胸骨劈开纵隔清扫术在分化型甲状腺癌中的应用

Mediastinal dissection via sternotomy for well differentiated thyroid carcinoma

目的评价采用胸骨劈开纵隔清扫术治疗分化型甲状腺癌上纵隔转移的安全性、合理范围及肿瘤学效果。方法回顾性分析我院头颈外科单一治疗组自2001年1月～2010年12月采用胸骨劈开纵隔清扫治疗18例分化型甲状腺癌患者,统计其转移淋巴结的部位、术后并发症及随访情况。结果上纵隔清扫标本检出淋巴结8～19枚,平均14枚,全组病例均检出阳性淋巴结。不同分区受累比例包括2R 83.3%(15/18),2L 72.2%(13/18),4R 55.6%(10/18),4L 16.7%(3/18),3a 38.9%(7/18)。低位气管旁淋巴结(4R或4L区)转移的病例均伴随同侧的高位气管旁淋巴结(2R或2L区)转移。全组并发症发生率50.0%(9/18)。上纵隔清扫相关并发症包括胸骨裂开1例,胸腔积液1例。全组病例随访时间18～120个月,全部生存,上纵隔局部控制率为94.4%(17/18)。结论胸骨劈开纵隔清扫术是治疗分化型甲状腺癌广泛纵隔淋巴转移安全有效的术式,清扫标本应包括心包以上两侧纵隔胸膜间大血管表面及间隙的淋巴结、软组织及胸腺。

OBJECTIVE To evaluate the safety, extent and effectiveness of mediastinal dissection via sternotomy for well differentiated thyroid carcinoma. METHODS The clinical data of 18 cases treated in a single team in our hospital from Jan. 2001 to Dec.2010 were retrospectively analyzed. Location of the positive lymph nodes, complications and follow-up data included in the analysis. Mediastinal lymph nodes mapping of AJCC 7th was used for classification. RESULTS An average of 14 lymph nodes （8-19） were detected in each mediastinal dissection specimen and positive mediastinal nodes were found in all cases. Metastatic rates of different levels were as follow： 2R 83.3% （15/181 , 2L 72.2% /13/18） , 4R 55.6% （10/18） , 4L 16.7% （3/18） , 3a 38.9% （7/18） . All lower paratracheal nodes metastasis accompanied with ipsilateral upper paratracheal nodes metastasis. Complication rate was 50% /9/181 . Complications related to mediastinal dissection included delayed sternal healing in 1 case and pleural effusion in 1 case. Follow-up period of the series was 18 to 120 months with all cases alive. The local （superior mediastinum） control rate was 94.4% （17/18） . CONCLUSION Mediastinal dissection via sternotomy is safe and effective for mediastinal metastasis of well differentiated thyroid carcinoma. The extent of the dissection should include the thymus, lymph nodes and soft tissue between the bilateral mediastinal pleura, superior to the pericardium.