头颈部皮脂腺癌的诊断与治疗探讨

头颈部皮脂腺癌的诊断与治疗探讨         &nb sp;    作者:黄健男～占顺堂～邹苑斌～张学辉～赵晓明～彭树文～郑明奋 【关键词】  皮脂腺癌,头颈部,病理学 ,摘要,  目的  探讨头部皮脂腺癌的诊断与治疗～进一步提高诊治率。方法  收集28例经病理证实的头颈部皮脂腺癌患者的临床～其中眼睑皮脂腺癌10例,腮腺皮脂腺癌2例,外耳道皮脂腺癌5例,颌面部皮脂腺癌7例,颈部皮脂腺癌4例～颈部淋巴结转3例～采用手术、放疗、化疗等综合治疗。结果  皮脂腺癌确诊需要免疫组化检测～而罕见的腮腺皮脂腺癌还需和透明细胞癌、黏液皮样癌和腺泡细胞癌鉴别～全组病例5年以上随访～5年生存率可达71.4%,20/28,～5年内原发灶复发10例～其中～3例伴有区域淋巴结转移而再次手术～4例失访,按死亡计,,2例死于远处转移,2例死于其他疾病。结论  皮脂腺癌多发于头面部尤其是眼睑～罕见的腮腺皮脂腺癌易被临床忽视～主要复发在局部病灶～较少发生淋巴结转移～死亡原因主要为远处转移～早期诊断、早期根治性综合治疗是提高5年生存率的关键。     ,关键词,  皮脂腺癌,头颈部,病理学     Diagnosis and treatment of sebaceous carcinoma in the Head and Neck (Report of 28 Cases) ,Abstract,  Objective  To study the diagnosis and treatment of sebaceous carcinoma in Head and Neck. Methods  Collecting 28 cases with sebaceous carcinoma in Head and Neck which was diagnosed with pathology. Of all these patients, the eyelid in 10 cases, parotid in 2cases, external auditory meatus in 5 cases, maxillofacial in 7 cases, neck portion in 4 cases, neck lymph node metastasis in 3 cases. They were treated with surgical operation, radical therapy and chemistry therapy.Results  Diagnosis of sebaceous carcinoma demanded immunohistochemistry (IHC), and rare parotid sebaceous carcinoma was still distinguished with clear cell carcinoma, grume epidermis carcinoma and acinic cell carcinoma in pathology. By Follow-up of the all patients over 5 years, survival rate for 5 years was 71.4% (20/28), primary focus recurrence in 10 cases, in which, neck lymph node metastasis was discovered in 3 cases, and one was performed operation once again. Four cases lost communication (count for death); 2cases died of distant metastasis; 2cases died of other diseases.Conclusion  The sebaceous carcinoma mostly occurred in Head and neck, especially in eyelid, rare in parotid, which were easily ignored in diagnosis. Recurrence mostly presented in primary focus,and neck lymph node metastasis is much less. The cause of death mainly is distant metastasis. It is key point that forepart diagnosis and treatment can promote survival rate for 5 years. ,Key words,  sebaceous carcinoma;head and neck;pathology INTRODUCTION     Sebaceous carcinoma is a rare malignant tumor, whose incidence is more in eyelid than other portion, and more in old age man. From 1985 to 2001, 28 of patients with sebaceous carcinoma were collected and treated in our hospital. It is reported as following. 1  MATERIALS AND METHODS 1.1  Common Materials  Twenty-eight patients were selected to receive treatment including 20 males and 8 females; age ranged: ,50 years old in 22 cases,,50 years old in 6cases;ill-period:at ,4 years in 16 cases, 2 years in 6 cases,1，3 months in 6 cases. one of all was the longest ill-period for 10 1years.Twenty-eight patients with sebaceous carcinoma in Head and Neck, which was approved with pathology. Of all these patients, the eyelid in 10 cases, parotid in 2 cases, external auditory meatus in 5 cases, maxillofacial in 7 cases, neck portion in 4 cases, neck lymph node metastasis in 3 cases. 1.2  Diagnosis and treatment methods  All of these 30 cases were diagnosed as to sebaceous carcinoma through paraffin section and EMA, S-100, CK/H, ACTIN of IHC staining examination. All of these patients, primary focus of tumors were totally resected, treating neck lymph node dissection in 3 cases, preventing neck lymph node dissection in 7 cases. Twenty-eight patients receipted radical therapy 40GY and 5-FU 600mg, cisplatin 20 mg of chemistry therapyper day, in number 10 days, postoperatively. 