腔镜辅助下改良颈淋巴结清扫术在甲状腺乳头状癌中应用的安全性

目的评价腔镜辅助下改良颈淋巴结清扫术在甲状腺乳头状癌中应用的安全性。方法我们回顾分析了2006年6月1日至2013年6月1日于吉林大学第一医院甲状腺外科行腔镜辅助下改良颈淋巴结清扫术41例的甲状腺乳头状癌患者资料。统计分析其手术并发症以评价此种术式的安全性。结果纳入研究的41例患者按术式被分为以下4组：I：单独行侧颈淋巴结清扫。Ⅱ：甲状腺全切加侧颈淋巴结清扫。Ⅲ：甲状腺全切加中央区淋巴结及侧颈淋巴结清扫。Ⅳ：侧颈淋巴结清扫加中央区淋巴结清扫术。术后并发症发生率平均为58．5％。患者术后并发症发生率在第Ⅲ组中高达68％,Ⅱ组其次,可达66．7％,单独清扫侧颈淋巴结组的并发症发生率最低,仅有20％。其中暂时性甲状旁腺功能低下的发生率最高（41．5％）。无1例出现永久性并发症。无手术死亡。结论腔镜辅助下改良颈淋巴结清扫术安全性较高,较少发生永久性并发症,这种手术方式不仅保留颈部功能,保留切口美观,而且并不降低手术的安全性。然而,如果联合中央区淋巴结清扫,特别是甲状腺全切的患者,并发症的发生率将会增加。其中甲状旁腺的损伤最为常见,所以术中保护甲状旁腺显得尤为重要。     

Indications for bilateral modified radical neck dissection in patients with papillary carcinoma of the thyroid

HYPOTHESES: After subtotal thyroidectomy with modified radical neck dissection of the affected side, nodal recurrence at the contralateral cervical side indicates a poor prognosis for patients with papillary thyroid cancer. Bilateral modified radical neck dissection is beneficial for patients at high risk for contralateral nodal recurrence. DESIGN AND SETTING: Retrospective study of patients with papillary cancer who were treated surgically from January 1, 1970, through December 31, 1995, at the Noguchi Thyroid Clinic and Hospital Foundation, Beppu, Japan. PATIENTS: Patients (N = 1776) had primary tumors greater than 10 mm in maximum diameter and underwent thyroidectomy and ipsilateral modified radical neck dissection with curative intent. RESULTS: Thirty-two patients (1.8%) developed contralateral lymph node metastases during the mean follow-up period of 12.1 years. The risk factors for contralateral nodal recurrence were male sex, large primary tumor, tumor extension over the isthmus, extracapsular adhesion or invasion to surrounding tissues, and the presence of gross nodal metastasis at initial surgery. These patients had a greater number of distant metastases (31.1% vs 0.7%; P<.001) and a lower 10-year survival rate (83.7% vs 99.3%; P<.001) than patients without nodal recurrence. CONCLUSION: Bilateral modified radical neck dissection should be considered for patients with papillary carcinoma who show risk factors for contralateral nodal recurrence, as it could prevent a second operation and may improve their outcome.     

Analysis of disability resulting from treatment including radical neck dissection or modified neck dissection

A multiinstitutional study to define the impact of total treatment programs involving radical neck dissection (RND) and modified neck dissection (MND) on patients' permanent disability was undertaken. A total of 243 patient responses were included in the study. Comparative analyses between the treatment groups show no advantage of one surgical operation over the other in returning patients to their pretreatment employment status. Radiation therapy was identified as adding significantly to the patient's permanent disability.     

Initial lymph node dissection increases cure rates in patients with medullary thyroid cancer

OBJECTIVE: Medullary thyroid carcinoma (MTC) is the third most common type of thyroid cancer. MTC spreads early to local lymph nodes, and most endocrine surgeons recommend total thyroidectomy with central lymph node dissection (CLND) as the minimum initial operation. We reviewed our experience to determine if the initial operation influences clinical outcomes. METHODS: Twenty-two patients with sporadic or inherited MTC who received surgery at one academic centre between 1994 and 2004 were identified. Clinical, operative, and pathology findings were reviewed. RESULTS: Ten patients had prophylactic thyroidectomy for hereditary MTC, while 12 patients underwent therapeutic operations for sporadic MTC. The average age of the prophylactic group was 11 +/- 3, and 43 +/- 6 years for the therapeutic group. All patients in the prophylactic group received thyroidectomy without neck dissection. No patient in the prophylactic group had residual disease or required re-operation. In the therapeutic surgery group, three patients were treated with thyroidectomy plus CLND, and nine patients received thyroidectomy alone. The CLND group had a significantly higher cure rate as demonstrated by a lower incidence of residual disease (0% vs. 89%, p = 0.018), and re-operations (0% vs. 78%, p = 0.045). CONCLUSION: Initial CLND for MTC increases cure rates by reducing residual disease and re-operations.     

