[甲状腺功能亢进症与甲状腺癌]

Ardito G, Mantovani M, Vincenzoni C, Guidi M L, Corsello S, Rabitti C, Fadda G, Di Giovanni V

Istituto di Semeiotica Chirurgica, Università Cattolica del Sacro Cuore, UCSC, Roma.

Ann Ital Chir. 1997 Jan-Feb;68(1):23-7; discussion 27-8.

The incidence of thyroid carcinoma in hyperthyroidism varies considerably from as low as 0.3% to as high as 16.6% with a higher rate in toxic nodular goiters. Occult thyroid carcinoma (< 1.5 cm or microscopic foci) is the rule and only a few tumors are suspected preoperatively with ultrasonography or fine needle aspiration or 131 I scan. In 408 patients who underwent surgery for hyperthyroidism in our Surgery Department from January 1967 through December 1994 the incidence of thyroid carcinoma was 5.6% (23 cases). In detail, a neoplasm occurred in 5 cases of Graves' disease (specific incidence: 3.8%), in 13 cases of toxic nodular goiter (12.5%) and in 5 cases of hyperfunctioning adenomas (2.8%). 19 cancers were papillary (12 in toxic nodular goiter, 3 in Graves' disease, 4 in hyperfunctioning adenomas), three were follicular (1 in Graves' disease, 1 in toxic nodular goiter, 1 in hyperfunctioning adenomas) and 1 medullary in Graves' disease. A papillary carcinoma was diagnosed preoperatively on fine needle aspiration with ultrasonography in only two patients with Graves' disease and confirmed by postoperative histological examination on permanent section. We do not believe in the frozen-section examination intraoperatively because it's not diagnostical for follicular lesions and evaluates rarely capsular invasion. Twenty patients received total thyroidectomy and four of them also lymphoadenectomy. Three patients received emithyroidectomy: in two cases for occult papillary carcinoma and in the last case for local cancer invasion (T4N0M0). Twenty patients are alive and with no evidence of cancer recurrence. Mean follow-up is 59.6 months. Our retrospective study shows a progressive increase of the incidence of coexisting thyroid malignancy and hyperthyroidism especially in toxic nodular goiter, probably related to extended surgical indications. Our findings do confirm that, even in the presence of hyperthyroidism, all thyroid nodules require careful diagnostics for exclusion of malignancy.

甲状腺功能亢进症患者中甲状腺癌的发病率差异很大，低至0.3%，高至16.6%，毒性结节性甲状腺肿的发病率更高。隐匿性甲状腺癌（<1.5 cm或微小病灶）很常见，术前仅通过超声检查、细针穿刺或131碘扫描怀疑有少数肿瘤。1967年1月至1994年12月期间，在我们外科接受甲状腺功能亢进症手术的408例患者中，甲状腺癌的发病率为5.6%（23例）。具体而言，5例格雷夫斯病患者发生肿瘤（特定发病率：3.8%），13例毒性结节性甲状腺肿患者发生肿瘤（12.5%），5例高功能腺瘤患者发生肿瘤（2.8%）。19例癌症为乳头状癌（毒性结节性甲状腺肿12例，格雷夫斯病3例，高功能腺瘤4例），3例为滤泡状癌（格雷夫斯病1例，毒性结节性甲状腺肿1例，高功能腺瘤1例），格雷夫斯病中有1例髓样癌。术前仅通过超声引导下细针穿刺诊断出2例格雷夫斯病患者为乳头状癌，并经术后永久切片组织学检查证实。我们不主张术中进行冰冻切片检查，因为它对滤泡性病变无诊断价值，且很少评估包膜侵犯情况。20例患者接受了甲状腺全切除术，其中4例还进行了淋巴结清扫术。3例患者接受了甲状腺次全切除术：2例为隐匿性乳头状癌，最后1例为局部癌侵犯（T4N0M0）。20例患者存活，无癌症复发迹象。平均随访时间为59.6个月。我们的回顾性研究表明，甲状腺恶性肿瘤与甲状腺功能亢进症并存的发病率呈逐渐上升趋势

，尤其是在毒性结节性甲状腺肿中，这可能与手术适应症的扩大有关。我们的研究结果确实证实，即使存在甲状腺功能亢进症，所有甲状腺结节都需要进行仔细诊断以排除恶性肿瘤。