美国甲状腺结节和分化型甲状腺癌诊疗指南(PDF版)
美国甲状腺学会_甲状腺结节和分化型甲状腺癌的诊断治疗指南_评介
作者单位:西安交通大学医学院第一附属医院内分泌科,陕西西安710061E m ai:l sh i b i ngy@pub xaon li ne co m 临床指南评介美国甲状腺学会 甲状腺结节和分化型甲状腺癌的诊断治疗指南 评介施秉银文章编号!1005-2194(2007)17-1345-05∀∀∀中图分类号!R5∀∀文献标志码!A关键词!∀甲状腺结节;分化型甲状腺癌;美国甲状腺学会;指南K eyword s∀Thyro i d nodules;Thyro i d earci noma;ATA;G ui de li nes∀∀∀施秉银,男。
教授,博士研究生导师。
1983年毕业于北京医科大学医疗系,现为中华医学会内分泌学会常委暨甲状腺专业学组副组长,陕西省内分泌学会主任委员,西安交通大学医学院第一附属医院大内科副主任、内分泌科主任。
曾荣获第二届中国医师奖及第五届吴阶平医学研究奖。
先后主持国家自然科学基金、国家 十五 攻关等多项科研项目。
在国内外发表文章100余篇。
美国甲状腺学会根据近10年来新的循证医学证据,在#Thyro i d∃杂志2006年第2期上发表了甲状腺结节和分化型甲状腺癌的诊断治疗指南%%%#M anagem ent G u i deli nes for P ati ents w ith T hy ro i d N odu les and D ifferentiated T hy ro i d Cancer∃。
该指南也是对美国甲状腺学会1996所发表指南的更新。
主要内容包括甲状腺结节的诊断与处理,分化型甲状腺癌的初始治疗及长期随访与处理。
分化型甲状腺癌是指乳头状甲状腺癌和滤泡性甲状腺癌,新指南不包括髓样癌、未分化癌及甲状腺淋巴瘤等方面的内容。
在编写过程中参考了美国国立卫生研究院关于指南或共识编写的建议方法,指南编写委员会首先提出甲状腺结节和分化型甲状腺癌临床诊断和处理中的相关问题,然后在M ed line上用相关关键词搜索了近10年的英文文献,也参考了10年以前的部分重要文献,通过对文献进行分析整理,根据文献的可靠程度和编写者的判断对提出的问题进行解答,并提出不同级别的建议,包括 强烈建议 、 一般建议 、 不建议 及 不建议也不反对 等级别,其中 一般建议 和 不建议 中又根据是否为循证医学证据或编写者个人的判断分为二级。
甲状腺结节和分化型甲状腺癌诊治指南
近年来,随着人们健康意识的增强,甲状腺结节和分化型甲状腺癌的发病率 逐渐升高。为了规范诊断和治疗,美国甲状腺学会(ATA)发布了甲状腺结节和 分化型甲状腺癌的诊断治疗指南。本次演示将对这一指南进行解读,以帮助临床 医生和患者更好地理解并遵循指南。
一、甲状腺结节
甲状腺结节是指甲状腺内的肿块,可随吞咽动作而上下移动。大多数甲状腺 结节无临床症状,但部分患者可能出现颈部不适、呼吸困难等症状。以下为ATA 指南中关于甲状腺结节的主要内容:
诊断策略
根据患者的病史、体检发现、影像学检查和病理学检查,可以对甲状腺结节 和分化型甲状腺癌进行明确诊断。对于可疑的甲状腺结节,应首先进行超声波检 查,根据影像学特征对结节性质进行初步评估。对于怀疑恶性的结节,需进一步 进行FNA或血清学检测。若FNA结果为恶性,则可确诊为分化型甲状腺癌。同时, 根据患者的年龄、性别、体重、病史及体检发现等,制定个性化的治疗方案。
比较两国指南的异同,可以发现中国指南更加注重疾病的分类和诊断,而美 国指南更加疾病的治疗和预后评估。此外,中国指南在手术范围和放疗方式上具 有较高的推荐力度,而美国指南在个体化治疗和新型药物方面更具优势。
总结来说,中国与美国甲状腺结节与分化型甲状腺癌诊治指南各有优点和不 足。中国指南在分类和诊断方面具有一定优势,而美国指南在治疗方法选择上更 具特色。未来,两国指南的改进方向应充分考虑各自特点,互相借鉴,以提高甲 状腺结节和分化型甲状腺癌的治疗效果和患者生活质量。同时,加强国际合作, 开展多中心临床研究,为制订更加科学、规范的诊治指南提供有力支持。
疾病概况方面,中国和美国的甲状腺结节和分化型甲状腺癌的发病情况存在 一定差异。中国的诊治指南将甲状腺结节分为良性、恶性两类,而美国则采用 Bethesda分类系统,根据恶性风险程度将其分为六类。在疾病诊断方面,两国指 南均强调了超声检查的重要性和细针穿刺活检的价值,但美国指南更加注重分子 标志物和基因检测的应用。
甲状腺结节和分化型甲状腺癌诊治指南
• 评估颈部区域有无淋巴结和淋巴结的大小、形态和结 构特点
触诊与甲状腺超声检查比较
通常可触及的甲状腺结节直径大于1cm;
超声检查可发现小至2mm结节 在体检时未触及结节者,50%超声检查可 发现结节 体检发现的孤立性结节中,50%超声检查 为多发性结节
超声检查在甲状腺结节评估中的 作用
• 某些超声征象有助于甲状腺结节的良恶性 鉴别 • 通过超声检查鉴别甲状腺结节良恶性的能 力与超声医师的临床经验相关 • 近年来,弹性超声和甲状腺超声造影技术 在评估甲状腺结节中的应用日益增多,其 临床价值有待进一步研究
问题3. 甲状腺结节的评估要点
• 良恶性甲状腺结节的临床处理不同 • 对患者生存质量(quality of life, QOL)的影 响和涉及的医疗花费也有显著差异。 • 甲状腺结节评估的要点是良恶性鉴别。
推荐1-1:
• 甲状腺结节的评估要点是 良恶性鉴别 (推荐级别A)
问题4. 甲状腺结节的临床表现
病因及分类
增生性结节性甲状腺肿 肿瘤性结节 良性肿瘤 恶性肿瘤
囊肿
炎症性结节
问题1. 甲状腺结节的定义
• 甲状腺结节是指甲状腺细 胞在局部异常生长所引起 的散在病变 • 虽能触及、但在超声检查 中未能证实的“结节”, 不能诊断为甲状腺结节 • 体检未能触及、而在影像 学检查偶然发现的结节称 作“甲状腺意外结节”
• 大多数甲状腺结节患者没有临床症状。
• 合并甲状腺功能异常时,可出现相应的临 床表现。 • 部分患者由于结节压迫周围组织,出现压 迫症状
• 声音嘶哑、压气感、呼吸/吞咽困难等。
下述病史和体格检查结果是
甲状腺癌的危险因素
• ①童年期头颈部放射线照射史或放射性尘埃接触史; • ②全身放射治疗史; • ③有分化型甲状腺癌(DTC)、甲状腺髓样癌(MTC)或 多发性内分泌腺瘤病2型(MEN2型)、家族性多发性息 肉病、某些甲状腺癌综合征的既往史或家族史; • ④男性; • ⑤结节生长迅速; • ⑥伴持续性声音嘶哑、发音困难,并可排除声带病变; • ⑦伴吞咽困难或呼吸困难; • ⑧结节形状不规则、与周围组织粘连固定; • ⑨伴颈部淋巴结病理性肿大。
2009年美国甲状腺学会甲状腺结_省略_和分化型甲状腺癌诊断治疗指南解读_郭朱明
作者单位:中山大学附属肿瘤医院头颈外科,广东广州510060通讯作者:郭朱明,E-mail:lql2206@ 指南与解读文章编号:1005-2208(2010)10-0859-042009年美国甲状腺学会甲状腺结节和分化型甲状腺癌诊断治疗指南解读郭朱明,李秋梨,李浩中图分类号:R6文献标志码:A【关键词】美国甲状腺学会;甲状腺结节;分化型甲状腺癌Keywords American Thyroid Association;thyroid nodules;differentiated thyroid carcinoma(DTC)2009年11月美国甲状腺学会(ATA)修订了第三版甲状腺结节和分化型甲状腺癌诊断治疗指南,第二版修订时间为2006年,而第一版制订的时间为1996年。
期间在甲状腺结节和分化型甲状腺癌的诊断和治疗方面有很多进展,但在多方面仍存争议,包括甲状腺结节评价措施中性价比最高的方法、甲状腺癌的手术范围、甲状腺切除术后残余组织放射性碘消融的应用、促甲状腺素抑制治疗的合理应用和人重组促甲状腺素(rhTSH)的作用等。
ATA认识到这些临床重要问题的处理方法已经发生了变化,故指定一个工作组重新审视当前诊断和治疗甲状腺结节和分化型甲状腺癌的策略,并按照循证医学原则修订了新的临床指南。
