壹生资讯-指南精华！非小细胞肺癌的放疗问题，都是干货！建议收藏！

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指南精华！非小细胞肺癌的放疗问题，都是干货！建议收藏！

2020-12-21作者：cmt佳玲资讯

支持护理和治疗的相关问题癌症筛查

非小细胞肺癌(non-small cell lung cancer, NSCLC)占所有最常见肿瘤——肺癌病例的80%~85%。

根据大样本人群数据显示，初诊NSCLC患者中约20%为早期约25%为局部晚期，约55%已发生远处转移[2]。

放疗对于非小细胞肺癌来说，是一种效果不错的治疗手段，那么在对于非小细胞肺癌的放疗中，需要注意哪些问题呢？今天小编来说一说。

往期精彩：

指南精华！一文掌握非小细胞肺癌的诊断问题！

指南精华又来了！非小细胞肺癌治疗的问题，一文掌握！

NSCLC的放疗

1．总体原则。

NSCLC患者放疗主要适应证包括以下5种情况：

(1)有手术禁忌证患者或拒绝手术早期NSCLC的根治性治疗，采用SRT技术；

(2)部分可手术局部晚期患者的术前或术后治疗；

(3)局部晚期NSCLC的根治性治疗，通常与化疗结合；

(4)寡进展和寡转移患者的局部巩固治疗；

(5)晚期NSCLC患者的姑息治疗。放疗的目标是最大限度地控制肿瘤并减少治疗相关毒不良反应。

先进的精确放疗技术，如调强放疗、容积调强弧形治疗、4D-CT模拟定位、MR模拟定位、图像引导放疗、运动管理策略等，已被证明能显著降低不良反应并提高生存率。NSCLC患者至少应接受基于CT模拟图像的三维适形、调强放疗技术。

2．体位固定及CT模拟定位：

体位固定应满足精确放疗要求，可采用真空袋、体罩、或结合立体放疗定位架方式。

无禁忌的情况下均推荐增强CT模拟定位，扫描范围应超出拟照射的肿瘤范围及相应正常组织如全肺，一般为第4颈椎至第2腰椎，扫描层厚应≤5 mm。有条件的单位应采用4DCT定位等呼吸运动管理方式，如有需要(如肺不张、脑转移行SRT等)可结合PET-CT或磁共振模拟定位图像以更准确显示肿瘤范围。

对于SBRT，4D-CT模拟是首选的定位技术；定位前应进行必要的呼吸训练，扫描范围应包括整个肺以便进行肺的总剂量评估，扫描层厚≤3 mm。

3．放疗计划制定：

放疗计划制定的最低要求是基于CT模拟定位的三维适形放疗，应使用多野照射并且所有射野均应每日同照。

有条件的单位可以使用更先进的调强放疗、容积调强弧形治疗、图像引导放疗、运动管理等放疗技术。

SBRT采用调强放疗、容积调强弧形治疗技术时需关注子野大小、外形和每个子野的跳数(monitor unit, MU)。SBRT单次治疗时间偏长，治疗技术选择时需要考虑到治疗时间长短对患者治疗过程中体位一致性的影响。

4．正常组织剂量限制：

放疗计划完成以后，应对靶区剂量及OAR剂量进行评估和优化。以剂量体积直方图作为基本工具，并根据三维空间中区域等剂量曲线的分布，评估PTV及OAR的剂量分布。计划评价中OAR受照剂量限制：

95%PTV剂量均匀度93%~107%，双肺V20Gy<30%(同步放化疗可使控制更加严格)、V20Gy<28%、肺叶切除术后放疗V20Gy<20%、全肺除术后放疗V20Gy<10%)、肺Dmean<17 Gy，计划脊髓危及体积Dmax<45~50 Gy，食管Dmean≤34 Gy、V60Gy≤17%，心脏Dmean≤20 Gy、V50Gy≤25%。

SBRT正常组织限量应根据不同分次进行限制，具体可参照NCCN指南并结合本单位和具体设备经验建立自己的剂量限制表格。

由于目前国内开展SBRT技术的单位之间实践及经验差异性较大的现状，建议进行OAR剂量限制推荐时应进行更严格的剂量限制。

本文作者：中华医学会放射肿瘤治疗学分会中国医师协会放射肿瘤治疗医师分会中国抗癌协会放射治疗专业委员会中国临床肿瘤学会肿瘤放疗专家委员会

本文来源：《中华放射肿瘤学杂志》2020年第8期第29卷，第599-607页.

