普通外科

甲状腺疾病3091例外科治疗分析；分化型甲状腺癌的治疗；异位甲状腺癌的诊断和治疗；甲状腺癌的外科治疗；原发性甲状腺功能亢进症合并甲状腺微小癌：附32例报告；腔镜甲状腺手术：附42例报告；不同年代甲状腺恶性肿瘤构成分析(附1011例病理报告)；高分化甲状腺癌侵犯喉气管的治疗及预后；巨大甲状腺切除术中发生窒息的紧急处理；甲状腺良性病变部分切除术后功能减退的诊断与治疗；分化型甲状腺癌的治疗及影响复发的因素分析；90例甲状腺乳头状癌的针吸细胞学诊断；甲状腺癌术前辅助检查对于病理分型和术式的选择意义；外科手术治疗桥本病的临床意义；不同术前准备方法对甲状腺功能亢进症术中心血管反应的影响；CT测量在评价甲状腺残留量及残留率中的应用研究；原发性甲状旁腺功能亢进的手术治疗(综述）。     

分化型甲状腺癌颈淋巴结清扫术式的选择

甲状腺癌是头颈部最常见的恶性肿瘤,其中以分化型甲状腺癌最为多见,约占90％。分化型甲状腺癌淋巴结转移的发生率较高,文献报道高达50％～75％。分化型甲状腺癌颈淋巴结清扫术式的选择是外科医师常常遇到的问题。     

加强分化型甲状腺癌的规范化治疗

手术是治疗分化型甲状腺癌的重要手段和有效方法,已在我国各级医院广泛开展.但由于对疾病认识的不足和技术条件的限制,分化型甲状腺癌的外科治疗在不同地区、不同医疗机构和不同医生之间存在着很大的差异,其治疗结果也迥然不同.尽管目前对分化型甲状腺癌的外科治疗还存在一些不同的观点和尚需进一步研究和探讨的问题,但在很多方面已逐渐达成共识,治疗方案也逐渐趋于规范化,现就以下几个方面浅谈加强分化型甲状腺癌的规范化治疗,旨在提高分化型甲状腺癌的诊治水平.     

浅谈甲状腺外科的现状

在我国老一辈外科专家裘法祖、黄芺庭、杜如昱、朱预、张嘉庆、吴在德等教授的亲切关怀和指导下,2001年在上海召开的全国普外科学术交流会期间,成立了中华外科分会内分泌乳腺外科学组。中华外科杂志社于2003年4月在南京召开了内分泌乳腺外科学术会议,取得很好的效果。现结合会议交流的情况,对甲状腺外科的现状谈谈自己粗浅的看法。分化型甲状腺癌的诊断与治疗对分化型甲状腺癌的手术治疗、甲状腺切除范围及常规颈淋巴结清扫与否一直有争论。由于分化型甲状腺癌发展缓慢,病人手术后大部分能长期生存,因而难以组织前瞻性随机临床试验,专家们从…     

规范的甲状腺癌颈部淋巴结清扫是降低复发的关键

外科手术是甲状腺癌的首选治疗手段。除滤泡型甲状腺癌以血行转移为主外,其余类型甲状腺癌淋巴结转移均较常见,所以颈部淋巴结清扫是甲状腺癌外科治疗中非常重要的一环。由于分化型甲状腺癌病人的生存率相对较高,减少局部复发并提高病人的生活质量成为临床医师关注的重点。     

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甲状腺癌是一种十分常见的内分泌腺恶性肿瘤，其病理类型大多数为分化型甲状腺癌，包括乳头状腺癌和滤泡状腺癌。分化型甲状腺癌如果治疗得当，预后很好，10年生存率在90％以上。但是如果首次外科治疗不及时或治疗方式选择不当，相当一部分病人会发生复发或转移，甚至死亡。虽然近年来甲状腺癌的外科治疗原则已经趋于规范，但临床上仍常常可以遇到因首次外科治疗方法不当而就诊的病人或术后复发的病人，这些病人往往需要再次手术治疗。鉴于甲状腺癌的再次手术具有一定的特殊性，本文对甲状腺癌再次手术治疗的有关问题探讨如下。     

妊娠期分化型甲状腺癌的诊治进展

目的探讨妊娠期分化型甲状腺癌的诊治进展。方法复习妊娠期分化型甲状腺癌诊治的相关文献,进行回顾性分析和总结。结果妊娠期分化型甲状腺癌禁忌行核素扫描和放射性碘治疗,在妊娠中期行使手术相对安全,推迟到分娩后手术并不影响产妇的预后,但需在妊娠全程严密监测肿瘤的生长速度。结论妊娠期分化型甲状腺癌的诊治变得更复杂,其是内分泌科、外科及妇产科医生共同面临的挑战。     

