策略性甲状旁腺自体移植在甲状腺乳头状癌再次中央区淋巴结清扫中的应用

目的探讨策略性甲状旁腺自体移植是否能有效减少甲状腺乳头状癌(PTC)再次中央区淋巴结清扫术后甲状旁腺功能低下的发生率。方法回顾性分析2009年1月至2015年10月期间在四川大学华西医院甲状腺外科因PTC复发(淋巴结转移)再次行单侧或双侧中央区淋巴结清扫(包括颈侧区清扫)患者的临床资料,根据初次手术是否行策略性甲状旁腺自体移植分为移植组和未移植组。统计及比较2组患者一般情况、术前血Ca2+及甲状旁腺激素水平、首次手术方式、再次手术前是否存在声带麻痹、再次手术方式和术后并发症。结果 74例PTC再次手术患者纳入研究,其中移植组35例,未移植组39例。术后1 d血Ca2+及甲状旁腺激素水平移植组明显高于未移植组(P0.05);移植组2例患者新出现喉返神经损伤,未移植组5例新出现喉返神经损伤(5.7%比12.8%,P0.05);移植组和未移植组分别有4例和12例出现暂时性甲状旁腺功能低下,1例和4例出现永久性甲状旁腺功能低下,2组甲状旁腺功能低下发生率差异有统计学意义(14.3%比41.0%,P0.05)。术后病理学检查结果提示2组中央区淋巴结清扫数目分别为(2.1±1.3)枚和(1.4±0.7枚),其差异有统计学意义(P0.05)。结论策略性甲状旁腺自体移植可有效减少PTC再次中央区淋巴结清扫术后甲状旁腺功能低下的发生,从而大大提高手术安全性及彻底性。     

70例甲状腺乳头状癌手术治疗的临床分析

目的 :探讨甲状腺乳头状癌(PTC)临床特点和手术治疗效果及其预后。方法:回顾性分析2005~2012年手术治疗的70例PTC患者临床资料,并对其预后进行随访观察。结果:54例(77.1%)患者行甲状腺切除术及颈部淋巴结清扫,其余患者仅行甲状腺腺叶切除术。术后病理提示,31例(44.3%)患者的肿瘤长径1 cm,29例(41.4%)患者伴有颈部淋巴结转移,27例(38.6%)患者伴有中央区淋巴结转移。25例术前检查淋巴结转移阴性在术中进行预防性中央区淋巴结清扫的患者中,4例(16%)病理显示淋巴结转移。4例患者出现术后并发症。4例患者出现局部复发,2例患者出现远处转移,在术后1年内死亡。至末次随访,患者总生存率为97.1%。结论:手术是PTC安全有效的治疗手段,术中预防性中央区淋巴结清扫是有必要的。对于分期较晚的PTC患者,术后进行放射性碘治疗可降低复发风险。     

甲状腺系膜切除术在中央区淋巴结清扫的临床研究

目的探讨甲状腺乳头状癌(PTC)患者行甲状腺系膜切除术的中央区淋巴结清扫的临床价值。方法回顾性分析2017年10月至2019年4月173例PTC患者临床资料。根据术式不同分为两组,常规组98例,术中行常规中央区淋巴结清扫;系膜组75例,术中行甲状腺系膜切除术清扫中央区淋巴结。使用统计软件SPSS 24.0分析,围术期指标、甲状旁腺素(PTH)、血钙等计量资料采用(±s)表示,独立样本t检验;术后并发症、复发转移率等计数资料采用χ²检验。以P<0.05差异有统计学意义。结果两组患者在手术时间、术中出血量、术后住院时间及中央区淋巴结清扫数目中差异均无统计学意义(P>0.05);两组患者术后3 d PTH及血钙水平均较术前明显下降,且常规组较系膜组均更低(P<0.05);常规组术后并发症发生率为20.4%明显高于系膜组9.3%(P<0.05);术后平均随访12.7个月,术后3个月内,所有患者PTH均恢复正常,无永久性喉返神经损伤及永久性甲状旁腺功能低下发生。随访期内常规组复发转移率为5.1%,系膜组为2.7%,差异无统计学意义(P>0.05)。结论在PTC手术中,通过甲状腺系膜切除术清扫中央区淋巴结,具有手术并发症发生率低,更好地保护甲状旁腺功能,避免血钙水平过度下降的优势。     

