Section of Endocrine Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles.
Department of Biomathematics, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles.
JAMA Surg. 2018 Dec 1;153(12):1098-1104. doi: 10.1001/jamasurg.2018.2659.
One-third of patients with papillary thyroid cancer (PTC) develop persistent or recurrent disease after initial therapy. Most patients with persistent or recurrent disease undergo reoperation, but the role of treatment with radioactive iodine (RAI) after reoperation is unclear.
To determine whether receipt of RAI after reoperation for recurrent PTC is associated with improved outcomes.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study included electronic health record data from 102 patients who underwent neck reoperation for persistent or recurrent PTC at a tertiary referral center from April 2006 to January 2016; 50 patients received RAI after reoperation, and 52 did not receive RAI after reoperation. Data analysis was performed from September 1, 2017, to December 1, 2017.
Suppressed thyroglobulin (Tg) levels were compared between patients who underwent reoperation and received RAI and patients who underwent reoperation without receipt of RAI at the following time points: before reoperation (Tg0), after reoperation (Tg1), and after RAI or a comparable time interval among patients whose cases were managed without RAI (Tg2). Outcomes were biochemical response and structural recurrence after reoperation.
The cohort comprised 102 patients who underwent neck reoperation for persistent or recurrent PTC (median age, 44 years [interquartile range, 33-54 years; SD, 14 years]; 67 [66%] female), 50 of whom received treatment with RAI after reoperation. Clinicopathologic characteristics of the patients at the time of the initial surgical procedure were similar between the reoperation with RAI group and the reoperation without RAI group with the exception of tumor (T) stage (T3 and T4, 28 of 50 [56%] vs 19 of 52 [37%]). Although median Tg levels were similar between the reoperation with RAI group and the reoperation without RAI group (Tg0, 3.3 ng/mL vs 2.4 ng/mL; Tg1, 0.6 ng/mL vs 0.2 ng/mL; and Tg2, 0.5 ng/mL vs 0.2 ng/mL; all differences were nonsignificant), the rate of excellent response at Tg1 was lower in the reoperation with RAI group (4 of 33 [12%] vs 24 of 51 [47%]; P = .007). Structural recurrence after reoperation occurred in 18 of 50 patients (36%) in the reoperation with RAI group and 10 of 52 patients (19%) in the reoperation without RAI group. In multivariable analysis accounting for clinicopathologic characteristics and Tg0, receipt of RAI after reoperation was not associated with the rate of a second structural recurrence. In subset analyses limited to patients with incomplete response to reoperation and patients with T3 or T4 tumors, no association between receipt of RAI and the risk of a second recurrence was found.
Patients who received RAI after reoperation had outcomes similar to those in patients who underwent reoperation alone. RAI after reoperation was not associated with a significant clinical benefit in this limited series. Larger multicenter studies are required to determine whether receipt of RAI after reoperation improves outcomes among patients with recurrent PTC.
三分之一的甲状腺乳头状癌（PTC）患者在初始治疗后会出现持续性或复发性疾病。大多数持续性或复发性疾病患者需要再次手术，但再次手术后是否使用放射性碘（RAI）治疗尚不清楚。
确定复发性 PTC 再次手术后接受 RAI 是否与改善结局相关。
设计、地点和参与者：这项回顾性队列研究纳入了 2006 年 4 月至 2016 年 1 月期间在一家三级转诊中心因持续性或复发性 PTC 接受颈部再次手术的 102 例患者的电子健康记录数据；50 例患者在再次手术后接受了 RAI，52 例患者未接受 RAI。数据分析于 2017 年 9 月 1 日至 2017 年 12 月 1 日进行。
在以下时间点比较再次手术且接受 RAI 治疗与再次手术但未接受 RAI 治疗的患者的甲状腺球蛋白（Tg）水平：再次手术前（Tg0）、再次手术后（Tg1）和再次手术后 RAI 或无 RAI 患者可比时间间隔（Tg2）。结局是再次手术后的生化反应和结构复发。
该队列包括 102 例因持续性或复发性 PTC 接受颈部再次手术的患者（中位年龄为 44 岁[四分位距 33-54 岁；标准差 14 岁]；67[66%]为女性），其中 50 例患者在再次手术后接受了 RAI 治疗。再次手术后接受 RAI 组和再次手术后未接受 RAI 组患者在初始手术时的临床病理特征相似，但肿瘤（T）分期（T3 和 T4，28 例[56%]比 19 例[37%]）除外。尽管再次手术后接受 RAI 组和再次手术后未接受 RAI 组的 Tg 水平中位数相似（Tg0，3.3ng/mL 比 2.4ng/mL；Tg1，0.6ng/mL 比 0.2ng/mL；Tg2，0.5ng/mL 比 0.2ng/mL；所有差异均无统计学意义），但再次手术后 Tg1 时的完全缓解率较低（再次手术后接受 RAI 组为 4 例[12%]，再次手术后未接受 RAI 组为 24 例[47%]；P = .007）。再次手术后结构复发发生在再次手术后接受 RAI 组的 50 例患者中的 18 例（36%）和再次手术后未接受 RAI 组的 52 例患者中的 10 例（19%）。在考虑临床病理特征和 Tg0 的多变量分析中，再次手术后接受 RAI 与第二次结构复发的发生率无关。在仅限于再次手术无反应患者和 T3 或 T4 肿瘤患者的亚组分析中，未发现再次手术后接受 RAI 与复发风险之间存在关联。
再次手术后接受 RAI 的患者的结局与单独再次手术的患者相似。在这项有限的研究中，再次手术后接受 RAI 并没有显著的临床获益。需要更大规模的多中心研究来确定复发性 PTC 患者再次手术后接受 RAI 是否能改善结局。
