Pennestrì Francesco, Procopio Priscilla Francesca, Laurino Antonio, Martullo Annamaria, Santoro Gloria, Gallucci Pierpaolo, Prioli Francesca, Sessa Luca, Rossi Esther Diana, Pontecorvi Alfredo, De Crea Carmela, Raffaelli Marco
UOC Chirurgia Endocrina e Metabolica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.
Centro di Ricerca in Chirurgia delle Ghiandole Endocrine e dell'Obesità, Università Cattolica del Sacro Cuore, Rome, Italy.
World J Surg. 2025 Jan;49(1):187-197. doi: 10.1002/wjs.12440. Epub 2024 Dec 4.
Management of clinically unifocal node-negative papillary thyroid carcinoma ≤1 cm (PTMC) is controversial with nonsurgical treatment as a potential alternative to thyroid lobectomy (TL). However, conservative strategies, such as active surveillance or thermal ablation, do not allow the evaluation of biological aggressive features or occult lymph node metastases (LNMs), which play a primary role as prognostic factors.
Among 4216 thyroidectomies for malignancy (between September 2014 and September 2023), TL plus ipsilateral central neck dissection was performed in 203 (4.8%) unifocal N0 PTMCs. Completion thyroidectomy was accomplished in case of positive frozen section examination of removed nodes or within 6 months from index operation in presence of biological aggressive features.
Seventy-six out of 203 (37.4%) patients were staged pN1a and extranodal extension was detected in 5 (6.6%) patients. At final histology, biological aggressive features, including multifocality, lymphovascular invasion (LVI), extracapsular invasion, tumor aggressive subtypes, and BRAF-V600E mutation, were detected in 69 (34%), 93 (45.8%), 3 (1.5%), 30 (14.8%), and 7 (3.5%) patients, respectively. A comparative analysis between pN0 and pN1a patients showed younger age (p < 0.001), LVI (p = 0.037), and multifocality (p < 0.001) as risk factors for occult central LNMs. After logistic regression analysis, age (p < 0.001) and multifocality (p < 0.001) were confirmed as independent risk factors for nodal involvement.
Although most PTMC has been widely defined as indolent disease, a non-negligible rate of patients may present one or more biologically aggressive features including nodal involvement. Nonsurgical management should be considered with caution to avoid undertreatment especially in the younger population.
临床单灶、淋巴结阴性的直径≤1厘米的甲状腺乳头状癌（PTMC）的治疗存在争议，非手术治疗可作为甲状腺叶切除术（TL）的一种潜在替代方案。然而，保守策略，如主动监测或热消融，无法评估生物学侵袭性特征或隐匿性淋巴结转移（LNM），而这些在预后因素中起主要作用。
在2014年9月至2023年9月期间进行的4216例恶性甲状腺切除术患者中，203例（4.8%）单灶N0 PTMC患者接受了TL加同侧中央区淋巴结清扫术。如果切除淋巴结的冰冻切片检查结果为阳性，或者在出现生物学侵袭性特征的情况下，在初次手术后6个月内完成甲状腺全切除术。
203例患者中有76例（37.4%）为pN1a期，5例（6.6%）患者检测到淋巴结外侵犯。在最终组织学检查中，分别有69例（34%）、93例（45.8%）、3例（1.5%）、30例（14.8%）和7例（3.5%）患者检测到生物学侵袭性特征，包括多灶性、淋巴血管侵犯（LVI）、包膜外侵犯、肿瘤侵袭性亚型和BRAF-V600E突变。pN0和pN1a患者之间的比较分析显示，年龄较小（p < 0.001）、LVI（p = 0.037）和多灶性（p < 0.001）是隐匿性中央区LNM的危险因素。经过逻辑回归分析，年龄（p < 0.001）和多灶性（p < 0.001）被确认为淋巴结受累的独立危险因素。
尽管大多数PTMC被广泛定义为惰性疾病，但仍有不可忽视比例的患者可能呈现一种或多种生物学侵袭性特征，包括淋巴结受累。应谨慎考虑非手术治疗，以避免治疗不足，尤其是在年轻人群中。
