功能性与根治性颈淋巴清扫术在早期口腔鳞状细胞癌治疗中的疗效比较

目的:探讨功能性颈淋巴清扫术(functional neck dissection,FND)与根治性颈淋巴清扫术(radical neckdissection,RND)在口腔鳞状细胞癌中的临床疗效.方法:63例口腔鳞状细胞癌患者,分为FND组(n=30)和RND组(n=33),FND组保留胸锁乳突肌、副神经、颈内静脉及耳大神经,术后随访2组患者的肩外展功能、耳大神经功能、颈部是否明显凹陷及颈部复发率.应用SPSS 18.0软件包对数据进行单因素x2检验、两独立样本均数t检验,以及Fisher确切概率检验.结果:FND与RND组之间在年龄、性别、肿瘤部位、T分期、N分期、组织学分化程度、病理学类型、术前化疗及术后化疗等方面无显著差异(P＞0.05).所有患者均为N0或N1期,FND组术后肩关节活动度、耳垂感觉麻木及颈部凹陷改善程度显著优于RND组(P＜0.05);术后随访2年,FND组的颈部复发率与RND组无显著差异(P=1.000).结论:对于N0或N1期口腔鳞状细胞癌患者,FND与RND相比,患者颈部复发率无显著差异,但其并发症显著减少,可明显提高患者术后的生活质量.     

Neck dissection with the harmonic scalpel in patients with squamous cell carcinoma of the oral cavity

Our purpose was to evaluate the use of the Harmonic scalpel in neck dissections.Material and methodsWe conducted a randomized prospective intervention study to compare the Harmonic scalpel (32 patients) with the conventional technique (31 patients).ResultsOperative time was lowered by 64 min (p < 0.001) and 7.5 min (p = 0.367); blood lost during surgery was lowered by 80.5 ml (p < 0.001) and 76.6 ml (p < 0.001); the length of time the drains were kept in place was lowered by 1.3 days (p < 0.001) and 1.5 days (p < 0.01); and the volume of drainage was lower by 228.7 ml (p < 0.001) and 187.6 ml (p < 0.01) in selective and comprehensive neck dissections respectively in patients treated with the Harmonic scalpel.ConclusionsThe Harmonic scalpel shortens operative time in selective dissections. It reduces blood loss during surgery; time drains are kept in place and the amount of drainage in comprehensive and selective neck dissections.     

The role of elective supraomohyoidal neck dissection in the treatment of early, node-negative oral squamous cell carcinoma (OSCC): A retrospective analysis of 122 cases

The adequate treatment of the neck in early, clinically node-negative oral squamous cell carcinoma (OSCC) remains controversial. To assess whether elective supraomohyoid neck dissection is reasonable and efficient in early, locally circumscribed OSCC, the outcomes of treatment of 122 patients with an OSCC of clinical UICC stage I or II were retrospectively analysed in this study. Occult lymph node metastases were detected in 13.9% (17/122) of cases. They were more frequently found in T2 compared to T1 tumours (19.7% (14/71) vs. 5.9% (3/51), p = 0.03), age, gender and grading had no influence on the prevalence of occult lymph node metastases (all p-values > 0.05) in a multivariate logistic regression model. Subsequent multivariate survival analysis found that the presence of occult metastases was an independent predictor of reduced disease-free survival after 5 years (82.2% vs. 62.5%, p = 0.004, and 61.9% vs. 17.8%, p < 0.001, respectively). Elective supraomohyoid neck dissection detects occult metastases in early, node-negative OSCC, and patients with early OSCC exhibiting occult metastases should be considered as high risk patients, warranting additional therapeutic regimes.     

