位于頸3的上頸椎脊索瘤

Author：LiangJiang

作者：姜亮

OrthopaedicDepartment,PekingUniversityThirdHospital,

單位：北醫(yī)三院當前第1頁\共有28頁\編于星期四\15點Chordomaisararelow-grademalignantneoplasmderivedfromtheremnantsoftheembryonicnotochord.Thislocallyinvasiveneoplasmissubjecttorecurrenceaftertreatment.Themediansurvivaltimeisestimatedtobe6.3years.

定義：脊索瘤是一種少見的起源于胚胎脊索殘留組織的低分化惡性腫瘤。

特點：容易復發(fā)。

統(tǒng)計學：中位生存期是6.3年。

Abstract當前第2頁\共有28頁\編于星期四\15點Varioustreatmentapproacheshavebeenattempted,includingradicalexcision,radiotherapyandchemotherapy.Treatmentoutcomeissignificantlyinfluencedbythesizeandsiteofthechordoma.Recently,Imatinib,amolecular-targetedagent,hasbeenshowntohaveantitumoractivityinchordoma.Protonradiotherapy,stereotacticradiotherapyandintensity-modulatedradiotherapyhavealsobeenused.Surgicaltreatmentisstilltheprimarychoiceforchordoma.Ithasbecomemoreaggressiveinrecentyears,evolvingfromintralesionalorpartialexcisiontoenblocresection.However,uppercervical

localizationsmakesuchenblocresectioninmostcasesnotpossible.

治療進展：傳統(tǒng)治療包括根治性切除、放療和化療等?！癐matinib”的分子靶向治療藥物顯示對于脊索瘤有治療效果。光子放療，stereotactic放療以及調強放療亦應用于脊索瘤的治療。外科治療仍舊是脊索瘤的首選治療方法。近一些年脊索瘤的外科治療從瘤內刮除發(fā)展至部分切除直至全脊椎大塊切除。然而，上頸椎獨特的解剖位置使大塊全脊椎切除治療脊索瘤很難實現(xiàn)。

Abstract當前第3頁\共有28頁\編于星期四\15點

Wepresentanddiscussthetherapeuticchallengesofayoungfemalewithlargeretropharyngealchordomawhopresentedtoourinstitutionafterconventionalphotonbeamradiotherapy.ThisC2/3tumorwasclassifiedIBaccordingtotheEnnekingclassification.ItdistributedtolayersA–Dandsectors1–6accordingtotheWeinsteinBorianiBiaginiClassification.Theleftvertebralartery(VA)wasencapsulatedanddisplaced.Onestageintralesionalextracapsulartumorexcisionandreconstructionwasachievedbycombinedbilateralhighanteriorcervicalapproachesandposteriorapproach.Norecurrenceormetastasiswasobserved3yearsaftertheoperation.Shereturnedtoherpreviousoccupationasofficeworker.

本文內容：我們在這里報道一位經(jīng)過放療的年輕的咽后脊索瘤女性患者。根據(jù)Enneking分期為IB期，根據(jù)WBB分期則為1-6區(qū)A-D層，左側椎動脈被包繞并且移位。一期采用上頸椎聯(lián)合雙前外側切口以及后側入路對該例患者成功實施了囊外切除術。術后3年隨訪患者無局部復發(fā)以及轉移。

Abstract當前第4頁\共有28頁\編于星期四\15點

Keywords

Keywords

ChordomaAtlantoaxialspineSurgery

關鍵詞脊索瘤寰樞椎外科手術當前第5頁\共有28頁\編于星期四\15點

A26-year-oldfemalepresentedtoourinstitutionafteratransoralbiopsyofalargeretropharyngealtumor,whichwasdiagnosedasachordoma.Shehaddysphagiaandneckpain9monthsago.Theretropharyngealmasswasnoticedbyotolaryngologist.Aftertransoralbiopsy,shehadconventionalphotonbeamradiotherapywith40Gyandthenhersymptomstotallydisappeared.Sincetherewasnoreductionoftumorvolume6monthsafterradiotherapy,shewasreferredtoourdepartment.Shehadnoothersignificantmedicalhistoryandshedidnotexhibitanyneurologicaldeficit.

