儿童甲状腺结节的管理

2011年7月8日

Sancak Yuksel, MD
Associate Professor

In contrast to adults, the diagnosis of a thyroid nodule in children is rare. In these cases, the workup and treatment generally follows the guidelines set forth by the美国甲状腺协会（ATA）和甲状腺结节成人的国家综合癌症网络（NCCN）。没有针对儿童甲状腺结节管理的具体准则。但是，文献中有良好支持的报告突出了儿童和成人中甲状腺结节之间的差异。

Children with thyroid nodules are more likely to present with a palpable neck mass.1这与成年人相矛盾，在成年人中，在颈部或胸部X光片上偶然发现了无症状甲状腺结节的比例上升，这些结节是为了进行无关的工作。除少数例外外，由于甲状腺向胸部的发展下降，并且由于随着年龄的增长，甲状腺的发育下降，甲状腺大小的甲状腺结节比成人更容易触及。

与成年人一样，儿童中甲状腺结节的检查包含四个部分：

  • 历史和体格检查
  • Thyroid laboratory studies
  • 超声（美国）
  • 细针吸入（FNA）活检

儿童中的甲状腺结节的恶性风险比成年人高得多（25％对5％）。2鉴于这一发现，必须将儿童中的所有甲状腺结节视为令人担忧，直到使用超声（US）和细针吸入活检（FNAB）证明否则。带有低风险细胞学发现的结节需要与我们间隔密切监测，以确认大小没有变化。

A thorough history will focus on symptoms of hypothyroidism or hyperthyroidism, voice or swallow disturbance, history of malignancy, family history, and exposures to radiation. The physical examination will assess the thyroid bed, the lateral neck, and if indicated, a laryngeal examination. Laboratory studies include a thyroid panel. In nodules concerning for medullary thyroid carcinoma, a calcitonin level is indicated.

US and FNAB remain the most important studies to stratify the risk of malignancy in a thyroid nodule. The US should be performed by a radiologist, endocrinologist , or surgeon with experience in neck ultrasonography. The US evaluation includes an assessment of the thyroid gland size and echotexture as well as the sonographic characteristics of the nodule. In children, as in adults, microcalcifications are noted as a more worrisome finding, but the presence of microcalcifications is not pathognomonic for malignancy.3

超声检查的一个经常被忽略的组成部分包括表征颈部中央和外侧隔室中的任何腺病。应当警告一下，在许多中心，在订购“甲状腺超声波”时，超声技术人员通常不常规地进行美国对横向和中央隔间的调查。人们普遍注意到，甲状腺恶性肿瘤的儿童比成年人具有更高的淋巴结转移风险（40-80％对20-50％）。4For this reason, the ultrasonographer should routinely perform a survey of the lateral and central neck as part of the workup of all pediatric thyroid nodules.

Stevens et al. reported on the favorable specificity and sensitivity of FNAB in pediatric thyroid nodules. A meta-analysis of twelve studies suggests a sensitivity and specificity of 94% and 81%, respectively.5在儿童中，可能需要镇静作用才能进行足够的FNA。所有异常的侧颈节点也应在同一坐姿上进行FNA。最好在FNAB时确定细胞学标本的病理充足性，以消除第二次镇静的需要重复FNA。

In pediatric thyroid nodules that are found to have malignant cytologic features, total thyroidectomy is recommended. A central compartment nodal dissection, while potentially increasing the risk of surgical hypoparathyroidism and recurrent laryngeal nerve injury, is indicated in cases with suspicious adenopathy in the central neck. Lateral neck dissection should only be performed in cases where there is US and/or FNAB evidence of metastases. In patients with lateral neck metastases, a formal neck dissection is preferred over “berry picking” and may decrease the risk of recurrent or residual disease in the neck. Pediatric thyroid surgery is ideally performed by a high-volume thyroid surgeon.

术后放射性碘适用于具有高风险特征的小儿甲状腺结节，包括远处转移，阳性边缘，手感外延伸和攻击性组织学。术后放射性碘治疗的肿瘤学益处必须与风险平衡，这可能包括与放射线暴露有关的继发性恶性肿瘤。此外，儿童放射性碘的给药算法尚未确定，因此应在儿科癌症经验的三级中心进行。

Children with well-differentiated thyroid cancer tend to present with more advanced disease than in adults. Some reports suggest that as many as 10-20% of pediatric thyroid cancer patients will have evidence of distant metastases on initial workup. However, prognosis for children with well-differentiated thyroid cancer remains very favorable and approaches nearly 100% 10-year survival1.The favorable survival of children with thyroid carcinoma reflects the finding that the most pediatric thyroid malignancies are well-differentiated and display very good uptake of radioactive iodine.

参考

  1. Waguespack S, Francis G.Initial management and follow-up of differentiated thyroid cancer in children.J NCCN 2010; 8(11) 1289-1300.
  2. Niedziela M.Pathogenesis, diagnosis and management of thyroid nodules in children.Endocr Relat Cancer 2006;13：427-453。
  3. Corrias A, et al.Diagnostic features of thyroid nodules in pediatric.Arch Pediatr Adolesc Med 2010; 164(8) : 714-719
  4. Dinauer C, Breuer C, Rivkees S.儿童分化的甲状腺癌：诊断和管理。Curr OPin Oncol 2008; 20:59-65.
  5. Stevens C，Lee J，Sadatsafavi M，Blair G.Pediatric thyroid fine-needle aspiration cytology : a meta-analysis.J Ped Surg 2009;44，2184-2191。
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