




版權(quán)說明:本文檔由用戶提供并上傳,收益歸屬內(nèi)容提供方,若內(nèi)容存在侵權(quán),請進行舉報或認領(lǐng)
文檔簡介
Thyroiddisease
LiboLiMD
DepartmentofGeneralSurgery
SirRunRunShawHospital
Schoolofmedicine,ZhejiangUniversity
Thyroiddisease
LiboLiMD
AnatomyofThyroidAnatomyofThyroidAnatomyofThyroidAnatomyofThyroidThyroiddiseaseNontoxicgoiterHyperthyroidismThyroidCancerThyroiditisThyroiddiseaseNontoxicgoiterNontoxicGoiterGoiterfromtheFrench(goitre)andLatin(guttur),bothmeaningthroatDefinedasanenlargementofthethyroidglandEndemicwhenitinvolvesmorethan10%ofthepopulationThemajority,secondarytoiodinedeficiencyEspeciallyfoundinhighmountainregionsNontoxicGoiterGoiterfromtheNontoxicGoiter
ClinicalthinkingWhetherthepatienthaslocalsymptomsWhetherthegoiteristoxicornontoxicWhetheranyofthenodulesharboracancerThenumberandbilateralityofthenodulesTSHlevel,differentialdiagnosisofhypothyroidismorhyperthyroidismAppropriatetreatmentoptionsforeachparticularpatient
NontoxicGoiter
TakinghistoryAsymptomaticneckmassAcough,shortnessofbreath,stridor,orhoarsenessChokingoraspiration,dysphagia,orpainSymptomsofhyperthyroidismWhetherthepatienthascosmeticconcernsFromiodinedeficiencyregion
NontoxicGoiter
PhysicalexaminationWhetherthegoiterisconfinedtotheneckWhetherithasasubsternalcomponentWhethertrachealdeviationispresentThesizeandconsistencyofthegoiterThemobilityofthevocalcordsbyeitherindirectordirectlaryngoscopy
NontoxicGoiter
UltrasoundHowmanynodules?Bilateral?Ultrasoundcharacteristics
NontoxicGoiterCTscanNeckandchest,especiallysubsternalthyroidRareintrathoracicoraberrantthyroidNontoxicGoiterCTscanNontoxicGoiterFineneedleaspiration(FNA)SuspiciousmalignentgoiterNontoxicGoiterFineneedleaspNontoxicGoiter
TreatmentIodinedietreplacement(endemicgoitor)SurgicalresectionSymptomsLocalcompressionSecondaryhyperthyroidisimAnysuspiciousormalignantlesionCosmeticreasonsRadioiodinetherapy,highriskofptsThyroidhormonesuppression(notforsporadicgoiter)
SporadicNontoxicGoiterAsymptomaticEuthyroidMostbilaterallyNoefficiencyofthyroidhormonereplacementHighrecurrencepostoperatively30%~40%SporadicNontoxicGoiterAsymptNontoxicGoiter
HistoryofThyroidSurgeryFirstthyroidectomy,inParisin1791byPierre-JosephDesaultAntisepsis,hemostasis,andgeneralanesthesiainthe1840sthyroidsurgerybecamesafeTheodoreKocher,aNobelPrizein1909FromBern,SwitzerlandHispioneeringeffortsinthyroidsurgery
PrimaryHyperthyroidsim
Grave’sDiseasePrimaryHyperthyroidsim
GraveClinicalStatisticsGravesDiseaseisthemostcommoncauseofhyperthyroidism(60-80%)ofallcasesFemalesareaffectedmorefrequentlythanmen10:1.5Monozygotictwinsshow50%concordanceratesIncidencepeaksfromages20-40IncidenceissimilarinwhitesandAsians,butissomewhatdecreasedforAfricanAmericansClinicalStatisticsGravesDiseGraves'DiseaseAutoimmunesystemicdisorderThyroidreceptorantibodybindingtoandstimulatingtheTSHreceptorExcessivesynthesisandsecretionofthyroidhormoneUsuallydiffuselyandsymmetricallyenlargedandfirmGraves'DiseaseAutoimmunesystHyperthyroidism—uptakeA.NormalB.Graves’DzC.ToxicMultinodularGoiterD.ToxicAdenomaE.ThyroiditisHyperthyroidism—uptakeA.NormaHyperthyroidism
