甲状腺髓样癌并发乳头状癌的诊治进展

甲状腺癌为目前最常见的内分泌系统恶性肿瘤, 其发病呈逐年上升且呈年轻化的趋势。甲状腺癌病理类型分为乳头状癌、滤泡型癌、髓样癌和未分化癌。甲状腺髓样癌(medullary thyroid carcinoma, MTC)和甲状腺乳头状癌(papillary thyroid carcinoma, PTC)是两种常见的甲状腺癌病理类型。MTC起源于滤泡旁细胞(C细胞), PTC起源于滤泡上皮细胞, 两者起源不同, 故MTC与PTC两种病理类型同时发生十分罕见, 国内外鲜有报道。由于MTC和PTC具有不同的生物学来源、侵袭性和预后, 治疗具有挑战性。本文主要围绕该病的发病机制、辅助检查、诊断和治疗等方面进行综述, 以期为MTC并发PTC患者的临床诊疗提供参考。     

甲状腺髓样癌的靶向治疗

甲状腺癌是内分泌系统最常见的恶性肿瘤,也是近年来发病率上升最快的恶性肿瘤[1]。其病理类型主要包括分化型甲状腺癌（甲状腺乳头状癌和甲状腺滤泡状癌）、甲状腺髓样癌（medullary thyroid cancer,MTC）和未分化癌。其中,MTC为低分化癌,属于中度恶性的肿瘤。临床上MTC具有早期侵犯区域淋巴结和易向肝、肺、骨等远处转移的倾向。     

同期双侧颈淋巴结清扫治疗高分化及髓样甲状腺癌

目的 探讨同期双侧颈淋巴结清扫治疗高分化及髓样甲状腺癌的适应证、原发灶的根治范围和颈淋巴结清扫术式的选择。方法 回顾我院收治的22例双侧颈淋巴结转移的甲状腺乳头状、滤泡状及髓样癌的病例资料,10例行一侧叶切除加对侧叶近全切除根治原发癌,同时行一侧传统颈清扫加对侧改良清扫（下称传统清扫组）;12例行全甲状腺切除根治并行同期双侧颈淋巴结改良清扫（下称改良清扫组）。结果 单侧癌9例,双侧癌13例,20例原发癌为多中心性。双侧改良清扫组颜面水肿率显著低于传统清扫组（16．7％vs100％,P〈0．01）,渗出量[（300．4±40．65）ml vs（406．8±39．85）ml]、术后住院时间[（8．3±1．16）d vs（12．5±1．58）d]也低于传统清扫组（P〈0．01）。结论 发生双侧颈淋巴结转移的高分化甲状腺癌及髓样癌,应行全甲状腺切除及双侧颈淋巴结清扫,同期双侧的改良颈淋巴结清扫不但术后恢复快、生活质量高,而且远期疗效肯定,值得推广和应用。     

甲状腺癌动物模型建立研究的现状与展望

正甲状腺癌系指源于甲状腺上皮细胞的恶性肿瘤,包括甲状腺乳头状癌(PTC)、甲状腺滤泡状癌(FTC)、甲状腺未分化癌(ATC)及源自甲状腺滤泡旁细胞(C细胞)的恶性肿瘤即甲状腺髓样癌(MTC)。甲状腺癌是一种高发的内分泌恶性肿瘤,2018年中国国家癌症预防和控制中心发布的癌症发病率和死亡率数据显示,2014年中国新发甲状腺癌约17万病例(女性约12.7万例,男性约4.3万     

p14ARF、p53及脆性组氨酸三联体蛋白在甲状腺肿瘤中的表达

目的探讨p14ARF、p53及脆性组氨酸三联体(FHIT)蛋白在甲状腺肿瘤组织中的表达及其意义。方法采用免疫组织化学法检测20例甲状腺腺瘤和28例甲状腺癌组织(其中包括11例甲状腺滤泡癌(FTC)、12例乳头状癌(PTC)、4例髓样癌(MTC)以及1例未分化癌(UDTC)中p14ARF、p53及FHIT蛋白的表达。结果p14ARF、p53及FHIT蛋白在甲状腺腺瘤和甲状腺癌中阳性率分别为90%、36%;15%、75%;90%、7%,这3种蛋白在甲状腺腺瘤及甲状腺癌的表达差异均有统计学意义(P<0.05)。p14ARF、p53及FHIT蛋白的表达在FTC与腺瘤之间,PTC与腺瘤之间有统计学意义(P<0.05),p53及FHIT的表达在MTC与腺瘤间差异有统计学意义(P<0.05)。p14ARF、p53及FHIT蛋白的表达与甲状腺肿瘤的恶性进程有关,与患者年龄、性别以及淋巴结转移无关。另外p14ARF与FHIT蛋白的表达正相关,并且它们与p53均负相关。结论肿瘤抑制蛋白p14ARF和FHIT的缺失以及癌蛋白p53的高表达是甲状腺肿瘤发生的重要原因之一;联合检测p14ARF、p53及FHIT蛋白有助于区分甲状腺腺瘤和甲状腺滤泡癌。     

