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研究生:吳忠倫
研究生(外文):Chung-Lun Wu
論文名稱:回朔性分析口咽鱗狀上皮細胞癌患者無臨床淋巴轉移之對側頸部的治療結果
論文名稱(外文):A Retrospective Analysis of Therapeutic Outcomes for the Contralateral cN0 Neck in Patients with Oropharyngeal Squamous Cell Carcinoma
指導教授:張文正
學位類別:碩士
校院名稱:長榮大學
系所名稱: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:2012
畢業學年度:100
語文別:中文
論文頁數:57
中文關鍵詞:口咽癌淋巴轉移治療
外文關鍵詞:oropharyngeal cancerneck metastasisoutcome
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在頭頸部上呼吸消化道的癌症中,包括口腔癌、鼻咽癌、口咽癌、下咽癌及喉癌。由於頭頸部的構造複雜且淋巴循環豐富,發生在頭頸部的癌症經常藉由淋巴系統轉移至同側頸部的淋巴結。在胚胎發育形成的過程中,口咽部位居中線處的構造是由兩側的胚層融合而成,故中線處器官的淋巴系統會同時引流至雙側的頸部。當癌症發生於近中線處或甚至跨越中線的位置時,便容易出現對側頸部或雙側頸部的淋巴轉移。
頭頸部上呼吸消化道的癌症最主要是以手術的方式治療,包含原發腫瘤切除與同側頸部淋巴廓清術,再針對較具進展性的癌症施以輔助性放射線治療(合併或不合併化學治療)。口咽鱗狀上皮癌對放射線治療敏感性佳,反應僅次於鼻咽癌,是少數可以單獨以放射線治療(合併或不合併化學治療)治癒的癌症。
當頸部淋巴轉移的機率超過20%時,即便是臨床檢查時無發現淋巴轉移,針對頸部的治療是被廣泛建議的。許多研究均指出頸部淋巴轉移是口腔與口咽鱗狀上皮癌患者存活率最重要的預測因子。手術治療可同時具有診斷、治療、與評估預後的優點;放射線治療屬於低侵入性的治療方式,較不影響音聲及吞嚥機能。在口咽鱗狀上皮癌患者,針對臨床檢查時無發現淋巴轉移的對側頸部的治療方式是相當重要但卻仍然具有爭議的課題。
本回朔性研究分析單純放射線治療、手術合併放射線治療、與未接受治療三種不同的治療方式,針對臨床檢查時無淋巴轉移的對側頸部,各種治療方式均可達到相同的控制效果,但須定期追蹤以免影響預後。雖然本研究存活率並無顯著差異存在,與其他學者研究的結論類似,卻仍有治療越複雜存活率越低的趨勢,尚需大型前瞻性的研究再做進一步的討論。對存活率的最大影響因素還是診斷時的癌症期別,包括T3-4與N3都是預後的不良因子。早期診斷、早期治療、定期追蹤才是增加存活率的不二法門。


There are many kinds of cancers located in upper aerodigestive tract in head and neck area, including oral cancer, nasopharyngeal cancer, oropharyngeal cacer, hypopharyngeal cancer, and laryngeal cancer. Because of complicated structures and aboundant lymphatic drainage, it’s not rare that lymph nodes metastasis can occur in ipislateral neck in head and neck cancers. During the development of human embryo, the midline structures in oropharynx are fused by bilateral germinal layers. Therefore, the lymphatic drainage of the midline organs can be toward bilateral lymphatic systems of neck. When the cancers locate near midline even cross midline, contralateral neck metastases or bilateral neck metastases can easily occur.
The gold standard treatment policy for cancers located in upper aerodigestive tract in head and neck area is surgery, including primary tumor resection and ipislateral neck lymph node dissection, and adjuvant radiotherapy with or without chemotherapy is suggested for advanced cancers. Oropharyngeal squamous cell carcinoma(SCC)is highly sensitive to radiotherapy, and the response rate is only inferior to nasopharyngeal cancers. Using radiotherapy with or without chemotherapy, oropharyngeal squamous cell carcinoma can be primarily cured.
It’s widely accepted that treatment for clinically nodal negative(cN0)neck is suggested when the probability of neck lymph node metastasis is over 20%. The presence of cervical node metastasis is the most important predictor of survival for patients with squamous cell carcinoma of the oral cavity and oropharynx. There are many advantages with surgical treatment, including prognostic evaluation, diagnostic and therapeutic benefits; however, radiotherapy belongs to low-invasive way of treatment, and can preserve better voice and swallowing functions than surgery.
Therapeutic management of the contralateral cN0 neck is an important but still controversial issue in patients with oropharyngeal squamous cell carcinoma.
The purpose of this retrospective analysis was to evaluate the therapeutic outcome of radiotherapy, surgery with radiotherapy, and observation only in patients with oropharyngeal squamous cell carcinoma. There is no difference in the regional control rates of contralateral cN0 neck in the three different treatment groups, but regularly follow up is necessary for better prognosis. Although there is no difference in overall survival rates in this study, compatible with other researches, there is a trend of more treatment modalities, more poor survival, but further large study is needed to confirm this finding. The most important factor for survival is the cancer stage when first diagnosed, while T3-4 and N3 are factors for poor prognosis. Early diagnosis, early treatment, and regularly follow up are key factors to increase survival rates.


目 錄
頁次
英文縮寫 I
中文摘要 II
英文摘要 IV
壹、導論 1
一、頭頸部的癌症 1
二、頭頸部癌症的病因及危險因子 2
三、頸部轉移對預後的影響 3
四、台灣的口腔及口咽癌現況 4
五、口腔及口咽癌的治療 5
六、手術治療的優缺點 7
七、放射線治療的優缺點 8
八、合併手術治療與放射線治療的文獻探討 10
九、對側頸部不接受治療的文獻探討 10
貳、研究構想 12
參、研究材料與方法 13
一、研究材料 13
1. 患者特徵 13
2. 癌症原發部位、組織分化、與分期 13
3. 治療方式與追蹤期間 14
二、研究方法 14
1. 病患分組 14
2. 統計方法 15
肆、結果 17
一、各治療組別年齡與追蹤時間分析 17
二、各變異項在各治療組別內的分布情況分析 17
三、各變異項跟癌症死亡的相關性 18
四、各變異項跟對側頸部轉移的相關性 19
五、各治療組別的存活分析 19
六、T分期再分組的存活分析 19
七、N分期再分組的存活分析 20
八、單變異項與多變異項Cox比例風險回歸分析 20
伍、討論 21
陸、結論 26
柒、參考文獻 27
捌、表 39
表一:各治療組別年齡與追蹤時間分析 39
表二:各變異項在各治療組別內的分布情況分析 41
表三:各變異項跟癌症死亡的相關性 42
表四:各變異項跟對側頸部轉移的相關性 44
表五:各治療組別的存活分析 46
表六:T分期再分組的存活分析 47
表七:N分期再分組的存活分析 48
表八:單變異項與多變異項Cox比例風險回歸分析 49
玖、圖 50
圖一:各治療組別的存活分析 50
圖二:T分期再分組的存活分析 51
圖三:N分期再分組的存活分析 52
拾、附圖 53
附圖一:頸部淋巴結分布的區域 53
附圖二:NCCN Guideline for Cancer of the Oropharynx 54
附圖三:American Joint Commission on Cancer(AJCC)分期系統原發腫瘤大小(T)的分期 56
附圖四:American Joint Commission on Cancer(AJCC)分期系統區域淋巴轉移(N)的分期 57


行政院衛生署,民國97年癌症登記報告;台北:行政院衛生署

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