Lymph node‐positive head and neck cancer treated with definitive radiotherapy

BACKGROUND: The purpose was to determine if postradiotherapy (RT) neck dissection can be limited to the neck levels of residual adenopathy on post-RT computed tomography (CT). METHODS: In all, 274 patients with lymph node-positive head and neck squamous cell carcinoma were treated with definitive RT. All patients had a contrast-enhanced CT performed 4 weeks after completing RT to evaluate tumor response. Two hundred eleven heminecks were dissected, either planned pre-RT or because of residual adenopathy on post-RT CT. CT images were reviewed to determine the presence and location of residual adenopathy. Radiographic complete response (rCR) was defined as lymph node size < or =1.5 cm and normal radiographic morphology (no filling defects or calcifications). For each neck level the CT findings were correlated with neck dissection pathology. RESULTS: Correlation of CT nodal response with neck dissection pathology revealed the following negative predictive values of rCR: level I, 100%; level II, 95%; level III, 98%; level IV, 96%; and level V, 96%. A subset analysis was performed on 61 neck levels with initially positive lymph nodes that completely responded to RT that were in a hemineck with residual lymphadenopathy elsewhere in the neck. Correlation of nodal response on CT to pathology indicated a negative predictive value of an rCR of 95% for this high-risk scenario. In 71 heminecks that underwent a selective neck dissection (defined as dissection of less than levels I-V) the 5-year neck control rate was 100%. CONCLUSIONS: rCR on post-RT CT has a negative predictive value of > or =95% for each neck level. This suggests that limiting neck dissection based on post-RT CT is safe.     

Is elective neck treatment indicated for T2N0 squamous cell carcinoma of the glottic larynx?

This is an analysis of 98 patients with T2N0 squamous cell carcinoma of the glottic larynx treated with radiation therapy. Patients received irradiation to the primary lesion alone; the neck was not treated electively. All patients had at least 2 years of follow-up; patients who died within 2 years from treatment with the neck continuously disease-free were excluded from the analysis. The rate of control of neck disease following irradiation was as follows: primary site continuously disease-free, 73/75 (97%); primary tumor recurrence, 18/23 (78%). Salvage treatment was successful in 4 of 7 patients who developed recurrent disease in the neck. We conclude that elective treatment to the clinically negative neck is not indicated for patients with T2N0 squamous cell carcinoma of the glottic larynx. However, patients who develop a local recurrence following irradiation have a substantial risk of harboring disease in the neck and should undergo a neck dissection in conjunction with the surgical procedure selected to resect the recurrent disease at the primary site.     

Sentinel lymph node biopsy as guidance for central neck dissection in patients with papillary thyroid carcinoma

BACKGROUND.

Occult lymph node metastasis of papillary thyroid carcinoma (PTC) can be detected by sentinel lymph node (SLN) biopsy, but studies in larger patient cohorts undergoing complete central neck dissection may be required to assess the diagnostic accuracy of SLN. Therefore, the authors prospectively assessed the usefulness of SLN biopsy for the detection of central lymph node metastasis in patients with differentiated PTC who had no suspicious cervical lymphadenopathy.

METHODS.

After peritumoral injection of methylene blue, SLN biopsy was performed in 50 patients with newly diagnosed PTC who had no palpable or ultrasound (US)‐detected lymph node involvement. After SLN biopsy, all patients underwent total thyroidectomy and central neck dissection. The diagnostic accuracy of intraoperative SLN sampling was calculated by comparison with the final pathologic diagnosis.

RESULTS.

SLNs were identified in 46 of 50 patients (92%); of these, 14 SLNs were positive and 32 SLNs were negative on intraoperative frozen sections. One patient had a positive SLN in the jugular region and subsequently underwent modified radical neck dissection. Final pathologic examination revealed that 18 patients (36%), including 4 who had negative SLNs, had central lymph node metastasis. Thus, the sensitivity, specificity, accuracy, and positive and negative predictive values of SLN biopsy were 77.8%, 100%, 92%, 100%, and 88.9%, respectively. Temporary and permanent hypocalcemia developed in 19 patients and 1 patient, respectively. There were no direct complications of SLN sampling.

CONCLUSIONS.

