Value of neck dissection in patients with squamous cell carcinoma of unknown primary.

Lymph node metastases of cancer of an unknown primary (CUP syndrome) are responsible for 3-5% of the malignant diseases in the head and neck area. More than 70% of these patients show lymph node metastases of an unknown squamous cell carcinoma. The survival depends immediately on number and location of lymph node metastases. For a curative approach modified radical neck dissection combined with postoperative radiation therapy with or without chemotherapy should be considered in N1-N3 lymph node status. A radical neck dissection with postoperative radiation therapy should only be approved in cases of infiltration of the internal jugular vein, the accessory nerve and/or the sternocleidomastoid muscle. The different prognosis of patients with upper cervical and lower cervical lymph nodes should influence the indication and the extent of a neck dissection in the contralateral N0 neck.     

喉癌同侧颈淋巴结转移癌穿透包膜的相关因素及其与对侧颈淋巴结转移和患者预后的关系

目的探讨喉癌同侧颈部淋巴结转移癌穿透包膜的相关因素及其与对侧颈部淋巴结转移和患者预后的关系。方法对184例喉癌患者进行手术治疗的同时,行经典或改良经典颈廓清术,对颈廓清标本采用透明淋巴结摘出连续切片法,摘出淋巴结,并进行病理检查。采用Kaplan-eier方法对随访资料进行生存分析。结果184例喉癌患者中,颈部淋巴结转移癌80例,其中穿透包膜26例,穿透包膜率为32．5％。单因素分析结果表明,淋巴结转移癌是否穿透包膜与病理N分期和同侧颈部淋巴结转移数有关。淋巴结转移癌穿透包膜者同侧颈部复发转移率（34.6%）、对侧颈部转移率（46．2％）均高于未穿透包膜者。淋巴结转移癌穿透包膜患者3、5年生存率分别为53．9％和23．1％,其生存率低于未穿透包膜患者。结论淋巴结转移癌是否穿透包膜与病理N分期和同侧颈部淋巴结转移数有关。淋巴结转移癌穿透包膜患者的对侧转移率高,应行双颈廓清术。淋巴结转移癌穿透包膜是影响患者预后的重要因素,病理科应当检查转移淋巴结被膜是否穿破,并予以报告。     

甲状腺切除联合同期双侧颈淋巴结清扫术治疗分化型甲状腺癌

目的 探讨分化型甲状腺癌行甲状腺切除联合同期双侧颈淋巴结清扫（颈清）术的安全性、适应证和手术难点。方法对1991年1月至2004年6月我科收治的分化型甲状腺癌行甲状腺切除联合同期双侧颈清术患者36例作回顾性分析,手术切口选择根据原发癌灶的位置及颈淋巴结可疑转移情况,选择相应的H型、L型或衣领式,甲状腺组织行近全切或全切,双侧颈清术原则上按保留颈内静脉、副神经、胸锁乳突肌改良颈清术式进行。结果全组36例患者无一例手术死亡,术后并发症为创口出血2例,一侧喉返神经损伤4例,一侧喉上神经内支损伤2例,一侧喉上神经外支损伤9例,一侧副神经损伤3例,一侧颈交感神经损伤5例,一侧膈神经损伤2例,一侧乳糜瘘6例,暂时性甲状旁腺功能减退13例,永久性甲状旁腺功能减退3例。淋巴结阳性数0-21个,平均8．3个／例,双侧淋巴结均阳性31／36,一侧淋巴结阳性,另一侧淋巴结阴性3／36,双侧淋巴结均阴性2／36。经1-13年随访,4例死亡,7例失访,25例存活,3例复发。结论分化型甲状腺癌行甲状腺切除联合同期双侧颈清术是安全的,关键是至少保留一侧颈内静脉,不要同时损伤双侧喉返神经和膈神经;对双侧颈淋巴结病理证实转移或临床判断转移（淋巴结明显肿大、质地偏硬或淋巴结为典型的紫葡萄颜色）的分化型甲状腺癌,均应行甲状腺切除联合同期双侧颈清;至少保留一个有血供的甲状旁腺;尽可能将甲状腺组织近全切或全切;应兼顾手术彻底性和机体功能保留。     

甲状腺乳头状癌颈部的处理

目的 探讨甲状腺乳头状癌颈部处理的最佳方案。方法 总结１９６５年１月～１９８７年１月４２４例甲状腺乳头状癌的临床资料,根治原发灶的同时,对颈部淋巴结阳性（Ｎ＋）患者进行颈清扫术,对颈部淋巴结阴性（Ｎ０）患者进行观察,待出现颈淋巴结转移后再行治疗性颈清扫术。所有患者均随访１０年以上。结果 ２５８例颈部Ｎ＋患者的５,１０年生存率分别为８４．３％和８０．４％,而１６６例Ｎ０患者的５,１０年生存率分别为９     

