颈内静脉肩胛舌骨肌淋巴结在判断甲状腺乳头状癌侧颈隐匿性转移中的价值

Value of jugulo-omohyoid lymph nodes in predicting lateral cervical occult metastasis in patients with papillary thyroid carcinoma

目的探讨颈内静脉肩胛舌骨肌淋巴结（JOHLN）判断甲状腺乳头状癌患者侧颈隐匿性淋巴结转移的价值。方法对2010年1月至2015年12月收治的2 100例甲状腺乳头状癌患者资料进行回顾性分析，其中136例侧颈部高危转移的患者采用超择区性（Ⅲ、Ⅳ区）颈清扫术并检测JOHLN，分析JOHLN在判断甲状腺乳头状癌患者侧颈淋巴结转移中的价值。结果136例患者中，行甲状腺全切除术76例（55.9%），一侧腺叶＋峡部切除60例（44.1%）；行超择区性颈清扫术72例（52.9%），Ⅱ-Ⅳ区清扫术15例（11.0%），Ⅱ-Ⅴ区颈清扫术49例（36.0%）。患者术后病理分期为pN0期38例（27.9%）, pN1a期18例（13.2%）, pN1b期80例（58.8%）。全组患者的Ⅱ、Ⅲ、Ⅳ、Ⅴ、Ⅵ区淋巴结转移率分别为19.9%、43.4%、42.6%、2.9%和59.6%。JOHLN诊断甲状腺乳头状癌侧颈部淋巴结转移的敏感度、特异度、阳性预测值、阴性预测值和准确率分别为58.8%、62.9%、100.0%、62.9%和76.7%，诊断Ⅱ区淋巴结转移的敏感度、特异度、阳性预测值、阴性预测值和准确率分别为81.5%、43.2%、51.2%、76.2%和59.4%。随访过程中，全组无患者死亡，1例患者出现Ⅱ区淋巴结转移，再次清扫Ⅱ、Ⅴ区淋巴结后获得区域控制。结论利用JOHLN判断甲状腺乳头状癌患者侧颈转移的准确率较高，对Ⅱ区转移也有较高的敏感度；侧颈高危转移的患者如术中JOHLN明确为转移，建议行Ⅱ、Ⅲ、Ⅳ区清扫术，超择区性颈清扫术能明确分期，减少再次手术风险。

Objective To investigate the value of jugulo-omohyoid lymph nodes （JOHLN） in predicting occult lateral cervical lymph node metastasis in patients with papillary thyroid carcinoma （PTC）. Methods The clinicopathological data of 136 out of 2 100 PTC patients, who had a high risk of lateral neck lymph node metastasis and treated by us from January 2010 to December 2015, were retrospectively analyzed. Super selective neck dissection （SSND, level Ⅲ and Ⅳ） was performed and JOHLNs were sent for frozen section in all the 136 cases. The clinicopathologieal data was analyzed and the significance of JOHLN in predicting lateral cervical LNM was calculated using the SPSS software package. Results Of the 136 patients, total thyroidectomy was performed in 76 cases （55.9%） and unilateral lobeetomy plus isthmus was performed in the other 60 cases （44.1%）. SSND was performed in 72 patients （52.9%）, level Ⅱ-Ⅳ dissection in 15 （ 11.0% ）, and level Ⅱ-Ⅴ dissection in 49 （36.0%）. According to the pathological results, 38 patients were pN0（27.9%）, 18 （13.2%） were pNla and 80 （58.8%） were pNlb. The lymph node metastasis（LNM） rates at level Ⅱ-Ⅵ were 19.9%, 43.4%, 42.6%, 2.9%, and 59.6%, respectively. The sensitivity, specificity and accuracy of JOHLN in predicting lateral neck metastasis were 58.8%, 62.9%,and 76.7%, respectively. The rates for predicting level Ⅱ metastasis were 81.5%, 43.2%, and 59.4%, respectively. None of the patients died in the follow-up. Only 1 recurrence was found in level Ⅱ and regional control was achieved after level Ⅱ and V dissection. Conclusions JOHLN has a high accuracy for predicting lateral cervical lymph node metastasis and high sensitivity for level Ⅱ metastasis. For patients with high risk of lateral cervival metastasis, super-selective neck dissection including level Ⅲ and Ⅳ can confirm the stage and reduce the risk of reoperation. Dissection for level Ⅱ , Ⅲ, and Ⅳ is recommended.