Noncervical lymph node metastasis from head and neck cancer.

Nonregional lymph node dissemination must be classified as distant metastasis but axillary and mediastinal metastases can be part of a regional dissemination of the disease. Metastases to lymph nodes of the upper mediastinum are very common among patients with subglottic, hypopharynx and thyroid carcinomas. Axillary metastases are found at autopsy in 2-9% of the patients who died of head and neck squamous cell carcinoma (SCC) and are frequently associated with skin implantation in aggressive recurrent head and neck carcinomas. The possible explanations for this location of metastasis were retrograde dissemination due to lymph system blockage, further tumor dissemination after a parastomal recurrence, hematogenous dissemination, and metastasis from a second primary tumor. Patients with distant metastasis have been considered incurable and only palliative treatment was instituted. Treatment planning for cases with axillary metastasis must take in consideration the likelihood of other regional recurrences and/or distant metastasis. Also, the presence of a second primary tumor must be ruled out. Whenever axilla is the only site of cancer recurrence, a standard axillary dissection must be considered. Upper mediastinal metastases from subglottic and hypopharyngeal cancer are managed by paratracheal and mediastinal dissection through the neck and postoperative radiotherapy.     

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。     

Simultaneous bilateral neck dissections

From April 1985 to December 1989, 65 patients with advanced head and neck squamous cell carcinoma, underwent simultaneous bilateral neck dissection (SBND) at Saitama Cancer Center. Three and five year survival percentages were 53 and 42%, respectively. In patients without histologic involvement of cervical nodes, five year survival rate was 83%, whereas in those with nodal involvement five year survival fell to 32% (p less than 0.005). The conclusion were the following: (1) Of 38 patients diagnosed to have lymph node involvements on one side of neck before operation, 8 patients (22%) were found to have bilateral lymph node metastasis in clinicopathological study. Of 13 patients having no clinical lymph node metastasis on both sides of neck, 7 patients (54%) were found to have unilateral lymph node metastasis. Of 16 patients diagnosed to have bilateral lymph nodes involvement, 10 patients were found to have bilateral neck metastasis and 2 had unilateral neck metastasis. (2) Of 35 cases of hypopharyngeal canners, 19 cases had clinically positive lymph nodes on one side of neck. Of these 19 cases, 5 cases (26%) had histologically positive nodes on the opposite side. 14 (40%) of 35 cases had metastasis on the opposite side. In conclusion, SBND is a proper treatment for metastatic cervical cancer from a primary lesion of the head and neck, especially in hypopharyngeal cancers, because the rate of recurrence seems to be related more to the difficulty in controlling lymph node metastasis than to the failure in treatment of the primary cancer.     

A clinical study of ultrasonography for lymph node metastases in head and neck cancer

Ultrasonography (US) is very useful in evaluating cervical lymph node swelling in head and neck cancers. We studied problems with US in evaluating lymph nodes. Cervical lymph nodes were removed by radical neck dissection or modified radical neck dissection from 79 patients with squamous cell carcinoma in the head and neck. We studied the correlation between preoperative US findings and the histopathological features. Preoperative lymph nodes were measured three-dimensionally. We diagnosed lymph nodes as metastases when they meet two criteria: One is the shortest diameter exceeding 7 mm in level I and II and 6 mm in level III, IV and V. The other is shortest to longest diameter ratio exceeding 0.5. A total of 2004 lymph nodes were removed by neck dissection, and 199 lymph nodes were diagnosed histopathologically as metastases. Of the 199 metastatic lymph nodes, 93 (46%) were diagnosed as metastases by preoperative US findings and 33 (17%) were false negative. Thirty-six cases were diagnosed preoperatively as N0 by US findings, but 15 of these were pN(+) histopathologically. In the 15 cases, 21 lymph nodes were metastases. Of the 21 metastatic lymph nodes, 10 nodes were not detected by US. Thirty-one cases were diagnosed preoperatively as N1 by US findings, but 20 of these were pN2b histopathologically. In the 20 cases, 66 lymph nodes were metastases. Of the 66 metastatic lymph nodes, 46 were not diagnosed as metastases. They often located distant level from the lymph node diagnosed correctly as a metastasis. US is very useful in evaluating cervical lymph node metastasis, but it has the limitations indicated above. If 1 metastatic lymph node is detected by US, there will be multiple metastatic lymph nodes and sometimes they are distant from the original level. Radical neck dissection should be done for positive lymph nodes detected by US findings. If a lymph node is not clearly a metastasis, fine-needle aspiration cytology (FNA) should be done, because it provides more accurate diagnosis for metastatic lymph nodes.     

