甲状腺影像报告和数据系统联合甲状腺细胞病理学Bethesda报告系统对甲状腺结节的应用价值

•浅表器官超声影像学•甲状腺影像报告和数据系统联合甲状腺细胞病理学Bethesda报告系统对甲状腺结节的应用价值宋琳琳1　周贵明1　朱莉1　孟召伟2　仇晓菲3　陈冬玥1【摘要】　目的　探讨甲状腺影像报告和数据系统（TI-RADS）与甲状腺细胞病理学Bethesda报告系统（TBSRTC）对甲状腺结节的应用价值。

方法　收集2013年11月至2015年4月于天津医科大学总医院行超声引导下细针穿刺活检（US-FNAB）的207例甲状腺结节患者，共216个甲状腺结节。

其中170个结节经天津医科大学总医院及天津医科大学肿瘤医院手术病理证实，46个结节超声随访6个月以上。

对所有甲状腺结节进行TI-RADS及TBSRTC分类。

以手术病理结果及超声随访结果作为“金”标准，计算超声TI-RADS与细胞学TBSRTC鉴别诊断甲状腺结节良恶性的敏感度、特异度、准确性、阳性预测值及阴性预测值。

结果　170个甲状腺结节经手术病理证实，其中恶性146个，均为甲状腺乳头状癌；良性24个，其中结节性甲状腺肿16个，桥本甲状腺炎6个，滤泡性腺瘤2个。

46个甲状腺结节细胞学评估为TBSRTC II类，超声评估为TI-RADS 3类，且超声随访6~15个月结节大小、形态无明显变化视为良性。

216个甲状腺结节中TI-RADS 3类8个，4a类19个，4b类55个，4c类130个，5类4个；其中甲状腺恶性结节分别为0个、5个、23个、114个、4个。

TI-RADS鉴别诊断甲状腺结节良恶性的敏感度、特异度、准确性、阳性预测值及阴性预测值分别为100%、11.4%、71.3%、70.2%、100%。

216个甲状腺结节中TBSRTC Ⅱ类57个，Ⅲ类24个，Ⅳ类3个，Ⅴ类83个，Ⅵ类49个；其中甲状腺恶性结节分别为2个、16个、2个、77个、49个。

TBSRTC鉴别诊断甲状腺结节良恶性的敏感度、特异度、准确性、阳性预测值及阴性预测值分别为98.4%、90.2%、95.8%、95.5%、96.5%。

本组细胞学TBSRTC为恶性的甲状腺结节，超声TI-RADS分类均为4a-5类。

结论　TI-RADS的建立有助于穿刺目标结节的选择，TBSRTC具有很高的诊断能力，为甲状腺结节临床处理提供了重要依据，二者联合应用能进一步提高对甲状腺恶性结节的诊断能力。

【关键词】　超声检查；　细针穿刺活检；　细胞病理学；　甲状腺结节Application value of The Thyroid Imaging Reporting and Data System and The Bethesda System forReporting Thyroid Cytopathology in thyroid nodules　Song Linlin1, Zhou Guiming1, Zhu Li1, MengZhaowei, Qiu Xiaofei, Chen Dongyue1. 1Department of Ultrasonography, 2Department of Nuclear Medicine,Tianjing Medical University General Hospital, Tianjing 300052, China; 3Pathological Teaching and ResearchOffice, Tianjin Medical University, Tianjing 300070, ChinaCorresponding author: Zhou Guiming, Email: zhouguiming_ucgok@【Abstract】　Objective　To investigate the value of Thyroid Imaging Reporting and Data System(TI-RADS) and The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) for thyroid nodules.Methods　A total of 216 thyroid nodules were obtained from 207 patients with thyroid nodules underultrasound-guided fine needle aspiration biopsy (US-FNAB) from November 2013 to April 2015 at theGeneral Hospital of Tianjin Medical University. 170 nodules were confirmed by surgical pathology of TianjinMedical University General Hospital and Tianjin Medical University Cancer Hospital, and 46 nodules wereDOI：10.3877/cma.j.issn.1672-6448.2018. 09.013基金项目：国家自然科学基金（81571709）作者单位：300052　天津医科大学总医院超声科1、核医学科2；300070　天津医科大学病理教研室3通信作者：周贵明，Email：zhouguiming_ucgok@细针穿刺活检是目前术前评估甲状腺结节最好的方法，而超声检查是甲状腺结节检查的重要手段。

