Intensity-modulated Radiation Therapy in Treating Unknown Primary Head and Neck Cancer: Single Institute Experience

強度調控放射線治療治療原發部位不明之頭頸癌：單一機構經驗

賴宜君(I-Chun Lai) ； 蕭志柔(Chih-Jo Hsiao) ； 胡育文(Yu-Wen Hu) ； 朱本元(Pen-Yuan Chu) ； 何青吟(Ching-Yin Ho) ； 許彥彬(Yen-Bin Hsu) ； 邱宗傑(Tzeon-Jye Chiou) ； 楊慕華(Mu-Hua Yang) ； 鄧豪偉(Hao-Wei Teng) ； 李永賢(Wing-Yin Li) ； 顏上惠(Sang-Hue Yen) ； 王令瑋(Ling-Wei Wang)

《放射治療與腫瘤學》 19卷3期 (2012/09) Pp. 213-226

https://doi.org/10.6316/TRO/201219(3)213

摘要

目的：回溯性研究原發部位不明之頭頸癌經強度調控放射線治療之結果。材料及方法：從2005年至2010年間，共14位診斷原發部位不明之頭頸部麟狀上皮癌之病人轉介至本科接受強度調控放射治療。年齡中位數為48歲（間距為33 至67歲）。臨床N期N1, N2a, N2b及N3分別有1（7%）, 3（21%）, 6（43%）及4（29%）人。其中十二位病人（86%）接受頸部淋巴廓清術，兩位僅接受淋巴切片而已。有五位病人（36%）之淋巴轉移到下頸部，另外九位（64%）病人之病灶僅侷限在上頸部。有五位病人之淋巴結有囊外擴散之情形。在接受頸部廓清術的病人，在具有囊外擴散的範園給予66 Gy之劑量，沒有囊外擴散者給予60 Gy。對於僅接受淋巴切除的人，原病灶處則給予70 Gy的劑量。所有的病人，在咽軸接受59.4 Gy，而未被轉移淋巴侵犯的下頸部則接受到50 Gy。本研究照射之咽軸，包含鼻咽、口咽、下咽部上方黏膜，避開了聲帶及其後下方之下咽部黏膜。結果：經過36.4個月的追蹤，四位病人（21%）有遠端轉移並且死亡，三年的整體存活率及遠端轉移無病存活率為79%。在追蹤期間沒有原發腫瘤之出現，亦沒有局部復發，三年局部控制率為100%。兩位病人有第二原發腫瘤之產生，一個在上食道，一個在口腔黏膜。在亞組分析上，當病人為臨床N3期（p=0.036; p=0.016）、淋巴轉移至下頸部（p=0.001; p=0.001）或具有囊外擴散者（p=0.003; p=0.007），有較低的整體存活率及遠端轉移無病存活率。對於N2b或N3期病人，僅接受淋巴切除者相較於接受淋巴廓清術之患者，具有較差的整體活率（p=0.001）和遠端轉移無病存活率（p=0.029）。在副作用方面，五位病人（36%）有第三級急性副作用，其中四位是口腔黏膜發炎或白血球過低，有一位兩者都發生。這些病人中，有八成的患者接受了同步放化療。追蹤至目前為止，沒有第三級以上之慢性副作用產生。結論：在我們的經驗中，強度調控放射治療並且閃避聲帶及下咽下半部位，不但可以降低副作用，同時不會犧牲疾病控制率。是一個可以被用在原發部位不明頭頸部麟狀上皮癌病患上之安全又有效的治療。對於N3期、下頸部淋巴轉移以及淋巴具有囊外擴散之病人，有較差之整體存活率及遠端轉移無病存活率。針對這群病人，應發展更強效的治療方針。

關鍵字

原發部位不明腫瘤 ； 頭頸部癌症 ； 強度調控放射治療

並列摘要

Purpose: To retrospectively review the results of patients with metastatic squamous cell carcinoma of the head and neck (SCCHN) from an unknown primary site (UPS) treated with intensity-modulated radiation therapy (IMRT) in a single institute.Methods and Materials: Fourteen male patients with a median age of 48 (range 33 to 67) who presented with unknown primary SCCHN were treated with IMRT with or without cisplatin-based chemotherapy from 2005 to 2010. The number of patients with initial presentation of N1, N2a, N2b and N3 was, 1 (7%), 3 (21%), 6 (43%) and 4 (29%), respectively. Twelve patients (86%) received neck dissections and two had excision biopsies only. Five patients (36%) had metastatic nodes involving both upper and lower neck, where 9 (64%) had nodes limited to the upper neck only. Five (36%) patients presented with extracapsular spread (ECS). Patients undergoing neck dissection were treated with a median dose of 66 Gy to the ECS surgical bed. Those who did not undergo neck dissection were given 60 Gy. For those who had only excision biopsy, 70 Gy was prescribed to the tumor bed and suspected Iymphadenopathy. For all patients, a median dose of 59.4 Gy and 50 Gy was given to the pharyngeal mucosa and uninvolved lower neck, respectively. The irradiated pharyngeal mucosa, included the nasopharynx, oropharynx, surpaglottis and upper hypopharynx, but spared the vocal cords and lower hypopharynx.Results: After a median follow up of 36.4 months, four patients (21%) developed distant metastases and died, yielding a 3-year overall survival rate of 79%. There was no occurrence of the occult primary and no local regional recurrence noted. The control rate was 100%. Two patients had second primary tumors noted over the cervical esophagus and the buccal mucosa. In subgroup analysis, patients with clinical N3 stage, with nodal involvement over the lower neck region and nodes possessing ECS had significantly poorer overall survival and poor distant metastases-free survival rates. In patients with cN2 or cN3 disease, those receiving excision biopsy had a poor overall survival (p=0.001) and distant metastases-free survival (p=0.029) compared to those undergoing neck dissection. There was no grade III chronic toxicity during follow-up.Conclusions: In our experience, IMRT with vocal cords and lower hypopharyngeal sparing can achieve excellent functional outcomes without compromising disease control and may be adopted as a safe and effective treatment for SCCHN of UPS Patients with clinical N3 stage, lower neck involvement and nodes with ECS have significantly poorer overall survival and distant metastases-free survival rates. More intense regimens should be developed for such patients.

並列關鍵字

Unknown primary neoplasm ； Head and neck cancer ； Intensity modulated radiation therapy