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Toasts G. I., Medvedsky V. V.
Radiation therapy of a breast cancer.
The verified breast cancer 2-3 stages for preoperative radiation therapy in respect of the combined treatment. Existence of metastasises in the lymph nodes found during operation; 3rd stage of a disease; operation without preliminary radiation; not radical operation for postoperative radiation therapy, Radiation therapy according to the radical program is carried out at nonresectable tumors, existence of contraindications to an operative measure in connection with existence of associated diseases or refusal of the patient of operation.
Cardiovascular or pulmonary insufficiency in a stage sub - or decompensations; tuberculosis and rheumatism in an acute form; diffusion toxic craw; obesity 3 and more degrees; disintegration of a tumor with an inflammation or massive bleeding; psychological diseases (epilepsy, schizophrenia, etc.).
All mammary gland and lymph nodes enter the volume of the fabrics which are subject to radiation. If prior to treatment metastasises in lymph nodes clinically are not defined, then in the preoperative period axillary and subclavial lymph nodes are irradiated. If there are clinical signs of metastasises - all groups of regional lymph nodes are irradiated: axillary, subclavial, supraclavicular and parasterialny.
The mammary gland is irradiated from two counter rectangular tangential fields, axillary, subclavial and supraclavicular lymph nodes with one direct figured field, parasterialny group of lymph nodes - the certain rectangular direct field. As axillary lymph nodes are located at bigger distance from a surface, than over - and subclavial, the smaller dose is the share of them. The missing dose on axillary lymph nodes is brought from the scapular rectangular field.
Fractionation of a dose is possible in the following options:
- on a mammary gland of 13 Gr once on lymph nodes (only axillary and subclavial) 10 Gr once operation in day of radiation
- on a mammary gland on 5 Gr five fractions (totally 25 Gr) on lymph nodes on 4 Gr five fractions (totally 20 Gr), operation not later than 2 days after the termination of a course of radiation therapy
- on a mammary gland and lymph nodes on 2 Gr, five fractions a week, totally to 40 - 45 Gr. operation in 2-3 weeks after the termination of a course of radiation therapy
In the last option radiation therapy is carried out for the purpose of transfer of a nonresectable tumor to resectable now.
The volume of radiation and total dose in postoperative radiation therapy depend on the reasons causing the necessity of postoperative radiation.
If before operation of radiation it was not carried out, then after operation the postoperative hem from two counter tangential fields, and all groups of lymph nodes in the mode of usual fractionation to a total dose of 40 Gr is irradiated.
If before operation axillary and subclavial lymph nodes were irradiated, then after operation supraclavicular and parasterialny lymph nodes to a total dose of 40 Gr in the usual mode of fractionation are exposed to beam influence.
If before operation all groups of lymph nodes were irradiated, then after operation are irradiated supraclavicular and parasterialny to a total dose of 20 Gr in the usual mode of fractionation.
At radiation therapy of a breast cancer according to the radical program the mammary gland and all groups of lymph nodes from the above-stated fields in a single dose 2gr to a total dose on a mammary gland of 65-70 Gr and on lymph nodes of 40-45 Gr are irradiated. In the presence of clinical signs of metastasises in lymph nodes, on reaching a dose of 45 Gr decreases by all groups of lymph nodes, the size of the field of radiation to the sizes of the affected lymph node and on it the dose of 20 Gr in addition is given.
Radiation therapy of cancer of lung.
Not small-celled cancer of a lung 3 stages for preoperative radiation therapy in respect of the combined treatment; metastasises in lymph nodes at not small-celled cancer of a lung for postoperative radiation therapy; mlekokletochny cancer-sided for radiation therapy according to the radical program in respect of complex treatment.
Disintegration of a tumor or atelectasis with formation of a cavity of disintegration; bleeding; existence of a pneumonitis; specific pleurisy; multiple metastasises in lungs; cancer lymphangitis; mental disorders; a dekompensirovanny state owing to a disease of cardiovascular system, lungs, kidneys, a liver and so forth.
