分化型甲状腺癌手术范围探讨

分化型甲状腺癌包括乳头状腺癌和滤泡性腺癌(按《医学名词》规定命名)，中日联谊医院统计其占甲状腺癌的85．39％，上海医科大学肿瘤医院报告占甲状腺癌的92．11％。     

分化型甲状腺癌再次手术的策略及技巧

尽管分化型甲状腺癌（differentiated thyroidcar-cinoma,DTC）大多具有良好的预后,但是较高的术后复发率是不容忽视的事实,其40年累积复发率高达35％,并且有约1／3的复发患者死于该病。手术是治疗DTC最主要和最有效的方式。     

颈淋巴结清扫在分化型甲状腺癌再手术中的价值

目的：探讨颈淋巴结清扫术在分化型甲状腺癌再手术中的价值。指导甲状腺癌再手术的术式选择。方法。回顾性分析122分化型甲状腺癌再次手术病人中88例作颈淋巴结清扫术的临床资料。88例中，甲状腺肿瘤局部切除术38例，甲状腺腺叶加峡部切除术16例，全甲状腺切除2例，颈淋巴结活检32例，结果：甲状腺微小癌11例，颈淋巴结转移率65．91％（58／88），甲状腺残癌率31．59％（12／38）。结论：颈淋巴结清扫术在甲状腺癌再次手术中具有明确的治疗作用，对侵及包膜，颈淋巴结肿大以及甲状腺微小癌应作颈淋巴结清扫术。对复发癌应再次手术。再手术需彻底切除癌灶，保护甲状旁腺及喉返神经。     

分化性甲状腺癌的术式选择

由于分化型甲状腺癌（differentiated thyroid carcinoma,DTC）具有生长缓慢、细胞分化好、恶性度低、预后好等生物学特性,经外科手术切除后病人预后较好、多能长期生存。但对DTC手术的甲状腺体切除和淋巴清扫范围,至今仍存在一些争议,现综述如下。     

分化型甲状腺癌初始手术治疗的争论焦点

<正>分化型甲状腺癌(differentiated thyroid cancer,DTC)包括乳头状和滤泡状甲状腺癌,占甲状腺恶性肿瘤的90%以上。与未分化型和其他类型的甲状腺恶性肿瘤相比,DTC具有发展缓慢、治疗效果好和预后良好等特点。DTC的初始手术治疗目标是~[1];切除原发病灶和涉及的区域淋巴结;降低术后肿瘤局部复发和转移的风险;方便术后I~(131)     

分化型甲状腺癌颈淋巴结清扫的相关问题

分化型甲状腺癌(differentiated thyroid carcinoma,DTC)大多分化程度较高,预后较好,约占全部甲状腺癌的90％[1].DTC包括乳头状癌(papillary thyroid carcinoma,PTC)及滤泡性癌(follicular thyroid carcinoma,FTC).FTC约占DTC的10％[2],主要经血循环转移,较少经颈淋巴结转移.     

分化型甲状腺癌颈淋巴结清扫术式的选择

甲状腺癌是头颈部最常见的恶性肿瘤,其中以分化型甲状腺癌最为多见,约占90％。分化型甲状腺癌淋巴结转移的发生率较高,文献报道高达50％～75％。分化型甲状腺癌颈淋巴结清扫术式的选择是外科医师常常遇到的问题。     

分化型甲状腺癌颈侧区淋巴结清扫术中神经损伤的预防

手术是分化型甲状腺癌颈淋巴结转移的首选治疗方法。由于甲状腺癌预后良好,因而在肿瘤根治的基础上对原有功能的保护愈发重要。颈淋巴结清扫术中易造成舌下神经、下颌缘支、副神经、迷走神经、颈交感神经、颈丛、臂丛等重要神经的损伤而引起术后相应症状,而正确的解剖认知、丰富的手术经验以及熟练的手术技巧是预防分化型甲状腺癌颈侧区淋巴结清扫术中神经损伤的关键。     

分化型甲状腺癌区域淋巴结清扫策略及争议

甲状腺乳头状癌颈部淋巴结转移出现早,但预后好。甲状腺切除手术和彻底合理的淋巴结清扫是公认治疗甲状腺癌的最佳选择。cN1 病人需要行颈淋巴结清扫术,但cN0 病人是否需要进行预防性中央区或颈侧区淋巴结清扫术仍有很多的争议。     

中央区淋巴结清扫在分化型甲状腺癌治疗中的必要性探讨

目的 探讨分化型甲状腺癌手术中行中央区淋巴结清扫的临床意义.方法 术前或术中病理确诊为分化型甲状腺癌125例,手术方式为甲状腺全切或患侧全切+峡部+对侧近全切除术,同时加行颈中央区淋巴结清扫术;如术前、术中怀疑或明确颈侧区淋巴结转移时,则进一步行颈侧区淋巴结清扫.结果 中央区(Ⅵ区)淋巴结转移发生率为57.6％ (72/125),5例发生跳跃性转移.中央区淋巴结转移率与性别(P =0.705)、单双侧(P =0.504)及有无周围组织侵犯(P=0.086)无明显相关;而年龄＜45岁患者、非微小癌患者的中央区淋巴结转移率明显高于年龄≥45岁的患者(70.8％ vs 43.3％,P=0.002)、微小癌患者(68.8％ vs 25％,P=0.000).cN0患者中仍有43.8％(25/57)术后证实中央区淋巴结有转移.甲状腺全切组甲状旁腺及喉返神经并发症发生率(29.1％)与患侧全切+峡部+对侧近全切组(10％)相比有明显升高(P=0.008).结论 中央区淋巴结在分化型甲状腺癌中有较高的转移率,中央区淋巴结的清扫可以清除隐匿性淋巴结转移,进行准确的病理分期以指导手术后治疗,故应常规进行中央区淋巴结清扫.     

