基于血管移位的诊断评分和诺莫图在鉴别颈部迷走神经鞘瘤和颈部交感神经鞘瘤中的应用

doi:10.19401/j.cnki.1007-3639.2025.07.008

摘要/Abstract

摘要：

背景与目的：颈部迷走神经鞘瘤（vagal nerve cervical schwannomas，VNCS）和颈部交感神经鞘瘤（sympathetic chain cervical schwannomas，SCCS）的术后并发症不同，术前准确鉴别VNCS与SCCS具有重要的临床意义。本研究旨在构建并验证基于血管移位情况建立的诊断评分和诺莫图模型，用于术前区分VNCS与SCCS。方法：本研究为横断面研究。回顾性分析2017年1月—2022年4月复旦大学附属肿瘤医院收治的经病理学检查证实的VNCS和SCCS患者资料，本研究经复旦大学附属肿瘤医院伦理委员会批准（伦理编号：1612167-18）。纳入标准：① 经活检或手术病理学检查证实的VNCS和SCCS；② 临床数据完整；③ 在术前进行增强计算机体层成像（computed tomography，CT）或磁共振成像（magnetic resonance imaging，MRI）检查。排除标准：① 对比剂过敏者；② 扫描图像质量差者；③ 图像伪影严重者；④ 扫描方式不符合要求者。所有患者以7∶3的比例随机分配到训练集和验证集。基于患者术前CT或MRI图像评估肿瘤的位置、大小及血管移位情况，由放射诊断科1名住院医师和1名主治医师分别独立阅片评估。使用Lasso回归分析筛选出独立预测因子，建立诊断评分和诺莫图，通过受试者工作特征（receiver operating characteristic，ROC）曲线评估模型性能。结果：共纳入患者110例，训练集77例，验证集33例，年龄24~78岁，平均（51.22±12.36）岁。两组患者的年龄、性别、肿瘤位置及大小等基线资料差异均无统计学意义（P>0.05）。影像学分析显示，颈内动脉（internal carotid artery，ICA）与颈外动脉（external carotid artery，ECA）的分离状态与SCCS显著相关（P<0.001），而ICA与颈内静脉（internal jugular vein，IJV）的分离则与VNCS显著相关（P<0.001）。ICA后外侧移位与SCCS显著相关（P<0.001），而ICA前内侧移位与VNCS显著相关（P<0.001）。基于肿瘤大小、ICA移位方向、IJV移位方向、ICA/ECA分离及ICA/IJV分离5个影像学特征构建的诊断评分模型与诺莫图，在区分VNCS与SCCS时表现出显著效能，训练集与验证集的ROC曲线的曲线下面积（area under curve，AUC）分别为0.953（95% CI：0.912~0.994）和0.939（95% CI：0.885~0.993）。结论：基于血管移位的诊断评分和诺莫图模型在鉴别VNCS与SCCS中表现出良好的预测效能，可能有助于临床决策。

关键词: 颈部迷走神经鞘瘤, 颈部交感神经鞘瘤, 血管移位, 诊断评分, 诺莫图, 横断面研究

Abstract:

