The Bethesda System For Reporting Thyroid Cytopathology

Malignancy Risk of Paediatric Thyroid Nodules Classified According to the Bethesda System

INTRODUCTION

Thyroid nodules are less common in children than in adults; however, when diagnosed, they carry a greater risk of malignancy. The Bethesda System for Reporting Thyroid Cytopathology uses six cytological categories to predict thyroid nodule malignancy using fine-needle aspiration. This study aimed to estimate the malignant potential of thyroid nodules in children using the Bethesda system.

METHODS

We conducted a retrospective study of 121 patients aged ≤ 19 years who underwent thyroid surgery following fine-needle aspiration (FNA) of a suspicious nodule between 2001 and 2019 at two tertiary medical centres. All FNA specimens were evaluated and categorised according to the Bethesda classification system. The prevalence of malignancy for each cytological category was calculated and subsequently compared with the findings of the final pathology.

RESULTS

The mean age at the time of operation was 14.8 years, and 79.5% of the patients were female. The mean nodule size was 24.8 mm. The distribution of nodules across Bethesda cytological categories, from B1 to B6, was as follows: 2, 50, 19, 17, 10, 23 nodules. An analysis of the final pathology reports revealed 66 malignant nodules (54.5%). The malignancy risk was 24% for nodules categorised as B2, 52.6% for nodules categorised as B3, 58.8% for nodules categorised as B4, and 100% each for nodules categorised as B5-B6.

CONCLUSIONS

Our findings indicate that the malignancy rates for all categories of the Bethesda system were higher in paediatric patients than in adults, including a substantial proportion of cytologically benign nodules. Moreover, our observed rates exceeded those previously reported in comparable studies of the paediatric population, as indicated by the American Thyroid Association guidelines. We propose a more intensive approach for paediatric patients with suspected clinical or sonographic features.

Beyond genomics: artificial intelligence-powered diagnostics for indeterminate thyroid nodules-a systematic review and meta-analysis

Introduction

In recent years, artificial intelligence (AI) tools have become widely studied for thyroid ultrasonography (USG) classification. The real-world applicability of these developed tools as pre-operative diagnostic aids is limited due to model overfitting, clinician trust, and a lack of gold standard surgical histology as ground truth class label. The ongoing dilemma within clinical thyroidology is surgical decision making for indeterminate thyroid nodules (ITN). Genomic sequencing classifiers (GSC) have been utilised for this purpose; however, costs and availability preclude universal adoption creating an inequity gap. We conducted this review to analyse the current evidence of AI in ITN diagnosis without the use of GSC.

Methods

English language articles evaluating the diagnostic accuracy of AI for ITNs were identified. A systematic search of PubMed, Google Scholar, and Scopus from inception to 18 February 2025 was performed using comprehensive search strategies incorporating MeSH headings and keywords relating to AI, indeterminate thyroid nodules, and pre-operative diagnosis. This systematic review and meta-analysis was conducted in accordance with methods recommended by the Cochrane Collaboration (PROSPERO ID CRD42023438011).

Results

The search strategy yielded 134 records after the removal of duplicates. A total of 20 models were presented in the seven studies included, five of which were radiological driven, one utilised natural language processing, and one focused on cytology. The pooled meta-analysis incorporated 16 area under the curve (AUC) results derived from 15 models across three studies yielding a combined estimate of 0.82 (95% CI: 0.81-0.84) indicating moderate-to-good classification performance across machine learning (ML) and deep learning (DL) architectures. However, substantial heterogeneity was observed, particularly among DL models (I² = 99.7%, pooled AUC = 0.85, 95% CI: 0.85-0.86). Minimal heterogeneity was observed among ML models (I² = 0.7%), with a pooled AUC of 0.75 (95% CI: 0.70-0.81). Meta-regression analysis performed suggests potential publication bias or systematic differences in model architectures, dataset composition, and validation methodologies.

Conclusion

This review demonstrated the burgeoning potential of AI to be of clinical value in surgical decision making for ITNs; however, study-developed models were unsuitable for clinical implementation based on performance alone at their current states or lacked robust independent external validation. There is substantial capacity for further development in this field.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42023438011.

