甲状腺乳头状癌淋巴结转移对预后影响的系列研究

发布时间：2018-09-08 11:13

【摘要】：颈部淋巴结转移在甲状腺乳头状癌(papillary thyroid cancer,PTC)患者中的发生率较高,约为20%~50%,且对PTC患者的复发和死亡率也有一定的影响。本文第一部分以治疗反应为动态监测指标,探讨淋巴结转移率(lymph node metastatic ratio,LR)对PTC患者131I后治疗反应的预测作用;第二部分从以远处转移(distant metastasis,DM)为预后判断指标,探讨LR对PTC患者发生DM风险的预测价值;第三部分则进一步比较LR和淋巴结转移数目(the number of metastatic lymph nodes,LNs)对PTC患者131I后治疗反应的预测价值。现将三部分的研究内容报告如下:第一部分:LR对PTC患者131I治疗后治疗反应的预测作用目的:探讨PTC患者的LR与131I清甲治疗后临床转归的关系及其预测价值。方法:回顾性分析于北京协和医院行甲状腺次/全切术后131I治疗的143例非远处转移性PTC患者,根据LR将其患者分为Ⅰ组(0~10%)、Ⅱ组(10%~25%)、Ⅲ组(25%~50%)、Ⅳ组(50%)4组,经过20.7个月的中位随访将患者的临床转归分为满意(excellent response,ER)、不确切(indeterminate response,IDR)、血清学反应欠佳(biochemical incomplete response,BIR)和影像学反应欠佳(structural incomplete response,SIR)4类。比较4组患者的基本临床特征、临床转归有无差异;应用受试者工作特征(receiver operating characteristic curves,ROC)曲线评估LR在预测ER方面的价值并确定预测的最佳界值点,进一步通多因素分析评估LR是否可以作为预测ER的独立因素。结果:4组患者的性别、肿瘤(T)分期差异无统计学意义(P均0.05),Ⅰ组年龄显著高于其他3组(F=6.114,P=0.001)。随LR增高,临床转归达到ER者呈下降趋势,同时BIR及SIR者总体呈升高趋势。其中,Ⅳ组的治疗反应ER率明显低于其他3组(27.8%),而更易呈现为BIR(27.80%)及SIR(11.10%)(H=18.816,P=0.000)。LR可以作为预测ER的独立因素(OR=10.011,P=0.000),当其为52.27%时对预测ER具有较高特异性(95.09%),ROC曲线下面积为0.668(P=0.002)。结论:随着LR的增高,患者131I清甲治疗后更易出现较差的临床转归;52.27%这一LR界值点,可以作为预测PTC患者131I治疗后临床转归的独立特异性指标。第二部分:LR对PTC患者发生远处转移风险的预测作用目的:探讨PTC患者LR与DM的关系,及其对DM的预测价值。方法:随访162例PTC患者,将其分为非DM组(M0组)和DM组(M1组)41例和非DM组(M0)121例,采用t检验、χ2检验分别比较两组患者的基本病理特征。采用多因素分析评估LR在预测DM的意义。利用ROC曲线及最佳诊断界值点评估LR及LNs对DM的预测价值,进一步采用Kaplan-Meier曲线评估LN及LNs发生DM的累积风险,使用Log-rank法对差异进行统计学分析。结果:两组患者在年龄及多灶性方面无统计学差异(P0.05),在男性(χ2=13.039,P=0.000)、腺外侵犯(χ2=2.941,P=0.000)、病灶大小(t=-4.485,P=0.000)方面存在显著差异。LR可以作为预测DM的独立因素(OR=1.133,P=0.000),随着LR的增高,LNs≥15组患者的DM风险显著高于LNs15组(P=0.0002)。结论:LR可作为DM的独立预测指标,其与LNs结合可以更好地预测DM的发生风险。第三部分:比较LR和LNs对PTC患者治疗反应的预测价值目的:探讨LR及LNs在不同淋巴结清扫范围(number of dissected LNs,DLNs)下对PTC患者131I治疗反应的预测价值。方法:纳入384名行术后131I治疗的PTC患者,经过中位25.7个月的随访,将患者的治疗反应分为ER、IDR、BIR和SIR四种。应用ROC曲线分别比较在不同DLNs下LR和LNs对ER的预测价值。并进一步应用多因素分析来探索LR及LNs在不同DLNs时是否能够作为预测ER的独立因素。结果:在DLNs≤10这部分患者当中,LR在预测ER的ROC曲线下面积大于LNs(LR:0.687,LNs:0.556,P=0.02);而当DLNs10时,LR在预测ER的ROC曲线下面积小于LNs。多因素分析发现,当DLNs≤10的情况下,LR(OR=1.037,P=0.001)和ps-Tg(OR=1.056,P=0.01)是预测ER的独立因素,而LNs不能作为预测的独立因素(OR=0.752,P=0.09);而当DLNs10时,LNs(OR=1.062,P=0.04)、ps-Tg(OR=1.071,P=0.00)和性别(OR=0.570,P=0.02)成为了预测ER的独立因素。结论在DLNs≤10的情况下,LR对ER具有较好的预测价值;而当DLNs10,LNs对ER的预测更有意义。
[Abstract]:The incidence of cervical lymph node metastasis in patients with papillary thyroid cancer (PTC) is higher, about 20% ~ 50%, and it also affects the recurrence and mortality of PTC patients. The prognostic value of LR in predicting the risk of DM in PTC patients was evaluated by distant metastasis (DM), and the prognostic value of LR and the number of lymph node metastases (LNs) in predicting the response to treatment after 131I in PTC patients was further compared in the third part. Value. The three parts of the study are reported as follows: Part I: Predictive effect of LR on the treatment response of patients with PTC after 131I. Objective: To investigate the relationship between LR and clinical outcome after 131I nail removal and its predictive value. Patients with distant metastatic PTC were divided into four groups according to LR: group I (0-10%), group II (10-25%), group III (25-50%) and group IV (50%). After a median follow-up of 20.7 months, the patients were divided into four groups: excellent response (ER), inaccurate response (IDR), and poor serological response (BIR). Comparing the basic clinical characteristics of the four groups, there was no difference in clinical outcomes; using receiver operating characteristic curves (ROC) curve to evaluate the value of LR in predicting ER and to