-
行乳腺癌改良根治术的高危患者最常见的复发部位依次为胸壁、锁骨上下区、腋窝和内乳,因此胸壁和锁骨上下区为术后放疗常规照射部位[1]。乳腺癌患者行全乳切除术后胸壁较薄,在进行术后放疗时,通常对胸壁采用电子线照射,对锁骨上下区应用X射线照射,该放疗方式涉及到照射野的布野以及射野衔接问题。合理的体位设计能够保证混合射线照射野的布置,稳定的体位固定能够保证射野衔接处剂量分布的准确性,减小摆位误差,提高放疗位置的准确性。本研究回顾性分析采用两种装置(头颈肩热塑网罩和颈胸一体热塑体膜)固定患者的锁骨上下区的摆位误差和肩锁关节的位置移动,比较两种不同固定方式的优势。
-
由表1可知,颈胸一体膜组在头脚方向的平移摆位误差和矢状面的旋转摆位误差的差异均有统计学意义(均P<0.05)。
组别 平移摆位误差(mm) 旋转摆位误差(度) 左右方向 头脚方向 腹背方向 矢状面 横断面 冠状面 头颈肩网罩组
(n=19)1.78±2.40 2.88±2.44 2.48±1.79 0.91±0.61 1.69±0.70 1.02±0.82 颈胸一体膜组
(n=21)2.26±1.91 2.29±1.89 1.66±2.00 0.67±0.53 0.92±0.75 0.75±0.71 t值 0.687 2.249 0.998 3.555 0.288 0.303 P值 0.496 0.030 0.325 0.001 0.776 0.763 注:∑为系统摆位误差(个体患者误差平均值的标准差);σ为随机摆位误差(个体患者误差标准差的均方根) 表 1 2组不同固定方式放疗患者锁骨上下区的平移和旋转摆位误差结果(∑±σ)
Table 1. Translation and rotation positioning errors of supra/infraclavicular of two groups of patients received radiotherapy with different fixation methods(∑±σ)
头颈肩网罩组和颈胸一体膜组在3个方向的平移摆位误差区间分布情况见图3~5。头颈肩网罩组和颈胸一体膜组在左右方向X、头脚方向Y、腹背方向Z平移摆位误差<3 mm的百分比分别为66.4%、57.0%、68.8%和67.1%、53.1%、73.4%,<5 mm的百分比分别为90.6%、81.3%、89.8%和89.5%、87.4%、93.0%;在矢状面、横断面、冠状面的旋转误差<1°的百分比分别为42.2%、43.0%、50.8%和74.8%、58.7%、67.8%,<2°的百分比分别为77.3%、64.8%、86.7%和97.2%、88.8%、93.7%。
图 3 2组不同固定方式放疗患者左右方向X平移误差的分布图
Figure 3. Distribution of translational errors of two groups of patients received radiotherapy with different fixation methods in left and right direction X
-
头颈肩网罩组和颈胸一体膜组在左右方向X、头脚方向Y、腹背方向Z的位置移动幅度Δ X 、Δ Y 、Δ Z的平均值分别为3.65、4.61、3.11 mm和2.32、1.97、1.63 mm,三维空间位移d的平均值分别为7.36 mm和4.03 mm;在3个方向的最大位置移动幅度分别为14、20、13 mm和9、9、9 mm,最大三维空间位移分别为21.5 mm和15.0 mm。肩锁关节位置移动幅度及三维空间位移分布见图6。头颈肩网罩组的肩锁关节位置移动幅度ΔX、ΔY、ΔZ<10 mm的百分比分别为96.1%、88.3%、96.9%,<4 mm的百分比分别为55.5%、50.0%、67.2%;颈胸一体膜组的肩锁关节位置移动幅度ΔX、ΔY、ΔZ<6 mm的百分比分别为90.2%、93.7%、91.6%,<2 mm的百分比分别为45.5%、49.0%、66.4%。头颈肩网罩组和颈胸一体膜组的肩锁关节三维空间位移d<14 mm的百分比分别为89.1%和99.3%,d<10 mm的百分比分别为73.4%和93.0%,d<6 mm的百分比分别为46.9%和79.0%。
-
由表2可知,BMI<24 kg/m2组和BMI≥24 kg/m2组患者在3个方向的平移和旋转摆位误差的差异均无统计学意义(均P>0.05)。
组别 平移摆位误差(mm) 旋转摆位误差(度) 左右方向 头脚方向 腹背方向 矢状面 横断面 冠状面 BMI<24组
(n=13)2.29±1.94 2.53±1.98 2.51±1.94 0.79±0.54 1.56±0.61 0.86±0.74 BMI≥24组
(n=27)1.92±2.24 2.87±2.25 1.91±1.89 1.01±0.58 1.20±0.77 0.89±0.78 t值 −0.439 0.478 0.218 0.938 −1.085 −1.103 P值 0.663 0.635 0.829 0.354 0.285 0.277 注:BMI为体重指数;∑为系统摆位误差(个体患者误差平均值的标准差);σ为随机摆位误差(个体患者误差标准差的均方根) 表 2 2组不同BMI放疗患者在3个方向的平移和旋转摆位误差(∑±σ)
Table 2. Setup errors of translation and rotation in three directions between the two groups of patients received radiotherapy with different body mass index(∑±σ)
-
头颈肩网罩组和颈胸一体膜组在左右方向X-sc、头脚方向Y-sc和腹背方向Z-sc的PTV外放边界值分别为6.1、8.9、7.5 mm和7.0、7.0、5.5 mm。
乳腺癌改良根治术后放疗两种固定方式在锁骨上下区摆位误差的比较
Comparison of the setup errors of two mask systems for immobilizing supra/infraclavicular nodal region of breast cancer patients received postmastectomy radiotherapy
