The thyroid cancer on the ICD 10 enters the group of neoplasms of malignant current - C73 code. Cancer of the thyroid house is constantly on the control of physicians. Scientists monitor the development of the disease, its distribution speed. The first data on the localization of the disease was recorded in 2005. Diseases began to hit the younger generation. Forms of tumor formations of modernity are differentiated. The disease is diagnosed today twice as often. The ratio of lesion between the floors shows a greater number of patients among the female half. The age of patients subject to pathology is ranging from 40 to 60 years.

Recently, scientists - doctors reveal the causes of the disease, try to identify the conditions for occurrence. They study statistical data, regional, etiological and hereditary factors.

When studying statistical data, two patterns can be observed:

1. The percentage of terrible pathology in the total number of diseases is low - 2.2%.
2. One of the most frequent diseases (first lines) aged 20 to 29 years old.

Various etiological factors affect the development and distribution of cancer tumors:

1. The brightest and noticeable - radioactive irradiation. Sharp growth is noted after the explosions of atomic bombs (Japan), nuclear power plants (Chernobyl).
2. The use of treatment methods with radiation equipment: fork iron, inflammation of almonds.
3. Lack of iodine intake in the human body.
4. Prolonged treatment with medical preparations - thyareostatics (tiamazole).
5. Disorders of the functional morphological state of Glandula Thyreoidea.

Malignant thyroid neopoid, cancer tumor lesions are manifested against the background of other organ disorders. Often there is a disease near the arranged organs, tumors are manifested in several systems human organism At the same time.

All diseases are distributed by scientists - doctors and doctors - practitioners in groups. Each type is based on common symptoms and treatment methods. International classification is created to help professionals.

Endocrinologists are repelled in classification from the basic provisions and principles of separation.

1. Epithelial deviations: papillar, follicular, medullar, anaplastic cancer.
2. Carcinoma Gürtle.
3. Cellular forms of tumors: spine, giant, finely, flat.
4. Nepphelial pathology: Fibrosarkom.
5. Mixed diseases: carcinosarkom, teratoma, malignant forms of lymphoma, hemangioendothelioma.
6. Secondary manifestations.
7. Not classified species.

The international list gives physicians numerous information and data on the flow of each type of illness.

1. T - the size of the tumor and its appearance, distribution by the organ and nearby systems. The numbers characterize the transition of the tumor outside the thyroid, germination in the larynx, the transition and defeat of the esophagus.
2. N - gives a characteristic and assessment of the state of lymph nodes, metastatic signs. Each particular figure decrypts the distribution and appearance of metastasis, their quality and signs of lemon lesion.
3. M - decrypts in more detail the signs and location of metastasis, their remoteness.

Classification allocates each disease in the patient's age, age. Presents data on substabs of complex pathologies.

The most common is a papillar form. The disease proceeds for a long time. The dimensions of tumor formations can be microscopic or large, striking all the thyroid.

The structure of the tumor considered under the microscope can be described as:

• packaceous, with cubic and cylindrical epithelium;
• having extensive cell fields;
• having a composition with polymorphic cells.

Forecast treatment favorable.

Follicular cancer meets less often. Tumor neoplasms are accompanied by metastasis flowing into lungs, bone tissues. Often the view extends and germinates in blood vessels.

Medullar species is the most rare pathology. The tumor proceeds aggressively. There are two forms: sporadic, Maine. Of particular importance is heredity.

Anaplastic cancer has an unfavorable forecast and the aggressive nature of the flow.

Metastasation is one of the symptoms of all types of cancer. Identification is carried out using scintigraphy.

Signs of the disease detected by experts are built into a specific system. Symptoms allow you to timely determine the beginning of the transition to the malignant current.

Classification of the ICD 10 divides signs into 3 groups:

1. Tumor development: fast growth, bugger of seals, dense consistency or uneven location.
2. Tumor germination: limited mobility, squeezing voice nerve, difficulty in the operation of the respiratory system, the expansion of the veins.
3. Launched forms of cancer tumor, burdened by metastasis of regional and remote character: the development of nodes of the jugular, lateral chain, the departure of pathology in light, bones and other organs.

The main goal of the doctor is to establish the nature of the disease, identify the type of neoplasm on the tissues and in the cells of the gland.

Specialists are diagnosed at certain stages and sequences:

1. Clinical examination: study history, physical observation, histological examination, verification of the state of organs in which primary tumor lesions are fixed.
2. Tool methods: ultrasound. Modern medical equipment will allow you to identify nodes that are not felt with palpation. Ultrasound gives a tumor description, tissue structure, contours of nodal boundaries, the nature of pathology. Scintigraphy provides an endocrinologist with data on cold and hot nodes. The difference in the ability to accumulate or not concentrate radio-pharmacological preparations.

The purpose of the Classification of the Cancer Cancer of the CCB 10 is to provide the exact data on the identified disease to those skilled in the art. This is a regulatory document that facilitates the work of practical specialists. The classification is used by endocrinologists of 117 countries. Therefore, it makes it possible to use all the latest data from doctors to receive on time, to know about achievements in treatments, new drugs and means.

RCRZ (Republican Center for Health Development MD RK)
Version: Clinical Protocols MOR RK - 2015

Malignant thyroid neopoid (C73)

Oncology

general information

Short description

Recommended
Expert Council
RGP on PFV "Republican Center
Health Development »
Ministry of Health
and social development
Republic of Kazakhstan
from October 30, 2015
Protocol No. 14.

Thyroid cancer - malignant tumor, developing from thyroid tissue. Developing B. thyroid gland Cancer is divided into highly differentiated (papillary and follicular) and anaplastic, occurring from the epithelium of follicles. C - cellular (medullar) cancer, emanating from parapollicular cells, according to the degree of malignancy occupies an intermediate position (UD-A).

Protocol name:Thyroid cancer.

Protocol code:

ICB-10 code:
C 73 Malignant tumor of thyroid gland.

Abbreviations used in the protocol:

Alt.alaninotransferase AST.aspartataminotransferase Achtvactivated partial thromboplastin time v / B.intravenously v / M.intramuscular G.gray Zhkt.gastrointestinal tract IFAlinked immunosorbent assay Kt.cT scan LDlymphodissection N.international Normalized Attitude MRImagnetic resonance imaging Oakgeneral analysis blood OAMgeneral urine analysis Birdprotombian index PATpositron-emission tomography Rankone-time focal dose Sodatotal focal dose SCS.the cardiovascular system STT.suppressive therapy thyroxine Ttg.thyroid-stimulating hormone T3.triiodthththinine T4.tyroxin UDGultrasonic Doppler Ultrasoundultrasound procedure ECGelectrocardiogram Ehocheechocardiography per Os.orally TNM.Tumor Nodulus MetaStasis - International classification of stages of malignant neoplasms

Protocol revision date:2015 year.

Users Protocols: Surgeons, endocrinologists, cancer, radiologists, general practitioners, therapists, doctors emergency care.

Assessment on the degree of evidence of the recommendations given.
The scale of the level of evidence:

BUT	High-quality meta-analysis, systematic Overview of RCA or large RCCs with a very low probability (++) systematic error, the results of which can be distributed to the corresponding population.
IN	High-quality (++) systematic overview of cohort or studies Case-control or high-quality (++) cohort or studies Case control with a very low risk of systematic error or RCK with not high (+) risk of systematic error, the results of which can be distributed to the appropriate Population.
FROM	Cohort or study case-monitoring or controlled study without randomization with a low risk of systematic error (+). The results of which can be distributed to the appropriate population or rock with a very low or low risk of systematic error (++ or +), the results of which cannot be directly distributed to the corresponding population.
D.	A description of a series of cases or an uncontrolled study, or the opinion of experts.
GPP.	Best pharmaceutical practice.

