早期cN0 PTC预防性中央区淋巴结清扫的临床研究

doi:10.6040/j.issn.1673-3770.0.2021.462

摘要/Abstract

摘要： 目的探究早期(T1、T2,N0M0)cN0甲状腺乳头状癌(PTC)发生隐匿性中央区淋巴结转移的危险因素并构建预测模型,结合预防性中央区淋巴结清扫术(PCLND)的并发症发生率,为早期cN0 PTC的PCLND提供决策依据。方法回顾性分析454例早期cN0 PTC患者的临床资料,进行统计学分析,并统计入组患者术后并发症发生率。结果男性、年龄≤45岁、直径>1 cm、砂砾体/微钙化形成是隐匿性中央区淋巴结转移的独立危险因素。依据独立危险因素建立预测模型: Logit(P)=-1.735-0.717×性别+0.442×年龄+1.245×肿瘤直径+1.349×砂砾体/微钙化形成。与其他研究相比,本研究PCLND并未显著增加并发症发生率。结论建立的早期cN0 PTC隐匿性中央区淋巴结转移的预测模型有较好的预测效果及实用价值。术前可使用此模型计算隐匿性中央区转移的概率,P值越大,淋巴结转移风险越大,越应该行PCLND。本次研究术后暂时性并发症发生率并未增加,可见规范的手术步骤及良好的手术技巧可提高PCLND的安全性。由于早期cN0 PTC隐匿性中央区淋巴结转移的比例较高(本研究为33.3%),因此对此类患者应积极行PCLND,以清除可能存在的隐匿恶性淋巴结,前提是手术团队的水平能够不增加并发症风险。

关键词: 甲状腺乳头状癌, 中央区淋巴结转移, 危险因素, 预测模型

Abstract: Objective In this study, we explore the risk factors and construct a predictive model for the occult central lymph node metastasis in early cN0 papillary thyroid carcinoma(PTC), combining with the complication rate of prophylactic central lymph node dissection(PCLND), to provide its decision basis. Methods Clinical data of 454 early cN0 PTC patients was retrospectively analyzed. And the incidence of complications was collected. Results Male, age ≤45, diameter>1 cm, and formation of microcalcifications were independent risk factors for occult central lymph node metastasis. A prediction model for occult lymph node metastasis in the central region was established: Logit(P)=-1.735-0.717×gender +0.442×age +1.245×tumor diameter +1.349×microcalcifications. And our PCLND did not increase the incidence of complications. Conclusion The model should be used to calculate the probability of occult central lymph node metastasis before surgery. The larger the P-value is, the higher the risk of lymph node metastasis will be, and PCLND should be performed for these patients. The incidence of temporary postoperative complications in our study is lower than other studies, which showing surgery with good skills will not increase the complication incidence after PCLND. Thus, for the possibility of occult central lymph node metastasis(33% in our study), PCLND should be actively performed in all patients with early cN0 PTC to remove possible occult malignant lymph nodes.

Key words: Papillary thyroid carcinoma, Central lymph node metastasis, Risk factors, Predictive model

中图分类号:

R739.6

肖富亮,林云,潘新良. 早期cN0 PTC预防性中央区淋巴结清扫的临床研究[J]. 山东大学耳鼻喉眼学报, 2023, 37(1): 64-71.

XIAO Fuliang, LIN Yun, PAN Xinliang. A clinical study on prophylactic central lymph node dissection in early cN0 papillary thyroid carcinoma[J]. Journal of Otolaryngology and Ophthalmology of Shandong University, 2023, 37(1): 64-71.

