Momin Suhael, Chute Deborah, Burkey Brian, Scharpf Joseph
Endocr Pract. 2017 Sep;23(9):1053-1058. doi: 10.4158/EP161684.OR. Epub 2017 Jul 6.
Identifying prognostic risk factors and determining the efficacy of common surgical treatments is critical to determine optimal treatment strategies for patients with medullary thyroid carcinoma (MTC). The objective of this study was to review a contemporary institutional experience with MTC primary treatment with 2 goals: to identify prognostic factors that impact survival and to study the effect of neck dissection on those outcomes.
This study was a retrospective case series of patients with MTC who underwent at least a total thyroidectomy with curative intent. Clinical parameters including tumor and nodal staging with corresponding pathology findings were identified. Survival endpoints included overall survival, disease-free survival, and biochemical cure.
Sixty-seven patients were included. The majority presented with early T-stage disease. Fifty (76%) patients were N0 at presentation. Seventeen (24%) had some evidence of neck disease on clinical examination or imaging. Forty (71%) achieved biochemical cure, and the 5-year biochemical recurrence-free survival for those cases was 86.5%. Among patients who had successful resection of all gross disease, 92% had no evidence of structural disease at 5 years. Overall survival was 91% at 5 years. Increased pre-operative calcitonin (Ct) level, primary tumor size, extrathyroidal extension, and neck metastases decrease the rate of biochemical cure. Larger tumor size increases the risk of structural disease recurrence and biochemical relapse after initial cure. The presence and number of neck metastases correlate with biochemical relapse. The presence of lateral neck nodes (pN1b) does not have different survival implications than centrally confined disease (pN1a).
This study shows increasing tumor size, increased Ct level, and cervical metastases are poor prognostic factors. Patients with large tumors, high Ct level, or unfavorable pathologic findings may warrant more aggressive initial treatment, although limitations of the study prevent any conclusion regarding the effect of neck dissection.
ATA = American Thyroid Association BRFS = biochemical recurrence-free survival CND = central neck dissection Ct = calcitonin DFS = disease-free survival MTC = medullary thyroid carcinoma OR = odds ratio OS = overall survival pCND = prophylactic CND.
识别预后风险因素并确定常见手术治疗的疗效对于确定甲状腺髓样癌（MTC）患者的最佳治疗策略至关重要。本研究的目的是回顾当代机构对MTC初始治疗的经验，有两个目标：识别影响生存的预后因素，并研究颈淋巴结清扫术对这些结果的影响。
本研究是对接受至少全甲状腺切除术且有治愈意图的MTC患者的回顾性病例系列研究。确定了包括肿瘤和淋巴结分期以及相应病理结果在内的临床参数。生存终点包括总生存、无病生存和生化治愈。
纳入67例患者。大多数患者表现为早期T分期疾病。50例（76%）患者就诊时为N0。17例（24%）在临床检查或影像学检查中有颈部疾病的一些证据。40例（71%）实现了生化治愈，这些病例的5年生化无复发生存率为86.5%。在成功切除所有大体疾病的患者中，92%在5年时无结构疾病证据。5年总生存率为91%。术前降钙素（Ct）水平升高、原发肿瘤大小、甲状腺外侵犯和颈部转移会降低生化治愈率。肿瘤越大，初始治愈后结构疾病复发和生化复发的风险越高。颈部转移的存在和数量与生化复发相关。侧颈淋巴结（pN1b）的存在与中央局限疾病（pN1a）相比，对生存的影响没有差异。
本研究表明，肿瘤大小增加、Ct水平升高和颈部转移是不良预后因素。肿瘤大、Ct水平高或病理结果不佳的患者可能需要更积极的初始治疗，尽管该研究的局限性妨碍了就颈淋巴结清扫术的效果得出任何结论。
ATA = 美国甲状腺协会；BRFS = 生化无复发生存率；CND = 中央颈淋巴结清扫术；Ct = 降钙素；DFS = 无病生存；MTC = 甲状腺髓样癌；OR = 比值比；OS = 总生存；pCND = 预防性中央颈淋巴结清扫术
