七、研究方向展望
在精准医学、大数据等现代化医学发展的大背景下，PTMC领域中也有很多值得研究的方向。
第一，也是最为重要的，是研究能够准确划分PTMC风险级别的因素和模型。因为若想对PTMC进行理性化、个体化管理，准确的风险分层至关重要。而且，风险分层要从术前就开始，以便甄别出具备惰性特征的“静息癌”，采取不同于有进展潜能的“早期癌”的管理策略，比如随访观察。此外，对PTMC的风险评估，还要探讨如何根据随访过程中获得的最新数据，实时修订患者的风险分层，连续地、动态地、精准地综合评价患者对治疗的反应，帮助临床医生提出恰当的治疗方案或修订后续的随访策略，以面对不同的病情发展走势，避免诊疗不足或过度。期望肿瘤的分子标志物等指标能够为PTMC的风险分层提供有价值的信息。
第二，组织精心设计、严谨执行的大样本多中心临床研究，前瞻性观察现有的PTMC诊疗推荐下患者的长期预后，探讨一些存在争议的治疗方式（如是否常规行中央区淋巴结清扫等）的临床获益大小。特别是我国缺乏甲状腺微小癌的高质量循证医学数据，目前的观点大多数基于国外的研究，这一现状亟待改变。
第三，对PTMC的筛查和诊断策略进行规范。为了避免“过度诊断和治疗”临床无害性的PTMC，应避免普遍筛查，提高术前诊断水平。
第四，鉴于PTMC是生存期长的恶性肿瘤，对其诊疗方案的卫生经济学研究，以及其患者生存质量的观察，都是未来应当关注的方向。如何既能合理使用医疗资源、保障患者利益，又能缓解患者心理压力、提高他们的生活质量，需要积累更多的经验。
参考文献
[1] DeLellis R A, Lloyd R V, Heitz P U, et al.World Health Organization classification of tumours.Pathology and genetics of tumours of endocrine organs[S].Lyon: IARC Press, 2004,54-55.
[2] 关海霞， 滕卫平.甲状腺微小癌的现代观点[J].中华内科杂志， 2016， 55（1）： 1-3.DOI： 10.3760/cma.j.issn.0578-1426.2016.01.001.
[3] Vaccarella S, Franceschi S, Bray F, et al.Worldwide thyroid-cancer epidemic? The increasing impact of overdiagnosis [J].N Engl J Med, 2016, 375(7): 614-617.DOI: 10.1056/NEJMp1604412.
[4] Kitahara C M, Sosa J A.The changing incidence of thyroid cancer [J].Nat Rev Endocrinol, 2016, 12(11): 646-653.DOI: 10.1038/nrendo.2016.110.
[5] Roti E, degli Uberti E C, Bondanelli M, et al.Thyroid papillary microcarcinoma: a descriptive and meta-analysis study [J].Eur J Endocrinol, 2008, 159(6):659-673.
[6] Mehanna H, Al-Maqbili T, Carter B, et al.Differences in the recurrence and mortality outcomes rates of incidental and nonincidental papillary thyroid microcarcinoma: a systematic review and meta-analysis of 21 329 personyears of follow-up [J].J Clin Endocrinol Metab, 2014,99(8):2834-2843.
[7] Lo C Y, Chan W F, Lang B H, et al.Papillary microcarcinoma: is there any difference between clinically overt and occult tumors [J].World J Surg,2006, 30(5):759-766.
[8] Hay I D, Hutchinson M E, Gonzalez-Losada T, et al.Papillary thyroid microcarcinoma: a study of 900 cases observed in a 60-year period [J].Surgery,2008, 144(6):980-987.
[9] 关海霞.甲状腺微小乳头状癌的观察——慎思之，明辨之，笃行之[J].中华内分泌代谢杂志， 2017， 33（4）：92-95.(https://www.daowen.com)
[10] Haugen B R Md, Alexander E K, Bible K C, et al.2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer [J].Thyroid,2015,Oct 14.[Epub ahead of print].
[11] American Thyroid Association (ATA) guidelines taskforce on thyroid nodules and differentiated thyroid cancer,Cooper DS, Doherty GM, et al.Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer [J].Thyroid, 2009, 19(11):1167-1214.
[12] 中华医学会内分泌学分会，中华医学会外科学分会内分泌学组，中国抗癌协会头颈肿瘤专业委员会，等.甲状腺结节和分化型甲状腺癌诊治指南[J].中华内分泌代谢杂志， 2012， 28（10）： 779-797.DOI：10.3760/cma.j.issn.1000-6699.2012.10.002.
[13] Lamartina L, Durante C, Filetti S, et al.Low-risk differentiated thyroid cancer and radioiodine remnant ablation: a systematic review of the literature [J].J Clin Endocrinol Metab, 2015, 100(5):1748-1761.
[14] McLeod D S, Sawka A M, Cooper D S.Controversies in primary treatment of low-risk papillary thyroid cancer [J].Lancet,2013, 381(9871):1046-1057.
[15] 关海霞.甲状腺微小癌术后促甲状腺激素抑制治疗：认识和挑战[J].中国实用外科杂志， 2016， 36 （5）：524-527.
[16] Amit M, Rudnicki Y, Binenbaum Y, et al.Defining the outcome of patients with delayed diagnosis of differentiated thyroid cancer [J].Laryngoscope, 2014,124(12): 2837-2840.DOI: 10.1002/lary.24744.
[17] Miyauchi A.Clinical trials of active surveillance of papillary microcarcinoma of the thyroid [J].World J Surg,2016, 40: 516-522.DOI: 10.1007/s00268-015-3392-y.
[18] Sugitani I, Toda K, Yamada K, et al.Three distinctly different kinds of papillary thyroid microcarcinoma should be recognized: our treatment strategies and outcomes [J].World J Surg, 2010, 34(6): 1222-1231.DOI: 10.1007/s00268-009-0359-x.
[19] Tuttle R M.Successful implementation of an active surveillance management approach to low risk papillary thyroid cancer in the United States.Oral presentation at the 87th ATA annual meeting [J].Thyroid, 2016, 26(S1):A-138-A-163.DOI: 10.1089/thy.2016.29027.abstracts.
[20] Yoshida A, Okamoto T.Japanese management guidelines for thyroid tumors 2010.Edited by the Japanese Association of Endocrine Surgeons and the Japanese Society of Thyroid Surgery[M].Tokyo: Kanehara Shuppan,2010.
[21] 中国抗癌协会甲状腺癌专业委员会（CATO）.甲状腺微小乳头状癌诊断与治疗中国专家共识（2016版）[J].中国肿瘤临床， 2016， 43（10）： 95-98.DOI： 10.3969/j.issn.1000- 8179.2016.10.001.
[22] Tufano R P, Noureldine S I, Angelos P.Incidental thyroid nodules and thyroid cancer: considerations before determining management [J].JAMA Otolaryngol Head Neck Surg, 2015, 141(6): 566-572.DOI: 10.1001/jamaoto.2015.0647.
[23] Haser G C, Tuttle R M, Su H K, et al.Active surveillance for papillary thyroid microcarcinoma: new challenges and opportunities for the health care system [J].Endocr Pract,2016, 22(5): 602-611.DOI: 10.4158/EP151065.