甲状腺癌纵隔淋巴转移的外科治疗

Surgical treatment of thyroid carcinoma with the upper mediastinal metastasis

目的探讨甲状腺癌纵隔淋巴转移的发病特点和治疗方法。方法回顾性分析中国医学科学院肿瘤医院1985年1月—2004年10月诊断为甲状腺癌纵隔淋巴转移122例患者的临床资料。分析其基本情况、诊断、术式、病理结果、并发症和预后,并比较胸骨劈开(34例)和颈部入路上纵隔清扫(88例)两种术式的并发症、生存率和复发情况。结果按美国胸科协会纵隔分区,上纵隔(2R/2L 区)受累最为常见,占98.4%(120/122)。有20.5%(25/122)病例有下纵隔受累,主要是左、右下气管旁淋巴结(4R/4L)区。胸骨劈开组并发症发生率38.2%(13/34)高于颈部入路组28.4%(25/88),但与纵隔手术有关的并发症仅有胸腔积液3例、纵隔感染1例、上腔静脉损伤1例,均痊愈。全组病例随访时间12～249个月,中位随访时间60个月。失访9例,随访率92.6%。采用 Kaplan-Meier 法计算生存率。劈胸骨劈开组(34例)5年生存率中,分化型甲状腺癌(22例)90.9%,髓样癌(12例)87.1%;颈部入路组(88例)5年生存率中,分化型甲状腺癌(76例)85.4%,髓样癌(12例)92.3%,两种病理类型组间的生存率差异均无统计学意义(P 值分别为0.252和0356)。胸骨劈丌组3年、5年复发率为3.8%、12.2%,颈部入路组为7.9%、14.2%,组间差异无统计学意义(P=0.504)。结论甲状腺癌纵隔淋巴转移的病例下纵隔受累并不少见。这部分患者颈部入路手术困难,应积极行胸骨劈开纵隔清扫术。对于仅局限在上纵隔的病灶,胸骨劈开入路纵隔清扫未能明显改善生存率,但因其术野暴露好,适用于转移淋巴较多,或与大血管关系密切的患者。

Objective To study the clinical characteristics and management of thyroid cancer with the upper mediastinal metastasis. Methods A retrospective study was performed to analysis the clinical characteristics, treatment and prognosis of 122 cases who underwent mediastinal dissection for thyroid cancer invasion in Cancer Hospital of Chinese Academy of Medical Science from Jan. 1985 to Oct. 2004. Results According to postoperative pathological diagnosis, upper mediastinal（2R/2L） were the most common areas invaded, 98. 4%. The incidence rate of lower mediastinal invasion was 20. 5% , which often occurred in the area of lower paratrachea （4R/4L） , The complication rate of the sternotomy group（ 38. 2% ）was higher than the other（28.4% ）, but complications associated with mediastenal operation were rare, including pleural effusion（3 cases）, mediasternal infection（ 1 case） and superior vena cava rupture（ 1 case）, which were all cured. After a median follow-up of 60 months （range from 12 to 249 months） ,9 patients were lost in the follow-up, the follow-up rate was 92. 6%. The anticipate 5-year survival rate of differentiated thyroid carcinoma and medullary carcinoma in the sternotomy group from Kaplan-Meier curve were 90. 9% , 87. 1% while the other group 85.4% , 92. 3% （ P 〉 0. 05 ）. Three-year and 5-year mediastinal recurrence rate of sternotomy group were 3.8%, 12. 2%, while transcervical operation group 7. 9%, 14. 2%. Conclusions It is noticed that there is a big percentage of patients with lower mediastinal invasion as well as upper area lesions. Radical operation is needed via sternotomy for these patients. For those who have many lymph nodes or the condition that lymph nodes adhere to the vessels , sternotomy also should be considered.