鼻咽癌首程根治性放疗后鼻咽坏死治疗策略及预后分析

Treatment strategy and prognostic analysis of nasopharyngeal necrosis after first radical radiotherapy for nasopharyngeal carcinoma

目的探讨鼻咽癌根治性放疗后鼻咽部坏死的治疗策略及预后影响因素.方法回顾性分析2013年1月至2022年1月江苏省肿瘤医院放疗科收治的1020例鼻咽癌行首程根治性调强放疗患者的资料,使用鼻咽部MRI、电子鼻咽镜检查及病理活检确认发生鼻咽部坏死的患者.鼻咽部坏死患者行电子鼻咽镜下冲洗清创,联合全身抗感染及营养支持治疗.应用Kaplan-Meier方法统计生存,Cox回归模型分析临床因素与预后的关系.结果鼻咽癌首程根治性调强放疗后出现鼻咽部坏死的患者共计20例,其发生率为1.96%.鼻咽部坏死患者以鼻咽部恶臭味及头痛症状多见.所有鼻咽部坏死的患者初治时鼻咽癌均为局部晚期,T3期2例(10%),T4期18例(90%).鼻咽部坏死均发生在原鼻咽病灶处,根据鼻咽部坏死分期,Ⅰ期6例(30%),Ⅱ期14例(70%),无Ⅲ期.鼻咽部坏死发生时间距放疗结束时间为2~24个月,中位时间为5个月.16例鼻咽部坏死患者经鼻咽镜下清创冲洗联合抗感染及对症支持治疗后,均临床痊愈,其中无痕愈合9例,有痕愈合7例.4例因不能耐受鼻咽冲洗或诊治延误,病灶累及大血管致大出血死亡.累及颈内动脉组与不累及组5年总生存率分别为37.5%和85.7%(P=0.008),有、无糖尿病组5年总生存率分别为25.0%和77.8%(P=0.016).Cox回归单因素分析显示,坏死灶累及颈内动脉(HR=5.80,95%CI为1.14~29.38,P=0.034)及糖尿病(HR=10.24,95%CI为1.19~88.04,P=0.034)是患者总生存的影响因素.结论初治鼻咽癌患者首程根治性调强放疗后鼻咽部坏死经以鼻咽镜下清创冲洗为基础的抗感染及营养支持治疗可取得较好疗效,坏死病灶累及颈内动脉及合并糖尿病是影响患者生存的重要因素,血管侵犯致血管破裂是死亡主要原因.

Objective To investigate the treatment strategy and prognostic factors of nasopharyngeal necrosis after the first radical radiotherapy for nasopharyngeal carcinoma.Methods Clinical data of 1020 patients with nasopharyngeal carcinoma undergoing radical intensity-modulated radiotherapy in Jiangsu Cancer Hospital from January 2013 to January 2022 were retrospectively analyzed.Nasopharyngeal necrosis was confirmed by nasopharyngeal MRI,electronic nasopharyngoscopy and biopsy.Patients with nasopharyngeal necrosis were treated with electronic nasopharyngoscope irrigation debridement,combined with systemic anti-infection and nutritional support therapy.Kaplan-Meier method was used to calculate the survival,and Cox regression analysis was used to analyze the relationship between clinical factors and patients'survival.Results Nasopharyngeal necrosis occurred in 20 cases of 1020 nasopharyngeal carcinoma patients after the first radical intensity-modulated radiotherapy,with an incidence rate of 1.96%.Odd smell and headache were common in nasopharyngeal necrosis patients.All patients had locally advanced nasopharyngeal carcinoma at initial treatment,including 2(10%)cases of T3 stage and 18(90%)cases of T4 stage.Nasopharyngeal necrosis occurred in the primary nasopharyngeal lesions.According to the stages of nasopharyngeal necrosis,there were 6(30%)cases of stageⅠ,14(70%)cases of stageⅡand no stageⅢ.The occurrence time of nasopharyngeal necrosis was from 2 to 24 months after radiotherapy,and the median time was 5 months.All 16 cases of nasopharyngeal necrosis were cured clinically after debridement and irrigation under nasopharyngoscope,systemic anti-infection and symptomatic support treatment.Among them,9 cases had no necrotic cavity and complete healing and 7 cases had residual necrotic cavity.Four patients died of massive nasopharyngeal hemorrhage or due to the inability to nasopharyngeal irrigation.The 5-year survival rates were 37.5%and 85.7%in patients with and without internal carotid artery involvement(P=0.008),and 25.0%and 77.8%in patients with and without diabetes mellitus(P=0.016).Univariate Cox regression analysis showed that necrotic lesions involving internal carotid artery(HR=5.80,95%CI=1.14-29.38,P=0.034)and diabetes mellitus(HR=10.24,95%CI=1.19-88.04,P=0.034)were the influencing factors of overall survival.Conclusions Nasopharyngoscope irrigation debridement combined with anti-inflammation and nutritional support treatment are effective interventions for nasopharyngeal necrosis after the first radical intensity-modulated radiotherapy in patients with nasopharyngeal carcinoma.The necrosis involving the internal carotid artery and diabetes mellitus are important factors affecting the survival of patients.Vascular invasion caused by vascular rupture is the main cause of death.