第一部分：cN0甲状腺乳头状癌中央区淋巴结、喉前及气管前淋巴结转移的危险因素分析及临床预测模型构建
一、cN0甲状腺乳头状癌中央区淋巴结转移的危险因素分析及临床预测模型构建
中文摘要
目的
随着甲状腺乳头状癌（papillary thyroid carcinoma，PTC）真实患病率的增加以及常规辅助检查技术的发展，甲状腺恶性结节尤其是微小结节的检出率不断升高。目前，诊断明确的甲状腺乳头状癌的首选治疗方式仍是手术，然而，关于PTC的最佳手术范围仍存在争议，其中，中央区淋巴结转移（central lymph node metastasis，CLNM）状态是影响手术方式决策的关键因素。既往研究对PTC患者的中央区淋巴结转移风险进行了评估，但缺乏术中观察到的肿瘤原发灶的病理特征及临床实验室结果对淋巴结转移状态影响的研究。因此，为了弥补既往研究的不足，本研究旨在系统探讨cN0 PTC患者术前及术中可观测的促进中央区淋巴结转移的危险因素，并基于筛选的危险因素构建cN0 PTC患者中央区淋巴结转移的临床预测模型，以期在临床实践中制定更精准的临床治疗决策。
方法
本研究回顾性分析了2015-1-1~2022-12-1初诊于中国医学科学院肿瘤医院头颈外科的2435例接受单侧或双侧甲状腺切除+预防性中央区淋巴结清扫的PTC患者的临床病例资料。系统性收集术前辅助检查、实验室检查结果、手术记录及术后病理结果，通过相关系数矩阵检查、方差膨胀因子（variance inflation factor,VIF）检验和容忍度(Tolerance)分析评估变量共线性，采用Logistic回归分析筛选与CLNM相关的危险因素，基于筛选的危险因素构建评估PTC患者中央区淋巴结转移风险的临床预测模型。
结果
本研究共纳入2435例cN0甲状腺乳头状癌患者，其中933例患者的术后病理提示中央区淋巴结转移。单因素和多因素回归分析显示，年龄、血清TR-Ab水平、钙化、多灶性、甲状腺腺外侵犯、肿瘤大小和肿瘤位置是CLNM的危险因素。基于这些危险因素建立的预测模型具有良好的预测准确性，受试者工作特征曲线下面积为0.76。临床决策曲线分析表明，除了小范围的低阈值概率外，基于模型预测的结果进行临床干预可以产生更大的临床获益。
结论
病理性钙化、肿瘤最大直径＞10 mm、超声观察到的甲状腺腺外侵犯、肿瘤位于甲状腺中部和下极、年轻和高水平TR-Ab是PTC患者发生CLNM的独立危险因素。
 

二、cN0甲状腺乳头状癌喉前及气管前淋巴结转移的危险因素分析及临床预测模型构建
中文摘要
目的
喉前及气管前淋巴结因其特殊的解剖位置和甲状腺区域淋巴循环的特点，目前针对喉前及气管前淋巴结转移的研究尚不完善。为了弥补既往研究的不足，本研究旨在系统探讨cN0 PTC患者术前及术中可观测的影响喉前及气管前淋巴结转移的危险因素，并基于筛选的危险因素构建cN0 PTC患者喉前及气管前淋巴结转移的临床预测模型，以期在临床实践中指导更精准的治疗决策。
方法
本研究回顾性分析了2015-1-1~2022-12-1初诊于中国医学科学院肿瘤医院头颈外科的919例接受单侧或双侧甲状腺切除+预防性中央区淋巴结清扫，并术中单独送检喉前及气管前淋巴结标本的PTC患者的临床病例资料。系统收集术前辅助检查、化验结果、手术记录及术后病理结果，通过相关系数矩阵检查、方差膨胀因子检验和容忍度分析筛选自变量，采用Logistic分析筛选与喉前及气管前淋巴结转移相关的危险因素，基于筛选的危险因素构建评估cN0 PTC患者中央区淋巴结转移风险的临床预测模型。
结果
本研究共纳入705例甲状腺乳头状癌患者，其中201例（28.51%）发现喉前及气管前淋巴结转移。综合分析结果显示，病理性钙化、肿瘤位于甲状腺中部、病理证实的双侧甲状腺乳头状癌及肿瘤原发灶同侧中央区淋巴结转移是cN0 PTC患者喉前及气管前淋巴结转移的独立危险因素。基于这些危险因素建立的预测模型具有良好的预测效能，受试者工作特征曲线下面积为0.81。临床决策曲线分析表明，除了小范围的低阈值概率外，基于模型预测的结果进行临床干预可以获得更大的整体获益。
结论
病理性钙化、肿瘤位于甲状腺中部、病理证实的双侧甲状腺乳头状癌及肿瘤原发灶同侧中央区淋巴结转移是cN0 PTC患者喉前及气管前淋巴结转移的独立危险因素。基于危险因素构建的临床预测模型表现出稳健的预测效能。
 

