A cyst, being a benign neoplasm, is a cavity with fluid inside. Statistics show that about 5% of the world's population suffer from this disease, and most of them are females. Despite the fact that the cyst is initially benign, its presence in the thyroid gland is not the norm and requires the use of therapeutic measures.
Types of pathology
According to the international classification of this disease, code D 34 is assigned. Cysts can be:
- single;
- multiple;
- toxic;
- non-toxic.
According to the possible nature of the course, they are divided into benign and malignant. Therefore, with a thyroid cyst, the ICD 10 code is determined depending on the type of this endocrine pathology.
A cyst is considered such a formation, the diameter of which exceeds 15 mm. In other cases, there is a simple expansion of the follicle. The thyroid gland consists of many follicles that are filled with a kind of helium liquid. If the outflow is disturbed, it is able to accumulate in its cavity and eventually forms a cyst.
There are the following types of cysts:
- Follicular. This formation consists of many follicles with a dense structure, but without a capsule. At the initial stage of its development, it has no clinical manifestations and can be visually detected only with a significant increase in size. As it develops, it begins to acquire pronounced symptoms. This type of neoplasm has the ability to malignant degeneration with significant deformities.
- colloidal. It has the form of a knot, which contains a protein liquid inside. Most often, it develops with non-toxic goiter. This type of cyst leads to the formation of a diffuse nodular goiter.
The colloidal type of neoplasm mainly has a benign course (more than 90%). In other cases, it can transform into a cancerous tumor. Its development, first of all, causes a lack of iodine, and secondly, a hereditary predisposition.
With a size of such a formation of less than 1 cm, it has no symptoms of manifestation and does not pose a health hazard. Anxiety is caused when the cyst begins to increase in size. A less favorable course is of the follicular type. This is due to the fact that the cyst often turns into a malignant formation in the absence of treatment.
Causes and symptoms
The cause of the formation of cysts in the tissue of the thyroid gland are various factors. The most common and significant, according to endocrinologists, are the following reasons:
- hereditary predisposition;
- lack of iodine in the body;
- diffuse toxic goiter;
- exposure to toxic substances;
- radiation therapy;
- radiation exposure.
Often, hormonal imbalance becomes the factor that affects the thyroid gland, causing the formation of cystic cavities in it. Both hypertrophy and dystrophy of thyroid tissue can be a kind of impetus to the formation of cysts.
It should be noted that such formations do not affect the functioning of the thyroid gland. Attachment of characteristic symptoms occurs with concomitant lesions of the organ. The reason for contacting an endocrinologist is a significant increase in the size of the formation, which deforms the neck. With the progression of this pathology, patients develop the following symptoms:
- sensation of a lump in the throat;
- respiratory failure;
- hoarseness and loss of voice;
- difficulty in swallowing;
- pain in the neck;
- feeling of sore throat;
- swollen lymph nodes.
Clinical manifestations depend on the type of pathology that has appeared. So, with a colloid cyst, the following joins the general symptoms:
- tachycardia;
- excessive sweating;
- increase in body temperature;
- chills;
- headache.
The follicular cyst has distinctive symptoms:
- difficulty breathing;
- neck discomfort;
- frequent coughing;
- increased irritability;
- fatigue;
- drastic weight loss.
In addition, such a hollow formation with large sizes is visually noticeable and well palpable, but there are no painful sensations.
Diagnosis and treatment
Diagnosis of neoplasms in the thyroid gland is carried out by various methods. It could be:
- visual inspection;
- palpation;
- ultrasound procedure.
Often they are discovered by chance during examination for other diseases. In order to clarify the nature of the formation, a cyst puncture may be prescribed. As additional measures for examining the patient, a blood test is prescribed to determine thyroid hormones - TSH, T3 and T4. For differential diagnosis are carried out:
- radioactive scintigraphy;
- CT scan;
- angiography.
The treatment of this pathology is individual and depends on the symptoms of manifestation and the nature of the neoplasm (type, size). If the detected cyst does not exceed 1 cm in size, then the patient is shown dynamic observation, which includes an ultrasound examination once every 2–3 months. This is necessary in order to see if it increases in size.
Treatment can be conservative and operational. If the sheets are small and do not affect the functioning of the organs, then thyroid hormone preparations are prescribed. In addition, you can influence the cyst with the help of an iodine-containing diet.
Most often, sclerotherapy is used to treat large cysts. This procedure consists in emptying the cyst cavity with a special thin needle. Surgical treatment is used if the cyst is of considerable size. In this case, it can provoke suffocation, as well as a tendency to suppuration, and therefore, in order to avoid more serious complications, it must be removed.
Since in most cases such a pathology has a benign course, the prognosis will be favorable accordingly. But this does not exclude the occurrence of its relapse. Therefore, after successful treatment, it is necessary to conduct a control ultrasound of the thyroid gland every year. In the case of a cyst becoming malignant, the success of treatment depends on its location and the presence of metastases. Upon detection of the latter, the thyroid gland is completely removed along with the lymph nodes.
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Features of thyroid cancer, ICD code 10
According to ICD 10, thyroid cancer is included in the group of neoplasms of a malignant course - code C73. Thyroid cancer is constantly under the control of physicians. Scientists track the development of the disease, the speed of its spread. The first data on the localization of the disease were recorded in 2005. Diseases began to affect the younger generation. Forms of modern tumor formations are differentiated. The disease is diagnosed today twice as often. The ratio of lesions between the sexes shows a greater number of patients among the female half. The age of patients affected by pathology ranges from 40 to 60 years.
Causes and conditions of occurrence
Recently, medical scientists have been identifying the causes of the disease, trying to identify the conditions for the occurrence. They study statistical data, regional, etiological and hereditary factors.
When studying statistical data, two patterns can be observed:
- The percentage of terrible pathology in the total number of diseases is low - 2.2%.
- One of the most common diseases (first lines) at the age of 20 to 29 years.
Various etiological factors influence the development and spread of cancerous tumors:
- The brightest and most noticeable is radiation exposure. A sharp increase is noted after the explosions of atomic bombs (Japan), nuclear power plants (Chernobyl).
- The use of treatment methods with the help of radiation equipment: thymus gland, inflammation of the tonsils.
- Lack of iodine intake in the human body.
- Long-term treatment with medications - thyreostatics (thiamazole).
- Violations of the functional morphological state of the glandula thyreoidea.
A malignant neoplasm of the thyroid gland, cancerous tumor lesions appear against the background of other disorders of the organ. Often there is a disease of nearby organs, tumors appear on several systems of the human body at the same time.
All diseases are distributed by scientists - physicians and doctors - practitioners into groups. Each type is based on common symptoms and treatments. The international classification was created to help specialists.
Endocrinologists make a start in classification from the main provisions and principles of division.
- Epithelial abnormalities: papillary, follicular, medullary, anaplastic cancer.
- Hürthle carcinoma.
- Cellular forms of tumors: spindle-, giant-, small-, flat-.
- Non-epithelial pathologies: fibrosarcoma.
- Mixed diseases: carcinosarcoma, teratoma, malignant forms of lymphoma, hemangioendothelioma.
- secondary manifestations.
- Unclassified species.
The international list provides doctors with numerous information and data on the course of each type of disease.
- T - the size of the tumor and its type, spread throughout the organ and nearby systems. The numbers characterize the transition of the tumor beyond the thyroid gland, germination into the larynx, the transition and damage to the esophagus.
- N - gives a characterization and assessment of the state of the lymph nodes, metastatic signs. Each specific figure deciphers the spread and appearance of metastases, their quality and signs of lymph damage.
- M - deciphers in more detail the signs and location of metastases, their remoteness.
Classification distinguishes each disease by stages, age of the patient. Data on substages of complex pathologies are presented.
The structure of the tumor, examined under a microscope, can be characterized as:
- papillary, with cubic and cylindrical epithelium;
- having extensive cellular fields;
- having a composition with polymorphic cells.
The prognosis of treatment is favorable.
Follicular cancer is less common. Tumor neoplasms are accompanied by metastasis, leaving in the lungs, bone tissues. Often the species spreads and grows into the blood vessels.
The medullary appearance is the rarest pathology. The tumor proceeds aggressively. There are two forms: sporadic, MEN. Of particular importance is heredity.
Anaplastic cancer has a poor prognosis and an aggressive course.
Metastasis is one of the symptoms of all types of cancer. It is detected using scintigraphy.
The signs of the disease, identified by specialists, line up in a certain system. Symptoms allow you to timely determine the beginning of the transition to a malignant course.
The ICD 10 classification divides signs into 3 groups:
- Tumor development: rapid growth, tuberosity of seals, dense consistency or uneven location.
- Germination of the tumor: limited mobility, compression of the vocal nerve, difficulty in the functioning of the respiratory system, varicose veins.
- Advanced forms of cancer, aggravated by metastasis of a regional and distant nature: the development of nodes of the jugular, lateral chain, the departure of pathology to the lungs, bones and other organs.
