学科主题临床医学
病例为基础的局部晚期NSCLC靶区勾画共识与争议
赵丹; 傅小龙; 王绿化; 曲宝林; 李宝生; 赵路军; 徐向英; 王建华; 曲雅勤; 祝淑钗; 郁志龙; 李光; 于洪; 杨永净; 李杰; 徐博; 殷蔚伯; 朱广迎
关键词癌,非小细胞肺/调强放射疗法 靶区勾画 共识 Carcinoma non-small cell lung/radiotherapy Delineation Consensus
刊名中华放射肿瘤学杂志
2017
DOI10.3760/cma.j.issn.1004-4221.2017.09.002
26期:9页:985-991
关键词[WOS]癌,非小细胞肺/调强放射疗法 ; 靶区勾画 ; 共识 ; Carcinoma ; non-small cell lung/radiotherapy ; Delineation ; Consensus
摘要目的 分析局部晚期NSCLC靶区勾画中的专家共识与争议.方法 调查国内12家单位对NSCLC靶区勾画相关15个问题意见.由复旦大学附属肿瘤医院选择1份局部晚期NSCLC病例,将定位CT图像和病史资料发送至12家单位,各单位自行组织讨论并委派1位医师在第六届肿瘤精准放化疗暨肺癌多学科高峰论坛上主讲对该病例靶区勾画情况及理论认识,参会专家共同讨论.结果 12家单位全部填写问卷并按时发回.肺癌靶区勾画标准肺窗的窗宽/窗位为800~1600/-600~-750 HU,纵隔窗为350~400/20~40 HU.呼吸动度的测量:经验外扩2~5 mm、模拟定位机测定、四维CT测定、模拟定位机+四维CT测定.GTV外扩CTV距离:原发灶鳞癌5~6 mm、腺癌5~8 mm;纵隔淋巴结转移灶6家单位采用5 mm,6家单位采用同原发病灶一致距离.摆位误差:10家单位5 mm、1家单位3 mm、1家单位4~6 mm.双肺V20限定:10家单位<30%、1家单位<35%、1家单位<28%.局部晚期NSCLC同步放化疗放疗剂量:9家单位60 Gy分30次、1家单位62.7 Gy分33次、1家单位50~60 Gy分25~30次、1家单位60~70 Gy分25~30次.肺内原发病灶靶区勾画:3家GTV→IGTV→PTV、8家GTV→CTV→ITV→PTV、1家GTV→CTV→PTV或GTV→IGTV→CTV→PTV;纵隔淋巴结转移灶靶区勾画:3家GTV→IGTV→PTV、8家GTV→CTV→ITV→PTV、1家GTV→CTV→PTV.放疗过程中10%~100%患者需要改野,38~50 Gy时改野合适.关于PET-CT定位及靶区勾画SUV值尚无统一标准,7家单位已开展MRI定位,10家单位已开展了SBRT治疗早期NSCLC.早期NSCLC (T1-2N0M0)的SBRT靶区勾画:5家单位GTV→IGTV→PTV、3家单位IGTV→PTV、2家单位GTV→CTV→ITV→PTV.周围型早期NSCLC分割6.0~12.5 Gy/次,3~12次;中央型早期NSCLC分割4.6~10.0 Gy/次,5~10次.靶区勾画讨论结果:肺癌靶区勾画目前应采用4DCT或模拟机测定呼吸动度;勾画肺癌靶区时CT肺窗的窗宽/窗位为1600/-600 HU,纵隔窗为400/20 HU;争议主要是纵隔转移淋巴结CTVnd为累及野照射还是选择性淋巴结预防照射.结论 对局部晚期NSCLC靶区勾画的CT的窗宽、窗位,呼吸运动和摆位误差测量、原发灶靶区勾画方法、同步放化疗放疗剂量及改野时机均已基本达成共识.主要争议和尚未达成共识的是PET-CT定位勾画靶区时显示病灶的最佳SUV值、SBRT治疗早期NSCLC最佳剂量分割模式、CTVnd的勾画. Objective To investigate the consensus and controversies on the delineation of radiotherapy target volume for patients with locally advanced non-small cell lung cancer (LA-NSCLC).Methods Questionnaires including 15 questions on the delineation of radiotherapy target volume of NSCLC were sent to 12 radiation departments in China in November 2015.A patient with LA-NSCLC was selected by Fudan University Shanghai Cancer Center, and simulation CT images and medical history data were sent to the 12 radiation departments.Twelve radiation oncologists from the 12 radiation departments showed and explained the delineation of radiotherapy target volume of their own, and the patient was discussed by all experts in the sixth multidisciplinary summit forum of precise radiotherapy and chemotherapy for tumor and lung cancer.Results All receivers of the questionnaire answered the questions.The standard lung window width/level for the delineation of lung cancer was 800-1600/-600 to-750 HU, and the mediastinum window was 350-400/20-40 HU.Respiratory movement was measured by stimulator, 4D-CT, and stimulator+4D-CT with 2-5 mm expansion based on experience.The primary clinical target volume (CTV) was defined as gross target volume (GTV) plus 5-6 mm for squamous carcinoma/5-8 mm for adenocarcinoma.The metastatic lesion of mediastinal lymph nodes was delineated as 5 mm plus primary lesion in 6 departments and as primary lesion in another 6 departments.Of the 12 departments, 10 applied 5 mm of set-up error, 1 applied 3 mm, and 1 applied 4-6 mm.For V20 of the lungs, 10 departments defined it as<30%, 1 as<35%, and 1 as 28%.Nine departments defined the radiation dose of concurrent chemoradiotherapy (CCRT) for LA-NSCLC as 60 Gy in 30 fractions, 62.7 Gy in 33 fractions in 1 department, 50-60 Gy in 25-30 fractions in 1 department, and 60-70 Gy