Hölzer S, Reiners C, Mann K, Bamberg M, Rothmund M, Dudeck J, Stewart A K, Hundahl S A
Institute of Medical Informatics, Justus-Liebig-University of Giessen, Giessen, Germany.
Cancer. 2000 Jul 1;89(1):192-201. doi: 10.1002/1097-0142(20000701)89:1<192::aid-cncr26>3.0.co;2-7.
To determine current patterns of care and disease characteristics for patients with thyroid carcinoma, a Patient Care Evaluation Study was initiated in 1996 in the U.S. and Germany. This project addresses ongoing concerns with respect to the diagnostic evaluation and treatment of patients diagnosed with thyroid carcinoma and raises questions concerning how physicians are interpreting current standards and acting on the basis of these recommendations.
Patients with primary thyroid carcinoma were entered into a prospective multicenter observational study with free choice of treatment (no control group) between January 1, 1996 and December 31, 1996 in Germany. This resulted in a total of 2537 cases under observation and analysis; 1685 patients had papillary carcinoma (66.4%), 691 had follicular carcinoma (27.2%), 70 had medullary carcinoma (2.8%), and 91 had anaplastic carcinoma (3.6%). The 2376 patients with carcinoma of either papillary or follicular histology were included in the current analysis.
The major symptoms reported for patients with papillary and follicular thyroid carcinoma was neck mass (reported in 76% and 79%, respectively) followed by dysphagia (reported in 25% and 27%, respectively), stridor (reported in 9% and 14%, respectively), and neck pain (reported in 7% and 8%, respectively). Greater than 50% of the patients with papillary thyroid carcinoma were reported to have American Joint Committee on Cancer/International Union Against Cancer Stage I disease. Between 37-39% of the follicular carcinoma patients had Stage I and Stage II disease. Only slight differences in the diagnostic approach to patients with papillary or follicular carcinoma were noted. The majority of patients underwent an ultrasound of the thyroid region (78.1%), which was suggestive of carcinoma in only 39% of the cases. A thyroid scan was performed on 76.6% of patients, and the results were suggestive of carcinoma in 44.8% of the individuals. In contrast, fine-needle aspiration biopsy of the thyroid is highly recommended in the current Clinical Practice Guidelines (CPG) but results were obtained in only 27.4% of the patients. Total thyroidectomy without lymph node dissection was the most commonly used surgical procedure in the treatment of patients with papillary and follicular thyroid carcinoma. Only approximately 2% of patients at low risk in the group with Stage I disease were treated with a lobectomy. In 80% of the patients with Stage I papillary thyroid carcinoma and approximately 90% of those patients diagnosed with Stage II, III, and IV disease treating physicians chose to utilize radioiodine as adjuvant treatment after disease-directed surgery. External beam radiation was added to the treatment regimen for many patients diagnosed with Stage III and IV disease (30% in patients with papillary thyroid carcinoma and 33% in patients with follicular thyroid carcinoma).
To the authors' knowledge no single effective diagnostic test for thyroid carcinoma currently is available and in the majority of cases a combination of ultrasound, thyroid scan, or fine-needle aspiration biopsy together with the clinical findings (e.g., thyroid mass) led to a diagnosis of carcinoma. The authors suspect that the high prevalence of concomitant pathologic findings such as goiter, even in the healthy population in Germany, reduces the accuracy of all diagnostic test methods and may account for the frequent use of imaging techniques. The majority of patients underwent a total or near-total thyroidectomy. Total thyroidectomy with radical lymph node dissection was used very frequently in those patients with papillary thyroid carcinoma (22%). German physicians tend to surgically treat early stage thyroid carcinoma somewhat more radically than recommended in the CPG. With respect to other treatment options employed as part of the first course of treatment, radioiodine appears to play the most important role. [See commentary o
为确定甲状腺癌患者当前的治疗模式和疾病特征，1996年在美国和德国启动了一项患者护理评估研究。该项目解决了对甲状腺癌诊断评估和治疗的持续关注，并提出了关于医生如何解读当前标准以及根据这些建议采取行动的问题。
1996年1月1日至1996年12月31日期间，德国对原发性甲状腺癌患者进行了一项前瞻性多中心观察性研究，患者可自由选择治疗方法（无对照组）。这导致共有2537例病例接受观察和分析；1685例患者为乳头状癌（66.4%），691例为滤泡状癌（27.2%），70例为髓样癌（2.8%），91例为未分化癌（3.6%）。本分析纳入了2376例乳头状或滤泡状组织学类型的癌患者。
乳头状和滤泡状甲状腺癌患者报告的主要症状是颈部肿块（分别为76%和79%），其次是吞咽困难（分别为25%和27%）、喘鸣（分别为9%和14%）以及颈部疼痛（分别为7%和8%）。据报告，超过50%的乳头状甲状腺癌患者患有美国癌症联合委员会/国际抗癌联盟I期疾病。37%至39%的滤泡状癌患者患有I期和II期疾病。乳头状或滤泡状癌患者的诊断方法仅存在细微差异。大多数患者接受了甲状腺区域超声检查（78.1%），其中仅39%的病例提示为癌。76.6%的患者进行了甲状腺扫描，44.8%的个体扫描结果提示为癌。相比之下，当前临床实践指南（CPG）强烈推荐甲状腺细针穿刺活检，但仅27.4%的患者进行了该项检查。甲状腺全切术且不进行淋巴结清扫是治疗乳头状和滤泡状甲状腺癌患者最常用的手术方法。I期疾病低风险组中只有约2%的患者接受了甲状腺叶切除术。在I期乳头状甲状腺癌患者中，80%以及在诊断为II期、III期和IV期疾病的患者中约90%，治疗医生选择在针对疾病的手术后使用放射性碘作为辅助治疗。许多诊断为III期和IV期疾病的患者在治疗方案中增加了外照射放疗（乳头状甲状腺癌患者中为30%，滤泡状甲状腺癌患者中为33%）。
据作者所知，目前尚无单一有效的甲状腺癌诊断测试方法，在大多数情况下，超声、甲状腺扫描或细针穿刺活检与临床发现（如甲状腺肿块）相结合可诊断为癌。作者怀疑，即使在德国健康人群中甲状腺肿等伴随病理发现的高患病率也会降低所有诊断测试方法的准确性，这可能解释了成像技术的频繁使用。大多数患者接受了甲状腺全切术或近全切术。甲状腺全切术加根治性淋巴结清扫在乳头状甲状腺癌患者中使用非常频繁（22%）。德国医生对早期甲状腺癌的手术治疗倾向于比CPG推荐的更为激进。关于作为初始治疗一部分采用的其他治疗选择，放射性碘似乎发挥着最重要的作用。[见评论]
