目的 研究核磁共振（MR）引导的海马保护技术应用于小细胞肺癌全脑放射治疗（放疗）的效果。方法 对确定行全脑放疗的30例小细胞肺癌脑转移患者,行常规放疗CT定位后以定位体位行全头颅MR平扫,将计算机断层扫描（CT）和MR的T1加权像在Monaco 5.1计划系统上进行精准融合,勾画全脑放疗及海马区域,在海马区域三维方向上分别外扩5、15 mm作为海马与计划靶区之间的剂量跌落,每一例患者在Monaco 5.1计划系统上按照不保护海马组织以及外扩5、15 mm进行保护设计3个容积旋转调强技术（VMAT）放疗计划,观察海马组织的平均及最大放疗剂量。结果 增加保护海马组织之后,3个放疗计划的D100均≥95%,每例的3个放疗计划间D100比较差异无统计学意义（P>0.05）;设置外扩5、15 mm的剂量跌落区后,左、右海马的平均剂量、最大剂量均明显降低,而且3个放疗计划的海马平均剂量、最大剂量之间对比差异有统计学意义。结论 小细胞肺癌脑转移患者进行全脑放疗时,利用MR引导的海马保护技术并设置外扩15 mm的剂量跌落区,能够显著降低海马的剂量,达到保护目的。

Objective To explore the application of MR guided hippocampal avoidant whole brain radiotherapy（WBRT）for small cell lung cancer（SCLC）．Methods Thirty SCLC patients with brain metastases who underwent WBRT were enrdled．After routine CT localization was performed,and a head MR was performed in a the same position．T1 weighted images of MR and CT images were accurately fused on the Monaco 5.1 planning system．The entire brain tissue and hippocampus region were delineated． The dose drop areas between the hippocampus and the planned target area were expanded 5mm and 15mm in the three-dimensional direction of the hippocampus,respectively．Three volumetric modulated arc therapy（VMAT）radiotherapy plans were designed for each patient on the Monaco 5.1 planning system based on whether the hippocampal tissue was avoid．The average and maximum doses of hippocampal tissue were observed．Results After the avoidance of hippocampal tissue,the D100 of the three radiotherapy plans reached ≥95%,and there was no significant difference in D100 between the three radiotherapy plans in each case．After setting dose drop areas of 5mm and 15mm for external expansion,the average and maximum doses of the left and right hippocampus were significantly reduced,and there was a significant difference in the comparison between the average and maximum doses in the hippocampus of the three radiotherapy plans．Conclusions MR guided hippocampal avoidant technology and the setting of a 15 mm dose drop area can significantly reduce the dose to the hippocampus in patients with SCLC undergo whole brain radiotherapy．

目的 探讨容积调强（VMAT）在全脊柱骨多发转移瘤放疗中的运用,观察疗效及安全性。方法 选取 2018年1月—2021年1月本科室收治的50例全脊柱骨多发转移瘤姑息止痛放疗的临床资料,分别对全脊柱靶区设计适形放疗（CRT）和VMAT多中心计划,运用剂量体积直方图及所对应的统计表评估靶区及危及器官剂量覆盖情况,放疗结束后通过1-8周视觉模拟评分法评价近期疗效,每3个月复查全脊柱MRI观察放疗不良反应。结果 采用VMAT技术放疗靶区剂量覆盖度、靶区适形指数和剂量均匀指数均优于CRT技术（P<0.01）,照射野重叠区未见明显剂量热点和冷点。采用VMAT技术危及器官V5 Gy受照体积高于CRT（P<0.01）,除了胃、胰腺和小肠,危及器官V10 Gy受照体积高于CRT（P<0.01或P<0.05）,危及器官V20 Gy受照体积则低于CRT（P<0.01）,除了肾,危及器官V30 Gy受照体积也低于CRT（P<0.01）。采用VMAT技术时危及器官的最大受照量低于CRT（P<0.01或P<0.05）,但除了心脏、胰腺和小肠,VMAT技术的危及器官平均受照量高于CRT（P<0.01或P<0.05）。采用VMAT技术较CRT出束时间增加（P<0.01）,采用CRT时技师摆位时间较VMAT增加（P<0.05）,对于总治疗时间VMAT较CRT增加（P<0.01）。8周后评估疼痛完全缓解16例,部分缓解 22例,轻度缓解8例,无效4例,总有效率为76%。随访日期截至2021年 12月,所有配合随诊的患者3、6、9、12个月全脊柱MRI复查结果显示,VMAT技术照射野内重叠处均未见脊髓及其他组织急慢性损伤情况。结论 VMAT技术对长靶区多中心放疗剂量分布均匀,近期疗效显著,安全性良好。

