甲状腺乳头状癌术中喉前及气管前淋巴结联合冷冻病理检测的临床价值
|
摘要
目的:探讨甲状腺乳头状癌(PTC)术中喉前淋巴结(DLN)及气管前淋巴结(PLN)联合冷冻病理检测的临床价值。方法:收集2015年1月—2016年12月昆明医科大学第二附属医院甲状腺乳腺外科术前经细针穿刺活检明确诊断并接受首次手术治疗的245例PTC患者的临床资料,患者均行DLN与PLN术中冷冻病理检测,并根据DLN与PLN转移情况选择手术方式。结果:245例患者术中冷冻病理均发现DLN与PLN,淋巴结数目2～11枚,126例(51.43%)发现DLN与PLN转移。术后病检气管旁淋巴结转移165例,侧颈区淋巴结转移62例。76例行单侧腺叶及峡部全切+患侧中央区淋巴结清扫,42例行全甲状腺切除+患侧中央区淋巴结清扫,101例行全甲状腺切除+双侧中央区淋巴结清扫,26例行全甲状腺切除+双侧中央区淋巴结清扫+侧颈区清扫。统计分析表明包膜侵犯是DLN与PLN转移的独立风险因素(OR=9.62,P=0.021)。结论:DLN与PLN可作为PTC前哨淋巴结,其转移与气管旁淋巴结转移、侧颈区淋巴结转移密切相关。术中行DLN与PLN联合冷冻病理检测有助于选择最佳手术方式,实现对PTC更加精准的治疗。
Objective: To investigate the clinical value of intraoperative frozen section analysis for prelaryngeal/Delphian lymph nodes(DLN) and pretracheal lymph nodes(PLN) in surgery for papillary thyroid carcinoma(PTC). Methods: The clinical data of 245 patients with PTC diagnosed by preoperative fine-needle aspiration biopsy and accepted the first-time surgery in the Department of Thyroid and Breast Surgery of the Second Affiliated Hospital, Kunming Medical University from January 2015 to December 2016 were collected. All patients underwent intraoperative frozen section examination for both DLN and PLN, and then surgical procedures were decided according to the metastasis status of the DLN and PLN.Results: DLN and PLN were detected in the intraoperative frozen sections for all the 245 patients, with the number of lymph nodes ranged from 2 to 11, and DLN and PLN metastases were found in 126 patients(51.43%). Paratracheal lymph node metastases were found in 165 patients, and lateral cervical metastases were found in 26 patients by postoperative pathological examination. Seventy-six patients underwent unilateral lobectomy with isthmusectomy plus ipsilateral central neck dissection, 42 patients underwent total thyroidectomy plus central neck dissection of the affected side, 101 patients underwent total thyroidectomy plus bilateral central neck dissection, and 26 patients underwent total thyroidectomy plus bilateral central neck dissection along with lateral neck dissection. Results of statistical analyses demonstrated that capsular invasion was an independent risk factor for DLN and PLN metastases(OR=9.62, P=0.021). Conclusion: DLN and PLN can be considered as the sentinel lymph nodes of PTC, and their metastases are closely related to paratracheal lymph node and lateral cervical lymph node metastases. The intraoperative frozen section examination for DLN and PLN will help to choose the best surgical procedure and thereby provide more precise treatment for PTC.
Objective: To investigate the clinical value of intraoperative frozen section analysis for prelaryngeal/Delphian lymph nodes(DLN) and pretracheal lymph nodes(PLN) in surgery for papillary thyroid carcinoma(PTC). Methods: The clinical data of 245 patients with PTC diagnosed by preoperative fine-needle aspiration biopsy and accepted the first-time surgery in the Department of Thyroid and Breast Surgery of the Second Affiliated Hospital, Kunming Medical University from January 2015 to December 2016 were collected. All patients underwent intraoperative frozen section examination for both DLN and PLN, and then surgical procedures were decided according to the metastasis status of the DLN and PLN.Results: DLN and PLN were detected in the intraoperative frozen sections for all the 245 patients, with the number of lymph nodes ranged from 2 to 11, and DLN and PLN metastases were found in 126 patients(51.43%). Paratracheal lymph node metastases were found in 165 patients, and lateral cervical metastases were found in 26 patients by postoperative pathological examination. Seventy-six patients underwent unilateral lobectomy with isthmusectomy plus ipsilateral central neck dissection, 42 patients underwent total thyroidectomy plus central neck dissection of the affected side, 101 patients underwent total thyroidectomy plus bilateral central neck dissection, and 26 patients underwent total thyroidectomy plus bilateral central neck dissection along with lateral neck dissection. Results of statistical analyses demonstrated that capsular invasion was an independent risk factor for DLN and PLN metastases(OR=9.62, P=0.021). Conclusion: DLN and PLN can be considered as the sentinel lymph nodes of PTC, and their metastases are closely related to paratracheal lymph node and lateral cervical lymph node metastases. The intraoperative frozen section examination for DLN and PLN will help to choose the best surgical procedure and thereby provide more precise treatment for PTC.