SymptomsHeatintolerance,sweating,palpitations,fatigueWeightloss,diaphoresis,increasedstoolfrequencyMuscleweakness,anxiety,insomniaNervousnessorrestlessness;irritability,emotionallabilityInwomen,irregularmenses
Hyperthyroidism
ClinicalfindingsTremor,tachycardia(A.fib),Goiter,lidlag,proptosis,periorbitaledema,exophthalmos;chemosis;hyperreflexiaWarm,moistskin;dermopathy;andpretibialedema,
osteoporosis
ExopthalamosinGravesDiseaseLidLaginGravesDiseaseExopthalamosinGravesDiseaseHyperthyroidism—treatmentBeta-blockers:controlsxsPropranololdecrperipheralT4->T3conversionGraves’DzPTU(safeinpregnancy)ormethimazoleRaresideeffect:agranulocytosisRadioactiveiodine75%oftreatedptsbecomehypothyroidSurgeryToxicAdenomaorTMNGRAIorsurgeryHyperthyroidism—treatmentBeta-Hyperthroidism
SurgerySurgicalapproachBilateralnear-totalortotalthyroidectomyIndicationofsurgery(InChina)CompressivesymptomsSecondaryoradenomaRecurrenceofmedicineoriodine-131NoefficiencyofmedicineSecondtrimesterofpregnancy
Surgeryforhyperthyroidism
PreoperativepreparationAbsolutelyrequiredantithyroiddrugs,for3to6weekswithagoalofnearlynormalizingtheT3andT4PropranololoratenololrapidlycontrolstheadrenergicsideeffectsofexcessT4andT3tachycardia,tremor,anddiaphoresisLugol'ssolutionrapidlybuttemporarilyrestoresnormalthyroidfunctionandreducesthyroidglandvascularity
SurgicalcomplicationsBleedingRecurrentLaryngealNerveDamageHypoparathyroidismandHypocalcemiaSuperiorlaryngealnervedamageThyroidstormSurgicalcomplicationsBleedinThyroidcancerThyroidcancerThyroidcancer
IntroductionThemostcommon,95%ofallendocrinecancersIncreasingfasterthananyothercancerMorethan90%,welldifferentiatedGoodlong-termprognosis
Thyroidcancer
ClinicalPresentationMost,clinicallywithapalpablenoduleUsuallyasymptomaticRarecases,withhoarseness,pain,dysphagia,dyspnea,coughing,orchokingspellsPain,withthesuspicionforMedullarythyroidcarcinomaAnaplasticcarcinomaLymphoma
PertinenthistoricalfactorspredictingmalignancyAhistoryofheadandneckirradiationTotalbodyirradiationforbonemarrowtransplantationExposuretofalloutfromtheexplosionoftheChernobylnuclearpowerplantin1986,especiallyinchildren;Afamilyhistoryofthyroidcancer;andrapidgrowthorhoarseness.Children,men,andadultsolderthan60yearshaveanincreasedriskofmalignancyPertinenthistoricalfactorspIncreasetheriskofthyroidcancerPersonalandfamilyhistoryofotherendocrinedisorders,specificallyhyperparathyroidism,pituitaryadenomas,pancreaticisletcelltumors,adrenaltumors,andbreastcancer.Afamilyhistoryofpapillaryormedullarycarcinoma(MENsyndromes),familialpolyposis,Gardner'ssyndrome,andCowden'ssyndromeIncreasetheriskofthyroidcPertinentphysicalfindingsSuggestingpossiblemalignancyGrittytexture”(顆粒樣)ofthethyroidnoduleCervicallymphadenopathyVocalcordparalysisFixationofthenoduletosurroundingtissuePertinentphysicalfindingsSuThyroidcancer
