Kim Dongju, Bang Seunguk, Yu Gwangju
Department of Surgery, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 03083, Republic of Korea.
Department of Anesthesiology and Pain Medicine, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 03083, Republic of Korea.
J Clin Med. 2025 Sep 3;14(17):6217. doi: 10.3390/jcm14176217.
: Papillary thyroid carcinoma (PTC) frequently presents with cervical lymph node metastasis, even in small tumors, and lateral lymph node involvement serves as an important prognostic factor. Therapeutic lateral neck dissection is typically recommended when nodal metastasis is clinically evident, usually including levels II-V. However, the necessity of routine level II dissection in patients without clinical or radiologic evidence of level II involvement remains controversial, given its association with increased surgical morbidity, particularly injury to the spinal accessory nerve. Identifying reliable clinicopathological predictors of occult level II metastasis may enable more selective surgical approaches that minimize unnecessary dissection while preserving oncologic safety. Therefore, this study aimed to identify clinicopathological risk factors associated with occult level II lymph node metastasis in patients with PTC who have clinically positive lateral nodes but no clinical evidence of level II involvement. : We retrospectively analyzed 1247 patients who underwent thyroidectomy for PTC between 2015 and 2022. Of these, 67 patients with clinically positive lateral lymph node metastasis and clinically negative Level II nodes who underwent therapeutic lateral neck dissection were included. Clinicopathological features were compared between patients with and without occult Level II metastasis. Univariate and multivariate logistic regression analyses were performed to identify independent risk factors. : Among the 67 patients analyzed, 24 (35.8%) had occult Level II metastasis. Compared to those without, patients with occult Level II metastasis had significantly larger primary tumors (2.18 ± 1.31 cm vs. 1.51 ± 1.02 cm, = 0.024), a greater number of central lymph node metastases (5.88 ± 4.41 vs. 3.37 ± 2.66, = 0.005), larger maximum size of metastatic central lymph node (1.44 ± 1.07 cm vs. 0.87 ± 0.48 cm, = 0.004), and a higher number of metastatic lateral lymph nodes (7.63 ± 3.75 vs. 3.19 ± 2.21, < 0.001). Multivariate analysis identified the number of metastatic lateral lymph node as the only independent predictor of occult Level II involvement (OR = 1.57, 95% CI: 1.213-2.044, = 0.001). The final multivariate model demonstrated a Nagelkerke R of 0.46. ROC curve analysis confirmed good predictive performance (AUC = 0.85), and the optimal cut-off value was ≥ 5 metastatic lateral lymph nodes. : A substantial proportion of patients with clinically negative Level II nodes harbor occult metastasis. The number of metastatic lateral lymph nodes is an independent predictor of occult Level II involvement and may assist in tailoring the extent of lateral neck dissection in patients with PTC.
甲状腺乳头状癌（PTC）常伴有颈部淋巴结转移，即使是小肿瘤也如此，而侧方淋巴结受累是一个重要的预后因素。当临床上明显存在淋巴结转移时，通常建议进行治疗性侧颈清扫，通常包括Ⅱ - Ⅴ区。然而，对于没有Ⅱ区受累的临床或影像学证据的患者，常规进行Ⅱ区清扫的必要性仍存在争议，因为这与手术并发症增加有关，尤其是副神经损伤。识别隐匿性Ⅱ区转移的可靠临床病理预测因素可能有助于采用更具选择性的手术方法，在保持肿瘤学安全性的同时尽量减少不必要的清扫。因此，本研究旨在确定在临床上侧方淋巴结阳性但无Ⅱ区受累临床证据的PTC患者中，与隐匿性Ⅱ区淋巴结转移相关的临床病理危险因素。
我们回顾性分析了2015年至2022年间因PTC接受甲状腺切除术的1247例患者。其中，67例临床上侧方淋巴结转移阳性且Ⅱ区淋巴结临床阴性并接受了治疗性侧颈清扫的患者被纳入研究。对有和没有隐匿性Ⅱ区转移的患者的临床病理特征进行了比较。进行单因素和多因素逻辑回归分析以确定独立危险因素。
在分析的67例患者中，24例（35.8%）有隐匿性Ⅱ区转移。与没有隐匿性Ⅱ区转移的患者相比，有隐匿性Ⅱ区转移的患者原发肿瘤明显更大（2.18±1.31 cm对1.51±1.02 cm，P = 0.024），中央淋巴结转移数量更多（5.88±4.41对3.37±2.66，P = 0.005），转移的中央淋巴结最大径更大（1.44±1.07 cm对0.87±0.48 cm，P = 0.004），以及转移的侧方淋巴结数量更多（7.63±3.75对3.19±2.21，P < 0.001）。多因素分析确定转移的侧方淋巴结数量是隐匿性Ⅱ区受累的唯一独立预测因素（OR = 1.57，95%CI：1.213 - 2.044，P = 0.001）。最终的多因素模型显示Nagelkerke R为0.46。ROC曲线分析证实了良好的预测性能（AUC = 0.85），最佳截断值为≥5个转移的侧方淋巴结。
相当一部分Ⅱ区淋巴结临床阴性的患者存在隐匿性转移。转移的侧方淋巴结数量是隐匿性Ⅱ区受累的独立预测因素，可能有助于确定PTC患者侧颈清扫的范围。
