鼻咽癌外照射加腔内近距离超分割推量照射的远期疗效分析

背景与目的:鼻咽癌的后装治疗一般采用鼻咽腔内治疗的方法进行推量照射,适用于局部早期鼻咽癌.福建省肿瘤医院率先开展鼻咽旁插植技术,无颅底破坏的局部晚期鼻咽癌采用后装治疗推量照射.本文分析腔内后装推量照射的远期疗效,探讨常规外照射的合适剂量配合后程超分割后装推量照射的临床价值.方法:1998年1月～2002年12月体外照射加腔内后装超分割推量放射治疗鼻咽癌患者352例,体外常规放射治疗50～70 Gy后进行腔内近距离超分割推量照射,外照射后咽旁间隙肿瘤残留者配合咽旁区插植放疗.采用个体化鼻咽腔内施源器,超分割照射每次2.5～3.0 Gy,2次/天,间隔6 h,总剂量5～32 Gy,中位剂量17 Gy.结果:本组l、2、3、5年生存率分别为97.0%、91.3%、87.6%、84.7%.总体5年生存率Ⅰ、Ⅱ期88.2%,Ⅲ、Ⅳ期79.2%(log-rank检验,P=0.016);总体局控率Ⅰ、Ⅱ期94.1%,Ⅲ、Ⅳ期91.7%(log-rank检验,P＞0.05).后组颅神经损伤32例(9.4%).结论:鼻咽腔内后装联合咽旁间隙捅植近距离放射治疗鼻咽癌取得良好的局控率和生存率,局部晚期鼻咽癌取得与早期鼻咽癌类似的局控率,咽旁间隙受累者咽旁插植增加颈动脉鞘区照射剂量,后组颅神经损伤发生率较高.     

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.     

47例鼻咽癌外照射配合咽旁间隙插植后装治疗的研究

目的:探讨外照射配合咽旁间隙插植治疗鼻咽癌的价值。方法:初治的鼻咽癌患者常规行外照射68～70Gy后复查CT或MRI,有咽旁间隙残留的98例,随机分成2组。一组行咽旁间隙插植后装补量(插植组),共47例。插植的方法是在模拟定位机引导下,经颌下插入1～3根施源管至咽旁区。后装机采用核通公司生产的192Ir高剂量率近距离治疗机,补量12～15Gy/4～6次/2～3d(2次/d,2.5～4Gy/次,每次间隔>6h);另一组行耳后野补量12～14Gy(对照组),共51例。结果:插植组与对照组3年总生存率及3年无远处转移生存率,差异无显著意义(P>0.05);3年无局部复发生存率,插植组显著高于对照组(P<0.05);晚期放射反应中的口干及张口受限等,插植组显著低于对照组(P<0.05)。结论:做为鼻咽癌咽旁间隙的补量,咽旁间隙插植后装治疗可显著提高咽旁间隙区残留的局部控制率,且晚期放射反应显著低于耳后野补量照射,具有较理想的临床应用价值。     

鼻咽癌腔内近距离超分割推量照射的研究

目的 分析鼻咽癌腔内近距离超分割放射治疗的临床及效及适应证的选择。方法 体外照射＋腔内后装超分割推量放射治疗鼻咽癌128例，体外常规放射治疗50－66Gy后进行腔内近距离放射治疗，1996年6月以后由于经颌下鼻咽旁区插植术的开展，腔内后装的适应证的选择严格按肿瘤侵犯深度在鼻咽部粘膜下≤10mm。施源管技术采用个体化模块将施源管固定在鼻咽腔内，并将软腭推开，剂量分割采用超分割法2．5－3．0Gy／次，2次／d，间隔6h，总剂量12－24Gy，中位剂量18Gy。体外照射剂量分为3个组，即：56Gy组44例（其中37例为56Gy），60Gy组54例，66Gy组30例。结果 全组3、4年无瘤生存率分别为84．2％、74．9％，3、4年局部无复发生存率分别为97．1％、92．7％。体外照射56、60和66Gy组的3年无瘤生存率分别为83．6、88．4％和84．6％（X^6=0.92,P=0.63),3年局部无复发生存率分别为100％、90．9％、93．3％（X^2=0.25,P=0.88)，差异均无统计学意义。结论 腔内近距离治疗前应该进行CT或MRI影像评价并进行严格的适应证选择及后装技术的选择，腔内近距离治疗的适应证为病变厚度≤10mm的病例为好。在此基础上T1、T2期鼻咽癌计划外照射的剂量可以降低至56Gy。腔内近距离治疗超分割方法的晚期放射性反应少，患者可以耐受，具有可行性。     

