基层医院分化型甲状腺癌131I规范化诊疗的临床体会

目的 分析安庆地区分化型甲状腺癌（DTC）的131I规范化治疗过程及现状，评价DTC在基层医院的治疗效果。 方法 收集2015年7月至2018年7月中国人民解放军海军安庆医院收治的219例DTC患者男性48例、女性171例，年龄22~68（44.6±5.4）岁]，观察131I治疗（所有患者行131I治疗前均停服左旋甲状腺素3~4周，无碘饮食，经过检查排除131I治疗禁忌后给予DTC个体化剂量口服131I治疗）后不同病理类型和是否出现转移的患者临床治疗效果，以及在治疗过程中存在的一些不规范现象；同时根据“皖西南地区核医学规范化治疗与诊断”学习班发放问卷调查表调查基层医院核医学科建设和规范化治疗开展现状，以及基层医师对DTC规范化治疗知识的掌握程度；结合门诊随访患者甲状腺球蛋白（Tg）的水平，以及甲状腺功能、甲状腺摄碘率、影像学检查的结果进行总结分析。 结果 219例DTC患者131I治疗后的平均有效率为98.6%（216/219）。在治疗过程中出现了57例患者不规范治疗现象，其中38例患者经二次手术再行131I治疗，7例转移患者经放疗或放疗后再行手术+131I治疗，8例患者“清甲”后颈部发现淋巴结转移，2例患者因促甲状腺激素（TSH）抑制不到位出现转移，2例患者（外院）未行Tg及 甲状腺球蛋白抗体的定期监测而发生转移。DTC规范化诊疗知识调查结果显示，安庆地区成立核医学的医院有2家，可以开展核素治疗的只有1家。在基层医院的医务人员中能掌握 DTC的规范化治疗知识者仅有30%（62/128） 。 随访患者Tg水平阴性187例、阳性32例，患者TSH水平控制均较理想。门诊患者甲状腺摄碘率检查结果均<1%，影像学检查结果多数为阴性。 结论 131I规范化治疗效果明显，虽然在治疗过程中还存在着一些不规范现象，但通过严格执行治疗制度，加强规范化诊疗意识，可以避免或减少不规范治疗现象的出现。

Clinical experience of 131I standard diagnosis and treatment of differentiated thyroid carcinoma in basic hospital

Objectives To evalute treatment effect of differentiated thyroid cancer (DTC) in primary hospitals while observing the standardized treatment process and status quo of DTC in Anqing Province, China. Methods A total of 219 DTC patients 48 males and 17 females, aged between 22 to 68 (44.6±5.4) years old] admitted to our hospital from July 2015 to July 2018 received 131I treatment. Specifically, these patients stopped taking levothyroxine 3 to 4 weeks before treatment, were given an iodine-free diet, and were administered oral 131I by DTC individualized dose after examining and excluding any contraindication of the treatment. The clinical treatment effect on patients with different pathological types was then examined, and each patient was checked for metastatic lesions to ensure that no non-standard phenomenon occurred during the treatment. The nuclear medicine discipline and status quo of standardized DTC treatment in primary hospitals and the degree of related knowledge of primary doctors were also examined by conducting a questionnaire survey. The questionnaires were distributed to the participants in the Standardized Treatment and Diagnosis of Nuclear Medicine seminar in Southwest Anhui. Tg was monitored among the follow-up outpatients, and their thyroid function, thyroid iodine uptake rate, and imaging examination results were used to determine the key points. Results The 131I treatment achieved an effective rate of 98.6% (216/219) among the DTC patients. A total of 57 cases demonstrated non-standard phenomena, among which 38 cases were cured by 131I in a secondary operation, 7 were cured via radiotherapy or 131I treatment after radiotherapy, 8 cases developed cervical lymph node metastases after a partial thyroidectomy operation, 2 cases developed DTC metastases due to limited TSH inhibition, and 2 cases (in other hospitals) developed metastases due to irregular monitoring of Tg or TgAb. The survey results showed that Anqing only has two medical hospitals, and our hospital is the only institution that can administer the 131I treatment. The number of medical staff in primary hospitals who mastered standardized DTC treatment knowledge was less than 30% (62 of 219). A total of 187 follow-up patients were Tg negative, whereas 32 were Tg positive, thereby indicating a satisfactory control level of TSH among these patients. The thyroid iodine uptake rate of the outpatients was less than 1%, and the imaging examination results of most outpatients were negative. Conclusions The observation results highlighted a positive standard treatment effect. Although some abnormal phenomena were observed during the course of the treatment, they can be avoided or reduced by strictly implementing the treatment system and strengthening the standardized treatment knowledge of the medical staff.