分化型甲状腺癌姚峰孙圣荣实习PPT课件.ppt

分化型甲状腺癌的手分化型甲状腺癌的手术治治疗 甲状腺癌指南解甲状腺癌指南解读 武武汉大学人民医院乳腺甲状腺外科大学人民医院乳腺甲状腺外科姚姚 峰峰 孙圣荣圣荣1 1.发病率不断上升病率不断上升甲状腺癌甲状腺癌发发病率每年均在上升，病率每年均在上升，20102010年年为为女性女性恶恶性性肿肿瘤第五位瘤第五位1973-20021973-2002年年发发病率增加了病率增加了2.42.4倍，主要倍，主要为为乳乳头头状状癌，其癌，其发发病率增加了病率增加了2.92.9倍倍5 515%15%的甲状腺的甲状腺结节结节是癌是癌49%1cm49%1cm，87%2cm87%2cm，这这与与颈颈部超声部超声检查检查的广的广泛泛应应用，用，获获得早期得早期诊诊治有关治有关2 2.3 3.4 4.NCCN 指南在甲状腺在甲状腺专业专业医生的正确治医生的正确治疗疗下大部分病人可以治愈，下大部分病人可以治愈，治治疗疗包括包括手手手手术术、（只要可能均需手、（只要可能均需手、（只要可能均需手、（只要可能均需手术术），），），），然后予以放射然后予以放射碘及碘及TSHTSH抑制治抑制治疗疗，外放，外放疗疗和化和化疗疗作用有限。作用有限。5 5.ATA指南合适的手合适的手合适的手合适的手术术方案方案方案方案是影响是影响预预后最重要的因素，碘后最重要的因素，碘131131、TSHTSH抑制及外放抑制及外放疗疗只起只起辅辅助作用助作用6 6.分化型甲状腺癌手术方式甲状腺手甲状腺手术术方式方式 只有三种甲状腺手只有三种甲状腺手术术方式：患方式：患侧侧腺叶切除、甲状腺全切或腺叶切除、甲状腺全切或近全切近全切淋巴淋巴结结清清扫扫 对对于于临临床阳性或超声、床阳性或超声、FNAFNA提示淋巴提示淋巴结转结转移，均需治移，均需治疗疗性清性清扫扫 对对于于临临床淋巴床淋巴结结阴性，是否阴性，是否预预防性清防性清扫扫？大多主？大多主张张做做7 7.NCCN指南（甲状腺全切除术）甲状腺全切除适应症乳头状癌 以下任一条 年年龄龄154545 放射放射线线照射史照射史 有有远处转远处转移移 双双侧侧均有均有结节结节 病灶已浸病灶已浸润润甲状腺外甲状腺外 肿肿瘤瘤4cm4cm 颈颈部淋巴部淋巴结结有有转转移移 高侵高侵袭袭性性亚亚型型滤泡状癌和许特氏细胞癌 所有浸所有浸润润性癌性癌 微小浸微小浸润润癌也可癌也可选择选择 8 8.ATA指南（甲状腺全切除术）For patients with thyroid cancer 1 cm,the initial surgical procedure should be a near-total or total thyroidectomy unless there are contraindications to this surgery 对于甲状腺癌病灶1cm者，初始手术治疗应该选择近全或全甲状腺切除术，除非患者对该术式有禁忌 9 9.NCCN指南（患侧腺叶全切除术）患侧腺叶全切除适应症乳头状癌满足以下所有 年年龄龄15-4515-45 无放射无放射线线照射史照射史 无无远处转远处转移移 未侵及甲状腺外未侵及甲状腺外 肿肿瘤瘤4cm4cm 颈颈部淋巴部淋巴结结无无转转移移 非侵非侵袭袭性性亚亚型型滤泡状癌和许特氏细胞癌 经严经严格病理学格病理学检查检查（至少（至少1010张组织张组织切片）切片）证实证实的微小浸的微小浸润润癌可癌可选择选择 1010.ATA指南（患侧腺叶全切除术）Thyroid lobectomy alone may be sufficient treatment for small(1 cm),low-risk,unifocal,intrathyroidal papillary carcinomas in the absence of prior head and neck irradiation or radiologically or clinically involved cervical nodal metastases 甲状腺腺叶切除甲状腺腺叶切除术对术对那些病灶小（那些病灶小（1cm1cm），低），低危、危、单单一病灶、局限于甲状腺内的乳一病灶、局限于甲状腺内的乳头头状癌且没状癌且没有既往有既往头颈头颈部放射部放射线线照射史、无照射史、无临临床淋巴床淋巴结结受累受累者可能是可行的者可能是可行的术术式式 1111.Total thyroidectomy VS Lobectomy（1）To determine whether total thyroidectomy resulted in improved recurrence and long-term survival rates for patients with PTCTo determine whether a specific tumor size threshold could be identified above which total thyroidectomy was associated with a decreased risk of recurrence and deathBilimoria,K Y,et al.Annals of Surgery.2007;246:375-3841212.Total thyroidectomy VS Lobectomy（1）Bilimoria,K Y,et al Annals of Surgery.2007;246:375-3841313.Total thyroidectomy VS Lobectomy（1）Bilimoria,K Y,Annals of Surgery.2007;246:375-384Bilimoria,K Y,et al Annals of Surgery.2007;246:375-3841414.Total thyroidectomy VS Lobectomy（1）Recurrence rates after surgery for patients with PTC(B)by extent of surgery.Bilimoria,K Y,et al Annals of Surgery.2007;246:375-3847.7%9.8%P0.051515.Total thyroidectomy VS Lobectomy（1）Bilimoria,K Y,et al Annals of Surgery.2007;246:375-384Relative survival rates after surgery for patients with