梨状窝癌同期颈淋巴结转移特点

目的：研究梨状窝癌同期颈淋巴结转移特点和规律。方法：回顾性分析102例梨状窝癌临床、病理资料,并对其颈淋巴结同期转移的特点和分布规律等情况进行统计分析。结果：T1、T2、T3和T4梨状窝癌同期颈淋巴结转移率分别为16.7%、59.4%、70.8%和63.6%。T1梨状窝癌同期颈淋巴结转移率与T2、T3和T4梨状窝癌同期颈淋巴结转移率相比均差异有统计学意义（均P〈0.05）。T2、T3和T4梨状窝癌同期双侧颈淋巴结转移分别为2.7%（1/37）、12.5%（6/48）、18.1%（2/11）,T2和T3、T4之间梨状窝癌同期双侧颈淋巴结转移率相比均差异有统计学意义（均P〈0.05）。14例无颈淋巴结转移（cN0）梨状窝癌行改良颈清扫术,术后病理证实有10例出现颈淋巴结转移,转移率达71.4%。64例梨状窝癌73侧出现同期颈淋巴结转移,转移区域主要集中在Ⅱ区、Ⅲ区和Ⅳ区,其转移例次构成比分别为33.55%、30.97%和25.16%;而Ⅰ区、Ⅴ区、Ⅵ区转移率较低,分别为3.87%、5.16%和1.29%。cN0和cN1转移淋巴结全分布在Ⅱ、Ⅲ和Ⅳ区,无Ⅰ区、Ⅴ区和Ⅵ区转移。cN0梨状窝癌Ⅱ、Ⅲ和Ⅳ区转移率分别为46.7%、33.3%和20.0%,cN1梨状窝癌Ⅱ、Ⅲ和Ⅳ区转移例次构成比分别为41.7%、33.3%和25.0%。cN2和cN3除Ⅱ、Ⅲ和Ⅳ区转移外,尚有少数病例出现Ⅰ区、Ⅴ区、Ⅵ区转移。结论：T2、T3和T4梨状窝癌易发生同期颈淋巴结转移;T3和T4梨状窝癌易发生同期双侧颈淋巴结转移;T3、T4梨状窝癌和颈淋巴结双侧转移的梨状窝癌较易出现转移淋巴结包膜外侵;cN0和cN1转移淋巴结全部分布在Ⅱ、Ⅲ和Ⅳ区;cN2和cN3转移淋巴结主要分布在Ⅱ、Ⅲ和Ⅳ区转移,Ⅰ、Ⅴ、Ⅵ区转移相对较少。     

梨状窝癌对侧颈淋巴结转移的临床病理研究

目的:研究梨状窝癌颈淋巴结对侧转移的相关因素。方法:收集1993年10月~1999年10月同期行颈廓清术53例梨状窝癌,术后颈廓清标本采用透明淋巴结摘出连续切片法,观察颈淋巴结转移状况,再通过随访资料,分析肿瘤对侧转移与临床病理因素及同侧颈淋巴结转移状况的关系。结果:53例梨状窝癌颈淋巴结转移率为79.2%,对侧颈淋巴结转移率为35.8%。对侧转移与临床N分级、病理分化程度、同侧转移淋巴结中融合转移及破膜转移密切相关。结论:对于N2~3病例及肿瘤分化程度中、低病例,或者同侧转移淋巴结发现融合转移及破膜转移,都应该积极地作肿瘤对侧颈廓清术。     

99m锝-右旋糖酐颈淋巴显像对喉癌和下咽癌颈淋巴结转移的诊断价值

目的：探讨乳突区皮下注射^99m锝-右旋糖酐（^99mTc-DX105）单光子发射计算机断层扫描（SPECT）颈淋巴显像对喉癌和下咽癌颈淋巴结转移的诊断价值。方法：对30例喉癌和下咽癌患者术前经双侧乳突区皮下注射^99mTc-DX105 SPECT颈淋巴显像与颈廓清标本病理检查进行对比研究。结果：30例患者53侧颈部SPECT，显像阳性24侧，其中3侧为假阳性；阴性29侧，其中1侧为假阴性。53侧SPECT颈淋巴显像的敏感性、特异性及准确率分别为95．5％（21／22）、90．3％（28／31）和92．5％（49／53）。8侧隐匿性转移淋巴结中SPECT显像检出7侧，检出率为87．5％（7／8）。结论：乳突区皮下注射^99mTc-DX105 SPECT颈淋巴显像对指导喉癌和下咽癌的临床分期及颈淋巴结清扫，具有一定的临床意义。     

