cervical lymph node metastasis
Introduction
Introduction to cervical lymph node metastasis Cervical mphnode metastatic cancer accounts for about 3/4 of the total number of malignant tumors in the neck; in the neck mass, the incidence is second only to chronic lymphadenitis and thyroid disease, and most of the primary cancer (85%) The head and neck, especially the metastasis of nasopharyngeal carcinoma and thyroid cancer, are the most common. The primary tumor of metastatic tumor of the supraclavicular fossa is mostly in the chest and abdomen (including lung, mediastinum, breast, gastrointestinal tract, pancreas, etc.); However, the gastrointestinal tract, cervical lymph node metastasis of pancreatic cancer, and the transthoracic duct occur mostly in the left supraclavicular fossa. It must be noted that in many patients with head and neck malignancies (such as nasopharyngeal cancer, thyroid cancer), cervical metastatic tumors are often the first major symptoms. In contrast, primary cancers tend to be small. The patient does not feel it at all, and it is difficult to find even when examined. Therefore, it is necessary to conduct a thorough and detailed examination to confirm the diagnosis. basic knowledge The proportion of illness: 0.005% Susceptible people: more common in men aged 50 to 60 Mode of infection: non-infectious complication:
Cause
Causes of cervical lymph node metastasis
(1) Causes of the disease
Cervical lymph node metastasis has an important relationship with its anatomical features. The deep cervical lymph nodes are located between the infering fascia and the prevertebral fascia. There are 10 groups, about 300, and the lymph nodes surround the carotid artery. , nerves, muscles and neck organs.
The cervical lymph is the total area of the whole body lymph, and the whole body lymph can be drained through it. For example, the lymphatic drainage of the nasopharynx passes through the posterior pharyngeal lymph nodes and merges into the lymph nodes of the internal jugular vein; the lymphatic vessels at the bottom of the mouth enter the axillary lymph nodes, and then The submandibular lymph nodes and deep cervical lymph nodes are merged; the thoracic and abdominal fluids are transferred into the thoracic duct, and then drained to the supraclavicular lymph nodes, so that the systemic cancer may be transferred to the cervical lymphoids after the invasion of the lymphatic system, and the cancer is transferred to the neck. Lymph often passes through three pathways:
1. Transfer from the lymphatics, the most common.
2. The blood is transferred to the capsule of the lymph node and the blood vessels of the trabeculae.
3. Carcinomas (such as parotid gland and thyroid carcinoma) directly invade nearby lymph nodes.
Because there is an output or input lymphatic line between the lymph nodes of the neck, the lymph nodes of a certain group are transferred and can be successively invaded.
In order to facilitate the distribution of lymph nodes, in 1991 the United States published a clinical division of the cervical lymph nodes and sub-regional division (Figure 2), widely used by physicians in various countries.
Area I: including the infraorbital area and the submandibular area.
IA: His Majesty District, no clinical importance.
IB: Submandibular area, where the oral tumor metastasis is located.
Zone II: the upper part of the internal jugular vein lymph node, that is, under the second abdominal muscle, which is equivalent to the level of the skull base to the hyoid bone. The front boundary is the lateral edge of the sternohyoid muscle, and the posterior border is the posterior margin of the sternocleidomastoid muscle.
IIA: The internal jugular vein lymph node, which is the main lymphatic drainage area of the head and neck tumor, is the first station sentinel lymph node.
IIB: Position on the posterior, covered by sternocleidomastoid muscle, this part of the lymph node is often the metastasis of nasopharyngeal carcinoma, recurrence after surgical neck dissection is also often here.
Zone III: The middle segment of the internal jugular vein, from the level of the hyoid bone to the intersection of the scapula and the internal jugular vein, the anterior and posterior borders are the same as the II.
Zone IV: The area under the internal jugular vein lymph nodes, from the scapula of the scapula to the clavicle, the anterior and posterior borders are the same as the II.
V-zone: including the posterior occipital triangle lymph node (or para-neuro-lymphatic chain) and supraclavicular lymph nodes, the anterior border is the posterior margin of the sternocleidomastoid muscle, the posterior border is the anterior border of the trapezius muscle, and the lower boundary is the clavicle.
VA: Paraspinal paraganglia
VB: supraclavicular lymph nodes.
General clinical treatment can be mixed with VA and VB, but an in-depth discussion of supraclavicular lymph node problems should be separated.