鼻咽癌调强放疗初步结果

目的:探讨鼻咽癌三维适形调强放射治疗(intensity-modulatedradiotherapy,IMRT)的初步疗效。方法:对91例经病理确诊的鼻咽低分化鳞癌患者进行调强放疗。处方剂量分别为GTV(鼻咽部和颈部淋巴结肿瘤靶区)66~70Gy,CTV1(临床靶区)60~62Gy,CTV2和CTVn(颈部淋巴结区域)54~56Gy。11例患者IMRT结束后有局部残留,1例采用IMRT追量照射10Gy/4次,其余给予鼻咽腔内后装追量照射9~15Gy/3~5次。分析疗效及放射治疗毒性。结果:中位随访时间12个月,1和2年生存率为97·1%和97·1%,局控率为97·1%和92·5%。急性放射反应多为Ⅰ度和Ⅱ度以口干和放射性口腔炎为主,分别占72·5%和58·2%。远期放射反应表现为不同程度的口干和听力下降,占患者的39·6%和17·6%。GTV、CTV1及CTV2的平均剂量分别为70·6、67·9和65·0Gy;5%体积的正常器官受照射剂量的平均值为:脑干41·4Gy,脊髓35·4Gy,左腮腺46·5Gy,右腮腺51·8Gy。结论:调强放疗能使得鼻咽癌各靶区得到很好的剂量分布,提高了初治鼻咽癌的局部控制率,明显减轻了急性放射反应。鼻咽癌IMRT处方剂量70Gy以上,CTV2预防照射的范围有待于进一步探讨。     

复发性鼻咽癌三维适形放射治疗的疗效分析

目的 分析复发性鼻咽癌三维适形放射治疗的疗效及影响疗效的因素.方法 56例复发性鼻咽癌接受三维适形放射治疗,鼻咽部剂量50～70Gy/36～52d(中位64Gy/44d).结果 全组病例随访3年以上.3年总生存率、无瘤生存率和鼻咽部局部控制率分别为48.2 %、44.6%和53.6%.复发间隔时间＞2年和复发临床分期T2期者,3年生存率和局部控制率高(P＜0.05);再程放疗剂量≥60Gy者,3年生存率和局部控制率优于＜60Gy.结论 三维适形放射治疗是复发性鼻咽癌有效的治疗手段,其复发间隔时间、复发临床分期和再程放疗剂量是影响预后的因素.     

鼻咽癌放疗后颈淋巴结残留及复发的组织间插植放疗

[目的] 分析鼻咽癌放疗后颈淋巴结残留及复发组织问插植近距离后装推量放疗的临床疗效。[方法] 全量放疗后鼻咽癌颈部淋巴结残留15例直接组织间插植后装推量放疗，鼻咽癌放疗后单纯颈部复发8例先局部外照射DT40～50Gy，然后组织间插植后装推量放疗，保留置管，超分割照射，250～400cGy／次，2次／天，残留者DTl0～20Gy，复发者24～35Gy。[结果] 肿块全消22例(95．7％)，残留l例(4.3％)，l、3、5年生存率为95．65％、57．9l％、41．36％：无严重并发症发生，死亡原因主要为远处转移及鼻咽复发。[结论] 组织间插植后装推量放疗是鼻咽癌放疗后颈部残留或复发安全有效的挽救治疗手段。     