引文
[1]高明,魏松锋.甲状腺癌精准治疗概念下的加法与减法[J].中国肿瘤外科杂志,2017, 9(4):207-210. doi:10.3969/j.issn. 1674-4136.2017.04.001.Gao M, Wei SF. Addition and subtraction of under the concept pf precise treatment of thyroid cancer[J]. Chinese Journal of Surgical Oncology, 2017, 9(4):207-2 10. doi:10.3969/j.issn. 1674-4136.2017.04.001.
[2] Mehanna H,Al-Maqbili T, Carter B,et al. Differences in the recurrence and mortality outcomes rates of incidental and nonincidental papillary thyroid microcarcinoma:a systematic review and meta-analysis of 21 329 person-years of follow-up[J].J Clin Endocrinol Metab, 2014, 99(8):2834-2843. doi:10.1210/jc.2013-2118.
[3]高明.甲状腺癌的诊疗进展及策略[J].中华耳鼻咽喉头颈外科杂志,2010, 45(1 1):887-890. doi:10.3760/cma.j.issn. 1673-0860.2010.11.003.Gao M. Progresses and strategies in diagnosis and treatment of thyroid carcinoma[J]. Chinese Journal of Otorhinolaryngology Head and Neck Surgery 2010, 45(11):887-890. doi:10.3760/cma.j.issn. 1673-0860.2010.11.003.
[4] Iyer NG, Shaha AR, Ferlito A, et al. Delphian node metastasis in head and neck cancers--oracle or myth?[J]. J Surg Oncol, 2010,102(4):354-358. doi:10.1002/jso.21640.
[5] Iyer NG, Kumar A,Nixon IJ, et al. Incidence and significance of Delphian node metastasis in papillary thyroid cancer[J]. Ann Surg,2011, 253(5):988-991. doi:10.1097/SLA.0b013e31821219ca.
[6] Pinyi Z, Bin Z, Jianlong B, et al. Risk factors and clinical indication of metastasis to lymph nodes posterior to right recurrent laryngeal nerve in papillary thyroid carcinoma:a single-center study in China[J]. Head Neck, 2014, 36(9):1335-1342. doi:10.1002/hed.23451.
[7] Haugen BR, Alexander EK, Bible KC, et al. 2015 American Thyroid Association Management Guidelines for Adult Patients with 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.
[8] Zhao Q, Ming J, Liu C, et al. Multifocality and total tumor diameter predict central neck lymph node metastases in papillary thyroid microcarcinoma[J]. Ann Surg Oncol, 2013, 20(3):746-752. doi:10.1245/s 10434-012-2654-2.
[9] Lim YC, Choi EC, Yoon YH, et al. Central lymph node metastases in unilateral papillary thyroid microcarcinoma[J]. Br J Surg, 2009,96(3):253-257. doi:10.1002/bjs.6484.
[10]翟宝伟,高庆军,赵代伟.甲状腺微小乳头状癌颈部淋巴结转移的危险因素分析[J].中国普通外科杂志,2016, 25(11):1573-1579.doi:10.3978/j.issn. 1005-6947.2016.11.009.Zhai BW, Gao QJ, Zhao DW. Analysis of risk factors for cervical lymph node metastases in papillary thyroid microcarcinoma[J].Chinese Journal of General Surgery, 2016, 25(11):1573-1579.doi:10.3978/j.issn. 1005-6947.2016.11.009.
[11]陈征,吕晶.甲状腺微小癌颈淋巴结转移危险因素分析及手术范围的探讨[J].中国普通外科杂志,2016, 25(5):659-664.doi:10.3978/j.issn. 1005-6947.2016.05.006.Chen Z, Lu J. Analysis of risk factors for cervical lymph node metastasis and the scope of surgical dissection in thyroid microcarcinoma[J]. Chinese Journal of General Surgery, 2016,25(5):659-664. doi:10.3978/j.issn. 1005-6947.2016.05.006.
