手术联合放射治疗伴有淋巴样间质的未分化癌的疗效分析

目的：分析涎腺伴有淋巴样间质的未分化癌（恶性淋巴上皮病Malignant lymphoepithelial lesions,MLEL)的临床特点、发展规律治疗方法及转归。方法：收集自1989年－1997年来收治的涎腺伴有淋巴样间质的未分化癌患者共21例，其中原发于腮腺18例。对腮腺Ⅱ，Ⅲ期患者行肿专人切除＋腮腺浅叶或全叶切除＋面部神经保留术。对Ⅳ期患者根据情况，行腮颌颈联合根治术或腮颈联合根治术。术后2－9周内行原发灶或加同侧颈部照射，肿瘤剂量平均为52．03Gy。以寿命表法对生存率进行分析。结果；全组病例中，3／21有良性淋巴上皮病复发史，其中，第2次复发至确诊为伴有淋巴样间质的未分化癌最长2a，最短0.5a。Ⅱ，Ⅲ，Ⅳ期患者分别为8（42．9％）、3（14．3％）、10（47．6％）例。Ⅱ，Ⅲ期者均为NO。全组5年生存率达70．66％，Ⅱ，Ⅲ，Ⅳ期的5年生存率分别为86．68％、66．67％、33．3％。本组死亡5例，均为Ⅳ期，死于肿瘤复发；其中4／5例颈上、中淋巴结有转移。复发者7／21，其中5／7为Ⅳ期，N2、N3患者。复发后经治疗死亡者，最短存活7个月，最长7a。4／21有远处转移，均为T4N2MO。结论：对复发性良性淋巴上皮病患者应高度警惕其恶变。Ⅳ期患者应行腮腺全叶切除，面神经未受累者可考虑保留面神经，因同侧下颌下、颈淋巴结转移多见，建议行根治性或功能性颈清，术后放疗范围应包括原发灶和同侧锁骨上颈淋巴区。     

Histopathological factors affecting nodal metastasis in tongue cancer: analysis of 94 patients in Taiwan

The overall prognosis for tongue cancer patients in Taiwan is unpredictable, even when patients are treated following the guidelines according to TNM stages. In order to determine the optimal treatment modality for tongue cancer in Taiwan the authors aimed to correlate histopathological parameters with neck nodal metastasis. A retrospective analysis of 94 patients with different stages of tongue cancer treated in the Taipei Veterans General Hospital was performed. All 94 patients were clinically diagnosed with stage I-IV tongue cancer before surgery and received primary tumor-wide excision and neck dissection. There were 42 (45%) patients with nodal metastasis. Univariate analysis revealed that cases of tongue cancer with moderate or poor differentiation, an invasion depth more than 3mm and positive perineural invasion or lymphovascular permeation at the time of presentation may be subject to a higher incidence of neck nodal metastasis. An elective neck dissection or neck treatment should be considered if these histopathological risk factors are present. Cases of tongue cancer with these risk factors also warrant close follow-up after surgery.     

口底区域淋巴组织清扫术在舌癌根治术中的应用

目的:为减少舌癌患者术后复发率及转移率,探讨口底区域淋巴组织清扫术的范围、术式及其临床意义。方法:收集随访2000年5月～12月本科舌癌手术患者20例(原发灶T2或T3,未明显侵犯口底,颈部N0)。同期舌-(颌)-颈联合根治术,术中于颏孔前断离并外展下颌骨,以利直视下彻底清扫同侧口底中间带淋巴组织,达到完整舌-(颌)-颈根治。同期调查我院和外院舌癌手术后患者20例(术中口底中间带淋巴组织保留或未彻底清扫)作为对照,比较两组患者复发率与颈部淋巴结转移率。结果:实验组局部无1例复发,对侧淋巴结转移2例(T3),转移率10%。对照组口底或下颌下复发7例,对侧颈淋巴转移5例,复发转移率60%。P<0.05,有统计学显著性差异。结论:传统非连续性颈清扫并不能清除所有可能受累的淋巴结。对T2以上的舌癌患者,宜在传统的颈清术式基础上,断离、外展下颌骨,行同侧口底中间带组织的彻底清扫。     

Recurrent neck disease in oral cancer.