PTC(B)by extent of surgery.98.4%97.1%P4cm4cm 切切缘缘阳性阳性 明明显显侵及甲状腺外侵及甲状腺外 肉眼下肉眼下为为多灶性多灶性 已已证实证实有淋巴有淋巴结转结转移移 1-4cm1-4cm或侵或侵袭袭性性亚亚型也可型也可选择选择追加甲状腺全切除追加甲状腺全切除滤泡状癌和许特氏细胞癌 所有伴有明所有伴有明显显血管浸血管浸润润的浸的浸润润性癌，微小浸性癌，微小浸润润癌也可癌也可选选择择追加甲状腺全切除追加甲状腺全切除 2222.ATA指南（初次手术后追加全切术）Completion thyroidectomy should be offered Completion thyroidectomy should be offered to those patients for whom a near-total or to those patients for whom a near-total or total thyroidectomy would have been total thyroidectomy would have been recommended had the diagnosis been recommended had the diagnosis been available before the initial surgery.This available before the initial surgery.This includes all patients with thyroid cancer includes all patients with thyroid cancer except those with small(1 cm),unifocal,except those with small(1 cm),unifocal,intrathyroidal,node-negative,low-risk intrathyroidal,node-negative,low-risk tumors tumors 首次手首次手术术前若能确前若能确诊诊即需行（而即需行（而实际实际未行）全或近全甲状未行）全或近全甲状腺切除腺切除术术的病人的病人应应行追加的甲状腺全切除行追加的甲状腺全切除术术。仅肿仅肿瘤小瘤小(1 cm)(1 cm)、单单病灶、病病灶、病变变局限于甲状腺体内、淋巴局限于甲状腺体内、淋巴结结阴性、阴性、低危低危肿肿瘤者除外瘤者除外 2323.ATA指南（初次手术后追加全切术）Ablation of the remaining lobe with Ablation of the remaining lobe with radioactive iodine has been used as an radioactive iodine has been used as an alternative to completion thyroidectomy.It is alternative to completion thyroidectomy.It is unknown whether this approach results in unknown whether this approach results in similar long-term outcomes.Consequently,similar long-term outcomes.Consequently,routine radioactive iodine ablation in lieu of routine radioactive iodine ablation in lieu of completion thyroidectomy is not completion thyroidectomy is not recommended.recommended.用放射性碘行残余腺叶消融治用放射性碘行残余腺叶消融治疗疗被作被作为为甲状腺全甲状腺全切除切除术术的一种替代的一种替代选择选择，这这种方法是否可取得相种方法是否可取得相似的似的长长期效果尚不清楚。因此，不推荐常期效果尚不清楚。因此，不推荐常规应规应用用放射性碘消融作放射性碘消融作为为甲状腺全切除甲状腺全切除术术的替代的替代 2424.Completion Thyroidectomy（1）Kim ES,et al Clinical Endocrinology.2004;61:145-1481995-2001年年,243例病人因甲状腺例病人因甲状腺结节FNA提示提示滤泡泡性性肿瘤病瘤病变接受手接受手术，214例接受患例接受患侧腺叶及峡叶切除，腺叶及峡叶切除，其中其中81例例术后后诊断断为甲状腺癌而接受追加的全甲状腺切甲状腺癌而接受追加的全甲状腺切除除术，平均年，平均年龄40.7岁对侧对侧腺叶存在癌腺叶存在癌2929（36%36%）滤滤泡状癌泡状癌6 6许许特氏特氏细细胞癌胞癌1 1乳乳头头状癌状癌2222对侧癌灶均1cm，中央区淋巴结转移（包括对侧中央区淋巴结转移）均明显增加3737.Central Neck Dissection（2）Moo TS,et al.Annals of Surgery 2009；250:403408并发症（甲旁腺）3838.Central Neck Dissection（2）Moo TS,et al.Annals of Surgery 2009；250:403408并发症（永久低钙和喉返损伤）3939.Central Neck Dissection（3）Our strategy was to do a total thyroidectomy and a careful central neck dissectionTisell LE,et al.World J.Surg.1996;20:854859 4040.Central Neck Dissection（4）Palestini N,et al.Langenbecks Arch Surg 2008；393:693698305 例甲状腺乳头状癌病人行甲状腺全切除术分为三组group A(n=64)淋巴结阳性，行治疗性双侧中央区淋巴结清扫group B(n=93)淋巴结阴性，行预防性患侧中央区淋巴结清扫group C(n=148)淋巴结阴性，不做中央区淋巴结清扫比较三组的手术后并发症发生率4141.Central Neck Dissection（4）Palestini N,et al.Langenbecks Arch Surg 2008；393:6936984242.Central