《头颈部肿瘤》PPT课件.ppt
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1、头颈部肿头颈部肿瘤瘤头颈部肿瘤概述头颈部肿瘤概述口腔肿瘤口腔肿瘤新辅助化疗新辅助化疗2015 ASCO流行病学占全身占全身恶性性肿瘤的瘤的5 5第第6 6大常大常见的的恶性性肿瘤瘤肿瘤相关死亡原因的第瘤相关死亡原因的第8 8位位头颈部部肿瘤的患者有可能罹患第瘤的患者有可能罹患第2 2个原个原发性的性的头颈部、肺部、肺部或食管的部或食管的肿瘤瘤病因吸烟和嗜酒吸烟和嗜酒口咽癌:人乳口咽癌:人乳头瘤病毒瘤病毒(HPV)60-70%(HPV)60-70%鼻咽癌:鼻咽癌:EBVEBVHPV+口咽部肿瘤的疗效和生存情况口咽部肿瘤的疗效和生存情况均比均比HPV-的肿瘤要好的肿瘤要好治治疗疗前前血血浆浆EBV
2、-DNA水水平平越越高高,则则治治疗疗后后出出现现远处转移的概率越高;监测随访远处转移的概率越高;监测随访Humanpapillomavirusandsurvivalofpatientswithoropharyngeal cancer.N Engl J Med.2010 Jul 1;363(1):24-35.头颈部肿瘤特点90%90%以上以上EGFREGFR过表达表达以以鳞癌癌为主主视、听、嗅、听、嗅觉、呼吸、呼吸、发声、声、进食、容貌食、容貌局部局部结构复构复杂、险隘,安全隘,安全边缘有限有限“不可切除的病不可切除的病变”没有定没有定义不同部位特点不同喉癌:喉癌:声声门上区上区肿瘤在确瘤在确
3、诊时通常已通常已经为局部晚期;局部晚期;但是但是声声门区区肿瘤瘤发现时多多为早期,治愈率非常高:早期,治愈率非常高:约80%90%80%90%咽癌:大咽癌:大约60%的下咽部的下咽部肿瘤患者已属局部晚期伴区瘤患者已属局部晚期伴区域淋巴域淋巴结转移,移,预后通常都很差后通常都很差分期唇部、口腔及口咽部唇部、口腔及口咽部肿瘤根据瘤根据瘤体大小瘤体大小界定界定T分期分期声声门区、声区、声门上区、喉咽及鼻咽部上区、喉咽及鼻咽部肿瘤根据各自瘤根据各自亚区区侵犯侵犯情况界定情况界定T分期分期除了鼻咽癌的区域淋巴除了鼻咽癌的区域淋巴结(N)分期之外,)分期之外,对于不同于不同部位部位肿瘤的瘤的N及及远处转移
4、(移(M)的界定)的界定标准是一致的准是一致的喉、口咽、下咽:喉、口咽、下咽:VII区(上区(上纵膈)膈)转移也被移也被认为是区是区域淋巴域淋巴结转移移治疗特点T1-2N0M0T1-2N0M0期期:单纯手手术或或单纯放放疗局部晚期局部晚期:手手术+放放疗+化化疗复复发和和转移,姑息性化移,姑息性化疗放放疗+化化疗+手手术鼻咽癌主要以放化鼻咽癌主要以放化疗为主主新辅助治疗例如:例如:对可手可手术切除的局部晚期喉癌、咽癌,切除的局部晚期喉癌、咽癌,术前前诱导化化疗/同步放化同步放化疗不不仅可以提高保喉率,而且可提可以提高保喉率,而且可提高患者生存率高患者生存率放疗原发病灶和受侵淋巴结需要每天2.0
5、 Gy,总量为70 Gy或以上的剂量对于颈部风险较低的淋巴结群的放疗剂量为每天2.0 Gy,总量50 Gy或以上化疗新辅助化疗同步放化疗(根治性、辅助性)辅助化疗姑息化疗靶向治疗西妥昔西妥昔单抗抗 早中期:同步放疗 晚 期:单药或联合化疗尼妥珠尼妥珠单抗(抗(nimotuzumab)吉非替尼、厄洛替尼:未吉非替尼、厄洛替尼:未观察到察到临床受益床受益不良预后因素淋巴结包膜外受侵和淋巴结包膜外受侵和/或手术切缘阳性:或手术切缘阳性:术后进行辅助术后进行辅助性化放疗性化放疗其他不良预后因素:其他不良预后因素:多个阳性淋巴结(无包膜外受侵)多个阳性淋巴结(无包膜外受侵)、血管、血管/淋巴管淋巴管/神
6、经周围侵犯、原发肿瘤神经周围侵犯、原发肿瘤T4aT4a及具有及具有IVIV区淋巴结阳性区淋巴结阳性术后放疗,但是否进行放化疗可根术后放疗,但是否进行放化疗可根据临床判断据临床判断复发和(或)转移复复发病病变可治愈:可治愈:应积极极寻求根治性手求根治性手术 或同步放化或同步放化(靶)(靶)疗无局部治愈可能:无局部治愈可能:姑息性化姑息性化疗和和(或或)靶向治靶向治疗 支持治支持治疗姑息化疗的中位生存时间大约为6个月,1年生存率大约为20%Induction ChemotherapyInduction chemotherapy plus radiation compared with surger
7、y plus radiation in patients with advanced laryngeal cancer.The Department of Veterans Affairs Laryngeal Cancer Study GroupN Engl J Med.1991;324(24):1685332 ptsmedian follow-up of 33 monthssurgery+radiotherapyinduction chemotherapy+radiotherapySalvage surgerycisplatin+fluorouraci(PF)Focus on larynx
8、preservation 2-yearsurvival:68%:68%P=0.1195Larynx preservation in pyriform sinus cancer:preliminary results of a European Organization for Research and Treatment of Cancer phase III trial.EORTCHead and Neck Cancer Cooperative Group J Natl Cancer Inst.1996202 ptssurgery+radiotherapyinduction chemothe
