对cN0喉及下咽癌患者进行Ⅳ区和Ⅴ区的颈清扫是否合理

目的:为了制定恰当的颈清扫治疗方案,对cN0喉癌和下咽癌患者的淋巴结累及区域和复发率作一评价。方法:回顾性分析接受局限性颈淋巴结清除术的238例cN0患者,至少随访24个月,并对局部复发进行评估。结果:Ⅳ区的隐匿性淋巴结转移率是3.4%;其中单独转移至Ⅳ区的是1.5%。我们观察发现颈部的局部复发率是5.6%,在Ⅴ区没有发现淋巴结转移和局部复发。结论:当术中颈淋巴结冷冻切片为阴性,对cN0患者可合理性做出Ⅱ、Ⅲ区清扫术,Ⅳ区部分清扫术及对侧颈部淋巴结清扫术,得出结论:Ⅴ区颈清扫术是没有必要的,除非在Ⅴ区有明显的转移灶。     

声门上型喉癌临床颈淋巴结阴性患者颈清扫区域的选择

目的　探讨声门上型喉癌临床诊断N0 (clinicalN0 ,cN0 )患者颈淋巴结转移的特点 ,选择合理的清扫区域。方法　 5 7例声门上型喉癌患者行喉切除术的同时行改良性颈清扫术 ,将颈清扫的淋巴结标本分区域逐一行病理学检查 ,确定转移区域或复发的区域。结果　 5 7例 (6 3侧 )颈清扫标本共获淋巴结 1877枚 ,平均每侧获 2 9 8枚 ,有转移的 4 3枚 ,其中 4 1枚位于Ⅱ、Ⅲ区 ,占 95 4 % (41/ 4 3)。15例 (17侧 )患者有淋巴结转移 ,转移率为 2 6 3% (15 / 5 7)。其中 14例位于Ⅱ、Ⅲ区 ,占转移例数的93 3% (14 / 15 )。颈部复发 3例 ,复发率为 5 3% (3/ 5 7) ,复发部位分别位于Ⅱ、Ⅲ、Ⅳ区。 5年生存率为 80 7% (46 / 5 7)。结论　对声门上型喉癌cN0重点行Ⅱ和Ⅲ区颈淋巴结清扫术 ,Ⅲ区受累时应包括Ⅳ区 ,Ⅰ、Ⅴ区在无明显转移证据时可避免行颈清扫术     

叶绿素染色在喉癌下咽癌颈淋巴结清扫术中的应用

目的 :探讨喉癌、下咽癌的颈淋巴结转移方式。方法 :对 5 0例喉癌、下咽癌患者于颈清扫术前 ,在喉及下咽粘膜下注射叶绿素使颈淋巴结系统染色 ,指导施行颈清扫术并收集淋巴结 ,进行连续切片观察。结果 :颈淋巴结被染成深绿色 ,与周围组织颜色对比明显 ,便于颈部手术和采集淋巴结 ;经病理检查证实 ,颈淋巴结总的转移率为 4 8% ,Ⅰ、Ⅴ区转移时均伴有其它区域的转移 ,Ⅱ、Ⅲ区转移率高于Ⅰ、Ⅳ、Ⅴ区 (P <0 .0 1) ;临床诊断颈淋巴结阴性 (cN0 )的患者淋巴结转移率为 2 3.5 % ,转移区域均在Ⅱ、Ⅲ区。结论 :临床诊断颈淋巴结阳性 (cN+ )喉癌、下咽癌患者的颈清扫手术 ,首先要保证清扫II、III区淋巴结 ,术中所见决定选择性颈清扫术式 ,对cN0 的下咽癌或声门上癌可行单侧或双侧颈深上、中淋巴结清扫术。叶绿素染色清晰 ,安全无毒 ,便于手术 ,可以在颈清扫术中常规应用     

