cN0T1/T2期甲状腺乳头状癌中央区淋巴结清扫范围的临床研究
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摘要
目的:分析c N0T1/T2甲状腺乳头状癌(papillary thyroid carcinoma,PTC)中央区淋巴结的转移规律,探讨其中央区淋巴结清扫的合理范围。方法:以2013年10月至2016年9月昆明医科大学第一附属医院甲状腺外科同一治疗组连续收治的c N0T1/T2期的532例PTC患者作为研究对象,所有患者均行甲状腺全切加预防性双侧中央区淋巴结清扫术。统计分析性别、年龄、原发灶肿瘤直径及病灶数目与中央区淋巴结转移的关系。结果:c N0 T1/T2期PTC患者年龄>45岁的中央区淋巴结转移(central lymph nodes,CLNs)转移率为27.0%(67/248),≤45岁的CLNs转移率为44.0%(125/284),χ2=16.584,P=0.000;女性的CLNs转移率为34.9%(150/430),男性的CLNs转移率为41.2%(42/102),χ2=1.415,P=0.234;多灶癌的CLNs转移率为40.0%(76/190),单灶癌的CLNs转移率为33.9%(116/342),χ2=2.103,P=0.147;非微小癌的CLNs转移率为50.3%(80/159),微小癌的CLNs转移率为30.0%(112/373),χ2=19.893,P=0.000;病灶数目与患侧中央区淋巴结(ipsilater central lymph nodes,Ipsi-CLNs)转移不相关(χ2=0.884,P=0.347)、单侧病灶的肿瘤直径与Ipsi-CLNs转移相关(χ2=6.648,P=0.010);病灶数目与对侧中央区淋巴结(contralateral central lymph nodes,Cont-CLNs)转移不相关(χ2=0.202,P=0.653)、单侧病灶的肿瘤直径与Cont-CLNs转移相关(χ2=17.268,P=0.000);双侧多灶癌的肿瘤直径与喉返神经后中央区淋巴结(posterior to right recurrent laryngeal nerve central lymph nodes,LNpr RLN-CLNs)转移相关,(χ2=4.260,P=0.039)、左、右单侧单灶的肿瘤直径与LN-pr RLN-CLNs转移不相关(χ2=0.166,P=0.684;χ2=3.226,P=0.072)。结论:推荐对c N0 T1/T2期甲状腺乳头状癌在有技术保障的情况下应常规行预防性中央区淋巴结清扫,合理的清扫范围推荐为:(1)单侧非微小癌和双侧多灶癌尤其年龄≤45岁者,均应行双中央区淋巴结清扫;(2)单侧单灶或多灶微小癌仅行患侧中央区清扫;(3)一般无须常规清扫右侧喉返神经后淋巴结,但对于双侧非微小癌、右侧非微小癌仍应注意右喉返神经后淋巴结的清扫。
Objective:To investigate the reasonable range of central lymph node(CLN) dissection for papillary thyroid carcinoma(PTC)in c N0 T1/T2 by analyzing the metastatic pattern of PTC in c N0 T1/T2. Methods:A total of 532 patients with PTC in c N0 T1/T2 who were consecutively admitted to the same treatment group in Department of Thyroid Surgery,The First Affiliated Hospital of Kunming Medical University,from October 2013 to September 2016 were enrolled in this study. All the patients underwent total thyroidectomy and prophylactic operation of bilateral CLN dissection. The relationship between the sex,age,diameter of primary tumor,and number of lesions and CLN metastasis was analyzed. Results:There was a significant difference in CLN metastasis rate between the patients aged >45 years and the patients aged ≤45 years(27.0%[67/248] vs. 44.0%[125/284],χ2=16.584,P=0.000)and between the patients with non-microcarcinoma and the patients with microcarcinoma(50.3%[80/159] vs. 30.0%[112/373],χ2=19.893,P=0.000). However,there was no significant difference in CLN metastasis rate between the female patients and the male patients(34.9%[150/430] vs. 41.2%[42/102],χ2=1.415,P=0.234)and between the patients with single focal carcinoma and the patients with multifocal carcinoma(33.9%[116/342] vs. 40.0%[76/190],χ2=2.103,P=0.147). Ipsilateral central lymph node(Ipsi-CLN)metastasis was not associated with the number of lesions(χ2=0.884,P=0.347),but was associated with the ipsilateral tumor diameter(χ2=6.648,P=0.010). Contralateral central lymph node metastasis was not associated with the number of lesions(χ2=0.202,P=0.653),but was associated with the contralateral tumor diameter(χ2=17.268,P=0.000). The posterior to right recurrent laryngeal nerve central lymph node(LN-pr RLN-CLN) metastasis was associated with the tumor diameter of bilateral multifocal carcinoma(χ2=4.260,P =0.039),but was not associated with the tumor diameter of left and right unilateral single focal lesion(χ2=0.166,P=0.684;χ2= 3.226,P=0.072). Conclusion:It is recommended that PTC in c N0 T1/T2 should be routinely treated with prophylactic CLN dissection in the case of technical support. The reasonable range of CLN dissection for PTC in c N0 T1/2 should be based on individual features:1)the patients with unilateral non-microcarcinoma and bilateral multifocal carcinoma should undergo bilateral CLN dissection,especially the patients aged ≤45 years;2)the patients with unilateral single or multifocal microcarcinoma should undergo Ipsi-CLN dissection;3)LN-pr RLN-CLN dissection is not necessary to do generally,but the patients with bilateral non-microcarcinoma and right non-microcarcinoma should undergo LN-pr RLN-CLN dissection.
