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Nasopharyngeal Carcinoma with Postradiation Nasopharyngeal Necrosis-Case Report

鼻咽癌放射治療後鼻咽壞死-病例報告

摘要


Radiotherapy is an effective treatment for nasopharyngeal carcinoma. However, irradiation has many acute and chronic side effects. Postradiation nasopharyngeal necrosis (PRNN) is necrosis of the surrounding and affiliated tissues of the nasopharynx, including the mucosa, muscle, and skull base. The necrosis can occur several months or years after radiotherapy and becomes life-threatening when the carotid sheath is involved. A 63-year-old woman was diagnosed with stage IV nasopharyngeal carcinoma and underwent concurrent chemoradiotherapy with adjuvant chemotherapy. The tumor recurred 9 months later, and she underwent left modified radical neck dissection and laser-assisted nasopharyngectomy. She also received postoperative cetuximab-based bioradiotherapy. After radiotherapy, endoscopic examination revealed necrosis of the soft tissue and accumulation of pus in the left side of the nasopharynx. The patient received regular endoscopic local treatment and antibiotic treatment, but the necrosis and pus persisted. Four months after surgery, she was admitted to our hospital due to severe left-sided headache. Magnetic resonance imaging showed a soft tissue lesion in the left side of the nasopharynx, suspected to be extensive nasopharyngeal necrosis or tumor recurrence. Transnasal endoscopic biopsy and debridement was performed, but massive bleeding occurred due to internal carotid artery rupture during tissue dissection of the parapharyngeal space. Hemostasis was achieved after local compression. A pedicled posterior nasoseptal flap was created to cover the raw surface of the nasopharynx. Postoperative computed tomography and angiography showed a pseudoaneurysm in the left internal carotid artery, and a stent was placed. However, the patient died of hydrocephalus caused by suspected infection of the central nervous system. Patients with PRNN should be carefully assessed before surgery, especially those with carotid artery involvement.

並列摘要


於鼻咽癌而言,放射治療為有效的治療方式,但卻可能造成許多急性與慢性的副作用。放射治療後鼻咽壞死為鼻咽及周遭組織壞死,包含黏膜、肌肉及顱底;壞死可發生於放射治療數月或數年之後,當壞死侵犯到頸動脈鞘時易危及生命。本案例為1名63歲女性,診斷為鼻咽癌第四期而接受同步化學併放射治療,再接受輔助性化學治療;9個月後腫瘤復發,病患接受左側頸部淋巴廓清術及左側鼻咽切除術,術後接受標靶併放射治療。完成放射治療後門診追蹤時,內視鏡檢查發現左側鼻咽壞死蓄膿,且對局部治療及抗生素反應不佳,術後4個月病患因嚴重左側頭痛入院,核磁共振影像顯示左側鼻咽病變,疑似廣泛性鼻咽壞死或腫瘤復發,之後執行左側鼻咽切片併清創手術,術中因內頸動脈破裂大量出血,經壓迫止血及後鼻中膈皮瓣覆蓋鼻咽傷口,出血獲得控制,然而,術後電腦斷層及血管攝影顯示左側內頸動脈假性動脈瘤,隨即放置內頸動脈支架,最後病患因疑似中樞神經感染引發水腦症而死亡。針對放射治療後鼻咽壞死此臨床狀況,在進行手術前應審慎評估,尤其是對於內頸動脈有受影響之病患。

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