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Source: Butterfly College Guide: Do all thyroid nodules need surgery? If there is no surgery, can other methods be used for treatment? At the 14th Merck Forum, Professor Liu Chao from Jiangsu Branch of China Academy of Chinese Medical Sciences gave a wonderful academic sharing on the topic of "Non-surgical Treatment of Thyroid Nodules"
.
Expert profile Professor Liu Chao, chief physician, professor, and doctoral supervisor
.
Presided over and participated in 12 national, provincial and ministerial scientific research projects such as the National Natural Science Foundation of China, including 6 national scientific research projects
.
More than 3000 academic papers have been published, and more than 100 papers have been included in SCI
.
Editor-in-chief and co-editing 45 academic monographs
.
Received 6 awards for scientific research achievements at all levels
.
Treatment of thyroid nodules At present, there are surgical treatments and non-surgical treatments for thyroid nodules.
Non-surgical treatments include follow-up observation, drug therapy, chemical ablation, isotope therapy, and thermal ablation.
Different measures have their own advantages and disadvantages ( Figure 1) From the perspective of implementation difficulty and patient acceptance, follow-up observation is the most acceptable and easiest for patients; surgical treatment is the most consistent, but the cost is higher and related complications will occur
.
How to weigh the different treatment options? Professor Liu Chao pointed out that although there are benign and malignant thyroid nodules, the benign and malignant nodules are not a decisive factor in the choice of treatment
.
Specifically: ➤For benign nodules that are large (>4cm), repeat fine needle aspiration (FNA) are benign but continue to grow, cause compression or structural symptoms, etc.
, the guidelines recommend surgery; ➤For malignant nodules Nodules, except for papillary thyroid microcarcinoma (PTMC), the first choice for thyroid cancer is surgery
.
Figure 1 Comparison of various treatment measures.
Non-surgical treatment of benign thyroid nodules.
Non-surgical treatment methods of benign thyroid nodules include follow-up observation, thyroid hormone suppression therapy, cyst fluid aspiration/injection therapy, radioactive iodine therapy, thermal ablation therapy, and Other medications
.
1.
Follow-up observation Follow-up observation is of great significance to the treatment of thyroid nodules.
Local compression caused by the growth of nodules can be detected in time, and the progress of potential malignant tumors can be discovered
.
The 5-year follow-up results of 1567 benign thyroid nodules in 992 patients by Durante.
C et al.
showed that 88.
9% of the nodules had no significant changes or even shrunk
.
Therefore, the 2012 edition of "Guidelines for the Diagnosis and Treatment of Thyroid Nodules and Differentiated Thyroid Cancer" recommends that most benign thyroid nodules can be followed up every 6-12 months; the follow-up interval recommended by foreign guidelines is longer, even if The ultrasound risk stratification is a high-risk cytological benign nodule, and the follow-up interval recommended by the ATA guidelines is only 12 months (Figure 2)
.
Figure 2 Follow-up of ATA guidelines for cytological benign thyroid nodules 2.
The goal of thyroid hormone suppression therapy is to make serum thyroid stimulating hormone (TSH) ≤ 0.
3 U/L
.
It should be noted that if the nodule volume does not change or even increases after six months to one year of treatment, thyroid hormone suppression therapy should be stopped, and further examinations should be made to determine benign and malignant nodules
.
In foreign countries, the ATA and AACE guidelines do not recommend the routine application of L-T4 suppression in the treatment of benign thyroid nodules in iodine-sufficient areas to reduce the volume of the nodules
.
Based on the fact that the vast majority of the population in China is in a state of sufficient iodine or even excess iodine, when TSH suppression treatment is performed for patients with normal thyroid function and benign thyroid nodules, the risks and benefits should be carefully weighed to avoid overtreatment
.
3.
A pharmaceutical injection therapy available injectable pharmaceutical anhydrous isopropyl alcohol, glucocorticoids, other somatostatin analogues
.
The American AACE guidelines recommend that percutaneous alcohol injection can be used for cystic and predominantly cystic nodules, especially the first choice for recurrent cystic nodules; ➤It is not recommended for solid nodules (including high-functioning adenomas)
.
However, before alcohol injection therapy, the nodules need to be evaluated.
If the nodules are recurrent pure cystic nodules, they can be injected without FNA; ➤If the nodules are mainly cystic and have spongy or comet tails, then An FNA result ≥1 time is considered to be benign for injection treatment; ➤If it is a substantial cystic nodule, FNA ≥2 times is considered to be benign before injection treatment
.
4.
Radioactive iodine therapy Radioactive iodine can also be used for the treatment of benign thyroid nodules, especially autonomic functional nodules, toxic nodular goiter and nodular goiter with normal thyroid function
.
5.
Thermal ablation Globally, thermal ablation includes radio frequency ablation (RFA), microwave ablation (MWA), laser ablation (LA) and high-energy focused ultrasound ablation (HIFU).
Microwave ablation is commonly used in China
.