[12]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].中华内分泌代谢杂志,2012, 28(10):779-797.do i:10.3760/c ma.j. is sn. 1000-6699.2012.10.002.Chinese Society of Endocrinology, Endocrine Group of Society of Surgery of Chinese Medical Association, Committee of Head and Neck Oncology, Chinese Anti-Cancer Association, et al. Guidelines for diagnosis and treatment of thyroid nodules and differentiated thyroid carcinoma[J]. Chinese Journal of Endocrinologyand Metabolism, 2012, 28(10):779-797. doi:10.3760/cma.j.issn. 1000-6699.2012.10.002.
[13]郑荆洲,童传明,吴高松,等.微小甲状腺癌合并桥本氏甲状腺炎的临床病理及颈淋巴结转移特征[J].中国普通外科杂志,2014,23(11):1557-1560. doi:10.7659/j.issn. 1005-6947.2014.11.020.Zheng JZ, Tong CM, Wu GS, et al. Clinicopathologic and cervical lymph node metastatic features in patients with papillary thyroid microcarcinoma and concomitant Hashimoto's thyroiditis[J].Chinese Journal of General Surgery, 2014, 23(11):1557-1560.doi:10.7659/j.issn. 1005-6947.2014.11.020.
[14]李宇杰,黄小娥,周小栋.预防性中央区淋巴结清扫与甲状腺乳头状癌局部复发的Meta分析[J].中国普通外科杂志,2013,22(5):608-612. doi:10.7659/j.issn. 1005-6947.2013.05.016.Li YJ, Huang XE, Zhou XD. Prophylactic central neck dissection and local recurrence in papillary thyroid cancer:a Meta-analysis[J].Chinese Journal of General Surgery, 2013, 22(5):608-612.doi:10.7659/j.issn. 1005-6947.2013.05.016.
[15]林晓东,陈晓意,黄宝骏,等.预防性颈中央区淋巴结清扫对cN0分化型甲状腺癌分期与复发危险度分层的意义[J].中国普通外科杂志,2015, 24(5):633-637. doi:10.3978/j.issn.1005-6947.2015.05.003.Lin XD, Chen XY, Huang BJ, et al. Significance of prophylactic central lymph node dissection in tumor stage classification and risk stratification of recurrence for cNO differentiated thyroid carcinoma[J]. Chinese Journal of General Surgery, 2015, 24(5):633-637. doi:10.3978/j.issn. 1005-6947.2015.05.003.
[16] Glover AR, Gundara JS,Norlen O,等.预防性中央区淋巴结清扫治疗甲状腺乳头状癌的利与弊[J].中国普通外科杂志,2014,23(5):567-574. doi:10.7659/j.issn. 1005-6947.2014.05.001.Glover AR, Gundara JS, Norlen O, et al. The pros and cons of prophylactic central neck dissection in papillary thyroid carcinoma[J]. Chinese Journal of General Surgery, 2014, 23(5):567-574. doi:10.7659/j.issn. 1005-6947.2014.05.001.
[17]朱精强,雷建勇,姜可.甲状腺微小乳头状癌淋巴结转移特点及处理策略[J].中国普外基础与临床杂志,2016, 23(10):1160-1165.Zhu JQ, Lei JY, Jiang K. Features of lymphatic metastases in papillary thyroid microcarcinoma and the treatment strategies[J].Chinese Journal of Bases and Clinics In General Surgery, 2016,23(10):1160-1165.
[18]高庆军,王南鹏,周彦,等.甲状腺乳头状癌颈部淋巴结转移规律及影响因素分析[J].中国普外基础与临床杂志,2013, 20(3):303-309.Gao QJ, Wang NP, Zhou Y, et al. Metastatic Pattern and Influencing Factors of Cervical Lymph Node in Papillary Thyroid Carcinoma[J].Chinese Journal of Bases and Clinics In General Surgery, 2013,20(3):303-309.
[19] Isaacs JD, Lundgren CI, Sidhu SB, et al. The Delphian lymph node in thyroid cancer[J]. Ann Surg, 2008, 247(3):477-482. doi:10.1097/SLA.0b013e31815efdc4.
[20] Isaacs JD, McMullen TP, Sidhu SB, et al. Predictive value of the Delphian and levelⅥnodes in papillary thyroid cancer[J]. ANZ J Surg, 2010, 80(11):834-838. doi:10.1111/j.1445-2197.2010.05334.x.
