巨滤泡型甲状腺乳头状癌（附3例报告）

目的 探讨巨滤泡型甲状腺乳头状癌（macrofollicular variant of papillary thyroid carcinoma,MFPTC）的临床病理特点。方法 回顾分析3例MFPTC病人临床资料、病理形态学及免疫组织化学检测结果。结果 MFPTC超声检查主要表现为不规则强回声,血流丰富。显微镜下可见巨大滤泡,腔内富含胶质。滤泡上皮细胞核被挤压呈立方至扁平状。免疫组织化学显示与其他类型PTC相同。MFPTC的肿瘤上皮细胞CK19、galectin-3、HBME-1呈弥漫或部分阳性。结论 MFPTC在临床病理诊断中容易漏诊。结合临床资料,独特的组织学形态以及免疫组织化学检查有助于明确诊断。     

甲状腺低分化癌合并乳头状癌个案报道并文献复习

本文回顾了2019年3月20日解放军总医院第一医学中心普通外科收治的1例典型单侧甲状腺低分化癌合并乳头状癌的治疗全过程,结合多学科综合治疗模式,提高对该类疾病的认识,为个体化方案制定提供参考。     

Intravascular extension of papillary thyroid carcinoma to the internal jugular vein: A case report

INTRODUCTION

Papillary thyroid cancer (PTC) is the most common thyroid malignancy and usually spreads via lymphatic system. PTC can sometimes show microscopic vascular invasion, but rarely causes tumour thrombus in the internal jugular vein (IJV) or other great veins of the neck.

PRESENTATION OF CASE

We report a case of a 62-year-old female presented with symptomatic central neck mass. Clinical examination revealed a hard solitary right-sided thyroid nodule with ipsilateral cervical lymphadenopathy. Ultrasonography (US) confirmed the clinical diagnosis and visualised a dilated ipsilateral IJV. Fine-needle aspiration cytology revealed PTC cells so total thyroidectomy with right neck dissection was done. A tumour thrombus was discovered in the distended right IJV and was cleared successfully. The patient recovered well after the operation with no local or distant metastasis detected.

DISCUSSION

Tumour vascular spread is observed in tumours with angio-invasive features including follicular carcinoma of the thyroid gland where great cervical veins can be affected. PTC commonly spreads to the lymph nodes and vascular spread via direct intravascular extension is extremely rare. Neck US has an important role in the diagnosis, and operators should attempt to detect signs of tumour thrombi in all patients with thyroid masses. Aggressive surgical treatment with vascular repair is recommended whenever possible to minimise the risk of potentially fatal complications of the intraluminal masses.

CONCLUSION

Intravascular tumour extension of PTC is rare but with serious consequences. Diagnosis with neck US is possible but some cases are only discovered intraoperatively. Thrombectomy with vascular repair or reconstruction is usually possible.     

Papillary thyroid carcinoma in children: risk factors and complications of disease recurrence

Introduction

Optimal treatment of recurrent papillary thyroid carcinoma (PTC) in children remains controversial. We reviewed our experience with recurrent PTC to better identify children diagnosed with it.

Aims

The objective of this study was to determine the risk factors, optimal treatment, complications, and prognosis of recurrent PTC in children.

Methods

This is a retrospective review of all thyroid resections for children aged 18 years or younger who have PTC at a single institution from 1987 to 1999.

Results

Thirty-six children, 7 boys (19%) and 29 girls (81%), underwent initial cervical exploration for PTC. Lymph node involvement was noted in 25 patients (69%); however, there was no distal disease. An equal number of children underwent subtotal thyroidectomy (n = 18) and total (n = 18) thyroidectomy as their initial operation. Papillary thyroid carcinoma recurrences developed in 17 patients (47%) a median of 7 months (range, 1-43 months) after their initial operation. Recurrence was more common for patients with lymph node involvement (P < .01) and multiple nodules (P < .05) at presentation. Recurrence developed in 5 patients after subtotal thyroidectomy and in 12 patients after total thyroidectomy. Sixteen children with recurrent PTC had a second operation and 6 required a third operation. Total operative complications included 2 patients with permanent hypocalcemia and 1 patient with permanent recurrent laryngeal nerve injury, all of whom had a total thyroidectomy. No patient died; however, 3 continue to harbor disease. Mean follow-up for patients with PTC was 65 months (range, 15 to 144 months).

