乳头状甲状腺癌侧颈淋巴结隐匿性转移相关因素分析

目的分析cN0乳头状甲状腺癌(PTC)行选择性颈淋巴结清扫的结果,研究不同临床病理特征对侧颈隐匿性淋巴结转移的影响。方法回顾性分析2008年1月至2011年3月109例我院行选择性颈淋巴结(包括同侧颈淋巴结)清扫的cN0期PTC患者资料,对其术后侧颈隐匿性淋巴结转移率与各临床病理特征的相关性进行分析。结果所有cN0病例中,Ⅵ区隐匿性转移率为46.8%,侧颈淋巴结隐匿性转移率为33.9%。淋巴结转移相关的因素有原发肿瘤大小(超声长径或病理长径)、腺外组织侵犯,侧颈淋巴结超声特点(包括淋巴门消失、皮髓质结构不清、血流丰富)及Ⅵ区淋巴结转移,同淋巴结阴性组差异具有统计学意义(P<0.05)。结论选择性颈淋巴结清扫后发现cN0期PTC患者存在一定的侧颈淋巴结隐匿性转移率,转移的概率与以上临床病理因素相关,对具有高危因素的患者建议行选择性淋巴结清扫术。     

Thyroid metastasis from breast cancer presenting with enlarged lateral cervical lymph nodes: A case report

BACKGROUND Secondary malignancy of the thyroid occurs infrequently and mainly originates from malignant tumors of the kidney,gastrointestinal tract,lungs,breast,and skin.The correct diagnosis is important but difficult.Importantly,there are major differences in the treatment of primary and metastatic thyroid cancer,which has a significant impact on prognosis and survival.Therefore,how to diagnose thyroid metastasis(TM)correctly before surgery is a major concern for surgeons.CASE SUMMARY We report a 38-year-old woman who presented with palpable cervical lymph nodes after breast cancer(BC)surgery 2 years ago.Ultrasonography and computed tomography revealed thyroid nodules with irregular margins and enlarged cervical lymph nodes.Biopsy was performed for the right largest cervical lymph node,and immunohistochemical analysis revealed negativity for thyroglobulin,estrogen receptor,and progestin receptor and positive for human epidermal growth factor receptor 2.The diagnosis was TM from BC with cervical lymph node metastasis.Total thyroidectomy with bilateral central and lateral neck lymph node dissection was performed.After a 5-mo follow-up,no recurrence or novel distant metastasis was identified.CONCLUSION TM from BC is a rare secondary malignancy.Broad differential diagnosis by biopsy and immunohistochemical analysis needs to be considered.     

超声检查对甲状腺癌术后颈淋巴结转移的诊断价值

目的探讨超声对甲状腺癌术后颈部肿大淋巴结的鉴别诊断价值。方法回顾性分析40例甲状腺癌术后患者颈部淋巴结的超声表现 ,比较转移性淋巴结和非转移性淋巴结在二维超声和彩色多普勒超声的表现 ,以及阳性淋巴结与原发病灶的位置关系。结果67枚转移性淋巴结中 ,沙粒样钙化点出现率为67.16% (45/67) ,周边缺损率为41.79 %(28/67) ,外周长入血管支数>2支的占77.61 %(52/67) ,26枚非转移性淋巴结中 ,沙粒样钙化点出现率为3.85% (1/26) ,周边缺损率为7.69 %(2/26) ,外周长入血管支数>2支的占7.69%(2/26)。转移性淋巴结中有38.81% (26/67)出现在第III群 ,有25.37 %(17/67)出现在第IV群。结论高频超声对甲状腺术后颈部肿大淋巴结的诊断和鉴别诊断具有重要价值。     

超声检测颈部淋巴结对弥漫性硬化型甲状腺乳头状癌的诊断价值

目的 探讨超声检测颈部淋巴结对弥漫性硬化型甲状腺乳头状癌(DSV)的诊断和鉴别诊断价值.方法 4年中甲状腺恶性肿瘤192例,从甲状腺乳头状癌中筛选出20例DSV(10.4%,20/192),分析DSV病例手术前颈部转移淋巴结声像图及甲状腺病变程度与淋巴结转移的关系.结果 DSV 20例,淋巴结转移18例(均为中央区淋巴结转移)侧颈区转移16例(88.9%).转移淋巴结直径5～32 mm,平均13 mm,呈等回声5例(27.8%)或偏高回声13例(72.2%),转移淋巴结皆伴沙粒体和血流信号增加.结论 DSV发生在相对年轻的患者,90%发生颈部淋巴结转移,超声检出颈部淋巴结特征性表现有助于DSV的鉴别诊断.     

