颈淋巴结清扫在甲状腺癌再手术中的价值

  目的 探讨颈淋巴结清扫术在甲状腺癌不规范手术后再手术中的价值及术式选择。方法 回顾性分析1997年至2005年间38例甲状腺癌不规范手术后再次手术患者中32例作颈淋巴结清扫术的临床资料。其中，功能性颈清扫+患侧残叶+峡部切除24例，功能性颈清扫+全叶切除术2例，单纯行功能性颈清扫4例，区域性颈清扫2例。结果　颈清扫淋巴结阳性率68.75 %（22／32），甲状腺肿瘤残留率47.38 %（18／38），总残留率73.68 %（28／38）。结论　甲状腺癌不规范手术的颈淋巴结肿瘤残留率较高，颈淋巴结清扫术在甲状腺癌再次手术中具有明确的治疗作用。     

83例鼻咽癌放射治疗后颈淋巴结转移复发的治疗

目的 探讨颈淋巴结清扫术治疗鼻咽癌放射治疗后颈部淋巴结转移未控或复发患者的疗效。方法 回顾性分析因鼻咽癌放射治疗后颈淋巴结转移未控或复发行颈清扫术的83例患者，其中rN1期54例，rN2期19例，rN3期10例。按年龄、性别、放射治疗结束至手术之日的间隔时间、rN分期、是否行术后放射治疗、是否有软组织侵犯、病理检测阳性淋巴结个数和各组淋巴结阳性情况分为2个组。生存率分析采用Kaplan—Meier法，差异显著性检验采用Logrank法，多因素分析采用Cox模型。结果 1、3、5年总生存率分别为80、7％、47、1％、34．9％，其预后因素与有无软组织侵犯、放射治疗结束至手术之日间隔时间有关，术后放射治疗可提高生存率。结论 鼻咽癌放射治疗后颈部复发或未控的淋巴结的治疗可采用根治性颈淋巴结清扫术，对有包膜浸润和(或)周围软组织侵犯的患者可补充放射治疗。     

甲状腺乳头状微小癌中央区淋巴结转移的多因素Logistic回归分析

目的探讨甲状腺乳头状微小癌患者临床病理参数与中央区淋巴结转移的相关性。方法分析经手术治疗的136例甲状腺微小癌的临床病理资料。结果单因素分析显示：肿瘤大小、有无包膜侵犯与中央区淋巴结转移相关;CD 44v6的表达接近显著性水平。多因素分析显示：肿瘤大小、包膜侵犯是影响中央区淋巴结转移的独立因素。结论对肿瘤〉0.5 cm侵犯包膜的甲状腺乳头状微小癌患者可同时行中央区颈淋巴结清扫,而对不具有上述高危因素的患者可以行腺叶切除,辅以术后密切随访。     

头颈部肿瘤颈部淋巴结分区及其靶区的勾画

大量的手术与病理资料证实，头颈部肿瘤的颈部淋巴结转移是有规律的，即从一个区域向邻近区域转移，就特定肿瘤而言，还存在淋巴结转移的高危区域。基于这种规律性转移，外科手术已由根治性颈清扫术发展到依据肿瘤部位和病理类型进行选择性颈清扫术。颈部淋巴结转移规律及选择性颈清扫的治疗效果为头颈部肿瘤进行选择性颈淋巴结照射（ENI）提供了依据。     

颈部肿瘤累及颈动脉的外科治疗体会

对12例累及颈动脉的颈部良性及低恶度肿瘤的外科治疗进行探讨。认为:应依据累及颈动脉的不同情况对颈动脉采用不同的手术方法。对无法进行血管重建的颈动脉切除的患者,采取分期手术,预先一期手术结扎或部分结扎患侧颈总动脉,形成长期的持续性颈动脉阻断锻炼,可缩短二期颈动脉切除手术的术前锻炼时间和提高手术安全性。术前在压迫患侧颈总动脉的同时分别做椎动脉造影及对侧颈动脉造影,可直观显示脑底动脉侧支循环情况,作为术前评价脑侧支循环水平的依据之一。     

