• 中国科技论文统计源期刊
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Volume 44 Issue 9
Sep.  2019
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Effect of ultrasound-guided percutaneous microwave ablation in the treatment of benign thyroid nodules on the thyroid hormone level and safety of patients

  • Received Date: 2018-07-30
    Accepted Date: 2019-08-06
  • ObjectiveTo investigate the effects of ultrasound-guided percutaneous microwave ablation in the treatment of thyroid benign nodules on the levels of thyroid hormones and safety of patients.MethodsOne hundred and seventy-five patients with benign thyroid nodules were divided into the observation and control group.The observation group was treated with ultrasound-guided percutaneous microwave ablation, and the control group was treated with traditional surgery.The levels of thyroid hormone before and after operation and postoperative complications between two groups were compared, and the effects of different treatments on the thyroid function and incidence rate of complications were analyzed.ResultsBefore treatment, the differences of the age, course of disease, number of nodules, and levels of TSH, FT3 and FT4 between two groups were not statistically significant(P>0.05).After treatment, the level of TSH, and levels of FT3 and FT4 in control group were higher and lower than those before treatment, respectively(P < 0.01), and the level of TSH, and levels of FT3 and FT4 in control group were significantly higher and lower than those in observation group, respectively(P < 0.01).The total incidence rate of postoperative complications in observation group and control group were 6.1% and 31.2%, respectively, and the difference of which was statistically significant(P < 0.01).ConclusionsThe effect of ultrasound-guided percutaneous microwave ablation in the treatment of thyroid benign nodules is better than that of traditional surgery, and its postoperative complication is less.It is an effective alternative to traditional surgical treatment.
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  • [1] 胡越, 高毅娜, 陈宝定, 等.甲状腺结节微波消融治疗对甲状腺功能的近期影响[J].江苏大学学报:医学版, 2015, 25(3):274.
    [2] 曲明, 尹惠生, 杨强, 等.超声引导下微波消融治疗甲状腺良性结节[J].实用医药杂志, 2015, 32(6):502.
    [3] 奚淑芳, 徐栋, 王群江, 等.甲状腺肿瘤微波消融33例临床分析[J].肿瘤学杂志, 2013, 19(11):897. doi: 10.11735/j.issn.1671-170X.2013.11.B016
    [4] TENG D, SUI G, LIU C, et al.Long-term efficacy of ultrasound-guided low power microwave ablation for the treatment of primary papillary thyroid microcarcinoma:a 3-year follow-up study[J].J Cancer Res Clin Oncol, 2018, 144(4):408.
    [5] 马芳花, 黄品同, 戚瑞祥, 等.超声引导下微波消融治疗甲状腺微小乳头状癌与外科手术切除的研究[J].中国超声医学杂志, 2017, 33(5):399. doi: 10.3969/j.issn.1002-0101.2017.05.006
    [6] 杨雪丰, 陈建发, 冯蕊, 等.超声引导下经皮微波消融术治疗甲状腺良性结节55例临床分析[J].广东医学院学报, 2016, 34(2):169. doi: 10.3969/j.issn.1005-4057.2016.02.017
    [7] LIU YJ, QIAN LX, LIU D, et al.Ultrasound-guided microwave ablation in the treatment of benign thyroid nodules in 435 patients[J].Exp Biol Med (Maywood), 2017, 242(15):1515. doi: 10.1177/1535370217727477
    [8] 徐萍, 徐岷, 葛璐, 等.超声引导下微波消融单次治疗多发甲状腺结节的疗效和安全性评估[J].实用医学杂志, 2018, 34(1):96. doi: 10.3969/j.issn.1006-5725.2018.01.024
    [9] 孙浩, 贺春雨, 李潜, 等.儿童分化型甲状腺癌临床特征及预后分析[J].郑州大学学报:(医学版), 2017, 52(6):746.
    [10] 中华医学会内分泌学分会《中国甲状腺疾病诊治指南》编写组.中国甲状腺疾病诊治指南——甲状腺功能亢进症[J].中华内科杂志, 2007, 46(10):876. doi: 10.3760/j.issn:0578-1426.2007.10.035
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Effect of ultrasound-guided percutaneous microwave ablation in the treatment of benign thyroid nodules on the thyroid hormone level and safety of patients

