Distribution of metastatic lymph nodes in oropharyngeal carcinoma and its implications for the elective treatment of the neck

OBJECTIVES: To analyze the distribution of lymph node metastases in patients with oropharyngeal squamous cell carcinoma and improve the rationale for elective treatment of the neck. DESIGN AND SETTING: Retrospective cohort study of patients evaluated from 1990 to 1998 in a tertiary cancer care center. PATIENTS:The 81 consecutive patients who were identified from the hospital database. Patients were eligible for the study if they had a previously untreated squamous cell carcinoma of the oropharynx and histopathologically diagnosed lymph node metastases without a second primary tumor treated by an en bloc resection. MAIN OUTCOME MEASURES: We analyzed the anatomic distribution of lymph node metastases. RESULTS: The clinical neck cancer stages were N0 in 22 cases, N1 in 22, N2a in 8, N2b in 14, N2c in 4, and N3 in 11. The most common sites for the metastases detected clinically as well as histopathologically were at levels II and III. Histologically, level I alone was involved in 5 cases and level IV alone was involved in none. Sixteen patients with N0 neck cancer stage underwent a radical neck dissection. There were 2 cases of metastases at level I and no level IV involvement. CONCLUSIONS: Pathological lymph nodes in oropharyngeal squamous cell carcinoma are more frequent at level I than at level IV. This finding suggests that elective neck dissection for patients with oropharyngeal carcinoma should be a supraomohyoid neck dissection (levels I, II, and III) rather than a lateral neck dissection (levels II, III, and IV).     

Is Dissection of Level IV Necessary in Patients With T1‐T3 N0 Tongue Cancer?

OBJECTIVE: Dissection of the lower jugular level of lymph nodes (level IV), as part of an elective neck dissection, has been advocated recently for all patients with oral tongue cancer because of the possibility of "skip metastases" to levels III and IV. The current study was undertaken to evaluate the need to perform a dissection of level IV in patients with oral tongue cancer with no clinical evidence of nodal metastases. METHODS: Fifty-one patients with T1-3, N0 squamous cell carcinoma of the oral tongue were treated with a partial glossectomy and a selective neck dissection of levels I, II, and III. When enlarged nodes were encountered during surgery in level II or III, the dissection was extended to include the nodes in level IV. Involvement of level IV was determined either by the presence of carcinoma on pathological examination or by the development of recurrence in the untreated level IV during a follow-up period of at least 2 years. RESULTS: Level IV was resected as part of the specimen in 17 of the 51 patients and metastatic tumor was found in this level in only one patient. At an average follow-up of 4.1 years, only one patient recurred at level IV, which had been addressed at the initial neck dissection. Consequently, the rate of metastases to undissected level IV was 2%. CONCLUSIONS: Metastases to level IV lymph nodes is rare in patients with T1-T3, N0 oral tongue cancer. Dissection of these nodes only when there is intraoperative suspicion of metastases in levels II or III does not increase the risk or recurrence of tumor in 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.     

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.     

Involvement of level I neck lymph nodes in advanced squamous carcinoma of the larynx

This study was performed to evaluate the incidence of metastasis at level I in patients with squamous laryngeal cancer. One hundred consecutive patients with squamous carcinoma of the larynx were submitted to surgical treatment including radical neck dissection. The tumor stage was T3 or T4, and the neck stage was N1-N2c. Lymph node metastases were pathologically confirmed in 80 patients. Metastases were concentrated within level II in 59% of cases, level III in 17% of cases, level IV in 11% of cases, and level V in 6% of cases. Only 2 patients (2%) had detectable tumors in the lymph nodes of the submandibular triangle (level IB). This study shows that patients with laryngeal cancer rarely present metastases at the submandibular triangle, even in advanced local disease with cervical metastasis staged as N1 to N2c. Therefore, dissection of the submandibular triangle is indicated only in the presence of clinical, radiographic, or cytologic evidence of metastatic disease at level I.     

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.     

