Thyroid nodule size and prediction of cancer

The Utility of ACR TI-RADS in Predicting False-Negative Fine Needle Aspiration for Thyroid Cancer

BACKGROUND

Thyroid nodule fine needle aspiration (FNA) biopsies are associated with a low false-negative rate. There is limited data regarding the predictive value of American College of Radiology Thyroid Imaging Reporting and Data System for false-negative FNA.

METHODS

This single-center retrospective study evaluated 119 patients who underwent thyroidectomy. The association of TR category, along with other clinical variables, with false-negative FNA was evaluated.

RESULTS

The overall false-negative rate of FNA was 10.8% (n = 9). False-negative FNAs were associated with younger age (mean 42 years vs 50.6 years, P = .04), larger nodule size (mean 4.4 cm vs 3.2 cm, P = .03), and a lower TR category (median 3 v 4, P = .01).

DISCUSSION

Lower TR category, younger age, and larger nodule size were associated with false-negative FNA of thyroid nodules. These findings should be taken into context when counseling patients with thyroid nodules who have a benign FNA.

Malignancy Risk of Follicular Neoplasm (Bethesda IV) With Variable Cutoffs of Tumor Size: A Systemic Review and Meta-Analysis

CONTEXT

The decision on diagnostic lobectomy for follicular neoplasms (FN) is challenging.

OBJECTIVE

This meta-analysis investigates whether an appropriate size cutoff exists for recommending surgery for thyroid nodules diagnosed as FN by fine needle aspiration.

METHODS

The Ovid-Medline, EMBASE, Cochrane, and KoreaMed databases were searched for studies reporting the malignancy rate of FN/suspicious for FN (FN/SFN) according to tumor size, using search terms "fine needle aspiration," "follicular neoplasm," "lobectomy," "surgery," and "thyroidectomy."

RESULTS

Fourteen observational studies comprising 2016 FN/SFN nodules with postsurgical pathologic reports were included, and 2 studies included malignancy rates with various tumor sizes. The pooled malignancy risk of FN/SFN nodules according to size was: odds ratio (OR) 2.29 (95% CI, 1.68-3.11) with cutoff of 4 cm (9 studies), OR 2.39 (95% CI, 1.45-3.95) with cutoff of 3 cm (3 studies), and OR 1.81 (95% CI, 0.94-3.50) with cutoff of 2 cm (5 studies). However, tumors ≥2 cm also showed a higher risk (OR 2.43; 95% CI, 1.54-3.82) based on the leave-one-out meta-analysis after removal of 1 influence study. When each cutoff size was evaluated by summary receiver operating characteristic (sROC) curves, the cutoff of 4 cm showed the highest summary area under the curve (sAUC, 0.645) compared to other cutoffs (sAUC, 0.58 with 2 cm, and 0.62 with 3 cm), although there was no significant difference.

CONCLUSION

Although the risk of malignancy increases with increasing tumor size, the risk remains significant at all tumor sizes and no cutoff limit can be recommended as a decision-making parameter for diagnostic surgery in Bethesda IV thyroid nodules.

Clinical, Histopathological, and Radiological Profile of Patients Presenting With Thyroid Malignancies Among the Kerala Population

BACKGROUND AND OBJECTIVE

Thyroid cancer, though relatively uncommon among all cancer types, stands as the primary form of endocrine tumor. Over the last 20 years, there has been a significant uptick in its occurrence. Papillary thyroid carcinoma (PTC), which is well-differentiated, emerges as the dominant subtype, in regions where iodine levels are deemed adequate. The study aimed to study the clinicopathological profile of patients diagnosed with thyroid malignancies at the Muslim Educational Society (MES) Medical College Perinthalmanna.

MATERIALS AND METHODS

This is a retrospective study undertaken at the MES Medical College by the Department of General Surgery and Endocrine Surgery. The study focuses on patients who have been diagnosed with thyroid cancer through a biopsy. Case sheets of all those patients diagnosed with thyroid malignancy were referred from the Medical Records Library to collect the relevant medical and sociodemographic data. This data was entered in the proforma, which was transferred to the Excel sheet and processed in IBM SPSS Statistics for Windows, Version 20 (Released 2011; IBM Corp., Armonk, New York, United States).

RESULTS

The study included predominantly middle-aged individuals (40-60 years), with 22 (55%) falling within this age range, followed by 14 (35%) aged between 20 and 40 years, and only four (10%) above 60 years. Female patients constituted 82.5% of the study group. Most cases presented with swelling lasting less than six months 23 (57.5%), while only four (10%) had swelling lasting more than five years. Compression symptoms were rare, with only three (7.5%) experiencing dysphagia or dyspnea. Pain was reported in two (5%) of the cases. Hypothyroidism, toxic manifestations, or hoarseness were observed in one (2.5%) of the patients. Regarding swelling characteristics, most were greater than 4 cm in size (29, 72%) and firm in consistency (25, 62.5%). Nodular surfaces were present in 19 (47.5%) of the cases, while 38 (95%) of the swellings were mobile. Palpable lymph nodes were noted in 13 (32.5%) of cases. Radiologically, hypoechoic lesions were observed in 26 (65%) of cases, with microcalcification in 29 (72.5%) and peripheral vascularity in 31 (77.5%). Papillary carcinoma was the most common histological type (34, 85%), with medullary and follicular carcinomas accounting for five (12.5%) and one (2.5%), respectively. An association was found between the duration of swelling and histological type (p = 0.05) and between the mobility of swelling and histological type (p < 0.05). However, no significant associations were observed between imaging findings and histological type (p > 0.05). The gender distribution did not show a statistically significant association with histological type.

CONCLUSION

The findings of the study revealed a statistically insignificant association between age, gender, clinical features, and the histological type of thyroid malignancy. Additionally, there was no statistically significant association between the histological type of thyroid malignancy and the size or type of surface or consistency of thyroid swelling or ultrasonographic findings of the swelling like echogenicity, microcalcification, increased peripheral vascularity, or loss of peripheral halo.

Diagnostic utility of RAS mutation testing for refining cytologically indeterminate thyroid nodules

RAS mutations are prevalent in indeterminate thyroid nodules, but their association with malignancy risk and utility for diagnosis remains unclear. We performed a systematic review and meta-analysis to establish the clinical value of RAS mutation testing for cytologically indeterminate thyroid nodules. PubMed and Embase were systematically searched for relevant studies. Thirty studies comprising 13,328 nodules met the inclusion criteria. Random effects meta-analysis synthesized pooled estimates of RAS mutation rates, risk of malignancy with RAS positivity, and histologic subtype outcomes. The pooled mutation rate was 31 % (95 % CI 19-44 %) among 5,307 indeterminate nodules. NRAS mutations predominated at 67 % compared to HRAS (24 %) and KRAS (12 %). The malignancy rate with RAS mutations was 58 % (95 %CI=48-68 %). RAS positivity increased malignancy risk 1.7-fold (RR 1.68, 95 %CI=1.21-2.34, p=0.002), with significant between-study heterogeneity (I2=89 %). Excluding one outlier study increased the relative risk to 1.75 (95 %CI=1.54-1.98) and I2 to 14 %. Funnel plot asymmetry and Egger's test (p=0.03) indicated potential publication bias. Among RAS-positive malignant nodules, 38.6 % were follicular variant papillary carcinoma, 34.1 % classical variant, and 23.2 % follicular carcinoma. No statistically significant difference in the odds of harboring RAS mutation was found between subtypes. In conclusion, RAS mutation testing demonstrates clinical utility for refining the diagnosis of cytologically indeterminate thyroid nodules. Positivity confers a 1.7-fold increased malignancy risk, supporting use for personalized decision-making regarding surgery vs. monitoring. Follicular variant papillary carcinoma constitutes the most common RAS-positive malignant histological subtype. See also the graphical abstract(Fig. 1).

Correct and Incorrect Recommendations for or against Fine Needle Biopsies of Hypofunctioning Thyroid Nodules: Performance of Different Ultrasound-based Risk Stratification Systems

PURPOSE

 To evaluate the recommendations for or against fine needle biopsy (FNB) of hypofunctioning thyroid nodules (TNs) using of five different Ultrasound (US) -based risk stratification systems (RSSs).

METHODS

 German multicenter study with 563 TNs (≥ 10 mm) in 534 patients who underwent thyroid US and surgery. All TNs were evaluated with ACR TI-RADS, EU-TIRADS, ATA, K-TIRADS 2016 and modified K-TIRADS 2021. A correct recommendation was defined as: malignant TN with recommendation for FNB (appropriate) or benign TN without recommendation for FNB (avoided). An incorrect recommendation was defined as: malignant TN without recommendation for FNB (missed) or benign TN with recommendation for FNB (unnecessary).

RESULTS

 ACR TI-RADS demonstrated the highest rate of correct (42.3 %) and lowest rate of incorrect recommendations (57.7 %). The other RRSs showed similar results for correct (26.5 %-35.7 %) and incorrect (64.3 %-73.5 %) recommendations. ACR TI-RADS demonstrated the lowest rate of unnecessary (73.4 %) and the highest rate of appropriate (26.6 %) FNB recommendation. For other RSSs, the rates of unnecessary and appropriate FNB were between 75.2 %-77.1 % and 22.9 %-24.8 %. The lowest rate of missed FNB (14.7 %) and the highest rate of avoided FNB (85.3 %) was found for ACR TI-RADS. For the other RSSs, the rates of missed and avoided FNB were between 17.8 %-26.9 % and 73.1 %-82.2 %. When the size cutoff was disregarded, an increase of correct recommendations and a decrease of incorrect recommendations was observed for all RSSs.