Supraomohyoid neck dissection and modified radical neck dissection for clinically node-negative oral squamous cell carcinoma: A prospective study of prognosis,complications and quality of life

BackgroundTo assess the prognosis and morbidity between supraomohyoid neck dissection (SOND) and modified radical neck dissection (MRND) for oral squamous cell carcinoma (OSCC) in patients with a clinically node-negative neck (cN0).Patients and methodsThis prospective randomized study began in June 1999, and patient accrual concluded in May 2010. The cN0 neck was confirmed on clinical palpation by senior doctors. Ultimately, there were 322 patients recruited into the study.ResultsPatient demographics were well balanced between the two groups. There were 10 patients in the SOND group and 21 patients in the MRND group who developed nodal recurrence without associated local recurrence or distant metastasis. The 3-year neck control rate (NCR) rate was 92.6% for the SOND group and 87.5% for the MRND group (in favor of SOND, P = 0.108). There was no significant difference between the SOND group and the MRND group in the 3-year disease-specific survival (DSS) rate (79.0% vs. 76.9%, P = 0.659). Importantly, there were significantly fewer complications in the SOND group compared with the MRND group (13.0% vs. 21.9%, P = 0.040). The disease-free survivors in the SOND group also reported better pain relief (P = 0.013) and shoulder function (P < 0.001) than those in the MRND group one year after treatment.ConclusionsWe recommend SOND as a priority treatment for cN0 OSCC patients.     

Quantitative methylation analysis of resection margins and lymph nodes in oral squamous cell carcinoma

Resection is the preferred treatment for oral squamous cell carcinoma, and pathological staging of the resected specimen is crucial. The role of molecular biology in the diagnosis of minimal residual disease has not been fully investigated and may improve staging. Multiple adjacent specimens were taken from the tumour, the invasive front, the surgical margin, and the lymph nodes of 20 specimens from patients with oral cancer. Bisulphite-treated DNA from these specimens was assayed quantitatively with pyrosequencing methylation assays (PMA) of CpG islands within the gene promoters of the p16 and CYGB genes. Results were recorded with histopathological results, and compared with clinical outcome. Biological and technical replicates confirmed the reliability of the techniques. PMA upgraded 13 of the 20 surgical margins, 6 of which subsequently had a recurrent tumour. Not all of these recurrences were predicted and the effects of adjuvant treatment make firm conclusions difficult.     

Prognostic value of lymph node count from selective neck dissection in oral squamous cell carcinoma

Unlike the levels of anatomical exploration, there is no consensus on the extent of lymph node dissection, or lymph node count (LNC), during selective neck dissection (SND). The aim of this study was to validate the prognostic impact of LNC on survival and to determine an optimal LNC cut-off value for SND. A retrospective investigation identified 78 patients with a diagnosis of oral squamous cell carcinoma (OSCC) who underwent SND (levels I–III or levels I–IV). LNC and clinicopathological variables were analyzed for any association with survival in Cox proportional hazards models. Based on the receiver operating characteristic curve, a cut-off value of 19 lymph nodes was found to predict overall survival (OS) (area under the curve 0.732, sensitivity 67.8%, specificity 75.0%; P = 0.026) and disease-specific survival (DSS) (area under the curve 0.762, sensitivity 68.1%, specificity 77.8%; P = 0.011). On Cox regression, LNC (≥19 vs. <19) was the only independent predictor of OS (hazard ratio 5.29, 95% confidence interval 1.39–20.05; P = 0.014) and DSS (hazard ratio 6.76, 95% confidence interval 1.40–32.77; P = 0.018). Similar results were obtained in the pathologically lymph node-negative subgroup (n = 66). Based on the study findings, SND should include 19 or more lymph nodes for a survival benefit.     

Diagnostic value of intraoperative bone marrow assessment for bone margins in patients with head and neck squamous cell carcinoma: a systematic review and meta-analysis

