双侧甲状腺癌的外科治疗

目的总结双侧甲状腺癌的外科治疗方法及疗效。方法回顾性分析32例双侧甲状腺癌的临床资料。4例为双侧甲状腺微小癌,其中3例行双甲状腺次全切除术,1例行甲状腺全切除术;7例合并一侧微小癌,其中1例行甲状腺全切除外,6例行一侧近全切除 对侧全切除术;余21例中行一侧全切 对侧近全甲状腺切除术3例,全甲状腺切除术18例。行一侧颈清扫术14例,同期双侧颈总清扫术11例,其中1例因与颈总动脉粘连而有癌灶残留,术后予核素碘治疗。结果32例中除1例失访外,其余随访6月~9年,3例局部复发,其中2例死亡,另1例再次手术痊愈;1例出现远处转移死亡,1例死于其他疾病。结论双侧甲状腺癌甲状腺切除的范围应视癌灶大小和数量以及侵犯程度而定;如伴颈部淋巴结肿大,应同期行颈清扫术。     

甲状腺微小癌的诊断和治疗

目的 探讨甲状腺微小癌的诊断和治疗。方法 总结1993年12月～2002年1月53例术中及术后发现甲状腺癌的临床资料，其中甲状腺微小癌42例。结果 53例中2例合并对侧癌变，3例伴有颈淋巴结转移。术中冰冻切片诊断甲状腺癌35例，术后病理证实甲状腺癌18例。35例行一侧腺叶全切除加峡部切除术，7例加颈淋巴结清扫术，其余行一侧腺叶全切除和一侧或两侧腺叶次全切除。随访35例，时间2月～96月，平均46月，2例复发，无死亡。结论 甲状腺微小癌术前诊断率较低。微小癌应予手术切除。     

双侧甲状腺癌外科诊治体会

目的 探讨双侧甲状腺癌的诊断与外科治疗经验.方法 回顾分析72例双侧甲状腺癌外科治疗临床资料.结果 术后石蜡切片均证实为双侧甲状腺癌,其中双侧微小癌17例,一侧微小癌、一侧非微小癌41例,双侧均非微小癌14例.双侧乳头状癌67例(93.1%),双侧滤泡性癌2例(2.8%),双侧髓样癌2例(2.8%),双侧低分化癌1例(1.4%).62例行双侧甲状腺全切除术,2例行双侧甲状腺近全切除术,8例行一侧全切加对侧次全切除术,常规行双侧中央组淋巴结清扫.加行一侧改良颈淋巴结清扫术19例.中央组淋巴结转移率33.33%(24/72).即使双侧甲状腺微小癌灶中央区淋巴结转移率亦有17.65%(3/17).肿块大小与中央区淋巴转移率有一定相关性,但无统计学意义(P＞0.05).70例随访3个月至8年,中位随访时间5年6个月,67例无瘤生存,另外3例出现颁部淋巴结转移.术后无.例出现永久性甲状旁腺机能减退和喉返神经麻痹.结论 双侧甲状腺癌主张行双侧甲状腺腺叶全切除;应重视中央组淋巴结清扫.     

甲状腺癌诊断及复发因素分析

目的探讨甲状腺癌的诊断及与术后复发有关的因素。方法回顾性分析1999年3月至2006年2月期间上海市第一人民医院宝山分院收治的256例经手术及病理检查证实的甲状腺癌患者的临床资料。结果甲状腺乳头状癌235例(91.8%),滤泡状癌11例(4.3%),髓样癌7例(2.7%),未分化癌3例(1.2%)。所有病例均行手术治疗,手术方式包括:患侧腺叶+峡部+对侧甲状腺腺叶大部切除+病变侧中央区颈淋巴结清扫术;明确颈淋巴结转移或肿块明显外侵者,则行功能性颈淋巴结清扫术;对多灶癌或双腺叶癌者则施行双侧甲状腺全或近全切除,单或双侧Ⅵ区颈淋巴结清扫或一侧功能性颈淋巴结清扫+对侧Ⅵ区颈淋巴结清扫术。228例患者有完整的术后随访资料,随访3～9年,平均随访(6.5±1.3)年。随访期间14例发生复发或转移,其中6例死亡,死亡原因均为术后复发或远处转移。结论影像学检查是诊断甲状腺癌最主要的检查方法,肿块细针穿刺细胞学检查对肿块性质的判断准确率高,可靠性强。淋巴结转移率与原发病灶直径有关,肿瘤病理类型、分期、肿瘤外侵程度、淋巴结转移度、年龄及初次手术方式的选择与术后复发有关。     

