69Shih et al IJROBP Nov 2005Massachusetts General HospitalProstate Cancer Nodal Spread Step wise f
7、rom pelvis to abdomen Nodal metastases more likely with:lIncreasing T stagelIncreasing PSAlIncreasing GS LNM%=2/3(PSA)+(Gs 6)x10 Partins TablesRoach 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
8、-sacral lymph nodes Para Aortic(optional)Prostate Cancer pelvic nodal irradiationMSKCC 前列腺癌放疗指南前列腺癌放疗指南结合结合2009.2 NCCN指南指南Clinical Target VolumeRisk Group Low-Risk Intermediate-RiskHigh-RiskT1T2aPSA 10 ng/mL GS 20 ng/mL GS 810CTVProstate OnlyProstate+2-2.5Cm SVProstate+2-2.5Cm SV+Nodal regions(when
9、risk of involvement 15%)Risk stratification and treatment recommendationLow riskIntermediate riskHigh riskT1T2aPSA 10 ng/mL GS 20 ng/mL GS 8103DCRT/IMRT=70 Gy3DCRT/IMRT=76 Gy3DCRT/IMRT 76 Gy+neoadjuvant and adjuvant ADTSimulation CT Scan:from bottom of SI joints to 1.5 cm below the level of ischial
10、tuberosities.Maximal slice thickness of 5 mm Patient set-up:be treated in the supine position.Immobilization: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 t
11、o sim/treatment,patient to drink 500cc water soon thereafter)Rectum:Instruct patients to evacuate their 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 w
12、all:from 1 cm above to 1 cm below the PTV.Consider contouring the whole length of the rectum.Contour 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：靶区勾画规定：CTV=GTV PTV=CTV+1 cm margin，向后方向，向后方向仅外放仅外放0.5 cm以减少直肠照射。
13、以减少直肠照射。缩缩 野野 from PTV1 volume to PTV2 volume between 46 and 60 Gy.Dose constraints rectum50 Gy 50%70 Gy 20%the bladder55 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 a
14、cquired at least weekly during treatment.前列腺和精囊腺的前列腺和精囊腺的CTV包含盆腔淋巴结预防照射的前列包含盆腔淋巴结预防照射的前列腺癌靶区勾画腺癌靶区勾画RTOG GU REACH CONSENSUS ON PELVICLYMPH NODE the pelvic lymph node volumes to be irradiated include:l distal common iliac,l presacral lymph nodes(S1-S3)l external iliac lymph nodesl internal iliac lymp
15、h nodeslobturator lymph nodesIJROBP,2008RTOG GU REACH CONSENSUS ON PELVICLYMPH NODE CTVs include the vessels(artery 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,2008uL5/S1水平包全髂总骶前淋巴结IJROBP,
16、20081.5 Cm0.7 CmuS1-S3水平包全髂内外和骶前淋巴结uCarve out小肠、膀胱、肌肉和骨等IJROBP,2008uS3以下包全髂内外淋巴结u骶前淋巴结终止于梨状肌出现层面IJROBP,2008u髂外淋巴结一直要勾画至股骨头顶端层u即腹股沟韧带处（髂外A与股A分界处IJROBP,2008u 闭孔淋巴结要勾画至耻骨联合上缘水平 IJROBP,2008我们科勾画情况我们科勾画情况References RTOG GU RADIATION ONCOLOGY SPECIALISTS REACH CONSENSUS ON PELVIC LYMPH NODE VOLUMES FOR HI
17、GH-RISK PROSTATE CANCER.Int.J.Radiation Oncology Biol.Phys.,2008 EAU guidelines on prostate cancer Mapping of nodal disease in locally advanced prostate cancer:Rething the clinical target volume for pelvic nodal irradiation based on vascular rather than bony anatomy.MSKCC 临床前列腺癌放疗指南 2008年ESTRO前列腺癌靶区勾画 2008年SANTRO会议 2009.2 NCCN guideline 殷主任主编，肿瘤放射治疗学第四版李主任：前列腺癌谢谢 谢！谢！
