分化型甲状腺癌的-姚峰孙圣荣.ppt

分化型甲状腺癌的手术治疗 甲状腺癌指南解读,武汉大学人民医院乳腺甲状腺外科姚 峰 孙圣荣,发病率不断上升,甲状腺癌发病率每年均在上升，2010年为女性恶性肿瘤第五位1973-2002年发病率增加了2.4倍，主要为乳头状癌，其发病率增加了2.9倍515%的甲状腺结节是癌49%1cm，87%2cm，这与颈部超声检查的广泛应用，获得早期诊治有关,NCCN 指南,在甲状腺专业医生的正确治疗下大部分病人可以治愈，治疗包括手术、（只要可能均需手术），然后予以放射碘及TSH抑制治疗，外放疗和化疗作用有限。,ATA指南,合适的手术方案是影响预后最重要的因素，碘131、TSH抑制及外放疗只起辅助作用,分化型甲状腺癌手术方式,甲状腺手术方式 只有三种甲状腺手术方式：患侧腺叶切除、甲状腺全切或近全切淋巴结清扫对于临床阳性或超声、FNA提示淋巴结转移，均需治疗性清扫对于临床淋巴结阴性，是否预防性清扫？大多主张做,NCCN指南（甲状腺全切除术）,甲状腺全切除适应症乳头状癌 以下任一条 年龄45 放射线照射史 有远处转移 双侧均有结节 病灶已浸润甲状腺外 肿瘤4cm 颈部淋巴结有转移 高侵袭性亚型滤泡状癌和许特氏细胞癌 所有浸润性癌 微小浸润癌也可选择,ATA指南（甲状腺全切除术）,For patients with thyroid cancer 1 cm,the initial surgical procedure should be a near-total or total thyroidectomy unless there are contraindications to this surgery 对于甲状腺癌病灶1cm者，初始手术治疗应该选择近全或全甲状腺切除术，除非患者对该术式有禁忌,NCCN指南（患侧腺叶全切除术）,患侧腺叶全切除适应症乳头状癌满足以下所有 年龄15-45 无放射线照射史 无远处转移 未侵及甲状腺外 肿瘤4cm 颈部淋巴结无转移 非侵袭性亚型滤泡状癌和许特氏细胞癌 经严格病理学检查（至少10张组织切片）证实的微小浸润癌可选择,ATA指南（患侧腺叶全切除术）,Thyroid lobectomy alone may be sufficient treatment for small(1 cm),low-risk,unifocal,intrathyroidal papillary carcinomas in the absence of prior head and neck irradiation or radiologically or clinically involved cervical nodal metastases 甲状腺腺叶切除术对那些病灶小（1cm），低危、单一病灶、局限于甲状腺内的乳头状癌且没有既往头颈部放射线照射史、无临床淋巴结受累者可能是可行的术式,Total thyroidectomy VS Lobectomy（1）,To determine whether total thyroidectomy resulted in improved recurrence and long-term survival rates for patients with PTCTo determine whether a specific tumor size threshold could be identified above which total thyroidectomy was associated with a decreased risk of recurrence and death,Bilimoria,K Y,et al.Annals of Surgery.2007;246:375-384,Total thyroidectomy VS Lobectomy（1）,Bilimoria,K Y,et al Annals of Surgery.2007;246:375-384,Total thyroidectomy VS Lobectomy（1）,Bilimoria,K Y,Annals of Surgery.2007;246:375-384,Bilimoria,K Y,et al Annals of Surgery.2007;246:375-384,Total thyroidectomy VS Lobectomy（1）,Recurrence rates after surgery for patients with PTC(B)by extent of surgery.,Bilimoria,K Y,et al Annals of Surgery.2007;246:375-384,7.7%,9.8%,P0.05,Total thyroidectomy VS Lobectomy（1）,Bilimoria,K Y,et al Annals of Surgery.2007;246:375-384,Relative survival rates after surgery for patients with PTC(B)by extent of surgery.,98.4%,97.1%,P0.05,Total thyroidectomy VS Lobectomy（1）,Bilimoria,K Y,et al.Annals of Surgery.2007;246:375-384,Total thyroidectomy VS Lobectomy（2）,1656 patients with AMES low-risk PTC The median age of the patients was 43 years,with a range of 4 to 87 years.,Hay,ID,et al.Surgery.1998;124:958-966,Total thyroidectomy VS Lobectomy（2）,Hay,ID,et