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。     

Incidence and location of positive nonsentinel lymph nodes in head and neck melanoma

Background

The complex lymphatic drainage in the head and neck makes sentinel lymph node biopsy (SLNB) for melanomas in this region challenging. This study describes the incidence, and location of additional positive nonsentinel lymph nodes (NSLN) in patients with cutaneous head and neck melanoma following a positive SLNB.

Methods

A retrospective review was performed using a single institution prospective database. Patients with a primary melanoma in the head or neck with a positive cervical SLNB were identified. The lymphadenectomy specimen was divided intraoperatively into lymph node levels I–V, and NSLN status determined for each level.

Results

Of 387 patients with melanoma of the head and neck who underwent cervical SLNB, 54 had a positive SLN identified (14%). Thirty six patients (67%) underwent immediate completion lymph node dissection (CLND) of whom eight patients (22%) had a positive NSLN. The remaining 18 patients (33%) did not undergo CLND and were observed. Half of positive NSLNs (50%) were in the same lymph node level as the SLN and 33% were in an immediately adjacent level; only two patients were found to have NSLNs in non-adjacent levels. The only factor predictive of NSLN involvement was the size of the tumor deposit in the SLN>0.2 mm (p = 0.05). Superficial parotidectomy at CLND revealed metastatic melanoma only in patients with a positive parotid SLN.

Conclusions

A positive NLSN was identified in 22% of patients undergoing CLND after a positive SLNB. The majority of positive NSLNs are found within or immediately adjacent to the nodal level containing the SLN.     

Patterns of failure in patients with cutaneous head and neck melanoma

IntroductionThe incidence of head and neck melanoma is increasing. Various factors influence prognosis.ObjectiveWe sought to investigate the subgroup of patients with head and neck melanoma who fail primary treatment and to define the patterns of failure.MethodsThe database of a tertiary medical center was reviewed for patients diagnosed and surgically treated for cutaneous head and neck melanoma in 1995–2014. Regional disease failure was defined as disease confirmed in positive SLNB at first assessment or at recurrence.ResultsThe cohort included 141 patients followed for a median duration of 6.8 years (range 1–20 years). Median tumor thickness was 2.1 mm (range 0.5–12 mm). Ulceration was documented in 38 patients (26.9%). Sentinel lymph node biopsy (SLNB) was positive in 18 patients (12.8%). Total disease failure rate was 32.6% with similar rates of regional (n = 26, 18.4%) and distal (n = 22, 15.6%) failure. Most patients (86.3%) with systemic recurrence had a negative SNLB as did 6/26 patients (23%) with regional failure. Forty-three patients (30.4%) died during follow-up, half of them (23 patients, 16.3%) of melanoma. On multivariate analysis, Breslow thickness was the only significant predictor of outcome.ConclusionsThe pattern of treatment failure in patients with head and neck melanoma relate predominantly to Breslow thickness. The high false-negative rate of SNLB and the relatively high rate of systemic failures in patients with negative SNLB indicate a low predictive value of this procedure. Efforts to detect systemic disease during follow-up need to be intensified.     

Prediction of non-sentinel node status and outcome in sentinel node-positive melanoma patients

Aims: Sentinel lymph node (SLN) -positive melanoma patients are usually recommended completion lymph node dissection (CLND) with the aim to provide regional disease control and improve survival. Nevertheless, only 20% these patients have additional metastases in non-sentinel lymph nodes (NSLN), indicating that CLND may be unnecessary in the majority of patients. In this retrospective study, we (i) sought to identify clinico-pathological features predicting NSLN status, as well as disease-free (DFS) and -specific (DSS) survival and (ii) evaluated the applicability of previously published algorithms, which were able to define a group of patients at zero-risk for NSLN-metastasis.     