Modified radical neck dissection via extra-thyroideal space (MRND vets) in papillary thyroid carcinoma

The purpose of this study was to describe an alternative lateral neck access to perform lymph nodes sampling and/or neck dissection via extra-thyroideal space (MRND vets) in papillary thyroid carcinoma with lymph nodes involvment. Twenty-four consecutive patients with papillary thyroid carcinoma were included. Lymph nodes sampling and modified radical neck dissection, unilateral or bilateral, were performed acceding via a lateral dissection through a traditional Kocher incision, running along the medial fascia of the neck, posteriorly to the sterno-cleido-mastoideus muscle (SCM). Mean age was 39.04 +/- 13.69 years. Twenty patients were women, and 4 were men. Mean tumor size was 2.5 +/- 1 cm.. Total thyroidectomy with lymph nodes dissection of the central compartment associated to modified radical neck dissection was performed in 17 patients: among these, nine patients had a preoperative diagnosis of the latero-cervical lymph nodes metastases, and eight had a perioperative diagnosis of metastases of the extensive sampling of the lower third of the jugular chain. Metastatic lymph nodes were found in 107 out of 615 lymph nodes dissected. The MNRD vets access for modified lateral neck dissection seems to carry a lower risk in terms of specific morbility and allows a quicker recovery and a better cosmetic result. This access has to be considered as a less invasive procedure compared to other surgical accesses for the radical modified lateral neck dissection.     

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.     

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.     

Bilateral radical neck dissection: results in 193 cases

BACKGROUND AND OBJECTIVES: Indications of simultaneous bilateral radical neck dissection remains controversial. The main objectives of this analysis were to study: a) the frequency of postoperative complications, b) the patterns of metastatic lymph nodes in the surgical specimen, c) the predictive factors of neck recurrences, d) the prognostic factors related to overall survival. METHODS: A retrospective review of results in 193 consecutive patients submitted to a simultaneous bilateral radical neck dissection from 1960-1990. RESULTS: Postoperative complications occurred in 60.8% of the cases. The most frequent ones were: fistula, wound infection, flap dehiscence and necrosis. There were four postoperative deaths (2.7%). The lymph nodes most frequently involved were of the upper jugular and upper accessory groups. Only patients with lip and paranasal sinus tumors never presented metastatic nodes at Levels IV and V. Tumor recurrences were more common at the ipsilateral neck (13.5%) or at distant sites (12.4%). The predictive factors of neck recurrences were: age, N stage, ipsilateral metastasis at Level II, and contralateral metastasis at Levels II and IV. The overall 5-year survival rates for the two age groups, that is, younger than 40 and older than 40 years of age, were respectively, of 8.5% and 35.6% (P = 0.0296). There were no survivals among the group of patients with neck lymph nodes staged as N3 or Nx. The overall 5-year survival rates were significantly influenced by contralateral metastatic lymph nodes at any level. The results of multivariate analysis using the Cox regression technique, showed that Level II ipsilateral metastatic lymph nodes, Levels II and IV contralateral metastatic lymph nodes, and age were the independent predictors of the risk of death. CONCLUSIONS: This study demonstrates that simultaneous bilateral neck dissection has a high morbidity and should be contraindicated as an elective procedure. Further studies with selective neck dissections are warranted.     

Modified functional neck dissection: a useful technique for oral cancers

Among 60 patients with oral squamous cell carcinoma, 30 were treated by the modified functional neck dissection (preserve 8 functional tissues), 30 were treated by functional neck dissection (preserve 3 functional tissues). The recurrent rate of cervical lymph node and the sense of skin were assessed. The recurrence rates in cervical nodes was 6.67% and 10%, respectively (p > 0.05) in patients who accepted modified functional neck dissection and functional neck dissection. The sensation in skin in patients who accepted modified functional neck dissection was better than those who accepted functional neck dissection (p < 0.01). Modified functional neck dissection is helpful to decrease postoperative complications, without increasing recurrent rates of cervical lymph node.     

采用领式皮纹延长切口进行甲状腺癌颈淋巴结清扫

目的 探索甲状腺癌颈清扫术术后更加美观的手术切口.方法 对82例分化型甲状腺癌患者采用领式皮纹延长切口行改良颈清扫术.在常规甲状腺领式切口的基础上,在颈清扫侧沿皮纹延长到斜方肌前缘位置,避免曲棍球棒切口的垂直段.82例患者共行颈清扫术96侧,术式分别是根治性颈清扫术1侧,改良性颈清扫术Ⅰ型1侧,改良性颈清扫术Ⅱ型8侧,改良性颈清扫术Ⅲ型86侧.结果 采用领式皮纹延长切口患者平均手术麻醉时间为197 min.每侧平均清扫淋巴结37.5枚,平均阳性淋巴结8.8枚.与颈清扫术有关的并发症发生率为9.8%(8/82).淋巴结复发率1.2%,未发生远地转移和死亡.结论 采用领式皮纹延长切口行改良颈清扫术治疗分化型甲状腺癌颈淋巴结转移在技术上可行,肿瘤治疗效果满意,颈部切口瘢痕小,满足了部分患者维护颈部外观的需求.     

