【作者】 王猛；

【导师】 赵永福；

【作者基本信息】 大连医科大学 ， 外科学， 2018， 硕士

【摘要】 目的:探讨甲状腺微小乳头状癌（papillary thyroid microcarcinoma,PTMC）中央区淋巴结癌转移影响因素,明确临床颈部淋巴结阴性（clinically negative central compartment lymph nodes,CN₀）PTMC行预防性中央区淋巴结清扫的临床意义。同时分析PTMC侧颈区淋巴结癌转移的影响因素。方法:通过回顾性研究分析,收集数据来源于某医院甲状腺外科2014年6月至2017年6月期间术后病理诊断为甲状腺微小乳头状癌患者739例。其中684例术前影像学提示CN₀ PTMC,55例术前影像学及穿刺病理提示侧颈区淋巴结癌转移。通过分析患者年龄、性别、肿瘤直径、有无甲状腺被膜侵犯、有无合并桥本氏甲状腺炎、有无甲状腺外组织侵犯、病理学血管侵犯、多发肿瘤癌灶、有无远处转移,从而探讨PTMC中央区淋巴结转移及侧颈区淋巴结转移的影响因素,明确PTMC行预防性中央区淋巴结清扫的临床意义。结果:通过对684例PTMC患者行单变量分析得出结论:男性,年龄<45岁,肿瘤直径>0.55cm,多发肿瘤癌灶,病理学血管侵犯,侵犯甲状腺被膜,和甲状腺外组织侵犯等临床及病理特征对PTMC中央区淋巴结转移有明显影响。对上述因素行logistic回归分析结果:男性、年龄<45岁、肿瘤直径>0.55cm、多发肿瘤癌灶、甲状腺被膜侵犯等临床及病理特征均与PTMC中央区淋巴结转移呈明显相关性（P<0.05）。通过对739例PTMC患者（包含55例侧颈区淋巴结癌转移患者）行单变量分析:男性,肿瘤直径>0.55cm,病理学血管侵犯,病理学甲状腺被膜侵犯,甲状腺外侵犯,远处转移等特征（P<0.05）对PTMC侧颈区淋巴结癌转移有影响。进一步logistic回归分析分析验证:男性,病理学甲状腺被膜侵犯;甲状腺组织外侵犯等（P<0.05）,均与PTMC侧颈区淋巴结转移呈明显相关性。结论:临床CN₀ PTMC中央区淋巴结癌转移的影响因素分析:年龄<45岁、男性、最大肿瘤直径>0.55cm、多发肿瘤癌灶、病理学被膜侵犯。以上变量是PTMC中央区淋巴结癌转移的高危影响因素。PTMC侧颈区淋巴结癌转移的影响因素分析:男性、病理学甲状腺被膜侵犯、甲状腺组织外侵犯。以上变量是PTMC侧颈区淋巴结癌转移的高危影响因素。从数据分析得知,PTMC中央区淋巴结转移率相对较高,且伴随高危险因素者易发展为侧颈区淋巴结癌转移。虽然预防性清扫中央区淋巴结,可增加术后并发症的危险,但大多数为暂时性,且随着术者技术水平的提高及经验的丰富,术后并发症发生率明显降低。因此,研究结果支持对CN₀ PTMC行预防性中央区淋巴结清扫。更多还原

【Abstract】 Objective:This study is aimed to identify the clinical and pathologic factors associated with lymph node metastasis（LNM）including central lymph node metastasis（CLNM）in clinically lymph node negative（CN₀）PTMC patients and lateral lymph node metastasis（LLNM）.The results of our study might be helpful in making optimal therapeutic decision in PTMC patients.Methods:This retrospective cohort study included PTMC patients who underwent primary thyroidectomy with neck dissection at the Department of General Surgery,the Hospital between January 2014 and January 2017.Statistics on the size,age,gender,Hashimoto’s thyroiditis,multifocality,Vascular invasion,extrathyroidal extensions,Capsular invasion,Distant metastasis explore the reasons of central lymph node metastasis and lateral lymph node metastasis.We also discuss the meaning of central lymph node dissection（CLND）.Results:On univariate analyses,Male gender,age<45 years,tumor size>0.55cm,multifocality,Vascular invasion,Capsular invasion and extrathyroidal extension were significantly associated with a high prevalence of CLNM.On logistics regression analysis,male gender,age<45year,tumor size>0.55 cm,multifocality and Capsular invasion were found to be independent predictors of CLNM.However,extrathyroidal extension and Vascular invasion were not independent predictors of high prevalence of CLNM.On univariate analyses,Male gender,tumor size>0.55cm,Vascular invasion,Capsular invasion,extrathyroidal extension and Distant metastasis were significantly different between LLN-positive and LLN-negative groups.On logistics regression analysis,male gender,Capsular invasion,and Extrathyroidal extension were found to be independent predictors of LLNM.However,tumor size>0.55cm and Vascular invasion were not independent predictors of high prevalence of LLNM.All of 55 patients with LLNM defined as LLNM with CLNM.Conclusion:we found a high incidence of CLNM in clinically lymph node-negative PTMC patients.Subclinical CLNM in PTMC patients might be predicted by the following factors:male sex,age<45 years,tumor size>0.55 cm,capsular invasion and multifocality.LLNM in PTMC patients might be predicted by the following factors:male sex,extrathyroidal extension and capsular invasion.According to the analysis,the rate of CLNM in PTMC patients are high,and those with risk factors tend to develop into LLNM.The postoperative complications of CLND are temporary,and with the improvement of technical level and rich experience,the incidence of postoperative complications is decreasing.These findings support that patients with PTMC are likely to benefit from CLND.更多还原