Level IIb lymph node metastasis in elective neck dissection of oropharyngeal squamous cell carcinoma

This study investigated the oncologic safety of preserving level IIb lymph nodes in ipsilateral and/or contralateral elective neck dissection (END) in patients with oropharyngeal squamous cell carcinoma (SCC). Fifty-one oropharyngeal SCC patients who underwent surgery as an initial treatment were reviewed. Twenty-one patients had clinically node negative necks (cN0) while 30 patients had ipsilateral clinically node positive necks (cN+). Of the cN0 patients, bilateral or ipsilateral END was performed in 15 and six patients, respectively. For the cN+ cases, ipsilateral therapeutic neck dissection with contralateral END was performed in 24 of 30 patients. In the cN0 patients, nodal metastasis to level IIb lymph nodes was not observed in any ipsilateral (21) or contralateral necks (15). Of the 24 cN+ patients who underwent contralateral END, two cases (8.3%) showed contralateral occult level IIb lymph node metastasis. Our data suggest that in cN0 oropharyngeal cancer patients, level IIb lymph nodes may be preserved in ipsilateral and contralateral neck dissection. However, caution is advised when preserving contralateral level IIb nodes in ipsilateral cN+ cases.     

Radiotherapy for Oropharyngeal Carcinoma With an Uninvolved Contralateral Neck: The Safety of Omission of Contralateral High Level II and Retropharyngeal Lymph Nodes From Elective Target Volumes

AimsTo analyse outcomes and patterns of failure in patients with oropharyngeal carcinoma (OPC) treated with definitive volumetric modulated arc therapy with omission of contralateral high level II lymph nodes (HLII) and retropharyngeal lymph nodes (RPLN) in the contralateral uninvolved neck.Materials and methodsPatients with OPC treated between January 2016 and July 2019 were retrospectively identified. In the absence of contralateral neck disease, institutional protocols allowed omission of contralateral HLII and contralateral RPLN in the additional absence of ipsilateral RPLN, soft palate/posterior pharyngeal wall primary.ResultsIn total, 238 patients with OPC and an uninvolved contralateral neck received definitive (chemo)radiotherapy with bilateral neck treatment. The median follow-up was 30.6 months. Two-year local control, regional control and overall survival were 91.0, 91.6 and 86.5%, respectively. Contralateral HLII were omitted in 159/238 (66.8%) patients; this included 106 patients in whom the primary tumour was at/crossed the midline. The contralateral RPLN region was omitted from elective target volumes for 175/238 (73.5%); this included 114 patients with a primary tumour at/crossed the midline. The mean contralateral parotid dose when contralateral HLII and RPLN were both omitted was 24.4 Gy, compared with 28.3 Gy without HLII/RPLN omission (P < 0.001). Regional progression occurred in 18/238 (7.6%) patients, all involving the ipsilateral neck with one bilateral. There were no recurrences in the contralateral HLII or RPLN regions.ConclusionIn patients with OPC and an uninvolved contralateral neck receiving bilateral (chemo)radiotherapy, the omission of contralateral RPLN and HLII from elective target volumes was safe and could lead to reduced contralateral parotid doses.     

局部晚期喉癌颈部淋巴结转移规律及相关因素分析

目的 分析局部晚期(T3、T4期)喉癌颈部淋巴结转移(LNM)规律,为喉癌放疗颈部靶区勾画提供参考。方法 回顾分析2000-2017年中国医学科学院肿瘤医院初治局部晚期喉癌患者,所有患者至少行双颈Ⅱ-Ⅳ区淋巴结清扫,计算颈部各区LNM率。采用Logistic回归分析LNM相关因素。结果 共272例患者纳入研究,全组患者LNM率为57.1%(156/272)。根据原发病变部位分3个组:A组(72例),原发灶局限于一侧;B组(86例),原发灶主体偏于一侧但侵犯过中线;C组(114例),原发灶为巨大或中央型病变。各组不同颈部分区LNM率:A组同侧颈部Ⅱ区36.3%、Ⅲ区26.4%、Ⅳ区6.9%,对侧分别为13.9%、8.3%、1.4%;B组:同侧颈部Ⅱ区41.9%、Ⅲ区29.1%、Ⅳ区11.6%,对侧分别为18.6%、14.0%、1.2%;C组:左侧Ⅱ区24.6%、Ⅲ区 23.7%、Ⅳ区2.6%,右侧分别为21.9%、26.3%、6.1%。局限单侧(A组)与中线受侵(B、C组)双侧LNM率相近(15.3%、25.0%,P=0.093)。同侧Ⅲ区是否转移和临床淋巴结分期与对侧颈是否LNM相关(OR=2.929,95%CI为1.041~8.245,P=0.042)和OR=0.082,95%CI为0.018~0.373,P=0.001)。同侧Ⅱ区、Ⅲ区转移是同侧Ⅳ区转移的危险因素(P=0.043、0.009)。结论 双侧颈部Ⅱ、Ⅲ区是高危LNM区,Ⅳ、Ⅴ区转移较少见;同侧Ⅱ、Ⅲ区转移是同侧Ⅳ区及对侧颈LNM的相关因素,cN0期患者少见对侧颈LNM。     

