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浙江大学学报(医学版)  2021, Vol. 50 Issue (6): 722-729    DOI: 10.3724/zdxbyxb-2021-0289
专题报道     
甲状腺微小乳头状癌患者颈部中央淋巴结清扫术后假阴性风险概率的评估
刘文,董治中,苏艳军,马云海,张建明,刁畅,钱军,程若川()
昆明医科大学第一附属医院甲状腺疾病诊治中心,云南 昆明 650032
Risk probability model for residual metastatic lymph node in patients with papillary thyroid microcarcinoma undergoing cervical central lymph node dissection
LIU Wen,DONG Zhizhong,SU Yanjun,MA Yunhai,ZHANG Jianming,DIAO Chang,QIAN Jun,CHENG Ruochuan()
Thyroid Disease Diagnosis and Treatment Center, the First Affiliated Hospital of Kunming Medical University, Kunming 650032, China
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摘要:

目的:通过大样本甲状腺微小乳头状癌(PTMC)队列建立概率模型,量化颈部中央淋巴结(简称中央淋巴结)清扫术后残余转移性淋巴结风险。方法:回顾性分析2007—2020年昆明医科大学第一附属医院甲状腺疾病诊治中心诊断为PTMC、由高手术量医生执行甲状腺切除+中央淋巴结清扫且至少检测1枚淋巴结的病例,进一步描述阳性淋巴结的分布特征并建立评价隐匿性转移性淋巴结风险的数学模型。使用β-二项分布估计隐匿性转移性中央淋巴结的概率作为淋巴结清扫(检测)数的函数。结果:概率模型共纳入5399例连续病例,观察到转移性中央淋巴结1664例(30.8%)。经过模型校正,真实淋巴结转移率由30.8%升高至38.9%。在清扫(检测)1枚淋巴结时,中央淋巴结假阴性的概率为31.3%,而当清扫(检测)7枚和12枚淋巴结时,假阴性的概率分别降低至10.0%和4.9%。合并桥本甲状腺炎病例的概率模型敏感性分析与主分析显示基本一致的稳健结果。结论:本研究量化了PTMC患者中央淋巴结清扫术后的隐匿性残余转移性淋巴结风险,可以作为评估术后复发/残余风险的补充指标,也为通过回顾性数据资料评估残余转移性淋巴结对肿瘤患者预后的影响提供新的方法。

关键词: 甲状腺乳头状癌概率模型中央淋巴结清扫数假阴性    
Abstract:

Objective:To establish a risk probability model for residual metastatic lymph nodes in patients with papillary thyroid microcarcinoma (PTMC) after cervical central lymph node dissection (CLND). Methods:The clinical data of patients with PTMC treated in the First Affiliated Hospital of Kunming Medical University from 2007 to 2020 were retrospectively reviewed. All patients underwent thyroidectomy with CLND, and at least one lymph node was examined. Based on the distribution characteristics of metastatic lymph nodes from this retrospective cohort, a probabilistic model for the risk of residual metastatic lymph node was established. β-Binomial distribution was used to estimate the probability of residual metastatic lymph node as a function of the number of lymph nodes examined. Results: Among 5399 patients included in the probabilistic model, central lymph node metastases were observed in 1664 cases (30.8%). After model correction, the real lymph node metastasis rate increased from 30.8% to 38.9%. The probability of false negative of central lymph node was estimated to be 31.3% for patients with a single node examined, while decreased to 10.0% and 4.9% when 7 and 12 nodes were examined, respectively. In the sensitivity analysis limited to patients with or without Hashimoto thyroiditis, the performance of probability model was also satisfactory. Conclusions: The established risk probability model in this study quantifies the risk of residual metastatic lymph nodes after CLND in patients with PTMC, which can be used as complementary indicators for the risk of recurrence/persistence disease at postoperative evaluation. The study also provides a new method to evaluate the impact of residual metastatic lymph nodes on the prognosis of tumor patients through retrospective data.

