106 : ( [Differentiated Thyroid Cancer; DTC]) DTC-1-1 ( [Differentiated Thyroid Cancer; DTC]) DTC (PET)X (CT) (MRI) (PET) (CT) (MRI) 1

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5 years ago
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2 106 : ( [Differentiated Thyroid Cancer; DTC]) DTC-1-1 ( [Differentiated Thyroid Cancer; DTC]) DTC (PET)X (CT) (MRI) (PET) (CT) (MRI) 癌症診療指引384 ( [Differentiated Thyroid Cancer; DTC]) DTC / (DTC-5DTC-6)

3 ( [Differentiated Thyroid Cancer; DTC]) DTC CT / MRI ( ) CT / MRI 2. ( N1) (small volume N1a ) 3. 2A. >45 >55 4. / minimal extrathyroid extension (T3), 5. DTC-6 DTC small volume N1a meta<5 involved nodes with no meta > 2mm in largest dimension 4. Completion thyroidectomy is not requried for small volume N1a meta 癌症診療指引385

4 ( [Differentiated Thyroid Cancer; DTC]) DTC-4-4 ( [Differentiated Thyroid Cancer; DTC]) DTC ( VI) ; cn1a ( VI or VII) ; cn1a 2. (cn0) 3. ( II-V) ( ); cn1b ( I-V or retropharyngeal LN) ( )cn1b / minimalextrathyroid extension (T3) / 癌症診療指引386

5 / minimal extrathyroid extension (T3) ( [Differentiated Thyroid Cancer; DTC]) DTC-6-6 (macroscopic multifocal)gross ETE (N1a ) 1. Tg>5-10 ng/ml, TgAb, MRI, CT, PET ( 131 ) 2. (+), MRI, CT, PET ( 131 ) 癌症診療指引387 CONSIDERATION FOR INITIAL POSTOPERATIVE RAI THERAPY AFTER TOTAL THYROIDECTOMY

105 106 ( [Differentiated Thyroid Cancer; DTC]) DTC-7 ( [Differentiated Thyroid Cancer; DTC])

Intrathyroidal, encapsulated follicular variant of papillary thyroid cancer 癌症診療指引388 (

6 ( [Differentiated Thyroid Cancer; DTC]) DTC-7 ( [Differentiated Thyroid Cancer; DTC]) DTC-8 ( [Differentiated Thyroid Cancer; DTC]) - 5 Tg < 1, Tg < 2 Tg < 0.2, Tg < 1 2. Intrathyroidal, encapsulated follicular variant of papillary thyroid cancer 癌症診療指引388 ( [Differentiated Thyroid Cancer; DTC]) Microscopic invasion of tumor into the perithyroidal soft tissues (T3)

7 1 ( [Differentiated Thyroid Cancer; DTC]) -1 1 *TSH ATA( ) 2016NCCN ( 1) ( ) ( 2) ( 3) TSH (PET)X (CT) (MRI) : 99m Tc 131 I TSH ( 3) 3. DTC-2-1 DTC-2-2 癌症診療指引389

8 2-1 ( [Differentiated Thyroid Cancer; DTC]) ; Bethesda Papillary, medullary, anaplastic Follicular or Hurthle cell neoplasm 0-3% : : (DTC-5) 1. : > 50% >20% in 2-3 ( >2mm) 2. >50% (DTC-5) 癌症診療指引 > 4cm

9 2-2 ( [Differentiated Thyroid Cancer; DTC]) ; Bethesda ( ) / (atypia/undetermined) 6-12 / ( ) 12 / (DTC-3 DTC5) 癌症診療指引391

10 3 ( [Differentiated Thyroid Cancer; DTC]) -3 1 X CT / MRI ( ) A. > 4cm B. ( T4) C. (small volume N1a ) D. E. F. G. : DTC : A. > 45 ; B. ; C. 1cm < 4cm B CDEF 1cm( 4; 4 ) BC DE F DTC-6 / 癌症診療指引392 small volume N1a meta<5 involved nodes with no meta > 2mm in largest dimension Completion thyroidectomy is not requried for small volume N1a meta

