鼻咽癌放疗后放射性视神经损伤的临床研究
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摘要
目的探讨鼻咽癌放疗后放射性视神经损伤(Radiation-induced optic neuropathy,RION)的临床特点。方法回顾性分析9例鼻咽癌放疗后临床诊断为RION患者的病历资料,总结其临床表现、眼科检查及影像学表现。结果 9例患者均以突发性、无痛性单眼或双眼视力下降,甚至失明为主要表现,共有2只眼失明,15只眼视力下降,出现RION的潜伏期为2～8年,平均(5.4±0.7)年;8例患者还出现不同程度的视野缺损;影像学检查发现视神经增粗6例,视神经曲折、边缘粗糙4例,视神经明显萎缩3例。9例患者经改善循环、营养神经、激素及高压氧等治疗,但效果差,视力均无改善。结论 RION所致视力损伤往往是灾难性的,引发RION的主要原因为照射剂量,目前尚无有效的治疗措施,因此,今后在给鼻咽癌患者制定放疗计划时需进行全面的评估以防止此类并发症的出现。
OBJECTIVE To investigate the clinical characteristics of radiation-induced optic neuropathy(RION) in patients with nasopharyngeal carcinoma after radiotherapy. METHODS A retrospective study was performed on the clinical data of 9 RION patients with nasopharygeal carcinoma(NPC) after radiotherapy. Their clinical manifestations, ophthalmologic examinations and imaging findings were analyzed. RESULTS The 9 cases manifested as sudden binocular or monocular painless vision decline, or even blindness. Among them, 2 eyes were visionless,15 eyes had decreased vision; the latent time of RION was 2 to 8 years(5.4±0.7) years; eight cases showed different degree of visual field defect; radiological imagine showed optic nerve enhancement in 6 cases, tortuous optic nerves and rough edges in 4 cases, optic nerve atrophy in 3 cases. Although all patients received active treatment, including circulation-improving drugs, neurotrophic drugs,corticosteroids and hyperbaric oxygen therapy, their visual acuity failed to restore. CONCLUSIONS The RION is a catastrophic complication of radiotherapy that results in progressive blindness in patients with NPC. The occurrence of RION may has a correlation with radiation dose.Since there is no effective treatment available, medical practitioners need to be aware of the complications of radiotherapy when developing a treatment plan for patient with NPC.
OBJECTIVE To investigate the clinical characteristics of radiation-induced optic neuropathy(RION) in patients with nasopharyngeal carcinoma after radiotherapy. METHODS A retrospective study was performed on the clinical data of 9 RION patients with nasopharygeal carcinoma(NPC) after radiotherapy. Their clinical manifestations, ophthalmologic examinations and imaging findings were analyzed. RESULTS The 9 cases manifested as sudden binocular or monocular painless vision decline, or even blindness. Among them, 2 eyes were visionless,15 eyes had decreased vision; the latent time of RION was 2 to 8 years(5.4±0.7) years; eight cases showed different degree of visual field defect; radiological imagine showed optic nerve enhancement in 6 cases, tortuous optic nerves and rough edges in 4 cases, optic nerve atrophy in 3 cases. Although all patients received active treatment, including circulation-improving drugs, neurotrophic drugs,corticosteroids and hyperbaric oxygen therapy, their visual acuity failed to restore. CONCLUSIONS The RION is a catastrophic complication of radiotherapy that results in progressive blindness in patients with NPC. The occurrence of RION may has a correlation with radiation dose.Since there is no effective treatment available, medical practitioners need to be aware of the complications of radiotherapy when developing a treatment plan for patient with NPC.
引文
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[25]BHANDARE N,MONROE AT,MORRIS CG,et al.Does altered fractionation influence the risk of radiation-induced optic neuropathy?[J].Int J Radiat Oncol Biol Phys,2005,62(4):1070-1077.
[26]GUY J,MANCUSO A,QUISLING RG,et al.Gadolinium-DTPA-enhanced magnetic resonance imaging in optic neuropathies[J].Ophthalmology,1990,97(5):599-600.
[27]GLANTZ MJ,BURGER PC,FRIEDMAN AH,et al.Treatment of radiation-induced nervous system injury with heparin and warfarin[J].Neurology,1994,44(11):2020-2027.
[28]GUY J,SCHATZ NJ.Hyperbaric oxygen in the treatment of radiationinduced optic neuropathy[J].Ophthalmology,1986,93(8):1083-1088.
[2]WELZEL G,FLECKENSTEIN K,MAI SK,et al.Acute neurocognitive impairment during cranial radiation therapy in patients with intracranial tumors[J].Strahlenther Onkol,2008,184(12):647-654.
[3]DANESH-MEYER HV,SAVINO PJ,SERGOTT RC.Visual loss despite anticoagulation in radiation-induced optic neuropathy[J].Clin Exp Ophthalmol,2004,32(3):333-335.
[4]FERGUSON I,HUECKER J,HUANG J,et al.Risk factors for radiation-induced optic neuropathy:a case-control study[J].Clin Exp Ophthalmol,2017,45(6):592-597.
