2015美國甲狀腺學會成人甲狀腺結節(jié)與分化型甲狀腺癌診治指南精細版

《2015年ATA成人甲狀腺結節(jié)及分化型甲狀腺癌指南》—Lessismore2009:80recommendations;434citations2015:101recommendations;996citations2015版指南的變化1FewerFNA2LessExtensiveSurgeries3LessRadioactiveIodine2015版指南:4Less4LessStimulatedThyroglobulinTesting1FewerFNA2LessExtensiveSurgeries3LessRadioactiveIodine4LessStimulatedThyroglobulinTestingThyroidNoduleRiskStratification:Sonographicpatternmoreimportantthangrowth變化1超聲甲狀腺結節(jié)頸部淋巴結體積2015:惡性特征,淋巴結轉移2009版指南傾向于結節(jié)體積的變化Thyroidfunction甲狀腺結節(jié)的良惡性評估及FNA指征Solid,hypoechoic,irregularmargins,Microcalcifications,tallerthanwide,Extrathyroidalextension2009版指南FNA指征體積危險分層FNAC≥0.8-

1.0cm高危

或中危?≥1.0-4.0cm任何低危至高危?-良性?（＞4cm）甲狀腺結節(jié)的FNAC條件分子基因檢測1FewerFNA2LessExtensiveSurgeries3LessRadioactiveIodine4LessStimulatedThyroglobulinTestingSurgicalManagement:

Allowingforlobectomyinthetreatmentofthyroidcancer變化2為什么?WhenATAlowtointermediateriskpatientscanbeidentified:ClinicalOutcomesareverysimilarbetweenhemivsnear-totalthyroidectomySurgerycarriesriskInsomecases,I131maynotbenecessary先前指南2015ATA指南:甲狀腺近全切術甲狀腺腺葉切除術或甲狀腺近全切術最重要變革—手術術式“Totalthyroidectomyisnolongermandatedforallpatientswithprimarythyroidcancerslargerthan1cm.”回顧性研究Bilimoria等(52173例)

TTx的10年生存率稍優(yōu)于甲狀腺腺葉切除術Haigh等(5432例)Barney等(23605例Mendelsohn等(22724例)

TTx與甲狀腺腺葉切除術生存率無顯著差異甲狀腺腺葉切除術的選擇依據(jù)術式變化的因素DecreasingindicationsforI-131therapyandscanningCriticalre-assessmentofstudiescomparingoutcomeswithlobectomyvs.totalthyroidectomyThebeliefthatsalvagetherapyiseffectiveinmostcasesifpersistent/recurrentdiseaseisidentified）甲狀腺腺葉切除術甲狀腺全切術（TTx）PTC<4cm性質(zhì)不明實性結節(jié)≥4cm性質(zhì)不明實性結節(jié)PTC<1cm位于甲狀腺內(nèi)，不伴淋巴結轉移及遠處轉移>1cm甲狀腺癌PTC1cm-4cm位于甲狀腺內(nèi)，不伴淋巴結轉移及遠處轉移PTC

1cm-4cm

位于甲狀腺內(nèi)，不伴淋巴結轉移及遠處轉移家族史或放射暴露史,雙側病灶，明顯異型性2015版ATA指南手術更新要點甲狀腺近全切術/全切術的選擇病理提示可疑惡性基因突變陽性伴腫瘤或結節(jié)＞4cm高危家族史雙側甲狀腺結節(jié)伴有明顯的合并癥傾向于甲狀腺近全切術/全切術者極低危風險

(如，甲狀腺微小乳頭狀癌不伴局部侵犯或轉移，病理學未提示高危亞型)密切隨訪

術后并發(fā)癥風險高

預期壽命短

2015版ATA指南

非手術管理123無法手術

(術前因醫(yī)療或手術問題須立即處理)4中國PTMC密切觀察適應癥病理學非高危亞型腫瘤直徑≤5mm（≤1cm）腫瘤位于甲狀腺腺體內(nèi)且無被膜及周圍組織侵犯無淋巴結或遠處轉移無甲狀腺癌家族史無青少年或童年時期頸部放射暴露史患者心理壓力不大、能積極配合滿足以上全部條件者可建議密切觀察（同時具備①～⑥屬于低危PTMC）腫瘤大小增大超過3mm出現(xiàn)臨床淋巴結轉移患者改變意愿，要求手術密切觀察過程中若出現(xiàn)上述情況應考慮手術治療中國PTMC隨訪管理如何預測應行手術治療的PTMC？BRAF無法單獨預測病灶侵襲性

