【摘要】：頸部淋巴結(jié)轉(zhuǎn)移在甲狀腺乳頭狀癌(papillary thyroid cancer,PTC)患者中的發(fā)生率較高,約為20%~50%,且對PTC患者的復(fù)發(fā)和死亡率也有一定的影響。本文第一部分以治療反應(yīng)為動(dòng)態(tài)監(jiān)測指標(biāo),探討淋巴結(jié)轉(zhuǎn)移率(lymph node metastatic ratio,LR)對PTC患者131I后治療反應(yīng)的預(yù)測作用;第二部分從以遠(yuǎn)處轉(zhuǎn)移(distant metastasis,DM)為預(yù)后判斷指標(biāo),探討LR對PTC患者發(fā)生DM風(fēng)險(xiǎn)的預(yù)測價(jià)值;第三部分則進(jìn)一步比較LR和淋巴結(jié)轉(zhuǎn)移數(shù)目(the number of metastatic lymph nodes,LNs)對PTC患者131I后治療反應(yīng)的預(yù)測價(jià)值。現(xiàn)將三部分的研究內(nèi)容報(bào)告如下:第一部分:LR對PTC患者131I治療后治療反應(yīng)的預(yù)測作用目的:探討PTC患者的LR與131I清甲治療后臨床轉(zhuǎn)歸的關(guān)系及其預(yù)測價(jià)值。方法:回顧性分析于北京協(xié)和醫(yī)院行甲狀腺次/全切術(shù)后131I治療的143例非遠(yuǎn)處轉(zhuǎn)移性PTC患者,根據(jù)LR將其患者分為Ⅰ組(0~10%)、Ⅱ組(10%~25%)、Ⅲ組(25%~50%)、Ⅳ組(50%)4組,經(jīng)過20.7個(gè)月的中位隨訪將患者的臨床轉(zhuǎn)歸分為滿意(excellent response,ER)、不確切(indeterminate response,IDR)、血清學(xué)反應(yīng)欠佳(biochemical incomplete response,BIR)和影像學(xué)反應(yīng)欠佳(structural incomplete response,SIR)4類。比較4組患者的基本臨床特征、臨床轉(zhuǎn)歸有無差異;應(yīng)用受試者工作特征(receiver operating characteristic curves,ROC)曲線評(píng)估LR在預(yù)測ER方面的價(jià)值并確定預(yù)測的最佳界值點(diǎn),進(jìn)一步通多因素分析評(píng)估LR是否可以作為預(yù)測ER的獨(dú)立因素。結(jié)果:4組患者的性別、腫瘤(T)分期差異無統(tǒng)計(jì)學(xué)意義(P均0.05),Ⅰ組年齡顯著高于其他3組(F=6.114,P=0.001)。隨LR增高,臨床轉(zhuǎn)歸達(dá)到ER者呈下降趨勢,同時(shí)BIR及SIR者總體呈升高趨勢。其中,Ⅳ組的治療反應(yīng)ER率明顯低于其他3組(27.8%),而更易呈現(xiàn)為BIR(27.80%)及SIR(11.10%)(H=18.816,P=0.000)。LR可以作為預(yù)測ER的獨(dú)立因素(OR=10.011,P=0.000),當(dāng)其為52.27%時(shí)對預(yù)測ER具有較高特異性(95.09%),ROC曲線下面積為0.668(P=0.002)。結(jié)論:隨著LR的增高,患者131I清甲治療后更易出現(xiàn)較差的臨床轉(zhuǎn)歸;52.27%這一LR界值點(diǎn),可以作為預(yù)測PTC患者131I治療后臨床轉(zhuǎn)歸的獨(dú)立特異性指標(biāo)。第二部分:LR對PTC患者發(fā)生遠(yuǎn)處轉(zhuǎn)移風(fēng)險(xiǎn)的預(yù)測作用目的:探討PTC患者LR與DM的關(guān)系,及其對DM的預(yù)測價(jià)值。方法:隨訪162例PTC患者,將其分為非DM組(M0組)和DM組(M1組)41例和非DM組(M0)121例,采用t檢驗(yàn)、χ2檢驗(yàn)分別比較兩組患者的基本病理特征。采用多因素分析評(píng)估LR在預(yù)測DM的意義。利用ROC曲線及最佳診斷界值點(diǎn)評(píng)估LR及LNs對DM的預(yù)測價(jià)值,進(jìn)一步采用Kaplan-Meier曲線評(píng)估LN及LNs發(fā)生DM的累積風(fēng)險(xiǎn),使用Log-rank法對差異進(jìn)行統(tǒng)計(jì)學(xué)分析。結(jié)果:兩組患者在年齡及多灶性方面無統(tǒng)計(jì)學(xué)差異(P0.05),在男性(χ2=13.039,P=0.000)、腺外侵犯(χ2=2.941,P=0.000)、病灶大小(t=-4.485,P=0.000)方面存在顯著差異。LR可以作為預(yù)測DM的獨(dú)立因素(OR=1.133,P=0.000),隨著LR的增高,LNs≥15組患者的DM風(fēng)險(xiǎn)顯著高于LNs15組(P=0.0002)。結(jié)論:LR可作為DM的獨(dú)立預(yù)測指標(biāo),其與LNs結(jié)合可以更好地預(yù)測DM的發(fā)生風(fēng)險(xiǎn)。第三部分:比較LR和LNs對PTC患者治療反應(yīng)的預(yù)測價(jià)值目的:探討LR及LNs在不同淋巴結(jié)清掃范圍(number of dissected LNs,DLNs)下對PTC患者131I治療反應(yīng)的預(yù)測價(jià)值。方法:納入384名行術(shù)后131I治療的PTC患者,經(jīng)過中位25.7個(gè)月的隨訪,將患者的治療反應(yīng)分為ER、IDR、BIR和SIR四種。應(yīng)用ROC曲線分別比較在不同DLNs下LR和LNs對ER的預(yù)測價(jià)值。并進(jìn)一步應(yīng)用多因素分析來探索LR及LNs在不同DLNs時(shí)是否能夠作為預(yù)測ER的獨(dú)立因素。