CONCLUSION

 The RSSs vary in their ability to correctly recommend for or against FNB. An understanding of the impact of nodule size cutoffs seems necessary for the future of TIRADS.

Can we better advise our patients with nodular thyroid disease?

BACKGROUND

The 2014 British Thyroid Association guidelines acknowledged the value of risk-stratifying thyroid nodules by utilising an ultrasound reporting system ('U' classification). This study assessed whether using pre-existing parameters in combination can better stratify patients' malignancy and completion thyroidectomy risks.

METHOD

A multicentre, retrospective, observational review identified 936 NHS Greater Glasgow and Clyde patients from pathology records who underwent hemithyroidectomy between 1 January 2014 and 31 December 2019.

RESULTS

A total of 308 patients had thyroid malignancy, 180 (58.4 per cent) progressed to completion thyroidectomy. A nodule classified as 'U3' (indeterminate) was associated with a 35.4 per cent chance of malignancy and a 21.6 per cent risk of requiring completion surgery. Amalgamation of 'U' score with Thy score enhanced risk prediction. The malignancy rate in U3, Thy-3f nodules was 38 per cent, and 21 per cent required completion surgery. The malignancy and completion thyroidectomy rates were comparatively lower for U3, Thy-3a nodules (22 per cent and 14.3 per cent, respectively).

CONCLUSION

Combining ultrasound 'U' score and Thy score improves pre-operative thyroid nodule risk stratification, leading to better informed patients regarding the risks of malignancy and completion surgery. A move towards an integrated assessment approach should be considered.

Diagnostic Performance of Thyroid Nodule Risk Stratification Systems: Comparison of ACR-TIRADS, EU-TIRADS, K-TIRADS, and ATA Guidelines

ABSTRACT

The purpose of this study was to compare the diagnostic performance of 4 different ultrasound-based risk scoring systems for thyroid nodules (TNs). This study consecutively included 256 patients (mean age: 43.98 ± 12.94 years, min-max: 18-89 years; 225 females, 31 males) with 266 TNs. Each nodule was evaluated and classified according to the American Thyroid Association (ATA), American College of Radiology (ACR), European Thyroid Association, and Korean Thyroid Imaging Reporting and Data System (ACR-TIRADS, EU-TIRADS, and K-TIRADS, respectively) before performing ultrasound-guided fine-needle aspiration biopsy. Pathological results were reported according to the Bethesda system. Outcomes of the 4 classification systems were compared with respect to Bethesda results. Twenty-eight (10.5%) nodules had malignant cytology results. Diagnostic performances of the scoring systems were comparable with similar area under the curve values according to the reference standards of category 5 of each scoring system. The sensitivity and specificity values of these guidelines were as follows: ACR-TIRADS, 60.7% and 95.4%; EU-TIRADS, 71.4% and 93.3%; ATA-2015, 71.4% and 93.3%; and K-TIRADS, 67.9% and 93.3%. The biopsy rate of malignant nodules was 57.1% for K-TIRADS and ATA, whereas this value was 46.4% for ACR and EU-TIRADS. ACR-TIRADS had the lowest unnecessary biopsy rate (141 of 238 benign nodules, 46%). The diagnostic performance of 4 risk stratification systems appears to be comparable, as shown by similar sensitivity, specificity, and area under the curve values. However, the ACR-TIRADS had slightly higher accuracy and necessitated fewer unnecessary biopsies for benign nodules.

The Role of Blood Microbiome in the Development of Thyroid Cancer in Breast Cancer Survivors

Patients diagnosed with breast cancer are likely to be diagnosed with thyroid cancer as a second primary cancer. Similarly, patients with thyroid cancer are likely to develop breast cancer. In this study, we found an association between these two types of cancers in the microbiomes of patients with breast cancer. Blood samples were collected from 96 patients with breast cancer, their bacterial extracellular vesicles were isolated, and their microbiomes were analyzed. After microbiome analysis, researchers performed thyroid function tests, estrogen levels, and thyroid ultrasound results of these patients, and the relationships among these parameters were analyzed. Based on the thyroid ultrasonography results, differences in the microbiome were confirmed in the normal, cyst, nodule, and thyroid lobectomy groups. We investigated the microbiome differences between normal thyroid and thyroid cancer. In particular, the abundance of the genus Bacillus is related to estrogen levels, which could affect thyroid abnormalities and increase thyroid-stimulating hormone levels. This study explains the causes of thyroid cancer in patients with breast cancer using microbiomes and serological tests for thyroid hormones and estrogen. These can be used as basic data for preventing thyroid cancer in patients with breast cancer.

Comparison of the diagnostic accuracy of K-TIRADS and EU-TIRADS guidelines for detection of thyroid malignancy on ultrasound

INTRODUCTION

This retrospective study compared the diagnostic accuracy of histopathologically proven thyroid nodules between the Korean Thyroid Imaging Reporting and Data System (K-TIRADS) and the European Thyroid Imaging Reporting and Data System (EU-TIRADS) guidelines for the management of thyroid nodules characterized by ultrasonography.

MATERIAL AND METHODS

For thyroid nodules resected from 2018 to 2021 at our institution, static ultrasound images of each nodule were reviews and stratify into both systems. Agreement between above two classifications was compared based on histopathological results.

RESULTS

A total 403 thyroid nodules from 213 patients were evaluated. Each nodule was characterized by ultrasonography and stratified into K-TIRADS and EU-TIRADS classifications. The diagnostic accuracy was as follows: K-TIRADS sensitivity 85.3% (95% CI, 78.7-91.9) specificity 76.8% (95% CI, 72.1-81.7), positive predictive value 57.8% (95% CI, 50.1-65.4) negative predictive value 93.4% (95% CI, 90.3-96.5); EU-TIRADS sensitivity 86.2% (95% CI, 79.7-92.7), specificity 75.5% (95% CI, 70.6-80.4), positive predictive value 56.6% (95% CI, 49.1-64.2), negative predictive value 93.7% (95% CI, 90.6-96.8). Excellent agreement in risk stratifications between both systems was found (kappa 0.86).

CONCLUSIONS

Ultrasound thyroid nodules categorized by either by K-TIRADS or EU-TIRADS are useful to predicting malignancy and perform risk stratification with similar results.

IMPLICATIONS FOR PRACTICE

This study confirmed that both K-TIRADS and EU-TIRADS have high diagnostic accuracy and both guidelines may be used as an effective tool for management planning of patients with thyroid nodules in daily clinical practice.

Trends in Thyroid Nodules and Malignancy: A Two-Year Retrospective Study in a Tertiary Care Centre

Thyroid nodules are one of the most common presentations faced by ENT clinicians, and the prevalence of differentiated thyroid cancer is increasing worldwide. We found no other study showing a clear occurence of cancer in thyroid nodules in the state of West Bengal. Hence, we undertook this study to determine the occurence of thyroid cancer among people with thyroid nodules. A retrospective review was performed for 96 patients with thyroid nodules who underwent USG and Fine Needle Aspiration Cytology (FNAC) and thyroid surgery at a tertiary hospital in Kolkata over a 2-year period from January 2020 to December 2021. The occurence of thyroid cancer in patients with thyroid nodules; association with age, sex, duration of thyroid swelling and thyroid stimulating hormone (TSH) levels of the patients; the sonographic findings (nodule size and number) and Bethesda classification on FNAC were reviewed. A total of 96 cases were reviewed. The highest malignancies were seen in swellings of 3-5 years duration (50%), and in patients with increased TSH levels (60%). Patients with single vs. multinodular goitre had comparable rates (23.07 vs 22.22%). The highest risk was seen in nodules 1-2 cm in size. A TIRADS score of 2 had a negative predictive value of 86.95% and a score of 5 had a positive predictive value of 100%. BETHESDA II lesions had a 3.44% rate of malignancy, while BETHESDA V and VI had rates of 100% and 75% respectively. While most of the thyroid swellings were benign, 22.91% were malignant, the most common being papillary carcinomas.

Clinico-cytopathological subcategorization in thyroid nodules of atypia of undetermined significance/follicular lesion of undetermined significance using the TIRADS and Bethesda classifications

Introduction

Bethesda category III - atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS) is a heterogeneous class of the Bethesda system for thyroid nodules. In order to clarify the therapeutic road for clinicians, this category was subclassified based on the cytopathological features. In this study, we evaluated the risk of malignancy, surgical outcome, demographic characteristics, and correlation of ultrasound features with the final outcome in patients with thyroid nodules based on AUS/FLUS subclassification.

Method

After evaluating 867 thyroid nodules from three different centers, 70 (8.07%) were initially diagnosed as AUS/FLUS. The cytopathologists re-interpreted the FNA samples and subclassified them into five subcategories: architectural atypia, cytologic atypia, cytologic and architectural atypia, and Hürthle cell AUS/FLUS, and atypia, which was not specified. Based on the suspicious ultrasound features, an appropriate ACR TI-RADS score was allocated to each nodule. Finally, the malignancy rate, surgical outcomes, and ACR TI-RADS scores were evaluated among Bethesda category III nodules.

Results

Among the 70 evaluated nodules, 28 (40%) were subclassified as Hürthle cell AUS/FLUS, 22 (31.42%) as cytologic and architectural atypia, 8 (11.42%) as architectural atypia, 7 (10%) as cytologic atypia, and 5 (7.14%) as atypia which was not specified. The overall malignancy rate was 34.28%, and the architectural atypia and Hürthle cell nodules displayed lower malignancy compared to other groups (P-Value<0.05). Utilizing ACR TI-RADS scores showed no statistical significance between Bethesda III subcategorization and ACR TI-RADS scores. However, ACR TI-RADS can be a reliable predictor for Hürthle cell AUS/FLU nodules.