SLN biopsy in patients with PTC without gross clinical or US lymph node involvement was able to detect occult metastasis with high accuracy and may have the potential to select patients who require central neck dissection. Cancer 2008. © 2008 American Cancer Society.     

Long-term regional control after radiation therapy and neck dissection for base of tongue carcinoma

: Minimal literature exists with 10-year data on neck control in advanced head and neck cancer. The purpose of this study is to determine long-term regional control for base of tongue carcinoma patients treated with primary radiation therapy plus neck dissection.

: Between 1981–1996, primary radiation therapy was used to treat 68 patients with squamous cell carcinoma of the base of tongue. Neck dissection was added for those who presented with palpable lymph node metastases. The T-stage distribution was T1, 17; T2, 32; T3, 17; and T4, 2. The N-stage distribution was N0, 10; N1, 24; N2a, 6; N2b, 11, N2c, 8; N3, 7; and Nx, 2. Ages ranged from 35 to 77 (median 55 years) among the 59 males and nine females. Therapy generally consisted of initial external beam irradiation to the primary site (54 Gy) and neck (50 Gy). Clinically positive necks were boosted to 60 Gy with external beam irradiation. Three weeks later, the base of tongue was boosted with an Ir-192 interstitial implant (20–30 Gy). A neck dissection was done at the same anesthesia for those who presented with clinically positive necks, even if a complete clinical neck response was achieved with external beam irradiation. Neoadjuvant cisplatin-based chemotherapy was administered to nine patients who would have required a total laryngectomy if their primary tumors had been surgically managed. The median follow-up was 36 months with a ranged from 1 to 151 months. Eleven patients were followed for over 8 years. No patients were lost to follow-up.

: Actuarial 5- and 10-year neck control was 96% overall, 86% after radiation alone, and 100 after radiation plus neck dissection. Pathologically negative neck specimens were observed in 70% of necks dissected after external beam irradiation. The remaining 30% of dissected necks were pathologically positive. These specimens contained multiple positive nodes in 83% despite a 56% overall complete clinical neck response rate to irradiation. Regional failure occurred in only two patients, neither of whom underwent adjuvant neck dissection. Symptomatic neck fibrosis (RTOG grade 3) was not observed. Actuarial 5- and 10-year local control was 88% and 88%, disease-free survival was 80% and 67%, and overall survival was 86% and 52%.

: For base of tongue cancer, most patients can obtain long-term regional control with no severe complications after definitive radiation therapy, plus neck dissection for those who present with lymphadenopathy. Complete clinical regression of palpable neck metastases after irradiation poorly correlates with pathologic outcome. Our current policy is to include neck dissection at the time of implantation for patients who present with palpable neck metastases. We realize that this therapeutic approach may overtreat some patients, but we are reluctant to change our policy in light of these excellent outcomes.     

Therapeutic neck dissection in head and neck melanoma patients: Comparing extent of surgery and clinical outcome in two cohorts

BackgroundThe extent of surgical management of regional lymph nodes in the treatment of cutaneous head and neck melanoma on and anterior to O'Brien's watershed line is controversial. By comparing patients' cohorts of two separate melanoma expert centers we investigate the effectiveness of comprehensive versus (super-) selective neck dissection approach.MethodsSixty patients with macroscopic (palpable) neck node metastases (N2b) from anterior scalp and face melanoma were retrospectively studied. Forty therapeutic modified radical neck dissections (MRND; levels I–V) combined with elective parotidectomy from The Netherlands Cancer Institute (NCI) were compared with 16 (super-) selective neck dissections [(S)SND; 3–4 levels] and 4 solely MRNDs from Erasmus Medical Center (EMC). Cohorts were analyzed for site of recurrence, overall survival (OS), melanoma-specific survival (MSS), and disease-free survival (DFS).ResultsClinical characteristics of patients were equal in both groups. In the NCI cohort 62.5% (n = 25) of patients recurred versus 65% (n = 13) in the EMC cohort. None of the NCI recurrences affected the parotid gland in contrast to 3 patients in the EMC group. Survival characteristics were not different between the two groups: OS (p = 0.56), MSS (p = 0.98), DFS (p = 0.92).ConclusionThis study does not support to continue the practice of routine elective parotidectomy and MRND in melanoma patients undergoing a lymph node dissection for macroscopic (palpable) nodal disease and justifies (S)SND.     

