喉癌颈部淋巴结转移的彩超临床诊疗价值探讨
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摘要
目的：
通过采用彩色多谱勒超声进行喉癌患者颈部淋巴结检查,依据术后病理结果将术前颈部淋巴结彩超检查结果与喉部CT检查及颈部触诊检查结果进行对比分析，以评价彩超对喉癌颈部淋巴结肿大检查的检出率和颈部淋巴结转移诊断的符合率，探讨彩超对喉癌颈部淋巴结转移的临床诊疗价值。
方法：
选择2009年12月至2011年10月在我科行喉（部分、全）除术+颈淋巴结清扫术治疗，病理诊断为喉鳞状细胞癌的30例（60侧）患者为研究对象。30例喉癌患者行颈部淋巴结彩超检查，结合喉部CT分析彩超的检查结果行手术治疗。通过术前颈部淋巴结彩超淋巴结肿大检出率与术前喉部CT淋巴结肿大检出结果、术前颈部淋巴结彩超淋巴结肿大检出与术前颈部触诊淋巴结肿大检出结果、术前颈部淋巴结彩超与术前喉部CT转移淋巴结诊断与术后病理符合结果、术前颈部淋巴结彩超与术前颈部触诊转移淋巴结诊断与术后病理符合结果及喉癌颈部淋巴结经颈部淋巴结彩超诊断与术后病理符合结果中小于1.5cm与大于1.5cm的淋巴结转移对比分析、研究。采用McNemar配对卡方检验、Pearson卡方检验及Fisher精确检验方法进行统计学分析。
结果：
1.彩超对喉癌患者颈部淋巴结肿大的检出率为81.67%，CT检出率为68.33%，经McNemar配对卡方检验，P值>0.05；彩超对喉癌患者颈部淋巴结转移诊断与术后病理的符合率为97.14%，CT的符合率为91.43%，经Pearson卡方检验，P值>0.05；彩超与CT对喉癌颈部淋巴结肿大的检测及喉癌颈部淋巴结转移的诊断效能均无显著性差异。
2.彩超对30例喉癌患者颈部淋巴结肿大的检出率为81.67%，触诊检出率为25.00%，经McNemar配对卡方检验，P值<0.05,差异有统计学意义；彩超诊断喉癌颈部淋巴结转移与术后病理的符合率为97.14%，触诊的符合率为28.57%，经Pearson卡方检验，P值<0.05,差异统计学意义显著。应用彩超对喉癌患者颈部淋巴结检测能发现触诊不易发现的淋巴结肿大，并且彩超检测发现而触诊未能发现的淋巴结肿大经术后病理证实为淋巴结转移，彩超对喉癌颈部淋巴结肿大的检测及淋巴结转移的诊断效能均明显优于触诊。
3.喉癌颈部淋巴结转移经彩超诊断与术后病理的符合结果中，小于1.5cm淋巴结与大于1.5cm淋巴结的转移率，经Fisher精确检验，P值<0.05,差异有统计学意义。当彩超检查发现1.5cm以上的颈部淋巴结，转移的可能性明显增加。
结论：
1.彩超对喉癌颈部淋巴结肿大检测及颈部淋巴结转移诊断敏感性强。
2.彩超的检查结果对喉癌颈部淋巴结手术方案的制定提供佐证。减少了过度治疗带给患者的创伤，对喉癌颈部淋巴结转移具有重要的临床诊疗价值。
3.喉癌颈部淋巴结转移是影响喉癌预后的重要因素。大于1.5cm的颈部淋巴结转移可能性大，应予以高度重视。
Objective:
Through the examination of cervical lymph nodes for laryngeal carcinomawith metastasis by Color Doppler ultrasound，analysis the preoperativeexamination results of color Doppler ultrasound,CT and palpation according tothe post-operative pathological diagnosis， evaluate the Coincidence ratebetween the detection rate of laryngeal carcinoma with enlarged lymph nodesand laryngeal carcinoma with lymph node metastasis. Discuss the value ofColor Doppler ultrasound in clinical diagnosis and treatment of laryngealcarcinoma with cervical lymph node metastasis.