甲状腺微小癌29例报告

探讨甲状腺微小癌的临床特点诊断及手术的切除范围。对14年间收治的29例甲状腺微小癌的临床资料进行回顾性分析。术前6例经纫针穿刺细胞学检查结合B超确诊。颈淋巴结转移为首发症状者10例。14例行一例腺叶全切加峡部切除术，9例加颈淋巴清扫术，5例行一侧腺叶全切加对侧次全切除术；1例行甲状腺全切并同侧颈淋巴结清扫术。29例中乳头状腺癌28例，滤泡状腺癌1例。术后随访1—12年，仅1例术后3年复发，无1例死亡。提示甲状腺微小癌恶性程度低，颈部淋巴结转移多见，手术切除预后好。     

手术治疗分化型甲状腺癌48例

目的探讨分化型甲状腺癌的治疗方法。方法 48例均行手术治疗,据病理组织类型、肿瘤大小、病变范围、年龄和颈部淋巴结转移选择不同术式。单侧分化型甲状腺癌行患侧甲状腺及峡部切除或加对侧甲状腺部分切除;双侧者行全甲状腺切除,保留背侧部分组织;高危患者(年龄>45岁,肿瘤>4 cm)行颈淋巴结清扫术,术后辅以内分泌治疗。结果患侧腺叶+峡部切除术12例,患侧腺叶+峡部切除术+对侧腺体部分切除术34例,双侧甲状腺全切除术2例,功能性颈淋巴结清扫术16例,中央区颈淋巴结清扫术18例。术后发生神经损伤及甲减3例,无手术死亡病例。随访5 a以上者44例,无死亡病例,颈部淋巴结转移4例,无远处转移病例。结论分化型甲状腺癌应根据病理组织类型、肿瘤大小、病变范围、年龄和颈部淋巴结转移选择不同手术方式。     

分化型甲状腺癌的外科治疗

目的总结分化型甲状腺癌的诊治经验。方法回顾性分析110例分化型甲状腺癌的临床资料。结果全组均行手术治疗辅以内分泌治疗,110例分化型甲状腺癌中,乳头状癌88例(80.0%),滤泡状腺癌22例(20.0%);淋巴结转移者22例(20.0%)。手术方式包括单侧病变行患侧腺叶 峡部及对侧大部切除60例(其中功能性颈清扫12例),患侧腺叶 峡部切除29例(其中功能性颈清扫7例);双侧病变行一侧腺叶 峡部及对侧大部分切除18例(其中功能性颈清扫5例),甲状腺全切除术 双侧颈清扫2例;1例肺转移患者行甲状腺全切及颈部淋巴结清扫术后行131I内放射治疗。98例术后随访,10年生存率91.8%。结论分化型甲状腺癌预后较好,治疗关键是正确选择适当的手术方式。     

桥本病合并甲状腺癌的诊治体会

目的 探讨桥本病合并甲状腺癌的诊断和治疗方法.方法 回顾分析74例桥本病合并甲状腺癌的临床资料.结果 2002年1月-2009年8月共收治252例桥本病,其中74例为桥本病合并甲状腺癌,均为乳头状癌,其中56例TGAb升高,68例MeAb升高,74例TPOAb升高.手术行患侧甲状腺全切除、峡部切除加对侧次全切除术45例,双侧甲状腺近全切除术1例(峡部癌).26例微小癌行甲状腺次全切除术或一侧腺叶全切除,2例双侧癌行双侧甲状腺全切除.所有病例同时行中央区淋巴结清扫,中央区淋巴结转移率20/74(27%).10例因患侧颈淋巴结转移行一侧颈部淋巴结改良清扫术.69例获得随访,随访时间1个月-7年,中位随访时间29个月.4例患者因发生一侧颈淋巴结转移而再次入院行改良颈淋巴清扫术. 结论'TGAb、McAb、B超、FNAB对术前诊断桥本病合并甲状腺癌有重要价值,手术应按甲状腺癌根治原则进行.     

