Volume 102 ·  Issue 48 ·  2022

Thyroid cancer is the most common endocrine tumor. Although the research on thyroid cancer has been studied in depth, there are still many problems remaining controversial. In this article, the routine screening and preoperative evaluation of differentiated thyroid carcinoma, surgical management and adjuvant therapy, and basic translational research were analyzed from multiple perspectives. Besides, the current hot spots and controversies in the field of thyroid cancer from basic to clinical research were reviewed, aiming to further promote the hierarchical management and precise diagnosis and treatment of thyroid tumors.

The fifth edition of World Health Organization (WHO) classification of thyroid tumors replaced the "borderline tumors" in the fourth edition with "low-risk tumors", including noninvasive follicular thyroid neoplasms with papillary-like nuclear features, uncertain malignant potential and hyalinizing trabecular tumors. All of them are thyroid tumors with follicular epithelial cell origin, capsule/clear boundary, no lymph node and distant metastasis (EX0, N0, M0). The spread probability of "low-risk tumor" is extremely low, and this new classification can protect the pathologists from medical litigation when encountering rare and special metastatic cases. Based on the interpretation of the thyroid tumor classification, this paper further discussed several low-risk tumors, which were not listed in the current WHO classification.

Stress urinary incontinence is a medical problem that afflicts women worldwide. The causes can be mainly divided into 4 parts: increased abdominal pressure and chronic ischemia of pelvic floor muscles, endocrine changes, pelvic structural damages, inflammatory and consumptive states. The choice of prevention and treatment should also be based on a comprehensive assessment of individualized factors. Treatment techniques which are more minimally invasive or even non-invasive than surgery are currently a hot topic of research in the field of pelvic floor and urinary control, including laser and radiofrequency therapy, periurethral injection therapy, exogenous stem cell therapy and technology for activation of endogenous stem cells. They are expected to solve the clinical problem of stress urinary incontinence with a wider scope of application, lower trauma and fewer complications in the future.

It is still common for terminally ill patients to suffer from pain, and the development of palliative care faces many obstacles. The value of death to human society is ignored, and the intrinsic relationship between the meaning of life and the value of death has not been fully explored. This article discusses the current status of palliative care in China, how clinicians reflect and respond, the change of the whole society's concept of palliative care, and suggestions for action, and tries to provide a medical humanistic perspective for walking out of the dilemma of palliative care.

Non-small cell lung cancer (NSCLC) is the most common histological type of lung cancer, accounting for more than 85% of lung cancer. However, most lung cancer patients are advanced when diagnosed, and traditional chemotherapy regimens have little efficacy. Anti-angiogenic drugs can act on tumor microenvironment, degenerate existing tumor blood vessels, and inhibit tumor neovascularization. At present, they have become one of the indispensable treatments for patients with advanced NSCLC. This consensus is based on the "Chinese Expert Consensus on the Treatment of Antiangiogenic Drugs in Advanced Non-small Cell Lung Cancer (2020 Edition)", and was compiled by the consensus writing team based on the clinical research evidence related to antiangiogenic drugs updated and published in the field of advanced NSCLC in the past two years, and combined with clinical practice. In patients with advanced non-squamous NSCLC with negative driver gene mutations, nivolumab combined with bevacizumab, carboplatin and paclitaxel is newly recommended as a first-line treatment option; In patients whose human epidermal growth factor receptor (EGFR) -sensitive mutations are treated with tyrosine kinase inhibitor (TKI) and have developed disease progression, pemetrexed and cisplatin combined with bevacizumab and sintilimab can be used as a post-line treatment option; At the same time, based on the current status of clinical diagnosis and treatment and research progress, this edition of the consensus has also adjusted the recommendation level of some recommendations. On the basis of several discussions by many experts, this edition of the consensus has reached a unified opinion to guide the rational and standardized use of anti-angiogenic drugs in clinical departments related to lung cancer treatment in China, and further improve the standardized diagnosis and treatment level of lung cancer in China.