Squamous cell carcinoma of the head and neck treated with radiation therapy: the role of neck dissection for clinically positive neck nodes

This is an analysis of 161 patients with squamous cell carcinoma of the head and neck treated with irradiation to the primary site and neck followed by a neck dissection(s) for clinically positive neck nodes. Patients were treated between October 1964 and December 1982; there was a minimum 2-year follow-up. Fifty-two patients were deleted from analysis of neck disease control because they died of intercurrent disease or cancer less than 2 years from treatment with the neck continuously disease-free. All patients are included in the analysis of complications. Neck disease control rate was the same for radiation plus neck dissection or radiation therapy alone for solitary nodes less than 3 cm. As the size and number of nodes increased, there was a higher rate of neck disease control for combined treatment as compared with irradiation alone. The neck disease control rate, size for size, was lower for patients with fixed nodes and for those with residual tumor in the pathologic specimen. There was no difference in neck disease control as a function of the interval between irradiation and neck dissection. For nodes less than or equal to 6 cm, a minimum node dose of 5000 rad appeared to be sufficient for control, whereas for nodes greater than 6 cm, at least 6000 rad appeared to be required for optimal control. Fixed nodes required a higher dose compared to mobile masses. The incidence of postoperative complications was increased with maximum subcutaneous doses of greater than or equal to 6000 rad. There was also an increased incidence of postoperative complications for patients undergoing simultaneous, as compared with staged, bilateral neck dissection.     

The role of selective neck dissection (I-III) in the treatment of node negative (N0) neck in oral cancer

It is now possible to limit the extent of selective neck dissection for mucosal squamous cell carcinoma of the head and neck by sparing selected lymphatic levels thereby reducing the morbidity. This has been brought about by our improved understanding of the metastasis behavior of these cancers. Studies have demonstrated similar rates of neck recurrences and survival after selective neck dissection compared to modified radical neck dissection. The purpose of this study was to evaluate the efficacy of selective neck dissection (SND) in managing the N0 neck in oral cavity carcinomas. A retrospective analysis of Squamous cell carcinoma of oral cavity with N0 neck from 1998 to 2004 was performed. Statistical analysis was done using SPSS software. The chi-square test was used to compare the various proportions. The overall and disease-free survival were estimated using the Kaplan–Meier method and statistical significant difference in survival was tested by log rank test. Out of the 219 cases, 84% were in the early stage and 16% were in the late stages. Seventy two percent of the patients had primary tumors in the anterior two-thirds of the tongue. One hundred and sixty one patients were pathologically node negative. There was no statistically significant difference in the regional recurrence between the pN0 and pN+ patients. There was no difference in the regional recurrence inside and outside the surgical field. The pathological node positive patients had a worse disease-free survival (DFS) compared to the node negative patients, and the patients with nodal recurrence had a significantly worse DFS compared to patients without nodal recurrence. SND (I–III) is a sound and effective procedure in the management of clinically negative neck in squamous cell carcinoma of the oral cavity. Clinically N0 neck but pathologically N+ neck requires adjuvant radiation therapy. It probably has a therapeutic role in the selected cases of squamous cell carcinoma of the oral cavity with N1 neck, and in these cases an extension of dissection to levels IV and V is beneficial.     

Management of the lateral neck in well differentiated thyroid cancer

Lateral neck lymph node metastases in well differentiated thyroid cancer are common, ranging from 30% to 60%, with the majority of these foci identifiable only as microscopic deposits. A skilled ultrasound evaluation of the lymph nodes in the lateral neck is recommended for all patients presenting with newly diagnosed thyroid cancer undergoing surgical management. Ultrasound guided fine needle aspiration biopsy may be used to cytologically confirm suspected lateral neck nodal metastases prior to surgery. For patients with large volume nodal disease, extranodal extension, or multiple nodal metastases, computed tomography (CT) scan of the neck with contrast is an important additional imaging modality to accurately localize disease prior to surgery. Primary surgical management for lateral neck disease typically includes lateral neck dissection in conjunction with total thyroidectomy. Postoperative adjuvant radioactive iodine is typically recommended for patients with clinically evident nodal metastases, or for those with over 5 micrometastatic nodes. In the recurrent or persisting disease setting, complete surgical resection of local and regional disease remains the main treatment approach. However, sub-centimeter nodal disease may take an indolent course, and active surveillance may be a reasonable approach in selected clinical circumstances. Conversely, external beam radiation therapy (EBRT) may be considered for scenarios with unresectable disease, or microscopic residual disease following surgery in a clinically unfavorable setting. Two multi-kinase inhibitors (sorafenib and lenvatinib) are now FDA approved for treatment of RAI refractory thyroid cancer and now play an important role in the management of progressive, metastatic and surgically incurable disease.     

