实时二维灰阶超声造影对甲状腺恶性结节的诊断价值

超声造影(contrast-enhanced ultrasound,CEUS)为近十年来超声医学领域内出现的一项重要技术,其原理是通过经外周静脉注入超声造影剂在低机械指数状态下实时观察病灶与邻近组织结构血流灌注信息,目前在肝脏、子宫、前列腺等领域已广泛应用[1,2],也为甲状腺良恶性结节的鉴别提供了新的方法.本研究探讨实时二维灰阶CEUS对甲状腺良恶性结节的诊断价值.     

甲状腺乳头状癌伴颈内静脉癌栓的临床特点

目的 探讨甲状腺乳头状癌伴颈内静脉癌栓的临床特点.方法 回顾性分析2例复发性甲状腺乳头状癌伴颈内静脉癌栓患者的临床表现,影像学检查资料、治疗方式及临床转归.结果 2例患者除颈部肿物外,均无明显临床症状,经CT检查均发现颈内静脉内低密度影,但不能确诊为癌栓,其中1例经彩色多普勒超声及超声造影检查可诊断颈内静脉癌栓.2例均接受了甲状腺全切除+单侧颈淋巴清扫+同侧颈内静脉切除术,术后病理证实为甲状腺乳头状癌伴颈内静脉癌栓.2例患者分别于术后4个月、13个月因肿瘤局部未控死亡.结论 甲状腺乳头状癌伴颈内静脉癌栓临床症状缺乏特异性,术前诊断主要依靠影像学检查.手术切除全甲状腺及受累静脉有可能延长患者生存期,术后还应补充放疗及131I治疗,但总体预后不良.     

超声诊断甲状腺占位性病变的价值

目的统计分析甲状腺占位性病变的超声图像资料,总结有价值的超声学特点,提高术前诊断准确率.方法收集2002年1月-2005年12月1700例术前超声图像资料,分析灰阶和彩色超声表现.本组病例全部经手术及病理证实.诊断良性占位性病变的依据为：①多发病灶;②病灶周边有完整“晕环”;③病灶形态规则,边界清晰,内部回声均匀;④有粗大钙化影像;⑤血流丰富程度多数为Ⅰ或Ⅳ级,血流分布多数为Ⅰ型;⑥血流阻力指数高于0.6,血流峰值速度低于12 cm/s.诊断恶性占位性病变的依据为：①单发病灶;②病灶形态欠规则,边界欠清晰;③内部不均匀低回声;④有细沙粒样钙化影像;⑤血流丰富程度多数为Ⅱ或Ⅲ级,血流分布多数为Ⅱ型;⑥颈部淋巴结转移病灶;⑦血流阻力指数低于0.6,血流峰值速度高于12 cm/s.结果良性病变1284例,恶性病变416例.单纯依据灰阶超声表现,诊断甲状腺良性病变准确率为80.0%,恶性准确率为75.0%.综合彩超表现,诊断良性病变准确率为86.0%,恶性准确率为82.0%,总的准确率为85.0%.结论灰阶超声特点对鉴别良、恶性非常重要,彩色超声可明显提高诊断准确率,其中血流指数测定对鉴别良、恶性病变意义不大.超声诊断甲状腺占位性病变的准确率较高,可作为术前影像检查首选方法.     