Thyroid cancer is the most common malignant tumor in the head and neck, and it has a high lymph node metastasis rate. Lymph node tracing technology is an important auxiliary technology in the surgical treatment of thyroid cancer. In order to standardize its clinical application, relevant societies organized experts from head and neck surgery, thyroid surgery, general surgery, oncology surgery, imaging department, ultrasound department and nuclear medicine department to formulate this consensus. This consensus covers thyroid cancer neck lymph node dissection, lymph tracing principle and classification, application technology, side effects and negative parathyroid imaging, etc., and forms a relatively unified process and specification, so as to popularize this technology and benefit the majority of thyroid cancer patients.

To investigate the role and significance of ultrasound-guided inferior parathyroid gland (IPTG) localization in searching and protecting parathyroid glands before thyroid surgery.

A randomized controlled trial study was conducted. A total of 306 patients (433 cases of lateral parathyroidectomy) who underwent primary thyroidectomy and central lymph node dissection in Beijing Tongren Hosipital from March to October 2021 were enrolled. In order to locate IPTG more quickly and effectively, new IPTG classification and the definition of quadrant position were carried out. The patients were divided into the study group (n=228) and the control group (n=205). The study group underwent ultrasound-guided IPTG examination before operation and measured the distance between the IPTG and the lower pole of the thyroid and the midline of the trachea. During the operation, the IPTG was found and protected depending on the localization. The control group did not use any auxiliary preoperative positioning method. The distribution ratio of IPTG and the coincidence rate between intraoperative validation and ultrasound localization were calculated.

There were 306 patients enrolled in the final analysis (95 males and 211 females), with a median age of 41 years old (18-70). Type Ⅱ and Ⅲ IPTG accounted for 77.2% (176/228) of the total cases. The total coincidence rate ranged from 72.8% to 79.4% in different IPTG groups. Type Ⅲ and quadrant 2 IPTG had the highest coincidence rate [92.4% (73/79) and 92.9% (79/85), respectively]. The study group had better in situ retention rate [82.0% (187/228) vs 73.2% (150/205), χ²=4.896, P=0.027] and less implantation rate [8.8% (20/228) vs 16.1% (33/205), χ²=5.393, P=0.020] than those of the control group. The in situ retention rate were better in type Ⅲ IPTG group, compared with those of the control group [94.9% (74/78) vs 77.4% (48/62), χ²=7.898, P=0.005]. There was no permanent hypoparathyroidism in two groups and the temporary hypoparathyroidism rate was 32.0% (24/75) and 34.6% (18/52), respectively (χ²=0.095, P=0.758).

Ultrasound-guided IPTG localization examination has important implications for searching and protecting IPTG during operation, which can significantly increase in situ retention rate of IPTG and decrease the implantation rate.

To analyze the risk factors of recurrence or metastasis of medullary thyroid carcinoma (MTC) and the influencing factors of disease-free survival (DFS).

The clinicopathological data of MTC patients who visited Tianjin Medical University Cancer Institute and Hospital and underwent surgery from August 2014 to August 2019 were retrospectively analyzed. The patients were divided into recurrence or metastasis group and no recurrence or metastasis group. Multivariate logistic regression analysis was used to analyze the risk factors for recurrence or metastasis. Kaplan-Meier survival analysis and Cox regression analysis were used to determine the risk factors of DFS.

A total of 158 MTC patients were enrolled in final analysis, including 83 females and 75 males, with a median age of 52 (19-74) years. There were 146 cases of sporadic MTC (92.4%) and 12 cases of familial MTC (7.6%), respectively. Bilateral thyroid lesions presented in 33 cases (20.9%) and multiple lesions presented in 57 cases (36.1%), respectively. The median follow-up time was 59.7 (10.0-93.0) months and the median DFS was 55.5 (0-92.9) months. Presence of multifocality, the largest tumor size>2 cm, T3/4, N1b, clinical stage Ⅲ/Ⅳ, lymph node metastasis ratio (LNR)>0.3, preoperative calcitonin>2 000 ng/L, postoperative calcitonin>40 ng/L and no biochemical cure were significantly correlated with the recurrence or metastasis and DFS of MTC (all P<0.05). Clinical stage Ⅲ/Ⅳ (OR=36.57, 95%CI: 1.33-1 006.98, P=0.033), the largest tumor size>2 cm (OR=5.81, 95%CI: 1.01-33.33, P=0.049), multifocality (OR=3.64, 95%CI: 1.03-12.88, P=0.045) and postoperative calcitonin>40 ng/L (OR=15.03, 95%CI: 1.39-162.61, P=0.026) were independent risk factors of recurrence or metastasis. Clinical stage Ⅲ/Ⅳ (HR=19.39, 95%CI:1.40-268.19, P=0.027), the largest tumor size>2 cm (HR=3.64, 95%CI: 1.02-13.02, P=0.047) and postoperative calcitonin>40 ng/L (HR=10.68, 95%CI: 1.34-84.95, P=0.025) were influencing factors for DFS (all P<0.05).