  • Department of Ultrasound, Tangshan People's Hospital, Tangshan Hebei 063000, China

Abstract: ObjectiveTo investigate the effects of ultrasound-guided percutaneous microwave ablation in the treatment of thyroid benign nodules on the levels of thyroid hormones and safety of patients.MethodsOne hundred and seventy-five patients with benign thyroid nodules were divided into the observation and control group.The observation group was treated with ultrasound-guided percutaneous microwave ablation, and the control group was treated with traditional surgery.The levels of thyroid hormone before and after operation and postoperative complications between two groups were compared, and the effects of different treatments on the thyroid function and incidence rate of complications were analyzed.ResultsBefore treatment, the differences of the age, course of disease, number of nodules, and levels of TSH, FT3 and FT4 between two groups were not statistically significant(P>0.05).After treatment, the level of TSH, and levels of FT3 and FT4 in control group were higher and lower than those before treatment, respectively(P < 0.01), and the level of TSH, and levels of FT3 and FT4 in control group were significantly higher and lower than those in observation group, respectively(P < 0.01).The total incidence rate of postoperative complications in observation group and control group were 6.1% and 31.2%, respectively, and the difference of which was statistically significant(P < 0.01).ConclusionsThe effect of ultrasound-guided percutaneous microwave ablation in the treatment of thyroid benign nodules is better than that of traditional surgery, and its postoperative complication is less.It is an effective alternative to traditional surgical treatment.

  • 甲状腺良恶性结节是内分泌系统中常见的疾病,据报道,4%~8%的成年人可通过触诊触及甲状腺结节,其中女性发病率较男性高,甲状腺结节的发病率随着年龄的增长而升高,在儿童时期有颈部放射治疗史或碘缺乏地区,甲状腺结节的发病率更高[1]。甲状腺结节大部分为良性结节,恶性结节占1%~5%。甲状腺良性结节也并非可以不治疗,其中3%~5%的良性结节有恶变可能,较大的甲状腺良性结节不仅会影响美观,甚至可能压迫气管导致窒息等严重并发症。目前,甲状腺结节的主要治疗方式是外科手术切除,但手术切除可能会产生如喉返神经损伤、甲状腺功能减低、切口不美观等并发症。近年来,超声引导下经皮微波消融治疗甲状腺结节渐渐成为替代传统甲状腺结节切除术的一种治疗手段。有文献证明,超声引导下经皮微波消融术具有创伤小、定位准确、切除率高、复发率低等优点[2]。但对于该治疗方法在甲状腺良性结节的术后甲状腺功能及激素水平文献报道较少见。本文回顾性分析175例甲状腺良性结节的病人术前及术后临床资料,评价超声引导下经皮微波消融术对甲状腺良性结节的甲状腺激素水平及安全性影响,以便为临床提供有效的治疗依据,现作报道。

1.   资料与方法
  • 选取我院2016年1月至2018年1月收治的175例甲状腺良性结节病人,按照手术方式分为观察组和对照组,观察组病人均采用超声引导下经皮微波消融术,对照组病人则采用传统的甲状腺结节切除术。2组一般资料比较均具有可比性(见表 1)。

    分组 n 年龄 病程/年 结节数 TSH/(mIU/L) FT3/(mmol/L) FT4/(mmol/L)
    观察组 90 49.76±4.89 2.26±0.79 1.24±0.68 2.31±1.27 5.78±1.21 17.88±2.49
    对照组 85 49.99±4.72 2.32±0.81 1.38±0.69 2.29±1.32 5.76±1.23 17.96±2.53
    t 0.32 0.50 1.35 0.10 0.10 0.21
    P >0.05 >0.05 >0.05 >0.05 >0.05 >0.05
  • 纳入标准:(1)穿刺活检病理结果为甲状腺良性肿瘤者。(2)年龄>18周岁。(3)签署知情同意书者。(4)能够按期随访者。排除标准:(1)未签署知情同意书者。(2)不配合治疗者。(3)合并有严重疾病如心脏、脑及肝肾功能疾病者。(4)甲状腺恶性肿瘤者。(5)临床资料不全者。

