甲状腺乳头状癌颈侧区淋巴结转移与各临床病理特点的相关性及其诊断价值评估

发布时间：2018-09-07 17:49

【摘要】：目的分析甲状腺乳头状癌(papillary thyroid carcinoma, PTC)颈侧区淋巴结转移的相关临床病理特点,并评估这些特点在诊断颈侧区淋巴结转移中的价值。同时总结低位领式切口行PTC择区性清扫的临床应用的可行性。方法搜集2009年1月至2014年12月在南京大学医学院附属鼓楼医院普通外科行低位领式切口下甲状腺全叶切除术+择区性颈淋巴结清扫术的357例术前临床体检及影像学检查均未见明确肿大淋巴结(clinical lymph node negative, CN-)PTC患者及同期在“L”型切口下行甲状腺癌功能性淋巴结清扫术的78例PTC患者。回顾性分析其临床病理资料。淋巴结清扫的范围至少包括同侧的中央区(VI区)、Ⅱ a、Ⅲ、 Ⅳ及Ⅴ b区淋巴结。卡方检验或Fisher确切概率法比较被膜外侵情况、性别、年龄(年龄45岁组与年龄≥45岁组)、Ⅵ区淋巴结、原发灶大小(T≤1cm、1cmT≤4cm及T4cm组)、多灶性情况、彩超淋巴结特点、侧别、彩超颈部淋巴结大小(L1.5cm、1L≤1.5cm及L≤1cm组)与颈侧区淋巴结转移的关系,寻找相关的临床病理特点,比较每一个相关的临床病理特点对颈侧区淋巴结转移的影响度。影响度分析采用主成分分析的方法,以对转移结果的方差解释度的大小来判断影响度的大小每一个临床病理特点及临床病理特点的个数对颈侧区淋巴结转移的诊断价值用敏感度、特异度、阳性预测值(positive predictive value, PPV)、阴性预测值(negative predictive value, NPV)表示。诊断价值的评价指标用约登指数(Youden index, YI)及受试者工作特征曲线(receiver operating characteristic curve, ROC)的曲线下面积(area under the curve, AUC)表示。YI及AUC越大,诊断价值越大。P0.05为有统计学差异。同时比较“L”型切口及低位领式切口行择区性淋巴结清扫术在切口长度、手术时间、清扫总的淋巴结个数、颈侧区淋巴结个数及术后并发症的差异。P0.05为有统计学差异。结果357例CN-的PTC患者中246例(68.91%)发生Ⅵ区淋巴结转移,207例(57.98%)发生颈侧区淋巴结转移,27例(7.56%)发生跳跃性转移。无出现声音嘶哑、术后大出血及复发的病例。与传统的“L”型切口行功能性颈淋巴结清扫术相比,采用颈部低位领式切口行择区性淋巴结清扫术具有切口小(6.5±1.40 vs 13.9+2.33cm)、手术时间短(172.9±41.60 vs 257.3±67.59min)、住院日短(6.7+3.71 vs 7.3±1.67d)、颈部感觉障碍发生率低(1.68%vs15.38%)、美观度高(6.16%vs46.15%)等特点(P0.05),而且术后发生乳糜漏(1.87%vs5.13%)、临床症状性缺钙(22.67%vs28.21%)、清扫的淋巴结个数总和(15.7±7.98 vs 14.7±6.95个)及颈侧区淋巴结个数(10.1±6.58 vs 9.9±5.82个)并无明显差异(P0.05)。颈侧区淋巴结转移与患者的年龄(年龄45岁组66.18%vs年龄≥45岁组47.06%)、Ⅵ区淋巴结情况(有转移73.17%vs无转移24.32%)、被膜累及情况(累及被膜69.90%vs未累及53.15%)、原发灶的大小(T≤1cm组28.57%vslcmT-4cm组59.38%vsT4cm组88.89%)、病灶单发或多发(单发52.0%vs多发68.18%)、彩超淋巴结有无钙化或强回声(有微钙化或强回声67.57%vs无微钙化或强回声53.66%)及彩超淋巴结大小(L1.5cm组75.0%vs1L≤1.5cm组69.57%vs及L≤1cm组35.56%)有关(P0.05),与患者的性别(男60.0%vs女55.93%)、肿瘤侧别(左侧57.69%vs右侧58.21%)无关(P0.05)。建立由这些相关的临床病理特点组成的诊断标准包括年龄45岁、B超颈部淋巴结直径≥1.05cm、原发灶多灶性、Ⅵ区淋巴结有转移、侵犯甲状腺被膜、颈部淋巴结微钙化或强回声及原发灶大小≥1.15cm七个特点。在这七个临床病理特点中,对颈侧区淋巴结转移影响度最大的为颈部淋巴结直径≥1.05cm及Ⅵ区淋巴结有转移这两个特点,其对总方差的解释度百分比依次为27.58%和19.25%。诊断价值最高的为Ⅵ区淋巴结有转移这一特点,其YI为42.96%。随着具备临床病理特点个数的增加(从0至7),颈侧区淋巴结转移率逐渐增高(0.0%、12.90%、30.77%、51.04%、72.16%、90.32%、100.0%及100.0%),灵敏度逐渐下降(100.0%、100.0%、98.07%、88.41%、64.73%、42.03%、14.98%及0.485),特异度逐渐升高(0.0%、2.67%、20.67%、50.67%、82.0%、96.0%、100.0%及100.0%)。具有四个临床病理特点的约登指数最大(YI=46.73%)。AUC为0.81071。ROC曲线中具有四个临床病理特点的点的斜率最接近1(斜率=1.18863)。根据YI及ROC曲线提示具有四个该标准中的临床病理特点显示出了最佳的诊断价值。结论CN-的PTC患者若具备年龄45岁、B超颈部淋巴结直径≥1.05cm、原发灶多灶性、Ⅵ区淋巴结有转移、侵犯甲状腺被膜、原发灶的大小≥1.15cm及淋巴结有微钙化或强回声七个相关临床病理特点中的四个特点,可考虑建议行颈侧区淋巴结清扫。若需清扫,采用低位领式切口行PTC择区性颈部淋巴结清扫是安全可行的。
[Abstract]:Objective To analyze the clinicopathological features of cervical lymph node metastasis in papillary thyroid carcinoma (PTC) and evaluate their value in the diagnosis of cervical lymph node metastasis. In February, 357 patients who underwent total thyroidectomy and selective cervical lymphadenectomy through a low-level neck incision in the General Surgery Department of the Gulou Hospital Affiliated to the Medical College of Nanjing University did not have clear enlarged lymph node negative (CN-) PTC and thyroid gland descending from an "L" incision at the same time. Seventy-eight patients with PTC who underwent functional lymphadenectomy for carcinoma were retrospectively analyzed.The extent of lymph node dissection included at least the ipsilateral central area (VI), the lymph nodes in areas IIa, III, IV and V b.Chi-square test or Fisher exact probability method were used to compare the extracapsular invasion, sex, age (45-year-old group and 45-year-old group) and area VI. Lymph nodes, primary lesion size (T < 1cm, 1cm T < 4cm and T4cm group), multifocal lesions, color Doppler ultrasonography lymph node characteristics, lateral, color Doppler ultrasonography cervical lymph node size (L1.5cm, 1L < 1.5cm and L < 1cm group) and cervical lymph node metastasis in the relationship, looking for the relevant clinical and pathological characteristics, comparing each related clinical and pathological characteristics of the cervical region lymph node metastasis. Influences were analyzed by principal component analysis (PCA). The variance of metastasis results