cN0声门上型喉癌颈淋巴结隐匿性转移规律及处理

目的:探讨cN0声门上型喉癌患者颈部淋巴结隐匿性转移规律并选择合理的颈清扫区域。方法:139例cN0声门上型喉癌患者在行喉切除术同时行颈淋巴结清扫术,其中行改良性颈清扫57例,肩胛舌骨肌上淋巴结清扫30例,颈Ⅱ、Ⅲ区淋巴结清扫52例。将所获淋巴结按颈部分区逐一行组织病理学检查,观察其转移规律及临床疗效。结果:139例cN0声门上型喉癌患者中,同期行单侧颈清扫113例,同期行双侧颈清扫26例。139例(165侧)颈清扫标本经病理学检查,颈淋巴结阳性36例(25.9%),首次病理学检查颈淋巴结阴性者在随访中发现未手术侧淋巴结转移6例,总颈淋巴结隐匿性转移率为30.2%(42/139),单侧隐匿性转移率为26.6%(37/139),双侧隐匿性转移率为3.6%(5/139)。165侧颈清扫标本共获得淋巴结3 594枚,平均每侧21.8枚,共获病理阳性淋巴结83枚,其中位于Ⅰ区1枚(1.2%),Ⅱ区65枚(78.3%),Ⅲ区16枚(19.3%),Ⅳ区1枚(1.2%),Ⅴ区0枚。颈部复发率为5.0%(7/139),pN0与pN+的颈部复发率分别为0和16.7%(7/42),差异有统计学意义(P<0.05),总5年生存率为76.3%(106/139)。结论:颈Ⅱ、Ⅲ区是cN0声门上型喉癌颈部淋巴结隐匿性转移的主要区域,择区性(Ⅱ、Ⅲ区)颈淋巴结清扫术治疗cN0声门上型喉癌是合适的。     

对cN0喉及下咽癌患者进行Ⅳ区和V区的颈清扫是否合理

目的:为了制定恰当的颈清扫治疗方案,对cNO喉癌和下咽癌患者的淋巴结累及区域和复发率作一评价.方法:回顾性分析接受局限性颈淋巴结清除术的238例cNO患者,至少随访24个月,并对局部复发进行评估.结果:Ⅳ区的隐匿性淋巴结转移率是3.4%;其中单独转移至Ⅳ区的是1.5%.我们观察发现颈部的局部复发率是5.6%,在V区没有发现淋巴结转移和局部复发.结论:当术中颈淋巴结冷冻切片为阴性,对cNO患者可合理性做出Ⅱ、Ⅲ区清扫术,Ⅳ区部分清扫术及对侧颈部淋巴结清扫术,得出结论:Ⅴ区颈清扫术是没有必要的,除非在Ⅴ区有明显的转移灶.     

声门上型喉癌临床N1患者转移颈淋巴结的分布

目的 分析声门上型喉癌病例早期颈淋巴转移(clinical N1，cN1)的特点，探讨合理的颈清扫手术方式。方法 1987年3月-1997年10月收治108例声门上型喉癌cN1的患者行喉原发灶切除时，先行改良或经典颈清扫术，将颈清扫标本的淋巴结分区行病理学检查，确定最常见颈淋巴转移的分布。结果 108例(147侧)颈清扫标本中检出转移淋巴结126个，其中Ⅱ、Ⅲ区转移淋巴结占总数的89．7％(113／126)，Ⅱ、Ⅲ、Ⅳ区占97．6％(123／126)。126个转移淋巴结分布在109个区次，其中Ⅱ、Ⅲ区占88．1％(96／109)，Ⅱ，Ⅲ和Ⅳ区占97．2％(106／109)。45例(63侧)术后颈淋巴结病理检查阳性，声门上喉癌cN1的转移率为41．7％(45／108)，双颈转移率为18．5％(20／108)。随访5～14年，随访率为98％，颈部复发8例，复发率为7．4％(8／108)，复发部位分别位于Ⅱ、Ⅲ和Ⅳ区。5年生存率为81．5％(88／108)。结论 对声门上型喉癌cN1病例可行颈侧清扫术(即Ⅱ、Ⅲ、Ⅳ区的清扫)，Ⅰ、Ⅴ区在无明显转移证据时可避免行该区的清扫术；一侧术后病理证实有转移或对侧cN1的病例，对侧亦应行颈侧清扫术。     

