放射肿瘤科住院医师训练手冊

放射肿瘤科住院医师训练手冊 林口長庚醫院放射腫瘤科 99.03. 編輯: (依姓名筆劃序排列) 王俊傑、白冰清、林信吟、洪志宏、范綱行、林倩伃、梁為民、陳彥超、曾雁明、曾振淦、張東杰、黃意婷、黃炳勝、詹頂立、劉義誠 校稿: 詹頂立、林士敏、沈奕良 1 目錄 一, 放射腫瘤科住院醫師訓練 制度 关于办公室下班关闭电源制度矿山事故隐患举报和奖励制度制度下载人事管理制度doc盘点制度下载 P 3-17 二, 模擬攝影, 麻醉下檢查, 手術中放射治療 P 18-25 三, 放射手術 P 26-31 四, 標準作業 流程 快递问题件怎么处理流程河南自建厂房流程下载关于规范招聘需求审批流程制作流程表下载邮件下载流程设计 P 32-41 五, 腻部腫瘤 P 42-50 六, 鼻咽癌及頭頸部癌 P 51-70 七, 肺癌 P 71-76 八, 食道癌, 胃癌及直腸癌 P 77-90 九, 肝癌 P 91-93 十, 乳癌 P 94-101 十一, 子宮頸癌及子宮內膜癌 P 102~110 十二, 攝護腺癌及膀胱癌 P 111~121 十三, 淋巴癌及軟組織肉瘤 P 122-137 附錄: 非本院區住院醫師工作規範 腫瘤內科住院醫師教學工作規範 P 138-141 2 放射腫瘤科 住院醫師訓練制度 黃炳勝醫師/洪志宏醫師 一、 訓練年限:48個月 (前3年住院醫師,最後1年總住院醫師) 二、 訓練目標: 讓住院醫師在上級醫師的監督及指導下,具 備輻射生物、放射物理學、癌症病例寫作、實證醫學、臨 床腫瘤學、放射治療計畫設計與評估、特殊放射治療技術 等知識,以及多科際合作之經驗,確實獲得成為放射腫瘤 專科醫師之技能與學識。 三、 師資: (如附表一) 四、 教學資源: (如附表二) 五、 訓練項目內容:(如附表三) 六、 腫瘤專科教學研討會時間表:(如附表四) 七、 考評暨雙向回饋機制: (一) 住院醫師評量: 1第一年住院醫師 (1) 每月由負責指導之主治醫師依『住院醫師訓練考核表』予 以考核(包含學習態度、工作表現、及和工作人員、病患 3 互動之狀況),其成績佔年度晉升考核總成績80 %。(50 % 為於科內期間由科內主治醫師評分,30 %為PGY訓練期 間之評分) (2) 每年於科內晨會報告一次Resident seminar,每次均由當 次出席之主治醫師依報告內容(50 %)、組織能力(15 %)、 表達能力(15 %)、美術設計(10 %)、即時間控制(10 %) 予以評分,其成績佔年度晉升考核總成績20 %。 2第二年住院醫師以上 (1) 每月由負責指導之主治醫師依『住院醫師訓練考核表』予 以考核(包含學習態度、工作表現、及和工作人員、病患 互動之狀況),其成績佔年度晉升考核總成績50 %。 (2) 每年舉行兩次筆詴,分科內自行舉辦及學會舉辦之全國性 測驗,包含臨床腫瘤學、放射治療學、放射生物、放射物 理等,以了解學習障礙之所在,其成績佔年度晉升考核總 成績30 %。(20 %為科內自行舉辦之考詴,10 %為學會 舉辦之考詴) (3) 每年於科內晨會報告三次Resident seminar,每次均由當 次出席之主治醫師依報告內容(50 %)、組織能力(15 %)、 表達能力(15 %)、美術設計(10 %)、即時間控制(10 %) 4 予以評分,其三次報告之評分成績佔年度晉升考核總成績 20 %。 (二) 住院醫師回饋:每半年針對科內主治醫師、晨會及教學活 動填寫回饋問卷。另每次對於主治醫師Journal Club予 以評分 (如附表五) 八、 第一年住院醫師應參與一般醫學訓練計畫:PGY1:, 所有住院醫師應參加醫院所舉辦新興傳染病:ex. SARS, 禽流感:之全院性演講。 九、 第三年住院醫師結束前需至少有一篇第一作者論文發 表在本科學會『放射治療與腫瘤學雜誌』上 5 (表一) 師資: 醫師 次專科 梁為民醫師 breast cancer, genitourinary tumor 曾雁明醫師 head and neck cancer, gastrointestinal tumor, rectal cancer, NPC 洪志宏醫師 HCC, genitourinary tumor, gynecology tumor, lymphoma 張東杰醫師 head and neck cancer, gastrointestinal tumor, NPC 蔡介生醫師 breast cancer, gynecology tumor 曾振淦醫師 brain tumor, esophageal cancer, sarcoma, pediatric tumor 王俊傑醫師 lung cancer, gynecology tumor, brain tumor 白冰清醫師 brain tumor, esophageal cancer, lung cancer 林信吟醫師 brain tumor, lung cancer, lymphoma, rectal cancer, HCC 林倩伃醫師 head and neck cancer, NPC 黃意婷醫師 breast cancer, gynecology tumor, gastrointestinal tumor 陳彥超醫師 NPC, head and neck cancer, genitourinary tumor 范綱行醫師 NPC, head and neck cancer, genitourinary tumor, HCC 6 (表二) 1. 直線加速器8部含4部影像導引放射治療系統 2. 遙控後荷近距治療設備 3. 模擬攝影機 4. 電腻斷層模擬x光機2部 5. 電腻治療計畫系統 6. 合金鉛製作系統 7. 面具等製作系統 8. 放射治療劑量量測設備 (1) 固態水假體 (2) 擬人假體 (3) 電腻化水假體掃瞄系統 (4) 游離槍、電量計 (5) 熱發光劑量計系統 7 (表三) 放射腫瘤科專科醫師訓練內容 第一年 訓練年 訓練項目 訓練時間 備註 一般醫學實務 醫策會規定 3第3個月 社區醫學基本課程 個一社區相關選修 月 年 醫策會規定 3第3個月 專科相關選修課程: 個一一般內科或一般外科 月 年 含病理診斷、第放射腫瘤病歷寫作 20例 分期、現在病一史、過去病年 史、家族病 史、系統回 顧、物理檢 查、病灶圖 小組討論、 問第醫學倫理:醫學倫理、專業精4小時 題導向、 課堂一神、放射治療病人安全 授課 年 第醫病關係與臨床溝通技巧:會診4小時 實際參與、授 一病患、放射治療中病人、腫瘤課 追蹤門診病人醫病關係之建年 立與溝通練習 輻射安全相關法規與輻射防第3小時 護:輻射防護法規、專業輻射一6防護訓練 年 個 第腫瘤實證醫學:實證醫學的方1小時 研討會、授課 月 一法與應用及限制 年 1.Principle & 第常見癌症教學:常見癌症之個20小時 Practice of 一案導向式教學與教科書研讀radiation Oncology 年 會 2.Cancer.Principle & Practice of Oncology 第放射腫瘤門診教學:放射治療20診次(每次門診實作 一中病患診查技巧、腫瘤追蹤門至少2小時) 年 診 第個案討論會:科內之新病例、20小時 參與討論會 一癌症分期、併發症、或死亡討 年 論會 多科聯合討論第多科聯合討論會:跨領域醫療12小時 會 一團隊實際運作 8 年 Radiobiology 輻射生物學與放射物理學 第共12小時 for 一Radiologists 年 四年結束輻射 生物學與放射 物理學至少各 頇滿50小時 第放射治療計畫:全時於電腻室學1週 習放射治療影像學、腫瘤描繪、一 電腻計畫實作、DVH判讀 年 第放射治療品質保證:全時參與1週 一物理師之治療機之每日檢、每 年 週檢、每月檢,輻射偵檢技術 放射腫瘤月會 第至少六次 一 年 住院醫師學習成果測驗 測驗內容含全第一次 人醫療精神 一 年 9 第二年 含病理診斷、分病歷寫作 第二年 40例 期、現在病史、 過去病史、家族 病史、系統回 顧、物理檢查、 病灶圖、病歷檢 查 1. 可參與學會 共24小時第二年 輻射生物學與放射物理學 或他院課程 2. 四年結束 輻射生物學 與放射物理 學至少各頇 滿50小時 可參與學會或4 小時 第二年 醫學倫理: 他院課程 醫學倫理、專業精神、放射 治療病人安全 第二年 20小時 定位片、驗證放射治療品質保證:治療時 片討論會、相依據定位之重現度如何確關演講 認、強度調控放射治療的治 療確認、治療機品質保証與 校驗 第二年 24小時 學習跨領域醫多科聯合討論會:實際參與 療團隊實際運多科研討會 作 病人應包含中第二年 40例 放射治療會診:學習會診診樞、頭頸、胸 腔、腸胃道、造查技巧與流程、資料搜集、血、肌肉骨骼、 會診單回覆 小兒(第二年及 第三年共計90 例) 第二年 40小時 訓練學員之病個案討論會:科內之新病 例報告、回答例、癌症分期、併發症、或題與臨床知識 死亡討論會 與應用 第二年 40診次(每使學員熟悉門放射腫瘤門診教學:放射治 次至少2小診診療技巧 療中病患診查技巧、腫瘤追時) 蹤門診 第二年 80小時 使學員熟悉電放射治療計畫:電腻室學 腻治療計畫之習、腫瘤描繪、電腻計畫實各步驟 作、DVH判讀 第二年 40小時 小組報告教科書與期刊研讀:常見癌 10 症之病因、症狀、診斷、治 療及最新發展 可至放射診斷第二年 20小時 放射治療影像學:中樞、頭科進修以不超 過兩個月為限 頸、胸、腹、骨盆之電腻斷 層及核磁共振判讀 第二年 各20例 特殊診查技術:鼻咽喉內視 鏡、婦科診查技術 第二年 一篇 論文寫作與學術研討會報 告:論文主題之選擇、研 究設計;或醫學會年會口頭 報告或海報展示 放射腫瘤月會 第二年 至少六次 住院醫師學習成果測驗 訓練內容含該第二年 一次 年度訓練項目 11 第三年 訓練年 訓練項目 訓練時間 備註 1.可參與學會輻射生物學與放射物理學 共24小時 第三年 或他院課程 2.四年結束輻 射生物學與放 射物理學至少 各頇滿50小時 可參與學會或4小時 第三年 醫學倫理:醫學倫理、專業 他院課程 精神、放射治療病人安全 病房照顧、遠安寧照護 第三年 12小時 距教學、年 會、研討會 第三年 放射治療品質保證:治療時12小時 定位片、驗證 片討論會、相依據定位之重現度如何確 關演講 認、強度調控放射治療的治 療確認、治療機品質保証與 校驗 第三年 12小時 學習跨領域醫多科聯合討論會:實際參與 療團隊實際運多科研討會 作 第三年 50例 病人應包含中放射治療會診:學習會診診 樞、頭頸、胸查技巧與流程 腔、腸胃道、造 血、肌肉骨骼、 小兒(第二年及 第三年共計90 例) 訓練學員之病第三年 個案討論會:科內之新病40小時 例報告、回答例、癌症分期、併發症、或題與臨床知識死亡討論會 與應用 第三年 40診次(每 放射腫瘤門診教學:放射治 次至少2小療中病患診查技巧、腫瘤追 時) 蹤門診 第三年 40小時 小組報告教科書與期刊研讀:常見癌 症之病因、症狀、診斷、治 療及最新發展 第三年 100小時 放射治療計畫:電腻室學 習、腫瘤描繪、電腻計畫實 作、DVH判讀 第三年 內視鏡與婦 特殊診查技術:鼻咽喉內視 科檢查各20鏡、婦科診查技術 例 12 第三年 共20人次 可至他院進行 特殊治療方法:腔內治療、 插種治療、立體定位放射手 術、全身照射 放射腫瘤月會 第三年 至少六次 血液腫瘤、耳鼻喉、病理科、可依各院需求第三年 選修總計最 婦產科選修 自行安排 多兩個月 住院醫師學習成果測驗 訓練內容含該第三年 一次 年度訓練項目 13 第四年 訓練年 訓練項目 訓練時間 備註 1.可參與學會共24小時 第四年 輻射生物學與放射物理學 或他院課程 2.四年結束輻 射生物學與放 射物理學至少 各頇滿50小時 第四年 多科聯合討論會:實際參與20小時 多科研討會 第四年 放射治療會診:獨立執行會20例 重點為病人治 療計畫之決定 診與設計治療 培養獨立思考第四年 個案討論會:主持晨會與個20小時 與主持討論之案討論會 能立 放射腫瘤門診教學:獨立看診 第四年 10診(每診 至少2小時) 指導資淺者 第四年 教科書與期刊研讀:常見癌20小時 症之病因、症狀、診斷、治 療及最新發展 第四年 特殊診查技術:鼻咽喉內視內視鏡與婦 鏡、婦科診查技術 科檢查各20 例 第四年 論文寫作:資料分析及撰寫 一篇 特殊治療方法:腔內治療、共20人次 可至他院進行 第四年 插種治療、立體定位放射手 術、全身照射 放射腫瘤月會 第四年 至少六次 14 (表四) 放射腫瘤科 腫瘤專科教學研討會時間表 課 程 內 容 目 標 時 間 鼻咽癌聯合討論會 鼻咽癌病例聯合討論 每週二上午 頭頸部腫瘤聯合討論會 頭頸部腫瘤病例聯合討論 每週二上午 乳癌聯合討論會 乳癌病例聯合討論 每週二下午 腻部腫瘤聯合討論會 腻部腫瘤病例聯合討論 每週二上午 血液腫瘤聯合討論會 血液腫瘤病例聯合討論 每週ㄧ中午 肺癌聯合討論會 肺癌病例聯合討論 每週五下午 食道癌聯合討論會 食道癌病例聯合討論 每週三下午 肉癌聯合討論會 肉癌病例聯合討論 每週三上午 肝癌聯合討論會 肝癌病例聯合討論 每週三下午 婦癌聯合討論會 婦癌病例聯合討論 每週四下午 大腸直腸癌聯合討論會 大腸直腸癌病例聯合討論 每週二上午 小兒腫瘤聯合討論會 小兒腫瘤病例聯合討論 每週一上午 小兒腻部腫瘤聯合討論會 小兒腻部腫瘤病例聯合討論 隔週二中午 泌尿腫瘤聯合討論會 泌尿系統腫瘤病例聯合討論 每週二上午 腫瘤科聯合討論會 腫瘤科病例聯合討論 每週二中午 期刊研討會 新近發表期刊研讀、討論 每週三上午 複雜治療之電腻治療計劃說明每月第一週之週六治療計劃討論會 及討論 上午 專科教學研討會如與其它訓練項目有所衝突時則以指導主治師所指 定參加為準。 15 (表五) 住院醫師訓練滿意度調查表 主治醫師: 填表日期: 1. 主治醫師在您學習上遇到困難時給予協助, ?非常同意 ?同意 ?普通 ?不同意 ?非常不同意 2. 主治醫師會協助修改您的病歷紀錄, ?非常同意 ?同意 ?普通 ?不同意 ?非常不同意 3. 主治醫師對您的教導是否有幫助, ?非常同意 ?同意 ?普通 ?不同意 ?非常不同意 4. 您與主治醫師互動關係的滿意度為何, ?非常滿意 ?滿意 ?普通 ?不滿意 ?非常不滿意 5. 主治醫師於門診教學上您是否滿意, ?非常滿意 ?滿意 ?普通 ?不滿意 ?非常不滿意 6. 主治醫師於治療計畫時的教學您是否滿意, ?非常滿意 ?滿意 ?普通 ?不滿意 ?非常不滿意 7. 您是否積極參與主治醫師的臨床活動,(門診、治療計畫…) ?非常積極 ?積極 ?普通 ?不積極 ?非常不積極 16 科內學術活動 1. 對於晨會活動的討論情況是否滿意, Journal Club ?非常滿意 ?滿意 ?普通 ?不滿意 ?非常不滿意 Chart Round ?非常滿意 ?滿意 ?普通 ?不滿意 ?非常不滿意 Treatment Plan ?非常滿意 ?滿意 ?普通 ?不滿意 ?非常不滿意 2. 科內晨會活動對您的學習是否有幫助, Journal Club ?非常滿意 ?滿意 ?普通 ?不滿意 ?非常不滿意 Chart Round ?非常滿意 ?滿意 ?普通 ?不滿意 ?非常不滿意 Treatment Plan ?非常滿意 ?滿意 ?普通 ?不滿意 ?非常不滿意 3. 對於晨會活動您個人參予的情況, Journal Club ?非常積極 ?積極 ?普通 ?不積極 ?非常不積極 Chart Round ?非常積極 ?積極 ?普通 ?不積極 ?非常不積極 Treatment Plan ?非常積極 ?積極 ?普通 ?不積極 ?非常不積極 4. 對於科內教學活動您是否滿意 輻射生物 ?非常滿意 ?滿意 ?普通 ?不滿意 ?非常不滿意 輻射物理 ?非常滿意 ?滿意 ?普通 ?不滿意 ?非常不滿意 Book Reading ?非常滿意 ?滿意 ?普通 ?不滿意 ?非常不滿意 模擬攝影(Simulation) 黃炳勝醫師 , 模擬攝影的目的 1. 定義病人治療照野及腫瘤部位 2. 確定治療部位之準確性 3. 確定病人體表厚度 4. 提供X-ray作為臨界器官的準確阻擋,以利mold room 之 block 製作,進而減少normal tissue damage 5. 作為日後治療的依據並減少醫療糾紛之發生 , 準備工作 1. Study thoroughly about the diagnosis of the Pt and its disease extent via all available diagnostic images, plain X-ray, CT scanning, MRI, bone scan… etc. 2. If the Pt is expected to require immobilization mould / shell, stthat should be made and brought to the 1 simulation. 3. All available diagnostic images should be brought to the simulation room. , CT simulation 傳統的模擬攝影在照出X光片之後, 多是依據Bony marker或參考對照CT/MRI 上的腫瘤位置, 以決定最後的治療範圍(treatment field), 較易有miss target or inadequate margin 等發生. 本科自引進 CT simulation 後, 可大幅改善以上情形. 經由軟體協助, 可將腫瘤及正常組織countoring 在CT slices 上(Target delineation), 再決定treatment field, gantry angle等參數, 或直接利用軟體功能檢視每一個CT slice 上的腫瘤位置及treatment field, 可減少geometrical miss, 並可更精準地避免照射到正常組織. 下圖為Acqusim (Picker)系統CT simulation的視窗, 亮黃色線為field border及其投影, 淺藍色線為block border及其投影, 深黃色線為在Visual fluoroscopy 畫的腫瘤投影. 18 Field border Tumor Block , Treatment plan: 1. 開立treatment plan 之order: α-cradle or cast x 1( 視病人情況) Simulation x 1 Treatment plan CT scan Block x 2 (視病人情況) 照射與定位 x 2 (視病人情況) 2. 於simulation 時定出CT scan 的center, 使物理師可依laser 放鉛線.同時定出病人CT scan 的範圍. 3. 當CT scan之影像down load 至treatment planning 之電腻 中, 應儘快定出tumor 之GTV( gross tumor volume), CTV( clinical target volume) and PTV( planning target 19 volume). 並與主治醫師討論tumor 侵犯程度. 根據ICRU No.50報告, GTV, CTV & PTV 定義如下: Gross tumor volume (GTV): gross demonstrable extent & location of the malignant growth, (包含Primary tumor & gross enlarged lymph nodes), Clinical target volume (CTV): a tissue volume that contains a demonstrable GTV and/or subclinical malignant disease that must be eliminated, (包含Microsopic tumor infiltration & metastatic lymph nodes), Planning target volume, (PTV): in considering of the margins for geometric variations & uncertainties, internal margin (to compensate for all movement & all variations in size, site & shape of the organs & tissues contained in or adjacent to CTV) & set-up margin (or set-up error); PTV is defined to select appropriate beam size & beam arrangements, to ensure that the prescribed dose is actually delivered to the CTV. Note: The penumbra of the beams is NOT considered when delineation of the PTV. When selecting of the beam sizes, the widths of the penumbra has to be taken into account and beam size adjusted accordingly. 4. 當tumor target 決定之後, 於未plan之前, 應與物理師討論 beam arrangement, 同時告訴物理師planning dose and critical organ. 5. 當物理師完成治療計劃後, 應以tumor control , normal tissue tolerance, & DVH (dose-volume histogram)作考量, 並與主 治醫師討論. 20 Outpatient Clinic 黃炳勝醫師 本科醫師與患者 (及其家屬) 互動、評估患者的病情及狀況、解釋病 情、安排必要的模擬攝影或其它相關之檢查的機會,以在門診室中進 行居多。本科門診依其性質約可分為三大類:初診 (New patient)、 治療中門診 (On treatment)、複診 (Follow-up) 初診 (New patient):被轉診至放射腫瘤科的病人其診斷大都已被確 立;即使如此,若本科醫師對其診斷尚有任何的質疑或發現臨床上有 不相符之處,應酌情與轉診醫師詳加討論,或排更進一步的相關檢 查。如此,方能對未來的治療計畫及病人的預後發揮最理想的助益。 1. Determine if radiotherapy is really indicated and will do better for the patients 2. Contemplate the intent the treatment 3. Examine the potential extent of tumor in terms of local, regional, or distal involvement (by virtue of the associated symptoms and signs, the history, physical examination, various useful investigations) 4. Estimate the most possible treated volume which will be included and the potential treatment-related sequelae 5. Well explain the future radiotherapeutic procedures that will be undertaken, the prognosis of the patient, the potential benefits and risks brought by radiotherapy to the patient and his/her family 6. Discuss with the referring physician for better treatment strategies 治療中門診 (On treatment): 1. Access and manage the acute reactions caused by irradiation with or without concurrent chemotherapy 2. Evaluate the response of the tumor (bed) and the status of the regional lymphatic drainage 3. Consider modification of the radiotherapy scheme (in terms of time, dose, fractionation) or treatment strategy if unacceptable acute adverse effects or observed tumor progression are occurring 4. Arrange simulation for further cone down boost or any necessary procedures according to the disease entity, the 21 tumor response, and the patient’s general condition 複診 (Follow-up): 1. Ascertain whether tumor control (local, regional, distant) is maintained, paying special attention to any suspicious symptoms and sings, performing physical examinations, and reviewing the recently performed investigations (including laboratory examination, imaging studies, and instrumental investigations) 2. Recognize if any treatment-related late complications happened 3. In case there is any treatment failure or late complication being documented, review all the past treatment modalities and the detailed radiation treatment planning. Attempt to find out what the actual causes contributing to the treatment failure or morbidity were 22 Examination under Anesthesia (EUA),麻醉下檢查 黃炳勝醫師 在麻醉狀態下,患者可達到完全的肌肉鬆弛、麻痺不動、且不會因醫師的檢查或醫療處置而感到疼痛;如此臨床醫師可詳細徹底地檢查病人的病灶處,可藉此評估腫瘤的大小及侵犯的範圍可幫助define the gross target volume;並可評估該腫瘤對於已給予的放射治療或化學治療的反應究竟達到何種程度,依此輔助決定接下來的治療策略。 本科利用EUA來評估的惡性腫瘤中,最常見的要屬cervical cancers了。針對cervical cancers患者施行EUA,除了評估腫瘤的大小 (最大橫徑是否超過4公分) 及腫瘤的侵犯範圍 (是否侵犯至陰道或子宮旁組織parametrium),通常還會接著施行dilatation of the cervical os and intracavitary insertion of an applicator for simulation which is utilized to brachytherapy treatment planning (針對腫瘤最大橫徑不超過4公分且腫瘤未波及至最末端陰道之病人)。若於病人麻醉狀況下為其施行婦科內診發現其腫瘤侵犯範圍超過4公分,或在陰道末端仍有殘餘腫瘤,則應思量是否brachytherapy真的能夠給予腫瘤足夠且均勻的照射劑量,考慮是否應以全程體外放射治療來取代local boost by brachytherapy. 23 手術中放射治療, IORT 曾雁明醫師 手術中放射治療 (Intraoperative radiotherapy, IORT) 是在手術過程中將正常組織器官做適當的保護,再轉送病人至治療室中,給予腫瘤部位集中、高劑量且通常是單次的照射。目的在給予腫瘤足夠的高劑量照射但卻降低了傳統放射治療對正常組織的傷害,如此提高了腫瘤的局部控制率,卻不增加副作用的產生。 IORT的治療方式主要分為兩大類,一為手術中電子射線放射治療 (Intraoperative electron radiotherapy, IOERT),其利用直線加速器的電子射束,主要適用於腫瘤部位在開刀中能被暴露出來、治療錐體能完全罩住的腫瘤,如胰臟癌、膽管癌、胃癌。放射腫瘤科醫師必頇根據腫瘤之大小及深度來選擇適當的電子能量、百分深度劑量和照射劑量,並配合適當形狀、大小的治療錐體來照射腫瘤。 若腫瘤位於身體內部的彎曲面上、治療錐體無法完全罩住腫瘤部位,如復發的直腸癌延伸到骨盆腔側壁上,則適合採用手術中近接治療 (Intraoperative brachytherapy, IOBRT)。利用高劑量率遙控後荷式近接治療機以及一種特殊超級柔軟的應用器 (applicator),這個柔軟的軟墊可以順應身體內部的曲度做彎曲,緊密地貼在彎曲面上,可使輻射劑量隨著曲面做適當的分布來治療腫瘤 根據不同部位腫瘤的適應性,手術中放射治療可使用直線加速器中的電子射線治療 (IOERT),或是後荷治療中的高劑量率近接放射治療 (IOBRT)。不管選用何種方式,最終目的皆是希望消除惡性腫瘤、減輕腫瘤引起的疼痛,而又減少放射線對正常組織的傷害。 IORT是結合了外科、麻醉科、放射腫瘤科各組同仁 (包括負責此領域的主治醫師、物理師、技術師、及護理人員) 的高度團隊合作。身為一放射腫瘤醫師,主要任務在於: 1. 根據腫瘤的部位及特性,判斷IORT是否對患者有實質的助益或 存活率的改善;若確實符合適應症,決定應採用IOERT還是 IOBRT,並與病患及其家屬充分討論此特殊治療是否可行。 2. 於IOERT之時,頇根據腫瘤之大小及深度來選擇適當的電子能 量、百分深度劑量和照射劑量,並配合適當形狀、大小的治療錐 體來照射腫瘤。於IOBRT之時,亦頇根據腫瘤之範圍、分布及大 小來選擇軟墊應用器之大小、治療長度、百分深度劑量和照射劑 量。 3. 於IORT轉送病患至治療室,於治療室中裝配治療機器及輔具的 過程中,放射腫瘤科醫師是熟稔這所有流程的總指揮官。與麻醉 24 科醫師配合,嚴格監控病人於轉送及治療中的生命徵象;與外科 醫師及所有工作人員配合,確保所有流程皆在無菌環境下操作; 與技術師配合,使所有與治療有關的架設及擺位精準無誤。 現時IORT大部份的病人皆是在2樓手術室處理後再轉送致地下室的放射腫瘤治療室。病人並不會因轉送的過程增加感染的機會。病人在2樓手術符合病人的利益、因2樓設備齊全且容易得各專科的支援。主刀醫師也可選在放射腫瘤科於治療室隔壁設置的手術室,優點是不需轉送病人、缺點是整組手術人員需下來支援。 IORT健保沒有給付、頇向病人說明清楚需自費。自費的理由是病人所佔用的整個治療室的時間約一小時、此段時間該治療室不能治療任何其他病人。 25 Radiosurgery 放射手術 曾振淦醫師 , Introduction Radiosurgery is multiple narrow radiation beams directed stereotactically toward common point in order to produce a radiobiological effect such as blood vessel thrombosis, reproductive cell death, or radionecrosis , Goals 1) to define a small three dimensional intracranial target volume 2) to deliver a clinically significant dose of radiation to the target volume 3) to avoid delivering a clinically significant dose of radiation to the critical area , Difference between radiosurgery & conventional RT 1) small treatment volume : 1ess than 3 cm in diameter2) usually a single fraction, but fractionation is feasible in mask system 3) Extra precision localization : +/- 1 mm 4) sharp dose fall-off outside the target : 90 - 10 % within 1 cm 5) larger fraction size in radiosurgery , Brief History of Radiosurgery Year author place invention 1951 Leksell Stockholm 200-300 kvp X-ray 1954 Lawrence Berkly C.P for pituitary suppression 1958 Larsson Uppsala Proton used as radiosurgery 1962 Kjellberg Boston Proton experience begin 1965 Koroshkov Moscow Proton irradiation 1967 Leksell Stockholm 179 Co-60 Gamma knife 1970 Steiner Stockholm Gamma knife for AVM nd1975 Leksell Stockholm 2 generation Gamma knife 1980 Fabrikant Berkeley Helium for AVM 1982 Barcia-Lolario Madrid Co-60 for carotid cavernous fistula Madrid 1982 Betti Paris Linac modified for radiosurgery 1982 Colombo Vicenza Modified Linac 1984 Bunge Buenos Aires 3rd generation Gamma knife 1986 Lutz Boston Modified Linac 1992 Loeffler Boston 1st commercially dedicated 26 Year author place invention 1994 Lee Taoyuan 1st linac based radiosurgery in Taiwan 1994 Adler California Prototype unit of Cyber knife 2002 Liang Tainan 1st Cyber knife in Taiwan , Radiosurgery system included 3 components as follow: 1) Fixation: stereotactic frame base system or image guided mask system 2) Radiation delivery system 3) Dedicated hardware and treatment plan software , Use of radiosurgery for CNS tumors in literatures Vascular lesions: Arterio-venous malformation, Angiogram-occult venous malformation, Carotid cavernous fistula Benign tumors: Acoustic neuroma, Meningioma, Choroid plexus papilloma, Pineocytoma, Craniopharyngioma, Pituitary adenoma, Neurocytoma Malignancy: Glioblastoma, Glioma, Lymphoma, Medulloblastoma, Germinoma, Pineoblastoma, Chordoma, Recurrent NPC, Brain Metastasis Functional Radiosurgery: Trigeminal neuralgia, , Devices and comparison: 27 From Luxton G. et al.; Stereotactic Radiosurgery: Principles and Comparison of Treatment Methods J. Neurosurg; 1993 , Procedures 1) Affix the stereotactic frame to the patient or apply head mask 2) Obtain radiological studies for treatment planning 3) Delineate the target and organs at risk 4) Position the patient for treatment, and apply image checkup in mask system. 5) Irradiate the target(s) 6) Remove the frame or mask , Technique: , A stereotactic frame is fixed to the patient ‘s skull or head mask ---provide highly secure landmarks that allow for stereotactic localization 28 , head mask + image-guided verification of target position , neuroimaging study: angiography, CT, MRI, fMRI, PET scan , treatment plan: circular field based, multi-leaf collimator based , Indication for radiosurgery: A suitable size (usually <=3cm), radiologically distinct lesion that has potential to respond to a single, large dose of radiation , Examples of radiosurgery: , AVM: target volume: entire nidus of vascular lesion 1) Defined by angiogram and CT or MRI 2) Obliteration rate:70-80% 3) Clear dose response up to at least 25Gy 29 4) Larger AVM had lower obliteration rates 5) Follow up: MRI every 6 months was highly suggested, angiogram to document complete obliteration. 6) Retreatment: similar success and complication as initial , Acoustic neuroma: 1) local control rate:85-96% 2) useful hearing preservation:34-61% facial and trigeminal dysfunction:8-30% Comparsion with surgery a) suitable for tumor <3cm b) preservation of hearing (class I-II)-> radiosurgery: 75% vs surgery: 14% c) normal facial nerve function: radiosurgery: 83% vs surgery: 63% d) tumor control : no significant difference , Meningoma: 1) long term local control: 95% 2) significant tumor shrinkage: 35% 3) optic nerve and chiasma dose: <8Gy , Pituitary adenoma: 1) for well-localized tumor by imaging and it is 5 mm or more away from optic chiasm/nerves 2) radiosurgery offer faster and higher response rates than fractionated RT with greater chance of preservation of normal pituitary function 3) normalization rates were dose-related , Brain metastasis: 1) local tumor control:65-96% 2) survival benefit in RTOG RPA Class I patients with solitary metastasis 3) increase local failure associated with infratentorial location and a history of recurrence , Refractory Trigeminal neuralgia: 1) High single fraction size: 60-90Gy to isocenter 2) Initial symptom relief rate: 80-96% , Complication: 30 1) Limited by careful treatment planning to limit normal tissue irradiation and reasonable treatment dose selection 2) Post- radiosurgery imaging (PRI) changes: increased MRI T2 signal in surrounding brain a) occur more often with AVM (30% vs 5-10% with benign tumor) b) occur from 1-24 months postradiosurgery (typically 6-12 months) c) asymptomatic in more than half of patients depending on location (brainstem changes are usually symptomatic) d) resolution occurs in approximately 90% cases at a median of 14 months e) imaging change associated with treatment volume f) symptomatic PRI change correlated with radiosurgery 12 Gy volume and lesion location 3) Cranial nerve injury: a) Dmin <=13Gy: no facial or trigeminal neuropathy b) post-radiosurgery CN V,VII,VIII neuropathy correlated with minimal radiosurgery dose and radiosurgery treatment volume c) Optic nerve tolerance to stereotactic radiosurgery: radiosurgery dose optic apparatus complication % dose < 10Gy 0% dose 10-15 Gy 26.7% dose >= 15Gy 77.8% 31 標準作業規範 模擬定位攝影 標準作業規範 技術組 劉義誠組長 1. 目的: 1.1 確定各項模擬定位攝影作業之正確性及安全性。 1.2 確定各項模擬透視定位作業之正確性及安全性。 2. 適用範圍: 放射治療前之各項模擬定位照相與透視定位。 3. 安全作業規範: 3.1 診療醫囑處方作業 3.1.01放射腫瘤醫師必頇了解游離輻射對懷孕婦女可能造成胎兒的 影響,如果有懷孕的可能,宜加會婦產部(科)評估對胎兒影 響,並向病人解釋可能造成的影響。 3.1.02放射腫瘤醫師在開立處方前需瞭解病患之診斷、分期、影像資 料如CT、MRI、Sono、核醫影像等,以利對計畫所需檢查或 治療影像處方之開立。 3.1.03放射腫瘤醫師開立處方前必頇先確認瞭解病人,是否有任何藥 物過敏現象或對任何造影劑有過敏的經驗。 3.1.04檢查處方應詳細載明:病患姓名、病歷號碼、臨床診斷、日期、 造影劑名稱、造影劑濃度及使用量、檢查部位、檢查姿勢及檢 查的特殊要求。 3.2 攝影室作業 3.2.01模擬定位攝影應由經過合格訓練並領有合格證照之放射師操 作。 3.2.02 攝影檢查前應仔細核對、確認受檢者之身分、基本資料及檢 查部位是否正確(至少兩種以上病患辨識的方法),並應注意醫 囑要求之病患固定裝置及姿勢。 3.2.03應使模擬定位攝影床降到適當高度,以利檢査病患上下檢查 台。對體弱、婦孺或行動不便者,檢查前後必頇扶持上下檢查 台。 3.2.04對於推床患者移動到檢查台,必頇使用滑板並固定推床,避免 搬運時使病患受到二次傷害。 3.2.05對於意識不清或無法配合者,如需請家屬協助者,必頇提供伴 護家屬鉛衣作防護,並應於事前告知家屬輻射可能造成的影 32 響。 3.2.06詢問婦女是否懷孕,如果有懷孕,反映其主治醫師,如一定需 作該項檢查加會婦產部(科)評估對胎兒影響,並向病人解釋可 能造成的影響。 3.2.07對於生育年齡之婦女及小孩應視檢查部位對生殖器官實施必 要之防護。 3.2.08如需注射造影劑進行定位或透視檢查者,應再確認患者有無過 敏反應病史,及是否符合離子性對比劑之禁忌症,如病人不符 合離子性對比劑之禁忌症自願給付差額使用非離子性對比 劑,需填寫自費同意書。 3.2.09檢查區需備妥抗過敏反應、急救所需要之藥物及器械,如 adrenaline、oxygen…..等等,以應不時之需。 3.2.10指示受檢病患換下有鈕扣及有拉鍊的衣服、褲子及移除任何可 能影響攝影的東西。 3.2.11 透視定位時,請其主治醫師現場修正決定照野之Gantry角 度、部位及大小等。 3.2.12 攝影中必頇注意監視系統,如病患有任何不適現象或移動位 置時必頇隨時終止攝影,並呼叫其主治醫師診療處理。 3.2.13檢查後應親自核對檢視X光片受檢者之基本資料、攝影部位 與影像品質。 3.2.14檢查時應製作記錄:受檢日期、受檢者基本資料、檢查部位及 影像資料處理情形。 3.2.15檢查後應於申請單上及登記簿上簽章,並填註執行時間以示負 責。 3.2.16 完成攝影程序後即刻沖洗影像軟片傳送至診療室,或即刻已影 像儲傳方式將影像傳送至診療室或劑量室。 3.2.17各項檢查記錄應至少保存三年。 3.3 造影劑使用作業 3.3.01 檢查前確認病患短期間有無在本科或他科檢查並已使用造影 劑。 3.3.02 通知護理師依醫囑備妥一般(離子性)造影劑、非離子造影劑、 或口服之鋇劑等,或準備攝影前口服造影劑;及造影劑預熱加 溫至約35?。 3.3.03 設定病患受檢之適當攝影部位後,通知其主治醫師使用造影 劑。 3.3.04 常用的離子性造影劑為Angiografine,非離子性造影劑有 Ultravist 370及Iopamiro 370等;依醫囑使用人工注射或自動 33 注射配備。 3.3.05 使用注射造影劑時,完全注射前先預推約5 cc左右進入,以 觀察病患是否有過敏現象,待病患確定無過敏反應後才完全注 射造影劑。 3.3.06 依醫囑準備濃度與使用量。(使用鋇劑之參考量如下表:) 70 80 100 110 120 130 150 濃度W/V (%) 720 620 470 410 370 330 270 水量ml 860 750 600 550 500 460 400 懸浮量(約)ml 3.4 設備及影像品管作業 3.4.01模擬攝影機應定期(包含每月、季、年)檢測其射線品質、劑量 輸出值、電流量、照野對稱性及中心線之吻合度等。 3.4.02依照各機器特性實施各項QA(品質保證)之定期檢測。 3.4.03洗片機需每日檢測顯影液溫度、速率指標、對比指標、霧化加 基底光度。 3.4.04攝影用軟片匣、增感屏應定期清理保養。 3.4.05隨時檢測X光影像之黑白對比度、清晰度、是否有假影。 3.4.06定位用雷射燈組應定期QA校正。 3.4.07防護用鉛衣應以衣架掛放,不得摺疊。 3.4.08各項檢查記錄應至少保存三年。 3.5 廢棄物處理作業 3.5.01 X光片、定影液處理過程應依「事業廢棄物儲存清除處理方法 及設施標準」規定辦理,經環保主管機關認可核可之廠商處理。 3.5.02遇傳染病患者,必頇依照法定傳染病規定通報、預防傳染、消 毒等作業後,始能繼續後續之診療作業。 3.5.03各種失能性因素造成污染,必頇先行清理無誤後始能繼續治檢 測療作業。 3.5.04廢棄物必頇加以分類處理,不可混雜丟棄。 3.6 病患衛教與諮詢作業 3.6.01攝影檢查前應告知受檢者或家屬,說明檢查項目、目的及過程。 3.6.02應製作檢查流程壁報,以便民眾了解檢查目的及過程。 3.6.03提供有關放射性檢查及輻射安全等相關問題的諮詢。 3.6.04醫事放射師(士)不得將檢查結果告知受檢者或其家屬,以免滋 生困擾。 3.6.05製作衛教單張資料,以便民眾取閱,了解檢查目的及過程。 34 CT模擬定位攝影 標準作業規範 技術組 劉義誠組長 1.目的: 確定各項CT模擬定位攝影作業之正確性及安全性。 2.適用範圍: 放射治療前之各項CT模擬定位攝影。 3.安全作業規範: 3.1 診療醫囑處方作業 3.1.01放射腫瘤醫師必頇了解游離輻射對懷孕婦女可能造成胎兒的 影響,如果有懷孕的可能,宜加會婦產部(科)評估對胎兒影 響,並向病人解釋可能造成的影響。 3.1.02放射腫瘤醫師在開立處方前需瞭解病患之診斷、分期、影像資 料如CT、MRI、Sono、核醫影像等,以利對計畫所需檢查或 治療影像處方之開立。 3.1.03放射腫瘤醫師開立處方前必頇先確認瞭解病人,是否有任何藥 物過敏現象或對任何造影劑有過敏的經驗。 3.1.04檢查處方應詳細載明:病患姓名、病歷號碼、臨床診斷、日期、 造影劑名稱、造影劑濃度及使用量、檢查部位、檢查姿勢及檢 查的特殊要求。 3.2攝影室作業 3.2.01 CT模擬定位攝影應由經過專業訓練並領有合格證照之放射師 操作。 3.2.02 檢查前應仔細核對、確認受檢者之身分、基本資料及檢查部 位是否正確(至少兩種以上病患辨識的方法),並注意病患應設 定之固定裝置及姿勢。 3.2.03應使CT攝影床降到適當高度,以利檢査病患上下檢查台。對 體弱、婦孺或行動不變者,檢查前後必頇扶持上下檢查台。 3.2.04對於推床患者移動到檢查台,必頇使用滑板並固定推床,避免 搬運時使病患受到二次傷害。 3.2.05對於意識不清或無法配合者,如需請家屬協助者,必頇提供伴 護家屬鉛衣作防護,並應於事前告知家屬輻射可能造成的影 響。 3.2.06詢問受檢婦女是否懷孕,如果有懷孕,則反應其主治醫師評估。 3.2.07對於生育年齡之婦女及小孩應視檢查部位對生殖器官實施必 要之防護。 3.2.08如需注射對比劑進行X光檢查者,應再確認患者有無過敏反 35 應病史,及是否符合離子性對比劑之禁忌症,如病人不符合離 子性對比劑之禁忌症自願給付差額使用非離子性對比劑,需填 寫自費同意書。 3.2.09 檢查區需備妥抗過敏反應、急救所需要之藥物及器械,如 adrenaline、oxygen…..等等,以應不時之需。 3.2.10指示病患換下有鈕扣及有拉鍊的衣服、褲子及移除任何可能影 響攝影的東西。 2.2.11 攝影中必頇注意監視系統,如病患有任何不適現象必頇隨時 終止攝影,並呼叫其主治醫師診療處理。 3.2.12檢查後應親自核對檢視影像裡受檢者之基本資料、攝影部位與 影像品質。 