??t?e?, Te?ape?a ?a? ??????? t??

1
(No Transcript)
2
??????? t?? µeta?t?????? ????st?µ?a?

• ?? ??µ?t???? ?. G?????
• Ot??????a??????????, ?d??t?at???
• ?p?st?µ?????? S??e???t?? t?? Rinecker Proton
  Therapy Center, München, Germany

3
?a???sµ?a ep?pt?s? t?? ?a?????? t?? ?efa??? ?a?
t?? t?a?????

• ???e ?????, pa???sµ??? d?a?????s???ta?
  pe??ss?te?a ap? 500.000 ?t?µa µe ??p??? ?a?????
  t?? ?efa??? ?a? t?? ??a?????

Adesanya MR, Redman RS, Baum BJ, O'Connell BC.
Immediate inflammatory responses to
adenovirus-mediated gene transfer in rat salivary
glands. Hum Gene Ther. 1996 Jun 107(9)1085-93.
4
T??????? ?O? ??????O? ??S ??F???S ??? ??? ????????

• ?? pe??ss?te??? ap? t??? p?s???te? ?a de?????
  ??p??a ?e?ape?a p?? µp??e? ?a pe???aµß??e?
• ?e????????? ?e?ape?a
• ?e????????? ?e?ape?a ??µe???e?ape?a
• ??t????e?ape?a
• ??? ? a?t????e?ape?a e??a? p??? ap?te?esµat??? ??
  ep?p??s?et? ?e?ape?a t?? ?a??????, e? t??t???
  ?µ?? µp??e? ?a ß???e? t??? pa?a?e?µe???? ???e??
  ?st???

5
?a?e????e?e? ??t????e?ape?a?

• ??t?? ap? f??? t?? ?a???????? ??tt???? e???
  ?????, ? ???????sa a?t???ß???a p???a?e? ß??ße?
  st??? f?s?????????? ?st??? p?? e?t?p????ta? p????
  t?? ?????

6
??????? pa?e????e?e? t?? a?t????e?ape?a?

• ?e t?? ???t????sa a?t???ß???a p??sß?????ta?
• ??e????????
• ??e? µas?se?? ?a? ?at?p?s??
• S?e??????? ad??e?
• ?d??te?
• ?st? ??????- ???taf???a????? d?a????se??
• ??ata?a?? t?? ??tta????? ?e?t?????a?

7
???µe? ape???? t?? a?t????e?ape?a? t?? ?efa???
?a? ??a?????

• ?p???e? ???d???? a??pt????
• ?e??d??a? ap? a?t???ß???a ?a?
• ?ste??????s?? µe ???d??? eµf???s?? t??? ?a????
  t? d????e?a t?? ????

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? ?p??e?t?????a t?? s?e??????? ad???? p???a?e?

• ??e???????t?da ?a? ????st?µ?a, ????f???a
• ??s?atap?s?a- ??ata?a?? t?? ??????
• ?p??e?a t?? ??e???
• ?p??e?a ß?????
• ?p??e?a t?? d?ast????t?ta?
• ?at??????
• ??s? p??? a?t??t???a
• ??ata?a?? s??se?? µeta?? s???e??? ?a? ???????a?

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?????? ap?te??sµata st??? µ?e? t?? ?efa??? ?a?
t?? ??a?????

• F?e?µ???de?? a?t?d??se??
• ?p?d??? ?at?p?s?
• ????? t?? ?at?p?s??
• ?e?????sµ?? t?? s?t?s??
• ? ????st?? a?s???eta? d?st???? ?a? se ap????s?
• ??a??pte? t?? f?s????????? a????p??e? ?a?
  ?????????? s??se??

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???a??sµ?? t?? p?????s?? ??e???????t?da? ?a?
????st?µ?a?

• ?a?? t?? e?tetaµ??e? ??e??a? se ????? µ??t??a ?
  a???ß?? µ??a??sµ?? t?? p???a???µ???? ß?aß?? st?
  ß?e??????? t?? a????p?? pa?aµ??e? ????st??

