局部晚期鼻咽癌调强放疗后颈动脉损伤的临床分析

[目的]探讨局部晚期鼻咽癌调强放疗与颈动脉损伤的关系。[方法]系统随访91例Ⅲ-Ⅳa期鼻咽癌初治患者。全组患者均采用调强放疗技术（原发灶总剂量70-72Gy/32f,42-44d;颈淋巴结转移灶65-68Gy/32f,42-44d;高危预防区域60Gy/32f,42-44d;低危预防区域50Gy/28f,35-38d）放疗结束后定期通过磁共振颈血管成像（MRA）和/或颈部血管彩色多普勒随访患者颈动脉损伤发生情况。[结果]至随访截止日,91例患者中共有20例在MRA和/或颈部血管彩色多普勒上表现出颈动脉损伤,发生率为22.0%,1年、2年、3年、4年的发生率分别为11.0%（10/91）、16.5%（15/91）、20.9%（19/91）、22.0%（20/91）,其中有10例患者同时进行了MRA及颈部血管彩色多普勒检查,6例患者颈部血管彩色多普勒的阳性结果出现在MRA之前,3例患者仅颈部血管彩色多普勒有阳性结果,1例两者同时发现颈部血管损伤。发生损伤的主要部位为颈总动脉（12例）、椎动脉（11例）及颈内动脉（6例）。[结论]局部晚期鼻咽癌患者调强放疗后颈动脉损伤的发生率高,联合多种影像学检查定期复查可以及早发现放疗后颈动脉损伤。     

头颈部恶性肿瘤放射性颈动脉损伤的研究进展

放射治疗是头颈部恶性肿瘤主要治疗手段之一.然而,颈部接受放疗后所造成的颈动脉损伤对患者的长期生存和生活质量有着不可忽视的影响.目前临床上多采用彩色多普勒超声来检测放疗后颈动脉的变化情况,主要是观察颈动脉的内径及内膜的变化情况.积极预防并治疗放疗后颈动脉的损伤对于患者的长期生存和提高生活质量有着重要的临床意义.为此本文综述了头颈部恶性肿瘤患者放疗后发生颈动脉损伤的研究现状和进展方向.     

鼻咽癌放疗后的颈动脉狭窄

ＣｈｅｎｇＳＷＫ等回顾性分析了９６例鼻咽癌患者放疗后颈动脉狭窄的状况。９６例均无颈动脉手术史 ,放疗为主要治疗或术后辅助治疗。原发灶放疗量为６４Ｇｙ～７２Ｇｙ,若颈部淋巴结阴性 ,颈部放疗量为４５Ｇｙ～５０Ｇｙ,若颈部淋巴结阳性 ,颈部放疗量为６０Ｇｙ～６６Ｇｙ。放疗结束时间至少１２个月以上。所有患者的双侧颈总、颈内和颈外动脉均行彩色多普勒超声检查。颈动脉狭窄程度≥７０ %为有临床意义。对年龄、性别、吸烟史、糖尿病、缺血性心脏病、脑血管病、放疗后时间间隔等因素作单独分析。以９６例健康人作为对照组。所得数据…     

放疗致颈动脉损伤的研究进展

摘 要：近年来随着放疗技术的提高及多学科综合治疗的运用,头颈部恶性肿瘤患者的生存期明显延长。颈部放疗后引起的血管损伤以及后期发展形成的颈动脉狭窄（carotid artery stenosis,CAS）越来越引起更多的关注。许多研究表明放射线可促使血管内皮活化,并在氧化损伤机制和炎性反应的参与下引起血管内皮损伤,促进颈动脉内膜中层厚度（carotid intima-media thickness,CIMT）增加,导致颈动脉狭窄,从而增加发生脑血管事件的风险,如短暂性脑缺血发作和脑卒中。文章就有关颈部放疗后诱导颈动脉损伤的发生率、发病机制、危险因素、临床特点、诊断及治疗方法、未来研究领域进行综述。     