Prophylactic neck dissection for submandibular gland cancer

The indication and preferred dissection field for prophylactic neck dissection for submandibular gland cancer are controversial and have not been standardized. We reviewed 27 patients who underwent a definitive operation for previously untreated submandibular gland cancer. The 27 patients consisted of 13 patients with adenoid cystic carcinoma, 6 patients with mucoepidermoid carcinoma, 6 patients with adenocarcinoma, and 2 patients with squamous cell carcinoma. The diagnostic accuracies of malignancy and histology with fine needle aspiration cytology were 86% and 56%, respectively. In sixteen out of 21 cases without neck lymph node metastasis, a prophylactic neck dissection was performed and pathological neck lymph node metastases were detected in five cases. On the other hand, in five cases that did not receive a prophylactic neck dissection, latent neck lymph node metastasis was observed in 2 cases. In both cases of neck lymph node metastasis, pathological positive lymph nodes were observed in only level 2 or level 3. The rates of occult neck lymph node metastasis according to the T stage were 0% in T1, 33.3% in T2, 57.1% in T3 and 100% in T4. The rates of occult neck lymph node metastasis according to the histopathology were 46.2% in adenoid cystic carcinoma, 50% in mucoepidermoid carcinoma, 50% in adenocarcinoma, and 50% in squamous cell carcinoma. In conclusion, we believe that supraomyohoid neck dissection is suitable for N0 cases of submandibular gland cancer because of four reasons: 1) rate of occult neck lymph node metastasis in submandibular gland cancer is high, 2) pathological neck lymph node metastasis in N0 cases and latent neck lymph node metastasis were observed in level 2 and level 3, 3) the prognosis of cases with neck lymph node metastasis was poor, and 4) same skin incision can be used not only for the primary resection but also for the neck dissection.     

The node-negative neck: accuracy of clinical intraoperative lymph node assessment for metastatic disease in head and neck cancer

OBJECTIVES/HYPOTHESIS: Often, the type of neck dissection performed in patients with head and neck malignancy is finally determined by intraoperative assessment of clinically suspect lymph nodes by frozen section. This prospective study aimed to assess the accuracy of clinical intraoperative lymph node assessment and therefore to examine validity of the underlying assumption that the surgeon can consistently identify nodes that contain metastatic tumor. We also aimed to assess whether gross morphological characteristics of the lymph nodes examined could be correlated with nodal status and therefore used to predict those nodes containing metastatic disease. STUDY DESIGN: A prospective study assessing the accuracy of clinical intraoperative lymph node assessment in the node-negative neck. METHODS: Forty-six neck dissections from 34 patients with head and neck cancer were prospectively examined intraoperatively by a single surgeon. All obvious nodes were clinically assessed, morphologically described, and subsequently correlated with pathological findings. RESULTS: Sixty palpable nodes were identified in 32 neck dissections. They were clinically categorized as malignant or suspect (22) or benign (38). Pathological examination revealed a false-positive rate of 30% and a false-negative rate of 44%. The sensitivity of intraoperative lymph node assessment was 56%, and the specificity was 70%. Apart from "infiltration," morphological characteristics could not be correlated with nodal status. In the 14 neck dissections with no obviously palpable lymph nodes, 4 (29%) were positive for metastatic disease. CONCLUSIONS: In the node-negative neck, intraoperative assessment does not seem to improve the accuracy of staging. The only parameter of benefit and correlating with metastatic disease is clinical evidence of infiltration. The assumption that frozen section is a good determinate for selection of type of neck dissection is questionable. If selective neck dissection is not found to be therapeutic, its use leads to over-reliance on other therapeutic treatment such as postoperative radiotherapy, depriving the patient of a potential useful treatment modality in cases of locoregional recurrence.     

