局限性残留、复发鼻咽癌的鼻内镜进路救援性外科治疗

背景与目的:对于放疗后鼻咽局限性残留、复发鼻咽癌,二程放疗可以使部分患者得到长期局部控制,但其放射性后遗症也相当严重:而救援性外科手术在取得相仿甚至更优疗效的同时,避免了这些放射性后遗症.然而,传统开放式手术进路创伤大,术野欠清晰,难以按肿瘤外科原则进行连续、整块切除.本研究旨在探索一种新的微创性鼻内镜进路的复发鼻咽癌外科治疗方法.方法:从2004年9月至2007年1月,25例放疗后鼻咽局限性残留或复发鼻咽癌患者在中山大学肿瘤防治中心进行经鼻内镜鼻咽切除术,将鼻咽肿瘤和足够的安全边缘连续、整块切除.观察其疗效和并发症.结果:25例患者均在鼻内镜进路下按肿瘤外科手术原则进行根治性整块切除,仅1例切缘阳性,鼻咽创面愈合良好,均未追加术后放疗.中位随访时间13个月(3～31个月),1例原位残留,3例术后原位复发,无远处转移和死亡.1年总生存率100%,无局部复发生存率达86.0%.无张口、吞咽、发音困难和其他手术并发症发生,无围手术期死亡.结论:鼻内镜进路鼻咽癌救援手术能充分暴露鼻咽以及咽旁间隙浅部,能将鼻咽残留、复发病灶按肿瘤外科原则进行连续、整块根治性切除,并发症少而轻,近期疗效满意.     

62例鼻咽癌常规放疗5年后局部区域复发的再程常规放疗分析

目的 了解鼻咽癌患者放疗后的远期(疗后5年以上)局部区域复发情况,以及复发患者再程治疗的预后.方法 2000年前10年经病理组织学确诊并接受旨程常规放疗的鼻咽癌患者1384例中局部区域复发350例,疗后至复发时间6-171个月.5年后复发62例,其中鼻咽复发41例,颈部复发19例,鼻咽+颈部复发2例.62例中37例接受了再程常规放疗,其中1例颈部淋巴结复发者再程常规放疗4年后再次复发,接受第3程常规放疗;25例末接受再程常规放疗,其中1例颈部淋巴结复发行外科颈清扫,余因各种原因未接受再次治疗或仅行对症处理.结果 全部随访到的患者(1277例)中复发后无再放疗者中位生存14个月(95%CI=7.1～20.8个月),无5年生存;接受冉程放疗者中位生存44个月(95%CI=30.4～57.6个月),5年生存率达42%.结论 鼻咽癌常规放疗5年后仍有局部区域复发,复发患者再程放疗预后较好.     

69例复发鼻咽癌近距离超分割放疗远期疗效分析

背景与目的:局部复发是鼻咽癌治疗失败的原因之一.复发鼻咽痛再治疗有放疗、手术、化疗及靶向治疗等,其中放疗是最主要的方法.再放疗有多种方式,包括常规外照射、近距离治疗、三维适形及调强放疗等.本研究通过回顾性分析局部复发再分期为早期的鼻咽痛采用单纯腔内近距离超分割放疗或联合常规外照射的远期疗效及晚期放射性损伤,评估近距离超分割放疗在复发鼻咽癌中的应用价值.方法:鼻咽癌首程放疗后局部复发再分期为T1和T2的69例患者,其中rT1 51例,rT2 18例.20例接受单纯腔内近距离超分割放疗,每次2.5～3.0 Gy,每天2次,间隔超过6 h,连续治疗5 d,休息1周后再连续治疗5 d.照射剂量为40~50 Gy,中位剂量50 Gy.49例在常规外照射剂量达30~65 Gy,中位剂量50 Gy,休息1～4 d后加用腔内近距离推量8～48 Gy,中位剂量20 Gy,近距离照射方式同前.结果:全组再程放疗后3年和5年生存率分别为59.66%和39.66%:3年和5年局部摔制率分别为86.3%和77.2%;晚期并发症中鼻咽溃疡发生率26.1%;张口受限39.1%;后组颅神经损伤30.4%;放射性脑病13.0%.再放疗后单纯近距离治疗组及联合治疗组张口受限分别为4例和23例(P=0.038),鼻咽溃疡分别为6例和12例(P=0.636).结论:鼻咽癌复发再分期为早期者采用腔内近距离超分割放疗临床实施可行,值得推荐.     

