Thyroid Nodule Evaluation and Management in Older Adults: A Review of Practical Considerations for Clinical Endocrinologists

Pituitary-Thyroid Hormones and Related Indices in Euthyroid Type 2 Diabetes: Association With Thyroid Nodules

Aim

Diabetes is an independent risk factor for thyroid nodules (TNs), however, the influencing factors of TNs have not been fully clarified under the condition of diabetes. Previous studies have shown a connection between pituitary-thyroid hormone (TH) functions and TNs in different populations. However, the potential link in euthyroid patients with diabetes is unclear. We aimed to explore the correlates of TNs in euthyroid type 2 diabetes (T2D) patients.

Methods

This cross-sectional study included 1965 euthyroid adults with T2D. Clinical and biochemical data, including TH and relevant covariates were collected. TNs were evaluated using ultrasound. Univariate and multivariate logistic regression analyses were performed to identify factors associated with TNs, with analyses stratified by sex.

Results

The overall prevalence of TNs was 51.9%. The prevalence of TNs was higher in females. Stratified by sex, the results from univariate and further logistic regression analyses showed that free triiodothyronine (FT3) (OR: 1.381; 95% CI: 1.066-1.790) and thyroid-stimulating hormone index (TSHI) (OR: 0.740; 95% CI: 0.584-0.937) were independently correlated with TNs only in females, while no TH-related indicators entered the regression model in males.

Conclusion

The relationship between TH and related indices with TNs exhibited sex differences. Specifically, FT3 and TSHI were independently associated with TNs in females. These findings underscore the importance of evaluating TH and related indices for early monitoring and management of TNs, particularly in euthyroid female T2D patients.

Evaluation of Knowledge, Attitudes, and Practices Toward Thyroid Nodules in 456 Patients with Thyroid Nodules

BACKGROUND Thyroid nodules, common in adults, especially females and older individuals, are mostly asymptomatic. While the nodules are largely benign, distinguishing malignant lesions is crucial. Overdiagnosis and overtreatment pose risks. Knowledge, attitude, and practice (KAP) surveys can identify knowledge gaps and inform targeted education; however, no studies have explored this in Chinese patients with thyroid nodules. This study aimed to investigate the KAP toward thyroid nodules among patients with thyroid nodules. MATERIAL AND METHODS This web-based cross-sectional study was conducted among patients with thyroid nodules, using a self-administered questionnaire. RESULTS A total of 456 valid questionnaires were included. The mean knowledge, attitude, and practice scores were 7.07±3.19, 26.39±3.98, and 29.16±4.65, respectively. Knowledge (OR=1.111, P=0.002), junior college (OR=1.933, P=0.035), and bachelor's degree or above (OR=2.193, P=0.015) were associated with proactive practice. Structural equation modeling showed knowledge directly influenced attitude (ß=0.244, P<0.001) and practice (ß=0.404, P<0.001). Attitude directly influenced practice (ß=-0.129, P=0.020). Occupation (ß=-0.279, P=0.038), marital status (ß=-0.752, P=0.002), thyroid nodule TIRADS classification (ß=-0.699, P=0.004), and education (ß=0.501, P<0.001) directly influenced knowledge. Average per capita income (ß=0.942, P<0.001) and education (ß=0.380, P=0.309) directly influenced attitude. Education (ß=0.457, P=0.028) directly influenced practice. CONCLUSIONS Patients with thyroid nodules have poor knowledge and unfavorable attitudes but proactive practice toward thyroid nodules. Anxiety-reducing techniques should be incorporated during education sessions, and workplace wellness programs should be explored, to promote healthy practices and early detection.

Impact of real-time contrast-enhanced ultrasound on thyroid function in microwave ablation treatment of thyroid tumors

OBJECTIVE

To investigate the impact of contrast-enhanced ultrasound on the efficacy of microwave ablation in the treatment of benign thyroid tumors, as well as its effect on thyroid function, to assess its application value.

METHODS

We retrospectively analyzed data from 60 patients with benign thyroid nodules treated at Sichuan Provincial People's Hospital from January 2021 to December 2021. All patients underwent microwave ablation. Based on the intraoperative assessment of the ablation effect, they were divided into a contrast-enhanced ultrasound group (n=34) and a conventional ultrasound group (n=26). Postoperatively, the treatment outcomes were classified into complete ablation or the presence of residual nodules. We also assessed the recurrence rate one year after treatment, along with inflammatory factors, stress response indicators, and effects on thyroid function.

