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目的 探讨甲状腺髓样癌患者颈部淋巴结转移规律.方法 回顾性分析1999年1月至2014年10月初治的甲状腺髓样癌91例患者临床资料,其中临床淋巴结阴性(cN0) 39例,临床淋巴结阳性(cN+)52例.91例均行中央区淋巴清扫,52例cN+患者共行71侧颈部淋巴清扫.按颈部分区计数淋巴结数目,研究cN+甲状腺髓样癌患者颈部淋巴结转移规律,以及性别、年龄、髓样癌家族史、原发肿瘤大小、双侧癌灶、多癌灶、被膜侵犯及远处转移等因素与中央区淋巴转移的关系.影响淋巴转移率的单因素差异比较采用x2检验,采用Logistic模型进行多因素分析.结果 本组甲状腺髓样癌患者颈部淋巴结转移率73.6％ (67/91),双侧颈淋巴结转移率19.8％(18/91);中央区淋巴结转移率68.1％(62/91),其中cN0患者33.3％(13/39),cN+患者94.2％ (49/52);上纵隔淋巴结转移率27.5％(25/91),其中cN0患者2.6％(1/39),cN+患者46.2％(24/52).影响中央区淋巴转移的独立危险因素是甲状腺被膜受侵犯(x2=15.592,P=0.000,OR=12.876).cN+甲状腺髓样癌患者颈部淋巴结转移各区转移为Ⅱ区62.9％(44/70)、Ⅲ区84.5％(60/71)、Ⅳ区83.1％ (59/71),Ⅴ区50.0％ (32/64),以多个分区转移为主.术前检测降钙素水平的47例患者中,33例术前降钙素＞300 ng/L,侧颈淋巴结转移率为66.7％ (22/33),较降钙素＜300 ng/L侧颈淋巴结转移率28.6％(4/14)的14例患者增高,两组差异有统计学意义(x2=5.771,P=0.016).结论 甲状腺髓样癌的颈部淋巴结转移率高,对于cN0被膜受侵患者需要清扫中央区淋巴结.对于cN+患者建议清扫同侧Ⅱ-Ⅶ区淋巴结.术前检查降钙素可用来初步预测颈侧淋巴结转移情况.

Objective To study the patterns of cervical lymph node metastasis of medullary thyroid carcinoma.Methods Ninety-one patients with medullary thyroid carcinoma first treated between January 1999 and October 2014 were analyzed retrospectively.Of 91 patients,39 cases presented with clinical negative node (cN0) and 52 cases with clinical positive node (cN +).Central compartment dissection was performed in all cases.Lateral neck dissection was performed in 52 cN + cases (71 sides).All neck dissection specimens were obtained and analyzed for lymph node (LN) involvement with respect to neck levels.The distribution of LN with metastasis was studied in cN + patients and the following factors were used to study the predictive value of central compartment LN metastasis:sex,age,family history,tumor size,bilateral tumor,multifocality of the tumor,extracapsular spread,and remote metastasis.Univariate analysis with the x2 test was used to analyze the statistical correlation between central compartment LN metastasis and other clinical factors.Multiple logistic regression analysis was used to identify the factors related to central compartment metastasis.Results Neck and bilateral neck metastasis rates were 73.6％,19.8％ respectively.Metastasis rates in central compartment and superior mediastinal region were 68.1％ and 27.5％ respectively.The central compartment metastasis rate was 33.3％ in cN0 patients and 94.2％ in cN + patients.The superior mediastinal metastasis rate was 2.6％ in cN0 patients and 46.2％ in cN + patients.Extracapsular spread was an independent predictive factor for central compartment metastasis (x2 =15.592,P =0.000,OR =12.876).The incidences of LN metastases at level Ⅱ,Ⅲ,Ⅴ were 62.9％,84.5％,83.1％,50.0％ in cN + patient,respectively.Multi-sites were involved.The possibility of lateral neck metastasis was higher when preoperative value of calcitonin was higher than 300 ng/L (66.7％ vs 28.6％,x2 =5.771,P =0.016).Conclusions Cervical lymph node metastasis of medullary thyroid carcinoma is higher.Central compartment dissection is necessary in cN0 patients with extracapsular spread.Neck dissection from level Ⅱ to level Ⅶ was necessary in cN + patients.Preoperative value of calcitonin maybe can predict the lateral neck metastasis incidence.