放射治疗诱发的第二肿瘤

十、放射治疗诱发的第二肿瘤

随着放疗技术的进步和放化综合治疗水平的提高, 鼻咽癌患者的生存期延长。长期生存患者的生活质量越来越受到学者重视, 放疗诱发的恶性肿瘤是其最严重的并发症, 也是影响患者生存及生活质量的重要因素。

（一）发病机制

目前关于放疗诱发恶性肿瘤的机制有不同报道:放射线可导致DNA的单链或双链断裂从而诱发细胞突变⁽⁵²⁾、电离辐射可诱发基因组的不稳定性⁽⁵³⁾、放疗引起机体免疫功能下降、遗传基因决定的放射敏感性差异⁽⁵⁴⁾等。

（二）临床症状

Wang等⁽⁵⁵⁾报道1549例鼻咽癌，中位随访期7年，年平均发病率0.55%。Kong等⁽⁵⁶⁾报道的年平均发病率为0.56%。放疗诱发的恶性肿瘤发病率比实际的要高， 因为诱发肿瘤的发生需要较长的潜伏期，诱发肿瘤尚未表现出来，患者可能因为原发肿瘤局部未控、复发或远处转移而死亡，还有一些因为失访而丢失数据。放疗诱发第二肿瘤的潜伏期与鼻咽癌放疗时年龄、放疗程式、放疗总剂量、鼻咽癌化疗有关。初次接受放疗年龄小于50岁者潜伏期较长，究其原因，可能为大多数诱发肿瘤的发病年龄接近其自然发病高峰年龄，年轻患者在接受放疗后需要较长的时间才能达到其发病高峰⁽⁵⁷⁾，因而潜伏期相对较长；放疗总剂量增高会使照射野内的正常组织细胞受到较高剂量的照射，细胞DNA 损伤严重，细胞突变率增高；化疗尤其是烷化剂等细胞毒制剂的使用降低了患者免疫能力，降低了机体的免疫监视功能，从而促进诱发肿瘤的发生。

放射治疗导致的第二肿瘤的诊断需满足下列标准:① 肿瘤的病理类型与原肿瘤不同；② 肿瘤发生于放射野范围内；③ 肿瘤发生于放疗结束后5年。其临床症状主要是第二肿瘤引起的占位、压迫或器官功能障碍等。

（三）预防和治疗

鼻咽癌放疗后诱发的恶性肿瘤中以口腔肿瘤最多, 而口腔肿瘤中以舌癌、牙龈癌多见，因此鼻咽放疗过程中减少舌及口腔黏膜的受照剂量是减少鼻咽癌放疗后诱发肿瘤发生的关键。在放疗过程中，利用口腔支架将舌和一部分口腔黏膜推离照射野范围，在保护舌和部分口腔黏膜、味觉的同时，以期降低诱发肿瘤的发生率。

对于放疗诱发的恶性肿瘤多数学者不主张放射治疗，因为诱发肿瘤位于照射野内，对放疗和化疗相对不敏感，周围正常组织再程放疗耐受性差，诱发肿瘤的治疗应尽量选择非放射治疗。也有学者认为对于诱发肿瘤的治疗应根据肿瘤发生的部位、病理类型、放射敏感性等进行恰当处理。

（吕　星　郭　灵）

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