Endocr Pract. 2017 Apr 2;23(4):442-450. doi: 10.4158/EP161540.OR. Epub 2017 Jan 17.
Increasing emphasis is being placed on appropriateness of care and avoidance of over- and under-treatment. Indeterminate thyroid nodules (ITNs) present a particular risk for this problem because cancer found via diagnostic lobectomy (DL) often requires a completion thyroidectomy (CT). However, initial total thyroidectomy (TT) for benign ITN results in lifelong thyroid hormone replacement. We sought to measure the accuracy and factors associated with the extent of initial thyroidectomy for ITN.
We queried a single institution thyroid surgery database for all adult patients undergoing an initial operation for ITN. Multivariate logistic regression identified factors associated with either oncologic under- or overtreatment at initial operation.
There were 639 patients with ITN. The median age was 52 (range, 18 to 93) years, 78.4% were female, and final pathology revealed a cancer >1 cm in 24.7%. The most common cytology was follicular neoplasm (45.1%) followed by Hürthle cell neoplasm (20.2%). CT or initial oncologic undertreatment was required in 58 patients (9.3%). Excluding those with goiters, 19.0% were treated with TT for benign final pathology. Multivariate analysis failed to identify any factor that independently predicted the need for CT. Female gender was associated with TT in benign disease (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.0 to 4.5; P = .05). Age >45 years predicted correct initial use of DL (OR, 2.6; 95% CI, 1.2 to 5.7; P = .02). Suspicious for papillary thyroid carcinoma (OR, 5.7; 95% CI, 2.1 to 15.3; P<.01) and frozen section (OR, 9.7; 95% CI, 2.5 to 38.6; P<.01) were associated with oncologically appropriate initial TT. The highest frequency of CT occurred in patients with follicular lesion of undetermined significance (11.6%). TT for benign final pathology occurred most frequently in patients with a Hürthle cell neoplasm (24.8%).
In patients with ITN, nearly 30% received an inappropriate extent of initial thyroidectomy from an oncologic standpoint. Tools to pre-operatively identify both benign and malignant disease can assist in the complex decision making to gauge the proper extent of initial surgery for ITN.
ATA = American Thyroid Association AUS = atypia of undetermined significance CI = confidence interval CT = completion thyroidectomy FLUS = follicular lesion of undetermined significance ITN = indeterminate thyroid nodule OR = odds ratio PTC = papillary thyroid carcinoma TT = total thyroidectomy.
人们越来越重视医疗的适宜性，避免过度治疗和治疗不足。不确定的甲状腺结节（ITN）特别存在这个问题的风险，因为通过诊断性甲状腺叶切除术（DL）发现的癌症通常需要完成甲状腺切除术（CT）。然而，对良性 ITN 进行初始全甲状腺切除术（TT）会导致终身甲状腺激素替代治疗。我们旨在衡量初始甲状腺切除术治疗 ITN 的准确性和相关因素。
我们对一家机构的甲状腺手术数据库进行了查询，以确定所有接受初始 ITN 手术的成年患者。多变量逻辑回归确定了初始手术中与肿瘤治疗不足或过度治疗相关的因素。
共有 639 例 ITN 患者。中位年龄为 52 岁（范围为 18 至 93 岁），78.4%为女性，最终病理显示癌症>1cm 占 24.7%。最常见的细胞学类型是滤泡性肿瘤（45.1%），其次是 Hurthle 细胞肿瘤（20.2%）。58 例（9.3%）需要 CT 或初始肿瘤治疗不足。不包括甲状腺肿患者，19.0%的良性最终病理采用 TT 治疗。多变量分析未能确定任何可独立预测 CT 需求的因素。女性是良性疾病中 TT 的相关因素（比值比[OR]，2.1；95%置信区间[CI]，1.0 至 4.5；P=0.05）。年龄>45 岁预测 DL 的初始使用正确（OR，2.6；95%CI，1.2 至 5.7；P=0.02）。可疑甲状腺乳头状癌（OR，5.7；95%CI，2.1 至 15.3；P<0.01）和冷冻切片（OR，9.7；95%CI，2.5 至 38.6；P<0.01）与肿瘤学上适当的初始 TT 相关。滤泡性意义未确定病变（11.6%）患者的 CT 发生率最高。良性最终病理的 TT 最常发生在 Hurthle 细胞肿瘤患者（24.8%）。
在 ITN 患者中，近 30%的患者从肿瘤学角度来看，初始甲状腺切除术的范围不合适。术前识别良性和恶性疾病的工具可以帮助我们在复杂的决策中评估 ITN 的初始手术的适当范围。