The additive value of real-time elastography to thyroid ultrasound in detecting papillary carcinoma in nodules over 20 mm in diameter

PURPOSE

Ultrasonography (US) is the most accurate and cost-effective imaging method for identifying thyroid nodules. The difficulty in determining which nodules to sample for fine-needle aspiration (FNA) cytology has prompted the introduction of the Thyroid Imaging Reporting and Data Systems (TIRADS), which assesses the malignancy risk associated with thyroid nodules. Real-time elastography (RTE), coupled with strain ratio (SR) measurements, offers a means to evaluate the nodule stiffness and potentially discern their likelihood of being malignant. The present study aimed to investigate the efficacy of RTE and SR, combined with the TIRADS grading systems, in distinguishing between benign and malignant thyroid nodules.

METHODS

From 1094 patients with thyroid nodules referred for thyroid ultrasound at a University Hospital, those with thyroid nodules ≥20 mm in diameter were enrolled. Each nodule was categorized according to European (EU)- and American College of Radiology (ACR)-TIRADS systems, ranging from 2-5. Nodules' SRs were evaluated together with RTE. The thyroid nodule diagnosis was documented by post-thyroidectomy histopathological examination and/or US-guided FNA according to the Bethesda classification of the examined smears.

RESULTS

The study involved 267 patients (mean age 60.3 ± 14.3 years; 46 males and 221 females) with 308 nodules categorized into EU-TIRADS categories 3, 4, and 5. Of these nodules, 22 proved malignant, and 286 benign. The elastography ratio exhibited high predictive performance in diagnosing thyroid malignancy (p < 0.001) at a threshold value of >0.84 (sensitivity 90.9%, specificity 73.4%). In the 168 nodules with EU-TIRADS 3, this threshold had 100% sensitivity and 75.1% specificity in discriminating malignant thyroid nodules.

CONCLUSION

Combining TIRADS with data derived from RTE reduces unnecessary FNAs and surgeries in patients with thyroid nodular disease.

Toward Optimizing the Impact of Digital Pathology and Augmented Intelligence on Issues of Diagnosis, Grading, Staging, and Classification

The introduction of new diagnostic information in pathology requires effective dissemination and adoption strategies. Although traditional methods like journals, meetings, and atlases have been used, they pose challenges in accessibility, interactivity, and performance validation. Digital pathology (DP) and artificial or augmented intelligence (AI) offer promising solutions to address these limitations. This paper advocates the use of DP and AI tools to facilitate the introduction of new diagnostic information in pathology. It highlights the importance of standardized training and validation sets, digital slide libraries, and AI-enhanced diagnostic tools. Although AI can improve efficiency and accuracy, it is crucial to address potential pitfalls such as over-reliance on AI, bias, and the need for human oversight. By leveraging DP and AI, the efficiency and accuracy of diagnosis, grading, staging, and classification can be augmented, ultimately improving patient care.

Clinical management of indeterminate thyroid nodules needs to be revisited. New evidence for a personalized approach to the problem

PURPOSE

Thyroid nodules diagnosed by fine needle aspiration cytology (FNAC) as TIR3A or Class III subgroup "other types of atypia" (indeterminate thyroid nodules - ITNs), are the only ones without a unique clinical action indicated for management. This leads to multiple FNAC repetitions (FNAC-reps) and lifelong follow-up, with huge consumption of time and resources. The aims of the study were to inquire the usefulness of repeating FNAC in ITNs and perform an evaluation of a long-term follow-up of a large cohort of ITNs.

METHODS

The study was conducted in two Italian high-volume tertiary centres. We selected patients who underwent the first FNAC with subsequent diagnosis of ITN in a centre involved and who then repeated it in the same institute.

RESULTS

We included 506 patients. The FNAC-rep determined the "change in management indications" (CMIs) in 30 cases. The binomial test showed that this proportion was not significant (p 0.36). The factors related to CMIs were age (OR = 0.97; 95%CI = 0.95-0.99; p = 0.04), margins (OR = 5.6; 95%CI = 1.7-18.1; p = 0.004), and echogenicity (hypoechoic vs. isoechoic: OR = 5.2; 95%CI = 1.87-14.5; p = 0.002| hypoechoic vs. iso-anechoic: OR = 5.9; 95%CI = 1.32-26.2; p = 0.02). Follow-up of cases without CMIs showed that 20 of 476 cases required surgery. Of these, only four were malignant and all occurred within the first 8 years of observation.