声门上型喉癌临床颈淋巴结阴性患者颈清扫区域的选择

目的 探讨声门上型喉癌临床诊断NO(clinical NO,cNO）患者颈淋巴结转移的特点，选择合理的清扫区域。方法 5例声门上型喉癌患者行喉切除术的同时行改良性颈清扫术，将颈清扫的淋巴结标本分区域逐一行病理学检查，确定转移区域或复发的区域。结果 57例（63侧）颈清扫标本共获淋巴结1877枚，平均每侧获29．8枚，有转移的43枚，其中41枚位于Ⅱ、Ⅲ区，占转移例数的95．4％（41／43）。15例（17侧）患者有淋巴结转移，转移率为26．3％（15／57）。其中14例位于Ⅱ、Ⅲ区，占转移例数的93．3％（14／15）。颈部复发3例，复发率为5．3％（3／57），复发部位分别为Ⅱ、Ⅲ、Ⅳ区。5年生存率为80．7％（46／57）。结论 对声门上型喉癌cNO重点行Ⅲ和Ⅲ区颈淋巴结清扫术，Ⅲ区受累时应包括Ⅳ区，Ⅰ、Ⅴ区在无明显转移证据时可避免行颈清扫术。     

下咽癌颈部淋巴结转移规律的临床分析

目的:研究下咽癌颈部淋巴结转移的临床规律,辅助下咽癌治疗。方法:回顾性分析45例下咽癌55侧颈淋巴结清扫术,分析颈部出现淋巴结转移及结外侵犯与临床病理因素的关系。结果:①45例下咽癌颈部淋巴结转移率为75.56%,10例双侧清扫中5例(11.11%)为双侧转移,2例(4.44%)为单侧转移;转移淋巴结结外侵犯率为79.41%,2例(5.88%)为双侧清扫双侧结外侵犯,2例(5.88%)为双侧清扫单侧结外侵犯。②45例共清扫淋巴结411枚,转移淋巴结163枚,转移率为39.66%,Ⅰ、Ⅱ、Ⅲ、Ⅳ、Ⅴ区转移淋巴结构成比分别为0.61%、49.08%、25.77%、21.47%、3.07%,各区转移率分别为3.57%、62.02%、37.17%、42.17%、8.62%;③Ⅰ+Ⅴ、Ⅱ+Ⅲ+Ⅳ比较差异有统计学意义;Ⅰ、Ⅴ比较差异无统计学意义;Ⅱ、Ⅲ、Ⅳ比较差异有统计学意义;Ⅱ、Ⅲ+Ⅳ比较差异有统计学意义;Ⅱ、Ⅲ比较差异有统计学意义;Ⅱ、Ⅳ比较差异有统计学意义;Ⅲ、Ⅳ比较差异无统计学意义;Ⅰ、Ⅴ分别与Ⅱ、Ⅲ、Ⅳ、Ⅱ+Ⅲ+Ⅳ比较均差异有统计学意义。④T1+T2与T3+T4两组之间和T1、T2、T3、T4任意两期之间淋巴结...     

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。     

舌活动部鳞癌颈淋巴结阴性（cN0）的处理

目的：通过分析舌活动部鳞癌病人临床检查颈淋巴结阴性（cN0)的隐匿性淋巴结转移在颈部各区的分布，显示舌活动部鳞癌的淋巴结转移规律，并指导舌活动部鳞癌cN0的分区性颈淋巴清扫的范围。方法：回顾分析33例cN0的舌活动部鳞癌行选择性全颈淋巴结清扫和挽救性颈淋巴结清扫术的病例，分析手术后病理阳性淋巴结（pN^ )在颈部各区的分布。结果：病理证实单个淋巴结转移14例，其中Ⅰ区淋巴结转移3例，Ⅱ区淋巴结转移7例，Ⅲ区淋巴结转移4例，Ⅳ区和Ⅴ区未见淋巴结转移，多个淋巴结转移19例，各区转移频率分别为：Ⅰ区27.45%,Ⅱ区39.22%，Ⅲ区31.37%,Ⅳ区0%，Ⅴ区1.96%。结论：舌活动部鳞癌cN0的颈部处理没有必要采用经典性全颈清扫术，建议行肩胛舌骨肌上的分区性清扫，即Ⅰ区清扫 Ⅱ区清扫 Ⅲ区清扫即可，避免全颈清术给患者造成的术后损害。     

