影响碘难治性分化型甲状腺癌的预后因素分析

The analysis of prognostic factors influencing the radioiodine refractory⁃differentiated thyroid cancer

目的:探讨影响碘难治性分化型甲状腺癌(radioiodine refractory-differentiated thyroid cancer,RAIR-DTC)的预后因素及预测碘难治(radioiodine refractory,RAIR)的指标。方法:回顾性分析2009年1月—2017年12月在南京医科大学第一附属医院进行甲状腺癌根治术、术后经131I治疗和随访的分化型甲状腺癌(differentiated thyroid cancer,DTC)患者,分析其临床特征、对131I治疗反应的动态风险分层及预后分层,探究影响RAIR-DTC预后的因素,计算相关因素的受试者工作特征(receiver operator characteristic,ROC)曲线的曲线下面积(area under curve,AUC)及95%CI,计算重要截点值的敏感性和特异性。结果:①共纳入318例DTC患者,其中272例(85.5%)无远处转移,46例(14.5%)有远处转移;32例(10.1%)为RAIR,286例(89.9%)为非碘难治(non-radioiodine refractory,NRAIR)。RAIR组的年龄、男性比例、癌灶的最长径、接受131I治疗的次数、远处转移率、动态风险分层及预后分层更高,癌灶是否存在局部侵犯、合并结节性肿、左右灶、多灶性特点的发生率两组差异无统计学意义(P<0.001)。②二元Logistic回归分析结果显示,男性、131I治疗次数、淋巴结反应均为DTC预后的危险因素(P<0.001)。③ROC曲线结果显示131I治疗次数预测RAIR具有较高的准确性。当131I治疗次数≥3时,预测RAIR的AUC为0.861(95%CI:0.817~0.897),灵敏度为78.12%,特异度为88.85%(P<0.001)。结论:当DTC患者年龄≥55岁、接受131I治疗≥3次后仍存在至少1处不摄碘的转移灶或病情进展时,应及时评估RAIR的可能性,尽早采取靶向治疗。

Objective:This study aimed to investigate the prognostic factors affecting the radioiodine refractory⁃differentiated thyroid cancer(RAIR⁃DTC)and the predictive index.Methods:Differentiated thyroid cancer(DTC)patients who received total thyroid resection were retrospectively collected,with 131I treatment and follow⁃up in the First Affiliated Hospital of Nanjing Medical University from January 2009 to December 2017.The clinical characteristics,dynamic risk stratification and prognosis stratification were analyzed.The prognostic factors affecting the RAIR⁃DTC were explored,and the area under the receiver operating characteristic(ROC)curve and 95%confidence interval(CI),sensitivity and specificity of important intercept points were calculated.Results:①A total of 318 DTCs,272(85.5%)had no distant metastasis,46(14.5%)had distant metastasis;32(10.1%)patients were RAIR,286(89.9%)were non⁃radioiodine refractory(NRAIR).Comparing with those of NRAIR patients,age and male proportion of RAIR patients was higher,the longest diameter of thyroid lesions of RAIR patients was larger,and the 131I treatment frequency,the distant metastasis rate,the dynamic risk stratification and prognosis stratification of RAIR patients were higher.There was no significant difference in the incidence of nodular lesions,lesions on the left and right,and multifocal lesions between RAIR and NRAIR patients.②Binary logistic regression analysis showed that males,131I treatment frequency,cervical lymph node reaction were prognostic factors affecting RAIR⁃DTC.③The area under the ROC(AUC)indicated that 131I treatment frequency was a major prognostic factor.When DTC patients receiving≥3131I treatment,the AUC of predicting RAIR was 0.861(95%CI 0.817⁃0.897),the sensitivity was 78.12%and the specificity was 88.85%(P<0.001).Conclusion:It is suggested to assess the probability of RAIR in≥55 years DTC patients who received≥3131I treatment still with at least 1 metastasis without 131I uptake or progressive disease.Once diagnosed as RAIR,molecular targeted therapy should be taken as soon as possible.