分化型甲状腺癌淋巴结转移特点及颈侧方淋巴结清扫术局部应用解剖

分化型甲状腺癌是最常见的甲状腺癌,包括乳头状癌和滤泡状癌,多为低度恶性的甲状腺肿瘤,经过手术及术后辅助治疗后预后较好,可获得长期生存。有淋巴结转移者需要行颈淋巴结清扫是基本的外科治疗原则,但由于分化型甲状腺癌生物学行为的特殊性以及颈部解剖复杂,手术危险性相对较大,易发生意外损伤和并发症,目前国内外对分化型甲状腺癌颈部淋巴结清扫原则的认识仍未完全达成一致。     

分化型甲状腺癌甲状腺切除范围的争论

数十年来,对于分化型甲状腺癌的手术范围争论不休。目前对预防性和功能性颈淋巴结根治术的意义已渐趋一致,但对甲状腺的切除范围仍有较大分歧。本文单从分化型甲状腺癌的甲状腺切除范围这一方面综观全球之争论,并从我国国情出发略谈个人意见,以求我国内分泌外科医师加以关注,并建议进一步进行临床研究,希望能提出我国的各项治疗标准。争论缘由分化型甲状腺癌本身生长较缓慢,生存期长,死亡率低,治疗后的动态变化周期漫长,可达数十年,因此对此病的真实病情进展难以全面了解。另外,手术范围并非是决定预后的唯一因素,特别是病理上有多灶性特征,…     

分化型甲状腺癌脊柱转移的治疗进展

脊柱转移瘤中,甲状腺癌是常见的原发癌,其中最常见的是分化型甲状腺癌（differentiated thyroid cancer, DTC）。总体上,分化型甲状腺癌脊柱转移（Spinal Metastasis, SM）患者的生存期较长、预后较好。脊柱外科医生关注的重点是如何控制脊柱转移灶、提高患者生存质量,同时尽可能减小外科干预的风险。近年来,对于分化型甲状腺癌脊柱转移的临床治疗有了较大的进展,现将目前常用的分化型甲状腺癌脊柱转移的诊断及治疗进展综述如下。     

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??Issues about the diagnosis and the treatment of differentiated thyroid cancer WU Yi. Department of Head and Neck Surgery??Fudan University Shanghai Cancer Center, Shanghai 200032,China
Abstract There are still some issues about the diagnosis and the treatment of differentiated thyroid cancer, like the clinicians rely on the ultrasound too much or the limited application of PET-CT. The strategy against the special situation like the microcarcinoma and the thyroid cancer accompanied with Hashimoto thyroiditis is also very tricky. Surgeons should be more thoughtful when considering about the indication and the extension of the operation.     

儿童及青少年甲状腺癌病理学特点及其临床意义

儿童及青少年甲状腺癌发生率在过去的几十年中有明显的上升趋势,儿童及青少年甲状腺癌在发病机制、病理学特点、临床表现、疾病转归等方面明显有别于成人甲状腺癌,另外由于其生存期长以及特殊的生理发展需要,在诊疗方案制定、新药临床试验等方面需要单独讨论研究。儿童及青少年甲状腺癌的病理学类型以甲状腺乳头状癌为主,其次为甲状腺滤泡状癌和甲状腺髓样癌,甲状腺低分化癌及未分化癌相对罕见。得益于基因检测技术近期的飞速发展,儿童及青少年甲状腺癌的驱动基因特点也逐渐清晰,与成人甲状腺癌相比最主要的特点是融合基因的比例相对较高,乳头状癌中RET、NTRK、ALK的融合基因最常见,滤泡状癌及低分化癌中DICER1的突变基因最常见,在分子诊断试剂盒设计时应充分考虑儿童与成人的差异性。近年来,多激酶抑制剂如索拉菲尼、仑伐替尼,以及针对RET、NTRK、ALK等融合基因的单基因靶向治疗在成人的临床试验中也有了实质性的进展,鉴于医学伦理的限制,儿童及青少年的临床试验相较成人滞后,尽管如此,对于碘难治性分化型甲状腺癌以及局部晚期病人的的探索性治疗已逐步展开。肿瘤驱动基因的全面检测以及单靶点药物的精准治疗,为晚期儿童及青少年甲...     

