ATA 甲状腺结节指南

ATA在2009年修订的甲状腺结节指南中，首先要求询问患者是否具有甲状腺癌的高危病史。高危因素包括：童年时期放射性暴露史，结节生长迅速，声音嘶哑，声带麻痹，吞咽困难，甲状腺癌家族史或多发性内分泌肿瘤综合征。如果患者具有前述高危因素，则建议对于任何超过5mm具有可疑特征的甲状腺结节施行穿刺活检。

对于没有前述高危因素的患者，该指南要求下一步（查体或超声检查）检查颈部是否存在异常的淋巴结。如果有，应该对淋巴结本身施行活检，而对可疑的甲状腺结节可以施行或不施行穿刺活检。

微钙化对于甲状腺乳头状癌具有高度特异性。因此，建议对所有可见微钙化并且超过1cm的结节施行穿刺活检。

对于那些不具有前述高危因素、异常淋巴结或微钙化的病例，ATA建议根据甲状腺结节的内部构成对结节进行分类。将结节分为：完全实性、囊实混合型、海绵状或纯囊性。ATA建议对所有的超过1cm的完全实性的低回声结节施行穿刺活检；超过1~1.5cm的等回声或高回声结节可以施行穿刺活检；建议对超过1.5~2cm的囊实混合型结节如果具有以下可疑超声特征时施行穿刺活检：不规则边界，微钙化或周围组织侵润；对于不具有上述可疑超声特征的囊实混合性结节，如果超过2cm也可以穿刺活检。对于海绵状结构的结节，仅仅在直径超过2cm后才考虑穿刺活检。

对所有的纯囊性结节ATA都不建议穿刺活检。

ATA Guidelines

The ATA guidelines, revised in 2009, begin by asking whether the patient has a history suggestive of a high risk for thyroid cancer. Risk factors include radiation exposure during childhood, rapid growth of a nodule, hoarseness, vocal cord paralysis, dysphagia, or a family history of thyroid cancer or multiple endocrine neoplasia syndrome. If the patient has a high-risk history, the recommendation is to obtain a biopsy specimen from any thyroid nodule larger than 5 mm in diameter with suspicious features.

For patients without a high-risk history, the guidelines then ask whether abnormal cervical lymph nodes are present, detected by either physical examination or ultrasound study. If so, biopsy samples should be obtained from the lymph nodes themselves, with or without biopsy of any suspicious thyroid nodules present.

Microcalcifications have a high specificity for papillary cancer. Thus, biopsy is recommended for any nodule exhibiting microcalcifications and measuring more than 1 cm.

For those patients without a high-risk history, abnormal lymph nodes, or microcalcifications, the ATA guidelines then divide the thyroid nodules into categories on the basis of their composition. Nodules are characterized as entirely solid, mixed cystic-solid, spongiform, or purely cystic. Biopsy is recommended for all solid hypoechoic nodules that exceed 1 cm in diameter. Isoechoic or hyperechoic nodules exceeding 1 to 1.5 cm should undergo biopsy. Biopsy is recommended for mixed cystic-solid nodules that exceed 1.5 to 2 cm, if they have irregular margins, microcalcifications, or infiltration of the surrounding tissue. The recommendation for mixed cystic-solid nodules without suspicious ultrasonographic features is for biopsy if they are larger than 2 cm. Those nodules exhibiting a spongiform echotexture should undergo biopsy only if they are larger than 2 cm in diameter. Finally, purely cystic nodules do not require biopsy under the ATA guidelines.