美国国家癌症研究所（National Cancer Institute，NCI）于2007年提出了甲状腺细胞病理学Bethesda报告系统（The Bethesda System for Reporting Thyroid Cytopathology，TBSRTC），为甲状腺结节相关专业医师的诊断及临床处理提供了指南，目前国内外学者对此有一些研究［1-3］。

此外，目前国内外多位学者对甲状腺影像报告和数据系统（the Thyroid Imaging Reporting and Data System，TI-RADS）进行了研究［4-5］，以建立甲状腺结节的超声诊断标准，而该系统的诊断价值仍需进一步探讨。

本研究采用TI-RADS与TBSRTC分别对甲状腺结节进行评估，旨在探讨二者对甲状腺结节的应用价值。

资料与方法一、对象收集2013年11月至2015年4月于天津医科大学总医院行超声引导下细针穿刺活检（ultrasound guided fine needle aspiration biopsy，US-FNAB）的207例甲状腺结节患者，共216个甲状腺结节。

其中男性50例，女性157例，年龄20~79岁，平均年龄（46.8±12.5）岁。

其中170个结节经天津医科大学总医院及天津医科大学附属肿瘤医院手术病理证实，46个结节超声随访6个月。

二、仪器与方法1. 超声检查及TI-RADS分类：采用荷兰Philips HD11型彩色多普勒超声诊断仪，线阵探头，探头频率为3~12 M Hz。

患者平卧，充分暴露颈前区，于肩和颈下垫枕，颈部保持后仰。

对目标结节进行常规超声扫查并存储图像，根据Kwak等［4］建立的超声TI-RADS系统对目标结节进行评估。

5项可疑恶性超声指标分别为：实性、低回声或极低回声、微小分叶或边缘不规则、微钙化以及纵横比＞1。

由2名超声医师采用盲法对图像进行回顾性分析，若评估不一致，经协商达成一致后记录数据资料。

确立TI-RADS 3类（无可疑超声表现）、4a类（1个可疑超声表现）、4b类（2个可疑超声表现）、4c类（3个或4个可疑超声表现）和5类（5个可疑超声表现）。

将4a-5类归为阳性，3类归为阴性。

2. 超声引导下FNAB及TBSRTC分类：常规followed up for more than 6 months. The classifications of TI-RADS and TBSRTC were performed for all thyroid nodules. The sensitivity, specificity, accuracy, positive predictive value and negative predictive value of ultrasound TI-RADS and cytology TBSRTC in differential diagnosis of benign and malignant thyroid nodules were calculated using surgical pathological results and ultrasound follow-up results as the ″gold″ standard. Results　170 thyroid nodules were confirmed by operational pathology, including 146 malignant nodules, all of which were papillary thyroid carcinoma; and 24 benign nodules, which were 16 nodular goiters, 6 Hashimoto′s thyroiditis, and 2 follicular adenomas. The thyroid nodules were cytologically evaluated as TBSRTC class Ⅱ, and ultrasonically evaluated as TI-RADS class 3, and no significant changes in the size and morphology of the nodules at 6 to 15 months , which were considered benign. Among the 216 thyroid nodules, 8 were TI-RADS class 3, 19 were TI-RADS class 4a, 55 were TI-RADS class 4b, 130 were TI-RADS class 4c, 4 were TI-RADS class 5. Among them, there were 0, 5, 23, 114, and 4 malignant thyroid nodules, respectively. The sensitivity, specificity, accuracy, positive predictive value and negative predictive value of TI-RADS for differential diagnosis of benign and malignant thyroid nodules were 100%, 11.4%, 71.3%, 70.2%, and 100%, respectively. Of the 216 thyroid nodules, 57 were TBSRTC classⅡ, 24 were TBSRTC class Ⅲ, 3 were TBSRTC class Ⅳ, 83 were TBSRTC class Ⅴ, and 49 were TBSRTC class Ⅵ. Among them, there were 2, 16, 2, 77, 49 thyroid malignant nodules, respectively. The sensitivity, specificity, accuracy, positive predictive value and negative predictive value of TBSRTC for differential diagnosis of benign and malignant thyroid nodules were 98.4%, 90.2%, 95.8%, 95.5%, and 96.5%, respectively. In the subgroup of nodules with malignant classification on cytology TBSRTC, their ultrasound classifications were all TI-RADS 4a-5. Conclusions　TI-RADS contribute to select the target nodule to puncture. TBSRTC has a high diagnostic capability, and provides an important basis for clinical treatment of nodules. The combination of the two methods will further improve the diagnosis of malignant nodules.【Key words】　Ultrasonography;　Fine needle aspiration biopsy;　Cytopathology;　Thyroid nodules消毒颈前区皮肤，使用5 ml注射器与23G针头。