甲状腺癌的诊断及再次手术治疗的意义

目的分析甲状腺癌再次手术的原因及探讨甲状腺癌的诊断，选择合适的甲状腺癌再次手术方式，了解甲状腺癌再手术患者的生存情况。方法总结1992至2000年10月因原发癌灶残留或甲状腺微小癌原发灶未切除到本院行再次手术治疗的128例患者的临床资料。再手术方式包括：①第一次对原发灶只进行单纯肿瘤剜除或腺叶部分切除者，再手术时切除残叶及峡部，或加对侧叶部分或近全切除；颈淋巴转移者，行经典性或改良性颈清扫术；②对甲状腺微小性癌进行患侧腺叶及峡部切除及改良或择区性颈清扫术。对1999至2004年78例我院首诊的表现为单纯甲状腺结节性肿物、临床检查为可疑甲状腺癌患者，术前行细针抽吸细胞学检查（fine needle aspiration，FNA）、术中淋巴结冰冻切片检查（frozen section，FS）、FNA＋FS分别为10例、55例和13例，将检查结果与术后病理结果对照。结果病理检查证实冉次手术的甲状腺癌患者残癌率68．8％（88／128），并发症发生率23．4％（30／128），其中喉返神经损伤率2．3％（3／128），暂时性低钙血症发生率19．5％（25／128）。术后随访，复发5例，颈淋巴转移3例；再手术患者5年、10年生存率分别为92．0％（101／110）、86．9％（17／20）。78例甲状腺肿物术前行FNA、术中FS及FNA＋FS诊断准确率分别为90．0％、87．3％和92．3％。结论由于误诊与不规范手术致甲状腺癌术后残癌率较高，积极合理的再手术是必要的。再次手术增加了手术并发症，提高术前诊断准确率和规范的首次手术治疗是减少手术并发症的根本。

Diagnosis and reoperation for thyroid carcinoma

OBJECTIVE: To analysis the reasons of the reoperation of thyroid neoplasm and the efficiency of the surgery and to explore the diagnosis of thyroid neoplasm in order to choose the rational surgical method. METHODS: Reoperation of thyroid cancers were performed in 128 patients from Oct. 1992 to Oct. 2000. The causes of reoperation were thyroid cancer remnants and persistence of the micro carcinoma The type of reoperation includes: 1. completion of lobectomy and isthmectomy or subtotal thyroidectomy. Radical neck dissection or modified neck dissection were indicated for the neck of lymph node metastasis. 2. completion of lobectomy and isthmectomy and modified neck dissection or selective neck dissection for patient with thyroid micro carcinoma. Preoperative fine needle aspiration (FNA) (10 cases), intra-operative frozen section (FS) (55 cases), FNA and FS (13 cases) were done in 78 patients who first visited our hospital, with pure (solitary) thyroid nodule suspected thyroid carcinoma clinically. The results of the above examinations were compared with postoperative pathological results. RESULTS: For the patients with reoperation, the rate of remained cancer was 68.8% (88/128) which was comfirmed by pathological results. The occuring of complication was 23.4% (30/128). Laryngeal recurrent nerve paralysis was accounted for 2. 3% and transient postoperative hypocalcemia occurred in 19.5%. Five patients developed local recurrence and 3 had neck metastasison the following up. The 5-, 10-year survival rates of these patients were 92.0% (101/110) and 86.9% (17/20) respectively. The diagnostic accuracy of preoperative FNA, intra-operative FS, FNA and FS were 90.0%, 87.3% and 92.3% respectively. CONCLUSIONS: The rate of postoperative residual carcinoma in thyroid was relatively higher because of misdiagnosis and inadequate operation. It was necessary to take active and reasonable reoperation. Reoperation added to surgical complications. Increasing preoperative diagnostic accuracy & carrying out standard, adequate surgical treatment are the essence to decrease surgical complication.