11 4 ( [Differentiated Thyroid Cancer; DTC]) -4 2( ) ( VI) ; cn1a + (cn0) ( I-V or retropharyngeal LN) ( )cn1b : T3 T4 + + 癌症診療指引393

12 5 ( [Differentiated Thyroid Cancer; DTC]) DTC-3 DTC-4 / DTC-6 癌症診療指引394 / +

13 6 ( [Differentiated Thyroid Cancer; DTC]) > 4cm 2. (macroscopic multifocal)gross ETE (N1a ) 3. / A. DTC B. DTC-7 ( 5) DTC-4 癌症診療指引395

14 CONSIDERATION FOR INITIAL POSTOPERATIVE RAI THERAPY AFTER TOTAL THYROIDECTOMY Clinicopathological risk factors RAI not typically recommended (if all present): Classic papillary thyroid carcinoma (PTC) Primary tumor <2 cm Intrathyroidal Unifocal or multifocal No detectable anti-tg antibodies Postoperative unstimulated Tg <1 ng/ml k RAI selectively recommended (if any present): Primary tumor 2 4 cm High-risk histologyl Lymphatic invasion Cervical lymph node metastases Macroscopic multifocality (one focus >1 cm Postoperative unstimulated Tg <5 10 ng/ml k RAI typically recommended (if any present): Gross extrathyroidal extension Primary tumor >4 cm Postoperative unstimulated Tg >5 10 ng/ml Know or suspected distant mets at presentation RAI ablation is not required in classical PTC T1b/T2 (1 4 cm) cn0 disease or small-volume N1a disease RAI ablation is recommended when combination of individual clinical factors (such as the size of the tumor, histology, degree of LVI, LN meta, postoperative thyroglobulin, age of diagnosis and microscopic positive margins) predicts a significant risk of recurrence, distant metastases, or disease-specific mortality. RAI is indicated RAI not typically indicated RAI being considered *Tg values obtained 6 12 weeks after total thyroidectomy. *High risk histology:poorly differentiated,tall cell columnar cell,and hobnail variant * Tg >5 10 ng/ml :Additional cross-sectional image (CT or MRI of the neck with contrast and chest CT with contrast) should be considered to rule out the presence of significant normal thyroid remnant or gross residual disease and to detect clinically significant distant metastases 癌症診療指引396

7 ( [Differentiated Thyroid Cancer; DTC]) -7 / -131 (T) AJCC ( 5) T 2cm T1, N0/Nx, M0/Mx 2 < T 4cm T2, N0/Nx, M0/Mx T > 4cm T3, N0/Nx, M0/Mx -131 / <1cm (1-2cm -131 ) / / 30 m Ci/100-150 mci / /

15 7 ( [Differentiated Thyroid Cancer; DTC]) -7 / -131 (T) AJCC ( 5) T 2cm T1, N0/Nx, M0/Mx 2 < T 4cm T2, N0/Nx, M0/Mx T > 4cm T3, N0/Nx, M0/Mx -131 / <1cm (1-2cm -131 ) / / 30 m Ci/ mci / / mci/30 mci / / 4-6 / Tc99mO4-131 / (pt1) (mpt1) Tg <1 ng/ml anti-tg not routinerai maybe considered for Tg>5-10 ng/ml,macroscopic multifocality (one focus >1cm) (>55 ) T1-3 T3, N0/Nx, M0/Mx / / Gross Extension to strap muscles T1-3 T1-3,N1a( 3), M0/Mx / / ( 3) or ENE (+) 5 0.2cm >55 T1-3 T1-3, N1b, M0/Mx / / retropharygeal T4, any N, any M / 150 mci M1, any T, any N / 150 mci 1. I-131 CT 2. Tg > 5-10 ng/ml ( 1). Tg > 10 ng/ml, ( PET), mci I-131 ( 2). <5 <0.2cm ( 3) cm 癌症診療指引397

