Zhu Xun is one of the most famous female hosts on CCTV. Whenever the audience sees her on TV, they will be impressed by her bright appearance and elegant conversation. However, in 2007, she was diagnosed with thyroid cancer and , and she briefly bid farewell to the stage and fought against the disease. To this day, Zhu Xun's courage and strength have brought her back to her post and allowed the audience to appreciate her style again.
Let’s talk about the standardized treatment process of differentiated thyroid cancer in detail through a real case
Case introduction
Yuan Moumou, male, 62 years old, was admitted to the hospital with the main complaint of "3 years of tumor in the right neck".
medical history: The patient found a tumor in the front of the right neck for physical examination 3 years ago, without any discomfort such as hoarseness, pain, palpitations, hand tremors, and the tumor gradually enlarges and has not been treated.
Other past history, personal history, and family history are not special.
Specialty examination: the trachea is centered, the carotid artery pulsates normally on both sides, the jugular vein is not angrily opened, and the hepatojugular vein reflux sign is negative. The right thyroid area can pave the tumor, about 4*4cm in size, medium-quality, smooth surface, no tenderness, and activity with swallowing, normal skin on the surface, and no adhesion to the skin. No obvious tumor was found in the left thyroid area and isthmus. The Ⅲ and Ⅳ areas of the right neck can be palpated with swollen lymph nodes. The larger ones are about 3*2cm in size, medium in texture, smooth surface, no tenderness, and movement. The left neck did not touch abnormally enlarged lymph nodes.
Preliminary diagnosis of
Right thyroid malignant tumor with right cervical lymph node metastasis? How to further check to clarify the diagnosis? 1. Ultrasound examination evaluates primary foci and cervical lymph nodes Ultrasound-guided fine needle puncture biopsy (US-FNAB) thyroid nodules US-FNAB indications: thyroid nodules with a diameter of 1 cm, and US malignant signs are recommended for US-FNAB; thyroid nodules with a diameter of ≤1 cm, and routine puncture biopsy is not recommended. However, if one of the following conditions exists, ultrasound-guided FNAB can be considered: US suggests malignant signs of thyroid nodules; accompanied by abnormal neck lymph nodes seen in US; history of neck radiation or contact with radiation contamination in childhood; family history of thyroid cancer or history of thyroid cancer syndrome; positive 18F-FDG imaging; accompanied by abnormal elevation of serum calcitonin levels. Puncture pathology report (right thyroid) tends toward papillary carcinoma. It is recommended to mark CK19, MC, Galectin-3, CD56, Tg, TTF-1. Tumors/lesions with papillary structures were seen under the microscope.It is recommended to mark Tg, TTF-1, Galectin-3, CD56, MC, CK19, Ki-6 How to clarify the pathological properties?
2. Next? Assess the lesion range
- Electronic computed tomography (CT)
- Magnetic resonance imaging (MRI)
- Positron emission computed tomography (PET-CT)
What tests do you need to supplement for locally advanced patients?
- electronic nasopharyngeal and laryngeal scope
- electronic bronchoscope
- electronic esophageal scope
What laboratory tests need to be done?
1. Laboratory routine examination: blood routine, liver and kidney function, ion
2. Thyroid hormone, thyroid autoantibodies and tumor markers examination
(1) Thyroid hormone detection: T3, FT3, T4, FT4, TSH
(2) Thyroid autoantibodies detection: TgAb, TPOAb, TRAb
(3) Thyroid cancer tumor marker detection: thyroglobulin (thyroglobulin, Tg), calcitonin (Ct) and carcinoembryonic antigen (carcinoembryonic) antigen, CEA)
(4) Related molecular detection for diagnosis: such as BRAF mutation, Ras mutation, RET/PTC rearrangement, etc.
This patient: TG500ng/ml (3.5-77ng/ml) Calcitonin 24.20pg/ml (0-9.52ng/ml) How to treat
?
. Principles of treatment for differentiated thyroid cancer
1. The treatment of differentiated thyroid cancer (DTC) is mainly surgical treatment, supplemented by postoperative endocrine therapy and radionuclide therapy. In some cases, radiotherapy and targeted therapy are required.
2. Medullary thyroid carcinoma (MTC) is mainly surgical treatment, and in some cases it needs to be supplemented with radiation therapy and targeted therapy.
(1). Selection of primary foci surgical methods:
One-sided lobe and isthmus resection (lesions of T1 and T2 without high-risk factors)
Total thyroidectomy (lesions of T3a, T3b, T4a, N1b, M1, T1 and T2 lesions with high-risk factors, bilateral lesions, and multi-focal lesions)
Specific surgical plans need to weigh the benefits and risks of surgery.
(2) Treatment of regional lymph nodes
Central area Lymph nodes (area VI):
cN1a should be dissipated on the affected central area. If it is a unilateral lesion, the central area cleaning scope is recommended to include the affected tracheoesophageal sulcus and the anterior trachea.
For patients with cN0, if there are high-risk factors (such as T3-T4 lesions, multifocal cancer, family history, and childhood ionizing radiation contact history, etc.), central area cleaning can be considered. For patients with low risk of cN0 (without high-risk factors), they can be treated individually.
lateral cervical lymph node treatment (areas I~V)
therapeutic dissection, that is, when preoperative evaluation or intraoperative freezing is confirmed as N1b. The scope of
lateral neck cleaning includes areas II, III, IV, VB, and the minimum range is areas IIA, III, and IV. Area I does not require regular cleaning.
