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UDC: 616.441-008.61 + 616-089.873.4
ZAYNIYEV Alisher Faridunovich
KURBANIYAZOV Zafar Babajanovich
RAKHMANOV Kosim Erdanovich
ABDURAKHMANOV Diyor Shukurillaevich
Samarkand State Medical Institute, Uzbekistan.
MODERN STATE OF THE PROBLEM OF DIAGNOSIS OF THYROID NODULES
(LITERATURE REVIEW)
For citation:
Zayniyev Alisher Faridunovich, Kurbaniyazov Zafar Babajanovich, Rakhmanov
Kosim Erdanovich. Abdurakhmanov Diyor Shukurillaevich MODERN STATE OF THE PROBLEM
OF DIAGNOSIS OF THYROID NODULES (LITERATURE REVIEW). Journal of Biomedicine
and Practice. 2021, vol. 6, issue 4, pp.137-142
http://dx.doi.org/10.26739/2181-9300-2021-4-20
ABSTRACT
the question of modern possibilities of complex diagnostics of thyroid nodules is considered. Despite
the large number of studies conducted, it is not always possible to correctly establish an accurate
morphological diagnosis of thyroid nodules, which indicates the need to improve existing and search
for new, more informative diagnostic methods. In this regard, reports on the use of measurements of
tissue pressure in the thyroid gland for the differential diagnosis of various pathologies of this organ
are very promising.
Key words:
thyroid gland, morphological form, nodular formation, thyroid cancer.
ЗАЙНИЕВ Алишер Фаридунович
КУРБАНИЯЗОВ Зафар Бабажанович
РАХМАНОВ Косим Эрданович
АБДУРАХМАНОВ Диёр Шукуриллаевич
Самаркандский Государственный медицинский институт, Узбекистан.
СОВРЕМЕННОЕ СОСТОЯНИЕ ПРОБЛЕМЫ ДИАГНОСТИКИ УЗЛОВ
ЩИТОВИДНОЙ ЖЕЛЕЗЫ (ОБЗОР ЛИТЕРАТУРЫ)
РЕЗЮМЕ
рассматривается вопрос о современных возможностях комплексной диагностики узловых
образований щитовидной железы. Несмотря на большое количество проведенных
исследований, не всегда удается правильно установить точный морфологический диагноз
узлов щитовидной железы, что свидетельствует о необходимости совершенствования
существующих и поиска новых, более информативных методов диагностики. В этом
отношении весьма перспективными представляются сообщения об использовании измерений
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тканевого давления в щитовидной железе для дифференциальной диагностики различных
патологий этого органа.
Ключевые слова:
щитовидная железа, морфологическая форма, узловое
образование, рак щитовидной железы.
ЗАЙНИЕВ Алишер Фаридунович
КУРБАНИЯЗОВ Зафар Бабажанович
РАХМАНОВ Қосим Эрданович
АБДУРАХМАНОВ Диёр Шукуриллаевич
Самарқанд Давлат тиббиёт институти, Ўзбекистон.
ҚАЛҚОНСИМОН БЕЗ ТУГУНЧАЛАРИДА ДИАГНОСТИК МУАММОСИНИНГ
ҲОЗИРГИ ҲОЛАТИ (АДАБИЁТЛАР ШАРҲИ)
РЕЗЮМЕ
қалқонсимон без тугунчаларининг мураккаб диагностикасининг замонавий
имкониятлари масаласи кўриб чиқилади. Ўтказилган кўплаб тадқиқотларга қарамасдан,
қалқонсимон без тугунларининг аниқ морфологик ташхисини тўғри белгилаш ҳар доим
ҳам мумкин емас, бу мавжуд бўлган ва янги, кўпроқ информацион диагностика
усулларини қидириш зарурлигини кўрсатади. Шу муносабат билан, ушбу органнинг
турли патологияларини дифференциаль ташхислаш учун қалқонсимон бездаги тўқима
босимини ўлчашлардан фойдаланиш бўйича ҳисоботлар жуда истиқболли.
Калит сўзлар
:
қалқонсимон без, морфологик шакл, тугун ҳосил бўлиши,
қалқонсимон без саратони.
