Добавил:

Sekretar kiopkiopkiop18@yandex.ru t.me/Prokururor I Вовсе не секретарь, но почту проверяю Опубликованный материал нарушает ваши авторские права? Сообщите нам.

Вуз:

Ростовский Государственный Медицинский Университет

Предмет:

Медицина общая

Файл:

Книга_4624_Библиотеки_им_академика_М_И_Перельмана

.pdf

Скачиваний:

Добавлен:

15.09.2026

Размер:

13 Мб

Скачать

☆

<<< < Предыдущая 1 2 3 4 5 6 7 8 9 10 11 1213 / 2213 14 15 16 17 18 19 20 21 22 > Следующая >>>

9 Prostheses for Cosmetic and Functional Restoration After Ablative Surgery…

https://t.me/medicina_free

105. Jodat YA, Kiaee K, Vela Jarquin D, De la Garza Hernández RL, Wang T, Joshi S, et al. A 3D-printed hybrid nasal cartilage with functional electronic olfaction. Adv Sci. 2020;7:1901878.

115

External Beam Radiotherapy forNose

https://t.me/medicina_free

Vestibule Malignancies

IdaD’Onofrio, RobertoGallus, FabrizioSanna, DalilaDi Mario, EmiliaDegni, SalvatriceCampoccia, LucaTagliaferri, andYunGanTao

10.1 Introduction

Squamous cell carcinoma of the nasal vestibule (NV), which is the most common NV cancer, is relatively rare (<1% of H&N cancer), even if probably its incidence is underestimated, and presents, as described in the previous chapters, several anatomical clinical and histological peculiarities when compared with malignancies of the nasal cavity proper and skin (see Chap. 3) [1, 2]. In general, the prognosis is

I. D’Onofrio Radiation Oncology, Ospedale del Mare, ASL Napoli 1 Centro, Naples, Italy e-mail: ida.donofrio@aslnapoli1centro.it

R. Gallus ( Otolaryngology, Mater Olbia Hospital, Olbia, Italy e-mail: roberto.gallus@materolbia.com

F. Sanna · D. Di Mario Institute of Radiological Sciences, Azienda Ospedaliero Universitaria, Sassari, Italy e-mail: fabrizio.sanna@aouss.it; dalila.dimario@aouss.it

E. Degni Otolaryngology Division, Azienda Ospedaliero Universitaria, Sassari, Italy e-mail: emilia.degni@aouss.it

S. Campoccia Radioterapia Oncologica, Ospedale “San Francesco”, Nuoro, Italy e-mail: salvatrice.campoccia@aslnuoro.it

L. Tagliaferri UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A.Gemelli, IRCCS, Rome, Italy e-mail: luca.tagliaferri@policlinicogemelli.it

Y. G. Tao Department of Oncology-Radiotherapy, Gustave Roussy, Villejuif, France e-mail: Yungan.tao@gustaveroussy.fr

https://doi.org/10.1007/978-3-031-32850-3_10

117

118

https://t.me/medicina_free

considered favorable, with 3-year locoregional control and overall survival rates ranging from 67% to 92% and from 50% to 90%, respectively [3–5].

The most frequent presenting symptoms and signs are not specic, including nasal airway obstruction, associated with epistaxis and rhinorrhea, and this causes a delay of the diagnosis. Also, as the most frequent presenting site is the perinasal skin, these cases are often primarily referred to plastic surgeons and dermatologists, which misclassify them as primary skin cancer with improper primary denition of the extension and of the origin of the tumor [6].

Due to the rarity of the condition and to the lack of randomized/prospective studies, a class I evidence is missing. The therapeutic decision is based on a retrospective series with a limited number of patients, enrolled over a long period of time.

I. D’Onofrio et al.

10.1.1 Potential Predictive Factors, Data toGuide

Treatment Recommendation

The series describing NV SCC are few and generally small. Different authors describe different putative predictive factors with the potential to guide treatment decisions. No denitive conclusion can currently be drawn on the subject.