A clear bone margin is essential for complete resection of the bone-involved tumour, but the evaluation of hard tissue takes time and is impractical intraoperatively. Bone marrow assessment remains controversial. The aim of this study was to investigate the diagnostic value of intraoperative bone marrow assessment for bone margins. PubMed and Web of Science were searched for studies published between 1990 and 2017. A systematic review was conducted. After quality assessment, 10 articles with 11 cohorts and 404 patients were identified. Sensitivity, specificity, and other measures were pooled for meta-analysis; the estimates for intraoperative bone marrow assessment were as follows: sensitivity 0.82 (95% confidence interval (CI) 0.62–0.93), specificity 0.99 (95% CI 0.96–1.00), positive likelihood ratio 109.79 (95% CI 22.99–524.34), negative likelihood ratio 0.18 (95% CI 0.08–0.42), and diagnostic odds ratio 241.82 (95% CI 90.33–647.38). Furthermore, sensitivity and specificity at the summary operating point of the summary receiver operating characteristic curve were 0.82 and 0.99, respectively, and the area under the curve was 0.99. Intraoperative bone marrow assessment was investigated by meta-analysis and shown to have a high level of overall accuracy for the diagnosis of bone margins.     

Treatment delay in early-stage oral squamous cell carcinoma and its relation to survival

The aim of this study was to investigate the impact of a prolonged treatment delay on survival in patients with primary oral squamous cell carcinoma. The investigators hypothesized that treatment delay affects survival, supposing a poor outcome in patients with prolonged treatment initiation. In addition, a critical treatment delay should be defined.Inclusion criteria were a histopathological diagnosis of primary squamous cell carcinoma of the oral cavity and a surgery-based treatment of the tumor. Patients with a history of previously diagnosed malignancies and patients with distant metastasis at the time of diagnosis were excluded from this protocol. Common clinical and histopathological data were assessed retrospectively. Treatment delay was analyzed for the interval between initial presentation and the date of surgery.A total of 484 patients could be included. Considering early-stage patients, the risk of death increases by 1.8% for each day that the treatment delay is prolonged if all other characteristics do not change (p = 0.0035). In patients with advanced disease, a prolonged treatment delay does not affect the risk of death (p = 0.9134). In terms of progression-free survival, treatment delay tends to be associated with a higher risk of recurrence in early-stage disease, but without being statistically significant (p = 0.0718). For patients with early-stage disease, a treatment delay of 20 days is critical regarding overall survival (p = 0.011). For patients with advanced-stage disease, no significant differences have been observed.As patients with early-stage oral squamous cell carcinoma profit from early treatment initiation, we suggest an acceptable maximum treatment delay of no more than 20 days in the surgical management of these patients.     

早期口腔鳞状细胞癌行Ⅱb区颈淋巴清扫术的意义

目的: 评估临床无颈淋巴结转移(cN0)口腔鳞癌患者Ⅱb 区淋巴清扫术的意义。方法: 回顾2012年1月—2014年12月期间在上海交通大学医学院附属第九人民医院口腔颌面-头颈肿瘤科治疗的203例cN0口腔鳞癌患者,平均年龄59.7岁(41~79岁),术前均未接受其他治疗;男127例,女76例;舌癌101例,颊癌45例,口底癌30例,牙龈癌19例,其他8例。根据术后病理结果,203例患者的TNM分期为T1或T2,均接受病灶切除+肩胛舌骨上颈淋巴清扫术,其中115例患者接受Ⅱb区淋巴清扫。对接受Ⅱb区淋巴清扫与未接受Ⅱb区淋巴清扫的2组患者数据采用独立样本t检验,分析2组患者的术后并发症(主要是肩胛综合征)发生率、Ⅱb区淋巴结转移率(主要针对未做颈淋巴清扫患者),采用SPSS 22.0软件包、Kaplan-Meier生存分析法评估2组患者的3年总生存率。结果: 在接受Ⅱb区淋巴清扫的115例患者中,7例(6.09%)患者术后病理证实Ⅱb区淋巴结转移。术后随访3年,Ⅱb区淋巴清扫组中,83例(72.17%)出现不同程度的肩胛综合征,27例(32.53%)患者通过康复锻炼症状减轻,但仍未完全恢复,Ⅱb区淋巴清扫组患者3年总生存率为86.09%;在未接受Ⅱb区淋巴清扫的88例患者中,4例(4.55%)出现肩胛综合征,术后均通过康复锻炼恢复,Ⅱb区淋巴未清扫组患者3年总生存率为84.09%,2组比较无统计学差异(P>0.05)。结论: cN0口腔鳞癌患者出现Ⅱb区淋巴结转移率较低,因此行肩胛舌骨上颈淋巴清扫术时可选择性清扫Ⅱb区淋巴结,从而保护副神经及其分支不受损伤,提高患者术后生活质量。     

