腺外浸润的晚期甲状腺癌的外科治疗

为评价腺外浸润的晚期甲状腺癌的手术疗效和预后，回顾性分析了１６例手术治疗的甲状腺癌病例，其中侵及范围为气管、食管、喉、喉返神经、下咽和颈部大血管等。１例行根治性手术，其它均行功能性手术，对喉、气管、食管及下咽的缺损进行了修复重建，全部病例均有１年以上的随访。结果发现，１１例喉气管重建者均拔管，２例下咽食管成形者吞咽功能良好．１例术后４年双肺转移死亡，余１５例未发现复发及转移。其中生存１年、３年、５     

侵犯喉气管或/和下咽颈段食管的甲状腺癌的外科治疗

目的探讨侵犯喉气管或/和下咽颈段食管的甲状腺癌的有效治疗方法。方法对21例伴气管或/和下咽、颈段食管受侵的甲状腺癌患者行Ⅰ期肿瘤扩大根治切除。21例患者均有不同程度喉或气管受侵犯,其中4例同时伴有下咽侵犯,11例伴有颈段食管侵犯。所有病例根据原发肿瘤大小及侵犯范围行甲状腺癌根治切除、受侵器官的扩大切除及功能修复术。其中16例术后病理为乳头状癌行131Ⅰ辅助治疗;差分化癌3例,髓样癌2例,术后辅助放疗,放疗剂量60GY。结果 21例患者手术顺利,术后病理乳头状腺癌16例,髓样癌2例,差分化腺癌3例。本组病例中有11例术后行气管造瘘,3个月后,有7例去除气管套管。1例术后食道瘘伴颈部感染行换药处理后清创加食道修补术后痊愈;5例手术后发生暂时的低钙抽搐,补钙后控制;1例复发再手术病例术后发生永久性的低钙抽搐,1年后死于颈部大出血;1例术后6年,发现肺部转移,带瘤生存2年死亡;1例1年半后死于颈段食管局部复发。术后随访1~10年,5年生存率92.3%。结论对于侵犯喉气管或/和下咽颈段食管的晚期甲状腺癌患者积极的手术切除及修复重建并配合个体化辅助治疗,可以提高患者的治愈率,延长生存时间,提高生活质量。     

下咽及颈胸段食管多原发癌一期手术

目的 探讨下咽、颈胸段食管多原发癌（multiple primary carcinoma,MPC）在胸腔镜辅助下行全喉、下咽、食管切除并管状胃重建一期手术的应用及疗效。方法 胸科组行胸腔镜辅助下分离食管及纵膈淋巴结清扫后开腹行管状胃成形,头颈组行颈部淋巴结清扫、全喉下咽切除、咽胃吻合术。术后常规补充放化疗。结果 本组全部病例均一期完成手术,肺部感染3例,胸腔积液2例、气管撕裂1例;无吻合口瘘及围手术期死亡病例;3年生存率63.6%,5年生存率50.0%。结论 下咽癌应常规行胃镜检查以免MPC的漏诊;胸腔镜辅助下全喉、下咽、食管切除并管状胃重建术可一期完成以往分次手术难以完成的手术治疗,有效提高下咽颈胸段食管多重癌的治疗效果。     

侵及上呼吸消化道甲状腺癌的外科治疗

报道25例累及邻近结构如喉返神经、喉、气管及食管的甲状腺癌，占300例甲状腺癌总数的8．3％。除1例纤维肉瘤及1例透明细胞癌外．其余23例均为乳头状、滤泡型或二者的混合型癌，可根据受累情况分别切除喉返神经、自气管壁上切下肿瘤、切除喉、部分气管和食管。不超过1／4周径的气管缺损可用邻近组织修补，大的缺损可用胸大肌皮瓣丙置不锈钢丝予以重建。颈段食管也可应用胸大肌皮瓣重建。切缘不够可补以术后放射治疗．累及邻近结构的甲状腺癌经恰当处理后可获长期生存．本组1、5、10年生存率分别为96．0％、86．6%和83．3％．     

