根治性颈清扫术与改良根治性颈清扫术

根治性颈清扫术（radical neck dissection，RND）与改良根治性颈清扫术（modified radical neck dissection，MRND）同属全颈清扫术（comprehensive neck dissection，CND）的范畴，即术中清扫一侧颈部Ⅰ～Ⅴ区的全部淋巴结。RND术中同时牺牲副神经、颈内静脉和胸锁乳突肌，而MRND则保留了一个或数个上述结构。虽然近年来选区性颈清扫术（selective neck dissection，SND）在头颈癌N＋颈部处理的应用已经越来越多，特别是N1颈部，但是，RND和MRND仍然是目前处理头颈部淋巴结转移（N＋）的主流和经典术式，特别是MRND。     

颈清扫术几种改进术式的比较研究

目的 通过两种改进颈清扫术式MRND与RND和FND术后肩功能的比较研究,观察MRND1和MRND2能否较好地保留或恢复斜方肌的功能。方法46例需行颈清扫术的患者,分成4组,分别行RND、FND和MRND1、MRND2,通过肩功能临床检查的主客观评价标准及斜方肌肌电检测进行对比研究。结果MRND1和MRND2均可获得较大程度的斜方肌功能恢复,MRND1和MRND2的上肢平均最大外展角度分别为96.67°和98.13°,50％的患者外展上臂超过90°,两种改进术式的术后肩功能明显优于RND。结论MRND1和MRND2较FND有广泛的适应证,又可较大程度地保存和恢复术后斜方肌的功能,改善传统RND术后的肩综合征,临床上可以用来代替传统RND,以提高患者的生存质量。     

颈清扫术中改善术后肩功能方法的初步探讨

目的　观察并论证两种改进颈清扫术式的优越性及改善术后斜方肌功能的效果。方法　 2 4例需行颈清扫术的患者 ,每组 12例 ,分别在颈清扫术中保留颈丛斜方肌分支 (MRND1)或采用颈丛肩胛提肌支与副神经移位吻合 (MRND2 )。结果　手术 6月后 ,MRND1和 MRND2均可获得较大程度的斜方肌功能恢复 ,MRND1和MRND2的上肢平均最大外展角度分别为 96 .6 7°和 98.13°,5 0 %的患者可以外展上臂超过 90°。结论　 MRND1和MRND2均可较大程度地保存和恢复术后斜方肌的功能 ,改善传统颈清扫术 (RND)后的肩综合征 ,既不违反根治肿瘤的原则 ,同时具有简便、无联带运动、利于斜方肌神经再生、功能恢复等优点。临床上可以用来代替传统 RND,以提高患者的生存质量     

功能性与根治性颈淋巴清扫术在早期口腔鳞状细胞癌治疗中的疗效比较

目的:探讨功能性颈淋巴清扫术(functional neck dissection,FND)与根治性颈淋巴清扫术(radical neckdissection,RND)在口腔鳞状细胞癌中的临床疗效.方法:63例口腔鳞状细胞癌患者,分为FND组(n=30)和RND组(n=33),FND组保留胸锁乳突肌、副神经、颈内静脉及耳大神经,术后随访2组患者的肩外展功能、耳大神经功能、颈部是否明显凹陷及颈部复发率.应用SPSS 18.0软件包对数据进行单因素x2检验、两独立样本均数t检验,以及Fisher确切概率检验.结果:FND与RND组之间在年龄、性别、肿瘤部位、T分期、N分期、组织学分化程度、病理学类型、术前化疗及术后化疗等方面无显著差异(P＞0.05).所有患者均为N0或N1期,FND组术后肩关节活动度、耳垂感觉麻木及颈部凹陷改善程度显著优于RND组(P＜0.05);术后随访2年,FND组的颈部复发率与RND组无显著差异(P=1.000).结论:对于N0或N1期口腔鳞状细胞癌患者,FND与RND相比,患者颈部复发率无显著差异,但其并发症显著减少,可明显提高患者术后的生活质量.     

