The effect of Hashimoto's thyroiditis on the diagnostic efficacy of ultrasound-guided fine needle aspiration cytology for thyroid nodules ≥ 1 cm
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摘要: 目的 探讨超声引导下细针穿刺细胞学检查(US-FNAC)对≥1 cm甲状腺结节的诊断效能，及合并桥本甲状腺炎(HT)对诊断效能的影响。方法 回顾性分析1027例≥1 cm行US-FNAC的甲状腺结节患者的临床资料，所有患者均行二维超声检查及BRAFV600E基因检测，并对其进行随访，手术者以术后病理结果为判定标准，未手术者结合二维超声检查、临床特征、随访结果及BRAFV600E判定，比较HT(+)组与HT(-)组US-FNAC诊断效能，分析影响诊断效能的因素。结果 1027例结节中，无法诊断或标本不满意73例(7.1%)，良性282例(27.5%)，意义不明确的细胞非典型病变或意义不明确的滤泡病变230例(22.4%)，滤泡肿瘤或可疑的滤泡肿瘤20例(1.9%)，可疑恶性肿瘤120例(11.7%)，恶性302例(29.4%)。515例行结节手术，其中恶性肿瘤495例，良性20例；512例未手术继续随访，均为BRAFV600E野生型，结合二维超声检查、临床特征、随访结果，判定其为良性。US-FNAC的准确度、灵敏度、特异度、阳性预测值、阴性预测值、假阳性率和假阴性率分别为98.7%、98.4%、99.3%、99.5%、97.5%、0.7%和1.6%。HT(+)组的准确度、灵敏度、阴性预测值分别为95.5%、95.4%、82.8%，低于HT(-)组的99.5%、99.4%、99.2%(P=0.001、0.018及P < 0.001)，HT(+)组的假阴性率(4.6%)高于HT(-)组(0.6%)(P=0.018)，且HT为假阴性率升高的危险因素(OR=7.596，95%CI：1.452~39.740)。结论 US-FNAC是甲状腺结节诊断的有效手段，在≥1 cm结节中，灵敏度和特异度高，但合并HT降低了诊断准确度，且HT为假阴性率升高的危险因素。Abstract: Objective To explore the diagnostic efficacy of ultrasound-guided fine needle aspiration cytology(US-FNAC) for thyroid nodules ≥1 cm, and the effect of Hashimoto's thyroiditis(HT) on it.Methods The clinical data of 1027 cases of thyroid nodules ≥ 1 cm were retrospectively analyzed. Two-dimensional ultrasound, US-FNAC and BRAFV600E gene testing were performed. The postoperative pathological results were used as the criterion. The two dimensional ultrasound examination, clinical characteristics, follow-up results, and BRAFV600E were used to diagnosis for unoperated patients. The diagnostic efficiency of US-FNAC in HT(+) group and HT(-) group was compared, and the factors affecting the diagnostic efficiency were analyzed.Results Of the 1027 nodules, the cytological results were nondiagnostic/unsatisfactory in 73 nodules(7.1%), benign in 282(27.5%), atypia of undetermined significance/follicular lesion of undetermined significance in 230(22.4%), follicular neoplasm/suspicious for a follicular neoplasm in 20(1.9%), suspicious for malignancy in 120(11.7%), and malignant in 302(29.4%). 515 cases underwent surgery. Among them, 495 were malignant and 20 were benign. 512 cases continued to be followed up without surgery, and the BRAFV600E of them were wild type. Combined with the two dimensional ultrasound examination, clinical features, and follow-up results, they were judged to be benign. The accuracy, sensitivity, specificity, positive predictive value, negative predictive value, false positive rate and the false negative rate the of US-FNAC were 98.7%, 98.4%, 99.3%, 99.5%, 97.5%, 0.7% and 1.6%, respectively. The accuracy, sensitivity and negative predictive value of the HT(+) group were 95.5%, 95.4% and 82.8%, respectively, which were lower than that of HT(-) group (99.5%, 99.4%, 99.2%)(P=0.001, 0.018, P < 0.001). The false negative rate of the HT(+) group was 4.6%, higher than 0.6% of the HT(-) group(P=0.018), and HT was an risk factor for increased FNR(OR=7.596, 95%CI: 1.452-39.740).Conclusion US-FNAC is an effective method for the diagnosis of thyroid nodules and it has high sensitivity and specificity in ≥ 1 cm nodules. However, the combination of HT reduces the diagnostic accuracy and HT is a risk factor for increased false negative rate.