結(jié)果:在DLNs≤10這部分患者當(dāng)中,LR在預(yù)測ER的ROC曲線下面積大于LNs(LR:0.687,LNs:0.556,P=0.02);而當(dāng)DLNs10時(shí),LR在預(yù)測ER的ROC曲線下面積小于LNs。多因素分析發(fā)現(xiàn),當(dāng)DLNs≤10的情況下,LR(OR=1.037,P=0.001)和ps-Tg(OR=1.056,P=0.01)是預(yù)測ER的獨(dú)立因素,而LNs不能作為預(yù)測的獨(dú)立因素(OR=0.752,P=0.09);而當(dāng)DLNs10時(shí),LNs(OR=1.062,P=0.04)、ps-Tg(OR=1.071,P=0.00)和性別(OR=0.570,P=0.02)成為了預(yù)測ER的獨(dú)立因素。結(jié)論在DLNs≤10的情況下,LR對ER具有較好的預(yù)測價(jià)值;而當(dāng)DLNs10,LNs對ER的預(yù)測更有意義。
[Abstract]:The incidence of cervical lymph node metastasis in patients with papillary thyroid cancer (PTC) is higher, about 20% ~ 50%, and it also affects the recurrence and mortality of PTC patients. The prognostic value of LR in predicting the risk of DM in PTC patients was evaluated by distant metastasis (DM), and the prognostic value of LR and the number of lymph node metastases (LNs) in predicting the response to treatment after 131I in PTC patients was further compared in the third part. Value. The three parts of the study are reported as follows: Part I: Predictive effect of LR on the treatment response of patients with PTC after 131I. Objective: To investigate the relationship between LR and clinical outcome after 131I nail removal and its predictive value. Patients with distant metastatic PTC were divided into four groups according to LR: group I (0-10%), group II (10-25%), group III (25-50%) and group IV (50%). After a median follow-up of 20.7 months, the patients were divided into four groups: excellent response (ER), inaccurate response (IDR), and poor serological response (BIR). Comparing the basic clinical characteristics of the four groups, there was no difference in clinical outcomes; using receiver operating characteristic curves (ROC) curve to evaluate the value of LR in predicting ER and to determine the best predictive threshold point, further unifying multiple factors Results: There was no significant difference in sex, T stage (P 0.05). The age of group I was significantly higher than that of the other three groups (F = 6.114, P = 0.001). With the increase of LR, the clinical prognosis to ER showed a downward trend, while the BIR and SIR showed an overall upward trend. The response ER rate was significantly lower than that of the other three groups (27.8%) and was more likely to be BIR (27.80%) and SIR (11.10%) (H = 18.816, P = 0.000). LR could be an independent predictor of ER (OR = 10.011, P = 0.000). When it was 52.27%, it had a higher specificity for predicting ER (95.09%) and the area under ROC curve was 0.668 (P = 0.002). Conclusion: With the increase of LR, patients with 131I nail clearance therapy had higher specificity (OR = 10.011, P = 0.000). The LR threshold of 52.27% could be used as an