局部晚期喉癌颈部淋巴结转移规律及相关因素分析

目的 分析局部晚期(T3、T4期)喉癌颈部淋巴结转移(LNM)规律,为喉癌放疗颈部靶区勾画提供参考。方法 回顾分析2000-2017年中国医学科学院肿瘤医院初治局部晚期喉癌患者,所有患者至少行双颈Ⅱ-Ⅳ区淋巴结清扫,计算颈部各区LNM率。采用Logistic回归分析LNM相关因素。结果 共272例患者纳入研究,全组患者LNM率为57.1%(156/272)。根据原发病变部位分3个组:A组(72例),原发灶局限于一侧;B组(86例),原发灶主体偏于一侧但侵犯过中线;C组(114例),原发灶为巨大或中央型病变。各组不同颈部分区LNM率:A组同侧颈部Ⅱ区36.3%、Ⅲ区26.4%、Ⅳ区6.9%,对侧分别为13.9%、8.3%、1.4%;B组:同侧颈部Ⅱ区41.9%、Ⅲ区29.1%、Ⅳ区11.6%,对侧分别为18.6%、14.0%、1.2%;C组:左侧Ⅱ区24.6%、Ⅲ区 23.7%、Ⅳ区2.6%,右侧分别为21.9%、26.3%、6.1%。局限单侧(A组)与中线受侵(B、C组)双侧LNM率相近(15.3%、25.0%,P=0.093)。同侧Ⅲ区是否转移和临床淋巴结分期与对侧颈是否LNM相关(OR=2.929,95%CI为1.041~8.245,P=0.042)和OR=0.082,95%CI为0.018~0.373,P=0.001)。同侧Ⅱ区、Ⅲ区转移是同侧Ⅳ区转移的危险因素(P=0.043、0.009)。结论 双侧颈部Ⅱ、Ⅲ区是高危LNM区,Ⅳ、Ⅴ区转移较少见;同侧Ⅱ、Ⅲ区转移是同侧Ⅳ区及对侧颈LNM的相关因素,cN0期患者少见对侧颈LNM。     

喉癌同侧颈淋巴结转移癌穿透包膜的相关因素及其与对侧颈淋巴结转移和患者预后的关系

目的探讨喉癌同侧颈部淋巴结转移癌穿透包膜的相关因素及其与对侧颈部淋巴结转移和患者预后的关系。方法对184例喉癌患者进行手术治疗的同时,行经典或改良经典颈廓清术,对颈廓清标本采用透明淋巴结摘出连续切片法,摘出淋巴结,并进行病理检查。采用Kaplan-eier方法对随访资料进行生存分析。结果184例喉癌患者中,颈部淋巴结转移癌80例,其中穿透包膜26例,穿透包膜率为32．5％。单因素分析结果表明,淋巴结转移癌是否穿透包膜与病理N分期和同侧颈部淋巴结转移数有关。淋巴结转移癌穿透包膜者同侧颈部复发转移率（34.6%）、对侧颈部转移率（46．2％）均高于未穿透包膜者。淋巴结转移癌穿透包膜患者3、5年生存率分别为53．9％和23．1％,其生存率低于未穿透包膜患者。结论淋巴结转移癌是否穿透包膜与病理N分期和同侧颈部淋巴结转移数有关。淋巴结转移癌穿透包膜患者的对侧转移率高,应行双颈廓清术。淋巴结转移癌穿透包膜是影响患者预后的重要因素,病理科应当检查转移淋巴结被膜是否穿破,并予以报告。     