Key words: Papillary thyroid carcinoma    Probabilistic model    Central lymph node    Lymph node yield    False negative
收稿日期: 2021-08-06 出版日期: 2022-03-22
CLC:  R736.1  
基金资助: 云南省普通外科疾病临床医学中心建设项目(2X2019-03-03);云南省“万人计划”——名医专项(RLCRC20210412)
通讯作者: 程若川     E-mail: cruochuan@foxmail.com
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引用本文:

刘文,董治中,苏艳军,马云海,张建明,刁畅,钱军,程若川. 甲状腺微小乳头状癌患者颈部中央淋巴结清扫术后假阴性风险概率的评估[J]. 浙江大学学报(医学版), 2021, 50(6): 722-729.

LIU Wen,DONG Zhizhong,SU Yanjun,MA Yunhai,ZHANG Jianming,DIAO Chang,QIAN Jun,CHENG Ruochuan. Risk probability model for residual metastatic lymph node in patients with papillary thyroid microcarcinoma undergoing cervical central lymph node dissection. J Zhejiang Univ (Med Sci), 2021, 50(6): 722-729.

链接本文:

https://www.zjujournals.com/med/CN/10.3724/zdxbyxb-2021-0289        https://www.zjujournals.com/med/CN/Y2021/V50/I6/722

=P(TP)+P(FN)=TP+FNTP+FN+TN(1)
  
P(FNm)=Beta?(αβ+m)Beta?(α+?β)(2)
  
FNm=P(FNm)?×TPmP(TPm)=P(FNm)×TPm1?P(FNm)(3)
  
=?m(TP+FN)?m(TP+FN+TN)(4)
  
图 1  建模队列入组流程图

淋巴结转移情况

n

年龄

女性

淋巴结清扫数(枚)

术前cN0状态

腺外浸润

阳性

1664

40(33,48)

1193(71.7)

9(6,13)

1312(78.8)

125(7.5)

阴性

3735

45(38,52)*

3111(83.3)*

6(4,10)*

3469(92.9)*

77(2.1)*

合计

5399

43(36,51)

4304(79.7)

7(4,11)

4781(88.6)

202(3.7)

淋巴结转移情况

n

甲状腺切除范围#

中央淋巴结清扫范围

合并HT

全切

腺叶切除

全中央淋巴结

单侧中央淋巴结

阳性

1664

1078(64.8)

586(35.2)

1138(68.4)

526(31.6)

451(27.1)

阴性

3735

2075(55.6)*

1660(44.4)*

2062(55.2)*

1673(44.8)*

1064(28.5)

合计

5399

3153(58.4)

2246(41.6)

3200(59.3)

2199(40.7)

1515(28.2)

表 1  基于淋巴结转移情况的建模队列患者特征
图 2  根据中央淋巴结清扫数估算中央淋巴结假阴性的概率HT:桥本甲状腺炎.

淋巴结清扫数

总人群(n=5150)

未合并HT(n=3653)

合并HT(n=1497)

淋巴结清扫数

总人群(n=5150)

未合并HT(n=3653)

合并HT (n=1497)

1

31.3

31.1

29.5

11

5.6

5.1

7.1

2

25.3

24.7

24.7

12

4.9

4.4

6.3

3

20.6

19.8

20.9

13

4.3

3.9

5.7

4

16.9

16.1

17.7

14

3.9

3.5

5.2

5

14.1

13.3

15.2

15

3.5

3.1

4.7

6

11.8

11.0

13.2

16

3.1

2.8

4.3

7

10.0

9.3

11.5

17

2.8

2.5

3.9

8

8.6

7.9

10.1

18

2.5

2.3

3.6

9

7.4

6.7

8.9

19

2.3

2.1

3.3

10

6.4

5.8

7.9

20

2.1

1.9

3.1

表 2  甲状腺微小乳头状癌患者中央淋巴结清扫数对应的转移性淋巴结假阴性概率
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