胸腔镜纵隔良性肿瘤切除术后不留置引流管的安全性及可行性分析

目的:探讨胸腔镜纵隔良性肿瘤切除术后不留置引流管的安全性及可行性。 方法:采用随机对照法对比胸腔镜纵隔良性肿物切除术后留置与不留置引流管的效果,将 2017 年12月至2018年12月于我科进行胸腔镜纵隔良性肿瘤切除手术的64例患者分为观察组(n=32)与对照组(n=32)。观察组术后不留置引流管,对照组术后常规留置引流管。对比两组患者的手术时间、术中出血量、术后住院天数、术后疼痛评分及术后并发症情况。 结果:两组患者均顺利完成手术。观察组术后住院时间短于对照组,差异有统计学意义,两组术中出血量、手术时间差异无统计学意义。术后第1天、第3天疼痛评分,观察组低于对照组,差异有统计学意义。术后并发症发生率两组差异无统计学意义。 结论:胸腔镜纵隔良性肿瘤切除术后不留置引流管可缩短患者术后住院时间,减轻患者术后疼痛,且不额外增加术后并发症的种类及发生率,安全且可行,符合快速康复外科理念。     

1 173例甲状腺乳头状癌外科治疗远期疗效观察

目的：探讨甲状腺乳头状癌的外科治疗效果和影响生存因素。方法：选取1954-1991年闾手术治疗，并随访10年以上甲状腺乳头状癌1173例。按手术方式分为腺叶切除术组和腺叶切除合并颈淋巴结清除术组．两组进行分析。结果：腺叶切除术组中腺内型癌的10和20年无瘤生存率分别为94．6％、94．0％，腺外型癌分别为40．8%、35．0％。腺叶切除合并颈淋巴结清除术组中腺内型癌施行选择性和治疗性颈清术的10年无瘤生存率分别为97．0％、90．8％．腺外型癌分别为87．9％、53．2％；20年无瘤生存率腺内及腺外型癌分别为93．9％、84.3％，77．4%、31．9%。结论：甲状腺乳头状癌的外科治疗均需施行患侧腺叶切除术，当同侧颈淋巴结出现转移时．需合并功能性或传统性颈淋巴结清除术；当触不到颈部肿大淋巴结时，根据原发癌侵犯程度决定是否合并颈清术；包膜内癌的颈淋巴结转移率为20．5％．不宜施行颈清术：癌侵出包膜的腺内型癌及腺外型癌，其淋巴结转移率分别为69．1％、73.4％，均宜施行选择性功能性颈清术。     

甲状腺乳头状癌患者术后并发症的分析与护理

目的探讨甲状腺乳头状癌患者术后并发症的发生情况与护理方法。方法回顾性选取2018年10月至2019年1月间中国医学科学院肿瘤医院收治的247例甲状腺乳头状癌患者的临床资料,统计术后并发症,分析发生原因及护理要点。结果247例甲状腺乳头状癌手术患者中,术后伤口出血2例,喉返神经损伤2例,甲状旁腺功能减退55例,低钙血症54例,淋巴漏1例,伤口积液1例,颈面部肿胀、颈周麻木疼痛、抬肩困难共12例,压力性损伤1例。术后平均住院时间(2.74±1.37)d,均痊愈出院。结论甲状腺乳头状腺癌术后并发症不能完全避免,术后密切观察、早期发现和及时处理是并发症护理的要点。     

腔镜技术在甲状腺乳头状癌中的应用进展

随着微创外科的发展及人们对美容切口的迫切要求,颈部无瘢痕腔镜甲状腺切除术(scarless endoscopic thyroidectomy,SET)越来越受到人们的关注。对于甲状腺良性肿瘤,与传统开放甲状腺手术(traditional open thyroidectomy,TOT)相比,SET具有明显美容效果,且手术疗效及预后无明显差异。但腔镜下甲状腺乳头状癌(papillary thyroid carcinoma,PTC)的手术具有时间长、切除范围广、行淋巴结清扫难度大等特点[36-37],因此SET应用于甲状腺乳头状癌的可行性及安全性是目前争议的热点。现对腔镜技术在甲状腺乳头状癌手术中的应用进展进行综述,供临床同道参考。     

