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Il nodulo tiroideo: iter diagnostico Mauro Maccario Divisione di Endocrinologia e Malattie del Metabolismo Università di Torino.

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Presentazione sul tema: "Il nodulo tiroideo: iter diagnostico Mauro Maccario Divisione di Endocrinologia e Malattie del Metabolismo Università di Torino."— Transcript della presentazione:

1 Il nodulo tiroideo: iter diagnostico Mauro Maccario Divisione di Endocrinologia e Malattie del Metabolismo Università di Torino

2 Diagnosi differenziale del nodulo tiroideo Lesioni tiroidee –gozzo nodulare –adenoma –tiroidite di Hashimoto –tiroidite subacuta –cisti del dotto tireoglosso –neoplasie maligne Lesioni non tiroidee –linfoadenopatia –adenoma delle paratiroidi –ascesso cervicale –igroma cistico –ectopia gh. salivari –aneurisma –laringocele

3 Tumori maligni della Tiroide Derivati dallepitelio follicolare Forme differenziate o scarsamente differenziate - Papillare - Follicolare (varianti: Ca a cell. di Hurtle e Insulare) - Carcinoma misto papillare- follicolare Forme indifferenziate - Carcinoma anaplastico Derivati dalle cellule C parafollicolari Carcinoma midollare Non-epiteliali Linfomi Sarcomi Teratomi Secondari

4 Cancro della Tiroide - Epidemiologia meno dell1% dei tumori maligni (1,5% donne - 0,5% uomini) incidenza 5-10 / (in Piemonte nuovi casi /anno) frequenza simile al mieloma ed al carcinoma dellesofago della laringe e del collo dellutero doppia rispetto al m. di Hodgkin 0.4% dei decessi per neoplasia raro? guaribile!

5 Nodulo tiroideo - Epidemiologia 4-7 % popolazione U.S.A. ha un nodo palpabile aumento di frequenza con letà netta prevalenza femminile 40-50% della popolazione ha un nodulo dimostrabile allETG raramente espressione di lesione neoplastica evolutiva

6 Nodulo tiroideo - percorso diagnostico Anamnesi Esami di LaboratorioImaging Esame obiettivo TSH (fT3, fT4,) AbTPO Tireoglobulina Calcitonina Ecotomografia Scintigrafia CT, RMN Esame citologico su agoaspirato Screening ? Popolazioni a rischio Caratteri del nodulo Incidentaloma

7 Carcinoma tiroideo Screening in soggetti asintomatici? Beneficio della diagnosi precoce –prognosi migliore? –stadio alla diagnosi nella storia naturale –storia naturale del tumore occulto

8 Importanza della diagnosi precoce Cancer Res (4): Survival and causes of death in thyroid cancer: a population-based study of 2479 cases from Norway. Akslen LA, Haldorsen T, Thoresen SO, Glattre E Department of Pathology, Gade Institute, University of Bergen, Norway. Survival and prognostic factors were studied in 2479 clinically presenting thyroid cancers (TC) reported from the entire Norwegian population from 1970 to Complete follow-up was obtained (median, 48 months), with information on causes of death. At the end of the observation period, 498 patients were reported to have died of TC, representing 69.7% of all deaths. Among 216 patients dying of other main causes, TC was considered to be a contributing cause of death in 80 cases (11.2%). Multivariate regression analysis of TC deaths showed no significant difference according to sex in any of the histological types. Age had a strong impact on survival, and for papillary carcinomas this effect was apparent after the age of 55 years. Marked differences were observed between various histological types, even between papillary and follicular carcinomas when interactions were included. Furthermore, tumor stage was a strong predictor of TC deaths, and a reduced survival was also found in patients with lymph node metastases. In conclusion, the importance of age, histological type, and tumor stage as major prognostic factors has been documented in this population-based study from Norway.

