2018年食管癌放化疗面临的挑战和对策-文档资料.ppt
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1、1,发病率高 死亡率高 早诊率低 生存率低,2,放化疗最佳受益人群?,辅助化疗需要吗?,一,三,二,四,问题与挑战,靶区如何勾画?,放疗最佳剂量?,?,3,一、放化疗最佳受益人群?,RTOG8501实验 123例T13N01M0的食管癌患者,其中82%为鳞癌,随机分为两组,单放64y,放疗50.4Gy 同步PF方案4W/次,共4次,4,5,Definitive chemoradiotherapy for T4 and/or M1 lymph node squamous cell carcinoma of the esophagus,T4M0 21例,T2M1a1例,T3M1a17例,T4M1a
2、15例。 49例 (91%) 按规定完成同步放化疗。 18例 (33%) 临床完全缓解,其中36例T4期患者有9例 (25%) 、18例非T4期有9例 (50%) 临床完全缓解。 主要毒副作用为血液学毒性和放射性食管炎,4例 (7%) 治疗相关死亡 。 中位随访43个月,中位生存时间 9个月, 3年生存率 23%。,J Clin Oncol. 1999 Sep;17(9):2915-21.,6,2005.1-2006.12,共153例鳞癌,不能手术 3D-CRT 35%同步铂类化疗 中位剂量64GY(50-74GY) 5Y-OS 26.3% 预后因素:GTV和病灶长度,7,Preoperati
3、ve Chemoradiotherapy for Esophageal or Junctional Cancer,CROSS研究 Chemoradiotherapy for Oesophageal Cancer Followed by Surgery Study,N Engl J Med 2012;366:2074-84.,March 2004 through December 2008,carboplatin (doses titrated to achieve an area under the curve of 2 mg per milliliter per minute) paclit
4、axel (50 mg per square meter of body-surface area) for 5 weeks concurrent radiotherapy (41.4 Gy in 23 fractions,5 days per week), followed by surgery.,8,CROSS研究,9,CROSS研究,10,CROSS研究,11,CROSS研究,12,CROSS研究,13,CROSS研究,14,Complete resection with no tumor within 1 mm of the resection margins (R0) was ach
5、ieved in 92% of patients in the chemoradiotherapysurgery group versus 69% inthe surgery group (P0.001) A pathological complete response was achieved in 47 of 161 patients (29%) who underwent resection after chemoradiotherapy,CROSS研究,N Engl J Med 2012;366:2074-84.,15,Quantifying the benefit of pathol
6、ogic complete response after neoadjuvant chemoradiotherapyin the treatment of esophageal cancer,荟萃分析了2 2篇文献研究结果,进展期术前行新辅助放化疗 结果:pCR者3年总生存为75.0,5年总生存率为50.0 ; 未达pCR者3、5年生存率分别为29.0和22.6( P 0.025 ) 。 研究结论:综合多项研究结果发现行术前放化疗治疗进展期食管癌,术后达pCR患者3、5总生存率均明显提高。因此,行术前新辅助放化疗治疗进展期食管癌,评价术后pCR对判 断患者预后有重要的意义 。,Scheer R
7、,et al. Int J Radiat Oncol Biol Phys,2011, 80 (4) :996-1001,16,同步放化疗后达PET-CR者手术和非手术预后相似,17,Annals of Oncology 24: 12621266, 2013,Association between clinical complete response and pathological complete response after preoperative chemoradiation in patients with gastroesophageal cancer: analysis in a
8、 large cohort M. D. Anderson Cancer Center, Houston, USA,Background: clinCR 定义为术前同步放化疗后手术前内镜阴性+PET阴性 pathCR 术后病理阴性,Results: 284 patients, 218 (77%) achieved clinCR. 67 (31%) of the 218 achieved pathCR. The sensitivity of clinCR for pathCR was 97.1% (67/69), The specificity was low (29.8%; 64/215). O
9、f the 66 patients who had less than a clinCR, only 2 (3%) had a pathCR. Thus, the rate of pathCR was significantly different in patients with clinCR than in those with less than a clinCR (P 0.001).,18,术前同步放化疗后达PCR患者治疗前分子特征是什么 基础研究能否找到标记,19,二、放疗最佳剂量?,RTOG8501 50.4GY 日本 60GY 中国 教科书 60GY或更高(同步) 60-70GY
10、(根治性放疗) 2011卫生部规范 50-50.4GY (同步),20,Phase II Study of Concurrent Chemoradiotherapy at the Dose of 50.4 Gy with Elective Nodal Irradiation for Stage IIIII Esophageal Carcinoma,60GY,Jpn J Clin Oncol 2013;43(6)608615,50.4GY,21,科学合理的个体化剂量应根据肿瘤放疗敏感性,22,三、靶区如何勾画?,23,24,1. 局部失败和远处转移是食管癌治疗失败的主要原因 2. 转移淋巴结诊断
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