甲状腺癌侵及气管的外科处理

目的：探讨侵及气管的甲状腺癌的外科处理方法及疗效。方法：回顾性分析了1975年～1999年共收治的侵及气管的甲状腺癌71例，根据侵及程度分三类：仅侵及气管外膜；侵及气管软骨；侵及气管全层并突入管腔引起呼吸困难。术中分别行切除气管外膜、气管壁开窗造瘘、部分气管切除及全喉切除术。其中17例未分化癌患者术后均行放疗。甲状腺滤泡癌及乳头滤泡癌患者均行碘^[3]治疗。结果：分化型甲状腺癌，1年生存率94．4％，3年生存率88．9％，5年生存率85．2％，10年生存率31．5％。未分化型患者17例均在1年内死亡。结论：侵及气管的甲状腺癌在全身状态允许的条件下是可以采用外科手术治疗的，但未分化型甲状腺癌的预后较差。     

分化型甲状腺癌的诊断与治疗

甲状腺癌是常见的头颈部恶性肿瘤，约占全身恶性肿瘤的1．0％～1．5％。由于临床上最常见的分化型甲状腺癌恶性程度低，生长缓慢，生存期长，死亡率低，预后较好，因此对这类甲状腺癌的手术切除范围以及颈淋巴清扫等问题仍有很多争议。当前亟待解决的主要问题是避免治疗不足或治疗过度两个极端。甲状腺癌常见的病理分类包括：乳头状腺癌、滤泡状腺癌、髓样癌和未分化癌。其中以乳头状腺癌和滤泡状腺癌在临床上最为多见（占90％以上）。因这两种病理类型分化较好，故称为分化型甲状腺癌。     

甲状腺癌再手术15例

目的：探讨甲状腺癌患者再手术的相关因素,选择合理的手术方式。方法：对15例再手术的分化型甲状腺癌患者的资料进行回顾性分析。结果：15例中二次手术者12例,三次手术者3例;15例分化型甲状腺癌再次手术发现总残癌率为60.0%(9/15),其中原发部位残癌率46.7% (7/15),颈部淋巴结转移40.0（6/15）。结论：甲状腺肿瘤手术应行甲状腺腺叶切除,疑有颈淋巴结转移时要行规范化的颈淋巴结清扫术。     

分化型甲状腺癌再次手术临床分析

目的 探讨分化型甲状腺癌再次手术治疗的原因、术式的选择、并发症的发生及疗效.方法 回顾性分析1995年1月至2005年1月期间收治再次手术治疗的49例分化型甲状腺癌患者的临床资料.再次手术方式:①误诊为良性病变者,再手术时切除残叶及峡部,其中对于颈淋巴无转移者,同时加Ⅵ区颈清扫,而颈淋巴有转移者,同时加Ⅱ～Ⅵ区颈清扫;②复发患者再手术时行甲状腺全切或复发灶切除,对于颈淋巴有转移者,同时加Ⅱ～Ⅵ区颈清扫.结果 再次手术患者残癌率59.2%(29/49),其中原发部位残癌率53.1%(26/49),术后有3例出现喉返神经损伤,4例出现甲状旁腺损伤,采用Kaplan-Meier法计算生存率,再手术患者5年、10年累积生存率分别为95.8%、86.9%.结论 对于分化型甲状腺癌再次手术患者,选择适当的再手术方式,可以提高生存率并改善患者生活质量,术中应仔细解剖,尽量防止并发症的发生,重点是避免喉返神经和甲状旁腺损伤.     

分化型甲状腺癌的颈淋巴结转移及处理

本从淋巴结转移方式、外科治疗和预后三个方面论述了分化型甲状腺癌淋巴结转移及处理的近期进展。在甲状腺手术的同时应切除其周围的淋巴结。大多数外科医生采用治疗性颈清扫。改良性颈清扫为大家普遍接受，与除转移淋巴结方式相比，前颈部复发率低且预后好。虽然关于颈淋巴结转移对预后的影响众说不一，但近来年龄配伍研究表明，颈转移是分化型甲状腺癌患预后差的指标，在年龄大于４５岁这组患尤其明显，对于这些患应采     

