舌鳞状细胞癌颈部淋巴结转移的治疗

Treatment on metastatic lymph nodes in tongue squamous cell carcinoma

目的分析舌鳞状细胞癌颈部淋巴结转移性的分布规律,探讨舌鳞状细胞癌cN0患者的颈部处理。方法回顾性分析1975年1月￣2000年12月初次在我院诊治的329例舌鳞状细胞癌患者的临床资料。cN0179例,cN1131例,cN2+319例(2例出现双侧颈淋巴结转移)。在cN0患者中,肩胛舌骨肌上清扫或单纯颌下清扫20例,根治性颈清扫93例,扩大的肩胛舌骨上(包括Ⅳ区)清扫8例。在cN1患者中,30例接受颈部单纯放疗;肩胛舌骨肌上清扫6例,根治性颈清扫94例,扩大的肩胛舌骨上清扫1例。所有cN2+3患者均行根治性颈清扫。结果舌鳞状细胞癌颈部淋巴结隐性转移率为8.3%(10/121),其中T1为1.3%(1/76),T2为4.3%(4/93),T3为44.4%(4/9),T4100%(1/1)。实际颈部淋巴结转移率为71.7%(81/113)。91例患者组织学检查发现颈清扫标本中淋巴结转移阳性,Ⅰ区淋巴结转移占39.6%(36/91)、Ⅱ区71.4%(65/91)、Ⅲ区19.8%(18/91)和Ⅳ区8.8%(8/91)。有2例患者发生对侧Ⅰ、Ⅱ和Ⅳ区的淋巴结转移。在cN0患者中,颈部单纯放疗的同侧颈部复发率为7.5%(3/40),综合治疗为7.5%(6/80),单纯手术为2.4%(1/41),等待观察为16.7%(3/18);颈部单纯放疗的5年生存率分别为42.0%,综合治疗为55.6%,单纯手术为79.6%,等待观察为48.6%。结论Ⅱ区是舌鳞状细胞癌最易转移的部位,不主张对所有cN0患者实施择区性颈清扫,对T3和T4患者可考虑扩大的肩胛舌骨肌上清扫(Ⅰ～Ⅳ)。

OBJECTIVE To analyze the distribution of the metastatic lymph nodes and evaluate the treatment of the neck for clinical negative lymph nodes in the patients with squamous cell carcinoma of tongue. METHODS The files of 329 patients with squamous cell carcinoma of tongue were retrospectively analyzed at Chinese Academy of Medical Sciences ,Peking Union Medical College, Cancer Hospital between January 1975 and December 2000. The patients with cN0 were 179 cases, 131 cases for cN1, 19 cases for cN2＋3. In the patients with cN0, 20 patients underwent superaomohyoid dissections or only submandibular dissections, 93 patients radical neck dissections, and 8 patients entended superaomohyoid dissections that included level Ⅳ. In patients with cN1 , 6 patients underwent superaomohyoid dissections, 94 patients radical neck dissections, and one patients extended neck dissections. In patients with cN2＋3, all patients underwent classic radical neck dissections. RESULTS The neck occult lymph node metastasis rate for the patients with cN0 was 8.3 %（10/121） , the rate for the patient with T1 was1.3 % （1/76）,T2 4.3 % （4/93）,T3 44.4 % （4/9）,T4 100 % （1/1）.The neck lymph node metastasis rate for the patients with cN＋ was 71.7 % （81/ 113）. The neck positive lymph nodes were found histopathologically in 91 patients. Metastatic lymph nodes at level Ⅰ was 39.6 % （36/91）, level Ⅱ 71.4% （65/ 91）, level Ⅲ 19.8 % （18/91）, and level Ⅳ in 8.8% （8/91）. Two patients developed contralateral metastatic lymph nodes located in level Ⅰ, Ⅱ, and Ⅳ.In the patients with cN0, the ipsilateral neck recurrence rate and 5- year cumulative survival rate for alone radiotherapy in neck were 7.5 % （3/40） and 42.0 %, 7.5 % and 55.6% for combined therapy in neck, 2.4 % and 79.6 % for alone surgery in neck, 16.7 % and 48.6 % for “watch waiting” in neck. CONCLUSION Level Ⅱ was the most frequent site for lymph node metastases in the patients with squamous cell carcinoma of tongue. We don＇t advocate selective neck dissection in all cN0 patients with tongue cancer, but the ipsilateral extended superaomohyoid dissection（ Ⅰ-Ⅳ） may be considered for the patient with T3 and T4.