Research progress of molecular detection in diagnosis of thyroid nodule
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摘要: 甲状腺结节(TN)是一种临床上常见的内分泌系统疾病，超声检出率可达20%~76%。明确TN病理性质对于临床选择合适的治疗方案具有重要意义。超声引导下细针穿刺(US-FNA)是TN术前鉴别诊断的金标准，美国甲状腺学会建议对直径大于1 cm的结节行US-FNA, 由于US-FNA具有一定的局限性，仍有部分样本不能被明确诊断，给临床治疗带来困难。研究表明，对细针穿刺(FNA)样本进行分子检测能在一定程度上弥补细胞病理学诊断的不足。本文就分子标志物对TN诊断及预后评估相关进展的研究进行综述。Abstract: Thyroid nodule (TN) is a common endocrine disease in clinic, and the detection rate of ultrasound is ranging from 20% to 76%. It is of great significance to clarifythe pathological properties of TN for clinical selection of appropriate treatment. Ultrasound-guided fine-needle aspiration (US-FNA) is the gold standard for preoperative differential diagnosis of TN. The American Thyroid Association (ATA) recommends US-FNA for nodules with a diameter greater than 1 cm. Due to the limitations of US-FNA, the nature of US-FNA can not be clearly diagnosed in some samples, which brings difficulties to clinical treatment. Studies have shown that molecular testing for fine needle aspiration (FNA) samples can make up for the lack of cytopathological diagnosis to a certain extent. This article reviewed the progress of molecular markers in TN diagnosis and prognosis assessment.
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急性脑梗死是临床常见缺血性脑血管疾病，指脑供血突然中断，使脑组织坏死。急性脑梗死危害性较大，易合并缺氧、酸中毒和休克症状，导致凝血功能紊乱和凝血系统异常激活[1]。研究[2]认为，血小板水平、D-二聚体、纤维蛋白原等凝血相关指标是评价脑梗死患者病情和预后的重要指标。血栓弹力图(TEG)能够对血凝块的形成过程、形成强度、速度和血凝块的稳定性进行检测，可反映血液凝固和溶解的全过程[3-4]。本研究探讨常规凝血检测与TEG联合检测对评估急性脑梗死患者近期预后的价值，现报告如下。
1. 资料与方法
1.1 一般资料
选取2019年7月—2020年7月收治的86例急性脑梗死患者，根据患者脑梗死复发情况将患者分为对照组(预后不良)和观察组(预后良好)，每组43例。纳入标准: ①均符合相关诊断标准者; ②均为首次发病者; ③均于发病2周内入院者。排除标准: ①患血液系统疾病者; ②抗凝药物用药史患者; ③肝、肾等重要器官功能障碍者; ④ 2周内有外伤史或外科手术史者。对照组男29例，女14例; 年龄24~71岁，平均(58.74±3.81)岁; 体质量指数(BMI)21~28 kg/m2, 平均(24.69±2.73) kg/m2; 有吸烟史13例; 高血压29例，冠心病12例，糖尿病16例。观察组男30例，女13例；年龄25~72岁，平均(59.35±3.92)岁; BMI 21~27 kg/m2, 平均(24.11±2.69) kg/m2; 有吸烟史10例; 高血压26例，冠心病10例，糖尿病12例。2组性别、年龄、BMI等基线资料比较，差异均无统计学意义(P>0.05), 具有可比性。
1.2 方法
入院时，采用含3.2%枸椽酸钠的0.2 mL真空采血管取2组患者的1.8 mL静脉血，混合均匀后使用全自动凝血分析仪检测纤维蛋白原(FIB)、活化部分凝血活酶时间(APTT)、凝血酶原时间(PT)、凝血酶时间(TT)、血小板计数(PLT)等凝血功能指标水平; 用含抗凝剂的真空采血管采集患者2 mL静脉血，混合均匀后使用全自动血细胞分析仪检测PLT水平。2组患者入院时和随访3个月后，使用含0.102 mL枸椽酸钠的真空采血管取患者清晨空腹2 mL静脉血，将1 mL血样置于含氯化钙20 mL、高岭土340 mL的样杯中，采用CFMS LEPU-8800 TEG分析仪在2 h内检测凝血形成时间、凝血反应时间、凝块形成速率与最大振幅等TEG指标参数。所有试验均使用配套试剂盒，具体操作严格按照说明书进行。