At present, there is a trend towards an increase in the number of thyroid nodular formations
(TNF) [10]. The frequency of detectable nodes in the thyroid gland (thyroid gland) depends on the
method of investigation. At palpation of the thyroid gland, nodal formations are found in 4-6% of the
population in areas with a sufficient content of iodine in water and food, in the zones of goiter endemia
their prevalence is somewhat higher. With ultrasound thyroid, the frequency of detection of
previously unidentified knots in adults is 13-40%. At autopsy of persons, who died from non-thyroid
diseases, nodes in the thyroid gland find more than half of people [3]. The prevalence of thyroid
cancer among the nodular formations, thyroid gland, according to different authors, is from 2.4 to
31.4%. According to V.V. Dvoyrina (2001), the growth rate of thyroid cancer over the past decade
was 131-133%, which is significantly higher than other cancer. According to the American Cancer
Society, about 17,000 new cases and about 1,300 deaths associated with thyroid cancer are reported
annually in the United States. In this regard, the problem of differential diagnosis of thyroid cancer
becomes especially urgent [5].
The problem of early diagnosis and timely adequate treatment of pathological formations of
the thyroid gland, which today are found in 4-10% of the population, is still relevant. The incidence
of nodal euthyroid diseases ranges from 10 to 62%. Under the term "nodular diseases", the nodal
colloid goiter (NTG), adenomas, " pseudo nodes " for chronic autoimmune thyroiditis (CAIT),
various morphological variants of the thyroid gland, as well as their combinations. The fact that the
prevalence of focal lesions of the thyroid gland is extremely high in many countries of the world,
according to numerous studies. So in France, for 1,000 people, an average of 35% of thyroid nodules,
in the USA for 100 people, 21% (4-7% of the total population), in Japan for 450 people - 19%. In
Uzbekistan there are an average of 10% of focal pathology per 2 thousand population [3]. A number
of authors noted that the number of focal thyroid lesions increases with age [11]. The main cause of
nodal colloid goiter is iodine deficiency of various origins. When insufficient intake of iodine to
maintain a euthyroid state is amplified products iodinated less, but biologically more active T3,
whereas the content of T4 decreases. By the feedback mechanism, secretion of TG increases, which
leads to an increase in the number of thyocytes. In addition to TG, there are polypeptides that increase
the functional activity and the ability to multiply thyroid cells - " epidermal growth factor", "growth
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stimulating immunoglobulin", growth hormone. Elevated levels of fluoride and calcium in drinking
water lead to the development of nodes in the thyroid. Antithyroid drugs and sulfonamides can also
give a creeping effect [4].
The appearance of adenomas and thyroid cancer (thyroid cancer) is a consequence of a
disorder in the cell proliferation of thyroid cells. Not the last place in this is allocated to the hereditary
predisposition, the effects of ionizing radiation [8]. Identify the thyroid cancer based on only the
history and physical examination is difficult. This is due to the fact that most of the thyroid tumors
are highly differentiated and do not differ from benign thyroid nodules. Such generally accepted
criteria of malignancy, such as rapid node growth and dense consistency, are of little help in the
differential diagnosis of benign diseases and thyroid cancer. So, on the one hand, the rapid growth of
the node is often observed with hemorrhage to the adenoma, and in persons with thyroiditis
Hashimoto in thyroid gland find dense knots, on the other hand the malignant node can be soft upon
palpation and last for a long time to exist in the thyroid gland without signs of growth. Such criteria
of knot malignancy, as lack of displacement during swallowing, hoarseness of voice, increase of
regional lymph nodes, are more specific, but are extremely rare. Meanwhile, clinical data should be
taken into account when evaluating the thyroid gland. First of all, those of them that indicate a high
risk of malignancy of this node, namely, the age of the patient over 60 years and under the age of 25,
male gender, irradiation of the head and neck area in history, knot size exceeding 3-4 cm [9].
The informative value of palpation survey ranges from 35 to 62.5%, and in 25 to 36% of cases,
palpable solitary nodes are multiple when using additional techniques [10]. The analysis shows that
in 26 - 40% of cases there is a discrepancy between the data of the palpation survey in relation to the
number of nodes with operative findings [11]. Reliability of palpation research depends on the size
and location of the node, the size and shape of the neck, the experience of the doctor. Along with the
generally accepted laboratory tests (general blood test, general urine analysis, biochemical blood test,
coagulogram), patients with thyroid cancer need to study the hormonal status. When the patient is
diagnosed with UA thyroid, an evaluation of the TG level by a highly sensitive method is shown [7].