Conclusion

ACR TI-RADS helps evaluate malignancy only in the Hürthle cell AUS/FLUS subcategory of AUS/FLUS. Besides, cytopathological reporting based on the suggested AUS/FLUS subclassification could help clinicians take appropriate measures to manage thyroid nodules.

Clinical and Sonographic Features of Noninvasive Follicular Thyroid Neoplasm With Papillary-Like Nuclear Features: A Retrospective Study

ABSTRACT

This study was designed to investigate the clinical and sonographic features of noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTPs) as compared with classical papillary thyroid carcinoma (cPTC), follicular adenoma (FA), and follicular thyroid carcinoma (FTC). A total of 178 patients were enrolled in this study. The clinical characteristics and sonographic features of thyroid nodules were compared between NIFTP and cPTC or FA/FTC. All nodules were reclassified according to the Thyroid Ultrasound Imaging Reporting and Data System and American Thyroid Association guidelines classification. The mean size of NIFTP was 29.91 ± 14.71 mm, which was larger than that of cPTC ( P = 0.000). Significant difference was found in lymph node metastases between NIFTP and cPTC ( P = 0.000). Most NIFTPs showed solid composition, hypoechoic echogenicity, smooth margin, wider than tall shape, none echogenic foci, absence of halo, and perinodular vascularity, which were similar with FA and FTC. Compared with NIFTP, hypoechoic and very hypoechoic, taller than wide, irregular margin, punctate echogenic foci, absence of halo, and low vascularity were more commonly observed in cPTC. There were statistical differences both in American College of Radiology Thyroid Ultrasound Imaging Reporting and Data System and in American Thyroid Association classification between NIFTP and cPTC ( P < 0.05), but there were no significant differences between NIFTP and FTC/FA ( P > 0.05). The ultrasonographic characteristics of NIFTP were obviously different from cPTC but overlapped with FTC and FA. Ultrasound could help increase preoperative attention of NIFTP in an appropriate clinical setting, which may lead to a more conservative treatment approach.

The Significance of Unsampled Microscopic Thyroid Carcinomas in Multinodular Goiter

Thorough gross examination and appropriate sampling of the thyroidectomy specimens are fundamental to the diagnosis and clinical risk management of patients. This study aims to investigate the frequency and clinical significance of initially unsampled microscopic thyroid carcinomas in total thyroidectomy specimens with presumed benign multinodular thyroid disease. Seventy-two total thyroidectomy specimens belonging to multinodular goiter patients were randomly selected and included in this prospectively designed study. Inclusion criteria were set as no suspicion of malignancy before surgery as well as lack of intra-parenchymal primary thyroid carcinoma after histopathological evaluation of slides generated from initial sampling. Subsequently, the remaining thyroidectomy specimens were submitted for microscopic examination and sign-outs were finalized following the microscopic examination of the entire thyroid tissue. Microcarcinomas, with a maximum diameter of 3.5 mm, were detected in 29 cases (40.2%) after the whole gland sampling. Although most of these tumors were low-risk papillary microcarcinomas confined to the thyroid, one specimen also showed a medullary microcarcinoma measuring 1.5 mm. Three had micrometastatic nodal disease. There was no local recurrence or distant metastatic disease during the follow-up (mean 51.4 months). This study further supports microscopic carcinomas, including papillary microcarcinoma, and medullary microcarcinoma might stay hidden in thyroidectomy specimens. Increased glandular weight, male gender, and advanced age were significant risk factors in the detection of microcarcinomas in this series. While each multinodular thyroidectomy specimen is unique, we recommend dynamic extensive sampling (rather than bare-minimum approach) strategy based on careful gross and initial histologic examination findings as well as by taking into consideration risk factors.

The sonographic pattern of nodule and thyroid fine needle aspiration cytology in the evaluation of thyroid malignancy risk

Introduction: Thyroid fine-needle aspiration biopsy (TFNAB), which is basically planned according to the ultrasonographic features is of clinical importance; since it helps early diagnosis of malignancy, facilitates the selection of patients who will undergo thyroid surgery and prevents unnecessary surgical procedures. In our study, we aimed to evaluate the adequacy of TFNAB as well as the retrospective investigation of the link between the estimated malignancy risk and the descriptive features, radiologic findings and biopsy cytology of patients who underwent ultrasonography guided TFNAB.Methods: In this study, the ultrasonographic characteristics of 659 thyroid nodules belonging to 523 patients who underwent TFNAB between 2018 and 2021 were evaluated. The correlation between the risk of malignancy and demographic data, thyroid hormone levels, and ultrasonographic characteristics of nodules was examined. The diagnostic accuracy performances of European thyroid imaging reporting and data system (EU-TIRADS) classification prepared by the European Thyroid Association (ETA), the risk classification systems recommended by the American Thyroid Association (ATA) and the Society of Endocrinology and Metabolism of Turkey (TEMD) were compared with The Bethesda System for Reporting Thyroid Cytopathology (Bethesda). The adequacy of biopsy was also evaluated. The data which is obtained from the study was statistically analyzed by means of SPSS 20.0 (Statistical Package for the Social Sciences; SPSS Inc. Chicago, IL, USA) program.Results: In this study, the biopsies of 41 (6.2%) among 659 thyroid nodules appeared to be malignant. A statistically significant correlation was detected between malignancy and hypoechogenicity (p=0.011), microcalcification (p=0.005), irregular margins (p=0.028), and accompanying pathological lymph node (p=0.002). Compared to the surgical pathology results, the accuracy that was closest to that of Bethesda System (AUC: 0.778) (Area Under Curve) was found in EU-TIRADS (AUC:0.715). In the biopsies performed in our own endocrinology clinic (43.7% of the total biopsies), the ratio of non-diagnostic results was found to be 8.3%, whereas it was 29.1% in the biopsies performed in other clinics (56.3% of the total biopsies).Conclusion: It should always be kept in mind that, in the cytologic evaluation, the ultrasonographic nodule pattern recommended by the guidelines is very important in the management of patients, because cytology may show false negative and false positive results as well as unclear or non-diagnostic pathological findings. However, clinicians should also understand that classification systems may have strengths and weaknesses. Our study also emphasizes the importance of how experienced a clinic performing biopsy is as well as the role of cytopathologist in obtaining diagnostic results in biopsy.Keywords: Thyroid nodule, neoplasia, ultrasonography, biopsy fine-needle

Patients undergoing endocrine consultation and first diagnosis of nodular disease: Indications of thyroid ultrasound and completeness of ultrasound reports

PURPOSE

To evaluate reasons for performing ultrasonography (US) and completeness of US reports in patients undergoing endocrine consultation with the first diagnosis of nodular disease.

METHODS

Since January 1 to June 30, 2021, we prospectively collected patient data (age and thyroid-stimulating hormone concentrations), reasons for performing thyroid US, and completeness of reports regarding the description of the thyroid gland and nodules. In the case of multiple nodules, we considered the nodule suspected of malignancy and the largest one. To evaluate the accuracy of thyroid nodule description, we referred to the five characteristics suggested by the ACR TI-RADS system.

RESULTS

A total of 341 patients with thyroid nodules received endocrine consultation (female, 78%). The most frequent reasons for performing thyroid US were unrelated to a suspected thyroid disease (31.7%), followed by incidentaloma (23.5%), dysfunction or positivity for thyroid antibodies (19.1%), symptomatic or visible nodules (17.6%), and family history of any thyroid disease (8.2%). Gland texture was not reported in 41.9%. The depth of the lobes was the dimension reported most frequently (42.2%), but any diameter was not reported in 57.8% of the cases. As regards the description of the most relevant nodule, length was reported more frequently (75.9%). Margins and echogenicity were more frequently described (54.5% and 44.3%, respectively) than other characteristics (composition: 27%; shape: 8.8%; echogenic foci: 6.7%). No reports had indicated the malignancy risk stratification.

CONCLUSIONS

The results of the study demonstrate that in patients undergoing endocrine consultation with first detected thyroid nodules, US was mostly performed in asymptomatic cases, US reports were incomplete, and no risk stratification system was reported.

The impact of the ultrasound classification on the rate of thyroid surgery indications: a 577 cases series

OBJECTIVES

Nodules of the thyroid gland are common but rarely malignant. Their management can range from simple monitoring to surgery. The use of ultrasound and fine needle aspiration can reduce the rate of unnecessary surgeries. However, there is a risk of false positives and false negatives of malignancy that only pathology can avoid. The objective of this study is to assess the impact of ultrasound classification on the rate of surgical indications.

MATERIAL AND METHODS

Between 2013 and 2017, the ultrasound classification was gradually adopted in our daily practice to become now routine. During this period, we conducted a retrospective study of all the patients who presented to our department for one or more thyroid nodules.

RESULTS

A total of 577 patients were included in the study. We compared two groups, a first where the ultrasound classification was used and a second where this classification was not used. In the end, we found that this classification significantly reduced the surgical indication by 19% while increasing the malignancy detection rate in operated patients by 21%.

CONCLUSIONS

The use of ultrasound classification reduces the indications for surgery while increasing the rate of malignancy in operated patients. The generalization of the use of the ultrasound classification score is strongly recommended in daily practice.

Is conservative management of the indeterminate thyroid nodule [Thy3f or Bethesda category IV] safe?

PURPOSE

The histological diagnosis after diagnostic thyroidectomy for indeterminate thyroid nodules is often non-malignant and some cancers detected are considered 'indolent'. The safety and effectiveness of conservative management in these patients are unclear. The aim of this study was to determine the safety of conservative management of indeterminate thyroid nodules and to explore association between clinical features and pathology in patients undergoing surgery.