The tumor extension can have an impact on the treatment choice: septum inva- sion has been reportedly associated with a signicantly higher risk of recurrence [7,

8]. In particular, the involvement of deep tissues of the septum and the columella,

especially around the anterior nasal spine, had been described to have a worse prognosis when treated with radiotherapy alone [9].

Tumors of the oor of the vestibule, extending into the upper lip, and of the alar wall, invading the underlying cartilage, have been often considered unsuitable for surgery, due to poor cosmetic results, difcult to correct even with complex reconstructions [10]. The tumor size seems to have an impact on local control (LC) as well [4, 11]. Wong etal. [12] found that tumor size of 2cm or more and the involvement of the lip, the columella, and the skin of the ala nasi were associated with a worse LC rate. Wray etal. found that patients who received radiotherapy alone had an excellent disease control except for tumors with a maximum diameter of more than 4cm [4]. Compared with similarly sized T1-T2, T4 cancers according to AJCC, with a diameter of less than 4cm, had no higher risk of local recurrence [13]. No difference was found in the probability of LC after radiotherapy of newly diagnosed primary lesions compared to that of recurrences after previous surgery [4]. Tumor diameter >1.5 cm and T2 stage are associated with a decreased regional control [14]. Poor histologic differentiation is a risk factor for poor LC [15]. Not surprisingly, patients with clinically metastatic neck lymph nodes (cN+) have a poor prognosis and might have benets from more aggressive/combined treatment [11]. In our opinion, neck dissection remains the mainstay of treatment for patients with metastatic lymph nodes in the neck.

In any case, clear evidence supporting one treatment modality versus another is lacking, and the choice of the treatment is described more extensively in other chapters of this monograph. The foregoing chapter will focus on technical aspects

10 External Beam Radiotherapy forNose Vestibule Malignancies

https://t.me/medicina_free

and clinical outcomes of external beam radiotherapy (EBRT) for nasal vestibule cancers.

119

10.1.2 EBRT

Radiotherapy has a role as primary treatment for early-stage nasal vestibule cancer and in the postoperative setting for advanced lesions. Radiotherapy modalities vary among different treatment centers from external irradiation alone, interstitial brachytherapy alone, or combinations of external irradiation and brachytherapy (BRT).

EBRT alone is indicated for small primaries with cN0 necks, cT3 (according to Wang classication) and/or cN+ cases are often treated with concomitant chemotherapy (usually cisplatin).

In any case, it is hard to compare the different series for several reasons: (1) no universally recognized classication (see Chaps. 4 and 5), (2) different radiation treatment modalities and schedules used across the years, (3) radiotherapy treatment often highly individualized without clear denition of the criteria and available guidelines.

10.1.2.1 Early Stage (T1–T2 According toWang)

In early stages, radiotherapy or surgery could result in equally good oncological outcomes [16] producing LC rates of 90% or more. Choice of treatment is based on size, extension, and anticipated cosmetic outcomes. Surgery is a good option for small, well-delineated, and supercial lesions [17], usually not invading the skin [10]. Several reports proposed radiotherapy as primary treatment in early stages for its better cosmetic results compared to surgery [3, 12, 13, 16, 18, 19].

In a retrospective study by Langendijk etal. [3], primary EBRT (with or without endocavitary brachytherapy boost) is the standard treatment for T1 and T2 patients, according to the WANG system. The choice of radiation technique depended on tumor extension and radiation oncologist’s experience. Specically, EBRT alone was reserved for tumors involving the upper lip. Primary radiotherapy was considered effective for early stage tumors, resulting in 2-year LC of 80%, with a 2-year ultimate LC rate of 95%, after salvage surgery.

In fact, in another retrospective study, Levandang etal. [11] reported only 3% of recurrence in patients treated by brachytherapy alone versus 13% and 38% in EBRT only and combined EBRT-brachytherapy groups, respectively, which may be due to selection bias (the majority of T2 stage was treated with combined modality).

In a report by Vanneste etal. [20], patients with T1 or selected T2 (no bulky, no invasion of upper lip or nasal septum) were treated with interstitial brachytherapy. Other T2 and T3 patients were treated with EBRT.LC rate for T1 was extremely high (97% at 5years). For T2, recurrences were observed only in the EBRT group, probably attributable to the selection bias. This report conrmed that higher T class was associated with poorer LC (only 53% for cT3 tumors according to Wang’s classication).

