Corrias Andrea, Mussa Alessandro
Department of Pediatric Endocrinology and Diabetology, University of Torino, Regina Margherita Children's Hospital, Torino, Italy.
J Clin Res Pediatr Endocrinol. 2013;5 Suppl 1(Suppl 1):57-69. doi: 10.4274/jcrpe.853.
Thyroid nodules are less frequent in childhood than in adulthood, but are more often malignant. Recent estimates suggest that up to 25% of thyroid nodules in children are malignant, therefore, a more aggressive approach is recommended. In this review, we suggest an approach based on a first-step clinical, laboratory, and sonographic evaluation. A history of irradiation of the neck, cranium or upper thorax, previous thyroid diseases or thyroid neoplasms in the family should alert clinicians as being associated with a greater likelihood of malignant nodules. Signs or symptoms of hyperthyroidism and dysmorphic features should be carefully considered during the physical examination. Palpable firm lymph nodes, found in some 70% of cases, are the most significant clinical finding in children with malignant nodules. Although the routine determination of calcitonin levels is not uniformly practiced, it can help recognize sporadic or familial medullary thyroid neoplasms. Blood thyroid stimulating hormone, free thyroxine, and free triiodothyronine determinations (the latter in case of symptoms of hyperthyroidism) are aimed at identifying the few hyperthyroid patients, for whom the next step should be scintiscan. Hyperthyroid patients usually disclose an increased uptake, and a diagnosis of toxic adenoma is commonly made. Cases with normal thyroid function or hypothyroidism (which is usually subclinical) should be evaluated by fine-needle aspiration biopsy (FNAB). In eu/hypo-thyroid patients, scintiscan provides poor diagnostic information and should not be routinely employed. Thyroid ultrasonography is used to select cases for FNAB. Although ultrasound cannot reliably discriminate between benign and malignant lesions, it does provide an index of suspicion. Sonographic features that increase the likelihood of malignancy are microcalcifications, lymph node alterations, nodule growth under levothyroxine treatment, and increased intranodular vascularization demonstrated by color Doppler. There is growing evidence that elastography may provide further information on nodule characteristics. FNAB is indicated in all cases with a likelihood of malignancy. FNAB has a diagnostic accuracy of approximately 90% and is used in selection of patients which require surgery. Recently, histological markers and elastography have been introduced to increase the specificity of FNAB and ultrasound, respectively. The pitfall in FNAB cytology is the follicular cytology, in which it is not possible to distinguish between adenoma and carcinoma and therefore thyroidectomy is advised.
甲状腺结节在儿童期比成人期少见，但恶变的可能性更大。最近的估计表明，儿童甲状腺结节中高达25%是恶性的，因此，建议采取更积极的治疗方法。在本综述中，我们建议采用基于第一步临床、实验室和超声评估的方法。颈部、颅骨或上胸部的放射史、既往甲状腺疾病或家族性甲状腺肿瘤病史应提醒临床医生，这些情况与恶性结节的可能性增加有关。体格检查时应仔细考虑甲亢的体征或症状以及畸形特征。在约70%的病例中可触及的硬实淋巴结是恶性结节患儿最重要的临床发现。虽然降钙素水平的常规测定并非普遍应用，但它有助于识别散发性或家族性甲状腺髓样肿瘤。测定血甲状腺刺激激素、游离甲状腺素和游离三碘甲状腺原氨酸（后者用于有甲亢症状的情况）旨在识别少数甲亢患者，对这些患者下一步应进行闪烁扫描。甲亢患者通常显示摄取增加，通常可诊断为毒性腺瘤。甲状腺功能正常或减退（通常为亚临床状态）的病例应通过细针穿刺活检（FNAB）进行评估。在甲状腺功能正常/减退的患者中，闪烁扫描提供的诊断信息较差，不应常规使用。甲状腺超声用于选择进行FNAB的病例。虽然超声不能可靠地区分良性和恶性病变，但它确实提供了一个可疑指标。增加恶性可能性的超声特征包括微钙化、淋巴结改变、左甲状腺素治疗下结节生长以及彩色多普勒显示的结节内血管增多。越来越多的证据表明，弹性成像可能提供有关结节特征的更多信息。所有有可能为恶性的病例均应进行FNAB。FNAB的诊断准确率约为90%，用于选择需要手术的患者。最近，分别引入了组织学标志物和弹性成像以提高FNAB和超声的特异性。FNAB细胞学的陷阱是滤泡细胞学，在这种情况下无法区分腺瘤和癌，因此建议进行甲状腺切除术。