2009年版指南与2006年版相比,内容更多、更细化,主要有以下改动:(1)在甲状腺结节处理方面更重视甲状腺结节病人血清促甲状腺激素(TSH)的测定、超声检查及超声引导下的细针穿刺细胞学检查(FNA);对于FNA不能确诊的病人可考虑检测相关分子标志物以指导处理;明确甲状腺结节增大的定义;对于细胞学结果良性的复发囊性甲状腺结节,可以考虑行手术切除或经皮乙醇注射(PEI);细针穿刺结果可疑或确诊为乳头状癌的孕妇可考虑予左旋甲状腺素治疗,控制促甲状腺素在0.1~1.0mU/L范围。
(2)在分化型甲状腺癌的首次处理方面重视对超声可疑的淋巴结行超声引导下的FNA以明确诊断;双侧结节病变可行全甲状腺切除或近全甲状腺切除术;直径>1cm的甲状腺癌,除非有禁忌证,首次手术方式应为近全或全甲状腺切除术;腺叶切除术对直径<1cm、低危、单灶、腺体内乳头状癌、无头颈部放疗史及无淋巴结转移的病人可能已满足治疗需要;明确T3和T4期的病人,可行预防性中央区淋巴结清扫术,而对T1和T2期且组织病理为非侵袭性类型的病人可不行预防性中央区淋巴结清扫术。
2015年美国甲状腺学会《成人甲状腺结节与分化型甲状腺癌诊治指南》解读_分化型甲状腺癌131I治疗新
2015年美国甲状腺学会《成人甲状腺结节与分化型甲状腺癌诊治指南》解读_分化型甲状腺癌131I治疗新进展专业品质权威编制人:______________审核人:______________审批人:______________编制单位:____________编制时间:____________序言下载提示:该文档是本团队精心编制而成,期望大家下载或复制使用后,能够解决实际问题。
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2015年美国甲状腺学会_成人甲状腺结节与分化型甲状腺癌诊治指南_解读_外科部分
13通信作者:李小毅 E-mail:li.xiaoyi@2015年美国甲状腺学会《成人甲状腺结节与分化型甲状腺癌诊治指南》解读:外科部分李小毅中国医学科学院北京协和医院基本外科,北京 100730 [摘要] 甲状腺结节特别是分化型甲状腺癌(differentiated thyroid carcinoma,DTC)近年来呈高发趋势。
随着患者数量以及相关研究的增加,2015年美国甲状腺学会(American Thyroid Association ,ATA)更新了甲状腺结节与DTC治疗指南。
指南中明确提出其主要目标是:减小对大多数与疾病相关的死亡、复发的风险,并降低对患者的过度治疗带来的潜在危害,而给予高危险患者恰当的治疗和监控。
该文对2015年ATA《成人甲状腺结节与分化型甲状腺癌诊治指南》的外科部分做一解读。
[关键词] 甲状腺结节;分化型甲状腺癌;美国甲状腺学会指南 DOI: 10.3969/j.issn.1007-3969.2016.01.002 中图分类号:R739.63 文献标志码:A 文章编号:1007-3639(2016)01-0013-06The interpretation of 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: Surgery part LI Xiaoyi (Department of General, Surgery Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730)Correspondence to: LI Xiaoyi E-mail: li.xiaoyi@ [Abstract ] The prevalence of thyroid nodules, especially differentiated thyroid cancer, has increased during the past decades. With the consideration of increasing prevalence of the disease, American Thyroid Association (ATA) updated the guidelines for adult patients with thyroid nodules and differentiated thyroid cancer in 2015. The aim of the new guidelines was to minimize potential harm from overtreatment in majority of patients at low risk for disease-specific mortality and morbidity while appropriately treat and monitor those patients at higher risk. The updates of surgery-related contents in new ATA guidelines are interpreted in this article. [Key words ] Thyroid nodules; Differentiated thyroid cancer; American Thyroid Association Guidelines李小毅,北京协和医院基本外科副主任医师、副教授、硕士生导师。
分化型甲状腺癌诊治指南
手术后行131I治疗的DTC患者,如 何评估肿瘤是否临床治愈??
• 手术后行131I治疗的DTC患者,如满足下 列标准,可被认定为“肿瘤临床治愈”:
• ①没有肿瘤存在的临床证据。
• ②没有肿瘤存在的影像学证据。
• ③清甲治疗后的Rx-WBS没有发现甲状 腺床和床外组织摄取131I。
• ④TSH抑制状态下和TSH刺激后,在无 TgAb干扰时,测不到血清Tg(一般为 Tg<1ng/mL)。
DTC 术后TSH抑制治疗的作用和副 作用
TSH的一般认识
➢ 腺垂体分泌TSH
➢ 一方面受下丘脑分泌的促 甲状腺激素释放激素( TRH ) 的促进性影响
➢ 另方面又受到T3、T4反馈 性的抑制性影响,二者互 相拮抗,它们组成下丘脑腺垂体-甲状腺轴
• 高危DTC患者术后TSH抑制至<0.1 mU/L时 ,肿瘤复发、转移显著降低。低危DTC患 者术后TSH抑制于0.1~0.5 mU/L即可使总 体预后显著改善,而将TSH进一步抑制至 <0.1 mU/L时,并无额外收益。
• 某些低分化DTC的生长、增殖并非依赖于 TSH的作用,对此类患者,即便将TSH 抑 制到较低的水平,仍难以减缓病情进展。
• 1 甲状腺癌约占人体恶性肿瘤的0.2%-1% 。 • 2 据中山医科大学肿瘤医院资料统计, • 甲状腺癌占头颈恶性肿瘤的3.06%。 • 3 女性多于男性,一般为2~4:1, • 发病年龄一般为21-40岁,以40岁左右中年人
居多。
二 甲状腺癌的病因
• 甲状腺癌的病因尚不明了,可能与下列因素有关:
• 对cN1b 的DTC 患者,行侧颈区淋巴结清扫 术已达成共识,建议行功能性清扫,在保 证彻底清扫的前提下,尽可能保留功能和 外形,严禁“摘果式”手术。
ATA甲状腺癌治疗指南中文版
《甲状腺结节与分化型甲状腺癌管理》(第三版)
美国临床内分泌学家协会和美国内分泌外科医师协会、英国甲状腺协会和皇家医学院、国立综合癌症 网络(NCCN)均是由于缺乏随机对照试验的高品质证据而制订了一些互相矛盾的临床指南。欧洲甲状腺协 会发布了统一的DTC 治疗指南。欧洲核医学协会近期也发布了统一的DTC放射碘(RAI)治疗指南。