年齡：26歲

性別：女性

病史：患者9月前出現(xiàn)頸痛并吞咽困難，首先是由耳鼻喉科醫(yī)生發(fā)現(xiàn)咽后腫物。在經(jīng)口活檢確診后患者接受了40個Gy的放療，癥狀完全消失。由于放療后6月瘤體未見縮小，患者遂來就診?；颊呒韧w健，無神經(jīng)損傷癥狀。

臨床資料當前第6頁\共有28頁\編于星期四\15點Fig.1張口位像可以看到頸2椎體左側邊界不清的溶骨性改變。CT平掃可以看到頸2-3蟲蝕樣骨質破壞。矢狀位MRI可以看到腫瘤從齒狀突基底延伸至頸3椎體。在軸位像上腫瘤壓迫硬膜囊以及左側頸內動脈。左椎動脈被包繞并移位。脊髓被擠向右側。根據(jù)WBB分區(qū)病變位于A-D層和1-6區(qū)，根據(jù)Enneking分期為IB期。當前第7頁\共有28頁\編于星期四\15點Fig.2Layers(A–D)andQuadrantsinvolvementaccordingtoWeinsteinBorianiClassification(normalcervicalvertebrarepresented)

當前第8頁\共有28頁\編于星期四\15點Chordomaisarelativelyrarelow-grademalignantneoplasmderivingfromremnantsofthenotochord,constitutingbetween1and4%ofmalignantbonetumors.Itpredominantlyarisesfromtheaxialskeleton,whileextra-axialchordomahasalsobeenreported.Itsincidencehasbeenestimatedtobeoneperonemillioninhabitantsperyear.Itcanaffectpatientsfromallageswithapredilectionformenwitharatioof1.6–1(10).Thefrequentlyreportedanatomicdistributionofchordoma,sacral*50%,spheno-occipital*35%,spinal*15%,wasbasedprimarilyon262patientsfromtheMayoClinicexperience.Basedonmorerecent400casesfromtheUnitedStates[10],32%ofcaseswerepresentedatcranialsites,33%spinaland29%sacral.Medianageisaround60years,butskull-basepresentationsaffectayoungerage,andmayevenoccurinchildrenandadolescents.

脊索瘤是少見的起源于胚胎殘留脊索組織的低分化惡性腫瘤，占惡性骨腫瘤的1-4%，主要起源于中軸骨骼系統(tǒng)，其他部位也見報道。統(tǒng)計學顯示其每年發(fā)病率為百萬分之一。各個年齡段均可發(fā)病，男性多于女性，男女比率為1.6：1。美國紐約的Mayo醫(yī)學中心統(tǒng)計262例脊索瘤按照解剖部位分類，蝶枕部為35%，骶骨50%。其他脊柱階段15%。美國最近的400例病例統(tǒng)計，32%位于顱部，33%脊柱，29%位于骶骨。平均發(fā)病年齡為60歲，顱底部脊索瘤發(fā)病年齡較輕，甚至見于兒童和青少年。

診斷和流行病學當前第9頁\共有28頁\編于星期四\15點Chordomaischaracteristicallyslow-growing,locallyinvasiveneoplasm.Inmostcases,theEnnekingstageisIB—lowgrademalignant,extracompartmental.Additionally,theycanbedifficulttodistinguishradiographicallyandpathologicallyfromchondrosarcoma.Sometimes,chordomahasdumbbellshapewhichcouldbediagnosedasneuromas.Spinechordomashavealsobeendiagnosedastuberculosisandhemangioma.ThemainstaytoachieveappropriatediagnosisisabiopsyperformedbytrocarunderCTscancontrolwiththebiopsytrackthatcanbeexcisedduringthesurgicalexcision.

脊索瘤具有緩慢生長、局部侵襲的特點。大部分病例為IB期-低度惡性、間室外。依靠影像學和病理學資料仍舊難以將其與軟骨肉瘤鑒別。有時具有扇貝樣表現(xiàn)被誤診為神經(jīng)瘤。脊柱脊索瘤也有誤診為結核和血管瘤的報道。獲得正確診斷的主要依據(jù)是在CT引導下用套管針行穿刺活檢，穿刺路徑可以在之后的外科手術中切除。

診斷和流行病學當前第10頁\共有28頁\編于星期四\15點Metastasesarerareandoccurtothelungortothespine,exceptionallytheycanoccurinothersitesofthemusculoskeletalsystemorevenintheskin,brain,andotherorgans.Thesurvivalrateappearstobeaffectedmorebylocaltumorprogressionthanbymetastasis.Thelifeexpectancyfromdiagnosisis6monthsto2yearsintheuntreatedskullbasechordomapatient.Mediansurvivalwas6.3yearsintheSurveillance,Epidemiology,andEndResults(SEER)programoftheNationalCancerInstitute,lookingata22yearsdatabaserecord.IntheUnitedStatesthe5-and10-yearrelativesurvivalrateswere67.6and39.9%,respectively.Therewerenosignificantdifferencesinsurvivalalthoughmediansurvivalwasslightlylowerinspinalchordomas(5.9years)comparedtocranial(6.9years)andsacral(6.5years)presentations.