Specialists carry out diagnostics according to certain stages and sequence:
- Clinical examination: study the anamnesis, physical observation, histological examination, check the condition of the organs in which primary tumor lesions were recorded.
- Instrumental methods: ultrasound. Modern medical equipment will allow you to identify nodes that are not felt by palpation. Ultrasound gives a description of the tumor, the structure of the tissues, the contours of the nodal boundaries, the nature of the pathology. Scintigraphy provides the endocrinologist with data on cold and hot nodes. The difference is in the ability to accumulate or not concentrate radiopharmaceuticals.
The purpose of the ICD 10 classification of thyroid cancer is to provide specialists with accurate data on the identified disease. This is a regulatory document that facilitates the work of practitioners. The classification is used by endocrinologists in 117 countries. Therefore, it makes it possible to use all the latest data from doctors to receive on time, to know about advances in treatment systems, new drugs and means.
Hyperglycemia and hypoglycemia: ICD 10 codes
According to the international classification of diseases of the tenth revision (1989), hyperglycemia (in Latin - hyperglykaemia) has code 73. Russia adopted ICD 10 in 1999.
The classifier adopted a new extended three-digit designation, which includes descriptions of a large number of disease complications.
All diseases according to the classification are divided into 21 classes, where endocrine pathologies are IV and VIII classes of diseases.
What diseases are accompanied by hyperglycemia syndrome?
Hyperglycemia syndrome is a complex of specific symptoms, which is accompanied by partial or complete indigestion of glucose by the cells of the body. Pathological syndrome is preceded by a number of diseases:
- type 1 and type 2 diabetes;
- hyperthyroidism;
- Cushing's syndrome;
- acute pancreatitis;
- tumors of the pancreas of a different nature;
- cystic fibrosis.
The state of hyperglycemia is ambiguous. It can be caused both by isolated cases of increased blood sugar, and by a stable chronic state of elevated glucose levels.
In addition to the established causes of hyperglycemia, there are cases of an unspecified pathology genesis.
Types of hyperglycemia
According to the nature of the manifestation, the state of high blood sugar is divided into several types:
- chronic;
- transient;
- unspecified.
Each type of hyperglycemia has its own causes and features of development.
Chronic hyperglycemia
This is a symptom complex of stable manifestations of metabolic disorders, which is combined with certain neuropathies. It is characteristic, first of all, for diabetes mellitus.
The chronic form is distinguished by the fact that the state of high sugar is permanent, and in the absence of measures to eliminate the pathology, it can lead to hyperglycemic coma.
An analysis for hyperglycemia is taken on an empty stomach, the indicators of which determine the true ratio of sugar in the blood.
Transient
This type of pathology is temporary, sugar rises, usually after a hearty meal, with a lot of carbohydrates, and also due to stress.
unspecified
According to the international classification, unspecified hyperglycemia is allocated under the code 73.9. It can manifest itself in the same way as any other hyperglycemia in three degrees of severity:
- mild - up to 8 mmol / l of glucose in blood taken on an empty stomach;
- medium - up to 11 mmol / l;
- severe - more than 16 mmol / l.
Unlike other types of pathology, this disease has no clear causes for its occurrence, and requires close attention and emergency care in case of a severe course.
For a complete diagnosis, additional research methods are assigned:
- Ultrasound of the abdominal cavity;
- brain MRI;
- blood biochemistry;
- Analysis of urine.
According to the data received, the doctor establishes the true cause and prescribes treatment aimed at eliminating the underlying disease. As the healing progresses, the attacks of hyperglycemia go away on their own.
hypoglycemia
No less dangerous is the state of hypoglycemia (in Latin - hypoglykaemia), which is characterized by a decrease in the concentration of sugar in the blood. Hypoglycemia is designated under the code E15 and E16 according to ICD 10.
Important! A prolonged state of low blood glucose can cause a person to go into a hypoglycemic coma with a fatal outcome.
Therefore, when the amount of sugar is below 3.5 mmol / l, urgent measures must be taken.
Hypoglycemia syndrome is a special symptom complex of pronounced signs of an illness with certain neuropathies. It manifests itself with the following symptoms:
- weakness;
- pallor of the skin;
- nausea;
- sweating;
- inconsistency of the heart rhythm;
- tremor of the limbs, gait disturbance.
In severe cases, hypoglycemia syndrome manifests itself with convulsions and loss of consciousness. Such a person needs to be helped immediately: to inject glucose and monitor the state of the tongue so that it does not sunk.
Forms of hypoglycemia
There are three forms of hypoglycemia according to severity:
- first degree;
- second degree;
- hypoglycemic coma.
Each form has its own manifestations and symptoms. If a person has already experienced a mild or moderate form of hypoglycemia, then he should always have something sweet on hand in order to quickly stop a new attack.
First stage
The initial stage is characterized by the following features:
- heavy sweating;
- pallor;
- increased muscle tone;
- change in heart rate, its acceleration.
A person at this moment may feel a strong attack of hunger, irritation. The resulting dizziness can lead to optical effects.
Moderate severity
It is determined by the deterioration of the state of the first degree, up to loss of consciousness and severe weakness.
Coma
It is determined by the level of sugar in the blood less than 1.6 mmol / l. In this case, the following symptoms may appear:
- coordination is disturbed;
- loss of clarity of vision;
- convulsive condition;
- cerebral hemorrhage in severe cases.
Often a coma develops rapidly and spontaneously, such a pathology is especially dangerous for diabetics.
There are many types of hypoglycemia. All of them differ in the causes of occurrence and the method of treatment. There are the following types of pathology:
- Alcoholic occurs with prolonged use of alcohol in large quantities. Violations in the liver provoke a sharp drop in blood sugar.
- The neonatal form of hypoglycemia develops in children who were born to mothers with diabetes mellitus, or in premature babies. This type of illness manifests itself in the first hours of a child's life and requires adjustment of the condition.
- The reactive form of the pathology is associated with malnutrition, but it does not lead to diabetes. Such people tend to be overweight, they move little.
- Chronic hypoglycemia is permanent and needs regular treatment. Most often, this form is a consequence of a violation of the higher endocrine glands - the hypothalamus and pituitary gland. The provocation of the state is prolonged fasting.
- A sharp drop in blood glucose down provokes acute hypoglycemia. This form of the disease often requires quick assistance to the patient in the form of an injection of glucose. Diabetes mellitus can provoke acute hypoglycemia if a large dose of insulin has been administered.
- The latent form proceeds without visible symptoms, very often it manifests itself at night. As a rule, this type of hypoglycemia is established after acute attacks of the disease. The latent type of the disease can be chronic. 0 of 5 )
23464 0
ICD-10 CODE
C73. Malignant neoplasm of the thyroid gland.
Epidemiology
Thyroid cancer in 2005 in the Russian Federation was first diagnosed in 8,505 people, which is 5.99 per 100,000 population. Over the past 20 years, the incidence of cancer of this localization has doubled, mainly due to young and middle-aged people, who mainly develop differentiated forms of the tumor.The disease is much more common in females (the ratio of women and men is 4:1). In 69.3% of patients, thyroid cancer is detected at the age of 40 to 60 years.
In the general structure of oncological morbidity, the proportion of thyroid cancer is small (2.2%), but in the age group from 20 to 29 years old, it takes one of the first places.
Etiology
Among the etiological factors influencing the development of malignant tumors of the thyroid gland, ionizing radiation should be especially highlighted.Thus, there was a sharp increase in the incidence, especially in children, after the explosion of the atomic bomb in Japan and the accident at the Chernobyl nuclear power plant; Numerous cases of the development of tumors of the thyroid gland in persons irradiated in childhood due to diseases of the thymus and tonsils are known. The occurrence of thyroid tumors is promoted by a lack of iodine and the associated hypothyroidism and a high level of pituitary TSH.
Long-term use of thyreostatics, in particular thiamazole, can also provoke the development of thyroid tumors. The functional and morphological state of the thyroid gland is also important: cancerous tumors often occur in this organ against the background of nodular euthyroid goiter, adenomas, and thyroiditis. Thyroid tumors are characterized by multiple rudiments, combination with tumors of other organs (6.9-23.8%).
Pathogenesis
During the formation of tumors in the tissue of the thyroid gland, a number of complex molecular genetic disorders occur: the activity of growth suppressor genes (p53) changes and mutations of oncogenes (met) are activated, and the expression of proteoglycans (CD44, mdm2) increases.Classification
International morphological classification of thyroid tumors- Epithelial tumors:
- papillary cancer;
- follicular cancer (including the so-called Hurtle carcinoma);
- medullary cancer;
- undifferentiated (anaplastic) cancer:
- spindle cell;
- giant cell;
- small cell; - squamous cell (epidermoid) cancer.
- Non-epithelial tumors:
- fibrosarcoma;
- others.
- Mixed tumors:
- carcinosarcoma;
- malignant hemangioendothelioma;
- malignant lymphoma;
- teratoma.
- secondary tumors.
