加强甲状腺结节及恶性肿瘤的规范治疗

近年来,甲状腺结节和甲状腺癌的发病率逐渐增高。针对甲状腺结节和甲状腺癌的诊断和治疗技术快速发展,分子生物学检测手段成为甲状腺恶性肿瘤诊断的重要补充,为临床决策提供了更多有价值的信息。新的治疗方式不断出现,比如颈外径路腔镜辅助甲状腺手术以及机器人手术,很大程度上满足了患者对于美观的诉求。与此同时,越来越多的争议和讨论相应出现,如射频消融技术在甲状腺结节中的应用价值、分化型甲状腺癌的切除范围、预防性中央区淋巴结清扫的指征、侧颈淋巴结清扫的范围、放射性碘治疗的指征等。将理论研究与临床实践相结合,讨论并概述了甲状腺结节与甲状腺癌的疾病特点、诊断、治疗、随访等环节的争议热点和最新进展,为该类疾病的临床管理提供方法和思路。     

34βE12、Galectin-3及HBME-1在甲状腺良、恶性结节中的表达差异及临床诊断价值

目的：分析甲状腺良恶性结节中34βE12、Galectin-3及HBME-1的表达状况,并探讨其在鉴别甲状腺乳头状癌（papillary thyroid carcinoma,PTC）与甲状腺良性结节中的临床价值。方法采用免疫组化En VisionTM两步法检测352例患者中34βE12、Galectin-3及HBME-1的表达水平,分析这3个蛋白标记物与PTC临床病理特征的相关性,利用ROC曲线评估其鉴别诊断价值。结果34βE12、Galectin-3及HBME-1在PTC病灶中的阳性率均显著高于甲状腺良性结节中的表达水平,且这3个蛋白标记物在PTC不同性别、年龄、病灶数目、肿瘤大小、包膜是否突破、有无淋巴结转移以及TNM分期中的表达差异均无统计学意义（P均>0.05）。34βE12、Galectin-3及HBME-1对鉴别PTC与甲状腺良性疾病中的ROC曲线下面积（AUC）分别为0.936、0.915、0.898,灵敏度分别为94.3%、95.5%、91.1%,特异度分别为81.1%、71.7%、83.0%,准确度分别为90.3%、88.4%、88.6%。结论34βE12、Galectin-3及HBME-1在甲状腺良恶性结节中的表达存在统计学差异,并且与PTC的临床病理特征无关,对鉴别甲状腺良恶性结节的性质具有重要的临床辅助价值。     

甲状腺结节性疾病的诊疗现状

甲状腺结节性疾病起病隐匿,触诊检出率只有4％～7％[1],随着影像学检查的普及应用,甲状腺结节的检出率明显提高,临床发病率显著升高.美国甲状腺学会(American Thyroid Association,ATA)定义甲状腺结节为甲状腺内散在病灶,影像学能将其和周围甲状腺组织清楚分界[2],可见影像学检查在甲状腺结节诊断中的地位.甲状腺结节按病理分为良性和恶性,其中恶性结节约占5％ ～ 10％[3].近年来,全球范围内均报道甲状腺癌发病率呈显著上升趋势,最常见的类型是乳头状癌[4-11].为确定手术指征和避免过度医疗,甲状腺结节影像学诊断的准确性在制定治疗决策时尤为重要.甲状腺结节性疾病的规范化治疗对患者的生存质量及疾病预后有着非常重要的影响.现对甲状腺主要影像学检查方法和甲状腺结节性疾病的诊治进行简要论述.     

