Department of Surgery, Catholic University of Korea, Seoul, Korea.
Thyroid. 2011 Aug;21(8):873-7. doi: 10.1089/thy.2010.0214. Epub 2011 Jul 11.
Substantial controversy exists over the role of prophylactic neck dissection for patients with papillary thyroid carcinoma (PTC). We hypothesized that a therapeutic strategy of performing a routine intraoperative frozen section of the ipsilateral central lymph node (CLN) after elective ipsilateral CLN dissection (CLND) for all unilateral PTC and then performing a contralateral CLND if the frozen section is positive for malignancy would reduce morbidity compared to a therapeutic strategy of routine bilateral CLND.
In a group of 419 patients with PTC undergoing thyroidectomy during study the period, the 203 patients who had unilateral PTC and no evidence of adenopathy on ultrasonography were prospectively enrolled in our nonrandomized study that was performed between March 2009 and February 2010. Patients underwent a total thyroidectomy if tumor size was over 1 cm or extrathyroidal was detected on ultrasonography. Patients underwent a subtotal or near-total thyroidectomy if tumor size was <1 cm and additional benign tumor existed on contralateral lobe. There were 25 patients who had a unilateral CLND with a subtotal or near-total thyroidectomy, and 178 patients who underwent a unilateral or bilateral CLND with a total thyroidectomy.
There was no difference in the rate of major complications between unilateral CLND group and bilateral CLND group. The rate of transient hypocalcemia was 31.8% in the unilateral CLND group and 45.7% in the bilateral CLND group (p = 0.084). The rate of voice change was 7.6% in the unilateral CLND group 4.3% in the bilateral CLND group (p = 0.438). The ratio of malignant to all nodes retrieved was 0.5/7.88 in the unilateral CLND group and 5.13/17.20 in the bilateral CLND group. There was 78.3% sensitivity and 100% specificity for frozen biopsy of ipsilateral CLN to predict contralateral CLN metastasis. A positive ipsilateral CLN frozen biopsy was significantly associated with contralateral CLN metastasis (p < 0.001), as was younger age (p = 0.002) and existence of extrathyroidal extension (p = 0.031), each on univariate analysis.
In patients with unilateral PTC, routine ipsilateral CLND with intraoperative reading of the frozen section can be employed to assess the risk of contralateral CLN metastasis. This information should be of value in deciding whether to perform contralateral CLND or not.
对于患有甲状腺乳头状癌（PTC）的患者，预防性颈部清扫术的作用存在很大争议。我们假设，对于所有单侧 PTC 患者，在行选择性单侧中央淋巴结清扫术（CLND）后，对同侧中央淋巴结（CLN）进行常规术中冷冻切片检查，如果冷冻切片显示恶性，则采用治疗策略比常规双侧 CLND 的治疗策略可降低发病率。
在研究期间进行甲状腺切除术的 419 例 PTC 患者中，前瞻性纳入了 203 例单侧 PTC 且超声检查无淋巴结病的患者，这些患者于 2009 年 3 月至 2010 年 2 月进行了非随机研究。如果肿瘤大小超过 1cm 或超声检查显示甲状腺外浸润，则行全甲状腺切除术。如果肿瘤大小<1cm 且对侧叶存在其他良性肿瘤，则行甲状腺次全或近全切除术。单侧 CLND 伴甲状腺次全或近全切除术患者 25 例，单侧或双侧 CLND 伴全甲状腺切除术患者 178 例。
单侧 CLND 组和双侧 CLND 组之间主要并发症的发生率无差异。单侧 CLND 组暂时性低钙血症的发生率为 31.8%，双侧 CLND 组为 45.7%（p=0.084）。单侧 CLND 组声音改变的发生率为 7.6%，双侧 CLND 组为 4.3%（p=0.438）。单侧 CLND 组恶性与所有检出淋巴结的比值为 0.5/7.88，双侧 CLND 组为 5.13/17.20。同侧 CLN 冷冻活检预测对侧 CLN 转移的敏感性为 78.3%，特异性为 100%。同侧 CLN 冷冻活检阳性与对侧 CLN 转移显著相关（p<0.001），年龄较小（p=0.002）和存在甲状腺外延伸（p=0.031）也与单侧 CLN 冷冻活检阳性显著相关，这在单因素分析中均有体现。
对于单侧 PTC 患者，可采用常规同侧 CLND 联合术中冷冻切片阅读来评估对侧 CLN 转移的风险。这一信息对于决定是否进行对侧 CLND 具有重要价值。