CONCLUSIONS

The study demonstrated that FNAC-rep is useless for the most of cases, hence it should only be considered for young adults having nodules with suspicious characteristics. Furthermore, a 10-year follow-up for ITNs is safe enough rather than a long-life follow-up.

Serum Thyroid-Stimulating Hormone (sTSH) Levels as a Predictor of Thyroid Malignancy: A Retrospective Analysis of 102 Patients

Introduction Thyroid nodules are common, with a significant proportion presenting with indeterminate cytology on fine-needle aspiration cytology (FNAC). Thyroid-stimulating hormone (TSH) has been proposed as a potential biochemical marker to aid in malignancy risk stratification, though findings across studies remain inconsistent. This study evaluates the association between preoperative serum TSH (sTSH) levels and histopathologically confirmed malignancy in patients undergoing thyroidectomy. Method We conducted a retrospective observational study on 102 patients who underwent total or partial thyroidectomy between 2019 and 2022 at a tertiary care centre. Preoperative sTSH levels, FNAC results, ultrasound characteristics, and final histopathological outcomes were analysed. Statistical analysis included independent t-tests and chi-squared tests to assess associations. Results Of the 102 patients, 18 (17.6%) were diagnosed with malignant lesions, predominantly papillary thyroid carcinoma. The mean sTSH level was slightly higher in malignant cases (1.378 μIU/mL) compared to benign cases (1.350 μIU/mL), but this was not statistically significant (p = 0.68). Histopathological features such as lymphovascular invasion (LVI) and extrathyroidal extension (ETE) were significantly more common in malignant cases (p < 0.01). FNAC had limited predictive accuracy, correctly identifying 61.1% of malignant cases. Conclusion Whilst no significant association was found between sTSH levels and malignancy, features such as LVI, ETE, and certain ultrasound characteristics remain valuable predictors. sTSH may be useful as part of a broader, multimodal risk assessment approach but should not be relied upon as a standalone diagnostic tool.

Cyto-Histomorphological Analysis of Thyroid Lesions and Risk Assessment of Malignancy/Neoplasia: Insights From a North Indian Tertiary Oncology Center

Background Thyroid nodules, whether benign or malignant, are commonly identified as palpable or incidental findings. Accurate diagnosis is critical, with fine-needle aspiration cytology (FNAC) playing a crucial role in distinguishing between benign and malignant lesions. The Bethesda System for Reporting Thyroid Cytopathology (BSRTC) standardizes FNAC reporting and estimates the risk of malignancy (ROM), aiding treatment decisions. This study aims to determine the risk of malignancy for each category of the Bethesda System and to evaluate the sensitivity and specificity of FNAC in diagnosing thyroid swellings. Methodology Clinicopathological data of thyroid FNAC and corresponding thyroid resection cases, collected over four years at the Department of Oncopathology, Mahamana Pandit Madan Mohan Malviya Cancer Centre and Homi Bhabha National Institute, Varanasi, were analyzed. Results A total of 559 patients (372 females, 187 males) with a median age of 49 years were evaluated. Among the BSRTC categories, Category VI (32.4%) and Category II (29.2%) were the most common. ROM for each category was as follows: 50%, 25%, 30%, 85.71%, 97%, and 100%, respectively. FNAC demonstrated a sensitivity of 98%, a specificity of 64%, a positive predictive value of 96%, and a negative predictive value of 75%. Concordance between cytopathological and histopathological findings for malignant cases was 69.8%. Papillary thyroid carcinoma was the most common malignancy. Conclusions The ROM for categories I, II, and III was significant, highlighting the importance of the six-tier reporting system. The BSRTC system standardizes reporting and clinical management. Our data, primarily from an oncology center, may vary based on the expertise of the pathologist, laboratory setup, and patient demographics.

Utility of Sydney system for reporting the neck lymphadenopathy underwent real-time ultrasound guided fine-needle aspiration

The Sydney lymphadenopathy cytology system was proposed in 2020, but its validation for neck ultrasound-guided fine-needle aspiration cytology remains to be explored. Patients with lymphadenopathy who underwent ultrasound and cytology were included. The final diagnosis relies on histology and consensus of the multidisciplinary team. Cytology results follow the Sydney system (L1-L5); L3-L5 categories indicate malignancy, and we further calculate sensitivity, specificity, and overall accuracy. From July 2020 to April 2023, a total of 208 patients were included, of which 68 had malignant tumors and 140 were benign cases. According to the Sydney system, the malignancy rates for L2 to L5 are 2%, 89%, 100%, and 98%, respectively. The Sydney system demonstrated 97% sensitivity, 99% specificity, and 99% accuracy in the diagnosis of neck lymphadenopathy. The study shows that the Sydney system is highly effective in reporting neck lymphadenopathy.

