【干货分享】甲状腺癌的预后都很好吗？并否则......
<span style="color: black;"><span style="color: black;"><strong style="color: blue;"><strong style="color: blue;"><strong style="color: blue;">⊙</strong></strong></strong>作者</span><span style="color: black;"> / 刘林玲</span></span><span style="color: black;"><span style="color: black;"><strong style="color: blue;"><strong style="color: blue;"><strong style="color: blue;">⊙</strong></strong></strong>单位</span><span style="color: black;"> / 四川省简阳市人民医院</span></span><span style="color: black;">一<span style="color: black;">说到</span>「甲状腺癌」，<span style="color: black;">非常多</span>人就想到这是一种类似良性的恶性肿瘤，预后很好，<span style="color: black;">乃至</span>大<span style="color: black;">都数</span>都不<span style="color: black;">必须</span>手术治疗。</span><span style="color: black;">然而，<span style="color: black;">这儿</span>所说的「甲状腺癌」，其实是甲状腺乳头状癌，但其他类型的甲状腺癌可能就没这么好。</span><span style="color: black;"><span style="color: black;">例如</span>今天<span style="color: black;">咱们</span>说的甲状腺髓样癌。与其他类型的甲状腺恶性肿瘤相比，甲状腺髓样癌发病年龄相对更低，易复发，易转移，预后较差。</span><span style="color: black;"><strong style="color: blue;">典型病例 1</strong></span><span style="color: black;"><span style="color: black;">病人</span>男， 61 岁，因<span style="color: black;">发掘</span>右侧颈部肿块 2 周就诊。</span><span style="color: black;">超声<span style="color: black;">检测</span><span style="color: black;">发掘</span>甲状腺右叶范围约 66×41×38 mm 的混合性回声团，形态较规则，边界较清楚，其内可见稍强回声及低回声。</span><span style="color: black;">另可见斑片状强回声伴声影，其内可见较多条状血流信号， PSV 0.26 m/s，RI 0.9 。</span><img src="https://mmbiz.qpic.cn/mmbiz_jpg/vic7oO6o0kytWyg2nBBm0OL2ibuzfMHoibzK2HDtKGbugU39JI47Qu2wcmGxLVtRRzNqWq8nKdM9JhJkMIWojhibGA/640?wx_fmt=jpeg&tp=webp&wxfrom=5&wx_lazy=1&wx_co=1" style="width: 50%; margin-bottom: 20px;"><span style="color: black;">图 1a 甲状腺右叶横切面示肿块内稍强回声和低回声及钙化灶，边界较清</span><img src="https://mmbiz.qpic.cn/mmbiz_jpg/vic7oO6o0kytWyg2nBBm0OL2ibuzfMHoibzAuzQBNibVQYCqCUum0vrBZw4yVh4l0OOUZUFDmck2AMSTa4LKTmq6gQ/640?wx_fmt=jpeg&tp=webp&wxfrom=5&wx_lazy=1&wx_co=1" style="width: 50%; margin-bottom: 20px;"><span style="color: black;">图 1b 甲状腺右叶纵切面示肿块内稍强回声和低回声及钙化灶，边界较清</span><img src="https://mmbiz.qpic.cn/mmbiz_jpg/vic7oO6o0kytWyg2nBBm0OL2ibuzfMHoibzqicibr0OLyQrvbcmbyiajNdVJ3ZeiaHYrP5AULn6c6IEcaGYIInn9FhRoQ/640?wx_fmt=jpeg&tp=webp&wxfrom=5&wx_lazy=1&wx_co=1" style="width: 50%; margin-bottom: 20px;"><span style="color: black;">图 1c 凸阵探头示肿块形态较规则，边界较清</span><img src="https://mmbiz.qpic.cn/mmbiz_jpg/vic7oO6o0kytWyg2nBBm0OL2ibuzfMHoibzOHJuKzicMY9FW24jpSOXQjE2zY2PicAP449n206BNWWFxrkyo6Nlqpqw/640?wx_fmt=jpeg&tp=webp&wxfrom=5&wx_lazy=1&wx_co=1" style="width: 50%; margin-bottom: 20px;"><span style="color: black;">图 1d CDFI 示肿块内较多条状血流信号，<span style="color: black;">没</span>周边环状血流</span><span style="color: black;">完善<span style="color: black;">关联</span><span style="color: black;">检测</span>后行手术治疗。</span><span style="color: black;">术中于甲状腺右叶见一<span style="color: black;">体积</span>约 5×4×3 cm 肿块，质地较硬，与<span style="color: black;">周边</span>组织分界不清，肿块向前方生长突破包膜。右侧颈动脉旁可见肿大淋巴结。</span><span style="color: black;">术后病理证实为甲状腺右叶髓样癌，未见转移淋巴结。