Level IIb lymph node metastasis in laryngeal squamous cell carcinoma

OBJECTIVES: Selective neck dissection, despite preservation of the spinal accessory nerve, can lead to some degree of postoperative shoulder dysfunction as a result of removal of level IIb lymph nodes. The aim of this study was to determine whether level IIb lymph nodes can be preserved in elective or therapeutic neck dissection as a treatment for patients with laryngeal squamous cell carcinoma (SCC). STUDY DESIGN: This was a prospective analysis of a case series. METHODS: A prospective analysis of 65 patients with laryngeal SCC who underwent surgical treatment of the primary lesion with simultaneous neck dissection from January 1999 to December 2002 was performed. During the neck dissection, the contents of the level IIb lymph nodes were dissected, labeled, and processed separately from the remainder of level II nodes and the main neck dissection specimen. The incidence of pathologic metastasis to level IIb lymph nodes and the regional recurrence within this area were evaluated. In addition, several potential risk factors for metastatic disease in the level IIb lymph nodes such as sex, age, cT stage, cN stage, and the presence of other positive lymph nodes were also evaluated. RESULTS: A total of 125 neck dissections were performed in this series. Of these dissections, 102 (82%) were elective and 23 (18%) were therapeutic. The prevalence of metastases in the level IIb lymph nodes was 1% (one of 46) and 0% (zero of 56) in clinically node-negative (N0) ipsilateral and contralateral necks, respectively, and 37% (seven of 19) and 0% (zero of four) in clinically node-positive ipsilateral and contralateral necks, respectively. There was a statistically significant association between level IIb metastases and clinically positive N stage (P<.001). The presence of other positive lymph nodes was also shown to have a statistically significant association with metastasis in the level IIb lymph nodes (P=.001). Only two of 46 patients (4%) with clinically N0 necks developed a regional recurrence. However, three of eight cases (38%) with positive pathologic level IIb lymph nodes developed regional recurrence. CONCLUSION: Level IIb lymph node pads may be preserved in elective neck dissection in patients with laryngeal SCC. However, this area should be removed thoroughly during therapeutic neck dissection in the treatment of clinically node-positive necks.     

Selective neck dissection (IIA, III): a rational replacement for complete functional neck dissection in patients with N0 supraglottic and glottic squamous carcinoma

INTRODUCTION: The purpose of this paper is to determine the optimal elective treatment of the neck for patients with supraglottic and glottic squamous carcinoma. During the past century, various types of necks dissection have been employed including conventional and modified radical neck dissection (MRND), selective neck dissection (SND) and various modifications of SND. MATERIALS AND METHODS: A number of studies were reviewed to compare the results of MRND and SND in regional recurrence and survival of patients with supraglottic and glottic cancers, as well as the distribution of lymph node metastases in these tumors. RESULTS: Data from seven prospective, multi-institutional, pathologic, and molecular analyses of neck dissection specimens, obtained from 272 patients with laryngeal squamous carcinoma and clinically negative necks, revealed only four patients (1.4%) with positive lymph nodes at sublevel IIB. Data was also collected from three prospective, multi-institutional, pathologic and molecular studies of neck dissection specimens which include 175 patients with laryngeal squamous carcinoma (only 2 with subglottic cancer) and clinically negative necks. Only six patients (3.4%) had positive nodes at level IV. CONCLUSIONS: SND of sublevel IIA and level III appears to be adequate for elective surgical treatment of the neck in supraglottic and glottic squamous carcinoma. Dissection of level IV lymph nodes may not be justified for elective neck dissection of stage N0 supraglottic and glottic squamous carcinoma. Bilateral neck dissection in cases of supraglottic cancer may be necessary only in patients with centrally or bilaterally located tumors.     