甲状腺癌侵及气管的外科处理

目的:探讨侵及气管的甲状腺癌的外科处理方法及疗效。方法:回顾性分析了1975年～1999年共收治的侵及气管的甲状腺癌71例,根据侵及程度分三类:仅侵及气管外膜;侵及气管软骨;侵及气管全层并突入管腔引起呼吸困难。术中分别行切除气管外膜、气管壁开窗造瘘、部分气管切除及全喉切除术。其中17例未分化癌患者术后均行放疗。甲状腺滤泡癌及乳头滤泡癌患者均行碘~(131)治疗。结果:分化型甲状腺癌,1年生存率94.4％,3年生存率88.9％,5年生存率85.2％,10年生存率31.5％。未分化型患者17例均在1年内死亡。结论:侵及气管的甲状腺癌在全身状态允许的条件下是可以采用外科手术治疗的,但未分化型甲状腺癌的预后较差。     

分化型甲状腺癌外科治疗的术式选择

目的 :探讨分化型甲状腺癌外科治疗术式的选择。方法 :对 6 6例分化型甲状腺癌病例行患侧腺叶、峡部加对侧次全切除术 49例 ,患侧腺叶及峡部切除术 7例 ,一侧腺叶次全切除及对侧部分切除术 6例 ,全甲状腺切除术 4例。行患侧功能性颈清扫术加对侧功能性颈清扫术 43例 ,双侧功能性颈清扫术 1例及患侧传统性颈清扫术 10例 ,患侧传统性颈清扫术 5例。结果 :3年生存率 96 % (2 5 /2 6 ) ,5年生存率 94% (17/18) ,1例死于白血病 ,1例失访。 4例行全甲状腺切除术的病例术后均出现甲状腺功能减退 ,其中 2例出现甲状旁腺功能减退(5 0 % ) ,其他病例均未发生甲状腺功能和甲状旁腺功能减退。无一例发生喉返神经麻痹。结论 :对分化型甲状腺癌 ,主张行患侧腺叶切除加对侧次全切除或大部切除 ;如术前发现颈淋巴结肿大 ,应同时行患侧淋巴结清扫术。而N0 患者 ,除了对高危组 (男 >41岁 ,女 >5 1岁 )患者腺体外乳头状瘤或明显侵犯包膜的滤泡型腺癌者应行功能性颈清扫术 ,其他随访容易的N0 患者可以不必常规行颈清扫术 ,并提倡长期密切随访。     

中央区淋巴结快速病理检查指导分化型甲状腺癌手术方式的选择

目的探讨分化型甲状腺癌患者中央区肿大淋巴结的快速病理检查,对选择分化型甲状腺癌患者手术方式的意义,以避免过多切除甲状腺组织,影响患者的生活质量.方法1997年1月至2000年9月在甲状腺癌患者手术中,根据对中央区淋巴结快速病理的检查结果,分别对甲状腺癌患者行甲状腺双侧全切除术、一侧全切+峡部切除以及单侧或双侧功能性颈淋巴结清扫术.结果术后随访4～6年,1例于手术后1年半复发而再次手术,其他患者无复发,复发率为2.78%.结论在分化型甲状腺癌患者的手术中,对中央区淋巴结的术中快速病理检查,可以指导对甲状腺癌患者手术方式的选择,减少手术后癌的复发率及转移率,提高患者的生活质量.     

复发转移性分化型甲状腺癌诊疗进展

分化型甲状腺癌以手术治疗为主，虽然其预后较好，但易复发转移。对于复发转移性分化型甲状腺癌，早期诊断及治疗对提高患者生活质量及延长患者生存期相当重要。本文结合相关文献，对复发转移性分化型甲状腺癌的诊断及治疗进展进行综述。     

分化型甲状腺癌侵犯喉气管临床分析

目的　探讨甲状腺癌累及喉、气管时的外科处理方法。方法　2000年1月～2010年12月在我院手术治疗晚期分化型甲状腺癌24例,根据肿瘤侵犯喉、颈段气管的范围及程度分别行肿瘤削除术和气管袖状切除端端吻合术;喉部分切除胸锁乳突肌或颈阔肌皮瓣修复术。结果　24例患者均接受根治性手术切除,喉、气管缺损修复重建。术式：肿瘤削除术8例,气管袖状切除8例,喉部分切除术8例。吻合方式：气管端端吻合8例,胸锁乳突肌皮瓣修复4例,颈阔肌皮瓣修复4例。本组患者肿瘤复发率为8.3%,5年累积生存率为91.6%。结论　对侵犯喉、气管的分化型甲状腺癌患者应采取更为积极的外科治疗,以减少术后复发,提高生存率。     