下咽癌颈淋巴结转移的临床病理学特点及其对预后的影响

目的探讨影响下咽癌颈淋巴结转移的临床病理因素和颈淋巴结转移对预后的影响。方法采用X^2检验和Logistic回归分析，对98例下咽癌患者的临床病理学因素与颈淋巴结转移的关系进行回顾性研究。并对颈淋巴结转移状态、转移颈淋巴结大小、转移颈淋巴结数目、转移颈淋巴结累及区域数、转移颈淋巴结最低受累区域等淋巴结病理学因素对生存率的影响，进行Cox回归分析。结果下咽癌患者5年生存率为28．6％。单因素和多因素分析均证实，肿瘤生长方式、肿瘤大小与发生颈淋巴结转移关系密切。而肿瘤突破基底膜达黏膜下层后对下咽癌颈淋巴结转移发生率不再产生进一步影响。Cox回归分析表明，临床N分期、颈淋巴结转移状态、转移颈淋巴结大小、转移颈淋巴结最低受累区域因素影响患者生存率，特别是转移颈淋巴结大小、转移颈淋巴结最低受累区域因素与下咽癌患者生存率明显相关。结论下咽癌颈淋巴结转移是影响患者预后的重要因素，预测下咽癌颈淋巴结，对其作出早期正确诊断，并对影响预后的淋巴结因素采取相应治疗措施是提高下咽癌治疗效果的关键。     

梨状窝癌对侧颈淋巴转移的临床特点

目的分析影响梨状窝癌肿瘤对侧颈淋巴转移的相关因素。方法选择术前没有接受其他治疗的96例梨状窝癌，通过随访资料分析肿瘤对侧颈淋巴转移与哪些因素相关。判定肿瘤对侧颈淋巴转移的条件是：①双侧颈淋巴清扫术后在肿瘤对侧可病理确诊的转移淋巴结(pN2c)；②术后首先发现有肿瘤对侧转移的复发病例，其中除外有原发病灶的复发。结果96例中有31例出现肿瘤对侧颈淋巴转移，总转移率为32％。与T分期的关系是：T1无肿瘤对侧转移(0／3)，T2病例中肿瘤对侧转移占18％(2／11)，113占37％(22／60)，T4占32％(7／22)。与N分期的关系是：NO病例中肿瘤对侧转移占12％，N1占13％，N2a占17％，N2b占39％，N2c占100％，N3占75％。与肿瘤是否过中线的关系是：过中线组肿瘤对侧转移为52％，未过中线组为18％。结论梨状窝癌随着T分期和N分期的增高，肿瘤对侧淋巴颈淋巴转移率有增高趋势。肿瘤过中线后肿瘤对侧淋巴转移率明显增高，应积极选择颈清扫术。     

头颈部鳞癌颈淋巴结转移方式的临床病理学研究

为了探讨头颈肿瘤颈淋巴结转移的规律，对３８４侧根治性颈淋巴清扫标本进行连续切片观察，发现颈淋巴结转移病理阳性的总发生率为６０．４％，其中Ｎ０病例颈淋巴结转移率为３１．７％，Ｎ１－３颈转移率为８１．２％，口腔癌主要向Ⅰ，Ⅱ和Ⅲ区转移，口咽癌，下咽癌和喉癌主要向Ⅱ，Ⅲ和Ⅳ区转移，转移的淋巴结主要分布于一个或相邻的三个解剖区。颈淋巴结转移病理阳性和淋巴结包膜破坏的发生率随着临床Ｎ分期的增加而升高，且后者     