-
摘要:
目的 比较使用头颈肩热塑网罩和颈胸一体热塑体膜固定的乳腺癌改良根治术后放疗患者锁骨上下区的摆位误差。 方法 回顾性分析2019年6至12月中国医学科学院北京协和医学院肿瘤医院放疗科收治的40例女性乳腺癌改良根治术后患者[中位年龄46(29~68)岁]的锁骨上下区靶区的锥形束CT(CBCT)图像,其中19例使用头颈肩热塑网罩进行体位固定(头颈肩网罩组,128次CBCT图像),21例使用颈胸一体架膜进行体位固定(颈胸一体膜组,143次CBCT图像)。分析2组患者锁骨上下区的摆位误差,并分别测量肩锁关节的位置移动幅度ΔX、ΔY、ΔZ和三维空间位移d。应用公式计算临床靶区至计划靶区(PTV)的外放边界值。将所有患者分成体重指数(BMI)<24 kg/m2组(13例,86次CBCT扫描)和BMI≥24 kg/m2组(27例,185次CBCT扫描),分析比较2组的摆位误差。2组之间的比较采用独立样本t检验。 结果 头颈肩网罩组和颈胸一体膜组在锁骨上下区的平移摆位误差分别为左右方向:(1.78±2.40) mm和(2.26±1.91) mm(t=0.687,P=0.496)、头脚方向:(2.88±2.44) mm和(2.29±1.89) mm(t=2.249,P=0.030)、腹背方向:(2.48±1.79) mm和(1.66±2.00) mm(t=0.998,P=0.325);在矢状面的旋转摆位误差分别为(0.91±0.61)度和(0.67±0.53)度,差异有统计学意义(t=3.555,P=0.001)。头颈肩网罩组和颈胸一体膜组在肩锁关节的位置移动幅度ΔX、ΔY、ΔZ的平均值分别为3.65、4.61、3.11 mm和2.32、1.97、1.63 mm,三维空间位移d的平均值分别为7.36 mm和4.03 mm。头颈肩网罩组和颈胸一体膜组锁骨上下区在左右方向、头脚方向和腹背方向的PTV外放边界值分别为6.1、8.9、7.5 mm和7.0、7.0、5.5 mm。BMI<24 kg/m2组和BMI≥24 kg/m2组患者在3个方向的平移和旋转摆位误差的差异均无统计学意义(t=−1.103~0.938,均P>0.05)。 结论 对于乳腺癌改良根治术后行锁骨上下区放疗的患者,相比头颈肩网罩固定,使用颈胸一体膜固定在头脚方向的摆位误差更小,而且对肩锁关节的体位固定效果更优。 -
关键词:
- 乳腺肿瘤 /
- 乳房切除术,改良根治性 /
- 放射疗法,计算机辅助 /
- 体位固定 /
- 摆位误差
Abstract:Objective To compare the setup errors of breast cancer patients who received postmastectomy radiotherapy (PMRT) with head/neck and shoulder thermoplastic mask and integral cervicothoracic mask. Methods A retrospective analysis was performed on 40 female breast cancer patients (median age 46 (29–68) years) who treated with PMRT in Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College from June to December 2019. The supra/infraclavicular nodal region was irradiated with intensity-modulated radiotherapy technique and chest wall ± internal mammary chain were irradiated with electrons. A total of 271 cone beam CT (CBCT) images of the supra/infraclavicular nodal region were analyzed retrospectively. One hundred and twenty eight CBCT images were from 19 patients immobilized with head/neck and shoulder thermoplastic mask, and 143 CBCT images were from 21 patients immobilized with integral cervicothoracic thermoplastic mask. The setup errors of the two groups were analyzed, and the movement amplitude ΔX, ΔY, ΔZ and three-dimensional displacement d of acromioclavicular joint were measured. According to van Herk's formula, MPTV=2.5∑+0.7σ, the margin from clinical target volume to planning target volume (PTV) is calculated. According to whether body mass index (BMI)≥24 kg/m2, the patients were divided into two groups to analyze whether there was statistical difference of the setup errors. The differences were compared by independent sample t test. Results The translational setup errors of the supra/infraclavicular nodal region for head/neck and shoulder and integral cervicothoracic thermoplastic mask groups