1999-2006 年期间治疗的甲状腺乳头状癌行初次外科治疗时优化手术方式的风险和适宜性。
Risks and adequacy of an optimized surgical approach to the primary surgical management of papillary thyroid carcinoma treated during 1999-2006.
机构信息
Department of Gastrointestinal and General Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
出版信息
World J Surg. 2010 Jun;34(6):1239-46. doi: 10.1007/s00268-009-0307-9.
BACKGROUND
Intense disease surveillance and frequent lymph node metastases (LNMs) in papillary thyroid cancer (PTC) have resulted in increased locoregional recurrences. We examined the safety and efficacy of an optimized surgical approach including preoperative ultrasonography (US), bilateral thyroidectomy, routine compartment VI dissection, and lateral neck dissection for LNM.
METHODS
During 1999-2006, a total of 420 patients underwent optimized primary surgery; 291(69%) females, median age 46 years; follow-up 98%, median 4.4 years. Patients were reviewed for tumor characteristics, pattern of LNM, staging, and outcomes.
RESULTS
Total or near-total thyroidectomy was performed in 212 (51%) and 208 (49%) patients, respectively. Tumors were multicentric, 40% (average 1.7 cm); were bilateral, 30%; and showed extrathyroidal extension, 17%. Overall, 223 (53%) patients had LNMs: 213 (51%) were central and 85 (20%) were lateral jugular. pTNM staging: I, 258 (61%); II, 35 (8%); III, 88 (21%); IV, 39 (9%). AGES (age, grade, extension, and size-thyroid tumor; and MACIS (metastasis, age, completeness of resection, invasion, and size) prognostic scores were low risk in 362 (86%) and 352 (84%), respectively. Relapse developed in 57 (14%) patients: LNM in 44, soft tissue local recurrence (LR) in 5, distant metastases (DM) in 8. Hypoparathyroidism occurred in 5 (1.2%) patients and 1 had unintentional laryngeal nerve damage. Relapse with LNM occurred in previously operated fields in 19 (5%) patients, 11(3%) from disease virulence (LR or DM), preoperative false-negative (FN) US in 12 (3%), and combination of FN-US and recurrence in the operated field in 5 (1%) patients.
CONCLUSIONS
Recurrence was limited to 5% of patients when the extent of disease was accurately defined and potentially curable. This optimized surgical strategy is relatively safe.
背景
由于甲状腺乳头状癌（PTC）疾病监测强度大且淋巴结转移（LNM）频繁，导致局部区域复发率增加。我们研究了一种优化的手术方法的安全性和有效性，该方法包括术前超声检查（US）、双侧甲状腺切除术、常规 VI 区解剖和 LNM 侧颈部清扫术。
方法
1999 年至 2006 年期间，共有 420 例患者接受了优化的初次手术；291 例（69%）为女性，中位年龄 46 岁；中位随访时间为 4.4 年。对患者的肿瘤特征、LNM 模式、分期和结果进行了回顾性分析。
结果
分别有 212 例（51%）和 208 例（49%）患者接受了全甲状腺或近全甲状腺切除术。肿瘤多灶性，占 40%（平均 1.7cm）；双侧受累占 30%；有甲状腺外侵犯占 17%。总体而言，223 例（53%）患者存在 LNM：213 例（51%）为中央区 LNM，85 例（20%）为侧颈区 LNM。pTNM 分期：I 期 258 例（61%）；II 期 35 例（8%）；III 期 88 例（21%）；IV 期 39 例（9%）。AGEs（年龄、分级、侵犯程度和肿瘤大小）和 MACIS（转移、年龄、切除术完整性、侵犯程度和肿瘤大小）预后评分低危的分别有 362 例（86%）和 352 例（84%）。57 例（14%）患者出现复发：44 例 LNM，5 例软组织局部复发（LR），8 例远处转移（DM）。5 例（1.2%）患者出现甲状旁腺功能减退，1 例患者出现喉返神经损伤。19 例（5%）患者在原手术区域复发，其中 11 例（3%）为疾病进展（LR 或 DM），12 例（3%）为术前超声检查假阴性（FN-US），5 例（1%）为 FN-US 联合原手术区域复发。
结论
当准确确定疾病范围且具有潜在治愈可能时，复发仅局限于 5%的患者。这种优化的手术策略相对安全。
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