头颈部鳞癌颈淋巴结转移诸因素对预后的影响

对382例头颈部原发鳞癌病人颈清扫标本连续切片病理观察结果和临床资料进行回顾性分析，探讨淋巴结转移的各项临床和病理学因素与病人预后的关系。发现总体5年生存率为46.1％，口腔癌、口咽癌、下咽癌和喉癌的5年生存率分别为49．7％，39．7％，35．0％和60．3％。表明颈淋巴结的临床分期、触诊淋巴结大小、病理转移淋巴结情况、颈淋巴解剖分区受累数和最低受累平面与病人5年生存率有密切关系（均P＜0．01），而阳性淋巴的个数对病人预后无明显影响。提示针对影响预后的淋巴结因素应采取相应的治疗措施，以提高病人的5年生存率。     

颈部淋巴结阴性下咽癌患者的预后及远期生存分析[论著]

目的　研究分析淋巴结病理阴性（pN0）下咽鳞状细胞癌患者的生存和预后影响因素。方法　回顾性分析2001年1月~2014年12月在复旦大学附属眼耳鼻喉科医院行下咽切除术的53例下咽鳞状细胞癌患者资料,所有患者经术前评估均无颈部淋巴结转移,均行颈清扫术并且病理证实无颈部淋巴结转移。收集患者临床病理资料,随访其生存情况并分析预后影响因素。结果　梨状窝癌37例,环后区癌7例,咽后壁癌9例。T1级2例,T2级21例,T3级21例,T4级9例。5年无病生存率、疾病特异性生存率、总生存率分别为61.1%、63.6%、42.4%。多因素分析显示食管侵犯是影响复发率、疾病特异性生存率、总生存率的独立危险因素。结论  食管侵犯是颈部淋巴结阴性下咽鳞状细胞癌患者的重要预后影响因素,对于食管发生侵犯的患者术后应密切随访。     

下咽癌累及颈段食管的处理

目的总结下咽癌累及颈段食管的处理经验。方法回顾性分析1989年—2000年48例累及颈段食管的下咽癌患者的手术治疗情况，其中男38例，女10例；年龄26～71岁，平均54．3岁。梨状窝癌33例，下咽后壁区癌14例，环后癌1例，均无远处转移。根据UICC1997年TNM分期标准均为T4M0期，其中cN0 28例，cNl 15例，cN2 5例。喉全切除术8例，喉部分切除残喉气管瓣修复下咽17例，23例保留了喉功能。所有病例均行改良性颈清扫术，其中单侧清扫38例，双侧清扫10例。患侧甲状腺叶切除42例。下咽食管缺损的修复方法分别为：喉气管瓣修复11例，胸大肌肌皮瓣13例，喉气管瓣＋胸大肌肌皮瓣6例，裂层皮片＋胸大肌肌皮瓣10例，胃上提咽胃吻合3例，结肠上徙5例。术后均接受放射治疗，剂量为55—75Gy。结果手术证实颈部淋巴结转移20例病理诊断；高分化鳞状细胞癌18例，中分化鳞状细胞癌24例，低分化鳞状细胞癌6例。术后并发症包括胸部刀口裂开1例，咽瘘10例。直接法计算生存率，失访2例以死亡计。全组患者3、5年生存率分别为52．1％（25／48）和27．3％（12／44）。保留喉功能组3、5年生存率分别为65．2％（15／23）和33．3％（7／21），不保留喉功能组3、5年生存率分别为40．0％（10／25）和21．7％（5／23）。23例保留了喉功能，15例患者拔除了气管套管，恢复了全部喉功能（发音、呼吸、吞咽保护），8例患者恢复了部分喉功能（发音、吞咽保护），拔管率为65．2％（15／23）。结论下咽癌累及颈段食管的处理以手术＋放疗的综合治疗为主，需行患侧颈清扫术，应尽量保留喉功能，无法保留喉功能时可以采用喉气管瓣或联合裂层皮片、胸大肌肌皮瓣修复下咽颈段食管缺损，颈段食管缺损较大时则采用胃或结肠代替。     

