Thyroid nodule guidelines: agreement, disagreement and need for future research

Microcalcifications in breast cancer tissue studied by X-ray absorption, emission, scattering and diffraction

Microcalcifications (MC) are observed in various tissues and in relation to several diseases. For breast cancer, recent studies have reported differences in the nature of the MC and correlations to the degree of malignancy of the neoplasm. Here, investigations of benign, ductal carcinoma in situ (DCIS) and invasive ductal carcinoma (IDC) breast MC using X-ray fluorescence, X-ray absorption spectroscopy and wide-angle X-ray scattering are reported. While Mg has been observed in all MC, only for the benign MC has a rim of crystalline whitlockite been identified as a minor crystalline phase in addition to the major hy-droxy-apatite (HAP) one. MC in DCIS and IDC tissue exhibit a higher abundance of a high-crystallinity HAP phase in comparison with the less well ordered MC in the benign tissue. Moreover, the distribution of other trace elements in the MC, such as Na, S, Cl, Sr and Y, is observed. For the quantitative analysis of the elemental maps, the experimentally determined sample thickness in each pixel has been incorporated as an additional parameter in the fitting process to account for sample roughness.

Does Radioactive Iodine Treatment Affect Thyroid Size and Tracheal Diameter?

Background/Objectives: There exist three principal treatment modalities employed in the management of hyperthyroidism attributable to excessive hormone secretion by the thyroid gland: antithyroid pharmacotherapy, surgical intervention, and radioactive iodine (RAI) therapy. Surgical intervention is typically indicated for markedly enlarged thyroid glands that exert pressure on the trachea. The objective of this investigation was to ascertain the influence of RAI on thyroid volume and tracheal diameter. Methods: This study included 20 patients, six females and 14 males, who received 20 mCi radioactive iodine treatment for toxic nodular goiter at a tertiary university hospital between March 2019 and February 2020. Pre-treatment and six-month post-treatment neck MRI scans were conducted on the cohort. Thyroid and tracheal volumes were quantified using the Cavalieri method based on MRI sections, and comparisons were conducted pre-and post-treatment. Statistical analysis of the comparative values was performed using the dependent samples t-test. Results: A statistically significant reduction in thyroid volume was observed among the 20 patients, averaging a decrease of 36.06% following RAI treatment compared to baseline measurements (p < 0.001). Additionally, an average increase of 12.76% in tracheal volume was noted post-treatment in comparison to initial measurements, which was also statistically significant (p < 0.05). None of the patients exhibited respiratory distress in the immediate postoperative period. Conclusions: The findings indicate that RAI therapy leads to a reduction in thyroid size, accompanied by an increase in tracheal diameters subsequent to treatment. Given the potential complications and risks associated with surgical intervention, it may be prudent to consider large thyroids for RAI therapy as an alternative to surgery.

Progress in diagnosing and treating thyroid squamous cell carcinoma under the 5th edition of WHO classification

Squamous cell carcinoma of the thyroid (SCCT) is a rare thyroid gland malignancy, with only a few hundred cases reported in the literature, mostly as case reports or small sample studies. In the previous WHO classification, squamous cell carcinoma of the thyroid was defined as a carcinoma composed entirely of squamous cells without differentiated carcinoma components. It was once included in the WHO tumor classification separately. However, the 2022 WHO classification of squamous cell carcinoma of the thyroid was reclassified as a morphologic subtype of anaplastic thyroid carcinoma (ATC). The squamous cell carcinoma pattern is similar to the other histologic types of ATC, but the phenotype associated has a poorer prognosis. The typical clinical manifestation of this condition is a cervical mass, accompanied by indications and symptoms of compression on adjacent structures such as the esophagus and trachea in advanced stages. Secondary squamous cell carcinoma of the thyroid may occur due to the spread of squamous carcinoma of the larynx or esophagus or distant metastases from other sites. Diagnosis of squamous cell carcinoma of the thyroid includes neck Ultrasound (US), Computed Tomography (CT) or Magnetic Resonance Imaging (MRI), puncture tissue biopsy, and full endoscopy to identify metastatic lesions from the nasopharynx, oropharynx, hypopharynx, larynx, esophagus, or bronchi and to help with the initial staging of the tumor. Current treatment modalities include surgery, radiotherapy, chemotherapy, or a combination. Because of the poor prognosis of patients with this disease, the short survival period, usually less than one year, and the difficulty of preoperative diagnosis, this article reviews the epidemiological features, origin, clinical features, pathological features, and differential diagnosis to improve the diagnosis and treatment of this disease by clinicians.

Neglected massive multinodular goiter during pregnancy with dyspnea and successful normal delivery: A case report

Key Clinical Message

Prompt coordinated care enables vaginal delivery for severe goiter-induced airway compression in late pregnancy when expectant management is precluded.

Abstract

Long-standing neglected multinodular goiter rarely causes life-threatening airway compression in late pregnancy. Most cases report cesarean delivery to relieve respiratory distress. Vaginal birth may also be possible, but the evidence is limited. A 30-year-old woman with a 7-year goiter history developed severe dyspnea at 34 weeks gestation. Despite the risks, labor was induced by urgent decompression. She vaginally delivered a premature but healthy infant. Her breathing improved after delivery. She later underwent an uncomplicated thyroidectomy. With careful selection and monitoring, vaginal delivery can be considered for goiter-induced respiratory compromise when expectant management is precluded. This case demonstrates successful urgent decompression and favorable maternal-fetal outcomes are possible with a coordinated approach despite the high-risk scenario.

The EANM guideline on radioiodine therapy of benign thyroid disease

This document provides the new EANM guideline on radioiodine therapy of benign thyroid disease. Its aim is to guide nuclear medicine physicians, endocrinologists, and practitioners in the selection of patients for radioiodine therapy. Its recommendations on patients' preparation, empiric and dosimetric therapeutic approaches, applied radioiodine activity, radiation protection requirements, and patients follow-up after administration of radioiodine therapy are extensively discussed.

Introducing ethanol ablation as a treatment for thyroid cysts in the emergency setting

BACKGROUND

Ethanol ablation for the treatment of thyroid cysts has been well documented in the literature as a safe, effective treatment option in the elective setting. This study demonstrates the use of ethanol ablation in the emergency setting.

METHODS

Three patients presenting with airway-threatening compressive symptoms secondary to a thyroid cyst were treated with ethanol ablation within 24 hours of presentation to hospital.

RESULTS

All patients had symptom resolution at a median of nine months follow up post procedure. Sixty-six per cent of patients required only one treatment. There was a median of 100 per cent radiological resolution of the cystic component. The median Glasgow Benefit Inventory score was +27.7, similar to that for tonsillectomy.

CONCLUSION

Ethanol ablation is a safe, cost-effective and efficient treatment option for thyroid cysts in the acute setting.

Quantitative differentiation of malignant and benign thyroid nodules with multi-parameter diffusion-weighted imaging

BACKGROUND

The value of conventional magnetic resonance imaging in the differential diagnosis of thyroid nodules is limited; however, the value of multi-parameter diffusion-weighted imaging (DWI) in the quantitative evaluation of thyroid nodules has not been well determined.

AIM

To determine the utility of multi-parametric DWI including mono-exponential, bi-exponential, stretched exponential, and kurtosis models for the differentiation of thyroid lesions.

METHODS

Seventy-nine patients (62 with benign and 17 with malignant nodules) underwent multi-b value diffusion-weighted imaging of the thyroid. Multiple DWI parameters were obtained for statistical analysis.