鼻咽癌首程放疗后578例颈部淋巴结复发因素分析

[目的]研究鼻咽癌首程放疗后颈部淋巴结复发的相关因素.[方法]3124例鼻咽癌初诊患者采用60Co分段放射治疗和连续放射治疗后分析淋巴结分期、照野布野、放射剂量及分段治疗问题与颈部淋巴结复发的相关性.[结果]治疗前淋巴结分期高与颈淋巴结复发有关,N0、N1、N2、N3期复发率分别为12.8%、12.2%、23.7%和27.5%(P＜0.001).全颈和半颈照射的复发率分别为19.3%和16.9%(P＞0.05).在终止剂量为60Gy和65Gy时,消退剂量45Gy复发率均较55Gy低,分别为12.4%对24.1%(P＞0.001)和11.5%对23.3%(P＜0.001).连续放疗复发率11.9%,低于分段放疗组的21.8%(P＜0.001),分段放疗间隙时间长也与高复发有关(P=0.038).[结论]鼻咽癌放疗后颈淋巴结复发与N分期高以及疗程长成正比,靶区漏照或剂量不足也是复发的重要因素.     

鼻咽癌放疗致颈动脉损伤的研究进展

颈部放疗是防治鼻咽癌颈部淋巴结转移的重要手段，但放射线可直接或间接损伤血管，加速动脉粥样硬化进程，进而导致颈动脉狭窄，增加放疗后短暂性脑缺血和脑卒中发生的风险。目前多采用彩色多普勒超声检测颈动脉的变化情况，并通过积极预防及减少危险因素来降低颈动脉狭窄的发生率。颈动脉狭窄可采用药物早期干预及手术治疗。本文就放疗致颈动脉损伤的研究现状进行综述。     

超分割后加速放疗鼻咽癌患者的疗效和安全性研究

目的 研究超分割后加速放疗鼻咽癌患者的疗效和安全性.方法 将48例经CT或MRI确诊的鼻咽癌患者随机分为超分割后加速放疗组(研究组)和常规放疗组(对照组),每组24例,对照组每周5次,每次2 Gy,总量70Gy/7周;研究组1.2 Gy/次,每周5天,每天2次,间隔不小于6h,剂量48 Gy/40次,后2周采用后加速超分割:1.5 Gy/次,每周5天,每天2次,间隔不小于6h,剂量30 Gy/20次,整个疗程总剂量为78 Gy/60次,共6周完成.结果 研究组与对照组治疗后36个月及60个月复发率分别为12.5％、20.8％和25.0％、37.5％,差异有统计学意义(P＜0.05).对照组5年转移率为33.3％,研究组5年转移率为20.8％,差异显著(P＜0.01);对照组5年总生存率为62.5％,研究组5年总生存率为83.3％,差异显著(P＜0.01).研究组与对照组皮肤3级和4级损伤发生率比较有显著差异(P＜0.05),粘膜2～4级损伤发生率比较有显著差异(P＜0.05).两组晚期损伤在耳聋、放射性脑病和颈部纤维化方面比较差异有显著性(P＜0.05).结论 超分割后加速放疗治疗鼻咽癌提高了疗效降低了复发率和转移率,提高了生存率,提高了安全性.     

鼻咽癌放疗后晚期血管损伤临床观察三例

虽然放疗是鼻咽癌重要治疗方法 之一,且约70%～80%鼻咽癌患者由此获得长期生存,处于放射野内的动脉是否被诱发血管内皮损伤及造成相应并发症正日益受到关注[1-3].笔者回顾本科收治的鼻咽癌放疗后晚期血管损伤患者的临床表现和影像学资料,探讨鼻咽癌放疗后晚期血管损伤影像学特点,为制定合理的预防措施提供依据.     