峡部甲状腺乳头状癌中央区淋巴结处理的研究进展

峡部甲状腺乳头状癌(PTC)中央区淋巴结的处理问题存在争议.对于未发生中央区淋巴结转移(cN0)的峡部PTC患者是否预防性中央区淋巴结清扫(PCND)以及采用同侧中央区淋巴结清扫术(IpsiCND)亦或双侧中央区淋巴结清扫术?本文就该问题近年来的研究进展进行综述.     

甲状腺乳头状癌行预防性中央区淋巴结清扫的争议、共识与对策

对术前或术中检查中央区淋巴结阴性（cN0）的甲状腺乳头状癌（PTC）是否行预防性中央区淋巴结清扫（pCND）目前还存在争议性。尽管pCND对cN0 PTC病人长期存活率、复发率和术后甲状腺球蛋白的影响仍不明确,但能够清除中央区潜在的转移淋巴结,有利于手术的彻底性和降低再手术时并发症的发生率,有利于术后准确分期和合理选择放射性碘治疗,并对颈侧方淋巴结转移具有一定的预测价值。2012年我国《甲状腺结节及分化型甲状腺癌诊治指南》及国内学者主流观念,推荐对cN0 PTC病人行病灶同侧的pCND。在行pCND时,应该确保手术范围的规范,减少术后并发症的发生。     

多灶性甲状腺乳头状癌的临床病理及颈淋巴结转移特征

目的:探讨多灶性甲状腺乳头状癌(PTC)的临床病理及颈淋巴结转移特征。方法:回顾性分析2016年6月—2016年10月于郑州大学第一附属医院甲状腺外科行手术治疗并经术后病理证实的323例PTC患者的临床资料,其中多灶性PTC患者148例,单灶性PTC患者175例。结果:多灶性PTC患者与单灶性PTC患者间性别、年龄、癌灶最大径差异无统计学意义(均P0.05),但前者更易发生颈部中央区淋巴结转移(P0.001)、颈侧区淋巴结转移(P=0.028)及腺外浸润(P0.001);多灶性PTC患者中,癌灶数≥3的患者中央区淋巴结转移率(P=0.010)、侧区淋巴结转移率(P=0.018)及腺外浸润的发生率(P=0.020)明显高于癌灶数=2的患者;多因素分析显示,癌灶最大径(P=0.005)及癌灶数量(P=0.006)为多灶性PTC中央区淋巴结转移的独立危险因素。结论:多灶性PTC较单灶性PTC侵袭性强,更易发生转移、浸润,建议选择全甲状腺切除加中央区淋巴结清扫作为标准化手术方式,颈侧区存在可疑肿大淋巴结者应积极行颈侧区淋巴结清扫术。     

甲状腺乳头状癌行预防性中央区淋巴结清扫术研究进展

甲状腺乳头状癌(PTC)是最常见的甲状腺恶性肿瘤,预后良好.但颈部淋巴结转移却很常见,其中最常见的转移区域是颈部中央区(即Ⅵ区).目前对于临床可疑或确定有颈淋巴结转移者,需行治疗性中央区颈淋巴结清扫术,国内外观点基本一致,然而对于cN0 PTC患者是否应该常规行预防性中央区颈淋巴结清扫术仍存较大争议.本文就PTC行预防性中央区颈淋巴结清扫术研究进展做一综述.     

