Study on LevelⅣmetastasis risk factor of oral squamous cell car-cinoma patients / 中国肿瘤临床

Objective:To investigate the Level Ⅳ metastasis risk factor of oral cancer patient's ipsilateral neck. Methods:The medical records of 624 cases (644 sides of the neck) that underwent neck dissection at the time of primary surgery for oral carcinoma were included. Chi-square test and logistic regression analysis were performed to determine the factors associated with LevelⅣmetas-tasis. Results:Out of 334 cases (345 neck sides) with positive lymph nodes, only 35 sides (5.43%, 35/644) showed LevelⅢinvolve-ment and only 4 sides (0.62%, 4/644) developed skip metastasis (LevelⅢ). The metastatic rate of LevelⅣwas 1.31%(4/303) for pN-LevelsⅠ-Ⅲnecks and 9.14%(31/341) for pN+LevelsⅠ-Ⅲnecks. Using Chi-square test, pN+LevelsⅠ-Ⅲlymph node metastases were associated with the LevelⅣnodal metastases. For necks with pN+LevelⅢ, with three positive Levels among LevelsⅠ-Ⅲ, and with positive lymph node≥3 among LevelsⅠ-Ⅲ, the LevelⅣmetastasis rates were 22.47%(20/89), 28.57%(10/35), and 14.60%(20/137), respectively. Furthermore, logistic regression was applied to identify the relationship between the metastasis situation of the afore-mentioned three Levels and LevelⅣ. Three positive Levels among LevelsⅠ-Ⅲ(pN+LevelⅠ+pN+LevelⅡ+pN+LevelⅢ) were confirmed to correlate with the presence of the positive lymph nodes in LevelⅣ. Conclusion:In oral cancer patients, LevelsⅠ-Ⅲmetastaces will increase the risk of LevelⅣmetastasis.

Predictive Factors of Central Lymph Node Metastasis in Papillary Thyroid Microcarcinoma / 대한내분비외과학회지

PURPOSE: Despite the excellent overall prognosis for patients with papillary thyroid microcarcinoma (PTMC), the rate of central lymph node (CLN) metastasis has been reported to be as great as 60% and the optimal surgical extent of PTMC has been controversial. The aim of this study is to identify factors for predict CLN metastasis in patients with PTMC. METHODS: We conducted a retrospective study of 535 patients with PTMC who underwent total thyroidectomy with prophylactic CLN dissection between Jan. 2008 and Aug. 2011. We analyzed the association of CLN metastasis and clinicopathologic characteristics. RESULTS: CLN metastasis was found in 181 patients (33.8%). Results of univariate analysis showed an association of younger than 45 years of age, male gender, a tumor size greater than 5 mm, bilaterality, multiplicity, extrathyroidal extension, and positivity of resection margin with CLN metastasis. Of these, results of multivariate analysis showed that age (P=0.003), gender (P=0.004), tumor size (P5 mm), male gender, young age (<45 yr), extrathyroidal extension, and positive resection margin were determined as the predictive factors for CLN metastasis, which occurred in approximately one third of patients with PTMC. Therefore, prophylactic CLN dissectionshould be considered in patients with PTMC who have these factors through investigation before surgery.

Pattern of Lateral Neck Metastasis and Predictors of Level V Metastasis in Papillary Thyroid Carcinoma / 대한내분비외과학회지

