声门上型喉癌颈淋巴隐匿性转移及其处理

目的 探讨声门上型喉癌颈淋巴隐匿性转移规律及其处理方法。方法 选择术前未行放疗、化疗的声门上喉鳞状细胞癌，临床N0M0病例，共30例，男19例，女11例；年龄40～72岁，平均54．8岁；按UICC(1997年)标准分期1、28例，1318例，T44例。行主病变侧肩胛舌骨肌上颈清扫术(supraomohyoid neck dissecton，SOHND)，将获得淋巴结逐一行病理组织学检查，观察其转移规律及临床治疗效果。结果 首次颈清扫术30例中有6例颈淋巴结转移癌阳性，在2～3年随访中有3例发生对侧颈淋巴结转移，计有9例颈淋巴转移，隐匿性转移率同侧为20％(6／30)，对侧为10％(3／30)。颈清扫术共获淋巴结527个，平均每侧17．6个。获转移阳性淋巴结10个，其中Ⅱ区9个，Ⅲ区1个，Ⅰ区无癌转移。喉及主病变侧颈部均无复发，2年无瘤生存率86．7％(26／30)。结论 声门上型喉癌颈淋巴结隐匿性转移率达30％，采用Ⅱ、Ⅲ区的择区性颈清扫术处理其颈淋巴结(Ⅰ区可不必作为常规清扫区域)是切实可行的。     

声门上型喉癌临床颈淋巴结阴性患者颈清扫区域的选择

目的 探讨声门上型喉癌临床诊断NO(clinical NO,cNO）患者颈淋巴结转移的特点，选择合理的清扫区域。方法 5例声门上型喉癌患者行喉切除术的同时行改良性颈清扫术，将颈清扫的淋巴结标本分区域逐一行病理学检查，确定转移区域或复发的区域。结果 57例（63侧）颈清扫标本共获淋巴结1877枚，平均每侧获29．8枚，有转移的43枚，其中41枚位于Ⅱ、Ⅲ区，占转移例数的95．4％（41／43）。15例（17侧）患者有淋巴结转移，转移率为26．3％（15／57）。其中14例位于Ⅱ、Ⅲ区，占转移例数的93．3％（14／15）。颈部复发3例，复发率为5．3％（3／57），复发部位分别为Ⅱ、Ⅲ、Ⅳ区。5年生存率为80．7％（46／57）。结论 对声门上型喉癌cNO重点行Ⅲ和Ⅲ区颈淋巴结清扫术，Ⅲ区受累时应包括Ⅳ区，Ⅰ、Ⅴ区在无明显转移证据时可避免行颈清扫术。     

声门上型喉癌临床颈淋巴结阴性患者颈清扫区域的选择

目的　探讨声门上型喉癌临床诊断N0 (clinicalN0 ,cN0 )患者颈淋巴结转移的特点 ,选择合理的清扫区域。方法　 5 7例声门上型喉癌患者行喉切除术的同时行改良性颈清扫术 ,将颈清扫的淋巴结标本分区域逐一行病理学检查 ,确定转移区域或复发的区域。结果　 5 7例 (6 3侧 )颈清扫标本共获淋巴结 1877枚 ,平均每侧获 2 9 8枚 ,有转移的 4 3枚 ,其中 4 1枚位于Ⅱ、Ⅲ区 ,占 95 4 % (41/ 4 3)。15例 (17侧 )患者有淋巴结转移 ,转移率为 2 6 3% (15 / 5 7)。其中 14例位于Ⅱ、Ⅲ区 ,占转移例数的93 3% (14 / 15 )。颈部复发 3例 ,复发率为 5 3% (3/ 5 7) ,复发部位分别位于Ⅱ、Ⅲ、Ⅳ区。 5年生存率为 80 7% (46 / 5 7)。结论　对声门上型喉癌cN0重点行Ⅱ和Ⅲ区颈淋巴结清扫术 ,Ⅲ区受累时应包括Ⅳ区 ,Ⅰ、Ⅴ区在无明显转移证据时可避免行颈清扫术     