甲状腺结节消融术研究进展

甲状腺良性结节是一种常见的临床疾病。随着诊断治疗技术的提高和科技的进步,消融在有效缩小甲状腺实性结节、改善相关症状的同时,也具有微创、美观的优越性。本文就甲状腺结节热消融和化学消融的原理、治疗及预后,适应症及禁忌证等情况作一个综述,期望为临床筛选甲状腺结节患者选择合理的治疗方案提供帮助。     

彩色多普勒超声对诊断甲状腺结节的临床效果分析及准确率研究

目的 探讨彩色多普勒超声在甲状腺结节上的临床诊断效果和准确率。方法 本研究的对象为2020年5月至2021年5月期间到我院就诊的200例甲状腺结节患者,200例患者均需接受彩色多普勒超声检查,以手术病理检查结果作为金标准,比较200例患者使用彩色多普勒超声检查后的甲状腺良性、恶性结节的检出率、诊断效能和血流动力学指标。结果 手术病理检查结果显示,200例患者中共有212个结节,其中,检测有36个恶性结节,有176个良性结节;彩色多普勒超声的检查结果显示,200例患者中共有212个结节,其中,检测有48个恶性结节,有164个良性结节;彩色多普勒超声在甲状腺结节的诊断中,灵敏度为91.67%,特异度为91.48%,诊断符合率为91.51%;彩色多普勒超声的检查结果显示,甲状腺恶性结节的血流阻力指数和血流收缩期峰值流速均明显高于甲状腺良性结节(P<0.05)。结论 彩色多普勒超声在甲状腺结节的诊断中应用价值较为理想,不仅诊断准确率较高,还能有效鉴别甲状腺良性结节和恶性结节之间的血流动力学,值得临床进一步推广。     

细针穿刺在甲状腺结节诊断中的应用

甲状腺结节的发病率为20％～45％,但恶性结节仅占5％～l5％.明确甲状腺结节的性质对减少不必要的手术有着非常重要的意义.本文从穿刺在甲状腺疾病诊断中的应用及甲状腺肿瘤分子生物学方面探讨甲状腺结节的诊断模式.     

超声影像及临床体征综合分级对甲状腺结节良恶性诊断的价值分析

目的探讨甲状腺超声影像学结合临床查体分级系统在诊断甲状腺结节良恶性中的应用价值。方法回顾2014年1月~2015年1月经我院甲状腺超声影像学结合临床查体系统分级诊断的300例甲状腺结节患者,均经手术治疗并作了组织病理学诊断,对照比较两者间的关系及相关性。结果甲状腺良性结节组和甲状腺恶性结节组比较,肿块形态、纵横比、边缘、回声类型、声晕、结节内微钙化、淋巴结、CDFI、触诊质地、表面光滑程度、活动度均具有统计学差别。查体提示结节质硬、活动度差、表面结节状的多为恶性结节。肿块超声结合临床查体诊断良性结节104例,而手术病理诊断良性结节116例;超声结合临床查体考虑恶性结节196个,手术确诊恶性结节184个。采用超声及临床查体综合分级进行评价,并与术后病理结果进行比较。良性结节以I^III级为主,恶性结节以IV^V级为主。结论超声影像学结合临床查体系统分级将更有利于对甲状腺良恶性结节的诊断。     

甲状腺结节应积极主动干预

甲状腺结节十分常见,流行病学调查显示一般人群甲状腺可触及结节的检出率约4%,如行超声检查普通人群中20%～70%可发现有甲状腺结节[1-2].通过在诊断、治疗和随访的多个层面进行积极主动干预,可使恶性结节得到早期诊断,并在早期阶段给予规范合理的治疗,可以达到彻底治愈或大大延长生存时间的目的.也可使大量良性患者避免过度治疗、减少医疗费用及整个社会医疗资源的浪费.     

纳米磁珠联合基质辅助激光解吸电离飞行时间质谱技术对甲状腺微小结节良恶性的鉴别价值

目的　应用纳米磁珠联合基质辅助激光解吸电离飞行时间质谱（matrix-assisted laser desorption/ionization time of flight mass spectrometry,MALDI-TOFMS）技术检测甲状腺微小结节患者的血清蛋白标志物,探讨对甲状腺微小结节良恶性鉴别的诊断价值。方法  应用纳米磁珠联合MALDI-TOF-MS技术检测甲状腺微小结节115例的血清,其中微小恶性结节65例,微小良性结节对照50例,获得鉴别诊断甲状腺微小结节良恶性的最佳血清标志物,建立诊断模型。结果　单独区分甲状腺微小结节良恶性鉴别意义最强的3个蛋白质峰分别为3320.19、8127.39、4302.35（m/z）,构建甲状腺微小恶性结节最佳诊断模型,交叉检验敏感性为88.6%,特异性为80%。验证组盲法监测该诊断模型的敏感性为80%,特异性为86.7%。结论　纳米磁珠联合MALDI-TOF-MS技术能在甲状腺微小结节患者血清中筛选出区分良恶性的特异性强、敏感性高的差异蛋白,对甲状腺微小结节的良恶性鉴别有临床意义。     

