數(shù)字化醫(yī)院建設課件

Thyroiddisease

LiboLiMD

DepartmentofGeneralSurgery

SirRunRunShawHospital

Schoolofmedicine,ZhejiangUniversity

Thyroiddisease

LiboLiMD

AnatomyofThyroidAnatomyofThyroidAnatomyofThyroidAnatomyofThyroidThyroiddiseaseNontoxicgoiterHyperthyroidismThyroidCancerThyroiditisThyroiddiseaseNontoxicgoiterNontoxicGoiterGoiterfromtheFrench(goitre)andLatin(guttur),bothmeaningthroatDefinedasanenlargementofthethyroidglandEndemicwhenitinvolvesmorethan10%ofthepopulationThemajority,secondarytoiodinedeficiencyEspeciallyfoundinhighmountainregionsNontoxicGoiterGoiterfromtheNontoxicGoiter

ClinicalthinkingWhetherthepatienthaslocalsymptomsWhetherthegoiteristoxicornontoxicWhetheranyofthenodulesharboracancerThenumberandbilateralityofthenodulesTSHlevel,differentialdiagnosisofhypothyroidismorhyperthyroidismAppropriatetreatmentoptionsforeachparticularpatient

NontoxicGoiter

TakinghistoryAsymptomaticneckmassAcough,shortnessofbreath,stridor,orhoarsenessChokingoraspiration,dysphagia,orpainSymptomsofhyperthyroidismWhetherthepatienthascosmeticconcernsFromiodinedeficiencyregion

NontoxicGoiter

PhysicalexaminationWhetherthegoiterisconfinedtotheneckWhetherithasasubsternalcomponentWhethertrachealdeviationispresentThesizeandconsistencyofthegoiterThemobilityofthevocalcordsbyeitherindirectordirectlaryngoscopy

NontoxicGoiter

UltrasoundHowmanynodules?Bilateral?Ultrasoundcharacteristics

NontoxicGoiterCTscanNeckandchest,especiallysubsternalthyroidRareintrathoracicoraberrantthyroidNontoxicGoiterCTscanNontoxicGoiterFineneedleaspiration(FNA)SuspiciousmalignentgoiterNontoxicGoiterFineneedleaspNontoxicGoiter

TreatmentIodinedietreplacement(endemicgoitor)SurgicalresectionSymptomsLocalcompressionSecondaryhyperthyroidisimAnysuspiciousormalignantlesionCosmeticreasonsRadioiodinetherapy,highriskofptsThyroidhormonesuppression(notforsporadicgoiter)

SporadicNontoxicGoiterAsymptomaticEuthyroidMostbilaterallyNoefficiencyofthyroidhormonereplacementHighrecurrencepostoperatively30%~40%SporadicNontoxicGoiterAsymptNontoxicGoiter

HistoryofThyroidSurgeryFirstthyroidectomy,inParisin1791byPierre-JosephDesaultAntisepsis,hemostasis,andgeneralanesthesiainthe1840sthyroidsurgerybecamesafeTheodoreKocher,aNobelPrizein1909FromBern,SwitzerlandHispioneeringeffortsinthyroidsurgery

PrimaryHyperthyroidsim

Grave’sDiseasePrimaryHyperthyroidsim

GraveClinicalStatisticsGravesDiseaseisthemostcommoncauseofhyperthyroidism(60-80%)ofallcasesFemalesareaffectedmorefrequentlythanmen10:1.5Monozygotictwinsshow50%concordanceratesIncidencepeaksfromages20-40IncidenceissimilarinwhitesandAsians,butissomewhatdecreasedforAfricanAmericansClinicalStatisticsGravesDiseGraves'DiseaseAutoimmunesystemicdisorderThyroidreceptorantibodybindingtoandstimulatingtheTSHreceptorExcessivesynthesisandsecretionofthyroidhormoneUsuallydiffuselyandsymmetricallyenlargedandfirmGraves'DiseaseAutoimmunesystHyperthyroidism—uptakeA.NormalB.Graves’DzC.ToxicMultinodularGoiterD.ToxicAdenomaE.ThyroiditisHyperthyroidism—uptakeA.NormaHyperthyroidism