晚期下咽癌手术保留喉功能的临床观察

目的 :探讨晚期下咽癌手术治疗中如何保留喉功能 ,保留喉功能可能发生的问题及其处理。方法 :在下咽癌根治性切除的手术中 ,根据喉受累及的情况 ,施行喉部分切除或喉全切除发音重建术。同时根据临床检查结果及术前病理诊断决定行单侧或双侧颈廓清术。为防止术后并发症及发音重建失败 ,笔者对手术方法进行探讨。下咽及颈段食管缺损的修复 ,均采用硅橡胶管重建的方法。结果 :晚期下咽癌手术共 2 7例 ,长期保留喉发音功能者 2 1例 ,喉发音功能恢复率为 77.8%。术后并发症 ,咽瘘发生率为 2 2 .2 % (6 / 2 7) ,误吸发生率为 11.1% (3/ 2 7)。局部癌复发 4例 (14 .8% )。 3年生存率为 4 8.1% ,5年生存率为 30 %。主要死亡原因为颈淋巴结转移和局部复发。结论 :晚期下咽癌手术 ,可在彻底切除肿瘤的基础上 ,根据喉受累及情况 ,施行保留喉功能的手术 ,以利提高病人的生存质量。对喉部分切除术者 ,应严格掌握适应证 ,手术方法要注意预防术后并发症的发生。因颈淋巴结癌转移与预后关系较大 ,所以临床诊断 N0 者 ,也要行患侧颈淋巴结清扫术。     

晚期甲状腺癌局部侵犯的临床特点

目的探讨晚期甲状腺癌局部侵犯的临床特点.方法回顾分析1988年1月至2001年10月收治的25例晚期甲状腺癌患者的临床资料,其中16例为原发性肿瘤,9例为复发癌.结果晚期甲状腺癌累及颈部组织的顺序为颈段气管、喉返神经、颈段食管、喉、颈内静脉及胸锁乳突肌等.21例喉气管受累(84.0%),14例病理证实存在肿瘤转移.结论晚期甲状腺癌治疗对喉、气管受累及颈淋巴结转移的处理是必须要考虑的问题.     

晚期下咽癌手术残存喉组织的应用(附7例报告)

目的探讨晚期下咽癌手术切除后,利用残余喉组织重建下咽的手术方法.方法总结1990至1996年7例晚期下咽癌患者的临床资料.结果实行广泛手术切除,以残存喉组织重建下咽腔,7例患者一期愈合,无咽瘘等并发症,1年生存6例,3年生存3例,5年生存1例.结论利用残存喉组织重建下咽,方法相对简便,患者损伤小,手术在同一视野中完成,残存喉组织血供良好,有利于减少术后并发症的发生.     

晚期下咽癌手术保留喉功能的临床观察

目的：探讨晚期下咽癌手术治疗中如何保留喉功能，保留喉功能可能发生的问题及其处理，方法：在下咽癌根治性切除的手术中，根据喉受累及的情况，施行喉部分切除或喉全切除发音重建术，同时根据临床检查结果及术前病理诊断决定行单侧或双侧或双侧颈廓清术，为防止术后并发症及发音重建失败，笔者对手术方法进行探讨，下咽及颈段食管缺损的修复，均采用硅橡胶管重建的方法。结果：晚期下咽癌手术共27例，长期保健喉发音功能者21例，喉发音功能恢复率为77.8%，术后并发症，咽瘘发生率为22.2%(6/27)，误吸发生率为11.1%(3/27)，局部癌复发4例（14.8%)，3年生存率为48.1%，5年生存率为30%，主要死亡原因为颈淋巴结转移和局部复发，结论：晚期下咽癌手术，可在彻底切除肿瘤的基础上，根据喉受累及情况，施行保留喉功能的手术，以利提高病人的生存质量，对喉部分切除术者，应严格掌握适应证，手术方法要注意预防术后并发症的发生，因颈淋巴结癌转移与预后关系较大，所以临床诊断N0者，也要行患侧颈洒巴结清扫术。     