不同病理类型甲状腺癌颈部转移淋巴结的声像图分析

目的探讨不同病理类型甲状腺癌颈部转移淋巴结的声像图特征。方法分析75例甲状腺癌颈部转移淋巴结的声像图的特点,其中乳头状癌50例,滤泡癌8例,髓样癌10例,未分化癌7例。结果甲状腺乳头状癌颈部转移性淋巴结局部可见团状偏高回声,部分淋巴结内可见沙砾样的微小钙化点,局部或整体可出现囊性变;甲状腺髓样癌颈部转移性淋巴结皮髓质分界不清,部分转移性淋巴结内也可见沙砾样的微小钙化点,但未见囊性变;滤泡癌和未分化癌颈部转移性淋巴结纵横比缩小,近似球形,皮髓质分界不清,淋巴门结构消失,呈低回声,均未见微小钙化点和囊性变。结论不同病理类型的甲状腺癌颈部转移淋巴结具有不同的声像图特征,病变淋巴结的超声表现与其病理改变密切相关。     

颈部增强CT在甲状腺癌发生颈部淋巴结转移患者中的诊断效果

  目的  分析颈部增强CT对甲状腺癌颈部淋巴结转移的诊断效能。  方法  回顾性分析76例甲状腺乳头状癌患者的临床资料。以病理诊断结果为金标准,分析增强CT检查对甲状腺癌颈部淋巴结转移的诊断价值。  结果  病理学检查确诊本组患者颈部淋巴结转移153枚,未转移533枚,中央区淋巴结转60.13%;以病理诊断结果为金标准,增强CT诊断颈部中央区淋巴结转移准确率为83.61%,诊断颈侧区淋巴结转移准确率为89.26%;增强CT显示本组患者颈部转移淋巴结平均短径高于未转移淋巴结（8.91±2.62 mm vs 8.02±2.51 mm）,转移与未转移淋巴结短径>10 mm、明显增强、明显不均匀强化、囊变、病灶内钙化及周围组织侵犯数目的差异有统计学意义（P < 0.05）。  结论  增强CT对甲状腺癌颈部中央区淋巴结转移的诊断效能低于颈侧区淋巴结,建议结合超声或MRI检查综合评估。      

Section 2. Thyroid: Sentinel lymph node biopsy in patients with thyroid carcinoma

The subject of performing prophylactic or elective modified dissections of the neck in patients with clinically occult lymph nodal metastases from thyroid cancers is controversial since metastases to lymph nodes are associated with high rates of recurrences. Biopsies of sentinel lymph nodes can be performed successfully in patients with thyroid cancers since they can be identified with dyes or 99mTc. Our preliminary findings indicate that biopsies of sentinel lymph nodes can be useful in the treatment of thyroid cancers; however, the clinical significance of identifying metastases in regional lymph nodes by this technique remains to be determined.     

超声在甲状腺癌颈部淋巴结转移的诊断价值探讨

目的：探讨超声在甲状腺癌颈部淋巴结转移中的诊断价值。方法：术前超声检查47例甲状腺癌患者的颈部淋巴结,超声所见与手术切除病理结果对照分析。结果：超声检查与病理结果对照,符合的淋巴结41个,符合率78.8%。淋巴结的内部回声不均、髓质变形或缺失、周边型及混合型血流预示淋巴结有转移。结论：超声检查对甲状腺癌颈部淋巴结转移具有较高的诊断价值。     

彩色多普勒超声对甲状腺乳头状癌颈部淋巴结囊性转移的诊断价值

目的探讨甲状腺乳头状癌颈部淋巴结囊性转移的超声表现。方法对经病理证实为甲状腺乳头状癌颈部淋巴结囊性转移的18例患者,44枚囊性转移性淋巴结进行高频彩色多普勒超声检查,观察其二维声像图,结节、分隔内部的血流情况。结果囊性转移性淋巴结二维声像图表现为完全囊性变和部分囊性变两种类型,42枚为部分囊性变,2枚为完全囊性变。其中38枚囊性变区透声差,39枚囊壁较厚且毛糙,23枚有壁结节,18枚内部有粗细不均分隔,19枚内部见点状高回声,40枚囊性转移性淋巴结实性成分内见点状、条状血流信号。结论彩色多普勒超声是诊断甲状腺乳头状癌颈部淋巴结囊性转移的一项重要检查方法,颈部淋巴结囊性变对于甲状腺乳头状癌转移的诊断有较高的特异性。     