If a reduced level of TG is detected, an additional determination is made of the level of free T 4 and
free T3, if an increased TG level of free T4 is detected. Determining the level of thyroglobulin, as
well as antibodies to thyroid cancer in diagnostic search for nodular goiter is not advisable.
Laboratory methods of diagnosis can clarify the diagnosis of the disease, but do not exclude
errors in their interpretation. So, with climax in the blood, there may be an increase in the TG content
in the intact thyroid gland. Elevated titer of antibodies to thyroglobulin and peroxidase of thyrocytes
can be obtained in patients with nonendocrinediseases when taking drugs that affect the nature of the
immune response. The wide introduction of modern instrumental research methods into clinical
practice allowed to significantly increase the differential capabilities in diagnosis of thyroid cancer
[6]. However, in numerous works contradictory data are presented on the diagnostic value of each of
the existing methods, as well as on the possibilities of their combination or sequential application.
Until now, the "gold" standard for diagnosis of thyroid gland remains a planned histological study.
Timely and accurate diagnosis of thyroid cancer is important in the choice of method of treatment,
the scope and nature of surgical intervention. Survey radiography is not significant in the diagnosis
of ultrasound and allows you to judge the nature of the lesion only by indirect signs of displacement,
retrotracheal space.
Widely used method of pneumothyroidography, which consists in contrasting the thyroid
gland by introducing oxygen into the interfascial space of the neck [9]. Direct (changes in the visible
contours of the thyroid gland) and indirect signs (displacement and compression of the trachea,
esophagus, muscles, large blood vessels) of the thyroid gland were isolated. This method was used
for the diagnosis of a retrosternal goiter, nodular forms of goiter [4].
About three decades ago, the first works on the use of thermography in the diagnosis of thyroid
diseases appeared. Most of the work was devoted to differential diagnosis of malignant and benign
thyroid diseases [5]. However, a number of authors note the fact that there is no correlation between
the thermography, the histological structure and the size of the thyroid tumor [2].
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Until now, for indirect diagnosis of thyroid gland diseases, indirect percutaneous
thyroidulymphography is used. This method allows obtaining additional information on the structure,
topography, shape, contours and dimensions of the thyroid gland, to a certain extent assess the
intraorganic prevalence of the pathological process, while being fairly simple and accessible [5].
Thyroidulymphography can be used for in vivo study of lymph circulation in the thyroid gland.
According to some authors, thyroidulymphography allows judging on the functional state of the
thyroid gland on the basis of data on the speed of spreading and excretion of contrast medium [1].
This method makes it possible to visualize small nodal formations more reliably than scanning
differential diagnosis between nodular and multinodular goiter helps in the diagnosis of thyroid
cancer.
However, according to M.P. Cherenko (1989) thyroidulymphography is not critical in the
diagnosis of thyroid cancer. I.A. The accountant and co-workers. (1987) believe that with the
development of cancer in a benign tumor (nodular goiter, adenoma), there are no lymphographic signs
of malignancy until the moment the process leaves the capsule. S.A. Sergeev (1985) emphasizes that
the thyroidographic criteria for malignancy were reliable only with common malignant lesions and
had no practical significance for differential diagnosis. A.Bollo at al. (1959) proposed a method of
arteriographyfor the diagnosis of thyroid diseases. A number of researchers used it in the diagnosis
of benign and malignant tumors of the thyroid gland. Arteriography in the diagnosis of thyroid
diseases has an auxiliary significance and should be carried out according to strict indications only in
cases when other methods do not provide the necessary diagnostic information [6].
One of the methods used to examine patients with thyroid cancer is the PHC. The nature of
the accumulation of the radiopharmaceutical in the thyroid is determined by its functional activity.
The scanogram makes it possible to determine the topography, the shape, the size of the fraction, and
also the functional activity of the nodal formations and the parenchyma of the thyroid [3].
It is difficult not to agree with the opinion of a number of researchers that at the present stage
of development of thyroidology, the detection of thyroid cancer in radionuclide scanning (RNS) is
inadvisable, since the information obtained by the method is not of great diagnostic value. Pre-
existing opinion that suspicious for cancer are "cold" nodes that are currently being questioned, as
there is evidence that cancers are also able to store pharmaceuticals, cases of detection of cancer are
described in functioning, "warm" and hyperfunctioning " hot "nodes. The frequency of malignancy
in the "hot knots", according to various authors, is 16-20%. On the other hand, the cancer of thyroid
cancer looks like a dysfunctional or "cold" node, most of the "cold" nodes are colloidal in histological
research, among them, 15-20% of the observations are detected [9].
