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作为临床上最常见的内分泌恶性肿瘤之一,甲状腺癌近年的发病率呈显著上升的趋势。2012年国家癌症中心的统计数据显示,我国甲状腺癌的年龄标准化发病率已达2.8/10万[1-2]。分化型甲状腺癌(differentiated thyroid cancer,DTC)占甲状腺恶性肿瘤的90%以上,是甲状腺癌中最为常见的类型。目前,国内外对DTC患者普遍采用“手术+131I治疗+TSH抑制治疗”的综合方案[3-5]。甲状旁腺功能减退是甲状腺外科手术后常见的并发症之一,一旦发生,患者生活质量会受到较大影响。目前很少有关于DTC患者术后出现甲状旁腺功能减退症骨代谢的相关研究。本研究分析了DTC患者术后继发性甲状旁腺功能减退对骨代谢的影响,以期为后续甲状腺癌的临床治疗以及术后健康管理提供初步的理论依据。
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检测30例甲旁减组患者血清骨代谢指标结果发现,术后1个月甲旁减组患者的PTH、血清钙水平均较低,分别为(6.11±3.97)pg/mL和(1.94±0.29)mmol/L;术后12个月PTH、血清钙分别升至(15.46±16.27)pg/mL和(2.25±0.18)mmol/L。术后1个月血清磷水平较高[(1.56±0.19)mmol/L];术后12个月血清磷水平降至(1.28±0.22)mmol/L。由表1可知,术后1个月与术后6个月、术后6个月与术后12个月的PTH、血清钙、血清磷水平的比较,差异有统计学意义。
术后时间 PTH(pg/mL) 维生素D(ng/mL) 血清钙(mmol/L) 血清磷(mmol/L) ALP(U/L) 1个月 6.11±3.97 8.69±1.57 1.94±0.29 1.56±0.19 64.50±14.62 6个月 13.83±15.12a 9.53±1.66 2.10±0.16c 1.44±0.18e 58.20±17.57 12个月 15.46±16.27b 8.91±1.75 2.25±0.18d 1.28±0.22f 61.11±18.46 注:表中,a:与术后1个月PTH比较,差异有统计学意义(t=−2.467, P<0.05);b:与术后6个月PTH比较,差异有统计学意义(t=−2.753,P<0.05);c:与术后1个月血清钙比较,差异有统计学意义(t=−2.941,P<0.05);d:与术后6个月血清钙比较,差异有统计学意义(t=−3.652,P<0.05);e:与术后1个月血清磷比较,差异有统计学意义(t=4.550,P<0.05);f:与术后6个月血清磷比较,差异有统计学意义(t=4.167,P<0.05)。PTH:甲状旁腺激素; ALP:碱性磷酸酶。 表 1 30例甲状旁腺功能减退患者的血清骨代谢指标结果(
)${{\bar x}} \pm {{s}}$ Table 1. Serum bone metabolism index results in 30 patients with hypoparathyroidism (
)${{\bar x}} \pm {{s}}$ -
由表2可知,术后12个月甲旁减组患者股骨颈的BMD下降,与对照组比较,差异有统计学意义;2组患者在术后1个月、6个月及12个月甲状腺功能水平(FT3、FT4、TSH)及腰椎(L2~L4)、华氏三角、股骨粗隆的BMD比较,差异均无统计学意义(FT3:t=0.24~1.61,均P>0.05;FT4:t=0.86~1.38,均P>0.05;TSH:t=0.19~0.24,均P>0.05;L2~L4:t=1.01~1.80,均P>0.05;华氏三角:t=0.60~1.82,均P>0.05;股骨粗隆:t=0.40~1.66,均P>0.05)。
术后时间 分组 例数 FT3 (pmol/L) FT4 (pmol/L) TSH (mIU/L) BMD L2~L4
(g/cm2)股骨颈
(g/cm2)华氏三角(g/cm2) 股骨粗隆(g/cm2) 1个月 甲旁减组 30 1.23±0.69 3.09±1.44 108.45±34.89 1.122±0.001 1.133±0.017 1.225±0.008 1.199±0.009 对照组 30 1.08±0.49 3.40±1.09 110.47±37.24 1.124±0.006 1.147±0.014 1.229±0.009 1.196±0.004 6个月 甲旁减组 30 5.46±0.87 19.66±2.63 0.07±0.04 1.242±0.006 1.03±0.013 1.247±0.009 1.292±0.007 对照组 30 5.51±0.75 20.72±2.75 0.08±0.06 1.240±0.009 1.04±0.017 1.249±0.016 1.281±0.038 12个月 甲旁减组 30 5.44±0.57 21.40±2.02 0.09±0.06 1.211±0.007 0.77±0.027* 1.110±0.010 1.249±0.006 对照组 30 5.80±0.89 22.57±3.74 0.08±0.07 1.213±0.005 0.95±0.040 1.122±0.035 1.247±0.027 注:表中,*:与对照组(术后6个月)比较,差异有统计学意义(t=1.08,P=0.002)。FT3:游离三碘甲状腺原氨酸;FT4:游离甲状腺素;TSH:促甲状腺激素。 表 2 分化型甲状腺癌患者术后甲旁减组与对照组的甲状腺功能水平及骨密度值(
