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Article(id=1203033496915767730, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1203033494428541350, articleNumber=null, orderNo=null, doi=10.11855/j.issn.0577-7402.2023.05.0530, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=research-article, receivedDate=1672675200000, receivedDateStr=2023-01-03, revisedDate=null, revisedDateStr=null, acceptedDate=1682265600000, acceptedDateStr=2023-04-24, onlineDate=1764755136946, onlineDateStr=2025-12-03, pubDate=1685203200000, pubDateStr=2023-05-28, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1764755136946, onlineIssueDateStr=2025-12-03, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1764755136946, creator=13701087609, updateTime=1764755136946, updator=13701087609, issue=Issue{id=1203033494428541350, tenantId=1146029695717560320, journalId=1189873630562394117, year='2023', volume='48', issue='5', pageStart='489', pageEnd='626', issueExtLink='null', onlineDate='null', pubDate='null', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=0, createTime=1764755136353, creator=13701087609, updateTime=1764756085669, updator=13701087609, preIssue=null, nextIssue=null, ext={EN=IssueExt(id=1203037476202967229, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1203033494428541350, language=EN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=), CN=IssueExt(id=1203037476202967230, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1203033494428541350, language=CN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=)}, issueFiles=null}, startPage=530, endPage=536, ext={EN=ArticleExt(id=1203033497289060791, articleId=1203033496915767730, tenantId=1146029695717560320, journalId=1189873630562394117, language=EN, title=Analysis of consistency between ultrasound and pathological diagnosis of Hashimoto thyroiditis, columnId=1203033497192591798, journalTitle=Medical Journal of Chinese People’s Liberation Army, columnName=Special Issue on Risk Factors Related to Thyroid Malignant Nodules, runingTitle=null, highlight=null, articleAbstract=

Objective To explore the consistency of ultrasonography and histopathology in diagnosis of Hashimoto thyroiditis. Methods The clinical data of 6238 patients, who underwent surgical treatment for thyroid nodules in the First Medical Center of Chinese PLA General Hospital from January 2016 to December 2020, were collected and retrospectively analyzed. The preoperative thyroid function and ultrasound examination data of the included patients were complete, and the postoperative pathological results were clear. The effectiveness of ultrasound imaging in diagnosis of Hashimoto thyroiditis was analyzed, and the consistency between ultrasound and pathological diagnosis was evaluated by use of Cohen's kappa coefficient (κ). According to the preoperative thyroid stimulating hormone (TSH) level, the patients were divided into TSH elevated group (n=329), TSH normal group (n=5662) and TSH decreased group (n=247). The diagnostic efficacy of ultrasound examination under different preoperative thyroid function states and its consistency with pathological diagnosis were discussed. Results (1) Among the 6238 patients, preoperative ultrasound examination revealed 1549 cases of Hashimoto thyroiditis, and postoperative pathological diagnosis revealed 1182 cases of Hashimoto thyroiditis; Only 687 patients (58.1%) had positive ultrasound and pathological diagnoses. Among the confirmed patients, 88.7% were women (1048/1182) and 11.3% were men (134/1182); The three typical ultrasound manifestations in women, including reduced parenchymal echo (17.9% vs. 11.8%), grid like changes (7.5% vs. 4.7%), increased blood flow (14.5%vs. 8.3%, P<0.001), as well as the positive rate of ultrasound diagnosis (27.8% vs. 17.1%, P<0.001) and pathological diagnosis (23.3%vs. 7.7%, P<0.001), were significantly higher than those in men. (2) Consistency analysis showed that the consistency between ultrasound diagnosis and pathological diagnosis was general (κ=0.367). The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of ultrasound diagnosis were 58.1%, 83.0%, 44.4%, 89.4% and 78.2%, respectively. The sensitivity, specificity, positive predictive value and negative predictive value of single imaging features (reduced parenchymal echo, grid like changes and increased) were 33.2%, 22.0%, 28.8%, 87.8%, 96.9%, 91.0%, 38.8%, 62.4%, 42.7% and 84.9%, 84.2%, 84.5%, respectively.The accuracy was 77.4%, 82.7% and 79.2%, respectively. Receiver operating characteristic (ROC) curve analysis showed that the predictive value of single imaging feature or the combination of two imaging features was poor in diagnosis. Among them, reduced parenchymal echo and reduced parenchymal echo combined with grid like changes were slightly better in diagnosis. (3) The positive rates of ultrasound and pathological diagnosis were higher in preoperative TSH elevated group and TSH decreased group (57.9% and 52.2% respectively in TSH elevated group; and 33.7% and 15.5% respectively in TSH decreased group, while TSH normal group was lower (22.9% and 17.7%, respectively). In addition, the consistency between ultrasound and pathological diagnosis in elevated TSH group was relatively the best, close to moderate (κ=0.399). Conclusions Both ultrasound diagnosis and single imaging features have good specificity and poor sensitivity in the diagnosis of Hashimoto thyroiditis. The consistency between ultrasound diagnosis and pathological diagnosis is general, and the consistency is slightly enhanced when combined with preoperative TSH elevation, but it can only be used as a reference. For female patients having thyroid dysfunction; the significance of combined ultrasound diagnosis will be greater. Ultrasonography is a convenient and quick supportive diagnosis of Hashimoto 's thyroiditis.