合理的根治性颈淋巴清扫术的临床应用评价

目的:评价保留颈外静脉、耳大神经和颈神经丛深支的新型改良根治性颈淋巴清扫术(或称合理的根治性颈淋巴清扫术)在治疗口腔癌颈淋巴转移灶中的临床应用价值。方法:TNM分期在T2N1M0~T4N3M0之间的口腔鳞癌初诊患者45例,随机分为2组(RND组和RRND组),RND组行传统根治性颈淋巴清扫术(22例),RRND组行合理的根治性颈淋巴清扫术(23例),比较2种手术方式的颈淋巴结术后复发率和并发症。结果:RRND组术后患者面部水肿及头晕、头痛症状显著低于RND组(P<0.05);术后6个月复查,RRND组患者耳廓和肩部麻木感显著低于RND组,耳廓皮肤感觉功能和肩运动功能显著高于RND组(P<0.05);随访3年,RRND组和RND组术后颈淋巴结复发率分别为8.70%、4.55%,差别无统计学意义(P>0.05)。结论:合理的根治性颈淋巴清扫术与传统根治性颈淋巴清扫术相比,不会增加术后颈淋巴结复发率,但极大地提高了患者术后的生存质量。     

不同颈清术式对口腔鳞癌患者术后肩功能的影响

目的:比较4种不同颈清术式对患者术后肩功能的影响.方法:选择4|D例接受不同颈清术式的患者,其中7例保留副神经及C2-C4斜方肌支(A组);8例仅保留副神经(B组);11例保留C3-C4斜方肌支(C组);14例切除副神经及C2-C4斜方肌支(D组),分别于术前、术后2周及6个月检测各患者的肩功能和斜方肌肌电指标进行比较.结果:A、B组术后肩功能恢复最好;C组在6个月时的各项指标也明显优于D组.结论:在根治性颈清扫术中保留有功能的颈丛斜方肌支,可在一定程度上改善患者术后肩功能.     

口腔癌cN0患者颈淋巴清扫术中Ⅱb区淋巴结的处理

目前,择区性颈淋巴清扫术(selective neck dissection,SND)已经被广泛应用于头颈部鳞癌cN0颈部淋巴结处理.与传统的根治性颈淋巴清扫术(mdical neck dissection,RND)和改良根治性颈淋巴清扫术(modified radical neck dissection,MRND)不同,SND并不是常规清扫一侧颈部的全部五个区域,而是有选择地清扫颈部最有可能发生淋巴结隐匿性转移的区域,其中,口腔癌常选用的SND术式为清扫Ⅰ～Ⅲ区的肩胛舌骨上颈淋巴清扫术(supraomohyoid neck dissection,SOND)[1].     

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目的探讨口腔黏膜鳞状细胞癌颈Ⅱ区连续整块切除的意义。方法选取安徽医科大学附属省立医院口腔医学中心颌面头颈外科1999年1月至2004年1月期间行颈清扫术且病例记录及术后随访资料完整的117例病例,以颈Ⅱ区连续整块切除与否为指标,观察根治性颈清扫术(RND)和功能性颈清扫术(FND)两种术式的术后颈部淋巴结复发率。结果117例病例中,术后病理诊断为淋巴结转移癌32例,转移率为27.35%(32/117),其中RND26例,FND6例。经3年期随访,颈清扫术后淋巴结复发18例,复发率为15.38%,其中RND12例,FND6例。位于Ⅱ区淋巴结复发有15例,占83.33%,其中RND9例,FND6例。结论对FND应有严格的指征,确定癌肿病例的生存质量必定建立于肿瘤控制的基础上,得出肿瘤不能根治则谈不上生存质量的结论,建议提倡施行保留胸锁乳突肌(必要时加副神经)的FND术式。     

