鼻咽癌病案讨论

鼻咽癌病例一患者男性，39岁，因“颈部包块3+年，右头面部疼痛伴麻木4+月，复视1+月”就诊。患者3+年前无明显诱因发现右下颌角后下方肿大淋巴结，大小约lxl.5cm,质硬，边界不清，固定，无明显压痛。无鼻塞、回吸性涕血，无耳鸣、耳塞。患者自诉于当地医院行淋巴结针吸病检提示“炎性病变”，鼻腔镜检查未见新生物,未进一步诊治，右颈淋巴结缓慢增长。4+月前患者无明显诱因出现右侧头面部疼痛，呈阵发性刺痛，并渐出现右侧面部麻木、张口困难、咀嚼无力、右耳塞、右耳听力下降，无复视、回吸涕血。于当地医院就诊，患者自述诊断为“面瘫”，行针灸治疗，症状无缓解。3+月前患者无明显诱因出现回吸性涕血，无鼻塞。1+月前患者无明显诱因出现复视，视力无明显下降。体格检查：生命体征平稳。右下颌角后下方扪及一肿大淋巴结，大小约2.5*3.5cm，质硬，边界不清，固定，无压痛。双眼视力正常。右侧眼裂缩小，右眼瞳孔扩大，直径约4mm,对光反射灵敏。右眼外展受限。右耳听力下降。右侧鼻唇沟变浅，鼓腮时右侧嘴角漏气。伸舌右偏。心肺腹(一)。辅助检查：活检病理诊断：“鼻咽部坏死渗出组织旁查见少量异型细胞,免疫组化示PCK(+)，EMA(+)，EBER-ISH(+)，CD3(-),CD56(-),粒酶B(-)，结合形态学改变，考虑为低分化癌(非角化型)”。鼻咽、颈部MRI示“鼻咽右侧新生物，考虑鼻咽癌可能性大，累及右侧海绵窦、右侧翼腭窝、右侧咀嚼肌间隙、右侧后鼻孔、右侧头长肌、斜坡、右舌下神经管、右口咽。右上颈淋巴结肿大。”骨扫描、胸部CT、全腹超声未发现异常。EB病毒DNA为4.90*10"copies/ml。问题1：初诊时应考虑与哪些疾病的鉴别诊断？问题2：鼻咽癌常见的症状和体征有哪些？问题3：为明确诊断及分期，应依次安排哪些检查问题4：鼻咽癌的AJCC第八版分期内容？该病人的诊断和分期？T4N1M04人期(AJCC第七版)问题5：初治鼻咽癌治疗原则？该病人治疗方案的选择？

（1）治疗原则：见临床肿瘤学P97页Prtrtic酣Yafeii怖arfon1Ej1b.39I7*I1：b3^QHU.F>*Hr»rjuiarj.Sdap^iwK BatbdZ4npnb«raW«打wutr 展,&Hg*raRiui^k.NationalNCCNoi^Pfdi^iveNCCNGuideline$Version2.2。仃NCCNI：点CanceroftlieNasopharynxTREATMEJ'JTOFPRIMARYANDNECKFOLLOW-UPMultimadalitycllni&altnale(pre1eiT4d|ClinicalinalBIpr^rerr-QdlDrPlGUnuim-basedC4iriblnsti4richemotherapy®CLINICALSTAGINGD&filbiiliMeRTtonaaDpharyiiK-aindeleciiueIRTftnneckIndiictiondiHnci山如npy[匚油?5阳山怕II。删TREATMEJ'JTOFPRIMARYANDNECKFOLLOW-UPMultimadalitycllni&altnale(pre1eiT4d|ClinicalinalBIpr^rerr-QdlDrPlGUnuim-basedC4iriblnsti4richemotherapy®CLINICALSTAGINGD&filbiiliMeRTtonaaDpharyiiK-aindeleciiueIRTftnneckIndiictiondiHnci山如npy[匚油?5阳山怕II。删<1bvehflmOkRT11314 ••-厂：hen-reel a甘|IFQLL-AdOf用iidjijtfBnldicimoiiheraRyTH,Hl3：TS-Ti.田町M ►SeR-F口llaw-UpRec'DaniTi^e-ndatianx ►POiGCli&fr'i^iadl^likMhOfIRTIFOLl-A.2cl21Coneurrentcherno/RTffllno<followedbyadjuvanl |categoryRecurrentorPersiBtenlO-ise-MeIS；附■PIP甘3RT*Ijoprimal^andrrnk.Follow-up 「Clwmo/RTfi0|a&clrnicisllyindicDtcdi(SeeFOLLA)Rec；urT^nii<wPersistentUi细阴EConeurrent钊“网卅RTF".SeeiFoio^-ypRecQrHm^ndaiKmB亡he□「RT『FULLAMoT2i2）选择：患者属于局部晚期鼻咽癌，可选用放疗与化疗、靶向药物治疗的综合治疗，包括同期放化疗、新辅助化疗（诱导化疗）、辅助化疗。（临床肿瘤学）Multimodalityclinicaltrials(p-reftrred]orConcurrentchem&iRTfr9followedbyadjjvantchemotherapyfT1,N1-3;T2-T4.anyMorT1,N1-3;T2-T4.anyMConcurrentchernoJRTfr0notfollowedbyadjjvantchemotherapyfGatEgQr^2H)orIriductionchemotherapy(category3)9hfollowedbych^mo^RT^3