Zone VI: Lymph nodes around the visceral (or anterior region), including the circumflex lymph node, the peri-tracheal (recurrent laryngeal nerve) lymph nodes, the lymph nodes around the thyroid gland, and some of the posterior pharyngeal lymph nodes are also assigned to this area. The common artery and internal jugular vein, the upper boundary is the hyoid bone, and the lower boundary is the sternal fossa.
Zone VII: Upper mediastinal lymph nodes, due to laryngeal cancer, esophageal cancer and thyroid cancer can be transferred to this, it is recommended that the upper mediastinal lymph nodes be classified as VII.
(two) pathogenesis
1. The relationship between metastatic lymph nodes and primary tumors The cervical lymph node metastasis of tumors usually begins in the sentinel lymph nodes (or the first station lymph nodes) and tends to be the largest, 95% of which are unilateral (usually ipsilateral) lymph node involvement, but The tumors of the soft palate and the Wechsler ring can be metastasized to bilateral cervical lymph nodes, especially nasopharyngeal carcinoma. The tendency of epithelial cancer is sometimes not obvious. Patients often have the internal jugular vein lymph node group (region II). Swollen surgery; oral cancer can be transferred to the submandibular and axillary lymph nodes, while nasopharyngeal, hypopharyngeal and laryngeal cancer rarely occurs here lymph node metastasis; internal jugular vein lymph node upper group and posterior group (IIB area) main drainage from the nose Lymphatic pharynx, oropharyngeal lymph node; lymph node metastasis in the posterior triangle of the neck is mainly from the nasopharynx, a small part is from the oropharynx and occipital skin tumor, while the VB area is mainly the supraclavicular metastasis, and the primary tumor of the thoracic and abdominal organs should be explored; Cervical lymph node metastasis is more common in laryngeal cancer (subglottic type), piriform fossa cancer, thyroid cancer, esophageal cancer (upper segment) and tracheal tumor. In general, lymph node metastasis of head and neck tumors is performed according to lymphatic drainage direction. But should Note that the 2% to 10% of cervical lymph node metastasis is the jump, Table 2 lists the sources of cervical lymph lymphatic drainage, easy to find the primary tumor.
2. Relationship between pathological type and primary tumor (Table 3)
(1) metastatic carcinoma originating from the head and neck: mostly squamous cell carcinoma, especially the highly differentiated and moderately differentiated types, mainly from the oral cavity, sinus, throat and pharynx, and the poorly differentiated cancer mainly comes from the nose. Pharyngeal, a small number can also come from the base of the tongue and piriform fossa, adenocarcinoma is more than the primary thyroid gland, often a typical thyroid papillary adenocarcinoma structure, a small number can also come from the parotid gland or nasal cavity. Malignant lymphoma is less , the original multi-line pharyngeal tonsil, sputum tonsil, tongue root and other pharyngeal lymphatic zone, can also be the neck manifestation of systemic malignant lymphoma, malignant melanoma mostly from the skin of the head and neck, especially the hairy scalp, a few from the mouth, Nasal mucosa or eye.
(2) metastatic carcinoma originating from the chest, abdomen and pelvic cavity: mostly adenocarcinoma, mostly from the breast, stomach, colon, rectum, a few from the prostate, liver, pancreas, uterus, ovary and kidney, etc., squamous cells Less cancer, mostly from the esophagus, lung, small cell cancer is mainly from the lungs.
(3) Metastatic cancer with unknown origin: There are two cases: one is that the primary lesion was not found at the time of initial diagnosis, and it was finally found after 3 to several years. This kind of case accounts for about 1/3, and the other is always It was not found that even the autopsy could not find the primary tumor. Most of these metastatic cancers were squamous cell carcinoma, and a few were poorly differentiated cancer, adenocarcinoma, malignant melanoma and other types of cancer.
3. The relationship between the degree of tumor differentiation and the primary tumor In addition to the poorly differentiated or undifferentiated carcinoma of the Wei's ring tumor, the head and neck tumors in other parts are more common with better differentiated cancer. China is a high incidence area of nasopharyngeal carcinoma. At the time of initial diagnosis, the neck mass was the main complaint of 45% to 55% of patients with nasopharyngeal carcinoma, and the actual lymph node metastasis rate was more than 70% at the time of diagnosis, and 80% to 85% of nasopharyngeal carcinoma was poorly differentiated cancer. For the upper cervical metastatic poorly differentiated cancer (especially lymphoid follicular carcinoma), the nasopharyngeal part should be carefully examined first, and the nasopharyngeal biopsy should be performed. It is reported that the microscopic examination showed that the primary tumor was located in the nasopharynx and hypopharynx. % ~ 40%, it has also been reported that the primary tumor is located in the tonsils and tongue roots accounted for about 82%.
