喉癌治疗后原发灶复发的手术救援

目的：总结治疗后原发灶复发的喉癌病例，探讨与手术挽救相关的问题。方法：回顾1990～1995年于中山大学肿瘤防治中心住院治疗的278例喉癌病例，对28例治疗后出现原发灶复发的病例进行总结分析。出现复发后进行手术挽救13例，其中行部分喉手术挽救5例、行全喉切除术挽救6例、其余2例行复发肿物局部广泛切除。另外15例中进行化疗12例(包括DBF方案5例、DDP BLM1例、其余6例行FT-207姑息化疗)、进行放疗挽救2例(放疗剂量分别为40和50Gy)、另外1例复发后未进行挽救治疗。结果：本组28例原发灶复发的喉癌病例再次治疗后总体的5年累计生存率为40．3％。手术挽救组和非手术挽救组的5年生存率分别为61l5％(8／13)和6．7％(1／15)，具有显著差异(Log Rank=13．72，P=0．0002)。13例进行手术挽救的病例中3例再次复发，手术挽救的成功率为69．2％，其中部分喉手术挽救和全喉切除术挽救的成功率分别为60％和83．3％，统计学无显著性差异(P=O．545)。患者的年龄、病变分期、病变部位、鳞癌分化程度、首次治疗方式、放疗以及复发间隔时间等因素不影响原发灶复发后手术挽救的进行。本组手术挽救的13例病例中出现术后并发症5例．约为38．5％。结论：复发性喉癌能够手术挽救的病例具有较好的生存率，手术挽救是治疗复发性喉癌较好的选择。部分喉和全喉切除手术挽救的成功率相当。     

T3声门上喉癌33例的治疗

目的：研究T3声门上癌的治疗效果，讨论分析T3病变的临床处理方法。方法：回顾1982年－1991年于中山医科大学肿瘤医院住院治疗的T3声门上喉癌33例。声门上癌原发灶均行手术治疗，其中27例行全喉切除术，6例行声门上水平部分喉切除术。颈部的处理方式包括：13例临床N（＋）的患者中2例行根治性颈淋巴结清扫术，11例行区域性颈淋巴结清扫术；20例临床N0病例中1例选择性颈淋巴结清扫术，其余19例均随诊观察。本组病例中单纯手术治疗19例，其余14例手术加放疗的综合治疗。结果：本组T3声门上喉癌治疗后的五年生存率为63．6％（21／33），五年的无瘤生存率为57．6％（19／33），Kaplan-Meier分析总体的五年累计生存率为63．9％。原发灶部分喉手术和全喉手术的五年生存率分别为80％和59．9％，Kaplan-Meier分析两者间差异无显著性（Log Rank=0.82,P=0.3646）。单纯手术和手术加放疗的五年生存率分别为56．4％和67．3％，Kaplan-Meier分析两组间差异无显著性（Log Rank＝0．61，P＝0．4341）。33例临床T3的声门上喉癌病例治疗后有5例出现原发灶复发，12例出现颈部复发，治疗对原发灶和颈部的控制率分别为84．8％（28／33）和63．6％（21／33）。结论：声门上癌侵犯会厌前间隙和舌根的T3亚型，声门上水平喉切除术可以获得较好的疗效。对于伴声带固定的T3病变，应谨慎选择部分喉手术。手术加放疗虽然不能显著影响生存率，但较单纯手术有较高的五年生存率的趋势。结合放化疗治疗声门上T3病变仍有待进一步探讨。     

喉咽鳞癌不同治疗方案对喉功能保留及预后的影响

目的：回顾性分析初治的97例喉咽鳞癌患者应用不同治疗方法后的生存率、喉功能保留率和复发与转移情况等,探索更合理的处理方法。方法：采用SPSS10．0统计软件Kaplan—Meier法和PearsonY。检验／Fisher’s确切概率比较单纯放疗组30例,新辅助化疗＋放疗组17例,单纯手术组11例,手术＋术后放疗组33例,姑息化疗组6例的治疗效果。结果：97倒喉咽鳞癌总的3、5年累计生存率分别为46．43％和31．88％,中位生存时间是28个月。单纯放疗组、新辅助化疗＋放疗组、单纯手术组、手术＋术后放疗组5年生存率分则是18．33％、23．53％、36．36％和53．65％,5年复发率分别是70．00％、52．94％、36．36％和27．27％。接受原发灶手术共41例,喉功能部分或全部保留的手术患者与全喉切除术不保留喉功能的患者的5年生存率分别是57．14％、39．16％,P=0．3574;两组的5年局部复发率分剐是21．05％、13．64％,差异均无统计学意义,P=0．4140。结论：喉咽鳞癌患者接受单纯放疗或新辅助化疗＋放疗生存率较低,单纯手术治疗也不能明显提高生存率,手术＋放疗的治疗模式可使患者生存率有明显提高,部分喉咽鳞癌肿瘤局限,可考虑行保留喉功能的喉部分切除术,并不增加复发的风险。     

