2015年ATA儿童指南用于儿童甲状腺乳头状癌外科治疗的单中心经验

2015 American Thyroid Association Children's Guidelines for surgical management of papillary thyroid cancer:A single⁃center experience

目的探讨2015年美国甲状腺协会(American Thyroid Association,ATA)发布的第一版“儿童甲状腺结节和分化型甲状腺癌管理指南”所推荐的手术方式是否适用于我国儿童乳头状甲状腺癌(papillary thyroid carcinoma,PTC)的外科治疗。方法收集2012年4月至2018年12月在昆明医科大学第一附属医院连续收治并接受初次手术治疗的PTC患儿(≤18岁)42例的临床资料,其中男5例,女37例,年龄(15.1±3.0)岁,年龄范围6~18岁。PTC患儿常规行颈中央区淋巴结清扫术(central neck dissection,CND),对进行全甲状腺切除术的患儿行双侧CND,但对行甲状腺腺叶及峡部切除的患儿行同侧CND。结果42例PTC患儿中,69.05%为单灶癌(29/42),30.95%(13/42)为多灶癌。单侧癌76.19%(32/42),双侧癌23.81%(10/42)。T1,T2,T3和T4病变分别为38.10%(16/42),19.05%(8/42),23.81%(10/42)和19.05%(8/42)。颈中央区淋巴结转移率显著高于颈外侧区(88.10%和69.05%,P=0.033),且随着T分期升高,中央区淋巴结转移(central lymph node metastasis,CLNM)及颈侧区淋巴结转移(lateral lymph node metastasis,LLNM)率均逐渐升高,T3、T4期CLNM率均为100%,LLNM率分别为100%和87.50%。术前cN1b(‒)的患儿常规CND,淋巴结转移率(lymph node metastasis,LNM)为66.67%,显著低于cN1b(+)的100%(P=0.007),cN1b(+)患儿的CLNM和LLNM率均为100%。对整组患儿的数据进行分析发现,同侧CLNM和LLNM率均显著高于对侧中央区(88.10%和59.52%,P=0.003)和对侧颈侧区(64.29%和33.33%,P=0.005)。对27例cN1b(+)的41侧颈侧区淋巴结清扫术(lateral neck dissection,LND)结果分析,Ⅴ区的转移率(17.07%)显著低于Ⅱ,Ⅲ和Ⅳ区(P=0.000,P=0.000,P=0.000);Ⅲ区转移率高于Ⅱ区(95.12%和75.61%,P=0.012,χ^(2)=6.248),但与Ⅳ区比较差异无统计学意义;Ⅱa区和Ⅱb区转移率差异也无统计学意义(60.98%和43.90%,P=0.127)。随访结果显示cN1b(‒)与cN1b(+)患儿的再手术率差异无统计学意义(13.33%和11.11%,P=0.596)。接受选择性颈侧区淋巴结清扫(selective lateral neck dissection,SLND)和超选择性颈侧区淋巴结清扫(super selective lateral neck dissection,SSLND)的颈侧区复发再手术率差异无统计学意义(0%和9.68%,P=0.422)。结论基于单中心数据,2015年ATA儿童指南适用于我国儿童PTC的外科治疗。

Objective To summarize the institutional experiences of treating pediatric papillary thyroid carcinoma(PTC)at a single center and explore whether or not surgical approach recommended by the First Edition of American Thyroid Association(ATA)Guidelines for Managing Children with Thyroid Nodules&Differentiated Thyroid Cancer in 2015 is applicable to pediatric patients in China.Methods From April 2012 to December 2018,clinical data were retrospectively reviewed for 42 consecutive PTC children(aged≤18 years)undergoing initial operations.There were 5 boys and 37 girls with an age range of(15.1±3.0)(6-18)years.Central neck dissection(CND)was performed for central neck PTC while the remainders with bilateral CND underwent total thyroidectomy and ipsilateral CND for thyroid lobectomy and isthmus.Results The clinical types were unifocal(n=29,69.05%)and multifocal(n=13,30.95%).And the lesions were unilateral(n=32,76.19%)and bilateral(n=10,23.81%).T1,T2,T3 and T4 lesions accounted for 38.10%,19.05%,23.81%and 19.05%.Central lymph node metastasis(CLNM)rate was significantly higher than that in lateral neck(88.10%vs.69.05%,P=0.033)and CLNM/LLNM rate gradually increased with advanced T stage.CLNM rates in T3 and T4 were 100%while LLNM rates 100%and 87.50%.Lymph node metastatic rate was significantly lower in cN1b(-)than that in cN1b(+)children after routine CND(66.67%vs.100%,P=0.007)and both CLNM and LLNM rates were 100%in cN1b(+)children.Both ipsilateral CLNM and LLNM rates were significantly higher than that in contralateral central compartment(88.10%vs.59.52%,P=0.003)and contralateral lateral neck(64.29%vs.33.33%,P=0.005).lymph nodes of 41 lateral LND from 27 cN1b(+)children were analyzed,Level V(17.07%)was rarely involved than level II/III/IV(P=0.000);metastatic rate was higher in level III than in level II(95.12%vs.75.61%,P=0.012).However,there was no significant difference as compared with level IV.No significant difference existed in metastatic rate between levels IIa and IIb(60.98%vs.43.90%,P=0.127).Follow-up results revealed no significant difference in re-operation rates between children with cN1b(-)and cN1b(+)(13.33%vs.11.11%,P=0.596)and between selective lateral neck dissection(SLND)and super-selective lateral neck dissection(SSLND)(0%vs.9.68%,P=0.422).Conclusion Based upon single-center data,2015 ATA Guidelines for Children are applicable to surgery of PTC children in China.