术前超声评估甲状腺乳头状癌N分期及不同N分期的影响因素
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摘要
目的探讨术前超声对人甲状腺乳头状癌N分期的评估价值及其不同N分期的相关影响因素。方法回顾性分析358例经手术及病理结果证实的乳头状癌患者的临床资料,以美国癌症联合委员会(AJCC)甲状腺癌分期系统(第8版)作为标准,将358例病例分为pN0期(无淋巴结转移)、pN1a期(中央淋巴结转移)和pN1b期(侧区淋巴结转移)。比较不同N分期患者的临床资料(性别、年龄、肿瘤大小、是否多灶、包膜外侵犯、桥本甲状腺炎、BRAF突变),并采用Kappa一致性检验分析超声评估N分期与实际病理N分期的一致性。结果 358例患者均行颈部淋巴结清扫,其中pN0期196例,pN1a期129例,pN1b期33例。术前超声评估N分期与实际病理结果分期基本一致(Kappa=0.320,P <0.01);在pN0期和pN1期(pN1a期+pN1b期)2组之间,患者的年龄、肿瘤大小及BRAF突变比较差异有统计学意义(χ~2=10.214、4.818、7.126,P均<0.05)。pN1b期与非pN1b期(pN0期+pN1期)2组之间,患者的肿瘤大小、多灶癌、包膜外侵犯比较差异有统计学意义(χ~2=19.638、14.193、9.330,P均<0.01)。结论术前超声对评估甲状腺乳头状癌N分期具有一定价值,可为临床提供诊疗支持。年龄<55岁、肿瘤> 1 cm及BRAF阳性患者更倾向于发展为pN1期;在pN1b期中,肿瘤> 1 cm、多灶癌和包膜外侵犯更为常见。
Objective To evaluate the value of preoperative ultrasound in evaluating N stage of human papillary thyroid carcinoma and its predictive factors of lymph nodes metastasis. Methods All358 patients with papillary carcinoma confirmed by surgery and pathology were retrospectively analyzed.The American Joint Committee on Cancer(AJCC) thyroid cancer staging system(8 th edition) was used as a standard, and postoperative pathological results were used as the golden criteria, 358 cases were divided into pN0 stage group(no lymph node metastasis), pN1 a stage group(central lymph node metastasis), and pN1 b stage group(lateral lymph node metastasis). The clinical predictive factors between different groups were compared(gender, age, tumor size, multifocal, extramural invasion, hashimoto thyroiditis, BRAF mutation),and the consistency of preoperative sonographic N stage and actual pathological N stage were analyzed.We try to find the capacity of the evaluation the N stage of papillary carcinoma by preoperative ultrasound examination, and the clinical predictive factors that may affect N stage. Results All 358 patients underwent cervical lymph node dissection. Results showed 196 patients in pN0 group, 129 patients in pN1 a group,and 33 patients in pN1 b group. The N stage evaluated by preoperative ultrasound was basically consistent with the actual pathological N stage(Kappa=0.320, P < 0.01). Between the pN0 group and the pN1 group,the age, the tumor size and the BRAF mutuation was significantly different(χ~2=10.214, 4.818 and 7.126,P < 0.05 for all). Between the pN1 b group and the non-pN1 b group(pN0 + pN1 group), tumor size,multifocality of tumor, and extrathyroid extention(ETE) were significantly different between these groups(χ~2=10.638, 14.193 and 9.330, P < 0.01 for all). Conclusion Preoperative ultrasound is useful in evaluating the N stage of thyroid papillary carcinoma, which can provide clinical support for diagnosis and treatment.Patients < 55 years of age, with tumor > 1 cm and BRAF mutation positive are more likely to develop to pN1 phase. In the pN1 b stage, tumors > 1 cm, multifocal cancer and capsular invasion are more common.