al.Surgery.1998;124:958-966,死亡率及远处转移率没有区别,Total thyroidectomy VS Lobectomy（2）,Hay,ID,et al.Surgery.1998;124:958-966,局部复发率及淋巴结转移率有区别,Total thyroidectomy VS Lobectomy（2）,Hay,ID,et al.Surgery.1998;124:958-966,剔除接受放射碘治疗病例，局部复发率及淋巴结转移率仍有区别,NCCN指南（初次手术后追加全切术）,非全切术后确诊癌追加全切适应症乳头状癌以下任一条 肿瘤4cm 切缘阳性 明显侵及甲状腺外 肉眼下为多灶性 已证实有淋巴结转移 1-4cm或侵袭性亚型也可选择追加甲状腺全切除滤泡状癌和许特氏细胞癌 所有伴有明显血管浸润的浸润性癌，微小浸润癌也可选择追加甲状腺全切除,ATA指南（初次手术后追加全切术）,Completion thyroidectomy should be offered to those patients for whom a near-total or total thyroidectomy would have been recommended had the diagnosis been available before the initial surgery.This includes all patients with thyroid cancer except those with small(1 cm),unifocal,intrathyroidal,node-negative,low-risk tumors 首次手术前若能确诊即需行（而实际未行）全或近全甲状腺切除术的病人应行追加的甲状腺全切除术。仅肿瘤小(1 cm)、单病灶、病变局限于甲状腺体内、淋巴结阴性、低危肿瘤者除外,ATA指南（初次手术后追加全切术）,Ablation of the remaining lobe with radioactive iodine has been used as an alternative to completion thyroidectomy.It is unknown whether this approach results in similar long-term outcomes.Consequently,routine radioactive iodine ablation in lieu of completion thyroidectomy is not recommended.用放射性碘行残余腺叶消融治疗被作为甲状腺全切除术的一种替代选择，这种方法是否可取得相似的长期效果尚不清楚。因此，不推荐常规应用放射性碘消融作为甲状腺全切除术的替代,Completion Thyroidectomy（1）,Kim ES,et al Clinical Endocrinology.2004;61:145-148,1995-2001年,243例病人因甲状腺结节FNA提示滤泡性肿瘤病变接受手术，214例接受患侧腺叶及峡叶切除，其中81例术后诊断为甲状腺癌而接受追加的全甲状腺切除术，平均年龄40.7岁,对侧癌灶均1cm,Completion Thyroidectomy（1）,Kim ES,et al Clinical Endocrinology.2004;61:145-148,Characteristics of patients underwent completion thyroidectomy,69%的对侧腺叶中有癌灶者，患侧癌灶为多发灶，但只有26.9%的对侧腺叶无癌灶者，患侧为多发灶,Completion Thyroidectomy（2）,Erdem E,et al.European Journal of Surgical Oncology.2003;29:747-749,该研究比较追加甲状腺全切除术（141例）与初始行甲状腺全切除术（92例）的并发症发生率.,Completion Thyroidectomy（2）,Erdem E,et al.European Journal of Surgical Oncology.2003;29:747-749,3.3%,4.3%,3.5%,4.2%,NCCN指南（中央区淋巴结清扫）,中央区淋巴结清扫 如果淋巴结可触及或活检为阳性，需行治疗性清扫 乳头状癌和许特氏细胞癌如果淋巴结阴性，可考虑行预防性清扫，但滤泡状癌不考虑,ATA指南（中央区淋巴结清扫）,对于临床中央组及颈侧方淋巴结受累者应该行甲状腺全切除联合治疗性中央组淋巴结清扫术临床无中央区淋巴结受累的甲状腺乳头状癌患者可行预防性中央区淋巴结清扫（同侧或双侧），特别是对于T3或 T4病例近全或全甲状腺切除术（不含预防性中央区淋巴结清扫），对于T1或T2病变、非侵袭性、临床淋巴结阴性的乳头状癌和大多数滤泡性癌可能是合适的,Central Neck Dissection（1）,Brian M,et al.Surgery 2009；146:696705,This study is based on a retrospective review of 310 patients treated for PTC between January 2000 and May 2008,乳头状癌病人中患侧及双侧中央区淋巴结转移的几率是较高的,Central Neck Dissection（1）,Brian M,et al.Surgery 2009；146:696705,常规双侧中央区淋巴结清扫并没用显著增加喉返神经损伤的几率,Central Neck Dissection（2）,Moo TS,et al.Annals of Surgery 2009；250:403408,乳头状癌病人中患侧及双侧中央区淋巴结转移的几率是较高的,Central Neck