第二部分：cN0甲状腺微小乳头状癌同侧中央区淋巴结转移的危险因素分析
中文摘要
目的
甲状腺微小乳头状癌（papillary thyroid microcarcinoma,PTMC）作为甲状腺乳头状癌的特殊亚型，随着甲状腺乳头状癌发病率的增加以及常规辅助检查技术的发展，PTMC的真实检出率不断升高。其淋巴结转移风险一直是临床关注的重点。既往研究报道的PTMC患者的整体中央区淋巴结转移发生率与PTC患者相仿，但是缺少系统性的关于cN0 PTMC中央区淋巴结转移风险的研究，为了弥补既往研究的不足，本研究通过回顾性分析cN0 PTMC患者队列，比较不同中央区淋巴结转移状态间PTMC患者临床及病理特征的差异，系统探讨与cN0 PTMC患者中央区淋巴结转移相关的危险因素。
方法
本研究回顾性分析2015-1-1~2022-12-1初诊于**医院头颈外科的1845例接受单侧或双侧甲状腺切除+预防性中央区淋巴结清扫的cN0 PTMC患者的病例资料。系统性收集术前检查结果、实验室检查结果、手术记录及术后病理结果，采用Logistic分析探索与PTMC患者同侧中央区淋巴结转移相关的危险因素。
结果
本研究共纳入1845例cN0 PTMC患者，其中579/1845例（31.38%）例术后病理证实为存在中央区淋巴结转移。分析结果显示：年轻、低BMI、血清高水平TR-Ab和低水平的TG-Ab、男性、钙化、术后病理证实的更大的肿瘤原发灶最大径是cN0 PTMC患者中央区淋巴结转移的独立危险因素。以5mm和7mm作为肿瘤最大径的分组标准对PTMC患者进行分组，结果显示肿瘤直径更大的PTMC患者组的CLNM风险更高，且不同分组间PTMC患者的淋巴结转移率差异具有统计学意义。
结论
年轻、低BMI指数、血清高水平TR-Ab和低水平的TG-Ab、男性、钙化、术后病理证实的更大的肿瘤原发灶最大径是PTMC患者中央区淋巴结转移的独立危险因素。本研究结果提示，5mm和7mm是预测cN0 PTMC患者CLNM状态较为理想的分界标准。
关键词：甲状腺微小乳头状癌，中央区淋巴结转移，危险因素，肿瘤最大径，回顾性研究