- Unclassified tumors.
papillary cancer- the most common tumor of the thyroid gland (65-75%); the ratio of men and women is 1:6, young people predominate (average age 40.4 years).
The course of the disease is long, and the prognosis is favorable. This form of tumor is characterized by multiple primordia and a high frequency of regional metastasis (35-47%). Distant metastases are rare. Regional metastases may be the first and even the only clinical manifestation of papillary cancer; they often outpace 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.
On microscopic examination, the structure of the tumor can be varied: the tumor consists of papillary formations lined with cuboidal or columnar epithelium; along with papillary structures, follicular, and in some cases, solid cell fields are often found; psammoma bodies are often found. The presence of follicular structures in a papillary tumor does not affect the clinical course; the appearance of solid structures with cell polymorphism and an increase in the number of mitoses is an unfavorable sign that determines a more malignant clinical course of the tumor.
In immunocytochemical studies, in 92% of cases, the presence of thyroglobulin is detected in papillary carcinoma cells, which indicates the preservation of high differentiation and functional activity.
Follicular cancer occurs 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. The course is long, the prognosis is favorable. This tumor is characterized by hematogenous metastasis (more often to the lungs and bones), regional metastases are rare.
Microscopic examination reveals follicles, trabecular structures, as well as solid fields; papillary structures are absent. The tumor often grows into the blood vessels.
Sometimes follicular cancer from highly differentiated follicular epithelium is called "malignant adenoma", "metastasizing struma", "Langhans' struma", thereby introducing only confusion, since the term "struma" means a usually benign adenoma.
Medullary cancer(from parafollicular C-cells) is 2.6-8.2% of cases, the average age of patients is 46 years, the ratio of men and women is 1:1.5. This tumor is more aggressive than well-differentiated adenocarcinoma. Medullary cancer is a hormonally active tumor, it is characterized by a high level of thyrocalcitonin, which is ten times higher than normal. In 24-35% of patients, this disease is manifested by diarrhea, which disappears after radical removal of the tumor. Medullary cancer is characterized by a high frequency of regional metastasis (65-70%). Only in 50% of patients, the first symptom of medullary cancer is a tumor node in the thyroid gland, in the remaining patients - metastatically enlarged cervical lymph nodes.
Microscopic examination in this form of cancer reveals fields and foci of tumor cells surrounded by a fibrous stroma containing amorphous masses of amyloid.
Distinguish sporadic form of medullary carcinoma and MEN.
- In MEN-2 syndrome, medullary thyroid cancer is combined with adrenal pheochromocytoma and parathyroid adenoma (Sipple's syndrome).
- The MEN-2B syndrome includes medullary thyroid cancer, pheochromocytoma, mucosal neuromas, and intestinal neurofibromatosis. Patients are characterized by a marfan-like physique.
undifferentiated cancer clinically proceeds very aggressively, the forecast is unfavorable. Patients over 50 years of age predominate, the ratio of men and women is 1:1. Regional metastases occur in 52.3% of patients, distant - in 20.4%.
Metastasis. The most common localization of distant metastases is the lungs (19.8%). With follicular cancer, metastases to this organ are found in 22% of patients, with papillary cancer - in 8.2%, with papillary-follicular cancer - in 17.6%, with medullary cancer - in 35.0%. Metastases can be either single or multiple.
The frequency of metastasis of thyroid cancer in the bone is 5.9-13.6%. Metastases, usually of the osteolytic type, are found most often in flat bones (skull, sternum, ribs, pelvic bones, spine); in the focus of destruction, the bone swells, an extraosseous component appears. Metastases to the spine are characterized by the destruction of intervertebral discs and the formation of a single focus of destruction of adjacent vertebrae. Bone metastases in thyroid cancer can remain X-ray negative from 1.5 months to 1 year, in the early stages they can be detected using scintigraphy with 131 I or 99m Tc.
International Clinical Classification of TNM reflects the size of the primary tumor (T), metastasis to regional lymph nodes (N) and the presence of distant metastases (M).
T - primary tumor:
- T x - insufficient data to assess the primary tumor;
- T 0 - primary tumor was not detected;
- T 1 - a tumor no more than 2 cm in the largest dimension, not extending beyond the thyroid gland;
- T 2 - tumor from 2 to 4 cm in greatest dimension, not extending beyond the thyroid gland;
- T 3 - a tumor of more than 4 cm in the largest dimension, not extending beyond the thyroid gland, or a tumor of any size with minimal spread to the tissues surrounding the gland (for example, sternothyroid muscles);
- T 4 - a tumor that spreads beyond the capsule of the thyroid gland and grows into the surrounding tissues, or any anaplastic tumor:
- T 4a - tumor, sprouting soft tissues, larynx, trachea, esophagus, recurrent laryngeal nerve;
- T 4b - a tumor that invades the prevertebral fascia, mediastinal vessels or surrounding the carotid artery;
- T 4a * - anaplastic tumor of any size within the thyroid gland;
- T 4b * - an anaplastic tumor of any size, spreading beyond the capsule of the thyroid gland.
- N x - insufficient data to evaluate regional lymph nodes;
- N 0 - no signs of metastatic lesions of regional lymph nodes;
- N 1 - lymph nodes are affected by metastases:
- N 1a - affected by metastases pre - and paratracheal nodes, including preglottic;
- N 1b - metastases on the side of the lesion, on both sides, on the opposite side and / or in the upper mediastinum.
- M x - insufficient data to evaluate distant metastases;
- M 0 - no signs of distant metastases;
- M 1 - distant metastases are determined.
Stages of thyroid cancer determined taking into account the age of the patient, the class of the tumor according to the TNM system and its histological type.
In patients under the age of 45 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
- 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
- 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, mild and similar to the clinical signs of benign tumors.As the tumor develops, clinical signs appear that make it possible to suspect its malignant nature.
These symptoms can be divided into 3 groups:
1) associated with the development of a tumor in the thyroid gland
- rapid node growth;
- dense or uneven consistency;
- tuberosity of the node;
- restriction of the mobility of the thyroid gland;
- voice change (compression and paralysis of the recurrent nerve);
- difficulty breathing and swallowing (compression of the trachea);
- expansion of the veins on the anterior surface of the chest (compression or germination of the veins of the mediastinum);
- increase, compaction and limitation of mobility of regional lymph nodes (paratracheal, anterior jugular nodes - the so-called nodes of the jugular chain; less often - lateral cervical nodes, that is, lymph nodes of the lateral triangle of the neck, behind the accessory region, anterior superior mediastinum);
- distant (hematogenous) metastases:
- metastases to the lungs (radiological picture of "scattering coins": multiple round shadows in the lower parts of the lungs, sometimes resembling pulmonary tuberculosis);
- bone metastases (osteolytic foci in the bones of the pelvis, skull, spine, sternum, ribs);
- metastases to other organs - pleura, liver, brain, kidneys (less common).
Included: endemic conditions associated with iodine deficiency in the natural environment, both directly and as a result of iodine deficiency in the mother's body. Some of these conditions cannot be considered true hypothyroidism, but are the result of inadequate secretion of thyroid hormones in the developing fetus; there may be a connection with natural goiter factors. If necessary, to identify concomitant mental retardation, use an additional code (F70-F79). expelled: subclinical hypothyroidism due to iodine deficiency (E02)
- E00.0 Congenital iodine deficiency syndrome, neurological form. Endemic cretinism, neurological form
- E00.1 Congenital iodine deficiency syndrome, myxedematous form Endemic cretinism: hypothyroid, myxedematous form
- E00.2 Congenital iodine deficiency syndrome, mixed form. Endemic cretinism, mixed form
- E00.9 Congenital iodine deficiency syndrome, unspecified Congenital hypothyroidism due to iodine deficiency NOS. Endemic cretinism NOS
- E01 Thyroid disorders associated with iodine deficiency and related conditions. Excluded: congenital iodine deficiency syndrome (E.00-), subclinical hypothyroidism due to iodine deficiency (E02)
- E01.0 Diffuse (endemic) goiter associated with iodine deficiency
- E01.1 Multinodular (endemic) goiter associated with iodine deficiency. Nodular goiter associated with iodine deficiency
- E01.2 Goiter (endemic) associated with iodine deficiency, unspecified Endemic goiter NOS
- E01.8 Other thyroid disorders associated with iodine deficiency and related conditions Acquired hypothyroidism due to iodine deficiency NOS
- E02 Subclinical hypothyroidism due to iodine deficiency
- E03 Other forms of hypothyroidism.
- E03.0 Congenital hypothyroidism with diffuse goiter. Goiter (non-toxic), congenital: NOS, parenchymal, expelled: transient congenital goiter with normal function (P72.0)
- E03.1 Congenital hypothyroidism without goiter. Aplasia of the thyroid gland (with myxedema). Congenital: thyroid atrophy hypothyroidism NOS
- E03.2 Hypothyroidism due to drugs and other exogenous substances
- E03.3 Post-infectious hypothyroidism
- E03.4 Thyroid atrophy (acquired) Excluded: congenital atrophy of thyroid gland (E03.1)
- E03.5 Myxedema coma
- E03.8 Other specified hypothyroidisms
- E03.9 Hypothyroidism, unspecified Myxedema NOS
- E04 Other forms of non-toxic goiter.