脊索瘤少見轉移，一般轉移至肺臟或者脊柱，偶爾也可轉移至肌骨系統(tǒng)其它部位或者皮膚、顱內等臟器。生存率多與原發(fā)灶關系密切而與轉移灶則關系甚微。未經(jīng)治療的顱底脊索瘤從診斷開始預計生存期為6月至2年。美國國家腫瘤研究中心22年數(shù)據(jù)統(tǒng)計顯示其脊索瘤中位生存期為6.3年。在美國其5年和10年生存率分別是67.6%和39.9%。盡管脊柱脊索瘤的中位生存率稍低，但是與顱底和骶骨相比并無明顯統(tǒng)計學差異。

診斷和流行病學當前第11頁\共有28頁\編于星期四\15點Becauseoftheirlocation,behavior,andtheconfusingdiagnosticpicture,chordomascanbedifficulttomanage.Treatmentoutcomeissignificantlyinfluencedbythesizeandsiteofthechordoma.Ingeneral,cervicalchordomasaresouncommonthatarticleshavereportedlong-termfollow-upevaluationofsuchtumorsonacase-by-casebasisonly.Atlantoaxialchordomaisextremelydifficulttotreatmainlybecauseofitslocationclosetovitalstructures.SincethereisalargeduralspaceattheC1–C2location,thetumorusuallygetsquitelargebeforethepatienthassomeclinicalmanifestation.Compressionofneuraltissuesandinvasionofthebrainstemorspinalcanalmayresultinseriousneurologiccomplications.Itoftenencapsulatesand/ordisplacesthevertebralarteryandnerveroots.

由于脊索瘤發(fā)病部位、生物學行為以及難以診斷，治療較難。療效明顯與腫瘤的大小、部位相關。一般而言，頸椎的脊索瘤非常少見，長期隨訪結果都是建立在個案報道基礎之上。

由于寰樞椎臨近較多重要的解剖結構，治療尤為困難。由于C1-2椎管寬闊，患者往往在腫瘤相當大時方出現(xiàn)臨床癥狀。壓迫神經(jīng)組織以及侵襲腦干或者椎管可以導致嚴重的神經(jīng)系統(tǒng)并發(fā)癥。腫瘤經(jīng)常侵襲椎動脈和神經(jīng)根并使其移位。

診斷和流行病學當前第12頁\共有28頁\編于星期四\15點Varioustreatmentapproacheshavebeenattempted,includingisolatedradiotherapy,combinedradiationandsurgicalexcision,andsurgicalexcisionalone.Surgeryremainsthetreatmentmainstayofchordoma.Excellentteamworkisneededforaggressiveandsuccessfulsurgicaltreatmentinmostcases.Thesefactorspleadforearlyreferraltoatertiarycarecenterwithadvancedsurgicalcapabilitiesandavailabilityofnewermodalitiesofradiationtherapy.

對脊索瘤已經(jīng)采取包括適形放療、外科手術治療和二者結合的治療法方法。外科治療仍舊是脊索瘤的首選方法。成功的外科手術需要優(yōu)秀的醫(yī)生團隊，并且需要早期在具有專業(yè)外科技術和放療設備的中心進行治療。治療方法和文獻依據(jù)當前第13頁\共有28頁\編于星期四\15點Chemotherapyhaslongbeenknowntobeinactiveinchordoma.Italonemightbeanoptionforsupportivecareoncethediseaseextendsandprogresses.Cisplatincouldbeusedlocallyaftertumorresection,ifmarginaltumorcontaminationissuspected.Recently,Imatinib,aproteintyrosinekinaseinhibitorandamolecular-targetedagent,hasbeenshowntohaveantitumoractivityinchordoma[9].Themechanismispoorlyunderstood,althoughblockadeofplatelet-derivedgrowthfactor(PDGF)signalinghasbeenproposedasthecauseoftumorcontrol.

