后贝塞斯达时代术中冷冻切片在甲状腺结节手术决策中的应用价值与争议

Application value and controversies of intraoperative frozen section in surgical decision-making for thyroid nodules in the post-Bethesda era

摘要:

随着细针穿刺活检（FNA）在甲状腺结节诊断中的广泛应用，术中冷冻切片（FS）在手术决策中的价值在“后贝塞斯达时代”受到重新审视。本文系统综述FS在不同Bethesda分类甲状腺结节中的应用价值，重点分析其在避免过度手术与防止手术不足中的作用，并比较东、西方国家在临床实践上的差异。现有证据表明：在Bethesda Ⅵ类结节中，FNA阳性预测值极高，常规使用FS难以改善手术决策，且可能因假阴性导致手术不足；在Bethesda Ⅴ类结节中，FS的应用价值与不同人群中该类结节的恶性风险（ROM）密切相关，西方国家因ROM相对较低，FS可减少FNA假阳性导致的过度手术，而中国等亚洲人群ROM显著升高，常规使用FS难以带来额外获益；在Bethesda Ⅱ类结节中，FS缺乏成本效益，仅适用于影像高度可疑的选择性病例；在Bethesda Ⅰ类和部分Bethesda Ⅲ类结节中，FS有助于明确诊断并优化初次手术范围，而在Bethesda Ⅳ类结节中，由于诊断敏感度低，不推荐常规使用FS。多基因检测技术为不确定结节的风险分层提供了新的工具，但在我国的临床应用仍受限制。综上，FS在甲状腺结节中的应用不宜“一刀切”，应结合不同Bethesda分类、人群ROM及各医疗机构自身FS诊断效能，制定个体化术中决策策略。

Abstract:

With the widespread adoption of fine-needle aspiration (FNA) in the diagnostic workup of thyroid nodules, the role of intraoperative frozen section (FS) in surgical decision-making has been increasingly re-evaluated in the post-Bethesda era. This review systematically summarizes the clinical value of FS across different Bethesda categories, with particular focus on its role in preventing overtreatment and avoiding insufficient surgery, as well as the notable differences between Western and Asian clinical practices. Current evidence indicates that for Bethesda Ⅵ nodules, the positive predictive value of FNA is extremely high, and routine FS rarely alters surgical management while potentially increasing the risk of under-treatment due to false-negative results. For Bethesda V nodules, the utility of FS largely depends on the population-specific risk of malignancy (ROM): in Western countries with relatively lower ROM, FS may reduce overtreatment caused by FNA false positives, whereas in China and other Asian populations with significantly higher ROM, routine FS provides limited additional benefit. For Bethesda Ⅱ nodules, routine FS is not cost-effective and should be reserved for selected high-risk cases. FS is beneficial in Bethesda I and some Bethesda Ⅲ nodules for clarifying diagnosis and optimizing the extent of initial surgery, but it is not recommended for routine use in Bethesda Ⅳ nodules due to low diagnostic sensitivity. Molecular testing offers new tools for risk stratification in indeterminate nodules, although its application remains limited in China. In conclusion, FS should not be applied uniformly across all patients but rather tailored according to Bethesda category, population-specific ROM, and institutional diagnostic performance of FS.