桥本氏甲状腺炎伴多灶性甲状腺乳头状癌的BRAF基因突变分析及预警信号的研究

发布时间：2018-03-10 02:38

本文选题：桥本氏甲状腺炎　切入点：甲状腺乳头状癌　出处：《浙江大学》2016年博士论文　论文类型：学位论文

【摘要】：背景和目的：桥本氏甲状腺炎(HT)癌变问题是近年一个研究的热点,很多机制尚不明朗,而且治疗方案存在争议。以往认为桥本氏甲状腺炎是良性病变且会引起甲状腺功能减低故不宜手术治疗,但近年发现HT可能为癌前病变,如有癌变迹象需积极手术治疗。已有报告显示,HT伴PTC发生率由过去的23%上升为近年的58.3%,所以桥本氏甲状腺炎与癌变有非常大的关系。近年来HT伴发甲状腺癌的发病率呈上升趋势,尤以HT伴发甲状腺乳头状癌(PTC)发病率增长明显,且往往伴发多灶性PTC。如HT伴发多灶性癌变应行甲状腺全切,但目前尚无明确指标能预先判断HT伴发的是单发癌灶还是多灶性癌变。术中冰冻切片往往会遗漏微小癌灶,只有行甲状腺全切进行常规病理检查才能明确是否存在多灶癌,但这样做可能使低危的单发癌患者接受了过度治疗,且增加了术后并发症的发生几率。因此进行HT多灶性癌变预警信号的研究对指导临床治疗方案具有重要意义。方法：1.回顾性分析2008年6月至2013年6月期间行甲状腺手术的HT伴PTC及单纯HT患者808例病例资料,其中男性206例,女性602例,患者均为体检彩超发现甲状腺结节因怀疑恶性或因结节较大有症状而行手术治疗。所有因具备甲状腺手术指征行手术治疗而术后病理证实为HT伴PTC或单纯HT的病例均纳入,但要排除有甲亢、亚急性甲状腺炎、结核病史或有其他恶性肿瘤病史、免疫功能低下、其他重大疾病史的病例,所有患者术前均未行化疗、放疗及无免疫治疗史。根据术后病理结果将其分为3组：A组(HT伴多灶性PTC)、B组(HT伴单发PTC)、C组(单纯HT)。将术后常规病理结果与术前TPOAb检测结果进行比对分析,并将术后病理结果与术前患者基础情况、TSH等化验结果进行对比分析。分析与单发癌、多灶癌的相关性以及与淋巴结转移的相关性。2.取我院2012年6月至2014年6月甲状腺手术患者术后常规病理确诊HT(30例)、HT单发癌(30例)及HT多灶癌(30例)病例的病理标本制成的石蜡切块共90例。所有病例均经病理诊断证实,且术前均未行化疗、放疗及无免疫治疗史。按要求对HT单发癌、HT多灶癌、HT组织蜡块进行切片,分别进行CK-19、COX2、 Galectin-3、HBME-1四个蛋白的免疫组化IHC实验。3.取我院2012年6月至2014年6月甲状腺手术患者术后常规病理确诊HT(10例)、HT单发癌(40例)及HT多灶癌(30例)病例的病理标本制成的石蜡切块进行DNA提取,然后进行PCR及基因测序实验检测BRAF基因突变。结果：1.232例HT伴多灶性PTC(A组)患者中有196例TPOAb指标明显升高1300IU/mL；另外469例HT伴单发PTC(B组)患者中有416例TPOAb指标1000 IU/mL(多数在400-600之间)；其余107例HT患者TPOAb指标差异较大；TPOAb指标在HT伴单发和多灶性PTC患者之间有显著差异(P0.01)。2.C组免疫组化指标表达最低,与各组有显著差异(P0.05)。CK19:A组明显高于B组,有显著差异(P0.05)。COX-2:A组与B组没有显著差异(P0.05)。Galectin-3:A组与B组没有显著差异(P0.05)。HBME-1:A组与B组没有显著差异(P0.05)。CK19免疫组化平均光密度定量0.007时A、B两组差异最大(P0.001),根据ROC曲线0.007可作为区分HT单发癌和多灶癌的界点。3.A组(HT伴多灶性PTC)BRAF基因突变明显高于B组(HT伴单发PTC),而C组(单纯HT)无BRAF基因突变,A组有29.63%出现BRAF基因突变,B组有10.26%出现BRAF基因突变,各组有显著差异(P0.05)。结论：1. TPOAb1300IU/mL是HT伴多灶性PTC的高危因素,对术中冰冻病理报告为HT伴PTC(而术前TPOAb1300 IU/mL)的患者建议行甲状腺全切除术。但TSH增高伴TPOAb轻中度升高(1300 IU/mL)并不能作为判断HT伴发多灶性PTC的高危风险因素,TSH增高只能作为辅助参考因素。在HT伴发多灶性PTC中TPOAb指标的高低对颈中央区淋巴结转移阳性率无影响,但多灶癌比单发癌转移阳性率要高,因此无论TPOAb指标高低都建议行中央区淋巴结清扫。2.仅发现CK19在HT伴多灶性PTC组免疫组化呈强阳性表达,明显高于HT伴单发癌组,有显著差异,其余指标无显著差异。如术前或术中CK19免疫组化平均光密度定量0.007则很有可能是HT伴多灶癌,结合术中冰冻切片建议行甲状腺全切。3.HT伴多灶癌的BRAF基因突变率明显高于HT伴单发癌,HT伴PTC患者如检测发现有BRAF基因突变则很有可能为HT伴多灶癌,结合术中冰冻切片建议行甲状腺全切。
[Abstract]:Background and objective: Hashimoto's thyroiditis (HT) cancer problem is a hot research topic in recent years, many mechanisms are still unclear, but controversial treatment. The past that Hashimoto's thyroiditis is a benign lesion and cause hypothyroidism is not suitable for surgery, but in recent years HT may be precancerous lesions, such as there are signs of cancer need surgical treatment. The report shows that HT with the incidence of PTC increased from 23% to 58.3% in the past, so there is a very large Hashimoto's thyroiditis and cancer. In recent years, HT associated with thyroid cancer incidence is rising, especially in HT associated with thyroid papillary carcinoma (PTC) the incidence rate increased significantly, and often accompanied by multifocal PTC. HT with multifocal carcinoma should be underwent total thyroidectomy, but there is no clear indicators to judge beforehand associated with HT is a single tumor or multi focal cancer surgery. Frozen sections often left small foci, only underwent total thyroidectomy for routine pathological examination to confirm the existence of multifocal carcinoma, but this may lead to low-risk single cancer patients received excessive treatment, and increase the incidence of postoperative complications. Therefore HT multifocal carcinogenesis with early warning signals an important significance for guiding the clinical treatment. Methods: a retrospective analysis of 1. during the period from June 2008 to June 2013 for thyroid surgery with HT PTC and the HT patients 808 cases, including 206 cases of male, female 602 cases, patients were found by ultrasound examination of thyroid nodules or suspected malignant nodules due to larger symptoms and surgical treatment all due to have thyroid surgery indications for surgery and postoperative pathology confirmed HT with PTC or HT alone were included, but to exclude hyperthyroidism and subacute thyroiditis. The history of nuclear or other malignant tumor history, immune dysfunction, other major disease cases, all patients had not received chemotherapy, radiotherapy and immunotherapy. According to the postoperative