甲状腺微小乳头状癌84例临床病理分析

目的探讨甲状腺微小乳头状癌（papillarymicrocarcinomaofthyroid,PMCT）的临床病理特点。方法分析84例PMCT的淋巴结转移率与患者性别、发病年龄、病灶数目及有无伴发良性病变或同时患有对侧甲状腺乳头状癌等因素的相关性。结果84例PMCT中,男11例、女73例,男、女性的平均发病年龄分别为51．7和47．4岁,淋巴结转移率分别为45．45％和10．96％（P=0．003）。84例PMCT中,57例伴发甲状腺其他良性病变,9例同时患有另一叶甲状腺乳头状癌,66例淋巴结转移率为6．06％（4／66）,明显较单纯PMCT者的50．0％（9／18）为低（P=0．000）。以45岁为界〈45岁和≥45岁组的淋巴结转移率分别为10．81％,19．15％（P=0．294）。多灶与单发结节者淋巴结转移率分别为17．65％和7．46％,（P=0．314）。结论PMCT淋巴结转移率与病灶数目及患者年龄不相关（P〉0．05）,与性别及有无伴发甲状腺其他病变相关（P〈0．05）。男性PMCT淋巴结转移率较高,单纯PMCT淋巴结转移率较高。     

甲状腺全切除术对甲状腺乳头状癌伴桥本甲状腺炎患者术后PTH的影响

目的 探讨甲状腺全除切术对甲状腺乳头状癌伴桥本甲状腺炎患者术后甲状旁腺激素(PTH)的影响.方法 选取467例甲状腺乳头状癌患者,其中单纯甲状腺乳头状癌患者332例(对照组),甲状腺乳头状癌伴桥本甲状腺炎患者135例(观察组).对两组患者进行手术治疗,观察并比较两组患者术后PTH和血钙水平.结果 术后7天,观察组患者的PTH和血钙水平分别为(1.28±0.32)pmol/L和(2.21±0.32)mmol/L,分别低于对照组的(2.57±0.44)pmol/L和(2.48±0.40)mmol/L,差异均有统计学意义(P﹤0.05);术后观察组患者甲状旁腺功能减退、低血钙和水肿的发生率分别为60.74%、46.67%和31.85%,高于对照组的28.01%、18.07%和18.98%,差异均有统计学意义(P﹤0.05).观察组患者的术后引流量为(78.20±14.29)ml,高于对照组的(32.02±10.03)ml,差异有统计学意义(P﹤0.05).观察组中行甲状腺全切除术的患者术后甲状旁腺功能减退和低血钙的发生率均为15.56%,均低于行甲状腺全切除术+中央区淋巴结清扫和甲状腺全切除术+中央区及侧颈淋巴结清扫的患者(P﹤0.05).结论 与单纯甲状腺乳头状癌患者相比,伴桥本甲状腺炎的甲状腺乳头状癌患者行甲状腺全切除术后发生甲状旁腺功能减退和低血钙的比例高,且手术方式对术后甲状旁腺功能减退和低血钙的发生有影响.     

甲状腺乳头状微小癌临床病理分析及术中中央区淋巴结清扫的探讨

目的 分析甲状腺乳头状微小癌（PTMC）的临床病理因素,探讨术中中央区淋巴结清扫的病理诊断方法。 方法 复习存档病理资料125例PTMC（2010年）,详细描述其组织学诊断标准,并与近3年来PTMC病理资料作比较。 结果 微小乳头状癌以女性患者居多,共107例,占85.6%（男女比例为1∶6）;≤45岁58例（46.4%）,＞45岁64例（51.2%）,差异无统计学意义;左侧49例（39.38%）,右侧63例（50.4%）,双侧12例（9.6%）,峡部1例。术中冰冻切片检查121例,未做4例,确诊113例（88.43%）,冰冻切片漏诊8例（6.6%）。确诊病例中92例做了同侧中央区淋巴结清扫,淋巴结出现转移28例（30.44%）,无转移64例（69.7%）。其中原发灶≥0.5 cm者中央区淋巴结转移率为34.0% （18/53）,＜0.5 cm者转移率为25.6% （10/39）,两者比例为1.71∶1,但差异无统计学意义（P=0.391）。 结论 术中冰冻切片确诊为PTMC者应行预防性中央区淋巴结清扫。     

甲状腺乳头状癌的变异型

甲状腺乳头状癌(PTC)组织学变异型众多,大部分变异型与典型乳头状癌有相似的临床行为,但有少数变异型预后较差,如高细胞变异型、柱状细胞变异型、实体/梁状变异型等;且有一些变异型在诊断上有争议,如滤泡变异型易误诊为滤泡腺瘤、透明细胞变异型可能与肾细胞癌混淆、诊断高细胞变异型所需的高细胞的比例和细胞高度有分歧意见等.     