determine the best predictive threshold point, further unifying multiple factors Results: There was no significant difference in sex, T stage (P 0.05). The age of group I was significantly higher than that of the other three groups (F = 6.114, P = 0.001). With the increase of LR, the clinical prognosis to ER showed a downward trend, while the BIR and SIR showed an overall upward trend. The response ER rate was significantly lower than that of the other three groups (27.8%) and was more likely to be BIR (27.80%) and SIR (11.10%) (H = 18.816, P = 0.000). LR could be an independent predictor of ER (OR = 10.011, P = 0.000). When it was 52.27%, it had a higher specificity for predicting ER (95.09%) and the area under ROC curve was 0.668 (P = 0.002). Conclusion: With the increase of LR, patients with 131I nail clearance therapy had higher specificity (OR = 10.011, P = 0.000). The LR threshold of 52.27% could be used as an independent and specific predictor of clinical outcome in patients with PTC after 131I. Part II: The predictive role of LR in the risk of distant metastasis in patients with PTC Objective: To explore the relationship between LR and DM in patients with PTC and its predictive value for DM. Methods: 162 patients with PTC were followed up. They were divided into non-DM group (M0 group) and DM group (M1 group) with 41 cases and non-DM group (M0 group) with 121 cases. The basic pathological characteristics of the two groups were compared by t test and_2 test. The significance of LR in predicting DM was evaluated by multivariate analysis. The predictive value of LR and LNs for DM was evaluated by ROC curve and the best diagnostic threshold, and Kaplan-Meier curve was further used. The cumulative risk of DM in LN and LNs was assessed by Log-rank analysis. Results: There was no significant difference in age and multifocal sex between the two groups (P 0.05). There were significant differences in male (2 = 13.039, P = 0.000), extraglandular invasion (2 = 2.941, P = 0.000) and lesion size (t = - 4.485, P = 0.000). Independent factors (OR = 1.133, P = 0.000), with the increase of LR, the risk of DM in LNs < 15 group was significantly higher than that in LNs < 15 group (P = 0.0002). Conclusion: LR can be used as an independent predictor of DM, and its combination with LNs can better predict the risk of DM. Part III: Comparing the predictive value of LR and LNs on the treatment response of patients with PTC Objective: To explore the LR and LNs in patients with PTC. The predictive value of 131I response in patients with PTC under different number of dissected LNs (DLNs) was evaluated. Methods: 384 PTC patients treated with 131I were enrolled and divided into ER, IDR, BIR and SIR after a median follow-up of 25.7 months. Results: Among the patients with DLNs < 10, the area under the ROC curve of LR was larger than that of LNs (LR: 0.687, LNs: 0.556, P = 0.02), while the area under the ROC curve of LR was smaller than that of LNs. Element analysis showed that LR (OR = 1.037, P = 0.001) and ps-Tg (OR = 1.056, P = 0.01) were independent predictors of ER when DLNs were less than 10, while LNs could not be independent predictors (OR = 0.752, P = 0.09), while LNs (OR = 1.062, P = 0.04), ps-Tg (OR = 1.071, P = 0.00) and gender (OR = 0.570, P = 0.02) were independent predictors of ER when DLNs were 10. When Ns is less than 10, LR has a good predictive value for ER, while DLNs10 and LNs are more meaningful for ER prediction.
【学位授予单位】：青岛大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R736.1

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