超声造影在鉴别伴有钙化的甲状腺结节良恶性中的价值

目的 评价超声造影在鉴别伴有钙化的甲状腺结节良恶性中的价值.方法 对2009年2月至2012年9月期间的179例伴有钙化的甲状腺结节患者经浅静脉注入造影剂微泡行超声造影检查,观察结节的造影剂灌注过程,并采用TomTec软件进行量化分析,获得造影定量参数,患者术后均经病理证实,以评估其灵敏性、特异性、阳性预测值、阴性预测值和诊断符合率.结果 良性结节110例,其中结节性甲状腺肿中46例伴粗大钙化和16例伴微钙化;腺瘤中28例粗大钙化和1例微钙化;桥本甲状腺炎中13例伴粗大钙化和4例伴微钙化,2例缝线肉芽肿均伴微钙化.恶性结节69例,其中乳头状癌中60例伴微钙化和8例伴粗大钙化,1例髓样癌伴微钙化.恶性结节主要表现为不均匀弱增强,峰值强度(51.38±14.33) dB,低于良性结节(92.37±33.36)dB,而良性结节为等增强或高增强,二者差异有统计学意义(t=14.33,P＜0.05),但是造影定量参数中始增时间与达峰时间良恶性结节相比差异无统计学意义.超声造影诊断伴有钙化的甲状腺结节良恶性的灵敏性、特异性、阳性预测值、阴性预测值、诊断符合率分别为92.75％、90.91％、86.49％、95.24％、91.62％.结论 超声造影对伴有钙化的甲状腺结节有较高的鉴别诊断价值.     

超声造影诊断甲状腺癌的临床价值

目的　探讨超声造影诊断甲状腺癌的临床价值。方法　对2014年1月～2015年8月在上海新华医院行甲状腺超声造影的129例甲状腺结节患者的临床资料进行分析,比较超声造影与病理结果,总结其影像学特征。结果　129例中共有甲状腺结节132枚,超声造影诊断为甲状腺癌103枚、良性结节24枚、甲状腺炎5枚。与病理结果比较,超声造影诊断准确度88.6%,灵敏度92.2%,特异度75.9%。31例诊断不符合,8例甲状腺癌误诊为良性结节,3例甲状腺炎误诊为甲状腺癌,20例结节性甲状腺肿误诊为甲状腺癌。恶性 结节以乳头状癌居多,在超声造影中以“低增强”与“慢进快出”为特征表现。结论　超声造影对甲状腺癌的诊断具有较理想的特异性和灵敏性,“低增强”与“慢进快出”征象为甲状腺癌的重要影像特征。     

超声造影和弹性成像鉴别良恶性甲状腺结节作用的Logistic回归分析

目的 应用Logistic回归模型评价超声造影及弹性成像在甲状腺结节良恶性鉴别诊断中的价值.方法 对149例患者的甲状腺结节进行超声造影及弹性成像检查,建立以甲状腺结节超声特征为变量的Logistic回归模型.绘制受试者工作特征曲线,评价Logistic回归模型的预报能力,通过比较各变量的似然比,评价超声造影及弹性成像在甲状腺结节良恶性鉴别诊断中的价值.结果 运用前进法二分类Logistic回归分析,筛选出对甲状腺结节良恶性鉴别诊断中有统计学意义的特征变量包括钙化、增强程度、最大灌注强度及弹性评分.超声造影定量指标的似然比明显高于其他变量.所建立的回归模型对甲状腺结节良恶性预报的正确率为91.90％.结论 超声造影和弹性成像对诊断甲状腺结节的良恶性具有较高的价值,所建立的Logistic回归模型具有较高的诊断正确率.     

B超等影像检查在脉络膜血管瘤诊断中的应用

目的 探讨B超等（CT和MR）影像检查对于脉络膜血管瘤的诊断价值。方法 回顾分析经临床证实的脉络膜血管瘤11例病例资料,均行B超检查,其中行CT增强扫描1例、 MR检查4例、眼底血管荧光造影2例。结果 11例B超检查呈梭形或橄榄形高回声占位,其中肿块实质均质8例,呈实质不均质占位3例; CT增强扫描示后极部球壁增厚1例,密度均匀,强化明显; MRI4例中T1WI呈等信号3例, T1WI呈高信号1例,T2WI均呈高信号,4例增强后瘤体显著强化。眼底血管荧光造影2例均显示动脉早期窦状强荧光,静脉期荧光渗漏,晚期瘤体高荧。结论 B超、增强CT和MRI对脉络膜血管瘤可作出定位的影像学诊断,B超（＋眼底血管荧光造影）在早期诊断方面有一定优势,MRI对该病的诊断及鉴别诊断较具特征性。     