下咽癌颈淋巴结转移的颈侧清扫探讨

目的 为了探讨颈侧清扫可否应用于临床Ｎ＋的下咽癌的颈部治疗。方法 对９３例下咽部颈清扫标本的转移性淋巴结在颈部的分布进行了回顾性分析。结果 颌下淋巴结转移占３．２％。Ｎ０,Ｎ１,Ｎ２ａ和Ｎ２ｂ～Ｎ３的颈后三角淋巴结转移率分别为：５．９％,７．０％,３７．５％和３６．０％。病理证实仅有颌下淋巴结转移或上、中颈深淋巴结转移,而无下颈深淋巴结转移时,颈后三角淋巴结转移率为４．０％,有下颈深淋巴结转移时,     

Management of contralateral N0 neck in tonsillar squamous cell carcinoma

OBJECTIVES: It is well established that tonsillar squamous cell carcinomas have a high probability of disseminating to the neck. An ipsilateral neck treatment is mandatory during initial treatment of stages II to IV tonsillar carcinomas. However, as of yet, no consensus exists whether to perform elective contralateral neck management. MATERIALS AND METHODS: A retrospective analysis of 43 N0-3 tonsillar cancer patients with contralateral clinically negative necks from 1992 to 2002 was performed. All patients had a contralateral elective neck dissection. Surgical treatment was followed by postoperative radiotherapy in 33 patients. The follow-up period ranged from 2 to 120 (mean 38) months. The Kaplan-Meier method and log-rank test were used to calculate the disease-specific survival rates and prognostic significance of contralateral occult lymph node metastasis. RESULTS: Clinically negative, but pathologically positive, contralateral lymph nodes occurred in 16% (7 of 43). Of the 33 cases with an ipsilateral node positive neck, contralateral occult lymph node metastases developed in 21% (7 of 33), in contrast with 0% in ipsilateral N0 necks. On the basis of the clinical staging of the tumor, 5% (1 of 22) of the cases showed lymph node metastases in T2 tumors, 36% (5 of 14) in T3, and 25% (1 of 4) in T4. None of the T1 tumors (3 cases) had pathologically positive lymph nodes (T1 + T2 vs. T3 + T4, P < .05). Patients with no evidence of contralateral nodal cancer had significantly improved disease-specific survival over patients with any pathologically positive nodes (5 year disease-specific survival rate 92% vs. 28%, P = < .05). CONCLUSION: The risk of contralateral occult neck involvement in above T3 staged tonsillar squamous cell carcinomas with unilateral metastases was high (approximately 21%), and patients who present with a contralateral metastatic neck have a worse prognosis than those who are staged as N0. Therefore, we advocate an elective contralateral neck treatment in tonsillar squamous cell carcinoma patients with ipsilateral node metastases.     

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.     

Clinical pathology of hypopharyngeal cancer--comparison between TN and pTN]

