Except undifferentiated cancer, most of this disease has a slow onset and is one of the malignant tumors with good prognosis. Its etiology is not clear, and it is related to the increase of thyroid stimulating hormone secretion, benign goiter, hyperthyroidism, nodular goiter or adenoma.
There are many cell types of thyroid cancer, and the following four are common:
1. Papillary carcinoma: accounting for 60% ~ 75% of thyroid carcinoma, mostly under 40 years old. Cancer tissue is composed of papillary structure, which is easy to metastasize to cervical lymph nodes and has low malignancy.
2. Follicular carcinoma: accounting for 12% ~ 25%, mostly over 40 years old. Cancer cells are follicular or glandular tubular and metastasize late, but they can migrate to the whole body in the blood.
3. Medullary carcinoma: accounting for 1% ~ 10% of thyroid carcinoma, it is a solid carcinoma with amyloid stroma.
4. Undifferentiated cancer: rare, mostly occurring in women over 50 years old, is the most malignant type of thyroid cancer.
Others are squamous cell carcinoma, spindle cell carcinoma, adenoid cystic carcinoma, mucinous adenocarcinoma and acid cell carcinoma, which are relatively rare.
The clinical manifestations of thyroid cancer are asymptomatic in the early stage, similar to benign thyroid tumors, but the texture is tougher than adenoma and grows rapidly. When the tumor develops further, the tumor is mostly uneven, adhered to the surrounding area, and the swallowing activity is limited. If the tumor continues to grow and oppresses the esophagus, trachea or recurrent laryngeal nerve, dysphagia, dyspnea and hoarseness will occur. Ulcer caused by tracheal erosion can cause hemoptysis. When the jugular vein is compressed, facial edema will appear. Hard lymphadenopathy can be seen in metastatic neck.
Different types of thyroid cancer may have different clinical manifestations:
1. Papillary carcinoma: It is easy to metastasize to cervical lymph nodes after remission.
2. Follicular carcinoma: mostly unilateral and single, the tumor is large, the neck metastasis is less, and it is easy to metastasize to organs such as bones.
3. Medullary cancer: slow development, long course of disease, multiple single, if there is a family history, it is often multiple on both sides, and more than half of it has metastasized to the neck. Because cancer cells secrete calcitonin, blood calcium is temporarily reduced, and prostaglandin and 5- hydroxytryptamine are secreted, which leads to intractable watery diarrhea in 1/3 patients, which lasts for many years until cancer becomes.
4. Undifferentiated cancer: It often occurs after middle age, especially in elderly women. It is common in goiter with nodules for many years, which suddenly increases and develops rapidly in a short time, forming diffuse huge masses on both sides of the thyroid gland and invading adjacent tissues, causing hoarseness and dysphagia, and prone to blood metastasis.
diagnose
1. Symptoms and signs: If thyroid cancer is early and has no metastasis, it is often difficult to distinguish it from benign thyroid tumor, but if it can be carefully examined, more than 80% can be diagnosed by palpation. Thyroid cancer often has the following manifestations: the tumor is hard, uneven and unclear; Tumors can extend beyond the thyroid gland, with poor mobility or fixation, and often grow suddenly and rapidly on the basis of long and stable tumors. Sometimes papillary carcinoma is cystic, and puncture can suck out brown or dark brown liquid; The enlargement and compression of tumor cause dyspnea, dysphagia and hoarseness; There are swollen and hard lymph nodes near the sternocleidomastoid muscle in the middle of the neck; More than 30% of medullary cancers can have intractable watery diarrhea with unknown causes, which lasts for many years.
2.x-ray examination: scattered calcification, tracheal compression, displacement or bone metastasis can be seen in thyroid tumor.
3. Ultrasonic examination: The boundary of malignant tumor is unclear, the internal echo is uneven, mostly hypoechoic, and the rear echo is weakened. Calcified strong echo light masses are common in tumors.
4.CT and MRI examination: CT can clearly show the shape and size of thyroid tumor and its relationship with larynx, trachea and esophagus, and can see the scope of tumor infiltration. MRI can clearly distinguish the images of lymphatic vessels, blood vessels and tumors in the soft tissues of the neck.
5. Radioactivity associated element examination: cold nodules can appear, but there is no specificity.
6. radioimmunoassay: The increase of serum calcitonin in patients with medullary cancer is mostly above 1 000pg/ml, while that in normal people is between 380 ~ 5 10 pg/ml.
7. Others: In order to make a clear pathological diagnosis, puncture aspiration biopsy, metastatic lymph node biopsy or frozen section resection should be performed before operation.
differential diagnosis
1. Thyroid adenoma: female, mostly localized single nodule, with capsule, smooth surface, rubbery hardness, mobility, clear boundary, often stable for many years, slow growth and mostly asymptomatic.
