以颈部淋巴结转移为首发症状的隐匿性甲状腺癌的诊治探讨

Diagnosis and treatment of occult carcinoma of the thyroid with neck lymph node metastasis as the first symptom

目的探讨以颈部淋巴结转移为首发症状的隐匿性甲状腺癌(occult carcinoma of the thyroid,OCT)的诊断策略及治疗方案。方法回顾性收集2003年2月至2013年2月期间笔者所在医院收治的35例以颈部淋巴结肿大为首发症状的OCT病例,分析其临床特点、诊断方法、手术方式、术后复发及死亡情况,结合OCT相关文献资料,讨论正确的诊断方法及手术方式。结果 35例患者中,因为颈部淋巴结肿大而就诊者28例,7例体检时行彩超检查发现;彩超发现甲状腺结节32例,未提示甲状腺结节3例。行颈部淋巴结超声引导下的细针穿刺细胞学检查(US-FNAB)23例,结果表明恶性及可疑恶性16例,占69.56%。行甲状腺结节穿刺者21例,结果表明恶性及可疑恶性者11例,占52.38%。35患者中,行不规范手术5例,行腺叶切除+峡部切除+侧颈区区域性淋巴结清扫术11例,行全甲状腺切除+侧颈区功能性淋巴结清扫术19例。本组所有患者均获访3~10年,中位数为7年。随访期间,复发10例,其中不规范手术组3例,腺叶切除+峡部切除+侧颈区区域性淋巴结清扫术组5例,全甲状腺切除+侧颈区功能性淋巴结清扫术组2例;随访期间,死亡3例,其中不规范手术组、腺叶切除+峡部切除+侧颈区区域性淋巴结清扫术组及全甲状腺切除+侧颈区功能性淋巴结清扫术组各有1例。全甲状腺切除+侧颈区功能性淋巴结清扫术组患者的复发率低于不规范手术组(χ~2=4.751,P<0.05)和腺叶切除+峡部切除+侧颈区区域性淋巴结清扫术组(χ~2=5.874,P<0.05),但不规范手术组和腺叶切除+峡部切除+侧颈区区域性淋巴结清扫术组的复发率比较差异无统计学意义(χ~2=0.291,P>0.05);3组患者的死亡率比较差异无统计学意义(P>0.05)。结论 USFNAB和术中快速冰冻病理切片是诊断OCT的重要手段,规范化手术是治疗以颈部淋巴结肿大为首发症状的OCT的重要方式。

Objective To investigate the optimal thyroid （OCT） with neck lymph node metastasis as the first diagnosis and treatment strategy of occult carcinoma of the symptom. Method In order to discuss the optimal diagnosis and treatment strategy of OCT with neck lymph node metastasis as the first symptom, we collected 35 cases and analyzed their characteristics, diagnostic methods, operative schemes, metastasis situation, and death situation. Results Of the 35 cases, 28 cases went to hospital because of swollen lymph nodes, and other 7 cases were discovered by color Doppler ultrasound in medical examination. Thyroid nodules were found by color Doppler ultrasound in 32 cases, 3 cases were found no thyroid nodule. Lymph node of 23 cases were determined by ultrasound-guided fine-needle aspiration biopsy （US-FNAB）, and 16 cases （69.56%） were diagnosed as metastasis of thyroid carcinoma or suspicious metastasis by US- FNAB. Thyroid biopsy were done in 21 cases, and 11 cases （52.38%） were diagnosed as thyroid carcinoma or suspicious thyroid carcinoma by fine needle aspiration biopsy. Of the 35 cases, 19 cases were performed total thyroidectomy and functional neck lymph node dissection, 11 cases were performed resection of unilateral thyroid and isthmus and regional neck lymph node dissection, 5 cases were performed nonstandard operations. All cases were followed up for 3-10 years after operation, and the median time was 7-year. During follow up period, 10 cases suffered from reccurrence. Among them, 3 cases reoccurred in the nonstandard operation group, 5 cases reoccurred in resection of unilateral thyroid and isthmus and regional neck lymph node dissection group, 3 cases reoccurred in total thyroidectomy and functional neck lymph node dissection group, There were 3 cases died. Among them, there was 1 case in each group of nonstandard operation group, resection of unilateral thyroid and isthmus and regional neck lymph node dissection group, and total thyroidectomy and functional neck lymph node dissection group. The recurrence rate of total thyroidectomy and functional neck lymph node dissection group was markedly lower than those of resection of unilateral thyroid and isthmus and regional neck dissection group （χ^2=4.751, P〈0.05） and nonstandard operation group （χ^2=5.874, P〈0.05）. While there was no significance difference of the recurrence rate between the resection of unilateral thyroid and isthmus and regional neck dissection group and nonstandard operation group （χ^2=0.291, P〉0.05）. There was no significance difference in the mortality among the three groups （P〉0.05）. Conclusion US-FNAB and intraoperation rapid frozen pathological section are important methods for diagnosis of OCT with neck lymph node metastasis as the first symptom, and standard operation is an principal treatment method for it.