甲状腺微小乳头状癌淋巴结转移相关因素及手术方式探讨

目的 分析甲状腺微小乳头状癌原发灶与颈淋巴结转移的相关性,探讨甲状腺微小乳头状癌的手术方式.方法 回顾首都医科大学附属北京友谊医院2013年1月-2016年12月间手术治疗的545例甲状腺微小乳头状癌患者资料,其中女性432例,男性113例(性别比例3.82∶1);年龄14 ～ 80岁,平均(46.7±11.8)岁.手术方式:全/近全切除70.6％(385/545),腺叶+峡部切除29.4％(160/545);颈中央区淋巴结清扫524例,其中单侧清扫78.3％ (427/524),双侧清扫17.8％ (97/524);颈侧区淋巴结清扫14例,均为单侧清扫.共切除甲状腺腺叶标本930个,颈中央区淋巴结标本622个,颈侧区淋巴结标本14个.从中筛选出甲状腺癌腺叶与同侧颈淋巴结有对应关系的576组标本,癌灶长径(0.58±0.25) cm,单灶513例(89.1％),多灶63例(10.9％).无甲状腺被膜侵犯441例(76.6％),有甲状腺被膜侵犯135例(23.4％).颈中央区淋巴结清扫数量(4.7±3.8)枚,颈中央区淋巴结转移率31.8％,颈侧区淋巴结清扫数量(17.8±10.0)枚,颈侧区淋巴结转移率2.4％.使用SPSS 19.0统计学软件进行数据分析,计量资料用均数±标准差((x)±s)表示,分类变量资料用率(％)或构成比(％)表示,单因素相关性分析用Pearson检验,计数资料组间比较采用x2检验.结果 甲状腺微小乳头状癌癌灶长径与颈中央区淋巴结转移率呈高度正相关关系(r =0.847),癌灶长径＞0.8 cm时颈中央区淋巴结转移率明显增加;癌灶长径与颈侧区淋巴结转移率呈显著正相关关系(r =0.557),癌灶长径＞0.9 cm时颈侧区淋巴结转移率明显增加.单灶和多灶病例颈中央区和颈侧区淋巴结转移率相似.有被膜侵犯比无被膜侵犯颈中央区和颈侧区淋巴结转移率均增加.结论 甲状腺微小乳头状癌的癌灶长径、有被膜侵犯是颈淋巴结转移的相关因素,癌灶数量不是颈淋巴结转移的相关因素.甲状腺微小乳头状癌尽早手术能够使很多已经发生颈淋巴结转移、但无法获得术前诊断的患者得到及时治疗.初次治疗的手术方式选择腺叶峡部切除或全/近全切除+病灶同侧/双侧颈中央区和(或)加行颈侧区淋巴结清扫.     

甲状腺乳头状癌预防性中央区淋巴结清扫可行性分析

目的 探讨预防性中央区淋巴结清扫术在临床颈淋巴结阴性(cN0)甲状腺乳头状癌治疗中的价值.方法 对82例cN0甲状腺乳头状癌行原发灶根治性切除,同时行患侧中央区淋巴结清扫术,清扫标本常规送病理检查.结果 cN0甲状腺乳头状癌患者中央区淋巴结转移率56.1%(46/82),中央区淋巴结转移与肿瘤大小(χ2=4.98,P<0.05),原发灶侵犯包膜(χ2=8.76,P<0.05)及年龄>45岁者(χ2=6.62,P<0.05)有关,82例均无永久性喉返神经损伤和永久性甲状旁腺功能低下等并发症发生.结论 cN0甲状腺乳头状癌行中央区淋巴结清扫术是必要的和安全的处理方式.     