Hyperfractionation for head and neck cancer

Between March 1978 and April 1984, 144 patients with 148 moderately advanced to advanced primary squamous cell carcinomas of the head and neck received treatment with curative intent with twice-a-day irradiation (120 cGy/fraction, 4-6 hour interfraction interval). Eighty-eight percent of the patients had AJCC Stage III-IV cancers. One hundred and thirty-two patients received irradiation alone to the primary site with or without radical neck dissection, with surgery reserved for salvage. The total doses administered were 7440-7920 cGy in the majority of instances. In 19 patients with oropharyngeal lesions, a 1000-1500 cGy radium needle boost was added after the basic dose. Twelve patients received preoperative irradiation (5040-6000 cGy) followed by primary resection and radical neck dissection. Local control results following irradiation alone to total doses of greater than 7000 cGy with minimum 2-year follow-up were 25/31 (81%), 38/50 (76%), and 5/25 (20%) for T2, T3, and T4 cancers, respectively. Local control rates did not correlate well with total dose. Local control following preoperative irradiation plus primary resection was obtained in 4 of 5 T3 and 2 of 3 T4 primary lesions. The 5-year actuarial rates of neck control were 100% for N0 (45 patients), 90% for N1 (25 patients), 77% for N2 (23 patients), 50% for N3A (9 patients), and 70% for N3B (42 patients). The 5-year actuarial rates of continuous disease control above the clavicles were 73% for Stage III, 64% for Stage IVA, and 32% for Stage IVB. The actuarial 4-year rate of continuous disease control above the clavicles was 78% for Stage II. For patients whose disease was controlled above the clavicles, distant metastases developed in 4% of patients with Stage II-III disease and in 18% of patients with Stage IV disease. Radiation complications following irradiation alone to the primary site correlated with total dose. Complications of planned neck dissection(s) were acceptable. Complications of salvage surgery at the primary site were similar to those seen in patients treated once a day. The actuarial 5-year survival rates, according to modified AJCC stage, were 59% for Stage III, 37% for Stage IVA, and 23% for Stage IVB. The actuarial 4-year survival rate for Stage II was 69%. Compared to historical control groups treated with once-a-day, continuous-course irradiation at our institution, twice-a-day treatment has produced local control results that are higher by 10-15 percentage points.     

The accuracy of head and neck carcinoma sentinel lymph node biopsy in the clinically N0 neck

BACKGROUND: Sentinel lymph node (SLN) biopsy originally was described as a means of identifying lymph node metastases in malignant melanoma and breast carcinoma. The use of SLN biopsy in patients with oral and oropharyngeal squamous cell carcinoma and clinically N0 necks was investigated to determine whether the pathology of the SLN reflected that of the neck. METHODS: Patients undergoing elective neck dissections for head and neck squamous cell carcinoma accessible to injection were enrolled into our study. Sentinel lymph node biopsy was performed after blue dye and radiocolloid injection. Preoperative lymphoscintigraphy and the perioperative use of a gamma probe identified radioactive SLNs; visualization of blue stained lymphatics identified blue SLNs. A neck dissection completed the surgical procedure, and the pathology of the SLN was compared with that of the remaining neck dissection. RESULTS: Sentinel lymph node biopsy was performed on 40 cases with clinically N0 necks. Twenty were pathologically clear of tumor and 20 contained subclinical metastases. SLNs were found in 17 necks with pathologic disease and contained metastases in 16. The sentinel lymph node was the only lymph node containing tumor in 12 of 16. CONCLUSIONS: The SLN, in head and neck carcinomas accessible to injection without anesthesia, is an accurate reflector of the status of the regional lymph nodes, when found in patients with early tumors. Sentinel lymph nodes may be found in clinically unpredictable sites, and SLN biopsy may aid in identifying the clinically N0 patient with early lymph node disease. If SLNs cannot be located in the neck, an elective lymph node dissection should be considered.     