16 8 ( [Differentiated Thyroid Cancer; DTC]) -8 / / : I-131 :(1) (2) (3) ( 5) / / / -131 /, -131 / / CT,MR / FDG PET ( 3), -131 ( 6) Tg=thyroglobulin (ng/ml) : (L-thyroxin) / ( TSH IU/L ; IU/L ) : *( ) Tg +TgAb- TSH ( 7); ; ATA 2015( 6) : *( ) TSH ( 7); Tg < 2+ TgAb- ; ATA 2015( 6) : *( ) TSH ( 7); Tg < 1, Tg < 2 ; + TgAb-, ( 6) : *( ), Tg < 0.1, Tg < 1 + TgAb-, -131 ( 6) TSH < 0.1(undetectable) or ( ) 4-6 rhtsh I-131 I-131 I-131 avid I-131 TSH ( 7) ; /CT/MRI/PET TSH < 0.1(undetectable) ( 7); 4-6 rhtsh I-131 I-131 I-131 avid I-131 : * : / 1. The risk and benefit of TSH suppression must be balanced for each individual. Patients whose serum TSH levels are chronically suppressed: daily intake of calcium (1200 mg/d) and Vit. D. 2. (Thyroglobulin, Tg) 131 癌症診療指引398

17 1-10 ng/ml -131 >10 ng/ml, ( PET) TSH mci ( -131 ) / -131 ( -131 ), / -131 EBRT, IMRT,RFA 癌症診療指引 ,, -131, EBRT IMRTRFA

18 (Kinase inhibitor; KI) (NCCN 2016) 1. : (1) ( ) (2) 2. : (1) Kinase inhibitor (2) Kinase inhibitor (3) 3. : 4. ( ) 5. 癌症診療指引400

19 (EBRT,IMRT) 癌症診療指引401

20 1 ( [Differentiated Thyroid Cancer; DTC]) - 1 (2015ATA) Stratification of Sonographic Findings According to Probability of malignancy High suspicion [malignancy risk > 70-90%]: Solid hypoechoic nodule or a solid hypoechoic component in a partially cystic nodule with one or more of the following features: irregular margins (specifically defined as infiltrative, microlobulated, or spiculated), microcalcifications, taller than wide shape, disrupted rim calcifications with small extrusive hypoechoic soft tissue component, or evidence of extrathyroidal extension. A nodule demonstrating this ultrasound pattern is highly likely to be a papillary thyroid cancer. Intermediate suspicion [malignancy risk 10-20%]: Hypoechoic solid nodule with a smooth regular margin, without microcalcifications, extrathyroidal extension, or taller than wide shape Low suspicion [malignancy risk 5-10%]: Isoechoic or hyperechoic solid nodule, or partially cystic nodule with eccentric uniformly solid areas without microcalcifications, irregular margin or extrathyroidal extension, or taller than wide hape. Very low suspicion [malignancy risk < 3%]: Spongiform or partially cystic nodules without any of the sonographic features described in the low, intermediate or high suspicion patterns ; A spongiform appearance is defined as the aggregation of multiple microcystic components in more than 50% of the volume of the nodule Benign [malignancy risk < 1%]: Purely cystic nodules 癌症診療指引402

21 1 ( [Differentiated Thyroid Cancer; DTC]) - 1 ATA Nodule Sonographic Pattern Risk of Malignancy 癌症診療指引403

22 2 ( [Differentiated Thyroid Cancer; DTC]) - Sonographic features and threshold for FNA (NCCN guideline) Nodule Solid nodule with suspicious features without suspicious features Mixed cystic-solid nodule with suspicious features without suspicious features 1.0 cm 1.5 cm Threshold for fine needle aspiration (FNA) (Cyst: correlate ultrasound and re-aspirate suspicious area) Solid component 1.0 cm Solid component 1.5 cm Sponge form nodule Simple cyst Suspicious cervical lymph node 2.0 cm Not required FNA node + FNA associated suspicious thyroid nodule(s) of any size Suspicious feature: hypoechoic, microcalcification, infiltrative margins, tall than wide in transverse plane. Low suspicious feature: isoechoic or hyperechoic solid, mixed solid-cystic, spongiform nodules. Aggregation of multiple microcystic components in more than 50% volume Tg washout may be helpful in the diagnosis of lymph node metastasis 癌症診療指引404 : <1cm : (may) (6-12 ) (40 60 )

