小児の甲状腺結節 (補)

Carrias A (2010) "Diagnostic features of thyroid nodules in pediatrics." より 補足:腫瘤サイズ 1cm 以上を精査対象とした、超音波計測にて平均最大径 2.1cm (SD 1.0, median 2.11), 径のレンジは 1.00-4.50
15
Seiichi Ushikubo @sushikubo

Corrias A (2010) "Diagnostic features of thyroid nodules in pediatrics." http://t.co/EujVjV7J47

2013-03-29 19:19:51
Seiichi Ushikubo @sushikubo

Corrias A (2010) イタリアの9つの小児内分泌施設で過去10年間、120名の1cm以上の甲状腺結節を持つ小児、最終的に63名に対して手術を行った。http://t.co/faeWFOeint

2013-03-29 19:31:34

ABSTRACT

Objective:
 To investigate a cohort of pediatric patients with thyroid nodules, defining histotype frequency and differences between subjects with hyperthyroidism and euthyroidism and benign and malignant nodules.

Design:
 Retrospective cohort.
 (後ろ向き調査)

Setting:
 Consecutive cases from 9 Italian pediatric endocrinology centers for the last 10 years.
 (過去10年間イタリアの9小児内分泌センターでの症例)

Patients
 One hundred twenty pediatric patients with thyroid nodules.
 (120人の甲状腺結節を持つ小児)

Intervention:
 Doppler ultrasonography was performed in 71 subjects; scintiscan, in 56; fine-needle aspiration biopsy in 104; and 63 underwent surgery.
 (71人に超音波検査, 56人にシンチスキャン, 104人に針生検, 63人に手術を行った)

Main Outcome Measures:
 The differences in clinical, laboratory, and ultrasonographic data between patients with hyperthyroidism and euthyroidism and malignant and benign nodules were evaluated.

Results:
 One hundred fourteen patients had euthyroidism and 6, hyperthyroidism.
 (140人は甲状腺機能は正常, 6人は甲状腺機能亢進)

 The latter had more compressive signs (P = .003), greater nodule diameter (P = .02), intranodular vascularization pattern (P = .01), and increased scintiscan uptake (P < .001).
 (甲状腺機能が亢進していた人は, 結節の大きさが大きく, 結節内に血管が豊富 vascularization で, シンチスキャンでの取り込みが増加していた)

 Fine-needle aspiration biopsy disclosed benign lesions in 77 cases, malignant lesions in 19, and “suspicious” lesions in 8.
 (針生検では, 77人が良性像, 19人が悪性像, 8人が疑いだった)

 Histologic examination disclosed 1 Hurthle cell and 5 follicular adenomas in patients with hyperthyroidism, whereas in patients with euthyroidism, 33 hyperplasic nodules, 19 carcinomas (14 papillary, 3 follicular, and 2 medullary), 3 follicular and 1 Hurthle cell adenoma, and 1 teratoma were detected. Nine patients had enhanced scintiscan uptake.
 (甲状腺機能亢進だった人のうち, 1人が Hurthle cell adenomas, 5人が follicular adenomas だった。一方, 甲状腺機能が正常だった人では, 33人が hyperplasic nodules, 19人が 悪性腫瘍 (14 papillary, 3 follicular, and 2 medullary), 3人が follicular adenoma, 1人が Hurthle cell adenoma, 1人が teratoma だった)

 Among the patients with euthyroidism, malignancies more frequently had palpable lymph nodes (P < .001), compressive signs (P = .004), microcalcifications (P < .001), intranodular vascularization (P = .01), and lymph node alterations (P < .001).
 (甲状腺機能が正常だった人のうち, 悪性腫瘍は 触知可能なリンパ節があり, 圧迫症状があり, 超音波所見で microcalcifications, intranodular vascularization, and lymph node alterations がある傾向があった)

Although thyroid nodules in childhood and adolescence are rare, with an estimated prevalence ranging from 0.05% to 1.8%, they are more often malignant (up to 25% of cases) compared with those observed in adulthood and therefore require a careful evaluation and a more aggressive diagnostic approach.
(小児の甲状腺結節はまれで, prevalence は 0.05% から 1.8%と推定されているが、悪性である頻度は成人に比べて高く 25% 程度 (up to 25% of cases) とされている。そのため注意深い評価とより積極的な診断アプローチが必要である)

