甲狀腺結(jié)節(jié)的治療過程柳秀敏ppt課件

1、尸體解剖：50.5%人群普查可觸及：3-6%超聲發(fā)現(xiàn)非觸及：20-60%甲狀腺結(jié)節(jié)的惡性率：6%左右甲狀腺結(jié)節(jié)的患病率 年齡：小兒患病率在0.051.8%，隨年齡增大而添加 性別：男女比可到達(dá)1:2-4 既往史：頭頸部有照射史者新結(jié)節(jié)以2%/年 遞增，10-15年達(dá)頂峰 檢查方法：超聲觸診；尸檢：50%60歲 飲食中碘含量：低碘區(qū)發(fā)病率高影響甲狀腺結(jié)節(jié)患病率的要素華北地域甲狀腺結(jié)節(jié)的患病率華北地域甲狀腺結(jié)節(jié)的患病率年齡段年齡段男性男性女性女性P值值*總?cè)藬?shù)總?cè)藬?shù) 有結(jié)節(jié)人數(shù)有結(jié)節(jié)人數(shù) 患病率患病率總?cè)藬?shù)總?cè)藬?shù) 有結(jié)節(jié)人數(shù)有結(jié)節(jié)人數(shù) 患病率患病率1830405060合計(jì)合計(jì)75 3 4.0108

2、 5 4.6161 14 8.7 252 42 16.7 215 32 14.9 811 96 11.8 148 8 5.4 358 45 12.6 343 56 16.3 393 118 30.0 227 84 37 1469 313 21.30.890.030.030.010.010.01*0 010102020303040405050606070708080(%)(%)202020-2920-2930-3930-3940-4940-4950-5950-5960-6960-697070TotalTotalMaleMaleFemaleFemaleTotalTotal0 00.10.10.20

3、.20.30.30.40.40.50.50.60.60.70.70.80.820-2920-2930-3930-3940-4940-4950-5950-5960-6960-697070TotalTotalSolitarySolitaryMultiplyMultiplysolidsolid68.4%68.4%cysticcystic12.3%12.3%mixedmixed19.3%19.3%solitarysolitary53.5%53.5%multiplemultiple46.5%46.5%占全部癌的占全部癌的1% 乳頭狀癌乳頭狀癌(65%)，頂峰，頂峰20-30歲，女性幾倍于歲，女性幾倍于男

4、性男性濾泡細(xì)胞癌濾泡細(xì)胞癌(15%)，頂峰，頂峰30-40歲，女性幾倍歲，女性幾倍于男性于男性未分化癌未分化癌(5-10%)，多見于老年或老年前期，多見于老年或老年前期，男女發(fā)病相等男女發(fā)病相等髓樣癌髓樣癌(10%)，男女發(fā)病相等，男女發(fā)病相等淋巴瘤淋巴瘤(4%), 癌轉(zhuǎn)移癌轉(zhuǎn)移 老年男性單結(jié)節(jié)要多思索甲狀腺癌老年男性單結(jié)節(jié)要多思索甲狀腺癌兒童甲狀腺癌幾乎都是乳頭狀癌兒童甲狀腺癌幾乎都是乳頭狀癌甲狀腺癌甲狀腺癌甲狀腺癌的病理特點(diǎn)甲狀腺癌的病理特點(diǎn)胞膜浸潤(rùn)胞膜浸潤(rùn)了解結(jié)節(jié)能否惡性病變了解結(jié)節(jié)能否惡性病變 甲狀腺結(jié)節(jié)診斷的關(guān)鍵甲狀腺結(jié)節(jié)診斷的關(guān)鍵- -區(qū)分良惡性區(qū)分良惡性良性能夠性大良性能夠性大有

5、橋本氏甲狀腺炎、良性甲狀腺結(jié)節(jié)或甲狀腺有橋本氏甲狀腺炎、良性甲狀腺結(jié)節(jié)或甲狀腺腫的家族史腫的家族史有甲亢或甲減的病癥有甲亢或甲減的病癥痛性結(jié)節(jié)或質(zhì)地柔軟的結(jié)節(jié)痛性結(jié)節(jié)或質(zhì)地柔軟的結(jié)節(jié) 年輕年輕207070歲歲男性男性兒童或青春期頸部外照射史兒童或青春期頸部外照射史有甲狀腺癌既往史有甲狀腺癌既往史近期有發(fā)聲、呼吸或吞咽改動(dòng)近期有發(fā)聲、呼吸或吞咽改動(dòng)有甲狀腺癌或有甲狀腺癌或2 2型多發(fā)性內(nèi)分泌腫瘤的家族史型多發(fā)性內(nèi)分泌腫瘤的家族史甲狀腺查體時(shí)觸及鞏固、外形不規(guī)那么、活動(dòng)度差的結(jié)甲狀腺查體時(shí)觸及鞏固、外形不規(guī)那么、活動(dòng)度差的結(jié)節(jié)節(jié)甲狀腺結(jié)節(jié)惡性指征甲狀腺結(jié)節(jié)惡性指征甲狀腺結(jié)節(jié)與甲狀腺結(jié)節(jié)與MENME