cN0 甲状腺乳头状癌对侧中央区淋巴结转移相关 因素的探讨

  目的  分析 cN0 甲状腺乳头状癌(papillary thyroid carcinoma,PTC) 对侧中央区淋巴结(contralateral central lymph nodes, Cont-CLNs) 转移相关因素,探讨 Cont-CLNs 清扫适应证。  方法  回顾性分析 2013 年 6 月至 2015 年 12 月就诊于重庆医科大学附属第一医院的单侧 PTC 患者 149 例,均已接受甲状腺全切以及预防性 Cont-CLNs 清扫。分析性别、年龄、肿瘤直径、包膜外侵犯、原发灶数目、是否合并甲状腺炎、喉前淋巴结、Ipsi-CLNs 与 Cont-CLNs 转移的关系。  结果  本组患者 Ipsi-CLNs 转移率和 Cont-CLNs 转移率分别为 73.2%和 23.5%,其中性别、年龄、肿瘤直径、原发灶数目、是否合并甲状腺炎与 Cont-CLNs 转移均不相关(P=0.792、 0.097、0.531、0.578、0.269、1.000) ,包膜外侵犯(P=0.017) 、喉前淋巴结转移(P=0.006) 和 Ipsi-CLNs 转移(P＜0.001) 与 Cont-CLNs 转移相关。但多因素分析后发现 Ipsi-CLNs 转移数目≥3 枚是 Cont-CLNs 转移的独立危险因素(P=0.010) 。  结论  包膜外侵犯、喉前淋巴结和 Ipsi-CLNs 是 Cont-CLNs 的影响因素;当 Ipsi-CLNs 转移数目≥3 枚,且合并喉前淋巴结或包膜外侵犯时,可考虑行 Cont-CLNs 清扫。       

A study of a regional lymph node metastasis in a well-differentiated thyroid carcinoma

Forty-eight patients with a well-differentiated thyroid cancer that occupied unilateral lobe were given, a modified radical neck dissection (unilateral or bilateral). After an examination of their lymph nodes, a retrospective analysis showed that the metastasis extended to the lateral cervical lymph node on the ipsilateral neck in 43.8% of all cases, and to at least the paratracheal lymph node on the contralateral neck in 27.2% of all cases. Therefore a bilateral modified radical neck dissection is needed surgical treatment for such patients.     

口腔癌患者对侧颈部淋巴结转移危险因素的多因素分析

目的:探讨口腔癌患者对侧颈淋巴结转移特点及其危险因素。方法:收集同期行双侧颈淋巴结清扫术患者82例,分析对侧颈部淋巴结转移风险因素。结果:对侧转移29例,伴有同侧转移27例（93.10%）。分析结果表明同侧转移与对侧转移关联性有统计学意义。结论:口腔癌同侧颈部转移将增加对侧转移的风险。     