Objective To evaluate the value of preoperative ultrasound in evaluating N stage of human papillary thyroid carcinoma and its predictive factors of lymph nodes metastasis. Methods All358 patients with papillary carcinoma confirmed by surgery and pathology were retrospectively analyzed.The American Joint Committee on Cancer(AJCC) thyroid cancer staging system(8 th edition) was used as a standard, and postoperative pathological results were used as the golden criteria, 358 cases were divided into pN0 stage group(no lymph node metastasis), pN1 a stage group(central lymph node metastasis), and pN1 b stage group(lateral lymph node metastasis). The clinical predictive factors between different groups were compared(gender, age, tumor size, multifocal, extramural invasion, hashimoto thyroiditis, BRAF mutation),and the consistency of preoperative sonographic N stage and actual pathological N stage were analyzed.We try to find the capacity of the evaluation the N stage of papillary carcinoma by preoperative ultrasound examination, and the clinical predictive factors that may affect N stage. Results All 358 patients underwent cervical lymph node dissection. Results showed 196 patients in pN0 group, 129 patients in pN1 a group,and 33 patients in pN1 b group. The N stage evaluated by preoperative ultrasound was basically consistent with the actual pathological N stage(Kappa=0.320, P < 0.01). Between the pN0 group and the pN1 group,the age, the tumor size and the BRAF mutuation was significantly different(χ~2=10.214, 4.818 and 7.126,P < 0.05 for all). Between the pN1 b group and the non-pN1 b group(pN0 + pN1 group), tumor size,multifocality of tumor, and extrathyroid extention(ETE) were significantly different between these groups(χ~2=10.638, 14.193 and 9.330, P < 0.01 for all). Conclusion Preoperative ultrasound is useful in evaluating the N stage of thyroid papillary carcinoma, which can provide clinical support for diagnosis and treatment.Patients < 55 years of age, with tumor > 1 cm and BRAF mutation positive are more likely to develop to pN1 phase. In the pN1 b stage, tumors > 1 cm, multifocal cancer and capsular invasion are more common.
引文
1卢伟,杨剑,金鑫荔,杨超.经导管动脉栓塞联合阿帕替尼治疗甲状腺未分化癌二例[J/CD].中华介入放射学电子杂志,2017,5(2):120-122.
2 Siegel RL,Miller KD,Fedewa SA,et al.Colorectal cancer statistics,2017[J].CA Cancer J Clin,2017,67(3):177-193.
3 Eskander A,Merdad M,Freeman JL,et al.Pattern of spread to the lateral neck in metastatic well-differentiated thyroid cancer:a systematic review and meta-analysis[J].Thyroid,2013,23(5):583-592.
4 Roh JL,Kim JM,Park CI.Lateral cervical lymph node metastases from papillary thyroid carcinoma:pattern of nodal metastases and optimal strategy for neck dissection[J].Ann Surg Oncol,2008,15(4):1177-1182.
5孙威,贺亮,张浩.美国癌症联合委员会甲状腺癌分期系统(第8版)更新解读[J].中国实用外科杂志,2017,37(3):255-258.
6 Trzebińska A,Dobruch-Sobczak K,Jakubowski W,et al.Standards of the Polish Ultrasound Society-update.Ultrasound examination of thyroid gland and ultrasound-guided thyroid biopsy[J].J Ultrason,2014,14(56):49-60.
7 Yoon JH,Kim EK,Kwak JY,et al.Sonographic features and ultrasonography-guided fine-needle aspiration of metastases to the thyroid gland[J].Ultrasonography,2014,33(1):40-48.
8 Pacini F.Management of papillary thyroid microcarcinoma:primum non nocere[J].J Clin Endocrinol Metab,2013,98(4):1391-1393.
9 Wada N,Duh QY,Sugino K,et al.Lymph node metastasis from 259papillary thyroid microcarcinomas:frequency,pattern of occurrence and recurrence,and optimal strategy for neck dissection[J].Ann Surg,2003,237(3):399-407.
10 Lee SH,Roh JL,Gong G,et al.Risk factors for recurrence after treatment of N1b papillary thyroid carcinoma[J].Ann Surg,2018 Feb16.doi:10.1097/SLA.0000000000002710.
11 Kuna SK,BracicⅠ,Tesic V,et al.Ultrasonographic differentiation of benign from malignant neck lymphadenopathy in thyroid cancer[J].J Ultrasound Med,2006,25(12):1531-1537.
12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/CD].中华医学超声杂志(电子版),2014,11(11):52-56.
13 Ito Y,Tomoda C,Uruno T,et al.Clinical significance of metastasis to the central compartment from papillary microcarcinoma of the thyroid[J].World J Surg,2006,30(1):91-99.
14 Wu LM,Gu HY,Qu XH,et al.The accuracy of ultrasonography in the preoperative diagnosis of cervical lymph node metastasis in patients with papillary thyroid carcinoma:A meta-analysis[J].Eur J Radiol,2012,81(8):1798-1805.
15 Ito Y,Tomoda C,Uruno T,et al.Ultrasonographically and anatomopathologically detectable node metastases in the lateral compartment as indicators of worse relapse-free survival in patients with papillary thyroid carcinoma[J].World J Surg,2005,29(7):917-920.
