Empfehlung zum Calcitonin-Screening bei Struma nodosa

Was ist neu? Calcitonin-Bestimmung Die neuen vollautomatischen Chemilumineszenz-Immunoassays erlauben eine sichere Festlegung geschlechtsspezifischer oberer Referenzwerte für Calcitonin. Calcitonin-Erhöhung Der Graubereich mit unspezifisch erhöhten Calcitonin-Spiegeln durch andere Erkrankungen oder Medikamente ist inzwischen besser zu definieren. Calcitonin-Screening bei Struma nodosa Eine Empfehlung zur Schilddrüsenoperation wird ab einem basalen Calcitonin-Grenzwert von über 30 pg/ml bei Frauen und über 60 pg/ml bei Männern gesehen. Damit gelingt aus unserer Sicht eine gute Balance zwischen Übertherapie, d. h. Schilddrüsenoperationen bei erhöhtem Calcitonin und benigner Histologie, und dem Risiko, ein im Frühstadium befindliches MTC zu übersehen. Die Durchführung eines Calcitonin-Stimulationstests ist nicht mehr erforderlich. Werte im Graubereich (20 – 30 pg/ml bei Frauen und 30 – 60 pg/ml bei Männern) sollten im Abstand von 3 – 6 Monaten kontrolliert und bei Überschreitung der Grenzwerte operiert werden. Berücksichtigt man zusätzlich die Tatsache, dass bei Calcitonin-Werten < 100 pg/ml eine nahezu 100 %ige Heilungsrate zu erreichen ist, führt dies zu einer weiteren Verbesserung der Zuverlässigkeit in der Nutzung basaler Calcitonin-Werte im Calcitonin-Screening der Struma nodosa. Calcitonin-Screening bei familiären medullären Schilddrüsenkarzinomen Zum Ausschluss einer hereditären Variante eines medullären Schilddrüsenkarzinoms (RET-Mutation) sollte bei Erstdiagnose eine molekulargenetische Untersuchung erfolgen. Ein Phäochromozytom und ein primärer Hyperparathyreoidismus sollten vor Thyreoidektomie ausgeschlossen/diagnostiziert werden. Der optimale Zeitpunkt der prophylaktischen Thyreoidektomie wird unter Berücksichtigung des Aggressionspotenzials der RET-Mutation und des Calcitonin-Spiegels gewählt.

Surgical cure rates of sporadic medullary thyroid cancer in the era of calcitonin screening

Objective Time trends of the extent of disease at first diagnosis and biochemical cure remain ill-defined for sporadic medullary thyroid cancer (MTC). This investigation aimed to delineate time trends and biochemical cure rates for sporadic MTC. Design This was an observational study of consecutive patients operated on for sporadic MTC between 1995 and 2015. Methods Time trends of clinical and histopathological variables indicative of the extent of disease and biochemical cure were calculated for 600 patients with sporadic MTC, 322 of whom had initial neck surgery and 278 of whom had neck reoperation at a tertiary surgical center in Germany. Results From 1995–2000 to 2011–2015, significant declines (all P<0.001) were noted in the percentage of node-positive tumors (from 73 to 49%), mediastinal lymph node metastasis (from 21 to 6%) and distant metastasis (from 23 to 6%). These changes were paralleled by significant increases (all P<0.001) in mean patient age (from 49.1 to 57.3years) and the percentage of MTC ≤10mm (from 19 to 39%) and biochemical cure (from 28 to 62%). When only patients with primary tumors >10mm were considered, the decreasing percentage of mediastinal lymph node metastasis and distant metastasis, and rising mean patient age and biochemical cure rates remained statistically significant. Conclusions Significant reductions in the extent of the disease and improved biochemical cure rates pointed toward increasing therapeutic control of sporadic MTC. The independent contribution of routine calcitonin screening to these time-dependent changes warrants more research.

Twenty Years of Experience with the Preoperative Diagnosis of Medullary Cancer in a Moderately Iodine-Deficient Region

Background. There is a current debate in the medical literature about plasma calcitonin screening in patients with nodular goiter (NG). We decided on analyzing our 20-year experience with patients in an iodine-deficient region (ID).Patients and Methods. 22,857 consecutive patients with NG underwent ultrasonography and aspiration cytology (FNAC). If FNAC raised suspicion of medullary cancer (MTC), the serum calcitonin was measured.Results. 4,601 patients underwent surgery; there were 23 patients among them who had MTC (0.1% prevalence). Significantly more MTC cases were diagnosed cytologically in the second decade than in the first: 11/12 and 6/11, respectively. The frozen section was of help in 2 cases out of 3. Two patients suffered from a 3-year delay in proper therapy, and reoperation was necessary in 1 case. FNAC raised the suspicion of MTC in 20 cases that were later histologically verified and did not present MTC. The diagnostic accuracy of FNAC in diagnosing MTC was 99.2%. Two false-positive serum calcitonin tests (one of them in a hemodialyzed patient) and one false-negative serum calcitonin test occurred in 40 cases.Conclusion. Regarding the low prevalence of MTC in ID regions, calcitonin screening of all NG patients does not only appear superfluously but may have more disadvantages than advantages.