头颈肿瘤颈淋巴结清扫的手术选择

作为治疗与预防头颈恶性肿瘤颈部淋巴结转移的首要方法,颈淋巴结清扫术经过一百多年的发展,已经日趋规范合理。但是,由于头颈恶性肿瘤的种种特殊性导致其颈部淋巴结转移有较大的不确定性,头颈外科医师在施行原发灶手术时,往往会面临是否需要行颈淋巴结清扫术、如何确定颈淋巴结清扫范围的困惑。根据常见头颈恶性肿瘤的颈淋巴结转移特性及手术对患者的创伤程度,梳理出当前较为规范的颈淋巴结清扫术术式,为头颈外科医师提供参考,有助于改善头颈恶性肿瘤颈部淋巴结治疗和预防的总体效果。     

Value of Postoperative Radiation Therapy for Regional Control after Dissection in Head and Neck Squamous Cell Carcinoma Cases

Objective: We aimed to define clinicopathologic risk factors associated with regional recurrence (RR) andthus the effectiveness of postoperative radiotherapy (PORT) for neck control for head and neck squamous cellcarcinomas (HNSCCs) with differing cervical lymph node status. Methods: A retrospective study was performedin 196 HNSCC patients with pathologically positive neck node (N+) to evaluate the high-risk factors for RR andto define the role of PORT in control after neck dissection and postoperative radiotherapy (PORT). Results:Overall, the RR rate after neck dissection and PORT was 29%. Extracapsular spread (ECS) was confirmedto be the only independent risk factor for RR. There were no significant risk factors associated with RR in theECS- group. The 5-year disease-specific survival rate was 45%, which descended to 10% with the emergence ofRR. Conclusions: ECS remains a determined risk factor for RR after neck dissection and PORT in patients withN+. PORT alone is not adequate for preventing RR in the neck with ECS after neck dissection. More intensivepostoperative adjuvant therapies, especially combined chemotherapy and radiotherapy, are needed to preventregional failure in HNSCC patients with ECS.     

Necessity for adjuvant neck dissection in setting of concurrent chemoradiation for advanced head-and-neck cancer

PURPOSE: Neck dissection has traditionally played an important role in the treatment of patients with squamous cell carcinoma of the head and neck who present with regionally advanced neck disease (N2-N3). Radiotherapy and concurrent chemotherapy improves overall survival in advanced head-and-neck cancer compared with radiotherapy alone. The necessity for postchemoradiation neck dissection is controversial. The intent of this report was to define the value of neck dissection in this patient population better. METHODS AND MATERIALS: Patients with locally advanced squamous carcinoma of the head and neck who also presented with nodal disease and underwent hyperfractionated radiotherapy and concurrent cisplatin/5-fluorouracil chemotherapy constituted the study population. Adjuvant modified neck dissection (MND) was planned 6 to 8 weeks after completion of chemoradiation in those patients who had a biopsy-proven pathologically complete response at the primary tumor site, irrespective of the clinical/radiographic neck response. A cohort of patients underwent electrode assessment of tumor oxygenation. Pathologic findings from the MND were used to compute the negative and positive predictive values and overall accuracy of the clinical/radiographic response (cCR). Regional control, failure-free survival, and survival were compared according to whether patients actually underwent MND. RESULTS: A total of 154 patients received concurrent chemoradiation. Of these, 108 presented with nodal disease: N1, n = 30; and N2-N3, n = 78. MND was performed in 65 (60%) of 108 patients, including 13 (43%) of 30 with Stage N1 and 52 (66%) of 78 with Stage N2-N3. For N1 patients, the negative predictive value of a cCR, positive predictive value of less than a cCR, and the overall accuracy for clinical response was 92%, 100%, and 92%, respectively. For N2-N3 patients, the corresponding values were 74%, 44%, and 60%. Patients with poorly oxygenated tumors were more likely to have residual disease at MND. The median follow-up was 4 years. The 4-year disease-free survival rate was 70% for N1 patients, irrespective of the clinical response or whether MND was performed. The 4-year disease-free survival rate was 75% for N2-N3 patients who had a cCR and underwent MND vs. 53% for patients who had a cCR but did not undergo MND (p = 0.08). The 4-year overall survival rate was 77% vs. 50% for these two groups of patients (p = 0.04). CONCLUSION: The clinical and pathologic responses in the neck correlated poorly with one another for patients with N2-N3 neck disease undergoing concurrent chemoradiation for advanced head-and-neck cancer. MND still appears to confer a disease-free survival and overall survival advantage with acceptably low morbidity. Tumor oxygenation assessment may be useful in selecting patients who are especially prone to have residual disease. Better tools need to be developed to determine prospectively whether this procedure is required for individual patients.     