The influence of excisional or incisional biopsy of metastatic neck nodes on the management of head and neck cancer

Between November 1964 and December 1981, 80 patients who had undergone an open biopsy of a cervical lymph node containing squamous cell carcinoma were treated with curative intent in the University of Florida Division of Radiation Therapy. Irradiation was the initial step in the definitive treatment of all patients, followed by neck dissection and/or primary resection, as indicated. The patients were divided into two groups. (a) NX (no gross residual neck disease) (25 patients): According to the referring surgeons' and pathologists' reports, a single, clinically positive lymph node was totally excised in 25 patients. No other clinically positive lymph nodes were appreciated upon referral. No neck dissections were added following irradiation in this group of patients. The absolute 5 year disease-free survival in the NX group was 79%, and the rate of neck disease control was 96%. (b) Gross residual neck disease (55 patients): Gross residual disease remained in the neck in 55 patients following biopsy. In some patients, only an incisional biopsy of a large mass had been performed; in others, only one of several involved nodes was removed. The absolute 5 year disease-free survival in this group of patients was 31%, and the rate of neck disease control was 64%. The more consistent addition of a neck dissection in recent years has resulted in improved neck control rates in this group: 13/20 (65%) for N1-N2 disease and 2/7 (29%) for N3A disease following irradiation alone versus 6/7 (86%) for N2 disease and 5/8 (63%) for N3A disease when a neck dissection was added following irradiation. There are some differences in the rates of neck control, control above the clavicles, survival, distant metastasis, and complications between this series and other reported series in which open neck-node biopsy preceded definitive treatment. Possible reasons for these differences are discussed.     

口底鳞状细胞癌颈淋巴结转移规律及处理的探讨

背景与目的：口底癌颈淋巴结转移规律方面的研究较少,本研究探讨口底癌颈淋巴结转移的分布特点和合理的治疗方法。方法：回顾性分析经根治性治疗的79例口底鳞癌病例,比较其临床和病理阳性淋巴结分布差异;比较临床淋巴结阳性组经根治性颈清扫术,上半颈清扫术术后颈部的复发率和临床淋巴结阴性组经根治性颈清扫术,上半颈清扫术,颌下三角清扫术的复发率,及临床观察组颈部的复发率。结果：临床和病理阳性淋巴结分布都以Ⅱ区为主,分别占61.8%和40.0%。其次是Ⅰ区和/或Ⅲ区,而Ⅳ,Ⅴ,Ⅵ区则极少;临床淋巴结阳性组中根治性颈清扫术术后颈部的复发率低于上半颈清扫术者,但无统计学意义（X^2=3.403,P=0.065);临床颈淋巴结阴性组中上半颈清扫术,颌下三角清扫术,临床观察等方法处理的颈部复发率分别是11.1%(1/9),40.0%(2/5)和23.5%(4/17),组间差异无统计学意义（X^2=1.554,P=0.46)。结论：口底鳞癌颈淋巴结转移的分布主要在Ⅰ、Ⅱ、Ⅲ区;临床颈淋巴结阴性者宜进行Ⅰ、Ⅱ、Ⅲ区（上半颈）淋巴结清扫术。     

A study of a regional lymph node metastasis in a well-differentiated thyroid carcinoma

Forty-eight patients with a well-differentiated thyroid cancer that occupied unilateral lobe were given, a modified radical neck dissection (unilateral or bilateral). After an examination of their lymph nodes, a retrospective analysis showed that the metastasis extended to the lateral cervical lymph node on the ipsilateral neck in 43.8% of all cases, and to at least the paratracheal lymph node on the contralateral neck in 27.2% of all cases. Therefore a bilateral modified radical neck dissection is needed surgical treatment for such patients.     