RESULTS

Good agreement was found for diffusion parameters of thyroid nodules. Malignant lesions displayed lower diffusion parameters including apparent diffusion coefficient (ADC), the true diffusion coefficient (D), the perfusion fraction (f), the distributed diffusion coefficient (DDC), the intravoxel water diffusion heterogeneity (α) and kurtosis model-derived ADC (Dapp), and higher apparent diffusional kurtosis (Kapp) than benign entities (all P < 0.01), except for the pseudodiffusion coefficient (D*) (P > 0.05). The area under the ROC curve (AUC) of the ADC_{(0 and 1000)} was not significantly different from that of the ADC_{(0 and 2000)}, ADC_{(0 to 2000)}, ADC_{(0 to 1000)}, D, DDC, Dapp and Kapp (all P > 0.05), but was significantly higher than the AUC of D*, f and α (all P < 0.05) for differentiating benign from malignant lesions.

CONCLUSION

Multiple DWI parameters including ADC, D, f, DDC, α, Dapp and Kapp could discriminate benign and malignant thyroid nodules. The metrics including D, DDC, Dapp and Kapp provide additional information with similar diagnostic performance of ADC, combination of these metrics may contribute to differentiate benign and malignant thyroid nodules. The ADC calculated with higher b values may not lead to improved diagnostic performance.

The relationship between ultrasound-based TIRADS and BETHESDA categories in patients undergoing thyroid biopsy

The TIRADS is a scoring system used for the selection of nodules for FNA and classification of the risk of malignancy based on ultrasound characteristics. The BETHESDA is a standard reporting system used for the classification of FNA results based on six criteria with risks for malignancy. The objective of this study was to evaluate the relationship between TIRADS and BSRTC classifications in patients undergoing thyroid biopsy. A total of 350 consecutive patients were retrospectively evaluated using TIRADS and BETHESDA reporting systems for determining preoperative diagnosis of thyroid nodules. Patients' demographics, size, echogenicity and contour status of the nodules, TIRADS and BETHESDA scores were recorded and analyzed. Data obtained in this study were expressed as mean, standard deviation, frequency and percentage descriptive statistics. The mean age of the patients was 49.03 ± 17.58 years. The mean nodule size was measured as 20.56 ± 10.47 mm. TIRADS TR3 category was found in 165 (47.14%), TR4 in 154 (44%) and TR5 in 31 (8.86%) patients, while BETHESDA II category was found in 288 (82.28%), BETHESDA III category in 1 (0.29%), BETHESDA IV category in 19 (5.43%), BETHESDA V in 37 (10.57%) and BETHESDA VI in 5 (1.43%) patients. There was a general concordance between BETHESDA and TRIADS categories. The most significant concordance was found between BETHESDA IV and TR4 categories (84.21%). Combined use of TRIADS and BETHESDA can be efficiently used to provide the most accurate results for making preoperative diagnosis of thyroid nodules and to determine the risk of malignancy.

Thyroid function disorders and secondary cancer following haematopoietic stem cell transplantation in pediatrics: State of the art and practical recommendations for a risk-based follow-up

Thyroid disorders (TD) represent a remarkable share of all the late morbidities experienced following pediatric haematopoietic stem cell transplantation (HSCT), with long-term reported occurrence often exceeding 70%. In addition, the data collected on wide cohorts of survivors assessed longitudinally outlined a progressive increase in the cumulative incidence of TD as far as 30 years following transplantation. Accordingly, a life-long monitoring of thyroid health is warranted among patients exposed to HSCT in childhood, in order to early detect TD and undertake a prompt dedicated treatment. Although several national and international consortia have provided recommendations for the early detection of thyroid disorders among childhood cancer survivors exposed to radiotherapy and alkylating agents, no guidelines specifically and thoroughly focused on HSCT-related TD have been published to date. As stem cell transplantation has become the standard-of-care in a growing body of non-oncological conditions, this urge has become pivotal. To highlight the challenging issues specifically involving this cohort of patients and to provide clinicians with the proposal of a practical follow-up protocol, we reviewed published literature in the light of the shared experience of a multidisciplinary team of pediatric oncologists, transplantologists, pathologists and endocrinologists involved in the long-term care of HSCT survivors. As a final result, we hereby present the proposals of a practical and customized risk-based approach to tailor thyroid health follow-up based on HSCT-related detrimental factors.

Accuracy of shear wave elastography in characterization of thyroid nodules in children and adolescents

BACKGROUND

Thyroid nodules are an important health problem in children and adolescents. They possess a higher risk of malignancy in comparison to adults. This fact forms a great dilemma for clinicians. The aim of this study was to evaluate the reliability of shear wave elastography (SWE) as a non-invasive technique in the characterization of thyroid nodules in children and adolescents.

METHODS

This prospective study included 56 patients with thyroid nodules. All the patients underwent clinical assessment, laboratory investigations, ultrasound, and Doppler examination, followed by an SWE assessment. Statistical analysis was performed and the best cut-off value to differentiate benign from malignant nodules was determined using the ROC curve and AUC.

RESULTS

Seventy-two nodules were detected in the examined patients (ages ranged from 11 to 19 years, with mean age of 14.89 ± 2.3 years). Fifty-eight nodules (80.6%) were benign, and fourteen nodules (19.4%) were malignant (histopathologically proved). Highly suspicious criteria for prediction of malignancy by ultrasound and Doppler were hypoechoic echopattern, internal or internal and peripheral vascularity, microcalcifications, taller-than-wide dimensions, irregular outlines, and absence of halo (p < 0.05). The diagnostic performance for their summation was 70.69% sensitivity, 82.8% specificity, 80.45% accuracy, a 63.79% positive predictive value (PPV), and 87.9% negative predictive values (NPV). Regarding SWE, our results showed that 42.2 kPa was the best cut-off value, with AUC = 0.921 to differentiate malignant from benign nodules; the diagnostic performance was 85.71% sensitivity, 94.83% specificity, 93.06% accuracy, 76.9% PPV, and 93.2% NPV.

CONCLUSION

Shear wave elastography is a non-invasive technique that can assist in the diagnosis of malignant thyroid nodules among children and adolescents.

Long-Term Efficacy of Ultrasound-Guided Percutaneous Laser Ablation for Low-Risk Papillary Thyroid Microcarcinoma: A 5-Year Follow-Up Study

Objective

To evaluate the long-term efficacy and safety of ultrasound-guided percutaneous laser ablation (PLA) for the treatment of low-risk papillary thyroid microcarcinoma (PTMC).

Methods

From June 2012 to May 2015, 105 patients with solitary, pathologically confirmed PTMC lesions were treated with ultrasound-guided PLA. Nodule location, nodule volume, thyroid function, and clinical symptoms were evaluated before ablation. Contrast-enhanced ultrasound (CEUS) was performed 1 h after treatment to evaluate whether the ablation was complete. Ultrasound examination was performed at 1, 3, 6, and 12 months after ablation and every 6 months thereafter to determine the size of the ablation area and search for recurrence in the thyroid parenchyma and lymph node metastasis. Thyroid function was examined before and 1 month after ablation. Fine needle aspiration biopsy was performed for any suspicious metastatic lymph nodes and recurrent lesions in the thyroid.

Results

All 105 lesions were completely inactivated after one ablation, making the success rate for single ablation 100%. The average ablation time was 2.78 ± 1.05 min, and the average ablation energy was 505 ± 185 J. All patients could tolerate and complete the ablation. No serious complications occurred during the treatment; only minor side effects such as pain and local discomfort were reported. The volume reduction rates were −781.14 ± 653.29% at 1 h posttreatment and −268.65 ± 179.57%, −98.39 ± 76.58%, 36.78 ± 30.32%, 75.55 ± 21.81%, 96.79 ± 10.57%, and 100% at 1, 3, 6, 12, 18, and 24 months after ablation, respectively. This rate remained 100% at the later follow-up times. Overall, 28 (26.67%), 74 (70.48%), 96 (91.43%), and 103 (100%) were completely absorbed by 6, 12, 18, and 24 months after PLA. One patient developed another lesion 12 months after ablation, and two patients had central cervical lymph node metastasis 24 months after ablation.