保留喉功能疗法在喉癌 T3期病例中的应用探讨

目的：探讨在喉癌 T3期病例中 3种保留喉功能的治疗方法的优劣。方法：将保留喉功能的治疗方法分为单纯根治性放疗、根治性放疗失败后挽救性手术切除、部分喉切除术 3种,分析采用此 3种方法治疗的 94例 T3期喉癌病例的总体生存率、原发灶和继发灶复发率、并发症发生率。结果：在声门上型喉癌中部分喉切除术组的生存率优于单纯根治性放疗组 (P=0.0248);在声门型喉癌中部分喉切除术组的生存率与根治性放疗失败后挽救性手术切除组相当,都高于单纯根治性放疗组 (P=0.0075);在根治性放疗失败后挽救性手术切除、部分喉切除术组中,并发症发生率分别为 60％、 16.7％,前组高于后组（ P<0.05）;放疗组（包括单纯根治性放疗组和根治性放疗失败后挽救性手术切除组）与部分喉切除术组的原发灶复发率分别为 45.8％、 19.4％,差异有显著性（ P< 0.05）。结论：在 T3期喉癌病例中,上述 3种保留喉功能的治疗方法以部分喉切除术效果最佳。     

喉癌治疗方法的选择和治疗失败原因分析

目的：探讨喉癌治疗方法的选择和分析喉癌治疗失败的原因。方法：总结本科１９８９～１９１年３月间经根治的１５１例喉癌病例,分单纯放疗、全喉切除术、部分喉切除术、挽救性手术４个治疗组,分别各组的３年和５年生存率以及各组的失败原因。结果：单纯放疗组栓喉切除组、部分喉切除组、挽救性手术组的３年和５年生存率,分别为４５．９％,６６．７％,９４．４％,８８．９％和２４．３％,５６．５％,８６．１％,６６．７％,     

65例T3声门型喉癌的治疗与预后分析

背景与目的:T3声门型喉癌目前临床治疗上仍有较多争议,本文旨在探讨T3声门型喉癌的不同治疗方案、颈淋巴结转移情况及切缘阳性对预后的影响。方法:回顾性研究1990年1月1日～1998年12月30日中山大学肿瘤防治中心诊治的T3声门型喉癌65例,比较不同治疗方法、切缘情况、颈淋巴结转移情况对预后的影响。结果:全组总的3、5年生存率为75.47%、65.07%。单纯手术、单纯放疗与手术 辅助放疗三组生存率无差异(P=0.914);部分喉切除术与全喉切除术生存率无差异(P=0.710);切缘阳性患者术后加放疗的生存率与切缘阴性患者无差异(P=0.176)。颈淋巴结转移率18.5%,隐性淋巴结转移率10.8%,淋巴结转移是影响预后的重要因素(P<0.001)。结论:对于T3声门型喉癌,单纯手术、单纯放疗与手术 辅助放疗患者生存率无差异;部分喉切除术患者生存率不比全喉切除术低;淋巴结转移影响预后,对cN0患者颈部主张观察;切缘阳性术后加放疗生存率不降低。     

下咽鳞癌不同治疗方案的临床分析

目的　探讨不同的治疗方案治疗下咽鳞癌的疗效 ,提出规范化的治疗方案。方法　回顾性分析 4 6 4例下咽鳞癌患者的临床特征和不同治疗方案的治疗结果 ,运用SPSS 10 .0软件包进行统计分析。结果　术前放疗 +手术 2 0 2例 ,手术 +术后放疗 2 2例 ,单纯手术 2 6例 ,根治性放疗失败挽救性手术 4 0例 ,单纯放疗 174例。总的 5年生存率为 34.2 % ,术前放疗 +手术组、手术 +术后放疗组、单纯手术组、根治性放疗失败挽救性手术组及单纯放疗组 5年生存率分别为 4 6 .3%、4 9.2 %、2 2 .8%、4 0 .8%和 18.0 % (P <0 .0 1)。术前放疗 +手术组与单纯手术组比较 ,生存率差异有统计学意义 (P =0 .0 4 6 )。术前放疗 +手术组喉功能保留者 80例 ,占 39.6 % ;手术 +术后放疗和单纯手术组喉功能保留者 8例 ,占 16 .7% ,差异有统计学意义 (P =0 .0 0 3)。单纯放疗组和术前放疗 +手术组死于局部复发分别为 2 7.6 %和 8.9% (P =0 .0 0 8)。结论　下咽鳞癌患者首先应选择术前放疗 +手术或手术 +术后放疗的综合治疗方案 ,术前放疗 +手术能明显提高下咽鳞癌的喉功能保留率。     