鼻咽癌放射治疗临床病理资料回顾性分析

目的:探讨分析鼻咽癌外照射结合腔内近距离放疗的疗效.方法:回顾性分析1997-01-2002-10我院171例鼻咽癌患者经60Co外照射后给予鼻咽局部192Ir高剂量率近距离放疗的临床资料.结果:171例5年生存率为72.88%;Ⅰ、Ⅱ和Ⅲ期5年生存率分别为100.0%、86.75%和64.45%,P=0.000 8;外照射后鼻咽局部无残留108例,5年生存率为82.24%;残留63例,5年生存率为63.53%,P=0.026 2.鼻咽近距离剂量≥8 Gy,长期生存率影响明显;未出现软腭穿孔、鼻咽大出血、蝶骨坏死严重放疗并发症.结论:外照射后对鼻咽近距离照射,局部控制率提高,提高生存率;对鼻咽癌外照射残留近距离放疗,疗效比较肯定;增加鼻咽局部近距离剂量,对长期生存率影响明显.     

鼻咽癌UICC分期(1997)的临床评价

目的：评价鼻咽癌UICC（1997）分期的预后预测价值。方法：1992年8月至1993年12月,本院621例经鼻咽活检证实,治疗前均行CT或MR检查的MO鼻咽癌患者,根据UICC（1997）分期,对621例病人重新分期。放射治疗：NPDT：66-74Gy/33-37次,共7-8周;LNDT：60-70Gy/33-35次,共7-8.5周;颈部预防量：48-50Gy。结果：Ⅰ-Ⅳ期的病例分别为6.1%、43.5%、25.1%及25.3%。本组病例咽旁侵犯的发生率为74.1%,在460例咽旁侵犯的病例中,310例（67.4%)划分为T2。Ⅰ-Ⅳ期的5年生存率分别为89%、70%、53%及37%;Ⅰ-Ⅳ期的5年无瘤生存率分别为84%、69%、51%及36%。T1-4的5年无局部复发生存率分别为93%、84%、71%及58%;N1-4的5年无远处转移生存率分别为90%、81%、62%及51%。结论：UICC（1997）分期能较好的预测鼻咽癌预后,然而,病例分布不合理,Ⅱ期病人占总病例的43.5%。建立下一版UICC鼻咽癌分期进行咽旁侵犯程度的划分。     

后程加速超分割放射治疗鼻咽癌的临床研究

[目的]观察后程加速超分割治疗鼻咽癌的疗效及毒副反应。[方法]对45例初治鼻咽癌患者分为常规分割组(常规组)和后程加速超分割组(后超组)。常规分割组:22例,每天2Gy/次,5次/周,鼻咽原发灶中位肿瘤剂量70Gy～72Gy/DT;后程加速超分割组:23例,先常规分割照射,每天2Gy/次,5次/周,放射剂量至38Gy～40Gy/DT后改用加速超分割放疗方案,1.5Gy/次,2次/d(相隔≥6h),5d/周,总剂量72Gy～76Gy。[结果]放疗结束后3个月,常规组、后超组内窥镜检查鼻咽原发灶完全消退率分别为90.91%、100%。常规组、后超组1、3年鼻咽原发灶控制率分别为95.45%、67.53%和100%、90.91%,有显著性差异(χ2=4.03,P﹤0.05);1、3年生存率分别为95.45%、63.64%和95.65%、73.91%,无显著性差异(χ2=0.59,P>0.05)。常规组、后超组放射治疗的早期放射急性口腔黏膜反应Ⅲ级发生率,分别为18.18%(4/22),52.17%(12/23)(χ2=4.28,P﹤0.05),差异有显著性;两组病例的远期放射反应未见有显著性差异。[结论]后程加速超分割治疗鼻咽癌的近期肿瘤局部控制率明显高于常规分割组,但生存率无差别;早期放射急性口腔黏膜反应较常规组严重,但大多患者能够耐受。     

