甲状腺结节的处理

甲状腺结节的处理北京医院（１００７３０）曹金择，朱明炜甲状腺结节是甲状腺组织内的局限性肿胀。临床上较常见。可及结节者约占人口的４％～７％，中年女性可达１１．３％。其征象为颈前肿物并随吞咽而上下移动。可仅为１个单发或孤立性结节，也可为２个以上的多发结节...     

甲状腺结节的诊断

甲状腺结节临床较常见,但其性质可以迥然不同,诊断的关键是鉴别结节的性质,外科医师的职责在于早期发现恶性肿瘤.     

甲状腺结节的非手术治疗

随着人们生活水平的不断提高,生活环境的恶化,高频彩超在临床的普及应用,被发现的甲状腺结节患者日益增多.这些结节绝大多数是良性(主要是结节性甲状腺肿),仅约5%～15%为恶性,这部分患者绝大多数应该选择手术治疗.良性结节中,除有压迫症状(气管、食管)、继发或合并甲状腺功能亢进、胸骨后甲状腺肿、影响美观并造成心理负担等需要手术治疗外,仅需非手术治疗.因此,规范的非手术治疗显得十分重要.甲状腺结节的非手术治疗包括随访观察、抑制治疗、囊内无水乙醇注射术、<'131>I治疗等.     

甲状腺结节钙化的临床价值

目的探讨甲状腺结节钙化在临床诊治中的意义。方法回顾性分析2002年6月至2003年8月中山大学附属第一医院收治的543例甲状腺结节病人的临床、B超扫描和病理资料。543例甲状腺结节中良性病变473例(87·1%),恶性病变70例(12·9%)。结果121例甲状腺结节有钙化,占22·3%,其中恶性肿物的钙化发生率(52·9%)明显高于良性甲状腺肿物(17·8%,P<0·05)。单发结节、伴有颈部淋巴结肿大甲状腺肿物为恶性的可能性大(P<0·05)。结论B超检查发现甲状腺结节钙化,并有结节边界模糊、形态不规则、低回声和血流信号丰富时,宜采用积极的治疗方法。     

甲状腺外科甲状腺结节的诊断

甲状腺结节临床较常见,但其性质可以迥然不同,诊断的关键是鉴别结节的性质,外科医师的职责在于早期发现恶性肿瘤。要强调询问病史,了解发现结节的时间,近期生长的速度,有无症状诸如疼痛与否,是否影响吞咽,发音有无变化以及全身有无症状,病人的年龄、性别、家族史均应重视。必须     

重视甲状腺结节的处理

甲状腺结节的处理,此乃临床外科常见问题,而且近来变化和争论较多,应该引起临床外科足够重视. 甲状腺结节中90%～95%为良性结节,5%～10%为甲状腺癌.甲状腺结节关注所在是恶性结节.美国临床内分泌协会分别于2003年和2006年制订临床实用规范,提出有恶性结节高危倾向的因素有:髓样甲状腺癌家族史,多发内分泌肿瘤Ⅱ型(MENⅡ),头颈部放疗史,年龄<20岁或>70岁,男性,结节直径>4 cm,质地硬而结实,颈部淋巴结肿大,结节固定和声音嘶哑.     

甲状腺扫描对甲状腺结节的诊断价值

通过对425例甲状腺结节患者的甲状腺扫描与术后病理结果的分析，发现热、温、凉、冷结节中发生甲状腺癌的机会分别为4．8％、11．1％、8．1％和5．9％；而扫描所显示的结节位置与手术所见的符合率为88．9％。认为，甲状腺扫描对甲状腺结节的定位有帮助，但无鉴别肿瘤良、恶性的临床价值。     

Thyroid nodules in children

Thyroid nodules are infrequently encountered in children. During the era of low-dose therapeutic irradiation, the incidence of malignancy in these lesions was 40% to 70%. Recent studies suggest that this incidence is declining, resulting in a concomitant relative increase in the proportion of benign nodular conditions. There is also a heightened awareness that secondary thyroid neoplasms may occur in children surviving primary malignant diseases. Records of 38 children treated surgically at Texas Children's Hospital between 1972 and 1984 have been reviewed to determine the incidence of benign vs. malignant pathosis and to study the role of prior irradiation or chemotherapy in the pathogenesis of thyroid disease. Benign conditions were diagnosed in 27 children (71%), with diffuse hyperplasia (10 children, 26%) and follicular adenoma (8 children, 21%) occurring most frequently. Thyroid carcinoma was diagnosed in the remaining 11 children (29%). All of these patients were euthyroid at presentation, none had received multimodal therapy for a prior malignant condition, and only one had a history of head and neck irradiation in infancy for a treatment of a benign condition (a congenital hemangioma). The clinical presentation, diagnostic evaluation, and surgical management of these patients are reviewed and closely parallel those of patients in other recently published series. No conclusions can be drawn regarding the development of thyroid neoplasia following multimodal therapy for primary disease; however, this incidence must be very low.     

