魏波 顧強(qiáng)榮 杜小濤 李棟 王黎明

甲狀腺濾泡癌多發(fā)胸椎轉(zhuǎn)移一例

魏波 顧強(qiáng)榮 杜小濤 李棟 王黎明

分化型甲狀腺癌包括甲狀腺乳頭癌和濾泡癌，其中甲狀腺濾泡癌生長(zhǎng)緩慢，其發(fā)病率遠(yuǎn)低于甲狀腺乳頭癌，而且體積小、生長(zhǎng)緩慢，常無(wú)明顯的局部惡性表現(xiàn)。然而Do 等[1]研究發(fā)現(xiàn)甲狀腺濾泡癌的骨轉(zhuǎn)移發(fā)生率( 6.8% )明顯高于甲狀腺乳頭癌的骨轉(zhuǎn)移發(fā)生率( 0.4% )。臨床上甲狀腺濾泡癌骨轉(zhuǎn)移的好發(fā)部位以肋骨、髂骨和胸骨多見(jiàn)，以溶骨性病變?yōu)橹鳌９寝D(zhuǎn)移會(huì)引發(fā)骨痛、病理性骨折和脊髓壓迫等并發(fā)癥，患者的生活質(zhì)量將受到嚴(yán)重的影響[2]。同時(shí)，甲狀腺濾泡癌骨轉(zhuǎn)移患者的 10 年生存率為 13%～21%[3]。因此，對(duì)甲狀腺濾泡癌骨轉(zhuǎn)移的早期診斷和治療非常重要。2013 年 12 月 9 日，我科收治 1 例甲狀腺濾泡癌多發(fā)胸椎轉(zhuǎn)移病例，現(xiàn)報(bào)道如下。

資料與方法

一、一般資料

患者，男，69 歲。2007 年，因診斷為甲狀腺濾泡癌，行甲狀腺濾泡癌根治術(shù)；2009 年，因左側(cè)淋巴結(jié)轉(zhuǎn)移，行左頸部淋巴結(jié)根治切除術(shù)。兩次手術(shù)后均采用放射性131I 治療，以清除手術(shù)后殘留的正常甲狀腺組織，并服用左旋甲狀腺素鈉替代抑制治療?；颊呓?jīng)“手術(shù)＋131I＋甲狀腺素替代抑制”治療后，病情穩(wěn)定。

二、診斷

近 1 年來(lái)患者漸感腰背部酸脹不適，在我院門(mén)診查體胸腰段局部未見(jiàn)明顯后凸及側(cè)彎，未及明顯壓痛、扣擊痛，攝頸、胸、腰椎 MRI 提示：T5、T7、T8、T11椎體及部分附件見(jiàn)異常信號(hào)( 圖1 )。單光子放射計(jì)算機(jī)斷層成像術(shù)( single-photon emission computed tomography，SPECT )示：T5、T7、T8、T11局部骨質(zhì)破壞，且可見(jiàn)軟組織密度影，其中 T5、T11可見(jiàn)異常放射性濃聚區(qū)，T7、T8病灶呈放射性稀疏區(qū)( 圖2 )。結(jié)合患者相關(guān)病史，診斷為甲狀腺濾泡癌多發(fā)胸椎轉(zhuǎn)移。

三、治療方法

考慮患者病情穩(wěn)定，但存在椎體不穩(wěn)情況，發(fā)生椎體塌陷和脊髓神經(jīng)損傷的風(fēng)險(xiǎn)較大，有行 T4～12長(zhǎng)節(jié)段椎體固定的指征，故在全麻下行甲狀腺濾泡狀癌多發(fā)胸椎轉(zhuǎn)移切開(kāi)內(nèi)固定手術(shù)，腫瘤暫予姑息治療，術(shù)后再針對(duì)甲狀腺濾泡癌胸椎轉(zhuǎn)移行進(jìn)一步治療。