BRAF聯(lián)合其他致癌突變(如PIK3CA,AKT1)及TERT或TP53突變或可作為評估PTC預后的特異性指標ManagementofSuspiciousLymphNodesandNodalMetastases:

Focuson>8-10mm變化3淋巴結清掃Recommendation36A)Therapeuticcentral-compartment(levelVI)neckdissectionforpatientswithclinicallyinvolvedcentralnodesshouldaccompanytotalthyroidectomytoprovideclearanceofdiseasefromthecentralneck.(StrongRecommendation,Moderate-qualityevidence)淋巴結清掃Recommendation36B)Prophylacticcentral-compartmentneckdissection(ipsilateralorbilateral)shouldbeconsideredinpatientswithpapillarythyroidcarcinomawithclinicallyuninvolvedcentralnecklymphnodes(cN0)whohaveadvancedprimarytumors(T3orT4),clinicallyinvolvedlateralnecknodes(cN1b),oriftheinformationwillbeusedtoplanfurtherstepsintherapy.(WeakRecommendation,Low-qualityevidence)淋巴結清掃Recommendation36C)Thyroidectomywithoutprophylacticcentralneckdissectionmaybeisappropriateforsmall(T1orT2),noninvasive,clinicallynode-negativePTC(cN0)andformostfollicularcancers.

(StrongRecommendation,Moderate-qualityevidence)InitialversusDynamicRiskstratification:

Morelowriskpatients變化4AJCC/UICCstagingATAInitialRiskStratificationATAResponsetoTherapy(Introduced2009;Modified2015)(New2015)2015版ATA指南

臨床分級系統(tǒng)分級系統(tǒng)AJCC/UICC*stagingSystem

預測疾病死亡率ATAInitialRiskStratificationSystem

預測疾病復發(fā)率與/或持續(xù)性ATAResponsetoTherapySystem

評估風險變化

(重新評估風險)*AmericanJointCommitteeonCancer/UnionforInternationalCancerControl分級系統(tǒng)的意義甲狀腺癌的分級FullResource:AJCCCancerStagingManual,7thEdition(2010),SpringerPublishingT1a <1cm.無甲狀腺外轉移T1b 1-2cm.無甲狀腺外轉移T2 2-4cm.無甲狀腺外轉移N0 無淋巴結轉移N1a 轉移至Ⅵ區(qū)淋巴結(頸部中央?yún)^(qū))AJCC分級作用IdentifyHigh-RiskPatientsinwhommortalitymaybeincreasedAllowAccurateCommunicationMaintainCommonCancerRegistries大多數(shù)患者傳統(tǒng)分級:腫瘤體積&淋巴結轉移

30年生存率>95%AJCC7thEdition/TNMSystem甲狀腺內(nèi)DTC<4cm無甲狀腺外侵犯

無血管侵犯無淋巴結轉移85%在甲狀腺切除術±I131清甲治療后未再復發(fā)ATA風險分層–2009版

低危復發(fā)Cooper,etal.Thyroid2009Cooperetal,Thyroid2009甲狀腺內(nèi)DTC<4cm無甲狀腺外侵犯無血管侵犯無淋巴結轉移最小程度侵犯的濾泡癌(僅有包膜侵犯)高危亞型PTC(高細胞變異型，等)≤5微小淋巴結轉移(<0.2cm)ATA風險分層–2015版

低危風險85%在甲狀腺切除術±I131清甲治療后未再復發(fā)低危風險:高危風險:

濾泡變異型,PTC

典型PTC高細胞或柱狀細胞變異型PTC

鞋釘狀PTC

廣泛侵犯的FTC

最小程度侵犯的FTC??彌漫硬化變異型PTC乳頭狀癌的變異亞型中危風險高危風險腫瘤不完全切除肉眼可見腺外侵犯遠處轉移Castagna,EurJEndo2011;Tuttle,Thyroid2010;Vaisman,ClinEndo2012;Pitoia,Thyroid2013~20%~60%ATA風險分層–2009版