140例局部复发鼻咽癌患者三维适形放疗的疗效分析

背景与目的:局部复发鼻咽癌再次放疗的方式很多,但常规放疗后良反应大,目前关于三维适形放疗(three dimensional conformal radiation therapy,3D-CRT)治疗复发鼻咽癌的报道较少,本研究旨在分析3D-CRT对140例局部复发鼻咽癌患者的疗效及其不良反应.方法:本院于1997年5月-2009年6月对140例经病理活检和(或)通过CT/MRI证实颅底病变或颅神经症状进展而确诊为局部复发的鼻咽癌患者采用3D-CRT治疗.患者中位复发时间为27.5个月(1～156个月),50.7％患者的复发为T3-4期,患者3D-CRT治疗的最小计划放疗剂量是GTV-P为DT 59.4 Gy/1.8～2 Gy(联合或不联合化疗).结果:复发后中位照射剂量是62 Gy (39～82 Gy);中位随访时间25.5个月(3～135个月),随访率100％.3、5年的总生存率(overall survival,OS),无瘤生存率(disease-free survival,DFS),局部控制率(locoregional recurrence-free survival,LRRFS)分别为44.53％ vs 31％,42.82％ vs 29.13％,44.19％ vs 30.76％.48例患者(34.3％)出现中重度并发症,其中鼻咽溃疡13例(9.29％),颅神经损伤21例(15％),张口困难20例(14.3％),听力下降16例(11.4％).多因素分析显示年龄是独立的预后不良因素.结论:采用3D-CRT对局部复发鼻咽癌安全、有效,不良反应可以耐受.     

30例复发鼻咽癌陀螺旋转式60Co放射治疗系统放疗的疗效

目的分析陀螺旋转式60Co放射治疗系统(以下简称陀螺刀)治疗复发鼻咽癌的疗效。方法回顾性分析30例复发鼻咽癌中男24例,女6例,中位年龄52岁(34～73岁)。中位复发时间24个月(6～125个月)。所有患者均接受局部陀螺刀放疗,放疗剂量:2.5Gy/次,16～20次,每周照射5次。观察放疗疗效以及相关毒副反应。结果 1年总生存率87%,1年局部无进展生存率67%;1例出现Ⅲ度以上皮肤黏膜反应,余急性反应轻;肿瘤控制情况:CR57%(17/30),PR30%(9/30),NC10%(3/30),PD3%(1/30);4例因鼻咽大出血休克死亡,1例因全身衰竭死亡。结论陀螺刀是复发鼻咽癌有效的治疗手段,急性损伤小,鼻咽大出血可能是主要的死因。     

24例局部进展期胃癌术中放疗预后分析

目的 初步探索局部进展期胃癌手术联合术中放疗的治疗效果.方法 对24例局部进展期胃癌患者手术加术中放疗的临床病理资料进行前瞻性研究.运用Kaplan-Meier法计算患者无瘤生存率和总生存率,运用Cox比例风险回归模型对患者术后复发的影响因素进行分析.结果 24例患者中,21例患者行D2淋巴结清扫胃癌根治术;3例患者接受了姑息性切除手术,其中2例患者镜下切缘阳性,1例患者肉眼切缘阳性.所有患者均接受了术中放疗(1500 cGy,6 MeV).所有患者未出现手术并发症和放疗并发症.术后中位随访时间为19.5个月(2~63个月),1例患者出现局部复发,2例患者出现肺转移,3例患者出现腹腔转移,7例患者出现肝转移,局部控制率为95.8%.Kaplan-Meier法计算结果 显示,术后患者的中位无进展生存期为18个月,中位总生存期为23个月,5年总生存率为35.4%.Cox比例风险回归分析未发现无进展生存的独立影响因素.结论 术中放疗是局部进展期胃癌综合治疗的有效手段之一,可以提高局部进展期胃癌的局部控制率.     