圖1 術(shù)前頸、胸、腰椎 MRI( 矢狀位 )。T5、T7、T8、T11椎體及部分附件異常信號(hào)。紅色箭頭示 T5和 T11椎體及附件異常信號(hào)圖2 術(shù)前單光子放射計(jì)算機(jī)斷層成像術(shù)( SPECT )。T5、T11可見(jiàn)異常放射性濃聚區(qū)，局部融合顯像：T5、T7、T8、T11局部骨質(zhì)破壞，且可見(jiàn)軟組織密度影，其中 T7、T8病灶呈放射性稀疏區(qū)。紅色箭頭示異常放射性濃聚區(qū)圖3 術(shù)后胸椎 X 線正位片。示釘棒系統(tǒng)位置良好圖4 術(shù)后胸椎 X 線側(cè)位片。示釘棒系統(tǒng)位置良好Fig.1 The preoperative MRI of the cervical, thoracic and lumbar spine( sagittal view )demonstrated that there were abnormal signals existed in T5, T7, T8, T11and some accessories. The red arrow revealed abnormal signals in T5, T11and some accessoriesFig.2 The preoperative SPECT showed radioactive concentration area in T5and T11. Local fusion images showed local bone destruction in T5, T7, T8and T11. Moreover, soft tissue density shadow was visible. The radioactive sparse area in T7and T8could be seen. The red arrow demonstrated abnormal radioactive concentration areaFig.3 The postoperative anteroposterior X-ray of the thoracic vertebra demonstrated good position of the pedicle screw systemFig.4 The postoperative lateral X-ray of the thoracic vertebra showed good position of the pedicle screw system

術(shù)中于腰背部后正中取長(zhǎng)約 30 cm 縱形切口，依次切開(kāi)皮膚、皮下組織、深筋膜，鈍性剝離椎旁肌，顯露T4～12棘突及兩側(cè)椎板、關(guān)節(jié)突。于 T4、T6、T10、T12兩側(cè)椎弓根進(jìn)針點(diǎn)進(jìn)針、開(kāi)孔、擴(kuò)深后，置入定位針，C 型臂機(jī)透視位置良好后，置入相應(yīng)位置的椎弓根螺釘，再次C 型臂機(jī)透視位置良好后，置入預(yù)彎的連接桿和橫連。

四、術(shù)后療效

術(shù)后 1 個(gè)月患者一般情況良好，脊柱穩(wěn)定性恢復(fù)，腰部活動(dòng)無(wú)明顯受限，未見(jiàn)切口感染、神經(jīng)損傷和下肢深靜脈血栓等并發(fā)癥。術(shù)后復(fù)查 X 線片示：釘棒系統(tǒng)位置良好，未發(fā)生內(nèi)固定物松動(dòng)、彎曲、斷釘和斷棒的現(xiàn)象( 圖3，4 )。

討 論

臨床上診斷骨轉(zhuǎn)移癌的影像學(xué)方法主要包括：X 線片、CT 和 MRI 等。不過(guò) X 線檢查的敏感性較低，而 CT對(duì)于骨髓病變不敏感，難以診斷未發(fā)生成骨或溶骨反應(yīng)的骨轉(zhuǎn)移癌。近年來(lái)，隨著 SPECT 和全身磁共振成像( whole-body MRI )的臨床應(yīng)用，顯著提高了對(duì)骨轉(zhuǎn)移癌患者的早期發(fā)現(xiàn)和診斷[4-6]。本例經(jīng)頸、胸、腰椎 MRI 和SPECT 檢查，結(jié)合相關(guān)病史，診斷為甲狀腺濾泡癌多發(fā)胸椎轉(zhuǎn)移。

甲狀腺癌骨轉(zhuǎn)移的治療方案主要包括放射性碘(131I )治療、姑息性治療和外科手術(shù)治療等[7]。其中，放射性131I 治療作為一線治療方案，具有較好的療效，但會(huì)引起一些與累積劑量有關(guān)的并發(fā)癥，如鼻淚管阻塞、唾液腺損傷和繼發(fā)惡性腫瘤，而且年輕甲狀腺癌骨轉(zhuǎn)移患者因轉(zhuǎn)移灶攝碘能力強(qiáng)，故預(yù)后相對(duì)老年患者好[8]。姑息性治療主要包括血管栓塞和外照射治療等，能明顯緩解疼痛、神經(jīng)壓迫等相關(guān)癥狀，改善患者的生活質(zhì)量。但 Bernier等[9]研究發(fā)現(xiàn)，甲狀腺癌骨轉(zhuǎn)移患者分別經(jīng)動(dòng)脈栓塞和外照射治療后，其中位生存期與未行治療患者相比，差異均無(wú)統(tǒng)計(jì)學(xué)意義( P＞0.05 )。外科手術(shù)治療主要適用于骨轉(zhuǎn)移灶處持續(xù)性疼痛和內(nèi)科治療效果不佳等情況。此外，甲狀腺癌脊柱轉(zhuǎn)移導(dǎo)致穩(wěn)定性降低和脊髓神經(jīng)損傷也是手術(shù)治療的適應(yīng)證[10]。本例胸椎轉(zhuǎn)移癌導(dǎo)致患者椎體穩(wěn)定性較差，存在椎體塌陷和脊髓神經(jīng)損傷的風(fēng)險(xiǎn)，故考慮先行外科手術(shù)治療恢復(fù)脊柱的穩(wěn)定性，再針對(duì)性的治療胸椎轉(zhuǎn)移病灶。因此，須綜合分析骨轉(zhuǎn)移灶的位置、數(shù)量及患者的一般情況，制訂出最適合的治療方案。本例經(jīng)“手術(shù)＋131I＋甲狀腺素替代抑制”治療后，效果滿意，病情控制穩(wěn)定。