</span><span style="color: black;"><strong style="color: blue;">典型病例 2</strong></span><span style="color: black;"><span style="color: black;">病人</span>女， 65 岁，<span style="color: black;">发掘</span>右侧颈部肿物 30 余年， 11 年前行手术治疗，证实为甲状腺髓样癌，10 年前再次发现右颈部肿物并<span style="color: black;">逐步</span><span style="color: black;">成长</span><span style="color: black;">迄今</span>。</span><span style="color: black;">超声<span style="color: black;">检测</span><span style="color: black;">发掘</span>甲状腺右叶区域查见数个混合性回声及稍强回声肿块，形态较规则，边界尚清楚，<span style="color: black;">很强</span>者约 42× 34 mm ， CDFI 示肿块内及周边可见较丰富的条状血流信号。</span><img src="https://mmbiz.qpic.cn/mmbiz_jpg/vic7oO6o0kytWyg2nBBm0OL2ibuzfMHoibzmPd9PG2SmNCAM3TayichKllBeaacOSShsBHX7icWM0geR9WCjyfd8gkg/640?wx_fmt=jpeg&tp=webp&wxfrom=5&wx_lazy=1&wx_co=1" style="width: 50%; margin-bottom: 20px;"><span style="color: black;">图 2a 右侧颈部横切面示原甲状腺右叶区的混合性回声肿块，形态较规则，边界尚清楚</span><img src="https://mmbiz.qpic.cn/mmbiz_jpg/vic7oO6o0kytWyg2nBBm0OL2ibuzfMHoibz10U83K1BwXIxnLrcgUHpAJ4Edbpnv5dkGnYF2hNtevibYjlL69btacQ/640?wx_fmt=jpeg&tp=webp&wxfrom=5&wx_lazy=1&wx_co=1" style="width: 50%; margin-bottom: 20px;"><span style="color: black;">图 2b 示肿块似与前方肌肉关系密切</span><img src="https://mmbiz.qpic.cn/mmbiz_jpg/vic7oO6o0kytWyg2nBBm0OL2ibuzfMHoibzibBRaDLTRKG4whH1BDQibZA9Rm1pHiaPeuTMx6dHhcHoGY2KicHEXCeyRA/640?wx_fmt=jpeg&tp=webp&wxfrom=5&wx_lazy=1&wx_co=1" style="width: 50%; margin-bottom: 20px;"><span style="color: black;">图 2c 示肿块内可见部分不均质低回声及少许<span style="color: black;">没</span>回声</span><img src="https://mmbiz.qpic.cn/mmbiz_jpg/vic7oO6o0kytWyg2nBBm0OL2ibuzfMHoibzoE6ke9D3h6tR9Eq7OBWuvLNrH1VsTzzmzibeKlzJ28SZX4R9ia8lFssw/640?wx_fmt=jpeg&tp=webp&wxfrom=5&wx_lazy=1&wx_co=1" style="width: 50%; margin-bottom: 20px;"><span style="color: black;">图 2d CDFI 示肿块内杂乱的较丰富血流</span><span style="color: black;">入院后行手术治疗。</span><span style="color: black;">术中见甲状腺右叶多发肿物，呈融合状，<span style="color: black;">体积</span>约 6×4×4 cm ，质硬，有包膜，突破甲状腺被膜，颈前肌广泛受累，部分侵及食管。</span><span style="color: black;">术后病理证实为髓样癌术后复发，淋巴结未见累及。</span><span style="color: black;"><strong style="color: blue;">典型病例 3</strong></span><span style="color: black;"><span style="color: black;">病人</span>女， 51 岁，因<span style="color: black;">发掘</span>右侧颈部肿块 1+ 年就诊。</span><span style="color: black;">超声<span style="color: black;">检测</span><span style="color: black;">发掘</span>甲状腺右叶中下份见范围约 21×18×15 mm 的低回声肿块，形态规则，边界清楚，其内可见大片状不连续强回声，部分伴浅声影，余为低回声， CDFI 示其内可见散在点状及短条状血流信号。</span><img src="https://mmbiz.qpic.cn/mmbiz_jpg/vic7oO6o0kytWyg2nBBm0OL2ibuzfMHoibzIHcBfu7CsBpXfK6yZS8D4UJ330kLp25TPZJJibkOv4Zy9speN4lmZNA/640?wx_fmt=jpeg&tp=webp&wxfrom=5&wx_lazy=1&wx_co=1" style="width: 50%; margin-bottom: 20px;"><span style="color: black;">图 3a 甲状腺右叶纵切示腺体中下份的低回声肿块，其内见大片状不连续钙化灶</span><img src="https://mmbiz.qpic.cn/mmbiz_jpg/vic7oO6o0kytWyg2nBBm0OL2ibuzfMHoibzcxELLT15JwhIoht2ibfAtVhV60zICIVRW5KsDq2CwBmCtD8e3gicKeLA/640?wx_fmt=jpeg&tp=webp&wxfrom=5&wx_lazy=1&wx_co=1" style="width: 50%; margin-bottom: 20px;"><span style="color: black;">图 3b 颈部横切面示肿块形态规则，边界清楚，其内见钙化灶</span><img src="https://mmbiz.qpic.cn/mmbiz_jpg/vic7oO6o0kytWyg2nBBm0OL2ibuzfMHoibzzfL0WhJFXd3Tjficuem94iccKxEjHP9ic6KpDUyUoTVYRB7RVVvRXs40g/640?wx_fmt=jpeg&tp=webp&wxfrom=5&wx_lazy=1&wx_co=1" style="width: 