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Key words:
- thyroid nodule /
- fine needle puncture cytology /
- thyroiditis /
- BRAFV600E
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表 1 1027例结节的细胞学、超声特征、手术与否及BRAFV600E结果
例(%) 例数 ND/UNS 良性 AUS/FLUS FN/SFN SUS 恶性 大小 ≥3 cm 54 5(9.3) 22(40.7) 13(24.1) 3(5.6) 0(0.0) 11(20.4) < 3 cm 973 68(7.0) 260(26.7) 217(22.3) 17(1.7) 120(12.3) 291(29.9) 回声 等/高 283 16(5.7) 132(46.6) 68(24.0) 7(2.5) 18(6.4) 42(14.8) 低 744 57(7.7) 150(20.2) 162(21.8) 13(1.7) 102(13.7) 260(34.9) 纵横比 > 1 428 26(6.1) 90(21.0) 88(20.6) 4(0.9) 70(16.4) 150(35.0) ≤1 599 47(7.8) 192(32.1) 142(23.7) 16(2.7) 50(8.3) 152(25.4) 钙化 无钙化 253 10(4.0) 105(41.5) 56(22.1) 10(4.0) 20(7.9) 52(20.6) 微钙化 629 44(7.0) 123(19.6) 135(21.5) 9(1.4) 89(14.1) 229(36.4) 大钙化 145 19(13.1) 54(37.2) 39(26.9) 1(0.7) 11(7.6) 21(14.5) 血流 丰富 431 21(4.9) 136(31.6) 89(20.6) 16(3.7) 43(10.0) 126(29.2) 不丰富 596 52(8.7) 146(24.5) 141(23.7) 4(0.7) 77(12.9) 176(29.5) HT 是 181 8(4.4) 29(16.0) 37(20.4) 2(1.1) 33(18.2) 72(39.8) 否 846 65(7.7) 253(29.9) 193(22.8) 18(2.1) 87(10.3) 230(27.2) 手术 是 515 3(0.6) 15(2.9) 71(13.8) 4(0.8) 120(23.3) 302(58.6) 否 512 70(13.7) 267(52.1) 159(31.1) 16(3.1) 0(0.0) 0(0.0) BRAFV600E(未手术) 突变型 0 0(0.0) 0(0.0) 0(0.0) 0(0.0) 0(0.0) 0(0.0) 野生型 512 70(13.7) 267(52.1) 159(31.1) 16(3.1) 0(0.0) 0(0.0) 良恶性 恶性 495 1(0.2) 7(1.4) 66(13.3) 1(0.2) 118(23.8) 302(61.0) 良性 532 72(13.5) 275(51.7) 164(30.8) 19(3.6) 2(0.4) 0(0.0) 
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表 2 六类细胞学HT(+)组和HT(-)组良恶性情况
例(%) 诊断 ND/UNS 良性 AUS/FLUS FN/SFN SUS 恶性 合计 HT(+) 良性 8(11.0) 24(8.5) 20(8.7) 2(10.0) 1(0.8) 0(0.0) 55 恶性 0(0.0) 5(1.8) 17(7.4) 0(0.0) 32(26.7) 72(23.8) 126 HT(-) 良性 64(87.7) 251(89.0) 144(62.6) 17(85.0) 1(0.8) 0(0.0) 477 恶性 1(1.4) 2(0.7) 49(21.3) 1(5.0) 86(71.7) 230(76.2) 369 合计 73 282 230 20 120 302 1027
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表 3 HT(+)组和HT(-)组US-FNAC诊断效能比较
% 组别 例数 准确度 灵敏度 特异度 PPV NPV FPR FNR HT(+)组 134 95.52) 95.41) 96.0 99.0 82.82) 4.0 4.61) HT(-)组 570 99.5 99.4 99.6 99.7 99.2 0.4 0.6 总计 704 98.7 98.4 99.3 99.5 97.5 0.7 1.6 与HT(-)组比较，1) P < 0.05；2) P < 0.01。
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表 4 影响≥1 cm甲状腺结节US-FNAC假阴性率的危险因素单因素分析
因素 P OR 95% CI 血流丰富 0.544 0.600 0.115~3.129 ≥3 cm 0.182 6.197 0.687~55.932 等/高回声 0.291 2.447 0.464~2.908 大钙化 0.413 2.000 0.380~10.516 HT(+) 0.016 7.596 1.452~39.740
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