SPECT-PET显像在分化型甲状腺癌~(131)I治疗预后中的应用价值

目的探讨SPECT及PET显像在诊断甲状腺癌放射治疗后复发和转移中的应用价值。方法对103例接受131I治疗的分化型甲状腺癌(DTC)患者的核医学显像资料、影像学资料及血浆Tg、TSH的水平测定结果进行分析,其中的85例为有效病例,作为本研究的研究对象,分为实验组和对照组,实验组行131I SPECT/CT、131I-WBS显像,对照组行124I-PET和FDG SPECT/CT显像,并同期测定患者的血浆Tg、TSH水平及常规检查,同时让患者口服重组人促甲状腺激素(rhTSH)后再次显像,分析其显像资料及血浆Tg、TSH水平,结合患者的临床表现,综合分析患者同期的各项影像学检查结果(131I SPECT/CT断层显像、18F-FDG显像、CT、B超、MRI等)及血清TSH、Tg水平测定值,对患者是否发生分化型甲状腺癌术后转移复发进行判断,并以此做出诊断。血浆Tg水平诊断肿瘤复发转移的判断阈值为>10 ng/mL。结果以Tg血浆水平>10 ng/mL做为肿瘤复发转移判断界值得出SPECT/CT较131I全身显像具有更高的灵敏度;124I-PET较131 I-WBS有着更好的空间分辨率和灵敏度,可提高DTC定位诊断的准确性;18F-FDGPET/CT显像对Tg水平明显增高的甲状腺癌复发和转移患者有重要的诊断价值;服rhTSH可进一步提高18F-FDG检查的准确性。结论 131I SPECT-PET显像,可提高病灶定位的准确性,为肿瘤预后的评价提供了更准确的判断依据,将进一步推动分化型甲状腺癌临床诊疗水平的提升。     

Anaplastic carcinoma of the thyroid gland

The aim of the present paper was to study some characteristics and possibility of surgery of anaplastic thyroid cancer. During five years period in Center for endocrine surgery, we found anaplastic thyroid cancer in 65 patient (44 female and 21 male), median age 63 years (from 37 to 88 years). Surgical treatment was peerformed in one half (32) anaplastic thyroid cancer patients, at majority of them operative biopsy or tumor reduction only. Radical surgery was performed in about 10% patients. Possibility of surgery in anaplastic thyroid cancer are very limited. In one third patients there were long standing goiter or thyroid nodule or histological verified dedifferentiation of papillary thyroid cancer. This patient should be operated formerly, before anaplastic transformation.     

Surgical therapy of thyroid cancer

There are controversial views and discussions on surgical treatment of thyroid cancer. A retrospective study covering the period from 1979 through 1988 has been conducted by the authors to analyse resective approaches to thyroid cancer. Operations were performed on papillary carcinoma in 37.6% and on follicular carcinoma in 31.8% of the cases. An overall five-year survival rate for differentiated thyroid cancer was recorded from 81.5%, with 100% in stage T1N0M0 (microcarcinoma) according to publications. Hence, much less radical procedures like hemithyroidectomy is fully supported by the authors for microcarcinoma. The total thyroidectomy only should be applied to differentiated thyroid cancer in the advanced stages, to medullary and anaplastic carcinoma.     

血清蛋白质指纹图谱在甲状腺癌诊断中的应用

目的 检测甲状腺癌、甲状腺良性结节和正常人血清中蛋白质组图谱，筛选特异的蛋白质标记物。构建用于甲状腺癌早期诊断的血清蛋白质指纹图谱模型。方法 应用表面增强激光解吸电离飞行时间质谱（SELDI-TOF-MS）技术检测108例血清标本的蛋白质质谱，其中甲状腺癌40例（Ⅰ～Ⅱ期26例，Ⅲ～Ⅳ期14例），甲状腺良性结节36例，正常人32例。随机抽取87例标本（甲状腺癌32例，甲状腺良性结节30例，正常人25例）作为训练组，应用支持向量机和判别分析的方法分析质谱数据，建立甲状腺癌诊断模型，留一法交叉验证。结果区分甲状腺癌和正常人的诊断模型交叉检验敏感性87．5％，特异性80．0％，用15例未知血清盲法测试敏感性100％。特异性86％。区分甲状腺癌和甲状腺良性结节的诊断模型交叉检验敏感性81％，特异性87％，用14例未知血清盲法测试敏感性88％，特异性83％。结论 SELDI-TOF-MS技术结合生物信息学方法检测甲状腺癌血清蛋白质指纹图谱是早期诊断甲状腺癌的一种特异性强。敏感性高的新方法。值得进一步研究。     