甲状腺乳头状癌颈部淋巴结转移规律的临床分析

目的 探讨甲状腺乳头状癌颈淋巴结转移规律,为选择最佳手术方式提供参考。方法 回顾分析2001年1月至2013年8月济南军区总医院甲状腺乳腺外科616例诊断为甲状腺乳头状癌患者的临床和病理资料。结果 616例有完整统计资料的甲状腺乳头状癌患者中,病理诊断颈部淋巴结总转移率为58.77%(362/616),中央区(Ⅵ区)淋巴结转移率为48.70%(300/616),颈侧区(Ⅱ、Ⅲ、Ⅳ、Ⅴ区)淋巴结转移率为38.80%(239/616),原发肿瘤的部位、最大直径、是否累及包膜、是否为多发病灶及患者年龄对颈部淋巴结转移率有显著影响,差异有统计学意义(P＜0.05),且双因素方差分析显示,肿瘤直径越大,转移到颈侧区的可能性越大。结论 甲状腺乳头状癌最常见的转移部位是Ⅵ区,术中应常规清除,其次依次为Ⅲ、Ⅳ、Ⅱ、Ⅴ区,对于患者原发肿瘤具有累及包膜、直径＞1cm、多发病灶及位于双侧等特点应清扫颈侧区,术中快速病理检查颈侧区淋巴结病理状态,确定颈侧区淋巴结清扫范围。     

甲状腺乳头状癌cN0患者中央区淋巴转移的研究

目的 探讨临床淋巴结阴性(cNO)甲状腺乳头状癌患者中央区(Ⅵ区)淋巴转移规律及清扫的临床价值.方法 回顾性分析中国医学科学院肿瘤医院头颈外科2003年1月至2006年12月初治的cNO甲状腺乳头状癌并行中央区淋巴清扫的108例患者临床资料.研究患者性别、年龄、肿瘤多中心病灶、被膜外侵、肿瘤大小、部位与中央区淋巴转移的关系.影响中央区淋巴转移率单因素差异比较采用 x2检验,Logistic模型进行多因素分析,Kaplan-Meier法计算生存率、颈侧复发率和远处转移率.结果 cNO甲状腺乳头状癌中央区淋巴转移率为59.2%(64/108),年龄小于45岁、甲状腺被膜受侵、肿瘤直径＞3 cm是中央区淋巴转移的独立危险因素(比值比分别为5.514、5.610和3.122,P值均＜0.05).本组中央区淋巴清扫喉返神经暂时性麻痹发生率为1.8%(2/108).术后暂时性低钙发生率为4.6%(5/108),永久性低钙发生率为0.9%(1/108).中位随访时间53个月,6例患者颈侧复发转移,2例局部复发,其中1例患者局部复发后死亡.5年颈侧复发率、生存率分别为4.8%、99.1%.结论 cNO甲状腺乳头状癌中央区淋巴转移率高,中央区淋巴清扫术后并发症的发生率低,建议对cNO甲状腺乳头状癌患者行中央区淋巴清扫.     