Modified radical neck dissection for metastatic carcinoma of the thyroid. A reappraisal

From January 1958 through December 1983, 56 modified radical neck dissections were performed on 47 patients with metastases to the cervical nodes from differentiated carcinomas of the thyroid. In nine patients, a second modified radical neck dissection was performed either simultaneously or at a later date. Lymph node clearance was performed on all but one surgical specimen. The number of nodes in each specimen ranged from 10 to 96, and the number of involved nodes ranged from 1 to 20. Thirty-eight of the 56 neck specimens contained four or more positive nodes. Seventeen patients were followed for 10 to 26 years, 18 patients for 5 to 9 years, and 5 patients for less than 5 years. Seven other patients died, three from other causes and four from lung metastases. There were no recurrences in the neck sides that would have been cleared if standard radical neck dissection had been performed. This reappraisal with long-term follow-up supports our initial impression that a modified radical neck dissection sparing the spinal accessory nerve, the sternocleidomastoid muscle, the internal jugular vein, or any combination thereof is an effective procedure for differentiated cancer of the thyroid, with preservation of good shoulder function and improvement in the cosmetic appearance of the neck.     

纳米碳示踪剂在甲状腺癌根治术中的应用

目的:探讨纳米碳示踪剂在甲状腺癌根治术中的应用价值。方法:将2013年1月—2014年5月收治的80例甲状腺癌患者随机均分为试验组与对照组,试验组术中甲状腺内注入纳米碳混悬液后按黑染淋巴结的范围清扫患侧VI区淋巴结,对照组常规清扫患侧VI区淋巴结。比较两组淋巴结清扫数、癌转移淋巴结数及术后甲状旁腺损伤发生率。结果:试验组共清扫461枚,其中黑染淋巴结441枚,对照组共清扫淋巴结272枚;试验组中发现癌转移淋巴结数量为197枚,而对照组中为106枚,以上指标两组间差异均有统计学意义(均P0.05)。试验组与对照组癌细胞淋巴结转移率无明显差异(42.73%vs.38.97%,P0.05)。试验组术后病理未找到甲状旁腺组织,也未出现低钙血症,而对照组有5例找到甲状旁腺组织,同时5例出现低钙血症,但两组间差异未达统计学意义(P=0.055)。结论:纳米碳在甲状腺癌根治术中能够使VI区淋巴结得到很好的显影,利于淋巴结彻底清扫,同时碳不会黑染甲状旁腺,可以避免甲状旁腺的误切。     

Chylothorax after neck dissection for thyroid carcinomas: report of three cases

Chylothorax is a rare complication of neck dissection. We report three cases of chylothorax after neck dissections for thyroid carcinoma and attribute this relatively high incidence to the assumption that most patients are asymptomatic. Thus, conventional chest X-ray or ultrasonography in the early postoperative period may be warranted to exclude asymptomatic chylothorax, especially if the thoracic duct is injured and ligated during the operation. We suggest that for chylothorax induced by ligation of the thoracic duct, which may be transient and resolve quickly, short-term thoracic drainage is enough.     

Sonographic predictors of aggressive behavior in medullary thyroid carcinomas

ObjectiveTo identify the clinical and sonographic risk factors for aggressive behavior of Medullary Thyroid Carcinomas (MTCs).Material and methodsThis is a retrospective analysis. The informed consents were waived. Totally, 127 patients were selected from the database. Two radiologists were invited to review the clinical records and ultrasonic images and scored all the cases according to ACR TI-RADS, retrospectively. Kappa test was used to evaluate the consistency between the two reviewers. Logistic regression analysis was carried to identify the risk factors for aggressive behaviors of MTCs. Comparison of survival proportions between different groups were calculated by Kaplan–Meier method and log-rank test.ResultsFemale patients with MTCs were more commonly seen than male (1.7:1), male sex was a risk factor for both metastasis (OR: 4.471, P = 0.001) and perithyroidal invasion (OR = 4.674, P = 0.004). Consistency between the two reviewers were quite high (K value, 0.797–0.988). On sonograms, typical MTCs manifest as hypoechoic (96.9%) solid nodules (94.5%). Sex of patients (P = 0.001), margin (P = 0.003) and focality (P = 0.01) of the nodule were independent risk factors for metastasis, whereas sex of the patients (P = 0.004) and margin (P = 0.000) were independent risk factors for perithyroidal invasion. By Kaplan–Meier analysis, survival proportions different between groups with/without perithyroidal extension (P = 0.000) but not between groups with/without metastasis (P = 0.473).ConclusionHigh frequency ultrasound and TI-RADS were effective methods for preoperative diagnosis of MTC. Sex of the patients and margin of the nodule are common risk factors for both metastasis and perithyroidal invasion. Focality of the tumor is another independent risk factor for metastasis.     