- E04.0 Non-toxic diffuse goiter. Goiter non-toxic: diffuse (colloidal), simple
- E04.1 Non-toxic uninodular goiter. Colloidal node (cystic), (thyroid). Non-toxic mononodous goiter. Thyroid (cystic) node NOS
- E04.2 Nontoxic multinodular goiter Cystic goiter NOS. Polynodous (cystic) goiter NOS
- E04.8 Other specified forms of non-toxic goiter
- E04.9 Nontoxic goiter, unspecified Goiter NOS. Nodular goiter (nontoxic) NOS
- E05 Thyrotoxicosis [hyperthyroidism]
- E05.0 Thyrotoxicosis with diffuse goiter. Exophthalmic or toxic goiter. NOS. Graves' disease. Diffuse toxic goiter
- E05.1 Thyrotoxicosis with toxic single nodular goiter. Thyrotoxicosis with toxic mononodous goiter
- E05.2 Thyrotoxicosis with toxic multinodular goiter. Toxic nodular goiter NOS
- E05.3 Thyrotoxicosis with ectopic thyroid tissue
- E05.4 Artificial thyrotoxicosis
- E05.5 Thyroid crisis or coma
- E05.8 Other forms of thyrotoxicosis Hypersecretion of thyroid stimulating hormone
- E05.9 Thyrotoxicosis, unspecified Hyperthyroidism NOS. Thyrotoxic heart disease (I43.8*)
- E06 Thyroiditis.
- E06.0 Acute thyroiditis. Thyroid abscess. Thyroiditis: pyogenic, purulent
- E06.1 Subacute thyroiditis De Quervain's thyroiditis, giant cell, granulomatous, non-purulent. expelled: autoimmune thyroiditis (E06.3)
- E06.2 Chronic thyroiditis with transient thyrotoxicosis
- E06.3 Autoimmune thyroiditis Hashimoto's thyroiditis. Chasitoxicosis (transient). Lymphoadenomatous goiter. Lymphocytic thyroiditis. Lymphomatous struma
- E06.4 Drug-induced thyroiditis
- E06.5 Chronic thyroiditis: NOS, fibrous, woody, Riedel's
- E06.9 Thyroiditis, unspecified
- E07 Other thyroid disorders
- E07.0 Hypersecretion of calcitonin. C-cell hyperplasia of the thyroid gland. Hypersecretion of thyrocalcitonin
- E07.1 Dishormonal goiter. Familial dyshormonal goiter. Syndrome Pendred.
- E07.8 Other specified diseases of thyroid gland Tyrosine-binding globulin defect. Hemorrhage, infarction in the thyroid gland.
- E07.9 Thyroid disorder, unspecified
RCHD (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical Protocols of the Ministry of Health of the Republic of Kazakhstan - 2015
Malignant neoplasm of thyroid gland (C73)
Oncology
general information
Short description
Recommended
Expert Council
RSE on REM "Republican Center
health development"
Ministry of Health
and social development
Republic of Kazakhstan
dated October 30, 2015
Protocol #14
thyroid cancer- a malignant tumor that develops from thyroid tissue. Cancer developing in the thyroid gland is divided into highly differentiated (papillary and follicular) and anaplastic, originating from the epithelium of the follicles. C - cell (medullary) cancer, originating from parafollicular cells, occupies an intermediate position according to the degree of malignancy (UD-A).
Protocol name: Thyroid cancer.
Protocol code:
ICD-10 code:
C 73 Malignant neoplasm of the thyroid gland.
Abbreviations used in the protocol:
|
ALTalanine aminotransferase ASTaspartate aminotransferase APTTactivated partial thromboplastin time i/vintravenously i/mintramuscularly Grgray gastrointestinal tractgastrointestinal tract ELISAlinked immunosorbent assay CTCT scan LDlymph node dissection INRinternational normalized ratio MRIMagnetic resonance imaging UACgeneral blood analysis OAMgeneral urine analysis PTIprothrombin index PATpositron emission tomography GENUSsingle focal dose SODtotal focal dose CCCthe cardiovascular system STTthyroxine suppressive therapy TSHthyroid-stimulating hormone T3triiodothyronine T4thyroxine UZDGultrasound dopplerography ultrasoundultrasound procedure ECGelectrocardiogram echocardiographyechocardiography per osorally TNMTumor Nodulus Metastasis - international classification of stages of malignant neoplasms |
Date of protocol revision: 2015
Protocol Users: surgeons, endocrinologists, oncologists, radiologists, general practitioners, therapists, emergency physicians.
Evaluation of the degree of evidence of the given recommendations.
Evidence level scale:
| BUT | High-quality meta-analysis, systematic review of RCTs, or large RCTs with a very low probability (++) of bias, the results of which can be generalized to an appropriate population. |
| AT | High-quality (++) systematic review of cohort or case-control studies or high-quality (++) cohort or case-control studies with very low risk of bias or RCTs with not high (+) risk of bias, the results of which can be extended to the appropriate population. |
| With |
Cohort or case-control or controlled trial without randomization with low risk of bias (+). The results of which can be generalized to the appropriate population or RCTs with a very low or low risk of bias (++ or +), the results of which cannot be directly generalized to the appropriate population. |
| D | Description of a case series or uncontrolled study, or expert opinion. |
| GPP | Best Pharmaceutical Practice. |
Classification
International histological classification of thyroid tumors.
epithelial tumors;
A. Benign:
Follicular adenoma;
· Other.
B. Malignant:
· Follicular carcinoma;
papillary carcinoma;
Medullary (C-cell) carcinoma;
Undifferentiated (anaplastic) carcinoma;
· Other.
non-epithelial tumors;
malignant lymphoma;
Other tumors;
Secondary tumors;
Unclassified tumors;
Tumor-like lesions.
Clinical classification:
Currently, the degree of spread of tumors is determined in the framework of the TNM classification of malignant tumors (6th edition 2002).
The classification is applicable only for cancer, and morphological confirmation of the diagnosis (LE-A) is required.
TNM classification:
T-primary tumor:
Tx-insufficient data to assess the primary tumor;
T0-primary tumor is not determined;
T1 tumor up to (£) 2 cm in greatest dimension, limited to thyroid tissue;
T1a tumor up to no more than 1 cm in the greatest dimension, limited to the tissue of the thyroid gland;
T1b tumor greater than 1 cm in greatest dimension, limited to thyroid tissue;
T2 tumor more than 2 cm, but not more than 4 cm in greatest dimension, limited to thyroid tissue;
T3 tumor larger than 4 cm in greatest dimension, limited to thyroid tissue, or any tumor with minimal extension beyond the thyroid gland (germination into the sublingual muscles or soft tissues);
T4a - tumor of any size, spreading beyond the thyroid capsule with germination in the subcutaneous soft tissues, larynx, trachea, esophagus, recurrent laryngeal nerve;
T4b tumor invades prevertebral fascia, carotid artery, or mediastinal vessels;
Undifferentiated (anaplastic) carcinomas are always categorized as T4:
T4a - anaplastic tumor of any size, limited to thyroid tissue;
T4b anaplastic tumor of any size extends beyond the thyroid capsule.
N-regional lymph nodes:
Nx-insufficient data to evaluate regional lymph nodes;
N0 - no signs of metastatic lesions of regional lymph nodes;
N1 - there is a lesion of regional lymph nodes with metastases;
N1a - pretracheal, paratracheal and preglottic lymph nodes are affected (level VI);
N1b-metastatic lesion (unilateral, bilateral or contralateral) of the submandibular, jugular, supraclavicular and mediastinal lymph nodes (levels I-V).
On the neck, it is customary to distinguish six levels of lymphatic drainage (UD-A):
Submandibular and submental lymph nodes.
Superior jugular lymph nodes (along the neurovascular bundle of the neck above the bifurcation of the common carotid artery or hyoid bone)
Middle jugular lymph nodes (between the edge of the scalene-hyoid muscle and the bifurcation of the common carotid artery).
Lower jugular lymph nodes (from the edge of the scalene-hyoid muscle to the collarbone).
Lymph nodes in the posterior triangle of the neck.
Pre-, paratracheal, prethyroid and cricothyroid lymph nodes.
pTNM is a histological confirmation of the spread of thyroid cancer.
M-distant metastases:
M0-distant metastases are absent;
M1 - has distant metastases.
Grouping of thyroid cancer by stages, in addition to TNM categories, takes into account the histological structure of the tumor and the age of patients (UD-A):
Papillary or follicular cancer
Age of patients up to 45 years:
Stage I (any T, any N, M0);
Stage II (any T, any N, M1).
