Morphologische Diagnostik und genetische Alterationen von Schilddrüsentumoren mit Follikelzelldifferenzierung

Zusammenfassung

Die morphologische Diagnostik von Schilddrüsentumoren dient in erster Linie dem klinischen Management. Die Feinnadelbiopsie (FNB) soll eine Entscheidungshilfe für oder gegen eine Operation sein; der intraoperative Gefrierschnitt soll das Operationsausmaß mitbestimmen und Zweitoperationen vermeiden helfen. Die beiden letztgenannten Methoden haben aber beträchtliche Limitationen, sodass in vielen Fällen die morphologische Dignitätsbestimmung erst in der endgültigen Paraffinhistologie gelingt, wobei für die exakte Diagnosefindung auch der Einsatz der Immunhistochemie und zunehmend molekularpathologischer Analysen zur Verfügung stehen.

Die klassische Unterteilung der Schilddrüsentumoren in benigne und maligne wurde nach der 2017 veröffentlichen WHO-Klassifikation um die Gruppe der Neoplasien mit unsicherem/(extrem) geringem Malignitätspotenzial erweitert. Durch die Etablierung der „nicht invasiven follikulären Neoplasie mit PTC-äquivalenten Kernmerkmalen (NIFTP)“ wird erstmalig aufgrund des erwiesenen indolenten biologischen Verhaltens eine Subgruppe von nach bisherigen Diagnosekriterien als gekapselte follikuläre Variante des papillären Karzinoms (FV-PTC) klassifizierte Tumoren nicht mehr als Krebs bezeichnet, wodurch den betroffenen Patienten sowohl eine Übertherapie als auch die psychologische Belastung durch die Krebsdiagnose erspart wird.

Der in der Pathologie erhobene Befund von Schilddrüsenneoplasien beruht zwischenzeitlich auf einer Reihe durchaus subtiler morphologischer und/oder molekularpathologischer Kriterien. Dieser Befund ist aber der entscheidende Parameter des weiteren Managements der betroffenen Patienten/Patientinnen, was auch maßgeblich die Nuklearmedizin betrifft. Darüber hinaus bietet die Nuklearmedizin äußerst vielversprechende neue diagnostische und auch therapeutische Ansätze zur Behandlung des Schilddrüsenkarzinoms.

Abstract

The morphological diagnosis of thyroid tumours determines primarily the clinical management of the respective patients. The fine needle biopsy (FNB) should be a decision-making tool for or against surgery; the intraoperative frozen section is intended to help determine the extent of surgery and to help prevent second surgeries. However, the latter two methods have considerable limitations. Thus in many cases the final diagnosis has to be made on paraffin histology. Immunohistochemistry and increasingly molecular pathological analyzes are available for exact diagnosis.

According to the in 2017 published WHO classification, the traditional classification of thyroid tumours into benign and malignant tumours has been expanded by the introduction of the group of neoplasms with uncertain/(extremely) low malignant potential. Due to the establishment of „non-invasive follicular neoplasia with papillary-like nuclear features (NIFTP)“ a subgroup of encapsulated follicular variant papillary carcinoma (FV-PTC) with proven indolent biological behavior is no longer referred to as cancer thus avoiding overtreatment as well as the psychological burden of cancer diagnosis.

The pathological diagnosis of thyroid tumours is based on a variety of quite subtle morphological and/or molecular pathological criteria, representing the decisive parameter for the further management of patients, which also applies to nuclear medicine. In addition, nuclear medicine offers highly promising new diagnostic and therapeutic approaches to both diagnosis and therapy of thyroid carcinoma.

Schlüsselwörter

Schilddrüsenneoplasie - Morphologische Diagnose - Molekularpathologie - NIFTP - Übertherapie

Keywords

Thyroid neoplasia - morphological diagnosis - molecular pathology - NIFTP - overtreatment

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