3.2.13檢查完成時應製作記錄,記錄受檢日期、受檢者基本資料、檢 查部位及影像資料處理情形。 3.2.14檢查後應於申請單上及登記簿上簽章,並填註執行時間以示負 責。 3.2.15 完成影像掃描完成後,將影像傳送至Eclipse,簡單治療或急 治療由放射師來標定影像中心點,完成後交由醫師進行virtual simulation;複雜治療統一由物理師於進行treatment plan時 標定出影像中心點,待整個treatment plan完成之後將180度 與270度及任一治療角度之DRR影像以A4紙張列印出來夾 放在治療病歷上,同時亦將上述之影像exposed出來再傳送 至Veiwer伺服器,以作為線上比對BF時的依據。 3.2.16各項檢查記錄應至少保存三年。 3.3 造影劑使用作業 3.3.01 檢查前確認病患短期間有無在本科或他科檢查並已使用造影 劑。 3.3.02 通知護理師依醫囑備妥一般(離子性)造影劑、非離子造影劑、 或口服之鋇劑等,或準備攝影前口服造影劑;及造影劑預熱加 溫約35?。 3.3.03 設定病患受檢之適當攝影部位後,通知其主治醫師使用造影 劑。 3.3.04 本科常用的離子性造影劑為Angiografine,非離子性造影劑有 Ultravist 370及Iopamiro 370等;依醫囑使用人工注射或自動 注射配備。 3.3.05 使用注射造影劑時,完全注射前先預推約5 cc左右進入,以 觀察病患是否有過敏現象,待病患確定無過敏反應後才完全著 述造影劑。 36 3.3.06 攝影前確認病患是否在短期內已作過鋇劑造影。 3.4 品管作業 3.4.01CT scanner應定期(包括每月、季、年)檢測其射線品質、劑量 輸出值、電流量、照野對稱性及中心線之吻合度等。 3.4.02依照各機器特性實施各項QA(品質保證)之定期檢測。 3.4.03隨時檢測X光影像之黑白對比度、清晰度、是否有假影。 3.4.04定位用雷射燈組應定期QA校正。 3.4.05防護用鉛衣應以衣架掛放,不得摺疊。 3.4.06各項檢查記錄應至少保存三年。 3.5 廢棄物處理作業 3.5.01 X光片處理過程應依「事業廢棄物儲存清除處理方法及設施標 準」規定辦理,經環保主管機關認可核可之廠商處理。 3.5.02遇傳染病患者,必頇依照法定傳染病規定通報、預防傳染、消 毒等作業後,始能繼續後續之診療作業。 3.5.03各種失能性因素造成污染,必頇先行清理無誤後始能繼續治檢 測療作業。 3.5.04加以分類處理,不可混雜丟棄。 3.6 病患衛教與諮詢作業 3.6.01攝影檢查前應告知受檢者或家屬,說明檢查項目、目的及過程。 3.6.02應製作檢查流程壁報,以便民眾了解檢查目的及過程。 3.6.03提供有關放射性檢查及輻射安全等相關問題的諮詢。 3.6.04醫事放射師不得將檢查結果告知受檢者或其家屬,以免滋 生困擾。 3.6.05製作單張衛教資料,以便民眾取閱,了解檢查目的及過程。 37 手術中放射治療(IORT) 標準作業規範 技術組 劉義誠組長 1.目的: 確定手術中放射治療之正確性與安全性 2.適用範圍: 手術中放射治療技術 3.安全作業規範: 3.1 醫囑計畫診療作業 3.1.01 放射腫瘤專科醫師應先瞭解診斷及病況與外科醫師討論治療方法。 3.1.02 病人先接受外科手術切除或切片檢查確定診斷並決定治療部 位及範圍。 3.1.03 病人於手術室進行手術,確定需要給予放射治療時,先給予 無菌包封後再送至治療室照射治療。 3.2治療室之手術中放射治療作業 3.2.01放射治療作業應由經過專業訓練並領有合格證照之放射師操 作。 3.2.02放射治療前應仔細核對、確認接受治療者之身分、基本資料及 治療部位(至少兩種以上病患辨識的方法)。 3.2.03於麻醉及無菌操作,細心移動病人至治療機器下,對準位置, 避開正常組織,進行手術中放射治療操作。 3.2.04治療中必頇隨時監看監視系統,若病患有任何異動現象,必頇 隨時停止治療,待重新核對定位後,再繼續啟動治療。 3.2.05治療中若因機械故障因素中斷治療,必頇先核對並紀錄已完成 數據以利後續治療。 3.2.06治療區需備有開刀房隨行之急救所需要設備、藥品,以應不時 之需。 3.2.07治療完成時應製作記錄,記錄治療日期、治療部位、劑量及其 他處理情形。 3.2.08治療後應於治療紀錄上簽章以示負責。 3.2.09各項治療記錄應依法規規定之至少保存年限。 3.3品質管制作業 3.3.01治療設備應實施定期(每日,月、年)品質檢測校正作業。 3.3.02依照各機器特性實施各項QA(品質保證)之定期檢測。 3.3.03定位用雷射燈組應每日QA校正。 38 3.3.04各治療設備若有任何維修更換零件後,必頇確認治療機各項狀 況穩定並經測詴後,始能恢復治療作業。 3.3.05各項治療記錄應依法規之規定保存至少年限。 3.4廢棄物處理規範 3.4.01若有法定傳染病患者,必頇依照法定傳染病規定通報、預防傳 染、消毒等作業後,始能繼續後續治療作業。 3.4.02治療之病患因各種施能性因素造成污染,必頇先行清理無誤後 始能繼續治療作業。 3.4.03各類污染廢棄物應依規定加以分類處理,不可混雜丟棄。 3.5病患衛教與諮詢作業 3.5.01治療前應告知受治療者或家屬,說明治療項目、目的及過程。 3.5.02應製作治療流程壁報,以便病患及家屬了解治療目的及過程。 3.5.03提供有關放射治療及輻射安全等相關問題的諮詢。 3.5.04醫事放射師不得將治療結果告知患者或其家屬,以免滋生困擾。 3.5.05製作單張衛教資料,以便民眾取閱,了解檢查目的及過程。 39 放射手術(Radiosurgery) 標準作業規範 技術組 劉義誠組長 1.目的: 確定放射手術放射治療之正確性與安全性。 2.適用範圍: 放射手術治療技術。 3.安全作業規範: 3.1 診療醫囑處方作業 3.1.01放射腫瘤醫師必頇了解游離輻射對懷孕婦女可能造成胎兒的 影響,如果有懷孕的可能,宜加會婦產部(科)評估對胎兒影 響,並向病人解釋可能造成的影響。 3.1.02 腫瘤醫師應先確定診斷及與神經外科醫師討論治療方法。 3.1.03 安排病人釘頭架或Head ring mask製作、完成後進行CT scan、與醫學物理師進行電腻治療計劃、決定治療範圍及劑 量。 3.1.04 完成病歷記錄及電腻治療計劃後通知放射師安排治療。 3.2治療室放射治療作業 3.2.01放射手術治療應由經過專業訓練並領有合格證照之放射師操 作。 3.2.02治療放射師前應仔細核對、確認接受治療者之身分、基本資料 (至少兩種以上病患辨識的方法)及治療部位是否正確、清晰。 3.2.03 放射師必頇先詳細瞭解電腻治療計劃、治療部位、範圍及劑 量等。 3.2.04應使治療床調降到適當高度,以利治療病患上下治療床。對體 弱、婦孺或行動不變者,治療前後必頇扶持上下治療床。 3.2.05對於推床患者移動到治療床,必頇使用滑板並固定推床,避免 搬運時使病患受到任何意外傷害。 3.2.06對於意識不清或無法配合之患者,必頇請家屬或充分人力之同 仁協助搬移或完全確認固定無誤,方能進行治療。 3.2.07詢問婦女病患是否懷孕,如果有懷孕即知會並轉至其主治醫師 作適當評估繼續治療的適當性。 3.2.08 治療中必頇隨時監看監視系統,若病患有任何異動現象,必 頇隨時停止治療重新核對定位後,再繼續啟動治療。 3.2.09 治療中若因機械故障因素中斷治療,必頇先核對並紀錄已完 成數據以利後續治療。 3.2.10 確定依照放射手術治療程序進行治療。 40 3.2.11治療區需備急救所需要設備,以應不時之需。 3.2.12治療前指示病患準備妥治療時所需之穿著,以利治療之進行。 3.2.13治療後應於治療紀錄上簽章以示負責。 3.2.14各項治療記錄應依法規規定之至少保存年限。 3.3品質管制作業 3.3.01治療設備應實施每日、月、年之定期品質檢測校正作業。 3.3.02治療開始前需由物理師進行QA,項目包括雷射燈(Laser)、治 療床(Couch)與準直儀(Collimator)之吻合度,誤差值頇小於 0.75 mm以下。 3.3.03定位用雷射燈組應定期QA校正。 3.3.04各治療設備若有任何維修更換零件後,必頇確認治療機各項狀 況穩定並於必要時先行緊急測詴步驟後,始能恢復治療作業。 3.3.05各項治療記錄應依法規規定至少之保存年限。 3.4廢棄物處理作業 3.4.01若有法定傳染病患者,必頇依照法定傳染病規定通報、預防傳 染、消毒等作業後,始能繼續後續治療作業。 3.4.02治療之病患因各種施能性因素造成污染,必頇先行清理無誤後 始能繼續治療作業。 3.4.03各類污染廢棄物應依規定加以分類處理,不可混雜丟棄。 3.5病患衛教與諮詢作業 3.5.01治療前應告知受治療者或家屬,說明治療項目、目的及過程。 3.5.02應製作治療流程壁報,以便病患及家屬了解治療目的及過程。 3.5.03提供有關放射治療及輻射安全等相關問題的諮詢。 3.5.04醫事放射師不得將治療結果告知患者或其家屬,以免滋生 困擾。 3.5.05製作單張衛教資料,以便民眾取閱,了解檢查目的及過程。 41 Malignant Radiotherapy (RT) Protocol for brain tumor 2010-01 *This document is aimed to set up RT protocols for brain tumor. The treatment guideline for brain tumor will not be covered here. A. Preinciples of brain tumors images 1. MRI: • Gold standard • Provide a reasonably good delineation of tumors usually enhance。 2. Enhanced CT of the brain: • Should be used in patients who cannot have a MRI • Claustrophobia or implantable devices are not an issue，an be done faster than MRI。 3. MR spectroscopy: • Assess metasbolities within tumors and normal tissue。 • Use is to differentiate tumor from radiation necrosis;may be helpful in grading tumors or assessing response。 • Area most abnormal would be the best place to target for biopsy 4. MR perfusion: • May be helpful in differentiating grade of tumor or tumor versus radiation necrosis。 Area of highest perfusion would be the best place to biopsy。 B. Localization, Simulation, and Immobilization The patient shall be treated in the supine or other appropriate position for the location of the lesion. A head-holding device to ensure adequate immobilization during therapy and ensure reproducibility is strongly recommended. Simulation may include a virtual simulation using a treatment planning CT. Fusion with MR images is strongly recommended, whenever feasible. For patients accrued to the protocol, treatment verification and documentation should be carried out, at least for the first treatment fraction, and more frequently, weekly verification is the present department policy. Orthogonal images for documenting isocenter setup accuracy is required for the first fraction. These orthogonal images can be obtained with film, On Board Imager, BrainLab ExacTrac system or cone-beam CT. C. Treatment Planning 42 The inhomogeneity within the target volume shall be kept to ? 10% of the prescribed dose. The minimum dose to the target volume should be kept within 10% of the dose at the center of the volume. Doses are specified such that at least 95% of the PTV shall receive 100% of the prescribed dose; DVHs are encouraged to make this selection. A. CT-based treatment planning is necessary to assure accuracy in the selection of field arrangements. A treatment planning CT scan will be required to define tumor, clinical and planning target volumes. The treatment planning CT should be acquired with the patient in the same position, immobilization device, and conditions as she/he will be for treatment. Each patient will be positioned and immobilized with an individualized thermoplastic cast or molded foam cradle on a flat table top. The CT scan should start at the top of the cranial vertex and down to the neck to encompass the entire cranial contents and the head. CT scan thickness should be < 0.5 cm through the region that contains the target volumes. The regions above and below the target volume may be scanned with slice thickness of < 1 cm. The GTV, CTV and PTV and all normal tissues must be outlined on all CT slices in which the structures exist. The post-operative MRI will be used to define the GTV if available, and CT to MRI registration software should be used to assist in defining the MRI based GTV on the treatment planning CT. It is strongly encouraged that post operative MRI scanning is done ? 72 hours after surgery. B. Patients were treated using linear accelerator beams with minimal nominal energy of 6MV. For simulation, performed using a clinical computed tomography (CT) simulator and a helical image acquisition technique, all patients were immobilized using a commercially available thermoplastic mask system. C. CT image data, reconstructed in 2.5- or 3-mm slice thicknesses, were coregistered with available MRI data in T2 or fluid attenuation inversion recovery and T1 postcontrast weighting。 D. Target Volume and RT dose 1. HIGH GRADE GLIOMAS: , Target volumes will be based upon preoperative-enhanced MRI. Post-operative imaging should be used for correlation and improved identification. , The gross tumor volume (GTV) consisted of the entire visible tumor at preoperative contrast-enhanced CT or MRI. The clinical target volume (CTV) included the entire enhanced tumor (according to preoperative 43 contrast CT or MRI) plus a 2- to 3-cm margin。 , In cases of apparently complete or subtotal removal, the position of the tumor bed was shifted, and CTV estimation took pre- and postoperative CT/MRI into account. In cases of complete surgical removal, care was taken to ensure that the GTV-CTV margin was still 2 to 3 cm, and this measurement was left to the discretion of individual radiation oncologists。The planning target volume (PTV) included CTV plus 0.3-0.5-cm margin. , RT consisted of a conventionally fractionated regimen, with the delivery of a total dose of 60 Gy in 6 weeks, in a once-daily schedule of 2 Gy per fraction for a total of 30 fractions. , Alternatively, if postoperative MRI is available- , GTV is defined by the physician as all known gross disease as defined by the treatment planning CT and/or postoperative MRI scan (resection cavity and gross residual tumor). Every attempt should be made to obtain postoperative MRI ? 72 hours after surgery. , CTV1 is the resection cavity or residual tumor (contrast-enhancing region) plus at least a 15-mm margin. CTV2 is the resection cavity or GTV (post-operative (contrast-enhancing region and surrounding edema). The CTVs will be limited to the brain and adjacent nervous tissue. The CTVs need not extend beyond the cranial contents. The 15 mm margin refers to a margin of non-enhancing brain or nervous tissue adjacent to the GTV. , A minimum of 0.3~0.5 cm around the CTV is required to define each respective PTV. , This initial target volume (PTV1) will be treated to 46.0 Gy in 23 fractions. After 46 Gy the cone-down tumor volume should include the contrast enhancing lesion (without edema; PTV2) on the post-surgery CT/MRI scan. 2. LOW GRADE GLIOMAS: , Tumor volume is best defined using pre- and postoperative imaging, usually FLAIR and or T2 signal abnormality on MRI for GTV. CTV included entire GTV plus 1-2 cm margin. The planning target volume (PTV) included CTV plus 0.3 to 0.5-cm margin. SRS has not been established to have a role in the management of low grade gliomas. , RT consisted of a conventionally fractionated regimen, with the delivery of a total dose of 45-54 Gy in 6 weeks, in a once-daily schedule of 1.8-2 Gy per fraction. 44 1. Ependymoma: , GTV is best defined using pre/post-operative imaging, usually enhanced T1 and FLAIR/T2. Anatomic areas touched by preoperative tumor volume plus postoperative signal abnormality on MRI. , CTV included entire GTV plus 1-2 cm margin. The planning target volume (PTV) included CTV plus 0.3 to 0.5-cm margin. , Craniospinal field for spinal seeding tumors: whole brain and spine (to bottom of thecal sac). , Limited field: RT consisted of a conventionally fractionated regimen, with the delivery of a total dose of 54-59.4 Gy in 6 weeks, in a once-daily schedule of 1.8-2 Gy per fraction. , Craniospinal field: receive 36Gy in 1.8 Gy per fraction, followed by limited field to metastatic spine lesion to 45-50Gy. Primary brain tumor site should receive total dose of 54-59.4 Gy. 2. Malignant meningioma: , GTV was defined as enhancing mass as defined by postoperative contrast-enhanced CT and/or MRI scan , CTV includes gross disease, operative bed, hyperostotic bones and areas of dural thickening with approximately 1 cm margin and peritumoral edema. Volume reductions to GTV were performed after the initial 50–54 Gy. , PTV included CTV plus 0.3 to 0.5-cm margin. , This initial target volume will be treated to 50 Gy, then cone-down boost to gross tumor with the delivery of a total dose of 60 Gy in 6 weeks, in a once-daily schedule of 1.8-2 Gy per fraction. 3. Organs at risk: Eyes, optic nerves, optic chiasm, and brainstem, were delineated, and great care was taken to limit the dose to the optic chiasm and brainstem to less than 55Gy and the retina to less than 50 Gy and to ensure that the lens was not encompassed by any direct beam. E. Follow-up schedule Baseline evaluations were performed within 14 days (28 days for imaging) from entry into treatment and included a complete medical history, physical 45 examination, determination of performance status, hematology and clinical chemistry assessments, and gadolinium-enhanced MRI or contrast-enhanced CT of the brain. During RT, complete blood counts were checked weekly, and blood chemistry was checked monthly. During adjuvant temozolomide treatment, patients underwent at least one monthly physical examination. Complete blood counts and blood chemistry were drawn before each cycle. Gadolinium-enhanced MRI was performed before the first adjuvant treatment cycle and then every 3 months during the first two year and every 3 to 6 months after the third year after treatment. , For recurrent or progressive disease: Re-irradiation with highly conformal RT is suggested, especially if long interval since prior RT and /or good response to prior RT. Highly conformal RT: 1. Sereotactic radiosurgery (SRS): i. A contrast-enhanced MRI shows one to three recurrent tumors with a maximum diameter of 4 cm for the largest lesion and additional lesions not exceeding 3 cm in diameter. ii. The target was defined as the contrast-enhancing lesion in T1-weighted MR images, adding a 2-5 mm safety margin. iii. The dose was normalized to 100% isodose contour. Minimum peripheral doses of 10 to 20 Gy were delivered to target volume. 2. Fractionated stereotactic radiotherapy (FSRT): i. PTV consists of the area of contrast enhancement in T1-weighted sequences, adding a 1 cm margin. ii. The dose was normalized to 100% isodose contour. FSRT was performed with a dose of 37.5 Gy in 15 fractions. 3. High-dose-rate (HDR) stereotactic brachytherapy (STBT) i. Eligible criteria: supratentorial, well-demarcated GBM with a maximal diameter of 5 cm after EBRT (3) KPS at least 70; (4) non-midline tumor ii. Before the first fraction of HDR STBT was given, a Brown-Roberts-Wells (BRW) base ring was attached to the patient’s skull with a CT localization frame attached to the base ring. The patient then underwent a contrast enhanced CT scan. The CT images were transferred using optical discs as storage media to a 3-D STBT treatment planning system (BrainSCAN). The target volume, which included the gross tumor or tumor bed plus a 0.5 cm margin, was determined by a neurosurgeon. iii. 300 cGy isodose line (dose level) was the prescribed point of HDR 46 brachytherapy, which just covered the entire target volume. F. Schema of CNS malignant tumor management guidelines 47 48 References 1. Shapiro, W.R. and D.F. Young, Treatment of malignant glioma. A controlled study of chemotherapy and irradiation. Archives of Neurology, 1976. 33(7): p. 494-50. 2. Walker, M.D., et al., Randomized comparisons of radiotherapy and nitrosoureas for the treatment of malignant glioma after surgery. New England Journal of Medicine, 1980. 303(23): p. 1323-9. 3. Green, S.B., et al., Comparisons of carmustine, procarbazine, and high-dose methylprednisolone as additions to surgery and radiotherapy for the treatment of malignant glioma. Cancer Treatment Reports, 1983. 67(2): p. 121-32. 4. Shapiro, W.R., et al., Randomized trial of three chemotherapy regimens and two radiotherapy regimens and two radiotherapy regimens in postoperative treatment of malignant glioma. Brain Tumor Cooperative Group Trial 8001. Journal of Neurosurgery, 1989. 71(1): p. 1-9. 5. Curran, W.J., Jr., et al., Recursive partitioning analysis of prognostic factors in three Radiation Therapy Oncology Group malignant glioma trials.[see comment]. Journal of the National Cancer Institute, 1993. 85(9): p. 704-10. 6. Curran, W.J., Jr., et al., Survival comparison of radiosurgery-eligible and -ineligible malignant glioma patients treated with hyperfractionated radiation therapy and carmustine: a report of Radiation Therapy Oncology Group 83-02. Journal of Clinical Oncology, 1993. 11(5): p. 857-62. 7. Nelson, D.F., et al., Hyperfractionated radiation therapy and bis-chlorethyl nitrosourea in the treatment of malignant glioma--possible advantage observed at 72.0 Gy in 1.2 Gy B.I.D. fractions: report of the Radiation Therapy Oncology Group Protocol 8302. International Journal of Radiation Oncology, Biology, Physics, 1993. 25(2): p. 193-207. 8. Hoegler, D.B. and P. Davey, A prospective study of short course radiotherapy in elderly patients with malignant glioma. Journal of Neuro-Oncology, 1997. 33(3): p. 201-4. 9. Black, P., Management of malignant glioma: role of surgery in relation to multimodality therapy. Journal of Neurovirology, 1998. 4(2): p. 227-36. 10. Scott, C.B., et al., Validation and predictive power of Radiation Therapy Oncology Group (RTOG) recursive partitioning analysis classes for malignant glioma patients: a report using RTOG 90-06. International Journal of Radiation Oncology, Biology, Physics, 1998. 40(1): p. 51-5. 11. Lacroix, M., et al., A multivariate analysis of 416 patients with glioblastoma multiforme: prognosis, extent of resection, and survival.[see comment]. 49 Journal of Neurosurgery, 2001. 95(2): p. 190-8. 12. Laperriere, N., et al., Radiotherapy for newly diagnosed malignant glioma in adults: a systematic review. Radiotherapy & Oncology, 2002. 64(3): p. 259-73. -dose-rate stereotactic brachytherapy for patients 13. Chang, C.-N., et al., High with newly diagnosed glioblastoma multiformes. Journal of Neuro-Oncology, 2003. 61(1): p. 45-55. 14. Grossman, S.A., et al., Phase III Study Comparing Three Cycles of Infusional Carmustine and Cisplatin Followed by Radiation Therapy With Radiation Therapy and Concurrent Carmustine in Patients With Newly Diagnosed Supratentorial Glioblastoma Multiforme: Eastern Cooperative Oncology Group Trial 2394. J Clin Oncol, 2003. 21(8): p. 1485-1491. 15. McDermott, M.W., et al., Stereotactic radiosurgery and interstitial brachytherapy for glial neoplasms. Journal of Neuro-Oncology, 2004. 69(1-3): p. 83-100. 16. Souhami, L., et al., Randomized comparison of stereotactic radiosurgery followed by conventional radiotherapy with carmustine to conventional radiotherapy with carmustine for patients with glioblastoma multiforme: report of Radiation Therapy Oncology Group 93-05 protocol.[see comment]. International Journal of Radiation Oncology, Biology, Physics, 2004. 60(3): p. 853-60. 17. Tsao, M.N., et al., The American Society for Therapeutic Radiology and Oncology (ASTRO) evidence-based review of the role of radiosurgery for malignant glioma. International Journal of Radiation Oncology, Biology, Physics, 2005. 63(1): p. 47-55. 18. Vordermark, D., et al., Hypofractionated stereotactic re-irradiation: treatment option in recurrent malignant glioma. BMC Cancer, 2005. 5(1): p. 55. 19. Mirimanoff, R.-O., et al., Radiotherapy and temozolomide for newly diagnosed glioblastoma: recursive partitioning analysis of the EORTC 26981/22981-NCIC CE3 phase III randomized trial. Journal of Clinical Oncology, 2006. 24(16): p. 2563-9. 20. Westphal, M., et al., Gliadel wafer in initial surgery for malignant glioma: long-term follow-up of a multicenter controlled trial. Acta Neurochirurgica, 2006. 148(3): p. 269-75; discussion 275. 21. Perry, J., et al., Adjuvant chemotherapy for adults with malignant glioma: a systematic review. Canadian Journal of Neurological Sciences, 2007. 34(4): p. 402-10. 50 Radiotherapy (RT) Protocol for Nasopharyngeal Carcinoma 2010-01 *This document is aimed to set up RT protocols for nasopharyngeal carcinoma. The treatment guideline for nasopharyngeal carcinoma will not be covered here. A. Pre-RT work-up and preparations Mandatory - H&P - ENT check-up - Nasopharyngoscopy - Nasopharyngeal biopsy - CXR - CBC & SMA-12 1-5- MRI (preferred) with gadolinium of nasopharynx and base of skull to clavicles 6and/or CT with contrast 5, 7-1011- PET/CT (preferred) or whole-body 3-T MRI or imaging for distant metastases(chest, liver, bone) - Dental care/evaluation - Multidisciplinary consultation Optional 12- Thyroid hormones (TSH, free T4) 13- Audiogram - Bone scan (for patient without PET/CT) - Prolactin - Survey of Quality of life B. Definitions for RT treatment planning Two- to Three-phase RT guidelines (For patients joint in specific protocol, please refer to the statement of that protocol) 1. Immobilization: 1.1 Both thermoplastic ―Head-and-Shoulder‖ or ―Type-S Head-and-Neck‖ mask are accepted 1.2 Both D-pillow (preferred) or C-pillow could be used. However, if the patient 51 use D-pillow with a hollow space more than 3 cm between neck and table, a customized small neck-shoulder α-cradle or cushion-bag may be helpful to minimize C-spine setup inaccuracy. 1.3 For patients treated by RapidArc for their lower neck, the use of shoulder extractor at both CT simulation and whole course of RT is suggested for minimizing the dose inaccuracy resulted from shoulder disposition. 2. CT simulation: 2.1 A CT scan of head and neck with 2.5 to 3.75 mm contiguous slices in immobilization system is required for all patients 2.2 Contrast (50-100 cc ) enhancement is suggested, for more accurate GTVs contouring 3. GTV/CTV/PTV delineation: 3.1 GTV delineation 3.1 .1 GTVs are delineated as a comprehensive judgment from imaging of 14planning CT, MRI, and/or PET/CT scan. 3.1.2 The use of image-fusion software for more accurate target-contouring is encouraged. 3.1.3 If a second CT-simulation for reduce-plan is performed, physicians should pay attention to avoid apparent GTVs (primary tumor, neck lymph nodes) discrepancy between the initial and the second CT simulation, especially for those who receive 2-phase treatment with rapid initial response. 52 3.2 CTV delineation 3.2.1 CTV0-46(50)Gy: 3.2.1.1 The initial field usually includes lower 2/3 of sphenoid sinus, posterior and lower parts of ethmoid sinuses, whole nasopharynx, posterior 1/3 to 2/3 nasal cavity, posterior and medial wall of maxillary sinus, bilateral pterygopalatine fissures, bilateral neck lymphatics (according to N stage, see description bellow) down to sterno-clavical junction. 3.2.1.2 5(minimum)-10 mm margin between CTV and GTV is suggested (at least 5 mm), however, physicians could tailor margins based on 1) T and N stages 2) nature behavior of NPC local extension. 3) anatomic barriers. 4) critical organs. 15-17Below is elected 3.2.1.3 If N(-), then the ipsilateral level Ib spared. 3.2.1.4 If N(+), then the ipsilateral level Ib is prophylactically(46-50 Gy) irradiated. 3.2.1.5 If level Ib(+), then ipsilateral level Ia is prolyplactically irradiated. 53 3.2.2 CTV46(50)-56(60)Gy(optional): 3.2.2.1 Includes PET/MRI score 2 or 3 (equivocal) lesions 3.2.2.2 High-risk local extension route(s)(eg. Whole nasopharynx, parapharyngeal space, skull base, pterygopalatine fissures) 3.2.2.3 High-risk nodal regions (eg. the next echelon of LN positive regions/ adjacent muscles of bulky or ECS LNs). 3.2.3 CTV56(60)-72(70~76)Gy: 3.2.3.1 All GTVs with 3-5 mm margin (may tailor to 1mm if the tumor abutting critical organs which will over the acceptable tolerance dose of those organs). For slow-regression or bulky tumors, the total dose to gross tumor(s) may be escalated up to 76 Gy. 3.3 Rules for creating PTV by expanding each CTV: 3.3.1 For image-guided radiotherapy (IGRT): add 1-3 mm in 3 axes for setup errors (depends on the ways that physicians contouring CTV) 3.3.2 For non-IGRT: add 3-5 mm for setup errors. 