cN0T1/T2期甲状腺乳头状癌中央区淋巴结清扫范围的临床研究

A clinical study of range of central lymph node dissection for papillary thyroid carcinoma in cN0 T1/T2

目的:分析c N0T1/T2甲状腺乳头状癌(papillary thyroid carcinoma,PTC)中央区淋巴结的转移规律,探讨其中央区淋巴结清扫的合理范围。方法:以2013年10月至2016年9月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c N0T1/T2期的532例PTC患者作为研究对象,所有患者均行甲状腺全切加预防性双侧中央区淋巴结清扫术。统计分析性别、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:c N0 T1/T2期PTC患者年龄>45岁的中央区淋巴结转移(central lymph nodes,CLNs)转移率为27.0%(67/248),≤45岁的CLNs转移率为44.0%(125/284),χ2=16.584,P=0.000;女性的CLNs转移率为34.9%(150/430),男性的CLNs转移率为41.2%(42/102),χ2=1.415,P=0.234;多灶癌的CLNs转移率为40.0%(76/190),单灶癌的CLNs转移率为33.9%(116/342),χ2=2.103,P=0.147;非微小癌的CLNs转移率为50.3%(80/159),微小癌的CLNs转移率为30.0%(112/373),χ2=19.893,P=0.000;病灶数目与患侧中央区淋巴结(ipsilater central lymph nodes,Ipsi-CLNs)转移不相关(χ2=0.884,P=0.347)、单侧病灶的肿瘤直径与Ipsi-CLNs转移相关(χ2=6.648,P=0.010);病灶数目与对侧中央区淋巴结(contralateral central lymph nodes,Cont-CLNs)转移不相关(χ2=0.202,P=0.653)、单侧病灶的肿瘤直径与Cont-CLNs转移相关(χ2=17.268,P=0.000);双侧多灶癌的肿瘤直径与喉返神经后中央区淋巴结(posterior to right recurrent laryngeal nerve central lymph nodes,LNpr RLN-CLNs)转移相关,(χ2=4.260,P=0.039)、左、右单侧单灶的肿瘤直径与LN-pr RLN-CLNs转移不相关(χ2=0.166,P=0.684;χ2=3.226,P=0.072)。结论:推荐对c N0 T1/T2期甲状腺乳头状癌在有技术保障的情况下应常规行预防性中央区淋巴结清扫,合理的清扫范围推荐为:(1)单侧非微小癌和双侧多灶癌尤其年龄≤45岁者,均应行双中央区淋巴结清扫;(2)单侧单灶或多灶微小癌仅行患侧中央区清扫;(3)一般无须常规清扫右侧喉返神经后淋巴结,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结的清扫。

Objective:To investigate the reasonable range of central lymph node(CLN) dissection for papillary thyroid carcinoma(PTC)in c N0 T1/T2 by analyzing the metastatic pattern of PTC in c N0 T1/T2. Methods:A total of 532 patients with PTC in c N0 T1/T2 who were consecutively admitted to the same treatment group in Department of Thyroid Surgery,The First Affiliated Hospital of Kunming Medical University,from October 2013 to September 2016 were enrolled in this study. All the patients underwent total thyroidectomy and prophylactic operation of bilateral CLN dissection. The relationship between the sex,age,diameter of primary tumor,and number of lesions and CLN metastasis was analyzed. Results:There was a significant difference in CLN metastasis rate between the patients aged >45 years and the patients aged ≤45 years(27.0%[67/248] vs. 44.0%[125/284],χ2=16.584,P=0.000)and between the patients with non-microcarcinoma and the patients with microcarcinoma(50.3%[80/159] vs. 30.0%[112/373],χ2=19.893,P=0.000). However,there was no significant difference in CLN metastasis rate between the female patients and the male patients(34.9%[150/430] vs. 41.2%[42/102],χ2=1.415,P=0.234)and between the patients with single focal carcinoma and the patients with multifocal carcinoma(33.9%[116/342] vs. 40.0%[76/190],χ2=2.103,P=0.147). Ipsilateral central lymph node(Ipsi-CLN)metastasis was not associated with the number of lesions(χ2=0.884,P=0.347),but was associated with the ipsilateral tumor diameter(χ2=6.648,P=0.010). Contralateral central lymph node metastasis was not associated with the number of lesions(χ2=0.202,P=0.653),but was associated with the contralateral tumor diameter(χ2=17.268,P=0.000). The posterior to right recurrent laryngeal nerve central lymph node(LN-pr RLN-CLN) metastasis was associated with the tumor diameter of bilateral multifocal carcinoma(χ2=4.260,P =0.039),but was not associated with the tumor diameter of left and right unilateral single focal lesion(χ2=0.166,P=0.684;χ2= 3.226,P=0.072). Conclusion:It is recommended that PTC in c N0 T1/T2 should be routinely treated with prophylactic CLN dissection in the case of technical support. The reasonable range of CLN dissection for PTC in c N0 T1/2 should be based on individual features:1)the patients with unilateral non-microcarcinoma and bilateral multifocal carcinoma should undergo bilateral CLN dissection,especially the patients aged ≤45 years;2)the patients with unilateral single or multifocal microcarcinoma should undergo Ipsi-CLN dissection;3)LN-pr RLN-CLN dissection is not necessary to do generally,but the patients with bilateral non-microcarcinoma and right non-microcarcinoma should undergo LN-pr RLN-CLN dissection.