RESULTS

The complete ablation rate for thyroid nodules in the contrast-enhanced ultrasound group was significantly higher than that in the conventional ultrasound group (P<0.05). Intraoperative measurements revealed lower ablated nodule volumes, bleeding volumes, and in situ replacement rates in the contrast-enhanced ultrasound group, with statistically significant differences (P<0.05). Preoperative thyroid function hormone indicators, inflammatory factors and stress response indicators did not significantly differ between the two groups. Postoperatively, both groups had lower levels of free triiodothyronine (FT3) and free thyroxine (FT4), along with higher levels of thyroid-stimulating hormone (TSH), white blood cells (WBC), serum C-reactive protein (CRP), interleukin-6 (IL-6), norepinephrine (NE), epinephrine (E), and cortisol (Cor) compared to preoperative levels. However, the contrast-enhanced ultrasound group demonstrated higher FT3 and FT4 levels and lower WBC, serum CRP, IL-6, NE, E, Cor and TSH levels than the conventional ultrasound group, with statistically significant differences (all P<0.05). No statistically significant differences in complication rates were observed between the two groups.

CONCLUSION

Contrast-enhanced ultrasound in microwave ablation for benign thyroid nodules can improve the complete ablation rate, reduce recurrence, and have a minimal impact on thyroid function, without increasing complication rates. It is recommended for clinical use.

Comparison of clinical and patient-reported outcomes in patients with benign euthyroid solitary nodules after ultrasound-guided percutaneous microwave ablation and endoscopic thyroidectomy

BACKGROUND

Percutaneous ultrasound-guided microwave ablation (MWA) for benign solid thyroid nodules is the newest modality for treatment. However, the differences in treatment outcomes between MWA and endoscopic thyroidectomy vestibular approach (TOETVA) for patients with benign euthyroid solitary nodules remain unknown. We are sharing initial results from our prospective study.

METHODS

Prospective study between January 2022 and December 2023 was conducted and data were noted at 3 time points in patients planned for treatment (Preoperative, 1 week, and 12 months). Main outcome measures were clinical outcome and comparison of thyroid-related quality of life using the ThyPRO-39hin and swallowing-related quality of life using the SWAL-QoL.

RESULTS

Of the 36 included patients, 20 patients underwent TOETVA and 16 underwent MWA. Both the groups were comparable in terms of demographic and clinicopathological profiles. The nodule volume reduction rate of patients at 12 months after MWA was 75.10% and 100% for TOETVA. The mean preoperative ThyPRO-39hin and SWAL-QoL scores were comparable in all domains between the two groups. Mean ThyPRO-39hin and SWAL-QoL scores on postoperative day 7 were significantly better in the MWA group in domains impaired social life (p < 0.0001) and impaired daily life (p = 0.0002). However, at the end of 12 months, mean ThyPRO-39hin and SWAL-QoL scores became significantly better in the TOETVA group as compared to the MWA group.

CONCLUSION

Our findings suggest that transoral endoscopic thyroidectomy results in significant superior clinical outcome, thyroid-related quality of life, and swallowing-related quality of life in the long term.

Evaluation of the clinical efficacy of microwave ablation for benign thyroid nodules based on contrast-enhanced ultrasound

This study evaluates the clinical efficacy of microwave ablation in patients with benign thyroid nodules based on contrast-enhanced ultrasound. A total of 92 patients with benign thyroid nodules admitted to our hospital from January 2020 to December 2022 were selected as research subjects and divided into control group and observation group according to different treatment methods, with 46 cases in each group. All patients received microwave ablation. Imaging examination and monitoring were performed before and after microwave ablation. The control group underwent routine ultrasound examination, and the observation group underwent contrast-enhanced ultrasound examination. It was determined whether or not to terminate ablation therapy according to the imaging examination results. Results of enhanced MRI were used as the gold standard to evaluate the clinical efficacy, thyroid nodule volume, thyroid nodule volume reduction rate, nodule recurrence, and complication rate of the 2 groups. Using the results of enhanced MRI as the gold standard, the total ablation rate of observation group was 96.55%, which was significantly higher than that of control group 85.96%, and the nodule survival rate of 3.45% was significantly lower than that of control group 14.04% (P < .05). After 1 month, 3 months, 6 months, and 12 months, the thyroid nodule volume of both groups was significantly reduced, and the thyroid nodule volume of observation group was significantly smaller than that of control group (P < .05). After 1 month, 3 months, 6 months, and 12 months, the reduction rate of thyroid nodule volume in 2 groups was significantly increased, and the reduction rate of thyroid nodule volume in observation group was significantly higher than that in control group (P < .05). After treatment, the recurrence rate of nodule in observation group was 4.35%, which was significantly lower than that in control group, 15.22% (P < .05). After treatment, the complication rate of observation group was 8.70%, which was significantly lower than that of control group 26.09% (P < .05). Contrast-enhanced ultrasound can effectively monitor the treatment range of benign thyroid nodules by microwave ablation, improve clinical efficacy, reduce the recurrence rate of nodules, and has high effectiveness and safety.