【A8】超声检查决定是否施行FNA检查。 甲状腺结节的各种超声特征常常能提示恶变的可能,如超声显示与正常甲状腺组织相比结节有低回 声、结节内血供丰富、不规则的边缘侵犯、结节出现微小钙化、晕圈缺如或结节高度超过宽度等。超声提 示可疑的颈部淋巴结浸润病变存在,往往是恶性结节的特异性改变,但超声检查的敏感性较低,否则超声 影像的一种或多种改变无论是在敏感性还是在特异性方面都不足以证明所有恶性结节的存在。但是,某些 影像改变对预测恶性变有较高的价值。再者,最常见的甲状腺乳头状和滤泡状癌的超声改变两者不同。乳 头状甲状腺癌通常为实性或大部分为实性的低回声改变,常伴有不规则的边缘浸润和结节内丰富的血供。 微小钙化对乳头状癌来说特异性较强,但是不易与胶质分辨清。相反,滤泡状癌多为等回声或高回声改变 并有较厚的不规则晕圈,但是没有微小钙化。直径<2cm的滤泡状癌多不伴有远处转移。 某些超声改变高度提示结节为良性,如一个纯囊性结节(罕见,在所有结节中发生率<2%)极少恶 性变。另外,如出现含多个小囊泡(占该结节体积的50%以上)的海绵状改变,则99.7%的可能为良性甲 状腺结节。最近的研究发现360 名恶性结节患者中仅1 名为海绵状改变者,另一项研究指出98.5%的海绵状 形态的结节不会发生恶变。Elastography是一种有待批准使用的有发展前景的超声检查技术。 对小于1cm的结节来说,不推荐将FNA作为常规检查。然而,如果超声显示为微小钙化的实性低回 声结节,则高度提示为乳头状甲状腺癌(PTC)。大多微小乳头状癌是意外发现的,但是那些直径大于 5mm 的结节仍会有一定的临床意义,这些结节往往是在临床检查或影像学检查发现异常淋巴结后才被发 现。因此,如果影像学检查发现小于1cm的结节形态可疑时,应该行超声检查颈部淋巴结包括侧颈部以 及由于甲状腺的存在而难以检查的颈部中央区。如发现有异常淋巴结,应对其行FNA检查。对小于1cm 的结节行FNA检查的其他情况是有以下恶变的高危因素:1)PTC 家族史;2)儿童期有放射线暴露史; 3)儿童期或青春期有电离辐射暴露史;4)因甲状腺癌行单侧甲状腺切除术病史;5)18FDG-PET 检查 阳性的甲状腺结节。 混合型囊实性结节和大于50%为囊性的结节常规应对实性部分(特别是伴有血管的部分)行FNA 活 检。对那些有症状的患者可考虑予以行囊泡引流。
美国甲状腺学会分化型甲状腺癌指南解读
I-不建议也不反对
5
解读内容
一、分化型甲状腺癌-首次处理指南 二、分化型甲状腺癌-长期处理指南
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首次处理指南
一、分化型甲状腺癌-首次处理指南
1、DTC首次治疗的目标 (1)DTC的术前分期
1)颈部影像学 2)血清Tg
(2)甲状腺手术 3)活检不能诊断的手术 4)活检诊为恶性的手术 5)淋巴结清扫 6)甲状腺全切除术(Completion Thyroidectomy)
推荐等级:C
(2)建议对以下病人行全甲状腺切除术(Total Thyroidectomy):
• 结节>4 cm、但未能确诊; • 活检时见到明显的不典型病理改变; • 活检报告疑为乳头状癌,且有甲状腺癌家族史或放射线暴
露史。 推荐等级:A
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首次处理指南
(3)双侧未能确诊结节,或病人希望行双侧甲 状腺切除术以避免对侧腺叶以后再行手术的 风险,也应行全或近全甲状腺切除术。
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首次处理指南
7、AJCC/UICC TNM分期
由于其在预测肿瘤死亡率中的意义和在癌症 登记中的作用,建议对所有DTC病人行 AJCC/UICC分期。也建议对DTC病人采用术 后临床病理分期系统以提高预后预测的准确 性和计划性随访的效率。 推荐等级:B
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ATA危险分层
低危组: 无局部或远处转移、肉眼见肿瘤已切除、肿瘤未 侵犯邻近组织、非侵袭性组织亚型(高细胞、岛 状、圆柱状细胞癌)、无血管侵犯、全身131I扫 描甲状腺床外无摄取。
适应证: 首次手术前若能取得病理即需行(而实际未行)全或近
全甲状腺切除术的病人,这包括大多数甲状腺癌病人; 肿瘤小(<1 cm)、单病灶、腺体内病变、淋巴结阴性、低
甲状腺结节与分化型甲状腺癌诊治指南比较
%
甲状腺结节的发病率为18.6%
甲 状 腺 结 节 发 病 率 ( )
流行病学抽样调查研究:中国10城市15,181例社区居民(≥20岁)接受调查。 10城市甲状腺结节总发病率为18.6%(单发结节11.6%,多发结节7%)。 滕卫平. 2010年中华医学会第九次内分泌学学术会议大会报告.
甲状腺结节的超声检出率为20%~76% • 超声检出率为20%~76% • 触诊检出率为3%~7%
增长包括各种族、年龄、性别、分期
美国1989-2012年每年新发病例数 资料来源:A
在女性恶性肿瘤中上升惊人!
公认的甲状腺癌患病危险因素
• 外源性 • 幼年时期射线接触史 • 碘过量(绝经后女性,乳头状癌,日本资料) • 碘缺乏(未分化癌,印度资料) • 内源性 • 甲状腺肿、甲状腺结节个人史 • 甲状腺癌家族史 • 甲状腺相关遗传性疾病,如2等
征的既往史或家族史; 结节特点:生长迅速、不规则、与周围组织粘连固定; 相关症状:持续性声音嘶哑、发音困难、吞咽困难、呼吸困难等; 其他:男性、颈部淋巴结病理性肿大。
实验室检查
• 所有甲状腺结节患者均应检测血清水平 • 水平低于正常,恶性的比例低于水平正常或升高者。 • 甲状腺球蛋白()是甲状腺产生的特异性蛋白。包括(分化型甲状腺癌)、甲状腺肿、甲状腺组织炎症或损伤、甲亢等多种甲
对策
欧美各国非常重视制定甲状腺癌,尤其是分化型甲状腺癌的诊治规范,包括 美国甲状腺学会()、美国国立综合癌症网络()、欧洲肿瘤学会()等相 关学术组织定期更新临床指南。
国内也逐渐开始重视甲状腺疾病的规范化治疗。
4个学会 中华医学会内分泌学分会 中华医学会普通外科学分会 中国抗癌协会头颈肿瘤专业委员会 中华医学会核医学分会
甲状腺癌国外指南解读
术后管理
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定期复查
术后应定期进行甲状腺功能和影 像学检查,以便早期发现复发或 转移。
药物治疗
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03
生活方式调整
根据病情需要,医生可能会开具 甲状腺激素、碘131等药物治疗, 以降低复发风险。
建议患者在术后保持健康的生活 方式,包括合理饮食、适量运动 和保持良好的心理状态。
放射治疗
国外指南对于低危患者不推荐常规放疗,国内实践则 根据病情和手术情况选择性使用放疗。
药物治疗
国外指南推荐使用甲状腺激素抑制治疗,国内实践也 广泛应用。
管理方式的异同
随访监测
国外指南强调长期、定期随访,国内实 践也重视术后监测,但随访周期可能较 短。
VS
生活质量评估
国外指南重视患者生活质量评估和心理支 持,国内实践也逐渐加强这方面关注。
02
国外指南在甲状腺癌的诊断、治疗和随访方面提供了详尽的建议,为 临床医生提供了重要的参考依据。
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指南强调了多学科综合治疗的重要性,包括手术、放疗和药物治疗等, 以提高治疗效果和患者生存率。
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指南还对甲状腺癌的预防和筛查提出了建议,强调了定期体检和早期 发现的重要性。
对未来研究的展望
需要进一步研究甲状腺癌的发 病机制和病因,以更好地预防
复发和转移的管理
再次手术
对于局部复发的患者,可能需要进行再次手术以 清除复发病灶。
放射治疗
对于无法手术或术后复发的患者,放射治疗是一 种有效的治疗手段。
药物治疗
除了手术和放疗,药物治疗也是重要的治疗手段, 包括化疗、靶向治疗等。
患者教育和心理支持
疾病知识普及
向患者和家属普及甲状腺 癌的疾病知识和治疗过程, 提高他们的认知水平。
2019ATA分化型甲癌指南解读-DavidCooper-中文-PPT文档资料
分化型甲状腺癌的手术:中央区颈淋巴结清扫
旧版 建议27 • 对甲状腺乳头状癌和可疑的嗜酸细胞癌患者应考虑
中央区 (VI区)颈淋巴清扫术。
• 不伴中央区淋巴结清扫的甲状腺全切术或近全切术, 可能适用于滤泡状癌;也可以用于乳头状癌和嗜酸 细胞癌,但术后需给予放射性碘治疗。 推荐级别 B
分化型甲状腺癌的手术:中央区颈淋巴结清扫
甲状腺癌中央区颈清扫 术语及手术分类的共识
• 治疗性颈部淋巴结清扫术:意味着有明确的淋巴
结转移(术前、术中发现或影像学表现)(临床分 期 N1a).
