A Cohort Analysis of Clinical and Ultrasound Variables Predicting Cancer Risk in 20,001 Consecutive Thyroid Nodules

Deciphering the progression of fine-needle aspiration: A bibliometric analysis of thyroid nodule research

This study aims to dissect the evolution and pivotal shifts in Fine-Needle Aspiration (FNA) research for thyroid nodules over the past 2 decades, focusing on delineating key technological advancements and their impact on clinical practice. A comprehensive bibliometric analysis was conducted on 5418 publications from the Web of Science Core Collection database (2000-2023). Publications were rigorously selected based on their contributions to the advancement of FNA techniques and their influence on thyroid nodule management practices. Our analysis uncovered significant breakthroughs, most notably the incorporation of ultrasound and molecular diagnostics in FNA, which have markedly elevated diagnostic accuracy. A pivotal shift was identified towards minimally invasive post-FNA treatments, such as Radiofrequency Ablation, attributable to these diagnostic advancements. Additionally, the emergence of AI-assisted cytology represents a frontier in precision diagnostics, promising enhanced disease identification. The geographical analysis pinpointed the United States, Italy, and China as key contributors, with the United States leading in both publication volume and citation impact. This bibliometric analysis sheds light on the transformative progression in FNA practices for thyroid nodules, characterized by innovative diagnostic technologies and a trend towards patient-centric treatment approaches. The findings underscore the need for further research into AI integration and global practice standardization. Future explorations should focus on the practical application of these advancements in diverse healthcare settings and their implications for global thyroid nodule management.

Traditional Chinese medicine treatment for benign thyroid nodules: Literature review

Thyroid nodules (TNs) are pathological changes characterized by abnormal proliferation of thyroid gland tissue. Approximately 19% to 67% of asymptomatic individuals are diagnosed with TNs, with the majority being benign nodules and 4% to 6.5% being thyroid cancer nodules. Western medicine recommends regular examinations and surgery, while traditional Chinese medicine (TCM) provides an alternative choice to maintain thyroid function and reduce the need for surgery. However, in Taiwan, research on TCM treatment for benign TNs is primarily limited to case reports, lacking large-scale and systematic clinical studies. We conducted a search of electronic databases including PubMed, Google Scholar, Wanfang Data, and China National Knowledge Infrastructure to collect clinical trials related to TCM treatment for TNs. Our goal is to provide new treatment options, further validate the value of TCM in the treatment of TNs, and lay a foundation for future clinical research.

Age-related variation in malignant cytology rates of thyroid nodules: insights from a retrospective observational study assessing the ACR TI-RADS

OBJECTIVE

The influence of age on the malignant cytology rate of thyroid nodules remains uncertain. The American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS) is currently used to guide subsequent investigations of thyroid nodules, regardless of clinical variables. This study aimed to investigate the impact of age on the malignant cytology rates of thyroid nodules and the diagnostic performance of ACR TI-RADS across different age groups.

DESIGN

A retrospective, single-center, observational study.

METHODS

Patients aged ≥ 20 years with thyroid nodules, who underwent fine-needle aspiration biopsy between 2012 and 2019 were evaluated. Ultrasound images were used to obtain the TI-RADS data. Malignancy was determined based on suspicious for malignancy (Bethesda V) and malignant (Bethesda VI) cytology results or malignancy in cell block analysis.

RESULTS

A total of 1023 nodules from 921 patients (88.2% female) were analyzed. The median age was 58.5 (interquartile range [IQR], 41.1-66.6) years, and the median nodule size was 2.4 (IQR, 1.7-3.6) cm. Stratification by age revealed a decreasing prevalence of malignant cytology across subgroups of 20-39, 40-59, and ≥60 years (10.7%, 8.5%, and 3.7%, respectively; P = .002). After adjusting for sex, multinodularity, nodule size, and ACR TI-RADS category, we observed that each year of age reduced the OR for malignant cytology by 3.0% (95% CI: 0.7%-5.3%; P = .011). When comparing the subgroups of 20-39 and ≥60 years, the malignant cytology rate decreased by half in TI-RADS 4 (from 21.4% to 10.4%) and two-thirds in TI-RADS 5 (from 64.7% to 22.6%).

CONCLUSIONS

Our study demonstrated that as patient age increased, the rate of malignant cytology in thyroid nodules decreased. Moreover, age significantly influences the malignancy rates of thyroid nodules classified according to the ACR TI-RADS.

Computer-interpretable guidelines: electronic tools to enhance the utility of thyroid nodule clinical practice guidelines and risk stratification tools

Clinicians seeking guidance for evaluating and managing thyroid nodules currently have several resources. The principal ones are narrative clinical guidelines and clinical risk calculators. This paper will review the strengths and weaknesses of both. The paper will introduce a concept of computer interpretable guideline, a novel way of transforming narrative guidelines in to a clinical decision support tool that can provide patient specific recommendations at the point of care. The paper then describes an experience of developing an interactive web based computer interpretable guideline for thyroid nodule management, called Thyroid Nodule Management App (TNAPP). The advantages of this approach and the potential barriers for widespread adaptation are discussed.

