妊娠期甲状腺结节和甲状腺癌

十六、妊娠期甲状腺结节和甲状腺癌

1.流行病学：在比利时、中国、德国进行的研究结果表明，甲状腺结节的患病率在3%～21%，且随着妊娠次数增加而增加。比利时和德国的研究报道在妊娠早期发现结节的妊娠妇女有11%～20%在妊娠过程中出现再发结节。随着妊娠妇女年龄增加，甲状腺结节患病率随之增加。妊娠期间甲状腺结节体积可能增加，产后3个月可恢复到妊娠早期的体积。来自中国妊娠妇女的研究发现，妊娠期间甲状腺结节发生率为15.3%（34/212），女性分化型甲状腺癌（DTC）患病率为男性的3倍，在生育期的妇女发病率达到高峰[143]。美国加利福尼亚癌症中心对当地1991—1999年所有妊娠妇女进行回顾性分析，发现甲状腺癌在妊娠妇女中的发病率为14.4/10万，乳头状甲状腺癌为最常见的病理类型。不同时间诊断为甲状腺癌的比例分别为：分娩前3.3/10万、分娩时0.3/10万，分娩后1年10.8/10万[144]。

2.诊断：对甲状腺结节患者应该询问甲状腺疾病家族史。2015年美国甲状腺学会成人甲状腺结节和分化型甲状腺癌治疗指南推荐通过颈部超声和细针穿刺活检（FNA）作为甲状腺结节诊断方法。妊娠16周后TSH仍然持续偏低的妊娠妇女，建议产后进行甲状腺结节的细针穿刺活检。TSH未被抑制的妊娠期间新发甲状腺结节建议进行甲状腺结节细针穿刺活检。在甲状腺结节的妊娠妇女中检测降钙素的证据不充分，目前尚不建议对甲状腺结节的妊娠妇女常规检测血清降钙素。妊娠期间不能进行甲状腺放射性核素扫描或者放射性碘摄取检查。

3.治疗：

（1）良性/性质未定甲状腺结节治疗：没有充分证据表明L-T4可以阻止甲状腺结节生长，故妊娠期间不建议补充L-T4治疗甲状腺结节。甲状腺细针穿刺活检证实结节良性，但是生长迅速或超声显示可疑恶性病变者可以考虑手术治疗。妊娠期间，性质未明的甲状腺结节如持续生长或者良性结节压迫气管或食管时，应考虑手术治疗。妊娠期间甲状腺结节生长不明显，结节病理为良性或不确定良恶性时暂时不需要手术治疗。妊娠期间正常生理变化也可以使母亲甲状腺体积增加，包括甲状腺结节体积增加，故需要密切监测妊娠期间甲状腺结节变化。

（2）甲状腺癌治疗：妊娠早期细针穿刺细胞学证实的甲状腺乳头状癌应该超声监测，如果妊娠24周增长迅速或者存在颈部淋巴结转移，应该考虑妊娠中期手术。如果妊娠中期稳定或者如果在妊娠后期确诊，建议分娩后再做手术。如果诊断时分化型甲状腺癌在进展期或者如果细胞学提示甲状腺髓样癌或者未分化甲状腺癌，建议妊娠中期手术。日本研究观察了45例分化型甲状腺癌患者，24例妊娠期间行甲状腺切除术（19例在妊娠中期），21例分娩后手术。两组间母亲甲状腺癌复发率没有差异，没有流产或者胎儿出生缺陷。考虑妊娠早期手术麻醉可影响胎儿器官形成及引起自发性流产，妊娠晚期手术易发生早产，有研究对妊娠中期甲状腺切除术的作用进行评估，未发现母亲或胎儿并发症，故妊娠期甲状腺手术应尽量在妊娠中期实施，以降低母亲及胎儿并发症的发生。放射性碘治疗育龄妇女合并分化型甲状腺癌并未增加今后不育或妊娠不良结局的风险，育龄妇女接受放射性131I治疗后至少推迟6个月妊娠，131I治疗可能引起男性精子活动度降低，故男性接受131I治疗后在计划妊娠之前至少等待120d（精子的寿命）。

4.妊娠期甲状腺癌预后：7项回顾性研究比较了妊娠期间、产后1年和其他时间诊断为分化型甲状腺癌妇女的预后，其中6项研究没有发现预后存在差异，1项研究显示妊娠期间或产后1年内诊断的DTC患者预后较差。目前尚无妊娠增加分化型甲状腺癌复发风险的证据。

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