Thyroid nodules and differentiated thyroid cancer treatment guidelines
Time:2009-11-05 10:02 Author:admin Hits:
Differentiated thyroid cancer long-term follow-up
Differentiated thyroid cancer patients on long-term follow-up objective is of possible relapse in patients with close monitoring in order to early detection of recurrent lesions, early detection of recurrent lesion contribute to the implementation of effective treatment for patients. Follow-up of patients with lesions in accordance with the contents of the persistence or the size of the risk of recurrence varies. United States Joint Committee on Cancer (AJCC) / International Union Against Cancer (UICC) TNM staging despite the risk of death in patients with a predictable, but can not predict the risk of tumor recurrence. To assess prognosis and determine treatment options, we must follow the degree of risk of recurrence patients were divided into three levels:
Low-risk patients: In the initial surgical treatment and eliminate residual disease after no local or distant metastases, all visible tumors have been removed, tumors did not invade local tissue and no high-performance or violation of pathological vascular invasion. If you are using 131I, then the initial post-operative radioactive iodine whole body scan (RxWBS) when no 131I uptake outside the thyroid bed.
In critically ill patients: In the initial operation, visible thyroid tumor invaded adjacent soft tissue, or tumors invasive or invasive vascular pathological features.
High-risk patients: In the initial operation, visible tumors invade surrounding tissue, tumor resection is incomplete, there is distant metastasis, or residual tumor in the thyroid removed after 131I scan lines can be seen outside the thyroid bed iodine intake.
In an interview with a cut or near total thyroidectomy in patients with wide resection, while those who possess all of the following conditions, namely, disease-free status: there is no clinical evidence of tumor presence that there was no evidence of tumor imaging (whole body scan after the operation, the newly diagnostic scan and neck ultrasound examination, there was no iodine uptake outside the thyroid bed), in the absence of interfering antibodies circumstances, the TSH suppression and stimulation during the period and were unable to detect thyroglobulin (Tg) (Figure 1) .
Serum Tg level is a monitoring of residual or metastatic lesions of the important ways, their thyroid cancer has a high degree of sensitivity and specificity, especially in the line cut total thyroidectomy and removal of residual disease after surgery. Disable thyroid hormone or recombinant human thyroid stimulating hormone (rhTSH) for stimulation, the highest detection sensitivity. In the TSH secretion by thyroid hormone suppression during the detection of Tg can not be detected a small amount of residual tumor.
When there is no treatment or only a small amount of residual normal thyroid tissue, the diagnostic RxWBS is the most useful follow-up methods. In the radioactive iodine treatment, RxWBS sensitivity decreased, so there is no clinical residual tumor foci, can not be detected in Tg during thyroid hormone suppression and negative neck ultrasound in patients with low-risk no-line RxWBS. Neck ultrasound examination is to test in patients with differentiated thyroid cancer neck metastasis of highly sensitive methods. Sometimes, even in the TSH stimulation have not detected when the serum Tg and neck ultrasound already detected metastasis.
At present the efficacy of thyroid hormone suppression therapy remains controversial. Studies have shown that thyroid hormone suppression therapy can reduce the long-term follow-up period in patients with thyroid cancer, a large incidence of clinical adverse events, but with L-thyroxine (LT4) the optimal level of thyroid suppression is unknown. With TSH higher levels (≥ 1 mU / L) when compared with sustained suppression TSH (≤ 0.05 mU / L) allows patients with relapse-free survival prolonged. In multivariate analysis, TSH suppression level is an independent predictor of tumor recurrence. The other a large-scale study shows that disease stage, patient age and 131I treatment of the disease were independent predictors of prognosis, while the TSH inhibition is not.
If the tumor metastases were detected during follow-up, 131I treatment is usually futile. Of invasive upper respiratory tract and upper digestive tract cancer, we recommend use surgery plus adjuvant therapy [131I and (or) in vitro exposure to radiation therapy (EBRT)]. Patient's prognosis is determined by, whether complete resection of tumor lesions and to retain the relevant physiological function in patients, and whether it was superficial invasion from the tracheal or esophageal cancer on the peel. When the tumor invaded the trachea of the deep tissue (such as direct invasion lumen), the required resection of the trachea, or pharynx esophagectomy. Patients that can not be cured should be held in less invasive treatment for such patients with tracheal stent or a tracheotomy to improve their quality of life. To have symptoms of asphyxia or hemoptysis patients can tolerate radical surgery or laser treatment of pre-treatment line.