甲状腺乳头状癌合并髓样癌1例报告

<正>甲状腺乳头状癌(papillary thyroid carcinoma,PTC)与甲状腺髓样癌(medullary thyroid carcinoma,MTC)均为临床常见肿瘤,但由于二者癌细胞分化起源不同,故临床上PTC并发MTC甚少[1-4]。笔者科室近期收治1例PTC并发MTC病例。现报告如下。1病历简介病人女性,57岁,因"体检彩超发现双侧甲状腺结节2 d"于2014-06-05入院。既往有2型糖尿病病史2年。病     

Smad4蛋白在结节性甲状腺肿与甲状腺癌并存组织中的表达及其影响

目的:研究结节性甲状腺肿与甲状腺癌并存病变组织中Smad4蛋白的表达及其影响。方法:采用免疫组化SP法对结节性甲状腺肿并存甲状腺癌组织84例、结节性甲状腺肿并存甲状腺瘤50例组织及相应的40例结节性甲状腺肿组织中的Smad4进行检测。结果:Smad4蛋白在甲状腺癌、甲状腺瘤、结节性甲状腺肿组织中的阳性表达率分别为52.38%、74.00%、82.50%,甲状腺癌组织阳性表达率低于甲状腺瘤及结节性甲状腺肿者阳性表达率(P0.05或P0.01)。Smad4蛋白在乳头状癌、滤泡状癌、未分化癌的阳性表达率分别为57.45%、58.33%、23.08%,未分化癌Smad4蛋白阳性表达率低于乳头状癌及滤泡状癌者表达率(P0.05)。结论:检测Smad4蛋白表达对阐述结节性甲状腺肿与甲状腺癌并存病变的生物学行为及评估其预后具有重要意义。     

分化型甲状腺癌术后RAI治疗的分歧与共识

<正>甲状腺癌根据组织形态结构、侵袭性、基因表达等不同病理学特征分为4个亚型:乳头状癌(PTC),滤泡型癌(FTC),未分化癌(ATC)和髓样癌(MTC)。在过去的30年里,甲状腺癌的发病率在全球范围内持续增长。然而,同时期内甲状腺癌的死亡率却无明显变化[1]。分化型甲状腺癌(DTC)包括PTC和FTC,占所有甲状腺癌的90%以上[2]。对DTC的治疗,根据不同的疾病分期,通常为手术切除联合放射     

家族性甲状腺癌诊治进展

甲状腺癌可分为散发性和家族性。目前主要将家族性甲状腺癌分为家族性甲状腺髓样癌和家族性非髓样甲状腺癌(familial nonmedullary thyroid carcinoma,FNMTC)两大类。其中家族性甲状腺髓样癌又称遗传性甲状腺髓样癌。1家族性甲状腺髓样癌甲状腺髓样癌(MTC)大约占甲状腺癌的5%~1     

甲状腺结节钙化在超声诊断甲状腺癌中的意义秦巧娜

目的探讨甲状腺结节内钙化在诊断甲状腺癌中的意义。方法回顾性分析306例结节性甲状腺肿伴钙化患者的术前彩色多普勒超声检查及术后病理结果。结果经病理确诊为甲状腺癌157例占306例结节性甲状腺肿伴钙化患者的比例为51．31％（157／306）,其中乳头状癌126例所占比例为80．25％,滤泡状癌13例为8．28％,未分化癌10例为6．37％,髓样癌8例为5．10％。微小钙化在306例钙化中比例为65．5％（200／306）,其中乳头状癌为73．81％（93／126）;微小钙化比例在不同年龄组之间（≥45岁和〈45岁）分别为39．33％、67．95％,二者间存在显著差异（P〈0．05）。结论超声可早期发现甲状腺钙化,对诊断甲状腺癌临床诊断价值大。     

Vasopressor hormone response following mesenteric traction during major abdominal surgery