Ⅲ、Ⅳa期鼻咽癌患者放疗同期化疗加辅助化疗的疗效

背景与目的:较多研究认为放疗前诱导化疗未能提高中晚期鼻咽癌的生存率,对放疗后的辅助化疗能否提高中晚期鼻咽癌的生存率有争议.有作者报道同期放化疗能提高中晚期鼻咽癌患者的疗效.本研究着重探讨放疗同期化疗加辅助化疗治疗Ⅲ、Ⅳa期鼻咽癌的疗效.方法:将80例Ⅲ、Ⅳa期鼻咽癌患者随机分为放疗同期化疗加辅助化疗组(研究组)及单纯放疗组(对照组),每组各40例.研究组于放疗第一周开始使用同期化疗,顺铂25 mg/m2静脉滴注,每周一次,连用6周.辅助化疗于放疗结束后一个月开始,顺铂25 mg/m2,静脉滴注,第1～3天;氟尿嘧啶1000 mg/m2,静脉滴注,第1～3天.每月一次,连用3次.放疗使用常规分割放疗,鼻咽部总剂量70Gy.对照组放疗方法与放疗加化疗组相同,不使用化疗.生存率采用Kaplan-Meier法,生存期的差别比较用log-rank检验,计数资料组间差异用卡方检验.结果:治疗后,研究组和对照组分别有34例和32例鼻咽肿瘤达到CR者(x2=0.35,P＞0.05);颈部淋巴结达到CR者分别为37例和30例(x2=4.50,P＜0.05).研究组1、3、5年生存率分别为92.7%、78.6%、64.2%,对照组1、3、5年生存率分别为81.2%、52.7%、42.3%,两组比较差异有显著性(P＜0.01).研究组1、3、5年无瘤生存率分别为91.2%、76.7%、63.5%,对照组1、3、5年无瘤生存率分别为78.2%、51.9%、40.3%,两组比较差异有显著性(P＜0.01).5年累积远处转移发生率研究组为15.0%,对照组为35.0%,两组比较差异有显著性(x2=4.27,P＜0.05).Ⅲ度口腔粘膜炎发生率研究组为75.0%,对照组为25.0%(x2=20.00,P＜0.01).结论:同期加辅助化疗联合放疗较单纯放疗提高了Ⅲ、Ⅳa期鼻咽癌的颈部淋巴结完全缓解率以及1、3、5年生存率和无瘤生存率,显著降低了远处转移的发生率,但增加了Ⅲ度口腔粘膜炎的发生率.     

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.     

Neck irradiation, carotid injury and its consequences

Carotid stenosis is a major sequela of head and neck irradiation that has not received the attention it deserves. Its impact on the quality of life of patients can be substantial. This review discusses the incidence, pathogenesis and consequences of radiation-induced carotid stenosis following head and neck irradiation. This review is based on literature search (Medline and Pub Med) and cross-referencing. The incidence of significant carotid stenosis following head and neck irradiation range from 30% to 50%. Patients with carotid stenosis are at increased risk for stroke. Factors such as hypertension, diabetes, smoking and obesity increase the risk. Increased attention to the clinical signs of carotid stenosis and evaluation of these patients with appropriate imaging studies, together with strict implementation of management of hypertension and diabetes and, counseling on obesity and smoking have the potential to reduce the incidence of this sequela of head and neck irradiation. Those patients with severe carotid stenosis can be managed with endarterectomy or carotid artery stenting.     

A historical prospective cohort study of carotid artery stenosis after radiotherapy for head and neck malignancies

PURPOSE: To determine carotid artery stenosis incidence after radiotherapy for head-and-neck neoplasms. METHODS AND MATERIALS: This historical prospective cohort study comprised 44 head-and-neck cancer survivors who received unilateral neck radiotherapy between 1974 and 1999. They underwent bilateral carotid duplex ultrasonography to detect carotid artery stenosis. RESULTS: The incidence of significant carotid stenosis (8 of 44 [18%]) in the irradiated neck was higher than that in the contralateral unirradiated neck (3 of 44 [7%]), although this difference was not statistically significant (p = 0.13). The rate of significant carotid stenosis events increased as the time after radiotherapy increased. The risk of ipsilateral carotid artery stenosis was higher in patients who had undergone a neck dissection vs. those who had not. Patients with significant ipsilateral stenosis also tended to be older than those without significant stenosis. No other patient or treatment variables correlated with risk of carotid artery stenosis. CONCLUSIONS: For long-term survivors after neck dissection and irradiation, especially those who are symptomatic, ultrasonographic carotid artery screening should be considered.     

CT and duplex scanning: a comparison of imaging techniques for evaluation of the carotid tree in head and neck cancer patients

Carotid artery disease is a common condition which, like head and neck cancer, is primarily smoking related. Internal carotid stenosis may result in cerebro-vascular complications, while severe stenosis of the external carotid can potentially compromise microvascular free tissue transfer reconstruction. We were interested to see whether any co-existing carotid artery disease could be assessed on the neck CT scan by comparing it to definitive duplex scanning in head and neck cancer patients. CT and duplex scanning of the common, internal and external carotid arteries was compared in 30 patients (180 vessels). The arterial phase of the neck CT scans were reviewed by two radiologists and all duplex scans were performed by one vascular technician to minimise inter-operator variability. The respective findings were blinded. Significant correlations were found between CT and duplex in confirming stenosis of the common and internal carotid arteries (P<0.001). There was a weak correlation between CT and duplex in the assessment of the external carotid system (P=0.02 and P=0.08), with CT under-estimating the true extent of stenosis in this vessel. The sensitivity and specificity of CT compared to duplex was 77% and 94% respectively. CT is useful not only for imaging the neck of head and neck cancer patients, but also in screening for carotid stenosis. Duplex scanning is more accurate than CT in assessing the external artery, and is useful for evaluating patients with significant stenosis of the carotid tree.     