Objective:To investigate the reasonable range of central lymph node(CLN) dissection for papillary thyroid carcinoma(PTC)in c N0 T1/T2 by analyzing the metastatic pattern of PTC in c N0 T1/T2. Methods:A total of 532 patients with PTC in c N0 T1/T2 who were consecutively admitted to the same treatment group in Department of Thyroid Surgery,The First Affiliated Hospital of Kunming Medical University,from October 2013 to September 2016 were enrolled in this study. All the patients underwent total thyroidectomy and prophylactic operation of bilateral CLN dissection. The relationship between the sex,age,diameter of primary tumor,and number of lesions and CLN metastasis was analyzed. Results:There was a significant difference in CLN metastasis rate between the patients aged >45 years and the patients aged ≤45 years(27.0%[67/248] vs. 44.0%[125/284],χ2=16.584,P=0.000)and between the patients with non-microcarcinoma and the patients with microcarcinoma(50.3%[80/159] vs. 30.0%[112/373],χ2=19.893,P=0.000). However,there was no significant difference in CLN metastasis rate between the female patients and the male patients(34.9%[150/430] vs. 41.2%[42/102],χ2=1.415,P=0.234)and between the patients with single focal carcinoma and the patients with multifocal carcinoma(33.9%[116/342] vs. 40.0%[76/190],χ2=2.103,P=0.147). Ipsilateral central lymph node(Ipsi-CLN)metastasis was not associated with the number of lesions(χ2=0.884,P=0.347),but was associated with the ipsilateral tumor diameter(χ2=6.648,P=0.010). Contralateral central lymph node metastasis was not associated with the number of lesions(χ2=0.202,P=0.653),but was associated with the contralateral tumor diameter(χ2=17.268,P=0.000). The posterior to right recurrent laryngeal nerve central lymph node(LN-pr RLN-CLN) metastasis was associated with the tumor diameter of bilateral multifocal carcinoma(χ2=4.260,P =0.039),but was not associated with the tumor diameter of left and right unilateral single focal lesion(χ2=0.166,P=0.684;χ2= 3.226,P=0.072). Conclusion:It is recommended that PTC in c N0 T1/T2 should be routinely treated with prophylactic CLN dissection in the case of technical support. The reasonable range of CLN dissection for PTC in c N0 T1/2 should be based on individual features:1)the patients with unilateral non-microcarcinoma and bilateral multifocal carcinoma should undergo bilateral CLN dissection,especially the patients aged ≤45 years;2)the patients with unilateral single or multifocal microcarcinoma should undergo Ipsi-CLN dissection;3)LN-pr RLN-CLN dissection is not necessary to do generally,but the patients with bilateral non-microcarcinoma and right non-microcarcinoma should undergo LN-pr RLN-CLN dissection.
引文
[1]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.
[2]Pitoia F,Miyauchi A.2015 American Thyroid Association Guidelines for thyroid nodules and differentiated thyroid cancer and their implementation in various care settings[J].Thyroid,2016,26(2):319-321.