[21] Shaha AR. Thyroid cancer and Delphian node[J]. Eur Arch Otorhinolaryngol, 2013, 270(9):2381-2382. doi:10.1007/s00405-013-2477-1.
[22] Ito Y, Jikuzono T, Higashiyama T, et al. Clinical significance of lymph node metastasis of thyroid papillary carcinoma located in one lobe[J]. World J Surg, 2006, 30(10):1821-1828. doi:10.1007/s00268-006-0211-5.
[2] Mehanna H,Al-Maqbili T, Carter B,et al. Differences in the recurrence and mortality outcomes rates of incidental and nonincidental papillary thyroid microcarcinoma:a systematic review and meta-analysis of 21 329 person-years of follow-up[J].J Clin Endocrinol Metab, 2014, 99(8):2834-2843. doi:10.1210/jc.2013-2118.
[3]高明.甲状腺癌的诊疗进展及策略[J].中华耳鼻咽喉头颈外科杂志,2010, 45(1 1):887-890. doi:10.3760/cma.j.issn. 1673-0860.2010.11.003.Gao M. Progresses and strategies in diagnosis and treatment of thyroid carcinoma[J]. Chinese Journal of Otorhinolaryngology Head and Neck Surgery 2010, 45(11):887-890. doi:10.3760/cma.j.issn. 1673-0860.2010.11.003.
[4] Iyer NG, Shaha AR, Ferlito A, et al. Delphian node metastasis in head and neck cancers--oracle or myth?[J]. J Surg Oncol, 2010,102(4):354-358. doi:10.1002/jso.21640.
[5] Iyer NG, Kumar A,Nixon IJ, et al. Incidence and significance of Delphian node metastasis in papillary thyroid cancer[J]. Ann Surg,2011, 253(5):988-991. doi:10.1097/SLA.0b013e31821219ca.
[6] Pinyi Z, Bin Z, Jianlong B, et al. Risk factors and clinical indication of metastasis to lymph nodes posterior to right recurrent laryngeal nerve in papillary thyroid carcinoma:a single-center study in China[J]. Head Neck, 2014, 36(9):1335-1342. doi:10.1002/hed.23451.
[7] Haugen BR, Alexander EK, Bible KC, et al. 2015 American Thyroid Association Management Guidelines for Adult Patients with 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.
[8] Zhao Q, Ming J, Liu C, et al. Multifocality and total tumor diameter predict central neck lymph node metastases in papillary thyroid microcarcinoma[J]. Ann Surg Oncol, 2013, 20(3):746-752. doi:10.1245/s 10434-012-2654-2.
[9] Lim YC, Choi EC, Yoon YH, et al. Central lymph node metastases in unilateral papillary thyroid microcarcinoma[J]. Br J Surg, 2009,96(3):253-257. doi:10.1002/bjs.6484.
[10]翟宝伟,高庆军,赵代伟.甲状腺微小乳头状癌颈部淋巴结转移的危险因素分析[J].中国普通外科杂志,2016, 25(11):1573-1579.doi:10.3978/j.issn. 1005-6947.2016.11.009.Zhai BW, Gao QJ, Zhao DW. Analysis of risk factors for cervical lymph node metastases in papillary thyroid microcarcinoma[J].Chinese Journal of General Surgery, 2016, 25(11):1573-1579.doi:10.3978/j.issn. 1005-6947.2016.11.009.
[11]陈征,吕晶.甲状腺微小癌颈淋巴结转移危险因素分析及手术范围的探讨[J].中国普通外科杂志,2016, 25(5):659-664.doi:10.3978/j.issn. 1005-6947.2016.05.006.Chen Z, Lu J. Analysis of risk factors for cervical lymph node metastasis and the scope of surgical dissection in thyroid microcarcinoma[J]. Chinese Journal of General Surgery, 2016,25(5):659-664. doi:10.3978/j.issn. 1005-6947.2016.05.006.
[12]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].中华内分泌代谢杂志,2012, 28(10):779-797.do i:10.3760/c ma.j. is sn. 1000-6699.2012.10.002.Chinese Society of Endocrinology, Endocrine Group of Society of Surgery of Chinese Medical Association, Committee of Head and Neck Oncology, Chinese Anti-Cancer Association, et al. Guidelines for diagnosis and treatment of thyroid nodules and differentiated thyroid carcinoma[J]. Chinese Journal of Endocrinologyand Metabolism, 2012, 28(10):779-797. doi:10.3760/cma.j.issn. 1000-6699.2012.10.002.