Background and purpose: Accurate preoperative differentiation between vagal nerve cervical schwannomas (SCCS) and sympathetic chain cervical schwannomas (SCCS) in the neck is crucial because of their different postoperative complication. This study aimed to construct and validate a Diagnosis Score and vascular displacement nomogram for the preoperative differentiation of VNCS from SCCS in the neck. Methods: This cross-sectional study retrospectively analyzed patients with pathologically confirmed VNCS and SCCS at Fudan University Shanghai Cancer Center from January 2017 to April 2022. This study was approved by the medical ethics committee of Fudan University Shanghai Cancer Center (approval number: 1612167-18). Inclusion criteria: ① histopathological diagnosis of VNCS or SCCS through biopsy or surgical resection; ② patients with complete clinic data; ③ availability of preoperative contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI) examinations. Patients were excluded for: ① contrast agent contraindications; ② poor image quality; ③ severe artifacts; ④ non-standard scanning protocols. The cohort was randomly divided into training and validation sets in a 7∶3 ratio. Two radiologists (one resident and one attending physician) independently evaluated tumor characteristics (location, size and vascular displacement patterns) on preoperative imaging. Independent predictors were selected using LASSO regression analysis to construct a diagnostic scoring system and nomogram, with model performance evaluated by the receiver operating characteristic (ROC) curve. Results: A total of 110 patients were enrolled, with 77 cases allocated to the training set and 33 cases to the validation set. The age range was 24-78 years, and the mean age was (51.22±12.36) years. There were no statistically significant differences in baseline characteristics including age, gender, tumor location and size between the two patient groups (P>0.05). ICA/ECA splaying was significantly associated with SCCS (P<0.001), while the ICA/IJV splaying was significantly associated with VNCS (P<0.001). Lateral and posterior ICA displacement were significantly associated with SCCS (P<0.001), and medial and anterior ICA displacement were significantly associated with VNCS (P<0.001). Five features including tumor size, ICA displacement direction, IJV displacement direction, ICA/ECA splaying and ICA/IJV splaying were used to establish the Diagnosis Score and nomogram. The nomogram combined imaging features showed favorable preference value for differentiating VNCS from SCCS, with area under curve (AUC) values of 0.953 (95% CI: 0.912-0.994) and 0.939 (95% CI: 0.885-0.993) for the training and validation cohorts, respectively. Conclusion: The Diagnosis Score and vascular displacement nomogram showed favorable predictive efficacy for differentiating VNCS from SCCS in the neck, and might be useful for clinical decision-making.

Key words: Vagal nerve cervical schwannomas, Sympathetic chain cervical schwannomas, Vascular displacement, Diagnosis score, Nomogram, Cross-sectional study

中图分类号:

R739.91

向诗语, 李桥, 沈长青, 顾雅佳, 吴斌. 基于血管移位的诊断评分和诺莫图在鉴别颈部迷走神经鞘瘤和颈部交感神经鞘瘤中的应用[J]. 中国癌症杂志, 2025, 35(7): 695-701.

XIANG Shiyu, LI Qiao, SHEN Changqing, GU Yajia, WU Bin. Preoperative differentiation of vagal nerve cervical schwannomas from sympathetic chain cervical schwannomas based on diagnosis score and vascular displacement nomogram[J]. China Oncology, 2025, 35(7): 695-701.

