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）1. 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
2、/AME GuidelinesThyroid Nodule Guidelines, Endocr Pract. 2006;12AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTSAND ASSOCIAZIONE MEDICI ENDOCRINOLOGIMEDICAL GUIDELINES FOR CLINICAL PRACTICE FOR THEDIAGNOSIS AND MANAGEMENT OF THYROID NODULESAACE/AME/ETA GuidelinesThese guidelines are based on Endocr
3、Pract. 2006 Jan-Feb;12(1):63-102. Used with permission. ENDOCRINE PRACTICE Vol 16 (Suppl 1) May/June 2010American Association of Clinical Endocrinologists ,Associazione Medici Endocrinologi, and European Thyroid Association Medical Guide lines for Clinica l Practice for the Diagnosis and Management
4、of Thyroid NodulesAACE/AME/ETA GuidelinesREFERENCES-214Note: All reference sources are followed by an evidencelevel (EL) rating of 1, 2, 3, or 4. The strongest evidence levels (EL 1 and EL 2) appear in red for easier recognition.NCCN Clinical Practice Guidelines in OncologyThyroidCarcinomaV.2.2011甲状
5、腺结节流行病学1. thyroid nodulesPalpable ： 3% to 7%US ：20%-76% 1 palpation:20%-48% additional nodules on US investigation1. Annual incidence rate of 0.1% (300000) new nodules in USA every year浙江省6000万人口，杭州市600万人口甲状腺结节-原因The clinical importance of thyroid nodules1. local compressive symptoms 2. thyroid hype
6、rfunction3. 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 19812001 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. Multinodular goiter(MTG)2. H
7、ashimotos thyroiditis(HT,HD)3. Simple or hemorrhagic cysts4. Follicular adenomas5. Subacute thyroiditis 甲状腺结节恶性结节1. Papillary carcinoma2. Follicular carcinoma3. Hrthle cell carcinoma4. Medullary carcinoma5. Anaplastic carcinoma6. Primary thyroid lymphoma7. Metastatic malignant lesionDIAGNOSISHistory
8、 and Physical Examinationgrow 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 polyposis coli,DIAGNOSISPatients with rapid growth of a large solid thy
9、roid 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 does not rule out a malignant tumor (grade C)DIAGNOSISToxic MNGshyper
10、functioning (benign) areas cold (potentially malignant) lesionsThyroid nodules in patients with Graves disease are reported to be malignant in about 9% of casesDIAGNOSISRemember that the vast majority of nodules are asymptomatic, and absence of symptoms does not rule out a malignant lesion (grade C)
11、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)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.CT and MRI are not indicated in routine no
12、dular evaluation(grade C)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：Results of Literature SurveyFeatureMean(%)Range(%)Sensitivity8365-98Specificity9272-100Positive predictive value7550-96False-negative rate51-11Fal
13、se-positive rate50-7FNA is now considered safe, useful, and cost-effective其他检查的意义Third-generation TSH（0.01IU/ml）T3 、T4TPOAbThyroglobulin (TG)Routine assessment is not recommended (grade C).Calcitonin-MTC (not routine testing)FNA-Positive Thyroid Nodule按照NCCN的有关标准治疗FNA-Negative Thyroid NoduleLevothyr
14、oxine Suppressive Therapy(TSH 0.1 IU/mL)1.a controversial therapeutic practice2.Efficacy ：20 effective In Small, recently diagnosed thyroid nodulesIn lesions with colloid features at FNA evaluation in geographic regions with iodine deficiency1. A 5-year prospective randomized studynodule growth, new