Conclusion

PLA is a safe and effective alternative clinical treatment for low-risk PTMC.

Shear Wave Elastography Combined with Thyroid Imaging Report and Data System for Risk Stratification of Thyroid Nodule Malignant Tumor

Benign and malignant thyroid cancer diagnosis is crucial. Our study intends to evaluate the role of shear wave elastography (SWE) and thyroid imaging report and data system (TI-RADS) in diagnosing the benign and malignant thyroid nodules. 100 thyroid nodules patients were recruited and evaluated by SWE and TI-RADS before fine needle biopsy and/or surgery. The maximum elastic index (Emax), mean elasticity index of thyroid nodules (Emean), minimum elastic index (Emin) and elastic ratio (ER) was measured and compared between different imaging. Ultrasound diagnosis showed solid nodules with significant hypoechoic, unclear boundary, and microcalcification. TI-RADS value was measured based on suspected ultrasound features. Combination of SWE and TI-RADS was performed. Among the 100 nodules, 38 were benign (38.0%), 62 were malignant (62.0%), and malignant nodules had significantly elevated SWE and TI-RADS compared with benign nodules (P < 0.001). The optimal SWE threshold for Emax was 51.95 kPa, with a sensitivity of 81.44% and specificity of 83.19%. There were two methods for combining SWE and TI-RADS. One was sequential detection, with a specificity of 95.80%, positive similarity ratio of 18.16 and PPV of 96.73%; the other was parallel detection method with a sensitivity of 94.85%, negative similarity ratio of 0.07 and PPV of 90.00%. Our results suggest that combination of SWE and TI-RADS might be applied to identify benign and malignant thyroid cancers.

Effect of thyroidectomy on circulating angiogenic cytokines in papillary thyroid carcinoma and benign goiter: Potential for new biomarkers?

BACKGROUND

Circulating angiogenic factors have been associated with clinical outcomes of papillary thyroid carcinoma, although they may also be released in the context of benign multinodular goiter. We sought to investigate the effect of thyroidectomy on the activity and importance of multiple circulating angiogenic factors in papillary thyroid carcinoma and benign multinodular goiter.

METHODS

Between May 2015 and December 2016, patients scheduled for total thyroidectomy for papillary thyroid carcinoma or benign multinodular goiter were offered to enroll in this study. Serum levels of angiopoietin-2, fibroblast growth factor-2, hepatocyte growth factor, platelet-derived growth factor-BB, placenta growth factor, heparin-binding epidermal growth factor, and vascular endothelial growth factor-A and -C were collected preoperatively and 2 weeks postsurgery. These levels were measured by enzyme-linked immunosorbent assay and compared with those of 35 healthy control subjects.

RESULTS

Sixty patients with a median age of 52 years, 37 of whom were females, were included: 36 had papillary thyroid carcinoma, and 24 had benign multinodular goiter. In both benign multinodular goiter and papillary thyroid carcinoma, preoperative, circulating angiogenic factors levels were increased with respect to controls (P < .0001), and a decrease after total thyroidectomy was observed in the levels of angiopoietin-2 (P < .0001), fibroblast growth factor-2 (P < .0001), hepatocyte growth factor (P < .001), and heparin-binding epidermal growth factor (P < .01 each). Only patients with papillary thyroid carcinomas, however, showed decrease in the postoperative levels of platelet-derived growth factor-BB and vascular endothelial growth factor-A (P = .001 each).

CONCLUSION

Results from this study raise the potential for vascular endothelial growth factor-A and platelet-derived growth factor-BB to be used as biomarkers of the effectiveness of treatment of papillary thyroid carcinoma. These results warrant further investigation and may have potential prognostic implications.

Differential diagnosis of thyroid nodules through a combination of multiple ultrasonography techniques: A decision-tree model

The present study aimed to establish a decision tree (DT) model by combining the parameters of conventional gray-scale ultrasonography (US), elastosonography (ES), color Doppler US (CDUS) and contrast-enhanced US (CEUS) for the differential diagnosis of thyroid nodules. A single-center, retrospective study of 321 thyroid nodules was conducted. For 222 nodules, parameters of conventional gray-scale US, CDUS, ES and CEUS were evaluated using univariate logistic regression. Factors for with P<0.10 were further assessed using multivariate logistic regression. Significant factors (P<0.05) were used to establish a DT. The diagnostic accuracy of this DT was then evaluated by its application to the other 99 nodules. After univariate logistic analysis, factors including gender, number of nodules and diffuse disease were excluded, due to P>0.10. The results of multivariate logistic analysis determined that the following factors were required for the DT: Extent of blood flow determined by CDUS (P=0.002), area ratio determined by ES (P=0.033), peak phase patterns determined by CEUS (P<0.001) and micro-calcification determined by conventional gray-scale US (P=0.015). When compared to the pathological or cytological results of 99 nodules, the resulting DT had a sensitivity of 98.6%, specificity of 80.1%, positive predictive value of 93.5% and negative predictive value of 95.5%. These results suggested that a DT combining conventional gray-scale US, ES, CDUS and CEUS may be helpful for differentiating between types of thyroid nodules.

The Bethesda System for Reporting Thyroid Cytology (TBSRTC): From look-backs to look-ahead

The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) was formalized in October 2007 by experts in thyroidology at the National Institute of Health in Bethesda, Maryland. The first edition of the TBSRTC book was published in 2010 and the second edition in 2018. The TBSRTC is widely employed in cytology practices in the United States and has also served as a model for similar tiered classification schemes for reporting thyroid cytopathology specimens. The tremendous success of TBSRTC cannot be underscored, it has provided a diagnostic framework which is well aligned with the present and the future of thyroid nodule management.

ABLATION OF CYSTIC THYROID NODULES WITH N-BUTYL CYANOACRYLATE: A PRELIMINARY STUDY

Objective: Generally recommended treatment options for cystic nodules with compressive symptoms are simple aspiration, percutaneous ethanol injection, or surgery. N-butyl cyanoacrylate (NBCA) is a glue-like substance widely used in neurointerventions, mainly for treating arteriovenous malformations. It obstructs and attaches to the vessel walls, preventing recanalization. Our purpose was to investigate the efficacy and safety of NBCA in volume reduction of benign cystic thyroid nodules with compressive symptoms. Methods: Twenty patients with 21 benign pure or partially cystic nodules were enrolled. After simple cyst aspiration, NBCA/lipiodol mixture was injected within the cyst cavity. Success was defined as at least 50% volume reduction after the intervention. Pre- and postintervention longest diameter and volume (calculated with ultrasonography after measuring three dimensions) of the nodules were compared. Posttreatment measurements were made at the 9-month final visit. Results: Median largest diameter of the nodules measured before and after NBCA treatment was 4.8 cm (min-max, 3.1 and 6.3 cm) and 3.4 cm (min-max, 2.4 and 5.6 cm), respectively. Pre-NBCA treatment median volume was 24.8 mL (min-max, 10.9 and 46.1 mL), whereas post-treatment median volume was 5.5 mL (min-max, 2.1 and 29.6 mL). Median volume reduction was 72.6% (min-max, 21.0 and 95.4%). Intervention was successful in 20 of 21 nodules according to the predefined criteria. The changes in pre- and postintervention median longest diameter and volume were statistically significant. Conclusion: For large cystic thyroid nodules, ablation with NBCA may be an effective treatment choice, as it significantly reduces the cyst volume and prevents fluid re-accumulation. There is need for further studies with a larger number of patients and longer follow-up. Abbreviations: NBCA = N-butyl cyanoacrylate; PEI = percutaneous ethanol injection; US = ultrasonography.

