甲状腺结节诊疗流程ppt课件

1、甲状腺结节诊疗流程（规范）,浙江大学医学院附属第二医院 外科三病区 王平,1,.,国内甲状腺疾病治疗,肿瘤医院头颈外科 综合医院 甲乳科 五官科 普外科 内分泌科（组）、面颌整形科 肿瘤外科（浙江省的教学或附属医院） 甲状腺专科医院,“各自为政”，参加不同的学组组织的会议，某组织的标准很难在全国范围内统一实行,2,.,国内甲状腺疾病治疗,全国内分泌年会05广州会议 分化型甲状腺癌（DTC）的甲状腺切除范围 全国内分泌年会08沈阳2010年济南 分化型甲状腺癌（DTC）的淋巴结清扫范围 结节性甲状腺肿的手术治疗问题 耳鼻喉-头颈外科2011济南会议 制定甲状腺癌中国指南？ ATA、ETA，-CT

2、A？,3,.,AACE/AME GuidelinesThyroid Nodule Guidelines, Endocr Pract. 2006;12,AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND ASSOCIAZIONE MEDICI ENDOCRINOLOGI MEDICAL GUIDELINES FOR CLINICAL PRACTICE FOR THE DIAGNOSIS AND MANAGEMENT OF THYROID NODULES,4,.,AACE/AME/ETA GuidelinesThese guidelines

3、are based on Endocr Pract. 2006 Jan-Feb;12(1):63-102. Used with permission. ENDOCRINE PRACTICE Vol 16 (Suppl 1) May/June 2010,American Association of Clinical Endocrinologists , Associazione Medici Endocrinologi, and European Thyroid Association Medical Guide lines for Clinica l Practice for the Dia

4、gnosis and Management of Thyroid Nodules,5,.,AACE/AME/ETA Guidelines,REFERENCES-214 Note: All reference sources are followed by an evidence level (EL) rating of 1, 2, 3, or 4. The strongest evidence levels (EL 1 and EL 2) appear in red for easier recognition.,6,.,NCCN Clinical Practice Guidelines in

5、 Oncology Thyroid Carcinoma V.2.2011,7,.,甲状腺结节流行病学,thyroid nodules Palpable ： 3% to 7% US ：20%-76% 1 palpation:20%-48% additional nodules on US investigation 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,8,.,甲状腺结节-原因,9,.,The clinical importance of thyroid

6、nodules,local compressive symptoms thyroid hyperfunction thyroid malignant lesion(about 5%),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，对甲状腺结节的诊断与治疗要有一个切实可行、有效的策略,10,.,甲状腺结节流行病学,良性绝大多数 95% 其中囊性病变者约占25% 甲状腺癌 5%,11,.,那些甲状腺结节可能是恶性？,12,.,甲状腺癌流行病学（天津市）,研究单位 天津医科大学附属肿瘤医院流行病室 研究时段 19812001 结 果 平均年发病率1,770 /10万 男女发病比例

7、1: 2. 74 平均死亡率0. 368 /10万,13,.,甲状腺结节,良性结节 Multinodular goiter(MTG) Hashimotos thyroiditis(HT,HD) Simple or hemorrhagic cysts Follicular adenomas Subacute thyroiditis,14,.,甲状腺结节,恶性结节 Papillary carcinoma Follicular carcinoma Hrthle cell carcinoma Medullary carcinoma Anaplastic carcinoma Primary thyroi

8、d lymphoma Metastatic malignant lesion,15,.,DIAGNOSIS,History and Physical Examination grow insidiously for many years discovered incidentally on physical examination, self-palpation, or imaging studies performed for unrelated reasons. FMTC, MEN2, familial papillary thyroid tumors, familial polyposi

9、s coli,16,.,DIAGNOSIS,Patients with rapid growth of a large solid thyroid mass and vocal cord paresis should undergo surgical treatment even if cytologic results are benign (grade C) DTC, however, rarely cause airway obstruction, vocal cord paralysis, or esophageal symptoms, and absence of symptoms

10、does not rule out a malignant tumor (grade C),17,.,DIAGNOSIS,Toxic MNGs hyperfunctioning (benign) areas cold (potentially malignant) lesions Thyroid nodules in patients with Graves disease are reported to be malignant in about 9% of cases,18,.,DIAGNOSIS,Remember that the vast majority of nodules are

11、 asymptomatic, and absence of symptoms does not rule out a malignant lesion (grade C) Always obtain a biopsy specimen from solitary, firm, or hard nodules. The risk of cancer is similar in a solitary nodule and MNG (grade B),19,.,检查手段,B超声：最常用，约50%结节由超声检查发现 TSH：监测垂体甲状腺轴对内分泌治疗的反应 细针穿刺活检(FNA)：确定肿瘤良恶性的有

