目的:研究宫颈癌图像引导调强放射治疗(image guided radiation therapy,IGRT)同步剂量补偿腔内后装治疗(intracavitary brachytherapy,ICBT)中膀胱、直肠、高危临床靶区(high risk clinical target volume,HRCTV)和中危临床靶区(intermediate risk clinical target volume,IRCTV)体积对器官受照剂量的影响.方法:回顾性分析64例根治性宫颈癌患者数据,每位患者至少接受了2次IGRT+ICBT,处方剂量HRCTV D90％=600 cGy,IRCTV D90％=500 cGy,分别按照膀胱、直肠、HRCTV、IRCTV的体积将患者数据分为高、低两组,统计这两组数据的靶区Dmin、D90％,危及器官的热点剂量(D0.1cm3、D1cm3和D2cm2)和D50％,采用统计学软件分析器官体积对剂量分布的影响.结果:靶区的Dmin和D90％均不受膀胱、直肠体积的影响.增加膀胱体积会明显地增加膀胱的热点剂量,但是未明显降低膀胱D50％.膀胱体积的改变不影响直肠的受照剂量.小肠的受照剂量随着膀胱体积的增加而减小.高体积组直肠的热点剂量明显高于低体积组(P<0.001),不过两组之间直肠D50％的改变不明显.增加靶区的体积并不会明显降低靶区的最小剂量Dmin,随着靶区体积的增加,膀胱、直肠的D50％都有显著增加.结论:宫颈癌IGRT+ICBT治疗中膀胱体积增大会增加膀胱的热点剂量,但可以降低小肠的热点剂量,建议根据不同患者保护不同器官的需要,选择合适的膀胱充盈程度.直肠应始终处于排空状态,以减小直肠所受的照射剂量.

目的 比较分析Ⅱb～Ⅲb期宫颈癌腔内联合宫旁插植近距离治疗计划中的3种优化方法的剂量学差异.方法 选取Ⅱb～Ⅲb期宫颈癌患者33例,对每例患者制订3种计划,分别为手动优化组、模拟退火逆向计划优化算法(IPSA)组、混合逆向计划优化算法(HIPO)组.比较3组计划中高危临床靶区(HR-CTV)的体积剂量参数V150、V100、D100、D90、均匀性指数(HI),以及危及器官(直肠、膀胱、乙状结肠)的剂量参数D0.1 cm3、D1 cm3、D2 cm3.结果 IPSA组和HIPO组的V150、V100均低于手动优化组,HI均高于手动优化组,HIPO组的V100高于IPSA组,差异均有统计学意义(P﹤0.05).IPSA组和HIPO组直肠、膀胱、乙状结肠的D0.1 cm3、D1 cm3和D2 cm3均低于手动计划组,差异均有统计学意义(P﹤0.05);HIPO组直肠、膀胱的D0.1 cm3、D1 cm3和D2 cm3均低于IPSA组,差异均有统计学意义(P﹤0.05).结论 对于局部晚期宫颈癌腔内联合宫旁插植技术,基于3组优化方法的计划均能满足临床需求.HIPO计划和IPSA计划能提高靶区剂量覆盖;HIPO计划较IPSA计划可以进一步提高靶区的V100和HI指数,同时减少膀胱和直肠的受量.

目的:探讨注射聚乙二醇重组人粒细胞集落刺激因子(PEG-rhG-CSF)治疗宫颈癌化疗所致中性粒细胞减少症的有效性和安全性.方法:筛选2016年1月-2018年12月来甘肃省肿瘤医院进行宫颈癌治疗的女性患者162例,随机分成对照组和治疗组.对照组79例,平均年龄为(38.7±3.6)岁;治疗组83例,平均年龄为(41.2±4.3岁).2组皆进行同步放化疗,对照组患者化疗24 h注射重组人粒细胞集落刺激因子(rhG-CSF),治疗组患者化疗24 h后注射聚乙二醇重组人粒细胞集落刺激因子(PEG-rhG-CSF);2组患者化疗后定期复查血常规,检查骨髓抑制差异、中性粒细胞绝对值随时间变化差异、化疗延迟率及不良反应发生率.结果:治疗组给药后12～144 h中性粒细胞数与增殖率,化疗第一周期中性粒细胞数减少、白细胞减少方面均有显著差异(P＜0.05);治疗组中性粒细胞数绝对值在不同时间点高于对照组,在给药第5、10天有显著性差异(P＜0.05);另外治疗组的化疗延迟人数少于对照组(P＜0.05);2组不良反应无显著差异(P＞0.05).结论:PEG-rhG-CSF在治疗宫颈癌同步放化疗中有较好的疗效和安全性.