Comparison of Number of Passes and Cytopathological Specimen Adequacy for Thyroid Fine-Needle Aspiration Biopsy in the Absence of an On-Site Pathologist

AIM

Ultrasound-guided fine-needle aspiration biopsy (FNAB) is a reliable, minimally invasive diagnostic method with high sensitivity and specificity in the evaluation of thyroid nodules. Our aim in this retrospective study was to determine if there was a difference in the adequacy ratio based on the number of needle passes in the thyroid FNABs in the absence of rapid on-site evaluation (ROSE) by the pathologist and to determine the optimal needle pass number for FNAB.

METHODS

Between November 2018 and February 2019, thyroid FNABs of 121 (99 female, 22 male) patients were evaluated retrospectively. Samples for each biopsy were numbered according to the order of retrieval, and 4 pairs of slides were prepared by the radiologist without on-site microscopic evaluation. Cytological results were determined according to the Bethesda classification.

RESULTS

The rate of adequacy in the first, second, third, and fourth passes were 76.0, 82.6, 77.7, and 71.2%, respectively. No statistically significant difference was found between these four groups in terms of adequacy (p = 0.21). The adequacy rates of the 1st, 1st+2nd, 1st+2nd+3rd, and cumulative evaluation of all four biopsies were 76.0, 87.6, 90.1, and 91.7%, respectively (p = 0.001). A statistically significant difference was found in the comparison of the 1st biopsy and the cumulative 1st+2nd biopsy in terms of adequacy rates (p = 0.019). However, there was no statistically significant difference between the cumulative 1st+2nd biopsy and the cumulative 1st+2nd+3rd biopsy in terms of adequacy rates (p = 0.54).

CONCLUSIONS

In cases where ROSE cannot be performed, we recommend a minimum of 2 and a maximum of 3 needle entries for FNAB adequacy with the right technique and preparation.

Single-Fiber Laser Ablation in Treating Selected Metastatic Lymph Nodes of Papillary Thyroid Carcinoma and Benign Cold Thyroid Nodules-Preliminary Results

Background and Objectives

To evaluate the feasibility and efficacy of single‐fiber laser ablation (LA) under ultrasound guidance and appropriate ablation modes in the treatment of selected metastatic lymph nodes of papillary thyroid carcinoma (PTC) and benign cold thyroid nodules

Study Design/Materials and Methods

A total of 18 patients (consisting of 8 patients with 18 metastatic lymph nodes of PTC and 10 patients with 10 benign cold thyroid nodules) each underwent one session of single‐fiber LA under ultrasound guidance. On the basis of the sizes of the nodules, the ablation modes were chosen accordingly. The single‐dot ablation mode was used in the nodules with three orthogonal diameters measuring no greater than 10 mm in diameter, with a dot, a level and an insertion. The double‐dots overlapping ablation mode was used in the nodules with the largest diameters measuring greater than 10 mm (in which the nodules measured no more than 15 mm in diameter and with the other two perpendicular diameters measuring no greater than 10 mm in diameter) with two dots, a level and two insertions. The multiple levels and dots overlapping ablation mode was used in the nodules with the three orthogonal diameters all measuring larger than 10 mm, with multiple dots, levels and insertions.

Results

After 12 months of follow‐up in the treated nodules of the metastatic lymph nodes of PTC and benign cold thyroid nodules, the mean baseline volumes decreased from 0.29 ± 0.12  to 0.03 ± 0.03 ml and 3.85 ± 0.64 to 1.1 ± 0.37 ml, respectively, and the mean volume reduction ratios (VRRs), which was calculated as {[(initial volume−final volume) × 100%]/initial volume}, were 90.3 ± 7.6% and 72 ± 5.8%, respectively. There were six ablative zones that completely disappeared, whereas the ablative zones that still existed presented as scar‐like areas or small hyperechoic areas that were compatible with scar tissue among the 18 malignant nodules at the last follow‐up.

Conclusions

Single‐fiber LA under ultrasound guidance, with the appropriate ablation modes, is feasible and effective for the treatment of selected metastatic lymph nodes of PTC and benign cold thyroid nodules. This study suggests that single‐fiber LA may be applied to selected cases with appropriate ablation modes. Lasers Surg. Med. 2019 © 2019 Wiley Periodicals, Inc.

Single-session treatment of benign thyroid nodules with radiofrequency ablation: Results at 6 months in 24 patients

OBJECTIVE

To evaluate the efficacy and safety of one single-session of radiofrequency ablation (RFA) performed in thyroid benign and predominantly solid nodules.

PATIENTS AND METHOD

Unicentric retrospective study in usual clinical setting that included patients with solid and benign thyroid nodules treated with one single session of RFA and with folllow-up of at at least 6 months after the procedure. RFA was performed as an alternative to surgery in cases of pressure symptoms or nodular growth evidence. Patients were evaluated basally and at one, 3 and 6 months after RFA and also at 12 months if the follow-up was available. In each evaluation efficacy variables were recorded (percentual change from basal volume, percentage of nodules reaching a volume reduction above 50% from baseline, patients with disappearance of pressure symptoms and the possibility of antithyroid drug withdrawal) and safety variables were also registered including minor complications (pain needing analgesic drugs, hematoma) and major complications (voice changes, braquial plexus injury, nodule rupture and thyroid dysfunction).

RESULTS

Twenty-four patients with a follow-up of at least 6 months after RFA were included, 16 of them with more than 12 months of follow-up. Mean nodule volume changed from 25.4±15.5ml basally to 10.7±9.9ml at month 6 (P<.05) and to 9.9±10,4ml at month 12 in 16 nodules. Six months after RFA mean volumetric reduction was 57.5±24% and 65% of the nodules reached a volume reduction above 50% from baseline. Median percentage of reduction at month 6 was 50.4±25.8% for nodules with a basal volume above 20ml (n=13) and 65.3±20.1% for nodules with a lower basal volume (n=11). Pressure symptoms reported in 12 patients disappeared in all cases. Antithyroid drugs could be stopped in 3 of 4 cases treated before RFA. A mild and transient pain responsive to conventional analgesic drugs was recorded in 9 patients during the 24h after the procedure and in 7 a small perithyroid and transient hematoma was observed in the 48 following hours. One major complication was described as a nodule rupture that recovered spontaneously. There were no changes in hormonal values in euthyroid cases.

CONCLUSION

A single session of RFA seems to be an effective and safe procedure in patients with solid thyroid nodules with pressure symptoms or relevant growth evidence. As an outpatient and scarless procedure with no need of general anaesthesia it could become an useful alternative to lobectomy when surgery is refused or in patients at high surgical risk.

Radioisotope imaging for discriminating benign from malignant cytologically indeterminate thyroid nodules

The risk of malignancy in thyroid nodules with indeterminate cytological classification (Bethesda III-IV) ranges from 10% to 40%, and early delineation is essential as delays in diagnosis can be associated with increased mortality. Several radioisotope imaging techniques are available for discriminating benign from malignant cytologically indeterminate thyroid nodules, and for supporting clinical decision-making. These techniques include iodine-123, technetium-99m-pertechnetate, technetium-99m-methoxy-isobutyl-isonitrile (technetium-99m-MIBI), and fluorine-18-fluorodeoxyglucose (fluorine-18-FDG). This review discusses the currently available radioisotope imaging techniques for evaluation of thyroid nodules, including the mechanism of radiotracer uptake and the indications for their use.

Long-term outcome following laser therapy of benign cystic-solid thyroid nodules

OBJECTIVE

Laser therapy (LT) is considered a safe and effective procedure for inducing thyroid nodule necrosis, fibrosis and shrinkage. Little is known about long-term efficacy of LT in benign complex thyroid nodules, which we report here.