PURPOSE: Cervical lymphadenectomy is frequently performed in patients with lateral cervical lymph node metastasis to improve regional control of disease. However, there is controversy regarding appropriate levels of the neck that need to be dissected. In particular, the routine dissection of level V remains an annoying and time consuming procedure due to the injury of the spinal accessory nerve. METHODS: To identify clinical and pathological predictors of cervical node metastases to level V in papillary thyroid carcinoma, we analyzed 42 patients who underwent modified radical neck dissection (MRND), which were separately performed by each strict anatomical level. Five patients underwent both MRND, 29 patients received total thyroidectomy with central neck node dissection and MRND at the time of initial operation. Thirteen patients underwent MRND later when lateral neck metastases were found at the follow-up after total thyroidectomy with central neck node dissection. RESULTS: In our series, 11.9% of neck specimens harbored metastatic thyroid carcinoma at level V. The metastatic rate of level II, III, and IV was 54.7%, 85.7%, and 64.2%, respectively. The presence of level V metastases was not significantly associated with level II, III metastases, age, sex, and histopathologic findings. But, it seemed to be associated with level IV metastases if the proportion of metastasis of level IV exceeded 50%. CONCLUSION: Cervical node metastasis seems to be associated with level IV metastases if the proportion of metastasis of level IV exceeds 50%.

A Scoring System for Prediction of Lateral Neck Node Metastasis from Papillary Thyroid Cancer

Lateral neck node metastasis is an important prognostic factor in thyroid carcinoma. We developed a scoring system for use in prediction of lateral neck node metastasis from papillary thyroid cancer. In this study, 161 consecutive patients were included in the training data set. This scoring system, named the Yonsei Estimated Value (YEV) for lymph node metastasis in papillary thyroid cancer, was developed on the basis of results from multivariate logistic regression analysis of preoperative clinical and radiologic data. Sixty eight consecutive patients were included for testing of the validity of the scoring system. The equation for prediction of lateral neck node metastasis was follows: YEV (Yonsei Estimated Value) = 1/(1+X) X = Exp (5.333-[0.902 x sex]+[0.036 x age]-[1.020 x tumor size]-[0.177 x lymph node size]-[0.032 x lymph node density]) When the YEV was 0.3 or more, the probability of lateral neck node metastasis was 79.0%, with sensitivity of 76.3%, specificity of 69.8%, positive predictive value of 56.7%, and negative predictive value of 85.1% in the training set. When fine needle aspiration biopsy for suspicious lateral neck nodes is not possible, or the results are inadequate, our scoring system for prediction of lateral neck node metastasis can be helpful in optimization of the surgical extent for each patient.

A Study on the Risk Factors for Recurrence of Recurrent Papillary Thyroid Cancer after Surgery / 대한내분비외과학회지

PURPOSE: Papillary thyroid carcinoma (PTC) is known to have a favorable prognosis and long-term survival due to its biologic characteristics of slow growth and late distant metastasis. However, its characteristic of lymph node metastasis has resulted in a high incidence of neck recurrence and only rare lung metastasis. The objective of this study is to analyze the characteristics of recurrent or persistent thyroid cancer and to evaluate the risk factors for the development of recurrence. METHODS: We retrospectively reviewed 479 consecutive cases of PTC and these patients had undergone surgical operations from January 2004 to December 2006. We assessed age, gender, the tumor characteristics, the operative methods and the recurrence patterns, and the correlations between these factors and recurrence were analyzed. RESULTS: Of the 479 patients with PTC and who were initially treated with surgery at our hospital, 42 patients (8.8%) had recurrent disease. Univariate analysis showed that an age less than 45 years, male gender, extra-thyroidal extension, lymph node metastasis, multifocality, bilaterality and neck node dissection were related to a higher rate of recurrence. Of these, lymph node metastasis and central or lateral neck node dissection were the independent risk factors for recurrent PTC on the multivariate analysis. CONCLUSION: The significant factors influencing locoregional recurrence and distant metastasis were cervical lymph node metastasis and incomplete neck node dissection. In order to reduce the rate of recurrence of PTC, an exact preoperative evaluation of the nodal status and formal neck node dissection are recommended during the initial surgery in patients who have these factors of recurrence.