Prevention
Cervical lymph node metastasis prevention
There is no effective preventive measure for this disease. Early detection and early diagnosis are the key to the prevention and treatment of this disease.
Complication
Cervical lymph node metastasis Complication
Currently there are no related content description.
Symptom
Symptoms of cervical lymph node metastasis Common symptoms Radioactive pain abnormal uterine bleeding lymph node swelling nodules and shoulder skin hard neck lymph nodes swollen gray nodules
What are the manifestations of cervical lymph node metastases and how to diagnose them?
1. Symptoms and signs are mainly characterized by a hard, stone-like enlarged lymph node in the cervical or supraclavicular fossa. It is usually single-shot, painless, and can be pushed at the beginning; multiple lymph nodes appear soon after, and invade the surrounding area. Tissue, at this time, the mass is nodular, fixed, local or radioactive pain, necrosis can occur in the late mass, resulting in ulceration, infection, bleeding, appearance of cauliflower, secretions with stench.
The primary site of metastatic cancer is different, and its symptoms and signs have their own characteristics.
(1) metastatic carcinoma originating in the head and neck: mostly distributed in the lymph nodes of the internal jugular vein, showing lymph nodes around the sternocleidomastoid muscle. As shown in Figure 3, squamous cell metastasis is generally very hard; A small number may be cystic due to tissue necrosis, liquefaction, single or several, progressive enlargement, often adhesion to surrounding soft tissue, eventually fixed, generally painless, mostly accompanied by the symptoms and signs of primary cancer.
(2) metastatic carcinoma originating from the chest, abdomen and pelvic cavity: mainly in the left supraclavicular lymph node, a few can also be in the right supraclavicular upper or lower jugular vein, or in the submandibular, upper neck or even The posterior triangle of the neck appears to be advanced, with many symptoms and signs of primary cancer.
(3) metastatic cancer with unknown origin: more common in men aged 50-60 years, the location of metastatic cancer is not limited, the majority of the neck below l/3 to the supraclavicular region, generally lack of symptoms or signs produced by the primary tumor .
2. Clinical Classification and Staging In 2002, the International Union Against Cancer (UICC) and the United States Joint Committee on Cancer Staging (AJCC) revised the TNM classification staging criteria for head and neck cancer (UICC and AJCC-2002).
T: primary tumor.
Tx: The primary lesion cannot be evaluated.
T0: No primary tumor was found.
Tis: carcinoma in situ.
N: regional lymph nodes (Fig. 4).
NX: Regional lymph nodes cannot be assessed.
N0: no regional lymph node metastasis.
N1: ipsilateral, single metastatic lymph node with a maximum diameter of 3 cm or less.
N2: ipsilateral, single metastatic lymph node, diameter greater than 3 cm, less than 6 cm; ipsilateral, multiple metastatic lymph nodes, maximum diameter less than 6 cm; bilateral or contralateral lymph node metastasis maximum diameter less than 6 cm.
N2a: ipsilateral, single metastatic lymph node, greater than 5 cm in diameter, less than 6 cm.
N2b: ipsilateral, multiple metastatic lymph nodes with a maximum diameter of less than 6 cm.
N2c: bilateral or contralateral lymph node metastasis with a maximum diameter of less than 6 cm.
N3: metastatic lymph nodes, greater than 6 cm in diameter.
In patients over 40 years old, there is a persistent swelling of the cervical lymph nodes, no acute inflammation or tuberculosis. It is not effective after 2 weeks of conservative treatment, especially if the lymph nodes are hard and the surrounding tissues are stuck. The cancer must be excluded. History and find the primary lesion.
The diagnostic procedure for cervical lymph node metastasis can be performed by reference to the diagnostic treatment method recommended by the National Cancer Network (NCCN, 2000) (Fig. 6).
Examine
Examination of cervical lymph node metastasis
What should I do for cervical lymph node metastasis?
1. Epstein-Barr virus (EBV) antibody detection of VCA-IgA is more sensitive, but the specificity is slightly worse, while EA-IgA is more sensitive, but the specificity is higher, the patient's serum EBV antibody is positive, especially It is a high-risk area from nasopharyngeal cancer and should focus on the nasopharynx.