External carotid artery stenosis in patients with head and neck squamous cell carcinoma--a prospective study

Vascular disease, which can be asymptomatic until arterial stenosis is severe, is common in head and neck cancer patients as the risk factors for both cancer and atherosclerosis are similar. Although studies of common and internal carotid artery stenosis in head and neck patients have been reported, none have specifically assessed the external carotid system, especially in asymptomatic patients undergoing major microvascular free flap reconstructive surgery. A prospective study of 44 patients using pre-operative duplex scanning to assess the common, external and internal carotid arteries bilaterally. Eighteen patients (41%) had no obvious carotid disease in any vessel. Although the remaining 26 patients (59%) had some carotid tree stenosis, only nine patients (20% of study group) had disease affecting the external carotid artery, with significant stenosis (greater than 50%) of this vessel being found in only three patients (7%). A correlation was found between the degree of carotid stenosis and hypertension (P<0.05). No correlation was found between carotid artery stenosis and flap failure (t=5.4; P=1). Significant stenosis of the external carotid artery, even in the presence of atherosclerosis elsewhere in the carotid tree, is uncommon. The screening of the external carotid artery in head and neck patients requiring microvascular reconstruction should be considered when there are significant risk factors for carotid stenosis, including hypertension.     

Incidence of carotid stenosis in nasopharyngeal carcinoma patients after radiotherapy.

BACKGROUND: Radiation-induced carotid stenosis in patients with head and neck tumors can cause significant mortality and morbidity. This study examined the incidence of stenosis in the extracranial carotid arteries of nasopharyngeal carcinoma patients after radiotherapy. METHODS: The extracranial carotid arteries of 71 (53 male and 18 female; mean age of 53.6 years) postradiation patients with nasopharyngeal carcinoma were examined with color Doppler ultrasound. The distribution of the arterial stenosis and the degree of stenosis were documented. The results were compared with the control group, which comprised 51 newly diagnosed nasopharyngeal carcinoma patients (35 male and 16 female, mean age of 48.8 years) before radiotherapy. Incidences of risk factors for arterial stenosis such as hypertension, smoking, and hypercholesterolemia also were studied in these two groups. RESULTS: There was no significant difference in the incidence of risk factors between the two groups. Arterial stenosis was, however, more common in the postradiation group than the preradiation group (56 of 71 vs. 11 of 51). The common/internal carotid arteries (CCA/ICA) were most commonly involved (55 of 71 vs. 11 of 51; P < 0.01), followed by the external carotid artery (ECA) (32 of 71 vs. 1 of 51; P < 0.01) and vertebral artery (VA; 5 of 71 vs. 0; P = 0.069). Significant stenosis (> 50% reduction of luminal diameter) was only found in the postradiation group (21 of 71 in CCA/ICA, 11 of 71 in ECA, 4 of 71 in VA). CONCLUSIONS: This study showed that radiation could cause significant carotid stenosis. Ultrasound examinations for these patients therefore are necessary for early detection and possible intervention of this late radiation-induced complication.     

Increased risk of stroke in young head and neck cancer patients treated with radiotherapy or chemotherapy

Background

Chemo-radiotherapy-induced carotid stenosis and cerebrovascular events in head and neck cancer patients can cause severe disability and death. We aimed to estimate the risk of stroke in such patients over a six-year follow-up period.

Patients and methods

The study cohort consisted of head and neck cancer patients (n = 10,172). Cox proportional hazard model was used to compare the stroke-free survival rate between the patients treated with radiotherapy or chemotherapy, surgery alone, and surgery with adjuvant therapy after adjusting for possible confounding factors.

