甲状腺微小癌的诊断和治疗

学 校 代 码 10459学号或申请号密 级专业硕士学位论文甲状腺微小癌的诊断和治疗作 者 姓 名：导 师 姓 名：专业学位名称：普通外科培 养 院 系：完 成 时 间：2016年5月A thesis(dissertation) submitted toZhengzhou Universityfor the degree of Master（doctor）Diagnosis and treatment of thyroid cancerBy Zhijian MengXiuBo LUGeneral SurgeryThe First Affiliated Hospital of Zhengzhou UniversityMay,2016原创性声明本人郑重声明：所呈交的学位论文，是本人在导师的指导下，独立进行研究所取得的成果。

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学位论文作者：日期：年月日中文摘要甲状腺微小癌的诊断和治疗中文摘要背景：甲状腺癌是较为常见的恶性肿瘤，有研究表明，在我国甲状腺癌人群发病率约为1.5/10万，但近年来发病率呈现出年轻化和升高的趋势[1、2、3]。

甲状腺微小癌属于特殊类型甲状腺癌，直径多小于1cm[4、5 ]。

随着现代医疗技术的发展，高分辨率超声的应用以及病理诊疗技术水平的进步，对于甲状腺微小癌的诊断和治疗报道逐年增加，但是许多病例确诊是在术中偶然发现或术后甲状腺病理检查中发现的，在临床诊疗的过程中漏诊率高[6]。

甲状腺微小癌起病隐匿，常与其他甲状腺疾病共存，有的病变长期处于一种亚临床的状态，其肿瘤行为被认为是一种良性病变，但是不是所有甲状腺微小癌都处于静止状态，也有可能出现肿瘤侵袭性生长和淋巴结转移现象，淋巴转移是其主要转移途径，甲状腺微小癌发生淋巴结转移后就会出现临床表现，此时必须予以治疗[7、8、9]。

既往研究表明甲状腺微小癌治疗效果较为理想，外科治疗能彻底治愈[10]。

因而，要特别重视甲状腺微小癌的诊断和治疗，降低复发和转移的发生率。

目的：回顾性分析甲状腺微小癌患者的临床特征，淋巴结转移、手术方式，以期为甲状腺微小癌的诊疗提供指导。

方法：回顾分析2012年1月-2014年1月到郑大一附院甲状腺外一科住院101 例甲状腺微小癌患者，且经术后病理证实的甲状腺微小癌患者。

在性别方面：男 26 例，女 75 例，在年龄方面，所有患者年龄均在 23-68 岁之间，其中年龄在45岁以下患者58 例，45岁以上患者43 例，平均年龄为46.39±17. 85岁，在临床分型方面，其中T1N0M0 54 例，T1N1M0 47 例。

在发病情况方面，双侧腺发病20例，单侧腺发病81例，在合并症方面，101例患者中合并其他甲状腺的良性疾病61例。

1、本次入选的101例甲状腺微小癌患者术前均行超声影像学检查及细针穿I中文摘要刺针吸细胞学检查；2例患者行放射性核素扫描；5例患者行CT 检查。

2、所入选的101 例患者均采用外科手术治疗方式。

其中行11例单侧腺叶及峡部切除术，双侧甲状腺全切术6例，患侧甲状腺切除并中央区淋巴结清扫54例，双侧甲状腺切除并患侧中央区淋巴结清扫25例，甲状腺改良根治术5例。

在淋巴结的清扫方面，84例患者行颈部淋巴结清扫术，其中79例患者行单纯VI区淋巴结清扫术。

3、所有数据通过spss19.0处理，计量资料应用t检验，计数资料应用X2检验；采用单因素方差分析对年龄、性别有无淋巴转移、肿瘤直径、病灶情况、手术方式、是否侵袭包膜等因素进行分析。

P<0.05作为有临床意义的标准。

结果：1、甲状腺微小癌的超声影像学结果：术前甲状腺结节超声根据Kwak等[1]提出的TI-RADS分级方法，在本次临床研究的101例甲状腺微小癌患者中，Ⅲ级7例、Ⅳa级 46例、Ⅳb级 32例、Ⅳc级5例、Ⅴ级5例。

