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研究生:黃啟哲
研究生(外文):Chi-Che Huang
論文名稱:鼻咽癌病人於放射治療前和放射治療後之鼻竇黏膜疾病的特色及演變
論文名稱(外文):The Characteristics and Evolution of Pre-irradiation and Post-irradiation Sinus Mucosa Disease in Nasopharyngeal Carcinoma Patients
指導教授:李達人李達人引用關係
指導教授(外文):Ta-Jen Lee
學位類別:碩士
校院名稱:長庚大學
系所名稱:臨床醫學研究所
學門:醫藥衛生學門
學類:醫學學類
論文種類:學術論文
論文出版年:2007
畢業學年度:95
語文別:英文
論文頁數:34
中文關鍵詞:鼻竇黏膜疾病核磁共振攝影鼻咽癌
外文關鍵詞:sinus mucosa diseasemagnetic resonance imagingnasopharyngeal carcinoma
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研究目標:使用核磁共振攝影來研究在鼻咽癌病人於放射治療前和放射治療後之鼻竇黏膜疾病的發生率及其促成的危險因子。同時,並觀察及探討放射治療引起的鼻竇黏膜疾病的臨床演變。

實驗設計:
1.案例對照研究
2.回溯性研究

實驗方法:回溯性研究病人的病歷及核磁共振攝影結果,以Lund-Mackay 鼻竇炎評分系統作工具予以評分。

實驗結果:
1.於放射治療前鼻咽癌病人鼻竇黏膜疾病的情況:
在鼻咽癌病人於放射治療前鼻竇黏膜疾病的發生率為32.1%,而對照組(非鼻咽癌病人)的發生率為20.1%,兩者間有明顯統計上的差異(P=0.041),在鼻咽癌病人相較於對照組病人有較高機會有鼻竇黏膜疾病存在。而在鼻咽癌病人中所有鼻竇黏膜疾病的發生率都較對照組為高,但只有後篩竇(P=0.002)及蝶竇(P=0.006)的黏膜疾病發生率有達到統計上的意義。而在鼻咽癌病人當中,鼻竇黏膜疾病的發生率及嚴重度,在男性病人有明顯比女性病人為高;而在臨床分期T stage愈嚴重者也比早期T stage的病人有較嚴重程度的鼻竇黏膜疾病(P=0.015) 。
2.於放射治療後鼻咽癌病人鼻竇黏膜疾病的變化:
放射治療後將使至少三分之二原本無鼻竇黏膜疾病的鼻咽癌病人產生鼻竇黏膜疾病。上頜竇、前篩竇及後篩竇是最常被影響的地方。當觀察不同時段放射治療後病人的鼻竇黏膜疾病嚴重度的Lund score評分,可發現在放射治療後3個月最為嚴重,而在放射治療後前3年有逐漸緩減的現象。且以放射治療後三個月的鼻竇黏膜疾病嚴重度為參考指摽時,可見有抽菸習慣和較嚴重的T stage是影響Lund score的兩個重要因素。而放射治療劑量在我們的病人當中,並非一個重要的決定因素。

結論:
在排除鼻咽腫瘤阻塞而致鼻竇黏膜異常的因素後,在鼻咽癌病人確實比對照組病人有較高的鼻竇黏膜疾病發生率,臨床分期愈嚴重的病人其鼻竇黏膜疾病的嚴重程度愈厲害。這結果佐證鼻咽癌病人在診斷時較易因EB病毒感染而產生部分的免疫不全及持續性感染的現象,以致於較易產生鼻竇黏膜疾病;特別是在臨床T stage愈嚴重的病人。而在女性病人,可能因為先天遺傳因子及免疫內分泌系統的差異,較不易因EB病毒感染而產生後續的持續感染及致癌現象。但仍需進一步的研究。
而在這些鼻咽癌病人接受進一步放射治療後,在放射治療後3個月時是鼻竇黏膜疾病最嚴重的時侯,此後隨時間有逐漸緩減的現象。在初期保守性的治療方式而非手術治療應是較為適當的方法。若想以手術治療也最好在放射治療3年後施行。在我們病人當中,因接受了相對性較高的放射劑量,故放射劑量並非預測鼻竇黏膜病變嚴重度的參考因素;抽煙習慣及愈嚴重的T stage才是決定鼻竇黏膜疾病的重要因素。
Objectives/Hypothesis:
We sought to determine the incidence and the risk factors for pre-irradiation and post-irradiation sinus mucosa disease (SMD) in nasopharyngeal carcinoma (NPC) patients by magnetic resonance imaging (MRI). Meanwhile, it is also expected that the clinical evolution of radiation-related SMD could be clarified.