颈部淋巴结内囊性变在甲状腺乳头状癌转移诊断中的作用

目的:观察高分辨率超声仪在诊断甲状腺乳头状癌颈部淋巴结转移中的作用,并评价颈部淋巴结内囊性变作为甲状腺乳头状癌转移的特征性改变及其特异性和敏感性。方法:回顾性分析87例颈部淋巴结异常的患者,所有患者均曾行灰阶及彩色多普勒检查、超声引导细针穿刺活检和/或术后组织病理学检查。结果:所有患者超声显示淋巴结异常,在69%甲状腺乳头状癌患者的转移淋巴结中可见囊性变。而在非甲状腺乳头状癌患者的转移淋巴结中仅有2例可见此现象。颈部淋巴结内部出现囊性变作为甲状腺乳头状癌转移的超声特征性改变,其敏感度为69%,特异度为96.6%,阳性预测值为90.9%,阴性预测值为83.6%,准确度为87.4%。结论:颈部淋巴结内出现囊性变高度提示甲状腺乳头状癌转移。     

Recent results of reoperative surgery in medullary carcinoma of the thyroid

Reoperative surgery of medullary carcinoma of the thyroid can be avoided by meticulous primary surgery. Reoperative surgery can succeed even if the tumour and its metastases are bilateral, as is often the case in hereditary cases. Even patients with numerous macroscopic metastases can show normaligation of their calcitonin (CT) levels in response to reoperative surgery. Patients with normal postoperative CT values after the combined short time Ca++ and pentagastrin test continued to show normal results when followed up for up to eight years.     

Sipple syndrome (bilateral phaeochromocytoma medullary C-cell carcinoma of the thyroid gland) with exceptionally prolonged clinical course

The sporadic occurrence of the Sipple syndrome with bilateral phaeochromocytoma and medullary thyroid carcinoma is a well-known pathological entity. The present report refers to a patient with medullary thyroid carcinoma, initially misdiagnosed as Hurthle-cell adenoma after partial resection of the thyroid gland. 5 and 8 years later the patient underwent bilateral adrenalectomy for phaeochromocytoma. 4 years after the second phaeochromocytoma a palpable thyroid nodule developed, thyroidectomy was performed and the tumour diagnosed as a medullary thyroid carcinoma. This diagnosis was confirmed by reexamination of the histological specimens obtained during the first surgical intervention. We were prompted to report the current case history, because of the protracted course of the medullary thyroid carcinoma in this patient and to point out the value of the determination of pentagastrin stimulated calcitonin values in patients with medullary thyroid carcinoma for diagnosis, postoperative follow-up and in family screening studies.     

甲状腺乳头状癌伴颈部淋巴结转移相关超声征象分析

目的：探讨甲状腺乳头状癌（PTC）与颈部淋巴结转移相关的超声征象,为判断PTC有无颈部淋巴结转移提供参考。方法回顾性分析2011-2013年哈尔滨医科大学附属第一医院经手术后病理证实的170例PTC患者的超声征象。其中59例伴颈部淋巴结转移,111例无颈部淋巴结转移。采用操作者工作特性（ROC）曲线分析阻力指数（RI）、收缩期峰值血流速度（PSV）判断PTC有无颈部淋巴结转移的最佳诊断界限值。采用χ2和秩和检验比较PTC伴颈部淋巴结转移患者与无颈部淋巴结转移患者原发灶超声征象差异。采用Logistic回归分析PTC伴颈部淋巴结转移的相关因素。结果 ROC曲线分析显示,RI、PSV判断PTC有无颈部淋巴结转移的最佳诊断界限值分别为0.735、13.95 cm/s。与PTC无颈部淋巴结转移患者比较,PTC伴颈部淋巴结转移患者原发灶直径、是否有晕环、是否累及甲状腺上极、有无微钙化、血供分级、RI及PSV差异均有统计学意义;而原发灶回声、边界是否清晰、纵横比差异均无统计学意义。多因素Logistic回归分析显示,PTC原发灶直径及PSV这2个因素是PTC伴颈部淋巴结转移的相关独立因素。结论 PTC原发灶的一些超声征象与PTC有无颈部淋巴结转移有密切的相关性,可为术前PTC患者颈部淋巴结有无转移的诊断提供有价值的信息。     

