鼻咽癌放疗后颈部淋巴结复发或残留的手术治疗

Salvage surgery for neck recurrence or residue of nasopharyngeal carcinoma after primary radiotherapy

目的 探讨鼻咽癌放疗后颈部淋巴结复发或残留患者的手术方式和预后影响因素.方法 回顾性分析2001年1月至2011年12月因鼻咽癌放疗后颈部淋巴结复发或残留行手术治疗的153例患者的临床资料.复发分期rN1 109例,rN2 17例,rN3 27例.其中17例为双侧,共170侧颈部手术,其中66侧行改良性颈淋巴清扫术,28侧行择区性颈淋巴清扫术,9侧行局部切除术,3侧行腮腺切除术,48侧行根治性颈淋巴清扫术,16侧行扩大根治性颈淋巴清扫术.使用SPSS 16.0统计软件包建立数据库,组间差异采用x2检验.生存分析采用Kaplan-Meier法,采用Log-rank检验进行单因素分析,采用Cox回归模型进行多因素分析.结果 本组患者转移淋巴结Ⅰ区转移20例（13.1％）,腮腺区转移7例（4.6％）.全组3年和5年累积生存率分别为57.2％和40.6％,中位生存期49个月.Cox分析显示,复发分期（rN）,淋巴结大小和患者年龄是影响预后的危险因素.结论 鼻咽癌放疗后颈部挽救性手术治疗安全有效,可合理选择改良或择区性颈淋巴清扫术以改善功能.临床Ⅰ区和腮腺区淋巴结未见转移者可不做常规清扫,但需高度警惕.复发分期rN3或转移淋巴结长径＞6 cm,年龄＞50岁者预后差.

Objective To investigate the surgical procedures and prognosis for neck recurrence or residue of nasopharyngeal carcinoma（NPC） after primary radiotherapy.Methods A total of 153 cases with neck recurrence or residue after radiotherapy in NPC who received salvage neck surgery between January 2001 and December 2011 were retrospectively analyzed.There were rN1 109 cases,rN2 17 cases and rN3 27 cases.Of them 17 cases received bilateral neck dissection（ND） simultaneously.The surgical procedures included the modified radical neck dissection （MRND） in 66 cases,radical neck dissection （RND） in 48 cases,selective neck dissection （SND） in 28 cases,enlarged radical neck dissection （ERND） in 16 cases,local excision in 9 cases,and parotidectomy in 3 cases.The Kaplan-Meier method was used to calculate survival curves,and the differences between groups were calculated by x2 tests.Results There were 20 cases（13.1％）with lymph node（LN） metastasis in level Ⅰ and 7 cases （4.6％） with parotid gland LN metastasis.The 3-year and 5-year overall survival rates were 57.2％ and 40.6％ respectively,and the median survival time was 49 months.Cox regression analysis revealed that rN staging,size of LN and age were the main prognosis factors for survival.Conclusions Salvage surgery was effective for neck recurrence or residue of NPC after primary treatment,and MRND and SND are reasonable options so as to improve functionality.Dissection of LN in level Ⅰ and parotid gland should be selective.Patients with stage rN3 or LN ＞ 6 cm or age ＞ 50 years had poor prognosis.