图/表 8

图1

表1

图2

图3

表2

表3

图4

图5

参考文献 18

[1]	KITAZUME Y, OHASHI I, KATAYAMA T, et al. Diffusion-weighted magnetic resonance neurography for parapharyngeal schwannomas: preoperative determination of the originating nerves[J]. J Comput Assist Tomogr, 2014, 38(6): 930-935. doi: 10.1097/RCT.0000000000000141 pmid: 25170536
[2]	PHULWARE R H, SARDANA R, CHAUHAN D S, et al. Extracranial schwannomas of the head and neck: a literature review and audit of diagnosed cases over a period of eight years[J]. Head Neck Pathol, 2022, 16(3): 707-715. doi: 10.1007/s12105-022-01415-y pmid: 35157211
[3]	DOSEMANE D, KABEKKODU S, JAIPURIA B, et al. Extracranial non-vestibular head and neck schwannomas: a case series with the review of literature[J]. Braz J Otorhinolaryngol, 2022, 88(Suppl 4): S9-S17.
[4]	LOPERFIDO A, CELEBRINI A, FIONDA B, et al. Diagnostic and therapeutic strategy for vagal schwannoma: case series and literature review[J]. Medicina (Kaunas), 2023, 59(6): 1013.
[5]	KIM S H, KIM N H, KIM K R, et al. Schwannoma in head and neck: preoperative imaging study and intracapsular enucleation for functional nerve preservation[J]. Yonsei Med J, 2010, 51(6): 938-942. doi: 10.3349/ymj.2010.51.6.938 pmid: 20879063
[6]	王保鑫, 董频, 陈歆维, 等. 颈部神经鞘瘤的CT表现与病理基础[J]. 中国中西医结合耳鼻咽喉科杂志, 2014, 22(4): 283-284.
	WANG B X, DONG P, CHEN X W, et al. CT appearances and corresponding pathologic basis of cervical neurilemmoma[J]. Chin J Otorhinolaryngol Integr Med, 2014, 22(4): 283-284.
[7]	郑晓珂, 王卓颖. 颈动脉间隙神经鞘瘤的诊治进展[J]. 中国癌症杂志, 2016, 26(11): 952-956. doi: 10.19401/j.cnki.1007-3639.2016.11.013
	ZHENG X K, WANG Z Y. Advances in the diagnosis and management of schwannomas in carotid space[J]. China Oncol, 2016, 26(11): 952-956.
[8]	ANIL G, TAN T Y. CT and MRI evaluation of nerve sheath tumors of the cervical vagus nerve[J]. AJR Am J Roentgenol, 2011, 197(1): 195-201.
[9]	VERMA R R, VERMA R. Ancient schwannoma: Cervical sympathetic chain with review of literature[J]. Indian J Otolaryngol Head Neck Surg, 2022, 74(Suppl 2): 1886-1892.
[10]	FURUKAWA M, FURUKAWA M K, KATOH K, et al. Differentiation between schwannoma of the vagus nerve and schwannoma of the cervical sympathetic chain by imaging diagnosis[J]. Laryngoscope, 1996, 106(12 Pt 1): 1548-1552. doi: 10.1097/00005537-199612000-00021 pmid: 8948621
[11]	ANIL G, TAN T Y. Imaging characteristics of schwannoma of the cervical sympathetic chain: a review of 12 cases[J]. AJNR Am J Neuroradiol, 2010, 31(8): 1408-1412.
[12]	GRAFFEO C S, VAN ABEL K M, MORRIS J M, et al. Preoperative diagnosis of vagal and sympathetic cervical schwannomas based on radiographic findings[J]. J Neurosurg, 2017, 126(3): 690-697. doi: 10.3171/2016.1.JNS151763 pmid: 27104848
[13]	GIOVAGNORIO F, MARTINOLI C. Sonography of the cervical vagus nerve: normal appearance and abnormal findings[J]. AJR Am J Roentgenol, 2001, 176(3): 745-749.
[14]	MIKAELIAN D O, HOLMES W F, SIMONIAN S K. Parapharyngeal schwannomas[J]. Otolaryngol Head Neck Surg, 1981, 89(1): 77-81. pmid: 6784086
[15]	SHERIDAN M F, YIM D W. Cervical sympathetic schwannoma: a case report and review of the English literature[J]. Otolaryngol Head Neck Surg, 1997, 117(6): S206-S210.
[16]	DAS K N, MURALEEDHARAN M, KESHRI A, et al. Comprehensive analysis of radiological and surgical predictors in cervical sympathetic schwannomas: a novel staging approach and its implications[J]. Eur Arch Oto Rhino Laryngol, 2025, 282(2): 1005-1015.
[17]	WONG C E, HUANG C C, CHUANG M T, et al. Quantification of vessel separation using the carotid-jugular angle to predict the nerve origin of neck peripheral nerve sheath tumours: a pooled analysis of cases from the literature and a single-center cohort[J]. Int J Surg, 2023, 109(9): 2704-2713.
[18]	SANDLER M L, SIMS J R, SINCLAIR C, et al. Vagal schwannomas of the head and neck: a comprehensive review and a novel approach to preserving vocal cord innervation and function[J]. Head Neck, 2019, 41(7): 2450-2466.

Characteristic	VNCS (n=46)	SCCS (n=64)	P value
Gender			0.653
Male	25 (54.3)	32 (50.0)
Female	21 (45.7)	32 (50.0)
Median age/year $\bar{x}±s$	50.10±11.23	49.70±12.47	0.171
Tumor distribution			0.067
Upper neck	33 (71.7)	57 (89.1)	0.020^*
Middle neck	6 (13.0)	3 (4.7)	0.115
Lower neck	7 (15.3)	4 (6.2)	0.122
Tumor location			0.409
Left side	22 (47.8)	28 (43.8)
Right side	24 (52.2)	36 (56.2)
Maxium transverse diameter/mm $\bar{x}±s$	39.12±6.53	42.01±9.75	0.177

Item	AUC (95% CI)	Sensitivity/%	Specificity/%	Accuracy/%
Training set (n=63)	0.953	0.826	0.974	0.919
Validation set (n=27)	0.939	0.800	0.944	0.893