Jansen E P, Keus R B, Hilgers F J, Haas R L, Tan I B, Bartelink H
Department of Radiation Oncology, The Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands.
Int J Radiat Oncol Biol Phys. 2000 Aug 1;48(1):27-35. doi: 10.1016/s0360-3016(00)00594-0.
To determine the contribution of debulking surgery on local control and survival in paranasal sinus tumors. As most patients present with locally advanced disease, the possibility of radical surgery is limited. Consequently, radiotherapy is often needed as monotherapy or as an adjunct to surgery.
Between 1977 and 1996, 73 patients (50 male: 23 female) with a paranasal sinus carcinoma were treated. The histology distribution was as follows: squamous cell carcinoma, 55%; adenocarcinoma, 19%; adenoid cystic carcinoma, 11%; and undifferentiated carcinoma, 15%. The clinical T classification was (UICC/TNM 1997): T2 14%, T3 27%, and T4 59%. Pathological neck nodes were found in 11% of patients. Treatment consisted of surgery only in 3, chemotherapy only in 1, radiotherapy only in 18, both surgery and radiotherapy in 50 patients. One patient did not receive any treatment at all. Three patients had concurrent chemotherapy. Median follow-up was 66 months (range, 1-213 months).
Five-year local control (LC) was 65% with combination of radiotherapy and debulking surgery in comparison with 47% with radiotherapy alone, but this difference was not statistically significant (p = 0.58). However, combination treatment gave significantly better 5-year overall survival (OS) (60% vs. 9%; p = 0.001) and 5-year disease-free survival (DFS) (53% vs. 6%; p < 0. 0001). Cox-regression analysis showed that pathologic N status (p = 0.04), palliative intention of treatment (p = 0.018), clinical orbital invasion (p = 0.003), and orbital wall invasion (p = 0.003) were parameters significantly associated with poor local control. Total radiation dose of greater than 65 Gy (p = 0.05) and treatment consisting of radiotherapy alone (p = 0.002) were associated with worse overall survival; for disease-free survival clinical orbital invasion (p = 0.0005), age of greater than 65 years (p = 0.013) and pathologic T4 classification (p = 0.002) were significant factors for an unfavorable outcome. In 19 of 73 patients, 26 serious (mainly ophthalmological) complications were reported; in the majority of these, the visual tract was (partly) included in the treatment fields because of tumor extension. To analyze on which basis patients were selected for the combination therapy, a logistic regression was performed, concluding that clinical T4 classification (p = 0.05), radiological evidence of skull base invasion (p = 0.005), age of greater than 65 years (p = 0.026), radiological evidence of nasopharynx invasion (p = 0.02), clinical suspicion of palate invasion (p = 0.02), and radiological evidence of skin invasion (p = 0.009) were associated with choosing radiotherapy alone.
Debulking surgery of paranasal sinus malignancies followed by high-dose radiotherapy to the involved sites was associated with better survival and (although not statistically significant) local control. Patient selection, based on clinical and radiological impression of tumor extension, was the main factor explaining these favorable results. We favor this combination regimen because the surgery gives quick relief of complaints and, at the same time, offers an excellent histologically proven staging method, enabling radiotherapy to be adjusted to the involved sites, thereby decreasing the risk of complications. This can all be achieved with a very low orbital exenteration rate.
确定鼻窦肿瘤减瘤手术对局部控制和生存的贡献。由于大多数患者就诊时已处于局部晚期疾病，根治性手术的可能性有限。因此，放疗常作为单一疗法或手术辅助手段。
1977年至1996年间，对73例（50例男性，23例女性）鼻窦癌患者进行了治疗。组织学分布如下：鳞状细胞癌55%；腺癌19%；腺样囊性癌11%；未分化癌15%。临床T分类为（UICC/TNM 1997）：T2 14%，T3 27%，T4 59%。11%的患者发现有病理颈部淋巴结转移。治疗方案包括仅手术治疗3例，仅化疗1例，仅放疗18例，手术和放疗联合治疗50例。1例患者未接受任何治疗。3例患者接受了同步化疗。中位随访时间为66个月（范围1 - 213个月）。
放疗与减瘤手术联合治疗的5年局部控制率（LC）为65%，单纯放疗为47%，但差异无统计学意义（p = 0.58）。然而，联合治疗的5年总生存率（OS）显著更高（60%对9%；p = 0.001），5年无病生存率（DFS）也显著更高（53%对6%；p < 0.0001）。Cox回归分析显示，病理N状态（p = 0.04）、治疗的姑息意图（p = 0.018）、临床眼眶侵犯（p = 0.003）和眼眶壁侵犯（p = 0.003）是与局部控制不良显著相关的参数。总放射剂量大于65 Gy（p = 0.05）和仅放疗的治疗方式（p = 0.002）与总生存率较差相关；对于无病生存率，临床眼眶侵犯（p = 0.0005）、年龄大于65岁（p = 0.013）和病理T4分类（p = 0.002）是预后不良的重要因素。73例患者中有19例报告了26例严重（主要是眼科）并发症；其中大多数情况下，由于肿瘤扩展，视路（部分）被纳入治疗野。为分析选择联合治疗的患者依据，进行了逻辑回归分析，得出临床T4分类（p = 0.05）、颅底侵犯的放射学证据（p = 0.005）、年龄大于65岁（p = 0.026）、鼻咽侵犯的放射学证据（p = 0.02）、临床怀疑腭部侵犯（p = 0.02）和皮肤侵犯的放射学证据（p = 0.009）与选择单纯放疗相关。
鼻窦恶性肿瘤减瘤手术后对受累部位进行高剂量放疗与更好的生存率以及（虽无统计学意义）局部控制相关。基于肿瘤扩展的临床和放射学印象进行患者选择是解释这些良好结果的主要因素。我们支持这种联合治疗方案，因为手术能迅速缓解症状，同时提供一种经组织学证实的出色分期方法，使放疗能根据受累部位进行调整，从而降低并发症风险。这一切都能在极低的眼眶内容摘除率下实现。
