Периоперационное мультимодальное секвенирование с привязкой к хирургическому вмешательству при местно-распространенном плоскоклеточном раке полости рта: Современное состояние и перспективы
DOI:
https://doi.org/10.70439/2075-8790.2025.98.3.003Ключевые слова:
плоскоклеточный рак полости рта, хирургическое вмешательство, диссекция шеи, глубина инвазии, послеоперационная лучевая терапияАннотация
Хирургическое лечение остается краеугольным камнем при резектабельном местно-распространенном плоскоклеточном раке полости рта. Оптимальные результаты зависят от точного отбора пациентов, онкологической экстирпации со стратификацией патологического риска, своевременной адъювантной лучевой терапии с сопутствующей системной терапией или без нее, основанных на фактических данных реконструктивных стратегий и, в последнее время, хорошо разработанной неоадъювантной/адъювантной иммунотерапии. Мы синтезировали доказательства I–III уровня и современный консенсус из авторитетных журналов и руководств по следующим вопросам: уточнение стадирования, стандарты края/глубины инвазии, плановое ведение пациентов с заболеваниями шеи, сроки/техника послеоперационной лучевой терапии/послеоперационной сопутствующей химиолучевой терапии и ускоренное восстановление после операции, а также периоперационная системная терапия.
Важные рандомизированные исследования показали, что в послеоперационных когортах высокого риска (положительный край и/или экстранодальное распространение) добавление высокой дозы цисплатина к послеоперационной лучевой терапии улучшает локорегиональный контроль и безрецидивную выживаемость; Еженедельное введение цисплатина (40 мг/м²) не уступает 3 недельному введению 100 мг/м² и менее токсично. Плановое лечение шейного отдела cN0 улучшает выживаемость по сравнению с терапевтической шейной диссекцией после рецидива лимфоузлов, а биопсия сторожевого лимфоузла онкологически эквивалентна селективной шейной диссекции при заболевании cT1–2N0 с меньшей ранней заболеваемостью. Послеоперационная лучевая терапия с модулированной интенсивностью снижает ксеростомию по сравнению с 3D-CRT; задержки более ~6 недель после операции и увеличение времени прохождения курса лечения связаны с худшей выживаемостью. Ранние признаки подтверждают эффективность периоперационной анти-PD-1 терапии при резектабельном плоскоклеточном раке головы и шеи, в то время как адъювантная анти-PD-L1 монотерапия после стандартного лечения оказалась отрицательной. Реконструкция, адаптированная к классу дефекта с приоритетом функции и готовности к адъювантной терапии, обеспечивает высокую выживаемость лоскута, ускоренное восстановление после
операции и сокращает продолжительность госпитализации без ущерба для безопасности. Хирургически фиксированная, чувствительная ко времени и адаптируемая к риску последовательность лечения, включающая современные методы лечения заболеваний шеи, послеоперационную лучевую терапию с модулированной интенсивностью, послеоперационную реконструкцию с помощью химиолучевой терапии и селективную иммунотерапию, обеспечивает наилучшие текущие результаты лечения распространенного плоскоклеточного рака полости рта. Продолжающиеся исследования позволят определить эффективность интеграции периоперационной иммунотерапии, деэскалацию при промежуточном риске и уточнение показаний к применению биомаркеров.
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