Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Canada.
Thyroid. 2013 May;23(5):583-92. doi: 10.1089/thy.2012.0493. Epub 2013 Apr 18.
There remains controversy surrounding the extent of lateral neck dissection required in patients with papillary thyroid cancer (PTC) and suspicious or confirmed metastatic lateral neck lymphadenopathy. The evidence for this clinical dilemma has never been reviewed systematically nor has there been an attempt to meta-analyze the data by lymph node levels to better characterize the pattern of spread.
This meta-analysis used MEDLINE and EMBASE including all cohort studies reporting the pattern of lateral neck disease in patients who underwent a neck dissection for clinically, radiographically, or cytologically suspicious or confirmed metastatic lymphadenopathy for PTC. Our main outcome was the number of patients with positive involvement at a given level as a percentage of the cohort of patients with positive lateral neck disease, each level being measured separately.
Eighteen studies with a total of 1145 patients and 1298 neck dissections were included in our meta-analysis. Levels IIa and IIb had disease in 53.1% [95% confidence interval (CI) 46.6-59.5%] and 15.5% [CI 8.2-27.2%], respectively. Studies that did not distinguish between level IIa and IIb or in which both were collapsed into one category showed a total level II involvement of 53.4% [CI 49.7-57.1%]. Level III and level IV were involved in 70.5% [CI 67.0-73.9%] and 66.3% [CI 61.4-70.9%] of specimens. Studies that did not distinguish between level Va and Vb or in which both were collapsed into one category showed a total level V involvement of 25.3% [CI 20.0-31.5%]. Levels Va and Vb had positivity in 7.9% [CI 2.8-20.0%] and 21.5% [CI 7.7-47.6%], respectively, but had only three studies that could be meta-analyzed.
This systematic review of the literature and meta-analysis of the pattern of spread indicates significant rates of lymph node metastasis to all lateral neck levels in patients with PTC with regional involvement. This evidence leads us to recommend a comprehensive selective neck dissection of levels IIa, IIb, III, IV, and Vb in patients with lateral neck disease from PTC. The evidence for level Va is lacking, as most studies did not distinguish between levels Va and Vb, and the border between the two levels was inconsistent. Future studies will need to address these sublevels separately.
在患有甲状腺乳头状癌（PTC）且疑似或确诊转移性侧颈部淋巴结病的患者中，需要进行多大范围的侧颈部清扫术仍存在争议。针对这一临床难题，尚未进行过系统的评估，也从未尝试过通过淋巴结水平进行荟萃分析来更好地描述疾病的扩散模式。
本荟萃分析检索了 MEDLINE 和 EMBASE 数据库，纳入了所有报告 PTC 患者因临床、影像学或细胞学疑似或确诊转移性淋巴结病而行颈部清扫术的侧颈部疾病模式的队列研究。我们的主要结局是在给定水平上阳性受累患者的数量占侧颈部阳性疾病患者队列的百分比，每个水平均单独测量。
共有 18 项研究纳入本荟萃分析，共纳入 1145 例患者和 1298 例颈部清扫术。IIa 区和 IIb 区的疾病发生率分别为 53.1%（95%置信区间 46.6-59.5%）和 15.5%（8.2-27.2%）。未区分 IIa 区和 IIb 区或两者合并为一个分类的研究显示，II 区总受累率为 53.4%（95%置信区间 49.7-57.1%）。III 区和 IV 区的受累率分别为 70.5%（95%置信区间 67.0-73.9%）和 66.3%（95%置信区间 61.4-70.9%）。未区分 Va 区和 Vb 区或两者合并为一个分类的研究显示，V 区总受累率为 25.3%（95%置信区间 20.0-31.5%）。Va 区和 Vb 区的阳性率分别为 7.9%（95%置信区间 2.8-20.0%）和 21.5%（95%置信区间 7.7-47.6%），但仅有 3 项研究可进行荟萃分析。
对文献的系统回顾和扩散模式的荟萃分析表明，在患有 PTC 伴区域性疾病的患者中，所有侧颈部水平均存在明显的淋巴结转移率。这一证据使我们建议对来自 PTC 的侧颈部疾病患者行 IIa、IIb、III、IV 和 Vb 水平的全面选择性颈部清扫术。Va 区的证据不足，因为大多数研究没有区分 Va 区和 Vb 区，且两个区域之间的边界并不一致。未来的研究需要分别解决这些亚区。