2  RESULTS     The diameter of tumor was 0.5，7 cm and color in hoar, dark blueness and rosiness, small saccule cavities in tumor were formed over 60%; the tumor bourn clear but non-full envelope; the edge became swelling property or local soakage. In cell modality, the tumor made up of many and large cells of nest, piece shape, nucleolus deep staining, abundant clear and acidophilia cells. Degree was not identical in pleomorphism and non-typicality of cells and squamaous and basilar shape differentiation became more in tumor. Of 28 cases, differentiation type in 21 cases, basilar cell type in 4 cases; squamaous cell type in 3 cases and EMA,，,～CK/H,，,～Actin,,,S-100,,, in total. Followed up the all patients over 5 years, Survival rate for 5 years in 71.4% (20/28), primary focus recurrence in 10 cases, in which, neck lymph node metastasis was discovered in 3 cases, and was performed operation once again. Four cases lost communication (count for death); 2cases died of distant metastasis; 2cases died of other diseases. 3  DISCUSSIONS     The real sebaceous carcinoma is rare and mainly occurred in head- maxillofacial and was lower degree malignant tumor. It always arises in eyelid, lacrimal caruncle and orbit, rare in parotid, and more appearance in middle-old age people; but aggression of the sebaceous carcinoma at above portion was stronger than other ones. Yang Xiao-xiang(2004) searches interior data reportorial 22 cases of sebaceous carcinoma, only one case located thigh skin. Skin tissue of eyelid was differ from other ones, tarsal gland was largest sebaceous gland, tumor of origin from it was rare in other places,1,.     The clinical pictures of sebaceous carcinoma was non-specificity, and according to observation in our group, it commonly appears as nodus neoplasm, afterwards, form cauliflower shape and depressed ulceration and a majority of skin conglutination. The sebaceous carcinoma in parotid might form a neoplasm in parotid region touching as upward or downward action worse and ahead or backward better. Literature reported: 20% of patients with the parotid sebaceous carcinoma might reveal facial nerve involved, however, not find facial nerve dysfunction in our group. As malignant degree lower, forepart neck lymph node metastasis was much less, but in case primary focus recurred, neck lymph node metastasis might appear such as 33%(3/10) in our group.     In tissue of the sebaceous carcinoma, it might occur variations according to many or less of cell component; give priority to sebaceous cell for differentiation type;basilar cell for basilar type; squamaous cell for squamaous type, in common, it might not make clinical subtype as pathological subtype had not prominence relation with the prognosis,2,. The diagnosis of sebaceous carcinoma depended on pathology and IHC was key action, CK,，,～EMA,，,～S-100,,,～ Actin,,,, which was important conditions to support pathological diagnosis in the group. The sebaceous carcinoma in parotid was a rare tumor and the cell shape became the pleomorphism and nucleus aberrance. In histology, tumor was formed from sebaceous cell of various degree, in which, cells were arranged as nest and piece shape and remarkably involved neighborhood tissues. The special stain includes Sudan III or Sudan IV positive, IHC stained CK,EMA positive. It was important that parotid sebaceous carcinoma must be distinguished with clear cell carcinoma, grume epidermis carcinoma and acinus cell carcinoma in pathology. Non-verdiction was contributed in the origin of sebaceous cell differentiation from parotid, a great number of the specialists considered as obstructing parotid canal by inflammation or tumor and arose local sebaceous cell metaplasia. Skin appeared sebaceous “activation” after youthhood as well as sebaceous cell in parotid～and the sebaceous cell of “activation” maybe give birth to the sebaceous carcinoma,3,. Literature reports,4,: Studies of that p21ras protein related with tissue subtype clue on p21ras protein positive expressing rate was 52.9% and neck lymph node non-metastasis was 54.5% in eyelid sebaceous carcinoma of differentiation better, but p21ras protein positive expressing rate was 100% and neck lymph node metastasis was 100% in differentiation lower, respectively. Conclusions made that p21ras protein higher expressing was easier in neck lymph node metastasis of sebaceous carcinoma than non-expressing or lower-expressing and existing remarkable difference between higher and lower. Higher expressing p21ras positive rate clued on tumor malignant degree higher and  metastasis potency larger, which got up active guidance function in the operation, radical therapy, chemistry therapy and evaluating prognosis for patients.     