患者李x x，女性，51岁，主因“进食后上腹不适伴皮肤黄染2月”于2006年4月18日收住入院，患者于2月前始出现进食后上腹部不适，随后出现全身皮肤黄染，在江苏省人民医院行CT示：胆总管狭窄，怀疑胰腺癌，遂剖腹探查见胰腺肿物血运丰富，手术无法切除，行胆总管上段与空肠吻合术，术后恢复好，黄疸渐消退。为求进一步治疗来我院就诊，2006年4月19日我院CT示：胰头颈部占位，CA199为41.63ug/L，诊断为胰腺癌。查体见腹部正中一长约20cm陈旧性手术疤痕，腹部无压痛。入院后全院会诊后行质子治疗，治疗中发现血糖值为：14.37mmol/L,多次复查血糖均高于正常,遂应用胰岛素治疗，效果可；共行胰腺病灶适行放疗90%等剂量线包PTV归一治疗36Gy/18F,5F/W;质子治疗95%等剂量线包PTV治疗28CGE/14F, 5F/W,未出现明显不良反应;复查CT示:病灶较前缩小.
 
    2006年7月22日回访,患者一般情况良好,复查CT示病灶缩小;正准备行化疗.

 
    患者仪x x，男性，58岁，主因上腹胀不适伴消瘦1月于2005年7月22日收入院，患者于一月前无明显诱因出现上腹部不适，伴有腹胀，近一个月以来出现明显消瘦，体重减轻约10公斤，不伴有明显上腹部疼痛，无恶心、呕吐，无反酸，无黄疸，于2005年7月11日在青岛大学医学院附属医院就诊行B超检查示：胰腺肿大、胰头及胰体部探及约10×4.9cm实性肿块，考虑：胰腺占位，查CA19-9：59.21u/ml，（参考值0-39 u/ml），诊断：胰腺癌，于2005年7月18 日在中国人民解放军总院行CT检查诊断：胰腺癌，患者既往身体健康，体格检查：患者一般情况好，KPS评分：90，心肺查体无明显异常，腹部无异常。入院检查血常规，以及、肝、肾功能均无异常，血糖7.87mmol/L，稍高于正常，AFP<10ng/ml，CEA：9.8ng/ml，诊断胰腺癌，于2005年8月10日行质子治疗：胰腺病灶90%等剂量线包绕PTV归一，设2野，剂量为：3CGE×21F，于2005年9月7日治疗顺利结束。质子治疗结束后，又口服2个月化疗药物：去氧氟尿苷胶囊0.4 每日三次。
    于2005年8月30日行PET-CT检查腹部胰头、胰颈各见一4.1×3.7cm、2.1×1.6cm异常放射性摄取增高灶，最大SUV13.1，相应CT层面见胰头肿大，胰头、胰颈可见低密度灶。肝脏、脾脏及胃肠道未见异常。诊断：胰腺癌。
    2006年6月7日患者无特殊不适，饮食、睡眠可，体重增加，一般情况好，腹部无压痛，无黄疸，来我院复查PET-CT示：腹部胰头可见一不规则异常放射性摄取增高区，其最大SUV10，相应CT层面可见低密度灶，与以前PET结果相比较代谢活度无明显变化，病灶范围缩小，胰腺颈部未见明显异常，肝脏、脾脏正常显影，未见异常放射性摄取增高。
    2006年7月22日电话回访，现患者一般情况好，腹部无疼痛，无黄疸，病情稳定，现在当地医院行化疗。
（患者未复查CA19-9）

    患者于x x，男性，69岁，主因“胆囊切除术后20余天”于2005年12月27日收入院。患者20天前因无明显诱因出现全身皮肤粘膜黄染，伴有瘙痒，到张店区医院B超检查示，胆囊积液，肝内外胆管及胰管扩张，考虑胰头癌。2005年11月25日到上海东方肝胆外科医院就诊，确诊为胰头癌。2005年12月5日给予手术切除，术中所见，胆囊张力较高，明显肿大，胆总管扩张，内径1.5cm未触及结石。Kocher切口探查胰头，胰颈，胰体部可触及一约6*7cm肿物，质硬边界不清，未侵及肠系膜上动静脉及结肠中动脉，癌肿活动度差，与周围轻度粘连，胰头及十二指肠周围未触及肿大淋巴结，腹内未见明显种植转移。2005年12月30日我院PET-CT检查示：患者系胆囊切除术后，胆囊缺如，术区可见团块状等低泚杂密度灶，相应PET未见异常放射性摄取增高灶。胰头、颈及部分胰体区可见点片状异常放射性摄取增高灶，最大SUV值7.3，延迟显像后最大SUV值7.0；相应CT层面示胰腺萎缩周边可见银夹，其内可见低密度灶，边界欠清。胰尾部未见异常密度灶，相应PET层面亦未见异常放射性摄取增高灶。结合手术所见考虑胰腺癌。肿瘤相关抗原199：48.1ug/L。2006年1月3日给予胰腺病灶质子治疗，具体计划为：胰头+胰颈+胰体病灶95%等剂量线包PTV归一，DT54CGE/27F/qd，5F/W,Ap和 PA野两野对穿治疗，每日一野，两野交替。GTV65.54cm3 PTV209 cm3,治疗后复查肿瘤相关抗原199：45.71ug/L。
    2006年6月15日回访，CT检查病灶减小，一般情况明显好转。
    2006年7月20日回访，病灶明显缩小。

    1: Med Dosim. 2001 Fall;26(3):255-9.
    Comparative treatment planning between proton and X-ray therapy in pancreatic cancer.
    •     Hsiung-Stripp DC,
    •     McDonough J,
    •     Masters HM,
    •     Levin WP,
    •     Hahn SM,
    •     Jones HA,
    •     Metz JM.
    Department of Radiation Oncology, University of Pennsylvania, Philadelphia 19104, USA. stripp@xrt.upenn.edu
    With the utilization of new biologic agents and experimental chemotherapy in the treatment of pancreatic cancer, the issue of local-regional control will become increasingly important. This study was undertaken to determine the feasibility of dose escalation using proton therapy, as compared to conventional 3-dimensional conformal radiation, by minimizing the dose to normal tissues.   

