甲状腺隐匿性癌及意外瘤从研究到临床实践课件

Thyroid occult carcinoma & incidentaloma -from evidence to practice,Bingyin Shi MD Department of Endocrinology First Affiliated Hospital Medical School of Xian Jiaotong University Shenyang China,甲状腺隐匿性癌及意外瘤 -从研究到临床实践,西安交通大学医学院第一附属医院 内分泌科 施秉银,Thyroid nodule,The incidence of thyroid nodules detected by palpation is estimated to be 0.1% per year Prevalence between 4% and 7% in the general population,Terminology occult thyroid cancer(隐匿性) occult papillary thyroid cancer（OPTC） tumors that are not evident clinically less than 1-1.5cm in length discovered after a lymph node biopsy or incidental finding Head and Neck Medicine and Surgery 26 (2005) 8790,Terminology Thyroid incidentaloma（意外瘤） impalpable thyroid nodule detected fortuitously during a radiological investigation performed for reasons unrelated to the thyroid gland World J Surg (2008) 32:12641268,occult thyroid cancer,Prevalence Mortensen JD, Bennett WA, Woolner LB. Surg Forum 1954;5:659 Incidence of carcinoma of the thyroid glands removed in 1000 consecutive necropsies. 2.8% prevalence of thyroid cancer,Prevalence United States-5.7% and 13% Fukunaga FH, Yatani R. Geographic pathology of occult thyroid carcinomas. Cancer 1975;36:1095- 9. Harach HR, Franssila KO, Wasenius U-M. Occult papillary carcinoma of the thyroid. Cancer 1985;56:531 -8 Sampson RJ, Woolner LB, Bahn RC, et al. Occult thyroid carcinoma in Olmstead County, Minnesota: prevalence at autopsy compared with that of Hiroshima and Nagasaki, Japan. Cancer 1974;34:2072- 6.,Most of the occult carcinomas were cases of papillary cancer 67 occull carcinomas in different populations, all but I case were cases of papillary cancer Cancer 1975:36:1095-9.,occult papillary thyroid cancer(OPTC),Prevalence 150 cadavers 41.3 18.8 years (range, 17.0-86.0 years) Macroscopic abnormalities were found in a total of 17 glands, representing 11% The incidence of OPTC for overall series was 2.0%(3 cases),GEOGRAPHIC PATHOLOGY OF OCCULT THYROID CANCINOMAS Cancer 1975;36:1095-1099 1167 autopsy: southeastern Canada northeastern Japan Poland,Colombia Japan 28.4% Canada 6% Poland 9.1% Colombia 5.6%,Occult Papillary Carcinoma of the Thyroid A Normal finding in Finland. A Systemic Autopsy study Cancer 1985:56:531-538 101 consecutive autopsies from Finland 36 thyroid,52 foci of occult cancer prevalence-35.6% male 43.3% female 27.1% NS,Occult Papillary Carcinoma of the Thyroid A Normal finding in Finland. A Systemic Autopsy study Cancer 1985:56:531-538 OPC can be regarded as a normal finding which should not be treated when incidentally found. In order to avoid unnecessary operations it is suggested that incidentally found small OPCs(5mm) were called occult papillary tumor instead of carcinoma,ResultsThirty-seven patients - 32 benign cervical cyst - 1 occult tonsillary primary Papillary - 4 papillary thyroid carcinoma(10.8%),Am J Otolaryngol 2004;25:11-17,Conclusion: nearly 1 out of every 10 lateral cervical cysts in young adult patients represents lymphatic metastases from occult thyroid carcinoma. An excisional biopsy for definitive diagnosis should be undertaken without prolonged delay, even if FNA does not reveal malignancy,18-year-old F -10-month painless left-sided neck swelling round, nontender, fluctuant mass 43 cm in size CT scan -2-3 cm in size, cystic mass at the anterior border of the middle third of the sternocleidomastoid muscle normal thyroid gland and a lymph node suspected for malignancy (1.5 - 0.8-cm in size)-lower jugular chain Histopathological examination revealed a unifocal papillary thyroid carcinoma 0.50.3 cm in size,5400 patients-surgery for papillary thyroid carcinoma 17(0.3%) -occult papillary carcinoma 16 clinically apparent node metastasis in the lateral compartment 1 mediastinal compartment 5 patients (29%) multiple metastatic nodes,Conclusion Patients with occult papillary thyroid carcinoma were found to have a favorable overall prognosis Extranodal tumor extension portends a worse prognosis for patients with occult papillary carcinoma careful total thyroidectomy with lymph node dissection is recommended except for elderly or high-risk patients,proposed observation without surgical therapy as a treatment option in 732 patients diagnosed with papillary microcarcinoma by the above technique from 1993 to 2001. 