晚期鼻腔鼻窦恶性肿瘤的内镜外科治疗

Endoscopic surgery for advanced malignant nasal and sinus tumors

目的探讨晚期鼻腔鼻窦恶性肿瘤内镜下外科治疗的疗效。方法回顾性分析2004年1月至2010年10月间解放军总医院收治的晚期的鼻腔鼻窦恶性肿瘤患者49例，按UICC6版标准分期，T3期12例、T4a期13例、T4b期24例；病理类型为鳞癌20例，腺癌12例，恶性黑色素瘤8例，嗅神经母细胞瘤6例，横纹肌肉瘤、软骨肉瘤、神经胶质瘤各1例。所有患者均接受单纯鼻内镜手术或辅助鼻外入路根治手术，其中36例术后采用放化疗。随访数据采用Kaplan—Meier法生存分析。结果术中出血200～5000ml，平均约600ml；术后未发生术腔（包括颅内）感染，经全量放疗未发生脑脊液鼻漏，失明1例。4例（8．2％）患者随访期内失访。随访期内30例复发转移，部分患者出现多处复发及转移，局部复发是治疗失败的主要原因，占复发病例的86．7％（26例）。16例死亡患者中除3例外术前均有颅和（或）眼受累；嗅神经母细胞瘤及神经胶质瘤等其他病理类型组患者预后差，9例患者中随访期内5例患者死亡，其中3例伴颅内转移，目前生存时间尚无超过25个月者。2年和3年总体生存率分别为62．5％和58．4％，2年和3年无瘤生存率为34．2％和21．4％。Log—rank检验证实不同T分期、是否接受术后治疗以及切缘性质对患者无瘤生存率影响差异有统计学意义（X^2值分别为7．7、6．8和4．9，P值均〈0．05）。结论内镜经鼻或鼻外辅助路径下对晚期鼻腔鼻窦恶性肿瘤切除满意，结合术后综合治疗，患者生存率满意，并发症少，是鼻腔鼻窦晚期恶性肿瘤外科治疗的良好术式。

Objective To evaluate the effect of endoscopic surgery for advanced malignant tumors in the nasal cavity and paranasal sinuses. Methods A retrospective data analysis was performed on 49 patients with advanced sinonasal tumors undergoing either an exclusive endoscopic approach or with a complemental approach from January 2004 to October 2010. Forty-nine patients were considered eligible for the present analysis, among them, T3： T4a： T4b were 12：13：24 （T stage was assessed with the sixth editions of the UICC staging systems）. The histotypes encountered were squamous cell carcinoma 20 cases, adenocarcinoma 12 cases, mucosal melanoma 8 cases, olfactory neuroblastoma 6 cases, others 3 cases. These patients were operated on either by an exclusive endoscopic endonasal approach or with a complementary external approach; 36 patients received adjuvant radiotherapy or/and chemotherapy. The data were analyzed by Kaplan-Meier method and Log-rank test. Results The hemorrhage varied from 200 to 5000 ml during the operation, with an average of 600 ml. The post-operative complications were rare, 1 patient lost her sight after operation, and no patient got infected at the site of operation （nor intracranial infection）. After full amount of radiotherapy, no cerebrospinal fluid rhinorrhea was found. Four patients （8.2%） lost to follow-up. Sixteen patients died during the follow-up period, only three of them were without crauiocerebral or orbital invasion. Four in 9 patients in the other pathological group （with the pathology of olfactory neuroblastoma or glioma etc） , which had a poor prognosis, died during the follow-up period, of them, 3 had definitive evidence of intracranial metastasis, and none of the nine patients had been followed- up beyond 25 months. The 2 and 3 year disease-free rates were 34.2% and 21.4% , and overall survival rates were 62. 5% and 58. 4% respectively. The T stage, margin status, and whether accepted post operative adjuvant therapy were significant factors in predicting disease recurrence（ X^2 were 7.7, 4.9, 6.8respectively and P 〈 0.05 ）. Conclusions Now the endoscopic techniques with or without complementary approaches is an effective way for complete tumor removal. With postoperative complementary therapy, it provides a satisfactory survival rate with few side effects and better quality of life.