50%; margin-bottom: 20px;"><span style="color: black;">图 3c 颈部横切面示肿块纵横比 < 1</span><img src="https://mmbiz.qpic.cn/mmbiz_jpg/vic7oO6o0kytWyg2nBBm0OL2ibuzfMHoibz1JhicSEIQxZ2qgAQ4Ey9Lq0IHDg9sOBJzrKyKTnyqeeBU434QbBRcAQ/640?wx_fmt=jpeg&tp=webp&wxfrom=5&wx_lazy=1&wx_co=1" style="width: 50%; margin-bottom: 20px;"><span style="color: black;">图 3d CDFI 示肿块内散在点状及短条状血流信号</span><span style="color: black;">入院后行手术治疗。</span><span style="color: black;">术中于甲状腺右叶见<span style="color: black;">始终</span>径约 2 cm 质硬肿瘤，边界较清，与甲状腺粘连。</span><span style="color: black;">术后病理和免疫组化证实为甲状腺髓样癌，淋巴结未见累及。</span><span style="color: black;"><strong style="color: blue;">病例分析</strong></span><span style="color: black;">甲状腺髓样癌源于分泌降钙素的甲状腺滤泡旁细胞 (又<span style="color: black;">叫作</span> C 细胞)，是神经内分泌细胞，和甲状腺滤泡细胞<span style="color: black;">没</span>关，它只占甲状腺肿瘤 一小部分（约占 3% ）。</span><span style="color: black;">典型甲状腺髓样癌的超声特点<span style="color: black;">包含</span>：</span><p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">1. 髓样癌肿瘤内部回声<span style="color: black;">一般</span>不均匀，<span style="color: black;">平常</span>不完整粗大钙化。</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">2. 肿瘤多<span style="color: black;">没</span><span style="color: black;">显著</span>包膜，边界<span style="color: black;">一般</span>较清晰，边缘较规则，周边晕环不<span style="color: black;">显著</span>或不完整。</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">3. 与甲状腺乳头状癌不同，髓样癌肿瘤形态纵横比<span style="color: black;">一般</span>＜ 1 。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">4. 相<span style="color: black;">针对</span>甲状腺乳头状癌，髓样癌<span style="color: black;">一般</span>体积<span style="color: black;">很强</span>，血供更丰富，血流类型以混合型<span style="color: black;">占多数</span>。</span></p><span style="color: black;">
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">手术是治疗甲状腺髓样癌首选治疗<span style="color: black;">办法</span>。诊断时的<span style="color: black;">疾患</span>分期、肿瘤<span style="color: black;">体积</span>和淋巴结侵犯程度、肿瘤的遗传类型（散发型和遗传型）、<span style="color: black;">病人</span>年龄和性别以及降钙素倍增时间等<span style="color: black;">原因</span>影响<span style="color: black;">疾患</span>预后。</p>
</span><span style="color: black;">参考文献</span><span style="color: black;"><span style="color: black;">岳林先. 甲状腺超声医学. 北京:人民卫生出版社,2015: 216-217.</span></span><span style="color: black;"> 张冬艳,王勇贵,高玉龙,陈丽.甲状腺髓样癌的超声诊断价值探讨.心理月刊,2018(07):206.</span><span style="color: black;"> 袁玉洁,陆凡倩,张淑君,陈晓红.甲状腺髓样癌的超声鉴别诊断及临床<span style="color: black;">道理</span>.中国耳鼻咽喉头颈外科,2015,22(04):163-166.</span><span style="color: black;"> 王满立,李妙珊,冯占武,甘科红,黄春旺.甲状腺髓样癌超声特征与病理结果对比分析.实用医学杂志,2015,31(05):799-801.</span><span style="color: black;"> 周黎光,张华伟,梁波,陈波.甲状腺髓样癌的超声诊断.医学影像学杂志,2013,23(12):1897-1900.</span><span style="color: black;"> 邬宏恂,张冰洁,戴军,王铁生.甲状腺髓样癌超声征象分析.中国超声医学杂志,2013,29(10):868-871.</span><span style="color: black;"> 蔡迪明,李永忠,彭玉兰,宋彬.甲状腺髓样癌的超声诊断价值.华西医学,2012,27(11):1656-1659.</span><span style="color: black;"> 杨小磊,李荣堂.甲状腺髓样癌140例<span style="color: black;">初期</span>诊治回顾性分析.现代医药卫生,2017,33(02):265-267.</span>
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