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DOI: 10.1055/s-0029-1243052
© Georg Thieme Verlag KG Stuttgart · New York
Abklärung des euthyreoten Schilddrüsenknotens: Wann punktieren?
Stellenwert der SonographieDiagnostic work-up of euthyroid nodules: which nodules should undergo fine-needle aspiration biopsy?Relevance of ultrasoundPublication History
eingereicht: 26.8.2009
akzeptiert: 20.11.2009
Publication Date:
25 November 2009 (online)
Zusammenfassung
Um unter der großen Zahl der Schilddrüsenknoten diejenigen Knoten mit einem erhöhten Karzinomrisiko oder einer Schilddrüsenautonomie zu identifizieren bedarf es effektiver rationaler differentialdiagnostischer Methoden und Entscheidungsalgorithmen. Mittels Anamnese, Sonographie sowie TSH- und Calcitonin-Bestimmung ist eine Schilddrüsenkarzinom-Risikobeurteilung und Selektion der Schilddrüsenknoten für die weitere Diagnostik möglich. Insbesondere sonographische Malignitätskriterien erlauben eine Schilddrüsenkarzinomrisiko-Stratifizierung und eine effektive Schilddrüsenknotenselektion für die Feinnadelaspirationszytologie (FNAZ). Die FNAZ ist die Methode mit der besten Sensitivität und Spezifität für die weitere Differenzierung sonographisch darstellbarer solitärer benigner und maligner Schilddrüsenknoten > 1 cm. Voraussetzungen für einen effektiven Einsatz der FNAZ in der klinischen Routine sind allerdings eine adäquate Ausbildung und umfangreiche Erfahrungen von Punkteur und Zytopathologen. Während malignitätsverdächtige Schilddrüsenknoten unverzüglich dem Chirurgen zugeführt werden müssen, sollte bei fehlenden klinischen, sonographischen und zytologischen Malignitätskriterien, normalem Calcitonin sowie Euthyreose die Verlaufsbeobachtung erfolgen.
Summary
Efficient and rational methods for the differential diagnosis and decision are required to identify those nodules with an increased carcinoma risk or those which are hot among the many thyroid nodules.
History, ultrasound and TSH- and CT-determination do allow a risk assessment for the further diagnostic work up. Especially ultrasound criteria for malignancy lead to a risk stratification and efficient selection of thyroid nodules for Fine needle aspiration biopsy (FNAB). FNAB is the diagnostic method with the best sensitivity and specificity for the distinction between benign and malignant thyroid nodules. However, the efficiency of the fine needle aspiration biopsy requires sufficient training and experience of both the cytopathologist and the person performing the fine needle aspiration biopsy.
Thyroid nodules with a suspicion for malignancy should be referred to the surgeon. Euthyroid thyroid nodules with lack of clinical, ultrasound or cytologic criteria for malignancy and normal calcitonin should be followed up.
Schlüsselwörter
Schilddrüsenknoten, euthyreot - Feinnadelaspirationszytologie (FNAZ) - sonographische Malignitätskriterien
Keywords
thyroid nodule, euthyroid - fine needle aspiration biopsy (FNAB) - ultasound malignancy criteria
Literatur
-
1 Krebs in Deutschland,
Häufigkeiten und Trends. 2006. Gesellschaft der epidemiologischen
Krebsregister in Deutschland e. V.(GEKID) in Zusammenarbeit
mit dem Robert Koch Institut (RKI).
- 2 Alexander E K, Hurwitz S, Heering J P, Benson C B, Frates M C, Doubilet P M. et al . Natural history of benign solid and cystic thyroid nodules. Ann Intern Med. 2003; 138 315-8
- 3 Ashcraft M W, Van Herle A J. Management of thyroid nodules. II: Scanning techniques, thyroid suppressive therapy, and fine needle aspiration. Head Neck Surg. 1981; 3 297-322
- 4 Bahre M, Hilgers R, Lindemann C, Emrich D. Physiological aspects of the thyroid trapping function and its suppression in iodine deficiency using 99mTc pertechnetate. Acta Endocrinol (Copenh). 1987; 115 175-82
- 5 Brauer V F, Hentschel B, Paschke R. [Euthyroid thyroid nodules. Aims, results and perspectives concerning drug therapy]. Dtsch Med Wochenschr. 2003; 128 2381-7
- 6 Cappelli C, Castellano M, Pirola I, Gandossi E, De Martino E, Cumetti D. et al . Thyroid nodule shape suggests malignancy. Eur J Endocrinol. 2006; 155 27-31
- 7 Cooper D S, Doherty G M, Haugen B R, Kloos R T, Lee S L, Mandel S J. et al . Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2009; 19 1167-214
- 8 Fish S A, Langer J E, Mandel S J. Sonographic imaging of thyroid nodules and cervical lymph nodes. Endocrinol Metab Clin North Am. 2008; 37 401-17, ix
- 9 Frates M C, Benson C B, Charboneau J W, Cibas E S, Clark O H, Coleman B G. et al . Management of thyroid nodules detected at US: Society of Radiologists in Ultrasound consensus conference statement. Radiology. 2005; 237 794-800
- 10 Frates M C, Benson C B, Doubilet P M, Kunreuther E, Contreras M, Cibas E S. et al . Prevalence and distribution of carcinoma in patients with solitary and multiple thyroid nodules on sonography. J Clin Endocrinol Metab. 2006; 91 3411-7