Level IIb lymph node metastasis in thyroid papillary carcinoma

The objective of the study was to evaluate the incidence of level IIb lymph node metastases in neck dissections for thyroid papillary carcinoma (TPC) patients. 47 neck dissections of 33 patients with TPC were prospectively evaluated. Selective neck dissections (levels II, III, IV, and V) were performed in all cases. If level I lymph node metastasis was suspected during the procedure, level I dissection was also performed. All level IIb specimens were sent separately from the remainder of the neck dissection for the pathological examination. The number of dissected and metastatic lymph nodes in each specimen was recorded. Twenty-two of 47 neck dissections (46.8%) were positive for the lymph node metastasis. Among 47 neck dissection specimens, the incidence of lymph node metastasis at level II was 12.7% (6 of 47) and level IIb was 2.1% (1 of 47). The rate of level IIb lymph node involvement among patients with metastatic cervical lymph nodes was 4.5% (1 of 22). The specimen with metastatic lymph node at level IIb had also metastasis at levels IIa, III, IV, and V. The results of the present study suggested that lymph node metastases in level IIb are rare in patients with TPC undergoing neck dissection.     

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.     

喉及下咽鳞癌颈淋巴结隐匿性转移灶的研究

目的 :进一步探讨喉及下咽鳞癌颈淋巴结转移规律 ,为喉及下咽鳞癌颈淋巴结清扫术提供理论依据。方法 :收集 1997年 5月～ 1999年 7月 4 0例临床颈淋巴结阴性 ( c N0 )的喉及下咽鳞癌患者改良根治性颈清扫术所得标本 ,且术前未经任何治疗者为研究病例。对颈清扫淋巴结 (共 2 2 19枚 )进行常规 HE及免疫组化法检查。全部病例随访 1年以上。结果 :喉及下咽鳞癌出现颈淋巴结转移 14例 ( 3 5 % ) ,共 3 1枚 ( 1.4 % )淋巴结 ,其中声门上癌 6例 ( 6/2 0 ) ,跨声门癌 1例 ( 1/1) ,下咽癌 7例 ( 7/10 )。 9例声门癌无颈淋巴结转移。颈淋巴结转移均位于颈 、 区。结论 :喉及下咽鳞癌颈淋巴结转移多发生于患侧颈 、 区 (局限于声门区喉癌除外 )。对于 T2 ～ T4 声门上癌、跨声门癌及下咽癌的 c N0 患者 ,根据其可能发生颈淋巴结隐匿性转移的高危险性 ,建议行患侧或双侧颈 及 区淋巴结清扫术。     

A 3-year study of supraomohyoid neck dissection and modified radical neck dissection type I in oral cancer: with special reference to involvement of level IV node metastasis

The present study was undertaken to determine the pattern and incidence of predictable lymphatic spread and skip metastasis in oral cancer and analyze the prognostic implications of different therapeutic modalities in the neck metastases. The study includes 81 patients with squamous cell carcinoma of oral cavity with T1-2N0M0 and T1-3N1-3M0 who were admitted to the Department of ENT and Head and Neck Surgery, SMS Medical College and Hospital, Jaipur, from June 2006 to May 2008. After complete diagnostic evaluation (imaging, FNAC), all these patients were operated (wide primary excision with SOHND/Extended SOHND/MRD-I) and followed up periodically till date. Occult metastasis was found in 26% of the patients. Level I, II, III was most commonly involved. We did not find any metastasis or recurrence at level IV in N0 cases. Involvement of level IV node in N0 and N+ neck were 0 and 9%, respectively. We did not find any “skip metastasis” at level IV in oral cancers. We concluded that SOHND for N0 and MRND type I for N+ neck for oral cancers is an appropriate treatment.     