头颈肿瘤功能性颈淋巴结清扫术的适应证及临床根治效果

背景与目的：功能性颈淋巴结清扫术自1967年Bocca提出后,在头颈外科临床中已被推广应用,但对其临床应用适应证及其临床根治效果,国内外头颈外科专家特有不同观点,本研究旨在探索功能性颈淋巴结清扫术临床应用适应证和临床根治效果。方法：对152例次功能性颈淋巴结清扫术病例,利用手术标本病理检查及随诊资料进行分析讨论。结果：152例次功能性颈清扫术,舌鳞癌20例次,喉鳞癌23例次,甲状腺乳头状癌96例次,滤泡状腺癌9例次,髓样癌4例次,舌,喉鳞癌N0,N1,N2病例术后5年复发率分别为12．5％,14．3％,40．0％和20％,16．7％,50．0％,甲状腺乳头状腺癌N1a,N1b病例术后5年复发率分别为：6．5％,7．1％。结论：功能性颈淋巴结清扫术适用于较早期及低度恶性的头颈肿瘤手术治疗,且可获得良好的临床根治效果。     

头颈部肿瘤放疗对腮腺影响的相关研究

 头颈部肿瘤患者放疗过程中,部分腮腺不可避免的被包在计划靶体积（PTV）中,使得此部分腮腺接受与PTV同样剂量的照射。在放疗过程中由于受患者年龄、初始腮腺体积、接受10～40 Gy剂量照射的腮腺体积（V_10-40）、患者体重、体厚及腮腺平均受照剂量等的影响使得放疗中腮腺体积最多可缩小至原体积的50%左右,并向体中线处移动,结果腮腺所受实际照射剂量高于处方剂量,造成腮腺分泌功能降低,发生严重口腔干燥症,大大影响患者日后生活质量。     

Effects of radiotherapy on parotid salivary sialochemistry in head and neck cancer patients

Aim

To determine the effects of high dose irradiation on parotid salivary sodium and pH concentration at subsequent duration of 1.5, 3 and 6 months following radiotherapy.

Materials and methods

Eighty parotid glands of head and neck cancer patients were irradiated with mean dose of 66 Gy. The stimulated parotid flow (PF) was collected by a cannulation of Stenson’s duct followed by analysis of sodium (PF sodium) by Easylyte Sodium/Potassium auto analyzer and pH by litmus narrow band pH paper.

Results

A steep elevation of PF sodium was found in post-RT period after 1.5 months of starting RT followed by gradual increase up to 6 months and pH changed towards acidity.

Conclusions

A high dose of 66 Gy causes irreversible damage to parotid salivary duct system.     

Unilateral big hockey stick incision for neck dissection in head and neck carcinoma

Objective: To investigate for the feasibility and advantages performed by the unilateral big hockey stick incision (BHSI) in head and neck carcinoma. Methods:Neck dissection by using the unilateral big hockey stick incision (BHSI) was performed on 93 patients with head and neck carcinoma. Results: The big hockey stick incision has a cosmetic scar and not scar contraction and is barely visible and easily covered in hair and clothing; sufficient exposure of the operation field; a small area of marginal necrosis was occasionally seen at the apex of the skin flap due to having preoperative radiotherapy. Conclusion: The unilateral big hockey stick incision has adequate surgical access, good healing of skin flaps, and a good cosmetic result.     

Sentinel node biopsy versus elective lymph node dissection in patients with cutaneous melanoma in a Japanese population