3.3.3 At the aspects of critical organs which might approach maximal acceptable tolerance dose, tighter margin down to 1 mm is allowed. 4. Dose coverage and critical normal organs sparing 4.1 Attached below is an example (for reference only) of initial-phase dose-constraints which could be achieved for most T1-3 N+ patients. 4.2 However, the final constraints of each phase should be modified case by case based on 1) the distance(s) between PTV and critical normal organs. 2) the technique 54 applied (3D-CRT, 5- or 7- or 9-field IMRT, RapidArc…etc) 17-204.3 Though whole course of IMRT is preferred, however, partial course treated by 3D-CRT technique is allowed, if the constraints could meet the criteria of each treating physician. 4.4 For patient who is suitable for brachytherapy, concomitant boost 200 cGy/fx/week to 0.5 cm below mucosa for 4 times could be incorporated into the course of external beam radiotherapy for enhancing local control. 4.5 For patients >75 year-old, multiple co-morbidities, poor performance status, fractional dose may lower down to 1.8 Gy. 4.6 If the patient is treated by RapidArc(2-arc) with IG (image-guided) technique, then right and/or left parotids V< 40% is usually achievable for most 40% of prescribed dose T1-3N+ patients. 55 Diagnosis: NPC Dose/frac.:200cGy Total dose:4600cGy Organ Dose Constraints Name Dose (%) Vol % Priority Remark Min Middle Max 102 100 GTV 1 112 0 95 100 CTV 4 0-46FIF* 107 0 90 100 PTV 10 0-46FIF** 102 0 100 R’t&L’t 45 45 2 parotid 0 100 Stem 6 75 0 100 Cord 5 65 0 100 Mandibles 3 102 0 100 Eyes 7 50 0 100 Inner ears 8 80 0 100 Larynx 9 80 0 * PTV0-46FIF(Field-In-Field)= PTV0-46 sub CTV0-46 ** CTV0-46FIF(Field-In-Field)= CTV0-46 sub GTV 56 C. Schema of RT guidelines 57 58 Reference 1. Chang JT, Lin CY, Chen TM, et al. Nasopharyngeal carcinoma with cranial nerve palsy: the importance of MRI for radiotherapy. IntJRadiatOncolBiolPhys 2005;63:1354-60. 2. Emami B, Sethi A, Petruzzelli GJ. Influence of MRI on target volume delineation and IMRT planning in nasopharyngeal carcinoma. IntJRadiatOncolBiolPhys 2003;57:481-8. 3. Ng SH, Chang TC, Ko SF, et al. Nasopharyngeal carcinoma: MRI and CT assessment. Neuroradiology 1997;39:741-6. 4. Liu L, Liang S, Li L, et al. Prognostic impact of magnetic resonance imaging-detected cranial nerve involvement in nasopharyngeal carcinoma. Cancer 2009;115:1995-2003. 5. Ng SH, Chan SC, Yen TC, et al. Staging of untreated nasopharyngeal carcinoma with PET/CT: comparison with conventional imaging work-up. Eur J Nucl Med Mol Imaging 2009;36:12-22. 6. v.1. Head and Neck Cancers. In: NCCN Clinical Practice Guidelines in Oncology; 2009:66-8. 7. Liu FY, Chang JT, Wang HM, et al. [18F]fluorodeoxyglucose positron emission tomography is more sensitive than skeletal scintigraphy for detecting bone metastasis in endemic nasopharyngeal carcinoma at initial staging. JClinOncol 2006;24:599-604. 8. Liu FY, Lin CY, Chang JT, et al. 18F-FDG PET can replace conventional work-up in primary M staging of nonkeratinizing nasopharyngeal carcinoma. JNuclMed 2007;48:1614-9. 9. Ng SH, Chang JT, Chan SC, et al. Nodal metastases of nasopharyngeal carcinoma: patterns of disease on MRI and FDG PET. EurJNuclMedMolImaging 2004. 10. Yen TC, Chang JT, Ng SH, et al. The value of 18F-FDG PET in the detection of stage M0 carcinoma of the nasopharynx. JNuclMed 2005;46:405-10. 11. Ng SH, Chan SC, Yen TC, et al. Pretreatment evaluation of distant-site status in patients with nasopharyngeal carcinoma: accuracy of whole-body MRI at 3-Tesla and FDG-PET-CT. Eur Radiol 2009. 12. Wu YH, Wang HM, Hi-Wen Chen H, et al. Hypothyroidism After Radiotherapy for Nasopharyngeal Cancer Patients. Int J Radiat Oncol Biol Phys 2009. 13. Chen WC, Jackson A, Budnick AS, et al. Sensorineural hearing loss in combined modality treatment of nasopharyngeal carcinoma. Cancer 2006;106:820-9. 14. Liang SB, Sun Y, Liu LZ, et al. Extension of local disease in nasopharyngeal carcinoma detected by magnetic resonance imaging: improvement of clinical target volume delineation. Int J Radiat Oncol Biol Phys 2009;75:742-50. 59 15. Lin S, Pan J, Han L, Zhang X, Liao X, Lu JJ. Nasopharyngeal carcinoma treated with reduced-volume intensity-modulated radiation therapy: report on the 3-year outcome of a prospective series. Int J Radiat Oncol Biol Phys 2009;75:1071-8. 16. Tang L, Mao Y, Liu L, et al. The volume to be irradiated during selective neck irradiation in nasopharyngeal carcinoma: analysis of the spread patterns in lymph nodes by magnetic resonance imaging. Cancer 2009;115:680-8. 17. Tham IW, Hee SW, Yeo RM, et al. Treatment of nasopharyngeal carcinoma using intensity-modulated radiotherapy-the national cancer centre singapore experience. Int J Radiat Oncol Biol Phys 2009;75:1481-6. 18. Lee N, Xia P, Quivey JM, et al. Intensity-modulated radiotherapy in the treatment of nasopharyngeal carcinoma: an update of the UCSF experience. IntJRadiatOncolBiolPhys 2002;53:12-22. 19. Wolden SL, Chen WC, Pfister DG, Kraus DH, Berry SL, Zelefsky MJ. Intensity-modulated radiation therapy (IMRT) for nasopharynx cancer: update of the Memorial Sloan-Kettering experience. IntJRadiatOncolBiolPhys 2006;64:57-62. 20. Kwong DL, Pow EH, Sham JS, et al. Intensity-modulated radiotherapy for early-stage nasopharyngeal carcinoma: a prospective study on disease control and preservation of salivary function. Cancer 2004;101:1584-93. 60 Radiotherapy (RT) Protocol for Pharyngolaryngeal Cancer 2010-01 *This document is aimed to set up RT protocols for pharyngolaryngeal SCC or other variant carcinoma. The treatment guideline for pharyngolaryngeal cancer and other type of histology will not be covered here. A. Pre-RT work-up and preparations 1. Initial workup CLINICAL TUMOR INIITIAL WORKUP WORK-UP PRESENTATION EXTENSION , Oral ulcer and / or , Physical examination , Histologic , Blood counts and mass , ENT check-up confirmation of chemistries , Neck mass , Biopsy of lesion SCCHN , Chest X-ray , Pharyngolaryngeal , Pathologic review: , Tumor extension , Sonography of liver symptoms / sign , Squamous cell classified as AJCC , Bone scan (optional , Ear symptoms / sign carcinoma staging system 2002 for patient with PET) , Dental symptoms/ , Differentiation , CT scan and/or MRI of head and neck sign , Nasal symptom/ sign , FDG-PET scan , Cranial nerve (optional for T1-2 symptom/ sign glottic cancer) , Pain , Panendoscopy (optional) , Dental consultation 2. In the patient who has inconsistent finding in nodal metastasis between CT/MRI and FDG-PET scan, lymph node biopsy for tissue proof may help to conclude the nodal status. 3. Esophagogastroduodenoscopy (EGD) is indicated in patients who are suspicious nd2 primary cancer at esophagus.(1;2) 4. To improve the treatment quality, customized thermoplastic immobilization system and CT simualtion is required. 5. 3D conformal RT or Intensity modulatory radiotherapy (IMRT) and image-guided radiotherapy (IGRT) is preferred. 6. Medical staff should pay attention to patients swallowing functions, expectoration, airway patency and body weight. B. General principle and Treatment strategy 61 1. For early glottic cancer: laser surgery or small field RT can achieve relatively equal disease control and voice quality.(3-6) 2. For resectable-disease and medical-operable patients: , Radical surgery and postoperative adjuvant treatment for high risk group.(7) , organ preservation protocol with radical RT, salvage surgery is reserved for non-responders.(6;8;9) Concurrent chemotherapy during RT is optional in T2N0, and it is strong indicated in disease T3-4 or N+ patients.(10;11) Alternative bioradiotherapy is for patients who cannot tolerate cisplatin-based chemotherapy. (12-14) 3. For unresectable-disease or medical-inoperable patients: radical RT for curative intent is indicated. Concurrent chemotherapy during RT is optional for T2N0, and it is strong indicated in disease T3-4 or N+ patients. Alternative bioradiotherapy is for patients who cannot tolerate cisplatin-based chemotherapy.(12-14) 4. For poor medical condition or M1 patients: palliative chemotherapy with or without local palliative RT for symptoms relief is recommended. 5. Patients entering clinical trial are exceptions. C. Definitions for target delineations for treatment planning 1. Gross Tumor Volume (GTV) is defined as all known gross disease as defined by clinical physical examination and image findings. Gross tumor includes the primary tumor and macroscopically involved lymph nodes. Dose prescription is minimum 100% coverage, and maximal dose is 110% inside. 2. Clinical Target Volume (CTV) includes all the risk areas of subclinical involvement around GTV and neck lymphatic prophylaxis. The volume of CT is dependent on tumor’s location, tumor behaviors, tumor staging and physicians’ preference. Dose prescription is minimum 95% coverage, and maximal dose is 110% inside. 3. Planning Target Volume (PTV) provide margin around the CTV to compensate for variability in treatment position setup. Dose prescription is minimum 90% coverage, and maximal dose is 110% inside. , For non-IGRT patients: 3-5 mm margin is added to CTV , For IGRT patients: 1-5 mm margin is added to CTV , Margins of expansion may be modified for special condition, such as overalapping with critical organ or other concerns on set-up error. 4. Organ at risks (OAR) , Spinal cord: maximal dose should be kept from 50Gy at least , Brain stem surface: maximal dose should be kept form 60Gy at least 62 D. General principles for radiation dose 1. Definitive RT: standard fractionation was given 1.8 to 2 Gy per fraction, and five to six fractions per week , Primary tumor dose - early glottic cancer for RT alone: 2.2 Gy perfraction is to gross tumor with total dose 66Gy; or 66 Gy/33 fractions with 6 fractions per week. - For T1-2 non-glottic cancers: minimal dose is 70 and maximal dose is 72 Gy. - For T3-4 non-glottic cancers: minimal dose is 70 and maximal dose is 72 Gy. , Neck lymphatics - prophylaxis for neck lymphatic drainage, minimal doe is 46 Gy. - For gross involved neck nodes: minimal dose is 70 Gy, and maximal dose is 72 Gy. Dose escalation to bulky neck nodes is allowed. 2. Postoperative RT: standard fractionation was given 1.8 to 2 Gy perfraction, and five to six fractions per week , For prophylaxis of neck lymph nodes: minimal dose is 46Gy. , For primary tumor bed and initial grossly involved nodal area: minimal dose is 60 and maximal dose is 66 Gy. Dose escalation can be considered for site of positive resection margin or metastatic node with extracapsular spread. E. Follow-up schedule , ENT field check up, nasofiberoscopy and physical examinations is performed ndat least every 3 months for the first year, every 4 - 6 months in the 2 year, and every 6 months thereafter. Frequency should be increased if there is any suspicion of tumor recurrence or severe adverse event. , CT scan or MRI of head and neck region should be performed 3-4 months after treatment for tumor response. Annual local-regional image examination is recommended then every 1 year for at least 3 years. , CT scan or MRI of head and neck prn for clinical suspicious recurrence. , Annual systemic workup is recommended for at least 3 years. , Esophagogastroduodenoscopy (EGD) or direct larynscopy is considered in patients with progressive dysphagia but without evidence of recurrent disease. nd, Medical staff should focus at disease control status, 2 primary cancer and swallowing rehabilitation as well.(15;16) 63 References 1. Lee KD, Lu CH, Chen PT et al. The incidence and risk of developing a second primary esophageal cancer in patients with oral and pharyngeal carcinoma: a population-based study in Taiwan over a 25 year period. BMC.Cancer 2009;9:373. 2. Yoshida T, Koyanagi Y, Yoshida H et al. [Clinical and pathological study of esophageal mucosa with hypopharyngeal cancer]. Nippon Jibiinkoka Gakkai Kaiho 1997;100:7-12. 3. Higgins KM, Shah MD, Ogaick MJ, Enepekides D. Treatment of early-stage glottic cancer: meta-analysis comparison of laser excision versus radiotherapy. J.Otolaryngol.Head Neck Surg. 2009;38:603-12. 4. Ansarin M, Santoro L, Cattaneo A et al. Laser surgery for early glottic cancer: impact of margin status on local control and organ preservation. Arch.Otolaryngol.Head Neck Surg. 2009;135:385-90. 5. Agrawal N, Ha PK. Management of early-stage laryngeal cancer. Otolaryngol.Clin.North Am. 2008;41:757-vii. 6. Eckel HE, Schroder U, Jungehulsing M, Guntinas-Lichius O, Markitz M, Raunik W. [Surgical treatment options in laryngeal and hypopharyngeal cancer]. Wien.Med.Wochenschr. 2008;158:255-63. 7. Pfister DG, Laurie SA, Weinstein GS et al. American Society of Clinical Oncology clinical practice guideline for the use of larynx-preservation strategies in the treatment of laryngeal cancer. J.Clin.Oncol. 2006;24:3693-704. 8. Foote RL, Foote RT, Brown PD, Garces YI, Okuno SH, Strome SE. Organ preservation for advanced laryngeal carcinoma. Head Neck 2006;28:689-96. 9. Quer M, Leon X. [Organ preservation in laryngeal and hypopharyngeal cancer]. Acta Otorrinolaringol.Esp. 2007;58:476-82. 10. Forastiere AA. Chemotherapy in the treatment of locally advanced head and neck cancer. J.Surg.Oncol. 2008;97:701-7. 11. Lambert L, Fortin B, Soulieres D et al. Organ Preservation with Concurrent Chemoradiation for Advanced Laryngeal Cancer: Are We Succeeding? Int.J.Radiat.Oncol.Biol.Phys. 2009. 64 12. Bonner JA, Harari PM, Giralt J et al. Radiotherapy plus cetuximab for locoregionally advanced head and neck cancer: 5-year survival data from a phase 3 randomised trial, and relation between cetuximab-induced rash and survival. Lancet Oncol. 2009. 13. Le QT, Raben D. Integrating biologically targeted therapy in head and neck squamous cell carcinomas. Semin.Radiat.Oncol. 2009;19:53-62. 14. Koukourakis G, Kouloulias V, Koukourakis M, Kouvaris J, Zacharias G, Gouliamos A. The efficacy of combined treatment with cetuximab (erbitux) and radiation therapy in patients with head and neck cancer. J.BUON. 2009;14:19-25. 15. Platteaux N, Dirix P, Dejaeger E, Nuyts S. Dysphagia in Head and Neck Cancer Patients Treated with Chemoradiotherapy. Dysphagia 2009. 16. Rosenthal DI, Lewin JS, Eisbruch A. Prevention and treatment of dysphagia and aspiration after chemoradiation for head and neck cancer. J.Clin.Oncol. 2006;24:2636-43. 65 Radiotherapy (RT) Protocol for Oral Cavity Cancer 2010-02 *This document is aimed to set up RT protocols for oral cavity cancer. The treatment guideline for oral cavity cancer will not be covered here. , Postoperative radiotherapy A. General Principle 1. At first consultation, double check of indications of RT following current treatment guideline is required. A complete physical examination to rule out any residual tumor or rapid tumor recurrence is important. Wound healing status should also be inspected. 2. Intensity-modulation technique is recommended for normal tissue sparing. 3. Image-guide technique is recommended for precision of the treatment. 4. Customized head and neck fixation cast is the minimal requirement for fixation. Other device, such as extended (to shoulder) case, oral bite block, or dental plate, can be applied to improve precision. 5. CT simulation should be performed after wound healing status stabilized. 6. Medical staff should pay attention to the body weight and contour change of the patient. Nutrition consultation and tube feeding should be considered if the body weight loss > 5% of the initial weight at CT simulation. Re-simulation is recommended if there is obvious change in body shape or tumor/metastatic node. 7. If the wound healing status is good, postoperative radiotherapy should be initiated within 6 weeks after radical surgery. 8. Concurrent chemotherapy is indicated if there is positive resection margin or nodal metastasis with extracapsular spread. (1, 2) Concurrent chemotherapy can be considered if there is one or more poor prognostic factors listed below (1, 2) A. Pathologic N2b or above B. Co-existence of multiple risk factors (? 3 risk factors) C. Perineural invasion D. Lymphovascular invasion E. Low neck nodal metastasis B. Contouring of Clinical Target Volume (CTV) and Planning Target Volume (PTV) 1. Clinical target volume should at least include tumor bed and involved nodal 66 area. Prophylactic neck irradiation is recommended, but the lymphatic region should be modified individually. In general, bilateral neck irradiation is recommended for tumor originating from or involving midline structures, such as tongue, mouth floor, and palate. 2. Contouring CTV should follow the anatomical boundary. Detail of delineation of lymph node region follows the RTOG Guidelines for CT-based delineation of lymph node levels in the N0 neck or CT-based delineation of lymph node levels and related CTVs in the node-negative neck: DAHANCA, EORTC, GORTEC, NCIC,RTOG consensus guidelines. (3, 4) 3. The safe margin for 3 dimensional expansions to create PTV from CTV should not be less than 3 mm without image guidiance. But the margin may be further reduced if image-guided radiotherapy is applied. PTV can be modified if it is close or overlap with critical structures, like spinal cord, brain, stem, and optic apparatus. C. Dose Schedule and Prescription 1. Risk classification: A. High risk region: tumor bed and involved nodal region stB. Intermediate risk region: 1 echelon lymph node region of tumor or involved nodal region C. Low risk region: other uninvolved lymphatic region. 2. Dose prescription: A. High risk region: 60 – 66Gy B. Intermediate risk region: 46 – 60 Gy C. Low risk region: 45 – 50 Gy 3. Fraction size and dose schedule: A. Conventional daily fraction: 5 – 6 fractions per week, 1.8 – 2 Gy per fraction B. Simultaneous integrated boost with daily fraction: 5 – 6 fractions per week. Fraction size are 2 – 2.2 Gy to high risk region, 1.8 – 2 Gy to intermediate risk region, and 1.6 – 1.8 Gy to low risk region. C. Accelerated fractionation: daily fraction in first 3 weeks with fraction size 1.8 – 2 Gy, followed by bid fractions with > 6 hours interval with fraction size 1.8 Gy in first and 1.5 – 1.6 Gy in second fraction. (5) D. Hyperfractionation is not recommended since there is no evidence to support its benefit. 67 , Primary radiotherapy A. General Principle 1. At first consultation, staging work-up should be arranged, which includes CT or MRI, liver sonography, bone scan or PET/CT, and chest image. Evaluation of general status is also required, such as blood cell count, liver function test, renal function test, and blood sugar. Pretreatment dental survey should be scheduled; extraction is not absolute and should be judged by physician. 2. Submit to cancer conference to review staging result and discuss treatment policy. 3. Intensity-modulation technique is recommended for normal tissue sparing. 4. Image-guide technique is recommended for precision of the treatment. 5. Customized head and neck fixation cast is the minimal requirement for fixation. Other device, such as extended (to shoulder) case, oral bite block, or dental plate, can be applied to improve precision. 6. CT simulation should be performed after wound healing status stabilized. 7. Medical staff should pay attention to the body weight and contour change of the patient. Nutrition consultation and tube feeding should be considered if the body weight loss > 5% of the initial weight at CT simulation. Re-simulation is recommended if there is obvious change in body shape or tumor/metastatic node. B. Contouring of Gross Tumor Volume (GTV), Clinical Target Volume (CTV), and Planning Target Volume (PTV) 1. Gross tumor volume includes primary tumor and metastatic lymph node(s). Image fusion of simulation CT and MRI or PET may help the physician to identify the GTV and its extension. 2. Clinical target volume should at least include suspicious microscopic extension of primary tumor and involved nodal area. Prophylactic neck irradiation is recommended, but the lymphatic region should be modified individually. In general, bilateral neck irradiation is recommended for tumor originating from or involving midline structures, such as tongue, mouth floor, and palate. 3. Contouring CTV should follow the anatomical boundary. Detail of delineation of lymph node region follows the RTOG Guidelines for CT-based delineation of lymph node levels in the N0 neck or CT-based delineation of lymph node levels and related CTVs in the node-negative neck: DAHANCA, EORTC, GORTEC, NCIC,RTOG consensus guidelines. (3, 4) 68 4. The safe margin for 3 dimensional expansions to create PTV from CTV should not be less than 3 mm without image guidiance. But the margin may be further reduced if image-guided radiotherapy is applied. PTV can be modified if it is close or overlap with critical structures, like spinal cord, brain, stem, and optic apparatus. C. Dose Schedule and Prescription 1. Risk classification: i. High risk region: gross tumor and involved nodal region stii. Intermediate risk region: 1 echelon lymph node region of tumor or involved nodal region iii. Low risk region: other uninvolved lymphatic region. 2. Dose prescription: i. High risk region: 70 – 72 Gy ii. Intermediate risk region: 46 – 66 Gy iii. Low risk region: 45 – 50 Gy 3. Fraction size and dose schedule: i. Conventional daily fraction: 5 – 6 fractions per week, 1.8 – 2 Gy per fraction ii. Simultaneous integrated boost with daily fraction: 5 – 6 fractions per week. Fraction size are 2 – 2.2 Gy to high risk region, 1.8 – 2 Gy to intermediate risk region, and 1.6 – 1.8 Gy to low risk region. iii. Accelerated fractionation: daily fraction in first 3 weeks with fraction size 1.8 – 2 Gy, followed by bid fractions with > 6 hours interval with fraction size 1.8 Gy in first and 1.5 – 1.6 Gy in second fraction. (6, 7) iv. Hyperfractionation: bid fraction with > 6 hours interval with fraction size 1.1 – 1.3 Gy. (6, 7) 69 References 1. Bernier J, Domenge C, Ozsahin M, et al. Postoperative irradiation with or without concomitant chemotherapy for locally advanced head and neck cancer. N Engl J Med 2004;350:1945-1952. 2. Cooper JS, Pajak TF, Forastiere AA, et al. Postoperative concurrent radiotherapy and chemotherapy for high-risk squamous-cell carcinoma of the head and neck. N Engl J Med 2004;350:1937-1944. 3. RTOG. RTOG - Guidelines for CT-based delineation of lymph node levels in the N0 neck. 4. Gregoire V, Levendag P, Ang KK, et al. CT-based delineation of lymph node levels and related CTVs in the node-negative neck: DAHANCA, EORTC, GORTEC, NCIC,RTOG consensus guidelines. Radiother Oncol 2003;69:227-236. 5. Ang KK, Trotti A, Brown BW, et al. Randomized trial addressing risk features and time factors of surgery plus radiotherapy in advanced head-and-neck cancer. Int J Radiat Oncol Biol Phys 2001;51:571-578. 