Conclusions

Thyroid resection combined with selective use of radioactive iodine ablation is a safe and effective treatment for recurrent PTC in children. The best predictors of this recurrent disease are lymph node involvement and multiple thyroid nodules at presentation.     

Mandibular metastasis revealed papillary thyroid carcinoma: Rare case

IntroductionPapillary carcinoma is the most frequent differentiated malignant thyroid neoplasm, Metastasis occurs frequently in regional lymph nodes and mandibular metastasis are very rare and most are secondary to follicular carcinomas due to their blood diffusion, The mandibular metastasis of papillary carcinoma is exceptional.Case reportWe report a rare case of mandibular metastasis revealing papillary thyroid carcinoma in a 52-year-old patient, with a review of the literature on clinical features, radiological aspect, and treatment options.Discussion conclusionMandibular metastasis of thyroid cancer are rare and the initial metastases revealing papillary carcinoma are exceptional, few cases are reported in the literature, and due to their rarities and relative lack of data on their management, There is no clearly defined processing algorithm.     

多灶性甲状腺乳头状癌的生物学特性及治疗分析

目的 探讨多灶性甲状腺乳头状癌的临床特性及治疗.方法 回顾性分析1995-1997年间在天津市肿瘤医院手术治疗并经病理证实的86例多灶性甲状腺乳头状癌的临床资料,研究其临床生物学特征.结果 多灶性甲状腺乳头状癌者共86例,占同期甲状腺乳头状癌的23.4%.病灶位于单侧12例,位于双侧74例;颈部淋巴结转移51例(59.3%);病灶中含微小癌者46例(53.5%);合并桥本甲状腺炎者23例(26.7%);周围组织侵犯19例(22.1%);发生远处转移者1例(1.2%);10年生存率95.3%.美国癌症联合会(AJCC)分期与预后相关(x2=63.395,P=0.000).结论 多灶性甲状腺乳头状癌多发生于双侧甲状腺,病灶中含微小癌者及合并桥本甲状腺炎者较多,AJCC分期是多灶性甲状腺乳头状癌的重要预后因素.     

甲状腺峡部乳头状癌手术方式分析

目的：探讨甲状腺峡部乳头状癌的手术方式。方法以2012年1月～2014年1月我院收治的52例甲状腺峡部乳头状癌患者为研究对象,A 组36例采取患侧腺叶和峡部切除术,B 组16例采取全甲状腺切除,两组均行中央区淋巴结清扫,比较两组手术方式的临床效果。结果 A 组的手术时间（132.5±22.5）min,甲状腺功能低下发生率0,B 组的手术时间（162.5±28.5）min,甲状腺功能低下发生率100％,上述差异有统计学意义（P ＜0.05）,两组的术后出血、喉返神经损伤、喉上神经损伤发生率和术后复发率比较差异无统计学意义（P ＞0.05）。结论患侧腺叶和峡部切除术对甲状腺峡部乳头状癌治疗效果更佳,值得临床借鉴。     

