下咽癌侵犯颈段食管的治疗
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摘要
目的探讨下咽癌侵犯颈段食管的最佳治疗方案和处理经验。方法通过回顾性分析71例累及颈段食管的下咽癌患者临床资料,总结几种安全有效的治疗方式。71例均行颈淋巴结清扫术,切除患侧甲状腺37例,保留喉功能28例,全喉切除气管造瘘31例,喉气管代下咽食管12例。消化道重建方法有胸大肌肌皮瓣22例、喉气管瓣修复12例、裂层皮片或生物修复膜+胸大肌肌皮瓣6例,全食管切除后胃或结肠代食管31例。术后接受局部放疗(55~70 GY)65例。结果术后病理均为鳞状细胞癌,其中高、中、低分化分别为21例、18例、32例。淋巴结转移率45.2%,切除甲状腺37例中病理查见肿瘤14例,占比37.8%,甲状腺受侵犯占总病例19.7%。喉功能保留占39.4%,保留喉功能的患者中拔管率67.8%,术后咽瘘12例,刀口感染2例,吻合口狭窄1例。kaplan-meier生存率统计所有病例总的3年和5年无瘤生存率为43.7%和23.9%,其中喉功能保留组分别为50%和28.6%,喉功能不保留组分别为39.5%和20.9%。两组比较差异无统计学意义(χ2=1.244,P=0.265)。结论下咽癌侵犯颈段食管的治疗以手术+放疗的综合治疗为主,胸大肌肌皮瓣、喉气管瓣、全食管切除胃或结肠代食管的手术方式安全有效,部分患者采用合适的手术方式可以保留喉功能。
Objective To explore the best treatment plan and treatment experience of the cervical esophagus invasion of cervical esophagus. Methods From2001 to 2012,seventy-one patients with advanced hypopharyngeal cancer and cervical esophageal invasion were retrospectively reviewed to summarize several safe and effective treatment methods,including 64 males and 7 females. The medianage was 56. 8 years old,ranged from 36 to77 years old. According to AJCC2002 criteria,all the tumors were T4 stage and originated from the pyriform sinus( 51),posterior pharyngeal wall( 18),post cricoid area( 2),there were 44 patient sinc N0,4 in c N1,20 in c N2,3 in c N3 and no distant metastasis. Precise preoperative evaluation was performed with computed tomography scan,barium swallowperspective and biopsy. All the patients received neck dissection,including both unilateral( 57 patients) and bilateral( 14 patients). Pharyngoesophageal defect reconstruction methods were: pectoralis major musculocutaneous flap in 22 patients,laryngotracheal flap in 11,pectoralis major musculocutaneous flap combined with split thickness skin graft in 6,stomach pulling-up or coloninterpositionin in 31 patients. Total laryngectomy was carried out in 31 patients. 65 patients received radio therapy postoperatively( dose55-70 Gy). Results The cervical lymph node metastasis rate was 45. 1%. In 28 patients whose laryngeal function was preserved,the trachea cannula was extracted in 19 patients,with the decanulation rate as 67. 8%. A total of 37 patients underwent thyroidectomy,14 cases of postoperative patients with pathologically confirmed thyroid invasion. The common complications after surgery with pharyngeal fistula in 12 cases,2 cases of incision infection,anastomotic stenosis in 1 cases. The 3 years and 5 years disease-free survival rate in all patients were 43. 7%and 23. 9% which calculated by Kaplan-Meier methods. The 3 years and 5 years disease-free survival rate of laryngeal function preservation group were 50% and 28. 6%,while in non-functionally preserved group were 39. 5% and 20. 9%.There was no significantly different between the two groups( χ2= 1. 244,P = 0. 265). Conclusion Combined therapywas the best choice for hypopharyngeal cancer with cervical esophageal invasion. The continuity of the pharyngoesophagus was restored by laryngotracheal flap,pectoralis major muculocutaneous flap or with split thickness skin graft. Stomach trans-position or colon interposition was used while the defect of the esophagus was greater. All of those operation methods were safe and effective. Some patients with appropriate surgical procedures can retain the patient's laryngeal function.
