Tiroid Nodülleri
Özet
Tiroid nodülleri, tiroid bezinde yerleşen ve radyolojik yöntemlerle çevre paranşim dokusundan ayırt edilebilen, toplum genelinde oldukça yaygın görülen lezyonlardır. Çoğunlukla herhangi bir belirti göstermeyen ve başka nedenlerle yapılan tetkikler sırasında tesadüfen saptanan bu lezyonlar "tiroid insidentaloma" olarak adlandırılır. Klinik olarak saptanan nodüllerin yaklaşık %4 ila %6,5'i malign karakterde olduğundan, değerlendirmedeki temel amaç kanser riskinin doğru tespit edilmesidir. Etyolojisinde iyot eksikliğinin yanı sıra genetik ve çevresel etkenlerin sinerjistik rolleri öne çıkmaktadır. Hastaya yaklaşımda ilk olarak detaylı anamnez, fizik muayene ve serum TSH düzeyi ölçümü gerçekleştirilir; TSH seviyesi yükseldikçe malignite prevalansının da arttığı bilinmektedir. Tanı sürecinde tiroid ultrasonografisi kritik bir role sahip olup, nodüllerin risk yönetimi için ATA ve ACR TI-RADS gibi uluslararası sınıflama sistemlerinden yararlanılır. Şüpheli sonografik özellikler taşıyan nodüllere, ayırıcı tanıda altın standart kabul edilen ultrason eşliğinde ince iğne aspirasyon biyopsisi (TİİAB) uygulanır. Biyopsi sonuçları Bethesda Sistemi ile raporlanarak hastanın izlem, girişimsel tedaviler (etanol ablasyonu, aspirasyon) veya cerrahi (lobektomi/tiroidektomi) stratejileri netleştirilir.
Thyroid nodules are highly prevalent lesions within the thyroid gland that can be radiologically distinguished from the surrounding parenchyma. Frequently presenting as asymptomatic, these lesions are often discovered incidentally during unrelated imaging studies and are clinically termed "thyroid incidentalomas". Given that approximately 4% to 6.5% of all thyroid nodules possess malignant characteristics, the primary objective of clinical evaluation is the accurate identification of thyroid cancer. The underlying etiology involves a complex, synergistic combination of iodine deficiency, genetic predispositions, and environmental factors. Initial clinical assessment mandatorily encompasses a thorough medical history, physical examination, and serum TSH measurement, as elevated TSH levels are independently associated with a higher risk and more advanced stages of malignancy. Thyroid ultrasonography remains the definitive imaging modality, utilizing validated risk stratification models such as the ATA guidelines and ACR TI-RADS. For nodules displaying suspicious features, ultrasound-guided fine-needle aspiration biopsy (FNAB) is deployed as the diagnostic gold standard. Cytological classifications are subsequently standardized using the Bethesda System, which effectively guides subsequent therapeutic pathways, ranging from active surveillance and minimally invasive procedures (such as ethanol injection) to definitive surgical interventions like lobectomy or total thyroidectomy.
Referanslar
Alexander, E. K., Heering, J. P., Benson, C.B. & et al. (2002). Assessment of nondiagnostic ultrasound-guided fine needle aspirations of thyroid nodules. J Clin Endocrinol Metab, 87, 4924.
Bennedbaek, F. N. & Hegedüs, L. (2003). Treatment of recurrent thyroid cysts with ethanol: a randomized double-blind controlled trial. J Clin Endocrinol Metab, 88, 5773.
Boelaert, K., Horacek, J., Holder, R. L. & et al. (2006). Serum thyrotropin concentration as a novel predictor of malignancy in thyroid nodules investigated by fine-needle aspiration. J Clin Endocrinol Metab, 91, 4295.
Bomeli, S. R., LeBeau, S. O. & Ferris, R. L. (2010). Evaluation of a thyroid nodule. Otolaryngol Clin North Am, 43, 229-238.
Brander, A., Viikinkoski, P., Nickels, J. & Kivisaari, L. (1991). Thyroid gland: US screening in a random adult population. Radiology, 181, 683.
Brito, J. P., Ito, Y., Miyauchi, A. & Tuttle, R. M. (2016). A Clinical Framework to Facilitate Risk Stratification When Considering an Active Surveillance Alternative to Immediate Biopsy and Surgery in Papillary Microcarcinoma. Thyroid, 26, 144.
Castro, M. R., Caraballo, P .J. & Morris, J. C. (2002). Effectiveness of thyroid hormone suppressive therapy in benign solitary thyroid nodules: a meta-analysis. J Clin Endocrinol Metab, 87, 4154.
