~Teachingcenter的醫學筆記~

先複習：

=甲狀腺癌比例
-Follicular epithelial cell
~~~Well-differentiated:
70~80% Papillary carcinomas
10~20% Follicular carcinomas
~~~Undifferentiated:
<1% Anaplastic carcinomas
-C cell (Calcitonin-producing)
<5% Medullary thyroid carcinoma
-Others
1~2% Lymphomas, Sarcomas, Metastasis

Papillary carcinoma:
-濾泡細胞長出，5年存活率90%，好淋巴轉移，多為女性，多為15~35歲
-可能和radiation exposure有關
-Pathology: papillary arrangement, vascular stalks, large and pale nuclei, intranuclear inclusion bodies, Ground-glass nuclei = 空洞核 (empty nuclei) = orphan-Annie eyes, pasammoma bodies (calcified spheres)
-生長緩慢，但在多年後可能會有anaplastic shift
-可有intraglandular轉移或局部淋巴結侵犯
-Low risk (relative good prognosis): 40歲以下女性，無轉移，no capsular invasion，小於2公分，Well differentiated

Follicular carcinoma:
-較Papillary惡性
-濾泡細胞長出，5年存活率65%，好血液轉移，多為女性，多為>30歲，FNAC不易與腺瘤區分
-侵犯包膜或血管為診斷重要參考
-Pathology: cuboidal, large nuclei, follicular arrangement
-對碘131的治療效果好但Hurthel除外
-可以局部侵犯血管，進行血行性轉移
※Hurthele cell (variant of follicular): older age, resistant I131, lymphatic system invasion

Medullary carcinoma:
-源自濾泡旁細胞(C cell)，5年存活率50%
-Tumor marker: Calcitonin, CEA
-Calcitonin, histaminase, prostaglandin, serotonin, other peptides會變多
-其中sporadic佔90%，familial (MEN IIa or IIb, C cell hyperplasia)佔10%
-RET point mutation (chormosome 10)

Anaplastic carcinoma:
-濾泡細胞長出，預後極差，容易經血液淋巴轉移，且對各種治療效果都不好
-生長極快，容易壓迫神經而造成聲音沙啞
-平均存活3個月

治療：
※central neck: 上界為舌骨，下界為胸骨切跡，側界為頸動脈鞘

1. 分化良好(Well-differentiated)的Papillary and Follicular
A.手術治療：Total thyroidectomy (若為low-risk，可以僅做near-total thyroidectomy)
B.臨床上有摸得到的淋巴結，要做Central neck dissection，沒摸到的話，是no indication for prophylatic neck dissection (但有時還是會拿個幾顆送frozen)
C.若想要做碘131治療去除residual cancer or metastatic cancer，則是要等到術後4周
※雖Follicular對碘131的吸收效果好，但若是Hurthel  cell則不佳
D.抑制TSH作為治療：tumor marker: thyroglobulin、復發則要做碘131
E.追蹤：術後要追蹤human thyroglobulin, I131 scan, thyroxine withdrawal

2. Medullary carcinoama
A.手術治療：total thyroidectomy + central neck dissection
B.臨床上懷疑淋巴結轉移：modified ipsilateral lateral neck dissection
C.髓性惡性腫瘤對碘131吸收不佳

3. Anaplastic carcinoma
A.若手術可行：total thyroidectomy
B.緩和、安寧治療、external irradiation or/and chemotherapy