【作者】 王菁；

【导师】 蒋天安；

【作者基本信息】 浙江大学 ， 影像医学与核医学， 2014， 硕士

【摘要】 背景和目的：早在19世纪就已出现甲状腺结节细针穿刺技术,但一直到了20世纪80年代才应用于临床。甲状腺细针穿刺细胞学(Fine-needle aspiration cytology, FNAC)分为超声引导下甲状腺细针穿刺细胞学(Ultrasound fine-needle aspiration cytology, US-FNAC)和触诊下甲状腺细针穿刺细胞学(Freehand fine-needle aspiration cytology, Freehand-FNAC)。国内外文献均认为US-FNAC更能充分发挥精确定位的优势,提高甲状腺结节穿刺的准确性。目前US-FNAC被认为是鉴别甲状腺结节良恶性的最准确、最有效的诊断方法,同时减少了25%不必要的外科手术。根据2007年美国国家癌症研究所的甲状腺细针穿刺专题讨论,将FNAC诊断结果分为6类：无法诊断、良性病变、不能明确意义的滤泡性病变或不能明确意义的不典型滤泡性病变、滤泡性或嗜酸性细胞(Hurthle细胞)肿瘤、可疑为甲状腺癌、甲状腺癌。无法诊断的标本是指在细胞学上无法做出进一步的描述的标本。无法诊断标本被认为是细胞过少,即少于6组可诊断的甲状腺细胞,且每组少于10个细胞。近年来将血凝块遮盖无法显示细胞、抽吸到结节内胶冻样或液性成分造成滤泡上皮细胞过少者纳入无法诊断标本。不恰当的US-FNAC会使无法诊断标本所占的比率增高,浪费有限的医疗资源。本研究旨在探讨甲状腺结节中的钙化与因细胞过少而造成无法诊断标本的关系,从而希望为临床诊疗提供参考,减少不必要的USFNAC。方法：回顾性分析421例患者447个甲状腺结节。所有结节均获得细胞学诊断结果。根据结节内有无钙化及钙化形态分为微钙化、粗钙化、周边弧形钙化及无钙化结节组。根据各型钙化结节及无钙化结节大小(穿刺切面)各分3组：<5mm、5～10mm、≥10mm组。对粗钙化结节根据钙化单或多发(穿刺切面)、钙化表面光滑或粗糙(穿刺切面)进行比较。在穿刺切面上用3个比值来表示粗钙化分布范围及位置：A/B比值(穿刺切面钙化区范围左右径／结节左右径)表示钙化区的范围,C/D比值(穿刺切面上钙化区与结节前缘距离／结节前后径)、E/F比值(穿刺切面上钙化区与结节左(右)缘距离／结节左右径)表示钙化区在结节内位置,分别对无法诊断结节和可以诊断结节的A/B、C/D、E/F比值进行比较,并绘制ROC曲线得出无法诊断界点。结果：1.447个甲状腺结节中钙化结节208个,无法诊断率25.5%(53/208),无钙化结节239个,无法诊断率11.7%(28/239)。2.钙化结节中微钙化100个,无法诊断率16.0%(16/100),粗钙化结节91个,无法诊断率26.4%(24/91),周边弧形钙化17个,无法诊断率76.5%(13/17)。3.周边弧形钙化比微钙化、粗钙化、无钙化结节无法诊断率均高(p<0.01)。4.粗钙化结节比无钙化结节无法诊断率高(p<0.01),但与微钙化结节无法诊断率比较无统计学差异(p>0.05)。5.微钙化结节与无钙化结节无法诊断率比较无统计学差异(p>0.05)。6.不同大小(<5mm、5～10mm、≥10mm)(穿刺切面)各型钙化结节及无钙化结节在无法诊断率上比较无统计学差异(p>0.05)。7.粗钙化结节中钙化呈单发者59个,无法诊断率27.1%(16/59),多发者32个,无法诊断率25.0%(8/32),两者在无法诊断率上比较无统计学差异(p>0.05)。8.粗钙化结节中钙化表面光滑者39个,无法诊断率23.1%(9/39),钙化表面粗糙者52个,无诊断率28.8%(15/52),两者在无法诊断率上比较无统计学差异(p>0.05)。9.A/B比值在无法诊断结节中较大,与可以诊断结节比较有统计学差异(p<0.01),以A/B比值0.55为界点预测无法诊断标本,敏感度、特异度为64.1%、79.2%,AUC为0.73。10.C/D比值在无法诊断结节中较小,与可以诊断结节比较有统计学差异(p<0.01),以C/D比值0.25为界点预测无法诊断标本,敏感度、特异度为75.4%、60.0%,AUC为0.74。11.E/F比值在无法诊断结节中较小,与可以诊断结节比较有统计学差异(p<0.01),以E/F比值0.25为界点预测无法诊断标本,敏感度、特异度为81.3%、62.5%,AUC为0.76。结论：周边弧型钙化结节无法诊断率高,粗钙化结节中钙化区范围较大及钙化区距结节边缘较近者无法诊断率较高,需尽量避免此类钙化结节行US-FNAC。微钙化结节与无钙化结节无法诊断率较低,均可行US-FNAC。更多还原