Surgical Outcomes of Thyroidectomy in Geriatric Patients Aged 80 Years and Older: A Single-Center Retrospective Cohort Study

Background and Objectives: As the global aging population grows, the incidence of thyroidectomy in elderly patients is increasing. This study aimed to evaluate the surgical outcomes of thyroidectomy in patients aged 80 years and older. Materials and Methods: All patients aged 80 years and older who underwent thyroidectomies at our hospital between January 2015 and December 2022 were reviewed in this retrospective cohort study. Collected data consisted of patients' clinical characteristics, functional status, compression symptoms, preoperative assessments, perioperative outcomes, postoperative complications (such as bleeding events, recurrent laryngeal nerve injury, hypocalcemia), pathological findings, readmission, and follow-up outcomes. Results: Seventeen patients were included in this study, with female predominance (82.4%). The mean age was 85.6 ± 4.8 years. Fourteen patients (82.4%) exhibited compression-related symptoms as surgical indications. Based on pathological reports, patients were categorized into benign (12/17, 70.6%) and malignancy (5/17, 29.4%) groups. The benign group had a shorter operation time compared with the malignancy group (164.3 ± 32.0 min vs. 231.0 ± 79.1 min, p = 0.048). No major postoperative complications developed. The median postoperative follow-up duration was 28 months (range: 2-91 months). Thirteen patients (76.5%) were alive at the end of the study period. Conclusions: Despite potential age-related risks, thyroidectomy is feasible for carefully selected patients aged 80 years and older. It provides benefits not only in terms of oncological curative treatment but also in improving the quality of life, such as compressive symptoms and wound condition.

Oncocytic cell carcinoma of the thyroid with TERT promoter mutation presenting as asphyxia in an elderly: a case report

Introduction

The prevalence of thyroid nodules and malignancies in the elderly is a growing concern. Thyroid nodules in this population have unique characteristics, requiring careful treatment strategies that balance risks and benefits. Oncocytic carcinoma of the thyroid (OCA) is a rare, aggressive subtype with diagnostic challenges.

Methods

This case features an 84-year-old patient who presented with a neck mass and symptoms of asphyxia. Clinical evaluation, imaging studies, and biopsy were conducted to assess the nature of the thyroid lesion. Molecular testing, including genetic analysis, was performed to identify specific mutations associated with OCA and guide treatment decisions.

Results

The patient was diagnosed with oncocytic carcinoma of the thyroid. The molecular testing revealed specific genetic mutations indicative of OCA, confirming the diagnosis. The presence of these mutations guided the treatment plan, emphasizing the importance of molecular diagnostics in managing thyroid malignancies, especially in the elderly.

Discussion

This case illustrates the complexities of diagnosing and treating thyroid malignancies in the elderly. Biopsy and molecular testing provided diagnostic accuracy and informed treatment. Individualized approaches are essential for better outcomes, especially in aggressive subtypes, balancing the risks and benefits of intervention.

Defining inappropriate thyroid biopsy?-Proposed definition based on clinical evidence and stakeholder engagement

PURPOSE

Identify factors that can be used to assess the appropriateness of a thyroid biopsy and propose a pathway to define inappropriate thyroid biopsies in practice.

METHODS

We identified factors utilized in clinical guidelines and existing literature to determine the clinical indications for a thyroid biopsy. Subsequently, we assembled a multidisciplinary panel of experts, including patients, clinicians, researchers, and quality experts, to integrate these factors and develop a pathway for assessing the appropriateness of thyroid biopsies.

RESULTS

Through literature review and stakeholder engagement, we identified multiple factors to determine if a thyroid biopsy is necessary: ultrasound risk assessment, presence of compressive symptoms and/or clinical suspicion of high-risk thyroid cancer, life expectancy, comorbidity burden, surgical risk, personal risk factors for thyroid cancer, thyroid function levels, local resources and medical expertise and patient values and preferences. We proposed a multiple-tier classification for the appropriateness of thyroid biopsy that begins with ultrasound findings (e.g., size, thyroid cancer risk) and encompasses the evaluation of additional patient-specific factors.