120

https://t.me/medicina_free

In fact, in a multivariate analysis, Wray etal. [4] found no signicant differences between radiation treatment modalities (BRT alone, EBRT alone, or combined BRT-EBRT) in terms of LC, local-regional control (LRC), distant metastases (DM), overall survival (OS), and cause-specic survival (CSS). On a stage-by-stage basis, the overall LC in early-stage tumors was 100% with BRT alone, 88% and 86% with combined EBRT-BRT and EBRT alone, respectively.

No specic parameters contraindicating radiotherapy as primary modality were found in retrospective studies. Mccollough [13] noted that cartilage invasion was not associated with worse LC rates in patients treated with radiotherapy alone.

However, a recent multicentric analysis [14] describes that BRT provided higher 3-year LC and nose preservation rate, compared with EBRT (95% vs. 71%), also in multivariable risk-stratied analysis, in cT1-T2 (according to Wang) NV carcinomas. This would conrm studies reporting lower survival and worse LC rates of EBRT compared to brachytherapy or surgery [11, 19].

I. D’Onofrio et al.

10.1.2.2 Advanced Stage (T3 According toWANG or More

Than 4cm)

In a denitive radiotherapy setting, EBRT treatment combined with chemotherapy has been recommended in large size and/or deep inltrating tumors, solely or in combination with brachytherapy as a boost. Anyway, it is difcult to obtain LC of advanced tumors, and there is a high tendency to relapse after irradiation. Therefore, tumors larger than 4cm and/or with bone invasion are unsuitable for either radiation therapy or surgery alone but should rather be treated with a combination of these two modalities [19, 21]. A retrospective study of the DAHANCA group reported very poor results in Wang cT3 tumors, mainly treated by EBRT: 39% 5-year diseasespecic survival (DSS) and 0% 5-year OS, which suggested the necessity of the combination with a surgical approach [17]. In fact, in advanced stages, the surgical resection associated with postoperative EBRT offered higher LC rates [4].

In general, in the postoperative setting, adjuvant EBRT is indicated in case of advanced tumors (classied as T3 WANG or T4 AJCC), involved or unclear margin, nodal involvement, or perineural invasion [4, 17].

In some reports, the use of preoperative (in case of neoadjuvant irradiation, but mostly in case of recurrence after denitive EBRT) radiotherapy appeared to be associated with a greater risk of sequelae such as bone exposure or wound complication when patients are submitted to ablative surgery [4, 22].

10.2 Role ofChemotherapy

There are few data on the role of chemotherapy in NV cancer treatment, as NV cancer is generally considered as more similar to the skin than to mucosal malignancies, even if this is not demonstrated by evidence. Therefore, the choice of chemotherapy is left to the discretion of the clinician, based on the stage and risk factors. cT3 according to Wang and clinical nodal involvement can be considered parameters to indicate concomitant chemotherapy in cases treated primarily by EBRT.

10 External Beam Radiotherapy forNose Vestibule Malignancies

https://t.me/medicina_free

On the other hand, in the postoperative setting, extensive neck involvement, namely pN2-3 (according to eighth AJCC classication), and incomplete resection (R1) usually indicate adjuvant concomitant chemoradiotherapy in other head and neck subsites and can be considered valid criteria also for operated NV carcinomas.

Table 10.1 analytically describes the results of the main studies reporting the outcomes of radiotherapy for treatment of nose vestibule carcinomas.

121

10.3 EBRT Techniques

EBRT is the most common modality of radiotherapy, which delivers radiation beams from a source external to the patient.

Megavoltage (MV) photons and electron beams are generated from linear accelerators. MV electron beams represent an important radiation treatment modality often providing a unique option in the treatment of supercial targets. This is possible because the electron beam exhibits a higher surface dose than MV photon beams. The electron beam has a sharp fall-off of the dose sparing deeper tissues. The depth of penetration may be adjusted by varying the energy of the electron beam. On the contrary, megavoltage photons are more penetrating, and their slow fall-off is an issue in case of supercial lesions as most often nose vestibule cancers are.

