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131I治疗分化型甲状腺癌的工作已经在全国普及并取得了非常显著的临床效果。我们从学习、摸索、不断总结经验到使治疗工作逐渐规范化,这是一个不断提高的过程。在这个过程中有两个标志性的文件指导着我们的临床工作。这两个文件均由中华医学会核医学分会发布,分别是131I治疗分化型甲状腺癌指南(2014版)(简称2014版)[1]和131I治疗分化型甲状腺癌指南(2021版)(简称2021版)[2]。2014版指南的主要贡献是规范化了全国核医学医师131I治疗分化型甲状腺癌工作,在这部指南的指引下我国的甲状腺癌治疗工作有了迅速进展,同时也培养出一大批核医学治疗专家并丰富了他们的临床经验。但遗憾的是,其引用的参考文献几乎都是国外的研究,内容也多受美国甲状腺学会(AmericanThyroid Association,ATA)2009版指南[3]的影响。相较之下,2021版指南提出的观点融汇了我国核医学专家多年来丰富的临床经验,创造性地提出了辅助治疗等新观点。这版指南不仅引用了大量国内研究,还在多个关键观点上与ATA 2015版指南[4]有所区别,它是我们走131I治疗分化型甲状腺癌中国道路的起点,是一部接地气的指南。
指南是指导临床工作的文件,临床工作是千变万化的,在临床工作中以指南为总纲并结合临床的具体情况对患者进行治疗是医师应具有的能力。现就131I治疗分化型甲状腺癌在临床实践工作中的几个问题与大家进行探讨。
推动131I治疗分化型甲状腺癌工作走中国道路
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[1] 中华医学会核医学分会. 131I治疗分化型甲状腺癌指南(2014版)[J]. 中华核医学与分子影像杂志, 2014, 34(4): 264−278. DOI: 10.3760/cma.j.issn.2095-2848.2014.04.002.
Chinese Society of Nuclear Medicine. Guidelines for radioiodine therapy of differentiated thyroid cancer (2014 edition)[J]. Chin J Nucl Med Mol Imaging, 2014, 34(4): 264−278. DOI: 10.3760/cma.j.issn.2095-2848.2014.04.002.[2] 中华医学会核医学分会. 131I治疗分化型甲状腺癌指南(2021版)[J]. 中华核医学与分子影像杂志, 2021, 41(4): 218−241. DOI: 10.3760/cma.j.cn321828-20201113-00412.
Chinese Society of Nuclear Medicine. Guidelines for radioiodine therapy of differentiated thyroid cancer (2021 edition)[J]. Chin J Nucl Med Mol Imaging, 2021, 41(4): 218−241. DOI: 10.3760/cma.j.cn321828-20201113-00412.[3] Cooper DS, Doherty GM, Haugen BR, et al. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer[J]. Thyroid, 2009, 19(11): 1167−1214. DOI: 10.1089/thy.2009.0110. [4] Haugen BR, Alexander EK, Bible KC, et al. 2015 American Thyroid Association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer: the American Thyroid Association guidelines task force on thyroid nodules and differentiated thyroid cancer[J]. Thyroid, 2016, 26(1): 1−133. DOI: 10.1089/thy.2015.0020. [5] Greenhalgh T, Howick J, Maskrey N, et al. Evidence based medicine: a movement in crisis?[J]. BMJ, 2014, 348: g3725. DOI: 10.1136/bmj.g3725. [6] Tonelli MR. The philosophical limits of evidence-based medicine[J]. Acad Med, 1998, 73(12): 1234−1240. DOI: 10.1097/00001888-199812000-00011. [7] 姜礼红, 范鹰, 孟佳, 等. 如何正确处理循证医学与经验医学之间的关系[J]. 医学与哲学, 2010, 31(24): 1−2.
Jiang LH, Fan Y, Meng J, et al. How to deal with the relationship between evidence-based medicine and modern experimental medicine[J]. Med Philos, 2010, 31(24): 1−2.[8] Rui ZY, Wu RX, Zheng W, et al. Effect of 131I therapy on complete blood count in patients with differentiated thyroid cancer[J]. Med Sci Monit, 2021, 27: e929590. DOI: 10.12659/MSM.929590. [9] National Cancer Institute. Thyroid cancer—cancer stat facts[EB/OL]. [2023-07-27]. https://seer.cancer.gov/statfacts/html/thyro.html. [10] Zeng HM, Chen WQ, Zheng RS, et al. Changing cancer survival in China during 2003-15: a pooled analysis of 17 population-based cancer registries[J/OL]. Lancet Glob Health, 2018, 6(5): e555−e567[2023-07-27]. https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(18)30127-X/fulltext. DOI: 10.1016/S2214-109X(18)30127-X. [11] 黄乃思, 陈嘉莹, 嵇庆海, 等. 靶向药物时代局部晚期甲状腺癌的新辅助治疗[J]. 外科理论与实践, 2021, 26(6): 493−496. DOI: 10.16139/j.1007-9610.2021.06.006.
Huang NS, Chen JY, Ji QH, et al. New adjuvant treatment of locally advanced thyroid carcinoma in era of targeted therapy[J]. J Surg Cocepts Pract, 2021, 26(6): 493−496. DOI: 10.16139/j.1007-9610.2021.06.006.[12] 季艳会, 王萱, 李雪, 等. 靶向药物治疗对碘难治性分化型甲状腺癌患者生命质量的短期影响[J]. 中华核医学与分子影像杂志, 2022, 42(11): 656−660. DOI: 10.3760/cma.j.cn321828-20220729-00246.
Ji YH, Wang X, Li X, et al. Short-term effect of targeted drugs on quality of life in patients with radioactive iodine-refractory differentiated thyroid cancer[J]. Chin J Nucl Med Mol Imaging, 2022, 42(11): 656−660. DOI: 10.3760/cma.j.cn321828-20220729-00246.
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