伴有呼吸道梗阻的晚期甲状腺恶性肿瘤的多学科协同处理
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摘要
目的探讨多学科协同诊疗模式(MDT)在伴有呼吸道梗阻的局部晚期甲状腺恶性肿瘤治疗中的应用。方法回顾性分析四川省肿瘤医院2015年10月至2017年7月收治的31例局部晚期甲状腺恶性肿瘤患者临床资料,其中伴有明显呼吸道梗阻症状(Shin分级Ⅳ级)13例。术前支气管镜及CT检查均明确诊断为肿瘤压迫或侵犯气管伴严重狭窄,所有患者术前经MDT讨论制定治疗方案,后期9例手术治疗,4例非手术治疗。结果乳头状癌7例,乳头状癌合并鳞癌1例,低分化癌3例,未分化癌1例,淋巴瘤1例。根据2017年AJCC第8版临床肿瘤分期:Ⅲ期4例,Ⅳa期7例,Ⅳb期1例,淋巴瘤为Ⅳ期。患者呼吸困难症状均在急症气管支架置入后明显改善,9例限期完成手术,其中8例行甲状腺癌联合根治术及气管袖状切除一期气管重建,1例行甲状腺癌联合根治术及全喉、颈段及部分胸段气管切除、气管-胸骨柄低位造瘘。除1例患者术后第7天死于心肺功能衰竭外,7例气管切除端-端吻合重建者均一期愈合,无气管瘘发生。气管-胸骨柄低位造瘘者术后19 d出院。所有患者术后予以~(131)I治疗和TSH抑制治疗。随访时间4～22个月,均无瘤生存。4例未手术治疗者中2例后期行局部放射治疗,生存期分别为1年及9个月;1例甲状腺淋巴瘤行化疗;1例未分化癌仅姑息对症治疗,生存期3个月。结论晚期甲状腺恶性肿瘤侵犯气管导致的气道梗阻直接危及患者生命,MDT并拟定个体化诊疗方案具有显著优势。对于需要手术的患者,MDT模式的开展能显著减低围术期风险,提高生存率;对于无手术指征的患者,MDT可详细评估病情,制定对应的合理治疗方案,为患者姑息治疗提供机会,延长患者生命。
Objective To explore the application of multidisciplinary treatment(MDT) mode in the treatment of local advanced thyroid cancer with respiratory obstruction. Methods The clinical data of thirty-one cases with locally advanced thyroid cancer were retrospectively analyzed from Sichuan Cancer Hospital & Institute during October 2015 to July 2017, 13 of whom were accompanied by obvious respiratory tract obstruction symptoms. Preoperative bronchoscopy and CT examination showed clear diagnosis of tracheal tumor invasion and severe stenosis, with 9 cases of surgery and 4 cases of non-surgical treatment under MDT mode. Results There were 7 cases of papillary carcinoma, 1 case of papillary squamous carcinoma, 3 cases of low differentiation, 1 case of undifferentiated carcinoma, and 1 case of thyroid lymphoma. According to a 2017 AJCC version 8 clinical oncology, 4 cases were clinical stage Ⅲ, 7 cases stage Ⅳa, 1 case stage Ⅳb, 1 case stage Ⅳ. Dyspnea improved obviously after emergency tracheal stent implantation. 9 patients complete the surgery before deadline, 8 of whom underwent thyroid carcinoma combined radical prostatectomy and tracheal sleeve shape stage I tracheal reconstruction, and 1 underwent thyroid carcinoma combined radical neck and throat, section and part of the thoracic trachea, trachea-slow colostomy. Except 1 case died of cardiopulmonary failure on the 7th day after surgery, the other 7 cases of tracheal resection I-end anastomosis of the reconstructive patients were all healed with no tracheal fistula. The tracheal-steroid hilt was discharged 15 days after surgery, and all patients were treated with 131-iodine therapy and TSH inhibition. The follow-up time was 4 to 22 months, with no tumor survival. 4 cases underwent non-surgical treatment, 2 of local radiotherapy in the later period, and the survival period was 1 year and 9 months respectively; 1 case of chemotherapy for thyroid lymphoma; 1 case of undifferentiated carcinoma was treated with only palliative care, and the survival period was 3 months. Conclusions The airway obstruction caused by the trachea is a direct threat to patients, while MDT and the formulation of the individualized diagnosis and treatment scheme have significant advantages. For patients who need surgical treatment, MDT mode can significantly reduce perioperative risks and improve survival rates. For patients with no surgical indications, MDT can assess the condition in detail, and develop a reasonable treatment plan to provide the opportunity to prolong the life of patients.