6、N Cross-Sectional Ultrasonogram Showing a Solid, Hypoechoic Nodule (Dark Gray) in the Right Thyroid Lobe. 篩查及隨診 區(qū)分囊性和實(shí)性病變 限定甲狀腺穿刺的范圍和輔助穿刺定位甲狀腺囊腫無血流甲狀腺囊腫無血流o缺乏暈環(huán)征缺乏暈環(huán)征o實(shí)體或低回聲實(shí)體或低回聲o回聲異質(zhì)性回聲異質(zhì)性o邊緣不規(guī)那么邊緣不規(guī)那么o微鈣化微鈣化o腺體外延伸腺體外延伸Transverse sonogram of a 35-year-old man with a hypoechoic solid papillary thyr

7、oid carcinoma (arrowheads) with numerous punctate echogenic foci with no acoustic shadow representing microcalcifications. This nodule also has a partial hypoechoic halo. Papillary carcinoma in a 27-year-old woman with a palpable mass. Sagittal view of the left lobe of the thyroid gland shows a larg

8、e, solid mass containing psammomatous calcifications, suspicious for papillary carcinoma. Cytology of a fine-needle aspirate confirmed the diagnosis. Papillary carcinoma. US of the thyroid gland shows an irregular, solid, hypoechoic nodule (arrows) containing some coarse calcifications (curved arrow

9、).Longitudinal sonogram of a 39-year-old woman with a papillary thyroid carcinoma with peripheral, “egg-shell calcifications casting an acoustic shadow which obscures other sonographic features of this nodule.Longitudinal sonogram of a 47-year-old man with a papillary thyroid carcinoma metastasis to

10、 a cervical lymph node (arrowheads). Numerous punctate microcalcifications are clearly seen. A, Longitudinal sonogram of a 35-year-old woman with a solid papillary thyroid carcinoma (arrowheads) with mixed echo texture and a partial, hypoechoic halo. B, Color Doppler imaging of the same nodule shown

11、 in shows extensive intrinsic flow. 不能發(fā)現(xiàn)小于10mm的結(jié)節(jié)對(duì)癌癥診斷的敏感性是89-93%特異性僅有5%順應(yīng)征：高功能腺瘤(良性居多) 檢查頸部轉(zhuǎn)移甲狀腺核素掃描甲狀腺核素掃描準(zhǔn)確性準(zhǔn)確性95%特異性特異性92%敏感性敏感性83% 假陰性假陰性5% 假陽(yáng)性假陽(yáng)性0-3%失敗率失敗率5-15%FNAC甲狀腺穿刺細(xì)胞學(xué)甲狀腺穿刺細(xì)胞學(xué)敏感性敏感性65-100% 65-100% 特異性特異性70-100% 70-100% 準(zhǔn)確度準(zhǔn)確度92-95%92-95%對(duì)癌變的診斷價(jià)值對(duì)癌變的診斷價(jià)值 美國(guó)美國(guó) 結(jié)節(jié)手術(shù)率結(jié)節(jié)手術(shù)率 手術(shù)甲癌發(fā)現(xiàn)率手術(shù)甲癌發(fā)現(xiàn)率19801

12、980年年 89.9% 14.7% 89.9% 14.7%19931993年年 46.6% 32.9% 46.6% 32.9%甲狀腺穿刺細(xì)胞學(xué)甲狀腺穿刺細(xì)胞學(xué) 可以一定診斷的疾病可以一定診斷的疾病o乳頭狀甲狀腺癌乳頭狀甲狀腺癌 o甲狀腺髓樣癌甲狀腺髓樣癌o未分化癌未分化癌 o橋本甲狀腺炎橋本甲狀腺炎o(hù)亞急性甲狀腺炎亞急性甲狀腺炎o(hù)化膿性甲狀腺炎化膿性甲狀腺炎o(hù)甲狀腺囊性病變甲狀腺囊性病變o甲狀旁腺囊腫甲狀旁腺囊腫A, Position of patient during FNA. Note: supine position and pillow under patients shoulder

