鼻咽癌残存病灶分次立体定向放射治疗临床研究
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摘要
第一部分分次立体定向放疗在残存鼻咽癌治疗中的作用
目的：总结我院应用分次立体定向放疗(FSRT)推量治疗鼻咽癌根治性外照射后残存病灶的结果,进一步探讨分次立体定向放疗在局部残存鼻咽癌治疗中的作用。
资料和方法：回顾性分析我院放疗科2000年1月至2009年12月收治的136例首程根治性放疗后局部残存鼻咽癌患者资料。男性104例(76.5%),女性32(23.5%)例；中位年龄43.0岁(13-77岁)；初诊分期(2002年UICC)为：Ⅰ期1例(0.8%),Ⅱ a期6例(4.4%),Ⅱ b期24例(17.6%),Ⅲ期70例(51.5%),Ⅳa期24例(17.6%),Ⅳb期11例(8.1%)。首程放疗鼻咽部总剂量为68.0-78.0Gy(中位剂量70.0Gy),其中常规放疗85例,调强放疗51例。首程放疗与FSRT的中位时间为24.5天。残存病灶体积为0.60-77.13cm3(中位体积13.45cm3)。FSRT总剂量为8.0-32.0Gy(中位剂量19.5Gy),单次剂量2.0-10.0Gy/次(33例>5Gy,103例≤5Gy)。FSRT的BED为10.1-44.8Gy(中位数为28Gy)。应用Kaplan-Meier和Cox回归分析研究各因素对预后的影响。
结果：完全缓解率为72.1%,部分缓解率为23.5%。全组病人的5年无局部失败生存率(LFFS)、5年无远转生存(FFDM)率、5年总生存率(OS)和5年无病生存率(DFS)分别为92.5%,77.0%,76.2%和73.6%。36例(26.8%)在FSRT后出现远处转移(中位时间9个月)。Ⅰ+Ⅱ期和Ⅲ+Ⅳ期患者的5年LFFS分别为89.9%和93.3%,DFS分别为83.2%和70.8%,OS分别为86.3%和70.7%；均无统计学差异。19例出现晚期并发症(8例颅神经损伤,5例鼻咽部大出血,6例颞叶坏死)。多因素分析显示T分期是DFS和OS的独立预后因素,年龄是OS的另一预后因素。
结论：分次立体定向放射治疗对鼻咽癌放疗后残存病灶的推量治疗有显著临床疗效,严重晚期并发症的发生率可接受。改进的剂量分割模式可减少晚期并发症的发生。
第二部分保护颈动脉鞘的鼻咽癌立体定向推量放疗初探
目的：本研究采用保护颈鞘技术的分次立体定向放疗推量治疗鼻咽癌根治性外照射后残存病灶,评价其疗效及其并发症。
材料与方法：2006年8月至2010年8月,36例我院鼻咽癌初程根治性放疗后局部残存患者接受分次立体定向放射治疗(FSRT)推量。患者中位年龄41.3岁(13-76岁),男性25例,女性11例。初诊UICC2002分期为Ⅱa期2例,Ⅱ b期5例,Ⅲ期18例,Ⅳa期7例,Ⅳb期4例。残存肿瘤部位为：限于鼻咽腔(52.8%),鼻咽腔并咽旁间隙(8.3%),咽后淋巴结(19.4%),鼻咽腔并咽后淋巴结(13.9%),咽旁间隙并咽后淋巴结(2.8%),海绵窦(2.8%)。首程放疗鼻咽部总剂量69.96-76.90Gy(中位剂量72.58Gy),其中常规放疗9例,调强放疗27例,首程同步放化疗20例。首程放疗与FSRT的间隔时间为12-147天(中位时间39.8天)。残存肿瘤体积为1.46cm3-32.98cm3(中位体积14.94mm3)。FSRT应用小多叶光栅旋转适形照射,颈动脉鞘受量低于2Gy/次。FSRT总剂量10.0-24.0Gy(中位剂量16.5Gy),2.0-5.0Gy/次,常用分割方式为15Gy/3Gy/5f。
结果：随诊时间为12-59月(中位时间为34月),肿瘤完全缓解率为100%。3年局部控制率为100%；3年总生存率为94.4%；3年无病生存率为77.8%。无严重急性放疗反应发生,晚期并发症包括1例(2.8%)轻度后组颅神经损伤,2例(5.6%)颞叶坏死：无鼻咽部大出血或溃疡发生。
结论：本组立体定向放射治疗剂量分割模式对首程放疗后残存鼻咽癌有显著临床疗效,FSRT注重保护颈鞘有利于降低放疗后晚期神经、血管损伤。
Part I:Fractionated stereotactic radiotherapy for136patients with locally residual nasopharyngeal carcinoma
Objective To evaluate the efficacy and toxicity of fractionated stereotactic radiotherapy (FSRT) in patients with residual nasopharyngeal carcinoma (NPC).
