대한갑상선학회 갑상선결절 및 암 ... - thyroid.kr

1 1, 2, 7, 3, 13, 4, 8, 5, 9, 12, 15, 6, . 10, 11, 14. 1, 2, 3, 4, 5, 6, 7, 7, 8, 9, 10, 11, 12, 13, 14, 15, 2. Revised Korean thyroid Association Management Guidelines for Patients with thyroid Nodules and thyroid Cancer Ka Hee Yi1, Young Joo Park2, Sung-Soo Koong3, Jung-Han Kim4, Dong Gyu Na5, Jin-Sook Ryu6, So Yeon Park7, In Ae Park7, Chung-Hwan Baek8, Young Kee Shong9, Young Don Lee10, Jaetae Lee11, Jeong Hyun Lee12, Jae Hoon Chung13, Chan Kwon Jung14, Seung-Ho Choi15 and Bo Youn Cho2. Department of Internal Medicine, Korea Cancer Center Hospital, Korea Institute of Radiological & Medical Sciences1; and 2 7. Departments of Internal Medicine ; Pathology , Seoul National University College of Medicine; and Department of Internal Medicine, College of Medicine, Chungbuk National University3; and Departments of Medicine13; Surgery4.

2 Otorhinolaryngology-Head and Neck Surgery8, Sungkyunkwan University School of Medicine; and Human Medical Imaging and Intervention Center5; and Departments of Endocrinology and Metabolosm9; Radiology12; Otolaryngology15; Nuclear Medicine6, University of Ulsan College of Medicine; and Department of Surgery, School of Medicine, Gachon University10;. 11. and Department of Nuclear Medicine, Kyungpook National University School of Medicine ; and Department of Hospital 14. Pathology, College of Medicine, The Catholic University of Korea , Korea . 2). 2006 . NCCN (National Comprehensive Cancer , Network: Clinical practice guidelines in oncology - thyroid (5 10%) carcinoma, version 1, 2005 professionals/.. 10 physician_gls/PDF/ ).

3 , , 2 . , , , .. , . , . 1).. , 2004 . , . 2007 , . 1).. , 2009 . 3). , , 2010 NCCN (Clinical practice guidelines in oncology - thyroid carcinoma, , , , , . , . , Table 1.. ) AACE/AME/ETA (American Association . of Clinical Endocrinologists/Associazione Medici Endo- 1 : . crinologi/EuropeanThyroid Association) . 4).. 2 : . 5 , , .. 3 : (expert opinion) .. , 4 : .. BRAFV600E , . , .. ,6) . , 2009 , 2010 .. NCCN AACE/AME/ETA , .. , , , , , ..7) 1 cm . , .. 2010 .. , , . , (purely . cystic) spongiform .. 2 cm . 2007 ..8-10) , . , 1) . , . , 2) , , . 3) , 4) . , , F-18 FDG- , . PET , MEN2/FMTC RET . Table , 100 pg/ml . 1 .. 1) . 1 cm .. : 1) . , 2) (fine needle (taller than wide), 2) (spiculated) . aspiration cytology, FNAC).

4 5). , 3) , 4) . Bethesda system , 3) . , 5) 11-15) .. 2007 .. 1 cm FNAC.. NCCN (2010) . Latin American thyroid Sociey16) .. , AACE/.. AME/ETA .. 4). FNAC . , .. cm FNAC , .. 3). FNAC . , 1 cm (Fig. 1). , . 17). FNAC , , 14 . 18). , .. , cm . , . , cm , . FNAC . , .. cm . FNAC . , TSH : . TSH . TSH . FNAC . , .. , FNAC .. Fig. 1.. TSH .. TSH .. 1 FNAC , - . FNAC . TSH , , , .. 2009 National Cancer Institute , thyroid Fine-Needle Aspiration State of the Science , Conference Bethesda system . , 50% , 1) , 2) , 3) (atypia of undetermined significance or follicular lesion of . undetermined significance), 4) . FNAC (H rthle ), 5) . 19) 5).. , 6) (Table 2).. 29). FNAC . 6,20,21).. TSH (cervical lymphadeno- FNAC pathy) , FNAC.

5 30).. ( ) ..22,23). Table 2. Bethesda system .. 1 Nondiagnostic or unsatisfactory . 1 Cyst Fluid Only Vertually acellular specimen, No follicular cells present : (thyroglobulin, Other (obscuring blood, clotting artifact, poor fixation, Tg) : Tg poor cell preservation etc). 2 Benign . 24). Consistent with a benign follicular nodule (includes . adenomatoid nodules, colloid nodule, etc.). Consistent with lymphocytic (Hashimoto) thyroiditis in the proper clinical context Tg Consistent with granulomatous (subacute) thyroiditis . 1 Other 3 Atypia of undetermined significance or follicular lesion of undetermined significance : 4 Follicular neoplasm or suspicious for a follicular 25-27) neoplasm . Specify if H rthle cell (oncocytic) type 5 Suspicious for malignancy C Suspicious for papillary carcinoma Suspicious for medullary carcinoma.