目的 探讨腔内联合宫旁插植治疗(IC/ISBT)和腔内后装治疗(ICBT)对局部晚期宫颈癌的临床疗效.方法 选取经体外照射放疗(50 Gy/25 f)后肿瘤消退不明显且宫旁受侵的局部晚期(ⅡB～ⅢB期)宫颈癌患者100例.采用随机数字表法将患者分为ICBT组和IC/ISBT组,每组50例.然后进行CT,将图像传至Oncentra Brachy Therapy计划系统,行靶区勾画,采用模拟退火逆向优化方式进行计划设计,比较ICBT组和IC/ISBT组患者的近期疗效、肿瘤复发或转移率、并发症发生率.结果 IC/ISBT组患者的完全缓解(CR)率为96.0％,高于ICBT组的88.0％,差异有统计学意义(P﹤0.05);IC/ISBT组患者的客观缓解率(ORR)为98.0％,高于ICBT组的92.0％,差异有统计学意义(P﹤0.05).IC/ISBT组患者的肿瘤复发或转移率为4.0％,低于ICBT组的16.0％,差异有统计学意义(P﹤0.05).IC/ISBT组患者放射性皮炎的发生率为38.0％,与ICBT组的42.0％比较,差异无统计学意义(P﹥0.05);IC/ISBT组患者放射性直肠炎的发生率为14.0％,低于ICBT组的32.0％,差异有统计学意义(P﹤0.05);IC/ISBT组患者放射性膀胱炎的发生率为30.0％,与ICBT组的28.0％比较,差异无统计学意义(P﹥0.05).结论 对外照射后肿瘤消退不明显、宫旁受侵的局部晚期宫颈癌患者采用IC/ISBT治疗方式,可取得较好的宫旁控制率和近期疗效,且能够降低放射性直肠炎的发生率,值得临床推广应用.

目的 比较局部晚期宫颈癌三维近距离治疗3D打印阴道多通道个体化施源管与常规施源器剂量学差异,观察疗效及毒副反应.方法 50例初治局部晚期宫颈癌行近距离根治性放射治疗,其中25例患者行3D打印多通道施源器(3DP-ISBT组),25例患者采用传统施源管(ICBT组).比较2组患者的HR-CTV剂量分布,评价危及器官的剂量分布、近期疗效与毒副反应.结果 3DP-ISBT、ICBT组近距离HR-CTV D90分别为(87±7)、(76±16)Gy.组间比较,3D打印多通道个体化施源管较常规施源器剂量分布更合理,且差异有统计学意义(P＜0.05).膀胱D2cc3DP-ISBT组为(81±8)Gy,ICBT组为(86±17)Gy;直肠D2cc3DP-ISBT组为(72±10)Gy,ICBT组为(79±14)Gy.组间比较,3D打印多通道个体化施源管患者放射性膀胱炎及放射性直肠炎发生率均低于常规施源器,且差异均有统计学意义(P＜0.05).结论 3D打印个体化施源管与传统常规施源器行腔内放射治疗相比剂量分布更加合理,降低正常组织受量有明显优势,具有疗效好、毒副反应轻的特点.

