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。     

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.     

甲状腺微小癌中央区淋巴结清扫临床价值

甲状腺微小癌发病率逐年升高,对于中央区淋巴结清扫时机和范围的选择国内外观点有所差异,争议主要集中在中央区淋巴结无转移（cN0）病人是否须常规清扫中央区淋巴结。不支持常规清扫的观点主要基于在全甲状腺切除联合同位素治疗前提下预防性中央区清扫未改善整体预后,同时有增加手术并发症的风险。支持的观点主要基于中央区淋巴结转移发生率较高,常规清扫有助于增加局部控制率,减少复发后再次手术相关并发症的发生。随着指南中甲状腺原发灶切除范围和核素治疗指征的改变,常规中央区淋巴结清扫的重要性将逐步体现。而解决争议的关键在于提高中央区淋巴结转移的诊断准确率,根据病人复发危险因素进行个体化选择,规范专科化操作,从而提高治疗效果并同时减少并发症的发生。     

cNO期甲状腺微小乳头状癌中央区淋巴结转移的危险因素及预防性清扫的临床分析

目的 探讨临床颈淋巴结阴性(cN0期)甲状腺微小乳头状癌中央区淋巴结转移的临床特点及预防性清扫的意义及可行性,为临床治疗提供参考.方法 回顾性分析2011年7月-2015年12月在连云港市东方医院普外科接受手术的277例cN0期甲状腺微小乳头状癌患者的临床资料,评估预防性中央区淋巴结清扫的必要性,采用x2检验及Logistic回归分析中央区淋巴结转移与患者的性别、年龄、肿瘤数目、肿瘤大小、包膜浸润、单双侧肿瘤的关系.277例患者全部行原发灶根治性切除加患侧中央区淋巴结清扫术,清扫标本送检常规病理检查.结果 甲状腺微小乳头状癌中央区淋巴结转移阳性率为36.8％(102/277),在男性患者(P=0.023)、年龄＜45岁(P＜0.001)和肿瘤直径＞0.5 cm(P =0.019)中阳性率高;通过多变量分析可以表明男性患者(OR =2.63,P＜0.001)、年龄＜45岁(OR =2.25,P=0.016)、肿瘤直径＞0.5 cm(OR =2.13,P=0.009)均能独立作为CLN转移的危险因素.15例(5.4％)出现暂时性喉返神经麻痹,43例(15.5％)出现暂时性甲状旁腺功能低下,无永久性喉返神经麻痹和甲状旁腺功能低下并发症患者.结论 预防性中央区淋巴结的清扫有助于准确进行肿瘤的分期分级以及危险度的评估,对患者术后治疗随访方案的选择有重要意义,对于男性、年龄＜45岁、肿瘤直径＞0.5 cm、有包膜浸润的患者应常规行中央区淋巴结清扫.     

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。     

甲状腺乳头状癌中央区淋巴结清扫术后复发临床研究

目的对甲状腺乳头状癌中央区淋巴结清扫术后淋巴结复发进行临床研究。方法回顾性分析2011年1月至2013年12月间在上海交通大学医学院附属瑞金医院普外科手术治疗的38例病人临床资料。结果行淋巴结再清扫的38例病理检查证实均有乳头状癌转移。其中34例位于原右侧中央区清扫区域,发生率为89.5%,4例(10.5%)位于原左侧中央区清扫区域。右侧复发者淋巴结位于右颈总动脉深面的气管右侧、右喉返神经内侧和右肺尖上方所构成的三角内,左侧复发者淋巴结位于锁骨深面的气管左侧和左颈总动脉之间。术后7例(18.4%)出现暂时性声音嘶哑,1例(2.6%)出现永久性喉返神经损伤。6例(6/38,15.8%)出现暂时性低钙血症。结论再次清扫中央区淋巴结风险大,因此,首次清扫务必彻底和规范。特别不要遗漏斜行的右颈总动脉深面,位于气管右侧、右喉返神经内侧和右肺尖上方的这一区域。     

