cN_0甲状腺乳头状癌190例术式选择及复发分析

[目的]探讨颈淋巴结阴性（cN0）甲状腺乳头状癌（PTC）的外科治疗方式及复发情况。[方法]回顾性分析2000年1月至2009年1月收治的未行预防性颈侧区淋巴结清扫术190例PTC患者的临床资料。[结果]190例患者中,术后出现颈侧区淋巴结转移4例,再次行颈侧区淋巴结清扫术后治愈。术后颈侧区淋巴结转移与各临床病理因素均无关。[结论]原发灶根治＋同侧中央区域淋巴结清扫是治疗cN0PTC的一种值得推荐术式。对cN0PTC患者不主张行预防性颈侧区淋巴结清扫。     

甲状腺癌颈部淋巴结转移区域的超声特点研究

目的：探究甲状腺癌颈部淋巴结转移区域的超声特点。方法回顾性分析58例甲状腺癌患者的临床资料。将患者术前颈部淋巴结转移区域的超声诊断与患者的病理诊断进行比较,分析其超声表现的特点。结果58例患者中经术前超声诊断显示,有36例（62．07％）颈部淋巴结转移,其中3例单纯中央区淋巴结转移、18例单纯颈侧区淋巴结转移、15例颈侧区合并中央区淋巴结转移;中央区淋巴结转移率为31．03％,显著低于颈侧区淋巴结转移率56．89％。病理诊断结果显示,58例患者中有33例（56．89％）颈部淋巴结转移,其中21例单纯中央区淋巴结转移,2例单纯颈侧区淋巴结转移,10例颈侧区合并中央区淋巴结转移;中央区淋巴结转移率为53．44％,显著高于颈侧区淋巴结转移率20．68％。超声诊断颈部转移性淋巴结的特异性为80．0％（12／15）,敏感性为100．0％（33／33）。超声检查对中央区转移性淋巴结的检出率为58．06％（18／31）,显著低于颈侧区转移性淋巴结的检出率100．0％（12／12）。超声诊断颈侧区淋巴结转移与病理结果的符合率为36．36％（12／33）,显著低于中央区淋巴结转移与病理结果的符合率58．06％（18／31）,差异具有统计学意义（P＜0．05）。颈侧区和中央区中淋巴门回声消失和低回声占较高的比例,且颈侧区和中央区颈侧区转移性淋巴结中L／T＜2所占的比例差异具有统计学意义（P＜0．05）。结论甲状腺癌多转移至颈部中央区淋巴结,采用超声检查具有较高的特异性,对中央区淋巴结的诊断有十分重要的意义。     

Ⅵ区淋巴结在甲状腺乳头状癌治疗中的价值

 目的 评价在临床Ⅱ～Ⅴ区（颈侧区加颈侧后区）淋巴结阴性（cN0）的甲状腺乳头状癌（PTC）患者中行Ⅵ区（中央区）淋巴结清扫的价值。方法 回顾性分析98例临床cN0的PTC患者行功能性颈淋巴结清扫术后的病理结果，并将Ⅵ区淋巴结与Ⅱ～Ⅴ区淋巴结进行区分分析。结果 98例患者中，Ⅵ区淋巴结转移20例（20.4 ％），Ⅱ～Ⅴ区转移13例（13.3 ％）。在Ⅵ区淋巴结（+）患者中Ⅱ～Ⅴ区转移率为45.0 %（9／20），明显高于Ⅵ区淋巴结（-）者的Ⅱ～Ⅴ区转移率5.1 %（4／78）（P＜0.01）。结论 将Ⅵ区淋巴结与Ⅱ～Ⅴ区淋巴结明确区分对临床治疗具有指导价值。对于cN0的PTC患者应常规行Ⅵ区淋巴结清扫术并行术中冷冻切片检查。     

