The frequency of malignancy and the relationship between malignancy and ultrasonographic features of thyroid nodules with indeterminate cytology

Correlation of TIRADS scoring in thyroid nodules with preoperative fine needle aspiration biopsy and postoperative specimen pathology

INTRODUCTION

The aim of our study is to determine the value of Thyroid Imaging Reporting and Data Systems (TIRADS) scoring in predicting malignancy in thyroid nodules by examining its relationship with fine needle aspiration biopsy and postoperative histopathological results.

MATERIALS AND METHODS

In this study, patients who underwent surgery after ultrasonographic examination and fine needle aspiration biopsy for thyroid nodules at the General Surgery Clinic of Çukurova University Faculty of Medicine between January 2014 and November 2021 were retrospectively analyzed. The thyroid ultrasonography and fine needle aspiration biopsy of the included patients were performed by a clinician with 15 years of experience. The ultrasonographic features of the nodules were re-evaluated by the same clinician, and the American College of Radiology (ACR) TIRADS score was determined. Fine needle aspiration biopsy results were grouped according to Bethesda criteria. Postoperative histopathological examination results were divided into two groups: benign and malignant. The ACR TIRADS score was compared with fine needle aspiration biopsy and histopathological results. The performance of the ACR TIRADS score in predicting malignancy was determined.

RESULTS

79.8% of the 397 patients were female, and the mean age was 50.9 ± 12.8 years. The mean diameter of the nodules was 27.4 ± 15.8 mm. There was a significant, positive, but weak correlation between ACR TIRADS and Bethesda (p < 0.001) (r = 0.33). When the ACR TIRADS score was compared with histopathological results, it was found that the rate of malignancy increased as the TIRADS score increased (p < 0.001). The rates of malignancy diagnosis were 0% for TR1, 13.2% for TR2, 21.7% for TR3, 50.3% for TR4, and 72.4% for TR5. The area under the receiver operating characteristic curve for TIRADS in predicting malignancy was 0.747 (95% CI: 0.699-0.796, p < 0.001). TIRADS can distinguish malignancy with 75% accuracy. The optimal cutoff point was determined as TR4 with 80.3% sensitivity and 60.8% specificity.

CONCLUSION

The ACR TIRADS scoring system is an effective risk classification system for thyroid nodules, providing 75% accuracy in predicting malignancy, with 80.3% sensitivity and 60.8% specificity values.

Sonographic Features Differentiating Follicular Thyroid Cancer from Follicular Adenoma-A Meta-Analysis

Simple Summary

The risk of thyroid malignancy assessment may include certain ultrasound features. The analysis is lacking for the differentiation of follicular thyroid adenomas and cancers (FTAs and FTCs). Our meta-analysis aimed to identify sonographic features suggesting malignancy in the case of follicular lesions, potentially differentiating FTA and FTC. Based on twenty studies describing sonographic features of 10,215 nodules, we found that the most crucial feature associated with an increased risk of FTC were tumor protrusion (odds ratios—OR = 10.19), microcalcifications or mixed type of calcifications: 6.09, irregular margins: 5.11, marked hypoechogenicity: 4.59, and irregular shape: 3.6.

Abstract

Certain ultrasound features are associated with an increased risk of thyroid malignancy. However, they were studied mainly in papillary thyroid cancers (PTCs); these results cannot be simply extrapolated for the differentiation of follicular thyroid adenomas and cancers (FTAs and FTCs). The aim of our study was to perform a meta-analysis to identify sonographic features suggesting malignancy in the case of follicular lesions, potentially differentiating FTA and FTC. We searched thirteen databases from January 2006 to December 2020 to find all relevant, full-text journal articles written in English. Analyses assessed the accuracy of malignancy detection in case of follicular lesions, potentially differentiating FTA and FTC included the odds ratio (OR), sensitivity, specificity, positive and negative predictive values. A random-effects model was used to summarize collected data. Twenty studies describing sonographic features of 10,215 nodules met the inclusion criteria. The highest overall ORs to increase the risk of malignancy were calculated for tumor protrusion (OR = 10.19; 95% confidence interval: 2.62–39.71), microcalcifications or mixed type of calcifications (coexisting micro and macrocalcifications): 6.09 (3.22–11.50), irregular margins: 5.11 (2.90–8.99), marked hypoechogenicity: 4.59 (3.23–6.54), and irregular shape: 3.6 (1.19–10.92). The most crucial feature associated with an increased risk of FTC is capsule protrusion, followed by the presence of calcifications, irrespectively of their type.