23 3 ( [Differentiated Thyroid Cancer; DTC]) - 3 Ultrasound features of lymph nodes indicating high specificity (43-100%) of malignant involvement Lymph node features Microcalcifications Cystic aspect Peripheral vascularity Hyperechogenicity Round shape 癌症診療指引405

24 4 ( [Differentiated Thyroid Cancer; DTC]) - 4 An active surveillance management can be considered as an alternative to immediate surgery in: Patients with very low risk tumors (e.g. papillary microcarcinomas or follicular variant of papillary carcinoma without clinically evident metastases or local invasion, with no convincing cytological or molecular (if performed) evidence of aggressive disease, not at a location adjacent to the trachea or on the dorsal surface of the lobe close to the recurrent laryngeal nerve, and with no signs of progression during follow-up 癌症診療指引406

25 5 ( [Differentiated Thyroid Cancer; DTC]) - 5 Initial Risk (of persistence/recurrence) Stratification System 1 (Modified from 2015 ATA Guidelines) Low Risk 1. Papillary Thyroid Cancer with all of the following (1)No local or distant metastases; (2)All macroscopic tumor has been resected (3)No tumor invasion of loco-regional tissues or structures (4)The tumor does not have aggressive histology (e.g., tall cell, hobnail variant, columnar cell carcinoma, diffuse sclerosing variant) (5)If I-131 is given, there are no RAI avid metastatic foci outside the thyroid bed on the first post-treatment whole-body RAI scan (6)No vascular invasion (7)Clinical N0 or 5 pathologic N1 micrometastases (< 0.2 cm in largest dimension)* 2. Intrathyroidal, well differentiated follicular thyroid cancer with capsular invasion and no or minimal (< 4 foci) vascular invasion* 3. Intrathyroidal, papillary microcarcinoma, unifocal or multifocal, including V600E BRAF mutated (if known)*, without other worrisome features (e.g., aggressive histology, vascular invasion) 4. Intrathyroidal, papillary thyroid cancer, primary tumor 1-4 cm, V600E BRAF wild type, without other worrisome features (e.g., aggressive histology, vascular invasion) 癌症診療指引407

26 5 ( [Differentiated Thyroid Cancer; DTC]) - 5 Initial Risk (of persistence/recurrence) Stratification System 2 (Modified from 2015 ATA Guidelines) Intermediate Risk 1. RAI avid metastatic foci in the neck on the first post-treatment whole-body RAI scan 2. Aggressive histology (e.g., tall cell, hobnail variant, columnar cell carcinoma, diffuse sclerosing variant) 3. Papillary thyroid cancer with vascular invasion 4. Clinical N1 or > 5 pathologic N1 with all involved lymph nodes < 3 cm in largest dimension* 5. Intrathyroid, papillary thyroid cancer, primary tumor 1-4 cm, V600E BRAF mutated (if known)* 6. Multifocal papillary microcarcinoma with extrathyroidal extension and V600E BRAF mutated (if known)* High Risk 1. Macroscopic invasion of tumor into the perithyroidal soft tissues (gross extrathyroidal extension), 2. Incomplete tumor resection 3. Distant metastases 4. Post-operative serum thyroglobulin suggestive of distant metastases 5. Pathologic N1 with any metastatic lymph node 3 cm in largest dimension* 6. Follicular thyroid cancer with extensive vascular invasion (> 4 foci of vascular invasion 癌症診療指引408

