甲状腺乳头状癌再次手术的原因探讨

Discussion about Reasons of Reoperation of Papillary Thyroid Carcinoma

目的通过统计残余癌灶和颈淋巴结转移数据以探讨甲状腺乳头状癌(PTC)合理的切除范围。方法回顾性分析我院2009年1月至2011年9月期间收治的163例PTC再次手术患者的临床资料。结果 163例患者中男24例,女139例,年龄(38.22±14.57)岁(10～75岁)。在行残余甲状腺切除的131例患者中,<45岁者88例,残癌率为60.23%(53/88);≥45岁者43例,残癌率为76.74%(33/43),二者比较差异无统计学意义(P=0.062)。158例进行了颈淋巴结清扫术,其中<45岁者105例,淋巴结转移率为77.14%(81/105);≥45岁者53例,淋巴结转移率为81.13%(43/53),二者比较差异无统计学意义(P=0.958)。首次手术小于侧叶切除者78例,残癌率为74.36%(58/78);侧叶(峡部)切除者41例,残癌率为53.66%(22/41);侧叶加对侧次全切除者12例,残癌率为50.00%(6/12);全切除或近全切除者32例,残癌率为0(0/32)。再次手术后发现,总残癌率为65.65%(86/131),双侧癌发生率为52.76%(86/163)。首次手术未行颈淋巴结清扫术130例(79.75%)。再次手术对132例进行了中央区淋巴结清扫,中央区淋巴结转移率为71.21%(94/132);103例进行了颈侧区淋巴结清扫,颈侧区淋巴结转移率为80.58%(83/103)。结论本组中PTC的多灶性特点较明显;≥45岁的PTC患者的残癌率及淋巴结转移率均高于<45岁患者,但结果差异并无统计学意义;对于多数PTC病例,甲状腺切除范围越小,残余癌的几率越大,甲状腺全切除术后残余癌的可能性最小;颈淋巴结转移为其重要的转移途径,行颈淋巴结清扫是预防复发、减少再次手术的必要手段。美国甲状腺协会的《甲状腺结节与分化型甲状腺癌诊治指南》是目前治疗PTC较为合理的指南,同时建议首次手术常规行中央区淋巴结清扫。

Objective To discuss the resection extent of primary surgery for papillary thyroid carcinoma （PTC） based on the analysis of the remaining thyroid gland residue and lymph nodes metastasis. Methods The clinical data of 163 patients with PTC received reoperation from January 2009 to September 2011 in our hospital were analyzed retrospectively. Results There were 24 males and 139 females in these patients. The age was 10-75 years old with （38.22± 14. 57） years old. Among 131 patients received residual thyroid thyroidectomy, 88 patients were below 45 years old, and the cancer residual rate was 60. 23% （53/88） ; the others were over 45 years old, and the cancer residual rate was 76.74% （33/43）, which was no significant difference （P= 0. 062）. The lymph nodes metastasis rate was 77. 14% （81/105） in the patients below 45 years old and 81.13% （43/53） in the patients over 45 years old among 158 patients received cervical lymph nodes dissection, which was no significant difference （P= 0. 958）. The cancer residual rate was 74.36% （58/78）, 53.66% （22/41）, 50.00% （6/12）, and 0 （0/32） in the patients with the tissue less than one lobe resection, lateral lobe （isthmus） resection, lateral lobe plus opposite side subtotal resection, total or subtotal resection, respectively. The total cancer residual rate was 65.65% （86/131） and the bilateral cancer residual rate was 52.76% （86/163） after reoperation. 79.75% （130/163） of the patients didn＇t received lymph nodes dissection in the primary surgery. The lymph nodes metastasis rate was 71.21% （94/132） and 80. 58% （83/103） in the reoperation patients received central region lymph nodes dissection and cervical lateral lymph nodes dissection, respectively. Conclusions Multifocus is an obvious character of PTC. Patients over 45 years old have more opportunities of tumor residual than that of the youngers （below 45 years old）, but the result was no statistic value. For the most patients with PTC, a smaller resection extent suggests a larger risk for cancer residual, and total thyroidectomy or subtotal thyroidectomy leads to the least possibility for the risk. Cervical lymph node is a major type for its metastasis. Proper lymph nodes dissection is an essential way to reduce recurrence and reoperation. The Revised American Thyroid Association Management Guidelines for Patients with Thyroid Nodules and Differentiated Thyroid Cancer （2009） could be a best choice for therapy of PTC. And it is proposed to take central region lymph nodes dissection during primary surgery.