手术治疗分化型甲状腺癌190例回顾性分析

目的：通过190例分化型甲状腺癌手术治疗回顾性分析，旨在探讨分化型甲状腺癌的手术切除范围及颈部淋巴结清扫回顾。方法：选取1980年1月至1996年12月收治190例经手术、病理证实为分化型甲状腺癌，其中长期随访140例。结果：156例限于一侧腺叶内的肿瘤，行甲状腺腺叶、峡部切除术，随访102例，仅1例对侧腺叶出现癌复发。96例肿物直径大于1．5cm，并且颈部淋巴结无肿大者，行预防性颈淋巴结清扫，54例发现颈部淋巴结有转移灶。结论：为了降低复发率和避免并发症，甲状腺腺叶、峡部切除是理想的术式；对于原发肿瘤直径大于1．5cm，无论术前、术中是否触到肿大淋巴结，均需作改良颈淋巴结清扫；对临床颈淋巴结阳性者，应根据具体情况实施功能或传统颈淋巴结清扫术。     

择区性颈淋巴结清扫术在临床颈淋巴结阴性甲状腺癌患者中的应用

目的 探讨择区性颈淋巴结清扫术在颈部高危临床颈淋巴结阴性(cN0)甲状腺癌患者中的应用价值.方法 前瞻性分析2006年8月至2011年6月,中国医学科学院肿瘤医院头颈外科收治的63例颈部高危cN0甲状腺癌患者的临床资料.结果 63例患者均经病理证实为甲状腺乳头状癌,侧颈淋巴结隐性转移率为39.7％.单因素分析结果显示,63例患者术后病理检查甲状腺被膜侵犯患者的侧颈淋巴结隐性转移率为46.9％,而甲状腺被膜未侵犯患者的侧颈淋巴结隐性转移率为14.3％,差异有统计学意义(P=0.028).Ⅵ区淋巴结转移患者的侧颈淋巴结隐性转移率为54.3％,而Ⅵ区淋巴结阴性患者的侧颈淋巴结隐性转移率为21.4％,差异有统计学意义(P=0.008).原发灶肿瘤≥2 cm患者的侧颈淋巴结隐性转移率为41.4％,而原发灶肿瘤＜2 cm患者的侧颈淋巴结隐性转移率为38.2％ (P =0.803).术前超声检查发现侧颈淋巴结肿大,但不考虑转移的34例患者中,17例出现隐性淋巴结转移,转移率为50.0％,而侧颈淋巴结术前超声检查阴性患者的隐性淋巴结转移率为27.6％ (P =0.072).多因素Logistic回归分析结果显示,仅Ⅵ区淋巴结转移与侧颈淋巴结隐性转移有关(P=0.017).而原发灶肿瘤被膜侵犯、原发肿瘤大小和术前超声检查侧颈淋巴结状态与侧颈淋巴结隐性转移无关(均P ＞0.05).结论 择区性颈淋巴结清扫术对颈部高危的cN0甲状腺癌患者是可行的,能及时发现和清除侧颈隐性淋巴结的转移.建议对甲状腺被膜侵犯和Ⅵ区淋巴结转移的cN0甲状腺癌患者,常规行颈部Ⅲ、Ⅳ区淋巴结清扫.     

分化型甲状腺癌再手术42例分析

１９８５年１月至１９９５年１０月，４２例分化型甲状腺癌施行了再手术治疗。其中男性７例，女性３５例。再手术原因：原发癌灶残留；术后复发；颈淋巴结转移灶残留；对侧甲状腺及对侧颈淋巴结出现癌灶。再手术方式：原发癌灶局切者应再次切除残叶及峡部；对肿瘤侵出包膜者，作者认为应放宽预防性淋巴结清扫术的指征，有淋巴结转移者施行传统性或功能性颈淋巴结清扫术；对侧腺叶出现癌灶或对侧出现颈淋巴结转移者，应做对侧甲状腺癌的根治手术。     

保留颈丛的功能性颈清扫术在分化性甲状腺癌治疗上的应用

目的：探讨保留颈丛感觉神经的功能性颈清扫术在分化性甲状腺癌上的应用。方法：15例甲状腺乳腺乳头状癌患者,施行保留颈丛感觉神经的功能性颈清扫术。结果：颈部阳性淋巴结主要分布在Ⅲ区,Ⅳ区,Ⅵ区。Ⅵ区淋巴结阳性者颈部淋巴结转移率为（57．1％）。15例患者术后全部耳部感觉良好,下颈部及肩部无麻大感。结论：手术适应证：①N0的甲状腺乳头状腺癌。②N1的甲状腺乳头状腺癌,淋巴结转移仅仅局限Ⅵ区者,或颈内静脉旁淋巴结较小（N＜3cm）无包膜外侵犯者。手术禁忌征：①手术前已有不规范颈清扫术史者;②颈淋巴结广泛转移或淋巴结有明显外侵者。     

