2023年 · 第38卷第10期

In the past 20 years, the discipline of thyroid oncology has made remarkable and rapid development at home and abroad. The concept and standardization process of thyroid tumor diagnosis and treatment in China have been greatly improved, and the outstanding achievements are obvious to all. In the early stage, the implementation and promotion of the discipline goal of "one morning, one night, one standard" for thyroid cancer that we have been advocating has been in-depth, that is, emphasizing and improving the primary and secondary prevention of thyroid cancer, while the treatment of early cancer should be formulated according to risk stratification, realizing the observation, diagnosis and treatment strategy of low-risk cancer; Focus on and improve the therapeutic effect of advanced thyroid cancer, the research and development and application of new drugs and treatment methods, emphasize precise and comprehensive treatment, and effectively improve the survival time and quality of life of patients; All staged thyroid cancers, especially "mid-stage" patients with common clinical treatment, put more emphasis on the standardization of treatment, including surgery, nuclear medicine and endocrine therapy. The promotion of these advocates has achieved remarkable results through the continuous efforts of thyroid oncology scholars in China for more than ten years. According to the data of the National Cancer Center, the 5-year survival rate (all-cause death) of thyroid cancer patients in China has increased from 67.5% 20 years ago to 84.3%. It is believed that with the statistical results in recent years, the survival rate will be significantly improved. This is the core symbol of disciplinary progress.

A 70-year-old male was admitted to the hospital due to "colic in the upper abdomen for 2 months after repeated eating". Physical examination showed that a surgical scar of about 20 cm long was visible on the abdomen, mild tenderness in the upper abdomen, no rebound pain, and slightly active intestinal sounds. The patient underwent open total gastrectomy and Roux-en-Y gastrointestinal reconstruction for gastric cancer in 2020. The patient had a BMI of 18.9 kg/m at admission²。 The rest of the medical history is not special. Whole abdominal enhanced CT showed a "beak-shaped" superior mesenteric vein (Figure 1), and a "vortex sign" of mesenteric fat and vascular structures (Figure 2), suggesting the presence of intestinal obstruction or volvulus. Exploratory laparotomy revealed approximately 1 m of the small intestine crossing to the right through the Petersen space formed by the transverse colon and Roux haptics (Figure 3). The herniated small intestine was free of ischemic necrosis, and the herniated small intestine was recovered and closed with 4-0 absorbable thread suture. After the operation, the patient's symptoms were significantly relieved, and he was discharged from hospital on the 4th day after the operation. No recurrence has been seen since the follow-up.

A 22-year-old male was admitted mainly for "hematochezia for 2 days". Physical examination: All abdominal soft, lower abdominal tenderness, no rebound pain and muscle tension. Blood routine: RBC 1.92×10¹²/L, HGB 58 g/L, HCT 16.9%, HE% 83.6%. Colonoscopy showed more blood accumulation in the intestine. Enhanced CT of the whole abdomen and pelvis showed intussusception of the left middle and lower abdomen, and obvious enhanced nodules were seen in the small intestine cavity of the insertion part (Figure 1). Surgical treatment was performed in the emergency department. During the operation, intussusception occurred in the ileum about 50 cm away from the ileocecal region. A hard mass was palpable in the intestinal lumen, and dark red blood was visible in the distal intestinal lumen. The intussusception was reset. It was found that the cause of intussusception was Meckel's diverticulum and a mass at the distal end of the diverticulum. The diverticulum was inverted into the intestinal lumen, and the proximal intestinal tube was inserted into the distal end (Figure 2). The intussusception was about 20 cm long, with obvious edema and stiffness. The diverticulum and the edematous ileum were removed, the corresponding mesenteric membrane was cut off, the distal and proximal ends of the intestinal tube were cut off, and the proximal and distal ileal anastomosis was performed. Postoperative pathological examination revealed ectopic pancreas (small intestine) (Figure 3).