Objective To explore the best treatment plan and treatment experience of the cervical esophagus invasion of cervical esophagus. Methods From2001 to 2012,seventy-one patients with advanced hypopharyngeal cancer and cervical esophageal invasion were retrospectively reviewed to summarize several safe and effective treatment methods,including 64 males and 7 females. The medianage was 56. 8 years old,ranged from 36 to77 years old. According to AJCC2002 criteria,all the tumors were T4 stage and originated from the pyriform sinus( 51),posterior pharyngeal wall( 18),post cricoid area( 2),there were 44 patient sinc N0,4 in c N1,20 in c N2,3 in c N3 and no distant metastasis. Precise preoperative evaluation was performed with computed tomography scan,barium swallowperspective and biopsy. All the patients received neck dissection,including both unilateral( 57 patients) and bilateral( 14 patients). Pharyngoesophageal defect reconstruction methods were: pectoralis major musculocutaneous flap in 22 patients,laryngotracheal flap in 11,pectoralis major musculocutaneous flap combined with split thickness skin graft in 6,stomach pulling-up or coloninterpositionin in 31 patients. Total laryngectomy was carried out in 31 patients. 65 patients received radio therapy postoperatively( dose55-70 Gy). Results The cervical lymph node metastasis rate was 45. 1%. In 28 patients whose laryngeal function was preserved,the trachea cannula was extracted in 19 patients,with the decanulation rate as 67. 8%. A total of 37 patients underwent thyroidectomy,14 cases of postoperative patients with pathologically confirmed thyroid invasion. The common complications after surgery with pharyngeal fistula in 12 cases,2 cases of incision infection,anastomotic stenosis in 1 cases. The 3 years and 5 years disease-free survival rate in all patients were 43. 7%and 23. 9% which calculated by Kaplan-Meier methods. The 3 years and 5 years disease-free survival rate of laryngeal function preservation group were 50% and 28. 6%,while in non-functionally preserved group were 39. 5% and 20. 9%.There was no significantly different between the two groups( χ2= 1. 244,P = 0. 265). Conclusion Combined therapywas the best choice for hypopharyngeal cancer with cervical esophageal invasion. The continuity of the pharyngoesophagus was restored by laryngotracheal flap,pectoralis major muculocutaneous flap or with split thickness skin graft. Stomach trans-position or colon interposition was used while the defect of the esophagus was greater. All of those operation methods were safe and effective. Some patients with appropriate surgical procedures can retain the patient's laryngeal function.
引文
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[2]王天铎,李学忠,于振坤,等.保留喉功能的下咽癌手术[J].中华耳鼻咽喉科杂志,1999,34(4):4-7.WANG Tianduo,LI Xuezhong,YU Zhenkun,et al.Preservation of laryngeal function in surgical treatment of hypopharyngeal carcinoma[J].Chin J Otorhinolaryngol,1999,34(4):4-7.
[3]李德志,徐震纲,祁永发,等.游离空肠修复下咽及颈段食管肿瘤切除后组织缺损的临床分析[J].中华外科杂志,2006,44(11):733-736.LI Dezhi,XU Zhengang,QI Yongfa,et al.Reconstruction w ith free jejunal interposition for defect after tumor resection of hypopharyngeal and cervical esophageal cancer[J].Chin J Surg,2006,44(11):733-736.
[4]潘新良,雷大鹏,许风雷,等.下咽癌的外科治疗[J].山东大学耳鼻喉眼学报,2007,21(1):1-7.PAN Xinliang,LEI Dapeng,XU Fenglei,et al.Surgical treatment of hypopharyngeal carcinoma[J].J Otolaryngolo Ophthalmol Shandong Univ,2007,21(1):1-7.
[5]雷大鹏,许风雷,张立强,等.下咽癌累及颈段食管的处理[J].中华耳鼻咽喉头颈外科杂志,2005,40(9):58-62.LEI Dapeng,XU Fenglei,ZHANG Liqiang,et al.Surgical treatment of hypopharyngeal cancer w ith cervical esophageal invasion[J].Chin J Otorhinolaryngol Head Neck Surg,2005,40(9):58-62.
[6]潘新良,栾信庸,解光,等.胸大肌肌皮瓣在耳鼻咽喉头颈外科中的应用[J].山东大学耳鼻喉眼学报,2005,19(5):277-282.PAN Xinliang,LUAN Xinyong,XIE Guang,et al.Applieation of pectoralis major myocutaneous flap in otorhinolaryngology&head and neck surgery[J].J Otolaryngol Ophthalmol Shandong Univ,2005,19(5):277-282.
[7]袁英,潘新良,栾信庸,等.下咽后壁癌的手术治疗[J].山东大学耳鼻喉眼学报,2007,21(1):15-19.YUAN Ying,PAN Xinliang,LUAN Xinyong,et al.Surgical treatment for posterior hypopharyngeal w all carcinoma[J].J Otolaryngol Ophthalmol Shandong Univ,2007,21(1):15-19.
[8]Morshed K,Szymański,Goabek.Reconstruction of the hypopharynx w ith U-shaped pectoralis major myocutaneous flap after total pharyngo-laryngectomy[J].Eur Arch Otorhinolaryngol,2005,262(4):259-262.
[9]Espitalier F,Ferron C,Leux C,et al.Results after Ushaped pectoralis major myocutaneous flap reconstruction of circumferential pharyngeal defects[J].Laryngoscope,2012,122(12):2677-2682.