6. Fu KK, Pajak TF, Trotti A, et al. A Radiation Therapy Oncology Group (RTOG) phase III randomized study to compare hyperfractionation and two variants of accelerated fractionation to standard fractionation radiotherapy for head and neck squamous cell carcinomas: first report of RTOG 9003. Int J Radiat Oncol Biol Phys 2000;48:7-16. 7. Bourhis J, Overgaard J, Audry H, et al. Hyperfractionated or accelerated radiotherapy in head and neck cancer: a meta-analysis. Lancet 2006;368:843-854. 70 Radiotherapy (RT) Protocol for Lung Cancer 2010-02 *This document is aimed to set up RT protocols for lung cancer (squamous cell carcinoma or adenocarcinoma). The treatment guideline for lung cancer will not be covered here. A. Pre-RT wok-up and preparations 1. Pre-entry CTs of chest and abdomen are required for all patients because it is important for staging and treatment choice. Data on T stage, N stage and M stage will be collected and recorded as AJCC staging criteria. . 2. Mediastinoscopy or bronchoscopic lymph node biopsy is not mandatory unless the suspect node(s) are outside the radiation field and can be done with low invasive procedure (ex. FNA). 3. PET-CT scan is suggested when conventional workup didn’t show distant lymph node or organ metastasis (not M1b stage). 4. The pre-treatment extent of dysphagia should be recorded. (Asymptomatic; Symptomatic: unrestricted diet; Symptomatic: soft foods only; Symptomatic: liquids only; Cannot swallow) 5. To improve the treatment quality, alpha cradle or alternative immobilization system is required and image-guided radiotherapy is recommended. B. Definitions for RT treatment planning , Gross Tumor Volume (GTV) is defined as all known gross disease as defined by the planning CT and clinical information. The pulmonary extent of lung tumors should be delineated on pulmonary windows, and the mediastinal extent of tumors should be delineated using mediastinal windows. The FDG-PET images can help to categorize suspected mediastinal and hilar adenopathy and differentiate between collapsed lung tissue from tumor (1). However, false-positive PET scans can be caused by inflammation, and a biopsy is recommended if there is any question. , Clinical Target Volume (CTV) includes the area of subclinical involvement around the GTV. For the lung parenchymal disease, a margin with 8 mm is required to cover the gross and microscopic disease with 95% accuracy. In the absence of radiographic proof of invasion, the CTV of the primary lesion should 71 not extend into the chest wall or mediastinum. 8 mm expansions of involved nodes of the CTV is recommended, but not extend into the major airways or lung, chest wall, or vertebral body without evidence of invasion. , Planning Target Volume (PTV) provide margin around the CTV to account for daily setup error and target motion. When patients are immobilized with a Vac-Loc bag or other devices, expansion long all axes of 7 mm is recommended for the setup uncertainty. The setup uncertainty can be reduced to 5 mm, if a daily image-guided setup is used. Tumor motion is best assessed individually for each patient. For patients with tumor motion of < 5mm, simple expansion for the GTV margin is adequate. For patients with substantial tumor motion, the maximal intensity projection (MIP) based on 4-D CT is recommended to define the internal target volume (ITV). C. General principles for radiation therapy 1. Elective nodal irradiation may not be necessary, particularly in patients staged with both CT and PET (2); however, low dose (< 50 Gy) could be helpful to control some subclinical nodal metastasis (3). 2. Immobilization devices, such as Vac-Loc bag, are recommended. 3. A 4-D CT simulation is desirable for evaluating tumor motion and individualizing the target volume and margin (4). 4. Respiratory gating is an option to reduce the irradiated normal lung tissue; however, attention should be paid to irregular breathing and variation in the breathing pattern over the course of the treatment. 5. In clinical practice, if the patient has very poor pulmonary function or a very large GTV, clinical judgment should be applied to balance the optimal tumor coverage and radiation toxicity. D. Treatment guidelines for non-small cell lung cancer (NCCN guideline) 1. Treatment for stage I or II disease (medical inoperable) I. Definitive radiotherapy for stage I/II NSCLC 甲、 PET should be used for stage work-up to rule out distant metastasis and nodal involvement. 乙、 A dose of approximately 70 Gy delivered as 2 Gy/fraction should be considered for patients with stage I/II NSCLC. 丙、 Adjuvant chemotherapy may be considered for stage IB and II disease if the patient can tolerate it. II. Stereotactic body radiation therapy in selected patients (T1-3N0). Total dose: 6000 cGy/6 fractions by intensity modulated radiotherapy (IMRT) 72 or RapidArc? radiotherapy technology with daily onboard imaging. 6000 cGy/10 fractions could be applied to tumor around the central regions. Dose to the rib (2 cm3) should be < 7 Gy to reduce the possibility of rib fracture (5). 2. Treatment for advanced Stage IIIA or IIIB disease I. Concurrent chemotherapy and radiotherapy , CCRT has been considered the standard treatment for patients with a good performance status and inoperable stage IIIA or IIIB. , Total dose: 70-74 Gy delivered as 1.8-2 Gy/fraction by 3D-CRT or IMRT. When radiation is given concurrently with chemotherapy, a dose up to 74 Gy may be delivered safely, if the dose to normal structures are strictly limited (6). II. Induction chemotherapy followed by chemoradiotherapy , Induction chemotherapy followed by chemoradiotherapy is another option, particularly for a very bulky lesion. , For patients who receive induction chemotherapy, the GTV should include the lung extent of the GTV after chemotherapy, abnormal lymph node stations before chemotherapy. , Total dose: 70-74 Gy delivered as 1.8-2 Gy/fraction by 3D-CRT or IMRT. If the patient has a complete response after chemotherapy, the areas of lymph node station and of lung parenchymal disease before chemotherapy should be included as CTV and treated with at least 50 Gy. 3. Pre-operative radiotherapy I. Indications , Potential respectable disease. , Clinical N0 or N1. For N2 disease, CCRT is preferred if extensive resection is required (7). II. Radiation technique , Preoperatively, a dose of 45-50 Gy is recommended. Doses greater than 50 Gy in the preoperative setting have been reported to be safe and achieved favorable survival outcome (8). , Definitive CCRT should be considered after planned preoperative CCRT if pneumonectomy is the only way to acquire adequate resection. 73 4. Post-operative radiotherapy (PORT) III. Indications Any positive N2 node (9), , , Gross residual disease, , Close or positive margins, , Other adverse factors: T4, inadequate mediastinal lymph node dissection, extracapsular spreading, multiple positive hilar nodes IV. Radiation technique , Radiation therapy should start earlier as local recurrence is the most common failure in tumors with pN2 and positive resection margins (10). , If results from the resection margin are negative and those from the mediastinal nodes are positive, 2-4 cycles of adjuvant chemotherapy should be given, followed by radiotherapy. , If results form the resection margin are positive, PORT should be given first, followed by adjuvant chemotherapy. , Complete the resection with negative margins: 44-50 Gy in 2Gy / faction, off protocol , Positive nodal disease or with extra-nodal extension: 54 Gy , Margin positive for microscopic disease: 60 Gy , Gross residual disease: 66-70 Gy with concurrent chemotherapy E. Treatment guidelines for small cell lung cancer (NCCN guideline) 1. Treatment for limited disease 甲、 Radiation is suggested to start with chemotherapy cycle 1 or 2.. 乙、 No significant difference in survival when patients received post- chemotherapy volume compared with prechemotherapy volume irradiated (11). However, prechemotherapy CT scan should be reviewed to include the originally involved lymph node regions in the target volume. 丙、 Elective treatment of uninvolved nodes is not necessary. 丁、 An adapted radiation target after about 3 week treatment is recommended to reduce toxicity. 戊、 Total dose up to 60 Gy if 45 Gy by hyperfractionation treatment is not feasible. 己、 Prophylactic cranial irradiation is recommended for patients with complete response (either limited or extensive disease). 25 Gy/10 fx can significantly reduce the risk of brain metastasis and improve the 2-year survival for around 5% (12). 74 References 1. Bradley J, Thorstad WL, Mutic S, et al. Impact of FDG-PET on radiation therapy volume delineation in non-small-cell lung cancer. International journal of radiation oncology, biology, physics 2004;59(1):78-86. 2. Belderbos JS, Kepka L, Spring Kong FM, Martel MK, Videtic GM, Jeremic B. Report from the International Atomic Energy Agency (IAEA) consultants' meeting on elective nodal irradiation in lung cancer: non-small-Cell lung cancer (NSCLC). International journal of radiation oncology, biology, physics 2008;72(2):335-42. 3. Kepka L, Maciejewski B, Withers RH. Does incidental irradiation with doses below 50 gy effectively reduce isolated nodal failures in non-small-cell lung cancer: dose-response relationship. International journal of radiation oncology, biology, physics 2009;73(5):1391-6. 4. Zhao B, Yang Y, Li T, Li X, Heron DE, Huq MS. Image-guided respiratory-gated lung stereotactic body radiotherapy: which target definition is optimal? Medical physics 2009;36(6):2248-57. 5. Pettersson N, Nyman J, Johansson KA. Radiation-induced rib fractures after hypofractionated stereotactic body radiation therapy of non-small cell lung cancer: a dose- and volume-response analysis. Radiother Oncol 2009;91(3):360-8. 6. Schild SE, McGinnis WL, Graham D, et al. Results of a Phase I trial of concurrent chemotherapy and escalating doses of radiation for unresectable non-small-cell lung cancer. International journal of radiation oncology, biology, physics 2006;65(4):1106-11. 7. van Meerbeeck JP, Kramer GW, Van Schil PE, et al. Randomized controlled trial of resection versus radiotherapy after induction chemotherapy in stage IIIA-N2 non-small-cell lung cancer. Journal of the National Cancer Institute 2007;99(6):442-50. 8. Cerfolio RJ, Bryant AS, Jones VL, Cerfolio RM. Pulmonary resection after concurrent chemotherapy and high dose (60Gy) radiation for non-small cell lung cancer is safe and may provide increased survival. Eur J Cardiothorac Surg 2009;35(4):718-23; discussion 23. 9. Bradley JD, Paulus R, Graham MV, et al. Phase II trial of postoperative adjuvant paclitaxel/carboplatin and thoracic radiotherapy in resected stage II and IIIA non-small-cell lung cancer: promising long-term results of the Radiation Therapy Oncology Group--RTOG 9705. J Clin Oncol 2005;23(15):3480-7. 10. Jaklitsch MT, Herndon JE, 2nd, DeCamp MM, Jr., et al. Nodal downstaging predicts survival following induction chemotherapy for stage IIIA (N2) non-small cell lung cancer in CALGB protocol #8935. Journal of surgical oncology 2006;94(7):599-606. 75 11. Liengswangwong V, Bonner JA, Shaw EG, et al. Limited-stage small-cell lung cancer: patterns of intrathoracic recurrence and the implications for thoracic radiotherapy. J Clin Oncol 1994;12(3):496-502. 12. Le Pechoux C, Dunant A, Senan S, et al. Standard-dose versus higher-dose prophylactic cranial irradiation (PCI) in patients with limited-stage small-cell lung cancer in complete remission after chemotherapy and thoracic radiotherapy (PCI 99-01, EORTC 22003-08004, RTOG 0212, and IFCT 99-01): a randomised clinical trial. The lancet oncology 2009;10(5):467-74. 76 Radiotherapy (RT) Protocol for Esophageal Cancer 2010-01 *This document is aimed to set up RT protocols for esophageal cancer (squamous cell carcinoma or adenocarcinoma). The treatment guideline for esophageal cancer will not be covered here. A. Pre-RT work-up and preparations 1. Pre-entry CTs of chest and abdomen are required for all patients because it is important for staging and treatment choice. Endoscopic ultrasound is required for patients of T1&T2 disease. Data on T stage, N stage and M stage will be collected and recorded as AJCC staging criteria. . 2. Lymph node biopsy is not mandatory unless the suspect node(s) are outside the radiation field and can be done with low invasive procedure (ex. FNA). 3. PET-CT scan is suggested when conventional workup didn’t show distant lymph node or organ metastasis when T stage >=2 (not M1b stage). 4. The pre-treatment extent of dysphagia should be recorded. (Asymptomatic; Symptomatic: unrestricted diet; Symptomatic: soft foods only; Symptomatic: liquids only; Cannot swallow) 5. To improve the treatment quality, alpha cradle or alternative immobilization system is required and image-guided radiotherapy is recommended. B. Definitions for RT treatment planning Gross Tumor Volume (GTV) is defined as all known gross disease as defined by the planning CT and clinical information. Gross tumor includes the primary tumor (GTV-P) and macroscopically involved lymph nodes (GTV-LN) . Clinical Target Volume (CTV) includes the area of subclinical involvement around the GTV. We have chosen to define the CTV a minimum of 3-5 cm proximal and distal and 1 cm lateral beyond the GTV delineated by CT scan and/or endoscopy. All GTV-LN were included with a margin of 1 cm. The final CTV may be larger since for cervical primaries, the supraclavicular nodes need to be included, and for distal primaries, the celiac nodes need to be included in the treatment fields. 77 D. For cervical esophagus 1. Clinical target volume that included the superior mediastinal nodes located above the level of the carina if the primary tumor did not extend below aortic arch level, the bilateral supraclavicular and cervical zone III & IV lymph nodes, and normal-appearing esophagus/pharynx 3-5 cm above and below the GTV-P, except where constrained by anatomic barrier. E. For thoracic esophagus 1. For upper-third esophageal primaries (above the carina), the paraesophageal nodes need to be included to the supraclavicular or mediastinal nodes, and normal-appearing esophagus 5 cm above and below the GTV-P, except where constrained by anatomic barrier. 2. For mid-third esophageal primaries (at or below the carina), the paraesophageal nodes need to be included to the supraclavicular or celiac nodes and normal-appearing esophagus 5 cm above and below the GTV-P, except where constrained by anatomic barrier.. 3. For low-third esophageal primaries (with/without ECJ involvement), the following elective lymph nodes stations were irradiated: mediastinal nodes, the left and right cardiac lymph nodes, the lymph nodes along the left gastric artery and the lesser curvature, the celic axis lymph nodes, and normal-appearing esophagus/stomach 3-5 cm above and below the GTV-P, except where constrained by anatomic barrier. Planning Target Volume (PTV) provide margin around the CTV to compensate for variability in treatment setup, breathing, or motion during treatment. A margin around the CTV will define the PTV. The PTV volume must include a minimum of 1 cm and a maximum of 2 cm around the CTV. Therefore, the superior and inferior margins will be approximately 4-6 cm beyond the GTV-P, and the lateral margins will be approximately 2-3 cm beyond the GTV. C. General principles for radiation dose 1. Full-dose treatment (60 Gy) in two split courses will be delivered to all unresectable/inoperable patients as protocol. 2. The simultaneous integrated boost (SIB) technique for boost to poor responsive primary or lymph node after the first 30Gy RT is allowed. 3. For primary surgery patients, 44 Gy will be prescribed for microscopic nodal disease in T1 or T2 tumors, and 60 Gy as CCRT protocol will be prescribed in T3 or T4 tumors 4. For organ-metastatic lesions, palliative radiotherapy is prescribed as indicated. 78 D. Treatment guidelines for esophageal cancer 1. Treatment for T1, T2 disease III. Treatment for T1, T2 disease unfit for surgery 1. Combination of high-dose-rate (HDR) brachytherapy plus external radiotherapy (EXRT) if without chemotherapy [1] HDR brachytherapy: 10 Gy/2fx. prescribed to the esophageal wall of GTV-P with interval between fractions at least 1week. EXRT: 50 Gy/25 fx to PTV 2. EXRT alone: For patients who refuse/unfit for chemotherapy. [2] , Total dose to GTV = 66-70 Gy/33-35 fx. - Dose prescription and delivery technique: 50 Gy/25 fx to PTV, and boost with 16-20 Gy/8-10 fx to GTV. RT given by intensity modulated radiotherapy (IMRT) or RapidArc? radiotherapy technology is preferred. - Requirement of dose coverage: 100% dose to CTV, and PTV is treated by 95% of prescribed dose. Maximal dose inside the PTV is < 110% of prescribed dose. The maximal dose to spinal cord is less than 70% of prescribed dose. 3. Chemoradiation: For patients who refuse surgery and receive chemotherapy as T3-T4 protocol. , Total dose to GTV = 60 Gy/30 fx - Dose prescription and delivery technique: 50 Gy/25 fx to PTV, and boost with 10 Gy/5 fx to GTV. RT given by intensity modulated radiotherapy (IMRT) or RapidArc? radiotherapy technology is preferred. - Requirement of dose coverage: 100% dose to CTV, and PTV is treated by 95% of prescribed dose. Maximal dose inside the PTV is < 110% of prescribed dose. The maximal dose to spinal cord is less than 80% of prescribed dose. IV. Treatment for T1&T2, postoperative N(+) disease 1. EXRT alone: , Total dose to PTV = 44 Gy/22 fx. - Dose prescription and delivery technique: 44 Gy/ 22 fx to PTV without consideration of the cephalo-caudal extension of GTV-P. RT given by intensity modulated radiotherapy (IMRT) or RapidArc? radiotherapy technology is preferred. - Requirement of dose coverage: 100% dose to CTV, and PTV is treated 79 by 95% of prescribed dose. Maximal dose inside the PTV is < 110% of prescribed dose. 4. Chemoradiation: For patients who receive chemotherapy as T3-T4 protocol. , Total dose to PTV = 30 Gy/15 fx - Dose prescription and delivery technique: 30 Gy/15 fx to PTV without consideration of the cephalo-caudal extension of GTV-P. RT given by AP/PA, or 3D-CRT or intensity modulated radiotherapy (IMRT) or RapidArc? radiotherapy technology is acceptable. - Requirement of dose coverage: 100% dose to CTV, and PTV is treated by 95% of prescribed dose. Maximal dose inside the PTV is < 110% of prescribed dose. 2. Treatment for T3-T4 disease 1. Chemoradiation: For patients who receive chemotherapy as protocol. [3-6] , Total dose to PTV = 60 Gy/30 fx in 2 split courses for unresectable tumors or pStage T3&T4 - Dose prescription and delivery technique: 60 Gy/30 fx to PTV. RT given by intensity modulated radiotherapy (IMRT) or RapidArc? radiotherapy technology is preferred. - Requirement of dose coverage: 100% dose to CTV, and PTV is treated by 95% of prescribed dose. Maximal dose inside the PTV is < 110% of prescribed dose. The maximal dose to spinal cord is less than 80% of prescribed dose. - The simultaneous integrated boost (SIB) technique for concomitant boost 10-20% dose to poor responsive primary or lymph node in the second course of 30Gy RT treatment is allowed. , Total dose to GTV = 60 Gy/30 fx in preoperative and postoperative courses for ypStage T3&T4 disease - Dose prescription and delivery technique: 30 Gy/15 fx to PTV in preoperative course, 30 Gy/15 fx to GTV (tumor bed) in postoperative course. RT given by AP/PA is acceptable in the preoperative course, and RT given by intensity modulated radiotherapy (IMRT) or RapidArc? radiotherapy technology is preferred. - Requirement of dose coverage: 100% dose to CTV, and PTV is treated by 95% of prescribed dose. Maximal dose inside the PTV is < 110% of prescribed dose. The maximal dose to spinal cord is less than 80% of prescribed dose. 80 - The simultaneous integrated boost (SIB) technique for concomitant boost 10-20% dose to residual primary or lymph node in the postoperative course of 30Gy RT treatment is allowed. , Total dose to PTV = 30 Gy/15 fx in preoperative course for ypStage T0-T2 disease - Dose prescription and delivery technique: 30 Gy/15 fx to PTV. RT given by AP/PA, or 3D-CRT or intensity modulated radiotherapy (IMRT) or RapidArc? radiotherapy technology is acceptable. - Requirement of dose coverage: 100% dose to CTV, and PTV is treated by 95% of prescribed dose. Maximal dose inside the PTV is < 110% of prescribed dose. 2. EXRT alone: For patients who refuse/unfit for chemotherapy. , Total dose to GTV = 70 Gy/35 fx. - Dose prescription and delivery technique: 50 Gy/25 fx to PTV, and boost with 20 Gy/10 fx to GTV. RT given by intensity modulated radiotherapy (IMRT) or RapidArc? radiotherapy technology is preferred. - Requirement of dose coverage: 100% dose to CTV, and PTV is treated by 95% of prescribed dose. Maximal dose inside the PTV is < 110% of prescribed dose. The total dose to spinal cord is kept below 5000cGy. - The simultaneous integrated boost (SIB) technique for concomitant boost 10-20% dose to poor responsive primary or lymph node in the second course RT treatment is allowed. F. Follow-up schedule , Patients will come back to RTO OPD at 1 month after RT, and then every 3 months. Chest-abdomen CT scan is regularly checked in 6-month interval for 3 years, then yearly up to 5 years for stage II-IV patients. EGD scopy is regularly checked in 6-month interval for 3 years, then yearly up to 5 years. , Clinical failure is defined as local or distant failure. Local failure is defined when tumor is detected through biopsy by EGDscopy and/or CT scan shows unequivocal or progressive positive findings. Biopsy is not an absolute indication for diagnosis of local relapse because many patients might refuse EGDscopy biopsy and tissue proof of local failure does not help further management for most of the patients. 81 References 1. Akagi, Y., et al., Optimum fractionation for high-dose-rate endoesophageal brachytherapy following external irradiation of early stage esophageal cancer. International Journal of Radiation Oncology, Biology, Physics, 1999. 43(3): p. 525-30. 2. Ishikawa, H., et al., Clinical outcomes and prognostic factors for patients with early esophageal squamous cell carcinoma treated with definitive radiation therapy alone. Journal of Clinical Gastroenterology, 2005. 39(6): p. 495-500. 3. Cooper, J.S., et al., Chemoradiotherapy of locally advanced esophageal cancer: long-term follow-up of a prospective randomized trial (RTOG 85-01). Radiation Therapy Oncology Group. JAMA, 1999. 281(17): p. 1623-7. 4. Minsky, B.D., et al., INT 0123 (Radiation Therapy Oncology Group 94-05) phase III trial of combined-modality therapy for esophageal cancer: high-dose versus standard-dose radiation therapy.[see comment]. Journal of Clinical Oncology, 2002. 20(5): p. 1167-74. 5. Chao, Y.-K., et al., Pretreatment T3-4 stage is an adverse prognostic factor in patients with esophageal squamous cell carcinoma who achieve pathological complete response following preoperative chemoradiotherapy. Annals of Surgery, 2009. 249(3): p. 392-6. 