Objective To explore the application of multidisciplinary treatment(MDT) mode in the treatment of local advanced thyroid cancer with respiratory obstruction. Methods The clinical data of thirty-one cases with locally advanced thyroid cancer were retrospectively analyzed from Sichuan Cancer Hospital & Institute during October 2015 to July 2017, 13 of whom were accompanied by obvious respiratory tract obstruction symptoms. Preoperative bronchoscopy and CT examination showed clear diagnosis of tracheal tumor invasion and severe stenosis, with 9 cases of surgery and 4 cases of non-surgical treatment under MDT mode. Results There were 7 cases of papillary carcinoma, 1 case of papillary squamous carcinoma, 3 cases of low differentiation, 1 case of undifferentiated carcinoma, and 1 case of thyroid lymphoma. According to a 2017 AJCC version 8 clinical oncology, 4 cases were clinical stage Ⅲ, 7 cases stage Ⅳa, 1 case stage Ⅳb, 1 case stage Ⅳ. Dyspnea improved obviously after emergency tracheal stent implantation. 9 patients complete the surgery before deadline, 8 of whom underwent thyroid carcinoma combined radical prostatectomy and tracheal sleeve shape stage I tracheal reconstruction, and 1 underwent thyroid carcinoma combined radical neck and throat, section and part of the thoracic trachea, trachea-slow colostomy. Except 1 case died of cardiopulmonary failure on the 7th day after surgery, the other 7 cases of tracheal resection I-end anastomosis of the reconstructive patients were all healed with no tracheal fistula. The tracheal-steroid hilt was discharged 15 days after surgery, and all patients were treated with 131-iodine therapy and TSH inhibition. The follow-up time was 4 to 22 months, with no tumor survival. 4 cases underwent non-surgical treatment, 2 of local radiotherapy in the later period, and the survival period was 1 year and 9 months respectively; 1 case of chemotherapy for thyroid lymphoma; 1 case of undifferentiated carcinoma was treated with only palliative care, and the survival period was 3 months. Conclusions The airway obstruction caused by the trachea is a direct threat to patients, while MDT and the formulation of the individualized diagnosis and treatment scheme have significant advantages. For patients who need surgical treatment, MDT mode can significantly reduce perioperative risks and improve survival rates. For patients with no surgical indications, MDT can assess the condition in detail, and develop a reasonable treatment plan to provide the opportunity to prolong the life of patients.
引文
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[2]王朝晖,蔡永聪,李春华,等.侵犯喉、气管的分化型甲状腺癌的外科治疗[J].中华内分泌外科杂志, 2014, 8(4):278-281.
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[7]李仕晟,李友忠,唐青来,等.侵犯气管的分化型甲状腺癌的外科处理及预后分析[J].中华耳鼻咽喉头颈外科杂志, 2014,49(10):802-806.
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[9]Kebebew E, Greenspan FS, Clark OH, et al. Anaplastic thyroid carcinoma. Treatment outcome and prognostic factors[J]. Cancer,2005, 103(7):1330-1335.
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[11] Graff-Baker A, Roman SA, Thomas DC, et al. Prognosis of primary thyroid lymphoma:demographic, clinical, and pathologic predictors of survival in 1,408 cases[J]. Surgery, 2009, 146(6):1105-1115.
[12] Graff-Baker A, Sosa JA, Roman SA. Primary thyroid lymphoma:a review of recent developments in diagnosis and histology-driven treatment[J]. Curr Opin Oncol, 2010, 22(1):17-22.
