cN0多灶甲状腺微小乳头状癌与中央区淋巴结转移关系的研究进展

Research progress in the relationship between cN0 multifocal thyroid micropapillary carcinoma and central lymph node metastasis

目的总结目前国内外关于cN0多灶甲状腺微小乳头状癌(papillary thyroid microcarcinoma,PTMC)与中央区淋巴结转移(central lymph node metastasis,CLNM)关系的最新研究进展,为外科医生平衡手术的益处和风险,选择最佳治疗方案提供参考。方法检索有关cN0多灶PTMC肿瘤特性(包括癌灶数目、肿瘤总直径、原发肿瘤直径、肿瘤总表面积等)与CLNM关系的最新研究并作一综述。结果目前国内外指南在cN0的PTMC是否行预防性中央区淋巴结清扫(prevent central lymph node dissection,pCLND)问题上存在分歧。支持者认为在有技术保障的前提下pCLND可减少疾病复发率,有助于术后风险分层及术后管理;而反对者认为pCLND是否确实改善PTMC患者的预后尚无定论,但术后并发症确实与pCLND有关。为指导pCLND在cN0 PTMC手术治疗中的应用,近年来大量研究报道了PTMC发生CLNM的危险因素,其中多灶被认为是CLNM十分重要的危险因素。为进一步了解多灶PTMC与CLNM的关系,国内外学者将多灶这一特征量化为各种参数,多维度研究它们与CLNM的关系,发现肿瘤总直径>1 cm、肿瘤数量增加、肿瘤总表面积>3.14 cm^(2)、直径比<0.56、肿瘤体积>90 mm^(3)和双侧多灶可能是cN0多灶PTMC患者CLNM风险增高的危险因素。结论这些筛选出的参数被初步认为是预测多灶PTMC发生CLNM风险的有效工具。对于多项危险参数并存,尤其是含有双侧叶内多灶特点的多灶PTMC患者,pCLND有望使其受益更多。但目前仍需要大量的临床研究为临床诊疗提供可靠的循证依据。未来通过结合这些有价值的参数构建一个评分系统,更加精准化预测多灶PTMC的疾病状态,识别有pCLND必要的患者,将对PTMC的适当治疗有重要意义。

Objective To summarize the latest research progress on the relationship between cN0 multifocal papillary thyroid microcarcinoma(PTMC)and central lymph node metastasis(CLNM)at home and abroad,so as to provide a reference for surgeons to balance the benefits and risks of surgery and select the best treatment plan.Method The latest studies on the relationship between CLNM and tumor characteristics of cN0 multifocal PTMC(including number of tumor foci,total tumor diameter,primary tumor diameter,total tumor surface area,etc.)were reviewed.Results Current domestic and international guidelines differ on whether cN0 PTMC should be used to prevent central lymph node dissection(pCLND).Proponents believe that pCLND could reduce the recurrence rate of disease and facilitate postoperative risk stratification and management under the premise of technical support.Opponents argue that it was not clear whether pCLND actually improves the prognosis of PTMC patients,but postoperative complications do correlate with pCLND.In order to guide the application of pCLND in the surgical treatment of cN0 PTMC,a large number of studies had reported the risk factors of CLNM in PTMC in recent years,among which multifocal was considered to be a very important risk factor for CLNM.In order to further understand the internal relationship between multifocal PTMC and CLNM,scholars at home and abroad quantified the feature of multifocal PTMC into various parameters,and studied the relationship between them and CLNM in multiple dimensions.It was found that total tumor diameter>1 cm,increased tumor number,total tumor surface area>3.14 cm^(2),diameter ratio<0.56,tumor volume>90 mm 3 and bilateral multifocal PTMC might be the risk factors for increased CLNM risk in patients with cN0 multifocal PTMC.Conclusion These screened parameters are initially considered to be effective tools for predicting the risk of CLNM in multifocal PTMC.Multiple risk parameters coexist,especially in patients with multifocal PTMC characterized by bilateral intralar multifocal PTMC,who are expected to benefit more from pCLND.However,a large number of clinical studies are still needed to provide reliable evidence-based evidence for clinical diagnosis and treatment.In the future,by combining these valuable parameters,a scoring system can be constructed to predict the disease status of multifocal PTMC more accurately and identify patients with necessary pCLND,which will be of great significance for the appropriate treatment of PTMC.