中央区淋巴结清除术在甲状腺乳头状癌术中应用的研究

甲状腺癌〉80％为分化型腺癌，起病较隐匿，恶性程度低，病程长，且颈部淋巴结转移率高。手术治疗分化型甲状腺癌，常根据肿瘤的生物学特性采取不同的手术方式。过多的切除甲状腺组织会降低器官的功能，并影响患者的生活质量；过少地切除甲状腺组织则宜复发，需再次手术，增加患者痛苦及治疗费用，故手术方式的选择非常重要。我们共收治甲状腺乳头状腺癌52例，术中对中央区淋巴结清除20例，就手术中淋巴结转移情况，术后随访结果报道如下。     

甲状腺乳头状癌的外科治疗与争论

甲状腺乳头状癌的外科治疗历来存在争论。我科30余年来治疗甲状腺癌1780例的过程亦反映出这种争论。现将我们的经验教训提出供参考讨论。一、甲状腺切除范围主张全甲状腺切除者认为 (1)一叶甲状腺癌播散至对侧甲状腺的比例可高达19～88％,切除全甲状腺就可避免这种潜在的复发。(2)未分化甲状腺癌中21％由分化好的转化而来,对侧叶的播散灶同样可转化成未分化癌。(3)全甲状腺切除后有利于用~(131)Ⅰ的检测与治疗。(4)全甲状腺切除后有利于应用     

甲状腺乳头状癌与乳头状增生的病理研究

  目的 探讨Galectin3，CK19及Ki-67在甲状腺乳头状癌与乳头状增生中的表达，寻找有助于两者鉴别诊断的标志物。方法 运用免疫组化方法检测100例甲状腺乳头状癌、100例良性乳头状增生中Galectin3，CK19及Ki-67的表达。结果 Galectin3，CK19及Ki-67在甲状腺乳头状癌阳性表达率分别为100 %，97 %及93 %，而在乳头状增生中表达率分别为13 %，30 %及1 %，3种蛋白在乳头状癌与良性乳头状增生间差异有统计学意义（P＜0.05）。在乳头状癌中2种或3种蛋白同时阳性表达为94.3 %，而乳头状增生为0。结论 Galectin3，CK19及Ki-67是鉴别诊断甲状腺乳头状癌与乳头状增生的有用标志物，尤其联合使用更有价值。     

Less extensive surgery for low-risk papillary thyroid cancers post 2015 American Thyroid Association guidelines in an Australian tertiary centre

IntroductionThe 2015 American Thyroid Association guidelines (ATA15) consider hemithyroidectomy (HT) a viable treatment option for low-risk papillary thyroid cancers (PTCs) between 1 and 4 cm. We aimed to examine the impact of ATA15 in a high-volume Australian endocrine surgery unit.MethodsA retrospective study of all patients undergoing thyroidectomy from January 2010 to December 2019. Inclusion criteria: PTC histopathology, Bethesda V-VI, size 1–4 cm, and absence of clinical evidence of lymph node or distant metastases pre-operatively. Primary outcome was rate of HT before and after ATA15.ResultsOf 5408 thyroidectomy patients, 339 (6.3%) met the inclusion criteria – 186 (54.9%) pre-ATA15 (2010–2015) and 153 (45.1%) post-ATA15 (2016–2019). The patient groups were similar; there were no significant differences between groups in age, sex, tumour size, proportion with Bethesda VI cytology, compressive symptoms, or thyrotoxicosis. Post-ATA15, there was a significant increase in HT rate from 5.4% to 19.6% (P = 0.0001). However, there was no corresponding increase in completion thyroidectomy (CT) rate (50.0% versus 27.6%, P = 0.2). The proportion managed with prophylactic central neck dissection (pCND) fell from 80.5% to 10.8% (P < 0.0001). Pre-ATA15, the only factor significantly associated with HT was Bethesda V. In contrast, post-ATA15, HT was more likely in patients with younger age, smaller tumours, and Bethesda V.ConclusionAfter the release of 2015 ATA guidelines, we observed a significant increase in HT rate and a significant decrease in pCND rate for low-risk PTCs in our specialised thyroid cancer unit. This reflects a growing clinician uptake of a more conservative approach as recommended by ATA15.     

Active surveillance in low risk papillary thyroid carcinoma

In recent decades, while the incidence of thyroid cancer has increased exponentially around the world, mortality has remained stable. The vast majority of this increase is attributable to the identification of intrathyroidal papillary microcarcinomas, which exhibit slow growth rates with indolent courses. A diagnosis of thyroid cancer based upon the presence of these small tumors could be considered as an overdiagnosis, as the majority of these tumors would not likely result in death if left untreated. Although surgical resection was the classical standard therapy for papillary microcarcinomas, active surveillance (AS) has emerged over the last three decades as an alternative approach that is aimed to recognize a minority group of patients who will clinically progress and would likely benefit from rescue surgery. Despite the encouraging results of AS, its implementation in clinical practice is strongly influenced by psychosocial factors. The aim of this review is to describe the epidemiology, clinical evolution, prognostic factors, and mortality of papillary thyroid microcarcinomas. We also summarize the AS strategy according to published evidence, characterize the criteria for selecting patients for AS according to risk factors and environmental characteristics, as well as analyze the current limitations for AS implementation.     

