鼻咽癌腮腺淋巴结转移危险因素及高危患者腮腺局部调强放疗的探讨

目的 探讨鼻咽癌腮腺淋巴结转移的高危因素,评价高危者腮腺放疗的可行性。方法 收集2011-2017年江苏省肿瘤医院放疗科收治的440例初诊鼻咽癌患者的临床资料,回顾性分析腮腺淋巴结转移相关的影像特点、治疗及预后。全组采用调强放疗技术,全腮腺或部分腮腺照射、选择性PLN照射,X线和(或)电子线补量,剂量45~60 Gy。χ²检验或Fisher's精确概率法检验和单因素分析,Logistic回归模型多因素分析。Kaplan-Meier法生存分析,Logrank检验差异。结果 腮腺区影像学可见淋巴结者共230例。确诊腮腺转移11例(占2.5%,11/440),其中腮腺淋巴结最大径≥5 mm者占81.8%(9/11)。多因素分析显示Ⅱ区淋巴结包膜外侵为其转移的独立危险因素。将腮腺区淋巴结最大径≥5 mm、Ⅱ区淋巴结包膜外侵者筛选为腮腺淋巴结转移高危组,根据腮腺区是否放疗分为放疗组及未放疗组。生存分析发现,在230例患者中,高危组腮腺区放疗者与未放疗者无局部复发生存率不同(P<0.05),总生存、无远处转移生存、无进展生存均相近(P>0.05)。结论 鼻咽癌腮腺淋巴结转移率低,Ⅱ区淋巴结包膜外侵为其独立高危因素。对于腮腺淋巴结最大径≥5 mm,或腮腺区存在影像学可见淋巴结,即使其最大径<5 mm,但若合并Ⅱ区淋巴结包膜外侵,建议行腮腺区放疗。

The risk factors of parotid lymph node metastasis of nasopharyngeal carcinoma and the feasibility of local intensity-modulated radiotherapy for high-risk patients

Objective To investigate the high-risk factors for parotid lymph node (PLN) metastasis from nasopharyngeal carcinoma (NPC) and evaluate the feasibility of local intensity-modulated radiotherapy (IMRT) in patients with high-risk NPC. Methods Clinical data of 440 NPC patients admitted to Department of Radiotherapy of Jiangsu Cancer Hospital from May,2011 to March,2017 were collected. The imaging features,treatment strategies and clinical prognosis of PLN metastasis were retrospectively analyzed. The whole group adopts the technique of intensity modulated radiotherapy. Total parotid or partial parotid irradiation, selective PLN irradiation, X-Ray and/or electronic line supplementation, dose 45-60 Gy. The χ² test or Fisher's accurate probability method test and single factor analysis,Logistic regression model multi-factor analysis. Kaplan-Meier survival analysis,log-rank test differences. Results PLN was observed in the parotid of 230 cases. At the end of follow-up,11 patients (2.5%,11/440) were diagnosed with PLN metastases. Among 11 cases,9 patients (81.8%) had PLN size ≥5 mm. Multivariate analysis demonstrated that extracapsular spread of level Ⅱ was an independent risk factor for PLN metastasis. The patients with PLN size ≥5 mm or extracapsular spread of level Ⅱ were assigned into the high-risk PLN metastasis group. The patients in the high-risk group were further divided into the radiotherapy and non-radiotherapy subgroups. Survival analysis demonstrated that for 230 patients with PLN metastasis,the local recurrence-free survival (LRFS) significantly differed,whereas the overall survival (OS),disease metastasis-free survival (DMFS) and progression-free survival (PFS) did not considerably differ between the radiotherapy and non-radiotherapy subgroups in the high-risk PLN metastasis patients. Conclusions The PLN metastasis rate of NPC is low. Extracapsular spread of level Ⅱ is an independent risk factor. Radiotherapy of the parotid region is considered for patients with PLN size≥5 mm or those with PLN size<5 mm complicated with extracapsular spread of level Ⅱ.