PURPOSE: The goals were to examine the clinical and pathologic features of patients who developed metastatic squamous cell carcinoma in the cervical lymph nodes after initial treatment and to identify any common patterns. PATIENTS AND METHODS: A retrospective analysis of 35 patients of varying initial tumor stage was performed. There were 18 patients who had an initial neck dissection and 17 patients whose neck was managed by a "watch and wait" policy. RESULTS: Recurrence frequently involved level II nodes, and extracapsular spread was invariably present. The time taken for recurrence to develop was the same in both groups of patients (15 months, P =.35), and the overall median survival time after recurrence was 18 months (12 to 25 months, 95% confidence interval). In 27 of 29 patients (93%) who had the primary tumor resected, the thickness of tumor was greater than 5 mm. CONCLUSION: Neck recurrence may represent residual disease; it has histologically unfavorable features and consequently a poor prognosis. The frequency of recurrence at level II emphasizes the need for meticulous dissection in this region, and tumor thickness needs to be considered in planning treatment of the clinically negative neck.     

Management of oral squamous cell carcinoma treated with inadequate excisional biopsy.

PURPOSE: When an initial "excisional biopsy" has been performed on a primary oral carcinoma, microscopic tumor may remain and the usual landmarks that enable the surgeon to plan his safe margin are destroyed. This article analyzes the impact that such a biopsy may have on treatment and patient outcome. PATIENTS AND METHODS: A retrospective chart review of a consecutive series of 350 oral cancer patients treated by 1 surgeon in an 8-year period identified 33 (9.4%) patients who originally had inadequate excisional biopsies. Exclusion criteria eliminated 7 patients who were lost to follow-up or who had undergone previous treatment with radiation therapy or chemotherapy. Data extracted included age, sex, race, primary intraoral site, estimated tumor (T) stage, method of treatment, histology, follow-up, and outcome. RESULTS: Twenty-four of the 26 patients underwent re-excision of their oral cancer. Ten of these patients (38.4%) also underwent selective neck dissection. Fifteen of the 24 patients (62.5%) had residual carcinoma identified in the re-excision specimen, and 3 of the patients who underwent elective neck dissection had micrometastasis identified. The patients were followed for an average of 35.5 months. Two of 24 (8.3%) patients had local recurrence at 36 and 84 months, respectively. Both patients were managed with re-excision and are still alive with no evidence of disease. Of the 10 patients originally treated with elective neck dissection, there has been no regional recurrence. However, of the 14 patients who underwent re-excision of the lesion without neck dissection, 3 developed regional disease at 1, 5, and 6 months, respectively, postoperatively. These patients underwent neck dissection and radiation therapy. Two patients are alive with no evidence of disease, and the third died of a second primary lung cancer. Twenty-five of the 26 patients (96.2%) are still alive and well with no evidence of disease. CONCLUSIONS: Patients who have had inadequate excisional biopsies can be effectively managed with re-excision plus neck dissection when indicated by T stage or more than 3 mm depth of invasion.     

Clinical evaluation of serum immunosuppressive acidic protein (IAP) and acid soluble glycoproteins (ASP) in patients with malignant tumors

In order to study the clinical significance of IAP and ASP, we have measured serum concentration of IAP and ASP in patients with different cancer types including digestive organs, head and neck. Significantly higher correlation (coefficient of correlation = 0.924) was found between IAP and ASP. IAP and ASP levels were elevated in about 60-80% of cancer from digestive organs except hepatocellular carcinoma, and in about 56-100% of head and neck tumor. There was no correlation between IAP, ASP and various tumor markers (CEA, CA19-9, AFP) in all malignancies except pancreatic cancer. There was positive correlation between CEA and IAP, ASP in pancreatic cancer. IAP and ASP levels were significantly higher in patients with cancer having evidence of disease than the patients with cancer who had no evidence of disease, and so the determination of IAP and ASP was clinically useful for the diagnosis of tumor existence. At the time of diagnosis of recurrence, the levels of IAP and ASP were elevated in about 70% of patients with cancer recurrence. There was a definite relation between IAP, ASP and the gastric cancer stage. In later state (stage III and IV), serum IAP and ASP levels were significantly higher than the levels of stage I and II. In hepatocellular carcinoma without liver cirrhosis, the levels of IAP and ASP were higher than the patients with cirrhosis. The determination of IAP and ASP seems to be useful for monitoring clinical course, judgement of therapeutic effects.     

