1. 雙側頸側區(qū)淋巴結轉移患者的頸淋巴結清掃策略 對術前影像學或細胞學懷疑雙頸側區(qū)淋巴結轉移的患者，應行治療性雙側頸淋巴結清掃術。其治療過程的特殊性主要體現(xiàn)在其手術風險較大，產生術后并發(fā)癥的概率較大，患者術后恢復期較長。因此在行雙頸側區(qū)淋巴結清掃時，術式盡量選擇保留頸內靜脈、副神經和胸鎖乳突肌的改良性頸淋巴結清掃術，若一側病灶局部進展，需行根治性頸淋巴結清掃術時，應仔細保留該側的頸外靜脈和對側的頸內靜脈。手術時機的選擇亦十分重要，對大多數(shù)患者應常規(guī)行一期手術，其優(yōu)點是住院時間短，費用少，并減少麻醉風險。對單側或雙側頸內靜脈侵犯以及不能耐受長時間手術的患者，可考慮行二期手術治療，先行手術難度較大一側的頸淋巴結清掃術，一個月后再行對側頸淋巴結清掃術，其優(yōu)點是第一次手術后視該側頸內靜脈的保留和通暢情況決定二期手術的范圍，或直接行保守治療，以避免雙側頸內靜脈同時結扎造成急性腦水腫，并且有利于患者的術后恢復，提高生活質量。

2. cNx患者的頸側區(qū)淋巴結清掃策略 cNx定義為無法評估的頸部淋巴結病灶，以及當臨床或影像學檢查懷疑轉移可能，但無法進一步確定的患者。事實上在臨床工作中經常會遇到這類患者。如圖9– 4所示病例，對此我們可選擇下頸部橫切口，以功能性頸淋巴結清掃（保留頸叢）的方式對CT發(fā)現(xiàn)的可疑淋巴結進行探查，到達可疑淋巴結區(qū)域后行擇區(qū)性頸淋巴結清掃術（該病例行Ⅲ、Ⅳ區(qū)清掃），并送術中冰凍病理檢查。若冰凍結果為惡性，則原切口繼續(xù)行功能性頸清掃術，或延長切口行改良性頸淋巴結清掃術。需要指出的是，行擇區(qū)性頸淋巴結清掃術的范圍還應參考甲狀腺病灶的位置，對于位于上極的病灶不應遺漏Ⅱ區(qū)淋巴結。

圖9–4　cNx患者術前CT表現(xiàn)。箭頭所示術前頸部CT發(fā)現(xiàn)左頸部Ⅲ區(qū)小淋巴結，影像學表現(xiàn)并不典型，但B超提示轉移性淋巴結

3. 青少年甲狀腺癌的頸淋巴結清掃策略 目前多數(shù)文獻將青少年甲狀腺癌的年齡界限劃定在20歲，20歲以下人群甲狀腺癌的發(fā)病率約為成人的1/10，但是近年來呈上升趨勢。青少年甲狀腺癌較成年人甲狀腺癌有如下特點：① 頸淋巴結轉移率高（40%～90%），且雙頸轉移患者也較高；② 遠處轉移率高（20%～30%），以肺轉移多見；③ 甲狀腺病灶常呈現(xiàn)出多灶性；④ MTC比例升高；⑤ 即使病灶局部進展，甚至出現(xiàn)遠處轉移，該疾病的預后仍然極好。筆者單位曾對69例雙頸淋巴結轉移陽性的青少年甲狀腺癌患者進行了超過20年的隨訪，結果顯示盡管有20.8%的局部復發(fā)率和12.5%的遠處轉移率，但這些患者的10年以及20年生存率分別高達100%和90.9%。對于青少年DTC應常規(guī)行全甲狀腺切除術+雙側PCND，但是預防性側頸淋巴結清掃目前并不推薦。青少年MTC的頸淋巴結清掃原則與成年人相同。為了盡可能保留頸部功能外形，術式常選擇改良性頸淋巴結清掃術或保留頸叢的功能性頸淋巴結清掃術，下頸部橫切口或大弧形切口均為理想的手術切口。由于預后極好，部分患者仍處于生長發(fā)育中，因此在行頸淋巴結清掃時應更注意保留正常組織器官，行中央?yún)^(qū)淋巴結清掃術時應仔細保護雙側喉返神經和甲狀旁腺，避免術后終身氣管造瘺和永久性低鈣血癥的出現(xiàn)，必要時可不強求R0切除，術后輔以放射性核素治療或補充外放射治療。

