| Background and ObjectiveNasopharyngeal carcinoma is a common malignant tumor in southern China, especially in Guangdong province. The exact etiology of nasopharyngeal carcinoma is unclear, which is considered to be related to genetic factors, viral infections, environmental factors, eating habits and so on. According to statistics, male incidence of NPC is two-three times as high as that female, and40-50years-old is high-incidence group of nasopharyngeal carcinoma. Surgery has difficulty in excising malignant tumor completely because of its deep location and surrounded by a lot of important organizations and tissues. In our country, more than90%of nasopharyngeal carcinoma (NPC) is non-keratinising undifferentiated carcinoma, which is extremely sensitive to radiation therapy. Therefore, Radiotherapy (RT) is the primary treatment for nasopharyngeal carcinoma (NPC) due to its anatomy and biology characteristic.Radiotherapy methods of nasopharyngeal carcinoma mainly include conventional radiation therapy and intensity-modulated radiation therapy. Conventional radiation usually treats with large lateral opposing faciocervical fields which has a big target area and inevitably covers a great amount of normal tissues. Therefore, conventional radiation usually results in undesirable curative effect and serious complications. However, conventional radiotherapy is still very important in our country because of the poor economic level. Intensity-modulated radiation therapy(IMRT) is a new radiotherapy technology which developed rapidly in the90s and has the advantage of radiation field highly adapted to the target area and the dose in the target area evenly distributed. Compared with conventional radiotherapy, intensity-modulated radiation therapy can improve the curative effect and protect the normal tissues surrounded by the nasopharynx effectively.While the therapeutic result of patients with early nasopharyngeal carcinoma treated with radiotherapy alone is desirable which has the5-year survival rate more than90%, most patients with NPC are diagnosed only when the tumor has reached an advanced stage (stages â…¢ and â…£) due to the non-specific nature of the nasal and aural early symptoms, the difficulty of making a clinical examination of the nasopharynx and the deep location of NPC. The treatment effect of patients with locally advanced nasopharyngeal treated with radiotherapy alone is poor. A great amount of papers reported has showed that treatment failure is due mainly to distant metastasis. Radiotherapy is local treatment which can’t effectively kill distant metastasis cancer cells, whereas the chemotherapy is systemic treatment which has advantage in killing distant metastasis cancer cells. Radiotherapy with concomitant chemotherapy has increased the overall survival of patients with local advanced nasopharyngeal carcinoma, however the side effects of chemoradiation are serious caused poor tolerability and lower completion rate of chemotherapy. Induction chemotherapy is applied before radiotherapy when patient general condition is good; therefore, the durability and treatment adherence of patients are good. At the same time, induction chemotherapy does not significantly crease the side effects of radiotherapy. Induction chemotherapy has preliminary showed advantage in improving survival rates in patients with locally advanced nasopharyngeal carcinoma. Therefore, induction chemotherapy+radiotherapy and chemoradiation are the two combination modalities that may result in survival benefit; however, it remains unknown whether sequential application of Induction chemotherapy+radiotherapy and chemoradiation will lead to further improvement of the survival rate.Compared with most of the other malignant tumors, the curative effect of nasopharyngeal carcinoma is good, which has a long-term survival rate. Along with good survival benefits obtained, how to improve the quality of life of patients is taken seriously day by day. Various complications are often caused by radiotherapy, such as secretory otitis media, nasal cavity adhesion, dry mouth, radiation encephalopathy, cranial nerve injury and so on, which seriously affect the quality of life of patients. How to reduce the complications of patients with nasopharyngeal carcinoma caused by radiotherapy and take good measures to treat the complications has become another important challenge.To offer clinical data to explore how to improve the curative effect, reduce the complications after radiotherapy and improve quality of life of patients with locally advanced nasopharyngeal carcinoma, this study compared the curative effect and complications of patients with nasopharyngeal carcinoma (NPC) treated with different therapeutic regimens, adopted tympanic cavity catheter method to prevent secretory otitis media and took operation to treat nasal adhesion after radiation therapy.Methods1. The curative effect and complications of95patients with newly diagnosed nasopharyngeal carcinomaThis study retrospectively analyzed the treatment effect and complications of95patients with newly diagnosed nasopharyngeal carcinoma treated during April2008to December2010in the department of Otolaryngology head and neck surgery, Zhu Jiang hospital, Southern medical university.95patients were divided into three groups:1.neoadjuvant chemotherapy plus concurrent chemoradiation (intensity-modulated radiation therapy)[(NA+CCRT(IMRT),n=20];2.neoadjuvant chemotherapy plus concurrent chemoradiation (conventional radiotherapy)[NA+CCRT(2DRT),n=50];3.neoadjuvant chemotherapy plus radiation therapy (conventional radiation therapy)[(NA+RT(2DRT),n=25]. All patients were treated the same neoadjuvant chemotherapy regimen:platinum (cisplatin or Nedaplatin)+5-FU (cisplatin or Nedaplatin60-100mg/m2d1+5-FU500-1000mg/m2d2-5); some of these patients were combined with Docetaxe or cyclophosphamide on the basis of that (T60-75mg/m2d1/CTX1.2-1.4g/m2d1). Cisplatin was applied every three weeks or one week (50-80mg/m2or20-40mg/m2) during radiotherapy. Group1were applied intensity-modulated radiation therapy