Radiofrequency ablation of Bethesda category III thyroid nodules with benign molecular testing: Preliminary findings from a single institution

BACKGROUND

The efficacy of radiofrequency ablation (RFA) in treating thyroid nodules with indeterminate cytology remains less studied. The objective of this study was to determine the efficacy of RFA in treating nodules with Bethesda III that have been molecularly profiled benign (BIII-MPN).

METHODS

We included prospectively enrolled patients who underwent RFA for benign and BIII-MPN thyroid nodules. Primary outcome measures were volume reduction ratio (VRR), symptom score (range 0-10), and cosmetic score (range 0-3) at 1, 3, 6, and 12 months after RFA, as well as complication rates.

RESULTS

A total of 258 nodules in 192 patients were included (benign: 238 in 174; BIII-MPN: 20 in 18). The median VRR differed insignificantly, whereas symptom and cosmetic score improvements were similar between two cohorts. BIII-MPN thyroid nodules were associated with lower rates of infection and temporary voice change.

CONCLUSION

Our preliminary findings suggest that RFA may be a feasible management option for BIII-MPN thyroid nodules. However, appropriate will be important to address the important risk of potentially missed malignancies.

The Routine Collection of "Just-in-Case" Thyroid Aspirates for Molecular Testing at the Time of Initial Fine Needle Aspiration. Our Experience

ABSTRACT

Patients with Bethesda III/IV thyroid nodules may benefit from molecular testing in order to determine the likelihood of malignancy. The goal is to avoid unnecessary surgery for these often-benign nodules. The decision to acquire samples for molecular testing is typically made after formal cytologic interpretation. This creates anxiety and inconvenience for patients who must return for a repeat biopsy. We explored the impact of routinely collecting "just-in-case" samples from each thyroid nodule. Thus, a minimum of 4 samples were acquired from each nodule: 2 for routine cytologic analysis and 2 for possible genomic sequencing. Nodules subsequently determined to be Bethesda III/IV, were further evaluated by sending the prospectively acquired aspirates for genomic sequencing. Over a 7-month period, there were 69 consecutive patients with ages ranging from 24 to 88 years. There were 16 males and 63 females. Six patients had 2 nodules sampled, yielding total of 75 nodules. Of the 75 nodules, 4 (5.3%) were Bethesda I, 37 (49.3%) Bethesda II, 30 (40%) Bethesda III, 0 (0%) Bethesda IV, 1 (1.3%) Bethesda V, and 3 (4%) Bethesda VI. Of the 30 Bethesda III, 18 (60%) were deemed benign (4% risk of malignancy) by genomic testing. Nine (30%) were deemed 50% or 75% suspicious for malignancy. Two (6.7%) yielded insufficient material for analysis and 1 (3.3%) analysis was canceled because of nonpayment. There were no patient complications. Just-in-case samples prevented call-back of 40% of sampled nodules and thus deemed worthwhile and efficient despite adding an estimated 10 minutes to overall procedure time.

Utility of Liquid-Based Cytology and Conventional Smears in Fine Needle Aspirates of Thyroid Lesions: A Comparative Study

Fine needle aspiration (FNA) is an established technique in evaluation of thyroid nodules. Traditionally, conventional smears (CS) are prepared as an accepted method for cytologic interpretation. However, with the advent and success of liquid-based cytology (LBC) in gynecological and non-gynecological specimens, there has been an increased interest in its application in thyroid FNA as well. Studies evaluating LBC in thyroid aspirates have emerged in recent years and have shown variable results. Patients presenting with complaints of a palpable swelling in the thyroid/midline neck area or with a detectable lesion on ultrasound were subjected to FNA. A split sample technique was used to prepare CS and LBC smears. The cytological diagnosis of CS and LBC was compared with each other and with follow up. The performance of both methods was estimated in terms of sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy. The specificity, positive and negative predictive value, and accuracy of LBC were comparable to CS. The sensitivity of LBC was slightly lower than CS. The diagnostic accuracy of LBC was comparable to CS demonstrating its utility in thyroid FNAs. LBC offers the advantages of lesser screening time, decreased obscuration by blood, decreased artefactual changes, and potential for adjunctive immunocytochemistry/molecular testing. However, due to a higher unsatisfactory rate in benign lesions, LBC may be used as a supplement to CS in thyroid FNAs.