Classification

International Histological Classification of Thyroid Tumors.
Epithelial tumors;
A. Benign:
· Follicular adenoma;
· Others.
B. Malignant:
· Follicular carcinoma;
· Papillary carcinoma;
· Medullar (C-cell) carcinoma;
· Untifferentiated (anaplastic) carcinoma;
· Others.
Non-epithelial tumors;
Malignant lymphoma;
Other tumors;
Secondary tumors;
Non-classified tumors;
Tumor-like lesions.

Clinical classification:
Currently, the degree of propagation of tumors is determined within the framework of the TNM classification of malignant tumors (6th ed. 2002).
The classification is applicable only for cancer, the morphological confirmation of the diagnosis is necessary (UD-A).
TNM classification:
T-primary tumor:
TX-not enough data for the assessment of the primary tumor;
T0 primary tumor is not determined;
T1-tumor to (£) 2 cm in the largest measurement bounded by the tissue of the thyroid gland;
T1a-tumor to no more than 1 cm in the largest measurement, bounded by tissue of the thyroid gland;
T1B-tumor is more than 1 cm in the largest dimension bounded by tissue of the thyroid gland;
T2-tumor more than 2 cm., But not more than 4 cm in the greatest measurement bounded by the tissue of the thyroid gland;
T3-tumor is more than 4 cm in size in the largest measurement, limited to the tissue of the thyroid gland, or any tumor with minimal distribution beyond the thyroid gland (germination in the sublingual muscles or soft tissues);
T4a-tumor of any size extending beyond the thyroid capsule with germination into subcutaneous soft fabrics, larynx, trachea, esophagus, returned guttural nerve;
T4B-tumor germinates in the prevertabral fascia, carotid artery, or mediastinal vessels;
Untifferentiated (anaplastic) carcinomas are always referred to as T4 category:
T4A-anaplastic tumor of any size bounded by tissue of the thyroid gland;
The T4B-anaplastic tumor of any size extends beyond the thyroid capsule.
N-regional the lymph nodes:
NX-insufficient data to evaluate regional lymph nodes;
N0-no signs of metastatic lesion of regional lymph nodes;
N1-there is a damage to regional lymph nodes by metastasis;
N1A-amazed pretragal, pararaheal and precentable lymph nodes (level VI);
N1B-metastatic lesion (unilateral, bilateral or contralateral) submandibular, jugular, pressed and mediastinal lymph nodes (I-V levels).
The neck is made to allocate six levels of lymphottock (UD-A):
Submandibular and chinful lymph nodes.
Upper jugular lymph nodes (along the neck of the neck of the neck above the bifurcation of the total carotid artery or sub-language bone)
Middle jugular lymph nodes (between the edge of the staircase-speaking muscle and bifurcation of the common carotid artery).
Bottom jugular lymph nodes (from the edge of the ladder-lift muscle to the clavicle).
Lymph nodes of the rear triangle neck.
Pre-, paratraheal, pretimeoid and cryotheroid lymph nodes.
pTNM - histological confirmation of the spread of thyroid cancer.
M-distant metastasis:
M0-remote metastasis;
M1 - There are distant metastases.

The thyroid cancer group in addition to the categories of TNM, takes into account the histological structure of the tumor and the age of patients (UD-A):
Papillar or follicular cancer
The age of patients under 45:
Stage I (any T, any n, m0);
Stage II (any T, any N, M1).
The age of patients is 45 years old and more:
Stage I (T1N0M0);
Stage II (T2N0M0);
Stage III (T3N0M0, T1-3N1AM0);

Medullar Cancer
Stage I (T1N0M0);
Stage II (T2-3N0M0);
Stage III (T1-3N1AM0);
STAGE IVA (T4AN0-1AM0, T1-4AN1BM0);
STAGE IVB (T4B, any N, M0);
STAGE IVS (any T, any N, M1);

Untifferentiated (anaplastic) Cancer:
In all cases, the IV stage of the disease is considered;
Stage IVA (T4a, any N, M0);
STAGE IVB (T4B, any N, M0);
Stage IVS (any T, any N, M1).

Diagnostics

List of basic and additional diagnostic measures:
Main (mandatory) diagnostic surveys conducted on an outpatient level:
· Collect complaints and anamnesis;
· General physical examination.
· Determination of calcitonin in the serum of IFA-method method MOBLOBULIN;
· Determination of thyreoglobulin in blood serum IFA method;
· Definition thyreotropic hormone (TG) in the serum of the IFA-method, when the reduced level of TSH is detected, the additional determination of the level of free triiodothyronine (T3) in the serum of the IFA method and the free definition of free thyroxine (T4) in the blood serum by the IFA method.
· Ultrasound of the thyroid gland and lymph nodes of the neck;
· Thin game aspiration biopsy.

Additional diagnostic surveys conducted on an outpatient level:
· OAK;
· OAM;



· Determination of reserves - blood factor.
· ECG Study;
· Radiography of organs chest in two projections

· PET / CT;






· Videoolaringoscopy (with the presence of germination in a return nerve);
· Thyroid scintigraphy with technetium (TC99M) or iodine (I131) - to identify a "cold" node (a section of a reduced radioisotope accumulation), characteristic of a tumor tumor of the thyroid gland and a "hot" node (a plot of increased accumulation of radioisotope), characteristic of toxic adenoma .

The minimum list of the survey, which must be carried out in the direction of the planned hospitalization: according to the internal regulation of the hospital, taking into account the current order of the authorized body in the field of health.

Main (mandatory) diagnostic surveys conducted at the stationary level (for emergency hospitalization, diagnostic surveys are conducted on an outpatient basis):
· OAK;
· OAM;
· biochemical analysis blood (general protein, urea, creatinine, glucose, alt, asthome bilirubin);
· Coagulogram (PH, prothrombin time, MNA, fibrinogen, ABTV, thrombin time, ethanol test, thrombotest);
· Determination of blood group by ABO system standard serum;
· Determination of blood reserves.
· ECG;
· Radiography of chest organs in two projections.

Additional diagnostic surveys conducted at the stationary level (with emergency hospitalization, diagnostic surveys are conducted on an outpatient basis:
· CT and / or MRI of soft tissues of the neck and mediastinum (with contrast - with the presence of germination in the main vessels, during the progress);
· PET / CT;
· CT of chest organs with contrasting (if there are metastases in the lungs);
· Uzi organs abdominal cavity and the retroperitoneal space (to eliminate the metastatic lesion and the pathology of the abdominal organs and the retroperitoneal space);
· EchoCG (patients of 70 years and older);
· UDG (with vascular lesions);
· X-ray examination of the esophagus with contrasting / videosophagastrodenoscopy (if there is a tumor germination in the esophagus);
· Fibrobronchoscopy diagnostic (if there is a progress, compression, germination in the upper airways);
· Videoolaringoscopy (with the presence of germination in a return nerve).

Diagnostic measures carried out at the emergency stage: Do not be held.