13、to allow hyperextension of the neck and maximal exposure. B, Syringe is placed in syringe-holder. C, Nodule is identified and stabilized with operators nonaspirating hand. The operator stands on the side of the patient opposite to that of the thyroid nodule. Current OSHA regulations require the use

14、of gloves because of concern about blood-borne diseases. D, With a quick motion, the needle passes through the skin and enters the nodule. Immediate mild suction follows. As soon as aspirate appears, suction is released and the needle is withdrawn. 用生理劑量用生理劑量L-T4(優(yōu)甲樂優(yōu)甲樂100 g/天天)可反響可反響抑制抑制TSH抑制效果：彌漫性

15、多結(jié)節(jié)，多結(jié)節(jié)抑制效果：彌漫性多結(jié)節(jié)，多結(jié)節(jié)單結(jié)節(jié)單結(jié)節(jié)某些甲狀腺癌亦可部分抑制某些甲狀腺癌亦可部分抑制T4抑制實(shí)驗(yàn)抑制實(shí)驗(yàn)101036364040141425250 01010202030304040 (%)(%)disappeareddisappeareddecreaseddecreasedunchangedunchangedincreasedincreasedSolitary toSolitary tomultiplemultiple武曉泓、陸曉婕、劉超等，甲狀腺偶發(fā)結(jié)節(jié)的臨床篩查及隨訪，中國(guó)適用內(nèi)科雜志，武曉泓、陸曉婕、劉超等，甲狀腺偶發(fā)結(jié)節(jié)的臨床篩查及隨訪，中國(guó)適用內(nèi)科雜志，2005

16、；259：823-824 o 對(duì)絕大多數(shù)患者而言隨訪即可，隨訪過程中結(jié)節(jié)o 增大者可重新穿刺確定病變性質(zhì)或直接手術(shù)o 多發(fā)結(jié)節(jié)可采用L-T4抑制治療o 對(duì)高功能腺瘤可采用放射治療o 可手術(shù)治療：一側(cè)或一側(cè)大部切除良性甲狀腺結(jié)節(jié)的處置原那么甲狀腺囊性病變的處置原那么甲狀腺囊性病變的處置原那么o 保守治療：行單純細(xì)針穿剌抽吸治療，部分保守治療：行單純細(xì)針穿剌抽吸治療，部分o 囊性病變可經(jīng)一次穿剌而愈；復(fù)發(fā)者可于囊性病變可經(jīng)一次穿剌而愈；復(fù)發(fā)者可于2-2-o 4 4周后再次穿剌；經(jīng)周后再次穿剌；經(jīng)2-32-3次單純抽吸治療后仍次單純抽吸治療后仍o 復(fù)發(fā)者可行硬化治療復(fù)發(fā)者可行硬化治療o 硬化治療：吸

17、盡囊液后向囊腔內(nèi)注入鹽酸四硬化治療：吸盡囊液后向囊腔內(nèi)注入鹽酸四o 環(huán)素生理鹽水環(huán)素生理鹽水( (濃度濃度100mg/ml)100mg/ml)或者無水乙醇或者無水乙醇o(jì) ( (每每10ml10ml囊液：囊液：1ml1ml硬化劑硬化劑) )o 吸出囊液行常規(guī)病理檢查，必要時(shí)行T3、T4及o PTH等激素分析o 囊液吸盡后仍遺留結(jié)節(jié)者對(duì)其結(jié)節(jié)也應(yīng)行細(xì)針o 穿剌確定性質(zhì)o 囊液中或遺留結(jié)節(jié)穿出物發(fā)現(xiàn)癌細(xì)胞或可疑癌o 細(xì)胞者均應(yīng)手術(shù)治療o 遺留結(jié)節(jié)為良性僅隨訪或用甲狀腺素抑制治療甲狀腺囊性病變的處置原那么甲狀腺囊性病變的處置原那么可疑癌性病變可疑癌性病變癌性病變癌性病變手術(shù)治療：?jiǎn)蝹?cè)切除，普通不需冰凍切片手術(shù)治療：?jiǎn)蝹?cè)切除，普通不需冰凍切片短期治療察看：結(jié)節(jié)明顯減少或消逝可排除短期治療察看：結(jié)節(jié)明顯減少或消逝可排除手術(shù)治療手術(shù)治療甲狀腺可疑癌性甲狀腺可疑癌性/ /癌性病變的處置癌性病變的處置甲狀腺結(jié)節(jié)甲狀腺結(jié)節(jié)病史、體檢、病史、體檢、TSH測(cè)定測(cè)定TSH正?；蛘呱哒；蛘呱?/p>