• 预防性颈部淋巴结清扫术:临床或影像学均未发
现淋巴结转移(临床分期 N0). 两者的区别非常 重要,因为临床可检出的淋巴结转移与显微镜下淋 巴结转移所造成的影响是不一样的。 • 预防性清扫术是选择性清扫术的同义词。
分化型甲状腺癌的甲状腺全切术
Hay I Surgery 2019
乳头状甲状腺癌手术切除范围影响生存率
Bilimoria et al. Ann Surg 2019
•全国肿瘤数据库的52,173名患者 •随访中位时间:70 个月 •43,277为甲状腺全切术(83%), 8946为甲状腺叶切除术(17%)
E
反对
中等
研究的数据
F
反对
好
RCT’s, MA’s, “精心设计及 进行的研究”
I
---------
不足
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专家意见在该指南中所占的百分比
% of Recommendations
50 45 40 35 30 25 20 15 10
5 0
Nodules
CA: Initial Mgt CA: Long term
2016甲状腺结节临床诊疗指南 (1)全文
述两种疾病家族史的患者(BEL 2, 等级 A) • 不推荐进行五肽促胃酸激素刺激实验(BEL 3, 等级 C)。
3. PTH
• 怀疑结节为甲状旁腺腺瘤时建议检测 PTH。(BEL 3, 等级 B)
BEL 2, 等级 B)。
• 禁忌证: • 妊娠和哺乳期妇女(BEL 2, 等级 A)。 • 育龄期妇女,治疗前应随访: • 建议长期监测甲状腺功能(BEL 2, 等级 A)。 • 若治疗后 3-6 个月结节未明显减小、甲亢未缓解或甲亢复
发,可再次进行放射性碘治疗(BEL 3, 等级 B)。
• 推荐手术治疗(BEL,等级 A)。
妊娠期甲状腺结节
• 妊娠期甲状腺结节的管理与非妊娠患者相同 • 临床或超声怀疑恶性时建议进行 FNA 活检 • 诊断和治疗中,避免使用放射性试剂 • 妊娠晚期发现 TSH 低于正常时,应在分娩和哺乳停止后
再进行放射性核素扫描。 • 妊娠期患者,不推荐使用甲状腺素抑制性治疗,在碘缺乏
其他影像学诊断技术:
• CT 和 MRI
不推荐作为甲状腺结节的常规评估手段(BEL 2, 等级 A) 但可作为评估结节大小、气道压迫情况、结节胸骨后生长范围以及超声
未探测到的颈部淋巴结病变的方法(BEL 3, 等级 B)
PET/CT
只作为术前对具有侵袭性特征的恶性结节的评估手段,不推荐作为常规 评估手段,但对细胞学检查结果不明确的结节,可以作为辅助手段对 结节的恶性风险做进一步评估(BEL 3, 等级 B)
• 不推荐超声检查作为正常人群和甲状腺疾病低风险人群的 筛查手段(BEL 4, 等级 C)。
2009美国甲状腺诊疗指南
ORIGINAL STUDIES,REVIEWS,AND SCHOLARLY DIALOGTHYROID CANCER AND NODULESRevised American Thyroid Association ManagementGuidelines for Patients with Thyroid Nodulesand Differentiated Thyroid CancerThe American Thyroid Association (ATA)Guidelines Taskforceon Thyroid Nodules and Differentiated Thyroid CancerDavid S.Cooper,M.D.1(Chair)*,Gerard M.Doherty,M.D.,2Bryan R.Haugen,M.D.,3Richard T.Kloos,M.D.,4Stephanie L.Lee,M.D.,Ph.D.,5Susan J.Mandel,M.D.,M.P.H.,6Ernest L.Mazzaferri,M.D.,7Bryan McIver,M.D.,Ph.D.,8Furio Pacini,M.D.,9Martin Schlumberger,M.D.,10Steven I.Sherman,M.D.,11David L.Steward,M.D.,12and R.Michael Tuttle,M.D.13Background:Thyroid nodules are a common clinical problem,and differentiated thyroid cancer is becoming increasingly prevalent.Since the publication of the American Thyroid Association’s guidelines for the man-agement of these disorders was published in 2006,a large amount of new information has become available,prompting a revision of the guidelines.Methods:Relevant articles through December 2008were reviewed by the task force and categorized by topic and level of evidence according to a modified schema used by the United States Preventative Services Task Force.Results:The revised guidelines for the management of thyroid nodules include recommendations regarding initial evaluation,clinical and ultrasound criteria for fine-needle aspiration biopsy,interpretation of fine-needle aspiration biopsy results,and management of benign thyroid nodules.Recommendations regarding the initial management of thyroid cancer include those relating to optimal surgical management,radioiodine remnant ablation,and suppression therapy using levothyroxine.Recommendations related to long-term management of differentiated thyroid cancer include those related to surveillance for recurrent disease using ultrasound and serum thyroglobulin as well as those related to management of recurrent and metastatic disease.Conclusions:We created evidence-based recommendations in response to our appointment as an independent task force by the American Thyroid Association to assist in the clinical management of patients with thyroid nodules and differentiated thyroid cancer.They represent,in our opinion,contemporary optimal care for pa-tients with these disorders.Thyroid nodules are a common clinical problem.Epi-demiologic studies have shown the prevalence of palpa-ble thyroid nodules to be approximately 5%in women and 1%in men living in iodine-sufficient parts of the world (1,2).In contrast,high-resolution ultrasound (US)can detect thyroid nodules in 19–67%of randomly selected individuals with higher frequencies in women and the elderly (3).The clinical importance of thyroid nodules rests with the need to exclude thyroid cancer which occurs in 5–15%depending on age,sex,radiation exposure history,family history,and other factors*Authors are listed in alphabetical order and were appointed by ATA to independently formulate the content of this manuscript.None of the scientific or medical content of the manuscript was dictated by the ATA.1The Johns Hopkins University School of Medicine,Baltimore,Maryland.2University of Michigan Medical Center,Ann Arbor,Michigan.3University of Colorado Health Sciences Center,Denver,Colorado.4The Ohio State University,Columbus,Ohio.5Boston University Medical Center,Boston,Massachusetts.6University of Pennsylvania School of Medicine,Philadelphia,Pennsylvania.7University of Florida College of Medicine,Gainesville,Florida.8The Mayo Clinic,Rochester,Minnesota.9The University of Siena,Siena,Italy.10Institute Gustave Roussy,Paris,France.11University of Texas M.D.Anderson Cancer Center,Houston,Texas.12University of Cincinnati Medical Center,Cincinnati,Ohio.13Memorial Sloan-Kettering Cancer Center,New York,New York.THYROIDVolume 19,Number 11,2009ªMary Ann Liebert,Inc.DOI:10.1089=thy.2009.01101167(4,5).Differentiated thyroid cancer(DTC),which includes papillary and follicular cancer,comprises the vast majority (90%)of all thyroid cancers(6).In the United States,approx-imately37,200new cases of thyroid cancer will be diagnosed in2009(7).The yearly incidence has increased from3.6per 100,000in1973to8.7per100,000in2002,a2.4-fold increase (p<0.001for trend)and this trend appears to be continuing (8).Almost the entire change has been attributed to an in-crease in the incidence of papillary thyroid cancer(PTC), which increased2.9-fold between1988and2002.Moreover, 49%of the rising incidence consisted of cancers measuring 1cm or smaller and87%consisted of cancers measuring2cm or smaller(8).This tumor shift may be due to the increasing use of neck ultrasonography and early diagnosis and treat-ment(9),trends that are changing the initial treatment and follow-up for many patients with thyroid cancer.In1996,the American Thyroid Association(ATA)pub-lished treatment guidelines for patients with thyroid nodules and DTC(10).Over the last decade,there have been many advances in the diagnosis and therapy of both thyroid nodules and DTC.Controversy exists in many areas,including the most cost-effective approach in the diagnostic evaluation of a thyroid nodule,the extent of surgery for small thyroid cancers, the use of radioactive iodine to ablate remnant tissue following thyroidectomy,the appropriate use of thyroxine suppression therapy,and the role of human recombinant thyrotropin (rhTSH).In recognition of the changes that have taken place in the overall management of these clinically important prob-lems,the ATA appointed a task force to re-examine the current strategies that are used to diagnose and treat thyroid