^(131)I治疗分化型甲状腺微小乳头状癌的疗效及影响因素分析

The Therapy Response and Influencing Factors of ^(131) I for Treating Papillary Thyroid Microcarcinoma

目的研究手术联合^(131)I治疗比较单纯手术治疗,对分化型甲状腺微小乳头状癌的不同疗效及无进展生存期(progression-free survival,PFS)有无影响。方法回顾性分析186例甲状腺切除术联合^(131)I治疗的分化型甲状腺微小乳头状癌(papillary thyroid microcarcinoma,PTMC)患者和185例单纯手术治疗的PTMC患者,共371例患者。术后6~12个月后根据血清学及影像学指标评估所有患者的疗效。对371例患者随访12~84个月,收集治疗后的血清学、影像学及治疗记录资料。根据治疗反应评估体系将186例^(131)I治疗患者分为疗效满意(ER)、疗效不确切(IDR)、生化疗效不佳(BIR)、结构性疗效不佳(SIR),评估病情有无进展。采用卡方检验、t检验、Fisher确切法比较各治疗组的疗效差异及影响因素;采用Kaplan-Meier法及Log-rank检验分析比较无进展生存期(PFS),Cox比例风险模型评估PFS的独立预测因子。结果(1)中位随访60个月,手术联合^(131)I治疗组病情进展患者20例(5.39%),手术治疗组病情进展患者35例(9.43%)。手术联合^(131)I治疗组的PFS率为89.2%,手术治疗组的PFS率为81.1%,不同治疗组之间的PFS差异有统计学意义(P=0.026)。(2)手术联合^(131)I治疗组的ER率为72.04%(134/186),IDR率4.30%(8/186),BIR率12.90%(24/186),SIR率10.75%(20/186)。(3)诊断SIR的ps-Tg的界值点为29.22ng/mL(灵敏度50.0%,特异性91.0%),ROC曲线下面积AUC为0.729(95%CI:0.659~0.791)。(4)有无^(131)I治疗、多灶性、病灶直径、有无颈部淋巴结转移、有无甲状腺外侵犯、复发危险度分层、^(131)I治疗前刺激性Tg和治疗后抑制性Tg水平是影响患者PFS的重要因素。结论对于分化型微小甲状腺癌的患者,术后辅以^(131)I治疗可改善患者的PFS;多发病灶、病灶直径>0.5cm、淋巴结转移、复发危险度分层为中高危、甲状腺外侵犯及治疗前刺激性球蛋白(preablations-Tg)水平>29.22ng/mL是降低患者PFS的重要因素;治疗前ps-Tg≤1.31ng/mL的患者^(131)I治疗后疗效较好。

Objective To investigate therapy response and progression-free survival(PFS)of the surgical treatment combined with ^(131)I and surgical treatment alone in patients with papillary thyroid microcarcinoma(PTMC).Methods 371 PTMC patients with a total of 186 surgical treatment combined with ^(131)I and 185 surgical treatment alone were retrospectively analyzed.Diagnostic whole-body scan or neck ultrasound was measured 6-12 months after ^(131)I ablation,and TSH,FT 3,FT 4,Tg and TgAb were also examined for treatment response evaluation.Patients were followed up for 6 to 84 months,and serological,imaging and treatment records were collected after ^(131)I to assess the progression.χ^(2) test and Fisher’s exact test were used for data analysis.Kaplan-Meier method and log-rank test were used to compared progression-free survival(PFS)among groups.Cox proportional risk model was used evaluate the independent risk factors for PFS.Results(1)The median follow-up time was 60 months.20 patients(5.39%)had progressed in the surgical treatment combined with ^(131)I group,and 35 patients(9.43%)had progressed in the surgical treatment group.PFS rate in the surgical treatment combined with ^(131)I group was 89.2%,and the PFS rate was 81.1%in the surgical treatment group(P=0.026).(2)ER/IDR/BIR/SIR rate in the surgical treatment combined ^(131)I group was 72.04%(134/186),4.30%(8/186),12.90%(24/186),and 10.75%(20/186).(3)The cut-off point of ps-Tg for SIR was 29.22ng/mL(sensitivity50.0%,specificity 91.0%),and the area under the curve was 0.729(95%CI:0.659-0.791).(4)The presence of ^(131)I treatment,multifocal,focal diameter,presence of cervical lymph node metastasis,presence of external thyroid invasion,recurrence risk stratification,Tg before ^(131)I treatment and inhibitory Tg levels were important factors affecting PFS in patients.Conclusion For middle and high-risk patients with PTMC,surgical treatment with ^(131)I can improve PFS;Multifocal,lesion diameter>0.5cm,cervical lymph node metastasis,external thyroid invasion and ps-Tg>29.22ng/mL are important factors to reduce PFS;Patients with ps-Tg≤1.31ng/mL have a better effect after the ^(131)I treatment.