比较宫颈癌近距离治疗中肿块体积在50～90 cm3之间,应用3D打印阴道模型塞插植治疗与常规三维腔内治疗的剂量学差异,研究3D打印阴道模型塞应用在大肿块宫颈癌近距离治疗中的可行性,为临床应用提供参考.收集甘肃省肿瘤医院放疗科2017年5月至2019年5月收治的宫颈癌患者行近距离放射治疗,肿块体积在50～90 cm3之间的患者27例,其中14例患者在近距离治疗中行3D打印阴道模型塞插植治疗(3D printing interstitial BT,3DP-ISBT),另13例行常规三维腔内治疗(Intracavitary BT,ICBT).在高危临床靶区(HR-CTV)处方剂量为6 Gy的情况下,评估HR-CTV体积大小,HR-CTV的D90(90％体积接收到的最低吸收剂量)、膀胱、直肠的剂量学差异.与ICBT组相比,3DP-ISBT组HR-CTV的体积及D90、直肠大于1 cm3、2 cm3、3 cm3体积接收到的吸收剂量D1cc、D2cc和D3cc均无统计学差异(p>0.05).膀胱的D1cc、D2cc和D3cc低于ICBT组,有统计学差异(p<0.05).宫颈癌近距离治疗中肿块体积在50～90 cm3之间应用3DP-ISBT技术在剂量学上能够满足临床要求,与ICBT技术相比能更好地保护膀胱,在直肠的保护上未显示出优势.

目的:探讨组织间插植在宫颈残端癌、阴道残端复发癌放疗中的近期疗效.方法:对35例诊断明确的宫颈残端癌、阴道残端复发癌行组织间插植放疗联合经典的体外照射及近距离腔内照射的模式,观察近期疗效及不良反应.结果:35例宫颈残端癌、阴道残端复发癌放疗结束评价疗效,达到完全缓解30例患者(85.7％),部分缓解5例患者(14.3％),治疗有效率可达100％.观察不良反应:35例患者均出现了不同程度的骨髓抑制,其中30例患者(85.7％)出现1～3级骨髓抑制,5例患者(14.3％)出现3～4级骨髓抑制.22例患者(62.9％)出现1～3级急性放射性直肠炎症状,15例患者(42.9％)出现1～3级急性放射性膀胱炎症状,但未出现3级以上的急性放射性副反应.结论:组织间插植对于宫颈残端癌、阴道残端复发癌是一种有效的治疗方式,可明显提高局部控制率高、完全缓解率、部分缓解率,且无严重的近期不良反应发生,具有很好的治疗可行性,相对安全可靠.

探讨局部外生型宫颈癌组织间插植近距离放射治疗疗效及不良反应。随机选取非手术大肿块宫颈癌病例53例作为盆腔外照射和腔内后装放疗联合宫旁插植放疗，剂量800~1000cGy/次，共1~2次。对照组60例行盆腔外照射和单纯腔内后装放疗。剂量500cGy/4~6次。对比观察两组1、3年期的治疗效果、副反应及耐受性。所有患者都按计划完成了治疗，宫颈插植组和对照组的局控率分别为96.7%、76.7%，差异有统计学意义(P<0．05)；治疗副反应及并发症少见。宫颈插植放疗是一种安全、有效的治疗方法，能明显提高Ⅱb、IIIb期宫颈癌患者治疗效果，且不增加毒副反应。

