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

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1 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

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 *TSH: Tc99m TSH

3 評估甲狀腺結節是否為癌症 -2: 細針檢結果 ; 按 Bethesda 細胞診斷系統 1-4% > 50% Differentiated Thyroid Cancer; DTC -2-1 DTC % DTC-5 > 50% DTC-5 > 4cm 369 甲狀腺癌診療指引共識2 -

4 評估甲狀腺結節是否為癌症 -2: 細針檢結果 ; 按 Bethesda 細胞診斷系統 ( 續 ) / Atypia 5-15% 6-12 Differentiated Thyroid Cancer; DTC -2-2 甲狀腺癌診療指引共識2 2-12/ / 15-30% DTC-5 DTC % DTC % DTC-3

5 共識初始甲狀腺手術 -1 X CT/ MRI A. > 4cm B. T4 C.N1 D. E. F. 1cm < 4cm B C D E F 1cm B C D E4 4 F 26 TSH TSH Differentiated Thyroid Cancer; DTC -3 / DTC-4 / A. > 45B. 3 C. DTC-6 / > 50% 371 甲狀腺癌診療指引

6 共識初始甲狀腺手術 -2( 淋巴結清除術 ) VI cn1a / 甲狀腺癌診療指引4 Differentiated Thyroid Cancer; DTC -4 II-V cn1b T3 T4 / / VI II-V 372

7 共識初始甲狀腺手術 DTC-3 / Differentiated Thyroid Cancer; DTC -5 DTC-4 5 / DTC-6 / 373 甲狀腺癌診療指引

8 共識決定是否再次做完成甲狀腺全切除 / 近全切除手術之考量因素 1. > 4cm 2. / A. DTC B. DTC-7 5 / DTC-4 6 Differentiated Thyroid Cancer; DTC 甲狀腺癌診療指引

9 共識全切除 / 近全切除手術後決定是否做碘 -131 治療碘 -131 治療 / 劑量復發危險分類 ( 註 5) 依據病理報告 / 手術發現 / 手術 4-6 週後的甲狀腺球蛋白 /Tc99mO4 或碘 -131 掃描 /± 頸部超音波 AJCC 分期腫瘤大小 (T) 描述 T1a, N0/Nx, M0/Mx T 1cm pt1ampt1a / T1b, T2, N0/Nx, M0/Mx 1 < T 4cm / / T1b, T2, N0/Nx, M0/Mx 1 < T 4cm / / T3, N0/Nx, M0/Mx T > 4cm / / T3, N0/Nx, M0/Mx > 45 / -131 / / T1-3, N1a, M0/Mx / T1-3, N1b, M0/Mx 50.2cm / T1-3, N1b, M0/Mx / T4, any N, any M / M1, any T, any N 7 Differentiated Thyroid Cancer; DTC 甲狀腺癌診療指引

10 共識第一次評估治療效果 / 手術 / 碘 -131 治療後 6-12 個月復發危險分類 ( 註 5) 手術方式評估方法治療反應 ( 註 6) / / -131 後續處理建議 ATA 2015 後續處理甲狀腺素抑制性治療 ( 以血清中 TSH 濃度評估 ) TSH Differentiated Thyroid Cancer; DTC -8 甲狀腺癌診療指引 / / / -131 ATA 2015 / /(CT MRI) / FDG PET/ -131 ATA 2015 TSH TSH TSH /CT/MRI TSH < 0.1 ATA

11 Differentiated Thyroid Cancer; DTC - 1 識註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 shape. 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 377 甲狀腺癌診療指引共

12 Differentiated Thyroid Cancer; DTC - 1 識註1 續 ATA Nodule Sonographic Pattern Risk of Malignancy 甲狀腺癌診療指引共378

13 Differentiated Thyroid Cancer; DTC - 2 識註2 Sonographic features Sonographic features Nodule With high suspicion sonographic pattern With intermediate suspicion sonographic pattern With low suspicion sonographic pattern With very low suspicion sonographic pattern Purely cystic Suspicious cervical lymph node > 1.0 cm > 1.0 cm > 1.5 cm Threshold for fine needle aspiration (FNA) > 2cm or observe Not required FNA node + FNA associated suspicious thyroid nodule(s) of any size <1cm(may) 甲狀腺癌診療指引共

14 Differentiated Thyroid Cancer; DTC - 3 識註3 Ultrasound features of lymph nodes indicating high specificity (43-100%) of malignant involvement Microcalcifications Cystic aspect Peripheral vascularity Hyperechogenicity Round shape 甲狀腺癌診療指引共380

15 Differentiated Thyroid Cancer; DTC - 4 識註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 without clinically evident metastases or local invasion, with no convincing cytologic 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.) 甲狀腺癌診療指引共381

16 Differentiated Thyroid Cancer; DTC - 5 識註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 131I 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, encapsulated follicular variant of papillary thyroid cancer* 3. Intrathyroidal, well differentiated follicular thyroid cancer with capsular invasion and no or minimal (< 4 foci) vascular invasion* 4. Intrathyroidal, papillary microcarcinoma, unifocal or multifocal, including V600E BRAF mutated (if known)*, without other worrisome features (e.g., aggressive histology, vascular invasion) 5. Intrathyroidal, papillary thyroid cancer, primary tumor 1-4 cm, V600E BRAF wild type, without other worrisome features (e.g., aggressive histology, vascular invasion) 382 甲狀腺癌診療指引共

17 Differentiated Thyroid Cancer; DTC - 5 識註5 續 Initial Risk (of persistence/recurrence) Stratification System-2 (Modified from 2015 ATA Guidelines) Intermediate Risk 1. Microscopic invasion of tumor into the perithyroidal soft tissues 2. RAI avid metastatic foci in the neck on the first post-treatment whole-body RAI scan 3. Aggressive histology (e.g., tall cell, hobnail variant, columnar cell carcinoma, diffuse sclerosing variant) 4. Papillary thyroid cancer with vascular invasion 5. Clinical N1 or > 5 pathologic N1 with all involved lymph nodes < 3 cm in largest dimension* 6. Intrathyroid, papillary thyroid cancer, primary tumor 1-4 cm, V600E BRAF mutated (if known)* 7. 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) 383 甲狀腺癌診療指引共

18 Differentiated Thyroid Cancer; DTC - 6 識註6 治療效果定義治療效果分類定義壓抑下 : 口服甲狀腺素時刺激下 : 停服甲狀腺素或注射 rtsh; Thyrogen 時 1. <0.2ng/ml 2. <1ng/ml 甲狀腺癌診療指引共 1. >1ng/ml 2. >10ng/ml ; ( ) ( ) < 1 ng/ml < 10 ng/ml ( )

19 考文獻 1. NCCN Clinical Practice Guidelines in Oncology Thyroid Carcinoma Version American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer. 3. 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: 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: 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: 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: 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: 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: 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: 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: 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: 甲狀腺癌診療指引參

聖馬爾定醫院正子中心健保開單診療指引（guideline）

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