6. Wong, R.K., et al., Combined modality radiotherapy and chemotherapy in nonsurgical management of localized carcinoma of the esophagus: a practice guideline. International Journal of Radiation Oncology, Biology, Physics, 2003. 55(4): p. 930-42. 82 Radiotherapy (RT) Protocol for Gastric Cancer 2010-01 *This document is aimed to set up RT protocols for gastric cancer. The treatment guideline for gastric cancer will not be covered here. A. General Irradiation Information The intent of treatment is to deliver 45-50.4 Gy in 1.8 Gy/fraction, 5 days a week for 5 weeks, to the entire gastric bed (including anastomosis) and draining lymph nodes. The radiotherapy plus concurrent chemotherapy should begin within 6 weeks after postop chemotherapy. CT planning will be used. Localization (simulation) films of initial fields will demonstrate the use of contrast media and blocking. Boost to the residual tumor area to total 50.4-59.4 Gy (another 5.4-14.4 Gy) was suggested in R2 resection.(with gross residual disease) B. Equipment Isocentric teletherapy units with minimum photon energies of 10 MV C. Treatment Delay Prior to beginning EBRT, patient’s blood counts need to have recovered to ? 1,500 absolute neutrophil count and platelets ? 100,000. Caloric intake should be ? 1,500 kilocalories/day and general health should be sufficient to allow initiation of EBRT + chemotherapy. D. Technique IMRT or 3D conformal technique is highly recommended but AP-PA is acceptable AP-PA: The gastric fundus, in a significant minority, extends too far posteriorly to routinely use lateral portals to spare spinal cord or kidney as in pancreatic or biliary lesions. Parallel opposed AP:PA portals are, therefore, the most practical field arrangement for most patients and are therefore recommended. Tightly contoured fields are used to spare as much bone marrow, small bowel, liver, and kidney as possible. Occasionally, patients may have pretreatment CT or barium swallow definition of stomach (with a cross table lateral film) which demonstrates that the stomach is sufficiently anterior to allow treatment via laterals to the stomach and draining lymph nodes with 1.5-2.0 cm margin while sparing spinal cord. Patients with such pre-treatment demonstration of anterior target volume location may have more liberal use of laterals with multifield techniques usually 4-field (AP:PA opposed laterals). Patients without anteriorly located target volume should usually receive lateral field treatments only to the dose necessary to limit spinal cord dosage to 45 Gy. 83 E. Treatment Volume The treatment volume will require some individualization. However, pre-treatment diagnostic studies (UGI, CT scan) and clip placement should be used liberally to identify the tumor/gastric bed and pertinent nodal groups Definition of Target Volume 1. Clinical target volume (CTV) is equal to the gastric remnant and the adjacent remaining perigastric nodal tissue, anastamosis(es), lymph node regions of the celiac axis (celiac, splenic,pancreatoduodenal, suprapancreatic nodal beds), porta hepatis lymph node bed, and upper para- aortics (to the level of approximately L3). For patients who had proximal gastric lesions, CTV should also include the lower paraesophageal nodal regions (to the level of approximately T9). 2. Planning target volume (PTV) is equal to the CTV and an appropriate margin for organ and setup variation as per the discretion of the physician, but a minimum of 0.5 cm. In some cases, this may have to be considerably more, such as when respiratory variation causes significant superior-inferior movement of the gastric remnant. , Extension Through Wall: For proximal T3 and T4 lesions the medial 2/3-3/4 of the left hemidiaphragm should be included as target volume with 1.5 cm margins. If the lesion is confined to the gastric wall or is distal, left hemidiaphragm treatment is not necessary. , Proximal lesions involving the cardia or gastroesophageal junction: The paraesophageal nodes are at risk and should be included in the target volume. A 5-cm margin of esophagus should be included in the cephalad field margin. , Distal lesion at or near gastroduodenal junction: A ? 5 cm margin of duodenal stump should be included if the gross lesion extended to the gastroduodenal junction as defined pathologically. F. CT Simulation CT Simulation is required for all patients and should be performed with the patient in the supine position. Simulation must be performed on a diagnostic quality radiation therapy simulator which reproduces the geometry of the treatment machine. All patients are to be treated isocentrically. The maximum accepted field size is 400 cm2 (i.e. 20 x 20 cm or the equivalent). Every attempt should be made to decrease actual volume to 225 cm2 (15 X 15 cm or equivalent thereof). 84 G. Initial Treatment Field Definition Prior to simulation, pertinent radiographs, operative notes and the surgical pathology report must be reviewed. This will allow an informed determination of treatment volume and field borders prior to simulation. These field borders are then set after appropriate patients’ positioning using CT simulation. 1. AP:PA Initial Field Borders: In general: , Superior Border – will be at the T8, T9 or T10 interspace (to treat the celiac axis, gastroesophageal junction), gastric fundus, and dome of diaphragm). , Inferior Border – the L3-L4 lateral to the vertebral body (to encompass the porta hepatis, gastric antrum, medial duodenal wall, and gastroduodenal nodes). If the distal stomach was involved, the entire circumference of duodenum should be included in the field for ? 5 cm beyond gross disease. , Left Margin: Sufficiently lateral to include the tumor bed and if appropriate, 2/3 – 3/4 of the left hemidiaphragm (to include the gastric fundus, splenic and suprapancreatic nodes, and left hemidiaphragm in proximal T3, T4 lesions). These borders may be modified based on pre-treatment imaging, laparoscopy descriptions, clip placement and postoperative imaging (including planning CT) information of the tumor and nodal site location. 2. Lateral Field Borders: The borders of the lateral fields (if used) are usually as follows: , Superior and Inferior Margin: Identical to the AP:PA field. , Posterior Margin: Posterior enough to treat at least 1/2-2/3 of the vertebral bodies along the entire length of field while sparing spinal cord. Almost always, the superior portion of the field will require the most posterior coverage; in view of the posterior location of suprapancreatic and splenic hilar nodes and gastric bed, the lateral fields may need to be obliqued slightly to spare the spinal cord. , Anterior Margin: The gastric bed extends anteriorly to the anterior abdominal wall in most patients. Therefore, the anterior abdominal wall is the appropriate anterior border for the majority of patients. Note: these borders will require individualization. Radiographs are then obtained for AP:PA and lateral fields. Appropriate skin localization marks are made on the patients to ensure that patients positioning will be identical in all planning steps. 3. Kidney Volume Definition:CT target planning with or without contrast will be used to define the kidneys. 4. Definition of Stomach and Duodenum:Oral contrast: the patient drinks oral contrast (barium orgastrografin +/- esophotrast) in order to document the 85 position of the gastric remnant, distal esophagus anastomosis and duodenum. Radiographs are again obtained for the AP:PA and lateral fields. 5. Blocking: Custom blocking is necessary to reduce unnecessary dose to normal structures including liver, lung, small bowel, kidneys, and heart. Special attention should be given to renal, hepatic and cardiac shielding. 6. Renal Shielding:In most patients, a portion of both kidneys is within the treatment field and one should, therefore, shield at least 2/3 of one kidney. For proximal gastric lesions, as least 1/2 of the left kidney is usually within the EBRT portal and the right kidney must be appropriately spared. For distal lesions with duodenal inclusion, a similar amount of right kidney is often included and then every effort should be made to spare enough left kidney. 7. Cardiac Shielding: With proximal gastric lesions or lesions at the esophagogastric junction, inclusion of 3-5 cm margin of distal esophagus is indicated as well as inclusion of a major portion of the left hemidiaphragm when a lesion extends through the entire alimentary wall. In these circumstances, blocks should be used to decrease the amount of heart within the field. When lesions involve distal esophagus and AP:PA fields include excess heart, lateral fields can be very useful in decreasing cardiac volume. H. Dose – Time Factors • The specification of the target dose is in terms of a dose to a point at or near the center of the target volume. ICRU prescription point = isocenter = center of CTV (should also be the center of PTV). • All fields will be treated each day. • Isodose distributions on a plane containing the central axis are mandatory. • Central axis isodose distributions should have no more than +/- 10% dose variation within the target volume. • Patients receive 1.8 Gy per day to isocenter, five days per week. I. Dose Limiting Structures • The spinal cord dose must not exceed 45 Gy. • The cardiac silhouette must not have greater than 30% of its area exposed to a dose of 40 Gy. • At least 2/3 of one functioning kidney should receive a dose ? 20 Gy. • The liver must not have more than 60% of its volume exposed to more than 30 Gy. J. Radiation Checklist During irradiation, patients are seen for status check at least once a week with notation of tolerance, weight, and blood counts. Blood counts are obtained weekly to minimize the chance of continuing irradiation during unacceptable nadir counts. If the 86 absolute neutrophil count falls below 1,000/mm3 or the platelet count falls below 50,000/mm3 during the course of radiation therapy, treatment should be delayed until the counts rise above these levels. References: 1. Dahele M, Skinner M, Schultz B, Cardoso M, Bell C, Ung YC. Adjuvant radiotherapy for gastric cancer: A dosimetric comparison of 3-dimensional conformal radiotherapy, tomotherapy(R) and conventional intensity modulated radiotherapy treatment plans. Med Dosim. 2009 Apr 15. [Epub ahead of print] 2. Jansen EP, Nijkamp J, Gubanski M, Lind PA, Verheij M. Interobserver Variation of Clinical Target Volume Delineation in Gastric Cancer. Int J Radiat Oncol Biol Phys. 2009 Oct 14. [Epub ahead of print] 3. Alani S, Soyfer V, Strauss N, Schifter D, Corn BW. Limited advantages of intensity-modulated radiotherapy over 3D conformal radiation therapy in the adjuvant management of gastric cancer. Int J Radiat Oncol Biol Phys. 2009;74(2):562-6. 4. Ringash J, Perkins G, Brierley J, Lockwood G, Islam M, Catton P, Cummings B, Kim J, Wong R, Dawson L. IMRT for adjuvant radiation in gastric cancer: a preferred plan? Int J Radiat Oncol Biol Phys. 2005;63(3):732-8. 5. John S. Macdonald, M.D., Stephen R. Smalley, M.D., Jacqueline Benedetti, Ph.D., Scott A. Hundahl, M.D., Norman C. Estes, M.D., Grant N. Stemmermann, M.D., Daniel G. Haller, M.D., Jaffer A. Ajani, M.D., Leonard L. Gunderson, M.D., J. Milburn Jessup, M.D., and James A. Martenson, M.D. Chemoradiotherapy after Surgery Compared with Surgery Alone for Adenocarcinoma of the Stomach or Gastroesophageal Junction 2001; 345:725-730. 87 Radiotherapy (RT) Protocol for Rectal Cancer 2010-02 *This document is aimed to set up RT protocols for rectal cancer. The treatment guideline for rectal cancer will not be covered here. There are two common types schemes employed in the setting of neoadjuvant radiotherapy (pre-OP RT) for adenocarcinomas of the rectum, the so called short-course (hypofractionated, 25 Gy/5 fractions) radiotherapy without the concomitant use of chemotherapy and the long-course (conventional, 50.4 Gy/28 fractions) radiotherapy which is concurrent with chemotherapy (CCRT). The long course scheme consists of a total dose of 50.4 Gy delivered in 28 daily fractions with a 1.8 Gy per fraction. Dose prescription and recording should comply with the recommendations of the ICRU 50/62. A. Definitions for RT treatment planning For those whose radiotherapy will be given with using 2-D treatment planning (via CT simulation) to whole (or low) pelvis, the omission of countering GTV and CTV is acceptable and treatment fields could be directly defined by the conventional treatment field as described in the textbooks. Intensity-modulated radiation therapy (IMRT) can be suggested for the pelvic fields encompassing the gross tumor and potential lymphatics at risk in the pelvis. B. Dose specifications If IMRT-based radiation therapy administered to the pelvis (rectum and the draining lymphatics at risk) is utilized, acceptable treatment plans will be established from a DVH-based analysis of the volumetric dose to both the PTV and critical normal structures to ensure that minimally acceptable constraints for each volume of interest have been met. C. Technical Factors Megavoltage equipment (minimum acceptable energy is 6 MV) capable of delivering static intensity modulation with a multileaf collimator is required. D. Localization, Simulation, and Immobilization Planning CT simulation is mandatory. The oral administration of positive or negative contrast media for the planning CT scan can be used without affecting the 88 dose calculation because the treatment volume is far below the lower level of small intestine (Shibamoto et al., 2007). CT-based simulation (maximum 5 mm slice thickness and preferring 2.5 mm slice thickness) is required and bowel-exclusion techniques can be used when possible and feasible. Patients may be simulated with a supine or prone position (Drzymala et al., 2009). Patients should be simulated in the ―arms up‖ position no matter what position the patient is taking. A customized immobilization device (thermoplastic device or vacuum cushion) can be used for the patient positioned in the supine position as the radiation oncologist in charge prefers. Full bladder filling is not compulsorily necessary (Drzymala et al., 2009). E. Treatment Planning/Target Volumes The Gross Tumor Volume (GTV) is defined as all known gross diseases as determined from a combination of physical examination, colonoscopy, transrectal ultrasound, and CT scan-comparable image studies (i.e., MRI or PET-CT). The Clinical Target Volume (CTV) is defined as the GTV plus the areas considered at a significant risk of harboring microscopic disease. The CTV for a T3 tumor should include all gross disease (rectal and nodal) as well as the internal iliac lymph nodes and the mesorectum (perirectal fat and the presacral space). The CTV for a T4 tumor will include the same structures as for a T3 tumor but will include the external iliac lymph nodes as well. The Planning Target Volume (PTV) will provide a margin around the CTV to compensate for the inter- and intra-fraction uncertainty consequent to daily setup uncertainty and to the potential internal organ motion. By definition, the PTV will consist of a symmetrical 5 mm expansion around the CTV. In the situation that PTVs extend outside the skin surface, the clinician should manually trim the PTV contours to be 3-5 mm inside the outer skin (unless there is direct skin involvement by tumor). The followings are guidelines for generating CTV and a unified PTV. GTV (+1.5 cm radially) = CTV Presacral lymphatic CTV is generated by contouring 1 cm tissue anterior to the anterior border of the sacral bone The CTV concerning the mesorectum and perirectal lymphatics is generated by utilizing anatomic landmarks: Posterior Border: anterior border of the sacrum and gluteus maximus Lateral Border: ileum, piriformis and obturator muscles 89 Anterior Border: should overlap by 1 cm into the bladder, vagina or prostate The PTV is generated by expanding all of the above structures by 0.5 cm symmetrically and unifying them into one 3-dimensional volume for planning purposes. Treatment interruptions are usually discouraged; however, they may be considered in the situation of uncontrolled diarrhea or other intolerable acute complications. When chemotherapy is held due to the concerns of significant adverse effects, radiation therapy can still be continued. References 1. Drzymala M, Hawkins MA, Henrys AJ, Bedford J, Norman A, Tait DM. The effect of treatment position, prone or supine, on dose-volume histograms for pelvic radiotherapy in patients with rectal cancer. Br J Radiol. 2009 Apr;82(976):321-7. 2. Shibamoto Y, Naruse A, Fukuma H, Ayakawa S, Sugie C, Tomita N. Influence of contrast materials on dose calculation in radiotherapy planning using computed tomography for tumors at various anatomical regions: a prospective study. Radiother Oncol. 2007 Jul;84(1):52-5. 90 Radiotherapy (RT) Protocol for Hepatocellular Carcinoma 2010-02 *This document is aimed to set up RT protocols for HCC. The treatment guideline for HCC will not be covered here. A. Pre-RT work-up and preparations 1. For patients without tissue proof, the diagnosis of HCC must meet the criteria defined in the HCC treatment guideline. 2. Pre-treatment Child-Pugh score (for those with cirrhosis), biochemistry, hepatitis carrier status, should be available for curative case. 3. If the CTV can not cover the gross tumor (e.g. the treatment is mainly for relief of portal vein thrombosis), or tumor(s) outside the treatment field can not be effectively handled by other local treatment modalities such as PAI, RFA, TACE, the treatment for this patient should be considered as palliative purpose. 4. Immobilization with arm elevation to overhead is recommended for curative case. 5. 4-D CT scan to evaluate organ motion and respiratory gating at expiratory phase is suggested for curative case. Contrast enhancement is suggested for case whose tumor is difficult to define without contrast medium. 6. 3-D conformal or IMRT is recommended for patients treated with curative attempt. B. General principles for radiotherapy (for curative case) 1. Definition: A. GTV: Gross tumor shown on the CT scan ― with or without fusion‖ B. CTV: Definition for CTV can be omitted if it is taken into account by PTV. 5-10 mm expansion from the GTV is suggested if CTV is defined. C. PTV: Expansion of PTV depends on if techniques such as 4-D CT scan to evaluate organ motion and IGRT, respiratory gating in the treatment are used. The recommend margin for the R-L direction is 0.5 - 1 cm, cephalic-caudal direction is 0.5 -1.5 cm, and anterior-posterior is 0.5 – 1 cm. 2. Dose Specification Considerations for dose prescription: 91 A. Increased sensitivity to radiation-induced liver disease was shown in Taiwanese patients with HBV carriers or Child-Pugh B. The constraints given to these patients (and HCV carrier) should be conservative, as 1,2compared with the data from Western country. B. The data from proton beam treatment showed that hypo-fractionated and higher-dose dose is feasible for HCC, if normal liver can be appropriately protected or spared. This principle is therefore applied to X-ray in our 3-5hospital. Dose prescription: (A.) Dose = 60- 66 Gy/20-22 fx for those with Child A, and V30 < 30% (may reduce to V27 for those with liver cirrhosis or viral carrier). (B.) The prescribed dose is adjusted based on the consideration of liver tolerance dose (V27-30 < 30%). For those with palliative purpose, the prescribed dose is usually lower than the dose defined above and is based on the preferences of the physicians. 3. Radiation Adverse Events Hepatic: RILD: clinical syndrome of anicteric ascites, hepatomegaly, and elevation of alkaline phosphatase (ALP: >2-fold increased above the baseline) that may occure 2 weeks to 3 months following radiation to the liver 6Table 1:. Encephalopathy: West Haven Criteria for semi-quantitative grading of mental status, referring to the level of impairment of autonomy, changes in consciousness, intellectual function, behavior, and the dependence on therapy West Haven Criteria Grade 1 Trivial lack of awareness; Euphoria or anxiety; Shortened attention span; Impaired performance of addition 2 Lethargy or apathy; Minimal disorientation for time or place; Subtle personality change; Inappropriate behavior; Impaired performance of subtraction 3 Somnolence to semistupor, but responsive to verbal stimuli; Confusion; Gross disorientation 4 Coma (unresponsive to verbal or noxious stimuli) 7,8Table 2: Child-Pugh Score: Biochemical Parameters Scores (Points) for Increasing Abnormality 92 1 2 3 Encephalopathy (Grade) None 1-2 3-4 Ascites None Slight Moderate Albumin (g/dL) >3.5 2.8-3.5 <2.8 PT (sec)/ INR 1-4/ 1.7 4-6/ 1.8-2.3 >6/ >2.3 Bilirubin (mg/dL) 1-2 2-3 >3 Class A= 5-6 points; Class B= 7-9 points; Class C= 10-15 points References 1. Inclusion of biological factors in parallel-architecture normal-tissue complication probability model for radiation-induced liver disease. Int J Radiat Oncol Biol Phys. 62(4):1150-6.2005 2. Biologic susceptibility of hepatocellular carcinoma patients treated with radiotherapy to radiation-induced liver disease. Int J Radiat Oncol Biol Phys. 60(5):1502-9, 2004) 3. Proton beam therapy for hepatocellular carcinoma: the University of Tsukuba experience. Cancer. 115(23):5499-506, 2009 4. A prospective study of hypofractionated proton beam therapy for patients with hepatocellular carcinoma. Int J Radiat Oncol Biol Phys. 74(3):831-6, 2009 5. Phase II study of radiotherapy employing proton beam for hepatocellular carcinoma. J Clin Oncol. 23(9):1839-46, 2005 6. Ferenci P, Lockwood A, Mullen K, Tarter R, Weissenborn K, Blei A (2002). "Hepatic encephalopathy--definition, nomenclature, diagnosis, and quantification: final report of the working party at the 11th World Congresses of Gastroenterology, Vienna, 1998". Hepatology 35 (3): 716–21. 7. Trey C, Burns DG, Saunders SJ. Treatment of hepatic coma by exchange blood transfusion. N Engl J Med 1966;274(9):473-481. 8. Pugh R, Murray-Lyon I, Dawson J, et al: Transection of the oesophagus for bleeding oesophageal varices. Br J of Surg 1973;60(8):646-649. 93 Radiotherapy (RT) Guideline for Breast Cancer 2010-01 *This document is aimed to set up RT protocols for breast cancer. The treatment guideline for breast cancer will not be covered here. A. Indication for post-operative RT in breast cancer 1. Whole breast irradiation is indicated after breast-conserving surgery for DCIS or invasive breast cancer. 2. Post-mastectomy radiotherapy (PMRT) is recommended in (1) patients of ? T3 disease (2) patients with ? 