Diagnosis of thyroid nodules for ultrasonographic characteristics indicative of malignancy using random forest

Background

Various combinations of ultrasonographic (US) characteristics are increasingly utilized to classify thyroid nodules. But they lack theories, and heavily depend on radiologists’ experience, and cannot correctly classify thyroid nodules. Hence, our main purpose of this manuscript is to select the US characteristics significantly associated with malignancy and to develop an efficient scoring system for facilitating ultrasonic clinicians to correctly identify thyroid malignancy.

Methods

A logistic regression (LR) model is utilized to identify the potential thyroid malignancy, and the least absolute shrinkage and selection operator (LASSO) method is adopted to simultaneously select US characteristics significantly associated with malignancy and estimate parameters in LR model. Based on the selected US characteristics, we calculate the probability for each of thyroid nodules via random forest (RF) and extreme learning machine (ELM), and develop a scoring system to classify thyroid nodules. For comparison, we also consider eight state-of-the-art methods such as support vector machine (SVM), neural network (NET), etc. The area under the receiver operating characteristic curve (AUC) is employed to measure the accuracy of various classifiers.

Results

The US characteristics: nodule size, AP/T≥1, solid component, micro-calcifications, hackly border, hypoechogenicity, presence of halo, unclear border, irregular margin, and central vascularity are selected as the significant predictors associated with thyroid malignancy via the LASSO LR (LLR). Using the developed scoring system, thyroid nodules are classified into the following four categories: benign, low suspicion, intermediate suspicion, and high suspicion, whose rates of malignancy correctly identified for RF (ELM) method on the testing dataset are 0.0% (4.3%), 14.3% (50.0%), 58.1% (59.1%) and 96.1% (97.7%), respectively.

Conclusion

LLR together with RF performs better than other methods in identifying malignancy, especially for abnormal nodules, in terms of risk scores. The developed scoring system can well predict the risk of malignancy and guide medical doctors to make management decisions for reducing the number of unnecessary biopsies for benign nodules.

Utilizing the McGill Thyroid Nodule Score to compare between hemithyroidectomy cases who required completion thyroidectomy and cases of hemithyroidectomy alone

OBJECTIVES

This study aims to evaluate whether the McGill Thyroid Nodule Score (MTNS) accurately helps to decide the extent of surgery (hemithyroidectomy versus total thyroidectomy) based on the malignancy risk and to assess whether its use lowers the rate of completion thyroidectomy in cases of indeterminate thyroid nodules.

METHODS

We performed a retrospective cohort study comparing MTNS results of patients undergoing hemithyroidectomy in King Abdulaziz Medical City, NGHA, Jeddah from the period of January 2013 to December 2017. We divided the cases into hemithyroidectomy who required completion and hemithyroidectomy who did not need completion surgery. The pre-operative indeterminate FNA biopsy subgroup comprised of Bethesda type III (atypia of undetermined significance/follicular lesion of undetermined significance) and Bethesda type IV (follicular neoplasm/suspicious for a follicular neoplasm/Hurthle cell neoplasm). Post-operative histopathology was divided into benign or malignant groups.

RESULTS

Of the 501 patient charts reviewed, 111 (22.2%) had an indeterminate FNA biopsy. 97 (87.4%) patients were females and 14 (12.6%) were males. In the hemithyroidectomy group, the pre-operative mean of the MTNS was 6.65, while in the completion thyroidectomy the mean was 11.47. The median MTNS was 7 (32% risk of malignancy) for the hemithyroidectomy group and 11 (63% risk of malignancy) for the completion thyroidectomy group (p < 0.001).

