本文選題：復(fù)發(fā)鼻咽癌 + 調(diào)強(qiáng)放射治療�。� 參考：《廣州醫(yī)學(xué)院》2010年碩士論文

【摘要】：背景與目的:鼻咽癌(Nasopharyngeal carcinoma NPC)通常對放療和化療敏感,放化綜合治療可以取得良好的局部區(qū)域控制率。然而即使這樣,局部區(qū)域復(fù)發(fā)仍然是鼻咽癌治療后失敗的主要模式之一。相當(dāng)部分局部早期復(fù)發(fā)鼻咽癌患者在采取積極的治療措施如鼻咽內(nèi)鏡手術(shù)、近距離放射治療、放射外科手術(shù)后,仍然可以獲得長期的生存。然而局部晚期復(fù)發(fā)鼻咽癌(NPC)由于鼻咽腫瘤侵犯范圍廣,并不適合這些挽救治療手段,這些患者常常預(yù)后也比較差;因此外照射往往是唯一的可能治愈的治療手段,但效果通常很差。局部晚期復(fù)發(fā)鼻咽癌治療計劃的設(shè)計通常是非常困難的,這是擺在我們臨床放射腫瘤工作者面前的一個嚴(yán)峻挑戰(zhàn)。調(diào)強(qiáng)放射治療(Intensity-modulated radiation therapy IMRT)既可以提高腫瘤靶區(qū)的適形度,同時也可以更好地保護(hù)周邊重要的組織器官。由于鼻咽癌靶區(qū)的不規(guī)則性且周邊臨近重要組織結(jié)構(gòu),因此調(diào)強(qiáng)放射治療非常適合鼻咽癌的治療。早期研究顯示,對初治鼻咽癌患者來說,調(diào)強(qiáng)放射治療提高了靶區(qū)劑量分布和治療效果。臨床研究也證實,調(diào)強(qiáng)放射治療提高了局部復(fù)發(fā)鼻咽癌患者的療效。誘導(dǎo)化療后腫瘤體積縮小使得放療計劃的設(shè)計和實施變得更為容易,這對復(fù)發(fā)鼻咽癌再治療是非常重要的。腫瘤體積的縮小可以改善腫瘤靶區(qū)的劑量分布和覆蓋,特別是對rT3-4患者更有利,因為對于這類患者來說要保護(hù)臨近重要組織器官是非常困難的。 本臨床研究采用放療前TP方案誘導(dǎo)化療聯(lián)合調(diào)強(qiáng)放射治療期間同期化療治療局部晚期復(fù)發(fā)鼻咽癌,旨在觀察近期療效、急性毒副反應(yīng)及晚期放射損傷,研究其臨床獲益性。材料與方法:2008年3月至2009年10月,我院放療二區(qū)收治31例局部晚期復(fù)發(fā)鼻咽癌,其中同時伴頸部淋巴結(jié)轉(zhuǎn)移6例;男性22例,女性9例;中位年齡46.5歲(29-60歲),中位復(fù)發(fā)時間為24個月(13-176個月)。根據(jù)廣州2008年鼻咽癌分期標(biāo)準(zhǔn),rT2、rT3、rT4分別為4例、11例、16例;N0、N1、N2分別為25例、4例、2例;Ⅱ、Ⅲ、Ⅳ期分別為3例、12例、16例。全組患者先予TP方案DDP20mg/m2d1-4;TXT60mg/m2d1㖞誘導(dǎo)化療2-3個療程,每3周化療一次,放療于末次誘導(dǎo)化療結(jié)束后2-3周開始。放療期間予相同化療方案同期化療2個療程。調(diào)強(qiáng)放射治療采用6mvX線,鼻咽GTV授予處方劑量64～68Gy(中位劑量為66Gy),分次劑量2.19—2.33 Gy(中位劑量為2.21Gy);GTV-N授予處方劑量64～66Gy(中位劑量為65Gy),CTV處方劑量為54～58Gy(中位劑量為55Gy)。結(jié)果:誘導(dǎo)化療后患者鼻咽復(fù)發(fā)病灶部分緩解(PR)24例,穩(wěn)定(SD)7例;頸部轉(zhuǎn)移淋巴結(jié)PR 1例,SD 5例;鼻咽復(fù)發(fā)灶及頸部淋巴結(jié)皆PR 22例,有效率為71%;同期放化療結(jié)束后鼻咽復(fù)發(fā)灶完全緩解(CR)20例,PR 7例,SD4例;頸部轉(zhuǎn)移淋巴結(jié)CR1例,PR3例,SD2例;鼻咽復(fù)發(fā)灶及頸部淋巴結(jié)皆CR 19例,PR6例,SD6例,有效率為80.6%。同期放化療結(jié)束后3月鼻咽復(fù)發(fā)灶CR 22例,PR 7例,SD2例;頸部轉(zhuǎn)移淋巴結(jié)CR 2例,PR 3例,SD1例;全部病人鼻咽部原復(fù)發(fā)灶及頸淋巴結(jié)在治療后3個月皆CR 21例,PR 7例,SD3例,有效率為90.3%。逆向治療計劃顯示, GTV-T的中位體積為37.46 cm3(14.30～167.52cm3),GTV-N的中位體積為3.26(1.74-6.57cm3)。DVH圖顯示:覆蓋鼻咽GTV-T D95的平均劑量為65.56 Gy,GTV-T V95的平均體積為96.69%;覆蓋鼻咽GTV-N D95的平均劑量為62.68 Gy,GTV-N V95的平均體積為99.56%;靶區(qū)內(nèi)GTV-T、GTV-N和CTV的平均劑量分別為71.2Gy、68.02 Gy和65.4Gy;GTV的平均分割劑量為2.23 Gv(2.19～2.33 Gy)。急性毒性反應(yīng)主要表現(xiàn)為骨髓抑制(尤其是III度以上中性粒細(xì)胞減少)、胃腸道反應(yīng)、脫發(fā)、口腔粘膜炎,但未影響治療進(jìn)程; 31例患者中位隨訪時間為13月(4-23)。