Thyroid nodules indeterminate by needle biopsy

In our experience with 121 patients 18 (15 percent) thyroid nodules studied by needle biopsy were considered indeterminate relative to the presence of a low-grade, well-differentiated carcinoma. For 11 of, the 18 patients, operation was performed with carcinoma identified in two (18 percent). Although experience reduced this problem, the frequency of carcinoma justifies operation for patients with indeterminate thyroid nodules by needle biopsy, unless other factors dictate otherwise. Inadequate results of fine-needle aspiration biopsy requires a determination of therapy on the basis of other clinical factors. However, permanent disappearance or great reduction in size following aspiration of cystic nodules, repeat biopsy, and biopsy with large needles are important in supporting nonoperative therapy. The indeterminate and inadequate cases must be considered in assessing reports of the use of needle biopsy of thyroid nodules. The large size of a thyroid nodule and previous external radiation therapy are factors supporting operative treatment. Improved selection of patients with benign thyroid nodules for thyroid hormone suppression therapy is needed—thyroid-releasing hormone testing may be of help.     

Thyroid nodules and thyroid carcinoma.

Seventy carcinomas of the thyroid gland were found in 1300 thyroidectomies for an incidence of 5.4%. The incidence of malignancy in single nodules was 9.7% and in multinodular nontoxic goiter 4.3%. The risk of cancer was higher (14.2%) in males than in females (4.3%). The highest incidence of cancer was found in children under the age of 10 (40%). Radioactive iodine scintiscanning was of limited help in differentiating benign from malignant nodules. Early surgery is advised for all patients with single thyroid nodules and all thyroid nodules in children should be excised.     

Thyroid function after hemithyroidectomy for benign nodules

In order to assess the need for thyroxine therapy to maintain normal thyroid function in patients who have undergone hemithyroidectomy for benign solitary nodules, pre- and postoperative serum thyroxine (T₄) and serum thyrotropin (TSH) concentrations were measured in a prospective study on 103 patients. Thyroid function measurements were normal before the operation. Postoperative thyroid function tests showed a significant reduction of serum T₄ at 3 years and a significant elevation of serum TSH between 6 months and 3 years after surgery, but the altered levels remained within the normal range. Thirteen patients had abnormal postoperative thyroid function tests. Eight patients had subnormal T₄ levels, which were accompanied by concomitant increases in TSH levels above normal in 3 individuals. Five patients had supranormal TSH values associated with normal T₄ levels, but only 1 of them showed clinical recurrence of a goiter. These observations suggest that most patients remain clinically and biochemically euthyroid after hemithyroidectomy. Thus, routine replacement thyroxine therapy is not necessary to prevent biochemical hypothyroidism, but it may be indicated in the few patients in whom a subnormal T₄ level develops. The clinical significance of these subtle changes in serum T₄ and TSH within the normal range is not clear especially with respect to goiter recurrence.

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Resumen Con el propósito de determinar la necesidad de terapia con tiroxina para el mantenimiento de función tiroidea normal en pacientes que han sido sometidos a hemitiroidectomía por nódulos tiroideos benignos, se midieron las concentraciones pre- y postoperatorias de T₄ y de TSH en un estudio prospectivo realizado en 103 pacientes. Las mediciones de función tiroidea aparecieron normales antes de la operación. Las pruebas postoperatorias de función tiroidea mostraron una reducción significativa de T₄ sérica a los 3 años y una elevación significativa de TSH entre 6 meses y 3 años después de la cirugía, pero tales niveles alterados permanecieron dentro del rango normal. Trece pacientes exhibieron pruebas postoperatorias de función tiroidea anormales. Ocho pacientes presentaron niveles subnormales de T₄, los cuales se acompanaron de elevaciones concomitantes, por encima del nivel normal, de TSH en 3 individuos. Cinco pacientes presentaron valores supranormales de TSH asociados con niveles normales de T₄, pero solo 1 de ellos desarrolló recurrencia clínica del bocio. Estas observaciones sugieren que la mayoría de los pacientes permanecen clinica y bioquímicamente eutiroideos después de la hemitiroidectomía. Por consiguiente, la terapia rutinaria de reemplazo con tiroxina no es necesaria para la prevención del hipotiroidismo bioquímico, pero puede estar indicada en los pocos pacientes que desarrollen un nivel subnormal de T₄ sérico. La significación clínica de estos sutiles cambios que se presentan dentro de los niveles normales de T₄ y de TSH no es clara en lo que se refiere a la posibilidad de recurrencia del bocio.