CONCLUSIONS

Based on the MTNS the risk of malignancy in cases of hemithyroidectomy who required completion surgery was significantly higher than those who underwent hemithyroidectomy only. The MTNS can be of value to thyroid surgeon in the pre-operative decision-making when dealing with an indeterminate thyroid nodule on FNA biopsy.

Predictive Factors of Malignancy in Cytology of Indeterminate Follicular and Hürthle Cell Neoplasms of the Thyroid Gland

The objective of the current study was to determine the risk of malignancy in patients with thyroid nodules with cytology of indeterminate follicular and indeterminate Hürthle cell neoplasm (HN). The cytologic diagnosis of follicular neoplasm (FN) or HN remains a diagnostic challenge. Often, surgery is recommended for such lesions. A retrospective analysis was performed on 80 patients who underwent thyroid surgery following a diagnosis of indeterminate FN and indeterminate HN in thyroid fine-needle aspiration biopsy. Sex; age; family history of thyroid cancer and radiation exposure; coexisting thyroid conditions, such as solitary nodule; multinodularity; cytologic diagnosis; sonographic features; type of surgical treatment; and histopathologic results were recorded. Of the 80 patients, 52 (65%) had FN on fine-needle aspiration biopsy cytology and 28 (35%) had HN. A total of 23 patients (28.7%) had primary thyroid cancers on surgical pathology, and 57 (71.3%) had benign diagnoses. Univariate analysis showed no differences between the benign and malignant groups by sex, nodule size, family history of thyroid cancer, history of radiation exposure, presence of solitary nodule or multinodularity in the nodular features. In multivariate binary logistic regression analysis, the factors that were statistically significant predictors of malignancy were microcalcification [odds ratio (OR), 10.9; 95% confidence interval (CI), 2.18–54.7; P = 0.004], being older than 45 years (OR, 4.2; 95% CI, 1.25–14.63; P = 0.02]. The independent predictors of malignancy in FN and HN are micorcalcification and being older than 45 years, the use of which may predict the risk of thyroid cancer.

Diagnostic Utility of Molecular and Imaging Biomarkers in Cytological Indeterminate Thyroid Nodules

Indeterminate thyroid cytology (Bethesda III and IV) corresponds to follicular-patterned benign and malignant lesions, which are particularly difficult to differentiate on cytology alone. As ~25% of these nodules harbor malignancy, diagnostic hemithyroidectomy is still custom. However, advanced preoperative diagnostics are rapidly evolving.This review provides an overview of additional molecular and imaging diagnostics for indeterminate thyroid nodules in a preoperative clinical setting, including considerations regarding cost-effectiveness, availability, and feasibility of combining techniques. Addressed diagnostics include gene mutation analysis, microRNA, immunocytochemistry, ultrasonography, elastosonography, computed tomography, sestamibi scintigraphy, [18F]-2-fluoro-2-deoxy-d-glucose positron emission tomography (FDG-PET), and diffusion-weighted magnetic resonance imaging.The best rule-out tests for malignancy were the Afirma® gene expression classifier and FDG-PET. The most accurate rule-in test was sole BRAF mutation analysis. No diagnostic had both near-perfect sensitivity and specificity, and estimated cost-effectiveness. Molecular techniques are rapidly advancing. However, given the currently available techniques, a multimodality stepwise approach likely offers the most accurate diagnosis, sequentially applying one sensitive rule-out test and one specific rule-in test. Geographical variations in cytology (e.g., Hürthle cell neoplasms) and tumor genetics strongly influence local test performance and clinical utility. Multidisciplinary collaboration and implementation studies can aid the local decision for one or more eligible diagnostics.

