Ruel Ewa, Thomas Samantha, Perkins Jennifer M, Roman Sanziana A, Sosa Julie A
Department of Medicine (Endocrinology, Metabolism and Nutrition), Duke University Medical Center, Durham, NC, USA.
Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA.
Ann Surg Oncol. 2017 Jul;24(7):1935-1942. doi: 10.1245/s10434-016-5719-9. Epub 2017 Jan 26.
Management of patients with low-risk papillary thyroid cancer (PTC) with clinically uninvolved lymph nodes (cN0 LNs), but who harbor metastatic central LNs (pN1a), remains unclear. The number of central LNs examined, radioactive iodine (RAI) utilization, and survival were compared across cN0 patients based on pN stage: pN0 (negative) versus pNx (unknown) versus pN1a (pathologically positive).
Adults with a PTC ≥1 cm who were cN0 preoperatively were compared based on surgical pathology using the National Cancer Data Base (NCDB; 2003-2011), after univariate and multivariate adjustment. Overall survival (OS) was examined using Kaplan-Meier curves, the log-rank test, and Cox proportional hazards modeling.
Overall, 39,301 patients were included; median tumor size was 1.9 cm. More LNs were examined for pN1a versus pN0 diagnosis (pN1a median = 5 LNs vs. pN0 median = 2 LNs; p < 0.0001), with a median of two central LNs found to be positive on surgical resection. Compared with pN0, pN1a patients were 78% more likely to receive RAI (odds ratio 1.78, 95% confidence interval [CI] 1.65-1.91; p < 0.0001). After adjusting for receipt of RAI, no difference in OS was observed for pN1a versus pN0 or pNx patients (p = 0.72). Treatment with RAI was associated with improved OS (hazard ratio 0.78, 95% CI 0.62-0.98, p = 0.03), but the effect of RAI did not differ based on pN stage (interaction p = 0.67).
More LNs were examined for positive versus negative pN diagnosis in patients with cN0 PTC. Unsuspected central neck nodal metastases in cN0 PTC patients are associated with increased RAI utilization, but no survival difference.
对于低风险乳头状甲状腺癌（PTC）且临床无淋巴结受累（cN0 LNs）但存在中央区淋巴结转移（pN1a）的患者，其管理方法仍不明确。根据pN分期，对cN0患者的中央区淋巴结检查数量、放射性碘（RAI）使用情况及生存率进行比较：pN0（阴性）、pNx（未知）和pN1a（病理阳性）。
使用国家癌症数据库（NCDB；2003 - 2011年），对术前cN0且PTC≥1 cm的成年人进行手术病理比较，经过单因素和多因素调整。采用Kaplan - Meier曲线、对数秩检验和Cox比例风险模型检查总生存期（OS）。
共纳入39301例患者；肿瘤大小中位数为1.9 cm。与pN0诊断相比，pN1a诊断检查的淋巴结更多（pN1a中位数 = 5个淋巴结，pN0中位数 = 2个淋巴结；p < 0.0001），手术切除时发现中央区淋巴结阳性的中位数为2个。与pN0相比，pN1a患者接受RAI的可能性高78%（优势比1.78，95%置信区间[CI] 1.65 - 1.91；p < 0.0001）。在调整RAI使用情况后，未观察到pN1a与pN0或pNx患者在OS方面存在差异（p = 0.72）。RAI治疗与OS改善相关（风险比0.78，95% CI 0.62 - 0.98，p = 0.03），但RAI的效果在pN分期方面无差异（交互作用p = 0.67）。
cN0 PTC患者中，pN阳性与阴性诊断检查的淋巴结更多。cN0 PTC患者未被怀疑的中央区颈部淋巴结转移与RAI使用增加相关，但生存率无差异。
