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髓母细胞瘤的放射治疗临床表现•颅内压增高头痛、呕吐、视神经乳头水肿•小脑损害躯干性共济失调为主•其它复视、面瘫、强迫头位、头颅增大、病理反射阳性、呛咳、小脑危象、蛛网膜下腔出血•脊髓转移灶症状背部或双下肢痛、进行性

加重的截瘫或四肢瘫分级StageRiskstagingsystemStageChang'sMstagingsystemLow-riskLocalizeddiseaseatthetimeofdiagnosisM0Noevidenceofgro

sssubarachnoidorGroupAge>3yearshematogenousmetastasisTotaltumorresectionorsubtotalwithresidualtumor<1.5cm3High

-riskDisseminateddiseaseatthetimeofdiagnosisM1MicroscopictumorcellsfoundinGroupcerebrospinalfluidAge≤

3yearsM2GrossnoduleseedingseeninthecerebellarorcerebralsubarachnoidspaceorinthethirdorlateralventriclesSubtotaltumorresectionwitharesidu

altumorM3Grossnoduleseedinginthespinal≥1.5cm3subarachnoidspacemetastasisM4Extraneural治疗方案•标准治疗方案(“Philadelphiaprotocol”)•手术•放疗术后28天内开始。

•化疗(VCP)放疗中VCR1.5mg/m2/w，共8周；•放疗后6周开始CCNU75mg/m2•DDP75mg/m2•VCR1.5mg/m2/w×3w，•每6周一个周期，共8个周期。放疗剂量•低危组CSI23.4Gy/13f+后颅

窝加量至54Gy•高危组CSI36Gy/20f+后颅窝加量至54Gy放疗技术•常规分割CSI+Boosttoposteriorfossa•超分割CSI+Boosttoposteriorfossa•SRTBoosttoposte

riorfossaCraniospinalirradiation(CSI):methods•俯卧位，双手置于体侧•头部两侧对穿野照射全脑及上段颈髓•单后野照射脊髓•各野皮肤间隔1cm•每照射10Gy移动一次射野以减少各野间交叉高剂量•6MVX线照射•剂量(DT)23.4Gy~36

Gy,1.8Gy/fcerebellarorcerebralsubarachnoidProtractedRadiotherapyTreatmentDurationinMedulloblastomaAmJClinOncol(CCT)2

6(1):55–59,2003.M分期高/低龄儿预后差；210–221,2006RadiationOncologyBiol.standardradiotherapy放疗剂量和射野同常规分割放疗剂量和射野同常规分割Parotidgland14.

RadiationOncologyBiol.Low-riskLocalizeddiseaseatthetimeofdiagnosisM0NoevidenceofgrosssubarachnoidorradiotherapyaloneNEnglJMed2005;352:978-86

.cerebellarorcerebralsubarachnoidRadiationOncologyBiol.POSTOPERATIVENEOADJUVANTCHEMOTHERAPYBEFORERADIOTHERAPYASCOMPAR

EDTOIMMEDIATERADIOTHERAPYFOLLOWEDBYMAINTENANCECHEMOTHERAPYINTHETREATMENTOFMEDULLOBLASTOMAINCHILDHOOD:RESULTSOFTHEGERMANPROSPECTIVERANDOMIZEDTRIALHIT’

91Int.Age≤3yearsM2Grossnoduleseedingseeninthe4Gy/13f+后颅窝加量至54GyCraniospinalirradiation(CSI):doseradiotherapyalone（5-ye

arEFS）Chemotherapy+（5-yearEFS）standardradiotherapyreduced-doseradiotherapy60%±7.8%41%±8%75%±7%69%±8%Prospectiverandomisedtrialofchemotherapygivenbe

foreradiotherapyinchildhoodmedulloblastoma:InternationalSocietyofPaediatricOncology(SIOP)andthe(German)Soci

etyofPaediatricOncology(GPO)—SIOPII.MedPediatrOncol25:166-178,199523.4GyCSI的疗效23.4GyCSI对智力的影响(POG8631)Journa

lofClinicalOncology,Vol16,No5,pp.1723–28,1998CSI:cranialspinaljunctionsiteTHECRANIAL-SPINALJUNCTIONINMEDULLOBLASTOMA:DOESITMATTER?Int.J.RadiationO

ncologyBiol.Phys.,Vol.44,No.1,pp.81–84,1999Organlowjunction(SD)highjunction(SD)Cord40.3Gy(0.5)38.4Gy(1.3)

Thyroidgland20.3Gy(9.2)26.3Gy(0.6)Mandible6.2Gy(0.6)10.9Gy(5.1)Larynx8.3Gy(3.9)27.2Gy(0.4)Pharynx11.9Gy(5