Radiotherapy of Neck Node Metastases from an Unknown Primary Cancer / 대한방사선종양학회지

PURPOSE: The aim of this retrospective analysis was to analyze the results of radiotherapy administered to patients with neck node metastases from an unknown primary cancer, with or without neck dissection. MATERIALS AND METHODS: From January 1986 to December 2005, 88 patients with neck node metastases from an unknown primary cancer were treated with curative intent. The age of the patients ranged from 35 to 74 years (median age, 59 years). There were 74 male and 14 female patients. Distribution of patients by N status was as follows: N1, 4 patients; N2a, 10 patients; N2b, 48 patients; N2c, 8 patients; N3, 18 patients. Fifty-one patients underwent neck dissection and 37 patients had only a biopsy (31 patients had fine-needle aspiration and 6 patients had an excisional biopsy). All patients received radiotherapy. The follow-up time ranged from 1 to 154 months, with a median time of 32 months. RESULTS: The overall survival (OS) and disease-free survival (DFS) rate at 5 years were 43.9% and 41.7%, respectively. The factors associated with the OS rate were neck dissection, and a subsequent primary tumor. Factors associated with the DFS rate were N stage, neck dissection, and a subsequent primary tumor. Neck failure was noted in 15 patients, distant metastases in 18 patients, and a subsequent primary tumor in 8 patients. CONCLUSION: With comprehensive radiotherapy given to the bilateral neck and the potential mucosal sites, good survival rates can be obtained in patients with neck node metastases from an unknown primary cancer. However, considering the side effects, a randomized trial is required to determine the optimal radiotherapy volume.

Recent Trends in the Surgical Treatment of Thyroid Cancer

Thyroid cancer is a malignant disorder with a wide spectrum of disease ranging from indolent papillary microcarcinoma to fatal anaplastic carcinoma. The most common type is papillary carcinoma followed by follicular carcinoma. Most surgeons agree that total thyroidectomy followed by radioactive iodine therapy and TSH suppression is needed in the majority of patients with well-differentiated thyroid carcinoma. In some patients with papillary microcarcinoma, a less aggressive approach may be advised(lobectomy or isthmusectomy) because of its favorable long-term prognosis. The central compartment node dissection is routinely performed in thyroid cancer whether or not clinically involved, but the lateral neck node dissection is done only in patients with clinically positive. Medullary carcinoma is far less common, but has a worse prognosis. This type of cancer requires total thyroidectomy plus central and lateral neck node dissection. Anaplastic carcinoma is the least common and the most aggressive thyroid cancer. In most cases the cancer spreads very early to vital neck structures and metastasizes extensively to cervical lymph nodes and distant organs. Even with aggressive therapy, almost all patients are associated with a fatal outcome within 6 months after diagnosis. For localized thyroid lymphoma, external-beam radiotherapy has been the standard practice, and for advanced tumor, the radiotherapy preceded by chemotherapy has been recommended. For locoregional recurrence, complete resection should be attempted in all patients and high-dose radioactive iodine or external-beam radiotherapy should be added to improve the survival rates.

The Usefulness of Ultrasound-Guided Fine Needle Aspiration Cytology of Impalpable Neck Nodes in Patients with Lung Cancer / 결핵