[13]郑荆洲,童传明,吴高松,等.微小甲状腺癌合并桥本氏甲状腺炎的临床病理及颈淋巴结转移特征[J].中国普通外科杂志,2014,23(11):1557-1560. doi:10.7659/j.issn. 1005-6947.2014.11.020.Zheng JZ, Tong CM, Wu GS, et al. Clinicopathologic and cervical lymph node metastatic features in patients with papillary thyroid microcarcinoma and concomitant Hashimoto's thyroiditis[J].Chinese Journal of General Surgery, 2014, 23(11):1557-1560.doi:10.7659/j.issn. 1005-6947.2014.11.020.
[14]李宇杰,黄小娥,周小栋.预防性中央区淋巴结清扫与甲状腺乳头状癌局部复发的Meta分析[J].中国普通外科杂志,2013,22(5):608-612. doi:10.7659/j.issn. 1005-6947.2013.05.016.Li YJ, Huang XE, Zhou XD. Prophylactic central neck dissection and local recurrence in papillary thyroid cancer:a Meta-analysis[J].Chinese Journal of General Surgery, 2013, 22(5):608-612.doi:10.7659/j.issn. 1005-6947.2013.05.016.
[15]林晓东,陈晓意,黄宝骏,等.预防性颈中央区淋巴结清扫对cN0分化型甲状腺癌分期与复发危险度分层的意义[J].中国普通外科杂志,2015, 24(5):633-637. doi:10.3978/j.issn.1005-6947.2015.05.003.Lin XD, Chen XY, Huang BJ, et al. Significance of prophylactic central lymph node dissection in tumor stage classification and risk stratification of recurrence for cNO differentiated thyroid carcinoma[J]. Chinese Journal of General Surgery, 2015, 24(5):633-637. doi:10.3978/j.issn. 1005-6947.2015.05.003.
[16] Glover AR, Gundara JS,Norlen O,等.预防性中央区淋巴结清扫治疗甲状腺乳头状癌的利与弊[J].中国普通外科杂志,2014,23(5):567-574. doi:10.7659/j.issn. 1005-6947.2014.05.001.Glover AR, Gundara JS, Norlen O, et al. The pros and cons of prophylactic central neck dissection in papillary thyroid carcinoma[J]. Chinese Journal of General Surgery, 2014, 23(5):567-574. doi:10.7659/j.issn. 1005-6947.2014.05.001.
[17]朱精强,雷建勇,姜可.甲状腺微小乳头状癌淋巴结转移特点及处理策略[J].中国普外基础与临床杂志,2016, 23(10):1160-1165.Zhu JQ, Lei JY, Jiang K. Features of lymphatic metastases in papillary thyroid microcarcinoma and the treatment strategies[J].Chinese Journal of Bases and Clinics In General Surgery, 2016,23(10):1160-1165.
[18]高庆军,王南鹏,周彦,等.甲状腺乳头状癌颈部淋巴结转移规律及影响因素分析[J].中国普外基础与临床杂志,2013, 20(3):303-309.Gao QJ, Wang NP, Zhou Y, et al. Metastatic Pattern and Influencing Factors of Cervical Lymph Node in Papillary Thyroid Carcinoma[J].Chinese Journal of Bases and Clinics In General Surgery, 2013,20(3):303-309.
[19] Isaacs JD, Lundgren CI, Sidhu SB, et al. The Delphian lymph node in thyroid cancer[J]. Ann Surg, 2008, 247(3):477-482. doi:10.1097/SLA.0b013e31815efdc4.
[20] Isaacs JD, McMullen TP, Sidhu SB, et al. Predictive value of the Delphian and levelⅥnodes in papillary thyroid cancer[J]. ANZ J Surg, 2010, 80(11):834-838. doi:10.1111/j.1445-2197.2010.05334.x.
[21] Shaha AR. Thyroid cancer and Delphian node[J]. Eur Arch Otorhinolaryngol, 2013, 270(9):2381-2382. doi:10.1007/s00405-013-2477-1.
[22] Ito Y, Jikuzono T, Higashiyama T, et al. Clinical significance of lymph node metastasis of thyroid papillary carcinoma located in one lobe[J]. World J Surg, 2006, 30(10):1821-1828. doi:10.1007/s00268-006-0211-5.