下咽癌颈淋巴结转移区域探讨

目的 研究下咽癌颈淋巴结转移区域的特点及术后治疗策略,改善预后.方法 回顾性分析2002年7月～2008年7月于我科住院治疗的35例下咽癌患者的临床资料,29例患者均行手术治疗,且术前未行放疗或化疗,将术中肿瘤原发灶及颈清扫术中的颈淋巴结标本按区域标记逐一进行病理观察,确定肿瘤原发部位及颈淋巴结转移区域.通过随访3～5年,观察转移及预后.结果 29例下咽癌总的颈淋巴结转移率为86.2％(25/29),颈淋巴结转移的主要区域为Level Ⅱ区、Level Ⅲ区,转移率为73.8％、69.0％,其次为Level Ⅳ区7.7％,未发现Level Ⅰ区、Level Ⅴ及LevelⅥ区淋巴结转移.结论 下咽癌颈淋巴结转移率较高,转移区域同侧为主,以Level Ⅱ、Level Ⅲ区常见.随着颈淋巴结位置的下移及转移淋巴结直径的增大,患者的预后越来越差.     

The impact of paratracheal lymph node metastasis in squamous cell carcinoma of the hypopharynx

The aim of this study was to analyze the prevalence and prognostic importance of paratracheal lymph nodes in squamous cell carcinoma of the hypopharynx. A retrospective review of 64 previously untreated patients with squamous cell carcinoma (SCC) of the hypopharynx that underwent surgery was performed. Ipsilateral paratracheal lymph node metastases occurred in 22% (14 out of 64) and the mean number of paratracheal lymph nodes dissected per side was 2.3 (range 1–6). Contralateral paratracheal lymph node metastases were present in 2% (1 out of 42). Sixty-seven percent with postcricoid SCC and 22% with pyriform sinus SCC developed clinical node-positive ipsilateral paratracheal lymph node metastases, whereas 11% with posterior pharyngeal wall SCC developed paratracheal metastases. There was a significant correlation between paratracheal lymph node metastasis and cervical metastasis (p = 0.005), and the primary tumor site (postcricoid, 57.1%; pyriform sinus, 20.0%; posterior pharyngeal wall, 8.3%) (p = 0.039). Patients with no evidence of paratracheal lymph node metastasis may have a survival benefit (5-year disease-specific survival rate, 60 vs. 29%). However, this result did not reach statistical significance (p = 0.071). The patients with SCC of the postcricoid and/or pyriform sinus were at risk for ipsilateral paratracheal lymph node metastasis; furthermore, patients with paratracheal node metastasis had a high frequency of cervical metastasis and a poorer prognosis. Therefore, routine ipsilateral paratracheal node dissection is recommended during the surgical treatment of patients with SCC of the postcricoid and/or pyriform sinus with clinical node metastases.     

保留喉功能喉咽癌的手术切除与修复

目的 评价喉咽癌保留喉功能手术临床治疗效果和影响预后因素.方法 回顾性分析1974年9月至2003年7月收治的45例喉咽癌保留喉功能手术临床治疗效果.其中梨状窝癌23例,环后癌13例,喉咽后壁癌9例.术前放疗2例,放疗量40～50 Gy;术后放疗32例,放疗剂量60～70 Gy.分析影响患者生存率的危险因素.结果 45例保留喉功能术后发音清晰者88.9%,发音轻度含混者占11.1%;23例拔除气管套管,拔管率51.1%,全部能进普食.出现术后并发症19例(42.2%);术后颈部淋巴结转移20例,占44.4%.Kaplan-Meier法统计全组患者5年生存率为53.3%.T1+T2组和T3+T4组患者术后5年生存率分别为66.7%和43.3%;cN0和cN1、cN2组生存率分别为65.2%和46.7%、28.6%;病理分化程度高、中和低组生存率分别为62.3%、42.1%和30.8%.单因素分析生存率与术前有无颈淋巴转移及病理分化程度有关(x2值为5.297和11.556,P值为0.021和0.003).Cox回归多因素分析显示,术前有无颈淋巴转移和病理分化程度是影响预后的独立危险因素(x2值为4.365和4.600,P值为0.041和0.032,OR值1.151和0.610).结论 喉咽癌保留喉功能手术为T1、T2患者的最佳术式,部分T3、T4晚期喉咽癌也可以采用保留喉功能手术.正确选择颈清扫的方法,有助于提高喉咽癌保留喉功能手术的生存率.     