传统涂片联合液基细胞学在甲状腺细胞学诊断中的应用价值探讨

目的　探讨传统涂片联合液基细胞学在超声引导下甲状腺细针穿刺细胞学诊断中的应用价值。方法　超声引导下对152例甲状腺结节行细针穿刺传统细胞涂片及液基细胞学涂片，且152例患者均行手术治疗，将细胞学与组织病理进行对比分析。结果　细针穿刺细胞学与术后组织病理结果进行对照，传统涂片联合液基细胞学涂片对于甲状腺结节诊断的符合率为91%，对于甲状腺恶性结节的诊断符合率达到93.2%，均高于单纯传统涂片。结论　甲状腺结节细针穿刺传统涂片与液基细胞学联合使用，诊断准确性更高，具有良好的应用价值，值得临床推广使用。     

Evaluation of cytologically benign solitary thyroid nodules by ultrasonography: A retrospective analysis of 1877 cases

Objective

The purpose of this study is to evaluate the role of ultrasonography (US) in the management of thyroid nodules when the cytology is benign tumor on fine needle aspiration biopsy (FNAB).

Methods

Between 2006 and 2011, we investigated 13,972 patients who had solitary thyroid nodule with cytological findings of benign. Surgery was performed according to our criteria for surgical indication. Of these patients, 1877 (13%) patients who underwent surgery were enrolled in this study. We compared the results of clinical findings including US classification and final histopathological diagnosis.

Results

One hundred seven (6%) after surgery were diagnosed as malignancy pathologically. Large nodule or high serum thyroglobulin level were not associated with an increased risk of malignancy. Ultrasonographic evaluation as malignancy was directly linked to pathological diagnosis as thyroid carcinoma (p < 0.001).

Conclusion

US may help to play a role in deciding whether surgical treatment is necessary for cytologically benign thyroid nodules.     

Needle aspiration biopsy of thyroid nodules

Needle aspiration biopsies for cytology were performed on 224 patients with thyroid nodules. Diagnosis was confirmed by surgical exploration in 134 patients. Twenty-four biopsies were reported positive for malignancy; 23 were confirmed at operation and there was 1 false positive. Forty-one biopsies were reported benign. Three of these lesions were found to be malignant, representing false negatives. Sixty-nine biopsies were in the questionable category; 16 (23%) of these were malignant. None of the patients suffered complications from the biopsies. Routine employment of needle aspiration biopsy on our service has resulted in a marked increase in the incidence of carcinoma in thyroid nodules selected for surgery. This has resulted from detection of otherwise unsuspected malignancy, as well as avoidance of surgery in patients with benign lesions. Needle aspiration is not a substitute for surgery. It is a valuable diagnostic procedure, and should be performed in the evaluation of essentially all thyroid nodules. We continue to use radioiodine scanning to evaluate our patients, but have found the routine use of ultrasonography unnecessary when needle aspiration is employed. The ultimate decision regarding surgical exploration is based on a combination of factors including history, physical findings, radioiodine scan and needle aspiration biopsy.     