分化型甲状腺癌再手术42例分析

１９８５年１月至１９９５年１０月，４２例分化型甲状腺癌施行了再手术治疗。其中男性７例，女性３５例。再手术原因；原发癌灶残留；术后复发；对侧甲状腺及对侧颈淋巴结出现癌灶，再手术方式：原发癌灶局切者应再次切除残叶及峡部；对肿瘤侵出包膜者，作者认为应放宽预防性淋巴结清扫术的指征，有淋巴结转移者施行生或功能性颈淋巴结清扫术；对侧腺叶出现癌灶或对侧出现颈淋巴结转移者，应做对侧甲状腺癌根治手术。     

A historical prospective cohort study of carotid artery stenosis after radiotherapy for head and neck malignancies

PURPOSE: To determine carotid artery stenosis incidence after radiotherapy for head-and-neck neoplasms. METHODS AND MATERIALS: This historical prospective cohort study comprised 44 head-and-neck cancer survivors who received unilateral neck radiotherapy between 1974 and 1999. They underwent bilateral carotid duplex ultrasonography to detect carotid artery stenosis. RESULTS: The incidence of significant carotid stenosis (8 of 44 [18%]) in the irradiated neck was higher than that in the contralateral unirradiated neck (3 of 44 [7%]), although this difference was not statistically significant (p = 0.13). The rate of significant carotid stenosis events increased as the time after radiotherapy increased. The risk of ipsilateral carotid artery stenosis was higher in patients who had undergone a neck dissection vs. those who had not. Patients with significant ipsilateral stenosis also tended to be older than those without significant stenosis. No other patient or treatment variables correlated with risk of carotid artery stenosis. CONCLUSIONS: For long-term survivors after neck dissection and irradiation, especially those who are symptomatic, ultrasonographic carotid artery screening should be considered.     

头颈部肿瘤术后致命性大出血分析

目的 探讨头颈部肿瘤术后致命性大出血的处理方法.方法 对32例头颈部肿瘤术后大出血患者进行回顾性分析.结果 32例头颈部肿瘤术后大出血患者中,颈动脉出血20例,其中下咽及颈段食管癌11例,甲状腺癌3例,喉癌3例,鼻咽癌、口咽癌和腮腺癌各1例;有14例患者获得手术机会,其中13例行动脉结扎,1例患者应用碘纺压迫止血,6例获得长期生存.气管无名动脉瘘导致出血12例,其中下咽及颈段食管癌6例,甲状腺癌3例,喉癌2例,舌癌1例;有2例获得手术机会,其中1例行动脉结扎,另1例因破裂处位于主动脉弓,无法修补及结扎,无一例长期生存.结论 头颈部肿瘤术后的致命性大出血是危及生命的严重并发症,早期发现和处理有助于提高抢救成功率.     

Gastric pull-up for cancers of the hypopharynx and cervical esophagus: our experience

Twenty-five cases of squamous cancer of the hypopharynx and cervical esophagus treated with laryngopharyngoesophagectomy and pharyngogastric anastomosis are presented. In all cases the lesion was such that a complete circumferential pharyngectomy was necessitated. Twelve patients had received full radiation therapy and surgery was undertaken for residual and recurrent disease. Eleven patients had a concurrent unilateral radical neck dissection and two patients a concurrent bilateral neck dissection. Five patients died within 1 month following surgery. The causes of death are discussed. The most notable features of this method of pharyngeal and cervical esophageal reconstruction is the early restoration of swallowing (20 patients were on oral feed in less than 10 days following surgery), a very low incidence of anastomatic leak and subsequent hazards of a carotid hemorrhage (only one patient had a major leak leading to carotid hemorrhage), and absence of subsequent anastomotic stenosis as is seen after reconstruction with skin tubes.     

Sonographic evaluation of operability of malignant cervical lymph nodes

Infiltration of the carotid artery by malignant cervical nodes is considered to be a contraindication for radical neck dissection in many centers. Clinical examination alone is unlikely to provide information on the fixity of nodes to the carotid artery. We studied the role of ultrasonography as an adjunct to clinical examination in screening patients for neck dissection. Twenty-seven patients with clinical neck node metastasis were chosen for ultrasonography. All of them had surgery and the findings were correlated. The findings revealed that this procedure is effective in delineating involvement of carotid artery by neck nodes and in identifying false-positive and false-negative cases. Since the sample of patients studied was small, the study is continuing in order to accrue a larger sample.     