  • 所有病人治疗前均行常规术前准备,查血常规、凝血功能、肝肾功能、电解质、心电图等,确定病人有无手术禁忌证。行甲状腺彩超等相关检查确定甲状腺结节的位置、大小、数量及血供情况。查甲状腺相关组织自身抗体及激素水平等。对甲状腺结节进行经皮穿刺活检确定其病理分型。确定病人有手术适应症,无手术禁忌证后,对照组采用常规甲状腺结节手术切除术。病人取仰卧位,全麻后与胸骨切迹上2~3 cm做3~5 cm横行切口,依次分离皮下组织、颈部肌肉,观察甲状腺病变位置,确定病变位置后切除甲状腺结节,止血,保留并缝合甲状腺被膜,放置引流装置并依次缝合切口。

    观察组采用超声引导下经皮微波消融术治疗甲状腺良性结节,具体步骤如下:病人取仰卧位,充分保留颈部,使用超声再次对甲状腺组织进行探查,以确认甲状腺结节的数量、大小、部位、血供等情况,防止术中损伤甲状腺周围组织、血管及神经。于结节周围组织注射一定量的0.9%氯化钠注射液,在甲状腺组织与颈动脉鞘直接形成液体隔离带,以尽可能保护颈动脉。确定皮肤穿刺点,在穿刺点左微小切口,在超声引导下将微波针刺入结节。消融相关参数设定为中心温度80~85 ℃,功率30 W,时间45 s。在超声的持续引导下将穿刺针自上而下、由内向外、由深至浅进行多点消融。消融结束后对消融部位进行超声探查,仔细判断消融是否完全,对未完全消融部位进行补充消融。

  • (1) 良性结节的手术切除率。(2)术前TSH、FT3、FT4浓度。(3)术后TSH、FT3、FT4浓度。(4)术后并发症(如术后呼吸困难、甲状腺功能低下、饮水呛咳、切口瘢痕增生等)。(5)术后随访复发情况。

  • 采用t检验和χ2检验。

2.   结果
  • 治疗前, 2组病人TSH、FT3和FT4水平差异无统计学意义(P>0.05)。对照组治疗后TSH浓度明显高于治疗前(P < 0.01),FT3和FT4水平明显低于治疗前(P < 0.01);且对照组病人TSH水平明显高于观察者(P < 0.01),FT3和FT4水平明显低于观察者(P < 0.01)(见表 2)。

    分组 n TSH/(mIU/L) FT3/(mmol/L) FT4/(mmol/L)
    治疗前
      观察组 90 2.31±1.27 5.78±1.21 17.88±2.49
      对照组 85 2.29±1.32 5.76±1.23 17.96±2.53
       t 0.10 0.11 0.21
       P >0.05 >0.05 >0.05
    治疗后
      观察组 90 2.33±1.32 5.64±1.20 17.01±2.69
      对照组 85 3.04±1.56** 4.79±1.35** 15.74±2.33**
       t 3.26 4.41 3.33
       P < 0.01 < 0.01 < 0.01
    组内比较**P < 0.01
  • 观察组术后呼吸困难1例,对照组3例;观察组甲状腺功能低下3例,对照组12例;观察组切口瘢痕增生2例,对照组7例;观察组饮水呛咳0例,对照组3例;观察组总并发症发生6例,发生率6.1%,对照组25例,发生率31.2%。2组术后并发症发生率差异有统计学意义(χ2=15.52,P < 0.01)。