9、rapy+radiotherapySalvage surgerycisplatin+fluorouraci(PF)Focus on larynx preservation Induction-chemotherapy arm vs.Surgery armOS:44:25months3-yearsurvival:57%:43%PFS:25:20monthsTPF vs.PFInduction chemotherapy with cisplatin and fluorouracil alone or in combination with docetaxel in locally advanced
10、 squamous-cell cancer of the head and neck:long-term results of the TAX 324 randomised phase 3 trial.Lancet Oncol.2011;12(2):153-9Median follow-up of 6.0 years(72.2 months)55 centers 501 patientsOS:70.6 vs.34.8 moPFS:38.1 vs.13.2 mohypopharyngeal and laryngealPFS:20.9 vs.10.1 moOS:51.9 vs.23.5 moLon
11、g-term results of GORTEC 2000-01:A multicentric randomized phase III trial of induction chemotherapy with cisplatin plus 5-fluorouracil,with or without docetaxel,for larynx preservation.France213 ptsMedian follow-up 105 months TPF vs.PFThe 5-and 10-year larynx preservation rates 74.0%vs.58.1%70.3%vs
12、.46.5%The 5-and 10-year LDFFS rates 67.2%vs.46.5%63.7%vs.37.2%OS,PFS no difference (LDFFS:larynx dysfunction-free survival)ASCO2015Taxane-cisplatin-fluorouracil as induction chemotherapy for advanced head and neck cancer:a meta-analysis of the 5-year efficacy and safety.Springerplus.2015;4:208.7 ran
13、domized clinical (mata analysis)TPF vs.PF 3-year OS rate(HR:1.14;95%CI:1.03 to 1.25;P=0.008)3-year PFS rate(HR:1.24;95%CI:1.08 to 1.43;P=0.002)5-year OS rate(HR:1.30;95%CI,1.09 to 1.55;P=0.003)5-year PFS rate(HR:1.39;95%CI,1.14 to 1.70;P=0.001)The TPF induction chemotherapy improved PFS and OS compa
14、red with PFInduction Chemotherapy vs.Concurrent ChemoRTLong-Term Results of RTOG 91-11:A Comparison of ThreeNonsurgical Treatment Strategies to Preserve the Larynx inPatients With Locally Advanced Larynx Cancer J Clin Oncol 2013;31:845-852Patients with stage III or IV glottic or supraglottic squamou
15、s cell cancerlaryngectomy-free survival(LFS)(PF)For selected patients with hypopharyngeal and laryngeal cancers less than T4a in extent,inductionchemotherapyused as part of a larynx preservation strategyis category 2AThus,induction chemotherapy has a category 3recommendation for the management of bo
16、th locally and regionally advanced oropharyngeal cancerInduction Chemotherapy in Oral Squamous Cell CarcinomaRandomized Phase III Trial of Induction Chemotherapy With Docetaxel,Cisplatin,and Fluorouracil Followed by Surgery Versus Up-Front Surgery in Locally Advanced Resectable Oral Squamous Cell Ca
17、rcinoma J Clin Oncol.2013;31(6):744-51256 patientsLocallyadvancedResectable Oral Squamous Cell Carcinoma,TPFMedian follow-up of 30 monthscN2Induction chemotherapy+Concurrent chemoradiotherapyInduction chemotherapy followed by concurrentchemoradiotherapy(sequential chemoradiotherapy)versusconcurrent