甲状腺乳头状癌Ⅵ区淋巴结的归属

目的 评价临床颈侧区淋巴结阴性(cN0)的甲状腺乳头状癌(PTC)患者行选择性颈侧淋巴结清扫的价值。方法 通过分析139例PTC患者(初治时为cN0)的复发和(或)转移部位(甲状腺,Ⅵ区,颈侧区,远处),把Ⅵ区淋巴结转移归入原发灶复发,明确与颈侧区淋巴结转移的区分,逆向分析评价cN0 PTC患者选择性颈侧清扫的临床价值。结果 PTC患者甲状腺复发83％(73／88),Ⅵ区转移76％(67／88),17例为已作选择性颈侧淋巴结清扫,占65％(17／26)。颈侧区淋巴结转移为17％(17／98),其中5例发生于已作选择性颈侧淋巴结清扫,占19％(5／26)。结论 支持对cN0 PTC患者行患侧腺叶切除加Ⅵ区清扫,不支持颈侧区(Ⅱ-V)的选择性颈侧淋巴结清扫。而对初治时为cN0,但术前超声和CT为N 的患者,则支持行颈侧区淋巴结的选择性清扫。在甲状腺癌诊治中,CT检查是必要的。     

分化型甲状腺癌区域淋巴结清扫策略及争议

甲状腺乳头状癌颈部淋巴结转移出现早,但预后好。甲状腺切除手术和彻底合理的淋巴结清扫是公认治疗甲状腺癌的最佳选择。cN1 病人需要行颈淋巴结清扫术,但cN0 病人是否需要进行预防性中央区或颈侧区淋巴结清扫术仍有很多的争议。     

甲状腺乳头状癌淋巴结转移相关因素分析

目的 探讨甲状腺乳头状癌颈淋巴结转移的相关因素.方法 收集2005年1月-2008年3月接受手术并进行淋巴结切除的38例(44侧)甲状腺乳头状癌患者的临床资料(不包含因复发手术的病例),回顾分析甲状腺乳头状癌淋巴结转移的相关因素.结果 在38例(44侧)患者中,颈淋巴结的转移率为57.89%,颈部中央区淋巴结转移(47.37%)为最常见的转移部位,出现颈侧区淋巴结转移的患者(31.58%)中66.67%同时伴有中央区淋巴结转移.颈部淋巴结转移的相关冈素为年龄＜45岁和肿瘤侵犯被膜,多因素分析显示,年龄为淋巴结转移的独立相关因素.结论 颈淋巴结转移是甲状腺乳头状癌的常见情况,尤其是中央区淋巴结;建议有甲状腺被膜侵犯的甲状腺乳头状癌患者应常规清扫中央区淋巴结.     

颈淋巴结阴性的甲状腺乳头状癌中央区淋巴结清扫的临床意义

目的:研究中央区淋巴结清扫在c N0甲状腺乳头状癌治疗中的意义。方法:回顾性分析2010年1月-2014年6月间收治的83例c N0甲状腺乳头状癌患者的临床资料,对中央区淋巴结转移的单因素和转移率进行统计分析。结果:83例c N0甲状腺乳头状癌患者的中央区淋巴结转移率为48.2%,中央区淋巴结转移与患者性别、年龄、肿瘤多灶性、肿瘤大小及是否侵犯甲状腺包膜有关(P0.05)。结论:c N0甲状腺乳头状癌患者的中央区淋巴结转移率较高,中央区淋巴结清扫术在减少肿瘤复发、改善存活率、降低颈侧区淋巴结转移率、肿瘤准确临床分期、制定术后综合治疗方案和判断。     

cN0甲状腺乳头状癌行中央区颈淋巴结清扫术的临床研究

目的探讨中央区颈淋巴结清扫术对cN0甲状腺乳头状癌患者的意义。方法对解放军总医院2010年12月至2012年7月期间128例行中央区颈淋巴结清扫术的cN0甲状腺乳头状癌患者的临床资料进行回顾性分析。结果cN0甲状腺乳头状癌患者中央区颈淋巴结转移率为35．94％（46／128）。年龄〈45岁、原发病灶直径〉1cm、包膜或腺外侵犯的cN0甲状腺乳头状癌患者中央区颈淋巴结转移率均明显高于年龄≥45岁、原发病灶直径≤1cm、无包膜或腺外侵犯者（P〈0．05）。术后22例（17．19％）患者出现暂时性甲状旁腺功能低下,3例（2．34％）患者出现暂时性喉返神经损伤,无永久性喉返神经损伤及永久性甲状旁腺功能低下发生。术后随访14～32个月（平均23．4个月）,2例患者出现颈侧区淋巴结转移。结论中央区颈淋巴结清扫术对cN0甲状腺乳头状癌患者是一种必要、安全且有效的术式,且应由经验丰富的专科医生来实施。     

