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。     

桥本病并存甲状腺结节外科治疗的临床分析

目的探讨桥本病并存甲状腺结节的临床特征和外科诊治经验。方法对1985年 1月至2004年12月因发现甲状腺结节行外科手术,术后经病理证实为桥本病的299例患者的临床特征进行分析。结果桥本病并存甲状腺癌52例(17．4％),甲状腺腺瘤103例(34．4％),结节性甲状腺肿17例(5．7%),甲状腺功能低下11例(3．7％),甲状腺功能亢进7例(2．3％)。1995年以前桥本病与甲状腺癌并存患者6例,占同期手术治疗的桥本病65例的9．2％;1996年以后桥本病与甲状腺癌并存患者46例,占同期手术治疗桥本病234例的19．7％(P<0．05)。并存甲状腺癌中乳头状癌 35例,滤泡状癌11例,混合性癌4例,黏膜相关淋巴瘤1例,全组中隐匿性甲状腺癌17例,占并存甲状腺癌的32．7％。手术方式由患者具体情况并结合术中冰冻结果确定,包括一侧或双侧甲状腺全切除或次全切除、部分切除或活检术。结论桥本病与甲状腺癌、甲状腺腺瘤并存率高,其发病率近年来有明显增高趋势;应警惕桥本病并存甲状腺肿瘤特别是隐匿性甲状腺癌的可能性。     

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。     

胸骨后甲状腺肿瘤34例的外科治疗

目的 探讨胸骨后甲状腺肿瘤的诊断及手术方法。方法 回顾性分析了1982～1998年手术治疗的胸骨后甲状腺肿瘤34例，对其术前检查、手术方法、术后并发症进行分析研究。结果 胸骨后甲状腺肿瘤发病率约为4％(34／920)，女性多见于男性；恶性肿瘤5例，约占15%(5／34)。术前X线检查发现气管移位7例、约占21％(7／34)，食管受压6例、约占18％(6／34)；计算机体层摄影(CT)、磁共振(MRI)检查发现颈部大血管移位3例，约占9％(3／34)。胸部平片与CT检查的确诊率分别为82％和94％。结论 胸骨后甲状腺肿一般可经颈部切除，不需做胸骨切开。晚期恶性肿瘤，姑息切除后辅以放、化疗，仍可取得较好疗效。     

甲状腺未分化癌综合治疗18例分析

目的 探讨手术及放化疗结合的综合治疗对甲状腺未分化癌的临床意义.方法 对2002年1月以来收治18例甲状腺未分化癌患者的临床资料进行回顾性分析.结果 3例Ⅳa期患者均接受甲状腺癌根治+淋巴结清扫术,术后辅以局部放疗和静脉化疗,其中1例术后34个月死亡,另2例已分别存活27个月、68个月;14例Ⅳb期患者中,除放化疗外,行联合颈前肌或胸锁乳突肌的根治性切除术3例,生存时间分别为16、11、20个月,肿瘤姑息性部分切除术2例,生存时间分别为10、7个月,其余9例未手术或仅行探查、活检性手术,生存时间分别为7、5、8、5、9、2、12(仍存活)、7、6个月;1例Ⅳc期的患者因肿块较大未行手术,且对放化疗均不敏感,于确诊后2个月死于全身衰竭.结论 对甲状腺未分化癌应综合采用手术、放疗和化疗等各种治疗手段,以达到延长患者生命、改善生活质量的目的.     