Although 131I therapy for many patients with significant efficacy, but has not yet determine the optimal therapeutic dose. 131I treatment methods are three kinds: ① empirical fixed-dose treatment; ② through blood and body of the radiation tolerance dose and specific volume of tumor to determine the maximum tolerated dose of radiation dose; ③ to have distant metastasis, or other special circumstances ( such as kidney failure), or really need rhTSH stimulation in patients with dose titration should be used. Are no studies comparing the prognosis after the use of these methods. In the treatment of thyroid cancer in the process of radioactive iodine more widely used, doctors need to better understand the long-term risk of the use of radioactive iodine, such as the impact of the therapy on the salivary glands, thyroid cancer and its impact on men suffering from incurable and female reproductive system to produce long-term effects, as well as after treatment of secondary parotid tumors, gastrointestinal tumors, bladder cancer and colon cancer and other diseases.
The use of rhTSH is not only not inhibit metastasis, but may accelerate the growth of tumor metastases. Without prejudice to the case of iodine uptake, lithium can inhibit the release of thyroid iodine, therefore, can contribute to 131I in normal thyroid tissue and residual tumor cells. Studies have found that lithium will gather tumor metastasis 131I radiation dose increased by an average 2-fold, while the original release of iodine in these tumors faster.
If the case without the stimulus detected Tg, or in the case of being stimulated Tg> 2 ng / ml, should line the neck and chest imaging tests such as ultrasound and chest, neck, thin (5 ~ 7 mm) spiral CT, to check for cancer metastasis. Although the intravenous injection of iodine will help to distinguish tumor metastases, but if the plan check within a few months after the implementation of the radioactive iodine treatment, they should avoid using iodine to enhance scanning. If the scan results were negative, then surgical treatment may cure disease, but patients should also be considered OK empirical radioactive iodine therapy (100 ~ 200 mCi).
Iodine resistance in advanced differentiated thyroid cancer patients with chemotherapy is rare. Amount of doxorubicin (every 3 weeks for 60 ~ 75 mg/m2) for more than 40% of the patients (mostly partially effective or stable disease), but the duration of its role uncertain.
Prospect
This guide describes the surgery and radioactive iodine therapy can cure the majority of patients with differentiated thyroid cancer, but a small number of tumors in patients with rapid growth, widespread metastasis, and even life-threatening for these patients can be taken to trial treatment. Current of thyroid cancer molecular and cytological deepening understanding of the pathogenesis of a variety of targeted therapies have entered clinical evaluation stage, these treatments include: inhibiting cancer genes regulating growth or apoptosis, inhibit angiogenesis, immune regulation and gene therapy and so on.
Differentiated thyroid cancer patients on long-term follow-up objective is of possible relapse in patients with close monitoring in order to early detection of recurrent lesions, early detection of recurrent lesion contribute to the implementation of effective treatment for patients. Follow-up of patients with lesions in accordance with the contents of the persistence or the size of the risk of recurrence varies. United States Joint Committee on Cancer (AJCC) / International Union Against Cancer (UICC) TNM staging despite the risk of death in patients with a predictable, but can not predict the risk of tumor recurrence. To assess prognosis and determine treatment options, we must follow the degree of risk of recurrence patients were divided into three levels:
Low-risk patients: In the initial surgical treatment and eliminate residual disease after no local or distant metastases, all visible tumors have been removed, tumors did not invade local tissue and no high-performance or violation of pathological vascular invasion. If you are using 131I, then the initial post-operative radioactive iodine whole body scan (RxWBS) when no 131I uptake outside the thyroid bed.
In critically ill patients: In the initial operation, visible thyroid tumor invaded adjacent soft tissue, or tumors invasive or invasive vascular pathological features.
High-risk patients: In the initial operation, visible tumors invade surrounding tissue, tumor resection is incomplete, there is distant metastasis, or residual tumor in the thyroid removed after 131I scan lines can be seen outside the thyroid bed iodine intake.
In an interview with a cut or near total thyroidectomy in patients with wide resection, while those who possess all of the following conditions, namely, disease-free status: there is no clinical evidence of tumor presence that there was no evidence of tumor imaging (whole body scan after the operation, the newly diagnostic scan and neck ultrasound examination, there was no iodine uptake outside the thyroid bed), in the absence of interfering antibodies circumstances, the TSH suppression and stimulation during the period and were unable to detect thyroglobulin (Tg) (Figure 1) .
Serum Tg level is a monitoring of residual or metastatic lesions of the important ways, their thyroid cancer has a high degree of sensitivity and specificity, especially in the line cut total thyroidectomy and removal of residual disease after surgery. Disable thyroid hormone or recombinant human thyroid stimulating hormone (rhTSH) for stimulation, the highest detection sensitivity. In the TSH secretion by thyroid hormone suppression during the detection of Tg can not be detected a small amount of residual tumor.
