基于FNAB的分子检测技术在甲状腺结节诊断中的研究进展

随着各种检测技术的相继问世,甲状腺结节的检出率明显上升。尽管大多数甲状腺结节是良性的,但良恶性病变之间的判定仍然是临床医生面临的挑战。对于所有可疑甲状腺结节患者均应进行颈部超声检查。甲状腺超声可评估结节特征,某些甲状腺结节具有可疑恶性超声征象。然而,这些特征缺乏准确性,无法明确诊断结节的良恶性。目前的指南仍然推荐超声引导细针穿刺活检（FNAB）作为评估甲状腺结节良恶性的首选检查。FNAB是一种经济高效的诊断方法,由于其创伤小,敏感性和特异性较高,可用于术前评估甲状腺结节的性质,已成为临床不可或缺的检查手段之一。近年来国内关于FNAB的报道日益增多,国内外指南关于FNAB指征尚有争议,同时由于其自身存在一定的局限性,FNAB技术的全面实施需要严格把握指征及准确判读穿刺病理结果。FNAB虽然是术前评估甲状腺结节最常用的诊断技术,但仍有灰区结节需要进一步诊断研究。为了制定合理的手术方案及判断预后,指南推荐术前可测定促甲状腺激素（TSH）水平。FNAB作为一个简单且相对无创的技术,但也可产生相应的并发症,FNAB的并发症主要与甲状腺结节的位置、穿刺针的直径、穿刺医师的操作经验等因素相关,严重程度较轻,多呈自限性。对于FNAB无法诊断或意义不明确的非典型病变或滤泡性病变,学者们一直在努力寻找一种新的方法来精确地诊断甲状腺癌。分子生物学方法是目前的最佳选择。分子生物学方法通过检测特定甲状腺肿瘤易感基因的驱动突变来确认甲状腺肿瘤活检的恶性程度,如BRAF和RAS癌基因突变、RET/PTC重排和TERT突变检测,从而提高术前诊断效率。甲状腺乳头状癌最常见的转移部位是局部淋巴结,虽然FNAB对异常淋巴结有诊断价值,但小或囊性淋巴结可能由于缺乏肿瘤细胞而无法诊断。检测可疑颈部淋巴结细针穿刺活检冲洗液中甲状腺球蛋白含量可作为细胞学诊断的辅助手段。笔者认为FNAB联合分子生物学的多层次诊断体系可提高术前诊断的精准性,对指导治疗、判断预后具有重要价值。     

Systematic review of outcomes and meta-analysis of risk factors for prognosis after liver resection for hepatocellular carcinoma without cirrhosis

Long-term overall survival (OS) after liver resection for non-cirrhotic hepatocellular carcinoma (NCHCC) has been reported recently. The aim of this study was to review outcomes systematically and analyze risk factors for survival after surgical resection for HCC without cirrhosis. A literature search was performed of the PubMed and Embase databases for papers published between January 1995 and October 2012, which focused on hepatic resection for HCC without underlying cirrhosis. Cochrane systematic review methodology was used for this review. Outcomes were OS, operative mortality and disease-free survival (DFS). Pooled hazard ratios (HR) were calculated using the random effects model for parameters considered as potential prognostic factors. Totally, 26 retrospective case series were eligible for inclusion. The 1-, 3- and 5-year OS rate after surgical resection of NCHCC ranged from 62% to 100%, 46.3%–78.0%, and 30%–64%, respectively. The corresponding DFS rates ranged from 48.7% to 84%, 31.0%–66.0%, and 24.0%–58.0%, respectively. Five variables were related to poor survival: multiple tumors (HR 1.68, 95%CI 1.25–2.11); larger tumor size (HR 2.66, 95%CI 1.69–3.63); non-clear resection margin (R0 resection) (HR 3.52, 95%CI 1.63–5.42); poor tumor stage (HR 2.61, 95%CI 1.64–3.58); and invasion of the lymphatic vessels (HR 4.85, 95%CI 2.67–7.02). In sum, hepatic resection provides excellent OS rates for patients with NCHCC, and results have tended to improve recently. Risk factors for poor prognosis comprise multiple tumors, lager tumor size, non-R0 resection and invasion of the lymphatic vessels.     