nodules and DTC,and to develop clinical guidelines using principles of evidence-based medicine.Members of the taskforce included experts in thyroid nodule and thyroid cancer management with representation from thefields of endocrinology,surgery, and nuclear medicine.The medical opinions expressed here are those of the authors;none were dictated by the ATA.The final document was approved by the ATA Board of Directors and endorsed(in alphabetical order)by the American Asso-ciation of Clinical Endocrinologists(AACE),American College of Endocrinology,British Association of Head and Neck Oncologists(BAHNO),The Endocrine Society,European As-sociation for Cranio-Maxillo-Facial Surgery(EACMFS),Eur-opean Association of Nuclear Medicine(EANM),European Society of Endocrine Surgeons(ESES),European Society for Paediatric Endocrinology(ESPE),International Association of Endocrine Surgeons(IAES),and Latin American Thyroid So-ciety(LATS).Other groups have previously developed guidelines,in-cluding the American Association of Clinical Endocrinologists and the American Association of Endocrine Surgeons(11),the British Thyroid Association and The Royal College of Physi-cians(12),and the National Comprehensive Cancer Network (13)that have provided somewhat conflicting recommenda-tions due to the lack of high quality evidence from random-ized controlled trials.The European Thyroid Association has published consensus guidelines for the management of DTC (14).The European Association of Nuclear Medicine has also recently published consensus guidelines for radioiodine(RAI) therapy of DTC(15).The ATA guidelines taskforce used a strategy similar to that employed by the National Institutes of Health for its Consen-sus Development Conferences(http:===aboutcdp.htm),and developed a series of clinically relevant questions pertaining to thyroid nodule and thyroid cancer di-agnosis and treatment.These questions were as follows:—Questions regarding thyroid nodulesWhat is the appropriate evaluation of clinically or inci-dentally discovered thyroid nodule(s)?*What laboratory tests and imaging modalities are in-dicated?*What is the role offine-needle aspiration(FNA)?What is the best method of long-term follow up of pa-tients with thyroid nodules?What is the role of medical therapy of patients with benign thyroid nodules?How should thyroid nodules in children and pregnant women be managed?—Questions regarding the initial management of DTCWhat is the role of preoperative staging with diagnostic imaging and laboratory tests?What is the appropriate operation for indeterminate thyroid nodules and DTC?What is the role of postoperative staging systems and which should be used?What is the role of postoperative RAI remnant ablation? What is the role of thyrotropin(TSH)suppression therapy?Is there a role for adjunctive external beam irradiation or chemotherapy?—Questions regarding the long term management of DTC What are the appropriate features of long-term man-agement?What is the role of serum thyroglobulin(Tg)assays? What is the role of US and other imaging techniques during follow-up?What is the role of TSH suppression in long-term follow-up?What is the most appropriate management of patients with metastatic disease?How should Tg-positive,scan-negative patients be managed?What is the role of external radiation therapy?What is the role of chemotherapy?—What are directions for future research?The initial ATA guidelines were published in2006(16). Because of the rapid growth of the literature on this topic, plans for revising the guidelines within24–36months of publication were made at the inception of the project.Re-levant articles on thyroid cancer were identified using the same search criteria employed for the original guidelines(16). Individual task force members submitted suggestions for clarification of prior recommendations,as well as new infor-mation derived from studies published since2004.Relevant literature continued to be reviewed through December2008. To begin the revision process,a half-day meeting was held on June2,2007.The Task Force was broadened to include European experts and a head and neck surgeon.Three sub-sequent half-day meetings were held on October5,2007;July 13,2008;and October5,2008,to review these suggestions and for additional comments to be considered.The meeting in July 2008also included a meeting with six additional surgeons in1168COOPER ET AL.REVISED ATA THYROID CANCER GUIDELINES1169anization of Management Guideline Recommendations,Tables,and Figuresfor Patients with Thyroid Nodules and Differentiated Thyroid CancerPage Location key a Sections and subsections Item b1171[A1]THYROID NODULE GUIDELINES T11171[A2]Evaluation of Newly Discovered Thyroid Nodules F11171[A3]Laboratory tests1171[A4]Serum TSH R1–R2 1171[A5]Serum thyroglobulin(Tg)R31171[A6]Serum calcitonin R41173[A7]Role offine-needle aspiration(FNA)1173[A8]Ultrasound(US)with FNA R5,T3 1174[A9]Cytopathological interpretation of FNA samples1174[A10]Nondiagnostic cytology R61174[A11]Cytology suggesting papillary thyroid cancer(PTC)R71174[A12]Indeterminate cytology R8–R10 1175[A13]Benign cytology R111175[A14]Multinodular goiter(MNG)=multiple thyroid nodules R12–R13 1175[A15]Long-Term Follow-Up of Thyroid Nodules R14–R15 1176[A16]Medical therapy for benign thyroid nodules R16–R17 1176[A17]Thyroid nodules in children R181176[A18]Thyroid nodules in pregnant women R19–R20 1176[B1]DIFFERENTIATED THYROID CANCER(DTC):INITIAL MANAGEMENT GUIDELINES1176[B2]Goals of Initial Therapy of DTC1177[B3]Preoperative staging of DTC1177[B4]Neck imaging R21–R22 1177[B5]Serum Tg R231177[B6]Thyroid surgery1178[B7]Surgery for nondiagnostic biopsy R24–R25 1178[B8]Surgery for biopsy diagnostic of malignancy R261179[B9]Lymph node dissection R27–R28,F2 1180[B10]Completion thyroidectomy R29–R30 1180[B11]Postoperative staging systems1180[B12]Role of postoperative staging1180[B13]AJCC=UICC TNM staging R31,T4 1181[B14]Role of postoperative remnant ablation R32,T5 1183[B15]Preparation for radioiodine(RAI)remnant ablation R33,F3 1183[B16]rhTSH preparation R341183[B17]RAI scanning before RAI ablation R351185[B18]Radiation doses for RAI ablation R36–R37 1185[B19]Low-iodine diet for RAI ablation R381185[B20]Post RAI ablation whole-body RAI scan R391185[B21]Post Initial Therapy of DTC1185[B22]Role of TSH suppression therapy1185[B23]Degree of initial TSH suppression required R401186[B24]Adjunctive measures1186[B25]External beam irradiation R411186[B26]Chemotherapy R421186[C1]DTC:LONG-TERM MANAGEMENT1186[C2]Appropriate Features of Long-Term Management1186[C3]Appropriate method of follow-up after surgery F41186[C4]Criteria for absence of persistent tumor1186[C5]Role of serum Tg assays R43–R45 1189[C6]Whole body RAI scans,US,and other imagingIf viewing these guidelines on the Web,or in a File,copy the Location Key to the Find or Search Function to navigate rapidly to the desired section.b R,recommendation;T,table;F,figure.