Diagnostic criteria for diagnosis:
Complaints and history;
Complaints (UD-A):
· Enlargement of the gland;
· The appearance of tumor education on the front and side surface of the neck;
· Change of voice (during germination in a return nerve);
· Fast tumor growth;
· Dyspnea, sense of lack of air (when germinating a tumor in a return nerve, upper respiratory tract).
Anamnesis (UD-A):
· Diseases of the thyroid gland (hypothyriosis, eutiriosis, hypertyriosis, thyroids);
· Prolonged reception of antithyroid drugs;
· Ionizing radiation;
· A history of receipt radiation therapy on the head and neck area.

Physical examinations (UD-A):
· In case of inspection, the deformation of the neck (uniform swelling on the front surface of the neck, asymmetry due to the increase in any thyroid gland, an increase in regional l / y);
· Palpator examination of the thyroid gland - the presence of assembly formation in the thicker of the thyroid gland, dense consistency;
· Palpator examination of regional lymph nodes - constant consistency, soreness, movable, fixed, partially movable)

Laboratory research:
· cytological research (an increase in the size of the cell up to the giant, change in the shape and number of intracellular elements, an increase in the size of the kernel, its contours, the different degree of the maturity of the kernel and other cell elements, the change in the number and shape of the nucleus);
· Histological study (large polygonal or spiked cells with well-pronounced cytoplasm, rounded nuclei with clear nucleolines, with the presence of mitoses, cells are located in the form of cells and chickens with or without keratin formation, the presence of tumor emboliths in vessels, the severity of lymphocytic-plasmocyte infiltration, mitotic The activity of tumor cells).

Tools:
· The ultrasound of the thyroid gland (determine the structures of the gland and tumor, the presence of assembly formation, cystic cavities, the size of echogenicity);
· Ultrasound of cervical, submandibular, pressed, subclavian lymph nodes (the presence of increased lymph nodes, structure, echogenicity, sizes);
· CT and / or MRI of soft tissues of the neck and mediastinum (with contrast - with the presence of germination in the main vessels, during the progress);
· Continuous aspiration biopsy from the tumor (allows you to determine the tumor and non-tumor processes, a benign and malignant nature of the tumor).

Indications for the consultation of narrow specialists:
· Consultation of cardiologist (50 years old and older patients, as well as patients under the age of 50 in the presence of concomitant Patology of the SCC);
· Consultation of a neuropathologist (with vascular brain violations, including strokes, head injuries and spinal cord, epilepsy, myasthenia, neuroinfection diseases, and in all cases of loss of consciousness);
· Consultation of the gastroenterologist (in the presence of concomitant pathology of the gastrointestinal organs in history);
· Consultation of the neurosurgeon (in the presence of cerebral metastases, spine);
· Consultation of a thoracic surgeon (in the presence of metastases in the lungs);
· Consultation of the endocrinologist (in the presence of concomitant pathology of endocrine bodies).

Differential diagnosis

Differential diagnosis (UD-A):
Table 1.

Nonological form	Clinical manifestations
Nodal goiter	Palpatorically defined nodal education in the projection of the thyroid gland. Renal biopsy is needed.
Diffuse-toxic goiter	The humidity of the skin, tremor, tachycardia, visible increase in the thyroid gland.
Autimmune thyroiditis	Diffuse increasing thyroid gland, uniform rustic density. Surface homogeneous, grainy. TrepaBiopia is needed.

Treatment abroad

Treat treatment in Korea, Israel, Germany, USA

Get advice on medical examination

Treatment

Treats of treatment:
· Elimination of tumor focus and metastases;
· Achieve full or partial regression, stabilization of the tumor process.

Tactics of treatment (UD-A):
General principles of treatment.
Surgical tumor removal is the main component of the radical treatment of thyroid cancer.
At the I-IV stage with differentiated and undifferentiated tumors, radical surgical intervention is independent method Treatment.
The cervical lymphodissection is shown only if there are metastases in lymph nodes.
Supply therapy of thyroxine (STT) is used as a component of the complex treatment of patients with thyroid cancer after thyroidectomy in order to suppress the secretion of TSH.
Radioiodterepia - applied after surgical treatment in order to destroy the residues of thyroid tissue (ablation), iodine-zeal metastases, relapses and residual carcinomas.
Replacement hormone therapy (GT) is used in patients with thyroid cancer in the postoperative period, regardless of the histological form of the tumor and the volume of the operational operation in order to eliminate thyroxine hypothyroidism in physiological doses.
Radiation therapy is applied in an independent form:
· In patients with a common primary or recurrent tumor process;
· In persons who planned repeated interventions due to the nera-digital nature of the first operation;
· In patients with less differentiated forms of thyroid cancer.
· Combined treatment shows:
· With the prevalence of primary or recurrent thyroid cancer;
· Untifferentiated forms of cancer, incorrect irradiation.
Currently, there is no evidence of the effectiveness of systemic chemotherapy in papillary and follicular thyroid cancer. Drug antitumor treatment is shown in analplastic (undifferentiated) thyroid cancer.

Not medicia treatment
Patient mode when conducting conservative treatment - Common. In the early postoperative period - bed or semicessary (depending on the volume of operation and the concomitant pathology). In the postoperative period - the cessation.
Diet table - №15.

Medical treatment:
Suppressive therapy Tyroxin (STT) (UD-A)
It is used as a component of the complex treatment of patients with thyroid cancer after thyroidectomy in order to suppress the secretion of TSH with supraphysiological doses of thyroxine.
Justification: TG - factor of the growth of cells of papillary and follicular thyroid cancer. Suppression of the secretion of TSH reduces the risk of relapse in thyroid tissue and reduces the likelihood of remote metastases.
Indications: When papillary and folicular cancer, regardless of the volume of the operation produced.
To achieve the suppressive effect, Tyroxin Naz-starts in the following doses:
2.5-3 μg per 1 kg of mass in children and adolescents;
2.5 μg per 1 kg of mass in adults ..

The rate of TSH in the blood - 0.5 - 5.0 Mu / L.
Level TSH with thyroxine suppressive therapy:
TSH - in the range of 0.1-0.3 Mu / L;
TTG control: must be carried out every 3 months during the first year after the operation. In subsequent time - no less often 2 times a year.
Correction of the Tyroxine dose (increase, decrease) - should be carried out gradually 25 μg per day.
Side effects of STT:
· Development of hyperthyroidism;
· Osteoporosis arising from the loss of mini-rally bone components increases the risk of developing rebuilding.
· Violations of the cardiovascular system: tachycardia, left ventricular hypertrophy exercise, increase the risk of atrial fibrils.
In the event of these complications, it is necessary to move to substitution therapy.
STT duration:
· It is established individually taking into account the morphological features of the carcinoma, its propagation, the radicality of the operation, the age of patients.
· In adults up to 65 years, patients with papillary and follicular extractoreroid cancer, with pt4n0-1m0-1, STT should be carried out for life.
· With a follicular cancer with a reduced diffraction-reaction with pt1-4n0-1m0-1, a life-long application of STT is necessary.
· Indications for the transfer of patients with STT to Tiro-Ksin's replacement therapy:
· In case of intratyroid papillary and high-diffe-renacesed follicular cancer (PT2-3N0-1M0) after radical operation and radioioddddiagnosis, if there were no relapse and metastases for 15 years;
· With a microcarcinoma (pt1an1am0) of a papillary and highly differentiated follicular structure, if there were no relapse and metastases for 10 years.

