甲状腺癌的手术方式和影响预后相关因素探讨

目的探讨甲状腺癌的手术方式和影响预后相关因素。方法选取2014年10月-2016年8月期间在我院确诊的213例甲状腺癌患者作为研究对象,其中未分化型36例,分化型177例。在此基础上,结合患者具体情况给予手术治疗后,对其进行随访,分析患者预后复发的相关因素。结果未分化型甲状腺癌患者主要是采用姑息性切除和放射外照射治疗,分化型甲状腺癌患者主要是采用患侧叶切除加峡部切除(未行颈部淋巴结清扫和行颈部淋巴结清扫),患侧腺叶、峡部加对侧次全切(未行颈部淋巴结清扫和行颈部淋巴结清扫),甲状腺全切加颈部淋巴结清扫。213例患者均获得随访,随访率100.00%,患者的复发率为8.92%(19/213)。且甲状腺癌患者预后在性别、年龄、手术方式和淋巴结清扫是否清扫等方面比较情况无统计学意义(P0.05)。结论甲状腺癌手术方式通常受肿瘤位置、肿瘤大小、B超诊断结果的影响。并且患者术后的复发率与性别、年龄、手术方式和淋巴结清扫等因素有直接的关系。     

老年甲状腺癌术后复发的危险因素

目的探讨老年甲状腺癌术后复发的危险因素。方法回顾性收集233例接受手术治疗的甲状腺癌患者临床资料,对患者进行随访,观察术后复发情况,单因素和多因素分析甲状腺癌术后复发的危险因素。结果 233例患者中220例(94.42%)获得随访,其中57例(25.91%)出现术后肿瘤复发;单因素分析发现,老年甲状腺癌术后复发与年龄、病理类型、肿瘤大小、腺体包膜、淋巴结转移、手术方式有关(P0.05),而与性别、肿瘤分期和淋巴结清扫无关(P0.05);多因素分析发现,肿瘤大小、淋巴结转移、腺体包膜、手术方式、病理类型是老年甲状腺癌术后复发的危险因素(OR=5.082、2.224、2.019、1.214、3.278)。结论肿瘤直径大、有淋巴结转移、腺体包膜出现浸润或浸出、手术切除范围不足、病理组织学恶性程度高是老年甲状腺癌术后复发的危险因素,临床要加强预防。     

老年分化型甲状腺癌患者术后复发转移的影响因素

目的观察老年分化型甲状腺癌患者术后复发转移情况,并找出其诱发危险因素。方法回顾性分析120例老年分化型甲状腺癌患者的临床资料,根据术后有无复发转移,将发生复发转移(包括死亡)的32例纳入复发转移组,其余88例纳入未复发转移组。根据自行设计的一般资料调查量表,通过问卷填写的方式,对所有患者的基线资料进行统计、分析,记录患者性别、年龄、病理类型、肿瘤直径、术前淋巴转移、多发病灶、手术方式、肿瘤分期、术后是否接受~(131)I治疗等。将可能导致患者术后复发转移的危险因素纳入,经χ~2检验及Logistic多因素分析,找出可能导致老年分化型甲状腺癌患者术后发生复发转移的影响因素。结果随访结束时,复发转移组淋巴转移10例(31.25%),肺部转移12例(37.50%),其他转移10例(31.25%);将单因素检验有意义的自变量纳入,经非条件多项Logistic回归分析证实高龄(≥75岁)、病理类型(滤泡状瘤)、肿瘤直径(≥5 cm)、术前伴淋巴转移、多发病灶、TNM分期(Ⅲ～Ⅳ期)及术后未给予~(131)I治疗均是导致老年分化型甲状腺癌患者术后复发转移的危险因素(OR1,P0.05)。结论高龄、滤泡状瘤、肿瘤直径较大、术前伴淋巴转移、多发病灶、TNM分期Ⅲ～Ⅳ期及术后未给予~(131)I治疗均可能增加老年分化型甲状腺癌患者术后复发转移的风险,故针对合并上述危险因素的患者,临床应提高警惕,积极采取预防措施,以降低术后复发转移,改善预后。     

分化型甲状腺癌预后因素分析

目的探讨影响分化型甲状腺癌预后的相关因素。方法对658例接受手术治疗的分化型甲状腺癌患者的临床资料作单因素和多因素分析。结果单因素分析显示,性别、年龄、肿瘤大小、肿瘤侵犯程度、分期、淋巴结转移、远处转移、癌灶数目与分化型甲状腺癌预后有关;COX多因素分析显示,年龄、分期、淋巴结转移、肿瘤侵犯程度、远处转移与分化型甲状腺癌预后有关。结论分期、淋巴结转移、年龄、肿瘤侵犯程度、远处转移是影响分化型甲状腺癌预后的主要因素。     