改良根治性颈淋巴清扫术后颈内静脉的畅通率

大量的研究表明,对早期颈部病变,根治性颈淋巴清扫术(RND,Crile,1906)与改良RND(Suarez,1967)的肿瘤控制率相似,但对两种手术的功能效果,却很少有研究报道。保存副神经的改良RND,使肩功能并发症率大大降低;在双侧RND,保留颈内静脉(IJV)对患     

根治性颈清扫术对肩功能的影响

目的　分析研究根治性颈清扫术后发生的肩综合征对患者生活、工作的影响，进一步研究探讨科学合理的评价标准。方法　对50例根治性颈清扫术(RND)患者通过主观评价和客观检查进行回顾性分析。结果　68％患者认为RND对生活和工作有较大妨碍，所有RND患者术后均有不同程度的肩功能障碍。结论　RND后均有不同程度的肩功能障碍，并对患者生活质量产生较明显的影响。通过患者自我评价可较好地了解RND对生活质量的影响；用上肢外展能否大于90°来评价颈清扫术后肩功能恢复程度，是科学合理的。     

Shoulder complaints after neck dissection; is the spinal accessory nerve involved?

The purpose of the current study was to investigate the relation between shoulder morbidity (pain and range of motion), and the function of the spinal accessory nerve after neck dissection. Identifying dysfunction of the nerve gives insight in the mechanisms of post-operative shoulder complaints. In total 112 patients after neck dissection (73 males/39 females), mean (SD) age 61 (13) years, participated in the study. The mean duration of follow up was 3 (2) years. Five patients had radical, 43 modified radical, 48 supraomohyoid, and 16 posterolateral neck dissection. Thirty-nine complained of shoulder pain of whom 20 (51%) had dysfunction of the spinal accessory nerve, and 19 (49%) did not. In total 29 patients (26%) had dysfunction of the spinal accessory nerve of whom 20 (69%) had shoulder pain. Shoulder pain was significantly related to dysfunction of the nerve (P < 0.001). Twenty-three patients had a difference in active range of motion in shoulder abduction of > or =40 degrees, of whom 22 (96%) had dysfunction of the nerve. A difference in active shoulder abduction of > or =40 degrees was significantly related to loss of function of the spinal accessory nerve (P < 0.001). CONCLUSION: Shoulder pain after neck dissection can only be attributed to dysfunction of the spinal accessory nerve in about 50%. If patients experience shoulder pain after neck dissection examination of the trapezius muscle and active bilateral abduction of the shoulder should be made to find out if the spinal accessory nerve is involved.     

Neck management of pathological N1 oral squamous cell carcinoma: a retrospective study

This study was performed to compare the effects of neck dissection procedures on the prognosis of patients with pathological N1 (pN1) oral squamous cell carcinoma (OSCC), analyse factors affecting the prognosis, and provide a neck management strategy for clinical N1 (cN1) oral cancer. The study patients were divided into two groups according to the neck dissection: a selective neck dissection (SND) group (n = 85) and a radical or modified radical neck dissection (RND/MRND) group (n = 22). There was no statistically significant difference in recurrence rates at local, regional, and distant sites between the SND and RND/MRND groups. The 5-year overall survival was 68.3% for SND and 65.2% for RND/MRND patients (P = 0.590), while the 5-year disease-specific survival was 70.4% for SND and 75.7% for RND/MRND patients (P = 0.715). Histological grade and postoperative radiotherapy were independent predictors of the outcome for SND patients. For histological grade II/III cases, 5-year overall survival (P = 0.004) and disease-specific survival (P = 0.002) outcomes differed significantly between patients treated with and without postoperative radiotherapy, with worse survival for patients not treated with radiotherapy. Therefore, SND appears appropriate for cN1 OSCC patients, and postoperative radiotherapy is recommended for those with histological grade II or III tumours.     