Objective:To explore the occurrence of radiation proctitis after-loading brachytherapy of cervical cancer patients byimproved vaginal packing technology. Methods: A retrospective analysis on 76 patients with cervical squamous cell carcinoma in our department from 2005 to 2008 were treated with IIb 192Ir high dose rate intracavitary after-loading radiotherapy process and improved vaginal packing method in which all patients were randomly divided into accordion-style vaginal packing group(40 cases) and the control group (36 cases conventional saline gauze packing 4~5 blocks) . Short-term effect was evaluated by RECIST criteria, and adverse events were evaluated by NCI CTC3.0 criteria. Results: All the patients were followed up for 36 months in which follow-up rate was more than 88.16%. In observation group (accordion-style vaginal packing group of 40 patients),complete remission was 20(50.00%) cases, partial remission was 17(42.50%) patients, stable disease was 2(5.00%) cases,disease progression was 1(2.50%) case, objective efficiency(RR) was 90.00%. In control group, RR was 88.89%, and there was no significant difference in short-term effect rate(P0.05). Proctitis incidence of the two groups was respectively 10.00% and 11.11% in grade I, II grade of 2.50% and 2.78% in the observation group. Proctitis of III and IV grade level did not occur in the observation group, III,IV levels was respectively 5.56 % and 2.78% in control group, and the overall incidence of proctitis in two groups was respectively 12.50% and 22.22%(P0.05). Conclusion: Accordion-style vaginal packing technology can ensures Yindao Yuan and intrauterine source of cloth source rationality, and can be worthy of wider application,which not only improves the gain ratio of tumor treatment, but also reduce the rectal dose .

Objective To investigate the radical feasibility and clinical advantages of three-dimensional conformal radiotherapy in treating cervical cancer.Methods 90 cases of cervical cancer were selected and they were divided into observation group with 46 cases for three-dimensional conformal radiotherapy and control group with 44 for conventional radiotherapy.A comprehensive evaluation was made to judge the clinical efficacy,treatment side effects,quality of life and etc for two treatment options.Results The 2-year survival and local control rates for both groups were 100%.But there were difference in adverse reactions:the observation group's response rates to the rectum,bladder reaction were lower than those of the control group,and the difference was statistically significant(P0.05).Conclusion Although the overall curative effect between three-dimensional conformal radiotherapy and conventional radiotherapy is similar and has no difference in statistically significance,the treatment of the former can reduce the incidence of rectal and severity of reaction,and can improve the patients' quality of life.

目的:宫颈癌腔内放疗时采用超分割的治疗模式,探讨其方法的可行性。方法:体外放疗+腔内放疗:体外照射采用西门子加速器6MV-X线,全盆腔前后2野等中心技术照射,DT=2Gy(/次·d),5次/周,总剂量DT:46-50Gy(/25次·5周),外照射全盆腔剂量DT=30Gy/15次时盆腔中央挡铅(中央遮挡铅块5HVL,4cm宽)并开始配合腔内近距离治疗,采用铱-192高剂量率后装治疗机,Ⅱb,Ⅲ期A点4Gy/次,2次/d,两次间隔≥6h,每5d重复治疗1次,总计10次/5d,在3-4周内完成,A点剂量DT=40Gy。腔内照射当天不做体外照射。结果:近期有效率(CR+PR)Ⅱ期、Ⅲ期均为100%。1年生存率Ⅱ期100%(12/12),Ⅲ期95%(19/20)。放射性直肠炎、膀胱炎的发生率分别为12.50%(4/32)和6.25%(2/32)。结论:该方法可行,近期疗效满意。HDR腔内后装治疗宫颈癌,应用足够的分割(包括次数及剂量)是提高疗效、减少晚期并发症的关键,但晚反应组织损伤、远期生存率尚有待进一步随访及评诂。

Objective To explore the possibility and biological effect in clinic by applying unconventional fractionation of intracavitary brachytherapy.Methods In vitro radiotherapy + high dose rate brachytherapy(HDR) cavity radiotherapy were applied in the treatment:the accelerator 6 MV-X lines by Simens were used in vitro illumination;around entire pelvic cavity 2 wilds central technology illuminations etc were also used;integral dose was 46-50 Gy,23-25 fractions, for 5 weeks.When external irradiation entire pelvic cavity dosage was 30 Gy,15 fractions the pelvic cavity central kept off the lead(4 cm×10 cm) and started to work in short-distance cavity treatment.The ~(192)Ir high dose rate breech loading therapeutic equipment was used,without cavity internal radiation in vitro illumination at the same day.In the HDR cavity the ultra division group:point A(Ⅱb,Ⅲ) received 4 Gy perfraction,twice daily of intracavitary irradiation at point A.The intrafraction interval was more than 6 hours daily.The total dose at point A was 40 Gy in 10 fractions,5 days,3-4 weeks.In HDR cavity conventional division group:point A(Ⅱb,Ⅲ) received 6 Gy perfraction.The total dose at point A was 36 Gy in 6 fractions,6 days,6 weeks. Results By the end of radiotherapy,local control of 24 patients complete remission + partial remission was 100%and the control was 95.83%after a year.Early vagina reaction was:Ⅰdegree for 10 cases,Ⅱdegree for 11 cases andⅢdegree for 3 cases.The reaction did not cause any break-up of treatment.Conclusion Enough fractionation including fraction number and dose perfraction are very important to improve the treatment effect and decrease the later complications of the HDR intracavitary brachytherapy for cervix carcinoma.The method is applicable because of its satisfactory early effects.Further follow-up is needed to evaluate its survival rate as well as later tissue injury.