Threatened carotid artery rupture: a complication of radical neck surgery

Carotid artery rupture is an infrequent but highly dangerous postoperative complication of radical head and neck surgery. The principal predisposing factors are radiation therapy, infection, tissue necrosis, vessel exposure, and pharyngeal fistula formation. Actual or threatened carotid artery rupture has been most commonly managed by ligation of the involved vessel. We present a patient who showed signs of impending carotid artery rupture after both irradiation and radical neck surgery. Balloon embolization was employed in preference to traditional carotid artery ligation. The patient's risk factors for carotid artery rupture are analyzed and the application of balloon embolization is discussed.     

Extended neck dissection

From the time Crile described radical neck dissection in 1906, this surgical procedure became popular in the management of metastatic cancer in the neck. Over the past two decades, the modified neck dissection has been effectively utilized for conservation of function and cosmesis while achieving the same oncologic goals. However, there are several instances where the above standard procedures are not adequate for resection of malignant tumors. Although there is a definite trend toward conservation procedures, extended neck dissection is often necessary especially in patients with N2 and N3 disease. Apart from the standard structures removed in radical neck dissection, the other structures removed in extended neck dissection include skin, the digastric muscle, hypoglossal nerve, vagus nerve, sympathetic chain, ramus mandibularis, carotid artery, tracheo-esophageal nodes, etc. Over the past seven years, we have performed 40 extended neck dissections. All the patients had N2 or N3 disease in the neck. Nine patients had unknown primaries. Thirteen patients had their primary tumors in the oral cavity and 11 in the laryngopharynx. Five patients had primary tumor in the salivary glands and two patients had metastatic melanoma. Patients who underwent extensive skin excision had pectoralis myocutaneous flap reconstruction. All patients received postoperative radiation therapy. One patient died of cardiac problems 4 weeks after operation. Local control was achieved in 70%. The most difficult region for local control was the disease behind the mastoid process, and the most difficult problems were patients with involvement of the subdermal lymphatics. Our data suggests that there are definite situations where extended neck dissection is indicated with satisfactory local control of the nodal disease.     

Variations of the Cervical Internal Carotid Artery

The objective of this study was to report the variations of the cervical internal carotid artery, as encountered during neck dissection for head and neck malignancies. A retrospective analysis of neck dissections performed for the management of various head and neck cancers, during 2006–2010 was carried out. Among 102 patients and 119 neck dissections, five of them were found to be having abnormalities of the cervical part of the internal carotid artery during its course in the neck and were analyzed in detail. Out of five subjects, four were males and the other was female with age ranging from 50 to 74 years. Of the five patients two had mild degree of tortuosity, two patients had moderate degree of tortuosity and another patient had severe degree of tortuosity in the course of internal carotid artery in the neck. Based on our cases, the possibilities of various vascular variations should be kept in mind while performing the neck dissection. This will help in preventing inadvertent injury to these vital structures and prevents subsequent consequences.     

甲状腺乳头状腺癌颈清扫的争议

甲状腺乳头状腺癌颈淋巴结转移率较高是其特点之一,多数认为临床阴性者无需行预防性颈清扫术,治疗性清扫以颈改良性清扫术为标准治疗术式.颈清扫的范围越来越多的处于争议之中,Ⅰ区不必常规清扫,Ⅱ区倾向于包括,Ⅴ区的清扫对颈肩部功能有不同程度的影响,低危者可以观察,密切随访,一旦复发及时治疗.常规中央区清扫有助于降低复发率.择区性清扫术在甲状腺乳头状腺癌中的应用还有待于进一步研究和确定.     

Neck dissection: current concepts and future directions

For individuals diagnosed with head and neck cancer, neck dissection may be performed for therapy or disease staging. The classification of neck dissection and the definition of precise anatomic landmarks have allowed for this operation, and its many variations, to become standardized world-wide. SLNBX shows promise in its ability to accurately stage NO head and neck cancer and may allow patients with no micro metastatic disease to avoid neck dissection. Before this technique becomes adopted into routine clinical practice, however, it must first be prospectively scrutinized in large patient populations. Regardless of the future role of SLNBX in the management of head and neck cancer, currently it is only through a complete understanding of the clinical, theoretic, and technical aspects of neck dis-section that surgeons may benefit individual patients and the head and neck cancer patient population as a whole.