Effect of Hashimoto's thyroiditis on degree of necklymph node dissection and prognosis in patients with papillary thyroid carcinoma
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摘要:目的 探讨桥本甲状腺炎（HT）对甲状腺乳头状癌（PTC）患者颈淋巴结清扫程度及预后的影响。方法 回顾性分析2013年1月—2015年12月武汉市红十字会医院收治的180例行甲状腺全切除术联合中央区淋巴结清扫术的PTC患者的临床病理资料。根据术后HT诊断结果将患者分为PTC伴HT组（n=55）和PTC不伴HT组（n=125），手术后随访5年。根据初始治疗反应，依据2015年美国甲状腺协会指南进行动态危险度分层（DRS）。比较2组患者的临床病理特征和DRS；应用受试者工作特征（ROC）曲线评估转移性淋巴结数（PLN）、清扫淋巴结数（LNY）、转移性淋巴结比率（LNR）预测结构性复发/持续性疾病的价值及最佳界值点，并进一步通过Cox比例风险模型评估结构性复发/持续性疾病的风险因素。结果 2组患者颈中央区淋巴结转移差异无统计学意义（P=0.508），伴发HT并不能降低颈淋巴结转移的风险。PTC伴HT组LNY多于PTC不伴HT组，差异有统计学意义（P=0.001）。PTC伴HT组LNR显著较小（P=0.040），并与结构性复发/持续性疾病独立相关（OR=59.574，P=0.012）。在调整了其他临床病理因素后，HT本身与结构性复发/持续性疾病呈显著负相关（OR=0.064，P=0.032）。结论 无论淋巴结清扫达到何种程度，伴发HT是与PTC患者预后良好相关的独立因素。Abstract:Objective To investigate the effect of Hashimoto's thyroiditis (HT) on the degree of neck lymph node dissection and prognosis in patients with papillary thyroid carcinoma (PTC).Methods The clinical and pathological materials of 180 PTC patients underwent total thyroidectomy combined with central lymph node dissection in Wuhan City Red Cross Hospital from January 2013 to December 2015 were retrospectively analyzed. According to the postoperative HT diagnosis, the patients were divided into PTC combined with HT group (n=55) and PTC without HT group (n=125), and all the patients were followed up for 5 years after operation. According to the initial response to treatment, dynamic risk stratification (DRS) was performed according to the guidelines of the American Thyroid Association in 2015. The clinicopathological characteristics and DRS of the two groups were compared. The value and the best cut-off point of the number of positive lymph nodes (PLN), the number of lymph nodes yield (LNY) and lymph nodes ratio (LNR) in predicting structural relapse or persistent disease were evaluated by receiver operating characteristic (ROC) curve, and the risk factors of structural relapse or persistent disease were further evaluated by Cox proportional hazards model.Results There was no significant difference in central cervical lymph node metastasis between the two groups (P=0.508), which suggested that complicating with HT was unable to reduce the risk of cervical lymph node metastasis. LNY in the PTC combined with HT group was significantly more than that in the PTC without HT group (P=0.001). LNR was significantly lower in the PTC with HT group (P=0.040), and was independently associated with structural relapse or persistent disease (OR=59.574, P=0.012). After adjusting for other clinicopathological factors, HT itself was negatively correlated with structural relapse or persistent disease (OR=0.064, P=0.032).Conclusion Regardless of the extent of lymph node dissection, HT is an independent prognostic factor for PTC patients.
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表 1 2组患者临床病理特征(x±s)[n(%)]
变量 PTC伴HT组(n=55) PTC不伴HT组(n=125) t/χ2/Z P 年龄/岁 52.05±11.11 52.40±10.22 -0.203a 0.839 性别 女 51(92.73) 93(74.40) 8.018b 0.005 男 4(7.27) 32(25.60) FT3/(pmol/L) 4.88±0.77 4.86±0.71 0.143a 0.886 FT4/(pmol/L) 15.30±3.83 16.31±2.37 -1.696c 0.090 TSH/(mIU/L) 5.46±11.50 2.60±1.67 -2.036c 0.042 肿瘤直径/cm 1.19±0.35 1.18±0.26 -0.347c 0.728 多灶性 是 17(30.91) 37(29.60) 0.031b 0.860 否 38(69.09) 88(70.40) 甲状腺外侵犯 是 32(58.18) 23(18.40) 0.030b 0.863 否 23(41.82) 102(81.60) 中央区淋巴结转移 是 38(69.09) 80(64.00) 0.438b 0.508 否 17(30.91) 45(36.00) PLN/枚 1.11±0.94 1.26±1.16 -0.609c 0.543 LNY/枚 10.29±1.66 8.07±1.99 7.234a 0.001 LNR 0.10±0.08 0.13±0.12 -2.054c 0.040 a表示采用t检验, b表示采用χ2检验, c表示采用Mann-Whitney U检验。PTC: 甲状腺乳头状癌;
HT: 桥本甲状腺炎; PLN: 转移性淋巴结数; LNY: 清扫淋巴结数; LNR: 转移性淋巴结比率。
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表 2 2组患者动态风险分层[n(%)]
动态风险分层 PTC伴HT组(n=55) PTC不伴HT组(n=125) 反应良好 41(74.54) 90(72.00) 反应不确切 5(9.09) 17(13.60) 生化反应欠佳 6(10.91) 11(8.80) 结构反应欠佳 3(5.46) 7(5.60) PTC: 甲状腺乳头状癌; HT: 桥本甲状腺炎。
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表 3 PTC患者结构性复发/持续性疾病危险因素的单因素和多因素Cox回归分析[n(%)]
变量 单因素分析 多因素分析 复发(n=17) 未复发(n=163) P B OR 95%CI P 年龄≥55岁 13(76.47) 69(42.33) 0.007a 2.884 17.878 3.890~82.172 0.001 女性 15(88.23) 129(79.14) 0.531b - - - - 肿瘤直径>1 cm 13(76.47) 82(50.31) 0.040a 0.679 1.972 0.621~6.261 0.249 多灶 14(82.35) 40(24.54) 0.001a -2.365 0.094 0.008~1.122 0.062 腺外侵犯 12(70.59) 91(55.83) 0.242a - - - - PLN>2枚 14(82.35) 17(10.43) 0.001b 2.187 8.908 1.250~63.478 0.029 LNY>11枚 7(41.18) 42(25.77) 0.249b - - - - LNR>0.4 15(88.23) 23(14.11) 0.001b 4.087 59.574 2.502~1 418.524 0.012 伴发HT 1(5.88) 54(33.13) 0.020a -2.754 0.064 0.005~0.784 0.032 a表示采用Pearson χ2检验, b表示采用Fisher检验。PTC: 甲状腺乳头状癌; HT: 桥本甲状腺炎;
PLN: 转移性淋巴结数; LNY: 清扫淋巴结数; LNR: 转移性淋巴结比率。
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