)${{\bar x}} \pm {{s}}$ Table 2. Thyroid function and bone mineral density in patients with differentiated thyroid cancer after surgery for hypoparathyroidism and normal parathyroid function (
)${{\bar x}} \pm {{s}}$ -
随着术后药物的治疗,术后6个月以及术后12个月,甲旁减组中有28例患者的低血钙症状得到明显缓解,有2例患者在术后12个月时仍呈现低血钙症状(双手、双足或口周麻刺感;异常的肌肉收缩,如痉挛;感觉疲倦、易激惹、焦虑等)。30例甲旁减组患者术后1个月服用药物的依从性最高,为100%;术后6个月与术后12个月时下降为90%和80%(表3)。
临床表现及服药依从性 术后1个月 术后6个月 术后12个月 例数 百分比(%) 例数 百分比(%) 例数 百分比(%) 双手、双足或口周的麻刺感 27 90.00 12 40.00 2 6.67 异常的肌肉收缩,如震颤、颤搐或痉挛 26 86.67 10 33.33 2 6.67 感觉疲倦、易激惹、焦虑或抑郁 26 86.67 11 36.67 2 6.67 服用维生素D及钙剂的依从性 30 100.00 27 90.00 24 80.00 表 3 30例甲状旁腺功能减退患者的临床表现及服药依从性情况
Table 3. Clinical manifestations and medication adherence of 30 patients with hypoparathyroidism
DTC患者术后继发性甲状旁腺功能减退对骨代谢的影响及其健康管理
Secondary hypoparathyroidism after DTC effects on bone metabolism and health management
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摘要:
目的 探讨分化型甲状腺癌(DTC)患者术后继发性甲状旁腺功能减退对骨代谢的影响及其健康管理。 方法 选取2017年1月至2018年5月行甲状腺全切或次全切术的DTC患者60例。其中30例患者术后出现继发性甲状旁腺功能减退合并低血钙(甲旁减组);另外30例患者术后甲状旁腺功能正常(对照组)。2组患者分别于术后1个月、6个月以及12个月常规检查甲状旁腺素(PTH)、维生素D、血清钙、血清磷、碱性磷酸酶(ALP)、游离三碘甲状腺原氨酸(FT3)、游离甲状腺素(FT4)、促甲状腺激素(TSH),并进行双能X线骨密度(BMD)的测定与健康管理相关指标检测。甲旁减组的PTH、维生素D、血清钙、血清磷、ALP采用配对t检验;甲旁减组及对照组之间的组间比较(FT3、FT4、TSH及L2~L4、股骨颈、股骨粗隆 、华氏三角的BMD值)采用独立样本t检验。 结果 ①甲旁减组患者在甲状腺全切或次全切术后1个月与术后6个月、术后6个月与术后12个月的PTH、血清钙、血清磷的比较,差异有统计学意义(PTH:t=−2.467、−2.753 ,P=0.021、0.033;血清钙:t=−2.941、−3.652,P=0.007、0.002;血清磷:t=4.550、4.167,P=0.000、0.004),维生素D、ALP的比较,差异无统计学意义(维生素D:t=2.153、1.965,P=0.062、0.074;ALP:t=1.970、1.672,P=0.061、0.066);②术后12个月时,甲旁减组患者股骨颈的BMD下降,与对照组比较,差异有统计学意义(t=1.08,P=0.002);术后1个月、6个月及12个月,甲旁减组患者与对照组比较,甲状腺功能水平(FT3、FT4、TSH)及腰椎(L2~L4)、华氏三角、股骨粗隆的BMD差异均无统计学意义(t=0.60~1.82,均P>0.05);③随着钙剂及维生素D的服用,甲旁减组患者低血钙的临床症状明显改善,至术后12个月时,以手足麻木、肌肉痉挛为主要表现的患者占6.67%,但服用钙剂及维生素D的依从性下降至80%。 结论 ①甲旁减组患者股骨颈的BMD在术后12个月时出现降低,腰椎(L2~L4)、华氏三角、股骨粗隆的BMD影响不显著;②DTC术后合并甲旁减组患者多有低血钙的临床表现,在给予钙剂和活性维生素D治疗后症状明显缓解,但患者服药依从性逐渐下降,因此应进一步加强健康教育和管理。 Abstract:Objective To investigate the effects of secondary hypoparathyroidism on bone metabolism and health management in patients with differentiated thyroid carcinoma(DTC). Methods Sixty patients with DTC who underwent total or subtotal thyroidectomy from January 2017 to May 2018 were enrolled. Among them, 30 patients had secondary hypoparathyroidism and hypocalcemia(hypothyroidism), while the other 30 patients had normal parathyroid function(control group). These