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。     

甲状腺乳头状癌行预防性中央区淋巴结清扫的纷争

中央区淋巴结转移可发生于高达80%的甲状腺乳头状癌(PTC)患者中,但对患者的生存率无明显影响。对临床检查阴性的中央区淋巴结(cN0)行预防性清扫(pCLD),可清除潜在病灶,有助于术后的准确分期和复发危险度分层,指导后续治疗,并降低再次手术的并发症发生率,但可能增加甲状旁腺功能减退等并发症的风险。所以,对是否需常规性pCLD,各家指南或多或少有所保留,但对肿瘤较大、分期较晚、多灶癌、有包膜侵犯、或不良病理学亚型的PTC,建议积极的pCLD,同时术中应注意喉返神经的全程暴露和甲状旁腺及其血供的保护。大宗的临床研究数据将为争议的解决提供依据。     

甲状腺乳头状癌颈部淋巴结转移规律及影响因素分析

目的探讨甲状腺乳头状癌（papillary thyroid carcinoma,PTC）颈部淋巴结的转移规律及其影响因素,为PTC颈部淋巴结清扫手术方式的选择提供依据。方法收集贵阳医学院附属医院甲状腺外科2009年1月至2011年12月期间收治的98例PTC患者的临床资料,对其淋巴结转移特点、规律及其影响因素进行回顾性分析。结果 98例患者中,共行颈部淋巴结清扫114侧。总颈淋巴结转移率为77.55%（76/98）,其中Ⅵ区淋巴结转移率为74.49%（73/98）,颈侧Ⅱ＋Ⅲ＋Ⅳ区为42.86%（42/98）,Ⅴ区为5.10%（5/98）。单因素分析结果显示：当肿瘤直径大于1 cm、侵犯甲状腺包膜、呈多灶性或年龄大于45岁时,Ⅵ区和Ⅱ＋Ⅲ＋Ⅳ区的淋巴结转移率较高（P〈0.05）。多因素分析结果显示：患者年龄、肿瘤直径、包膜侵犯及多灶性是颈部淋巴结转移的影响因素（P〈0.05）;包膜侵犯、多灶性、合并Ⅵ区淋巴结转移及合并颈侧Ⅱ＋Ⅲ＋Ⅳ区淋巴结转移是喉前淋巴结转移的影响因素（P〈0.05）;包膜侵犯和多灶性是跳跃性淋巴结转移的影响因素（P〈0.05）。结论 PTC易发生Ⅵ、Ⅲ及Ⅳ区淋巴结转移,应常规清扫Ⅵ区淋巴结。对颈部淋巴结转移规律的研究可为临床选择合理的颈部淋巴结清扫手术方式提供依据。     

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。     

纳米碳在cNO期甲状腺乳头状癌中央区淋巴结清扫手术中的应用

目的研究纳米碳混悬液示踪技术在cN0期甲状腺乳头状癌中央区淋巴结清扫手术中的应用价值。方法将2012年5～10月期间在笔者所在医院科室治疗的68例cN0期甲状腺乳头状癌患者随机分为2组：未使用纳米碳淋巴示踪剂（对照组）32例,使用纳米碳淋巴示踪剂（示踪组）36例,均行甲状腺全切除术、患侧和（或）对侧中央区（Ⅵ区）淋巴结清扫术。比较2组患者的淋巴结清扫数、淋巴结转移情况以及手术相关指标（手术时间、术中出血量、术后引流时间和住院时间）。结果对照组和示踪组分别清扫中央区淋巴结205枚和324枚。其中,对照组手术清扫中央区淋巴结（6．41±1．56）枚／例,示踪组为（8．99±2．24）枚／例,多于对照组（P〈0．001）。对照组的中央区淋巴结转移率为40．6％（13／32）,与示踪组（47．2％,17／36）相比差异无统计学意义（P=0．762）,但示踪组喉返神经内侧区的淋巴结转移率（38．9％,14／36）高于对照组（12．5％,4／32）,P=0．029。2组患者的手术时间、术中出血量、术后引流时间、住院时间、术后切口出血发生率、一过性低血钙发生率及喉上神经损伤发生率比较差异均无统计学意义（P〉0．05）。2组患者术后均随访6个月,均无术后肿瘤复发、转移及死亡发生。结论纳米碳淋巴示踪技术可明显提高cN0期甲状腺乳头状癌患者中央区淋巴结的清扫数目,能比较准确地反映淋巴结的转移情况,从而对肿瘤进行准确的分期,以指导术后治疗,同时不增加（或延长）术中出血量、手术时间、术后住院时间及手术并发症发生率。     