CONCLUSION

Assessment of the appropriateness of a thyroid biopsy is possible. Although, thyroid nodule ultrasound risk assessment is a pivotal factor for this assessment, additional factors should be considered (e.g., life expectancy, personal risk factors for thyroid cancer, patient preferences). Yet, additional efforts are needed to operationalize the objective implementation of these factors in clinical practice.

Machine learning to predict the occurrence of thyroid nodules: towards a quantitative approach for judicious utilization of thyroid ultrasonography

Introduction

Ultrasound is instrumental in the early detection of thyroid nodules, which is crucial for appropriate management and favorable outcomes. However, there is a lack of clinical guidelines for the judicious use of thyroid ultrasonography in routine screening. Machine learning (ML) has been increasingly used on big data to predict clinical outcomes. This study aims to leverage the ML approach in assessing the risk of thyroid nodules based on common clinical features.

Methods

Data were sourced from a Chinese cohort undergoing routine physical examinations including thyroid ultrasonography between 2013 and 2023. Models were established to predict the 3-year risk of thyroid nodules based on patients' baseline characteristics and laboratory tests. Four ML algorithms, including logistic regression, random forest, extreme gradient boosting, and light gradient boosting machine, were trained and tested using fivefold cross-validation. The importance of each feature was measured by the permutation score. A nomogram was established to facilitate risk assessment in the clinical settings.

Results

The final dataset comprised 4,386 eligible subjects. Thyroid nodules were detected in 54.8% (n=2,404) individuals within the 3-year observation period. All ML models significantly outperformed the baseline regression model, successfully predicting the occurrence of thyroid nodules in approximately two-thirds of individuals. Age, high-density lipoprotein, fasting blood glucose and creatinine levels exhibited the highest impact on the outcome in these models. The nomogram showed consistency and validity, providing greater net benefits for clinical decision-making than other strategies.

Conclusion

This study demonstrates the viability of an ML-based approach in predicting the occurrence of thyroid nodules. The findings highlight the potential of ML models in identifying high-risk individuals for personalized screening, thereby guiding the judicious use of ultrasound in this context.

Clinician feedback using a shared decision-making tool for the evaluation of patients with thyroid nodules-an observational study

BACKGROUND

We pilot-tested an encounter conversation aid to support shared decision making (SDM) between patients with thyroid nodules and their clinicians.

OBJECTIVE

Characterize the clinician feedback after providing care to patients with thyroid nodules using a tool to promote SDM conversations during the clinical encounter, and evaluate how clinicians used the tool during the visit.

METHODS

Mixed method study in two academic centers in the U.S., including adult patients presenting for evaluation of thyroid nodules and their clinicians. We thematically analyzed interviews with clinicians after they used the SDM tool in at least three visits to characterize their feedback. Additionally, investigators evaluated visits recordings to determine the extent to which clinicians engaged patients in the decision-making process (OPTION score, scale 0 to 100, higher levels indicating higher involvement), the tool's components used (fidelity), and encounter duration. Using a post-visit survey, we evaluated the extent to which clinicians felt the tool was easy to use, helpful, and supportive of the patient-clinician collaboration.

RESULTS

Thirteen clinicians participated in the study and used the SDM tool in the care of 53 patients. Clinicians thought the tool was well-organized and beneficial to patients and clinicians. Clinicians noticed a change in their routine with the use of the conversation aid and suggested it needed to be more flexible to better support varying conversations. The median OPTION score was 34, the fidelity of use 75%, and the median visit duration 17 min. In most encounters, clinicians agreed or strongly agreed the tool was easy to use (86%), helpful (65%), and supported collaboration (62%).

CONCLUSION

Clinicians were able to use a SDM tool in the care of patients with thyroid nodules. Although they wished it were more flexible, they found on the whole that its use in the clinical encounter was beneficial to patients and clinicians.

Geriatric Importance of Histopathological Parameters Evaluated in Thyroidectomy Specimens: A Single Center Retrospective Analysis

Nowadays, the aging human population exerts a notable influence on the treatment of thyroid diseases. The most appropriate approach for the treatment of benign and malignant thyroid diseases in older adults has not yet been determined. The aim of our study is to evaluate the effect of thyroidectomies in geriatric patients considering age, sex and histopathological parameters and to determine the importance of thyroidectomy as a treatment option in the geriatric population. A total of 910 cases from all age groups were included, for which thyroidectomies were examined and reported. In accordance with the College of American Pathologists Cancer Protocol for thyroid reporting, considering geriatric patients, the rate of Thyroid Follicular Nodular Disease was significantly higher among the tumor types in the benign tumor group (p = 0.033), while Anaplastic Thyroid Carcinoma rate was higher in the malignant tumor group. The diagnosis rate of malignant tumors was higher in males, reflecting a more advanced pT stage (p < 0.001), larger tumor size (p < 0.001) and increased lymph node involvement rate (p = 0.039). Given that increasing age is associated with a heightened incidence of thyroid disease, the safety of surgery for geriatric patients is an important issue. Thyroidectomy should be considered in the treatment of these patients, especially in males, as the rate of malignant diagnosis and worse histopathological parameters are seen with increasing age.

