JOURNAL OF HEPATO-GASTROENTEROLOGY RESEARCH | ЖУРНАЛ ГЕПАТО-ГАСТРОЭНТЕРОЛОГИЧЕСКИХ ИССЛЕДОВАНИЙ
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Зайниев Алишер Фаридунович,
Ассистент кафедры хирургических болезньей №1
Самаркандский Государственный Медицинский Институт
Самарканд, Узбекистан
Рахманов Косим Эрданович,
Доцент кафедры хирургических болезньей №1
Самаркандский Государственный Медицинский Институт
Самарканд, Узбекистан
Гозибеков Жамшид Исанбаевич,
Ассистент кафедры хирургических болезньей №1
Самаркандский Государственный Медицинский Институт
Самарканд, Узбекистан
ПРОБЛЕМЫ ДИАГНОСТИКИ УЗЛОВЫХ ОБРАЗОВАНИЙ ЩИТОВИДНЫЙ ЖЕЛЕЗЫ НА
СОВРЕМЕННОМ ЭТАПЕ (ОБЗОР ЛИТЕРАТУРЫ)
АННОТАЦИЯ
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 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,
1-сонли хирургик касалликлари кафедраси ассистенти
Самарқанд Давлат тиббиёт институти
Самарқанд, Ўзбекистон
Рахманов Косим Эрданович,
1-сон хирургик касалликлари кафедраси дотсенти
Самарқанд Давлат тиббиёт институти
Самарқанд, Ўзбекистон
Ғозибеков Жамшид Исанбаевич,
1-сон хирургик касалликлари кафедраси ассистенти
Самарқанд Давлат тиббиёт институти
Самарқанд, Ўзбекистон
ҚАЛҚОНСИМОН БЕЗ ТУГУНЛИ ХОСИЛАЛАРИ ДИАГНОСТИКА МУАММОСИНИНГ
ЗАМОНАВИЙ БОСҚИЧИ (АДАБИЁТЛАР ШАРҲИ)
АННОТАЦИЯ
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.
Zayniyev Alisher Faridunovich,
Assistant of the Department of Surgical Diseases No. 1
Samarkand State Medical Institute
JOURNAL OF HEPATO-GASTROENTEROLOGY RESEARCH | ЖУРНАЛ ГЕПАТО-ГАСТРОЭНТЕРОЛОГИЧЕСКИХ ИССЛЕДОВАНИЙ
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Samarkand, Uzbekistan
Rakhmanov Kosim Erdanovich,
Associate Professor of the Department of Surgical Diseases No. 1
Samarkand State Medical Institute
Samarkand, Uzbekistan
G’ozibekov Jamshid Isanbayevich,
Assistant of the Department of Surgical Diseases No. 1
Samarkand State Medical Institute
Samarkand, Uzbekistan
THE PROBLEMS OF THE DIAGNOSIS OF THYROID NODES AT THE PRESENT STAGE
(LITERATURE REVIEW)
ANNOTATION
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.
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
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
JOURNAL OF HEPATO-GASTROENTEROLOGY RESEARCH | ЖУРНАЛ ГЕПАТО-ГАСТРОЭНТЕРОЛОГИЧЕСКИХ ИССЛЕДОВАНИЙ
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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].
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].
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
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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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