复发鼻咽癌挽救性手术方法研究进展

鼻咽癌是我国常见的恶性肿瘤之一，尽管三维适形放疗、调强放疗、同步放化疗等治疗手段使鼻咽癌的局部控制率及总体生存率得到显著提高，仍有约10%的鼻咽癌在经过正规根治性治疗后发生局部或(和)区域复发。目前，复发鼻咽癌多采用再程放疗和手术治疗，对复发鼻咽癌常用的手术治疗方式进行综述。     

复发鼻咽癌手术治疗地位的思考

外科治疗在复发鼻咽癌的治疗中越来越受到重视。随着手术技术的不断提高,特别是经鼻内镜外科挽救手术的开展,对于经过选择的复发鼻咽癌患者,其标准治疗逐渐从再程放疗向手术治疗转换。检索收集近年发表的重要文献,介绍了复发鼻咽癌的各种手术方式,分析各种手术方式的优劣势,并对疗效及不良反应等进行阐述。     

鼻咽癌治疗后颈转移灶残留或复发的再治疗

目的探索一种适合鼻咽癌首程治疗后颈淋巴结残留或复发的再治疗方案,为这类患者的临床治疗提供参考。方法总结46例鼻咽癌患者首程治疗后颈淋巴结残留或复发的再治疗资料,将不同的治疗方案与疗效之间的关系应用统计学进行分层分析。结果 46例患者5年生存率为59%。手术再治疗组术后5年生存率为72%,放、化疗组再治疗后5年生存率为26%,差异有显著的统计学意义。结论鼻咽癌首程治疗后颈淋巴结残留或复发的再治疗,手术是首选的治疗方式,能显著提高生存率。     

脱氧葡萄糖-正电子发射断层显像在鼻咽癌诊断和放疗后肿瘤残留或复发判定中的价值

鼻咽癌放疗后残留或复发的早期诊断和鉴别诊断是正确再治疗的前提。CT是鼻咽癌诊断和随诊的主要手段，但由于放疗后会出现纤维化或不对称性的改变，CT仍有一定假阳性率。复发病灶常在黏膜下生长，致使CT易漏诊。脱氧葡萄糖-正电子发射断层显像（F-18-fluoro-2-deoxyglucose positron emission tomography，FDG—PET）用于鼻咽癌诊断的经验不多，本文评价在鼻咽癌诊断和放疗后复发或残留的临床价值。     

鼻咽癌局部复发或残留病灶的Nd：YAG激光手术挽救治疗

目的 探讨Nd:YAG激光手术挽救治疗鼻咽癌放射治疗后鼻咽局部复发或残留的可行性和临床疗效。方法在鼻内镜下经鼻腔Nd:YAG激光,对35例鼻咽癌经根治性放射治疗后鼻咽局部复发或残留病灶进行治疗。手术在局麻下进行,在鼻内镜直视下,激光功率调整在50W左右,YAG激光光纤经同侧或对侧鼻腔导入鼻咽部,气化切除肿瘤病灶。部分患者术后接受了再放射治疗,放射剂量20-60Gy不等。结果 手术均顺利完成。术后3年、5年生存率分别为51.4%、30.3%。结论 鼻内镜下Nd:YAG激光挽救手术是治疗鼻咽癌放射治疗后鼻咽局部复发或残留的有效手段,丰富了鼻咽癌放射治疗失败后的外科治疗手段。术后是否再需放射治疗,视具体情况决定。     