Patients aged 45 years or more:
Stage I (T1N0M0);
Stage II (T2N0M0);
Stage III (T3N0M0, T1-3N1aM0);
Medullary 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 IVc (any T, any N, M1);
Undifferentiated (anaplastic) cancer:
In all cases, it is considered stage IV of the disease;
Stage IVa (T4a, any N, M0);
Stage IVb (T4b, any N, M0);
Stage IVc (any T, any N, M1).
Diagnostics
The list of basic and additional diagnostic measures:
The main (mandatory) diagnostic examinations carried out at the outpatient level:
collection of complaints and anamnesis;
general physical examination.
Determination of calcitonin in blood serum by ELISA-methodomethyroglobulin;
Determination of thyroglobulin in blood serum by ELISA method;
Determination of thyroid-stimulating hormone (TSH) in blood serum by ELISA method, if a reduced level of TSH is detected, additional determination of the level of free triiodothyronine (T3) in blood serum by ELISA method and free determination of free thyroxine (T4) in blood serum by ELISA method.
Ultrasound of the thyroid gland and lymph nodes of the neck;
fine needle aspiration biopsy.
Additional diagnostic examinations performed at the outpatient level:
UAC;
· OAM;
determination of the Rh factor in the blood.
ECG study;
X-ray of the chest in two projections
· PET/CT;
Video laryngoscopy (in the presence of germination in the recurrent nerve);
Thyroid scintigraphy with technetium (Tc99m) or iodine (I131) - to detect a "cold" node (area of reduced accumulation of a radioisotope), characteristic of a cancerous tumor of the thyroid gland and a "hot" node (area of increased accumulation of a radioisotope), characteristic of a toxic adenoma .
The minimum list of examinations that must be carried out upon referral for planned hospitalization: in accordance with the internal regulations of the hospital, taking into account the current order of the authorized body in the field of healthcare.
The main (mandatory) diagnostic examinations carried out at the inpatient level (in case of emergency hospitalization, diagnostic examinations not performed at the outpatient level are carried out):
UAC;
· OAM;
biochemical blood test (total protein, urea, creatinine, glucose, ALT, AST, total bilirubin);
· coagulogram (PTI, prothrombin time, INR, fibrinogen, APTT, thrombin time, ethanol test, thrombotest);
determination of the blood group according to the ABO system with standard sera;
Determination of the Rh factor in blood.
ECG;
x-ray of the chest in two projections.
Additional diagnostic examinations carried out at the inpatient level (in case of emergency hospitalization, diagnostic examinations not performed at the outpatient level are carried out:
CT and / or MRI of the soft tissues of the neck and mediastinum (with contrast - in the presence of germination in the main vessels, with retrosternal location);
· PET/CT;
CT scan of the chest with contrast (in the presence of metastases in the lungs);
Ultrasound of the abdominal cavity and retroperitoneal space (to exclude metastatic lesions and pathology of the abdominal cavity and retroperitoneal space);
Echocardiography (patients 70 years and older);
Ultrasound (with vascular lesions);
X-ray examination of the esophagus with contrast / video esophagogastroduodenoscopy (in the presence of tumor invasion into the esophagus);
diagnostic fibrobronchoscopy (in the presence of retrosternal location, compression, germination in the upper respiratory tract);
Video laryngoscopy (in the presence of germination in the recurrent nerve).
Diagnostic measures taken at the stage of emergency care: are not carried out.
Diagnostic criteria for making a diagnosis:
Complaints and anamnesis;
Complaints(UD-A):
Enlargement of the gland
The appearance of a tumor formation on the anterior and lateral surface of the neck;
change in voice (with germination in the recurrent nerve);
Rapid tumor growth
Shortness of breath, feeling of lack of air (when the tumor grows into the recurrent nerve, upper respiratory tract).
Anamnesis(UD-A):
Thyroid diseases (hypothyroidism, euthyroidism, hyperthyroidism, thyroiditis);
long-term use of antithyroid drugs;
· ionizing radiation;
a history of receiving radiation therapy to the head and neck area.
Physical examinations(UD-A):
On examination, deformation of the neck (uniform swelling on the anterior surface of the neck, asymmetry due to an increase in any part of the thyroid gland, an increase in regional lymph nodes);
palpation examination of the thyroid gland - the presence of a nodular formation in the thickness of the thyroid gland, a dense consistency;
palpation examination of regional lymph nodes - dense consistency, soreness, movable, immobile, partially movable)
Laboratory research:
Cytological examination (increase in cell size up to giant, change in the shape and number of intracellular elements, increase in the size of the nucleus, its contours, different degrees of maturity of the nucleus and other elements of the cell, change in the number and shape of nucleoli);
histological examination (large polygonal or spike-shaped cells with well-defined cytoplasm, rounded nuclei with clear nucleoli, with the presence of mitoses, cells are arranged in the form of cells and strands with or without keratin formation, the presence of tumor emboli in the vessels, the severity of lymphocytic-plasmacytic infiltration, mitotic tumor cell activity).
Instrumental research:
Ultrasound of the thyroid gland (determine the structure of the gland and tumors, the presence of nodular formation, cystic cavities, the size of echogenicity);
Ultrasound of the cervical, submandibular, supraclavicular, subclavian lymph nodes (presence of enlarged lymph nodes, structure, echogenicity, size);
CT and / or MRI of the soft tissues of the neck and mediastinum (with contrast - in the presence of germination in the main vessels, with retrosternal location);
Fine-needle aspiration biopsy from the tumor (allows to determine tumor and non-tumor processes, benign and malignant nature of the tumor).
Indications for consultation of narrow specialists:
consultation with a cardiologist (patients aged 50 and older, as well as patients younger than 50 years in the presence of concomitant CVS pathology);
consultation of a neuropathologist (for cerebrovascular disorders, including strokes, brain and spinal cord injuries, epilepsy, myasthenia gravis, neuroinfectious diseases, as well as in all cases of loss of consciousness);
consultation of a gastroenterologist (in the presence of concomitant pathology of the digestive tract in history);
consultation of a neurosurgeon (in the presence of metastases to the brain, spine);
consultation of a thoracic surgeon (in the presence of metastases in the lungs);
consultation with an endocrinologist (if there is a concomitant pathology of the endocrine organs).
Differential Diagnosis
Differential diagnosis (UD-A):
Table 1.
|
Nosological form |
Clinical manifestations |
|
nodular goiter |
Palpation determined nodular formation in the projection of the thyroid gland. A needle biopsy is required. |
|
Diffuse toxic goiter |
Humidity of the skin, tremor, tachycardia, visible enlargement of the thyroid gland. |
|
Autoimmune thyroiditis |
Diffuse enlargement of the thyroid gland, uniform woody density. The surface is homogeneous, granular. A trepanbiopsy is required. |
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Treatment
Treatment goals:
elimination of the tumor focus and metastases;
Achievement of complete or partial regression, stabilization of the tumor process.
Treatment tactics (UD-A):
General principles of treatment.
Surgical removal of the tumor is the main component of the radical treatment of thyroid cancer.
In stage I-IV with differentiated and undifferentiated tumors, radical surgery is an independent method of treatment.
Neck lymph node dissection is indicated only in the presence of metastases in the lymph nodes.
Thyroxine suppressive therapy (STT) is used as a component of complex treatment of patients with thyroid cancer after thyroidectomy in order to suppress TSH secretion.
Radioiodine therapy is used after surgical treatment to destroy the remnants of thyroid tissue (ablation), iodine-positive metastases, relapses and residual carcinomas.
Hormone replacement therapy (HRT) 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 performed, in order to eliminate hypothyroidism with thyroxine in physiological doses.
Radiation therapy is used in an independent form:
in patients with widespread primary or recurrent tumor process;
in persons who were scheduled for repeated interventions due to the non-radical nature of the first operation;
in patients with less differentiated forms of thyroid cancer.
Combination treatment is indicated:
with the prevalence of primary or recurrent thyroid cancer;
undifferentiated forms of cancer that have not been exposed to radiation.
Currently, there is no evidence of the effectiveness of systemic chemotherapy in papillary and follicular thyroid cancer. Drug antitumor treatment is indicated for anaplastic (undifferentiated) thyroid cancer.
Non-drug treatment
The patient's regimen during conservative treatment is general. In the early postoperative period - bed or semi-bed (depending on the volume of the operation and concomitant pathology). In the postoperative period - ward.
Diet table - No. 15.
Medical treatment:
Thyroxine Suppressive Therapy (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.
Rationale: TSH is a growth factor for papillary and follicular thyroid cancer cells. Suppression of TSH secretion reduces the risk of recurrence in the thyroid tissue and reduces the likelihood of distant metastases.
Indications: with papillary and follicular cancer, regardless of the volume of the operation performed.
To achieve a suppressive effect, thyroxine is prescribed in the following doses:
2.5-3 mcg per 1 kg of weight in children and adolescents;
2.5 mcg per 1 kg of body weight in adults.
The norm of TSH in the blood is 0.5 - 5.0 mU / l.