Diagnostic Performance of European and American College of Radiology Thyroid Imaging Reporting and Data System Classification Systems in Thyroid Nodules Over 20 mm in Diameter

OBJECTIVE

The challenge of selecting thyroid nodules for fine needle aspiration (FNA) cytology has led to the development of the Thyroid Imaging Reporting and Data System, primarily in 2 formats: European Thyroid Imaging Reporting and Data System (EU-TIRADS) and American College of Radiology Thyroid Imaging Reporting and Data System (ACR-TIRADS). Clinical observations suggest imperfect risk assessment for TIRADS 3 nodules ≥20 mm. This study aimed to evaluate the efficacy of TIRADS systems in distinguishing benign from malignant nodules in this subgroup.

METHODS

From May 2023 to March 2024, 1094 patients with thyroid nodules were referred for ultrasound at a University Hospital. Data on clinical, ultrasound, cytological, and histopathological parameters were collected. Nodules ≥20 mm were categorized by EU-TIRADS and ACR-TIRADS, and their predictive performance for malignancy was assessed through postthyroidectomy histopathology or FNA cytology (Bethesda classification).

RESULTS

Two hundred sixty-seven patients (mean age 60.3 ± 14.3 years; 46 men, 221 women) with 308 nodules were analyzed. Twenty-two malignancies and 286 benign nodules were recorded. Recalculating European Thyroid Imaging Reporting and Data System 3 performance using 25-mm and 30-mm thresholds (ACR-modified EU-TIRADS) avoided 24% and 41% of FNAs, respectively, while ACR-TIRADS would prevent 26.6% (P > .05). Two malignancies were missed.

CONCLUSION

EU-TIRADS and ACR-TIRADS show similar efficacy when using a 25 mm FNA threshold. Raising the cutoff for FNA in European Thyroid Imaging Reporting and Data System 3 nodules could reduce unnecessary procedures but may increase the risk of missed malignancies, impacting patient outcomes.

Nondiagnostic Fine Needle Aspiration of Thyroid Nodules: Review of Predisposing Factors

OBJECTIVE

Fine needle aspiration (FNA) of thyroid nodules is the gold standard screening test for thyroid malignancy. Unfortunately, FNA may produce insufficient material for diagnosis. If nodules requiring FNA with a higher risk for nondiagnostic (ND) cytology could be identified pre-procedure, this might allow better patient guidance and potentially facilitate an altered approach to FNA.

METHODS

The literature investigating risk factors for ND cytology was reviewed, including studies of patient factors, sonographic or nodule factors, and procedural factors. Twenty-five studies that included assessment of at least two potential factors in ND outcomes for initial FNA were identified. Individual factors were evaluated in terms of the general consensus of studies reporting either a positive significant association with ND cytology or no association.

RESULTS

Most patient and nodule factors lack consensus as far as their association with ND cytology across these studies. Factors where there are some consensuses include practitioner experience, depth of nodule, and cystic content; however, hypervascularity of the nodule does not appear to have a consensus.

CONCLUSION

A number of study design improvements suggested by this review could realistically be incorporated into higher powered future studies. Novel factors such as tissue composition anterior to the nodule or the age of the patient could also be investigated in future work. Operator experience is the most convincing procedural factor, and approaches to future studies of the FNA technique itself are proposed. That said, the factors with consensus among studies can be seen leading candidates for this future research, and the published studies illuminate a number of as yet unexplored factors that could in many cases be studied retrospectively.

The Bethesda System for Reporting Thyroid Cytopathology in the African American population: A tertiary centre experience

BACKGROUND

The reported risk of malignancies (ROM) remains controversial for fine needle aspiration (FNA) of thyroid nodules in the African American (AA) population. Herein, the ROM along with frequency was assessed for each of the Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) diagnostic categories.