Elective neck irradiation in the treatment of cancer of the oral tongue

A total of 69 patients with squamous cell carcinoma of the oral tongue Stages T1-2-3 N0 were treated between 1952 and 1982 at one cancer center in Montevideo, Uruguay. Of 52 patients with the primary disease controlled, 2 had elective cervical lymph node dissection, and were therefore excluded from the study, 25 were treated with elective neck irradiation, and 25 were followed without irradiation to the neck. In the untreated group, 40% developed neck node metastases, while this was observed only in 20% of the group receiving elective neck irradiation, but only 4% recurred in the elective irradiated areas of the neck (p: 0.0028). The survival was the same for each group (5-year absolute survival with NED 67% for the neck irradiation group and 64% for the unirradiated group). From this retrospective study, we conclude that elective neck irradiation in carcinoma of the oral tongue decreases the incidence of neck metastases but an improvement in survival of these patients was not demonstrated.     

Surgical management of the neck in squamous cell carcinoma of the floor of the mouth

Nodal involvement in squamous cell carcinoma considerably lowers survival rate. Despite its importance, neck management has still not been adequately explored. The Authors have retrospectively reviewed the records of 112 cases. Unilateral N+ were treated with a homolateral therapeutic and a controlateral prophylactic neck dissection; bilateral N+ were treated with a bilateral therapeutic neck dissection. On first observation the majority of cases (66.1%) were T1–2. N+ patients accounted for 45.5%. Among N− patients, 21.3% of occult nodal metastases were observed. The 5-year survival rate was 52.7%. With N+ lesions, a radical neck dissection should be performed; the dissection should be performed bilaterally. With N− lesions a prophylactic modified radical neck dissection is recommended in T2–4 lesions.     

Influence of initial neck node biopsy on the incidence of recurrence in the neck and survival in patients who subsequently undergo curative resectional surgery

During a period of 23 years, 57 patients who had an initial neck node biopsy elsewhere, with the diagnosis of metastatic squamous cell carcinoma established, underwent curative resection by our department after the site of head and neck primary was found. Ten patients free of disease died of other causes, leaving 47 patients who were eligible for at least 3 years of follow-up. Nineteen patients are aliye after 3 or more years. The incidence of recurrence in the neck was 57% (27/47). The 3-year survival in this group of Stage III was 40% (19/47) and 5-year survival was 34% (16/47). Compared with historical data, it appears from the present study that a previous biopsy of a neck node did not adversely affect the incidence either of neck recurrence or survival when appropriate surgery is performed.     

颈淋巴结阴性鼻咽癌颈部的放射治疗

背景与目的:颈淋巴结阴性鼻咽癌(简称N0鼻咽癌)约占全部鼻咽癌病例的20%～30%,对这部分患者,治疗规范是在照射鼻咽病灶的同时预防照射双上颈部。但有些研究者主张行全颈预防照射。本研究分析和比较上颈部预防照射和全颈预防照射的颈部复发率和生存率的影响,以探讨N0鼻咽癌颈部的放射治疗。方法:选取178例经病理组织学确诊的N0鼻咽癌患者,其中88例接受上颈预防照射(上颈照射组),90例接受全颈预防照射(全颈照射组)。用Kaplan-M eier和log-rank法计算和比较两组生存率,用Cox模型分析影响预后的因素。结果:上颈照射组和全颈照射组的1、3、5年生存率分别为98.9%、90.9%、80.7%和97.8%、80.0%、71.1%(P=0.224);1、3、5年无瘤生存率分别是93.2%、80.7%、77.3%和85.6%、68.9%、64.4%(P=0.163);颈部复发率分别是1.14%和1.08%(P>0.05)。多因素分析显示:性别、T分期和近期疗效是影响N0鼻咽癌预后的独立因素。结论:对于颈淋巴结阴性鼻咽癌患者只需作上颈预防性照射。     

