Approach to Management of the Patient with Primary or Secondary Intrathoracic Goiter
Approach to Management of the Patient with Primary or Secondary Intrathoracic Goiter
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DOI：
10.1210/jc.2010-1638
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发表时间：
2010-12-01
影响因子：
5.8
通讯作者：
Bonnema, Steen J.
中科院分区：
文献类型：
--
作者：
Hegedus, Laszlo;Bonnema, Steen J.
胸内（胸骨后）甲状腺肿，取决于定义，在所有甲状腺肿手术患者中高达45%。它可以是原发性的（异位甲状腺组织从颈部甲状腺肿块脱离），这是非常罕见的（1%），或（更常见）继发性的，其中一部分甲状腺肿延伸到胸骨后。在诊断或治疗管理上没有共识，部分原因是许多人没有症状。分类包括血清TSH的功能特征和诊断成像和细胞学的形态特征，以排除恶性肿瘤，这并不比宫颈甲状腺肿更常见。无症状个体的肺功能也经常受到影响。因此，也因为自然史是从甲状腺功能正常到甲状腺功能亢进的持续增长和演变，大多数专家建议治疗。在原发性和继发性胸内甲状腺肿，治疗的选择是全/近全甲状腺切除术和随后的左旋甲状腺素替代。数据表明，并发症仅比颈部甲状腺肿略多。虽然左旋甲状腺素不推荐用于甲状腺肿缩小，但放射性碘作为继发性胸内甲状腺肿手术的替代治疗越来越受到关注。在这里，它可以在1年后平均减少甲状腺大小40%，并改善呼吸功能和生活质量。最近的研究表明，重组人促甲状腺激素，目前使用的标签外，可以增加放射性碘相关的甲状腺肿缩小30- 50%。目前使用的剂量的重组人促甲状腺激素，副作用，除了甲状腺功能减退，是罕见的和轻微的。未来的研究还应探讨放射性碘在原发性胸内甲状腺肿中的应用，并对手术和放射性碘进行头对头比较。（临床内分泌代谢杂志95：5155-5162，2010）
Intrathoracic (substernal) goiter, depending on definition, is seen in up to 45% of all patients operated for goiter. It can either be primary (ectopic thyroid tissue detached from a cervical thyroid mass), which is very rare (1%), or (more commonly) secondary, where a portion of the goiter extends retrosternally. There is no consensus on diagnostic or therapeutic management, partly because many are asymptomatic. Classification involves functional characterization with serum TSH and morphological characterization with diagnostic imaging and cytology to rule out malignancy, which is not more common than in cervical goiters. Pulmonary function is often affected in asymptomatic individuals also. Therefore, but also because natural history is continuous growth and evolution from euthyroidism to hyperthyroidism, most experts recommend therapy. In primary as well as secondary intrathoracic goiter, the therapy of choice is total/ near-total thyroidectomy and subsequent levothyroxine substitution. Data suggest that complications are only slightly more prevalent than in cervical goiters. Although levothyroxine is not recommended for goiter shrinkage, there is increasing focus on radioactive iodine as an alternative to surgery in secondary intrathoracic goiters. Here it can reduce thyroid size by on average 40% after 1 yr and improve respiratory function and quality of life. Recent studies show that recombinant human TSH, currently used off-label, can augment the radioiodine-related goiter shrinkage by 30-50%. With currently used doses of recombinant human TSH, the side effects, besides hypothyroidism, are rare and mild. Future studies should also explore the use of radioiodine in primary intrathoracic goiter and compare surgery and radioiodine, head to head. (J Clin Endocrinol Metab 95: 5155-5162, 2010)