METHODS

This is a retrospective cohort study of patients presenting to a single centre over a 4-year period (2013-2016) with thyroid nodules that were considered indeterminate (thy3f in the UK RCPath classification) on cytology. Demographic data, ultrasound features, follow-up details (in those undergoing conservative management) and histology details (in those undergoing surgery) were collected.

RESULTS

Of 164 patients that had Thy3f cytology, 34 were initially managed conservatively; however, 4 of these eventually had surgery (due to patient preference). No patient on conservative management had significant disease progression on ultrasound at a median (interquartile range) of 27 (16-40) months. Of the 134 patients that underwent surgery, 26 had thyroid malignancy. The BTA 'U' classification, gender and age (> 55) were not associated with malignancy in these nodules, but larger nodules (> 40 mm) were more likely to be malignant (p = 0.042).

CONCLUSIONS

Conservative management of indeterminate (Thy3f or Bethesda stage IV) thyroid nodules is safe in the short term and may be indicated in selected cases after appropriate discussion of risks and benefits of surgery.

Diagnostic performance of ACR-TIRADS, Korean TIRADS, and American Thyroid Association guidelines for risk stratification of thyroid nodules: a prospective study

BACKGROUND

In the present study, the first aim was to compare the accuracy of three guidelines in the diagnosis of thyroid nodule malignancy. The second purpose was to find sonographic features potentially associated with the risk of malignancy.

METHODS

In this cross-sectional study, we prospectively recruited patients referred with a diagnosis of thyroid nodule (≥ 1 cm) for fine-needle aspiration (FNA). Sonographic features were recorded and scored according to the American Thyroid Association (ATA-2015), the American College of Radiology-Thyroid Imaging Reporting and Data System (ACR-TIRADS), and the Korean TIRADS (K-TIRADS). FNA was conducted and cytological findings were reported.

RESULTS

A total of 984 thyroid nodules were ultimately included, of which 144 (14.6%) were malignant and 840 (85.4%) were benign. The accuracy of ACR-TIRADS categories TR5 and TR4/5 was 88.3% and 69.3%, respectively. This rate for ATA-2015 classes High suspicion and Intermediate suspicion/High suspicion was 87.9% and 80.4%, respectively. For K-TIRADS classes 5 and 4/5, the diagnostic accuracy was 88.0% and 80.6%, respectively. The rate of unnecessary FNA was highest with ATA-2015 and K-TIRADS guidelines (53.9% and 53.7%, respectively), followed by ACR-TIRADS (32.0%). Significant direct associations were observed between malignancy and hypoechogenicity (odds ratio [OR] 5.78), fine calcification (OR = 6.7), rim calcification (OR = 2.56), ill-defined margin (OR = 3.31), and irregular margin (OR = 6.95).

CONCLUSIONS

There are different strengths of ACR-TIRADS, K-TIRADS, and ATA-2015 guidelines in the prediction of malignant thyroid nodules, and clinicians and radiologists should consider these differences in the management of thyroid nodules.

An Indeterminate for Malignancy FNA Report Does Not Increase the Surgical Risk of Incidental Thyroid Carcinoma

Incidental thyroid carcinomas (ITCs) are a fairly frequent finding in daily routine practice, with papillary thyroid microcarcinoma being the most frequent entity. In our work, we isolated incidental cases arising in thyroids removed for other cytologically indeterminate and histologically benign nodules. We retrospectively retrieved cases with available thyroid Fine Needle Aspiration (FNA, 3270 cases), selecting those with an indeterminate cytological diagnosis (Bethesda classes III−IV, 652 cases). Subsequently, we restricted the analysis to surgically treated patients (163 cases) finding an incidental thyroid carcinoma in 22 of them. We found a 13.5% ITC rate, with ITCs representing 46.8% of all cancer histologically diagnosed in this indeterminate setting. Patients received a cytological diagnosis of Bethesda class III and IV in 41% and 59% of cases, respectively. All ITC cases turned out to be papillary thyroid microcarcinomas; 36% of cases were multifocal, with foci bilaterally detected in 50% of cases. We found an overall ITC rate concordant with the literature and with our previous findings. The assignment of an indeterminate category to FNA did not increase the risk of ITCs in our cohort. Rather, a strong statistical significance (p < 0.01) was found comparing the larger size of nodules that underwent FNA and the smaller size of their corresponding ITC nodule.

Serum TSH Level as a Simple Efficient Tool to Assess the Risk of Thyroid Malignancy in Euthyroid Patients with Indeterminate Cytology - A Cohort Study

Context

A significant number of fine-needle aspiration cytology (FNAC) for thyroid nodules is reported as indeterminate. Expensive molecular testing can give a clue to the possibility of malignancy in this group. The effectiveness of serum thyroid-stimulating hormone (TSH) levels as a diagnostic tool in euthyroid patients with indeterminate cytology has not been previously studied, especially in the Indian population.

Aims

This study was conducted to evaluate the predictive efficacy of serum TSH in the early diagnosis and treatment of malignancy.

Settings and Design

This is a retrospective cross-sectional study on a cohort of patients who presented to our department with complaints of thyroid swelling and underwent thyroidectomy.

Methods and Material

Euthyroid patients who underwent thyroid surgery for newly diagnosed thyroid nodules with FNAC reported as indeterminate cytology were included in our study. Based on the histopathological report, the patients were divided into two groups and into quartiles based on TSH values.

Statistical Analysis Used

The mean difference in the numerical variables between groups was compared using the independent two-sample 't' test for parametric data and Mann-Whitney 'u' test for non-parametric data. A logistic regression analysis was done with age, sex, TSH level and nodule size as dependant variables and malignancy as the independent variable.

Results

There were 211 patients in group A and 93 in group B. Patients with malignancy confirmed on final histopathology showed higher serum TSH levels compared to benign nodules (2.93 ± 1.067 vs 1.73 ± 1.051, P = <0.001). The mean TSH levels of all types of malignant nodules correlated with our test model (>2.185 mIU/L).

Conclusions

Serum TSH above 2.185 mIU/mL is a good predictor of malignancy in indeterminate nodules. It is an inexpensive, safe and reliable diagnostic screening test for the risk of malignancy in an indeterminate nodule.

Clinicopathologic characteristics of incidental thyroid carcinoma in euthyroid patients receiving total thyroidectomy for multinodular goiter: A retrospective cohort study

BACKGROUND

Total thyroidectomy is the treatment of choice for multinodular goiter (MNG). In some of these cases, incidental thyroid cancer (ITC) is detected postoperatively. Papillary thyroid microcarcinoma (PTMC), the most common type of ITC, has clinical factors and pathologic similarities with ITC that have not been well clarified previously. We investigated the incidence and characteristics of ITC and PTMC in euthyroid patients undergoing total thyroidectomy for MNG.

METHODS

We retrospectively investigated the data of 151 euthyroid patients who underwent total thyroidectomy for MNG between January 2016 and December 2020. Patients with PTMC were then selected from among those with ITC for further data analysis.

RESULTS

The incidence rates of ITC and PTMC were 31.1% (47/151) and 21.1% (32/151), respectively. The mean age of patients with ITC was 52.8 ± 11.7 years, which was younger than that of patients with benign MNG (57.2 ± 12.5 years, p < 0.05). Bilateral cancer was observed in 17 patients with ITC (17/47, 36.2%) and nine with PTMC (9/32, 28.1%). The numbers of patients in the ITC and PTMC groups whose cancer was not on the side comprising the dominant tumor were 15 (15/47, 31.9%) and 13 (13/32, 40.6%), respectively. The multivariate analysis demonstrated that younger age was a clinical factor associated with ITC and PTMC.

CONCLUSION

Younger age is a clinical factor for ITC and PTMC. We recommend taking considering clinical factors and pathologic characteristics of ITC and PTC when considering total thyroidectomy in euthyroid patients with MNG.

Management of thyroid nodules

In the past 30 years, there has been a substantial rise in the detection of thyroid nodules. Largely asymptomatic, thyroid nodules are most often incidental findings that typically pose minimal risk. Data supporting these findings show a rapid rise in the incidental detection of thyroid nodules and cancer, but minimal effect on mortality rates, despite treatment. These data imply that historical approaches to thyroid nodule and cancer care might at times include unnecessary or excessive care. To address this issue, the past decade has witnessed an increasingly conservative approach to nodule management, seeking to individualise care and provide the most focused intervention that leads to favourable outcomes. Benign nodules can be safely monitored with minimal, or long-interval follow-up imaging. Molecular testing should be considered for cytologically indeterminate nodules because of its ability to improve preoperative cancer risk determination and reduce unnecessary surgery. The treatment of biopsy-proven malignant nodules has become increasingly nuanced, since recommendations for near-total thyroidectomy are no longer routine. Hemithyroidectomy is now commonly considered when operative intervention is favoured. Some patients with small volume, isolated cancerous nodules are safely managed non-operatively with active monitoring. In summary, modern management strategies for thyroid nodular disease seek to incorporate the growing amount of available diagnostic and prognostic data, inclusive of demographic, radiological, pathological and molecular findings. Once obtained, an individualised management plan can be effectively formulated.

Clinical Efficacy of Chinese and Western Medicine in the Treatment of Benign Thyroid Nodules: A Meta-Analysis

Background

Studies have shown that Chinese herbal medicine (CHM) effectively improved the response rate and reduced the maximum nodule diameter of benign thyroid nodules (BTN). This study aimed at systematically reviewing all related studies to assess the clinical efficacy of CHM and Western medicine in the treatment of BTN.

