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     

喉癌和下咽癌颈淋巴结转移临床对比分析

目的：探讨喉癌、下咽癌患者颈淋巴结转移的特点和分布规律。方法：对全喉切除术同期及复发后第1次行颈淋巴结清扫的129例喉癌、下咽癌患者的临床资料进行回顾性对比分析，研究不同类型的喉癌、下咽癌患者颈淋巴结的转移情况。结果：声门上型喉癌、下咽癌患者易发生早期淋巴结转移；下咽癌患者的转移淋巴结融合率高，颈静脉下区出现阳性淋巴结的比率高；声门上型喉癌、下咽癌患者原发病灶分化差的比率相对偏高；同期与复发后行颈淋巴结清扫的患者原发病灶分期差异无显著性意义。结论：对T2期及以上的声门上型喉癌及下咽癌患者，尤其当细胞分化比较差时，即使颈淋巴结阳性体征不明显亦应积极考虑颈淋巴结清扫问题，对下咽癌患者行颈淋巴结清扫时应考虑彻底清扫颈静脉下区的淋巴结。     

Neck dissection in squamous cell carcinoma of the larynx. Indication of elective contralateral neck dissection

Unilateral or bilateral neck dissection must be considered in the treatment of laryngeal cancerAimTo evaluate the prevalence of contralateral metastases in larynx cancer and distribution of these metastases according to lymph node levels in the neck.MethodRetrospective longitudinal study of 272 charts from patients with squamous cell cancer of the larynx treated between 1996 and 2004; and we selected 104 surgical cases submitted to neck dissection. We evaluated the incidence of bilateral or contralateral metastases, according to the location and extension of the primary tumor, considering the anatomical sub-sites and the midline.ResultsContralateral metastases in lateral tumors were observed in 3.5% of glottic lesions and in 26% of supraglottic lesions. Contralateral metastases were uncommon in N0 patients. Lymph nodes levels IIa and III were the most commonly involved in the neck.ConclusionIn lateral glottic tumors there is no need for elective contralateral neck dissection. In supraglottic lesions without ipsilateral metastases, the incidence of hidden metastasis does not justify elective contralateral dissection. The midline is not a reliable indicator of the risk of contralateral laryngeal tumors.     

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.     

Level IIb lymph node metastasis in laryngeal squamous cell carcinoma

OBJECTIVES: Selective neck dissection, despite preservation of the spinal accessory nerve, can lead to some degree of postoperative shoulder dysfunction as a result of removal of level IIb lymph nodes. The aim of this study was to determine whether level IIb lymph nodes can be preserved in elective or therapeutic neck dissection as a treatment for patients with laryngeal squamous cell carcinoma (SCC). STUDY DESIGN: This was a prospective analysis of a case series. METHODS: A prospective analysis of 65 patients with laryngeal SCC who underwent surgical treatment of the primary lesion with simultaneous neck dissection from January 1999 to December 2002 was performed. During the neck dissection, the contents of the level IIb lymph nodes were dissected, labeled, and processed separately from the remainder of level II nodes and the main neck dissection specimen. The incidence of pathologic metastasis to level IIb lymph nodes and the regional recurrence within this area were evaluated. In addition, several potential risk factors for metastatic disease in the level IIb lymph nodes such as sex, age, cT stage, cN stage, and the presence of other positive lymph nodes were also evaluated. RESULTS: A total of 125 neck dissections were performed in this series. Of these dissections, 102 (82%) were elective and 23 (18%) were therapeutic. The prevalence of metastases in the level IIb lymph nodes was 1% (one of 46) and 0% (zero of 56) in clinically node-negative (N0) ipsilateral and contralateral necks, respectively, and 37% (seven of 19) and 0% (zero of four) in clinically node-positive ipsilateral and contralateral necks, respectively. There was a statistically significant association between level IIb metastases and clinically positive N stage (P<.001). The presence of other positive lymph nodes was also shown to have a statistically significant association with metastasis in the level IIb lymph nodes (P=.001). Only two of 46 patients (4%) with clinically N0 necks developed a regional recurrence. However, three of eight cases (38%) with positive pathologic level IIb lymph nodes developed regional recurrence. CONCLUSION: Level IIb lymph node pads may be preserved in elective neck dissection in patients with laryngeal SCC. However, this area should be removed thoroughly during therapeutic neck dissection in the treatment of clinically node-positive necks.     

