DeGroot L J, Kaplan E L, McCormick M, Straus F H
Department of Medicine, University of Chicago, Illinois 60637.
J Clin Endocrinol Metab. 1990 Aug;71(2):414-24. doi: 10.1210/jcem-71-2-414.
We have analyzed the course of papillary thyroid carcinoma in 269 patients managed at the University of Chicago, with an average follow-up period of 12 yr from the time of diagnosis. Patients were categorized by clinical class; I, with intrathyroidal disease; II, with cervical nodal metastases; III, with extrathyroidal invasion; and IV, with distant metastases. Half of the patients had a history of thyroid enlargement known, on the average, for over 3 yr. In 15% of patients given thyroid hormone, the mass decreased in size. The peak incidence of cancer was when subjects were between 20-40 yr of age. Tumors averaged 2.4 cm in size; 21.6% had tumor capsule invasion, and 46% of patients had multifocal tumors. Sixty-six percent of the patients had near-total or total thyroidectomy. The overall incidence of postoperative hypoparathyroidism was 8.4%, but the incidence was zero in 83 near-total or total thyroidectomies carried out by 1 surgeon. Twenty-five percent of the patients had continuing or recurrent disease, and 8.2% died from cancer. Deaths occurred largely in patients with class III or IV disease. Cervical lymph nodes were associated with increased recurrences, but not increased deaths. Extrathyroidal invasion carried an increased risk of 5.8-fold for death, and distant metastases increased this risk 47-fold. Age over 45 yr at diagnosis increased the risk of death 32-fold. Tumor size over 3 cm increased the risk of death 5.8-fold. Surgical treatment combining lobectomy plus at least contralateral subtotal thyroidectomy was associated, by Cox proportional hazard analysis, with decreased risk of death in patients with tumors larger than 1 cm and decreased risk of recurrence among all patients, including patients in classes I and II, compared to patients who underwent unilateral thyroid surgery or bilateral subtotal resections. By chi 2 analysis, 131I ablation of residual thyroid tissue after operation was associated with decreased risk of recurrence in tumors larger than 1 cm and decreased risk of death in patients in classes I and II with tumors more than 1 cm in size. The data strongly support the use of more extensive initial surgery in class I and II patients with tumors more than 1 cm in size as well as postoperative radioactive 131I ablation of thyroid remnant tissue.
我们分析了在芝加哥大学接受治疗的269例甲状腺乳头状癌患者的病程，自诊断之时起平均随访期为12年。患者按临床分级分类：I级，甲状腺内疾病；II级，颈部淋巴结转移；III级，甲状腺外侵犯；IV级，远处转移。一半患者有甲状腺肿大病史，平均已知超过3年。在接受甲状腺激素治疗的患者中，15%的患者肿块大小减小。癌症的发病高峰年龄在20至40岁之间。肿瘤平均大小为2.4厘米；21.6%有肿瘤包膜侵犯，46%的患者有多灶性肿瘤。66%的患者接受了近全甲状腺切除术或全甲状腺切除术。术后甲状旁腺功能减退的总体发生率为8.4%，但由1名外科医生进行的83例近全甲状腺切除术或全甲状腺切除术中，发生率为零。25%的患者有持续性或复发性疾病，8.2%死于癌症。死亡主要发生在III级或IV级疾病患者中。颈部淋巴结与复发增加有关，但与死亡增加无关。甲状腺外侵犯使死亡风险增加5.8倍，远处转移使该风险增加47倍。诊断时年龄超过45岁使死亡风险增加32倍。肿瘤大小超过3厘米使死亡风险增加5.8倍。通过Cox比例风险分析，与接受单侧甲状腺手术或双侧次全切除术的患者相比，对于肿瘤大于1厘米的患者，联合叶切除术加至少对侧次全甲状腺切除术的手术治疗与死亡风险降低相关，对于所有患者，包括I级和II级患者，与复发风险降低相关。通过卡方分析，术后对残留甲状腺组织进行131I消融与肿瘤大于1厘米的患者复发风险降低以及I级和II级肿瘤大小超过1厘米的患者死亡风险降低相关。这些数据有力地支持了对肿瘤大小超过1厘米的I级和II级患者采用更广泛的初始手术以及术后对甲状腺残余组织进行放射性131I消融。