Redefining classification of central neck dissection in differentiated thyroid cancer

Therapeutic central neck dissection for differentiated thyroid cancer is recommended in the setting of clinically positive disease. The role of lymphadenectomy in patients with clinically negative disease is a matter of controversy and therefore extent of surgery varies. The boundaries of the central neck are variably described, as are the components of a central neck dissection. Patients with aggressive disease are managed with a comprehensive dissection, yet there is no classification system to distinguish this from a less rigorous operation. Therefore, there is variability in reporting and difficulty in the interpretation of results in the published literature. Here we propose a novel classification system for central neck dissection in thyroid cancer that allows accurate reporting of extent of surgery. The objectives are to reduce ambivalence and allow documentation of extent of lymphadenectomy, such that comparisons can be made between the varied strategies in the management of the central compartment. © 2013 Wiley Periodicals, Inc. Head Neck 36: 286–290, 2014     

分化型甲状腺癌诊治中值得关注的一些问题

分化型甲状腺癌的诊断与治疗仍存在一些值得关注的问题,如临床医师过度依赖超声检查结果。PET-CT在分化型甲状腺癌的诊断价值有限。对特殊类型的分化型甲状腺癌的处理,特别是微小癌及桥本甲状腺炎合并甲状腺癌的外科治疗,外科医师应严格掌握手术指征与合理选择手术方式。     

甲状腺癌手术质量控制争议与共识

目前,甲状腺癌发病率在世界范围内均呈明显上升趋势,尤其是乳头状癌。其发病率明显升高很可能是因为检出率的增加。提高其疗效和减少复发的关键因素是首次手术治疗的规范化。准确的术前分期、合适的甲状腺切除和淋巴结清扫范围都是甲状腺癌规范化治疗中尤其应该重视的问题。我们建议,对甲状腺单发、较小,没有外侵的癌灶行单侧腺叶切除术。对cN0病人常规进行同侧中央区(Ⅵ区)淋巴结清扫;不推荐行预防性颈侧区淋巴结清扫。     

The role of a more extensive surgical approach in the initial multimodality management of papillary thyroid cancer in children

Purpose

Papillary thyroid cancer (PTC) in children is rare. The optimal initial surgical treatment remains controversial, given the generally favorable overall prognosis but high rate of cervical metastasis and local recurrence. Our objective was to examine the surgical outcomes of a policy of total thyroidectomy and routine selective lymph node dissection (SLND) as the initial surgical approach to children with PTC.

Methods

This is a retrospective cohort study comprising 14 children (age, ≤17 years) with PTC referred for thyroid surgery during the past 15 years. Clinical presentation, the surgical procedure, final pathology, lymph node involvement, complications, and recurrence rates are reported.

Results

There were 9 females and 5 males, with an average age of 12.5 years. Seven patients (50%) had clinically apparent cervical lymphadenopathy at the time of surgical referral. All subjects underwent total thyroidectomy, and 12 (86%) had SLND. Of the 12 who underwent SLND, 10 (83%) had nodal metastases. Temporary hypocalcemia was noted in 3 of the patients (21%), and 1 patient has required ongoing intermittent calcium supplementation. All patients are alive and well at follow-up with no clinical, biochemical, or radiological evidence of local recurrence.

Conclusions

Total thyroidectomy with initial SLND is an appropriate surgical approach in children with PTC. It can be done without a significantly increased risk for permanent complications and may reduce the requirement for subsequent surgical intervention for local recurrence in this young population.     

分化型甲状腺癌430例手术方式与并发症分析

目的探讨分化型甲状腺癌的合理手术方式的选择及其并发症的预防方法。方法回顾性分析2003年6月至2006年9月收治430例分化型甲状腺癌的临床资料。430例均行双侧甲状腺全切除,加或不加颈淋巴结清扫术。结果全组无手术及住院期间死亡。喉神经损伤5例(1.16%),均为单侧;甲状旁腺损伤2例(0.47%),均为部分损伤;喉上神经损伤3例(0.69%),术后出血3例(0.69%),食管损伤1例(0.23%)。结论分化型甲状腺癌是双侧甲状腺全切除的适应证,安全可行。     

Indications for bilateral neck dissection in well-differentiated carcinoma of the thyroid

This paper analyses the results of sixty-eight patients with thyroid carcinoma in whom bilateral modified radical neck dissection was performed, and discusses the indications for bilateral modified radical neck dissection. High frequencies of bilateral jugular lymph node metastases were found in eleven patients with obviously widespread involvement of both thyroid lobes, 13 with cancer mainly located in the isthmus, 2 with clinically detectable bilateral or contralateral jugular chain lymph node metastases, and 10 with recurrent thyroid cancer. Bilateral modified radical neck dissection, therefore appears to be indicated for those conditions. On the other hand, lymph node metastases in the contralateral neck were histologically confirmed in 6 out of 27 patients (22 per cent), in whom papillary carcinoma was clinically confined to one lobe, and where there were no obviously enlarged lymph nodes in the contralateral neck. In those patients, the histological confirmation of the contralateral thyroid lobe involvements, and of the contralateral paratracheal lymph node metastasis, appears to be a valid indication for elective contralateral modified radical neck dissection.     

分化型甲状腺癌131I治疗

应用131I治疗甲状腺疾病已有近70年的历史。手术+131I治疗 +TSH抑制的综合疗法是目前公认的分化型甲状腺癌（differentiated thyroid cancer,DTC）治疗的有效方法,在临床得到了越来越广泛的应用。随着人们对DTC疾病认识的不断深入,DTC 131I治疗的必要性、适应证、临床应用及注意事项等都有了较明确的规范。