Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.
Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania.
Ann Surg. 2020 Oct;272(4):621-627. doi: 10.1097/SLA.0000000000004130.
FN present a management quandary as they are often benign but may also be aggressive TC. Consensus recommendations have historically advised thyroidectomy for definitive diagnosis. Although MT have robust benefit in hypothetical cost analyses, under current management guidelines a real-time study of their clinical utility in FN is awaited. We investigate if MT use for FN directs appropriate thyroidectomy for TC while triaging to surveillance nodules that are likely benign.
Data were analyzed for 389 consecutive patients managed from 11/14 to 9/19 for 405 FN, excluding oncocytic neoplasms. TC was defined as same-nodule histologic malignancy. When obtained, MT was performed using ThyroSeq (TS) v2 or 3.
With a mean nodule size of 2.7 ± 1.3 cm, MT was used in 89% and was positive in 39%. When MT was positive, thyroidectomy was more often utilized (91% v. MT- 27%; P < 0.001) and more likely for histologic TC (70% vs 16%, P < 0.001). With preoperative MT, all American Thyroid Association intermediate, high-risk, and medullary TC were positive whereas all MT- malignancies were low-risk. With TSv3, ultrasound surveillance was more likely for MT- FN (90% vs TSv2 65%, P < 0.001), and occurred for a total of 174 MT- FN. With mean follow-up of 24.6 months, 82% remained stable in size.
MT use for FN increased the surgical yield of cancer by 4-fold, identified all potentially aggressive malignancies, and allowed apparently safe nonoperative surveillance for >80% of MT-negative patients. Thyroid nodule MT optimizes patient outcomes sufficiently to justify its incorporation into routine practice.
滤泡性腺瘤（FN）的处理存在困境，因为它们通常为良性，但也可能是侵袭性的甲状腺滤泡细胞癌（TC）。既往的共识建议对其进行甲状腺切除术以明确诊断。尽管多基因检测（MT）在假设性成本分析中具有显著优势，但在当前的管理指南下，仍需对其在 FN 中的临床应用进行实时研究。我们研究了 MT 在 FN 中的应用是否能在为 TC 患者进行适当甲状腺切除术的同时，对可能为良性的监测性结节进行分类。
分析了 2014 年 11 月至 2019 年 9 月期间收治的 389 例连续患者的资料，这些患者共 405 个 FN，不包括嗜酸细胞肿瘤。TC 定义为同结节组织学恶性肿瘤。当获得样本时，采用 ThyroSeq（TS）v2 或 v3 进行 MT。
平均结节大小为 2.7±1.3cm，89%的患者进行了 MT，其中 39%的患者 MT 阳性。MT 阳性时，甲状腺切除术的应用更为常见（91%比 MT-组 27%；P<0.001），且更可能为组织学 TC（70%比 MT-组 16%；P<0.001）。在术前 MT 中，所有美国甲状腺协会（ATA）的中危、高危和髓样 TC 均为阳性，而所有 MT-恶性肿瘤均为低危。采用 TSv3 时，MT- FN 更倾向于进行超声监测（90%比 TSv2 组 65%；P<0.001），共对 174 例 MT- FN 进行了监测。平均随访 24.6 个月后，82%的 MT- FN 大小保持稳定。
MT 在 FN 中的应用使癌症的手术检出率提高了 4 倍，识别出所有潜在侵袭性恶性肿瘤，并使>80%的 MT-阴性患者能够进行安全的非手术监测。甲状腺结节 MT 优化了患者的预后，足以证明其纳入常规实践的合理性。
