局部复发鼻咽癌的再程放疗

中位随访: 23 months (range 3-143 months) 2年无进展生存、总 生存：39%、48% 5年无进展生存、总 生存：23%、28%
Local progression-free and overall survival
Oksuz DC, et al. Int J Radiat Oncol Biol Phys 2004;60:388–394.

Lee AWM, et al. Int J Radiat Oncol Biol Phys 1992;23:261–270 Sham JST, et al. Br J Radiol 1990;63:51-58 Yamashita, et al. Acta Radiol Oncol 1985;24:315-320

The 1-, 2- and 3-year survival was 54.9, 30.2 and 22.1%, respectively
Overall survival of recurrent NPC patients.


Complications: Hearing loss and trismus: all Brain necrosis: conventional RT: 13 pts 3DCRT: none Severe complications: conventional RT: 22.9% 3DCRT: 9.3% (p=0.04)


治疗选择： 鼻咽切除术(Nasopharyngectomy) 腔内近距离治疗(Intracavitary Brachytherapy) 组织间放射性粒子植入（Interstitial Radoactive Implantation) 放射外科（Radiosurgery) 立体定向放疗（Stereotactic Radiotherapy) 外照射(External Beam Radiotherapy)

Toxicities:
Arm I Grade III oral mucositis Nasopharyngeal mucositis 17% 25% Arm II 17% 17% Arm III 0 17%
1.
2.
结论： 高剂量3DCRT补量技术可获得高的局部控制率 ，毒性反应可以耐受 对大体肿瘤追加剂量至78Gy（54Gy＋24Gy boost）可以提高局部无复发生存率
Li J, et al. Int J Radiat Oncol Biol Phys 2005;63(suppl):S154
Guangzhou 3DCRT study



3DCRT detail: CTV=GTV+5-10mm margin, PTV=CTV+2.5mm margin, Beam arrangement: 6 MV X-ray, 5-7 static coplanar or noncoplanar portals. Wedges used if necessary Dose: dose prescribed(66-72Gy, 2Gy/fx) to the geometric center of the PTV
Incidence of radiation-induced severe late complications after reirradiation
结论：局部复发的早期诊断和高剂量放疗 （60Gy）对于提高局控和生存至关重要
Taiwan study

Treatment detail: Conventional RT: 151 pts 3DCRT: 35 pts Median dose: 50Gy Dose constrains to organs at risk: optic apparatus: ＜8Gy, brain stem: ＜15Gy
Choo R, et al. Cancer 1991;68:2120-2124 Oksuz DC, et al. Int J Radiat Oncol Biol Phys 2004;60:388-394
再程放疗

源自文库
高剂量放疗（＞60Gy）vs. 低剂量放疗（＜ 60Gy）：局部控制，生存率 高剂量放疗与严重并发症风险增加有关
Univariate analyses of prognostic factors for overall survival and local progression-free rate
Multivariate analyses of prognostic factors for overall survival and local progression-free rate
Matched-pair study: Hong Kong and Sun Yat-Sen University

No. of pts: 86 Technique: SRS: 43 pts SRT: 43 pts Dose fractionation SRS: median dose 12.5Gy in single fraction SRT: 34Gy in 2-6 fractions
Shanghai 3DCRT dose escalation study


Eligibility criteria: Interval between 1st RT and local recurrence of ＞ 6 months No cervical lymph node involvement No distant metastasis




Difference in local control were mainly observed in pts with recurrence or rT2-4 disease No significant difference in local control in pts with persistent or rT1 disease Severe complications: SRS 33% SRT 21% Brain necrosis (16% vs. 7%)、brain stem necrosis (0 vs. 5%)、mucosal necrosis (0 vs. 12%)、hemorrhage (5% vs. 2%)
Actuarial overall survival by age Actuarial overall survival by stage ＜50ys vs. ≥50ys (36% vs. 18%，p=0.025) Oksuz DC, et al. Int J Radiat Oncol Biol Phys 2004;60:388–394.