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Résumé Au cours d'une étude prospective concernant 103 sujets, les concentrations dans le sérum de la T₄ et de la TSH ont été dosées en préopératoire et en postopératoire dans le but de savoir s'il était nécessaire de leur donner de la thyroxine pour maintenir une fonction thyroïdienne normale après qu'ils aient subi une hémithyroïdectomie pour traiter un noyau thyroïdien bénin. Les dosages étaient normaux avant l'intervention. Les tests après l'opération ont montré une réduction significative du T₄ sérique après 3 ans et une élévation également significative de TSH de 6 mois à 3 ans après l'exérèse mais ces variations restaient dans les limites de la normale. Treize opérés ont présenté des tests fonctionnels thyroïdiens anormaux. Huit d'entre eux présentaient un dosage au-dessous de la normale de T₄ qui s'accompagnait 3 fois d'une élévation de TSH au-dessus de la normale. Les 5 autres avaient des taux de TSH supérieurs à la normale avec des taux normaux de T₄ mais un seul présentait une récidive clinique de goitre. Ces observations suggèrent que la majorité des opérés qui ont subi une hémithyroïdectomie restent cliniquement et biologiquement euthyroïdiens. Par conséquent, l'emploi classique de la thyroxine en postopératoire n'est pas nécessaire pour prévenir un éventuel hypothyroïdisme mais il peut être indiqué chez quelques opérés chez qui apparait un dosage de T₄ dont le taux est inférieur à la normale. La signification clinique de ces modifications discrètes du taux sérique de T₄ et de TSH n'est pas évidente, en particulier en ce qui concerne la récidive du goitre.

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Presented at the International Association of Endocrine Surgeons in Paris, September 1985.

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Supported by grants from the University Research Grants Committee, the Medical Faculty Research Grant Fund, and the Pauline Chan Medical Research Fund of the University of Hong Kong.     

Thyroid nodules; evaluation of malignancy by ultrasonography

Preoperative ultrasonic examination was correlated to final pathological diagnosis in 102 cases which underwent thyroidectomy in our clinic from 1979 to May 1985. Preoperative ultrasonic diagnosis was as follows: Sensitivity was 78% (45/58 cases), and specificity was 86% (38/44 cases). Four factors in ultrasonic image were considered: Shape, boundary, internal echo and margin were featured, and correlated to malignancy in 75 cases with mainly solid nodules. Among 34 nodules with irregular shape, 33 (97%) were pathologically malignant and 40 of 42 (95%) with rugged boundary were also malignant. Whether internal echo was even or not could not be used as a diagnostic criteria. Similarly, whether a nodule had well defined margin or not was found not to be a significant criteria in order to differentiate malignant from benign lesions. In 15 of 34 cases with lymph node metastases, metastatic lymph nodes were detected by ultrasonography. Lymph node metastases must be also evaluated by ultrasonography preoperatively in thyroid diseases. Each of these factors must be considered individually in the diagnosis of thyroid nodules. By evaluation of the ultrasonography findings the pathological characteristics may be inferred, and consequently being possible to reach a correct diagnosis.     

Thyroid nodules: Evaluation with power Doppler and duplex Doppler ultrasound

This study purposes a new classification of thyroid nodules blood flow by power duplex Doppler ultrasound. A total of 177 nodules were studied with B-mode scanning, power Doppler, and spectral analysis. These data were compared with cytological results from ultrasound-guided fine-needle aspiration biopsy. Univariate and multivariate logistic regression analysis were performed. The power Doppler analysis of the nodules produced 5 vascular patterns: I, absence of signal blood flow; II, exclusively perinodular blood flow; III, perinodular >/= central blood flow; IV, central blood flow > perinodular blood flow; V, exclusively central blood flow. Statistical analysis revealed a significant relationship between these vascular patterns and cytological results. The spectral analysis demonstrated that the resistance index were higher in nodules with malignant versus other cytology ( P < 0.001). The results indicate that power duplex Doppler facilitates screening of thyroid nodules at high risk for malignancy with elevated sensitivity (92.3%) and specificity (88%).     