3. Stage, prognosis, next step of treatment?
Primary foci (T) Stage
pTX: Primary tumor cannot be evaluated
pT0: No evidence of tumor
pT1: Tumor is localized in the thyroid gland, maximum diameter ≤2cm
pT1a Maximum diameter of tumor ≤1cm
pT1b Maximum diameter of tumor >1cm, ≤2cm
pT2: Tumor 2~4cm
pT3: Tumor 4cm, localized in the thyroid gland or generally invade the thyroid extraband muscle
pT3a: Tumor 4cm, localized in the thyroid gland, localized in the thyroid gland,
pT3a: Tumor 4cm, localized in the thyroid gland, localized in the thyroid gland,
pT30: Tumor 4cm, localized in the thyroid gland,
pT3a: Tumor 4cm, localized in the thyroid gland,
0pT30: Tumor 4cm, localized in the thyroid gland,
000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000 pT3b: generally invades the outer thyroid muscle, regardless of the size of the tumor
band muscles include: sternal hyoid muscle, sternal thyroid muscle, thyroid muscle, scapulohyoid muscle
pT4: generally invades the outer thyroid muscle
pT4a: generally invades the larynx, trachea, esophagus, recurrent laryngeal nerve and subcutaneous soft tissue
pT4b: invades the pre-vertebral fascia, or wraps the carotid artery and mediastinal blood vessels
2. Regional lymph node (N) stage
pN0: no evidence of lymph node metastasis
pN1: regional lymph node metastasis
00: no evidence of lymph node metastasis
pN1: regional lymph node metastasis
000: no evidence of lymph node metastasis
pN1: regional lymph node metastasis
000: pN1a: Transfer to the lymph nodes of zone VI and VII (including paratracheal, anterior tracheal, anterior laryngeal/or superior mediastinum), which can be unilateral or bilateral.
pN1b: unilateral, bilateral or contralateral cervical lymph node metastasis (including zones I, II, III, IV or V) lymph node metastasis or postpharyngeal lymph node metastasis.
Which thyroid cancer patients need 131I treatment?
Recurrence risk stratification is an important decision-making basis for follow-up treatment of patients with atarctic cancer
131I treatment indication
1. The 2015 ATA Guide strongly recommends 131I treatment for patients with high-risk recurrence risk stratification.
2. For patients with intermediate risk stratification, 131I treatment can be considered. However, 131I treatment can be performed in patients with microscopic extrathyroid invasion but small cancer foci or few lymph node metastases, small involvement diameter and no high-invasive tissue subtype or vascular invasion. 131I treatment can be performed.
3. For low-risk stratification patients, 131I treatment is not recommended.
4. The 2015 ATA Guidelines are no longer recommended for patients with lymph node involvement in low-risk groups (no extra-court invasion, involvement <0.2>
?
Foreign guidelines recommend TSH inhibition treatment targets for postoperative TSH inhibition
Set TSH inhibition treatment targets based on dual risk stratification
DTC medium- and high-risk patients TSH inhibition treatment targets for medium- and high-risk patients with medium- and high-risk patients with medium- and high-risk patients with medium- and high-risk patients with medium- and high-risk patients with TSH inhibition treatment risk for medium- and high-risk patients with medium- and high-risk patients with TSH inhibition treatment can be relaxed to 0.5 mIU/L after one year of surgery.
DTC risk of recurrence
Medium-risk group
Medium-risk group
Medium-risk group
Medium-risk group
Medium-risk group
Pathological examination after the initial operation can be found under the microscope of the tumor with soft tissue surrounding the thyroid gland
Unrespective of WBS after neck lymph node metastasis or after clearing the nails, it was found that abnormal radioactive uptake
Underacting the tumor with histological subtype, or vascular invasion
High-risk group
Meet any of the following conditions
Underacting the tumor with soft tissue or organs can be seen in the naked eye
Unremoval of the tumor with residual
Accompanies distant metastasis
0Unremoval of the tumor with residual
Accompanies distant metastasis
High-risk group
After total thyroidectomy, serum Tg level is still high
There is a family history of thyroid cancer
Summary: Studies show that nearly half of DTC patients in the initial postoperative evaluation are medium and high-risk patients, and the risk of recurrence and mortality in medium and high-risk DTC patients has a high risk of postoperative recurrence and mortality, and they must be paid enough attention;
Evidence-based medicine confirms that timely and long-term TSH inhibition of DTC patients after surgery can significantly reduce recurrence and improve patient survival;
study suggests that when TSH is controlled to an extremely low (such as 0.02 mU/L), the cardiac function has a significant impact. In addition, TSH inhibition treatment is more likely to affect cardiac function in elderly patients; Chinese guidelines recommend: During the TSH inhibition treatment, actively monitor cardiovascular response, and use β-blockers to prevent it correctly according to the indications of preventive medication;
existing studies have not found that TSH inhibition treatment has an impact on the bones of men and women before menopause . Some studies have shown that TSH inhibition treatment has a risk of reducing bone density in postmenopausal women; Chinese guidelines recommend: During the TSH inhibition treatment, the bone condition is actively monitored. Female DTC patients after menopause should receive osteoporosis (OP) prevention, and those who meet the OP diagnosis criteria should initiate regular anti-OP treatment.