Methods From January2000to December2009,136NPC patients with residual lesions after primary radiotherapy (RT) were treated by FSRT. The patients aged between13and77years with a median of43.0years,104of them were males and32were females. The stages (2002UICC) before primary RT were:Ⅰ1(0.8%),Ⅱa6(4.4%), Ⅱb24(17.6%),Ⅲ70(51.5%),Ⅳa24(17.6%),Ⅳb (8.1%). In primary RT,85patients received conventional RT,51patients received IMRT and75out of the136patients received concurrent chemoradiotherapy. The total dose of primary RT was68.0-78.0Gy (median,70.0Gy). The median time from the primary RT to FSRT was24.5days (range,2-147). Residual tumor volumes ranged from0.60to77.13cm3(median,13.45cm3). The total FSRT doses were8.0-32.0Gy (median,19.5Gy) with2.0-10.0Gy per fraction.
Results The actuarial CR rate was72.1%and PR rate was23.5%. Five-year local failure-free survival (LFFS), freedom from distant metastasis (FFDM), overall survival (OS), and disease free survival (DFS) rates for all patients were92.5%,77.0%,76.2%, and73.6%, respectively. No statistical significant differences were found in LFFS, DFS and OS in comparison of stage Ⅰ/Ⅱ and stage Ⅲ/Ⅳ disease. Nineteen patients exhibited late toxicities including massive nasopharyngeal hemorrhage (3.7%), cranial nerve injuries (5.9%) and temporal lobe necrosis (4.4%). T stage at diagnosis was an significant prognostic factor for OS and DFS. Age is another prognostic factor for OS.
Conclusion FSRT after external beam radiotherapy provides excellent local control for patients with residual NPC. The incidence of severe late toxicity was found to be acceptable with FSRT. Improved fractionation regimens of FSRT can avoid long-term complications.
Part Ⅱ:Fractionated stereotactic radiotherapy with carotid sheath protection technique for local residual nasopharyngeal carcinoma after primary radiotherapy
Objective Local failure of nasopharyngeal carcinoma (NPC) after radiotherapy (RT) remains one of the major treatment failures. This study aimed to evaluate the clinical efficacy and complications of fractionated stereotactic radiotherapy (FSRT) with vagina carotica protection technique for local residual of NPC patients after the primary RT.
Methods and Materials From August2006to August2010, FSRT with carotid sheath protection technique was applied to36patients in our department, the patients aged between13and76years with a median of41.3years,25of them were males and11were females. According to2002UICC Staging System, the stages before primary radiotherapy were:Ⅱa2,Ⅱb5,Ⅲ18,Ⅳa7, Ⅳb4. In the first course of radiotherapy,9patients received conventional RT,27patients received IMRT and20out of the36patients received concurrent chemoradiotherapy. The total dose in the first course of RT was69.96-76.90Gy (median,72.58Gy). The intervals between the primary RT and FSRT ranged from12to147days (median,39.8days). Target volumes ranged from1.46to32.98cm3(median,14.94cm3). The total FSRT doses were10.0-24.0Gy (median,16.5Gy) with2.0-5.0Gy per fraction. The most common regimen was15Gy in5fractions of3Gy, the irradiation dose to carotid sheath was less than2Gy per fraction.
Results The median follow-up time was34months (range,12-59months). The3-year local control rate was100%; the3-year overall survival rate was94.4%; the3-year disease-free survival rate was77.8%. In this study, we had one case of cranial nerve injury, two cases of temporal lobe necrosis, and no nasopharyngeal massive hemorrhage was observed.
Conclusions FSRT with carotid sheath protection technique is an effective and safe RT regimen for local residual of NPC with reduction of radiation-related neurovascular lesions.
