甲状腺结节诊疗流程.pptx
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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
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