and group2and3were applied conventional radiotherapy. All patients received radiotherapy after neoadjuvant chemotherapy within5to15days and were irradiated using linear accelerator6MV photon irradiation. In the conventional radiotherapy group (group2+group3,n=75) faciocervical portals were exposed to36-40Gy in the first course. In the second course, faciocervical splitting portals were exposed to the total dose (66-78Gy), and spinal cord was not irradiated. Conventional fractionated radiotherapy (2Gy once daily,5times per week) was applied in all cases in the conventional radiotherapy group, a dose of66-78Gy was given to the primary tumor and60-66Gy to the involved neck nodes, whereas the dose for prophylactic treatment for a node-negative neck is50-54Gy. In the IMRT group (group1, n=20), the gross target volume (GTV) was given prescription Dose68-72Gy with2.2-2.4Gy once daily and5times per week.2. Tympanostomy tube placement to prevent secretory otitis media in patients with nasopharyngeal carcinoma after radiotherapy. Fifty-sixth nasopharyngeal carcinoma patients were randomly divided into two groups:the bilateral ventilating tube insertion group (n=27) and the control group (n=29) before conventional radiotherapy. The incidences of SOM in two groups were calculated and analyzed one year after radiotherapy.3. Nasal endoscopic surgery of nasal adhesion after radiotherapyBetween April2008to December2010,95patients with newly diagnosed nasopharyngeal carcinoma were treated in the department of Otolaryngology head and neck surgery, zhu jiang hospital, Southern medical university,27cases out of them complicated with nasal adhesion after radiotherapy [25cases in the2DRT group(group2+group3) and2cases in the IMRT group(groupl)].The nasopharyngeal CT examination showed:the gap between middle septum and nasal turbinate disappeared and was replaced by soft tissue density shadow, and the space between the nasopharyngeal and total nasal passages was completely cut off by soft tissue density shadow in some cases. Nasal endoscopic examination showed:back-end of inferior turbinate and middle turbinate adhesion with middle septum, the gap of total nasal cavity narrowed, absolute choanal atresia occurred in some patients, a large amount of purulent secretion was observed in nasal passages in cases complicated with nasal sinusitis. Most of the patients have various symptoms such as nasal obstruction, discharge, hyposmia and so on. All cases were operated under nasal endoscopic surgery.Results1. The curative effect of95patients with newly diagnosed nasopharyngeal carcinomaTwo-year overall survival rate, local relapse-free survival rate and distant metastasis-free survival rate were100%,95%and95%in the NA+CCRT(IMRT) group, respectively; the2-year corresponding rates were96%,96%and90%in the NA+CCRT(2DRT) group and96%,100%and76%in the NA+2DRT group, respectively. No significant difference in overall survival rate, local relapse-free survival rate and distant metastasis-free survival rate was found between NA+CCRT(IMRT) and NA+CCRT(2DRT)(p>0.05);there was no significant difference in overall survival rate, local relapse-free survival rate and distant metastasis-free survival rate between NA+CCRT(2DRT) and NA+2DRT (p>0.05)2. The complications of95patients with newly diagnosed nasopharyngeal carcinomaGrade1,2and3acute radioactive mucositis were observed in20%,60%å'Œ20%of patients of IMRT respectively, no grade4acute radioactive mucositis was found, the corresponding rates were9.3%,40%,48%and2.7%in the2DRT group respectively. There was significant difference in grade3acute radioactive mucositis between the two groups (x2=4.21,p<0.05). The incidence of grade1,2and3acute radioactive dermatitis of IMRT were55%,35%and10%respectively, no grade4case occurred; the corresponding rates were16%,46.7%,36%and1.3%in the2DRTgroup respectively. Significant difference was found in grade3acute radioactive dermatitis between2DRT group and IMRT group (x2=4.81,p<0.05)Secretory otitis media, nasal cavity adhesion, radiation encephalopathy, and dry mouth reaction were observed in80(ear),25,3, and75cases in the2DRT group respectively, corresponding incidences were8(ear),2,1and11cases in the IMRT group, respectively. The late complications after radiotherapy such as secretory otitis media, nasal cavity adhesion and dry mouth of IMRT group were significant lower than the2DRT group(p<0.05); the incidence of radiation encephalopathy was similar between IMRT group and2DRT group (5%vs4%), there was no significant difference ((x2=0.35,P>0.05)3. Tympanostomy tube placement to prevent secretory otitis media in patients with nasopharyngeal carcinoma after radiotherapyOne year after radiotherapy, the incidences of SOM in ventilating tube insertion and the control groups were22.22%and62.07%, respectively. There was difference in two groups (X=9.065, P<0.01).The ventilating tube insertion group had no obvious adverse reaction.4. Nasal endoscopic surgery of Nasal adhesion after radiotherapyTwenty six cases were cured after the first operation and the remaining one was cured after repeated four times operation.Conclusions1. Compared with the NA+CCRT (2DRT) program, the NA+CCRT (IMRT) program used in this study did not improve the survival rate in patients with nasopharyngeal carcinoma. There was no significant difference in survival rate between NA+CCRT (2DRT) program and NA+2DRT program. Compared with the NA+2DRT program, distant metastasis-free survival rate in the NA+CCRT (2DRT) group obviously improved (90%vs76%).2. Compared with2DRT, IMRT can effectively reduce the complications after radiation therapy and improve the quality of life of patients with nasopharyngeal carcinoma.3. The ventilating tube insertion pre-irradiation could effectively decrease the incidence of SOM and might reduce the risk of adhesion in Tympani cavity in the future in patients with NPC after conventional radiotherapy.4. Nasal endoscopic surgery is the best way to treat nasal adhesion after radiation therapy of NPC. |
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