Papillary thyroid cancer treated at the Mayo Clinic, 1946 through 1970: initial manifestations, pathologic findings, therapy, and outcome

We performed a retrospective study of 859 patients with papillary thyroid cancer, who had received their primary treatment at the Mayo Clinic during the period 1946 through 1970. The maximal follow-up was 39 years. All but 2 patients underwent a thyroid operation; 319 (37%) had metastatic cervical nodes. Of the 800 patients without distant metastatic lesions on initial examination who underwent a potentially curative surgical procedure, postoperatively 7% had nodal metastatic lesions, 6% had a local tumor recurrence, and 5% had a distant metastatic lesion. In patients who had intrathyroidal tumors initially, postoperative local recurrences or distant metastatic lesions resulted in a 10-year cancer mortality of 17 and 41%, respectively; in those with extrathyroidal tumors, postoperative recurrences were associated with significantly higher death rates. Death from thyroid cancer was highly associated with the following factors: age more than 50 years, male sex, tumor size, tumor grade, initial extent of disease, and absence of Hashimoto's disease. Earlier studies of Mayo patients treated between 1926 and 1960 described no deaths due to thyroid cancer in patients with occult tumors (1.5 cm or less). Four such patients were identified among our 859 patients; all had been examined and treated after 1961. To date, 56 (6.5%) of the 859 patients have died as a result of papillary thyroid cancer. In this study, in which 16% of patients underwent total thyroidectomy and 3% had radioiodine ablation, the overall mortality observed at 30 years was only 3% above that expected.     

甲状腺微小乳头状癌超声特征与淋巴结转移的分析

目的探讨超声检查结果对于甲状腺微小乳头状癌合并颈部淋巴结转移的诊断价值。方法回顾性分析136例经病理证实为甲状腺微小乳头状癌患者的超声影像学资料及术后颈部淋巴结病理结果,分析超声特征与颈部淋巴结转移的相关因素。结果单因素分析结果显示,多发病灶、结节边界模糊及结节与甲状腺被膜接触的患者易发生颈部淋巴结转移(P<0.05);多因素分析结果显示,边界模糊及结节与甲状腺被膜接触是颈部淋巴结转移的独立危险因素。结论多发病灶、结节边界模糊及结节与甲状腺被膜接触对甲状腺乳头状癌患者颈部淋巴结转移具有良好的预测价值。     

Occult metastasis.

The most important factor affecting the outcome of patients with invasive cancers is whether the tumor has spread, either regionally (to regional lymph nodes) or systemically. However, a proportion of patients with no evidence of systemic dissemination will develop recurrent disease after primary 'curative' therapy. Clearly, these patients had occult systemic spread of disease that was undetectable by methods routinely employed (careful pathological, clinical, biochemical and radiological evaluation). In addition, the success of adjuvant therapy is assumed to stem from its ability to eradicate occult metastases before they become clinically evident [1]. Therefore, methods for the detection of occult metastases in patients with the earliest stage of cancer, i.e., prior to detection of metastases by any other clinical or pathological analysis, have received a great deal of attention.     

Occult sclerosing carcinoma of the thyroid.

A case of occult sclerosing thyroid carcinoma is reported. The primary requirement for diagnosis is that the cancer is less than 1.5 cm in diameter. In addition, a fibrosing component with varying degrees of sclerosis is present. Lymph node metastases are frequent and may appear as benign thyroid follicles. Occasional direct invasion or vascular invasion may occur. Distant metastases were not reported in the series reviewed. Adequate therapy would seem to be total thyroidectomy of the involved lobe and radical subtotal thyroidectomy of the opposite lobe with excision of all enlarged or involved lymph nodes.     