The level of TSH during suppressive therapy with thyroxine:
TSH - within 0.1-0.3 mU / l;
TSH control: should be carried out every 3 months during the first year after surgery. In subsequent periods - at least 2 times a year.
Correction of the dose of thyroxin (increase, decrease) - should be carried out gradually at 25 mcg per day.
Side effects of STT:
Development of hyperthyroidism
Osteoporosis, resulting from the loss of bone mineral components, increases the risk of fractures.
Cardiovascular disorders: tachycardia, left ventricular hypertrophy during exercise, increased risk of atrial fibrillation.
If these complications occur, you should switch to replacement therapy.
STT duration:
It is established individually, taking into account the morphological features of the carcinoma, its spread, the radical nature of the operation, and the age of the patients.
In adults under 65 years of age, patients with papillary and follicular extrathyroid cancer with pT4N0-1M0-1, STT should be carried out for life.
· in case of follicular cancer with reduced differentiation with pT1-4N0-1M0-1, lifelong use of STT is necessary.
Indications for the transfer of patients with STT to thyroxine replacement therapy:
In case of intrathyroid papillary and highly differentiated follicular cancer (pT2-3N0-1M0) after radical surgery and radioiodine diagnostics, if there has been no recurrence and metastases for 15 years;
· with microcarcinoma (рT1aN1aM0) of papillary and highly differentiated follicular structure, if within 10 years there was no recurrence and metastases.
Hormone Replacement Therapy (HRT) (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 performed, in order to eliminate hypothyroidism with thyroxine in physiological doses.
Indications:
in persons over 65 years of age with concomitant pathology of the cardiovascular system;
In case of adverse reactions and complications (osteoporosis, heart disease) developed as a result of treatment with suppressive doses of thyroxine.
in cases of achieving stable long-term remission without relapse and metastases in children over 10 years old, in adults - over 15 years old.
in all other cases where suppressive therapy is not possible.
TSH monitoring and thyroxine dose adjustment:
The dose of thyroxine in HRT is the recommended dose: 1.6 mcg per kg of body weight in adults.
The level of TSH with HRT in the blood is in the range of 0.5-5.0 mU / l.
Monitoring the level of TSH in the blood once every six months.
Replacement therapy in patients with thyroid cancer is usually carried out for life. (UD-A).
Chemotherapy is a drug treatment of malignant cancerous tumors, aimed at destroying or slowing down the growth of cancer cells with the help of special drugs, cytostatics. Treatment of cancer with chemotherapy occurs systematically according to a certain scheme, which is selected individually. As a rule, tumor chemotherapy regimens consist of several courses of taking certain combinations of drugs with pauses between doses to restore damaged body tissues (UD-A).
There are several types of chemotherapy, which differ in purpose of appointment:
Neoadjuvant chemotherapy of tumors is prescribed before surgery, in order to reduce the inoperable tumor for surgery, as well as to identify the sensitivity of cancer cells to drugs for further prescription after surgery.
Adjuvant chemotherapy is given after surgery to prevent metastasis and reduce the risk of recurrence.
Therapeutic chemotherapy is prescribed to reduce metastatic cancerous tumors.
· Thyroid cancer belongs to the category of neoplasms for which existing anticancer drugs do not have a pronounced therapeutic effect.
Indications for chemotherapy (UD-A):
undifferentiated (anaplastic) thyroid cancer
· widespread process of differentiated form of thyroid cancer, insensitive to hormone therapy and radioiodine therapy;
inoperable medullary thyroid cancer.
Contraindications to chemotherapy:
Contraindications to chemotherapy can be divided into two groups: absolute and relative.
Absolute contraindications:
hyperthermia >38 degrees;
disease in the stage of decompensation (cardiovascular system, respiratory system, liver, kidneys);
the presence of acute infectious diseases;
mental illness;
The ineffectiveness of this type of treatment, confirmed by one or more specialists;
Severe condition of the patient on the Karnovsky scale of 50% or less.
· pregnancy;
intoxication of the body;
When conducting polychemotherapy for thyroid cancer, it is possible to use the following schemes and combinations of chemotherapy drugs:
Schemes and combinations of chemotherapy drugs(UD-A):
doxorubicin 60 mg/m2 IV on day 1;
cisplatin 40 mg/m2 for 1 day;
doxorubicin 70 mg/m2 IV for 1 day;
· bleomycin 15 mg/m2 1-5 days;
Vincristine 1.4 mg/m2 on days 1 and 8;
repeated course in 3 weeks.
doxorubicin 60 mg/m2 IV for 1 day;
vincristine 1 mg/m2 IV for 1 day;
bleomycin 30 mg IV or IM 1,8,15,22 days;
repeated course in 3 weeks.
Vincristine 1.4 mg/m2;
Doxorubicin 60 mg/m2 IV for 1 day;
Cyclophosphamide 1000 mg/m2 IV for 1 day;
repeated course in 3 weeks.
· doxorubicin - 60 mg/m2 1 day;
docetaxel 60 mg/m2 for 1 day;
repeated course in 3 weeks.
Targeted Therapy
For radioiodine-refractory well-differentiated thyroid cancer in the targeted drug group sorafenib 400 mg po twice daily (UD-B) (UD-A):
total thyroidectomy (total thyroidectomy);
total lobectomy (unilateral lobectomy);
Hemithyroidectomy with resection of the isthmus (unilateral lobectomy, intersection of the isthmus);
Cervical lymph node dissection (fascial-case excision of the cervical lymph nodes).
Types of cervical lymph node dissection(UD-A):
radical cervical lymph node dissection (Crail operation) - removal of a single block of lymph nodes and tissue of the neck together with the sternocleidomastoid muscle, internal jugular vein, accessory nerve, submandibular salivary gland and the lower pole of the parotid salivary gland.
· modified cervical lymph node dissection - removal of lymph nodes of all 5 levels with preservation of one or more of the following anatomical formations: accessory nerve, sternocleidomastoid muscle, internal jugular vein.
Selective cervical lymph node dissection - removal of lymph nodes of 1 or several levels while maintaining all the following anatomical formations: accessory nerve, sternocleidomastoid muscle, internal jugular vein.
Indications for surgical treatment of thyroid cancer:
morphologically verified thyroid cancer;
in the absence of contraindications to surgical treatment.
Contraindications for surgical treatment of thyroid cancer:
The patient has signs of inoperability and severe concomitant pathology;
· undifferentiated thyroid cancer, which may be offered as an alternative to radiation treatment;
In the presence of metastatic regional lymph nodes of an infiltrative nature, sprouting the internal jugular vein, the common carotid artery;
Extensive hematogenous metastasis, disseminated tumor process;
synchronously existing tumor process in the thyroid gland and a common inoperable tumor process of another localization, for example, lung cancer, breast cancer;
· chronic decompensated and/or acute functional disorders of the respiratory, cardiovascular, urinary system, gastrointestinal tract;
Allergy to drugs used in general anesthesia.
Surgical intervention provided on an outpatient basis: no.
Surgical intervention provided in a hospital:
Scope of operation (UD-A):
Total thyroidectomy - for papillary and follicular cancer with tumor spread T1-4N0M0, in all cases for medullary, undifferentiated and squamous cell cancer;
Total lobectomy, hemithyroidectomy with resection of the isthmus - with solitary microcarcinoma (T1aN0M0) located in the lobe of the thyroid gland and with favorable prognostic signs (patients under 45 years old, female and in the absence of a history of radiation exposure to the neck area);
selective, modified cervical lymph node dissection (LD) - with unilateral or multiple displaceable metastases in the lymph nodes of the neck on one or both sides;
radical cervical LD (Crail operation) - with single or multiple limitedly displaceable metastases with germination of the jugular vein and sternocleidomastoid muscle on one side or both sides.
Treatment of recurrence of thyroid cancer is also applied surgical treatment.
Other types of treatment:
Other types of outpatient treatment: radiation therapy, radioiodine therapy.
Other types of treatment provided at the inpatient level: radiation therapy, radioiodine therapy.
Radiation therapy- This is one of the most effective and popular methods of treatment.
Types of radiation therapy:
remote radiation therapy;
· 3D conformal irradiation;
intensity-modulated radiation therapy (IMRT).
Indications for radiotherapy (UD-A):
Preoperative radiation therapy is indicated in adult patients with undifferentiated (anaplastic) and squamous cell thyroid cancer;
Postoperative irradiation is advisable in patients with undifferentiated, medullary and squamous cell carcinoma, if radiation therapy was not performed in the preoperative period, and surgical treatment was not sufficiently ablasted.
During radiation treatment according to the radical program, SOD 70 Gy is applied to the primary tumor focus and metastases in the cervical lymph nodes, and SOD 50 Gy is applied to unchanged regional lymph nodes in highly malignant tumors.
Single focal doses depend on the rate of tumor growth and its degree of differentiation. For slow-growing tumors, the ROD is 1.8 Gy; for high-grade, fast-growing tumors, the ROD is 2 Gy x 5 fractions per week.
