甲状腺癌侵犯气管,食管的外科处理

１９９０年５月～１９９７年５月,我们手术治疗甲状腺癌１０６例,其中３例肿瘤侵犯气管壁及２例侵犯食管的患者,均经积极治疗后痊愈出院,现报道如下。１病例报告例１男,１８岁。因发现右颈部肿块３月入院。于１９９０年６月在基础麻醉加局麻下手术,术中见肿瘤侵犯第...     

侵犯气管的局部晚期甲状腺癌的外科诊疗经验

背景与目的 手术是治疗侵犯气管的局部晚期甲状腺癌的首选方法。根据侵犯气管位置和程度的不同,其处理方法也不尽相同。选择合适的治疗方式对患者的预后和生活质量尤为重要。通常甲状腺癌气管侵犯时已伴有颈淋巴结转移、颈部大血管粘连,甚至食管和喉的侵犯,因其解剖结构复杂多变,目前仍没有高级别的循证医学证据指导治疗。本文旨在探讨侵犯气管的局部晚期甲状腺癌的临床特点和外科处理方法。方法 回顾2019年7月—2021年7月重庆大学附属肿瘤医院头颈肿瘤中心诊治的20例侵犯气管的局部晚期甲状腺癌患者资料,其中,男16例,女4例;年龄13~78岁,中位年龄53.5岁;甲状腺滤泡癌2例,髓样癌2例,甲状腺乳头状癌16例;3例锐性削除受侵气管外壁,5例行局部气管窗式切除术,10例行气管袖式切除+端端吻合术,1例行全喉切除+气管永久造瘘,1例行全喉切除+永久气管造瘘+胸大肌皮瓣修复,术后均接受131I治疗或分子靶向药物的综合治疗。结果 患者随访时间4个月至2年不等。3例锐性削除受侵气管外壁患者未见肿瘤复发,无气管瘘;5例行气管窗式切除患者均Ⅰ期缝合气管创面;10例气管袖式切除+端端吻合患者均未出现气道狭窄和双侧声带麻痹,其中1例出现术后局部感染和局部气管瘘口,换药后愈合;1例同时侵犯喉行全喉切除+气管永久造瘘,1例同时侵犯喉和颈部皮肤行全喉切除+永久气管造瘘+胸大肌皮瓣修复,后2例患者带管生存。截止投稿时本文纳入患者未出现肿瘤进展情况。结论 颈段气管的切除和修复是外科医生常常需要面对和处理的难题,笔者的治疗原则是在病灶可完整切除和患者能耐受的前提下,尽可能选择外科手术治疗。对于侵犯气管及其邻近器官的局部晚期甲状腺癌患者,应在MDT讨论指导下制定治疗方案,术前进行充分的方案准备和应对并发症的措施。根据侵犯程度不同选择合适的气管切除范围和修复重建方式,首选Ⅰ期修复和重建的方案,其次选择Ⅱ期或多期方案。但无论选择手术治疗还是综合治疗,治疗宗旨都是延长甲状腺癌患者生存期和提高生活质量。     

侵犯气管的甲状腺癌切除后锁骨头带蒂软骨修补术12例报告

目的探讨甲状腺癌侵犯气管的外科处理及预后。方法分析2001年1月至2005年12月对12例甲状腺癌侵犯气管2～4个软骨环,周径<50%的患者,行气管窗式切除后采用自体胸锁关节的锁骨头带骨膜肌瓣软骨修补气管缺损区的疗效。结果本组乳头状癌9例,滤泡状癌1例,髓样癌1例,B细胞淋巴瘤1例,均行甲状腺全切除术加患侧颈淋巴结清扫术。分化性甲状腺癌术后辅助Ⅰ治疗;B细胞淋巴瘤术后辅助化疗。术后半年纤维气管镜检查可见气管修补处已骨化,气管内黏膜拉网脱落细胞检查未找到癌细胞。全组随访6个月至4年,1例滤泡状癌于术后3年气管内局部肿瘤复发行气管镜下微波治疗和再次Ⅰ治疗后病情得到控制,仍然存活,其他病例无复发转移及死亡,生活质量较好。结论甲状腺癌侵犯气管采用前侧壁窗式切除结合自体带蒂软骨修补气管壁缺损是一种有效的治疗方法。     

分化型甲状腺癌侵犯上呼吸消化道的外科处理

分化型甲状腺癌（difFerentiated thyroid carcinoma,DTC）大多恶性程度低、生长缓慢、预后好,完善治疗后其10年生存率在90％以上。然而,有6％～13％的肿瘤町能发生周围组织或器官的侵犯,     

分化型甲状腺癌的外科治疗

目的总结分化型甲状腺癌的诊治经验。方法回顾性分析110例分化型甲状腺癌的临床资料。结果全组均行手术治疗辅以内分泌治疗,110例分化型甲状腺癌中,乳头状癌88例(80.0%),滤泡状腺癌22例(20.0%);淋巴结转移者22例(20.0%)。手术方式包括单侧病变行患侧腺叶 峡部及对侧大部切除60例(其中功能性颈清扫12例),患侧腺叶 峡部切除29例(其中功能性颈清扫7例);双侧病变行一侧腺叶 峡部及对侧大部分切除18例(其中功能性颈清扫5例),甲状腺全切除术 双侧颈清扫2例;1例肺转移患者行甲状腺全切及颈部淋巴结清扫术后行131I内放射治疗。98例术后随访,10年生存率91.8%。结论分化型甲状腺癌预后较好,治疗关键是正确选择适当的手术方式。     