Wang SL, Gao RT. Gene transfer-mediated
functional restoration for irradiated salivary
glands. Chin J Dent Res. 201114(1)7-13.
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??ßa?? e??a? ? ??tta???? ?p??e?t?????a, p??
?d??e? se

• ?p?s?a??sµ?
• ?p??e?a t?? ?e?s??
• ?p??e?a t?? e?a?s??s?a? t?? ß?e????????
• ?e?????sµ? t?? µ????? ??a??t?ta? ??a µetaf?????
  ?e?t?????a t?? ß??µ??
• ?ste?a?t????????s?-?e??d??a
• ???sµ?
• ????st?µ?a

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??ast????µa ?a? µ? a?ast????µa epa??????a t??
a?t????e?ape?a?

• ? ß?e???????t?da ?a? ? ap??e?a t?? ?e?s?? e??a?
  a?ast????µe? ap? e????? µet? t?? a?t????e?ape?a
• ? ?p?s?a??sµ?? ?a? ? ????st?µ?a s?????? e??a? µ?
  a?ast????µa (Bruce J. et al, 2009)

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H ?p??e?t?????a t?? s?e??????? ad???? µet? ap?
s?µßat??? a?t????e?ape?a µe f?t???a

• St??? pe??ss?te???? as?e?e?? ? s?µßat???
  a?t????e?ape?a µe f?t???a p???a?e? d?aµat???
  ap??e?a t?? ??ß?d?a??? ??tt???? p?? e????????
  s?e??, d??t? ?? s?e??????? ad??e? e??a? p???
  e?a?s??t?? st?? a?t???ß???a.
• ?e???? p???a?e?ta? s?ßa?? ?p??e?t?????a t??
  s?e??????? ad????, e??tt?s? t?? pa?a????? s?????
  ?a? ????st?µ?a (Vissink et al. 2003 Nagler and
  Baum 2003).

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??e????t? ? ß??ß? t?? s?e??????? ad???? µet? ap?
a?t????e?ape?a

• ? ß??ß? p?? ?f?sta?ta? ?? s?e??????? ad??e? µet?
  ap? a?t????e?ape?a pa?aµ??e? a????µat???, ?a???
  ta ??ß?d?a?? ??tta?a e??a? ?a??? d?af???p???µ??a,
  d?a?????ta? ß?ad???, p???µa p?? e??a? a?t??et? µe
  t?? ??ass??? st??? t?? a?t????e?ape?a?

Shiboski CH, Hodgson TA, Ship JA, et al.
Management of salivary hypofunction during and
after radiotherapy. Oral Surg. 2007103(Suppl)S66
.e119.
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?? d?at????e? ?µ??, µeta?t?????, epa????
??ß?d?a??? ?st?? e??a? p??a??? ?a a?t?µet?p?ste?
? ?p??e?t?????a t?? s?e??????? ad???? µe
?????e????? f??µa?a
Shiboski CH, Hodgson TA, Ship JA, et al.
Management of salivary hypofunction during and
after radiotherapy. Oral Surg. 2007103(Suppl)S66
.e119.
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?eta?t?????? ?st???????? a??a??? t?? s?e???????
ad????

• ??st???? ?? pe??ss?te??? µeta?t?????? as?e?e??
  ????? s?e???????? ad??e? p?? ?a?a?t??????ta? ap?
  a?ep???e?a ??ß?d?a??? µ??a? ?a? µe ep?ß??s? ?a?
  ep????t?s? p?????? ??tt????, p?? de? e????????
  ????.

(Vissink et al. 2003 Nagler and Baum 2003).
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?pa??????? t?? µeta?t?????? ?p?s?a??sµ?? at?µ??
p?? a?t???ß??????a? se ??p??a pe????? t?? ?efa???
?a? t?? ??a????? e??a? ?

• ????st?µ?a

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?pa??????a t?? µeta?t?????? ????st?µ?a?

• ??ata?a?? t?? p???t?ta? ???? se ?e?ape?µ????? ap?
  ?a????? as?e?e?? ?a? p?????s? s?ßa??? ?a?
  µa?????????? st?µat???? d?ata?a???

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Te?ape?a t?? µeta?t?????? ????st?µ?a?