多灶性甲状腺乳头状癌168例临床研究

目的:探讨多灶性甲状腺乳头状癌的临床特征及外科治疗方式.方法:回顾分析1997年1月至2006年12月间首次手术并经病理证实的甲状腺乳头状癌648例,其中多灶病例168例.比较单灶组与多灶组及多灶组间的临床病理学差异.结果:本组多灶性甲状腺乳头状癌发生率为25.9%,其中双侧甲状腺多发病灶者117例(69.6%).多灶组在男性(P=0.004)、甲状腺癌家族史(P=0.031)、体检(P=0.000)及B超发现颈部淋巴结肿大(P=0.001)、B超提示结节钙化灶(P=0.001)、颈淋巴结转移(P=0.008)及甲状腺外侵犯(P=0.001)发生率等方面叫显高于单灶患者.而单灶组在伴有良性甲状腺疾病的比例明显高于多灶组(P=0.000).多灶性甲状腺乳头状癌病例中,男性、体检颈部淋巴结大、肿瘤位于双侧及病灶数目≥3个倾向于肿瘤较大、颈部淋巴结转移或甲状腺外侵犯的比例较高;而伴有良性甲状腺疾病的多灶性癌恶性度相对较低.本组164例(97.6%)获得随访;平均随访46.1个月(2～127个月).随访中5例死亡,1例胸部X线片怀疑肺部转移,16个月健在;6例于术后3～41个月因颈淋巴结复发再次手术;2例于术后13个月、24个月残余腺体肿瘤复发手术切除.总的1、2、5、10年生存期分别为98.2%、97.4%、96.5%、96.5%.美国癌症联合会(AJCC)分期与预后相关(X<'2=168.832,P=0.000).结论:多发病灶是甲状腺乳头状癌的临床特征之一,其生物学恶性度更高.甲状腺全切+中央区淋巴结清扫可视为标准手术方式,在外侧区出现淋巴结肿大时需加行侧方清扫.AJCC分期仍是多灶性甲状腺乳头状癌的重要预后因素.     

Risk group stratification and prognostic factors in papillary carcinoma of thyroid

Background: Our understanding of the natural history of differentiated thyroid carcinoma has improved with the definition of prognostic factors. These prognostic factors have helped us identify patients in various risk groups. Methods: A retrospective review of a consecutive series of 810 previously untreated patients with papillary carcinoma of the thyroid was undertaken to analyze the prognostic factors and risk groups. There were 403 patients in the low-risk group, 313 in the intermediate group, and 94 classified in the high-risk group. Results: With a median follow-up of 20 years, 99% survival was achieved in the low-risk group, whereas only 43% survived in the high-risk group. The intermediate-risk group had a 20-year survival of 83%. The favorable prognostic factors included female sex, young age, absence of distant metastases and extrathyroidal extension of the disease, size <4 cm, and low-grade histology. Focality, presence of lymph node metastasis, and pure papillary or mixed variant had no statistical significance on prognosis. Conclusions: Based on various prognostic factors, low-, intermediate-, and high-risk groups are identified. Patients in the low-risk group have excellent survival (99%). Appropriate selection of surgical and adjuvant treatment should therefore be used based on prognostic factors and risk group stratification.Presented at the 48th Annual Cancer Symposium of The Society of Surgical Oncology, Boston, Massachusetts, March 23–26, 1995.     

复发性甲状腺癌37例临床分析

目的探讨复发性甲状腺癌的诊断、治疗和预后。方法回顾性分析我院1985年4月～2005年8月收治的37例复发性甲状腺癌的临床资料。结果37例复发性甲状腺癌中,34例采用手术治疗,3例采用化疗及对症、支持治疗。5年总生存率为91.9%。结论除未分化癌外,对于复发性甲状腺癌,只要具备手术条件,需积极采取手术治疗。     

Papillary Thyroid Carcinoma: Factors Influencing Recurrence and Survival

Background The prognosis of patients with papillary thyroid carcinoma (PTC) is usually favorable; however, a subset of patients can develop local recurrence or distant metastases. The aim of this study was to evaluate the prognostic factors influencing the recurrence and the survival rate in 950 PTC patients. Materials and Methods From 1990 to 2005, 950 consecutive patients affected by PTC were operated on at our Department. We analyzed the prognostic role of the following parameters: gender, age at initial treatment, extent of thyroid surgery, node dissection, tumor size, node metastases, distant metastases, stage, and 131-I therapy. Results Seventy-nine patients (8.3%) developed locoregional or distant metastases after an average follow-up of 7.8 years (range 2–17 years); in particular local recurrence was observed in 25 cases and distant metastases in 54 cases. The global 10- and 15-year survival rates were 91.38% and 88.69%, respectively. At univariate analysis, all variables were significantly correlated with recurrence (P = .001) except gender (P = .3); moreover, gender (P = .2), node dissection (P = .5), and node metastases (P = .06) were not significant on 10- and 15-year survival. At multivariate analysis the age at first treatment, T4, M+, stage IV, the extent of thyroid surgery, and the 131-I therapy resulted to be significant and independent prognostic factors (P < .001). Conclusion Our data, in disagreement with other staging systems, suggest that gender does not play a significant role both in recurrence and survival. Moreover, the 131-I therapy was a statistically significant prognostic factor at univariate and multivariate analyses.     