Objective To investigate the application of volumetric modulated arc therapy（VMAT） in the radiotherapy for multiple bone metastases in the whole spine,and observe of efficacy and evaluation of safety．Methods The clinical data were selected from 50 patients who were treated in our department between January 2018 and January 2021 with palliative analgesic radiotherapy for multiple metastases of the whole spine．Conformal radiotherapy（CRT）and multicenter VMAT plans were respectively applied to target areas of whole spine,and dose volume histogram was used to evaluate the dose coverage of target area and organ at risk（OAR）. After radiotherapy,the short-term efficacy was evaluated by visual analog scale in between 1-8 weeks,and the whole spine MRI was reviewed every 3 months to observe the adverse reactions of radiotherapy．Results The dose coverage,target conformality index and homogeneity index of VMAT treatment were significantly better than those of CRT treatment（P<0.01）,and no obvious dose hotspots and cold spots were observed in the overlapping area of irradiation field. When VMAT treatment was applied,the exposure volume of V5 Gy in OAR was significantly higher when compared with CRT treatment（P<0.01）．Except for stomach,pancreas and small intestine,the exposure volume of V10 Gy in OAR was significantly higher for VMAT treatment when compared with CRT treatment （P<0.01 or P<0.05）．When VMAT treatment was applied,the exposure volume of V20 Gy in OAR was significantly lower when compared with CRT treatment（P<0.01）,and except for kidney,the exposure volume of V30 Gy in OAR was significantly lower when compared with CRT treatment（P<0.01）．When VMAT treatment was applied,the maximum exposure of OAR was significantly lower than that of CRT（P<0.01 or P<0.05）,however,except for the heart,pancreas and small intestine,the average exposure of VMAT treatment to OAR was higher than that of CRT （P<0.01 or P<0.05）．Compared with CRT,VMAT treatment had significantly increased beam-out time（P<0.01）,the therapist setting time of CRT was increased when compared with that of VMAT（P<0.05）,and the total treatment time of VMAT was increased when compared with that of CRT（P<0.01）. In the assessment 8 weeks after the treatments,16 patients had complete pain relief,22 had partial relief,8 had mild relief,and 4 had no effect,which total effective rate was 76%．The follow-up was ended in December 2021．There was no acute or chronic injury to the spinal cord and other tissues in the overlapping areas of the irradiation fields observed for all follow-up patients in the 3rd,6th,9th and 12th month whole-spine MRI re-examination．Conclusions VMAT has uniform dose distribution in multi-center radiotherapy for long target areas,with significant short-term efficacy and safety.

目的 利用高精确的外照射治疗技术,即图像引导放射治疗/容积旋转调强放疗(IGRT/VMAT) 时,使用千伏锥形束CT (kV-CBCT)定位来获得最佳的宫颈癌治疗获益。方法 205例接受IGRT/VMAT治疗的宫颈癌患者纳入实验组。每周做一次kV-CBCT定位后,将这些图像与计划CT扫描图像匹配后记录摆位误差。总共研究了1 025个kV-CBCT图像。采取同时期常规X片定位的90例宫颈癌患者作为对照组。根据定位中的摆位误差计算计划靶区(PTV)的边界。结果 实验组前后、上下和左右方向的摆位误差分别为(1.8±1.1)mm、(2.8±2.2)mm和(1.7±1.4)mm,对照组分别为(2.8±2.1)mm、(3.9±2.2)mm和(2.7±2.4)mm,两组差异具有统计学意义(P<0.05)。实验组前后、上下和左右方向的CTV-PTV边界分别为5.27 mm、8.54 mm和5.23 mm,对照组分别为8.47 mm、11.29 mm和8.43 mm。结论 在采用高精度技术治疗宫颈癌时,每周kV-CBCT是一种令人满意的精确定位方法,有助于减少CTV-PTV边界。

