臺灣博碩士論文加值系統

背景
肝癌在台灣是排名第二常見的惡性腫瘤。當肝癌合併肝門靜脈或下腔靜脈阻塞時，目前為止治療效果不好，預後差。對於上述情形，放射線是主要的治療方式。腫瘤於放射治療時需增加安全距離，以防止正常組織在放射治療時受到過多的傷害。本研究的目的主要在探討治療相關的預後因子，如何執行有品質與安全的放射線治療。
方法
選擇分析肝癌合併門靜脈阻塞病人資料，包含人口基本資料，於治療前後的血液生化值、腫瘤相關特性，放射治療方式。主要觀察的為整體存活時間。上述可能的預後因子，須經過單變相與多變項分析。計算計劃靶體積，以評估進行肝腫瘤放射治療時需增加多少安全距離，能符合國際上對於肝臟放射耐受之安全劑量範圍。藉由螺旋光子刀，於腹腔腫瘤放射治療時，記錄肝臟不同方向的每日誤差。
結果
自2009年4月至2012年10月，共10位病人有肝癌合併肝門靜脈阻塞，並接受放射線治療。整體平均存活時間，有超過一半治療反應的約14.1個月，無反應或變差的，只有4.3個月（p=0.001）。治療前的不好預後因子包含嚴重的期別、年紀大於60歲、B型肝炎陽性、高AST數值與差的child-pugh classification。治療後的不好預後因子包含高膽紅素值、低白蛋白、高AST數值（p <0.05）。可視腫瘤需增加距離成為計劃靶體積，X（左/右），Y（上/下），Z（進/出）最大值分別為 4公厘、8公厘、8公厘。每日隨機誤差X、Y、Z平均值分別為3.01公厘、2.8公厘、3.14公厘。
結論
研究結果有助於了解對於肝癌合併肝門靜脈栓塞病人，會影響生存時間的預後因子。放射線治療對於肝門靜脈治療是有效的。須小心增加適當且安全的距離，來克服每日移動的誤差。

BACKGROUND
Hepatocellular carcinoma（HCC）is the second most common malignancies in Taiwan. Patients with HCC who had portal vein or inferior vena cava tumor thrombosis （PVT or IVCT） are considered as poorer treatment outcomes and radiotherapy （RT） is main treatment for those patients. In cancer radiotherapy, safety margin should be added around gross tumor volume （GTV） to overcome uncertainties in planning or treatment delivery. To clarify prognostic factors, safety and quality of RT in those patients is important for further therapeutic design.
METHODS
Patients with HCC who had PVT or IVCT and received RT were enrolled in this study. Demographic variables, laboratory values, tumor characteristics, and RT modalities were determined before and post RT. The primary end point was overall survival. Predicted factors of survival were identified using the univariate and multivariate analysis. Calculation of planning target volume （PTV） was used to evaluate the safety margin. The imaging records of TomoTherapy in treatment of abdomen or pelvic tumors were used to evaluate daily different directions motion of liver.
RESULTS
Ten patients with HCC who had PVT or IVCT received RT between April 2009 and October 2012 were enrolled. Overall median survival in partial response group was 14.1 months versus 4.3 months in stable or progress group （p =0.001）. Pretreatment unfavorable predictors were advanced stage, old age, positive of HBsAg, higher AST（aspartate aminotransferase） and poorer Child–Pugh classification. Post treatment unfavorable predictors were higher total biliribum, lower albumin, higher AST （95% confidence interval, p <0.05）. GTV safety maximal margin at different directions of X（right/left）, Y（up/down）, Z（in/out） were 4mm, 8mm and 8mm, respectively. Daily random motion of abdomen or pelvic tumor treatment, mean value at different directions of X, Y and Z were 3.01mm, 2.8mm and 3.14mm, respectively.
Conclusions
The results will help in understanding the potential factors that influence survival for patients with HCC after RT. Radiotherapy is effective for PVT or IVCT. Careful add adequate margin could safely overcome daily motions.

第一章 前言-----------------------------------------------------------------------1
第二章 文獻探討-----------------------------------------------------------------2
第一節 肝癌致病因子與診斷--------------------------------------------2
1. 致病與危險因子----------------------------------------------2
2. 臨床症狀與致死原因----------------------------------------2
3. 診斷方法-------------------------------------------------------3
3-1血液檢查--------------------------------------------------3
3-2腹部超音波檢查-----------------------------------------4
3-3電腦斷層掃描--------------------------------------------4
3-4核磁共振攝影--------------------------------------------5
3-5穿刺切片檢查--------------------------------------------5
第二節 肝癌的期別分級--------------------------------------------------6
1. 美國癌症聯合協會(AJCC TNM)分級系統--------------6
2. 巴賽隆納臨床肝癌系統-------------------------------------9
第三節 肝腫瘤的治療----------------------------------------------------10
1. 外科手術治療------------------------------------------------10
2. 射頻灼燒法---------------------------------------------------10
3. 經肝動脈栓塞治療------------------------------------------10
4. 標靶藥物治療------------------------------------------------10
5. 體外放射線治療---------------------------------------------11
第四節 肝癌治療預後----------------------------------------------------12
第五節 ICRU62報告-----------------------------------------------------13
第三章 研究設計----------------------------------------------------------------14
第一節 研究背景與動機-------------------------------------------------14
第二節 研究目的----------------------------------------------------------16
第三節 肝癌病人對於放射線治療反應與預後之差異因子分析-17
1. 研究對象------------------------------------------------------17
2. 研究方法與紀錄---------------------------------------------17
3. 統計分析方法------------------------------------------------19
第四節 肝癌放射治療計劃評估研究----------------------------------20
1. 研究對象------------------------------------------------------20
2. 研究方法與紀錄---------------------------------------------20
第四章 研究結果----------------------------------------------------------------25
第一節 肝癌病人對於放射線治療反應與預後之差異因子分析-25
第二節 肝癌放射治療計劃評估研究----------------------------------27
第五章 討論----------------------------------------------------------------------30
第一節 肝癌病人對於放射線治療反應與預後之差異因子分析-30
第二節 肝癌放射治療計劃評估研究----------------------------------35
第六章 結論與建議-------------------------------------------------------------36
第七章 未來展望----------------------------------------------------------------38
參考文獻--------------------------------------------------------------------------39

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