The combined cancer therapy of a lung is carried out at 30% of again revealed patients, in the preoperative period the tumor and pulmonary fabric at distance of 3-4 cm from the borders of a tumor defined radiological and also regional lymph nodes is subject to radiation: paratracheal, bifurcation and bronkho-pulmonic. Radiation is carried out most often from two fields: front direct figured field and zadnero rectangular field at an angle 15-20 hail. to a backbone, for a dose decline on a spinal cord. A single focal dose of 5 Gr to a total dose of 25 Gr, or in the usual mode of fractionation to a total dose 40-45 gr on a tumor. At the same time zones of regional innidiation have to enter 80% an isodose. In the postoperative period irradiate regional lymph nodes and a stump of a bronchial tube in the usual mode of fractionation from two counter rectangular fields to a total dose of 40 Gr if preirradiation was not, at the same time from the back field the backbone is shielded by the block.
Treatment of tumors of a lung is more often will see according to the radical program for the split course in the usual mode of fractionation to a total dose of 60-65 Gr. The volume and fields of radiation are identical to that at preoperative radiation therapy. At the same time on reaching a dose of 40 Gr do a break for two-three weeks, and then continue treatment. Often at the first stage use other mode of fractionation - 7 fractions on 4 Gr. at the same time the mode of fractionation and a total dose of the second stage does not change.
Radiation therapy of a carcinoma cutaneum.
Beam the method of treatment is a choice method at localization of a tumor on a face and pilar speak rapidly the heads. On a histologic structure meet basal and cellular, planocellular not keratosic and the planocellular keratosic carcinoma cutaneum, optimum proceeds a skin basal cell carcinoma. This tumor slowly grows and, practically, does not give the regional and remote metastasises. These tumors pose threat for life in process of germination in the subject fabrics, including a sievebone, an eye orbit, a brain. Planocellular forms of a carcinoma cutaneum often give metastasises, first of all in regional lymph nodes. Therefore tactics of treatment of tumors of skin depends not only on the sizes and localization of a tumor, but also on its histologic structure.
At bazalioma of the I-II stage treatment is carried out on devices for a korotkodistantny (short-distance) rentgenterapiya from one direct field which size has to exceed visible borders of a tumor on 0,5 cm in each party. The single focal dose at the same time makes 3.0 - 4.0 Gr, and total 50 - 55 Gr. Planocellular forms of the same size are irradiated similarly, but to a dose of 60 - 65 G of river. At tumors of the bigger size or with an invasion more than 1 cm is used by the gamma radiation or fast electrons. Radiation is carried out from two counter tangential fields by a single dose of 2 Gr to a total dose of 60 - 65 Gr.
In the presence of metastasises carry out gamma therapy or a limfadenektomiya to regional lymph nodes.
Radiation therapy of cancer of neck of uterus.
The verified cancer of a neck of uterus 1-3 stages for the combined radiation therapy.
At a cancer of a neck of uterus most often carry out the combined radiation therapy including an intracavitary and remote method of radiation. Treatment is begun with remote radiation therapy. At the same time can be used both gamma radiation sources, and a bremsstrahlung of high energy. Radiation is conducted with two counter open fields: inguinal and ileal. The volume of radiation joins primary tumor and a parametric fat. Calculation of a dose is made on points "And" also by "B". The point "And" is two cm above a lateral vault of the vagina and on two cm lateralny uterus axes. Anatomically this point corresponds to crossing of a uterine artery and an ureter. The point of "B" is located at the same level, but on 5 cm lateralny the central axis of gas. Anatomically it corresponds to borders of a small pelvis. When calculating a dose on a point "And" define beam impact on a tumor, when calculating a dose on a point of "B" - on a parametric fat. The single focal dose at this stage makes 2 Gr on both points. On reaching a dose on a point of "B" of 8-13 Gr. attach intracavitary therapy. From this point the main objective of remote radiation therapy is impact on a parametric fat therefore at radiation from the same fields, the area of a neck of uterus is shielded by the lead block. At the same time the single dose on a point of "B" remains 2 GR, and on a point "And" - there will be less than 1 Gr. Also other option of placement of fields at static remote therapy is possible - chetyrekhpolny radiation (two ileal and two sacral). At the same time before accession of intracavitary therapy of the field are located in parallel each other and a midline with distance between medial edges of 1 cm. After accession of intracavitary therapy, bottom edges of fields get divorced in the parties to distance of 6 cm between them. According to indications also two-axial radiation in the pendular mode is carried out.