Risk factors associated with the prevalence of thyroid nodules in adults in Northeast China: a cross-sectional population-based study

OBJECTIVES

This study examined the association between anthropometric measurements, lifestyle factors and the prevalence of thyroid nodules among adults in Northeast China.

DESIGN

We employed a cross-sectional approach involving a questionnaire survey, which focused on participants' living habits, and a physical examination that included anthropometry and ultrasound imaging.

SETTING

The data were procured during multiple trips by medical teams from the first hospital of China Medical University to towns in Northeast China.

PARTICIPANTS

Of the 1092 participants, 489 did not have thyroid nodules (mean age: 54.02±11.49 years; 297 females (60.7%)), 99 had single thyroid nodules (mean age: 58.19±10.77 years; 59 females (59.6%)) and 504 had multiple thyroid nodules (mean age: 60.05±10.68 years; 394 females (78.2%)). Inclusion criteria mandated participants be over 20 years old without other medical conditions. We excluded individuals who had undergone surgical resection for thyroid nodules.

RESULTS

The prevalence of thyroid nodules was significantly associated with being female (OR 2.569, 95% CI 1.937 to 3.405, p<0.001) and increased age (OR 1.054, 95% CI 1.041 to 1.066, p<0.001). This association was more pronounced in those with multiple thyroid nodules. For males under 60, non-smoking was inversely correlated with the prevalence of multiple thyroid nodules (OR 0.321, 95%CI 0.149 to 0.69, p<0.05). For females under 60, diastolic blood pressure (DBP) was significantly linked with the prevalence of thyroid nodules (OR 0.978, 95% CI 2.614 to 2.705, p<0.05).

CONCLUSIONS

Besides gender and age, the prevalence of thyroid nodules in Northeast China correlates with smoking habits and DBP.

Management of thyroid dysfunction and thyroid nodules in the ageing patient

Thyroid dysfunction is a common endocrine disorder in the general population, with a reported prevalence of 10-15%. However, this rate is even higher in older adults, with an estimated prevalence of ≈25% in some populations. Since elderly patients usually present more comorbidities than younger individuals, thyroid dysfunction may carry a synergistic negative health impact, mainly due to increased cardiovascular disease risk. Moreover, thyroid dysfunction in the elderly can be more difficult to diagnose due to its subtle or even asymptomatic clinical presentation, and the interpretation of thyroid function tests may be affected by drugs that interfere with thyroid function or by the coexistence of several diseases. On the other hand, thyroid nodules are also a prevalent condition in older adults, and its incidence increases with age. The assessment and management of thyroid nodules in the ageing patient should take into account several factors, as risk stratification, thyroid cancer biology, patient´s overall health, comorbidities, treatment preferences, and goals of care. In this review article, we summarize the current knowledge on the pathophysiology, diagnosis, and therapeutic management of thyroid dysfunction in elderly patients and we also review how to identify and manage thyroid nodules in this population.

The Size of a Thyroid Nodule with ACR TI-RADS Does Not Provide a Better Prediction of the Nature of the Nodule: A Single-Center Retrospective Real-Life Observational Study

We investigated if thyroid nodule size has a predictive value of malignancy on a par with composition, echogenicity, shape, margin, and echogenic foci, and what would be the consequence of observing the rule of the American College of Radiology (ACR) to perform a fine-needle aspiration biopsy (FNAB). We conducted a retrospective real-life observational study on 86 patients who underwent surgery after a standardized diagnostic protocol. We divided the TR3, TR4, and TR5 classes into sub-classes according to the size threshold indicating FNAB (a: up to the threshold for no FNAB; b: over the threshold for FNAB suggested). We computed sensitivity, specificity, and positive (PPV) and negative predictive value (NPV) for the different sub-classes and Youden's index (Y) for the different possible cutoffs. Each sub-class showed the following PPV (0.67, 0.68, 0.70, 0.78, 0.72), NPV (0.56, 0.54, 0.51, 0.52, 0.59), and Y (0.20, 0.20, 0.22, 0.31, 0.30). In this real-life series, we did not find a significant difference in prediction of malignancy between the sub-categories according to the size threshold. All nodules have a pre-evaluation likelihood of being malignant, and the impact and utility of size thresholds may be less clear than suggested by the ACR TIRADS guidelines in patients undergoing standardized thyroid work up.