BACKGROUND: In lung cancer patients, the presence of metastatic neck nodes is a crucial indicator of inoperabilty. So thorough physical examination of neck is always mandatory, but sometimes those are hardly palpable even by the skillful hand. Ultrasonography is a useful diagnostic method in detection of small impalpable lymph nodes and in guidance of fine needle aspiration biopsy. In this study we evaluated the clinical usefulness of ultrasonography(USG) and ultrasound-guided fine needle aspiration cytology(US-FNA) in lung cancer patients without palpable neck nodes. METHODS AND MATERIALS: From Sep 2002 to Sep 2003, 36 non-small cell lung cancer patients (20 adenocarcinoma, 16 squamous cell cancer) and 10 small cell lung cancer patients without palpable neck nodes on physical examiation were enrolled. patients who had contralateral mediastinal nodal enlargement(>1cm) on chest CT were excluded. After the routine check of USG on the neck, US-FNA was done in cases with enlarged neck nodes (> or =5 mm in the short axis). The presence of enlarged lymph node on USG, and of malignant cells on cytology were evaluated by the histological type and the patients' clinical stage of lung cancer. RESULTS: Among 36 non-small lung cell cancer patients, 14 (38.8%) had enlarged neck nodes on USG, and 5 of 10 small cell lung carcinoma patients. The mean diameter of the neck nodes was 9.8 mm (range, 7-12 mm). US-FNA of 14 non-small cell lung cancer patients revealed tumor cells in eight patients (57.1%). In 5 small cell lung cancer pateints, tumor cells were found in all cases. By the result of US-FNA, the clinical stage of 8 out of 36 (22.2%) non-small cell lung cancer patients had changed, including two cases of shift from the operable IIIa to the inoperable IIIb. In small cell lung cancer patients their clinical stage was not changed after US-FNA, but their pathological diagnosis was easily done in two cases, in whom endobronchial lesions were not found on bronchoscopy. CONCLUSIONS: USG and US-FNA of neck node seem to be safe, sensitive and cost-effective diagnostic tools in the evaluation of lung cancer patients without palpable neck nodes.

Morbidity of Lymph Node Dissection in Central Neck Area for Operations of Differentiated Thyroid Carcinoma

PURPOSE: To date, the benefits of central neck node dissection (CND) in patients with differentiated thyroid carcinoma (DTC) have not been clearly demonstrated and must be considered against the potential risks of the procedure. However, recent papers suggest that lymph node metastasis exerts a significant influence on survival and is associated with a higher risk of recurrence. The purpose of our study was to assess the recurrent laryngeal nerve and parathyroid risks of CND following total thyroidectomy in patients with DTC and to compare the results with those obtained in patients who underwent total thyroidectomy only. METHODS: We retrospectively analysed 143 consecutive patients with DTC (116 with papillary, 24 with follicular, and 3 with Hurthle cell carcinoma) operated on by a single experienced endocrine surgeon from January 1989 to January 1999. There were 61 total thyroidectomies with CND (Group 1) and 82 total thyroidectomies only (Group 2). Group 1 patients displayed evidence of macroscopic lymph node invasion during surgery. The definitions of the two main complications in the thyroid surgery were as follows: transient and permanent recurrent laryngeal nerve palsy (persisting hoarseness over six months after thyroidecomy), transient and permanent hypoparathyroidism (non-recovery of normal parathyroid function and calcemia below 8.0 mg/dl over six momths after thyroidectomy). RESULTS: There was no difference observed in the demographic data between the two groups. Three cases (4.9%) of transient hypocalcemia were detected in Group 1 and two cases (2.4%) in Group 2. Five cases (8.2%) of transient nerve palsy were presented in Group 1 and one case (1.2%) in Group 2. However, there was no significant statistical difference between the two groups (p=0.051). None of the patients demonstrated permanent nerve palsy. CONCLUSION: Following total thyroidectomy for DTC, CND does not increase the morbidity of parathyroid gland and recurrent laryngeal nerve. Therefore, in order to decrease the incidence of regional recurrence and avoid the risk of reoperation in the central neck area, we recommend cervical neck node dissection from the central neck compartment concomitant with total thyroidectomy when overt lymph nodes are palpated.