The larger tumor size, advanced clinical stage and higher postoperative calcitonin at the initial treatment of MTC are risk factors for recurrence or metastasis and influencing factors for DFS.

To investigate the related factors of radioiodine-refractory thyroid cancer (RAIR-DTC) and the increase of cumulative iodine treatment dose.

The data of patients with papillary thyroid cancer who underwent surgery and iodine treatment for the first time in the Affiliated Cancer Hospital of Zhengzhou University from January 2015 to December 2017 were retrospectively analyzed. The related factors of RAIR-DTC and the increase of cumulative iodine treatment dose were explored.

A total of 650 patients were enrolled, including 217 males (33.4%) and 433 females (66.6%), aged 45 (34, 53) years. There were 123 patients (18.9%) over 55 years old, 171 patients (26.3%) with extranodal extension and 18 patients (2.8%) with distant metastasis. The median lymph node ratio was 0.22 (0.11, 0.33). Twenty patients (3.1%) had an accumulated iodine treatment dose>400 mCi and 19 patients (2.9%) had RAIR-DTC. Multivariate logistic regression analysis showed that extranodal extension (OR=19.833, 95%CI: 6.057-73.325, P<0.001) was related factors for the increase of cumulative iodine treatment dose. Age>55 years old (OR=3.322, 95%CI: 1.136-9.466, P=0.024), distant metastasis (OR=10.059, 95%CI: 2.508-38.888, P<0.001), extranodal extension (OR=5.278, 95%CI: 1.707-19.813, P=0.006) and lymph node ratio (OR=34.724, 95%CI: 2.749-384.575, P=0.004) were related factors for RAIR-DTC.

Extranodal extension and lymph node ratio are related factors for RAIR-DTC. In clinical practice, more attention should be paid to the influence of different lymph node metastasis characteristics on the occurrence of RAIR-DTC and the cumulative therapeutic dose of iodine.

To investigate the correlation between dyslipidemia and the risk of papillary thyroid carcinoma (PTC).

A case-control study was conducted. PTC patients diagnosed by pathology in Tianjin Medical University Cancer Institute and Hospital from April 2014 to August 2019 were enrolled as the experimental group, and healthy controls in the physical examination center at the same time were also enrolled as the control group. The demographic data and blood lipid parameters of the subjects were collected. Multivariate logistic analyses were used to assess the correlation between dyslipidemia and the risk of PTC.

A total of 2 000 cases of PTC were enrolled, with a mean age of (42±12) years, including 1 419 females (71.0%) and 581 males (29.0%). There were 4 524 cases in the control group, with a mean age of (42±9) years, including 3 311 females (73.2%) and 1 213 males (26.8%). There was no statistically difference in age and gender between the two groups (both P>0.05). Compared with the control group, triglyceride (TG) [(1.7±1.1) vs (1.4±1.0) mmol/L, P<0.001] and low-density lipoprotein (LDL) [(2.9±0.8) vs (2.8±0.7) mmol/L, P=0.015] increased in peripheral blood of PTC patients, while high-density lipoprotein (HDL) [(1.3±0.4) vs (1.4±0.3) mmol/L, P<0.001] decreased, but the difference was not statistically significant in total cholesterol (TC) [(4.9±1.0) vs (4.9±0.8) mmol/L, P=0.172]. After adjusting for age and gender, increase of TC (OR=1.20, 95%CI: 1.06-1.34, P=0.003), TG (OR=1.73, 95%CI: 1.55-1.94, P<0.001), LDL (OR=1.21, 95%CI: 1.08-1.36, P=0.001), LDL/HDL (OR=1.77, 95%CI: 1.56-2.02, P<0.001) and decrease of HDL (OR=3.15, 95%CI: 2.78-3.58, P<0.001) were the related factors of PTC.