脊索瘤對化療不敏感。但是當疾病進展時化療又成為唯一的選擇。在腫瘤切除后如果懷疑邊界被腫瘤污染，可以在局部應用順鉑。最近有一種稱作Imatinib的分子靶向治療藥物顯示對于脊索瘤有治療效果。盡管血小板源性生長因子信號傳遞阻止被懷疑為抑制腫瘤的機制，但其機理仍不清楚。治療方法當前第14頁\共有28頁\編于星期四\15點Chordomasweretraditionallyrecognizedasradioresistant.Thetolerancedoseofthespinalcordislowerthanthecurativedose,whichshouldatleastbeinthe70Gyrange[3].Butradiationisvaluable,especiallyforincompleteexcision.Inconventionalphotonradiotherapyadoseoflessthan45–50Gyiswellwithintheradiationtolerance,givenlessthana5%probabilityofmyelopathywithin5years.However,withtheadventofnewradiationmodalities(i.e.theprotonbeam,chargedcarbonions,stereotacticradiotherapyandintensity-modulatedradiotherapy),itispossibletodeliverhighdosesofradiationwhileprotectingvitalstructures.Adjuvantradiationisnowwarrantedandhasofferedimprovedclinicaloutcomes.Thereisextensiveexperienceinthemanagementofchordomaswithprotonbeamtherapy,andfavorableresultshavebeendemonstrated[6].Fortheradiationoncologistitiseasiertoidentifythetumormarginbeforethesurgery,butsuchpreoperativeradiotherapymightleadtohigheroperativeandpostoperativecomplicationrates.Postoperativeradiationismorecommoninclinicalpractice,butthetumormarginismoredifficulttoidentifyandthemetalimplantsmightdisturbtheradiationefficacy.Radiation

portsalsoneedtobeconfiguredtotreatthesurgicalrouteandthetumorbedinordertoreducetheriskofsurgicalseeding.Thecost-effectivenessratioforcarbonradiotherapyis2,539€per1%increaseinsurvival,or7,692€peradditionallifeyear[7].

Mostauthorssuggestthatmaximaltumorexcisionsurgeryfollowedbyhigh-doseradiotherapyshouldbethestandardofcareforthesepatients,whileBorianihavedemonstratedthatmargin-freeen-blocresectionaloneisenough.

放療當前第15頁\共有28頁\編于星期四\15點既往認為脊索瘤對放療不敏感。放療治療劑量至少需要70Gy，但是脊髓的承受劑量低于此水平。但是放療對于未能完全切除的脊索瘤是很有必要的。普通放療中患者的承受劑量范圍是小于40-50Gy，并且5年內發(fā)生放射性脊髓病的幾率小于5%。然而新放療技術的應用，可以在給予大劑量放療射線的同時保護重要組織。輔助放療目前已經(jīng)被認可，取得較好的臨床療效。采用光子射線治療脊索瘤目前已經(jīng)取得較好的療效，并積累了豐富的經(jīng)驗。對腫瘤放療專家而言，在術前比術后更容易確認腫瘤邊界。但是術前放療增加了手術以及術后并發(fā)癥的發(fā)生率。術后放療在臨床上應用更為普遍，但是腫瘤邊界更難確定，并且內植物會影響放療效果。要調整放療設備來照射手術徑路以及腫瘤邊界以降低外科腫瘤種植的風險。費用量效比率為生存率增加1%的代價為2539元，或者每延長生存期1年代價為7692元。

大部分的醫(yī)生認為最大范圍的腫瘤切除和最大量的放療應該作為治療的標準。但是Boriani認為沿邊界行全椎體切除已經(jīng)足夠。放療當前第16頁\共有28頁\編于星期四\15點Chordomasarecharacterizedbyfrequentrecurrencesafterincompletesurgicalresection,usuallywithin2–3years.Boriani,statesthat‘‘Prognosisisheavilyaffectedbytheappropriatenessofthefirstsurgicaltreatment;oncerecurred,furthertreatmentsarealwaysunsuccessfulatmidterm.’’Othersmaypreferincompletesurgicalexcisiontopreserveinitiallytheneurologicfunction,despitetheriskofincreasedrecurrencethatwillleadto

furtherpalliativesurgery.