Replacement hormone therapy (HGT) (UD-A):
It is used in patients with thyroid cancer in the postoperative period, regardless of the histological form of the tumor and the volume of the operation of the operation in order to eliminate the thyroxine hypothyroidism in physiological doses.
Indications:
· People over 65 years old with concomitant pathology from the cardiovascular system;
· Ply adverse reactions and complications (osteoporosis, heart disease), developed due to the treatment of thyroxine suppressive doses.
· In cases of achieving a resistant continuous remission without relapse and metastases in children for more than 10 years, in adults - more than 15 years.
· In all other cases, when suppressive therapy is impossible.
Control over TSH and dose correction Tyroxine:
Dose Tyroxine with UGT Recommended dose: 1.6 μg per kg of weight in adults.
The level of TSH in the blood of the blood is in the range of 0.5-5.0 m / l.
Control over the TSTH level in the blood is 1 time per six months.
Replacement therapy in patients with thyroid cancer is usually carried out for life. (UD-A).

Chemotherapy is a drug treatment of malignant cancer tumors aimed at destruction or slowing down the growth of cancer cells with special preparations, cytostatics. The treatment of chemotherapy cancer occurs systematically according to a certain scheme, which is selected individually. As a rule, tumor chemotherapy schemes consist of several courses for receiving certain combinations of drugs with pauses between receptions, to restore damaged organism tissues (UD-A).
There are several types of chemotherapy, which differ in the purpose of destination:
· Neadaduvant chemotherapy of tumors is prescribed to surgery, in order to reduce the inoperable tumor for carrying out an operation, as well as to detect sensitivity of cancer cells to drugs for further assignment after the operation.
· Adjuvant chemotherapy is prescribed after surgical treatment to prevent metastasis and reduce the risk of relapses.
· Medical chemotherapy is prescribed to reduce metastatic cancer tumors.
· Thyroid cancer refers to the category of neoplasms to which existing antitumor drugs do not have a pronounced therapeutic effect.
Indications for Chemotherapy (UD-A):
· Untifferentiated (anaplastic) thyroid cancer
· The common process of differentiated shape of the thyroid cancer, insensitive to hormone therapy and radioiodatery;
· Not OPEROUS medullar thyroid cancer.

Contraindications for chemotherapy:
Contraindications to chemotherapy can be divided into two groups: absolute and relative.
Absolute contraindications:
· Hypertermia\u003e 38 degrees;
· Disease in the decompensation stage (cardiovascular system, liver, kidney respiratory system);
· The presence of acute infectious diseases;
· Mental diseases;
· The ineffectiveness of this type of treatment, confirmed by one or several specialists;

· Heavy condition of the patient on the scale of Karnahsky 50% and less.

· Pregnancy;
· Incixation of the body;


When carrying out polyhimotherapy with thyroid cancer, it is possible to use the following schemes and combinations of chemotherapy products:

Schemes and combinations of chemotherapy (UD-A):
· Doxorubicin 60 mg / m2 V / in 1 day;
· Cisplatin 40 mg / m2 1 day;

· Doxorubicin 70 mg / m2 V / in 1 day;
· Bleomycin 15 mg / m2 1-5 days;
· Vincristian 1.4 mg / m2 in 1, 8 days;
Repeated course after 3 weeks.

· Doxorubicin 60 mg / m2 V / in 1 day;
· Winkerstine 1 mg / m2 V / in 1 day;
· Bleomycin 30 mg in / in or per / m 1,8,15,22 days;
Repeated course after 3 weeks.

· Vincristin 1.4 mg / m2;
· Doxorubicin 60 mg \\ m2 V / in 1 day;
· Cyclophosphamide 1000 mg / m2 V / in 1 day;
Repeated course after 3 weeks.

· Doxorubicin - 60 mg / m2 1 day;
· Docetaxel 60 mg / m2 1 day;
Repeated course after 3 weeks.

Targeted therapy
For radio -odrefkitarian high-differentiated cancer of the thyroid gland from the group of targeted preparations of seraplenib 400mg 2 times a day orally (dd-c) (UD-A):
· Total thyroidity (complete thyroidetomy);
· Total lobectomy (one-sided lobectomy);
· Hemitreaodectomy with resection of the Isthmus (one-sided lobectomy, crossing the transfer);
· Cervical lymphodissection (fascial - case excision of cervical lymph nodes).

Types of cervical lymphodissection(UD-A):
· Radical cervical lymphodissection (kraila operation) - removal of a single block of lymph nodes and the fiber of the neck together with the mouse muscle, an inner jugular vein, an additional nerve, submandibular salivary gland and the lower pole of the parole salivary gland.
· Modified cervical lymphodissection - removal of lymph nodes of all 5 levels while preserving one or more of the following anatomical formations: an additional nerve, municipal muscle, internal jugular vein.
· Selective cervical lymphodissection - removal of lymph nodes 1 or several levels while preserving all the following anatomical formations: an additional nerve, a municipal muscle, internal jugular vein.

Indication to the surgical treatment of thyroid cancer:
· Morphologically verified cancer of the thyroid gland;
· In the absence of contraindications to surgical treatment.

Contraindication to the surgical treatment of thyroid cancer:
· The presence of patients with signs of inoperability and severe concomitant pathology;
· Untifferentiated thyroid cancer, which, as an alternative, a radiation treatment may be proposed;
· In the presence of metastatic regional lymph nodes of an infiltrative nature, germinating the inner jugular vein, a common carotid artery;
· Extensive hematogenous metastasis, disseminated tumor process;
· Synchronously existing tumor process in the thyroid gland and a common non-oroebile tumor process of another localization, such as lung cancer, breast cancer;
· Chronic decompensated and / or acute functional impaired respiratory disorders, cardiovascular, urinary system, gastrointestinal tract;
· Allergies to preparations used with general anesthesia.

Surgical intervention rendered on outpatient conditions:not.

Surgical intervention provided in stationary conditions:
Operation volume (UD-A):
· Total thyroidectomy - with papillary and follicular cancer with the propagation of tumor T1-4N0M0, in all cases with medullar, undifferentiated and flat-cell cancer;
· Total lobectomy, hemiteodectomy with resection of the carbon - with a solitar microcarcinoma (T1an0m0) located in the fraction of the thyroid gland and with favorable prognostic signs (patients under 45 years of 45 years, female floors and in the absence of a history of radiation on the neck);
· Selective, modified cervical lymphodissection (LD) - with one-sided or multiple displaceable metastases in the lymph nodes of the neck with one or both sides;
· Radical cervical LD \u200b\u200b(Evro Operation) - with single or multiple limited displaceable metastases with germination yarem Vienna and the mouse muscle on one side or both sides.
Treatment of thyroid cancer recurrences also applies surgical treatment.

Other types of treatment:
Other types of treatment rendered on an outpatient level: radiation therapy, radio pooderates.

Other types of treatment rendered at the stationary level: Radiation therapy, radio pooderates.

Radiation therapy - This is one of the most effective and sought-after treatment methods.

Types of radiation therapy:
· Remote radiation therapy;
· 3D conformal irradiation;
· Modulated intensity radiation therapy (IMRT).

Indications for radiation therapy (UD-A):
· Preoperative radiation therapy is shown in adult patients with undifferentiated (anaplastic) and flat-stacked thyroid cancer;
· Postoperative irradiation is suitable in patients with undifferentiated, medullar and flat-cell cancer, if the radiation therapy in the preoperative period was not carried out, and surgical treatment was not enough ablassially.

For radiation treatment According to the radical program on the primary tumor focus and metastases in the cervical lymph nodes, SOD 70 gr is supplied, on the unchanged regional lymph nodes with high-altitude tumors of SOD 50 gr.
One-time focal doses depend on the rate of tumor growth and its degree of differentiation. With slowly growing tumors, the genus of 1.8 gr, with high-altitude fast-growing - genus 2 gr x 5 fractions per week.

