读文献要有主见，赶潮流要会分析――评“先化疗放疗喉功能保留”等方案(3)
我科于70年代，开始对声门上型喉癌N0病例进行区域引流淋巴结(即，颈内静脉淋巴结上组，按照美国分区为第II区淋巴结)的切除活检，这是一个局部小手术。从解剖上看，这一区淋巴结为喉声门上组织的第一站引流淋巴结。手术切除上颈淋巴结后送病理检查，如冰冻病理阳性，即刻做颈清扫术；如病理阴性，颈部不处理，只做原发喉部手术。1976年-1990年共治疗155例声门上型喉癌T1-T4N0M0病例，均做原发病变重的一侧上颈清扫，有的做双上颈淋巴结(II区)切除手术。有13例颈淋巴结有微小转移，立即做颈清扫术。其余142例局部淋巴结病理阴性，颈部不处理，观察5年后有15例颈部淋巴结复发，颈部复发率为10.6%。10例在同侧，5例在对侧。全组生存率80.8%[18]。以上资料可以与国内外主张全颈清扫术的结果相比(Byers报告[19]，颈部全颈清扫术后复发率为12.9%。 Spiro报告为9.7%[20])。这说明，对N0病例，无需全颈淋巴结清扫。90年代以来，由于科技进步，大量临床经验积累，外科治疗趋向微创手术(microinvasive surgery)。在改良根治性颈清扫术的基础上，进一步合理地缩小切除范围，提出各类分区性或局限性颈清扫手术(Selective Neck Dissection)[20-22]，给各类颈部转移癌一个恰当的治疗，基本废除了传统的全颈清扫术：即根据原发病变设计颈部分区性治疗方案，在根治肿瘤的同时减少不必要的手术创伤。能更有效地在术后保留患者外观和功能。使患者顺利恢复，治疗后可以恢复工作，生活愉快。近年来在乳腺癌的治疗上发生的变化，有异曲同工之妙。对乳腺癌N0病例，不再做腋下清扫，而应用前哨淋巴结检查(sentinel node biopsy)[23，24]来确定淋巴结转移状况，决定下一步治疗。受这一思潮影响，头颈外科界也开始应用这一手段来检查患者[25]，避免一律手术。实际上，前哨淋巴结就是区域性引流第一站淋巴结。就是我科在声门上型喉癌N0应用十几年的上颈淋巴结清扫术。这样处理上的变化，就基本上废除了对N0淋巴结的大面积清扫手术。区域性淋巴结转移的治疗，经历了大面积整块根治到分区性局限性手术到前哨淋巴结检测是一个时代的进步。说明肿瘤医师已经较好的掌握肿瘤转移的一些规律性的东西，有利于患者的治疗和疗后的生存质量保存。
, 百拇医药
参考文献
1. Sackett DL, Rosenberg WMC, Gray JAM, et al. Evidence-based medicine: what it is and what it isn't. BMJ, 1996，312:71-2
2. 房居高，等. 保留喉功能的梨状窝癌的综合治疗. 临床耳鼻咽喉科杂志 2000，14 ：104
3. The Department of Veterans Affairs Laryngeal Cancer Study Group. Induction chemotherapy plus radiation compared with surgery plus radiationin patients with advanced laryngeal cancer. N Engl J Med 1991,324:1685-90
, 百拇医药
4. Shirinian MH, Weber RS, Lippman SN, et al. Laryngeal preservation by induction chemotherapy plus radiotherapy in locally advanced head and neck cancers. The MD Anderson Cancer Center experience. Head & Neck, 1994,16:39-44
5. Clayman GL, Weber RS, Guillamondegui O, et al. Laryngeal preservation for advanced laryngeal and hypopharyngeal cancers. Arch Otolaryngol Head Neck Surg, 1995,121:219-23
6. Lefebvre JL, Chevalier D, Luboinski B, et al. Larynx preservation in pyriform sinus cancer: preliminary results of a European Organization for Research and Treatment of Cancer, phase III trial. J Natl Cancer Inst, 1996,88:890-9
, http://www.100md.com
7. 屠规益. 喉癌外科治疗的重点转移.中华耳鼻咽喉科杂志，1994，29：223-224
8. 王天铎. 下咽癌的手术治疗现状. 临床耳鼻咽喉科杂志，2000，14：243-245
9. 卢伟，罗军，吕明拴.改良Majer-Piquet手术治疗晚期声门型喉癌21例报告. 临床耳鼻咽喉科杂志，2000，14：110-111
10. Sisson GA. The head and neck story. The American Society for Head and Neck Surgery. Kascot Media, Inc. Chicago, 1983,1-3
11. Ogura JH，Jurema AA, Watson RK. Partial laryngopharyngectomy and neck dissection for pyriform sinus cancer. Laryngocope, 1960,70:1399-1417
, 百拇医药
12. Josephson JS, Krespi YP, Eisele DW, et al. Pyriform sinus cancer. Operative Techniques in Otolaryngology Head and Neck Surg, 1990,1:75-78
13. 屠规益.喉癌外科治疗的重点转移. 中华耳鼻咽喉科杂志，1994，29：323-325
14. Wolf GT, Forestiere A, Ang K, et al. Workshop Report: Organ preservation strategies in advanced head and neck cancer. Head & Neck 1999, 21:689-693
15. Lefebvre JL. Larynx preservation: the discussion is not closed. Otolaryngol Head Neck Surg, 1998 ,118:389-93
, 百拇医药
16. Snow GB, Patel P, Leemans CR, Tiwari R. Management of cervical lymph nodes in patients with head and neck cancer. Eur Arch Otorhinolaryngol. 1992;249:187-194
17. Pillsbury HC. A rational for therapy of the N0 neck. Laryngoscope 1997,107:1294-1315
18. Tu GY. Upper neck (Level II) dissection for N0 neck supraglottic carcinoma. Laryngoscope, 109,467-470
19. Byers RM, Wolf PF, Ballantyne AJ. Rational for elective modified neck dissection. Head and Neck Surg, 1988, 10:160-167
, http://www.100md.com
20. Spiro RH, Gallo O, Shah JP. Selective jugular node dissection in patients with squamous carcinoma of the larynx and pharynx. Am J Surg, 1993,166:399-402
21. Traynor SJ, Cohen JI, Gray J, Andersen PE, Everts EC. Selective neck dissection and the management of the node-positive neck. Am J Surg. 1996;172:654-657.
