133例Ⅲ期鼻咽癌调强放疗的疗效及不良反应分析

Efficacy of clinical stage Ⅲ nasopharyngeal carcinoma treated by intensity-modulated radiation therapy combined with chemotherapy

背景与目的:调强放疗(intensity-modulated radiation therapy,IMRT)是最大限度提高肿瘤靶区照射剂量的同时明显减少周围正常组织的剂量的放疗技术,调强放疗联合化疗治疗局部晚期鼻咽癌取得了较好的疗效,如何在此基础上进一步提高疗效成为肿瘤学者共同关注的话题。鼻咽癌分期不同,疗效不同,同一分期各亚组间疗效有无差别,尚有待研究。通过回顾性分析临床Ⅲ期鼻咽癌各亚组间调强放疗联合化疗的疗效,探讨进一步提高疗效的方法。方法:对我院2003年1月—2006年6月期间收治的133例临床Ⅲ期鼻咽癌患者进行分析,根据AJCC 2002分期,其中T3N07例(5.3%),T3N139例(29.3%),T2N248例(36.1%),T3N239例(29.3%)。所有患者均完成调强放疗,124例患者行诱导化疗,其中24例患者行同期化疗,33例患者行辅助化疗。结果:全组5年局部控制率、无远处转移生存率、无瘤生存率和总生存率分别为:90.9%、89.9%、82.5%和83.4%。T2、T3期患者5年局部控制率分别为93.1%、89.4%(χ2=0.407,P=0.524),无远处转移生存率分别为91.2%、89.3%(χ2=0.152,P=0.697),无瘤生存率分别为86.5%、80.0%(χ2=0.899,P=0.343),总生存率分别为81.1%、84.7%(χ2=0.311,P=0.577)。N0-1、N2期患者5年局部控制率分别为91.1%、90.9%(χ2=0.007,P=0.933),无远处转移生存率分别为97.8%、85.8%(χ2=4.69,P=0.030),无瘤生存率分别为88.9%、79.2%(χ2=1.746,P=0.183 6),总生存率分别为93.5%、78.1%(χ2=5.052,P=0.025)。辅助化疗对IMRTⅢ期鼻咽癌未能获益,但3、4级毒性不良反应明显增加(48%vs 27.6%,P<0.005)。结论:对临床Ⅲ期鼻咽癌患者,IMRT联合化疗可以取得较好的疗效,N0-1期较N2期患者有较高的总生存率和无远处转移生存率,进一步提高IMRTⅢ期鼻咽癌疗效还需寻找更有效的化疗药物、靶向药物及更合理的联合治疗方案。

Background and purpose： Intensity-modulated radiation therapy （IMRT） enables the delivery of higher radiation dose to the primary disease and neck metastases while sparing the organs/tissues at risk （OARs） thereby IMRT combined with chemotherapy enhancing the therapeutic ratio. How to further improve the efficacy became a common topic of the oncologists. Different stages ofnasopharyngeal carcinoma （NPC） have different efficacy. The subgroups in the same stage whether have different efficacy still remain to be studied. This study retrospectively analyzed the outcome of clinical stage ⅢNPC patients treated with IMRT after induction chemotherapy with or without adjuvant chemotherapy. Methods： From Nov. 2003 to Jan. 2006, 133 patients with untreated stage m NPC were analyzed retrospectively. According to the AJCC 2002 staging system： 7（5.3%） patients were T3N0, 39（29.3%） patients were TAN1, 48（36.1%） patients were T2N2, 39（29.3%） patients were T3N2. All the patients received IMRT. One hundredand twenty-four patients received induction chemotherapy. Twenty-four patients received concurrent chemotherapy. Thirty-three patients received adjuvant chemotherapy. Results： The 5-year local-regional free survival （LRFS）, distant metastasis-free survival （DMFS）, disease-free survival （DFS） and overall survival （OS） were 90.9%, 89.9%, 82.5%, and 83.4%. The 5-year LRFS, DMFS, DFS and OS of patients with T2, T3 disease were 93.1% vs 89.4% （X^2=0.407, P=0.524）, 91.2% vs 89.3% （X^2=0.152, P=0.697）, 86.5% vs 80.0% （X^2=0.899, P=0.343）, 81.1% vs 84.7% （3（X^2=0.311, P=0.577）. The 5-year LRFS, DMFS, DFS and OS of patients with N0-1, N2 disease were 91.1% vs 90.9% （X^2=0.007, P=0.933）, 97.8% vs 85.8% （X^2=4.69, P=0.030）, 88.9% vs 79.2% 0（X^2=1.746, P=0.1836）, 93.5% vs 78.1% （X^2=5.052, P=0.025）. Adjuvant chemotherapy provided no significant benefit to IMRT in stage Ⅲ NPC, but was responsible for higher rates of grade 3 or 4 toxicities （48% vs 27.6%, P〈0.005）. Conclusion： IMRT combined with chemotherapy is an effective treatment for patients diagnosed with stage IU NPC. Patients with N0-1 disease have a better OS and DMFS than patients with N2 disease. Further improving the effect of stage Ⅲ NPC still need to explore the significance of adjuvant chemotherapy and look for more effective chemotherapy drugs, targeted drugs and more reasonable combined treatments.