2. Thyroid cyst: mostly unilateral and single, smooth and active, with obvious cystic cavity feeling when touched, often increasing or decreasing by itself in a short time, mostly asymptomatic, lasting for months or years. Ultrasonic examination is cystic, and light yellow liquid can be sucked out by puncture.
3. Simple goiter: This disease, also known as nodular goiter, mostly occurs in adolescence or pregnancy, lactation and menopause, and is related to iodine deficiency. Most of them are diffuse and gradually increasing, and the surface is smooth and soft in the early stage, and nodules or cyst-like appearances with different sizes and hardness can appear in the later stage. Sometimes the gland is highly enlarged, which can also compress trachea, esophagus, recurrent laryngeal nerve and superior vena cava, which is easy to cause corresponding symptoms. It is difficult to distinguish it from cancer at this time. The disease develops slowly without metastasis, and sometimes pathological differentiation is needed.
4. Subacute thyroiditis: unilateral or bilateral localized enlargement of the thyroid gland with pain, radiating to the ear, temporal bone, neck or pharyngeal isthmus, with tumors one after another, mostly occurring in women aged 20-40. Symptoms such as upper respiratory tract infection, low fever, mental stress, accelerated erythrocyte sedimentation rate and elevated white blood cells often appear before onset. If treated with prednisone, the disease can be controlled quickly, but it is easy to relapse.
5. Lymphatic thyroiditis (Hashimoto's goiter): Generally, bilateral goiter is about 2-4 times that of the original thyroid gland. Thyroid morphology is maintained, the tumor is rubbery and lobulated, with slightly raised nodules on the surface, and there is no adhesion around the thyroid. It is generally believed that this disease is an autoimmune disease, mostly middle-aged women, mostly asymptomatic, accompanied by mucinous edema and compression of esophagus, trachea and recurrent laryngeal nerve.
6. Chronic woody goiter: mostly occurs in women around 50 years old. The thyroid gland is generally progressive, highly fibrotic and spreads to adjacent tissues, and its quality is as hard as wood. Adhesion between the lesion site and surrounding tissues causes compression symptoms of trachea, esophagus, recurrent laryngeal nerve and blood vessels, which is similar to thyroid cancer in clinic. Hard texture is the characteristic of this disease, which can be used for identification.
The treatment of thyroid cancer is mainly based on the early or late stage, metastasis, cancer cell type and patient quality, combined with the characteristics of various treatment methods for selection and comprehensive treatment. Surgery is still the main treatment for thyroid cancer. Early simple resection is feasible, and neck lymph node dissection can be done if there is external invasion and neck metastasis; Radiotherapy is not sensitive to thyroid cancer (except undifferentiated cancer). If there must be residual cancer during the operation, lobular irradiation can be performed on the residual cancer focus. Chemotherapy is not ideal, except for undifferentiated cancer, which is treated with chemotherapy as a supplementary treatment of radiotherapy, the effect of other types is very low. Although traditional Chinese medicine has no direct anticancer effect, it can balance yin and yang, improve the anti-cancer ability of the body, and has a good effect on the inhibition of residual cancer after surgery and radiotherapy, with no side effects after long-term administration. Especially for the recurrence and distant metastasis after surgery, radiotherapy and chemotherapy, Chinese medicine has become the main treatment method in the case that it cannot be treated.
1. surgical treatment: mainly suitable for papillary carcinoma, follicular carcinoma and medullary carcinoma. Select other types as appropriate.
When the lesion is confined to glands and cervical lymph node metastasis is not found in clinic and surgery, only lobectomy can be performed on the affected side; If the lesion involves two lobes or isthmus, total thyroidectomy or Ye Quan resection is performed, and most of the other lobe is removed; If the cancer focus invades the gland, or the cervical lymph node is enlarged in clinic and operation, it is necessary to carry out combined radical resection of primary cancer and cervical lymph node metastasis; For bilateral cervical lymph node metastasis, bilateral cervical lymph node radical operation should be performed by stages, and in principle, 1 internal jugular vein or 1 modified cervical lymph node dissection should be reserved. The recurrent laryngeal nerve is involved. If papillary carcinoma and follicular carcinoma can be separated, try to keep them. If it is undifferentiated cancer, it is estimated that it can be eliminated if it can be eliminated, and it can be preserved if it cannot be eliminated. The tumor invades and compresses the trachea, causing dyspnea. Tracheotomy is feasible.