[10]Disa J J,Pusic A L,Hidalgo D A,et al.Microvascular reconstruction of the hypopharynx:defect classification,treatment algorithm,and functional outcome based on165 consecutive cases[J].Plast Reconstr Surg,2003,111(2):652-660.
[11]Sun F,Li X,Lei D,et al.Surgical management of cervical esophageal carcinoma w ith larynx preservation and reconstruction[J].Int J Clin Exp M ed,2014,7(9):2771-2778.
[12]雷大鹏,栾信庸,许风雷,等.颈段食管癌的手术治疗[J].中华耳鼻咽喉科杂志,2002,37(2):9-12.LEI Dapeng,LUAN Xinyong,XU Fenglei,et al.Surgical management of cervical esophageal carcinoma[J].Chin J Otorhinolaryngol,2002,37(2):9-12.
[2]王天铎,李学忠,于振坤,等.保留喉功能的下咽癌手术[J].中华耳鼻咽喉科杂志,1999,34(4):4-7.WANG Tianduo,LI Xuezhong,YU Zhenkun,et al.Preservation of laryngeal function in surgical treatment of hypopharyngeal carcinoma[J].Chin J Otorhinolaryngol,1999,34(4):4-7.
[3]李德志,徐震纲,祁永发,等.游离空肠修复下咽及颈段食管肿瘤切除后组织缺损的临床分析[J].中华外科杂志,2006,44(11):733-736.LI Dezhi,XU Zhengang,QI Yongfa,et al.Reconstruction w ith free jejunal interposition for defect after tumor resection of hypopharyngeal and cervical esophageal cancer[J].Chin J Surg,2006,44(11):733-736.
[4]潘新良,雷大鹏,许风雷,等.下咽癌的外科治疗[J].山东大学耳鼻喉眼学报,2007,21(1):1-7.PAN Xinliang,LEI Dapeng,XU Fenglei,et al.Surgical treatment of hypopharyngeal carcinoma[J].J Otolaryngolo Ophthalmol Shandong Univ,2007,21(1):1-7.
[5]雷大鹏,许风雷,张立强,等.下咽癌累及颈段食管的处理[J].中华耳鼻咽喉头颈外科杂志,2005,40(9):58-62.LEI Dapeng,XU Fenglei,ZHANG Liqiang,et al.Surgical treatment of hypopharyngeal cancer w ith cervical esophageal invasion[J].Chin J Otorhinolaryngol Head Neck Surg,2005,40(9):58-62.
[6]潘新良,栾信庸,解光,等.胸大肌肌皮瓣在耳鼻咽喉头颈外科中的应用[J].山东大学耳鼻喉眼学报,2005,19(5):277-282.PAN Xinliang,LUAN Xinyong,XIE Guang,et al.Applieation of pectoralis major myocutaneous flap in otorhinolaryngology&head and neck surgery[J].J Otolaryngol Ophthalmol Shandong Univ,2005,19(5):277-282.
[7]袁英,潘新良,栾信庸,等.下咽后壁癌的手术治疗[J].山东大学耳鼻喉眼学报,2007,21(1):15-19.YUAN Ying,PAN Xinliang,LUAN Xinyong,et al.Surgical treatment for posterior hypopharyngeal w all carcinoma[J].J Otolaryngol Ophthalmol Shandong Univ,2007,21(1):15-19.
[8]Morshed K,Szymański,Goabek.Reconstruction of the hypopharynx w ith U-shaped pectoralis major myocutaneous flap after total pharyngo-laryngectomy[J].Eur Arch Otorhinolaryngol,2005,262(4):259-262.
[9]Espitalier F,Ferron C,Leux C,et al.Results after Ushaped pectoralis major myocutaneous flap reconstruction of circumferential pharyngeal defects[J].Laryngoscope,2012,122(12):2677-2682.
[10]Disa J J,Pusic A L,Hidalgo D A,et al.Microvascular reconstruction of the hypopharynx:defect classification,treatment algorithm,and functional outcome based on165 consecutive cases[J].Plast Reconstr Surg,2003,111(2):652-660.
[11]Sun F,Li X,Lei D,et al.Surgical management of cervical esophageal carcinoma w ith larynx preservation and reconstruction[J].Int J Clin Exp M ed,2014,7(9):2771-2778.
[12]雷大鹏,栾信庸,许风雷,等.颈段食管癌的手术治疗[J].中华耳鼻咽喉科杂志,2002,37(2):9-12.LEI Dapeng,LUAN Xinyong,XU Fenglei,et al.Surgical management of cervical esophageal carcinoma[J].Chin J Otorhinolaryngol,2002,37(2):9-12.
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