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Chirurgie der Schilddrüsenkarzinome

Sollten nach Einführung der neuen TNM-Klassifikation die chirurgischen Leitlinien geändert werden?

Surgery for thyroid cancer

Should surgical guidelines be changed following the introduction of the new TNM classification?

  • Leitthema
  • Published:
Der Onkologe Aims and scope

Zusammenfassung

Durch Änderung der TNM-Klassifikation (2002) hat sich erneut eine intensive Diskussion über die Leitlinien der Chirurgie der Schilddrüsenkarzinome (2000), v. a. in Bezug auf die Frühformen des differenzierten Karzinoms (DTC) entwickelt. Da keine ausreichenden Literaturdaten vorliegen, die eine Definitionsänderung der bisherigen Hauptkategorien der TNM-Klassifikation begründen könnten, die TNM-Klassifikationen von 2002 und 1997 nicht kompatibel sind und die fortgeschrittenen Tumoren (pT3/4) nur in Verbindung mit dem klinischen Befund definiert werden können, stellt die neue TNM-Klassifikation keine geeignete Grundlage zur Stadieneinteilung der Schilddrüsenkarzinome dar. Unabhängig von der neuen TNM-Klassifikation ergibt sich Änderungsbedarf bei den chirurgischen Leitlinien besonders bezüglich der prophylaktischen zentralen Lymphadenektomie beim DTC, für die sich aufgrund vorliegender Daten keine Evidenz nachweisen lässt. Beim hereditären medullären Karzinom ist bei Genträgern ohne klinisch manifesten Tumor wegen der Genotyp-Phänotyp-Korrelation ein risikoadaptiertes Vorgehen hinsichtlich Zeitpunkt und Ausmaß der prophylaktischen Operation zu empfehlen. Bei resektablen, wenig differenzierten und undifferenzierten Karzinomen nimmt die Chirurgie innerhalb eines multimodalen Therapiekonzepts eine wichtige Stellung ein.

Abstract

Due to the recent changes of the TNM classification (2002), the discussion about the German guidelines on thyroid cancer surgery (2000), in particular with regard to the treatment of differentiated (DTC) microcarcinomas, has become very intense. Several facts argue against the new TNM classification: (1) the available literature does not support the changes of the TNM classification, (2) the new (2002) and the old TNM classifications (1997) are not compatible, and (3) according to the new classification, diagnosis of more advanced forms of thyroid cancer (pT3/4) relies on the information given by the surgeon and cannot be made by the pathologist alone. Independent from the new TNM classification, the German guidelines on thyroid cancer surgery require an update since it has become obvious that the current recommendation of prophylactic cervicocentral lymph node dissection in DTC is not evidence based. Patients with asymptomatic hereditary medullary thyroid cancer may undergo a risk-adapted surgical approach based on the genotype-phenotype correlation. Surgery plays an important role in the multimodal therapeutic approach of resectable poorly differentiated and undifferentiated thyroid carcinomas.

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  1. Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Martin-Luther-Universität Halle-Wittenberg, Klinikum Kröllwitz

    H. Dralle, A. Machens, M. Brauckhoff, J. Ukkat, C. Sekulla, P. Nguyen-Thanh, K. Lorenz & O. Gimm

  2. Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Martin-Luther-Universität Halle-Wittenberg, Klinikum Kröllwitz, Ernst-Grube-Straße 40, 06097, Halle (Saale)

    H. Dralle

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  1. H. Dralle
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Dralle, H., Machens, A., Brauckhoff, M. et al. Chirurgie der Schilddrüsenkarzinome. Onkologe 11, 58–69 (2005). https://doi.org/10.1007/s00761-004-0809-x

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