Results

At the end of follow-up, 384 patients had strokes: 126 (4.3%) from the surgery alone group, 167 (3.8%) from the radiotherapy or chemotherapy group, and 91 (3.2%) from the surgery with adjuvant therapy (P = 0.222). Head and neck cancer patients aged less than 55 years treated with radiotherapy or chemotherapy conferred a 1.8-fold higher risk for stroke (95% CI, 1.22–2.56; P = 0.003) after adjusting for patient characteristics, co-morbidities, geographic region, urbanization level, and socio-economic status. There was no statistical difference in stroke risk between different treatment modalities in head and neck cancer patients aged 55 years and more.

Conclusions

Young head and neck cancer patients treated with radiotherapy or chemotherapy have higher risks for stroke. Different treatment strategies should be considered in such patients.     

Clinical Features of Radiation-induced Carotid Atherosclerosis

Carotid arteries frequently receive significant incidental doses of radiation during the treatment of malignant diseases, including head and neck cancer, breast cancer and lymphoma. Vascular injury after treatment may result in carotid artery stenosis and increased risk of neurological sequelae, such as stroke and transient ischaemic attack. The long latent interval from treatment to the development of clinical complications makes investigation of this process difficult, particularly in regard to the design of interventional clinical studies. Nevertheless, there is compelling clinical evidence that radiation contributes to carotid atherosclerosis. This overview examines the effect of radiotherapy on the carotid arteries, the underlying pathological processes and their clinical manifestations. The use of serum biomarkers in risk-prediction models and the potential value of new imaging techniques as tools for defining earlier surrogate end points will also be discussed.     

Concomitant cisplatin and radical radiation in locally advanced head & neck carcinoma

Effective treatment modalities for locally advanced squamous cell carcinoma of the head and neck are limited and seldom result in long term survival. The improved results with cisplatin chemotherapy are encouraging and represent an additional therapeutic modality for head and neck cancer. To estimate the effectiveness, safety and tolerance of simultaneous cisplatin and radiotherapy in advanced carcinoma of the head and neck this phase II study was undertaken. 40 eligible patients with advanced squamous cell carcinoma of the head and neck were entered into the study. Group I (20 patients) received conventional radical radiation 64 Gy/32 F/6.5 weeks and Group II (20 patients) received in addition to above radiotherapy, concomitant cisplantin 100 mg/m² every 3 weeks for three doses with forced diuresis and antiemetic schedule, on day 1, 22 and 43rd of rediation treatment. The complete response with RT alone was 40% and with combined treatment 70%. The treatment tolerance was approximately equal in both groups and all patients completed treatment in scheduled time.     

Percutaneous endoscopic gastrostomy as a multidisciplinary treatment in head and neck cancer

The objective of this study was to evaluate the results of using the percutaneous endoscopic gastrostomy (PEG) in patients with head and neck cancer. Forty-six patients with head or neck cancer who required a PEG were evaluated over a 3-year period. The main indications were dysphagia and as a palliative treatment. The early perioperative and short and long term complications were assessed as well as the morbidity and mortality rate related to the procedure. In all cases, the PEG was successfully placed. Perioperative complications were observed in 6 (13%) cases, and the short and long term morbidity were seen in 4 (9%) cases. The side effects were considered as minor in all but 1 case, which required open surgery to remove the gastric tube because its bumper had become fully imbedded in the gastric wall after a 1-year period. No patient died from the procedure. PEG is an easy, quick and safe technique for the short and long term nutrition in head and neck cancer patients, who need a combined treatment of chemotherapy, surgery and/or radiotherapy and in which complications related to any of these treatment were expected. PEG should be placed routinely if enteral feeding with a gastric tube is expected to be longer than 3 weeks.     

Increased carotid wall thickening after radiotherapy on the neck

Patients treated for head and neck tumours with local radiotherapy (RT) on the neck harbour an increased risk of stroke. This may be due to accelerated atherosclerotic changes within the RT-field; however, the real impact of local RT on the carotid artery remains debatable. The aim of the present study was to assess the difference in carotid wall thickness (intima-media thickness) in 42 unilaterally irradiated parotid tumour patients by performing B-mode ultrasonography. A mean difference in intima-media thickness (IMT) of the irradiated compared with the non-irradiated carotid artery of 0.30 mm (P=0.031) was found. A significant correlation was established with a longer post-RT interval (P=0.008). RT on the neck is associated with increased thickening of carotid IMT. Screening and treatment of additional cerebrovascular risk factors which contribute to further IMT thickening and stroke development is recommended, especially in radiotherapy patients with a favourable prognosis.