甲状腺结节诊疗流程

1、国内甲状腺疾病治疗国内甲状腺疾病治疗1.肿瘤医院肿瘤医院头颈外科头颈外科2.综合医院综合医院n甲乳科甲乳科n五官科五官科n普外科普外科n内分泌科（组）、面颌整形科内分泌科（组）、面颌整形科n肿瘤外科（浙江省的教学或附属医院）肿瘤外科（浙江省的教学或附属医院）3.甲状腺专科医院甲状腺专科医院“各自为政各自为政”，参加不，参加不同的学组组织的会议，同的学组组织的会议，某组织的标准很难在全某组织的标准很难在全国范围内统一实行国范围内统一实行国内甲状腺疾病治疗国内甲状腺疾病治疗1.全国内分泌年会全国内分泌年会05广州会议广州会议分化型甲状腺癌（分化型甲状腺癌（DTC）的甲状腺切除范围的甲状腺切除范围2

2、.全国内分泌年会全国内分泌年会08沈阳沈阳2010年济年济南南o分化型甲状腺癌（分化型甲状腺癌（DTC）的淋巴结清扫范围的淋巴结清扫范围o结节性甲状腺肿的手术治疗问题结节性甲状腺肿的手术治疗问题3.耳鼻喉耳鼻喉-头颈外科头颈外科2011济南会议济南会议n制定甲状腺癌中国指南？制定甲状腺癌中国指南？4.ATA、ETA，-CTA？AACE/AME GuidelinesThyroid Nodule Guidelines, Endocr Pract. 2006;12AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTSAND ASSOCIAZIONE MED

3、ICI ENDOCRINOLOGIMEDICAL GUIDELINES FOR CLINICAL PRACTICE FOR THEDIAGNOSIS AND MANAGEMENT OF THYROID NODULESAACE/AME/ETA Guidelines ENDOCRINE PRACTICE Vol 16 (Suppl 1) May/June 2010AACE/AME/ETA GuidelinesNCCN Clinical Practice Guidelines in OncologyThyroidCarcinomaV.2.20111.thyroid nodulesnPalpable

4、： 3% to 7%nUS ：20%-76% n1 palpation:20%-48% additional nodules on US investigation2.Annual incidence rate of 0.1% (300000) new nodules in USA every year浙江省6000万人口，杭州市600万人口The clinical importance of thyroid nodules1.local compressive symptoms 2.thyroid hyperfunction3.thyroid malignant lesion(about 5

5、%)对所有的甲状腺结节进行长期随访，经济上也对所有的甲状腺结节进行长期随访，经济上也不可行，也没有必要；因此，对甲状腺结节的不可行，也没有必要；因此，对甲状腺结节的诊断与治疗要有一个切实可行、有效的策略诊断与治疗要有一个切实可行、有效的策略 研究单位研究单位 天津医科大学附属肿瘤医院流行病室天津医科大学附属肿瘤医院流行病室 研究时段研究时段 19812001 结结 果果 平均年发病率平均年发病率1,770 /10万万 男女发病比例男女发病比例1: 2. 74 平均死亡率平均死亡率0. 368 /10万万1.Multinodular goiter(MTG)2.Hashimotos thyroid

6、itis(HT,HD)3.Simple or hemorrhagic cysts4.Follicular adenomas5.Subacute thyroiditis1.Papillary carcinoma2.Follicular carcinoma3.Hrthle cell carcinoma4.Medullary carcinoma5.Anaplastic carcinoma6.Primary thyroid lymphoma7.Metastatic malignant lesionDIAGNOSISnHistory and Physical Examinationngrow insid

7、iously for many years ndiscovered incidentally on physical examination, self-palpation, or imaging studies performed for unrelated reasons.nFMTC, MEN2, familial papillary thyroid tumors, familial polyposis coli,DIAGNOSISnPatients with rapid growth of a large solid thyroid mass and vocal cord paresis

8、 should undergo surgical treatment even if cytologic results are benign (grade C)n DTC, however, rarely cause airway obstruction, vocal cord paralysis, or esophageal symptoms, and absence of symptoms does not rule out a malignant tumor (grade C)DIAGNOSISnToxic MNGsnhyperfunctioning (benign) areas nc