原发灶不明的颈部转移癌的放射治疗：选择性黏膜腔照射是否临床获益？

目的： 探讨对原发灶不明的颈部转移癌患者行黏膜腔预防性照射是否有临床获益。方法： 收集2009年1月—2016年4月接受放疗的所有原发灶不明的颈部转移癌患者的临床资料，采用SPSS 20.0软件包中的Kaplan-Meier法进行生存分析和Log-rank法检验。结果： 62例患者纳入研究，中位随访时间为63个月（5 ~126个月）。选择性黏膜腔照射组和单纯颈部处理组5年黏膜控制率分别为100%和72.0%（P=0.003），5年颈部控制率分别为92.9%和57.7%（P=0.002）。单纯颈部处理组有7例（26.9%）出现原发肿瘤，2组之间在晚期毒性方面无显著差异。结论： 选择性黏膜腔照射有助于在原发灶不明的颈部转移癌患者中寻找一种疗效和毒性之间可能的平衡，但仍需要长期随访的前瞻性研究给出更好的答案。     

Metastasis of maxillary carcinoma to the parapharyngeal space: rationale and technique for concomitant en bloc parapharyngeal dissection.

PURPOSE: En bloc resection of the primary tumor and regional lymph nodes is the classic method of surgery in cases of head and neck cancer, but it is not performed in cases of carcinoma of the maxillary gingiva or antrum for anatomic reasons. One of the reasons for the poor prognosis of patients with maxillary cancer and N+ stage necks is thought to be recurrence in the parapharyngeal space, which is out of the surgical field in radical neck dissection. The purpose of this study was to discuss the rationale and indication for en bloc resection and parapharyngeal dissection for maxillary cancer. PATIENTS AND METHODS: Ninety-nine patients with maxillary cancer (54 in the gingiva and 45 in the antrum) treated at our institution between 1980 and 2000 were studied retrospectively. RESULTS: In 4 patients, there was recurrence in the parapharyngeal spaces despite good control of tumors in the maxilla and the neck. These 4 patients had all undergone resection of maxilla and neck lymph nodes separately. We also report the case of a patient with carcinoma of the maxillary antrum who underwent en bloc resection of the maxilla and neck. After radical neck dissection, parapharyngeal dissection was performed with a mandibular ramus osteotomy approach, and the maxilla and neck tissue were resected en bloc. CONCLUSIONS: Although en bloc resection causes more extensive surgical damage, it may be useful in patients with maxillary cancer who have metastasis in the upper jugular lymph nodes.     

改良胸大肌肌皮瓣在复发性头颈癌挽救性手术缺损重建中的应用

目的探讨改良胸大肌肌皮瓣在复发性头颈癌挽救性手术缺损重建中的应用价值。方法选择19例局部复发头颈癌患者,复发癌临床分期为2例rCS Ⅲ期,17例rCS Ⅳ期;挽救性手术前,17例接受肿瘤根治手术,16例接受放射治疗。应用胸大肌肌皮瓣重建挽救性手术缺损,制备时血管蒂内同时保留胸肩峰血管的胸肌支及胸外侧血管的分支,形成起始部不含肌肉的双蒂血管筋膜束。结果胸大肌肌皮瓣全部成活,2例肌皮瓣与受区缝合处局部开裂,经换药1例5周后延期愈合,1例不愈出现咽瘘;13例患者的血管蒂置于锁骨下,另6例血管蒂位于锁骨表面;蒂长平均15.7 cm,最长达20 cm,修复高度达颧弓平面。随访 6~48 个月,10例患者无复发生存,5例患者带瘤生存,4例患者死于肿瘤复发和转移。结论改良后的胸大肌皮瓣,双血管供血血运得到充分保证,避免了皮瓣局部坏死,其修复半径明显延长,解决了保留胸外侧血管修复半径缩短的难题,在复发头颈癌挽救性手术缺损重建中应用效果满意。     