选择性中央区淋巴结清扫治疗cNO甲状腺乳头状癌的临床价值

目的探讨选择性中央区淋巴结清扫术在临床颈淋巴结阴性（cN0）的甲状腺乳头状癌患者中的治疗价值。方法回顾性分析中国医科大学附属第一医院2007年1月至2011年12月期间收治的326例cN0甲状腺乳头状癌患者的临床资料,并对影响中央区淋巴结转移的相关因素进行分析。结果本组326例cN0甲状腺乳头状癌患者的中央区淋巴结转移率为35．89％（117／326）。年龄在〈45岁、肿瘤直径〉1cm及原发灶浸润包膜的cN0甲状腺乳头状癌患者的淋巴结转移率明显高于年龄≥45岁、肿瘤直径≤1cm及原发灶未浸润包膜的oN0甲状腺乳头状癌患者（年龄：46．56％比28．72％,P=0．001;肿瘤直径：44．44％比26．45％,P=0．001;包膜浸润：50．00％比33．09％,P=0．020）。进一步的多因素分析显示,年龄〈45岁和肿瘤直径〉1cm是cN0甲状腺乳头状癌中央区淋巴结转移的独立危险因素（P〈0。05）。术后6例出现暂时性喉返神经损伤,18例并发暂时性甲状旁腺功能低下,4例出现暂时性喉上神经损伤,1例并发急性喉头水肿,无永久性喉神经损伤、甲状旁腺功能低下等并发症发生。术后266例（81．60％）获得随访,随访7～67个月（平均31．2个月）,有3例发生侧颈区淋巴结转移。结论cN0甲状腺乳头状癌行选择性中央区淋巴结清扫术是必要的、安全的处理方式,建议对cN0甲状腺乳头状癌常规行患侧中央区淋巴结清扫术,特别是年龄〈45岁和肿瘤直径〉1cm的cN0甲状腺乳头状癌患者。     

中央区淋巴结清扫在cN0期甲状腺乳头状癌中的应用

目的 观察不同临床特点cN0期甲状腺乳头状癌患者的中央区淋巴结转移情况,探讨预防性中央区淋巴结清扫术的应用指征及手术范围。方法 回顾性分析2015年3月至2016年12月期间我院收治的93例甲状腺乳头状癌患者的病历及病理资料。分析患者性别、年龄、肿瘤大小、是否为多灶癌、肿瘤是否累及被膜等因素与中央区淋巴结转移率的关系。所有病例均行甲状腺全切除或近全切除术+患侧中央区淋巴结清扫术,并将患侧中央区标本送冰冻及石蜡病理检查,后再行对侧中央区淋巴结清扫术。观察中央区淋巴结转移情况及患侧中央区淋巴结冰冻与石蜡病理检查符合情况。结果 本组病例男性18例,女性75例;平均年龄41±13.9岁。T165例,T218例,T310例,T40例;单侧多灶癌8例;肿瘤突破甲状腺包膜9例。本组中央区淋巴结转移率为46.2%（43/93）,18.2%（17/93）为双侧中央区淋巴结转移。性别、肿瘤位置、年龄、肿瘤直径、T分期等因素与CLN转移差异无统计学意义。患侧中央区淋巴结冰冻病理检查的敏感性、特异性、准确性分别为86.0%、100%、93.5%。结论 对cN0期甲状腺乳头状癌应常规行患侧中央区淋巴结清扫术;术中冰冻检查能准确预测患侧中央区淋巴结转移状态;术中应常规行冰冻切片检查,如患侧中央区淋巴结转移时,建议行双侧中央区淋巴结清扫术。     