CT与超声在甲状腺乳头状癌患者术前淋巴结评估中的价值比较#br#

目的根据甲状腺乳头状癌（PTC）原发灶的大小不同,探讨CT、超声及CT联合超声检查在PTC患者术前颈部淋巴结转移情况评估中的诊断效能。方法回顾性分析2017年1月至2021年1月宿迁市第一人民医院收治的经病理学检验证实为PTC的209例患者的术前CT和超声图像。根据PTC原发肿瘤的大小分成3组：肿瘤直径<1 cm组99例,1～2 cm组68例,＞2 cm组42例,比较CT、超声及CT联合超声检查在术前颈部淋巴结评估中的敏感度、特异度及准确度。结果CT联合超声诊断颈部中央区淋巴结转移有高准确度、高敏感度、低特异度,但对颈侧区淋巴结转移诊断的准确度较低;当肿瘤较小时（<1 cm）,超声比CT诊断颈侧区淋巴结转移的特异度和准确度均较高;当肿瘤较大时（≥1 cm）,CT比超声诊断中央区淋巴结转移有更高的敏感度和准确度,但超声诊断颈侧区淋巴结的转移有较高的特异度和准确度。结论对于术前PTC病灶≥1 cm的患者,CT检查在发现中央区淋巴结转移方面优于超声。当原发灶较小时(<1 cm),CT联合超声检查诊断颈侧区淋巴结转移方面并无优势。     

甲状腺乳头状癌中央区淋巴结清扫的临床意义

[目的]探讨临床颈淋巴结阴性(CN0)的甲状腺乳头状癌中央区淋巴结清扫的临床意义.[方法]对2010年1月至2011年6月收治的178例CN0甲状腺乳头状癌患者行中央区淋巴结清扫,其中67例同期行外侧区淋巴结清扫.评估中央区淋巴结清扫术的安全性,并对中央区及外侧区淋巴结转移相关因素进行分析.[结果]中央区淋巴结清扫没有明显增加手术并发症.中央区淋巴结转移率为44.4％;中央区淋巴结转移率与肿瘤大小有关,外侧区淋巴结转移率与中央区淋巴结阳性数目有关.[结论]中央区淋巴结清扫是一个方便安全的手术,能使部分患者免除外侧区颈清扫,应列为CN0甲状腺乳头状癌患者的常规选择.     

颈中央区域淋巴结清扫58例颈淋巴结阴性（CN0）甲状腺乳头状癌手术治疗应用

[目的]探讨颈中央区域淋巴结完整切除在临床颈部淋巴结阴性（cN0）甲状腺乳头状癌手术中的临床意义。[方法]58例甲状腺乳头状癌（cN0期）患者,在根治原发病灶的同时联合清扫同侧颈中央区域淋巴结。[结果]颈中央区域淋巴结（或Ⅵ区）淋巴结清扫数目平均2．8枚／例,淋巴结转移率37．93％（22／58）。[结论]原发灶根治＋同侧颈中央区域淋巴结清扫是治疗cN0甲状腺乳头状癌的一种有效术式．     

甲状腺乳头状癌侧颈淋巴结转移术前超声诊断及预测因素分析

[目的]探讨甲状腺乳头状癌颈部淋巴结转移患者术前颈部超声诊断的价值,以及侧颈淋巴结转移的风险因素。[方法]回顾性分析仙居县中医院2001年12月至2011年12月间治疗的112例甲状腺乳头状癌病例的术前超声检查结果、甲状腺癌原发灶特点、颈部淋巴结转移情况等临床资料。[结果]对经手术清扫后病理证实的病例,超声诊断中央区淋巴结转移和侧颈淋巴结转移的敏感性、特异性分别为51.6%、70.4%和94.9%、100.0%。而原发灶侵及甲状腺上极的病例,发生侧颈(Ⅲ区)淋巴结转移的风险较病灶局限于甲状腺中极或下极的病例要高约3倍。[结论]超声检查在甲状腺乳头状癌术前侧颈淋巴结转移评估方面有着较高的敏感性和特异性,对是否行颈侧区清扫有参考意义。甲状腺乳头状癌一旦侵及甲状腺上极,会大大增加侧颈(Ⅲ区)淋巴结转移的风险,术前及术中需仔细评估侧颈淋巴结转移情况,避免手术切除范围不足。     