早期口腔癌扩大切除颈部淋巴结处理的回顾性研究

目的探讨早期口腔癌扩大切除颈部淋巴结观察的临床疗效。方法收集45例早期口腔癌患者,男性20例,女性25例,其中舌癌18例,下颌牙龈癌8例,上颌牙龈癌7例,口底癌6例,颊癌3例,软腭癌3例。对本组患者均采用原发灶外1cm扩大切除术,不同期行颈淋巴结清扫术,术后对患者进行严密随访,最长5年,最短1年。结果 3例患者1年后失访。在随访期内有1例舌癌患者扩大切除原发灶后2个月复发,41例患者随访期内原发灶控制良好。有6例舌癌患者,术后3个月内出现颈部以及颌下出现肿大的淋巴结,并且伴有疼痛,1例下颌牙龈癌的患者术后6个月出现颌下淋巴结肿大,均行治疗性颈清术,病理证实均为颈部转移淋巴结,其余35例患者在随访期内颈部淋巴结未见明显异常。结论早期口腔癌患者可以单纯行原发灶扩大切除术,术后进行密切随访,如有颈部肿大淋巴结,应给予积极的手术治疗。     

265例舌癌的临床特点及其对肿瘤颈淋巴结转移的预测价值

目的探讨舌癌颈淋巴结转移的临床特点,为临床治疗提供参考。方法回顾265例舌癌患者的临床资料,根据术前发病时间、肿物大小、肿瘤部位、TNM分类、肿瘤类型、CT表现特点和颈淋巴结转移情况进行分析。结果 265例舌癌患者术后证实颈淋巴结转移者54例。舌鳞状细胞癌260例,其中舌高分化鳞状细胞癌181例,转移11例(6.1%);舌中分化鳞状细胞癌71例,转移35例(49.3%);舌低分化鳞状细胞癌8例,转移5例(62.5%),不同分化程度舌癌转移率差异具有统计学意义(χ2=69.68,P<0.001),低分化(χ2=63.834,P<0.001)、中分化(χ2=24.615,P<0.001)比高分化转移机会大,差异有统计学意义。舌黏液表皮样癌2例,同侧Ⅰ区淋巴结转移1例(50%);舌平滑肌肉瘤1例,同侧颌下淋巴结转移;舌基底细胞癌1例,无淋巴结转移;舌肉瘤样癌1例,同侧Ⅲ区淋巴结转移。不同部位肿瘤转移率差异有统计学意义(χ2=32.76,P<0.001)。肿物位于舌前缘187例,转移21例(11.2%);位于舌中后份78例,转移33例(42.3%),其中双侧63例中转移35例(55.6%)。临床分期,0期2例,Ⅰ期18例,Ⅱ期180例,Ⅲ期33例,Ⅳ期32例;术前作CT检查185例,提示淋巴结直径大于1.0 cm 15例,转移7例,转移率46.6%(7/15),对87例病灶大小判断较模糊。结论舌癌术后颈淋巴结转移与肿瘤部位、大小、分化程度、肿瘤类型密切相关,CT检查对颈淋巴结评估价值不大,舌癌手术方式应主要根据肿瘤类型、部位、大小、分化程度综合考虑。     

临床舌鳞癌N0患者的颈部处理

目的 :探讨舌鳞癌N0 的治疗方法。方法 :对四川大学华西口腔医院 1986～ 1998年间 14 5例舌鳞癌N0患者进行回顾性研究。对T1患者切除原发灶 ,颈部观察 ,对于T2 以上患者或无法随访者采取选择性颈清扫 ,术后随访 3年以上或至死亡。各组间的比较采用卡方检验。结果 :12 3例行选择性颈淋巴清扫术 (END) ,3 3例术后病理证实淋巴结转移 ,2 2例颈部观察组中 4例出现颈淋巴转移。淋巴结隐匿性转移率为 2 5 .5 2 % ,且随临床T分期的增高而增高。总体颈部失控死亡率 ,观察组 (18.18% )与END组 (5 .69% )相比 ,差异有显著性 (P <0 .0 5 )。T1期观察组和END组的颈部失控死亡率分别为 7.69%和 4.5 5 % ,两组间差异无显著性 (P >0 .0 5 ) ,而将T2 、T3 期作为中期病变合并 ,观察组 (3 3 .3 3 % )和END组 (0 % )差异显著 (P <0 .0 0 1)。结论 :舌鳞癌颈部隐匿性转移率较高 ,对T2 期以上N0 舌鳞癌患者应考虑行选择性颈清扫术 ,可提高其颈部控制率和生存率     

Osteoradionecrosis of the jaws: clinical characteristics and relation to the field of irradiation.

