术前超声评估分化型甲状腺癌颈部淋巴结转移
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摘要
目的探讨术前超声诊断分化型甲状腺癌(DTC)颈中央区及颈侧区淋巴结转移的临床价值。方法回顾性分析2017年4月至2018年8月术后病理证实的186例DTC患者,所有患者均于山东大学齐鲁医院(青岛)超声科行术前超声检查,并于耳鼻咽喉头颈外科行颈中央区淋巴结清扫术,其中71例同时行颈侧区择区淋巴结清扫术。以石蜡切片病理结果为金标准,计算术前超声诊断颈中央区淋巴结转移及颈侧区淋巴结转移的敏感度、特异度、阳性预测值(PPV)和阴性预测值(NPV)。根据患者有无桥本甲状腺炎(CLT),将所有病例分为两组,A组合并CLT,B组不合并CLT;分别计算两组超声诊断中央区淋巴结转移的敏感度、特异度、PPV、NPV。结果术前超声诊断甲状腺癌颈中央区及颈侧区淋巴结转移的敏感度分别为:68.9%、95.3%,特异度分别为:56.3%、57.1%,PPV分别为:75.0%、95.3%,NPV分别为:48.6%、57.1%。A组(60例)与B组(126例),术前超声对颈中央区淋巴结转移诊断的敏感度分别为:85.0%、62.5%,特异度分别为:35.0%、67.4%,PPV分别为:72.3%、76.9%,NPV分别为:53.8%、50.8%。结论术前超声检查对DTC颈中央区及颈侧区淋巴结转移的诊断有价值,对颈侧区的诊断准确性高于中央区。合并CLT的DTC患者,超声对颈中央区淋巴结转移的诊断准确性低于不合并CLT的患者。
Objective To investigate the clinical value of preoperative ultrasonography in detecting central compartment and lateral neck lymph node metastasis. Methods In total,186 consecutive patients with pathologically proven differentiated thyroid cancer were involved in this retrospective study. All patients underwent operative US examination in the Department of Ultrasound and central-compartmental lymph node dissection in the Department of Otorhinolaryngology Head and Neck Surgery in Qilu Hospital of Shandong University( Qingdao),while 71 of them underwent lateral neck compartmental lymph node dissection between April 2017 and August 2018. According to the gold standard of biopsy,the sensitivity,specificity,positive predictive value( PPV),and negative predictive value( NPV) were calculated using SPSS 20. 0 statistical software. All the patients were divided into two groups;groups A and B included patients with or without chronic lymphocytic thyroiditis( CLT). The sensitivity,specificity,PPV,and NPV of central neck compartmental lymph node metastasis detected using US were calculated. Results The sensitivity,specificity,PPV,and NPV of central compartmental lymph node metastasis detected using US were 68.9%,56.3%,75.0%,and 48.6%,respectively; those of lateral neck compartmental lymph node metastasis detected using US were 95.3%,57.1%,95.3%,and 57.1%,respectively. The sensitivity,specificity,PPV,and NPV in group A were 85.0%,35.0%,72.3%,and 53.8%,respectively; those in group B were 62.5%,67.4%,76.9%,and 50.8%,respectively. Conclusion Preoperative US for central and lateral neck lymph node metastasis is valuable for the management of cervical lymph node dissection. The diagnosis of lateral neck lymph node metastasis is much more accurate than that of central neck lymph node metastasis,while the diagnosis of central neck lymph node metastasis in patients with CLT is more accurate than that in patients without CLT.
