双侧乳腺癌同步放疗设计中多射野中心及固定钨门技术的应用
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摘要
目的:拟利用双射野中心及固定钨门限定射野范围方式分别设计双侧乳腺癌的容积弧形旋转调强及三维静态调强放疗计划,并对两者放射治疗计划的结果进行评价,分析此放疗技术在临床治疗的可行性。方法:选取8例确诊且进行放疗的双侧乳腺癌患者进行回顾性研究。利用Ray Station v4.5系统,基于Trilogy加速器参数分别设计两种固定射野的调强计划:双射野中心容积旋转调强(D-VMAT)、双射野中心三维静态调强(D-sIMRT)。肿瘤计划靶区(PTV)处方剂量为5 000 cGy/25 f,要求双侧乳腺靶区PTV-L、PTV-R均至少95%以上的靶区体积达到处方剂量,利用剂量体积直方图及计划系统的Clincal goal工具比较两者剂量分布、靶区剂量的均匀性及适形性和心脏、双肺、肝脏、脊髓等重要危及器官的剂量差异。结果:两种双中心固定射野的调强计划均可以满足双侧乳腺肿瘤靶区的处方剂量,同时重要器官的剂量满足临床放疗医师限定标准。D-VMAT计划在剂量均匀性指数(HI)及靶区适形度指数(CI)方面均优于D-s IMRT计划(P<0.05)。两者在心脏V_(20)、肝脏V_5和D_(mean)以及脊髓D_(max)保护上并无明显差异。D-s IMRT与D-VMAT计划在全肺的剂量上相比较,后者可以显著降低全肺区域的剂量受量,V5(47.9%±4.6%vs 42.2%±3.9%, P=0.001)、V20(22.9%±6.7%vs 17.5%±4.3%, P=0.021)、V_(30)(15.7%±5.8%vs 11.7%±3.6%, P=0.031)、D_(mean)[(1 222.5±246.7)cGy vs(1 009.5±161.3)cGy, P=0.009],且能更好降低心脏的平均剂量(P<0.05);机器跳数MU为(1 177±311 vs 908±130, P=0.036)。结论:双射野中心及限定射野钨门技术的调强计划均可以满足双侧乳腺癌的临床放疗实施,同时D-VMAT计划可给予靶区更好的剂量均匀性及适形性,降低心脏和肺放疗损伤剂量以及提高治疗效率。
Objective To apply double-isocenter and fixed-jaw technology for the design of volumetric modulated arc therapy(VMAT) and static intensity-modulated radiotherapy(s IMRT) plans for bilateral breast cancer and evaluate the dosimetric results of the two plans, so as to discuss the feasibility of double-isocenter and fixed-jaw technology in radiotherapy for bilateral breast cancer. Methods The clinical data of 8 patients with confirmed bilateral breast cancer were retrospective analyzed. Based on Trilogy accelerator parameters, 2 fixed-field radiotherapy plans, namely double-isocenter VMAT(D-VMAT) and double-isocenter s IMRT(D-s IMRT), were designed on Ray Station v4.5 system. The planning target volume(PTV) was irradiated with a prescribed dose of 5 000 c Gy in 25 fractions. At least 95% of bilateral breast target areas, namely PTV-L and PTV-R, were covered with prescribed dose. The dose-volume histogram and the Clincal goal tool of treatment planning system were used to compare the target dose distribution, the conformity index and homogeneity index of PTV, and the dosimetric characteristics of organs-at-risk,such as heart, lungs, liver and spinal cord. Results Both of two radiotherapy plans satisfied the treatment criteria. The bilateral breast target areas were irradiated by prescribed dose and the doses of organs-at-risk were within the limits determined by the clinical physicists. D-VMAT was superior to D-sIMRT in the homogeneity index and conformity index of PTV(P<0.05). No statistical differences were found in the V_(20) of heart, the V5 and D_(mean) of liver and the D_(max) of spinal cord between two plans.However, the V_5, V20, V30 of lungs and mean lung dose were significantly reduced in D-VMAT as compared with D-sIMRT[47.9%±4.6% vs 42.2%±3.9%, 22.9%±6.7% vs 17.5%±4.3%, 15.7%±5.8% vs 11.7%±3.6%,(1 222.5±246.7) cGy vs(1 009.5±161.3) cGy; P=0.001, 0.0021, 0.031, 0.009]. Moreover, compared with D-sIMRT, D-VMAT decreased the mean dose of heart(P<0.05) and increased monitor units(1 177±311 vs 908±130, P=0.036). Conclusion The radiotherapy plan using doubleisocenter and fixed-jaw technology meets the requirements of radiotherapy for bilateral breast cancer. Meanwhile, D-VMAT not only achieves better homogeneity index and conformity index of target areas, but also reduces the radiation-induced injuries to heart and lung and increase the efficiency of treatment.
