鼻咽癌调强放疗后发生腮腺淋巴结转移的临床分析
发布时间：2018-08-21 08:36
【摘要】：[背景]随着放疗技术不断发展进步,调强放疗应用越来越广泛,尤其在头颈部肿瘤中更是得到广泛的应用。在鼻咽癌的放射治疗中调强放疗(intensity modulated radiation therapy,IMRT)较常规放射治疗(conventional radiotheraphy,CRT)优势明显,因鼻咽癌位置较深,放射治疗靶区形状极不规则,IMRT具有较好的适形度,能降低周围组织正常组织剂量,同时靶区剂量大为提升能,另外靶区内的不同位置所照射剂量不同,原发肿瘤及转移的淋巴结所需剂量较高,预防区域所需剂量偏低,因此靶区内的剂量需要按要求分布。另外鼻咽癌邻近有腮腺、脑干、脊髓等较多的危及器官,与靶区位置较近且关系较为复杂。IMRT可使周围组织的放疗副反应降低,提高了患者的生存率,保存和改善了患者的生活质量。鼻咽癌颈部淋巴结转移率较高,初诊时约80%—90%有淋巴结转移,较常见的为Ⅱ区淋巴结,Ⅱ区淋巴结经淋巴管网顺流而下,经过Ⅲ区可达锁骨上,跳跃转移发生率较低,Ⅱ、Ⅲ、Ⅳ区的淋巴结转移发生率约为95.5%,60.7%和34.8%。鼻咽癌发生腮腺淋巴结转移率很低,有文献报道约为1.4%—3.4[1-2]。腮腺淋巴结常见的引流部位为头皮、面部、眼、外耳等,不常见的引流部位来自鼻、鼻窦、鼻咽、口腔等组织器官。鼻咽癌发生腮腺转移较为罕见,且腮腺分泌唾液的功能的好坏影响患者的生活质量,腮腺在鼻咽癌IMRT中作为被保护的器官,在鼻咽癌IMRT中腮腺是腮腺的剂量通常限制为V30小于50%或腮腺的平均剂量小于26 Gy[3]。近年来不断有鼻咽癌IMRT后发生腮腺淋巴结转移的报道,既往未见鼻咽癌CRT后发生腮腺淋巴结转移情况发生,可能是在鼻咽癌CRT中,双侧腮腺均包含在照射野内,腮腺全部体积受到照射,且照射剂量为靶区剂量,其唾液分泌功能严重下降,造成口干等不良反应,而在鼻咽癌IMRT中腮腺照射剂量及体积均较CRT低,从而改善了腮腺的分泌功能,降低了 口干的发生率,提高了患者的生存质量,但腮腺淋巴结转移的概率有所提高。[目的]本研究的目的:(1)比较鼻咽癌IMRT与CRT的靶区及腮腺区的剂量分布,回顾性分析两组腮腺淋巴结转移的概率。(2)通过观察鼻咽癌IMRT后发生腮腺淋巴结转移的病例特点,了解鼻咽癌容易发生腮腺淋巴结转移的特征,为靶区勾画腮腺剂量限制提供一定的临床指导价值。[方法]选择本院自2009年1月至2015年12月初治的鼻咽癌IMRT患者323例,均有病理证实,选择2003年1月初至2009年12月鼻咽癌CRT的病例数约312人。了解既往鼻咽癌IMRT与CRT的靶区及腮腺区的剂量分布,复习文献及相似报道的病例进行分析及总结规律。[结果]鼻咽癌IMRT组3例患者分别于IMRT后1年半、7个月及6年余后发生腮腺淋巴结转移。3例均位于腮腺浅叶。1例经病理学证实,行腮腺切除术及术后放化疗。1例经超声影像学发现,1例经CT影像学发现。鼻咽癌CRT组无1例出现腮腺淋巴结转移,1例有颈部淋巴结切除活检史且咽旁间隙有巨大肿大淋巴结,另外2例均见颈部Ⅱ区肿大淋巴结,发生腮腺转移的部位均发生在腮腺浅叶。鼻咽癌对放疗敏感,放射治疗是鼻咽癌的首选治疗手段,在鼻咽癌IMRT治疗中,鼻咽癌靶区剂量通常为69.96Gy/33f,鼻咽癌CRT时靶区剂量通常设置为70Gy/30f。腮腺的剂量通常限制为V30小于50%或腮腺的平均剂量小于26 Gy。而CRT时鼻咽癌靶区处方剂量达到70 Gy时,双侧腮腺的剂量接近70Gy。[结论]本研究中鼻咽癌调强放疗后腮腺转移发生率约0.93%,发生率极低,鼻咽癌调强放疗仍然应按照规定的剂量限制保护腮腺的功能。对于咽旁间隙有巨大淋巴结;颈部Ⅱ区存在较大肿大淋巴结;颈部淋巴结数目多、巨大或先前颈部行手术或者放疗治疗破坏了淋巴正常的引流途径的患者,在制定此类放疗计划时作者认为应根据实际情况放宽对同侧腮腺的剂量限制,同时加强对对侧腮腺的保护。
[Abstract]:[background] with the continuous development of radiotherapy technology, intensity modulated radiation therapy has been applied more and more widely, especially in head and neck tumors. In the radiotherapy of nasopharyngeal carcinoma, intensity modulated radiation therapy (IMRT) is superior to conventional radiotherapy (conventional radiotheraphy, CRT) because of nasopharyngeal carcinoma. IMRT has a good conformity, can reduce the dose of normal tissue around, and the target dose can be greatly increased. In addition, the target area of different location of the irradiation dose is different, the primary tumor and metastatic lymph nodes need a higher dose, the prevention area needs a lower dose, so the target In addition, nasopharyngeal carcinoma is adjacent to parotid gland, brain stem, spinal cord and other more dangerous organs, and the target location is closer and the relationship is more complex. IMRT can reduce the side effects of radiation therapy in the surrounding tissues, improve the survival rate of patients, preserve and improve the quality of life of patients with nasopharyngeal carcinoma cervical lymph node metastasis rate. The incidence of lymph node metastasis in the second, third and fourth regions is about 95.5%, 60.7% and 34.8%. The rate of lymph node metastasis in the parotid gland of nasopharyngeal carcinoma is very low. About 1.4%-3.4[1-2]. The common drainage sites of parotid lymph nodes are scalp, face, eye, external