多学科团队在晚期特殊类型甲状腺癌诊治中的应用价值

目的探讨多学科协作团队(MDT)模式在晚期且失去手术机会的特殊类型甲状腺癌诊治中的应用价值。方法对2例恶性程度较高且已失去手术可能的晚期特殊类型甲状腺癌经MDT讨论后采用小剂量(250 mg/d)阿帕替尼单药治疗。结果 1例纵隔内转移肿大淋巴结压迫气管、不能平卧休息的甲状腺髓样癌患者经多次手术治疗无效,最后采用小剂量阿帕替尼单药治疗后1个月时,纵隔内淋巴结缩小,能够平卧,无呼吸困难并能自由活动,生活质量明显提高,没有发生严重的药物毒副反应。1例肺转移、咯血、瘤体侵犯气管致不能平卧休息、呼吸困难的甲状腺未分化癌患者经手术切除受侵犯气管后仍不能平卧休息、呼吸困难、咯血、胸水增多,最后应用小剂量阿帕替尼单药治疗后1个月时,胸水消失、能平卧、咯血停止、无呼吸困难,能做一些轻微家务活,没有发生药物毒副反应。结论 2例晚期特殊类型甲状腺癌病例经过MDT讨论应用单药小剂量阿帕替尼治疗后的近期疗效可靠、安全性好,可作为失去手术机会的晚期甲状腺癌的新补救方法,但其远期疗效还有待增加样本量、长期随访等进一步研究证实。     

原发性胃肠道淋巴瘤的诊断与治疗

目的探讨原发性胃肠道淋巴瘤的诊治经验。方法回顾性分析12例原发性胃肠道淋巴瘤,均行剖腹探查,其中行根治性切除7例,姑息性手术3例,肿块活检术2例。结果胃淋巴瘤5例,肠淋巴瘤7例。病理分类:弥漫性非何杰金氏淋巴瘤9例,粘膜相关性淋巴瘤2例,高度恶性淋巴瘤1例。Ann Arbor临床分期:ⅡE期3例,ⅢE期7例,ⅣE期2例。平均随访18(6~72)月,6例存活,死亡6例。结论内镜和消化道造影是淋巴瘤主要诊断手段,手术切除为主的综合治疗为最佳治疗方案。     

局部晚期分化型甲状腺癌临床特点和疗效分析

目的 探讨局部晚期分化型甲状腺癌的临床特点及治疗方法,以期提高患者的生存时间及生存质量.方法 回顾性分析南昌大学第二附属医院1996年1月至2005年12月治疗的23例局部晚期分化型甲状腺癌的临床病理资料,包括年龄、病理类型、肿瘤局部侵犯情况、手术方案、术后并发症及生存期等.根据随访结果进行疗效及预后分析.结果甲状腺乳头状癌15例,滤泡状癌6例,乳头滤泡状癌2例.肿瘤局部侵犯喉返神经8例,侵犯气管12例,侵犯气管及食道3例,合并侵犯颈前肌群8例.23例均行手术治疗,其中肿瘤根治6例,肿瘤剔除14例,姑息性切除3例(2例术后加行局部放疗).全组1、3、5年总生存率为91.3%(21/23)、82.6%(19/23)、60.8%(14/23).其中根治组和剔除组预后明显好于姑息组.结论 局部晚期分化型甲状腺癌手术治疗后仍能取得较好疗效,重视保护局部器官功能是提高术后生存质量的保证.     

Nevin Ⅳ、Ⅴ期胆囊癌62例的外科治疗

目的　总结NevinⅣ、Ⅴ期胆囊癌的外科治疗经验 ,探讨提高晚期胆囊癌生存率的方法。方法　回顾性分析 1993年 1月至 2 0 0 2年 12月间经手术治疗并有病理诊断的 6 2例NevinⅣ、Ⅴ期胆囊癌的临床资料 ,分析不同手术方式与预后之间的关系。结果　 6 2例中NevinⅣ期 17例 ,Ⅴ期4 5例。 30例行剖腹探查术 ,32例切除胆囊 ,切除率 5 2 % (32 /6 2 ) ,其中行根治性切除术 7例 ,扩大根治术 10例 ,姑息性切除术 15例 ,根治率 2 7% (17/6 2 )。根治性切除并发症发生率为 35 % (6 /17)。 1、3、5年生存率根治性切除分别为 6 1%、31%和 11% ,姑息性切除分别为 2 7%、13%、0 (P <0 0 1) ;剖腹探查术后 1年生存率仅为 3% ,3年以上生存率为 0。结论　对NevinⅣ、Ⅴ期胆囊癌应进行积极的手术治疗 ,根治术或扩大根治术是提高患者长期生存率的有效手段 ,姑息性切除术也能改善患者生活质量 ,延长生存期。     