27 6 ( [Differentiated Thyroid Cancer; DTC]) - 6 (ATA) : : rtsh;thyrogen 1. <0.2ng/ml 2. <1 ng/ml 1. >1ng/ml 2. >10ng/ml ( ) (+) (-) (bed) 3. < 1 ng/ml < 10 ng/ml (+) 4. 癌症診療指引409

28 7 ( [Differentiated Thyroid Cancer; DTC]) - 7 (TSH) 1. TSH <0.1 mu/l 2. (low risk patient) TSH 3. TSH mu/l(tg positive, imaging negative) 4. (disease free) TSH 癌症診療指引410

29 1. Brito JP, Gionfriddo MR, Al NA, et al. The accuracy of thyroid nodule ultrasound to predict thyroid cancer: systematic review and meta-analysis. J Clin Endocrinol Metab. 2014;99: Chen W, Parsons M, Torigian DA, et al. Evaluation of thyroid FDG uptake incidentally identified on FDG-PET/CT imaging. Nucl Med Commun. 2009;30: Horvath E, Majlis S, Rossi R, et al. An ultrasonogram reporting system for thyroid nodules stratifying cancer risk for clinical management. J Clin Endocrinol Metab. 2009;94: Ito Y, Amino N, Yokozawa T, et al. Ultrasonographic evaluation of thyroid nodules in 900 patients: comparison among ultrasonographic, cytological, and histological findings. Thyroid. 2007;17: Kwak JY, Han KH, Yoon JH, et al. Thyroid imaging reporting and data system for US features of nodules: a step in establishing better stratification of cancer risk. Radiology. 2011;260: NCCN Clinical Practice Guidelines in Oncology:Thyroid Carcinoma Version Smith-Bindman R, Lebda P, Feldstein VA, et al. Risk of thyroid cancer based on thyroid ultrasound imaging characteristics: results of a population-based study. JAMA Intern Med. 2013;173: Soelberg KK, Bonnema SJ, Brix TH, et al. Risk of malignancy in thyroid incidentalomas detected by 18F-fluorodeoxyglucose positron emission tomography: a systematic review. Thyroid. 2012;22: Tae HJ, Lim DJ, Baek KH, et al. Diagnostic value of ultrasonography to distinguish between benign and malignant lesions in the management of thyroid nodules. Thyroid. 2007;17: Takami H, Ito Y, Okamoto T, et al. Revisiting the guidelines issued by the Japanese Society of Thyroid Surgeons and Japan Association of Endocrine Surgeons: a gradual move towards consensus between Japanese and western practice in the management of thyroid carcinoma. World J Surg. 2014;38: American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer. 癌症診療指引411

30 癌症診療指引412Chemotherapy for Advanced or Metastastic Disease of Thyroid Cancer 131 I-refractory locally advanced or metastatic differentiated thyroid cancer mg/m 2 Sorafenib 400mg PO BID Q4W 1 1. Brose, Marcia S et al. Sorafenib in radioactive iodine-refractory, locally advanced or metastatic differentiated thyroid cancer: a randomised, double-blind, phase 3 trial. The Lancet, Volume 384, Issue 9940,

共識評估甲狀腺結節是否為癌症 -1 *TSH American Thyroid Association; ATA 甲狀腺癌診療指引1 Differentiated Thyroid Cancer; DTC DTC-2-1 DTC-2-2

共識評估甲狀腺結節是否為癌症 -1 *TSH American Thyroid Association; ATA 甲狀腺癌診療指引1 Differentiated Thyroid Cancer; DTC DTC-2-1 DTC-2-2 甲狀腺癌診療指引一參院參與討論同仁主席 / 附設醫院萬芳醫院雙和醫院二討論日期 :104 年 11 月 25 日三校稿人員 : 張俊仁主任 / 胡瑾瑜個管師共識評估甲狀腺結節是否為癌症 -1 *TSH 1. 2. 3. 2015American Thyroid Association; ATA 1 2 3 甲狀腺癌診療指引1 Differentiated Thyroid Cancer;