数字化医院建设课件

Thyroid diseaseLibo Li MDLibo Li MDDepartment of General SurgeryDepartment of General SurgerySir Run Run Shaw HospitalSir Run Run Shaw HospitalSchool of medicine,Zhejiang UniversitySchool of medicine,Zhejiang UniversityThyroid diseaseLibo Li MDAnatomy of ThyroidAnatomy of ThyroidAnatomy of ThyroidAnatomy of ThyroidThyroid diseasen nNontoxic goiterNontoxic goitern nHyperthyroidismHyperthyroidismn nThyroid CancerThyroid Cancern nThyroiditisThyroiditisThyroid diseaseNontoxic goiterNontoxic Goitern nGoiterGoiter from the French from the French(goitre)(goitre)and Latin and Latin(guttur)(guttur),both meaning throat,both meaning throatn nDefined as an enlargement of the thyroid gland Defined as an enlargement of the thyroid gland n nEndemic when it involves more than 10%of the Endemic when it involves more than 10%of the populationpopulationn nThe majority,secondary to iodine deficiencyThe majority,secondary to iodine deficiencyn nEspecially found in high mountain regions Especially found in high mountain regions Nontoxic GoiterGoiter from the Nontoxic Goiter Nontoxic GoiterClinical thinkingn nWhether the patient has local symptoms Whether the patient has local symptoms n nWhether the goiter is toxic or nontoxicWhether the goiter is toxic or nontoxicn nWhether any of the nodules harbor a cancerWhether any of the nodules harbor a cancern nThe number and bilaterality of the nodules The number and bilaterality of the nodules n nTSH level,differential diagnosis of TSH level,differential diagnosis of hypothyroidism or hyperthyroidismhypothyroidism or hyperthyroidismn nAppropriate treatment options for each particular Appropriate treatment options for each particular patientpatient Nontoxic Goiter Nontoxic Goiter Taking historyn nAsymptomatic neck massAsymptomatic neck mass A cough,shortness of breath,stridor,or hoarseness A cough,shortness of breath,stridor,or hoarseness Choking or aspiration,dysphagia,or pain Choking or aspiration,dysphagia,or pain Symptoms of hyperthyroidism Symptoms of hyperthyroidism Whether the patient has cosmetic concernsWhether the patient has cosmetic concernsn nFrom iodine deficiency regionFrom iodine deficiency region Nontoxic Goiter Nontoxic GoiterPhysical examinationn nWhether the goiter is confined to the neck Whether the goiter is confined to the neck n nWhether it has a substernal componentWhether it has a substernal componentn nWhether tracheal deviation is present Whether tracheal deviation is present n nThe size and consistency of the goiter The size and consistency of the goiter n nThe mobility of the vocal cords by either indirect The mobility of the vocal cords by either indirect or direct laryngoscopyor direct laryngoscopy Nontoxic Goitern nUltrasound Ultrasound How many nodules?How many nodules?Bilateral?Bilateral?Ultrasound characteristicsUltrasound characteristics Nontoxic Goitern nCT scan CT scan Neck and chest,especially substernal thyroidNeck and chest,especially substernal thyroid Rare intrathoracic or aberrant thyroidRare intrathoracic or aberrant thyroidNontoxic GoiterCT scan Nontoxic Goitern nFine needle aspiration(FNA)Fine needle aspiration(FNA)Suspicious malignent goiterSuspicious malignent goiterNontoxic GoiterFine needle asp Nontoxic Goiter Nontoxic GoiterTreatmentn nIodine diet replacement(endemic goitor)Iodine diet replacement(endemic goitor)n nSurgical resectionSurgical resection SymptomsSymptomsn nLocal compressionLocal compressionn nSecondary hyperthyroidisimSecondary hyperthyroidisim Any suspicious or malignant lesionAny suspicious or malignant lesion Cosmetic reasonsCosmetic reasonsn nRadioiodine therapy,high risk of ptsRadioiodine therapy,high risk of ptsn nThyroid hormone suppression(not for sporadic Thyroid hormone suppression(not for sporadic goiter)goiter)Sporadic Nontoxic Goitern nAsymptomaticAsymptomaticn nEuthyroidEuthyroidn nMost bilaterallyMost bilaterallyn nNo efficiency of thyroid hormone replacementNo efficiency of thyroid hormone replacementn nHigh recurrence