骨轉(zhuǎn)移癌外科手術(shù)治療的適應(yīng)證主要是頑固性疼痛的轉(zhuǎn)移病灶，而對(duì)其它單發(fā)骨轉(zhuǎn)移病灶、病理性骨折、神經(jīng)壓迫和截癱等治療不敏感[11]。本例雖目前病情穩(wěn)定，但胸椎轉(zhuǎn)移癌侵犯了椎管及椎體，破壞了脊柱原有的穩(wěn)定性，發(fā)生椎體塌陷和脊髓神經(jīng)損傷的風(fēng)險(xiǎn)較大，限制了對(duì)甲狀腺胸椎轉(zhuǎn)移癌的針對(duì)性治療。而隨著脊柱內(nèi)固定系統(tǒng)應(yīng)用的普及，能使術(shù)后脊柱保持較佳的穩(wěn)定性。目前，脊柱內(nèi)固定手術(shù)治療一般包括開(kāi)放手術(shù)與微創(chuàng)手術(shù)[12-13]。開(kāi)放手術(shù)治療能夠直接暴露手術(shù)視野，術(shù)中能更好地控制手術(shù)區(qū)出現(xiàn)的一些情況，不過(guò)手術(shù)創(chuàng)傷較大，術(shù)中出血較多，術(shù)后恢復(fù)時(shí)間較長(zhǎng)。微創(chuàng)手術(shù)治療具有創(chuàng)傷小、出血少和恢復(fù)時(shí)間短等優(yōu)點(diǎn)，但存在對(duì)術(shù)者的技術(shù)要求較高、手術(shù)視野不開(kāi)闊及治療不徹底等潛在缺陷。本例胸椎轉(zhuǎn)移癌導(dǎo)致T5、T7、T8、T11局部骨質(zhì)破壞，同時(shí)附件區(qū)也出現(xiàn)異常信號(hào)，結(jié)構(gòu)破壞較為復(fù)雜，行直視下開(kāi)放手術(shù)較為安全，故采用 T4～12長(zhǎng)節(jié)段椎體切開(kāi)內(nèi)固定手術(shù)治療。術(shù)后 1 個(gè)月隨訪檢查釘棒系統(tǒng)位置良好，未見(jiàn)內(nèi)固定物松動(dòng)、彎曲、斷釘和斷棒的現(xiàn)象，但長(zhǎng)期效果有待進(jìn)一步隨訪觀察。同時(shí)，脊柱穩(wěn)定性的恢復(fù)，將便于術(shù)后針對(duì)甲狀腺濾泡癌胸椎轉(zhuǎn)移行進(jìn)一步地治療。

[1] Do MY, Rhee Y, Kim DJ, et al. Clinical features of bone metastases resulting from thyroid cancer: a review of 28 patients over a 20-year period. Endocr J, 2005, 52(6):701-707.

[2] Zettinig G, Fueger BJ, Passler C, et al. Long-term follow-up of patients with bone metastases from differentiated thyroid carcinoma-surgery orconventional therapy? Clin Endocrinol (Oxf), 2002, 56(3):377-382.

[3] Zanotti-Fregonara P, Rubello D, Hindié E. Bone metastases of differentiated thyroid cancer: the importance of early diagnosis and 131I therapy on prognosis. J Nucl Med, 2008, 49(11): 1902-1903.

