B超、双能CT、细针穿刺在甲状腺乳头状癌术前评估淋巴结转移中的优化选择

The optimal selection of B-ultrasound,dual-energy computed tomography,and fine-needle aspiration for preoperative prediction of lymph node metastases in papillary thyroid carcinoma

目的探寻高分辨率超声检查(B超)、双能计算机断层扫描(DECT)以及细针穿刺抽吸活检(FNAB)在甲状腺癌患者术前淋巴结转移(LNM)诊断时的最佳选择。方法回顾性分析了1174例在南京医科大学第一附属医院行手术治疗的甲状腺乳头状癌患者的资料,术前所有患者均行B超和DECT检查,其中167例患者加做侧区淋巴结FNAB和细针穿刺抽吸物洗脱液甲状腺球蛋白测定(FNA-TG)以评估LNM情况,手术后的常规病理结果作为诊断“金标准”,分析不同情况下甲状腺乳头状癌(PTC)LNM评估方法的最优选择。结果DECT对于中央区淋巴结转移(CLNM)和侧区PTC淋巴结转移(LLNM)预测的灵敏度较B超有显著提高(55.4%vs.44.8%,P<0.001)(90.9%vs.71.6%,P<0.001),B超在LLNM预测的特异性较DECT有优势(72.7%vs.42.7%,P<0.001);B超、DECT联合诊断对CLNM和LLNM的阳性预测准确率较高(91.6%,94.8%),当联合诊断结果不一致时其阳性预测值明显下降(74.3%,63.1%)。此时,增加可疑淋巴结FNAB及FNA-TG检测后其准确率增加至87.9%。结论B超、DECT联合评估是必要的;联合诊断均有转移时,不需要进行额外检查,联合诊断结果不一致时,需要进一步进行淋巴结的FNAB和FNA-TG检测以避免不必要的侧区清扫。

Objective To determine the best preoperative diagnostic method for lymph node metastasis(LNM)in thyroid cancer by comparing high-resolution ultrasonography(US),dual-energy computed tomography(DECT),and fine-needle aspiration biopsy(FNAB).Methods The data of 1,174 papillary thyroid carcinoma(PTC)patients treated surgically at the First Affiliated Hospital of Nanjing Medical University was retrospectively analyzed.All patients were assessed preoperatively using US and DECT;One hundred and sixty-seven patients also underwent FNAB with thyroglobulin(TG)testing in washout fluid for LNM evaluation.Postoperative pathology was the diagnostic“gold standard”for assessing the best method to evaluate PTC LNM.Results DECT had a higher sensitivity for predicting LNM than US(55.4%vs 44.8%,P<0.001),albeit with lower specificity(42.7%vs 72.7%,P<0.001).When combined together,US and DECT’s diagnostic accuracy for CLNM and LLNM varied:higher when findings are consistent but substantially lower when results are inconsistent(75.5%vs.63.4%,P<0.001).At this time,the accuracy of FNAB and FNA-TG testing in suspicious lymph nodes increased to 87.9%.Conclusions Combining US and DECT is necessary for LNM evaluation;When the combined diagnosis has metastasis,no additional examination is required.When the combined diagnosis results are inconsistent,further FNAB and FNA-TG detection of lymph nodes are required to avoid unnecessary lateral dissection.