Methods

PubMed, Web of Science, Embase, China National Knowledge Infrastructure, and Wanfang databases were searched for randomized controlled trials, published between 2000 and 2021, on CHM for treating BTN. The control group comprised patients treated with Western medicine (oral thyroxine tablets or microwave ablation), while the treatment group was treated with CHM combined with Western medicine. Meta-analysis was performed using the Stata 16.0 software.

Results

A total of 264 articles were retrieved, of which 12 were finally selected for analysis after screening. The results showed that combined therapy was associated with a higher response rate (OR = 3.35, 95% CI (2.40, 4.68), P < 0.05). After treatment, the maximum nodule diameter (SMD = −0.76, 95%, CI (−0.98, −0.53), P < 0.05) and thyroid volume (SMD = −1.14, 95%, CI (−1.94, −0.35), P < 0.05) of the treatment group were smaller than those of the control group. Furthermore, the combined treatment was associated with lower levels of free triiodothyronine (FT3), free thyroxine (FT4), and thyroid-stimulating hormone (TSH) in the serum of patients and lower traditional Chinese medicine (TCM) syndrome score (SMD = −1.87, 95%, CI (−3.16, −0.58), P < 0.05).

Conclusion

CHM combined with thyroid hormone/microwave improved the response rate of BTN. The combined treatment was also associated with reducing the maximum nodule diameter, thyroid volume, levels of FT3, FT4, and TSH, and TCM syndrome score. Therefore, combining CHM with WM could be considered as an alternative and effective treatment for treating BTN, suggesting promising integration of Chinese medicine with Western medicine.

Thyroid tumor ratio: Improving the assessment of the impact of size in pediatric thyroid cancer

BACKGROUND

The impact of thyroid nodule size is less useful in children who have smaller thyroid volumes than in adults. We investigate using a novel thyroid tumor ratio measurement in children with thyroid cancer.

METHODS

Patient and pathologic characteristics were investigated via Student's t-test in a univariate analysis for any correlation with the log-transformed tumor ratio, followed by a multivariate linear regression.

RESULTS

Of 75 patients with malignancy and tumor ratio information, mean ratio decreased with increasing age (p = 0.04). Out of several clinical factors, patients with lymph node metastases and those treated with postoperative radioactive iodine had significantly higher mean tumor ratios on multivariate analysis (p = 0.04 for both factors).

CONCLUSIONS

Our study is the first to describe thyroid tumor volume in pediatric thyroid cancer and shows that increased tumor ratio was associated with indicators of more advanced disease such as lymph node metastases and use of radioactive iodine.

Ultrasound classification of thyroid nodules: does size matter?

Objective

To determine whether the size of thyroid nodules in ACR-TIRADS ultrasound categories 3 and 4 is correlated with the Bethesda cytopathology classification.

Methods

Thyroid nodules (566) subclassified as ACR-TIRADS 3 or 4 were divided into three size categories according to American Thyroid Association guidelines. The frequency of different Bethesda categories in each size range within ACR-TIRADS 3 and 4 classifications was analyzed.

Results

Most nodules in both ACR-TIRADS classifications fell in the Bethesda 2 category, regardless of size (90.8% and 68.6%, ACR-TIRADS 3 and 4 respectively). The prevalence of Bethesda 6 nodules in the ACR-TIRADS 4 group was 14 times higher than in the ACR-TIRADS 3 group. There were no significant differences between nodule size and fine needle aspiration biopsy classification in any of the ACR-TIRADS categories.

Conclusion

Size does not appear to be an important criterion for indication of fine needle aspiration biopsy in thyroid nodules with a high suspicion of malignancy on ultrasound examination.

Fine Needle Aspiration Cytology vs. Core Needle Biopsy for Thyroid Nodules: A Prospective, Experimental Study Using Surgical Specimen

PURPOSE

To evaluate and compare the diagnostic outcomes of ultrasonography (US)-guided fine needle aspiration (FNA) and core needle biopsy (CNB) performed on the same thyroid nodule using a surgical specimen for direct comparison.

MATERIALS AND METHODS

We included 89 thyroid nodules from 88 patients from February 2015 to January 2016. The inclusion criterion was thyroid nodules measuring ≥ 20 mm (mean size: 40.0 ± 15.3 mm). Immediately after surgical resection, FNA and subsequent CNB were performed on the surgical specimen under US guidance. FNA and CNB cytopathologic results on the specimen were compared with the surgical diagnosis.

RESULTS

Among the 89 nodules, 30 were malignant and 59 were benign. Significantly higher inconclusive rates were seen in FNA for malignant than benign nodules (80.0% vs. 39.0%, p < 0.001). For CNB, conclusive and inconclusive rates did not differ between benign and malignant nodules (p = 0.796). Higher inconclusive rates were seen for FNA among cancers regardless of US features, and in the subgroup of size ≥ 40 mm (62.5% vs. 22.9%, p = 0.028). Eleven cancers were diagnosed with CNB (36.7%, 11/30), while none was diagnosed using FNA.

CONCLUSION

In this experimental study using surgical specimens, CNB showed a potential to provide improved diagnostic sensitivity for thyroid cancer, especially when a conclusive diagnosis is limited with FNA.

Utility of Fine-Needle Aspirations to Diagnose Pediatric Thyroid Nodules

INTRODUCTION

Risk of malignancy for pediatric thyroid nodules classified according to The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) is not well defined. Correlations between risk of malignancy and ancillary clinical data remain inconclusive. We report a single institutional experience of fine-needle aspiration (FNA) to improve upon current management paradigm of thyroid nodules.

METHODS

A retrospective chart review of 575 thyroid nodules was performed of 324 patients who underwent 340 FNAs between 2008 and 2018 at the Children's Hospital of Philadelphia. Demographics, ultrasound (US) characteristics, FNA cytology, surgical pathology, and ancillary data were reviewed.

RESULTS

The rate of malignancy according to TBSRTC was 0.0% for category I, 0.8% for category II, 15.6% for category III, 54.5% for category IV, 100.0% for category V, and 100.0% for category VI. The cumulative Thyroid Imaging Reporting and Data System (TI-RADS) score was significantly correlated with benign and malignant nodules on pathology (p < 2.2e-16). Distribution of TI-RADS for cytologically indeterminate nodules with benign or malignant pathology revealed significant differences for composition (p = 3.20e-8) and echogenic foci (p = 0.005) but not for echogenicity (p = 0.445), shape (p = 0.160), margins (p = 0.220), and size (p = 0.105). Distributions of thyroid-stimulating hormone levels between benign and malignant patients was significant (p = 1.58e-3).

CONCLUSIONS

Nodules with TI-RADS scores >3 should undergo FNA, irrespective of size; surgical resection is recommended for nodules classified as TBSRTC category IV and V due to high risk of malignancy. US surveillance instead of FNA can be performed for nodules with TI-RADS scores ≤3.

Elastography and Doppler May Bring a New Perspective to TIRADS, Altering Conventional Ultrasonography Dominance

RATIONALE AND OBJECTIVES

The main aim of ultrasonography (US) examining thyroid nodules is to differentiate malignant nodules from benign nodules. Several professional societies and groups of investigators have defined guidelines such as Thyroid Imaging Reporting and Data System (TIRADS) to provide the standardized language and approach to thyroid nodules. This study is aimed to investigate the compatibility of such classification systems with the pathological diagnosis of nodules and evaluate the contribution of the Shear-wave elastography (SWE) and Doppler ultrasonography (DUS) findings.

MATERIALS AND METHODS

This is a prospective study. Patients with thyroid US exams between December 2017 and April 2019 were included. In the study, eligible 210 nodules from 210 patients were enrolled. For stratification, the conventional B-mode US, SWE and DUS were performed. According to Kwak, American College of Radiology (ACR), and European (EU)-TIRADS, Nodules were classified separately, and a new scoring system whose the criteria was put defined in the study has developed.

RESULTS

For SWE; Emean cut-off value was 33 kPa with a sensitivity and specificity of 95,6% (95% CI: 0,85-0,98) and 95% (95% CI:0,90-0,97) respectively (p <0.001). For spectral DUS; resistivity index (RI) cut-off value was 0.64 with a sensitivity and specificity of 73,3% (95% CI:0,59-0,83) and 80% (95% CI:0,73-0,85) respectively (p <0.001). Kwak TIRADS, American College of Radiology TIRADS, EU-TIRADS, and new system were compared by ROC curve analysis. The new system has the highest sensitivity, specificity, PPV, NPV, accuracy, and AUC compared to others.

CONCLUSIONS

The new scoring system has shown that SWE and DUS findings may alter the categorization in TIRADS and increase sensitivity and specificity.

Characterization of focal hypermetabolic thyroid incidentaloma: An analysis with F-18 fluorodeoxyglucose positron emission tomography/computed tomography parameters

BACKGROUND

Incidentally found thyroid tumor (thyroid incidentaloma, TI) on F-18 fluorodeoxyglucose (FDG) positron emission tomography-computed tomography (PET-CT) is reported in 2.5%-5% of patients being investigated for non-thyroid purposes. Up to 50% of these cases have been diagnosed to be malignant by cytological/histological results. Ultrasonography (US) and fine-needle aspiration cytology are recommended for thyroid nodules with high FDG uptake (hypermetabolism) that are 1 cm or greater in size. It is important to accurately determine whether a suspicious hypermetabolic TI is malignant or benign.

AIM

To distinguish malignant hypermetabolic TIs from benign disease by analyzing F-18 FDG PET-CT parameters and to identify a cut-off value.