, correspAuthors=Zhao-Hui Lv, authorNote=null, correspAuthorsNote=
* E-mail:
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目的 探讨超声检查与组织病理学检查诊断桥本甲状腺炎的一致性。方法 收集2016年1月－2020年12月在解放军总医院第一医学中心因甲状腺结节行手术治疗的6238例患者的临床资料进行回顾性分析，所有患者术前甲状腺功能及超声检查资料完整，术后病理诊断明确。分析超声影像诊断桥本甲状腺炎的效能，并通过Cohen的Kappa系数（κ）评估超声与病理诊断的一致性。根据术前促甲状腺激素（TSH）水平将患者分为TSH升高组（n=329）、TSH正常组（n=5662）及TSH降低组（n=247），探讨在术前不同甲状腺功能状态下超声检查的诊断效能，以及与病理学诊断的一致性。结果 （1）6238例患者中，术前超声检查提示桥本甲状腺炎1549例，术后病理诊断桥本甲状腺炎1182例；超声及病理学诊断均阳性的患者仅687例（58.1%）。确诊患者中女性占88.7%（1048/1182），男性占11.3%（134/1182）；女性中3种典型超声表现[实质回声减低（17.9% vs. 11.8%）、网格样改变（7.5% vs. 4.7%）、血流增加（14.5% vs. 8.3%），P<0.001]以及超声诊断阳性率（27.8% vs. 17.1%，P<0.001）、病理诊断阳性率（23.3% vs. 7.7%，P<0.001）均明显高于男性。（2）一致性分析提示，超声诊断与病理诊断的一致性为一般（κ=0.367）。超声诊断的敏感度为58.1%，特异度为83.0%，阳性预测值为44.4%，阴性预测值为89.4%，准确度为78.2%，其中，单一超声特征（实质回声减低、网格样改变、血流增加）在诊断时的敏感度分别为33.2%、22.0%、28.8%，特异度分别为87.8%、96.9%、91.0%，阳性预测值分别为38.8%、62.4%、42.7%，阴性预测值分别为84.9%、84.2%、84.5%，准确度分别为77.4%、82.7%、79.2%。受试者工作特征（ROC）曲线分析提示，单一超声特征或两种超声特征相结合在诊断时的预测性均较差，其中，实质回声减低及实质回声减低结合网格样改变在诊断时的表现稍好。（3）术前TSH升高组、TSH降低组的超声及病理诊断阳性率较高（TSH升高组分别为57.9%、52.2%，TSH降低组分别为33.7%、15.5%），而TSH正常组则偏低（分别为22.9%、17.7%）。此外，TSH升高组中超声与病理诊断的一致性相对最好，接近中等程度（κ=0.399）。结论 超声诊断及单一影像学特征在诊断桥本甲状腺炎时的特异度良好而敏感度欠佳。超声诊断与病理诊断的一致性程度一般，联合术前TSH升高时二者的一致性稍增强，但仅可作为参考。女性患者出现甲状腺功能异常时，联合超声诊断的价值更高。超声检查是桥本甲状腺炎的一项方便、快捷的支持性诊断方法。

, correspAuthors=吕朝晖, authorNote=null, correspAuthorsNote=
吕朝晖，E-mail：
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赵思童，硕士研究生，主治医师，主要从事内分泌代谢疾病方面的研究

, authorsList=赵思童, 胡晓东, 许怀瑾, 聂智梅, 李洁菲, 康邵洋, 柳洪宙, 王玉寒, 王安宁, 吕朝晖)}, authors=[Author(id=1203264439232471870, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1203033496915767730, orderNo=0, firstName=null, middleName=null, lastName=null, nameCn=null, orcid=null, stid=null, country=null, authorPic=null, dead=0, email=null, emailSecond=null, emailThird=null, correspondingAuthor=0, authorType=1, ext={EN=AuthorExt(id=1203264439307969345, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1203033496915767730, authorId=1203264439232471870, language=EN, stringName=Si-Tong Zhao, firstName=Si-Tong, middleName=null, lastName=Zhao, prefix=null, suffix=null, authorComment=null, nameInitials=null, affiliation=null, department=null, xref=1, address=1Department of Endocrinology, the First Medical Center of Chinese PLA General Hospital, Beijing 100853, China, bio=null, bioImg=null, bioContent=null, aboutCorrespAuthor=null), CN=AuthorExt(id=1203264439366689602, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1203033496915767730, authorId=1203264439232471870, language=CN, stringName=赵思童, firstName=思童, middleName=null, lastName=赵, prefix=null, suffix=null, authorComment=null, nameInitials=null, affiliation=null, department=null, xref=1, address=1解放军总医院第一医学中心内分泌科，北京 100853, bio={"content":"

赵思童，硕士研究生，主治医师，主要从事内分泌代谢疾病方面的研究

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赵思童，硕士研究生，主治医师，主要从事内分泌代谢疾病方面的研究

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Acta Otorhinolaryngol Ital, 2021, 41(2): 142-145., articleTitle=Hashimoto's thyroiditis in papillary thyroid carcinoma: a 22-year study, refAbstract=null), Reference(id=1203264447977595818, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1203033496915767730, doi=null, pmid=null, pmcid=null, year=2021, volume=30, issue=5, pageStart=606, pageEnd=612, url=null, language=null, rfNumber=[29], rfOrder=35, authorNames=Su DT, Ouyang H, Li XY, journalName=Chin J Gen Surg, refType=null, unstructuredReference=Su DT, Ouyang H, Li XY. Research progress on the correlation between Hashimoto's thyroiditis and papillary thyroid carcinoma[J]. Chin J Gen Surg, 2021, 30(5): 606-612., articleTitle=Research progress on the correlation between Hashimoto's thyroiditis and papillary thyroid carcinoma, refAbstract=null), Reference(id=1203264448040510379, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1203033496915767730, doi=null, pmid=null, pmcid=null, year=2021, volume=30, issue=5, pageStart=606, pageEnd=612, url=null, language=null, rfNumber=[29], rfOrder=36, authorNames=粟敦涛, 欧阳辉, 李新营, journalName=中国普通外科杂志, refType=null, unstructuredReference=[粟敦涛, 欧阳辉, 李新营. 桥本氏甲状腺炎与甲状腺乳头状癌相关性研究进展[J]. 中国普通外科杂志, 2021, 30(5): 606-612.], articleTitle=桥本氏甲状腺炎与甲状腺乳头状癌相关性研究进展, refAbstract=null), Reference(id=1203264448103424940, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1203033496915767730, doi=null, pmid=null, pmcid=null, year=2022, volume=35, issue=2, pageStart=186, pageEnd=193, url=null, language=null, rfNumber=[30], rfOrder=37, authorNames=Chen RX, Chen WZ, journalName=J Canc Control Treat, refType=null, unstructuredReference=Chen RX, Chen WZ. Research progress on the correlation between Hashimoto's thyroiditis and papillary thyroid carcinoma[J]. 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HT. 桥本甲状腺炎；ROC. 受试者工作特征；AUC. 曲线下面积