Thyroid Nodules and Obesity

A widely discussed topic in the pathophysiology of thyroid nodules is the role of obesity, a state that leads to increased systemic inflammatory markers. Leptin plays a vital role in forming thyroid nodules and cancer through several mechanisms. Together with chronic inflammation, there is an augmentation in the secretion of tumor necrosis factor (TNF) and the cytokine interleukin 6 (IL-6), which contributed to cancer development, progression and metastasis. In addition, leptin exerts a modulatory action in the growth, proliferation and invasion of thyroid carcinoma cell lines via activating various signal pathways, such as Janus kinase/signal transducer and activator of transcription, mitogen-activated protein kinase (MAPK) and/or phosphoinositide 3-kinase (PI3K)/protein kinase B (Akt). Through several proposed mechanisms, aberrant endogenous estrogen levels have been suggested to play a vital role in the development of both benign and malignant nodules. Metabolic syndrome triggers the development of thyroid nodules by stimulating thyroid proliferation and angiogenesis due to hyperinsulinemia, hyperglycemia and dyslipidemia. Insulin resistance influences the distribution and structure of the thyroid blood vessels. Insulin growth factor 1 (IGF-1) and insulin affect the regulation of the expression of thyroid genes and the proliferation and differentiation of thyroid cells. TSH can promote the differentiation of pre-adipocytes to mature adipocytes but also, in the presence of insulin, TSH possesses mitogenic properties. This review aims to summarize the underlying mechanisms explaining the role of obesity in the pathophysiology of thyroid nodules and discuss potential clinical implications.

Ultrasound-Based Risk Stratification System for the Assessment of Partially Cystic Thyroid Nodules

OBJECTIVE

To develop and validate a risk stratification system for the prediction of malignancy in Partially Cystic Thyroid Nodules (PCTNs).

METHODS

From January 2020 to December 2021, we retrospectively reviewed the sonography data of PCTNs patients from Hangzhou TCM Hospital, Hangzhou First People's Hospital two medical centers. The independent risk factors of malignant PCTNs were evaluated using univariate and multivariate logistic regression analysis. The nomogram prediction efficiency was assessed using Area Under the Curve (AUC) and calibration curves. To determine the clinic value of the predictive model, Decision Curve Analysis (DCA) was used.

RESULTS

In this retrospective study, a total of 285 patients (301 PCTNs) were enrolled, 242 nodules were benign, and 59 nodules were malignant. Younger age, hypoechoic, irregular margin and microcalcifications were found to be the independent risk factors associated with malignant PCTNs. The AUC, sensitivity, and specificity were 0.860, 77.1%, and 84.7% in the training set and 0.897, 91.7%, and 87.0% in the external validation set, respectively. The total point of nomogram is greater than 161, which shows the best to predict the malignancy of PCTNs.

CONCLUSIONS

Our findings demonstrated that the risk stratification system for the assessment of PTCNs showed good prediction capacities.

Loss of thyroid gland circadian PER2 rhythmicity in aged mice and its potential association with thyroid cancer development

Molecular clocks operate in peripheral tissues, including endocrine glands, and play important regulatory roles in this context. However, potential age-related changes in the expression rhythmicity of clock genes and the effects of these changes on the thyroid gland remain unknown. In the present study, we evaluated the expression rhythmicity of peripheral thyroid clock genes in aged mice using RNA-seq transcriptomic analysis in young (3.5-month) versus aged (20-month) mice. In addition, we determined the cellular effects of silencing of PER2, a major clock gene regulator, in human thyroid cell lines. Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analysis revealed that differentially expressed genes (DEGs) in the thyroid glands of aged mice were involved in mitogen-activated protein kinase (MAPK) signaling, chemokine signaling, circadian entrainment, PI3K/AKT signaling, and Apelin signaling. The expression of circadian clock genes Arntl/Bmal1 was significantly downregulated in thyroid glands of aged mice, whereas the expression of genes involved in regulation of cell proliferation, migration, and tumorigenesis was upregulated. Peripheral thyroid clock genes, particularly Per mRNA and PER2 protein, were downregulated in the thyroid glands of aged mice, and circadian oscillation of these genes was declined. Knockdown of the circadian clock gene PER2 in human thyroid follicular cells induced AP-1 activity via JNK MAPK signaling activation, which increased cell proliferation. Furthermore, the aging-related loss of PER2 circadian oscillation activated the AP-1 transcription factor via the JNK MAPK pathway, which could contribute to thyroid hyperplasia, a common age-related condition.