Objective To investigate the clinical value of preoperative ultrasonography in detecting central compartment and lateral neck lymph node metastasis. Methods In total,186 consecutive patients with pathologically proven differentiated thyroid cancer were involved in this retrospective study. All patients underwent operative US examination in the Department of Ultrasound and central-compartmental lymph node dissection in the Department of Otorhinolaryngology Head and Neck Surgery in Qilu Hospital of Shandong University( Qingdao),while 71 of them underwent lateral neck compartmental lymph node dissection between April 2017 and August 2018. According to the gold standard of biopsy,the sensitivity,specificity,positive predictive value( PPV),and negative predictive value( NPV) were calculated using SPSS 20. 0 statistical software. All the patients were divided into two groups;groups A and B included patients with or without chronic lymphocytic thyroiditis( CLT). The sensitivity,specificity,PPV,and NPV of central neck compartmental lymph node metastasis detected using US were calculated. Results The sensitivity,specificity,PPV,and NPV of central compartmental lymph node metastasis detected using US were 68.9%,56.3%,75.0%,and 48.6%,respectively; those of lateral neck compartmental lymph node metastasis detected using US were 95.3%,57.1%,95.3%,and 57.1%,respectively. The sensitivity,specificity,PPV,and NPV in group A were 85.0%,35.0%,72.3%,and 53.8%,respectively; those in group B were 62.5%,67.4%,76.9%,and 50.8%,respectively. Conclusion Preoperative US for central and lateral neck lymph node metastasis is valuable for the management of cervical lymph node dissection. The diagnosis of lateral neck lymph node metastasis is much more accurate than that of central neck lymph node metastasis,while the diagnosis of central neck lymph node metastasis in patients with CLT is more accurate than that in patients without CLT.
引文
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[6]黄丽燕,何以敉,薛恩生,等.超声对甲状腺癌颈部转移性淋巴结区域及特点的评价[J].中华超声影像学杂志,2014,23(9):769-772. doi:10.3760/cma.j.issn.1004-4477.2014.09.010.HUANG Liyan,HE Yimi,XUE Ensheng,et al. Ultrasound evaluation on cervical lymph nodes metastasis regions and characteristics in thyroid carcinoma[J]. Chinese Journal of Ultrasonography,2014,23(9):769-772. doi:10.3760/cma.j.issn.1004-4477.2014.09.010.
[7]原韶玲,陈然.甲状腺结节和颈部淋巴结超声标准化报告及建议[J].中华医学超声杂志(电子版),2016,13(8):567-572. doi:10. 3877/cma. j. issn. 1672-6448. 2016.08.003.
[8]Podnos YD,Smith D,Wagman LD,et al. The implication of lymph node metastasis on survival in patients w ith w ell-differentiated thyroid cancer[J]. Am Surg,2005,71(9):731-734.
[9]Haugen BR,Alexander EK,Bible KC,et al. 2015 american thyroid association management guidelines for adult patients w ith thyroid nodules and differentiated thyroid cancer:the american thyroid association guidelines task force on thyroid nodules and differentiated thyroid cancer[J]. Thyroid,2016,26(1):1-133. doi:10. 1089/thy.2015.0020.
[10]中华医学会内分泌学分会,中华医学会外科学分会内分泌学组,中国抗癌协会头颈肿瘤专业委员会,等.甲状腺结节和分化型甲状腺癌诊治指南[J].中华核医学与分子影像杂志,2013,33(2):96-115. doi:10.3760/cma.j.issn.2095-2848.2013.02.003.
[11]Barczyński M. Author's reply:Prophylactic central neck dissection for papillary thyroid cancer[J]. Br J Surg,2013,100(8):1115. doi:10.1002/bjs.9173.
[12] Hartl DM,Mamelle E,Borget I,et al. Influence of prophylactic neck dissection on rate of retreatment for papillary thyroid carcinoma[J]. World J Surg,2013,37(8):1951-1958. doi:10.1007/s00268-013-2089-3.
[13]Sywak M,Cornford L,Roach P,et al. Routine ipsilateral level VI lympha-denectomy reduces postoperative thyroglobulin levels in papillary thyroid cancer[J]. Surgery2006,140:1000-1005. doi:10.1016/j.surg.2006.08.001
[14]Lang BHH,Wong KP,Wan KY,et al. Impact of routine unilateral central neck dissection on preablative and postablative stimulated thyroglobulin levels after total thyroidectomy in papillary thyroid carcinoma[J]. Ann Surg Oncol,2012,19(1):60-67. doi:10.1245/s10434-011-1833-x.
[15] Viola D,Materazzi G,Valerio L,et al. Prophylactic central compartment lymph node dissection in papillary thyroid carcinoma:clinical implications derived from the first prospective randomized controlled single institution study[J]. J Clin Endocrinol M etab,2015,100(4):1316-1324. doi:10.1210/jc.2014-3825.
[16]Iyer NG,Shaha AR. Central compartment dissection for w ell differentiated thyroid cancer and the band plays on[J]. Curr Opin Otolaryngol Head Neck Surg,2011,19(2):106-112. doi:10.1097/MOO.0b013e328343af58.