PURPOSE: This study focuses on the clinical characteristics of patients with osteoradionecrosis (ORN) of the jaws and on the relation between the extent of the ORN and the field of irradiation. PATIENTS AND METHODS: The study group consisted of 80 patients referred for treatment of ORN. Charts of the extent of ORN, based on panoramic radiographs, were drawn by the clinical investigator and compared with charts of the field of irradiation drawn by the oncologists. Also recorded was diagnosis of the lesion, stage, location, treatment schedule, and period and dose of irradiation. Also documented were various potential initiating factors for ORN. RESULTS: Smoking habits of ORN patients were similar to those of other patients with head and neck cancer. A new primary tumor or a recurrence was diagnosed in 10% of the patients at the time of ORN. Only 3 patients had received accumulated doses of less than 60 Gy. More than half of the cases were initiated by removal of teeth; however, one third occurred spontaneously. ORN developed within the first 3 years in 74%; but ORN can emerge on a traumatic basis for an infinite number of years after radiation therapy. Widespread ORN may be symptomless apart from a discrete dehiscense of the oral mucosa. The predilection site for ORN is the mandibular molar region. All cases of ORN but 1 were found in the field of radiation. CONCLUSION: Because many ORN case are symptomless, more focus on mucosal dehiscence in the follow-up after radiation therapy is advocated in an effort to detect ORN at an early stage. The consequence of practically all ORN cases being located in the field of irradiation, together with tooth removal frequently being the initiating factor, should lead to a more aggressive preirradiation approach to dental pathology located within the field of radiation.     

The occurrence of cervical metastases in squamous cell carcinoma of the tongue: Is there a rationale for bilateral neck dissection in early-stage tumors?

IntroductionThe aim of this retrospective study was to evaluate the incidence of regional metastases in squamous cell carcinoma (SCC) of the tongue, in order to validate different neck management regime recommendations.Materials and methodsA cohort of 97 patients suffering from primary SCC of the tongue was analyzed in regard to the development of primary and late neck node metastases, considering tumor stage and affected side. Survival analysis was performed to determine the impact of different relevant clinical and pathological factors on overall and progression-free survival.ResultsRegional metastases occurred in 29 patients (29.9%). In early-stage tumors (T1 and T2), the rates of primary metastases were 28.6% and 22.4%, respectively. Bilateral cervical metastases are rare but were detected in early-stage cancer in several cases (T1: 2.1%; T2: 11.8%).ConclusionThe development of regional metastases in the ipsilateral and contralateral neck, even in early-stage SCC of the tongue, illustrates the importance of elective bilateral neck dissection in the treatment of affected patients.     

Head and neck cancer patients’ recollection of their clinical characteristics

Patient-reported outcomes (PRO) are an important component of treatment evaluation. Typically they are completed by patients on paper, but through advances in technology such as mobile phone apps and websites, there is a great opportunity for electronic completion. It can be challenging, particularly at a regional or national level, to maintain accurate core clinical records on head and neck cancer (HNC) (baseline, recurrence, second primary, and further treatment), and these will influence PROs and the reporting of outcomes. In addition, with data security and confidentiality there is merit in undertaking anonymous surveys, but in this approach, there is a reliance on patients’ recall. The aim of this study therefore was to compare updated hospital records with details completed by patients. In January 2019, 395 HNC patients who had been treated in 2015 and 2016 were sent a survey. They were asked to recall the clinical variables of gender, age at diagnosis, tumour site, tumour stage, and primary treatment, and these were analysed for agreement with the hospital records. The kappa statistic (KP) was used to measure the strength of agreement for categorical variables. There were 146 responders and one patient correctly stated that they did not have cancer. Five indicated further disease rather than primary cancer. Agreement between the hospital record and patients’ recall was excellent for gender (KP=0.97) and age group (KP=0.92), very good for treatment (KP=0.79), and good for site of cancer (KP=0.61), but poor for stage of cancer (KP=0.18). In general, patients gave accurate accounts of these details apart from tumour stage.     

