射频消融与甲状腺叶切除术治疗低危甲状腺微小乳头状癌的临床结局相近

发表者：周建华人已读

甲状腺微小乳头状癌(PTMC)定义为最大径不超过1cm的甲状腺乳头状癌，其全球发病率在过去的数十年间明显增加，而其最佳治疗方案仍存在争议。近期，甲状腺疾病和研究领域的权威杂志Thyroid发表了《超声引导射频消融与甲状腺叶切除术治疗低危甲状腺微小乳头状癌的比较：一项针对884名患者的倾向性评分匹配队列研究》。这项大型队列研究表明射频消融和甲状腺叶切除术治疗低危PTMC的4年临床结局相近。作为一种微创手术方式，热消融已经成为低危PTMC可选治疗方案之一。

热消融已被多个国际指南推荐用于甲状腺良性结节以及复发性甲状腺癌的治疗，近年来也应用于拒绝手术和积极监测的低危PTMC患者的治疗。最近，其也被提议作为适合手术或积极监测的患者的可选择的治疗方案。然而，由于缺乏足够的数据，热消融与手术的治疗效果仍然存在争议。本研究旨在通过大型队列研究，比较射频消融和甲状腺叶切除术治疗低危PTMC的临床结局。

本回顾性研究评估了2014年6月至2018年3月接受甲状腺叶切除或射频消融治疗的884例单灶性低危PTMC患者，其中460例接受甲状腺叶切除术，424例拒绝手术和主动监测接受射频消融术。患者治疗后定期随访。在倾向评分匹配 (PSM) 后比较局部肿瘤进展、无复发生存率、并发症以及治疗变量（包括手术时间、失血量、住院时间和费用）等。

在随访期间（中位随访时间：48.3个月），甲状腺叶切除和射频消融患者的局部肿瘤进展、淋巴结转移、复发率、肿瘤残留和4年无复发生存率均无显著差异（P>0.05）。所有患者均未发现远处转移。接受射频消融治疗的患者均未接受延迟手术。同时，相比于甲状腺叶切除术，接受射频消融的患者手术时间更短，失血量更低，住院时间更短、费用更低，且有并发症发生率更低（P<0.001）,同时最大限度的保留了正常的甲状腺腺体。

甲状腺微小乳头状癌近年发病率显著增加，由于大部分的PTMC预后非常好，由此带来过度诊断和过度治疗的问题，其临床处理存在较大争议。积极监测是低危PTMC的可选择的处理方法之一，主要在日本应用较多。然而由于临床缺乏有效的手段区分低危PTMC和小部分侵袭性PTMC，选择积极监测的患者面临潜在的肿瘤进展转移风险，以及由此带来的心理上的巨大焦虑，因此，大部分的PTMC患者选择手术治疗，但手术会带来颈部疤痕影响美观，手术后并发症，以及腺体切除后需终身甲状腺素替代治疗等问题，从而影响病人生活质量。超声引导下PTMC的热消融治疗作为介于积极监测与手术之间的一种治疗，既消灭了甲状腺内的肿瘤，缓解了患者的焦虑情绪，也降低了手术费用以及手术并发症的问题，已经成为PTMC的有效治疗方式之一，本研究为PTMC的热消融治疗提供了循证医学证据。

原文摘要

Background:Thermal ablation (TA) has been applied in patients with low-risk papillary thyroid microcarcinoma (PTMC) who refuse surgery or active surveillance (AS). Recently, TA is also proposed as a potential therapeutic option for patients who are suitable for surgery or AS. However, the clinical outcomes of TA versus surgery remains controversial because of lacking sufficient data. This study aimed to compare the clinical outcomes between radiofrequency ablation (RFA) versus thyroid lobectomy (TL) for low-risk PTMC in a large cohort.

Methods:This retrospective study evaluated 884 patients with unifocal low-risk PTMC treated with TL or RFA from June 2014 to March 2018. Among them, 460 patients underwent TL(TL group) and 424 who refused surgery or AS underwent RFA(RFA group). Patients were regularly followed up after treatment. Local tumor progression, recurrence-free survival (RFS), complications and treatment variables, including procedure time, estimated blood loss, hospitalization and cost, were compared after propensity score matching(PSM).

Results:After PSM, a total of 332 patients underwent TL (mean ages, 43.8 ± 9.5 years) and 332 underwent RFA (mean ages, 44.1 ± 9.5 years). During the follow-up (median [interquartile ranges], 48.3 [23.2] months), no significant differences were observed in the local tumor progression (1.8% vs. 3.3%, P=.209), lymph node metastasis (0.6% vs. 0.6%, P=1.000), recurrent PTMC (1.2% vs. 2.4%, P=.244), persistent lesion (0% vs. 0.3%, P=.317) and 4-year RFS rates (98.2% vs. 97.0%, P=.223) between the TL and RFA groups. Distant metastasis was not detected. None of the patients who were treated by RFA underwent delayed surgery. Patients undergoing RFA had shorter procedure time (3.4 [2.5] vs. 86.0 [37.0] min , P<.001), lower estimated blood loss (0 vs. 20[10.0] mL, P<.001), shorter hospitalization (0 vs. 7.0[3.0] d, P<.001), lower cost ($2035.7 [254.0] vs. $2269.1 [943.4], P<.001) and lower complication rate (0% vs. 4.2%, P<.001) than those treated by TL. The association between treatment modality and recurrence remained nonsignificant after Cox analysis (P=.247).

Conclusions:This large, matched study revealed comparable 4-year clinical outcomes between RFA and TL for low-risk PTMC. As a minimally invasive modality, RFA may be a promising complementary to the existing treatment for low-risk PTMC.

(Yan L, Zhang M, Song Q, Luo Y. Ultrasound-Guided Radiofrequency Ablation Versus Thyroid Lobectomy for Low-Risk Papillary Thyroid Microcarcinoma: A Propensity-matched Cohort Study of 884 Patients. Thyroid. 2021 Jul 16. doi: 10.1089/thy.2021.0100. Epub ahead of print. PMID: 34269611.)

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