摘要目的 探讨甲状腺乳头状癌临床NO( clinical NO,cN0)患者颈部淋巴结转移规律和外科处理方式.方法 前瞻性研究2007年8月至2010年9月51例甲状腺乳头状癌cNO患者.术前采用核素法和染料法定位前哨淋巴结,并行术中冰冻病理检查,与术后颈清扫标本常规病理进行对照.记录51例患者53侧颈部淋巴结清扫转移淋巴结的数量及在Ⅱ、Ⅲ、Ⅳ、Ⅴ、Ⅵ区的分布情况.研究患者年龄、肿瘤多中心病灶、被膜外侵、肿瘤大小、中央区淋巴转移数目与颈侧区淋巴转移的关系,影响颈侧区淋巴转移率单因素差异比较采用x2检验,Logistic模型进行多因素分析.结果 颈部淋巴结隐匿性转移率77.4％ (41/53),颈侧隐匿性转移率58.5％(31/53),中央区淋巴转移≥3枚是颈侧区淋巴转移的独立危险因素.pNO 12侧,pN+41侧,17侧仅有1个分区转移,占pN+的41.5％( 17/41)；2个或2个以上分区转移24侧,占pN+的58.5％( 24/41).转移淋巴结分布以Ⅵ区最常见,为62.3％(33/53),其次为Ⅲ区52.8％(28/53),Ⅳ区30.2％(16/53),Ⅱ区18.9％(10/53),Ⅴ区0％ (0/53).结论 甲状腺乳头状癌cNO患者隐匿性淋巴结转移以多区转移为主,Ⅵ、Ⅲ、Ⅳ、Ⅱ区常见.中央区淋巴转移≥3枚较易出现颈侧淋巴转移,对cNO患者选择性清扫Ⅱ、Ⅲ、Ⅳ、Ⅵ区能清除大部分存在的颈部隐匿性转移淋巴结.

abstractsObjective To study the patterns of cervical lymph nodes metastasis and the surgical managements of cervical lymph nodes in clinical NO (cNO) papillary thyroid carcinoma.Methods Fiftyone consecutive patients with papillary carcinomas without clinical evidence of cervical lymph node involvement were included in the study between August 2007 and September 2010,in which 53 sides underwent neck lymph node dissection.Preoperative lymphoscintigraphy intra-operative hand-held gamma probe detecting and blue dye techaique were used to detect the sentinel lymph node ( SLN ).SLNs were sent to frozen-section and the results were compared with specimen of roufine selective neck dissection.All the pathologic specimens were reviewed by pathologists,counting the numbers of pathologic positive nodes and mapping the localization of positive nodes in level Ⅱ,Ⅲ,Ⅳ,Ⅴ and Ⅵ respectively.The following criteria were used to study the predictive value of lateral neck compartment lymph node metastasis:age,multifocality of the tumor,extracapsular spread (ECS),tumor size,and the number of central compartment metastasis nodes.Univariate analysis with the x2 test was used to analyze the statistical correlation between lateral neck compartment lymph node metastasis and the other clinical factors.Multiple logistic regression analysis was used to identify the multivariate correlates of lateral neck compartment metastasis.Results The occult lymph node metastasis and lateral neck metastasis rates were 77.4％ and 58.5％ respectively,central compartment metastasis ≥3 nodes was the only independent predictive factor for the metastasis in lateral neck.Twelve sides were pNO and other 41 sides were pN + in all 53 side specimens.Of 41 sides with pN +,17 sides (41.5％) involved single site and 24 sides (58.5％) involved multi-sites.The distribution of metastasis lymph nodes:level Ⅵ 62.3％,level Ⅲ 52.8％,level Ⅳ 30.2％,level Ⅱ 18.9％,and level Ⅴ 0％.Conclusions Cervical occult lymph node metastasis in cNO papillary thyroid carcinoma mainly localizes in level Ⅵ,level Ⅲ,level Ⅳ and level Ⅱ.Selective neck dissection including level Ⅵ,Ⅲ,Ⅳ,Ⅱ is enough for papillary carcinoma without clinical evidence of cervical lymph node involvement.