postoperatively 30%40%High recurrence postoperatively 30%40%Sporadic Nontoxic GoiterAsympt Nontoxic Goiter Nontoxic GoiterHistory of Thyroid Surgeryn nFirst thyroidectomy,in Paris in 1791 by Pierre-First thyroidectomy,in Paris in 1791 by Pierre-Joseph DesaultJoseph Desaultn nAntisepsis,hemostasis,and general anesthesia in Antisepsis,hemostasis,and general anesthesia in the 1840s the 1840s thyroid surgery became safe thyroid surgery became safen nTheodore Kocher,a Nobel Prize in 1909Theodore Kocher,a Nobel Prize in 1909 From Bern,SwitzerlandFrom Bern,Switzerland His pioneering efforts in thyroid surgeryHis pioneering efforts in thyroid surgery Primary HyperthyroidsimGraves Disease Primary HyperthyroidsimGraveClinical Statisticsn nGraves Disease is the most common cause of Graves Disease is the most common cause of hyperthyroidism(60-80%)of all caseshyperthyroidism(60-80%)of all casesn nFemales are affected more frequently than men Females are affected more frequently than men 10:1.510:1.5n nMonozygotic twins show 50%concordance ratesMonozygotic twins show 50%concordance ratesn nIncidence peaks from ages 20-40Incidence peaks from ages 20-40n nIncidence is similar in whites and Asians,but is Incidence is similar in whites and Asians,but is somewhat decreased for African Americanssomewhat decreased for African AmericansClinical StatisticsGraves DiseGraves Diseasen nAutoimmune systemic disorderAutoimmune systemic disordern nThyroid receptor antibody binding to and Thyroid receptor antibody binding to and stimulating the TSH receptorstimulating the TSH receptorn nExcessive synthesis and secretion of thyroid Excessive synthesis and secretion of thyroid hormonehormonen nUsually diffusely and symmetrically enlarged Usually diffusely and symmetrically enlarged and firmand firmGraves DiseaseAutoimmune systHyperthyroidismuptaken nA.NormalA.Normaln nB.Graves DzB.Graves Dzn nC.Toxic Multinodular C.Toxic Multinodular GoiterGoitern nD.Toxic AdenomaD.Toxic Adenoman nE.ThyroiditisE.ThyroiditisHyperthyroidismuptakeA.Norma Hyperthyroidism HyperthyroidismSymptomsn nHeat intolerance,sweating,palpitations,fatigueHeat intolerance,sweating,palpitations,fatiguen nWeight loss,diaphoresis,increased stool Weight loss,diaphoresis,increased stool frequencyfrequencyn nMuscle weakness,anxiety,insomnia Muscle weakness,anxiety,insomnia n nNervousness or restlessness;irritability,Nervousness or restlessness;irritability,emotional lability emotional lability n nIn women,irregular mensesIn women,irregular menses Hyperthyroidism HyperthyroidismClinical findingsn nTremor,tachycardia(A.fib),Tremor,tachycardia(A.fib),n nGoiter,lid lag,proptosis,periorbital edema,Goiter,lid lag,proptosis,periorbital edema,exophthalmos;chemosis;hyperreflexiaexophthalmos;chemosis;hyperreflexian n Warm,moist skin;dermopathy;and pretibial Warm,moist skin;dermopathy;and pretibial edema,edema,osteoporosisosteoporosis Exopthalamos in Graves Exopthalamos in Graves DiseaseDiseaseLid Lag in Graves Lid Lag in Graves DiseaseDiseaseExopthalamos in Graves DiseaseHyperthyroidismtreatmentn nBeta-blockers:control sxsBeta-blockers:control sxs Propranolol decr peripheral T4-T3 conversionPropranolol decr peripheral T4-T3 conversionn nGraves DzGraves Dz PTU(safe in pregnancy)or methimazolePTU(safe in pregnancy)or methimazolen nRare side effect:agranulocytosisRare side effect:agranulocytosis Radioactive iodineRadioactive iodinen n75%of treated pts become hypothyroid75%of treated pts become hypothyroid SurgerySurgeryn nToxic Adenoma or TMNGToxic Adenoma or TMNG RAI or surgeryRAI or surgeryHyperthyroidismtreatmentBeta-Hyperthroidism HyperthroidismSurgeryn nSurgical approachSurgical approach Bilateral near-total or total thyroidectomyBilateral near-total or total thyroidectomyn nIndication of surgery(In China)Indication of surgery(In China)Compressive symptomsCompressive symptoms Secondary or adenomaSecondary or adenoma Recurrence of medicine or iodine-131Recurrence of medicine or iodine-131 No efficiency of