中低危分化型甲状腺癌患者131I治疗前TSH变化与疗效间关系的研究

Change of pre-ablative thyroid-stimulating hormone after thyroid hormone withdrawal and its response to 131I therapy in patients with low to intermediate risk differentiated thyroid cancer

目的 探索中低危DTC患者131I治疗前TSH变化情况与131I治疗疗效的关系.方法 回顾性分析中低危DTC患者120例[男38例,女82例,年龄（40.8±10.9）岁],分别监测停用甲状腺激素当天及131I治疗当天TSH水平（分别记作TSH1和TSH2）,获得TSH变化值,并计算TSH变化速率（V）.依据ATA指南将疗效分为满意（ER）、不确切（IDR）、血清学反应欠佳（BIR）和影像学反应欠佳（SIR）.依据TSH2水平（mU/L）（30≤TSH2＜ 60、60≤TSH2＜ 90、90≤TSH2＜ 120、120≤TSH2＜150、TSH2≥150）将患者分成G1～G5组,比较各组患者的临床病理特征、停药时间、TSH变化速率、残余甲状腺、治疗剂量、随访时间等参数.依据TSH变化速率,将患者分成3组：V1组（V≤2.5）、V2组（2.5＜V≤5.0）、V3组（V＞5.0）,比较3组间治疗疗效.最后依据疗效将患者分为R1组（ER和IDR）及R2组（BIR和SIR）,观察2组间TSH变化速率、停药时间、131I剂量、随访时间、残余甲状腺等有无差异.进一步应用logistic回归分析TSH及停药时间是否可作为预测预后欠佳的独立因素.结果 男性（x2=11.863）、年轻（F=4.975）、TSH变化速率快（H=44.911）及残余甲状腺少的患者（H=18.159）TSH2水平较高（均P＜0.05）;G3组的ER率最高（83.8％,31/37）.不同TSH变化速率组患者治疗疗效差异无统计学意义（U=407.5,P＞0.05）,但V2组患者取得较好预后的比例（92.4％,61/66）高于V1组（85.7％,18/21）和V3组（5/7）.TSH2（OR=0.835）及Tg水平（OR=1.196）是治疗反应欠佳的独立影响因素（均P＜0.05）.结论 中低危DTC患者TSH的停药后升高速度并不影响131I治疗效果,而131I治疗当日的TSH水平影响其疗效,90～ 120 mU/L的TSH水平有助于获得最佳131I治疗疗效.

Objective To investigate the relationship between the change of pre-ablative TSH after thyroid hormone withdrawal（THW） and the response of subsequent 131I therapy in patients with low to intermediate risk DTC after total or near total thyroidectomy.Methods A total of 120 DTC patients （38 males,82 females,age （40.8±10.9） years） were enrolled in this retrospective study.Serial TSH levels determined on the day of THW and on the day of receiving 131I ablative therapy were monitored,which were marked as TSH1 and TSH2 accordingly.The THW duration （t） was recorded,the change of TSH was defined as △TSH and the change rate of TSH was calculated （V=△TSH/t）.The responses to 131I therapy were classified as excellent response （ER）,indeterminate response （IDR）,biochemical incomplete response （BIR） and structural incomplete response （SIR） according to ATA guideline.According to the TSH2（mU/L） levels,patients were divided into G1 group （30≤TSH2〈60）,G2 group （60≤TSH2〈90）,G3 group （90≤TSH2〈 120）,G4 group （120≤TSH2〈150） and G5 group （TSH2 ≥ 150）.Clinical and pathological features,THW duration,the change rate of TSH,residual thyroid,131 I dose and follow-up time were compared among these groups.In order to evaluate the relationship between response to 131I ablation and change rate of TSH,patients were divided into V1 group （V≤2.5）,V2 group （2.5〈V≤5.0） and V3 group （V〉5.0）,and their responses to 131I ablation were compared.Patients were classified into RI group （including ER and IDR）and R2 group （including BIR and SIR）,the differences of clinical and pathological features,131I doses between the two groups were explored.Furthermore,logistic regression was performed to identify factors associated with BIR and SIR.Results Patients with male gender （x2=11.863）,younger age （F =4.975）,and faster TSH change rate （H =44.911） and lower thyroid residue （H =18.159） achieved a higher value of TSH2（all P〈0.05）.G3 group presented the highest rate of ER （83.8%,31/37）.The percentage of ER ＋ IDR in V2 group was higher than those in V1 group and V3 group,which was 92.4% （61/66）,85.7% （18/21） and 5/7,respectively,but the difference was not significant （U=407.5,P〉0.05）.TSH2 level （OR=0.835） and pre-ablative Tg level （OR =1.196） were independent factors in predicting BIR and SIR （both P〈0.05）.Conclusions The changing rate of TSH before 131 I ablation may not be associated with the response to 131I therapy in patient with low to intermediate risk DTC,while the level of TSH2 does.Patients with TSH2 ranging from 90 to 120 mU/L could be of help in achieving a better clinical response.