DESIGN AND METHODS

One hundred and ten euthyroid outpatients (28 men and 82 women; median age 48 years (range 17-82)) with a recurrent cytologically benign cystic (≥2 mL cyst volume) thyroid nodule causing local discomfort were assigned to LT. LT was performed after complete cyst aspiration and under continuous ultrasound (US) guidance. Nineteen patients (17 within 6 months) had surgery after LT. The median follow-up for the remaining 91 patients was 45 months (range: 12-134).

RESULTS

The overall median nodule volume in the 110 patients decreased from 9.0 mL (range: 2.0-158.0) to 1.2 mL (range: 0.0-85.0) (P < 0.001) at the final evaluation, corresponding to a median reduction of 85% (range: -49 to 100%). Remission of the cystic part (volume ≤1 mL) was obtained in 82 of 110 (75%) patients after LT. The median cyst volume decreased from 6.3 mL (range: 2.0-158.0) to 0.0 mL (range: 0.0-85.0) (P < 000.1), corresponding to a median reduction of 100% (range: -49 to 100%). These results correlated with a significant decrease in pressure as well as cosmetic complaints. Side effects were restricted to mild local pain.

CONCLUSION

US-guided aspiration and subsequent LT of benign recurrent cystic thyroid nodules results in a satisfactory long-term clinical response in the majority of patients. LT constitutes a clinically relevant alternative to surgery in such patients.

Long-Term Endocrine and Metabolic Consequences of Cancer Treatment: A Systematic Review

The number of patients surviving ≥5 years after initial cancer diagnosis has significantly increased during the last decades due to considerable improvements in the treatment of many cancer entities. A negative consequence of this is that the emergence of long-term sequelae and endocrine disorders account for a high proportion of these. These late effects can occur decades after cancer treatment and affect up to 50% of childhood cancer survivors. Multiple predisposing factors for endocrine late effects have been identified, including radiation, sex, and age at the time of diagnosis. A systematic literature search has been conducted using the PubMed database to offer a detailed overview of the spectrum of late endocrine disorders following oncological treatment. Most data are based on late effects of treatment in former childhood cancer patients for whom specific guidelines and recommendations already exist, whereas current knowledge concerning late effects in adult-onset cancer survivors is much less clear. Endocrine sequelae of cancer therapy include functional alterations in hypothalamic-pituitary, thyroid, parathyroid, adrenal, and gonadal regulation as well as bone and metabolic complications. Surgery, radiotherapy, chemotherapy, and immunotherapy all contribute to these sequelae. Following irradiation, endocrine organs such as the thyroid are also at risk for subsequent malignancies. Although diagnosis and management of functional and neoplastic long-term consequences of cancer therapy are comparable to other causes of endocrine disorders, cancer survivors need individually structured follow-up care in specialized surveillance centers to improve care for this rapidly growing group of patients.

X-ray scanning microscopies of microcalcifications in abdominal aortic and popliteal artery aneurysms

Abdominal aortic and popliteal artery aneurysms are vascular diseases which show massive degeneration, weakening of the vascular wall and loss of the vascular tissue functionality. They are driven by inflammatory, hemodynamical factors and biological alterations that may lead, in the case of an abdominal aortic aneurysm, to sudden and dangerous ruptures of the arteries. Here, human aortic and popliteal aneurysm tissues were obtained during surgical repair, and studied by synchrotron radiation X-ray scanning microdiffraction and small-angle scattering, to investigate the microcalcifications present in the tissues. Data collected during the experiments were transformed into quantitative microscopy images through the combination of statistical approaches and crystallographic methods. As a result of this multi-step analysis, microcalcifications, which are markers of the pathology, were classified in terms of chemical and structural content. This analysis helped to identify the presence of nanocrystalline hy-droxy-apatite and microcrystalline cholesterol, embedded in myofilament, and elastin-containing tissue with low collagen content in predominantly nanocrystalline areas. The generality of the approach allows it to be transferred to other types of tissue and other pathologies affected by microcalcifications, such as thyroid carcinoma, breast cancer, testicular microli-thia-sis or glioblastoma.

Features and trends of thyroid cancer in patients with thyroidectomies in Beijing, China between 1994 and 2015: a retrospective study

OBJECTIVES

This study aims to summarise the features and trends of thyroid carcinoma in the past two decades in China.

DESIGN, SETTING AND PARTICIPANTS

Clinical data obtained from 10 798 patients treated by thyroidectomy from 1994 to 2015 at the Department of General Surgery of the People's Liberation Army General Hospital, Beijing, China were retrospectively analysed.

OUTCOME MEASURES

Incidence and histopathological features of thyroid cancer were compared and the risk factors for local lymph node metastasis analysed.

RESULTS

Our data indicated a significant increase in the detection of thyroid cancer (from 16.8% to 69.8%, p<0.01). Among the 5235 thyroid cancer cases, papillary thyroid carcinoma (PTC) was the most common histotype, accounting for 95.1% of all malignancies over the 22-year period. Among the 4979 PTCs, micro-PTCs (mPTC) with the largest diameter ≤10 mm has gradually become the dominant form, and its percentage in PTCs has increased from 13.3% in the biennial period of 1994-1995 to 51.2% in 2010-2011. Furthermore, the size of the tumour has decreased significantly from 2.3±1.1 cm in 1994 to 1.2±0.9 cm in the largest diameter (p<0.01), while the average age at diagnosis and female dominance remained unchanged during the period. Logistic regression showed that tumour nodules>1 cm and male gender were the main risk factors for local lymph node metastasis (LNM), whereas patients over 45 years had lower risk.

CONCLUSIONS

During the 22-year period, an increased detection of thyroid cancer, particularly mPTC, was found while the occurrence of LNM decreased. Our results suggest that the current preoperative diagnosis and risk stratification are adequate, supporting the published guidelines for the diagnosis of thyroid cancer.

Percutaneous laser ablation of benign thyroid nodules: a one year follow-up study

Objective

To evaluate safety and effectiveness of nodule volume reduction and thyroid function after percutaneous laser ablation treatment in patients with benign nonfunctioning thyroid nodules.

Methods

Prospective single-center study, from January 2011 to October 2012, which evaluated 30 euthyroid and thyroid antibodies negative patients with benign solitary or dominant nodule with indication of treatment due to compressive symptoms and aesthetic disturbances. The clinical and laboratory (thyroid ultrasound, TSH, FT4, TG, TG-Ab, TPO-Ab and TRAb levels) evaluations were performed before the procedure, and periodically 1 week, 3 months and 6 months after. The ablation technique was performed under local anesthesia and sedation. In each treatment, one to three 21G spinal needle were inserted into the thyroid nodule. The laser fiber was positioned through the needle, which was then withdrawn 10mm to leave the tip in direct contact with the nodule tissue. Patients were treated with a ND: Yag-laser output power of 4W and 1,500 to 2,000J per fiber per treatment. The entire procedure was performed under US guidance.

Results

Thirty patients, with a total of 31 nodules submitted to laser ablation were evaluated. The median volumetric reduction of the nodule was approximately 60% after 12 months. No statistical significance was observed on thyroid function and antibodies levels. There was a peak on the level of thyroglobulin after the procedure due to tissue destruction (p<0.0001). No adverse effects were observed.

Conclusion

Percutaneous laser ablation is a promising outpatient minimally invasive treatment of benign thyroid nodule.