Is routine bilateral neck dissection absolutely necessary in the management of N0 neck in patients with supraglottic carcinoma?

The supraglottic larynx has a rich lymphatic network that places patients with supraglottic laryngeal carcinomas at high risk for early dissemination of the disease into the cervical lymphatics. Therefore, elective neck treatment of clinically N0 neck in patients with supraglottic carcinomas is widely accepted as a standard approach. However, the issue whether elective neck treatment should routinely be directed on both sides of the neck is still controversial. The present study is aimed at determining whether T2–T4 stage supraglottic carcinomas require bilateral neck dissection in the management of N0 necks. We designed a prospective study on 72 patients with N0 supraglottic laryngeal carcinoma. Patients were divided into three groups according to the site and extension of the primary tumors. Group I consisted of 21 patients with lateralized (clear lateral) lesion reaching but not crossing the midline. Group II comprised 25 patients with cancer largely involving one side and crossing to the midline. Group III included 26 patients with carcinoma equally involving both sides of the larynx or growth into the midline larynx. All patients underwent bilateral lateral neck dissection in conjunction with various types of laryngectomies selected to the status of the primary. Of the 72 patients, 16 were found to have occult regional metastases in pathologic examination (9 pN1, 4 pN2b, 3 pN2c). The prevalence of occult metastases proportionally increased with T stage from 8.3 to 22.7 and 31.2%, respectively, for T2, T3 and T4. Bilateral neck metastases were found in 2 of 26 patients (7.7%) with central lesions. There was only one patient (4%) with both ipsilateral and contralateral lymph node metastasis in group II. None of the 21 patients with lateral lesion (group I) had contralateral neck metastasis. Routine bilateral elective neck dissection may not be a part of the surgical procedure in all supraglottic laryngeal carcinoma patients. Bilateral neck dissection should be preferred for cases with central tumors and lateral tumors with positive nodes in the ipsilateral side of the neck.     

Upper neck (level II) dissection for N0 neck supraglottic carcinoma

OBJECTIVES: Elective neck dissection for the N0 neck in head and neck surgery is still controversial. This prospective nonrandomized study of N0 supraglottic carcinoma was designed to find an appropriate method of neck management. STUDY DESIGN: Anatomical studies show that the first echelon of lymphatic drainage from the supraglottic larynx is toward the upper jugular nodes (level II). An upper neck dissection (UND) was applied and all the lymph nodes were sent for frozen section. If the subclinical metastasis was found, a modified neck dissection was performed. If the nodes harbored no foci of cancer, the patients were observed after surgery on the supraglottic lesions. METHODS: Patient records of 142 patients with supraglottic laryngeal cancer (T1-4N0M0) were reviewed, with special attention paid to neck recurrences and survival rates. The cases were treated between 1976 and 1990 and all were observed for at least 5 years after the operation or until the time of death. RESULTS: The UND specimens of 142 patients were negative for metastasis. The 5-year survival rate for this group after surgery was 80.8%, according to the life table analysis. Fifteen of the 142 patients (10.6%) had neck recurrences during the period of observation within 5 years. The recurrence rate of this series with limited dissection on the neck was comparable with those reported in the literature after neck dissection, either radical or modified. CONCLUSIONS: There is no need for a comprehensive neck dissection for N0 supraglottic laryngeal cancer. A selective neck dissection such as UND (level II) or a supraomohyoid neck dissection (sparing the submandibular region) of level II and III will serve the purpose of radical neck treatment for the supraglottic cancer.     

Selective neck dissection in the management of the clinically node-negative neck

OBJECTIVE: To evaluate the efficacy of the selective neck dissection (SND) in the management of the clinically node-negative neck. STUDY DESIGN: Case histories were evaluated retrospectively. METHODS: The results of 300 neck dissections performed on 210 patients were studied. RESULTS: The primary sites were oral cavity (91), oropharynx (30), hypopharynx (16), and larynx (73). Seventy-one necks (23%) were node positive on pathological examination. The number of positive nodes varied from 1 to 9 per side. Of necks with positive nodes, 17 (24%) had extracapsular spread. The median follow-up was 41 months. Recurrent disease developed in the dissected neck of 11 patients (4%). Two recurrences developed outside the dissected field. The incidence of regional recurrences was similar in patients in whom nodes were negative on histological examination (3%) when compared with patients with positive nodes without extracapsular spread (4%). In contrast, regional recurrence developed in 18% of necks with extracapsular spread. This observation was statistically significant. Patients having more than two metastatic lymph nodes had a higher incidence of recurrent disease than the patients with carcinoma limited to one or two nodes. Recurrence rate in the pathologically node positive (pN+) necks was comparable to recurrence in those pathologically node negative (pNO) necks in the patients who did not have irradiation. CONCLUSION: SND is effective for controlling neck disease and serves to detect patients who require adjuvant therapy.     