SymptomsHeatintolerance,sweating,palpitations,fatigueWeightloss,diaphoresis,increasedstoolfrequencyMuscleweakness,anxiety,insomniaNervousnessorrestlessness;irritability,emotionallabilityInwomen,irregularmenses

Hyperthyroidism

ClinicalfindingsTremor,tachycardia(A.fib),Goiter,lidlag,proptosis,periorbitaledema,exophthalmos;chemosis;hyperreflexiaWarm,moistskin;dermopathy;andpretibialedema,

osteoporosis

ExopthalamosinGravesDiseaseLidLaginGravesDiseaseExopthalamosinGravesDiseaseHyperthyroidism—treatmentBeta-blockers:controlsxsPropranololdecrperipheralT4->T3conversionGraves’DzPTU(safeinpregnancy)ormethimazoleRaresideeffect:agranulocytosisRadioactiveiodine75%oftreatedptsbecomehypothyroidSurgeryToxicAdenomaorTMNGRAIorsurgeryHyperthyroidism—treatmentBeta-Hyperthroidism

SurgerySurgicalapproachBilateralnear-totalortotalthyroidectomyIndicationofsurgery(InChina)CompressivesymptomsSecondaryoradenomaRecurrenceofmedicineoriodine-131NoefficiencyofmedicineSecondtrimesterofpregnancy

Surgeryforhyperthyroidism

PreoperativepreparationAbsolutelyrequiredantithyroiddrugs,for3to6weekswithagoalofnearlynormalizingtheT3andT4PropranololoratenololrapidlycontrolstheadrenergicsideeffectsofexcessT4andT3tachycardia,tremor,anddiaphoresisLugol'ssolutionrapidlybuttemporarilyrestoresnormalthyroidfunctionandreducesthyroidglandvascularity

SurgicalcomplicationsBleedingRecurrentLaryngealNerveDamageHypoparathyroidismandHypocalcemiaSuperiorlaryngealnervedamageThyroidstormSurgicalcomplicationsBleedinThyroidcancerThyroidcancerThyroidcancer

IntroductionThemostcommon,95%ofallendocrinecancersIncreasingfasterthananyothercancerMorethan90%,welldifferentiatedGoodlong-termprognosis

Thyroidcancer

ClinicalPresentationMost,clinicallywithapalpablenoduleUsuallyasymptomaticRarecases,withhoarseness,pain,dysphagia,dyspnea,coughing,orchokingspellsPain，withthesuspicionforMedullarythyroidcarcinomaAnaplasticcarcinomaLymphoma

PertinenthistoricalfactorspredictingmalignancyAhistoryofheadandneckirradiationTotalbodyirradiationforbonemarrowtransplantationExposuretofalloutfromtheexplosionoftheChernobylnuclearpowerplantin1986,especiallyinchildren;Afamilyhistoryofthyroidcancer;andrapidgrowthorhoarseness.Children,men,andadultsolderthan60yearshaveanincreasedriskofmalignancyPertinenthistoricalfactorspIncreasetheriskofthyroidcancerPersonalandfamilyhistoryofotherendocrinedisorders,specificallyhyperparathyroidism,pituitaryadenomas,pancreaticisletcelltumors,adrenaltumors,andbreastcancer.Afamilyhistoryofpapillaryormedullarycarcinoma(MENsyndromes),familialpolyposis,Gardner'ssyndrome,andCowden'ssyndromeIncreasetheriskofthyroidcPertinentphysicalfindingsSuggestingpossiblemalignancyGrittytexture”(顆粒樣）ofthethyroidnoduleCervicallymphadenopathyVocalcordparalysisFixationofthenoduletosurroundingtissuePertinentphysicalfindingsSuThyroidcancer

DiagnosisUltrasoundFeatureofmalignancyIrregularmarginsIntranodularvascularpatternMicrocalcificationsFineneedleaspiration(FNA)Themostreliableandcost-efficientmethod

Thyroidcancer

DiagnosisThyroidfunctiontestsSerummarkersThyroglobulin(TG)forwell-differentiatedthyroidcancerCalcitoninandCEAformedullarythyroidcancerAllptswithmedullarythyroidcancerRETproto-oncogenepheochromocytomaandhyperparathyroidism