参考文献

[1] GBD Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016[J]. Lancet, 2017, 390(10100): 1211-1259. doi:10.1016/S0140-6736(17)32154-2
[2] 潘新良. 加强甲状腺结节及恶性肿瘤的规范治疗[J]. 山东大学耳鼻喉眼学报, 2020, 34(3): 1-12. doi:10.6040/j.issn.1673-3770.1.2020.037 PAN Xinliang. Improving the standard treatments for thyroid nodules and malignant tumors[J]. Journal of Otolaryngology and Ophthalmology of Shandong University, 2020, 34(3): 1-12.doi:10.6040/j.issn.1673-3770.1.2020.037
[3] Haugen BR, Alexander EK, Bible KC, et al. 2015 American thyroid association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer: the American thyroid association guidelines task force on thyroid nodules and differentiated thyroid cancer[J]. Thyroid, 2016, 26(1): 1-133. doi:10.1089/thy.2015.0020
[4] 中华人民共和国国家卫生健康委员会. 甲状腺癌诊疗规范(2018年版)[J]. 中华普通外科学文献(电子版), 2019, 13(1): 1-15. doi:10.3877/cma.j.issn.1674-0793.2019.01.001 National Health Commission of the People's Republic of China. Diagnosis and treatment guidelines for thyroid cancer(2018 edition)[J]. Chinese Archives of General Surgery(Electronic Edition), 2019, 13(1): 1-15. doi:10.3877/cma.j.issn.1674-0793.2019.01.001
[5] 中国临床肿瘤学会指南工作委员会. 中国临床肿瘤学会(CSCO)分化型甲状腺癌诊疗指南2021[J]. 肿瘤预防与治疗,2021,34(12):1164-1201. doi:10.3969/j.issn.1674-0904.2021.12.013 Guidelines Working Committee of Chinese Society of Clinical Oncology. Guidelines of Chinese Society of Clinical Oncology(CSCO). Differentiated Thyroid Cancer [J]. J Cancer Control Treat, 2021, 34(12):1164- 1201. doi:10.3969/j.issn.1674-0904.2021.12.013
[6] 中华医学会核医学分会. ¹³¹I治疗分化型甲状腺癌指南(2014版)[J]. 中华核医学与分子影像杂志, 2014, 34(4): 264-278. doi:10.3760/cma.j.issn.2095-2848.2014.04.002
[7] 中华医学会超声医学分会浅表器官和血管学组, 中国甲状腺与乳腺超声人工智能联盟. 2020甲状腺结节超声恶性危险分层中国指南: C-TIRADS[J]. 中华超声影像学杂志, 2021, 30(3): 185-200. doi:10.3760/cma.j.cn131148-20210205-00092 Superficial Organ, Vascular Ultrasound Group, Society of Ultrasound in Medicine, Chinese Medical Association; Chinese Artificial Intelligence Alliance for Thyroid, BREAST Ultrasound. 2020 Chinese guidelines for ultrasound malignancy risk stratification of thyroid nodules: the C-TIRADS[J]. Chinese Journal of Ultrasonography, 2021, 30(3): 185-200. doi:10.3760/cma.j.cn131148-20210205-00092
[8] Maneck M, Dotzenrath C, Dralle H, et al. Complications after thyroid gland operations in Germany: a routine data analysis of 66, 902 AOK patients[J]. Chirurg, 2017, 88(1): 50-57. doi:10.1007/s00104-016-0267-1
[9] Zhao HQ, Li HH. Meta-analysis of ultrasound for cervical lymph nodes in papillary thyroid cancer: diagnosis of central and lateral compartment nodal metastases[J]. Eur J Radiol, 2019, 112: 14-21. doi:10.1016/j.ejrad.2019.01.006