18、chemoradiotherapy alone in locally advanced headand neck cancer(PARADIGM):a randomised phase 3 trialLancet Oncol 2013;14:25764145 patients across 16 sitesMedian follow-up of 49 months Induction chemotherapy+Concurrent chemoradiotherapy Concurrent chemoradiotherapy3-yearoverallsurvivalwas73%vs.78%OSP
19、FSPhase III randomized trial ofinduction chemotherapyin patients with N2 or N3 locally advancedhead and neck cancer.J Clin Oncol.2014;32(25):2735285 patients,with N2 or N3 diseaseFollow-up of 30 monthsInduction chemotherapy+Concurrent chemoradiotherapy Concurrent chemoradiotherapyNO difference:OS,Re
20、lapse-FreeSurvival,Distant Failure-Free SurvivalIs there a role for induction chemotherapy in the setting of concomitant chemoradiation in locally advanced head and neck cancer:A systematic review and meta-analysis of randomized controlled trialsMeta-analysis,5 RCTs(4 TPF,1 PF)1229 patientsIndu-chem
21、otherapy+concomitant chemoradiation concomitant chemoradiationOS,PFS no difference have a trendDisease control,CR Imply that selected patients may benefit from the addition of induction chemotherapyASCO2015New aspects regarding the induction chemotherapy with TPF and radio chemotherapy in head and n
22、eck cancer GermanyMeta-analysis,5 RCTs(TPF)1060 patients,locally advanced53.4%oropharyngeal,17.3%hyopharyngeal,6.4%laryngeal,18.5%oral cavity,4.4%other SCCHNTPF+concomitant chemoradiation concomitant chemoradiationNot result in a significant improvement of OS(Hazard Ratio:0.950,0.791-1.140,p=0.579)A
23、SCO2015Radiotherapy plus cetuximabRadiotherapy plus cetuximab for locoregionally advanced head and neck cancer:5-year survival data from a phase 3 randomised trial,and relation between cetuximab-induced rash and survival Lancet Oncol.2010;11(1):21-8424 pts:locoregionally advanced squamous-cell carci
24、noma(oropharynx,hypopharynx,or larynx)73 centresmedian follow-up 60 monthsradiotherapy aloneradiotherapy plus cetuximabOS:49.0 months versus 29.3 months5-year overall survival was 45.6%versus 36.4%Randomized phase III trial of concurrent accelerated radiation plus cisplatin with or without cetuximab
25、 for stage III to IV head and neck carcinoma:RTOG 0522.J Clin Oncol.2014 Sep 20;32(27):2940-50.891 analyzed patientsMedian follow-up 3.8 yearsCetuximab plus cisplatin-radiationcisplatin-radiation alone3-year PFS(61.2%v.58.9%,P=.76),3-year OS(72.9%v.75.8,P=.32)p16-positive compared with p16-negative
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