口腔颌面部肿瘤总论_ 上海交通大学医学院精品课程课件

口腔颌面部肿瘤总论( 二) 季 彤 上海第二医科大学 口腔医学院 附属第九人民医院 口腔颌面外科 n口腔颌面肿瘤的治疗 n治疗原则 n治疗方法 手术、放射治疗 、化疗、生物治疗、其它 n口腔颌面肿瘤的预防 口腔颌面部肿瘤的治疗 治疗原则 n综合治疗 n个体化方案（individualization） 因人因病 量体裁衣 根治外科和功能外科并重 n良性肿瘤：手术治疗 n恶性肿瘤：综合序列治疗 combined and sequential therapy 化疗手术放疗其它 根据组织来源、细胞分化程度、肿瘤生长部位、临 床分期(TNM)及全身情况选择 n组织来源 来源不同，治疗方法不同 上皮来源 间叶来源 淋巴造血系统 骨肉瘤 n细胞分化 分化好手术 分化差放、化疗 n生长部位 颅底、深部、重要结构功能障碍 面部、皮肤、颌骨肿瘤手术 n临床分期 早期 晚期综合治疗 TNM分期(UICC) n全身情况 口腔颌面部肿瘤的治疗方法 n手术治疗(Surgery) 根治术与功能外科的概念，无瘤原则 n放射治疗(Radiation therapy) n化疗(Chemotherapy) n生物治疗(Biotherapy) 免疫治疗(Immunotherapy) 手术治疗原则 n明确诊断 n明确手术作用，制定合理治疗方案 诊断，探查，治愈，姑息，修复重建，预防 n全面考虑，选择合理术式 n保存性功能性外科 (conservative functional surgery) n修复性功能性外科 (reconstructive functional surgery) n防止医源播散 无瘤原则 切缘在正常组织内 整块切除（en bloc） 避免挤压 肿瘤表面纱布覆盖 使用电刀 冲洗更换器械 n根治与功能并重 Tongue Reconstruction Mandible Reconstruction Radiation Therapy nProf. Rontgen X ray Prof. Marie Curie Radium element nDefinition ionizing radiation nComponent of multi-modality therapy nIncreasing use for head and neck cancer nPrinciple nRadiation sensitive nTypes of radiation therapy External beam(外照射) vs. Brachytherapy(腔内照射) nCommon complications General Principle nBasis ionizing(电离) particles interact with cellular molecules nDamages DNA n impossible for the cells to grow nDamages both cancer and normal cells, the latter are able to repair themselves nUsed to: nCombined or as single modality nTreat localized tumors nTreat leukemia and lymphoma nRapidly dividing cell populations are the most sensitive to radiation tumors, epithelial cells, hemopoietic cells(造血细胞) RadiobiologyRadiobiology External beamExternal beam Electron linear accelerator 直线加速器 Gamma rays(Co60) To patient Shielded container Radioactive sources Flexible hose Catheter Radioactive wire Radium “needles” After loading BrachytherapyBrachytherapy Internal radiotherapyInternal radiotherapy Treatment plan system Complications nAcute Tissue Reactions nLate Tissue Reactions Acute Toxicity nMucosal reactions 2nd week of XRT Mucositis nSkin reactions 5th week nGenerally subside several weeks after completion of treatment Late Toxicity nInjury tends to be permanent nDevelop within months to years nXerostomia(口干症), radionecrosis of bone, dental caries, fibrosis, soft-tissue necrosis, nerve tissue damage Chemotherapy nOne of the main technologies against cancer nDefinition nNot curative, used only as an adjunct nFirst applied in 1946 nUsed to: nCure cancer nControl cancer nRelieve symptoms cancer can cause nUsually used in addition with the other treatments nCan be given: nAt home nDr.s office nClinic nOutpatient dept. nAs an inpatient in a hospital nClassification of chemotherapy drugs Chemical structure cell cycle the drug interrupts nProtocol of chemotherapy mono drug and combination drug nSide effect of chemotherapy nCell and Tumor Kinetics nG1synthesis RNA nSDNA synthesis nG2synthesis of mitotic spindle nG0rest nMmitosis Chemotherapeutic Agents nAlkylating agents(烷化剂) nAntimetabolites(抗代谢类) nAntitumor Antibiotics(抗生素) nSteroid hormones(激素类) nPlant Alkaloids(植物类) Alkylating Agents nLink to DNA bases stop replication nNitrogen Mustards, HN2 Cyclophosphamide, CTX Antimetabolites nInhibit synthesis of bases nMethotrexate n5-Fluorouracil Antitumor antibiotics nPingyangmycin nBleomycin nAdriamycin nMitomycin nActinomycin D Hormones nPrednisone nEstrogen nTestosterone Plant Alkaloids nDisrupt mitotic spindle during M phase (cell cycle phase specific) nVinca Alkaloids Camptothecins Taxanes Cell Cycle Cell Cycle Specific Agents Antimetabolites Bleomycin Podophyllin Alkaloids Plant Alkaloids Cell Cycle Non-Specific Agents Alkylating Agents Antibiotics Cisplatin Nitrosoureas Chemotherapy Protocol nOften combination of agents nDifferent modes of action nReduced chance of resistance nReduced toxicity nOften combined with other treatments (Adjuvant) nPre nReduce tumour load nPost nReduce sub-clinical disease nCombination Chemotherapy nmore effective than single agent nadditive antitumor effects without additive host toxicity ndelayed resistance to drugs nUse nRapidly dividing tumours most susceptible nBalance between efficacy and toxicity Side effect of chemotherapy nmyelosuppression, low blood cell counts ngastrointestinal tract problems nhair loss nskin rashes nfatigue ninfertility ErythemaErythema（红斑）红斑） Hairy tongueHairy tongue Candidiasis(念珠菌病) nBiotherapies or Immunotherapy (免疫治疗) nCryotherapy (低温治疗) nLaser Surgery (激光外科) nThermotherapy (加热治疗) nChinese Medicine (中医药治疗) nGene Therapy(基因治疗) nImmunotherapy (active) sNon-specific bacillus Calmette-Guerin(mycobacteria) interferons interleukins sSpecific tumor cell vaccines gene therapy nPassive Immunotherapy smonoclonal antibodies Laser Surgery Naked DNANaked DNA Target Target CellCell Therapeutic Therapeutic ProteinProtein AAVAAV Retrovirus/Retrovirus/LentivirusLentivirus AdenovirusAdenovirus NucleusNucleus Gene Therapy Principles Prevention of oral & maxillofacial tumor nDelete the risk factor nTreatment of precancerous lesion nAnticancer propaganda Leukopl