侵及颈动脉的晚期转移头颈鳞状细胞癌的挽救手术

目的探讨侵及颈动脉的晚期转移头颈鳞状细胞癌(简称鳞癌)患者的外科治疗。方法回顾性分析中国医学科学院肿瘤医院10年来对57例侵及颈总或颈内动脉的晚期转移头颈鳞癌患者实施外科治疗的病例资料及术后生存情况。48例患者术中可将肿瘤由颈动脉壁剥离而保留颈动脉；9例肿瘤已侵到动脉壁中膜层而切除动脉，术中不作动脉切除后的Ⅰ期动脉重建术。对手术中认为肿瘤残留和术前未放射治疗(简称放疗)或放疗剂量不足70Gy的患者，进行术后放疗40～70Gy。结果57例患者中4例长期生存；53例死亡，死于术后多器官衰竭1例，死于局部复发10例，颈部复发19例，远处转移14例，颈总动脉出血7例，非肿瘤因素2例。用Kaplan-Meier生存率统计法计算，患者的中位生存时间为13个月；1、2、3、5年生存率分别为51．8％、19．6％、12．5％、8．3％。术中肉眼切净与肉眼残留的复发率分别为26．7％、50．0％；2年生存率分别为22．2％、0。椎前组织受侵与椎前组织未受侵的术后复发率为76．0％、28．3％，2年生存率为12．0％、25．0％。术后放疗与未放疗的复发率分别为46．4％、73．1％；2年生存率分别为21．4％、15．4％。结论对于侵及颈动脉的晚期转移头颈鳞癌患者，应进行积极的外科挽救性手术治疗，术中应尽量整块切除肿瘤，且与周围组织应有合理的安全界限，对于受侵的动脉除非肿瘤已侵及动脉的中膜层，否则，应尽量剥离肿瘤保持动脉的完整，不切除动脉，以减少术后死亡及神经系统并发症。术后放疗可以减低肿瘤复发，可能延长患者的生存时间。

Salvage surgery for patients with metastatic squamous cell carcinoma involving carotid artery in head and neck]

OBJECTIVE: To study the surgical approaches for metastatic squamous carcinoma involving carotid artery in head and neck. METHODS: Fifty-seven patients with metastatic squamous carcinoma involving carotid artery were analyzed retrospectively. Forty-eight were undergone peel-off tumor from carotid artery and another 9 with carotid artery resection due to being invaded in the middle layer of the carotid artery wall. None of them were received artery reconstruction. Postoperative radiotherapy was given to those who had radiation with the total dose less than 70 Gy or no radiotherapy, or gross tumor residue during operation. RESULTS: Of all the 57 patients, 53 had been death and only four survived without clinical lesion. One patient died of postoperative multi-organ failure, 10 of local recurrence, 19 of regional recurrence, 14 of distance metastases, 7 of carotid artery bleeding eroded by tumor, and the remaining 2 of unknown causes. Median survival was 13 months and 1, 2, 3, 5-year overall survival rate was 44.6%, 16.2%, 12.5%, 8.3% respectively, as estimated by the Kaplan-Meier approach. The recurrent rate of gross negative and positive were 26.7% and 50.0% respectively. 2-year survival rate of those were 22.2% and 0 respectively. Recurrent rate and 2-year overall survival rate in patients with and without postoperative radiotherapy was 46.4% and 21.4%, 73.1% and 15.4% respectively. CONCLUSIONS: It is necessary to perform aggressive salvage operation for patients with metastatic squamous cell carcinoma involving carotid artery. En blok removal of the tumor and the reasonable safe margin should be achieved. Unless the middle layer of the artery wall is involved, tumor peel-off is preferred to carotid resection to reduce the mortality and cerebrovascular complication. Postoperative radiotherapy reduces the recurrent rate and improves overall survival rate potentially.