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HT. 桥本甲状腺炎；ROC. 受试者工作特征；AUC. 曲线下面积

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Comparison of general clinical data of patients undergoing thyroid nodulectomy

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指标合计(n=6238)男性(n=1737)女性(n=4501)P
年龄(岁，$\bar{x}±s$)45.5±11.744.8±11.945.8±11.60.156
超声检查阳性[例(%)]1549(24.8)297(17.1)1252(27.8)<0.001
 实质回声减低1032(16.2)205(11.8)805(17.9)
 网格样改变418(6.7)81(4.7)337(7.5)
 血流增加798(12.8)144(8.3)654(14.5)
组织病理学阳性[例(%)]1182(18.9)134(7.7)1048(23.3)<0.001
超声学及组织病理学均为阳性[例(%)]687(11.0)69(3.9)618(13.7)<0.001
), ArticleFig(id=1203264443711988608, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1203033496915767730, language=CN, label=表1, caption=

甲状腺结节切除患者的一般临床资料比较

, figureFileSmall=null, figureFileBig=null, tableContent=
指标合计(n=6238)男性(n=1737)女性(n=4501)P
年龄(岁，$\bar{x}±s$)45.5±11.744.8±11.945.8±11.60.156
超声检查阳性[例(%)]1549(24.8)297(17.1)1252(27.8)<0.001
 实质回声减低1032(16.2)205(11.8)805(17.9)
 网格样改变418(6.7)81(4.7)337(7.5)
 血流增加798(12.8)144(8.3)654(14.5)
组织病理学阳性[例(%)]1182(18.9)134(7.7)1048(23.3)<0.001
超声学及组织病理学均为阳性[例(%)]687(11.0)69(3.9)618(13.7)<0.001
), ArticleFig(id=1203264443779097473, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1203033496915767730, language=EN, label=Tab. 2, caption=

Effectiveness of preoperative ultrasonic diagnosis and different ultrasonic characteristics in diagnosis of Hashimoto thyroiditis (%)

, figureFileSmall=null, figureFileBig=null, tableContent=
超声特征敏感度特异度阳性预测值阴性预测值准确度
实质回声减低33.287.838.884.977.4
网格样改变22.096.962.484.282.7
血流增加28.891.042.784.579.2
超声综合表现58.183.044.489.478.2
), ArticleFig(id=1203264443846206338, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1203033496915767730, language=CN, label=表2, caption=

超声检查及不同超声特征对HT的诊断效能(%)

, figureFileSmall=null, figureFileBig=null, tableContent=
超声特征敏感度特异度阳性预测值阴性预测值准确度
实质回声减低33.287.838.884.977.4
网格样改变22.096.962.484.282.7
血流增加28.891.042.784.579.2
超声综合表现58.183.044.489.478.2
), ArticleFig(id=1203264443913315203, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1203033496915767730, language=EN, label=Tab. 3, caption=

Comparison of the positive rate of HT in different genders, ultrasonic features and pathological diagnosis under different preoperative thyroid function status

, figureFileSmall=null, figureFileBig=null, tableContent=
项目TSH正常组(n=5662)TSH升高组(n=329)TSH降低组(n=247)P
年龄(岁，$\bar{x}±s$)45.4±11.645.2±11.848.6±13.70.093
性别[例(%)]   <0.001
 男1639(28.9)50(15.2)(1)21(20.6)(1)
 女4026(71.1)279(84.8)(1)196(79.4)(1)
超声诊断阳性[例(%)]1295(22.9)143(57.9)(1)111(33.7)(1)<0.001
 实质回声减低846(14.9)88(35.6)(1)76(23.1)(1)
 网格样改变345(6.1)41(16.6)(1)32(9.7)(1)
 血流增加660(11.7)84(34.0)(1)54(16.4)(1)
病理诊断阳性合并HT[例(%)]1002(17.7)129(52.2)(1)51(15.5)(1)<0.001
), ArticleFig(id=1203264443993006980, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1203033496915767730, language=CN, label=表3, caption=

不同术前甲状腺功能状态下各性别、超声特征及病理诊断HT的阳性率比较

, figureFileSmall=null, figureFileBig=null, tableContent=
项目TSH正常组(n=5662)TSH升高组(n=329)TSH降低组(n=247)P
年龄(岁，$\bar{x}±s$)45.4±11.645.2±11.848.6±13.70.093
性别[例(%)]   <0.001
 男1639(28.9)50(15.2)(1)21(20.6)(1)
 女4026(71.1)279(84.8)(1)196(79.4)(1)
超声诊断阳性[例(%)]1295(22.9)143(57.9)(1)111(33.7)(1)<0.001
 实质回声减低846(14.9)88(35.6)(1)76(23.1)(1)
 网格样改变345(6.1)41(16.6)(1)32(9.7)(1)
 血流增加660(11.7)84(34.0)(1)54(16.4)(1)
病理诊断阳性合并HT[例(%)]1002(17.7)129(52.2)(1)51(15.5)(1)<0.001
), ArticleFig(id=1203264444064310149, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1203033496915767730, language=EN, label=Tab. 4, caption=

Characteristics of false negative and false positive cases diagnosed by ultrasound