喉鳞癌治疗后原发灶复发的相关因素分析

背景与目的:分析与喉鳞癌治疗后原发灶复发相关的因素。方法:回顾1990年～1995年于原中山医科大学肿瘤防治中心住院治疗的喉鳞癌病例166例。治疗后随访满6个月以上病理活检证实原发灶出现复发者定为喉癌治疗后复发病例。分析与喉癌治疗后原发灶复发可能相关的因素,包括年龄、病理分化、病变部位、分期、治疗方式、手术术式、切缘、放疗等。结果:本组病例治疗后原发灶复发率为16.3%(27/166)。治疗方式中原发灶行单纯放疗、单纯手术和综合治疗的原发灶复发率分别为50%、8.9%和14.1%,存在显著差异(P<0.05)。原发灶行手术治疗和非手术治疗(包括放疗以及放疗加化疗)的复发率分别为11.3%和44%,存在显著差别(P<0.05)。对比不同治疗方式间T分期显示单纯放疗较单纯手术和综合治疗原发灶的T分期相对较早(P<0.05)。术后切缘阳性和阴性的原发灶复发率分别为34.8%和6.1%,具有显著性差别(P<0.05)。结论:原发灶的处理方式直接影响治疗后原发灶的复发,原发灶手术治疗相对非手术治疗对原发灶的控制较好,喉鳞癌原发灶单纯放疗后复发的机会较大。手术切除的干净程度直接影响对原发灶的控制。     

喉部分切除术失败原因分析

目的：探讨提高喉部分切除术患者的生存率及生存质量，方法：对346例喉部分切除术后一年内肿瘤复发，术式选择失当，肺部感染伴心衰死亡，严重误吸再手术，颈转移或远膈转移的50例临床资料进行分析。结果：发现37／50（74．0％）为肿瘤复发，7／50（14．0％），为颈转移，4／50（8．0％），为远膈转移，2／50／4．0％）为极度呛咳再手术，结论：了解喉癌病理特点，选择适当的术式，提高手术技巧是提高喉癌患者生存率及生活量的关键。     

下咽及颈段食管鳞癌的治疗

目的：研究下咽及颈段食管鳞癌的治疗效果。方法：回顾性分析117例初治下咽及颈段食管鳞癌不同治疗方法的效果。结果：总3年生存率为60．0％，术前放疗原发灶达到完全缓解与非完全缓解者3年生存率分别为82.0%、45.0%。术后发生并发症27例（23．1％）。死亡47例，其中局部复发未控15例（31．9％），颈部复发未控11例（23．4％），远处转移6例（12．8％）。术前放疗喉功能保留率为46．3％，而单纯手术或术后放疗者为27．3％。结论：术前放疗为主的综合治疗可提高下咽颈段食管鳞癌的生存率及喉功能的保留率；术前放疗完全缓解者生存率较高。局部复发与颈部淋巴结转移是下咽颈段食管癌的主要死亡原因。     

The treatment of early (T1) glottic and supra-glottic carcinoma: does partial laryngectomy have a place?

A series of 900 patients with laryngeal carcinoma is described. Patients with glottic T1N0 tumours were treated by radiotherapy with a 5-year survival of 92%. Seven per cent of patients suffered recurrence and most were salvaged by surgery: vertical hemilaryngectomy was occasionally useful as a salvage procedure. Patients with supra-glottic T1N0 tumours were treated for the first 7 years by supra-glottic laryngectomy and prophylactic neck dissection and thereafter by radiotherapy. The results were equally good in both series: a 5-year survival of 75-80%. Salvage surgery for failed radiotherapy or surgery for supra-glottic carcinoma gave poor results.     