pathological results, it can be divided into 3 groups: group A (HT with multifocal PTC), group B (with HT single PTC), C group (HT alone). The routine pathological results with preoperative TPOAb detection results were compared and analyzed, and the postoperative pathological results and preoperative patients, TSH test results were analyzed. Correlation analysis and single cancer, multifocal carcinoma and lymph node.2. correlation the transfer of the conventional HT diagnosed in our hospital from June 2012 to June 2014 in thyroid surgery patients (30 cases), HT single cancer (30 cases) and HT multifocal carcinoma (30 cases) were made of paraffin slice specimens were 90 cases. All cases were confirmed by pathological diagnosis, and no preoperative chemotherapy, radiotherapy and Immunotherapy. According to the requirements of the HT single cancer, HT multifocal carcinoma, HT biopsy tissue blocks, respectively CK-19, COX2, Galectin-3, HBME-1 four protein immune group IHC experimental.3. conventional HT diagnosed in our hospital from June 2012 to June 2014 in thyroid surgery patients (10 cases), HT single cancer (40 cases) and HT multifocal carcinoma (30 cases) were made of paraffin slice specimens for DNA extraction and detection of BRAF gene and PCR gene sequencing the mutation. Results: 1.232 cases of HT with multifocal PTC (A group) of 196 patients with TPOAb significantly increased 1300IU/mL; the other 469 cases of HT patients with single PTC (B group) of 416 patients with TPOAb index of 1000 IU/mL (mostly in 400-600); the remaining 107 cases TPOAb index in patients with HT are different; the TPOAb index in HT with a significant difference between solitary and multifocal PTC patients (P0.01 group.2.C) immunohistochemical expression index Low, there was significant difference in each group (P0.05) of.CK19:A group was significantly higher than that in B group, there was significant difference (P0.05) of.COX-2:A group had no significant difference with group B (P0.05).Galectin-3:A group had no significant difference with group B (P0.05).HBME-1:A group had no significant difference with group B (P0.05).CK19 immunohistochemistry. The average optical density quantitative 0.007 A, B two group (P0.001), the biggest difference according to the ROC curve of 0.007 can be used as the dividing points between.3.A group and HT single cancer multifocal carcinoma (HT with multifocal PTC) BRAF gene mutation was significantly higher than B group (HT with single PTC) C group, (HT only) BRAF gene the A group had 29.63% mutations, BRAF gene mutation, B group had 10.26% BRAF mutations in each group have significant difference (P0.05). Conclusion: 1. TPOAb1300IU/mL is a high risk factor of HT with multifocal PTC, the intraoperative frozen pathology report with HT PTC (preoperative TPOAb1300 IU/mL) were recommended for total thyroidectomy but TSH. TPOAb increased with mild to moderate increase (1300 IU/mL) and high risk factors and can't be judged as HT associated with multifocal PTC, TSH increased only as auxiliary reference factors. In the HT TPOAb index with multiple focal PTC in the level of central neck lymph node metastasis positive rate has no effect, but more than single foci the positive rate of cancer metastasis is higher, so both TPOAb index level recommended for central lymph node dissection.2. found only in HT CK19 with multifocal PTC immunohistochemical expression was strongly positive, HT was significantly higher than that of patients with single cancer group, there are significant differences, other indexes had no significant difference. As before or during operation average optical density of CK19 immunoreactivity quantitative 0.007 is likely to be HT with multifocal carcinoma, with sections suggested BRAF gene.3.HT underwent total thyroidectomy with multifocal carcinoma and the mutation rate was significantly higher than that of HT with single cancer intraoperatively, HT patients with PTC such as the detection of BRAF gene mutation It is likely to be HT with multiple cancer, combined with intraoperative frozen section recommended for total thyroidectomy.

【学位授予单位】：浙江大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R736.1;R581.4

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