超声诊断对甲状腺乳头状腺癌中央区清扫的临床指导意义

目的:探讨超声诊断对甲状腺乳头状腺癌(特别是甲状腺微小灶癌)是否行中央区淋巴结清扫的临床指导意义。方法:分析2012-09-2013-12期间在我科(同一术者、同一标准)进行甲状腺乳头状腺癌行中央区淋巴结清扫手术的临床资料121例,评价术前超声对甲状腺微小灶癌和非微小灶癌中央区淋巴结转移的诊断价值。结果:121例患者中甲状腺微小灶癌(原发病灶d≤1.0cm)62例,其颈中央区淋巴结超声诊断的准确率为74.2%(46/62),漏诊率为61.9%(13/21),误诊率为7.3%(3/41),灵敏度为38.1%(8/21)、特异度为92.7%(38/41),阳性预测值为72.7%(8/11),阴性预测值为74.5%(38/51),Kappa值为0.3485(<0.4),表示在PTMC中术前超声与术后病理诊断一致性较差;非微小灶癌(原发病灶d>1.0cm)患者59例,其术前超声中央区淋巴结诊断的准确率为55.9%(33/59),漏诊率为58.3%(21/36),误诊率为21.7%(5/23),灵敏度为41.7%(15/36),特异度为78.3%(18/23),阳性预测值75.0%(15/20),阴性预测值为46.2%(18/39),Kappa值为0.1757(<0.4),表示超声诊断与术后病理诊断一致性仍较差。结论:甲状腺微小灶癌术前中央区淋巴结超声诊断提示可疑阳性的,需常规行颈中央区淋巴结清扫。对于中央区淋巴结超声提示阴性的,可结合患者高危因素决定是否行预防性颈中央区淋巴结清扫。非微小灶型甲状腺乳头状腺癌中央区淋巴结超声检查无论是否提示有无异常淋巴结,均应行颈中央区淋巴结清扫。     

甲状腺肿瘤外科手术2228例临床分析

目的探讨甲状腺肿瘤外科治疗效果，总结甲状腺肿瘤的诊疗经验。方法回顾性分析1992年-2004年间2228例甲状腺肿瘤(2072例甲状腺良性肿瘤，156例甲状腺癌)的临床资料及随访结果。结果2072例甲状腺良性肿瘤中，术后喉返神经损伤4例，永久性喉返神经损伤率是0．1％，暂时性喉返神经损伤率为0．1％；55例复发行二次手术，复发率为2．6％。术后无甲状旁腺功能低下和出血。甲状腺癌156例，8例复发，3例死亡，直接法统计5年生存率为95．50k，(64／67)，Kaplan-Meier法统计5年生存率为98．0％。60例微小癌中无1例复发或转移，5年生存率为100．0％。156例甲状腺癌中1例喉返神经损伤，发生率为0．6％，术后无出血和甲状旁腺功能低下。结论遵循甲状腺肿瘤正确外科治疗原则能有效降低甲状腺疾病患者手术并发症、复发率等，并改善预后。     

甲状腺乳头状腺癌选择性颈清扫术后并发症

目的 探讨甲状腺乳头状腺癌选择性颈清扫(selective neck dissection,SND)术后并发症的发生原因及预防措施.方法 回顾性分析94例行甲状腺乳头状腺癌SND的患者的临床资料.结果 颈后外侧淋巴清扫术(posterolateral neck dissection,PLND)组29例;PLND 甲状腺次全切除术组16例;PLND加颈前清扫(anterior compartment neck dissection,ACND)加甲状腺次全切除术组34例;PLND加ACND加甲状腺全切除术组15例.副神经损伤发生率为9.6%,喉返神经损伤发生率为10.7%,6例患者出现了乳糜漏,6例出现术后甲状旁腺功能减退.结论 甲状腺乳头状腺癌SDN并发症发生率较低,手术是比较安全的.     

双侧甲状腺癌1例

1病例报告 患者,女,48岁。因＂发现颈部肿物2个月余＂于2013年6月18日入院。患者2个月前无意中发现颈部有一肿物,无疼痛、发热、呼吸及吞咽困难,无食欲减退、盗汗、消瘦,无声嘶、情绪暴躁易怒。自发病来肿物无明显增大,体重未见下降,未予诊治。患者平素健康,无结核病及糖尿病病史。     

Papillary carcinoma of the thyroid associated with sarcoidosis

A case of papillary carcinoma of the thyroid occurring in association with systemic sarcoidosis is reported. Although benign thyroid disorders occurring in conjunction with sarcoidosis have previously been documented, a search of the literature found no report of thyroid carcinoma occurring in association with sarcoidosis. Diagnosis and therapeutic management prove difficult when thyroid carcinoma and sarcoidosis co-exist. Transbronchial biopsy of lung lesions is warranted in staging thyroid carcinoma in order to exclude the possibility of unknown co-existent disease. The management of cervical lymphadenopathy in thyroid carcinoma should not be altered because of the presence of sarcoidosis, and should include a neck dissection.     