甲状腺乳头状癌颈淋巴结转移的影响因素分析

分析甲状腺乳头状癌(PTC)颈淋巴结转移的影响因素。对2006年5月—2012年10月收治的60例PTC颈淋巴结转移患者的临床资料进行回顾分析。60例患者均行Ⅰ期单侧或双侧中央区淋巴结清扫术,11例患者术后出现并发症,并发症发生率为18.3%,其中暂时性甲状旁腺功能减退5例,肩无力2例,乳糜漏2例,颈丛神经病理性疼痛综合征1例,喉返神经损伤1例,均于术后3个月内恢复正常。多因素回归分析发现,除性别外,年龄、肿瘤直径及肿瘤侵犯包膜均为影响PTC颈淋巴结转移的独立危险因素(P<0.05)。对于年龄≥45岁、肿瘤直径≥1 cm及肿瘤侵犯包膜的PTC患者,应于术前结合超声诊断制定术中淋巴结清扫方案,以减少复发风险,改善预后。     

甲状腺全切联合中央区淋巴结清除术治疗颈淋巴结阴性甲状腺乳头状癌94例

甲状腺全切(TT)联合中央区淋巴结清除术(CLND)治疗颈淋巴结阴性(cN_0)甲状腺乳头状癌(PTC)的临床效果。选择2010年11月—2012年12于广东省惠州市第三人民医院普外科接受治疗的cN_0-PTC患者188例,依照随机数字表法均分为实验组与对照组各94例,两组一般资料差异无统计学意义(P0.05)。研究组行TT联合CLND治疗,对照组行甲状腺腺叶、峡部切除联合CLND治疗。观察两组原发病灶、淋巴结及误切甲状旁腺情况;损伤喉返神经、喉上神经及低钙血症情况;复发及转移情况。研究组病灶部位、病灶直径、病理分期与对照组差异无统计学意义(P0.05)。研究组单发病灶数低于对照组,多发病灶高于对照组,差异有统计学意义(P0.05)。研究组清除中央区淋巴结数、中央区淋巴结转移率、甲状旁腺误切率与对照组差异无统计学意义(P0.05)。研究组喉返神经损伤率、喉上神经损伤率、一过性低钙血症发生率、永久性低钙血症与对照组差异无统计学意义(P0.05)。研究组复发率、转移率低于对照组,差异有统计学意义(P0.05)。TT联合CLND治疗cN_0-PTC可一次完成原发病灶切除及中央区淋巴结清除,效果显著,但术中要避免损伤甲状旁腺及喉返神经,以降低并发症发生率。     

术中选择性淋巴结冷冻病理检查对甲状腺乳头状癌中央区淋巴结状态的预测作用

目的:探讨甲状腺乳头状癌(PTC)中央区淋巴结细化分区术中冷冻病理结果对淋巴结转移的提示作用,从而指导手术治疗方式。方法:选择2016年1月—2018年12月术后病理明确诊断PTC并有中央区淋巴结转移的患者298例为研究对象,回顾性分析术中喉前淋巴结、气管前淋巴结、气管旁淋巴结冷冻病理结果与术后石蜡病理结果的一致性,以及术中送检淋巴结数量与术后病理结果一致性的关系。结果:所有PTC患者均合并中央区淋巴结转移。术中冷冻送检淋巴结与术后石蜡病理结果一致性达到81.2%,假阴性率为15.4%。当送检淋巴结数量5个时,术中冷冻病理结果与术后病理结果的一致性可达到93.7%,假阴性率为6.3%。结论:PTC颈部中央区淋巴结转移较为常见。术中选择喉前淋巴结、气管前淋巴结、气管旁淋巴结进行冷冻病理检查,可有效提示中央区淋巴结是否受累,且送检淋巴结数量5个时可更加有助于判断中央区淋巴结是否转移。结合淋巴结转移的危险因素可为患者设计更为精准的手术方案。     

