分化型甲状腺癌误诊误治再手术108例分析

目的：探讨甲状腺癌首次误诊误治再手术的适应证及手术方式。方法：对1991/2000年分化型甲状腺癌108例首次外院术式不当再手术进行分析。结果：行患侧甲状腺残叶＋峡部切除者81例,行患侧甲状腺残叶＋峡部切除＋功能性颈淋巴结清扫术20例,双侧甲状腺癌根治术7例。再手术病理证实癌残留55例（50.9%）,颈淋巴结有癌转移20例（18.5%）。随访5 a,至今均生存。结论：甲状腺癌行局部肿块切除术,残癌率高,再手术是必要的。术中应常规行冰冻病理检查,是避免甲状腺癌再手术关键。     

甲状腺髓样癌8例分析

目的　探讨甲状腺髓样癌 (Medullary thyroid carcinoma;MTC)的诊断要点及治疗原则。方法　对我们1989～ 2 0 0 0年收治的 8例 MTC的临床资料进行回顾性分析。结果　患者均以颈部肿块就诊 ,1例伴有腹泻。散发型MTC7例 ,家族型 MTC1例。治疗方法均以手术切除原发灶或合并颈淋巴结清除为主。术后随访 3例死亡 ,5例存活。结论　 MTC术前诊断困难 ,但有下列情况应考虑本病 :不论甲状腺是否触及肿块 ,但有淋巴结肿大伴有顽固性非炎性腹泻者 ;有家族史 ;血清降钙素明显高于正常者。对 MTC均应做原发灶根治性切除加同侧颈部淋巴清扫术。     

微小型甲状腺癌26例临床诊治分析

目的:探讨研究微小型甲状腺癌(TMC)的临床诊断与治疗特点。方法:对1995年5月至2005年5月收治的26例TMC患者的资料进行回顾性分析。结果:16例(61.54%)术中冰冻切片发现,10例(38.46%)术后病理确诊。行单侧甲状腺叶加峡部切除术18例;双侧甲状腺次全切除术3例;单侧腺叶、峡部切除术加同侧颈淋巴结清扫术4例;双侧甲状腺次全切除加淋巴结清扫1例。全组26例无一例手术死亡和出现术后并发症。结论:甲状腺腺叶加峡部切除是TMC手术治疗较理想的术式;有淋巴结转移者同时行功能性颈淋巴结清扫术。     

分化型甲状腺癌近期再手术30例分析

目的：探讨分化型甲状腺癌再次手术的原因、手术时机及其手术方法。方法：对因误诊误治后再手术的37例分化型甲状腺癌进行回顾性分析。结果：再手术原因有：首次于外院误诊为甲状腺瘤16例行甲状腺肿瘤局部切除，9例诊断为甲状腺癌者6例行患侧甲状腺叶次全切除，3例行患侧甲状腺叶加峡部切除术。我院冰冻切片误诊为良性肿瘤5例。两次手术间隔时间6d～3个月。患侧残留腺叶全切、峡部切除加对侧叶次全切除30例，附加患侧功能性淋巴结清扫7例，传统颈淋巴结清扫2例。再手术后残留甲状腺及周围疤痕迹组织无残癌9例，有残癌21例；5a、10a生存率84％、64％。结论：甲状腺癌误诊误治而导致术式选择不当，术后具有较高的残癌率，应尽早选择恰当的手术方式行再次手术。     

分化型甲状腺癌再手术162例分析

目的探讨甲状腺癌首次误诊治再手术的适应证及手术方式。方法对1991-2005年分化型甲状腺癌162例首次外院术式不当再手术进行分析。结果行患侧甲状腺残叶+峡部切除者121例,行患侧甲状腺残叶+峡部切除+功能性颈淋巴结清扫术40例,双叶甲状腺癌根治术14例。再手术病理证实癌残留83例(52.86%),颈淋巴结转移38例(23.45%),随访5 a,至今均生存。结论甲状腺癌行局部肿块切除术,残癌率高,再手术是必需的。术中应常规行冰冻病理检查,是避免甲状腺癌再手术关键。     

甲状腺良性病变合并甲状腺微小癌28例报告

目的 探讨甲状腺良性病变合并甲状腺微小癌（TMC）的诊断和治疗。方法 分析1994年1月～2004年12月收治的经外科手术和病理证实为甲状腺良性病变合并甲状腺微小癌28例临床资料。结果 术前确诊2例，仅占7．1％，28例均送术中冰冻切片检查发现阳性16例，诊断阳性率57．4％，17例术前、术中确诊者行患侧腺叶并峡部切除，颈VI区淋巴结清除术，平均随访4～6年无复发。术后病理确诊者3例见手术标本周围组织癌细胞浸润，包膜受侵犯，再次手术后无复发。结论 甲状腺微小癌漏诊率高，术前术中要高度重视质实可凝小结节，提高术中冰冻切片阳性率是关键。对于甲状腺良性肿瘤应常规行腺叶切除，可避免二次手术。术前术中确诊者应行患侧腺叶＋峡部切除，颈VI区淋巴结清扫术。术后确诊者应检查TMC周围组织有无癌细胞浸润，包膜有无侵犯，如证实TMC已完整切除，则不必再行手术，如发现包膜受侵犯或切缘有癌细胞浸润，应补行二次手术。     