Objective To obtain the best cervical cancer treatment benefit through kilovoltage cone-beam CT (kV-CBCT) positioning, by using high-precision external beam therapy technology, that is, image-guided radiation therapy/volumetric modulated arc therapy (IGRT/VMAT). Methods Two hundred and five patients with cervical cancer treated with IGRT/VMAT were included in the experimental group. After kV-CBCT positioning once a week, these images were matched with the planned CT scan images and the setup errors were recorded. A total of 1 025 kV-CBCT images were studied. Ninety patients with cervical cancer positioned by conventional X-ray during the same period were selected as the control group. The boundary of the planned target volume (PTV) was calculated based on the setup errors. Results In the experimental group, the setup errors in the anteroposterior, superoinferior and mediolateral direction were (1.8±1.1) mm, (2.8±2.2) mm, and (1.7±1.4) mm, respectively. And in the control group, the setup errors were (2.8±2.1) mm, (3.9±2.2) mm, and (2.7±2.4) mm, respectively. The differences between the two groups were statistically significant (P<0.05). In the experimental group, the CTV-PTV boundaries in the anteroposterior, superoinferior and mediolateral direction were 5.27 mm, 8.54 mm, and 5.23 mm, respectively. And in the control group, the CTV-PTV boundaries were 8.47 mm, 11.29 mm, and 8.43 mm, respectively. Conclusion When using high-precision technology to treat cervical cancer, weekly kV-CBCT is a satisfactory and accurate positioning method, which helps to reduce the CTV-PTV boundary.

目的 分析立体定向体部放射治疗(SBRJ)应用于孤立性肺肿瘤的疗效,探讨其临床价值。方法 采用拓能(TOPSLANE)全身X线立体定向放射治疗系统治疗15例孤立性肺肿瘤患者,其中I期非小细胞肺癌患者8例,单个肺转移瘤患者7例。单次剂量为5~8Gy／次,每天1次,每周3次,共8~10次,总剂量50~64Gy,生物有效剂量(BED)75~115Gy。分析治疗的近期疗效、急性放射损伤和局部控制率。结果 3例患者完全缓解(20.0%),10例患者部分缓解(66.7%),2例患者病灶稳定(13.3%),没有疾病进展的患者。15例患者总有效率为86.7%(13/15)。BED<90Gy的患者有效率为33.3%,而BED>90Gy的患者有效率为100%,差异有统计学意义(P＜0.05)。3例患者出现2级急性放射损伤,未见3级以上毒副反应。1年和2年局控率分别为92.3%和81.2%。结论 SBRT治疗孤立性肺肿瘤可获得较好的近期疗效和局部控制率,急性放射损伤较轻。

Objective To analyze the efficacy of stereotactic body radiation therapy(SBRT) onsolitary pulmonary tumor and explore its clinical value. Methods TOPSLANE X-ray stereotactic body radiation therapy system was used for treatment of fifteen patients with solitary pulmonary tumor, including eight patients with stage I non-small cell lung cancer and seven patients with single lung metastasis. Fraction dose of 5 to 8Gy was prescribed once a day, three times a week, totally 8 to 10 times to a total dose of 50 to 64 Gy and biological effective dose(BED) of 75 to 115Gy. Short-term efficacy, acute radiation injury and local control rate were analyzed. Results After treatment, there were three patients with complete response (CR) (20.0%), ten patients with partial response (PR) (66.7%), tow patients with stable disease (SD) (13.3%), and no patients with progressive disease (PD). The total response rate was 86.7% (13/15). The response rate was 33.3% in patients with BED <90 Gy, while it was 100% in patients with BED> 90 Gy, and the difference was statistically significant (P<0.05). Grade 2 acute radiation injuries were observed in three patients, and no toxicity greater than grade 3 was observed. The 1-year and 2-year local control rate was 92.3% and 81.2%, respectively. Conclusion SBRT on solitary pulmonary tumor has good short-term efficacy and local control rate with mild acute radiation injury.