鼻咽癌放疗后颈部淋巴结残留或复发对预后的影响

目的探讨鼻咽癌放疗后颈部淋巴结残留或复发对预后的影响。方法对67例鼻咽癌放疗后颈部淋巴结残留或复发而原发灶未复发的患者的临床病理资料进行回顾分析。选择性别、年龄、原发癌病理类型、残留或复发淋巴结大小、累及的侧数、淋巴结累及区域、累及区域数量、复发淋巴结的手术方式、颈动脉是否受侵、术后是否有严重并发症、是否补充放疗、是否复发、有无远处转移等临床病理因素,用χ2检验和Cox回归进行单因素和多因素分析,并用Kaplan-Meier法对残留和复发患者进行生存分析。结果单因素分析显示有无远处转移与预后明显相关,多因素分析结果表明,残留或复发淋巴结大小、是否累及Ⅴ区、残留或复发淋巴结累及区域数量、手术方式和有无远处转移与预后明显相关。Kaplan-Meier法进行生存分析显示颈部淋巴结残留或复发患者再次治疗的总1、3、5年生存率分别为88.6%、52.2%、38.6%,而采用根治性手术较采用局部手术生存率高。结论远处转移是影响鼻咽癌放疗后颈部淋巴结残留或复发患者预后的决定性因素。而残留或复发淋巴结大小、是否累及Ⅴ区、累及区域数量和手术方式也是重要因素,根治性手术可提高生存率。     

鼻内镜下手术治疗鼻咽癌放疗后鼻咽颅底肉瘤5例

目的探讨鼻内镜下手术治疗鼻咽癌放疗后诱发鼻咽颅底肉瘤的可行性，并分析其临床疗效。方法回顾性分析鼻内镜下手术治疗的鼻咽癌放疗后诱发鼻咽颅底肉瘤5例患者临床资料。结果5例患者均于气管插管全麻下行经鼻内镜下鼻咽颅底肿瘤切除术，所有患者术后相关症状均有不同程度改善，未出现并发症。其中2例术后影像学检查示肿瘤残留，1例海绵窦区肿瘤残留者，术后3个月脑侵犯死亡；另外1例存活16个月后死于肿瘤复发压迫脑干呼吸衰竭。3例术后影像学检查未见肿瘤残留，其中1例拒绝放化疗，先后4次内镜手术，9个月后死于全身重要器官衰竭；1例术后行放化疗，20个月后死于颅内侵犯；另外1例行根治量放疗，存活20个月，最后因严重放射性脑病致无法进食，呼吸困难，全身重要器官衰竭死亡。结论鼻咽癌放疗后诱发肉瘤恶性程度高，预后差，如具备手术指征，应首选外科手术治疗，内镜手术联合术后放化疗有可能改善预后。     

复发性鼻咽癌的光动力学疗法

[英]／Lof－grenLA…ArchOtolaryngolHeadNeckSurg．－1995，121（9）．－997～1002鼻咽癌局部复发或残留的处理困难，对复发的治疗有近距离放疗、放疗和手术、手术和术中放疗以及联合治疗。尽管采用最先进的治疗，鼻咽癌初次放疗后残留和复发率仍为10％～30％。光动力疗法是发展中的治疗肿瘤的方法，是基于将可见光的能量转移到光敏感药物。该药物具有能吸收光能，并将能量转移到周围环境的O3，使之转化为高毒性的单氧及在肿瘤组织中存留时间更长的特性，Profimer纳最常用。该文重点研究这些药物在光动力疗法治疗放疗失败的复发或残留…     

三维适形放疗治疗复发鼻咽癌的疗效及预后因素分析

鼻咽癌的主要治疗方法是放射治疗。但根治性治疗后有18%~35%的患者出现局部复发。局部复发后的治疗以再程放疗为主,但其疗效和生存期均不尽如人意。近年来,随着放疗技术的发展,三维适形放疗(3D CRT)或调强放疗(IMRT)可以取得比常规放疗更好的疗效。因此本研究采用3DCRT的方法治     

