甲状腺微小乳头状癌颈侧区淋巴结清扫81例临床分析

2017-03-02 19:00徐立林小雷蔡铭智
中外医疗 2016年32期
关键词:危险因素

徐立++林小雷++蔡铭智

DOI:10.16662/j.cnki.1674-0742.2016.32.017

[摘要] 目的 探討甲状腺微小乳头状癌颈侧区淋巴结转移的检查方法、危险因素及手术方法。方法 方便选取该院2009年1月—2016年6月收治的81例次行颈侧区淋巴结清扫的甲状腺微小乳头状癌患者进行回顾性病例分析。分析该81例次患者颈侧区淋巴结转移情况及临床资料的相关性。结果 超声对颈侧区淋巴结转移的敏感性约为88.8%、特异性约为56.5%。有被膜浸润的病灶49例次中转移31例次,无被膜浸润的病灶32例次中转移19例次,差异有统计学意义(P=0.002)。对于单灶病变,位于上极的病灶22例次中转移17例次,位于中下极的病灶41例次中转移16例次,差异有统计学意义(P=0.004)。多灶癌18例次中转移7例次,单灶癌转移63例次中转移33例次,差异无统计学意义(P=0.313)。男性25例次中转移15例次,女性56例次中转移25例次,差异无统计学意义(P=0.202)。年龄<45岁46例次中转移26例次,年龄≥45岁35例次中转移14例次,差异无统计学意义(P=0.141)。59例次采用颈根部衣领式切口,22例次采用传统的L形切口,前者同样能很好的清扫颈侧区淋巴结,不增加手术并发症,在外观满意度及颈肩部活动度方面均优于后者。 结论 甲状腺微小乳头状癌颈侧区淋巴结转移的问题不容忽视,术前超声等检查可以提供较好的敏感性,但特异性不足。癌灶浸润甲状腺被膜及位于上极可能是甲状腺微小乳头状癌颈侧区淋巴结转移的危险因素。

[关键词] 甲状腺微小乳头状癌;颈侧区;淋巴结清扫;危险因素

[中图分类号] R73 [文献标识码] A [文章编号] 1674-0742(2016)11(b)-0017-03

Clinical Analysis of 81 Cases of Lateral Neck Lymph Node Dissection in Papillary Thyroid Microcarcinoma

XU Li ,LIN,Xiao-lei ,CAI Ming-zhi

Zhangzhou City, Fujian Hospital General Surgery Second Department, Zhangzhou, Fujian Province,363000 China

[Abstract] Objective To investigate the check method, risk factor and operation method of the lymph node metastasis in lateral neck of papillary thyroid microcarcinoma.Methods Convenient selection retrospective case analysis was performed on 81 cases from January 2009 to June 2016 with papillary thyroid microcarcinoma which had underwent lateral neck lymph node dissection.To analyze the correlation between the lateral neck lymph node metastasis and the clinical data in these cases.Results The sensitivity of ultrasound to the lymph node metastasis of lateral neck was about 88.8%, and the specificity was about 56.5%.31 caess had metastasis in 49 cases of extracapsular invasion, and 9 caess had metastasis in 32 cases of no extracapsular invasion.The difference was statistically significant (P=0.002).To single lesion cases,7 caess had metastasis in 22 cases located in the upper third of the thyroid lobe,and 16 cases had metastasis in 41 cases located in the middle and lower third of the thyroid lobe.The difference was statistically significant (P=0.004).There was no significant difference between the 7 cases had metastasis in 18 cases with multiple lesions and 33 cases had metastasis in 63 cases with a single lesion (P=0.313).15 cases had metastasis in 25 cases of male,and 25 cases had metastasis in 56 cases of female,the difference was not statistically significant (P=0.202).26 cases had metastasis in 46 cases of age < 45 years, 14 cases had metastasis in 35 cases of age≥ 45 years , there was no statistically significant difference (P=0.141).59 cases with neck root collar incision, 22 cases with traditional L-shaped incision. The former can also very good cleaning the lateral neck lymph node, not increase complications, in appearance satisfaction and neck and shoulder activity degree are superior to those of the latter.Conclusion The problem of lateral neck lymph node metastasis in papillary thyroid microcarcinoma can not be ignored. Preoperative ultrasonography can provide a good sensitivity, but the specificity is not enough. Tumor extracapsular invasion and loction in the upper third of the thyroid lobe may be the most likely risk factors for lymph node metastasis in lateral neck of papillary thyroid microcarcinoma.

