Letter to the editor
Letter to the editor
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DOI：
10.1002/hed.20138
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发表时间：
2004-12
期刊：
影响因子：
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通讯作者：
M. Hamoir;G. Desuter
中科院分区：
文献类型：
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作者：
M. Hamoir;G. Desuter
致编辑：我们饶有兴趣地阅读了意大利布雷西亚的 Lombardi 等人在 2004 年 2 月号《Head & Neck》上发表的“咽旁淋巴结转移：甲状腺乳头状癌的异常表现”。该出版物证实咽旁转移应该是甲状腺癌淋巴播散的一种公认模式，这是有用且及时的。最近，我们报告了在我们机构连续治疗的 696 名甲状腺癌患者中出现 3 例咽旁转移病例。所有三名患者均已通过颈后入路手术切除成功治疗。我们同意作者的结论，即当头颈外科医生面对咽旁茎突后肿块时，应意识到甲状腺癌转移的可能性。但是，我们想对本文的某些方面发表评论。病例2左侧VI层有3个阳性淋巴结，左侧咽旁转移瘤，右侧III层有微转移。因此，根据美国癌症分期联合委员会手册，该疾病应分期为 pT4N1bM0，而不是 pT4N1aM0。作者通过查阅文献，发现了 12 例（10 例甲状腺乳头状癌和 2 例滤泡性甲状腺癌）。我们承认作者的观察，强调 Sirotnak 等人和 Carter 等人的文章报告了同一案例。然而，使用MEDLINE数据库，我们能够识别出30例甲状腺癌咽旁转移病例。所有案例的参考文献都可以在我们文章的参考文献列表中找到。如果我们认为卡特等人报告的病例是重复的，那么包括作者的病例和我们自己的患者在内，迄今为止报告的最终病例数为 34 例。 Lombardi 等人报告了两例没有既往治疗过甲状腺癌病史的病例。事实上，文献综述显示了两种不同的临床情况。据报道，少数病例偶然发现隐匿性甲状腺癌咽旁淋巴结转移，而大多数病例是在既往接受甲状腺癌治疗的患者随访过程中诊断为咽旁转移。近 50% 的病例报告有转移性颈后淋巴结。当指出时，所有病例的原发肿瘤都位于甲状腺上极。临床发现的潜伏期变化很大，从手术后几周（表明治疗前可能存在）到初次治疗后许多年。我们完全同意 Lombardi 等人的观点，即咽旁转移是甲状腺癌侵袭的一种罕见模式。然而，它也不应该被忽视。在初步检查中，如果怀疑甲状腺癌且颈部淋巴结临床受侵，CT 或 MRI 可能有用。除了确认淋巴结转移外，还可以准确评估咽旁间隙。在接受分化型甲状腺癌治疗的患者的随访过程中，如果出现不明原因的甲状腺球蛋白浓度升高以及颈部存在转移性淋巴结，应通过鼻纤维镜检查以及颈部 CT 或 MRI 检查口咽部，包括咽旁间隙。手术是唯一有效的治疗方法。
To the Editor: We read with interest ‘‘Parapharyngeal lymph node metastasis: an unusual presentation of papillary thyroid carcinoma,’’ by Lombardi et al of Brescia, Italy, in the February 2004 issue of Head & Neck. The publication confirming that parapharyngeal metastasis should be a recognized pattern of lymphatic dissemination from thyroid carcinoma is useful and timely. Recently, we reported three cases of parapharyngeal metastasis among a consecutive series of 696 patients treated for thyroid cancer in our institution. All three patients have been successfully treated by surgical resection through the laterocervical approach. We agree with the authors’ conclusions, namely, that when the head and neck surgeon is faced with a parapharyngeal retrostyloid mass, he or she should be aware of the possibility of a metastasis from thyroid carcinoma. However, we would like to comment on some aspects of this article. Case 2 had three positive nodes in the left level VI, a left parapharyngeal metastasis, and a micrometastasis in the right level III. Consequently, according to the American Joint Committee on Cancer Staging Manual, the disease should be staged as pT4N1bM0 and not pT4N1aM0. From their literature review, the authors found 12 cases (10 cases of papillary thyroid carcinoma and two cases of follicular thyroid carcinoma). We acknowledge the authors’ observation emphasizing that the articles of Sirotnak et al and Carter et al report the same case. However, using a MEDLINE database, we were able to identify 30 cases of parapharyngeal metastasis from thyroid carcinoma. The references of all cases may be found in the reference list of our article. Including the authors’ cases and our own patients, the ultimate number of cases reported to date is 34, if we consider that the case reported by Carter and al is a duplicate. Lombardi et al report two cases without history of previously treated thyroid carcinoma. As a matter of fact, the literature review shows two different clinical pictures. The incidental discovery of a parapharyngeal lymph node metastatic from an occult thyroid carcinoma was reported in a few cases, whereas the diagnosis of a parapharyngeal metastasis during the follow-up of patients previously treated for thyroid cancer was made in most of the cases. Metastatic laterocervical lymph nodes were reported in almost 50% of the cases. When pointed out, the primary tumor was in the upper pole of the thyroid gland in all cases. The latency of clinical discovery is highly variable, from a few weeks after surgery, suggesting a possible presence before treatment, to many years after the initial treatment. We totally agree with Lombardi et al that parapharyngeal metastasis is a rare pattern of invasion from thyroid carcinoma. However, it should not be overlooked. In the initial workup, CT or MRI may be useful if there is suspicion of thyroid carcinoma with clinically invaded lymph nodes in the neck. Besides the confirmation of lymph node metastases, the parapharyngeal space may be accurately assessed. During the follow-up of patients treated for differentiated thyroid carcinoma, the presence of an unexplained thyroglobulin concentration and the presence of a metastatic lymph node in the neck should lead to examination of the oropharynx by nasofibroscopy and CT or MRI of the neck, including the parapharyngeal space. Surgery is the only efficient treatment.