甲状腺癌行弧形切口颈部淋巴结清扫术临床分析

目的探究低位弧形切口在甲状腺乳头状癌(PTC)功能性颈部淋巴结清扫术中的应用可行性及安全性。方法回顾性分析2012年3月至2014年3月200例PTC伴有颈部淋巴结转移手术患者的临床资料。根据切口形状的不同分为低位组(132例)和传统组(68例),采用SPSS 19.0软件,对两组患者切口长度、淋巴结清扫数目及术后生活质量和外观满意度等连续变量分析使用t检验;术后并发症及复发情况的比较选用χ~2检验,P0.05认定为有统计学意义。结果低位组在手术用时、切口长度均较传统组短(P0.05);在其他颈侧区淋巴结清扫数目上两组间没有明显差别(P0.05),但在Ⅱb区和Ⅴ区淋巴结数目低位组却少于传统组(P0.05)。在切口瘢痕色泽、厚度、柔软程度、血管分部和患者肩部僵硬感、疼痛、麻木感等方面低位组得分均低于传统组(P0.05)。淋巴结转移累及Ⅱa区时,Ⅱb区转移风险增高(r=0.183,P0.001);多区转移时,Ⅱb和Ⅴ区转移风险均增高(r=0.241、0.242,P0.001)。结论低位弧形切口PTC功能性颈部淋巴结清扫术安全可行,并可以明显改善患者术后生活质量,但对Ⅱb区和Ⅴ区以及多区转移的患者,建议仍采用传统的"L"形切口进行手术。     

��״����ͷ״����Ԥ�����������ܰͽ���ɨ�����顢��ʶ��Բ�

??Controversy, consensus and treatment strategies on prophylactic central neck dissection in clinical lymph node negative papillary thyroid carcinoma ZHANG Hao??SUN Wei. Department of Thyroid Surgery??the First Affiliated Hospital of China Medical University??Shenyang 110001??China
Corresponding author??ZHANG Hao??E-mail??haozhang@cmu.edu.cn
Abstract The significance of prophylactic central neck dissection (pCND) in clinical lymph nodes negative (cN0) papillary thyroid carcinoma (PTC) patients remains controversial. Although the effects of pCND on long-term survival, recurrence, and postoperative Tg are still unclear. However, pCND can remove the potential metastatic central lymph nodes, be beneficial to the thoroughness of the operation, reduce the complications of reoperation, be helpful to postoperative staging and radioiodine treatment and also can predict the lateral lymph nodes metastasis. Therefore,ipsilateral pCND is recommended by 2012 Guideline for the Treatment of Thyroid Nodules and Differentiated Thyroid Cancer in China and mostly domestic scholars.Surgeons should also ensure standard dissection extent and decrease postoperation complications during pCND.     

Central neck lymph node removal during minimally invasive video-assisted thyroidectomy for thyroid carcinoma: a feasible and safe procedure

BACKGROUND AND PURPOSE: In 1998, we developed a technique for video-assisted thyroidectomy (VAT) which we proposed using also in patients with small low-risk papillary thyroid carcinomas (PTC). In some cases, enlarged lymph nodes are incidentally found at surgery for PTC. These nodes should be removed because of the risk of metastases. In this paper, we report on the patients in whom we removed enlarged central neck lymph nodes during VAT for PTC and discuss the feasibility and safety of video-assisted central neck lymph node dissection (VALD). PATIENTS AND METHODS: The procedure is performed by a totally gasless video-assisted technique through a single 1.5-to 2.0-cm skin incision above the sternal notch. Dissection is performed under endoscopic vision using a technique very similar to that of conventional surgery. Only enlarged lymph nodes were removed and sent for frozen section examination (FS). No other dissection was performed in case of negative FS. Five patients underwent VALD during VAT for PTC. RESULTS: The mean number of lymph nodes removed was 2.4. No metastases were found at FS or final histology examination. Postoperative complications included two transient postoperative hypocalcemias. No evidence of residual or recurrent disease was observed at postoperative follow-up. The cosmetic result was excellent. CONCLUSION: Our experience demonstrates that removal of central compartment lymph nodes is feasible and safe. Perhaps also complete central neck lymph node dissection can be performed. Some doubts persist about the oncologic validity of this approach. For definitive conclusions, larger series and comparative studies are necessary.     