未行预防性侧颈清扫的CN0甲状腺乳头状癌的临床转归

目的：研究未行预防性侧颈清扫的CN0甲状腺乳头状癌（papillary thyroid carcinoma，PTC）患者初次手术后出现临床侧颈淋巴结转移的发生率。方法：回顾性分析复旦大学附属肿瘤医院1991年11月-2001年11月收治的未行预防性侧颈清扫的CN0甲状腺乳头状癌患者380例临床资料。结果：380例患者中出现临床同侧颈淋巴结转移的有8例再行侧颈淋巴结清扫术；术前行颈CT检查未提示有侧颈淋巴结肿大的56例在术后随访中无临床侧颈淋巴结转移。病灶大小、年龄、中央区淋巴结转移情况均不是预示随访中出现侧颈淋巴结转移的高危患者因素。结论：对CN0期甲状腺乳头状癌患者不主张行预防性侧颈清扫，可观察；术前CT检查能减少术后侧颈淋巴结的转移率。     

单灶甲状腺乳头状癌淋巴结转移超声特征分析

目的：通过回顾性分析单灶甲状腺乳头状癌（papillary thyroid carcinoma,PTC）的超声声像特征,寻找单灶PTC颈部淋巴结转移（lymphnode metastasis,LNM）的相关高危因素,总结单灶PTC颈部淋巴结转移规律,提高单灶PTC颈部淋巴结的超声检出率,用以指导临床对单灶PTC颈部淋巴结清扫手术方式的选择。方法：回顾性分析2018年1月至2020年1月于我院进行的甲状腺癌手术且术后病理证实为单灶PTC的95个病例,分析病灶的超声声像特征,并探讨影响PTC颈部淋巴结转移的因素。结果：肿瘤所在长轴方位与淋巴结转移区域的相关性有统计学意义（P=0.025）。位于侧叶下部的肿瘤可局限于下极周围中央区淋巴结转移,少部分并发同侧颈侧区淋巴结转移;上中部区域的肿瘤如果发生淋巴结转移,则多数为同侧颈侧区淋巴结转移合并中央区上极周围淋巴结转移,只是中央区淋巴结术前超声发现率较低。不同肿瘤大小的病理淋巴结转移区域的差异有统计学意义（P<0.001）。建立模型预测术前淋巴结转移的风险发现,当肿瘤大小取最大直径,ROC曲线Cut-off值为9,即肿瘤最大直径＞9mm时有统计学意义（P＜0.05）。结论：根据单灶PTC淋巴结转移规律,当肿瘤最大直径＞9mm、肿瘤位于下部时,增加了超声医师提示可疑中央区淋巴结转移的依据,有望提高中央区转移淋巴结的检出率。对单灶PTC在超声声像图上中肿瘤最大直径＞9mm、肿瘤位于下部时临床可以考虑行中央区淋巴结清扫,为颈部淋巴结清扫术的选择及淋巴结清扫范围提供了一定的根据。     