in the left–right, superior–inferior, and anterior–posterior directions were as follows: (1.78±2.40) mm and (2.26±1.91) mm (t=0.687, P=0.496); (2.88±2.44) mm and 2.29±1.89 mm (t=2.249, P=0.030); (2.48±1.79) mm and (1.66±2.00) mm (t=0.998, P=0.325), respectively; the rotational setup errors in the sagittal directions were (0.91±0.61)° and (0.67±0.53)°, and the difference was statistically significant (t=3.555, P=0.001). The arithmetic mean of movement amplitude of the acromioclavicular joint ( ΔX, ΔY, and ΔZ ) were 3.65, 4.61, 3.11 mm and 2.32, 1.97, 1.63 mm in the X, Y, and Z directions, respectively. The arithmetic mean of three-dimensional displacement d were 7.36 mm and 4.03 mm, respectively. The calculated PTV margin in the left–right, superior–inferior, and anterior–posterior directions with head/neck and shoulder and integral cervicothoracic mask groups were 6.1, 8.9, and 7.5 mm and 7.0, 7.0, and 5.5 mm, respectively. No significant difference was found between the BMI<24 and BMI≥24 kg/m2 groups in translation and rotation setup errors in the three directions (t=−1.103 to 0.938, all P>0.05). Conclusions The integral cervicothoracic mask system for patients who received PMRT in the supra/infraclavicular nodal region after the modified radical mastectomy provides smaller setup errors than the head and neck–shoulder thermoplastic mask system in the superior–inferior direction. This system also has remarkable body position fixation effects on the acromioclavicular region. -
表 1 2组不同固定方式放疗患者锁骨上下区的平移和旋转摆位误差结果(∑±σ)
Table 1. Translation and rotation positioning errors of supra/infraclavicular of two groups of patients received radiotherapy with different fixation methods(∑±σ)
组别 平移摆位误差(mm) 旋转摆位误差(度) 左右方向 头脚方向 腹背方向 矢状面 横断面 冠状面 头颈肩网罩组
(n=19)1.78±2.40 2.88±2.44 2.48±1.79 0.91±0.61 1.69±0.70 1.02±0.82 颈胸一体膜组
(n=21)2.26±1.91 2.29±1.89 1.66±2.00 0.67±0.53 0.92±0.75 0.75±0.71 t值 0.687 2.249 0.998 3.555 0.288 0.303 P值 0.496 0.030 0.325 0.001 0.776 0.763 注:∑为系统摆位误差(个体患者误差平均值的标准差);σ为随机摆位误差(个体患者误差标准差的均方根) 表 2 2组不同BMI放疗患者在3个方向的平移和旋转摆位误差(∑±σ)
Table 2. Setup errors of translation and rotation in three directions between the two groups of patients received radiotherapy with different body mass index(∑±σ)
组别 平移摆位误差(mm) 旋转摆位误差(度) 左右方向 头脚方向 腹背方向 矢状面 横断面 冠状面 BMI<24组
(n=13)2.29±1.94 2.53±1.98 2.51±1.94 0.79±0.54 1.56±0.61 0.86±0.74 BMI≥24组
(n=27)1.92±2.24 2.87±2.25 1.91±1.89 1.01±0.58 1.20±0.77 0.89±0.78 t值 −0.439 0.478 0.218 0.938 −1.085 −1.103 P值 0.663 0.635 0.829 0.354 0.285 0.277 注:BMI为体重指数;∑为系统摆位误差(个体患者误差平均值的标准差);σ为随机摆位误差(个体患者误差标准差的均方根) -
[1] 王淑莲, 李晔雄, 宋清坤, 等. 1999−2008年中国乳腺癌根治术后放疗部位变化的临床流行病学研究[J]. 中华放射肿瘤学杂志, 2013, 22(5): 347−351. DOI: 10.3760/cma.j.issn.1004-4221.2013.05.002.