16 Jonklaas J,Nogueras-Gonzalez G,Munsell M,et al.The impact of age and gender on papillary thyroid cancer survival[J].J Clin Endocrinol Metab,2012,97(6):E878-E887.
17 Ito Y,Miyauchi A,Kihara M,et al.Relationship between prognosis of papillary thyroid carcinoma patient and age:a retrospective singleinstitution study[J].Endocr J,2012,59(5):399-405.
18 Hu D,Zhou J,He W,et al.Risk factors of lateral lymph node metastasis in cN0 papillary thyroid carcinoma[J].World J Surg Oncol,2018,16(1):30.
19 Zhan WW,Zhou P,Zhou JQ,et al.Differences in sonographic features of papillary thyroid carcinoma between neck lymph node metastatic and nonmetastatic groups[J].J Ultrasound Med,2012,31(6):915-920.
20 Yu XM,Wan Y,Sippel RS,et al.Should all papillary thyroid microcarcinomas be aggressively treated?An analysis of 18,445cases[J].Ann Surg,2011,254(4):653-660.
21 Radowsky JS,Howard RS,Burch HB,et al.Impact of degree of extrathyroidal extension of disease on papillary thyroid cancer outcome[J].Thyroid,2014,24(2):241-244.
22 So YK,Kim MJ,Kim S,et al.Lateral lymph node metastasis in papillary thyroid carcinoma:A systematic review and meta-analysis for prevalence,risk factors,and location[J].Int J Surg,2018,50:94-103.
23 Qu H,Sun G R,Liu Y,et al.Clinical risk factors for central lymph node metastasis in papillary thyroid carcinoma:a systematic review and meta-analysis[J].Clinical Endocrinology,2014,83(1):124-132.
24 de Meer SG,Dauwan M,de Keizer B,et al.Not the number but the location of lymph nodes matters for recurrence rate and diseasefree survival in patients with differentiated thyroid cancer[J].World J Surg,2012,36(6):1262-1267.
25 Kim SK,Woo JW,Lee JH,et al.Role of BRAF V600E mutation as an indicator of the extent of thyroidectomy and lymph node dissection in conventional papillary thyroid carcinoma[J].Surgery,2015,158(6):1500-1511.
26 Wei X,Li Y,Zhang S,et al.Prediction of thyroid extracapsular extension with cervical lymph node metastases(ECE-LN)by CEUSand BRAF expression in papillary thyroid carcinoma[J].Tumour Biol,2014,35(9):8559-8564.
27 Lei J,Zhong J,Jiang K,et al.Skip lateral lymph node metastasis leaping over the central neck compartment in papillary thyroid carcinoma[J].Oncotarget,2017,8(16):27022-27033.
28 Javid M,Graham E,Malinowski J,et al.Dissection of levelsⅡthrough V is required for optimal outcomes in patients with lateral neck lymph node metastasis from papillary thyroid carcinoma[J].J Am Coll Surg,2016,222(6):1066-1073.
2 Siegel RL,Miller KD,Fedewa SA,et al.Colorectal cancer statistics,2017[J].CA Cancer J Clin,2017,67(3):177-193.
3 Eskander A,Merdad M,Freeman JL,et al.Pattern of spread to the lateral neck in metastatic well-differentiated thyroid cancer:a systematic review and meta-analysis[J].Thyroid,2013,23(5):583-592.
4 Roh JL,Kim JM,Park CI.Lateral cervical lymph node metastases from papillary thyroid carcinoma:pattern of nodal metastases and optimal strategy for neck dissection[J].Ann Surg Oncol,2008,15(4):1177-1182.
5孙威,贺亮,张浩.美国癌症联合委员会甲状腺癌分期系统(第8版)更新解读[J].中国实用外科杂志,2017,37(3):255-258.
6 Trzebińska A,Dobruch-Sobczak K,Jakubowski W,et al.Standards of the Polish Ultrasound Society-update.Ultrasound examination of thyroid gland and ultrasound-guided thyroid biopsy[J].J Ultrason,2014,14(56):49-60.
7 Yoon JH,Kim EK,Kwak JY,et al.Sonographic features and ultrasonography-guided fine-needle aspiration of metastases to the thyroid gland[J].Ultrasonography,2014,33(1):40-48.
8 Pacini F.Management of papillary thyroid microcarcinoma:primum non nocere[J].J Clin Endocrinol Metab,2013,98(4):1391-1393.