Seventy patients with the hypopharyngeal cancer who underwent pharyngolaryngoesophagectomy with bilateral neck dissection between 1978 and 1990 were examined retrospectively to compare TN and pTN in these patients and clarify the clinical pathology of the hypopharyngeal cancer. Among the 70 cases of hypopharyngeal cancer, there were 46 cases of piriformis sinus cancer (PSC) and 24 cases of postcricoid cancer (PCC). The pathological diagnosis of all these cases was squamous cell carcinoma (SCC). The following results were obtained: 1. Invasion of the thyroid gland was seen in 8 cases of PCC (33.3%) and 6 cases of PSC (13.0%). The thyroid gland can be preserved in PSC, whereas its removal is indicated in PCC. 2. Twenty-nine cases of N0 necks proved to be pN0-2b in 27 cases (93.1%) which may be controlled by homolateral neck dissection, and pN2c in 2 cases (6.9%), which requires bilateral neck dissection. On the other hand, 29 cases of N1-2b necks which represent one-sided neck metastasis were pN0-2b in 15 cases (51.7%) and pN2c in 14 cases (48.3%). These results demonstrate that N0 necks can, in the majority of cases, be controlled by homolateral neck dissection alone but that N1-2b necks require bilateral neck dissection. 3. Occult neck metastases were observed in PCC more often than in PSC, because paratracheal metastases of PCC were difficult to expose before surgery. 4. Pathological neck metastases of both PSC and PCC were most commonly situated in the superior and middle internal jugular nodes. Paratracheal metastases of PCC was found pathologically in 10 cases (41.7%). Paratracheal nodes must be dissected meticulously during the resection of PCC.(ABSTRACT TRUNCATED AT 250 WORDS)     

Management of contralateral N0 neck in pyriform sinus carcinoma

OBJECTIVE: The hypopharynx has a rich lymphatic network that places patients with tumors of the hypopharynx at high risk for early dissemination of the disease into the cervical lymphatics. Therefore, ipsilateral elective neck dissection of clinically N0 neck in lateralized lesions of hypopharyngeal squamous cell carcinomas (SCCs) is widely accepted as a standard treatment. However, the management of the contralateral N0 neck is still controversial. The aim of this study was to evaluate the incidence and predictive factors of contralateral occult lymph node metastasis in pyriform sinus SCC. MATERIALS AND METHODS: We performed a retrospective analysis of 43 patients with N0 to 3 pyriform sinus SCC with contralateral clinically node-negative necks who had also received contralateral elective neck dissections from 1994 to 2003. Surgical treatment was followed by postoperative radiotherapy in 41 patients. The follow-up period ranged from 4 to 135 months (mean, 40 months). The Kaplan-Meier method and log-rank test were used to calculate the disease-specific survival rates and prognostic significance of contralateral occult lymph node metastasis. RESULTS: Contralateral occult lymph node metastases occurred in 16% (seven of 43) of the subjects. Twenty-six percent of the 27 subjects with clinically node-positive ipsilateral neck developed contralateral occult lymph node metastases, whereas 0% of the 16 subjects with N0 ipsilateral necks (P=.035) developed the disease. Moreover, in cases with primary site extension across the midline, the rate of contralateral occult neck metastasis was significantly higher (P=.010). However, there were no statistically significant differences in age, sex, early versus advanced T stage, number of ipsilateral positive nodes, lymph nodes with extracapsular spread, primary subsite of medial versus lateral pyriform sinus, pyriform sinus apex involvement, and growth type. Patients with no evidence of contralateral nodal cancer had significantly improved disease-specific survival over patients with any pathologically positive nodes (5-year disease-specific survival rate, 66% vs. 33%, P<.05). CONCLUSION: The patients with pyriform sinus SCC with clinically ipsilateral N+ neck and/or extension across the midline are at greater risk for contralateral occult neck metastases. Furthermore, patients who present with a contralateral metastatic neck have a worse prognosis than those staged as N0. Therefore, we advocate bilateral neck treatment in patients with pyriform sinus SCC with clinically ipsilateral node metastases and/or extension across the midline.     

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.     