4 positive axillary nodes (also including supraclavicular LN and axillary apex field RT) 3. Data regarding net benefits of PMRT in cases of T1/T2 tumors and one to three metastatic nodes is insufficient to warrant its routine use. 4. Full axillary RT is not routinely recommended to an adequately dissected axilla. Many indications remain for targeting the Level I/II axilla, such as patients with positive sentinel lymph nodes who do not have a subsequent complete axillary dissection and patients with positive lymph nodes who have undergone axillary sampling surgery only. 5. Consensus has not been reached regarding treatment to the internal mammary region. If internal mammary LNs are clinically or pathologically positive, RT should be given to the internal mammary nodes, otherwise the treatment to the internal mammary nodes is at the discretion of the attending radiation oncologist. CT treatment planning should be used in all cases where radiation therapy is delivered to the internal mammary lymph node field. , In patients received neoadjuvant chemotherapy Indications for RT and fields of treatment should be based upon the pretreatment tumor characteristics. B. Pre-RT preparations 94 1. Radiation therapy typically begins 4-6 weeks after surgery or chemotherapy completion. 2. Patients are treated in the supine position, with the ipsilateral arm elevated above the head and the head is rotated slightly toward the contralateral side. 3. A custom-molded immobilization device such as alpha cradle is typically used to reproduce daily position and minimizing day-to-day set up errors. 4. CT simulation images were obtained with 2.5-5-mm spacing, extending from the neck through the mid-abdomen to make sure the breast is included entirely. 5. The treatment fields are then designed on the CT-simulation data set with the aid of virtual reality type techniques. The goal of the design is to include the target regions while avoiding normal structures, such as the heart, lung and the contralateral breast. C. Definitions for RT treatment planning 1. Breast clinical target volume (CTV) : (1) Radioopaque wires are taped to the skin to delineate the anatomic boundaries of the breast and the lumpectomy scar, and computed tomographic (CT) simulation scans are obtained. (2) A standard window level (0) and width (500) was considered optimal for visibility of the glandular breast tissue was used to display the images. If no lead wire was present, the delineation of the CTV was based on the visible breast parenchyma. If a lead wire was present, the position of the wire could be used as an aid in the delineation of the CTV. (3) The breast target volume was defined as the glandular tissue apparent on CT scan. Target delineation includes the majority of breast tissue, with a 3 to 5-mm rim of the skin removed. The retraction of the breast contour 3-5 mm from the skin surface was to account for dose build-up during treatment planning. (4) The breast contour was defined medially at the lateral edge of the sternum, inferiorly at the inframammary fold, superiorly at the inferior edge of the medial head of the clavicle, and laterally to include all apparent breast tissue. Posteriorly, the CTV was the junction of the breast tissue and chest wall or pectoralis major muscle. Anteriorly, the CTV was parallel to, but 3-5 mm inside, the skin. (5) A planning treatment volume (PTV) was constructed by expanding the CTV by 7-10 mm. This margin was estimated to be adequate to account for the 95 uncertainty in the patient setup and CTV delineation. The expansion from CTV to PTV was not performed toward the skin. 2. Chest wall CTV : The chest wall includes the ribs, intercostal muscles, and the serratus anterior muscle. The clinically defined borders, however, are generally the clavicular head superiorly, 1-2 cm below the contralateral inframammary fold inferiorly, the midline medially, and the midaxillary line laterally. 3. SCF field CTV: Medially : the SC fossa extended to the lateral edge of the trachea. Superior: this region extended to the level of the lower edge of the cricoid cartilage. Anterior: the SC nodal bed was bounded by the posterior border of the sternocleidomastoid muscle. Posterolateral : The posterolateral border of SC nodal bed was defined by the anterior border of the anterior scalene muscle. Inferior : The inferior border of the SC nodal bed was defined by the subclavian artery. 4. Axillary level III (axillary apex or infraclavicular region) CTV: The IFV fossa was also outlined on successive CT sections by using easily delineated anatomic structures Superior : The superior border the axillary level III (LIII) nodal bed was defined as the most superior aspect of the pectoralis minor muscle. 96 Inferior : The inferior border was defined at the level of the insertion of the clavicle into the manubrium. Anterior : the LIII nodal bed was bounded by pectoralis major muscle. Posterior : Posterior border of the LIII nodal bed was defined by subclavian-axillary artery. Laterally : the LIII nodal bed extended to the medial aspect of the pectoralis minor muscle. Medially : the LIII nodal bed extended to the lateral edge of the clavicle. 97 5. Axilla level I and II CTV: (1) Level I : The AX Level I nodal bed was defined as the region lateral to the pectorialis minor, which extended posteriorly to latissimus dorsi. Cranial : Caudal CT-slice tendon latissimus dorsi m. Caudal : Caudal CT-slice free edge pectoralis major m., caudal CT-slice subscapular m. Ventral : skin Dorsal : Dorsal border axillary vessels, subscapular m., serratus anterior m. Lateral : Latissimus dorsi m., teres major m., subscapular m.b Medial : Biceps brachii m., coracobrachialis m., lateral border pectorales mm.c and breast (2) Level II Cranial : Cranial CT-slice axillary vessels Caudal : Caudal CT-slice free edge pectoralis minor m. 98 Ventral : Dorsal surface pectoralis minor m. Dorsal : Dorsal border axillary vessels, rib, serratus anterior m. Lateral : Lateral border pectoralis minor m.c Medial : Medial border pectoralis minor m. 6. IMN CTV (1) For internal mammary nodes identification, the internal mammary artery and vein location can be used as a surrogate for the nodal locations, which usually are not visible on imaging. (2) The IMNs lie deep to the chest wall on the endothoracic fascia in interspaces 1-6, between the costal cartilages. Because the majority of the IMNs are located in the upper chain, and inclusion of the lower chain in the radiotherapy field could increase the risk of cardiac toxicity, a compromise often occurs when only the superior half of the IMN chain is treated. The IMN target will be defined as interspaces 1-3. (3) Although these nodes are often not visible on CT scans, the adjacent IMN vessels provide a reliable guide to their location. A conservative approach in contouring this region is to extend the target 1 cm laterally to the vessels, 1cm medially or to the edge of the sternum, posteriorly to the visceral pleura, and anteriorly to the intercostal fascia. 7. Planning treatment volume (PTV) : PTV was constructed by expanding the CTV by 7-10 mm. This margin was estimated to be adequate to account for the uncertainty in the patient setup and CTV delineation. The expansion from CTV to PTV was not performed toward the skin. D. General principles for radiation dose 1. Whole breast dose (1) A uniform dose distribution is objective, using compensators such as wedges, forward planning using segments, or IMRT. (2) The breast should receive a dose of 45-50 Gy in 1.8-2.0 Gy per fraction, five weekly fractions over a 5- to 6-week period of time (3) Alternative fractionation schemes are allowed in particular cases, such as for palliation purpose. (4) Boosts a. Controversy exists concerning the need for delivering an additional boost dose to the primary site. When used, boost irradiation usually is delivered using electron 99 beam or photon to lumpectomy cavity with margins . The total dose to the primary tumor site is treated to approximately 6,000-6,600 cGy in conventional fractionation. b. For DCIS : A boost may not be required for patients who have been treated with extensive breast resections and have margins of resection clearly negative. 2. PMRT dose: The preferred total dose is 50~50.4 Gy in 1.8 or 2.0 Gy fractions, 5 times per week. Use of a mastectomy scar boost is reasonable, and should be given for residual microscopic disease. 100 References 1. CW Hurkmans, JH Borger, BR Pieters et al. Variability in target volume delineation on CT scans of the breast. Int. J. Radiation Oncology Biol. Phys., Vol. 50, No. 5, pp. 1366–1372, 2001 2. WA Beckham, CC Popescu, VV Patenaude, et al. Is multibeam IMRT better than standard treatment for patients with left-sided breast cancer? Int. J. Radiation Oncology Biol. Phys., Vol. 69, No. 3, pp. 918–924, 2007 3. Liengsawangwong R, Yu TK, Sun TL, et al. Treatment optimization using computed tomography-delineated targets should be used for supraclavicular irradiation for breast cancer. Int J Radiat Oncol Biol Phys 2007;69:711–715. 4. IM Dijkema, P Hofman, C. P. J. Raaijmakers, et al. Loco-regional conformal radiotherapy of the breast: delineation of the regional lymph node clinical target volumes in treatment position Radiotherapy and Oncology 71 (2004) 287–295 5. CN Madu, DJ Quint, DP Normolle, et al. Definition of the supraclavicular and infraclavicular nodes: implications for three-dimensional CT-based conformal radiation therapy. Radiology. 2001 Nov;221(2):333-9. 6. ME Taylor, BG Haffty, R Rabinovitch, ACR Appropriateness Criteria? on Postmastectomy Radiotherapy : Expert Panel on Radiation Oncology—Breast. Int. J. Radiation Oncology Biol. Phys., Vol. 73, No. 4, pp. 997–1002, 2009 7. Recht A, Edge SB. Evidence-based indications for postmastectomy irradiation. Surg Clin North Am 2003; 83(4):995–1013. 8. Recht A, et al. Postmastectomy radiotherapy: clinical practice guidelines of the American Society of Clinical Oncology. J Clin Oncol 2001;19(5):1539–69. 9. Practice Guideline for the Management of Ductal Carcinoma In-Situ of the Breast (DCIS) J Am Coll Surg 2007;205:145–161. 101 RT Protocol for Prostate Cancer-2010 Radiotherapy (RT) Protocol for Cervical Cancer 2010-02 *This document is aimed to set up RT protocols for cervical cancer. The treatment guideline for cervical cancer will not be covered here. A. Pre-RT work-up and preparations 1. MRI is the preferred modality than CT scan in evaluating extension of primary tumor. However, CT scan is also an acceptable modality. 12. Pre-treatment Hb, SCC-ag and CEA levels are required for all patients. 3. If pathology report is from other hospital, a review by pathologist of CGMH is highly recommended. 4. The findings of pelvic examination, including tumor size, vaginal and parametrial extension, should be clearly described and recorded in the chart, and drawn in the figures (in the RTO chart). 5. For those will be treated by IGRT and IMRT (or Rapidarc) to LN and primary tumors, the rectum should be emptied before CT simulation and each treatment, to reduce the anterior displacement for cervix, uterus and vagina. Patients will be educated to take 350 ml water 30 minutes (more water and/or waiting time, if necessary) before treatment or CT simulation. 6. The simulation is done by CT simulator. B. Definitions for RT treatment planning For those whose radiotherapy will be given by 2-D treatment planning (through CT simulator) to whole (or low) pelvis, the omission of countering GTV and CTV is acceptable and treatment field could be directly defined by the conventional treatment field as described in the textbooks. A. CTV for lymph node (CTVn): 1. Pelvic lymph node (LN) only: the anatomical component of pelvic nodes, including external, internal and common iliac nodes. The upper margin is at the bifurcation of aorta into bilateral common iliac vessels. 2. Extended-field: the anatomical component of pelvic nodes and para-aortic LN (PALN). The upper margin is at the lower border of T12 for 102 RT Protocol for Prostate Cancer-2010 prophylactic RT or if visible PALNs are located below L2. The upper margin should extend to lower border of T10 if visible PALNs are located above L3. B. CTV for primary tumors 1. Uterus: Whole uterus should be included in the initial 39.6 - 45 Gy22-25 fx, but only gross tumor with 1.5- 2 cm margin is included in the final boost. 2. Cervix: cervix and bilateral parametrium 3. Vagina: at least 2 cm below visible tumors. C. PTV 1. If no IGRT is used, the PTV is suggested to be at least 1 cm around the CTV. 2. When IGRT is used, the PTV for lymphatics is suggested to be 0.5 – 1 cm around CTV. Since the position of uterus and cervix is strongly affected by the bladder and rectum, the PTV is suggested to be at least 1 cm around the CTV. C. General principles for radiation dose , Adjuvant RT for patients treated by radical surgery and with pathological risk factors (deep stromal invasion; parametrial invasion, positive or close resection margin, lymph node or other organ metastasis), or by inadequate surgery. 1. For patients with no LN metastasis (after adequate LN dissection), but with other local risk factors 21. Low pelvis 5040 cGy/28 fx. Low pelvic RT includes the low pelvic LN (first lymphatic drainage). Upper margin: 1-2 cm above the lower border of S-I joint, lateral field: 1.5-2 cm out of the pelvic brim. 2. Intravaginal brachytherapy (optional): 200 cGy/per fx x 3 (Reference: 5 mm below mucosa). IV is mandatory for those with positive or close margin. 2. For patients with node metastasis limited in the low pelvis and positive node 3number < 3 1. Whole pelvis 4500 cGy, low pelvis to 5040 cGy , Box technique, AP/PA: bilateral= 1: 1 or , Rapidarc with IGRT 2. Intravaginal brachytherapy (optional): 200 cGy x 3 (optional). IV is mandatory for those with positive or close margin. 103 RT Protocol for Prostate Cancer-2010 3. Concurrent chemotherapy is recommended. 33. For patients with nodal metastasis above the low pelvic node I. Extended field (Whole pelvic and PALN) 4500 cGy/ 25 fx. , Box technique, AP/PA : bilateral= 2:1 or , Rapidarc with IGRT II. Low pelvis to 5040 cGy (Box technique, AP/PA: bilateral = 1:1) III. Intravaginal brachytherapy (optional): 200 cGy x 3. IV is mandatory for those with positive or close margin. IV. Concurrent chemotherapy is recommended. 4. For patients who receive simple hysterectomy due to CIN or other benign lesion and are found to have invasive cancer in the final pathological report, whole pelvis RT is suggested. , For patients treated primarily by RT 1. For patients with bulky IB/ IIA, and IIB-IIIB (exclude IIIA and IVA cases) but no enlarged node shown by imaging study 4-61. CCRT is indicated, by weekly CDDP x 6 courses . , Patients entering into clinical trial should follow the guideline of clinical trial. , For patients who have poor ECOG performances or are older than 70, chemotherapy can be waived. 2. RT: whole pelvis 4500 cGy/ 25 fx, , If the size of residual tumor is < = 4 cm and geometry is appropriate for brachytherapy i. Parametrial boost: 50-54 Gy for bulky IB/ IIA, or 54-57.6 Gy for IIB-IIIB. ii. Intracavity brachytherapy (IC): 430 cGy x 6 , If the size of residual tumor > 4 cm or geometry is not appropriate for 7brachytherapy i. Further RT to low pelvis: 50-54 Gy/28-30 fx. ii. Boost to cervical tumor up to 6660-7200 cGy/37-40 fx (by IMRT or Rapidarc) iii. Physicians may adjust the doses given from external beam and brachytherapy if the tumor is on the borderline for brachytherapy. 2. For patients with pelvic or PALN enlargement: 1. Extended field (pelvis + PALN): 45 Gy/25 Fx, for those with multiple pelvic LN (>3), upper pelvic LN involvement or PALN involvement. The 104 RT Protocol for Prostate Cancer-2010 gross LN can be boosted for 10-15% extra doses by field-in-field technique or small-field if feasible. However, for those with PET study, the PALN field can be omitted if there is no meaningful PALN enlargement shown in 8-9both CT/MRI and PET scan . 2. Pelvic RT: for those with LN limited in the low pelvis, and LN <=3. 3. Others are same as in ―A‖ 3. Non-bulky stage IB or IIA, without pelvic or PALN metastasis 1. RT alone or CCRT 2. RT Whole pelvis: 39.6-45 Gy/22-25 fx (lower dose for those with old age and good response after 39.6 Gy/22 fx), bilateral parametrial boost to 50.4 Gy, then intracavity brachytherapy (430 cGy/point A/fx x 6 fx) Patients entering into clinical trail should follow the guideline for trial. References 1. Hong JH, Tsai CS, Chang JT, et al. The prognostic significance of pre- 105 RT Protocol for Prostate Cancer-2010 and posttreatment SCC levels in patients with squamous cell carcinoma of the cervix treated by radiotherapy. Int J Radiat Oncol Biol Phys. Jul 1 1998;41(4):823-830. 2. Hong JH, Tsai CS, Lai CH, et al. Postoperative low-pelvic irradiation for stage I-IIA cervical cancer patients with risk factors other than pelvic lymph node metastasis. Int J Radiat Oncol Biol Phys. Aug 1 2002;53(5):1284-1290. 3. Tsai CS, Lai CH, Wang CC, et al. The prognostic factors for patients with early cervical cancer treated by radical hysterectomy and postoperative radiotherapy. Gynecol Oncol. Dec 1999;75(3):328-333. 4. Morris M, Eifel PJ, Lu J, et al. Pelvic radiation with concurrent chemotherapy compared with pelvic and para-aortic radiation for high-risk cervical cancer. N Engl J Med. 1999;340(15):1137-1143. 5. Rose PG, Bundy BN, Watkins EB, et al. Concurrent cisplatin-based radiotherapy and chemotherapy for locally advanced cervical cancer. N Engl J Med. 1999;340(15):1144-1153. 6. Thomas GM. Improved treatment for cervical cancer--concurrent chemotherapy and radiotherapy. N Engl J Med. Apr 15 1999;340(15):1198-1200. 7. Hong JH, Chen MS, Lin FJ, Tang SG. Prognostic assessment of tumor regression after external irradiation for cervical cancer. Int J Radiat Oncol Biol Phys. 1992;22(5):913-917. 8. Tsai CS, Chang TC, Lai CH, et al. Preliminary report of using FDG-PET to detect extrapelvic lesions in cervical cancer patients with enlarged pelvic lymph nodes on MRI/CT. Int J Radiat Oncol Biol Phys. Apr 1 2004;58(5):1506-1512. 9. Tsai CS, Lai CH, Chang TC, et al. A prospective randomized trial to study the impact of pretreatment FDG-PET for cervical cancer patients with MRI-detected positive pelvic but negative para-aortic lymphadenopathy. Int J Radiat Oncol Biol Phys. Feb 1 2010;76(2):477-484. 106 RT Protocol for Prostate Cancer-2010 Radiotherapy (RT) Protocol for Endometrial Cancer 2010-01 *This document is aimed to set up RT protocols for endometrial cancer. The treatment guideline for endometrial cancer will not be covered here. As for the indications of RT for Endometrial cancer, please refer to the resources of NCCN. * Endometrial cancer staging, unlike FIGO staging for cervical cancer, is mainly by surgical-pathology findings. This protocol therefore concentrates on RT management after hysterectomy, and has a high similarity with the RT protocol for cervical cancer. A. Pre-RT work-up and preparations 1. Pre-treatment Hb, CA-125 and CEA levels are suggested for all patients. For those with abnormal serum tumor marker before hysterectomy, recheck the value before RT is mandatory. 2. If pathology report is from other hospital, a review by pathologist of CGMH is highly recommended. 3. The findings of pelvic examination, including vaginal and parametrial extension, should be clearly described and recorded in the chart, and drawn in the figures (in the RTO chart). 4. For those will be treated by IGRT and IMRT (or Rapidarc) to LN and primary tumors, the rectum should be emptied before CT simulation and each treatment, to reduce the anterior displacement for cervix, uterus and vagina. Patients will be educated to take 350 ml water 30 minutes (more water and/or waiting time, if necessary) before treatment or CT simulation. 5. The simulation is done by CT simulator. B. Definitions for RT treatment planning For those whose radiotherapy will be given by 2-D treatment planning (through CT simulator) to whole (or low) pelvis, the omission of contouring GTV and CTV is acceptable, and treatment field could be directly defined by the conventional treatment field as described in the textbooks. 1. CTV for lymphatic drainage (CTVn): 107 RT Protocol for Prostate Cancer-2010 a. Pelvic lymph node (LN) only: the anatomical component of pelvic nodes, including external, internal and common iliac nodes. The upper margin for whole pelvis is at the bifurcation of aorta into bilateral common iliac vessels. As for the lower pelvis RT field, the upper margin is at 1-2 cm above the junction of bilateral lower ends of sacroiliac joints. b. Extended-field: the anatomical component of lymphatic drainage for pelvic nodes and para-aortic LN (PALN). The upper margin is at the lower border of T12 for prophylactic RT or if pathological confirmed PALNs are located below the upper border of L3. The upper margin of extended field should extend to lower border of T10 if involved PALNs are located above L3. 2. CTV for vaginal stump (CVTv): a. For uterine tumor WITHOUT invasion to the vagina: CTV includes the upper border of vaginal stump and extends downward for at least 3 cm. b. For uterine tumor invasion to vagina: CTV includes the upper border of vaginal stump and extends downward below the lower border of pubic symphysis. 3. PTV a. If no IGRT is used, the PTV is suggested to be at least 1 cm around the CTV. b. When IGRT is used, the PTV for lymphatics is suggested to be 0.5 – 1 cm around CTV. Since the position of vagina stump might be affected by the bladder and rectum, the PTV for vagina is suggested to be at least 1 cm around the CTV. 4. Vaginal brachytherapy Brachytherapy performed with Henschy applicator (3 lumens) is preferred than vaginal cylinder (single lumen) for a better coverage of vaginal cuff. C. General principles for radiation dose 1. Adjuvant RT for patients treated by radical surgery and with pathological risk factors (deep myometrial invasion; parametrial extension, positive or close resection margin, lymph node or other organ metastasis), or by 108 RT Protocol for Prostate Cancer-2010 inadequate surgery. (A.) For patients with no LN metastasis (after adequate LN dissection), but with other local risk factors 1. Low pelvis 5040 cGy/28 fx : Low pelvic RT includes the low pelvic LN (first lymphatic drainage). Upper margin: 1-2 cm above the lower border of S-I joint, lateral field: 1.5-2 cm out of the pelvic brim. 2. Intravaginal brachytherapy (optional): 200 cGy/per fx x 3 (prescribed at 5 mm below vaginal mucosa). IV is mandatory for those with positive or close vaginal margin. (B.) For patients with node metastasis limited in the low pelvis and positive node number < 3 1. Whole pelvis 4500 cGy, reduced upper margin to low pelvis to 5040 cGy , Box technique, AP/PA: bilateral= 1: 1 or judge by physicist , Rapidarc with IGRT 2. Intravaginal brachytherapy (optional): 200 cGy x 3 (optional). IV is mandatory for those with positive or close margin. 3. Systemic chemotherapy is decided by GYN referring physicians. (C.) For patients with nodal metastasis above the low pelvic node 1. Extended field (Whole pelvic and PALN) 4500 cGy/ 25 fx. , Box technique, AP/PA : bilateral= 2:1 or judge by physicist , Rapidarc with IGRT 2. Low pelvis to 5040 cGy (Box technique, AP/PA: bilateral = 1:1) 3. Intravaginal brachytherapy (optional): 200 cGy x 3. IV is mandatory for those with positive or close margin. 