Thyroid carcinoma in an endemic area presenting as solitary thyroid nodules

A retrospective analysis of 66 cases of thyroid cancer presenting as a solitary thyroid nodule (STN) from an endemic area is presented herein. The workup included TSH estimation and radionuclide scanning and patients were divided into two groups. Group A included cases of STN carcinoma diagnosed histologically in patients clinically presenting as a benign STN. Of all the patients who presented with a benign STN, malignancy was found more frequently in 'cold' nodules (13.5 per cent), than in nodules with a different presentation on scintiscanning (0-9.5 per cent). Cancers occurred in 5 per cent of the females and in 19.5 per cent of the males. Group B included patients with overt signs of malignancy. In both groups, the clinical behaviour was determined by the stage at presentation according to TNM classification. TNM staging was found to be a good prognostic indicator, comparable to histopathology. Thus, locoregional recurrence and mortality were found to be higher in advanced T3 lesions and in Group B patients. On the basis of these findings it is suggested that STN cancers may either be an earlier stage of the disease or that the STN cancers in the two groups may be separate disease entities.     

Thyroid carcinoma in an endemic area rresenting as solitary thyroid nodules

A retrospective analysis of 66 cases of thyroid cancer presenting as a solitary thyroid nodule (STN) from an endemic area is presented herein. The workup included TSH estimation and radionuclide scanning and patients were divided into two groups. Group A included cases of STN carcinoma diagnosed histologically in patients clinically presenting as a benign STN. Of all the patients who presented with a benign STN, malignancy was found more frequently in ‘cold’ nodules (13.5 per cent), than in nodules with a different presentation on scintiscanning (0–9.5 per cent). Cancers occurred in 5 per cent of the females and in 19.5 per cent of the males. Group B included patients with overt signs of malignancy. In both groups, the clinical behaviour was determined by the stage at presentation according to TNM classification. TNM staging was found to be a good prognostic indicator, comparable to histopathology. Thus, locoregional recurrence and mortality were found to be higher in advanced T3 lesions and in Group B patients. On the basis of these findings it is suggested that STN cancers may either be an earlier stage of the disease or that the STN cancers in the two groups may be separate disease entities.     

多发性甲状腺结节伴甲状腺癌23例的临床分析

目的 探讨多发性甲状腺结节中甲状腺癌的诊断。方法 回顾分析1988年5月至2000年12月治疗的23例多发甲状腺结节伴甲状腺癌病例。结果 23例患者中术前确诊仅6例，第2次手术患者13例，良性疾病与甲状腺癌并存20例。结论 多发性甲状腺结节中的甲状腺癌多与良性疾病并存，临床诊断困难，病理诊断是减少误诊率与再手术率的有效方法。     

Thyroid nodules: comparison of preoperative and intraoperative needle aspirate and definite histological study

The need to discover malignancy is the most challenging dilemma in the management of thyroid nodules, the most common endocrine disorders, affecting 4-5% of the general population. Malignancies account for only 2-3% of cases. The aim of our study was to evaluate the predictive value of preoperative fine-needle aspiration cytology (FNAC) in surgical decision making by evaluating the final pathologic diagnosis and comparing it to the preoperative and intraoperative diagnoses. We conducted a prospective study of 30 thyroid resections. The mean age was 49 years (range: 27 to 68 years). Preoperative physical and laboratory examinations, presenting symptoms, imaging studies and predictive values of preoperative and intraoperative FNAC were analyzed. The consistency of the lesion was strongly predictive of malignancy, when "hard". Single lesions were also predictive of malignancy. The diagnostic accuracy of preoperative FNAC vs intraoperative FNAC vs frozen section histopathology was 90% vs 100% vs 96.7%; sensitivity: 91.6% vs 100% vs 100%; specificity: 90.5% vs 100% vs 94.7%, while the positive predictive value was 84.6% vs 100% vs 91.7%, and the negative predictive value 95% vs 100% vs 100%. Ultrasound-guided preoperative FNAC showed high specificity, sensitivity and accuracy in diagnosing malignancy in thyroid nodules. Intraoperative FNAC was more accurate than intraoperative frozen sections in diagnosing malignancy in thyroid nodules.