B-mode Ultrasound Characteristics of Thyroid Nodules With High-Benign Probability and Nodules With Risk of Malignancy

INTRODUCTION

Thyroid nodules are commonly found on clinical examination or diagnostic imaging of the neck. Malignant thyroid nodules are increasing worldwide, making thyroid cancer one of the most common endocrine malignancies worldwide. The aim of this study was to determine B-mode ultrasound characteristics of benign thyroid nodules and nodules with risk of malignancy.  Material and methods: This retrospective study was conducted on subjects (n=99) who underwent thyroid ultrasound. Data were retrieved from the Thyroid Digital Image Database of Universidad Nacional de Colombia, a published open-access dataset, in which B-mode ultrasound images were interpreted by expert radiologists providing a complete diagnostic description of thyroid lesions using the Thyroid Imaging Reporting and Data System.

RESULTS

Sponge-like appearance (Pearson Chi-Square 4.6, p=0.02), cystic (Pearson Chi-Square 27.3, p<0.001), isoechoic (Pearson Chi-Square 26, p<0.001), and well-defined (Pearson Chi-Square 13.7, p<0.001) thyroid nodules were more likely to be observed in benign nodules (risk of malignancy <5%). On the other hand, predominately solid (Pearson Chi-Square 5.9, p=0.01), microcalcifications (Pearson Chi-Square 50.7, p<0.001), hypoechoic (Pearson Chi-Square 27.7, p<0.001), irregular shape (Pearson Chi-Square 6.6, p=0.01), and ill-defined (Pearson Chi-Square 8.8, p=0.003) thyroid nodules were more likely to be observed in nodules with risk of malignancy (>5%).

CONCLUSION

Ultrasound characteristics could be used to determine thyroid nodules with risk of malignancy and avoid over-diagnosing nodules with benign features. Further research evaluating the use of multiparametric ultrasound to distinguish between benign thyroid nodules and thyroid nodules with risk of malignancy is required.

A prospective comparison of ACR-TIRADS and EU-TIRADS in thyroid nodule assessment for FNA-US

OBJECTIVE

Prospective data on the accuracy of ultrasound (US) classification systems in thyroid nodules are still scarce. The aim of this study is to compare the accuracy of the American College of Radiology Thyroid Imaging Reporting and Data System (ACR-TIRADS) and European (EU)-TIRADS classification systems.

DESIGN AND PATIENTS

Consecutive patients with one or more thyroid nodule(s) who underwent fine-needle aspiration (FNA) under ultrasonographic guidance (FNA-US) were prospectively evaluated.

MEASUREMENTS

Clinical evaluation and US data were collected. The reference standard used for this study was FNA-US cytology and histopathological diagnosis.

RESULTS

A total of 186 thyroid nodules in 166 patients were evaluated, resulting in 168 nodules from 149 patients with conclusive benign or malignant results. Sensitivity, specificity, negative predictive value (NPV) and false negative (FN) were 100.0%, 28.7%, 100.0% and 0.0%, respectively, for ACR-TIRADS; and 90.0%, 19.1%, 96.8% and 9.1% (n = 1), respectively, for EU-TIRADS. The number of unnecessary FNA-US indicated by ACR-TIRADS was lower than EU-TIRADS (71.3% vs. 80.9%, p = .017), and the number of possibly avoided FNA-US was higher (26.7% vs. 17.8%). Using the same threshold of ACR-TIRADS to indicate FNA-US in EU-TIRADS 3 nodules (2.5 cm), there was an improvement in specificity (30.6%) and avoided FNA-US (28.6%). The best performance of both systems was demonstrated when FNA-US would be indicated only in highly suspicious nodules and/or in the presence of lymphadenopathy, with 85.7% and 89.3% of possibly avoided FNA-US for ACR-TIRADS and EU-TIRADS, respectively, without increasing FN.

CONCLUSION

Both systems presented high sensitivity, but low specificity in selecting nodules for FNA-US. The use of nodular size for FNA-US selection is questioned.

SFE-AFCE-SFMN 2022 Consensus on the management of thyroid nodules: Initial work-up for thyroid nodules

The SFE-AFCE-SFMN 2022 consensus deals with the management of thyroid nodules, a condition that is a frequent reason for consultation in endocrinology. In more than 90% of cases, patients are euthyroid, with benign non-progressive nodules that do not warrant specific treatment. The clinician's objective is to detect malignant thyroid nodules at risk of recurrence and death, toxic nodules responsible for hyperthyroidism or compressive nodules warranting treatment. The diagnosis and treatment of thyroid nodules requires close collaboration between endocrinologists, nuclear medicine physicians and surgeons, but also involves other specialists. Therefore, this consensus statement was established jointly by 3 societies: the French Society of Endocrinology (SFE), French Association of Endocrine Surgery (AFCE) and French Society of Nuclear Medicine (SFMN); the various working groups included experts from other specialties (pathologists, radiologists, pediatricians, biologists, etc.). This section deals with the initial work-up for thyroid nodules in adult patients, including clinical and biological evaluation, standardized ultrasound characterization and EU-TIRADS-based nodule selection for fine-needle aspiration biopsy. Indications for thyroid core-biopsies or open surgical biopsies and for cross-sectional imaging of the neck and upper chest are also mentioned.

The Italian Consensus for the Classification and Reporting of Thyroid Cytology: Cytohistologic and molecular correlations on 37,371 nodules from a single institution

BACKGROUND

The Italian Consensus for the Classification and Reporting of Thyroid Cytology (ICCRTC) includes six diagnostic categories (TIR 1/1C, TIR 2, TIR 3A, TIR 3B, TIR 4, and TIR 5), each indicating a different risk of malignancy. The objective of this monocentric retrospective study was to evaluate the distribution of the ICCRTC classes at the authors' institution and assess their cytohistologic correlations.