胰腺癌的神经侵犯和外科处理

近十年,我国胰腺癌的外科治疗水平有了明显进步,胰腺癌的手术切除率从15%以下升至约40%,术后严重并发症,如胰瘘、胆瘘、腹腔感染均有明显下降。然而,胰腺癌术后5年生存率却没有明显提高,多数报道在5%～10%,其原因一是早期诊断困难,临床诊断的胰腺癌85%以上属进展期;二是术后腹膜后复发、肝转移常见。这两个因素是制约胰腺癌外科治疗效果的两个亟待解决的难题。研究发现,胰腺癌有嗜神经生长、沿神经束膜内侵袭扩散的特性。文献报道胰腺癌胰外神经侵犯率64%～100%。神经侵犯与肿瘤位置、大小、组织学类型、淋巴结转移状况均无关系,是术后腹膜…     

局部进展甲状腺癌的外科处理

甲状腺癌是最常见的内分泌系统恶性肿瘤,发病率在世界范围内呈逐年上升趋势。尽管大多数甲状腺癌临床过程相对缓慢,手术、药物抑制和放射性核素治疗效果良好;但仍有部分甲状腺癌表现为侵袭性生物学行为,局部外侵严重,预后较差,包括局部进展或复发的分化型甲状腺癌、髓样癌及所有的未分化癌。在甲状腺乳头状癌的变型中,高细胞型弥漫硬化型柱状细胞型实体型梁状型和局     

Surgical management of thyroid carcinoma invading the trachea

Airway invasion by thyroid carcinoma is an uncommon but important clinical problem. The surgical management of airway invasion is somewhat controversial, with some studies suggesting that conservative shave procedures might be adequate; however, the standardization and safety of techniques of airway resection and reconstruction have made en bloc surgery a reasonable approach for the management of such carcinomas. Tracheal resection and reconstruction for thyroid carcinomas with airway invasion might provide long-lasting palliation and might even be curative in a significant number of patients suffering from this disease.     

Surgical treatment of differentiated thyroid carcinoma

Being the excellent prognosis, the extension of the thyroidectomy in the surgical management of differentiated thyroid carcinomas is still controversial: some authors recommend total thyroidectomy for all patients, others suggest a conservative approach, that guarantee the same good prognosis but is associated with fewer complications. Even the cervical lymph node dissection is discussed, both regarding to the indications and the extension. The authors reported a retrospective review of their experience of the last 10 years on 75 patients operated for differentiated thyroid cancer, 61 for papillary carcinoma and 14 for follicular carcinoma; 18 of them were men and 57 females, with a mean age of 48.2 years. We performed a total of 85 operations: 60 total thyroidectomy, 15 lobus-isthmusectomies and 10 completion thyroidectomy. Lymphadenectomy was performed in 17 patients with clinically or intraoperative evidence of enlarged lymph nodes. There was no surgical mortality. Permanent hypoparathyroidism occurred in 5 patients (5.8%) and permanent accidental laryngeal recurrent nerve injury, both monolateral, occurred in 2 cases (2.35%). The mean follow up was 53 months (4.5 years): 71 patients are still alive (94.7%), 68 of them disease free (90.6%) and 3 with recurrent disease (4%). Our results suggest that total thyroidectomy still represent the choice procedure for the treatment of differentiated carcinomas and that modified radical neck dissection is necessary in these patients with pre or intraoperative evidence of palpable lymph nodes. Some patients go well even undergoing more conservative surgery (lobectomy) but most problem is the impossibility to preoperatively identify these patients.     

分化性甲状腺癌的外科治疗

分化性甲状腺癌（包括乳头状癌、滤泡样癌、Hürthle细胞癌）约占甲状腺癌的90%。该类甲状腺癌肿有恶性程度低、发病缓慢、病程长的临床特点,通过适当的治疗,与其他甲状腺肿瘤相比．其治疗效果好,病人生存期长。所以,对分化性甲状腺癌病人的治疗可根据其所处的不同病期采取不同的手术方式．目的是在最大程度根治肿瘤的基础上,尽可能保留病人的甲状腺功能,提高其生存质量,     

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分化型甲状腺癌(乳头状癌、滤泡癌)约占甲状腺癌的80％，由于生长缓慢，病期长，病人无任何不适，常在无意中或体检中被发现，多延误治疗时机，导致肿瘤难以彻底切除或复发转移，以及严重并发症，为进一步治疗带来困难。尽管如此，仍有一部分病人获得较其他恶性肿瘤好的疗效。由于这些特殊的临床表现，临床医师很难确切掌握其真实的病情进展及不同的外科治疗方式后的动态变化情况，这些因素制约了其正确评价疗效，从而造成了多年来在外科治疗原则上存在着一些意见分歧。本文就此问题谈谈看法，供同道们讨论。     

