甲状腺全切除术治疗甲状腺癌的临床体会

目的探讨甲状腺全切除术在治疗甲状腺癌中的临床应用价值.方法我院1985～2000年经同一外科医生施行甲状腺全切除术治疗甲状腺癌87例,对其发生并发症及术后131I治疗进行回顾性分析.结果术后观察喉返神经损伤2例(2.3%),低钙血症1例(1.1%),无永久性喉返神经损伤或低钙血症,无死亡.84例患者术后获得随访,平均随访5年,无瘤生存82例(97.6%),其中选择性进行131I治疗58例,占70.7%(58/82).结论甲状腺全切除术是治疗甲状腺癌安全、有效的手术方式,能彻底切除腺体内恶性肿瘤的潜在转移性病变,为术后进行131I治疗创造有利条件.     

Surgical treatment of thyroid nodules. The immediate results after different thyroidectomy methods

The extension of the resection for thyroid nodules depends both on nodules' nature and immediate or late postoperative complications risks. This clinical study analyzed the immediate complications appeared after partial thyroidectomy comparatively with those developed after total thyroidectomy. We studied 1411 patients operated in two clinics (from Romania and from France) which have two different attitudes concerning the width of the resection. Paralysis of recurrent laryngeal nerve occurred in 1.0% of patients with partial thyroidectomy and 3.0% of patients with total thyroidectomy, while only one patient (0.6%) developed permanent hypoparathyroidism after total thyroidectomy. In conclusion, total thyroidectomy can be performed by experimented surgeons with a recurrent or parathyroid injury risk similar to partial thyroidectomy. However, the surgeon should take into account the patient survey capacity and the discomfort produced by life substitutive treatment.     

甲状腺腺叶切除术治疗不同年龄甲状腺良性肿瘤患者的临床疗效比较

目的 分析甲状腺叶切除术治疗不同年龄甲状腺良性肿瘤患者的临床效果.方法 行单侧甲状腺腺叶切除术的甲状腺良性肿瘤患者150例,按照其年龄大小将其分成青年组、中年组以及老年组,每组各50例,比较三组患者术后1周,术后1、3、6、12个月的游离三碘甲腺原氨酸(FT3)、游离甲状腺素(FT4)以及促甲状腺素(TSH)水平与术前的差异,并比较术后并发症的发生情况以及生活质量评分差异.结果 青年组患者FT3水平术后1周[(3.76±0.98) pmol/L]、1个月[(4.08±1.11) pmol/L]与术前[(4.99±0.87) pmol/L]比较明显降低(P＜0.05),TSH水平在术后1周以及术后1、3个月与术前比较,差异有统计学意义(P＜0.05);中年组患者的FT3、FT4以及TSH水平与术前比较,差异无统计学意义(P＞0.05);老年组患者的FT3水平在术后1周以及1、3个月明显降低,FT4水平在术后1、3、6个月明显降低,TSH水平在术后1周以及1、3、6个月明显增高(P＜0.05).青年组术后并发症的发生率(8.0％)显著低于老年组(28.0％,P＜0.05).青年组和中年组患者的术后生活质量与术前比较差异无统计学意义(P＞0.05),但老年组患者术后生理职能、一般健康状况、精力以及精神健康等方面评分,与术前比较明显降低(P＜0.05).结论 甲状腺腺叶切除术治疗不同年龄甲状腺良性肿瘤患者的临床效果较好,但术后甲状腺功能恢复存在差异,尤其老年患者较差.     