4. Concurrent chemotherapy is decided by GYN referring physicians. (D.) For patients who receive merely simple hysterectomy due to benign lesion and are found to have invasive cancer in the final pathological report, whole pelvis RT and total dose 5040 cGy are suggested. (E.) For high-dose rate vaginal brachytherapy alone, commonly used regimens include 7 Gy × 3 prescribed at a depth of 0.5 cm from the vaginal surface, or 6 Gy × 5 fractions prescribed to the vaginal surface. (NCCN guideline). 109 RT Protocol for Prostate Cancer-2010 References 1. Pecorelli S. Revised FIGO staging for carcinoma of the vulva, cervix, and endometrium. Int J Gynaecol Obstet. 2009;105:103–104. 2. Uterine neoplasms. NCCN practice guidelines in oncology –v.1.2010. Available online at: 3. American College of Obstetricians and Gynecologists. ACOG practice bulletin, clinical management guidelines for obstetrician gynecologists, number 65, August 2005: management of endometrial cancer. Obstet Gynecol 2005;106:413-425. 4. Creutzberg CL, van Putten WL, Koper PC, et al. Surgery and postoperative radiotherapy versus surgery alone for patients with stage-1 endometrial carcinoma: multicentre randomised trial. PORTEC Study Group. Post Operative Radiation Therapy in Endometrial Carcinoma. Lancet 2000;355:1404-1411. 5. Creutzberg CL, van Putten WL, Warlam-Rodenhuis CC, et al. Outcome of high-risk stage IC, grade 3, compared with stage I endometrial carcinoma patients: the Postoperative Radiation Therapy in Endometrial Carcinoma Trial. J Clin Oncol 2004;22:1234-1241. 6. Scholten AN, van Putten WL, Beerman H, et al; PORTEC Study Group. Postoperative radiotherapy for Stage 1 endometrial carcinoma: long-term outcome of the randomized PORTEC trial with central pathology review. Int J Radiat Oncol Biol Phys 2005;63(3):834-838. 7. Benedetti Panici P, Basile S, Maneschi F, et al. Systematic pelvic lymphadenectomy vs. no lymphadenectomy in early-stage endometrial carcinoma: randomized clinical trial. J Natl Cancer Inst 2008;100(23):1707-1716. 8. Nout RA, Putter H, Jürgenliemk-Schulz IM, et al. Vaginal brachytherapy versus external beam pelvic radiotherapy for highintermediate risk endometrial cancer: Results of the randomized PORTEC-2 trial [abstract]. J Clin Oncol 2008;26:LBA5503. 9. ASTEC/EN.5 Study Group, Blake P, Swart AM, et al. Adjuvant external beam radiotherapy in the treatment of endometrial cancer (MRC ASTEC and NCIC CTG EN.5 randomised trials): pooled trial results, systematic review, and meta-analysis. Lancet 2009;373(9658):137-146. Epub 2008 Dec 16. 110 RT Protocol for Prostate Cancer-2010 Radiotherapy (RT) Protocol for Prostate Cancer 2010-02 *This document is aimed to set up RT protocols for prostate cancer. The treatment guideline for prostate cancer will not be covered here. A. Pre-RT work-up and preparations 1. MRI is recommended for all patients because it is important for staging and 1treatment choice. Staging of primary tumor will base on DRE (for T1-2) and MRI (for T3-4). DRE findings should be described. 22. Pre-treatment PSA level is required for all patients and recommended to be 3measured by EIA instead of RIA. 43. Gleason score should be recorded. If pathology report is from other hospital, a eview by CGMH is highly recommended. The number of positive piece /total r piece for each side should be recorded. The percentage of positive tumor involvement in each section should be described. 54. Bone scan is suggested when either PSA >10, Gleason score > 6 or T2b or above. 5. The pre-treatment urination (including night and daytime) and sexual function should be recorded. The urination function should record the number of time needed to wake up for urination and the interval tolerable at the daytime. The sexual function should include (full or partial) erection and penetration. 6. When CT simulation shows that rectum is distended with gas or stuff or the bladder is not distended with water, a repeated CT simulation with good bowel and bladder preparation is necessary 7. Before CT simulation and each treatment, the rectum must be emptied to reduce the 6anterior displacement for prostate. Patients will be educated to take 350 ml water 30 minutes (more water and/or waiting time, if necessary) before treatment or CT simulation. 8. To improve the treatment quality, insertion of fiduical marker and image-guided 7,8radiotherapy is strongly recommended. B. Definitions for RT treatment planning 1. CTV for pelvic lymph node (CTVn): the anatomical component of pelvic nodes. The upper margin is higher than the junction of ext. and int. iliac vessels, but not 111 RT Protocol for Prostate Cancer-2010 higher than the junction of common iliac vessels. 2. CTV for seminal vesicles (CTVsv): visible prostate and SV shown in CT scan. 3. CTV for prostate (CTVp): visible prostate and the junction between prostate and SV. 4. Rules for creating PTV by expanding each CTV: Since fiducial markers are inserted into prostate and the position and shape of seminal vesicle will change with the distension of bladder and rectum, the margin between CTV and PTV is larger for SV than prostate in patients with fiduical markers. a. PTVn: 0.8 cm expansion in 3 axis from CTVn b. When fiducial marker is inserted for image guidance (PTV with ―i‖ prefix): i. iPTVsv1: 7 mm in dorsal direction and 1 cm for the rest from CTVsv ii. iPTVsv2: 7 mm in all directions from CTVsv. iii. iPTVp: 5 mm in 3 axis from CTVp c. Without fiduical marker i. PTVsv1: 7 mm expansion in dorsal direction and 1 cm for rest from CTVsv. ii. PTVsv2: 7 mm in ventral-dorsal axis and cranial-caudal axis, 1 cm in left-right axis from CTVsv. iii. PTVp1: 7 mm in dorsal direction and 1cm for rest from CTVsv. iv. PTVp2: 7 mm in ventral-dorsal axis and cranial-caudal axis, 1 cm in left-right axis from CTVsv. 9C. General principles for radiation dose 1. The dose escalation (> 75.6 Gy) will be only given to patients who are inserted with fiduical marker and treated with image-guided RT (IGRT) because these techniques improve the positional precision. 2. The reduction of RT dose is allowed if the dose constraints for rectal and bladder can not meet the safety criteria, especially for patients with multiple co-morbidity or taking anti-coagulant. 3. Radiation dose to primary tumors by external beam: RT dose to prostate: 75.6 Gy without marker and 78.4 Gy with marker, in 42 fractions. RT dose to SV: 50.4 Gy/28 fx for T1-2, 75.6 – 78.4 for T3. 10 RT dose to pelvic node: 45 Gy (by box) – 50.4 Gy (by IMAT). Boost dose to gross LN is allowed. 112 RT Protocol for Prostate Cancer-2010 D. Treatment guidelines for prostate cancer 1. Prostate irradiation for patients with evidence of distant metastasis RT to primary tumor is not routinely recommended except for those tumors refractory to hormone therapy and cause clinical symptoms. If RT is given under this condition, it will be considered as long-term palliation and the dose is recommended to be < 72 Gy (usually less than 66.6 Gy); dose will depend on patients’ disease extension and general condition. 2. Prostate irradiation for patients with evidence of regional nodal metastasis Patients whose disease spread to pelvic lymph nodes, but not to para-aortic LN or other organs are still candidates for curative RT after neo-adjuvant hormone therapy. Following 45 (box field) - 50.4 Gy (RapidArc) to whole pelvis, final dose to prostate/seminal vesicles will be ? 75.6 Gy if DVH for rectum and bladder tolerance is allowed. Additional boost dose to gross lymph node (by field-in-field or other techniques) will be decided individually. 3. Treatment for localized disease without surgery Low risk group, T1-2a and PSA<10 and Gleason score <7, M0 Radiotherapy (RT) 1. Combination of high-dose-rate (HDR) implant plus external radiotherapy 11(EXRT) HDR implant: 5.5 Gy/per fx., 3 fractions/24 hour with interval between fractions at least 6 hours. EXRT: , 50.4 Gy/28 Fx to prostate and seminal vesicle. The PTV is the CTV plus 1 cm margin in all the directions. , In the case whose covering index is < 88% or underdose region is not limited in the anterior part, the underdose region will be boosted by the external beam with the IMRT (IMAT) field-in-field technique. The minimal dose to the underdose region will be 110% of the prescribed dose, and the maximal dose is< 120%. 2. EXRT alone: For patients whose condition is not appropriate for surgery or HDR implant, or who chooses EXRT treatment. , With marker (Total dose to prostate = 78.4 Gy/42 fx). - Dose prescription and delivery technique: 50.4 Gy/28 fx to prostate 113 RT Protocol for Prostate Cancer-2010 and seminal vesicle, and boost with 28 Gy/14 fx to prostate. RT is given by image-guided radiotherapy (IGRT) with either RapidArc? radiotherapy technology or Novalis Tx? Radiosurgery. - Requirement of dose coverage: , 100% dose to CTV, and PTV is treated by 95% of prescribed dose. Maximal dose inside the PTV is < 110% of prescribed dose. The maximal dose to bladder and rectum is less than 105% of prescribed dose. Less than 10 % volume receives > 100% prescribed dose. Less than 25% volume of bladder 12and rectum receives dose > 70 Gy (90% prescribed dose). , Without marker (Total dose to prostate = 75.6 Gy/42 fx) - Dose prescription and delivery technique: 50.4 Gy to prostate and seminal vesicle and 75.6 Gy to prostate by RT to prostate will be given by intensity modulated radiotherapy (IMRT). The dose prescription is - Requirement of dose coverage: , 100% CTV is treated by prescribed dose 1.8 Gy, and PTV is treated by 95% of prescribed dose. Maximal dose inside the PTV is < 110% of prescribed dose. The maximal dose to bladder and rectum is less than 105% of prescribed dose. Less than 10 % volume receives > 100% prescribed dose. Less than 25% volume of bladder and rectum receives dose > 72 Gy (95% prescribed dose). Dose will be reduced to 72 Gy (or even lower) if patient’s bladder is so small that large volume of bladder is included in the PTV. However, repeated CT simulations and large volume of water intake will be tried to confirm the small bladder volume. Intermediate risk, T1-2, 10 ?PSA?20 and Gleason score ? 7, M0 A. RT , Neoadjuvant and concurrent total androgen blockade for 4 months, 13initiated 2 months before RT. However, patients might be treated without hormone therapy if there is only one risk factor (10 ?PSA?20 or GS =7, and no palpable T1). Patients will be treated by either HDR + EXRT or EXRT alone, based on the same criteria as in low risk group. Treatment methods are also same as those in the low risk group except pelvic RT is given for those with risk of pelvic node >=15%. CTVn and PTVn will be 114 RT Protocol for Prostate Cancer-2010 , No adjuvant hormone therapy is given after RT. , For those treated by EXRT alone , Risk of pelvic node >=15%, as calculated by Roach’s formula: 50.4 Gy/28 fx (for those with marker) or 45 Gy/25 fx (for those without marker) to pelvic node will be given for patients < 75 Y/O old, good performance and no severe co-modality. , Risk of pelvic node< 15%: 50.4 Gy to prostate and seminal vesicle and 78.4 Gy/42 fx to prostate by IGRT for those with marker, or 75.6 Gy/42 fx for those without marker. , Dose will be reduced to 72 Gy (or even lower) if patient’s bladder is small or rectum is highly distended so that large volume of bladder or rectum is included in the PTV. However, repeated CT simulation with good rectal preparation and taking large volume of water to confirm the bladder and rectal volume should be tried. High risk group: T3a, or Gleason score ?8, PSA > 20, Very high risk group: T3b-4, but M0 PSA > 20 is considered as high risk group in the literature, however, our experience of high-dose-rate brachytherapy suggested patients had good treatment outcome if they had only one risk factor of 20 < PSA< 80. We assign patients with one risk factor of 20 < PSA< 80 as high risk group, but their treatment follows the protocol of intermediate risk group. Patients who only have one risk factor that GS = 8 can be treated as intermediate risk. RT , Neoadjuvant hormone therapy by total androgen block, starting 2 months before RT and given during RT, was recommended as a treatment standard. HDR given to T3a patients will be limited to those with < 3 mm extracapsular extension shown in MRI, otherwise patients will be 11treated by EXRT alone. Two-year adjuvant hormone therapy with 14-16monthly leuplin will be given. However, adjuvant hormone therapy may be omitted if patient only have one risk factor of GS = 8. 115 RT Protocol for Prostate Cancer-2010 , Initial dose of EXRT is 50.4 Gy to prostate and seminal vesicle. For T3b, the dose to P+SV will be 78.4 Gy/42 fx (with marker); SV is excluded from CTV after 50.4 Gy for those <=T3a. 4. RT for patients with biochemical failure or impending biochemical failure after radical prostectomy Patients had PSA levels > 0.2 after radical prostectomy should be defined as 17biochemical failure. If systemic work-up does not detect distant failure, local RT should be considered. Progressive elevation of PSA in three consecutive measurements is also accepted as an indication for local RT, even the PSA is <0.2, However, when the PSA doubling time is less than 4-6 months, distant metastasis is more favored even negative system work-up. Only about 50% patients can get tissue proof for the local relapse. , For patients who have no pathological proof of local relapse, 66 Gy cGy/37 fx will be given to the target which includes prostate fossa, posterior bladder wall (1 cm) and anterior rectal wall (7 mm). The treatment is given by IMRT. , For patients with pathological proof of relapse in the urethra anastomosis but without visible tumor by MRI, 63 cGy/35 Fx to prostate target (as above) will be given. Further 9 Gy/5 fx will be boosted to urethra site and the final dose is 72 Gy/40 fx. , For patients with any visible tumor in the MRI, the dose to the target (as above) is 63 cGy/35 fx and final boost to gross tumor up to 75.6 Gy/42 fx will be given. 5. RT for patients with high risk factors in the pathological specimen after RP Patients who receive radical prostectomy and pathological reports show extracapslar extension, seminal vesicle invasion, or positive margin, are considered 18to receive post-operative radiotherapy. , 63 Gy/35 Fx to prostate target (as above) will be given for those with free margin. Dose will be increased to 66.6 Gy to prostate target for those with multiple positive margin, or to urethra anastomosis if only distal positive resection margin. , Risk of pelvic node >=15%, as calculated by Roach’s formula: If LN dissection is performed and adequate number of LN is reported, 116 RT Protocol for Prostate Cancer-2010 pelvic RT is omitted for pathological N0 case. Otherwise, 45 Gy to pelvic node will be given for patients < 75 Y/O old and has good performance and no severe co-modality. 5. Follow-up schedule , PSA is checked at the day of RT completion. , Patients will come back to RTO OPD at 1 month after RT, and then every 3 months. PSA is regularly checked q3 m for 2 years, q4-6 months up to 5 years, and q6 m afterward. However, if elevation of PSA is found, the frequency can be shifted to q 1-2m. Follow-up interval can be prolonged if patient has poor general performance or inconvenience for transportation. , Biochemical failure is defined by nadir + 2; the day of failure is defined as 19at the day of meeting this criterion. For patients who are treated with short-term hormone therapy, the PSA will rebound after withdraw of hormone therapy, and the nadir is defined as the nadir after the rebound. The day of failure should be recorded. , For those primarily treated with RT and found to have biochemical failure but PSA is <4, systemic work-up usually can not detect metastasis and is not required. MRI is not recommended either for those with negative DRE. , Clinical failure is defined as local or distant failure. Local failure is defined when tumor is palpable by DRE and/or MRI shows positive findings. Biopsy is not an absolute indication for diagnosis of local relapse because many patients might refuse biopsy and tissue proof of local failure does not help further management for most of the patients. However, a strong suggestion to patients should be made to patients. F. Schema of RT guidelines 117 RT Protocol for Prostate Cancer-2010 EXBRT boost by 3D CRT: No further No hormone therapy HDR 50.4 Gy/28 fx to PTVp1 + PTVsv1 treatment for good indicated brachytherapy: brachytherapy Low risk: T1-2a and plan T1-2, or T3a PSA<10 and Gleason EXBRT boost by IMRT (obvious underdose region): H H 50.4 Gy/28 fx to PTVp1 + PTVsv1 with FIF local Local boost to with ECE part < score <7, M0 boost compensate underdose region 3mm. EXBRT boost: For both post HDR T1 with 5.4 Gy/ 3 fx to 550 cGy x 3 fx H Short-term hormone brachytherapy or EXBRT single risk PTVp1 + without IG PTVsv1 by in 2 days Pelvic nodal metastatic risk therapy 3D-CRT < 15%: Intermediate risk: T1-2, 10 45 Gy/25 fx delievered to SV are involved: Total androgen block, PTVn by 3D-CRT 12.6 Gy/7 fractions delivered to External beam ?PSA?20 and Gleason PTVp1+PTVsv1 followed by 12.6 started 2 months before Gy/7 fractions delivered to radiotherapy score ? 7, M0 PTVp2+PTVsv2. RT, ended with RT E 75.6 Gy/42 fx E Pelvic nodal metastatic risk < SV are not involved: 15%: 12.6 Gy/7 fractions delivered to 50.4 Gy/28 fractions delivered to PTVp1 followed by 12.6 Gy/7 PTVp1 + PTVsv1 by IMRT fractions delivered to PTVp2. Long-term hormone T2 with single risk therapy IGRT with Pelvic nodal metastatic risk < 15%: SV are not involved: High risk: T3a, or Gleason 1. Total androgen block, fiducial marker 50.4 Gy/28 fx delivered to iPTVsv by 28 Gy/14 fx delivered to iPTVp. score ?8, PSA > 20, started 2 months IMAT or Novalis Tx? Radiosurgery assistance: Very high risk group: before RT, till the end 78.4 Gy/42 x G G SV are involved: T3b-4, but M0 of RT, followed by Pelvic nodal metastatic risk ? 1. iPTVp: 28 Gy/14 fx LHRH analogue 15% or N1:50.4 Gy/25 fx delievered 2. 12 Gy/7 fx to iPTVsv1 , injection for 2 years to to PTVn by IMAT 16Gy/7 fx delivered to life-long. or iPTVsv2 2. Orchiectomy 118 References 1. Westphalen, A. C., McKenna, D. A., Kurhanewicz, J., and Coakley, F. V.: Role of magnetic resonance imaging and magnetic resonance spectroscopic imaging before and after radiotherapy for prostate cancer. J Endourol, 22: 789, 2008. 2. Roach, M., III: The role of PSA in the radiotherapy of prostate cancer. Oncology (Williston Park), 10: 1143, 1996. 3. Benizri, E., Vassault, A., Nataf, J., Wilmart, J. F., Hennequin, C., Bailly, M. et al.: [Prostatic specific antigen (PSA). Interpretation of results as a function of the assay method]. Prog Urol, 1: 413, 1991. 4. Roach, M., III, Waldman, F., and Pollack, A.: Predictive models in external beam radiotherapy for clinically localized prostate cancer. Cancer, 115: 3112, 2009. 5. Albertsen, P. C., Hanley, J. A., Harlan, L. C., Gilliland, F. D., Hamilton, A., Liff, J. M. et al.: The positive yield of imaging studies in the evaluation of men with newly diagnosed prostate cancer: a population based analysis. J Urol, 163: 1138, 2000. 6. Kupelian, P. A., Willoughby, T. R., Reddy, C. A., Klein, E. A., and Mahadevan, A.: Impact of image guidance on outcomes after external beam radiotherapy for localized prostate cancer. Int J Radiat Oncol Biol Phys, 70: 1146, 2008. 7. Beltran, C., Herman, M. G., and Davis, B. J.: Planning target margin calculations for prostate radiotherapy based on intrafraction and interfraction motion using four localization methods. Int J Radiat Oncol Biol Phys, 70: 289, 2008. 8. Schallenkamp, J. M., Herman, M. G., Kruse, J. J., and Pisansky, T. M.: Prostate position relative to pelvic bony anatomy based on intraprostatic gold markers and electronic portal imaging. Int J Radiat Oncol Biol Phys, 63: 800, 2005. 9. National Comprehensive Cancer Network. Prostate Cancer, NCCN Clinical Practice Guidelines in Oncology. 2010.V.1. 10. Roach, M., III, DeSilvio, M., Lawton, C., Uhl, V., Machtay, M., Seider, M. J. et al.: Phase III trial comparing whole-pelvic versus prostate-only radiotherapy and neoadjuvant versus adjuvant combined androgen suppression: Radiation Therapy Oncology Group 9413. J Clin Oncol, 21: 1904, 2003. 119 11. Chen, Y. C., Chuang, C. K., Hsieh, M. L., Chen, W. C., Fan, K. H., Yeh, C. Y. et al.: High-dose-rate brachytherapy plus external beam radiotherapy for T1 to T3 prostate cancer: an experience in Taiwan. Urology, 70: 101, 2007. 12. Pollack, A., Zagars, G. K., Starkschall, G., Antolak, J. A., Lee, J. J., Huang, E. et al.: Prostate cancer radiation dose response: results of the M. D. Anderson phase III randomized trial. Int J Radiat Oncol Biol Phys, 53: 1097, 2002. 13. Roach, M., III, Bae, K., Speight, J., Wolkov, H. B., Rubin, P., Lee, R. J. et al.: Short-term neoadjuvant androgen deprivation therapy and external-beam radiotherapy for locally advanced prostate cancer: long-term results of RTOG 8610. J Clin Oncol, 26: 585, 2008. 14. Bolla, M., Collette, L., Blank, L., Warde, P., Dubois, J. B., Mirimanoff, R. O. et al.: Long-term results with immediate androgen suppression and external irradiation in patients with locally advanced prostate cancer (an EORTC study): a phase III randomised trial. Lancet, 360: 103, 2002. 15. Hanks, G. E., Pajak, T. F., Porter, A., Grignon, D., Brereton, H., Venkatesan, V. et al.: Phase III trial of long-term adjuvant androgen deprivation after neoadjuvant hormonal cytoreduction and radiotherapy in locally advanced carcinoma of the prostate: the Radiation Therapy Oncology Group Protocol 92-02. J Clin Oncol, 21: 3972, 2003. 16. Lawton, C. A., Winter, K., Murray, K., Machtay, M., Mesic, J. B., Hanks, G. E. et al.: Updated results of the phase III Radiation Therapy Oncology Group (RTOG) trial 85-31 evaluating the potential benefit of androgen suppression following standard radiation therapy for unfavorable prognosis carcinoma of the prostate. Int J Radiat Oncol Biol Phys, 49: 937, 2001. 17. Freedland, S. J., Sutter, M. E., Dorey, F., and Aronson, W. J.: Defining the ideal cutpoint for determining PSA recurrence after radical prostatectomy. Prostate-specific antigen. Urology, 61: 365, 2003. 18. Bolla, M., van, P. H., Collette, L., van, C. P., Vekemans, K., Da, P. L. et al.: Postoperative radiotherapy after radical prostatectomy: a randomised controlled trial (EORTC trial 22911). Lancet, 366: 572, 2005. 120 19. Roach, M., III, Hanks, G., Thames, H., Jr., Schellhammer, P., Shipley, W. U., Sokol, G. H. et al.: Defining biochemical failure following radiotherapy with or without hormonal therapy in men with clinically localized prostate cancer: recommendations of the RTOG-ASTRO Phoenix Consensus Conference. Int J Radiat Oncol Biol Phys, 65: 965, 2006. 