METHODS

The authors retrospectively collected 37,371 consecutive cytologic reports of thyroid nodules and described the clinical-pathologic features of the different cytologic categories. The cytologic diagnoses also were compared with histologic outcomes in a subset of patients.

RESULTS

The cytologic classes were distributed as follows: nondiagnostic, 15.6%; benign, 66.5%; low-risk indeterminate, 10% (TIR 3A); high-risk indeterminate, 3.5% (TIR 3B); suspicious, 1.7%; and malignant, 2.6%. According to histology, the risk of malignancy was very high in the nondiagnostic category (29.8%), with young male patients more exposed to malignancy, and it was relatively high among benign (7.8%) and indeterminate nodules (32.5% in TIR 3A; 52.1% in TIR 3B), mainly because of the high prevalence of follicular architecture in malignant tumors. On histology, the malignancy rates were 92.4% and 99.3% for the suspicious and malignant categories, respectively; aggressive variants of papillary thyroid carcinoma were mostly diagnosed in these categories.

CONCLUSIONS

In this series, nondiagnostic nodules showed high prevalence and, surprisingly, high malignancy rates. Malignant tumors with follicular architecture represented a diagnostic pitfall in benign and indeterminate nodules. The suspicious and malignant categories had high specificity for malignancy. Importantly, the ICCRTC had high reliability for identifying preoperatively aggressive histotypes of thyroid carcinoma.

Prevalence of Thyroid Nodules and Thyroid Cancer in Individuals with a First-Degree Family History of Non-Medullary Thyroid Cancer: A Cross-Sectional Study Based on Sonographic Screening

Background: The actual rates of suspicious thyroid nodules (TNs) and confirmed thyroid cancer (TC) in putatively "at-risk" selected populations (e.g., individuals with family history of TC) are still uncertain. Methods: Our aim was to explore the prevalence of TC and TN in a cross-sectional study of a consenting population of unaffected individuals (10 years of age or older) with a first-degree relative known to have non-medullary TC (NMTC). Enrolled subjects underwent ultrasonographic studies of the neck between 2009 and 2018. Nodules considered suspicious according to current guidelines were subjected to fine-needle aspiration biopsy (FNAB) for cytology. Results: The screenee population comprised 1176 individuals (median age 42 [26-56] years, 650 females, 55.3%) from 473 kindreds (346 with 1 established NMTC diagnosis at entry, 103 with 2 established NMTC diagnoses, and 24 with 3 or more established NMTC diagnoses at entry). Screening revealed TNs in 500 screenees (42.5%; confidence interval [CI] 39.7-45.4%). Ninety-seven of these (19.4%; CI 16.2-23.1%) underwent FNAB. Only 11 cases of TC were diagnosed in the whole population (0.9%; CI 0.5-1.7%). The prevalence of TC in screenees from kindreds with ≥3 cases (3/24, 12.5%) was higher than that for kindreds with one affected member (6/346, 1.7%; p = 0.01, odds ratio [OR] 7.99; CI 1.21-40.75) and for those with two affected members (2/103, 1.9%; p = 0.05, OR 7.05; CI 0.76-89.44). The prevalence of TNs was 61.8% (CI 56.6-66.8%), 75.7% (CI 66.6-83%), and 66.7% (CI 46.7-82%) in the kindreds with 1, 2, and ≥3 cases, respectively (p = 0.03). Conclusions: On the whole, ultrasound-based screening of unaffected relatives of individuals with established diagnoses of NMTC is likely to reveal a high prevalence of TN and a low prevalence of TC. However, a significantly higher prevalence of TC may be found among screenees from kindreds with at least three established NMTC diagnoses before screening, suggesting that closer surveillance may be warranted in kindreds with this level of familiality.

Malignancy rates in thyroid nodules: a long-term cohort study of 17,592 patients

Objectives

Ultrasound diagnosis of thyroid nodules has greatly increased their detection rate. Their risk for malignancy is estimated between 7 and 15% in data from specialized centers which are used for guidelines recommendations. This high rate causes considerable anxiety to patients upon first diagnosis. Here, we retrospectively analyzed the malignancy rate of sonographically diagnosed nodules larger than 1 cm from a primary/secondary care center when long-term longitudinal follow-up was included.

Patients/methods

In the study, 17,592 patients were diagnosed with a thyroid nodule larger than 1 cm, of whom 7776 were assessed by fine-needle aspiration cytology (FNAC) and 9816 by sonography alone. 9568 patients were initially discharged due to innocent results of FNAC and/or ultrasound. In 1904 patients, definitive histology was obtained, and 6731 cases were included in the long-term follow-up (up to 23 years, median 5 years).

Results

Malignancy was histologically confirmed in 189 patients (1.1% of all) when excluding accidentally diagnosed papillary microcarcinomas. 155 were diagnosed during the first year of management, 25 in years 2-5 of follow-up, 9 in years 6-10 and nil in 1165 patients followed beyond 10 years.

Conclusions

The malignancy rate of thyroid nodules from primary/secondary care was much lower than that previously reported. During follow-up for more than 5 years, their rate rapidly dropped to less than 1/1000 cases. This low malignancy rate may help to reassure patients first confronted with the diagnosis of a thyroid nodule, substantially reduce their anxiety and avoid unwarranted diagnostic and therapeutic procedures.