抗甲状腺球蛋白抗体对妇女甲状腺乳头状癌发病的影响

目的 探讨抗甲状腺球蛋白抗体(TgAb)对妇女甲状腺乳头状癌发病中的影响.方法 选取2018年2月至2019年12月间上海市宝山区罗店医院收治的72例女性甲状腺乳头状癌患者为研究组,选取同期行手术治疗并经病理结果 明确的80例良性甲状腺结节女性患者为对照组.比较两组患者抗甲状腺球蛋白抗体的差异和甲状腺乳头状癌患病风险与...     

甲状腺乳头状癌颈部淋巴结转移规律及其治疗方案选择的研究

目的:探讨临床淋巴结阴性的甲状腺乳头状癌患者的颈部淋巴结转移特点及淋巴结处理方法。方法:回顾性分析107例临床淋巴结阴性甲状腺乳头状癌患者的临床资料。按肿瘤大小及淋巴结的处理不同将患者分为3组,A组:肿瘤长径≤1cm行同侧Ⅵ区淋巴结清除;B组:肿瘤长径>1～3cm行双侧Ⅵ区淋巴结清除及同侧Ⅲ、Ⅳ区淋巴结冷冻病理;C组:肿瘤长径>3cm者行双侧Ⅵ区淋巴结清除及同侧Ⅲ、Ⅳ区淋巴结冷冻病理。B、C组患者中,同侧Ⅲ、Ⅳ区淋巴结冷冻病理转移者行改良性颈淋巴结清除。结果:3组患者同侧Ⅵ区转移率分别为41.1%、61.1%和73.3%,差异有统计学意义,χ2=6.610 9,P=0.036 7;B、C组患者的对侧Ⅵ区淋巴结转移率分别为30.5%和73.3%,差异有统计学意义,χ2=3.851 0,P=0.049 7;B、C组患者的Ⅲ、Ⅳ区转移率分别为19.4%和46.7%,差异有统计学意义,χ2=4.267 4,P=0.038 9。结论:临床淋巴结阴性的甲状腺乳头状癌患者易发生Ⅵ及Ⅲ、Ⅳ区淋巴结转移。肿瘤长径≤1cm者建议行同侧Ⅵ区淋巴结清除,肿瘤长径>1cm者建议行双侧Ⅵ区淋巴结清除及同侧Ⅲ、Ⅳ区淋巴结冷冻,转移者行改良性颈淋巴结清除。     

Lymph node management in clinically node-negative patients with papillary thyroid carcinoma

Aims

Systematic lymph node dissection in patients with papillary thyroid carcinoma (PTC) remains controversial. The objective of this study was to study the pattern of lymph node spread in patients with PTC clinically node-negative and then to propose a lymph node management strategy.

Methods

We retrospectively reviewed the records of patients who had undergone total thyroidectomy and a systematic central neck dissection (CND) and lateral neck dissection. Ninety patients with PTC without lymph nodes metastases (LNM) detected on preoperative palpation and ultrasonographic examination were included.

Results

Forty-one patients (45.5%) had LNM. Twenty-eight patients (31%) had a central and a lateral involvement. Thirteen patients (14.5%) had only a central involvement. All the patients without LNM in the central compartment were also free in the lateral compartment. There was no correlation between LNM status and TNM staging.The largest LNM in the central compartment was smaller than or equal to 5 mm in 66% of the cases, and that could explain the lack of sensitivity of the preoperative ultrasonographic examination.

Conclusion

CND could be considered at preoperative or intraoperative diagnosis of PTC whereas lateral neck dissection should be performed only in patients with preoperative suspected and/or intraoperatively proven LNM. Systematic CND allows an objective evaluation of lymph node status in this central cervical area where the LNM are particularly small and difficult to detect preoperatively.     

腔镜辅助颈部小切口甲状腺切除术治疗甲状腺癌

腔镜甲状腺手术以其美观、微创、并发症少及术后恢复快等优点应用于甲状腺良性疾病的治疗,目前已获得广泛认可,但对于其应用于治疗甲状腺癌的安全性、可行性等问题仍存在争议.我院自2006年1月至2008年12月行腔镜辅助颈部小切口甲状腺术式切除甲状腺癌15例,手术效果良好,现报告如下.     

Evaluating the effectiveness of prophylactic central neck dissection with total thyroidectomy for cN0 papillary thyroid carcinoma: An updated meta-analysis

Background

The effectiveness of prophylactic central neck dissection (pCND) following total thyroidectomy (TT) in patients with clinical node-negative (cN0) papillary thyroid carcinoma (PTC) is still controversial. The aim of this meta-analysis is to evaluate the outcome of pCND and to provide quantitative evidence.