Status of level IIb lymph nodes of the neck in squamous cell carcinoma of the oral tongue in patients who underwent modified radical neck dissection and lymph node sentinel biopsy

Status of lymph nodes of level IIb was examined to identify the incidence of nodal metastasis and the lymphatic drainage in squamous cell carcinoma of the oral tongue in patients undergoing modified radical neck dissection (MRND) and sentinel node biopsy (SNB). Overall, 72 patients were divided into two groups; 38 patients (Group A) of any T and N+ or T3-T4- N0 stage underwent MRND. The surgical specimens were sent to the Pathology Department, divided into specific levels (I, IIa, IIb, III, IV, V) and labelled. The remaining 34 patients (Group B) T1-T2 -N0 stage were submitted to SNB. The histological examination of the specimens of the two groups was performed by staining with haematoxylin and eosin several sections from each node at different levels and then using a molecular marker such as cytokeratin and Epithelial Membrane Antigen (EMA). In Group A: In N0 there were no occult metastases at level IIb; in N+ neck, 8 cases (33.3%) showed metastasis at level IIb (P = 0.04). Metastases at level IIb were observed only in combination with other levels (P = 0.03). In Group B, direct lymphatic drainage was found in 2 patients (5.9%) at level IIb. There were no occult metastases at level IIb. Out of the 54 sentinel nodes harvested, 4 lymph nodes (7.4%) were found to be metastatic; these 4 sentinel nodes were found respectively in 4 patients, 1 at level III, 3 at level II a with an occult metastasis rate of 11.7%. In conclusion, SNB has prospected a new concept of lymphatic drainage that is variable and individual. SNB has demonstrated that direct lymphatic drainage is possible to level II b. In our experience with early cancer of the tongue (T1-T2 NO ), SNB aided with lympho-scintigraphy seems to be a good technique for staging the neck with minimal morbidity.     

Immunohistochemical detection of cervical lymph node micrometastases from T2N0 tongue cancer

Conclusions

These results indicate that extensive, multiple cervical micrometastases occurred from an early stage in patients with T2N0 tongue cancer. The presence of micrometastases suggests the necessity of preventive neck dissection for Level I–IV nodes as a radical treatment.

Objective

Cervical lymph node metastases occur with a relatively high frequency in patients with T2N0 squamous cell carcinoma of the tongue, and control of the metastases greatly influences the prognosis of patients. In this study, micrometastases in the cervical lymph nodes were investigated to clarify the necessity and required extent of preventive neck dissection.

Material and methods

We investigated micrometastases in 24 subjects who had previously been diagnosed with T2N0 tongue cancer. We performed immunostaining with anti-cytokeratin antibody cocktail AE1/AE3 of sections of 401 paraffin-embedded lymph nodes obtained from these patients.

Results

Micrometastases were observed in 14 patients (58%) and were most abundant in Level II nodes (n=11; 46%). Micrometastases were observed in the Level IV nodes of 3 patients (13%), and upstaging to pN2b occurred in 7 patients (29%).     

What is optimum neck dissection for T3/4 buccal-gingival cancers?

Buccal-gingival (BG) cancers are an integral part of oral cancers but are biologically distinct, particularly with regard to the propensity and pattern of neck metastases. This study was undertaken to examine the adequacy of limited neck dissection in the management of these tumors. Between 1980 and 1989, 527 T3/4 BG cancers were treated surgically at Tata Memorial Hospital, Bombay. These cases were reviewed retrospectively. Among these, 178 underwent radical neck dissection (RND), 166 supradigastric dissection (SD) and 183 supraomohyoid dissection (SOHD) after confirming the negativity of levels II and III for nodal disease on frozen section. The overall incidence of histological node positivity was 42.5% (224/527). Level I was the most frequent site of metastases, with a skip rate of only 9%. The incidence of pure regional failure (primary controlled) was 3% with RND (67/178),12% with SD (11/95) and 5% with SOHD (7/141) in patients with N0 necks. In the N+ category the regional failure was 18% with RND (20/111), 34% with SD (24/71) and 19% with SOHD (8/42). These findings show that a limited (SD) dissection is grossly inadequate in the management of T3/4 BG cancers, whereas an SOHD when neck levels 11 and III are confirmed negative on frozen section yields results comparable to RND for both NO and N+ necks.Presented at the combined meetings of the Society of Head and Neck Surgeons and the European Organization for Research and Treatment of Cancer, Paris, France, 25–28 May 1994     

Selective neck dissection for N0 and N1 oral cavity and oropharyngeal cancer: are skip metastases a real danger?