Ultrasonography scoring systems can rule out malignancy in cytologically indeterminate thyroid nodules

PURPOSE

To assess the accuracy and reproducibility of ultrasonography classification systems in characterizing cytologically indeterminate thyroid nodules.

METHODS

We retrospectively identified 49 nodules that had been surgically resected owing to features classified as indeterminate according to 2010 Italian Consensus on Thyroid Cytology criteria. Three experienced sonographers independently reviewed original sonographic images of each nodule and classified it using the 2015 American Thyroid Association (ATA) guidelines and the Thyroid Imaging Reporting and Data System (TI-RADS) classification proposed by Korean radiologists; later, images were reviewed jointly to obtain consensus classifications of each nodule. Original cytology slides were similarly reviewed by three experienced cytopathologists, who reclassified the nodule (independently, then jointly) according to revised Italian Consensus on Thyroid Cytology (ICTC-2014) criteria. Consensus ICTC-2014, ATA, and TI-RADS classifications were analyzed against surgical histology reports to estimate each system's sensitivity, specificity, positive and negative predictive values.

RESULTS

Of the 49 indeterminate nodules examined, 30 (61.2 %) were histologically benign. Consensus ICTC-2014 classification correctly classified malignant nodules with positive predictive value of 50 % and negative predictive value of 90 %. Sonographic classification of nodules as intermediate to high suspicion by ATA or TI-RADS category 4c displayed positive predictive value of 63 and 71 %, respectively; positive predictive values dropped to 44 and 42 % when lower positivity thresholds were used (ATA low suspicion, TI-RADS category 4a). Negative predictive values for ATA and TI-RADS were 91 and 74 %, respectively, with higher positivity thresholds and 100 % for both with lower thresholds. All systems displayed appreciable inter-observer variability (Krippendorff alphas: ATA 0.36, TIRADS 0.42, ICTC-2014 0.74).

CONCLUSIONS

With stringent negativity cut-offs, American Thyroid Association and Thyroid Imaging Reporting and Data System assessment of cytologically indeterminate thyroid nodules allows high-confidence exclusion of malignancy.

Quantitative analysis of echogenicity for patients with thyroid nodules

Hypoechogenicity has been described qualitatively and is potentially subject to intra- and inter-observer variability. The aim of this study was to clarify whether quantitative echoic indexes (EIs) are useful for the detection of malignant thyroid nodules. Overall, 333 participants with 411 nodules were included in the final analysis. Quantification of echogenicity was performed using commercial software (AmCAD-UT; AmCad BioMed, Taiwan). The coordinates of three defined regions, the nodule, thyroid parenchyma, and strap muscle regions, were recorded in the database separately for subsequent analysis. And the results showed that ultrasound echogenicity (US-E), as assessed by clinicians, defined hypoechogenicity as an independent factor for malignancy. The EI, adjusted EI (EI_N-T; EI_N-M) and automatic EI_(N-R)/R values between benign and malignant nodules were all significantly different, with lower values for malignant nodules. All of the EIs showed similar percentages of sensitivity and specificity and had better accuracies than US-E. In conclusion, the proposed quantitative EI seems more promising to constitute an important advancement than the conventional qualitative US-E in allowing for a more reliable distinction between benign and malignant thyroid nodules.

Reliability of fine-needle aspiration and ultrasound-based characteristics of thyroid nodules for diagnosing malignancy in Iranian patients

BACKGROUND

Sonography and fine-needle aspiration biopsy (FNA-B) have been approved as method of choice in diagnosis of malignant thyroid nodules. Unnecessary FNA-B not only is invasive and costly but also results in second biopsy or unnecessary surgery. So we aimed to determine the specificity and sensitivity of sonography and FNA-B, without sonography guidance, in diagnosis of malignant and benign thyroid nodules.

METHODS

Patients with thyroid nodule referred to Baqiyatallah Hospital in 2014-2015 and candidates for surgical nodule resection were selected using simple random sampling method. Patients were evaluated by sonography and FNA. Sonographic characteristics of nodule were described. All patients underwent surgical resection and gross samples were sent for pathological evaluation, the gold standard for measuring the specificity and sensitivity of sonographic findings and FNA in diagnosis of malignant nodules.