medicineNo efficiency of medicine Second trimester of pregnancySecond trimester of pregnancy Surgery for hyperthyroidism Surgery for hyperthyroidismPreoperative preparationn nAbsolutely requiredAbsolutely requiredn nantithyroid drugs,for 3 to 6 weeks antithyroid drugs,for 3 to 6 weeks with a goal of nearly normalizing the T3 and T4 with a goal of nearly normalizing the T3 and T4 n nPropranolol or atenolol rapidly controls the Propranolol or atenolol rapidly controls the adrenergic side effects of excess T4 and T3 adrenergic side effects of excess T4 and T3 tachycardia,tremor,and diaphoresistachycardia,tremor,and diaphoresisn nLugols solution rapidly but temporarily restores Lugols solution rapidly but temporarily restores normal thyroid function and reduces thyroid normal thyroid function and reduces thyroid gland vascularitygland vascularity Surgical complicationsn nBleedingBleedingn nRecurrent Laryngeal Nerve DamageRecurrent Laryngeal Nerve Damagen nHypoparathyroidism and HypocalcemiaHypoparathyroidism and Hypocalcemian nSuperior laryngeal nerve damageSuperior laryngeal nerve damagen nThyroid stormThyroid storm Surgical complicationsBleedinThyroid cancerThyroid cancer Thyroid cancer Thyroid cancerIntroductionn nThe most common,95%of all endocrine cancersThe most common,95%of all endocrine cancersn nIncreasing faster than any other cancer Increasing faster than any other cancer n nMore than 90%,well differentiatedMore than 90%,well differentiatedn nGood long-term prognosisGood long-term prognosis Thyroid cancer Thyroid cancerClinical Presentationn nMost,clinically with a palpable noduleMost,clinically with a palpable nodulen nUsually asymptomaticUsually asymptomaticn nRare cases,with hoarseness,pain,dysphagia,Rare cases,with hoarseness,pain,dysphagia,dyspnea,coughing,or choking spellsdyspnea,coughing,or choking spellsn nPainPain，with the suspicion for with the suspicion for Medullary thyroid carcinoma Medullary thyroid carcinoma Anaplastic carcinomaAnaplastic carcinoma LymphomaLymphoma Pertinent historical factors predicting malignancyn nA history of head and neck irradiationA history of head and neck irradiationn nTotal body irradiation for bone marrow Total body irradiation for bone marrow transplantation transplantation n nExposure to fallout from the explosion of the Exposure to fallout from the explosion of the Chernobyl nuclear power plant in 1986,Chernobyl nuclear power plant in 1986,especially in children;especially in children;n nA family history of thyroid cancer;and rapid A family history of thyroid cancer;and rapid growth or hoarseness.growth or hoarseness.n nChildren,men,and adults older than 60 years Children,men,and adults older than 60 years have an increased risk of malignancyhave an increased risk of malignancyPertinent historical factors pIncrease the risk of thyroid cancern nPersonal and family history of other endocrine Personal and family history of other endocrine disorders,disorders,specifically hyperparathyroidism,pituitary adenomas,specifically hyperparathyroidism,pituitary adenomas,pancreatic islet cell tumors,adrenal tumors,and pancreatic islet cell tumors,adrenal tumors,and breast cancerbreast cancer.n nA family history of papillary or medullary A family history of papillary or medullary carcinoma(MEN syndromes),familial carcinoma(MEN syndromes),familial polyposis,Gardners syndrome,and Cowdens polyposis,Gardners syndrome,and Cowdens syndromesyndromeIncrease the risk of thyroid cPertinent physical findings Suggesting possible malignancy n nGritty texture”(Gritty texture”(颗粒样）颗粒样）of the thyroid nodule of the thyroid nodulen nCervical lymphadenopathyCervical lymphadenopathyn nVocal cord paralysisVocal cord paralysisn nFixation of the nodule to surrounding tissueFixation of the nodule to surrounding tissuePertinent physical findings Su Thyroid cancer Thyroid cancerDiagnosisn nUltrasound Ultrasound Feature of malignancy Feature of malignancyn nIrregular marginsIrregular marginsn nIntranodular vascular