兔VX2梨状窝癌模型建立及其生物学特性观察

目的 应用VX2瘤建立兔梨状窝癌的原位模型,并观察其生物学特性.方法 接种VX2瘤于15只新西兰兔的梨状窝黏膜下,将接种后的新西兰兔随机平均分为3组,分别在接种后14、21和28 d时各取一组观察其肿瘤生长情况,并立即进行组织病理学检查.结果 15只兔均接种成功,VX2梨状窝肿瘤成瘤率100%.14 d和21 d组,所有动物无明显进食减少、体重减轻及气促等症状;28 d组出现进食减少,体重减轻,鼻腔有较多分泌物及气急等症状.病理学检查证实,接种14、21、28 d后每组5只兔均出现同侧颈深淋巴结转移;而颌下淋巴结的同侧转移率在14、21和28 d时分别为3/5、4/5和5/5.气管旁淋巴结的同侧转移率在14、21和28 d时分别为0、4/5和5/5.14、21和28 d时分别有4、3、5只兔出现对侧颈深、颌下或气管旁淋巴结转移.14、21、28 d时颈深、颌下和气管旁淋巴结的最大直径中位数分别为1.50、0.60和0 cm,1.60、0.80和0.50 cm,1.80、0.80和0.65 cm,差异无统计学意义(P值均>0.05).结论 成功建立兔VX2梨状窝癌模型,14 d时出现颈深淋巴转移.     

Management of contralateral N0 neck in pyriform sinus carcinoma

OBJECTIVE: The hypopharynx has a rich lymphatic network that places patients with tumors of the hypopharynx at high risk for early dissemination of the disease into the cervical lymphatics. Therefore, ipsilateral elective neck dissection of clinically N0 neck in lateralized lesions of hypopharyngeal squamous cell carcinomas (SCCs) is widely accepted as a standard treatment. However, the management of the contralateral N0 neck is still controversial. The aim of this study was to evaluate the incidence and predictive factors of contralateral occult lymph node metastasis in pyriform sinus SCC. MATERIALS AND METHODS: We performed a retrospective analysis of 43 patients with N0 to 3 pyriform sinus SCC with contralateral clinically node-negative necks who had also received contralateral elective neck dissections from 1994 to 2003. Surgical treatment was followed by postoperative radiotherapy in 41 patients. The follow-up period ranged from 4 to 135 months (mean, 40 months). The Kaplan-Meier method and log-rank test were used to calculate the disease-specific survival rates and prognostic significance of contralateral occult lymph node metastasis. RESULTS: Contralateral occult lymph node metastases occurred in 16% (seven of 43) of the subjects. Twenty-six percent of the 27 subjects with clinically node-positive ipsilateral neck developed contralateral occult lymph node metastases, whereas 0% of the 16 subjects with N0 ipsilateral necks (P=.035) developed the disease. Moreover, in cases with primary site extension across the midline, the rate of contralateral occult neck metastasis was significantly higher (P=.010). However, there were no statistically significant differences in age, sex, early versus advanced T stage, number of ipsilateral positive nodes, lymph nodes with extracapsular spread, primary subsite of medial versus lateral pyriform sinus, pyriform sinus apex involvement, and growth type. Patients with no evidence of contralateral nodal cancer had significantly improved disease-specific survival over patients with any pathologically positive nodes (5-year disease-specific survival rate, 66% vs. 33%, P<.05). CONCLUSION: The patients with pyriform sinus SCC with clinically ipsilateral N+ neck and/or extension across the midline are at greater risk for contralateral occult neck metastases. Furthermore, patients who present with a contralateral metastatic neck have a worse prognosis than those staged as N0. Therefore, we advocate bilateral neck treatment in patients with pyriform sinus SCC with clinically ipsilateral node metastases and/or extension across the midline.     