经皮微波消融治疗甲状腺良性结节

甲状腺结节是临床常见的甲状腺疾病。微波消融治疗能有效地缩小实性甲状腺结节体积,改善结节相关症状。目前主要运用于良性结节,而对于恶性结节研究也在进行中,但能否达到同等效果,鲜有报道;甲状腺结节微波消融的并发症主要为喉返神经损伤、出血等,经治疗可痊愈,由于其良好的有效性及安全性,微波消融可推荐用于甲状腺结节的临床处理。     

甲状腺结节细针穿刺细胞学检查评估

目的 探讨甲状腺细针穿刺细胞学(fine-needle aspiration,FNA)检查的临床价值.方法 回顾性分析中国医学科学院肿瘤医院2005年10月至2011年1月行甲状腺细针穿刺的474例连续病例资料.B超引导下穿刺218例(46.0％),触诊穿刺256例(54.0％).细胞学诊断结果分为六级:无法诊断、良性、不典型细胞、滤泡样肿瘤、可疑恶性及恶性.将其中157例手术患者术前细胞学诊断结果与术后组织病理学诊断结果进行比较.结果 157例手术治疗患者中91例为恶性,术前FNA诊断为无法诊断2/7、良性16.7％ (9/54)、不典型细胞3/9、滤泡样肿瘤1/3、可疑恶性83.3％( 35/42)、恶性97.6％ (41/42).甲状腺细针穿刺鉴别甲状腺结节良恶性的敏感度为85.4％,特异度为86.9％.阳性预测值90.5％.结论甲状腺细针穿刺细胞学诊断能够为甲状腺疾病提供较为准确的术前诊断.六级诊断方法有助于临床治疗方案的选择.     

钙化对甲状腺肿瘤良恶性判断的意义及其分子生物学机制

许多恶性肿瘤和一些良性肿瘤中存在钙化现象,如甲状腺肿瘤,乳房肿瘤,肾黏液性腺癌,前列腺癌和颅咽管瘤等。甲状腺肿瘤中的钙化现象十分普遍,在甲状腺的影像学检查中,包括超声检查、X线平片、CT等常会检出钙化,通过活检组织病理     

小切口甲状腺切除术对甲状腺结节患者恢复情况及甲状腺激素水平的影响

目的探讨小切口甲状腺切除术对甲状腺结节患者恢复情况及甲状腺激素水平的影响。方法选取2017年1月至2019年12月收治的60例甲状腺结节患者进行观察,均接受小切口甲状腺切除术,观察甲状腺结节患者恢复情况,并检测观察甲状腺激素水平变化。结果60例甲状腺结节患者治疗总有效率为96.67%,并发症发生率为3.33%。术后7d患者游离三碘甲状腺原氨酸(FT3)及游离甲状腺素(FT4)等甲状腺激素水平较术前明显降低(P<0.05),总三碘甲状腺原氨酸(TT3)、总甲状腺素(TT4)较术前无明显变化(P>0.05),术后3个月甲状腺激素水平较术前无明显变化(P>0.05)。结论小切口甲状腺切除术治疗甲状腺结节手术及术后恢复效果好,术后并发症少,且不会对甲状腺激素水平造成明显影响,值得推广。     

Computed tomography versus ultrasound/fine needle aspiration biopsy in differential diagnosis of thyroid nodules: a retrospective analysis

IntroductionUltrasound sonography provides a quick method for determining which nodule to sample for fine needle aspiration biopsy in thyroid nodules. On the other hand, the computed tomography examination is not restricted by echo attenuation and distinguishes between benign and malignant nodules.ObjectiveTo compare computed tomography examinations against ultrasound/fine needle aspiration biopsy in the differential diagnosis of thyroid nodules.MethodsData regarding computed tomography examinations, sonographic finding following fine needle aspiration biopsy, and tumor histology of 953 nodules from 698 patients who underwent thyroidectomy were collected and analyzed. The beneficial score for detection of the malignant tumor for each adopted modality was evaluated.ResultsUltrasound images did not show a well-circumscribed solid mass in 89 nodules, and ultimately did not detect nodules in fine needle aspiration biopsies (false positive non-malignant nodules). Ultrasound images showed parenchymatous disease (false positive malignant nodules) in several nodules. Computed tomography examinations demonstrated higher difficulty in detection of malignant nodules of 1.0–2.0 cm size than ultrasound examination following fine needle aspiration biopsies; compared to tumor histological data, computed tomography examinations had a sensitivity of 0.879.ConclusionComputed tomography examinations are a more reliable method for differential diagnosis of thyroid nodules than ultrasound examinations followed by fine needle aspiration biopsy.Level of EvidenceIII.     