PRINCIPLESOFSYSTEMICTHERAPTThechoiceofsyetemlctherapy3lhduId&eIndividualizedbarsedlonpatientcharacterretlc；&[PS.goalsortlierapyj.Hiepreferredc-hefTioradibOierapyapproachforfitpatientswi1hloyallyodvfinceddi»e：D&e：remainswncurr^ntciakpl^dnjndradiQtheriipv・Cleplatln-ba&ednductlanchemo-therapycanbe“寻口旦Tollowedlb/radlatjonbasedlacoregion-altreatment(ie.Bequenuiallch^rmiORl).animprovcmeolinoverjllsurvivalwitihtJh«inftorporationofiinductionichcmothereipycomparedtoproceedingdir«c^iytostate-ol-[rtEi-fificanc：Liii«ntetemuRT(cl生pl和Inpr^r^rretl, 1|ihasnocbe^iieiialili&he也RandoivMjEidlpl诩eeIDgcuillgs；00kmpailngsequ^iiiialcliematfiflnpyiRTtoconcurr-entchemoth^rap/^RT-aloneorea-ngoiingsndhavenotdemonatratedo>{:DnvinGingsurvivalbenefitwitfitheoneofparslionafindiicTlotielienmcheflapy.CisplatinrbaB^dlndu^tianchemotherapyfollo弭odbyhi^h-dloaa.ever^-3-we^kcispLEVtincheirioniclioltierapyienotreconirnevideddu€toGQKicliiiycohceiiii4.1ja亠Afte『1用已uetioriah^inniatherap^r.multipleaptionecanbeusedfo『1hBr-adistjon-bas^d|pi3rtorioftherapy.RadiotliBnpyaloneversuaradi^thereipirplus carhofilsrin©rMtmiimab世usmio-ngthuop^oinsrSxiiianouma匚已ii匚Sxiiianouma匚已ii匚aacfeLiLirOralC^i’rty.OrcpnaryriM,H*pci||>nQryn城・Glottic：LJirvinx・§Li]HAQliZiHiuLNrymE[hi"i：iiiJ§油1岭_Miijdll;耳iy§油1岭_匚蚯亡・1[PiiiHiliy：Primary therapyconiCUUEntRTHiuh-doscciaplabn^^lprefcrrtdl(cjtegoij1}Cetuximab*(category1]rororophsr^nx.h/popharynx.orlarynx;tatisDorj/forlip,owlravity,罰hrnofcl疾皿即晶maiilllwrywiinu离occultpnmsry^Carboplaiiini/infusionall5-FU(c^icgor^1)E-rS-FUiHydroxyur^a3Cisplatin/fhaclrUxcCiapl^lin/irihisiDiial5-FUstCtirbopleitirk^aclitaxel"19(catcgar^2B|iwWeaklycbsfatailin n増MF忙■ateg心ry卫日;P九12-PostopwaitivethemoradialionCiapla1iiV3-1?(疋丽£0ory1forhigri-ri^k4'nDii-aropliaryngea]cancers)Mgmlorvn总ChcfT»orarffitiliD<iFoilowedby