Towards De-Implementation of low-value thyroid care in older adults

PURPOSE OF REVIEW

This review discusses the current literature regarding low-value thyroid care in older adults, summarizing recent findings pertaining to screening for thyroid dysfunction and management of hypothyroidism, thyroid nodules and low-risk differentiated thyroid cancer.

RECENT FINDINGS

Despite a shift to a "less is more" paradigm for clinical thyroid care in older adults in recent years, current studies demonstrate that low-value care practices are still prevalent. Ineffective and potentially harmful services, such as routine treatment of subclinical hypothyroidism which can lead to overtreatment with thyroid hormone, inappropriate use of thyroid ultrasound, blanket fine needle aspiration biopsies of thyroid nodules, and more aggressive approaches to low-risk differentiated thyroid cancers, have been shown to contribute to adverse effects, particularly in comorbid older adults.

SUMMARY

Low-value thyroid care is common in older adults and can trigger a cascade of overdiagnosis and overtreatment leading to patient harm and increased healthcare costs, highlighting the urgent need for de-implementation efforts.

Analysis of the influencing factors on fine-needle aspiration biopsy results of the thyroid

Objective

The objective of the study is to analyze the influencing factors on the results of thyroid fine-needle aspiration biopsy (FNAB).

Method

A total of 339 patients who underwent FNAB in our hospital from December 2018 to July 2021 were retrospectively selected. The patients were chosen according to the gender ratio, age, and thyroid ultrasound characteristics and were divided into three groups: (1) a 22G needle vacuum aspiration group (Group 1, n = 85), (2) a 22G biopsy needle non-vacuum aspiration group (Group 2, n = 50), and (3) a 25G biopsy needle non-vacuum aspiration group (Group 3, n = 204). Patients in these groups were evaluated for determining the FNAB dissatisfaction rate of pathological samples. A bivariate regression analysis of independent risk factors related to the unsatisfactory pathological diagnosis of samples was performed.

Results

The specimen dissatisfaction rates of the three groups were 22/85 (25.9%), 15/50 (30%), and 18/186 (9.7%), respectively. The overall sample dissatisfaction rate was 55/339 (16.2%), and the sample satisfaction rate of Group 3 was higher than that of Groups 1 and 2 (P < 0.05). Logistic bivariate regression analysis showed that the age of the patients and the capillary sampling needles and aspiration methods were two independent risk factors for determining the dissatisfaction rate of FNAB pathological samples.

Conclusion

A 25G capillary sampling aspiration biopsy needle was selected to perform FNAB in thyroid nodules without vacuum aspiration, which could effectively improve the accuracy of FNAB results with a high specimen satisfaction rate.

Clinician Agreement on the Classification of Thyroid Nodules Ultrasound Features: A Survey of 2 Endocrine Societies

CONTEXT

Thyroid nodule risk stratification allows clinicians to standardize the evaluation of thyroid cancer risk according to ultrasound features.

OBJECTIVE

To evaluate interrater agreement among clinicians assessing thyroid nodules ultrasound features and thyroid cancer risk categories.

DESIGN, SETTING, AND PARTICIPANTS

We surveyed Endocrine Society and Latin American Thyroid Society members to assess their interpretation of composition, echogenicity, shape, margins, and presence of echogenic foci of 10 thyroid nodule cases. The risk category for thyroid cancer was calculated following the American College of Radiology-Thyroid Imaging Reporting & Data System (ACR-TIRADS) framework from individual responses.

MAIN OUTCOMES AND MEASURES

We used descriptive statistics and Gwet's agreement coefficient (AC1) to assess the primary outcome of interrater agreement for ACR-TIRADS risk category. As secondary outcomes, the interrater agreement for individual features and a subgroup analysis of interrater agreement for the ACR-TIRADS category were performed (ultrasound reporting system, type of practice, and number of monthly appraisals).

RESULTS

A total of 144 participants were included, mostly endocrinologists. There was moderate level of agreement for the absence of echogenic foci (AC1 0.53, 95% CI 0.24-0.81) and composition (AC1 0.54, 95% CI 0.36-0.71). The agreement for margins (AC1 0.24, 95% CI 0.15-0.33), echogenicity (AC1 0.34, 95% CI 0.22-0.46), and shape assessment (AC1 0.42, 95% CI 0.13-0.70) was lower. The overall agreement for ACR-TIRADS assessment was AC1 0.29, (95% CI 0.13-0.45). The AC1 of ACR-TIRADS among subgroups was similar.

