最近幾位病友讓我很傷腦筋, 也讓我這幾天不斷思索未來的方向~
(1) 某位在 T 大開完刀的甲狀腺病友 (中年女性, 頗具教育水準), 手術採取單葉切除乳突癌 0.9公分, 術後追蹤另一葉仍有 0.5公分的結節, 據其轉述 T 大的 W 醫師不再為她處理, 但這位病友就不斷到我的汀州夜診, 她關心的問題是身上還有甲狀腺癌細胞嗎? 0.5 公分結節在超音波或細針穿刺一般情況下很難輕易診斷, 只能藉由持續追蹤看是否變大, 至於有無淋巴侵犯或遠端轉移目前也沒有可信賴的診斷方式(因為只切除單葉無法進行放射碘診斷), 雖經我再三的解釋, 這位病友無法接受, 無奈之下幫她排了一連串檢查, 建議他還是乖乖地追蹤比較適當, 得到的結果竟然是要拷貝我寫的病歷和影像資料~~她是懷疑我嗎?
(2) 另一位先前曾提到在本院手術也是乳突癌的病友(看診時小孩圍繞在身旁的中年女性), 術前診斷是 >1.5 公分的結節, 單葉切除術後診斷是乳突癌 <1.0 cm, 但病友抽血發現甲狀球蛋白 (thyroglobulin) 持續上升, 最近已經超過 27 ug/mL (註: 正常人在甲狀腺完整且無疾病下應該 < 25, 而切除單葉後推測低於 10-12), 病友術後曾陸續尋求幾位醫師看診(據病友陳述這些醫師都不太解釋後續處理方式, 甚至有位同仁告訴她說我們團隊會負起術後照護的責任), 由於無法得到是否還有殘餘癌症的答案, 她被轉到我的門診, 檢查後發現持續上升的甲狀球蛋白加上另一葉未切除的多發甲狀腺結節, 是否隱藏惡性更是感到令人憂心忡忡, 週五看診前一日在團隊會議中我卿幾位學弟就此病情發表意見, 討論中被某幾位學弟陶侃說病友是相信我的白頭髮才找我的, 事實上我常被這樣的問題困住才頭髮越來越白啊! 更令人難過的是這位病友的家屬用手機紀錄我說的話,事後還要求拷貝所有的病歷資料, 她說不相信我們醫生說的話了
(3) 另一位病友從石牌 V 醫院來到我的汀州夜診, 她的甲狀腺節結接近 1.0 cm, 細針穿刺診斷是疑似乳突癌, 但因為 C 醫師說讓她自己選擇單葉 (lobectomy) 或是全切除(total thyroidectomy), 她想聽我的意見; 簡單的說全切是方便以後的追蹤也比較能夠回答或解決 "是否隱藏惡性細胞未清除", "有無淋巴侵犯或遠端轉移" 此類的尷尬問題, 但病友又想會不會白白切掉另一葉好的甲狀腺, 又擔心全切的潛在危險(e.g. 副甲狀腺受傷), 唉! 很難決定啊!