[13] Breen DP, Dutau H. On-site customization of silicone stents:towards optimal palliation of complex airway conditions[J].Respiration, 2009, 77(4):447-453.
[14] Madan K, Shrestha P, Garg R, et al. Bronchoscopic management of critical central airway obstruction by thyroid cancer:Combination airway stenting using tracheal and inverted-Y carinal selfexpanding metallic stents[J]. Lung India, 2017, 34(2):202-205.
[15]曹芳,顾朝丽,陈培珺.团队合作对院内心肺复苏抢救成功率的影响[J/CD].中华卫生应急电子杂志, 2017, 3(6):367-368.
[16]何向辉,姜若愚,王义增,等.甲状腺癌的多学科综合治疗的必要性及策略[J].中华内分泌外科杂志, 2017, 11(1):1-3.
[2]王朝晖,蔡永聪,李春华,等.侵犯喉、气管的分化型甲状腺癌的外科治疗[J].中华内分泌外科杂志, 2014, 8(4):278-281.
[3]Avenia N, Vannucci J, Monacelli M, et al. Thyroid cancer invading the airway:diagnosis and management[J]. Int J Surg, 2016,28(Suppl 1):S75-S78.
[4]Kim H, Jung HJ, Lee SY, et al. Prognostic factors of locally invasive well-differentiated thyroid carcinoma involving the trachea[J]. Eur Arch Otorhinolaryngol, 2016, 273(7):1919-1926.
[5]Wang LY, Nixon IJ, Patel SG, et al. Operative management of locally advanced, differentiated thyroid cancer[J]. Surgery, 2016,160(3):738-746.
[6]刘宏伟,李振东,董慧蕾,等.侵犯上呼吸消化道甲状腺癌的治疗[J].临床耳鼻咽喉头颈外科杂志, 2014, 28(24):1927-1930.
[7]李仕晟,李友忠,唐青来,等.侵犯气管的分化型甲状腺癌的外科处理及预后分析[J].中华耳鼻咽喉头颈外科杂志, 2014,49(10):802-806.
[8]Keutgen XM, Sadowski SM, Kebebew E. Management of anaplastic thyroid cancer[J]. Gland Surg, 2015, 4(1):44-51.
[9]Kebebew E, Greenspan FS, Clark OH, et al. Anaplastic thyroid carcinoma. Treatment outcome and prognostic factors[J]. Cancer,2005, 103(7):1330-1335.
[10] Prasongsook N, Kumar A, Chintakuntlawar AV, et al. Survival in response to multimodal therapy in anaplastic thyroid cancer[J]. J Clin Endocrinol Metab, 2017, 102(12):4506-4514.
[11] Graff-Baker A, Roman SA, Thomas DC, et al. Prognosis of primary thyroid lymphoma:demographic, clinical, and pathologic predictors of survival in 1,408 cases[J]. Surgery, 2009, 146(6):1105-1115.
[12] Graff-Baker A, Sosa JA, Roman SA. Primary thyroid lymphoma:a review of recent developments in diagnosis and histology-driven treatment[J]. Curr Opin Oncol, 2010, 22(1):17-22.
[13] Breen DP, Dutau H. On-site customization of silicone stents:towards optimal palliation of complex airway conditions[J].Respiration, 2009, 77(4):447-453.
[14] Madan K, Shrestha P, Garg R, et al. Bronchoscopic management of critical central airway obstruction by thyroid cancer:Combination airway stenting using tracheal and inverted-Y carinal selfexpanding metallic stents[J]. Lung India, 2017, 34(2):202-205.
[15]曹芳,顾朝丽,陈培珺.团队合作对院内心肺复苏抢救成功率的影响[J/CD].中华卫生应急电子杂志, 2017, 3(6):367-368.
[16]何向辉,姜若愚,王义增,等.甲状腺癌的多学科综合治疗的必要性及策略[J].中华内分泌外科杂志, 2017, 11(1):1-3.