目的：总结我院应用分次立体定向放疗(FSRT)推量治疗鼻咽癌根治性外照射后残存病灶的结果,进一步探讨分次立体定向放疗在局部残存鼻咽癌治疗中的作用。
资料和方法：回顾性分析我院放疗科2000年1月至2009年12月收治的136例首程根治性放疗后局部残存鼻咽癌患者资料。男性104例(76.5%),女性32(23.5%)例；中位年龄43.0岁(13-77岁)；初诊分期(2002年UICC)为：Ⅰ期1例(0.8%),Ⅱ a期6例(4.4%),Ⅱ b期24例(17.6%),Ⅲ期70例(51.5%),Ⅳa期24例(17.6%),Ⅳb期11例(8.1%)。首程放疗鼻咽部总剂量为68.0-78.0Gy(中位剂量70.0Gy),其中常规放疗85例,调强放疗51例。首程放疗与FSRT的中位时间为24.5天。残存病灶体积为0.60-77.13cm3(中位体积13.45cm3)。FSRT总剂量为8.0-32.0Gy(中位剂量19.5Gy),单次剂量2.0-10.0Gy/次(33例>5Gy,103例≤5Gy)。FSRT的BED为10.1-44.8Gy(中位数为28Gy)。应用Kaplan-Meier和Cox回归分析研究各因素对预后的影响。
结果：完全缓解率为72.1%,部分缓解率为23.5%。全组病人的5年无局部失败生存率(LFFS)、5年无远转生存(FFDM)率、5年总生存率(OS)和5年无病生存率(DFS)分别为92.5%,77.0%,76.2%和73.6%。36例(26.8%)在FSRT后出现远处转移(中位时间9个月)。Ⅰ+Ⅱ期和Ⅲ+Ⅳ期患者的5年LFFS分别为89.9%和93.3%,DFS分别为83.2%和70.8%,OS分别为86.3%和70.7%；均无统计学差异。19例出现晚期并发症(8例颅神经损伤,5例鼻咽部大出血,6例颞叶坏死)。多因素分析显示T分期是DFS和OS的独立预后因素,年龄是OS的另一预后因素。
结论：分次立体定向放射治疗对鼻咽癌放疗后残存病灶的推量治疗有显著临床疗效,严重晚期并发症的发生率可接受。改进的剂量分割模式可减少晚期并发症的发生。
第二部分保护颈动脉鞘的鼻咽癌立体定向推量放疗初探
目的：本研究采用保护颈鞘技术的分次立体定向放疗推量治疗鼻咽癌根治性外照射后残存病灶,评价其疗效及其并发症。
材料与方法：2006年8月至2010年8月,36例我院鼻咽癌初程根治性放疗后局部残存患者接受分次立体定向放射治疗(FSRT)推量。患者中位年龄41.3岁(13-76岁),男性25例,女性11例。初诊UICC2002分期为Ⅱa期2例,Ⅱ b期5例,Ⅲ期18例,Ⅳa期7例,Ⅳb期4例。残存肿瘤部位为：限于鼻咽腔(52.8%),鼻咽腔并咽旁间隙(8.3%),咽后淋巴结(19.4%),鼻咽腔并咽后淋巴结(13.9%),咽旁间隙并咽后淋巴结(2.8%),海绵窦(2.8%)。首程放疗鼻咽部总剂量69.96-76.90Gy(中位剂量72.58Gy),其中常规放疗9例,调强放疗27例,首程同步放化疗20例。首程放疗与FSRT的间隔时间为12-147天(中位时间39.8天)。残存肿瘤体积为1.46cm3-32.98cm3(中位体积14.94mm3)。FSRT应用小多叶光栅旋转适形照射,颈动脉鞘受量低于2Gy/次。FSRT总剂量10.0-24.0Gy(中位剂量16.5Gy),2.0-5.0Gy/次,常用分割方式为15Gy/3Gy/5f。
结果：随诊时间为12-59月(中位时间为34月),肿瘤完全缓解率为100%。3年局部控制率为100%；3年总生存率为94.4%；3年无病生存率为77.8%。无严重急性放疗反应发生,晚期并发症包括1例(2.8%)轻度后组颅神经损伤,2例(5.6%)颞叶坏死：无鼻咽部大出血或溃疡发生。
结论：本组立体定向放射治疗剂量分割模式对首程放疗后残存鼻咽癌有显著临床疗效,FSRT注重保护颈鞘有利于降低放疗后晚期神经、血管损伤。
Part I:Fractionated stereotactic radiotherapy for136patients with locally residual nasopharyngeal carcinoma
Objective To evaluate the efficacy and toxicity of fractionated stereotactic radiotherapy (FSRT) in patients with residual nasopharyngeal carcinoma (NPC).