局部晚期鼻咽癌同步时辰放、化疗的近期疗效观察

目的:观察局部晚期鼻咽癌同步时辰放、化疗及后程三维适形放疗的肿瘤局部控制率和不良反应的发生情况.方法:2005年8月-2007年8月共纳入67例局部晚期鼻咽癌患者(Ⅲ～ⅣA),常规放疗40 Gy后行鼻咽病灶后程三维适形放疗30 Gy.整个放疗过程中同步时辰给予顺铂、氟尿嘧啶和亚叶酸钙化疗,观察患者的近期疗效和不良反应.结果:1例患者因发生Ⅳ级口腔黏膜炎而放弃同步放、化疗.放疗结束后3个月内,66例患者中无一例发生放疗野内的肿瘤复发,其中鼻咽部肿瘤和颈部病灶达完全缓解者49例(74.2%),部分缓解15例(22.7%),疾病稳定2例(3.0%),无一例患者发生疾病进展.治疗有效率达97.0%.不良反应均可耐受.结论:同步时辰放、化疗及后程三维适形放疗治疗局部晚期鼻咽癌的近期疗效令人满意,且不良反应基本可以耐受.     

经鼻咽旁插植组织间后装治疗在鼻咽癌放疗后程加量中的应用

背景与目的:后装近距离治疗常常用于早期鼻咽癌放射治疗后程加量,但常规施源器置入方法定位不准、重复性差,无法向咽旁追量.本研究采用存鼻窦内窥镜引导下进行咽旁插植后装放疗的新方法,旨在解决常规后装治疗的上述缺陷.方法:选择2005年9月至2006年8月初治和复发鼻咽癌外照射后仍有鼻咽粘膜下肿瘤残留超过1 cm或/和咽旁浸润但侵犯范围较局限的患者23例,在鼻窦内窥镜引导下经鼻腔进行鼻咽及咽旁施源器插植术,术后经CT扫描定位并确认插植位置合格后,利用三维近距离治疗系统进行鼻咽、咽旁肿瘤靶区勾画、剂量优化和组织问近距离治疗,测量治疗前后施源器植入的深度,并观察近距离治疗的疗效及并发症.结果:施源器均准确插入肿瘤区,插植位置100%合格.插人和拔出施源器时粘膜下植入深度分别为(9.59±2.72)mm和(9.43±2.30)mm,两者差异无统计学意义(t=0.23,P＞0.05);漂移长度为(0.75±0.75)mm.治疗后3个月内肿瘤完全消失,无肿瘤局部复发,无远处转移.随访3～15个月(中位随访时间6个月),随访率100%,无大出血、感染等手术并发症,无腭穿孔、鼻咽坏死等严重后装放疗并发症;3例鼻甲粘连,经分解后完全缓解.结论:经鼻窦内窥镜鼻咽、咽旁插植定位准确,固定良好,安全可行;对鼻咽癌放疗后鼻咽、咽旁残留病灶进行组织问近距离治疗近期疗效良好,无严重近期并发症.     

鼻咽癌调强放疗后局部复发的临床分析

[目的]探讨鼻咽癌调强放疗(IMRT)后局部复发的临床特征。[方法]回顾分析174例初治鼻咽癌IMRT局控率及11例确诊为局部复发患者的临床特点。[结果]1、3、5年局部复发率分别为0.6%、5.6%、6.4%。局部复发时间:放疗后11~61个月,其中9例(9/11,81.8%)3年内复发;余2例复发时间分别为53个月、61个月。11例局部复发病例中10例(10/11,90.9%)为原GTV区域野内复发。不同T分期及临床分期之间局部复发无明显差异。11例局部复发患者,7例接受了放疗为主的二程综合治疗,仅1例筛窦边缘复发的患者获得长期无瘤生存;其余6例,1例死于二程放疗后鼻咽大出血,5例均于二程放疗后1年内再复发。[结论]鼻咽癌IMRT后局部复发率低,局部复发形式以GTV高剂量区野内复发为主;局部复发与T分期及临床分期无明显相关性;复发患者二程调强放疗疗效差。     

