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2015年新版甲状腺癌诊治指南将有重大更新

Enhanced Thyroid Cancer Guidelines Expected in 2015

发布者:爱思唯尔 发布时间:2014-11-24

2015年初美国甲状腺学会将发布新版甲状腺癌诊治指南,预期可能会有重大更新。

在2014年美国甲状腺学会年会上,甲状腺癌指南工作小组主席Bryan R. Haugen教授透露道,甲状腺癌诊治指南上次更新是在2009年,而新版指南制定的目标是基于循证医学证据,并对临床有所帮助。例如,新版指南中主建议将从2009版80条增加至101条,分建议将从103条增加至175条,而参考文献数量将从437条增加至998条。尽管如此,现有的80条主建议中仍有59条无明显变动,提示过去5–6年期间整个甲状腺癌诊治领域总体较为稳定。

新版指南中一个重大的变化是,对于甲状腺癌初始治疗后无结构可识别性病灶患者而言,器质性病变复发风险定义将有明显变化。低危定义为甲状腺内分化型甲状腺癌,包括≤5个淋巴结受累,转移灶最大径<0.2cm。中危定义为组织学特征提示为侵袭性,有少量组织扩散至甲状腺外,侵犯血管,或>5个淋巴结受累,转移灶最大径0.2-0.3cm。高危定义为甲状腺外发生广泛扩散、肿瘤不完全切除治疗、远处转移,或淋巴结转移灶最大径>3cm。

此外,新版指南还纳入了患者治疗反应动态风险评估量表,美国科罗拉多大学健康科学中心内分泌、代谢性疾病和糖尿病部门主任Haugen教授指出,虽然这个动态风险评估量表绝对适用于高危患者,但最适宜用于低危和中危患者。低质量证据强烈推荐使用此治疗反应风险评估量表,但这些证据主要来自接受甲状腺切除术和放射性碘治疗患者。因此,对于仅接受甲状腺切除术,未接受放射性碘治疗患者,以及仅接受放射性碘治疗患者而言,是否适用于此治疗反应风险评估量表,我们有些迟疑。

新版指南其他一些变化包括不需要对每个直径超过1cm结节都进行活检。Haugen教授阐述道,可以通过超声影像图片指导我们那些患者需要活检,那些患者需要随访。新版指南中新增一条对不符合甲状腺细针穿刺活检(FNA)标准结节的随访指南。同时,我们也推荐使用Bethesda细胞学分类系统对结节进行细胞学分类。

新版指南中对于甲状腺癌初始治疗方案也进行了一些变动,包括对高危患者进行横断面影像对比增强检查,以及考虑对肿瘤直径1–4cm患者进行甲状腺叶切除术治疗。Haugen教授指出,这是一个有争议的建议,我们在询问一些会员是否会这么做时,得到了一些反馈,例如,这些患者TSH控制靶目标为多少?是否应给予这些患者系统性左旋甲状腺素治疗?我们根据大家的反馈结果对指南进行修订,以帮助临床医师诊治这些患者。

新版指南还要求病理学报告应更加详细和标准,包括描述淋巴结大小、结外侵润、受累血管数量。Haugen教授称,我与一些病理学家和临床医师进行交流时,他们对这部新的指南非常认可。但是,我们还需要进一步探讨患者的肿瘤分期、复发风险和治疗反应,以及选择性放射性碘治疗使用等问题。新版指南还对治疗反应差的患者,特别是低危患者提出了一些建议。

新版指南还首次分出一个章节详细讲述放射性碘治疗难治性分化型甲状腺癌,包括导向治疗技巧、临床试验结果、系统性治疗和骨特异性治疗。

Haugen教授透露道,他接受了Veracyte和Genzyme公司的津贴和科研赞助。

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CORONADO, CALIF. (FRONTLINE MEDICAL NEWS) – Expect significant enhancements to the updated thyroid cancer management guidelines from the American Thyroid Association, due to be released in early 2015.

Last updated in 2009, the goal of the new guidelines is to “be evidence based and helpful,” guidelines task force chair Dr. Bryan R. Haugen said at the annual meeting of the American Thyroid Association. For example, the new guidelines will contain 101 recommendations, up from 80 in the 2009 version; 175 subrecommendations, up from 103; and 998 references, up from 437. “Still, 59 of the existing 80 recommendations are not substantially changed, showing a general stability in our field over the past 5 to 6 years,” he said.

One enhancement is a definition of risk of structural disease recurrence in patients without structurally identifiable disease after initial therapy for thyroid cancer. Low risk is defined as intrathyroidal differentiated thyroid cancer involving up to five metastases less than 0.2 cm in size. Intermediate risk is defined as the presence of aggressive histology, minor extrathyroidal extension, vascular invasion, or more than five involved lymph nodes with metastases 0.2-0.3 cm in size. High risk is defined as the presence of gross extrathyroidal extension, incomplete tumor resection, distant metastases, or lymph node metastases greater than 3 cm in size.

The guidelines also include a table that defines a patient’s response to therapy as a dynamic risk assessment. “This best applies to the low- to intermediate-risk patients, although it definitely applies to high risk as well,” said Dr. Haugen, who heads the division of endocrinology, metabolism, and diabetes at the University of Colorado Health Sciences Center, Denver. “It’s [a] strong recommendation based on low-quality evidence to use this risk-based response to therapy. A lot of this data is generated from patients who’ve had a thyroidectomy and have received radioiodine. So we’re on a bit more shaky ground right now in a patient who’s had a thyroidectomy but no radioiodine, or a patient who’s had a lobectomy.”

Other changes include the concept that it’s not necessary to biopsy every nodule more than 1 cm in size. “We’re going to be guided by the sonographic pattern in who we biopsy and how we monitor them,” Dr. Haugen explained. “A new recommendation adds follow-up guidance for nodules that do not meet FNA [fine-needle aspiration] criteria. We’re also recommending use of the Bethesda Cytology Classification System for cytology.”

Changes in the initial management of thyroid cancer include a recommendation for cross-sectional imaging with contrast for higher-risk disease and the consideration of lobectomy for some patients with tumors 1-4 cm in size. “This is a controversial recommendation,” Dr. Haugen said. “We got some feedback from members asking if you do it, what’s the TSH target? Should we give them synthetic levothyroxine? We are revising the guidelines based on this feedback to help guide clinicians.”

The new guidelines also call for more detailed/standardized pathology reports, with inclusion of lymph node size, extranodal invasion, and the number of invaded vessels. “I’ve talked to a number of pathologists and clinicians who are very happy about this guidance,” he said. “We also need to look at tumor stage, recurrence risk, and response to therapy in our patients, and the use of selective radioiodine. There is some more information on considering lower administered activities, especially in the lower-risk patients.”

For the first time, the guidelines include a section on radioiodine treatment for refractory differentiated thyroid cancer, including tips on directed therapy, clinical trials, systemic therapy, and bone-specific therapy.

Dr. Haugen disclosed that he has received grants and research support from Veracyte and Genzyme.

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来源: 爱思唯尔
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