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。     

BRAFV600E 突变与乳头状甲状腺癌中央区淋巴结转移的关系

目的：探讨乳头状甲状腺癌（PTC）中BRAF基因突变的临床意义。 方法：选择2年间符合条件的PTC手术患者126例,提取患者石蜡切片中的DNA样本,用荧光PCR法检测BRAF基因V600E（BRAFV600E）的突变情况,分析BRAFV600E突变与PTC患者临床病理因素及中央区淋巴结转移的关系。 结果：126例PTC患者BRAFV600E突变的发生率为69.0%（87/126）。单因素与多因素分析显示,BRAFV600E突变与淋巴结转移有关（P<0.05）;中央区淋巴结转移与年龄、肿瘤大小、肿瘤分期和BRAFV600E突变有关（均P<0.05）。进一步分析显示,肿瘤直径≤10 mm时,BRAFV600E突变与中央区淋巴结转移无关（P>0.05）,肿瘤直径>10 mm时,BRAFV600E突变患者的中央区淋巴结转移率高于突变阴性患者（P<0.05）。 结论：BRAFV600E突变是PTC中央区淋巴结转移风险的独立预测因子;对于术前检测BRAFV600E突变阳性患者,肿瘤直径越大越应该重视中央区淋巴结清扫。     

中央区淋巴结清除在cN_0期甲状腺乳头状微小癌中的临床价值

目的:探讨中央区淋巴结清除术在cN0期甲状腺乳头状微小癌治疗中的价值。方法:回顾性分析2000年1月—2007年7月收治的89例cN0期甲状腺乳头状微小癌病例,按是否行中央区淋巴结清除分为2组,未行中央区淋巴结清除共40例(A组),行中央区淋巴结清除共49例(B组)。对89例患者进行长期随访,对比分析2组cN0甲状腺乳头状微小癌患者术后并发症、5年随访复发及转移情况。结果:A、B 2组术后相关并发症的发生率差异无统计学意义(P0.05)。随访5年后,2组均无死亡,无对侧淋巴结及远处转移;但同侧颈部淋巴结转移率方面A组高于B组,差异有统计学意义(P0.05)。结论:cN0期甲状腺乳头状微小癌行中央区淋巴结清除术是必要、安全的。     

Regional lymph node metastases in well-differentiated thyroid carcinoma

The status of regional lymph node metastases was assessed in 171 patients with thyroid cancer who underwent a variety of thyroidectomy procedures with regional lymph node dissection at Kanazawa University, from January 1979 to March 1986. The rates of regional lymph node metastasis in minimal and ordinary thyroid cancer were 57% and 84% respectively. Since the rates of lymph node metastasis were high not only in the central cervical compartment but also in the lateral jugular compartment, modified radical neck dissection in the ipsilateral neck is at least recommended in patients with these thyroid cancers. Furthermore, high frequencies of bilateral regional lymph node metastases were found in patients with obviously widespread involvement of the bilateral lobes, with cancer located in the isthmus, with clinically detectable bilateral or contralateral jugular lymph node metastases and with histological involvement in the contralateral paratracheal lymph nodes. Bilateral modified radical neck dissection is recommended in these patients.     

Simultaneous medullary and papillary thyroid carcinoma with lymph node metastasis in the same patient: case report and review of the literature

We report a rare case of simultaneous medullary thyroid carcinoma on the left thyroid lobe with lymph node metastasis and papillary thyroid cancer on the right thyroid lobe. The 55-year-old woman was diagnosed with medullary thyroid carcinoma after left hemithyroidectomy for goitre. Completion thyroidectomy, central neck dissection and left modified neck dissection revealed the presence of papillary carcinoma on the right side. The extreme rarity and interesting pathological features are discussed and we raise the question of whether the finding of another thyroid cancer on the opposite side was coincidental or from possible activation of a common tumorigenic pathway for both follicular and parafollicular thyroid cells.     