N0期鼻咽癌上半颈预防照射的长期随访结果

背景与目的:对N0期鼻咽癌患者的颈部预防照射,照射范围必须包括全颈还是上半颈,目前还存在争议。本研究的目的是通过回顾性分析评价N0期鼻咽癌半颈照射的合理性。方法:回顾性分析432例N0期鼻咽癌患者半颈预防照射颈部长期控制结果及相关因素。全部患者均接受根治性放疗,鼻咽中位剂量DT70Gy;颈部治疗范围只包括双侧上半颈,治疗中位剂量DT50Gy。Kaplan-Meier法计算相关生存率、颈部复发率,log-rank检验对颈部复发率差异进行分析,Cox比例风险模型进行多因素分析。结果:共有17例患者治疗后发生颈部淋巴结转移,颈部5年控制率96.06%;其中6例患者同时合并鼻咽部复发,11例单纯颈部复发。单纯野内和野外复发率分别为0.93%(4/432)和1.62%(7/432),两者差异无统计学意义(P=0.937)。63例患者有鼻咽复发,有鼻咽复发者的颈部复发率为9.52%(6/63),明显高于无鼻咽复发者的2.98%(11/371),两者差异有统计学意义(P=0.002)。多因素分析显示鼻咽复发是影响颈部控制的独立预后因素。结论:N0期鼻咽癌患者放射治疗后颈部复发率很低,颈部预防照射范围仅包括双上颈是合理的。     

Elective radiotherapy provides regional control for patients with cutaneous melanoma of the head and neck

BACKGROUND: In the current study, the authors assessed the efficacy of elective radiotherapy in providing regional (lymph node) control in patients with cutaneous melanoma of the head and neck who were at high risk for lymph node involvement. Toxicity was also assessed. METHODS: From 1983 to 1998, 157 patients with Stage I or II cutaneous melanoma of the head and neck received elective regional radiotherapy after wide local excision of the primary lesion. None of the patients had received sentinel lymph node biopsy or dissection of the lymph nodes. Their medical records were reviewed retrospectively and analyzed for outcome. RESULTS: The median follow-up for the current review was 68 months (range, 7-185 months). The disease recurred locally in 9 patients, in the neck lymph nodes in 15 patients, and distantly in 57 patients. The actuarial regional control rate was 89% at both 5 years and 10 years. The actuarial disease-specific survival and distant metastasis-free survival rates were 68% and 63%, respectively, at 5 years and 58% and 49%, respectively, at 10 years. Breslow thickness was a significant determinant of disease-specific survival and distant metastasis-free survival rates. At 10 years, 6% of patients had developed a symptomatic treatment-related complication. There were no treatment-related deaths. CONCLUSIONS: The results of the current study confirmed the efficacy and safety of elective regional radiotherapy for patients with cutaneous head and neck melanoma predicted to have a high rate of lymph node involvement. Elective irradiation was a viable alternative to elective lymph node dissection. It may also serve as an alternative to sentinel lymph node biopsy, particularly for patients for whom dissection and systemic therapy are not therapeutic options.     

头颈部肿瘤前哨淋巴结活检及示踪剂应用

前哨淋巴结活检(SLNB)可通过示踪法确定前哨淋巴结(SLN)并进行活检来评估头颈部肿瘤的区域淋巴结转移而指导颈淋巴结清扫术的进行。常用示踪法有染料识别法、放射性核素示踪法或二者联合应用法,常用染料示踪剂有异硫蓝、专利蓝和美蓝3种,常用核素示踪剂为~(99m)Tc。SLNB在乳腺癌研究中应用较广,近年来已应用于头颈部肿瘤的研究中。