two groups of patients were routinely examined for their parathyroid hormone(PTH), vitamin D, serum calcium, serum phosphorus, alkaline phosphatase(ALP), free triiodothyronine(FT3), free thyroxine(FT4), and thyroid stimulating hormone(TSH) at 1, 6, and 12 months after surgery and to determine dual-energy X-ray bone mineral density(BMD) and health-management-related indicators. PTH, vitamin D, serum calcium, serum phosphorus, and ALP in the parathyroid group were tested by conducting a paired t-test, and the indicators for the parathyroid and control groups(FT3, FT4, TSH, and L2 to L4, neck of femoral, femur trochanter, Ward’s triangle BMD value) were compared by conducting an independent sample t-test. Results 1. A statistically significant difference in PTH, serum calcium, and serum phosphorus was observed among patients with hypothyroidism at 1 and 6 months after surgery, 6 months after surgery, and 12 months after surgery(PTH: t=–2.467, –2.753, P=0.021, 0.033; serum calcium: t=–2.941, –3.652, P=0.007, 0.002; serum phosphorus: t=4.550, 4.167, P=0.000, 0.004), but no significant difference was observed in terms of vitamin D and ALP(vitamin D: t=2.153, 1.965, P=0.062, 0.074; ALP: t=1.970, 1.672, P=0.061, 0.066); 2. At 12 months after surgery, the BMD of the neck of femoral decreased in the parathyroid group, showing a statistically significant difference from the control group(t=1.08, P=0.002). At 1, 6, and 12 months after surgery, the patients with hypothyroidism showed no significant differences from the control group in terms of thyroid function level(FT3, FT4, and TSH), lumbar vertebrae(L2 to L4), Ward’s triangle, and femur trochanter BMD(t=0.606 to 1.82, all P>0.05). 3. After taking calcium and vitamin D, the clinical symptoms of hypocalcemia in patients with hypothyroidism were significantly improved. Twelve months after surgery, hand and foot numbness and muscle spasms accounted for 6.67% of the symptoms, and after taking calcium and vitamin D, the medication compliance of the patients decreased to 80%. Conclusions 1.The BMD of neck of femoral in patients with hypothyroidism decreased at 12 months after surgery, and the BMD of lumbar vertebrae(L2~L4), Ward’s triangle and femur trochanter was not significant; 2.Most patients with parathyroid hypofunction showed clinical manifestations of hypocalcemia after DTC, and their symptoms were significantly relieved after the calcium and active vitamin D treatment. However, the medication compliance of these patients gradually declined. Therefore, health education and management should be further strengthened. -