甲状腺髓样癌17例临床分析

目的探讨甲状腺髓样癌的诊治方法。方法回顾性分析17例甲状腺髓样癌患者临床资料。结果甲状腺髓样癌患者17例,采用患侧叶＋峡部切除、对侧叶次全或近全切除治疗,常规Ⅵ、Ⅶ区淋巴结清扫,合并淋巴结转移者行择区（Ⅱ～Ⅴ区）性颈淋巴结清扫;均经术中冰冻及术后组织病理证实为甲状腺髓样癌,8例有颈淋巴结转移,5a生存14例。结论甲状腺髓样癌术前确诊困难,颈淋巴结转移率高,外科手术治疗疗效满意。     

甲状腺微小癌37例临床诊治分析

目的探讨甲状腺微小癌的临床诊断和治疗方法。方法回顾性分析37例甲状腺微小癌病例资料。结果术前仅9例疑为甲状腺微小癌,术中冰冻切片确诊的35例,占94．59％。术后病理确诊2例,占5．41％。17例合并结节性甲状腺肿。颈淋巴结转移8例。患侧腺叶加峡部全切对侧次全切除33例;双侧腺叶全部切除2例。双侧腺叶次全加峡部切除2例。功能性颈淋巴结清扫8例,随访全部健在。结论甲状腺微小癌在女性发病较多,以单发癌结节为主。运用B超、术中快速冰冻病理检查等方法以求提高甲状腺微小癌的检出率,主张积极手术治疗,并根据肿块的数目、分布及有无颈部淋巴结转移,选择手术方式。甲状腺微小癌手术治疗的预后较好,但术后仍需长期随访。     

分化型甲状腺癌局部切除术后再手术56例临床分析

目的:探讨分化型甲状腺癌再次手术的必要性及手术方式.方法:对2001年1月～2004年12月56例分化型甲状腺癌再手术资料进行回顾性分析.结果:56例中首次行肿瘤结节切除42例,患侧腺叶部分切除6例,患侧腺叶次全切除8例.病理类型为甲状腺乳头状癌52例,滤泡状癌3例,髓样癌1例.再次手术行甲状腺残叶及峡部切除25例,患侧甲状腺残叶及峡部加对侧腺叶大部分切除31例.42例行颈部清扫术,2例加喉返神经松解.再次手术病理证实原发部位癌残留者24例,其中颈部淋巴结转移8例;原发部位无癌残留32例,其中3例颈淋巴结转移.本组首次手术残癌率42.9%(24/56),颈淋巴结转移率19.6%(11/56),占颈部清扫术的26.2%(11/42).结论:甲状腺癌局部切除术后残癌率高,建议废止该术式.而对于残癌再次手术治疗是非常必要的.     

甲状旁腺癌5例并文献复习

目的:总结甲状旁腺癌(PTC)的治疗经验.方法:回顾性分析5例PTC的治疗经验.结果:3例患者因颈部肿块就诊,2例有甲状旁腺功能亢进症的表现.首诊误诊率100%.1例仅行甲状腺旁肿块切取活栓,术后放疗6000cGy/30F,3例行患侧甲状腺及甲状旁腺切除,1例行患侧甲状腺及甲状旁腺切除加同侧颈清扫,术后出现对侧颈部淋巴结转移,再次行对侧颈清扫术.结论:PTC术前诊断非常困难,容易误诊.手术方式考虑患侧甲状腺及甲状旁腺切除,如术后出现淋巴结转移,可考虑再次行颈清扫术.     

Strategy for the surgical treatment of the well-differentiated thyroid carcinoma in our hospital

Well differentiated thyroid carcinoma (WDTC) consists of papillary thyroid carcinoma (PTC) and follicular thyroid carcinoma (FTC). Although both cancers are excellent prognosis, there are different in carcinogenesis by some genes, criteria of pathological diagnosis and transforming pattern between PTC and FTC. So the strategy for surgical treatment of them should be discussed separately. The patient with PTC less than 45 years old whose tumor is localized in a unilateral lobe without extra thyroidal invasion, lymph node metastasis and distant metastasis should be performed a unilateral lobectomy with central node dissection (D1). PTC patient over 45 years old except micro PTC case (T1a N0, M0) is recommended total thyroidectomy with modified radical neck dissection (D2 or D3). Encapsulated FTC is not necessary prophylactic lymph node dissection and only preformed unilateral lobectomy. If this patient has vascular invasion after lobectomy, completion thyroidectomy will be recommended for monitoring by serum Tg and whole body 123I scan.     