Methods:
We observed30patients (60) those accepted laryngectomy（partial、total）+neck dissection whose post-operative pathological diagnosis waslaryngeal squamous cell carcinomas with metastasis of cervical lymph nodein our department from December2009to October2011. All patients acceptedthe neck Color Doppler ultrasound examination and performed the surgeryreferring to the results of CT.we Comparative analysis the detection ratebetween pre-operative Color Doppler ultrasound and CT, pre-operative ColorDoppler ultrasound and neck palpation;the Coincidence rate betweenpre-operative Color Doppler ultrasound with CT and post-operativepathological diagnosis, pre-operative Color Doppler ultrasound with neckpalpation and post-operative pathological diagnosis;less than1.5cm andgreater than1.5cm metastasis of cervical lymph node in the post-operativepathological diagnosis for cervical lymph node with laryngeal carcinoma.Statistical tests performed by using McNemar chi-square test,Pearson chi-square test and Fisher accurate test. Results:
1. The detection rate of the neck lymph nodes of patients with laryngealcancer by color Doppler ultrasound is81.67%, the detection rate by CT is68.33%.McNemar paired chi-square test, P values>0.05; The diagnosis rate ofthe neck lymph nodes of patients with laryngeal cancer by color Dopplerultrasound is97.14%,the diagnosis rate by CT is91.43%., Pearson chi-squaretest, P>0.05; The misdiagnosis rate of the neck lymph nodes of patients withlaryngeal cancer by color Doppler ultrasound is17.14%, the missed rate is2.86%， the misdiagnosis rate by CT is25.71%，the missed rate by CT is8.57%; There was no significant difference in the detection of laryngeal andneck lymph nodes or the performance diagnosis of laryngeal and neck lymphnode metastasis between Ultrasonography and CT.
2. The detection rate of the neck lymph nodes of30patients with laryngealcancer by color Doppler ultrasound is81.67%,it was significantly higher thanthe detection rate of Palpation25.00%, McNemar paired chi-square test, Pvalues<0.05, there was significant difference;The diagnosis rate of the necklymph nodes of patients with laryngeal cancer by color Doppler ultrasound is97.14%, the rate of Palpation compliance is28.57%, Pearson chi-square test,P<0.05, there was significant difference.The application of color Dopplerultrasound can easily find cervical lymph node that palpation difficultly tofind,and the cervical lymph node that the Color Doppler ultrasound can easilyfind but the palpation failed to find were confirmed as lymph node metastasisThe detection of laryngeal with neck lymph nodes and the performancediagnosis of laryngeal and neck lymph node metastasis by Ultrasonography issignificantly superior to palpation.
3. By the Fisher exact test, the transfer rate of Laryngeal with neck lymphnode metastasis less than1.5cm and greater than1.5cm have significant difference,P<0.05.If color Doppler ultrasound examination revealed morethan1.5cm cervical lymph node, the possibility of transferring is significantlyincreased.Conclusions:
1.The sensitivity of the detection for laryngeal with neck lymph nodes and theperformance diagnosis for laryngeal and neck lymph node metastasis byUltrasonography is higher.
2. The results of examination can provide evidences for cervical lymphnode surgery while reduce the trauma form over-treatment.In summary,theColor Doppler have great value in the clinical diagnosis and treatment oflaryngeal cancer with cervical lymph node metastasis.
3. The metastasis of Laryngeal cancer lymph node is an important factorfor laryngeal cancer prognosis.The possibility of color Doppler ultrasoundexamination reveale the metastasis lymph node that greater than1.5cm isgreat,so we should give great attention.
