He Y Y, Chen Y T, Wang J, Chen M Q, Zhu Y M, Ni S, Liu S Y
Department of Head and Neck Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China.
Zhonghua Zhong Liu Za Zhi. 2023 Jan 23;45(1):82-87. doi: 10.3760/cma.j.cn112152-20210701-00490.
To investigate the clinicopathological characteristics of superior mediastinal lymph node metastases (sMLNM) in medullary thyroid carcinoma (MTC). This retrospective analysis enrolled the patients who were treated for sMLNM of MTC in our hospital from May 2012 to January 2021. All patients were suspected of sMLNM due to preoperative imaging. According to the pathological results, the patients were divided into two groups named sMLNM group and the negative superior-mediastinal-lymph-node group. We collected and analyzed the clinical features, pathological features, pre- and post-operative calcitonin (Ctn), and carcinoembryonic antigen (CEA) levels of the two groups. Logistic regression analysis was used to analyze risk factors, and receiver operation characteristic (ROC) curves were drawn to determine the optimal cut-off values of preoperative Ctn and preoperative CEA for predicting sMLNM. Among the 94 patients, 69 cases were in the sMLNM group and 25 cases were in the non-SMLNM group. Preoperative Ctn level (=0.003), preoperative CEA level (=0.010), distant metastasis (=0.022), extracapsular lymph node invasion (=0.013), the number of central lymph node metastases (=0.002) were related to sMLNM, but the multivariate analysis did not find any independent risk factors. The optimal threshold for predicting sMLNM by pre-operative Ctn is 1500 pg/ml and AUC is 0.759 (95% 0.646, 0.872). The sensitivity, specificity, positive predictive value, and negative predictive value of diagnosis are 61.2%, 77.3%, 89.1%, 39.5%, respectively. In patients who underwent mediastinal lymph node dissection through transsternal approach, the metastatic possibility of different levels from high to low were level 2R (82.3%, 28/34), level 2L (58.8%, 20/34), level 4R (58.8%, 20/34), level 3 (23.5%, 8/34), level 4L (11.8%, 4/34). Postoperative complications occurred in 41 cases (43.6%), and there was no perioperative death in all cases. 14.8% (12/81) of the patients achieved biochemical complete response (Ctn≤12 pg/ml) one month after surgery, 5 of these patients were in sMLNM group. For patients who have highly suspicious sMLNM through imaging, combining with preoperative Ctn diagnosis can improve the accuracy of diagnosis, especially for patients with preoperative Ctn over 1 500 pg/ml. The superior mediastinal lymph node dissection for the primary sternotomy should include at least the superior mediastinal levels 2-4 to avoid residual lesions. The strategy of surgery needs to be cautiously performed. Although the probability of biochemical cure in sMLNM cases is low, nearly 40% of patients can still benefit from the operation at the biochemical level.
探讨甲状腺髓样癌（MTC）上纵隔淋巴结转移（sMLNM）的临床病理特征。本回顾性分析纳入了2012年5月至2021年1月在我院接受MTC的sMLNM治疗的患者。所有患者因术前影像学检查怀疑存在sMLNM。根据病理结果，将患者分为sMLNM组和上纵隔淋巴结阴性组。我们收集并分析了两组患者的临床特征、病理特征、术前及术后降钙素（Ctn）和癌胚抗原（CEA）水平。采用逻辑回归分析危险因素，并绘制受试者操作特征（ROC）曲线以确定术前Ctn和术前CEA预测sMLNM的最佳截断值。94例患者中，sMLNM组69例，非sMLNM组25例。术前Ctn水平（=0.003）、术前CEA水平（=0.010）、远处转移（=0.022）、包膜外淋巴结侵犯（=0.013）、中央淋巴结转移数量（=0.002）与sMLNM相关，但多因素分析未发现任何独立危险因素。术前Ctn预测sMLNM的最佳阈值为1500 pg/ml，AUC为0.759（95% 0.646，0.872）。诊断的敏感性、特异性、阳性预测值和阴性预测值分别为61.2%、77.3%、89.1%、39.5%。在经胸骨入路行纵隔淋巴结清扫的患者中，不同水平转移可能性由高到低依次为2R区（82.3%，28/34）、2L区（58.8%，20/34）、4R区（58.8%，20/34）、3区（23.5%，8/34）、4L区（11.8%，4/34）。术后41例（43.6%）发生并发症，所有病例均无围手术期死亡。14.8%（12/81）的患者术后1个月达到生化完全缓解（Ctn≤12 pg/ml），其中5例患者在sMLNM组。对于经影像学检查高度怀疑sMLNM的患者，结合术前Ctn诊断可提高诊断准确性，尤其是术前Ctn超过1500 pg/ml的患者。经胸骨正中切口行上纵隔淋巴结清扫应至少包括上纵隔2 - 4区，以避免残留病变。手术策略需谨慎实施。虽然sMLNM病例生化治愈的概率较低，但近40%的患者仍可在生化水平上从手术中获益。
