模板联合肋骨钻孔技术辅助放射性粒子植入治疗肺癌的可行性

Feasibility of radioactive seed implantation in the treatment of lung cancer assisted by template combined with rib drilling technique

目的评价模板联合肋骨钻孔技术辅助CT引导下放射性粒子植入在肺癌中应用的可行性。方法选择2015年1月至2016年6月在天津医科大学第二医院接受放射性粒子植入治疗的肺癌患者21例。植入前行胸部CT扫描获得医学数据成像信息(DICOM),导入近距离治疗计划系统(BTPS)进行预计划,处方剂量120 Gy。除常规针道设计外,对于因肋骨遮挡产生剂量冷区的靶区层面模拟经肋骨预置针道,术中采用肋骨钻孔技术建立真实进针通道,同时应用模板控制针的插植和粒子的植入,CT扫描验证插植针及粒子空间位置分布,术后即刻进行剂量验证。验证结果与术前计划的剂量参数进行配对t检验。粒子植入过程中和植入后观察并记录并发症。结果 21例肺癌患者应用模板联合肋骨钻孔技术,均顺利完成放射性粒子植入。术后剂量验证靶区的体积、粒子数、针数、D90、V100及V200的平均值分别为47.6 cc、33颗、10支、12 765.1 Gy、92.6%、34.8%,术前计划分别为46.4 cc、33颗、10支、12 433.8 Gy、95.2%、28.8%(P=0.012、0.930、0.267、0.179、0.032、0.003)。术后质量验证满意率为90.5%(19/21)。气胸发生率19%(4/21),肺内出血9.5%(2/21),胸膜腔内积血4.7%(1/21),痰中带血19%(4/21),无大咯血。粒子移位发生率9.5%(2/21)。未观察到其他严重并发症。结论应用模板联合肋骨钻孔技术辅助CT引导下肺癌放射性粒子植入,方法安全可行,插植针定位、定向精准,可较好地在术中实现术前BTPS计划目标,避免徒手操作的盲目性和剂量不精准问题,对肺癌放射性粒子治疗的规范化和质量控制具有重要价值。

Objective To assess the feasibility of using radioactive seeds implantation assisted by template combined with rib drilling technique under CT guidance in the treatment of lung cancer. Methods The study involved 21 patients with lung cancer who underwent radioactive seeds implantation in our hospital during Jan. 2015 and Jun. 2016. Dicom data were acquired by chest CT scan before implantation,brachytherapy radiation treatment planning system（ BTPS）was introduced to carry out the plan,and the prescription dose was 120 Gy. In addition to the conventional needle design,the special design of penetrating rib was adopted in the dose cooling zone due to rib occlusion,rib drilling tech-nique was used to establish the real channel,and template was used to control implantation. The distribution of implanted needles and seeds were observed with CT scan. Dose verification was performed immediately after the operation. Intraoperative and postoperative complications were observed and recorded. Results All patients tolerated brachytherapy well. The mean gross tumor volume（ GTV）,seed number,needle number,D90,V100 and V200 in postoperative verification and preplan were 47. 6 vs 46. 4 cc,33 vs 33,10 vs 10,12 765. 1 vs 12 433. 8 Gy,92. 6% vs 95. 2% and34. 8% vs 28. 8%,respectively（ P = 0. 012,0. 930,0. 267,0. 179,0. 032,and 0. 003）. The satisfaction rate was90. 5% after operation. The incidence of pneumothorax,pulmonary hemorrhage,pleural cavity,bloody sputum and particle displacement were 19%,9. 5%,4. 7%,19% and 9. 5%. No massive hemoptysis or other complications occurred. Conclusion Template combined with rib drilling technique in radioactive seeds implantation is safe and feasible. The precise positioning can significantly improve the preoperative plan conformity and avoid the blindness of manual operation. It has important value for the standardization and quality control in the treatment of lung cancer.