第三部分 FOXM1驱动NCAPG基因表达及NCAPG基因对甲状腺乳头状癌生物学行为的影响和免疫调控
中文摘要
目的：探讨转录因子FOXM1对NCAPG基因的驱动意义、NCAPG基因在甲状腺乳头状癌发生发展、免疫调控和预后生存的作用，揭示不同NCAPG基因表达水平对甲状腺乳头状癌细胞系生物学行为的影响。
方法：基于癌症基因表达图谱（TCGA）、基因表达综合数据库（GEO）以及基因型-组织表达（GTEx）数据库的基因表达数据，通过对比不同肿瘤组织样本和正常组织样本的NCAPG基因的表达水平，描述NCAPG基因在肿瘤组织中的差异表达，利用蛋白-蛋白交互作用网络分析NCAPG蛋白与FOXM1转录因子的相关性，通过转录因子FOXM1及NCAPG基因的共表达分析，阐述转录因子FOXM1通过上调NCAPG基因的表达参与甲状腺乳头状癌发生发展过程的调控，探索不同NCAPG基因表达水平的甲状腺乳头状癌组织中各类肿瘤浸润淋巴细胞的浸润丰度差异，刻画不同NCAPG基因表达水平下甲状腺乳头状癌的免疫景观。通过Kaplan-Meier生存分析评估不同NCAPG基因表达水平中甲状腺乳头状癌患者的预后差异。通过基因编辑、细胞增殖、迁移等一系列细胞生物学实验技术，构建不同NCAPG基因表达水平的甲状腺乳头状癌细胞株，探索其对甲状腺乳头状癌细胞系生物学行为的影响。
结果：在肿瘤组织中，NCAPG表达水平显著升高，且在继发性肿瘤灶中的表达水平更高，转录因子FOXM1及NCAPG基因的共表达分析提示FOXM1上调NCAPG基因的表达，针对NCAPG表达水平对PTC患者预后意义的研究表明，在1、3、5年的观测节点下，不同NCAPG表达水平不影响PTC患者的总生存期和肿瘤特异性生存期，但是，低NCAPG表达水平的PTC患者无病生存期和肿瘤无进展生存期优于高NCAPG表达水平患者，提示NCAPG在增强PTC肿瘤侵袭性的意义。不同NCAPG表达水平下的PTC各免疫细胞亚群的浸润丰度分析结果显示，总T细胞、CD8+T淋巴细胞、NK细胞、B淋巴细胞、单核细胞、巨噬细胞、髓样树突状细胞和中性粒细胞的浸润丰度均随着NCAPG表达水平的升高而升高，其中，B淋巴细胞、单核细胞和巨噬细胞的升高趋势更明显。在高水平NCAPG表达的PTC中，肿瘤微环境中促进肿瘤免疫逃逸和淋巴结转移的细胞成分更高。细胞生物学实验证明，NCAPG基因敲除后的肿瘤细胞的增值能力显著减弱，当NCAPG表达减弱时，PTC肿瘤细胞的迁移能力减弱。提示NCAPG表达增强PTC肿瘤细胞的侵袭性及淋巴结转移潜能。
结论：NCAPG基因在肿瘤组织内表达升高，且表达水平与转录因子FOXM1相关，NCAPG基因在甲状腺乳头状癌细胞生物学行为和肿瘤免疫微环境调控中存在重要意义，NCAPG基因可作为甲状腺乳头状癌的独立预后因子，参与肿瘤发生发展的调控过程。本研究揭示了甲状腺乳头状癌的新的分子靶点，为探索甲状腺乳头状癌新的治疗策略提供分子基础。
 

Analysis of Risk Factors for Central Lymph Node Metastasis in cN0 Papillary Thyroid Carcinoma and Development of a Clinical Prediction Model

Abstract

Objective

With the increasing prevalence of papillary thyroid carcinoma(PTC) and advancements in auxiliary examination technology, the detection rate of malignant thyroid nodules, particularly small ones, continue to rise. However, there remains controversy surrounding the optimal treatment for PTC, and central lymph node metastasis(CLNM) status being a crucial factor influencing treatment decisions. While previous studies have assessed the risk of lymph node metastasis of PTC patients, there is a lack of research on clinical laboratory results and characteristics of the tumor observed during operation. Therefore, The present study aims to systematically investigate risk factors of CLNM in patients with PTC.

Methods

This study retrospectively analyzed the clinical data of 2,435 papillary thyroid carcinoma (PTC) patients who underwent unilateral or bilateral thyroidectomy combined with prophylactic central lymph node dissection (CLND) and were initially diagnosed in the Cancer Hospital Chinese Academy of Medical Sciences Department of Head and Neck Surgery between January 1, 2015, and December 1, 2022. We systematically collected preoperative auxiliary examinations, laboratory test results, surgical records, and postoperative pathological findings. Variable collinearity was assessed through correlation coefficient matrix checks, variance inflation factor (VIF) tests, and tolerance analyses. Logistic regression analysis was employed to identify risk factors associated with central lymph node metastasis (CLNM). Based on the selected risk factors, a clinical prediction model was developed to evaluate the risk of CLNM in PTC patients.