, figureFileSmall=null, figureFileBig=null, tableContent=
指标假阳性(n=862)假阴性(n=495)P
性别[例(%)]  <0.001
 男228(26.5)65(13.1)
 女634(73.5)430(86.9)
年龄(岁，$\bar{x}±s$)47.6±12.144.2±11.30.081
术前超声改变[例(%)]  <0.001
 实质回声减低618(71.7)0(0)
 网格样改变157(18.2)1(0.2)
 血流增加329(38.2)22(4.4)
术前自身抗体[例(%)]  <0.001
 TPOAb(+)218(25.3)261(52.7)
 TgAb(+)235(27.3)336(67.9)
术前TSH水平[例(%)]
 升高00
 正常862(100)495(100)
 降低00 
), ArticleFig(id=1203264444131419014, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1203033496915767730, language=CN, label=表4, caption=

超声诊断假阴性及假阳性病例特点

, figureFileSmall=null, figureFileBig=null, tableContent=
指标假阳性(n=862)假阴性(n=495)P
性别[例(%)]  <0.001
 男228(26.5)65(13.1)
 女634(73.5)430(86.9)
年龄(岁，$\bar{x}±s$)47.6±12.144.2±11.30.081
术前超声改变[例(%)]  <0.001
 实质回声减低618(71.7)0(0)
 网格样改变157(18.2)1(0.2)
 血流增加329(38.2)22(4.4)
术前自身抗体[例(%)]  <0.001
 TPOAb(+)218(25.3)261(52.7)
 TgAb(+)235(27.3)336(67.9)
术前TSH水平[例(%)]
 升高00
 正常862(100)495(100)
 降低00 
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桥本甲状腺炎超声与病理学诊断的一致性分析
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赵思童 1 , 胡晓东 1 , 许怀瑾 1, 2 , 聂智梅 1 , 李洁菲 1, 2 , 康邵洋 1 , 柳洪宙 1 , 王玉寒 1 , 王安宁 1 , 吕朝晖 1, 2, *
解放军医学杂志 | 甲状腺恶性结节相关危险因素专题研究 2023,48(5): 530-536
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解放军医学杂志 | 甲状腺恶性结节相关危险因素专题研究 2023, 48(5): 530-536
桥本甲状腺炎超声与病理学诊断的一致性分析
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赵思童1, 胡晓东1, 许怀瑾1, 2, 聂智梅1, 李洁菲1, 2, 康邵洋1, 柳洪宙1, 王玉寒1, 王安宁1, 吕朝晖1, 2, *
作者信息
  • 1解放军总医院第一医学中心内分泌科，北京 100853
  • 2南开大学医学院，天津 300071

    • 赵思童，硕士研究生，主治医师，主要从事内分泌代谢疾病方面的研究

通讯作者:

吕朝晖，E-mail：
Analysis of consistency between ultrasound and pathological diagnosis of Hashimoto thyroiditis
Si-Tong Zhao1, Xiao-Dong Hu1, Huai-Jin Xu1, 2, Zhi-Mei Nie1, Jie-Fei Li1, 2, Shao-Yang Kang1, Hong-Zhou Liu1, Yu-Han Wang1, An-Ning Wang1, Zhao-Hui Lv1, 2, *
Affiliations
  • 1Department of Endocrinology, the First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
  • 2School of Medicine, Nankai University, Tianjin 300071, China
出版时间: 2023-05-28 doi: 10.11855/j.issn.0577-7402.2023.05.0530
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摘要
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目的 探讨超声检查与组织病理学检查诊断桥本甲状腺炎的一致性。方法 收集2016年1月－2020年12月在解放军总医院第一医学中心因甲状腺结节行手术治疗的6238例患者的临床资料进行回顾性分析，所有患者术前甲状腺功能及超声检查资料完整，术后病理诊断明确。分析超声影像诊断桥本甲状腺炎的效能，并通过Cohen的Kappa系数（κ）评估超声与病理诊断的一致性。根据术前促甲状腺激素（TSH）水平将患者分为TSH升高组（n=329）、TSH正常组（n=5662）及TSH降低组（n=247），探讨在术前不同甲状腺功能状态下超声检查的诊断效能，以及与病理学诊断的一致性。结果 （1）6238例患者中，术前超声检查提示桥本甲状腺炎1549例，术后病理诊断桥本甲状腺炎1182例；超声及病理学诊断均阳性的患者仅687例（58.1%）。确诊患者中女性占88.7%（1048/1182），男性占11.3%（134/1182）；女性中3种典型超声表现[实质回声减低（17.9% vs. 11.8%）、网格样改变（7.5% vs. 4.7%）、血流增加（14.5% vs. 8.3%），P<0.001]以及超声诊断阳性率（27.8% vs. 17.1%，P<0.001）、病理诊断阳性率（23.3% vs. 7.7%，P<0.001）均明显高于男性。（2）一致性分析提示，超声诊断与病理诊断的一致性为一般（κ=0.367）。超声诊断的敏感度为58.1%，特异度为83.0%，阳性预测值为44.4%，阴性预测值为89.4%，准确度为78.2%，其中，单一超声特征（实质回声减低、网格样改变、血流增加）在诊断时的敏感度分别为33.2%、22.0%、28.8%，特异度分别为87.8%、96.9%、91.0%，阳性预测值分别为38.8%、62.4%、42.7%，阴性预测值分别为84.9%、84.2%、84.5%，准确度分别为77.4%、82.7%、79.2%。受试者工作特征（ROC）曲线分析提示，单一超声特征或两种超声特征相结合在诊断时的预测性均较差，其中，实质回声减低及实质回声减低结合网格样改变在诊断时的表现稍好。（3）术前TSH升高组、TSH降低组的超声及病理诊断阳性率较高（TSH升高组分别为57.9%、52.2%，TSH降低组分别为33.7%、15.5%），而TSH正常组则偏低（分别为22.9%、17.7%）。此外，TSH升高组中超声与病理诊断的一致性相对最好，接近中等程度（κ=0.399）。结论 超声诊断及单一影像学特征在诊断桥本甲状腺炎时的特异度良好而敏感度欠佳。超声诊断与病理诊断的一致性程度一般，联合术前TSH升高时二者的一致性稍增强，但仅可作为参考。女性患者出现甲状腺功能异常时，联合超声诊断的价值更高。超声检查是桥本甲状腺炎的一项方便、快捷的支持性诊断方法。