Objectives: To contribute to insight in therapeutic safety of selective neck dissections for oral cavity and oropharyngeal cancer with a special focus on the risk of skip metastases. Design: Retrospective data analysis. Setting: Tertiary referral centre. Participants: A total of 291 patients operated for oral cavity or oropharyngeal squamous cell cancer between 1999 and 2004. Main outcome measures: Incidence of skip metastases in both pathologically N0 and N+ necks for oral cavity and oropharyngeal cancer. Results: Of all neck dissections (n = 226) performed for oral cavity cancer, skip metastases to level III or level IV occurred in 14 cases (6%). Ten skip metastases occurred in level III only (10/226 = 4%). Thus, four necks had metastases in level IV, which would not have been removed in case of a Selective neck dissection level I–III (supraomohyoid neck dissection). In case of oropharyngeal cancer, skip metastases to level III or level IV occurred in six of 92 cases (7%). Five skip metastases occurred in level III only (5/92 = 5%). This means that of the necks containing skip metastases, only one neck (1%): had metastases in level IV, which would not have been removed in case of a Selective neck dissection level I–III (Supraomohyoid neck dissection). Conclusions: The question whether level IV should be included in the treatment of N0 and even N1 necks of patients with cancer of the oral cavity and oropharynx cannot be answered by all data available to us now. The fear of skip metastases including level IV does not seem to be justified.     

择区性颈清扫术治疗63例下咽鳞状细胞癌的颈淋巴转移

目的 分析下咽鳞状细胞癌(简称鳞癌)患者颈部淋巴转移规律,评价择区性颈清扫术(selective neck dissection,SND)在下咽癌颈淋巴转移治疗中的效果.方法 回顾性分析1990年1月至2004年12月在北京大学第一医院接受颈清扫术的下咽鳞癌患者63例,其中cN0患者17例,cN+46例.单侧SND共计15例;双侧SND共计22例;改良性颈清扫术(modified radical neck dissections,MRND)共计16例;一侧行经典性颈清扫术(radical neck dissections,RND)或MRND,另一侧行SND共计10例.随访48例(76.2%),随访时间范围为24～143个月,随访中位时间为41个月.结果 颈清扫术后发现淋巴结病理阴性(pN0)22例,淋巴结病理阳性(pN+)41例.95侧清扫标本中共发现106枚阳性淋巴结,其在颈部的分布如下:Ⅰ区0%,Ⅱ区47.2%(50/106),Ⅲ区33.0%(35/106),Ⅳ区11.3%(12/106),Ⅴ区2.8%(3/106),Ⅵ区5.7%(6/106).值得注意的是,无论是cNO还是cN+下咽癌患者,对侧颈部都可出现淋巴转移和复发.在随访的48例中,共有18例(21例次)复发.颈清扫术后淋巴结复发主要分布在Ⅱ区和Ⅲ区(19例次).根据Kaplan-Meier方法计算3年生存率,pN0患者为58.1%,pN1患者为44.9%,pN2患者为41.1%.Cox同归分析:N分级是影响预后最重要的因素,pN1的危险比为1.7,pN2的危险比为2.2.结论 淋巴转移是下咽鳞癌最重要的预后因素.恰当的选择双侧SND,可以取得较满意效果,同时减少患者形态和功能的损伤.     

Prospective analysis of 231 elective neck dissections in oral squamous cell carcinoma with node negative neck—To decide the extent of neck dissection

Objective

To evaluate the incidence of level IIB and IV lymph node metastases in patients of oral carcinoma with N0 necks. This study will help to decide the extent and need of routine comprehensive removal of these specific lymph node groups in selective neck dissection.