in 25-30 fractions in 1 department.For the delineation of target volume for the LA-NSCLC patient treated with CCRT, the primary planning target volume (PTV) was defined as GTV plus organ movement (IGTV) and set-up error (GTV→IGTV→PTV) in 3 departments, as CTV plus organ movement (ITV) and set-up error (GTV→CTV→ITV→PTV) in 8 departments, and as CTV plus set-up error/IGTV plus 5-6 mm for squamous carcinoma/5-8 mm for adenocarcinoma (CTV) and set-up error (GTV→CTV→PTV/GTV→IGTV→CTV→PTV) in 1 department.For the delineation of PTV in the mediastinal lymph node, GTV→IGTV→PTV was performed in 3 departments, GTV→CTV→ITV→PTV in 8 departments, and GTV→CTV→PTV in 1 department.For 10%-100% patients with LA-NSCLC, the radiation field needed to be replanned when 38-50 Gy was completed.There was no unified standard for the optimal standardized uptake value (SUV) of positron emission tomography (PET)-computed tomography (CT) simulation and delineation.Seven departments had applied magnetic resonance imaging (MRI) simulation and 10 departments had applied stereotactic body radiation therapy (SBRT) for the treatment of early-stage NSCLC.For the delineation of PTV for early-stage NSCLC (T1-2N0M0), GTV→IGTV→PTV was performed in 5 departments, IGTV→PTV in 3 departments, and GTV→CTV→ITV→PTV in 2 departments.In all the 12 departments, peripheral early-stage NSCLC was given 6.0-12.5 Gy/fraction, 3-12 fractions and central early-stage NSCLC was given 4.6-10.0 Gy/fraction, 5-10 fractions.The results of discussion on the delineation of target volume for the patient were as follows:respiratory movements should be measured by 4D-CT or simulator;the lung window width/level is 1600/-600 HU and the mediastinal window width/level is 400/20 HU;the primary controversy is whether the involved-field irradiation or elective nodal irradiation should be used for the delineation of CTVnd in the mediastinal lymph node.Conclusions Basic consensus is reached for the delineation of target volume in LANSCLC in these aspects:lung window width/level, respiratory movements and set-up error, primary lesion delineation, the radiation dose in CCRT, and the optimal time for replanning the radiation field.There are controversies on the optimal SUV in the delineation of target volume based on PET-CT simulation, the optimal dose fractionation in SBRT for early-stage NSCLC, and the delineation of CTVnd.
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第一作者单位北京大学肿瘤医院暨北京市肿瘤防治研究所放疗科恶性肿瘤发病机制及转化研究教育部重点实验室, 100142
ISSN1004-4221
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文献类型期刊论文
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条目标识符http://ir.bjmu.edu.cn/handle/400002259/141890
专题北京大学临床肿瘤学院_恶性肿瘤发病机制及转化研究教育部重点实验室
北京大学第一临床医学院_口腔科
北京大学临床肿瘤学院_肿瘤放疗科
北京大学临床肿瘤学院_后勤处
作者单位100142,北京大学肿瘤医院暨北京市肿瘤防治研究所放疗科恶性肿瘤发病机制及转化研究教育部重点实验室; 上海交通大学附属胸科医院放疗科; 中国医学科学院肿瘤医院放疗科; 解放军总医院放疗科; 山东省肿瘤医院放疗科; 天津市肿瘤医院放疗科; 哈尔滨医科大学附属肿瘤医院放疗科; 郑州大学附属肿瘤医院放疗科; 吉林大学第一医院放疗科; 河北医科大学第四医院放疗科; 内蒙古医学院附属医院放疗科; 中国医科大学第一附属医院放疗科; 辽宁省肿瘤医院放疗科; 吉林省肿瘤医院放疗科; 山西省肿瘤医院放疗科; 中日友好医院呼吸中心肺癌中心放射肿瘤科国家呼吸疾病临床研究中心 北京大学医学部
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赵丹,傅小龙,王绿化,等. 病例为基础的局部晚期NSCLC靶区勾画共识与争议[J]. 中华放射肿瘤学杂志,2017,26(9):985-991.
APA 赵丹.,傅小龙.,王绿化.,曲宝林.,李宝生.,...&朱广迎.(2017).病例为基础的局部晚期NSCLC靶区勾画共识与争议.中华放射肿瘤学杂志,26(9),985-991.
MLA 赵丹,et al."病例为基础的局部晚期NSCLC靶区勾画共识与争议".中华放射肿瘤学杂志 26.9(2017):985-991.
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