15、 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/mLIn postmenopausal women in men older than 60 years1. Osteoporosis2. cardiovascular disease3. systemi
16、c 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 with bone loss and arrhythmia in elderly patients and menopausal women (grade B)3.LT4 treatment shoul
17、d 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 continued long term (grade D)6.If thyroid nodule grows during LT4 treatment, reaspiration and possibl
18、y surgical treatment should be considered (grade D)Surgical TreatmentSurgical indications Associated local symptomsHyperthyroidism from a large toxic nodule, or hyperthyroidism concomitant MNGGrowth of the noduleSuspicious or malignant FNA resultsSurgical Treatment1.Total or near-total lobectomy, wi
19、th 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 thyroidectomy is appropriateSurgical Treatment4.With use of general anesthesia or local anesthesia5.A thyroid glan
20、d that extends substernally can almost always be resected through a cervical approach6.With experienced surgeons, associated complications are rarePalpable noduleHigh TSHUS not suspiciousTSH & thyroid USECTTPOAbBenignFNASurgeryMalignant or suspicious131I or follow_upExclusion CriteriaECTLow TSHUS su
21、spiciousLT4Normal 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 SurgeryHighLT4TPOAbNo
22、n-diagnosticClinical & US follow-upscintigraphyColdHotfollow_upLT410mm or risk factor suspicious US features suspicious US features Benign Follicular neoplasia甲状腺结节诊疗流程发现结节1. 测量血TSH（甲状腺功能全套）2. 甲状腺结节FNA3. 颈淋巴结FNA4. 患者的临床特征（恶性可能） Prior head and neck irradiationFamily history of MTC or MEN2Age 70 years
23、Male sexGrowing noduleFirm or hard consistency of nodule, ill-defined nodule margins on palpationCervical adenopathyFixed nodule on examinationDysphonia, dysphagia, and cough超声可疑的特性1. 中心血管过度形成2. 低回声结节3. 边界不规则4. 微钙化5. 直立位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
24、直径30%*PCI25%是不满意的，7年制规划教材P424武正炎观点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 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） 甲状腺结节诊疗流程手术全切除满足以下任何一种情况即行甲状腺全切除 1、年龄45y 2、有放射
25、物质暴露史 3、有远处转移 4、双侧病变 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）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、肿物直径10ng/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
26、证据）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甲状腺结节诊疗流程随访和评估方法1.2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）2.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
27、测1次（如果未发现复发、转移的）3.如果行甲状腺全切除术和消融，放射性碘扫描每年1次，直至扫描为阴性（停止甲状腺激素治疗或予rhTSH治疗）。4.考虑定期的颈部B超和胸片5.如果I131扫描阴性且活性甲状腺球蛋白2-5ng/mL，考虑行额外的非放射性碘影像学检查（例如，如果甲状腺球蛋白10ng/mL可行PETCT）6.考虑在低危的颈部B超阴性的患者采用rhTSH刺激甲状腺球蛋白甲状腺结节诊疗流程随访和评估阳性结果处理1、局部复发-如果能切除则手术（推荐） 如果放射性碘扫描阳性则行放射性碘治疗 放疗2、甲状腺球蛋白10ng/mL（停止予甲状腺激素）且扫描阴性-考虑100-150 mCi放射性碘治
28、疗，治疗后行131I扫描（3级证据）甲状腺结节诊疗流程随访和评估阳性结果处理3、转移性病灶 单个中枢神经系统病灶-考虑神经外科手术切除和/或如果放射性碘扫描阳性，则予放射性碘治疗并予rhTSH和类固醇预防和/或放疗 骨-如果有症状或无症状的承重肢体转移，应用外科姑息治疗和/或如果放射性碘扫描阳性，则予放射性碘治疗和/或放疗；考虑双磷酸盐治疗；考虑转移灶的栓塞治疗；骨水泥成行术。 其它颈部以外的病灶-对合适的增大的转移灶外科手术切除和/或如果放射性碘摄取为阳性，考虑测定最大剂量 和/或对于非碘浓集的肿瘤采用试验性化疗甲状腺结节诊疗流程1. AACE/AME Guidelines2. NCCN C
29、linical Practice Guidelines in Oncology3. 国内文献个人观点甲状腺结节诊疗流程1.考虑良性者尽可能不要手术，建议观察随访（甲低与复发问题），尤其是再次手术要谨慎2.首次手术要切除峡部与锥体叶，腺叶切除是甲癌的最小术式；术后发现的PTMC，切缘阴性可以观察（低危组）3.结节摘除要避免，甲状腺全切除要谨慎！4.避免甲状旁腺的永久性损伤！5.除非腺叶全切，不常规显露喉返神经（尤其是SET）6.不做预防性的颈淋巴结清扫术，取而代之择区性清扫术7.腔镜甲状腺手术有很好的市场，SET更受特殊人群的青睐结束语没有最好，只求更好没有最好，只求更好医使无求，但求完美医使无求，但求完美做一个手术，出一件精品；看一个病人，交一个朋友谢 谢！有十分钟的手术录像