METHODS

Totally, 12761 images of patients who underwent F-18 FDG PET-CT for non-thyroid purposes at our hospital between January 2016 and December 2020 were retrospectively reviewed, and 339 patients [185 men (mean age: 68 ± 11.2) and 154 women (mean age: 63 ± 15.0)] were found to have abnormal, either focal or diffuse, thyroid FDG uptake. After a thorough review of their medical records, US, and cytological/histological reports, 46 eligible patients with focal hypermetabolic TI were included in this study. The TIs were categorized as malignant and benign according to the cytological/histological reports, and four PET parameters [standardized uptake value (SUV)_max, SUV_peak, SUV_mean, and metabolic tumor volume (MTV)] were measured on FDG PET-CT. Total lesion glycolysis (TLG) was calculated by multiplying the SUV_mean by MTV. Both parametric and non-parametric methods were used to compare the five parameters between malignant and benign lesions. Receiver operating characteristic (ROC) curve analysis was performed to identify a cut-off value.

RESULTS

Each of the 46 patients [12 men (26.1%; mean age: 62 ± 13.1 years) and 34 women (73.9%; mean age: 60 ± 12.0 years)] with focal hypermetabolic TIs had one focal hypermetabolic TI. Among them, 26 (56.5%) were malignant and 20 (43.5%) were benign. SUV_max, SUV_peak, SUV_mean, and TLG were all higher in malignant lesions than benign ones, but the difference was statistically significant (P = 0.012) only for SUV_max. There was a positive linear correlation (r = 0.339) between SUV_max and the diagnosis of malignancy. ROC curve analysis for SUV_max revealed an area under the curve of 0.702 (P < 0.05, 95% confidence interval: 0.550-0.855) and SUV_max cut-off of 8.5 with a sensitivity of 0.615 and a specificity of 0.789.

CONCLUSION

More than half of focal hypermetabolic TIs on F-18 FDG PET-CT were revealed as malignant lesions, and SUV_max was the best parameter for discriminating between malignant and benign disease. Unexpected focal hypermetabolic TIs with the SUV_max above the cut-off value of 8.5 may have a greater than 70% chance of malignancy; therefore, further active assessment is required.

Navigating the Debate on Managing Large (≥4 cm) Thyroid Nodules

PURPOSE

Discordant practice guidelines for managing large thyroid nodules may result in unnecessary surgeries and costs. Recent data suggest similar false-negative rates in fine needle aspiration (FNA) biopsies between small (<4 cm) and large (≥4 cm) nodules, indicating that monitoring rather than surgery may be appropriate for large biopsy-negative nodules. We investigated the management of thyroid nodules ≥4 cm to determine the proportion of surgeries not necessary for diagnostic purposes and examined for potential predictors.

METHODS

This was a retrospective cohort study of patients who received a FNA of nodule(s) ≥4 cm between 11/1/2014 and 10/31/2019 at the University of Vermont Medical Center. A surgery was considered unnecessary if the FNA result was benign in the absence of any of the following: compressive symptoms, family history of thyroid cancer in a first degree relative, history of neck irradiation, toxic nodule or toxic multinodular goiter, or substernal extension. Data were analyzed with Wilcoxon rank sum tests, chi square, or Fisher's exact tests.

RESULTS

177 patients had a ≥4 cm nodule during the timeframe and half (54.2%) had surgery. Patients who underwent surgery were significantly younger (51.5 years vs. 62 years; P < 0.001), more likely to report obstructive symptoms (34.4% vs. 12.1%; P < 0.001) and had a larger nodule size (5.0 cm vs. 4.7 cm; P=0.26). Forty-one patients with benign (Bethesda II) FNA results had surgery, all with negative surgical pathology. Thirteen percentage (23/177) of surgeries were potentially not necessary for diagnostic purposes.

CONCLUSION

Approximately half of our patients with ≥4 cm nodules had surgery, with 13% having surgery not necessary for diagnostic purposes revealing opportunities for improving care and costs.

2021 Korean Thyroid Imaging Reporting and Data System and Imaging-Based Management of Thyroid Nodules: Korean Society of Thyroid Radiology Consensus Statement and Recommendations

Incidental thyroid nodules are commonly detected on ultrasonography (US). This has contributed to the rapidly rising incidence of low-risk papillary thyroid carcinoma over the last 20 years. The appropriate diagnosis and management of these patients is based on the risk factors related to the patients as well as the thyroid nodules. The Korean Society of Thyroid Radiology (KSThR) published consensus recommendations for US-based management of thyroid nodules in 2011 and revised them in 2016. These guidelines have been used as the standard guidelines in Korea. However, recent advances in the diagnosis and management of thyroid nodules have necessitated the revision of the original recommendations. The task force of the KSThR has revised the Korean Thyroid Imaging Reporting and Data System and recommendations for US lexicon, biopsy criteria, US criteria of extrathyroidal extension, optimal thyroid computed tomography protocol, and US follow-up of thyroid nodules before and after biopsy. The biopsy criteria were revised to reduce unnecessary biopsies for benign nodules while maintaining an appropriate sensitivity for the detection of malignant tumors in small (1-2 cm) thyroid nodules. The goal of these recommendations is to provide the optimal scientific evidence and expert opinion consensus regarding US-based diagnosis and management of thyroid nodules.

Current Evaluation of Thyroid Nodules

Thyroid nodules may be discovered in a variety of settings. Familiarity with their management is important for medical specialists. Workup should start with history and physical examination, proceed to laboratory studies, and then to imaging. Nodules are selected for fine needle aspiration (FNA) biopsy based on imaging criteria. Most nodules can be accurately diagnosed on cytopathology, but some may require additional molecular testing to evaluate risk of malignancy. Patients with malignant lesions require additional investigation before referral to an experienced thyroid surgeon. Those who have benign lesions may require monitoring by periodic ultrasound to identify nodules requiring reevaluation.

A practical approach for the management of small thyroid nodules referred for biopsy

OBJECTIVE

Current guidelines recommend against routine ultrasound (US) guided fine-needle aspiration biopsy (FNAB) of small (<1 cm) thyroid nodules and suggest follow-up of ≥5 mm small nodules only if they are TI-RADS-5. This study aims to determine the best suspicious ultrasound features related to cytology results in patients referred for FNAB of small thyroid nodules and construct an algorithm for declining unnecessary biopsies and selection of patients to be followed up.

METHODS

This prospective observational study enrolled patients referred for US-guided biopsy of ≤1 cm thyroid nodules. Ultrasound features including composition, echogenicity, shape, margin, echogenic focus, hypoechoic rim, vascularity were assessed. The cytology results were dichotomised as either benign or malignant/high risk. The features with excellent interobserver reliability and more than 90% sensitivity were selected.

RESULTS

Overall, 95 patients [82 (86.3%) females, mean age 48.5 ± 11.9 years] with 95 small (≤1 cm) thyroid nodules were biopsied. Cytology revealed 15 (15.8%) malignant nodules. Pure solid composition, hypoechogenicity, taller than wide shape and irregular margin of the nodules were significantly associated with malignancy. Hypoechogenicity (100%) and pure solid composition (93%) had very high sensitivity and excellent interobserver agreement (Cohen's Kappa 0.83, P = .003 for both) for predicting high risk/malignant nodule. In the absence of these two features, 48 (50.5%) nodules either would not require FNAB or follow-up.

CONCLUSION

The presence of cyst or iso/hyperechogenicity within a small thyroid nodule in patients already referred for invasive sampling safely allows for declining a decision of FNAB or follow-up without the concern of missing malignancy.

A Scoring System for Assessing the Risk of Malignant Partially Cystic Thyroid Nodules Based on Ultrasound Features

Objective

To assess the ultrasound (US) features of partially cystic thyroid nodules (PCTNs) and to establish a scoring system to further improve the diagnostic accuracy.

Methods

A total of 262 consecutive nodules from September 2017 to March 2020 were included in a primary cohort to construct a scoring system. Moreover, 83 consecutive nodules were enrolled as an validation cohort from May 2018 to August 2020. All nodules were determined to be benign or malignant according to the pathological results after surgery or ultrasound-guided fine-needle aspiration (US-FNA). The US images and demographic characteristics of the patients were analyzed. The ultrasound features of PCTNs were extracted from primary cohort by two experienced radiologists. The features extracted were used to develop a scoring system using logistic regression analysis. Receiver operating characteristic (ROC) curves were applied to evaluate the diagnostic efficacy of the scoring system in both the primary cohort and validation cohort. In addition, the radiologists evaluated the benign and malignant PCTNs of the validation cohort according to the ACR TI-RADS guidelines and clinical experience, and the accuracy of their diagnosis were compared with that of the scoring system.

Results

Based on the eight features of PCTNs, the scoring system showed good differentiation and reproducibility in both cohorts. The scoring system was based on eight features of PCTNs and showed good performance. The area under the curve (AUC) was 0.876 (95% CI, 0.830 - 0.913) in the primary cohort and 0.829(95% CI, 0.730 - 0.903) in the validation cohort. The optimal cutoff value of the scoring system for the diagnosis of malignant PCTNs was 4 points, with a good sensitivity of 71.05% and specificity of 87.63%. The scoring system (AUC=0.829) was superior to radiologists (AUC= 0.736) in diagnosing PCTNs and is a promising method for clinical application.

Conclusions

The scoring system described herein is a convenient and clinically valuable method that can diagnose PCTNs with relatively high accuracy. The use of this method to diagnose PCTNs, which have been previously underestimated, will allow PCTNs to receive reasonable attention, and assist radiologist to confidently diagnose the benignity or malignancy.