Treatment Results and Patterns of Failure after Surgery for the Squamous Cell Carcinoma of Hypopharynx / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Radical surgery with radiotherapy is regarded as a standard treatment modality of hypopharyngeal squamous cell carcinoma. However, reports on results of treatment and patterns of failure after surgery for hypopharyngeal cancer are lacking. PATIENTS AND METHODS: From July 1992 to December 1998, 39 previously untreated hypopharyngeal carcinoma patients were treated with surgery with or without postoperative radiotherapy at Severance Hospital. Ten were treated with surgery alone, RESULTS: The overall 5-year survival rate was 58.1%, of which 47.2% accounted for the group who received surgery only and 64.6% for the group who received surgery plus postoperative radiotherapy. Survival was best for posterior pharyngeal wall cancer (64.6%) and worst for pyriform sinus cancer (56.1%). Recurrence was noted in 31% (12/39) of the cases. The most common Failure site was the neck, Among the neck failures, three unusual retropharyngeal and paratracheal nodal failures were noted. CONCLUSION: Treatment with radical surgery may improve survival of patients with this notorious cancer. The extent of neck dissection for hypopharyngeal carcinoma may need to be evaluated with future trials. (Korean J Otolaryngol 2000; 43: 528-34)

Angiogenesis, Cellular Proliferation Index and Expression of nm23, p53 according to Lymph Node Metastasis in Supraglottic Cancer / 대한이비인후과학회지

BACKGROUND: Squamous cell carcinoma of the supraglottic larynx have a propensity to metastasize earlier to the regional lymph nodes compared to their glottic counterpart owing to their unique embryological origin and abundant lymphatic tissues. However, reliable biological markers for predicting lymph node metastasis with its associated poor outcome is lacking. OBJECTIVES: As a search for biologic markers related to nodal metastasis in supraglottic cancer, the authors have performed immunohistochemical staining of various gene products and tissue factors. The results were analysed to see if these markers influenced the metastatic capability of supraglottic cancers. MATERIALS AND METHODS: Twenty-nine cases of supraglottic cancers were subdivided into node negative group(group I, N=13) and node positive group(group II, N=16). Tumor angiogenesis was assessed by counting the peritumoral microvessels in which the endothelial cells are selectively stained by von Willebrand factor. PCNA-proliferation index(PI) was obtained, and the positivity of nm23 protein, a metastasis suppressor gene product and p53 protein, a tumor suppressor gene product were assessed. RESULTS: The mean vessel counts per high power fields(X 200) were 16.6 and 27.3 for node negative and node positive groups respectively(p=0.001). The mean PCNA-PI was 8.1 in node negative group and 18.4 in the node positive group(p=0.001). The expression of nm23 was 30.8% in the node negative group and 50.0% in the node positive group. p53 expression rate was higher in the node positive group; 50.0% compared to the node negative group; 38.5%, however there was no statistical significance. CONCLUSION: We conclude that the number of new vessels and PCNA-proliferation index, but not the nm23 and p53 expression rate, may be related to the lymph node metastasis in squamous cell carcinoma of the supraglottic larynx.

Metastatic Carcinoma of the Neck Node from an Unknown Primary Site / 대한치료방사선과학회지

From 1980 to 1986, 26 patients with metastatic carcinoma of the neck node from an unknown primary site were seen in the Department of Therapeutic Radiology of Seoul National University Hospital. Among these, three patients were excluded from further analysis due to incomplete treatment. So a retrospective analysis was undertaken on 23 patients who had complete treatment with radiation therapy alone or in combination with surgical treatment and chemotherapy. The overall three year actuarial survival rate was 32%. According to the staging system of the American Joint Committee on Cancer, the three year survival rates with N2 and N3 patients were 43% and 13%, respectively. In 16 patients with squamous cell carcinoma and seven with non-squamous cell carcinoma, the three year survival rates were 34% and 29%, respectively. Analysis according to site of nodal involvement was also done. Patients with cervical node and supraclavicular node involvement recorded 44% and 17% of three year survival rate, respectively. In the study, six patients eventually manifested the primary sites (three in the lung, one in the esophagus, one in the stomach, one in the nasopharynx). Presence of the primary site seemed to influence the prognosis (17% vs 38%). In analyzing the prognostic factors, the nodal stage and site of nodal involvement were important prognostic factors, and the presence of a primary site seemed to influence the patients' survival, but histology did not.