Treatment period: 19792000 Technique: 4-6MV X线或 Co-60 γ线 中位剂量50Gy，1.82Gy/fx Chemo: 41.5%
Oksuz DC, et al. Int J Radiat Oncol Biol Phys 2004;60:388–394.
Median follow-up: 34 moths for SRS, 18 months for SRT 1- and 3-y local failure-free survival (p=0.003): SRS: 70%、51%； SRT：91%、83% 1- and 3-y overall survival (p=0.31): SRS: 98%、66%； SRT：78%、61%
结论： 1. 局部复发鼻咽癌的再程放疗能够使相当多的病 人生存延长 2. 颅内受侵、颅神经麻痹、再放疗剂量影响预后 3. 剂量≥50Gy显著提高生存 4. 适形放疗可能减少严重并发症的发生
Chang JT, et al. Radiother Oncol 2000;54:135-142
Stereotactic Radiosurgery & Stereotactic Radiotherapy
Wang CC. Int J Radiat Oncol Biol Phys 1987;13:953–956. Lee AWM, et al. Int J Radiat Oncol Biol Phys 1997;38:43–52
Conventional Radiation Therapy
Turkey study
All boost doses were delivered as 3 fractions per week


Results: 36 pts enrolled Overall: 3-y OS: 65%, local recurrence-free survival: 45% 3-y distant metastasis: 10% 3-y local recurrence-free survival Arm I: 30%, Arm II: 28%, Arm III: 80% (p=0.047)



随着手术方式的改进和化疗药物的研究进展， 局部复发鼻咽癌的治疗取得了一定的疗效 手术治疗病人具有高选择性，对技术要求高 化疗可获得60%-70%部分或晚期缓解，但很少 能获得长期肿瘤控制 再程放疗仍然是局部复发鼻咽癌挽救治疗最有 效的治疗手段Lu T, et al. Int J Radiat Oncol Biol Phys 2004;58:682–687
结论：在局部失败鼻咽癌的挽救治疗方面，SRT 优于SRS，特别是对复发和rT2-4病例
Chua D, et al. Int J Radiat Oncol Biol Phys 2007;69(suppl):S442.
Three-dimensional Conformal Radiotherapy (3DCRT)
Actuarial overall survival by total reirradiation dose Actuarial overall survival by interval to recurrence ＞18months vs. ＜18months (5-y OS: 41% vs. 16%， 60Gy vs. ＜60Gy (5-y OS: 46% vs. 14%，p=0.01) p=0.053) Oksuz DC, et al. Int J Radiat Oncol Biol Phys 2004;60:388–394.
Schema Arm 1: 3DCRT boost: 16Gy(4Gy×4fx) Pts randomization having finishing smallfield RT
Arm 2: 3DCRT boost: 20Gy(4Gy×5fx)
Arm 3: 3DCRT boost: 24Gy(4Gy×6fx)


单因素分析： 年龄、放疗剂量是局部无进展生存显著预后因子。 年龄、放疗剂量、总分期、T分期是总生存的显著 预后因子 多因素分析： 总剂量是局部无进展生存显著预后因子。 总剂量、复发间隔、分期是总生存的显著预后因子
Oksuz DC, et al. Int J Radiat Oncol Biol Phys 2004;60:388–394.



3-y distant metastasis: Arm I: 17%, Arm II: 0, Arm III: 18% (p=0.35) 3-y overall survival: Arm I: 72%, Arm II: 59%, Arm III: 82% (p=0.60) Univariate analysis: skull base invasion and histology were prognostic factor for overall survival
REIRRADIATION FOR LOCALLY RECURRENT NASOPHARYNGEAL CARCINOMA
陆合明 广西壮族自治区人民医院临床肿瘤中心放疗科
局部复发鼻咽癌的再程放疗
概述
鼻咽癌是放射敏感性肿瘤，放疗可以获得良好 的局部区域控制率 对于T晚期病例，局部复发仍然是主要的失败 模式 5年局部复发率为15%-58%