Levels II and III neck dissection for larynx cancer with N0 neck

The removal of level II, III, and IV metastases has gained importance in the treatment of squamous cell carcinomas (SCC) of the neck and larynx. This study assessed the possibility of removing level II and level III metastases only, given the low likelihood of occurrence of metastatic lymph nodes on level IV in SCCs of the larynx.ObjectiveThis study aimed to analyze the prevalence rates of metastatic lymph nodes on level IV in laryngeal SCC patients.MethodsThis prospective study enrolled consecutive patients with laryngeal SCC submitted to neck lymph node dissection. Neck levels were identified and marked for future histopathology testing.ResultsSix percent (3/54) of the necks had level IV metastatic lymph nodes. All cN0 necks (42) were free from level IV metastasis. Histopathology testing done in the cN (+) necks (12) revealed that 25% of the level IV specimens were positive for SCC. The difference between cN0 and cN (+) necks was statistically significant (p = 0.009). Level IV metastases never occurred in isolation, and were always associated with level II or level III involvement (p = 0.002).ConclusionThe prevalence rate for lymph node metastasis in cN0 necks was 0%. Level IV metastatic lymph nodes were correlated to cN (+) necks. Level IV metastasis was associated with the presence of metastatic lymph nodes in levels II or III.     

Is routine bilateral neck dissection absolutely necessary in the management of N0 neck in patients with supraglottic carcinoma?

The supraglottic larynx has a rich lymphatic network that places patients with supraglottic laryngeal carcinomas at high risk for early dissemination of the disease into the cervical lymphatics. Therefore, elective neck treatment of clinically N0 neck in patients with supraglottic carcinomas is widely accepted as a standard approach. However, the issue whether elective neck treatment should routinely be directed on both sides of the neck is still controversial. The present study is aimed at determining whether T2–T4 stage supraglottic carcinomas require bilateral neck dissection in the management of N0 necks. We designed a prospective study on 72 patients with N0 supraglottic laryngeal carcinoma. Patients were divided into three groups according to the site and extension of the primary tumors. Group I consisted of 21 patients with lateralized (clear lateral) lesion reaching but not crossing the midline. Group II comprised 25 patients with cancer largely involving one side and crossing to the midline. Group III included 26 patients with carcinoma equally involving both sides of the larynx or growth into the midline larynx. All patients underwent bilateral lateral neck dissection in conjunction with various types of laryngectomies selected to the status of the primary. Of the 72 patients, 16 were found to have occult regional metastases in pathologic examination (9 pN1, 4 pN2b, 3 pN2c). The prevalence of occult metastases proportionally increased with T stage from 8.3 to 22.7 and 31.2%, respectively, for T2, T3 and T4. Bilateral neck metastases were found in 2 of 26 patients (7.7%) with central lesions. There was only one patient (4%) with both ipsilateral and contralateral lymph node metastasis in group II. None of the 21 patients with lateral lesion (group I) had contralateral neck metastasis. Routine bilateral elective neck dissection may not be a part of the surgical procedure in all supraglottic laryngeal carcinoma patients. Bilateral neck dissection should be preferred for cases with central tumors and lateral tumors with positive nodes in the ipsilateral side of the neck.     

Level V Lymph Node Dissection in Oral and Oropharyngeal Carcinoma Patients with Clinically Node‐Positive Neck: Is it Absolutely Necessary?