22. Pellitteri PK, Robbin KT, Neuman T. Expanded application of selective neck dissection with regard to nodal status. Head & Neck 1996;19:260-265.
, 百拇医药
23. 张跃，华积德.早期乳癌的哨兵淋巴结勘测性活检.中国肿瘤临床与康复，1999，6：94-95
24. Stanton P.Current status of sentinel node biopsy in breast cancer.Aust N Z J Surg,2000,70:86-87
25. Shoaib T, Soutar DS, Prosser JE, et al. A suggested method for sentinel node biopsy in squamous cell carcinoma of the head and neck. Head & Neck, 1999,21:728-733, 百拇医药
, 百拇医药
参考文献
1. Sackett DL, Rosenberg WMC, Gray JAM, et al. Evidence-based medicine: what it is and what it isn't. BMJ, 1996，312:71-2
2. 房居高，等. 保留喉功能的梨状窝癌的综合治疗. 临床耳鼻咽喉科杂志 2000，14 ：104
3. The Department of Veterans Affairs Laryngeal Cancer Study Group. Induction chemotherapy plus radiation compared with surgery plus radiationin patients with advanced laryngeal cancer. N Engl J Med 1991,324:1685-90
, 百拇医药
4. Shirinian MH, Weber RS, Lippman SN, et al. Laryngeal preservation by induction chemotherapy plus radiotherapy in locally advanced head and neck cancers. The MD Anderson Cancer Center experience. Head & Neck, 1994,16:39-44
5. Clayman GL, Weber RS, Guillamondegui O, et al. Laryngeal preservation for advanced laryngeal and hypopharyngeal cancers. Arch Otolaryngol Head Neck Surg, 1995,121:219-23
6. Lefebvre JL, Chevalier D, Luboinski B, et al. Larynx preservation in pyriform sinus cancer: preliminary results of a European Organization for Research and Treatment of Cancer, phase III trial. J Natl Cancer Inst, 1996,88:890-9
, http://www.100md.com
7. 屠规益. 喉癌外科治疗的重点转移.中华耳鼻咽喉科杂志，1994，29：223-224
8. 王天铎. 下咽癌的手术治疗现状. 临床耳鼻咽喉科杂志，2000，14：243-245
9. 卢伟，罗军，吕明拴.改良Majer-Piquet手术治疗晚期声门型喉癌21例报告. 临床耳鼻咽喉科杂志，2000，14：110-111
10. Sisson GA. The head and neck story. The American Society for Head and Neck Surgery. Kascot Media, Inc. Chicago, 1983,1-3
11. Ogura JH，Jurema AA, Watson RK. Partial laryngopharyngectomy and neck dissection for pyriform sinus cancer. Laryngocope, 1960,70:1399-1417
, 百拇医药
12. Josephson JS, Krespi YP, Eisele DW, et al. Pyriform sinus cancer. Operative Techniques in Otolaryngology Head and Neck Surg, 1990,1:75-78
13. 屠规益.喉癌外科治疗的重点转移. 中华耳鼻咽喉科杂志，1994，29：323-325
14. Wolf GT, Forestiere A, Ang K, et al. Workshop Report: Organ preservation strategies in advanced head and neck cancer. Head & Neck 1999, 21:689-693
15. Lefebvre JL. Larynx preservation: the discussion is not closed. Otolaryngol Head Neck Surg, 1998 ,118:389-93
, 百拇医药
16. Snow GB, Patel P, Leemans CR, Tiwari R. Management of cervical lymph nodes in patients with head and neck cancer. Eur Arch Otorhinolaryngol. 1992;249:187-194
17. Pillsbury HC. A rational for therapy of the N0 neck. Laryngoscope 1997,107:1294-1315
18. Tu GY. Upper neck (Level II) dissection for N0 neck supraglottic carcinoma. Laryngoscope, 109,467-470
19. Byers RM, Wolf PF, Ballantyne AJ. Rational for elective modified neck dissection. Head and Neck Surg, 1988, 10:160-167
, http://www.100md.com
20. Spiro RH, Gallo O, Shah JP. Selective jugular node dissection in patients with squamous carcinoma of the larynx and pharynx. Am J Surg, 1993,166:399-402
21. Traynor SJ, Cohen JI, Gray J, Andersen PE, Everts EC. Selective neck dissection and the management of the node-positive neck. Am J Surg. 1996;172:654-657.
22. Pellitteri PK, Robbin KT, Neuman T. Expanded application of selective neck dissection with regard to nodal status. Head & Neck 1996;19:260-265.
, 百拇医药
23. 张跃，华积德.早期乳癌的哨兵淋巴结勘测性活检.中国肿瘤临床与康复，1999，6：94-95
24. Stanton P.Current status of sentinel node biopsy in breast cancer.Aust N Z J Surg,2000,70:86-87
25. Shoaib T, Soutar DS, Prosser JE, et al. A suggested method for sentinel node biopsy in squamous cell carcinoma of the head and neck. Head & Neck, 1999,21:728-733, 百拇医药