RESULTS

Ninety patients with the mean age of 45.95 ± 12.3 years were evaluated (17 male and 73 female). Comparing the patients with correct and incorrect sonography-based diagnosis showed significant differences in nodule's width, area, calcification, border, and cervical lymphadenopathy (P < 0.05). Comparing the patients with correct and incorrect FNA-based diagnosis showed significant differences in patients' age and tall-shape nodule (P < 0.05). The diagnosis of sonographist had 56.25% sensitivity and 95.9% specificity, and the FNA-based diagnosis had 81.25% sensitivity and 93.7% specificity.

CONCLUSION

Among sonography findings, width and area of nodule, calcification, and nodule border have significant effect on malignancy diagnosis. Also FNA is necessary in nodules with calcification, border irregularity, and less width and area, especially in younger patients.

Value of sonographic features in predicting malignancy in thyroid nodules diagnosed as follicular neoplasm on cytology

BACKGROUND

The cytological diagnosis of follicular neoplasm (Thy3F) remains a diagnostic challenge. The main aim of this study was to stratify the risk of malignancy in thyroid nodules diagnosed as Thy3F on cytology (Thy3F) using thyroid imaging reporting and data system (TIRADS).

METHODS

A database of thyroid nodules with Thy3F cytological results from ultrasound-guided FNA (US-FNA) between January 2007 and March 2014 was studied retrospectively. Information on patient demographics, ultrasound characteristics and final histology of the nodules was collated. The number of suspicious US features of each thyroid nodule was counted based on TIRADS. The malignancy rate of each of the TIRADS category was also calculated based on the final histological outcomes of the nodules and compared to that calculated using a recently proposed thyroid malignancy risk prediction model.

RESULTS

The overall malignancy rate of Thy3F cytology was 24·3%. There were significantly higher percentages of malignant nodules with irregular margins (20·0% vs 0%, P = 0·000), hypo-echogenicity (74·3% vs 51·4%, P = 0·013) and taller-than-wide morphology (17·1% vs 0·9%, P = 0·001) when compared to benign nodules. The risk of malignancy increased with advancing TIRADS score: TIRADS 4A (14·3%), TIRADS 4B (23·1%), TIRADS 4C (87·5%) and TIRADS 5 (100%). The malignancy rate calculated using the prediction model similarly increased with advancing TIRADS score: TIRADS 4A (6·2%), TIRADS 4B (32·5%), TIRADS 4C (79·9%) and TIRADS 5 (90%).

CONCLUSION

Thyroid nodules with TIRADS scores 4C and 5 should be considered for single definitive surgery in view of the high malignant rate.

Higher body mass index and larger waist circumference may be predictors of thyroid carcinoma in patients with Hürthle-cell lesion/neoplasm fine-needle aspiration diagnosis

OBJECTIVE

High body mass index (BMI) has been found to be associated with raised thyroid cancer risk, particularly in women. We examined the associations for BMI and waist circumference (WC) with thyroid cancer risk among women with Hürthle-cell lesion/neoplasm (HLN) on fine-needle aspiration biopsy (FNAB) with the hypothesis that BMI and WC could guide the management of these challenging indeterminate lesions.

METHODS

This cross-sectional study included 224 women with HLN who underwent thyroidectomy. In all patients, TSH and thyroid auto-antibodies were evaluated, and thyroid nodule features were recorded. Patients were grouped according to BMI (<30 or ≥30 kg/m(2)) and WC (<88 or ≥88 cm). Relationships of thyroid cancer with BMI and WC were assessed using logistic regression analysis.