Implications of prognostic factors and risk groups in the management of differentiated thyroid cancer

OBJECTIVES/HYPOTHESIS: The outcome in differentiated thyroid cancer generally depends on the stage of the disease at the time of presentation; prognostic factors such as age, grade, size, extension, or distant metastasis; and risk groups (eg, low or high risk). The author has reviewed a large number of patients with differentiated thyroid cancer to analyze their hypothesis and to confirm that various risk groups have a major implication in relation to extent of the treatment and outcome. Differentiated thyroid cancers make up 90% of all thyroid tumors. The prognostic factors are well defined, such as age, size of the tumor, extrathyroidal extension, presence of distant metastasis, histological appearance, and grade of the tumor. The author has previously divided the risk groups into low-, intermediate-, and high-risk categories based on prognostic factors. The study describes the author's treatment approach related to the extent of thyroidectomy and adjuvant therapy based on various risk groups and the long-term survival. STUDY DESIGN: Retrospective. METHODS: In a retrospective review of 1038 patients with differentiated thyroid carcinoma, various prognostic factors were studied by univariate and multivariate analysis. The significant prognostic factors were studied in detail and, based on these prognostic factors, the patients were divided into low-, intermediate- and high-risk groups. The survival curves were plotted by Kaplan-Meier method. RESULTS: The long-term survivals in low-, intermediate- and high-risk groups were 99%, 87%, and 57% respectively. Based on these risk groups, a decision tree was made regarding extent of thyroidectomy and adjuvant treatment. In the high-risk group and selected patients in the intermediate-risk group, aggressive surgery including removal of all gross disease and extrathyroidal extension with postoperative radioactive iodine ablation is recommended. In the low-risk group and selected patients in the intermediate-risk group, lobectomy appears to be satisfactory with excellent long-term outcome. The surgical treatment offers the best long-term results in low-risk patients, and the role of adjuvant treatment in this group is questionable. CONCLUSION: The decisions in the management of well-differentiated thyroid cancer should be based on various prognostic factors and risk groups. The long-term survival in the low-risk group is excellent, and consideration should be given to conservative surgical resection depending on the extent of the disease. In the high-risk group and selected patients in the intermediate-risk group, total thyroidectomy with radioactive ablation is warranted. A consideration may be given to external-beam radiation therapy in selected high-risk patients. It is apparent, based on the author's clinical experience and critical retrospective analysis, that the author's hypothesis that risk groups are extremely important in the long-term outcome of patients with differentiated thyroid cancer is correct. Based on various risk groups, the author currently is able to guide the treatment policies for thyroid cancer.     

Pretherapeutic nutritional/inflammatory factors as predictors for survival of both early and advanced staged head and neck cancer patients

ObjectivesMalnutrition and inflammation are common in patients with head and neck cancer and are closely associated with prognosis. Although several parameters for evaluating nutritional/inflammatory status have been assessed in relation to the prognosis of patients with head and neck cancer, previous studies primarily included patients with advanced-stage disease. To date, there is no consensus regarding the most reliable parameter for predicting the prognosis of early and advanced-stage head and neck cancer. This study sought to evaluate nutritional/inflammatory prognostic factors before treatment in patients with early and advanced-stage head and neck cancer.MethodsWe retrospectively reviewed medical records of patients treated between 2008 and 2015 at our institution in order to evaluate the effects of nutritional/inflammatory parameters, including C-reactive protein/albumin ratio, modified Glasgow prognostic score, neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, and Geriatric Nutritional Risk Index, on overall survival. Effects of potential risk factors on overall survival were analyzed by computing Kaplan-Meier estimates; curves were compared using the log-rank test.ResultsA total of 164 patients were enrolled. C-reactive protein/albumin ratio, modified Glasgow prognostic score, platelet/lymphocyte ratio, and Geriatric Nutritional Risk Index were found to be statistically significantly correlated with overall survival. Only the Geriatric Nutritional Risk Index remained statistically significant in the multivariate analysis. The three-year survival rates according to the four-group Geriatric Nutritional Risk Index scores for normal, low, moderate, and high risk were 95.5%, 84.3%, 53.8%, and 23.4%, respectively.ConclusionThe Geriatric Nutritional Risk Index is therefore a useful prognostic factor for patients with early and advanced-stage head and neck cancer.     