When there is no treatment or only a small amount of residual normal thyroid tissue, the diagnostic RxWBS is the most useful follow-up methods. In the radioactive iodine treatment, RxWBS sensitivity decreased, so there is no clinical residual tumor foci, can not be detected in Tg during thyroid hormone suppression and negative neck ultrasound in patients with low-risk no-line RxWBS. Neck ultrasound examination is to test in patients with differentiated thyroid cancer neck metastasis of highly sensitive methods. Sometimes, even in the TSH stimulation have not detected when the serum Tg and neck ultrasound already detected metastasis.
At present the efficacy of thyroid hormone suppression therapy remains controversial. Studies have shown that thyroid hormone suppression therapy can reduce the long-term follow-up period in patients with thyroid cancer, a large incidence of clinical adverse events, but with L-thyroxine (LT4) the optimal level of thyroid suppression is unknown. With TSH higher levels (≥ 1 mU / L) when compared with sustained suppression TSH (≤ 0.05 mU / L) allows patients with relapse-free survival prolonged. In multivariate analysis, TSH suppression level is an independent predictor of tumor recurrence. The other a large-scale study shows that disease stage, patient age and 131I treatment of the disease were independent predictors of prognosis, while the TSH inhibition is not.
If the tumor metastases were detected during follow-up, 131I treatment is usually futile. Of invasive upper respiratory tract and upper digestive tract cancer, we recommend use surgery plus adjuvant therapy [131I and (or) in vitro exposure to radiation therapy (EBRT)]. Patient's prognosis is determined by, whether complete resection of tumor lesions and to retain the relevant physiological function in patients, and whether it was superficial invasion from the tracheal or esophageal cancer on the peel. When the tumor invaded the trachea of the deep tissue (such as direct invasion lumen), the required resection of the trachea, or pharynx esophagectomy. Patients that can not be cured should be held in less invasive treatment for such patients with tracheal stent or a tracheotomy to improve their quality of life. To have symptoms of asphyxia or hemoptysis patients can tolerate radical surgery or laser treatment of pre-treatment line.
Although 131I therapy for many patients with significant efficacy, but has not yet determine the optimal therapeutic dose. 131I treatment methods are three kinds: ① empirical fixed-dose treatment; ② through blood and body of the radiation tolerance dose and specific volume of tumor to determine the maximum tolerated dose of radiation dose; ③ to have distant metastasis, or other special circumstances ( such as kidney failure), or really need rhTSH stimulation in patients with dose titration should be used. Are no studies comparing the prognosis after the use of these methods. In the treatment of thyroid cancer in the process of radioactive iodine more widely used, doctors need to better understand the long-term risk of the use of radioactive iodine, such as the impact of the therapy on the salivary glands, thyroid cancer and its impact on men suffering from incurable and female reproductive system to produce long-term effects, as well as after treatment of secondary parotid tumors, gastrointestinal tumors, bladder cancer and colon cancer and other diseases.
The use of rhTSH is not only not inhibit metastasis, but may accelerate the growth of tumor metastases. Without prejudice to the case of iodine uptake, lithium can inhibit the release of thyroid iodine, therefore, can contribute to 131I in normal thyroid tissue and residual tumor cells. Studies have found that lithium will gather tumor metastasis 131I radiation dose increased by an average 2-fold, while the original release of iodine in these tumors faster.
If the case without the stimulus detected Tg, or in the case of being stimulated Tg> 2 ng / ml, should line the neck and chest imaging tests such as ultrasound and chest, neck, thin (5 ~ 7 mm) spiral CT, to check for cancer metastasis. Although the intravenous injection of iodine will help to distinguish tumor metastases, but if the plan check within a few months after the implementation of the radioactive iodine treatment, they should avoid using iodine to enhance scanning. If the scan results were negative, then surgical treatment may cure disease, but patients should also be considered OK empirical radioactive iodine therapy (100 ~ 200 mCi).
Iodine resistance in advanced differentiated thyroid cancer patients with chemotherapy is rare. Amount of doxorubicin (every 3 weeks for 60 ~ 75 mg/m2) for more than 40% of the patients (mostly partially effective or stable disease), but the duration of its role uncertain.
Prospect
This guide describes the surgery and radioactive iodine therapy can cure the majority of patients with differentiated thyroid cancer, but a small number of tumors in patients with rapid growth, widespread metastasis, and even life-threatening for these patients can be taken to trial treatment. Current of thyroid cancer molecular and cytological deepening understanding of the pathogenesis of a variety of targeted therapies have entered clinical evaluation stage, these treatments include: inhibiting cancer genes regulating growth or apoptosis, inhibit angiogenesis, immune regulation and gene therapy and so on.