Diagnostic Performance of Multiple Sound Touch Elastography for Differentiating Benign and Malignant Thyroid Nodules

This study evaluated the ability of Sound Touch Elastography (STE) to distinguish malignant from benign thyroid nodules by quantifying tumor stiffness using the elastic ratio (EI) and shear modulus (G). Eighty-six patients with 86 nodules were enrolled in this study. There were 24/86 (27.90%) thyroid papillary carcinomas (TPC) and 62/86 (72.10%) benign nodules. The mean EI was significantly lower in TPCs than in benign nodules. The EI area under the receiver operating characteristic curve (ROC) was 80%. The EI cutoff value for TPCs was 0.215%. The sensitivity (Sen), specificity (Spe), positive likelihood ratio (LR+), and negative likelihood ratio (LR-) were 71%, 73%, 2.58, and 0.40, respectively. G max, G mean, and G sd were significantly higher in TPCs than in benign nodules. There were no significant differences in G min. Compared with other G parameters, G max with an optimal cutoff value of 15.82 kPa had the highest AUROC value (84%). The Sen, Spe, LR+, and LR- were 79.17%, 79.03%, 3.776, and 0.261, respectively. We pooled the EI, G max, G mean, and G sd and the pooled-Sen, Spe, LR+, LR-, diagnostic odds ratio and odds ratio, and area under the summary ROC were 79%, 71%, 2.73, 0.29, 2.23, 9.29, and 82%, respectively. STE could be a new ultrasound diagnostic method for evaluating benign and malignant thyroid nodules.

Correlation between Ultrasound-based TIRADS and Bethesda System for Reporting Thyroid-cytopathology: 2-year Experience at a Tertiary Care Center in India

BACKGROUND

In recent times, high-resolution ultrasound thyroid imaging has paved the way for significant transformation in clinical approach to thyroid nodule. There are several risk stratification systems in thyroid imaging, developed with an aim, not only to reduce the inter-observer variability but also to establish effective communication system. Thyroid image reporting and data system (TIRADS) classification system, which is similar to breast imaging reporting and data system for breast lesion, is the most useful of all. To our knowledge, there is just a handful published research articles available based on Indian population in this regard. In this article, we study the thyroid nodules using high-resolution ultrasound in Indian population and we try to correlate the TIRADS and Bethesda system for reporting thyroid cytopathology.

MATERIALS AND METHODS

This prospective study includes 184 patients studied over a period of 2 years (April 2015-April 2017). Patients having thyroid nodule in B-mode ultrasound and are scheduled to get a fine-needle aspiration cytology (FNAC) done. Bethesda classification of these nodules is tabulated in follow-up period simultaneously. By comparing these data, efficacy of TIRADS in differentiating benign from malignant nodules are assessed finally using accuracy, positive predictive value (PPV), cross-tabulation, and Chi-square tests.

RESULTS

Out of the 117 TIRADS 2 nodules, none turned out to be Bethesda IV or higher, which means none of these nodules turned out to be malignant. The risk of malignancy for TIRADS 2, TIRADS 3, TIRADS 4, and TIRADS 5 was 0, 2.2, 38.5, and 77.8%, respectively. The risk of malignancy percentage in our study is similar to those values obtained in other prominent studies.

CONCLUSION

The probability of a particular nodule being malignant can be effectively inferred from the ultrasound-based TIRADS system with a certain level of confidence. Considering our results and other literature reviews, it be can be safely assumed that FNAC can be at least deferred in patients having TIRADS 2 nodules, which contribute to majority of newly detected cases. In our experience, there is a remarkable correlation exists between TIRADS ultrasound classification and Bethesda cytology, especially for benign nodules.

Ethanol Ablation for the Treatment of Cystic and Predominantly Cystic Thyroid Nodules

OBJECTIVE

To determine the efficacy and safety of percutaneous ethanol injection (PEI) for the treatment of symptomatic cystic thyroid nodules.

PATIENTS AND METHODS

Retrospective analysis of patients with benign cystic thyroid nodules treated with PEI from February 1, 2000, through October 31, 2016. The main outcomes were efficacy, defined as symptom relief or reduction in nodule volume of 50% or more, and safety, defined as no or minor adverse events.

RESULTS

Twenty patients had PEI. Mean age at the time of PEI was 50 years, and 13 (65%) were women; all patients were euthyroid. Twelve patients (60%) had complex cystic thyroid nodules (>50% cystic component), with the rest being purely cystic. The median largest diameter of the thyroid cyst was 4.5 cm (interquartile range [IQR], 3.2-5.3 cm; range, 2.3-8.0 cm); the median volume pre-PEI was 19.6 mL (IQR, 10.4-48.5 mL; range, 2.8-118.1 mL). The median amount of cystic fluid drained before PEI was 13.5 mL (IQR, 6.8-32.3 mL), and the median amount of ethanol administered was 3 mL (IQR, 2-5 mL; range, 0.5-20 mL). After median follow-up of 2 years, 17 of 19 patients (89%) were asymptomatic. Of 10 patients with available imaging on follow-up, 7 (70%) had a 50% or greater reduction in nodule volume (median volume decrease, 75.64% [IQR, 41.40%-91.99%]). Adverse effects occurred in 4 patients (20%) and were mild and temporary (slight pain, vagal reaction, and bleeding into the cyst).

CONCLUSION

Percutaneous ethanol injection seems to be a safe and effective alternative to surgical resection for patients with purely or predominantly cystic thyroid nodules and compressive symptoms who decline surgery or are not good surgical candidates.

Investigation of thyroid nodules: A practical algorithm and review of guidelines

BACKGROUND

High resolution ultrasound has led to early detection of subclinical tumors and drastic increase in incidence of thyroid malignancy. To achieve a balance in appropriate investigation without perpetuating an overdiagnosis phenomenon, a concise set of evidence-based recommendations to stratify risk is required.

METHODS

We sought to assemble an evidence-based diagnostic algorithm and accompanying pictorial review for workup of thyroid nodules that summarizes the most recent guidelines. In addition, we conducted a literature search and analysis of our imaging databases.

RESULTS

Although many imaging features of benign and malignant nodules can be nonspecific, others, such as microcalcifications, lymphadenopathy, and peripheral invasion, are highly suggestive of malignancy. The predictive values of salient imaging characteristics are presented.

CONCLUSION

Evidence-based guidelines are available such that a cost-effective algorithm for thyroid nodule workup can be devised. Conservative management with a focus on periodic monitoring is the working clinical consensus on the approach to thyroid nodules.

Shear wave elastography combined with the thyroid imaging reporting and data system for malignancy risk stratification in thyroid nodules

To retrospectively evaluate the diagnostic performance of shear wave elastography (SWE) and thyroid imaging reporting and data system (TI-RADS) in differentiating malignant and benign thyroid nodules. A total of 313 thyroid nodules in 227 patients were included. All thyroid nodules were underwent SWE and TI-RADS before fine needle aspiration biopsy and/or surgery. SWE elasticity indices of the maximum (Emax), mean (Emean), minimum (Emin) and elastic ratio (ER) in thyroid nodules were measured. Nodules with solid component, marked hypoechogenicity, poorly defined margins, micro-calcifications, and a taller-than-wide shape were classified as suspicious at gray-scale ultrasonography. The level of TI-RADS was determined according to the number of suspicious ultrasonography features. The combined methods of SWE and TI-RADS in thyroid nodules were calculated. In the 313 nodules, 194 were malignant, and 119 were benign. SWE and TI-RADS were significantly higher in malignant nodules than benign nodules (P < 0.001). The most accurate SWE cut-off value, 51.95 kPa for Emax, achieved a sensitivity of 81.44% and a specificity of 83.19% for discriminating malignant nodules from benign nodules. There are two methods in combination with SWE and TI-RADS. The one is "tandem" method, which has a higher specificity (95.80%), positive likelihood ratio (18.16) and positive predictive value (96.73%). The other one is "parallel" method, which shows sensitivity (94.85%), negative likelihood ratio (0.07) and negative predictive value (90.00%).We believe that the methods could be used as a simple tool to stratify the risk of thyroid nodules accurately.