Wang SL, Li YX, Song QK, et al. Changes in postmastectomy radiotherapy targets among breast cancer patients in China from 1999 to 2008: an epidemiological study[J]. Chin J Radiat Oncol, 2013, 22(5): 347−351. DOI: 10.3760/cma.j.issn.1004-4221.2013.05.002.[2] 国家肿瘤诊疗质控中心放疗质控专家委员会, 赫捷, 王绿化, 等. 放射治疗质量控制基本指南[J]. 中华放射肿瘤学杂志, 2018, 27(4): 335−342. DOI: 10.3760/cma.j.issn.1004-4221.2018.04.001.
Comittee of Quality Control in Radiotherapy, National Cancer Diagnosis and Treatment Quality Control Center, He J, Wang LH, et al. Basic guidelines of quality control for radiotherapy[J]. Chin J Radiat Oncol, 2018, 27(4): 335−342. DOI: 10.3760/cma.j.issn.1004-4221.2018.04.001.[3] 国际生命科学学会中国办事处中国肥胖问题工作组联合数据汇总分析协作组, 陈春明. 中国成人体质指数分类的推荐意见简介[J]. 中华预防医学杂志, 2001, 35(5): 349−350. DOI: 10.3760/j.issn.0253-9624.2001.05.019.
Joint Data Collection and Analysis Cooperation Group of Chinese Obesity Working Group of International Life Science Society China Office, Chen CM. A brief introduction to the recommendation of Chinese adult body mass index classification[J]. Chin J Prev Med, 2001, 35(5): 349−350. DOI: 10.3760/j.issn.0253-9624.2001.05.019.[4] van Herk M. Errors and margins in radiotherapy[J]. Semin Radiat Oncol, 2004, 14(1): 52−64. DOI: 10.1053/j.semradonc.2003.10.003. [5] Hugo GD, Yan D, Liang J. Population and patient-specific target margins for 4D adaptive radiotherapy to account for intra- and inter-fraction variation in lung tumour position[J]. Phys Med Biol, 2007, 52(1): 257−274. DOI: 10.1088/0031-9155/52/1/017. [6] 徐晓, 张敏娜, 王冰, 等. 乳腺癌保乳术后调强放疗摆位误差相关因素分析[J]. 中华放射医学与防护杂志, 2019, 39(6): 434−438. DOI: 10.3760/cma.j.issn.0254-5098.2019.06.006.
Xu X, Zhang MN, Wang B, et al. Factors associated with set-up errors in intensity-modulated radiotherapy after breast conserving surgery[J]. Chin J Radiol Med Prot, 2019, 39(6): 434−438. DOI: 10.3760/cma.j.issn.0254-5098.2019.06.006.[7] 谢涛, 许青, 彭佳元, 等. 乳腺癌胸壁野结合锁骨上野放疗时头部固定的重要性研究[J]. 中华放射肿瘤学杂志, 2018, 27(5): 500−503. DOI: 10.3760/cma.j.issn.1004-4221.2018.05.013.
Xie T, Xu Q, Peng JY, et al. Study of significance of head fixation in the chest wall field combined with supraclavicular field radiotherapy for breast cancer[J]. Chin J Radiat Oncol, 2018, 27(5): 500−503. DOI: 10.3760/cma.j.issn.1004-4221.2018.05.013.[8] 吴传锋, 吴锦昌, 顾科, 等. 利用CBCT研究乳腺托架固定下乳腺癌放疗下颈摆位误差及相应CTV外放边界[J]. 中华放射医学与防护杂志, 2016, 36(10): 753−756. DOI: 10.3760/cma.j.issn.0254-5098.2016.10.007.