Intracavitary therapy is carried out on hose devices now. Treatment is carried out in several etapob in the beginning have in the place of an endostata - the tubules soldered since one end. One endostat is entered into a cavity of the uterus, by two others into lateral vaults of the vagina. Lateral endostata have on the end of an ovoida from plexiglas or other material. Then make fixing of endostat among themselves and in relation to a body of the patient and carry out a control x-ray film behind placement of endostat. Radioactive sources from storage on hoses come to endostata and the radiation session begins. Movement of sources in endostata and back comes from storage under the influence of compressed air or sources are rigidly fixed on ropes and move together with them. Such option of carrying out intracavitary therapy is called method of automatic consecutive maintaining and excludes direct contact of personnel with radioactive sources that allows to use sources of bigger activity and, respectively, to reduce session time for achievement of the set dose. The single dose from intracavitary therapy on a point "And" makes 5 Gr, at the same time the dose about I Gr is the share of a point of "B". The total dose of the combined radiation therapy, depending on a disease stage, makes on a point "And" 70 - 90 Gr, on a point of "B" - 45 - 60 Gr.
Radiation therapy of throat cancer.
The verified throat cancer 1-2 stages of radio resistant forms and 3-4 stages of any forms predoperatsionno in respect of the combined treatment; postoperatively - if before operation radiation or not radical treatment was not carried out; radio sensitive forms of throat cancer of 1 - 2 stage - according to the radical program.
Transition to the next bodies, the disintegration of a tumor with bleeding expressed perikhoirit or hondronekrostenoz throats 2-3 degrees, existence
the remote metastasises with symptoms of intoxication: the general serious condition of the patient caused by associated diseases.
The size of the field of radiation and border of upper and lower fields depend on localization of tumoral process. At cancer of phonatory bands the upper bound of the field passes across the region of a mandible, lower - on a clavicle. Height of the field makes usually 8-9 cm. At tumors of vestibular and subcopular departments of a throat the field size on height increases by 1,5-2 cm at the expense of the upper bound in the first case or lower in the second. Most often radiation is carried out from two counter lateral fields 6 cm wide. At the same time the throat at the level of an arrangement of a tumor has to be covered by 90% an isodose. At local defeat of true phonatory bands it is possible to carry out mobile radiation by fields of 4x5 cm.
The single focal dose usually makes 2 Gr. The total dose predoperatsionno happens till 40-45 Gr, After a break 2-3 weeks estimate effect of treatment. At regression of a tumor and a beam pathomorphism 3-4 degrees treatment finish more than 50% according to the radical program, leading up a total dose till 65-70 Gr. At more resistant tumors right after a break carry out surgical intervention.
Radiation therapy of cancer of rectum.
Resectable cancer of a rectum 2-3 stages in the presence of verification for preoperative radiation therapy in respect of the combined treatment. Existence of metastasises in lymph nodes or histologically the confirmed tumor exit out of rectum limits for postoperative radiation therapy. Cancer of 1 stage and epidermoid cancer of proctal department for the combined radiation therapy of the radical program.
Germination of a tumor in the next bodies, disintegration of a tumor with bleeding, existence of the remote metastasises with the general intoxication, the general serious condition of the patient in connection with associated diseases.