RESULTS

Mean weight, BMI (31·26 ± 5·1 vs 26·47 ± 5·9, P < 0·001), WC (98·23 ± 7·6 vs 86·18 ± 11, P = 0·001), and proportion of patients with high BMI (≥30 kg/m(2)) (65·9 vs 33·8%, P < 0·001) or large WC (≥88 cm) (84·1 vs 47·9%, P < 0·001) were significantly higher in malignant group compared to benign group. In regression analysis, BMI and WC significantly associated with existence of malignancy. Malignancy risk was 3·819-fold higher (95% CI: 2·068-7·054) in BMI≥30 kg/m(2) group compared to BMI<30 kg/m(2), which was independent of TSH and age. Large WC was also associated with increased risk (OR = 5·593, 95% CI: 2·736-11·434). Baseline tumour characteristics were similar according to BMI and WC groups.

CONCLUSIONS

A great BMI and large WC were associated with higher thyroid cancer risk in patients with FNAB diagnosis of HLN. Further studies are needed to use BMI or WC in the management of patients with HLN.

The Mcgill thyroid nodule score - does it help with indeterminate thyroid nodules?

BACKGROUND

Ultrasound guided fine-needle aspiration (USFNA) biopsy of thyroid nodules often gives a result of indeterminate pathology, placing thyroid specialists in difficult management situations. The aim of this study is to evaluate the incidence of malignancy in patients undergoing surgery and to correlate these results with the McGill Thyroid Nodule Score (MTNS).

METHODS

We performed a retrospective study comparing USFNA results, MTNS and histopathology of patients undergoing thyroid surgery between 2010 and 2012. Pre-operative USFNA results were divided into three subgroups: benign, indeterminate and suspicious for/malignant. The indeterminate USFNA subgroup comprised of Bethesda type III (atypia of undetermined significance) and Bethesda type IV (follicular neoplasms, including Hurthle cell neoplasms) lesions. Post-operative histopathology was divided into benign or malignant groups.

RESULTS

Of the 437 patient charts reviewed, 57.0% had an indeterminate USFNA biopsy. Within the indeterminate group, the malignancy rate was 39.8%. For indeterminate USFNA, the median MTNS was 7 (32% risk of malignancy) for benign nodules and 9 (63% risk of malignancy) for malignant nodules on post-operative histopathology (p < 0.05).

CONCLUSION

The rate of malignancy in operated patients with an indeterminate USFNA result was 39.8%. The MTNS can be of value to thyroid specialists in pre-operative decision-making when dealing with an indeterminate result of a thyroid nodule on USFNA.

The use of semi-quantitative ultrasound elastosonography in combination with conventional ultrasonography and contrast-enhanced ultrasonography in the assessment of malignancy risk of thyroid nodules with indeterminate cytology

Background

The pre-surgical selection of thyroid nodules with indeterminate cytology (Thy 3 according to British Thyroid Association) after fine-needle aspiration biopsy (FNAB) is currently required in order to reduce unnecessary total thyroidectomy. The objective of our study was to use a surgical series of Thy 3 nodules to evaluate the predictive role of ultrasound elastosonography (USE) and contrast-enhanced ultrasonography (CEUS) in pre-surgical diagnoses of malignancy.

Subjects and methods

We enrolled 63 patients with Thy 3 nodules in which cytological–histological correlation was available. The ELX 2/1 strain index was obtained by means of semi-quantitative USE, which was performed before surgery in addition to conventional ultrasonography (US) and contrast-enhanced US (CEUS) on the Thy 3 nodules. The ELX 2/1 strain index, a five-item US score and both peak (P) index and time to peak (TTP) index from CEUS were correlated with the histological results. After surgical diagnosis, the data were analysed by using a receiver-operating characteristic (ROC) curve.