目的:探讨肿瘤合并糖尿病患者放疗同步射频热疗的适宜温度。方法:选择2008年3月至2009年10月间我科收治的肿瘤患者41例;除行常规放疗外,同时给予射频热疗,2次/周,温度范围为39℃～42℃,时间为升至要求温度后持续40min。通过观察热分布范围皮肤反应状况,调节和选择适宜热疗温度,重点跟踪观察肿瘤合并糖尿病患者的热分布范围皮肤反应状况,调节和选择适宜热疗温度。结果:单纯肿瘤患者的射频治疗温度范围为39℃～42℃;肿瘤合并糖尿病患者的射频治疗温度范围为39℃～40℃。结论:在适宜温度范围,肿瘤合并糖尿病患者也可行放疗同步射频热疗。

Objective:To explore the contrast-enhanced ultrasound evaluation of the clinical efficacy after radical radiotherapy of cervical cancer. Methods: More non-surgical phase IIb cervical cancer in 30 cases of squamous cell carcinoma patients given radical radiotherapy before and after ultrasound contrast set since June 2008 to August 2011 for the study group,the radical radiotherapy of 30 cases over the same period of cervical cancer before and after.The conventional ultrasound set control group,the study group and the control group in conjunction with cytology,cervical smears common residual tumor were compared cervix situation. Results:The results of the study group,tumor necrosis, liquefaction of 16( 53%) ,tumor inactivated 7( 23%) , cervical partial abnormal contrast agent Kuaijinkuaichu to show that the tumor residues in 7( 23%) . The same group of cervical smear cytology to see cancer 2( 6%) after radiotherapy two methods detected residual tumor more significant difference( P0.05) .Conclusion: Ultrasound Contrast-enhanced dynamic observed within the residual tumor and tumor number of peripheral vascular and its distribution,additional local intracavitary radiotherapy dose,location,as well as evaluating the prognosis objective theoretical basis.

目的:对妇科肿瘤近距离放疗填塞方法进行改进,杜绝纱布块的体内遗留。方法:自2005年3月起将我科妇科肿瘤患者行近距离放疗时的传统纱布块填塞模式改用自制手风琴式纱布条填塞。结果:使用改进填塞模式后,3246人次妇科肿瘤患者填塞物的清理快捷,无1例出现填塞物遗留体内现象。结论:该方法可用于妇科肿瘤患者行近距离放疗的填塞,值得推广。

目的:观察薄芝糖肽联合同步放化疗治疗中晚期宫颈癌的疗效。方法:70例中晚期宫颈癌患者随机分成两组:研究组34例,同步放化疗治疗同时联合薄芝糖肽,10mg/d,静滴,连续7周。对照组36例,单纯同步放化疗。两组放化疗方案均相同。评价治疗前后两组血液学毒性变化、患者生活质量及肝脏功能变化情况。结果:研究组血液学指标(白细胞、血红蛋白、血小板)在治疗前后无明显变化(P>0.05),而对照组的血液学指标在治疗后却明显下降,与治疗前相比差异有统计学意义(P<0.05)。两组治疗后血液学变化比较差异有统计学意义(P<0.05)。研究组患者的临床症状在治疗后明显改善,生活质量明显提高,与对照组比较差异有统计学意义(P<0.05)。研究组治疗后生活质量较治疗前比较,差异有统计学意义(P<0.05),生活质量有明显提高。两组患者肝脏功能情况在治疗前后无明显变化。结论:薄芝糖肽不仅可以有效预防同步放化疗后血血液学指标的下降,还可以明显改善患者的全身状况、提高患者的生活质量,且没有出现明显的肝脏功能损害情况。