1.3 观察指标
比较2组入院时FIB、APTT、PT、TT、PLT等凝血指标水平; 比较2组入院时及随访3个月后的凝血形成时间、凝血反应时间、α角(表示凝块形成速率)与最大振幅等TEG检测指标参数。
1.4 统计学分析
采用SPSS 22.0软件分析数据，性别、疾病史等计数资料采用[n(%)]表示，组间比较行χ2检验; 年龄、BMI等计量资料采用(x±s)表示，组间比较行t检验。P < 0.05表示差异有统计学意义。
2. 结果
2.1 2组入院时常规凝血检测指标水平比较
2组入院时APTT、TT、PT、FIB、PLT等常规凝血检测指标比较，差异均无统计学意义(P>0.05)。见表 1。
表 1 2组入院时常规凝血检测指标水平比较(x±s)指标 观察组(n=43) 对照组(n=43) APTT/s 31.39±3.54 30.47±4.12 TT/s 14.13±2.76 15.19±3.37 PT/s 10.83±0.67 10.72±0.89 FIB/(g/L) 3.13±1.02 3.41±0.58 PLT/(×109/L) 211.37±48.39 203.48±58.67 APTT: 活化部分凝血活酶时间; TT: 凝血酶时间;
PT: 凝血酶原时间; FIB: 纤维蛋白原; PLT: 血小板计数。2.2 2组血栓弹力图参数比较
入院时，观察组凝血形成时间、凝血反应时间长于对照组, α角小于对照组，最大振幅低于对照组，差异有统计学意义(P < 0.05)。随访3个月后，观察组最大振幅低于对照组，差异有统计学意义(P < 0.05), 但2组凝血形成时间、凝血反应时间和α角比较，差异均无统计学意义(P>0.05)。见表 2。
表 2 2组血栓弹力图参数比较(x±s)组别 凝血形成时间/min 凝血反应时间/min α角/ ° 最大振幅/mm 入院时 随访3个月后 入院时 随访3个月后 入院时 随访3个月后 入院时 随访3个月后 观察组(n=43) 1.64±0.35* 1.64±0.41 6.08±0.72* 6.09±0.87 62.71±4.36* 62.31±6.02 61.39±4.08* 58.64±6.27* 对照组(n=43) 1.46±0.45 1.51±0.43 5.67±1.01 5.88±0.71 64.76±4.92 63.59±5.87 66.79±5.28 61.48±4.69 与对照组比较, *P < 0.05。 3. 讨论
急性脑梗死是一种临床常见脑血管疾病，具有较高发病率、致残率和病死率，常由纤溶系统和凝血系统失衡、血小板活化造成血栓而引发[5-7]。急性脑梗死具有发病急、病情进展快等特点，早期CT检查不易检出，对即刻诊断造成困难，常错过溶栓时机，对治疗及预后产生影响[8-9]。常规凝血检测指标只能对凝血过程中部分及个别因子进行检测，无法完全反映患者凝血功能的真实状态[10-12], 而采用TEG联合检测可反映、评估凝血级联反应、纤溶活性、血小板和血细胞成分对血浆因子活动影响[13-15]。
凝血功能指标包括FIB、PT、PP、APTT, 这些指标可作为反映机体血液凝血功能的重要参考指标[16]。FIB为急性时相反应蛋白，血液高凝状态下FIB会升高，反之则会降低。PT、PP、APTT为重要的内外源凝血指标。FIB增加或PT、PP、APTT缩短表明血液高凝，反之凝血功能则降低[17-18]。TEG是一种可靠的凝血系统紊乱检测指标，具有易操作、用血量少和检测时间短等优点，为临床提供凝血因子活性、血小板功能等完整信息[19-21]。TEG主要包括凝血形成时间、凝血反应时间、α角和最大振幅等检测指标，分别能反映血小板与纤维蛋白在血凝块形成早期的相互作用，凝血开始时凝血因子的作用、血小板与纤维蛋白在增强血凝块中的作用，血小板在血凝块稳定阶段的作用[22-23]。
本研究结果显示, 2组入院时APTT、TT、PT、FIB、PLT等常规凝血检测指标比较均无显著差异，常规凝血指标并无明显异常，说明入院时凝血指标水平对预后良好和预后不良患者的预后效果均无明显影响。可能是因为APTT、PT等常规凝血指标检测只反映凝血开始时形成的少量凝血酶，并未能提供血栓强度、纤溶活性和血小板功能等完整信息。相关研究[24]认为，常规凝血指标检测不能很好反映出机体内真实凝血平衡情况，检测结果过于片面，肝素类物质会影响其检测结果。本研究结果表明，入院时，观察组的凝血形成时间、凝血反应时间显著长于照组, α角显著小于对照组、最大振幅显著低于对照组，提示在血凝块强化时，纤维蛋白原和血小板相互作用，以增加血块凝固速率，提高两者活性，使血液处于高凝状态，部分血小板活性受抗血小板治疗抑制，导致纤维蛋白、血小板结合形成血凝块的能力降低。随访3个月后，观察组最大振幅显著低于对照组，说明血小板仍存在较高活性，可形成新的血栓，对照组最大振幅增加可能与脑梗死复发存在一定关系。研究[25-27]认为，最大振幅可反映血小板、纤维蛋白凝块的最大强度，血小板发挥80%以上的作用，可反映其聚集功能。同时，最大振幅是导致缺血性脑卒中患者1年后发生预后不良的危险因素。
综上所述, TEG检测指标参数可全面反映出患者体内的凝血变化情况，参数异常说明急性脑梗死预后不良患者血液存在高凝状态。TEG联合检测可为及时诊断急性脑梗死、评估患者病情及治疗提供理论依据。但本研究仍存在一定局限性，研究的样本量较少，还需从多方面深入验证采用单独TEG指标检测急性脑梗死与缺血复发情况风险间的关系。
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