Neck failure following pathologically node-negative neck dissection (pN0) in oral squamous cell carcinoma: a systematic review and meta-analysis

Due to the risk of occult cervical metastasis, elective neck dissection (END) is recommended in the management of patients with early oral cavity squamous cell carcinoma (OSCC) and a clinically node-negative (cN0) neck. This paper presents a systematic review and meta-analysis of studies that recorded isolated regional recurrence (RR) in the pathologically node-negative neck dissection (pN0) neck following END in order to quantify the failure rate. Pubmed and Ovid databases were systematically searched for relevant articles published between January 2009 and January 2019. Studies reporting RR following END in patients with OSCC who had no pathological evidence of lymph node metastasis were eligible for inclusion in this meta-analysis. In addition, a selection of large head and neck units were invited to submit unpublished data. Search criteria produced a list of 5448 papers, of which 18 studies met the inclusion criteria. Three institutions contributed unpublished data. This included a total of 4824 patients with median follow-up of 34 months (2.8 years). Eight datasets included patients staged T1-T4 with RR 17.3% (469/2711), 13 datasets included patients staged T1-T2 with RR 7.5% (158/2113). Overall across all 21 studies, isolated neck recurrence was identified in 627 cases giving a RR of 13.0% (627/4824) on meta-analysis. Understanding the therapeutic effectiveness of END provides context for evaluation of clinical management of the cN0 in these patients. A pathologically negative neck does not guarantee against future recurrence.     

Clinicopathological study of involvement of the submandibular gland in oral squamous cell carcinoma

Our purpose was to provide a pathological basis for preservation of the submandibular glands during neck dissection for oral squamous cell carcinoma (SCC) by investigating whether intraglandular lymph nodes exist in submandibular glands, and the modes of involvement of submandibular glands in oral SCC. We studied the records of 95 patients with oral SCC (other than that in the floor of the mouth) treated at our hospital from January 2017 to June 2018. The specimens of submandibular glands discarded after neck dissection were analysed, and serially sectioned. Sections 5 μm thick were obtained at 0.5 mm intervals and stained with haematoxylin and eosin for examination under light microscopy. A total of 116 specimens were obtained from the 95 patients, and about 5000 slides were evaluated. No intraglandular lymph nodes were detected in the submandibular glands. In the subgroup of patients whose primary tumours had extended into the floor of the mouth, four submandibular glands were involved by direct spread of the primary tumour. In the subgroup with metastases to level Ib lymph nodes, four submandibular glands were involved by extranodal extension from the metastatic nodes. No intraglandular lymph nodes or micrometastases were detected. We conclude that no intraglandular lymph nodes are present in submandibular glands, which may be involved by direct extension of the primary carcinoma or metastatic cervical lymph nodes with extranodal extension. Preservation of the submandibular glands during neck dissection seems to be feasible and safe in selected patients with oral SCC.     

Risk factors in securing successful surgical resection of oral squamous cell carcinoma

The purpose of this retrospective study was to analyze the factors that had a significant effect on securing a successful surgical resection (surgical margin) in oral cancer surgery. One hundred forty-eight consecutive patients who underwent planned radical resection of oral squamous cell carcinoma (SCC) were analyzed. Successful resection was judged if pathological examination of the surgical specimen revealed a clear surgical margin (no SCC within 5 mm, n = 116), while an unsuccessful resection was judged if there was a close and involved surgical margin (SCC within 5 mm, n = 21; and SCC at margin, n = 11). Univariate analyses showed that gender, age, and T-classification had significant influence on successful surgical resection. The results of multivariate logistic regression analysis showed that age (odds ratio [OR] = 1.042, 95% CI = 1.001-1.084), T-classification (OR = 1.656, 95% CI = 1.060-2.587), and the presence of preoperative treatment (OR = 2.868, 95% CI = 1.047-7.85) had significant effects on successful surgical resection. The results of this study suggested that successful resection of oral SCC was difficult in patients with either older age or advanced (T4) tumor. It is also suggested that preoperative therapy had a positive effect on securing a pathologically clear surgical margin.     

