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1、前列腺癌靶区勾画,前列腺癌靶区勾画,前列腺癌发病率和死亡率,前列腺癌发病率和死亡率,Radiother Oncol. 2004 Apr;71(1):29-33.,J Clin Oncol. 2002 Aug 15;20(16):3376-85.,Radiother Oncol. 2004 Apr;71(1,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,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,解 剖,解 剖,Anatomy,Yellow: Peripheral gland Blue: Transitional zoneRed: Central glandGreen: A
2、nterior fibromuscular zone,AnatomyYellow: Peripheral glan,前列腺癌的靶区包括范围,前列腺精囊腺盆腔淋巴引流区,前列腺癌的靶区包括范围前列腺,前列腺及包膜受侵情况,前列腺及包膜受侵情况,CTV in Prostate Cancer,CTV=prostate (+SV) +LN ,CTV in Prostate CancerCTV=pros,Extracapsular Extension associated with PSA , GS, and T stages,P = : 3/2(PSA) + (Gleason score 3) x10
3、Partins Tables,Roach III. J Urol 150: 1923-24, 1993,Extracapsular Extension associ,Wang L, Radiology 2004,Extracapsular Extension,Wang L, Radiology 2004Extracap,勾画前列腺CTV时，幷不必刻意外扩很大边界,勾画前列腺CTV时，幷不必刻意外扩很大边界,精囊腺受侵情况,精囊腺受侵情况,SV involvement,Kestin et al IJROBP 2002,SV involvementKestin et al IJR,SV+ asso
4、ciated with PSA , GS, and T stages,Kestin et al IJROBP 2002,SV+ associated with PSA , GS,SV involvement,Kestin et al IJROBP 2002,SV involvementKestin et al IJR,When treating the SV for prostate cancer, only the proximal 2.0 2.5 cm be included within the CTV,Kestin et al IJROBP 2002,When treating the
5、 SV for prost,SV invasion,P= (PSA) + (Gleason score 6) x10Partins Tables,Roach III. J Urol 150: 1923-24, 1993,SV invasionP= (PSA) + (Gle,前列腺癌淋巴引流,前列腺癌淋巴引流,18 patients with pathologically proven lymph node metastases 69,Shih et al IJROBP Nov 2005,Massachusetts General Hospital,18 patients with pathol
6、ogicall,前列腺癌靶区勾画,Prostate Cancer Nodal Spread,Step wise from pelvis to abdomenNodal metastases more likely with:Increasing T stageIncreasing PSAIncreasing GS,Prostate Cancer Nodal SpreadSt,LNM%= 2/3(PSA) + (Gs 6)x10Partins Tables,Roach III. J Urol 150: 1923-24, 1993,LNM%= 2/3(PSA) + (Gs 6)x10R,Exter
7、nal iliac lymph nodes Internal iliac lymph nodes Obturator groupPerirectal LNPart of the common iliac nodesS1-3 pre-sacral lymph nodes Para Aortic (optional),Prostate Cancer pelvic nodal irradiation,External iliac lymph nodes Pro,MSKCC 前列腺癌放疗指南,结合2009.2 NCCN指南,MSKCC 前列腺癌放疗指南结合2009.2 NCCN指南,Clinical
8、Target Volume,Clinical Target Volume,Risk stratification and treatment recommendation,Risk stratification and tre,Simulation,CT Scan: from bottom of SI joints to 1.5 cm below the level of ischial tuberosities. Maximal slice thickness of 5 mmPatient set-up: be treated in the supine position. Immobili
9、zation: employ immobilization system that keeps random and systematic errors to acceptable limits,SimulationCT Scan: from bottom,Bladder：size should not vary between simulation and treatments. (e.g. bladder to be emptied 1 h prior to sim/treatment, patient to drink 500cc water soon thereafter) Rectu
10、m: Instruct patients to evacuate their bowels prior to planning and treatment.,Bladder：size should not vary b,Contouring:,Prostate apex: situated above the urogenital diaphragm. 5mm above the bulbospongiosus Contour base of SV only, if no clinical SV involvement. Rectal wall: from 1 cm above to 1 cm
11、 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.,Contouring:Prostate apex: sit,靶区勾画规定：,CTV = GTVPTV = CTV + 1 cm margin，向后方向仅外放0.5 cm以减少直肠照射。,靶区
12、勾画规定：,缩 野,from PTV1 volume to PTV2 volume between 46 and 60 Gy.,缩 野from PTV1 volume to PTV2,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% 50GySmall Bowel: 0% 52Gy; V505%Large Bowel: 0% 55Gy; V5010%,Dose constraints rectum,Ver
13、ification,Isocentre check using AP and lateral films be acquired at least weekly during treatment.,VerificationIsocentre check u,前列腺和精囊腺的CTV,前列腺和精囊腺的CTV,前列腺癌靶区勾画,前列腺癌靶区勾画,前列腺癌靶区勾画,前列腺癌靶区勾画,前列腺癌靶区勾画,包含盆腔淋巴结预防照射的前列腺癌靶区勾画,包含盆腔淋巴结预防照射的前列腺癌靶区勾画,RTOG GU REACH CONSENSUS ON PELVICLYMPH NODE,the pelvic lymph
14、 node volumes to be irradiated include: distal common iliac, presacral lymph nodes (S1-S3) external iliac lymph nodes internal iliac lymph nodesobturator lymph nodes,IJROBP, 2008,RTOG GU REACH CONSENSUS ON PEL,RTOG GU REACH CONSENSUS ON PELVICLYMPH NODE,CTVs include the vessels (artery and vein) and
15、 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, 2008,RTOG GU REACH CONSENSUS ON PEL,L5/S1水平包全髂总骶前淋巴结,IJROBP, 2008,1.5 Cm,0.7 Cm,L5/S1水平包全髂总骶前淋巴结IJROBP, 20081.,S1-S3水平包全髂内外和骶前淋巴结Carve out小肠、膀胱、肌肉和骨等,
16、IJROBP, 2008,S1-S3水平包全髂内外和骶前淋巴结IJROBP, 2008,S3以下包全髂内外淋巴结骶前淋巴结终止于梨状肌出现层面,IJROBP, 2008,S3以下包全髂内外淋巴结IJROBP, 2008,髂外淋巴结一直要勾画至股骨头顶端层即腹股沟韧带处（髂外A与股A分界处,IJROBP, 2008,髂外淋巴结一直要勾画至股骨头顶端层IJROBP, 2008,闭孔淋巴结要勾画至耻骨联合上缘水平,IJROBP, 2008,闭孔淋巴结要勾画至耻骨联合上缘水平 IJROBP, 200,我们科勾画情况,我们科勾画情况,前列腺癌靶区勾画,References,RTOG GU RADIATI
17、ON ONCOLOGY SPECIALISTS REACH CONSENSUS ON PELVIC LYMPH NODE VOLUMES FOR HIGH-RISK PROSTATE CANCER. Int. J. Radiation Oncology Biol. Phys., 2008EAU guidelines on prostate cancerMapping 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,ReferencesRTOG GU RADIATION ON,感谢聆听,感谢聆听,