9、old (potentially malignant) lesionsnThyroid nodules in patients with Graves disease are reported to be malignant in about 9% of casesDIAGNOSISnRemember that the vast majority of nodules are asymptomatic, and absence of symptoms does not rule out a malignant lesion (grade C)nAlways obtain a biopsy sp

10、ecimen from solitary, firm, or hard nodules. The risk of cancer is similar in a solitary nodule and MNG (grade B)甲状腺ECT检查n甲状腺实质性结节（1cm?）n高功能腺瘤、结甲伴甲亢n胸骨后甲状腺肿n亚急性甲状腺炎（T3、T4）n异位甲状腺n全身有没有转移（131I）n再次手术前甲状腺ECT检查甲状腺实质性结节（凉、冷结节）甲状腺实质性结节（温结节）亲肿瘤显像FNAC、手术FNA：Results of Literature SurveyFeatureMean(%)Range(%)S

11、ensitivity8365-98Specificity9272-100Positive predictive value7550-96False-negative rate51-11False-positive rate50-7FNA is now considered safe, useful, and cost-effective其他检查的意义nThird-generation TSH（0.01IU/ml）nT3 、T4nTPOAbnThyroglobulin (TG)Routine assessment is not recommended (grade C).nCalcitonin-

12、MTC (not routine testing)FNA-Positive Thyroid Nodule按照NCCN的有关标准治疗FNA-Negative Thyroid NoduleLevothyroxine Suppressive Therapy(TSH 0.1 IU/mL)1.a controversial therapeutic practice2.Efficacy ：20 effective nIn Small, recently diagnosed thyroid nodulesnIn lesions with colloid features at FNA evaluation

13、nin geographic regions with iodine deficiency3.A 5-year prospective randomized studynodule growth, new nodule appearance, and the growth of the thyroid gland as a whole may be decreased (grade A)The use of LT4 should be avoided1.large thyroid nodules or long-standing goiters2.the TSH level is 1 IU/m

14、LnIn postmenopausal women nin men older than 60 years3.Osteoporosis4.cardiovascular disease5.systemic illnesses.Facts to remember1.LT4 treatment induces a clinically significant reduction of thyroid nodule volume in only a minority of patients (grade B)2.Long-term TSH suppression may be associated w

15、ith bone loss and arrhythmia in elderly patients and menopausal women (grade B)3.LT4 treatment should never be fully suppressive (TSH 0.1 IU/mL) (grade C)Facts to remember4.Nodule regrowth is usually observed after cessation of LT4 therapy (grade C)5.If nodule size decreases, LT4 therapy should be c

16、ontinued long term (grade D)6.If thyroid nodule grows during LT4 treatment, reaspiration and possibly surgical treatment should be considered (grade D)Surgical TreatmentSurgical indications nAssociated local symptomsnHyperthyroidism from a large toxic nodule, or hyperthyroidism concomitant MNGnGrowt

17、h of the nodulenSuspicious or malignant FNA resultsSurgical Treatment1.Total or near-total lobectomy, with or without isthmectomy2.Completion thyroidectomy should require patience 3.For a solitary benign nodule, lobectomy plus isthmectomy is sufficient; for bilateral nodules, a near-total thyroidect

18、omy is appropriateSurgical Treatment4.With use of general anesthesia or local anesthesia5.A thyroid gland that extends substernally can almost always be resected through a cervical approach6.With experienced surgeons, associated complications are rarePalpable noduleHigh TSHUS not suspiciousTSH &

19、 thyroid USECTTPOAbBenignFNASurgeryMalignant or suspicious131I or follow_upExclusion CriteriaECTLow TSHUS suspiciousLT4Normal TSHHotColdMNGSNUS not suspiciousUS suspicious & not hotFollicular neoplasianondiagnosis or Us suspiciousCysticPEISolidColdHotfollow_upYesNoLT4Thyroid incidentaloma by USNormal10mm & no risk factor TSH No suspicious US features FNANo exclusion criteriaMalignant SurgeryHighLT4TPOAbNon-diagnosticClinical & US follow-upscintigraphyColdHotfol