局部晚期分化型甲状腺癌的手术治疗
Operative management of locally advanced, differentiated thyroid cancer.
作者信息
Wang Laura Y, Nixon Iain J, Patel Snehal G, Palmer Frank L, Tuttle R Michael, Shaha Ashok, Shah Jatin P, Ganly Ian
机构信息
Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.
Endocrinology, Memorial Sloan Kettering Cancer Center, New York, NY.
出版信息
Surgery. 2016 Sep;160(3):738-46. doi: 10.1016/j.surg.2016.04.027. Epub 2016 Jun 11.
BACKGROUND
The majority of differentiated thyroid cancer tends to present with limited locoregional disease, leading to excellent long-term survival after operative treatment. Even patients with advanced local disease may survive for long periods with appropriate treatment. The aim of this study is to present our institutional experience of the management of locally advanced differentiated thyroid cancer and to analyze factors predictive of outcome.
METHODS
We reviewed our institutional database of 3,664 previously untreated patients with differentiated thyroid cancer operated between 1986 and 2010. A total of 153 patients had tumor extension beyond the thyroid capsule that invaded the subcutaneous soft tissues, recurrent laryngeal nerve, larynx, trachea, or esophagus. Details on extent of operation and adjuvant therapy were recorded. Disease-specific survival and locoregional recurrence-free probability were determined by the Kaplan-Meier method. Factors predictive of outcome were determined by multivariate analysis.
RESULTS
The median age of the 153 patients with tumor extension beyond the thyroid capsule was 55 years (range 11-91 years). Eighty-nine patients (58.2%) were female. Twenty-three patients (15.0%) were staged as M1 at presentation, and 122 (79.7%) had pathologically involved lymph nodes. The most common site of extrathyroidal extension was the recurrent laryngeal nerve (51.0%) followed by the trachea (46.4%) and esophagus (39.2%). Sixty-three patients (41%) required resection of the recurrent laryngeal nerve due to tumor involvement. After surgery, 20 patients (13.0%) had gross residual disease (R2), 63 (41.2%) had a positive margin of resection (R1), and 70 (45.8%) had complete resection with negative margins (R0). With a median follow-up of 63.9 months, 5-year, disease-specific survival, when stratified by R0/R1/R2 resection, was 94.4%, 87.6%, and 67.9%, respectively (P = .030). The data do not demonstrate a statistical difference in survival between R0 versus R1 (P = .222). The 5-year distant recurrence-free probability for M0 patients was 90.8%, 90.3%, and 70.7% (P = .410). The locoregional recurrence-free probability was 85.8% for R0 patients and 85.5% for R1 patients (P = .593).
CONCLUSION
With an appropriate operative strategy, patients with locally advanced thyroid cancer with an R0 or R1 resection have excellent survival outcome.
背景
大多数分化型甲状腺癌倾向于表现为局部区域疾病局限，手术治疗后长期生存率良好。即使是局部晚期疾病患者，经过适当治疗也可能长期存活。本研究的目的是介绍我们机构对局部晚期分化型甲状腺癌的治疗经验，并分析预后的预测因素。
方法
我们回顾了1986年至2010年间在我们机构接受手术的3664例未经治疗的分化型甲状腺癌患者的数据库。共有153例患者的肿瘤侵犯超出甲状腺包膜，累及皮下软组织、喉返神经、喉、气管或食管。记录手术范围和辅助治疗的详细信息。采用Kaplan-Meier法确定疾病特异性生存率和局部区域无复发生存率。通过多变量分析确定预后的预测因素。
结果
153例肿瘤侵犯超出甲状腺包膜的患者中位年龄为55岁（范围11 - 91岁）。89例（58.2%）为女性。23例（15.0%）初诊时分期为M1，122例（79.7%）有病理证实的淋巴结受累。甲状腺外侵犯最常见的部位是喉返神经（51.0%），其次是气管（46.4%）和食管（39.2%）。63例（41%）患者因肿瘤侵犯需要切除喉返神经。手术后，20例（13.0%）有肉眼残留病灶（R2），63例（41.2%）切缘阳性（R1），70例（45.8%）切缘阴性的完整切除（R0）。中位随访63.9个月，按R0/R1/R2切除分层的5年疾病特异性生存率分别为94.4%、87.6%和67.9%（P = 0.030）。数据显示R0与R1之间的生存率无统计学差异（P = 0.222）。M0患者的5年远处无复发生存率分别为90.8%、90.3%和70.7%（P = 0.410）。R0患者的局部区域无复发生存率为85.8%，R1患者为85.5%（P = 0.593）。
结论
采用适当的手术策略，R0或R1切除的局部晚期甲状腺癌患者有良好的生存预后。
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