54例隐匿性甲状腺癌诊治的回顾性分析

目的探讨隐匿性甲状腺癌的诊断方法及手术方式.方法：回顾性分析54例隐匿性甲状腺癌患者的临床病理资料,采用SPSS 13.0统计软件进行t 检验、卡方检验及Kaplan-Meier生存曲线分析.结果：超声检查者54例,其中检出微小结节43例,CT检查者27例,其中14例发现甲状腺占位,9例有淋巴结转移;成功随访46例,其中甲状腺腺叶、峡部切除术者（腺叶、峡部切除组）32例,行甲状腺腺叶、峡部切除、改良颈淋巴结清除术（腺叶、峡部切除、淋巴结术组）者14例,死亡4例;腺叶、峡部切除组平均生存时间（84.0±29.5）个月,腺叶、峡部切除、淋巴结术组（75.6±36.8）个月（P=0.486）.结论：辅助检查是隐匿性甲状腺癌的必要诊断方法,手术为治疗隐匿性甲状腺癌的主要手段.     

甲状腺微小癌（附71例报告）

目的 探讨甲状腺微小癌诊断和外科治疗的经验。方法 总结１９８５年１月至１９９８年８月间经手术和病理证实的甲状腺微小癌７１例,结果 仅有５例术前诊断微小工由病理证实３例出现颈淋巴结转移,１例骨转移,２６例行一侧腺叶全切除加对侧次全切除术,３例加颈淋巴结清扫术,其余行一侧腺叶全切除和一侧或两侧腺叶次全切除,随访病例中,术后复发１例（１．６％）,无一例死亡,结论 甲状腺微小癌发生率较高,提高术术,术中的     

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??Total thyroidectomy plus bilateral central lymph node dissection for bilateral thyroid papillary cancer: an analysis of 33 cases SHAO Tang-lei, YIN Jia-han, WU Zhi-hao, et al. Department of Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200025,China
Corresponding author: YANG Wei-ping, E-mail:yangweipingmd@126.com
Abstract Objective To discuss the rationality of total thyroidectomy plus bilateral central lymph node dissection for bilateral thyroid papillary cancer. Methods The clinical data of 33 cases of bilateral thyroid papillary cancer performed total thyroidectomy plus bilateral central lymph node dissection from January 2007 to June 2010 at Ruijin Hospital and Yuanyang Hospital of Shanghai Jiaotong University School of Medicine were analyzed retrospectively. Results Among 33 cases, 3 cases had unilateral central lymph node metastasis and 23 cases had bilateral central lymph node metastasis. The rate of bilateral central lymph node metastasis was 69.70% (23/33) and the rate of the total central lymph node metastasis was 78.79% (26/33). Six cases (18.18%) developed transient hoarseness. The diameter of the recurrent laryngeal nerves was less than 1 mm. The voice of the cases recovered 3 months after operation. Nine cases ??27.27????developed transient hypocalcemia in whom one case (3.03%) developed permanent hypocalcemia. The ages of the 10 cases were all more than 50 years old, and the parathyroid gland was found in central lymph tissue in 6 cases. Conclusion Although there are some complications after total thyroidectomy plus bilateral lymph node dissection, most of them are transient. Because of the higher lymph node metastasis rate, it is necessary to perform total thyroidectomy plus bilateral lymph node dissection in bilateral thyroid papillary cancer.     

30例甲状腺微小癌的外科治疗体会

【摘要】 目的 总结甲状腺微小癌的外科治疗经验。方法 回顾性分析2010年5月至2014年5月收治30例甲状腺微小癌患者的临床资料。结果〓30例病例均行手术切除,其中24例(80.00%)术中冰冻切片证实,6例(20.00%)术后病理确诊。24例中,单侧甲状腺腺叶加峡部切除术加中央区颈淋巴结(VI)清扫术14例;双侧甲状腺全切7例;单侧腺叶、峡部切除术加同侧颈淋巴结清扫术3例。术后病理确诊的6例均采用一侧腺体大部切除。全组30例无手术死亡和术后并发症,随访未见肿瘤复发。结论〓单侧甲状腺腺叶及峡部切除是甲状腺微小癌手术治疗较理想的术式;有淋巴结转移者同时行功能性颈部淋巴结清扫术。     

Mediastinal lymph node involvement as the initial manifestation of occult thyroid cancer in the surgical treatment of lung cancer: Report of a case

A 63-year-old man was referred to our institute for the treatment of squamous cell carcinoma of the upper lobe of his right lung. A right upper lobectomy of the lung was performed with a mediastinal lymph node dissection. The postoperative pathological examination of the dissected specimens revealed one of the superior mediastinal lymph nodes to be morbid with micrometastasis of occult thyroid cancer, while no node involvement was seen due to lung cancer. A right lobectomy of the thyroid gland with a modified radical neck dissection was done 4 years later after the confirmation of the absence of any recurrent sign of lung cancer. In the resected specimen, papillary thyroid microcarcinoma was observed with several intraglandular metastases and right regional lymph node involvement. Eight months later, a new primary lung cancer developed in the left lung, and a left upper lobectomy of the lung with a mediastinal lymph node dissection was performed. At that time, the absence of mediastinal lymph node metastasis from lung cancer or thyroid cancer was confirmed. Mediastinal lymph node involvement as the initial manifestation of occult thyroid cancer in surgical treatment for lung cancer is rare, but it is important to be aware of the possibility of incidentally detecting occult thyroid cancer in surgical dissections in this area for lung cancer. The appropriate surgical treatment should be determined while carefully considering the prognosis of the lung cancer as well as that of any coexisting malignancy.     