下咽、颈段食管癌手术切除后保留喉功能与发声重建

目的：探讨下咽、颈段食管癌根治术患者喉功能保留与发声重建的手术方法。方法：对16例下咽、颈段食管癌患者手术切除肿瘤后，实施保留全喉及部分喉切除喉功能重建；全喉切除后Blom-Singer 1期、2期发声重建术，同时下咽及颈段食管缺损分别采用胃－咽吻合、前臂游离皮瓣、胸大肌肌皮瓣、胸三角皮瓣、胸锁乳突肌肌皮瓣，颈前肌皮瓣、喉气管粘膜瓣等方法进行整复。保留全喉8例，保留部分喉喉重建3例，全喉切除后行Blom-Singer发声重建1期4例，2期1例。结果：16例中除1例术后14d心脏病变发死亡外，均恢复了吞咽功能，13例恢复发声功能，6例恢复了全喉功能，2例恢复了部分喉功能（不能拔管）。5例行Blom-Singer发声重建者，均发声成功。结论：依据患者病变部位、肿瘤分期、身体状况、年龄等因素，切除肿瘤后采用不同的手术方法行喉功能保留及发声重建，可提高患者术后生存质量。     

侵及上呼吸消化道甲状腺癌的外科治疗

报道２５例累及邻近结构如喉返神经、喉、气管及食管的甲状腺癌，占３００例甲状腺癌总数的８．３％。除１例纤维肉瘤及１例透明细胞癌外，其余２３例均为乳头状、滤泡型或二者的混合型癌。可根据受累情况分别切除喉返神经、自气管壁上切下肿瘤、切除喉、部分气管和食管。不超过１／４周径的气管缺损可用邻近组织修补，大的缺损可用胸大肌皮瓣内置不锈钢丝予以重建。颈段食管也可应用胸大肌皮瓣重建。切缘不够可补以术后放射治疗。累及邻近结构的甲状腺癌经恰当处理后可获长期生存，本组１、５、１０年生存率分别为９６．０％、８６．６％和８３．３％。     

侵及气道和消化道的晚期甲状腺癌的外科治疗

OBJECTIVE: To study the surgical management of the advanced thyroid carcinoma with aero-digestive invasion. METHODS: To analyze 18 cases of advanced thyroid carcinoma which had aerodigestive invasion retrospectively, the patients were treated from 1988 to 1998. RESULTS: The rate of aerodigestive invasion occur was 3.5% (18/516), The inner cavity invaded rate was 2.7% (14/516). The most invaded organ was trachea; The others were esophagus and larynx, pharynx; Two and/or more organs invaded rates were 44. 4% (8/18). The cases that survived 1, 3, 5 and 10 year were 17, 14, 9 and 6. The 5 years survival rates of the differentiated thyroid cancer (61.5%) were more higher than the undifferentiated thyroid cancer (20.0%), but there were no statistical difference between them (P > 0.05) and the same in clinical stage (P > 0.05). CONCLUSIONS: Intraluminal extension is a more serious problem in which usually extensive resection of the aerodigestive tract is required. Effective surgical treatment combined with postoperative auxiliary management for this kind of patients may achieve a good long term results.     

累及喉气管的晚期甲状腺癌一期手术整复

目的：探讨晚期甲状腺癌累及喉、气管时的一期手术整复方法。方法：对18例存在喉气管受累的晚期甲状腺癌患者进行一期肿瘤全切及喉气管整复，其中7例喉受累患者全喉切除3例，喉部分切除4例；18例颈段气管受累患者中，8例直接切除肿瘤，10例切除受累气管壁后，修复方法包括：拉扰缝合1例，端端吻合3例、带蒂胸锁乳突肌骨膜瓣2例、岛状胸大肌肌皮瓣3例和颈部皮瓣1例。结果：住院期间肿瘤复发死亡1例。除3例全喉切除患者外，14例成功保留喉功能，其中拔除气管套管8例，堵管2例，继续带管4例。结论：对于累及喉气管的晚期甲状腺癌采用一期手术切除并整复不仅切实可行，而且可以提高此类患者的治愈机会，改善生活质量。     