Using a lead cut-out, the electron eld can be easily adapted to the area to treat, although the wide penumbra of the electron beam requires a larger margin (1.5cm) than that is required for photons treatments [23].

Historical series describe widely 2D conventional/3D conformal techniques for EBRT treatment of NV carcinoma. Over the last decades, intensity-modulated radiation therapy (IMRT) has become the standard treatment in head and neck cancers, improving conformability and homogeneity of dose distribution to the planning target volume (PTV) and sparing the adjacent structures at risk. Nowadays, modern techniques that include IMRT and volumetric-modulated radiation therapy (VMAT) are routinely used in most centers.

10.3.1 Positioning andImmobilization

10.3.1.1 3D Conformal Radiotherapy

Historically, EBRT treatment for nasal vestibule cancers consists of a combination of anterior elds using 20-MeV electrons and 6-MV photons weighted 4–1. Patient is immobilized in supine position using a thermoplastic mask, with the head +/− shoulder slightly exed. Placing a customized lead shield directly on the patient’s skin, the electron eld can be shaped to t the treatment area, reducing the penumbra of the electron beam and sparing critical tissues as the nasolacrimal duct and the eye (Fig.10.1).

To increase the dose delivery to the skin near the gross tumor volume (GTV) region, bolus material (0.5–1cm thickness) is often used for the electron portion of

122

https://t.me/medicina_free

I. D’Onofrio et al.

Regional

control (%) Note Late side effectsInstitution

Overall

survival

(%)

Local control

(%)

Rhinorrea (45%)

No statistically

2years RC

5years

2years LC

Nasal dryness

signicant

differences

between RT

87%

2years RC

OS 66%

5years

79%

LC (after

(39%)

modalities

97%

DSS

surgery) 95%

Epistaxis (15%)

Adhesions (4%)

Skin necrosis (5%)

1 Post-Rt sarcoma

87%

Epistaxis (11%)

All recurrences

5years

Persistent crust

among EBRT

pts

LCR 68%

10% Node

OS 59%

formation (28%)

Recurrence

PFS

Perforated septum

(3%)

(2%)

57%

Bulky=55%

T3=53% Severe Stenosis

EBRT+Endocavitary

BRT

9 EBRT alone (if

Primary

RT RT Technique

100% 47

WANG

(only

T1-T2)

No pts Classication

(1980–

2000)

Author, Year

Table 10.1 Results of the main studies reporting the outcomes of radiotherapy for treatment of nose vestibule carcinomas

Langendijk

etal. (2004)

[3]

upper lip involvement)

University

Medical

Center

Amsterdam

WANG 100% T1-T2=IRT 5years LC 5years

(1977–

2012)

Vanneste

etal. (2016)

[20]

T2 Bulky: EBRT T1=97% 5years

T3: EBRT T2

The

Nederlands

Cancer

institute

Amsterdam

10 External Beam Radiotherapy forNose Vestibule Malignancies

https://t.me/medicina_free

One second cancer

(Small cell

carcinoma) in

treatment eld

Severe

complication only

Overall

No statistically

Regional

control (%) Note Late side effectsInstitution

5years RC

survival

(%)

5years

signicant

differences

between RT

in N0 pts:

87%

OS:

77%

in surgical patients

modalities in

term of LC,

LCR OS, CSS,

M+

10years

RC in N0

pts: 87%

5years

CSS:

94%

10years

OS:

51%

10years

No data

Inuence of size

CSS:

94%

on local tumor

control

recurrence

(7%)

123

(continued)

Local control

(%)

Primary

RT RT Technique

No pts Classication

Author, Year

100%

86% 15 BRT 5years LC:

Sixth AJCC

skin cancer

(1970–

2013)

Wray etal.