胸骨后甲状腺疾病的诊断和外科治疗

目的探讨胸骨后甲状腺病变的临床表现、诊断方法和手术治疗。方法回顾性分析我院1999年1月至2005年6月收治的47例胸骨后甲状腺肿的临床资料。结果46例为Ⅰ°坠人性胸骨后甲状腺肿,均为部分型,1例为Ⅱ°异位胸内甲状腺肿。良性病变45例,恶性病变2例。均行手术治疗,43例采用颈部低领式切口,3例采用颈部低领式切口+部分胸骨劈开,1例行胸骨劈开。行甲状腺大部切除术31例,双侧甲状腺次全切除术14例,甲状腺癌根治术1例,甲状腺癌姑息切除术1例。全组无手术及住院死亡,声嘶恢复正常5例,声嘶无改善2例,一过性手足抽搐4例,1例甲状腺鳞状细胞癌术后一月因肿瘤局部复发堵塞气管窒息死亡。结论绝大多数胸骨后甲状腺病变是颈部病变向下延续所致。CT扫描是最佳的术前检查手段。绝大多数患者的手术可经颈部低领式切口完成,必要时附加胸骨部分劈开。     

Oncogenic emergency and treatment in thyroid disease

The urgent treatment of thyroid disease is mainly considered to be that of thyroid neoplasia, especially malignant thyroid tumors. The clinical symptoms produced by malignant neoplasia are acute respiratory failure caused by tumor compression and/or invasion of the trachea. Massive bleeding caused by tumor invasion of the major vessels also requires emergency therapy. In general, thyroid cancer has a favorable prognosis in patients with well-differentiated papillary carcinoma, which makes up more than 90% of thyroid malignancies. However, anaplastic carcinoma, undifferentiated papillary carcinoma, and malignant lymphoma originating from the thyroid sometimes require urgent therapy to save lives. Anaplastic carcinoma that is basically transformed from well-differentiated papillary carcinoma shows rapid growth and invades the surrounding tissue to produce tracheal obstruction. Repeated postoperative recurrences in patient with papillary carcinoma suggest undifferentiated carcinoma that eventually becomes the same endostage as anaplastic carcinoma. Radical surgery is needed in such cases initially, although making a differential diagnosis between well- and undifferentiated carcinoma is extremely difficult. Urgent treatment of these diseases consists of ensuring that the airway remains open to improve quality of life, but does not include radical treatment. Stent insertion is one adequate method for the urgent treatment of respiratory disturbance caused by tumor compression. Malignant lymphoma frequently develops from Hashimoto's thyroiditis. Immediately after making an accurate pathologic diagnosis, chemotherapy and/or radiation therapy are effective in reducing enlarged goiters rather than surgical management.     

Resection of the trachea infiltrated by thyroid carcinoma.

Twenty-four thyroid carcinoma patients with infiltration of the trachea were treated surgically. The histological diagnosis in these cases included papillary adenocarcinoma in 22 different patients, medullary carcinoma in one patient, and undifferentiated carcinoma in one patient. In 19 of the patients hemoptysis was noted, and dyspnea was present in ten patients. In 14 of the 24 patients the carcinoma was diagnosed by radiographs of the neck, while in seven patients it was demonstrated bronchoscopically. In three patients tracheal infiltration by thyroid carcinoma was diagnosed by biopsy of the tracheal wall at operation. When the tracheal wall was infiltrated by thyroid carcinoma, treatment consisted of circumferential resection of the involved segment of the trachea followed by an end-to-end anastomosis. Of the 24 patients, 17 survived and six died. In the 17 patients who survived, 13 were disease free. Of this number, six survived more than five years after the initial tracheal resection.     

Tracheal Stenting has Minimal Impact on Survival in Anaplastic Thyroid Carcinoma

Background

Anaplastic thyroid carcinoma (ATC) is the most aggressive form of thyroid cancer and it has an extremely poor prognosis. Rapid airway compromise is the main cause of death in patients with ATC.