SuperSonic shear imaging for the differentiation between benign and malignant thyroid nodules: a meta-analysis

PURPOSE

To assess the diagnostic value of SuperSonic shear imaging (SSI) for the differentiation between benign and malignant thyroid nodules through meta-analysis.

METHODS

Online database searches were performed on PubMed, EMBASE, the Cochrane Library, and the Web of Science until 31 July 2021. The Quality Assessment of Diagnostic Accuracy Studies-2 tool was used to assess the quality of the included studies. Three measures of diagnostic test performance were used to examine the value of SSI, including the summary area under the receiver operating characteristic curve (AUROC), the summary diagnostic odds ratio (DOR), and the summary sensitivity and specificity. Heterogeneity was explored using meta-regression and subgroup analyses.

RESULTS

Finally, 21 studies with 3376 patients were included in this study. There were a total of 4296 thyroid nodules, in which 1806 malignant nodules and 2490 benign ones were involved. Thyroid nodules exhibited a malignancy rate of 42.0% (range 5.6-79.8%), 95.1% of which were of papillary variant. SSI showed a summary sensitivity of 74% [95% confidence interval (CI) 67-79%], specificity of 82% (95% CI 77-87%) and AUROC of 0.85 (95% CI 0.82-0.88) for the differentiation between benign and malignant thyroid nodules. The summary positive likelihood ratio (LR), negative LR, and DOR were 4.2 (95% CI 3.3-5.3), 0.32 (95% CI 0.26-0.40), and 13 (95% CI 9-18), respectively.

CONCLUSIONS

SSI showed high accuracy in the diagnostic differentiation between benign and malignant thyroid nodules and can be served as a noninvasive and important adjunct for thyroid nodule evaluation.

Diagnosis of thyroid nodules

Thyroid nodules are common, usually asymptomatic, and often pose minimal risk to the affected patient. However, 10-15% prove malignant and serve as the rationale for diagnostic assessment. Safely identifying and treating a relevant thyroid cancer through a cost-effective process is the primary goal of the treating practitioner. Ultrasound is the principal means of initial nodule assessment and should be performed when any thyroid nodule is suspected. Fine-needle aspiration provides further cytological determination of benign or malignant disease and is generally applied to nodules larger than 1-2 cm in diameter, on the basis of holistic risk assessment. The Bethesda System for Reporting Thyroid Cytopathology provides standardised terminology, which enhances communication among health-care providers and patients. Benign cytology is highly accurate, whereas indeterminate cytology could benefit from further application of molecular testing. The ultimate goal of diagnostic assessment of thyroid nodules is to accurately identify malignancy while avoiding overtreatment. Low-risk thyroid nodules can be safely monitored in many patients with minimal diagnostic intervention.

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.

The Future of Thyroid Nodule Risk Stratification

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

Clinical experience following implementation of routine SPECT-CT imaging following 131-iodine administration for thyroid cancer

Background

Planar scintigraphy has long been indicated in patients receiving I-131 therapy for thyroid cancer to determine the anatomic location of metastases. We studied our experience upon implementing additional single-photon emission (SPECT)-CT scanning in these patients.

Method

We performed a retrospective study of consecutive adult patients with newly diagnosed thyroid cancer treated with I-131 between 2011 and 2017. Radiologic findings detected with planar scintigraphy alone vs those identified with SPECT-CT scanning were primary endpoints.

Result

In this study, 212 consecutive patients with thyroid cancer were analyzed in two separate cohorts (107 planar scintigraphy alone and 105 planar scintigraphy with SPECT-CT). The addition of SPECT-CT resulted in more findings, both thyroid-related and incidental. However, we identified only 3 of 21 cases in which SPECT-CT provided an unequivocal additional benefit by changing clinical management beyond planar scintigraphy alone. No difference in the detection of distant metastatic disease or outcome was identified between cohorts.

Conclusion

Synergistic SPECT-CT imaging in addition to planar nuclear scintigraphy adds limited clinical value to thyroid cancer patients harboring a low risk of distant metastases, while frequently identifying clinically insignificant findings. These data from a typical cohort of patients receiving standard thyroid cancer care provide insight into the routine use of SPECT-CT in such patients.

Point of Care Measurement of Body Mass Index and Thyroid Nodule Malignancy Risk Assessment

BACKGROUND

Large scale epidemiology studies have suggested obesity may increase the risk of thyroid cancer, though no prospective analyses using real-world measurement of BMI at a time proximate to initial thyroid nodule evaluation have been performed.

METHODS

We performed a prospective, cohort analysis over 3 years of consecutive patients presenting for thyroid nodule evaluation. We measured BMI proximate to the time of initial evaluation and correlated this with the final diagnosis of benign or malignant disease. We further correlated patient BMI with aggressivity of thyroid cancer, if detected.

RESULTS

Among 1,259 consecutive patients with clinically relevant nodules, 199(15%) were malignant. BMI averaged 28.6 kg/m² (SD: 6.35, range:16.46-59.26). There was no correlation between the measurement of BMI and risk of thyroid cancer (p=0.58) as mean BMI was 28.9 kg/m² and 28.6 kg/m² in cancerous and benign cohorts, respectively. Similarly, BMI did not predict aggressive thyroid cancer (p=0.15). While overall nodule size was associated with increased BMI (p<0.01), these data require further validation as obesity may hinder nodule detection until large.

