基于磁共振及调强放射治疗背景下的鼻咽癌新T分期研究

发布时间：2019-04-23 18:01

【摘要】：背景与目的:鼻咽癌是常见的头颈部恶性肿瘤之一,主要集中在我国南方地区,尤以两广地区多见。而鼻咽癌局部复发是影响临床分期、治疗疗效及预后的主要因素之一。近十几年来,常规二维放射治疗已经不再适用并逐渐被调强放射治疗(IMRT)所取代,而2010年发布的第七版UICC/AJCC鼻咽癌T分期标准主要是基于常规二维放射治疗的数据结果,没有反映诊治手段的变革对分期的影响。因此本研究旨在分析基于磁共振影像的局部解剖结构,包括鼻咽部、鼻腔、口咽、咽旁间隙、颅底、翼内肌、翼外肌、副鼻窦等结构对接受调强放射治疗的鼻咽癌患者预后的影响,为临床治疗及研究提供依据,为建立更适应调强放射治疗的新的T分期系统提供理论依据。方法:回顾性分析我院2008年1月至2010年3月经病理确诊初治无转移的鼻咽癌患者608例,阅读所有入组患者的MRI影像,结合查体及初诊时的临床资料按据鼻咽癌国际第7版UICC/AJCC分期标准进行重新分期。生存率的计算采用Kaplan-Meier法,单因素分析采用Log-rank检验,风险比计算及多因素分析采用COX模型;分析现行的第7版UICC/AJCC分期系统下对接受调强放射治疗的鼻咽癌患者的预后存在的弊端,建立基于MRI及IMRT下的鼻咽癌新T分期标准,参照临床分期原则对新T分期系统的合理性进行评价。结果:本组5年随访率为94.5%。全组5年DFS为80.1%,LRFS为86.0%,DMFS为81.1%,OS为81.5%。根据第7版UICC/AJCC分期系统,鼻咽癌侵犯周围结构的分布比例如下:608例患者中,肿物侵犯鼻咽部100%(608/608)、鼻腔34.4%(209/608)、咽旁82.4%(501/608)、口咽部17.6%(107/608)、颅底骨质72.2%(439/608)、翼内肌65.5%(398/608)、翼外肌32.1%(195/608)、鼻窦23.8%(145/608)、颞下窝13%(79/608)、眼眶15.5%(94/608)、颅神经6.9%(142/608)、颅内16.8%(102/608)。根据单因素及多因素分析显示,鼻腔、口咽部、咽旁间隙、颅底骨质、翼内肌、翼外肌、颞下窝、鼻窦、眼眶、颅内、颅神经侵犯均为影响患者预后的独立预后因素(P0.05)。根据风险差异性及生存曲线分布分析,建议基于磁共振成像以及调强放射治疗相适应的鼻咽癌临床T分期新标准为:T1,鼻咽、咽旁、口咽、鼻腔、颅底、翼内肌;T2,翼外肌、鼻窦、颞下窝、眼眶、颅内、颅神经。相对于第7版UICC/AJCC分期系统,推荐的新T分期系统风险差异性及分布均衡性均较好,无局部复发生存曲线及总生存曲线均能很好地拉开。结论:推荐的新T分期系统采用了基于磁共振影像及调强放射治疗基础,反映了当前鼻咽癌患者最先进的诊治模式,能较客观、准确地预测鼻咽癌患者的预后,可作为鼻咽癌临床新分期探索性的尝试。
[Abstract]:Background & objective: nasopharyngeal carcinoma (NPC) is one of the most common malignant tumors in head and neck. Local recurrence of nasopharyngeal carcinoma is one of the main factors affecting clinical stage, therapeutic efficacy and prognosis. In recent years, conventional two-dimensional radiotherapy is no longer applicable and gradually replaced by intensity-modulated radiotherapy (IMRT). However, the seventh edition of T-staging standard for nasopharyngeal carcinoma of UICC/AJCC published in 2010 is mainly based on the results of conventional two-dimensional radiotherapy. It does not reflect the influence of the change of diagnosis and treatment on staging. Therefore, the purpose of this study was to analyze the local anatomical structures based on MRI, including nasopharynx, nasal cavity, oropharynx, parapharyngeal space, skull base, internal pterygoid muscle and external pterygoid muscle. The effects of paranasal sinus and other structures on prognosis of nasopharyngeal carcinoma patients undergoing intensity modulated radiotherapy provide evidence for clinical treatment and research, and provide theoretical basis for establishing a new T stage system which is more suitable for intensity modulated radiotherapy. Methods: from January 2008 to March 2010, 608 cases of nasopharynx carcinoma without metastasis diagnosed by pathology were analyzed retrospectively. The MRI images of all the patients were read. Combined with the clinical data of physical examination and initial diagnosis, the patients were re-staging according to the UICC/AJCC staging standard of the 7th edition of nasopharyngeal carcinoma (NPC). The survival rate was calculated by Kaplan-Meier method, Log-rank test was used for univariate analysis, COX model was used for risk ratio calculation and multivariate analysis. To analyze the disadvantages of the current 7 edition UICC/AJCC staging system for the prognosis of nasopharyngeal carcinoma patients undergoing intensity modulated radiotherapy, and to establish a new T staging standard for nasopharyngeal carcinoma based on MRI and IMRT. According to the principle of clinical staging, the rationality of the new T staging system was evaluated. Results: the 5-year follow-up rate was 94.5%. The 5-year DFS, LRFS, DMFS and OS were 80.1%, 86.0%, 81.1% and 81.5%, respectively. According to the seventh edition of the UICC/AJCC staging system, the proportion of nasopharyngeal carcinoma invading the surrounding structures was as follows: 100% (608 / 608) of the 608 patients were involved in the nasopharynx, 34.4% (209 / 608) in the nasal cavity, 82.4% (501 / 608) in the parapharyngeal region, and 62.4% (581 / 608) in the parapharyngeal region. The oropharynx was 17.6% (107 / 608), the skull base was 72.2% (439 / 608), the medial pterygoid muscle was 65.5% (398 / 608), the external pterygoid muscle was 32.1% (195 / 608), the nasal sinus was23.8% (145 / 608), the infratemporal fossa was 13% (79 / 608). Orbit 15.5% (94 / 608), cranial nerve 6.9% (142 / 608), intracranial 16.8% (102 / 608). According to univariate and multivariate analysis, nasal cavity, oropharynx, parapharyngeal space, skull base bone, internal pterygoid muscle, lateral pterygoid muscle, infratemporal fossa, nasal sinus, orbital, intracranial, Cranial nerve invasion was an independent prognostic factor affecting the prognosis of the patients (P0.05). According to the difference of risk and the distribution of survival curve, it is suggested that the new criteria for clinical T staging of nasopharyngeal carcinoma based on MRI and intensity modulated radiotherapy are: T1, nasopharynx, parapharyngeal, oropharynx, nasal cavity, skull base, internal pterygoid muscle; T2, lateral pterygoid muscle, nasal sinus, infratemporal fossa, orbital, intracranial, cranial nerve. Compared with the UICC/AJCC staging system of the 7th edition, the risk difference and distribution balance of the new T staging system are better, and the survival curve without local recurrence and the total survival curve can be well opened. Conclusion: the recommended new T staging system adopts the basis of MRI and intensity modulated radiotherapy, which reflects the most advanced diagnosis and treatment mode of NPC patients, and can predict the prognosis of NPC patients objectively and accurately. It can be used as a new clinical stage of nasopharyngeal carcinoma.
【学位授予单位】：广西医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R739.63

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