Influence of close resection margins on local recurrence and disease-specific survival in oral and oropharyngeal carcinoma

There is a lack of consistency among published reports in the definition of what constitutes close resection margins (1-5mm) in the surgical treatment of oral and oropharyngeal squamous cell carcinoma (SCC). Our aim was to define what would constitute close resection margins in predicting local recurrence and disease-specific survival. The study comprised 192 previously untreated patients with oral and oropharyngeal SCC who were recruited at the Southern General Hospital, Glasgow, from 2001 to 2007 with a minimum follow-up of 2 years. Resection was the primary treatment and the surgical margins were recorded for all patients. Statistical analyses were aided by the Statistical Package for the Social Sciences, version 15.0, and MedCalc software. The status of the surgical margins was evaluated using a receiver operating characteristic (ROC) curve to define the cut-off point. Cox's proportional hazard model was used to establish predictive factors for local recurrence and disease-specific survival. Of 192 patients, 23 (12%) had involved margins (<1.0mm), 107 (56%) had close margins (1.0-2.0mm (16.1%); 2.1-3.0mm (12%); 3.1-4.0mm (10.4%); 4.1-5.0mm (17.2%), and 62 (32.3%) had clear margins (>5mm). No predictive cut-off point was found that related close surgical margins to local recurrence. However, there was a significant adverse association between surgical margins ≤1.6mm and disease-specific survival. In recommending postoperative adjuvant treatment for oral and oropharyngeal SCC, we suggest that surgical margins within 2mm should be considered as the cut-off. However, other clinical and pathological prognostic factors should also be taken into consideration when recommending further treatment.     

First report of elective selective neck dissection in the management of squamous cell carcinoma of the maxillary sinus

Controversy remains about management of the neck in squamous cell carcinoma (SCC) of the maxillary sinus and we know of no reports of the use of elective selective neck dissection for management in this site. We retrospectively reviewed 18 consecutive patients with SCC of the maxillary sinus who were managed by primary operation with curative intent. A total of 13 patients had an elective selective neck dissection, which was invaded in one case 8%. Four patients had regional metastases, two with positive nodal disease confirmed after elective selective neck dissection, and two who developed regional recurrence (both after elective selective neck dissections which were negative (pN0)). A review of other published articles in the English language showed no cases of elective selective neck dissections reported. The mean regional recurrence rate was 12% (range 0–26%) and total mean regional metastases rate 21% (range 5–36%). Elective selective neck dissection did not contribute to an improved rate of neck control with regional recurrence of 11% (2/18) compared with 12% in the review. There is no evidence in this report to indicate that elective selective neck dissections for maxillary sinus SCC will result in better disease control. Future research may indicate fewer radiotherapy fields for necks with pathologically clear nodes after elective selective neck dissection.     

颈清扫术不同术式对cN0口腔鳞状细胞癌患者肩功能的影响

目的比较颈清扫术（ND）不同术式对口腔鳞状细胞癌患者术后肩功能的影响.方法将66例临床颈部淋巴结阴性（cN0）口腔鳞状细胞癌患者按接受ND的术式分为根治性颈清扫术（RND）组、改良根治性颈清扫术（MRND）组和择区性颈清扫术（SND）组,采用Constant＇s肩功能量表和ND损伤指数量表对术后肩功能进行评价.结果保留副神经组的患侧肩功能优于RND组（P＜0.01）.在保留副神经组中,SND组的肩功能优于MRND组（P＜0.01）.SND术后的肩部疼痛和功能障碍轻微.结论SND对术后肩功能影响轻微,优于RND和MRND.     

