喉鳞癌术后淋巴引流规律及失败模式分析

Lymphatic metastasis and failure patterns in laryngeal squamous cell carcinoma after surgery

目的分析喉鳞癌术后颈部淋巴结转移规律,以及局部复发、区域淋巴结转移模式,探讨喉癌放疗临床靶区的勾画。方法回顾性分析2012年7月至2018年11月山东省肿瘤医院收治的123例喉鳞癌患者资料,包括初诊手术切除以及术后进展在我院接受挽救性手术的患者。根据术后病理分析颈部各淋巴结区淋巴结转移率(LMR)。根据随访结果分析初次治疗后局部、区域、远处失败模式,颈部淋巴结失败区域分布及对应的LMR,分析局部复发、区域淋巴结转移的潜在影响因素。结果Ⅱ、Ⅲ、Ⅳ、Ⅵ区LMR分别为42.86%、41.67%、27.27%、25.00%,未发现Ⅱ、Ⅴ和Ⅶ区转移。中位随访15个月,中位疾病无进展生存为16个月[95%可信区间(CI):8.9~23.1个月]。失败模式分别为:局部复发31例(35.23%),区域淋巴结转移22例(25.00%),远处转移9例(10.23%)。淋巴结失败区域分布及LMR分别为Ⅱ区63.63%,Ⅲ区36.36%,Ⅳ区18.18%,Ⅵ区13.63%。单因素分析显示:是否行淋巴结清扫术(χ^(2)=25.87,P<0.001)、术后是否行颈部预防性照射(χ^(2)=39.31,P<0.001)是区域淋巴结转移的影响因素;手术方式(χ^(2)=14.02,P=0.007)和术后辅助放射治疗(χ^(2)=15.92,P<0.001)是局部复发的影响因素。Cox回归模型多因素分析显示,颈部未行预防性照射是区域淋巴结转移的独立预测因素(OR=1.385,95%CI:1.264~12.62,P=0.018)。结论喉鳞癌淋巴结常见转移部位依次为Ⅱ、Ⅲ区,其次为Ⅳ、Ⅵ区,Ⅰ、Ⅴ和Ⅶ区在本回顾性研究中未发现转移。失败模式主要为局部复发,其次为区域淋巴结转移,通过颈部预防性照射可降低淋巴结转移率。

Objective To analyze the patterns of lymphatic metastasis and postoperative local recurrence in laryngeal squamous cell carcinoma(LSCC),with an aim to explore the delineation of clinical target volume for radiotherapy.Methods A total of 123 LSCC patients who had received surgical resection after first diagnosis or salvage surgery at Shandong Cancer Hospital between July 2012 and November 2018 were retrospectively analyzed.Lymph node metastasis was evaluated based on pathological findings.The patterns and potential factors for treatment failure were analyzed.The frequency and distribution of regional lymph nodal failure were recorded.Results The lymphatic metastasis rates at levels Ⅱ,Ⅲ,Ⅳ,and Ⅵ were 42.86%,41.67%,27.27%,and 25.00%,respectively.Lymph node metastasis at levels Ⅰ,Ⅴ,and Ⅶ were not found.The median follow-up time was 15 months,and the median time of progression-free survival was 16 months[95% confidence interval(CI):8.9~23.1 months].Thirty-one(35.23%)patients had local recurrence,22(25.00%)had regional lymph node metastasis,and 9(10.23%)had distant metastasis.The frequency and distribution of regional lymph node failure were as follows:Ⅱ 63.63%,Ⅲ 36.36%,Ⅳ 18.18% and Ⅵ 13.63%.Univariate analysis demonstrated that lymph node dissection(χ^(2)=25.87,P<0.001)and prophylactic neck irradiation(PNI)(χ^(2)=39.31,P<0.05)was significantly correlated with lower regional nodal failure.Surgery(χ^(2)=14.02,P=0.007)and postoperative radiotherapy(χ^(2)=15.92,P<0.001)was significantly correlated with local recurrence.Multivariate analysis using proportional hazards model revealed that failed PNI was an independent risk factor for regional lymph node metastasis(OR=1.385,95%CI:1.264~12.62,P=0.018).Conclusion The most frequently involved nodal levels were Ⅱ and Ⅲ,followed by Ⅳ and Ⅵ,whereas metastasis at levels Ⅰ,Ⅴ and Ⅶ were not found in our retrospective study.Local recurrence is the most common failure pattern,followed by regional lymph node metastasis.By means of PNI,the incidence of nodal failure can be reduced in LSCC patients.