Immunohistochemical detection of cervical lymph node micrometastases from T2N0 tongue cancer

CONCLUSIONS: These results indicate that extensive, multiple cervical micrometastases occurred from an early stage in patients with T2N0 tongue cancer. The presence of micrometastases suggests the necessity of preventive neck dissection for Level I-IV nodes as a radical treatment. OBJECTIVE: Cervical lymph node metastases occur with a relatively high frequency in patients with T2N0 squamous cell carcinoma of the tongue, and control of the metastases greatly influences the prognosis of patients. In this study, micrometastases in the cervical lymph nodes were investigated to clarify the necessity and required extent of preventive neck dissection. MATERIAL AND METHODS: We investigated micrometastases in 24 subjects who had previously been diagnosed with T2N0 tongue cancer. We performed immunostaining with anti-cytokeratin antibody cocktail AE1/AE3 of sections of 401 paraffin-embedded lymph nodes obtained from these patients. RESULTS: Micrometastases were observed in 14 patients (58%) and were most abundant in Level II nodes (n=11; 46%). Micrometastases were observed in the Level IV nodes of 3 patients (13%), and upstaging to pN2b occurred in 7 patients (29%).     

Selective neck dissection in the management of squamous cell carcinoma of the upper digestive tract

Selective neck dissection has been used clinically in elective treatment of carcinoma, although many surgeons continue to advocate modified radical or radical neck dissection for therapeutic management of the neck. In a retrospective study 167 previously untreated patients were reviewed following curative laser microsurgical resections of oral or pharyngeal primary tumors and a unior bilateral selective neck dissection. In all, 221 (54 bilateral) neck dissections were performed. In patients with oral primary disease lymph nodes of levels I–III were removed, while nodes in levels II and III were removed in patients with pharyngeal tumors. Level IV was dissected when several metastases were suspected during operation. The posterior triangle was not dissected. Lymph nodes were histopathologically negative in 73 patients and positive in 94 patients. Twenty-five of these latter cases had pN1 disease, 55 had pN2b disease and 10 had bilateral lymph node metastases. Twenty patients in the pN0 group and 63 patients in the pN⁺ group received postoperative radiotherapy (to 56.7 Gy to the primary site and 52.5 Gy to the neck). With a median follow-up interval of 34 months, recurrence in the dissected neck occurred in 3 of 73 patients (4.1%) with pN0 disease and 6 of 90 patients (6.6%) with pN⁺ necks. Four patients with pN⁺ necks had simultaneous recurrences at the primary site. The addition of adjuvant radiotherapy seemed to improve disease control in the neck and improve overall survival in patients with an unfavorable prognosis due to multiple metastases or metastases with extracapsular spread.Presented at the 66th Annual Meeting of the German Society for Otorhinolaryngology, Head and Neck Surgery, Karlsruhe, 27–31 May 1995     

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。     

Preliminary multi-institutional prospective pathologic and molecular studies support preservation of sublevel IIB and level IV for laryngeal squamous carcinoma with clinically negative neck

Level II–IV selective neck dissection, often performed bilaterally, has become the procedure of choice for elective dissection of the clinically negative (N0) neck in the treatment of laryngeal cancer. The most significant morbidity of this procedure is dysfunction of the accessory nerve, incurred by the necessity of mobilization and retraction of the nerve in order to remove the contents of sublevel IIB. Other morbidity includes possible injury to the phrenic nerve and chylous fistula. These complications are associated with the dissection of level IV. A number of prospective multi-institutional studies of the distribution of cervical lymph node metastases in the neck indicate that lymph nodes in sublevel IIB and level IV are rarely involved in cases of laryngeal cancer with N0 neck. Information was obtained by the study of neck dissection specimens by conventional light microscopy, and by molecular analysis of the specimens. Molecular analysis reveals a significant number of metastases that are not discovered by light microscopy, and is thus essential for this type of evaluation. The authors conclude that these preliminary studies indicate that it is safe and appropriate to eliminate dissection of sublevel IIB and level IV from the elective neck dissection performed for laryngeal cancer with N0 neck. This practice will reduce both operating time and morbidity, particularly accessory nerve dysfunction, without compromising the oncologic result. Further prospective studies are needed to confirm these conclusions.