基于IMRT时代的第八版AJCC/UICC鼻咽癌临床分期建议

本文首次发表在Cancer,2016,122(4):546-558.

目的 准确的分期系统对癌症的治疗至关重要。随着癌症分期和治疗方法的演变,需要不断评价分期的适用性和改进性。方法 基于第7版AJCC/UICC分期回顾性分析香港和中国大陆2个肿瘤中心收治的 1609例接受调强放射治疗的首诊无转移鼻咽癌患者临床资料,所有患者治疗前均行核磁共振分期评估。结果 无其他T₃、T₄期解剖结构受侵患者中,伴有咀嚼肌间隙(翼内肌和/或翼外肌)侵犯、椎前肌侵犯及咽旁间隙侵犯的三组患者之间OS相近。伴广泛软组织(上述侵犯结构以外的软组织)受侵患者OS与伴有颅内侵犯或颅神经侵犯相似。仅2%患者锁骨上窝以上淋巴结转移者直径>6 cm,其OS率与下颈淋巴结转移者类似。用下颈(环状软骨尾侧缘水平以下)代替锁骨上窝并不影响N分期之间的风险差异性。采用推荐的T、N分期,T₄N_0-2、T_1-4N₃期OS相近。结论 经AJCC/UICC分期筹备委员会审阅后,建议第8版分期应将翼内肌/翼外肌从T₄降到T₂期,增加椎前肌为T₂期,用下颈取代锁骨上窝,将淋巴结最大直径>6 cm合并归为N₃期,将T₄、N₃期统一归为Ⅳ_A期。这些改变不仅使得相邻分期间风险差异性更好,而且使得临床实践性与全球适用性之间达到最佳平衡。

Proposal for the 8th edition of AJCC/UICC staging system for nasopharyngeal cancer in the era of intensity-modulated radiotherapy

Objective An accurate staging system is crucial for cancer management .With the development of cancer staging systems and therapeutic methods, the applicability and improvement of staging systems should be evaluated constantly.Methods The clinical data of 1609 nasopharyngeal carcinoma patients without metastasis at initial diagnosis , who were admitted to two tumor centers in Hong Kong and Mainland China and received intensity-modulated radiotherapy (IMRT), were analyzed retrospectively based on the 7th edition of the American Joint Committee on Cancer (AJCC) or International Union Against Cancer (UICC) staging system, and all the patients underwent magnetic resonance imaging ( MRI) before treatment.Results Among the T3 /T4 patients without involvement of other anatomic structures, overall survival (OS)showed no significant differences between the patients with masticator space (medial pterygoid muscle and/or lateral pterygoid muscle) involvement, prevertebral muscle involvement, and parapharyngeal space involvement.The OS was similar between the patients with extensive soft tissue (soft tissues other than the structures mentioned above) involvement and those with intracranial involvement or cranial nerve involvement.Only2% of the patients had lymph node metastasis >6 cm above the supraclavicular fossa (SCF), with an OS similar to that of the patients with lower cervical lymph node metastasis .Replacing SCF with the lower neck(below the caudal border of the cricoid cartilage ) did not affect the risk difference between different N stages.With the proposed T and N staging systems, the OS showed no significant differences between T 4N 0-2 and T1-4 N3 patients.Conclusions After a review by AJCC/UICC staging system preparatory committees, the changes recommended for the 8th edition include changing medial pterygoid muscle or lateral pterygoid muscle involvement from T4 to T2 , adding prevertebral muscle involvement to T2 stage, replacing SCF with the lower neck and combining this with a maximum lymph node diameter of>6 cm as N3 stage, and integrating T4 and N3as stage ⅠVA.These changes result in a better risk difference between adjacent stages and achieve the optimal balance between clinical practicability and global applicability.