(continued)Table1.(Continued)Page Location key a Sections and subsections Item b 1189[C7]Diagnostic whole-body RAI scans R46–R47 1189[C8]Cervical ultrasound R48a–c 1189[C9]FDG-PET Scanning R48d1189[C10]Role of thyroxine suppression of TSH R491190[C11]Management of Metastatic Disease1190[C12]Surgery for locoregional metastases R501190[C13]Surgery for aerodigestive invasion R511191[C14]RAI for local or distant metastatic disease1191[C15]Methods for administering RAI R52–R54 1191[C16]The use of lithium in RAI therapy R551191[C17]Metastasis to various organs1192[C18]Pulmonary metastasis R56–R58 1192[C19]Non–RAI-avid pulmonary disease R591193[C20]Bone metastases R60–R64 1193[C21]Brain metastases R65–R67 1194[C22]Management of Complications of RAI Therapy R68–R70 1194[C23]Secondary malignancies and leukemia from RAI R711194[C24]Other risks to bone marrow from RAI R721194[C25]Effects of RAI on gonads and in nursing women R73–R74 1195[C26]Management of Tg Positive,RAI Scan–Negative Patients R75–R77,F5 1197[C27]Patients with a negative post-treatment whole-body scan R78–R79 1197[C28]External beam radiation for metastatic disease R801197[D1]DIRECTIONS FOR FUTURE RESEARCH1197[D2]Novel Therapies and Clinical Trials1197[D3]Inhibitors of oncogenic signaling pathways1197[D4]Modulators of growth or apoptosis1197[D5]Angiogenesis inhibitors1197[D6]Immunomodulators1197[D7]Gene therapy1198[D8]Better Understanding of the Long-Term Risks of RAI1198[D9]Clinical Significance of Persistent Low-Level Tg1198[D10]The Problem of Tg Antibodies1198[D11]Small Cervical Lymph Node Metastases1198[D12]Improved Risk StratificationTable2.Strength of Panelists’Recommendations Based on Available EvidenceRating DefinitionA Strongly recommends.The recommendation is based on good evidence that the service or intervention can improveimportant health outcomes.Evidence includes consistent results from well-designed,well-conducted studies in representative populations that directly assess effects on health outcomes.B Recommends.The recommendation is based on fair evidence that the service or intervention can improveimportant health outcomes.The evidence is sufficient to determine effects on health outcomes,but the strength of the evidence is limited by the number,quality,or consistency of the individual studies;generalizability toroutine practice;or indirect nature of the evidence on health outcomes.C Recommends.The recommendation is based on expert opinion.D Recommends against.The recommendation is based on expert opinion.E Recommends against.The recommendation is based on fair evidence that the service or intervention does notimprove important health outcomes or that harms outweigh benefits.F Strongly recommends against.The recommendation is based on good evidence that the service or interventiondoes not improve important health outcomes or that harms outweigh benefits.I Recommends neither for nor against.The panel concludes that the evidence is insufficient to recommend foror against providing the service or intervention because evidence is lacking that the service or interventionimproves important health outcomes,the evidence is of poor quality,or the evidence is conflicting.As a result,the balance of benefits and harms cannot be determined.Adapted from the U.S.Preventive Services Task Force,Agency for Healthcare Research and Quality(17).an effort to produce guidelines related to central neck dis-section that would be as authoritative as possible.The orga-nization of management guideline recommendations is shown in Table1.It was agreed to continue to categorize the published data and strength of recommendations using a modified schema proposed by the U.S.Preventive Services Task Force(17)(Table2).[A1]THYROID NODULE GUIDELINESA thyroid nodule is a discrete lesion within the thyroid gland that is radiologically distinct from the surrounding thyroid parenchyma.Some palpable lesions may not corre-spond to distinct radiologic abnormalities(18).Such abnor-malities do not meet the strict definition for thyroid nodules. Nonpalpable nodules detected on US or other anatomic im-aging studies are termed incidentally discovered nodules or ‘‘incidentalomas.’’Nonpalpable nodules have the same risk of malignancy as palpable nodules with the same size(19). Generally,only nodules>1cm should be evaluated,since they have a greater potential to be clinically significant can-cers.Occasionally,there may be nodules<1cm that require evaluation because of suspicious USfindings,associated lymphadenopathy,a history of head and neck irradiation,or a history of thyroid cancer in one or morefirst-degree relatives. However,some nodules<1cm lack these warning signs yet eventually cause morbidity and mortality.These are rare and, given unfavorable cost=benefit considerations,attempts to diagnose and treat all small thyroid cancers in an effort to prevent these rare outcomes would likely cause more harm than good.Approximately1–2%of people undergoing2-deoxy-2[18F]fluoro-d-glucose positron emission tomography (18FDG-PET)imaging for other reasons have thyroid nodules discovered incidentally.Since the risk of malignancy in these 18FDG-positive nodules is about33%and the cancers may be more aggressive(20),such lesions require prompt evaluation (21–23).When seen,diffuse18FDG uptake is likely related to underlying autoimmune thyroiditis.[A2]What is the appropriate evaluation of clinicallyor incidentally discovered thyroid nodule(s)?(See Fig.1for algorithm)With the discovery of a thyroid nodule,a complete history and physical examination focusing on the thyroid gland and adjacent cervical lymph nodes should be performed.Pertinent historical factors predicting malignancy include a history of childhood head and neck irradiation,total body irradiation for bone marrow transplantation(24),family history of thy-roid carcinoma,or thyroid cancer syndrome(e.g.,Cowden’s syndrome,familial polyposis,Carney complex,multiple en-docrine neoplasia[MEN]2,Werner syndrome)in afirst-degree relative,exposure to ionizing radiation from fallout in childhood or adolescence(25),and rapid growth and hoarseness.Pertinent physicalfindings suggesting possible malignancy include vocal cord paralysis,lateral cervical lymphadenopathy,andfixation of the nodule to surrounding tissues.[A3]What laboratory tests and imaging modalities are indicated?