Dissection（2）,Moo TS,et al.Annals of Surgery 2009；250:403408,当肿瘤1cm，中央区淋巴结转移（包括对侧中央区淋巴结转移）均明显增加,Central Neck Dissection（2）,Moo TS,et al.Annals of Surgery 2009；250:403408,并发症（甲旁腺）,Central Neck Dissection（2）,Moo TS,et al.Annals of Surgery 2009；250:403408,并发症（永久低钙和喉返损伤）,Central Neck Dissection（3）,Our strategy was to do a total thyroidectomy and a careful central neck dissection,Tisell LE,et al.World J.Surg.1996;20:854859,Central Neck Dissection（4）,Palestini N,et al.Langenbecks Arch Surg 2008；393:693698,305 例甲状腺乳头状癌病人行甲状腺全切除术分为三组group A(n=64)淋巴结阳性，行治疗性双侧中央区淋巴结清扫group B(n=93)淋巴结阴性，行预防性患侧中央区淋巴结清扫group C(n=148)淋巴结阴性，不做中央区淋巴结清扫比较三组的手术后并发症发生率,Central Neck Dissection（4）,Palestini N,et al.Langenbecks Arch Surg 2008；393:693698,Central Neck Dissection（4）,Palestini N,et al.Langenbecks Arch Surg 2008；393:693698,中央区淋巴结清扫并不增加永久性喉返神经麻痹及甲旁减的发生几率，当临床中央区淋巴结阴性时，从局部彻底清除病变、避免低估肿瘤分期同时降低并发症风险综合考虑，患侧中央区预防性清扫是最佳选择,NCCN指南（颈侧区淋巴结清扫）,颈侧区淋巴结清扫 不推荐预防性颈侧区淋巴结清扫，如果淋巴结可触及或淋巴结阳性，清扫、区淋巴结，根据临床和超声检查来考虑是否清扫、区,ATA指南（颈侧区淋巴结清扫）,Therapeutic lateral neck compartmental lymph node dissection should be performed for patients with biopsy proven metastatic lateral cervical lymphadenopathy.活检证实为颈侧淋巴结转移的病例应行治疗性颈侧淋巴结清扫术,Lateral Neck Dissection(1),术前超声检查颈侧方淋巴结阳性者无淋巴结复发生存率低于超声下淋巴结阴性者,Ito Y,et al.World J.Surg.2004；28：498501,Lateral Neck Dissection(1),Ito Y,et al.World J.Surg.2004；28：498501,术前超声检查颈侧方淋巴结阴性者，颈侧清对无淋巴结复发生存率没有影响,While most now agree that prophylactic lymph node dissections(LND)play no role,at the University of California,San Francisco(UCSF)we limit LND selectively on a level by level basis,and resect only the levels thought to harbor disease or to be at increased risk of metastases.This initial,selective LND usually includes levels III and IV(due to the well-documented increased likelihood of metastases to these levels)and levels I,II,and V are included when there is clinical or radiological evidence of disease or increased risk of it,Lateral Neck Dissection(2),Caron NR.,et al.World J.Surg.2006；30：833840,Lateral Neck Dissection(2),Caron NR.,et al.World J.Surg.2006；30：833840,A total of 140 initial lateral LND were performed:104 ipsilateral and 36 contralateral.,Lateral Neck Dissection(2),Caron NR.,et al.World J.Surg.2006；30：833840,Lateral Neck Dissection(2),Caron NR.,et al.World J.Surg.2006；30：833840,未 来,The Challenge of Managing Differentiated Thyroid Carcinoma Managing differentiated(i.e.,papillary,follicular,and Hrthle)thyroid carcinoma can be a challenge.Results from ongoing randomized trials will not be available for many years.,谢 谢,