预防性颈中央区淋巴结清扫术与传统甲状腺全切除术治疗cN0期甲状腺乳头状癌安全性及有效性的meta分析

Prophylactic Central Neck Dissection Versus Traditional Total Thyroidectomy for Stage cNO Papillary Thyroid Carcinoma:A Meta-Analysis

目的系统评价预防性颈中央区淋巴结清扫术(PCND)治疗c N0期甲状腺乳头状癌的安全性及有效性。方法计算机检索Pub Med、EMbase、The Cochrane Library(2015年第1期)、万方、中国生物医学文献数据库、CNKI等数据库,收集甲状腺全切除术(TT)联合PCND(TT+PCND组)与TT术(TT组)治疗c N0期甲状腺乳头状癌的随机或非随机同期对照试验,检索时限截止到2015年3月。由两名评价者按照纳入与排除标准选择试验、提取资料和评价质量后,采用Rev Man 5.1软件进行meta分析。结果最终纳入10个非随机对照试验共计3 661例患者,其中1 774例行TT+PCND(TT+PCND组),1 887例单行TT(TT组)。meta结果分析显示,TT+PCND组术后暂时性低钙血症发生率〔OR=0.40,95%CI(0.33,0.49),P<0.000 01〕和永久性低钙血症发生率〔OR=0.32,95%CI(0.19,0.55),P<0.000 1〕均明显高于TT组,但TT+PCND组术后复发率较TT组明显降低〔OR=1.51,95%CI(1.07,2.13),P=0.02〕,而TT+PCND组和TT组在暂时性喉返神经麻痹〔OR=0.73,95%CI(0.49,1.09),P=0.13〕、永久性喉返神经麻痹〔OR=0.87,95%CI(0.50,1.52),P=0.62〕方面比较差异无统计学意义。结论 TT+PCND治疗c N0期甲状腺乳头状癌与TT比较,二者在暂时性喉返神经麻痹和永久性喉返神经麻痹方面无明显差异,TT+PCND治疗的复发率低,但同时升高了暂时性低钙血症发生率和永久性低钙血症发生率。因此,在严格掌握TT+PCND治疗c N0期甲状腺乳头状癌适应证的前提下,采用TT+PCND治疗c N0期甲状腺乳头状癌是安全、可行的。由于纳入研究数量和质量存在局限性,上述结论仍需大样本、高质量的随机对照试验进一步验证。临床医生应根据c N0期甲状腺乳头状癌患者的具体情况,综合评估病情,选择最佳的治疗方式。

Objective To systematically evaluate effectiveness and safety of total thyroidectomy （TT） plus prophylactic central neck dissection （PCND） versus TT for stage cN0 papillary thyroid carcinoma （PTC）. Methods Databases including PubMed, EMbase, The Cochrane Library （Issuel, 2015）, WanFang Data, CBM, and CNKI were searched to collect the randomized controlled trails （RCTs） and non-RCTs about TT＋PCND versus TT for stage cN0 PTC. The retrieval time was from inception to March 2015. The studies were screened according to the inclusion and exclusion criteria, the data were extracted and the quality was evaluated independently by 2 reviewers. Then the meta-analysis was conducted using RevMan 5.1 software. Results A total of 10 non-RCTs involving 3 661 patients were included. There were 1 774 cases in the TT＋PCND group and 1 887 cases in the TT group. The results of meta-analysis showed that： Related to postoperative complications, compared with TT group, the postoperative transient hypocalcemia rate OR=0.40, 95% CI （0.33, 0.49）, P〈0.000 01 ） and permanent hypocalcemia rate were higher ~ OR=0.32, 95% C1 （0.19, 0.55）, P〈0.000 1], the recurrence rate was lower [ OR--1.51, 95% CI （1.07, 2.13）, P=0.02] in the TT＋PCND group. But there were no differences in the transient laryngeal nerve palsy rate [OR=0.73, 95% CI （0.49, 1.09）, P=0.13] and permanent laryngeal nerve palsy rate [OR=0.87, 95% CI （0.50, 1.52）, P=0.62] between the 2 groups. Conclusions TT＋PCND is superior to TT in treating stage cN0 PTC for it＇s lower recurrence, but it is raising transient hypocalcemia and permanent hypocalcemia rate at the same time. And it is similar as TT in transient laryngeal nerve palsy and permanent laryngeal nerve palsy rate. So TT＋PCND is safe and feasible tbr treating stage cN0 PTC when its indications are strictly controlled. However, for the quantity and quality limitation of the included studies, this conclusion still requires to be further proved by performing large scale and high quality RCTs. It suggests that doctors should choose a best therapy for stage cN0 PTC patients according to an integrative disease assessment.