Isthmectomy is effective and sufficient for selected patients with the isthmus-confined solitary papillary thyroid carcinoma

BackgroundTo retrospectively analyze the outcomes of patients treated with isthmusectomy for a solitary papillary thyroid carcinoma (PTC) confined to the isthmus, and re-assess the role of isthmusectomy in these patients.MethodsThe medical records of 65 patients who underwent isthmusectomy for a solitary PTC confined to the isthmus at the National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College between 1985 and 2015 were retrospectively reviewed. Demographic data, surgical procedures, pathological characteristics, stages, and outcomes were analyzed.ResultsPatients’ median age was 39 years (range, 19–63), and the majority were female (86.2% female, 13.8% male). All patients had a solitary PTC confined to the isthmus and were treated with isthmusectomy. Pretracheal lymph node dissection was performed in 34 patients, in which unilateral central neck dissection was performed in 4 patients and bilateral central neck dissection in 2 patients. Microscopic extrathyroidal extension (ETE) was observed in 23 (35.4%) patients, and macroscopic ETE was observed in 3 (4.6%) patients. Thirty-eight (58.5%) patients were stage pT1a, 19 (29.2%) patients were stage pT1b, 5 (7.7%) patients were stage pT2, and 3 (4.6%) patients were stage p3b. Fifteen (23.1%) patients were stage pN1a. Median follow-up time was 78 months (range, 12–274). Two patients experienced a recurrence and both achieved remission after re-operation. The 10-year recurrence-free survival was 92.1%. The 10-year overall survival and disease specific survival were 98.3% and 100%, respectively.ConclusionsIsthmusectomy is effective and sufficient for select patients with a solitary PTC confined to the isthmus.     

Prognosis After Reoperation for Local Recurrence of Papillary Thyroid Carcinoma

Purpose To investigate the factors associated with a favorable prognosis after reoperation for local recurrent papillary thyroid carcinoma (PTC), we reviewed 45 patients who underwent surgery for first local recurrence of PTC.Methods We divided the patients into two groups. Group A (n = 28) had no second recurrence, and group B (n = 17) had second local recurrence after surgery for recurrence.Results The mean follow-up period after reoperation was 56.9 months. The mean age at the time of reoperation in group A was significantly lower than that in group B, at 48.1 years versus 62.3 years, respectively (P = 0.0007). The mean age at the time of the initial operation in group A was also significantly lower than that in group B, at 40.1 years versus 55.1 years, respectively (P = 0.0006). Patients with recurrent tumors only outside the area dissected at the initial operation (n = 27) had a better outcome than those with recurrence within the dissected area (n = 18; P = 0.0127). Patients who underwent systematic partial or modified neck dissection (n = 36) had a better outcome than those who underwent only simple local resection (n = 9; P = 0.0169).Conclusion For local recurrent PTC, systematic neck dissection is recommended over local resection of recurrent tumors.     

Hyperfunctioning papillary thyroid carcinoma: A case report with literature review

IntroductionThyroid malignant tumors are rarely associated with hyperfunctioning thyroid. The incidence of this co-incidence is highly variable. Here we report a rare case of papillary thyroid cancer associated with hyperthyroidism with brief literature review.Case reportA 40-year-old male, presented with palpitation, excess sweating and weight loss for one month duration. There was asymmetrical swelling of the neck, more on right side, mobile. Free T3: 11.09 pmol/L, free T4: 34.41 pmol/L, TFT: less than 0.005 mIU/ml, Neck ultrasound showed features of background thyroiditis. Left lobe contained 9 × 7 × 5 mm nodule with irregular outline and multiple dots of calcification, other nodules are of the same features. Under ultrasound guide, fine needle aspiration cytology showed features of papillary carcinoma. After preparation, total thyrodectomy done and the result of histopathological examination confirmed papillary thyroid carcinoma. The patient was put on 0.2 mg thyroxine daily.DiscussionLiterature review has showed an increasing number of papers reporting the association of high level of thyroid function tests and thyroid malignancy. The cause of high level of TH in thyroid malignancy is thought to be due to an active mutation of the gene of TH receptor. Niepomniszcze and colleagues found that a combination of TSH receptor mutations and Ki-RAS was the main etiological factor for hyperfunction of the thyroid malignancy.ConclusionAlthough the coexistence of them is rare, thyroid malignancy should be put in the differential diagnosis of hyperthyroid goiter.     