TSH suppression in the management of thyroid nodules and thyroid cancer

Clinical and experimental data concerning TSH suppression, by giving exogenous thyroid hormone, in patients with goiter and in patients with thyroid cancer show a beneficial effect. In the goiter patients, TSH suppressive therapy seems most effective in young patients with diffuse or newly discovered goiters, in hypothyroid patients, and in patients with chronic lymphocytic thyroiditis or compensatory thyroid hypertrophy after partial thyroidectomy. With TSH suppressive therapy about 2/3 of thyroid nodules become smaller, but only about 5% to 10% disappear. In patients with differentiated thyroid cancer (papillary, mixed papillary-follicular, and follicular), tumor recurrence, tumor progression, and long-term survival all seem to be influenced favorably by TSH suppressive therapy. Experimental investigations demonstrate that both benign thyroid adenomas and differentiated thyroid carcinomas have TSH receptors situated on the plasma membranes. These TSH receptors appear to be coupled to the activation of adenylate cyclase in a one-to-one relationship. Experimental and clinical studies strongly support the use of thyroid hormone both for the treatment of patients after thyroidectomy for thyroid cancer and as prophylaxis to prevent the development of thyroid cancer in high-risk irradiated patients. The dose of thyroxine recommended for adequate TSH suppression is the lowest dose of thyroxine that will completely block the TSH response to TRH (usually 0.2 to 0.25 mg).Supported in part by a grant from the Veterans Administration.     

甲状腺癌肿瘤干细胞的研究进展

肿瘤干细胞(CSC)学说得到了越来越多的关注,已有研究证实在甲状腺癌中存在CSC。甲状腺癌CSC可能是甲状腺癌发生、转移、复发及耐药的根源,因此,甲状腺癌CSC的研究对甲状腺癌的诊断、治疗及预防具有重要意义。笔者对甲状腺癌CSC的最新研究进展进行综述。     

Carboplatin synergistically triggers the efficacy of photodynamic therapy via caspase 3-, 8-, and 12-dependent pathways in human anaplastic thyroid cancer cells

Anaplastic thyroid cancer is one of the most aggressive forms of malignancies which grow very rapidly. Several conventional methods have been applied for the treatment of anaplastic thyroid cancer, but most of them were not successful in complete recovery of the patients. Therefore, a combination of two or more conventional modalities is being applied nowadays for the treatment of this type of cancer. In this present study, the combination of photodynamic therapy (PDT) and chemotherapy has been studied in anaplastic thyroid cancer. Human anaplastic thyroid cancer cells FRO were treated with a chemotherapy drug, carboplatin (cis-diammine-1,1-cyclobutanedicarboxyl-ateplatinum II (CBDCA)), and radachlorin-mediated PDT individually and in combination. Several parameters like cytotoxicity assay by MTT, apoptosis study by annexin V and propidium iodide, cell cycle analysis by flow cytometry, confocal microscopic study, and Western blot analysis for different apoptosis-related proteins like Bax, cytochrome c, caspases 3, 9, 8, and 12, etc. were studied to check the efficacy of the combination treatment as well as to find out the mechanism of this enhanced efficacy. Results showed that both PDT and CBDCA can induce apoptosis in FRO cells. However, a synergistic efficacy was observed when the cells were treated with CBDCA and PDT in combination. Changes in mitochondrial membrane potential and an increase in reactive oxygen species generation were observed in combination treatments. The enhanced expression of different apoptotic pathway-related proteins like Bax, cytochrome c, caspase 3, caspase 8, caspase 12, etc. also confirmed the higher efficacy of combination treatment. Therefore, with this combination treatment, not only a higher efficacy can be achieved but also the effective dose of the chemotherapy drug can be reduced, and hence, the adverse side effects of the chemotherapy drugs can also be controlled.     

Inzidentalome der Schilddrüse

Thyroid incidentalomas have been found in about 20% of cases screened by neck ultrasound, and asymptomatic thyroid cancer is detected in about 10% of autopsies. The incidence of clinically treated thyroid cancer in Germany is increasing without an increase in cancer-specific mortality. Presently the incidence is about 4500 cases per year (7.3/100,000, 3000 females). For early detection and treatment of clinical thyroid cancer ultrasonography-guided fine needle aspiration cytology of suspicious nodules therefore is crucial. Thyroid lobectomy is the treatment of choice for suspicious nodules to lower the risk of morbidity in case of reoperation due to a postoperative diagnosis of cancer. However, subtotal lobectomy may also be justified, especially with nodules in anterior position, because the risk of malignancy is only 3–5%. Frozen selection and/or early final histopathology should be available to avoid two-stage thyroid cancer operations.