4. 二次清掃術的策略和原則 二次清掃是臨床工作中不可避免的問題，清掃的對象可能為中央?yún)^(qū)或側頸區(qū)。需要行二次清掃的患者主要分為兩類：① 規(guī)范頸淋巴結清掃術后淋巴結復發(fā)患者；② 不規(guī)范的擇區(qū)性頸淋巴結清掃及淋巴結切除活檢術后的患者。對于前者一般可行擇區(qū)性頸淋巴結清掃術或切除復發(fā)淋巴結，而后者則無論B超或CT等影像學檢查是否提示有殘留病灶，都應再次行規(guī)范系統(tǒng)的頸淋巴結清掃術。二次清掃的難點在于前次手術后形成的瘢痕粘連對正常層次的破壞，在此情況下極易損傷重要組織和器官。因此，手術時機應選擇為前次手術后兩周內或3個月后，以減少瘢痕粘連對操作的影響。此外，再次手術的切口應暴露充分，盡量從既往手術未到達的區(qū)域尋找解剖層次，并盡可能切除前次手術的瘢痕區(qū)。

（李端樹　魏文?。?/p>

參考文獻

[1] Zaydfudim V, Feurer ID, Griffin MR, et al. The impact of lymph node involvement on survival in patients with papillary and follicular thyroid carcinoma[J]. Surgery, 2008,144:1070–1077, 1077–1078.

[2] Leboulleux S, Rubino C, Baudin E, et al. Prognostic factors for persistent or recurrent disease of papillary thyroid carcinoma with neck lymph node metastases and/or tumor extension beyond the thyroid capsule at initial diagnosis[J]. J Clin Endocrinol Metab, 2005;90: 5723–5729.

[3] Podnos YD, Smith D, Wagman LD, et al. The implication of lymph node metastasis on survival in patients with well-differentiated thyroid cancer[J]. Am Surg, 2005, 71: 731–734.

[4] Mulla MG, Knoefel WT, Gilbert J, et al. Lateral cervical lymph node metastases in papillary thyroid cancer: a systematic review of imaging-guided and prophylactic removal of the lateral compartment[J].Clin Endocrinol (Oxf), 2012, 77: 126–131.

[5] Wang TS, Cheung K, Farrokhyar F, et al. A metaanalysis of the effect of prophylactic central compartment neck dissection on locoregional recurrence rates in patients with papillary thyroid cancer[J]. Ann Surg Oncol, 2013, 20: 3477–3483.

[6] Shaha AR. Central compartment dissection for papillary thyroid cancer[J]. Br J Surg, 2013, 100: 438–439.

[7] Cooper DS, Doherty GM, Haugen BR, et al. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer[J]. Thyroid, 2009, 19:1167–1214.

[8] Dralle H, Musholt TJ, Schabram J, et al. German Association of Endocrine Surgeons practice guideline for the surgical management of malignant thyroid tumors[J]. Langenbecks Arch Surg, 2013; 398: 347–375.

[9] Pacini F, Castagna MG, Brilli L, et al. Thyroid cancer:ESMO Clinical Practice Guidelines for diagnosis,treatment and follow-up[J]. Ann Oncol, 2012, 7: i110–i119.

[10] Pitoia F, Ward L, Wohllk N, et al. Recommendations of the Latin American Thyroid Society on diagnosis and management of differentiated thyroid cancer[J].Arq Bras Endocrinol Metabol, 2009,53:884–887.

[11] Martinez TJ, Capdevilla J, Cruz JJ, et al. SEOM clinical guidelines for the treatment of thyroid cancer[J]. Clin Transl Oncol, 2011, 13: 574–579.

[12] Cooper DS, Doherty GM, Haugen BR, et al. Management guidelines for patients with thyroid nodules and differentiated thyroid cancer[J]. Thyroid, 2006, 16:109–142.

[13] Bonnet S, Hartl D, Leboulleux Set al. Prophylactic lymph node dissection for papillary thyroid cancer less than 2 cm: implications for radioiodine treatment. J Clin Endocrinol Metab, 2009, 94: 1162–1167.