Neck Dissection（4）Palestini N,et al.Langenbecks Arch Surg 2008；393:693698中央区淋巴结清扫并不增加永久性喉返神经麻痹及甲旁减的发生几率，当临床中央区淋巴结阴性时，从局部彻底清除病变、避免低估肿瘤分期同时降低并发症风险综合考虑，患侧中央区预防性清扫是最佳选择4343.NCCN指南（颈侧区淋巴结清扫）颈侧区淋巴结清扫 不推荐预防性颈侧区淋巴结清扫，如果淋巴结可触及或淋巴结阳性，清扫、区淋巴结，根据临床和超声检查来考虑是否清扫、区 4444.ATA指南（颈侧区淋巴结清扫）Therapeutic lateral neck compartmental Therapeutic lateral neck compartmental lymph node dissection should be performed lymph node dissection should be performed for patients with biopsy proven metastatic for patients with biopsy proven metastatic lateral cervical lymphadenopathy.lateral cervical lymphadenopathy.活活检证实为颈侧淋巴淋巴结转移的病例移的病例应行治行治疗性性颈侧淋巴淋巴结清清扫术 4545.Lateral Neck Dissection(1)术前超声检查颈侧方淋巴结阳性者无淋巴结复发生存率低于超声下淋巴结阴性者Ito Y,et al.World J.Surg.2004；28：4985014646.Lateral Neck Dissection(1)Ito Y,et al.World J.Surg.2004；28：498501术前超声检查颈侧方淋巴结阴性者，颈侧清对无淋巴结复发生存率没有影响4747.While most now agree that While most now agree that prophylactic lymph node prophylactic lymph node dissections(LND)play no roledissections(LND)play no role,at the University of,at the University of California,San Francisco(UCSF)we limit LND California,San Francisco(UCSF)we limit LND selectively on a level by level basis,and resect only selectively on a level by level basis,and resect only the levels thought to harbor disease or to be at the levels thought to harbor disease or to be at increased risk of metastases.increased risk of metastases.This initial,selective This initial,selective LND usually includes levels III and IV(due to the LND usually includes levels III and IV(due to the well-documented increased likelihood of metastases well-documented increased likelihood of metastases to these levels)and levels I,II,and V are included to these levels)and levels I,II,and V are included when there is clinical or radiological evidence of when there is clinical or radiological evidence of disease or increased risk of itdisease or increased risk of itLateral Neck Dissection(2)Caron NR.,et al.World J.Surg.2006；30：8338404848.Lateral Neck Dissection(2)Caron NR.,et al.World J.Surg.2006；30：833840A total of 140 initial lateral LND were performed:104 ipsilateral and 36 contralateral.level I level I ipsilateral ipsilateral 3.9%3.9%contralateral contralateral 2.9%2.9%level IIlevel IIipsilateralipsilateral72.5%72.5%contralateral contralateral 60.0%60.0%level Vlevel Vipsilateralipsilateral18.6%18.6%contralateral contralateral 37.1%37.1%4949.Lateral Neck Dissection(2)Caron NR.,et al.World J.Surg.2006；30：8338405050.Lateral Neck Dissection(2)Caron NR.,et al.World J.Surg.2006；30：8338405151.未未 来来The Challenge of Managing Differentiated Thyroid Carcinoma Managing differentiated(i.e.,papillary,follicular,and Hrthle)thyroid carcinoma can be a challenge.Results from ongoing randomized trials will not be available for many years.5252.谢 谢5353.2024/3/1 2024/3/1 周五周五5454.