Surgicaltreatmenthasbecomemoreaggressiveinrecentyears,evolvingfromintralesionalorpartialexcisiontoenblocresection.In1997,Weinstein,Borianietal.describedtheirClassificationsystemforsurgicalstagingforspinetumors.Suchsystemisbasedondividingthevertebrain12quadrantsanddifferentlayersoftumorinvolvementfromAtoD.Tomitadescribedtotalenblocspondyloectomy(TES)usingathreadwireT-sawformalignantvertebraltumorsinthethoracolumbarspine.Toachieveawideresectionmargin,Borianiandhiscolleaguesevenremovedthedurainfiltratedbytumorandreconstructedtheduradefectwithduralpatch.

外科治療當前第17頁\共有28頁\編于星期四\15點脊索瘤的特點是外科不全切除后較高的復發(fā)率，一般是在2-3年內。Boriani認為預后受初次手術正確與否影響極大，一旦復發(fā)進一步的治療往往是徒勞的。另外有醫(yī)生更傾向于采用部分外科切除術以保留神經(jīng)功能，盡管這增加了復發(fā)的幾率并且需要進一步的姑息性手術治療。近年來外科治療迅速發(fā)展，已經(jīng)從瘤內刮除、部分切除發(fā)展至全椎體整塊切除。1997年，Weinstein等發(fā)表了他們的脊柱腫瘤分類分期方法。將椎體分為12個區(qū)域，A-D層。Tomita描述了他的采用線鋸對胸椎的惡性腫瘤進行了全椎體大塊切除術。為了能夠完整切除腫瘤Boriani甚至切除了被腫瘤侵蝕的硬膜，并且采用硬膜材料進行修補。外科治療當前第18頁\共有28頁\編于星期四\15點In2006,Borianiandhiscolleagues[1]publishedaretrospectivestudyof52chordomascasesofthemobilespineina50-yearperiod.Twelveof16caseshavingintralesionalextracapsularexcisionwithradiationhadrecurrenceataverage30months,while12of18patientshaving

enblocresectionarecontinuouslydisease-free(CDF)ataverage8years.TheynotedthattheonlytreatmentprotocolassociatedwithCDFatfollow-uplongerthan5yearsismargin-freeenblocresection.Majorcomplicationsincludevertebralarteryinjury,cerebrospinalfluid(CSF)leak,nervepalsiesandparalysis.Themortalityrateforskullbasetumorsisfrequentlyquotedat5%,andthisnumberis7.7%inBoriani’sspineseries.Inhisseriesnodifferentiationinthetypeofradiotherapyusedwasmentioned.Theyalsodidnotdiscussthedifferencebetweencervicalandthoracolumbarchordoma.Cervicaltumorexcision,especiallyintheatlantoaxialregion,mightmandatemoresophisticatedsurgicaltechnique.Inthecervicalspinefewcaseshavebeenreportedofenblocexcision,duetoanatomicalconstraints.Evenlessradicalresectioncasehaseverbeenreportedforatlantoaxialchordoma[11].Thepeculiaranatomicalcomplexityofthecervicalregionincludesthedens,thevertebralarteries,thetransverseprocessesaroundandthenerveroots.SincemostchordomasarestageIBatdiagnosis,marginfreeexcisionmeansresectionofparavertebralmuscle,nerveroot,vertebralartery,evenduraorretropharyngealmucosa.Theseseemimpossibleformostcases.

外科治療當前第19頁\共有28頁\編于星期四\15點2006年，Boriani及其同事發(fā)表了50年間52例脊索瘤患者的回顧性研究。16例瘤內刮除中的12例患者平均在30個月時復發(fā)。18例椎體全切中的12例平均8年完全緩解。他們指明唯一的與無癥狀生存相關的就是沿邊界切除。主要的并發(fā)癥包括椎動脈損傷、腦脊液漏、神經(jīng)損傷和癱瘓。顱底脊索瘤的病死率為5%，但是他們統(tǒng)計為7.7%。