Background : We investigated the vasopressor hormone response following mesenteric traction (MT) with hypotension due to prostacyclin (PGI₂) release in patients undergoing abdominal surgery with a combined general and epidural anesthesia. Methods : In a prospective, randomized, placebo-controlled study we administered 400 mg ibuprofen (i.v.) in 42 patients scheduled for abdominal surgery. General anesthesia was combined with epidural anesthesia (T4-L1). Before as well as 5, 15, 30, 45, and 90 min after MT we recorded plasma osmolality, hemodynamics and measured 6-keto-PGFlα (stabile metabolite of PGI₂), TXB₂ (stabile metabolite of thromboxane A₂) active renin, and arginine vasopressin (AVP) plasma concentrations by radioimmunoassay. Catecholamine levels were assessed by high-pressure liquid chromatography (HPLC) with electrochemical detection. Results : Following MT, arterial hypotension occurred along with a substantial PGI₂ release. This was completely abolished by ibuprofen administration. Although plasma levels of 6-keto-PGF_1α (1133 (708) vs. 60 (3) ng/L, median (median absolute deviation), P=0.0001, placebo vs. ibuprofen) remained significantly elevated, blood pressure was restored within 30 min after MT in the placebo group. At the same point in time plasma concentrations of TXB² (164 (87) vs. 58 (1) ng/L, P=0.0001), epinephrine (46 (33) vs. 14 (6) ng/L, P=0.001), AVP (41 ± (18) vs. 12 (7) ng/L, P=0.0004), and active renin (27 (12) vs. 12 (4) ng/L, P = 0.001) were significantly higher in placebo-treated patients. Conclusion : Under combined general and epidural anesthesia arterial hypotension following MT due to endogenous PGI₂ release is associated with enhanced release of AVP, active renin, epinephrine and thromboxane A₂, presumably contributing to hemodynamic stability within 30 min after MT.     

Microspheres Based Detoxification System: A New Method in Convective Blood Purification

Abstract: A variety of protein-bound or hydrophobic substances, accumulating as a result of pathologic conditions such as exogenous or endogenous intoxications, are removed poorly by conventional detoxification methods because of low accessibility (hemodialysis), insufficient adsorption capabilities (hemosorption), low efficiency (peritoneal dialysis), or economic limitations (high-volume plasmapheresis). Combining advantages of existing methods with microspheric technology, a module-based system was designed. Major operating parameters of the latter can be modified to allow for adjustment to individual clinical situations. An extracorporeal blood circuit including a plasmafilter is combined with a secondary high-velocity plasma circuit driven by a centrifugal pump. Different microspheric adsorbers can be combined in one circuit or applied in sequence. Thus, a prolonged treatment can be tailored using specially designed selective adsorber materials. Comparing this system with existing methods (high-flux hemodialysis, molecular adsorbent recycling system), results from our in vitro studies and animal experiments demonstrate the superior efficiency of substance removal.     

A Teaspoon Pump for Pumping Blood with High Hydraulic Efficiency and Low Hemolysis Potential

Abstract: Virtually all blood pumps contain some kind of rubbing, sliding, closely moving machinery surfaces that are exposed to the blood being pumped. These valves, internal bearings, magnetic bearing position sensors, and shaft seals cause most of the problems with blood pumps. The original teaspoon pump design prevented the rubbing, sliding machinery surfaces from contacting the blood. However, the hydraulic efficiency was low because the blood was able to "slip around" the rotating impeller so that the blood itself never rotated fast enough to develop adequate pressure. An improved teaspoon blood pump has been designed and tested and has shown acceptable hydraulic performance and low hemolysis potential. The new pump uses a nonrotating "swinging" hose as the pump impeller. The fluid enters the pump through the center of the swinging hose; therefore, there can be no fluid slip between the revolving blood and the revolving impeller. The new pump uses an impeller that is comparable to a flexible garden hose. If the free end of the hose were swung around in a circle like half of a jump rope, the fluid inside the hose would rotate and develop pressure even though the hose impeller itself did not "rotate"; therefore, no rotating shaft seal or internal bearings are required.     

Bariatric Surgery in Some "Central and East-European (former Eastern bloc)"Countries - Current Status and Prediction for the Next Millennium

Background: Obesity is increasing globallly, including in the formerly "Eastern Bloc" countries. Methods: A survey was made of obesity and bariatric surgery. Results: In the 8 East and Central European countries studied, with total population 300 million, roughly 43% of the population was overweight (BMI 25-30), 23% obese (BMI > 30), with about 15 million people morbidly obese (BMI > 40). From 0-10 morbidly obese individuals/100,000/year undergo bariatric surgery. Conclusion: Most countries were found to provide inadequate treatment for obesity.The majority of the morbidly obese are not treated effectively. However, health-care awareness of obesity and bariatric surgeons are slowly increasing.     