[17]张晓晓,詹维伟,周伟,等.术前超声检查评估甲状腺微小乳头状癌颈部淋巴结转移的临床价值[J].中华医学超声杂志(电子版),2014,11(11):919-924. doi:10.3877/cma.j.issn.1672-6448.2014.11.014ZHANG Xiaoxiao,ZHAN Weiw ei,ZHOU Wei,et al.Preoperative ultrasonography for lymph node metastasis:usefulness w hen designing lymph node dissection for papillary microcarcinoma of the thyroid[J]. Chinese Journal of M edical Ultrasound(Electronic Edition),2014,11(11):919-924. doi:10. 3877/cma. j. issn. 1672-6448.2014.11.014
[18]Lee DW,Ji YB,Sung ES,et al. Roles of ultrasonography and computed tomography in the surgical management of cervical lymph node metastases in papillary thyroid carcinoma[J]. Eur J Surg Oncol,2013,39(2):191-196. doi:10.1016/j.ejso.2012.07.119.
[19]Pereira JA,Jimeno J,Miquel J,et al. Nodal yield,morbidity,and recurrence after central neck dissection for papillary thyroid carcinoma[J]. Surgery,2005,138(6):1095-1100. doi:10.1016/j.surg.2005.09.013.
[20]Roh JL,Kim JM,Park CI. Central lymph node metastasis of unilateral papillary thyroid carcinoma:patterns and factors predictive of nodal metastasis,morbidity,and recurrence[J]. Ann Surg Oncol,2011,18(8):2245-2250. doi:10.1245/s10434-011-1600-z.
[21]Kouvaraki MA,Shapiro SE,Fornage BD,et al. Role of preoperative ultrasonography in the surgical management of patients w ith thyroid cancer[J]. Surgery,2003,134(6):946-954. doi:10.1016/S0039.
[22]Choi YJ,Yun JS,Kook SH,et al. Clinical and imaging assessment of cervical lymph node metastasis in papillary thyroid carcinomas[J]. World J Surg,2010,34(7):1494-1499. doi:10.1007/s00268-010-0541-1.
[23]Mizrachi A,Feinmesser R,Bachar G,et al. Value of ultrasound in detecting central compartment lymph node metastases in differentiated thyroid carcinoma[J]. Eur Arch Otorhinolaryngol,2014,271(5):1215-1218. doi:10.1007/s00405-013-2636-4.
[24]Ahn JE,Lee JH,Yi JS,et al. Diagnostic accuracy of CT and ultrasonography for evaluating metastatic cervical lymph nodes in patients w ith thyroid cancer[J]. World J Surg,2008,32(7):1552-1558. doi:10. 1007/s00268-008-9588-7.
[25]Paulson LM,Shindo ML,Schuff KG. Role of chronic lymphocytic thyroiditis in central node metastasis of papillary thyroid carcinoma[J]. Otolaryngol Head Neck Surg,2012,147(3):444-449. doi:10.1177/0194599812445727.
[26] Kashima K,Yokoyama S,Noguchi S,et al. Chronic thyroiditis as a favorable prognostic factor in papillary thyroid carcinoma[J]. Thyroid,1998,8(3):197-202.doi:10.1089/thy.1998.8.197.
[27] Loh KC,Greenspan FS,Dong F,et al. Influence of lymphocytic thyroiditis on the prognostic outcome of patients w ith papillary thyroid carcinoma[J]. J Clin Endocrinol M etab,1999,84(2):458-463. doi:10. 1210/jcem.84.2.5443.
[28]石臣磊,石铁锋,吴佳奇,等.桥本甲状腺炎对乳头状甲状腺癌颈淋巴结转移的影响[J].中国普通外科杂志,2013,22(5):580-584. doi:10. 7659/j. issn. 1005-6947.2013.05.010.SHI Chenlei,SHI Tiefeng,WU Jiaqi,et al. Does Hashimoto's thyroiditis have an influence on lymph node metastasis of papillary thyroid carcinoma?[J]. Chinese Journal of General Surgery,2013,22(5):580-584. doi:10.7659/j.issn.1005-6947.2013.05.010.