Methods From January2000to December2009,136NPC patients with residual lesions after primary radiotherapy (RT) were treated by FSRT. The patients aged between13and77years with a median of43.0years,104of them were males and32were females. The stages (2002UICC) before primary RT were:Ⅰ1(0.8%),Ⅱa6(4.4%), Ⅱb24(17.6%),Ⅲ70(51.5%),Ⅳa24(17.6%),Ⅳb (8.1%). In primary RT,85patients received conventional RT,51patients received IMRT and75out of the136patients received concurrent chemoradiotherapy. The total dose of primary RT was68.0-78.0Gy (median,70.0Gy). The median time from the primary RT to FSRT was24.5days (range,2-147). Residual tumor volumes ranged from0.60to77.13cm3(median,13.45cm3). The total FSRT doses were8.0-32.0Gy (median,19.5Gy) with2.0-10.0Gy per fraction.
Results The actuarial CR rate was72.1%and PR rate was23.5%. Five-year local failure-free survival (LFFS), freedom from distant metastasis (FFDM), overall survival (OS), and disease free survival (DFS) rates for all patients were92.5%,77.0%,76.2%, and73.6%, respectively. No statistical significant differences were found in LFFS, DFS and OS in comparison of stage Ⅰ/Ⅱ and stage Ⅲ/Ⅳ disease. Nineteen patients exhibited late toxicities including massive nasopharyngeal hemorrhage (3.7%), cranial nerve injuries (5.9%) and temporal lobe necrosis (4.4%). T stage at diagnosis was an significant prognostic factor for OS and DFS. Age is another prognostic factor for OS.
Conclusion FSRT after external beam radiotherapy provides excellent local control for patients with residual NPC. The incidence of severe late toxicity was found to be acceptable with FSRT. Improved fractionation regimens of FSRT can avoid long-term complications.
Part Ⅱ:Fractionated stereotactic radiotherapy with carotid sheath protection technique for local residual nasopharyngeal carcinoma after primary radiotherapy
Objective Local failure of nasopharyngeal carcinoma (NPC) after radiotherapy (RT) remains one of the major treatment failures. This study aimed to evaluate the clinical efficacy and complications of fractionated stereotactic radiotherapy (FSRT) with vagina carotica protection technique for local residual of NPC patients after the primary RT.
Methods and Materials From August2006to August2010, FSRT with carotid sheath protection technique was applied to36patients in our department, the patients aged between13and76years with a median of41.3years,25of them were males and11were females. According to2002UICC Staging System, the stages before primary radiotherapy were:Ⅱa2,Ⅱb5,Ⅲ18,Ⅳa7, Ⅳb4. In the first course of radiotherapy,9patients received conventional RT,27patients received IMRT and20out of the36patients received concurrent chemoradiotherapy. The total dose in the first course of RT was69.96-76.90Gy (median,72.58Gy). The intervals between the primary RT and FSRT ranged from12to147days (median,39.8days). Target volumes ranged from1.46to32.98cm3(median,14.94cm3). The total FSRT doses were10.0-24.0Gy (median,16.5Gy) with2.0-5.0Gy per fraction. The most common regimen was15Gy in5fractions of3Gy, the irradiation dose to carotid sheath was less than2Gy per fraction.
Results The median follow-up time was34months (range,12-59months). The3-year local control rate was100%; the3-year overall survival rate was94.4%; the3-year disease-free survival rate was77.8%. In this study, we had one case of cranial nerve injury, two cases of temporal lobe necrosis, and no nasopharyngeal massive hemorrhage was observed.
Conclusions FSRT with carotid sheath protection technique is an effective and safe RT regimen for local residual of NPC with reduction of radiation-related neurovascular lesions.
引文
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Chang JT et al.(2000). Locally recurrent nasopharyngeal carcinoma. Radiother Oncol. 54(2):135-142.
Chua DT et al.(2006). Predictive factors of tumor control and survival after radiosurgery for local failures of nasopharyngeal carcinoma. Int J Radiat Oncol Biol Phys.66(4):1415-1421.
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Le QT et al.(2003). Improved local control with stereotactic radiosurgical boost in patients with nasopharyngeal carcinoma. Int J Radiat Oncol Biol Phys.56(3): 1046-1054.
Leung TW et al.(2000). Salvage brachytherapy for patients with locally persistent nasopharyngeal carcinoma. Int J Radiat Oncol Biol Phys.47(1):405-412.