Shoulder complaints after nerve sparing neck dissections

The purpose of the study was to analyse the prevalence of shoulder complaints after nerve sparing neck dissection at least 1 year after surgery, and to analyse the influence of radiation therapy on shoulder complaints. Patients were interviewed for shoulder complaints, and patients filled out the shoulder disability questionnaire to evaluate shoulder disability in daily activities. In total 137 patients; 51 after modified radical neck dissection (MRND), 21 after postero-lateral neck dissection (PLND), and 65 after supraomohyoid neck dissection (SOHND) were analysed. After MRND 33.3% of the patients experienced shoulder complaints, after PLND 66.7%, and after SOHND 20% of the patients experienced shoulder complaints. Type of neck dissection was significantly (P < 0.001) related to shoulder complaints. Outcome on the shoulder disability questionnaire also showed a significant (P < 0.01) difference in outcome for type of neck dissection. The prevalence of shoulder complaints after SOHND are low, and reduce disability in daily activities. Radiation therapy does not have a significant effect on shoulder complaints and disability.     

Health-related quality of life in patients with T1N0 oral squamous cell carcinoma: selective neck dissection compared with wait and watch surveillance

Management of the neck in patients with clinical T1N0 oral squamous cell carcinoma (SCC) is controversial. The aim of this study was to report the health-related quality of life (HRQoL) in a consecutive group of patients with stage 1 disease at a time closest to two years after primary surgery. Of 216 patients treated between 2007 and 2012 (after excluding early death and regional recurrence), 195 were eligible. HRQoL was measured using the University of Washington quality of life questionnaire version 4. The overall response rate was 65% (126/195). HRQoL outcomes were good, but compared with patients in the wait and watch group, those who had selective neck dissection (SND) had more problems regarding appearance (14% compared with 1%, p = 0.008) and pain (19% compared with 6%, p = 0.04). Similar trends were seen for shoulder (14% compared with 8%), mood (16% compared with 8%), and speech (5% compared with 1%), and for poorer overall QoL (30% compared with 16%). It is difficult to establish why patients did or did not have neck dissection in a retrospective sample, but it is likely that those who had SND had larger tumours. The findings highlight the impact that SND has on HRQoL in domains such as appearance, pain, speech, swallowing, and chewing. Previous studies on SND have tended to focus on injury to the accessory nerve and shoulder function, but these new data emphasise the need to include other domains in future trials that compare wait and watch, SND, and sentinel lymph node biopsy.     

胸锁乳突肌-耳大神经瓣修复颈清扫术中缺损的副神经

目的　总结颈清扫术中用胸锁乳突肌 耳大神经瓣修复副神经缺损的一种方法。方法　将 34例需行传统根治性颈清扫术患者分为单纯颈清扫术组 ( 19例 )及副神经重建组 ( 15例 ) ,副神经重建组缺损副神经用新修复方法处理 ,比较两组病例术后肩功能恢复状况。结果　副神经重建组的术后肩部疼痛、肩臂活动能力及臂外展角度均明显优于单纯颈清扫术组。结论　利用胸锁乳突肌 耳大神经瓣修复缺损副神经是一种简单、有效、充分利用组织和不会带来并发症的可靠方法     

口腔癌患者术后生存质量评价及影响因素分析

目的：评价口腔癌患者术后的生存质量（quality of life,QOL）,并探讨影响无瘤生存者术后QOL的可能因素。方法：采用SF-36及UW-QOL测量55例口腔癌患者术前和术后12个月的QOL,采用SPSS12.0软件包对数据进行统计学分析。结果：①复发患者术后的QOL显著低于无瘤生存者。②与术前相比,术后12个月时,无瘤生存者仍存在较严重的治疗相关的特异性问题和较差的社会功能状况。③文化程度、婚姻状况、共病、缺损范围及放疗影响无瘤生存者术后QOL,初、高级文化程度、配偶健在、不伴有共病、缺损最大径〈6cm及术后未放疗的患者,术后QOL较高。④不同的颈清扫术式对无瘤生存者手术前后QOL总分的差值没有影响,但副神经保留组术后的肩功能明显优于副神经切除组。结论：保留副神经可改善颈清扫患者的肩功能;降低复发率、加强慢性病的预防及控制、改进放疗手段、增加社会支持及必要的康复指导和治疗可提高口腔癌患者术后的QOL。     