全甲状腺切除加功能性颈淋巴结清扫治疗甲状腺乳头状癌172例

目的 探讨甲状腺乳头状癌颈淋巴结转移模式以及全甲状腺切除+功能性颈淋巴结清扫术在甲状腺乳头状癌治疗中的作用.方法 回顾性分析一期全甲状腺切除+功能性颈淋巴结清扫术治疗的172例甲状腺乳头状癌患者的临床和病理资料.结果 172例患者的219侧功能性颈淋巴结清扫结果提示颈淋巴结转移率依次为Ⅵ区(96.3%)、Ⅳ区(78.5%)、Ⅲ区(62.1%).肿瘤浸润甲状腺被膜者颈淋巴结转移率明显增高(P＜0.05).124例术后1 d血清甲状旁腺素(15.87±8.03)pg/ml较术前(37.68±15.0)pg/ml显著降低(P＜0.01).患者5年、10年和15年的生存率分别为(98.83±0.82)%、(98.23±1.02)%和(96.42±1.43)%.结论 术中快速冰冻切片是确定Ⅵ区淋巴结病理状态的可靠方法.准确掌握全甲状腺切除+功能性颈淋巴结清扫术的适应证,术后患者可获得长期生存.     

Occult papillary carcinoma of the thyroid presenting as a cervical cyst

BACKGROUND. A cystic neck mass representing metastatic papillary thyroid cancer to a cervical lymph node may be the presenting symptom in patients with an occult papillary cancer of the thyroid. This cystic change can cause diagnostic problems and not infrequently delay identification of the primary thyroid tumor. This study investigates the frequency, treatment, and pathologic features of this entity. METHODS. All clinical charts and microscopic slides of 136 consecutive patients who underwent thyroid operation for papillary carcinoma (PC) from 1990 to 1995 were reviewed. Hematoxylin-and-eosin and immunohistochemical stains (IMHS) for thyroglobulin also were reviewed. RESULTS. Eight patients (5.8%) presented with a cystic neck mass and no palpable thyroid lesion. In all 8 patients, the diagnosis was made by an excision of the cystic neck mass. In 3 patients, the cyst demonstrated classical features of PC, such as papillae and psammoma bodies. In the remaining 5 (62%), only focal papillae or nuclear features of papillary carcinoma were present. A careful review of the histology and IMHS were necessary to arrive at the correct diagnosis in these 5 patients. CONCLUSIONS. Occult papillary cancer of the thyroid presenting as a cystic neck mass is not uncommon and must be considered in the differential diagnosis. Excision and careful review of the histology and IMHS is necessary to prevent delay of the proper diagnosis. Although the thyroid tumor was less than 1 cm and sometimes only microscopic, the extensive nodal metastasis has led us to favor near total or total thyroidectomy and modified neck dissection in this entity.     

Myasthenia gravis with thymoma associated with occult thyroid carcinoma

We report herein a case of myasthenia gravis associated with thymoma and occult thyroid carcinoma with metastasis to a cervical lymph node, which was treated in two stages by a total thymectomy and radical dissection of the bilateral neck after a total thyroidectomy. A 48 year old woman was admitted with right blepharoptosis and hypodynamia of the proximal muscles. After various examinations, a diagnosis of myasthenia gravis was made. The association of thymoma was clarified upon CT scanning and a total thymectomy performed. However, after surgery, swelling of the cervical lymph nodes became apparent and a biopsy revealed metastasis of thyroid carcinoma in the lymph nodes. A diagnosis of occult thyroid carcinoma with metastasis to a cervical lymph node was subsequently made and a total thyroidectomy and radical dissection of the bilateral neck performed 37 days after the total thymectomy. The patient's postoperative course was uneventful and for the time being, no recurrence is expected. It is considered better to perform two-stage operations for easier and safer postoperative management when myasthenia gravis associated with occult thyroid carcinoma is treated, although it depends on the development of thyroid carcinoma being occult.     