多功能保留颈清术治疗分化型甲状腺癌的临床效果观察

目的探讨多功能保留颈清术治疗分化型甲状腺癌患者的临床效果。方法选取2014-03~2014-11该院收治的分化型甲状腺癌患者60例,按随机数字法分为对照组和观察组各30例,对照组实施改良颈清术治疗,观察组实施多功能保留颈清术,比较两组患者的手术效果及并发症情况。结果两组患者均无手术死亡病例,颈部外观正常,恢复良好。术后随访,2年内无复发与死亡病例。观察组并发症发生率显著低于对照组(P0.05)。结论应用多功能保留颈清术治疗分化型甲状腺癌,能够有效保留耳廓区、颈部、锁骨上区的感觉,根治肿瘤,具有合理性、可行性,疗效可靠,值得临床推广使用。     

~(131)I治疗老年DTC术后的疗效和相关因素分析

目的探讨老年分化型甲状腺癌(DTC)术后131I治疗的疗效和相关影响因素以及临床应用价值。方法 156例患者手术治疗的老年DTC患者,依据术后是否接受131I治疗分为治疗组(n=130)和对照组(n=26),然后依据疗效对治疗组患者进行亚组分析,分为有效组和无效组。定期随访检查,总结分析其临床资料。结果治疗组患者的治愈率和总有效率〔(36.92%和86.15%)〕均明显高于对照组(7.69%和57.69%)(P<0.05)。通过亚组临床资料对比和回归分析发现,手术方式、原发灶状况、被膜侵犯、转移淋巴结数目、基础疾病、术后的首次131I应用时间与131I治疗老年DTC存在明显的相关性。结论术后131I对老年DTC治疗的疗效肯定,值得在临床推广应用,同时注意相关影响因素。     

甲状腺肿与甲状腺癌DNA倍体差异性研究

目的研究甲状腺肿与甲状腺癌DNA倍体差异的临床意义。方法采用流式细胞术对34例甲状腺肿(结节性甲状腺肿22例,弥漫性甲状腺肿12例)及29例甲状腺癌(分化型甲状腺癌20例、未分化型甲状腺癌9例)进行DNA倍体分析及细胞周期检测。结果甲状腺癌组(分化型、未分化型)DNA异倍体率明显高于甲状腺肿组(结节性、弥漫性)(P<0.05),甲状腺癌组(分化型、未分化型)DNA整倍体细胞S期百分率也明显高于甲状腺肿组(结节性、弥漫性)(P<0.05),未分化型与分化型甲状腺癌的DNA异倍体率之间无差异(P>0.05),未分化型与分化型甲状腺癌的DNA整倍体细胞S期百分率有差异(P<0.05)。结论DNA倍体分析及细胞周期检测有助于甲状腺癌的早期诊断。     

分化型甲状腺癌再次手术97例临床分析

目的 探讨分化型甲状腺癌再次手术的临床意义.方法 回顾性分析1993年1月～2013年1月收治的97例分化型甲状腺癌再次手术患者的临床资料.结果 再次手术的主要原因是复发和淋巴结转移,其次是初次手术不当.再次手术的5年生存83.9％,10年生存73.7％.结论 分化型甲状腺癌预后较好.如初次手术不当或者复发,再次手术是必要的.     

甲状腺乳头状癌临床及中央区淋巴结转移影响因素分析

目的分析甲状腺乳头状癌(papillary thyroid carcinoma,PTC)临床疗效及中央区淋巴结转移的影响因素,为个体化手术治疗提供临床依据。方法回顾性分析201例PTC的临床资料,将患者的年龄、性别、肿瘤大小、包膜情况、肿瘤分期等影响因素,进行统计分析,探讨中央区淋巴结转移的影响因素。结果该组201例PCT均行个体化手术治疗,TNM分期Ⅰ期108例,Ⅱ期43例,Ⅲ期42例,Ⅳ期8例。该组无围手术期死亡病例,术后并发症少,术后未出现气胸、乳糜瘘、气管食管瘘、永久性甲状旁腺功能低下、喉返神经损伤,住院期间出现一过性低钙血症2例(1.0%)。术后随访半年至5年,发现局部复发2例(1.0%),淋巴结转移2例(1.0%),远处转移1例(0.5%)。中央区淋巴结转移率为53.7%(108/201),侧颈区淋巴结转移率为64.8%(70/108)。影响中央区淋巴结转移的影响因素为TNM分期和肿瘤穿透被膜。结论 PTC需根据不同临床特点给予个体化手术治疗;中央区淋巴结转移率高,建议所有患者均常规清扫中央区淋巴结。对于中央区淋巴结转移的患者,建议行侧颈区淋巴结清扫术。     