cN0期甲状腺乳头状癌预防性中央区淋巴结清扫的争议与进展

甲状腺癌是近年来全世界发病率较高的恶性肿瘤之一,乳头状癌是其最常见的病理类型,治疗方式以手术为主,中央区淋巴结为其前哨淋巴结,故转移首先发生于此。对于存在中央区淋巴结转移的甲状腺乳头状癌患者,行中央区淋巴结清扫已被国内外学者所认可,但对于cN_0期肿瘤,是否行预防性中央区淋巴结清扫目前尚存争议。笔者就中央区淋巴结的解剖概念、cN_0期甲状腺乳头状癌转移规律、高危因素、对预防性淋巴结清扫的不同观点、并发症的预防及术式的选择等方面进行综述,旨在提高此类疾病的认识,为其治疗方式的完善提供参考。     

Skip metastases in thyroid cancer leaping the central lymph node compartment

HYPOTHESIS: Discontinuous nodal metastasis, or skip metastasis, in thyroid cancer may display clinicopathologic features different from those seen in continuous nodal metastasis and thus may have a different prognosis. DESIGN: Retrospective analysis. SETTING: Tertiary referral center at a university hospital. PATIENTS: Two hundred fifteen consecutive patients who underwent systematic central lymph node dissection for papillary, follicular, or medullary thyroid cancer and who on histopathologic analysis exhibited nodal metastases in at least 1 lateral or mediastinal lymph node compartment. MAIN OUTCOME MEASURES: Various clinicopathologic variables that were stratified for tumor entity and type of nodal metastasis (discontinuous vs continuous). RESULTS: Skip metastases (negative central and positive lateral or mediastinal compartments) were found in 13 (19.7%) of 66 papillary, 0 of 8 follicular, and 30 (21.3%) of 141 medullary thyroid cancers. After adjustment for multiple testing, skip metastasis was only associated with significantly fewer positive lymph nodes: 3.7 vs 12.9 nodes (r = -0.43, P<.001) in papillary thyroid cancer and 6.0 vs 17.1 nodes (r = -0.40, P<.001) in medullary thyroid cancer. No other significant correlation was identified with any other clinicopathologic variable. CONCLUSIONS: Skip metastasis is an epiphenomenon of low-intensity nodal metastasis in thyroid cancer and entails a moderate risk of local recurrence. Consequently, clearing the central lymph node compartment should be considered when lateral or mediastinal lymph node compartments are involved.     

Lymph Node Recurrence in Patients With N1b Papillary Thyroid Carcinoma Who Underwent Unilateral Therapeutic Modified Radical Neck Dissection

Background  

Therapeutic modified radical neck dissection (MND) is a mandatory surgical procedure for patients with papillary thyroid carcinoma (PTC) having clinical lateral node metastasis (N1b). However, N1b PTC is still likely to recur in regional lymph nodes after surgery. We investigated the clinicopathological features predicting recurrence in nodes in previously dissected compartments (ipsilateral lateral compartment or central compartment) and nodes in the contralateral lateral compartment for N1b patients who underwent unilateral therapeutic MND.     

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。     

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??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.     

Detection of sentinel lymph nodes in patients with papillary thyroid cancer

OBJECTIVES: To determine the feasibility of sentinel lymph node biopsy as a means of evaluating the cervical lymph nodes of patients with papillary thyroid cancer. METHODS: Isosulfan blue dye was injected around the tumour of 68 patients with papillary thyroid cancer; sentinel lymph node biopsy was performed in addition to subtotal thyroidectomy and central and modified lateral neck lymph node dissections. Surgical specimens were examined by routine processing to determine whether metastasis was present. RESULTS: Sentinel lymph nodes were identified in 63 (92.6%) of the 68 patients. There was concordance between the sentinel lymph node status and the final regional lymph node status in 58 (92.1%) of the 63 patients. There were five false-negative cases. Sentinel lymph node biopsy had a sensitivity of 87.5% (35/40), specificity of 100% (23/23), positive predictive value of 100% (35/35), negative predictive value of 82.1% (23/28), and accuracy of 92.1% (58/63). CONCLUSIONS: Sentinel lymph node biopsy may allow discrimination between patients with true lymph-node-negative papillary thyroid carcinoma and those with non-palpable metastatic lymph nodes. It may also be helpful in diagnosing metastases and avoiding unnecessary lymph node dissection in thyroid cancer.