Complications after total thyroidectomy in thyroid carcinoma]

Authors report the postoperative complication rate in 52 patients who had undergone total thyroidectomy for cancer between 1984 to 1989. Total thyroidectomy has been performed in 9.8% of patients surgically treated for nodular thyroid pathology. Patients age average 49 years in a range 16-75; they were 49 women and 3 men. In 50% of cases we found papillary cancer, follicular in 40%, medullary 4% and anaplastic 6%. We shared postoperative complications in two mean groups: 1) aspecific complications as cardiocirculatory failure, respiratory failure, wound infections or collections, granulomas, keloids; 2) surgery related complications such as hypocalcemia, dysphagia, recurrent++ paralyses. The first group, we noticed just one case of respiratory mechanical failure due to severe tracheomalacia that required a temporary tracheostomy performed at the end of surgical procedure; we did not notice any death due to cardio-circulatory or respiratory failure, nor did we notice any postoperative hemorrhage; one patient presented a wound seroma, two patients presented granulomas due to subcutaneous stitches, and three developed papulous drug-induced erythema. The second group, eight patients developed a transient hypocalcemia beginning on the second postoperative day, without relevant tetanic crisis, well treated by calcium administration; only two of these patients developed permanent hypoparathyroidism. In 3 cases we had to perform exeresis of a laryngeal inferior nerve involved by the cancer, while in 5 more cases we noticed a transient monolateral paralysis that disappeared in 2 or 3 months. Three patients presented dysphagia before intervention and healed post-surgery.(ABSTRACT TRUNCATED AT 250 WORDS)     

甲状腺癌患者甲状腺全切手术安全性探讨

目的 探讨甲状腺癌患者行甲状腺全切除手术的安全性.方法 回顾性分析1986年1月至2006年12月因甲状腺癌行甲状腺全切除(全切组)以及次全或近全切除术(双叶手术组)的患者资料,比较两组间喉返神经损伤和继发性甲状旁腺功能低下的发生率.结果 双叶切除手术组433例:13例发生暂时性单侧喉返神经损伤,5例发生永久性单侧喉返神经损伤;11例发生暂时性甲状旁腺功能低下,无永久性甲状旁腺功能下病例.甲状腺全切手术组共70例:4例发生暂时性单侧喉返神经损伤(P>0.05),1例发生永久性单侧喉返神经损伤(P>0.05);7例发生暂时性甲状旁腺功能低下(P<0.01),2例永久性甲状旁腺功能低下(P<0.05).结论 甲状腺全切除术并不增加喉返神经损伤的概率,但手术后甲状旁腺功能低下发生率增加,因此应该有选择的施行甲状腺全切除手术.     

甲状腺癌次全或全切除术后甲状腺功能的变化

目的 观察甲状腺癌行甲状腺叶全切或次全切术后甲状腺功能的变化,为术后补充甲状腺素提供时间和量的依据.方法 对我院2009年1月至2011年4月间行甲状腺叶全切或次全切除的88例甲状腺癌患者术前(0 d)、术后第1天(1 d)、术后第3天(3 d)和术后第5天(5 d)的甲状腺功能[游离三碘甲腺原氨酸(FT3)、游离甲状腺素(FT4)、血清三碘甲腺原氨酸(T3)、四碘甲腺原氨酸(T4)、促甲状腺激素(TSH)]进行检测,对比手术前后变化规律.结果 88例行甲状腺叶全切或次全切除患者的FT3和T3在各时点均呈下降趋势,差异有统计学意义(FT3:F =47.752,P＜0.01;T3:F=15.317,P＜0.01),且术后3d起FT3和T3逐渐上升接近正常值下限;FT4和T4术后1d均上升,随后逐渐下降,FT4值在0d、术后1d及5d差异无统计学意义(P＞0.05),T4值在0d、术后1d差异无统计学意义(P＞0.05),其余各时间点间差异均有统计学意义(P＜0.05);TSH在术后1d下降,3d及5d逐渐上升,TSH值在0d、术后1d差异无统计学意义(P＞0.05),其余各时间点间差异均有统计学意义(P＜0.05),且TSH在术后3d接近正常值上限,于术后5d超过正常值上限.结论 甲状腺癌患者行甲状腺全切或次全切除术后1d甲状腺功能不降或下降不明显,可不检测甲状腺功能和补充甲状腺激素;术后3d起甲状腺功能明显下降,应及时监测,并根据甲状腺功能下降情况适当补充甲状腺激素.     

