甲状腺结节的评估与管理

1、Evaluation and Management of Thyroid Nodules Prevalence medullary cancer in 10% cases.Aetiological factors Differential diagnosis of the thyroid nodule Colloid(adenomatoid) nodule Thyroid adenoma Follicular adenoma Hurthle cell Thyroid cancer Primary- Papillary,Follicular,Medullary,Anaplastic Meetas

2、tatic/direct invasion Renal cell,Breast,Lung,Melanoma, Colon cancer,Gastric carcinoma,Pancreatic carcinoma,Head and neck tumors, Hodgkins disease; Thyroid lymphoma Thyroid cyst-pure, complex Thyroiditis-Acute, Subacute, Hashimotos; Riedels disease Gravesdisease Infectious-Abscess, Tuberculosis; Infi

3、ltrative/granulomatous disease Sarcoidosis, Amyloidosis Developmental abnormalities Thyroid hemiagenesis Thyroglossal duct cyst Teratoma Neck structures simulating thyroid nodules Aberrant subclavian artery and vein Lipomas Extrathyroidal hematoma Esophageal diverticulum Parathyroid adenoma,cyst,or

4、carcinomaClassification of thyroid neoplasms Primary epithelial tumors Tumor of follicular cells Benign:follicular adenoma Malignant:carcinoma Differentiated-papillary,folllicular Poorly differentiated-insular,others Undifferentiated(anaplastic) Classification of thyroid neoplasms Tumor of C cells-M

5、edullary carcinoma Tumor of follicular and C cells Mixed medullary-follicular carcinoma Primary non epithelial tumors Malignant lymphomas Sarcomas Others Secondary tumorsSubtypes of follicular adenoma Conventional Trabecular/solid(embryonal) adenoma Microfollicular(fetal) adenoma Normofollicular(sim

6、ple) adenoma Macrofollicular(colloid) adenoma Variants Hyalinizing trabecular adenoma Oncocytic(oxyphilic or Hurthle cell) tumor Adenomas with papillary hyperplasia Hyperfunctioning(toxic) adenoma Atypical(hypercellular) adenoma History familial medullary thyroid cancerHistorical feature for benign

7、disease A family history of HT,benign thyroid nodule,or goiter; Symptoms of hypothyroidism or hyperthyroidism; Pain or tenderness associated with the nodule.Historical feature for maligancy Young(70 years old) patient age; Male sex; History of external neck radiation during childhood or adolescence;

8、 Previous history of thyroid cancer; Recent changes in speaking,breathing, or swallowing; A family history of thyroid cancer or type 2 MEN.Symptoms and signs 80%,respectively. laboratory evaluation Serum Tg concentrations reflect three factors Assessment of thyroid nodule Radionuclide imaging overly

9、ing normal tissue. This approach does not specifically distinguish benign from malignant lesions.Ultrasonography (halo sign). There are no sonographic criteria which are able to define benign or malignant disease.Thyroid hormone suppression Fine needle aspiration cytology first described in 1948 and

10、 pioneered by Scandinavian; now gained wide acceptance as the most accurate diagnostic procedure for distinguishing benign from malignant thyroid nodules it gives limited information in approximately 25 % of cases because of insufficient cellular yield or indeterminate diagnoses. Fine needle aspirat

11、ion cytology This in part is due to difficulty in distinguishing benign adenomas from malignant follicular neoplasms; surgical excision of all such lesions is therefore required The cytopathologist can report that an adequate smear contains normal cells only, cells from benign non-tumorous condition

12、s such as lymphocytic thyroiditis, or suspicious (indeterminate) or frankly malignant cells. Strategy for treatment of nodular thyroid disease Historical feature for maligancy Young(70 years old) patient age; Male sex; History of external neck radiation during childhood or adolescence; Previous history of thyroid cancer; Recent changes in speaking,breathing, or swallowing; A family history of thyroid cancer or type 2 MEN.Symptoms and signs 80%,respectively. laboratory evaluat