12、效手段 高分辨率超声：对结节诊疗手段的有力补充 甲状腺放射性核素显像（ECT） CT and MRI are not indicated in routine nodular evaluation(grade C),20,.,甲状腺ECT检查,甲状腺实质性结节（1cm?） 高功能腺瘤、结甲伴甲亢 胸骨后甲状腺肿 亚急性甲状腺炎（T3、T4） 异位甲状腺 全身有没有转移（131I） 再次手术前,21,.,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,22,.,FNA：Results of Literature Survey,FNA is

13、 now considered safe, useful, and cost-effective,23,.,其他检查的意义,Third-generation TSH（0.01IU/ml） T3 、T4 TPOAb Thyroglobulin (TG) Routine assessment is not recommended (grade C). Calcitonin-MTC (not routine testing),24,.,FNA-Positive Thyroid Nodule,按照NCCN的有关标准治疗,25,.,FNA-Negative Thyroid Nodule,26,.,Lev

14、othyroxine Suppressive Therapy (TSH 0.1 IU/mL) a controversial therapeutic practice Efficacy ：20 effective In Small, recently diagnosed thyroid nodules In lesions with colloid features at FNA evaluation in geographic regions with iodine deficiency A 5-year prospective randomized study nodule growth,

15、 new nodule appearance, and the growth of the thyroid gland as a whole may be decreased (grade A),27,.,The use of LT4 should be avoided,large thyroid nodules or long-standing goiters the TSH level is 1 IU/mL In postmenopausal women in men older than 60 years Osteoporosis cardiovascular disease syste

16、mic illnesses.,28,.,Facts to remember,LT4 treatment induces a clinically significant reduction of thyroid nodule volume in only a minority of patients (grade B) Long-term TSH suppression may be associated with bone loss and arrhythmia in elderly patients and menopausal women (grade B) LT4 treatment

17、should never be fully suppressive (TSH 0.1 IU/mL) (grade C),29,.,Facts to remember,Nodule regrowth is usually observed after cessation of LT4 therapy (grade C) If nodule size decreases, LT4 therapy should be continued long term (grade D) If thyroid nodule grows during LT4 treatment, reaspiration and

18、 possibly surgical treatment should be considered (grade D),30,.,Surgical Treatment,Surgical indications Associated local symptoms Hyperthyroidism from a large toxic nodule, or hyperthyroidism concomitant MNG Growth of the nodule Suspicious or malignant FNA results,31,.,Surgical Treatment,Total or n

19、ear-total lobectomy, with or without isthmectomy Completion thyroidectomy should require patience For a solitary benign nodule, lobectomy plus isthmectomy is sufficient; for bilateral nodules, a near-total thyroidectomy is appropriate,32,.,Surgical Treatment,With use of general anesthesia or local a

20、nesthesia A thyroid gland that extends substernally can almost always be resected through a cervical approach With experienced surgeons, associated complications are rare,33,.,Palpable nodule,High TSH,US not suspicious,TSH & thyroid US,ECT,TPOAb,Benign,FNA,Surgery,Malignant or suspicious,131I or fol

21、low_up,Exclusion Criteria,ECT,Low TSH,US suspicious,LT4,Normal TSH,Hot,Cold,MNG,SN,US not suspicious,US suspicious & not hot,Follicular neoplasia,nondiagnosis or Us suspicious,Cystic,PEI,Solid,Cold,Hot,follow_up,Yes,No,LT4,34,.,Thyroid incidentaloma by US,Normal,10mm & no risk factor,TSH,No suspicio

22、us US features,FNA,No exclusion criteria,Malignant,Surgery,High,LT4,TPOAb,Non-diagnostic,Clinical & US follow-up,scintigraphy,Cold,Hot,follow_up,LT4,10mm or risk factor,suspicious US features,suspicious US features,Benign,Follicular neoplasia,35,.,甲状腺结节诊疗流程,发现结节 测量血TSH（甲状腺功能全套） 甲状腺结节FNA 颈淋巴结FNA 患者的临

23、床特征（恶性可能）,36,.,Prior head and neck irradiation Family history of MTC or MEN2 Age 70 years Male sex Growing nodule Firm or hard consistency of nodule, ill-defined nodule margins on palpation Cervical adenopathy Fixed nodule on examination Dysphonia, dysphagia, and cough,37,.,超声可疑的特性,中心血管过度形成 低回声结节 边界