[4] Rybak LD, Rosenthal DI. Radiological imaging for the diagnosis of bone metastases. Q J Nucl Med, 2001, 45(1): 53-64.

[5] Nakanishi K, Kobayashi M, Nakaguchi K, et al. Whole-body MRI for detecting metastatic bone tumor: diagnostic value of diffusion-weighted images. Magn Reson Med Sci, 2007, 6(3): 147-155.

[6] Lauenstein TC, Freudenberg LS, Goehde SC, et al. Whole-body MRI using a rolling table platform for the detection of bone metastases. Eur Radiol, 2002, 12(8):2091-2099.

[7] 康杰, 樊友本. 分化型甲狀腺癌骨轉(zhuǎn)移治療進(jìn)展. 中華內(nèi)分泌外科雜志, 2009, 3(3):190-193.

[8] 蔣寧一, 戴文莉, 胡瑩瑩. 分化型甲狀腺癌的放射性碘治療.中華普通外科學(xué)文獻(xiàn)(電子版), 2007, 1(4):199-201.

[9] Bernier MO, Leenhardt L, Hoang C, et al. Survival and therapeutic modalities in patients with bone metastases of differentiated thyroid carcinomas. Journal of Clinical Endocrinology & Metabolism, 2001, 86(4):1568-1573.

[10] Muresan MM, Olivier P, Leclère J, et al. Bone metastases from differentiated thyroid carcinoma. Endocr Relat Cancer, 2008, 15(1):37-49.

[11] 尉然, 郭衛(wèi), 楊毅. 甲狀腺癌骨轉(zhuǎn)移的外科治療及預(yù)后因素分析. 中華骨科雜志, 2012, 32(11):1073-1080.

[12] 黃其杉, 池永龍, 王向陽(yáng), 等. 經(jīng)皮與開(kāi)放椎弓根螺釘固定治療胸腰椎骨折的比較研究. 中華外科雜志, 2008, 46(2): 112-114.

[13] 張海龍, 顧昕, 賀石生, 等. 微創(chuàng)經(jīng)椎間孔椎體間融合術(shù)與開(kāi)放手術(shù)治療腰椎滑脫癥的療效比較. 中華骨科雜志, 2011, 31(10):1088-1092.

( 本文編輯：代琴 )

Multiple thoracic vertebral metastases of thyroid follicular carcinoma: 1 case report

WEI Bo, GU Qiangrong, DU Xiao-tao, LI Dong, WANG Li-ming. Department of Orthopedics, Nanjing frst Hospital, Nanjing Medical University, Nanjing, Jiangsu, 210006, PRC

ObjectiveTo diagnose and treat multiple thoracic vertebral metastases of thyroid follicular carcinoma accompanied by vertebral instability.MethodsOn December 9th, 2013, a patient with multiple thoracic vertebral metastases of thyroid follicular carcinoma was adopted and treated, whose clinical data were analyzed.ResultsThe patient was diagnosed as multiple thoracic vertebral metastases of thyroid follicular carcinoma by single-Photon Emission Computed Tomography( SPECT )and whole-body Magnetic Resonance Imaging( MRI ). Due to the presence of vertebral instability, the risk of vertebral collapse or spinal cord injury existed. Open reduction and internal fxation were performed under general anesthesia. Moreover, palliative care of tumors was temporarily carried out, and thoracic vertebral metastases were further treated after the operation. The general condition of the patient was good postoperatively. Additionally, the X-ray showed good position of the pedicle screw system. Reexamination was performed at 1 month after the operation. The spinal stability recovered, and the range of motion of the lumbar was not obviously limited. No complications such as incision infections, nerve injuries or deep venous thrombosis of lower limbs were noticed. The postoperative X-ray showed good position of the pedicle screw system and no lossening, bending or breakage of the internal fxator.ConclusionsFor the patients with multiple thoracic vertebral metastases of thyroid follicular carcinoma accompanied by vertebral instability, surgical operation is an optimal option. With more secure and targeted therapy, satisfactory stability of the spine will be obtained.

Thyroid neoplasms; Neoplasm metastasis; Neoplasms, multiple primary; Thoracic vertebrae

10.3969/j.issn.2095-252X.2014.05.017

R738.1

210006 南京醫(yī)科大學(xué)附屬南京醫(yī)院( 南京市第一醫(yī)院 )骨科

王黎明，Email: limingwang99@hotmail.com

2014-01-29 )