Methods

The present study is based on a retrospective review of clinical data of patients with ATC treated over the last decade in a tertiary referral center.

Results

Between January 1998 and December 2010, 31 patients (13 males: 18 females) with a mean age of 74 years (range: 54–90 years) had a diagnosis of ATC made on fine-needle aspiration (n = 29) or biopsy (n = 2). Eight patients underwent total thyroidectomy and lymph node dissection, and five patients had attempted surgery but the procedure was abandoned because of inoperability. Airway compromise was clinically apparent in 11 patients. Five patients had tracheal stents inserted, with a median survival of 2 months (range: 1–36 months). In the whole cohort, 29 patients died of the disease, with a mean survival of 7 months (range: 1–36 months).

Conclusions

Survival of patients with undifferentiated thyroid cancer is severely compromised by airway obstruction. Palliation with tracheal stenting can rescue catastrophic airway obstruction but offers minimal survival benefit.     

Clinicopathologic study of thyroid carcinoma infiltrating the trachea

A clinicopathologic study of 14 cases of thyroid carcinoma with tracheal infiltration and 70 control cases of thyroid carcinoma without tracheal infiltration was performed. The cases with tracheal infiltration were classified into well differentiated carcinoma in 5 cases, poorly differentiated carcinoma in 6, undifferentiated in 2, and squamous cell carcinoma in one, thus showing a higher frequency (54.5%) of poorly differentiated carcinoma than that (11.4%) in the control cases. A comparative study of biological behavior between well differentiated and poorly differentiated carcinomas revealed that the latter was more aggressive, and the lymphnode metastatic rate of which was higher. The prognosis of poorly differentiated carcinoma was poorer than that of well differentiated carcinoma. Selective en bloc resection of the tumor including the larynx and trachea was followed by the improved prognosis of advanced thyroid carcinoma with tracheal infiltration.     

Undifferentiated thyroid cancer: improved therapeutic results following initial radical intervention and early postoperative radiotherapy

During a 16-year period (1972-1988), 40 out of 477 thyroid cancer patients underwent thyroidectomy for undifferentiated thyroid carcinoma. To analyse the significance of "radical" versus "palliative" surgical procedures with regard to early postoperative course, operative complications and survival, all patients records were reviewed and actually followed up. A significant better survival was correlated with radical (n = 17) versus palliative tumor resection (n = 23) (p less than 0.001), and total thyroidectomy (n = 22) versus subtotal thyroidectomy (n = 18) (p less than 0.006). Radical surgery with early postoperative external irradiation revealed no postoperative mortality and only one symptomatic cervical tumor recurrence. In contrast, palliative surgery, particularly in the case of synchronous tracheotomy, was attended with a relatively high mortality (30%) and symptomatic local recurrences. The results of this study suggest that in undifferentiated thyroid carcinoma without infiltration of the esophageal or tracheal mucosa an attempt of radical tumor resection should be undertaken, since palliative surgical procedures revealed a significantly lower survival due to complications of persistent or recurrent cervical tumor infiltration and frequently were accompanied by local complications during the postoperative course.     

Sixty tracheal resections--single center experience

This study evaluates the clinical outcome following surgery of our patients for the last seven years. Between 2001 and 2008 we performed tracheal resections in 60 patients. There were 46 cases of postintubation stenosis and 14 tumors. The range of resected rings was 1-8. The maximal resection length performed in our series (4 cm) was achieved using only basic releasing maneuvers such as anterior dissection of the trachea and cervical flexion. Emergency tracheal resection with no complications was performed in 12 patients who presented with severe dyspnea due to very tight stenosis. One patient died during the surgical intervention from a stroke. There were two postoperative deaths, both in patients with tracheo-esophageal fistula. As major complications we mention one patient with restenosis who underwent revision surgery. Among the patients with malignant tumors we had one local epidermoid carcinoma recurrence 18 months after surgery and the two patients with thyroid cancer who died six and nine months later. Basic releasing maneuvers allow a good length of the trachea to be resected with no complications. We consider that emergency tracheal resection can be performed with success. Squamous cell carcinoma was the most frequent histological type in our series.     