Under normal conditions, that sebaceous carcinoma was a lower degree malignant tumor mainly depended on local surgical wide excision in treatment, should enlarge safe edge as possible as your trying, and local recurrence could reduce efficie ntly, as we had done. Local surgical wide excision easily resulted in tissue defect, but along with the advancement of microsurgery and development of constructing technique, repairing technique of head and neck surgery had be more mature. As a result of increasing various approaches of autotranplant reconstruction in head and neck surgery, appeasement treatments might turn to more active to become possible for afternoon cancer patients who had to give up the operation because of repairing difficulty in past. Author considered that island myocutaneous flap had obviously common characteristics, but also had each peculiarities, and the operative approaches were decided basing on peculiarities of each patient, location and range of defects, which were not wholly replaced each other,5,.According to applying principles of myocutaneous flap, it was necessary for the comparative beauty and fine function, which should avoid complex methods and make myocutaneous flap from far-distance, and could apply with transplant of flap with pedicel , and adequately considered the contradictions of both the pedicel of myocutaneous flap and metastasis of neck lymph glands in same region. After local recurrence carcinomas of two cases 0f maxillary-face region and 1case of mandible region in the group were widely excised, the forehead and pectoralis major myocutaneous flap with pedicle were transplanted for reconstruction, respectively. It was generally agreed that neck lymph node metastasis of sebaceous carcinoma was less, but as soon as the primary focus recurred, the chance of metastasis maybe more, such as 33%(3/10) in our patients. The first treatment was emphasized to be very important. Of 28 cases with sebaceous carcinoma, preventing neck lymph node dissection were adopted in 7 cases and pathological tests were negative. Whether the neck dissection had clinic signification, we wanted to answer this question but needed more experience accumulating and farther exploration. Author suggest: We needed to test p21ras protein of preoperative examination in pathology,  that it was clued on higher malignant of the tumor and metastasis potency larger when higher expressing p21ras positive was contributed, to decide whether the dissection. ,REFERENCES, 1  Li Shu ling. Tumors of the head and neck.Tianjing: Tianjing science technique publishing company,1993,250-251. 2  Yang Xiao xiang, Ha Ying di, Dong Liang. Eight cases of Sebaceous carcinoma reports and clinical pathological research. Clinical Misdiagnosis and Mistherepy,2004,17(9):664-665. 3  Yu Guang yan. Sialoid gland diseases.Beijing:Beijing medical university and Chian xiehe medical university pubilishing company,1994,149. 4  Niu Ying jun, Liu Fu-ling. Express of eyelid malignant tumor p21ras protein. Journal of preclinical medical college,2002,16(2):97-98. 5  Huang Jian nan, Fu Xiang-jun, Peng Shu-wen, et, al. Same stage reconst ruction of the tissue defects with island myocutaneous flap in Head and Neck surgery. Chinese Journal of modern eye ear nose and throat, 2006～3,4,: 295-299.