was used to determine the degree of influence. The number of clinicopathological features and the number of clinicopathological features was used to determine the diagnostic value of lymph node metastasis in the cervical lateral region. The diagnostic value was evaluated by the area under the curve (AUC) of Youden index (YI) and receiver operating characteristic curve (ROC). The greater the YI and AUC, the greater the diagnostic value. There were significant differences in incision length, operative time, total number of lymph nodes, number of lymph nodes in the cervical side and postoperative complications between L-type incision and low-position collar incision. There were 7 cases (57.98%) with cervical lymph node metastasis and 27 cases (7.56%) with jumping metastasis. No hoarseness, massive hemorrhage or recurrence occurred. Compared with the traditional "L" incision for functional cervical lymph node dissection, the low neck incision for selective lymph node dissection had a smaller incision (6.5 + 1.40 vs 13.9 + 2.33). Cm, short operation time (172.9 + 41.60 vs 257.3 + 67.59 min), short hospital stay (6.7 + 3.71 vs 7.3 + 1.67 d), low incidence of cervical sensory impairment (1.68% vs 15.38%), high esthetic (6.16% vs 46.15%) and postoperative chylorrhea (1.87% vs 5.13%), symptomatic calcium deficiency (22.67% vs 28.21%) and total number of dissected lymph nodes (15.7 + 7.21%). There was no significant difference in the number of lymph nodes in cervical region (P 0.05). The lymph node metastasis in cervical region was not related to the age of patients (66.18% vs 47.06% vs 45 years old). The lymph node status in area VI (73.17% vs 24.32% without metastasis) was related to the capsule (69.90% vs 53.1%). 5%), primary lesion size (28.57% vs lcmT-4cm group, 59.38% vs T 4cm group, 88.89%), single or multiple lesions (52.0% vs multiple, 68.18%) and lymph node size (75.0% vs 1L < 1.5% vs 69.57% vs < 1 cm group and < 1.1 cm group) with or without calcification or strong echo (67.57% vs without microcalcification or strong echo, 53.66%) and color Doppler ultrasound 35.56% in group A (P 0.05) was associated with gender (60.0% vs 55.93% in males and 55.93% in females) and tumor size (57.69% vs 58.21% on the right side of the left side of the tumor) (P 0.05). The diagnostic criteria consisting of these clinical and pathological features were established, including age 45 years, cervical lymph node diameter (> 1.05 cm) on ultrasonography, multiple primary lesions, lymph node metastasis in area VI, invasion of thyroid capsule. Among the seven clinicopathological features, the cervical lymph node diameter (> 1.05 cm) and the area VI lymph node metastasis were the most influential. The explanatory percentages of the total variance were 27.58% and 19.25% respectively. With the increase of the number of clinicopathological features (from 0 to 7), the rate of lymph node metastasis in the cervical region increased gradually (0.0%, 12.90%, 30.77%, 51.04%, 72.16%, 90.32%, 100.0% and 100.0%). The sensitivity decreased gradually (100.0%, 100.0%, 98.07%, 88.41%, 64.73%, 42.03%, 14.98%, and 0.4%). The specificity increased gradually (0.0%, 2.67%, 20.67%, 50.67%, 82.0%, 96.0%, 100.0% and 100.0%). The Jordan index with four clinicopathological features was the largest (YI = 46.73%). The slope of the four clinicopathological features was the closest to 1 (slope = 1.18863) in the AUC 0.81071.ROC curve. Conclusion If the patient with CN-PTC is 45 years old, the diameter of cervical lymph node is more than 1.05 cm, the primary focus is multifocal, the lymph node in area VI has metastasis, invades the thyroid capsule, the size of primary focus is more than 1.15 cm, and the lymph node has micro-calcification or strong echo. It is safe and feasible to perform PTC selective neck lymph node dissection through low neck incision if neck lymph node dissection is required.
【学位授予单位】：东南大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R736.1

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