2. Common methods for pathological examination of lymph nodes include puncture suction and biopsy.
(1) puncture and aspiration method: simple and easy to perform, small trauma, can obtain pathological specimens and distinguish pathological types such as adenocarcinoma or squamous cell carcinoma, which is more commonly used in clinical practice. Due to the small number of tissues obtained, there are limitations in diagnosis.
(2) lymph node surgical resection: usually avoid cutting biopsy, suspected of malignant lesions, but in the recent repeated repeated examinations did not find the original lesion, or after the puncture examination failed or the diagnosis is still not clear, preferably selected A 2 to 3 cm size, comparing the active lymph nodes, the entire lymph node was removed for pathological examination, which has important clinical significance for clear pathological classification and classification, especially the classification of lymphoma.
(3) Random biopsy of suspicious primary mucosa: According to lymph node metastasis site and pathological type, the potential primary tumor site was inferred. Even if no tumor was detected, random biopsy was performed. Mendenhall retrospectively analyzed 130 cases of primary tumor unknown. The results of cervical metastatic squamous cell carcinoma were as follows: for cases without clinical and imaging evidence, the detection rate of primary biopsy was 17%; if there was one case of clinical or imaging, the case was The detection rate of biopsy primary lesions increased to 52% to 56%; if clinical and imaging studies have prompted cases, the detection rate of primary lesions can reach 65%.
Regardless of the above methods, it is only necessary to repeatedly search for the primary lesion in the near future without being diagnosed. Only if it is done too early or rashly, the following adverse effects may occur: promoting the spread of the lesion and cancer cells. Planting in the incision; destroying the normal tissue structure, forming scar adhesion, hindering the future neck dissection; disturbing and reducing local blood supply, reducing the sensitivity of future radiotherapy; delaying the search and treatment of the primary tumor, causing the patient to have a fake A sense of security, loss of vigilance, and difficulties in follow-up observation.
Ultrasound examination
(1) B-ultrasound: The sonogram shows multiple hypoechoic nodules of different sizes. As shown in Fig. 5, sometimes the nodules are fused with each other. Ultrasound can clearly indicate cervical lymphadenopathy, but pathological characterization is often difficult. Need to combine clinical.
(2) Color Doppler: In addition to further understanding the condition of the cervical lymph nodes for the staging, color Doppler examination can also detect the parotid gland, tiny lesions of the thyroid gland and primary foci from the breast, mediastinum, abdomen, pelvis .
2. Patients with digestive tract angiography may have no symptoms of digestive tract. The esophageal barium meal and other imaging tests should be performed according to the characteristics of the patient's area, and some patients with esophageal cancer are found.
3. Chest X-ray and breast image For patients with supraclavicular lymph node metastasis, the lung should be examined. Female patients should also be examined by mammography or breast ultrasound.
4. CT and MRI examination is the most commonly used and effective means of searching for the primary tumor. If the primary head and neck are suspected, the head and neck should be checked. For cases of supraclavicular lymph node metastasis, chest, abdomen and pelvic scan should be performed. Enhanced MRI, with different sequence and functional imaging can be found in oropharynx, hypopharyngeal lesions and posterior pharyngeal lymph nodes, small lesions in the parapharyngeal space and thyroid and mediastinal lesions, and the size, location, necrosis of lymph nodes in the neck. Observe the relationship with surrounding tissues and blood vessels, and provide a more accurate basis for staging.
5. Positron emission tomography (PET) PET is a feature of high metabolism and rapid proliferation of tumor cells. The FDG accumulated in cells is imaged by positron emission tomography, that is, the more FDG is concentrated, the metabolism of cells. The higher the activity, the difference between tumor tissue and normal tissue. However, in head and neck tumors, the total diagnostic accuracy of PET is 69%, but the clinical examination and imaging examination did not detect the primary lesion. The detection rate of PET is less than 25%, and the precise positioning is difficult. For the chest and abdominal tumor, the detection rate of PET is slightly higher, but because of the higher cost, PET is generally not recommended as a routine examination for finding the primary tumor.
Diagnosis
Diagnosis and diagnosis of cervical lymph node metastasis
Cervical lymph node metastasis must be differentiated from developmental malformations and inflammatory lesions. In addition to its pathological examination, the location of the mass is also an important clinical factor in determining its nature (Table 4).