基于CT的下咽癌淋巴结转移规律分析

目的 分析下咽鳞癌淋巴结转移规律,指导临床靶区的准确勾画。方法 2014—2017年在山东省肿瘤医院初诊的下咽鳞癌患者123例。经电子喉镜以及头颈部CT检查确诊,根据CT诊断标准判断颈部淋巴结转移,计算颈部各组淋巴结转移率(LMR)。采用单因素方差分析和χ²检验分析LMR与原发灶关系。结果 123例下咽鳞癌原发灶来源于梨状窝101例(82.1%),咽后壁15例(12.2%),环后区7例(5.7%)。123例患者中颈部淋巴结转移104例(84.6%),其中原发灶来源于梨状窝、咽后壁和环后区肿瘤的LMR分别为84.2%、93.3%和71.4%。颈部各组LMR:(1)梨状窝癌:同侧颈部Ⅰ a 0、Ⅰ b3.0%、Ⅱ a66.3%、Ⅱ b42.6%、Ⅲ46.5%、Ⅳ10.9%、Ⅴ5.0%、Ⅵ a2.0%、Ⅵ b7.9%、Ⅶ11.9%;对侧颈部Ⅰ a0、Ⅰ b0、Ⅱ a14.9%、Ⅱ b5.0%、Ⅲ3.0%、Ⅳ2.0%、Ⅴ0、Ⅵ a0、Ⅵ b3.0%、Ⅶ2.0%。(2)咽后壁肿瘤:同侧颈部Ⅰ a 6.7%、Ⅰ b6.7%、Ⅱ a66.7%、Ⅱ b46.7%、Ⅲ46.7%、Ⅳ20.0%、Ⅴ0、Ⅵ a13.3%、Ⅵ b33.3%、Ⅶ60.0%;对侧颈部Ⅰ a6.7%、Ⅰ b6.7%、Ⅱ a33.3%、Ⅱ b26.7%、Ⅲ20.0%、Ⅳ20.0%、Ⅴ0、Ⅵ a0、Ⅵ b13.3%、Ⅶ33.3%。(3)环后区肿瘤:同侧颈部Ⅱ a71.4%、Ⅱ b28.6%、Ⅲ14.3%、Ⅳ14.0%、Ⅴ14.0%、Ⅵ b14.3%;对侧颈部Ⅱ a14.3%,其余淋巴组未发现淋巴结转移。T1—T4期肿瘤平均转移2.4、1.9、2.2、3.3个淋巴组(P=0.023)。梨状窝癌、咽后壁肿瘤、环后区肿瘤平均转移2.2、4.5、1.6个淋巴组(P=0.000)。咽后壁受侵与Ⅶ组淋巴结转移差异有统计学意义(P=0.000);环后区或食管入口受侵与Ⅵ组淋巴结转移差异有统计学意义(P=0.002、0.001)。结论 下咽鳞癌颈部淋巴结转移以同侧Ⅱ a、Ⅲ、Ⅱ b组最常见,Ⅰ组和Ⅴ组少见。咽后壁来源肿瘤Ⅶ组淋巴结转移率高达60.0%。环后区或食管入口受侵,Ⅵ组淋巴结转移风险增加。     

甲状腺乳头状癌颈部淋巴结转移特点及清扫策略

背景与目的：目前,在甲状腺癌颈淋巴结清扫方面存有较大分歧。该研究总结甲状腺乳头状癌淋巴结转移的特点,为择区淋巴结清扫提供理论依据。方法：回顾性分析2006年7月—2014年8月收治的462例甲状腺乳头状癌患者病历资料,分析其淋巴结转移规律及其影响因素,评判cN0标准的准确性。结果：全组患者均行患侧中央区(Ⅵ区)淋巴结清扫,320例行侧颈区淋巴结清扫术(Ⅱ～Ⅴ区)或择区淋巴结清扫(Ⅱ～Ⅳ区中的部分或全部),90例行对侧中央区淋巴结活检。73.2%(338/462)符合cN0标准,病理证实其中有184例淋巴结转移,cN0标准误诊率达60.9%。颈部淋巴结总转移率为65.4%(302/462),侧颈区淋巴结转移率为42.6%(197/462),“跳跃转移”率为13.1%(42/320),对侧中央区淋巴结转移率为50%(45/90)。男性、肿瘤累及腺叶上1/3、肿瘤T3或T4、多中心病灶是淋巴结转移的危险因素。肿瘤累及腺叶上1/3是喉前淋巴结转移及“跳跃转移”的危险因素。喉前淋巴结转移及中央区淋巴结2个以上转移者侧颈区淋巴结转移率显著增加(分别为85.7%和83.3%, P＜0.05)。结论：现行cN0标准不能作为确定淋巴结清扫范围的依据;甲状腺乳头状癌易发生淋巴结转移,其中Ⅵ区淋巴结转移率最高,依次为Ⅲ区、Ⅱ区、Ⅳ区、Ⅴ区;初次手术应常规清扫患侧中央区淋巴结,建议将Ⅵ区淋巴结送冰冻病理;当喉前淋巴结有转移或Ⅵ区2个以上淋巴结转移时,或肿瘤累及腺叶上1/3者,有必要行侧颈区(或择区)淋巴结清扫;对侧中央区淋巴结转移率较高,需予以重视;中央区淋巴结再分亚区具有重要意义,应深入研究。     

Pattern of lymph node metastases in squamous cell carcinoma of the tonsil: implication for selective neck dissection

