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Epidemiologie, Pathophysiologie, leitliniengerechte Diagnostik und Therapie des Schilddrüsenknotens

Epidemiology, Pathophysiology, Guideline-Adjusted Diagnostics, and Treatment of Thyroid Nodules

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Zusammenfassung

Hintergrund:

Klinisch relevante Schilddrüsenkarzinome sind in 5–6% der operierten Knotenstrumen zu finden. Multinodöse Strumen weisen zudem häufig autonome Areale auf. Daher bedarf es effektiver rationaler differentialdiagnostischer Methoden und Entscheidungsalgorithmen, um unter der großen Zahl der Schilddrüsenknoten diejenigen Knoten mit einem erhöhten Karzinomrisiko oder einer Schilddrüsenautonomie zu identifizieren.

Methodik:

Darstellung einer aktuell überarbeiteten Leitlinie und weiterer Leitlinien und Konsensusstellungnahmen sowie selektive Literaturübersicht.

Ergebnisse:

Bereits mittels Anamnese, Sonographie und TSH-Bestimmung (thyreoideastimulierendes Hormon) sind eine erste Risikobeurteilung und Selektion für die weitere Schilddrüsendiagnostik möglich. Die Feinnadelbiopsie (FNB) ist die Methode mit der besten Sensitivität und Spezifität für die Dignitätsabklärung sonographisch darstellbarer, szintigraphisch normal speichernder oder kalter Schilddrüsenknoten > 1 cm. Voraussetzungen für einen effektiven Einsatz der FNB in der klinischen Routine sind allerdings eine adäquate Ausbildung und umfangreiche Erfahrungen von Punkteur und Zytopathologe.

Schlussfolgerung:

Während malignitätsverdächtige solitäre Schilddrüsenknoten unverzüglich dem Chirurgen zugeführt werden müssen, kann bei fehlenden klinischen, sonographischen und zytologischen Malignitätshinweisen, normalem Calcitonin sowie Euthyreose der Verlauf – ggf. unter Medikation – beobachtet werden, wenn nicht eine chirurgische Therapie aufgrund lokaler Beschwerdesymptomatik, trachealer Beteiligung oder mediastinaler Ausdehnung begründet ist.

Abstract

Background:

Clinically relevant thyroid carcinomas can be found in 5–6% of nodular goiters which undergo surgery. Moreover, multinodular goiters fre- quently contain hot areas. Therefore, efficient and rational methods for the differential diagnosis and decision are required to identify those nodules with an increased cancer risk or those which are hot among the many thyroid nodules.

Methods:

Description of a newly revised and further guidelines and consensus statements as well as selected literature search.

Results:

Already history, ultrasound and TSH (thyroid-stimulating hormone) determination do allow a first risk assessment for the further diagnostic work-up. Fine-needle biopsy (FNB) offers the best sensitivity and specificity for the distinction between benign and malignant thyroid nodules. The combination of several clinical and ultrasound criteria and laboratory determinations (calcitonin) can help with the selection of thyroid nodules with scintigraphically normal or decreased uptake > 1 cm for FNB. However, the efficiency of FNB requires sufficient training and experience of both the cytopathologist and the person performing FNB.

Conclusion:

Whereas solitary thyroid nodules with a suspicion for malignancy should be referred to the surgeon, euthyroid thyroid nodules without clinical ultrasound or cytological indicators of malignancy may be followed up – possibly under medication –, if surgery is not indicated by local complaints, tracheal or mediastinal involvement.

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Authors and Affiliations

  1. Medizinische Klinik und Poliklinik III, Universitätsklinikum Leipzig, Leipzig, Germany

    Ralf Paschke

  2. Institut für Pathologie und Neuropathologie, Universitätsklinikum Essen, Universität Duisburg-Essen, Duisburg-Essen, Germany

    Kurt Werner Schmid

  3. Medizinische Klinik Innenstadt, Klinikum der Universität München, München, Germany

    Roland Gärtner

  4. Klinik für Endokrinologie, Universitätsklinikum Essen, Universität Duisburg-Essen, Duisburg-Essen, Germany

    Klaus Mann

  5. Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Universitätsklinikum Halle, Halle, Germany

    Henning Dralle

  6. Klinik und Poliklinik für Nuklearmedizin, Universitätsklinikum Würzburg, Würzburg, Germany

    Christian Reiners

  7. Medizinische Klinik und Poliklinik III, Universität Leipzig, Philipp-Rosenthal-Straße 27, 04103, Leipzig, Germany

    Ralf Paschke

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  1. Ralf Paschke
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Correspondence to Ralf Paschke.

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Paschke, R., Schmid, K.W., Gärtner, R. et al. Epidemiologie, Pathophysiologie, leitliniengerechte Diagnostik und Therapie des Schilddrüsenknotens. Med Klin 105, 80–87 (2010). https://doi.org/10.1007/s00063-010-1011-9

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  • DOI: https://doi.org/10.1007/s00063-010-1011-9

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