Results

This study included a total of 2435 patients diagnosed with papillary thyroid carcinoma, among whom 933 were found to have central lymph node metastasis. Univariate and multivariate regression analysis identified age, serum TRAb levels, calcification, multifocality, extrathyroidal invasion, tumor size, and tumor location as risk factors associated with CLNM. The prediction model based on these risk factors demonstrated robust accuracy with an area under the receiver operating characteristic curve of 0.76. Clinical decision curve analysis indicated that aside from a small range of low threshold probabilities, clinical interventions based on model-predicted outcomes could yield greater clinical benefit.

Conclusion

This study comprehensively revealed key risk factors of CLNM in patients with PTC, including younger age, elevated serum TRAb levels, calcification, multifocality, extrathyroidal invasion, larger tumor size, and tumors located in the middle and lower regions of the thyroid. The nomogram model we developed provides valuable clinical insights for surgeons, enabling the formulation of more tailored surgical strategies for PTC patients, which may significantly improve patient outcomes.

Analysis of Risk Factors for Prelaryngeal and Pretracheal Lymph Node Metastasis in cN0 Papillary Thyroid Carcinoma and Development of a Clinical Prediction Model

Abstract

Objective‌

Due to their unique anatomical location and the characteristics of thyroid lymphatic drainage, the current understanding of prelaryngeal and pretracheal lymph node metastasis remains insufficient. To address gaps in previous research, this study aims to systematically investigate preoperative and intraoperative risk factors for prelaryngeal and pretracheal lymph node metastasis in cN0 papillary thyroid carcinoma (PTC) patients and to develop a clinical prediction model based on these factors, thereby guiding more precise therapeutic decision-making in clinical practice.

‌Methods‌

A retrospective analysis was conducted on 919 PTC patients who underwent unilateral or bilateral thyroidectomy with prophylactic central lymph node dissection (CLND) and intraoperative separate submission of PLN specimens at the **, from January 1, 2015, to December 1, 2022. Preoperative imaging/laboratory data, surgical records, and postoperative pathological findings were systematically collected. Independent variables were screened via correlation coefficient matrix examination, variance inflation factor (VIF) test, and tolerance analysis. Logistic regression analysis was employed to identify risk factors associated with PLN metastasis, and a clinical prediction model was subsequently constructed.

‌Results‌

Among the 919 PTC patients, 201 (28.51%) exhibited PLN metastasis. Multivariate analysis identified pathological calcification, tumor located in the middle third of the thyroid, pathologically confirmed bilateral PTC, and ipsilateral central lymph node metastasis as independent risk factors for PLN metastasis. The prediction model demonstrated robust accuracy, with an area under the curve of 0.81. Clinical decision curve analysis revealed that across most threshold probability ranges, clinical interventions based on model-predicted outcomes could obtain greater overall benefits.

‌Conclusion‌

Pathological calcification, mid-thyroid tumor location, bilateral PTC, and ipsilateral CLNM are independent risk factors for PLN metastasis in PTC patients. The developed clinical prediction model exhibits reliable predictive performance.

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Risk Factor Analysis for Ipsilateral Central Lymph Node Metastasis in cN0 Papillary Thyroid Microcarcinoma

Abstract

Objective‌

Papillary thyroid microcarcinoma (PTMC) is a distinct subtype of papillary thyroid carcinoma, has seen a rising overall detection rate due to increasing PTC prevalence and advancements in diagnostic imaging. The risk of lymph node metastasis in PTMC remains a critical clinical concern. While previous studies suggest comparable central lymph node metastasis rates between PTMC and PTC patients, systematic investigations into CLNM risk factors in PTMC are lacking. To address this gap, this study retrospectively analyzed a PTMC cohort to compare clinical and pathological characteristics between patients with and without CLNM, aiming to identify preoperative and intraoperative risk factors associated with CLNM.