[2]Shaha AR,Shah JP,Loree TR. Patterns of nodal and distant metastasis based on histologic varieties in differentiated carcinoma of the thyroid[J]. Am J Surg,1996,172(6):692-694. doi:10.1016/s0002-9610(96)00310-8.
[3]Zaydfudim V,Feurer ID,Griffin MR,et al. The impact of lymph node involvement on survival in patients w ith papillary and follicular thyroid carcinoma[J]. Surgery,2008,144(6):1070-1077. doi:10. 1016/j. surg. 2008. 08.034.
[4]Mazzaferri EL,Doherty GM,Steward DL. The pros and cons of prophylactic central compartment lymph node dissection for papillary thyroid carcinoma[J]. Thyroid,2009,19(7):683-689. doi:10.1089/thy.2009.1578.
[5]Leboulleux S,Girard E,Rose M,et al. Ultrasound criteria of malignancy for cervical lymph nodes in patients follow ed up for differentiated thyroid cancer[J]. J Clin Endocrinol M etab,2007,92(9):3590-3594. doi:10. 1210/jc.2007-0444.
[6]黄丽燕,何以敉,薛恩生,等.超声对甲状腺癌颈部转移性淋巴结区域及特点的评价[J].中华超声影像学杂志,2014,23(9):769-772. doi:10.3760/cma.j.issn.1004-4477.2014.09.010.HUANG Liyan,HE Yimi,XUE Ensheng,et al. Ultrasound evaluation on cervical lymph nodes metastasis regions and characteristics in thyroid carcinoma[J]. Chinese Journal of Ultrasonography,2014,23(9):769-772. doi:10.3760/cma.j.issn.1004-4477.2014.09.010.
[7]原韶玲,陈然.甲状腺结节和颈部淋巴结超声标准化报告及建议[J].中华医学超声杂志(电子版),2016,13(8):567-572. doi:10. 3877/cma. j. issn. 1672-6448. 2016.08.003.
[8]Podnos YD,Smith D,Wagman LD,et al. The implication of lymph node metastasis on survival in patients w ith w ell-differentiated thyroid cancer[J]. Am Surg,2005,71(9):731-734.
[9]Haugen BR,Alexander EK,Bible KC,et al. 2015 american thyroid association management guidelines for adult patients w ith thyroid nodules and differentiated thyroid cancer:the american thyroid association guidelines task force on thyroid nodules and differentiated thyroid cancer[J]. Thyroid,2016,26(1):1-133. doi:10. 1089/thy.2015.0020.
[10]中华医学会内分泌学分会,中华医学会外科学分会内分泌学组,中国抗癌协会头颈肿瘤专业委员会,等.甲状腺结节和分化型甲状腺癌诊治指南[J].中华核医学与分子影像杂志,2013,33(2):96-115. doi:10.3760/cma.j.issn.2095-2848.2013.02.003.
[11]Barczyński M. Author's reply:Prophylactic central neck dissection for papillary thyroid cancer[J]. Br J Surg,2013,100(8):1115. doi:10.1002/bjs.9173.
[12] Hartl DM,Mamelle E,Borget I,et al. Influence of prophylactic neck dissection on rate of retreatment for papillary thyroid carcinoma[J]. World J Surg,2013,37(8):1951-1958. doi:10.1007/s00268-013-2089-3.
[13]Sywak M,Cornford L,Roach P,et al. Routine ipsilateral level VI lympha-denectomy reduces postoperative thyroglobulin levels in papillary thyroid cancer[J]. Surgery2006,140:1000-1005. doi:10.1016/j.surg.2006.08.001
[14]Lang BHH,Wong KP,Wan KY,et al. Impact of routine unilateral central neck dissection on preablative and postablative stimulated thyroglobulin levels after total thyroidectomy in papillary thyroid carcinoma[J]. Ann Surg Oncol,2012,19(1):60-67. doi:10.1245/s10434-011-1833-x.
[15] Viola D,Materazzi G,Valerio L,et al. Prophylactic central compartment lymph node dissection in papillary thyroid carcinoma:clinical implications derived from the first prospective randomized controlled single institution study[J]. J Clin Endocrinol M etab,2015,100(4):1316-1324. doi:10.1210/jc.2014-3825.