Contraindications for radiation therapy:
Absolute contraindications:
· Psychic inadequacy of the patient;
· radiation sickness;
· Hypertermia\u003e 38 degrees;
· The difficult state of the patient on the scale of Karnovsky is 50% and less (see Appendix 1).
Relative contraindications:
· Pregnancy;
· Disease in the decompensation stage (cardiovascular system, liver, kidneys);
· Septis;
· Active pulmonary tuberculosis;
· Tumor disintegration (threat of bleeding);
· Resistant pathological changes in blood composition (anemia, leukopenia, thrombocytopenia);
· Cachexia;
· The presence of a history of previously conducted radiation treatment.

In case of anaplatical thyroid cancer, the competitive chemical therapy of Doxorubicin 20mg / m2 in / every 1 day, weekly within 3 weeks, with radiotherapy is 1,6gr, 2 times a day 5 fractions per week, to SOD 46 gr. Currently, when using IMRT technology allows you to bring irradiation on the bed of the main focus to 70gr.

Radioiodterepia(UD-A):
It is applied after surgical treatment in order to destroy the residues of thyroid tissue (ablation), iodo-zeal metastases, relapses and residual carcin.

Mandatory conditions for radioiodterepia:
· Complete or almost complete surgical removal of the thyroid gland and regional metastases;
· Cancel of hormonal therapy for 3-4 weeks after surgery;
· The level of TSH in the blood should be greater than 30 m / l;
· Pre-radio content.

Indications for radioiodtesta:
Radioioddddiagnosis is carried out in patients with papillary and follicular thyroid cancer in the following cases:
· Prior to the operation detected separate metastases in the lungs, bones, other organs and tissues;
· In adults in the age group up to 50 years, with the exception of solitary microcarcinoma (T1an0m0);
In people over 50 years old with the proven extractoreroidal distribution of carcinoma tumors and multiple regional metastases (PT4; PN1).
Hormonal control:
Held for 10-12 week after thyroidectomy:
· TG should be less than 0.1 m / l;
· T3 - within physiological values;
· T4 - above the norm;
· Tireoglobulin.
Radioiodddiagnosis is used for cancer RT2-4N0M0 300-400 MBQ RER OS I131 and then after 24-48 hours, scintigraphy of the entire body is produced. If the metastases, accumulating I131, is not detected (M0), then the radioiodohydrate should not be carried out. Radioiodterepia is necessary when cancer RT2-4N1M1. For adults, the maximum activity of the drug is 7.5 GBQ I131, and for children 100 MBQ i131 per kg body weight.
Control over the effectiveness of radioiodate
Every 6 months are undergoing general clinical studies, the definition of TSH, T3, T4, thyroglobulin, calcium, general blood test, neck ultrasound. Each 24 months is carried out radioioddddiagnosis (300-400 MBQ I131) after the preliminary cancellation of thyroxine in 4 weeks of lung radiography in 2 projections.

Palliative care:
· With pronounced pain syndrome, treatment is carried out in accordance with the recommendations of the Protocol « Palliative care for patients with chronic progressive diseases in the incorrect stage accompanied by chronic pain syndrome, "approved by the minutes of the meeting of the Expert Commission on Health Development of the Ministry of Health of Kazakhstan No. 23 from December 12, 2013.
· In the presence of bleeding, treatment is carried out in accordance with the recommendations of the Protocol "Palliative care for patients with chronic progressive diseases in the incorrect stage accompanying bleeding", approved by the minutes of the meeting of the Expert Commission on Health Development Mort RK No. 23 from December 12, 2013.

Other types of treatment rendered at the stage of ambulance:not.

Treatment Efficiency Indicators:
· "Tumor response" - the regression of the tumor after treatment;
· Without recurrent survival (three and five year old);
· "Quality of life" includes, except for the psychological, emotional and social functioning of a person, the physical condition of the organism of the patient.

Further maintenance:
Dispensary observation of cured patients:
During the first year after the completion of treatment - 1 time every 3 months;
During the second year after the completion of treatment - 1 time every 6 months;
From the third year after the completion of treatment - 1 time per year for 3 years.
Survey methods:
· Palpation of the lodge of the thyroid gland - with each examination;
· Palpation of regional lymph nodes - with each examination;
· Ultrasound of the lodge of the thyroid gland and the regional metastasis zone;
· Radiographic study of the chest organs - once a year;
· Ultrasound examination of the abdominal organs - once every 6 months (with primary and common and metastatic tumors).
· Tireoglobulin is a specific highly sensitive marker of thyroid cells, as well as cells of papillary and follicular thyroid cancer. Determine three months after surgery, any defined thyreoglobulin level is indications for further survey.
· TSH should be less than 0.1 m / l.

Preparations (active substances) used in the treatment

Hospitalization

Indications for hospitalization indicating the type of hospitalization:

Indications for emergency hospitalization:
· Bleeding from a tumor;
· Large stenosis.
Indications for planned hospitalization:
The presence of a patient of the morphologically verified cancer of the thyroid gland.

Prevention

Preventive actions:
· Previously began treatment of its continuity, complex nature, consideration of the individuality of the patient;
· Patient return to active work.

Information

Sources and literature

1. Protocols of the meetings of the Expert Council RCRs MZSR RK, 2015
   1. List of references: 1. Tumors of the head and neck, A.I. Parech.- M., 2000 2. TNM Classification of Malignant Tumours, 6th Edition, Author: Editors: L.h. Sobin, ch. Wittekind, 2002. 3. Tumors of the head and neck: Hands A.I. Parech. - 5th ed., Extra and recreation. -M.: Practical medicine, 2013. four. New approach To the classification of cervical lymphadenectomy // Successes modern natural science, Movergoz S.V., Ibrahimov V.R. - 2009; 5. Thyroid Tumors, M.Schlumberger, F. Pacini, R.Michael Tuttle: 6. Anticancer chemotherapy. Guide. R.T. Skila, Gootar-Media, Moscow, 2011. 7. Guidelines for chemotherapy of tumor diseases, N.I. Translator, Moscow, 2011 8. Guidelines for chemotherapy of tumor diseases, N.I. Translator, V.A. Gorbunova Moscow, 2015; 9. Diseases of the thyroid gland, E.A. Vintina, St. Petersburg, 2001; 10. Endocrinology. Edited by N. Lavina. Moscow. 1999; 11. Endocrinology. Volume 1. Diseases of the pituitary gland, thyroid gland and adrenal glands. St. Petersburg. Spets lit., 2011.

Information

List of protocol developers with qualified data:

1. Adilbaev Galym Bashenovich - Doctor Medical Sciences, Professor, "RSP on the PCW Kazakh Scientific Research Institute of Oncology and Radiology", Head of the Center;
2. Kydyrbayeva Gulzhan Zhanuzakovna - Kiddate of Medical Sciences, RGP on the PCB "Kazakh Scientific Research Institute of Oncology and Radiology", Researcher.
3. Kaibarov Murat Endalovich - Candidate of Mdicinsky Sciences, RGP on PVV "Kazakh Scientific Research Institute of Oncology and Radiology", doctor oncologist;
4. Shipilova Victoria Viktorovna - Candidate of Medical Sciences of the RGP on PVV "Kazakh Scientific Research Institute of Oncology and Radiology", Researcher of the Center for Head Tumors and Neck;
5. Tumanova Assel Kadyrbeckovna - Candidate of Medical Sciences, RSP on the PCB "Kazakh Scientific Research Institute of Oncology and Radiology", head of the department of day hospital Chemotherapy -1.
6. Savhatova Akmaral Dospail - RGP on the PKV "Kazakh Scientific Research Institute of Oncology and Radiology", head of the day hospital department.
7. Makhishova Aida Turarbekovna - RGP on PFV "Kazakh Scientific Research Institute of Oncology and Radiology", oncologist.
8. Tabarov Adlet Berikbolovich - Clinical Pharmacologist, RGP on PVV "Hospital medical center Management of the Office of the Republic of Kazakhstan, "head of innovation management department.