• ?e? ?p???e? ap?te?esµat??? s?µßat??? ?e?ape?a
• ?? ?p???e? ?e?t??????? ?p??e?p?µe??? ??ß?d?a???
  ?st?? ? s?a???? ?p??e?t?????a µp??e? ?a
  a?t?µet?p?ste? µe ?????e????? f??µa?a
• ?a ?????e????? f??µa?a ????? pa?e????e?e? p??
  a?a??????? t??? as?e?e?? ?a ta d?a??????
• G???d?a?? ?e?ape?a s?e??????? ad????Y, Baum BJ.
  Biochim Biophys Acta. 2011 Nov1812(11)1515-21.
  

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??a??a?t???? ?e?ape?e? t?? µeta?t??????
????st?µ?a?

• ?µ???pa??t??? st?µat?p??se?? µe TRAUMEEL S
• ?e????sµ?? (?? ?a? de? µp??e? ?a p????ße? te?e???
  t?? µeta?t?????? ß??ße? ? ße????sµ??, pe??????e?
  s?µa?t??? t?? µeta?t????? ????st?µ?a

• Braga Fdo P, Lemos Junior CA, Alves FA, Migliari
  DA. Acupuncture for the prevention of
  radiation-induced xerostomia in patients with
  head and neck cancer. Braz Oral Res. 2011
  Apr25(2)180-5.

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??????? t?? µeta?t?????? ????st?µ?a?

• ???s? ???? te?????? a?t????e?ape?a?
• ???s? p?t????? a?t? f?t?????
• IMRT (Intensity Modulated Radiotherapy
• Image Guided Radiotherapy
• ?et??es? s?e??????? ad????

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G?a t?? ??a ? asfa??ste?? te????? p??????? t??
µeta?t?????? ????st?µ?a? e??a? ? a?t????e?ape?a
µe p??t???a

• ?e t?? ?p???asµat??? ?e?ape?a p??t?????
  ?????e?ta? ? p??a?? s?st? d?s? st?? ????
• ????? t? 1/6 t?? d?s?? t?? ????? p??sp?pte? st???
  ???? ap? t?? ???? ?st???.
• ?e?????sµ?? t?? ?????? ?e?ape?a? ?at? 3-4
  eßd?µ?de? a?t? ??a t? ?e?ape?a t?? 8 eßd?µ?d??
  t?? ?e?ape?a? µe f?t???a.
• ?a p??t???a e??a? ?a??te?a a?e?t? ?a? e??a?
  ????te?? t?????, p??state???ta? ?a? d?at????ta?
  t??? s?e???????? ad??e? ?a? d?at????ta? t?? ?a??
  p???t?ta ???? t?? as?e???.

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?? e??a? ? a?t????e?ape?a µe p??t???a

• ?? a?t??e? ? ?a? ?? a?t??e? p??t????? µp??e? ?a
  e?t??e?t??? ?a? ?? d?? µe e?a??et??? a???ße?a.
• ?a?? t??t? ? s????t?ta t?? a?t??a? p??t?????
  µp??e? ?a e?e???e? µe a???ße?a ?a? ?a efa?µ?ste?
  µ?a ?e?ape?a t???? d?ast?se??, p???µa p?? de?
  s?µßa??e? µe t?? a?t??e? ?
• ???t? ?fe??eta? st? ?eµe???d? d?af??? µeta?? t??
  f?s???? ?d??t?t?? t?? ??e?t??µa???t???? ??µ?t??
  (a?t??e?-?) ?a? t?? ep?ta????µ???? s?µat?d???
  (p??t???a) ?a? e??a? ?e?ape?a t???? d?ast?se??

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??af???? d?s?????a? ß????? µeta?? t?? a?t???? ?
?a? t?? p??t?????

• ?? p??f?? t?? ??t???? - ?
• ?e?a??te?? d?s? µp??st? ap? t?? ????
• ? ????? pa???e? µ??? t? 76 t?? d?s??
• ?? ?st?? p?s? ap? t?? ???? d????ta? s?µa?t???
  a?t???ß???a

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??af???? d?s?????a? ß????? µeta?? t?? a?t???? ?
?a? t?? p??t?????