侧颅底手术治疗复发性鼻咽癌6例报告

由于鼻咽癌的原发灶在颅底，其病理类型分化程度差，对放疗敏感，故治疗上应将放疗列为首选，但对于放疗后复发或不能控制的病例，我们采用耳前颞-蝶径路侧颅底手术方法治疗，效果满意，报告如下。1资料与方法1．1；临床资料6例鼻咽癌患者，男5例，女1例；其中低分化鳞癌4例，未分化癌1例，腺样囊性癌1例。全部病例自1990～1997年在我院均以足量放疗后局部复发或残留，但未见颈部有淋巴结转移而施行手术治疗。1．2手术方法采用改良的侧颅底手术。即耳前额一煤径路侧颅底手术，手术切口为倾弓上于耳屏与额浅动脉间向上延伸入发际内，再沿额肌…     

鼻内镜手术治疗首诊局部晚期鼻咽癌及放疗后严重并发症的作用

随着鼻内镜技术的不断提高,其已逐渐成为鼻咽癌综合治疗中的重要方式之一。就首诊局部晚期鼻咽癌的手术治疗、鼻咽癌放疗后严重并发症放射性骨坏死的内镜手术治疗及内镜手术在未来鼻咽癌治疗中可能的发展前景等方面进行综述。     

鼻咽癌外科治疗的历史与现状及展望

近年来越来越多学者开始关注鼻咽癌（NPC）内镜手术治疗。虽然目前以放疗为主的综合治疗被认为是主流的治疗方法，但是随着研究的不断深入，有学者提出内镜手术治疗NPC不仅可取得较好的疗效，同时提高患者生活质量。本文通过国内外文献回顾分析，综述了外科手术在复发性NPC以及原发性NPC患者中的开展情况以及未来治疗NPC新的趋势。方法结果结论     

Endoscopic surgery in treatment of juvenile nasopharyngeal angiofibroma

OBJECTIVES: Juvenile nasopharyngeal angiofibroma (JNA) is a highly vascular and locally invasive tumor with a high incidence of persistence and recurrence. The classical treatment of this tumor is surgery and/or radiotherapy. Use of endoscopic techniques seems to be on the rise in treatment of these lesions. We tried to explore the roles and limits of endoscopic surgery alone or with classical surgical techniques in treatment of these tumors. METHODS: Retrospective case review was conducted at a tertiary referral center. Twelve patients were treated for nasopharyngeal angiofibroma using endoscopic approach between 1998-2002. The staging, average blood loss during surgery, residual, and/or recurrent tumor were evaluated. RESULTS: Eight of these patients (8/12) were up to stage IIC according to Radkowski staging. This group of patients has an average blood loss of 1000 ml and were followed for at least 6 months. We did not encounter any residual or recurrent tumor in this group. Four patients (4/12) had minimal intracranial extension, were staged IIIA, and had an average blood loss of 1500 ml during surgery. Two of these patients had minimal residual tumor around the cavernous sinus, but showed no progression of disease over a follow-up of 2 years with MRI. Two patients had no residual or recurrent tumor over a follow-up of 6 months. CONCLUSION: This data suggests that endoscopic surgery can be used in the treatment of JNA even with minimal intracranial extension with minimal morbidity and low recurrence rate.     

颈颌腭入路-下颌骨外旋在鼻咽癌挽救性手术中的应用

目的探讨鼻咽癌放射治疗后复发肿瘤的挽救性手术方法.方法回顾性分析应用颈颌腭-下颌骨外旋入路,手术治疗鼻咽癌放射治疗未控患者2例、鼻咽部复发病变8例;二程放射治疗后病变复发2例,共1 2例（rT1 4例、rT2 7例、rT3 1例）患者的临床资料、手术方法及随访结果.结果 12例患者通过颈颌腭（下颌骨外旋）入路切除肿瘤,10例术中用带蒂颌下组织瓣Ⅰ期修复鼻咽部缺损;2例用游离下鼻甲修复鼻咽顶部缺损,7例患者无瘤生存、1例带瘤生存、3例患者死于局部复发、1例死于远处转移;患者2年总生存率为75%（9/12）.结论颈颌腭-下颌骨外旋入路切除鼻咽部肿瘤手术视野显露良好;可在直视下切除鼻咽及咽旁肿瘤处理颈内动脉,肿瘤切除后用带蒂颌下组织瓣Ⅰ期修复鼻咽部缺损手术及术后并发症少,是鼻咽癌放射治疗后复发肿瘤挽救性手术的一种理想的手术入路.     