Compared with the control group, patients with PTC have higher level of TG and LDL and lower level of HDL. Dyslipidemia is an important factor related to the risk of PTC.

To investigate the clinical characteristics and risk factors of postoperative recurrence in papillary thyroid carcinoma (PTC) patients with recurrent laryngeal nerve (RLN) invasion.

The data of PTC patients with recurrent laryngeal nerve invasion treated in Beijing Tongren Hospital, Capital Medical University from January 2006 to December 2019 were retrospectively analyzed. The acoustic parameters were compared between different subgroups. Kaplan-Meier method was used to calculate the overall survival (OS) and the recurrence-free rate (RFS), and univariate and multivariate Cox regression analyses were performed to determine the risk factors for postoperative recurrence.

A total of 150 PTC patients were enrolled in the final analysis, including 102 females and 48 males, with an average age of (53.5±13.7) years, and 62 patients (41.3%) aged over 55 years. There were 88 cases with stage Ⅰ, and 62 cases with stage Ⅲ. Fifty-five patients presented with preoperative vocal cord paralysis. There were 75 cases appearing adhesion between tumor or lymph node and recurrent laryngeal nerve while 75 cases presented with direct invasion. The comparisons of acoustic parameters showed that patients with RLN invasion had higher jitter compared with patients without RLN invasion [2.3% (1.4%, 3.2%) vs 1.8% (0.8%, 2.6%), P<0.001]. Moreover, patients with preoperative vocal cord paralysis (VCP) had higher jitter[3.1% (2.2%, 4.6%) vs 2.0% (1.1%, 2.8%), P<0.001] and shimmer [7.1% (4.9%, 9.9%) vs 5.5% (4.2%, 7.3%), P<0.001] and shorter maximum phonation time (MPT) [8.0 (6.0, 10.0) s vs 12.0 (10.0, 15.3) s, P<0.001] compared with patients without preoperative VCP. However, there was no statistical difference in acoustic parameters between cases with RLN adhesion and RLN invasion (all P>0.05). Postoperative follow-up time ranged between 12-196 months, with an average of (65.0±35.9) months. Sixteen patients (10.7%) had recurrence or metastasis, and 8 cases (5.3%) died of recurrence or metastasis. The 5-year OS rate was 95.1%, and the 10-year OS rate was 92.8%. The 5-year RFS rate was 88.9%, and the 10-year RFS rate was 86.2%. Univariate Cox analysis showed that age of onset ≥ 55 years, preoperative recurrent laryngeal nerve palsy, laryngeal, trachea or esophageal invasion were the risk factors for postoperative recurrence of PTC with RLN invasion (all P<0.05). Multivariate Cox analysis showed that age of onset ≥ 55 years (OR=1.060, 95%CI: 1.011-1.110, P=0.015) was an independent risk factor.

Age of onset ≥ 55 years is an independent risk factor for postoperative recurrence in PTC patients with RLN invasion. Preoperative acoustic parameters may provide reference for evaluation of RLN function.

To compare the efficacy, safety and recurrence rate between ablation index (AI) and contact force (CF) guided radiofrequency ablation of paroxysmal atrial fibrillation in elderly patients.

Elderly patients (age ≥60 years) with paroxysmal atrial fibrillation who received radiofrequency ablation for the first time at Department of Cardiology, Beijing Friendship Hospital from April 2018 to April 2019 were enrolled. Patients were divided into 2 groups: AI-group (n=40) and CF group (n=37) depending on their ablation methods. Follow-up was performed until 1 year post the procedure, and efficacy related indexes like first-pass pulmonary vein isolation (PVI) rate, ablation duration, operation duration and major complications were compared between 2 groups. The recurrence rates between 2 groups and related risk factors after radiofrequency ablation were analyzed.

