患者の方へ

甲状腺細胞診『鑑別困難』特集

2015/09/17

甲状腺細胞診『鑑別困難』の特集を私が編集を担当しています J Basic and Clinical Medicineに掲載しました。論文内容を見たり、ダウンロードすることは無料(open access)の雑誌ですので、以下のURL http://sspublications.org/index.php/JBCM/index をご覧ください。中国、米国、イタリア、スイス、日本の著者から12編の論文を投稿いただきました。残念ながら英語の論文で、日本語でも順次これらを紹介したいと思っています。11月には、少し方向は違いますが、第54回秋期大会(名古屋)でシンポジウム『甲状腺細胞診(鑑別困難)を発癌の分子メカニズムから考える』を開催いたします。また来年5月横浜での国際細胞学会でも、『Comparison of different diagnostic systems of thyroid cytology, current and future.』をシンポジウムとして行います。興味のある方はご参加ください。

甲状腺癌被包型乳頭癌濾胞亜型が変わりました。

2015/04/16

NIFT

NIFT

2015年3月20日、21日米国ボストンにて、写真の病理医24名、臨床医3名、患者代表1名が集まり、現在癌とされている甲状腺腫瘍(被包型乳頭癌濾胞亜型の浸潤転移のないもの)の呼称を変更する会議がもたれました。この腫瘍は米国で癌として治療され、相当数の患者が、甲状腺全摘出、放射性ヨード治療を受けていました。しかし、24名の病理医で再検証した109例の症例(14年経過観察、放射性ヨード治療をされなかった症例)の予後から、再発転移が起こらないことが確認され、この確認を受け、NIFT (non-invasive follicular thyroid neoplasm with papillary-like nuclear features)と呼称を変更することが決定されました。癌が良性の前癌的病変に変更される歴史的場面に立ち会えたことを喜んでいます。これから多くの患者の治療にインパクトがあることを期待します。患者が診断名に意見を述べたり、臨床医が注文を付けたりするのは、日本ではない光景でした。  

甲状腺癌の過剰診断、過剰診療、過剰治療について。

2015/02/09

現在米国では(文献12参照)、甲状腺癌だけでなく、乳癌、前立腺癌などで、検診による早期発見、早期治療の功罪が問題とされています。早期発見早期治療により救われた生命よりも、治療の必要のない病変(治療しなくても生命予後に悪影響のない病変、近藤誠先生の『がんもどき』など)を、多数発見し、『がん』として治療することにより、
A) 癌死亡の減少に貢献していない。(癌患者は増えたが、癌死亡数は増えていない)
B) 医療費の無駄遣いをしている。
C) 患者を苦しめている。(治療しないで放置しても無害な病変を、お節介にも見つけて、無駄で有害な治療をしている)
などと議論されています。患者の皆様、臨床医の皆様どのようにお考えでしょうか?
患者の立場としては、見つかった病変を治療しないで持ち続けることは、たぶん不安でたまらないでしょう。少数かもしれませんが、本当の癌(治療しないで放置すると進行し、癌のために死亡する)かもしれません。後で後悔することがないように、普通の人は、迷うかもしれませんが、多くの場合、治療を受けようと考えるのではないでしょうか?このホームページの『医療の不確実性』の項を参照ください。
ここでは2点に分けて議論しなければいけないと考えています。
1. 病変の性質を正確に判断し、治療したほうがいいか、治療しないでそのまま持ち続けるかの判断をする。
ここで病理医の役割(本当の癌か癌に類似した無害な病変の区別)があります。
2. 治療が必要と判断した時、治療方法の中から、最も適した(治療効果が高く、治療による不愉快な、悪影響を最小にする)選択肢は何かを考える。
治療の中心を担うのは臨床医ですが、ここでも病理医の示す、病変の性質、病気の進み具合(病期)の診断が、治療方法の選択に重要な参考資料、判断根拠となります。
1. Esserman LJ et al: Addressing overdiagnosis and overtreatment in cancer: a prescription for change. Lancet Oncol, 15:e234-242, 2014.
2. Luster M et al: Differentiated thyroid cancer-personalized therapies to prevent overtreatment. Nat Rev Endocrinol 10:563-574, 2014.