Regression after 50 Gy as a selection for therapy in advanced laryngeal cancer

Radiation alone for advanced laryngeal cancer will result in an initial local control rate of 50%. When a local recurrence is diagnosed, only 50% will be successfully salvaged by surgery. To identify patients with a high chance of local control with radiation alone in advanced laryngeal cancer, the clinical response following radiotherapy was assessed a few days after 50 Gy/5 weeks. In patients with T-stage reduction or greater than 50% tumor regression radiotherapy was continued, if not, laryngectomy was performed after 4-6 weeks. According to this protocol 30 patients (out of 50) with T3/T4 laryngeal cancer were treated. Initial local control was assessed 6 weeks after radiotherapy, the ultimate local control included successful salvage surgery. Initial local control in patients, treated with a full course of radiotherapy after T-stage reduction or greater than 50% tumor regression, was 69% for T3 and 43% for T4 while the ultimate local control rate was 85% and 71% respectively. Although the percentage of voice preservation in our study was slightly lower (40%) than data from literature with radiation alone, the ultimate local control was high and comparable with those of combined therapy (in which laryngectomy is a part). The corrected actuarial 5-year survival in all T3 and T4 patients treated with radiation alone and salvage surgery was 73% and 31% respectively and was not different compared to surgery with pre- or post-operative radiotherapy, 74% and 53% respectively. We believe that this protocol may select a favorable group of patients for high dose radiation alone in T3 and probably in T4 laryngeal cancer.     

喉全切除术后咽皮瘘的治疗和相关因素分析

[目的]探讨喉全切除术后咽皮瘘的发生率、治疗效果和发生相关因素.[方法]回顾1990年至1995年于中山大学肿瘤防治中心住院治疗的107例行喉全切除术的患者,应用SPSS统计软件统计分析术后咽皮瘘的发生率、治疗效果和发生相关因素.[结果]全喉切除术后14.0%(15/107)的患者出现咽皮瘘.全喉切除术后至发生咽皮瘘的间隔时间5至28天,平均11天.80%(12/15)的患者保守治疗后可以自行愈合.保守治疗后咽皮瘘的愈合间隔时间介于12至90天,平均37天.3例无法自行愈合的咽皮瘘患者中,1例出现咽皮瘘口周围肿瘤复发,其余2例则需要手术修补.分析与喉全切除术后咽皮瘘发生有关的可能因素显示,首次治疗后复发再行喉全切除术挽救、喉全切除术前接受过放疗以及喉全切除术后伤口感染是影响咽皮瘘发生的显著因素.[结论]喉全切除术后咽皮瘘较为常见,发生后以保守治疗为主.初次治疗失败、术前放疗以及伤口感染可能是喉全切除术后咽皮瘘发生的相关因素.     

Surgical complications of salvage total laryngectomy following concurrent chemoradiotherapy

Background  Surgical complication rates of total laryngectomy vary according to the preoperative treatments performed and patient factors. Wound complications after salvage laryngectomy following concurrent chemoradiotherapy (CCRT) were analyzed. Methods  Eighty-six patients who had undergone total laryngectomy for laryngeal cancer at Hokkaido University Hospital, Japan, between 1990 and 2006 were divided into three groups according to preoperative treatments received: group I (n = 35) without radiotherapy (RT) or CCRT, group II (n = 17) RT alone, and group III (n = 34) low-dose CCRT. Salvage total laryngectomy was performed as a consequence of residual or recurrent disease after completion of the treatments. Wound complications such as pharyngocutaneous fistulas, bleeding, infections, and skin necrosis were retrospectively analyzed in each group. Results  A considerable (not statistically significant) difference in the incidence of major wound complications was observed between groups I and III (11.4% vs 29.4%, P = 0.078), but not between groups II and III. In stage III/IV patients, a significant increase in the incidence of wound complications was observed in group III compared to group I. Pharyngocutaneous fistulas were the most common complication, occurring in 8/34 (23.5%) of the group III patients. Additional pharyngeal reconstruction surgery was performed in 5 of the 8 (62.5%) group III patients with pha ryngocutaneous fistulas, while no such patients (0/3) in group I required reconstruction surgery. Conclusion  There was an increased risk of wound complications in patients undergoing salvage laryngectomy following CCRT. Patients who developed pharyngocutaneous fistulas after CCRT tended to require surgical reintervention for repair. These findings should be taken into account before the initiation of CCRT and salvage surgery.     

Supraglottic carcinoma: patterns of failure and salvage treatment after curatively intended radiotherapy in 410 consecutive patients