6 Suspicious for metastatic carcinoma , , Suspicious for lymphoma Other . 6 Malignant 100 pg/ml Papillary thyroid carcinoma Poorly differentiated carcinoma .28) Medullary thyroid carcinoma Undifferentiated (anaplastic) carcinoma Squamous cell carcinoma Carcinoma with mixed features (specify).. 3 Metastatic carcinoma Non-Hodgkin lymphoma Other FNAC . , 20 25% . 31,32) 33,34).. , . FNAC . 5). , , , . FNAC . (sarcoma) , (carcinoma) . , . , , . (follicular neoplasm/. suspicious for a follicular neoplasm): H rthle . FNAC .. 1 Bethesda system . ( , follicular neoplasm, H rthle (nondiagnostic/unsatisfactory): cell type/suspicious for a follicular neoplasm, H rthle 5). ( 10 cell type). 15 30% . 35). 6 ) , , . 36).

7 , .. , , ..5) .. 37-39). FNAC .. , TSH.. 2 .. 3. H rthle .. 1 , ..40) 1. (atypia of undetermined significance or . follicular lesion of undetermined significance): , . (follicular lesion) , (atypical) , (BRAF, RAS, RET/PTC, (follicular neoplasm) , (indeterminate Pax8-PPAR , galectin-3, cytokeratin-19 ) . for neoplasia) , (suspicious for malig- . 3. nancy) . , (suspicious for malignancy): . Bethesda system .. (atypia of undeter- , 60 . mined significance) , , 75% .5) H rthle .. 5 15% .5) . ( . 21). ) , , . 40).. 1 .. (malignancy) FNAC .. 41).. 15% . 45,49). 1 . 2 mm . : 20% . 12).. FNAC .. 50).. FNAC . 6).. FNAC 6 18 . , . 12,42).. 3.. 2 FNAC . FNAC FNAC . 2.. 2 . , . (ethanol ablation) . 2. FNAC.. 3.

8 TSH . 3 . , .. TSH .. FNAC . 2 ..51-53).. FNAC 5% . 1..43,44) ..45) .. , FNAC .. 4. FNAC ( ) 46) . FNAC (1 3%) .46-48).. FNAC 306 . FNAC : . 3 . 11 18 ..48) 5,000 1,000 . 20 , FNAC . 54). 1,000 7 . TSH 1 mU/L . 15 . 3. 55-57). 20% , . 58,59).. FNAC.. 55,57,58).. ( , (1) . TSH, , FNAC). 1 ..65-67). : (2) 68,69). (3) 70,71). 60).. (4) .72).. (5) 73). (6) 73-76).. FNAC .. (first trimester) TSH. : . FNAC , ( ).. 1 20 50% .77-81). 20 31% . FNAC , .. ( .82,83) . ) . CT, MRI, PET . 24 , . 61)..84,85).. 62,63).. 2. 63).. 1 Tg : Tg . 64).. , 24 ( ) Tg .. 2. , .. 3 . 3). , , . , , . , . , . (lobectomy), (near , 1 . total thyroidectomy, cricothyroid . 88). 1 g . 45 . ), . 65,71,72,92,93). (total thyroidectomy, . ).

9 1 cm .. , . 1. , , 1 cm , . , .. 3. , . : .. 3 20 90% , . , .94) ..77,95) . 4 cm , . (marked atypia) , , . , .78,94) ..96-99)..35,86,87) 1. , .. 2.. 3 , T3 T4 . (level VI) . : . 3. 88) (T1 T2), . 1 cm , .. , . 1 cm . 3.. 1 cm (level II-IV) (level V) . , , , H rthle . 77,100).. , . 89-91). , . , , . 95,101,102).. , Table 3. AJCC (7 ) TNM . 67,103-105). (berry picking) . (T). T1 2 cm . T1a 1 cm . T1b 1 cm 2 cm . T2 2 cm 4 cm . T3 4 cm .. 2 ( ) . T4a , , (completion thyroidectomy): , . T4b Prevertebral fascia / .. TX . (N). N0 . , N1a Level VI ( , , /. Delphian )..106-108) 2 ( N1b , , (level I, II, III, IV, V), ) (level VII) . NX .. (M)..109,110) M0 . M1 . MX .. Table 4.. , , , 45 . , Stage I Any T Any N M0.

10 Stage II Any T Any N M1.. 2 45 . Stage I T1 N0 M0. 111) Stage II T2 N0 M0.. Stage III T3 N0 M0. T1-T3 N1a M0.. , Stage IVA T4a N0, N1a M0. T1-T4a N1b M0.. 2 Stage IVB T4b Any N M0. Stage IVC Any T Any N M1.. MSKCC, NTCTCS , . : (1) 70,113-117).. , (2) TSH . , , . , (3) .. , (4) . (70 85%) , .. AJCC/UICC TNM : pTNM AJCC/. UICC . 70,112) . (Table 3, 4). AJCC/UICC . AJCC/UICC .. , . , .. 2.. CAEORTC, AGES, AMES, U of C, MACIS, OSU, , , , . ( , , ): AJCC/UICC , .. 2. , 3) 1 cm .. 3. 3).. : 1) , 2) . , 3) : , , 4) ( Tg . , , , TSH .. ) , 5) TSH 30 mU/L ..131) . ( thyroid bed) , TSH 1 TSH . 92,118,119).. 51 82 mU/L . : 1) .132,133) TSH . , 2) 1) levothyroxine (LT4) levotriiodothyronine (LT3). , 2 4 2 LT3 . , 2) 3 LT4.