几种特殊患者群体的颈淋巴结清扫策略

1. 双侧颈侧区淋巴结转移患者的颈淋巴结清扫策略 对术前影像学或细胞学怀疑双颈侧区淋巴结转移的患者，应行治疗性双侧颈淋巴结清扫术。其治疗过程的特殊性主要体现在其手术风险较大，产生术后并发症的概率较大，患者术后恢复期较长。因此在行双颈侧区淋巴结清扫时，术式尽量选择保留颈内静脉、副神经和胸锁乳突肌的改良性颈淋巴结清扫术，若一侧病灶局部进展，需行根治性颈淋巴结清扫术时，应仔细保留该侧的颈外静脉和对侧的颈内静脉。手术时机的选择亦十分重要，对大多数患者应常规行一期手术，其优点是住院时间短，费用少，并减少麻醉风险。对单侧或双侧颈内静脉侵犯以及不能耐受长时间手术的患者，可考虑行二期手术治疗，先行手术难度较大一侧的颈淋巴结清扫术，一个月后再行对侧颈淋巴结清扫术，其优点是第一次手术后视该侧颈内静脉的保留和通畅情况决定二期手术的范围，或直接行保守治疗，以避免双侧颈内静脉同时结扎造成急性脑水肿，并且有利于患者的术后恢复，提高生活质量。

2. cNx患者的颈侧区淋巴结清扫策略 cNx定义为无法评估的颈部淋巴结病灶，以及当临床或影像学检查怀疑转移可能，但无法进一步确定的患者。事实上在临床工作中经常会遇到这类患者。如图9– 4所示病例，对此我们可选择下颈部横切口，以功能性颈淋巴结清扫（保留颈丛）的方式对CT发现的可疑淋巴结进行探查，到达可疑淋巴结区域后行择区性颈淋巴结清扫术（该病例行Ⅲ、Ⅳ区清扫），并送术中冰冻病理检查。若冰冻结果为恶性，则原切口继续行功能性颈清扫术，或延长切口行改良性颈淋巴结清扫术。需要指出的是，行择区性颈淋巴结清扫术的范围还应参考甲状腺病灶的位置，对于位于上极的病灶不应遗漏Ⅱ区淋巴结。

图9–4　cNx患者术前CT表现。箭头所示术前颈部CT发现左颈部Ⅲ区小淋巴结，影像学表现并不典型，但B超提示转移性淋巴结

3. 青少年甲状腺癌的颈淋巴结清扫策略 目前多数文献将青少年甲状腺癌的年龄界限划定在20岁，20岁以下人群甲状腺癌的发病率约为成人的1/10，但是近年来呈上升趋势。青少年甲状腺癌较成年人甲状腺癌有如下特点：① 颈淋巴结转移率高（40%～90%），且双颈转移患者也较高；② 远处转移率高（20%～30%），以肺转移多见；③ 甲状腺病灶常呈现出多灶性；④ MTC比例升高；⑤ 即使病灶局部进展，甚至出现远处转移，该疾病的预后仍然极好。笔者单位曾对69例双颈淋巴结转移阳性的青少年甲状腺癌患者进行了超过20年的随访，结果显示尽管有20.8%的局部复发率和12.5%的远处转移率，但这些患者的10年以及20年生存率分别高达100%和90.9%。对于青少年DTC应常规行全甲状腺切除术+双侧PCND，但是预防性侧颈淋巴结清扫目前并不推荐。青少年MTC的颈淋巴结清扫原则与成年人相同。为了尽可能保留颈部功能外形，术式常选择改良性颈淋巴结清扫术或保留颈丛的功能性颈淋巴结清扫术，下颈部横切口或大弧形切口均为理想的手术切口。由于预后极好，部分患者仍处于生长发育中，因此在行颈淋巴结清扫时应更注意保留正常组织器官，行中央区淋巴结清扫术时应仔细保护双侧喉返神经和甲状旁腺，避免术后终身气管造瘘和永久性低钙血症的出现，必要时可不强求R0切除，术后辅以放射性核素治疗或补充外放射治疗。

4. 二次清扫术的策略和原则 二次清扫是临床工作中不可避免的问题，清扫的对象可能为中央区或侧颈区。需要行二次清扫的患者主要分为两类：① 规范颈淋巴结清扫术后淋巴结复发患者；② 不规范的择区性颈淋巴结清扫及淋巴结切除活检术后的患者。对于前者一般可行择区性颈淋巴结清扫术或切除复发淋巴结，而后者则无论B超或CT等影像学检查是否提示有残留病灶，都应再次行规范系统的颈淋巴结清扫术。二次清扫的难点在于前次手术后形成的瘢痕粘连对正常层次的破坏，在此情况下极易损伤重要组织和器官。因此，手术时机应选择为前次手术后两周内或3个月后，以减少瘢痕粘连对操作的影响。此外，再次手术的切口应暴露充分，尽量从既往手术未到达的区域寻找解剖层次，并尽可能切除前次手术的瘢痕区。

（李端树　魏文俊）

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