甲状腺乳头状癌中央区淋巴转移相关影响因素研究

Related factors of central lymph node metastasis in papillary thyroid carcinoma

目的分析甲状腺乳头状癌中央区淋巴转移规律，为中央区淋巴清扫术寻找依据并探讨合理的清扫范围。方法回顾性分析2009年1月至2010年12月期间手术治疗153例甲状腺乳头状癌患者的病历及病理资料。男性28例，女性125例；平均（面±S）年龄（44±14）岁。T151例，T210例，T381例，T411例；I期88例，Ⅱ期3例，Ⅲ期26例，Ⅳ期36例；多灶癌63例。eNl82例，oN071例。分析患者性别、年龄、肿瘤大小、是否为多灶癌、肿瘤是否累及被膜等因素与中央区淋巴转移率的关系。所有病例均行甲状腺全或近全切除＋中央区淋巴清扫术，有颈侧区淋巴结肿大或转移者视情况加行单或双侧颈侧区淋巴清扫术。结果所有患者均行甲状腺全或近全切除＋中央区淋巴清扫术，另64例患者加行单侧颈侧区淋巴清扫术，18例加行双侧颈侧区淋巴清扫术。中央区淋巴转移率68．6％（105／153），其中31．4％（48／153）为双侧中央区淋巴转移。oNl期及cNO期中央区淋巴转移率分别为86．6％（71／82）及47．9％（34／71），双侧中央区淋巴转移率分别为45．1％（37／82）及15．5％（11／71）。多因素分析表明，肿瘤侵犯被膜（P=0．002，OR=3．502）是影响中央区淋巴转移的独立危险因素。对患侧中央区有淋巴转移的病例行多因素分析表明：肿瘤侵犯周围组织（P=0．014，OR=3．113）、肿瘤最大径〉1em（P=0．012，OR=3．732）、颈侧区淋巴转移（P=0．028，OR=3．080）是双侧中央区淋巴转移的独立危险因素。结论从转移率角度及再次手术的高风险性出发，应对甲状腺乳头状癌患者常规行患侧-中央区淋巴清扫术。术中应常规行冰冻切片检查，如患侧中央区淋巴转移伴有肿瘤局部较晚（肿瘤侵犯周围组织者，，13、T4级）；肿瘤最大径〉1em；颈侧区淋巴转移之一时，建议行双侧中央区淋巴清扫术。

Objective To study the related factors of central lymph node （CLN） metastasis in papillary thyroid carcinoma （ PTC ）, the indications and the extent of central neck dissection （ CND ）. Methods A total of 153 cases treated between Jan. 2009 and Dec. 2010 was analysed retrospectively. Of the cases 28 males and 125 cases females, with a mean age of （44 ＋ 14） years. T1, T2, and T3 diseases accounted for 51, 10 and 81 cases, respectively; I , II, III and IV diseases for 88, 3, 26 and 36 cases, respectively. Multifocal tumors were found in 63 cases. The related clinicopathologic factors were analyzed, including sex, age, tumor size, extrathyroidal extension, and multifocal tumor. Results All the cases had total/near total thyroidectomy and CND, of them 64 cases had unilateral neck dissection and 18 cases had bilateral neck dissection. CLN metastases existed in 68. 6% （ 105/153 ） cases, 37.2% （ 57/153 ） for unilateral and 31.4% （48/153） for bilateral respectively. The rates of C LN metastasis were 86. 6% （71/82） in cN1 cases and 47.9% （34/71） cN0 cases, respectively, and the rates of bilateral CLN metastases were 45. 1% （37/82） in cN1 cases and 15.5% （11/71） in cN0 cases. Multivariate analysis showed thatextrathyroidal extension（ P = 0. 002, OR = 3. 502） was an independent risk factor for CLN metastasis and that lateral neck lymph node metastasis（ P = 0. 028, OR = 3. 080）, surrounding tissue invasion（ P = 0. 014, OR =3. 113） , and maximum tumor diameter greater than 1 cm （P =0. 012, OR =3. 732） were independent risk factors for bilateral CLN metastases. Conclusions It is indicated that ipsilateral CND should be obligatory for PTC. Intraoperative frozen section examination should be routine. Bilateral CND should be conducted when ipsilateral CLN metastases accompanied by one of following issues such as more invasive tumor （surrounding tissue invasion, T3 or T4 disease）, maximum tumor diameter greater than 1 cm, and lateral neck lvmoh node metastasis_