宫颈癌转移性淋巴结MRI影像学特征

目的探讨MRI检出宫颈癌转移淋巴结大小及盆腔内分布特点。方法54例宫颈癌患者,采用PACS记录MRI检出淋巴结的影像特点,分析MRI检出宫颈癌淋巴结转移的敏感性、特异性。结果MRI检出宫颈癌淋巴结中闭孔区淋巴结检出率最高,左侧为88％,右侧为90％;髂内区淋巴结检出率次之,左侧为85％,右侧为88％;腹股沟深区淋巴结检出率左侧为79％,右侧为77％;髂外区淋巴结检出率左侧为45％,右侧为43％;髂总区淋巴结检出率左侧为31％,右侧为17％;转移组中5～10mm淋巴结占检出总数的51．2％;ROC曲线示以淋巴结直径判断检出淋巴结是否转移,取8mm时敏感性为49．5％,特异性为69．6％,AUC为0．669。结论MRI检出宫颈癌淋巴结主要分布在闭孔区及髂内区,腹股沟深区及髂外区次之;淋巴结直径不能判断转移与否。     

Detection of Occult Medullary Thyroid Cancer Recurrence with 2-Deoxy-2-[F-18]fluoro-<Emphasis Type="SmallCaps">d</Emphasis>-glucose-PET and PET/CT

Purpose 2-Deoxy-2-[F-18]fluoro-d-glucose (FDG)-positron emission tomography (PET) has an established role in restaging of various cancers, including papillary and undifferentiated thyroid carcinoma. However, controversies exist regarding its ability to reliably assess recurrent medullary thyroid cancer (MTC). We were therefore prompted to review our experience with FDG-PET for detection of occult MTC. Methods This is a retrospective study (Apr 1, 1997–Mar 31, 2004) of 13 patients with histologic diagnosis of MTC, who had PET examinations. The group included six men and seven women, 15–62 years old (average: 48 ± 13). The PET scan request was triggered by rising levels of calcitonin and negative anatomical imaging studies. Results Recurrent/metastatic disease was identified by PET in seven (54%) of the 13 patients. The lesions were located in superior mediastinum (4), cervical lymph nodes (3), thyroid bed (2), lung (1) and liver (1). The calcitonin levels ranged from 52 to 5,090 pg/ml (average: 1,996 pg/ml) in patients with negative PET scans and from 132 to 9,500 pg/ml (average: 3,757 pg/ml) in patients with positive studies. The sensitivity and specificity of FDG-PET for disease detection in this cohort were 85.7% (95% CI: 48.7–97.4) and 83.3 % (95 % CI: 43.6–96.9), respectively. Conclusion Our findings suggest a significant role for FDG-PET in patients with suspected MTC recurrence, with sensitivity of 85.7% and specificity of 83.3% for disease detection. FDG-PET provides additional information in a significant fraction of cases (54%) and could be used for restaging of patients with MTC and elevated levels of biomarkers (calcitonin). Additional studies are necessary to further evaluate the role of FDG-PET in MTC.     

Sentinel-Lymphknoten bei oralen und oropharyngealen epithelialen Tumoren

Carcinomatous metastases in regional lymph nodes worsen substantially the prognosis of patients with oral cavity and oropharyngeal cancer. Due to the high probability of occult metastasis (about 30%), during surgical resection of the primary tumor usually also elective dissection of lymph nodes is performed. Opinions on the extent of the elective neck dissection still differ, whereas selective dissection increasingly gains in importance. The aim of selective dissections, based on the predictability of formation of metastases, is the identification and exstirpation of the sentinel lymph node. In this prospective study the applicability of the concept of the sentinel lymph node in patients with oral cavity and oropharyngeal cancer was analysed. 12 patients with oral cavity and orophangeal cancer, staging T1-T3, all N0 (examined by palpation and sonography) were included. The localization of the sentinel(s) was determined preoperatively by radioisotope (Tc Nanocolloid). Sentinel(s) were identified first with a gamma probe (Neoprobe 2000); we then injected methylene blue into the peritumoral area for easier detection of the sentinel(s). The sentinels were removed and sent for frozen section examination. Regardless of the findings of the frozen section examination modified dissection was carried out. Later we compared frozen sections with paraffin microtome sections of sentinel(s) and of other exstirpated neck lymph nodes. We could identify the sentinel lymph node in all patients, in 6/12 patients we found several sentinels. If sentinels were not affected by tumor cells, there were no metastases in the downstream neck lymph nodes either. If in the sentinel lymph nodes no metastases can be determined, eliminating the environment alone could be sufficient. However, this assumption requires verification in a larger patient group.