Management of the N0 neck in patients with laryngeal squamous cell carcinoma

Abstract

Background: Neck lymph node status is the chief prognostic index in patients with head and neck squamous cell carcinoma (SCC), yet the management of a clinically negative neck in this setting is still controversial, especially in patients with laryngeal SCC (LSCC).

Objectives: To evaluate the efficacy of selective neck dissection (SND) to control occult disease in patients with LSCC and clinically negative (cN0) necks.

Materials and methods: Medical records of 1476 patients with cN0 LSCC were analyzed. In conjunction with primary treatment, 126 (8.5%) underwent at least unilateral elective neck dissection, whereas most 1350 (91.5%) followed a wait-and-see protocol. Prognostic significance was indicated by the Kaplan–Meier survival estimates.

Results: The rate of occult neck disease was 15%. Five-year overall and disease-free survival rates were 74.4% and 66.7%, respectively. Prognosis was closely related to T stage, preoperative tracheotomy, and postoperative recurrence. There was no significant correlation with age, sex, or preoperative neck dissection; but in patients with supraglottic LSCC, the relation between prognosis and preoperative neck dissection was significant, with fewer neck and local recurrences than the wait-and-see group (p?<?.05).

Conclusions and significance: Selective neck dissection is serving as an accurate prognostic tool in patients with supraglottic laryngeal cancers.     

择区性颈清扫术治疗63例下咽鳞状细胞癌的颈淋巴转移

目的 分析下咽鳞状细胞癌(简称鳞癌)患者颈部淋巴转移规律,评价择区性颈清扫术(selective neck dissection,SND)在下咽癌颈淋巴转移治疗中的效果.方法 回顾性分析1990年1月至2004年12月在北京大学第一医院接受颈清扫术的下咽鳞癌患者63例,其中cN0患者17例,cN+46例.单侧SND共计15例;双侧SND共计22例;改良性颈清扫术(modified radical neck dissections,MRND)共计16例;一侧行经典性颈清扫术(radical neck dissections,RND)或MRND,另一侧行SND共计10例.随访48例(76.2%),随访时间范围为24～143个月,随访中位时间为41个月.结果 颈清扫术后发现淋巴结病理阴性(pN0)22例,淋巴结病理阳性(pN+)41例.95侧清扫标本中共发现106枚阳性淋巴结,其在颈部的分布如下:Ⅰ区0%,Ⅱ区47.2%(50/106),Ⅲ区33.0%(35/106),Ⅳ区11.3%(12/106),Ⅴ区2.8%(3/106),Ⅵ区5.7%(6/106).值得注意的是,无论是cNO还是cN+下咽癌患者,对侧颈部都可出现淋巴转移和复发.在随访的48例中,共有18例(21例次)复发.颈清扫术后淋巴结复发主要分布在Ⅱ区和Ⅲ区(19例次).根据Kaplan-Meier方法计算3年生存率,pN0患者为58.1%,pN1患者为44.9%,pN2患者为41.1%.Cox同归分析:N分级是影响预后最重要的因素,pN1的危险比为1.7,pN2的危险比为2.2.结论 淋巴转移是下咽鳞癌最重要的预后因素.恰当的选择双侧SND,可以取得较满意效果,同时减少患者形态和功能的损伤.     