Association of the Implementation of a Standardized Thyroid Ultrasonography Reporting Program With Documentation of Nodule Characteristics

Importance

Although most thyroid nodules are benign, the potential for malignant neoplasms is associated with unnecessary workup in the form of imaging, fine-needle aspiration, and diagnostic surgery. The American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS) is commonly used to assess the malignant neoplasm risk potential of thyroid nodules imaged by ultrasonography. However, standardized reporting of ACR TI-RADS descriptors is inconsistent.

Objective

To increase the documentation rate of ACR TI-RADS thyroid nodule characteristics to 80% in 18 months.

Design, Setting, and Participants

This prospective interrupted time series quality improvement study was conducted from December 1, 2018, to March 31, 2020, at a tertiary outpatient head and neck clinic among 229 patients who had at least 1 documented thyroid nodule identified on bedside clinic ultrasonography. Data analysis was performed throughout the entire study period because this was a quality improvement study with iterative small cycle changes; final analysis of the data was performed in April 2020.

Main Outcomes and Measures

The primary outcome was the documentation rates of 6 ACR TI-RADS ultrasonographic descriptors. Secondary outcomes included nodule fine-needle aspiration biopsy rate and physician-reported clinic flow efficiency.

Results

A total of 229 patients had at least 1 documented thyroid nodule and were included in the analysis. Size was the most frequently documented nodule characteristic (72 of 74 [97.3%]) at baseline, followed by echogenic foci (31 of 74 [41.9%]), composition (23 of 74 [31.1%]), echogenicity (17 of 74 [23.0%]), margin (6 of 74 [8.1%]), and shape (1 of 74 [1.4%]). After 3 Plan, Do, Study, Act (PDSA) cycles, the final intervention consisted of a standardized ultrasonography reporting form and educational initiatives for surgical trainees. After the third PDSA cycle (n = 36), reporting of nodule size, echogenic foci, and composition increased to 100%. Similarly, reporting of echogenicity (34 of 36 [94.4%]), shape (28 of 36 [77.8%]), and margin (25 of 36 [69.4%]) all increased. This represented a cumulative 90.3% documentation rate (195 of 216), a 56.5% increase from baseline (95% CI, 50.0%-61.9%). The standardized reporting form was used in 83.3% of eligible thyroid ultrasonography cases (30 of 36) after PDSA cycle 3, demonstrating good fidelity of implementation. There were no unintended consequences associated with clinic workflow, as a balancing measure, reported by staff surgeons.

Conclusions and Relevance

This study suggests that implementation of an ACR TI-RADS-based reporting form in conjunction with educational initiatives improved documentation of ultrasonographic thyroid nodule characteristics, potentially allowing for improved bedside risk stratification and communication among clinicians.

Impact of Ultrasonographic Features for Thyroid Malignancy in Patients With Bethesda Categories III, IV, and V: A Retrospective Observational Study in a Tertiary Center

Introduction: Although fine-needle aspiration biopsy (FNAB) with cytologic interpretation using the Bethesda System for Reporting Thyroid Cytopathology has been widely used for thyroid nodules, its efficiency in Bethesda categories of III, IV, and V has been questioned due to variable risk of malignancy. We aimed to evaluate the impact of radiological parameters in Bethesda category III, IV, and V for thyroid malignancy.

Methods: We performed a retrospective review of patients with Bethesda category III, IV, and V, and subsequent thyroidectomy. Demographic, ultrasonographic, and clinical variables were recorded. Independent variables for thyroid malignancy and the predictive power of imaging findings were analyzed.

Results: There were 159 patients with a mean age of 48.1±13.4 years. Hypoechogenicity of the index nodule was the most common finding in 87 patients (54.7%). There were 74 (46.5%), 34 (21.4%), and 51 patients (32.1%) with Bethesda III, IV, and V categories, respectively. There were 91 patients (57.2%) with a diagnosis of thyroid malignancy. Overall malignant pathology was detected in 18 (24.3%), 25 (73.5%), and 48 patients (94.1%) in Bethesda III, IV, and V categories, respectively (p=0.001). The presence of solitary nodule, hypoechogenicity, and solid structure of index nodule and Bethesda category IV and V were significant variables for final malignant pathology (p<0.05 for all).

Conclusion: Hypoechogenicity and solid structure in a solitary index nodule should be regarded as significant ultrasonographic findings for thyroid malignancy. Bethesda category IV and V were also significantly associated with malignancy.

Prevalence and predictors of thyroid cancer among thyroid nodules: a retrospective cohort study of 1,000 patients

INTRODUCTION

Thyroid cancer is increasing in incidence globally due either to early detection (overestimation) or true increment. A recent debate concerns multinodular goitre (MNG) or toxic goitres which have classically been considered at a lower risk for cancer.

METHODS

In this study, we enrolled retrospectively all patients with nodular goitre treated at our tertiary hospital and analysed their data with the aim of detecting the rate of cancer among different types of nodular goitre. We also studied predictors of incidental malignancy among thyroidectomies.

RESULTS

A predilection for solitary thyroid nodules (STNs) was found in women of younger age, with STNs tending to be larger in comparison with MNG in the same age group. However, both types of nodules were at equal risk of harbouring malignancy. Thyroid Imaging Reporting and Data System (TI-RADS) and Bethesda scores were the only dependent predictors of malignancy within thyroid nodules.

CONCLUSION

The authors recommend management of both STNs and MNG using the same algorithm.

Different sonographic features of peripheral thyroid nodule calcification and risk of malignancy: a prospective observational study

Purpose

To investigate the association of peripheral calcification, as well as its sonographic features, with thyroid nodule malignancy.

Material and methods

This study was prospectively conducted during 2015-2020 on patients diagnosed with thyroid nodule undergoing ultrasound-guided fine-needle aspiration in Shahid Beheshti teaching hospital or private offices in Babol, northern Iran. The ultrasonographic characteristics of the nodules, as well as the cytological findings, were recorded. Regression analysis was used to assess the relationship between sonographic results and malignancy. We also used receiver operator characteristics (ROC) analysis to estimate the ability of ultrasound to predict the characteristic features of malignancy, as estimated by the area under the curve (AUC).

Results

A total of 1857 thyroid nodules were finally included, of which 84 were peripherally calcified nodules. There was a significant positive association between the nodule malignancy and peripheral calcification (OR = 2.23, 95% CI: 1.13-4.35). In the nodules with peripheral calcification, significant positive associations were seen between malignancy and lobulated margin (OR = 3.85, 95% CI: 1.02-14.54) and solid composition (OR = 4.05, 95% CI: 0.99-16.53). The ROC analysis indicated that AUC for lobulated margin and solid composition was 63.8% and 66.5%, respectively, in predicting malignant thyroid nodules.

Conclusion

The findings showed that peripheral calcification on sonography can be a potential indicator of malignant thyroid nodules. Also, the presence of lobulated margin and/or solid composition, besides peripheral calcification, can be helpful in better distinguishing malignant from benign nodules.

Matrix 3D ultrasound-assisted thyroid nodule volume estimation and radiofrequency ablation: a phantom study

Background

Two-dimensional (2D) ultrasound is well established for thyroid nodule assessment and treatment guidance. However, it is hampered by a limited field of view and observer variability that may lead to inaccurate nodule classification and treatment. To cope with these limitations, we investigated the use of real-time three-dimensional (3D) ultrasound to improve the accuracy of volume estimation and needle placement during radiofrequency ablation. We assess a new 3D matrix transducer for nodule volume estimation and image-guided radiofrequency ablation.

Methods

Thirty thyroid nodule phantoms with thermochromic dye underwent volume estimation and ablation guided by a 2D linear and 3D mechanically-swept array and a 3D matrix transducer.

Results

The 3D matrix nodule volume estimations had a lower median difference with the ground truth (0.4 mL) compared to the standard 2D approach (2.2 mL, p < 0.001) and mechanically swept 3D transducer (2.0 mL, p = 0.016). The 3D matrix-guided ablation resulted in a similar nodule ablation coverage when compared to 2D-guidance (76.7% versus 80.8%, p = 0.542). The 3D mechanically swept transducer performed worse (60.1%, p = 0.015). However, 3D matrix and 2D guidance ablations lead to a larger ablated volume outside the nodule than 3D mechanically swept (5.1 mL, 4.2 mL (p = 0.274), 0.5 mL (p < 0.001), respectively). The 3D matrix and mechanically swept approaches were faster with 80 and 72.5 s/mL ablated than 2D with 105.5 s/mL ablated.

Conclusions

The 3D matrix transducer estimates volumes more accurately and can facilitate accurate needle placement while reducing procedure time.

Clinical Heterogeneity of Differentiated Thyroid Cancer between Children Less than 10 Years of Age and Those Older than 10 Years: A Retrospective Study of 70 Cases

OBJECTIVES

The objectives of this study were to explore the clinical heterogeneity of differentiated thyroid cancer (DTC) between prepubertal children and adolescents and guide clinical treatment.

METHODS

A retrospective study included patients with DTC aged ≤19 years in Beijing Children's Hospital from June 2014 to June 2019. All patients were enrolled and divided into 2 subgroups based on the threshold age of 10 years, namely the childhood group (CG) (≤10 years old); and the adolescent group (AG) (between 10 and 19 years old). The χ² test and Fisher's exact test were used to estimate the effect of risk factors in the 2 age groups. Multivariate binary logistic regression models were conducted to assess the recurrent risk factors.

RESULTS

Seventy cases of DTC were included with an average age of 9.94 ± 2.88 years, including 35 in CG and 35 in AG. The most common clinical manifestation was a painless mass in the neck, accounting for 77.1% (54/70) of patients. Compared with the AG, the CG was more likely to have lymph node metastasis (p = 0.022) and distant metastasis (p = 0.041). The CG was more likely to have extrathyroidal extension (p = 0.012) and had a significantly higher recurrence rate than the AG (p = 0.040). Age was an independent variable predictive of recurrence (p = 0.0347).