Strategy of neck dissection in parotid cancer

We conducted definitive surgery on 45 patients with untreated primary parotid cancer from 1975 to 1995, and evaluated methods of neck dissection and results of treatment. All 14 with clinical neck lymph node metastasis underwent ipsilateral radical neck dissection and only 1 developed neck lymph node recurrence at the peripheral dissected site. Of 31 patients without clinical neck lymph node metastasis, 27 of 19 of 36 with high-grade malignancy and 12 of 24 with T3 or T4 did not undergo prophylactic neck dissection and developed latent neck lymph node metastasis in 2 cases (7.4%). Whereas in most cases we achieved good control of the primary site but neck lymph node recurrences occurred, recurrent sites were observed all around the ipsilateral neck and prognosis were very poor if neck dissection was conducted as secondary treatment. Although histopathological diagnosis was considered feasible for predicting occult neck lymph node metastasis, correct diagnostic with fine needle aspiration cytology revealed only 21.8%. Pathological positive lymph nodes in 15 patients who underwent neck dissection were detected all over (level I to V) the ipsilateral neck and the recurrent positive rate at level II was 100%. Based on the above results, we conclude that (1) in cases with neck lymph node metastasis in preoperative evaluation, ipsilateral radical neck dissection is mandated, and (2) in cases without neck lymph node metastasis, prophylactic neck dissection is not usually needed. When pathological results of frozen section from intraoperative jugulodigastric nodal sampling are positive, ipsilateral radical neck dissection is mandated.     

下咽癌颈淋巴结转移的临床病理学特点及其对预后的影响

目的探讨影响下咽癌颈淋巴结转移的临床病理因素和颈淋巴结转移对预后的影响。方法采用X^2检验和Logistic回归分析，对98例下咽癌患者的临床病理学因素与颈淋巴结转移的关系进行回顾性研究。并对颈淋巴结转移状态、转移颈淋巴结大小、转移颈淋巴结数目、转移颈淋巴结累及区域数、转移颈淋巴结最低受累区域等淋巴结病理学因素对生存率的影响，进行Cox回归分析。结果下咽癌患者5年生存率为28．6％。单因素和多因素分析均证实，肿瘤生长方式、肿瘤大小与发生颈淋巴结转移关系密切。而肿瘤突破基底膜达黏膜下层后对下咽癌颈淋巴结转移发生率不再产生进一步影响。Cox回归分析表明，临床N分期、颈淋巴结转移状态、转移颈淋巴结大小、转移颈淋巴结最低受累区域因素影响患者生存率，特别是转移颈淋巴结大小、转移颈淋巴结最低受累区域因素与下咽癌患者生存率明显相关。结论下咽癌颈淋巴结转移是影响患者预后的重要因素，预测下咽癌颈淋巴结，对其作出早期正确诊断，并对影响预后的淋巴结因素采取相应治疗措施是提高下咽癌治疗效果的关键。     

Incidence and significance of clinically unsuspected thyroid tissue in lymph nodes found during neck dissection in head and neck carcinoma patients

OBJECTIVES/HYPOTHESIS: The objectives were to quantify the incidence of clinically unsuspected thyroid tissue in cervical lymph nodes encountered during neck dissection in patients with head and neck carcinoma, to describe the location and histological aspect of these inclusions, and to assess their clinical significance. STUDY DESIGN: Retrospective study. METHODS: The histological records of 1123 neck dissections in 752 patients with head and neck carcinoma were reviewed. In cases with thyroid inclusions, the pathological diagnosis was reviewed and an immunohistochemical study against thyroglobulin and calcitonin was carried out. RESULTS: Clinically unsuspected thyroid tissue was found in lymph nodes in 11 of the 752 patients with head and neck carcinoma treated with neck dissection. In five cases, the thyroid inclusion was compatible with a metastases of an occult papillary thyroid carcinoma. In the other six cases, a collection of thyroid follicles without malignant characteristics was found beneath the lymph node capsule. These latter cases were considered benign thyroid inclusions. A thyroidectomy was performed in three of the patients with lymph node metastases of the papillary carcinoma. An occult papillary carcinoma was found in only one case. The other two patients had been treated previously with radiotherapy for an early-stage glottic carcinoma. Immunohistochemical study did not find calcitonin-positive cells within the benign thyroid inclusions. After a follow-up period ranging from 1.2 to 8.2 years, no patient had any kind of local, regional, or distant relapse related to the thyroid disease. CONCLUSION: The incidence of unsuspected thyroid tissue in lymph nodes of patients with head and neck carcinoma treated with neck dissection was 1.5%. Both lymph node metastases of a papillary carcinoma and benign thyroid inclusions were found. The study results suggest that the incidental finding of thyroid tissue in the lymph nodes during a neck dissection in patients with head and neck carcinoma does not necessarily indicate the need for aggressive therapy.     