9 da: DOH 1999, Cancer in the District of Columbia Ca tiroide - Stadio alla diagnosi nella storia naturale Cancro della tiroideCancro del polmone

10 Nodulo tiroideo Screening in soggetti asintomatici? Beneficio della diagnosi precoce –prognosi migliore? –stadio alla diagnosi nella storia naturale –storia naturale del tumore occulto Rapporto costo/beneficio –autoscreening, screening periodico presso medico generale o presso centro specialistico? –efficacia dello screening –rapporto nodi benigni / maligni –modalità di screening (palpazione, ETG, …)

11 J Clin Ultrasound 1992 Jan;20(1):37-42 Clinical versus ultrasound examination of the thyroid gland in common clinical practice. Brander A, Viikinkoski P, Tuuhea J, Voutilainen L, Kivisaari L Hyvinkaa District Hospital, Finland. In a prospective series of 72 patients, clinical and ultrasonographic examination of the thyroid gland were compared in detail. Normal-sized lobes were differentiated from enlarged ones both by inspection and by palpation. When lobar size was assessed by palpation, the estimate was most clearly influenced by increase in width. The correlation between two examiners in lobe size assessment was significant. In the classification of thyroid disease as diffuse, solitary, or multinodular, clinical examination and ultrasonography correlated significantly. However, only one third of the clinically solitary nodules proved to be solitary by ultrasound examination. Of 77 separate nodules, 43 escaped detection on clinical examination. Of these 43, 14 nodules exceeded 2 cm in diameter. It is concluded that the use of ultrasonography frequently alters the primary evaluation of thyroid nodularity based on palpation. Palpazione del collo: sensibilità 44% vs ETG Of 77 separate nodules, 43 escaped detection on clinical examination. Of these 43, 14 nodules exceeded 2 cm in diameter. It is concluded that the use of ultrasonography frequently alters the primary evaluation of thyroid nodularity based on palpation.

12 Screening ecografico Radiology 1991 Dec;181(3):683-7 Thyroid gland: US screening in a random adult population. Brander A, Viikinkoski P, Nickels J, Kivisaari L Hyvinkaa District Hospital, Finland. High-frequency ultrasound examination of the thyroid was performed in 253 subjects (130 women and 123 men; age range, years) that were randomly selected from the population in an area of Finland where goiter is not endemic. Thyroid echo abnormalities were detected in 69 subjects (27.3%). Prevalence of abnormalities increased with age, and women showed more lesions than did men in each of the 3 decades. The abnormality was solitary in 39 subjects (57%), multiple in 15 (22%), and diffuse in 15 (22%). Of the 68 individual nodules, 48 (70%) were smaller than 1 cm in diameter. Anechoic rounded nodules 1-5 mm in diameter were found in 28 subjects. Fine-needle aspiration biopsy was performed in 30 subjects. Cytologic examination revealed no unequivocal malignancies. In eight subjects (3.2%) with a diffuse echo abnormality, cytologic evaluation indicated lymphocytic thyroiditis. It is concluded that the prevalence of small thyroid echo abnormalities in a randomly selected adult population is rather high, a fact that supports use of a conservative approach to these types of findings.

13 The Canadian Guide to Clinical Preventive Health Care

14 Give Yourself The Thyroid "Neck Check" It Could Save Your Life TO TAKE THE THYROID NECK CHECK... All you will need is: A glass of water A hand-held mirror 1. Hold the mirror in your hand, focusing on the area of your neck just below the Adam's apple and immediately above the collarbone. Your thyroid gland is located in this area of your neck. 2. While focusing on this area in the mirror, tip your head back. 3. Take a drink of water and swallow.. 4. As you swallow, look at your neck. Check for any bulges or a protrusion in this area when you swallow. Reminder: Don't confuse the Adam's apple with the thyroid gland. The thyroid gland is located further down on your neck, closer to the collarbone. You may want to repeat this process several times. 5. If you do see any bulges or protrusions in this area, see your physician immediately. You may have an enlarged thyroid gland or a thyroid nodule and should be checked to determine whether cancer is present or if treatment for thyroid disease is needed.