OBJECTIVES: Postoperative shoulder dysfunction has been significantly associated with any dissection of level V secondary to traction or with ischemic injury to the spinal accessory nerve. The aim of this study was to determine whether the dissection of level V lymph node pads is absolutely necessary in therapeutic neck dissection as a treatment for oral and oropharyngeal squamous cell carcinoma (OOSCC) patients with clinically N+ neck. STUDY DESIGN: Retrospective chart review. METHODS: We performed a retrospective analysis of 93 OOSCC patients who underwent surgical treatment of the primary lesion along with a simultaneous comprehensive neck dissection from January 1992 to December 2003. Of these, only one patient had a clinically positive neck node at level V. During the neck dissection, the contents of the level V lymph nodes were dissected, labeled, and processed separately from the remainder of the major neck dissection specimen. We studied the incidence of pathologic metastasis to level V lymph nodes. In addition, we also evaluated several potential risk factors for metastatic disease in the level V lymph nodes such as sex, age, T stage, N stage, histologic grade, and presence of other positive lymph nodes. RESULTS: A total of 96 comprehensive neck dissections were performed in this series. The prevalence of metastases in the level V lymph nodes was 5% (5 of 93) in ipsilateral and 0% (0 of 3) in contralateral necks. One case with clinically positive node at level V had a pathologic positive node in level II, III, IV, and V. Occult metastasis rate of ipsilateral level V was 4% (4 of 92). There was a statistically significant association between level V metastases and a positive N stage above N2b (P=.01). The presence of metastasis in other multiple neck levels, particularly the combined neck levels II, III, and IV, also have a statistically significant association with level V metastasis (P=.023). CONCLUSION: Level V lymph node pads may be preserved in modified neck dissections on OOSCC patients with clinically N+ neck below the nodal stage N2a.     

Distributions of cervical lymph node metastases in oropharyngeal carcinoma: therapeutic implications for the N0 neck

OBJECTIVES: This study sought to investigate the patterns and distributions of lymph node metastases in oropharyngeal squamous cell carcinoma (SCC) and improve the rationale for elective treatment of N0 neck. MATERIALS AND METHODS: One hundred four patients with oropharyngeal SCC who underwent neck dissection between 1992 and 2003 were analyzed retrospectively. All patients had curative surgery as their initial treatment for the primary tumor and neck. A total of 161 neck dissections on both sides of the neck were performed. Therapeutic dissections were done in 71 and 5 necks and elective neck dissection was done on 33 and 52 necks on the ipsilateral and contralateral sides, respectively. Surgical treatment was followed by postoperative radiotherapy for 78 patients. The follow-up period ranged from 1 to 96 months (mean, 30 months). RESULTS: Of the 161 neck dissection specimens evaluated, 90 (56%) necks were found to have lymph node metastases found by pathologic examination. These consisted of 76 (73% of 104 necks) of the ipsilateral side and 14 (25% of 57 necks) of the contralateral side dissections. The occult metastatic rate was 24% (8 of 33) of ipsilateral neck samples and 21% (11 of 52) of contralateral neck samples. Of the 68 patients who had a therapeutic dissection on the ipsilateral side and had lymphatic metastasis, the incidence rate of level IV and level I metastasis was 37% (25 of 68) and 10% (7 of 68), respectively. Isolated metastasis to level IV occurred on the ipsilateral side in three patients. There were no cases of isolated ipsilateral level I pathologic involvement in an N-positive neck or occult metastasis to this group. The incidence rate of level IV metastasis in patients with ipsilateral nodal metastasis was significantly higher in base of tongue cancer (86% [6 of 7]) compared with tonsillar cancer (34% [20 of 59]) (P=.013). Patients with level IV metastasis had significantly worse 5-year disease-free survival rates than patients with metastasis to other neck levels (54% versus 71%; P=.04). CONCLUSION: These results suggest that elective N0 neck treatment in patients with oropharyngeal SCC, especially base of tongue cancer, should include neck levels II, III, and IV instead of levels I, II, and III.     