声门型喉癌颈淋巴结转移相关因素的研究

目的 总结声门型喉癌颈淋巴结转移发生率，探讨影响声门型喉癌颈淋巴结转移的相关因素。方法 对1983年1月—1999年5月年间中国医科大学第一临床学院耳鼻咽喉科收治的452例声门型喉癌进行回顾性分析。男女比例约为10：1，年龄42—79岁之间，平均59．3岁。结果 声门型喉癌颈淋巴结转移发生率为3．54％(16／452例)，其中早期(T1和T2期)声门型癌颈淋巴结转移发生率为0．29％(1／340例)，晚期(T3和T4期)颈淋巴结转移发生率为13．39％(15／112例)。所有转移淋巴结均位于肿瘤病变侧Ⅱ、Ⅲ及Ⅳ区。结论 声门型喉癌肿瘤组织对声门下、室带等处侵及率相近，肿瘤累及上述不同部位其颈淋巴结转移的发生率差异无显著性。对于临床诊断无颈部淋巴结转移的声门型喉癌患者，不需要行颈清扫术。     

分化型甲状腺癌的颈淋巴转移规律

目的探讨分化型甲状腺癌颈部淋巴转移的规律及临床阳性淋巴结（cN＋）的颈部治疗模式；评价术前彩超在诊断甲状腺癌颈转移中的作用。方法回顾性分析我院2003年7月-2005年7月诊治93例（113侧）cN＋分化型甲状腺癌患者的临床资料，分为术前颈部淋巴结触诊阳性患者（64侧）和术前颈部触诊阴性，彩超诊断为颈淋巴转移患者（49侧）两组。记录术后颈清扫标本中转移淋巴结的数量及在Ⅱ、Ⅲ、Ⅳ、Ⅴ、Ⅵ区的分布。结果93例患者中双侧颈转移占21．5％（20／93），113侧颈清扫标本中92侧（81．4％）为多分区转移；转移淋巴结在颈部的分布以Ⅱ、Ⅲ、Ⅳ、Ⅵ区为主，分别为60．2％（68／113）、70．8％（80／113）、61．9％（70／113）、58．4％（66／113）；Ⅴ区较少分布22．1％（25／113），差异有统计学意义（χ^2=64．597，P〈0．001）。颈部触诊阳性患者颈清扫标本中转移淋巴结数量（10．1个），多于颈触诊阴性、彩超检查阳性患者（6．9个）；淋巴转移区域也多于后者（3．18区与2．61区）；术前彩超检查可以发现43．4％（49／113）的颈部触诊漏诊的颈部淋巴转移。结论分化型甲状腺癌的颈部淋巴转移为多分区分布，Ⅱ、Ⅲ、Ⅳ、Ⅵ区为主要的转移部位；彩超在甲状腺癌颈淋巴转移的诊断中具有重要的价值；对cN＋的分化型甲状腺癌患者，应进行包括Ⅱ、Ⅲ、Ⅳ、Ⅴ、Ⅵ区的改良性颈清扫术。     

cN0声门上型喉癌颈淋巴结隐匿性转移规律及处理

目的:探讨cN0声门上型喉癌患者颈部淋巴结隐匿性转移规律并选择合理的颈清扫区域。方法:139例cN0声门上型喉癌患者在行喉切除术同时行颈淋巴结清扫术,其中行改良性颈清扫57例,肩胛舌骨肌上淋巴结清扫30例,颈Ⅱ、Ⅲ区淋巴结清扫52例。将所获淋巴结按颈部分区逐一行组织病理学检查,观察其转移规律及临床疗效。结果:139例cN0声门上型喉癌患者中,同期行单侧颈清扫113例,同期行双侧颈清扫26例。139例(165侧)颈清扫标本经病理学检查,颈淋巴结阳性36例(25.9%),首次病理学检查颈淋巴结阴性者在随访中发现未手术侧淋巴结转移6例,总颈淋巴结隐匿性转移率为30.2%(42/139),单侧隐匿性转移率为26.6%(37/139),双侧隐匿性转移率为3.6%(5/139)。165侧颈清扫标本共获得淋巴结3 594枚,平均每侧21.8枚,共获病理阳性淋巴结83枚,其中位于Ⅰ区1枚(1.2%),Ⅱ区65枚(78.3%),Ⅲ区16枚(19.3%),Ⅳ区1枚(1.2%),Ⅴ区0枚。颈部复发率为5.0%(7/139),pN0与pN+的颈部复发率分别为0和16.7%(7/42),差异有统计学意义(P<0.05),总5年生存率为76.3%(106/139)。结论:颈Ⅱ、Ⅲ区是cN0声门上型喉癌颈部淋巴结隐匿性转移的主要区域,择区性(Ⅱ、Ⅲ区)颈淋巴结清扫术治疗cN0声门上型喉癌是合适的。     

