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Chirurgische Behandlung des differenzierten und medullären Schilddrüsenkarzinoms entsprechend internationaler Leitlinien

Surgical treatment of differentiated and medullary thyroid cancers according to international guidelines

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Der Onkologe Aims and scope

Zusammenfassung

Hintergrund

Die Häufigkeit des differenzierten Schilddrüsenkarzinoms (DTC) nimmt seit Jahren weltweit stark zu. Da qualitativ hochwertige Studien der Evidenzklasse I zur chirurgischen Therapie fehlen, wird diese kontrovers diskutiert.

Fragestellung

Definition eines international akzeptierten Standards in der chirurgischen Therapie des DTC und medullären Schilddrüsenkarzinoms (MTC).

Material und Methode

Es wurden die Empfehlungen der American Thyroid Association (ATA) mit den Leitlinien der British Thyroid Association (BTA), dem European Consensus Statement sowie den Deutschen Leitlinien verglichen.

Ergebnisse

Konsens in allen Leitlinien ist die Empfehlung zur Thyreoidektomie beim DTC > 4 cm, beim High-risk-DTC jeder Größe, beim MTC sowie die Lobektomie beim Low-risk-DTC < 1 cm. Auch die Empfehlung zur therapeutischen Lymphknotendissektion ist international unstrittig. Nicht einheitlich definiert ist die Indikation zur Thyreoidektomie beim DTC von 1–4 cm. Für das Stadium T1 bleibt bezüglich des Resektionsausmaßes ein individueller Ermessensspielraum offen. Die Empfehlungen zur prophylaktischen Lymphknotendissektion beim DTC sind widersprüchlich, die Indikation bleibt unverbindlich. Die ATA und deutschen Leitlinien machen beim MTC die prophylaktische Lymphknotendissektion vom Kalzitonin, die BTA von der Tumorgröße abhängig. Kontrovers ist die Empfehlung der BTA, auch beim kleinen MTC – unabhängig vom Kalzitonin – eine Lymphknotendissektion durchzuführen.

Schlussfolgerungen

Nur die Empfehlungen zum Resektionsausmaß des DTC > 4 cm und des MTC sind international weitgehend übereinstimmend. Die Empfehlung zur Behandlung des DTC < 4 cm sowie zur prophylaktischen Lymphknotendissektion beim DTC und MTC sind im internationalen Vergleich diskrepant.

Abstract

Background

The global frequency of thyroid carcinoma has been rapidly increasing for many years. A lack of high quality studies of evidence-based medicine (EBM) class I addressing surgical issues has led to significant controversy.

Objective

To compare national and international recommendations addressing the surgical therapy of differentiated thyroid cancer (DTC) and medullary thyroid cancer (MTC).

Material and methods

Recommendations were extracted from guidelines published by the American Thyroid Association (ATA), the British Thyroid Association (BTA), the European Consensus Statement Conference and by the surgical working group on endocrinology of the German Society of General and Visceral Surgery.

Results

There is broad consensus that patients presenting with a DTC > 4 cm, with a high-risk carcinoma of any size or with MTC should undergo thyroidectomy. For a low-risk DTC < 1 cm lobectomy is sufficient. There is also strong international consensus that therapeutic lymph node dissection is necessary in patients showing pathological lymph nodes. Most guidelines uniformly recommend a thyroidectomy for DTCs of 1–4 cm size with some discretionary powers remaining open for T1 tumors. Recommendations to perform a prophylactic lymph node dissection in DTC patients vary between guidelines. To establish indications for a prophylactic lymph node dissection in MTC, ATA and German guidelines recommend the use of calcitonin levels, whereas BTA guidelines recommend the use of tumor size. There is significant controversy between guidelines as to whether a lymph node dissection is indicated in small tumors or not.

Conclusion

There is broad international consensus as to when a thyroid resection should be carried out in DTC and MTC. Recommendations for thyroid resection in DTC < 4 cm and for a prophylactic lymph node dissection show discrepancies between different guidelines.

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Interessenkonflikt. H. Fürst gibt an, dass kein Interessenkonflikt besteht.

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  1. Krankenhaus Martha-Maria München, Wolfratshauser Str. 109, 81479, München, Deutschland

    H. Fürst

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Fürst, H. Chirurgische Behandlung des differenzierten und medullären Schilddrüsenkarzinoms entsprechend internationaler Leitlinien. Onkologe 21, 577–583 (2015). https://doi.org/10.1007/s00761-014-2857-1

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