Involvement of level I neck lymph nodes and submandibular gland in laryngeal and/or hypopharyngeal squamous cell carcinoma

OBJECTIVE: To investigate the prevalence of level I neck lymph node metastases or submandibular nodal metastases in laryngeal and/or hypopharyngeal squamous cell carcinoma (SCC). PATIENTS AND METHODS: One hundred fifty consecutive neck dissection specimens from 100 patients with laryngeal and hypopharyngeal SCC, who were treated at our institution between 1992 and 2002, were retrospectively reviewed. RESULTS: The tumour stage was T1-T4, and the neck stage was N0-N3. Metastases were never found in level I (Ia + Ib) or in the submandibular gland. Metastases were concentrated within the jugular chain (levels II-IV in 92.2% of the N-positive necks). CONCLUSION: Metastases of level I of the neck and the submandibular gland are extremely rare in cases of laryngeal and/or hypopharyngeal carcinoma. The risk of facial or hypoglossal nerve injury does not justify the dissection of level I and of the submandibular gland in this type of tumour.     

Surgical treatment of the neck in cancer of the larynx

Current concepts in management of the clinically negative and clinically positive neck in laryngeal cancer are reviewed. Occult disease in the neck not detected by physical and radiographic examination may also be difficult to identify on routine histologic examination. Immunohistochemistry or molecular analysis may detect metastatic involvement not apparent by light microscopy. The surgeon should be aware of the relatively high incidence of micrometastases in patients with laryngeal cancer to establish optimal treatment approaches. Elective treatment of the neck is recommended for supraglottic tumors staged T2 or higher, and glottic or subglottic tumors staged T3 or higher. The neck may be treated electively by either surgery or irradiation, but irradiation is best reserved for cases where that modality is employed for the primary tumor. Elective neck dissection provides important information for prognostic purposes and therapeutic decisions, by establishing the presence, number, location and nature of occult lymph node metastases. The selective lateral neck dissection (levels II, III and IV), unilateral or bilateral, is the procedure of choice for elective treatment. Paratracheal nodes (level VI) should be dissected in cases of advanced glottic and subglottic cancer. Complete radical or functional neck dissections are excessive in extent, as levels I and V are almost never involved. Sentinel lymph node biopsy may fail to detect tumor on frozen section examination or may not reveal 'skip' metastases. The clinically involved neck is usually treated by complete radical or functional neck dissection of levels I through V. Selective neck dissection has been employed successfully in selected cases, particularly for N1 or occasionally N2 nodal involvement. The selective neck dissection can be extended to include structures at risk. More advanced disease has been treated in this manner often in association with adjuvant chemotherapy and/or irradiation. While the benefit of adjuvant treatment is difficult to assess, it appears most useful in cases with extranodal spread of disease, a factor associated with the worst prognosis.     

Management of contralateral N0 neck in tonsillar squamous cell carcinoma

OBJECTIVES: It is well established that tonsillar squamous cell carcinomas have a high probability of disseminating to the neck. An ipsilateral neck treatment is mandatory during initial treatment of stages II to IV tonsillar carcinomas. However, as of yet, no consensus exists whether to perform elective contralateral neck management. MATERIALS AND METHODS: A retrospective analysis of 43 N0-3 tonsillar cancer patients with contralateral clinically negative necks from 1992 to 2002 was performed. All patients had a contralateral elective neck dissection. Surgical treatment was followed by postoperative radiotherapy in 33 patients. The follow-up period ranged from 2 to 120 (mean 38) 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: Clinically negative, but pathologically positive, contralateral lymph nodes occurred in 16% (7 of 43). Of the 33 cases with an ipsilateral node positive neck, contralateral occult lymph node metastases developed in 21% (7 of 33), in contrast with 0% in ipsilateral N0 necks. On the basis of the clinical staging of the tumor, 5% (1 of 22) of the cases showed lymph node metastases in T2 tumors, 36% (5 of 14) in T3, and 25% (1 of 4) in T4. None of the T1 tumors (3 cases) had pathologically positive lymph nodes (T1 + T2 vs. T3 + T4, P < .05). 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 92% vs. 28%, P = < .05). CONCLUSION: The risk of contralateral occult neck involvement in above T3 staged tonsillar squamous cell carcinomas with unilateral metastases was high (approximately 21%), and patients who present with a contralateral metastatic neck have a worse prognosis than those who are staged as N0. Therefore, we advocate an elective contralateral neck treatment in tonsillar squamous cell carcinoma patients with ipsilateral node metastases.