PURPOSE: In a series of consecutive patients with squamous cell carcinoma of the supraglottic larynx, in which almost all were treated by primary radiotherapy, the study describes the path from diagnosis to cure or death, and evaluates the patterns of failure and the treatment of recurrences. METHODS AND MATERIALS: The analysis included 410 patients, 104 females and 306 males, treated between 1963 and 1991. Most patients were in Stage I (33%), and the remaining were in Stage II (18%), III (23%), and IV (26%). Primary intended curative treatment was delivered in 398 (radiotherapy, 394; surgery, 4) of 410 cases (98%). RESULTS: Initial radical treatment resulted in 173 cured patients and 225 patients with a recurrence. Curatively intended salvage could be applied in 158 patients: surgery in 154 patients (74 cured) and radiotherapy in 4 (none cured). Overall, 247 patients (60%) obtained tumor control, 179 (44%) without a laryngectomy. Sixty-three patients had a total laryngectomy, and five had a partial laryngectomy. The 5-year locoregional tumor control, disease-specific survival, and overall survival rates were 43%, 61%, and 47%, respectively. With a follow-up of 20 years posttreatment, 91 new primary malignant tumors were detected. CONCLUSIONS: Radiotherapy is effective in the treatment of supraglottic laryngeal carcinoma, and the patients have a relatively good prognosis. Many patients retained their larynx intact. Recurrence after primary radiotherapy can be treated by surgery, with a high success rate even in advanced stages. Development of second primary cancer is a growing problem.     

Stomal recurrence in patients with T1 glottic cancer after salvage laryngectomy for radiotherapy failures: role of p53 overexpression and subglottic extension

The role of p53 overexpression in the development of stomal recurrence was studied in patients with T1 glottic cancer who had undergone salvage laryngectomy after primary radiotherapy failure (first recurrence). The role of subglottic extension of the recurrent tumor in the development of stomal recurrence was also studied. One hundred fourteen patients with T1 squamous cell carcinoma of the glottic larynx were irradiated with curative intent. A local recurrence (first recurrence) developed in 23 patients (20%), and salvage laryngectomy was performed for 20 of these patients. No postlaryngectomy radiation therapy was included in the treatment of recurrences. Several risk factors thought to be significant in the development of stomal recurrence were analyzed in these 20 patients. Prognostic factors analyzed include: p53 overexpression in the preradiation biopsy specimen, subglottic extension of the first recurrence, thyroid cartilage and lymph node involvement at the time of first recurrence, emergency tracheostomy performed before salvage laryngectomy, and the laryngectomy procedure performed for first recurrence. Presence of p53 protein in the preradiation biopsy specimen of laryngeal cancer did not show any adverse effect on the development of stomal recurrence. Stomal recurrence developed in 27% of patients with positive biopsies and in 20% of patients with negative biopsies (p = 1.00). Subglottic extension of the first recurrence was associated with an increased incidence of stomal recurrence. Rates of stomal recurrence were 6% in patients without subglottic extension and 100% in patients with subglottic extension (p = 0.001). All other risk factors studied showed no effect on stomal recurrence. In this study, p53 overexpression showed no effect on the development of stomal recurrence after salvage laryngectomy in patients with T1 glottic cancer. Conversely, subglottic extension of the recurrence was found to be strongly associated with stomal recurrence. All other factors analyzed showed no effect on stomal recurrence.     

Prognostic factors in early glottic carcinoma implications for treatment

AIM: In this study we aimed to determine the prognostic factors affecting local control (LC) in limited glottic carcinoma treated with definitive radiotherapy (RT). MATERIAL AND METHODS: Between June 1991 and December 2001, 114 patients with early squamous-cell carcinoma of the glottis were treated with definitive RT at our institution. Only four (3.5%) patients were women. The median age was 60 (27-79). Fifteen percent, 72% and 13% of the patients had Tis, T1 and T2 tumors, respectively. Forty-three (37.7%) patients had anterior commissure invasion. Prior to RT 35 (31%) patients had undergone vocal cord stripping and two (2%) cordectomy. A median dose of 66 Gy (50-70.2) was given over a median period of 46 days (20-60). Univariate and multivariate analyses were performed for LC. The prognostic parameters analyzed for LC were T classification, anterior commissure involvement, total RT dose, and overall treatment time. RESULTS: Five-year local and regional control rates were 84.2% and 97.7%. RTOG grade 3-4 late side effects were observed only in one (0.9%) patient. In 15 patients with local failure, salvage treatment consisted of partial laryngectomy in eight patients and total laryngectomy in five. One of the remaining two patients was medically inoperable, and the other refused salvage surgery. In one of the three patients with regional failure, salvage surgery was applied and the other two were given palliative chemotherapy because of unresectable disease. Following salvage treatments, the ultimate five-year LC rate was 96.9% and the five-year larynx preservation rate was 91.1%. Second primary cancer was diagnosed in 17 (14.9%) patients. Only one patient developed distant metastases and two patients died of laryngeal cancer. While T2 disease and anterior commissure involvement were found to be unfavorable prognostic factors significantly influencing LC in univariate analyses, only T2 disease remained independent in multivariate analysis. CONCLUSION: In patients with early glottic carcinoma, T classification proved to be the only independent prognostic factor affecting LC after primary radiotherapy according to the results of this study.