Managementofthyroidcancer

ThegoalsoftherapyRemovalofprimarytumor,diseasethatextendsbeyondthethyroidcapsule,andinvolvedcervicallymphnodesMinimizationoftreatment-anddisease-relatedmorbidityAccuratediseasestagingFacilitationofpostoperativetreatmentwithradioiodinewhenappropriateAccuratelong-termsurveillanceMinimizationoftheriskofrecurrentlocalandmetastatictumor

Well-DifferentiatedThyroidCarcinoma

PapillaryThyroidCarcinoma

Themostcommonendocrinemalignancy，approximately80%ofnewcasesAssociatedwiththebestprognosisAtleasttwiceascommoninwomenasmenApeakageofpresentationof38to45years90%ofradiation-induced，familialin5%

PapillaryThyroidCarcinomaPapillaryThyroidCarcinomaWell-DifferentiatedThyroidCarcinoma

PrognosesTheriskofdeathapproximately5%inthelow-riskgroup40%inthehigh-riskgroupFortunately,mostpts(70%)inthelow-riskgroup

OtherhistologicalfactorsTopredictthebehaviorofthyroidcancerPloidyofthetumorAdenylatecyclaseresponsetothyroidstimulatinghormone(TSH)RadioiodineuptakeApositivepositronemissiontomographyscanEpidermalgrowthfactor(EGF)receptorlevelandvariousgeneprofilesOtherhistologicalfactorsToPapillaryThyroidCarcinoma

Theextentofsurgicalresection

ControversialAmericanrecommondationTotalorneartotalthyroidectomy

complicationrateoflessthan2%SelectivenodalresectionPostoperativetreatmentwithiodine-131Low-riskptslessthan1cmthyroidlobectomyandisthmectomyOKReoperationmultifocal,withnodalmetastases,orwithlocalinvasion

BenefitsoftotalthyroidectomyPostoperativeradioiodinescanningandablativetherapycanbeeffectiveSerumthyroglobulinlevelsarerenderedmoresensitivefordetectingrecurrentorpersistentdiseaseIntrathyroidalcancerthatispresentinmorethan50%ofpatientsisremovedThesmallriskofadifferentiatedthyroidcancerbecominganundifferentiatedcancerisdecreased.BenefitsoftotalthyroidectomPapillaryThyroidCarcinoma

Theroleoflymphnodedissection

AlsocontroversialMicrometastasistocervicallymphnodesiscommon(80%)ProphylacticcervicallymphnodedissectionisnotwarrantedFunctionalneckdissectionandcentralneckdissectionshouldgenerallybeperformedonlyinptswithclinicalorsonographicevidenceoflymphnodeinvolvement

FollicularThyroidCarcinomaApproximately10%ofallthyroidmalignanciesTypicallyolderthanPTCUsuallyinthesixthdecadeoflifeThefemale-to-maleratioisbetween2:1and5:1AslowlygrowingsolitarythyroidnoduleAtendencytospreadhematogenouslyRarelywithsymptomsofdistantmetastasistothebone,lung,brain,andliverFollicularThyroidCarcinomaApFollicularThyroidCarcinomaLessthan6%metastasizetothecervicallymphnodesApproximately25%ofptshaveextrathyroidalinvasion10%to33%havedistantmetastasisatthetimeofinitialdiagnosisFollicularThyroidCarcinomaLeTheprognosisoffollicularcancerSlightlyworsethanthatforpapillarycancerOverallsurvivalrangesfrom43%to95%at10yearsLifelongsurveillanceisnotnecessaryTheprognosisoffollicularcaTheprognosisoffollicularcancerTheimportantprognosticfactorsPresenceofmetastaticdiseaseOlderage(usually>40years)Degreeofinvasion(microcapsularvs.angioinvasionwithorwithoutcapsularandwidelyinvasive)DegreeoftumordifferentiationTheprognosisoffollicularcaFollicularThyroidCarcinomaDiagnosisThewholespecimenmustbeevaluatedforvascularandcapsularinvasion.DiagnosisoffollicularcancercannotbemadeonFNABFollicularThyroidCarcinomaDiFollicularThyroidCarcinomaTreatmentTherecommendedinitialoperationislobectomyandisthmectomyLymphnodedissectionisrarelywarrantedbecausenodalmetastasesareuncommonFollicularThyroidCarcinomaTrMedullaryThyroidCarcinoma7%ofthyroidcancers15%ofallthyroidcancer–relateddeathsApprox75%sporadic零星的,25%hereditaryFromccellsorparafollicularcellsLocatedlaterallyatthejunctionoftheuppertwothirdsofthethyroidglandatapproximatelythelevelofthecricoidcartilageMedullaryThyroidCarcinoma7%MedullaryThyroidCarcinomaInthesporadicformUsuallyasinglefocusofmalignancyUnilateraldiseasein85%ofcasesInthehereditaryformMultifocalandbilateralin90%ofcasesC-cellhyperplasiaMedullaryThyroidCarcinomaInThehereditaryformsofMTCThehereditaryformsofMTCMedullaryThyroidCarcinoma

