淋巴转移阳性舌体鳞癌的颈部治疗策略探讨

Neck treatment strategy for pathologically node positive tongue squamous cell carcinoma

目的分析影响淋巴转移阳性（pathologically node positive，pN＋）舌体鳞癌患者颈部复发的相关因素和淋巴转移规律，探讨pN＋舌体鳞癌的颈部治疗策略。方法回顾性分析1991年1月至2006年12月期间138例pN＋舌体鳞癌患者的临床和随访资料，分析pN＋舌体鳞癌颈部转移淋巴结和复发淋巴结的分布规律和pN＋舌体鳞癌临床病理因素和治疗方法对颈部复发的影响。结果全部病例随访2年以上或至患者死亡。Kaplan—Meier法计算3年生存率为46．4％，5年生存率为36．2％。138例共203个分区发生转移，其中同侧Ⅰ、Ⅱ、Ⅲ区累及频率达94．6％，47例共66个分区出现颈部淋巴结复发，其中同侧Ⅰ、Ⅱ、Ⅲ区复发频率达77．3％。颈部复发率与一分期、pN分期、pTNM分期、淋巴结包膜外侵犯有关（P值均〈0．05）；当淋巴结有包膜外侵犯时，术后放疗组的颈部复发率低于未放疗组，但差异无统计学意义（P=0．076）；不同颈清扫方式间的颈部复发率差异无统计学意义（P值均〉0．05）。Cox多因素生存分析显示，pTNM分期和淋巴结包膜外侵犯是影响pN＋舌体鳞癌预后的独立危险因素。结论pT分期、pN分期、pTNM分期、淋巴结包膜外侵犯是影响pN＋舌体鳞癌颈部复发的因素；当淋巴结有包膜外侵犯时，术后放疗有可能降低颈部复发率；改良性颈清扫的颈部复发率与经典性颈清扫没有差异，对非淋巴结构无肿瘤侵犯的pN＋舌体鳞癌尽量行改良性颈清扫；pN＋舌体鳞癌转移和复发淋巴结主要分布在同侧Ⅰ、Ⅱ、Ⅲ区，择区性颈清扫可应用于pN＋舌体鳞癌。

Objective To analyze the related factors of neck recurrence and regularity of cervical lymph nodes metastasis of pathologically node positive （pN ＋ ） tongue sqaamous cell carcinoma （SCC） and explore the neck treatment strategy for pN ＋ tongue SCC. Methods Clinical and follow-up data of 138 patients with pN ＋ oral tongue SCC from Jan. 1991 to Dec. 2008 were reviewed. Distribution of neck metastatic and recurrent lymph nodes were analyzed. The influencing factors of neck recurrence of pN ＋ tongue SCC were analyzed. Results All patients were followed over two years or until death. Using Kaplan- Meier method, the 3-year and 5-year overall survival rates were 46.4% and 36.2% respectively. Two hundred and three levels of 138 patients had metastasis and the involvement frequency of ipsilateral Ⅰ, Ⅱ , Ⅲ reached to 94. 6%. Sixty-six levels of 47 patients had neck recurrences and the involvement frequency of ipsilateral Ⅰ, Ⅱ , Ⅲ reached to 77.3%. pT stage, pN stage, pTNM stage, extracapsular spread （ECS） of cervical lymph nodes were relevant to the neck recurrence of pN ＋ tongue SCC （ all P 〈 0.05）. When ECS of cervical lymph nodes was present, the neck recurrence rate of patients with postoperative radiation was lower than patients without postoperative radiation, but P value failed to demonstrate significant difference （ P = 0. 076）. There were no significant difference of neck recurrence rates between different neck dissection methods（P 〉 0. 05）. Multivariate Cox analysis showed that pTNM stage and ECS of cervical lymph nodes were the independent prognostic factors of pN ＋ oral tongue SCC. Conclusions pT stage, pN stage, pTNM stage, ECS of cervical lymph nodes were the influencing factors of neck recurrence of pN ＋ tongue SCC. Postoperative radiation may reduce the neck recurrence rate when ECS was present. There was no difference of the neck recurrence rate between modified neck dissection （MRND） and radical neck dissection （RND） and when the non-lymphatic structures were not involved, MRND should attempted. Metastatic and recurrent lymph nodes of pN ＋ tongue SCC were mostly distributed in ipsilateral Ⅰ, Ⅱ , Ⅲ level and selective neck dissection（SND） can be applied to pN ＋ tongue SCC.