A total of 77 patients [mean age (68.5±6.4) years, 40 were male] were enrolled at last. In AI guided patients, frequency of first-pass PVI rate was higher [52.5%(21 cases) vs 29.7%(3 cases), P=0.011] with a shorter ablation duration [(24.5±1.7) min vs (33.7±2.2) min, P<0.001] and operation duration [(136.6±6.1) min vs (139.7±7.4) min, P=0.048] compared with CF guided group. At 1 year follow-up, AI group showed an amendatory recurrence rate in Kaplan-Meier analysis (22.5% vs 40.5%,log-rank P=0.048). Multivariate Cox regression analysis showed that CF guided ablation (HR=3.272,95%CI:1.319-8.114,P=0.011), enlarged anteroposterior diameter of the left atrium (HR=4.233,95%CI:1.511-11.862,P=0.006) and complicated with coronary heart disease (HR=4.829,95%CI:1.399-16.666,P=0.013) were independent risk factors for recurrence of atrial fibrillation in elderly patients.

Compared with CF guided ablation, radiofrequency ablation of paroxysmal atrial fibrillation in elderly patients guided by AI showed a higher first-pass PVI rate, shorter procedure duration of both ablation time and total operation time, meanwhile a lower recurrence rate. Further analysis revealed that different ablation alternation (AI or CF), enlarged anteroposterior diameter of left atrium, and complicated with coronary heart disease are independent risk factors for recurrence after radiofrequency ablation of atrial fibrillation in elderly patients.

To evaluate the efficacy and safety of belimumab in children with systemic lupus erythematosus (cSLE).

The clinical data of 49 cSLE patients admitted into the Department of Rheumatology and Immunology, Children′s Hospital affiliated to the Capital Institute of Pediatrics, from August 2018 to December 2021 were collected. They were divided into the belimumab treatment group (18 cases) and the traditional treatment group (31 cases) according to whether they received belimumab treatment. The cSLE patients in the traditional group had similar baseline SLEDAI scores with the belimumab group and were treated with traditional immunosuppressive drugs. The clinical symptoms and improvements before and after treatment, as well as the differences in adverse events during follow-up were compared between the two groups.

In belimumab group, the age was (11.9±1.8) years old, the median (Q₁, Q₃) of disease duration was 7.5 (2.0, 16.8) months, 3 patients were male, and 15 patients completed 24 weeks of treatment. In the traditional treatment group, 31 patients with cSLE were enrolled, with an average age of (11.3±2.4) years, a median (Q₁, Q₃) of disease duration of 7.0 (2.5, 10.5) months, among whom 6 patients were male, and 25 patients completed 24 weeks of treatment. At baseline, the belimumab treatment group had a significantly lower oral prednisone dose than the conventional treatment group [(29.58±12.43) mg/d vs (38.20±14.11) mg/d, P=0.037]. After 24 weeks of treatment, the dosage of prednisone in both groups was reduced, and the dosage of prednisone in the belimumab group was (14.12±5.86) mg/d, which was lower than that in the traditional treatment group [(23.51±9.79) mg/d] (P=0.002). After 24 weeks of treatment, the levels of complement C3 and C4 increased, the dsDNA levels and SLEDAI score decreased in both groups (all P>0.05). The incidence of adverse events in belimumab group (3/15, 3 cases) was lower than that in traditional treatment group (32.0%, 8/25) (P>0.05).

Belimumab in the treatment of cSLE can reduce the initial dose of prednisone and facilitate the reduction of prednisone dose, significantly improve the clinical symptoms and organ involvement, and reduce the disease activity. The incidence of adverse events was low during belimumab treatment.

The prognosis of patients with cardiogenic shock (CS) is poor, so it is of great significance to study and summarize the treatment of cardiogenic shock. In recent years, some progress has been made in the research of the American Society for Cardiovascular Angiography and Intervention (SCAI) classification, drug and volume selection, revascularization therapy, and mechanical circulation assistance (MCS). While the guidelines are updated, networked collaborative therapy has become the general trend. This article will summarize the development status of cardiogenic shock, especially the networked collaborative therapy, focusing on the functions of regional referral centers and the networked collaboration and related referral procedures of CS patients referred under MCS. It is hoped that it will help to update the treatment concept and inspire the future exploration. On the basis of these experiences, we will establish a comprehensive treatment system in China and effectively improve the treatment ability of CS.