.1)20.3Gy(4.8)Parotidgland14.9Gy(4.2)14.1Gy(4.2)超分割放疗•TwicedailylGyfractionswereadministeredseparatedby46h.•放疗剂量和射野同常规分割SRTBoosttoposteriorfoss

aPOSTERIORFOSSABOOSTINMEDULLOBLASTOMA:ANANALYSISOFDOSETOSURROUNDINGSTRUCTURESUSING3-DIMENSIONAL(CONFORMAL)RADIOTHERAPYInt.J.RadiationOncologyBio

l.Phys.,Vol.46,No.2,pp.281–286,2000放疗反应•急性反应骨髓抑制、脑水肿等；•远期副作用•甲低•认知障碍•其它听力减退、骨骼发育障碍、周围组织损伤继发第二恶性肿瘤等。4Gy(CSI)+后颅窝加量5.cerebellarorcerebralsu

barachnoidTHECRANIAL-SPINALJUNCTIONINMEDULLOBLASTOMA:DOESITMATTER?Pharynx11.其它复视、面瘫、强迫头位、头颅增大、病理反射阳性

、呛咳、小脑危象、蛛网膜下腔出血放疗后6周开始CCNU75mg/m2SRTBoosttoposteriorfossa标准治疗方案(“Philadelphiaprotocol”)5)38.High-riskDisseminateddiseaseatt

hetimeofdiagnosisM1MicroscopictumorcellsfoundinM分期高/低龄儿预后差；ThyroidDysfunctionasaLateEffectinSurvivorsofPediatricMedulloblastoma/Primiti

veNeuroectodermalTumorsAComparisonofHyperfractionatedversusConventionalRadiotherapyCancer1997;80:798–804.RadiationOnc

ologyBiol.THECRANIAL-SPINALJUNCTIONINMEDULLOBLASTOMA:DOESITMATTER?POSTERIORFOSSABOOSTINMEDULLOBLASTOMA:ANANALYSISOFDOSETOSURROUNDING

STRUCTURESUSING3-DIMENSIONAL(CONFORMAL)RADIOTHERAPYInt.小脑损害躯干性共济失调为主TimingofRadiationinChildrenWithMedulloblastoma/PN

ETPediatrBloodCancer2007;48:416–422VCR1.Pharynx11.HYPOTHYROIDISMINCHILDRENWITHMEDULLOBLASTOMA:ACOMPARISONOF3600AND2340cGYCRANIOSPINALR

ADIOTHERAPYInt.甲低Hypothyroidp值年龄1<5岁7/7(100%)<0.0015~10岁9/15(60%)>10岁2/10(20%)照射剂量123.4Gy+CT10/12(83%)<0.02536Gy+CT6/10(60%)36Gy2/10(20%)照射方法2

常规分割21/34(62%)=0.02超分割2/14(14%)1.HYPOTHYROIDISMINCHILDRENWITHMEDULLOBLASTOMA:ACOMPARISONOF3600AND2340cGYCRANIOSPINALRADIOTHERAPYInt.J.Radiation

OncologyBiol.Phys.,Vol.53,No.3,pp.543–547,20022.ThyroidDysfunctionasaLateEffectinSurvivorsofPediatric

Medulloblastoma/PrimitiveNeuroectodermalTumorsAComparisonofHyperfractionatedversusConventionalRadiotherapyCancer1997;80:798–804.认知障碍IQ(pointde

clineperyear)23.4Gy(CSI)+后颅窝加量5.236Gy(CSI)+后颅窝加量3.923.4Gy(CSI)+瘤床加量2.4MODELINGRADIATIONDOSIMETRYTOPREDICTCOGNITIVEOUTCOM

ESINPEDIATRICPATIENTSWITHCNSEMBRYONALTUMORSINCLUDINGMEDULLOBLASTOMAInt.J.RadiationOncologyBiol.Phys.,Vol.65,No.1,pp.210–221,2006影响因素包括：受照射时

年龄（小于3岁差）、照射范围（全脑差于部分脑照射）、照射剂量(低剂量较好）特别是后颅窝最大剂量、肿瘤部位（幕上好于后颅窝）。联合化疗•常用方案•VCP(VCR+CCNU+DDP);•“8in1”(VCR+甲强龙+CCNU+羟基脲+甲基苄肼+DDP+CTX+Arac);•其他方案•MTX鞘内注射

•CTX、VCR、VP16、CCNU、CBP等组合手术+放/化疗POSTOPERATIVENEOADJUVANTCHEMOTHERAPYBEFORERADIOTHERAPYASCOMPAREDTOIMMEDIATERADI

OTHERAPYFOLLOWEDBYMAINTENANCECHEMOTHERAPYINTHETREATMENTOFMEDULLOBLASTOMAINCHILDHOOD:RESULTSOFTHEGERMANPROSPECTIVERANDOMIZEDTRIALHIT’91Int.

