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

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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.9 A 58-year-old woman underwent radical radiotherapy for nasopharyngeal carcinoma in March 2015, and accepted chemotherapy after recurrence of nasopharyngeal resection in June 2015 without surgical treatment
A-B. Lesion is controlled; C-D. August 2015; E-F. Lesion progresses in October 2015; G-H. In April 2017, nasal bleeding is controlled after conservative treatment. In August 2017, small repeated nosebleeds begin; I-J. On September 30, 2017, another episode of hemorrhage and hemorrhagic shock leads to hospital admission; K-M. The examination reveals a large area of ulceration of the left nasopharynx; The magnetic resonance image shows that the nasopharyngeal lesion eroded the left internal carotid artery. In the emergency department, internal carotid artery embolization was performed. On October 2, 2017, the patient died of hemorrhage.

表现为鼻咽癌放疗后鼻咽部组织坏死或颈部皮肤和软组织坏死,形成溃疡,反复动脉性出血，严重者可出现致死性鼻咽大出血。根治性放疗后出现的大出血有一定规律性，初期常表现为鼻咽部间断小量出血，一般在几十毫升以内，随着坏死进展，出血逐渐频繁，且出血量越来越多，多的时候可以达数百毫升，这时往往提示患者颈内动脉已经有了溃破或发生了假性动脉瘤，这时是抢救避免致死性大出血的最后时机，一旦颈内动脉大面积溃烂，患者往往在再一次的出血中失去抢救机会，即便做了动脉血管处理，后果依然严重(图9)。内镜下手术探查鼻咽部，清除感染坏死组织、保护颈内动脉,采用具有良好血供的组织瓣(带蒂鼻中隔黏膜瓣或阔肌筋膜、肌肉浆等)填充死腔、覆盖创面[30]。