Tissue perfusion in relation to cardiac output during continuous positive-pressure ventilation and administration of propranolol or verapamil

Background : Our objective was to determine whether administration of propranolol or verapamil modifies the hemodynamic adaptation to continuous positive-pressure ventilation (CPPV), in particular the regional distribution of cardiac output (CO).
Methods : General hemodynamics and regional blood flows assessed by microsphere technique (15 (μm) were recorded in 16 anesthetized pigs during spontaneous breathing (SB) and CPPV with 8 cm H₂O end-expiratory pressure (CPPV8) before and after intravenous administration of propranolol (0.3 mg · kg⁻¹ followed by 0.15 mg · kg⁻¹ · h⁻¹, n=8) or verapamil (0.1 mg · kg⁻¹ followed by 0.3 mg · kg⁻¹ · h⁻¹, n=8).
Results : CPPV8 depressed CO by 25% without shifts in its relative distribution with the exception of a noteworthy increase in adrenal perfusion. Propranolol increased arterial blood pressure, and due to a fall in heart rate, CO dropped by 25%. The kidneys and, to a lesser extent, the splanchic region and central nervous system received increased fractions of the remaining CO at the expense of skeletal muscle flow. Similar patterns were seen during SB and CPPV8 such that the combination of propranolol and CPPV8 depressed CO by 50%. The circulatory effects of verapamil were less evident but myocardial perfusion tended to increase.
Conclusions : The combination of propranolol or verapamil with CPPV does not result in any specific hemodynamic interaction in anesthetized pigs, except that the combined effect of propranolol and CPPV may severely reduce CO.     

Volatile anaesthetics reduce adhesion of blood platelets under low-flow conditions in the coronary system of isolated guinea pig hearts

Background : Inhibitory effects of volatile anaesthetics on platelet aggregation have been demonstrated in several studies. However, the influence of volatile anaesthetics on intracoronary platelet adhesion has not been elucidated so far.
Methods : Isolated hearts of guinea pigs were perfused with buffer in the absence or presence of volatile anaesthetics (0.5 and 1 MAC) at constant coronary flow rates of 5 ml/min for 25 min, then 1 ml/min for 30 min and again 5 ml/min for 10 min. Before, during and after low-flow perfusion, a bolus of human platelets was applied into the coronary system. To simulate thrombogenic conditions, 0.3 U/ml human thrombin was infused during low-flow perfusion and reperfusion. The number of platelets sequestered to the endothelium was calculated from the difference between coronary in- and output of platelets. The myocardial production of lactate and consumption of pyruvate and coronary perfusion pressure were also determined.
Results : At a flow rate of 5 ml/min only about 3% of the applied platelets did not emerge from the coronary system, in any group. In contrast, 13.1±1.2% (mean±SEM) of infused platelets became adherent in low-flow perfusion in the control group without anaesthetic. The adherence was reduced with each 1 MAC isoflurane (to 6.2±1.2%), sevoflurane (to 4.4±0.9%) or halothane (to 3.2±1.5%) (each P <0.05 vs. control). Volatile anaesthetic, 0.5 MAC, did not inhibit platelet adhesion to a statistically significant extent in any case. Perfusion pressure and metabolic parameters were not statistically different between the control and the hearts exposed to anaesthetics.
Conclusion : Volatile anaesthetics in a concentration of 1 MAC can reduce the adhesion of platelets in the coronary system under reduced flow conditions. This action does not arise from vasodilation or inhibition of ischaemic stress.     

Synergistic interaction between the effects of propofol and midazolam with fentanyl on phrenic nerve activity in rabbits

Background: It has been shown that the depressive effects of both propofol and midazolam on consciousness are synergistic with opioids, but the nature of their interactions on other physiological systems, e. g. respiration, has not been fully investigated. The present study examined the effect of propofol and midazolam alone and in combination with fentanyl on phrenic nerve activity (PNA) and whether such interactions are additive or synergistic. Methods: PNA was recorded in 27 anaesthetised and artificially ventilated rabbits. In three groups, propofol, fentanyl and midazolam were administered intravenously in incremental doses to construct dose-response curves for the depressant effects of each one on PNA. In another two groups, the effect of pretreatment with either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. on the effects of propofol and fentanyl respectively on PNA were studied. Results: Propofol and fentanyl caused a dose-dependent depression of PNA with complete abolition at the highest total doses of 16 mg · kg^?1 i. v. and 32 μg · kg^?1 i. v., respectively. In contrast, midazolam in incremental doses to a total of 0.8 mg · kg^?1 reduced mean PNA by 63%, but approximately 12% of PNA remained at a total dose as high as 6.4 mg · kg^?1. The mean ED₅₀s, calculated from dose-response curves, were 5.4 mg · kg^?1, 3.9 μg · kg^?1 and 0.4 mg · kg^?1 for propofol, fentanyl and midazolam, respectively. Initial doses of either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. acted synergistically with subsequent doses of either propofol or fentanyl to abolish PNA at total doses of 8 mg · kg^?1 and 8 μg · kg^?1, respectively. Conclusion: Fentanyl has a synergistic interaction with both propofol and midazolam on PNA and hence potentially on respiration.     