patternIntranodular vascular patternn nMicrocalcificationsMicrocalcificationsn nFine needle aspiration(FNA)Fine needle aspiration(FNA)The most reliable and cost-efficient methodThe most reliable and cost-efficient method Thyroid cancer Thyroid cancer Diagnosisn nThyroid function tests Thyroid function tests n nSerum markersSerum markers Thyroglobulin(TG)for well-differentiated thyroid Thyroglobulin(TG)for well-differentiated thyroid cancercancer Calcitonin and CEA for medullary thyroid cancerCalcitonin and CEA for medullary thyroid cancern nAll pts with medullary thyroid cancerAll pts with medullary thyroid cancer RET proto-oncogene RET proto-oncogene pheochromocytoma and hyperparathyroidismpheochromocytoma and hyperparathyroidism Management of thyroid cancer Management of thyroid cancer The goals of therapy n nRemoval of primary tumor,disease that extends beyond Removal of primary tumor,disease that extends beyond the thyroid capsule,and involved cervical lymph nodesthe thyroid capsule,and involved cervical lymph nodesn nMinimization of treatment-and disease-related morbidityMinimization of treatment-and disease-related morbidityn n Accurate disease staging Accurate disease stagingn nFacilitation of postoperative treatment with radioiodine Facilitation of postoperative treatment with radioiodine when appropriatewhen appropriaten nAccurate long-term surveillanceAccurate long-term surveillancen nMinimization of the risk of recurrent local and metastatic Minimization of the risk of recurrent local and metastatic tumortumor Well-Differentiated Thyroid Carcinoma Well-Differentiated Thyroid CarcinomaPapillary Thyroid Carcinoman nThe most common endocrine malignancyThe most common endocrine malignancy，approximately 80%of new cases approximately 80%of new cases n nAssociated with the best prognosisAssociated with the best prognosisn nAt least twice as common in women as men At least twice as common in women as men n nA peak age of presentation of 38 to 45 yearsA peak age of presentation of 38 to 45 yearsn n90%of radiation-induced90%of radiation-induced，familial in 5%familial in 5%Papillary Thyroid CarcinomaPapillary Thyroid Carcinoma Well-Differentiated Thyroid Carcinoma Well-Differentiated Thyroid CarcinomaPrognosesn nThe risk of death The risk of death approximately 5%in the low-risk group approximately 5%in the low-risk group 40%in the high-risk group 40%in the high-risk group n nFortunately,most pts(70%)in the low-risk Fortunately,most pts(70%)in the low-risk groupgroup Other histological factors n nTo predict the behavior of thyroid cancer To predict the behavior of thyroid cancer Ploidy of the tumorPloidy of the tumor Adenylate cyclase response to thyroid stimulating Adenylate cyclase response to thyroid stimulating hormone(TSH)hormone(TSH)Radioiodine uptakeRadioiodine uptake A positive positron emission tomography scanA positive positron emission tomography scan Epidermal growth factor(EGF)receptor level and Epidermal growth factor(EGF)receptor level and various gene profilesvarious gene profilesOther histological factors To Papillary Thyroid Carcinoma Papillary Thyroid Carcinoma The extent of surgical resection n nControversialControversialn nAmerican recommondationAmerican recommondation Total or near total thyroidectomyTotal or near total thyroidectomy complication rate of less than 2%complication rate of less than 2%Selective nodal resection Selective nodal resection Postoperative treatment with iodine-131 Postoperative treatment with iodine-131 n nLow-risk pts less than 1 cmLow-risk pts less than 1 cm thyroid lobectomy and isthmectomy OKthyroid lobectomy and isthmectomy OK Reoperation Reoperation n nmultifocal,with nodal metastases,or with local invasionmultifocal,with nodal metastases,or with local invasion Benefits of total thyroidectomyn nPostoperative radioiodine scanning and ablative Postoperative radioiodine scanning and ablative therapy can be effectivetherapy can be effectiven nSerum thyroglobulin levels are rendered