Indication for the absence of conflict of interest:

Reviewers:Kaidarov Bakyt Kasenovich - Doctor of Medical Sciences, Professor, Head of the Department of Oncology, Mammology and Radiation Therapy, RGP "Kazakh National Medical University named after S.D. Asphendiyarova. "

Note Protocol Review Conditions:the revision of the Protocol 3 years after its publication and from the date of its entry into force or in the presence of new methods with the level of evidence.

Attached files

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23464 0

Code of the ICD-10

C73. Malignant neoplasm of the thyroid gland.

Epidemiology

Thyroid cancer in 2005 in the Russian Federation was first diagnosed with 8505 people, which is 5.99 per 100 thousand population. Over the past 20 years, the incidence of cancer of this localization increased 2 times, mainly due to the people of young and middle age, which are mainly developing differentiated tumor forms.

The disease is much more common in female people (the ratio of women and men is 4: 1). 69.3% of patients with thyroid cancer are found between the ages of 40 and 60 years.

In the overall structure of the oncological morbidity, the proportion of the thyroid gland is small (2.2%), but in the age group of 20 to 29 years old, he goes to one of the first places.

Etiology

Among the etiological factors affecting the development of malignant tumors of the thyroid gland, it is necessary to especially allocate ionizing radiation.

Thus, there was a sharp increase in morbidity, especially in children, after the explosion of the atomic bomb in Japan and the accident at the Chernobyl NPP; Numerous cases of the development of tumors of the thyroid gland in individuals irradiated in childhood about diseases of the fork gland and almonds are known. The occurrence of thyroid tumors contributes to the lack of iodine and the associated hypothyroidism and high level TSG pituitary.

Long use Thyareostatikov, in particular thiamazole, can also provoke the development of thyroid tumors. The functional-morphological state of the thyroid gland is also important: cancer tumors often occur in this body against the background of the nodal euticide goiter, adenoma, thyroiditis. For tumors of the thyroid gland, multiple primitives are characterized, a combination with tumors of other organs (6.9 -23.8%).

Pathogenesis

In the formation of tumors in tissue of the thyroid gland, a number of complex molecular genetic disorders occur: the activity of growth suppressors (P53) is changed and oncogene mutations (MET) are activated, proteoglycan expression increases (CD44, MDM2).

Classification

International Morphological Classification of Thyroid Tumors

• Epithelial tumors:
• papillary cancer;
• follicular cancer (including the so-called Gürtle carcinoma);
• medullar cancer;
• untifferentiated (anaplastic) Cancer:
  - believer;
  - giant meal;
  - petty cell;
• plateLock cell (epidermoid) cancer.
• Nepphelial tumors:
• fibrosarka;
• others.
• Mixed tumors:
• carcinosarkom;
• malignant hemangioendothelioma;
• malignant lymphoma;
• teratoma.
• Secondary tumors.
• Unclassified tumors.

Papillar Cancer - the most frequent tumor of the thyroid gland (65-75%); The ratio of men and women is 1: 6, the people of young age prevail (the average age of 40.4 years).

The course of the disease is long, and the forecast is favorable. For this form, the tumor is characterized by multiple primitives and a high frequency of regional metastasis (35-47%). Remote metastases are rare. Regional metastasis can be the first and even only clinical manifestation Papillary cancer, often they are ahead of the growth of the primary tumor. The size of the tumor varies from microscopic (sclerosing microcarcinoma) to very large when the tumor covers the entire gland.

In a microscopic examination, the structure of the tumor can be diverse: the tumor consists of nipple formations lined with cubic or cylindrical epithelium; Along with papillary structures, follicular, and in some cases, solid cell fields are often detected; Frequently find the psammomy tales. The presence in the papillary tumor of follicular structures does not affect clinical current; The appearance of solid structures with polymorphism of cells and an increase in the number of mitoses is an unfavorable sign that determines a more malignant clinical course of the tumor.

In an immunocytochemical study, in 92% of cases in papillary carcinoma cells, the presence of thyroglobulin is detected, which indicates the preservation of high differentiation and functional activity.

Follicular cancer It is found in 9.3-13.6% of cases, the average age of patients is 46.6 years, the ratio of men and women is 1: 9. Long, prognosis is favorable. For this tumor, hematogenic metastasis is characterized (more often in lungs and bones), regional metastases are rare.

In microscopic examination, follicles, trabecular structures, as well as solid fields are found; Papillary structures are absent. The tumor often sprouts into the blood vessels.

Sometimes a follicular cancer from a highly differentiated follicular epithelium is called a "malignant adenoma", "metastatic stream", "Langhance," making it only confusion, since the term "stream" means a commonly benign adenoma.

Medullar Cancer (from parapollicular C-cells) is 2.6-8.2% of cases, the average age of patients is 46 years, the ratio of men and women - 1: 1.5. This tumor is more aggressive than highly differentiated adenocarcinoma. Medullar cancer is a hormonally active tumor, it is characterized by a high level of thyroallycitonin, which is ten times higher than normal. In 24-35% of patients, this disease is manifested by diarrhea, which passes after radical tumor removal. For medullary cancer, a high frequency of regional metastasis is characterized (65-70%). Only in 50% of patients with the first symptom of medullary cancer serves a tumor node in the thyroid gland, in the remaining patients - metastatic enlarged cervical lymph nodes.

Microscopic examination in this form of cancer allows you to identify fields and foci of tumor cells, surrounded by fibrous stroma containing amorphous mass of amyloid.

They distinguish the sporadic shape of medullary cancer and Maine.

• In the Men-2 syndrome, medullary cancer of the thyroid gland is combined with adrenal peaochromocytoma and parachite gland adenoma (Sipple syndrome).
• The Men-2B syndrome includes a medullary cancer of the thyroid gland, a peochromocytoma, the neuromet of mucous membranes and neurofibromatosis of the intestinal tract. For patients, a marfan-like physique is characterized.

The risk group on the disease of the family shape of medullalar cancer includes the presence of a patient of a patient of a marfan-like phenotype, feochromocytoma or other endocrinopathies, an elevated content of calcitonine (\u003e 150 pg / ml) in the blood serum, the protoncogencogens RET mutations.

Untifferentiated cancer Clinically proceeds very aggressively, the forecast is unfavorable. Patients over 50 years old, the ratio of men and women is 1: 1. Regional metastases occur in 52.3% of patients remote - in 20.4%.

Metastasis. The most frequent localization of remote metastases is light (19.8%). With a follicular metastase cancer in this organ, 22% of patients are found in the papillary - in 8.2%, with a papillary-follicular - in 17.6%, with medullary - in 35.0%. Metastases can be both single and multiple.