Percutaneous Ethanol Injection in Combination with Laser Ablation for a 100 ml Partially Cystic Thyroid Nodule

Until nonsurgical techniques like laser ablation (LA) or radiofrequency became available, patients suffering from large nodules with compressive symptoms were addressed to surgery. We describe the case of a 59-year-old woman with a large, partially cystic thyroid nodule having a volume of about 100 ml. As the patient refused surgery, despite her constant local discomfort, such large partially cystic nodule underwent several percutaneous ethanol injections (PEI) and then was submitted to LA. The combination of these two procedures allowed firstly complete disappearance of the cystic component and secondly a significant reduction of thyroid nodule, which finally measured 17 ml in volume (82% reduction compared to baseline). This case demonstrates that even in very large partially cystic nodules LA preceded by PEI represents a valid alternative to surgery.

Preoperative diagnostics in differentiated thyroid carcinoma

AIM

The preoperative diagnosis of differentiated thyroid carcinomas (DTC) is particularly challenging in view of the high prevalence of thyroid nodules in the general population. Incidental diagnosis of DTC, on the other hand, can lead to reoperations and increased risk of morbidity. This study aimed to assess the prediction value of preoperative DTC dignity assessment and it's impact on surgical approaches.

METHODS

We retrospectively reviewed 107 cases of DTC and subdivided them in three groups based on the preoperative dignity assessment: suspected malignancy (SM), unclear dignity (UD), and incidental findings (IF). The group differences were investigated in terms of diagnostic methods, findings, and impact on the subsequent surgical approach.

RESULTS

The patient groups consisted of n = 51 (SM), n = 32 (UD), and n = 24 (IF). The tumor size, T staging, and ultrasound (US) assessment had the largest impact on the dignity classification (each p < 0.001). Scintigraphy was performed in 80 % of the patients, fine-needle aspiration cytology (FNAC) in 28 %. Hypofunction at scintigraphy (p < 0.001) and cytology results (p < 0.01) were identified as significant predictors for group assignment. Other significant factors were the frequency of the US documentation of nodule characteristics (p < 0.001) and malignancy criteria (p < 0.01) as well as reduced thyroid-stimulating hormone (TSH) levels (p < 0.01). Frozen section (p < 0.001) and total thyroidectomy (p < 0.01) at initial surgery were performed significantly more often in the MV group. Reoperations were significantly more frequent in the IF group (p < 0.001).

CONCLUSIONS

A relevant number of DTC cases was diagnosed incidentally, leading to significantly more frequent reoperations. A more systematic diagnostic approach with complete documentation of the findings according to current guidelines should be pursued.

Buhr H, Lorenz D, Germer CT, E. Goretzki P. Indications for the Surgical Management of Benign Goiter in Adults

BACKGROUND

Thyroidectomy is still three to six times more common in Germany than in the USA, Great Britain, and the Scandinavian countries. Thus, the question is often asked whether thyroidectomy in Germany is being performed for the correct indications.

METHODS

This review is based on studies and guidelines containing information on the indications for surgery in benign goiter and Graves' disease; these publications were retrieved by a systematic literature search in the Medline and Cochrane Library databases (1990-2016). The indications recommended here were determined by vote by the German Society for General and Visceral Surgery (Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie, DGAV).

RESULTS

On the basis of the available evidence (levels 2-4), and in the absence of prospective studies, the indications for surgery in goiter include a well-founded suspicion of malignancy, local compressive symptoms, and, rarely, cosmesis. In hyperthyroid goiter and Graves' disease, surgery is a potential alternative to radio - iodine therapy, particularly if the volume of the thyroid gland exceeds 80 mL, in patients with advanced or active orbitopathy, and in female patients who are, or plan to be, pregnant. Large, asymptomatic, euthyroid nodular goiter without any suspicion of malignancy and scintigraphically "cold" nodules without any other evidence of malignancy are not indications for surgery. Thyroid operations of higher levels of difficulty (e.g., recurrent goiter, retrosternal extension, Graves' disease) should be carried out in institutions with special expertise in thyroid surgery.

CONCLUSION

The decision to operate should be made on an interdisciplinary basis and in conformity with the relevant guidelines after all of the appropriate diagnostic studies have been performed. The radicality of any proposed surgical procedure should be weighed against its potential complications.

MicroRNAs as Biomarkers in Thyroid Carcinoma

Optimal management of patients with thyroid cancer requires the use of sensitive and specific biomarkers. For early diagnosis and effective follow-up, the currently available cytological and serum biomarkers, thyroglobulin and calcitonin, present severe limitations. Research on microRNA expression in thyroid tumors is providing new insights for the development of novel biomarkers that can be used to diagnose thyroid cancer and optimize its management. In this review, we will examine some of the methods commonly used to detect and quantify microRNA in biospecimens from patients with thyroid tumor, as well as the potential applications of these techniques for developing microRNA-based biomarkers for the diagnosis and prognostic evaluation of thyroid cancers.

Quality of life after thyroidectomy in patients with nontoxic nodular goiter: A prospective cohort study

BACKGROUND

Using the thoroughly validated Thyroid-Related Quality-of-Life Patient-Reported Outcome (ThyPRO) questionnaire, the purpose of this study was to investigate changes in disease-specific quality of life (QOL) after surgical treatment in patients with benign nontoxic multinodular goiters.

METHOD

Patients with goiters scheduled for thyroid surgery (n = 106) and individuals from the general population (n = 739) were studied. The ThyPRO data before, 3 months, and 6 months after surgery were compared with normative scores from the general population using a linear mixed model and t tests.

RESULTS

Before surgery, patients with goiters experienced poorer scores on all scales compared to the general population. After surgery, moderate to large improvements were seen in goiter symptoms, tiredness, anxiety, and overall QOL. After surgery, all scales returned to values equal to the general population. The degree of anxiety was, in fact, lower than in the general population.

CONCLUSION

Thyroid surgery leads to significant benefit among patients with benign nontoxic goiters by restoring QOL equal to that in the general population.

Comparative analysis of diagnostic performance, feasibility and cost of different test-methods for thyroid nodules with indeterminate cytology

Since it is impossible to recognize malignancy at fine needle aspiration (FNA) cytology in indeterminate thyroid nodules, surgery is recommended for all of them. However, cancer rate at final histology is <30%. Many different test-methods have been proposed to increase diagnostic accuracy in such lesions, including Galectin-3-ICC (GAL-3-ICC), BRAF mutation analysis (BRAF), Gene Expression Classifier (GEC) alone and GEC+BRAF, mutation/fusion (M/F) panel, alone, M/F panel+miRNA GEC, and M/F panel by next generation sequencing (NGS), FDG-PET/CT, MIBI-Scan and TSHR mRNA blood assay.We performed systematic reviews and meta-analyses to compare their features, feasibility, diagnostic performance and cost. GEC, GEC+BRAF, M/F panel+miRNA GEC and M/F panel by NGS were the best in ruling-out malignancy (sensitivity = 90%, 89%, 89% and 90% respectively). BRAF and M/F panel alone and by NGS were the best in ruling-in malignancy (specificity = 100%, 93% and 93%). The M/F by NGS showed the highest accuracy (92%) and BRAF the highest diagnostic odds ratio (DOR) (247). GAL-3-ICC performed well as rule-out (sensitivity = 83%) and rule-in test (specificity = 85%), with good accuracy (84%) and high DOR (27) and is one of the cheapest (113 USD) and easiest one to be performed in different clinical settings.In conclusion, the more accurate molecular-based test-methods are still expensive and restricted to few, highly specialized and centralized laboratories. GAL-3-ICC, although limited by some false negatives, represents the most suitable screening test-method to be applied on a large-scale basis in the diagnostic algorithm of indeterminate thyroid lesions.

