中央区淋巴结清扫术在cN_0甲状腺乳头状癌治疗中的价值探讨
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摘要
研究目的甲状腺乳头状癌是甲状腺最常见的恶性肿瘤,也是内分泌系统的常见肿瘤。大部分患者以偶然发现的甲状腺内肿块为首发症状,颈部淋巴结转移是甲状腺乳头状癌最主要的转移方式。在临床颈淋巴结阴性(cN0)的甲状腺乳头状癌患者中,约有10%的患者最终将发展成为颈部淋巴结转移。越来越多的长期随访资料证明,颈部淋巴结转移与患者的长期生存率、无瘤生存等预后指标有关,是影响甲状腺乳头状癌患者预后的一个重要因素。淋巴结转移有明显的区域性转移倾向,尤其是中央区淋巴结为最先转移的部位。本文根据UICC2002年TNM分期,按照年龄、原发肿瘤大小、是否侵犯包膜,探讨中央区淋巴结转移的影响因素及中央区淋巴结清扫术在临床颈淋巴结阴性(cN0)甲状腺乳头状癌治疗中的价值。
研究方法以手术前cN0的甲状腺乳头状癌患者为研究对象,对我院2005年1月至2009年1月术中冰冻病理确诊为甲状腺乳头状癌而行中央区淋巴结清扫术的67例患者的临床资料进行回顾性统计分析,并对患者进行颈侧区淋巴结转移等为主要内容的随访。
结果67例患者中,男22例,女45例,年龄中位年龄42±2岁；其中大于或等于45岁35例,小于45岁32例,其中原发肿瘤直径小于1cm的22例,大于1cm的45例,有包膜浸润的27例,无包膜浸润的40例。67例cN0甲状腺乳头状癌患者中央区淋巴结转移率50.7%(34/67)。发现中央区淋巴结转移与原发肿瘤大小无关(χ2=0.42,P>0.05)；与原发肿瘤侵犯包膜(χ2=8.76,P<0.01)有关,与年龄在45岁及45岁以上者(χ2=4.30,P<0.05)有关,67例患者中无一例出现饮水呛咳,无一例出现淋巴瘘、乳糜瘘,出现一过性声音嘶哑5例(8.5%),均在术后3个月内恢复；暂时性低钙性手足麻木3例(4.5%),经过静脉推注葡萄糖酸钙后1周内缓解,无永久性喉返神经损伤、永久性低钙抽搐等并发症发生。
结论1.中央区淋巴结转移与原发灶侵犯包膜及年龄在45岁及45岁以上者有关；
2.中央区淋巴结转移与原发肿瘤大小无关；
3.cN0甲状腺乳头状癌行中央区淋巴结清扫术是必要的、安全的处理方式。
Objective Papillary thyroid carcinoma is the most common malignancy in thyroid gland as well as in the endocrine system. Most patients present a mass or masses in the thyroid gland with no evidence of lymph node metastasis as the first symptom, which we called cNo patient. But lymph node metastasis is the main metastatic way of papillary thyroid carcinoma which occurred in about 10% cNo cases. It is now well-accepted that there are relations between lymph node metastasis and prognosis of papillary thyroid carcinoma which is concluded from several long term follow-up investigations. According to the staging of TNM of UICC 2002, author aimed in this study to analyze discussed the influential factors of central lymph node metastasis and to evaluate the value of the central compartment neck dissection for cNo papillary thyroid carcinoma.
Methods Retrospective analysis had been done to patients of papillary thyroid carcinoma patients who had no evidence of lymph node metastasis before operation. From January 2005 to January 2009,67 patients with the central compartment lymph node dissection were studied. All the cases were underwent frozen section and were confirmed by pathological exam who followed-up for the cervicolateral compartment lymph node recurrence.