• ???f?? t?? p??t?????
• ???? t? 1/6 t?? d?s?? p??? ap? t?? ????
• 100 e?ap??es? t?? d?s?? µ?sa st?? ????
• ?aµ?a d?s? p?s? ap? t?? ????

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?a p??t???a e??a? ????te?? t?????

• ? a?t????e?ape?a ???eta? se t?e?? d?ast?se??
• ???? t? 1/6 t?? d?s?? t?? ????? p??a??e? st???
  ?st??? ???? ap? t?? ???? ?a? ?ts? ta e?a?s??ta
  ???a?a µp????? ?a p??state?t???

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• ?? ????? s???? ??e?????ta? ?????te?? d?s?
  a?t???ß???a? ap? t??? f?s?????????? ?st??? p??
  t??? pe??ß??????. ?? f?s????????? ?µ?? ?st?? de?
  a?????ta? a?t? t? d?s?????a.
• ?? ????? ???p?? ??e?????ta? ????? t?p??? d?s?
  a?t???ß???a?. St?? p???? ?µ?? a?t? de?
  ep?t?????eta?, d??t? ? d?s? pe??????eta?,
  p???e?µ???? ?a p??state?t??? ?? p???? t?? ?????
  ?st?? ?a? ?a pe?????st??? ?? pa?e????e?e?.
• S??epe?a t??t?? ? ????? de? µp??e? ?a ?atast?afe?
  ?a? ? ?p?t??p? e??a? a?ap?fe??t?.

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Ne?te?? te????? IMRT (Intensity Modulated Radio
Therapy). T??p?p??e? s??e??? t?? pe??µet?? ?a?
t?? ??tas? t?? a?t???? ? ?a? ? ?????d??? t??
a?t???? ? pe??st??feta? e?? a?t???ß??e?ta? ?
?????

• ?? ?a? ep?t?????eta? ??a ?a?? ap?t??esµa
  a????ep???????? t? ?eµe???de? p??ß??µa pa?aµ??e?
  ?? IMRT de? µp??e? ?a ?epe??se? t??? f?s?????
  pe?????sµ??? t?? a?t???? ?
• ?? IMRT de? pe??????e? ??s?ast??? t?? ???es? t??
  ????? ?st?? ap? t?? a?t???ß???a.
• ? µ? e?????? a?a????a t?? ???s?µ?? p??? t??
  ep????d??? a?t???ß???a de? t??p?p??e?ta?

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?d??t?te? t?? a?t???? p??t?????

• Se a?t??es? µe t?? a?t??e?-? ? a?t???ß???a
  p??t????? ap????e?e? µ?a µ????te?? d?s? µp??st?
  ap? t?? ????.
• ? ?st?? p?s? ap? t?? ???? de? e?t??eta? se
  ?p??ad?p?te a?t???ß???a. ??t? t? f?s???
  fa???µe?? ?a??st? p??a?? t?? ?a????sµ? t?? ß?????
  t?? ????f?? Bragg µ?s? t?? t??p?p???s?? t??
  ta??t?ta? t?? s?µat?d??? ?a? est?as?? t??
  a?t???ß???a? t??sd??stata µ?sa st?? ????,
  ße?t?????ta? s?µa?t??? t?? a?a????a t?? ?a???
  p??? t?? ?a?? a?t???ß???a

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St? t???? t?? d?e?sd?t???? ß????? st?? ????f?
Bragg, ta p??t???a d?at??p??ta? t?? ?st?
ape?e??e?????? ?µ??e? p?s?t?te? e????e?a? sta
µ???a, ?p?? ?????? ?a? ta f?t???a (a?t??e?-?) ,
t??????st?? ?s?? af??? t?? pa???s?a ?d??????? st?
??tta???? ?e??. ?a? st?? d?? pe??pt?se??, a?t?
p???a?e? ta µ???a ?a ap???s??? ??e?t????a. ?
?st?? st? s????e?a ?e???e? t?? a?t?a ap??e?a?
??e?t?????? (e?te e??a? f?t???a, e?te e??a?
p??t???a) ?a? t?? epa??????? ????sµ?. ? ????sµ??,
e??a? ?µ???? ?a? ??a t??? d?? t?p??? t??
a?t???ß???a?, a??? e??a? p?? ap?te?esµat????
st?? pe??pt?s? t?? p??t?????, d???ta? ??
??tta???? t????? ?p?? ape??????eta? st?? e????a .
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???s?µ?p????ta? a?t??e? p??t????? a?t? a?t???? ?
t? ?at???? p??s?p??? µp??e? ?a a???se? t?
?e?ape?t??? d?s? t?? a?t???? p??t?????, ? ?p??a
pe??????eta? st?? pe??pt?s? t?? a?t???? ?, ????
t?? pa?e?e??e??? t???, e?? ta?t?????a
pe??????eta? ? d?s? p?? e?ap?t??eta? st???
?st???.