参考文献

[1]GoldstrawP, ChanskyK, CrowleyJ, et al. The IASLC lung cancer staging project：proposals for revision of the tnm stage groupings in the forthcoming (eighth) edition of the TNM classification for lung cancer[J]. J Thorac Oncol, 2016, 11(1):39-51. DOI：10.1016/j.jtho.2015.09.009.

[2]NooneAM, HowladerN, KrapchoM, et al. SEER cancer statistics review, 1975-2015, based on November 2017 SEER data submission, posted to the SEER web site, April 2018[DB/OL][2020-05-20]．csr/1975_2015/.

[3]National Lung Screening Trial Research Team, AberleDR, AdamsAM, et al. Reduced lung-cancer mortality with low-dose computed tomographic screening[J]. N Engl J Med, 2011, 365(5):395-409. DOI：10.1056/NEJMoa1102873.

[4]Expert Panel on Thoracic Imaging, de GrootPM, ChungJH, et al. ACR appropriateness criteria(®) noninvasive clinical staging of primary lung cancer[J]. J Am Coll Radiol, 2019, 16(5S):S184-S195. DOI：10.1016/j.jacr.2019.02.008.

[5]VideticGMM, DoningtonJ, GiulianiM, et al. Stereotactic body radiation therapy for early-stage non-small cell lung cancer：executive summary of an ASTRO evidence-based guideline[J]. PractRadiat Oncol, 2017, 7(5):295-301. DOI：10.1016/j.prro.2017.04.014.

[6]GuckenbergerM, AndratschkeN, DieckmannK, et al. ESTRO ACROP consensus guideline on implementation and practice of stereotactic body radiotherapy for peripherally located early stage non-small cell lung cancer[J]. Radiother Oncol, 2017, 124(1):11-17. DOI：10.1016/j.radonc.2017.05.012.

[7]NCCN. NCCN clinical practice guidelines in oncology：non-small cell lung cancer.2020[DB/OL][2020-05-20]. .nccn.org/professionals/physician_gls/pdf/nscl.pdf.

[8]WangC, RimnerA, GelblumDY, et al. Analysis of toxic effects with antiangiogenic agents plus stereotactic body radiation in ultracentral lung tumors[J]. JAMA Oncol, 2019, 5(5):737-739. DOI：10.1001/jamaoncol.2019.0205.

[9]EberhardtWE, PöttgenC, GaulerTC, et al. Phase Ⅲ study of surgery versus definitive concurrent chemoradiotherapy boost in patients with resectable stage ⅢA(N2) and selected ⅢB non-small-cell lung cancer after induction chemotherapy and concurrent chemoradiotherapy (ESPATUE)[J]. J Clin Oncol, 2015, 33(35):4194-4201. DOI：10.1200/JCO.2015.62.6812.

[10]van MeerbeeckJP, KramerGW, Van SchilPE, et al. Randomized controlled trial of resection versus radiotherapy after induction chemotherapy in stage ⅢA-N2 non-small-cell lung cancer[J]. J Natl Cancer Inst, 2007, 99(6):442-450. DOI：10.1093/jnci/djk093.

[11]PlessM, StuppR, RisHB, et al. Induction chemoradiation in stage ⅢA/N2 non-small-cell lung cancer：a phase 3 randomised trial[J]. Lancet, 2015, 386(9998):1049-1056. DOI：10.1016/S0140-6736(15)60294-X.

[12]RuschVW, GirouxDJ, KrautMJ, et al. Induction chemoradiation and surgical resection for superior sulcus non-small-cell lung carcinomas：long-term results of Southwest Oncology Group Trial 9416(Intergroup Trial 0160)[J]. J Clin Oncol, 2007, 25(3):313-318. DOI：10.1200/JCO.2006.08.2826.

[13]KunitohH, KatoH, TsuboiM, et al. Phase Ⅱ trial of preoperative chemoradiotherapy followed by surgical resection in patients with superior sulcus non-small-cell lung cancers：report of Japan Clinical Oncology Group trial 9806[J]. J Clin Oncol, 2008, 26(4):644-649. DOI：10.1200/JCO.2007.14.1911.