中危風險高危亞型PTC（高細胞變異型）高危風險腫瘤不完全切除肉眼可見腺外侵犯遠處轉移Castagna,EurJEndo2011;Tuttle,Thyroid2010;Vaisman,ClinEndo2012;Pitoia,Thyroid2013~20%~60%ATA風險分層–2015版

RiskofStructuralDiseaseRecurrenceFTC,extensivevascularinvasion (~30-55%)pT4agrossETE (~30-40%)pN1w/extranodalextension,>3LNinvolved (~40%)PTC,>1cm,TERTmutated±BRAFmutated*(>40%)pN1,anyLN>3cm (~30%)PTC,extrathyroidal,BRAFmutated* (~10-40%)PTC,vascularinvasion (~15-30%)ClinicalN1 (~20%)pN1,>5LNinvolved (~20%)IntrathyroidalPTC,<4cm,BRAFmutated* (~10%)pT3minorETE (~3-8%)pN1,allLN<0.2cm (~5%)pN1,≤5LNinvolved (~5%)IntrathyroidalPTC,2-4cm (~5%)MultifocalPMC (~4-6%)pN1,≤3LNinvolved (~2%)FTC,MinimalCapsularInvasion (~2-3%)Intrathyroidal,<4cm,BRAFwildtype* (~1-2%)IntrathyroidalunifocalPMC,BRAFmutated*(~1-2%)Intrathyroidal,encapsulated,FV-PTC (~1-2%)UnifocalPMC (~1-2%)HigherRiskVeryLowRisk1FewerFNA2LessExtensiveSurgeries3LessRadioactiveIodine4LessStimulatedThyroglobulinTestingRadioactiveIodineTherapy:Fewerpatients,loweradministeredactivities變化5ATA低危風險的131I治療選擇ForTNMStage1/ATALow-RiskPatients:131Idoesnotimprovediseasespecificsurvival131IdoesnotimprovediseasefreesurvivalRadiationcarriesacumulativelifetimerisk先前指南:2015版ATA指南:建議131I治療

不常規(guī)推薦

DonotroutinelygiveRAIfor“l(fā)owrisk”PTCorFTC* WeakRecommendation;LowQualityevidence

DonotgiveRAIforunifocalMicroPTC*StrongRecommendation;ModerateQualityevidence

DonotgiveRAIformultifocalMicroPTC*

WeakRecommendation;LowQualityevidence*absentanyotherhigherriskfeatures2015版ATA指南131I治療更新要點

中危風險可考慮RAI清甲治療

位于甲狀腺內(nèi)1–4cm腫瘤伴淋巴結轉移其他高危征象(結合年齡，腫瘤體積，淋巴結轉移情況及病理提示為中危/高危風險或死亡)

不推薦，低質(zhì)量證據(jù)2015版ATA指南131I治療

高危風險應行RAI清甲治療遠處轉移甲狀腺腺外轉移（無論其體積大?。┠[瘤體積>4cm，甚至缺乏其他高危征象

強力推薦，中等質(zhì)量證據(jù)2015版ATA指南131I治療

≥4cmTTx1-4cm腺葉切除術(TTx)≤1cm腺葉切除術RAI>100mCi+/-RAI30mCi_2015版指南RAI劑量1FewerFNA2LessExtensiveSurgeries3LessRadioactiveIodine4LessStimulatedThyroglobulinTestingLong-termManagement:

LessTSHsuppression,lessstimulatedtesting變化6LowRiskInter.RiskHighRiskRAI30-100mCiRAI>100mCi_rhTSHHormonewithdrawalTSHSuppression(mU/L)0.5-20.1-0.5<0.1RAI分化型甲狀腺癌的隨訪動態(tài)風險分層ATAResponsetoTherapy：評估風險變化

(重新評估風險)LowRiskInter.RiskHighRisknoTg12-24m12-24m6-12mUS6-12m~12mRAI__

DiagnosticWBS6-12mIncompleteResponses

IndeterminateResponsesTg刺激試驗動態(tài)風險分層甲狀腺激素的抑制目標RecurrentNodalMetastases:

Watchfulwaitingforsmallones變化75cm8cm10cm淋巴結清掃微小淋巴結轉移的管理密切隨訪AdvancedDisease:Expandedguidance

變化8

Themalignant/