在他們的研究中，未提及不同的放療類型。也沒有提及頸椎與胸腰椎脊索瘤的不同。頸椎腫瘤特別是寰樞椎腫瘤要求更復雜的外科技術。由于解剖復雜，關于頸椎腫瘤少見全脊椎切除術的報道。寰樞椎的全脊椎切除術更為少見。復雜的解剖結構包括齒狀突、椎動脈、橫突和神經(jīng)根。由于大部分脊索瘤是IB期，邊界外切除意味著椎旁肌肉、神經(jīng)根甚至硬膜和咽后粘膜。對于大部分病例這似乎不可能。外科治療當前第20頁\共有28頁\編于星期四\15點In1999,Tomitaetal.[5]firstdescribedTESforcervicalchordoma(IB)throughasingleanteriorapproachwithT-saw.Unfortunately,aftertheC5vertebralbodyhadbeenremovedwithaT-sawtheresidualtumoralongtheC6rootandduramaterhadtoberemovedinapiecemealfashion.Thetumorbedwasirrigatedbydistilledwaterandcisplatinsolutionandthenunderwentadjunctiveradiotherapy.Unfortunately,thechordomarecurred9yearslaterinthesofttissue(Tomitapersonalcommunication).In2007,Borianietal.[8]reportedenblocexcisionforaC4chordoma(IA)withcombinedposteriorandanteriorapproach.HeconcludedthatTESisfeasibleinthemidcervicalspinebydoubleapproaches,providedthetumorinvolvesonlylayersBandC,withamaximumextensiontosectors5–8.Currieretal.[4]hasasimilarcasewith9yearsfollow-up.

Therearethreemajoranteriorapproachesforatlantoaxialchordoma.Theexperienceandabilitiesofthesurgicalteamdictatesthesurgicalprocedureused.(1)BilateralhighanteriorcervicalapproachcanprovideclearvisualizationofC2vertebralbodyandbilateraltransverseprocesses,whilethedensisnotappropriatelyexposed[13].(2)Theanteriormidlinetransoralwith/withouttranspalatineapproachisforspinallesionlocatedfromthemidclivusdowntothelevelofC3andlaterallywithin2cmtoeithersideofthemidline.However,thetumorcannotberadicallyexcisedbythisapproach,ifitextendslaterallyoutsidethetransverseprocess.Menezesreportedtranspalatopharyngealapproachfor18clivuscraniocervical

chordomacasesin2001.Heusedpiecemealexcisionwithjudicioususeofcuretandadiamondburforoccipitalcondylesoratlantallateralmasstumorinvolvement.Theauthordidnotprovideradiotherapyandfollow-upinformationindetail;atleastonepatienthadnotumorprogressionfor10years.(3)Transmandibleapproachcombinedwithanteriorcervicalapproachcouldprovideidealexposurefromclivustolowercervicalspine.Thisapproachismoreaggressiveandoftenrequiresafreeflapfortheposteriorpharyngealwallreconstruction.Rhinesetal.[12]reportedthemostaggressiveTESforC2–4chordoma(IB)in2005.Theyusedarightlateralneckdissectionandatransmandiblar,circumglossal,retropharyngealexposure.

外科治療當前第21頁\共有28頁\編于星期四\15點在1999年，Tomita等描述了他們采用單純前路利用線鋸對頸椎脊索瘤進行了全脊椎切除術。不幸的是在切除頸5后，頸6神經(jīng)根周圍的腫瘤和硬膜被一片片切除。腫瘤基底被用蒸餾水和順鉑溶液浸泡，術后接受化療。但是腫瘤9年后復發(fā)。2007年，Boriani描述了他們全椎體切除頸4椎體腫瘤采用聯(lián)合前后入路。他總結到，如果腫瘤位于B和C層并且5-8區(qū)采用前后聯(lián)合入路對于中段頸椎是可行的，并且同樣進行了9年的隨訪。

前路寰樞椎脊索瘤有三種手術方法。1、雙側高位前入路可以清楚暴露頸2椎體和橫突，但是齒狀突暴露欠佳。2、前正中經(jīng)口入路經(jīng)或不經(jīng)鄂部對于從斜坡向下直至頸3或者中線以內2厘米。但是如果腫瘤超過橫突，則不能全切。Menezes2001年報道經(jīng)咽入路切除了18例顱頸交界脊索瘤，他謹慎使用刮匙鉆處理枕骨髁和寰椎側塊。作者未提供詳細的放療以及隨后的治療信息。至少一名患者術后10年無腫瘤進展。3、經(jīng)下頜入路聯(lián)合前入路可以提供理想的從斜坡至下頸椎的顯露。這個入路暴露更為廣泛，需要將咽喉壁翻開以便重建。Rhines等2005報道采用最廣泛的暴露方法，采用右側頸部切開，經(jīng)下頜骨、舌周、咽后入路。外科治療當前第22頁\共有28頁\編于星期四\15點ThetumorwasclassifiedasIB,TESseemednotfeasible.Becauseo