Results There were 22 male and 45 female patients, media age of 42±2years. The age of 35 patients was 45years or more than 45 years.22 patients of the tumor size were less than 1.0cm,45 patients of the tumor size were more than 1.0cm. The tumor of 27 patients enveloped violations and 40 patients did not envelop violations. The central lymph node metastasis incidence is 50.7% in 67 cNo cases. The central lymph node metastasis was related with the carcinoma invaded thyroid envelope and age of 45 or more than 45 years. No death occurred in the 67 cases after operation in our hospital,5cases of whom showed temporary vocal cord paralysis and 3 cases showed temporary aeroanesthes due to hypocalcemia. There were no such complications as laryngeal nerves injury and hypocalcaemia tenancy.
Conclusions 1. The central lymph node metastasis was related with the carcinoma invaded thyroid envelope and age of 45 or more than 45 years;
2. The central lymph node metastasis was not related with tumor size.;
3. It is necessary and safe to perform central compartment neck dissection during cN0 papillary thyroid carcinoma operation.
研究方法以手术前cN0的甲状腺乳头状癌患者为研究对象,对我院2005年1月至2009年1月术中冰冻病理确诊为甲状腺乳头状癌而行中央区淋巴结清扫术的67例患者的临床资料进行回顾性统计分析,并对患者进行颈侧区淋巴结转移等为主要内容的随访。
结果67例患者中,男22例,女45例,年龄中位年龄42±2岁；其中大于或等于45岁35例,小于45岁32例,其中原发肿瘤直径小于1cm的22例,大于1cm的45例,有包膜浸润的27例,无包膜浸润的40例。67例cN0甲状腺乳头状癌患者中央区淋巴结转移率50.7%(34/67)。发现中央区淋巴结转移与原发肿瘤大小无关(χ2=0.42,P>0.05)；与原发肿瘤侵犯包膜(χ2=8.76,P<0.01)有关,与年龄在45岁及45岁以上者(χ2=4.30,P<0.05)有关,67例患者中无一例出现饮水呛咳,无一例出现淋巴瘘、乳糜瘘,出现一过性声音嘶哑5例(8.5%),均在术后3个月内恢复；暂时性低钙性手足麻木3例(4.5%),经过静脉推注葡萄糖酸钙后1周内缓解,无永久性喉返神经损伤、永久性低钙抽搐等并发症发生。
结论1.中央区淋巴结转移与原发灶侵犯包膜及年龄在45岁及45岁以上者有关；
2.中央区淋巴结转移与原发肿瘤大小无关；
3.cN0甲状腺乳头状癌行中央区淋巴结清扫术是必要的、安全的处理方式。
Objective Papillary thyroid carcinoma is the most common malignancy in thyroid gland as well as in the endocrine system. Most patients present a mass or masses in the thyroid gland with no evidence of lymph node metastasis as the first symptom, which we called cNo patient. But lymph node metastasis is the main metastatic way of papillary thyroid carcinoma which occurred in about 10% cNo cases. It is now well-accepted that there are relations between lymph node metastasis and prognosis of papillary thyroid carcinoma which is concluded from several long term follow-up investigations. According to the staging of TNM of UICC 2002, author aimed in this study to analyze discussed the influential factors of central lymph node metastasis and to evaluate the value of the central compartment neck dissection for cNo papillary thyroid carcinoma.
Methods Retrospective analysis had been done to patients of papillary thyroid carcinoma patients who had no evidence of lymph node metastasis before operation. From January 2005 to January 2009,67 patients with the central compartment lymph node dissection were studied. All the cases were underwent frozen section and were confirmed by pathological exam who followed-up for the cervicolateral compartment lymph node recurrence.