15 The Cancer Related Check-up Apart from participating in screening that has been recommended as part of a population-based initiative, an individual's periodic encounters with clinicians are viewed by the ACS as having potential for health counseling and a cancer-related check-up. Health counseling may include guidance about smoking cessation, diet, physical activity, and the benefits and risks of undergoing various screening tests. These encounters may include case- finding examinations of the thyroid, testicles, ovaries, lymph nodes, oral region, and skin. Also, self-examination of the skin and breasts can be encouraged, as can the importance of awareness of symptoms of testicular cancer in young men. The ACS recommends a cancer-related check-up every three years for asymptomatic individuals between the ages of 20 and 39, and annually for asymptomatic men and women ages 40 and older

16 Effectiveness of Early Detection of Thyroid Cancer The benefits of early detection of thyroid cancer in the general population are not well defined. For all histologic types, 5-year survival is significantly better with earlier stage at diagnosis. A cohort study of mass screening found a significantly higher 7-year cumulative survival rate in patients whose cancer was detected by screening (98%) when compared with those presenting with symptoms (90%). Cancers detected by screening were significantly more likely to have a favorable histology, however, and both lead-time and length biases are likely in this study. There have been no controlled trials demonstrating that asymptomatic persons detected by screening have a better outcome than those who present with clinical symptoms or signs. In addition, not all cancers detected through screening are likely to present clinically during the patient's lifetime. In autopsy studies in the U.S., the prevalence of occult thyroid carcinoma in adults ranges from 2-13%; in contrast, the annual incidence of thyroid carcinoma is only about 4/100,000 population. U.S. Preventive Services Task Force There have been no controlled trials demonstrating that asymptomatic persons detected by screening have a better outcome than those who present with clinical symptoms or signs. In addition, not all cancers detected through screening are likely to present clinically during the patient's lifetime. In autopsy studies in the U.S., the prevalence of occult thyroid carcinoma in adults ranges from 2-13%; in contrast, the annual incidence of thyroid carcinoma is only about 4/100,000 population.

17 Incidentaloma tiroideo Annals of Internal Medicine REVIEW Thyroid Incidentalomas: Management Approaches to Nonpalpable Nodules Discovered Incidentally on Thyroid Imaging Annals of Internal Medicine, 1 February : Gerry H. Tan, MD, and Hossein Gharib, MD Mayo Clinic and Mayo Foundation, Rochester, Minnesota.

18 Incidentaloma tiroideo G.H. Tan & H. Gharib, Annals of Internal Medicine, :

19 Incidentaloma tiroideo G.H. Tan & H. Gharib, Annals of Internal Medicine, : Conclusions:... Most of these lesions are benign. For most patients with non-palpable nodules that are incidentally detected by thyroid imaging, simple follow-up neck palpation is sufficient

20 Nodulo tiroideo - percorso diagnostico Anamnesi Esami di LaboratorioImaging Esame obiettivo Esame citologico su agoaspirato Screening ? Popolazioni a rischio Caratteri del nodulo Incidentaloma

21 Anamnesi - Esame obiettivo CONDIZIONE FAVOREVOLE Storia familiare di tiroidite cronica Storia familiare di struma Sintomi di ipo- / ipertiroidismo Dolore o tensione associata al nodulo nodulo liscio e mobile gozzo multinodulare CONDIZIONE SFAVOREVOLE Età 70 anni Sesso maschile Disfagia Storia di radioterapia del collo Nodulo duro, fisso, irregolare Adenopatia cervicale Storia di cancro della tiroide

22 Nodulo tiroideo - percorso diagnostico Anamnesi Esami di LaboratorioImaging Esame obiettivo Esame citologico su agoaspirato Screening ?Incidentaloma TSH, fT3, fT4 AbTPO Tireoglobulina Calcitonina

23 Bennedbaek FN, Perrild H, Hegedus L. Diagnosis and treatment of the solitary thyroid nodule. Results of a European survey. Clinical Endocrinol (Oxf) 1999; 50: Esami di laboratorio - funzionalità tiroidea Case hystory 42 y old Caucasian women nodule 2x3 cm mobile present from 3 months no lymphadenopathy no family history of thyroid disease no previous external irradiation

24 Esami di laboratorio - funzionalità tiroidea TSH ultrasensibile diminuito aumentato Scintigrafia Tc99 nodulo captante nodulo non captante AbTPO Nodo sospetto Nodo tossico (non sospetto) Tiroidite cronica autoimmune (nodo poco sospetto) positivo

