分化型甲状腺癌的外科治疗：一项回顾性研究。

De Falco M, Oliva G, Ragusa M, Misso C, Parmeggiani D, Sperlongano P, Calzolari F, Puxeddu E, Misso C, Marzano L A, Barbarisi A, Parmeggiani U, Avenia N

Second University of Naples, V Unit of Surgery and Advanced Surgical Procedures, Naples.

G Chir. 2008 Apr;29(4):152-8.

INTRODUCTION

We carried out a retrospective analysis of our experience in the management of Differentiated Thyroid Carcinoma (DTC), in order to better define prognostic factors (age, gender, histological type, stage) and outline a standard procedure, where it's possible, for surgical treatment.

PATIENTS AND METHODS

Patient population consisted of 432 cases, operated from 1978 to 2003. We carried out 285 operations of total thyroidectomy of which 39 associated to some kind of lymphadenectomy, 66 totalization (21 pts had been operated in other institutes), 60 subtotal thyroidectomies and 21 lobo-isthmectomies. Survival and mortality curves for age, sex, histological type, grading and staging have been calculated. Kaplan-Meyer statistical elaboration for disease-free interval and Mann-Whitney test for the comparison of different clinical and pathological data have been employed.

RESULTS

The statistical analysis puts in evidence that on 432 cases examined, with a follow-up from 1 to 25 ys (median = 6.33 ys) and with a drop-out of 60 cases (13.8 %), total mortality for cancer has been of 24 cases (6,4%), with a median interval free by disease of 4.2 ys (range 5 months to 25 ys), and a probability to stay free by disease at 12 and 24 months respectively of 95.1% and 91.6%. The median survival is resulted of 5.8 ys (range 1 to 25 ys) with a probability of survival at 24 and 48 months respectively of 97.5% and 94.3%. The multivariate analysis evidences the most important variables, i.e. age > 45 ys, tumor of intermediate malignancy, with size 1.5 cm, operative M+, significantly condition the prognosis, noticeably getting worse it, independently by the kind of carried out operation.

CONCLUSION

Our present therapeutic choices are: 1. total thyroidectomy in the treatment of the apparently benign pathology when bilaterally with spread; the checking at the final histological exam of a cancer makes however think adequate the carried out operation; 2. lobo-isthmectomy in the treatment of unilateral benign pathology or with suspect FNAB for follicular neoplasm; the histological checking of a cancer makes think the operation adequate only in presence of favourable prognostic parameters, but in presence even of just one unfavourable variable, we consider necessary the totalization; 3. total thyroidectomy in presence of a certain or strongly suspected preoperative diagnosis of cancer.

引言

我们对分化型甲状腺癌（DTC）的治疗经验进行了回顾性分析，以便更好地确定预后因素（年龄、性别、组织学类型、分期），并尽可能概述手术治疗的标准程序。

患者与方法

患者群体包括1978年至2003年接受手术的432例病例。我们进行了285例全甲状腺切除术，其中39例与某种淋巴结清扫术相关，66例甲状腺全切术（21例患者曾在其他机构接受手术），60例次全甲状腺切除术和21例甲状腺叶-峡部切除术。计算了年龄、性别、组织学类型、分级和分期的生存曲线与死亡曲线。采用Kaplan-Meier法对无病生存期进行统计学分析，采用Mann-Whitney检验对不同临床和病理数据进行比较。

结果

统计分析表明，在检查的432例病例中，随访时间为1至25年（中位数=6.33年），失访60例（13.8%），癌症总死亡率为24例（6.4%），无病间隔中位数为4.2年（范围为5个月至25年），12个月和24个月时无病概率分别为95.1%和91.6%。中位生存期为5.8年（范围为1至25年），24个月和48个月时的生存概率分别为97.5%和94.3%。多因素分析表明，最重要的变量，即年龄>45岁、中度恶性肿瘤、大小为1.5 cm、手术时M+，对预后有显著影响，明显使预后变差，且与所实施的手术类型无关。

结论

我们目前的治疗选择是：1. 对于双侧有扩散的明显良性病变，采用全甲状腺切除术；然而，最终组织学检查发现癌症时，所实施的手术被认为是合适的；2. 对于单侧良性病变或细针穿刺活检怀疑为滤泡性肿瘤的情况，采用甲状腺叶-峡部切除术；仅在存在有利的预后参数时，癌症的组织学检查才认为手术合适，但即使存在一个不利变量，我们也认为有必要进行甲状腺全切术；3. 对于术前确诊或高度怀疑为癌症的情况，采用全甲状腺切除术。