喉及下咽鳞癌颈淋巴结隐匿性转移灶的研究

目的 :进一步探讨喉及下咽鳞癌颈淋巴结转移规律 ,为喉及下咽鳞癌颈淋巴结清扫术提供理论依据。方法 :收集 1997年 5月～ 1999年 7月 4 0例临床颈淋巴结阴性 ( c N0 )的喉及下咽鳞癌患者改良根治性颈清扫术所得标本 ,且术前未经任何治疗者为研究病例。对颈清扫淋巴结 (共 2 2 19枚 )进行常规 HE及免疫组化法检查。全部病例随访 1年以上。结果 :喉及下咽鳞癌出现颈淋巴结转移 14例 ( 3 5 % ) ,共 3 1枚 ( 1.4 % )淋巴结 ,其中声门上癌 6例 ( 6/2 0 ) ,跨声门癌 1例 ( 1/1) ,下咽癌 7例 ( 7/10 )。 9例声门癌无颈淋巴结转移。颈淋巴结转移均位于颈 、 区。结论 :喉及下咽鳞癌颈淋巴结转移多发生于患侧颈 、 区 (局限于声门区喉癌除外 )。对于 T2 ～ T4 声门上癌、跨声门癌及下咽癌的 c N0 患者 ,根据其可能发生颈淋巴结隐匿性转移的高危险性 ,建议行患侧或双侧颈 及 区淋巴结清扫术。     

颈淋巴结转移临床处理概念上的变化─—分区性颈清扫术

分区性颈清扫术（selectiveneckdissection,SND）是根据头颈部特定部位肿瘤颈淋巴结转移规律而设定的非全颈性清扫,手术范围缩小而不影响根治性。有利于保留患者外观和术后功能。SND目前主要应用于临床颈淋巴结阴性（cN0）和部分阳性（cN1）的上呼吸消化道鳞癌患者,有多个淋巴结转移或术后病理提示淋巴结有包膜外侵犯的患者应配合应用放疗。不同术式的分区性颈清扫适应于不同原发灶的转移。治疗结果显示SND治疗后的效果及手术区域颈部淋巴结复发率与改良根治性颈清扫相似。     

Effectiveness and pitfalls of elective neck dissection in N0 laryngeal cancer

The aim of the study was to evaluate the efficacy and potential pitfalls of selective neck dissection of levels II-IV in controlling occult neck disease in clinically negative neck (cN0) of patients with laryngeal squamous cell carcinoma. Charts of 96 consecutive cN0 laryngeal cancer patients undergoing 122 neck dissections at the University of Florence from January 2000 to December 2004 were reviewed. N0 neck was defined with contrast enhanced computed tomography scan. Occult neck disease rate was 12.5%, involvement per level was: 47.6% at level II, 38.1% at level III, 9.5% at level IV. Six patients developed neck recurrence (6.25%) after selective neck dissection of levels II-IV within the first two years after treatment. In conclusion, selective neck dissection of levels II-IV is effective in N0 laryngeal squamous cell carcinoma; posterior limits of surgical resection are missing therefore if post-operative radiation is required, the field should be extended beyond the dissected levels. The low incidence of occult neck disease indicates the need to refine treatment strategy, restricting elective neck dissection only to supraglottic T2 with epilaryngeal involvement, supraglottic T3-4 and glottic T4 tumours, and considering a "wait and see" protocol implemented with imaging techniques and cytological assessments for other lesions.     

Results of selective neck dissection in the primary management of head and neck squamous cell carcinoma

Selective neck dissection (SND) is known to be a valid procedure to stage the clinically N0 neck but its reliability to control metastatic neck disease remains controversial. This study analysed if selective neck dissection is a reliable procedure to prevent regional metastatic disease in head and neck squamous cell carcinoma (HNSCC). We retrospectively analysed the medical records of 163 previously untreated patients with squamous cell carcinoma of the oral cavity, oropharynx, larynx and hypopharynx treated initially in our departement from January 1990 to December 2002. All patients had unilateral or bilateral SND, in combination with surgical resection of the primary tumour. SND was performed in 281 necks. Finally, 146 patients who underwent 249 SND (39 I–III, I–IV, 210 II–IV, II–V) had adequate follow-up and were assessed for the regional control. The median follow-up was 37 months (1–180 months). The end points of the study were neck control following SND and overall survival. Twenty-five percent (30/119) of patients staged cN0 had lymph node (LN) metastasis. Overall, regional recurrence was observed in 2.8% of the necks (7/249): 1.6% (4/249) in dissected field and 1.2% (3/249) in undissected field. Seventy-eight percent (194/249) of the necks were staged pN0 with a subsequent failure rate of 1.5% (3/194); 16% (39/249) were staged pN1 and postoperative radiotherapy (PORT) was proposed in 21 of these patients. The failure rate with PORT was 9.5% and 5.5% without PORT. Six percent (16/249) of the necks were staged pN2b and all had PORT with one subsequent recurrence. Extracapsular spread (ECS) was reported in 16.5% of positive SND specimens (9/55); all by one were treated by PORT with a subsequent failure rate of 22% (2/9). At 3 years, overall survival for the whole population was 70% and statistically highly correlated with pN stage (p<0.001). These results support the reliability of SND to stage the clinically N0 neck. SND is a definitive operation not only in pN0 but also in most pN1 and pN2b necks. PORT is not justified in pN1 neck without ECS. In pN2b necks, the low rate of recurrence supports adjuvant PORT. The presence of ECS, despite adjuvant PORT, remains associated with a higher risk of recurrence.     