[A4]Serum TSH with US and with or without scan.With the discovery of a thyroid nodule>1cm in any diameter or diffuse or focal thyroidal uptake on18FDG-PET scan,a se-rum TSH level should be obtained.If the serum TSH is subnormal,a radionuclide thyroid scan should be obtained to document whether the nodule is hyperfunctioning(i.e., tracer uptake is greater than the surrounding normal thy-roid),isofunctioning or‘‘warm’’(i.e.,tracer uptake is equal to the surrounding thyroid),or nonfunctioning(i.e.,has uptake less than the surrounding thyroid tissue).Since hyperfunc-tioning nodules rarely harbor malignancy,if one is found that corresponds to the nodule in question,no cytologic evaluation is necessary.If overt or subclinical hyperthy-roidism is present,additional evaluation is required.Higher serum TSH,even within the upper part of the reference range,is associated with increased risk of malignancy in a thyroid nodule(26).&RECOMMENDATION1Measure serum TSH in the initial evaluation of a patient with a thyroid nodule.If the serum TSH is subnormal,a radionuclide thyroid scan should be performed using either technetium99m Tc pertechnetate or123I.Recommendation rating:ADiagnostic thyroid US should be performed in all patients with a suspected thyroid nodule,nodular goiter,or radiographic abnormality;e.g.,a nodule found incidentally on computed tomography(CT)or magnetic resonance im-aging(MRI)or thyroidal uptake on18FDG-PET scan. Thyroid US can answer the following questions:Is there truly a nodule that corresponds to the palpable abnormal-ity?How large is the nodule?Does the nodule have benign or suspicious features?Is suspicious cervical lymphade-nopathy present?Is the nodule greater than50%cystic?Is the nodule located posteriorly in the thyroid gland?These last two features might decrease the accuracy of FNA bi-opsy performed with palpation(27,28).Also,there may be other thyroid nodules present that require biopsy based on their size and appearance(18,29,30).As already noted, FNA is recommended especially when the serum TSH is elevated because,compared with normal thyroid glands, the rate of malignancy in nodules in thyroid glands involved with Hashimoto’s thyroiditis is as least as high or possibly higher(31,32).&RECOMMENDATION2Thyroid sonography should be performed in all patients with known or suspected thyroid nodules.Recommenda-tion rating:A[A5]Serum Tg measurement.Serum Tg levels can be ele-vated in most thyroid diseases and are an insensitive and nonspecific test for thyroid cancer(33).&RECOMMENDATION3Routine measurement of serum Tg for initial evaluation of thyroid nodules is not recommended.Recommendation rating:F[A6]Serum calcitonin measurement.The utility of serum calcitonin has been evaluated in a series of prospective, nonrandomized studies(34–37).The data suggest that theREVISED ATA THYROID CANCER GUIDELINES1171use of routine serum calcitonin for screening may detect C-cell hyperplasia and medullary thyroid cancer at an earlier stage and overall survival may be improved.How-ever,most studies rely on pentagastrin stimulation test-ing to increase specificity.This drug is no longer available in the United States,and there remain unresolved issues of sensitivity,specificity,assay performance and cost-effectiveness.A recent cost-effectiveness analysis suggested that calcitonin screening would be cost effective in the United States (38).However,the prevalence estimates of medullary thyroid cancer in this analysis included patients with C-cell hyperplasia and micromedullary carcinoma,123I or 99Tc Scan a Normal or High TSHHistory, Physical, TSHLow TSHDiagnostic USRESULTS of FNAElevated TSHEvaluate and RxforHyperthyroidismNot Functioning HyperfunctioningNodule on US Do FNA (See R5a–c)No Nodule on USNormal TSHEvaluate andRx for Hypo-thyroidismFNA not IndicatedNondiagnosticMalignant PTCSuspicious for PTCBenignIndeterminateRepeat US- Guided FNANon-diagnosticClose Follow-Up or Surgery (SeeText)Pre-op USSurgeryFollicular NeoplasmHürthle Cell NeoplasmFollowConsider 123I Scanif TSH Low NormalNotHyperfunctioningHyperfunctioning WORKUP OF THYROID NODULEDETECTED BY PALPATION OR IMAGINGFIG.1.Algorithm for the evaluation of patients with one or more thyroid nodules.aIf the scan does not show uniform distribution of tracer activity,ultrasound may be considered to assess for the presence of a cystic component.1172COOPER ET AL.which have an uncertain clinical significance.If the un-stimulated serum calcitonin determination has been ob-tained and the level is greater than100pg=mL,medullary cancer is likely present(39).&RECOMMENDATION4The panel cannot recommend either for or against the routine measurement of serum calcitonin.Recommenda-tion rating:I[A7]What is the role of FNA biopsy?FNA is the most accurate and cost-effective method for evaluating thyroid nodules.Retrospective studies have reported lower rates of both nondiagnostic and false-negative cytology specimens from FNA procedures performed via US guidance compared to palpation(40,41).Therefore,for nodules with a higher likelihood of either a nondiagnostic cytology(>25–50%cystic component)(28)or sampling error(difficult to palpate or posteriorly located nodules),US-guided FNA is preferred(see Table3).If the diagnostic US confirms the presence of a pre-dominantly solid nodule corresponding to what is palpated, the FNA may be performed via palpation or US guidance. Traditionally FNA biopsy results are divided into four cate-gories:nondiagnostic,malignant(risk of malignancy at sur-gery>95%),indeterminate or suspicious for neoplasm,and benign.The recent National Cancer Institute Thyroid Fine-Needle Aspiration State of the Science Conference proposed a more expanded classification for FNA cytology that adds two additional categories:suspicious for malignancy(risk of ma-lignancy50–75%)and follicular lesion of undetermined sig-nificance(risk of malignancy5–10%).The conference further recommended that‘‘neoplasm,either follicular or Hu¨rthle cell neoplasm’’be substituted for‘‘indeterminate’’(risk of malig-nancy15–25%)(42).