The aim of this study was to prospectively analyze the distribution of neck metastases and the outcome in patients surgically treated for tonsillar carcinoma in order to deduce implications for selective neck dissection. The criteria for inclusion in the study were (1) previously untreated, histologically proven, resectable squamous cell carcinoma of the tonsil, (2) curative surgical intent on the primary tumor and neck, (3) no history of prior head and neck cancer, (4) absence of synchronous second primary in the upper aerodigestive tract, lung and esophagus, (5) absence of distant metastases. Fifty-eight previously untreated consecutive patients with tonsillar squamous cell carcinoma were included in this prospective study. Among 22 patients with clinically negative cervical lymph nodes, 4 patients (18.2%) had metastatic lymph nodes on pathologic examination. Occult node metastases were mainly located in ipsilateral II level. No occult metastases occurred at levels I and V. Among 36 patients with clinically positive cervical lymph nodes, 3 patients (8.3%) had an occult pathologic metastatic involvement of cervical lymph nodes of ipsilateral level V. Level I was free of lymph node metastases. Clinical N category >N2a (p=0.003), nodal metastases to levels III (p=0.026) and IV (p=0.009) were significantly related to level V nodal metastases. The 2 and 5 years actuarial disease-free survival was 82.7% (95% CI 71.2-93.5%) and 58.3% (95% CI 36.7-79.9%), respectively. The actuarial recurrence-free survival was 87.9% (95% CI 78.9-96.8%) and 72.2% (95% CI 53.9-90.5%) at 2 and 5 years, respectively. Our findings support the role of a selective lateral neck dissection in the management of clinically N0 necks and in selected N+ necks (N1 and N2a disease located at level II) in patients with tonsillar carcinoma without oral involvement.     

Clinical predictors for contralateral neck lymph node metastasis from unilateral squamous cell carcinoma in the oral cavity

The factors that predict contralateral (C-) lymph node metastasis (LNM) in patients with unilateral oral squamous cell carcinoma (SCC) were analyzed. One hundred and twenty-nine patients who had untreated SCC that originated from the lateral oral cavity, but not around the midline, were included. The impact of multiple clinicopathologic factors (sex, performance status, primary site, T-stage, number and level of ipsilateral LNM, growth type, histopathological grading, mode of invasion, extension across the midline, and systemic neoadjuvant/adjuvant chemotherapy) on time-to-C-LNM was assessed using the stepwise Cox proportional hazards model. The T-stage, number of ipsilateral LNM, and histopathological grading were independent and significant predictors for C-LNM. No C-LNM occurred in patients without ipsilateral LNM and in those with earlier cancers (T1 to T3) excepting tongue cancer. The results of this retrospective study suggested that patients with advanced tumors, multi-involvement of the ipsilateral neck nodes, or a higher degree of histopathological grading were at a higher risk for C-LNM.     

Retropharyngeal nodes in squamous cell carcinoma of oropharynx: incidence, localization, and implications for target volume

PURPOSE: To investigate the incidence and anatomic localization of retropharyngeal (RP) nodal involvement in patients with squamous cell carcinoma of the oropharynx. METHODS AND MATERIALS: The CT studies of 208 patients presenting with oropharyngeal carcinoma were retrospectively analyzed. The location of the nodal neck disease was registered according to recent consensus guidelines for target volume delineation, and special attention was given to the RP nodes. To obtain statistically significant predictors for RP nodal involvement, univariate and multivariate analyses were performed. RESULTS: RP adenopathies were present in 16% of all patients and in 23% of those patients with nodal disease in other neck sites. Ipsilateral involvement of Level II and contralateral involvement of Level III predicted for involvement of the ipsilateral RP nodes on multivariate analysis (p < 0.05). A solitary ipsilateral RP node was present in 3 (9%) of 34 patients with RP nodes; 2 of these 3 patients had a primary posterior pharyngeal wall tumor. No patients presented with a solitary contralateral RP node. CONCLUSION: Given the high incidence of RP nodal involvement in oropharyngeal cancer-16% of all patients and 23% of patients with pathologic nodal disease in other neck sites-RP nodes should be included in the target volume, especially in node-positive necks. In node-negative necks, inclusion of RP nodes into the target volume is advised in posterior pharyngeal wall tumors.     