鼻咽癌根治放疗后残留病变的两种推量治疗方法疗效比较

Objective： To compare the efficacy between stereotactic radiotherapy （SRT） and intracavitary brachytherapy （brachytherapy） in residual tumor of nasopharyngeal carcinoma （NPC） after treating with conventional external beam radiotherapy. Methods： 60 patients with residual tumor of NPC after radical external beam radiotherapy （range 68 to 72 Gy） were randomized into SRT group （27 patients） and brachytherapy group （33 patients）. Patients in SRT group received boost treatment of 10-20 Gy, 2-3 fractions, once every other day; patients in brachytherapy group were treated with boost 10-20 Gy, 5 Gy per fraction, twice a week. Results： Efficacy in the near future： in SRT group, the complete recession （CR）, partial recession （PR） and no change （NC） rates were 77.8% （21/27）, 18.5% （5/27）, 3.7% （1/27）, respectively and the efficacy rate was 96.3% （CR ＋ PR）; in brachytherapy group： the CR, PR and NC rates were 75.8% （25/33）, 18.2% （6/33）, 6.1% （2/33）, respectively and the efficacy rate was 93.9% （CR ＋ PR）. The efficacy rates of the above two groups were compared （x^2 = 0.032, P 〉 0.05）. Long term efficacy： in SRT group, 1-year and 3-year survival rates were 96.3%, 66.5% respectively and the median live time was 48 months; in brachytherapy group： 1-year and 3-year survival rates were 93.9%, 60.2% respectively and the median live time was 46 months. The survival rates of two groups were compared （x^2 = 0.172, P 〉 0.05）. Conclusion： Both boost techniques of SRT and brachytherapy had elevated efficacy in patients with residual tumor of NPC and there was no obvious difference between the efficacy of the near and long term in SRT and brachytherapy group.     

High-dose-rate intracavitary brachytherapy boost for early T stage nasopharyngeal carcinoma{private}

PURPOSE: To investigate any possible therapeutic gain from dose escalation with brachytherapy for early T stage nasopharyngeal carcinoma (NPC). METHODS AND MATERIALS: One hundred forty-five patients with T1-2b N0-3 NPC were boosted with high-dose-rate intracavitary brachytherapy after completion of two-dimensional external radiotherapy (ERT) during the period from 1999 to 2003. To compare the efficacy of brachytherapy boost, another 142 patients with T1-2b N0-3 disease who were treated with ERT alone during 1994 to 1999 were evaluated. All patients were treated with ERT to a total dose of 66 Gy in 6.5 weeks. The brachytherapy boost group was given 10-12 Gy in 2 weekly fractions. RESULTS: Dose escalation beyond 66 Gy with brachytherapy boost was shown to improve local control and survival. The 5-year actuarial local failure-free survival, regional failure-free survival, distant metastasis-free survival, progression-free survival, cancer-specific survival, and overall survival rates for the brachytherapy group and the control group were 95.8% and 88.3% (p = 0.020), 96% and 94.6% (p = 0.40), 95% and 83.2% (p = 0.0045), 89.2% and 74.8% (p = 0.0021), 94.5% and 83.4% (p = 0.0058), and 91.1% and 79.6% (p = 0.0062), respectively. The 5-year major-complication-free survival rate was 89.5% for the brachytherapy group and 85.6% for the control group (p = 0.23). CONCLUSIONS: For patients who are treated with two-dimensional treatment techniques, dose escalation with brachytherapy boost improves local control and overall survival of patients with T1-T2a and possibly non-bulky T2b disease.     

The role of brachytherapy in early-stage nasopharyngeal carcinoma

To present the treatment results and assess the optimal radiation dose and the role of brachytherapy in early stage nasopharyngeal cancer (NPC).

One hundred eighty-three patients with Stage I and II (American Joint Committee on Cancer Staging System, 1987) NPC completed the planned radiotherapy in our institution from 1979 to 1991. In 133 patients, radiotherapy was given to the nasopharynx by external beam to 64.8–68.4 Gy. Further boost was done by high dose rate (HDR) brachytherapy for 5–16.5 Gy in one to three fractions. For the remaining 50 patients, a course of external radiotherapy to the nasopharynx for 68.4–72 Gy was given to nasopharynx. Age (>40 or not) sex, neck boost or not, brachytherapy, and irradiation dose were analyzed to determine significant factors that influence the probabilities of local control and actuarial survival.