Contraindications for radiotherapy:
Absolute contraindications:
mental inadequacy of the patient;
· radiation sickness;
hyperthermia >38 degrees;
Severe condition of the patient on the Karnovsky scale of 50% or less (see Appendix 1).
Relative contraindications:
· pregnancy;
disease in the stage of decompensation (cardiovascular system, liver, kidneys);
· sepsis;
active pulmonary tuberculosis;
disintegration of the tumor (threat of bleeding);
Persistent pathological changes in the composition of the blood (anemia, leukopenia, thrombocytopenia);
· cachexia;
a history of previous radiation treatment.
In anaplastic thyroid cancer, it is also possible to use competitive chemoradiotherapy doxorubicin 20 mg/m2 IV 1 day, weekly for 3 weeks, with radiation therapy 1.6 Gy, 2 times a day, 5 fractions per week, up to SOD 46 Gy. , at present, when using IMRT technology, it makes it possible to irradiate up to 70 Gy on the bed of the main focus.
Radioiodine therapy(UD-A):
It is used after surgical treatment to destroy remnants of thyroid tissue (ablation), iodine-positive metastases, relapses and residual carcinomas.
Mandatory conditions for radioiodine therapy:
· Complete or almost complete surgical removal of the thyroid gland and regional metastases;
Cancellation of hormone therapy for 3-4 weeks after surgery;
The level of TSH in the blood should be more than 30 mU / l;
Preliminary radioiodine test.
Indications for radioiodine test:
Radioiodine diagnostics is performed in patients with papillary and follicular thyroid cancer in the following cases:
Before surgery, individual metastases were found 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 persons over 50 years of age with proven extrathyroidal spread of the carcinoma tumor and multiple regional metastases (pT4; pN1).
Hormonal control:
It is carried out at 10-12 weeks after thyroidectomy:
TSH should be less than 0.1 mU/l;
T3 - within physiological values;
T4 - above normal;
thyroglobulin.
Radioiodine diagnostics is used for cancer pT2-4N0M0 300-400 Mbq per os I131 and then whole body scintigraphy is performed 24-48 hours later. If metastases accumulating I131 are not detected (M0), then radioiodine therapy should not be carried out. Radioiodine therapy is necessary for pT2-4N1M1 cancer. For adults, the maximum activity of the drug is 7.5 Gbq I131, and for children 100 Mbq I131 per kg of body weight.
Monitoring the effectiveness of radioiodine therapy
Every 6 months, general clinical studies are performed, determination of TSH, T3, T4, thyroglobulin, calcium, complete blood count, ultrasound of the neck. Every 24 months, radioiodine diagnostics (300-400 Mbq I131) is carried out after preliminary cancellation of thyroxin for 4 weeks, radiography of the lungs in 2 projections.
Palliative Care:
In case of severe pain syndrome, treatment is carried out in accordance with the recommendations of the protocol «
Palliative care for patients with chronic progressive diseases in the incurable 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 the Republic of Kazakhstan No. 23 dated 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 an incurable stage, accompanied by bleeding", approved by the protocol of the meeting of the Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan No. 23 dated December 12, 2013.
Other types of treatment provided at the stage of emergency medical care: no.
Treatment effectiveness indicators:
Tumor response - tumor regression after treatment;
recurrence-free survival (three and five years);
· "quality of life" includes, in addition to the psychological, emotional and social functioning of a person, the physical condition of the patient's body.
Further management:
Dispensary observation of cured patients:
during the first year after completion of treatment - 1 time every 3 months;
during the second year after completion of treatment - 1 time every 6 months;
from the third year after completion of treatment - 1 time per year for 3 years.
Examination methods:
palpation of the bed of the thyroid gland - at each examination;
palpation of regional lymph nodes - at each examination;
Ultrasound of the thyroid bed and the area of regional metastasis;
x-ray examination of the chest - once a year;
Ultrasound examination of the abdominal organs - once every 6 months (for primary and metastatic tumors).
Thyroglobulin is a specific highly sensitive marker of thyroid cells, as well as papillary and follicular thyroid cancer cells. Determined three months after the operation, any determined level of thyroglobulin is an indication for further examination.
· TSH should be less than 0.1 mU/l.
Drugs (active substances) used in the treatment
Hospitalization
Indications for hospitalization, indicating the type of hospitalization:
Indications for emergency hospitalization:
Bleeding from the tumor
stenosis of the larynx.
Indications for planned hospitalization:
The patient has morphologically verified thyroid cancer.
Prevention
Preventive actions:
· earlier the beginning of treatment, its continuity, complex nature, taking into account the individuality of the patient;
return of the patient to active work.
Information
Sources and literature
- Minutes of the meetings of the Expert Council of the RCHD MHSD RK, 2015
- References: 1. Tumors of the head and neck, A.I. Paches.- M., 2000 2. TNM Classification of Malignant Tumors, 6th edition, Author: Editors: L.H. Sobin, Ch. Wittekind, 2002. 3. Tumors of the head and neck: hands A.I. Paches. - 5th ed., additional and revised. -M.: practical medicine, 2013. 4. A new approach to the classification of cervical lymphadenectomy // Successes of modern natural sciences, Movergoz S.V., Ibragimov V.R. – 2009; 5. Thyroid tumors, M. Schlumberger, F. Pacini, R. Michael Tuttle: 6. Antitumor chemotherapy. Management. R.T. Skyla, Geotar-media, Moscow, 2011 7. Guidelines for chemotherapy of neoplastic diseases, N.I. Translator, Moscow, 2011 8. Guidelines for chemotherapy of neoplastic diseases, N.I. Perevodchikova, V.A. Gorbunova Moscow, 2015; 9. Diseases of the thyroid gland, E.A. Valdina, St. Petersburg, 2001; 10. Endocrinology. Edited by N. Lavin. Moscow. 1999; 11. Endocrinology. Volume 1. Diseases of the pituitary, thyroid and adrenal glands. St. Petersburg. Special Lit., 2011.
Information
List of protocol developers with qualified data:
1. Adilbaev Galym Bazenovich - Doctor of Medical Sciences, Professor, "RSE on REM Kazakh Research Institute of Oncology and Radiology", head of the center;
2. Kydyrbayeva Gulzhan Zhanuzakovna - Candidate of Medical Sciences, RSE on REM "Kazakh Research Institute of Oncology and Radiology", researcher.
3. Kaybarov Murat Endalovich - Candidate of Medical Sciences, RSE on REM "Kazakh Research Institute of Oncology and Radiology", oncologist;
4. Shipilova Victoria Viktorovna - Candidate of Medical Sciences, RSE on REM "Kazakh Research Institute of Oncology and Radiology", researcher at the Center for Head and Neck Tumors;
5. Tumanova Asel Kadyrbekovna - candidate of medical sciences, RSE on REM "Kazakh Research Institute of Oncology and Radiology", head of the department of day hospital chemotherapy -1.
6. Savkhatova Akmaral Dospolovna - RSE on REM "Kazakh Research Institute of Oncology and Radiology", head of the day hospital department.
7. Makhyshova Aida Turarbekovna - RSE on REM "Kazakh Research Institute of Oncology and Radiology", oncologist.
8. Tabarov Adlet Berikbolovich - clinical pharmacologist, RSE on REM "Hospital of the Medical Center Administration of the President of the Republic of Kazakhstan", head of the department of innovation management.
Indication of no conflict of interest:
Reviewers: Kaydarov Bakyt Kasenovich — Doctor of Medical Sciences, Professor, Head of the Department of Oncology, Mammology and Radiation Therapy, RSE “Kazakh National Medical University named after S.D. Asfendiyarov".
Indication of the conditions for revising the protocol: 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 a level of evidence.
Attached files
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C73. It is he who encrypts a malignant disease that affects one of the most important glands of the human body. Consider what are the features of the disease, how you can recognize it, what are the approaches to treatment. Let us also pay attention to why this problem is so relevant in modern medicine.
general information
The thyroid gland is such a butterfly-shaped organ, the localization area of \u200b\u200bwhich is the frontal part of the neck. This gland is one of the blocks of the human endocrine system. The gland is responsible for generating a number of vital hormones. One of them (triiodothyronine) provides the body with the opportunity to develop and grow. Thyroxine, produced by this gland, is necessary for the normal rate of metabolic processes inherent in our body. Finally, the gland generates calcitonin, which monitors how calcium stores are consumed in the body.
Recorded as C73 (ICD code 10), thyroid cancer is a malignant process localized in the organic tissues that form the organ. In a cancerous tumor, cell growth is not controlled by standard mechanisms, and cell division is not regulated by anything.
Relevance of the issue
Record C73 (thyroid cancer code according to ICD 10) is on average every tenth person suffering from a tumor process in this organ. The main percentage (about 9 cases out of ten) falls on benign neoplasms. More often, the disease develops in females - up to three-quarters of cancer victims belong to him. In the female half of humanity, this disease is the fifth most common. As scientists who studied medical statistics found out, among women over 20 years old, but under 35, it is this type of oncological disease that is most common.