恶性肿瘤现已成为威胁人类健康,导致死亡的最主要疾病之一。现代西医治疗肿瘤公认的手术、放疗、化疗三大手段在抑制肿瘤细胞增殖的同时却损伤了正气,对机体正常组织细胞和免疫功能具有不同程度的破坏。临床实践表明,肿瘤的生长速度是可变的,有效的治疗不一定让肿瘤全部消失;以前医学界一味重视杀灭肿瘤细胞,试图通过扩大根治术,大剂量化疗来提高疗效,但事与愿违;过度的攻击性治疗不但没有起到延长生存期的作用,反而降低了患者的生活质量,个人和社会都未能从治疗中受益。本文简要阐述了扶正培本、补肾健脾及辨证施治等基础治疗在抗肿瘤治疗中发挥的独特作用。

宫颈癌是仅次于乳腺癌的第二妇女常见肿瘤,我国每年新发病例13.15万人,死亡率高,甘肃、陕西、山西、安徽是患病率最高省份,农村高于城市.是严重威胁妇女生命的恶性肿瘤[1].宫颈癌的治疗原则:Ⅰb期以前的早期癌:手术和放疗均可,疗效相同;Ⅱ-Ⅲ期:以放疗为主;Ⅲ-Ⅳ期:以放疗+化疗为主.在放疗期间皮肤黏膜放射性损伤给患者造成严重的精神及生理上的痛苦,总结在我科在护理过程中的护理体会现报告如下,参照皮肤黏膜放射性损伤的分级标准[2].

目的:探讨中晚期宫颈癌同步放化疗的耐受性和毒副反应。方法:2004年2005年我院开展了中晚期宫颈癌同步放化疗治疗患者54例,组织学类型为鳞癌81.48%(44/54),腺癌18.51%(10/54),Ⅱb期34例,Ⅲ期18例,Ⅳ期2例。全部病例采用体外照射和腔内近距离照射的联合放疗方案,同步应用DF化疗方案。体外照射采用6MV-X线,前后野对穿照射,常规分割每周5次,每次2Gy,外照射全盆腔剂量24Gy~30Gy/2W~3W,盆腔野挡铅4×10 cm~17 cm,加腔内近距离治疗。腔内近距离治疗每次A点剂量5Gy~6Gy,腔内照射当日不作体外照射,共5次~7次,腔内照射A点总量25Gy~42Gy。体外和腔内照射A点总量为70Gy~82Gy,B点总剂量50Gy~70Gy,总疗程6周~8周。与放化疗开始之日常规应用升白胺3片,3次/天,至疗程结束。结果:达CR者49/54(90.74%),PR者5/54(9.25%)。放疗结束宫颈刮片阴性52/54(96.29%)。本组病例治疗后均满2年,2年总生存率77.78%。本组宫颈癌患者同步放化疗副反应主要为肠道反应、泌尿系统反应、血液学毒性。急性放射性直肠反应全组发生率为46.30%(25/54),其中18例(72%)为轻度,7例(24%)为中度,全组病例无直肠阴道瘘发生。血液学毒性主要表现为白细胞下降,RTO G1级9例(16.67%),RTO G2级5例(9.25%),无3级以上毒性反应。结论:中晚期宫颈癌同步放化疗具有较好的临床耐受性,两年生存率达77.78%。通过改进外照射方式(如IMRT),降低单次腔内治疗剂量(小于6Gy),将会减轻肠道副反应。