Management of benign thyroid nodules based on the findings of fine-needle aspiration

Fine-needle aspiration (FNA) biopsy is a safe, simple, and inexpensive procedure that is particularly applicable for lesions of the head and neck. In our department, it is widely used for the evaluation of thyroid nodules. A total of 189 patients participated in a prospective study of benign thyroid nodules. Our aim was to verify the modality of treatment used in our department and the reliability of benign cytologic results of colloid goiter. All patients had cold nodules on thyroid scanning. The patients were divided into two groups, the first comprising 93 patients who did not undergo thyroid surgery and were followed up for 5 to 11 years. One case of malignancy was found in this group during the follow-up. The second group was comprised of 96 patients who were operated on despite FNA results of colloid goiter. Among them, five cases of malignancy were found. Four of these five cases could not be regarded as FNA failure. Our study confirms that the combination of clinical findings with those of the FNA is a reliable approach to the management of benign thyroid nodules. Nevertheless, long-term follow-up is mandatory and repetitive aspirations should be considered.     

甲状腺良性结节微波消融短期疗效及影响因素分析

目的 探讨甲状腺良性结节微波消融治疗的短期疗效及影响因素。 方法 回顾性分析133例患者133个甲状腺良性消融结节,计算术后1、3、6个月结节体积缩小率,评估患者年龄、性别、消融能量、结节成分、结节初始体积、血供丰富程度等因素对结节体积缩小率的影响。 结果 甲状腺消融术后1、3、6个月结节体积逐渐缩小,体积缩小率分别为(47.48±23.24)%、(73.06±16.63)%、(84.44±14.68)%,患者性别、总消融能量、单位体积消融能量、结节成分均与消融术后6个月结节体积缩小率相关(P<0.05),患者性别、总消融能量及结节成分均为消融术后短期疗效的独立影响因素(P<0.05)。 结论 甲状腺良性结节微波消融是一种安全有效的治疗方法,男性、适当的消融能量及囊实性结节疗效更佳。     

Can the unnecessary operations for suspected thyroid nodules be avoided by the combined use of the strain ratio and elastography score?

IntroductionOnly 5%–15% of thyroid surgical specimens are reported as malignant. Most of the operations are performed due to suspicion of malignancy as a result of fine needle aspiration biopsy but invasiveness, non-diagnostic results and potential repeat biopsies are disadvantages of fine needle aspiration biopsy.ObjectiveThe aim of this study was to investigate the effectiveness of simultaneously using both the strain ratio and elasticity score in the differential diagnosis of thyroid nodules, as well as to assess the compatibility of these two methods.MethodsA total of 144 nodules were included in the study. The final histopathologic diagnosis was used as the reference standard. The area under the curve sensitivity, specificity, and cut-off values of the strain ratio and elasticity score were determined using receiver operating characteristic curve analysis. The compatibility and comparison of strain ratio and elasticity score were also performed.ResultsTwenty eight nodules (19.4%) were malignant. The strain ratio and elasticity score results were found to be significantly successful in predicting thyroid malignancy (p < 0.001 for both). Moreover, the area under the curve for the strain ratio and elasticity score were found to be 0.944 and 0.960, respectively. The diagnostic accuracy of the elasticity score was found to be superior to that of the strain ratio, but this difference was not statistically significant (p = 0.456). When the compatibility of the strain ratio and elasticity score was examined, the two evaluations were revealed to be statistically consistent with each other (Kappa = 0.767; p < 0.001). When the strain ratio and the elasticity score were used together, the specificity of capturing the correct diagnosis increased from 84.5% to 93.1%.ConclusionWhen the strain ratio an elasticity score were used together for the differential diagnosis of thyroid nodules, more accurate results were obtained. Thus, combining both methods may be a promising alternative to fine needle aspiration biopsy in order to prevent unnecessary surgical interventions for suspected thyroid nodules.