叶绿素染色在喉癌下咽癌颈淋巴结清扫术中的应用

目的 :探讨喉癌、下咽癌的颈淋巴结转移方式。方法 :对 5 0例喉癌、下咽癌患者于颈清扫术前 ,在喉及下咽粘膜下注射叶绿素使颈淋巴结系统染色 ,指导施行颈清扫术并收集淋巴结 ,进行连续切片观察。结果 :颈淋巴结被染成深绿色 ,与周围组织颜色对比明显 ,便于颈部手术和采集淋巴结 ;经病理检查证实 ,颈淋巴结总的转移率为 4 8% ,Ⅰ、Ⅴ区转移时均伴有其它区域的转移 ,Ⅱ、Ⅲ区转移率高于Ⅰ、Ⅳ、Ⅴ区 (P <0 .0 1) ;临床诊断颈淋巴结阴性 (cN0 )的患者淋巴结转移率为 2 3.5 % ,转移区域均在Ⅱ、Ⅲ区。结论 :临床诊断颈淋巴结阳性 (cN+ )喉癌、下咽癌患者的颈清扫手术 ,首先要保证清扫II、III区淋巴结 ,术中所见决定选择性颈清扫术式 ,对cN0 的下咽癌或声门上癌可行单侧或双侧颈深上、中淋巴结清扫术。叶绿素染色清晰 ,安全无毒 ,便于手术 ,可以在颈清扫术中常规应用     

颈淋巴结清扫对临床颈淋巴结阴性伴高危因素甲状腺乳头状癌治疗的意义

目的 探讨临床颈淋巴结阴性(cN0)伴高危因素甲状腺乳头状癌(papillary thyroid cancer,PTC)的颈淋巴结转移规律,并对其行选择性清扫的必要性.方法 回顾性分析87例临床颈淋巴结阴性伴高危因素甲状腺乳头状癌初次行甲状腺癌手术并同期行颈清扫术患者的临床资料,对结果进行统计学分析.结果 87例(89侧)患者中,颈淋巴结阳性率62.9％,其中中央组淋巴结(Ⅵ区)转移率58.4％,颈侧区(Ⅱ一Ⅳ)阳性率38.2％,Ⅵ区与颈侧区淋巴结阳性率比较,差异有统计学意义(配对x2检验,x2=11.12,P＜0.01),同时行关联性分析表明,VI区与颈侧区转移有相关性(x2=20.11,P＜0.05,Pearson列联系数C=0.43).Ⅵ区阳性者,Ⅱ、Ⅲ、Ⅳ区淋巴结转移率分别为30.8％、61.5％、42.3％,颈侧各区之间转移率差异有统计学意义(x2=10.30,P＜0.01).结论 cN0伴高危因素PTC患者,Ⅵ区与颈侧区淋巴结转移有相关性,且Ⅵ区阳性者,颈侧各区之间转移率有差异,建议此类患者在常规清扫VI区淋巴结基础上进一步行颈侧清扫术,并可根据肿瘤位于甲状腺不同部位,选择颈侧各区的清扫范围.     

舌活动部鳞癌颈淋巴结阴性（cN0）的处理

目的：通过分析舌活动部鳞癌病人临床检查颈淋巴结阴性（cN0)的隐匿性淋巴结转移在颈部各区的分布，显示舌活动部鳞癌的淋巴结转移规律，并指导舌活动部鳞癌cN0的分区性颈淋巴清扫的范围。方法：回顾分析33例cN0的舌活动部鳞癌行选择性全颈淋巴结清扫和挽救性颈淋巴结清扫术的病例，分析手术后病理阳性淋巴结（pN^ )在颈部各区的分布。结果：病理证实单个淋巴结转移14例，其中Ⅰ区淋巴结转移3例，Ⅱ区淋巴结转移7例，Ⅲ区淋巴结转移4例，Ⅳ区和Ⅴ区未见淋巴结转移，多个淋巴结转移19例，各区转移频率分别为：Ⅰ区27.45%,Ⅱ区39.22%，Ⅲ区31.37%,Ⅳ区0%，Ⅴ区1.96%。结论：舌活动部鳞癌cN0的颈部处理没有必要采用经典性全颈清扫术，建议行肩胛舌骨肌上的分区性清扫，即Ⅰ区清扫 Ⅱ区清扫 Ⅲ区清扫即可，避免全颈清术给患者造成的术后损害。     