DiagnosisUltrasoundFeatureofmalignancyIrregularmarginsIntranodularvascularpatternMicrocalcificationsFineneedleaspiration(FNA)Themostreliableandcost-efficientmethod
Thyroidcancer
DiagnosisThyroidfunctiontestsSerummarkersThyroglobulin(TG)forwell-differentiatedthyroidcancerCalcitoninandCEAformedullarythyroidcancerAllptswithmedullarythyroidcancerRETproto-oncogenepheochromocytomaandhyperparathyroidism
Managementofthyroidcancer
ThegoalsoftherapyRemovalofprimarytumor,diseasethatextendsbeyondthethyroidcapsule,andinvolvedcervicallymphnodesMinimizationoftreatment-anddisease-relatedmorbidityAccuratediseasestagingFacilitationofpostoperativetreatmentwithradioiodinewhenappropriateAccuratelong-termsurveillanceMinimizationoftheriskofrecurrentlocalandmetastatictumor
Well-DifferentiatedThyroidCarcinoma
PapillaryThyroidCarcinoma
Themostcommonendocrinemalignancy,approximately80%ofnewcasesAssociatedwiththebestprognosisAtleasttwiceascommoninwomenasmenApeakageofpresentationof38to45years90%ofradiation-induced,familialin5%
PapillaryThyroidCarcinomaPapillaryThyroidCarcinomaWell-DifferentiatedThyroidCarcinoma
PrognosesTheriskofdeathapproximately5%inthelow-riskgroup40%inthehigh-riskgroupFortunately,mostpts(70%)inthelow-riskgroup
OtherhistologicalfactorsTopredictthebehaviorofthyroidcancerPloidyofthetumorAdenylatecyclaseresponsetothyroidstimulatinghormone(TSH)RadioiodineuptakeApositivepositronemissiontomographyscanEpidermalgrowthfactor(EGF)receptorlevelandvariousgeneprofilesOtherhistologicalfactorsToPapillaryThyroidCarcinoma
Theextentofsurgicalresection
ControversialAmericanrecommondationTotalorneartotalthyroidectomy
complicationrateoflessthan2%SelectivenodalresectionPostoperativetreatmentwithiodine-131Low-riskptslessthan1cmthyroidlobectomyandisthmectomyOKReoperationmultifocal,withnodalmetastases,orwithlocalinvasion
BenefitsoftotalthyroidectomyPostoperativeradioiodinescanningandablativetherapycanbeeffectiveSerumthyroglobulinlevelsarerenderedmoresensitivefordetectingrecurrentorpersistentdiseaseIntrathyroidalcancerthatispresentinmorethan50%ofpatientsisremovedThesmallriskofadifferentiatedthyroidcancerbecominganundifferentiatedcancerisdecreased.BenefitsoftotalthyroidectomPapillaryThyroidCarcinoma
Theroleoflymphnodedissection
AlsocontroversialMicrometastasistocervicallymphnodesiscommon(80%)ProphylacticcervicallymphnodedissectionisnotwarrantedFunctionalneckdissectionandcentralneckdissectionshouldgenerallybeperformedonlyinptswithclinicalorsonographicevidenceoflymphnodeinvolvement