[14]ZhongWZ, WangQ, MaoWM, et al. Gefitinib versus vinorelbine plus cisplatin as adjuvant treatment for stage Ⅱ-ⅢA(N1－N2) EGFR-mutant NSCLC (ADJUVANT/CTONG1104)：a randomised, open-label, phase 3 study[J]. Lancet Oncol, 2018, 19(1):139-148. DOI：10.1016/S1470-2045(17)30729-5.

[15]YueD, XuS, WangQ, et al. Erlotinib versus vinorelbine plus cisplatin as adjuvant therapy in Chinese patients with stage ⅢA EGFR mutation-positive non-small-cell lung cancer (EVAN)：a randomised, open-label, phase 2 trial[J]. Lancet Respir Med, 2018, 6(11):863-873. DOI：10.1016/S2213-2600(18)30277-7.

[16]FengW, FuXL, CaiXW, et al. Patterns of local-regional failure in completely resected stage ⅢA(N2[J]. Int J Radiat Oncol Biol Phys, 2014, 88(5):1100-1107. DOI：10.1016/j.ijrobp.2013.12.048.

[17]MachtayM, LeeJH, ShragerJB, et al. Risk of death from intercurrent disease is not excessively increased by modern postoperative radiotherapy for high-risk resected non-small-cell lung carcinoma[J]. J Clin Oncol, 2001, 19(19):3912-3917. DOI：10.1200/JCO.2001.19.19.3912.

[18]CorsoCD, RutterCE, WilsonLD, et al. Re-evaluation of the role of postoperative radiotherapy and the impact of radiation dose for non-small-cell lung cancer using the National Cancer Database[J]. J Thorac Oncol, 2015, 10(1):148-155. DOI：10.1097/JTO.0000000000000406.

[19]AuperinA, Le PechouxC, RollandE, et al. Meta-analysis of concomitant versus sequential radiochemotherapy in locally advanced non-small-cell lung cancer[J]. J Clin Oncol, 2010, 28(13):2181-2190. DOI：10.1200/JCO.2009.26.2543.

[20]Curran JrWJ, PaulusR, LangerCJ, et al. Sequential vs. concurrent chemoradiation for stage Ⅲ non-small cell lung cancer：randomized phase Ⅲ trial RTOG 9410[J]. J Natl Cancer Inst, 2011, 103(19):1452-1460. DOI：10.1093/jnci/djr325.

[21]OgawaK, TakahashiY, MuraseK, et al. Treatment outcome of patients with unresectable stage Ⅲ non-small cell lung cancer and interstitial pneumonia. Respir Investig, 2019, 57(4):388-394. DOI：10.1016/j.resinv.2019.02.004.

[22]EberhardtWE, De RuysscherD, WederW, et al. 2nd ESMO consensus conference in lung cancer：locally advanced stage Ⅲ non-small-cell lung cancer[J]. Ann Oncol, 2015, 26(8):1573-1588. DOI：10.1093/annonc/mdv187.

[23]BiN, WangL. Superiority of concomitant chemoradiation over sequential chemoradiation in inoperable, locally advanced non-small cell lung cancer：challenges in the selection of appropriate chemotherapy[J]. SeminRadiat Oncol, 2015, 25(2):122-132. DOI：10.1016/j.semradonc.2014.11.003.

[24]LiangJ, BiN, WuS, et al. Etoposide and cisplatin vs. paclitaxel and carboplatin with concurrent thoracic radiotherapy in unresectable stage Ⅲ non-small cell lung cancer：a multicenter randomized phase Ⅲ trial[J]. Ann Oncol, 2017, 28(4):777-783. DOI：10.1093/annonc/mdx009.

[25]SureshS, AnthonyB, Lu-huaW, et al. PROCLAIM：randomized phase Ⅲ trial of pemetrexed-cisplatin or etoposide-cisplatin plus thoracic radiation therapy followed by consolidation chemotherapy in locally advanced nonsquamous non-small-cell lung cancer[J]. J Clin Oncol, 2016, 34(9):953-962. DOI：10.1200/JCO.2015.64.8824.

[26]VokesEE, HerndonJE 2nd, KelleyMJ, et al. Induction chemotherapy followed by chemoradiotherapy compared with chemoradiotherapy alone for regionally advanced unresectable stage Ⅲ non-small-cell lung cancer：cancer and leukemia group B[J]. J Clin Oncol, 2007, 25(13):1698-1704. DOI：10.1200/JCO.2006.07.3569.

