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1、Introduction Case Discussion,case,discussion,introduction,SNTCS,sino nasal terato carcino sarcoma, 80 cases reported,case,discussion,introduction,History,Vencent J. Hyams Director of the Otolaryngic Pathology branch of the Armed Forces Institute of Pathology，1968-1984,Teratoid carcinosarcoma ? Mixed
2、 mesodermal tumour ? Malignant teratoma and blastomas ?,1984,case,discussion,introduction,Characteristics,T1-weighted MR reveals a soft tissue filling the left ethmoid sinus, as uniformly high signal (*), and effusion (white arrowhead) in the left sphenoid sinus. Takasaki, K.,2006,Epithelial glandul
3、ar carcinoma (at right) and osteosarcoma component (at left). (hematoxylin-eosin, original magnification x40). Smith, S. L.,2008,Endoscopic examination showing a left sinonasal tumor in the left middle turbinate. M, middle turbinate; S, nasal septum. Su, Y. Y., 2010,Treatment,case,discussion,introdu
4、ction,Patients generally present with locally advanced-stage disease the highly malignant, aggressive biological behavior the presence of air filled paranasal spaces permits silent growth Distant metastasis of SNTCS is unusual and the most common cause of treatment failure is local recurrence Surgic
5、al excision and postoperative radiotherapy has become the most widely accepted therapeutic plan,Introduction Case Discussion,HPI,introduction,discussion,case,42-year-old man Two weeks history of progressive left nasal obstruction and intermittent nasal bleeding Nasal examination showed a moderately
6、firm, reddish-purple mass in the left meatus Biopsy of the tumor revealed a heterogeneous admixture of epithelial and mesenchymal elements, suggesting SNTCS,Teratocarcinosarcoma Teratocarcinosarcoma consists of two components, epithelial and mesenchymal (hematoxylin-eosin, original magnification 200
7、),cT3N0M0,MRI,introduction,discussion,case,MRI revealed a soft tissue filling the left meatus, maxillary and ethmoid sinus, and effusion in the left maxillary sinus,introduction,discussion,case,Anterior craniofacial resection IMRT GTV included the residual gross disease in the nasal cavity and paran
8、asal sinus CTV-60 includes the GTV with a 510 mm margin, the whole nasal cavity and the involved paranasal sinus CTV-54 high-risk local structures (including the whole nasopharynx, lower half of sphenoid sinus, et al) lymphatic regions (including ipsilateral lymph node levels IB, II, III and VA) A 3
9、-mm margin was added to produce PTVs PTV-66 was prescribed to 66 Gy with 2.2 Gy/fraction PTV-60 was prescribed to 60 Gy with 2.0 Gy/fraction PTV-54 was prescribed to 54 Gy with 1.8 Gy/fraction,Treatment,Follow-up,introduction,discussion,case,Now 3.5 years have passed since the irradiation therapy No
10、 severe dry-eye syndrome, and other severe radiation-induced ocular toxicities happened No evidence of recurrence or metastasis,Introduction Case Discussion,Shoulders ?,introduction,case,discussion,Sinonasal tumors,Frontal Sinus Maxillary Sinus Ethmoid Sinus Spenoid Sinus,1,2,3,4,Challenge !,introdu
11、ction,case,discussion,IMRT,introduction,case,discussion,3-beam conventional 2D,6-beam conventional 3D conformal,7-beam IMRT,A dosimetry comparison between (a) a 3-beam conventional 2D treatment, (b) a 6-beam conventional 3D conformal RT treatment, and (c) a 7-beam IMRT treatment. The PTV is represen
12、ted by the solid red line. The 100% and 70% of the prescription dose are shown by the green and red colour-washed areas. A better dose conformity to the PTV can be achieved in the IMRT treatment.,Ghent Experience,introduction,case,discussion,2009,Madani, I., 2009,Dosevolume Constraints,introduction,
13、case,discussion,Madani, I., 2009,Visual Pathway Dose,introduction,case,discussion,Madani, I., 2009,Acute Toxicity,introduction,case,discussion,Madani, I., 2009,Studies Reported,introduction,case,discussion,Madani, I., 2009,CTV Delineation,introduction,case,discussion,Implementation Strategy,2001,int
14、roduction,case,discussion,Claus, F.,2001,introduction,case,discussion,“Compartment-related CTV Definition”,In those regions where GTV was flanked by intact bone, no margin was added In those regions where GTV invaded compartments enclosed by bone, like other paranasal sinuses, or extended up to thei
15、r ostia, the whole compartment was included in the CTV contours In those regions where GTV invaded radiologically defined spaces known to resist poorly invasion by malignant tumors (e.g., masticator or parapharyngeal spaces), the entire space was added,Claus, F.,2001,Cervical Lymph Nodes,Duthoy, W.,
16、2005,introduction,case,discussion,2005,LN Recurrence,Duthoy, W.,2005,introduction,case,discussion,2006,introduction,case,discussion,CTV Delineation cont,CTV Delineation cont,“ Indeed, in absence of unambiguous information on the surgical procedure and comprehensive report of the pathological analysi
17、s, a too selective selection and delineation of the CTV may lead to an unacceptable high rate of loco-regional recurrences ”,Vincent Gregoire, 2006,It will not be inappropriate to be generous in target volume delineation,introduction,case,discussion,Conclusion,introduction,case,discussion,may result in a decrease in ocular toxicity,The appropriate implementation of IMRT for sinonasal tumors,including our SNTCS patient,without compromising local control,Thank you for your attention !,武汉协和医院,