2. Radiotherapy: After undifferentiated cancer surgery or biopsy is not suitable for surgery, large-scale radical irradiation is feasible; For postoperative patients with papillary carcinoma, follicular carcinoma and medullary carcinoma, we can try Xiao Ye irradiation on tumor focus to avoid large-area irradiation, so as not to damage the skin and lose the chance of radical surgery again. Follicular thyroid cancer with lung and distant metastasis, according to the high iodine absorption rate of this cancer, 13 1 iodine treatment, the effect is quite good; The dose of iodine for papillary carcinoma is low and the effect is poor; Undifferentiated cancer does not absorb iodine, and this method is ineffective.
3. Chemotherapy: Chemotherapy is not sensitive to thyroid cancer, but it can temporarily relieve symptoms for undifferentiated cancer. Because chemotherapy has certain side effects, it will reduce immune function, so other types of cancer should not be treated with conventional chemotherapy except undifferentiated cancer. Commonly used drugs are cisplatin, cyclophosphamide, fluorouracil and adriamycin. Combined chemotherapy can refer to nasopharyngeal carcinoma, laryngeal carcinoma and oral cancer.
4. Endocrine therapy: Thyroxine can inhibit the secretion of thyroid stimulating hormone (TSH) in the anterior pituitary, thus inhibiting the proliferation of thyroid tissue and the development of cancer cells. Therefore, taking thyroxine intermittently for a long time after operation has become a common routine therapy for clinicians to prevent recurrence and treat advanced thyroid cancer. It is considered that it has certain curative effect on papillary carcinoma, follicular carcinoma and medullary carcinoma, regardless of primary carcinoma or metastatic carcinoma. The effect on undifferentiated cancer is poor.
Dosage of thyroxine after thyroid cancer surgery;
(1) thyroid tablet (thyroid powder, dry thyroid), 30 ~ 60mg/ time, 2 ~ 3 times/day, and the maintenance amount is 2 times/day;
(2) The initial dose of levothyroxine was 50μg/ day and gradually increased to 100 ~ 150μg/ day.
The author thinks that thyroxine should be used according to the specific situation after thyroid cancer surgery, and it is not suitable for long-term use. For total thyroidectomy, it should be taken for life to avoid hypothyroidism and STH increase. Although most of the thyroid gland has been removed, it is still functional and hypothyroidism is not obvious. Small doses of thyroxine can be used to maintain balance. Thyroxine is not removed much, and those with normal thyroid function should not take it for a long time. From the point of view of traditional Chinese medicine, thyroxine is a yang-tonifying drug, which belongs to a hot substance. Long-term use will lead to imbalance between yin and yang and hyperthyroidism symptoms, such as irritability, impatience and insomnia. According to the author's observation, after thyroid cancer surgery and normal thyroid function, there is no significant difference in the long-term effect between taking thyroxine and not taking thyroxine, and long-term users feel uncomfortable or have other side effects.
5. TCM syndrome differentiation and treatment:
(1) Phlegm and blood stasis type: equivalent to stage ⅰ and ⅱ simple thyroid cancer, asymptomatic.
Main symptoms: the gall tumor in front of the neck is raised, and both sides are single or multiple. Hard or elastic in hard, generally movable, or slightly fixed, no swelling and pain spread in the neck. Generally, there are no obvious symptoms except nervousness and discomfort in front of the neck, chest tightness and irritability. The tongue is red or reddish, the coating is thin and white or normal, and the pulse is flat or slightly slippery.
Treatment: eliminating stagnation, regulating qi and resolving phlegm.
Prescription: seaweed 15g Prunellae Spica 15g Fritillaria thunbergii 12g Pericarpium Citri Reticulatae Viride 10g Dioscorea bulbifera 15g kelp 15g raw oyster, 30g salvia miltiorrhiza 15g poria cocos 12g Atractylodis Rhizoma.
(2) Yin deficiency and blood stasis type: middle and late stage, neck or distant metastasis, or recurrence after surgery, radiotherapy and chemotherapy.
The main symptoms: the gall tumor in front of the neck is gradually enlarged, and the gall tumor in the neck spreads, or after the invasion of surgery, radiotherapy and chemotherapy, the vitality is damaged, the yin and body fluid are flourishing, dry mouth and burning facial features appear, or the gall tumor blocks the meridians, qi stagnation and blood stasis, and dyspnea, dysphagia, joint pain, emaciation and occasional fever occur. The tongue is red or reddish purple or blue purple. Shit, mostly dry or secret Urine is short and red or normal.
Treatment: strengthening body resistance and nourishing yin, removing blood stasis and resolving hard mass.
Prescription: Ophiopogon japonicus 12g Radix Glehniae 12g Radix Scrophulariae 10g Radix Rehmanniae 15g Radix Pseudostellariae 15g Dendrobium 12g Rhizoma Sparganii 12g Rhizoma Curcumae 12g Rhizoma Dioscoreae Bulbiferae.