Methods‌

Clinical data from 1,845 PTMC patients who underwent unilateral or bilateral thyroidectomy with prophylactic central lymph node dissection at the Cancer Hospital Chinese Academy of Medical Sciences Department of Head and Neck Surgery between January 1, 2015, and December 1, 2022 were retrospectively analyzed. Preoperative imaging/laboratory results, surgical records, and postoperative pathology findings were systematically collected. Independent variables were screened via correlation coefficient matrix examination, variance inflation factor test, and tolerance analysis. Multivariate logistic regression analysis was performed to identify risk factors for ipsilateral CLNM.

Results‌

Among 1,845 PTMC patients, 579 (31.38%) had pathologically confirmed CLNM. Independent risk factors for CLNM included: Younger age‌, Lower BMI‌, Elevated serum TR-Ab levels‌, Lower serum TG-Ab levels‌, Male, Pathological calcification‌, Larger tumor maximum diameter‌ (confirmed postoperatively). Stratification by tumor size thresholds (5 mm and 7 mm) revealed statistically significant differences in CLNM rates, with larger tumors correlating with higher metastasis risks.

Conclusion‌

Younger age, lower BMI, elevated TR-Ab, reduced TG-Ab, male sex, calcification, and larger tumor maximum diameter are independent risk factors for CLNM in PTMC patients. Tumor size thresholds of ‌5 mm and 7 mm‌ serve as critical cutoffs for predicting CLNM status, aiding in preoperative risk stratification and surgical planning.

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FOXM1-Driven NCAPG Expression and Its Effects on Biological Behavior and Immune Regulation in Papillary Thyroid Carcinoma

Abstract

Objective: To investigate the roles of the transcription factor FOXM1 and the NCAPG gene in the pathogenesis, progression, immune regulation, and prognostic evaluation of papillary thyroid carcinoma (PTC), and to elucidate the impact of varying NCAPG expression levels on the biological behavior of PTC cell lines.

Methods: Gene expression data from The Cancer Genome Atlas (TCGA), Gene Expression Omnibus (GEO), and Genotype-Tissue Expression (GTEx) databases were analyzed to compare NCAPG expression levels between tumor and normal tissues. Protein-protein interaction (PPI) network analysis was employed to explore correlations between NCAPG-encoded proteins and the FOXM1 transcription factor. Co-expression analysis of FOXM1 and NCAPG was performed to delineate FOXM1-mediated upregulation of NCAPG in PTC progression. The infiltration abundance of tumor-infiltrating lymphocytes (TILs) in PTC tissues with distinct NCAPG expression levels was assessed to characterize the immune landscape. Kaplan-Meier survival analysis was used to evaluate prognostic differences among PTC patients stratified by NCAPG expression. Gene editing, cell proliferation, migration assays, and other cellular biology techniques were applied to establish PTC cell lines with varying NCAPG expression levels and explore their impact on cellular behavior.

Results: NCAPG expression was significantly elevated in tumor tissues, particularly in secondary tumor foci. Co-expression analysis revealed FOXM1-mediated upregulation of NCAPG. Prognostic analysis indicated that while NCAPG expression levels did not affect overall survival (OS) or cancer-specific survival (CSS) at 1, 3, and 5 years, lower NCAPG expression correlated with prolonged disease-free survival (DFS) and progression-free survival (PFS), suggesting NCAPG’s role in enhancing tumor invasiveness. Immune infiltration analysis demonstrated that higher NCAPG expression was associated with increased infiltration of total T cells, CD8+ T lymphocytes, NK cells, B lymphocytes, monocytes, macrophages, myeloid dendritic cells, and neutrophils, with more pronounced increases in B cells, monocytes, and macrophages. High NCAPG-expressing PTC tissues exhibited elevated proportions of immune cell subsets linked to tumor immune evasion and lymph node metastasis. Cellular experiments confirmed that NCAPG knockdown significantly reduced tumor cell proliferation and migration, indicating NCAPGs role in promoting PTC invasiveness and lymph node metastatic potential.

Conclusion: Elevated NCAPG expression in tumor tissues correlates with FOXM1 and plays a critical role in regulating PTC cell behavior and the tumor immune microenvironment. NCAPG may serve as an independent prognostic factor and molecular target for PTC, offering a foundation for novel therapeutic strategies.