临床颈淋巴结阴性甲状腺乳头状癌不同手术方式的疗效比较

Clinical effects of different surgical methods on papillary carcinoma of the thyroid with clinically negative lymph nodes

目的：探讨临床颈淋巴结阴性（cN0）甲状腺乳头状癌（papillary thyroid carcinoma,PTC）患者不同手术方式疗效和安全性,为手术方案的选择提供理论基础。方法：选取唐山市工人医院头颈外科2009年12月至2014年12月225例cN0期PTC患者,根据手术方式的差异分为全切组110例,行甲状腺全切;腺叶切除组115例,行患侧腺叶及峡部切除。所有患者均予以患侧中央区淋巴结清扫。分析两组患者的手术及住院情况、病理特征、并发症情况及随访和复发情况。结果：1）两组患者的切口长度、术中出血量、手术时间及住院时间比较均无显著性差异（P〉0.05）。2）全切组多发癌灶例数多于腺叶切除组患者,有显著性差异（P〈0.05）,两组患者癌灶平均直径比较无显著性差异（P〉0.05）;两组患者中央淋巴结清扫枚数、淋巴结转移总枚数、中央淋巴结转移例数比较均无显著性差异（P〉0.05）;两组患者误切甲状旁腺、一过性低血钙、暂时性喉返神经麻痹、喉上神经损伤发生率比较无显著性差异（P〉0.05）,无永久性低血钙及永久性喉返神经损伤出现。3）全部患者获得随访,随访2~4.5年,全切组患者无复发病例。腺叶切除组8例患者在对侧腺叶出现癌灶的转移,加做对侧腺叶切除,4例患者患侧颈部侧区出现淋巴结转移,给予功能性淋巴结清除。两组患者的转移和复发率存在显著性差异（P〈0.05）。随访期间无死亡病例。结论：对于cN0期PTC患者,甲状腺全切联合清除患侧中央区淋巴结可以减少微小病灶的残留,与手术范围仅包括患侧腺叶及峡部的手术相比,其癌灶残留、转移、复发的概率降低,术后并发症无显著增加。

Objective： To explore the efficacy and safety of different surgical methods in papillary thyroid carcinoma （PTC） patients with negative cervical lymph nodes （cN0） and to provide theoretical basis for the selection of surgical procedures. Methods： A total of 225 PTC cNO patients were selected and divided into two groups according to the operation method. Only 110 patients underwent total thy- roidectomy, whereas the 115 cases in the Iobectomy group underwent ipsilateral Iobectomy and isthmus resection. All patients were treated with ipsilateral central lymph node dissection. We analyzed both groups of patients in terms of surgery, hospitalization, pathological characteristics, complications, follow-up, and recurrence. Results： （1） The length of incision, blood loss, operation time, and length of stay were not significantly different between the two groups （P〉O.05）. （2） In the total resection group, the number of multiple foci of the cancer cases was significantly more than that of the Iobectomy patients （P〈0.05）. The average tumor diameter in both groups were not significantly different （P〉0.05）. Between the two groups, the number of central lymph node dissection and total lymph node metastasis, and the number of cases with central lymph node metastasis were not significantly different （P〉0.05}. Likewise, the incidence rates of mistakenly cut parathyroid, extremely low blood calcium levels, temporary larynx return nerve paralysis, and superior laryngeal nerve injury were not significantly different between the two groups （P〉0.05）. No permanent hypocalcemia or permanent recurrent laryngeal nerve injury occurred. （3） All patients were followed up for 2-4.5 years. No recurrent cases were reported in the total resection group. For the Iobectomy group, 8 patients with adenocarcinoma had contralateral tumor metastasis and underwent contralateral lobe resection, whereas 4 patients suffered from ipsilateral neck lymph node metastasis at the side area and underwent functional lymph node clearance. Significant differences were noted in the metastasis and recurrence rates between the two groups of patients （P〈0.05）. No deaths were reported during the follow-up period. Conclusion： For PTC cNO patients, total thyroidectomy with joint ipsilateral central lymph node clearance can reduce the residual tumor, metastasis, and risk of recurrence,compared with surgery limited to the affected lobe and isthmus. Postoperative complications were not significantly increased.