Twist、Snail、Slug在口腔鳞状细胞癌中的表达及其与各临床病理因素的关系

目的:探讨Twist、Snail、Slug在口腔鳞状细胞癌(oral squamous cell carcinoma,OSCC)中的表达水平及其与各临床病理因素之间的关系.方法:采用免疫组织化学方法检测术前未接受放化疗的有颈部淋巴结转移或无颈部淋巴结转移的60例原发OSCC患者肿瘤切除石蜡标本中Twist、Snail、...     

Higher distress relates to poor quality of life in patients with head and neck cancer

Cancers of the head and neck are unique because they may interfere with speech, swallowing, breathing and taste. This study investigated the effect of distress on quality of life in patients with head and neck cancer undergoing treatment and looked at the predictors of distress. 123 patients with head and neck cancer undergoing multimodal treatment were interviewed using the distress inventory for cancer version 2 (DIC2) and the functional assessment of cancer treatment Head Neck (FACT-HN) questionnaire. Nearly half of the patients had early, node negative (N0) disease. The mean distress score was 24.6 and the mean FACT-HN score was 114.5. There was a negative correlation between distress and quality of life scores (patients with higher distress had poor quality of life). Neither surgery nor chemotherapy affected distress or quality of life. Multivariate analysis identified education, occupation, tumor and nodal stage as predictors of distress. Tumor and nodal status influenced overall quality of life. High amounts of distress lead to poor quality of life in patients with head and neck cancers. Financial security, understanding and support from the partner reduced distress in these patients.     

Whole-body (18)F-fluorodeoxyglucose positron emission tomography in patients with head and neck cancer

OBJECTIVE: Because of the high risk of secondary primary malignancies in addition to possible distant metastases, whole-body evaluation is critically important in patients with head and neck cancer. We evaluated the clinical usefulness of whole-body (18)F-fluorodeoxyglucose (FDG) positron emission tomography (PET) before initial treatment. STUDY DESIGN: We performed whole-body FDG PET in 26 patients with head and neck cancer (squamous cell carcinoma, n = 20; salivary gland carcinoma, n = 6) before initial treatment. FDG images were prospectively evaluated, and further imaging studies were performed if required. Final diagnosis for the presence or absence of distant lesions was made by analysis of the pathologic findings of surgical specimens or by analysis of the clinical follow-up data for more than 1 year. RESULTS: PET images showed FDG avid lesions distant from the head and neck area in 3 of 26 patients (11.5%). Two patients were confirmed to have secondary primary cancer (one with colon cancer in the early stage and another with small lung metastasis from postoperative colon cancer). They were diagnosed and treated properly both for the head and neck cancer and the secondary primary cancer. One patient was confirmed to have large lung metastasis from head and neck cancer, and appropriate treatment was selected. CONCLUSIONS: Whole-body FDG PET has a clinical impact on the management of patients with head and neck cancer by detecting secondary primary malignancies as well as distant metastases.     

Multiple primary tumours following head and neck cancer in southern England during 1961–98

BACKGROUND: Successful initial treatment of oral and oro-phayngeal cancer has led to the emergence of second primary tumours (SPTs). Population data are meagre. METHODS: Occurrence of multiple primary cancers following a malignancy in a head and neck site was computed using data from a population-based cancer registry covering a population of 14 million. RESULTS: Among 59,958 subjects reported to the registry, 5.5% males and 3.6% females developed a second primary cancer. At the sites studied, a total of 2771 second primary cancers were found, compared with an expected number of 2341. The standardised incidence ratio (SIR) for contracting a new primary cancer was 1.14 (95% CI=1.09-1.19) for men and 1.34 (95% CI=1.24-1.44) for women. There was a significantly increased risk for a second cancer in most of the upper aerodigestive tract sites that are generally regarded as tobacco associated, with an SIR for subsequent oral cancer of 5.56 in men and 15.31 in women. Subjects first detected with a pharyngeal cancer experienced the highest SIR for a subsequent tumour. Excluding tobacco-associated sites, the risk of a subsequent cancer was not significantly raised in either sex (SIR 0.87 (95% CI 0.81-0.93) for men; SIR 0.99 (95% CI 0.90-1.09) for women). CONCLUSIONS: The relative risk for multiple primary cancer was higher in younger subjects, those detected with a head and neck cancer during the 1990s as compared with earlier decades of the study, and among patients who received radiotherapy for their first tumour. By 20 years from the time of the first head and neck cancer, we estimate that approximately 30% of male patients and 20% of female patients will have developed an SPT.