[Key words] Papillary thyroid microcarcinoma; Lateral neck region; Lymph node dissection; Risk factors

甲状腺微小乳头状癌(papillary thyroid microcarcinoma,PTMC)指的是病灶最长径≤1.0 cm的甲状腺乳头状癌[1]。绝大多数PTMC起病隐匿,无症状,以前常因合并其他甲状腺疾病手术时意外发现,其生物学行为较好,生长缓慢,部分患者终生携带病灶并无疾病进展。但PTMC不等于低危癌,仍有少数PTMC的生物学行为具有不低的侵袭性,容易出现颈部淋巴结甚至远处转移。PTMC的手术方式特别是淋巴结清扫的范围一直有争议。该研究对2009年1月—2016年6月收治的81例次行颈侧区淋巴结清扫的甲状腺微小乳头状癌患者进行回顾性病例分析,现报道如下。

1 资料与方法

1.1 一般资料

回顾性分析经过病理确诊为PTMC且行颈侧区淋巴结清扫的病例,共81例次。淋巴结分区参照国际颈部6区分区法[2],见图1。

图1 国际颈部6区分区法

1.2 统计方法

采用SPSS 21.0统计学软件版本分析数据,结果采用χ2检验,用(n)表示,进行单因素分析,P<0.05为差异有统计学意义。

2 结果

侧颈淋巴结转移情况与临床资料相关性分析,见表1所示。有被膜浸润的病灶49例次(31例次颈侧区淋巴结转移,18例次无转移),无被膜浸润的病灶32例次(9例次颈侧区淋巴结转移,23例次无转移),差异有统计学意义(P=0.002)。对于单灶病变,位于上极的病灶22例次(17例次颈侧区淋巴结转移,5例次无转移),位于中下极的病灶41例次(16例次颈侧区淋巴结转移,25例次无转移),差异有统计学意义(P=0.004)。多灶性、性别、年龄(<45岁,≥45岁)在颈侧区淋巴结转移率方面差异无统计学意义(P>0.05)。采用颈根部衣领式切口清扫颈侧区淋巴结59例次,采用传统的L形切口22例次;两种术式术后大部分患者均出現颈侧方疼通感,一般不超过2周,服用止痛药可缓解;术后2~4周颈部肿胀及紧缩感常比较明显,之后一般逐步缓解。随访2个月~6年。前组淋巴漏1例(保守治疗10天后好转),颈肩部活动较受限者1例(拿头顶以上的物品有困难),颈肩部受麻木困扰者1例。后组颈部血肿1例(颈横动脉出血,再次手术清除血肿后好转),颈肩部受麻木困扰1例、颈肩部疤痕挛缩1例。前组在外观满意度及颈肩部活动度方面均优于后组。

3 讨论

甲状腺微小乳头状癌的手术方式,尤其是颈侧区淋巴结清扫的必要性和范围,一直是困扰外科医生的问题。目前不同国家及地区对此仍有争议。美国的侧颈淋巴结清扫适应症相对保守,美国甲状腺协会(ATA)不主张行预防性侧颈淋巴结清扫而中国指南相对积极[3-4]。大部分学者认为正常淋巴结的最小径应该≤5 mm,II区淋巴结最大横径>10 mm,颈侧其他区淋巴结最大横径>8 mm应该考虑转移,同时淋巴结纵横比越趋于1.0,淋巴结转移的可能性增大。若想提高敏感性,可以将>5 mm作为诊断淋巴结转移的标准。超声筛查是发现甲状腺颈侧区淋巴结转移的重要检查方法之一,甲状腺癌颈侧区淋巴结转移的超声特征主要有:淋巴结内微小钙化、淋巴门结构消失、纵横比<2、高回声、囊内坏死等,除了微小钙化,其他特征的特异性都不够高。超声对颈侧区淋巴结转移的检出有较高的敏感性,但特异性不强[5-6]。