[A8]US for FNA decision making(see Table3).Various sonographic characteristics of a thyroid nodule have been associated with a higher likelihood of malignancy(43–48). These include nodule hypoechogenicity compared to the normal thyroid parenchyma,increased intranodular vascu-larity,irregular infiltrative margins,the presence of micro-calcifications,an absent halo,and a shape taller than the width measured in the transverse dimension.With the exception of suspicious cervical lymphadenopathy,which is a specific but insensitivefinding,no single sonographic feature or combi-nations of features is adequately sensitive or specific to identify all malignant nodules.However,certain features and combination of features have high predictive value for ma-lignancy.Furthermore,the most common sonographic ap-pearances of papillary and follicular thyroid cancer differ.A PTC is generally solid or predominantly solid and hy-poechoic,often with infiltrative irregular margins and in-creased nodular vascularity.Microcalcifications,if present, are highly specific for PTC,but may be difficult to distinguish from colloid.Conversely,follicular cancer is more often iso-to hyperechoic and has a thick and irregular halo,but does not have microcalcifications(49).Follicular cancers that are<2cm in diameter have not been shown to be associated with met-astatic disease(50).Certain sonographic appearances may also be highly pre-dictive of a benign nodule.A pure cystic nodule,although rare (<2%of all nodules),is highly unlikely to be malignant(47).In addition,a spongiform appearance,defined as an aggregation of multiple microcystic components in more than50%of the nodule volume,is99.7%specific for identification of a benignTable3.Sonographic and Clinical Features of Thyroid Nodules and Recommendations for FNA Nodule sonographic or clinical features Recommended nodule threshold size for FNAHigh-risk history aNodule WITH suspicious sonographic features b>5mm Recommendation A Nodule WITHOUT suspicious sonographic features b>5mm Recommendation I Abnormal cervical lymph nodes All c Recommendation A Microcalcifications present in nodule 1cm Recommendation B Solid noduleAND hypoechoic>1cm Recommendation B AND iso-or hyperechoic 1–1.5cm Recommendation C Mixed cystic–solid noduleWITH any suspicious ultrasound features b 1.5–2.0cm Recommendation B WITHOUT suspicious ultrasound features 2.0cm Recommendation C Spongiform nodule 2.0cm d Recommendation C Purely cystic nodule FNA not indicated e Recommendation E a High-risk history:History of thyroid cancer in one or morefirst degree relatives;history of external beam radiation as a child;exposure to ionizing radiation in childhood or adolescence;prior hemithyroidectomy with discovery of thyroid cancer,18FDG avidity on PET scanning;MEN2=FMTC-associated RET protooncogene mutation,calcitonin>100pg=mL.MEN,multiple endocrine neoplasia;FMTC,familial medullary thyroid cancer.b Suspicious features:microcalcifications;hypoechoic;increased nodular vascularity;infiltrative margins;taller than wide on transverse view.c FNA cytology may be obtained from the abnormal lymph node in lieu of the thyroid nodule.d Sonographic monitoring without biopsy may be an acceptable alternative(see text)(48).e Unless indicated as therapeutic modality(see text).REVISED ATA THYROID CANCER GUIDELINES1173。
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・临床指南・甲状腺结节和分化型甲状腺癌诊疗指南 2006年,美国甲状腺学会(AT A)制定了新的关于甲状腺结节和分化型甲状腺癌的诊疗指南,简介如下。
1 甲状腺结节发现患者有甲状腺结节后,应收集其完整病史并对甲状腺及邻近的颈部淋巴结做详细检查。
超声检查可将其与周围的甲状腺组织区分开,骨髓移植接受头颈部或全身放射线照射史、一级亲属甲状腺癌家族史、肿块快速生长和声嘶等病史均预示结节为恶性;声带麻痹、结节同侧颈部淋巴结肿大并与周围组织相对固定等也提示结节可能为恶性。
通常来讲,仅需对直径>1c m的结节进行评估,因为这些结节可能恶变。
当超声检查结果可疑,或患者有头颈部放射线照射史,或有甲状腺癌阳性家族史时,也应对直径<1c m 的结节进行评估。
对直径>1c m的应检查血清促甲状腺激素(TSH)水平。
如TSH低下,则应行放射线核素甲状腺扫描,以确定结节为功能性结节、等功能结节(“温结节”)或无功能结节。
功能性结节极少为恶性,因此无需对这类结节做细胞学评估。
如血清TSH未被抑制,应行诊断性甲状腺超声检查,有助于明确:是否确实存在与可触及病变相吻合的结节,结节的囊性部分是否>50%,结节是否位于甲状腺后侧等问题。
后两种情况会降低细针抽吸活检(F NA)的精确度。
即使TSH 升高,也建议行F NA,因为正常甲状腺组织与桥本甲状腺炎累及组织中结节的恶变率相似。
血清甲状腺球蛋白水平在多数甲状腺疾病时均会升高,这项指标对甲状腺癌既不敏感,也不特异。
血清降钙素是一项有意义的指标,常规检测血清降钙素可早期检出甲状腺旁细胞增生和甲状腺髓样癌,在未经刺激的情况下,血清降钙素>100pg/m l,则提示可能存在甲状腺髓样癌。
F NA是评估甲状腺结节最精确且效价比较高的方法。
传统上,F NA活检结果可分为:无法确诊、恶性、不确定(或可疑新生物)和良性。
无法确诊是指活检结果不符合现有特定诊断标准,此时需在超声引导下再行活组织检查。
反复活组织检查始终无法根据细胞学检查结果确诊的囊性结节很可能在手术时被确诊为恶性。
甲状腺多发性结节的恶性危险性与孤立结节相同。
应行超声检查确定多发性结节的形态,如仅对“优势”结节或最大结节做针吸活组织检查,则可能漏诊甲状腺癌。
如超声显示固体结节有微钙化、低回声或结节间有丰富的血供,则提示该结节可能为恶性。
对被诊断为良性甲状腺结节患者需进行随访,因为F NA的假阴性率可达5%。
良性结节的直径会越来越小,而恶性结节则会增大,增大的速度可能很慢。
结节生长本身不是恶性病变的指征,但这是再行活组织检查的适应证。
2 分化型甲状腺癌的初期治疗211 分化型甲状腺癌的根本治疗目的 (1)切除肿瘤原发灶、扩散至甲状腺包膜外的病变组织及受累颈部淋巴结;(2)降低与治疗和疾病相关的致残率;(3)对肿瘤进行精确分期;(4)便于在术后择期行131I放疗;(5)便于医师在术后长期精确监控疾病的复发情况;(6)有利于将肿瘤的复发和转移危险性控制在最低。
212 经标准病理学检查可知,有20%~50%的分化型甲状腺癌(特别是乳头状癌)患者颈部淋巴结受累。
术后超声检查20%~31%的患者颈部可检出可疑淋巴结,手术方案也会随之而改变。
对肿瘤进行精确分期对判断预后和指导治疗均至关重要,然而与其他肿瘤不同,存在转移灶并不意味着不能切除分化型甲状腺癌的原发灶。
转移灶对131I放疗敏感,因此,即便存在转移灶,也应在初期治疗时切除甲状腺原发肿瘤灶及其可能被累及的组织。
甲状腺癌的手术选择包括甲状腺叶切除术、近全甲状腺切除术(切除大部分可见的甲状腺组织,仅保留少量附着在喉返神经进入环甲肌周围的组织)和甲状腺全切术(切除所有可见的甲状腺组织)。
保留病变侧后部甲状腺组织(>1g)的次全切除术不适于治疗甲状腺癌。
如存在下列情况,建议行甲状腺近全或全切除术:(1)肿瘤直径>1cm;(2)肿瘤对侧存在甲状腺结节;(3)有局部或远端转移;(4)患者有头颈部放疗史;(5)患者一级亲属有分化型甲状腺癌病史。
年龄较大(>45岁)的患者复发率较高,建议采用上述术式。
因无法确诊而切除甲状腺叶或行非诊断性活检后被确诊为恶性病变时,应行甲状腺全切术。
对甲状腺多发癌患者应行甲状腺全切术,以确保彻底切除病灶,并为131I放疗做好准备。
甲状腺癌的术后分期可用于:(1)确定分化型甲状腺癌患者的预后;(2)指导术后辅助治疗,包括131I放疗和TSH抑制治疗,以减少患者的复发率和病死率;(3)确定随访的时间和频率,对高危患者进行更密集的随访。
美国癌症联合委员会(AJCC)/国际抗癌联合会(U I CC)对甲状腺T NM分期进行分类(见表1)。
3 分化型甲状腺癌的长期随访目标即是对可能复发的患者进行密切监测,以便尽早发现复发病灶。
随访的内容依患者病变持续存在或复发危险性的大小各不相同。
应按复发危险程度评估患者预后并确定治疗方案。
低危患者:在初次手术治疗并清除残留病灶后没有局部或远处转移灶,所有肉眼可见的肿瘤均已被切除,肿瘤未侵入局部组织且没有高侵犯性的病理表现或侵袭血管。
如果使用131I,那么在初次手术后进行全身放射碘扫描(Rx WBS)时,甲状腺床外无131I摄取。
・156・表1 分化型甲状腺癌的T NM分期系统定义T1肿瘤直径≤2c mT2原发肿瘤直径为2~4c mT3原发肿瘤直径>4c m,肿瘤局限在甲状腺内或有少量延伸至甲状腺外T4a肿瘤蔓延至甲状腺包膜以外,并侵犯皮下软组织、喉、气管、食管或喉返神经T4b肿瘤侵犯椎前筋膜、包裹颈动脉或纵隔血管T X原发肿瘤大小未知,但未延伸至甲状腺外N0无淋巴结转移N1a肿瘤转移至Ⅵ区〔气管前、气管旁和喉前(Del phian)淋巴结〕N1b肿瘤转移至单侧、双侧、对侧颈部或上纵隔淋巴结N X术中未评估淋巴结M0无远处转移灶M1有远处转移灶M X未评估远处转移灶分期患者年龄<45岁患者年龄≥45岁Ⅰ期任何T、N和M0T1,N0,M0Ⅱ期任何T、N和M1T2,N0,M0Ⅲ期T3,N0,M0;T1,N1a,M0;T2, N1a,M0;T3,N1a,M0ⅣA期T4a,N0,M0;T4a,N1a,M0;T1, N1b,M0;T2,N1b,M0T3,N1b, M0;T4a,N1b,M0ⅣB期T4b,任何N,M0ⅣC期任何T,任何N,M1 中危患者:在初次手术时,肉眼可见肿瘤侵入甲状腺旁软组织,或肿瘤有侵犯性的病理表现或侵入血管。
高危患者:在初次手术时,肉眼可见肿瘤侵入周边组织,肿瘤切除不完整、有远处转移,或在甲状腺残余病灶清除术后行131I扫描时可见甲状腺床外有碘摄取。
在接受了甲状腺全切或近全切除术的患者中,同时具备下列所有条件者即为无病状态:存在肿瘤的临床证据,不存在肿瘤的影像学证据(在术后全身扫描时、新近的诊断性扫描和颈部超声检查时,甲状腺床以外均无碘摄取),在缺乏干扰性抗体的情况下,用TSH抑制和刺激期间均无法检测到甲状腺球蛋白(Tg)。
检测血清Tg水平是一种监测残留或转移病灶的重要方法,对甲状腺癌具有高度的敏感度和特异性,特别是在行甲状腺全切术并去除残余病变后。
停用甲状腺激素或用重组型人促甲状腺激素(rhTSH)进行刺激后,该检测的敏感度最高。
在用甲状腺激素抑制TSH分泌期间检测Tg无法检出少量的残留肿瘤。
当治疗后没有或仅有少量正常甲状腺组织残留时,诊断性Rx WBS是最有用的随访方法。
在放射性碘治疗后,Rx WBS的敏感性有所降低,因此,临床没有残存肿瘤灶、甲状腺素抑制期间不能检出Tg且颈部超声检查阴性的低危患者无需行Rx WBS。
颈部超声检查是检测分化型甲状腺癌患者颈部转移的高敏感方法。
有时甚至在TSH刺激下尚未检测到血清Tg 时,颈部超声已可检出转移灶。
当前对甲状腺素抑制治疗的疗效存有争议。
有研究表明,甲状腺激素抑制治疗可降低甲状腺癌患者长期随访期间大型临床不良事件的发生率,但用左旋甲状腺素(LT4)抑制甲状腺的最佳程度尚不明了。
与TSH水平较高(≥1mU/L)时相比,持续抑制TSH(≤0105mU/L)可使患者的无复发生存时间延长。
在多变量分析中,TSH的抑制程度是肿瘤复发的独立预测因素。
而另一项大型研究表明,疾病分期、患者年龄和131I 治疗的情况均为疾病预后的独立预测因素,但不包括TSH抑制程度。
如在随访期间发现肿瘤转移灶,131I治疗通常无济于事。
对侵入上呼吸道和上消化道的肿瘤,建议选用手术治疗加辅助治疗〔131I和(或)体外照射放疗(EBRT)〕。
患者的转归决定于是否能完整地切除肿瘤灶并保留患者相关生理功能以及是否能从被浅表侵袭的气管或食管上剥离肿瘤。
当肿瘤侵入气管的深层组织(如直接侵入管腔)时,需行气管切除术或咽部食管切除术。
对无法治愈的患者应行创伤较小的治疗,对这样的患者使用气管支架或行气管切开术可改善其生活质量。
对有窒息或咯血症状的患者,可在根治手术或姑息治疗前行激光治疗。
尽管131I治疗对许多患者有显著疗效,但尚未确定其最佳治疗剂量。
131I治疗的方法有3种:(1)经验性固定剂量治疗;(2)通过血液和身体的放射线耐受量及特定量肿瘤的放射线耐受量上限确定治疗剂量;(3)对有远处转移或其他特殊情况(如肾功能衰竭),或确实需要rhTS H刺激的患者,则应采用剂量滴定法。
在治疗甲状腺癌的过程中,放射性碘的使用越来越广泛,医师们必须更好地理解使用放射性碘的长期危险,如该疗法对唾液腺的影响、对患可治愈甲状腺癌的男性和女性的生殖系统的长期影响以及治疗后继发腮腺肿瘤、胃肠道肿瘤、膀胱肿瘤和结肠癌等疾病的危险。
使用rhTSH不仅不能抑制转移灶,反而可能加速肿瘤转移灶的生长。
在不损害碘摄取功能的情况下,锂会抑制甲状腺释放碘,因此,可促使131I在正常甲状腺组织和肿瘤细胞中残留。
有研究发现,锂会使肿瘤转移灶中聚集的131I放射剂量平均增加2倍,肿瘤释放碘的速度较快。
如果在未经刺激的情况下检出了Tg,或在被刺激的情况下Tg>2ng/m l,则应行颈部及胸部成像检查,如颈部超声和胸部薄层(5~7mm)螺旋CT,查找肿瘤转移灶。
尽管静脉注射碘剂有助于分辨肿瘤的转移灶,但如果计划在检查后数月内实施放射性碘治疗,则应避免用碘进行加强扫描。
如果扫描结果呈阴性,则手术治疗可能使疾病治愈,但术后也应考虑行经验性放射性碘治疗(100~200mCi)。
针对晚期碘抵抗的分化型甲状腺癌患者进行化疗的研究很少。
适量的多柔比星(每3周使用60~75mg/m2)对40%以上的患者有效(多数为部分有效或可稳定病情),但其作用的持续时间不确定。
(本刊编辑部整理)・256・。