甲状腺癌精准管理的范式转变

Paradigm Transformation of Precision Management of Thyroid Cancer

摘要: 近年来，甲状腺癌发病率持续上升，而总体死亡率保持相对稳定，过度诊断与过度治疗问题逐渐凸显，促使其诊疗理念发生深刻转变。传统以手术和放射性碘为核心的“一刀切”模式，已难以同时满足惰性肿瘤精准降级管理与侵袭性、放射性碘难治性疾病强化治疗的双重需求。随着病理分类体系的更新、分子生物学研究的深入及系统治疗手段的发展，甲状腺癌正进入以分子特征和动态风险评估为导向的精准管理时代。本文系统综述了近年来甲状腺癌在病理分类与风险分层演进、诊断与初始管理策略转变，以及局部晚期和转移性疾病系统治疗方面的关键进展，重点讨论主动监测、分子诊断、再分化治疗、高选择性靶向治疗及免疫联合策略的临床价值与局限，并展望液体活检和多组学技术在未来管理中的潜在作用。总体而言，构建整合风险评估、治疗选择与随访调整的动态闭环管理模式，将是实现甲状腺癌精准全程管理的关键方向。

Abstract: In recent years, the incidence of thyroid cancer has continued to rise, while overall mortality has remained relatively stable. This epidemiological paradox has highlighted the growing problem of overdiagnosis and overtreatment, driving a fundamental shift in diagnostic and therapeutic paradigms. Traditional “one-size-fits-all” strategies centered on surgery and radioactive iodine are increasingly inadequate to meet the dual clinical demands of de-escalated management for indolent tumors and intensified treatment for aggressive or radioactive iodine-refractory disease. With updates in pathological classification systems, advances in molecular biology, and the rapid development of systemic therapies, thyroid cancer management is entering an era of precision medicine guided by molecular features and dynamic risk assessment. This review systematically summarizes recent progress in pathological classification and risk stratification, evolving diagnostic and initial management strategies, and systemic treatment for locally advanced and metastatic thyroid cancer. Particular emphasis is placed on the clinical value and limitations of active surveillance, molecular diagnostics, redifferentiation therapy, highly selective targeted therapies, and immunotherapy-based combination strategies, as well as the emerging roles of liquid biopsy and multi-omics technologies. Overall, the development of a dynamic, closed-loop management model integrating risk assessment, treatment decision-making, and follow-up adjustment will represent the critical direction for achieving truly individualized and comprehensive precision management of thyroid cancer.