纳米碳在分化型甲状腺癌再次手术中应用价值的探讨

目的探讨纳米碳在分化型甲状腺癌(differentiated thyroid carcinoma,DTC)再次手术中的应用价值。方法回顾性分析2012-07~2016-07该科收治的95例DTC患者再次手术临床资料,其中注射纳米碳50例为纳米碳组,未注射的45例为对照组。比较两组淋巴结清扫、转移枚数和术中识别、误切甲状旁腺枚数的差异,以及手术时间、术后甲状旁腺功能、喉上喉返神经损伤并发症的差异。结果纳米碳组淋巴结清扫枚数、转移淋巴结枚数多于对照组(P0.05),术中识别甲状旁腺枚数多于对照组(P0.05),而误切例数少于对照组(P0.05)。纳米碳组手术时间短于对照组(P0.05),且一过性的甲状旁腺功能减退及神经损伤发生率低于对照组(P0.05)。结论在DTC再次手术中使用纳米碳能提高淋巴结清扫的彻底性,起到了识别和保护甲状旁腺及神经的作用,减少术后并发症却未增加手术时间。     

分化型甲状腺癌的诊断和外科治疗

分化型甲状腺癌是最为常见的内分泌肿瘤,大部分患者预后较好。随着检查手段的不断丰富,术前确诊甲状腺癌已成为可能,大大减少了良性甲状腺疾患的手术率。高频超声检查、放射性核素扫描和针吸活检病理检查是廉价、有效的术前确诊手段。对于低危险度的分化型甲状腺癌而言,患侧腺叶加峡部切除为可接受的最小手术范围。为防止初次手术后复发、便于利用甲状腺球蛋白进行术后监测、利于转移病灶的放射性核素治疗,多数临床医师倾向于对分化型甲状腺癌患者进行全甲状腺切除或次全甲状腺切除。     

131I治疗分化型甲状腺癌

甲状腺癌为最常见的内分泌肿瘤,甲状腺癌组织类型主要为分化型甲状腺癌,手术+131I+甲状腺素抑制模式治疗分化型甲状腺癌久已得到认可和广泛应用.本文简要介绍131I治疗分化型甲状腺癌的现状并略加评述.     

分化型甲状腺癌预后相关因素分析并文献复习

对分化型甲状腺癌(DTC)预后相关因素进行分析并复习文献,为提高DTC诊断治疗水平及生存率提供依据.回顾性随访分析经术后组织病理学证实为DTC的150例(女性113例,男性37例)病例资料,乳头状癌131例(87.3％),滤泡癌19例(12.7％).随访4.15 ～31年,存活140例(93.3％),复发30例(20.0％),死亡10例(6.7％).手术方式中近全或次全切手术83例(55.3％),局部切除64例(42.7％),全切3例(2.0％).63例行淋巴结切除者中45例(71.4％)检出淋巴结转移.发病年龄、就诊时肿瘤大小及早期转移率在死亡组与存活组、复发组与未复发组间有统计学差异(P＜0.05).年龄、就诊时肿瘤大小及早期转移影响DTC预后.     

Gamma probe-guided surgery for revision thyroidectomy: in comparison with conventional technique

Reoperative thyroid surgery may be required in patients who undergo any procedure less than total or near total thyroidectomy. The aim of this study was to investigate advantages of gamma-probe guided revision thyroidectomy (GGRT) over conventional revision thyroidectomy (CRT) in patients with differentiated thyroid carcinoma (DTC). GGRT was assessed according to the TSH values, complication rates and the incidence of carcinoma in residual thyroid tissue. In this randomised prospective clinical trial, 25 patients with differentiated thyroid carcinoma who had previously undergone surgery for benign multinodular goiter were included in the study. GGRT was performed in 11 (44%) patients (Group 1) and CRT in 14 (65%) (Group 2). The intraoperative mean ratio of thyroid activity to background activity (T/B) was detected as 5.1 +/- 1.4 and the mean ratio of thyroid bed activity to background activity after excision (Tbed/B) was 1.3 +/- 0.3, (p < 0.01). Although the incidence of carcinoma in residual thyroid tissue was higher in group 1 (4/11) in comparison to group 2 (1/14), it was not statistically significant. The elevation of the TSH concentration at the first post-operative month was significantly higher in group 1 in comparison with group 2 (18 +/- 25 5 +/- 3 mlU/l), (p < 0.02). These results indicate that intraoperative gamma probe application may be beneficial to detect and remove residual thyroid tissue in revision thyroidectomy.     