2种颈淋巴清扫术对口腔鳞状细胞癌cN0期患者疗效的对比分析

目的 对比分析肩胛舌骨上颈淋巴清扫术(supraomohyoid neck dissection,SOND)和传统根治性颈淋巴清扫术(classical radical neck dissection,CRND)对口腔鳞状细胞癌cN0期患者术后颈部复发率、生存率和生存质量的影响。方法 68例临床cN0期的口腔鳞癌患者随机分为2组:CRND组和SOND组均为34例。统计比较术后颈部复发率,应用SPSS10.0软件统计分析2组患者术后3年、5年生存率,用华盛顿大学生存质量问卷评价两组患者的生存质量。结果 CRND组和SOND组3年颈部复发率分别为8.8%、11.7%,5年颈部复发率分别为11.8%、14.7%;CRND组和SOND组3年生存率分别为69.1%、68.4%,5年生存率分别为55.6%、54.9%;CRND组和SOND组生存质量平均总分各为533.57±112.22,653.06±84.92,有统计学差异。因而对cN0期的口腔鳞癌患者行肩胛舌骨上颈淋巴清扫术与传统根治性颈淋巴清扫术相比,没有降低患者术后生存率和颈部复发率,但显著地提高了患者术后的生存质量。结论 肩胛舌骨上颈淋巴清扫术在cN0期口腔鳞癌患者的治疗上可以取代传统根治性颈淋巴清扫术。     

口腔颌面-头颈鳞癌的分子生物学研究

口腔颌面-头颈鳞癌是发病率和死亡率较高的全球性疾病。临床常用的TNM分期不能对其遗传学特征和生物学特性作出正确的判断：肿瘤的分子特点对治疗方案选择、降低死亡率和提高生存率有一定帮助。特异基因表达谱的应用．能改善诊断方法．为个体化治疗提供基础；头颈鳞癌分子谱型的应用，可以对淋巴结转移和手术切缘作出正确的诊断．以便正确指导手术范围的确定。2000～2005年，约有40多篇有关头颈鳞癌基因表达谱的研究报道，本文就研究中发现有变化的基因进行综述和分析。结果表明，在肿瘤和非肿瘤之间，存在多个基因的变化。GO分类分析结果表明．这些基因涉及22种生理功能；进一步对这些变化基因进行基因组、蛋白组和功能的研究，将对揭示头颈鳞癌的分子病理学发生机制产生积极作用。     

肩胛舌骨上颈淋巴清扫术对控制口腔癌NO淋巴结转移的作用

目的:对施行根治性(RND)和肩胛舌骨上颈淋巴清扫术(SOHND)的NO期口腔癌患者进行回顾性比较研究,探讨肩胛舌骨上颈淋巴清扫术对控制口腔癌。NO淋巴结转移的作用。方法:对182例NO期口腔癌患者进行随访,并根据手术方式分为RND组和SOHND组,对颈淋巴转移、肿瘤复发及5年生存率进行统计分析。结果:本组资料颈淋巴结隐匿性转移率为27.5％,颈淋巴转移率随T分期升高而升高;口腔癌最易向颈深上淋巴结转移,其次是下颌下淋巴结和颈深中淋巴结,Ⅰ至Ⅲ平面转移占总转移率的92.0％;术后肿瘤复发率为17.0％,以局部和同侧颈部复发为主;RND对控制NO期口腔癌颈淋巴转移的有效率为95.2％,SOHND的有效率为94.8％;RND组5年生存率为67.6％,SOHND组为72.7％;两组间复发率及5年生存率无显著性差异。结论:肩胛舌骨上颈淋巴清扫术不仅能够评价NO期口腔癌颈淋巴结转移状况,而且能够有效控制发生隐匿转移的颈淋巴结。对于NO期口腔癌,选择性颈淋巴清扫术可采用肩胛舌骨上颈淋巴清扫术作为标准的治疗程序。