鼻咽癌放射治疗失败后的手术治疗

Salvage surgery for nasopharyngeal carcinoma after irradiation failure

目的为探索鼻咽癌放射治疗失败后的挽救治疗，回顾分析了我科手术治疗的鼻咽癌放射治疗未控或放射治疗后复发者１２１例（鼻咽病变４１例，颈部病变８０例）。术前接受放射治疗量为６０～１４５Ｇｙ。方法手术方案：①鼻咽原发灶手术，根据病变部位及侵及范围不同而选择不同术式，包括经硬腭入路病灶切除、鼻侧切开病灶切除、颈侧入路下颌骨升支切除＋翼板切除＋病灶切除、经口腔入路下颌骨部分切除＋病灶切除＋胸大肌肌皮瓣修复。②颈部手术，单个淋巴结转移行局部淋巴结切除术；多个淋巴结转移行颈淋巴结根治性切除术。术后放射治疗２０～８０Ｇｙ不等。结果手术并发症发生率为１０％（１２例）。随诊死亡６２例中，远处转移３０例（占４８％）。术后３年、５年生存率分别为４９％、３８％。结论①鼻咽癌首选放射治疗，首次放射治疗失败实施手术解救，术后是否再需放射治疗，视具体情况决定。②足量放射治疗对伤口愈合有影响，但只要充分作好术前准备，术中注意消灭死腔，术后加强护理，及合理应用抗生素，可以减少并发症发生。③该组死亡病例中远处转移率较高，故在今后治疗中应考虑术后化学治疗或免疫治疗以期控制远处转移。

Objective To study the salvage surgery for nasopharyngeal carcinoma after irradiation failure. Methods One hundred and twenty one full dose irradiation uncontrolled cases of nasopharyngeal carcinoma had undergone salvage surgery since 1965 till 1992, in which 41 had primary lesion and 80 neck lesion. All patients received radiation before surgery with the dose of 60Gy～145Gy. The patient selection for this report limited to those with recurrent tumors at the primary sites with no apparent bony involvement and no cranial nerve palsy, or cases with resectable neck recurrences. Results It showed that palatal fenestration was the best choice of approach for reccurent tumors located at the vault of the nasopharyngeal cavity. When the tumor invaded the parapharyngeal space or, owing to the after effect of radiotherapy, the patient presented with severe occlusion of the mandible, we preferred the lateral approach through partial mandi bulectomy. The lateral rhinotomy was only indicated for cases with tumor remnant at the posterior nares. Lymph node excision was performed for cases with single movable node on the neck, and RND for the cases with multiple nodes. The complication rate of after surgery was low (10%), considering the heavy dose of irradiation. The three and five year survival rate were 49% (59/121) and 38% (38/100) respectively. Conclusion It suggests that the surgery should be considered as a salvage procedure for cases of nasopharyngeal cancer after irradiaton failure. Because of high rate of distant metastasis (62 cases or 45% died after surgery), chemotherapy or other measures should be adopted after local treatment.