73例初治甲状腺髓样癌术式探讨

  目的  探讨甲状腺髓样癌初治合理手术术式。  方法  回顾性分析73例甲状腺髓样癌初治病例资料, 研究颈淋巴结转移规律及术后复发情况。  结果  多灶性甲状腺髓样癌占26.0%(19/73)。全组颈淋巴结转移率为58.9%(43/73), 其中中央区淋巴结转移率52.1%(38/73), 同侧颈淋巴结转移率53.4%(39/73), 双侧侧颈转移率11.O%(8/73), 临床NO颈淋巴结隐匿性转移率为18.9%(7/37)。多因素Logistic回归分析显示, 中央区淋巴结转移是该侧侧颈淋巴结转移的独立危险因素, 原发灶T4是对侧侧颈淋巴结转移的独立危险因素。全组局部区域复发率28.8%(21/73)。全组5年累积生存率为86.4%。多因素分析表明远处转移、年龄≥45岁和原发灶T4是影响预后的独立危险因素。  结论  建议甲状腺髓样癌手术应常规行患侧中央区清扫, 并包含上纵隔区域; 术中证实有中央区淋巴结转移的病例, 建议行该侧侧颈清扫术; T4病例建议行全甲状腺切除+中央区+双颈清扫术。      

Lymph node metastasis in maxillary sinus carcinoma

PURPOSE: To evaluate the incidence and prognostic significance of lymph node metastasis in maxillary sinus carcinoma. METHODS AND MATERIALS: We reviewed the records of 97 patients treated for maxillary sinus carcinoma with radiotherapy at Stanford University and at the University of California, San Francisco between 1959 and 1996. Fifty-eight patients had squamous cell carcinoma (SCC), 4 had adenocarcinoma (ADE), 16 had undifferentiated carcinoma (UC), and 19 had adenoid cystic carcinoma (AC). Eight patients had T2, 36 had T3, and 53 had T4 tumors according to the 1997 AJCC staging system. Eleven patients had nodal involvement at diagnosis: 9 with SCC, 1 with UC, and 1 with AC. The most common sites of nodal involvement were ipsilateral level 1 and 2 lymph nodes. Thirty-six patients were treated with definitive radiotherapy alone, and 61 received a combination of surgical and radiation treatment. Thirty-six patients had neck irradiation, 25 of whom received elective neck irradiation (ENI) for N0 necks. The median follow-up for alive patients was 78 months. RESULTS: The median survival for all patients was 22 months (range: 2.4-356 months). The 5- and 10-year actuarial survivals were 34% and 31%, respectively. Ten patients relapsed in the neck, with a 5-year actuarial risk of nodal relapse of 12%. The 5-year risk of neck relapse was 14% for SCC, 25% for ADE, and 7% for both UC and ACC. The overall risk of nodal involvement at either diagnosis or on follow-up was 28% for SCC, 25% for ADE, 12% for UC, and 10% for AC. All patients with nodal involvement had T3-4, and none had T2 tumors. ENI effectively prevented nodal relapse in patients with SCC and N0 neck; the 5-year actuarial risk of nodal relapse was 20% for patients without ENI and 0% for those with elective neck therapy. There was no correlation between neck relapse and primary tumor control or tumor extension into areas containing a rich lymphatic network. The most common sites of nodal relapse were in the ipsilateral level 1-2 nodal regions (11/13). Patients with nodal relapse had a significantly higher risk of distant metastasis on both univariate (p = 0.02) and multivariate analysis (hazard ratio = 4.5, p = 0.006). The 5-year actuarial risk of distant relapse was 29% for patients with neck control versus 81% for patients with neck failure. There was also a trend for decreased survival with nodal relapse. The 5-year actuarial survival was 37% for patients with neck control and 0% for patients with neck relapse. CONCLUSION: The overall incidence of lymph node involvement at diagnosis in patients with maxillary sinus carcinoma was 9%. Following treatment, the 5-year risk of nodal relapse was 12%. SCC histology was associated with a high incidence of initial nodal involvement and nodal relapse. None of the patients presenting with SCC histology and N0 necks had nodal relapse after elective neck irradiation. Patients who had nodal relapse had a higher risk of distant metastasis and poorer survival. Therefore, our present policy is to consider elective neck irradiation in patients with T3-4 SCC of the maxillary sinus.     