甲状腺乳头状癌颈侧区淋巴结跳跃转移危险因素分析

  目的  探讨甲状腺乳头状癌（papillary thyroid carcinoma,PTC）淋巴结跳跃转移（中央区无淋巴结转移,颈侧区有淋巴结转移）的规律及危险因素。  方法  回顾性分析2013年1月至2016年12月重庆医科大学附属第一医院521例行甲状腺全切+中央区及颈侧区淋巴结清扫的PTC患者的临床病理资料,分析跳跃转移的危险因素。  结果  本研究PTC跳跃转移率为8.3%（43/521）,肿瘤位于甲状腺上极（OR=3.401,95%CI:1.770~6.536;P=0.001）,年龄>45岁（OR=2.856,95%CI:1.488~5.482;P=0.002）,单侧癌（OR=3.424,95%CI:1.182~9.920;P=0.023）是PTC出现颈侧区淋巴结跳跃转移的独立危险因素。本研究比较cN1b的PTC患者和肿瘤位于甲状腺上极的cN0 PTC患者跳跃转移情况,发现肿瘤位于上极cN0的PTC患者出现潜在跳跃转移的可能性高于cN1b患者（P=0.022）。  结论  PTC颈侧区淋巴结跳跃转移并不少见,术前、术中针对颈侧区淋巴结转移状态的评估很重要,尤其是肿瘤位于上极,年龄>45岁的单侧PTC患者,必要时需行患侧颈侧区淋巴结清扫。      

Roles of ultrasonography and computed tomography in the surgical management of cervical lymph node metastases in papillary thyroid carcinoma

Aims

Adequate evaluation and surgical management of cervical lymph node metastasis is very important in papillary thyroid carcinoma (PTC). The aim of this study was to evaluate the impact of preoperative ultrasonography (US) and computed tomography (CT) on the surgical management of cervical lymph node metastases in PTC.

Methods

Medical records and imaging findings were retrospectively analyzed for 252 patients with PTC who underwent thyroidectomy with neck dissection.

Results

The sensitivity of both imaging techniques was lower in the central neck (US 23%, CT 41%) than in the lateral neck (US 70%, CT 82%). The specificities of US and CT were 97% and 90% in the central neck, and 84% and 64% in the lateral neck, respectively. Our surgical plans for therapeutic neck dissection were based on imaging findings in 59% of patients who underwent lateral compartment neck dissection and in 32.1% of patients who underwent central compartment neck dissection, respectively.

Conclusions

The roles of preoperative US and CT in surgical planning for central compartment neck dissection in PTC are limited because of their low sensitivity in the central neck, but US and CT may be useful in cases with non-palpable lateral neck nodes.     

甲状腺乳头状癌颈部淋巴结转移特点及清扫策略

背景与目的：目前,在甲状腺癌颈淋巴结清扫方面存有较大分歧。该研究总结甲状腺乳头状癌淋巴结转移的特点,为择区淋巴结清扫提供理论依据。方法：回顾性分析2006年7月—2014年8月收治的462例甲状腺乳头状癌患者病历资料,分析其淋巴结转移规律及其影响因素,评判cN0标准的准确性。结果：全组患者均行患侧中央区(Ⅵ区)淋巴结清扫,320例行侧颈区淋巴结清扫术(Ⅱ～Ⅴ区)或择区淋巴结清扫(Ⅱ～Ⅳ区中的部分或全部),90例行对侧中央区淋巴结活检。73.2%(338/462)符合cN0标准,病理证实其中有184例淋巴结转移,cN0标准误诊率达60.9%。颈部淋巴结总转移率为65.4%(302/462),侧颈区淋巴结转移率为42.6%(197/462),“跳跃转移”率为13.1%(42/320),对侧中央区淋巴结转移率为50%(45/90)。男性、肿瘤累及腺叶上1/3、肿瘤T3或T4、多中心病灶是淋巴结转移的危险因素。肿瘤累及腺叶上1/3是喉前淋巴结转移及“跳跃转移”的危险因素。喉前淋巴结转移及中央区淋巴结2个以上转移者侧颈区淋巴结转移率显著增加(分别为85.7%和83.3%, P＜0.05)。结论：现行cN0标准不能作为确定淋巴结清扫范围的依据;甲状腺乳头状癌易发生淋巴结转移,其中Ⅵ区淋巴结转移率最高,依次为Ⅲ区、Ⅱ区、Ⅳ区、Ⅴ区;初次手术应常规清扫患侧中央区淋巴结,建议将Ⅵ区淋巴结送冰冻病理;当喉前淋巴结有转移或Ⅵ区2个以上淋巴结转移时,或肿瘤累及腺叶上1/3者,有必要行侧颈区(或择区)淋巴结清扫;对侧中央区淋巴结转移率较高,需予以重视;中央区淋巴结再分亚区具有重要意义,应深入研究。     