more Serum thyroglobulin levels are rendered more sensitive for detecting recurrent or persistent sensitive for detecting recurrent or persistent diseasediseasen n Intrathyroidal cancer that is present in more than Intrathyroidal cancer that is present in more than 50%of patients is removed50%of patients is removedn nThe small risk of a differentiated thyroid cancer The small risk of a differentiated thyroid cancer becoming an undifferentiated cancer is becoming an undifferentiated cancer is decreased.decreased.Benefits of total thyroidectom Papillary Thyroid Carcinoma Papillary Thyroid CarcinomaThe role of lymph node dissectionn nAlso controversialAlso controversialn nMicrometastasis to cervical lymph nodes is Micrometastasis to cervical lymph nodes is common(80%)common(80%)n nProphylactic cervical lymph node dissection is Prophylactic cervical lymph node dissection is not warranted not warranted n nFunctional neck dissection and central neck Functional neck dissection and central neck dissection should generally be performed dissection should generally be performed only in pts with clinical or sonographic evidence of only in pts with clinical or sonographic evidence of lymph node involvementlymph node involvement Follicular Thyroid Carcinoman nApproximately 10%of all thyroid malignanciesApproximately 10%of all thyroid malignanciesn nTypically older than PTCTypically older than PTCn nUsually in the sixth decade of lifeUsually in the sixth decade of lifen nThe female-to-male ratio is between 2:1 and 5:1The female-to-male ratio is between 2:1 and 5:1n nA slowly growing solitary thyroid noduleA slowly growing solitary thyroid nodulen nA tendency to spread hematogenouslyA tendency to spread hematogenously Rarely with symptoms of distant metastasis to the Rarely with symptoms of distant metastasis to the bone,lung,brain,and liver bone,lung,brain,and liver Follicular Thyroid CarcinomaApFollicular Thyroid Carcinoman nLess than 6%metastasize to the cervical lymph Less than 6%metastasize to the cervical lymph nodesnodesn nApproximately 25%of pts have extrathyroidal Approximately 25%of pts have extrathyroidal invasioninvasionn n10%to 33%have distant metastasis at the time 10%to 33%have distant metastasis at the time of initial diagnosisof initial diagnosisFollicular Thyroid CarcinomaLeThe prognosis of follicular cancer n nSlightly worse than that for papillary cancerSlightly worse than that for papillary cancern nOverall survival ranges from 43%to 95%at 10 Overall survival ranges from 43%to 95%at 10 yearsyearsn nLifelong surveillance is not necessaryLifelong surveillance is not necessaryThe prognosis of follicular caThe prognosis of follicular cancer n nThe important prognostic factors Presence of metastatic disease Presence of metastatic disease Older age(usually 40 years)Older age(usually 40 years)Degree of invasion(microcapsular vs.angioinvasion Degree of invasion(microcapsular vs.angioinvasion with or without capsular and widely invasive)with or without capsular and widely invasive)Degree of tumor differentiation Degree of tumor differentiationThe prognosis of follicular caFollicular Thyroid Carcinoman nDiagnosisDiagnosis The whole specimen must be evaluated for vascular The whole specimen must be evaluated for vascular and capsular invasion.and capsular invasion.Diagnosis of follicular cancer cannot be made on Diagnosis of follicular cancer cannot be made on FNABFNABFollicular Thyroid CarcinomaDiFollicular Thyroid Carcinoman nTreatmentTreatment The recommended initial operation is lobectomy and The recommended initial operation is lobectomy and isthmectomyisthmectomy Lymph node dissection is rarely warranted because Lymph node dissection is rarely warranted because nodal metastases are uncommonnodal metastases are uncommonFollicular Thyroid CarcinomaTrMedullary Thyroid Carcinoman n7%of thyroid cancers 7%of thyroid cancers n n15%of all thyroid cancerrelated deaths15%of all thyroid cancerrelated deathsn nApprox 75%sporadicApprox 75%sp