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。     

Treatment of a thyroid neoplasm infiltrating the respiratory-digestive tracts

From 1992 to 1999, 58 thyroid gland operations (41 female and 17 male) were performed in ENT Department of the District Hospital in Rzeszów. In 14 (21.4%) cases (9 female and 5 male) thyroid surgery was done for malignant disorders: papillary carcinoma in 11 (79%) patients, follicular carcinoma in 2 patients and medullary carcinoma in 1 patient. There were neck metastases in 9/14 (64.4%) patients. In 3 cases with papillary carcinoma (all with neck metastases) aerodigestive tract was invaded. One patient had neoplasmatic invasion of the larynx and trachea, one patient had invasion of larynx et pharynx and in one patient tumour invaded the esophageal wall. In those patients radical surgery was done: total thyroidectomy with total laryngectomy and radical neck dissection (2 patients) and subtotal thyroidectomy with conservative neck dissection (1 patient). External beam irradiation and radioactive iodine 131 treatment followed surgery. Two patients are still alive 6 years after the treatment free of disease, and 1 patient died of unrelated causes 3 months after the surgery. Symptoms, diagnostic evaluation and treatment of thyroid papillary carcinoma invading the aerodigestive tract are detailed in paper.     

Surgical strategy of locally advanced differentiated thyroid cancer

Approximately 20% of patients with differentiated thyroid cancer (DTC) have direct tumor extension with invasion of the surrounding tissues such as the larynx, trachea, esophagus, or recurrent laryngeal nerve. Recent progress of molecular-targeted therapy, such as the use of tyrosine kinase inhibitors, improves survival outcome in patients with advanced DTC. However, induction of tyrosine kinase inhibitors for locally-advanced DTC has presented novel fatal adverse events including fistula in patients with infiltration toward to the trachea, pharynx and esophagus, and fatal bleeding in patients with great vessel invasion. Surgery therefore still has an important role in DTC management, particularly in local control. The surgical strategy for laryngeal/tracheal invasion, which commonly occurs by DTC, is decided according to the extension (depths and area) of the tumor. The “shave procedure” is performed when the tumor has superficially invaded the larynx/trachea. However, intra-luminal extension requires resection and reconstruction of the larynx/trachea wall. Large veins, such as the internal jugular vein and the subclavian vein, are also frequently directly invaded by DTC. Three types of jugular vein reconstruction have been advocated to avoid fatal complications according to bilateral jugular vein ligation. The majority of carotid artery invasion by DTC can be managed with tumor resection of the sub-adventitial layer without reconstruction surgery using an artificial vessel. In this review article, we examine surgery for advanced DTC, showing the surgical strategy toward DTC that has invaded the laryngotracheal, recurrent laryngeal nerve, esophagus/hypopharynx, or great vessels.     

侵犯气管的分化型甲状腺癌气管袖状切除术

目的 寻找侵入气管及喉的分化型甲状腺癌手术治疗的方法,探讨包括气管及喉部分切除在内的根治性手术可行性和有效性。 方法 3例均为女性,2例为甲状腺乳头状癌,1例滤泡状癌,均侵入气管。一例采取右侧甲状腺腺叶切除术、气管袖状切除术及声门下喉部分切除术,术后因喉切缘肿瘤残留补充放疗总量55 Gy;另一例采取左侧甲状腺腺叶切除术、气管袖状切除术及左改良根治性颈淋巴结清扫术;第三例采取全甲状腺切除、气管袖状和喉部分切除术、双侧改良根治性颈淋巴结清扫术和上纵隔淋巴结清扫术。 结果术后均无声音嘶哑,呼吸平稳,无需气管切开,均无吻合口漏。随访近2年均未见吻合口狭窄和肿瘤复发。 结论对侵入气管及喉的分化型甲状腺癌患者进行包括气管袖状切除术在内的根治性手术治疗是可行和有效的。     

Successful treatment of locally advanced anaplastic thyroid carcinoma by chemotherapy and hyperfractionated radiotherapy

The authors report a case of anaplastic thyroid carcinoma which was treated with chemotherapy and radiotherapy and proved to achieve pathological CR (complete response) after a radical operation. A 53-year-old female presented with a mass of about 4 cm in diameter arising from the left lobe of her thyroid and surrounding her cervical esophagus. Pre-operative aspiration cytology and open biopsy revealed the tumor was a giant cell anaplastic carcinoma. There was no sign of distant metastasis. Two cycles of chemotherapy were very effective in treating the tumor but regrowth appeared to occur during hyperfractionated radiotherapy. A radical operation, including a resection of the larynx, cervical trachea and esophagus, was successfully performed and no living cancer cells, only granulation and necrosis, were observed in the operation specimen. The patient has been alive for over 2 years since without any evidence of recurrence.     