25 Bennedbaek FN, Perrild H, Hegedus L. Diagnosis and treatment of the solitary thyroid nodule. Results of a European survey. Clinical Endocrinol (Oxf) 1999; 50: Esami di laboratorio - Tireoglobulina Case hystory 42 y old Caucasian women nodule 2x3 cm mobile present from 3 months no lymphadenopathy no family history of thyroid disease no previous external irradiation

26 Esami di laboratorio - Tireoglobulina AACE Clinical Practice Guidelines for the Diagnosis and Management of Thyroid Nodule Developed by The American Association of Clinical Endocrinologists and The American College of Endocrinology © 1996, AACE.. A baseline serum thyroglobulin levels in the evaluation of solitary thyroid nodule is not a useful or cost-effective test. The value of the thyroglobulin levels lies in serial determinations after thyroid cancer has been diagnosed and the patient has been treated by elimination of most or all of the thyroid gland....

27 Bennedbaek FN, Perrild H, Hegedus L. Diagnosis and treatment of the solitary thyroid nodule. Results of a European survey. Clinical Endocrinol (Oxf) 1999; 50: Esami di laboratorio - Calcitonina Case hystory 42 y old Caucasian women nodule 2x3 cm mobile present from 3 months no lymphadenopathy no family history of thyroid disease no previous external irradiation

28 Esami di laboratorio - Calcitonina J.R. Hahm et al. Routine Measurement of Serum Calcitonin is Useful for Early Detection of Medullary Thyroid Carcinoma in Patients with Nodular Thyroid Diseases. Thyroid, 11:73-79, 2001 CT = calcitoninemia MTC = carcinoma midollare PTC = carcinoma papillare FN = lesione follicolare

29 Esami di laboratorio - Calcitonina..If the family history is non contributory, routine serum calcitonin measurements are not cost- effective.....In the absence of suspicion of medullary thyroid cancer or multiple endocrine neoplasia II syndrome, it is neither routinely necessary nor cost effective to determine calcitonin levels in patients with solitary thyroid nodule... Treatment Guidelines for Patients With Thyroid Nodules and Well-Differentiated Thyroid Cancer Arch Int Med 1996 AACE Clinical Practice Guidelines for the Diagnosis and Management of Thyroid Nodules 1996

30 Nodulo tiroideo - percorso diagnostico Anamnesi Esami di LaboratorioImaging Esame obiettivo Esame citologico su agoaspirato Screening ?Incidentaloma TSH, fT3, fT4 AbTPO Tireoglobulina Calcitonina Ecotomografia Scintigrafia CT, RMN

31 Bennedbaek FN, Perrild H, Hegedus L. Diagnosis and treatment of the solitary thyroid nodule. Results of a European survey. Clinical Endocrinol (Oxf) 1999; 50: Imaging - Scintigrafia Case hystory 42 y old Caucasian women nodule 2x3 cm mobile present from 3 months no lymphadenopathy no family history of thyroid disease no previous external irradiation Scintigraphy 66 Scintigraphy and ultrasonography 58

32 Imaging - Scintigrafia Tc 99m / I 123 In paziente ipertiroideo: verifica della presenza di noduli iperfunzionanti (raramente maligni) In paziente eutiroideo: verifica dello stato funzionale dei noduli di un gozzo multinodulare

33 ... with the exception of hyperfunctioning nodules, the thyroid scan will not help to differentiate benign from malignant lesions. For this reason, many endocrinologists no longer advocate obtaining thyroid scans as part of the routine initial evaluation of a nodular goiter, and they prefer to perform an FNAB first. … Certainly, not all patients with thyroid nodules require nuclear imaging. In many centers, thyroid FNA biopsy has supplanted nuclear thyroid imaging as the initial technical procedure in Treatment Guidelines for Patients With Thyroid Nodules and Well-Differentiated Thyroid Cancer Arch Int Med 1996 AACE Clinical Practice Guidelines for the Diagnosis and Management of Thyroid Nodules 1996 Imaging - Scintigrafia evaluating nodules. AACE recommends that the physician use clinical judgment in considering the appropriateness of a thyroid nuclear scan, as it applies to each individual case.

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