99mTc-MIBI甲状腺显像诊断分化型甲状腺癌的影响因素

分化型甲状腺癌包括乳头状甲状腺癌及滤泡状甲状腺癌,在甲状腺癌发病率中约占88%～96%,其分化程度高,预后良好.甲状腺癌无明显的临床症状,多数表现为甲状腺结节,因此甲状腺结节性质判定是早期诊断及术前定性的关键[1,2].     

分化型甲状腺癌209例临床分析

对我院收治的209例分化型甲状腺癌(DTC)患者的临床资料进行回顾性分析,以探讨影响DTC长期预后及复发的因素.发现209例DTC患者的复发率为18.7%,其5、10 a生存率分别为93.3%、86.4%;多因素分析表明,年龄、浸润程度、远处转移、临床病理分期是影响DTC预后的独立因素.认为年龄、浸润程度、远处转移、临床病理分期是影响DTC长期预后及复发的重要因素.     

核素显像在分化型甲状腺癌术后随访中的应用

分化型甲状腺癌术后往往需要用~(131)I进一步清除术后残留的甲状腺功能组织并治疗可能存在的转移灶,以减少术后的复发率和转移率,核素显像在该病术后制定下一步诊疗方案、判断预后以及评价疗效等方面均有较大的应用价值。本文就核素显像在分化型甲状腺癌术后的应用进行综述。     

99m TcN-NOET 显像 SPECT／CT 检查在分化型甲状腺癌术后颈部淋巴结转移判断中的应用

目的探讨99mTc N-NOET显像SPECT/CT检查对分化型甲状腺癌(DTC)术后颈部淋巴结转移的判断价值。方法接受甲状腺切除术和131I治疗的DTC患者28例,所有患者诊断性131I全身显像(Dx-WBS)阴性、血清甲状腺球蛋白(Tg)阳性,且B超检查发现疑似颈部淋巴结转移。对28例进行99mTc N-NOET SPECT/CT早期、延迟显像。利用ROI技术在病变部位勾画感兴趣区ROI1,取对侧相同面积部位标记为ROI2,以ROI1/ROI2计算病变部位与正常组织摄取比值(T/N)。将SPECT/CT检查结果与颈部淋巴结病理检查结果进行对照。结果 28例(52个病灶)经病理检查证实颈部淋巴结转移21例(39个病灶),良性病变7例(13个病灶)。99mTc N-NOET显像提示转移灶17例(30个病灶)、良性病变4例(9个病灶)。99mTc N-NOET显像SPECT/CT检查判断DTC颈部淋巴结转移的灵敏性76.92%,特异性61.54%,准确性73.08%,假阳性率38.46%,假阴性率23.08%,阳性似然比2.00,阴性似然比0.38。7例病理诊断为颈部淋巴结良性病变者T/N,低于21例病理诊断为颈部淋巴结转移者(P<0.01)。结论99mTc N-NOET显像SPECT/CT检查判断DTC患者术后颈部淋巴结转移效能较好,尤其适合Dx-WBS阴性、Tg阳性、B超检查疑似颈部淋巴结转移的患者。     

血清促甲状腺激素浓度与分化型甲状腺癌的相关性

目的探讨血清促甲状腺激素(TSH)浓度与分化型甲状腺癌(DTC)之间的相关性。方法回顾性分析441例行甲状腺手术患者临床资料,其中良性肿瘤患者302例,DTC患者139例,TSH浓度0.28 mIU/L者17例,0.28~1.45 mIU/L者113例,1.46~2.28 mIU/L者125例,2.29~4.19 mIU/L者137例,≥4.2 mIU/L者49例,分析TSH与DTC间的相关性。结果良性肿瘤组患者年龄及肿瘤直径、TSH浓度与DTC组比较差异具有统计学意义(P0.05);TSH浓度0.28 mIU/L时DTC发病率最低,≥4.2 mIU/L时最高,随着TSH浓度升高DTC发病率随之升高(P0.05);TSH浓度在TNM分期Ⅲ~Ⅳ期患者中明显高于Ⅰ~Ⅱ期患者(P0.05),肿瘤直径2 cm、2~3.9 cm、≥4 cm时TSH浓度比较差异具有统计学意义(P0.05),滤泡状癌、乳头状癌TSH浓度比较差异无统计学意义(P0.05);Pearson相关性分析,TSH在参考值范围内对,其浓度升高与DTC发病率呈正相关(P0.05),DTC患者肿瘤直径、临床分期与TSH浓度呈正相关(P0.05)。结论随着血清TSH浓度升高,TDC患病风险增高,TSH浓度与患者肿瘤直径、临床分期关系密切。     

