颅底骨坏死对鼻咽癌患者生存率的影响及干预策略研究

Prognostic factors of skull base osteoradionecrosis in nasopharyngeal carcinoma patients: A retrospective cohort study

摘要:

目的 探索发生放射性颅底骨坏死(sbORN)的鼻咽癌(NPC)患者的预后因素，分析可能影响患者生存率的原因。方法 回顾性队列研究 2001 年 1 月 1 日—2023年 7月31日梅州市人民医院收治的发生sbORN的NPC患者临床数据，根据生存状态分为死亡组及存活组，使用t检验、Fisher’s精确检验比较两组之间差异；通过使用生存分析方法，Kaplan-Meier生存曲线和Cox比例风险模型，来评估不同预后因素对患者生存率的影响。结果 共纳入31例发生sbORN的NPC患者，男23例，女8例。16例死亡患者中大出血 6例(37.5%)、脓毒血症7例(43.75%)、多器官衰竭 2例(12.5%)、脑干脑梗1例(6.25%)。中位生存时间为23个月，1年生存率为70.96%(22/31)，2年生存率为54.83%(17/31)。降钙素原水平在sbORN发生方面达到显著水平(χ²=4.229，P=0.040)，降钙素原与sbORN的发生有关。在病变范围方面，病变涉及颅内的患者发生死亡的比例显著高于病变不涉及颅内的患者(χ²=7.515，P=0.006)。将患者分为死亡及存活组后发现，较低的体质指数(BMI)、较低的血红蛋白、较高的前白蛋白水平可能与患者预后差相关(P均＜0.05)。Cox回归多因素分析显示，坏死侵犯颅内(HR=0.206，95%CI：0.066~0.637，P=0.006)、 降钙素原升高(HR=3.311，95%CI：1.120~9.791，P=0.030)是预后不良的独立危险因素。结论 sbORN对于NPC生存率有着严重的负面影响。合并sbORN的NPC患者在治疗过程中需监测降钙素原水平及鼻咽部增强磁共振明确坏死是否侵犯颅内，提前干预，预防感染、改善营养状况，从而提高患者生存率。

Abstract:

Objective To explore prognostic factors associated with the occurrence of skull base osteoradionecrosis (sbORN) in patients with nasopharyngeal carcinoma (NPC) and analyze potential factors influencing patients’ survival.Methods A retrospective cohort study was conducted using clinical data of NPC patients with sbORN admitted to Meizhou People’s Hospital from January 1, 2001 to July 31, 2023. The patients were divided into deceased and surviving groups based on their survival status, and differences between the two groups were compared using t-tests and Fisher’s exact tests. Survival analysis was performed using Kaplan-Meier survival curves and Cox proportional hazards models to assess the impact of different prognostic factors on patients’ survival.Results A total of 31 patients were included, with 23 males and 8 females. Among them, 16 patients died, with the leading causes being septicemia (7 cases, 43.75%), massive bleeding (6 cases, 37.5%), multiple organ failure (2 cases, 12.5%), and brainstem infarction (1 case, 6.25%). The median survival time was 23 months, with a 1-year survival rate of 70.96% (22/31) and a 2-year survival rate of 54.83% (17/31). Serum parathyroid hormone (PTH) level reached a significant level concerning the occurrence of sbORN (χ² = 4.229,P=0.040), indicating a relationship between PTH and sbORN. In terms of lesion extent, patients with lesions involving the intracranial region had a significantly higher incidence of death compared to those with non-intracranial lesions (χ²=7.515,P=0.006). After dividing the patients into the deceased and surviving groups, lower BMI, lower hemoglobin levels, and higher pre-albumin levels were found to be associated with poorer prognosis (all P<0.05). Cox regression multivariate analysis revealed that intracranial involvement of necrosis (HR=0.206, 95%CI:0.066~0.637，P=0.006) and elevated PTH levels (HR=3.311, 95%CI:1.120~9.791,P=0.030) were independent risk factors for adverse prognosis.Conclusion sbORN has a serious negative impact on NPC survival rate. In the treatment of NPC patients with sbORN, monitoring procalcitonin levels and performing enhanced magnetic resonance imaging of the nasopharynx (to assess intracranial extension of necrosis) are necessary. Advanced interfere treatment to prevent infection and improve nutritional status can ultimately enhance patients’ survival.