甲状腺乳头状癌复发及持续状态再次手术临床分析

Clinical analysis of reoperation for recurrent/persistent papillary thyroid carcinoma

目的分析探讨甲状腺乳头状癌(papillary thyroid carcinoma,PTC)再次手术的原因及对预后的影响因素,总结经验,规范手术范围及方式,减少可避免的再次手术。方法回顾性分析2013年1月至2017年12月重庆医科大学附属第一医院乳腺甲状腺外科行再次手术的60例PTC患者的临床资料,通过不同区域肿瘤复发的临床特征描述及比较其与再次手术后复发的差异,分析再次手术原因及影响再复发的危险因素。结果本研究中,患侧中央区及侧区淋巴结转移(lymph node metastasis,LNM)有11例(18.3%);仅有患侧侧区淋巴结转移(lateral lymph node metastasis,LLNM)有34例(56.7%);喉返神经后方LNM有6例(10.0%);对侧LLNM有10例(16.7%)。单因素χ2分析发现再次手术后复发转移的患者,初次手术时年龄更大(P=0.003),LNM数目更多(P=0.037),再次手术前甲状腺球蛋白(thyroglobulin,Tg)水平更高(P=0.034)。多因素分析中,初次手术LNM数目(OR=1.174,P=0.008)、年龄(OR=1.130,P=0.014)及再次手术前Tg水平(OR=1.156,P=0.040)是手术后复发转移的独立危险因素。结论局部淋巴结复发及持续状态是致再次手术的主要原因,初次手术LNMN及年龄影响再次手术预后。再次手术操作难度大、风险较高,术中应配合神经监测和冰冻活检来加强喉返神经及甲状旁腺功能的保护。

Objective To analyze the causes of reoperation for papillary thyroid carcinoma(PTC)and summarize experience to reduce avoidable reoperations.Methods We retrospectively studied 60 patients with PTC who underwent reoperation in the Department of Breast and Thyroid Surgery of the First Affiliated Hospital of Chongqing Medical University from Jan.2013 to Dec.2017.Through the clinical description of the recurrence of tumors in different regions and the differences between the recurrence of reoperation and Clinical characteristics,the cause of the reoperation and the risk of recurrence are analyzed.Results Of the 60 PTC patients included in this study,11(18.3%)had lymph node metastasis(LNM)in the central plus lateral compartment of the affected side;34(56.7%)only had lymph node metastasis of the affected side compartment;There were 6(10.0%)metastasis to the lymph node posterior to right recurrent laryngeal nerve(LN-prRLN);10(16.7%)patients had lymph node metastases in the contralateral compartment;We found that patients with recurrence after reoperation were older(P=0.003),the more number of lymph node metastases(LNMN)(P=0.037),and with higher level of thyroglobulin than that before reoperation(P=0.034);and multivariate analysis indicated that LNMN in initial operation(OR=1.174,P=0.008),age(OR=1.130,P=0.014)and Tg level before reoperation(OR=1.156,P=0.040)were all independent predictors for recurrence after reoperation.Conclusions Local lymph nodes recurrence/persistence is the main reason for reoperation in our study.LNM of the initial operation and age affect the prognosis after reoperation.Reoperation is difficult and risky,and attention should be paid to the protection of parathyroid glands and recurrent laryngeal nerve by nerve monitoring and frozen biopsy.