independent and specific predictor of clinical outcome in patients with PTC after 131I. Part II: The predictive role of LR in the risk of distant metastasis in patients with PTC Objective: To explore the relationship between LR and DM in patients with PTC and its predictive value for DM. Methods: 162 patients with PTC were followed up. They were divided into non-DM group (M0 group) and DM group (M1 group) with 41 cases and non-DM group (M0 group) with 121 cases. The basic pathological characteristics of the two groups were compared by t test and_2 test. The significance of LR in predicting DM was evaluated by multivariate analysis. The predictive value of LR and LNs for DM was evaluated by ROC curve and the best diagnostic threshold, and Kaplan-Meier curve was further used. The cumulative risk of DM in LN and LNs was assessed by Log-rank analysis. Results: There was no significant difference in age and multifocal sex between the two groups (P 0.05). There were significant differences in male (2 = 13.039, P = 0.000), extraglandular invasion (2 = 2.941, P = 0.000) and lesion size (t = - 4.485, P = 0.000). Independent factors (OR = 1.133, P = 0.000), with the increase of LR, the risk of DM in LNs < 15 group was significantly higher than that in LNs < 15 group (P = 0.0002). Conclusion: LR can be used as an independent predictor of DM, and its combination with LNs can better predict the risk of DM. Part III: Comparing the predictive value of LR and LNs on the treatment response of patients with PTC Objective: To explore the LR and LNs in patients with PTC. The predictive value of 131I response in patients with PTC under different number of dissected LNs (DLNs) was evaluated. Methods: 384 PTC patients treated with 131I were enrolled and divided into ER, IDR, BIR and SIR after a median follow-up of 25.7 months. Results: Among the patients with DLNs < 10, the area under the ROC curve of LR was larger than that of LNs (LR: 0.687, LNs: 0.556, P = 0.02), while the area under the ROC curve of LR was smaller than that of LNs. Element analysis showed that LR (OR = 1.037, P = 0.001) and ps-Tg (OR = 1.056, P = 0.01) were independent predictors of ER when DLNs were less than 10, while LNs could not be independent predictors (OR = 0.752, P = 0.09), while LNs (OR = 1.062, P = 0.04), ps-Tg (OR = 1.071, P = 0.00) and gender (OR = 0.570, P = 0.02) were independent predictors of ER when DLNs were 10. When Ns is less than 10, LR has a good predictive value for ER, while DLNs10 and LNs are more meaningful for ER prediction.
【學(xué)位授予單位】：青島大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R736.1

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