Role of chemotherapy in nodal metastasis of untreated squamous cell carcinoma of the head and neck

A multiple drug chemotherapeutic regime was used in thirty-two previously untreated patients of advanced squamous cell carcinoma of the head and neck, presenting with nodal metastasis. Each cycle of chemotherapy consisted of methotrexate, 5-flourouracil and cyclophosphamide. An overall response rate of 72% in the involved lymph nodes and 84.4% at the primary site was observed. The nodal metastasis from the tonsil had a major response rate of 75% while those from the larynx-hypo-pharynx responded in only 22.2% of the cases. Fixed lymph nodes displayed the lowest response rate (61.5%). The primary lesion and its nodal metastasis showed an identical response in 78% of the patients.     

Cancer of the tonsil: the results of ipsilateral radiation treatment.

BACKGROUND AND PURPOSE: The use of ipsilateral irradiation techniques to treat patients with carcinoma of the tonsil reduces the acute radiation reaction in the contralateral pharynx and late damage to the contralateral salivary tissue. However, this may also spare microscopic disease in apparently uninvolved contralateral lymph nodes. The purpose of this study was to analyse the survival and recurrence rates and sites of recurrance in a group of patients with carcinoma of the tonsil treated with ipsilateral techniques. MATERIALS AND METHODS: Between 1975 and 1993, 271 patients with invasive squamous cell cancer of the tonsil were referred to the Vancouver Cancer Centre (VCC). One hundred and seventy-eight received ipsilateral radiation treatment. Three received surgery only, six post-operative radiation, 12 supportive treatment only and 72 bilateral radiation treatment. In the absence of bilateral neck nodes and extensive lymphodenopathy, field sizes were generally kept small to include the primary tumour and the first echelon of nodes. The most common dose was 60 Gy in 25 daily fractions in 5 weeks (2.4 Gy per day). RESULTS AND DISCUSSION: The disease specific survival for all patients treated by radical radiation treatment was 61% at 5 years. For the 178 patients who received ipsilateral radiation treatment the overall primary tumour control rate by ipsilateral radiation treatment alone was 75% and for T1 and T2 tumours 84%. Eight (7.5%) of 101 of these patients with N0 nodes at presentation and without prior failure at the primary site, developed nodal recurrence (four within the initially radiated high dose volume). Two developed contralateral nodes, and two developed field edge nodal recurrence, one cured by surgery. In 54 patients with N1 disease, five developed nodal recurrence, two within field, two contralateral, one of whom was cured by surgery, and one at field edge. In 23 patients with N2a, N2b or N3 disease node control was achieved from radiation treatment in 11 and two more were cured by surgery. All nodal failures were within the radiated volume. Overall, 10 of the 25 patients with nodal failure were cured by subsequent surgery. CONCLUSIONS: Ipsilateral treatment of patients with carcinoma of the tonsil gives survival results that are at least as good as those reported with bilateral treatment with fewer side effects and a very low risk of failure in the contralateral neck.     

Predictive value of the Delphian lymph node in cervical lymph node metastasis of papillary thyroid carcinoma

IntroductionDelphian lymph node metastasis (DLNM) has proven to be a risk factor for a poor prognosis in head and neck malignancies. This study aimed to reveal the clinical features and evaluate the predictive value of the Delphian lymph node (DLN) in papillary thyroid carcinoma (PTC) to guide the extent of surgery.MethodsTianjin Medical University Cancer Institute and Hospital pathology database was reviewed from 2017 to 2020, and 516 PTC patients with DLN detection were enrolled. Retrospective analysis was performed, while multivariate analysis was performed to identify the risk factors for DLNM.ResultsAmong the 516 PTC patients with DLN detection, the DLN metastasis rate was 25.39% (131/516). Tumor size >1 cm, location in the upper 1/3, central lymph node metastasis (CLNM), lateral lymph node metastasis (LLNM) and lymphovascular invasion were independent risk factors for DLNM. Patients with DLNM had a higher incidence of ipsilateral CLNM, contralateral CLNM (CCLNM) and LLNM, and larger numbers and size of metastatic CLNs than those without DLNM. The incidence of CLNM among cN0 patients with DLNM was higher than that among those without DLNM. The incidence of CCLNM among unilateral cN + patients with DLNM was similarly higher than that among patients without DLNM.ConclusionsDLNM indicates a high likelihood and large number of cervical lymph nodes metastases in PTC patients. Surgeons are strongly recommended to detect DLN status during operation by means of frozen pathology, so as to evaluate the possibility of cervical nodal metastasis and decide the appropriate extent of surgery.     

