- 主 讲 人:
- Dr. Barbara-Ann Millar
以下为课程中英字幕：
Hello! I am delighted to introduce myself as Dr. Barbara-Ann Millar. I am a radiation oncologist at the Princess Margaret Cancer Center in Toronto, Canada, and and I'm the lead for the CNS site group in the Radiation Medicine Program.
您好! 我很高兴地介绍我自己，我是Barbara-Ann Millar博士，加拿大多伦多玛格丽特公主医院癌症中心的放射肿瘤学家，我是放射医学项目中的中枢神经系统组的负责人。
I'm very pleased to be here as part of the Accelerated Education Program. This is an introductory and talk about radiosurgery treatment - where it comes from and how we're moving forward.
我很高兴能作为加速教育计划的部分活动成员来到这里。这是一个关于放射外科治疗的介绍和讨论--它从何而来，我们如何向前发展。
I have no financial conflicts to disclose either in the content of the course or in this presentation.
我在课程内容和本次演讲中都没有任何财务冲突需要披露。
I will talk about the following: 我将谈论以下几点。
-The historical perspective in the development of radio surgery treatment for brain metastases
-脑转移瘤放射外科治疗发展史
-I'll mention a couple of clinical situations which have given rise for challenges in management of patients
-我将提到一些临床情况，这些情况对病人的管理有了新的挑战
-we're going to talk about the requirements for stereotypic radiation treatment and the challenges and
-我们将讨论立体定向放射治疗的要求和挑战
-the innovations and solutions that have been developed
-所开发的创新和解决方案
So first of all, I think it's important to think about how we've got to where we are now. This photograph of these 2 gentlemen is important in the development of the ability to locate locations very precisely within the brain, both for radio surgery and for surgery itself.
首先我认为有必要思考一下我们是如何走到今天的。 这两位先生对于发展在大脑中精确定位有着非常重要的作用，无论是对于放射外科还是对于手术本身。
So Victor Harsley and was an English neurosurgeon, and together with Robert Clark, they were working on the function of the cerebellum in primates and rats. They managed to develop this piece of equipment which used a cartesian coordinates to define a specific point in space, using 3 coordinates in the AP, lateral and vertical dimensions, and with this it was possible for surgeons to locate very accurately within the brain the targets that they wish to operate on.
Victor Harsley是一名英国神经外科医生，他和Robert Clark一起研究灵长类动物和大鼠的小脑功能。 他们设法开发了这一设备，该设备使用笛卡尔坐标，通过AP、侧向和垂直的3个维度坐标来定义空间中的特定点。有了这个设备，外科医生就有可能在大脑中非常准确地定位他们期望手术的目标。
It did, however, require a rigid fixation to the patients. Calvaryium to allow that precision to be utilized
然而，它确实需要对病人的颅骨进行刚性的固定，以使这种精确性得以利用
This gentleman is Professor Lars Leksell and he is widely recognized as being the father of radio surgery. He was a neurosurgeon in the 1950s, 60s, 70s, and 80s in Stockholm in Sweden, and he was really revolutionary in thinking about how we treat deep-seated intracranial tumours. He was frustrated by the challenges and the limitations of neurosurgery, neurosurgical techniques, and really was looking for a gentler and more targeted alternative to try and avoid the significant mortality related with neurosurgery for these challenging areas.
这位先生是Lars Leksell教授，他被广泛认为是放射外科之父。 他是20世纪50年代、60年代、70年代和80年代瑞典斯德哥尔摩的一名神经外科医生，他在如何治疗深部颅内肿瘤方面的思考对我们来说确实具有革命性意义。 他对神经外科、神经外科技术的挑战和局限性感到挫败，并真正在寻找一种更温和、更有针对性的替代方法，试图避免在这些具有挑战性的领域进行神经外科手术所带来的巨大死亡率。
He and his Colleague, Professor Bjorn Larsson from the Karolinska Institute in the University of Uppsala, started to look at ways of treating - initially with protons but that was abandoned due to the complexity and costs related however, this didn't put him off. He persevered, and in 1967 he oversaw and arranged the construction of the first ever gammaknife unit which utilized radioactive cobalt 60 sources as a radiation source.
他和他的同事，来自乌普萨拉大学卡罗林斯卡学院的Bjorn Larsson教授，开始研究治疗方法--最初是用质子，但由于太复杂和费用高而放弃了，然而这并没有使他放弃。他坚持不懈，并在1967年监督和建造了第一个利用放射性钴60作为辐射源的伽玛刀装置。
And this unit was used for over 12 years for the treatment of functional neurosurgical cases, such as pain or movement disorders.
而这个设备被用于治疗功能性神经外科病例超过12年，如疼痛或运动障碍。
This diagram shows the outline of the unit. The radioactive sources were housed within the unit itself and shielded, then there was a secondary helmet which had collimation to further shape the radiation beams before they came to a point inside guided by the Cartesian coordinates.