经鼻内镜挽救性手术治疗局部复发鼻咽癌

鼻咽癌多为低分化鳞状细胞癌,放疗为首选,5年总体生存率可达64.4%〔1〕,约10%左右的患者放疗后局部复发〔2〕。对于复发患者,挽救性放疗或手术治疗成为主要治疗手段。放疗需增加放射剂量,易并发口干、张口困难、听力损伤、放射性骨坏     

Endoscopic nasopharyngectomy and its role in managing locally recurrent nasopharyngeal carcinoma

Local recurrence after primary radiation of nasopharyngeal carcinoma (NPC) remains an important cause of morbidity and mortality. Salvage treatment using reirradiation or surgery has been shown to improve survival over nontreatment. Surgery is traditionally performed using an open approach. Advances in endoscopic approaches for resection of paranasal sinus tumors have been extended to NPC. This article reviews the treatment options, in particular the role of endoscopic nasopharyngectomy in the management of recurrent NPC. The endoscopic anatomy, surgical principles, and published results on endoscopic nasopharyngectomy are presented. Short-term outcomes for early-stage recurrences are promising but long-term follow-up is needed.     

Nasopharyngectomy and surgical margin status: a survival analysis

OBJECTIVE: To explore whether the margin status at surgical salvage nasopharyngectomy for local residual or recurrent nasopharyngeal carcinoma affects patient survival. DESIGN: Retrospective case series review. SETTING: Academic tertiary referral center. PATIENTS: Seventy-nine consecutive patients with operable local residual or recurrent nasopharyngeal carcinoma after failure of primary treatment with radiotherapy with or without chemotherapy underwent surgical salvage nasopharyngectomy with curative intent between November 28, 1987, and November 17, 2003. Sixty-one patients were men and 18 were women. Their mean age was 48 years (age range, 26-70 years). INTERVENTION: Surgical salvage nasopharyngectomy. MAIN OUTCOME MEASURES: The status of the closest margin at surgery was assessed as clear, close, or positive. Survival time was measured from the date of surgery to the date of the last follow-up, to the date of an event occurrence, or to the date of death. The Kaplan-Meier method was used to estimate the probability of local progression-free survival and overall survival at 5 years. Differences in survival rates between surgical margin statuses were assessed using the log-rank test. RESULTS: Five-year overall survival for patients with clear margins was 77%, for patients with close margins was 46% (P = .05), and for patients with positive margins was 23% (P < .001). CONCLUSION: Clear surgical margins at the time of surgical salvage nasopharyngectomy for residual or recurrent nasopharyngeal carcinoma positively affect patient survival.     

Current treatment options for recurrent nasopharyngeal cancer

Loco-regional control rate of nasopharyngeal carcinoma (NPC) has improved significantly in the past decade. However, local recurrence still represents a major cause of mortality and morbidity in advanced stages, and management of local failure remains a challenging issue in NPC. The best salvage treatment for local recurrent NPC remains to be determined. The options include brachytherapy, external radiotherapy, stereotactic radiosurgery, and nasopharyngectomy, either alone or in different combinations. In this article we will discuss the different options for salvage of locally recurrent NPC. Retreatment of locally recurrent NPC using radiotherapy, alone or in combination with other treatment modalities, as well as surgery, can result in long-term local control and survival in a substantial proportion of patients. For small-volume recurrent tumors (T1–T2) treated with external radiotherapy, brachytherapy or stereotactic radiosurgery, comparable results to those obtained with surgery have been reported. In contrast, treatment results of advanced-stage locally recurrent NPC are generally more satisfactory with surgery (with or without postoperative radiotherapy) than with reirradiation.