[27]HannaN, NeubauerM, YiannoutsosC, et al. Phase Ⅲ study of cisplatin, etoposide, and concurrent chest radiation with or without consolidation docetaxel in patients with inoperable stage Ⅲ non-small-cell lung cancer：the Hoosier oncology group and U. S. oncology[J]. J Clin Oncol, 2008, 26(35):5755-5760. DOI：10.1200/JCO.2008.17.7840.

[28]AhnJS, AhnYC, KimJH, et al. Multinational randomized phase Ⅲ trial with or without consolidation chemotherapy using docetaxel and cisplatin after concurrent chemoradiation in inoperable stage Ⅲ non-small-cell lung cancer：KCSG-LU05-04[J]. J Clin Oncol, 2015, 33(24):2660-2666. DOI：10.1200/JCO.2014.60.0130.

[29]KellyK, ChanskyK, GasparLE, et al. Phase Ⅲ trial of maintenance gefitinib or placebo after concurrent chemoradiotherapy and docetaxel consolidation in inoperable stage Ⅲ non-small-cell lung cancer：SWOG S0023[J]. J Clin Oncol, 2008, 26(15):2450-2456. DOI：10.1200/JCO.2007.14.4824.

[30]AntoniaSJ, VillegasA, DanielD, et al. Overall survival with durvalumab after chemoradiotherapy in stage Ⅲ NSCLC[J]. N Engl J Med, 2018, 379(24):2342-2350. DOI：10.1056/NEJMoa1809697.

[31]AntoniaSJ, VillegasA, DanielD, et al. Durvalumab after chemoradiotherapy in stage Ⅲ non-small-cell lung cancer[J]. N Engl J Med, 2017, 377(20):1919-1929. DOI：10.1056/NEJMoa1709937.

[32]WangJ, ZhouZ, LiangJ, et al. Intensity-modulated radiation therapy may improve local-regional tumor control for locally advanced non-small cell lung cancer compared with three-dimensional conformal radiation therapy[J]. Oncologist, 2016, 21(12):1530-1537. DOI：10.1634/theoncologist.2016-0155.

[33]ChunSG, HuC, ChoyH, et al. Impact of Intensity-modulated radiation therapy technique for locally advanced non-small-cell lung cancer：a secondary analysis of the NRG oncology RTOG 0617 randomized clinical trial[J]. J Clin Oncol, 2017, 35(1):56-62. DOI：10.1200/JCO.2016.69.1378.

[34]PengJ, PondG, DonovanE, et al. A comparison of radiation techniques in patients treated with concurrent chemoradiation for stage Ⅲ non-small cell lung cancer[J]. Int J Radiat Oncol Biol Phys, 2020, 106(5):985-992. DOI：10.1016/j.ijrobp.2019.12.027.

[35]BradleyJD, PaulusR, KomakiR, et al. Standard-dose versus high-dose conformal radiotherapy with concurrent and consolidation carboplatin plus paclitaxel with or without cetuximab for patients with stage ⅢA or ⅢB non-small-cell lung cancer (RTOG 0617)：a randomised, two-by-two factorial phase 3 study[J]. Lancet Oncol, 2015, 16(2):187-199. DOI：10.1016/S1470-2045(14)71207-0.

[36]SuSF, HuYX, OuyangWW, et al. Overall survival and toxicities regarding thoracic three-dimensional radiotherapy with concurrent chemotherapy for stage ⅠV non-small cell lung cancer：results of a prospective single-center study[J]. BMC Cancer, 2013, 13:474. DOI：10.1186/1471-2407-13-474.

[37]SuS, LiT, LuB, et al. Three-dimensional radiation therapy to the primary tumor with concurrent chemotherapy in patients with stage iv non-small cell lung cancer：results of a multicenter phase 2 study from PPRA-RTOG, China[J]. Int J Radiat Oncol Biol Phys, 2015, 93(4):769-777. DOI：10.1016/j.ijrobp.2015.08.012.

[38]MoellerB, BalagamwalaEH, ChenA, et al. Palliative thoracic radiation therapy for nonsmall cell lung cancer：2018 update of an American Society for Radiation Oncology (ASTRO) evidence-based guideline[J]. PractRadiat Oncol, 2018, 8(4):245-250. DOI：10.1016/j.prro.2018.02.009.