分化型甲状腺癌术后规范化管理

分化型甲状腺癌术后规范化管理是保证患者长期生存的关键.术后数周应根据术中情况、肿瘤病理、分子生物学特征、血浆甲状腺球蛋白水平、颈部超声等评估初始复发危险度以指导临床初始治疗方案及术后两年随访计划的制定与实施.根据患者对初始治疗的反应性,术后两年后应重新评估危险度以指导长期随访方案的制定.放射性碘治疗、促甲状腺激素抑制治疗、外照射治疗等是手术治疗的重要补充;随访中甲状腺球蛋白水平、甲状腺功能、超声、细针穿刺等监测手段是规范化管理的重要依据.     

131I治疗分化型甲状腺癌

甲状腺癌为最常见的内分泌肿瘤,甲状腺癌组织类型主要为分化型甲状腺癌,手术+131I+甲状腺素抑制模式治疗分化型甲状腺癌久已得到认可和广泛应用.本文简要介绍131I治疗分化型甲状腺癌的现状并略加评述.     

分化型甲状腺癌预后相关因素分析并文献复习

对分化型甲状腺癌(DTC)预后相关因素进行分析并复习文献,为提高DTC诊断治疗水平及生存率提供依据.回顾性随访分析经术后组织病理学证实为DTC的150例(女性113例,男性37例)病例资料,乳头状癌131例(87.3％),滤泡癌19例(12.7％).随访4.15 ～31年,存活140例(93.3％),复发30例(20.0％),死亡10例(6.7％).手术方式中近全或次全切手术83例(55.3％),局部切除64例(42.7％),全切3例(2.0％).63例行淋巴结切除者中45例(71.4％)检出淋巴结转移.发病年龄、就诊时肿瘤大小及早期转移率在死亡组与存活组、复发组与未复发组间有统计学差异(P＜0.05).年龄、就诊时肿瘤大小及早期转移影响DTC预后.     

分化型甲状腺癌术后首次131I清除剩余甲状腺组织的效果及影响因素

目的 观察分化型甲状腺癌术后首次131I清除剩余甲状腺组织(清甲)的效果并对其影响因素.方法 分化型甲状腺癌术后行131I首次清甲治疗患者177例,分别依据患者年龄、性别、病理类型、手术方式及术后到首次131I清甲间隔时间进行分组,131I清甲剂量均为3.7 GBq,治疗后3个月行颈部131I扫描,以颈部剩余甲状腺显像与周围本底相比未见摄碘灶为清除成功标准.结果 177例病人中成功清除者129例,首次131I清甲成功率为72.88%.患者年龄、性别及病理类型均不影响首次131I清甲效果;手术方式及术后到首次131I清甲间隔时间对首次131I清甲效果影响较大.结论 分化型甲状腺癌患者手术治疗应以甲状腺全切为首选,并在术后4个月内进行131I清甲治疗.     

二甲双胍抑制分化型甲状腺癌的作用及机制

二甲双胍是治疗糖尿病的一线药物,晚近其抗肿瘤效应受到广泛关注.研究发现,服用二甲双胍的2型糖尿病患者分化型甲状腺癌(differentiated thyroid cancer,DTC)的风险降低,其机制可能与一方面通过改善胰岛素抵抗、下调促甲状腺激素(thyroid-stimulating hormone,TSH)和激...     

99mTC-HL91显像对肺癌的诊断价值

目的　探讨新型乏氧组织显像剂 99m Tc- HL 91显像对肺癌诊断的临床价值。方法　对 4 5例疑为肺癌的肺部病变患者静脉注射 99m Tc- HL 911110 MBq后 2～ 6 h行胸部平面及断层显像。利用计算机感兴趣区 (ROI)技术 ,计算靶 /非靶比值 (T/NT) ,并对良恶性病变的 T/NT值进行比较 ,同时计算对肺癌诊断的灵敏度、特异性及准确性。结果　最终证实肺癌 30例 ,肺部良性病变 15例 ,在 2～ 6 h平面、断层图像的 T/NT值分别为 1.4 8± 0 .2 8、2 .15± 0 .6 5及 1.15± 0 .2 1、1.36± 0 .32。两组间相应的 T/NT值以及各组内断层与平面显像 T/NT值均有显著差异(P<0 .0 0 1～ P<0 .0 5 )。2～ 6 h平面、断层显像诊断肺癌的灵敏度、特异性、准确性分别为 88.5 %、80 .0 %及 85 .4 % ;92 .3%、80 .0 %及 87.8% ,其诊断效能类似于1 8F- FDGPET对肺癌的诊断效能。结论　 99m Tc- HL 91显像不但对肺癌的诊断具有一定的临床价值 ,而且能准确提示肺癌病灶的氧态信息 ,从而为制定治疗方案提供依据。     

