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摘要: 目的 探讨复发性鼻咽癌分别采用手术治疗+化疗及放疗+化疗的临床效果及并发症的对比，从而比较两种不同治疗方法的安全性及治疗效果。方法 回顾性分析2016年1月－2020年10月我院收治的40例鼻咽癌放化疗后复发的患者，其中26例(观察组)鼻内镜下切除复发的肿瘤的患者，术中冷冻切缘均为阴性，同期采用带蒂的鼻中隔黏膜瓣、颞肌瓣以及颏下瓣进行修复，rT3及rT4患者术后3~5周继续化疗。以14例采用二次放疗+化疗的方案的患者作为对照组。术后观察患者的并发症及生存率。结果 观察组26例患者中19例行鼻中隔黏膜瓣修复，5例行颞肌瓣修复，2例行颏下瓣修复，2例鼻中隔黏膜瓣出现坏死及脑脊液鼻漏，二期手术用颞肌瓣进行二次修复，8例需要行颈部淋巴结清扫术。患者术后恢复良好，rT3及rT4患者根据伤口情况术后3~5周进行化疗。比较2组并发症发生率及1~3年的生存率，差异均有统计学意义(P < 0.05)。结论 复发性鼻咽癌患者可以通过鼻内镜下手术治疗切除肿物，并且采用带蒂的鼻中隔黏膜瓣、颞肌瓣以及颏下瓣进行颅底重建，可以有效地预防颈内动脉破裂大出血等重大并发症，提高患者生存率及生活质量。为复发性鼻咽癌患者提供了一种安全、有效的治疗方式。Abstract: Objective To compare the clinical effects and complications of surgery + chemotherapy and radiotherapy + chemotherapy in patients with nasopharyngeal carcinoma recurrence, so as to compare the safety and efficacy of two different therapeutic methods.Methods A retrospective analysis was performed on 40 patients with recurrent nasopharyngeal carcinoma after radiotherapy and chemotherapy admitted to our hospital from January 2016 to June 2020. Among them, 26 patients were treated with surgery. The recurrent tumor was removed under nasal endoscope, and the frozen resection margin was negative during the operation. Chemotherapy was continued for stage Ⅲ and Ⅳ patients from 3 to 5 weeks after surgery. Fourteen patients received secondary radiotherapy and chemotherapy. Postoperative complications and survival rate were observed.Results There were 14 patients in the secondary chemoradiotherapy group(control group) and 26 patients in the nasal endoscopic surgery group(observation group). Among the 26 patients, 19 patients underwent nasal septal mucosal repair, 5 patients underwent temporal muscle flap repair, 2 patients underwent submental flap repair, 2 patients had nasal septal mucosal flap necrosis and cerebrospinal fluid leakage, and the temporal muscle flap was used for secondary repair in the second stage operation, and 8 patients needed cervical lymph node dissection. The patients recovered well after surgery, and the patients in stage Ⅲ and Ⅳ were treated with chemotherapy after 3 weeks to 5 weeks according to the patient's wound condition. There were significant differences in the incidence of complications and 1-, 2-, and 3-year survival rates between the two groups(P < 0.05).Conclusion Patients with recurrent nasopharyngeal carcinoma can be treated by nasal endoscopic surgery to remove the tumor, and the use of pedicled nasal septal mucosal flap or temporal muscle flap for skull base reconstruction, The operation can effectively prevent major complications such as internal carotid artery rupture and hemorrhage, and improve the survival rate and quality of life of patients. It provides a safe and effective treatment for patients with recurrent nasopharyngeal carcinoma.
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表 1 观察组与对照组患者一般资料比较
基本资料 观察组 对照组 χ2或t P 性别(男/女) 14/12 8/6 0.040 0.842 年龄/岁 58.0±7.2 60.0±6.7 0.858 0.400 首次放疗时间/月 42.0±6.8 41.0±5.6 0.470 0.641 病理/例 0.101 0.750 非角化性未分化型癌 18 9 鳞状细胞癌 8 5 T分期/例 0.586 0.899 rT1期 3 2 rT2期 7 3 rT3期 14 7 rT4期 2 2 N分期/例 0.064 0.969 rN0期 21 11 rN1期 3 2 rN2期 2 1 
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表 2 2组患者并发症比较
例 并发症 观察组 对照组 χ2或校正χ2 P 张口受限 2 8 9.38 < 0.01 吞咽困难 2 9 11.92 < 0.01 中重度贫血 3 5 2.38 0.123 颞叶坏死 0 4 5.38 0.020 颅底坏死或脑脊液漏 2 6 5.01 0.025 头颈部疼痛 2 10 14.70 < 0.01 咽干 1 12 24.19 < 0.01 鼻咽大出血 0 4 5.39 0.02
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表 3 2组患者生存率比较
例(%) 组别 例数 1年 2年 3年 观察组 26 24(92.31) 22(84.61) 17(65.39) 对照组 14 9(64.29) 6(42.86) 3(21.42) χ2或校正χ2 4.95 5.70 7.03 P 0.026 0.017 ＜0.01
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