根據最新的 2015 美國甲狀腺 (American Thyroid Association 2015) 指引:
(1) Decisions regarding the extent of surgery for indeterminate thyroid nodules (AUS/FLUS or FN or SUSP) are influenced by several factors, including the estimated presurgical likelihood of malignancy based upon clinical risk factors (>4 cm, family history, and/or Hx of radiation), sonographic pattern, cytologic category, and ancillary test findings. These risk factors, as well as patient preference, presence of contra-lateral nodularity or coexistent hyperthyroidism, and medical co-morbidities, impact decisions regarding thyroid lobectomy with the possible need for subsequent completion thyroidectomy versus total thyroidectomy up front. (page 24)
中文摘要: 術前診斷不確定(像是 AUS/FLUS, FN, Susp 註: 台灣還有些病理醫師沒引進此種報告方式) 手術方式應考慮危險因子(如>4cm, 家族史, 輻射照射史), 超音波診斷(註: 需要更好的內分泌或放射超音波判讀功力), 分子檢測 (註: 台灣還沒引進); 另外也考慮病人的喜好, 另一葉是否有結節, 同時存在甲亢以及身體的其他醫療狀況
(2) For patients with thyroid cancer >1 cm and <4 cm without extra-thyroidal extension, and without clinical evidence of any lymph node metastases (cN0), the initial surgical procedure can be either a bilateral procedure (near totalor total thyroidectomy) or a unilateral procedure (lobectomy). Thyroid lobectomy alone may be sufficient
initial treatment for low-risk papillary and follicular carcinomas; however, the treatment team may choose total thyroidectomy to enable RAI therapy or to enhance follow up based upon disease features and/or patient preferences. (page 31-32)
中文摘要: 1-4 公分甲狀腺癌但沒有甲狀腺外擴散或淋巴轉移可以選擇全切除或單葉切除, 低風險者可以單葉切除, 但可依據病人喜好(或選擇)採取全切除以利放射碘診療或追蹤
(3) If surgery is chosen for patients with thyroid cancer <1 cm without extrathyroidal extension and cN0, the initial surgical procedure should be a thyroid lobectomy unless there are clear indications to remove the contralateral lobe. Thyroid lobectomy alone is sufficient treatment for small, unifocal, intrathyroidal carcinomas in the absence of prior head and neck radiation, familial thyroid carcinoma, or clinically detectable cervical nodal metastases. (page 32)
中文摘要: 1 公分以下甲狀腺癌且沒有甲狀腺外擴散及淋巴轉移(註:需經影像或檢查確認) 應單葉切除作為初步選擇, 除非有明確需要做另葉切除, 單葉切除適用於小且單一及甲狀腺內之病灶, 不適用於先前頭頸之輻射病史, 家族史及淋巴轉移
(4) Surgery for thyroid cancer is an important element of a multifaceted treatment approach. The operation must be compatible with the overall treatment strategy and follow-up plan recommended by the managing team. Consideration should be given to referring patients with high-risk features (clinical N1 disease, concern for recurrent laryngeal nerve
[RLN] involvement, or grossly invasive disease) to experienced surgeons, as both completeness of surgery and experience of the surgeon can have a significant impact on clinical outcomes and complication rates (page 32).
中文摘要: 甲狀腺癌手術是多面向治療重要元素, 其選擇需符合治療團隊的策略和追蹤計畫
(5) However, recent data have demonstrated that in properly selected patients, clinical outcomes are very similar following unilateral or bilateral thyroid surgery. ........ In an analysis of 52,173 PTC patients diagnosed between 1985 and 1998 from the National Cancer Data Base (43,227 receiving total thyroidectomy, 8946 undergoing lobectomy), Bilimoria et al. demonstrated a slightly higher 10-year relative overall survival for total thyroidectomy as opposed to thyroid lobectomy (98.4% vs. 97.1%, respectively, p < 0.05) and a slightly lower 10-year recurrence rate (7.7% vs. 9.8%, respectively, p < 0.05). (page 32)
中文摘要: 經過慎重選擇的甲狀腺癌以全切除或單葉切除結果差異不大, Bilimoria 研究 52173 個乳突癌病患發現全切除 vs 單葉切除10年存活率為 98.4% vs. 97.1%; 全切除或單葉切除腫瘤復發率 7.7% vs. 9.8% (註:病友會不會為了增加一點存活率或減少一點復發率選擇全切呢?)
*******新的2015 ATA 指引能否適用在台灣真的令人擔心, 真的全盤接收對於醫生和病友可能會是大災難. 理由包括:
(1) 手術醫生能否在術前解釋清楚全切除 vs 單葉切除的後果, 而病友又能了解多少 (有限的健保給付怎容許花很長的時間去解釋)
(2) 台灣的健保制度和醫療環境及文化養成防衛性醫療(害怕被告)之傾向, 且咱們社會常以結果論斷醫療行為, 全切除 vs 單葉切除像是過猶不及的賭博
(3) 台灣很多甲狀腺癌相關診斷並不完全, 例如 Bethesda System 的落實, 超音波診斷判讀功力, 分子檢測等還未完善; 更枉論有些醫院的放射碘治療體系更本就沒設立或者甲狀腺癌治療團隊都沒有完整運作
(4) 台灣為數不少的甲狀腺病友也是"久病成疑", 而醫生只能閃閃躲躲避免被逮到語病
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