(3) Deficiency of both qi and blood: late disease, recurrence after comprehensive treatment, distant metastasis, or diarrheal medullary carcinoma.
Main symptoms: swelling and pain, neck tightness, dry mouth and hoarseness; Or due to the spread of scabies, the meridians are blocked; Or because of too many attacks, the vitality is injured; Or due to prolonged illness, exhaustion of body fluid, deficiency of kidney yin, general weakness, emaciation, dizziness, listlessness, persistent cough and asthma, frequent diarrhea, loss of appetite, pale or reddish tongue, or lavender or cyanosis. The pulse is thin or thin.
Treatment: Yiqi Yangxue, Fuzheng Jiedu.
Prescription: Ginseng (or American ginseng) 6g (decocted separately) Radix Astragali 15g Radix Pseudostellariae 15g Radix Glehniae 12g Radix Ophiopogonis 10g Herba Dendrobii 10g Rhizoma Polygonati 12g Fructus Lycii 12g Radix Rehmanniae/. +02g Radix Paeoniae Rubra 10g Prunellae Spica 15g Rhizoma Dioscoreae Bulbus 15g Radix Glycyrrhizae 3g Polyporus 12g.
6. Single prescription:
(1) seaweed jade pot soup. Seaweed 15g kelp 15g dried tangerine peel 9g Fritillaria 9g Green Peel 9g Chuanxiong 9g Guishen 9g Forsythia suspense 10g Radix Angelicae Pubescentis 9g Glycyrrhizae 3g
It is suitable for simple thyroid cancer without obvious symptoms or complications.
(2) Amber Black Dragon Dan. 30g of Amber, 60g of Sanguis Draxonis, Mo Jing, Oletum Trogopterori, Thallus Laminariae, seaweed, Rhizoma Arisaematis 1 5g, Radix Aucklandiae (9g) and Moschus (3g) are ground into fine powder, honey is refined into pills, 3g of gold foil is wrapped in each pill, and each pill is taken1pill, and hot wine is taken.
(3) 60g of Amorphophallus konjac (decocted for half an hour), 30g of Xanthium sibiricum and Rhizoma Osmundae each, and15g of Pollen Typhae, seaweed and Scrophularia each. If the tumor is hard, add 60g of raw oyster, decoct in water for 3 times, and take it repeatedly 1 day. Adapt to all kinds of thyroid cancer. Can take 30 ~ 60 doses continuously without obvious complications.
(4) seaweed 12g kelp 12g pumice 12g cuttlebone 12g coptis root 3g scutellaria root 6g honeysuckle stem 12g angelica 12g astragalus root 30g.
Decoct in water for 3 times, and take orally 1 day. Take 20 ~ 60 doses continuously, and you can continue to take it if it is effective.
(5) Salvia Miltiorrhiza 15g Alisma orientalis 12g Polyporus 15g Plantago 10g Seaweed 5g Oyster 30g Rhizoma Sparganii 12g Rhizoma Curcumae 12g Dioscorea bulbifera 12g Poria.
Decoct in water for 3 times, and take orally 1 day. This prescription is effective for thyroid cancer complicated with cyst or simple thyroid cyst.
(6) Add 30g leaf red (apricot-scented rabbit ears) 30g wild rose fruit 30g dog liver vegetables 20g jujube 6 pieces to decoct for tea. For thermal reaction after radiotherapy, postoperative infection, or cervical and pulmonary metastasis, it should be taken frequently to control the development of cancer and prolong life.
7. Symptomatic treatment of integrated traditional Chinese and western medicine: Once thyroid cancer causes corresponding symptoms and disease consumption to adjacent organs, it will cause imbalance in the body, such as pain, infection, fever, dysphagia, malnutrition, mental stress, insomnia, irritability, etc., and should be treated with Lexus capsules in time.
Except undifferentiated carcinoma, the prognosis of thyroid carcinoma is good, and the 5-year survival rate after operation is 83% ~ 95%, including papillary carcinoma 90% ~ 97%, medullary carcinoma 88%, follicular carcinoma 79% ~ 82%, undifferentiated carcinoma 12.5% ~ 20%. Papillary thyroid carcinoma is accompanied by lung and distant metastasis, and most of them are accompanied by tumor survival for many years. The author has clinically treated 5 cases of papillary thyroid carcinoma, all of which have extensive lung metastasis. The tumor focus is as small as walnut and as big as duck egg, accounting for 4-8 cases. After intermittent treatment by Chinese medicine, she survived for 12- 16 years, insisted on full-time labor, and finally died of infection and untreated.
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