Gallbladder cancer is the most malignant tumor of the biliary system with poor prognosis. Tyrosine kinase receptor (ErbB) signaling pathway is one of the most advanced signaling pathways in gallbladder cancer research, which is closely related to the occurrence, development, metastasis and drug resistance of gallbladder cancer. Some targeted therapeutic drugs targeting the ErbB signaling pathway have shown good therapeutic effects in clinical trials of gallbladder cancer. In this paper, the recent progress of ErbB signaling pathway in gallbladder carcinoma and the new concept of targeted therapy are reviewed.

In many countries and regions, the incidence of thyroid cancer has increased; However, the mortality rate has been stable at a low level. This epidemiological pattern is largely attributed to over-diagnostic effects. In order to ascertain the magnitude of the problem and the areas most affected by it, it is necessary to analyze the global epidemiological situation in a timely manner. Therefore, the study aims to provide up-to-date assessment data on the global distribution of thyroid cancer incidence and mortality in 2020. The study calculated the age-standardized incidence and mortality per 100,000 person-years of thyroid cancer by sex and 18 age groups from 185 countries or territories extracted from the GLOBOCAN database according to the International Classification of Diseases in Oncology, 10th edition (code C73). Morbidity and mortality estimates are provided by country and 20 world regions as defined by the United Nations and aggregated based on the four-level Human Development Indices (i.e. low, medium, high and very high) of the United Nations in 2020. Globally in 2020, the age-standardized incidence rate of thyroid cancer was 10.1/100,000 for women and 3.1/100,000 for men, and the age-standardized mortality rate was 0.5/100,000 for women and 0.3/100,000 for men. In all cases, the incidence rates in countries with high and very high HDI were 5 times higher than those with low and moderate HDI, while mortality rates were relatively consistent across settings. Incidence varies more than 15 times among women around the world, with the highest rates in the Federated States of Micronesia and French Polynesia (18.5/100,000), North America (18.4/100,000), and East Asia (17.8/100,000, with South Korea reaching 45/100,000). In most countries, mortality rates<1.0/100,000. South Korea has the highest morbidity-to-mortality ratio for both men and women, followed by Cyprus and Canada. The current epidemiological status of thyroid cancer strongly suggests that overdiagnosis has a huge impact in many countries and settings around the globe, confirming that overdiagnosis of thyroid cancer is a global public health problem.

In patients with low-risk differentiated thyroid cancer undergoing thyroidectomy, postoperative¹³¹The application of I is controversial and there is insufficient evidence to demonstrate its benefit. The study was a prospective, randomized, Phase III clinical trial in which patients with low-risk differentiated thyroid cancer who underwent total thyroidectomy were divided into two groups, one who received radioiodine treatment (1.1 GBq) after injection of recombinant human thyroid stimulating hormone (radioiodine group) and the other who did not receive radioiodine treatment after surgery (radioiodine-free group). The differences between the two groups were judged by the presence or absence of functional, structural and biological abnormalities within 3 years. Intergroup differences in the presence of abnormal radioactive iodine uptake lesions requiring subsequent treatment in the whole body scan (only in the radioactive iodine group), abnormal neck ultrasound, and elevated levels of thyroglobulin or thyroglobulin antibodies<5% were considered indifferent, and secondary measures included prognostic factors and molecular characteristics. It was found that of the 730 patients evaluable after 3 years, the rate of no adverse events in the radioiodine-free group was 95.6% (95%CI: 93.0% to 97.5%), and 95.9% (95%) in the radioiodine groupCI: 93.3% to 97.7%), and the difference between the two groups was-0.3% (95%CI：-2.7%~2.2%）。 Adverse events included structural or functional abnormalities in 8 patients and biological abnormalities in 23 patients (25 adverse events). Patients with postoperative serum thyroglobulin levels exceeding 1 μ g/L had the highest frequency of events during thyroid hormone therapy. Molecular alterations were similar in patients with or without adverse events, and no treatment-related adverse events were reported. It is therefore concluded that in low-risk thyroid cancer patients undergoing thyroidectomy, the follow-up strategy without radioactive iodine is not inferior to the one with radioactive iodine in terms of the occurrence of functional, structural and biologically abnormal events at 3 years after surgery.