If the price is right: Cost-effectiveness of radiofrequency ablation versus thyroidectomy in the treatment of benign thyroid nodules

BackgroundRadiofrequency ablation is an emerging technology in the United States to treat benign thyroid nodules. The cost-effectiveness of radiofrequency ablation in comparison with traditional thyroidectomy is unknown.MethodsA patient-level state transition microsimulation decision model was constructed comparing radiofrequency ablation with lobectomy in the management of benign thyroid nodules. Our base case was a 45-year-old woman with a solitary 30-cm³ nodule. Estimates of health utilities, complications, and mortality were obtained from the literature, and costs were estimated using Medicare reimbursement data. The primary outcomes of interest included total cost, quality-adjusted life years, and incremental cost-effectiveness ratios. All model estimates were subjected to 1-way sensitivity analyses to identify factors that strongly influence cost-effectiveness. A probabilistic sensitivity analysis was run across 1 million simulations to gauge outcome confidence with a willingness-to-pay threshold set at $100,000/quality-adjusted life year.ResultsRadiofrequency ablation was assumed to cost $5,000, with an initial success rate of 78%. Patients with volume reduction ratio <50% underwent a second treatment of radiofrequency ablation. Radiofrequency ablation represented the dominant strategy, yielding 21.31 quality-adjusted life years for a total cost of $16,563 in comparison to lobectomy, which yielded 21.13 quality-adjusted life years for a total cost of $19,262. In a 1-way sensitivity analysis varying the cost of radiofrequency ablation across of range of values, the radiofrequency ablation strategy remained cost-effective until the cost of radiofrequency ablation exceeded $12,330 at willingness-to-pay $50,000 or $17,950 at willingness-to-pay $100,000.ConclusionRadiofrequency ablation is a cost-effective strategy in the treatment of benign thyroid nodules but is most sensitive to the cost of radiofrequency ablation.     

Multifocality in well-differentiated thyroid carcinomas calls for total thyroidectomy

Background

Multifocality is an important factor when recommending surgery for papillary thyroid cancer (PTC). The aim of this study is to assess the incidence and characterize the spread pattern of multifocal PTC (mPTC) in patients undergoing total thyroidectomy.

Methods

All thyroidectomies performed between 2003 and 2008 were reviewed identifying 289 patients. Data were obtained for demographics, clinical data, and histopathological findings.

Results

Of the patients with papillary carcinoma, mPTC was identified in 150 patients (57%), of which 71% had lesions in the contralateral lobe. There were no significant differences in multifocality rate for gender, pathology type, and all tumor size subgroups including ≤1 cm. Pathology examination of representative sections versus the entire gland examination resulted in a significantly lower incidence of contralateral disease (P = .04).

Conclusions

Multifocal and contralateral lesions are common in PTC and their incidence is not related to tumor size. Pathology entire gland examination is strongly recommended to properly assess the rate of mPTC.     

Therapeutic strategies in differentiated cancer of the thyroid: total thyroidectomy

Differentiated thyroid cancer is peculiar for its prognosis often excellent. The Authors report their experience about 78 patients affected with differentiated thyroid carcinoma, operated between 1976-1999 at the Institute of Surgical Pathology and Surgical Clinic of Cagliari University. 70 (89.7%) patients underwent total thyroidectomy, 6 (7.5%) subtotal thyroidectomy and 2 (2.5%) thyroid lobectomy. In 11 patients total thyroidectomy was performed in two times within 60 days after initial lobectomy. Tumor was found in 2 (18%) of 11 of the reoperations. Lymphadenectomy was performed only in presence of cervical lymph nodal metastases. Following 70 total thyroidectomy the incidence of recurrent nerve palsy was 4.2% and permanent hypoparathyroidism 11.4%. 79% patients received adjuvant postoperative radioiodine therapy to ablate residual functioning tissue or distant suspected metastases. After a mean follow up period of 5.8 years, recurrences developed in 10.2%. Any local recurrences, 5 (6.4%) cervical nodal recurrences, 3 (3.8%) distant metastases were encountered. Two (2.5%) of the three patients with recurrence distant metastases died from thyroid carcinoma. The Authors identify total thyroidectomy as the minimal procedure. Surgical management of the cervical nodes is recommended only in the presence of metastatic lymph-nodes. Post surgical ablation with I131 of microscopic remnants optimize detection and treatment of the recurrence and distant metastases.     