Risks of complication following thyroidectomy

OBJECTIVE: Because hypoparathyroidism is a serious complication of thyroidectomy, we attempted to elucidate factors determining the risk of this postoperative outcome. SETTING: Four tertiary care hospitals in Albuquerque, New Mexico. PATIENTS: A retrospective study of 142 patients who underwent total or subtotal thyroidectomy between 1988 and 1995. MEASUREMENTS AND MAIN RESULTS: Permanent hypoparathyroidism was defined as hypocalcemic symptoms plus a requirement for oral vitamin D or calcium 6 months after thyroidectomy. Factors analyzed to determine their contribution to the risk of persistent postoperative hypoparathyroidism were the indication for thyroidectomy, performance of a preoperative thyroid needle biopsy, type of surgery, postoperative pathology, presence and stage of thyroid carcinoma, resident surgeon involvement, and specialty of the surgeon performing the procedure. Surgical specialty and stage of thyroid carcinoma were independent risk factors for persistent postoperative hypoparathyroidism by multivariate analysis. Nine (29%) of 31 patients who had thyroidectomy by otolaryngologists met criteria for permanent hypoparathyroidism, and 6 (5%) of 111 patients who had thyroidectomy by general surgeons met the same criteria (p<.001). Adjustment for the effect of stage did not eliminate the effect of specialty (p=.006), and adjustment for the effect of specialty did not eliminate the effect of stage (p=.02), on the occurrence of postoperative hypoparathyroidism. CONCLUSIONS: We conclude from our data that patients undergoing thyroidectomy by an otolaryngologist may be at a higher risk of permanent postoperative hypoparathyroidism than patients who undergo thyroidectomy by a general surgeon. This may reflect differences in case selection or surgical approach or both. Presented at the Western Regional Meeting of the American Federation of Medical Research, Carmel, Calif., February, 1996. Supported by the University of New Mexico Clinical Research Center (National Institutes of Health, National Center for Research Resources General Clinical Research Center Grant 5M01-RR00997).     

Intrathyroideal papillary thyroid carcinoma presenting with a solitary brain metastasis

Papillary thyroid carcinoma (PTC) is the most common type of well-differentiated thyroid carcinoma and typically has an excellent prognosis. The incidence of distant metastasis from PTC is low. However, once metastasis has developed in a distant site, prognosis is markedly diminished. Brain metastases from PTC are extremely rare. No consensus regarding management has yet been reached. We report on the case of a patient who presented with signs of intracranial hypertension. Cranial magnetic resonance imaging (MRI) identified a lesion of the right temporofrontoparietal lobe. The patient underwent a craniotomy with a total removal of the tumor. Histologic examination of the lesion showed a metastasis of papillary adenocarcinoma. We observed a cold nodule in the right lobe of the thyroid on physical examination and imaging techniques (e.g., CT and scintigraphy). Fine-needle-aspiration cytology of the nodule was reported as PTC. A total thyroidectomy was performed and histopathological examination showed intrathyroidal variant of PTC. Postoperatively adjuvant whole brain radiation therapy with 44 Gy to multiple brain metastases of PTC was applied. One month later, the patient then underwent ¹³¹I radioiodine therapy with 150 mCi of ¹³¹I given orally. In conclusion, the present case underwent an aggressive multimodal approach therapy. This report indicates that the early detection and control of brain metastases may contribute to a better quality of life for patients affected by brain metastases.     