Influence of dopexamine hydrochloride on haemodynamics and regulators of circulation in patients undergoing major abdominal surgery

Background: Catecholaminergic support is often used to improve haemodynamics in patients undergoing major abdominal surgery. Dopexamine is a synthetic vasoactive catecholamine with beneficial microcirculatory properties. Methods: The influence of perioperative administration of dopexamine on cardiorespiratory data and important regulators of macro- and microcirculation were studied in 30 patients undergoing Whipple pancreaticduodenectomy. The patients received randomized and blinded either 2 μg · kg^?1 · min^?1 of dopexamine (n=15) or placebo (n=15, control group). The infusion was started after induction of anaesthesia and continued until the morning of the first postoperative day. Endothelin-1 (ET-1), vasopressin, atrial natriuretic peptide (ANP), and catecholamine plasma levels were measured from arterial blood samples. Measurements were carried out after induction of anaesthesia, 2 h after onset of surgery, at the end of surgery, 2 h after surgery, and on the morning of the first postoperative day. Results: Cardiac index (CI) increased significantly in the dopexamine group (from 2.61±0.41 to 4.57±0.78 1 · min^?1 · m^?2) and remained elevated until the morning of the first postoperative day. Oxygen delivery index (DO₂I) and oxygen consumption index (VO₂I) were also significantly increased in the dopexamine group (DO₂I: from 416±91 to 717±110 ml/m² · m²; VO₂I: from 98±25 to 157±22 ml/m² · m²), being significantly higher than in the control group. pHi remained stable only in the dopexamine patients, indicating adequate splanchnic perfusion. Vasopressive regulators of circulation increased significantly only in the untreated control patients (vasopressin: from 4.37±1.1 to 35.9±12.1 pg/ml; ET-1: from 2.88±0.91 to 6.91±1.20 pg/ml). Conclusion: Patients undergoing major abdominal surgery may profit from prophylactic perioperative administration of dopexamine hydrochloride in the form of improved haemodynamics and oxygenation as well as beneficial influence on important regulators of organ blood flow.     

A comparison of the inhibitory effects of four volatile anaesthetics on the metabolism of chlorzoxazone, a substrate for CYP2E1, in rabbits

Background: Halothane inhibits in vitro and in vivo activity of cytochrome P-450 (CYP) 2E1. There are several fluorinated volatile anaesthetics besides halothane, and most of them are defluorinated by CYP2E1. It is unclear whether other fluorinated anaesthetics inhibit the in vivo activity of CYP2E1.
Methods: We compared the inhibitory effects of therapeutic concentrations of four inhalational anaesthetics, halothane, enflurane, isoflurane, and sevoflurane, on chlorzoxazone metabolism in rabbits receiving artificial ventilation.
Results: All four inhalational anaesthetics decreased arterial blood pressure and increased plasma chlorzoxazone concentration. However, no significant differences in the plasma chlorzoxazone concentration were found between the four anaesthetics. The estimated chlorzoxazone clearance increased after beginning inhalation with all four agents, but no significant difference in clearance was noted between agents.
Conclusions: At therapeutic concentrations, the in vivo inhibitory effect on chlorzoxazone metabolism was similar for all four inhalational anaesthetics examined, even though their chemical characteristics and extent of hepatic metabolism differ considerably.     

Systemic analgesia adapted to the children's condition

A concept of balanced analgesia using nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol (acetaminophen), opioids, and corticosteroids can also be used in patients with pre-existing illnesses. NSAIDs are the most effective treatment for acute pain of moderate intensity in children; however, these drugs should be avoided in patients at increased risk for serious side effects, e.g. patients with renal impairment, bleeding tendency, or extreme prematurity. NSAIDs can be given with minimal risks to the younger child with mild to moderate asthma, and, in these patients, the use of steroids can be encouraged; in addition to their antiemetic and analgesic action, a beneficial effect on asthma symptoms can be expected. In the non-intubated child with cerebral trauma, exaggerated sedation caused by opioids and increased bleeding tendency caused by NSAIDs must be avoided. In neonates and small infants, the oral administration of sucrose or glucose is helpful to minimize pain reaction during short uncomfortable interventions.