FollicularThyroidCarcinomaApproximately10%ofallthyroidmalignanciesTypicallyolderthanPTCUsuallyinthesixthdecadeoflifeThefemale-to-maleratioisbetween2:1and5:1AslowlygrowingsolitarythyroidnoduleAtendencytospreadhematogenouslyRarelywithsymptomsofdistantmetastasistothebone,lung,brain,andliverFollicularThyroidCarcinomaApFollicularThyroidCarcinomaLessthan6%metastasizetothecervicallymphnodesApproximately25%ofptshaveextrathyroidalinvasion10%to33%havedistantmetastasisatthetimeofinitialdiagnosisFollicularThyroidCarcinomaLeTheprognosisoffollicularcancerSlightlyworsethanthatforpapillarycancerOverallsurvivalrangesfrom43%to95%at10yearsLifelongsurveillanceisnotnecessaryTheprognosisoffollicularcaTheprognosisoffollicularcancerTheimportantprognosticfactorsPresenceofmetastaticdiseaseOlderage(usually>40years)Degreeofinvasion(microcapsularvs.angioinvasionwithorwithoutcapsularandwidelyinvasive)DegreeoftumordifferentiationTheprognosisoffollicularcaFollicularThyroidCarcinomaDiagnosisThewholespecimenmustbeevaluatedforvascularandcapsularinvasion.DiagnosisoffollicularcancercannotbemadeonFNABFollicularThyroidCarcinomaDiFollicularThyroidCarcinomaTreatmentTherecommendedinitialoperationislobectomyandisthmectomyLymphnodedissectionisrarelywarrantedbecausenodalmetastasesareuncommonFollicularThyroidCarcinomaTrMedullaryThyroidCarcinoma7%ofthyroidcancers15%ofallthyroidcancer–relateddeathsApprox75%sporadic零星的,25%hereditaryFromccellsorparafollicularcellsLocatedlaterallyatthejunctionoftheuppertwothirdsofthethyroidglandatapproximatelythelevelofthecricoidcartilageMedullaryThyroidCarcinoma7%MedullaryThyroidCarcinomaInthesporadicformUsuallyasinglefocusofmalignancyUnilateraldiseasein85%ofcasesInthehereditaryformMultifocalandbilateralin90%ofcasesC-cellhyperplasiaMedullaryThyroidCarcinomaInThehereditaryformsofMTCThehereditaryformsofMTCMedullaryThyroidCarcinoma
TumormarkerSerummarkersforcalcitoninsupportthediagnosiscorrelatewithtumorbulk,nodal,anddistantmetastasisHighCEAlevelscorrelatewithapoorerprognosisFlushinganddiarrheaalsohaveaworseprognosis
MedullaryThyroidCarcinoma
LymphnodemetastasesPositivein70%ofpatients81%ofpatientshadcentralnodedisease81%hadipsilateralcervicalnodedisease44%hadcontralateralcervicalnodaldisease
PreventionorcureofMTCBysurgerymainlydependentontheinitialstageandtheadequacyoftheinitialoperationIndicationRET-positivepatientswithfamilialdiseasebeforetheageofpossiblemalignantprogressiontotalthyroidectomybeforeage6PreventionorcureofMTCBysuSurgicalmanagementforMTCDependsonthepresentationofthediseaseThyroidectomyandcentralnodedissectionCentrallymphnodedissectionsincreasetheriskofrecurrentlaryngealnerveinjuryandhypoparathyroidismSurgicalmanagementforMTCDeAnaplasticThyroidCarcinomaRare,1%to2%ofthyroidmalignanciesMorethanhalfofthedeathsfromthyroidcancerSurvivalismeasuredinmonthsCommonlyinpatientsolderthan60yearsUsuallypresentsasarapidlyexpandingthyroidmassAnaplasticThyroidCarcinomaRaAnaplasticThyroidCarcinomaLymphnodeenlargementFrequent(84%)andearlyLocaltumorextensioncauseFixationofthelarynx,esophagus,andcarotidvesselsDysphagia,dysphonia,anddyspneaarecommonSystemicmetastasesoccurin75%ofpts,Usuallyinvolvingthelungs,bone,brain,andadrenalglandsAnaplasticThyroidCarcinomaLyAnaplasticThyroidCarcinomaThediagnosisBeestablishedbyFNABDifferentiatedfromthatoflymphomaandpoorlydifferentiatedmedullarycarcinomaAnaplasticThyroidCarcinomaThAnaplasticThyroidCarcinoma
SurgeyUsuallynotcurative,withdistantmetastasesMultimodalitytreatment,slightlyimprovedoutcomesIndicatelocalcontrolin22%to76%ofptsMediansurvivalrangesfrom2.5to9months,with2-yearsurvivaloflessthan20%
SubacuteThyroiditisPainlessThyroiditisPainfulThyroiditisRareSubacuteThyroiditisPainlessTPainlessThyroiditisAlsocalledlymphocyticthyroiditisSpontaneouslyresolvinghyperthyroidismAnautoimmunedisorderTypicallyelevatedthyroidperoxidaseantibodylevelsLymphocyticinfiltrationofthethyroidPainlessThyroiditisAlsocallePainlessThyroiditis
ClinicalPresentationAgesof30and60years40%ptswiththeclassicalafour-stageclinicalcourse(1)Destruction-inducedthyrotoxicosis,(2)euthryoidism,(3)hypothyroidism,and(4)returntoeuthyroidismUsually,firmglandandnon-tenderwithsymmetrical,modestenlargementNearlyonethirdofpts,permanentlyhypothyroid
溫馨提示
- 1. 本站所有資源如無特殊說明,都需要本地電腦安裝OFFICE2007和PDF閱讀器。圖紙軟件為CAD,CAXA,PROE,UG,SolidWorks等.壓縮文件請下載最新的WinRAR軟件解壓。
- 2. 本站的文檔不包含任何第三方提供的附件圖紙等,如果需要附件,請聯(lián)系上傳者。文件的所有權(quán)益歸上傳用戶所有。
- 3. 本站RAR壓縮包中若帶圖紙,網(wǎng)頁內(nèi)容里面會有圖紙預(yù)覽,若沒有圖紙預(yù)覽就沒有圖紙。
- 4. 未經(jīng)權(quán)益所有人同意不得將文件中的內(nèi)容挪作商業(yè)或盈利用途。
- 5. 人人文庫網(wǎng)僅提供信息存儲空間,僅對用戶上傳內(nèi)容的表現(xiàn)方式做保護處理,對用戶上傳分享的文檔內(nèi)容本身不做任何修改或編輯,并不能對任何下載內(nèi)容負責。
- 6. 下載文件中如有侵權(quán)或不適當內(nèi)容,請與我們聯(lián)系,我們立即糾正。
- 7. 本站不保證下載資源的準確性、安全性和完整性, 同時也不承擔用戶因使用這些下載資源對自己和他人造成任何形式的傷害或損失。
最新文檔
- 2025至2030中國旋轉(zhuǎn)渦旋空氣壓縮機行業(yè)發(fā)展趨勢分析與未來投資戰(zhàn)略咨詢研究報告
- 2025至2030中國新鮮水果和蔬菜行業(yè)發(fā)展趨勢分析與未來投資戰(zhàn)略咨詢研究報告
- 2025至2030中國新型塑料管材行業(yè)市場發(fā)展現(xiàn)狀及發(fā)展趨勢與投資報告
- 2025至2030中國廣告制作行業(yè)市場發(fā)展現(xiàn)狀及發(fā)展趨勢與投資報告
- 食品采購協(xié)議合同
- 2025年教師資格證面試結(jié)構(gòu)化面試真題卷:教育倫理與教師道德修養(yǎng)
- 2025年美容師(初級)職業(yè)技能鑒定實操試卷:美容院顧客滿意度調(diào)查與分析報告
- 2025年美容師(中級)美容師行業(yè)優(yōu)勢理論知識考核試卷
- 2025年茶藝師高級技能考核試卷:茶藝館經(jīng)營管理策略解析試題
- 2025年古箏演奏技能考核試卷-古箏演奏與音樂傳播研究試題
- 防治腦卒中專業(yè)知識講座
- 平壓平模切機安全操作規(guī)程、風險告知卡、應(yīng)急處置
- JJG 646-2006移液器
- GB/T 40167-2021紙和紙板加速老化(100 ℃)
- GB/T 17626.4-2018電磁兼容試驗和測量技術(shù)電快速瞬變脈沖群抗擾度試驗
- GB/T 1094.12-2013電力變壓器第12部分:干式電力變壓器負載導(dǎo)則
- 活性炭改性及吸附條件研究性實驗
- 小學(xué)體育教研活動記錄(有內(nèi)容)
- 核級閥門強度計算方法的分析
- 中國古代朝代歷史知識大漢王朝科普圖文PPT教學(xué)課件
- 氯氧鉍光催化劑的晶體結(jié)構(gòu)
評論
0/150
提交評論