(2016) [4]

84%

39 EBRT 5years LC:

University of

45 EBRT+BRT 5years LC:

Florida

86%

100% 36 BRT 90% 65% 4/56 node

WANG

(only

T1-T2-N0)

(1978–

1988)

Levendag

etal. (1990)

[11]

15 EBRT

6 EBRT+BRT

Hospital

Dijkzigt

Rotterdam

124

https://t.me/medicina_free

Overall

Regional

control (%) Note Late side effectsInstitution

survival

(%)

Maxillary

ostheonecrosis

(3%)

size >2cm or

more and

involvement of

lip, columella

recurrence

Nasal stenosis

(2%)

and skin of ala

nasi is

associated with

worse local

control rate

differences in

survival or

recurrence

comparing

primary surgery

to primary

EBRT.Septal

I. D’Onofrio et al.

One patient had

reconstructive

location is a risk

factor for local

recurrence

best managed

surgery for

radionecrosis

by surgery

Local control

Primary

Author, Year

Table 10.1 (continued)

(%)

RT RT Technique

Tumor size 100% EBRT <2cm=97% 66% 3/54 node

No pts Classication

(1958–

1983)

Wong etal.

(1986) [12]

>2cm=54% Epistaxis (2%)

Princess

Margaret

Hospital

WANG 66% EBRT (Electrons) 68% 48% No signicant

(1878–

1992)

Horsman

etal. (1999)

[8]

Odense

University

Hospital,

Denmark

WANG 54% Not recorded 50% 57% 90% T2-T3 lesion are

(1988–

2008)

Dowley

etal. (2008)

[9]

University

Hospital

Nottingham

10 External Beam Radiotherapy forNose Vestibule Malignancies

https://t.me/medicina_free

5-year incidence of

grade ≥2 toxicity

was higher after

BRT (20% vs. 3%,

p=0.03). Mostly

radiation ulcers.

(24%)

Septal defects

treated group,

OS was better in

54Gy/18

fractions rather

than 66Gy/33

Overall

Regional

control (%) Note Late side effectsInstitution

survival

(%)

fractions

495357

higher 3-year

survival with

3-year 89% BRT provided

82%

preserved nose

compared with

EBRT (82% vs.

61%, p<0.01).

3-year 89% Radiation ulcers

82%

(10%)

Chondronecrosis

(4%)

125

Local control

(%)

Primary

RT RT Technique

No pts Classication

Author, Year

28 Surgery+EBRT

22 Surgery alone

WANG 70% 120 EBRT In T1-EBRT

174

(1993–

2002)

DAHANCA

Agger etal.

database

(2009) [17]

T1 stage:

618794

63 EBRT

22 Surgery+EBRT

17 Surgery alone

100% 153 BRT 3-year 95% 3-year

WANG

(only

225

(2010–

Czerwinski

etal. (2021)

T1-T2)

2016)

[14]

65 EBRT 3-year 71% 3-year

6 Dutch

Institutions

<<< < Предыдущая 1 2 3 4 5 6 7 8 9 10 11 1213 / 2213 14 15 16 17 18 19 20 21 22 > Следующая >>>

Соседние файлы в папке Библиотека им академика М.И. Перельмана

#
15.09.202615 Мб0Книга_4612_Библиотеки_им_академика_М_И_Перельмана.pdf
#
15.09.202614 Мб0Книга_4614_Библиотеки_им_академика_М_И_Перельмана.pdf
#
15.09.202614 Мб0Книга_4616_Библиотеки_им_академика_М_И_Перельмана.pdf
#
15.09.202614 Мб0Книга_4617_Библиотеки_им_академика_М_И_Перельмана.pdf
#
15.09.202614 Мб0Книга_4621_Библиотеки_им_академика_М_И_Перельмана.pdf
#
15.09.202613 Мб0Книга_4624_Библиотеки_им_академика_М_И_Перельмана.pdf
#
15.09.202613 Мб0Книга_4628_Библиотеки_им_академика_М_И_Перельмана.pdf
#
15.09.202613 Мб0Книга_4630_Библиотеки_им_академика_М_И_Перельмана.pdf
#
15.09.202612 Мб0Книга_4632_Библиотеки_им_академика_М_И_Перельмана.pdf
#
15.09.202612 Мб0Книга_4634_Библиотеки_им_академика_М_И_Перельмана.pdf
#
15.09.202612 Мб0Книга_4635_Библиотеки_им_академика_М_И_Перельмана.pdf