甲状腺微小乳头状癌颈Ⅲ、Ⅳ区淋巴结转移相关因素分析及清扫方式

徐迎春　孟利伟　徐潮阳

[摘要] 目的 探討甲状腺微小乳头状癌颈Ⅲ、Ⅳ区淋巴结转移的相关因素和Ⅲ、Ⅳ区择区清扫的方式。 方法 回顾性分析2014年1月～2016年12月我院行同侧中央区及Ⅲ、Ⅳ区淋巴结清扫的甲状腺微小乳头状癌患者136例，分为颈Ⅲ、Ⅳ区淋巴结转移组（n=56）和未转移组（n=80），比较两组患者的临床资料。并与100例同期行中央区淋巴结清扫未行颈Ⅲ、Ⅳ区淋巴结清扫的患者比较，观察两组并发症。 结果 颈Ⅲ、Ⅳ区淋巴结转移组肿瘤最大径、包膜累犯、多灶性、中央区淋巴结阳性比例、平均年龄高于未转移组，差异具有统计学意义（P<0.05），两组患者性别、病灶位置差异无统计学意义（P>0.05）。Ⅲ、Ⅳ区淋巴结清扫组患者术后声音嘶哑、低钙血症和出血的发生率高于未清扫组，但差异无统计学意义（P>0.05），淋巴漏发生率则差异有统计学意义（P<0.05）。 结论 肿瘤最大径、多灶性、包膜累犯、中央区淋巴结阳性、年龄等是甲状腺微小乳头状癌颈Ⅲ、Ⅳ区淋巴结转移的相关因素，胸锁乳突肌内侧入路行Ⅲ、Ⅳ区淋巴结择区清扫创伤小、并发症少，在部分患者中可以替代改良根治性颈淋巴结清扫。

[关键词] 甲状腺微小乳头状癌；淋巴结转移；相关因素；择区清扫；胸锁乳突肌

[中图分类号] R736.1 [文献标识码] B [文章编号] 1673-9701（2018）12-0051-04

Sweeping patterns and analysis of the related factors of lymph node metastasis in region Ⅲ and Ⅳ papillary thyroid microcarcinoma

XU Yingchun MENG Liwei XU Chaoyang

Department of Breast and Thyroid Surgery， Shaoxing People's Hospital in Zhejiang Province， Shaoxing 312000， China

[Abstract] Objective To investigate the risk factors associated with lymph node metastases in papillary thyroid microcarcinoma and to explore the ways of dissecting them in Ⅲ and Ⅳ regions. Methods A retrospective analysis of 136 patients with papillary thyroid microcarcinoma dissected in the ipsilateral central region and Ⅲ and Ⅳ lymph nodes in our hospital from January 2014 to December 2016 was carried out. The cases were divided into two groups： Ⅲ and Ⅳ regions metastasis group（n=56） and no metastasis group （n=80）. The clinical data of two groups were compared. Comparisons were also made between the two groups and 100 patients who underwent lymphadenectomy in the central area without lymph node dissection in the central area. Results The maximum diameter of tumor， peplos recurrence， mulifocalityin， the positive proportion of lymph nodes in central region of Ⅲ and Ⅳ regions metastasis group was significantly higher than that of the non-metastatic group. The two groups had significant difference（P<0.05） There was no significant difference in gender and lesion location（P>0.05）. The incidence of postoperative hoarseness， hypocalcemia and hemorrhage in patients with lymph node dissection in group Ⅲ and Ⅳ was significantly higher than that in patients without lymph node dissection（P>0.05）， and the incidence of lymphoperation was statistically significant （P<0.05）. Conclusion The maximum diameter， multifocality， peplos recurrence， central node lymph node metastasis and age are the related factors of lymph node metastasis in region Ⅲ and Ⅳ papillary thyroid microcarcinoma. Sweeping the tumor in the area of Ⅲ and Ⅳ lymph node by approach of the sternocleidomastoid muscle showed little trauma， fewer complications， it can be an alternative to improve papillary thyroid microcarcinoma lymph node dissection in some patients.

[Key words] Thyroid papillary carcinoma； Lymph node metastasis； Related factors； Clean regions of interest； Sternocleidomastoid muscle

甲状腺微小乳头状癌（papillary thyroid microcarcinoma，PTMC）是指肿瘤直径≤1.0 cm的甲状腺乳头状癌（papillary thyroid carcinoma，PTC），文献报道占PTC的20.0%～42.8%[1]。近年来，随着超声检查的广泛应用和人们对于健康的重视，PTMC的检出率仍在不断增加。PTMC属于肿瘤早期，但并不意味是低危肿瘤，易出现淋巴结转移，文献报道转移率为12%～64%[2]。手术是其主要治疗方法。中国医师协会外科医师分会甲状腺外科医师委员会（Chinese thyroid association，CTA）推荐手术范围为患侧腺叶及峡部切除同时，行同侧中央区淋巴结清扫。多数专家也认同对于临床淋巴结阴性的PTMC患者行同侧中央区淋巴结清扫[3]。但PTMC的淋巴结转移并不局限于中央区，颈侧方也有一定比例转移，Ⅲ、Ⅳ区是侧方最易转移区域。对……