What is the care pathway of patients who undergo thyroid surgery in France and its potential pitfalls? A national cohort

CONTEXT

The rate of thyroid cancer is increasing in France, as well as concerns about overdiagnosis and treatment.

OBJECTIVES

To examine the care pathway of patients who undergo thyroid surgery in France and detect potential pitfalls.

DESIGN

A large observational study based on medical reimbursements, 2009-2011.

SETTING

Data from the Sniiram (National Health Insurance Information System).

PATIENTS

Patients with thyroid surgery in 2010, classified into 4 groups: thyroid cancer, benign nodule, goitre or multiple nodules, other (hyperthyroidism, head-neck cancer).

MAIN OUTCOME MEASURES

Medical investigations during, prior and after thyroidectomy.

RESULTS

A total of 35 367 patients underwent surgery (mean age 51 years, 80% women): 17% had a reported diagnosis of thyroid cancer, 20% benign nodule, 38% goitre or multiple nodules and 25% another diagnosis. The ratio of thyroidectomies with cancer over thyroidectomies with benign nodule was 0.8 and varied across regions. In the year preceding surgery, 82% of patients had an investigation by thyroid ultrasonography, 21% thyroid scintigraphy, 34% fine-needle aspiration cytology, 40% serum calcitonin assay and 54% serum calcium assay. In the following year, all patients with total thyroidectomy and 44% of patients with partial thyroidectomy and a diagnosis of benign nodule were taking thyroid hormone therapy. 100 patients had been reoperated for a compressive haematoma and 63 died during the first month, half of whom had been operated for cancer. Mean rates of recurrent laryngeal nerve injury and hypocalcaemia (requiring blood tests plus treatments within 4-12 months) were estimated at 1.5% and 3.4%, respectively, and were higher in the cancer group (2.3% and 5.7%).

CONCLUSIONS

This almost nationwide study demonstrates the suboptimal management of patients prior to thyroidectomy in France. It suggests overdiagnosis and potential harms to patients, and calls for a review of the relevance of thyroidectomy, particularly with regard to microcancers.

Correlation of Thyroid Imaging Reporting and Data System [TI-RADS] and fine needle aspiration: experience in 1,000 nodules

OBJECTIVE

To correlate the Thyroid Imaging Reporting and Data System (TI-RADS) and the Bethesda system in reporting cytopathology in 1,000 thyroid nodules.

METHODS

A retrospective study conducted from November 2011 to February 2014 that evaluated 1,000 thyroid nodules of 906 patients who underwent ultrasound exam and fine needle aspiration.

RESULTS

A significant association was found between the TI-RADS outcome and Bethesda classification (p<0.001). Most individuals with TI-RADS 2 or 3 had Bethesda 2 result (95.5% and 92.5%, respectively). Among those classified as TI-RADS 4C and 5, most presented Bethesda 6 (68.2% and 91.3%, respectively; p<0.001). The proportion of malignancies among TI-RADS 2 was 0.8%, and TI-RADS 3 was 1.7%. Among those classified as TI-RADS 4A, proportion of malignancies was 16.0%, 43.2% in 4B, 72.7% in 4C and 91.3% among TI-RADS 5 (p<0.001), showing clear association between TI-RADS and biopsy results.

CONCLUSION

The TI-RADS is appropriate to assess thyroid nodules and avoid unnecessary fine needle aspiration, as well as to assist in making decision about when this procedure should be performed.

OBJETIVO

Apresentar a correlação entre o Thyroid Imaging Reporting and Data System (TI-RADS) e o sistema Bethesda, para relatar citopatologia em 1.000 nódulos tireoidianos.

MÉTODOS

Estudo retrospectivo realizado no período de novembro de 2011 a fevereiro de 2014, que avaliou 1.000 nódulos tireoidianos de 906 pacientes submetidos a exame de ultrassonografia e à punção aspirativa por agulha fina.

RESULTADOS

Observou-se associação significativa entre o TI-RADS e o resultado da classificação de Bethesda (p<0,001). A maioria dos indivíduos com TI-RADS 2 ou 3 teve resultado citológico Bethesda 2 (95,5% e 92,5%, respectivamente). Entre aqueles classificados TI-RADS 4C e 5, a maioria teve resultado Bethesda 6 (68,2% e 91,3%, respectivamente; p<0,001). A proporção de malignidades em TI-RADS 2 foi 0,8% e em TI-RADS 3 foi 1,7%. Entre TI-RADS 4A, foi de 16,0%, 43,2% em 4B, 72,7% em 4C e em 5 foi de 91,3% (p<0,001), mostrando clara associação entre o TI-RADS e os resultados da biópsia.

CONCLUSÃO

O TI-RADS é apropriado para avaliar nódulos da tireoide e evitar punção aspirativa por agulha fina desnecessária, além de auxiliar na decisão sobre quando este procedimento deve ser realizado.

Serum thyroglobulin or thyroglobulin in fine-needle aspiration washout of metastatic lymph nodes: which one should we have confidence in for the surveillance of thyroid carcinoma?

BACKGROUND

The objective of this study was to evaluate the diagnostic performance of serum thyroglobulin (S-Tg), thyroglobulin in fine-needle aspiration washout (FNA-Tg) and fine-needle aspiration cytology (FNAC) in the detection of lateral metastatic lymph nodes (LNs) in patients with thyroid carcinoma.

METHODS

The study included 19 lateral metastatic LNs from 19 patients with thyroid carcinoma who underwent FNAC for the suspicion of metastatic disease on ultrasonogrphy (US). The S-Tg, FNA-Tg, FNAC, and histopathological results were correlated.

RESULTS

Compared with S-Tg, both FNAC and FNA-Tg showed higher sensitivity (89.5%, 89.5% versus 68.4%, respectively) and accuracy (89.5%, 89.5% versus 68.4%, respectively). The combined use of FNAC and FNA-Tg or FNAC and S-Tg showed superior diagnostic power.

CONCLUSIONS

S-Tg measurement is a less reliable method for follow-up in patients with thyroid carcinoma in comparison with FNA-Tg. For patients with negative S-Tg but suspicious features in US, FNAC combined with FNA-Tg is strongly recommended to confirm the diagnosis.

Determining Patient Preferences for Indeterminate Thyroid Nodules: Observation, Surgery or Molecular Tests

BACKGROUND

Gene-expression classifiers (GEC) and genetic mutation panels (GMP) have been shown to improve preoperative diagnostic evaluations of indeterminate thyroid nodules. Despite the improvement, uncertainty regarding the proper management exists. Patient preferences may better inform the management of these indeterminate thyroid nodules.

METHODS

Hypothetical scenarios were administered to two groups of patients: those with previous FNA-confirmed indeterminate thyroid nodules (Group A, n = 50) and those presenting to a general otolaryngology clinic for other reasons (Group B, n = 50). We evaluated patient preferences for surgery, observation and the use of molecular tests while varying the risk of malignancy, cost and diagnostic properties of the tests.

RESULTS

The mean threshold for choosing surgery over observation was a 38.6% risk of malignancy on FNA. When offered either GEC, GMP or both (with their inherent imperfect diagnostic properties) in addition to the indeterminate FNA, 85.0% of respondents picked at least one of the molecular tests over either observation or surgery if the test(s) were free of charge. However, only 51.7% of respondents chose at least one of the tests when asked to pay the current cost of the test(s) (p < 0.001). On multivariable analysis, sex, the presence of an indeterminate FNA diagnosis and income level significantly predicted the desire to proceed with a molecular test above standard management.

CONCLUSION

Patient preferences for thyroid nodule management are dependent on the risk of malignancy, prognosis of cancer and costs. Patients prefer molecular tests over standard management with indeterminate thyroid nodules, but the costs of the test(s) reduce the desire.