[5]MILLER NR.Radiation-induced optic neuropathy:still no treatment[J].Clin Exp Ophthalmol,2004,32(3):233-235.
[6]ESASSOLAK M,KARAGOZ U,YALMAN D,et al.Evaluation of the effects of radiotherapy to the chiasm and optic nerve by visual psychophysical and electrophysiologic tests in nasopharyngeal carcinoma[J].Int J Radiat Oncol Biol Phys,2004,58(4):1141-1146.
[7]刘金陵,吴乐正,潘国英.放射性视神经病变的临床分析[J].中华眼科杂志,1992,28(2):86-88.
[8]潘燚,胡伟汉,高艺,等.鼻咽癌放疗后视野与视觉诱发电位的改变[J].癌症,2005,24(6):722-726.
[9]WIJERS OB,LEVENDAG PC,LUYTEN GP,et al.Radiation-induced bilateral optic neuropathy in cancer of the nasopharynx.Case failure analysis and a review of the literature[J].Strahlenther Onkol,1999,175(1):21-27.
[10]TEO PM,LEUNG SF,CHAN AT,et al.Final report of a randomized trial on altered-fractionated radiotherapy in nasopharyngeal carcinoma prematurely terminated by significant increase in neurologic complications[J].Int J Radiat Oncol Biol Phys,2000,48(5):1311-1322.
[11]DANESH-MEYER HV.Radiation-induced optic neuropathy[J].JClin Neurosci,2008,15(2):95-100.
[12]闵华庆,张锦明,洪明晃,等.新编常见恶性肿瘤诊治规范·鼻咽癌分册[M].5版.北京:北京医科大学中国协和医科大学联合出版社,2009:21-28.
[13]刘军,肖颂华,刘中霖.鼻咽癌放疗后神经损伤学[M].广州:广东科技出版社,2010:141-142.
[14]FORREST AP,BROWN DA,MORRIS SR,et al.Pituitary radon implant for advanced cancer[J].Lancet,1956,270(6920):399-401.
[15]KLINE LB,KIM JY,CEBALLOS R.Radiation optic neuropathy[J].Ophthalmology,1985,92(8):1118-1126.
[16]KAM MK,CHAU RM,SUEN J,et al.Intensity-modulated radiotherapy in nasopharyngeal carcinoma:dosimetric advantage over conventional plans and feasibility of dose escalation[J].Int J Radiat Oncol Biol Phys,2003,56(1):145-157.
[17]RODEN D,BOSLEY TM,FOWBLE B,et al.Delayed radiation injury to the retrobulbar optic nerves and chiasm.Clinical syndrome and treatment with hyperbaric oxygen and corticosteroids[J].Ophthalmology,1990,97(3):346-351.
[18]GUY J,MANCUSO A,BECK R,et al.Radiation-induced optic neuropathy:a magnetic resonance imaging study[J].J Neurosurg,1991,74(3):426-432.
[19]ZIMMERMAN CF,SCHATZ NJ,GLASER J S.Magnetic resonance imaging of radiation optic neuropathy[J].Am J Ophthalmol,1990,110(4):389-394.
[20]BORRUAT FX,SCHATZ NJ,GLASER JS,et al.Visual recovery from radiation-induced optic neuropathy.The role of hyperbaric oxygen therapy[J].J Clin Neuroophthalmol,1993,13(2):98-101.
[21]JIANG GL,TUCKER SL,GUTTENBERGER R,et al.Radiation-induced injury to the visual pathway[J].Radiother Oncol,1994,30(1):17-25.
[22]PARSONS JT,BOVA FJ,FITZGERALD CR,et al.Radiation optic neuropathy after megavoltage external-beam irradiation:analysis of time-dose factors[J].Int J Radiat Oncol Biol Phys,1994,30(4):755-763.
[23]BOSCHETTI M,De LUCCHI M,GIUSTI M,et al.Partial visual recovery from radiation-induced optic neuropathy after hyperbaric oxygen therapy in a patient with Cushing disease[J].Eur J Endocrinol,2006,154(6):813-818.
[24]LEE MS,BORRUAT FX.Should patients with radiation-induced optic neuropathy receive any treatment?[J].J Neuroophthalmol,2011,31(1):83-88.
[25]BHANDARE N,MONROE AT,MORRIS CG,et al.Does altered fractionation influence the risk of radiation-induced optic neuropathy?[J].Int J Radiat Oncol Biol Phys,2005,62(4):1070-1077.
[26]GUY J,MANCUSO A,QUISLING RG,et al.Gadolinium-DTPA-enhanced magnetic resonance imaging in optic neuropathies[J].Ophthalmology,1990,97(5):599-600.
[27]GLANTZ MJ,BURGER PC,FRIEDMAN AH,et al.Treatment of radiation-induced nervous system injury with heparin and warfarin[J].Neurology,1994,44(11):2020-2027.
[28]GUY J,SCHATZ NJ.Hyperbaric oxygen in the treatment of radiationinduced optic neuropathy[J].Ophthalmology,1986,93(8):1083-1088.