江苏省肿瘤医院江苏省肿瘤医院肺的放射损伤江苏省肿瘤医院江苏省肿瘤医院 张宜勤张宜勤江苏省肿瘤医院江苏省肿瘤医院 正常组织的放射耐受剂量 （到目前为止采用的标准） The WHO Handbook for Reporting Results of Cancer Treatment M. Geneva, Switzerland：World Health Organisation, 1979:48 Tolerance of Normal Tissue to Therapeutic IrradiationB. Emami (1991) Acute & Late Radiation Morbidity Scoring System by EORTC/ RTOG (1983-1992) LENT SOMA Scales by EORTC/RTOG (1995) (subjective, objective, management, analytic scale, late effects of radiation on normal tissues ) Common Terminology Criteria for Adverse Events (CTCAE) by NCI (1988), V3 (2006) PROMISPROMIS Patient-Reported Outcomes Measurement Information System by National Institutes of Health (2004) 江苏省肿瘤医院江苏省肿瘤医院Int J. Radiation Oncology Biol. Phys. Vol. 21, pp. 109-122. 1991江苏省肿瘤医院江苏省肿瘤医院Tolerance of normal tissue. B. EMAMI et al. I. J. Radiation Oncology . Biol . Phys. May 15, 1991, Volume 21, Number I28 critical sites of normal tissue. 197 references 1,062 citations, No.1 in ISI Web of Science (Until 2009.2.3. )江苏省肿瘤医院江苏省肿瘤医院SOMA-late effects normal tissues (SOMA-LENT) systemSubjective findings (e.g.,symptoms of shortness of breath)； Objective findings (e.g.,changes in respiratory rate)； Management interventions (e.g., the institution of steroids or oxygen)； Analytic data (e.g., pulmonary function tests or blood gas results).江苏省肿瘤医院江苏省肿瘤医院The US National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE) v3.0 Some 27 items are listed at the website江苏省肿瘤医院江苏省肿瘤医院江苏省肿瘤医院江苏省肿瘤医院90年代前后放射治疗的改变江苏省肿瘤医院江苏省肿瘤医院QUANTECA kickoff workshop withA kickoff workshop with 5757 invited participants from North America and invited participants from North America and Europe was held in Madison, Wisconsin, Europe was held in Madison, Wisconsin, in October 2007in October 2007 with generous with generous financial support from the financial support from the A American merican A Association of ssociation of P Physicists in hysicists in MMedicine edicine and the Board of the and the Board of the A American merican S Society ociety for for T Therapeutic herapeutic R Radiationadiation OOncology.ncology. 江苏省肿瘤医院江苏省肿瘤医院 QUANTEC的任务vv通过现有资料的总结，对于正常组织特定观测终通过现有资料的总结，对于正常组织特定观测终点点( (E Endpondpoi intnt) )，提供量化的剂量效应，与剂量，提供量化的剂量效应，与剂量体积关系。体积关系。 vv根据上述剂量体积的数据与模型的研究结果，根据上述剂量体积的数据与模型的研究结果，给临床提供合理的毒性分类方法与工作指南。给临床提供合理的毒性分类方法与工作指南。 vv提出有助于正确估测和减轻急性、晚期放射治疗提出有助于正确估测和减轻急性、晚期放射治疗副作用的研究方向。副作用的研究方向。M. BENTZEN et al. QUANTEC: scientific issues. Int. J. Radiation Oncology Biol. Phys., Vol. 76, No. 3, Supplement, pp. S3S9, 2010江苏省肿瘤医院江苏省肿瘤医院Quantitative Analysis of Normal Tissue Effects in the ClinicGuest editors introduction to QUANTEC An introduction to scientific issues. Use of normal tissue complication probability models in the clinic16 organ specific clinical papers and each article is organized in a consistent format including 10 sectionsTrue Dose Imaging Biomarkers Data Sharing Lessons of QUANTECIntroductory PapersOrgan-Specific PapersVision PapersGUEST EDITORSGUEST EDITORS Lawrence b. Marks, M.D.(北卡罗来纳大学) Randall k. Ten Haken, Ph.D.(密歇根大学)Associate Guest EditorAssociate Guest Editor Mary K. Martel, PH.D. (MD安德森医院)QUANTECQUANTECInt. J. Radiation Oncology Biol. Phys., 2010年76卷3 Suppl期S1-160页 江苏省肿瘤医院江苏省肿瘤医院江苏省肿瘤医院江苏省肿瘤医院江苏省肿瘤医院江苏省肿瘤医院江苏省肿瘤医院江苏省肿瘤医院原始材料的局限性原始材料的局限性不同分次治疗方案的评估不同分次治疗方案的评估使用QUANTEC资 料时的注意事项预测模型的局限性预测模型的局限性综合治疗方案的影响综合治疗方案的影响不同器官危险性的平衡不同器官危险性的平衡病人因素的病人因素的影响影响随访时间的影响随访时间的影响急性毒性与晚期损伤的关系急性毒性与晚期损伤的关系控制肿瘤与正常组织副作用的取舍控制肿瘤与正常组织副作用的取舍儿童病人的特殊性儿童病人的特殊性NTCPNTCP模型生物学机制的了解模型生物学机制的了解江苏省肿瘤医院江苏省肿瘤医院LIMITATIONS INHERENT IN EXTRACTING DATA FROM THE LITERATUREThe information presented is largely extracted from publications. Because different investigators often present information differently (e.g., actuarial vs. crude complication rates), pooling data from multiple studies may be inaccurate. 资料主要地是从刊物（文献）提取。因为不同的作者提资料主要地是从刊物（文献）提取。因为不同的作者提 供的资料常常不同供的资料常常不同( (如，标化的如，标化的VSVS. .粗的并发症率粗的并发症率) )，源，源 自多个研究的汇总数据可能并不精确。自多个研究的汇总数据可能并不精确。江苏省肿瘤医院江苏省肿瘤医院 LIMITATIONS OF PREDICTIVE MODELSFig. 1. A three-dimensional dose distribution is reduced to a two-dimensional(2D) dosevolume histogram (DVH) by discarding all spatial, anatomic and physiologic data. The 2D graph is then further reduced to a single value of merit, such as the mean dose, the percent of the organ receiving20 Gy (V20), or a model- based normal tissue complication probability (NTCP). Often do not consider fraction size variations.Often do not consider fraction size variations.G. J. Kutcher et al. MSKCC江苏省肿瘤医院江苏省肿瘤医院 EVOLVING FRACTIONATION SCHEDULES放射引起的正常组织反应是放射引起的正常组织反应是分割大小依赖分割大小依赖的。在整个的。在整个 QUANTECQUANTEC的评述中，这一变量已被充分考虑，并且，的评述中，这一变量已被充分考虑，并且， 只要有可能，均依据线性二次只要有可能，均依据线性二次(LQ)(LQ)模型对分割大小进行模型对分割大小进行调整。调整。然而，然而，/的比的比值是不确定的。特别是值是不确定的。特别是QUANTEC QUANTEC 的数的数据用于据用于立体定向放射治疗立体定向放射治疗时，由于分割大小与文献中的时，由于分割大小与文献中的 完全不同，预测结果就更加不可信了。更有甚者，对于完全不同，预测结果就更加不可信了。更有甚者，对于 更加非常规的分割，更加非常规的分割，LQLQ模型本身的可靠性都值得怀疑。模型本身的可靠性都值得怀疑。江苏省肿瘤医院江苏省肿瘤医院 BALANCING THE RISKS TO DIFFERENT ORGA