诱导化疗联合调强同期放化疗治疗局部晚期复发鼻咽癌的临床研究

发布时间：2018-07-03 18:17

本文选题：复发鼻咽癌 + 调强放射治疗　；参考：《广州医学院》2010年硕士论文

【摘要】：背景与目的:鼻咽癌(Nasopharyngeal carcinoma NPC)通常对放疗和化疗敏感,放化综合治疗可以取得良好的局部区域控制率。然而即使这样,局部区域复发仍然是鼻咽癌治疗后失败的主要模式之一。相当部分局部早期复发鼻咽癌患者在采取积极的治疗措施如鼻咽内镜手术、近距离放射治疗、放射外科手术后,仍然可以获得长期的生存。然而局部晚期复发鼻咽癌(NPC)由于鼻咽肿瘤侵犯范围广,并不适合这些挽救治疗手段,这些患者常常预后也比较差;因此外照射往往是唯一的可能治愈的治疗手段,但效果通常很差。局部晚期复发鼻咽癌治疗计划的设计通常是非常困难的,这是摆在我们临床放射肿瘤工作者面前的一个严峻挑战。调强放射治疗(Intensity-modulated radiation therapy IMRT)既可以提高肿瘤靶区的适形度,同时也可以更好地保护周边重要的组织器官。由于鼻咽癌靶区的不规则性且周边临近重要组织结构,因此调强放射治疗非常适合鼻咽癌的治疗。早期研究显示,对初治鼻咽癌患者来说,调强放射治疗提高了靶区剂量分布和治疗效果。临床研究也证实,调强放射治疗提高了局部复发鼻咽癌患者的疗效。诱导化疗后肿瘤体积缩小使得放疗计划的设计和实施变得更为容易,这对复发鼻咽癌再治疗是非常重要的。肿瘤体积的缩小可以改善肿瘤靶区的剂量分布和覆盖,特别是对rT3-4患者更有利,因为对于这类患者来说要保护临近重要组织器官是非常困难的。本临床研究采用放疗前TP方案诱导化疗联合调强放射治疗期间同期化疗治疗局部晚期复发鼻咽癌,旨在观察近期疗效、急性毒副反应及晚期放射损伤,研究其临床获益性。材料与方法:2008年3月至2009年10月,我院放疗二区收治31例局部晚期复发鼻咽癌,其中同时伴颈部淋巴结转移6例;男性22例,女性9例;中位年龄46.5岁(29-60岁),中位复发时间为24个月(13-176个月)。根据广州2008年鼻咽癌分期标准,rT2、rT3、rT4分别为4例、11例、16例;N0、N1、N2分别为25例、4例、2例;Ⅱ、Ⅲ、Ⅳ期分别为3例、12例、16例。全组患者先予TP方案龴DDP20mg/m2d1-4;TXT60mg/m2d1㖞诱导化疗2-3个疗程,每3周化疗一次,放疗于末次诱导化疗结束后2-3周开始。放疗期间予相同化疗方案同期化疗2个疗程。调强放射治疗采用6mvX线,鼻咽GTV授予处方剂量64～68Gy(中位剂量为66Gy),分次剂量2.19—2.33 Gy(中位剂量为2.21Gy);GTV-N授予处方剂量64～66Gy(中位剂量为65Gy),CTV处方剂量为54～58Gy(中位剂量为55Gy)。结果:诱导化疗后患者鼻咽复发病灶部分缓解(PR)24例,稳定(SD)7例;颈部转移淋巴结PR 1例,SD 5例;鼻咽复发灶及颈部淋巴结皆PR 22例,有效率为71%;同期放化疗结束后鼻咽复发灶完全缓解(CR)20例,PR 7例,SD4例;颈部转移淋巴结CR1例,PR3例,SD2例;鼻咽复发灶及颈部淋巴结皆CR 19例,PR6例,SD6例,有效率为80.6%。同期放化疗结束后3月鼻咽复发灶CR 22例,PR 7例,SD2例;颈部转移淋巴结CR 2例,PR 3例,SD1例;全部病人鼻咽部原复发灶及颈淋巴结在治疗后3个月皆CR 21例,PR 7例,SD3例,有效率为90.3%。逆向治疗计划显示, GTV-T的中位体积为37.46 cm3(14.30～167.52cm3),GTV-N的中位体积为3.26(1.74-6.57cm3)。DVH图显示:覆盖鼻咽GTV-T D95的平均剂量为65.56 Gy,GTV-T V95的平均体积为96.69%;覆盖鼻咽GTV-N D95的平均剂量为62.68 Gy,GTV-N V95的平均体积为99.56%;靶区内GTV-T、GTV-N和CTV的平均剂量分别为71.2Gy、68.02 Gy和65.4Gy;GTV的平均分割剂量为2.23 Gv(2.19～2.33 Gy)。急性毒性反应主要表现为骨髓抑制(尤其是III度以上中性粒细胞减少)、胃肠道反应、脱发、口腔粘膜炎,但未影响治疗进程; 31例患者中位随访时间为13月(4-23)。1年无局部区域进展生存率为67.7%,1年无局部进展生存率74.2%,1年无区域淋巴结进展生存率87.1%,1年无远处转移生存率90.3%,1年总生存率83.9%。随访期间晚期放射损伤比较常见,但多为1-2级。结论:TP方案诱导化疗联合同期放化疗治疗局部晚期复发鼻咽癌是局部晚期复发鼻咽癌有效的治疗手段,近期疗效可靠;急性毒副反应常见,但可以耐受,经对症处理后绝大部分患者能按计划完成治疗。随访期间晚期放射反应较常见。远期疗效及晚期放射损伤尚需进一步研究和随访。
[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.
【学位授予单位】：广州医学院
【学位级别】：硕士
【学位授予年份】：2010
【分类号】：R739.63

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