Analysis of prognostic factors of chemoradiation therapy for advanced hypopharyngeal cancer--does tumor volume correlate with central necrosis and tumor pathology?

OBJECTIVES: Not all patients with hypopharyngeal cancer who undergo concurrent chemoradiation therapy have a good prognosis. We hope to find the significant prognostic factors that could help us in patient selection for concurrent chemoradiation therapy. STUDY DESIGN: We used a retrospective analysis on several prognostic factors which may affect the treatment outcome and prognosis. METHODS: We studied 51 patients with stage III-IV hypopharyngeal cancer who underwent chemoradiation therapy as the first treatment method. Possible significant prognostic factors (i.e. tumor volume, central necrosis, pathology, age) were collected to determine whether they correlate with local disease control and survival. RESULTS: Primary tumor volume correlated with local disease control and survival. The greatest risk for local failure was found among patients with primary tumor volumes >19.0 ml (p = 0.001). Other relatively significant prognostic factors were pathology and central necrosis. The survival rate among patients with primary tumor volumes >19.0 ml was only 39.3% compared with 78.3% for patients with volumes <19.0 ml (p = 0.036). A proportional hazard model indicated that significant parameters associated with overall survival were primary tumor volume (p = 0.036) and central necrosis (p = 0.008). According to the cancer cell differentiation, the hazard risk in the well-differentiated group was 5.62 folds higher than in the poorly differentiated group (p = 0.05). Patients with an initial complete response had a primary tumor volume <19 ml (p = 0.001, 0.016), poorly differentiated pathology (p = 0.001, 0.016), and no central necrosis (p = 0.001, 0.016). Other relatively poor significant factors were T stage above III (p = 0.047), cervical lymphadenopathy beyond level II (p = 0.046), and a nodal volume >10.0 ml (p = 0.029). N stage, age and gender were not significant prognostic factors. CONCLUSION: Tumor volume is the most important prognostic factor of treatment outcome for patients with hypopharyngeal cancer and should always be taken into consideration in treatment planning. Other possible prognostic factors which affect the initial complete response rate and survival rate including central necrosis, pathology, nodal number and nodal volume, T stage above III, and cervical lymphadenopathy beyond level II have a relatively low correlation with treatment outcome. In our study, there was a correlation between tumor volume and central necrosis, but no significant correlation between pathological differentiation and tumor volume, although both affect treatment outcome.     

Prognosticators of survival in differentiated thyroid carcinoma

Differentiated carcinoma of the thyroid has good prognosis, even in patients presenting in the late stage and with distant metastasis. In India, the incidence of papillary carcinoma and follicular carcinoma are in the ratio of 60∶40. A retrospective study was carried out to determine the impact of patient and tumor factors on survival, and to develop a simple rish group staging system to predict survival in patients with differentiated thyroid carcinomas. Four hundred and seventeen (417) patients undergoing primary treatment at our hospital between 197–1985, were entered to the study. There were 198 follicular carcinomas and 219 papillary carcinomas. Impact of patient and tumor variables were studied by drawing Kaplan Meier curves and comparing them by the Chi Sq Test. Age<=40 years (p=0.00001), tumor size <5cms (p=0.01), extrrathyroidal spread (p=0.001) and distant metastasis (p=0.00001) had significant impact on survival. These finding were true for a subset analysis follicular and papillary carcinomas separately. A Cox Regression Analysis was also performed and this showed the above factors to impact significantly on survival. Basing on the regression analysis we devised a simple risk group system and classified the patients as high and low risk. Low risk group patients had a significant survival advantage. Our findings show that the incidence of follicular carcinoma is significantly high in india (48%) and that 65% of our patients are in the high risk group. Incidence of contralateral lobe disease on completion thyroidectomy is as high as 53%. Hence, a more aggressive treatment policy is warranted and total thyroidectomy is the appropriate treatment of choice in our patients.     