121 Radiotherapy (RT) Protocol for Bladder Cancer 2010-02 *This document is aimed to set up RT protocols for bladder cancer. The treatment guideline for bladder cancer will not be covered here. Reminder: Not every bladder cancer patient needs RT. Under the following conditions, RT will be suggested: I. No cystectomy: (1) tumor recurrence and/or progression after BCG instillation, and patient refuses cystectomy (2) T3 lesion II. After cystectomy: (1) the bladder has multiple tumors (>3) with at least one broad base tumor (2) lymph node (+) or resection margin (+) III. The aim is palliation only A. Initial work-up for diagnosis (1) Physical examination (2) Urinalysis (3) IVP or Retrograde pyelogram (4) Cystoscopy ; simultaneous cystoscopy biopsy or TUR-BT B. Systemic work-up (1) CT scan or MRI (2) Bone scan (if bone metastasis is suspected) C. Staging TNM stage classification (UICC/AJCC 1997) D. Tumor Grade (according to WHO 2002) (1) Papilloma (2) Papillary urothelial neoplasm of low malignant potential (PUNLMP) (3) Low grade urothelial carcinoma 122 (4) High grade urothelial carcinoma E. Pre-RT paper works (1) Check and complete the ―Cancer Registry‖. (2) Ask and check the patient what previous treatment for bladder cancer he/she has already received. (3) Check, if available, what is the bladder tumor’s pathology, grade, stage, and diagnostic work-up. (4) Record patient’s co-morbidity, performance status (ECOG), and cancer history. F. RT procedures (1) Simulation Before simulation, patient will be instructed to empty the bladder. At simulation, patient should maintain a supine position with the arms holding to each other and rest at the level above the umbilicus. A four-field box technique RT is used. The anterior and posterior opposed fields start at upper border of L5 vertebra superiorly, at mid-acetabula laterally, and at least 3 cm below symphysis pubis to ensure treating the whole pelvic lymphatics and the whole prostatic or female urethra. The lateral opposed portals should be 2 cm anterior to the whole visualized bladder in the supine patient at simulation, and extend inferiorly to S2 vertebra. The upper corner blocks shield mainly the bowels away from the regional pelvic lymphatics during anterior-posterior irradiation. The lower corner blocks shield anterior and posterior femoral heads, and bilaterally the anal canal and posterior rectal wall. (2) Radiotherapy All patients will receive megavoltage (10MV) photon, four-field box technique RT with the corners shielded. This is planned by 2D planning system according to the images obtained from CT-simulator. (If necessary, 3D planning will be used). , For no cystectomy cases: Patient is ordered to empty the bladder each time before receiving RT. , For all cases: The pelvic will receive 4000–4400cGy irradiation, given in 20-22 fractions. 123 , For no cystectomy cases: After pelvic irradiation, the primary cancer (include local micro-extensions, all positive biopsied areas at the prior cystoscopy) will receive a cone-down boost. This boost should have ample safety-margins. Thus most of or the entire bladder will be irradiated. The total bladder dose should not exceed 6000cGy in 30 fractions if chemotherapy is given in concomitant to RT, otherwise, the total bladder dose may push up to 6400cGy. , For cystectomy cases: After pelvic irradiation, a cone-down boost to the true pelvic is recommended. Otherwise the pelvic will continue to receive RT. In both circumstances, the total dose should not exceed 5000cGy in 25 fractions. References 1. CANCER: Principles & Practice of Oncology, by DeVita, Lawrence & Rosenberg, 8th Edition, 2008. 2. RADIATION ONCOLOGY: Rationale, Technique and Results, by Cox, & thAng, 8 Edition, 2002. nd3. THERAPEUTIC RADIOLOGY, by Mansfield, 2 Edition, 1989. 4. CLINICAL RADIOLOGY, Indications, Techniques & Results, by Wang, 1988. 5. INNOVATIONS IN RADIATION ONCOLOGY, by Withers & Peters, 1988. 6. YEAR BOOK OF CANCER, by Hickey & Saunders, 2008. th7. RADIATION ONCOLOGY: Principles and Practice, by Perez and Brady, 5 Edition, 2008. nd8. ONCOLOGIC IMAGING, by Bragg, Rubin & Hricak, 2 Edition, 2002. 9. MODERN RADIATION ONCOLOGY: Classic Literature & Current Management, by Gilbert, 1984. 10. TECHNOLOGICAL BASIS OF RADIATION THERAPY: Practical Clinical ndApplications, by Levitt & Tapley, 2 Edition, 1992. 124 Radiotherapy (RT) Protocols for Hematopoietic Neoplasms 2010-01 *This document is aimed to set up RT protocols for hematopoietic neoplasms particularly focusing on various lymphomas. Actually the comprehensive treatment guidelines for prostate cancer will not be depicted here. A. Pre-RT work-up and preparation 1. Patients had better be examined by the radiation oncologist before the initiation of chemotherapy if the concept of INRT is considered to be implemented in the design of RT fields(1). 2. To achieve the best quality treatment, it is strongly recommended that pre- and post-chemotherapy CT scans be performed with patients in the treatment position. The same rules apply to FDG-PET/CT scans. .Fusion possibilities, allowing the overlapping of the pre- and post-chemotherapy CT scans are also strongly recommended (1). 3. Whenever possible and feasible, modern radiation techniques (such as 3D-conformal radiotherapy, IMRT, or image-guided radiotherapy) and immobilization devices are strongly recommended for proper implementation of radiation therapy. 4. The remission status after chemotherapy should be determined for each initially involved LN exclusively using CT scans. Complete remission (CR) is defined as the complete disappearance of clinically and/or radiologically detectable disease. A CRu is defined as at least a 75 % decrease in tumor size. A partial response (PR) is at least a 50 % decrease in tumor size. Failure is less than a 50 % decrease or any increase in tumor size(2). B. Definitions for RT treatment planning To achieve the best quality treatment it is strongly recommended that pre-and post-chemotherapy CT scans be performed with patients in the treatment position. The same rules apply to FDG-PET/CT scans. Fusion possibilities are also strongly recommended allowing the overlapping of the pre- and post-chemotherapy CT scans. As chemotherapy has become more efficient, extended fields have been 125 progressively replaced by involved fields. This was demonstrated to be sufficient in patients with early-stage unfavorable Hodgkin’s lymphoma by the German Hodgkin Study Group(3) and the EORTC-GELA cooperative H8 trial(4). Thus in our institute the radiation fields will generally be in accordance with the concept of involved field (IFRT) instead of extended field (EFRT) or regional field, especially if the treatment of choice is combined modality therapy (CMT). There are several functional RT field definitions: , Involved field (IFRT): An involved field includes not only the individual clinically involved or enlarged node(s), but also the other lymph nodes within the same lymph node region (see the following figure), thus encompassing the pre-chemotherapy involved LNs plus contiguous uninvolved LNs within the same lymph node regions. , Extended field (EFRT): An extended field includes the involved field (see the following figure), as well as all immediately adjacent lymph node regions. , Involved nodal (INRT)(1): A field includes only the initially involved lymph nodes and excludes the adjacent uninvolved nodal regions. The rationale is based on the observation that in patients treated with chemotherapy alone, recurrences typically occur in sites of initial nodal involvement. 126 127 128 C. General principles for radiation dose If HL patients will be managed with combined modality therapy (CMT) in a curative intent, the RT doses prescribed to the involved fields are most likely to be 3060 cGy approximately, which would probably be individualized according to the prognostic classification, the intensity of chemotherapy (ie., the number of cycles of chemotherapy), and the results of restaging workups after induction chemotherapy. The concept of response-adapted prescription of RT doses is allowed and at the discretion of the radiation oncologist in charge. For example, if complete response (CR) is recognized in restaging CT and/or FDG-PET scan, the cumulative dose used in the setting of consolidative RT can be diminished from 3060 cGy to 2520 cGy approximately. On the other hand, the dose reduction to 2000 cGy in the patient group with favorable early-stage disease will not be recommended, unless long-term clinical outcomes derived from the German HD10 trial(5) are available. D. Treatment Protocols for Miscellaneous NHL Subtypes in Which Local RT Can Be Implemented with a Curative Intent 1. Diffuse Large B-cell Lymphoma (DLBCL) DLBCL constitutes approximately 30 % of all NHLs. One third of DLBCL cases present with localized disease, in which local RT can be considered to be combined with systemic chemotherapy as a curative intent. For the DLBCL patients with stage I/II, non-bulky disease, either a full course of systemic treatment with R-CHOP for 6 – 8 cycles or a briefer course of systemic treatment with R-CHOP for 3 cycles followed by consolidative local RT can be prescribed(6). The involved 129 field will be irradiated to a cumulative tumor dose of 3600 cGy approximately. The RT dose can be decreased to 3060 cGy approximately if the restaging imaging studies before the initiation of consolidative local RT indeed disclose complete remission(7). 2. Primary CNS lymphomas (PCNSL) Whenever possible and feasible, all patients with PCNSL would be treated with combined chemoradiation in a ―sandwich‖ manner(8, 9). Systemic methotrexate 2(MTX, 1 g/m) plus six doses of intrathecal MTX at 12 mg per dose is administered before the initiation of cranial RT. Radiation therapy will be initiated on Day 19 and a full course of cranial RT will be delivered as follows, 3960 cGy/22 fx whole-brain RT plus an additional 1080 cGy/6 fx focal boost in case of a solitary brain lymphoma; otherwise a full course of 4500 cGy/25 fx whole-brain RT solely without further boost provided there are multifocal involvement. Three weeks after completion of cranial RT, 2 cycles of high-dose cytarabine (ara-C) will be prescribed. If the primary tumor involves the tissue of the eye itself, it is referred to as primary intraocular lymphoma and is, in essence, a subset of PCNS. Its management is essentially that of PCNSL(10). If lymphoma cells are initially present only in the eyes, without evidence of disease in the brain or other brain tissues, the RT volume encompassing both eyes and whole brain will be irradiated for 3600 – 3960 cGy. Whether whole brain excluding the eyes needs further RT boost would depend on if there is evidence of intracranial involvement or not. 3. Orbital MALT Lymphomas They typically arise in superficial tissues such as conjunctiva, eyelids, and lacrimal glands. If the oncological surveys support the diagnosis of localized disease, RT alone would be been recommended as the treatment of choice(11). A RT dose of 25.2 - 30.6 Gy approximately is adequate for local tumor control. Although field arrangements are somewhat controversial, it is suggested that in our institute the RT volume had better encompass the entire conjunctiva, eyelids, and lacrimal gland without intention to cover the entire orbit unless there is radiological evidence of retrobulbar involvement. Lens shielding usually is not employed in our institute due to the concerns of marginal misses and unavoidable eye movement. 4. Extranodal NK/T cell lymphoma, nasal type(12) Whenever possible and feasible, all patients with limited-stage NK/T cell lymphoma (nasal type) in our institute would be treated with combined chemoradiation in a ―sandwiched‖ manner. Systemic chemotherapy with CHOP is 130 administered for 3 cycles prior to the initiation of cranial RT. Radiation therapy will be delivered to nasal cavity, nasopharynx, and the adjacent paranasal sinuses for a cumulative total dose of 5040 cGy/28 fx. If initially the primary tumor involves the nasopharynx, the RT field is recommended to encompass the region of the first echelon lymph nodes (ie, the parapharyngeal, retropharyngeal, and the upper jugulodigastric LNs). After completion of the course of RT, there will be 3 additional cycles of chemotherapy with CHOP. 5. Primary Gastric MALT lymphomas(13) A unique feature of gastric MALT lymphomas is the association with H. pylori infection, which can be identified in up to 92 % of patients. Accordingly, treatment with appropriate antibiotics has been used. NCCN guidelines call for initial therapy with antibiotics and close follow-up because of the simplicity of this approach and the slow growth of MALT lymphomas. Local RT is reserved for the patients with limited-stage disease failing to respond to antibiotic therapy. A RT dose of 30 Gy approximately is considered to be quite adequate for tumor control. RT volume is supposed to encompass the whole stomach and perigastric lymphatics. The dose per fraction can be 1.5 – 1.8 Gy, depending on the patient’s age, general condition, and whether there is a clinical concern of possible gastric perforation due to rapid tumor shrinkage(14). 131 132 References 1. Girinsky T, van der Maazen R, Specht L, et al. Involved-node radiotherapy (INRT) in patients with early Hodgkin lymphoma: concepts and guidelines. Radiother Oncol 2006;79:270-277. 2. Cheson BD, Pfistner B, Juweid ME, et al. Revised response criteria for malignant lymphoma. Journal of Clinical Oncology 2007;25:579-586. 3. Engert A, Schiller P, Josting A, et al. Involved-field radiotherapy is equally effective and less toxic compared with extended-field radiotherapy after four cycles of chemotherapy in patients with early-stage unfavorable Hodgkin's lymphoma: results of the HD8 trial of the German Hodgkin's Lymphoma Study Group. J Clin Oncol 2003;21:3601-3608. 4. Ferme C, Eghbali H, Hagenbeek A, et al. MOPP/ABV (M/A) hybrid and irradiation in unfavorable supradiaphragmatic clinical stages (CS) I-II Hodgkin's disease (HD): Comparison of three treatment modalities. Preliminary results of the EORTC-GELA H8-U randomized trial in 995 patients. Blood 2000;96:2473. 5. Diehl V, Brillant C, Engert A, et al. Reduction of combined modality treatment intensity in early stage Hodgkin's lymphoma: Interim analysis of the HD 10 trial of the GHSG. Blood 2004;104:1307. 6. Shenkier TN, Voss N, Fairey R, et al. Brief chemotherapy and involved-region irradiation for limited-stage diffuse large-cell lymphoma: an 18-year experience from the British Columbia Cancer Agency. J Clin Oncol 2002;20:197-204. 7. Horning SJ, Weller E, Kim K, et al. Chemotherapy with or without radiotherapy in limited-stage diffuse aggressive non-Hodgkin's lymphoma: Eastern Cooperative Oncology Group study 1484. J Clin Oncol 2004;22:3032-3038. 8. DeAngelis LM, Seiferheld W, Schold SC, et al. Combination Chemotherapy and Radiotherapy for Primary Central Nervous System Lymphoma: Radiation Therapy Oncology Group Study 93-10. J Clin Oncol 2002;20:4643-4648. 9. DeAngelis LM, Yahalom J, Thaler HT, et al. Combined modality therapy for primary CNS lymphoma. J Clin Oncol 1992;10:635-643. 10. Hormigo A, Abrey L, Heinemann MH, et al. Ocular presentation of primary central nervous system lymphoma: diagnosis and treatment. Br J Haematol 2004;126:202-208. 11. Decaudin D, de Cremoux P, Vincent-Salomon A, et al. Ocular adnexal lymphoma: a review of clinicopathologic features and treatment options. Blood 2006;108:1451-1460. 133 12. Cheung MMC, Chan JKC, Lau WH, et al. Early stage nasal NK/T-cell lymphoma: Clinical outcome, prognostic factors, and the effect of treatment modality. International Journal of Radiation Oncology Biology Physics 2002;54:182-190. 13. Fischbach W, Dragosics B, Kolve-Goebeler ME, et al. Primary gastric B-cell lymphoma: Results of a prospective multicenter study. Gastroenterology 2000;119:1191-1202. 14. Schechter NR, Yahalom J. Low-grade malt lymphoma of the stomach: A review of treatment options. International Journal of Radiation Oncology Biology Physics 2000;46:1093-1103. 134 Radiotherapy (RT) Protocol for Soft Tissue Sarcoma 2010-02 *This document is aimed to set up RT protocols for soft tissue sarcoma of the extremity. The treatment guideline for soft tissue sarcoma will not be covered here. A. Pre-RT work-up and preparations 1. Pathology should be established before RT, including grade, histologic subtype and the status of margins of the excision. 2. Pre-entry MRI or CT of the primary tumor, and CT of the lung are required for all patients because it is important for staging and treatment choice. 3. To improve the treatment quality, Alpha cradle or alternative immobilization system is required and image-guided radiotherapy is recommended. B. Definitions for RT treatment planning Gross Tumor Volume (GTV) is defined as all known gross disease as defined by the planning CT and clinical information. Gross tumor includes the primary tumor only. Clinical Target Volume (CTV) includes the area of subclinical involvement around the GTV. We have chosen to define the CTV a minimum of 3-5 cm proximal and distal in the associated muscular compartment around the GTV delineated by CT scan. All macroscopically involved regional lymph nodes were included with a margin of 1 cm. The surgical scar should be included in the CTV. Planning Target Volume (PTV) provide margin around the CTV to compensate for variability in treatment setup. The PTV volume must include a minimum of 1 cm around the CTV. Therefore, the superior and inferior margins will be approximately 4-6 cm beyond the GTV. C. General principles for radiation dose [1-3] 1. For primary surgery patients, 60-64 Gy will be prescribed for negative margins, 66-70 Gy will be prescribed for microscopic residual tumors, and 70-74 Gy for gross residual tumors. D. Treatment guidelines for soft tissue sarcoma 135 1. Treatment for non-metastatic disease after surgery Radiotherapy (RT) 1. EXRT alone: , Total dose = 60-74 Gy/30-37 fx - Dose prescription and delivery technique: 50 Gy/25 fx to PTV, and boost with 10-14 Gy will be prescribed to GTV with 2cm margins in tumors with negative margins, 16-20 Gy will be prescribed to GTV with 4cm margins, restrained by muscle compartment, for microscopic residual tumors, and likewise, 20-24 Gy for gross residual tumors. RT given by 3D-conformal RT, intensity modulated radiotherapy (IMRT) or RapidArc? radiotherapy technology is preferred. [4, 5] - Requirement of dose coverage: 100% dose to > 95% CTV volume, and PTV is treated by 95% of prescribed dose to >95% volume. Maximal dose inside the PTV is < 108% of prescribed dose. The total dose to the whole circumference of the adjoining bone is kept below 7000cGy. 2. Treatment for non-metastatic disease before surgery Radiotherapy (RT) 1. EXRT alone: , Total dose = 50 Gy/25 fx - Dose prescription and delivery technique: 50 Gy/25 fx to GTV with 4cm margins, restrained by muscle compartment. [6] [7] RT given by 3D-conformal RT, intensity modulated radiotherapy (IMRT) or RapidArc? radiotherapy technology is preferred. - Requirement of dose coverage: 100% dose to > 95% CTV volume, and PTV is treated by 95% of prescribed dose to >95% volume. Maximal dose inside the PTV is < 108% of prescribed dose. E. Follow-up schedule , MRI or CT of the primary tumor site will be arranged at least once annually for the first 3 years and under circumstance of suspicious local tumor recurrence. , Patients will come back to RTO OPD at 3 months after RT, and then every 3 months for 2 years. Chest X-ray is regularly checked every 3 months for 2 years, then every 3-6 months for high grade sarcoma up to 5 years. 136 However, CT of chest will be arranged at least annually for high grade tumors in the first 3 years. References 1. Pisters, P.W.T., B. O'Sullivan, and R.G. Maki, Evidence-based recommendations for local therapy for soft tissue sarcomas. Journal of Clinical Oncology, 2007. 25(8): p. 1003-8. 2. Pisters, P.W.T., et al., Long-term results of prospective trial of surgery alone with selective use of radiation for patients with T1 extremity and trunk soft tissue sarcomas. Annals of Surgery, 2007. 246(4): p. 675-81; discussion 681-2. 3. Gerrand, C.H., et al., Classification of positive margins after resection of soft-tissue sarcoma of the limb predicts the risk of local recurrence. Journal of Bone & Joint Surgery - British Volume, 2001. 83(8): p. 1149-55. 4. Alektiar, K.M., et al., Impact of intensity-modulated radiation therapy on local control in primary soft-tissue sarcoma of the extremity. Journal of Clinical Oncology, 2008. 26(20): p. 3440-4. 5. Alektiar, K.M., et al., Adjuvant radiotherapy for margin-positive high-grade soft tissue sarcoma of the extremity. International Journal of Radiation Oncology, Biology, Physics, 2000. 48(4): p. 1051-8. 6. White, L.M., et al., Histologic assessment of peritumoral edema in soft tissue sarcoma. International Journal of Radiation Oncology, Biology, Physics, 2005. 61(5): p. 1439-45. 7. O'Sullivan, B., et al., Preoperative versus postoperative radiotherapy in soft-tissue sarcoma of the limbs: a randomised trial. Lancet, 2002. 359(9325): p. 2235-41. 137 非本院區住院醫師代訓工作規範 1. 住院醫師參加學術會議應準時參加,非本院區住院醫師代訓方面: 則至少參加一次該月份有舉行之各種combine conference, 如GYN combine conference 或 H&N combine conference. 2. Chart Round 細節:該月份的intern & clerk需準時參加chart round,列入被teaching的問題行列,由總醫師主持會議並提出問題,teaching問題的順序由 clerk , intern , R1 , R2 , R3。當問題不夠深入時,應由主治醫師補充。提報chart round之case的history由該月實習醫師以資料呈現與口頭報告。資料呈現應以 power point製作,報告時間不超過15分鐘。由總醫師提供個人手提電腻以供放映。history提報不全之處應由住院醫師補充。該月實習醫師應有2天緩衝期來準備,若chart round當天才報到,則不需報告case history,改由住院醫師呈報。 3. Chard Round時,需主治醫師的interaction以提昇對住院醫師的 訓練成效,因此主治醫師對於treatment的review需要Comment 10-15分鐘。所排定的醫師以專屬領域為主,由資淺至資深的順序 為原則,每一位主治醫師皆有輪流到的機會。 4. 住院醫師的seminar presentation由主治醫師評核。共有5個分項 評分基準:內容(50%)、組識能力(15%)、表達能力(15%)、美術設 計(10%)、時間掌控(10 %)。評核結果將於seminar presentation 後提供給該住院醫師,供做參考以利未來presentation時改善或鼓 勵。非本院區住院醫師代訓方面: 需要有一次的 心得 信息技术培训心得 下载关于七一讲话心得体会关于国企改革心得体会关于使用希沃白板的心得体会国培计划培训心得体会 報告, 題目著 重於兩院區之差異比較,需製作成power point,約30分鐘. 5. 非本院區住院醫師代訓期間: 由排定主治醫師親自指導,並且需在 主治醫師或該期間負責之住院醫師的指導下,負責起照顧病人與完 成治療計劃. 6. 非本院區住院醫師代訓期間, 鑑於兩院區作業系統有所差別與著 重在training的主旨下, 代訓醫師並不需要負起值班的職責. 教育委員會敬製 91-1-17 更新 97-1-09 138 林口長庚醫院放射腫瘤科 腫瘤內科醫師 工作規範 主旨:訓練腫瘤內科醫師對放射線在癌病治療上的應用。 說明:放射治療與開刀及化學治療是現今癌症最主要的治療方法,約有6成的癌症患者在治療過程中接受治癒性或姑息性的放射治療。放射治療是一種局部治療,可概分為遠隔治療(teletherapy)及近接治療(brachytherapy)。所謂遠隔治療乃是利用直線加速器或鈷六十來治療病人。而近接治療乃是將射源置入病人體內直接近距離照射,較常用於子宮頸癌、鼻咽癌及腻瘤的治療。如何提高局部劑量而不增加周圍正常組織的傷害,永遠是放射治療不斷努力的目標。為達此目的,可利用改變每次治療的劑量及時間間隔或使用先進的治療計畫系統,將劑量侷限於腫瘤組織,以達更佳的癌病控制率。 1. 臨床見習工作 本科醫師與患者 (及其家屬) 互動、評估患者的病情及狀況、解釋病情、安排必要的模擬攝影或其它相關之檢查的機會,以在門診室中進行居多。 地 點 項 目 次 數 說明 了解放射治療之適應症,並學習與RTO-C區門診 初診 每週二次 病患及家屬溝通 了解放射治療中常見的副作用及RTO-C區門診 治療中病患診察 每週一天 其處理方式 長期追蹤檢查,以觀察癌病治療結RTO-C區門診 追蹤複診 每週二次 果 模擬攝影室 模擬攝影 每週一次 放射治療之定位及照野的決定 139 模型室 模具製作 每週一次 治療用輔助模具製作之觀察 了解近接放射治療操作及適用時後荷治療室 近接放射治療 每週一次 機 手術室 麻醉下檢查 每週一次 評估腫瘤的大小及侵犯的範圍 其它的放射治療modern modalities包括:radiosurgery, brain implant, prostate implant, IOERT, IOBRT, TBI等。 2. 放射腫瘤科內會議需參加: 新病例討論會 研討排定病例 隔週五上午 期刊研討會 新近發表期刊研讀、討論 每週三上午 複雜治療之電腻治療計劃說明及討每月第一週之週六治療計劃討論會 論 上午 3. 腫瘤內科醫師醫師在放射腫瘤科接受放射治療基本訓練,除了參 與放射腫瘤科的常規性臨床作業外,其它的應參與的課程還包 括: 放射腫瘤學簡介 四小時 放射物理學 二小時 治療計劃介紹 二小時 另外教學活動與課程 課 程 內 容 目 標 時 間 放射腫瘤科介紹 了解本科治療流程及環境 見習第一天上午 臨床病理討論會 討論臨床及病理上有疑義的病例 隔週週二中午 140 乳癌聯合討論會 乳癌病例聯合討論 每週二下午 腻瘤聯合討論會 腻瘤病例聯合討論 每週四上午 婦癌聯合討論會 婦癌病例聯合討論 每週四下午 小兒腫瘤聯合討論會 小兒腫瘤病例聯合討論 每月末週、週四下午 泌尿系統腫瘤聯合討泌尿系統腫瘤病例聯合討論 每月週二上午 論會 見習報告討論會 見習結束前安排 4. 需要完成二腫瘤病例之電腻治療計劃才算訓練完全結束。 5. 教學訓練負責人、醫師與物理師名單 負責人: 洪志宏 主任 醫 師: 曾雁明、梁為民、張東杰、曾振淦、王俊傑、白冰清、林信吟、林倩妤、黃意婷、陳彥超 物理師: 葉建一、李宗其 141