Evaluation of the thyroid nodule with high-resolution ultrasonography and elastography without fine needle aspiration biopsy

Application of shear wave elastography in the management of thyroid nodules in children and adolescents: our experience and a review of the literature

Introduction

Shear wave elastography (SWE) is an ultrasound diagnostic method used to measure tissue stiffness. Since the mechanical properties of tissue involved in the pathological process change, SWE might indicate regions of the examined tissue covered by the disease. It is well documented that SWE helps to differentiate benign and malignant nodules in thyroid glands in adults, however, there are few studies on the application of SWE in thyroid diagnosis in children. The purpose of the study was to assess the application of SWE based on Young's modulus expressed in kPa in the management of thyroid nodules in children and adolescents.

Methods

In total, 116 pediatric patients (81 girls and 35 boys) with 168 thyroid nodules were enrolled in the study and qualified for SWE followed by fine needle aspiration biopsy.

Results

According to the result of the cytological examination presented in the Bethesda System, nodules were classified as benign (147 nodules classified as category II according to the Bethesda System) or indeterminate or suspicious (21 nodules classified as categories III, IV, and V according to the Bethesda System). Benign cytological diagnoses were nodular goiter, parenchymal goiter, nodular colloid goiter, or lymphocytic inflammation. Among the indeterminate or suspicious nodules, 15 were diagnosed as category III according to the Bethesda System (atypia of undetermined significance (AUS) or follicular lesion of undetermined significance (FLUS) in cytology), 1 nodule was diagnosed as category IV according to the Bethesda System (suspicious for follicular neoplasm - oxyphilic cell tumor), and 5 as category V according to the Bethesda System (suspicious for malignancy). There were no significant differences in thyrotropin (TSH) and free thyroxine (fT4) concentrations between the benign and suspicious groups. Patients with benign and indeterminate or suspicious thyroid nodules were of comparable age. Mean SWE in benign nodules was statistically significantly lower than in nodules with indeterminate or suspicious cytology (42.22 ± 16.69 vs. 57.4 ± 24.0 kPa, p=0.0004). Six patients from the indeterminate or suspicious group were revealed to be malignant in the final histopathological examination.

Conclusion

Our results suggest that SWE is a viable diagnostic method, however, it still seems to need some adjustment for pediatric patients.

Solitary and multiple thyroid nodules as predictors of malignancy: a systematic review and meta-analysis

BACKGROUND

The debate on whether or not there is a difference in the incidence of thyroid cancer between the patients with Solitary thyroid Nodule (STN) and Multinodular Goiter (MNG) has been constantly present for the last few decades. With newer studies yielding mixed results, it was imperative to systematically compile all available literature on the topic.

METHODS

PubMed/MEDLINE, Cochrane Central, ScienceDirect, GoogleScholar, International Clinical Trials registry, and reference lists of the included articles were systematically searched for article retrieval. No filter was applied in terms of time, study design, language or country of publication. Rigorous screening as per PRISMA guidelines was undertaken by 2 independent reviewers in order to identify the articles that were most relevant to the topic.

RESULTS

Twenty-two studies spanning from 1992 to 2018 were included in this analysis and encompassed 50,321 patients, 44.2% of which belonged to the STN subgroup and 55.37% to the MNG subgroup. MNG was found to be associated with a significantly lower risk of thyroid cancer (OR = 0.76; 95% CI 0.61-0.96) when compared with STN. Papillary carcinoma was the most frequently occurring carcinoma across both groups, followed by follicular and medullary carcinomas. A subgroup analysis was performed to assess the efficacy of the two most commonly employed diagnostic tools i.e. surgery and fine needle aspiration cytology (FNAC), however it yielded nonsignificant results, indicating a comparable usefulness of the two. Another subgroup analysis run on the basis of the presumed iodine status of the participants also yielded nonsignificant results.

CONCLUSION

There is a higher incidence of thyroid cancer among patients of STN, however, given the low quality of existing evidence on the topic, it is crucial to conduct larger studies that can establish association with a greater precision.

