Recurrence of nasopharyngeal carcinoma and application of endoscopic surgery

Yan JIANG

Journal of Otolaryngology and Ophthalmology of Shandong University 2019, 33 (2): 1-11. DOI: 10.6040/j.issn.1673-3770.1.2019.011

Abstract （2586）

HTML （45）

PDF（pc）（23617KB）（626）

Radiotherapy is the conventional treatment for nasopharyngeal carcinoma. Although the 5-year survival rate has greatly improved, there are still several cases of recurrent or residual nasopharyngeal carcinoma. The treatment principles of recurrent or residual lesions include second-course radiotherapy, chemotherapy, and surgery. The complications following radical radiotherapy and second-course radiotherapy seriously affect the quality of life in patients. The current surgical methods include open surgery and endoscopic surgery. Open surgery can provide a sufficiently open field of operation, but is associated with some serious damage. Endoscopic nasopharyngeal carcinoma resection has been carried out lately, and only few medical institutions in China perform these operations. However, with the emergence of the concept of endoscopic skull base surgery and new medical instruments and equipment, endoscopic nasopharyngeal carcinoma surgery has become a good surgical choice. However, this requires strict surgical indications, skills of endoscopic skull-base surgery, and long-term follow-up.

Fig.2 Resection steps and resection range of right nasopharyngeal carcinoma
A. Use of a plasma knife to cut the mucosa 0.2 cm outside the tumor boundary; B. Excised nasopharyngeal mucosal tissues under a plasma knife; C. Resection of the mucosa till the bone surface; D. Grinding the pterygoid process root bone; E. The right sphenoid sinus, medial and lateral plate of the pterygoid process, foramen rotundum, and vidian canal are shown; F. Resection of the right medial and lateral plate of the pterygoid process; G. The infratemporal region tumor tissue is shown; H. Resection of the subtemporal apex; I. The nasopharynx after the tumor is completely cut is shown.

鼻咽癌复发病灶的切除范围：内镜下鼻咽癌手术并不违背肿瘤外科学要求的整块切除病变原则。对于镜下可以明确病变范围的，一般以低温等离子刀作为切除工具，沿着肿瘤边界外0.2 cm处开始切除，平面上的病变切除相对简单，对于肿瘤深面的安全界限，一般切除直至骨质部分，骨性部分以电钻磨除。对于安全切缘的限定，有黏膜组织的以术中冰冻病理阴性为标准，取术野的上、下、左、右、深面切缘标本做快速冰冻检查。对于病变累及到软骨或骨性部分，因为冰冻病理对骨质无法鉴别是否有侵犯，故应尽可能磨除硬质骨，包括全部的翼突根部、斜坡浅面、鞍底、咽鼓管骨性部分(图2)。对于累及到海绵窦、硬脑膜和颈内动脉的病变，多属于rT₄晚期，在充分保障颈内动脉安全的前提下，尽可能全切肿瘤。也有学者[24]认为：rT₄期肿瘤已侵犯颅内和(或)颅神经、下咽、眼眶或颞下窝/咀嚼肌间隙，此期手术难度大、风险高，需要考虑到患者术后的生活质量和生存率，因此大多数时候仅能对肿瘤侵犯部位进行除重要神经、血管之外的区域切除，仅可达到肉眼和影像学阴性，难以做到肿瘤全切除。