24、不规则 微钙化 直立位,38,.,高度可疑的因素,结节迅速增长 非常硬的结节 固定的结节 有甲状腺癌家族史 声带麻痹 区域淋巴结增大 出现侵犯颈部结构的症状,39,.,甲状腺结节诊疗流程发现结节,只需随访患者临床特征 结节直径1cm 无颈部淋巴结肿大 随访至出现以上可疑因素,40,.,甲状腺结节诊疗流程FNA穿刺活检,良性 观察 结节增大，考虑行甲状腺的内分泌治疗重做FNA,41,.,甲状腺结节诊疗流程FNA穿刺活检,*肿瘤指数百分比（PCI） PCI,手术甲状腺癌例数,所有甲状腺结节例数,一般不仔细临床检查就手术：PCI约15% ECT、B-us、TSH抑制治疗：PCI约20% 根据FNAC

25、：PCI30%,*PCI25%是不满意的，7年制规划教材P424武正炎观点,42,.,甲状腺结节诊疗流程FNA穿刺活检,甲状腺的淋巴瘤 淋巴瘤全身治疗 ，必要时局部放疗,43,.,甲状腺结节诊疗流程FNA穿刺活检,可疑的或不典型的滤泡肿瘤或Hrthle细胞肿瘤或TSH低的结节 TSH高或正常手术 TSH 低甲状腺扫描 冷结节手术 热结节按甲状腺毒症处理,44,.,甲状腺结节诊疗流程 FNA穿刺活检,乳头状癌需行进一步检查 胸片 颈部淋巴结B超（颈内静脉后方深部） 评价声带活动性 对固定或胸骨下病灶行CT或MRI检查 （ 需避免使用碘油造影剂）,45,.,甲状腺结节诊疗流程手术全切除,满足以下任

26、何一种情况即行甲状腺全切除 1、年龄45y 2、有放射物质暴露史 3、有远处转移 4、双侧病变,46,.,甲状腺结节诊疗流程手术方式全切除,5、侵犯甲状腺以外组织 6、肿物直径4cm 7、颈淋巴结转移 8、有乳头状癌或滤泡癌的家族史,47,.,甲状腺结节诊疗流程手术-淋巴结清扫,淋巴结阴性不主张预防性淋巴结清扫 颈部淋巴结肿大术中活检证实转移，加行区淋巴结清扫或改良颈淋巴结清扫（可逐站进行选择性颈清扫术）,48,.,甲状腺结节诊疗流程手术全切除或腺叶切除,满足以下条件可行甲状腺全切除或腺叶切除： 1、年龄 15-45y 2、无放射物质暴露史 3、无远处转移 4、无侵犯甲状腺 以外的组织 5、肿

27、物直径4cm 6、无颈淋巴结转移 7、无甲状腺癌家族史,49,.,甲状腺结节诊疗流程手术全切除或腺叶切除,腺叶切除患者术后 监测 TG 口服甲状腺素片抑制TSH,50,.,甲状腺结节诊疗流程手术方式全切除或腺叶切除,腺叶切除术中冰冻发现以下情况需改行全切除术 侵袭性变异 淋巴结转移 切缘阳性 多发病灶,51,.,甲状腺结节诊疗流程甲状腺切除术后评估,颈部无肿块或颈部残留肿块已切除 检测TSH、甲状腺球蛋白、抗甲状腺球蛋白抗体（术后4-6周） 全身放射性碘扫描,52,.,甲状腺结节诊疗流程甲状腺切除术后治疗,甲状腺切除颈部无残留肿块 术后4-6周 甲状腺球蛋白未测到、放射性碘扫描阴性无需RAI

28、放射性碘扫描显示甲状腺床阳性甲状腺床放射性碘消融和治疗后扫描 放射性碘扫描显示远处转移-RAI，治疗后扫描 Tg10ng/ml(停止甲状腺内分泌治疗后)且放射性碘扫描阴性-考虑RAI，治疗后扫描（3级证据）,53,.,甲状腺结节诊疗流程甲状腺切除术后治疗,颈部无残留肿块I131治疗（如需要）后 T4a（手术见侵犯甲状腺以外组织）且年龄45岁：放疗放疗后甲状腺素抑制TSH 其他情况：口服甲状腺素抑制TSH,54,.,甲状腺结节诊疗流程甲状腺切除术后评估,颈部残留肿块不可切除 检测TSH和甲状腺球蛋白抗甲状腺球蛋白抗体（术后4-6周） 全身放射性碘扫描 无摄取放疗 扫描阳性、病理性摄取放射性I131治疗，治疗后 I131扫描，放疗治疗后甲状腺素抑制TSH,55,.,甲状腺结节诊疗流程随访和评估方法,2年内每3-6个月体检1次，以后每年1次（如果未发现复发、转移的） 第6和第12个月检测TSH和甲状腺球蛋白抗甲状腺球蛋白抗体，以后每年测1次（如果未发现