Key words:
- Differentiated thyroid carcinoma /
- Hypoparathyroidism /
- Bone density /
- Health management
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表 1 30例甲状旁腺功能减退患者的血清骨代谢指标结果(
)${{\bar x}} \pm {{s}}$ Table 1. Serum bone metabolism index results in 30 patients with hypoparathyroidism (
)${{\bar x}} \pm {{s}}$ 术后时间 PTH(pg/mL) 维生素D(ng/mL) 血清钙(mmol/L) 血清磷(mmol/L) ALP(U/L) 1个月 6.11±3.97 8.69±1.57 1.94±0.29 1.56±0.19 64.50±14.62 6个月 13.83±15.12a 9.53±1.66 2.10±0.16c 1.44±0.18e 58.20±17.57 12个月 15.46±16.27b 8.91±1.75 2.25±0.18d 1.28±0.22f 61.11±18.46 注:表中,a:与术后1个月PTH比较,差异有统计学意义(t=−2.467, P<0.05);b:与术后6个月PTH比较,差异有统计学意义(t=−2.753,P<0.05);c:与术后1个月血清钙比较,差异有统计学意义(t=−2.941,P<0.05);d:与术后6个月血清钙比较,差异有统计学意义(t=−3.652,P<0.05);e:与术后1个月血清磷比较,差异有统计学意义(t=4.550,P<0.05);f:与术后6个月血清磷比较,差异有统计学意义(t=4.167,P<0.05)。PTH:甲状旁腺激素; ALP:碱性磷酸酶。 表 2 分化型甲状腺癌患者术后甲旁减组与对照组的甲状腺功能水平及骨密度值(
)${{\bar x}} \pm {{s}}$ Table 2. Thyroid function and bone mineral density in patients with differentiated thyroid cancer after surgery for hypoparathyroidism and normal parathyroid function (
)${{\bar x}} \pm {{s}}$ 术后时间 分组 例数 FT3 (pmol/L) FT4 (pmol/L) TSH (mIU/L) BMD L2~L4
(g/cm2)股骨颈
(g/cm2)华氏三角(g/cm2) 股骨粗隆(g/cm2) 1个月 甲旁减组 30 1.23±0.69 3.09±1.44 108.45±34.89 1.122±0.001 1.133±0.017 1.225±0.008 1.199±0.009 对照组 30 1.08±0.49 3.40±1.09 110.47±37.24 1.124±0.006 1.147±0.014 1.229±0.009 1.196±0.004 6个月 甲旁减组 30 5.46±0.87 19.66±2.63 0.07±0.04 1.242±0.006 1.03±0.013 1.247±0.009 1.292±0.007 对照组 30 5.51±0.75 20.72±2.75 0.08±0.06 1.240±0.009 1.04±0.017 1.249±0.016 1.281±0.038 12个月 甲旁减组 30 5.44±0.57 21.40±2.02 0.09±0.06 1.211±0.007 0.77±0.027* 1.110±0.010 1.249±0.006 对照组 30 5.80±0.89 22.57±3.74 0.08±0.07 1.213±0.005 0.95±0.040 1.122±0.035 1.247±0.027 注:表中,*:与对照组(术后6个月)比较,差异有统计学意义(t=1.08,P=0.002)。FT3:游离三碘甲状腺原氨酸;FT4:游离甲状腺素;TSH:促甲状腺激素。 表 3 30例甲状旁腺功能减退患者的临床表现及服药依从性情况
Table 3. Clinical manifestations and medication adherence of 30 patients with hypoparathyroidism
临床表现及服药依从性 术后1个月 术后6个月 术后12个月 例数 百分比(%) 例数 百分比(%) 例数 百分比(%) 双手、双足或口周的麻刺感 27 90.00 12 40.00 2 6.67 异常的肌肉收缩,如震颤、颤搐或痉挛 26 86.67 10 33.33 2 6.67 感觉疲倦、易激惹、焦虑或抑郁 26 86.67 11 36.67 2 6.67 服用维生素D及钙剂的依从性 30 100.00 27 90.00 24 80.00 -
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