Effects of platelet‐rich plasma on the healing of sternal wounds: A meta‐analysis

Sternal wound infection (SWI) is a devastating complication after cardiac surgery. Platelet‐rich plasma (PRP) may have a positive impact on sternal wound healing. A systematic review with meta‐analyses was performed to evaluate the clinical effectiveness of topical application of autologous PRP for preventing SWI and promoting sternal wound healing compared to placebo or standard treatment without PRP. Relevant studies published in English or Chinese were retrieved from the Cochrane Central Register of Controlled Trials (The Cochrane Library), PubMed, Ovid EMBASE, Web of Science, Springer Link, and the WHO International Clinical Trials Registry Platform (ICTRP) using the search terms “platelet‐rich plasma” and “sternal wound” or “thoracic incision.” References identified through the electronic search were screened, the data were extracted, and the methodological quality of the included studies was assessed. The meta‐analysis was performed for the following outcomes: incidence of SWI, incidence of deep sternal wound infection (DSWI), postoperative blood loss (PBL), and other risk factors. In the systematic review, totally 10 comparable studies were identified, involving 7879 patients. The meta‐analysis for the subgroup of retrospective cohort studies (RSCs) showed that the incidence of SWI and DSWI in patients treated with PRP was significantly lower than that in patients without PRP treatment. However, for the subgroup of randomized controlled trials (RCTs), there was no significant difference in the incidence of SWI or DSWI after intervention between the PRP and control groups. There was no significant difference in PBL in both RCTs and RSCs subgroups. Neither adverse reactions nor in‐situ recurrences were reported. According to the results, PRP could be considered as a candidate treatment to prevent SWI and DSWI. However, the quality of the evidence is too weak, and high‐quality RCTs are needed to assess its efficacy on preventing SWI and DSWI.     

The anterior versus posterior approach for the treatment of ossification of the posterior longitudinal ligament in the cervical spine: A systematic review and meta-analysis

Study Design: Systematic review and meta-analysis.Objective: To compare the effectiveness and safety between anterior and posterior approach, and determine the best surgical methods for the treatment of ossification of the posterior longitudinal ligament (OPLL) in the cervical spine.Methods: We searched the Cochrane Library, PubMed, CNKI and Wanfang Med Data databases from January 2007 to March 2018. Japanese Orthopaedic Association (JOA) scores, cervical lordosis, functional recovery rates, excellent and good outcomes of the surgical approaches, and complication and reoperation rates were analyzed. RevMan 5.3 was utilized for data analysis.Results: Eleven studies were included in the meta-analysis. By comparing the anterior and posterior approaches for the treatment of OPLL in the cervical spine, statistically significant differences were found in the preoperative initial JOA, the postoperative final JOA scores, functional recovery rates, complication rates, excellent and good outcomes of the surgical approaches and reoperation rates. However, no statistically significant difference in the occurrence of the preoperative and postoperative cervical lordosis was noted.Conclusion: The anterior approach is superior to the posterior approach in terms of the postoperative final JOA score, functional recovery rate, and clinical outcomes. Although the complication and reoperation rates of the anterior approach are higher than those of the posterior approach. We recommend the anterior approach for the treatment of OPLL when patients with occupying ratio ≥ 60%. In addition, high-quality studies with long-term follow-up and large sample size are also needed.     

Short- and Long-Term Outcome after Emergent Cardiac Surgery during Transcatheter Aortic Valve Implantation

Objective: Our study aimed to evaluate short- and long-term outcomes of patients who required emergent conversion from transcatheter aortic valve implantation (TAVI) to open surgery. Besides, the reasons and procedural settings of emergent cardiac surgery (ECS) were also reported.Methods: We retrospectively reviewed the patients who underwent TAVI in our institution between 2012 and 2019 and collected the clinical data of cases who converted from TAVI to bail-out surgery. Telephone and outpatient follow-ups were performed.Results: Of 516 TAVI patients, 20 required ECS, and the bail-out surgery occurred less frequently with the increase in TAVI volume. The most common reason for conversion was left ventricular perforation (7/20, 35.0%). Thirty-day mortality was 35.0% in ECS patients. Kaplan–Meier survival curves showed that the cumulative survival rate was 65.0% at 1 year, 50.1% at 5 years in all ECS patients, and 77.1% at 5 years in patients who survived over 30 days after conversion.Conclusion: Although the bail-out operation was performed immediately after TAVI abortion, ECS still associated with high 30-day mortality. The long-term survival benefit was seen in patients surviving from bail-out surgery. An experienced TAVI team is of crucial importance in avoiding ECS-related life-threatening complications and providing effective salvage surgery.