通过采用彩色多谱勒超声进行喉癌患者颈部淋巴结检查,依据术后病理结果将术前颈部淋巴结彩超检查结果与喉部CT检查及颈部触诊检查结果进行对比分析，以评价彩超对喉癌颈部淋巴结肿大检查的检出率和颈部淋巴结转移诊断的符合率，探讨彩超对喉癌颈部淋巴结转移的临床诊疗价值。
方法：
选择2009年12月至2011年10月在我科行喉（部分、全）除术+颈淋巴结清扫术治疗，病理诊断为喉鳞状细胞癌的30例（60侧）患者为研究对象。30例喉癌患者行颈部淋巴结彩超检查，结合喉部CT分析彩超的检查结果行手术治疗。通过术前颈部淋巴结彩超淋巴结肿大检出率与术前喉部CT淋巴结肿大检出结果、术前颈部淋巴结彩超淋巴结肿大检出与术前颈部触诊淋巴结肿大检出结果、术前颈部淋巴结彩超与术前喉部CT转移淋巴结诊断与术后病理符合结果、术前颈部淋巴结彩超与术前颈部触诊转移淋巴结诊断与术后病理符合结果及喉癌颈部淋巴结经颈部淋巴结彩超诊断与术后病理符合结果中小于1.5cm与大于1.5cm的淋巴结转移对比分析、研究。采用McNemar配对卡方检验、Pearson卡方检验及Fisher精确检验方法进行统计学分析。
结果：
1.彩超对喉癌患者颈部淋巴结肿大的检出率为81.67%，CT检出率为68.33%，经McNemar配对卡方检验，P值>0.05；彩超对喉癌患者颈部淋巴结转移诊断与术后病理的符合率为97.14%，CT的符合率为91.43%，经Pearson卡方检验，P值>0.05；彩超与CT对喉癌颈部淋巴结肿大的检测及喉癌颈部淋巴结转移的诊断效能均无显著性差异。
2.彩超对30例喉癌患者颈部淋巴结肿大的检出率为81.67%，触诊检出率为25.00%，经McNemar配对卡方检验，P值<0.05,差异有统计学意义；彩超诊断喉癌颈部淋巴结转移与术后病理的符合率为97.14%，触诊的符合率为28.57%，经Pearson卡方检验，P值<0.05,差异统计学意义显著。应用彩超对喉癌患者颈部淋巴结检测能发现触诊不易发现的淋巴结肿大，并且彩超检测发现而触诊未能发现的淋巴结肿大经术后病理证实为淋巴结转移，彩超对喉癌颈部淋巴结肿大的检测及淋巴结转移的诊断效能均明显优于触诊。
3.喉癌颈部淋巴结转移经彩超诊断与术后病理的符合结果中，小于1.5cm淋巴结与大于1.5cm淋巴结的转移率，经Fisher精确检验，P值<0.05,差异有统计学意义。当彩超检查发现1.5cm以上的颈部淋巴结，转移的可能性明显增加。
结论：
1.彩超对喉癌颈部淋巴结肿大检测及颈部淋巴结转移诊断敏感性强。
2.彩超的检查结果对喉癌颈部淋巴结手术方案的制定提供佐证。减少了过度治疗带给患者的创伤，对喉癌颈部淋巴结转移具有重要的临床诊疗价值。
3.喉癌颈部淋巴结转移是影响喉癌预后的重要因素。大于1.5cm的颈部淋巴结转移可能性大，应予以高度重视。
Objective:
Through the examination of cervical lymph nodes for laryngeal carcinomawith metastasis by Color Doppler ultrasound，analysis the preoperativeexamination results of color Doppler ultrasound,CT and palpation according tothe post-operative pathological diagnosis， evaluate the Coincidence ratebetween the detection rate of laryngeal carcinoma with enlarged lymph nodesand laryngeal carcinoma with lymph node metastasis. Discuss the value ofColor Doppler ultrasound in clinical diagnosis and treatment of laryngealcarcinoma with cervical lymph node metastasis.
