晚期分化型甲状腺癌系统治疗的10年演进：2015与2025年版ATA指南对比分析

doi:10.19401/j.cnki.1007-3639.2025.10.005

摘要/Abstract

摘要：

分化型甲状腺癌（differentiated thyroid carcinoma，DTC）患者总体预后良好，大部分DTC患者经手术联合放射性碘（radioactive iodine，RAI）治疗可获得良好预后，10年生存率超过90%。然而，5%~10%的患者在诊疗过程中出现局部无法切除或远处转移，甚至逐渐发展为放射性碘难治性（radioiodine-refractory，RAIR）状态。对于这类晚期且不可手术的患者，传统治疗手段难以控制疾病进展，系统性药物治疗成为主要选择。10年来，分子靶向治疗与免疫治疗的进展显著改变了晚期DTC的治疗格局。2025年美国甲状腺学会（American Thyroid Association，ATA）发布的《2025版美国甲状腺学会成人分化型甲状腺癌管理指南》（简称2025年版ATA指南）提出以分子分型为核心的精准治疗模式，本文对比2015与2025年版ATA指南在晚期DTC系统治疗中的主要差异，结合关键临床试验和真实世界数据，分析10年来治疗策略的演进并对未来的治疗进行展望。

关键词: 晚期分化型甲状腺癌, 靶向治疗, 免疫治疗, 药物不良反应

Abstract:

Differentiated thyroid carcinoma (DTC) generally has a favorable prognosis. Most patients with DTC achieve good outcomes with surgery combined with radioactive iodine (RAI) therapy, with a 10-year survival rate exceeding 90%. However, about 5%-10% of patients develop unresectable local disease or distant metastases during the course of treatment, and may even gradually progress to a radioiodine-refractory (RAIR) state. For these advanced and inoperable patients, traditional treatments are difficult to control disease progression, making systemic drug therapy the mainstay of treatment. Over the past decade, significant advances in molecular targeted therapy and immunotherapy have transformed the landscape of advanced DTC. The2025 American Thyroid Association Management Guidelines for Adult Patients with Differentiated Thyroid Cancer (abbreviation ATA guideline) propose a precision treatment model centered on molecular subtyping. This article compares the main differences in systemic therapy for advanced DTC between the 2015 and 2025 ATA guidelines, and, by integrating key clinical trials and real-world data, analyzes the evolution of treatment strategies over the past ten years and future directions.

Key words: Advanced differentiated thyroid cancer, Target therapy, Immunotherapy, Adverse events

中图分类号:

R736.1

杨舒雯, 季冬梅, 王宇. 晚期分化型甲状腺癌系统治疗的10年演进：2015与2025年版ATA指南对比分析[J]. 中国癌症杂志, 2025, 35(10): 935-940.

YANG Shuwen, JI Dongmei, WANG Yu. The ten-year evolution of systemic therapy for advanced differentiated thyroid cancer: a comparison between the 2015 and 2025 American Thyroid Association Management Guidelines for Adult Patients with Differentiated Thyroid Cancer[J]. China Oncology, 2025, 35(10): 935-940.

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Key updates	2015 version	2025 version
TKI therapy	Consider TKI when imaging progression or obvious symptoms appear	Lenvatinib is established as the preferred MKI and is strongly recommended for first-line or sequential treatment of progressive RAIR-DTC (strong recommendation). Starting dose is fixed at 24 mg once daily, with an individualized dose-modification algorithm. Patients who are refractory to other selective inhibitors or for whom those drugs are contraindicated should also be switched to lenvatinib
Redifferentiation therapy	Not addressed in the guideline	Redifferentiation strategies (e.g., MAPK-pathway blockade with BRAF ± MEK inhibitors to restore ¹³¹I uptake) are now listed as an optional approach to be performed in experienced centers or within clinical trials
Immunotherapy	Not recommended	Immune-check-point inhibitors or other immunotherapies may be considered in selected cases (conditional recommendation)
AE management	TKI toxicities mentioned, but no detailed grading or operational algorithms provided	A comprehensive AE-management flow-chart is supplied: monitoring frequency, intervention steps and dose-reduction schedules are given for common toxicities such as hypertension, proteinuria, fatigue and stomatitis; patient education and multi-disciplinary care are emphasized