早期鼻咽非霍奇金淋巴瘤:不同免疫表型的预后差异和治疗对策分析

Prognosis and Treatment Strategies of Primary B-cell and NK/T-cell Nasopharyngeal Non-Hodgkin's Lymphoma at Early Stage

背景与目的:鼻咽是淋巴瘤较常见的发病部位之一,但对于不同病理免疫表型(B细胞与NK/T细胞)鼻咽淋巴瘤的临床特点和预后以及相应的治疗对策的区别,临床报道较少。本研究的目的在于探讨不同免疫表型的早期鼻咽非霍奇金淋巴瘤的临床表现和治疗效果,评估B细胞和NK/T细胞表型之间的预后差异,为治疗方案的相应调整提供依据。方法:回顾性分析1987年5月至2003年12月间80例初治的早期鼻咽非霍奇金淋巴瘤患者的临床资料,病理和免疫表型检查显示48例为B细胞来源(B组),32例为T和NK细胞来源(T组)。42例患者接受化放疗综合治疗,31例单纯化疗,7例单纯放疗。化疗多数采用标准CHOP方案,1～10周期(中位数5周期);放射治疗采用高能光子射线配合高能电子线,常规分割,照射剂量DT30～70Gy(中位数52Gy)。两组患者的治疗方式相近,但B组的化疗周期数大于后者。结果:B组和T组的5年总生存(OS)率分别为69.5%和35.5%(P=0.003),5年无疾病进展生存(PFS)率分别为53.3%和28.9%(P=0.032)。多因素分析显示,B细胞免疫表型、无全身症状、局部控制是OS有利的独立预后影响因素;B细胞免疫表型、治疗反应好(CR/PR)是PFS有利的独立预后因素。治疗方法影响OS的单因素分层分析显示:B组患者单纯化疗(19例)和放化疗综合治疗(25例)的5年OS分别为68.1%、61.7%,单纯放射治疗的4例随访期间全部生存(P=0.311);而T组患者单纯化疗(12例)和放化疗综合治疗(17例)的5年OS分别为0、44.1%,单纯放射治疗的3例中2例生存4、10个月后死亡,1例随访60个月生存(P=0.020)。结论:早期鼻咽非霍奇金淋巴瘤病例中,虽然B细胞表型患者的年龄偏大、颈淋巴结受侵比例偏高,其预后却优于NK/T细胞表型患者。后者全身症状多见,单纯化疗的缓解率和生存率较低,在综合治疗中应该更积极配合放射治疗。

BACKGROUND ＆ OBJECTIVE. Nasopharynx is a commonly involved site of non-Hodgkin＇s lymphoma（NHL）, but the differences of clinical characteristics, prognosis, and treatment strategy between B-cell and NK/T- cell nasopharyngeal NHL have seldom been reported. This study was to investigate the clinical manifestations and treatment outcomes of primary B- cell and NK/T-cell nasopharygeal NHL at early stage, and evaluate the prognostic differences, so as to provide evidences for treatment optimization. METHODS. Clinical data of 80 patients with previously untreated nasopharyngeal NHL at early stage, admitted from May 1987 to Nov. 2003, were reviewed. Of the 80 cases, 48 were B-cell original （B group）, 32 were NK/T-cell original（T group）. Of the 80 patients, 42 received chemoradiotherapy, 31 received chemotherapy alone, and 7 received radiotherapy alone. Most chemotherapy-treated patients received CHOP regimen （cyclophosphamide, vincristine, adriamycin, and prednisone） for 1-10 cycles （median 5 cycles）. Radiotherapy was given with high energy photon beams combined with high energy electron beams in conventional fractionation, with the total dose of 30- 70 Gy （median 52 Gy）. Treatment patterns of the 2 groups were similar, but B group received more chemotherapy cycles than T group did. RESULTS. The 5-year overall survival rate and 5-year progression-free survival rate were significantly higher in B group than in T group （69.5% vs. 35.5%, P=0.003;53.3% vs. 28.9%, P=0.032）. Cox multivariate regression analysis suggested that B-cell phenotype, no B symptoms, and local control were independent favorable predictors of overall survival, while B-cell phenotype and good treatment response were independent favorable predictors of progression-free survival. Univariate stratified analysis with Kaplan-Meier method showed that, for B group, the cumulative 5-year overall survival rate was 68.1% in the 19 patients received chemotherapy alone, 61.7% in the 25 patients received chemoradiotherapy, and 100% in the 4 patients received radiotherapy alone （P=0.311 ）;for T group, the cumulative 5-year overall survival rate was 0% in the 12 patients received chemotherapy alone, 44.1% in the 17 patients received chemoradiotherapy, and 33.3% in the 3 patients received radiotherapy alone （only 1 patient survived for 60 months）（P=0.020）. CONCLUSIONS：Among the patients with primary nasopharygeal NHL at early stage, those with B-cell phenotype may have better prognosis as compared with those with NK/T-cell phenotype. The patients with NK/T-cell phenotype often suffered from B symptoms, with poor response to chemotherapy. Radiotherapy or chemoradiotherapy should be more emphasized in this group of patients.