Objective To apply double-isocenter and fixed-jaw technology for the design of volumetric modulated arc therapy(VMAT) and static intensity-modulated radiotherapy(s IMRT) plans for bilateral breast cancer and evaluate the dosimetric results of the two plans, so as to discuss the feasibility of double-isocenter and fixed-jaw technology in radiotherapy for bilateral breast cancer. Methods The clinical data of 8 patients with confirmed bilateral breast cancer were retrospective analyzed. Based on Trilogy accelerator parameters, 2 fixed-field radiotherapy plans, namely double-isocenter VMAT(D-VMAT) and double-isocenter s IMRT(D-s IMRT), were designed on Ray Station v4.5 system. The planning target volume(PTV) was irradiated with a prescribed dose of 5 000 c Gy in 25 fractions. At least 95% of bilateral breast target areas, namely PTV-L and PTV-R, were covered with prescribed dose. The dose-volume histogram and the Clincal goal tool of treatment planning system were used to compare the target dose distribution, the conformity index and homogeneity index of PTV, and the dosimetric characteristics of organs-at-risk,such as heart, lungs, liver and spinal cord. Results Both of two radiotherapy plans satisfied the treatment criteria. The bilateral breast target areas were irradiated by prescribed dose and the doses of organs-at-risk were within the limits determined by the clinical physicists. D-VMAT was superior to D-sIMRT in the homogeneity index and conformity index of PTV(P<0.05). No statistical differences were found in the V_(20) of heart, the V5 and D_(mean) of liver and the D_(max) of spinal cord between two plans.However, the V_5, V20, V30 of lungs and mean lung dose were significantly reduced in D-VMAT as compared with D-sIMRT[47.9%±4.6% vs 42.2%±3.9%, 22.9%±6.7% vs 17.5%±4.3%, 15.7%±5.8% vs 11.7%±3.6%,(1 222.5±246.7) cGy vs(1 009.5±161.3) cGy; P=0.001, 0.0021, 0.031, 0.009]. Moreover, compared with D-sIMRT, D-VMAT decreased the mean dose of heart(P<0.05) and increased monitor units(1 177±311 vs 908±130, P=0.036). Conclusion The radiotherapy plan using doubleisocenter and fixed-jaw technology meets the requirements of radiotherapy for bilateral breast cancer. Meanwhile, D-VMAT not only achieves better homogeneity index and conformity index of target areas, but also reduces the radiation-induced injuries to heart and lung and increase the efficiency of treatment.
引文
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[7] MANSOURI S, NAIM A, GLARIA L, et al. Dosimetric evaluation of3-D conformal radiotherapy and intensity-modulated radiotherapy for left breast cancer after conservative surgery[J]. Asian Pac J Cancer Prev, 2013, 18(11):S171-S172.
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[9] PANET-RAYMOND V, ANSBACHER W, ZAVGORODNI S, et al.Coplanar versus noncoplanar intensity-modulated radiation therapy(IMRT)and volumetric-modulated arc therapy(VMAT)treatment planning for fronto-temporal high-grade glioma[J]. J Appl Clin Med Phys, 2012, 13(4):44-53.