An evaluation of the shoulder domain of the University of Washington quality of life scale

The aim of this study was to compare the shoulder domain in the University of Washington quality of life (UW-QoL) scale with two shoulder-specific questionnaires. METHODS: We did a cross-sectional survey of 100 consecutive outpatients who had had operations on the head and neck for cancer using the UW-QoL, the neck dissection impairment index, and the shoulder disability questionnaire. RESULTS: The types of neck dissection were none (n=12), unilateral selective (n=63), bilateral selective (n=17), and radical or modified radical (n=8). There were significant correlations among the three questionnaires. The worst scores were found in the group who had modified radical or radical neck dissection. Although responses were similar between those who had no neck dissection and those who had unilateral level 3 neck dissection, a few patients reported considerable dysfunction after selective neck dissection. CONCLUSION: Although the UW-QoL shoulder domain is limited to one of four responses, our results support the conclusion that it is sufficiently sensitive to screen for dysfunction of the shoulder.     

Supraomohyoid neck dissection and modified radical neck dissection for clinically node-negative oral squamous cell carcinoma: A prospective study of prognosis,complications and quality of life

BackgroundTo assess the prognosis and morbidity between supraomohyoid neck dissection (SOND) and modified radical neck dissection (MRND) for oral squamous cell carcinoma (OSCC) in patients with a clinically node-negative neck (cN0).Patients and methodsThis prospective randomized study began in June 1999, and patient accrual concluded in May 2010. The cN0 neck was confirmed on clinical palpation by senior doctors. Ultimately, there were 322 patients recruited into the study.ResultsPatient demographics were well balanced between the two groups. There were 10 patients in the SOND group and 21 patients in the MRND group who developed nodal recurrence without associated local recurrence or distant metastasis. The 3-year neck control rate (NCR) rate was 92.6% for the SOND group and 87.5% for the MRND group (in favor of SOND, P = 0.108). There was no significant difference between the SOND group and the MRND group in the 3-year disease-specific survival (DSS) rate (79.0% vs. 76.9%, P = 0.659). Importantly, there were significantly fewer complications in the SOND group compared with the MRND group (13.0% vs. 21.9%, P = 0.040). The disease-free survivors in the SOND group also reported better pain relief (P = 0.013) and shoulder function (P < 0.001) than those in the MRND group one year after treatment.ConclusionsWe recommend SOND as a priority treatment for cN0 OSCC patients.     

斜方肌神经支配的解剖学研究

目的 :通过解剖学研究 ,了解斜方肌神经支配方式对根治性颈清扫术术后肩功能可能产生的影响 ,根据神经支配的特点 ,探讨改进手术方法以改善根治性颈清扫术后肩功能的可能性 .方法 :解剖 16具成人尸体 2 2侧颈部 ,观察斜方肌的神经支配 .结果 :68.18%的副神经在胸锁乳突肌后缘前接受颈丛分支的交通 ,所有斜方肌均接受颈丛分支的支配 ,多来源于 C3、C4,其中 ,88.37%的分支在颈后三角位于椎前筋膜的浅面 ,颈丛均有肩胛提肌分支且位于椎前筋膜的深面 .结论 :斜方肌受副神经和颈丛的双重支配 ,大多数颈丛斜方肌支在根治性颈清扫术中会被切断 .通过颈清扫术中保留 C3、C4到斜方肌分支或用颈丛肩胛提肌支与副神经移位吻合来改善术后斜方肌功能具有解剖学上的依据 .