桥本甲状腺炎  /  甲状腺超声  /  甲状腺结节  /  组织病理学

Objective To explore the consistency of ultrasonography and histopathology in diagnosis of Hashimoto thyroiditis. Methods The clinical data of 6238 patients, who underwent surgical treatment for thyroid nodules in the First Medical Center of Chinese PLA General Hospital from January 2016 to December 2020, were collected and retrospectively analyzed. The preoperative thyroid function and ultrasound examination data of the included patients were complete, and the postoperative pathological results were clear. The effectiveness of ultrasound imaging in diagnosis of Hashimoto thyroiditis was analyzed, and the consistency between ultrasound and pathological diagnosis was evaluated by use of Cohen's kappa coefficient (κ). According to the preoperative thyroid stimulating hormone (TSH) level, the patients were divided into TSH elevated group (n=329), TSH normal group (n=5662) and TSH decreased group (n=247). The diagnostic efficacy of ultrasound examination under different preoperative thyroid function states and its consistency with pathological diagnosis were discussed. Results (1) Among the 6238 patients, preoperative ultrasound examination revealed 1549 cases of Hashimoto thyroiditis, and postoperative pathological diagnosis revealed 1182 cases of Hashimoto thyroiditis; Only 687 patients (58.1%) had positive ultrasound and pathological diagnoses. Among the confirmed patients, 88.7% were women (1048/1182) and 11.3% were men (134/1182); The three typical ultrasound manifestations in women, including reduced parenchymal echo (17.9% vs. 11.8%), grid like changes (7.5% vs. 4.7%), increased blood flow (14.5%vs. 8.3%, P<0.001), as well as the positive rate of ultrasound diagnosis (27.8% vs. 17.1%, P<0.001) and pathological diagnosis (23.3%vs. 7.7%, P<0.001), were significantly higher than those in men. (2) Consistency analysis showed that the consistency between ultrasound diagnosis and pathological diagnosis was general (κ=0.367). The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of ultrasound diagnosis were 58.1%, 83.0%, 44.4%, 89.4% and 78.2%, respectively. The sensitivity, specificity, positive predictive value and negative predictive value of single imaging features (reduced parenchymal echo, grid like changes and increased) were 33.2%, 22.0%, 28.8%, 87.8%, 96.9%, 91.0%, 38.8%, 62.4%, 42.7% and 84.9%, 84.2%, 84.5%, respectively.The accuracy was 77.4%, 82.7% and 79.2%, respectively. Receiver operating characteristic (ROC) curve analysis showed that the predictive value of single imaging feature or the combination of two imaging features was poor in diagnosis. Among them, reduced parenchymal echo and reduced parenchymal echo combined with grid like changes were slightly better in diagnosis. (3) The positive rates of ultrasound and pathological diagnosis were higher in preoperative TSH elevated group and TSH decreased group (57.9% and 52.2% respectively in TSH elevated group; and 33.7% and 15.5% respectively in TSH decreased group, while TSH normal group was lower (22.9% and 17.7%, respectively). In addition, the consistency between ultrasound and pathological diagnosis in elevated TSH group was relatively the best, close to moderate (κ=0.399). Conclusions Both ultrasound diagnosis and single imaging features have good specificity and poor sensitivity in the diagnosis of Hashimoto thyroiditis. The consistency between ultrasound diagnosis and pathological diagnosis is general, and the consistency is slightly enhanced when combined with preoperative TSH elevation, but it can only be used as a reference. For female patients having thyroid dysfunction; the significance of combined ultrasound diagnosis will be greater. Ultrasonography is a convenient and quick supportive diagnosis of Hashimoto 's thyroiditis.

