甲状腺结节诊疗流程

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国内甲状腺疾病治疗1.肿瘤医院－头颈外科2.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）3.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国内甲状腺疾病治疗1.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2.全国内分泌年会－08沈阳2010年济南o分化型甲状腺癌（DTC）的淋巴结清扫范围o结节性甲状腺肿的手术治疗问题3.耳鼻喉-头颈外科—2011济南会议制定甲状腺癌中国指南？4.ATA、ETA，-------CTA？？AACE/AMEGuidelinesThyroidNoduleGuidelines,EndocrPract.2006;12AMERICANASSOCIATIONOFCLINICALENDOCRINOLOGISTSANDASSOCIAZIONEMEDICIENDOCRINOLOGIMEDICALGUIDELINESFORCLINICALPRACTICEFORTHEDIAGNOSISANDMANAGEMENTOFTHYROIDNODULESAACE/AME/ETAGuidelinesTheseguidelinesarebasedonEndocrPract.2006Jan-Feb;12(1):63-102.Usedwithpermission.ENDOCRINEPRACTICEVol16(Suppl1)May/June2010AmericanAssociationofClinicalEndocrinologists,AssociazioneMediciEndocrinologi,andEuropeanThyroidAssociationMedicalGuidelinesforClinicalPracticefortheDiagnosisandManagementofThyroidNodulesAACE/AME/ETAGuidelinesREFERENCES-214Note:Allreferencesourcesarefollowedbyanevidencelevel(EL)ratingof1,2,3,or4.Thestrongestevidencelevels(EL1andEL2)appearinredforeasierrecognition.NCCNClinicalPracticeGuidelinesinOncologyThyroidCarcinomaV.2.2011甲状腺结节流行病学1.thyroidnodulesPalpable：3%to7%US：20%-76%1palpation:20%-48%additionalnodulesonUSinvestigation2.Annualincidencerateof0.1%(300000)newnodulesinUSAeveryyear浙江省6000万人口，杭州市600万人口甲状腺结节-原因Theclinicalimportanceofthyroidnodules1.localcompressivesymptoms2.thyroidhyperfunction3.thyroidmalignantlesion(about5%)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%那些甲状腺结节可能是恶性？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1981—2001结果平均年发病率－1,770/10万男女发病比例－1:2.74平均死亡率－0.368/10万甲状腺结节良性结节1.Multinodulargoiter(MTG)2.Hashimoto’sthyroiditis(HT,HD)3.Simpleorhemorrhagiccysts4.Follicularadenomas5.Subacutethyroiditis甲状腺结节恶性结节1.Papillarycarcinoma2.Follicularcarcinoma3.Hürthlecellcarcinoma4.Medullarycarcinoma5.Anaplasticcarcinoma6.Primarythyroidlymphoma7.MetastaticmalignantlesionDIAGNOSISHistoryandPhysicalExaminationgrowinsidiouslyformanyyearsdiscoveredincidentallyonphysicalexamination,self-palpation,orimagingstudiesperformedforunrelatedreasons.FMTC,MEN2,familialpapillarythyroidtumors,familialpolyposiscoli,DIAGNOSISPatientswithrapidgrowthofalargesolidthyroidmassandvocalcordparesisshouldundergosurgicaltreatmentevenifcytologicresultsarebenign(gradeC)DTC,however,rarelycauseairwayobstruction,vocalcordparalysis,oresophagealsymptoms,andabsenceofsymptomsdoesnotruleoutamalignanttumor(gradeC)DIAGNOSISToxicMNGshyperfunctioning(benign)areascold(potentiallymalignant)lesionsThyroidnodulesinpatientswithGraves’diseasearereportedtobemalignantinabout9%ofcasesDIAGNOSISRememberthatthevastmajorityofnodulesareasymptomatic,andabsenceofsymptomsdoesnotruleoutamalignantlesion(gradeC)Alwaysobtainabiopsyspecimenfromsolitary,firm,orhardnodules.TheriskofcancerissimilarinasolitarynoduleandMNG(gradeB)检查手段1.B超声：最常用，约50%结节由超声检查发现2.TSH：监测垂体甲状腺轴对内分泌治疗的反应3.细针穿刺活检(FNA)：确定肿瘤良恶性的有效手段4.高分辨率超声：对结节诊疗手段的有力补充5.甲状腺放射性核素显像（ECT）6.CTandMRIarenotindicatedinroutinenodularevaluation(gradeC)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：ResultsofLiteratureSurveyFeatureMean(%)Range(%)Sensitivity8365-98Specificity9272-100Positivepredictivevalue7550-96False-negativerate51-11False-positiverate50-7FNAisnowconsideredsafe,useful,andcost-effective其他检查的意义Third-generationTSH（0.01μIU/ml）T3、T4TPOAbThyroglobulin(TG)Routineassessmentisnotrecommended(gradeC).Calcitonin-MTC(notroutinetesting)FNA-PositiveThyroidNodule按照NCCN的有关标准治疗FNA-NegativeThyroidNoduleLevothyroxineSuppressiveTherapy(TSH0.1μIU/mL)1.acontroversialtherapeuticpractice2.Efficacy：20％effectiveInSmall,recentlydiagnosedthyroidnodulesInlesionswithcolloidfeaturesatFNAevaluationingeographicregionswithiodinedeficiency3.A5-yearprospectiverandomizedstudynodulegrowth,newnoduleappearance,andthegrowthofthethyroidglandasawholemaybedecreased(gradeA)TheuseofLT4shouldbeavoided1.largethyroidnodulesorlong-standinggoiters2.theTSHlevelis1μIU/mLInpostmenopausalwomeninmenolderthan60years3.Osteoporosis4.cardiovasculardisease5.systemicillnesses.Factstoremember1.LT4treatmentinducesaclinicallysignificantreductionofthyroidnodulevolumeinonlyaminorityofpatients(gradeB)2.Long-termTSHsuppressionmaybeassociatedwithbonelossandarrhythmiainelderlypatientsandmenopausalwomen(gradeB)3.LT4treatmentshouldneverbefullysuppressive(TSH0.1IU/mL)(gradeC)Factstoremember4.NoduleregrowthisusuallyobservedaftercessationofLT4therapy(gradeC)5.Ifnodulesizedecreases,LT4therapyshouldbecontinuedlongterm(gradeD)6.IfthyroidnodulegrowsduringLT4treatment,reaspirationandpossiblysurgicaltreatmentshouldbeconsidered(gradeD)SurgicalTreatmentSurgicalindicationsAssociatedlocalsymptomsHyperthyroidismfromalargetoxicnodule,orhyperthyroidismconcomitantMNGGrowthofthenoduleSuspiciousormalignantFNAresultsSurgicalTreatment1.Totalornear-totallobectomy,withorwithoutisthmectomy2.Completionthyroidectomyshouldrequirepatience3.Forasolitarybenignnodule,lobectomyplusisthmecto