择区性颈清扫术治疗下咽鳞状细胞癌颈部淋巴结转移的术式探讨

目的:探讨择区性颈清扫术(SND)治疗下咽鳞状细胞癌颈部淋巴结转移的手术范围。方法:回顾性分析接受SND的26例下咽癌患者,其中11例cN0患者,15例cN+患者。本组共有51侧的SND,其中34侧为选择性SND,17侧为治疗性SND。结果:发现隐匿性颈淋巴结转移6例(55%),颈淋巴结转移均限制在Ⅱ区和Ⅲ区内。cN+患者均证实有颈淋巴结转移,其中Ⅱ区转移占66.7%,Ⅲ区转移占86.7%,Ⅳ区转移占46.7%,Ⅴ区转移占20.0%,另外Ⅰ区仅1例发现转移(6.7%)。随访发现区域复发4例,均为cN+患者,且均未见Ⅰ区复发。结论:cN0下咽癌患者SND(Ⅱ～Ⅲ)清扫有一定的临床意义,尚需进一步验证;cN+患者Ⅰ区清扫尚无必要,SND(Ⅱ～Ⅴ)配合术后放疗能取得满意的疗效。     

The evolving role of selective neck dissection for head and neck squamous cell carcinoma

Neck dissection is an important part of the surgical treatment of head and neck squamous cell carcinoma (HNSCC). The historical concept of neck dissection implied the removal of all lymph node-bearing tissue in the neck, which began in the late nineteenth century. However, more conservative variations of neck dissection have been performed and promoted as well. Anatomic, pathologic, clinical investigations, and prospective studies have demonstrated that the lymphatic dissemination of HNSCC occurs in predictable patterns. Supported by these studies, selective neck dissection (SND), which consists of the removal of select levels of lymph nodes in the neck that have the highest risk of harboring undetected metastases, has become widely accepted in the treatment of the clinically uninvolved neck. More recently, evidence supports using SND in a therapeutic setting in selected cases of HNSCC with limited metastatic disease. Additionally, even more targeted dissections referred to as super-selective neck dissection have been explored for selected patients undergoing elective node dissection for supraglottic cancer and as an adjuvant therapy for salvage of residual lymphadenopathy confined to a single neck level following chemoradiation. In the future, the trend to tailor treatment to individual patients and to limit toxicity and morbidity may further increase the use of SND. The indications have to be guided by further research, in relation with non-surgical treatment options while optimizing oncological effectiveness.     

Level IIb lymph nodes metastasis in elective supraomohyoid neck dissection for oral cavity squamous cell carcinoma: a molecular-based study

OBJECTIVES: To identify the incidence of level IIb lymph nodes metastasis in elective supraomohyoid neck dissection (SOHND) as a treatment for patients with squamous cell carcinoma (SCC) of the oral cavity. STUDY DESIGN: Prospective analysis of a case series. METHODS: Forty-eight patients with SCC of the oral cavity and with no palpable lymph nodes at the neck who underwent an elective SOHND were prospectively studied. The incidence of micrometastasis to level IIb lymph nodes after performing elective SOHND was evaluated by pathologic examination and molecular analysis. RESULTS: Of the 48 patients, 15 (31%) by pathologic analysis and 22 (46%) by molecular analysis had lymph nodes positive for metastatic SCC. By molecular analysis, 5 (10%) of the 48 patients had involvement of level IIb lymph nodes. All patients with metastasis to level IIb lymph nodes have their primary lesions in the tongue and constituted 22% of patients with tongue lesions. There was no instance of isolated metastasis to level IIb lymph nodes without involvement of other nodes in the SOHND specimens. CONCLUSIONS: In this study, level IIb lymph node metastasis was only found in association with tongue carcinoma. Although this region may be preserved in elective SOHND in patients with SCC of the oral cavity, it should be included whenever the tongue is the primary site.     