甲状腺未分化癌的预后风险指数及治疗抉择

目的　探索甲状腺未分化癌（anaplastic thyroid carcinoma,ATC）的预后影响因素,确定ATC预后风险指数以指导治疗决择。方法　对60例ATC患者临床及随访 资料进行回顾性生存分析,探索预后风险指数及其对治疗抉择的价值。结果　单因素分析提示首诊时年龄、远处转移、白细胞计数、血小板计数、cTNM分期以及手术+术后放疗影响预后。多因素分析提示首诊时白细胞计数和手术+术后放疗是影响预后的独立因素。将首诊时年龄、白细胞计数、血小板计数和cTNM分期列为治疗前风险指数并评分及分组,低危组预后显著好于高危组;手术+术后放疗显著改善低危组患者预后,对高危组预后改善有限。结论　预后风险指数可用于ATC患者预后判断及指导治疗抉择。     

The treatment of differentiated carcinoma of the thyroid gland. Selective management?

Two hundred thirty patients with differentiated carcinoma of the thyroid gland received definitive treatment at the University of Texas M. D. Anderson Hospital and Tumor Institute (MDAH), Houston, from January 1960 through December 1975. Two thirds of these patients were women, and 127 of these female patients (55%) had not had any previous treatment. The mean follow-up period was 11.8 years. The vast majority of patients (80%) had mixed papillary and follicular cancers; 104 patients were seen with cervical metastases. Overall absolute survival was 72.6%. The prognosis was more favorable in the female patients and those persons who were treated solely at MDAH. In 4.4% of those patients treated with a total thyroidectomy, the cancer recurred locally. Of those whose operation was only a lobectomy, local recurrence developed in 10.7%. Several adverse prognostic factors were identified in this group of patients. This analysis would suggest the need for a more selective approach to the surgical treatment of this disease. Differentiated cancer of the thyroid gland affects a heterogeneous group of patients and also appears with varied clinical and anatomic manifestations.     

Distant metastases from thyroid and parathyroid cancer.

Thyroid cancer represents a unique biological tumor where even with the high incidence of distant metastases, the overall prognosis is not as poor as many other human cancers. The overall long-term survival in patients presenting initially with distant metastasis is approximately 50%. The overall incidence of distant metastases varies between 10 and 35%, depending upon the histology. The overall incidence is directly related to various histologies - being least in papillary thyroid carcinoma (10%) and highest in Hürthle cell tumor (33%). The incidence of distant metastases is also very high in patients with medullary and anaplastic thyroid cancer. The incidence of distant metastases at the time of initial presentation in differentiated thyroid cancer is approximately 4%. In high-risk patients - especially in patients with extrathyroidal extension or massive nodal metastasis - the distant metastases can be evaluated after total thyroidectomy with radioactive iodine ablation. Pulmonary metastases are very common in young individuals, but they are extremely well treated and the mortality from distant metastases in this group is very low. However, distant metastases in patients with poorly-differentiated carcinoma have a poor prognosis. In high-risk patients, generally a total thyroidectomy should be undertaken so that the patient can undergo radioactive iodine dosimetry and ablation as indicated. The surveillance in patients with thyroid cancer includes: close clinical follow-up, chest X-ray, and radioactive iodine dosimetry. Thyroglobulin is commonly used as a prognostic marker in patients having undergone total thyroidectomy. The incidence of distant metastases in medullary thyroid cancer is high, mainly to the lung and liver. Persistent hypercalcitonemia is an indication of regional or distant metastases. A variety of diagnostic tests are helpful, such as octreotide scanning, computed tomography scan, magnetic resonance imaging and positron emission tomography scan. Laparoscopy to evaluate the surface of the liver is also an important investigation to detect distant metastases. The incidence of distant metastases is very high in patients with anaplastic thyroid cancer, but most of the time the outcome depends on the locoregional recurrence and massive disease in the central compartment. The parathyroid cancer is quite rare, less than 1%, in patients undergoing parathyroidectomy. The diagnosis of parathyroid cancer is made by pathological features but the most certain method of diagnosis of a malignant tumor of the parathyroid is the identification of secondary deposits. The incidence of distant metastasis is difficult to determine due to the rarity of this condition, but the most common site is the lung. Patients with distant metastasis have recurrent progressive hypercalcemia along with high parathormone level.     