Thyroid carcinoma invading the upper aerodigestive system

Well-differentiated thyroid carcinoma infrequently invades the upper aerodigestive tract. However, when invasion occurs it is the source of significant morbidity and excess mortality. The most common structures invaded by thyroid carcinoma are the recurrent laryngeal nerves, larynx, pharynx, and esophagus, which can produce symptoms of airway insufficiency, dysphagia, and hemoptysis. Locally invasive thyroid carcinoma can often be successfully treated while preserving function of the upper airway. If the tumor involves only the wall of the larynx or trachea without intraluminal extension, "shaving" the tumor from the trachea or larynx will produce local control rates comparable to more radical and destructive procedures. Intraluminal extension is a more serious problem that usually requires resection of a portion of the aerodigestive tract. Even in this situation, partial laryngeal or tracheal resection with preservation of function might be possible and should be used. Adjuvant therapy using radioiodine or external beam radiotherapy should be considered an integral part of any treatment plan for these tumors. These modalities will significantly reduce the rate of local recurrence and control symptomatic local disease.     

有周围侵袭的高分化甲状腺癌的外科治疗

目的分析有周围侵犯的高分化甲状腺癌的外科治疗,总结其临床经验.方法回顾性分析1984-2000年在辽宁省肿瘤医院进行手术治疗,周围有侵犯的高分化甲状腺癌患者201例的临床资料.生存统计采用Kaplan-Meier法,组间比较采用Log-Rank检验,多因素分析采用Cox模型.结果喉全切和颈段部分气管切除3例,气管部分切除6例,喉、气管表面剔除67例,喉返神经切除9例,喉返神经表面剔除26例,包括带状肌、胸锁乳突肌、颈内静脉、迷走神经等周围软组织切除90例.201例中合并食管受累肌层切除19例,局部拉拢缝合,其中4例用胸锁乳突肌、2例用胸大肌瓣局部加固修补.甲状腺一侧叶及峡部切除189例,一侧腺叶及对侧次全切除5例,甲状腺全切除7例.颈清扫术129例（双颈清扫5例）,共134侧,其中经典性颈清扫75侧,改良性颈清扫59侧.5年生存率为85.6%,10年生存率为77.3%,15年生存率为69.4%.经Cox模型分析显示年龄、肿瘤侵犯部位是影响预后的独立因素.结论有周围侵袭的高分化甲状腺癌经过恰当的外科治疗,可以取得较好的疗效.     

累及颈动脉的复发恶性肿瘤诊治体会

目的 探讨累及颈动脉的复发恶性肿瘤有效的诊治方法.方法 首先明确肿瘤复发部位是否进行过手术和(或)放射治疗,再根据增强CT和(或)CT血管造影(CT angiography,CTA)评估复发灶与颈总动脉、颈总动脉分叉处以及颈内、外动脉的关系;对于双颈复发病例,需了解复发灶与颈内静脉的关系;对于颈根部复发病例,需评估复发灶与甲状颈干、椎动脉的关系.根据CT和(或)CTA的结果和患者的全身状况确定能否耐受手术,对不同的复发病例进行不同的处理.本组23例累及颈动脉的头颈肿瘤患者中喉癌复发8例,下咽癌复发10例,甲状腺癌复发2例,扁桃体癌复发1例,腮腺癌复发1例,下咽颈段食管肉瘤复发1例.23例患者经术前评估,7例患者行对症(包括止痛)、姑息放疗和化疗,16例行手术治疗.结果 7例姑息治疗患者皆在6个月内死于复发肿瘤出血、全身衰竭或肺部转移.16例手术病例中,14例肿瘤肉眼下完全切除,2例动脉壁上有残留;其中8例术前有颈部疼痛,手术后7例疼痛消失,1例疼痛减轻.2例患者于术后1周因颈部感染大出血死亡,2例手术8个月后死于肺部转移,1年后死于颈部局部复发3例,2年后死于肺部转移2例,死于颈部局部复发和心脏病各1例,其余5例健在.结论 CT和(或)CTA是累及颈动脉的复发恶性肿瘤术前评估的可靠方法,根据CT和(或)CTA部分病例选择地进行手术治疗是可行的,并可延长患者的生存时间,提高其生存质量.