择区性颈清扫术在临床N0舌鳞状细胞癌治疗中的应用

目的比较择区性颈清扫术(selective neck dissection，SND)与经典性或改良性颈清扫术(radical neck dissection，RND)在治疗舌鳞状细胞癌颈淋巴结临床阴性(cN0)患者中的效果。方法将1998年1月-2002年12月之间采用肩胛舌骨肌上颈清扫术(Ⅰ～Ⅲ区)14例及Ⅰ～Ⅳ区清扫19例(SND组)共33例与1980年1月-1997年12月之间112例采用经典性或改良性颈清扫术(RND组)的病例，根据T分期、综合治疗方式和淋巴结病理情况进行随机配对分析。Kaplan—Meier方法计算复发率和颈部淋巴结复发或生存趋势。结果RND组5年颈部复发率为9．1％(3例)，SND组5年同侧颈部复发率12．1％(4例)；两组的5年生存率分别是78．8％和82．9％(分别为26例和28例)。Ⅰ-Ⅲ区清扫组5年颈部复发率为21．2％(3例)，清扫野外复发率为14．3％(2例)；Ⅰ-Ⅳ区清扫组5年同侧颈部复发率5．3％(1例)，清扫野外复发率为0。结论与经典性或改良性颈清扫术相比，择区性颈清扫术并不影响cN0舌癌患者的肿瘤治疗效果，术式以Ⅰ～Ⅳ区清扫为适宜。     

Preliminary multi-institutional prospective pathologic and molecular studies support preservation of sublevel IIB and level IV for laryngeal squamous carcinoma with clinically negative neck

Level II–IV selective neck dissection, often performed bilaterally, has become the procedure of choice for elective dissection of the clinically negative (N0) neck in the treatment of laryngeal cancer. The most significant morbidity of this procedure is dysfunction of the accessory nerve, incurred by the necessity of mobilization and retraction of the nerve in order to remove the contents of sublevel IIB. Other morbidity includes possible injury to the phrenic nerve and chylous fistula. These complications are associated with the dissection of level IV. A number of prospective multi-institutional studies of the distribution of cervical lymph node metastases in the neck indicate that lymph nodes in sublevel IIB and level IV are rarely involved in cases of laryngeal cancer with N0 neck. Information was obtained by the study of neck dissection specimens by conventional light microscopy, and by molecular analysis of the specimens. Molecular analysis reveals a significant number of metastases that are not discovered by light microscopy, and is thus essential for this type of evaluation. The authors conclude that these preliminary studies indicate that it is safe and appropriate to eliminate dissection of sublevel IIB and level IV from the elective neck dissection performed for laryngeal cancer with N0 neck. This practice will reduce both operating time and morbidity, particularly accessory nerve dysfunction, without compromising the oncologic result. Further prospective studies are needed to confirm these conclusions.     

Therapeutic selective neck dissection: a 25-year review

OBJECTIVES/HYPOTHESIS: The aim of the study was to show the efficacy of selective neck dissection in combination with postoperative radiation therapy in controlling squamous cell carcinoma metastatic to the cervical lymph nodes. The study compared the incidence of recurrences and overall disease-free survival between comparable cohorts undergoing a selective neck dissection and classic radical or modified neck dissection. STUDY DESIGN: Retrospective, 25-year review was made of data from a tertiary care academic facility comprising both private patients and veterans. METHODS: Inclusion criteria studied patients with untreated head and neck cancer who had squamous carcinoma metastatic to cervical lymph nodes on histological examination and were treated with a selective (n = 61), modified (n = 54), or radical neck dissection (n = 61). The three groups were compared with respect to regional control and overall cancer-free survival. All patients remained cancer free at the primary site, received postoperative radiation therapy, and had a minimum follow-up of 2 years. The median follow-up was 4.3 years. RESULTS: Control of recurrent carcinoma in the neck, as well as the incidence of overall cancer-free survival, was comparable in the three cohorts with no significant statistical difference. Eight of 176 sides of the necks (4.5%) showed evidence of recurrence (2 of 61 [3.3%] in the selective neck dissection group and 6 of 115 [5.2%] in the radical and modified neck dissection group. Disease-free 2-year survival was 80% in the selective neck dissection group and 64% in the radical and modified neck dissection group. CONCLUSION: Selective neck dissection, when used in combination with postoperative radiation therapy, is an efficacious way to manage metastatic squamous cell carcinoma to the neck.