1年無局部區(qū)域進(jìn)展生存率為67.7%,1年無局部進(jìn)展生存率74.2%,1年無區(qū)域淋巴結(jié)進(jìn)展生存率87.1%,1年無遠(yuǎn)處轉(zhuǎn)移生存率90.3%,1年總生存率83.9%。隨訪期間晚期放射損傷比較常見,但多為1-2級。結(jié)論:TP方案誘導(dǎo)化療聯(lián)合同期放化療治療局部晚期復(fù)發(fā)鼻咽癌是局部晚期復(fù)發(fā)鼻咽癌有效的治療手段,近期療效可靠;急性毒副反應(yīng)常見,但可以耐受,經(jīng)對癥處理后絕大部分患者能按計劃完成治療。隨訪期間晚期放射反應(yīng)較常見。遠(yuǎn)期療效及晚期放射損傷尚需進(jìn)一步研究和隨訪。
[Abstract]:Background and objective: nasopharyngeal carcinoma (Nasopharyngeal carcinoma NPC) is usually sensitive to radiotherapy and chemotherapy, and a good local regional control rate can be achieved by chemoradiation. However, local regional recurrence is still one of the main modes of failure after nasopharyngeal carcinoma treatment. However, locally advanced recurrent nasopharyngeal carcinoma (NPC), however, is not suitable for these salvage treatments because of a wide range of nasopharyngeal tumors, and these patients often have poor prognosis; therefore, external radiation is often the only one. The results are usually very poor. The design of the local advanced recurrent nasopharyngeal carcinoma treatment plan is usually very difficult, which is a severe challenge in front of our clinical radiation oncologists. Intensity-modulated radiation therapy IMRT can improve the conformability of the tumor target area. The intensity modulated radiation therapy is very suitable for the treatment of nasopharyngeal carcinoma because of the irregularity of the target area of the nasopharyngeal carcinoma and the adjacent important tissue structure, so the early study shows that the intensity modulated radiation therapy improves the target dose distribution and therapeutic effect for the patients with nasopharyngeal carcinoma. The study also confirms that intensity modulated radiation therapy improves the curative effect of local recurrent nasopharyngeal carcinoma. The reduction of tumor volume after induction chemotherapy makes it easier to design and implement the radiotherapy plan, which is very important for retreating recurrent nasopharyngeal carcinoma. The reduction of tumor volume can improve the dose distribution and coverage of tumor target areas, especially to the target area. RT3-4 patients are more favorable because it is very difficult for such patients to protect adjacent important organs.