[10]HODAPP N. The ICRU report 83:prescribing, recording and reporting photon-beam intensity-modulated radiation therapy(IMRT)[J].Strahlenther Onkol, 2012, 188(1):97-99.
[11]HARTMAN M, CZENE K, REILLY M, et al. Incidence and prognosis of synchronous and metachronous bilateral breast cancer[J]. J Clin Oncol, 2007, 25(27):4210-4216.
[12]JOBSEN J J, PALEN J V, ONG F, et al. Synchronous, bilateral breast cancer:prognostic value and incidence[J]. Breast, 2003, 12(2):83-88.
[13]QI S, LIU R, LIAN J, et al. Volumetric modulated arc therapy for prostate radiation:a dosimetric comparison between VMAT techniques and fixed-beam IMRT[J]. Med Phys, 2012, 39(6):3837-3838.
[14]HAERTL P M, POHL F, WEIDNER K, et al. Treatment of left sided breast cancer for a patient with funnel chest:volumetric-modulated arc therapy vs. 3D-CRT and intensity-modulated radiotherapy[J]. Med Dosim, 2013, 38(1):1-4.
[15]MO J C, HUANG J, GU W D, et al. A dosimetric comparison of double-arc volumetric arc therapy, step-shoot intensity modulated radiotherapy and 3D-CRT for left-sided breast cancer radiotherapy after breast-conserving surgery[J]. Technol Health Care, 2017, 25(5):851-858.
[16]CHEN-HSI H, YU-CHIN L, KUO-HSIN C, et al. Image-guided intensity-modulated radiotherapy for refractory bilateral breast cancer in a patient with extensive cutaneous metastasis in the chest and abdominal walls[J]. Onco Targets Ther, 2016, 9:3025-3030.
[17]邵凯南,杜锋磊,李剑龙. Ray Arc在胸部旋转调强放射治疗计划设计中的应用[J].中国医学物理学杂志, 2017, 34(2):131-138.SHAO K N, DU F L, LI J L. Application of RayArc in volumetric modulated arc therapy planning of chest cancer[J]. Chinese Journal of Medical Physics, 2017, 34(2):131-138.
[18]KIM S J, LEE M J, YOUN S M. Radiation therapy of synchronous bilateral breast carcinoma(SBBC)using multiple techniques[J]. Med Dosim, 2018, 43(1):55-68.
[19]BOMAN E, ROSSI M, KAPANEN M. The robustness of dual isocenter VMAT radiation therapy for bilateral lymph node positive breast cancer[J]. Phys Med, 2017, 44:11-17.
[20]EKICI K, GOKCE T, KARADOGAN I, et al. Is helical tomotherapybased intensity-modulated radiotherapy feasible and effective in bilateral synchronous breast cancer? A two-center experience[J]. J BUON, 2016, 21(1):46-52.
[2] LIU H, CHEN X, HE Z, et al. Evaluation of 3D-CRT, IMRT and VMAT radiotherapy plans for left breast cancer based on clinical dosimetric study[J]. Comput Med Imaging Graph, 2016, 54:1-5.
[3] ZHAO H, HE M, CHENG G, et al. A comparative dosimetric study of left sided breast cancer after breast-conserving surgery treated with VMAT and IMRT[J]. Radiat Oncol, 2015, 10(1):231-241.
[4] HACIISLAMOGLU E, COLAK F, CANYILMAZ E, et al. Dosimetric comparison of left-sided whole-breast irradiation with 3DCRT,forward-planned IMRT, inverse-planned IMRT, helical tomotherapy,and volumetric arc therapy[J]. Phys Med, 2015, 31(4):360-367.
[5] LAUCHE O, KIROVA Y M, FENOGLIETTO P, et al. Helical tomotherapy and volumetric modulated arc therapy:new therapeutic arms in the breast cancer radiotherapy[J]. World J Radiol, 2016, 8(8):735-742.
