放疗后局部复发的鼻咽癌调强放疗的预后分析

Prognostic analysis of intensity modulated radiotherapy for locally recurrent nasopharyngeal carcinoma

目的回顾性分析和评价局部复发鼻咽癌调强放疗的临床结果和预后因素。方法共132例进入分析,其中男104例,女28例,中位年龄44．5岁(21～73岁)。全组中位复发时间为24个月(6～184个月)。依1992年福州分期标准再进行临床分期,Ⅰ、Ⅱ、Ⅲ、Ⅳa期分别为5、14、29、84例。其中T1、T2、T3、T4期各7、14、30、81例。22例同时伴有颈淋巴结复发。鼻咽大体肿瘤体积(GTV)处方剂量60～70 Gy,分次剂量1．94～2．80 Gy。60例接受了2～6个疗程的化疗。结果GTV中位体积为39．5cm^3(0．8～158．9 cm^3),治疗计划显示平均D95和V95分别达66．9 Gy和98．3%,平均剂量和分次剂量均值分别为69．8、2．32 Gy。全组中位随访时间12个月(2～47个月)。1、2、3年局部无进展生存率和总生存率分别为96．4%、88．4%、85．3%和65．9%、49．6%、41．6%。11例治疗后发生远处转移。47例治疗后出现鼻咽坏死或大出血,死亡57例。单因素及多因素分析显示分次剂量(P=0．016)和GTV体积(P=0．009)显著影响了患者的生存时间。结论IMRT可提高复发鼻咽癌患者的局部控制率和生存率。分次剂量和GTV体积为影响患者生存时间的独立预后因素。复发鼻咽癌治疗后的主要死亡原因为鼻咽坏死和大出血。

Objective To report the clinical outcome and prognostic factors for locally recurrent nasopharyngeal carcinoma（NPC） treated with intensity modulated radiothempy（IMRT）. Methods From January 2001 to August 2004, the data of 132 such NPC patients were analyzed retrospectively; 104 male and 28 female with a median of 44.5 years （range 21-73 years）. Ninety-eight patients（74.2%） were confirmed by biopsy as having NPC： 9 with WHO Type Ⅱ and 89 WHO Type Ⅲ. The other 34 patients were only diagnosed by MRI scan because of the extension/invasion was in the base of skull and/or cavernous sinus. Median interval time were 24 months （range 6-184 months） .According to the 1992 Chinese Fuzhou Staging System： stage 1 3.8%, Ⅱ 10.6%, Ⅲ 22.0% and Ⅳa 63.6%;T1 5.3%, T2 10.6%, T3 22.7% and T4 55.3%. Twenty-two patients had recurrence in the neck lymph nodes. IMRT was given with the sequential tomotherapy system （NOMOS Peacock systems）of 6 MV X-rays. Prescription dose was 60-70 Gy in GTV, with the fractional dose of 1.94-2.8 Gy. Sixty patients were also supplemented with two to six courses of cisplatin-based chemotherapy. Results The median volume of GTV was 39.5 cm^3（range 0.8-158.9 cm3）. The D95,V95, mean dose and fractionation dose of GTV was 66.9 Gy, 98.3 %, 69.8 Gy and 2.32 Gy, respectively. The median follow-up time was 12 months（range, 2-47 months）. The 1-, 2- and 3-year local progression-free rate was 96.4%, 88.4% and 85.3%, respectively. The overall 1-,2- and 3-year survival rate was 65.9%, 49.6% and 41.6% ,respectively. Eleven patients developed distant metastases. Forty-seven patients were observed to develop mucosa necrosis and/or massive hemorrhage in the nasopharynx. On univariate and multivariate analysis, fractional dose and volume of GTV were significant prognostic factors for overall survival（ P = 0.016,0.009）. Conclusions The local control and survival rate can be improved for patients with locally recurrent nasopharygeal carcinoma after treatment of intensity modulated radiotherapy. The fractional dose and volume of GTV are independent prognostic factors for the overall survival. The main death reasons are mucosa necrosis and/or massive hemorrhage in the nasopharynx.