CONCLUSION

Regional invasiveness, cervical lymph node metastasis, and distant metastasis of DTC were more likely to occur in children ≤10 years old. Meanwhile, children ≤10 years old with DTC were more likely to have recurrence than adolescent's postsurgical treatment. Thus, children younger than 10 years of age with DTC should be treated more aggressively.

Ultrasound Parameters of Thyroid Nodules and the Risk of Malignancy: A Retrospective Analysis

Ultrasonography-guided fine-needle aspiration biopsy is the common choice for diagnosis of the suspected thyroid nodule. An algorithm(s) that finds the malignant potential of a nodule preoperatively, to overcome unnecessary diagnostic methods, does not exist. The objective of the study was to correlate thyroid nodule sizes measured by ultrasonography and risk of malignancy assessed by cytologic and histologic examinations. Data regarding fine-needle aspiration cytology and the results of histologic examinations of surgical specimens of 260 nodules were collected and analyzed. The macro or multiple calcifications, the complex echo pattern, and posterior region homogeneity were considered suspicious in ultrasonography. Bethesda system for classification of thyroid nodules was used for cytopathology. Histopathology performed as per the 2004 World Health Organization classification system. The benefit score analysis was performed for determination of clinical usefulness. Twenty-eight of 49 malignant nodules and 46 of 68 malignant nodules detected through ultrasound following fine-needle aspiration cytopathology and histopathology were <2 cm in size. A correlation was found for malignancy rate detected by ultrasonography-guided fine-needle aspiration cytology and those of the surgical specimen (r = 0.945, P = .015, R² = 0.894). Ultrasonography-guided fine-needle aspiration cytology had 0.994 sensitivities, 0.721 accuracies, and 0.08 to 0.945 diagnostic confidence for the detection of malignant nodules. Nodule size less than 2 mm (P = .011) was associated with the malignancy potential of thyroid nodules. Ultrasonography-guided fine-needle aspiration cytology had 19 (7%) results as a false negative and 1 (1%) results were false positive. Ultrasound-guided fine-needle aspiration cytopathology reported oversize of thyroid nodule than original but can predict the risk of malignancy. Level of Evidence: III.

Multiparametric Photoacoustic Analysis of Human Thyroid Cancers In Vivo

Thyroid cancer is one of the most common cancers, with a global increase in incidence rate for both genders. Ultrasound-guided fine-needle aspiration is the current gold standard to diagnose thyroid cancers, but the results are inaccurate, leading to repeated biopsies and unnecessary surgeries. To reduce the number of unnecessary biopsies, we explored the use of multiparametric photoacoustic (PA) analysis in combination with the American Thyroid Association (ATA) Guideline (ATAP). In this study, we performed in vivo multispectral PA imaging on thyroid nodules from 52 patients, comprising 23 papillary thyroid cancer (PTC) and 29 benign cases. From the multispectral PA data, we calculated hemoglobin oxygen saturation level in the nodule area, then classified the PTC and benign nodules with multiparametric analysis. Statistical analyses showed that this multiparametric analysis of multispectral PA responses could classify PTC nodules. Combining the photoacoustically indicated probability of PTC and the ATAP led to a new scoring method that achieved a sensitivity of 83% and a specificity of 93%. This study is the first multiparametric analysis of multispectral PA data of thyroid nodules with statistical significance. As a proof of concept, the results show that the proposed new ATAP scoring can help physicians examine thyroid nodules for fine-needle aspiration biopsy, thus reducing unnecessary biopsies.

Taller-than-wide Thyroid Nodules With Microcalcifications Are at High Risk of Malignancy

BACKGROUND/AIM

Previous studies have shown that there may be a diversity in the ultrasonographic (US) features discriminating a malignant from a benign thyroid nodule. We determined the reliability of the specific nodule shape in combination with other US features in predicting thyroid carcinomas.

PATIENTS AND METHODS

This was a retrospective single-center study investigating the association of the morphological characteristics of nodular goiters from preoperative US and color Doppler images with malignancy based on pathology.

RESULTS

We evaluated 254 thyroid nodules (malignant, n=131) from 205 patients. Multivariable logistic regression analysis showed that taller-than-wide shape [odds ratio (OR)=25.3, 95% confidence interval (CI)=5.4-118.9; p<0.001], microcalcifications (OR=4.9, 95% CI=2.5-9.5; p<0.001), hypoechogenicity (OR=4.5; 95% CI=2-10.3; p<0.001) and size (OR=0.93; 95% CI=0.89-0.98; p=0.002) were independently associated with thyroid nodule malignancy. Additionally, we found a strong negative correlation between size and taller-than-wide shape of a thyroid nodule (r=-0.41, p<0.001).

CONCLUSION

Among the important indicators of thyroid malignancy, taller-than-wide nodules with microcalcifications are most likely to be malignant.

Effective rational humanization of a PASylated anti-galectin-3 Fab for the sensitive PET imaging of thyroid cancer in vivo

The lack of a non-invasive test for malignant thyroid nodules makes the diagnosis of thyroid cancer (TC) challenging. Human galectin-3 (hGal3) has emerged as a promising target for medical TC imaging and diagnosis because of its exclusive overexpression in malignant thyroid tissues. We previously developed a human-chimeric αhGal3 Fab fragment derived from the rat monoclonal antibody (mAb) M3/38 with optimized clearance characteristics using PASylation technology. Here, we describe the elucidation of the hGal3 epitope recognized by mAb M3/38, X-ray crystallographic analysis of its complex with the chimeric Fab and, based on the three-dimensional structure, the rational humanization of the Fab by CDR grafting. Four CDR-grafted versions were designed using structurally most closely related fully human immunoglobulin VH/VL regions of which one-employing the acceptor framework regions of the HIV-1 neutralizing human antibody m66-showed the highest antigen affinity. By introducing two additional back-mutations to the rodent donor sequence, an affinity toward hGal3 indistinguishable from the chimeric Fab was achieved (KD = 0.34 ± 0.02 nM in SPR). The PASylated humanized Fab was site-specifically labelled with the fluorescent dye Cy7 and applied for the immuno-histochemical staining of human tissue sections representative for different TCs. The same protein was conjugated with the metal chelator Dfo, followed by radiolabelling with 89Zr(IV). The resulting protein tracer allowed the highly sensitive and specific PET/CT imaging of orthotopic tumors in mice, which was confirmed by quantitative analysis of radiotracer accumulation. Thus, the PASylated humanized αhGal3 Fab offers clinical potential for the diagnostic imaging of TC.

Use of Predictive Modeling to Tailor Molecular Testing Utilization for Thyroid Nodules

OBJECTIVE

Various risk stratification systems for cytologically indeterminate thyroid nodules are available. However, malignancy risk assessment data, such as ultrasound features, are not always used when the decision is to order molecular testing or not. Our aim was to investigate the utility of molecular testing after incorporating an algorithm with ultrasound-based risk of malignancy (ROM) estimation.

STUDY DESIGN

Diagnostic/prognostic study.

SETTING

Single-institution urban tertiary care center.

METHODS

We performed a single-institution retrospective chart review of all thyroid nodules that had undergone molecular testing. A web-based Malignancy Risk Estimation System for Thyroid Nodules was utilized with ultrasound findings to stratify malignancy risk according to the Korean Thyroid Imaging Reporting and Data System (TI-RADS), French TI-RADS, American Association of Clinical Endocrinology guideline, and American Thyroid Association guideline. A novel algorithm for utilizing molecular testing at our institution was developed with the Korean TI-RADS and with recommendations from the American Thyroid Association and National Comprehensive Cancer Network.

RESULTS

The Korean TI-RADS performed best in our population (area under the curve = 0.83). A positive molecular test result had a positive association with a higher ROM according to all 4 models (P < .05). Use of our algorithm prior to molecular testing would have prevented 38% of benign/low-ROM negative nodules (n = 28) from being tested.

CONCLUSION

In patients with indeterminate thyroid nodules, an algorithm built on pre- and posttest probability to guide molecular testing might reduce unnecessary testing of benign and low-risk nodules.

Incidence, Clinical Characteristics, and Histopathological Results of Atypia of Undermined Significance in a Tertiary Center in UAE

<b><i>Introduction:</i></b> Bethesda classification of thyroid nodules cytology is an agreed upon method of classifying thyroid nodules according to risk of malignancy. Among them, Bethesda class III (Atypia of Undetermined Significance, AUS) has been a topic of great controversy. The reported estimated risk of malignancy associated with it varies in different studies. Our study investigates the associated incidence of malignancy in a single tertiary center in UAE. <b><i>Methodology:</i></b> Data were retrospectively collected over a 10-year period from January 2009 till December 2018 for cytology diagnosis of AUS. Patient charts were reviewed for method of management. Surgical and histopathology records were reviewed to compare findings on cytology versus histopathology. <b><i>Results:</i></b> A total of 180 cases were diagnosed Bethesda III (AUS) with a mean age of 45.09 ± 14.7 years. One hundred cases (55.6%) of them underwent surgical resection, and histopathological diagnosis was obtained. Among the operated cases, 46 were benign and 54 were malignant. Papillary thyroid cancer was the most common malignancy, seen in 39 (72.2%) of cases, and follicular cancer was the second most common, seen in 13 (24.1%) cases. <b><i>Conclusion:</i></b> The findings highlighted in our study suggest a higher incidence of malignancy in Bethesda III category than previously reported. It also puts in question the utility and benefit behind keeping a time gap and repeating FNA as previously recommended.

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

Simple Summary

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

Abstract

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