[3]高明.甲状腺结节和分化型甲状腺癌诊治指南[J].中国肿瘤临床,2012,28(17):1249-1272.
[4]Sun W,Lan X,Zhang H,et al.Risk factors for central lymph node metastasis in c N0 papillary thyroid carcinoma:a systematic review and meta-analysis[J].PLo S One,2015,10(10):e9013-9021.
[5]朱精强.甲状腺手术中甲状旁腺保护专家共识[J].中国实用外科杂志,2015,35(7):731-736.
[6]American Thyroid Association Surgery Working Group,American Association of Endocrine Surgeons,American Academy of Otolaryngology-Head and Neck Surgery,er al.Consensus statement on the terminology and classification of central neck dissection for thyroid cancer[J].Thyroid,2009,19(11):1153-1158.
[7]Cooper DS,Doherty GM,Haugen BR,et al.Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer[J].Thyroid,2009,19(11):1167-1214.
[8]王卓颖.甲状腺微小癌中央区淋巴结清扫临床价值[J].中国实用外科杂志,2016,36(5):508-511.
[9]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 Metab,2015,100(4):1316-1324.
[10]钱军,马云海,苏艳军,等.甲状腺乳头状癌中央区淋巴结清扫范围的合理选择[J].中国肿瘤,2015,24(6):444-447.
[11]Sancho JJ,Lennard TW,Paunovic I,et al.Prophylactic central neck disection in papillary thyroid cancer:a consensus report of the European Society of Endocrine Surgeons(ESES)[J].Langenbecks Arch Surg,2014,399(2):155-163.
[12]Zhang L,Wei WJ,Ji QH,et al.Risk factors for neck nodal metastasisin papillary thyroid microcarcinoma:a study of 1066 patients[J].J Clin Endocrinol Metab,2012,97(4):1250-1257.
[13]刘文,程若川,苏艳军,等.2015版美国甲状腺协会指南c N0甲状腺乳头状癌手术方案合理性分析[J].中国实用外科杂志,2017,37(5):568-571.
[14]Mulla M,Schulte KM.Central cervical lymph node metastases in papillary thyroid cancer:a systematic review of imaging-guided and prophylactic removal of the central compartment[J].Clin Endocrinol(Oxf),2012,76(1):131-136.
[15]杭家伊,王兆霞.甲状腺癌术后患者自我管理效能水平及影响因素分析[J].中国耳鼻咽喉颅底外科杂志,2017,24(2):67-70.
[16]Xue S,Wang P,Liu J,et al.Prophylactic central lymph node dissection in c N0 patients with papillary thyroid carcinoma:a retrospective study in China[J].Asian J Surg,2015[Epub ahead of print].DOI:10.1016/j.asjsur.2015.03.015.
[17]Applewhite MK,James BC,Kaplan SP,et al.Quality of life in thyroid cancer is similar to that of other cancers with worse survival[J].World Journal of Surgery,2016,40(3):551-561.
[18]Aschebrook-Kilfoy B,James B,Nagar S,et al.Risk factors for decreased quality of life in thyroid cancer survivors:initial findings from the North American thyroid cancer survivorship study[J].Thyroid,2015,25(12):1313-1321.
[19]中国抗癌协会甲状腺癌专业委员会.甲状腺微小乳头状癌诊断与治疗中国专家共识(2016版)[J].中国肿瘤临床,2016,43(10):405-411.
[20]程若川.2015年版较2009年版ATA指南对甲状腺乳头状癌的手术治疗变化及解读[J].中国普通外科基础与临床杂志,2016,23(10):1166-1168.
[21]Lundgren CI,Hall P,Dickman PW,et al.Clinically significant prognostic factors for differentiated thyroid carcinoma:a populationbased,nested case-control study[J].Cancer,2006,106(3):524-531.
[22]Shi JH,Xu YY,Pan QZ,et al.The value of combined application of ultrasound-guided fine needle aspiration cytology and thyroglobulin measurement for the diagnosis of cervical lymph node metastases from thyroid cancer[J].Pak J Med Sci,2015,31(5):1152-1155.
[23]王卓颖.规范的甲状腺癌颈部淋巴结清扫是降低复发的关键[J].外科理论与实践,2016,21(4):300-302.
[2]Pitoia F,Miyauchi A.2015 American Thyroid Association Guidelines for thyroid nodules and differentiated thyroid cancer and their implementation in various care settings[J].Thyroid,2016,26(2):319-321.