[39]PetrelliF, GhidiniA, CabidduM, et al. Addition of radiotherapy to the primary tumour in oligometastatic NSCLC：a systematic review and meta-analysis[J]. Lung Cancer, 2018, 126:194-200. DOI：10.1016/j.lungcan.2018.11.017.

[40]HendriksLEL, DoomsC, BerghmansT, et al. Defining oligometastatic non-small cell lung cancer：A simulated multidisciplinary expert opinion[J]. Eur J Cancer, 2019, 123(1):28-35. DOI：10.1016/j.ejca.2019.09.013.

[41]GomezDR, TangC, ZhangJ, et al. Local consolidative therapy vs. maintenance therapy or observation for patients with oligometastatic non-small-cell lung cancer：long-term results of a multi-institutional, phase Ⅱ，randomized study[J]. J Clin Oncol, 2019, 37(18):1558-1565. DOI：10.1200/JCO.19.00201.

[42]GomezDR, BlumenscheinGR, LeeJJ, et al. Local consolidative therapy versus maintenance therapy or observation for patients with oligometastatic non-small-cell lung cancer without progression after first-line systemic therapy：a multicentre, randomised, controlled, phase 2 study[J]. Lancet Oncol, 2016, 17(12):1672-1682. DOI：10.1200/JCO.19.00201.

[43]SperdutoPW, KasedN, RobergeD, et al. Summary report on the graded prognostic assessment：an accurate and facile diagnosis-specific tool to estimate survival for patients with brain metastases[J]. J Clin Oncol, 2012, 30(4):419-425. DOI：10.1200/JCO.2011.38.0527.

[44]SperdutoPW, YangTJ, BealK, et al. Estimating survival in patients with lung cancer and brain metastases：an update of the graded prognostic assessment for lung cancer using molecular markers (Lung-molGPA)[J]. JAMA Oncol, 2017, 3(6):827-831. DOI：10.1001/jamaoncol.2016.3834.

[45]BrownPD, BallmanKV, CerhanJH, et al. Postoperative stereotactic radiosurgery compared with whole brain radiotherapy for resected metastatic brain disease (NCCTG N107C/CEC·3)：a multicentre, randomised, controlled, phase 3 trial[J]. Lancet Oncol, 2017, 18(8):1049-1060. DOI：10.1016/S1470-2045(17)30441-2.

[46]BiN, MaY, XiaoJ, et al. A Phase Ⅱ trial of concurrent temozolomide and hypofractionated stereotactic radiotherapy for complex brain metastases[J]. Oncologist, 2019, 24(9):e914-e920. DOI：10.1634/theoncologist.2018-0702.

[47]MulvennaP, NankivellM, BartonR, et al. Dexamethasone and supportive care with or without whole brain radiotherapy in treating patients with non-small cell lung cancer with brain metastases unsuitable for resection or stereotactic radiotherapy (QUARTZ)：results from a phase 3, non-inferiority, randomised trial[J]. Lancet, 2016, 388(10055):2004-2014. DOI：10.1016/S0140-6736(16)30825-X.

[48]GondiV, PughSL, TomeWA, et al. Preservation of memory with conformal avoidance of the hippocampal neural stem-cell compartment during whole-brain radiotherapy for brain metastases (RTOG 0933)：a phase Ⅱ multi-institutional trial[J]. J Clin Oncol, 2014, 32(34):3810-3816. DOI：10.1200/JCO.2014.57.2909.

[49]BrownPD, GondiV, PughS, et al. Hippocampal avoidance during whole-brain radiotherapy plus memantine for patients with brain metastases：phase Ⅲ trial NRG oncology CC001[J]. J Clin Oncol, 2020, 38(10):1019-1029. DOI：10.1200/JCO.19.02767.

[50]YangJJ, ZhouC, HuangY, et al. Icotinib versus whole-brain irradiation in patients with EGFR-mutant non-small-cell lung cancer and multiple brain metastases (BRAIN)：a multicentre, phase 3, open-label, parallel, randomised controlled trial[J]. Lancet Respir Med, 2017, 5(9):707-716. DOI：10.1016/S2213-2600(17)30262-X.

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