头颈部鳞癌颈淋巴结转移方式的临床病理学研究

为了探讨头颈肿瘤颈淋巴结转移的规律，对３８４侧根治性颈淋巴清扫标本进行连续切片观察。发现颈淋巴结转移病理阳性的总发生率为６０．４％，其中Ｎ０病例颈淋巴结转移率为３１．７％，Ｎ１～３颈转移率为８１．２％；口腔癌主要向Ⅰ、Ⅱ和Ⅲ区转移，口咽癌、下咽癌和喉癌主要向Ⅱ、Ⅲ和Ⅳ区转移。转移的淋巴结主要分布于一个或相邻的三个解剖区。颈淋巴结转移病理阳性和淋巴结包膜破坏的发生率随着临床Ｎ分期的增加而升高，且后者在Ｎ２，３中的发生率明显高于Ｎ０，１。提示对Ｎ０，１的病例可行区域选择性颈清扫并追加术后放疗。对Ｎ２，３的病例应行根治性颈清扫术，以彻底清除转移灶并改善患者预后。     

Level IIb lymph node metastasis in thyroid papillary carcinoma

The objective of the study was to evaluate the incidence of level IIb lymph node metastases in neck dissections for thyroid papillary carcinoma (TPC) patients. 47 neck dissections of 33 patients with TPC were prospectively evaluated. Selective neck dissections (levels II, III, IV, and V) were performed in all cases. If level I lymph node metastasis was suspected during the procedure, level I dissection was also performed. All level IIb specimens were sent separately from the remainder of the neck dissection for the pathological examination. The number of dissected and metastatic lymph nodes in each specimen was recorded. Twenty-two of 47 neck dissections (46.8%) were positive for the lymph node metastasis. Among 47 neck dissection specimens, the incidence of lymph node metastasis at level II was 12.7% (6 of 47) and level IIb was 2.1% (1 of 47). The rate of level IIb lymph node involvement among patients with metastatic cervical lymph nodes was 4.5% (1 of 22). The specimen with metastatic lymph node at level IIb had also metastasis at levels IIa, III, IV, and V. The results of the present study suggested that lymph node metastases in level IIb are rare in patients with TPC undergoing neck dissection.     

喉癌T2-4临床N0颈淋巴结转移的临床病理研究

OBJECTIVE: To study the characteristics of the cervical lymph node metastasis in clinical N0 (cN0) patients with laryngeal carcinoma and its implication in clinical treatment. METHODS: 76 patients with laryngeal carcinomas of T2-4cN0 category were divided into two groups in random: 21(22 sides) radical neck dissection(RND) and 55(60 sides) functional neck dissection(FND) were performed. Lymph nodes were studied histologically according to the levels. RESULTS: On an average, 29.6 lymph nodes were obtained in one side of neck in RND group, and 24.7 in FND group(F = 3.145, P = 0.068). The occult metastasis rates were 33.3% (7/21) in RND group and 34.5% (19/55) in FND group. 25 of 26 patients (96.2%) who had positive nodes involved only the levels II and III. 2130 lymph nodes were obtained in all samples, 59 of 60 positive nodes(98.3%) were located in the level II and III. The 5 and 10-year survival rates of the two groups were 71.4% (15/21), 76.4% (42/55) and 61.9% (13/21), 68.9% (31/45), respectively with no statistical difference(chi 2 = 0.2394, P > 0.5; chi 2 = 0.3143, P > 0.05). Ipsilateral cervical recurrence rates in two groups were 9.5% (2/21) and 7.3% (4/55), respectively with no statistical difference (chi 2 = 0.1059, P > 0.900). 10-year mortalities with negative and positive cervical lymph nodes were 16.7% (7/42) and 62.5% (15/24) respectively, which had statistically difference (chi 2 = 14.4375, P < 0.005). CONCLUSION: The lateral neck (level II, III and IV) dissection may be suitable for the treatment laryngeal carcinoma patients with T2-4cN0.     

Levels II and III neck dissection for larynx cancer with N0 neck

The removal of level II, III, and IV metastases has gained importance in the treatment of squamous cell carcinomas (SCC) of the neck and larynx. This study assessed the possibility of removing level II and level III metastases only, given the low likelihood of occurrence of metastatic lymph nodes on level IV in SCCs of the larynx.ObjectiveThis study aimed to analyze the prevalence rates of metastatic lymph nodes on level IV in laryngeal SCC patients.MethodsThis prospective study enrolled consecutive patients with laryngeal SCC submitted to neck lymph node dissection. Neck levels were identified and marked for future histopathology testing.ResultsSix percent (3/54) of the necks had level IV metastatic lymph nodes. All cN0 necks (42) were free from level IV metastasis. Histopathology testing done in the cN (+) necks (12) revealed that 25% of the level IV specimens were positive for SCC. The difference between cN0 and cN (+) necks was statistically significant (p = 0.009). Level IV metastases never occurred in isolation, and were always associated with level II or level III involvement (p = 0.002).ConclusionThe prevalence rate for lymph node metastasis in cN0 necks was 0%. Level IV metastatic lymph nodes were correlated to cN (+) necks. Level IV metastasis was associated with the presence of metastatic lymph nodes in levels II or III.     

