下咽癌放疗后挽救性手术治疗的疗效及生存分析

Survival outcomes and prognostic factors of patients with salvage surgery for hypopharyngeal carcinoma after radiotherapy

目的探讨下咽癌放疗后肿瘤残留或复发患者实施挽救性手术治疗的疗效及预后影响因素。方法回顾性分析2010年1月至2015年12月宁波市医疗中心李惠利医院收治并进行挽救性手术的26例下咽癌放疗后患者的病例资料,患者均为男性,年龄48~83岁。再发方式包括局部单纯放疗后残留8例,局部术后放疗后复发8例,颈部淋巴结放疗后残留2例,颈部淋巴结放疗后复发2例,颈部淋巴结术后放疗后复发2例,造瘘口放疗后复发4例。挽救性手术治疗方案包括:局部切除,局部切除+颈淋巴清扫,单纯颈淋巴清扫以及造瘘口肿瘤切除,并根据缺损情况进行修复。应用χ^(2)检验进行复发及远处转移分析,Kaplan-Meier法进行生存分析,Log-rank检验进行单因素分析,Cox回归模型对预后的影响因素进行多因素分析。结果本研究实施挽救性手术的并发症发生率为23.1%(6/26)。术后5年内肿瘤再次复发率为65.4%(17/26),远处转移率为42.3%(11/26)。挽救性手术时患者年龄、肿瘤浸润深度与复发相关,肿瘤初治方式、再发方式、再发位置、浸润深度与远处转移相关(P值均<0.05)。挽救性手术后3年、5年的生存率分别为42.3%和23.1%。挽救性手术时患者年龄、肿瘤再发位置、挽救性手术切缘、浸润深度与患者的预后有关(χ^(2)值分别为6.56、10.68、9.32、7.90,P值均<0.05)。多因素分析结果表明:挽救性手术切缘、浸润深度是影响患者预后的独立危险因素[OR(95%CI)为3.19(1.03~9.84)和14.37(2.46~84.08),P值均<0.05]。结论下咽癌放疗后再发首选手术挽救治疗,术中应保证安全切缘,尤其对浸润深度达肌肉、骨组织或淋巴结包膜的病例。

Objective To investigate the survival outcomes and prognostic factors of patients with salvage surgery for hypopharyngeal carcinoma after radiotherapy.Methods A retrospective analysis was performed,including 26 patients treated in Ningbo Medical Center Lihuili Hospital between January 2010 and December 2015.All patients were males,aged 48-83 years,of whom 8 cases were local residual after radiotherapy alone,8 cases were local recurrence after postoperative radiotherapy,2 cases were residual of cervical lymph nodes after radiotherapy alone,2 cases were recurrence of cervical lymph nodes after radiotherapy alone,2 cases were recurrence of cervical lymph nodes after postoperative radiotherapy and 4 cases were recurrence of tracheal stoma.The salvage operations included:local resection,local resection with neck dissection,simple neck dissection,tumor resection of tracheostomy,and additional repair according to the defect.Chi square test was used for recurrence and metastasis analysis,Kaplan-Meier method for survival analysis,Log-rank test for univariate analysis,and Cox regression model for multivariate analysis.Results The complication rate of salvage surgery was 23.1%(6/26).The recurrence rate was 65.4%(17/26)and the distant metastasis rate was 42.3%(11/26)in the 5-year follow-up after salvage surgery.Patient′s age and tumor invasion extent were correlated with recurrence.Initial treatment,tumor persistence or recurrence after radiotherapy,recurrence location and tumor invasion extent were correlated with distant metastasis(all P<0.05).Overall,3 year and 5 year survival rates were 42.3%and 23.1%respectively.Age,recurrence location,surgical margin and tumor invasion extent were related to prognosis(χ^(2)=6.56,10.68,9.32,and 7.90 respectively,all P<0.05).Multivariate analysis showed that surgical margin and tumor invasion extent were independent risk factors for prognosis(OR(95%CI)=3.19(1.03-9.84),14.37(2.46-84.08),both P<0.05).Conclusion Salvage surgery is the first choice for patients with recurrence after radiotherapy for hypopharyngeal carcinoma.Safe surgical margin should be ensured,especially in tumors invading muscle,bone tissue or lymph node capsule.