The treatment of well-differentiated thyroid cancer

The management of well differentiated thyroid cancer continues to generate considerable debate and controversy regarding diagnostic evaluation, extent of surgery, and postoperative adjuvant therapy and follow-up. The fine-needle aspiration biopsy has been routinely used for diagnostic evaluation of thyroid nodule. Understanding prognostic factors and risk group analysis is extremely crucial in the overall management of thyroid cancer regarding the extent of thyroidectomy and adjuvant therapy. Patients in the low-risk group do extremely well and can be treated with lobectomy alone while those in the high-risk group invariably require total thyroidectomy due to the need of adjuvant radioactive iodine treatment. Thyroglobulin appears to be a good tumor marker in patients who have undergone total thyroidectomy during follow-up. One of the major nuances in the management of thyroid cancer is the availability of recombinant TSH which can be used for radioactive iodine dosimetry during the follow-up of patients with well differentiated thyroid cancer. This prevents patients from becoming hypothyroid for an extended period of time which directly affects their quality of life. Understanding poorly differentiated thyroid cancer is extremely crucial as an important histologic prognostic factor and generally being nonradioavid tumors. PET scan is useful in the follow-up of these patients to evaluate the extent of distant metastasis.     

Prognostic implications of site of recurrence in patients with recurrent well-differentiated thyroid cancer

OBJECTIVE: The site of treatment failure in patients with recurrent well-differentiated thyroid carcinoma (WDTC) has implications for both the mode of salvage therapy and disease-specific prognosis. The objective of this study was to evaluate the prognostic significance of the site of failure in patients with recurrent WDTC. DESIGN: Patients with recurrent thyroid cancer were identified retrospectively from 1963 to 2000. SETTING: Data were retrieved from the thyroid cancer database at the Department of Otolaryngology-Head and Neck Surgery, Mount Sinai Hospital, Toronto (1963-2000). METHODS: Patients were placed into four different groups according to their site of recurrence: group 1, local recurrence; group 2, regional recurrence; group 3, distant recurrence; and group 4, unspecified recurrence. Patient, tumour, and treatment data were collected and compared. The Kaplan-Meier method was used to calculate survival data, and curves were compared using the log rank test. MAIN OUTCOME MEASURES: Outcome included alive, no disease; alive with disease; dead, no disease; and dead of disease. RESULTS: Seventy-three patients (21 male, 52 female; median age 44 years, range 18-84 years) were eligible for inclusion in this study. Relevant data were divided according to group 1, 22 patients; group 2, 24 patients; group 3, 13 patients; and group 4, 14 patients. The groups were comparable in terms of primary tumour and treatment factors. The actuarial disease-specific survival rate after salvage therapy was less significant in patients who developed a distant recurrence versus a local recurrence, a regional recurrence, or an unspecified recurrence (ie, 66% vs 95%, 88%, and 92%, respectively; p = .06). CONCLUSIONS: Patients with distant recurrences have a poor prognosis, with a significant reduction in the actuarial disease-specific survival rate.     

青少年分化型甲状腺癌治疗及预后

目的探讨青少年分化型甲状腺癌(different-iated thyroid carcinoma,DTC)治疗模式的疗效和影响预后的因素。方法回顾性分析1981～2001年我科收治的年龄≤18岁DTC的随访资料74例(﹥13岁42例,≤13岁32例),均行手术加术后左旋甲状腺素治疗,13例伴肺转移患者行131I核素放射治疗。结果38例随访10年以上,6例随诊时间小于5年失访,中位随访时间(12～264)108个月;全组2例死于甲状腺癌局部复发;Kaplan-Meier法计算10年累积生存率和无瘤生存率分别为96.43%和78.90%。Cox多因素分析没有发现影响生存率的独立因素。Logistic回归分析发现原发灶累及双侧甲状腺腺叶是与复发相关的独立因素;原发灶外侵是影响并发症发生的独立因素;年龄≤13岁的青少年DTC更易发生肺转移,转移率为71.43%。结论在本组青少年DTC的治疗资料中,未发现影响生存率的独立因素。原发灶外侵和年龄≤13岁分别影响并发症发生和肺转移,此类患者应在术后行131I治疗。原发灶累及双侧甲状腺是复发的主要因素,对此类患者加强术前检查同时扩大手术范围。