肝移植术后原发性肝癌复发与乙型肝炎病毒再感染的关系

目的 探讨肝移植术后原发性肝癌复发与HBV再感染的关系.方法 对2004年1月-2008年12月在中山大学附属第三医院因乙型肝炎相关性终末期肝病行肝移植手术并长期随访的340例患者回顾性分析.患者被列入肝移植等待名单后给予核苷(酸)类似物抗病毒治疗,术中和术后均给予核苷(酸)类似物联合低剂量乙型肝炎免疫球蛋白进行预防.术后定期随访并监测患者HBV再感染的发生率及生存率,用多因素COX回归分析筛选出影响术后HBV再感染的危险因素.计量资料用t检验、计数资料用x2检验进行统计学处理.用Kaplan-Meier方法进行生存率分析,对HBV再感染危险因素用COX多因素回归分析,对HBV再感染与原发性肝癌复发的时间进行Spearman线性相关分析.结果 340例患者术后发生HBV再感染33例,术后1、3、5年再感染率分别为7%、10%、13%.HBV再感染的时间为1～21个月,中位数为5个月.原发病为原发性肝癌(风险比为2.98;95%可信区间为1.08～8.25,P＜0.05)、术前HBV DNA载量＞5log10拷贝/ml(风险比为3.99;95%可信区间为1.85～8.62,P＜0.01)是发生HBV再感染的危险因素.原发性肝癌复发者HBV再感染发生率高于未复发者,分别为27.9%和8.7%(风险比为4.58; 95%可信区间为1.88～11.12;P＜0.01).12例患者肝移植术后发生HBV再感染和原发性肝癌复发,两者的复发时间具有相关性(r=0.583,P＜0.05).结论肝移植术后原发性肝癌复发是HBV再感染的危险因素.

Abstract：

Objective To investigate the relationship between hepatocellular carcinoma (HCC)recurrence and hepatitis B virus (HBV) recurrence. Method The clinical data of 340 patients underwent liver transplantation due to HBV related end-stage liver disease and received long-term follow up in our hospital from Jan 2004 to Dec 2008 were retrospectively analyzed. All patients received nucleoside analogues therapy formally before entering into the waiting list and nucleoside analogues combined low-dose HBIG therapy during and after transplantation. Patients were regularly followed up at the outpatient, monitoring the HBV recurrence and survival. Multivariate Cox regression analysis was used to evaluate the risk factors for hepatitis recurrence. Result 33 patients suffered from HBV recurrence post transplantation.The 1-, 3- and 5- year recurrence rates were 7.0%, 10% and 13% respectively. The median HBV recurrence time was 5 months (1-21 months). COX regression analysis revealed that risk factors for HBV recurrence were HCC (HR = 2.98; 95% CI 1.08-8.25; P＜0.05) and pre-transplantation HBV-DNA load over 5 log10 copies/ml (HR = 3.99; 95% CI 1.85-8.62; P＜0.01). Further stratified analysis showed that patients who suffered from carcinoma recurrence had a higher incidence of HBV recurrence than those who did not, which were 27.9% and 8.7% (HR =- 4.58;95% CI 1.88-11.12; P＜0.01) respectively. 12 patients suffered from both HCC and HBV recurrence. Spearman correlation analysis demonstrated a strong correlation between HBV and HCC recurrence times (r= 0.583, P＜0.05). Conclusion Post transplantation HCC recurrence is a risk factor for HBV recurrence.     

