Zhong Xiang, Lu Yunpeng, Yin Xu, Wang Quhui, Wang Feiran, He Zhixian
Department of General Surgery, Affiliated Hospital of Nantong University, Nantong, China.
Department of Hepatobiliary and Pancreatic Surgery, Changzhou No.2 People's Hospital Affiliated to Nanjing Medical University, Changzhou, China.
Gland Surg. 2022 Feb;11(2):378-388. doi: 10.21037/gs-21-906.
This study aimed to explore the risk factors of central lymph node metastasis (CLNM) in patients with clinical central lymph node-negative papillary thyroid carcinoma (PTC), and emphasize the guidance of the risk scoring model for prophylactic central lymph node dissection (pCLND) in patients with clinical lymph node-negative (cN0) PTC.
A total of 582 patients with cN0 PTC who underwent unilateral/bilateral thyroidectomy and prophylactic central lymph node dissection (pCLND) in the Affiliated Hospital of Nantong University from January 2020 to February 2021 were retrospectively analyzed. Univariate and multivariate analyses were performed to determine the risk factors of cN0 PTC. According to the independent risk factors of patients with cN0 PTC, a risk-scoring model was established. Then, the rationality of this risk scoring model was verified by additional clinical data of 112 patients with cN0 PTC in the Affiliated Hospital of Nantong University from March 2021 to April 2021.
Among 582 cases of cN0 PTC, 53.6% of the patients with cN0 had CLNM. The independent risk factors for CLNM in patients with cN0 PTC included male gender, <45 years of age, tumor with a maximum diameter of ≥1.0 cm, tumor location: middle/lower poles of the thyroid gland, multifocality, and extrathyroidal extension (ETE), and some ultrasound features, such as intra-nodular vascularity, microcalcification, irregular shape, and infiltrative margin. According to independent risk factors, a 24-point risk scoring model was established to predict CLNM in patients with cN0 PTC.
Currently, prophylactic central neck lymph node dissection is a controversial operation, which should be selectively performed only for high-risk patients with cN0 PTC. For cN0 PTC patients with scores ≥14 and high-risk patients, even if no CLNM is found before surgery, routine prophylactic CLND is recommended. In addition, for cN0 PTC patients with a score of fewer than 14 points, it is recommended to perform fine-needle aspiration (FNA) before surgery, carefully assess the condition of the central lymph nodes, and then select the best surgical plan based on the results of the assessment.
本研究旨在探讨临床中央淋巴结阴性的乳头状甲状腺癌（PTC）患者中央淋巴结转移（CLNM）的危险因素，并强调风险评分模型对临床淋巴结阴性（cN0）PTC患者预防性中央淋巴结清扫（pCLND）的指导作用。
回顾性分析2020年1月至2021年2月在南通大学附属医院接受单侧/双侧甲状腺切除术及预防性中央淋巴结清扫（pCLND）的582例cN0 PTC患者。进行单因素和多因素分析以确定cN0 PTC的危险因素。根据cN0 PTC患者的独立危险因素，建立风险评分模型。然后，通过南通大学附属医院2021年3月至2021年4月112例cN0 PTC患者的额外临床数据验证该风险评分模型的合理性。
在582例cN0 PTC病例中，53.6%的cN0患者发生CLNM。cN0 PTC患者CLNM的独立危险因素包括男性、年龄<45岁、最大直径≥1.0 cm的肿瘤、肿瘤位置：甲状腺中/下极、多灶性和甲状腺外侵犯（ETE），以及一些超声特征，如结节内血管、微钙化、不规则形状和浸润性边缘。根据独立危险因素，建立了一个24分的风险评分模型来预测cN0 PTC患者的CLNM。
目前，预防性中央颈部淋巴结清扫是一项有争议的手术，应仅对cN0 PTC的高危患者选择性地进行。对于评分≥14分的cN0 PTC患者和高危患者，即使术前未发现CLNM，也建议进行常规预防性CLND。此外，对于评分低于14分的cN0 PTC患者，建议术前进行细针穿刺抽吸（FNA），仔细评估中央淋巴结情况，然后根据评估结果选择最佳手术方案。