局部晚期喉鳞癌cN0临床观察

目的：探讨喉癌cN0患者颈部处理的方法，降低颈淋巴结转移癌的复发率。方法：回顾分析87例T3、T4期cNo喉癌患者的临床资料，颈部处理方式为颈改良性清扫术或颈分区清扫术，分析手术组阳性淋巴结的分布情况及病理特点，观察颈清扫术对预后的影响，采用Kaplan—Meier方法计算肿瘤复发及生存趋势。结果：87例颈部淋巴结隐性转移率为36．8％，声门上型喉癌40．4％，声门型喉癌32．5％；淋巴结转移分布为：声门上型喉癌89．5％（17／19）位于Ⅱ和Ⅲ区，声门型喉癌92．3％（12／13）位于Ⅱ和Ⅲ区；5年颈部复发率：隐性淋巴结转移复发率为13．5％，无隐性淋巴结转移复发率6．7％；5年生存率：有淋巴结隐性转移生存率为53．8％，无隐性转移为71．1％。结论：晚期喉癌隐性转移率较高，分区清扫术后，隐性转移复发率与无隐性转移复发率无差别，分区清扫术十分必要，注意双侧Ⅱ、Ⅲ区的淋巴结清扫。     

Lateral approach to central compartment of neck

Revision surgery in central compartment of neck is often a challenge for the head and neck surgical oncologists/endocrine surgeons. This is often required for completion thyroidectomies, central compartment lymph node dissections, and re-exploration for persistent hyperparathyroidism. Scarring in midline due to prior surgery makes midline access to central compartment difficult and increases the risk of injury to recurrent laryngeal nerve and parathyroid glands. This article describes a simple technique of approaching central compartment between sternocleidomastoid and strap muscles.     

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.     

Radical neck dissection for cancer of the oral cavity

160 radical neck dissections (RND) were performed on 154 patients with cancer of the oral cavity in which cancer of the tongue predominated. The 3-, 5- and 10-year survival rates of these patients were 62.9%, 58.3% and 36.2%, respectively. Those with advanced lesions or positive lymph nodes had poor prognosis. The lymph nodes commonly involved were the submaxillary and the upper deep cervical nodes but "jumping" metastasis to the lower cervical nodes was observed. Elective radical neck dissection is advised for cancer of the tongue. The Survival rate of the patients treated by preoperative irradiation plus RND is higher than that by surgery alone. Proper management of the postoperative complications and regular follow-up of the patients are suggested.     

分区性颈清扫术应用在cN0和cN1期口腔癌中的远期效果

目的头颈部鳞状细胞癌的颈淋巴结的处理与预后密切相关,本文探讨了分区性颈清扫术应用于早期口腔鳞状细胞癌颈部转移的远期效果。方法84例cN0或cN1期患者均接受了术前化疗,分区性颈清扫术及术后放疗,并复习文献对比多种术式的颈部复发率。结果84例中1例死于肿瘤复发转移,53例cN1中有10例为pN0,全组颈部复发率为13＋2％。cN0中有6例出现隐性转移,该组复发率为6．5％。按是否侵犯包膜外颈部复发率分别是20．0％和10．3％。结论分区性颈清扫术在cN0和cN1期口腔鳞状细胞癌的治疗上可以取代改良性颈清扫和全颈清扫术。     

Ⅵ区淋巴清扫在甲状腺癌外科手术中的意义

背景与目的:Ⅵ区是甲状腺癌常见的淋巴转移区域,对cN1患者可常规行包括Ⅵ区的淋巴清扫手术,然而对于cN0患者是否需要常规清扫Ⅵ区,目前仍没有一个明确的指引。本研究探讨甲状腺癌Ⅵ区淋巴转移的特点,并明确甲状腺癌手术治疗中Ⅵ区淋巴清扫的意义。方法:回顾性分析1988年1月～2000年1月期间收治的均行含Ⅵ区在内的颈淋巴清扫手术的130例甲状腺癌患者的临床资料,并对此资料进行统计学处理。结果:130例患者中术后Ⅵ区淋巴结阳性者97例(74.6%);并发症发生率为10.8%(14/130),其中包括喉返神经损伤4例;多因素生存分析表明甲状腺癌Ⅵ区淋巴转移是影响患者生存的因素。结论:对甲状腺癌患者常规行Ⅵ区淋巴清扫有助于改善其生存情况;可以通过提高手术技巧降低手术的并发症发生率。     

PET/CT与增强CT诊断头颈肿瘤颈淋巴结转移的对比研究

目的:探讨18F-脱氧葡萄糖(FDG)PET/CT显像与螺旋CT增强扫描检测头颈肿瘤淋巴结转移的临床价值。方法:13个头颈肿瘤病人在颈部手术前,行PET/CT和增强CT检查。术后病理结果作为参考标准,PET/CT与增强CT的发现以左、右颈侧为记录单位进行比较。结果:在21个颈侧清扫(8个双侧,5个单侧)中,共清扫出440个淋巴结,其中的45个颈部淋巴结转移癌分布在14个颈侧。PET/CT检测颈淋巴结转移的敏感性、特异性和准确性分别为86%、100%和90%,增强CT分别为79%、86%和81%,PET/CT诊断的敏感性和准确性均显著高于增强CT(P<0.05)。结论:PET/CT在头颈肿瘤淋巴结转移的诊断中优于增强CT。本文结果为PET/CT在临床和放射影像诊断为颈部淋巴结阴性病人中发现转移的研究提供了可行性依据。