Methods:
We observed30patients (60) those accepted laryngectomy（partial、total）+neck dissection whose post-operative pathological diagnosis waslaryngeal squamous cell carcinomas with metastasis of cervical lymph nodein our department from December2009to October2011. All patients acceptedthe neck Color Doppler ultrasound examination and performed the surgeryreferring to the results of CT.we Comparative analysis the detection ratebetween pre-operative Color Doppler ultrasound and CT, pre-operative ColorDoppler ultrasound and neck palpation;the Coincidence rate betweenpre-operative Color Doppler ultrasound with CT and post-operativepathological diagnosis, pre-operative Color Doppler ultrasound with neckpalpation and post-operative pathological diagnosis;less than1.5cm andgreater than1.5cm metastasis of cervical lymph node in the post-operativepathological diagnosis for cervical lymph node with laryngeal carcinoma.Statistical tests performed by using McNemar chi-square test,Pearson chi-square test and Fisher accurate test. Results:
1. The detection rate of the neck lymph nodes of patients with laryngealcancer by color Doppler ultrasound is81.67%, the detection rate by CT is68.33%.McNemar paired chi-square test, P values>0.05; The diagnosis rate ofthe neck lymph nodes of patients with laryngeal cancer by color Dopplerultrasound is97.14%,the diagnosis rate by CT is91.43%., Pearson chi-squaretest, P>0.05; The misdiagnosis rate of the neck lymph nodes of patients withlaryngeal cancer by color Doppler ultrasound is17.14%, the missed rate is2.86%， the misdiagnosis rate by CT is25.71%，the missed rate by CT is8.57%; There was no significant difference in the detection of laryngeal andneck lymph nodes or the performance diagnosis of laryngeal and neck lymphnode metastasis between Ultrasonography and CT.
2. The detection rate of the neck lymph nodes of30patients with laryngealcancer by color Doppler ultrasound is81.67%,it was significantly higher thanthe detection rate of Palpation25.00%, McNemar paired chi-square test, Pvalues<0.05, there was significant difference;The diagnosis rate of the necklymph nodes of patients with laryngeal cancer by color Doppler ultrasound is97.14%, the rate of Palpation compliance is28.57%, Pearson chi-square test,P<0.05, there was significant difference.The application of color Dopplerultrasound can easily find cervical lymph node that palpation difficultly tofind,and the cervical lymph node that the Color Doppler ultrasound can easilyfind but the palpation failed to find were confirmed as lymph node metastasisThe detection of laryngeal with neck lymph nodes and the performancediagnosis of laryngeal and neck lymph node metastasis by Ultrasonography issignificantly superior to palpation.
3. By the Fisher exact test, the transfer rate of Laryngeal with neck lymphnode metastasis less than1.5cm and greater than1.5cm have significant difference,P<0.05.If color Doppler ultrasound examination revealed morethan1.5cm cervical lymph node, the possibility of transferring is significantlyincreased.Conclusions:
1.The sensitivity of the detection for laryngeal with neck lymph nodes and theperformance diagnosis for laryngeal and neck lymph node metastasis byUltrasonography is higher.
2. The results of examination can provide evidences for cervical lymphnode surgery while reduce the trauma form over-treatment.In summary,theColor Doppler have great value in the clinical diagnosis and treatment oflaryngeal cancer with cervical lymph node metastasis.
3. The metastasis of Laryngeal cancer lymph node is an important factorfor laryngeal cancer prognosis.The possibility of color Doppler ultrasoundexamination reveale the metastasis lymph node that greater than1.5cm isgreat,so we should give great attention.
引文
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[51]袁玉刚，韩德民，等.喉癌颈部淋巴结转移的MRI诊断[J].临床耳鼻咽喉科杂志，2000,14:449-451.
[52] Hao SP,NG SH. Magnetic resonance imaging versus clinical palpationin evaluating cervical metastasis from head and neck cancer[J].Otolaryngology Head and Neck surgery,2000,123:324-327.
[53]应海岳，吴海涛.头颈部恶性肿瘤颈淋巴结转移的影像学早期诊断[J].中国眼耳鼻喉科杂志，2005，5（5）：325-326.
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[1]冯帅，郭星.喉癌发病危险因素的病例对照研究[J].中国医科大学学报，2010,39（6）：474-475.
[2]高荫藻.临床耳鼻咽喉组织病理学(第1版)[M].陕西科学技术出版社，1981:219-243.