Hashimoto thyroiditis  /  thyroid ultrasound  /  thyroid nodules  /  histopathological
赵思童, 胡晓东, 许怀瑾, 聂智梅, 李洁菲, 康邵洋, 柳洪宙, 王玉寒, 王安宁, 吕朝晖. 桥本甲状腺炎超声与病理学诊断的一致性分析. 解放军医学杂志, 2023 , 48 (5) : 530 -536 . DOI: 10.11855/j.issn.0577-7402.2023.05.0530
Si-Tong Zhao, Xiao-Dong Hu, Huai-Jin Xu, Zhi-Mei Nie, Jie-Fei Li, Shao-Yang Kang, Hong-Zhou Liu, Yu-Han Wang, An-Ning Wang, Zhao-Hui Lv. Analysis of consistency between ultrasound and pathological diagnosis of Hashimoto thyroiditis[J]. Medical Journal of Chinese People’s Liberation Army, 2023 , 48 (5) : 530 -536 . DOI: 10.11855/j.issn.0577-7402.2023.05.0530
正文
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桥本甲状腺炎(Hashimoto thyroiditis，HT)在过去30年中发病率明显增高[1-2]，目前已成为常见的甲状腺疾病之一，发病率为(3～15)/10000，尽管其发病率上升的原因尚不十分明确，但可能与血清学诊断和超声影像学检查的普及有关。HT是导致甲状腺功能减退的重要原因[3]，且易并发心血管疾病和恶性肿瘤[4-7]。因此，早期发现和诊断可能对改善患者预后及预防相关并发症具有重要意义。甲状腺自身抗体包括抗甲状腺过氧化物酶抗体(anti-thyroid peroxidase antibody，TPOAb)和甲状腺球蛋白抗体(anti-thyroglobulin antibodies，TgAb)，常用于HT的临床诊断，近年来已有较多研究探讨了其诊断效能[8-10]，且有少部分研究专门分析了其与病理诊断的一致性[11-12]。随着超声影像学技术的进步和普及，甲状腺超声除用于结节性疾病的诊断及评估外，也越来越多地应用于HT等自身免疫性甲状腺疾病的辅助诊断及随访。然而，因超声检查存在医师主观性影响、实质表现多样、描述方式不统一等问题，其对HT诊断效能的研究鲜有报道[11]。本研究通过分析因甲状腺结节行手术治疗患者的临床资料，探讨超声与病理学检查诊断HT的一致性，并评估超声影像学的诊断效能，旨在提升HT的诊断精确度。
1 资料与方法
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1.1 研究对象
收集2016年1月－2020年12月就诊于解放军总医院第一医学中心普外科并行甲状腺结节切除手术的6238例患者的临床资料进行回顾性分析。所有患者均为评估甲状腺结节后需行甲状腺结节切除术者，手术指征包括：(1)出现明显的结节压迫症状；(2)结节进行性生长，临床考虑或者穿刺检查提示恶变倾向或合并甲状腺癌高危因素；(3)合并甲状腺功能亢进，且内科治疗无效。排除标准：(1)术前检查资料不完整、术后病理结果不明确；(2)患者年龄<18岁。本研究获解放军总医院第一医学中心伦理委员会审批(伦审第S2022-0115-01号)。
1.2 观察指标及其定义
记录患者的性别、年龄、术前血清促甲状腺激素(TSH)、TPOAb、TgAb水平和甲状腺超声检查结果，以及术后病理结果。血清学检测均采用化学免疫法，其中TSH采用德国西门子公司试剂盒进行检测(正常值范围为0.35～5.50 mU/L)，TPOAb和TgAb采用德国西门子抗体试剂盒进行检测(正常值均≤60 U/L)。超声检查采用西门子512超声诊断仪，探头中心频率为7 MHz；西门子S2000超声诊断仪，探头中心频率为8 MHz；迈瑞Resona 7超声诊断仪，探头频率为5.6～10.0 MHz。超声诊断报告均由本院经验丰富的超声科医师进行复审后出具，若报告中提到“甲状腺实质弥漫性不均匀改变”或“甲状腺实质回声减低”则为超声诊断HT。虽然很多研究中超声科医师会依据甲状腺实质形态、回声及血流变化情况对HT进行分类[13-14]，但是由于本研究样本量较大，无法重新对纳入病例进行超声分类，因此仅依据HT超声特征[15]，选取“实质回声减低”“网格样改变”及“血流增加”作为超声诊断的特异性表现。HT的病理诊断基于术后病理报告。
1.3 指标分析
分析纳入患者的一般临床资料、血清学指标、超声描述特点及病理诊断结果，对比不同超声影像特征的诊断效能(包括敏感度、特异度、阳性预测值、阴性预测值及准确度)，分析超声诊断与组织病理结果的一致性。依据术前甲状腺功能将入组患者分为TSH升高组(>5.50 mU/L)、TSH正常组(0.35～5.50 mU/L)及TSH降低组(<0.35 mU/L)，分析不同术前甲状腺功能状态下超声诊断的诊断效能。对比分析假阳性与假阴性病例的特征，探讨结合哪些指标进行诊断容易出现假阴性及假阳性的情况。
1.4 统计学处理
采用SPSS 26.0软件进行统计分析。计量资料符合正态分布者以$\bar{x}±s$表示，组间比较采用t检验，多组间比较方差齐时采用单因素方差分析，方差不齐时采用Kruskal-Wallis检验；计数资料以例(%)表示，组间比较采用χ2检验或Fisher精确检验。诊断效能采用敏感度、特异度、阳性预测值、阴性预测值及准确度进行描述，可信区间(CI)为95%。采用受试者工作特征(ROC)曲线分析不同超声表现诊断HT的价值。采用Cohen的Kappa系数(κ)评估超声与病理诊断的一致性[κ≤0.20(一致性差)；κ为0.21～0.40(一致性一般)；κ为0.41～0.60(一致性中等)；κ为0.61～0.80(一致性较强)；κ为0.81～1.00(一致性强)]。P<0.05为差异有统计学意义。
2 结果
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2.1 一般临床资料