其中在Ⅲ级及Ⅳ级中，有83例均行超声引导针吸细胞学检查，符合微小癌诊断的有75例。

2、在本组病例的101例均行术中冰冻病理检查，其中19例在术后病理检查中确诊，假阴性率19%；3、本组病例中出现VI区淋巴结转移的占38%（38/101），颈侧区淋巴结转移的占14%（14/101），两组具有显著差异（P<0.05），有统计学意义；4、在VI区淋巴结清扫中，术前超声检查发现转移为60.00%（30/50）；未发现转移淋巴结为25.00%（8/32），具有统计学意义（P<0.05）；颈侧区淋巴结清扫术中，术前超声检查发现及未发现转移淋巴结分别为63.16%和16.67%，有统计学意义（P<0.05）5、对影响预后、肿瘤复发的相关因素进行单因素方差分析及多因素Logistic回归分析，最后发现病灶为多发、有包膜以及出现淋巴转移为病人出现术后肿瘤复发的独立相关因素（P<0.05）。

6、本次临床研究中，8例患者手术后出现甲状旁腺功能低下，但在术后3II中文摘要个月内恢复，未出现喉返神经麻痹。

结论：1、目前高分辨率超声和超声引导针吸细胞学检查是术前诊断甲状腺微小癌的主要手段。

2、甲状腺微小癌的淋巴结转移率高，需要常规行患侧甲状腺全切除+VI区淋巴结清扫或者患侧腺叶加峡部切除。

结合病情开展综合个体化治疗。

3、甲状腺微小癌可能早期出现颈部淋巴结转移，所以并不都是早期癌。

关键词：甲状腺微小癌；早期诊断；超声；针吸细胞学；IIIAbstractAbstractBackground:Thyroid carcinoma is a common malignant tumor. The study shows that the incidence of thyroid carcinoma in China is about 15/100000, but in recent years, the incidence rate is younger and higher. Thyroid Mini carcinoma is a special type of thyroid carcinoma, with a diameter of more than 1cm, which is a special type of thyroid carcinoma. With the development of modern medical technology, high resolution ultrasound and pathological diagnosis and treatment level of technology progress and to report on the diagnosis and treatment of thyroid microcarcinoma increased year by year, but many cases is found accidentally discovered in the intraoperative or postoperative thyroid pathological examination, in the process of clinical diagnosis and treatment of misdiagnosis rate is high. Thyroid microcarcinoma of insidious onset, often coexist with other thyroid diseases, and some lesions in long-term a subclinical state. The tumor behavior is considered to be a benign lesion, but not all thyroid microcarcinoma in static state, may also appear tumor invasion hit growth and lymph node transfer phenomenon, lymphatic metastasis is the major route of metastasis, lymph node metastasis will appear after the clinical manifestations of thyroid microcarcinoma and must then be treated. Previous studies have indicated that the effect of thyroid Mini carcinoma treatment is more ideal, surgical treatment can be completely cured. Therefore, special attention should be paid to the diagnosis and treatment of small thyroid carcinoma, and to reduce the incidence of recurrence and metastasis.Objective: To retrospectively analyze the clinical characteristics, lymph node metastasis and surgical methods of small thyroid carcinoma patients, and to provide guidance for clinical diagnosis and treatment of thyroid carcinoma.Methods: a retrospective analysis of 101 cases of thyroid Mini carcinoma in theIVAbstractDepartment of thyroid surgery, the 1st Affiliated Hospital of Zhengzhou University, from January 2012 to January, and patients with thyroid carcinoma were confirmed by postoperative pathological examination. In terms of gender: 26 cases of male, female 75 cases, in terms of age, age of all the cases were 23-68 between the ages of. The age in 58 cases of patients under the age of 45, 43 cases of patients over 45 years old, average age for 46.39±17.85 years old, in the clinical type, including 53 cases of T1N0M0, t1n1m0 in 47 cases. In the incidence of the disease, 20 cases of bilateral gland disease, 81 cases of unilateral gland disease, in terms of the complications, 101cases of patients with other thyroid benign diseases in 61 cases.1.The selected 101 cases of patients with small thyroid carcinoma were examined by ultrasonography and fine needle aspiration cytology before operation. 2 patients underwent radionuclide scan and 5 patients underwent CT examination.2.Surgical treatment was adopted in 101 patients. Among them, 99 cases underwent subtotal thyroidectomy. 