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Ahn YC et al.(2000). Fractionated stereotactic radiationtherapy for extracranial head and neck tumors. Int J Radiat Oncol Biol Phys.48(4):501-505.
Chang JT et al.(2000). Locally recurrent nasopharyngeal carcinoma. Radiother Oncol. 54(2):135-142.
Chua DT et al.(2006). Predictive factors of tumor control and survival after radiosurgery for local failures of nasopharyngeal carcinoma. Int J Radiat Oncol Biol Phys.66(4):1415-1421.
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Hua YJ et al.(2009). Postradiation nasopharyngeal necrosis in the patients with nasopharyngeal carcinoma. Head Neck.31 (3):807-812.
Le QT et al.(2003). Improved local control with stereotactic radiosurgical boost in patients with nasopharyngeal carcinoma. Int J Radiat Oncol Biol Phys.56(3): 1046-1054.
Leung TW et al.(2000). Salvage brachytherapy for patients with locally persistent nasopharyngeal carcinoma. Int J Radiat Oncol Biol Phys.47(1):405-412.
Low JS et al.(2006). Stereotactic radiosurgery plus intracavitary irradiation in the salvage of nasopharyngeal carcinoma. Head Neck.28(5):321-329.
Seo Y et al.(2006). Robotic system-based fractionated stereotactic radiotherapy in locally recurrent nasopharyngeal carcinoma. Radiother Oncol.93(2):570-574.
Tate DJ et al.(1999). Stereotactic radiosurgical boost following radiotherapy in primary nasopharyngeal carcinoma:Impact on local control. Int J Radiat Oncol Biol Phys.45(3):915-921.
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Wu SX et al.(2007). Outcome of fractionated stereotactic radiotherapy for 90 patients with locally persistent and recurrent nasopharyngeal carcinoma. Int J Radiat Oncol Biol Phys.69(3):761-769.
Xiao JP et al.(2010). Stereotactic radiotherapy-an approach to improve local control of nasopharyngeal carcinoma. Chin J Cancer.29(2):129-131.
Xiao JP et al.(2001). Fractionated stereotactic radiosurgery for 50 patients with recurrent or residual nasopharyngeal carcinoma. Int J Radiat Oncol Biol Phys.51(2):164-170.
Xu ZG et al.(1998). Salvage surgery for nasopharyngeal carcinoma after irradiation failure. Chinese Journal of Otorhinolaryngology.33(2):103-105.
Yau TK et al.(2004). Effectiveness of brachytherapy and fractionated stereotactic radiotherapy boost for persistent nasopharyngeal carcinoma. Head Neck.26(6): 1024-1030.
Yau TK et al.(2006). Induction chemotherapy with cisplatin and gemcitabine followed by accelerated radiotherapy and concurrent cisplatin in patients with stage IV(A-B) nasopharyngeal carcinoma. Head Neck.28(4):880-887.
Yu KH et al.(2005). Survival outcome of patients with nasopharyngeal carcinoma with first local failure:a study by the Hong Kong Nasopharyngeal Carcinoma Study Group. Head Neck.27(2):397-405.
胡超苏等(2008).鼻咽癌放化综合治疗进展.中国癌症杂志.18(9)：667-671.
郎锦义等(2004).分次立体定向放射治疗(SRT)复发、残留鼻咽癌前瞻性临床研究.四川医学.25(2)：951-955.
肖建平等(2005).鼻咽癌初程放疗后残存的分次X刀治疗初探.中华放射肿瘤学杂志.14(2)：77-80.
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Baujat B et al.(2006). Chemotherapy in locally advanced nasopharyngeal carcinoma:an individual patient data Meta-analysis of eight randomized trials and 1753 patients. Int J Radiat Oncol Biol Phys.64(1):47-56.
Burtness B et al.(2005). Phase III randomized trial of cisplatin plus placebo compared with cisplatin plus cetuximab in metastatic/recurrent head and neck cancer:an Eastern Cooperative Oncology Group study. J Clin Oncol.23(34):8646-8654.
Chang T C et al.(2000).See L C, Liao C T, et al. Locally recurrent nasopharyngeal. Radiother Oncol.54(6):135-142.
Chen MY et al.(2007). Salvage surgical operation via endoscopic transnasal approach for local persistent or recurrent nasopharyngeal carcinoma. Ai Zheng.2007.26(7): 673-678.
Chua D et al.(2008). Capecitabine monotherapy for recurrent and metastatic nasopharyngeal cancer. Jpn-J-Clin-Oncol.38 (4):244-249.