原发中叶肺癌的外科治疗

目的探讨原发中叶肺癌的临床特点、诊断及外科治疗特点。方法对1987年1月～2006年12月经外科手术治疗的43例原发中叶肺癌的临床资料进行回顾性分析。结果本组原发中叶肺癌43例,占同期肺癌手术病例的3.7%,年龄≥50岁的占79.1%,男性多见。手术方式:单纯中叶切除16例,姑息切除10例,中上叶切除或中下叶切除术6例,剖胸探查4例,楔形切除3例,根治术4例。全组病例中除1例术后发生纵隔气肿再次剖胸修补肺断面漏气外,其余均无并发症,均痊愈出院。术后1年生存率67.44%,3年生存率25.58%,5年生存率9.3%。1年内死亡病例均为姑息切除和剖胸探查的患者。结论本组病例发现时多已是中晚期,病变常侵及心包、胸壁及膈肌,累及上叶或下叶,中叶支气管旁及纵隔淋巴结转移常见,手术效果欠理想。临床医生应提高对中叶肺癌的认识,提高早期确诊率,避免错过手术时机。术前掌握患者的肺功能及远处转移情况,制定合适的手术方案,尽可能行根治性切除,单纯中叶切除适合于肿瘤局限,无扩散或转移的病例。如肿瘤跨叶,可行双肺叶切除、袖式肺叶切除或全肺切除。如肿瘤已扩散或转移,可行局部姑息切除,但复发率高,远期效果差。     

Do medullary thyroid carcinoma patients with high calcitonin require bilateral neck lymph node clearance? A case report

BACKGROUNDIn clinical work, 85%-90% of malignant thyroid diseases are papillary thyroid cancer (PTC); thus, clinicians neglect other types of thyroid cancer, such as medullary thyroid carcinoma (MTC).CASE SUMMARYWe report a 53-year-old female patient with a preoperative calcitonin level of 345 pg/mL. There was no definitive diagnosis of MTC by preoperative fine-needle aspiration cytology or intraoperative frozen pathology, but the presence of PTC and MTC was confirmed by postoperative paraffin pathology. The patient underwent total thyroidectomy and bilateral central lymph node dissection. Close follow-up at 1.5 years after surgery revealed no signs of recurrence or metastasis.CONCLUSIONThe issue in clinical work-up regarding types of thyroid cancer provides a novel and challenging idea for the surgical treatment of MTC. In the absence of central lymph node metastasis, it is worth addressing whether patients with high calcitonin can undergo total thyroidectomy and bilateral central lymph node dissection without bilateral lateral neck lymph node dissection.     

Axillary lymph node metastasis in recurrence of papillary thyroid carcinoma: a case report

Papillary thyroid cancer usually metastasizes to regional lymph nodes and to distant sites such as lungs and bones. We report a case of axillary lymph node metastasis as a result of recurrence of papillary carcinoma in a 62-year-old woman with papillary thyroid cancer extending locally beyond the thyroid capsule. Six years after initial surgical treatment, a lymph node metastasis in the left axillary region was diagnosed with positron tomography. To our knowledge, only one previous case of confirmed axillary metastasis of thyroid cancer has ever been reported. These two cases provide some evidence that thyroid carcinoma may exceptionally spread to axillary lymph nodes. Hypotheses that may account for such unusual localization include hematogenous dissemination or retrograde dissemination to regional lymphatic channels. Thus, when recurrence of thyroid carcinoma is considered, careful clinical examination of the axilla is recommended. Furthermore, thyroid carcinoma must be considered in the differential diagnosis of an axillary mass, especially when breast cancer is ruled out.     

Clinical manifestations of familial medullary thyroid carcinoma.

We conducted a large-scale nation-wide questionnaire survey to ascertain the status of familial medullary thyroid carcinoma (MTC) in Japan in 2002. Out of a total of 271 MTC cases (male to female ratio 1:1.4), multiple endocrine neoplasia (MEN) 2A accounted for 83 cases (30.6%), familial MTC (FMTC) for 14 cases (5.1%), MEN for 11 cases (4.1%), and sporadic MTC for 163 cases (60.1%). Mean age at the time of diagnosis was 35.6 in MEN2A, 34.6 in FMTC, 30.5 in MEN2B, and 47.6 in sporadic MTC. Forty-five percent of MEN2A patients had pheochromocytoma and 11% of MEN2A patients had parathyroid disorders when MTC was diagnosed. Finally, the RET oncogene test yielded the largest number of initial findings that led to diagnosis of familial MTC.     