The frequency of thyroid cancer metastasis in the bone is 5.9-13.6%. Metastases, usually osteolytic type, are most often found in flat bones (skull, cheesecin, rib, pelvic bones, spine); In the focus of degradation, the bone swells, an extrasal component appears. For metastases in the spine is characteristic of destruction intervertebral disks and the formation of a single focus of the destruction of adjacent vertebrae. Metastases in the bone with thyroid cancer can remain x-ray from 1.5 months to 1 year, early stages They can be identified using scintigraphy from 131 I or 99M TCs.

International clinical classification TNM. Reflects the dimensions of the primary tumor (T), metastasis in regional lymph nodes (N) and the presence of remote metastases (M).

T - Primary tumor:

• T x - not enough data to estimate the primary tumor;
• T 0 - the primary tumor is not detected;
• T 1 - tumor not more than 2 cm in the largest measurement, not beyond the thyroid gland;
• T 2 - tumor from 2 to 4 cm in the largest measurement, not beyond the thyroid gland;
• T 3 is a tumor of more than 4 cm in the largest dimension that does not go beyond the thyroid gland, or a tumor of any size with a minimum distribution to the fabric surrounding gland (for example, breast-shaped muscles);
• T 4 is a tumor propagating the thyroid capsule and germinating surrounding tissues, or any anaplastic tumor:
  - T 4A - a tumor, gem, gentle fabrics, larynx, trachea, esophagus, returnable guttural nerve;
  - T 4B is a tumor, germinating the prevertabral fascia, mediastinal vessels or the surrounding carotid artery;
  - T 4A * - anaplastic tumor of any size within the thyroid gland;
  - T 4B * - Anaplastic tumor of any size propagating behind the capsule of the thyroid gland.

N - regional lymph nodes (lymphatic nodes of the neck and upper mediastinum):

• N x is not enough data to evaluate regional lymph nodes;
• N 0 - no signs of metastatic lesion of regional lymph nodes;
• N 1 - lymphatic nodes are amazed by metastasis:
  - n 1a - is amazed by metastases and pararathal nodes, including the precentable;
  - N 1B \u200b\u200b- metastases on the side of the lesion, on both sides, from the opposite side and / or in the upper mediastinum.

M - remote metastasis:

• X - not enough data to assess remote metastases;
• M 0 - no signs of remote metastases;
• M 1 - Defined remote metastases.

The results of histological examination of the drug remote during the operation are estimated by a similar system by adding the prefix "P". Thus, the recording "PN 0" means that metastases in lymph nodes are not detected. For an adequate estimate, the drug must contain at least 6 lymph nodes.

Thyroid cancer stage Determine taking into account the age of the patient, the tumor class on the TNM system and its histological type.

In patients under the age of 45 years old with papillary and follicular cancer, only 2 stages of the disease are distinguished:

• I.: any T, any n, m 0;
• II.: Any T, any N, M 1

In patients from 45 years and older with papillary, follicular and medullary cancer, 4 stages of the disease are distinguished:

• I.: T 1, N 0, m 0
• II.: T 2, N 0, M 0;
• III: T 3, N 0, M 0 or T 1-3, N 1a, m 0;
• IVA.: T 1-3, N 1B, m 0
• IVB.: T 4, any n, m 0;
• IVC.: Any T, any N, M 1

All cases of anaplastic undifferentiated cancer are referred to by the IV stage of the disease and are divided into substarty:

• IVA.: T 4A, any n, m 0;
• IVB.: T 4B, any n, m 0;
• IVC.: Any T, any N, M 1

Clinical picture

In the early stages of cancer, the symptoms are few, are not expressed and similar to the clinical signs of benign tumors.

As the tumor develops appear clinical signswhich allow you to suspect her malignant character.

These symptoms can be divided into 3 groups:

1) related to the development of tumor in the thyroid gland

• rapid growth of the node;
• dense or uneven consistency;
• jar of the node;

2) arising in connection with the germination of the tumor into the cloth surrounding gland

• restriction of thyroid mobility;
• voting change (compression and paralysis of the return nerve);
• difficulty breathing and swallowing (trachea compression);
• expansion of veins on the front surface of the breast (compression or germination of the mediastinal veins);

3) due to regional and remote metastasis, develop with launched forms of cancer

• increase, sealing and limiting the mobility of regional lymph nodes (paratraheal, front jugular nodes - the so-called nodes of the jugular circuit; less often - lateral cervical nodes, that is, the lymph nodes of the side triangle of the neck, the jocess region, the reserved mediastinum);
• remote (hematogenous) metastasis:
  - Metastases in the lungs (X-ray painting "Motsp coin": multiple round shadows in the lower parts of the lungs, sometimes resembling tuberculosis of lungs);
  - metastases in the bone (osteolatic foci in the bones of the pelvis, skull, spine, chest, ribrs);
  - Metastases in other organs - pleura, liver, brain, kidney (are less common).

IN. Olshansky, V.I. Numbers

A malignant tumor of the thyroid gland is a disease that occurs with an abnormal growth of cells inside the gland. The thyroid gland is located in the front of the neck and has a butterfly shape. It produces hormones that regulate energy consumption, providing normal organism's vital life.
The thyroid cancer is one of the low-prolonged types of cancer. The forecast for the victims of them in most cases is favorable, since this type of cancer is usually revealed in the early stages and is well treatable. Healing thyroid cancer can relap at least after treatment.
Papillar (about 76%).
Follicular (about 14%).
Medullar (about 5-6%).

Types of thyroid cancer:
Papillar (about 76%).
Follicular (about 14%).
Medullar (about 5-6%).
Untifferentiated and anaplastic cancer (about 3.5-4%).
Less often meets sarcoma, lymphoma, fibrosarcoma, epidermoid cancer, metastatic cancer, which account for 1-2% of all malignant neoplasms of the thyroid gland.
Papillar thyroid cancer. The papillar cancer of the thyroid gland is found in both children (less often) and in adults, reaching the peak of incidence at the age of 30-40 years. Papillar thyroid cancer is detected when scanning as a dense, single "cold" node. Almost in 30% of cases in papillary cancer there are metastases. In children (before puberty), papillar cancer of the thyroid gland proceeds more aggressively compared to adults, there are more often metastases in both cervical lymph nodes and lungs.
Follicular thyroid cancer.
It occurs in adults, more often aged 50-60 years. Characterized by slow growth. The flow of follicular cancer is more aggressive than papillary, often it gives metastases into the lymph nodes of the neck, less often - remote metastases in the bones, light and other organs.
Medullar thyroid cancer.
This type of cancer may be accompanied by an erased clinical picture of Incenco Cushing syndrome, "tides", redness of the face, diarrhea. Medullar cancer for the flow is more aggressive in comparison with papillary and follicular, gives metastases to nearby lymph nodes and can spread to the trachea and muscle. Metastases in lungs and various are relatively rarely rarely. internal organs.
Anaplastic thyroid cancer.
This cancer is a tumor consisting of so-called carcinosark cell cells and epidermoid cancer. Usually such a tumor precedes the nodal goiter, which was observed for many years. The disease develops in faces of the elderly, when the thyroid gland begins to increase rapidly, leading to violations of the function of the mediastinal organs (choking, difficulty in swallowing, dysphony). The tumor is growing rapidly, sprinkling in nearby structures.
Metastases are less common malignant tumor in the thyroid gland. Such tumors include melanoma, breast cancer, stomach, lungs, pancreas, intestines, as well as lymphoma.
Read more.

