73例初治甲状腺髓样癌术式探讨

  目的  探讨甲状腺髓样癌初治合理手术术式。  方法  回顾性分析73例甲状腺髓样癌初治病例资料, 研究颈淋巴结转移规律及术后复发情况。  结果  多灶性甲状腺髓样癌占26.0%(19/73)。全组颈淋巴结转移率为58.9%(43/73), 其中中央区淋巴结转移率52.1%(38/73), 同侧颈淋巴结转移率53.4%(39/73), 双侧侧颈转移率11.O%(8/73), 临床NO颈淋巴结隐匿性转移率为18.9%(7/37)。多因素Logistic回归分析显示, 中央区淋巴结转移是该侧侧颈淋巴结转移的独立危险因素, 原发灶T4是对侧侧颈淋巴结转移的独立危险因素。全组局部区域复发率28.8%(21/73)。全组5年累积生存率为86.4%。多因素分析表明远处转移、年龄≥45岁和原发灶T4是影响预后的独立危险因素。  结论  建议甲状腺髓样癌手术应常规行患侧中央区清扫, 并包含上纵隔区域; 术中证实有中央区淋巴结转移的病例, 建议行该侧侧颈清扫术; T4病例建议行全甲状腺切除+中央区+双颈清扫术。 

Type of Surgery for Untreated Medullary Thyroid Carcinoma: A Report of 73 Cases

  Objective  To study the optimum type of surgery for untreated medullary thyroid carcinoma.  Methods  To retrospectively analyse the clinical data of 73 patients with untreated medullary thyroid carcinoma who received surgical treatment at our hospital. The patterns of neck metastases and the postoperative recurrence were investigated.  Results  The rate of multifocal medullary thyroid carcinoma was 26.0 % (19 / 73). The overall cervical lymph node metastasis rate was 58.9 % (43 / 73). The central neck nodal metastasis rate was 52.1% (38 / 73). Ipsilateral and bilateral nodal metastasis rate was 53.4 % (39 / 73) and 11.0 % (8 / 73), respectively. The cervical occult metastasis rate in cN0 patients was 18.9 % (7 / 37). In multivariate analysis, central neck nodal metastasis remained an independent risk factor of ipsilateral nodal metastasis and primary T4 was an independent risk factor of contralateral lateral nodal metastasis. The loco-regional recurrent rate was 28.8 % (21 / 73). The overall 5-year survival rates was 86.4 %. Multivariate analysis revealed that distant metastasis, age ≥ 45 years and primary T₄ were independent prognostic factors.  Conclusion  A routine central compartmental neck dissection for medullary thyroid carcinoma is recommended, which includes removing the lymph nodes of superior mediastinum. Lateral neck compartmental dissection should be considered when lymph node metastasis is proved in ipsilateral central compartment intraoperatively. Total thyroidectomy, central and bilateral functional neck dissections should be considered in T4 patients.