9 Wada N,Duh QY,Sugino K,et al.Lymph node metastasis from 259papillary thyroid microcarcinomas:frequency,pattern of occurrence and recurrence,and optimal strategy for neck dissection[J].Ann Surg,2003,237(3):399-407.
10 Lee SH,Roh JL,Gong G,et al.Risk factors for recurrence after treatment of N1b papillary thyroid carcinoma[J].Ann Surg,2018 Feb16.doi:10.1097/SLA.0000000000002710.
11 Kuna SK,BracicⅠ,Tesic V,et al.Ultrasonographic differentiation of benign from malignant neck lymphadenopathy in thyroid cancer[J].J Ultrasound Med,2006,25(12):1531-1537.
12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/CD].中华医学超声杂志(电子版),2014,11(11):52-56.
13 Ito Y,Tomoda C,Uruno T,et al.Clinical significance of metastasis to the central compartment from papillary microcarcinoma of the thyroid[J].World J Surg,2006,30(1):91-99.
14 Wu LM,Gu HY,Qu XH,et al.The accuracy of ultrasonography in the preoperative diagnosis of cervical lymph node metastasis in patients with papillary thyroid carcinoma:A meta-analysis[J].Eur J Radiol,2012,81(8):1798-1805.
15 Ito Y,Tomoda C,Uruno T,et al.Ultrasonographically and anatomopathologically detectable node metastases in the lateral compartment as indicators of worse relapse-free survival in patients with papillary thyroid carcinoma[J].World J Surg,2005,29(7):917-920.
16 Jonklaas J,Nogueras-Gonzalez G,Munsell M,et al.The impact of age and gender on papillary thyroid cancer survival[J].J Clin Endocrinol Metab,2012,97(6):E878-E887.
17 Ito Y,Miyauchi A,Kihara M,et al.Relationship between prognosis of papillary thyroid carcinoma patient and age:a retrospective singleinstitution study[J].Endocr J,2012,59(5):399-405.
18 Hu D,Zhou J,He W,et al.Risk factors of lateral lymph node metastasis in cN0 papillary thyroid carcinoma[J].World J Surg Oncol,2018,16(1):30.
19 Zhan WW,Zhou P,Zhou JQ,et al.Differences in sonographic features of papillary thyroid carcinoma between neck lymph node metastatic and nonmetastatic groups[J].J Ultrasound Med,2012,31(6):915-920.
20 Yu XM,Wan Y,Sippel RS,et al.Should all papillary thyroid microcarcinomas be aggressively treated?An analysis of 18,445cases[J].Ann Surg,2011,254(4):653-660.
21 Radowsky JS,Howard RS,Burch HB,et al.Impact of degree of extrathyroidal extension of disease on papillary thyroid cancer outcome[J].Thyroid,2014,24(2):241-244.
22 So YK,Kim MJ,Kim S,et al.Lateral lymph node metastasis in papillary thyroid carcinoma:A systematic review and meta-analysis for prevalence,risk factors,and location[J].Int J Surg,2018,50:94-103.
23 Qu H,Sun G R,Liu Y,et al.Clinical risk factors for central lymph node metastasis in papillary thyroid carcinoma:a systematic review and meta-analysis[J].Clinical Endocrinology,2014,83(1):124-132.
24 de Meer SG,Dauwan M,de Keizer B,et al.Not the number but the location of lymph nodes matters for recurrence rate and diseasefree survival in patients with differentiated thyroid cancer[J].World J Surg,2012,36(6):1262-1267.
25 Kim SK,Woo JW,Lee JH,et al.Role of BRAF V600E mutation as an indicator of the extent of thyroidectomy and lymph node dissection in conventional papillary thyroid carcinoma[J].Surgery,2015,158(6):1500-1511.
26 Wei X,Li Y,Zhang S,et al.Prediction of thyroid extracapsular extension with cervical lymph node metastases(ECE-LN)by CEUSand BRAF expression in papillary thyroid carcinoma[J].Tumour Biol,2014,35(9):8559-8564.
27 Lei J,Zhong J,Jiang K,et al.Skip lateral lymph node metastasis leaping over the central neck compartment in papillary thyroid carcinoma[J].Oncotarget,2017,8(16):27022-27033.
28 Javid M,Graham E,Malinowski J,et al.Dissection of levelsⅡthrough V is required for optimal outcomes in patients with lateral neck lymph node metastasis from papillary thyroid carcinoma[J].J Am Coll Surg,2016,222(6):1066-1073.