162-observation group18 to 113 months and averaged 46.5 21.5 months more than 70% of tumors either did not change or decreased in size compared to their initial size at diagnosis,Enlarged by more than 10 mm in 10.2%, and lymph node metastasis in the lateral compartments appeared in only 1.2%,Outcome of the patients 16 of the 626 patients have shown recurrence, accounting for 2.6% of our series. The rate of recurrence was 2.7% at 5 years and 5.0% at 8 years,Of these 626 patients, lymph node dissection was performed in 594 patients, and metastasis was confirmed histologically in 50.5%. Multiple tumor formation was seen in 42.8% of patients.,Incidentalomas,“incidentalomas” -small and nonpalpable -incidentally discovered on ultrasonography Prevalence 1982, Carroll (21) found at least one incidental thyroid nodule in 13% of patients who had carotid ultrasonography,a 10-MHz system to examine 1000 consecutive patients for suspected parathyroid disease 462 (46.2%) The 67 patients/100 (67%) who had thyroid nodules 45% had more than one nodule 22% had solitary nodules,ultrasonography shows one or more additional nodules in about 50% of patients with clinically palpable solitary nodules,Computer tomography (CT) scanning detects 40.4% less thyroid nodules than USS with no reliable distinguishing features between benign and malignant nodules AJR Am J Roentgenol 187:13491356,PET scanning, whilst less likely to incidentally detect a thyroid lesion, seems to present a greater degree of specificity for thyroid cancer Focal rather than diffuse uptake and higher standardized uptake values are found in patients with thyroid malignancy,102 of 4525 FDG-PET examinations (2.3%) demonstrated thyroid incidentalomas Eighty-seven of 102 patients had no thyroid histology because of other malignancies Fifteen patients had thyroid biopsy: 7 (47%) with thyroid cancer, 6 (40%) with nodular hyperplasia, 1 with thyroiditis, and 1 with atypical cells of indeterminate origin,Risks for Malignancy of Incidentalomas J Clin Endocrinol. 1955;15:1270-80 autopsy study only 4.2% of nodular glands contained malignant nodules J Clin Endocrinol. 1952:12:112-29. 25 malignant nodules (12.5%) among 200 nodular growths examined at autopsy Thyroidology1985:1309-12 14 (2%) incidental thyroid carcinomas were detected among 689 patients,A total of 56 autopsy specimens (many obtained from trauma victims) 47 young adult patients with prior low-dose neck irradiation high incidence of malignancy (27 of 47 patients) in irradiation vs 1/56,Papillary cancer has an indolent course and an excellent prognosis. Because most occult thyroid carcinomas are papillary and are not aggressive, conservative treatment is appropriate,Possible Outcome of Thyroid Incidentalomas Most asymptomatic thyroid nodules are benign lesions,134 patients with thyroid nodules -benign aspiration biopsy cytology 9 to 11 years follow-up The most striking finding was a decrease in size or disappearance of the nodule in 42% to 79% of benign nodules. About 92% of nodules remained benign Only one case (0.9%) previously regarded as benign turned out to be malignant,benign thyroid nodules remain benign for a long lime the long-term course and final outcome of thyroid incidentalomas and palpable benign nodules would be similar,Mangement Most incidentalomas are histologicaily benign, and benign nodules remain so for a long time autopsy fewer than 5% of asymptomatic nodules may be malignant,The great disparity between the relatively high prevalence of unsuspceted nodules in the general population and the low frequency of malignancy in these nodules makes a conservative approach logical Factors in the medical history