[14] Mazzaferri EL, Doherty GM, Steward DL. The pros and cons of prophylactic central compartment lymph node dissection for papillary thyroid carcinoma[J].Thyroid, 2009, 19: 683–689.

[15] Cooper DS, Tufano RP. Prophylactic central neck dissection in differentiated thyroid cancer: a procedure in search of an indication[J]. Thyroid, 2012, 22: 341–343.

[16] Giordano D, Valcavi R, Thompson GB, et al.Complications of central neck dissection in patients with papillary thyroid carcinoma: results of a study on 1087 patients and review of the literature[J]. Thyroid,2012, 22: 911–917.

[17] Zetoune T, Keutgen X, Buitrago D, et al. Prophylactic central neck dissection and local recurrence in papillary thyroid cancer: a meta-analysis[J]. Ann Surg Oncol, 2010, 17: 3287–3293.

[18] Carling T, Carty SE, Ciarleglio MM, et al. American Thyroid Association design and feasibility of a prospective randomized controlled trial of prophylactic central lymph node dissection for papillary thyroid carcinoma[J]. Thyroid, 2012, 22: 237–244.

[19] Gyorki DE, Untch B, Tuttle RM, et al. Prophylactic central neck dissection in differentiated thyroid cancer: an assessment of the evidence[J]. Ann Surg Oncol, 2013, 20: 2285–2289.

[20] Zhang L, Wei WJ, Ji QH, et al. Risk factors for neck nodal metastasis in papillary thyroid microcarcinoma:a study of 1066 patients[J]. J Clin Endocrinol Metab,2012, 97: 1250–1257.

[21] Asari R, Koperek O, Scheuba C, et al. Follicular thyroid carcinoma in an iodine-replete endemic goiter region: a prospectively collected, retrospectively analyzed clinical trial[J]. Ann Surg, 2009, 249: 1023–1031.

[22] Bishop JA, Wu G, Tufano RP, et al. Histological patterns of locoregional recurrence in Hurthle cell carcinoma of the thyroid gland[J]. Thyroid, 2012, 22:690–694.

[23] Farrag T, Lin F, Brownlee N, et al. Is routine dissection of levelⅡ–B andⅤ–A necessary in patients with papillary thyroid cancer undergoing lateral neck dissection for FNA–confirmed metastases in other levels[J]. World J Surg, 2009, 33: 1680–1683.

[24] Zhang XJ, Liu D, Xu DB, et al. Should levelⅤbe included in lateral neck dissection in treating papillary thyroid carcinoma?[J] World J Surg Oncol, 2013,11:304.

[25] Stack BJ, Ferris RL, Goldenberg D, et al. American Thyroid Association consensus review and statement regarding the anatomy, terminology, and rationale for lateral neck dissection in differentiated thyroid cancer[J]. Thyroid, 2012, 22: 501–508.

[26] Eskander A, Merdad M, Freeman JL, et al. Pattern of spread to the lateral neck in metastatic welldifferentiated thyroid cancer: a systematic review and meta-analysis[J]. Thyroid, 2013, 23: 583–592.

[27] Sun G, Wang Y, Zhu Y, et al. Lymph node metastasis between sternocleidomastoid and sternohyoid muscle in clinically node-positive papillary thyroid carcinoma[J]. Head Neck, 2013, 35: 1168–1170.

[28] Moley JF. Medullary thyroid carcinoma: management of lymph node metastases[J]. J Natl Compr Canc Netw, 2010, 8: 549–556.

[29] Kloos RT, Eng C, Evans DB, et al. Medullary thyroid cancer: management guidelines of the American Thyroid Association[J]. Thyroid, 2009, 19: 565–612.

[30] Vander PV, Hens G, Delaere P. Thyroid cancer in children and adolescents[J]. Curr Opin Otolaryngol Head Neck Surg, 2013, 21: 135–142.

[31] Rivkees SA, Mazzaferri EL, Verburg FA, et al. The treatment of differentiated thyroid cancer in children:emphasis on surgical approach and radioactive iodine therapy[J]. Endocr Rev, 2011, 32: 798–826.

[32] 嵇慶海，王宇.改良性頸淋巴清掃術手術要點[J]. 中華耳鼻咽喉頭頸外科雜志，2007，319–320.