CONCLUSION

In contrast to findings published from large scale association studies drawn from national databases, these prospective data of consecutive patients presenting for nodule evaluation detect no association of obesity (as measured by BMI) with thyroid cancer. Real time measurement of BMI at the time of thyroid nodule evaluation does not contribute to cancer risk assessment.

The New Era of TIRADSs to Stratify the Risk of Malignancy of Thyroid Nodules: Strengths, Weaknesses and Pitfalls

Simple Summary

The aim of this review is to provide the reader with a comprehensive overview of thyroid imaging and reporting data systems used for thyroid nodules, so as to understand how nodules are scored with all existing systems. Both ultrasound based risk stratification systems and indications for fine-needle aspirations are described. Systems are compared by analyzing their strengths and weaknesses. Studies show satisfactory sensitivities and specificities for the diagnosis of malignancy for all systems, and none of them have shown a real significant advantage over the others in terms of raw diagnostic value. Interobserver agreement is also very similar for all systems, fairly adequate to robust. Dimensional cut-offs for fine-needle aspiration are quite similar and all RSSs seem to reduce effectively the number of unnecessary FNAs. Merging all existing systems in a common international one is desirable.

Abstract

Since 2009, thyroid imaging reporting and data systems (TI-RADS) have been playing an increasing role in the field of thyroid nodules (TN) imaging. Their common aims are to provide sonologists of varied medical specialties and clinicians with an ultrasound (US) based malignancy risk stratification score and to guide decision making of fine-needle aspiration (FNA). Schematically, all TI-RADSs scores can be classified as either pattern-based or point-based approaches. The main strengths of these systems are their ability (i) to homogenize US TN descriptions among operators, (ii) to facilitate and shorten communication on the malignancy risk of TN between sonologists and clinicians, (iii) to provide quantitative ranges of malignancy risk assessment with high sensitivity and negative predictive values, and (iv) to reduce the number of unnecessary FNAs. Their weaknesses are (i) the remaining inter-observer discrepancies and (ii) their insufficient sensitivity for the diagnosis of follicular cancers and follicular variant of papillary cancers. Most common pitfalls are degenerating shrinking nodules and confusion between individual and coalescent nodules. The benefits of all TI-RADSs far outweigh their shortcomings, explaining their rising use, but the necessity to improve and merge the different existing systems remains.

Relationship between TSHR, BRAF and PIK3CA gene copy number variations and thyroid nodules

PURPOSE

This study aims to investigate the relationship between the TSHR, BRAF, and PIK3CA gene copy number variations (CNVs) and thyroid nodules by analyzing gene CNVs, and to explore the interaction between iodine status and the above genes CNVs in the occurrence of thyroid nodules.

METHODS

Three hundred and ninety-five subjects were selected from 3 regions with different iodine status in Shanxi Province of China, including 192 patients with thyroid nodules and 203 healthy controls. The basic information about subjects had been obtained through a questionnaire. B ultrasound was utilized to check thyroid nodules. Blood and urine samples were harvested to detect the thyroid function and urinary iodine concentration. Real-time quantitative polymerase chains reaction (RT-PCR) served to detect CNVs in DNA from human blood.

RESULTS

There was an association between TSHR gene CNV and thyroid nodules (χ² = 8.403, P = 0.004). The prevalence of BRAF and PIK3CA gene CNVs was not statistically significant between the case group and the control group. Differences in the TSHR gene CNV rates for cases of the 3 areas were statistically significant (χ² = 10.072, P = 0.007). No statistical difference in the prevalence rates of the 3 genes CNVs between diverse characteristics of thyroid nodules was observed. UIC > 300 μg/L (OR = 1.74, 95% CI: 1.02-2.96, P = 0.041) and TSHR gene CNV (OR = 3.53, 95% CI: 1.40-8.92, P = 0.008) were risk factors for thyroid nodules. There was no significant interaction between the UIC and the examined genes CNVs.

CONCLUSIONS

TSHR gene CNV and high urinary iodine levels can increase the risk of thyroid nodules. But the interactions between the 3 above genes CNVs and iodine nutrition were not found in the occurrence of thyroid nodules.

Radiologic Evaluation of the Head and Neck Cancer Patient

CT, PET, ultrasound, and MRI examinations all have roles in the staging and surveillance of cancers in the head and neck. Contrast-enhanced CT is generally the primary examination because of availability, cost, reproducibility, and good overall quality regardless of where performed. PET, ultrasound, and MRI have more specific and nuanced applications. Good interdisciplinary interactions with radiologist consultation can streamline the examination process and reduce the examination burden on patients by limiting the number and maximizing the quality of the examinations and image-guided interventions performed.

American Association of Clinical Endocrinology And Associazione Medici Endocrinologi Thyroid Nodule Algorithmic Tool

OBJECTIVE

The first edition of the American Association of Clinical Endocrinology/American College of Endocrinology/Associazione Medici Endocrinologi Guidelines for the Diagnosis and Management of Thyroid Nodules was published in 2006 and updated in 2010 and 2016. The American Association of Clinical Endocrinology/American College of Endocrinology/Associazione Medici Endocrinologi multidisciplinary thyroid nodules task force was charged with developing a novel interactive electronic algorithmic tool to evaluate thyroid nodules.