The 5-year disease-specific survival was 85.8% and local control was 83%. Only the brachytherapy and irradiation dose significantly affected the results. The use of the brachytherapy had significant impact on overall survival and local control. Furthermore, we compared the prognostic effect of various radiation dosage among Group I of 50 patients (<72.5 Gy, no brachytherapy, excluding four patients who received brachytherapy), Group II of 71 patients (72.5–75 Gy; one to two fractions of brachytherapy), and Group III of 58 patients (>75 Gy; three fractions of brachytherapy). Five-year disease-specific survival rates of Group I, Group II, and Group III were 77, 95.5, and 82.4%, respectively. Five-year local control rates were: 73.7, 93.9, and 79.5%. We found that the Group II had the best actuarial survival and local control rate (log-rank test, p < 0.05). Most patients receiving brachytherapy encountered foul odor because of nasopharynx crust; 12 of them had palate or sphenoid sinus floor perforation or nasopharynx necrosis. None of the patients without brachytherapy experienced the same complications.

The optimal radiotherapy dose to the nasopharnyx area in early stage NPC may be within 72.5 to 75 Gy by our treatment protocol. A dose of more than 75 Gy did not have significant local control or survival advantage. The use of brachytherapy to elevate radiation dose had significant local control and survival benefit for early stage NPC patients, but the fractionation size should be decreased to reduce the complications.     

局部复发鼻咽癌超分割加立体定向适形放疗的临床研究

目的:初步评价超分割外照射加立体定 向适形放射剂量治疗局部复发鼻咽癌的临床疗 效及毒副反应。方法:对1999～2002年收治的 14例复发鼻咽癌进行超分割外照射(1.3Gy/次, 2次/d,总剂量42～60Gy)加立体定向适形放射 推量(4Gy/次,隔日照射,共10次,总量20Gy) 的临床研究。结果:总有效率(CR+PR)85.7% (12/14),其中完全消退(CR)64.3%(9/14),部分 消退(PR)21.4%,肿瘤稳定14.3%,2年总生存 率57.1%(8/14),无瘤生存率42.8%(6/14),靶 区肿瘤控制率为78.6%(11/14)。结论:超分割 外照射加立体定向适形放射剂量治疗局部复发 鼻咽癌在临床上是可行及有效的。     

HDR-brachytherapy boost for residual tumour after external beam radiotherapy in patients with tracheal malignancies.

Seven inoperable patients with tracheal neoplasms received a high dose rate (HDR) brachytherapy boost (median 15 Gy, single dose 3-5 Gy) for residual tumour after external beam radiotherapy (median 50 Gy, 5 x 2 Gy/week). The median actuarial survival was 34.3 months. The 1-, 2- and 3-year actuarial survival rates were 85.7%, 85.7% and 32%. Local control was obtained in 5/7 patients. Late toxicity occurred in three patients (stenosis n = 2, hemorrhage n = 1). Our data indicate, that a HDR brachytherapy boost is effective and feasible.     

Nasopharyngeal carcinoma treated by radical radiotherapy alone: Ten-year experience of a single institution

PURPOSE: To report on our experience in the treatment of nasopharyngeal carcinoma (NPC) by radical radiotherapy alone in our institution during the last decade. METHODS AND MATERIALS: From January 1990 to May 1999, 905 NPC patients were treated and were studied retrospectively. Radical radiotherapy was given to this cohort by conventional technique in a routine dose of 70-72 Gy to the primary tumor and metastatic lymph nodes. In case of residual primary lesion, a boost dose of 8-24 Gy was delivered by either 192Ir afterloading brachytherapy, fractionated stereotactic radiotherapy, conformal radiotherapy, or small external-beam fields. RESULTS: The 5-year and 10-year local-regional control, overall survival, and disease-free survival rates were 81.7% and 76.7%, 76.1% and 66.5%, 58.4% and 52.1%, respectively. In case of residual primary lesions after a dose of 70-72 Gy of conventional external-beam radiotherapy (EBRT), an additional boost was able to achieve a local control of 80.8%, similar to that obtained with primary lesions that completely disappeared at 70-72 Gy (82.6%, p = 0.892). CONCLUSIONS: The treatment results of radical EBRT followed by a boost dose to the residual primary tumor for nasopharyngeal carcinoma in our institution are promising.