CONCLUSIONS

This study found high variation of judgments about ACR-TIRADS risk category and individual features, which poses a potential challenge for the widescale implementation of thyroid nodule risk stratification.

Adherence to the Mediterranean Diet as a Modifiable Risk Factor for Thyroid Nodular Disease and Thyroid Cancer: Results From a Pilot Study

Iodine deficiency is the most important established nutritional risk factor for the development of thyroid nodular disease. Nevertheless, to the best of our knowledge, to date no study focused on the association between the adherence to the Mediterranean diet (MD) and thyroid nodular disease. Adherence to the MD was evaluated using the PREvención con DIetaMEDiterránea (PREDIMED) questionnaire. Physical activity, smoking habits, and anthropometric parameters were studied. PREDIMED was used to evaluate the degree of adherence to the MD. Evaluation of fine needle aspiration cytology of thyroid lesions based on 2013 Italian thyroid cytology classification system. Cytology of thyroid nodules was carried out through sonography-guided fine-needle aspiration and patients were divided into 5 categories: TIR2, TIR3a, TIR3b, TIR4, and TIR5. The study population consisted of 794 subjects (554 females, 69.8%), aged 18–65 years, with BMIs ranging from 19.4 to 55.3 kg/m². Thyroid nodular disease was present in 391 participants (49.2%), and the most frequent cytological categories was TIR2 (18.3 %), followed by a TIR4 (8.9 %). The presence of thyroid nodules was also significantly associated with the lowest adherence to the MD (OR 6.16, p < 0.001). Patients with TIR5 had the lower adherence to the MD (2.15 ± 1.12 score) compared to other TIRs (p < 0.001). The cytological category with high-risk of malignancy (TIR4/TIR5) was significantly associated with the lowest adherence to the MD (OR 137.55, p < 0.001) and PREDIMED score (OR = 0.33, p < 0.001, 95% IC = 0.26–0.41, R² = 0.462). At multiple regression analysis, PREDIMED score was the main predictor of both the presence of nodules (p < 0.001) and the cytological category with high-risk of malignancy (p < 0.001). At ROC analysis PREDIMED score ≤ 5 and ≤ 4 (p = 0.001) were the values that predicted the presence of thyroid nodular disease and cytological category with high-risk of malignancy, respectively. In conclusion, our study demonstrated that the low adherence to the MD is associated with the presence of thyroid nodular disease and in particular with those at high-risk of malignancy.

The Future of Thyroid Nodule Risk Stratification

Clinical evidence supports the association of ultrasound features with benign or malignant thyroid nodules and serves as the basis for sonographic stratification of thyroid nodules, according to an estimated thyroid cancer risk. Contemporary guidelines recommend management strategies according to thyroid cancer risk, thyroid nodule size, and the clinical scenario. Yet, reproducible and accurate thyroid nodule risk stratification requires expertise, time, and understanding of the weight different ultrasound features have on thyroid cancer risk. The application of artificial intelligence to overcome these limitations is promising and has the potential to improve the care of patients with thyroid nodules.

Nonsurgical Management of Thyroid Nodules: The Role of Ablative Therapies

CONTEXT

After a thorough evaluation most thyroid nodules are deemed of no clinical consequence and can be observed. However, when they are compressive, toxic, or involved by papillary thyroid carcinoma surgery or radioactive iodine (RAI) (if toxic) are the treatments of choice. Both interventions can lead to hypothyroidism and other adverse outcomes (eg, scar, dysphonia, logistical limitation with RAI). Active surveillance might be used for papillary thyroid microcarcinoma (PTMC) initially, but anxiety leads many cases to surgery later. Several ablative therapies have thus evolved over the last few years aimed at treating these nodules while avoiding described risks.

CASES

We present 4 cases of thyroid lesions causing concern (compressive symptoms, thyrotoxicosis, anxiety with active surveillance of PTMC). The common denominator is patients' attempt to preserve thyroid function, bringing into focus percutaneous ethanol injection (PEI) and thermal ablation techniques (radiofrequency ablation [RFA] being the most common). We discuss the evidence supporting these approaches and compare them with standard therapy, where evidence exists. We discuss additional considerations for the utilization of these therapies, their side-effects, and conclude with a simplified description of how these procedures are performed.

CONCLUSION

Thermal ablation, particularly RFA, is becoming an attractive option for managing a subgroup of solid thyroid nodules, while PEI has a role in managing thyroid cysts and a select group of PTMC. Their role in the algorithm of thyroid nodule management is still being refined and technical expertise will be essential to reproduce the reported results into everyday practice.