这张图显示了该装置的轮廓图。 放射源被放置在设备本身并且被屏蔽，然后有一个二级头盔，它有准直功能，可以进一步适形辐射束，然后在笛卡尔坐标的引导下，辐射束来到内部的一个点。
Realizing the potential to be able to use radiation for brain metastases, he then went on to develop a second gammaknife unit based at the Karolinska Institute in Stockholm. This was installed in 1975.
意识到放射线治疗脑转移瘤的潜力，他接着在斯德哥尔摩的卡罗林斯卡研究所开发了第二个伽玛刀装置。该装置于1975年安装。
A third unit was then built and installed in Buenos Aires in Argentina, and a fourth unit in Sheffield in the United Kingdom.
随后在阿根廷的布宜诺斯艾利斯建造并安装了第三套装置，在英国的谢菲尔德建造了第四套装置。
then around the world from that time many other models were available and in utilization across many, many different centers, but the initial B and C unit, which had 201 sources with separate collimator helmets with a collimation of 4, 8, 16, and 18, then most recently the Perfexion unit which uses 192 sources, with an integrated collimator helmet which allows the collimation to change from a 4 to 8 to 16 apertures.
然后在世界各地，从那时起就有许多其他型号的设备，并在许多不同的中心使用，但最初的B和C型伽玛刀装置有201个源，有独立的准直器头盔，准直器有4、8、16和18四种，然后最近的Perfexion，使装置有192个源，有一个集成的准直器头盔，允许准直度从4到8到16孔径变化。
So when we talk about radio surgery, what do you actually mean?
因此，当我们谈论放射外科时，实际上是什么意思呢？
We'd really talking about the delivery of a high doses, precisely delivered large single radiation treatment. And this is really dose that's ablative to the tissue being targeted and is tolerated only because of the very small volume. It requires stereotactic guidance with about 1mm setup accuracy, and the gammaknife unit itself has a very rapid fall off of dose to the addition normal tissues.
我们真正谈论的是高剂量的、精确治疗的，单次大分割的放射治疗。而这确实是对靶区组织的消融剂量，并且由于体积非常小才可以被忍受。 它需要立体定向引导，摆位精度约为1毫米，而且伽玛刀装置本身对其他正常组织的剂量跌落非常快。
Radiosurgery, although was initially one fraction, but with the development of a relocatable mask rather than the fixed frame, we can really consider radiosurgery to include up to 5 fractions with this very stereotactic guided image enhanced treatment modality.
放射外科虽然最初是一个分次，但随着可重复定位的面罩的发展，而不是固定框架，我们可以考虑放射外科多达5个分次的图像引导立体定向的治疗方式
So as I mentioned, there have been many developments over the last 10-20 years - in particular: 正如我所提到的，在过去的10-20年里有了很多发展，特别是:
- the increasing utilization of excellent quality, imaging with Ct and MRI to help delineate the targets 越来越多地使用高质量的CT和MRI成像来帮助勾画靶区
- our use of improved and relocatable frame development, which I'll talk about a little bit further, -我们使用的改进的和可重新定位的框架的发展，我将进一步讨论
- the technology, as I said onto the Icon unit with a no need for actual changing of helmets but an integrated collimator, as well as Linux accelerator modifications, as well as many linear accelerators on robotic arms, such as the cyber knife, -这项技术，就像我说的，在Icon装置实际上不需要更换头盔，而是一个集成的准直器，和直线加速器的射野准直器一样；和带有机械臂的加速器一样，如赛博刀，
- and also of much marked improvement in the treatment planning software for radio surgery cases 用于放射外科病例治疗的治疗计划软件也有显著改进
So if we go back to what fixed frame radio surgery would have involved and does still involve, usually an MRI is performed in advance of the day of treatment. On the day of treatment patients come in and with the neurosurgical team they have the frame fixed on to the calvarium using local anesthetic. So they're awake throughout, and with the frame in place, They then have a CTscan that is fused with the MRI. Then planning is undertaken, and the QA process is performed before the patient receives the radiosurgery treatment and which is performed on that day. When the treatment is delivered and rotation is then taken off the gamma knife and then the frame is removed and they go home, usually all within one day but generally a fairly long day and process for the patient.
所以如果我们回到固定框架的放射外科会涉及到的，现在仍然会涉及到，通常在治疗前一天进行MRI检查。在治疗当天，神经外科团队利用局部麻醉把框架固定在患者的颅骨上，患者全程都是清醒的，带着框架会去做一个用于与MR融合的CT扫描，在患者接受放射外科治疗之前，要进行计划制作和QA过程，并在当天执行治疗。当治疗完成后取下框架，患者就可以回家了。通常这个过程在一天内完成，但通常整个过程对病人来说是相当长的。
So as I mentioned there are challenges with the original fixed frame treatment and patients find it difficult tolerate that frame on all day and there are risks of bruising and bleeding with the frame placement and removal as well as significant headache. The image guidance has been improving, but the actual delivery of radiosurgery has been limited by the size that we can treat with the fixed frame - up to 3 cm - and also, because of the dose. We've had to modify that also bringing it down for single fractions because of the significant risk of radiation necrosis and the dose delivered as related to the size as a lesion.