[10] 张盼盼, 黄岩, 吕小勇, 等. 甲状腺癌中央区淋巴结转移的影响因素及超声检查转移淋巴结的检出率[J]. 临床与病理杂志, 2019, 39(5): 976-982. doi:10.3978/j.issn.2095-6959.2019.05.011 ZHANG Panpan, HUANG Yan, LÜ Xiaoyong, et al. Influencing factors of the central lymph node metastases in patients with thyroid carcinoma and efficacy of ultrasonography on its diagnosis[J]. Journal of Clinical and Pathological Research, 2019, 39(5): 976-982. doi:10.3978/j.issn.2095-6959.2019.05.011
[11] Asimakopoulos P, Shaha AR, Nixon IJ, et al. Management of the neck in well-differentiated thyroid cancer[J]. Curr Oncol Rep, 2020, 23(1): 1. doi:10.1007/s11912-020-00997-6
[12] Suteau V, Munier M, Briet C, et al. Sex bias in differentiated thyroid cancer[J]. Int J Mol Sci, 2021, 22(23): 12992. doi:10.3390/ijms222312992
[13] Kim K, Kim JH, Park IS, et al. The updated AJCC/TNM staging system for papillary thyroid cancer(8th edition): from the perspective of genomic analysis[J]. World J Surg, 2018, 42(11): 3624-3631. doi:10.1007/s00268-018-4662-2
[14] 庄欢, 廉猛, 房居高, 等. cN0甲状腺微小乳头状癌中央区淋巴结转移相关因素分析[J]. 中国耳鼻咽喉头颈外科, 2020, 27(6): 311-315. doi:10.16066/j.1672-7002.2020.06.005 ZHUANG Huan, LIAN Meng, FANG Jugao, et al. Related factors of central lymph node metastasis in cN0 papillary thyroid microcarcinoma[J]. Chinese Archives of Otolaryngology-Head and Neck Surgery, 2020, 27(6): 311-315. doi:10.16066/j.1672-7002.2020.06.005
[15] 金龙, 程春松, 陈一帆, 等. 微钙化在甲状腺微小乳头状癌患者中的临床意义[J]. 中国耳鼻咽喉头颈外科, 2018, 25(7): 345-348. doi:10.16066/j.1672-7002.2018.07.001 JIN Long, CHENG Chunsong, CHEN Yifan, et al. Clinical significance of microcalcification in patients with thyroid micropapillary carcinoma[J]. Chinese Archives of Otolaryngology-Head and Neck Surgery, 2018, 25(7): 345-348. doi:10.16066/j.1672-7002.2018.07.001
[16] 高晓倩, 姜震, 耿琛琛, 等. 术前超声评估分化型甲状腺癌颈部淋巴结转移[J]. 山东大学耳鼻喉眼学报, 2019, 33(1): 135-139. doi: 10.6040 /j.issn.1673-3770.0.2018.443 GAO Xiaoqian, JIANG Zhen, GENG Chenchen, et al. Preoperative ultrasonography in detecting cervical lymph node metastasis in differentiated thyroid cancer[J]. Journal of Otolaryngology and Ophthalmology of Shandong University, 2019, 33(1): 135-139. doi: 10.6040 /j.issn.1673-3770.0.2018.443
[17] Das DK, Sheikh ZA, George SS, et al. Papillary thyroid carcinoma: evidence for intracytoplasmic formation of precursor substance for calcification and its release from well-preserved neoplastic cells[J]. Diagn Cytopathol, 2008, 36(11): 809-812. doi:10.1002/dc.20898
[18] Zhang TT, Qi XZ, Chen JP, et al. The association between tumor's location and cervical lymph nodes metastasis in papillary thyroid cancer[J]. Gland Surg, 2019, 8(5): 557-568. doi:10.21037/gs.2019.10.02
[19] Lee DJ, Lee KH, Kim JH, et al. Posterosuperior lesion has a high risk of lateral and central nodal metastasis in solitary papillary thyroid cancer[J]. World J Surg, 2015, 39(2): 387-392. doi:10.1007/s00268-014-2839-x.
[20] Sui CQ, He Q, Du R, et al. Lymph node characteristics of 6279 N1 differentiated thyroid cancer patients[J]. Endocr Connect, 2020: EC-20-0019. doi:10.1530/EC-20-0019