ear, etc. The uncommon drainage sites come from nasal, paranasal, nasopharyngeal, oral and other tissues and organs. As a protected organ, the dosage of parotid gland to parotid gland in nasopharyngeal carcinoma (NPC) IMRT is usually limited to less than 50% of V30 or less than 26 Gy in parotid gland.In recent years, there have been reports of parotid lymph node metastasis after IMRT of NPC. Bilateral parotid glands are included in the irradiation field. The volume of parotid glands is irradiated, and the irradiation dose is the target dose. The salivary secretion function of parotid glands is severely decreased, resulting in adverse reactions such as dry mouth. The irradiation dose and volume of parotid glands in IMRT of nasopharyngeal carcinoma are lower than that of CRT, thus improving the secretion function of parotid glands, reducing the incidence of dry mouth and increasing the incidence of dry mouth [Objective] The purpose of this study was: (1) To compare the dose distribution of IMRT and CRT in the target area and parotid gland area, and to retrospectively analyze the probability of parotid lymph node metastasis in the two groups. (2) To investigate the characteristics of parotid lymph node metastasis after IMRT in nasopharyngeal carcinoma. [Methods] 323 patients with nasopharyngeal carcinoma treated in our hospital from January 2009 to early December 2015 were selected. The number of CRT cases of nasopharyngeal carcinoma from January 2003 to December 2009 was about 312. [Results] Three cases of nasopharyngeal carcinoma in IMRT group had parotid lymph node metastasis one and a half years after IMRT, seven months after IMRT and six years after IMRT. Three cases were located in the superficial lobe of parotid gland. In CRT group, no parotid lymph node metastasis occurred, 1 had a history of cervical lymphadenectomy and biopsy, and 1 had giant enlarged lymph nodes in parapharyngeal space. In the other 2 cases, enlarged lymph nodes in area II of the neck were found. The sites of parotid metastasis occurred in the superficial lobe of the parotid gland. Radiotherapy is the first choice for nasopharyngeal carcinoma. In IMRT, the target dose of nasopharyngeal carcinoma is 69.96 Gy/33f. The target dose of nasopharyngeal carcinoma in CRT is usually set at 70 Gy/30f. The dose of parotid gland is usually limited to V30 less than 50% or the average dose of parotid gland is less than 26 Gy. At 70 Gy, the dose of bilateral parotid glands was close to 70 Gy. [Conclusion] In this study, the incidence of parotid metastasis after intensity modulated radiation therapy for nasopharyngeal carcinoma was about 0.93%. Intensity modulated radiation therapy for nasopharyngeal carcinoma should still protect the function of parotid glands according to the prescribed dose limits. For patients with a large number of obstructions, large or previous cervical surgery or radiotherapy that disrupt the normal drainage of lymph nodes, the authors suggest that the dose limitation of ipsilateral parotid glands should be relaxed and the protection of the contralateral parotid glands should be strengthened according to the actual situation.
