晚期扁桃体癌术后缺损修复与功能重建

REPAIR AND FUNCTIONAL RECONSTRUCTION OF OROPHARYNGEAL DEFECTS AFTER RESECTION OF ADVANCED-STAGE TONSILLAR CANCER

目的探讨晚期扁桃体癌切除术后缺损修复与功能重建的组织瓣供区选择。方法 2000年10月-2010年2月收治13例晚期扁桃体癌患者。男11例,女2例;年龄39～67岁,平均53.6岁。高分化鳞状细胞癌5例,中分化鳞状细胞癌8例。按国际抗癌联盟(UICC)1997年口咽癌的分期标准:T1N1M0 1例,T2N1M0 2例,T2N2M0 2例,T3N1M0 3例,T3N2M0 2例,T4N1M0 2例,T4N2M0 1例。病程1～8个月,平均4.3个月。肿瘤侵及鼻咽侧壁1例、下咽侧壁3例、会厌1例、软腭4例、舌根部3例。肿瘤浸润范围2 cm×2 cm～12 cm×6 cm。患者均采取手术加术后补充放疗的综合治疗措施。经颈-颌-扁桃体联合入路切除肿瘤后,5例采用带蒂胸大肌皮瓣、5例采用游离前臂皮瓣、3例采用游离股前外侧皮瓣一期修复。结果术后病理报告示颈淋巴结转移10例;补充放疗后8个月～2年局部复发2例,颈部淋巴结转移3例。术后1例带蒂胸大肌皮瓣修复术后第5天出现颈部感染,1例游离前臂皮瓣修复术后12 h出现血管危象,均经对症处理后治愈;其余组织瓣均顺利成活,切口Ⅰ期愈合。1例股前外侧皮瓣供区切口裂开,二期缝合。患者均获随访,随访时间1～6年,平均3.6年。5例带蒂胸大肌皮瓣修复者,术后均有不同程度吞咽梗阻感及闭塞性鼻音,言语清晰度较差。8例游离皮瓣修复者术后外观、吞咽及发声功能较满意,供区无功能障碍。患者术后咬关系均恢复正常,面部外形和功能基本正常。按直接计算法,3年生存率为60.0%(6/10),5年生存率为37.5%(3/8)。结论对晚期扁桃体癌术后缺损的修复应首选游离前臂皮瓣及股前外侧皮瓣,但对于组织需要量大和术前放疗失败的患者,宜选用带蒂胸大肌皮瓣修复。

Objective To study the repair and functional reconstruction of oropharyngeal defects after resection of advanced-stage tonsillar cancer,and to select the donor site of appropriate flap.Methods Between October 2000 and February 2010,13 patients with advanced-stage tonsillar cancer were treated,including 5 cases of high differentiation squamous cell carcinomas and 8 cases of medium differentiation squamous cell carcinomas.There were 11 males and 2 females,with an average age of 53.6 years（range,39-67 years）.According to Union for International Cancer Control（UICC） 1997 standards of oropharyngeal cancer,1 case was classified as T1N1M0,2 as T2N1M0,2 as T2N2M0,3 as T3N1M0,2 as T3N2M0,2 as T4N1M0,and 1 as T4N2M0.The disease duration was 1-8 months with an average of 4.3 months.The tumor invaded lateral wall of nasopharyngeal in 1 case,lateral wall of hypopharynx in 3 cases,epiglottis in 1 case,soft palate in 4 cases,and tongue root in 3 cases.The tumor infiltrating range was from 2 cm × 2 cm to 12 cm × 6 cm.All the 13 cases underwent integrated methods of surgery and postoperative radiotherapy.After resection of tumor by combined neck-mandible-oral cavity approach,pectoralis major myocutaneous flaps were transplanted in 5 cases,forearm free skin flaps in 5 cases,and anterolateral thigh free skin flaps in 3 cases.Results The postoperative pathological results showed 10 cases of cervical lymph node metastasis;2 cases had local recurrence and 3 cases had cervical lymph node metastasis after postoperative radiotherapy.Neck infection occurred at 5 days after operation in 1 case undergoing transplantation of pectoralis major myocutaneous flap,and vascular crisis occurred at 12 hours after operation in 1 case undergoing transplantation of forearm free skin flap,which were cured after correspondent treatments.The other flaps survived with incision healing by first intention.Second suture was carried out in 1 case undergoing anterolateral thigh free skin flap transplantation because of wound disruption at the donor site.All the patients were followed up 1 to 6 years,with an average of 3.6 years.In 5 cases undergoing pectoralis major myocutaneous flap transplantation,swallowing obstruction and stomatolalia occurred.In 8 cases undergoing free skin flaps transplantation,the appearances of the flaps and the functions of swallowing or speaking were satisfactory,with no dysfunction at the donor site.All the patients returned to normal occlusion,facial appearance and function were normal.According to the direct calculation method,the three-year survival rate was 60.0%（6/10）,and five-year survival rate was 37.5%（3/8）.Conclusion For the patients with advanced-stage tonsillar cancer,forearm free skin flaps,or anterolateral thigh free skin flaps is the first choice for repairing defect.However,it is better to choose pectoralis major myocutaneous flaps in patients who need large flap and fail to radiotherapy.