[21] 鄢丹桂, 张彬, 王军轶, 等. 甲状腺乳头状癌cN0患者中央区淋巴转移的研究[J]. 中华耳鼻咽喉头颈外科杂志, 2010, 45(11): 891-894. doi:10.3760/cma.j.issn.1673-0860.2010.11.005 YAN Dangui, ZHANG Bin, WANG Junyi, et al. Central compartment lymph node metastasis in cN0 papillary thyroid carcinoma[J]. Chinese Journal of Otorhinolaryngology Head and Neck Surgery, 2010, 45(11): 891-894. doi:10.3760/cma.j.issn.1673-0860.2010.11.005
[22] Maneck M, Dotzenrath C, Dralle H, et al. Case volume and complications after thyroid gland surgery in Germany: an analysis of routine data from 48, 387 AOK patients[J]. Chirurg, 2021, 92(1): 40-48. doi:10.1007/s00104-020-01191-x
[23] 钟琦. 甲状腺手术中甲状旁腺的识别和保护[J]. 山东大学耳鼻喉眼学报, 2017, 31(6): 9-11. doi:10.6040/j.issn.1673-3770.1.2017.047 ZHONG Qi. Identification and protection of the parathyroid glands during thyroidectomy[J]. Journal of Otolaryngology and Ophthalmology of Shandong University, 2017, 31(6): 9-11. doi:10.6040/j.issn.1673-3770.1.2017.047
[24] 郭兴, 陈湘秋, 黄树平. 甲状旁腺的局部解剖及临床应用[J]. 解剖学研究, 2002, 24(4): 296-297 GUO Xing, CHEN Xiangqiu, HUANG Shuping. The regional dissection and clinical application of parathyoid gland[J]. Anatomy Research, 2002, 24(4): 296-297
[25] 焦梦思, 范宁, 石玉琦, 等. 喉返神经入喉处的精细解剖学研究[J]. 中国临床解剖学杂志, 2021, 39(6): 642-645. doi:10.13418/j.issn.1001-165x.2021.06.004 JIAO Mengsi, FAN Ning, SHI Yuqi, et al. Fine anatomy of recurrent laryngeal nerve entrance into the larynx[J]. Chinese Journal of Clinical Anatomy, 2021, 39(6): 642-645. doi:10.13418/j.issn.1001-165x.2021.06.004
[26] 朱精强, 田文, 苏安平. 甲状腺围手术期甲状旁腺功能保护指南(2018版)[J]. 中国实用外科杂志, 2018, 38(10): 1108-1113. doi:10.19538/j.cjps.issn1005-2208.2018.10.03.
[27] 蔡明, 苟菊香, 宁宁. 甲状腺切除术后暂时性甲状旁腺功能减退的发生情况及其影响因素分析[J]. 中国肿瘤外科杂志, 2020, 12(6): 568-570. doi:10.3969/j.issn.1674-4136.2020.06.017 CAI Ming, GOU Juxiang, NING Ning. Logistic analysis the incidence and influencing factors of temporary hypoparathyroidism after thyroidectomy[J]. Chinese Journal of Surgical Oncology, 2020, 12(6): 568-570. doi:10.3969/j.issn.1674-4136.2020.06.017
[28] Praženica P, O'Keeffe L, Holy R. Dissection and identification of parathyroid glands during thyroidectomy: association with hypocalcemia[J]. Head Neck, 2015, 37(3): 393-399. doi:10.1002/hed.23613.
[29] Păduraru DN, Ion D, Carsote M, et al. Post-thyroidectomy hypocalcemia-risk factors and management[J]. Chirurgia(Bucur), 2019, 114(5): 564-570. doi:10.21614/chirurgia.114.5.564
[30] 赵紫涵, 赵诣深, 孙辉. 我国甲状腺术中喉返神经损伤与保护现状[J]. 中国实用外科杂志, 2019, 39(3): 271-274. doi:10.19538/j.cjps.issn1005-2208.2019.03.21
[31] Gao HY, Liu XJ, Yu XF, et al. Application of nano-carbon tracing technology in thyroid cancer and its relationship with cytotoxic T lymphocyte antigen 4 gene polymorphism[J]. J Nanosci Nanotechnol, 2021, 21(2): 949-954. doi:10.1166/jnn.2021.18635

多维度评价

Viewed

Full text

Abstract

Cited

Shared

Discussed