Results There were 22 male and 45 female patients, media age of 42±2years. The age of 35 patients was 45years or more than 45 years.22 patients of the tumor size were less than 1.0cm,45 patients of the tumor size were more than 1.0cm. The tumor of 27 patients enveloped violations and 40 patients did not envelop violations. The central lymph node metastasis incidence is 50.7% in 67 cNo cases. The central lymph node metastasis was related with the carcinoma invaded thyroid envelope and age of 45 or more than 45 years. No death occurred in the 67 cases after operation in our hospital,5cases of whom showed temporary vocal cord paralysis and 3 cases showed temporary aeroanesthes due to hypocalcemia. There were no such complications as laryngeal nerves injury and hypocalcaemia tenancy.
Conclusions 1. The central lymph node metastasis was related with the carcinoma invaded thyroid envelope and age of 45 or more than 45 years;
2. The central lymph node metastasis was not related with tumor size.;
3. It is necessary and safe to perform central compartment neck dissection during cN0 papillary thyroid carcinoma operation.
引文
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[3]CaronNR, ClarkOH. Papillary thyroid cancer:surgical management lymph metast-ases. Current Treatment Options in Oncology 2005,6(4):311-322.
[4]Kowalski LP, Bagietto R, Lara JR, et al. ProgNostic significance of the distribution of neck Node metastasis from oral carcinoma [J] Head Neck,2000,22(3):207-217
[5]Leboulleux S, Rubino C Baudin E et al. Prognostic factor for persistent or recurrent disease of thyroid carcinoma with neck lymph node metastes and/or tumor extension beyond the thyroid capsule at intial diagnosis [J] Clinical Endocrinology & Metabolism, 2005,90(10):5723-5729.
[6]卢增红,杨安奎,宋明,等.cNo期甲状腺乳头状癌Ⅵ区淋巴结处理探讨78例报告[J]中国肿瘤,2006,15(1)：-64.
[7]李树玲.新编头颈肿瘤学.[M].科学技术文献出版社,2002：854-863.
[8]屠规益.颈清扫术100年-历史和今天[J]中国口腔领面外科杂志2006,(6)：461-466.
[9]CooPer DS, Doherty GM, HaugenBR,et al.Management guidelines for patients with thy-roid nodules and differentiated thyroid cancer [J] Thyroid,2006,1(6):109-141.
[10]Furio P, Martin S, Henning D, et al. EuroPean consensus for the management of pat-tients with differentiated thyroid carcinoma of the follicular epithelium [J] Eur J of End-oerino,2006,1 (54):787-803.
[11]Sywak M, Cornford L, Roach P, et al. Routine ipsilateral level Ⅵ lymph adenecto-my reduces postoperative thyroglobulin levels in papillary thyroid cancer.Surgery 2006 ,1(40):1000-1008
[12]吴毅,王卓颖.中央区淋巴结清扫术的临床应用[J].外科理论与实践,2003,8(4)：293-294.
[13]White ML, Doherty GM. Level Ⅵ lymph node dissection for papillary thyroid canc-er. Minerva Chir 2007,6(2):383-392.
[14]张仑,李树玲.1173例甲状腺乳头状癌外科治疗远期疗效观察[J]中国肿瘤临床,2003,30(11)：805-808.
[15]Lundgren CI, Hall P, Dickman PW, Zedenius J. Influence of surgical and postopera-tive treatment on survival in differentiated thyroid cancer[J].Br J Surg2007; 9(4):571-583
[16]Bilimoria KY, Bentrem DJ, Ko CY, et al. Extent of surgery affects survival for papillary thyroid cancer[J]. Ann Surg 2007,2(46):375-390.
[17]朱永学,王弘士,吴毅,等.甲状腺乳头状癌Ⅵ区淋巴结的归属[J]中华外科杂志,2004,42(14)：867-869.
[18]张福民,刘垚,李永春,等.前哨淋巴结活检在cNo分化型甲状腺癌的应用体会[J]国际外科学杂志,2007,34(7)：447-49-49.
[19]Alvarado R, Sywak MS, Delbridge L, Sidhu SB. Central lymph node dissection as a secondary procedure for papillary thyroid cancer:is there added morbidity? Surgery 2009; 145:514-526.
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