鼻咽癌放疗后海绵窦复发再程放疗临床回顾性分析

目的:探讨鼻咽癌放疗后海绵窦复发受侵再程放疗的临床特点及文献复习.方法:回顾分析2000-06- 2006-04我院诊断的鼻咽癌初次治疗后局部海绵窦复发受侵者55例.全部经CT和(或)MR诊断,部分鼻咽局部重新活检;分析海绵窦受侵的CT和MR诊断意义及再治疗的效果、毒副反应和并发症.结果:55例海绵窦受侵复发患者,CT检出13例,MR检出43例.全组主要的临床表现及体征是外展神经麻痹、颅骨破坏,伴发头痛及前组颅神经受损.再程治疗后、2、3和5年生存率分别为92.73％、78.18％、34.54％和9.09％.初治时有无颅底破坏对再次治疗后的生存率有一定影响,但1、2年生存率差异无统计学意义,3、5年以上生存率差异有统计学意义,P＜0.05.初治到复发间隔时间越短再次治疗后生存率越低,与间隔3年以内者比较,间隔＞3年者生存率有明显提高,P＜0.05.结论:MR较CT能更早期准确诊断鼻咽癌复发中海绵窦受侵,头痛和颅神经症状是海绵窦受侵的主要临床体征,放疗后海绵窦处复发再放疗有积极的治疗意义.     

Endoscopic microwave coagulation therapy for early recurrent T1 nasopharyngeal carcinoma

The result of reirradiation in recurrent T1 (rT1) nasopharyngeal carcinoma (NPC) is unsatisfactory. We sought to study the efficacy and complications of endoscopic microwave coagulation therapy (MCT) in salvaging rT1 NPC after primary radiotherapy. Between August 1994 and April 2005, 55 patients with rT1 NPC were treated with endoscopic MCT. With a median follow-up of 102.1 months, 52 of 55 patients are still alive. Five patients had local failure after retreatment. The overall survival and local progression-free survival were 100% (95% CI, 99.4% to 100%) and 94.5% (95% CI, 94.1% to 94.9%) at 2 years, respectively, and 93.6% (95% CI, 93.5% to 94.4%) and 90.7% (95% CI, 90.2% to 91.2%) at 5 years. The common complications of endoscopic MCT were mild postoperative pain and headache. Nasopharyngeal necrosis was transient in one patient and subsided in 1 month. Endoscopic MCT achieved significant survival and tumour control without severe complications in selective rT1 NPC.     

局部复发鼻咽癌超分割IMRT的临床分析

目的 分析LR鼻咽癌行再程超分割IMRT的临床疗效和不良反应。方法 2011—2015年间28例接受超分割IMRT患者入组,中位复发时间为17.5个月,其中男23例、女5例,年龄25~74岁。肿瘤局部剂量60~70 Gy,1.2 Gy/次,2 次/d,间隔6 h以上,每周连续治疗5 d。25例患者同期接受了奈达铂单药或联合方案化疗,4例接受了今又生p53基因治疗,6例接受EGFR单抗靶向治疗。结果 超分割IMRT后3个月,CR、PR率分别为89%(25/28)、11%(3/28)。中位随访27.5个月,1,2,3年OS、LRFS、PFS分别为100%、91%、80%,100%、80%、55%,88%、65%、55%。3例患者治疗后出现3级鼻咽黏膜溃疡坏死,经对症处理后好转。多因素分析PFS预后不良因素包括肿瘤分期rT₃—T₄期(P=0.00)、无化疗(P=0.04)。结论 超分割IMRT对复发鼻咽癌有良好的LC效果,不良反应可控,值得临床推荐试用。     

Re-irradiation of nasopharyngeal carcinoma with intensity-modulated radiotherapy.

BACKGROUND AND PURPOSE: To evaluate the treatment outcome in patients with locally recurrent nasopharyngeal carcinoma (NPC) treated with intensity-modulated radiation therapy (IMRT). MATERIALS AND METHODS: Between October 2001 and May 2004, 31 patients with locally recurrent NPC received re-irradiation using IMRT. The rT classification distribution was 3 for rT1, 5 for rT2, 9 for rT3, and 14 for r T4. Median time from first course of radiotherapy to re-irradiation was 51 months. IMRT was performed using step-and-shoot method with nine 4-6 MV photon fields and median prescribed dose was 54 Gy (range: 50-60 Gy). Additional treatments included cisplatin-based induction chemotherapy in 68% and radiosurgery boost with a single dose which ranged from 8.5 to 12.5 Gy in 32%. Median follow-up time was 11 months. RESULTS: After re irradiation, 58% of patients had complete regression of primary tumor. One-year loco-regional progression-free, distant metastasis-free and overall survival rates were 56, 90, and 63%, respectively. Significantly better 1-year local progression-free rate was observed in rT1-3 than r T4 tumor (100 vs. 35%). Grade 3 late toxicities, mostly ototoxicity/cranial neuropathy, occurred in six patients (19%). One-year actuarial rates of late toxicities were 70% for all grades and 25% for Grade 3. CONCLUSION: Our preliminary results showed that good control of rT1-3 NPC can be achieved using IMRT with a dose between 50 and 60 Gy, whereas the outcome for r T4 tumor remained poor. Late toxicities were common but incidence of severe toxicities was relatively low.     