that influence a more aggressive approach include a family history of thyroid cancer and a childhood history of neck or head irradiation,Ultrasonographic findings that suggest malignancy in a thyroid nodule a hypoechoic pattern, an incomplete peripheral halo, an irregular margin, or internal microcalcification more aggressive approach,In patients who have nodules larger than 1.5 cm in diameter, a histoiy of head or neck irradiation (particularly in childhood), a strong family history of thyroid cancer, or ultrasonographic findings suggesting malignancy, ultrasonographicaily guided biopsy,Results. Of the 1337 patients who underwent cervical lymphadenectomy during the 17-year period 27 (2.0%) had at least one lymph node harboring an unanticipated finding that raised the concern of a clinically unsuspected neoplasm. Sixteen (1.2%) of these patients had conclusive histologic evidence of an unexpected neoplasm including 6 patients (0.4%) with malignant lymphomas 10 patients (0.7%) with metastatic papillary thyroid carcinomas An additional 11 patients (0.8%) had lymph nodes harboring “benignthyroid inclusions or psammoma bodies. Four of these 11 patients underwent thyroidectomy, but thyroid cancer was not detected in the ipsilateral thyroid,Twenty micro medullary thyroid carcinomas (MTCs) were found in histologic specimens of 19 patients in our department from 1990 to 1998 14 women and 5 men, with a median age of 63 years 18 patients had unifocal micro-MTCs with a median diameter of 3.6 mm. One patient had a bilateral MTC (3 and 5 mm, respectively) 9 total thyroidectomies and 10 lobectomies or subtotal thyroidectomies. Of these 10 patients, 4 underwent reoperation One was operated on 48 months after a positive pentagastrin test: There was no thyroid residual tumor but three lymph node micrometastases,Among the six patients in whom thyroid tissue was left, a 91-year-old woman died of unrelated cause and the five others remain disease-free without biologic abnormalities at follow-ups of 18 to 70 months Because of the morbidity associated with reoperation and neck dissection, we propose that it is indicated only for microcarcinomas 5 mm in diameter, in cases of an abnormal response to pentagastrin, or when it is difficult to ensure prolonged follow-up of the patient,Patients with uninodular thyroid disease suspicious for malignancy on fine-needle aspiration biopsy no evidence of lymph node disease as assessed by B-mode ultrasonography,The lymph node mapping was performed by preoperative lymphoscintigraphy and intraoperative use of a hand-held gammaprobe Out of these six cases, lymphoscintigraphy was able to detect the SLN in three patients (50%) One of the three SLNs in the patient with a papillary carcinoma showed metastatic disease. All other SLNs were free of tumor.,CASE REPORT A 38-year-old white female presented with two masses in the left thyroid gland; one at the superior pole was soft, smooth, mobile, and 2.0 cm., and the other at the inferior pole was firmer and 1.4 cm,near-total thyroidectomy in September 2001, invasion of the strap muscles was identified and removed in continuity with the thyroid gland,Six weeks after thyroidectomy-Tg 1,780 ng/ml 200 mCi (I)-131-uptake in a focal area of the lower left neck Tg 33 to 54 ng/ml 1 year after I-131 treatment and revealed nonpalpable but definite focal increased uptake in the lower left neck 26 months after near-total thyroidectomy-suspicious lymph node was localized using the gamma probe, and a transverse neck incision was made, 2 cm in length. A 1 cm lymph node was identified beneath the left sternocleidomastoid muscle,On the day before the lymph node excision, 0.327 mCi of I-123 was administered by mouth the suspicious lymph node was localized using the gamma probe a whole-body scan failed to reveal any uptake Three months after the node excision, a thyrogen stimulated whole body uptake scan using 5.3 mCi of I-131 was negative for functioning thyroid tissue at that time the thyrogl