J.RadiationOncologyBiol.Phys.,Vol.46,No.2,pp.269–279,2000•维持化疗对6岁以上低危组更有效；•新辅助化疗增加放疗的骨髓抑制从而延长治疗时间；•M

分期高/低龄儿预后差；•手术是否有残留对预后无明显影响。POSTOPERATIVENEOADJUVANTCHEMOTHERAPYBEFORERADIOTHERAPYASCOMPAREDTOIMMEDIATERADIOTHERAPYFOLLOWEDBYMAI

NTENANCECHEMOTHERAPYINTHETREATMENTOFMEDULLOBLASTOMAINCHILDHOOD:RESULTSOFTHEGERMANPROSPECTIVERANDOMIZEDTRIALHIT’91Int.J.RadiationOncologyBi

ol.Phys.,Vol.46,No.2,pp.269–279,2000手术+化疗方案适用于低龄儿童、无手术残留、无转移病灶患者手术+化疗结果TreatmentofEarlyChildhoodMedulloblastomabyPostope

rativeChemotherapyAloneNEnglJMed2005;352:978-86.影响预后的因素•年龄•临床分级•术式•后颅窝生物有效剂量（BED）•放疗持续时间Onmultivariateanalysis,age3year

s,M0status,50GyPFBdose,radiotherapytreatmentduration50days,anduseofchemotherapycorrelatedwithbetterfreedom

fromprogressionandposteriorfossacontrolrates.ProtractedRadiotherapyTreatmentDurationinMedulloblastoma

AmJClinOncol(CCT)26(1):55–59,2003.影响因素的多变量分析Onmultivariateanalysis,age3years,M0status,50GyPFBdose,radiotherapytreatmentduration50days

,anduseofchemotherapycorrelatedwithbetterfreedomfromprogressionandposteriorfossacontrolrates.Protracte

dRadiotherapyTreatmentDurationinMedulloblastomaAmJClinOncol(CCT)26(1):55–59,2003.影响因素的多变量分析年龄TimingofRadiationinChildrenWithMedulloblastoma/PNET

PediatrBloodCancer2007;48:416–422CSFcytologyTimingofRadiationinChildrenWithMedulloblastoma/PNETPediatrBloodCan

cer2007;48:416–4225cm3subarachnoidspacemetastasis“8in1”(VCR+甲强龙+CCNU+羟基脲+甲基苄肼+DDP+CTX+Arac);M分期高/低龄儿预后差；标准治疗方案(“Philadelphiaprotocol”)Hypothyroi

dp值POSTERIORFOSSABOOSTINMEDULLOBLASTOMA:ANANALYSISOFDOSETOSURROUNDINGSTRUCTURESUSING3-DIMENSIONAL(CONFORMAL)RADIOTHERAPYInt.StageRiskstagingsy

stemStageChang'sMstagingsystemM分期高/低龄儿预后差；Prospectiverandomisedtrialofchemotherapygivenbeforeradiotherapyinchildhoodmedulloblastoma:International

SocietyofPaediatricOncology(SIOP)andthe(German)SocietyofPaediatricOncology(GPO)—SIOPII.维持化疗对6岁以上低危组更有效；M4ExtraneuralRadiationOn

cologyBiol.JournalofClinicalOncology,Vol16,No5,pp.放疗剂量和射野同常规分割4Gy(CSI)+后颅窝加量5.81–84,19995cm3subarachnoidspacemetastasisPro

tractedRadiotherapyTreatmentDurationinMedulloblastomaAmJClinOncol(CCT)26(1):55–59,2003.常规分割CSI+Boosttoposteriorfossa≥1.新辅助化疗增加

放疗的骨髓抑制从而延长治疗时间；手术切除范围TimingofRadiationinChildrenWithMedulloblastoma/PNETPediatrBloodCancer2007;48:416–422后颅窝BEDTimingofRa

diationinChildrenWithMedulloblastoma/PNETPediatrBloodCancer2007;48:416–422病理及免疫组化类型其它复视、面瘫、强迫头位、头颅增大、病理反射阳性、呛咳、小脑

危象、蛛网膜下腔出血ventriclesHYPOTHYROIDISMINCHILDRENWITHMEDULLOBLASTOMA:ACOMPARISONOF3600AND2340cGYCRANIOSPINALRADIOTHERAPYInt.Radiation

OncologyBiol.RadiationOncologyBiol.放疗剂量和射野同常规分割常规分割CSI+Boosttoposteriorfossa脊髓转移灶症状背部或双下肢痛、进行性加重的截瘫或四肢瘫6)10.cerebellarorcerebralsubar

achnoidRadiationOncologyBiol.Craniospinalirradiation(CSI):methods5mg/m2/w×3w，放疗术后28天内开始。每照射10Gy移动一次射野以减少各野间交叉高剂量spaceorinthethirdorlateralIQ(poin

tdeclineperyear)THECRANIAL-SPINALJUNCTIONINMEDULLOBLASTOMA:DOESITMATTER?谢谢观看！