Nodal basin recurrence following lymph node dissection for melanoma: implications for adjuvant radiotherapy

PURPOSE: To analyze patterns of failure in malignant melanoma patients with lymph node involvement who underwent complete lymph node dissection (LND) of the nodal basin. To determine prognostic factors predictive of local recurrence in the lymph node basin in order to select patients who may benefit from adjuvant radiotherapy. METHODS AND MATERIALS: A retrospective analysis of 338 patients undergoing complete LND for melanoma between 1970 and 1996 who had pathologically involved lymph nodes was performed. Mean follow-up from the time of LND was 54 months (range: 12-306 months). Lymph node basins dissected included the neck (56 patients), axilla (160 patients), and groin (122 patients). Two hundred fifty-three patients (75%) underwent therapeutic LND for clinically involved nodes, while 85 patients (25%) had elective dissections. Forty-four percent of patients received adjuvant systemic therapy. No patients received adjuvant radiotherapy to the lymph node basin. RESULTS: Overall and disease-specific survival for all patients at 10 years was 30% and 36%, respectively. Overall nodal basin recurrence was 30% at 10 years. Mean time to nodal basin recurrence was 12 months (range: 2-78 months). Site of nodal involvement was prognostic with 43%, 28%, and 23% nodal basin recurrence at 10 years with cervical, axillary, and inguinal involvement, respectively (p = 0.008). Extracapsular extension (ECE) led to a 10-year nodal basin failure rate of 63% vs. 23% without ECE (p < 0.0001). Patients undergoing a therapeutic dissection for clinically involved nodes had a 36% failure rate in the nodal basin at 10 years, compared to 16% for patients found to have involved nodes after elective dissection (p = 0.002). Lymph nodes larger than 6 cm led to a failure rate of 80% compared to 42% for nodes 3-6 cm and 24% for nodes less than 3 cm (p < 0.001). The number of lymph nodes involved also predicted for nodal basin failure with 25%, 46%, and 63% failure rates at 10 years for 1-3, 4-10, and > 10 nodes involved (p = 0.0001). There was no significant difference in nodal basin control in patients with synchronous or metachronous lymph node metastases, nor in patients receiving or not receiving adjuvant systemic therapy. Nodal basin failure was predictive of distant metastasis with 87% of patients with nodal basin recurrence developing distant disease compared to 54% of patients without nodal failure (p < 0.0001). On multivariate analysis, number of positive nodes and type of dissection (elective vs. therapeutic) were significant predictors of overall and disease-specific survival. Size of the largest lymph node was also predictive of disease-specific survival. Site of nodal involvement and ECE were significant predictors of nodal basin failure. CONCLUSIONS: Malignant melanoma patients with nodal involvement have a significant risk of nodal basin failure after LND if they have cervical involvement, ECE, >3 positive lymph nodes, clinically involved nodes, or any node larger than 3 cm. Patients with these risk factors should be considered for adjuvant radiotherapy to the lymph node basin to reduce the incidence of nodal basin recurrence. Patients with nodal basin failure are at higher risk of developing distant metastases.     

Lymph node involvement by direct extension in adenoid cystic carcinoma. Absence of classic embolic lymph node metastasis.

Thirty-four cases of adenoid cyctic carcinoma seen at the University of Virginia Hospital from 1946 to 1974 were reviewed, with special emphasis on lymph node involvement by tumor. Lymph node involvement was found in three cases of primary tumors of the submaxillary gland, and all of the affected lymph nodes were in the immediate vicinity of the primary tumor. Two lymph nodes were involved in two of the cases, and one node was involved in the third case. In all of these lymph nodes, adenoid cystic carcinoma was present in the soft tissue surrounding the node, and the tumor extended into the node. No metastatic tumors were observed in 46 lymph nodes removed incidentally at the time of local excision of the primary tumors in 10 additional cases or in 212 lymph nodes examined after unilateral radical neck dissections in six other cases. Five autopsies in this series showed no lymph node metastases. In this series of cases adenoid cystic carcinoma only invades lymph nodes in the immediate vicinity of the primary tumor. When lymph node involvement does occur, it does not result from embolic lymph node metastasis; rather, a direct invasion of the lymph node from tumor in the perinodal soft tissue occurs. Obviously, this small study does not completely exclude the possibility of embolic metastasis; however, if it does occur, it must be extremely rare.