METHODS

The Thyroid Nodule App (termed TNAPP) was based on the updated 2016 clinical practice guideline recommendations while incorporating recent scientific evidence and avoiding unnecessary diagnostic procedures and surgical overtreatment. This manuscript describes the algorithmic tool development, its data requirements, and its basis for decision making. It provides links to the web-based algorithmic tool and a tutorial.

RESULTS

TNAPP and TI-RADS were cross-checked on 95 thyroid nodules with histology-proven diagnoses.

CONCLUSION

TNAPP is a novel interactive web-based tool that uses clinical, imaging, cytologic, and molecular marker data to guide clinical decision making to evaluate and manage thyroid nodules. It may be used as a heuristic tool for evaluating and managing patients with thyroid nodules. It can be adapted to create registries for solo practices, large multispecialty delivery systems, regional and national databases, and research consortiums. Prospective studies are underway to validate TNAPP to determine how it compares with other ultrasound-based classification systems and whether it can improve the care of patients with clinically significant thyroid nodules while reducing the substantial burden incurred by those who do not benefit from further evaluation and treatment.

Agreement Between Ti-RADS Classification and Bethesda Cytopathological Findings from Thyroid Nodules in Young Adults

INTRODUCTION

Thyroid nodules are common in young adults. We sought to compare the sonographic characteristics (thyroid imaging reporting and data system [Ti-RADS] classification) with the reported cytological results (Bethesda categories) from thyroid nodules in young recruits and examine the efficiency of our unique multidisciplinary clinic.

MATERIALS AND METHODS

In this retrospective cohort, we identified young recruits (18-25 years) who underwent needle biopsies for asymptomatic thyroid nodule(s), with cytology reports of Bethesda categories II-V, performed in our "Rapid Diagnostic Service" at a large Israeli Defense Forces Medical Corps healthcare facility, between 2013 and 2018. We studied the concordance rates between their Ti-RADS and Bethesda grades, and the preoperative Bethesda grades accuracy versus final pathology results, and the time period needed for their thyroid nodules workup.

RESULTS

A total of 81 patients were included who contributed 91 nodules. A fair agreement was found between the Ti-RADS classifications and the Bethesda grades (Cohen's κ = 0.238) that was more noticeable in males than in females. The agreement rate was 87.5% in males (21 of 24), but only 77.6% in females (59 of 67) [P = .029]. Of the 5 operated benign cases, all had low Ti-RADS, and 2 had low Bethesda. Of the 8 operated malignant cases, 6 had high Ti-RADS, and 5 had high Bethesda. On average, 37.64 days elapsed between the first visit to the ultrasound study, and 24.2 days elapsed until biopsy was performed.

CONCLUSIONS

Despite an overall fair agreement between the sonographic features and cytological findings in young adults, we recommend a more aggressive approach and repeated biopsies despite reported benign pathology, because of a high false-negative rate.

The gray zone of thyroid nodules: Using a nomogram to provide malignancy risk assessment and guide patient management

Background

Thyroid nodules have a low prevalence of malignancy and most proven cancers do not behave aggressively. Thus, risk‐stratification of nodules is a critical step to avoid surgical overtreatment. We hypothesized that a risk management system superior to those currently in use could be created to reduce the number of clinically indeterminate nodules (i.e., the “gray zone”) by concurrently considering the malignancy risks conferred by clinical, ultrasonographic, and cytologic variables.

Methods

Thyroidectomy cases were reviewed from three institutions. Their benign versus malignant outcome was used to evaluate the variables for correlation. A binary logistic regression model was trained and, using indeterminate nodules with Bethesda III and IV results, validated. A scoring nomogram was designed to demonstrate the application of the model in clinical practice.

Results

One hundred thirty thyroidectomies (28% malignant) met inclusion criteria. The final logistic regression model included difficulty in swallowing, hypothyroidism, echogenicity, hypervascularity, margins, calcification, and cytology diagnosis as input parameters. The model was highly successful in determining the outcome (p value: 0.001) with a R²(Nagelkerke) score of 0.93. The area under the curve as determined by receiver operating characteristics was 0.91. The accuracy of the model on the training dataset was 93% (sensitivity and specificity 92% and 96%, respectively) and, on the validation dataset, 80% (sensitivity and specificity 91% and 67%, respectively).

Conclusions

We report a model for risk assessment of thyroid nodules that has the potential to significantly reduce indeterminates and surgical overtreatment. We illustrate its application via a straightforward nomogram, which integrates clinical, ultrasonographic, and cytologic data, and can be used to create clear, evidence‐based management plans for patients.

Clinical, Pathological, and Molecular Characteristics Correlating to the Occurrence of Radioiodine Refractory Differentiated Thyroid Carcinoma: A Systematic Review and Meta-Analysis

Background: Recently, radioiodine refractory differentiated thyroid cancer (RR-DTC) has received increasing attention due to its poor prognosis. The roles of clinical, pathological, and molecular features in the development of RR-DTC remain controversial and require additional investigation. This study aimed to evaluate the association between these risk factors and the occurrence of RR-DTC.

Methods: We performed a systematic search for relevant literature following the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) in PubMed, EMBASE, Medline, SCOPUS, and Web of Science up to the July 15, 2020. Observational studies that investigated the risk factors for RR-DTC were included. Fixed- or random-effects models were used to calculate pooled odds ratios (ORs) or mean differences (MD) with corresponding 95% confidence intervals.