Study Design:
1. Retrospective
2. Case-control

Methods:
The medical records and MRI results were reviewed. Lund-Mackay system for staging of rhinosinusitis (Lund score) was used as a tool for investigation.

Results:
1. The pre-irradiation sinus mucosa disease in nasopharyngeal carcinoma patients:
The incidence of SMD in NPC group was 32.1% and 20.7% in the control group, which was statistically significant (p = 0.041). The patients with NPC demonstrated a higher incidence of SMD than the control group in nearly all sinuses. However, only the incidence of the posterior ethmoid (p = 0.002) and sphenoid sinus diseases (p = 0.006) significantly increased in NPC patients. The incidence and the severity of SMDs among male NPC patients were significantly higher than among female NPC patients. The severity of SMD in patients with advanced T stage was significantly higher (p = 0.015) than that in patients with early T stage.
2. The post-irradiation sinus mucosa disease in nasopharyngeal carcinoma patients:
Radiotherapy (RT) in NPC patients would induce SMD in at least two third of patients who had normal sinus ventilation before RT. The maxillary, anterior ethmoid and posterior ethmoid sinuses were more easily affected. When comparing Lund score at different time, a significant decrease in Lund score could be noted between 3 months and 3 years after irradiation. In patients with SMD at 3 months post-RT, advanced tumor stage and smoking habit were the two variates found to influence Lund score. The RT dose was not a good predictor for post-irradiation SMD in our patients.

Conclusions:
After excluding those patients whose secondary sinus abnormalities were caused by tumor obstruction, there was statistically significant increase in the incidence of SMD in the NPC group than the control group. The more advanced NPC was, the more severity of SMD was. The results supported the hypothesis that patients of NPC at initial diagnosis might be prone to suffer from chronic infection and partial immunocompromised by EBV and developed SMD, especially in patients with more advanced T stage. In contrast, the female may have a genetic advantage in protection from EBV infection or lessen the devastating effect after being infected. The immunoendocrine system, inherited genetics and EBV infection might play roles in this phenomenon, but yet to be determined.
After these NPC patients received further radiotherapy, the incidence and severity of post-irradiation SMD was found to be highest at 3 months post-RT and decreased gradually with time. Conservative management instead of surgery should be tried in these patients firstly. The proper timing for surgical intervention may be at least 3 years post-RT. Because a relatively higher RT dose in these NPC patients, advanced tumor stage and smoking habit instead of RT dose would cause SMD development and aggravation after RT.
Table of Contents
Table of Contents
Abstract
中文摘要
CHAPTER I :Introduction………………………………… 1
1.1 Background………………………………………………… 1
1.2 Objectives of the Study……………………………… 3
CHAPTER II :Experimental Setup……………………… 4
2.1 Tumor staging and Lund-Mackay staging system…………… 4
2.2 The condition of MRI exam………………………………… 4
2.3 The dosage of radiotherapy…........................................ 5
2.4 The study of pre-irradiation sinus mucosa disease in nasopharyngeal carcinoma patients……..……………………… 5
2.5 The study of post-irradiation sinus mucosa disease in nasopharyngeal carcinoma patients………………………… 5
2.6 The statistical analysis …………………………………6
CHAPTER III :Experiment Results………………………………8
3.1 The pre-irradiation sinus mucosa disease in nasopharyngeal carcinoma patients…………………………………………… 8
3.2 The post-irradiation sinus mucosa disease in nasopharyngeal carcinoma patients………………………………………… 11
CHAPTER IV :Results and Conclusions………………………… 18
4.1 EBV-Mild Acquired Immune Deficiency Syndrome…………18
4.2 Gender difference and pre-irradiation sinus mucosa disease…21
4.3 The incidences and distributions of sinus mucosa disease
before radiotherapy ……………………………………………22
4.4 The post-irradiation sinus mucosa disease……………………23
CHAPTER V :Conclusions and Recommendations…………… 28
REFERENCES………………………………………………………30
Appendix……………………………………………………………35
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