【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R739.63
本文编号：2195159
[Abstract]:[background] with the continuous development of radiotherapy technology, intensity modulated radiation therapy has been applied more and more widely, especially in head and neck tumors. In the radiotherapy of nasopharyngeal carcinoma, intensity modulated radiation therapy (IMRT) is superior to conventional radiotherapy (conventional radiotheraphy, CRT) because of nasopharyngeal carcinoma. IMRT has a good conformity, can reduce the dose of normal tissue around, and the target dose can be greatly increased. In addition, the target area of different location of the irradiation dose is different, the primary tumor and metastatic lymph nodes need a higher dose, the prevention area needs a lower dose, so the target In addition, nasopharyngeal carcinoma is adjacent to parotid gland, brain stem, spinal cord and other more dangerous organs, and the target location is closer and the relationship is more complex. IMRT can reduce the side effects of radiation therapy in the surrounding tissues, improve the survival rate of patients, preserve and improve the quality of life of patients with nasopharyngeal carcinoma cervical lymph node metastasis rate. The incidence of lymph node metastasis in the second, third and fourth regions is about 95.5%, 60.7% and 34.8%. The rate of lymph node metastasis in the parotid gland of nasopharyngeal carcinoma is very low. About 1.4%-3.4[1-2]. The common drainage sites of parotid lymph nodes are scalp, face, eye, external ear, etc. The uncommon drainage sites come from nasal, paranasal, nasopharyngeal, oral and other tissues and organs. As a protected organ, the dosage of parotid gland to parotid gland in nasopharyngeal carcinoma (NPC) IMRT is usually limited to less than 50% of V30 or less than 26 Gy in parotid gland.In recent years, there have been reports of parotid lymph node metastasis after IMRT of NPC. Bilateral parotid glands are included in the irradiation field. The volume of parotid glands is irradiated, and the irradiation dose is the target dose. The salivary secretion function of parotid glands is severely decreased, resulting in adverse reactions such as dry mouth. The irradiation dose and volume of parotid glands in IMRT of nasopharyngeal carcinoma are lower than that of CRT, thus improving the secretion function of parotid glands, reducing the incidence of dry mouth and increasing the incidence of dry mouth [Objective] The purpose of this study was: (1) To compare the dose distribution of IMRT and CRT in the target area and parotid gland area, and to retrospectively analyze the probability of parotid lymph node metastasis in the two groups. (2) To investigate the characteristics of parotid lymph node metastasis after IMRT in nasopharyngeal carcinoma. [Methods] 323 patients with nasopharyngeal carcinoma treated in our hospital from January 2009 to early December 2015 were selected. The number of CRT cases of nasopharyngeal carcinoma from January 2003 to December 2009 was about 312. [Results] Three cases of nasopharyngeal carcinoma in IMRT group had parotid lymph node metastasis one and a half years after IMRT, seven months after IMRT and six years after IMRT. Three cases were located in the superficial lobe of parotid gland. In CRT group, no parotid lymph node metastasis occurred, 1 had a history of cervical lymphadenectomy and biopsy, and 1 had giant enlarged lymph nodes in parapharyngeal space. In the other 2 cases, enlarged lymph nodes in area II of the neck were found. The sites of parotid metastasis occurred in the superficial lobe of the parotid gland. Radiotherapy is the first choice for nasopharyngeal carcinoma. In IMRT, the target dose of nasopharyngeal carcinoma is 69.96 Gy/33f. The target dose of nasopharyngeal carcinoma in CRT is usually set at 70 Gy/30f. The dose of parotid gland is usually limited to V30 less than 50% or the average dose of parotid gland is less than 26 Gy. At 70 Gy, the dose of bilateral parotid glands was close to 70 Gy. [Conclusion] In this study, the incidence of parotid metastasis after intensity modulated radiation therapy for nasopharyngeal carcinoma was about 0.93%. Intensity modulated radiation therapy for nasopharyngeal carcinoma should still protect the function of parotid glands according to the prescribed dose limits. For patients with a large number of obstructions, large or previous cervical surgery or radiotherapy that disrupt the normal drainage of lymph nodes, the authors suggest that the dose limitation of ipsilateral parotid glands should be relaxed and the protection of the contralateral parotid glands should be strengthened according to the actual situation.
【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R739.63
【参考文献】
相关期刊论文 前10条
1 周路;刘杰明;;MRI联合CT诊断鼻咽癌颅底转移[J];现代肿瘤医学;2016年12期
2 王洪智;罗京伟;易俊林;黄晓东;张世平;曲媛;肖建平;李素艳;高黎;徐国镇;;鼻咽癌IMRT后腮腺区域失败分析[J];中华放射肿瘤学杂志;2016年03期
3 许超;包峗;周菊英;涂_g;;鼻咽癌淋巴结转移规律的Meta分析[J];国际肿瘤学杂志;2015年02期
4 尹珍珍;高黎;;靶向药物联合放疗在鼻咽癌治疗中的应用现状[J];中华放射肿瘤学杂志;2013年06期
5 程红蕾;王若雨;;鼻咽癌相关基因研究进展[J];国际肿瘤学杂志;2013年09期
6 杜清华;王仁生;;局部晚期鼻咽癌诱导化疗的研究进展[J];广东医学;2012年17期
7 邵明海;王建华;胡炜;丁维军;;鼻咽癌腮腺淋巴结转移2例[J];肿瘤学杂志;2012年01期
8 魏矿荣;徐莹;张文俊;梁智恒;刘静;;鼻咽癌的病理组织学分类[J];中华病理学杂志;2011年05期
9 吴隆秋;李金高;叶新芊;刘岚;王索宇;;鼻咽癌腮腺淋巴结转移临床分析[J];中国肿瘤临床;2011年02期
10 王丽红;余忠华;;局部晚期鼻咽癌放疗联合同步化疗研究进展[J];肿瘤预防与治疗;2011年01期
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