Related studies have also shown that microwave ablation is safe and effective in the treatment of benign thyroid nodules (Figure 3)
.
Professor Liu Chao mentioned that the patient's indications and contraindications should be grasped for thermal ablation
.
Thermal ablation is forbidden for patients with huge retrosternal goiter or most thyroid nodules located behind the sternum and contralateral vocal cord dysfunction
.
Figure 3 Effectiveness of microwave ablation treatment The non-surgical treatment of thyroid cancer is similar to that of benign thyroid nodules.
Non-surgical treatments are also available for thyroid cancer, including follow-up observation, drug ablation, thermal ablation and cryoablation, radioiodine therapy, and drug chemotherapy And local radiation therapy
.
In this part, Professor Liu Chao introduced the non-surgical treatment of undifferentiated thyroid cancer (DTC)/refractory differentiated thyroid cancer (RR-DTC) and PTMC based on the degree of differentiation of thyroid cancer
.
1.
Non-DTC/RR-DTC non-DTC/RR-DTC non-surgical therapies mainly include drug-targeted therapy and radioactive iodine therapy
.
Specifically: ➤Most non-DTC/RR-DTC patients can choose drug-targeted therapy; ➤If the patient is sensitive to radiotherapy, radioactive iodine therapy can be selected
.
2.
PTMCPTMC patients can choose active monitoring or thermal ablation therapy
.
Specifically: ➤Patients with no lymph node metastasis, no distant metastasis, and no extrathyroid invasion can be actively monitored.
The "Chinese Expert Consensus on the Diagnosis and Treatment of Papillary Thyroid Carcinoma" points out that for patients with PTMC with low risk factors, strict selection Indications and combined with the patient's wishes, close observation and follow-up can be considered
.
➤As for thermal ablation, the "Expert Consensus of the Thyroid Cancer Professional Committee of the Chinese Anti-Cancer Association" pointed out that thermal ablation is not recommended as a routine method for PTMC
.
However, studies have shown that compared with surgical treatment, WMA has significantly fewer adverse reactions (Figure 4), and the quality of life of PTMC patients after WMA is better than surgical treatment
.
Figure 4 WMA and surgical treatment adverse reaction comparison meeting summary meeting At the end of the meeting, Professor Liu Chao summarized the standard diagnosis and treatment of thyroid nodules: diagnosis is the basis of the treatment of thyroid nodules, and the patient’s personal and family history should be combined in clinical practice.
Diagnose the results of various examinations and genetic tests to identify benign nodules; in the selection of treatment options, the effectiveness, suitability, safety, economy, accessibility, and compliance of the options should be comprehensively considered, and over-diagnosis and treatment should be weighed.
With delayed illness, find the best treatment plan
.
.
Expert profile Professor Liu Chao, chief physician, professor, and doctoral supervisor
.
Presided over and participated in 12 national, provincial and ministerial scientific research projects such as the National Natural Science Foundation of China, including 6 national scientific research projects
.
More than 3000 academic papers have been published, and more than 100 papers have been included in SCI
.
Editor-in-chief and co-editing 45 academic monographs
.
Received 6 awards for scientific research achievements at all levels
.
Treatment of thyroid nodules At present, there are surgical treatments and non-surgical treatments for thyroid nodules.
Non-surgical treatments include follow-up observation, drug therapy, chemical ablation, isotope therapy, and thermal ablation.
Different measures have their own advantages and disadvantages ( Figure 1) From the perspective of implementation difficulty and patient acceptance, follow-up observation is the most acceptable and easiest for patients; surgical treatment is the most consistent, but the cost is higher and related complications will occur
.
How to weigh the different treatment options? Professor Liu Chao pointed out that although there are benign and malignant thyroid nodules, the benign and malignant nodules are not a decisive factor in the choice of treatment
.
Specifically: ➤For benign nodules that are large (>4cm), repeat fine needle aspiration (FNA) are benign but continue to grow, cause compression or structural symptoms, etc.
, the guidelines recommend surgery; ➤For malignant nodules Nodules, except for papillary thyroid microcarcinoma (PTMC), the first choice for thyroid cancer is surgery
.
Figure 1 Comparison of various treatment measures.
Non-surgical treatment of benign thyroid nodules.
Non-surgical treatment methods of benign thyroid nodules include follow-up observation, thyroid hormone suppression therapy, cyst fluid aspiration/injection therapy, radioactive iodine therapy, thermal ablation therapy, and Other medications
.
1.
Follow-up observation Follow-up observation is of great significance to the treatment of thyroid nodules.
Local compression caused by the growth of nodules can be detected in time, and the progress of potential malignant tumors can be discovered
.
The 5-year follow-up results of 1567 benign thyroid nodules in 992 patients by Durante.
C et al.
showed that 88.
9% of the nodules had no significant changes or even shrunk
.
