甲状腺乳头状微小癌手术方式探讨

Evaluation of adequate surgery for papillary thyroid microcarcinoma

目的探讨治疗甲状腺乳头状微小癌最佳的手术方式。方法2000年1月-2010年1月139例甲状腺乳头状微小癌患者在济南军区总医院甲状腺乳腺外科接受了不同范围的甲状腺切除＋选择性颈淋巴结清扫术，本文对其临床、病理和随访资料进行分析。结果139例甲状腺乳头状微小癌患者中，甲状腺全切除者91例，甲状腺大部切除或次全切除者48例，癌灶直径平均为（0．45±0．24）cm。其中42例（30．2％）甲状腺微小癌为多灶性，27例（19．4％）为双侧癌。59例（42．4％）伴有颈部淋巴结转移，其中Ⅵ、Ⅱa、Ⅲ或Ⅳ区淋巴结转移者分别为58例（41．7％）、3例（2．2％）、10例（7．9％）、5例（3．6％），仅有Ⅲ区淋巴结转移者1例。甲状腺乳头状微小癌颈淋巴结转移与微小癌浸润甲状腺被膜密切相关（χ^2=38．39，P〈0．001）。本组病例随访30～154个月，中位随访时间为103个月，2例对侧残留腺叶复发。无永久性甲状旁腺功能减退发生。随访满10年者16例，10年生存率为100％。结论多发癌灶和Ⅵ区淋巴结转移是甲状腺乳头状微小癌的2个重要的临床病理学特点。甲状腺乳头状微小癌初次手术时行甲状腺全切除＋Ⅵ区淋巴结清扫是最佳的术式，可降低术后复发。

Objective To explore the best operation method in the patients with papillary thyroid microcarcinoma. Methods A total of 139 patients with papillary thjroid microcarcinoma were treated at our institute between Jan. 2000 and Jan. 2010. The data on the clinicopathological characteristics of patients and treatment were collected. Results The mean tumor size was （0.45 ±0.24） cm. Of the 139 patients, 30.2% had multifocal tumors, 19.4% had bilateral tumors, 42.4% neck lymph node metastases. The number of cases of lymph node metastasis in level Ⅵ、Ⅱa、Ⅲ and Ⅳ was 58（41.7% ）, 3（2.2% ）, 10（7.9% ）, 5（3.6% ）, respectively. Only one had lymph node metastasis in Level m. Microscopic extrathyroid extension was associated with neck lymph node metastases in papillary thyroid microcarcinoma patients （χ^22 = 38.39, P 〈 0. 001 ）. No one developed permanent hypoparathyroidism. The median follow-up time was 103 （range, 30 -154） months, and local recurrence in the thyroid was diagnosed in 2 patients who underwent hemi-or subtotal thyroidectomy. Follow-up of 10 years was done in 16 cases, and the survival rate of 139 patients for 10-year was 100%. Conclusions It suggested that patients with papillary thyroid microcarcinoma has uniform clinicopathologic characteristics and the pattern of lymph node metastasis from those with papillary thyroid carcinoma. Total thyroidectomy plus level VI dissection is the optimal surgical treatment of papillary thyroid microcarcinoma.