散发性甲状腺髓样癌外科治疗策略选择与长期随访

Surgical strategies in the patients with sporadic medullary thyroid carcinoma: a long term follow-up

目的 通过回顾分析接受不同手术治疗的散发性甲状腺髓样癌患者的临床资料,探讨不同手术方式对患者的治疗效果和临床预后的影响.方法 1992年1月至2009年12月收治70例甲状腺髓样癌患者,男25 例,女35例,中位年龄49.2 岁.根据手术方式不同分为3组：A组12例,行甲状腺全切术＋中央区颈淋巴结清扫术;B组40例,行保留对侧喉返神经入喉处甲状腺组织的甲状腺次全切术＋单侧改良颈淋巴结清扫术;C组18例,行保留对侧喉返神经入喉处甲状腺组织的甲状腺次全切术＋双侧改良颈淋巴结清扫术.分析术后甲状旁腺功能低下和喉返神经损伤发生率、癌症复发率、生化治愈率和生存时间.结果 3组患者术后的甲状旁腺功能低下（χ2=40.9,P＜0.01）和喉返神经损伤发生率（χ2=32.9,P＜0.01）有明显不同.70例获随访12～169个月（平均90.5个月）,癌症复发率分别是75.0% （9/12）、2.5% （1/40）、44.4% （8/18）（χ2=31.1,P＜0.01）,生化治愈率分别是25.0%、97.5%、55.6%（χ2=31.1,P＜0.01）,平均生存时间分别是77.8、106.1和111.0个月（χ2=3.2,P＞0.05）.结论 与甲状腺全切术＋双侧中央区颈淋巴结清扫术组相比较,保留喉返神经入喉处甲状腺组织的甲状腺次全切术＋单侧或双侧改良颈淋巴结清扫术组具有同样的术后生存期、较低的甲状旁腺功能低下和喉返神经损伤发生率,以及较低的癌症复发率.

Objective The extent of surgical resection on patients with sporadic medullary thyroid carcinoma （ SMTC ） remains controversial. We reviewed our experience to discuss the prognosis of SMTC underwent the different surgical treatment in order to explore the different outcome of the patients. Methods Of 73 patients with 5MTC in the mean age of 49.2 at diagnosis, 70 patients were followed up for 12-169 months （median, 90.5 months）. Based on the choice of patients themselves, after getting a full understanding to the disease, 12 patients underwent total thyroidectomy with bilateral central neck dissection （ group A ） , 40 patients underwent subtotal thyroideetomy preserving eontralateral thyroid tissue on the entrance point of recurrent laryngeal nerve into the larynx with ipsilateral modified radical neck dissection （group B） , and 18 patients underwent subtotal thyroidectomy preserving contralatcral thyroid tissue on the entrance point of recurrent laryngeal nerve into the larynx with bilateral modified radical neck dissection（ group C）. The diagnosis were confirmed by the preoperatire and postoperative pathology examination. The incidence of hypoparathyroidism and recurrent laryngeal nerve injure, the cancer recurrent rate, the biochemical cure rate and survival time were investigated post-operatively. Results There were significant difference between the three groups on the incidence of hypoparathyroidism（χ^2 =40.9, P 〈 0.01 ）, as well as the incidence of recurrent laryngeal nerve injure （χ^2 = 32.9, P 〈 0.01 ）. The cancer recurrence rates in the three groups were 75.0% （9/12）, 2.5% （1/40） and 44.4% （8/18） （χ^2 = 31.1, P 〈0.01 ） and the biochemical cure rate in the three groups were 25% , 97.5% and 55.6% （χ^2 = 31.1, P〈0.01）, respectively. The mean survlval time in the three groups were 77.8, 106. 1 and 111.0 months without significant difference （χ^2 = 3.2, P 〉 0. 05 ） , respectively. Conclusions Compared to the total thyroidectomy with bilateral central neck dissection, the subtotal thyroidectomy with ipsilateral/bilateral modified radical neck dissection showed a lower incidence of hypoparathyroidism, recurrent laryngeal nerve injure and a lower recurrence along with a similar cumulative survival.