Cibas, E. S. & Ali, S. Z. (2017). The 2017 Bethesda System for Reporting Thyroid Cytopathology. Thyroid, 27, 1341.
Cooper, D. S., Doherty, G.M., Haugen, B. R., Kloos, R. T., Lee, S. L., Mandel, S. J. & et al. (2009). American Thyroid Association (ATA) Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid, 19, 1167-1214.
Curtis, R. E., Rowlings, P. A., Deeg, H. J., Shriner, D. A., Socíe, G., Travis, L. B. & et al. (1997). Solid cancers after bone marrow transplantation. N Engl J Med, 336, 897-904.
Date, J., Feldt-Rasmussen, U., Blichert-Toft, M., Hegedus, L. & Graversen, H. P. (1996). Long term observation of serum thyroglobulin after resection of nontoxic goiter and relation to ultrasonographically demonstrated relapse. World J Surg., 20, 351-356
de los Santos, E.T., Keyhani-Rofagha, S., Cunningham, J. J. & Mazzaferri, E. L. (1990). Cystic thyroid nodules. The dilemma of malignant lesions. Arch Intern Med, 150, 1422.
Del Prete, S., Caraglia, M., Russo, D. & et al. (2002). Percutaneous ethanol injection efficacy in the treatment of large symptomatic thyroid cystic nodules: ten-year follow-up of a large series. Thyroid, 12, 815.
Durante, C., Costante, G., Lucisano, G. & et al. (2015). The natural history of benign thyroid nodules. JAMA, 313, 926.
Elisei, R., Bottici, V., Luchetti, F., Di Coscio, G., Romei, C., Grasso, L. & et al. (2004). Impact of routine measurement of serum calcitonin on the diagnosis and outcome of medullary thyroid cancer: Experience in 10,864 patients with nodular thyroid disorders. J Clin Endocrinol Metab., 89, 163-168.
Ezzat, S., Sarti, D. A., Cain, D. R. & Braunstein, G. D. (1994). Thyroid incidentalomas. Prevalence by palpation and ultrasonography. Arch Intern Med, 154, 1838.
Gharib, H. & Mazzaferri, E. L. (1998). Thyroxine suppressive therapy in patients with nodular thyroid disease. Ann Intern Med, 128, 386.
Gharib, H., Papini, E., Paschke, R., Duick, D. S., Valcavi, R., Hegedüs, L. & et al. (2010). AACE/AME/ETA Task Force on Thyroid Nodules. American Association of Clinical Endocrinologists, Associazione Medici Endocrinologi, and EuropeanThyroid Association Medical Guidelines for Clinical Practice for the Diagnosis and Management of Thyroid Nodules. Endocr Pract, 16, 1-43.
Haugen, B. R., Alexander, E. K., Bible, K. C. & et al. (2016). 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid, 26: 1.
Haymart, M. R., Repplinger, D.J., Leverson, G. E. & et al. (2008). Higher serum thyroid stimulating hormone level in thyroid nodule patients is associated with greater risks of differentiated thyroid cancer and advanced tumor stage. J Clin Endocrinol Metab, 93, 809.
Krohn, K., Führer, D., Bayer, Y., Eszlinger, M., Brauer, V., Neumann, S. & et al. (2005). Molecular pathogenesis of euthyroid and toxic multinodular goiter. Endocr Rev., 26, 504-524.
Kwak, J. Y., Koo, H., Youk, J. H. & et al. (2010). Value of US correlation of a thyroid nodule with initially benign cytologic results. Radiology, 254, 292.
Lin, J. D., Chao, T. C., Huang, B. Y. & et al. (2005). Thyroid cancer in the thyroid nodules evaluated by ultrasonography and fine-needle aspiration cytology. Thyroid, 15, 708.
Maia, F. F. & Zantut-Wittmann, D. E. (2012). Thyroid nodule management: clinical, ultrasound and cytopathological parameters for predicting malignancy. Clinics (Sao Paulo), 67, 945-954.
Marqusee, E., Benson, C.B., Frates, M. C. & et al. (2000). Usefulness of ultrasonography in the management of nodular thyroid disease. Ann Intern Med, 133, 696.
McLeod, D. S., Cooper, D. S., Ladenson, P.W. & et al. (2014). Prognosis of differentiated thyroid cancer in relation to serum thyrotropin and thyroglobulin antibody status at time of diagnosis. Thyroid, 24, 35.
