Orlov Steven, Salari Farnaz, Kashat Lawrence, Freeman Jeremy L, Vescan Allan, Witterick Ian J, Walfish Paul G
Endocrine Division, Department of Medicine, Joseph and Mildred Sonshine Family Centre for Head & Neck Diseases, Mount Sinai Hospital, 413-7, 600 University Avenue, Toronto, ON, M5G 1X5, Canada,
Endocrine. 2015 Sep;50(1):130-7. doi: 10.1007/s12020-015-0575-0. Epub 2015 Mar 20.
The purpose of this study was to demonstrate the utility of a personalized risk stratification and radioactive iodine (RAI) selection protocol (PRSP) using post-operative stimulated thyroglobulin (Stim-Tg) and neck ultrasound in low- and intermediate-risk papillary thyroid carcinoma (PTC) patients. Patients with PTC tumors ≥1 cm were prospectively followed after total thyroidectomy and selective therapeutic central compartment neck dissection. Low/intermediate risk was defined as PTC confined to the thyroid or central (level VI) lymph nodes. Stim-Tg and neck ultrasound were performed approximately 3 months after surgery and used to guide RAI selection. Patients with Stim-Tg < 1 µg/L did not receive RAI, while those with Stim-Tg >5 µg/L routinely did. Those with Stim-Tg 1-5 µg/L received RAI on the basis of several clinical risk factors. Patients were followed for >6 years with serial neck ultrasound and basal/stimulated thyroglobulin. Among the 129 patients, 84 (65 %) had undetectable Stim-Tg after initial surgery, 40 (31 %) had Stim-Tg of 1-5 µg/L, and 5 (4 %) had Stim-Tg >5 µg/L. RAI was administered to 8 (20 %) patients with Stim-Tg 1-5 µg/L and 5 (100 %) with Stim-Tg >5 µg/L. Using this approach, RAI therapy was avoided in 17/20 (85 %) patients with tumors >4 cm, in 72/81 (89 %) patients older than 45 years, and in 6/9 (67 %) patients with central lymph node involvement. To date, 116 (90 %) patients in this cohort have not received RAI therapy with no evidence of residual/recurrent disease, whereas among the 13 patients who received RAI, 1 (8 %) had pathologic residual/recurrence disease. Using the proposed PRSP, RAI can be avoided in the majority of low/intermediate-risk PTC patients. Moreover, traditional risk factors considered to favor RAI treatment were not always concordant with the PRSP and may lead to overtreatment.
本研究的目的是证明使用术后刺激甲状腺球蛋白（Stim-Tg）和颈部超声的个性化风险分层及放射性碘（RAI）选择方案（PRSP）在低风险和中风险甲状腺乳头状癌（PTC）患者中的实用性。对甲状腺全切术和选择性治疗性中央区颈部淋巴结清扫术后的PTC肿瘤≥1 cm的患者进行前瞻性随访。低/中风险定义为局限于甲状腺或中央（VI区）淋巴结的PTC。术后约3个月进行Stim-Tg和颈部超声检查，并用于指导RAI的选择。Stim-Tg<1 μg/L的患者不接受RAI治疗，而Stim-Tg>5 μg/L的患者常规接受治疗。Stim-Tg为1-5 μg/L的患者根据若干临床风险因素接受RAI治疗。通过连续的颈部超声检查和基础/刺激甲状腺球蛋白对患者进行了>6年的随访。在129例患者中，84例（65%）初次手术后Stim-Tg检测不到，40例（31%）Stim-Tg为1-5 μg/L，5例（4%）Stim-Tg>5 μg/L。Stim-Tg为1-5 μg/L的8例（20%）患者和Stim-Tg>5 μg/L的5例（100%）患者接受了RAI治疗。采用这种方法，17/20（85%）肿瘤>4 cm的患者、72/81（89%）年龄大于45岁的患者和6/9（67%）有中央淋巴结受累的患者避免了RAI治疗。迄今为止，该队列中的116例（90%）患者未接受RAI治疗，且无残留/复发疾病的证据，而在接受RAI治疗的13例患者中，1例（8%）有病理残留/复发疾病。使用所提出的PRSP，可以在大多数低/中风险PTC患者中避免使用RAI。此外，被认为有利于RAI治疗的传统风险因素并不总是与PRSP一致，可能导致过度治疗。