Therefore, the 2012 edition of "Guidelines for the Diagnosis and Treatment of Thyroid Nodules and Differentiated Thyroid Cancer" recommends that most benign thyroid nodules can be followed up every 6-12 months; the follow-up interval recommended by foreign guidelines is longer, even if The ultrasound risk stratification is a high-risk cytological benign nodule, and the follow-up interval recommended by the ATA guidelines is only 12 months (Figure 2)
.
Figure 2 Follow-up of ATA guidelines for cytological benign thyroid nodules 2.
The goal of thyroid hormone suppression therapy is to make serum thyroid stimulating hormone (TSH) ≤ 0.
3 U/L
.
It should be noted that if the nodule volume does not change or even increases after six months to one year of treatment, thyroid hormone suppression therapy should be stopped, and further examinations should be made to determine benign and malignant nodules
.
In foreign countries, the ATA and AACE guidelines do not recommend the routine application of L-T4 suppression in the treatment of benign thyroid nodules in iodine-sufficient areas to reduce the volume of the nodules
.
Based on the fact that the vast majority of the population in China is in a state of sufficient iodine or even excess iodine, when TSH suppression treatment is performed for patients with normal thyroid function and benign thyroid nodules, the risks and benefits should be carefully weighed to avoid overtreatment
.
3.
A pharmaceutical injection therapy available injectable pharmaceutical anhydrous isopropyl alcohol, glucocorticoids, other somatostatin analogues
.
The American AACE guidelines recommend that percutaneous alcohol injection can be used for cystic and predominantly cystic nodules, especially the first choice for recurrent cystic nodules; ➤It is not recommended for solid nodules (including high-functioning adenomas)
.
However, before alcohol injection therapy, the nodules need to be evaluated.
If the nodules are recurrent pure cystic nodules, they can be injected without FNA; ➤If the nodules are mainly cystic and have spongy or comet tails, then An FNA result ≥1 time is considered to be benign for injection treatment; ➤If it is a substantial cystic nodule, FNA ≥2 times is considered to be benign before injection treatment
.
4.
Radioactive iodine therapy Radioactive iodine can also be used for the treatment of benign thyroid nodules, especially autonomic functional nodules, toxic nodular goiter and nodular goiter with normal thyroid function
.
5.
Thermal ablation Globally, thermal ablation includes radio frequency ablation (RFA), microwave ablation (MWA), laser ablation (LA) and high-energy focused ultrasound ablation (HIFU).
Microwave ablation is commonly used in China
.
Related studies have also shown that microwave ablation is safe and effective in the treatment of benign thyroid nodules (Figure 3)
.
Professor Liu Chao mentioned that the patient's indications and contraindications should be grasped for thermal ablation
.
Thermal ablation is forbidden for patients with huge retrosternal goiter or most thyroid nodules located behind the sternum and contralateral vocal cord dysfunction
.
Figure 3 Effectiveness of microwave ablation treatment The non-surgical treatment of thyroid cancer is similar to that of benign thyroid nodules.
Non-surgical treatments are also available for thyroid cancer, including follow-up observation, drug ablation, thermal ablation and cryoablation, radioiodine therapy, and drug chemotherapy And local radiation therapy
.
In this part, Professor Liu Chao introduced the non-surgical treatment of undifferentiated thyroid cancer (DTC)/refractory differentiated thyroid cancer (RR-DTC) and PTMC based on the degree of differentiation of thyroid cancer
.
1.
Non-DTC/RR-DTC non-DTC/RR-DTC non-surgical therapies mainly include drug-targeted therapy and radioactive iodine therapy
.
Specifically: ➤Most non-DTC/RR-DTC patients can choose drug-targeted therapy; ➤If the patient is sensitive to radiotherapy, radioactive iodine therapy can be selected
.
2.
PTMCPTMC patients can choose active monitoring or thermal ablation therapy
.
Specifically: ➤Patients with no lymph node metastasis, no distant metastasis, and no extrathyroid invasion can be actively monitored.
The "Chinese Expert Consensus on the Diagnosis and Treatment of Papillary Thyroid Carcinoma" points out that for patients with PTMC with low risk factors, strict selection Indications and combined with the patient's wishes, close observation and follow-up can be considered
.
➤As for thermal ablation, the "Expert Consensus of the Thyroid Cancer Professional Committee of the Chinese Anti-Cancer Association" pointed out that thermal ablation is not recommended as a routine method for PTMC
.
However, studies have shown that compared with surgical treatment, WMA has significantly fewer adverse reactions (Figure 4), and the quality of life of PTMC patients after WMA is better than surgical treatment
.
Figure 4 WMA and surgical treatment adverse reaction comparison meeting summary meeting At the end of the meeting, Professor Liu Chao summarized the standard diagnosis and treatment of thyroid nodules: diagnosis is the basis of the treatment of thyroid nodules, and the patient’s personal and family history should be combined in clinical practice.
Diagnose the results of various examinations and genetic tests to identify benign nodules; in the selection of treatment options, the effectiveness, suitability, safety, economy, accessibility, and compliance of the options should be comprehensively considered, and over-diagnosis and treatment should be weighed.
With delayed illness, find the best treatment plan
.
