Lectures on thyroid diseases (nine)Guide for diagnosis and treatment of differentiated thyroid carcinoma (2012) (I) (1)(a) overview:1, more
Lectures on thyroid diseases (nine)
Guide for diagnosis and treatment of differentiated thyroid carcinoma (2012) (I) (1)
1, more than 90% of thyroid cancer is differentiated thyroid carcinoma (DTC), DTC originated in thyroid follicular epithelial cells, including papillary thyroid carcinoma (PTC) and follicular carcinoma (FTC), a few Hurthle cells or eosinophilic cell tumor.
2, most of the slow progress of DTC, similar to the benign course, 10 year survival rate is very high. However, some subtypes, such as PTC's high cell type, columnar cell type, diffuse sclerosis type, solid subtype, extensive infiltration type of FTC, and so on, are prone to thyroid invasion and distant metastasis.
3, poorly differentiated thyroid cancer also belongs to the category of DTC, high invasion, easy metastasis, poor prognosis, treatment difficulties.
4, DTC treatment including surgery, postoperative 131I, TSH inhibition, surgical treatment is very important, individualized comprehensive treatment is the development trend.
(two) DTC, thyroidectomy:
1, to determine the factors of thyroid resection range: tumor size; there is no invasion of the surrounding tissue; metastasis; unifocal or multifocal; childhood has no radioactive contact history; there is no thyroid cancer or thyroid cancer syndrome family history; gender, pathological subtypes and other risk factors.
2, according to TNM (cTNM) staging, tumor recurrence / death risk, all of the advantages and disadvantages and the willingness of patients, comprehensive consideration, can not be generalized.
3, total / near total thyroidectomy:
1, resection range: total removal of the thyroid is to remove all visible thyroid tissue. Near total removal of the thyroid gland is the removal of almost all visible thyroid tissue, preserving < 1g of the thyroid tissue, such as the recurrent laryngeal nerve into the throat, parathyroid tissue of the thyroid.
2), advantages: a one-time treatment of multifocal lesions; to monitor postoperative recurrence and metastasis; 131I for treatment of postoperative tumor recurrence and reoperation; reduce the probability; accurate assessment of postoperative staging and risk stratification.
3), disadvantages: permanent hypothyroidism, parathyroid, laryngeal nerve injury probability increases, high demands on the surgeon skills.
4), indications: childhood neck irradiation history or history of exposure to radioactive dust; primary > 4cm; multi foci and bilateral tumor; adverse pathologic subtypes (high cell type, PTC columnar cell type and diffuse sclerosis, entity subtype, FTC wide infiltrative, low differentiated type); for distant metastasis, postoperative 131I treatment; bilateral cervical lymph node metastasis; extrathyroid invasion.
5, the relative indications: straight through 1~4cm with thyroid cancer risk factors or the combination of contralateral thyroid nodules.
In 4, lobectomy plus isthmus resection:
1, advantages: to protect the parathyroid gland, recurrent laryngeal nerve, part of the thyroid function.
2, the shortcoming: may omit the tiny focus; is not conducive to the monitoring of the disease by Tg and 131I whole body imaging.
Indications: 3), the side lobe lesion is less than or equal to 1cm, the risk of recurrence is low, no childhood head and neck radiation exposure history, lesions in contralateral lobe. 4), the relative indications of side lobe solitary lesions less than 4cm, more than.
5, central neck lymph node dissection: cervical lymph node metastasis is a risk factor for increased survival rate and reduce the recurrence rate of DTC, 20% to 90% of patients at the time of diagnosis for cervical lymph node metastasis occurred in the central neck lymph node (VI). 28% ~ 33% of lymph node metastasis, preoperative imaging and intraoperative exploration has not been found, but in the diagnosis of prophylactic central lymph node dissection. In preserving parathyroid and laryngeal nerve case for lesion ipsilateral central lymph node dissection. The dissection includes: the upper bound of the thyroid cartilage is lower than the thymus, and the lateral border is the medial margin of the carotid sheath.
In 6, cervical non central lymph node dissection: cervical lymph node metastasis can also involve the neck (II to V region) and anterior mediastinal lymph nodes (region VII) node can reduce the recurrence rate and mortality rate of resection of the lymph. Removal of lymph nodes by region is better than resection of affected lymph nodes. Non central lymph node metastasis in patients with DTC lymph node dissection of neck region.