Wu CF, Wu JC, Gu K, et al. Analysis of lower neck setup errors and planning target margin by CBCT for breast cancer radiation with breast bracket immobilized[J]. Chin J Radiol Med Prot, 2016, 36(10): 753−756. DOI: 10.3760/cma.j.issn.0254-5098.2016.10.007.[9] 马茗微, 王淑莲, 覃仕瑞, 等. 面罩及乳腺托架固定下乳腺癌保乳术后放疗锁骨上下区摆位误差分析[J]. 中华放射肿瘤学杂志, 2019, 28(3): 217−221. DOI: 10.3760/cma.j.issn.1004-4221.2019.03.012.
Ma MW, Wang SL, Qin SR, et al. Breast board combined with a thermoplastic head mask immobilization can improve the reproducibility of the treatment setup for breast cancer patients receiving whole breast and supraclavicular nodal region irradiation[J]. Chin J Radiat Oncol, 2019, 28(3): 217−221. DOI: 10.3760/cma.j.issn.1004-4221.2019.03.012.[10] Lee SW, Back GM, Yi BY, et al. Preliminary results of a phase Ⅰ/Ⅱ study of simultaneous modulated accelerated radiotherapy for nondisseminated nasopharyngeal carcinoma[J]. Int J Radiat Oncol Biol Phys, 2006, 65(1): 152−160. DOI: 10.1016/j.ijrobp.2005.10.040. [11] van Lin ENJT, van der Vight L, Huizenga H, et al. Set-up improvement in head and neck radiotherapy using a 3D off-line EPID-based correction protocol and a customised head and neck support[J]. Radiother Oncol, 2003, 68(2): 137−148. DOI: 10.1016/s0167-8140(03)00134-8. [12] 刘裕杰, 周莉钧, 管西寅, 等. 图像引导的放射治疗在头颈部肿瘤治疗中的应用[J]. 中国癌症杂志, 2010, 20(9): 707−711. DOI: 10.3969/j.issn.1007-3639.2010.09.014.
Liu YJ, Zhou LJ, Guan XY, et al. Application of image-guided radiotherapy in head-and-neck cancer[J]. China Oncol, 2010, 20(9): 707−711. DOI: 10.3969/j.issn.1007-3639.2010.09.014.[13] 林承光, 林刘文, 刘秉梯, 等. 鼻咽癌三维适形和调强放疗过程中头部与颈部摆位误差比较研究[J]. 中华放射肿瘤学杂志, 2011, 20(4): 322−325. DOI: 10.3760/cma.j.issn.1004-4221.2011.04.018.
Lin CG, Lin LW, Liu BT, et al. A study of the positioning errors of head and neck in the process of intensity modulation radiated therapy of nasopharyngeal carcinoma[J]. Chin J Radiat Oncol, 2011, 20(4): 322−325. DOI: 10.3760/cma.j.issn.1004-4221.2011.04.018.[14] 许森奎, 姚文燕, 胡江, 等. 鼻咽癌发泡胶个体化塑形与标准化头枕放疗体位固定精确度比较[J]. 中华放射肿瘤学杂志, 2015, 24(2): 196−199. DOI: 10.3760/cma.j.issn.1004-4221.2015.02.022.
Xu SK, Yao WY, Hu J, et al. The research of accuracy immobilized using individualized polyurethane scaling agent compared to positioning foam with standard plastics pillow in the radiotherapy of nasopharyngeal carcinoma[J]. Chin J Radiat Oncol, 2015, 24(2): 196−199. DOI: 10.3760/cma.j.issn.1004-4221.2015.02.022.[15] Batumalai V, Phan P, Choong C, et al. Comparison of setup accuracy of three different image assessment methods for tangential breast radiotherapy[J]. J Med Radiat Sci, 2016, 63(4): 224−231. DOI: 10.1002/jmrs.180. [16] 于舒飞, 王淑莲, 唐玉, 等. 乳腺托架固定下全乳调强放疗CBCT测定摆位误差的研究[J]. 中华放射肿瘤学杂志, 2019, 28(7): 532−535. DOI: 10.3760/cma.j.issn.1004-4221.2019. 07.012.
Yu SF, Wang SL, Tang Y, et al. Study of setup error in cone beam CT for whole breast intensity-modulated radiotherapy with breast board immobilization[J]. Chin J Radiat Oncol, 2019, 28(7): 532−535. DOI: 10.3760/cma.j.issn.1004-4221.2019. 07.012.