69例局部复发鼻咽癌调强放疗疗效及预后分析

目的回顾性分析局部复发鼻咽癌调强放疗的疗效及影响预后的相关因素。方法 69例局部复发鼻咽癌患者均行调强放疗,再程放疗pGTV总剂量为49.5～77.4Gy(中位剂量为66Gy),每次分割剂量1.86～2.5Gy(中位2.1Gy)。48例接受1～6个周期以铂类为基础的化疗。结果全组患者的中位随访时间为20个月,截止末次随访日期,死亡24例(34.8%)。1、2年局部无进展生存率、无远处转移生存率及总生存率分别为92.9%、81.8%、81.8%和88.8%、65.5%、65.5%。单因素分析结果显示,首程放疗方式(P=0.004)和再程放疗总剂量(P=0.011)与生存期相关;多因素分析发现影响局部复发鼻咽癌的独立预后因素有首程放疗方式(P=0.004)和再程放疗总剂量(P=0.004)。放疗期间的急性毒副反应均可耐受。结论 IMRT是局部复发鼻咽癌的有效治疗手段,可提高患者的生存率。首程放疗方式和再程放疗总剂量是影响患者生存时间的独立预后因素。     

Three-dimensional conformal radiation therapy for locally recurrent nasopharyngeal carcinoma

Local recurrence is a major cause of treatment failure for NPC,[1] seen in approximately 20%(30% of patients after radiation therapy with radical dose.[2(5] Retreatment for locally recurrent NPC is a real challenge, and radiation therapy is still the mainstay of retreatment modulates.[1] It was proved that conventional methods with X-ray simulation and 2-dimensional planning were not satisfactory for locally recurrent NPC. The prognosis for patients undergoing reradiation is grave,[2(4, 6(…     

局部复发鼻咽癌三维适形放疗初步观察

目的:探索三维适形放疗(3demensionalconformalradiationtherapy3DCRT)技术在局部复发鼻咽癌再程放疗中的应用。方法:1998年4月～1999年10月,采用3DCRT技术治疗局部复发鼻咽癌26例。其中低分化鳞癌25例,低分化腺癌1例。按92’福州分期标准再分期:T1N0M04例,T2N0M08例,T3N0M09例,T4N0M05例。密集肿瘤区(grosstumorvolumeGTV)最大径1.0～5.0cm(平均3.1cm)。全组病例均采用每次5～7个固定适形野照射,计划靶区(planningtargetvolumePTV)平均最大剂量、最小剂量、平均剂量分别为104.1±1.3%、92.1±2.8%、99.2.±1.7%。时间-剂量-分次处方:65～70Gy/26～28次,共5～5.5周。随访8～26个月,中位随访时间17个月。结果:再程放疗后随访期内靶区边缘复发2例,颈淋巴结复发3例,远处转移2例,死亡4例。随访期内肿瘤局部控制率88.5%(23/26),84.6%(22/26)患者生存,76.9%(20/26)无瘤生存。再程放疗所致急性放射反应少而轻。累计后遗症发生率19.2%(5/26),放射性功能损害发生率15.4%4/26。结论:三维适形放疗技术用于局部复发鼻咽癌具有明显的剂量分布优势。初步临床观察结果表明,这一放疗新技术用于局部复发鼻咽癌肿瘤局部控制率高、放射反应和后遗症较少,远期疗效和后遗症尚有待观察。     

A phase II study of capecitabine in patients with recurrent and metastatic nasopharyngeal carcinoma pretreated with platinum-based chemotherapy