纳入的6238例患者年龄为(45.5±11.7)岁，其中男性1737例(占27.8%)，女性4501例(占72.2%)。超声检查诊断为HT者1549例(24.8%)，术后组织病理学诊断为HT者1182例(18.9%)，二者均诊断为HT者仅为687例(11.0%)。此外，无论依据哪种指标进行诊断，女性患者占比均明显高于男性，差异有统计学意义(P<0.001，表1)。
2.2 超声检查及不同超声特征的诊断效能
术前超声诊断的敏感度为58.1%，特异度为83.0%，阳性预测值为44.4%，阴性预测值为89.4%，准确度为78.2%。单一超声特征(实质回声减低、网格样改变、血流增加)在诊断HT时均表现出良好的特异度(87.8% vs. 96.9% vs. 91.0%)，但敏感度均较差(33.2% vs.22.0% vs. 28.8%)；其中网格样改变的特异度最高(96.9%)(表2)。不同超声特征诊断HT的ROC曲线显示，单一超声特征预测HT的能力均不佳(AUC分别为0.605、0.599、0.595)，其中实质回声减低的判别能力稍好(AUC=0.605，图1)。结合任意两种超声特征进行诊断时的预测能力(AUC分别为0.671、0.655、0.641)均较综合影像学表现(AUC=0.705)差，但同时出现实质回声减低与网格样改变时诊断价值相对较高(AUC=0.671，图2)。
2.3 超声诊断与病理诊断的一致性
采用Cohen的Kappa系数评价超声与病理检查诊断HT的一致性，结果显示二者仅呈现一般程度的一致性(κ=0.367，95%CI 0.340～0.394)。
2.4 术前甲状腺功能状态对诊断阳性率及诊断一致性的影响
2.4.1 不同术前TSH水平下各诊断方式的HT阳性率
不同TSH分组人群HT患病年龄之间差异无统计学意义；TSH正常组中男性HT阳性率明显高于TSH升高组及TSH降低组，而女性HT阳性率明显低于TSH升高组及TSH降低组，差异均有统计学意义(P<0.001)。与TSH正常组比较，TSH升高组及TSH降低组各诊断方式的阳性率差异均有统计学意义(P<0.001)，但TSH升高与TSH降低组间各诊断方式及不同性别的HT阳性率差异无统计学意义(表3)。
2.4.2 与病理诊断的一致性
无论术前甲状腺功能状态如何，超声学诊断和病理学诊断的一致性均为一般程度(TSH升高组：κ=0.399，95%CI 0.299～0.499；TSH正常组：κ=0.360，95%CI 0.331～0.389；TSH降低组：κ=0.277，95%CI 0.171～0.383)，仅TSH升高组中二者的一致性有所提高，接近中等程度，而TSH正常组及TSH降低组中二者的一致性有所下降。
2.5 超声诊断假阳性及假阴性病例的特征比较
超声诊断假阴性患者年龄(44.2±11.3)岁，假阳性患者年龄(47.6±12.1)岁，二者在性别分布上差异有统计学意义(男性：26.5% vs. 13.1%，女性：73.5% vs.86.9%，P<0.001)。超声诊断假阳性患者同样可伴随甲状腺特异性抗体水平升高(TPOAb升高者218例，TgAb升高者235例)，术前甲状腺功能出现异常时诊断通常准确，不易出现假阳性及假阴性(表4)。
3 讨论
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HT发病隐匿且病程迁延，早期诊断的患者多为在体检或甲状腺结节风险评估时偶然发现，而最终诊断也多基于甲状腺特异性抗体升高和超声影像的特异性表现[16]。2021年日本甲状腺协会更新了HT诊断指南[17]，认为如果患者满足HT的下述临床表现和任意一项实验室检查结果，则应考虑其患有慢性甲状腺炎。(1)临床表现：除外任何其他原因(如Graves病)的甲状腺弥漫性肿胀(弥漫性甲状腺肿)；某些情况下，甲状腺可出现萎缩。(2)实验室检查：TPOAb阳性；TgAb阳性；细胞学检查证实甲状腺实质有淋巴细胞浸润。但指南同时特别指出，如果在甲状腺超声检查中观察到低回声和(或)不均匀回声，则提示患者可能患有慢性甲状腺炎。Pedersen等[18]发现，甲状腺回声弥漫性降低是自身免疫性甲状腺炎的有效预测因子，且这一超声特征可能较TPOAb更早出现。因此，超声诊断在早期预测及诊断HT时具有重要作用。
本研究发现，6238例患者中，术前超声检查诊断HT者共1549例(24.8%)，其中病理诊断阳性者仅687例(44.4%)，病理诊断阴性者862例(55.6%)；术前超声诊断阴性的4689例(75.2%)患者中，病理诊断阳性者495例(10.6%)，病理诊断阴性者4195例(89.5%)。该结果提示单独应用超声检查诊断HT存在局限性，可能导致误诊或漏诊，临床应结合甲状腺形态、性质和功能检查综合分析，以提高HT的术前诊断准确率。此外，本研究还发现，术前单独应用超声检查诊断HT时，其敏感度为58.1%，特异度为83.0%，阳性预测值为44.4%，阴性预测值为89.4%，准确度为78.2%，单独依据某一超声特征进行诊断的可信度更差，而最终超声及病理均提示HT的患者仅687例，有862例出现假阳性，495例出现了假阴性。因此，术前超声检查在单独应用时对HT的诊断效能有限。
Guan等[11]对825例甲状腺结节术后患者进行回顾性分析发现，超声诊断HT的敏感度、特异度、阳性预测值、阴性预测值和准确度分别为49.1%、88.9%、69.0%、77.6%和38.0%，与本研究结果相近。2021年南京医科大学的一项诊断性试验显示，超声影像诊断HT的敏感度、特异度、阳性预测值、阴性预测值和准确度分别为75.81%、83.30%、65.46%、89.19%和81.10%[12]，其诊断敏感度高于本研究，可能与前者在收集超声资料时由同一位专业医师进行术前评估有关，而本研究则更接近于日常临床超声工作对疾病的诊断能力与精度。
HT的典型病理改变包括慢性实质淋巴细胞浸润及后期出现的甲状腺实质纤维化。超声诊断是在实质病理变化的基础上呈现的不同影像学表现，不同超声表现可能代表了疾病处于不同的病程阶段。实质回声减低通常由淋巴细胞浸润造成，与HT患者甲状腺功能减退的发生有关，有研究认为也可用于HT复发的监测[19]，因此，实质回声减低被认为是HT最特异的表现。随着细胞介导的炎症浸润造成甲状腺实质滤泡破坏，发生纤维组织增生时，超声检查则表现为假结节或实质不均，即网格样或条索样改变。Thomas等[20]发现，144例HT患者中61.2%出现血流增加，提示血流改变可能是HT超声诊断的一项新特点。本研究中各项超声特征在诊断HT时均具有良好的特异度(87.8%、96.9%、91.0%)，提示如果超声报告中未提及上述特征性描述，患者实际患病的可能性并不大，其中尤以网格样改变的提示作用最为明显。然而，本研究各项表现的敏感度并不佳(33.2%、22.0%、28.8%)，因此，即使这些表现在HT中是特征性的，但通过单一特征描述进行诊断仍可能导致漏诊。本研究ROC曲线分析提示，实质回声减低的预测能力可能稍好；AUC值均偏低，但如果报告描述中同时出现网格样改变，则其预测性稍好，因为通常处于疾病后期的实质纤维化时才会出现该表现。