Incidence and significance of clinically unsuspected thyroid tissue in lymph nodes found during neck dissection in head and neck carcinoma patients

OBJECTIVES/HYPOTHESIS: The objectives were to quantify the incidence of clinically unsuspected thyroid tissue in cervical lymph nodes encountered during neck dissection in patients with head and neck carcinoma, to describe the location and histological aspect of these inclusions, and to assess their clinical significance. STUDY DESIGN: Retrospective study. METHODS: The histological records of 1123 neck dissections in 752 patients with head and neck carcinoma were reviewed. In cases with thyroid inclusions, the pathological diagnosis was reviewed and an immunohistochemical study against thyroglobulin and calcitonin was carried out. RESULTS: Clinically unsuspected thyroid tissue was found in lymph nodes in 11 of the 752 patients with head and neck carcinoma treated with neck dissection. In five cases, the thyroid inclusion was compatible with a metastases of an occult papillary thyroid carcinoma. In the other six cases, a collection of thyroid follicles without malignant characteristics was found beneath the lymph node capsule. These latter cases were considered benign thyroid inclusions. A thyroidectomy was performed in three of the patients with lymph node metastases of the papillary carcinoma. An occult papillary carcinoma was found in only one case. The other two patients had been treated previously with radiotherapy for an early-stage glottic carcinoma. Immunohistochemical study did not find calcitonin-positive cells within the benign thyroid inclusions. After a follow-up period ranging from 1.2 to 8.2 years, no patient had any kind of local, regional, or distant relapse related to the thyroid disease. CONCLUSION: The incidence of unsuspected thyroid tissue in lymph nodes of patients with head and neck carcinoma treated with neck dissection was 1.5%. Both lymph node metastases of a papillary carcinoma and benign thyroid inclusions were found. The study results suggest that the incidental finding of thyroid tissue in the lymph nodes during a neck dissection in patients with head and neck carcinoma does not necessarily indicate the need for aggressive therapy.     

Sonographically-directed neck dissection for recurrent thyroid carcinoma

Objective: To determine the effectiveness of sonographically‐directed compartmental neck dissection for recurrent differentiated thyroid carcinoma as confirmed by ultrasound surveillance and thyroid‐specific biochemical markers. Study Design: Retrospective chart review. Methods: Retrospective cohort study of 18 patients with sonographically localized and pathology‐confirmed recurrent differentiated thyroid carcinoma. Fifteen patients chose to undergo compartmental neck dissection by a single surgeon. Surgery involved central compartment (level VI) or functional lateral neck dissection (level II‐IV+/‐V). Three patients declined surgery despite proven recurrent lymph node disease. Results: All 18 patients started out with sonographic evidence of recurrent lymph node disease. Preoperative thyroglobulin or thyroglobulin antibody levels were positive in 17 of 18 patients (94%). Postoperatively, all 15 patients who underwent compartmental lymph node dissections had no sonographic evidence of lymph node disease. Of the 14 patients with preoperative positive thyroglobulin or thyroglobulin antibody levels, 9 patients converted to negative levels (64%). Furthermore, two of four patients (50%) converted to thyroglobulin antibody negative status after surgery. All three patients who declined surgery had persistently detectable sonographic nodal disease in addition to positive thyroglobulin and/or thyroglobulin antibody levels (100%). Surgical complications were minimal and self‐limited as no patient experienced permanent cranial nerve deficits. Conclusion: Ultrasound‐directed cranial nerve sparing compartmental lymph node dissection results in no sonographically detectable cervical lymph node disease and undetectable basal thyroglobulin or thyroglobulin antibody levels in the majority of patients with low morbidity.     