肿瘤直径>1cm甲状腺乳头状癌淋巴结转移规律及危险因素分析

目的  探讨肿瘤直径>1 cm甲状腺乳头状癌的颈部淋巴结转移规律及其危险因素,为规范手术清扫范围提供临床依据。方法  回顾性分析1998年3月至2018年4月在解放军第960医院甲状腺乳腺外科行甲状腺全切+颈部中央区和侧区淋巴结清扫手术治疗的685例肿瘤直径>1 cm甲状腺乳头状癌患者的临床资料,采用χ2检验分析不同临床特征患者的中央区淋巴结转移率及侧区淋巴结转移率的差异,采用多因素Logistic回归分析甲状腺乳头状癌颈部中央区及侧区淋巴结转移的影响因素。结果  685例肿瘤直径>1 cm甲状腺乳头状癌患者中,有542例出现颈部淋巴结转移,总转移率为791%;其中中央区淋巴结转移率为715%（490/685）,侧区淋巴结转移率为552%（378/685）,“跳跃性”转移率为267%（52/195）。在中央区转移的490例患者中,有326例（665%）出现侧区淋巴结转移。患者男性、年龄<55岁、肿瘤直径大、侵犯包膜、多灶性、双侧肿瘤和不合并结节性甲状腺肿患者的颈部中央区淋巴结转移率较高（P<005）;患者的肿瘤直径大、侵犯包膜、多灶性、双侧肿瘤和不合并结节性甲状腺肿患者的颈部侧区淋巴结转移率较高（P<005）。Logistic回归分析提示,年龄<55岁、男性、双侧性、侵犯包膜是颈部中央区淋巴结转移的独立危险因素;侵犯包膜、不合并结节性甲状腺肿是侧区淋巴结转移的独立危险因素。结论  肿瘤直径>1 cm甲状腺乳头状癌患者的颈部淋巴结转移率较高,应在常规进行规范的治疗性中央区淋巴结清扫的同时,积极行预防性侧区淋巴结清扫,尤其是对于伴中央区淋巴结转移、侵犯包膜、多灶癌、双侧肿瘤、不合并结节性甲状腺肿的患者。     

双侧甲状腺乳头状癌中央区隐匿转移相关因素分析

目的：探索双侧甲状腺乳头状癌（PTC）中央区隐匿转移的规律。方法对收治的56例中央区临床阴性（cN0期）的双侧PTC患者常规行中央区清扫,回顾性分析术后病理中央区转移的相关因素。结果全组患者中央区转移率为64.3%（36/56）,其中单侧中央区转移率为25.0%（14/56）,双侧转移率为39.3%（22/56）。在可区分轻重侧的33例患者中,无转移,双侧转移,仅轻侧转移和仅重侧转移比例分别为33.3%、39.4%、9.1%和18.2%,轻、重侧总转移概率分别为48.5%和57.6%,差异无统计学意义（χ2=0.547,P=0.459）。最大肿瘤直径﹥1 cm和颈侧转移是中央区隐匿转移的影响因素;以单侧病变为对象分析,肿瘤浸润包膜和侧颈转移是该侧中央区隐匿转移的独立危险因素。结论双侧PTC患者具有较为特殊的中央区转移规律且隐匿转移发生率较高,在情况允许下可考虑进行双侧中央区清扫。     

Lymph node management in clinically node-negative patients with papillary thyroid carcinoma

Aims

Systematic lymph node dissection in patients with papillary thyroid carcinoma (PTC) remains controversial. The objective of this study was to study the pattern of lymph node spread in patients with PTC clinically node-negative and then to propose a lymph node management strategy.