本研究发现超声与病理诊断的一致性仅为一般(κ=0.367)，而Guan等[11]的研究认为超声弥散异质性与HT的组织病理学诊断之间具有中等程度的一致性，这可能与两项研究分别针对国内外不同人群、不同样本量，超声仪器型号及国内外超声科医师对疾病的判断标准不同有关。而本次针对国内人群的大样本量研究提示超声的诊断能力不佳。
目前，国内外与HT诊断相关的实验多基于术前甲状腺功能降低或甲状腺功能正常人群，而为初步探究术前甲状腺功能状态对诊断效能的影响，本研究按术前TSH的水平将患者分为TSH升高组、TSH正常组及TSH降低组，结果发现，无论是诊断阳性率还是与病理学检查的一致性，TSH升高组均更明显，这与滤泡破坏导致甲状腺功能下降时超声更易检出实质不均及纤维增生变化有关。值得一提的是，TSH降低组中超声诊断阳性率略高于TSH正常组，但在与金标准的一致性上反而略低，这可能与HT早期滤泡发生破坏时可发生一过性甲状腺功能亢进有关，但该表现缺乏特异性，原发性甲状腺功能亢进、其他类型的甲状腺炎，以及其他原因导致甲状腺滤泡轻度破坏时，也可能导致这一现象的发生。
超声诊断HT时，男性患者更容易被误诊，而女性患者更易被漏诊。通过超声特征进行诊断易出现假阳性，而通过特异性抗体升高进行诊断易出现假阴性，从侧面证实了超声诊断的敏感度不高而特异度良好。假阴性患者几乎不会在超声报告中被描述为实质回声减低及网格样变化，而假阳性患者中同样可出现甲状腺特异性抗体升高，尤其是当患者缺乏明显临床特征时，则更难以直接辨别，因此，结合超声检查可提高HT的诊断准确度，再结合患者在术前出现的甲状腺功能异常，可大大降低超声科医师诊断的误诊率及漏诊率。近年来，人工智能应用于超声诊断的相关课题正在广泛进行[21-22]，超声诊断的准确度逐渐提高，然而受技术普及、隐性成本、额外的软件工程，以及系统维护时间等条件的限制，大部分研究成果尚不能在全国范围内推广，但结合彩色多普勒及弹性成像评分系统对HT进行相关评估仍可增加超声对该病的诊断强度[23-24]。
由于缺少整体患病人群的临床资料，行甲状腺结节切除手术治疗的患者常被用作HT相关研究的目标人群，因而可造成选择偏倚。国内外一些大样本量流行病学调查发现，HT患病率为20%～30%[25-26]，而2022年发表的一项荟萃分析结果显示，成人HT的全球患病率为7.5%，其中女性的患病率为17.5%，男性为6.0%，成年女性罹患HT的风险约为男性的4倍[27]。本研究发现，甲状腺结节术后人群中HT的患病率更高(18.9%)。究其原因，本研究纳入的甲状腺结节人群中83.3%经病理证实为甲状腺乳头状癌(papillary thyroid carcinoma，PTC)，而近年来大量研究试图探究HT与PTC的关系，有学者认为PTC是HT慢性炎症反应后的结果，还有学者认为HT可能是发展为PTC的前兆，因为二者之间存在共同的分子免疫机制[28-30]，因此，多数PTC人群中HT的发生率较高。本研究未对患者术前是否已接受甲状腺素治疗进行区分，而这也可能对结果造成一定影响。此外，由于患者多以评估结节性质为目的而进行超声检查，本研究获得的超声资料中缺少甲状腺腺体大小的相关数据，因此无法评估腺体大小对诊断的影响，未来需要更多相关研究加以证实。
综上所述，本研究发现，超声与病理学诊断HT的一致性仅为一般。单独应用超声检查诊断HT的效能不佳，但准确度接近80%，提示超声是诊断HT的支持性证据而非确诊依据。较好的特异度可使超声检查在疾病早期筛查中发挥重要作用。在临床工作中，女性患者合并甲状腺功能异常时，超声诊断HT的价值更高，但最好联合甲状腺特异性抗体检测以减少漏诊的发生。超声诊断因其无创、方便、快捷的特点而易被患者接受，随着影像技术的提升，通过联合血清学、性别、特殊的影像学改变，超声影像将在HT的诊断中发挥更大的作用。
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doi: 10.11855/j.issn.0577-7402.2023.05.0530
  • 接收时间：2023-01-03
  • 首发时间：2025-12-03
  • 出版时间：2023-05-28
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  • 收稿日期：2023-01-03
  • 录用日期：2023-04-24
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    1解放军总医院第一医学中心内分泌科，北京 100853
    2南开大学医学院，天津 300071

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吕朝晖，E-mail：
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2种不同金属材料的力学参数
科
Family		 属数
Number of
genus		 种数
Number of
species		 占总种数比例
Percentage of
total species (%)		 属
Genus		 种数
Number of
species		 占总种数比例
Percentage of total
species (%)
鹅膏菌科Amanitaceae 2 11 5.26 鹅膏菌属 Amanita 10 4.78
小菇科 Mycenaceae 2 12 5.74 丝盖伞属 Inocybe 5 2.39
多孔菌科 Polyporaceae 8 14 6.70 蜡蘑属 Laccaria 5 2.39
红菇科 Russulaceae 3 23 11.00 小皮伞属 Marasmius 6 2.87
小菇属 Mycena 11 5.26
光柄菇属 Pluteus 5 2.39
红菇属 Russula 17 8.13
栓菌属 Trametes 5 2.39
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