27842 0

Nodal and multi-nose toxic goiter

About 10-15% of the nodal forms of the goiter accounted for toxic gobles. However, subclinical forms of thyrotoxicosis are likely to be more common. All the above-mentioned node euthyroid zob is also true for toxic nodal forms with the difference only that the disease is complicated by thyrotoxicosis.

Thyareotoxicosis is a syndrome, which is based on hyperproduction and a resistant long-term increase in the level of thyroid hormones (T 3 and T 4) in the blood, which leads to pronounced metabolic disorders in the body.

Etiology and pathogenesis

Thyareotoxicosis in the node forms of the goiter is due to the functional autonomy of the thyroid gland, that is, independent of the influence of TSH by the capture of iodine and thyroxine products.

Clinical picture

Tireotoxicosis is not clinically manifested immediately. For a long time, the compensation period continues - the TSH levels and T 4 remain in the norms of the norm. However, with scintigraphy in the thyroid gland, it is fairly early, it is possible to reveal the areas of excess absorption of the radiopharmacological preparation on the background of the still normal capture of its surrounding tissue. As the degree of autonomy increases, the seizure of iodine is reduced by the surrounding tissue, the suppression of TTG secretion and the development of subclinical thyrotoxicosis (reduced TSH with normal T 4). Later, as a result of decompensation, pronounced thyrotoxicosis develops. In the blood there is a high level of T 4 with a low content of TSH. With scintigraphy, the surrounding "hot" zones thyroid tissue is completely blocked and does not accumulate the radiopharmacological drug.

Thyrotoxicosis is made to distinguish with severity:
subclined (easy current) - the clinical picture of the estimates, however, the frequency of heart abbreviations (heart rate) reaches 80-100 per minute, you can reveal a weak tremor of hands and psycho-emotional lability; The diagnosis is determined mainly on the basis of data of hormonal research - the TSTH level is reduced at normal levels T 3 and T 4;
manifeste (middle severity) - Deployed clinical picture of thyrotoxicosis: CSS reaches 100-120 per minute, the pulse pressure increases, the pronounced tremor of the hands and weight loss is noticeable to 20% of the initial mass of the body; The TSTG level is reduced until complete suppression, levels T 3 and T 4 are increased;
complicated (heavy) - CSS exceeds 120 per minute, characterized by high pulse pressure, cleaning arrhythmia, heart failure, thyreogenic adrenal insufficiency and dystrophic changes in parenchymal organs, the body weight is sharply reduced until the cachexia; TSH is not determined, levels T 3 and T 4 are very high.

Toxic thyroid adenoma

Codes on the ICD-10
E05.1. Thyrotoxicosis with toxic single-meloy goiter.

The nodal toxic goiter is isolated into a separate nosological unit - the toxic adenoma of the thyroid gland (the disease of the planmer).

Diagnostics

The diagnosis is based on clinical picture thyrotoxicosis in combination with the corresponding hormonal shifts, palpation and ultrasound data (solitary nodal education) and the results of a radionuclide study, in which the "hot" node is determined against the background of the blocked tisside fabric. It should be remembered that thyrotoxicosis does not exclude the presence of a malignant tumor, therefore, with suspected carcinoma, the execution of the tab is shown.

An example of the formulation of diagnosis

Nodal toxic goiter II degree, thyrotoxicosis of moderate severity. The diagnosis must necessarily reflect the severity of thyrotoxicosis.

Treatment

Treatment of toxic adenoma is only surgical. Perform an operation in the amount of hemitioticidectomy with mandatory preoperative preparation by thyaretatis (thiamazole) to achieve a eutheroid state. The volume and duration of thyaretic therapy depends on the severity of thyrotoxicosis. After the operation, the function of an extractor tissue is completely restored. Nevertheless, after an operational reduction in the volume of thyroid tissue, hypothyroidism is often developed, the need for substitution hormone therapy occurs.

After the operation, long-term monitoring is needed at the endocrinologist and control of the hormonal profile. In the presence of serious contraindications to the operation, radioiodterepia or glover of adenoma 96% can be applied ethyl alcohol. However, these methods are not dedicated and have limited use. After treatment radioactive iodom Heavy hypothyroidism develops, in addition, this method is very expensive. Sclerotherapy with ethanol is effective only with small adenoma.

Multi-nose toxic goiter

Code of the ICD-10
E05.2. Thyrotoxicosis with toxic multicolored goiter.

Diagnostics

Also, as in the nodal toxic zob, the diagnosis is based on the clinical pattern of thyrotoxicosis in combination with the corresponding change in the hormonal background, palpation data, ultrasound (multiple node formations) and the results of radionuclide scanning, in which multiple "hot" and the thyroid gland "Warm" foci. The diagnosis should also reflect the severity of thyrotoxicosis. In some cases, if the cancer is suspected, the tab of nodal formations is shown.

Treatment

The operation in the volume of the subtotal resection of the thyroid gland is shown. Preparation for operation and postoperative maintenance are the same as in the toxic adenoma of the thyroid gland. In the presence of contraindications to the operation, therapy is possible with radioactive iodine.

Diffuse non-toxic (euticoid) goiter

Code of the ICD-10
E01.0. Diffuse (endemic) goiter associated with iodine deficiency.

Visual and palpator assessment of thyroid sizes does not always allow objectively to determine the size of the goiter. Therefore, ultrasound should be used to diagnose diffuse non-toxic goiter. The volume of shares are calculated by the formula:

V \u003d axbxcxo, 52,

where a is the length;
In - thickness;
C - width of the lobe;
0.52 - correction coefficient on the ellipsoidal shape of the share.

The normal thyroid capacity for women does not exceed 18 ml, and for men - 25 ml. Operational treatment is shown only in the presence of a compression syndrome. In other cases, the drugs of iodine are prescribed.

Cyst thyroid gland

The cyst of the thyroid gland can be viewed as a variant of colloidate goiter. Clinically cyst is manifested as a nodal goiter, but it should be distinguished from the nodal goiter with cystovation. The diagnosis is confirmed with an ultrasound: cyst looks like a anechogenic formation of a rounded form, with thicker contours, which gives the effect of a dorsal increase in ultrasound. Small cysts do not provide negative influence On the health of the patient and do not require treatment. It is only necessary to observe repeated ultrasound. With large sizes of cyst or growth, the previously discovered cyst shows the puncture under the control of ultrasound, aspiration of content and sclerotherapy with ethyl alcohol. Strongly existing cysts with thick sclerized walls and large multi-chamber cysts after sclerotherapy are often recurrenced - in this case, in the threat of development of compression syndrome, operational treatment is necessary. The operation is performed in the same way as with the zero zob. Special attention deserves cysts with the growth of fabric on one of the walls, which is well noticeable when ultrasound. In order to exclude carcinoma with cystovation, the puncture of the solid segment of cystic education is shown.

Follicular adenoma

Code of the ICD-10
D34. Benignant thyroid neoptic gland.

Follicular adenoma is a benign tumor of the thyroid gland. Clinically, it is almost indistinguishable from the nodal euthyroid goiter and the diagnosis is based on the ultrasound and tab. When ultrasound, an iso- or hypo echogenic assembly formation with clear contours is found. However, cytologically follicular adenoma is difficult to distinguish from highly differentiated follicular cancer, so the diagnosis is made in a probabilistic form: "Follicular tumor, probably adenoma" or "Follicular tumor probably cancer". In addition, the follicular adenoma can be illicated, so the operation is always shown when establishing such a diagnosis. The minimum volume of operational intervention is hemitreoidectomy. After the operation shows replacement hormone therapy.

A.M. Slutko, V.I. Semikov