To evaluate the efficacy and toxicity of capecitabine as a salvage chemotherapy regimen in Chinese patients with recurrent or metastatic nasopharyngeal carcinoma (NPC) previously treated with platinum-based chemotherapy, 17 patients with recurrent or metastatic NPC previously treated with platinum-based chemotherapy as adjuvant or palliative treatments received oral capecitabine at a dose of 1.25 G/m(2) twice daily in 3-week cycles consisting of 2 weeks of treatment followed by rest period of 1 week. Seven patients had local recurrence, seven had distant metastases, one had loco-regional recurrence, and two had both local/regional recurrence and distant metastases. Patients received a median number of three cycles of capecitabine (range: 1-6). The median follow-up was 7.5 months (range: 3-25.3). All patients were included in the efficacy and adverse events analysis. Three patients (17.6%) achieved partial response and one patient (5.9%) achieved complete response, with an overall response rate of 23.5% (95% confidence interval, 7-50%). The duration of response's were 4.2, 5, 6+, and 23.1+ months. Nine patients (52.9%) had stable disease whereas four (23.5%) had progressive disease. The median time to progression was 4.9 months. The median survival was 7.6 months. Five patients are still alive with an estimated 1-year survival rate of 35%. Treatment-related adverse events were generally mild except hand-foot syndrome which occurred in 58.8% of patients. Capecitabine is an effective salvage regimen in patients with recurrent and metastatic NPC. Capecitabine as a single agent or in combination with other chemotherapeutic agents or treatment modalities should be further studied in NPC.     

Fractionated stereotactic radiotherapy in residual or recurrent nasopharyngeal carcinoma

The aim of this study was to evaluate results of fractionated stereotactic radiotherapy (FSRT) in patients with residual or recurrent nasopharyngeal carcinoma (NPC) in terms of local progression-free (LPFS) and overall survival (OS) rate and complications after treatment. There were 32 residual or recurrent NPC patients treated with FSRT using linac-based radiosurgery system. Time from the previous radiotherapy to FSRT was 1-165 months (median, 15). Two patients were treated for the second and one for the third recurrence. Thirteen patients (40.6%) also received chemotherapy with FSRT. Tumor volume ranged from 6.2-215 cc (median, 44.4). Average FSRT dose was 17-59.4 Gy (median, 34.6) in 4-25 fractions (median,6) in 1-5.5 weeks (median, 3). Median follow-up time was 25.5(3-67) months. LPFS rate at 1 and 3 years after FSRT was 67.8% and 37.9%. OS rate at 1 and 3 years was 89.7% and 71.2%. If all patients who had tumor progression with no further follow-up were assumed dead, the OS rate at 1 and 3 years would be 75.0% and 37.9%. Univariate analysis showed better local tumor control in patients with tumor volume ≤100 cc (p=0.04) or in those without chemotherapy (p=0.0005). Only chemotherapy retained significance in multivariate analysis (hazard ratio 5.47, 95%CI 1.86-16.04). Eight patients (25%) had complications after FSRT, all grade 2-3 except 1 grade 4 with complete recovery.     

Experience in fractionated stereotactic body radiation therapy boost for newly diagnosed nasopharyngeal carcinoma

PURPOSE: Radiotherapy is the most effective treatment for nasopharyngeal carcinoma (NPC). The aim of this study is to evaluate the efficacy and toxicity of fractionated stereotactic body radiation therapy (SBRT) boost for NPC. METHODS AND MATERIALS: Sixty-four patients with newly diagnosed, nonmetastatic NPC were treated with conventional radiotherapy 64.8-68.4 Gy followed by fractionated SBRT boost 12-15 Gy between January 2002 and July 2004. Most patients (72%) presented with Stage III-IV disease. Fifty-two patients also received cisplatin-based concurrent (38) or neoadjuvant (14) chemotherapy. The major endpoints were local control, overall survival, and complications. RESULTS: All patients finished the planned dose of radiotherapy. After a median follow-up of 31 months (range, 22-54), 15 patients developed tumor recurrences--3 in the nasopharynx, 4 in the neck, 5 in distant sites, 1 in both nasopharynx and neck, 2 in the neck and a distant site. The 3-year actuarial rate of local control was 93.1%, regional control 91.4%, freedom from distant metastasis 90.3%, and overall survival 84.9%, respectively. There were no Grade 4 acute or chronic radiation-related complications. CONCLUSIONS: Fractionated SBRT boost for NPC is technically feasible and provides good local control without any severe complications.