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[摘要] 目的:探讨分化型甲状腺癌再次手术的原因及对策。方法:回顾性分析本科2000年1月～2007年1月收治的甲状腺手术后病理证实为分化型甲状腺癌需再次手术治疗的45例临床病理资料。结果:45例再次手术患者原因为将甲状腺癌误诊为甲状腺良性病变35例(77.7%),首次手术时25例术前未行定性检查,8例病理误诊为良性,首次手术术式选择不当33例(73.3%),术后病理证实癌残留19例(42.2%),术后复发2例(4.4%)。发生短暂喉返神经损伤2例,短暂低钙抽搐2例,发生术后窒息1例,全组无手术死亡。再次手术者术后随访3～7年,平均随访5年,1例手术后34个月死于肺及骨转移,5年生存率为97.77%。结论:甲状腺癌的临床及病理误诊,手术切除范围不够是造成再次手术的主要原因,提高对甲状腺癌的认识水平,强调术前B超+穿刺细胞学检查,常规术中快速冰冻切片,选择正确的手术方式是避免甲状腺癌再次手术的重要环节,熟练掌握再次手术的入路及技巧是确保再次手术成功的关键。
[关键词] 分化型甲状腺癌;再手术;原因;对策
[中图分类号] R736.1 [文献标识码]A [文章编号]1674-4721(2010)05(a)-024-03
Analysis of 45 patients with differentiated thyroid carcinoma undergoing reoperation
LI Dingjun, ZENG Yuehong, CHEN Zhou
(Department of Generral Surgery,Yiyang City Central Hospital in Hunan Province, Yiyang413000, China)
[Abstract] Objective: To explore the cause of reoperation for differentiated thyroid carcinoma and their countermeasures. Methods: The clinicopathologic data were retrospectively analyzed from 45 cases of differentiated thyroid carcinoma confirmed by postoperative pathology undergoing reoperation from January 2000 to January 2007. Results: 45 cases undergoing reoperation, 35 cases (77.7%) were misdiagnosed as thyroid benign lesion in whom 25 cases didn"t received qualitative examination and the other 8 cases were misdiagnosed as benign lesion by pathology. Of all 45 reoperative cases, 33 cases (73.3%) underwent inappropriate surgery firstly, 19 cases (42.2%) were confirmed as residual carcinoma by postoperative pathology and 2 cases (4.4%) relapsed. Of all 45 cases, 2 cases were in the presence of recurrent laryngeal nerve injury transiently, 2 cases convulsion by hypocalcemia and 1 case postoperative asphyxia. None of all 45 cases were dead. During a follow-up period of 3 to 7 years (mean 5 years), 1 case died from pulmonary and osseous metastasis 34 months after surgery, with a 5-year survival of 97.77%. Conclusion: The insufficient extent of thyroidectomy resulting from clinicopathologic misdiagnosis of thyroid carcinoma is the major cause of the reoperation. Increased cognitive level of thyroid carcinoma, emphasis on the preoperative mode B ultrasonic inspection plus cytological examination, intra-operative rapid frozen section in routine and appropriate selection of surgical technique may be the important keys to avoidance of reoperation of thyroid carcinoma. And proficiently mastering the surgical approach and technique can be the key to ensuring the successful reoperation.
[Key words] Differentiated thyroid carcinoma; Reoperation; Cause; Countermeasure
分化型甲状腺癌是常见的内分泌系统恶性肿瘤,占所有甲状腺癌新发病例的80%,因其分化程度高,预后较好,10年生存率可达90%以上[1],但如果首次外科诊治延误或术式选择不当,部分患者发生复发、转移,甚至死亡[2]。本科2000年1月～2007年1月收治的甲状腺手术后再次手术的分化型甲状腺癌再次手术45例,现分析报道如下:
1资料与方法
1.1 一般资料
本组45例中,男16例,女29例,男女比例为1:1.8,年龄29～72岁,平均41.5岁。其中2次以上手术者9例,6例为癌残留,3例为转移癌,首次手术在外院施行者39例。其中16例在中心卫生院手术,术前、术中均未行定性检查,23例在二级医院手术,9例术前、术中未行定性检查,6例术前穿刺细胞学检查为良性,未行术中快速冰冻切片,8例行术中快速冰冻切片,5例诊断为良性结节,仅行肿瘤挖除术,3例病理可疑癌仅行部分切除, 术后病理会诊确诊为甲状腺乳头状癌。首次手术在本院施行者6例,均行穿刺细胞学检查及术中快速冰冷切片,其中3例术前穿刺细胞学检查发现异形细胞行术中快速冰冻切片,2例不能确定良恶性,1例为乳头状癌Ⅰ级,未行规范化手术,另3例术中快速冰冻切片诊断为良性,经外院病理会诊均为分化型腺癌。
1.2 首次手术方式
甲状腺瘤挖除术5例,甲状腺部分切除14例,甲状腺叶次全切除11例,甲状腺叶次全加峡部切除9例,甲状腺叶次全切除加不规范颈清扫6例,术后病理证实为分化型腺癌。
1.3 再次手术方式
甲状腺原发灶处理:全麻或颈丛阻滞麻醉下探查甲状腺,行患侧腺叶全切加峡部切除12例,甲状腺叶加峡部切除加对侧叶次全切除31例,峡部癌行峡部扩大切除2例;颈淋巴结的处理:在处理原发灶的同时,对术前临床检查、颈部B超、CT提示颈部有可疑淋巴转移行术中淋巴结病理检查、同期颈清扫27例,其中经典颈清扫8例,改良颈清扫19例,再次手术时间180～260 min,出血量300～450 ml,手术入路:侧入路21例,正中入路4例,正中入路与侧入路结合20例。
2结果
2.1 组织病理学
原发灶有癌残留29例,峡部癌残留6例,复发2例,对侧癌8例,27例颈清扫中颈淋巴结转移18例,颈淋巴转移率为66.7%。
2.2 再次手术并发症
2例暂时性喉返神经损伤,1例为分离时牵扯误伤喉返神经及其分支,1例在入喉处分离时因气管侵犯在切除部分气管壁时电凝轻度灼伤,均3～6个月恢复,无永久性喉返神经损伤。发生率为4.44%,1例喉上神经挫伤于术后2周内恢复,无呛咳。12例甲状腺叶全切除,2例出现术后低钙抽搐,经药物处理后于3～4周好转,无永久性低钙发生,1例经典根治术,术后发生呼吸道痰阻窒息行紧急气管切开后痊愈,全组无手术死亡。
2.3 随访
本组45例均获随访,随访时间3～7年,平均随访5年,颈部复发2例,其中行同期改良颈清扫1例对侧叶复发,1例未行颈清扫,同侧淋巴转移。分别于术后3.5年和第5年发生,行再次手术现仍生存,1例于术后34个月死于肺及骨转移。
3讨论
术前、术中定性诊断困难及准确率不高,是甲状腺癌易漏诊、误诊的主要原因,甲状腺癌术前诊断缺乏特异性手段,SPECT对诊断有一定参考意义,但难以作出决定性诊断,CT尚能发现甲状腺内