Methods

We retrospectively reviewed the records of patients who had undergone total thyroidectomy and a systematic central neck dissection (CND) and lateral neck dissection. Ninety patients with PTC without lymph nodes metastases (LNM) detected on preoperative palpation and ultrasonographic examination were included.

Results

Forty-one patients (45.5%) had LNM. Twenty-eight patients (31%) had a central and a lateral involvement. Thirteen patients (14.5%) had only a central involvement. All the patients without LNM in the central compartment were also free in the lateral compartment. There was no correlation between LNM status and TNM staging.The largest LNM in the central compartment was smaller than or equal to 5 mm in 66% of the cases, and that could explain the lack of sensitivity of the preoperative ultrasonographic examination.

Conclusion

CND could be considered at preoperative or intraoperative diagnosis of PTC whereas lateral neck dissection should be performed only in patients with preoperative suspected and/or intraoperatively proven LNM. Systematic CND allows an objective evaluation of lymph node status in this central cervical area where the LNM are particularly small and difficult to detect preoperatively.     

Predictive factors of skip metastases to lateral neck compartment leaping central neck compartment in papillary thyroid carcinoma

Skip metastasis, referred to as leaping metastasis to the lateral neck without associated lymphadenopathy in the central compartment (level VI), can occur in patients with papillary thyroid carcinoma (PTC). However, there have been few studies on its predictive value in PTC patients. We reviewed the medical records of 90 patients who underwent simultaneous central and lateral neck lymph node dissection for the primary treatment of lymph node metastasis in the lateral neck of PTC patients. No patient was suspected of having metastasis in the central compartment by preoperative imaging study. The frequency of skip metastasis to the lateral neck compartment without central neck metastasis was 19% (17/90). The number of metastatic lymph nodes dissected in the lateral neck of patients with and without skip metastasis was 5.1±2.7 and 9.5±2.6, respectively (P<0.001). Skip metastasis was closely associated with significantly fewer lymphovascular invasion (P=0.009) and extracapsular spread (P=0.035). Skip metastasis can occur significantly frequently in PTC patients. The presence of lymphovascular invasion, extracapsular spread, and number of positive lymph nodes dissected were inversely correlated with skip metastasis.     

Sentinel lymph node biopsy as guidance for central neck dissection in patients with papillary thyroid carcinoma

BACKGROUND.

Occult lymph node metastasis of papillary thyroid carcinoma (PTC) can be detected by sentinel lymph node (SLN) biopsy, but studies in larger patient cohorts undergoing complete central neck dissection may be required to assess the diagnostic accuracy of SLN. Therefore, the authors prospectively assessed the usefulness of SLN biopsy for the detection of central lymph node metastasis in patients with differentiated PTC who had no suspicious cervical lymphadenopathy.

METHODS.

After peritumoral injection of methylene blue, SLN biopsy was performed in 50 patients with newly diagnosed PTC who had no palpable or ultrasound (US)‐detected lymph node involvement. After SLN biopsy, all patients underwent total thyroidectomy and central neck dissection. The diagnostic accuracy of intraoperative SLN sampling was calculated by comparison with the final pathologic diagnosis.

RESULTS.

SLNs were identified in 46 of 50 patients (92%); of these, 14 SLNs were positive and 32 SLNs were negative on intraoperative frozen sections. One patient had a positive SLN in the jugular region and subsequently underwent modified radical neck dissection. Final pathologic examination revealed that 18 patients (36%), including 4 who had negative SLNs, had central lymph node metastasis. Thus, the sensitivity, specificity, accuracy, and positive and negative predictive values of SLN biopsy were 77.8%, 100%, 92%, 100%, and 88.9%, respectively. Temporary and permanent hypocalcemia developed in 19 patients and 1 patient, respectively. There were no direct complications of SLN sampling.

CONCLUSIONS.

SLN biopsy in patients with PTC without gross clinical or US lymph node involvement was able to detect occult metastasis with high accuracy and may have the potential to select patients who require central neck dissection. Cancer 2008. © 2008 American Cancer Society.