ctucniQihefFip/Cisplolin*口ITfolkiwedbyciBplErtinjyS-F'U1®-15ormrhQpIMiiiilSTll"(category20Fo<tarbo-plaHinn'S-FU)«Cisplatin+RTwithoutadpu^antah^miatheirapyiGotcgor^2B|s21Lip.ChiFilIlijiWilF-Ch心pTi^ryiljc.1~1丫|：1口卩11岂1¥门厦”|；1心【11亡L自iyilijL$up「3i口kittiELaryiiM・Etftmcikl名inu%川誇刈lliairv:ginij%■OeeijitPiimriy：・InductJon^/Sequ^nUalchsmotherapy・"8曲闡创紀ispIMin咼尸1」也祖(stugprF1iriFiduc^ionischtjsen>卜Pacilcaxel/clspiatlnnnmsional5-FLr5■Followinginductioni,越口硏口恬Uobuused«rllhQunrcurrtntcnemorsdlalii^nt^'pie^il^Includeweeklyc^rbopl^tlnor・Inductjon(category3)^equenUalldn^MiQtherap^rDoeelsjel^ls^nadiVS-FU^®Dgutasf右lkia<应tin<|category'2宦戸Cilapl3lln/5-FUM»■Cisplotin/cpinijbiGin'pocilitaicclFolto^injin^lLucilon.卸自哋s他beused«*MJiconn^rrenlch^moradiotiGntypioeillvincludew&ekl^ciaplalin1j，or■tarboplatin36•；ni~dill和尺rlcnnr：il~1）放疗方式选择：（待查）PRIPJCIPL三乞口FRA.DIATIOMTH三R离PH，DEF脚ITN巳RTAlore(IF<*irTq.NOorpat»ritswlhoar-enotelliigibletoreccirvech@rmoth-eriapy)IPTV ^Hrgihrisk:Priiiriiarytumorandinivoltvedlymphnodes(thisincludespossiblelocalsubclinicalinfiltrationiattheprimarysiiteandatthehigh・「同比levellymphnode(s))0GGGy{2.2Gy/frsciiori)to7C^70.2Gy(1.B-2.0Gy/frsc：ti*n]i：daiiII}/Monday-Fridayin6-7weeks^^C69.96Gy^2.112Gy/fraction)dailyMonday-FridayiinS-7weeks4Lowtointermediaterisk:Sites,ofsuspectedsubclinicalspread44-50Gy42.0Gy/fraction|to54-63Gy(1.6-1.8Gy/ftaction)5CONCIIRRENTCHEMOR典DIATION声(preferredforpatientseligibleforcliemotlierapyj<IPTVHighrisk:typically70-70.2Gy(1■®-2.0Gy/fraction):dailyMonday-Fridayiri7weeks2Lowtointernnediatemk:44-60Gy(2.0Gy.fraction)to54-63Gy(1.6-1-8Gy/fraction)5IMRTisprefe『阳dover头DconfornnalRTincance『ofthenasopharynxtoiriiininnizedoseto€ritualstructures.调强适形放疗(intensitymodulatedradiationtherapy,IMRT):鼻咽癌首选的治疗方式IGRT（鼻咽癌推荐的放疗方式，减少摆位误差，更加精准）与ART（可根据治疗过程肿瘤变化的情况自我调节后续放疗计划，提高精准性，降低放射性并发症发生概率）2）初治化疗方式选择:I新辅助化疗（放疗前化疗，诱导化疗）:可提高无病生存率，但未能显著提高总生存率。常用有PF、TPF、GP等。II同步放化疗：可提高局部中晚期鼻咽癌局部控制率和总生存率。常用单药铂类（顺铂、卡铂等）。推荐此项。（铂类药物选择待查）辅助化疗（放疗后化疗）：未有局部控制或生存上的获益，不推荐。DiscussionNCCMCategoriesofEvidenceandConsensusCategory1:Bas&duponhrgh-lsv«levidenee,thereisunffamnNC-CNconsensusthattheinftsrvsntionis即■pr申riiste.CategorySA:Basedupcnlow^rtevdevidence,thereis-uniformNCCNconsensusthatthe-interventioiisappropriate.Category2B;BaseduponIo时-bevelevidence,thereisNCX3Nconsensusthattheirnerventionisappropriate.Category3:Basexiuponanylevelofevidence,thereismajorNCCNdisagreementthattheinterventionisappropriate.AJIr«comnien