Results: We included 13 eligible studies incorporating 1,431 cases, of which 603 were patients with RR-DTC. The pooled analysis indicated that four parameters significantly increased the risk of RR-DTC: extrathyroidal extension (ETE) (OR: 2.28, 95% CI: 1.43–3.64, I² = 14%), BRAF^V600E mutation (OR: 3.60, 95% CI: 1.74–7.46, I² = 69%), TERT promoter mutation (OR: 9.84, 95% CI: 3.60–26.89, I² = 61%) and high-risk histological subtype (OR: 1.94, 95% CI: 1.15–3.27, I² = 15%), including tall cell variant papillary thyroid carcinoma (PTC), sclerosing diffuse PTC, hobnail variant PTC, follicular thyroid carcinoma (FTC) (including Hürthle cell), and poorly differentiated thyroid carcinoma (PDTC). However, there was no statistical significance regarding sex, age, tumor size, multifocality, or lateral lymph node metastasis. Subgroup and sensitivity analyses were conducted to further confirm the robustness of the results.

Conclusions: Histological subtype, ETE, BRAF^V600E mutation, and TERT promoter mutation could be considered clinicopathological factors and biomarkers. They could assist in risk stratification, prognostic prediction, and individual therapy options for RR-DTC.

Thyroid Incidentalomas: Practice Considerations for Radiologists in the Age of Incidental Findings

Radiologists very frequently encounter incidental findings related to the thyroid gland. Given increases in imaging use over the past several decades, thyroid incidentalomas are increasingly encountered in clinical practice, and it is important for radiologists to be aware of recent developments with respect to workup and diagnosis of incidental thyroid abnormalities. Recent reporting and management guidelines, such as those from the American College of Radiology and American Thyroid Association, are reviewed along with applicable evidence in the literature. Trending topics, such as artificial intelligence approaches to guide thyroid incidentaloma workup, are also discussed.

[Detection rate of thyroid nodules in routine health check-up and its influencing factors: a 10-year survey of 309 576 cases]

OBJECTIVE

To analyze the detection rate of thyroid nodules and its influencing factors among individuals undergoing routine health check-up in Guangdong Province.

METHODS

We analyzed the results of thyroid ultrasonography of 309 576 individuals receiving routine health check-up in a general hospital in Guangdong Province over the past 10 years. The data were compared between the individuals with and without thyroid nodules using two independent samples t test, MannWhitney U test and Chi-square test. Binary logistic regression was used to analyze the relationship between different factors and thyroid nodules, and the odds ratio (OR) and 95% confidence interval (95% CI) were calculated.

RESULTS

Based on the structured and standardized data, the total detection rate of thyroid nodules was 9.68% among the individuals, 7.71% in male and 13.51% in female subjects, showing a significant gender difference (χ²=2677.08, P < 0.001). In the overall population, the detection rates of thyroid nodules gradually increased with age, but in each age group, the detection rate remained significantly higher in female subjects than in male subjects (P < 0.001). The subjects with thyroid nodules showed a significant higher percentage of male gender, an older age, a greater BMI, and significantly higher SBP, DBP, FBG, TC, LDL-C, HDL-C, TG as well as higher detection rates of fatty liver, hyperlipidemia, hyperglycemia, and metabolic syndrome than those without thyroid nodules (all P < 0.001). Binary logistic regression analysis showed that thyroid nodules were significantly associated with gender (OR=0.455, 95%CI: 0.443-0.468), age (45-59 years: OR=1.660, 95%CI: 1.613-1.710; ≥ 60 years: OR=3.329, 95%CI: 3.202- 3.462), BMI (underweight: OR=0.808, 95%CI: 0.755-0.864; overweight: OR=1.074, 95%CI: 1.038-1.112; obesity: OR=1.281, 95%CI: 1.221-1.343), hyperlipidemia (OR=1.053, 95%CI:1.022-1.085), high blood glucose (OR=1.177, 95%CI: 1.105-1.252), and metabolic syndrome (OR=1.111, 95%CI: 1.071-1.152).

CONCLUSIONS

The detection rate of thyroid nodule is much higher in female than in male individuals in Guangdong Province and is significantly associated with gender, age, BMI and metabolic related diseases. Male gender and underweight might be protective factors for thyroid nodules, while an advanced age, overweight/obesity, hyperlipidemia, high blood glucose and metabolic syndrome are associated with an increased risk of thyroid nodules. Thyroid ultrasound examination is recommended in routine health check-up for early detection and treatment of thyroid diseases.

Differential Diagnosis of Benign and Malignant Thyroid Nodules Using Deep Learning Radiomics of Thyroid Ultrasound Images

PURPOSE

We aimed to propose a highly automatic and objective model named deep learning Radiomics of thyroid (DLRT) for the differential diagnosis of benign and malignant thyroid nodules from ultrasound (US) images.

METHODS

We retrospectively enrolled and finally include US images and fine-needle aspiration biopsies from 1734 patients with 1750 thyroid nodules. A basic convolutional neural network (CNN) model, a transfer learning (TL) model, and a newly designed model named deep learning Radiomics of thyroid (DLRT) were used for the investigation. Their diagnostic accuracy was further compared with human observers (one senior and one junior US radiologist). Moreover, the robustness of DLRT over different US instruments was also validated. Analysis of receiver operating characteristic (ROC) curves were performed to calculate optimal area under it (AUC) for benign and malignant nodules. One observer helped to delineate the nodules.

