cN0T1／T2期甲状腺乳头状癌行颈中央区淋巴清扫的合理性及其范围的探讨

Evaluation of central lymph node dissection for papillary thyroid carcinoma in cN0 T1/T2

目的分析原发病灶在eN0T1／T2期的甲状腺乳头状癌（PTC）中央区淋巴清扫的合理性及其范围。方法回顾性分析2014年10月至2016年9月就诊于昆明医科大学第一附属医院甲状腺外科同一治疗组连续收治的符合入组条件的eN0T1／T2期PTC患者，数据采用SPSS20．0统计软件进行统计分析，淋巴结转移率的比较分析采用x。检验以及Fisher精确概率法检验。分析性别、年龄、原发灶肿瘤直径及病灶数目与中央区淋巴结转移的关系。结果中央区淋巴结转移率：男性为41．2％（42／102），女性为34．9％（150／430），P=0．252；单灶癌为33．9％（116／342），多灶癌为40．4％（74／183），P=0．157；≤45岁的高于〉45岁的，差异有统计学意义[44．O％（125／284）比27．O％（67／248），P=0．000]；微小癌低于非微小癌，差异有统计学意义[30．3％（113／373）比50．9％（81／159），P=0．000]。单侧病灶的肿瘤直径与Ipsi-CLN转移相关（P=0．012）、病灶数目与Ipsi-CLN转移不相关（P=0．653）；单侧病灶的肿瘤直径与Cont-CLN转移相关（P=0．000），病灶数目与Cont-CLN转移不相关（P=0．815）；左、右单侧单灶癌的肿瘤直径与LN-prRLN-CLN转移不相关（P=0．652，0．088），双侧多灶癌的肿瘤直径与LN-prRLN-CLN转移相关（P=0．039）。结论cN0T1／T2期PTC行颈中央区淋巴清扫是合理的，其处理策略应为：建议对于双侧多灶性癌和／或单、双侧非微小癌尤其年龄≤45岁者，均应行双中央区淋巴清扫；对于单侧单灶微小癌，右侧者行右中央区喉返神经前淋巴清扫；左侧者行左中央区淋巴清扫；对于单侧多灶微小癌可考虑仅行患侧中央区淋巴清扫。一般无需常规清扫右侧喉返神经后淋巴，但对于双侧非微小癌、右侧非微小癌仍应注意右喉返神经后淋巴的清扫。

Objective To evaluate the application of the central lymph node dissection （CLND） for papillary thyroid carcinoma （PTC） in cN0 T1/T2. Methods Retrospective analysis of 532 cases with PTC in eN0 T1/T2 who underwent CLND between October 2014 and September 2016 in the Department of Thyroid Surgery, the First Affiliated Hospital of the Kunming Medical University. The incidence of central lymph node （CLN） metastasis and risk factors were analyzed. Results CLN metastasis rates： 41.2% （42/102） in males vs 34.9% （150/430） in females, P =0.252; 33.9% （116/342） in single focal carcinoma vs 40. 4% （74/183） in multifocal carcinoma, P =0. 157; 44. 0% （125/284） in patients with 45 years old or less vs 27, 0% （67/248） in patients more than 45 years old, P = 0. 000 ; 30. 3% （ 113/373 ） vs 50. 9% （81/159） in non-microcarcinoma, P = 0. 000. In unilateral lesions, ipsilateral CLN metastasis was correlated with the tumor diameter （ P = 0. 012 ） , but not with the number of lesions （P = 0. 653）. also contralateral CLN metastasis was correlated with the tumor diameter （P = 0. 000）, but not with the number of lesions （P = 0. 815 ）. For the left or right unilateral single focal lesion, the tumor diameter was not correlated with the metastasis of the posterior to right recurrent laryngeal nerve central lymph nodes （LN-prRLN-CLN） （P = 0. 652, P = 0. 088 ）. But in bilateral multifocal carcinoma the tumor diameter was correlated with metastasis of LN-prRLN-CLN （P = 0. 039）. Conclusions Prophylactic CLND is reasonable for PTC in cN0 T1/T2. A bilateral CLND should be conducted for patients with bilateral multi- focus cancer and unilateral or bilateral non-microcarcinoma, especially in patients more than 45 years old. For unilateral single focal microcarcinoma on the right, the content of CLND should be from laryngeal nerve on right center to posterior branche ; for unilateral single focal microcarcinoma on the left side, the left CLND should be conducted. An ipsilateral CLND can be considered in patients with unilateral multifocal microcarcinoma, and generally a routine dissection of the LN-prRLN-CLN is not required, however for bilateral non-microcarcinoma and the the non-microcarcinoma on the right side, the LN-prRLN-CLN dissection should be conducted.