RESULTS

Based on thyroid function, 6 patients had hyperthyroidism and 114, euthyroidism. Thyroid nodular disease was more frequent in girls and was diagnosed at a mean (SD) age of 11.5 (3.2) years (range, 2.5-16.9 years; median, 12.3 years). Nodules were detected by palpation in 100 cases (83.3%). Of these, 58 subjects also had palpable lymph nodes and/or compressive symptoms. The other 20 cases presenting with goiter alone or with palpable lymph nodes were found to have thyroid nodules by ultrasonography.
(6人が甲状腺機能亢進, 114人が甲状腺機能正常。女児に多い。診断された年齢の平均は11.5歳(2.5歳から16.9歳)。100人で腫瘤を触れた(83.3%), 58人でリンパ節触知/圧迫症状あり。甲状腺の腫脹またはリンパ節腫脹があった20人は超音波検査にて腫瘤が見つかった)

Seiichi Ushikubo @sushikubo

Corrias A (2010) Talbe 1 患者の臨床症状, エコー所見, シンチ所見, 生検所見 http://t.co/JgjX9lsNsT

2013-03-29 19:33:47
拡大

(中略)

The histologic data of the 63 patients who underwent surgery are reported in Table 2.
(手術を行った63人の組織所見を表2に示す)
Sixty-one patients underwent total or subtotal thyroidectomy and 2 underwent lobectomy.
(61人は全摘あるいは亜全摘を, 2人は葉切除を行った)
Five patients (3 with hyperthyroidism and 2 with euthyroidism) did not undergo FNAB prior to surgery.
(5人は術前に針生検を行わなかった)
By histologic examination, 19 nodules were considered to be malignant and 44, benign.
(組織診断で, 19人が悪性, 44人が良性と判断された)
Among the latter, 33 nodules had hyperplasic thyroidal tissue with degeneration or colloid areas without defined capsules and were considered to be hyperplasic/goitrous nodules, whereas 11 had a differentiated, uniform, orderly architecture with few mitoses and discrete capsules and were classified as benign adenomas.

Four patients with confirmed papillary thyroid cancer had no palpable nodules or symptoms and the malignant nodule was found incidentally.
(乳頭がんと診断されたもののうちの4人は, リンパ節を触知せず, 圧迫症状もなく, 腫瘤がたまたま発見された患者だった)

In the 6 patients with hyperthyroidism, histologic examination demonstrated 1 Hurthle cell and 5 follicular adenomas, whereas in patients with euthyroidism histologic examination detected 19 malignant tumors (14 papillary, 3 follicular, and 2 medullary cancers) and 38 benign lesions, including 3 follicular and 1 Hurthle cell adenomas, and 1 teratoma.
(甲状腺機能亢進があった6人は, 組織学的診断にて 腺腫(良性) だった。一方, 甲状腺機能が正常だった人のうち, 19人が悪性, 38人が良性だった)

Based on the 55 subjects with euthyroidism who underwent both FNAB and surgery, all 19 subjects with cancer were correctly identified as having malignant lesions by FNAB, and 30 adenomas/hyperplasic lesions were identified as benign. The histologic examination of the 6 suspicious FNAB specimens demonstrated 4 follicular adenomas (2 hyperthyroid, 2 euthyroid), 1 benign teratoma (euthyroid), and 1 Hurthle cell adenoma (hyperthyroid). Based on these results, FNAB had 100% sensitivity, 83.3% specificity, and 89.1% diagnostic accuracy.
(甲状腺機能が正常であった55人の針生検(FNAB)と術後の組織診断の一致:悪性腫脹だった19人はすべてFNABにて悪性と判定されていた。adenomas/hyperplasic lesions の30人は良性と判定されていた。疑いの6人のうち4人は follicular adenomas, 1人は Hurthle cell adenoma だった。FNAB は感度 100%, 特異度 83.3%, 診断精度 89.1% だった)

Seiichi Ushikubo @sushikubo

Corrias A (2010) Table 2 手術を行った63名の組織像と甲状腺機能 http://t.co/z5d4CQJYzK

2013-03-29 19:35:06
拡大

All 16 patients who underwent neither surgery nor FNAB, based on clinical and ultrasonographic characteristics highly indicative for benign nodules, were followed up by clinical, laboratory, and ultrasonographic evaluation every 6 to 12 months for a mean (SD) period of 1.9 (1.1) years. No modifications in nodule or lymph node characteristics occurred in this period.
(針生検も手術も行わなかった16人は, 臨床所見と超音波所見から良性であると判断し、6~12か月毎に臨床所見/血液検査/超音波検査にて経過観察を行っている。平均1.9年の経過観察期間中に変化は起きていない)