Evaluation and development of a predictive model for ultrasound-guided investigation of neck metastases

Ultrasound investigations for the correct identification of lymph node metastases depend on the experience and qualifications of the investigator; thus, model that provides better preoperative evaluation is desired. Data from 290 patients with an upcoming neck dissection were analyzed to compare the preoperative ultrasound assessment of neck metastases with the pathologically proven postoperative neck status. In total, 364 data sets with 200 malignant and 164 benign lymph nodes were explored. The minimal and maximal transverse diameters and their ratio were shown to be especially good parameters for sensitivity, whereas the echostructure and the presence of a hilum were good for specificity. A model incorporating the evaluated markers is presented. The model provides better judgement of neck lymph nodes in a more objective manner. Using logistic regression, five parameters were identified to predict metastases.     

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     

采用改良L型切口行甲状腺癌颈清扫术

目的：探索更加美观隐蔽的甲状腺癌颈清扫术手术切口。方法将2009年1月～2012年12月在我院接受颈清扫术的72例甲状腺癌颈淋巴结转移患者采用改良L型切口进行手术。其中22例患者行甲状腺全切术＋患侧Ⅰ～Ⅵ区颈清扫术;另50例患者单纯行颈清扫术,清扫范围主要为Ⅰ～Ⅴ区淋巴结。颈清扫切口行于斜方肌表面发际前缘自乳突尖后向下行至锁骨上约1.5cm处循皮纹横行向前至颈前中部或与原甲状腺手术切口相连。其中根治性颈清扫术4例,功能性颈清扫术68例。结果72例患者共行83侧颈清扫术,均行改良L型切口。手术过程均顺利,术野暴露满意,手术时间为128～196min,平均145.3±23.8min。共11例患者出现术后并发症,其中颈部积液6例、副神经损伤3例、乳糜漏2例。无皮瓣坏死、切口感染等并发症发生。术后患者颈部切口瘢痕隐蔽,外观影响小。术后随访6个月～4年,淋巴结复发率为0.0%。结论采用改良L型切口行颈清扫术暴露满意,手术并发症少,术后切口隐蔽,是甲状腺癌颈清扫术一种较为理想的手术入路。     

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。     

Lymph node metastases in the neck of unknown primary tumor

BACKGROUND: Cervical lymph nodes represent the most frequent manifestation of lymph node metastases of unknown primary. Nearly 3% of all malignant ENT-tumors are cervical lymph nodes metastases of unknown primary. This disease is a challenge for clinical working physician in diagnosis and therapy. MATERIAL AND METHOD: In a retrospective study we investigated 99 patients with the diagnosis cervical lymph node metastases of unknown primary, which were treated and observed in our department between 1975 and 1995. Within this group we observed the course of 83 patients completely. RESULTS AND CONCLUSIONS: The tumor-dependent 5 year-survival-rate was 11%. This is very low, but similar to the literature. 40% of patients, that were operated on neck dissection with or without postoperative irradiation survived tumor-dependent 5 years. In 42 cases we could find a primary tumor. 14 of these primaries were located in the upper aero-digestive-tract, 28 in other regions of the body. The identification of the primary did not improve the prognosis of the patients. A good prognosis was associated with further occult primary, location of the lymph nodes in the upper or middle level of the neck or parotid region and a histology of squamous cell or undifferentiated carcinoma. Signs of poor prognosis were metastasis in the supraclavicular region, of adenocarcinoma and inoperability of the lymph node. The combination therapy of neck dissection and irradiation proved to be best. The extended field radiation of the complete upper aero-digestive-tract did not cause a improvement of tumor-dependent 5-year-survival. We discovered a primary in 5 of 27 patients in this group within the irradiated area. In conclusion extended field radiation must be discussed critically for patients with lymph node metastasis of unknown primary.