The clinical study was used to treat locally advanced nasopharyngeal carcinoma with chemotherapy combined with TP regimen before radiotherapy combined with chemotherapy in the treatment of locally advanced nasopharyngeal carcinoma. The purpose of this study was to observe the short-term effect, acute side reaction and late radiation injury, and to study its clinical benefit. Materials and methods: 31 cases of local late radiotherapy in the two area of our hospital from March 2008 to October 2009. 6 cases of recurrent nasopharyngeal carcinoma, including 6 cases of cervical lymph node metastasis, 22 men, 9 women, 46.5 years of age (29-60 years old) and 24 months (13-176 months). According to the 2008 standard of nasopharyngeal carcinoma in Guangzhou, 4 cases, 11 cases, 16 cases, 11 cases, 16 cases, N0, N1, and N2 respectively, respectively, II, III, and IV respectively. For example, 16 cases were given TP regimen, DDP20mg/m2d1-4, TXT60mg/m2d1? Induction chemotherapy for 2-3 courses, once every 3 weeks and 2-3 weeks after the end of last induction chemotherapy. The same chemotherapy regimen was given for 2 courses during the same period of chemotherapy. The intensity modulated radiation therapy used the 6mvX line, and the nasopharyngeal GTV was given a prescription dose of 64 to 68Gy. 66Gy), the fractional dose of 2.19 - 2.33 Gy (median dose was 2.21Gy); GTV-N was given a prescription dose of 64 ~ 66Gy (median dose 65Gy), and CTV prescription dosage was 54 ~ 58Gy (median dose of 55Gy). Results: 24 cases of recurrent nasopharyngeal lesions (PR), 7 cases of stable (SD), 1 cases of cervical lymph node metastasis, 5 cases of nasopharyngeal recurrence and the recurrence of nasopharynx after induction chemotherapy. Cervical lymph nodes were PR 22 cases, the effective rate was 71%, 20 cases of nasopharyngeal recurrence (CR), 7 cases of PR, SD4 cases, CR1 cases of lymph nodes in the neck, PR3 cases, SD2 cases, CR 19 cases of nasopharyngeal recurrence and cervical lymph node, PR6 cases, SD6 cases, 22 cases of nasopharyngeal recurrence in March, 7 cases, 7 cases. D2 cases, cervical metastasis lymph node CR 2 cases, PR 3 cases, SD1 cases, all patients were CR 21 cases, PR 7 cases and SD3 cases in all patients 3 months after treatment. The effective rate was 90.3%. reverse therapy plan, the median volume of GTV-T was 37.46 cm3 (14.30 to 167.52cm3), and the median volume of GTV-N was 3.26 The average dose of GTV-T D95 for nasopharynx was 65.56 Gy, and the average volume of GTV-T V95 was 96.69%; the average dose of GTV-N D95 covering nasopharynx was 62.68 Gy, and the average volume of GTV-N V95 was 99.56%; the average dose of the target area was 68.02, and the average dose was 2.23 (2.19 to 2.33). The main reactions were myelosuppression (especially neutrophils above III degrees), gastrointestinal reactions, alopecia and oral mucositis, but did not affect the treatment process. The median follow-up time of 31 patients was 13 months (4-23).1, no local regional progression survival rate was 67.7%, 1 years had no local progression survival rate 74.2%, and no regional lymph node progression in 1 years was progressing. Rate 87.1%, 1 years without distant metastasis survival rate 90.3%, 1 years of total survival rate of 83.9%. in the period of late radiation injury is more common, but more than 1-2. Conclusion: TP chemotherapy combined with concurrent chemoradiotherapy for locally advanced recurrent nasopharyngeal carcinoma is an effective treatment of locally advanced recurrent nasopharyngeal carcinoma, the short-term effect is reliable; acute side effects are frequent. See, but it can be tolerated and most of the patients can be treated according to the plan after treatment. The late radiation reaction is more common during the follow-up period. Further study and follow-up are needed for the long term effect and late radiation injury.
【學(xué)位授予單位】：廣州醫(yī)學(xué)院
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2010
【分類號】：R739.63

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