Surgical treatment of advanced thyroid carcinoma invading the trachea

Operative methods, in relation to the completeness of resection and surgical results, and postoperative complications, in relation to operative methods, were discussed in 60 patients with advanced thyroid carcinoma in whom tumor invading the trachea was resected along with thyroid carcinoma. Laryngotracheal anastomosis was performed in 41 patients and tracheotracheal anastomosis in 19 patients. Complete resection was performed in 22 patients in the former group and in 12 patients in the latter group. Three-, 5-, and 10-year survival rates in patients undergoing complete resection were 87.0%, 78.1%, and 78.1%, respectively. Those for patients undergoing incomplete resection were 64.9%, 43.7%, and 24.3%, respectively. The locations of remaining tumor were the tracheal stump in patients in whom resection was incomplete. In four patients with esophageal invasion, the muscular layer of the esophagus was resected. Three of these patients had good postoperative results. Postoperative complications consisted of stenosis at the anastomosis in two patients, temporary mis-swallowing in three patients, temporary lower pharyngeal stenosis in one patient, temporary vocal cord edema in one patient, and tetany in two patients.     

Surgical strategies for differentiated carcinoma of the thyroid isthmus

The postoperative outcome (including clinicopathologic features) in 19 patients with differentiated thyroid cancer of the isthmus was investigated to develop more appropriate surgical strategies for these lesions. The extent of thyroidectomy, including neck dissection, tumor size, nodal involvement, and other clinical features were evaluated. The incidence of intraglandular dissemination was about 16% in all patients. Analysis of regional node metastatic distribution revealed no definite metastatic pattern. In addition, there was no apparent correlation between tumor size and nodal involvement. Two of the six patients who underwent total thyroidectomy suffered permanent postoperative hypoparathyroidism. It is thus recommended that isthmusectomy, including an adequate edge of surrounding normal thyroid tissues of each lobe and modified or limited neck dissection when cervical nodes are palpably enlarged is sufficient as an appropriate primary surgical procedure for differentiated carcinoma of the thyroid isthmus.     

Surgical treatment of locally advanced differentiated thyroid carcinoma

Patients with differentiated thyroid carcinoma (DTC), especially with papillary carcinoma, occasionally have direct tumor extension with invasion of surrounding tissues The presence of extrathyroidal invasion is one of the most important risk factors for mortality from DTC. However, leaving microscopic DTC on the surrounding structures usually does not lead to decreased survival or increased locoregional recurrence. Although endoscopic examinations, computed tomography, magnetic resonance imaging, and clinical presentations including hoarseness, dyspnea, and dysphagia are useful for the diagnosis of extrathyroidal extension, it is not easy to discriminate cancer invasion of adjacent structures from cancer adhesion preoperatively. The optimal surgical approach in patients with locally advanced DTC is controversial. Some experts support a conservative shave excision. They claim that these high-risk patients frequently have distant metastases and tumor dedifferentiation, and that survival advantage from extended surgery at the expense of significant morbidity is unclear. Others advocate an aggressive en bloc resection of the tumor and involved vital structures when technically feasible, because elimination of the risks of suffocation or major vessel hemorrhage is beneficial to patients. This paper discusses the management of patients with locally advanced DTC involving the recurrent laryngeal nerve, laryngotrachea, esophagus, major vessels, and mediastinum.     

Surgical treatment of recurrent differentiated thyroid carcinoma.

OBJECTIVE: To describe our experience of treating recurrent thyroid carcinoma. DESIGN: Retrospective study of casenotes. SETTING: Teaching hospital, Mexico. SUBJECTS: 20 patients who developed recurrences of 273 who presented with well-differentiated thyroid carcinoma between 1991 and 1999. MAIN OUTCOME MEASURES: Presentation, management, morbidity, and mortality. RESULTS: There were 18 men and 2 women, median age 51 years (range 28-75). 13 were treated initially by total thyroidectomy and 7 with less than total resection. 16 were given ablative doses of 311I. The median time between initial resection and recurrence was 3 years (range 1-6). The sites of recurrence were cervical lymph nodes (n = 12), thyroid bed (n = 3), or both (n = 5). During a median of 3 years 10 patients were free of disease and 2 had died. CONCLUSIONS: Well-differentiated thyroid cancer usually recurs in the cervical lymph nodes. Further resection offers a high cure rate.     

Risk group-based management of differentiated thyroid carcinoma

A number of controversies exist in the treatment of differentiated thyroid carcinoma with respect to the extent of surgery, use of radioactive iodine and post-operative thyroxine suppression. Recent recognition of prognostic factors has helped to assign patients, based on their risk profile, as being at high risk of developing recurrence. This has facilitated the development of a selective approach to therapy, thus, avoiding unnecessary treatment and reducing morbidity without compromising treatment outcome. This review attempts to evaluate the current concepts of management of differentiated thyroid carcinoma in the light of these new developments.