甲状腺乳头状癌右侧喉返神经深层淋巴结清扫的前瞻性分析

Prospective analysis of the risk factors and clinical indications of dissection of lymph node posterior to right recurrent laryngeal nerve in 283 cases of papillary thyroid carcinoma

目的 探讨甲状腺乳头状癌（PTC）右侧喉返神经深层淋巴结（LN-prRLN）转移的危险因素与手术适应证.方法 对2010年1月至2012年1月期间接受手术治疗的283例PTC患者进行前瞻性临床研究,手术均切除肿瘤腺叶并常规行同侧中央区淋巴结清扫（CLND）.将右侧中央区气管旁淋巴结以喉返神经（RLN）为界,分为浅层（Ⅵa亚区）与深层（Ⅵb亚区,即LN-prRLN）两部分,分别清除后进行病理检查,记录术后并发症及复发情况.结果 283例PTC患者中,中央区淋巴结（CCLN）转移率为47.7％（135/283）,Ⅵb亚区淋巴结转移率为27.2％ （77/283）,Ⅵa和Ⅵb亚区淋巴结同时转移率为20.5％ （58/283）,伴Ⅵa亚区阴性的Ⅵb亚区淋巴结转移率为6.7％（19/283）.Ⅵb亚区淋巴结清扫的相关并发症发生率为4.9％（14/283）,术后3年内局部复发率为2.1％ （6/283）.单因素分析显示,肿瘤大小、肿瘤数量、肿瘤侵袭程度、Ⅵa亚区淋巴结转移情况、颈侧区淋巴结转移情况和临床淋巴结分期与Ⅵb亚区淋巴结转移有关（P ＜0.001）.多因素分析显示,肿瘤大小、肿瘤数量、肿瘤侵袭程度、Ⅵa亚区淋巴结转移情况和颈侧区淋巴结转移情况是影响PTC患者Ⅵb亚区淋巴结转移的独立因素.结论 PTC发生右侧CCLN转移可仅累及RLN深层而无浅层转移.因此,右侧CLND应常规探查RLN深层区域.当右侧PTC肿瘤直径≥1 cm、多发肿瘤、伴甲状腺外侵袭或颈淋巴结转移时,完整的CLND应包含LN-prRLN清除.

Objective To investigate the risk factors for metastasis and clinical indications tor dissection of lymph node posterior to right recurrent laryngeal nerve （LN-prRLN） in papillary thyroid carcinoma （PTC）.Methods A prospective analysis including 283 consecutive patients with PTC who underwent total thyroidectomy with routine central lymph node dissection （CLND） in our hospital from Jan.2010 to Jan.2012 was performed.The right paratracheal lymph nodes in the central compartment lymph nodes （CCLN） were divided into the anterior （level Ⅵa） and posterior （level Ⅵb） compartments by recurrent laryngeal nerve （RLN）,and were removed respectively.The complications and recurrences were recorded with a follow-up of 3 months to 3 years.Results CCLN metastases were present in 47.7% （135/283） of the patients,and level Ⅵb metastases were present in 27.2% （77/283） of the patients.The incidence of level Ⅵ b metastasis was 20.5% （58/283） in level Ⅵ a-positive patients,while 6.7% （19/283） in level Ⅵ a-negative patients.Complications of level Ⅵ b dissection were found in 4.9% （14/283） of all patients.2.1% （6/283） of all patients were diagnosed with regional recurrence during the 3-year follow-up.Univariate analysis revealed that level Ⅵ b metastasis was significantly associated with tumor size,number,extrathyroidal invasion,clinical nodal stage,level Ⅵa and lateral lymph node metastases.Multivariate analysis revealed that tumor larger than 1 cm,multifocality,extrathyroidal invasion,level Ⅵ a and lateral lymph node metastases were independent risk factors for level Ⅵ b metastasis.Conclusions Lymph node posterior to right recurrent laryngeal nerve can be the only site of metastasis from PTC without other cervical compartment involvements.Therefore,routine intraoperative detection of these nodes may be necessary for patients with right PTC,and dissection should be considered when a right-side PTC tumor is larger than 1 cm,multifocality,with extrathyroidal invasion or cervical nodal metastases.