喉返神经入喉处淋巴结对于甲状腺乳头状癌中央区淋巴结清扫的重要性

目的 探讨喉返神经入喉处淋巴结转移在甲状腺乳头状癌手术诊治中的临床意义。方法 对2016年4月至11月接受手术治疗的598例甲状腺乳头状癌病人的临床资料进行临床研究。在中央区淋巴结清扫术中,探查喉返神经入喉处淋巴结,并采用纳米活性炭进行辅助示踪。将入喉处淋巴结与中央区其他淋巴结进行病理检查,并观察术后并发症发生情况。结果 喉返神经入喉处淋巴结检出率为 5.85%(35/598) ,肿瘤转移率为2.51%。该处淋巴结检出中,15例有转移,20例未转移。该处淋巴结转移与多种危险因素有关,包括肿瘤直径、位置和数量,肿瘤数量为其独立影响因素。该处淋巴结阳性病人中,石蜡病理检查证实伴有其他中央区淋巴结转移14例（93.3%）。7例（1.2%）发生术后近期并发症。结论 甲状腺乳头状癌可能发生喉返神经入喉处淋巴结转移。完整的中央区淋巴结清扫术应清扫喉返神经入喉处区域淋巴结。     

�������ֱ�����෽�ܰͽ���ɨ��Ӧ֤

??Management of the lateral lymph node dissection in rectal cancer LAN Ping??CHEN Yu-feng??WU Xian-rui. Department of Colorectal Surgery??the Sixth Affiliated Hospital??Sun Yat-sen University??Guangzhou 510655??China
Corresponding author: LAN Ping??E-mail: lanping@mail.sysu.edu.cn
Abstract Lateral lymph node dissection in rectal cancer, which is difficult in practice and has a high risk of postoperative urinal and sexual dysfunction??is not routinely performed in China. Neoadjuvant therapy??radiological evaluation and surgical method have great impact on the outcome of lateral lymph node dissection. It is better to beware of the management of lateral lymph node dissection??while planning the surgical intervention for the patients with rectal cancer. For patients with stage II and III local advanced rectal cancer, which locates below the peritoneal reflection, the lateral lymph node dissection is suggested to perform under the following criteria. Firstly, the surgical plan should be made based on the preoperative MR examination. For patients with resectable tumor, it’s not necessary to perform the lateral lymph node dissection when no lateral lymph node with short axis larger than 5 mm is found in MR examination. The dissection should be performed when lateral lymph node with short axis larger than 5 mm is indicated. For patients with unresectable tumor, such as pelvic invasion, it’s better to provide neoadjuvant therapy first, and then the lateral lymph node should be evaluated again. If lateral lymph node with short axis larger than 5 mm is still detected, the lateral lymph node dissection should be performed. But it’s unnecessary to do the dissection while no lateral lymph node with short axis larger than 5 mm is found. Secondly, as postoperative urinary dysfunction and sexual dysfunction are often observed, which might result from the injury to the pelvic plexuses in the surgery, unilateral lymph node dissection is suggested. Only when enlarged lymph nodes are found in both sides, bilateral dissection is performed. As well, pelvic automatic nerve should be preserved carefully during the surgery. Thirdly, for surgeons who are skillful in robotic and laparoscopy surgery, minimally invasive surgery could be used.     