There appeared publications of a number of authors about the successful detection of
malignant adenoma of the thyroid gland with simultaneous use of two isotopes - Th201 and I138. At
the same time, these authors, as well as most other researchers, do not consider the routine use of
RNS for differential diagnosis of thyroid tumors to be expedient. The disadvantages of the method
include the need for the introduction of radioactive material into the patient's div, the difficulty in
identifying the formation of less than 15 mm, the inability to differentially diagnose malignant and
benign nodules, in multinodular euthyroid craw (METC), the interpretation of scansis difficult and is
accompanied by the greatest number of errors [16,18]. However, the use of TN in the long-term period
is informative for clarifying the localization of residual and ectopic thyroid tissue, the definition of
metastases in regional lymph nodes. Thus, at the present time, scanning is not significant in the
differential diagnosis of thyroid cancer [10].
Computed tomography and magnetic resonance imaging methods are expensive, are not
available for most patients and not having significant advantages over traditional diagnostic tests -
may be used to identify retrosternal goiter, tumor metastasis, for the detection of invasion of adjacent
structures at locally advanced cancers [8]. In typical clinical cases, CT and MRT do not have any
statistically significant advantages over ultrasound in combination with NAB under ultrasound
control [6]. Most researchers, considering the above, do not consider them a method of choice for
most thyroid diseases [9,10,11,12].
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A preoperative examination of the patient attaches great importance to fine needle aspiration
biopsy (NAB). According to the summary data, the overall sensitivity of NAB in diseases of the
thyroid gland is 60 -94%, specificity reaches 94-100%. The percentage of false negative results varies
from 4 to 11 (an average of 5%), false positive - from 0 to 10 (an average of 3%) [13,14]. Obtaining
adequate cytological material with the help of NAB, according to the literature, is possible in 80 -
98% of observations, which largely depends on the experience of a specialist who conducts the
specified diagnostic procedure. Some researchers prefer a thick-needle biopsy of the thyroid gland,
pointing out its advantages [15,16,17]. With the help of this procedure it is possible to obtain a column
of tissue for histological examination. Many researchers believe that the effectiveness of NAB and
thick-needle biopsy in the. Diagnosis of thyroid disease is approximately the same, but with thicker
biopsy, there are more complications.
According to N.I. Nikitina (1972), the coincidence of cytological and histological data in
colloid goitre is observed in 75%, in adenomas - in 93%, in cancer of thyroid cancer - in 100% of
cases. The same data are given in other modern studies. The sensitivity of NAB in the detection of
thyroid cancer, according to the majority of authors, is from 10 to 62%. Puncture biopsy allows to
establish the diagnosis only in 3/4 of all cases of thyroid cancer [18,19]. The diagnostic value for
follicular cancer is lower (no more than 40%). It is especially difficult to distinguish follicular
adenoma, which is a benign tumor, from follicular cancer in case of puncture biopsy. Therefore, the
follicular adenoma, regardless of size and degree of activity, is an indication for surgical intervention.
The sensitivity of NAB in METC is reduced compared to the sensitivity of solitary thyroid. The
sensitivity of the method, according to different researchers, is 60 - 94%, specificity reaches 64 -
86%.
Morphological material obtained with NAB is usually divided into 4 categories: 1) benign
changes; 2) malignant changes; 3) suspicious for malignant; 4) insufficient material for research. The
disadvantage of NAB is that the manipulation is carried out practically "blindly", relying on the data
of palpation. The greatest prospect of the development of visual control during the puncture biopsy
of modern researchers see the use of ultrasound [19,20,21].
NAB with ultrasound guidance allows to increase sensitivity up to 93%, and specificity up to
89%. The preparation of a cytological material in non-palpable thyroid lesions is possible only under
the supervision of ultrasound. According to E.I. Trofimova (1997), in a comparative evaluation of the
results of cytological examination obtained with puncturenon-palpable nodal formations under the
control of ultrasound and a planned morphological study, diagnoses coincided in 77.1% of
observations.
Thus, as the literature data show, pre-operative methods of investigation do not allow
establishing a reliable diagnosis in 100% of cases. In this regard, a great deal of attention is paid to
methods of intraoperative diagnostics of thyroid gland.
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