In the preoperative period include a rectum and a pararectal fat in the volume of radiation. At the same time upper and lower borders the field have to be located not closer than 4 cm from edge of a tumor, and an isodose to pass 80% on internal walls of a small pelvis. At tumors of nizhneamulyarny department of a gut also the crotch is irradiated. At a verkhneampulyarny or rektosigmodny arrangement of a tumor the channel is excluded from a zone of radiation anal and the area of ileal and lumbar lymph nodes to the 4th lumbar vertebra joins. The remote gamma therapy or a bremsstrahlung of high energy is applied. In the static mode radiation is carried out from two counter fields of 12x15 cm in size or four fields by width of 8-10 cm at an angle 30-40 °. At pendular radiation use fields 6-8 cm wide with the angle of rotation 240 °. The mode of fractionation can be various: on 2 Gr x 20 with a break before operation 2-3 weeks, 5 Gr x 5 with operation next day, 13 Gr once with operation in day of radiation. At the combined radiation therapy according to the radical program use tele-irradiation and intracavitary therapy. Tele-irradiation is carried out by the above described techniques. Intracavitary therapy is carried out on hose devices by a single focal dose of 3-5 Gr now. The total dose is brought taking into account tolerance of healthy fabrics and should not exceed an equivalent of 150 pieces of VDF from both methods of radiation.
Radiation therapy of cancer of bladder.
Indications. The resectable verified bladder tumors 1-3 stages for preoperative radiation therapy in respect of the combined treatment, not radical operations and operations with disturbance of an ablastika for postoperative radiation therapy. Nonresectable tumors, serious associated diseases or refusal of operation - for radiation therapy according to the radical program.
The general serious condition of the patient caused by a basic disease; germination in the next bodies; the dysfunction of both kidneys which is followed by an urosepsis. pyelonephritis; process dissimination.
Both the remote gamma therapy, and bremsstrahlung of high energy can be applied. At static radiation dvukhpolny radiation by counter fields of 12x14 cm is used (with the palliative purpose to 40 Gr.) and trekhpolny radiation (pubic and two inguinal podzdoshnykh at an angle 45 °). At mobile radiation the size of the field makes 8x10 cm and the angle of rotation 220-240 °. At preirradiation of tumors 1-2 stages are recommended the mode of intensive concentrated irradiation: single focal dose of 4 Gr. daily to a total dose of 20 Gr. At the 3rd stage of a disease radiation in the usual mode of fractionation to 40 Gr is more reasonable. with a three-week break before operation. In the postoperative period radiation in the usual mode of fractionation to a total dose of 30-35 Gr. if preirradiation, and to 50 Gr was carried out if it was not. At not radical operations the total focal dose is carried to 60 Gr. Radiation therapy according to the radical program is carried out at the split course in the usual mode of fractionation to a total dose of 70 Gr. At the first stage of treatment the mode of fractionation can on average fractions - on 4 Gr of 7 fractions. The second stage at the same time remains without changes.
Radiation therapy of cancer of gullet.
Considering that the surgical cancer therapy of a gullet is carried out no more, than at 4% of again revealed patients, and the five-year survival does not exceed 10%, at 20-25% of a postoperative lethality, radiation therapy is carried out practically at all patients at a diagnosis verifition. Depending on extent of distribution of process and a condition of the patient treatment is planned according to the radical program or with the palliative purpose.
Germination of a tumor in the next bodies, disintegration of a tumor with bleeding or formation of fistulas, associated diseases of internals in a decompensation stage.
Two-chetyrekhpolnoye static radiation on gamma therapeutic devices or accelerators are used. It is sometimes possible to apply mobile methods of radiations. At the usual mode of fractionation the total focal dose happens till 60-70 Gr on the center and 45-50 Gr on zones of subclinical distribution of a tumor. At palliative courses the focal dose is not false to exceed 40-50 Gr. The size of fields of radiation is dictated to a lokalizatsiyey tumor. At cancer of an average third of a gullet in the field of radiation the chest department of a gullet to a diaphragm and the cellulose adjoining to it joins. At tumors of the lower third the radiation zone in addition joins a subphrenic segment. At tumors of an upper third, except chest department of a gullet, irradiate a cervical segment and regional lymph nodes. In this regard the size of fields on height varies from 18 to 22 cm. Field width usually makes 6 cm. Treatment according to the radical program is most often carried out at the split course with a break for 2-3 weeks after a total dose 40-45gr. At the same time at the second stage the size of the field of radiation on height can be reduced to visible borders of a tumor plus 3-4 cm above and below it.