肺转移性分化型甲状腺癌术后131I治疗疗效及其影响因素的分析

目的 探讨肺转移性分化型甲状腺癌（DTC）术后131I治疗疗效及其影响因素。 方法 回顾性分析1993年1月至2021年3月青岛大学附属医院收治的108例肺转移性DTC患者的临床资料，其中男性42例、女性66例，中位年龄54.3（17~77）岁，中位随访时间4.19（1.13~23.45）年。对患者行131I治疗，治疗前后进行促甲状腺激素（TSH）、甲状腺球蛋白（Tg）和甲状腺球蛋白抗体（TgAb）水平等血清学检测及胸部CT、131I全身显像、颈部超声等影像学检查，动态评估肺转移灶的进展情况。根据实体肿瘤疗效评价标准（RECIST）1.1及131I治疗前血清刺激性甲状腺球蛋白（sTg）水平变化评估131I治疗疗效，根据疗效将患者分为疾病控制组和疾病进展组。计算第2次131I治疗前较首次131I治疗前sTg与TSH水平比值的变化率（ΔsTg/TSH）。采用χ2检验、Kruskal-Wallis秩和检验对2组患者的临床病理学特征进行单因素分析；采用Logistic回归对上述单因素分析中差异有统计学意义的指标进行多因素分析；通过受试者工作特征（ROC）曲线及最佳临界值评估ΔsTg/TSH对疾病进展的预测价值。 结果 108例患者中，术后经131I治疗达到疾病控制的患者86例（79.6%），即为疾病控制组；疾病进展的患者22例（20.4%），即为疾病进展组。单因素分析结果显示，2组患者在年龄、病理学类型、DTC原发灶的长径、首次131I治疗前的血清sTg水平、ΔsTg/TSH、肺转移灶的长径、肺转移灶是否摄碘、肺转移确诊时间之间的差异均有统计学意义（H=?3.194，χ2=19.142，H=?2.888、?2.499、?4.140，χ2=15.380、4.069、10.362，均P<0.05）。多因素Logistic回归分析结果显示，2组患者在病理学类型、ΔsTg/TSH、肺转移灶的长径之间的差异均有统计学意义（B=3.059、0.048、4.140，OR=21.314、1.050、62.798，95%CI:1.112~408.369、1.009~1.092、1.528~2 581.064，均P<0.05）。ΔsTg/TSH预测疾病进展的最佳临界值为?0.785%，ROC曲线下面积为0.809（95%CI:0.701~0.917，P<0.001）。 结论 病理学类型、ΔsTg/TSH和肺转移灶的长径是影响肺转移性DTC术后 131I治疗疗效及预测进展的独立风险因子。

Therapeutic efficacy and influencing factors of postoperative 131I treatment for pulmonary metastatic differentiated thyroid cancer

Objective To investigate the therapeutic efficacy and influencing factors of postoperative 131I treatment for pulmonary metastatic differentiated thyroid cancer (DTC). Methods The clinical data of 108 patients with pulmonary metastatic DTC who were admitted to the Affiliated Hospital of Qingdao University from January 1993 to March 2021 were retrospectively analyzed. There were 42 males and 66 females, with a median age of 54.3(17–77) years old and a median follow-up of 4.19(1.13–23.45) years. Before and after 131I treatment, serum thyroid-stimulating hormone (TSH), thyroglobulin (Tg), and thyroglobulin antibody (TgAb) levels were detected; moreover, chest CT, 131I whole-body scan, neck ultrasound, and other imaging examinations were performed to evaluate the progression of lung metastases. The efficacy of 131I treatment was evaluated following the Response Evaluation Criteria for Solid Tumors (RECIST) 1.1 and the change in serum stimulated thyroglobulin (sTg) level before 131I treatment. On the basis of the efficacy of 131I treatment, the patients were divided into the disease control group and disease progression group. The ratio of sTg level to TSH level before the second 131I treatment compared with the first 131I treatment was calculated (△sTg/TSH). Chi-square test and Kruskal-Wallis rank sum test were used for univariate analysis of the clinical pathological characteristics of the two groups. Logistic regression was used for multivariate analysis of the indicators with statistically significant differences in the above univariate analysis. The predictive value of △sTg/TSH for disease progression was evaluated by receiver operating characteristic (ROC) curve and the optimal cut-off value. Results Among 108 patients, 86 patients (79.6%) were in the disease control group after surgery and 131I therapy. A total of 22 patients (20.4%) were in the disease progression group. The results of univariate analysis showed significant differences between the two groups in age, pathological type, long diameter of the primary DTC lesion, serum sTg level before the first 131I treatment, △sTg/TSH, long diameter of lung metastases, iodine uptake of lung metastases, and diagnosis time (H=?3.194, χ2=19.142, H=?2.888, ?2.499, ?4.140, χ2=15.380, 4.069, 10.362; all P<0.05). Multivariate logistic regression analysis showed significant differences in the pathological type, △sTg/TSH, and long diameter of lung metastases between the two groups (B=3.059, 0.048, 4.140; OR=21.314, 1.050, 62.798; 95%CI: 1.112–408.369, 1.009–1.092, 1.528–2 581.064; all P<0.05). The optimal cut-off value of △sTg/TSH for predicting disease progression was ?0.785%, and the area under the curve of the ROC was 0.809(95%CI: 0.701–0.917, P<0.001). Conclusion Pathological type, △sTg/TSH, and long diameter of lung metastases are independent risk factors affecting the efficacy of postoperative 131I treatment and predicting the progression of pulmonary metastatic DTC.