81例局部晚期鼻咽癌放疗的临床研究

Three schemes of radiation therapy for eight-one local-advanced nasopharyngeal carcinoma patients

目的观察3种不同治疗方案对局部晚期鼻咽癌的临床疗效、急性反应和晚期损伤。方法初治鼻咽癌81例,其中Ⅲ期50例,ⅣA期31例。单纯放疗组（RT）30例,常规放疗加化疗组（RT＋CT）33例,调强放疗加化疗组18例（IMRT＋CT）。常规放疗鼻咽部剂量70～76 Gy,肿大淋巴结60～65 Gy,颈部预防剂量50 Gy;调强放疗设鼻咽大体肿瘤为GTV（nx）、颈部阳性淋巴结GTV（nd）、高危临床靶体积CTV1和低危临床靶体积CTV2。处方剂量分别为GTV（nx） 70．6～76．6 Gy分31～33次、GTV（nd） 61．6～70．6 Gy分28～33次、CTV1 60 Gy分28次、CTV2 53．2 Gy分28次,化疗方案包括诱导、同期与辅助。生存率用Kaplan-Meier法计算,Logrank检验,RTOG或EORTC标准评价急性反应和晚期损伤。结果中位随访时间21．5个月,全组2和3年局部区域无进展、无远处转移生存率、总生存率分别为90%、85%、86%和83%、83%、83%;RT组分别为63%、82%、65%和52%、76%、60%;RT ＋CT组分别为76%、83%、77%和73%、83%、60%;IMRT＋CT组分别为100%、94%、100%和89%、94%、100%。RT组与RT＋CT组生存差异无统计学意义（X^2=0．53,P=0．473）,RT组与IMRT＋CT组生存差异有统计学意义（X^2=7．42,P=0．007）,RT＋CT组与IMRT＋CT组生存比较差异有统计学意义（X^2=5．06,P=0．028）。全组多数患者仅表现为1～2级急性反应和0～1级晚期损伤,RT组1例出现放射性脑病。放疗后1年中重度口干发生率RT组和RT＋CT组总计92%,而IMRT＋CT组仅表现为轻度口干。结论IMRT加化疗对局部晚期鼻咽癌患者可获得理想的局部区域控制和总生存率;IMRT可明显减轻放疗引发的口干。

Objective To present the preliminary results of three different radiotherapy schemes for 81 patients with nasopharyngeal carcinoma and to observe the acute and late normal tissue toxicities. Methods Between Jan, 2002 and Dec ,2005,81 patients with nasopharyngeal carcinoma were treated in our department, 50 patients had stage Ⅲ while 31 patients had stage IVA lesion. They were divided into 3 groups： conventional radiation group（RT） 30 patieents; conventional radiation combined with chemotherapy group （RT ＋ CT）, 33 patients; and intensity modulated radiation therapy combined with chemotherapy group（ IMRT ＋ CT）, 18 patients. The conventional radiation consisted of a prescription dose of 70-76 Gy to the target in the nasopharynx. For IMRT, the prescription dose delivered to the gross tumor volume in the nasopharynx （GTV） varied from 70.6-76.6 Gy/31-33f; 61.6-70.6 Gy/28-33f to the positive neck lymph nodes （GTVnd） ; to the high risk regions（CTV1 ） 60 Gy/28F; and low risk regions（CTV2） 53.2 Gy/28F. Chemotherapy included, induction, concurrent and adjuvant protocols. Kaplan-Meier method was used for local-regional progression-free rate, distant metastasis-free rate,and overall survival. Acute and late toxicities were graded according to RTOG radiation morbidity scoring criteria. Results With a median follow-up of 21.5 months （range 5-49）, the overall 2- and 3-year estimated local-regional progression-free survival rates, distant metastasis-free survival rate and overall survival rate was 90% ,85% ,86% and 83% ,83% ,83%, respectively. In RT group, was 63% ,82% ,65% and 52% ,76% ,60%, respectively. In RT ＋ CT group, it was 76% ,83% ,77% and 73% ,83% ,60% respectively. For IMRT ＋ CT group, it was 100% ,94% ,100% and 89% ,94%, 100% respectively. IMRT ＋ CT group had significantly higher overall survival rate than RT group （ X^2 = 7.42, P = 0. 007 ） and RT ＋ CT group （ X^2 = 5.06, P = 0. 028 ）. However, the difference between RT group and RT ＋ CT group in the overall survival was insignificant（ X^2 = 0.53 ,P =0. 437）. Most patients in all groups had grade 1-2 acute and Grade 0-1 late toxicities, one year later after radiotherapy, the moderate and high grade of xerostomia rate was 92% in RT and RT ＋ CT groups. In IMRT ＋ CT group, it had been only slight xerostomia. Conclusion IMRT plus chemotherapy may be able to improve the local-region control and overall survival for locally advanced nasopharyngeal carcinoma. Radiation, xerostomia can obviously be decreased by IMRT.