【Abstract】 Objective:To evaluate the relevant research of thyroid calcified nodules and the inadequate diagnostic rate of ultrasound guided fine needle aspiration cytology (USFNAC).Methods:447thyroid nodules in421patients were retrospective analyzed, and all of the nodules were acquired cytological diagnosis. There were micro calcification, macro calcification, circumjacent arc calcification and negative according to shapes of the calcification. Each of these were divided into3groups (group of<5mm、5-10mm、>10mm)according to the nodules’size (ultrasonic section of FNA). The nodules with macro calcification were divided into group of single and multiple according to the macro calcification’s number (ultrasonic section of FNA), and they were also divided into group of smooth and coarse according to the surface of macro calcification (ultrasonic section of FNA). There were3ratios in the macro calcified nodules in the ultrasonic section of FNA:A/B ratio (size of the calcification/left-right diameter of the nodule) means the range dimension of the calcification, C/D ratio (distance of calcification and anteroventral nodule/antero-posterior diameter of the nodule) means the place of the nodules’ inner, E/F ratio(distance of calcification and the left or right side of the nodule/left-right diameter of the nodule) means the place of the nodules’ inner. The ROC were drew according to the ratios of A/B, C/D, E/F, from which acquired the best cut-off value of inadequate diagnosis.Results:1. There were208nodules with calcification and239nodules with negative, which had the inadequate diagnostic rate of25.5%and11.7%.2. There were100nodules with micro calcification,91nodules with macro calcification and17nodules with circumjacent arc calcification, which had the inadequate diagnostic rate of16.0%,26.4%, and76.5%.3. The inadequate diagnostic rate in circumjacent arc calcification was higher than those in micro calcification,macro calcification and negative(P<0.01).4. The inadequate diagnostic rate in macro calcification was higher than those in the negative(P<0.01). The inadequate diagnostic rate was no significance difference in micro calcification and macro calcification(p>0.05).5. The inadequate diagnostic rate was no significance difference in micro calcification and the negative(p>0.05).6. There was no statistical significance difference in different size (ultrasonic section of FNA)of thyroid nodules(p>0.05).7. There were59nodules with single calcification and32nodules with multiple calcification, which had the inadequate diagnostic rate of27.1%and25.0%.There was no statistical significance difference in different number (ultrasonic section of FNA)(p>0.05).8.There were39nodules with smooth and52nodules with coarse, which had the inadequate diagnostic rate of23.1%and28.8%. There was no statistical significance difference in different surface of macro calcification (ultrasonic section of FNA)(p>0.05).9. The ratio of A/B was significantly higher in the inadequate diagnostic nodules(P <0.01). The best cut-off value was0.55, with the sensitivity, specificity, AUC of64.1%,79.2%,0.73.10. The ratio of C/D was significantly lower in the inadequate diagnostic nodules(P<0.01). The best cut-off value was0.25, with the sensitivity, specificity, AUC of75.4%,60.0%,0.74.11. The ratio of E/F was significantly lower in the inadequate diagnostic nodules(P <0.01). The best cut-off value was0.25, with the sensitivity, specificity, AUC of81.3%,62.5%,0.76.Conclusions:The inadequate diagnostic rate was higher in nodules with circumjacent arc calcification and macro calcified nodules with higher A/B, lower C/D, lower E/F. All of these should be avoid US-FNAC. The inadequate diagnostic rate was lower in nodules with micro calcification and negative. These nodules were suitable for US-FNAC.更多还原