[3]赵金惠,赵真.颈部淋巴结超声研究[J].国际耳鼻咽喉头颈外科杂志,2008,32(3):171.
[4]赵胤，喉癌的治疗进展[J]，中国社区医师，2011,7.
[5] Som PM.Detection of Metastasis in Lymph Nodes:CT and MR Criteriaand Different Diagnosis[J].AJR,1992,158(5):961-969.
[6] Lindberg R.Distribution of lymph node metastases from sauamous cellcarcinoma of the upper respiratory and digestive tracta.Csncer,1972,29;1446-1449.
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[10] Franceschi D, Gupta R, Spiro RH, et al. Improved survival in thetreatment of squamous carcinoma of the oral tongue [J]. Am JSurg,1993,166:360-365.
[11]孙卓贵，姜海娜.浅表淋巴结的超声诊断进展[J].牡丹江医学院学报，2010，2（31）：74-76.
[12] Van den Brekel MW, Castelijns JA, Stel HV, et al. Occult metastaticneck disease: detection with US and US-guided fineneedle aspirationcytology[J]. Radiology,1991,180(2):457-461.
[13] Kruk-Zagajewska A，Paprzycki W，Gawecki W，et al.Paratracheal lymphnodes in patients with larynx and hypopharynx cancer in radiological andclinical examination[J].Otolaryngol Pol.2008;62(3):278-282.
[14]侯新燕,张武.超声在淋巴结病变检查中的应用[J]，中国超生医学杂志，1997,13（3）：64-66.
[15]赵幼冰,李曼,王涛,等.彩色多普勒超声对浅表淋巴结病变的诊断价值[J].中国误诊学杂志,2009,9(10):2292-2293.
[16]杨晓华.彩色多普勒超声在诊断颈部淋巴结病变的应用价值[J].山西医药杂志,2009,38(4):350-351.
[17]施幼红,王涌.多普勒超声在鉴别良恶性腋下淋巴结中的意义探讨[J].上海医学影像,2008,17(2):159-164.
[18]姜静,罗春娥,李正斌,等.超声检查对颈部淋巴结的良恶性鉴别诊断的价值[J].中国医师杂志,2007,9(12):1691-1692.
[19]张纯,关绮.文彩色多普勒超声在头面部恶性肿瘤伴颈淋巴结转移的诊断价值[J].实用预防医学2008，4（15）：1189-1191.
[20]李锐，郭燕丽.高频超声与CT诊断喉癌的临床研究[J]，中华超声影像学杂志，2005，1（14）：48-50.
[21] MorrizJD，Ludwing A，Oestmann JW，et al.Conntrast-enhanced colorDoppler sonography for evaluation of enlarged cervical lymph nodes inhead and neck tumors.AJR,2000,174(5):1279-1284.
[22]任克，张景荣.喉癌颈部淋巴结转移的CT影像及其病理基础[J].中国医学影像学杂志，2000，5（8）：347-348.
[23]范文焱,孙敬武.增强CT对头颈部恶性肿瘤颈淋巴结转移的诊断价值[J].中国临床保健杂志。2006，3（9）:236-238.
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[51]袁玉刚，韩德民，等.喉癌颈部淋巴结转移的MRI诊断[J].临床耳鼻咽喉科杂志，2000,14:449-451.
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[53]应海岳，吴海涛.头颈部恶性肿瘤颈淋巴结转移的影像学早期诊断[J].中国眼耳鼻喉科杂志，2005，5（5）：325-326.
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[1]冯帅，郭星.喉癌发病危险因素的病例对照研究[J].中国医科大学学报，2010,39（6）：474-475.
[2]高荫藻.临床耳鼻咽喉组织病理学(第1版)[M].陕西科学技术出版社，1981:219-243.
[3]赵金惠,赵真.颈部淋巴结超声研究[J].国际耳鼻咽喉头颈外科杂志,2008,32(3):171.
[4]赵胤，喉癌的治疗进展[J]，中国社区医师，2011,7.
[5] Som PM.Detection of Metastasis in Lymph Nodes:CT and MR Criteriaand Different Diagnosis[J].AJR,1992,158(5):961-969.