[3]高明.甲状腺结节和分化型甲状腺癌诊治指南[J].中国肿瘤临床,2012,28(17):1249-1272.
[4]Sun W,Lan X,Zhang H,et al.Risk factors for central lymph node metastasis in c N0 papillary thyroid carcinoma:a systematic review and meta-analysis[J].PLo S One,2015,10(10):e9013-9021.
[5]朱精强.甲状腺手术中甲状旁腺保护专家共识[J].中国实用外科杂志,2015,35(7):731-736.
[6]American Thyroid Association Surgery Working Group,American Association of Endocrine Surgeons,American Academy of Otolaryngology-Head and Neck Surgery,er al.Consensus statement on the terminology and classification of central neck dissection for thyroid cancer[J].Thyroid,2009,19(11):1153-1158.
[7]Cooper DS,Doherty GM,Haugen BR,et al.Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer[J].Thyroid,2009,19(11):1167-1214.
[8]王卓颖.甲状腺微小癌中央区淋巴结清扫临床价值[J].中国实用外科杂志,2016,36(5):508-511.
[9]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 Metab,2015,100(4):1316-1324.
[10]钱军,马云海,苏艳军,等.甲状腺乳头状癌中央区淋巴结清扫范围的合理选择[J].中国肿瘤,2015,24(6):444-447.
[11]Sancho JJ,Lennard TW,Paunovic I,et al.Prophylactic central neck disection in papillary thyroid cancer:a consensus report of the European Society of Endocrine Surgeons(ESES)[J].Langenbecks Arch Surg,2014,399(2):155-163.
[12]Zhang L,Wei WJ,Ji QH,et al.Risk factors for neck nodal metastasisin papillary thyroid microcarcinoma:a study of 1066 patients[J].J Clin Endocrinol Metab,2012,97(4):1250-1257.
[13]刘文,程若川,苏艳军,等.2015版美国甲状腺协会指南c N0甲状腺乳头状癌手术方案合理性分析[J].中国实用外科杂志,2017,37(5):568-571.
[14]Mulla M,Schulte KM.Central cervical lymph node metastases in papillary thyroid cancer:a systematic review of imaging-guided and prophylactic removal of the central compartment[J].Clin Endocrinol(Oxf),2012,76(1):131-136.
[15]杭家伊,王兆霞.甲状腺癌术后患者自我管理效能水平及影响因素分析[J].中国耳鼻咽喉颅底外科杂志,2017,24(2):67-70.
[16]Xue S,Wang P,Liu J,et al.Prophylactic central lymph node dissection in c N0 patients with papillary thyroid carcinoma:a retrospective study in China[J].Asian J Surg,2015[Epub ahead of print].DOI:10.1016/j.asjsur.2015.03.015.
[17]Applewhite MK,James BC,Kaplan SP,et al.Quality of life in thyroid cancer is similar to that of other cancers with worse survival[J].World Journal of Surgery,2016,40(3):551-561.
[18]Aschebrook-Kilfoy B,James B,Nagar S,et al.Risk factors for decreased quality of life in thyroid cancer survivors:initial findings from the North American thyroid cancer survivorship study[J].Thyroid,2015,25(12):1313-1321.
[19]中国抗癌协会甲状腺癌专业委员会.甲状腺微小乳头状癌诊断与治疗中国专家共识(2016版)[J].中国肿瘤临床,2016,43(10):405-411.
[20]程若川.2015年版较2009年版ATA指南对甲状腺乳头状癌的手术治疗变化及解读[J].中国普通外科基础与临床杂志,2016,23(10):1166-1168.
[21]Lundgren CI,Hall P,Dickman PW,et al.Clinically significant prognostic factors for differentiated thyroid carcinoma:a populationbased,nested case-control study[J].Cancer,2006,106(3):524-531.
[22]Shi JH,Xu YY,Pan QZ,et al.The value of combined application of ultrasound-guided fine needle aspiration cytology and thyroglobulin measurement for the diagnosis of cervical lymph node metastases from thyroid cancer[J].Pak J Med Sci,2015,31(5):1152-1155.
[23]王卓颖.规范的甲状腺癌颈部淋巴结清扫是降低复发的关键[J].外科理论与实践,2016,21(4):300-302.