喉癌颈部转移淋巴结分布研究

目的 :回顾分析我院 1990年 4月～ 2 0 0 0年 4月收治的喉癌患者 2 89例颈部转移淋巴结的分布情况 ,指导颈清扫手术。方法 :将 2 89例分为 3组 :第 1组 :颈清扫术后有转移淋巴结的分布 (181例 ) ;第 2组 :术后病理诊断阴性淋巴结的免疫组化研究 (71例 ) ;第 3组 :未清扫者随访中再转移淋巴结的分布研究 (37例 )。结果 :第 1组清扫 2 4 2侧 ,颈部Ⅰ、Ⅱ、Ⅲ、Ⅳ、Ⅴ、Ⅵ区转移率分别为 2 .8%、98.3%、32 .6 %、15 .0 %、13.0 %、2 1.4 % ;第 2组 71例 ,其中 4 6例 (5 0侧 )免疫组化研究发现 13个淋巴结内有微灶转移 ,分布于 11例患者中 ,所有转移淋巴结均分布在Ⅱ区 ;第 3组 37例 ,施行挽救性手术共 4 5侧 ,Ⅰ、Ⅱ、Ⅲ、Ⅳ、Ⅴ区转移率分别为 2 .2 %、10 0 %、4 8.9%、2 6 .7%、13.3%。结论 :喉癌首先转移和主要转移部位为Ⅱ区 ,其次为Ⅲ区 ;Ⅳ、Ⅴ区发生率则较低 ,颌下区几乎不发生转移。喉癌患者的颈清扫应在常规清扫颈侧Ⅱ～Ⅳ区淋巴结的同时 ,根据病变范围情况行Ⅳ区的清扫 ,对颌下三角和颈后三角 (Ⅴ区 )在无影像学和术中证实的条件下 ,应予以保留 ,以缩短手术操作时间和减少术后并发症的发生     

Diagnosis of lateral cervical lymph node metastasis of papillary carcinoma of the thyroid by ultrasonography

No consensus for papillary carcinoma of the thyroid exists on the preoperative diagnosis of lateral cervical lymph node metastasis, indications, or range of neck dissection, so we studied the usefulness and limits of ultrasonography and sufficient dissection by comparing preoperative ultrasonographic and postoperative histopathological diagnosis. Subjects were 45 patients (51 affected sides) with lateral cervical lymph node metastasis of papillary carcinoma of the thyroid who underwent modified neck dissection between July 1997 and July 2003. Preoperative ultrasonographic and postoperative histopathological diagnosis were compared. Specimens excised by neck dissection contained 1,325 lymph nodes. Of these, 198 (15%) detected by preoperative ultrasonography were selected for investigation of diagnostic criteria for metastasis-positive lymph nodes. The best criterion for the diagnosis of metastasis-positive lymph node was 0.5 or greater [minor axis/major axis] with 6 mm or greater minor axis at levels III, IV, or V (7 mm or greater at level II), and sensitivity, specificity, and accuracy were 78%, 100%, and 84% respectively. The lateral cervical lymph node metastasis rate obtained by this diagnostic criterion was 41%. Regional histopathological metastasis positivity was investigated in the lateral cervical region, and high positivity rates were obtained: 57% at level II, 71% at level III, and 84% at level IV. Considering these findings and the preoperative ultrasonographic diagnosis rate of 41%, sufficient dissection at levels II-IV may be necessary for patients in whom lateral cervical metastasis is observed before surgery. The metastasis rate was 10% at level V, but dissection should always be done in lateral cervical metastasis-positive patients because: 1) No trend was observed in age, gender, the number of metastatic lymph nodes, or regional metastasis rate; 2) no anatomical boundary is present between levels II, III, IV and level V; 3) no functional disorder due to preservation of the accessory nerve occurred; 4) the prognosis of patients with advancement to the accessory nerve was poor; and 5) improvement of the prognosis of papillary carcinoma of the thyroid by modified radical neck dissection has been reported.