RESULTS

AUCs of DLRT were 0.96 (95% confidence interval [CI]: 0.94-0.98), 0.95 (95% confidence interval [CI]: 0.93-0.97) and 0.97 (95% confidence interval [CI]: 0.95-0.99) in the training, internal and external validation cohort, respectively, which were significantly better than other deep learning models (P < 0.01) and human observers (P < 0.001). No significant difference was found when applying DLRT on thyroid US images acquired from different US instruments.

CONCLUSIONS

DLRT shows the best overall performance comparing with other deep learning models and human observers. It holds great promise for improving the differential diagnosis of benign and malignant thyroid nodules.

Online Transfer Learning for Differential Diagnosis of Benign and Malignant Thyroid Nodules With Ultrasound Images

OBJECTIVE

We aimed to propose a highly automatic and objective model named online transfer learning (OTL) for the differential diagnosis of benign and malignant thyroid nodules from ultrasound (US) images.

METHODS

The OTL mothed combined the strategy of transfer learning and online learning. Two datasets (1750 thyroid nodules with 1078 benign and 672 malignant nodules, and 3852 thyroid nodules with 3213 benign and 639 malignant nodules) were collected to develop the model. The diagnostic accuracy was also compared with VGG-16 based transfer learning model and different input images based model. Analysis of receiver operating characteristic (ROC) curves were performed to calculate optimal area under it (AUC) for benign and malignant nodules.

RESULTS

AUC, sensitivity and specificity of OTL were 0.98 (95% confidence interval [CI]: 0.97-0.99), 98.7% (95% confidence interval [CI]: 97.8%-99.6%) and 98.8% (95% confidence interval [CI]: 97.9%-99.7%) in the final online learning step, which was significantly better than other deep learning models (P < 0.01).

CONCLUSION

OTL model shows the best overall performance comparing with other deep learning models. The model holds a good potential for improving the overall diagnostic efficacy in thyroid nodule US examinations.

SIGNIFICANCE

The proposed OTL model could be seamlessly integrated into the conventional work-flow of thyroid nodule US examinations.

Nutritional status and follicular-derived thyroid cancer: An update

The incidence of differentiated thyroid cancer has been increasing in the last decades all over the world. Such a steady growth cannot be entirely attributable to more intensive thyroid nodule screening and more sensitive diagnostic procedures. Several environmental factors have changed with sufficient rapidity in the same time frame and may represent credible candidates for this increase. They include modified iodine intake, lifestyle-associated risk factors, exposure to various toxic compounds, pollutants and xenobiotics, nutritional deficiencies, eating habits and comorbidities. Foremost, nutritional patterns have gained high interest as possible promoters and modifiable risk factors for thyroid cancer in recent years. The aim of this narrative review is to focus on the relationship between thyroid cancer and nutritional factors, dietary habits and obesity. Low iodine intake has been associated to increased risk of thyroid cancer, favoring the development of more aggressive histotypes. Moreover, correction of iodine deficiency can shift thyroid cancer subtypes toward less aggressive forms, without affecting the overall risk for cancer. Actually, evidence regarding the association between selenium and vitamin D deficiency and thyroid cancer is very limited, despite their well-known anti-cancer potentials, and the clinical usefulness of their supplementation is still uncertain in this setting. Albeit the relationship between single foods and thyroid cancer is difficult to examine, fish and iodine-rich foods, vegetables, and fruits might exert protective effects on thyroid cancer risk. Conversely, no clear association has been found for other foods to date. Lastly, a clear association between obesity and the risk of thyroid cancer, with more aggressive behavior, seems to emerge from most studies, likely involving variations in thyroid function and chronic inflammation mediated by cytokines, insulin, leptin and adiponectins. Although no definite association between dietary factors and thyroid cancer has been firmly established so far, some nutritional patterns, together with excessive weight, seem to play a relevant role in thyroid cancer carcinogenesis as well as in its severity and aggressiveness. These effects may play an additive role to the well-established one exerted by environmental carcinogens, such as pollutants and radiation exposure.

Thyroid nodules: diagnostic evaluation based on thyroid cancer risk assessment

Thyroid nodules are extremely common and can be detected by sensitive imaging in more than 60% of the general population. They are often identified in patients without symptoms who are undergoing evaluation for other medical complaints. Indiscriminate evaluation of thyroid nodules with thyroid biopsy could cause a harmful epidemic of diagnoses of thyroid cancer, but inadequate selection of thyroid nodules for biopsy can lead to missed diagnoses of clinically relevant thyroid cancer. Recent clinical guidelines advocate a more conservative approach in the evaluation of thyroid nodules based on risk assessment for thyroid cancer, as determined by clinical and ultrasound features to guide the need for biopsy. Moreover, newer evidence suggests that for patients with indeterminate thyroid biopsy results, a combined assessment including the initial ultrasound risk stratification or other ancillary testing (molecular markers, second opinion on thyroid cytology) can further clarify the risk of thyroid cancer and the management strategies. This review summarizes the clinical importance of adequate evaluation of thyroid nodules, focuses on the clinical evidence for diagnostic tests that can clarify the risk of thyroid cancer, and highlights the importance of considering the patient's values and preferences when deciding on management strategies in the setting of uncertainty about the risk of thyroid cancer.