正如我提到的，原有的固定框架治疗存在挑战，患者很难忍受整天带着固定框架而且框架的放置和移除存在挫伤和出血的风险以及严重的头痛。图像引导已经得到了改进，但实际的放射外科治疗受到了固定框架尺寸的限制(最高可达3厘米)，也受到了剂量的限制。我们不得不对其进行修改，也降低了单次治疗的剂量，因为辐射坏死的风险很大，而且所提供的剂量与病灶的大小有关。
The treatment dose is also limited according to where the lesion and the brain metastasis is, as well as any close proximity to sensitive structures, such as optic chiasm.
由于病变和脑转移的位置限制，其接近敏感结构如视交叉，从而治疗剂量受到限制。
Two cases that bring up the challenges of the fixed frame situation that have come up in my practice are
在我的临床实践中，有两个病例遇到了固定框架的挑战，它们是
The first one is an older gentlemen with good prognosis thyroid cancer but had significant medical comorbidities such he was not really considered safe for neurosurgical resection of these 3 large metastases. Therefore we had this situation where he had lesions, a limited in number but over 3 cm for one of them, which was too big for radio surgery with a fixed frame. The other option would be to consider whole brain and then potentially boosting after he had had whole brain RT to see if it was then small enough to boost with the fixed frame treatment.
第一位是一位年长的老先生，他的甲状腺癌预后良好，但有严重的并发症，因此他被认为对这3个大的转移灶进行神经外科切除手术并不安全。因此，我们遇到了这样的情况：他的病灶数量有限，但其中一个病灶超过3厘米，这对于带固定框架的放射手术来说太大了。 另一个选择是考虑全脑治疗，在他做完全脑放疗后再进行补量，看它是否小到可以用固定框架治疗。
Another example of a challenge is the patients who had previous radiosurgery with the fixed frame and then return with recurrent disease. Many of them have challenges going back to have the fixed frame version because it is quite a traumatic procedure, and even though the option was whole brain RT, many of them would refuse radiosurgery such as this young woman with breast cancer who had limited number of progressive seas. But was really traumatized by the frame placement.
另一个病例是以前做过固定框架放射外科的患者复发了。由于固定框架治疗是有创伤性，对于他们中的许多人再进行一次是有挑战的，即使选择全脑RT，他们中的许多人会拒绝放射外科，如这位患有乳腺癌的年轻女性，她进展期的转移瘤数量有限，但她真的被放置框架给伤透了
So the huge innovation for us in our department is the Icon unit which was actually developed with our team, and in particular Dr. David Jaffray led this development of the frameless radio surgery the Icon unit. The Icon unit allows relocatable mask to be created, convenient CT Imaging as part of the planning process with MRI, and then our imaging system, which allows to monitor and regulate patient movement to ensure the accuracy of delivery is as it was planned. This diagram shows the patient having an MRI performed, then the mask, then the cone beam Ct. Then the planning process. Then the patients get their planning performed, QA Check, and then they come as an outpatient for 1, 2, 3 fractions, on a daily basis for a short period of time each day. This is generally much better tolerated, and is much more accessible for our patients with brain mets. So as I mentioned it removes the need for the fixed frame immobilization. We can treat larger lesions, we can deliver over several fractions, therefore, increasing the dose to the targets, particularly for those larger lesions. So this has been a big advantage for our patient care.
在我们部门最大的创新就是我们团队共同开发的Icon装置，特别是David Jaffray博士领导开发的无框架放射外科Icon装置。Icon装置允许创建可重新定位的面罩，便于CT成像作为MRI计划制作过程的一部分，然后我们的成像系统能监控患者的运动，以确保投照剂量的准确性和计划一样。这张图显示病人做了磁共振检查，面罩固定，锥束CT(CBCT)扫描，计划制作，计划确认，QA检查，然后他们作为门诊病人来接受1 2 3次治疗，按天治疗，每天时间很短。这通常会有更好的耐受性，也更容易为我们的脑转移患者所接受。正如我提到的，它不需要固定头架，我们可以治疗更大的病灶，我们可以进行几个分次的治疗，因此增加对靶区的剂量，特别是对那些较大的病灶。这是我们治疗病人的一大优势。
Over the duration of the course, we will review the different systems that are available for radio surgery treatment for brain metastases. We will speak to you about the radiobiological principles underlying both the treatment and the side effects and the technological developments which have occurred.
在课程期间，我们将回顾不同的系统，用于脑转移瘤的放射外科治疗。我们会告诉你们放射生物学原理包括治疗副作用以及现有的技术发展
We talk about the similarities and delivery of treatment, and the differences in the different systems that are used and the treatment pathway for each system and we'll have an opportunity to discuss some cases as well as the challenges and give you an opportunity to do some contouring.
我们会谈到治疗执行的相似性，以及不同系统的不同之处，每个系统的治疗方式。我们将有机会讨论一些有挑战的病例，并给你们一个作业做一些勾画。
I want to thank you for your attention. I hope this has wetted your appetite for the course as we move forward, and I look forward to meeting you virtually later on in the course. Many thanks for your attention.
感谢大家的关注。我希望这能让你们对这门课更感兴趣，我很期待在之后的课程中与你们见面。非常感谢您的关注。