Chua DT et al.(2005). Sham JS, Leung LH, Au KH:Reirradiation of nasopharyngeal carcinoma with intensity-modulated radiotherapy. Radiother Oncol.77(2):290-294.
Chua DT et al.(2009).Comparison of single versus fractionated dose of stereotactic radiotherapy for salvaging local failures of nasopharyngeal carcinoma:a matched-cohort analysis. Head Neck Oncol.1(2):13.
Chua DT et al.(2006). Predictive factors of tumor control and survival after radiosurgery for local failures of nasopharyngeal carcinoma. Int J Radiat Oncol Biol Phys. 66(2):1415-1421.
Chua DT et al.(2007). Stereotactic radiosurgery versus gold gain implantation in salvaging local failures of nasopharyngeal carcinoma. Int J Radiat Oncol Biol Phys
69(4):469-474.
Chna D T, Wei W, Wong M P, et al. Phase Ⅱ study of gdltinib for the treatment of recurrent and metastatic nasopharyngeal carcinoma. Head-Neck,2008.30(7): 863-867.
Comoretto M et al.(2008). Detection and restaging of residual and/or recurrent nasopharyngeal carcinoma after chemotherapy and radiation therapy:comparison of MR imaging and FDG PET/CT. Radiology.249(1):203-11.
Danesi G et al.(2007).Salvage surgery for recurrent nasopharyngeal carcinoma. Skull Base.7(3):173-180.
Daniel TT et al.(2005).Chua, Ma Jun, et al. Long-term survival after cisplatin-based induction chemotherapy and radiotherapy for nasopharyngeal carcinoma:a pooled data analysis of two phase Ⅲ trials. J Clin Oncol.23(6):1118-1124.
Didem et al.(1998). Reirradiation for locally recurrent nasopharyngeal carcinoma: treatment results and prognostic factors. Int J Radiat Oncol Biol Phys.60(2):388-394.
Eher C et al.(2007). Phase Ⅱ trial of sorafenib in patients with recurrent or metastatic squmous cell carcinoma of the head and neek or nasopharyngeal carcinoma. Clin-Oncol.25(24):3766-3773.
Feng AC et al.(2006). Prevertebral muscle involvement in nasopharyngeal carcinoma. Int J Radiat Oncol Biol Phys.65(4):1026-1035.
Hao SP et al.(2010).Surgical management of recurrent nasopharyngeal carcinoma. Chang Gung Med J.33(4):361-369.
Hara W et al.(2008). Excellent local control with stereotactic radiotherapy boost after external beam radiotherapy in patients with nasopharyngeal carcinoma. Int J Radiat Oncol Biol Phys.71(2):393-400.
Hwang JM et al.(1998). Results and prognostic factors in the retreatment of locally recurrent nasopharyngeal carcinoma. Int J Radiat Oncol Biol Phys.41(5):1099-1111.
Kocher M et al.(2006).Linear accelerator radiosurgery for recurrent malignant tumors of the skull base. Am J Clin Oncol.21(1):18-22.
Le QT et al.(2003). Improved local control with stereotactic radiosurgical boost in patients with nasopharyngeal carcinoma. Int J Radiat Oncol Biol Phys.56(3): 1046-1054.
Lee AW et al.(2005).Treatment results for nasopharyngeal carcinoma in the modern era: the Hong Kong experience. Int J Radiat Oncol Biol Phys.61(4):1107-1116.
Lee AW et al.(2003). Contribution of radiotherapy to function preservation and cancer outcome in primary treatment of nasopharyngeal carcinoma.World J Surg.27(7): 838-43.
Lee AWM et al.(1992). Retrospective analysis of 5037 patients with nasopharyngeal carcinoma treated during 1976-1985:overall survival and pattern of failure. Int J Radiat Oncol Biol Phys.23(2):261-270.
Lu JJ et al.(2004). Adjuvant fractionated high-dose-rate intracavitary brachytherapy after external beam radiotherapy in T1 and T2 nasopharyngeal carcinoma. Head-Neck. 26(5):389-95.
Leung TW et al.(2005). Treatment results of 1070 patients with nasopharyngeal carcinoma:an analysis of survival and failure patterns. Head Neck.27(3):555-565.
Li JC et al.(2006). Dose escalation of three-dimensional conformal radiotherapy for locallyrecurrent nasopharyngeal carcinoma:a prospective randomised study. Clin Oncol (R Coll Radiol).18(4):293-299.
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