晚期分化型甲状腺癌侵犯喉气管食管后的切除与修复

Resection and reconstruction of advanced differentiated thyroid cancer invading the larynx, trachea, and esophagus

摘要:

分化型甲状腺癌（DTC）侵犯邻近重要结构时，治疗目标已从单纯追求肿瘤根治性切除转向涵盖气道通畅性、吞咽与发音功能保留的多维度功能保护。因此，平衡根治性切除范围与重要器官功能保留之间的矛盾，是局部晚期病变临床决策的核心难点。现有研究共识指出，针对该类患者，术前需系统评估肿瘤局部侵犯范围、浸润深度及远处转移风险，通过多学科协作制订个体化的治疗方案。针对喉返神经受侵的病例，推荐依据术前声带运动状态、肿瘤受侵程度及对侧喉返神经功能实施分层处理；针对气管受侵病例，需根据肿瘤浸润深度采取分级诊疗策略；针对食管受侵病例，诊疗核心在于评估黏膜保留可行性与缺损范围。术后重建方案的选择不应仅依据受侵器官类型，需结合缺损分型、局部组织条件与功能目标综合判定。区域皮瓣、游离皮瓣及消化道重建等术式在不同临床情况下均具备明确适应证。本文围绕晚期DTC侵犯喉、气管及食管后的切除原则、缺损分型、重建方法、肿瘤学与功能学结局、临床实践经验及未来发展方向展开综述，旨在为临床诊疗提供循证依据。

Abstract:

When differentiated thyroid cancer (DTC) invades adjacent vital structures, the treatment goal has shifted from simple radical tumor resection to multi-dimensional functional preservation covering airway patency, swallowing function, and voice function. Therefore, balancing the radical resection scope and the preservation of important organ functions is the core difficulty in clinical decision-making for locally advanced lesions. The current research consensus indicates that for such patients, preoperative systematic assessment of the local invasion range of the tumor, the depth of infiltration, and the risk of distant metastasis is required. An individualized treatment plan is formulated through multidisciplinary collaboration. For cases with recurrent laryngeal nerve invasion, stratified treatment is recommended based on the preoperative vocal cord movement, the degree of tumor invasion, and the function of the contralateral recurrent laryngeal nerve. For cases with tracheal invasion, a graded treatment strategy should be adopted according to the depth of tumor infiltration. For cases with esophageal invasion, the core of diagnosis and treatment lies in evaluating the feasibility of mucosa preservation and the extent of defect. The selection of postoperative reconstruction methods should not only be based on the type of invaded organ, but also take into account the classification of defects, local tissue conditions, and functional goals for a comprehensive decision. Various surgical techniques such as regional flaps, free flaps, and digestive tract reconstruction have clear indications in different clinical situations. This article reviews the principles of resection for advanced DTC invading the larynx, trachea, and esophagus, the classification of defects, reconstruction methods, oncological and functional outcomes, clinical experience, and future development directions, aiming to provide evidence-based guidance for clinical diagnosis and treatment.