该组超声对颈侧区淋巴结转移的敏感性约为88.8%、特异性约为56.5%。PTMC颈侧方淋巴结转隐匿性移率并不低,可达30%[7],该组cN0的PTMC颈侧区淋巴结转移率亦达23%,但可能均是因为纳入的病例多含有转移的危险因素。有研究学者认为,在微小癌或术前无确切证据证明颈淋巴结转移的患者中,亦有较高的颈淋巴结转移率[8]。而甲状腺被膜侵犯常备认为是淋巴结转移的独立危险因素,PTC具有侵犯周围组织的生长倾向,一旦肿瘤细胞突破甲状腺被膜,就容易沿被膜周围丰富的淋巴组织向周围淋巴结转移。该研究中有被膜浸润的病灶49例次中转移31例次,无被膜浸润的病灶32例次中转移19例次,差异有统计学意义(P=0.002)。肿瘤位于上极亦被认为是甲状腺癌颈侧区淋巴结转移的危险因素[9-10]。该研究中位于上极的病灶22例次中转移17例次,位于中下极的病灶41例次中转移16例次,差异有统计学意义(P=0.004)。而该研究中多灶性、性别、年龄(<45岁,≥45岁)在颈侧区淋巴结转移率方面差异无统计学意义(P>0.05)。

该研究中59例次采用颈根部衣领式切口,位于锁骨上约1~2 cm与锁骨平行,颈根部衣领式切口避免了侧颈部的竖切口,顺皮肤纹理切开,愈合后疤痕小,不容易疤痕挛缩,且位置低,较隐蔽,具有较好的美容效果及舒适度,且不增加手术并发症。对于临床颈侧区淋巴结阳性,或颈侧区淋巴结阴性但有上述危险因素的患者,建议用该术式行II、III、IV区淋巴结清扫。该研究为回顾性分析,有待更多的病例数及进一步的前瞻性研究,为外科医生提供手术治疗的策略。

[参考文献]

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[3] Mazzaferri EL, Sipos J. Should all patients with subcentimeter thyroid nodules undergo fine-needle aspiration biopsy and preoperative neck ultrasonography to define the extent of tumor invasion [J]. Thyroid, 2008, 18(6):597-602.

[4] 中国抗癌协会甲状腺癌专业委员会.甲状腺微小乳頭状癌诊断与治疗中国专家共识(2016版) [J].中国肿瘤临床,2016,43(10):405-411.

[5] Kim E,Park JS,Son KR, et al.Preoperative diagnosis of cervical metastatic lymph nodes in papillary thyroid carcinoma:comparison of ultrasound,computed tomography,and combined ultrasound with computed tomography[J].Thyroid,2008,18(4):411-418.

[6] Choi YI,Yun Js,Kook SH,et al.Clinical and imaging assessment of cervical lymph node metastatic in papillary thyroid carcinomas[J].World J Surg,2010,34(7):1494-1499.

[7] 陈锐.甲状腺乳头状癌cN0患者颈侧区淋巴结转移规律的探讨[J].中华耳鼻咽喉头颈外科杂志,2012,47(8):662-667

[8] 张广,张纯海,付言涛,等.甲状腺炎合并甲状腺癌颈淋巴结转 移情况及相关因素探讨[J].中国普外基础与临床杂志,2011, 18(6) :625-628.

[9] Zhang L, Wei WJ, Ji QH, et al. Risk factors for neck nodal metastasis in papillary thyroid microcarcinoma: a study of 1066 patients[J].J Clin Endocrinol Metab,2012,97(4):1250-1257.

[10] Jason P.Hunt,Luke.Buchmann,I,ibo wang,et al.An analy sis of factors predicting lateral cervical nodal metastases in papillary carcinoma of the thyroid[J].Arch Otoiaryngology Head Neck Surg,2011,137(11):1141-1145.

(收稿日期:2016-08-15)

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