甲状腺乳头状癌术中清扫右侧喉返神经深层淋巴结的临床价值

目的:探讨甲状腺乳头状癌(PTC)术中行右侧喉返神经深层淋巴结(VIb)清扫的临床价值。方法:选取238例PTC患者为研究对象,其中c N1患者35例,c N0患者203例,均行甲状腺切除并中央区淋巴结清扫(CLND),分析患者颈部淋巴结转移情况,以及可能与VIb淋巴结转移相关的危险因素,并观察患者预后情况。结果:238例PTC患者中,VIa淋巴结转移108例,VIb淋巴结转移67例,颈侧部淋巴结转移24例。c N1患者颈部淋巴结转移率明显高于c N0患者(94.29%vs. 46.31%,P0.05)。单因素和多因素分析结果显示,肿瘤长径、肿瘤浸润情况、淋巴结分期、肿瘤数量和VIa淋巴结转移为VIb转移的影响因素(均P0.05)。术后无1例损伤喉返神经,患者术后3年复发率为3.4%,复发中位数为26.3个月。结论:肿瘤长径、肿瘤浸润情况、淋巴结分期、肿瘤数量、VIa淋巴结转移情况是VIb淋巴结转移的危险因素,在行CLND时,应尽量完整切除VIb亚区,尤其是对具有上述危险因素的患者。     

合理把握直肠癌侧方淋巴结清扫适应证

直肠癌侧方淋巴结清扫手术难度高,术后排尿和性功能障碍等并发症发生率较高,在我国尚未常规开展。术前新辅助治疗、影像学评估和术式选择等均对侧方淋巴结清扫的效果具有重要影响。为直肠癌病人制定手术方案时,应合理把握侧方淋巴结清扫的适应证。对于腹膜返折以下的局部进展期（Ⅱ～Ⅲ期）直肠癌病人实施侧方淋巴结清扫可遵循以下原则：（1）术前应结合MRI检查进行综合判断。对于可根治性切除者,如术前检查提示侧方淋巴结短径≥5 mm,建议进行清扫,否则可不必进行清扫;而对于无法根治性切除者（如盆壁侵犯等）,建议先行新辅助放化疗,治疗后如仍有侧方淋巴结短径≥5 mm者,须进行清扫,否则可不必进行清扫。（2）由于侧方淋巴结清扫易损伤盆腔神经丛,导致术后排尿和性功能障碍,一般建议对淋巴结肿大的一侧进行清扫,仅两侧均出现侧方淋巴结肿大时才考虑进行双侧清扫,清扫过程应注意保留盆腔自主神经。（3）对于有腹腔镜和机器人手术操作经验的医生,可采用微创技术。     

Routine level VI lymph node dissection for papillary thyroid cancer: surgical technique

Total thyroidectomy is the treatment of choice for clinically significant papillary thyroid cancer (PTC); however, 10-15% develop palpable local recurrence in the cervical lymph nodes. Metastases in the cervical lymph nodes account for 75% of loco-regional recurrence and up to 50% of these patients eventually die of their disease. It is generally accepted that surgical excision of grossly involved lymph node disease should be carried out. The role of routine lymph node dissection, however, is greeted with far more controversy. Regional lymph node metastases have been shown to be associated with more frequent tumour recurrence. Not only is recurrence associated with increased disease-related mortality, but recent data have shown that the presence of involved lymph nodes is associated with adverse survival. Additionally, there have been significant changes to the way patients are managed after treatment for PTC in recent years. Surveillance previously relied on clinical assessment and radioiodine scans whereas now the use of serum thyroglobulin and high-resolution ultrasound are the standard as evidenced by recommendations by the American Thyroid Association. These techniques have greater sensitivity and subsequently lymph node metastases are being detected earlier and more frequently. This has led to a paradigm shift in the aims of treatment of PTC, from a focus on survival data to a focus on disease-free status. Routine central neck lymph node dissection can be carried out with no increased morbidity and can achieve lower 6-month stimulated thyroglobulin levels when compared with total thyroidectomy alone. Routine ipsilateral level VI lymph node dissection in addition to total thyroidectomy should be carried out for the management of clinically significant PTC.