神经元特异性烯醇化酶(neuron-specific enolase, NSE)是糖酵解途径中一种重要的同工酶;特异性位于神经元和神经内分泌细胞中。小细胞肺癌(small cell lung cancer,SCLC)细胞浆内含有神经内分泌颗粒,具有神经内分泌分化的特征,为恶性程度高的神经内分泌系统肿瘤。因此,NSE是SCLC诊断中最敏感的肿瘤标志物,在SCLC的临床诊断、治疗、预后均有重要应用价值,科学合理联合检测肿瘤标记物,将能为临床诊疗工作提供有力的帮助。

       目的   研究核磁共振（MR）引导的海马保护技术应用于小细胞肺癌全脑放射治疗（放疗）的效果。方法  对确定行全脑放疗的30例小细胞肺癌脑转移患者，行常规放疗CT定位后以定位体位行全头颅MR平扫，将计算机断层扫描（CT）和MR的T1加权像在Monaco 5.1计划系统上进行精准融合，勾画全脑放疗及海马区域，在海马区域三维方向上分别外扩5、15 mm作为海马与计划靶区之间的剂量跌落，每一例患者在Monaco 5.1计划系统上按照不保护海马组织以及外扩5、15 mm进行保护设计3个容积旋转调强技术（VMAT）放疗计划，观察海马组织的平均及最大放疗剂量。结果  增加保护海马组织之后，3个放疗计划的D100均≥95%，每例的3个放疗计划间D100比较差异无统计学意义（P＞0.05）；设置外扩5、15 mm的剂量跌落区后，左、右海马的平均剂量、最大剂量均明显降低，而且3个放疗计划的海马平均剂量、最大剂量之间对比差异有统计学意义。结论   小细胞肺癌脑转移患者进行全脑放疗时，利用MR引导的海马保护技术并设置外扩15 mm的剂量跌落区，能够显著降低海马的剂量，达到保护目的。

       Objective  To explore the application of MR guided hippocampal avoidant whole brain radiotherapy（WBRT）for small cell lung cancer（SCLC）．Methods  Thirty SCLC patients with brain metastases who underwent WBRT were enrdled．After routine CT localization was performed，and a head MR was performed in a the same position．T1 weighted images of MR and CT images were accurately fused on the Monaco 5.1 planning system．The entire brain tissue and hippocampus region were delineated．The dose drop areas between the hippocampusand the planned target area were expanded 5mm and 15mm in the three-dimensional direction of the hippocampus，respectively．Three volumetric modulated arc therapy（VMAT）radiotherapy plans were designed for each patient on the Monaco 5.1 planning system based on whether the hippocampal tissue was avoid．The average and maximum doses of hippocampal tissue were observed．Results  After the avoidance of hippocampal tissue，the D100 of the three radiotherapy plans reached ≥95%，and there was no significant difference in D100 between the three radiotherapy plans in each case．After setting dose drop areas of 5mm and 15mm for external expansion，the average and maximum doses of the left and right hippocampus were significantly reduced，and there was a significant difference in the comparison between the average and maximum doses in the hippocampus of the three radiotherapy plans．Conclusions  MR guided hippocampal avoidant technology and the setting of a 15 mm dose drop area can significantly reduce the dose to the hippocampus in patients with SCLC undergo whole brain radiotherapy．