[6] IN YOUNG J, SHIN-WOOK K, SEOK HYUN S. Dosimetric evaluation of the skin-sparing effects of 3-dimensional conformal radiotherapy and intensity-modulated radiotherapy for left breast cancer[J]. Oncotarget, 2017, 8(2):3059-3063.
[7] MANSOURI S, NAIM A, GLARIA L, et al. Dosimetric evaluation of3-D conformal radiotherapy and intensity-modulated radiotherapy for left breast cancer after conservative surgery[J]. Asian Pac J Cancer Prev, 2013, 18(11):S171-S172.
[8] PASLER M, GEORG D, BARTELT S, et al. Node-positive left-sided breast cancer:does VMAT improve treatment plan quality with respect to IMRT?[J]. Strahlenther Onkol, 2013, 189(5):380-386.
[9] PANET-RAYMOND V, ANSBACHER W, ZAVGORODNI S, et al.Coplanar versus noncoplanar intensity-modulated radiation therapy(IMRT)and volumetric-modulated arc therapy(VMAT)treatment planning for fronto-temporal high-grade glioma[J]. J Appl Clin Med Phys, 2012, 13(4):44-53.
[10]HODAPP N. The ICRU report 83:prescribing, recording and reporting photon-beam intensity-modulated radiation therapy(IMRT)[J].Strahlenther Onkol, 2012, 188(1):97-99.
[11]HARTMAN M, CZENE K, REILLY M, et al. Incidence and prognosis of synchronous and metachronous bilateral breast cancer[J]. J Clin Oncol, 2007, 25(27):4210-4216.
[12]JOBSEN J J, PALEN J V, ONG F, et al. Synchronous, bilateral breast cancer:prognostic value and incidence[J]. Breast, 2003, 12(2):83-88.
[13]QI S, LIU R, LIAN J, et al. Volumetric modulated arc therapy for prostate radiation:a dosimetric comparison between VMAT techniques and fixed-beam IMRT[J]. Med Phys, 2012, 39(6):3837-3838.
[14]HAERTL P M, POHL F, WEIDNER K, et al. Treatment of left sided breast cancer for a patient with funnel chest:volumetric-modulated arc therapy vs. 3D-CRT and intensity-modulated radiotherapy[J]. Med Dosim, 2013, 38(1):1-4.
[15]MO J C, HUANG J, GU W D, et al. A dosimetric comparison of double-arc volumetric arc therapy, step-shoot intensity modulated radiotherapy and 3D-CRT for left-sided breast cancer radiotherapy after breast-conserving surgery[J]. Technol Health Care, 2017, 25(5):851-858.
[16]CHEN-HSI H, YU-CHIN L, KUO-HSIN C, et al. Image-guided intensity-modulated radiotherapy for refractory bilateral breast cancer in a patient with extensive cutaneous metastasis in the chest and abdominal walls[J]. Onco Targets Ther, 2016, 9:3025-3030.
[17]邵凯南,杜锋磊,李剑龙. Ray Arc在胸部旋转调强放射治疗计划设计中的应用[J].中国医学物理学杂志, 2017, 34(2):131-138.SHAO K N, DU F L, LI J L. Application of RayArc in volumetric modulated arc therapy planning of chest cancer[J]. Chinese Journal of Medical Physics, 2017, 34(2):131-138.
[18]KIM S J, LEE M J, YOUN S M. Radiation therapy of synchronous bilateral breast carcinoma(SBBC)using multiple techniques[J]. Med Dosim, 2018, 43(1):55-68.
[19]BOMAN E, ROSSI M, KAPANEN M. The robustness of dual isocenter VMAT radiation therapy for bilateral lymph node positive breast cancer[J]. Phys Med, 2017, 44:11-17.
[20]EKICI K, GOKCE T, KARADOGAN I, et al. Is helical tomotherapybased intensity-modulated radiotherapy feasible and effective in bilateral synchronous breast cancer? A two-center experience[J]. J BUON, 2016, 21(1):46-52.