Primary tracheal tumours: a national survey.

BACKGROUND--Primary tracheal tumours are rare, so few physicians have extensive experience of their management. No direct comparisons have been made of surgical and radiotherapy treatment. METHODS--A postal survey of cases presenting in the last 10 years in the United Kingdom was conducted. Results were expressed as cumulative survival and survival curves were compared by the log rank test. RESULTS--Three hundred and twenty one patients were recruited. Overall five year survival rates were 25% for squamous cell carcinomas, and 80% for adenoid cystic carcinoma; 62% received radiotherapy but only 10% underwent surgery. Small cell carcinoma was more common than expected with an incidence of 6%. In patients with squamous carcinoma improved survival was seen in those with tumour in the upper trachea. High dose radiotherapy was more effective than low dose only in tumours of the upper trachea and in squamous carcinoma. In adenoid cystic carcinoma no significant difference in survival rate was seen between treatment with radiotherapy and surgery. No histological diagnosis was made in 44 patients, the most common reason being fear over the safety of fibreoptic bronchoscopy; however, this group had a cumulative survival at five years of 46%. CONCLUSIONS--Survival may be somewhat better in cases with tracheal tumours than in those with bronchial tumours. Small cell carcinoma is less rare than was previously thought. Upper tracheal tumours may merit more aggressive therapy. It is important to make a histological diagnosis even if rigid bronchoscopy is necessary, and referral to specialist centres is recommended. A larger prospective study is required to compare the value of surgery and radiotherapy.     

Surgical treatment of patients with stenosis of the central airway due to tracheal tumours

This study retrospectively evaluated bronchoscopic and surgical treatments for patients with central airway stenosis due to tracheal tumours. Seven patients treated by resection and reconstruction of the trachea for tracheal tumours between 1994 and 2008 were retrospectively reviewed. The most common histological finding was thyroid carcinoma (n = 3), followed by adenoid cystic carcinoma (n = 2), a metastatic thyroid tumour (n = 1), and a benign granular cell tumour (n = 1). Three of the patients required preoperative laser treatment (Nd:YAG) for recanalization. Five patients underwent end-to-end anastomosis for reconstruction. There was no postoperative mortality or morbidity such as anastomotic insufficiency of the reconstructed trachea. Three patients with a microscopic residual tumour required postoperative external radiotherapy. Surgical resection of malignant tracheal tumours is recommended not only for curative purposes, but also for reduction of the risk of smothering.     

A clinical study of surgical treatment of patients with carcinoma of the cervical esophagus extending to the thoracic esophagus.

OBJECTIVE: We studied optimum surgery for carcinoma of the cervical esophagus extending to the thoracic esophagus (Ce-Ut carcinoma). METHODS: Subjects were 13 patients diagnosed with Ce-Ut carcinoma treated at our institute from January 1989 to December 1998. Clinicopathologic information such as surgical procedures, pathologic findings, and postoperative complications were analyzed. RESULTS: In 10, laryngoesophagectomy was conducted due to tracheal invasion by the tumor. In 7, mediastinal tracheostomy was done because of the extended resection of the proximal trachea. In 3, the larynx was preserved and, in 2, cricopharyngeal myotomy was added. Lymph node metastasis was found only in the neck and the upper mediastinum at surgery and recurrences were all lung metastasis. The incidence of postoperative complications was very high (76.9%), and 1 patient died due to widespread tracheal necrosis. The cumulative 5-year survival rate for the group was 33.3% and that for the 9 curative cases was 50%, but most of the cases who underwent noncurative resection and/or who received preoperative therapy for widespread invasion to surrounding organs died within a year. CONCLUSION: The prognosis of patients who undergoing curative extended resection of the proximal trachea and suitable lymph node dissection in the neck and upper mediastinum may improve, and larynx-preserving surgery is recommended for patients without tracheal invasion. Despite preoperative chemoradiotherapy, the prognosis of patients with widespread invasion to surrounding organs was very poor, and clinical studies on new therapeutic strategies for these advanced cases are needed to improve the prognosis of Ce-Ut carcinoma patients.