甲状腺结节热消融后的手术：手术风险、策略及病理发现的系统综述

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中文摘要

背景： 热消融越来越多地用于部分甲状腺结节，但部分患者随后仍需行甲状腺切除术。既往消融对手术风险、手术策略及组织病理学的影响仍不明确。
方法： 检索PubMed/MEDLINE、EMBASE和Cochrane Library自建库至2026年5月，纳入报告射频、激光或微波消融后甲状腺切除术手术和/或组织病理学结局的研究。纳入队列研究和至少包含2例患者的病例系列。数据采用描述性综合，并按消融指征分层：良性/不确定结节与原发性甲状腺乳头状癌。
结果： 共纳入9项回顾性研究，包括150例患者：6项关于良性/不确定结节（n=105），3项关于原发性甲状腺乳头状癌（n=45）。在良性/不确定病例中，暂时性喉返神经麻痹发生率为0%至9.7%，暂时性甲状旁腺功能减退为0%至6.5%，需再次手术的血肿为0%至6.5%；未报告永久性喉返神经麻痹或甲状旁腺功能减退。对照研究显示，消融后手术时间更长、甲状腺切除术难度评分更高、粘连更严重，但总体并发症发生率无显著差异。组织病理学显示纤维化、玻璃样变、凝固性坏死及治疗相关异型性，可能使滤泡型肿瘤的评估复杂化；未发现消融区内发生的癌。在甲状腺乳头状癌组中，消融作为主要治疗后手术标本常显示残留肿瘤和淋巴结转移，而肿瘤学随访大多缺失。手术策略和术中辅助措施的报告不一致。
结论： 在有经验的内分泌外科中心，热消融后甲状腺切除术似乎可行，报告的永久性并发症发生率低，但可能比初次手术在技术上更复杂。当前证据仅限于小型、异质性回顾性系列，无法确定既往消融的真实增量手术风险、最佳手术策略或长期肿瘤学影响。需要采用标准化报告的前瞻性多中心比较研究。

英文摘要

BACKGROUND: Thermal ablation is increasingly used for selected thyroid nodules, but some patients subsequently require thyroidectomy. The effect of prior ablation on surgical risk, operative strategy, and histopathology remains unclear.
METHODS: PubMed/MEDLINE, EMBASE, and the Cochrane Library were searched from inception to May 2026 for studies reporting surgical and/or histopathological outcomes of thyroidectomy after radiofrequency, laser, or microwave ablation. Cohort studies and case series with at least two patients were included. Data were synthesized descriptively and stratified by ablation indication: benign/indeterminate nodules versus primary papillary thyroid carcinoma.
RESULTS: Nine retrospective studies including 150 patients were included: six on benign/indeterminate nodules (n = 105) and three on primary papillary thyroid carcinoma (n = 45). In benign/indeterminate cases, transient recurrent laryngeal nerve palsy ranged from 0% to 9.7%, transient hypoparathyroidism from 0% to 6.5%, and hematoma requiring reoperation from 0% to 6.5%; no permanent recurrent laryngeal nerve palsy or hypoparathyroidism was reported. Controlled studies showed longer operative times, higher thyroidectomy difficulty scores, and more severe adhesions after ablation, although overall complication rates did not differ significantly. Histopathology showed fibrosis, hyalinization, coagulative necrosis, and treatment-related atypia, potentially complicating assessment of follicular-patterned neoplasms; no carcinoma arising within the ablated zone was identified. In the papillary thyroid carcinoma group, surgical specimens frequently revealed residual tumor and lymph node metastases after ablation used as primary treatment, while oncological follow-up was largely absent. Reporting of surgical strategy and intraoperative adjuncts was inconsistent.
CONCLUSIONS: Thyroidectomy after thermal ablation appears feasible in experienced endocrine surgery centers, with low reported permanent morbidity, but may be technically more complex than primary surgery. Current evidence is limited to small, heterogeneous retrospective series and cannot define the true incremental surgical risk, optimal operative strategy, or long-term oncological impact of prior ablation. Prospective multicenter comparative studies with standardized reporting are needed.