- 11 Frates M C, Benson C B, Doubilet P M, Cibas ES, Marqusee E. Can color Doppler sonograpy aid in the prediction of malignancy of thyroid nodules?. J Ultrasound Med. 2002; 22 127-31
- 12 Gharib H, Papini E, Paschke R, Duick D S, Valcavi R, Hegedus L. et al . American Association of Clinical Endocrinologists, Italian Association of Clinical Endocrinologists and European Thyroid Association Medical Guidelines For Clinical Practice For the Diagnosis and Management of Thyroid Nodules. Endocr Pract, Hot Thyroidology, J Endocrin Invest . 2010; in press;
- 13 Grant C S, Hay I D, Gough I R, McCarthy P M, Goellner J R. Long-term follow-up of patients with benign thyroid fine-needle aspiration cytologic diagnoses. Surgery. 1989; 106 980-5
- 14 Hardt A, Sancak S, Gärtner R. et al . Comparison of colour flow doppler sonography (CFDS) and immunostaining in the detection of intranodular vessels. Annual Meeting of the American Thyroid Association, Palm Beach. 2009;
- 15 Hegedus L, Bonnema S J, Bennedbaek F N. Management of simple nodular goiter: current status and future perspectives. Endocr Rev. 2003; 24 102-32
- 16 Holzer S, Reiners C, Mann K, Bamberg M, Rothmund M, Dudeck J. et al . Patterns of care for patients with primary differentiated carcinoma of the thyroid gland treated in Germany during 1996. U.S. and German Thyroid Cancer Group. Cancer. 2000; 89 192-201
- 17 Horvath E, Majlis S, Rossi R, Franco C, Niedmann J P, Castro A, Dominguez M. An ultrasonogram reporting system for thyroid nodules stratifying cancer risk for clinical management. J Clin Endocrinol Metab. 2009; 94 1748-51
- 18 Kim E K, Park C S, Chung W Y, Oh K K, Kim D I, Lee J T, Yoo H S. New sonographic criteria for recommending fine-needle aspiration biopsy of nonpalpable solid nodules of the thyroid. AJR Am J Roentgenol. 2002; 178 687-91
- 19 Krohn K, Fuhrer D, Bayer Y, Eszlinger M, Brauer V, Neumann S, Paschke R. Molecular pathogenesis of euthyroid and toxic multinodular goiter. Endocr Rev. 2005; 26 504-24
- 20 Kuma K, Matsuzuka F, Kobayashi A, Hirai K, Morita S, Miyauchi A. et al . Outcome of long standing solitary thyroid nodules. World J Surg. 1992; 16 583-7
- 21 Moon W J, Jung S L, Lee J H, Na D G, Baek J H, Lee Y H. et al . Benign and malignant thyroid nodules: US differentiation – multicenter retrospective study. Radiology. 2008; 247 762-70
- 22 Oertel Y C, Miyahara-Felipe L, Mendoza M G, Yu K. Value of repeated fine needle aspirations of the thyroid: an analysis of over ten thousand FNAs. Thyroid. 2007; 17 1061-6
- 23 Pacini F, Schlumberger M, Dralle H, Elisei R, Smit J W, Wiersinga W. European consensus for the management of patients with differentiated thyroid carcinoma of the follicular epithelium. Eur J Endocrinol. 2006; 154 787-803
- 24 Popowicz B, Klencki M, Lewinski A, Slowinska-Klencka D. The usefulness of sonographic features in selection of thyroid nodules for biopsy in relation to the nodule’s size. Eur J Endocrinol. 2009; 161 103-11
- 25 Rago T, Di Coscio G, Basolo F, Scutari M, Elisei R, Berti P. et al . Combined clinical, thyroid ultrasound and cytological features help to predict thyroid malignancy in follicular and Hupsilonrthle cell thyroid lesions: results from a series of 505 consecutive patients. Clin Endocrinol (Oxf). 2007; 66 13-20
- 26 Rago T, Santini F, Scutari M, Pinchera A, Vitti P. Elastography: new developments in ultrasound for predicting malignancy in thyroid nodules. J Clin Endocrinol Metab. 2007; 92 2917-22
- 27 Raza S N, Shah M D, Palme C E, Hall F T, Eski S, Freeman J L. Risk factors for well-differentiated thyroid carcinoma in patients with thyroid nodular disease. Otolaryngol Head Neck Surg. 2008; 139 21-6
- 28 Tae H J, Lim D J, Baek K H, Park W C, Lee Y S, Choi J E. et al . Diagnostic value of ultrasonography to distinguish between benign and malignant lesions in the management of thyroid nodules. Thyroid. 2007; 17 461-6
- 29 Tee Y Y, Lowe A J, Brand C A, Judson R T. Fine-needle aspiration may miss a third of all malignancy in palpable thyroid nodules: a comprehensive literature review. Ann Surg. 2007; 246 714-20
- 30 Volzke H, Ludemann J, Robinson D M, Spieker K M, Schwahn C, Kramer A. et al. . The prevalence of undiagnosed thyroid disorders in a previously iodine-deficient area. Thyroid. 2003; 13 803-10
- 31 Wienke J R, Chong W K, Fielding J R, Zou K H, Mittelstaedt C A. Sonographic features of benign thyroid nodules: interobserver reliability and overlap with malignancy. J Ultrasound Med. 2003; 22 1027-31
- 32 Yeh M W, Demircan O, Ituarte P, Clark O H. False-negative fine-needle aspiration cytology results delay treatment and adversely affect outcome in patients with thyroid carcinoma. Thyroid. 2004; 14 207-15
Prof. Dr. Ralf Paschke
Universität Leipzig, Medizinische
Klinik und Poliklinik III
Liebigstr. 20
04103
Leipzig
Phone: 0341/9713200
Fax: 0341/9713209
Email: Ralf.Paschke@medizin.uni-leipzig.de