甲状腺偶发瘤评估的诊断效率及指南变异性的影响：回顾性队列研究启示
该回顾性队列研究纳入2018-2023年转诊至Zuyd甲状腺中心的1825例患者，其中630例（34.5%）存在甲状腺偶发瘤。核医学成像检出的偶发瘤恶性率显著高于常规成像（21.1% vs. 1.8%，p<0.001）。基于指南的模拟分析显示，ETA指南建议评估所有病例，ATA指南评估85.3%且均识别所有恶性，而荷兰指南避免评估96.9%的患者，在528例未评估者中漏诊7例恶性（1.3%），均为预后良好的亚型。
要点
- 常规成像检出的甲状腺偶发瘤恶性风险低，但诊断工作量高。
- 核医学成像检出的偶发瘤恶性率显著高于常规成像。
- 更严格的评估标准可大幅减少诊断负担，但可能漏诊少量低危恶性。
核心结论
- 常规成像检出的甲状腺偶发瘤恶性风险低，导致高诊断工作量以检出少数恶性。
- 更严格的评估标准可大幅减少诊断负担，但可能漏诊少量低危恶性。
- 需要改进选择标准，以最小化不必要操作并确保检出临床相关恶性。
研究设计与样本
- 回顾性队列研究，评估2018-2023年转诊至Zuyd甲状腺中心的所有患者。
- 共纳入1825例转诊患者，其中630例（34.5%）有一个或多个偶发瘤。
- 基于指南的模拟分析比较ETA、ATA和荷兰指南对恶性检出和诊断工作量的影响。
主要发现
- 630例偶发瘤患者中位年龄66岁（IQR 54-74），女性占70.6%。
- 核医学成像检出的偶发瘤恶性率为21.1%，常规成像为1.8%（p<0.001）。
- ETA指南建议评估所有病例，ATA指南（无临床警告信号）评估85.3%，两者均识别所有恶性。
- 荷兰指南避免评估96.9%的患者，在528例未评估病例中漏诊7例恶性（1.3%），均为预后良好亚型。
关键数值与推荐
- ETA指南（最积极）推荐评估所有常规成像检出的甲状腺偶发瘤。
- ATA指南（无临床警告信号时）推荐评估85.3%的病例。
- 荷兰指南（最严格）避免评估96.9%的病例。
临床怎么用
- 临床实践中应认识到常规成像检出的甲状腺偶发瘤恶性风险低，避免过度评估。
- 可参考更严格的评估标准以减少不必要的诊断操作和患者负担。
- 需平衡恶性检出与诊断工作量，关注临床相关恶性的识别。
局限性
- 回顾性研究设计可能引入选择偏倚。
- 模拟分析基于指南推荐，可能未完全反映实际临床决策。
- 研究人群来自单一中心，结果外推性需谨慎。
以上解读依据论文摘要（全文未开放获取或许可不允许翻译转载）。
原文
INTRODUCTION: Thyroid incidentalomas are lesions detected incidentally on imaging performed for unrelated indications. Determining which lesions warrant further evaluation to exclude malignancy introduces a dilemma: intensive diagnostic strategies maximize malignancy detection but increase diagnostic workload, patient burden, and overdiagnosis of indolent cancers, whereas restrictive approaches reduce these harms but risk missing malignancies. Guidelines balance these opposing considerations differently, resulting in substantial variation in recommendations for evaluating conventional imaging-detected thyroid incidentalomas (ultrasound, computed tomography, magnetic resonance imaging). In this study, we aimed to investigate the diagnostic yield of thyroid incidentaloma evaluation and the impact of guideline variability on malignancy detection and diagnostic workload. METHODS: We retrospectively assessed all patients referred to Zuyd Thyroid Center (2018-2023) for thyroid nodule evaluation. Data on diagnostic outcomes, treatments, and complications were collected. A guideline-based simulation analysis examined how applying the European Thyroid Association (ETA; most intensive), the American Thyroid Association (ATA), and the Dutch Federation of Medical Specialists (most restrictive) guidelines would affect malignancy detection and diagnostic workload. RESULTS: Of 1825 referred patients, 630 (34.5%) had one or more incidentalomas (median age 66 years [interquartile range 54-74]; 70.6% female). Malignancy rate was significantly higher for nuclear imaging-detected incidentalomas than for conventional imaging (21.1% vs. 1.8%, p < 0.001). In the guideline-based simulation analysis, ETA recommended evaluating all cases, while ATA (without clinical warning signs) evaluated 85.3%, both identifying all malignancies. The Dutch guideline avoided evaluation in 96.9% of patients, missing 7 malignancies among 528 unevaluated cases (1.3%), all subtypes with good prognosis even if left undetected. CONCLUSIONS: Conventional imaging-detected incidentalomas carry a low malignancy risk, resulting in a high diagnostic workload to detect few malignancies. More restrictive evaluation criteria can substantially reduce diagnostic burden but may miss a small number of low-risk malignancies. These findings highlight the need for improved selection criteria that minimize unnecessary procedures while ensuring detection of clinically relevant malignancies.
引用
- Willems JIA, van Twist DJL, Pickwell KM, et al. Diagnostic Yield of Thyroid Incidentaloma Evaluation and the Impact of Guideline Variability: Insights from a Retrospective Cohort Study. Thyroid. 2026. PMID: 41980912. doi:10.1177/10507256261440405
供执业医师工作参考，不替代临床判断；数值与分级以指南原文为准。