(中略)

Fifty-six patients underwent scintiscan; hot nodules (increased scintiscan uptake) were significantly more frequent in the hyperthyroidism group (P < .001), as found in 6 of 6 patients with hyperthyroidism and 3 of 50 patients with euthyroidism. Of the 3 subjects with euthyroidism with increased uptake, 1 was diagnosed as having multifocal papillary carcinoma.
(シンチスキャンを行った56人。取り込み増加していた hot nodules について。甲状腺機能亢進にていた6人中はすべて取り込み増加していた。甲状腺機能が正常だった50人中3人で取り込みが増加していた。この3人のうち1人は multifocal papillary carcinoma だった)
All the other nodules investigated by scintiscan disclosed normal or decreased uptake with respect to the gland and, in particular, 42 of 50 of the patients with euthyroidism had decreased scintiscan uptake.
(他の結節(50人)はシンチスキャンにて取り込み正常あるいは低下していた。甲状腺機能が正常だった50人のうち42人は取り込みが低下していた)
In 1 case, the nodule was not found.
(1人はシンチスキャンでは結節を同定できなかった)

Table 3 compares the clinical, laboratory, and ultrasonographic characteristics of patients with euthyroidism.
(表3に甲状腺機能が正常だった患者の臨床像/検査所見/超音波所見をまとめた)
Among these, the statistical comparison between benign and malignant lesions showed a difference for both clinical features and ultrasonographic parameters.
(良性と悪性の比較について)
Patients with malignant nodules more often disclosed palpable lymph nodes (68.4% of patients vs 26.3% with benign nodules; OR, 6.1; P < .001) and compressive signs (47.4% of patients vs 15.8% with benign nodules; OR, 4.8; P = .004), whereas ultrasonography revealed that, when compared with benign nodules, malignant nodules were more likely characterized by microcalcifications (47.4% of cases; OR, 16.2; P < .001), lymph node alterations (73.7%; OR, 85.8; P < .001), and intranodular central vascularization pattern (47.4%; OR, 5.0; P = .01).
'''(悪性であることが多いのは:
 臨床所見では, リンパ節が触れる, 圧迫所見がある
 超音波所見では, 微小な石灰化像がある, リンパ節の変化がある, 結節内の血管が豊富である)'''

Seiichi Ushikubo @sushikubo

Corrias A (2010) Table 3 良性と悪性での臨床像, 超音波所見の比較 http://t.co/CvePLP825K

2013-03-29 19:37:12
拡大

コメントより
In our case series, 19 patients (16%) had malignant tumors.
(われわれの検討では、小児甲状腺結節の 16% が悪性腫瘍だった)

papillary carcinoma is confirmed to be the most common malignant histotype and no undifferentiated thyroid cancer was found.
(乳頭がんが最も多い悪性腫脹の組織像であることが確認された。非分化癌はいなかった)

It is well-known that an increasing number of thyroid nodules in adulthood have been incidentally discovered in recent decades because of the widespread use of neck ultrasonography or other imaging methods.
(よく知られていることであるが、成人の甲状腺結節の頻度が近年増加しているのは、頚部超音波検査や他の画像診断手段の普及のために、たまたま発見されるようになったためである)
In children, too, the incidental diagnosis of thyroid nodules is not uncommon.
(小児でも同様に、偶発的に診断される甲状腺結節はまれではない)
In our case series, 20 patients with euthyroidism (16.7%) were referred to a pediatric endocrinologist for the incidental ultrasonographic finding of a thyroid nodule, and of these, 4 (20%) were diagnosed with papillary cancer.
(今回の報告では, 甲状腺機能が正常だった20人は偶発的に甲状腺結節を発見され小児内分泌医に紹介された患者だった。このうち4人 (20%) は乳頭がんだった)

Cancer rates in patients with incidentally discovered nodules (20%) strikingly match those we detected in patients with palpable nodules (16%).
(偶発的に発見された結節での悪性腫瘍の頻度と、触知された結節での悪性頻度は一致していた)

(以下略)

Seiichi Ushikubo @sushikubo

Corrias A (2012) "Thyroid Nodules in Pediatrics: Which Ones Can Be Left Alone, Which Ones Must Be Investigated, .." http://t.co/weI5Nw9TT0

2013-03-29 19:17:27