甲状腺癌纵膈淋巴结转移的外科治疗

Surgical management of mediastinal lymph node metastasis of thyroid carcinoma

目的探讨TC纵膈淋巴结转移的外科处理方法。方法回顾分析2004年2月至2015年4月四川省肿瘤医院头颈外科和胸外科收治的46例侵犯纵膈的TC患者的临床资料，对术前诊断、手术方式、手术入路及术后并发症进行分析。结果根据AJCC．UICC纵膈淋巴结分组，以上纵膈淋巴结转移为主，其中2区（2R／2L，上气管旁组）淋巴结受累居多有31例（31／46，67．39％）；3区（血管前气管后）和4区（4R／4L，下气管旁组）淋巴结受累16例（34．78％）（5例同时伴有多区淋巴结转移）；5区（主动脉下）和6区（主动脉旁）受累4例（8．696％）。术后病理诊断：乳头状癌39例，髓样癌6例．滤泡状腺癌1例；分期：Ⅰ期14例，Ⅱ期5例，Ⅲ期3例，Ⅳa22例，Ⅳc2例。手术入路：经颈部入路行上纵膈淋巴清扫34例，胸骨部分劈开上纵膈淋巴清扫7例，全胸骨劈开纵膈淋巴清扫1例，侧开胸纵膈淋巴清扫4例。术后并发症依次为：暂时性甲旁减低钙血症、RLN损伤、肺部感染伴胸水、乳糜瘘、气食管瘘、纵膈气肿。术后随访1～8年，失访4例，死亡2例。结论TC纵膈淋巴结转移，手术是主要治疗手段，术前应依靠颈部和胸部的CT、MRI评估淋巴结的范围，选择正确的手术入路，可提高患者的生存率。

Objective To explore the surgical technique for mediastinal lymph node metastasis of thyroid cancer. Methods We retrospectively reviewed clinical records of 46 patients with metastatic thyroid cancer in mediastinal lymph nodes and having received surgical treatment in Department of Head Neck Surgery and Thoracic Surgery of Sichuan Cancer Hospital from Feb. 2004 to Apr. 2015. We analyzed the diagnosis, surgical treat- ment methods, operative approach, and postoperative complications of these patients. Results The main metastatic region was superior mediastinum especially level 2 （2R/2L, lower parathymic lymph nodes） according to AJCC-UICC standard in 31 patients （67.39%）;16 patients （34.78%） had level 3 and level 4 （4R/4L lower parathymic） lymph node metastasis and 4 patients （8.696%） had level 5 （subaortic lymph node） and level 6 （para-aortic lymph node） metastasis. 39 patients were pathologically diagnosed with papillary carcinoma, 6 patients were diagnosed with medullary carcinoma, and 1 patient was diagnosed with follicular carcinoma. There were 14 patients with stage disease, 5 patients with stage Ⅱ disease, 3 patients with stage Ⅲ disease, 22 patients with stage IVa disease, and 2 patients with stage IVc disease. The most common complications were hoarseness, chylous fistu- la, hypocalcaemia, and airway obstruction. Patients were followed-up from 1 to 8 years. During the follow-up period, 4 cases were lost to follow-up and 2 patients died. Conclusions The main treatment approach for mediastinal lymph node metastasis of thyroid cancer is surgical operation. Pre-operative CT or MRI is needed to evaluate the metastatic region of the lymph nodes and to choose appropriate operative approach.