Axillary Lymph Node Metastasis from Papillary Thyroid Carcinoma: Report of a Case

We report a case of axillary lymph node metastasis (LNM) from papillary thyroid carcinoma (PTC) in a 21-year-old man. The patient presented with bilateral cervical and right axillary lymphadenopathy, and computed tomography (CT) showed a primary tumor of the thyroid and gross lymphadenopathy from the neck to the right axilla. We performed a total thyroidectomy with therapeutic nodal dissection. The resection of the primary thyroid tumor and all the node metastases was curative. Pathological examination confirmed that the resected lesions were PTC and nodal metastases from the primary tumor. Six years after the operation, cervical, upper mediastinal, and axillary lymph node recurrence developed and multiple lung metastases were found on a CT scan. He was treated with radioactive iodine therapy. Axillary LNM from PTC is unusual and seems to be associated with a poor prognosis. Thus, comprehensive treatment strategies are needed to improve the outcome of patients with PTC who present with axillary LNM.     

Lateral Cervical Lymph Node Metastases from Papillary Thyroid Carcinoma: Pattern of Nodal Metastases and Optimal Strategy for Neck Dissection

Background The pattern of lateral cervical metastases from papillary thyroid carcinoma (PTC) has been reported without a clear understanding of the distribution of central nodes at risk. The present study evaluated the pattern of central and lateral cervical metastases from PTC with respect to recently defined neck sublevels and subsites. Methods Between 2003 and 2006, 52 consecutive patients with lateral cervical metastases from previously untreated PTC underwent total thyroidectomy and therapeutic comprehensive neck dissection of the central and lateral compartments, including five bilateral neck dissections. Neck dissection specimens were separately obtained for analyzing lymph node involvement with respect to neck sublevels and subsites. Results For the lateral compartment, 75.9% of cases showed metastatic disease at level IV, 72.2% at IIa and III, 16.7% at IIb, 13.0% at Vai, 3.7% at Ib and Vb, and 0% at Vas. For the central compartment, 84.6% of cases showed metastatic disease at the ipsilateral paratracheal nodal site, 46.2% at the superior mediastinal, 30.8% at the pretracheal, and 8.9% at the contralateral paratracheal site. Forty-six of 57 lateral neck dissection samples (80.7%) showed multilevel disease, and skip lateral metastasis was found in five patients (9.6%). Level I and V involvements were always associated with multilevel disease. Conclusions Lateral cervical metastasis from PTC is commonly associated with multilevel disease and central nodal involvement. Neck dissection including ipsilateral central and lateral compartments may be the optimal treatment for these patients.     