Medullary carcinoma of the thyroid: diagnosis and therapy

Medullary thyroid carcinoma (MTC) originates in the thyroid C cells, or parafollicular cells, secreting calcitonin. It may be either sporadic or familial. Familial form can be isolated or expression of a multiple endocrine neoplasia type II. Mutations of the RET proto-oncogene have been identified in the germline DNA of patients with familial MTC syndromes. Genetic testing can identify patients affected by multiple endocrine neoplasia and familial MTC, allowing early diagnosis and possible cure. The initial treatment is surgical and the adequate surgery consists of total thyroidectomy. The treatment of occult or minimal disease can be curative. Plasma calcitonin measurements are excellent markers for post-operative follow-up. Imaging study can help to discover recurrent or metastatic disease. Adjunctive therapy includes radiotherapy and chemotherapy. Radiotherapy is reserved for bone metastases or for non resectable neck recurrences. Chemotherapy is reserved for patients with progressive MTC. Many chemotherapeutic regimens have been tried, results are controversial.     

A registry of medullary thyroid cancer in West Germany

A register for medullary thyroid carcinoma (MTC) in FRG has been set up by the "German Medullary Thyroid Carcinoma Study Group" in 1988. The aim is to provide a basis for collaborative work on MTC especially in the hereditary forms (i.e. multiple endocrine neoplasia [MEN] type IIa, IIb). For these hereditary varieties reliable screening tests exist and, if the disease is detected by family screening in an early stage, curative surgery is possible. Until now 408 patients (234 female, 174 male) with MTC have been reported by 17 cooperative centers. The mean age at diagnosis was 45.5 years. 25% (n = 104) are hereditary forms, most of them MEN IIa (n = 86), 13 are MEN IIb and 18 belong to the familial variety without other endocrinopathy. The mean age at diagnosis for MEN IIa was 36.5 years, MEN IIb 26.9 and for the pure familial form 27.5 years. As 33 patients per year have been diagnosed since 1982, nearly 25% of all expected cases of MTC in FRG have been registered.     

Graves病并发甲状腺微小癌14例临床分析

目的：探讨Graves病与并发甲状腺微小癌的临床关系以及其治疗与预后。方法：近20年来手术治疗400例Graves病中14例并发甲状腺微小癌，对其临床资料作回顾性分析。结果：本组并发甲状腺微小癌发病率为3．5％，女性居多，有长时间反复服用抗甲状腺药物史，全部采用甲状腺次全切除术，经随访1～20年均无复发或转移。结论：本病临床少见，手术治疗效果令人满意。     

Nuclear medicine procedures in the diagnosis and therapy of medullary thyroid carcinoma.

Medullary thyroid carcinoma (MTC) is a rare neuroendocrine tumor originating in the parafollicular cells (C cells) of the thyroid and secretes both calcitonin and carcino-embryonic antigen (CEA). Genetic and biochemical testing allow early pre-clinical identification of familial forms. Sporadic MTC usually presents as a solitary thyroid nodule; the diagnosis can be made preoperatively by fine-needle aspiration or by calcitonin assay, though it is usually established at the time of surgery. In the diagnostic assessment of MTC, nuclear medicine imaging provides its contribution mainly in the post-operative work-up to detect residual/recurrent tumor. For such purpose a number of radiopharmaceuticals, which take advantage of the specific expression of receptors (the somatostatin analogue (111)In-octreotide), hormone transporters (radiolabelled MIBG) or molecular targets (radiolabelled anti-CEA monoclonal antibodies) by MTC lesions are available; these tracers may be used also for the palliative treatment of advanced MTC. Interesting perspectives for MTC imaging are offered by PET radiopharmaceuticals.     

甲状腺手术喉返神经损伤原因分析及防治对策

目的:探讨甲状腺手术所致喉返神经(RLN)损伤的原因及预防措施。方法:回顾分析2000年—2005年420例甲状腺手术资料,对甲状腺病变的位置及手术方法与RLN损伤的关系进行比较分析。结果:发生不同程度声带麻痹21例,位于甲状腺背侧的病变RLN损伤率为14.29%,甲状腺腺叶切除RLN损伤率为12.5%,甲状腺次全切除RLN损伤率为2.27%。结论:甲状腺手术时喉返神经损伤与病变位置和手术方法明显相关;肿块位于甲状腺背侧和行甲状腺腺叶切除时,手术应常规显露RLN。甲状腺手术中喉返神经损伤与肿瘤位置和手术方式有关。