TumormarkerSerummarkersforcalcitoninsupportthediagnosiscorrelatewithtumorbulk,nodal,anddistantmetastasisHighCEAlevelscorrelatewithapoorerprognosisFlushinganddiarrheaalsohaveaworseprognosis

MedullaryThyroidCarcinoma

LymphnodemetastasesPositivein70%ofpatients81%ofpatientshadcentralnodedisease81%hadipsilateralcervicalnodedisease44%hadcontralateralcervicalnodaldisease

PreventionorcureofMTCBysurgerymainlydependentontheinitialstageandtheadequacyoftheinitialoperationIndicationRET-positivepatientswithfamilialdiseasebeforetheageofpossiblemalignantprogressiontotalthyroidectomybeforeage6PreventionorcureofMTCBysuSurgicalmanagementforMTCDependsonthepresentationofthediseaseThyroidectomyandcentralnodedissectionCentrallymphnodedissectionsincreasetheriskofrecurrentlaryngealnerveinjuryandhypoparathyroidismSurgicalmanagementforMTCDeAnaplasticThyroidCarcinomaRare,1%to2%ofthyroidmalignanciesMorethanhalfofthedeathsfromthyroidcancerSurvivalismeasuredinmonthsCommonlyinpatientsolderthan60yearsUsuallypresentsasarapidlyexpandingthyroidmassAnaplasticThyroidCarcinomaRaAnaplasticThyroidCarcinomaLymphnodeenlargementFrequent(84%)andearlyLocaltumorextensioncauseFixationofthelarynx,esophagus,andcarotidvesselsDysphagia,dysphonia,anddyspneaarecommonSystemicmetastasesoccurin75%ofpts,Usuallyinvolvingthelungs,bone,brain,andadrenalglandsAnaplasticThyroidCarcinomaLyAnaplasticThyroidCarcinomaThediagnosisBeestablishedbyFNABDifferentiatedfromthatoflymphomaandpoorlydifferentiatedmedullarycarcinomaAnaplasticThyroidCarcinomaThAnaplasticThyroidCarcinoma

SurgeyUsuallynotcurative,withdistantmetastasesMultimodalitytreatment,slightlyimprovedoutcomesIndicatelocalcontrolin22%to76%ofptsMediansurvivalrangesfrom2.5to9months,with2-yearsurvivaloflessthan20%

SubacuteThyroiditisPainlessThyroiditisPainfulThyroiditisRareSubacuteThyroiditisPainlessTPainlessThyroiditisAlsocalledlymphocyticthyroiditisSpontaneouslyresolvinghyperthyroidismAnautoimmunedisorderTypicallyelevatedthyroidperoxidaseantibodylevelsLymphocyticinfiltrationofthethyroidPainlessThyroiditisAlsocallePainlessThyroiditis

ClinicalPresentationAgesof30and60years40%ptswiththeclassicalafour-stageclinicalcourse(1)Destruction-inducedthyrotoxicosis,(2)euthryoidism,(3)hypothyroidism,and(4)returntoeuthyroidismUsually,firmglandandnon-tenderwithsymmetrical,modestenlargementNearlyonethirdofpts,permanentlyhypothyroid