The patient, a 56-year-old male, was admitted to hospital for "discovering a neck mass for more than 2 years". Physical examination: The trachea is deviated to the right, and a mass can be palpable in the left thyroid gland, which is the size of a table tennis ball, tough in texture, clear in boundary, and can be moved up and down with swallowing. The right thyroid gland is not palpable with obvious abnormalities, and the neck and other lymph nodes are not palpable with swelling. Thyroid ultrasonography revealed abnormal glandular morphology, with a large hypoechoic nodule accessible to the left lateral lobe, occupying almost the entire left lateral lobe, with a size of about 4.48 cm ×3.38 cm, regular morphology and clear border, C-TI-RADS 4a. Multiple oval isohypoechoic nodules were seen in the bilateral neck, with the larger one on the right side being 1.9 cm ×0.5 cm and the larger one on the left side being 1.2 cm ×0.6 cm, with clear boundaries and portal blood flow (Figure 1). Total thyroidectomy + bilateral zone VI lymph node dissection + bilateral recurrent laryngeal nerve exploration + lymph node marking + left recurrent laryngeal nerve suture. During the operation, it was found that the tumor invaded and compressed the left recurrent laryngeal nerve, so the left recurrent laryngeal nerve could not be separated, so the left recurrent laryngeal nerve was separated from the tightly wrapped place of the tumor, and end-to-end anastomosis was performed with polypropylene suture. Subsequently, the left thyroid gland and isthmus were removed and dissected, and cystic-solid necrotic tissue with yellowish-brown fluid was seen. The results of intraoperative rapid freezing pathological examination reported that some of them showed papillary thyroid carcinoma (PTC), and also saw spindle cell area with abnormal cells. The postoperative pathological results showed that the right thyroid was follicular nodular lesion, and there was no cancer metastasis in bilateral zone VI lymph nodes. Under the left thyroscope, three tumor histological manifestations of PTC, eosinophilic carcinoma and undifferentiated carcinoma (ATC) in the tumor area were interspersed and grown (Figure 2). The results of intraoperative frozen pathological immunohistochemistry were: CK19 (focus +), CD56 (focus +), Vimentin (weak), Ki-67 (30%), Galectin3 (-), HBME1 (focus +), TTF-1 (+), TG (focus +), CRA (-), Calcitonin (-), CK (+), CD68 (+); The results of postoperative pathological immunohistochemistry were: PAX8 (+), TTF-1 (+), CK19 (focus +), CAIX (-), CK (+), CD68 (+), CgA (-).

Thyroid nodules are very common in clinic. Ultrasound imaging and fine needle aspiration cytology are effective methods for the diagnosis of thyroid nodules at present. However, there are still a large number of thyroid nodules that cannot be clearly judged and decided. Guidelines such as "China Cancer Integrated Diagnosis and Treatment Guidelines-CACA Guidelines for Thyroid Cancer Diagnosis and Treatment", National Comprehensive Cancer Network (NCCN) guidelines, and American Thyroid Association (ATA) guidelines issued by China Anti-Cancer Association recommend that genetic testing should be applied to clinically assist in the diagnosis and prognosis of benign and malignant Thyroid nodules, and guide precise treatment. The 2023 edition of the Bethesda reporting system for thyroid cytopathology states that molecular testing is recommended for nodules with atypical morphology, follicular tumors, or suspected malignancy. Previous gene detection mostly used fluorescence quantitative polymerase chain reaction (qPCR) technology, and the genes detected were mostly single genes. In recent years, with the widespread use of high-throughput sequencing technology (next generation sequencing, NGS), its advantage is that it can realize the detection of unknown sites and multi-gene joint detection, but it also brings some problems. The amount of gene mutation information detected by NGS technology is huge, the test reports of various institutions are in various forms, uneven quality, and even the report interpretation is wrong, which brings a lot of confusion to clinicians. To this end, in April 2023, under the initiative and organization of the Chinese Anti-Cancer Association (CATO) and the Thyroidology Group Oncology Society (TGOCMA) of the Oncology Branch of the Chinese Medical Association, after extensive discussion and consultation, some suggestions were made on the standardization of thyroid NGS genetic test reports, including basic information of the report, summary of test results, annotation rules and detailed results of genetic variants, and specifications for report review and issuance, etc., hoping to help clinicians accurately and quickly extract key information from the report, correctly interpret and assist in clinical decision-making, and maximize the clinical benefits of patients.