Familial adenomatous polyposis (Gardner's syndrome) and thyroid carcinoma

Summary The case history of a 24-year-old woman with Gardner's syndrome [familial adenomatous polyposis (FAP)] and papillary thyroid carcinoma is presented, representing the 37th report of this association. Although FAP is transmitted as an autosomal dominant trait with similar penetrance in both sexes, thyroid carcinoma has been found almost exclusively in women (94.3%). The majority have been papillary carcinomas (88.5%), which have become apparent during the third decade (average 23.6, range 16–40 years). Most (55.5%) thyroid carcinomas have been discovered 1–17 years after FAP was identified, although some have been found before (29.6%), or at the same time (14.8%) FAP was diagnosed. Multicentric papillary carcinomas have been reported in 64% (14 of 22) of FAP patients, a frequency at least twofold greater than usual. Although papillary carcinoma found before age 30 (as it was in most patients with FAP) typically has an excellent prognosis, one patient with FAP developed distant metastases from thyroid carcinoma and a 28-year-old woman's death was attributed to papillary carcinoma. The high frequency of multicentric papillary thyroid carcinoma in young patients with FAP and the potential for metastases and death due to thyroid carcinoma warrant aggressive diagnostic screening at regular intervals with neck palpation, ultrasonography, and if necessary, fineneedle aspiration biopsy. When thyroid carcinoma is found, total or near-total thyroidectomy should be considered because of the tumor's high likelihood of being multifocal. Since almost 30% of the thyroid carcinomas associated with FAP have been diagnosed 4–12 years before polyposis was identified, young patients presenting with thyroid carcinoma should be questioned regarding bowel function and a family history of gastrointestinal disease, and consideration should be given to periodic testing for fecal occult blood.The views expressed herein are those of the authors and do not necessarily reflect those of the Army or the Department of Defense.     

经胸乳入路的腔镜甲状腺肿瘤切除术-附56例报告

目的探讨腔镜甲状腺肿瘤切除术的方法与优缺点。方法采用胸部乳晕入路行腔镜甲状腺切除术56例,其中结节性甲状腺肿53例、甲状腺癌3例。结果成功完成手术54例。手术时间88.5(50~210)min,行单侧甲状腺肿瘤切除术12例,甲状腺单叶大部分切除16例,甲状腺双叶大部分切除24例,甲癌行甲状腺单叶并峡部全切除2例。中转开放手术2例。无神经或甲状旁腺损伤等严重并发症。术后住院时间4.2(3~7)天,术后随访1~13月,无复发,病人均对手术的美容效果满意。结论内镜甲状腺手术是一种安全、理想的手术方法,微小切口选择在身体的隐蔽位置,具有很好的美容效果。     

Completion thyroidectomy in patients with thyroid cancer who initially underwent unilateral operation

BACKGROUND: In some instances, thyroid cancer may be diagnosed with histological examination after resection of putative or suspected benign nodule. In these cases, completion thyroidectomy followed by radioiodine ablation is usually recommended to prevent recurrence. If small intrathyroidal cancer is found, completion thyroidectomy may not be performed. Many patients have separate cancers in the contralateral lobe and in these cases completion thyroidectomy is essential even though primary tumour is small and limited within thyroid. OBJECTIVE: We analysed the frequency of malignant lesions in the contralateral lobe after completion thyroidectomy and assessed the predictive factors that may anticipate the presence of malignant lesion that may necessitate completion thyroidectomy. PATIENTS: Between 1995 and 2001, 243 patients were operated under the cytological diagnosis of follicular neoplasm. A total of 214 of them underwent lobectomy and isthmectomy and 81 turned out to have malignant disease in the resected lobe and they underwent completion thyroidectomy within a week to 6 months after the permanent section diagnosis of cancer. Their mean age was 40.7 +/- 12.1 years (range 14-71 years). RESULTS: After initial surgery, 53 patients had follicular carcinoma, 24 papillary carcinoma, one Hürthle cell carcinoma, one medullary, one insular and one anaplastic carcinoma. Mean tumour size was 4.1 +/- 2.6 cm (range 0.9-11 cm). After completion thyroidectomy, factors predicting the presence of cancer in the contralateral lobe were assessed according to clinical parameters and pathologic findings in ipsilateral lobe. First surgery revealed cancer multifocality in 34 cases, perithyroidal tumour extension in six and regional lymph node metastases in three. After completion thyroidectomy, 29 of the 81 patients revealed additional cancer in the contralateral lobe. Age, sex, size or pathologic type of the primary tumour was not associated with the presence of additional tumour in the contralateral lobe. Cancer multifocality in the ipsilateral lobe was the only significant variable to predict the presence of additional cancer in the contralateral lobe (relative risk = 6.03, confidence interval 2.23-16.35). Coexistence of benign nodule in ipsilateral lobe was not associated with increased cancer risk in the contralateral lobe. CONCLUSIONS: When diagnosed as thyroid cancer after unilateral surgery, the only predictive factor for the presence of additional contralateral cancer was multifocality of cancer in the ipsilateral lobe. We suggest that completion thyroidectomy is mandatory if multifocal cancers are found in the resected lobe, even though the cancers are very small and limited within the thyroid.