多功能保留在甲状腺癌颈淋巴结清扫术中的应用

目的探讨多功能保留在甲状腺癌颈淋巴结清扫术中的可行性及意义。方法回顾性分析我院2006年4月至2009年12月因甲状腺癌行甲状腺切除加Ⅱ~Ⅵ区多功能保留颈淋巴结清扫术61例,4例行双侧颈淋巴结清扫,共65例次。其中甲状腺乳头状癌54例,甲状腺滤泡状癌3例,甲状腺髓样癌4例。结果 61例中保留耳大神经60例次,枕小神经50例次,锁骨上皮神经59例次,颈横动、静脉48例次。术后患者随访0.5~4年,1例术后18个月复发,1例3年复发,59例无复发,术后患者均于3个月内耳廓感觉恢复,下颈部及肩部无麻木感,颈部外观无改变。结论多功能保留在甲状腺癌颈淋巴结清扫术中应用,既可达到根治肿瘤的目的,又能有效保留耳廓区、颈部、锁骨上区的感觉,具合理性、可行性。     

Morbidity of prophylactic lymph node dissection in the central neck area in patients with papillary thyroid carcinoma

The benefits of prophylactic central neck dissection (PCND) in patients with papillary thyroid carcinoma (PTC) have not been clearly demonstrated so far and should be weighed against the potential risks of the procedure. The aim of the study was to assess the recurrent laryngeal nerve and parathyroid risks of PCND after total thyroidectomy in patients with PTC and to compare the results with those obtained in patients who underwent total thyroidectomy only. Methods: We selected 100 patients who underwent a total thyroidectomy: 50 for nontoxic benign multinodular goiter (Group 1) and 50 for PTC (Group 2). Patients with PTC had no evidence of macroscopic lymph node invasion during surgery and underwent, in addition to the total thyroidectomy, a PCND. All of the 100 patients were operated on by two experienced endocrine surgeons. All patients had pre- and postoperative investigations of vocal cord movements. Calcemia and phosphoremia were systematically evaluated preoperatively and on day 1 and day 2 after surgery. All patients presenting a postoperative calcemia below 1.90 mmol/l were considered to present an early postoperative hypoparathyroidism and received calcium-vitamin D therapy. The hypoparathyroidism was considered permanent when calcium-vitamin D therapy was still necessary 1 year after surgery. Results: None of the patients presented permanent nerve palsy. There were three cases of transient nerve palsy (6%) in Group 1 and two (4%) in Group 2. In Group 1 there was no permanent hypoparathyroidism and four cases of transient hypoparathyroidism (8%). In Group 2, seven patients presented transient hypoparathyroidism (14%) and two patients (4%) remained with definitive hypoparathyroidism. Conclusion: After total thyroidectomy for PTC, PCND does not increase recurrent laryngeal nerve morbidity but it is responsible for a high rate of hypoparathyroidism, especially in the early postoperative course. Even taking into account the possible benefits, the results make it difficult to advocate PCND as a routine procedure in all patients presenting a PTC. Received: 27 January 1998     

56例复发性分化型甲状腺癌的临床分析

目的 探讨分化型甲状腺癌复发的可能原因.方法 对56例复发的分化型甲状腺癌患者的临床资料进行回顾性分析,总结引起复发的可能原因.结果 t检验结果显示,年龄、初次手术方式、病理类型及术后服药、放射性核素治疗对复发均有影响（P＜0.05）,而性别对分化型甲状腺癌复发无明显影响（P=0.240）;首次手术方式中单侧腺体切除对复发有影响（P =0.006）,双侧腺体切除对复发无明显影响（P=0.153）.多因素分析结果显示,首次手术方式是影响复发的独立影响因素（P＜0.05）.结论 复发可能性大的分化型甲状腺癌患者,应加强定期随访,如确诊复发,需积极采取规范的方式治疗.