鼻咽癌放射治疗后颈部残留或复发病变的手术治疗

Surgical managements for residual or recurrent diseases in the neck after radiotherapy innasopharyngeal carcinoma

目的总结鼻咽癌放疗后颈部残留或复发转移灶的手术治疗经验。方法回顾性分析1990年1月至2005年12月手术治疗鼻咽癌放疗后的颈部残留转移灶48例（其中单侧39例，双侧9例），复发转移灶30例。男56例，女22例，年龄28-65岁，中位年龄41岁。27例患者皮肤受侵。术前影像学评估17例患者颈总动脉或颈内动脉难以分离保留，后行颈动脉球囊阻断实验证实其中15例大脑动脉环开放得以代偿，2例代偿不良。颈部肿块扩大切除21例，单侧颈清扫术49例，双侧颈清扫术8例。切除颈内动脉5例，分离切除肿块并保留颈内动脉10例，2例保留颈内动脉但颈动脉壁上有残留肿块。带蒂胸大肌肌皮瓣修复皮肤缺损15例，带蒂斜方肌皮瓣修复3例，游离股前外侧皮瓣修复9例。63例术后未行放疗，另13例显微镜下基底见癌细胞和2例颈动脉壁肉眼残留肿块者，术后放疗45-50Gy。结果随访5-20年，5例失访。Kaplan-Meier法计算3年和5年生存率分别为46．2％和28．3％。27例行颈部皮肤一期修复者，26例痊愈，1例肩部伤口延迟愈合；51例颈部未予修复者中，45例伤口一期愈合，6例延迟愈合。颈清扫结果为Ⅰ区6例（10．5％），Ⅱ区35例次（61．4％），Ⅲ区6例次（10．5％），Ⅳ区1例（1．8％），Ⅴ区16例次（28．1％）。结论切除鼻咽癌放疗后残留病灶术前需行颈动脉球囊阻断实验，以评估大脑动脉环的开放和代偿状况；颈部残留或复发的病灶主要分布在Ⅱ、Ⅲ、ⅤA区，故颈清扫应以清除Ⅱ、Ⅲ、ⅤA区淋巴组织为主；胸大肌肌皮瓣或游离股前外侧皮瓣是修复放射性颈部皮肤缺损的良好材料。

Objective To investigate the surgical managements for residual or recurrent diseases in the neck after radiotherapy in nasopharyngeal carcinoma. Methods Seventy-eight cases of neck masses （39 cases for unilateral residual diseases, 9 for bilateral residual diseases and 30 for reccurent diseases）after radiotherapy in nasopharyngeal carcinoma who were treated surgically between January 1990 and December 2005 were retrospectively analyzed. There were 56 males and 22 females. Their ages ranged from 28 to 65 years（ median 41 years）. There were 27 patients with skin involvement. After preoperative imaging assessment, 17 patients whose common carotid arteries or internal carotid arteries were difficult to separate routinely attained the carotid balloon occlusion test which confirmed that 15 cases of cerebral arterial circle open to compensation, however, two cases of poor compensation. Surgical procedures included expanded neck mass resection （21 cases ）, unilateral radical neck dissection （49 cases ）and bilateral radical neck dissection（8 cases）. Of them 5 patients were with unilateral internal carotid artery resection. Neck defects were repaired with pectoralis major muscle flaps （15 cases）, free anterolateral femoral skin flaps （9 cases） and trapezius muscle flaps（3 cases）. Of the 78 patients, 13 with microscopic positive diseases and 2 with residual diseases in internal carotid artery walls underwent postoperative radiotherapy, with the doses of 45 to 50 Gy. Results All patients were closely followed-up more than 5 years. Three- and five-year survival rates were 46.2% and 28.3% respectively. Neck defects were successfully repaired with skin flaps immediately after resecting diseases in 27 cases, only one patient with delayed healing. Of 51 patients without skin fiat）repair, neck wounds healed successfully in 45 patients and with delayed healing in 6 patients. Pathological positive rates of lymph nodes located in the level Ⅰ , Ⅱ , Ⅲ, IV and V were 10.5% , 61.4% , 10.5%, 1.8% and 28.1% respectively. Conclusions Preoperative balloon occlusion test is required to assess the function of Willis＇ring before determining ligation or resection of internal carotid artery. Residual or recurrent diseases commonly exist in level Ⅱ , V A and Ⅲ, which should be included in neck dissection. Pectoralis major muscle flap and free anterolateral femoral skin flap are recommended for the repair of neck defect.