As can be seen from the statistics based on the use of the C73 cipher (ICD 10 code for thyroid cancer), this problem is really relevant for modern society. Of course, any person who is suspected of having a disease or has been accurately diagnosed is concerned about the issue of curability. According to experts, in the general case, cancer is treatable. As the information reports show, among other diseases in the field of oncology, this one has one of the best outcomes if treatment is started on time and correctly. The best prognosis is in people who were diagnosed with the disease at the initial level, and who managed to start treatment while the disease was in the first or second stage. If progress has reached the formation of metastases, the situation becomes much more complicated.
About categorization
Above was the ICD diagnosis code (C73). ICD 10 is an internationally accepted classification of diseases that develop in humans. This classification system is regularly reviewed, and the ten in the name reflects the current version number, that is, the tenth edition is current today. The classifier is accepted in medicine in many countries and is used to designate and encrypt a diagnosis. The system was created by WHO and is recommended for use everywhere.
C73 is the ICD diagnosis code, which encodes a malignant formation that has appeared in the thyroid gland. Experts note that the disease is more often observed, as mentioned above, in females.
Where did the trouble come from
Thyroid cancer is a disease whose causes are currently unknown to scientists. In rare cases, it is possible to formulate what exactly provoked oncology, but this is rather an exception than a rule. It is known that certain types of disease are initiated by genetic transformations at the cellular level.
Factors that increase the danger to humans have been identified. The first and main one is gender. Women are more susceptible to the development of the disease, the risk for representatives of this sex is three times greater than that characteristic of men.
It has been established that a cancerous neoplasm can appear unpredictably at any age, but more often it is either young women and middle-aged ladies, or men over 50 years old. If at least one close relative suffered from such a malignant disease, the likelihood of its development is much higher. The most significant relationship in the study of statistics was revealed with diseases that developed in parents, children, sisters and brothers.
About factors: continuing consideration
As observations have shown, various forms of thyroid cancer threaten people who eat inadequately, do not receive the amount of iodine necessary for a person with food. The risks are associated with the complete rejection of such nutrition, and with the partial exclusion of products, accompanied by the risk of micronutrient deficiency.
Another relationship has been identified with radiation exposure. If a person was previously treated for a malignant process, and was forced to undergo radiation as part of the course, the likelihood of thyroid pathology increases.
Is it possible to warn
Since the exact causes of the disease in most cases cannot be established, the prevention of thyroid cancer is difficult. Doctors do not know the ways and methods that could completely eliminate the risk of developing a malignant disease. General advice has been developed to reduce the risks for a particular person. Observations have shown that they are less if a person regularly goes in for sports and leads an active, healthy lifestyle. It is equally important to eat properly, in a balanced way, controlling the intake of essential elements and vitamins into the body.
The thyroid gland involves a complete rejection of any bad habits. To minimize the risks to yourself, you should monitor the iodine content in the body. To maintain it, you can revise the diet, consult a doctor in order to determine the feasibility of taking special nutritional supplements.
About Forms
Several types of thyroid cancer are known. The classification is based on the type of cellular structures from which the pathological area is formed. Another important parameter is differentiation. When determining the features of the case, the degree of prevalence must be checked.
There are three types of differentiation: high, medium and low. The lower the parameter, the faster the propagation speed will be. Poorly differentiated pathological processes have a worse prognosis, since they are difficult to treat.
Types: more
Most often, the papillary form of the disease is diagnosed. On average, it accounts for 80% of oncological ailments of the gland in question. Approximately in 8-9 people out of every ten cases, the process extends to only one part of the organ. Up to 65% is not accompanied by spread beyond it. Detection of metastases in the lymphatic system occurs in the diagnosis of approximately one in three cases. The papillary form slowly progresses. The prognosis is relatively favorable, since the disease is treatable.
Every tenth patient with oncology of the organ is diagnosed with follicular thyroid cancer. The prognosis in this case is also relatively good. The probability of spreading the process to other organs is estimated at no more than 10%. More often this type of pathology is found in women in whose body there is a lack of iodine.
Continuing the theme
Sometimes, when thyroid cancer is suspected, doctors talk about the possibility of a pathological process of the medullary type. This is observed on average in 4% of patients with oncology of the organ. Up to 70% is accompanied by metastasis to the regional nodes of the lymphatic system. Every third is found to spread to the skeletal system, in the tissue of the lungs, and the liver.
The prevalence of the anaplastic form is estimated at 2%. This format is considered the most aggressive. It tends to spread rapidly to the lymphatic system and to the cervical tissues. For many, the lungs are already affected at the stage of diagnosis. Most often, this disease can be detected only at the fourth stage of development.
Step by step
Like any other oncological disease, the one under consideration has several stages. Consider the generally accepted clinical system. According to it, a case is referred to the first stage, the dimensions of which do not exceed a centimeter, only the tissues of the gland itself are covered. The second stage is accompanied by growth up to 4 cm, so the gland is deformed. Spread to nearby lymph nodes (only on one side of the neck) is possible. This stage is accompanied by the first symptoms - the neck swells, the voice becomes hoarse.
Stage 3 thyroid cancer is characterized by the spread of the process outside the initial organ with lesions of the lymphatic system on both sides of the neck. Pathology initiates pain. The fourth stage is accompanied by secondary lesions, spreading to the musculoskeletal, respiratory and other systems.
How to suspect
Symptoms of thyroid cancer at an early stage usually do not appear. At the first stage, the disease can be noticed only as part of a specialized preventive examination. The first more or less noticeable manifestations are seen when the pathology has reached the second or third level. Symptoms are close to a variety of benign formations, so the diagnosis is complicated. To accurately determine what initiated the manifestations, it is necessary to undergo a comprehensive examination in a specialized clinic. It is recommended to visit a specialist if a swelling has formed near the gland, a seal is felt. It is recommended to contact a professional if the cervical lymph nodes have become larger than normal, the voice is often hoarse, and it is difficult to swallow. A potential symptom of the process is shortness of breath. Soreness in the neck can signal cancer.
How to clarify
If a malignant disease is suspected, the patient will be sent for a comprehensive laboratory and instrumental examination. Diagnostic measures will be chosen by the endocrinologist. First, they collect a medical history, study the condition of the lymph nodes, thyroid gland by palpation. Next, a person is sent to a laboratory for blood sampling in order to determine its qualities through a hormonal panel. TSH in thyroid cancer is either higher than noma, or significantly lower. The production of other hormones is corrected. Violation of the concentration of active substances in the circulatory system is not an unambiguous indication of oncology, but may indicate it.
An equally important examination is a blood test to determine the content of oncological markers. These are specific substances that are characteristic of a particular malignant process.
Continuing research
The patient must be sent for an ultrasound. A study using ultrasound allows you to assess the condition of both the organ and the lymph nodes nearby. As a result, the doctor will know what the dimensions of the gland are, whether there is a pathological formation in it, how large it is. Pathologically altered cells are taken from the identified area for biopsy. The procedure requires local anesthesia. A fine needle is used for the biopsy. Ultrasound allows you to control the accuracy of the selection of the site for obtaining cells. Organic samples are sent to a laboratory for evaluation. Based on the results of the study, the doctor will know what are the nuances of the structure, how malignant the process is, and will also determine the differentiation.
After the initial examination, the patient is sent for a chest X-ray. The alternative is computed tomography. The procedure helps to determine the presence of a secondary tumor process in the respiratory system. To exclude brain metastases, an MRI is prescribed. To assess the presence of metastases in the body, PET-CT is indicated. This technology helps to identify pathological foci up to a millimeter in diameter.
How to fight
After completing the diagnosis and determining all the features of the process, doctors select the appropriate therapy program. They may recommend surgery, medication, and a course of radiation treatment. A typical approach is an operation during which pathological cellular structures are removed. There are two main methods of operation, the choice in favor of a specific one is due to the spread of the disease. If it is necessary to remove only part of the gland, a lobectomy is prescribed. If it is necessary to remove the tissues of the gland completely or its large area, a thyroidectomy is prescribed. If malignant processes have captured not only the gland, but also the lymph nodes located nearby, they must also be removed.
About operations
The operation can be done in an open way. Tissues are cut horizontally on the neck. The length of the incision can be up to eight centimeters. For the patient, the main advantage of this approach is the affordable cost of the intervention. There were some disadvantages, because after the operation a large trace remains.
A more modern option is assisting with a video camera. To do this, a three-centimeter incision is sufficient, through which a tube with video equipment and a scalpel operating on ultrasonic radiation are inserted into the body. As a result, the scar will not be so noticeable, but the event is quite complex and expensive, not every clinic has the equipment to implement it.
An even more expensive and reliable method of operation is robotic. An incision is made in the armpit, through which a special robot is introduced into the body, which performs all surgical procedures. After such an operation, everything heals without any traces visible to the eye.
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