Total or near total thyroidectomy versus limited resection for radiation-associated thyroid nodules: a twelve-year follow-up of patients in a thyroid screening program

Controversy continues regarding the extent of thyroidectomy appropriate for patients with radiation-associated thyroid nodules. The incidence of cancer in this group of patients is more than 50% when near total or total thyroidectomy is done and all thyroid tissue is serially sectioned and examined. Tumor multicentricity is common. Is total or near total thyroidectomy warranted in all of these patients? A prospective study and follow-up program of 2118 patients with prior low-dose head and neck irradiation who entered into a thyroid screening program allowed us to examine how the extent of thyroidectomy influenced the clinical course of these patients. Near total or total thyroidectomy was performed in 59 patients (36 had cancer), and limited thyroid resection, that is, lobectomy or less, was done in 78 patients (four of whom had cancer). During follow-up, only three patients have developed recurrent cancer; two had near total thyroidectomy and one had total thyroidectomy at first operation. Two patients with limited thyroid resection have had reoperation for new thyroid nodules, both of whom had benign nodules. We conclude that although limited thyroid resection may leave occult malignancies in unresected thyroid tissue, there is no significant difference in outcome between patients with limited resection and those with near total or total thyroidectomy after a 12-year follow-up of the program. Significant differences in cancer recurrence rats may occur with longer follow-up.     

Benign diseases of the thyroid: indications for surgical treatment and the current role of total thyroidectomy

Total thyroidectomy is the most popular surgical option in a wide range of indications for the treatment of benign disease of the thyroid. The preference for the procedure derives from a long period of observation and clinical experience dating as far back as the early 'seventies and confirms its safety and efficiency. Nevertheless, many doubts still exist as to the indications in the context of benign thyroid disease, as well as the incidence and seriousness of the complications which, though not frequent, are often invalidating. On the basis of the experience gained over the period from January 1994 to November 2002 in 697 patients undergoing surgery for benign disease of the thyroid, the authors analyse the indications for the various different therapeutic options and evaluate the results of total thyroidectomy in terms of therapeutic efficiency, relapse rates and complications. The latter are analysed on the basis of dividing the patients into 2 groups, one comprising 545 patients treated with total thyroidectomy as first-line treatment and the second consisting of 34 patients treated with total thyroidectomy for relapsing goitre after subtotal thyroidectomy. Comparison of the respective incidences of complications reveals a significant difference between the two groups of patients. Total thyroidectomy after subtotal thyroidectomy presented a significantly higher percentage of complications than initial total thyroidectomy. The authors come out in favour of total thyroidectomy with its low incidence of complications and the radical control of the disease it affords, reserving lobectomy-isthmectomy for selected cases of patients with monolateral disease which does not expose the patient to any risk of relapse.     

Endoscopic versus conventional open thyroid lobectomy for benign thyroid nodules: a prospective study

The current study compared results between endoscopic thyroidectomy and conventional surgery in a prospective study. Twenty-two patients eligible for endoscopic thyroidectomy were evaluated. Patients were divided into group A, for conventional open thyroidectomy (n = 12), and group B, for endoscopic thyroidectomy (n = 10). Operative time, blood loss, postoperative complications and analgesic requirements, and time taken to return to normal activity were compared. Groups A and B were statistically balanced. Blood loss was significantly less in group B than in group A (11 versus 32 mL; P = 0.004), but no significant differences were observed in any of the other parameters. No postoperative complications (hemorrhage or recurrent laryngeal nerve paralysis) were present in either group. Compared with conventional surgery, endoscopic thyroidectomy for benign thyroid nodules was associated with less blood loss, although blood loss was minimal for both procedures. There were no practical differences in technical ability to perform.