• St?? ??????? p????, ? e?e???µe?? a?t???ß???a
  p??t?????, p?? e??a? t??sd??stat? µ?????, pa??
  d?sd??stat?, ??e?a t?? p????a? desµ?d?s??
  pe??????e? t?? a?t???ß???a p?? e?ap?t??eta? st???
  ???e?? ?st??? ???d???? se p?s?st? 43-78,
  a?????a µe t? ?e?µet??a t?? ?????.

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S?????se?? ?ata??µ?? d?s?? st?? ?d?? as?e??.
St?? a??ste?? e????a d?a????eta? ? s?µßat???
a?t???ß???a f?t????? p?? p?a?µat??? pa???e? ?
as?e???. St? de??? e????a fa??eta? ? ??tas? t??
p??a??? ???es?? t?? as?e???? st?? a?t???ß???a
p??t?????. ? ?ept? es?te???? ??aµµ? µ?sa st??
???e e????a de???e? ta ???a t?? ?????, p??
ß??s???ta? ?p? st??e?s?, e?? ta ???a ???µata
a?t?st?????? st? d?s? p?? ape?e??e???eta?
t?p???.

• X-rays

• Protons

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?p?t??p????? ????? t?? ????f?????a. ? s?µßat???
a?t????e?ape?a µe a?t??e? ? st?? a??ste?? e????a
de???e? t?? apa??de?t? ???es? st?? a?t???ß???a
t?? p???? t?? ????? ????? ?st??. Sa?t? t??
pe??pt?s? ?? s?e??????? ad??e? pa?a????? s?ßa??
ß??ß?. St?? a??ste?? e????a d?a????eta? ?
a?t???ß???s? t?? ?d??? ????? µe p??t???a, ?at?
t?? ?p??a de? ß??pt??ta? ?? s?e??????? ad??e?
Protons
X-rays
34

• ??t???ß???s? ????? t?? ????f?????a µe f?t???a
  (a?t??e? ?)

35

• ??t???ß???s? ????? ????f?????a µe p??t???a

36
??t???ß???s? e??efa????? µet?stas?? µe f?t???a
(a?t??e? ?)
37
??t???ß???s? e??efa????? µet?stas?? µe p??t???a
38
??????? ?f??? t?? ?e?ape?a? µe p??t???a

• ?e?t???e? t?? p??a??t?ta ?e?ape?a?
• ????te?e? s?ßa??? pa?e????e?e?.
• ?e??ss?te?e? ?e?ape?t???? d??at?t?te?
• ?e?????sµ?? t?? ?????? ?e?ape?a?
• ?p?f??? t?? ????st?µ?a? ?a? t?? d?s?atap?s?a?
• ??at???s? t?? ?a??? p???t?ta? t?? as?e????

39
???? t?? a?t???ß???a? p??t????? (superconducting
cyclotron, 250 Mev protons)
40
O ???aµ?? a?t????e?ape?a? p??t????? µe t? s?s?e??
st??e?s?? (gantry) st? Rinecker Proton Therapy
Center st? ???a?? t?? Ge?µa??a?
41
?at? t?? a?t???ß???s? µe p??t???a ? as?e???
a????t?p??e?ta? se e?at?µ??e?µ??? st??µa, ?p?? µe
e?d??? t??p? a????t?p??e?ta? p????? ? as?e???. ?
????? t?? a?t???ß???a? µp??e? ?a pe??st?afe? ?at?
360 µ???e? ???? ap? t?? as?e??
42
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