声门上型喉癌颈淋巴结转移方式及其对预后的影响

目的：探讨影响声门上型喉癌颈淋巴结转移的临床病理因素及颈淋巴结转移对预后的影响。方法：用x^2检验和Logistic回归分析，对55例声门上型喉癌患者的肿瘤临床病理学因素与颈淋巴结转移的关系进行回顾性分析；并对颈淋巴结转移状态，转移颈淋巴结大小、数目、累及区域、最低受累区域等病理学因素对预后的影响进行Cox回归分析。结果：单因素分析显示，肿瘤病理分级、肿瘤大小、肿瘤浸润深度与发生颈淋巴结转移有关；多因素分析显示，肿瘤病理分级、肿瘤大小与发生颈淋巴结转移明显相关；声门上型喉癌患者5年生存率为52．7％。Cox回归分析表明，临床N分期、颈淋巴结转移状态、转移颈淋巴结大小影响患者预后。结论：声门上型喉癌颈淋巴结转移的发生受原发癌病理学因素的影响，它从多个角度明显影响患者预后；对影响预后的淋巴结因素采取相应治疗措施，对提高声门上型喉癌的治疗效果具有重要意义。     

Clinical study of cervical lymph node metastasis in maxillary cancer patients

The clinical characteristics of lymph node metastasis in maxillary cancer patients were analyzed. Thirty-eight (23%) of the 166 patients who received intial treatment at Kurume University Hospital between 1978 and 2003 had cervical lymph node metastasis at the time of diagnosis. The disease-specific 5-year survival rate was 63% in the lymph node metastasis negative group and 18% in the lymph node metastasis positive group (p<0.01). There was a statistically significant correlation between bone invasion and lymph node metastasis in the case of the group with bone invasion of the posterior wall of the maxillary sinus. Cervical neck lymph node metastasis developed in 38 (28%) of 135 posterior-wall-invasion-positive group and in none (0%) of the 31 patients in the negative group (p<0.01). Because distant metastasis is common in patients with lymph node metastasis, postoperative adjuvant chemotherapy is highly recommended.     

Simultaneous bilateral neck dissections

From April 1985 to December 1989, 65 patients with advanced head and neck squamous cell carcinoma, underwent simultaneous bilateral neck dissection (SBND) at Saitama Cancer Center. Three and five year survival percentages were 53 and 42%, respectively. In patients without histologic involvement of cervical nodes, five year survival rate was 83%, whereas in those with nodal involvement five year survival fell to 32% (p less than 0.005). The conclusion were the following: (1) Of 38 patients diagnosed to have lymph node involvements on one side of neck before operation, 8 patients (22%) were found to have bilateral lymph node metastasis in clinicopathological study. Of 13 patients having no clinical lymph node metastasis on both sides of neck, 7 patients (54%) were found to have unilateral lymph node metastasis. Of 16 patients diagnosed to have bilateral lymph nodes involvement, 10 patients were found to have bilateral neck metastasis and 2 had unilateral neck metastasis. (2) Of 35 cases of hypopharyngeal canners, 19 cases had clinically positive lymph nodes on one side of neck. Of these 19 cases, 5 cases (26%) had histologically positive nodes on the opposite side. 14 (40%) of 35 cases had metastasis on the opposite side. In conclusion, SBND is a proper treatment for metastatic cervical cancer from a primary lesion of the head and neck, especially in hypopharyngeal cancers, because the rate of recurrence seems to be related more to the difficulty in controlling lymph node metastasis than to the failure in treatment of the primary cancer.     

喉近全切除术的扩大适应证

进一步总结这全切除术的经验。方法 选择Ｔ３，Ｔ４喉鳞状细胞部５７例行喉近全切除术。结果 术后发音成功率９３％，３年生存率为６７．５％，下咽癌为５０％，局部复发经仅３．５％。其适应征为适宜常规部分喉切除的喉癌；还可应用于舌根口咽癌，梨状窝癌，颈食食管癌等。