Pediatric Thyroid Nodules: Ultrasound Characteristics as Indicators of Malignancy

Objective

Pediatric thyroid nodules are uncommon but carry a 25% malignancy risk. Adult patients have well-established ultrasound characteristics that are predictive of malignancy, but these are not clearly defined in pediatric patients. We reviewed a case series of pediatric thyroid nodules.

Study Design

Retrospective chart review.

Setting

Tertiary children’s hospital.

Method

Institutional review board approval was obtained. This case series with chart review includes all pediatric thyroid nodules with ultrasounds from 2006 to 2016 at 2 pediatric tertiary care centers.

Results

An overall 112 pediatric thyroid nodules were analyzed. The mean patient age was 14.3 years; there was a female:male ratio of 4:1; and 94% were Caucasian. Seventeen percent (20/112) of nodules were malignant. In patients with malignant nodules, the average presenting age was 15.5 years, with a female:male ratio of 5.6:1. Seventy percent of malignant nodules had accompanying microcalcifications, 55% had abnormal lymph nodes, and 45% had irregular margins. In the benign nodules, 11% had microcalcifications, 12% had abnormal lymph nodes, and 26% had irregular margins. The presence of microcalcifications (odds ratio, 19.1 [95% CI, 6.0-61.0]; P < .0001), abnormal lymph nodes (odds ratio, 9.0 [95% CI, 3.0-26.6]; P = .0001), and size >3.5 cm (odds ratio, 5.8 [95% CI, 1.5-22.5]; P = .01) was associated with thyroid cancer. Irregular margins were not statistically significant (odds ratio, 2.3 [95% CI, 0.86-6.3]; P = .9).

Conclusions

Our data suggest that abnormal lymph nodes, microcalcifications, and size >3.5 cm could be predictors of malignancy in the pediatric population and influence clinical decision making.

Ultrasound Elastography is a Useful Adjunct to Conventional Ultrasonography and Needle Aspiration in Preoperative Prediction of Malignancy in Thyroid Nodules: A Northern India Perspective

INTRODUCTION

Data on ultrasound elastography (USE) are scant from India. This study aimed to compare the sensitivity and specificity of USE with thyroid ultrasonography (USG) and fine-needle aspiration (FNA) as preoperative predictor of malignancy, using postoperative histopathology as gold standard.

MATERIALS AND METHODS

Consecutive patients with thyroid swelling/goiter underwent thyroid USG followed by USE. Patients with pure cystic nodules or eggshell calcification were excluded. Patients with nodules >10 mm with one or more high-risk USG features underwent FNA. Patients with no USG high-risk features, benign score on USE, and benign FNA were conservatively followed. All other patients underwent thyroidectomy.

RESULTS

246 consecutive patients underwent USG. Data from 97 patients (117 nodules) were analyzed. Median age of patients was 43 years with 85.4% females. All patients with USE score-1 had benign USG and FNA characteristics. Of 86 nodules having USE score-2, 18.6% nodules were hypoechoic and 16.28% had microcalcification. Hypoechogenicity and microcalcifications were observed in 66.67% nodules with USE score-3. All nodules with USE score-4 and 5 were hypoechoic and had microcalcifications. Histopathology was benign in 84 and malignant in 33 patients. Occurrence of malignancy in USE scores 1-5 was 0, 4.65, 100, 90.5, and 100%, respectively. All eight nodules with diagnosis of follicular adenoma had preoperative USE score-2. The sensitivity of preoperative USG, USE, and FNA in picking up malignancy was 66.67, 87.88, and 69.70%, respectively. Specificity of USG, USE, and FNA in detecting thyroid malignancy was 88.10, 100, and 97.6%, respectively. False positivity rates for USG, USE, and FNA in diagnosing thyroid malignancy was 11.9, 0, and 2.4%, respectively. The overall diagnostic accuracy of USG, USE, and FNA cytology in this study was 82.05, 96.58, and 89.74%, respectively.

CONCLUSION

USE may be better than USG for preoperative detection of malignancy in thyroid nodules.