甲状腺乳头状癌侧颈部淋巴结二次清扫的治疗经验

Reoperation experience of lateral neck dissection for papillary thyroid carcinoma

目的探讨侧颈部二次淋巴结清扫手术的原因和疗效。方法选择2002年1月1日至2003年12月31日期间在中国医学科学院肿瘤医院行颈部淋巴结二次清扫的甲状腺乳头状癌（papillary thyroid carcinoma,PTC）病例共68例,统计临床资料并分析治疗结果和生存率。结果再次手术单纯清扫颈部淋巴结者50例,颈淋巴结清扫＋补充切除甲状腺的18例。单侧颈清扫62例,双侧颈清扫6例。除1例仅处理中央区淋巴结外,有50例行包括Ⅱ~Ⅴ区的淋巴结清扫,其余17例为择区性清扫。侧颈部清扫中,根治性清扫7例,改良性清扫的60例。术后病理阳性55例,分化差的癌2例,阴性11例。术后长期甲状旁腺功能减退3例,暂时性甲状旁腺功能减退6例。Ⅰ期和Ⅳ期10年总生存率分别为94.1%和63.9%,两者差异具有显著性（P=0.005）。Ⅰ期和Ⅳ期10年无复发生存率分别为96.7%和41.7%,两者差异有显著性（P=0.000）。结论 PTC颈部淋巴结二次清扫的主要原因是切除范围不够或术前诊断评估不足。侧颈淋巴结清扫范围至少应该包括Ⅱ、Ⅲ、Ⅳ区,原发灶有被膜外侵犯、颈静脉链多个区域淋巴结转移的病例,应增加Ⅴ区。再次颈清扫术后患者10年生存率较高。颈部淋巴结二次清扫中应尤其注意对甲状旁腺的保护。

Objective To investigate the reasons and effects of reoperational lateral neck dissection（ND） for papillary thyroid carcinoma（PTC）. Method 68 PTC patients were performed reoperational ND during 01/01/2002 to 31/12/2003. Case records were reviewed to identify the styles and results of both initial therapies and the reoperations. Morbidities and survival rates were analyzed statistically. Result Reoperational ND were performed on 50 patients, while ND＋ completion thyroidectomy on the other 18 patients. Unilateral ND on 62 patients and bilateral ND on six patients. Level Ⅱ to Ⅴ ND on 50 patients, selective ND on 17 patients and central ND only on one patient. Radical lateral ND on 7 patents and modified lateral ND on 60 patients. Fifty-seven patients had positive pathology results while the other 11 with negative results. Three patients had permanent hypoparathyroidism and six patients experienced temporary hypoparathyroidism. Ten-year overall survival rates of stagesⅠand Ⅳ were 94.1% and 63.9% respectively, with a significant difference（P=0.005） when comparing. Ten-year recurrence-free survival rates of stages Ⅰ and Ⅳ were 96.7% and 41.7% respectively, with a significant difference（P=0.000）. Conclusion Reoperation NDs were mainly due to insufficient initial resections or inadequate preoperative evaluation. Lateral ND should include at least level Ⅱ, Ⅲ, Ⅳ. Extracapsular invasion of the primary tumor and multiple levels metastasis were the risk factors for level V metastasis. Patients underwent reoperations had a good ten-year survival rate. Particular attention should be paid to the protection of the parathyroid glands during reoperaions.