A comparative study of the surgical outcomes of robotic and conventional open modified radical neck dissection for papillary thyroid carcinoma with lateral neck node metastasis

Background

Several endoscopic modified radical neck dissections (MRND) have been conducted since the introduction of the endoscopic technique to thyroid surgery with the aim of avoiding a long cervical scar. Furthermore, the recent introduction of surgical robotic systems has increased the precision of endoscopic techniques. The aim of this study was to evaluate and compare the early surgical outcomes of robotic and conventional open MRND for papillary thyroid carcinoma (PTC) with lateral neck node metastasis (LNM).

Methods

From January 2009 to May 2010, 165 patients with PTC underwent bilateral total thyroidectomy with central compartment neck dissection and ipsilateral MRND. Of these patients, 56 formed the robotic procedure group (RG) and 109 the conventional open procedure group. These two groups were retrospectively compared with respect to their clinicopathological characteristics, early surgical outcomes, and surgical completeness.

Results

The operative time was longer, mean tumor size was smaller, mean age was lower, and disease stage was earlier in the RG. However, mean numbers of retrieved lymph nodes were similar in the two groups, and mean hospital stay after surgery was shorter in the RG. Furthermore, complication rates were similar in the two groups, and there was no statistical difference in postoperative Tg levels between the groups.

Conclusions

Robotic MRND was found to be similar to conventional open MRND in terms of early surgical outcomes and surgical completeness but leaves no scar on the neck area. Robotic MRND can be viewed as an acceptable alternative method in low-risk PTC with LNM.     

Seroma prevention using fibrin glue during modified radical neck dissection in a rat model

Seroma is a frequent sequelae of neck dissection involving cervical lymphadenectomy. The incidence is correlated with flap elevation, lymphovascular interruption, and tissue removal. Current methods of resolving seroma, such as vacuum drainage, are not risk free. A novel approach to this problem was the use of intraoperative topical fibrin glue. A model producing seromas was developed by modified radical neck dissection on Sprague-Dawley rats. Forty rats underwent this procedure. Twenty rats were treated with saline solution (control group) and 20 were treated with fibrin glue. At necropsy on day 5, a significant reduction in the frequency of seroma was noted in the fibrin glue group. Seventeen of 20 control rats had seroma whereas only 2 of 20 experimental animals had serous collection. The Fisher exact statistical correlation revealed p less than 0.000002; therefore, the use of fibrin glue in this role merits further evaluation.     

Functional assessment using Constant's Shoulder Scale after modified radical and selective neck dissection

BACKGROUND: Constant's Shoulder Scale is a validated and widely applied instrument for assessment of shoulder function. We used this instrument to assess which treatment and demographic variables contribute to shoulder dysfunction after neck dissection in head and neck cancer patients. METHODS: A convenience sample of 54 patients with 64 neck dissections and minimum follow-up of 11 months were evaluated. Thirty-two accessory nerve-sparing modified radical (MRND) and 32 selective neck (SND) dissections were performed. Multivariable regression analysis was used to determine the variables that were predictive for shoulder dysfunction. Clinical variables included age, time from surgery, handedness, weight, radiation therapy, neck dissection type, tumor stage, and site. RESULTS: Patients receiving MRND had significantly worse shoulder function than patients with SND (p =.0007). Radiation therapy contributed negatively, whereas weight contributed positively (p =.0001). CONCLUSIONS: The critical factors contributing to shoulder dysfunction after neck dissection were weight, radiation therapy, and neck dissection type.     

Radical neck dissection in advanced thyroid cancer

We try to ascertain whether total thyroidectomy with radical neck dissection offers a survival and recurrency advantage for thyroid cancer. Between January 2000 and September 2009 in the 3rd Surgical Unit of the "Sf. Spiridon" Hospital of Ia?i 189 operations were performed for malign thyroid disorders, 164 (86,77%) of which were performed for the papillary or foliculary cancer. The diagnosis was confirmed by hystopathological examination. The patients had a medium age of 51,48 (extremes 19 - 81 years). Women had a greater proportion, as expected (sex ratio F:M = 2,85:1). 59 total thyroidectomy with radical or modified radical neck dissection were performed. There were immediate (6 bleedings which needed reoperation for haemostasis, 7 unilateral recurrent laryngeal nerve injury) and late complications (8 cases of recurrency in the first 2 years). Total thyroidectomy with radical neck dissection became the ellective method for advanced thyroid cancer (the best results were for papillary cancer, female and age over 55).