[16]Iyer NG,Shaha AR. Central compartment dissection for w ell differentiated thyroid cancer and the band plays on[J]. Curr Opin Otolaryngol Head Neck Surg,2011,19(2):106-112. doi:10.1097/MOO.0b013e328343af58.
[17]张晓晓,詹维伟,周伟,等.术前超声检查评估甲状腺微小乳头状癌颈部淋巴结转移的临床价值[J].中华医学超声杂志(电子版),2014,11(11):919-924. doi:10.3877/cma.j.issn.1672-6448.2014.11.014ZHANG Xiaoxiao,ZHAN Weiw ei,ZHOU Wei,et al.Preoperative ultrasonography for lymph node metastasis:usefulness w hen designing lymph node dissection for papillary microcarcinoma of the thyroid[J]. Chinese Journal of M edical Ultrasound(Electronic Edition),2014,11(11):919-924. doi:10. 3877/cma. j. issn. 1672-6448.2014.11.014
[18]Lee DW,Ji YB,Sung ES,et al. Roles of ultrasonography and computed tomography in the surgical management of cervical lymph node metastases in papillary thyroid carcinoma[J]. Eur J Surg Oncol,2013,39(2):191-196. doi:10.1016/j.ejso.2012.07.119.
[19]Pereira JA,Jimeno J,Miquel J,et al. Nodal yield,morbidity,and recurrence after central neck dissection for papillary thyroid carcinoma[J]. Surgery,2005,138(6):1095-1100. doi:10.1016/j.surg.2005.09.013.
[20]Roh JL,Kim JM,Park CI. Central lymph node metastasis of unilateral papillary thyroid carcinoma:patterns and factors predictive of nodal metastasis,morbidity,and recurrence[J]. Ann Surg Oncol,2011,18(8):2245-2250. doi:10.1245/s10434-011-1600-z.
[21]Kouvaraki MA,Shapiro SE,Fornage BD,et al. Role of preoperative ultrasonography in the surgical management of patients w ith thyroid cancer[J]. Surgery,2003,134(6):946-954. doi:10.1016/S0039.
[22]Choi YJ,Yun JS,Kook SH,et al. Clinical and imaging assessment of cervical lymph node metastasis in papillary thyroid carcinomas[J]. World J Surg,2010,34(7):1494-1499. doi:10.1007/s00268-010-0541-1.
[23]Mizrachi A,Feinmesser R,Bachar G,et al. Value of ultrasound in detecting central compartment lymph node metastases in differentiated thyroid carcinoma[J]. Eur Arch Otorhinolaryngol,2014,271(5):1215-1218. doi:10.1007/s00405-013-2636-4.
[24]Ahn JE,Lee JH,Yi JS,et al. Diagnostic accuracy of CT and ultrasonography for evaluating metastatic cervical lymph nodes in patients w ith thyroid cancer[J]. World J Surg,2008,32(7):1552-1558. doi:10. 1007/s00268-008-9588-7.
[25]Paulson LM,Shindo ML,Schuff KG. Role of chronic lymphocytic thyroiditis in central node metastasis of papillary thyroid carcinoma[J]. Otolaryngol Head Neck Surg,2012,147(3):444-449. doi:10.1177/0194599812445727.
[26] Kashima K,Yokoyama S,Noguchi S,et al. Chronic thyroiditis as a favorable prognostic factor in papillary thyroid carcinoma[J]. Thyroid,1998,8(3):197-202.doi:10.1089/thy.1998.8.197.
[27] Loh KC,Greenspan FS,Dong F,et al. Influence of lymphocytic thyroiditis on the prognostic outcome of patients w ith papillary thyroid carcinoma[J]. J Clin Endocrinol M etab,1999,84(2):458-463. doi:10. 1210/jcem.84.2.5443.
[28]石臣磊,石铁锋,吴佳奇,等.桥本甲状腺炎对乳头状甲状腺癌颈淋巴结转移的影响[J].中国普通外科杂志,2013,22(5):580-584. doi:10. 7659/j. issn. 1005-6947.2013.05.010.SHI Chenlei,SHI Tiefeng,WU Jiaqi,et al. Does Hashimoto's thyroiditis have an influence on lymph node metastasis of papillary thyroid carcinoma?[J]. Chinese Journal of General Surgery,2013,22(5):580-584. doi:10.7659/j.issn.1005-6947.2013.05.010.