2 patients underwent unilateral lobectomy and isthmus resection. In lymph node dissection, 99 cases of patients with cervical lymph node dissection, which 51 cases of patients with pure VI lymph node dissection, 31 cases underwent VI + neck region of lateral lymph node dissection; 5 cases and bilateral lateral neck dissection.3.All the data by spss19.0 processing, measurement data using t-test, count data using X2test. The single factor variance analysis of gender, age, lymph node metastasis, tumor size, tumor, surgical approach, invasion envelope and other factors were analyzed. P<0.05 as a standard of clinical significance.Result：1.Thyroid microcarcinoma of ultrasound imaging studies showed that preoperative ultrasound of thyroid nodules by Kwak et al proposed Ti radsclassification grade 7 cases in grade III, IV A-level 46 cases, IV grade B 32 cases, IV grade C in 5 cases,VAbstractgrade V 5 cases. Among them, 83 cases of grade III and IV were all performed by ultrasound guided needle aspiration cytology in 76 cases. Cervical lymph node enlargement: VI area in 35 cases, 25 cases of cervical side area, of which 8 cases of cervical lateral lymph node needle biopsy confirmed metastatic lymph nodes for thyroid cancer. CT examination results: 4 cases all showed no significant accounting, not all of the thyroid gland density, 2 cases showed that the neck and trachea lymph nodes increased. Cytological examination of cervical lymph nodes:. Thyroid “cold nodule”.2.In this group of cases, 101 cases were diagnosed by intraoperative frozen pathological examination, of which 19 cases were confirmed by pathological examination after operation, the false negative rate was 19%;3.In this group, there were 38% (38/101) in the lymph node metastasis in the VI teral cervical lymph node metastasis was 14% (14/101), the two groups had significant difference (P<0.05), there was statistical significance;4. In VI lymph node dissection, preoperative ultrasonography found for the transfer of 60.00% (30 / 50); no metastasis was found in the lymph node was 25.00% (8 / 32), with statistical significance (P < 0.05); neck region of lateral lymph node dissection, preoperative ultrasonography was found and no metastasis was found in the lymph node was 63.16% and 16.67% respectively, was statistically significant (P < 0.05) 5．Affect the prognosis and recurrence related factors of single factor variance analysis and multiple logistic regression analysis, finally found lesions were multiple, enveloped and lymph node metastasis tumor recurrence of independent factors (P < 0.05) for the patient.6. After surgery, there were 8 cases of patients with low parathyroid function, temporary, 3 months after the recovery, no recurrent laryngeal nerve palsy. Conclusion:High resolution ultrasound and ultrasound guided needle aspiration cytological examination areVIAbstractthe main methods for the diagnosis of thyroid micro carcinoma before operation. The rate of lymph node metastasis in thyroid carcinoma is high, which requires that the +VI region lymph node dissection in the near total resection of the thyroid gland is required. Thyroid cancer can be early cervical lymph node metastasis, not all of them early cancer.Key words: thyroid cancer; early diagnosis;ultrasound；needle aspiration cytologyVII目录目录正文部分前言 (1)资料与方法 (2)结果 (3)讨论 (6)结论 (21)参考文献 (21)综述部分甲状腺乳头状微小癌的主要诊断和外科治疗 (28)参考文献 (35)附录部分个人简介 (38)攻读硕士学位期间发表论文： (38)致谢 (39)VIII目录DIRECTORYBODY PARTPREFACE (1)MATERIALS AND METHODS (2)RESULT (3)DISCUSSION (6)CONCLUSION (21)REFERENCE (21)REVIEW SECTIONPRIMARY DIAGNOSIS AND SURGICAL TREATMENT OF PAPILLARYTHYROID CARCINOMA (28)REFERENCE (35)POSTSCRIPTURAL MATTERPERSONAL PROFILE (38)STUDY FOR A MASTER'S DEGREE IN PUBLISHED PAPERS： (38)THANKS (39)IX前言前言甲状腺癌是头颈部和内分泌系统最常见的恶性肿瘤，近十年来，其发病率在世界范围内呈现明显上升的趋势，而在育龄女性中的发病率更高[1]。