Simultaneous medullary and papillary thyroid carcinoma with lymph node metastasis in the same patient: case report and review of the literature

We report a rare case of simultaneous medullary thyroid carcinoma on the left thyroid lobe with lymph node metastasis and papillary thyroid cancer on the right thyroid lobe. The 55-year-old woman was diagnosed with medullary thyroid carcinoma after left hemithyroidectomy for goitre. Completion thyroidectomy, central neck dissection and left modified neck dissection revealed the presence of papillary carcinoma on the right side. The extreme rarity and interesting pathological features are discussed and we raise the question of whether the finding of another thyroid cancer on the opposite side was coincidental or from possible activation of a common tumorigenic pathway for both follicular and parafollicular thyroid cells.     

高分化甲状腺癌再手术原因和颈淋巴结转移的危险因素分析

目的 探讨高分化型甲状腺癌再手术的原因和再手术时肿大淋巴结转移的危险因素.方法 回顾性分析昆明医学院第一附属医院普通外科1998-2005年收治的54例行颈淋巴结清扫高分化型甲状腺癌再手术患者的病历资料.结果 39例不规范手术后的甲状腺残癌率和淋巴结转移率均显著高于15例根治后的患者(P<0.05).再手术时患者年龄<45岁、首次手术前同侧颈部淋巴结肿大、同侧癌灶残留或复发、原发癌的多中心性和再手术时B超提示淋巴结皮髓质分界不清等是再手术时同侧肿大淋巴结转移的危险因素(P<0.05);原发癌的多中心性和对侧癌灶的出现,是再手术时对侧肿大淋巴结转移的危险因素(P<0.05).结论 首次手术的个体化的规范根治和必要的颈部淋巴结清扫是避免高分化型甲状腺癌复发再手术的关键.再手术时应行全甲状腺切除,对有淋巴结转移危险因素的患者,应行改良性或选择性区域颈淋巴结清扫.     

颈淋巴结清扫在分化型甲状腺癌再手术中的价值

目的：探讨颈淋巴结清扫术在分化型甲状腺癌再手术中的价值。指导甲状腺癌再手术的术式选择。方法。回顾性分析122分化型甲状腺癌再次手术病人中88例作颈淋巴结清扫术的临床资料。88例中，甲状腺肿瘤局部切除术38例，甲状腺腺叶加峡部切除术16例，全甲状腺切除2例，颈淋巴结活检32例，结果：甲状腺微小癌11例，颈淋巴结转移率65．91％（58／88），甲状腺残癌率31．59％（12／38）。结论：颈淋巴结清扫术在甲状腺癌再次手术中具有明确的治疗作用，对侵及包膜，颈淋巴结肿大以及甲状腺微小癌应作颈淋巴结清扫术。对复发癌应再次手术。再手术需彻底切除癌灶，保护甲状旁腺及喉返神经。     

Management of carcinoma of the thyroid.

Greater precision has developed in recent decades in the selection of patients for operation for thyroid nodules suspicious for malignancy and in adapting operative procedures to the extent and pathologic variety of the individual thyroid carcinoma, when present. A thyroid lobectomy is considered to be the minimal operative procedure usually indicated for a suspicious thyroid nodule or carcinoma involving one lobe of the thyroid gland. Factors determining the extent of operation for thyroid carcinoma include the pathologic variety, gross distribution of the malignancy, and health status of the individual patient. Total or near total thyroidectomy should be considered for all patients with thyroid carcinoma except for single occult carcinomas and unilateral low grade angio-invasive carcinomas. Removal of lymph nodes in regions adjacent to the thyroid carcinoma is advisable, lateral neck dissections being reserved for patients with palpable lymphadenopathy, demonstrated metastases to lateral cervical lymph nodes, or a poorly differentiated carcinoma likely to metastasize to these lymph nodes. A modified radical lymph node dissection is satisfactory except for those carcinomas invading muscles in the neck. Anatomic neck dissections provide a better prognosis than incomplete lymph node procedures for patients with regional lymph node metastases. Following operation, patients should receive thyroid hormone therapy, be evaluated for possible treatment with radioactive iodine or other therapeutic measures, and be followed for evidence of recurrent disease as well as thyroid and parathyroid function. Adequate early operation is preferred to late ultraradical procedures, from standpoints of morbidity and prognosis. Unfavorable prognostic factors include extensive gross disease, poorly differentiated carcinoma present as the entire lesion or as foci in a differentiated carcinoma, and age over 40. With adequate surgical treatment, the prognosis for operable thyroid carcinoma is good.