Background In Japan, elective lymph node dissection (ELND) has been the standard treatment for patients with possible nodal melanoma. Sentinel node biopsy (SNB) has now replaced ELND, not only in Japan but also worldwide. The objective of this study was to compare the interim outcomes of SNB and ELND. Methods A retrospective study was conducted among patients with clinically node-negative disease treated at our institute with either SNB (n = 30) or ELND (n = 72). Results The background was similar in the two groups. Nodal metastases were found in 40.0% of patients in the SNB group, but in only 26.4% in the ELND group (P = 0.173). The median follow-up was 31.5 months for the SNB group and 82 months for the ELND group. The incidence of locoregional recurrence and distant metastasis in the SNB group was 10.0% and 16.7%, respectively, and for the ELND group the incidence was 5.6% and 31.9%, respectively. The 3-year disease-free survival rate was similar in the two groups (P = 0.280), and the 3-year disease-free survival rates for node-positive patients were also similar in the two groups (P = 0.90), as were the 3-year disease-free survival rates for node-negative patients (P = 0.193). Conclusion This interim result in a Japanese melanoma population with clinically node-negative disease demonstrated that SNB identified more nodal micrometastases than ELND. This increase in accurate staging likely resulted from the reliable identification of the lymph node field by lymphoscintigraphy, as well as the more detailed pathologic examination of the nodes removed in SNB. It is quite reasonable to perform SNB instead of ELND in this population.     

强负压吸引治疗8例颈淋巴结清扫术后乳糜瘘

背景与目的颈部乳糜瘘是颈部手术后的并发症之一,其产生机制与其特定的解剖位置及变异密切相关,有关其治疗的意见仍有分歧。本文总结8例颈清扫术后并发乳糜瘘患者采用强负压吸引和饮食处理的临床经验,以评价其疗效。方法全部病例在确诊为乳糜瘘后立即采用强负压(-50～-30kPa)吸引,嘱禁食并给予合理的静脉营养。结果7例患者经此保守治疗痊愈,未出现其他严重并发症;1例无效,采用胸大肌肌瓣填塞。结论强负压吸引和合理的饮食处理有可能是颈清扫术后并发乳糜瘘早期处理较为理想且安全的保守疗法之一。     

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。     

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^99mTc。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。     

头颈部恶性黑色素瘤的临床及病理研究

目的 研究头颈部恶性黑色素瘤的临床,病理及免疫组织化学特片,以提高临床和病理诊断率,方法 收集头颈部恶性黑色素瘤（除脉络膜外）68例,其中原发于鼻腔和口腔黏膜33例,头颈部皮肤35例。发病高峰年龄为41-60岁。52例为手术切除标本,16例为活检（咬取、切除）标本。复习所有患者的临床及病理资料,并对42例进行S-100、HMB45和NSE免疫组织化学观察。结果 在68例中,手术切除者52例,其中有13例行补充放疖1例进行了化疗单纯放疗0例;抿绝治疗6例,在获得随诊的56例中,存活5年以上者12例,其中头颈部皮肤恶性黑色素瘤9例,占75.0%;鼻腔及口腔黏膜者3例外中25.0%。结论 恶性黑色素瘤在组织学结构上的改变具有重要意义;免疫组织化学对恶性黑色素瘤诊断和鉴别诊断有重要价值;发生于鼻腔和口腔黏膜的恶性黑色素瘤的预后明显比发生在头颈部皮肤的差。     

The Indications and Clinical Curative Effects of Modified Neck Dissection in Head and Neck Cancers

OBJECTIVE Functional neck dissection was first described by Bocca and Pignataro in 1967. It has been used in clinical practice for years, but remains controversial among neck-surgery experts. This study was designed to evaluate indications and curative effects of functional-neck dissection (FND). METHODS One hundred and fifty-two cases which underwent FND were reviewed with an analysis of pathological specimens and follow-up datas. RESULTS The series of FND included 20 cases of tongue carcinoma, 23 cases of larynx carcinoma, 96 cases of thyroid papillary adenocarcinoma, 9 cases of follicular adenocarcinoma and 4 cases of medullary adenocarcinoma; the five-year recurrence rate for tongue carcinoma was 12.5%, 14.3%, 40.0% and for a larynx carcinoma was 20.0%, 16.7%, 50.0% in N0 stage, N1 stage, N2a stage, respectively. The 5-year recurrence rate of thyroid papillary adenocarcinoma was 6.5%, 7.1% in N1a, N1b, respectively. CONCLUSION Functional neck dissection is indicated in early and low malignant head and neck neoplasms and results in satisfactory curative effects.     

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.