择区性颈清扫术治疗63例下咽鳞状细胞癌的颈淋巴转移

Selective neck dissection on the treatment of neck metastases in 63 patients with squamous cell carcinoma of hypopharynx

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1％，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cN0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回归分析：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。

Objective To analyze the prevalence and distribution of cervical node metastases in squamous cell carcinoma of hypopharynx and evaluate the efficacy of selective neck dissection （SND） on the treatment of the neck metastases. Methods A retrospective review was performed for 63 patients with squamous cell carcinoma of hypopharynx from Janunary 1990 to December 2004. Lymph nodes were clinically negative in 17 patients and positive in 46 patients. There were 15 unilateral SND, 22 bilateral SND and 16 modified radical neck dissections （ MRND ）. Ipsilateral MRND or radical neck dissections （ RND ） and contralateral SNDs were performed in 10 cases. Forty-eight patients were followed up and the follow-up interval ranged from 24 to 143 months and the median was 41 months. Results Lymph nodes were pathologically negative （pN0） in 22 and positive （pN ＋ ） in 41 patients. A total of 106 positive nodes were found in 95 neck dissections. The distribution of the positive nodes were as follows： Level Ⅱ 47.2 % （50/106）, Level Ⅲ33. 0% （35/106）, Level Ⅳ11. 3% （ 12/106）, Level Ⅴ2. 8% （3/106）, Level Ⅵ 5.7% （6/106）. Contralateral nodal metastases and recurrence were observed in both cN0 and cN ＋ cases. There were 18 neck recurrent cases. High incidence of neck recurrence after SND was found in level Ⅱ and Ⅲ. The 3-year estimated survival rate analysis were 58. 1% for the pN0 and 44. 9% for pN1 and 41.1% for pN2 patients. Cox regression analysis suggested N stage was the most important prognostic factor. The risk ratio was 1.7 in pN1 and 2.2 in pN2. Conclusions Lymphatic metastases was the most significant prognostic factor of hypopharyngeal squamous cell carcinoma. Bilateral selective neck dissection, when carefully indicated, offers functional advantages without oncologic compromise.