侵犯气管、食管、喉部的分化型甲状腺癌的诊疗

Diagnosis and Treatment of Differentiated Thyroid Carcinoma Invading Trachea,Esophagus and Larynx

目的探讨侵犯气管、食管、喉部的分化型甲状腺癌(differentiatedthyroidcancer,DTC)的有效诊断、治疗方法,以提高患者生存率,降低术后并发症的发生。方法回顾性分析华中科技大学同济医学院附属协和医院耳鼻咽喉头颈外科收治的28例侵犯气管、食管、喉部的分化型甲状腺癌患者临床资料。手术治疗方式包括肿瘤削切术5例,气管壁窗式切除术11例,气管袖状切除术+气管端-端吻合术9例,气管、食管部分切除术+全喉切除术3例。随访评估治疗效果及预后。结果①28例患者中16例行气管切开术,气管切开率57.1%;6例顺利拔管,4例双侧喉返神经麻痹行声带外展术或杓状软骨切除术后拔管,2例因气管吻合口狭窄行激光或等离子刀狭窄疤痕切除术后拔管,拔管率75.0%;4例术后一直带管,未能拔管。②5例肿瘤切除术患者术后2~5年局部控制良好,未见复发,6~10年2例局部复发。③11例行气管壁窗式切除术患者,术后2~5年均局部控制良好,未见复发,术后6~10年3例复发、1例肺部转移。④9例行气管袖状切除+气管端-端吻合术患者术后2年均局部控制良好,未见复发;5年局部复发1例;6~10年2例局部复发,2例因肺部转移死亡。⑤3例气管、食管部分切除术+全喉切除术患者,术后2~5年均局部控制良好,未见复发;6~10年1例肺部转移,1例因颈部淋巴结、纵隔淋巴结、肺部广泛转移而死亡。结论分化型甲状腺癌若未侵犯气管腔内黏膜层,可采用肿瘤削切术,若穿透喉气管黏膜层突入腔内,则应行气管窗式切除术或气管袖状切除术。对于双侧喉返神经麻痹的患者,应选择喉外径路声带外展术或支撑喉镜下杓状软骨切除术,可以提高气管切开术后的拔管率,改善患者生活质量。

Objective To explore the effective diagnosis and treatment of differentiated thyroid cancer(DTC)invading trachea,esophagus and larynx,so as to improve the survival rate of patients and reduce the incidence of postoperative complications.Methods The clinical data of 28 cases of differentiated thyroid cancer invading the trachea,esophagus,or larynx were analyzed retrospectively.The reviewed patients were from the Department of Otolaryngology-Head and Neck Surgery of Union Hospital of Huazhong University of Science and Technology between January 2006 and December 2016.According to the extent and degree of tumor invasion of the trachea,esophagus and larynx,the patients received tumor excision(5 cases),trachea window drainage(11 cases),tracheal sleeve resection plus tracheal end-to-end anastomosis(9 cases),and trachea and esophagus partial resection plus total laryngectomy(3 cases).Results(1)Among the 28 patients,16 cases underwent tracheotomy,the tracheotomy rate was 57.1%;6 cases were successfully extubated;4 cases of bilateral recurrent laryngeal nerve paralysis were treated with vocal cord abduction or arytenoidectomy;2 cases were treated with laser or plasma knife scar excision because of tracheal anastomotic stenosis,the extubating rate was 75.0%;4 cases were kept with tube after operation,failed to extubate.(2)Among the 5 patients who underwent tumor resection,their diseases were controled well for 2-5 years after operation,no recurrence was found,but 2 patients had local recurrence in 6-10 years.(3)Eleven patients with tracheal window resection were locally controlled for 2 to 5 years after operation.The tumor recurred in 3 cases and 1 case had pulmonary metastasis after 6-10 years operation.(4)Nine patients underwent tracheal sleeve resection and end-to-end tracheostomy were locally controlled 2 years after operation,1 case had local recurrence in 5 years,2 cases had local recurrence in 6-10 years,and 2 cases died of pulmonary metastasis.(5)Three cases of total laryngectomy were locally controlled in 2-5 years after operation,1 case had pulmonary metastasis in 6-10 years,and 1 case died due to extensive metastasis of cervical lymph nodes,mediastinal lymph nodes and lungs.Conclusion If the differentiated thyroid carcinoma has not yet invaded the endotracheal mucosa,tumor resection can be performed.However,if the differentiated thyroid carcinoma penetrates the laryngotracheal mucous layer and protrudes into the lumen,tracheal window resection or tracheal sleeve resection should be performed.For patients with bilateral recurrent laryngeal nerve paralysis,external laryngeal approach vocal cord abduction or arytenoidectomy under supporting laryngoscope can increase the extubation rate after tracheectomy and improve the quality of life of the patients.