鼻咽癌調(diào)強放療后發(fā)生腮腺淋巴結(jié)轉(zhuǎn)移的臨床分析
發(fā)布時間：2018-08-21 08:36
【摘要】：[背景]隨著放療技術(shù)不斷發(fā)展進步,調(diào)強放療應(yīng)用越來越廣泛,尤其在頭頸部腫瘤中更是得到廣泛的應(yīng)用。在鼻咽癌的放射治療中調(diào)強放療(intensity modulated radiation therapy,IMRT)較常規(guī)放射治療(conventional radiotheraphy,CRT)優(yōu)勢明顯,因鼻咽癌位置較深,放射治療靶區(qū)形狀極不規(guī)則,IMRT具有較好的適形度,能降低周圍組織正常組織劑量,同時靶區(qū)劑量大為提升能,另外靶區(qū)內(nèi)的不同位置所照射劑量不同,原發(fā)腫瘤及轉(zhuǎn)移的淋巴結(jié)所需劑量較高,預(yù)防區(qū)域所需劑量偏低,因此靶區(qū)內(nèi)的劑量需要按要求分布。另外鼻咽癌鄰近有腮腺、腦干、脊髓等較多的危及器官,與靶區(qū)位置較近且關(guān)系較為復(fù)雜。IMRT可使周圍組織的放療副反應(yīng)降低,提高了患者的生存率,保存和改善了患者的生活質(zhì)量。鼻咽癌頸部淋巴結(jié)轉(zhuǎn)移率較高,初診時約80%—90%有淋巴結(jié)轉(zhuǎn)移,較常見的為Ⅱ區(qū)淋巴結(jié),Ⅱ區(qū)淋巴結(jié)經(jīng)淋巴管網(wǎng)順流而下,經(jīng)過Ⅲ區(qū)可達鎖骨上,跳躍轉(zhuǎn)移發(fā)生率較低,Ⅱ、Ⅲ、Ⅳ區(qū)的淋巴結(jié)轉(zhuǎn)移發(fā)生率約為95.5%,60.7%和34.8%。鼻咽癌發(fā)生腮腺淋巴結(jié)轉(zhuǎn)移率很低,有文獻報道約為1.4%—3.4[1-2]。腮腺淋巴結(jié)常見的引流部位為頭皮、面部、眼、外耳等,不常見的引流部位來自鼻、鼻竇、鼻咽、口腔等組織器官。鼻咽癌發(fā)生腮腺轉(zhuǎn)移較為罕見,且腮腺分泌唾液的功能的好壞影響患者的生活質(zhì)量,腮腺在鼻咽癌IMRT中作為被保護的器官,在鼻咽癌IMRT中腮腺是腮腺的劑量通常限制為V30小于50%或腮腺的平均劑量小于26 Gy[3]。近年來不斷有鼻咽癌IMRT后發(fā)生腮腺淋巴結(jié)轉(zhuǎn)移的報道,既往未見鼻咽癌CRT后發(fā)生腮腺淋巴結(jié)轉(zhuǎn)移情況發(fā)生,可能是在鼻咽癌CRT中,雙側(cè)腮腺均包含在照射野內(nèi),腮腺全部體積受到照射,且照射劑量為靶區(qū)劑量,其唾液分泌功能嚴重下降,造成口干等不良反應(yīng),而在鼻咽癌IMRT中腮腺照射劑量及體積均較CRT低,從而改善了腮腺的分泌功能,降低了 口干的發(fā)生率,提高了患者的生存質(zhì)量,但腮腺淋巴結(jié)轉(zhuǎn)移的概率有所提高。[目的]本研究的目的:(1)比較鼻咽癌IMRT與CRT的靶區(qū)及腮腺區(qū)的劑量分布,回顧性分析兩組腮腺淋巴結(jié)轉(zhuǎn)移的概率。(2)通過觀察鼻咽癌IMRT后發(fā)生腮腺淋巴結(jié)轉(zhuǎn)移的病例特點,了解鼻咽癌容易發(fā)生腮腺淋巴結(jié)轉(zhuǎn)移的特征,為靶區(qū)勾畫腮腺劑量限制提供一定的臨床指導(dǎo)價值。[方法]選擇本院自2009年1月至2015年12月初治的鼻咽癌IMRT患者323例,均有病理證實,選擇2003年1月初至2009年12月鼻咽癌CRT的病例數(shù)約312人。了解既往鼻咽癌IMRT與CRT的靶區(qū)及腮腺區(qū)的劑量分布,復(fù)習(xí)文獻及相似報道的病例進行分析及總結(jié)規(guī)律。[結(jié)果]鼻咽癌IMRT組3例患者分別于IMRT后1年半、7個月及6年余后發(fā)生腮腺淋巴結(jié)轉(zhuǎn)移。3例均位于腮腺淺葉。1例經(jīng)病理學(xué)證實,行腮腺切除術(shù)及術(shù)后放化療。1例經(jīng)超聲影像學(xué)發(fā)現(xiàn),1例經(jīng)CT影像學(xué)發(fā)現(xiàn)。鼻咽癌CRT組無1例出現(xiàn)腮腺淋巴結(jié)轉(zhuǎn)移,1例有頸部淋巴結(jié)切除活檢史且咽旁間隙有巨大腫大淋巴結(jié),另外2例均見頸部Ⅱ區(qū)腫大淋巴結(jié),發(fā)生腮腺轉(zhuǎn)移的部位均發(fā)生在腮腺淺葉。鼻咽癌對放療敏感,放射治療是鼻咽癌的首選治療手段,在鼻咽癌IMRT治療中,鼻咽癌靶區(qū)劑量通常為69.96Gy/33f,鼻咽癌CRT時靶區(qū)劑量通常設(shè)置為70Gy/30f。腮腺的劑量通常限制為V30小于50%或腮腺的平均劑量小于26 Gy。而CRT時鼻咽癌靶區(qū)處方劑量達到70 Gy時,雙側(cè)腮腺的劑量接近70Gy。[結(jié)論]本研究中鼻咽癌調(diào)強放療后腮腺轉(zhuǎn)移發(fā)生率約0.93%,發(fā)生率極低,鼻咽癌調(diào)強放療仍然應(yīng)按照規(guī)定的劑量限制保護腮腺的功能。對于咽旁間隙有巨大淋巴結(jié);頸部Ⅱ區(qū)存在較大腫大淋巴結(jié);頸部淋巴結(jié)數(shù)目多、巨大或先前頸部行手術(shù)或者放療治療破壞了淋巴正常的引流途徑的患者,在制定此類放療計劃時作者認為應(yīng)根據(jù)實際情況放寬對同側(cè)腮腺的劑量限制,同時加強對對側(cè)腮腺的保護。
[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.
【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R739.63
本文編號：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.
【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R739.63
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