Relationship between serum lipid profile and thyroid function after thyroid hormone withdrawal in patients with differentiated thyroid carcinoma

<正>Objective To observe the relationship between serum lipid concentration profiles and thyroid function after thyroid hormone withdrawal(THW)in patients with differentiated thyroid carcinoma(DTC).Methods Sixtyfive post-operative DTC patients who prepared to receive radioiodine ablation were included in this study.Serum     

Non-suppressed thyrotropin and elevated thyroglobulin are independent predictors of recurrence in differentiated thyroid carcinoma

OBJECTIVE: Although in most cases differentiated thyroid carcinoma (DTC) responds to surgery and radioiodine (RaI) therapy, some patients will have recurrence and eventually cancer-related death. However, although various prognostic factors of DTC have been identified (e.g. staging, suppressed thyrotropin), none of the previous studies have assessed simultaneously their role in multivariate analysis. DESIGN AND METHODS: In this retrospective population-based study, we reviewed the clinicopathological data of 254 DTC patients treated in eastern Finland during the years 1976-1995, for clinical characteristics, primary treatment, follow-up and cancer recurrence. Tumor stage was based on pathological tumor-node-metastasis (pTNM) classification, and histopathological specimens were re-evaluated. RESULTS: DTC recurrence occurred in 33 patients (13%). In univariate analyses, the predictors of recurrence were older age (>60 years, P<0.05), follicular tumor type (P<0.01), pTNM classification system (P<0.05) and post-ablative radioiodine uptake outside the neck (P<0.05). Non-suppressed serum thyrotropin (TSH) and elevated serum thyroglobulin (>3 microg/l) measured one year after operation were both related to tumor recurrence (P<0.05 and P<0.001 respectively). In multivariate analysis the independent predictors for recurrence were both elevated thyroglobulin (P<0.001) and non-suppressed TSH (P<0.05) independent of histology, pTNM stage and RaI uptake. Adjusted risk ratio for recurrence of DTC for unsuppressed thyrotropin was 2.3, for elevated thyroglobulin 14.0 and, if both conditions were present, the risk ratio increased to 45.1. CONCLUSION: Our results suggest that both non-suppressed serum TSH and elevated serum thyroglobulin are related to an increased risk of DTC recurrence independent of tumor type and pTNM stage.     

甲状腺癌复发与BRAF基因突变的关系探讨

目的 探讨甲状腺癌患者复发与BRAF基因突变的关系.方法 收集20例复发性甲状腺乳头状癌患者（复发组）的原发灶和复发灶标本及20例无复发生存的甲状腺癌患者（无复发组）的肿瘤组织标本,对BRAF基因进行测序,观察T1799A位点的V600E突变情况.结果 复发组原发与复发病灶BRAF基因T1799A位点V600E突变率为分别为55％ （11/20）、50％（10/20）.1例原发灶BRAF基因为突变型,而复发灶为野生型.无复发组BRAF基因1799A位点V600E突变率为25％（5/20）.复发组BRAF突变率高于无复发组（P均＜0.05）.结论 BRAF基因突变患者术后复发风险高,复发病灶基因表型与原发灶并不完全一致.     

Diagnostic 131I whole body scanning after thyroidectomy and ablation for differentiated thyroid cancer

OBJECTIVE: To assess the value of the diagnostic whole body (131)I scan after thyroidectomy and (131)I ablation. DESIGN: Retrospective analysis of all patients with differentiated thyroid cancer treated in one centre between 1990 and 2000. RESULTS: A total of 153 consecutive patients who underwent diagnostic scanning following ablative therapy were identified. This diagnostic scan was positive in 20 patients (13%) and faintly positive in 16 patients (11%). The majority (117 patients) had negative scans. Of the 20 patients with positive scans, four received no further treatment, nine showed no abnormal uptake following a second ablative (131)I dose and seven had uptake in the thyroid bed (six) or in neck nodes (one) after repeat ablation. OUTCOME: In the group with positive scans, the four patients who received no further treatment and the nine with a negative second ablation scan remained disease free during follow-up. No patient with a positive diagnostic scan received additional (131)I therapy which would not otherwise have been given based on the clinical findings, serum thyroglobulin (Tg) values or the presence of anti-Tg antibodies. Ten of the patients with negative scans developed recurrent disease which was always detected clinically or by a rising serum Tg value. CONCLUSIONS: Diagnostic whole body (131)I scans add little extra information and in our experience do not influence patient management. They should be reserved for patients in whom serum Tg levels are unreliable because of the presence of antibodies or when there is clinical suspicion of tumour.     