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A patient’s message from Turkey

2013/12/25

Dear Dr Kakudo
I wanted to write to you about how I feel on your second opinion diagnosis. For people who will read this story for the first time I would like to simply explain my situation. I’m a male at my 37. I had lobectomy operation due to a thyroid nodule of 2.7cm in size at my left thyroid lobe. Pathology report after surgery said “Follicular Variant of Papillary Carcinoma” and I was advised to go for completion surgery and radioactive iodine (RI) treatment.
After reading many articles including yours about borderline lesions I started to question if surgery was the best option for my health or not. Then I started to follow “thyroid cancer survivors association group” at “inspire.com”. Following this site gave me a better understanding of how people feel without thyroid gland, short and long term side effects. And based on an advice from a friend from that group I decided to contact you and you kindly accepted to give me your second opinion.
Your diagnosis result says “findings are incomplete and do not fulfill histopathologic criteria for either follicular carcinoma or papillary carcinoma”. And this type of tumor are “practically benign after simple excision”. This difference in opinion obviously makes a big change for management of the disease. No need for completion surgery and no need for RI treatment.
As a patient going through all this on one hand I feel lucky because it’s not a genuine cancer case where none of above mentioned discussion could be possible. I also feel lucky because I had a chance to read and better understand risks and downsides of surgery and RI treatment before deciding anything further. On the other hand not going down that road may have other risks in specific cases and today we are not 100% sure about long term outcome for each individual. However statistically there is a strong evidence that we are almost 100% sure (your study shows 0,03% missing malignancy judging) there will be no recurrence or distant metastasis.
Reflecting on my case and many others it’s clear to me that there is a difference in opinion between pathologists and this has a direct impact on management of the disease. Important point to me is to give enough information to patients so that they can make their own decisions. Not just say this is your problem and this is the one and only solution. Take it or not! I could have felt much better if risks of surgery and RI and not doing that was explained to me objectively. At the end it’s my life and I have to make a decision. Why should I have to find out difficulties in diagnosis and even classification of borderline lesions by myself? How many people will (be able to) do what I did? And how many people will just do what is told? Therefore how many people will possibly be treated for nothing? And their quality of life and feeling about their health is impacted adversely for the rest of their lives.
I hope answers to above questions will be discussed more and more in the coming years. And until we find a clear method to identify what is definitely malignant and what is not I hope doctors around the world will give more information to their patients and explain real difficulty to make this identification. And let people decide what is best for themselves.
Finally I want to say thank you for your second opinion diagnosis which made a big change in my life. And a big thank you for your life time studies and sharing what you believe is right to make a change in people’s lives.

category: 患者の方へ , 臨床医の方へ comment: (0)