    The photon treatment plans of 4 patients with unresectable pancreatic cancer treated on a biologic therapy trial were utilized.  Each patient was treated using a 3- or 4-field photon plan with 45 Gy to the clinical target volume (CTV), followed by a boost of 14.4 Gy to the gross target volume (GTV). Using a Helax treatment planning system, proton plans were generated to encompass the same CTV and GTV to the same prescribed dose. Dose-volume histograms (DVHs) were generated for the GTV, CTV, spinal cord, liver, and right and left kidneys. Each DVH was compared between the photon and proton plans. Proton plans utilized either a 2- or 3-field technique. Available energies included 130 or 180 MeV. Range modulators and bolus were used as needed to conform to the target volume. With the CTV and GTV receiving the same dose from the proton and photon plans, all individual proton plans were superior to the photon plans in reduction of normal tissue dose. For the 4 patients, the average dose reduction to 50% of the organ at risk was 78% to spinal cord (p = 0.003), 73% to left kidney (p = 0.025), 43% to right kidney (p = 0.059), and 55% to liver (p = 0.061). These comparative treatment plans show proton therapy results in significant reductions of dose to normal tissue compared to conventional photons while treating the same target volumes. This allows for the design of dose-escalation protocols using protons in combination with new biologic therapies and chemotherapy.
    PMID: 11704461 [PubMed - indexed for MEDLINE]

   THE ROLE OF PROTON THERAPY IN THE TREATMENT OF LARGE
   IRRADIATION VOLUMES: A COMPARATIVE PLANNING STUDY OF
   PANCREATIC AND BILIARY TUMORS
   ALFREDO ZURLO, M.D.,* ANTONY LOMAX, M.S., PH.D.,ANGELIKA HOESS, M.S.,
   THOMAS BORTFELD, M.S., PH.D.,‡ MARIATERESA RUSSO, M.S.,§ GUDRUN GOITEIN, M.D.,
   VINCENZO VALENTINI, M.D.,\ LAURA MARUCCI, M.D.,\ ROBERTO CAPPARELLA, M.S.,§ AND
   ARMANDO LOASSES, M.D.*
    *Cattedra di Radioterapia, University of Rome “Tor Vergata”, Rome, Italy; †Department of Radiation Medicine, Paul Scherrer Institute,
    Villingen, Switzerland; ‡Department of Medical Physics, Deutsches Krebsforschungszentrum (DKFZ), Heidelberg, Germany;
    Fondazione TERA per l’Adroterapia, Novara, Italy; \Cattedra di Radioterapia, Istituto di Radiologia, Universita` Cattolica
del Sacro Cuore, Rome, Italy; Expert System Lab, Regina Elena National Cancer Institute, Rome, Italy
Purpose: The purpose of this study was to examine the potential benefit of proton therapy for abdominal tumors.
Extensive comparative planning was conducted investigating the most up-to-date photon and proton irradiation
technologies.
    Methods and Materials: A number of rival plans were generated for four patients: two inoperable pancreatic
tumors, one inoperable and one postoperative biliary duct tumor. The dose prescription goal for these large
targets was 50 Gy, followed by a boost dose up to 20 Gy to a smaller planning target volume (PTV). Photon plans
were developed using “forward” planning of coplanar and noncoplanar conformal fields and “inverse” planning
of intensity-modulated (IM) fields. Proton planning was simulated as administered using the so called spotscanning
technique. Plans were evaluated on the basis of normal tissues’ dose–volume constraints (Emami B,
Lyman J, Brown A, et al. Tolerance of normal tissue to therapeutic irradiation. Int J Radiat Oncol Biol Phys
1990;21:109 –122) and coverage of treatment volumes with prescribed doses.
    Results: For all cases, none of the forward calculated photon plans was able to deliver 50 Gy to large PTVs at
the same time respecting the dose–volume constraints on all critical organs. Nine evenly spaced IM fields achieved
or nearly achieved all maximum dose constraints to critical structures for two out of three inoperable patients.
    IM plans also obtained good results for the postoperative patient, even though the dose to the liver was very close
to the maximum allowed. In all cases, photon irradiation of large PTV1s to 50 Gy followed by a 20 Gy boost
entailed a risk very close to or higher than 5% for serious complications to the kidneys, liver, or bowel. Simple
arrangements of 2, 3, and 4 proton fields obtained better dose conformation to the target, allowing the delivery
of planned doses including the boost to all patients, without excessive risk of morbidity. Dose homogeneity inside
the targets was also superior with protons.
    Conclusion: For the irradiation of large PTVs located in the abdominal cavity, where multiple, parallel structured
organs surround the target volumes, proton therapy, delivered with a sophisticated isocentric technique, has the
potential to achieve superior dose distributions compared with state-of-the-art photon irradiation techniques. IM
photon plans obtain better results in the postoperative case, because the reduced volume lessens the effect of the
unavoidable increase of integral dose to surrounding tissues. © 2000 Elsevier Science Inc.