Results

Histology was benign in 50 and malignant in 13 Thy 3 nodules. No difference in maximal diameter was noted between benign (22.8 ± 1.6 mm) and malignant (18.9 ± 2.9 mm) nodules. Significant correlations were found between histology and cumulative US findings (p=0.005), ELX 2/1 index (p=0.002), P index (p=0.01) and TTP index (p=0.02). On analysing data from US, USE and CEUS, significant ROC areas under the curve were observed (p<0.0001). A cut-off value was set for US (>2), ELX 2/1 (>0.95), P index (<0.99) and TTP index (>0.98) scores. The diagnostic power of the cumulative pre-surgical analysis of Thy 3 nodules with US, USE and CEUS, considering the experimental cut-off points obtained from the ROC curves was: sensitivity 64%, specificity 92%, PPV 75% and accuracy 84%.

Conclusion

The ELX 2/1 index in conjunction with the US score can be useful in orienting surgical strategies in Thy 3 nodules. The information added by CEUS is less sensitive than that provided by US and USE. The use of a cut-off based on histology can reduce thyroidectomy. Observation should be the first choice when not all instrumental results are suspect.

Follicular nodules (Thy3) of the thyroid: is total thyroidectomy the best option?

Background

Identification of the best management strategy for nodules with Thy3 cytology presents particular problems for clinicians. This study investigates the ability of clinical, cytological and sonographic data to predict malignancy in indeterminate nodules with the scope of determining the need for total thyroidectomy in these patients.

Methods

The study population consisted of 249 cases presenting indeterminate nodules (Thy3): 198 females (79.5%) and 51 males (20.5%) with a mean age of 52.43 ± 13.68 years. All patients underwent total thyroidectomy.

Results

Malignancy was diagnosed in 87/249 patients (34.9%); thyroiditis co-existed in 119/249 cases (47.79%) and was associated with cancer in 40 cases (40/87; 45.98%). Of the sonographic characteristics, only echogenicity and the presence of irregular margins were identified as being statistically significant predictors of malignancy. 52/162 benign lesions (32.1%) and 54/87 malignant were hypoechoic (62.07%); irregular margins were present in 13/162 benign lesions (8.02%), and in 60/87 malignant lesions (68.97%). None of the clinical or cytological features, on the other hand, including age, gender, nodule size, the presence of microcalcifications or type 3 vascularization, were significantly associated with malignancy.

Conclusions

The rate of malignancy in cytologically indeterminate lesions was high in the present study sample compared to other reported rates, and in a significant number of cases Hashimoto’s thyroiditis was also detected. Thus, considering the fact that clinical and cytological features were found to be inaccurate predictors of malignancy, it is our opinion that surgery should always be recommended. Moreover, total thyroidectomy is advisable, being the most suitable procedure in cases of multiple lesions, hyperplastic nodular goiter, or thyroiditis; the high incidence of malignancy and the unreliability of intraoperative frozen section examination also support this preference for total over hemi-thyroidectomy.

Patient's comfort with and tolerability of thyroid core needle biopsy

Recently, the core needle biopsy (CNB) has been proposed as a complementary test for thyroid nodules with inconclusive cytology by fine-needle aspiration (FNA). However, there have been no reports regarding patient comfort during and after CNB or tolerability of this procedure. Here we aimed to investigate and compare comfort with and tolerability of the CNB and FNA procedures. A 21 gauge needle was used for collection in CNB procedures, and a 23 gauge needle was used for collection in FNA procedures. Sixty-one consecutive patients underwent both biopsies and were asked to evaluate their comfort during and after these procedures by a structured questionnaire. A total of 58 (95 %) patients reported local pain during both biopsies. Two patients reported pain only during CNB, and one reported no pain. Mild pain was reported in 87 % of CNB cases. Local pain after biopsy was reported in 29 % of FNA and 45 % of CNB. The occurrence of pain in the first minutes following CNB was significantly higher than FNA (p = 0.008), while there was not a significant difference in pain at later time points after the procedures. Finally, patients were asked to evaluate the degree of tolerability of the two sampling techniques, and FNA and CNB were reported as tolerable in 82 and 83 %, respectively. The results from a questionnaire evaluating patients' comfort level showed no significant difference between the tolerability of CNB and FNA. This finding suggests that CNB may be performed with a reasonable level of patient comfort.