アメリカの甲状腺癌患者からの手紙

2012/09/18

医学研究に携わって多くの論文を書いてきましたが、研究内容が地味(?)なため、また基礎研究で重箱の隅をつつく内容(?)であるため、今まであまり注目を集めることはありませんでした。また治療に直接関与していないため、患者さんから感謝の言葉をいただいたこともありませんでした。しかし、先週初めて以下のようなmailを、面識のない患者(病院名、患者名は個人情報のため伏せさせていただきます)からいただき、インターネット情報はすごい、研究論文を書くことで患者に情報を発信し、時に役に立っているのだと実感することができ喜んでいます。どのような内容の論文であるか興味のある方はhttp://onlinelibrary.wiley.com/doi/10.1111/j.1440-1827.2011.02773.x/full をご参照ください。 Dear Dr. Kakudo, I wanted to write and thank you for publishing your comprehensive review of the literature on encapsulated thyroid tumors, and your related papers.  I am referring to Classification of thyroid follicular cell tumors: with special reference to borderline lesions (2011), and Encapsulated papillary thyroid carcinoma, follicular variant: a misnomer, (2012), which make many salient points and provide an excellent review of the literature for both professionals and interested patients. I am a patient who was diagnosed with an encapsulated, mutation-negative, non-invasive thyroid cancer in 2011 in the United States.  The pathology report read that it was an encapsulated classic PTC.  I did wonder a bit at the time whether there could be some kind of question or error about the diagnosis because the tumor did not appear to have been behaving in a way that could be construed as aggressive.  There was no spread to the nodes or outside the thyroid, molecular tests revealed no known genetic mutations and I was also tg undetectable, both basal and stimulated.  I was puzzled, and I did see while looking online that there was some kind of controversy about encapsulated FVPTC, but I was told that I didn’t have FVPTC and also that there are many cases of mutation negative thyroid cancer.  I was also told that I was “low risk” but on the advice of my endocrinologist I submitted to a treatment of radioiodine (50 mCi). Like many or even most patients, when I was diagnosed I really had very little idea of the definition of thyroid cancer according to tumor classification and how that plays into the reasoning of a given pathologist. I had no way of contextualizing “thyroid cancer” in a more meaningful way.  It seems that the hospital that I used treats classic encapsulated PTC the same as garden variety non-encapsulated PTC.  I had no idea that encapsulated PTC could be regarded as being under the same umbrella as encapsulated FVPTC until I did a Google search about it and saw your papers, which elucidate very effectively the problems of inter-observer variation among pathologists and also the questionable ascendency of PTC-N as a major diagnostic criterion.  I would even go beyond that and say that any patient with this type of thyroid tumor who has been diagnosed with cancer and who can read and understand your reports will probably come away feeling rather disturbed, or at the very least disconcerted by the implications.  A cancer diagnosis entails a considerable psychological burden even when the prognosis is good. It really surprised me to learn of the observer-dependent nature of the line between benign and malignant in certain situations.  But I guess what unnerved me the most is the realization that pathologists and other clinicians at times actually do not know with certainty the true nature of some lesions due to the limitations of current knowledge.  Yet these cases will nevertheless often be translated to the patient as definitively being cancer.  How is a patient to react when confronted with this actuality, other than by experiencing a lessening of confidence in the way in which thyroid pathology is being conducted in many hospitals and also with nagging uncertainty about whether their case has been over-treated?  I feel that I was not empowered as a patient and that more transparency is needed in medical practices as to the gaps in understanding in the current classification system, and the resultant gray zones in diagnosis which directly impact the lives of patients like me. It seems to be the case that there is a certain segment of patients who are the unwitting “poster children” of this gray zone in thyroid pathology. My case proceeded on the basis of PTC-N (FNA and pathology) alone because the molecular results were negative.  These uncertainties which have been unmasked by your reports suggest to me that a borderline category based upon degree of invasiveness is a very sensible solution until more hard data becomes available.  At least I can attest to what a difference it would have made to me personally.  Had I known of your research before I had my surgery and treatment, I may have insisted on a lobectomy and almost certainly would not have agreed to receive RAI ablation. Since I saw your papers I conferred with a second pathologist from New England about them, and he confirmed that the diagnosis of these “very low grade lesions” is subjective and sometimes even amounts to a “suggestion” from the pathologist.   I only wish that my original pathologist could have somehow conveyed this information to me. Maybe many pathologists and clinicians in the USA and elsewhere feel that their hands are tied due to legal concerns, but I think that for patients a borderline category makes very good sense and most likely will prevent overtreatment and psychological trauma.  It would have made such a difference for me in that it would have allowed for a lesser degree of treatment while preserving appropriate follow-up. Thank you again, Dr. Kakudo.
ResearchGate(Kennichi Kakud) Better Treatment 最適医療 (社) 日本病理学会 教育委員会編集 病理コア画像 和歌山県立医科大学人体病理学(第2病理学)教室 バーチャル臨床甲状腺カレッジ