侧颈部淋巴结示踪技术在甲状腺癌手术治疗中的应用

Lateral neck lymph node mapping in thyroid cancer surgery

目的探究纳米炭示踪技术在甲状腺癌侧颈部淋巴结评估中的价值。方法研究为前瞻性、多中心队列研究,纳入体格检查阴性、影像学怀疑侧颈部淋巴结转移的甲状腺乳头状癌患者。术中用纳米炭示踪后进行侧颈部淋巴结清扫术。根据是否炭染,将侧颈部淋巴结分区送检,统计两组淋巴结的分区以及转移情况,并根据患者的临床病理特征进行亚组分析。以颈部淋巴结清扫的结果作为金标准,计算前哨淋巴结活检的敏感度及准确率。结果122例患者接受示踪手术,共计颈部淋巴结125例/侧。其中有侧颈部淋巴结转移117例,有中央区淋巴结转移7例,无颈部淋巴结转移1例。炭染淋巴结的中位数为6枚,其分布为Ⅳ区>Ⅲ区>Ⅱ区>Ⅴ区,分布规律与肿瘤大小、位置、腺外侵犯无关。炭染淋巴结的转移概率在各个淋巴结分区中均显著高于非炭染淋巴结(Ⅱ区:19.9%比5.6%,P<0.001;Ⅲ区:35.0%比18.3%,P<0.001;Ⅳ区:37.1%比15.2%,P<0.001;Ⅴ区:14.8%比3.7%,P<0.05)。侧颈部前哨淋巴结活检的敏感度为89.5%,准确率为91.8%。结论侧颈部淋巴结的炭染规律与甲状腺癌淋巴引流的规律基本一致,炭染淋巴结的转移概率显著高于非炭染淋巴结,是潜在侧颈部前哨淋巴结活检的示踪方法。

Objective Despite the high incidence of lateral neck lymph node metastasis in papillary thyroid carcinoma(PTC),its management has remained controversial.The accuracy of ultrasound and computed tomography(CT)in lateral neck evaluation for PTC is unsatisfactory.An unnecessary neck dissection may lead to increased complications,while undetected lymph node metastasis may facilitate recurrences and necessitate resurgery.We aimed to map the draining lymph nodes in the lateral neck using carbon nanoparticles and explore its potential in neck assessment.Methods We conducted a multicenter,prospective study from August 2016 to April 2019 in PTC patients who had unpalpable lateral lymph nodes that appeared suspicious on ultrasound and/or CT.Carbon nanoparticles were injected peritumorally into the thyroid gland,and modified lateral neck dissection(compartmentⅡ-Ⅴ)was performed.The lateral lymph nodes were classified into dyed and undyed and sent for pathological analysis.Thyroidectomy and central neck compartment dissection were performed.Results A total of 125 neck dissections were performed in 122 patients.Of the dissections,117 were for lateral neck metastases,7 were for central metastases,and metastasis was absent in the remaining 1.A total of 4302 lateral lymph nodes were removed,952 of them were dyed.The median number of dyed nodes was 6 per case(range:1-33).The distribution of dyed nodes in the neck compartments wasⅣ>Ⅲ>Ⅱ>Ⅴ,independent of tumor size,location,or extra-thyroidal extension.The percentages of dyed lymph node metastasis inⅡ-Ⅴcompartments were 33.3%,60.0%,68.8%,and 40.0%,respectively,on a per-case basis and 10.2%,31.4%,27.5%,and 20.8%,respectively,on a per-node basis.Compared to undyed nodes,the risk of metastasis in dyed nodes was significantly higher in all neck compartments(compartmentⅡ:19.9%vs.5.6%,P<0.001;compartmentⅢ35.0%vs.18.3%,P<0.001;compartmentⅣ:37.1%vs.15.2%,P<0.001;compartmentⅤ:14.8%vs 3.7%,P<0.05).A lateral sentinel lymph node biopsy was performed in 51 patients.The sensitivity of the lateral neck sentinel lymph node biopsy was 89.5%,the false-negative rate was 26.7%,and the overall accuracy rate was 91.8%.Conclusion Using carbon nanoparticles,we successively mapped the lateral neck lymph nodes.We found that dyed nodes had a significantly higher risk of metastasis than that of undyed nodes.This method may be useful for lateral neck sentinel lymph node biopsies in PTC.