3.   讨论
  • 甲状腺良恶性结节是在临床中常见的疾病,其中甲状腺结节95%为良性结节。但甲状腺良性结节对人体的危害性仍是存在的,在良性结节中3%~5%有恶变可能,且随着良性结节的增大,正常的甲状腺组织受到压迫,血供受到影响,正常的甲状腺功能由此受损。以往甲状腺结节的主要治疗方式是传统的外科手术治疗,传统的手术治疗有多种弊端,如切口不美观、术后易甲状腺功能低下、易迷走神经损伤等多种并发症。近年来兴起的超声引导下经皮微波消融术治疗甲状腺结节具有创伤小、切口小、并发症少、安全性高等多种优势,渐渐成为替代传统手术疗法的一种新方式[3]

    微波消融的原理是以消融电极产生微波[4],微波使组织内的带电粒子高速运动并互相摩擦产生热量,当微波消融治疗甲状腺良性结节时,在超声的引导下,微波消融电极准确刺入靶组织,发射微波并使周围甲状腺组织温度升高至60 ℃以上,甲状腺组织内蛋白质变性坏死,肿瘤细胞被杀死。微波消融之所以精确,是由于其不仅在超声引导下,还可以通过控制消融范围、时间、功率以调整消融范围,此外,术前注射的液体隔离带会对周围的正常组织、血管、神经提供保护。

    在常规的外科甲状腺切除术后,由于腺体组织的损伤和甲状腺血供的改变,常常会导致甲状腺功能的紊乱,具体可能表现为TSH的升高,FT3和FT4水平下降,病人由于甲状腺功能的减退,常常需要服用优甲乐等药物替代治疗[5]。本研究中,对照组采用传统的手术切除术,术后TSH由(2.29±1.32)mIU/L升高至(3.04±1.56) mIU/L,而FT3由(5.76±1.23)mmol/L下降至(4.79±1.35)mmol/L,FT4由(17.96±2.53)mmol/L下降至(15.74±2.33)mmol/L,差异均具有统计学意义,由此可见,传统的外科切除术可能对甲状腺功能产生影响。

    本研究观察组中术后TSH、FT3、FT4的水平分别为(2.33±1.32) mIU/L、(5.64±1.20)mmol/L、17.01±2.69(mmol/L),与术前相比无明显变化,说明微波消融术治疗甲状腺良性结节对甲状腺功能的保护要优于传统外科切除术。一方面是由于微波消融较传统手术更为精确的定位病灶,在超声的引导下,穿刺针仅穿透很少的甲状腺正常组织而到达病灶范围,做到尽可能小的损伤正常甲状腺组织。另一方面,微波消融通过热效应来达到对靶组织的完全破坏变性,靶组织坏死后产生的残留激素或坏死因子相对较少[6-7]。此外,液体隔离带也会为正常的甲状腺组织,周围血管、神经提供有效的保护。超声引导下微波消融治疗老年人良性结节较传统手术更为安全有效,且病人耐受性较好,可能与老年人心肺功能减低而手术耐受性减低,麻醉风险升高有关,而微波消融术可以避免此风险。

    有文献报道[8],超声引导下微波消融治疗甲状腺良性结节成功率和传统手术切除术成功率相当。也有研究发现[9-10],传统手术治疗较微波消融术治疗,病人住院时间更长,术中出血和总的并发症更多。本研究中2组术后并发症发生率差异有统计学意义。说明微波消融术后并发症低于传统手术组。本研究接受微波消融的90例病人中,有36例出现暂时性颈部肿胀感,可能与术前注射液体隔离带有关,术后1周,此肿胀感均不同程度的缓解。有研究表明[10],微波消融术可能会导致喉返神经一过性的热损伤,可能由于消融电极的热效应有关,但此类损伤为可逆性的,大多数病人喉返神经功能会恢复。

    综上所述,超声引导下经皮微波消融治疗甲状腺良性结节有很好的临床疗效,在甲状腺功能的保护上,要优于传统的手术方式,在术后并发症方面,微波消融的并发症要小于传统手术治疗,因此,超声引导下经皮微波消融术是可以替代传统手术方式的一种疗法,值得应用和推广。

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