Clinical study on prognostic factors in thyroid carcinoma

We treated 227 patients, 45 men and 182 women, with thyroid carcinoma at our hospital from 1984 to 1998. Of these, 177 had papillary carcinoma and 50 follicular carcinoma. The extent of resection was based on tumor size in papillary carcinoma but not follicular carcinoma, and 70% of carcinoma patients underwent hemithyroidectomy. Neck lymph nodes were resected in 93.2% of papillary carcinoma patients, with D1 neck dissection in 45.7% and D2 or D3 neck dissection in 47.5%. In contrast, 70% of follicular carcinoma patients with lymph node resection had D1 dissection. Locoregional recurrence was noted in 22 patients and distant metastasis in 6 cases. Nonsurvivors numbered 17, 12 papillary and 5 follicular carcinoma patients, died of their primary disease. Almost all deaths were in patients with advanced disease, pT3 in 3, pT4 in 10, N1a in 3 and N1b in 8. The prognostic factors for papillary carcinoma were extracapsular spread, age, and distant metastasis, while the only factor for follicular carcinoma was distant metastasis. The 5-year survival for patients with papillary carcinoma was 93.0% and 10-year survival 88.8%, compared to 5-year survival for 93.5% of follicular carcinoma patients and 10-year survival for 93.5%.     

Incidental metastatic papillary thyroid carcinoma in microvascular reconstruction

OBJECTIVES/HYPOTHESIS: Occult papillary thyroid carcinoma has a reported prevalence of 1% to 35% based on autopsy studies. Cervical lymphatic metastases from papillary thyroid carcinoma have been associated with a higher likelihood of recurrence with a questionable impact on survival. Without clinically evident disease in the thyroid or cervical nodes, management of these patients presents a treatment dilemma. We propose an individualized treatment plan for patients in whom metastatic papillary thyroid carcinoma is incidentally detected during neck exploration for other purposes. STUDY DESIGN: Retrospective review and discussion of the literature. METHODS: The clinical course of two patients with incidentally discovered metastatic papillary thyroid carcinoma to the cervical lymph nodes is described. Both patients had previously received head and neck irradiation in childhood and required free flap reconstruction of extensive skull base defects following extirpation of meningiomas. RESULTS: Neck dissection specimens from levels I and II obtained during exposure of recipient vessels for microvascular tissue transfer revealed papillary thyroid carcinoma in both cases. The patients subsequently underwent total thyroidectomy, neck dissection, and postoperative radioactive iodine ablation of residual thyroid tissue. After 1 year of follow-up, both patients were without evidence of recurrent disease. CONCLUSIONS: An individualized approach is justified to treat metastatic papillary thyroid carcinoma incidentally discovered during other procedures. The case reports underscore the importance of pathological analysis of surgical specimens obtained during head and neck reconstruction.     

Globusgefühl als Zeichen eines medullären Schilddrüsenkarzinoms

Medullary carcinomas represent 4% of all thyroid carcinomas. Most important for diagnosis are ultrasound criteria and determination of serum calcitonin, using the pentagastrin test if necessary. We report on a 51-year-old woman who was suffering from persistent globus sensation. Ultrasound examination detected a small thyroid nodule with microcalcification in the right thyroid gland. Serum calcitonin representing the most important tumor marker was massively increased. We performed a total thyroidectomy with dissection of the paratracheal compartments and a conservative neck dissection on the side of the tumor. Postoperatively, serum calcitonin decreased but still remained increased overall. Because there is no other therapeutic option besides surgical treatment, the initial intervention is of tremendous importance. In addition, examination for a possible hereditary medullary thyroid carcinoma is required, which influences the patient’s prognosis considerably and necessitates screening examinations of other relatives.