Radioiodine therapy after pretreatment with bexarotene for metastases of differentiated thyroid carcinoma

Objective To evaluate the effects of pretreatment with the retinoid X receptor (RXR) agonist bexarotene on the efficacy of radioiodine therapy for metastases of differentiated thyroid carcinoma (DTC) with limited uptake of radioiodine (I‐131). Design An open prospective intervention study. Methods Eight patients with metastases of DTC, with insufficient uptake of I‐131 who showed increased uptake of radioiodine after previous treatment with bexarotene were treated with radioiodine (7400 MBq), preceded by 6 weeks of treatment with bexarotene 300 mg/day. Outcome parameters were serum thyroglobulin (Tg) levels and dimensions of metastases at computed tomography (CT), measured before and 6 months after therapy. Tissues of primary tumours were stained with antibodies against retinoic acid receptor (RAR) and RXR subtypes. Results Bexarotene pretreatment induced radioiodine uptake in metastases in all eight patients, although uptake was only discernable at single photon emission computed tomography (SPECT) and had incomplete matching with the metastases visualized by CT scanning. Six months after radioiodine therapy, six patients had progressive disease (defined as a > 10% increase in serum Tg and/or a > 25% increase in tumour dimensions), whereas two patients had stable disease. No relationship was observed between retinoid receptor staining pattern at immunohistochemistry and the outcome of therapy. Conclusions Bexarotene therapy did not result in restoration of susceptibility to radioiodine therapy.     

Clinical manifestations and diagnosis of distant metastases of differentiated thyroid carcinoma after initial therapy

We studied 58 patients with distant metastases of differentiated thyroid carcinoma diagnosed after initial therapy. Lymph node metastases were observed in 65% of the patients on initial presentation. All lymph node metastases, ninety percent of the lung metastases and only 25% of the bone metastases were asymptomatic. Radiography revealed lytic metastases in cases of bone involvement, was normal in 39.6% of the patients, and showed micrometastases in 34.5% and macrometastases in 25.8% of the patients with lung disease. Thyroglobulin (Tg) under thyroxine use was detectable in all patients without antibodies at a cut-off > 1 ng/ml, in 90% at > 5 ng/ml and in 80% at > 10 ng/ml, and after thyroxine withdrawal in 100% at a cut-off > 5 ng/ml and in 94% at > 10 ng/ml. In the case of patients with antibodies (13.8%), Tg was undetectable in half of them. Diagnostic scanning was positive in 83 and 77.6% of the patients with bone and lung metastases, respectively. After ablative therapy, the sensitivity was 100 and 93%, respectively. Eighty-five percent of patients with a negative diagnostic scan had lung metastases visible on radiographs. The determination of serum Tg is the best method in the follow-up of patients with differentiated thyroid cancer. Elevated Tg levels suggest the presence of metastases, indicating the need for ablative therapy with posttreatment scanning, which might reveal non-apparent metastases.     

Prognosis after lymph node recurrence in papillary thyroid carcinoma depends on age.

Papillary thyroid carcinoma (PTC) is a malignancy that has good prognosis especially among patients up to 45 years of age; about half of the patients are female and of childbearing age. Lymph node recurrence (LNR) occurs in 10%-14% of patients but is considered to be associated with relatively good prognosis. The purpose of this study was to estimate the association between patient age at primary operation, and the behavior of the disease after LNR. Between 1967 and 1994, 495 patients underwent surgery for primary PTC at the Department of Surgery, Helsinki University Central Hospital. There were 391 (79.0%) women and 104 (21.0%) men with a mean age of 44.5 years (range, 10.8-85.4 years). Fifty-eight patients in whom LNR was the first clinical sign of persistent disease after complete clinical response to primary treatment were included in this series. At the time of primary operation, 37 (64.3%) of the 58 patients who developed LNR were younger than 45 years of age and 21 patients were older. The mean times to LNR in these groups were 42.0 months (range, 3.0-194.5 months) and 49.0 months (range, 3.6-209.0 months) respectively. Carcinoma-specific 5-year survival after LNR was 100% (95% confidence interval [CI] 88.8%-100.0%) in patients ages up to 45 years and 61.1% (40.5%-82.8%) in older patients; 10-year survival rates were 100%, and 41.3% (p < 0.0001), respectively. Relative survival at 10 years was 98.6% for patients ages up to 45 years and 42.6% for older patients (p = 0.0014). Using the Cox model it was shown that development of LNR after primary treatment has an independent highly significant negative effect on survival (p < 0.001) in patients over 45 years of age. Prognosis of PTC even after LNR on patients ages up to 45 years at the time of the primary operation is almost parallel to the normal reference population, but in patients over 45 years of age the prognosis is relatively poor.