Endocrinology Service, Universidade Federal do Rio de Janeiro and Instituto Nacional do Cancer, Rio de Janeiro, Brazil.
Thyroid. 2011 Dec;21(12):1317-22. doi: 10.1089/thy.2011.0232.
We previously demonstrated the clinical utility of using response to therapy variables obtained during the first 2 years of follow-up to actively modify initial risk estimates which were obtained using standard clinic-pathologic staging systems. While our proposed dynamic risk stratification system accurately reclassified patients who demonstrated an excellent response to therapy as low-risk patients, it grouped patients with either biochemical or structural evidence of disease into a single incomplete response to therapy cohort. This cohort included a wide variety of patients ranging from very minor thyroglobulin (Tg) elevations in the absence of structurally identifiable disease to widespread, progressive structural disease. Here we determined whether subdivision of the incomplete response to therapy category more precisely predicted clinical outcomes. We hypothesized that patients with an incomplete response to therapy based on persistently abnormal Tg values alone would have better clinical outcomes than patients having structurally identifiable disease.
Following total thyroidectomy and radioactive iodine (RAI) ablation, 192 adult thyroid cancer patients were retrospectively identified as having either a biochemical incomplete response (abnormal Tg without structural evidence of disease) or structural incomplete response (structurally identifiable disease with or without abnormal Tg) as the best response to initial therapy within the first 24 months after RAI ablation. Clinical outcomes evaluated included structural disease progression, biochemical disease progression, and overall survival.
Sixty-three patients (33%) had a biochemical incomplete response while 129 (67%) had a structural incomplete response. Eleven to 156 months after evaluation of their responses (mean=70 months), patients with structural incomplete response were significantly more likely to have structural evidence of disease at final follow-up (37% vs. 17%, p=0.0004), structural progression (52% vs. 5%, p<0.001), biochemical progression (45% vs. 11%, p<0.001), and death from disease (38% vs. 0%, p<0.0001) than patients demonstrating a biochemical incomplete response. Overall survival was significantly better in patients with either a biochemical incomplete response or a loco-regional structural incomplete response than patients demonstrating a structural incomplete response with distant metastasis (Kaplan-Meier analysis, p<0.0001).
A structural incomplete response to initial therapy is associated with significantly worse clinical outcome than a biochemical incomplete response to therapy.
我们之前已经证明，使用治疗后前 2 年获得的反应变量来积极修改使用标准临床病理分期系统获得的初始风险估计是有用的。虽然我们提出的动态风险分层系统可以准确地将对治疗反应良好的患者重新分类为低风险患者，但它将有生化或结构疾病证据的患者分组到一个单一的不完全反应治疗队列中。该队列包括各种各样的患者，从无结构可识别疾病的甲状腺球蛋白（Tg）轻度升高到广泛的进行性结构疾病。在这里，我们确定了不完全反应治疗类别的细分是否更能准确预测临床结果。我们假设，仅基于持续异常 Tg 值的治疗后不完全反应患者的临床结局会比有结构可识别疾病的患者更好。
在全甲状腺切除术和放射性碘（RAI）消融后，192 名成年甲状腺癌患者被回顾性地确定为在 RAI 消融后 24 个月内的初始治疗中具有生化不完全反应（异常 Tg 而无结构疾病证据）或结构不完全反应（有或无异常 Tg 的结构可识别疾病）。评估的临床结局包括结构疾病进展、生化疾病进展和总生存。
63 名患者（33%）有生化不完全反应，而 129 名患者（67%）有结构不完全反应。在评估他们的反应后 11 至 156 个月（平均 70 个月），结构不完全反应患者在最终随访时更有可能有结构疾病证据（37%比 17%，p=0.0004）、结构进展（52%比 5%，p<0.001）、生化进展（45%比 11%，p<0.001）和疾病死亡（38%比 0%，p<0.0001）比有生化不完全反应的患者。与有结构不完全反应伴远处转移的患者相比，有生化不完全反应或局部结构不完全反应的患者的总生存明显更好（Kaplan-Meier 分析，p<0.0001）。
与治疗后的生化不完全反应相比，初始治疗的结构不完全反应与明显更差的临床结局相关。