腔镜辅助技术在T1期甲状腺乳头状癌手术中的应用

目的探讨腔镜辅助技术在T．期甲状腺乳头状癌（papillary thyroid carcinoma，PTC）中央区淋巴结清扫术中的可行性。方法回顾性分析2013年1—7月我科收治并经术中冰冻切片和术后石蜡切片确诊PTC53例的临床资料，病灶最大径≤2．0cm，全麻下行单侧腺叶加峡部切除加同侧中央区淋巴结清扫术。根据病人意愿分为常规手术组（n=34）和腔镜辅助组（n=19），比较2组手术时间、出血量、清除淋巴结数目和喉返神经损伤发生率。结果手术均获成功，与常规手术组相比，腔镜辅助组切口短[中位数2．5cm（2．0～3．0cm）VS．4．6cm（3．8～5．0cm），Z=-6．039，P=0．000]，但手术时间长[（76．6±29．0）minV8．（59．7±18．3）min，t=2．609，P=0．012]。2组清除淋巴结数、出血量和声音嘶哑发生率差异无显著性（P〉0．05）。结论应用腔镜辅助技术治疗T1期甲状腺乳头状癌的效果与常规手术相似，尽管手术时间稍长，但其小切口更易于为年轻患者选择。     

Chyle Leakage in Patients Undergoing Thyroidectomy Plus Central Neck Dissection for Differentiated Papillary Thyroid Carcinoma

Background  Chyle leakage is an uncommon complication of lateral neck dissection for metastatic papillary thyroid carcinoma (PTC). There have been no reports on chyle leakage after central neck dissection not combined with lateral neck dissection. We therefore investigated chyle leakage in PTC patients undergoing thyroidectomy and central neck dissection. Methods  A total of 283 new patients with differentiated PTC underwent total thyroidectomy plus central neck dissection. The amount and duration of drain leakage, and the concentrations of triglycerides and cholesterol in drain fluid and serum were measured in patients who had suspected postoperative chyle leakage. The incidence and management of chyle leakage were analyzed. Results  Intraoperative chyle leakage was not found in any patient, although postoperative leakage was detected in four patients (1.4%). Mean ± standard deviation peak 24-hour drainage was 122 ± 57 mL, and duration of leakage was 10 ± 7 days. Mean triglyceride concentration of drainage fluid was 433 ± 182 mg/dL. These patients were treated with pressure dressings and a medium-chain triglyceride diet. One patient underwent intralesional injection of OK-432 for localized chyle accumulation. All chyle leakages stopped after conservative management without surgical intervention. Conclusion  Chyle leakage can occur after thyroidectomy and central neck dissection not combined with lateral neck dissection. These findings will aid in the recognition and treatment of this uncommon complication during the early postoperative period.     

Extent of Prophylactic Lymph Node Dissection in the Central Neck Area of the Patients with Papillary Thyroid Carcinoma: Comparison of Limited Versus Comprehensive Lymph Node Dissection in a 2-Year Safety Study

Background  To compare the “comprehensive” (including bilateral paratracheal, pretracheal, prelaryngeal lymph nodes) (CCND) with “limited” (saving contralateral paratracheal lymph nodes) central node dissection (LCND) for postoperative complications and disease recurrence rate in sonographically node-negative papillary thyroid carcinomas. Materials and Methods  From 2003 to 2005, 114 consecutive patients, diagnosed as sonographically node-negative thyroid papillary carcinomas, were included retrospectively. Among them, the LCND was performed in 56 patients and CCND in 58 patients, in combination with total thyroidectomy, based on the operator-dependent decision. We compared the complication rates and the recurrence rates between these two groups with a mean follow-up duration of 2 years. Results  Transient hypocalcemia was more frequent in the CCND group than in the LCND group (48.3% vs 26.8%, P = .02, odds ratio [OR] = 2.55). However, the other complication rates were similar in the two groups. In addition, the immediate postoperative reduction of parathyroid hormone (PTH) was more evident in the CCND group. The postoperative PTH levels increased up to a similar level (12.4 vs 11.8 pg/mL) over 6 months. The incidence of permanent hypocalcemia did not differ significantly between the two groups. Four (7.1%) and five recurrences (8.6%) were found in two groups, respectively, implying similar oncological safety during the 2-year follow-up. Conclusion  The LCND with total thyroidectomy could be an alternative treatment option for node-negative papillary thyroid carcinomas, because LCND had fewer short-term hypocalcemia and similar oncological outcomes during the 2-year follow-up. Further study enrolling a large number of patients with long-term follow-up is needed.