喉癌单纯放疗失败挽救性喉切除术远期疗效及预后分析

Outcomes of salvage laryngectomy after initial radiation failure in laryngeal squamous cell carcinoma

目的探讨喉癌单纯放疗后原发灶及颈部淋巴结残留和复发患者实施挽救性手术治疗的远期疗效及预后影响因素。方法对72例患者进行回顾性分析，包括：放疗后原发灶及颈部复发22例，放疗后原发灶及颈部残留50例。均实施喉全切除术＋经典性颈清扫术或改良性颈清扫术。应用Kaplan．Meier法计算手术后总生存率，采用Log—rank检验单因素分析临床因素对预后的影响，对影响生存率的有关因素采用Cox模型进行多因素分析。结果实施挽救性手术的并发症发生率41．7％，其中咽瘘发生率20．8％。术后5年内肿瘤再次复发率34．7％（25／72），远处转移率22．2％（16／72），第二原发癌发生率6．9％（5／72）。术后的3、5年生存率为45．8％和36．1％。复发癌N分期（rN）、肿瘤放疗失败类型、切缘情况、浸润深度、有无颈淋巴转移、淋巴结包膜侵犯和颈部非淋巴结构侵犯与患者的预后有关（P值均〈0．05）。多因素分析结果表明：肿瘤放疗失败类型、切缘情况、肿瘤浸润深度是影响患者预后的独立危险因素。结论喉癌患者单纯放疗失败后应以手术挽救为主。对于术前及术中发现肿瘤侵犯肌肉及软骨的病例，特别是对根治性放疗效果不佳而肿瘤残留者，术中应充分估计肿瘤的范围，并冰冻病理检查切缘，以保证足够的安全切缘，提高挽救性手术的成功率。

Objective To investigate survival outcomes of salvage surgery preformed for laryngeal squamous cell carcinoma that recurred or progressed after radiotherapy alone. Methods A review of 72 patients who underwent salvage laryngectomy for laryngeal cancer failed in initial radiation therapy between 1996 and 2005 was performed. The tumor persistence occurred in 50 cases and recurrence in 22 cases. All patients received salvage total laryngectomy and radical neck dissection. Survival analysis was performed by using Kaplan-Meier method, Log-rank test and Cox proportional hazard model. Results Thirty patients developed a postoperative complication after salvage surgery. Pharyngocutaneous fistula occurred in 13 （20. 8% ） patients. During 5 years after salvage surgery, the rates of tumor recurrence, distant metastasis and second malignancy were 34. 7% , 22. 2% and 6. 9% , respectively. Kaplan-Meier analysis showed that overall 3 year and 5 year survival rates of those patients after operation were 45.8% and 36. 1%, respectively. Univariate analysis indicated that N restage, tumor persistence/recurrences after radiotherapy, surgical margin status, level of tumor invasion, pathologic N stage, extracapsular nodal spread and invasion of nonlymphatic structures were significantly associated with overall survival. Multivariate analysis showed the most significant prognostic factors were tumor persistence or recurrence after radiotherapy, surgical margin status and level of tumor invasion. Conclusions Surgical salvage remains the gold standard for management after failure of initial radiation therapy. The extent of tumor invasion must be assessed sufficiently before operation, and the surgical margin status must be identified in operation by using a frozen sectioning approach, especially in patients with tumor invasion to muscle/cartilage and tumor persistence after radiotherapy.