The influence of lymph node metastasis in the treatment of squamous cell carcinoma of the oral cavity, oropharynx, larynx, and hypopharynx:: N0 versus N+
The influence of lymph node metastasis in the treatment of squamous cell carcinoma of the oral cavity, oropharynx, larynx, and hypopharynx:: N0 versus N+
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DOI：
10.1097/01.mlg.0000161338.54515.b1
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发表时间：
2005-04-01
期刊：
影响因子：
2.6
通讯作者：
Lenox, J
中科院分区：
文献类型：
--
作者：
Mayland, MK;Sessions, DG;Lenox, J
目的/假设：0号颈的处理是一个持续的争议。本研究比较了5种不同治疗方式对口腔（OC）、口咽（OP）、喉（LX）和下咽（HP）鳞状细胞癌（SCCA）疗效的影响。该研究还比较了四种不同方法治疗0号颈的结果。研究设计：对3887例患者进行回顾性研究。方法：在华盛顿大学医学院（St. Louis， MO）耳鼻喉头颈外科肿瘤研究项目中，活检证实为上述四个区域之一的未治疗的SCCA患者，采用五种方式中的一种进行治疗，并符合5年随访条件。治疗方式包括原发性单纯局部切除（LR）、复合切除（原发性合并颈部清扫）、单纯放疗（RT）、局部切除合并放疗（LR/RT）、复合切除合并放疗（CR/RT）。0号颈部的治疗分为以下四种方法：观察并密切随访，仅对后续颈部疾病保留治疗，颈部清扫，颈部区域放疗，颈部清扫与放疗相结合。采用标准统计学分析对多项诊断、治疗和随访参数进行研究，以确定统计学意义。结果：全部位组5年疾病特异性生存率（DSS）为59%。子位点的DSS包括：OC， 53%；OP, 47%;LX, 70%;惠普占42%。N0病变患者在各部位的DSS均明显优于N+病变患者。NO患者的隐匿性颈部疾病发生率较低，ASG、OC和LX患者的pN1为4%，OP和HP患者的pN1为11%。LX为3% pN2， ASG和OC为4%，OP和HP为6%。隐匿性颈椎病患者的DSS与N+患者的DSS在统计学上相似。预后生存指标包括年龄、治疗年限、T期、N期、TN期、治疗方式、复发等。65岁以上患者的DSS较年轻患者差。分期T、N和TN影响所有部位的生存。局部切除对ASG、OC、LX和HP患者产生更好的DSS。局部切除加放疗增加了ASG和OC患者的DSS。HP患者的生存优势与治疗方式无关。对NO颈部进行观察治疗，并对随后的颈部疾病进行后续治疗，对ASG患者的生存有利。这一优势是针对ASG和LX分期T1NO患者的。对于T2N0、T3N0和T4N0分期的患者，四种颈部入路均无生存优势。结论：淋巴结转移对OC、OP、LX和HP的SCCA患者的DSS有显著的负面影响。在接受细致检查的NO患者中，隐匿性颈部疾病（pN+）的发生率很低。当存在时，它产生的DSS率与N+患者相似。在该研究系列中，年龄大于65岁的患者、晚期肿瘤（T、N、TN）患者和复发性疾病患者的生存率下降。目前治疗NO颈部的四种方法都没有显著的生存优势。密切观察为后续颈部疾病保留的后续治疗与三种选择性（预防性）治疗的生存率（DSS）在统计学上相似，是一种有效的治疗形式。它可以避免不必要的颈部治疗及其伴随的风险和并发症。关键词：淋巴结转移，鳞状细胞癌，口腔，口咽，喉，下咽，手术，放射治疗，生存结局。
Objectives/Hypothesis: Management of the N0 neck is a continuing controversy. The study compares the influence of N0 and N+ disease on the results of treating squamous cell carcinoma (SCCA) of the oral cavity (OC), oropharynx (OP), larynx (LX), and hypopharynx (HP) with five different treatment modalities. The study also compares the results of four different approaches to the treatment of the N0 neck. Study Design: A retrospective study of 3887 patients. Methods: Patients in the Tumor Research Project of the Department of Otolaryngology-Head and Neck Surgery of the Washington University School of Medicine (St. Louis, MO) with biopsy-proven previously untreated SCCA of one of the four above-mentioned regions who were treated with curative intent by one of five modalities and who were eligible for 5-year follow-up were included in the study. The treatment modalities included local resection of primary alone (LR), composite resection (primary with neck dissection) (CR), radiation therapy alone (RT), local resection with radiation therapy (LR/RT), and composite resection with radiation therapy (CR/RT). The N0 neck was treated with one of four approaches: observation with close follow-up reserving treatment only for subsequent neck disease, neck dissection, RT to the neck region, and a combination of neck dissection with RT. Multiple diagnostic, treatment, and follow-up parameters were studied using standard statistical analyses to determine statistical significance. Results: The 5-year disease-specific survival (DSS) for the all-sites group (ASG) was 59%. The DSS for the subsites included the following: OC, 53%; OP, 47%; LX, 70%; and HP, 42%. Patients with N0 disease had significantly better DSS than patients with N+ disease at all sites. Occult neck disease in NO patients was low with 4% pN1 for ASG, OC, and LX and with 11% pN1 for OP and HP. There was 3% pN2 for LX, 4% pN2 for ASG and OC, and 6% pN2 for OP and HP. The DSS for patients with occult neck disease was statistically similar to that of N+ patients. Prognostic survival indicators included age, decade of treatment, T stage, N stage, TN stage, treatment modality, and recurrence. Patients over 65 years of age had poorer DSS than younger patients. Staging T, N, and TN affected survival at all sites. Local resection produced better DSS for ASG, OC, LX, and HP patients. Local resection with radiation therapy produced increased DSS for ASG and OC patients. There was no survival advantage for HP patients related to treatment modality. Treatment of the NO neck with observation and later treatment for subsequent neck disease produced a survival advantage for patients in the ASG. This advantage was specific for ASG and LX patients staged T1NO. For patients staged T2N0, T3N0, and T4N0 at all four subsites there was no survival advantage for any of the four neck approaches. Conclusion: Lymph node metastasis significantly and negatively affects DSS in patients with SCCA of the OC, OP, LX and HP. The rate of occult neck disease (pN+) in NO patients receiving meticulous workup is low. When present, it produces DSS rates similar to those found in N+ patients. In the study series, there was decreased survival in patients older than 65 years of age, in patients with advanced tumor (T, N, TN), and in patients with recurrent disease. None of the four current approaches to treatment of the NO neck produces a significant survival advantage.Close observation with later treatment reserved for subsequent neck disease produces statistically similar survival (DSS) to the three elective (prophylactic) tratments and is a valid form of treatment. It may preclude unnecessary treatment of the neck with its attendant risks and complications. Key Words: Lymph node metastasis, squamous cell carcinoma, oral cavity, oropharynx, larynx, hypopharynx, surgery, radiation therapy, survival outcome.