[6] Lindberg R.Distribution of lymph node metastases from sauamous cellcarcinoma of the upper respiratory and digestive tracta.Csncer,1972,29;1446-1449.
[7] Harris on DF.The pathology and management of ubglottic cancer.AnnOtol Rhinol Laryngo,1971,80:6-12.
[8] Wenig BL,et al.Thesubmandibular triangle in squamous cell carcinoma ofthe larynx and hypopharynx[J]. Laryngoscope,1991,101:516-518.
[9] Zeitels SM,Domanowski GF,Vincent ME, et al.A model formultidisciplinary data collection for cervical metastasia[J]. Laryngoscope,1991,101;1311-1317.
[10] Franceschi D, Gupta R, Spiro RH, et al. Improved survival in thetreatment of squamous carcinoma of the oral tongue [J]. Am JSurg,1993,166:360-365.
[11]孙卓贵，姜海娜.浅表淋巴结的超声诊断进展[J].牡丹江医学院学报，2010，2（31）：74-76.
[12] Van den Brekel MW, Castelijns JA, Stel HV, et al. Occult metastaticneck disease: detection with US and US-guided fineneedle aspirationcytology[J]. Radiology,1991,180(2):457-461.
[13] Kruk-Zagajewska A，Paprzycki W，Gawecki W，et al.Paratracheal lymphnodes in patients with larynx and hypopharynx cancer in radiological andclinical examination[J].Otolaryngol Pol.2008;62(3):278-282.
[14]侯新燕,张武.超声在淋巴结病变检查中的应用[J]，中国超生医学杂志，1997,13（3）：64-66.
[15]赵幼冰,李曼,王涛,等.彩色多普勒超声对浅表淋巴结病变的诊断价值[J].中国误诊学杂志,2009,9(10):2292-2293.
[16]杨晓华.彩色多普勒超声在诊断颈部淋巴结病变的应用价值[J].山西医药杂志,2009,38(4):350-351.
[17]施幼红,王涌.多普勒超声在鉴别良恶性腋下淋巴结中的意义探讨[J].上海医学影像,2008,17(2):159-164.
[18]姜静,罗春娥,李正斌,等.超声检查对颈部淋巴结的良恶性鉴别诊断的价值[J].中国医师杂志,2007,9(12):1691-1692.
[19]张纯,关绮.文彩色多普勒超声在头面部恶性肿瘤伴颈淋巴结转移的诊断价值[J].实用预防医学2008，4（15）：1189-1191.
[20]李锐，郭燕丽.高频超声与CT诊断喉癌的临床研究[J]，中华超声影像学杂志，2005，1（14）：48-50.
[21] MorrizJD，Ludwing A，Oestmann JW，et al.Conntrast-enhanced colorDoppler sonography for evaluation of enlarged cervical lymph nodes inhead and neck tumors.AJR,2000,174(5):1279-1284.
[22]任克，张景荣.喉癌颈部淋巴结转移的CT影像及其病理基础[J].中国医学影像学杂志，2000，5（8）：347-348.
[23]范文焱,孙敬武.增强CT对头颈部恶性肿瘤颈淋巴结转移的诊断价值[J].中国临床保健杂志。2006，3（9）:236-238.
[24] Johnson JT.A surgeon looks at cervical lymph nodes[J]. Radiology,1990,175(3):607-610.
[25] Van den Brekel M W,Stel HV,Castelijns JA, et al. Cervical lymph nodemetastasis:assessment of radiologic criteria[J]. Radiology,1990,177(2):379-384.
[26] Van den Brekel M W, Castelijns JA, Stel HV, et al. Occult metastatic neckdisease: detection with US and US-guided fineneedle aspirationcytology[J]. Radiology,1991,180(2):457-461.
[27] Van den Brekel MW,Castelijns JA, Croll GA, et al. Magnetic ResonanceImaging vs Palpation of Cervical Lymph Node Metastasis[J]. ArchOtolaryngol Head Neck Surg,1991,117(6):663-673.