Miller, J. M., Zafar, S. U. & Karo, J. J. (1974). The cystic thyroid nodule. Recognition and management. Radiology, 110, 257.
MORTENSEN, J. D., WOOLNER, L. B. & BENNETT, W. A. (1955). Gross and microscopic findings in clinically normal thyroid glands. J Clin Endocrinol Metab, 15, 1270.
Nakamura, H., Hirokawa, M., Ota, H., Kihara, M., Miya, A. & Miyauchi, A. (2015). Is an Increase in Thyroid Nodule Volume a Risk Factor for Malignancy? Thyroid, 25, 804-811.
Özarmağan, S., Erbil, Y. & Ünalp, H., editörler. (2010). Tiroid ve Paratiroid Cerrahisi Atlası. İstanbul, Ekspres Basımevi.
Papini, E., Guglielmi, R., Bianchini, A. & et al. (2002). Risk of malignancy in nonpalpable thyroid nodules: predictive value of ultrasound and color-Doppler features. J Clin Endocrinol Metab, 87, 1941.
Popoveniuc, G. & Jonklaas, J. (2012). Thyroid nodules. Med Clin North Am, 96, 329-349.
Rice, C. O. (1932). Incidence of nodules in the thyroid. Arch Surg, 24: 505.
Reiners, C., Wegscheider, K., Schicha, H. & et al. (2004). Prevalence of thyroid disorders in the working population of Germany: ultrasonography screening in 96,278 unselected employees. Thyroid, 14, 926.
Salmaslıoğlu, A. & Bulakçı, M. (2018). Tiroid kanserlerinde tarama, tanı, izlem. Trd Sem, 6, 483-495.
Suh, C. H., Baek, J. H., Ha, E. J. & et al. (2015). Ethanol ablation of predominantly cystic thyroid nodules: evaluation of recurrence rate and factors related to recurrence. Clin Radiol, 70, 42.
Tan, G. H. & Gharib, H. (1997). Thyroid incidentalomas: management approaches to nonpalpable nodules discovered incidentally on thyroid imaging. Ann Intern Med, 126, 226.
Türkiye Endokrinoloji ve Metabolizma Derneği. Tiroid Tanı, Tedavi ve İzlem Kılavuzu, (2020).
US Preventive Services Task Force, Bibbins-Domingo, K., Grossman, D.C. & et al. (2017). Screening for Thyroid Cancer: US Preventive Services Task Force Recommendation Statement. JAMA, 317, 1882.
Valcavi, R. & Frasoldati, A. (2004). Ultrasound-guided percutaneous ethanol injection therapy in thyroid cystic nodules. Endocr Pract, 10, 269.
Vander, J. B., Gaston, E. A. & Dawber TR. (1968). The significance of nontoxic thyroid nodules. Final report of a 15-year study of the incidence of thyroid malignancy. Ann Intern Med, 69, 537.
Van Sande, J., Parma, J., Tonacchera, M., Swillens, S., Dumont, J. & Vassart, G. (1995). Somatic and germline mutations of the TSH receptor gene in thyroid diseases. J Clin Endocrinol Metab., 80, 2577-2585.
Wang, C. C., Friedman, L., Kennedy, G. C. & et al. (2011). A large multicenter correlation study of thyroid nodule cytopathology and histopathology. Thyroid, 21, 243.
Wémeau, J. L., Caron, P., Schvartz, C. & et al. (2002). Effects of thyroid-stimulating hormone suppression with levothyroxine in reducing the volume of solitary thyroid nodules and improving extranodular nonpalpable changes: a randomized, double-blind, placebo-controlled trial by the French Thyroid Research Group. J Clin Endocrinol Metab, 87, 4928.
Werk, E. E. Jr., Vernon, B. M, Gonzalez, J. J. & et al. (1984). Cancer in thyroid nodules. A community hospital survey. Arch Intern Med, 144, 474.
Yassa, L., Cibas, E. S., Benson, C. B. & et al. (2007). Long-term assessment of a multidisciplinary approach to thyroid nodule diagnostic evaluation. Cancer, 111, 508.
Yasuda, K., Ozaki, O., Sugino, K. & et al. (1992). Treatment of cystic lesions of the thyroid by ethanol instillation. World J Surg, 16, 958.
Zelmanovitz, F., Genro, S. & Gross, J. L. (1998). Suppressive therapy with levothyroxine for solitary thyroid nodules: a double-blind controlled clinical study and cumulative meta-analyses. J Clin Endocrinol Metab, 83, 3881.
