分化型甲状腺癌姚峰孙圣荣实习课件.ppt

1、甲状腺癌发病率每年均在上升，2010年为女性恶性肿瘤第五位NCCN 指南在甲状腺专业医生的正确治疗下大部分病人可以治愈，治疗包括然后予以放射碘及TSH抑制治疗，外放疗和化疗作用有限。Total thyroidectomy VS Lobectomy（1）Bilimoria,K Y,et al.Annals of Surgery.2007;246:375-384Total thyroidectomy VS Lobectomy（1）Bilimoria,K Y,et al Annals of Surgery.2007;246:375-384Total thyroidectomy VS Lobectom

2、y（1）Bilimoria,K Y,Annals of Surgery.2007;246:375-384Bilimoria,K Y,et al Annals of Surgery.2007;246:375-384Total 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%P0.05Total thyroidect

3、omy 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%P0.05Total thyroidectomy VS Lobectomy（1）Bilimoria,K Y,et al.Annals of Surgery.2007;246:375-384Total thyroidectomy VS Lobectomy（2）1656

4、patients with AMES low-risk PTC The median age of the patients was 43 years,with a range of 4 to 87 years.Hay,ID,et al.Surgery.1998;124:958-966Total thyroidectomy VS Lobectomy（2）Hay,ID,et al.Surgery.1998;124:958-966死亡率及远处转移率没有区别Total thyroidectomy VS Lobectomy（2）Hay,ID,et al.Surgery.1998;124:958-966

5、局部复发率及淋巴结转移率有区别Total thyroidectomy VS Lobectomy（2）Hay,ID,et al.Surgery.1998;124:958-966剔除接受放射碘治疗病例，局部复发率及淋巴结转移率仍有区别Completion Thyroidectomy（1）Kim ES,et al Clinical Endocrinology.2004;61:145-1481995-2001年年,243例病人因甲状腺结节例病人因甲状腺结节FNA提示滤泡性提示滤泡性肿瘤病变接受手术，肿瘤病变接受手术，214例接受患侧腺叶及峡叶切除，例接受患侧腺叶及峡叶切除，其中其中81例术后诊断为甲状

6、腺癌而接受追加的全甲状腺切例术后诊断为甲状腺癌而接受追加的全甲状腺切除术，平均年龄除术，平均年龄40.7岁岁对侧癌灶均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Central Neck Dissection（2）Moo TS,et al.Annals of Surgery 2009；250:403408并发症（甲旁腺）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）Central Neck Dissection（3）Our strategy was t

7、o do a total thyroidectomy and a careful central neck dissectionTisell LE,et al.World J.Surg.1996;20:854859 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

8、，不做中央区淋巴结清扫比较三组的手术后并发症发生率Central Neck Dissection（4）Palestini N,et al.Langenbecks Arch Surg 2008；393:693698Central 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术前超声检查颈侧方淋巴结阳性者无淋巴结复发生

9、存率低于超声下淋巴结阴性者Ito Y,et al.World J.Surg.2004；28：498501Ito 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While most now agree that prophylactic lymph node dissections(LND)play no role,at the University of California,San Francisco(UCSF)we limit LND selectively on a level by level b

10、asis,and resect only the levels thought to harbor disease or to be at increased risk of metastases.This initial,selective LND usually includes levels III and IV(due to the well-documented increased likelihood of metastases to these levels)and levels I,II,and V are included when there is clinical or

11、radiological evidence of disease or increased risk of itCaron NR.,et al.World J.Surg.2006；30：833840Caron NR.,et al.World J.Surg.2006；30：833840A total of 140 initial lateral LND were performed:104 ipsilateral and 36 contralateral.Caron NR.,et al.World J.Surg.2006；30：833840Caron NR.,et al.World J.Surg.2006；30：833840The 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.