高危因素指导下选择性中央区 淋巴结清扫在cN0-PTC中的 应用及预后研究

Application and Prognostic Study of Selective Central Lymph Node Dissection under High-Risk Factor Guidance in cN0-PTC

摘要: 目的：探讨选择性中央区淋巴结清扫术应用于cN0期甲状腺乳头状癌(papillary thyroid carcinoma, PTC)患者的临床疗效、安全性及对短期预后情况，分析不同高危因素与隐匿性中央区淋巴结转移的相关性，筛选高预测价值指标，为临床个体化手术方案制定提供参考依据。方法：回顾性选取2022年1月~2024年1月我院收治的86例cN0期甲状腺乳头状癌患者为研究对象，根据手术清扫方式分为观察组(选择性中央区淋巴结清扫，43例)和对照组(未行预防性中央区淋巴结清扫，仅行甲状腺病灶切除，43例)。对观察组患者按照高危因素进行亚组分层，分析单一及组合高危因素与隐匿淋巴结转移的关联；统计淋巴结阳性比率、转移淋巴结大小、包膜外侵犯(ENE)等病理细节；对比两组患者手术相关指标、术后并发症发生率、淋巴结隐匿转移情况及2年远期复发率。结果：观察组手术时间、术中出血量略高于对照组，但差异无统计学意义(P > 0.05)；观察组术后暂时性低钙血症、暂时性喉返神经损伤发生率与对照组比较，差异无统计学意义(P > 0.05)，两组均无永久性并发症发生。观察组术后病理检出隐匿性中央区淋巴结转移14例，整体隐匿转移率32.56%；阳性淋巴结共计27枚，阳性淋巴结比率8.65%；转移淋巴结最大径0.2~0.8 cm，平均(0.41 ± 0.15) cm，所有转移病例均未检出淋巴结包膜外侵犯(ENE)。亚组分析显示：肿瘤直径 > 1 cm、肿瘤侵犯甲状腺被膜、男性、多发病灶为隐匿淋巴结转移的强相关因素，其中肿瘤直径 >1 cm联合被膜侵犯的组合高危因素预测价值最高。随访2年，观察组局部复发率、颈部淋巴结复发率显著低于对照组，差异有统计学意义(P < 0.05)。结论：针对cN0期甲状腺乳头状癌患者，结合高危因素实施选择性中央区淋巴结清扫术，不会显著增加手术创伤及并发症风险，可有效清除隐匿转移淋巴结，在2年随访周期内可观察到复发风险有所下降。肿瘤直径 >1 cm、肿瘤侵犯甲状腺被膜是预测隐匿淋巴结转移的核心指标。受研究设计与随访时长限制，该术式的远期预后效果仍有待进一步验证，临床可结合高危因素个体化开展该术式。

Abstract: Objective: To investigate the clinical efficacy, safety, and short-term prognosis of selective central lymph node dissection (CLND) in patients with cN0-stage papillary thyroid carcinoma (PTC), analyze the correlation between different high-risk factors and occult central lymph node metastasis, and screen indicators with high predictive value, so as to provide reference for individualized surgical planning. Methods: A retrospective analysis was conducted on 86 cN0-stage PTC patients treated at our hospital from January 2022 to January 2024. Patients were divided into an observation group (43 cases receiving selective central regional lymphadenectomy) and a control group (43 cases undergoing thyroid lesion resection without prophylactic central regional lymphadenectomy). Patients in the observation group were stratified into subgroups according to high-risk factors, and the correlation between single/combined high-risk factors and occult lymph node metastasis was analyzed. Detailed pathological data including positive lymph node ratio, size of metastatic lymph nodes and extranodal extension (ENE) were recorded. Surgical indicators, postoperative complication rates and 2-year follow-up recurrence status were compared between the two groups. Results: The observation group exhibited slightly longer operative time and higher intraoperative blood loss compared to the control group, but these differences were not statistically significant (P > 0.05). The incidence of postoperative transient hypocalcemia and transient recurrent laryngeal nerve injury in the observation group showed no statistically significant difference from that of the control group (P > 0.05), and no permanent complications occurred in either group. Postoperatively, pathological examination revealed occult central region lymph node metastases in 14 cases (metastasis rate: 32.56%) in the observation group. A total of 27 positive lymph nodes were found, and the positive lymph node ratio was 8.65%. The maximum diameter of metastatic lymph nodes ranged from 0.2 to 0.8 cm, with an average of (0.41 ± 0.15) cm. No lymph node extranodal extension (ENE) was detected in all metastatic cases. Subgroup analysis showed that tumor diameter >1 cm, thyroid capsule invasion, male gender and multiple lesions were strongly correlated with occult lymph node metastasis. The combined risk factor of tumor diameter >1 cm combined with capsule invasion had the highest predictive value. During the 2-year follow-up, the cases of local recurrence and cervical lymph node recurrence in the observation group were fewer than those in the control group, and the difference was statistically significant (P < 0.05). Conclusion: For patients with cN0-stage PTC, selective CLND guided by high-risk factors will not significantly increase surgical trauma and complication risks, and can effectively detect and remove occult metastatic lymph nodes. A decreased recurrence risk was observed within the 2-year follow-up period. Tumor diameter >1 cm and thyroid capsule invasion are core indicators for predicting occult lymph node metastasis. Restricted by study design and follow-up duration, the long-term prognostic effect of this procedure needs further verification. Selective CLND can be carried out individually according to high-risk factors in clinical practice.