MATERIALS AND METHODS

The electronic pathology archive of a large academic hospital was retrospectively searched for cytopathology reports of thyroid nodules in AA patients (2010-2019) and Non-African American (NAA) control cases. The patients' demographic, thyroid nodule characteristics, FNA results using TBSRTC and surgical diagnoses were recorded, whenever available.

RESULTS

Three hundred ninety-one cases were identified, 317 females (81.1%) and 74 males (18.9%) with median age 50.0 (SD = 14.4). The mean size of the nodules was 2.1 cm (SD = 1.4). The Bethesda categories were: 5.4% (I), 35.0% (II), 35.3% (III), 7.7% (IV), 3.3% (V) and 13.3% (VI). The overall ROM of thyroid nodules was 43.8% (89/203) on surgical follow-up (203/391). The ROM in each Bethesda categories were: 33.3% (I), 11.6% (II), 35.2% (III), 15.8% (IV), 83.3% (V) and 100% (VI) on surgical follow-up. The frequency of thyroid nodules was higher in AA females; however, the ROM was higher in AA males (48.3%) compared with AA females (41.2%).

CONCLUSION

The ROM in Categories I, II and III was higher than those reported in the TBSRTC while being similar in Categories IV, V and VI. The overall risk of thyroid malignancy in our AA patient population was higher than those in the literature. The overall ROM of thyroid nodules in AA males was higher than of AA females.

Minimally invasive biopsy-based diagnostics in support of precision cancer medicine

Precision cancer medicine (PCM) to support the treatment of solid tumors requires minimally invasive diagnostics. Here, we describe the development of fine-needle aspiration biopsy-based (FNA) molecular cytology which will be increasingly important in diagnostics and adaptive treatment. We provide support for FNA-based molecular cytology having a significant potential to replace core needle biopsy (CNB) as a patient-friendly potent technique for tumor sampling for various tumor types. This is not only because CNB is a more traumatic procedure and may be associated with more complications compared to FNA-based sampling, but also due to the recently developed molecular methods used with FNA. Recent studies show that image-guided FNA in combination with ultrasensitive molecular methods also offers opportunities for characterization of the tumor microenvironment which can aid therapeutic decisions. Here we provide arguments for an increased implementation of molecular FNA-based sampling as a patient-friendly diagnostic method, which may, due to its repeatability, facilitate regular sampling that is needed during different treatment lines, to provide tumor information, supporting treatment decisions, shortening lead times in healthcare, and benefit healthcare economics.

Reappraisal of bone and soft tissue cytopathology classification using the modified Milan system

BACKGROUND

A standardized reporting system for bone and soft tissue tumor cytopathology has not yet been established. The objective of this study was to explore the potential utility of a classification modified from the Milan System for Salivary Gland Cytopathology and compared it with the upcoming World Health Organization (WHO) system for fine-needle aspiration of soft tissue lesions.

METHODS

The authors reviewed 285 cytology cases of bone/joint (n = 173) and soft tissue (n = 112) lesions, scoring each within diagnostic categories. The results were compared with histologic diagnoses and the risk of malignancy (ROM) for each category, and diagnostic reliability was analyzed.

RESULTS

All 285 cases were successfully classified into one of the following categories: nondiagnostic (6.3%), non-neoplastic (11.9%), atypia of uncertain significance (11.9%), benign neoplasm (5.6%), bone and soft tissue neoplasm of uncertain malignant potential (25.3%), suspicious for malignancy (1.4%), and malignant (37.5%). The ROM was 44.4% (eight of /18 cases) in nondiagnostic, 0% (zero of 34 cases) in non-neoplastic, 32.4% (11 of 34 cases) in atypia of uncertain significance, 0% (zero of 16 cases) in benign neoplasm, 16.7% (12 of 72 cases) in bone and soft tissue neoplasm of uncertain malignant potential, 75.0% (three of four cases) in suspicious for malignancy, and 100% (107 of 107 cases) in malignant categories. Using the WHO system, the proportion and ROM of the benign category (non-neoplastic and benign neoplasm) was 17.5% and 0%, respectively. Among benign and malignant lesions, the diagnostic accuracy, sensitivity, and specificity for detecting malignancy were 99.4%, 100%, and 98.0%, respectively.

CONCLUSIONS

The modified Milan system as well as the WHO system may be a useful cytopathologic classification tool for both bone and soft tissue lesions.

Diagnostic sensitivity of fine-needle aspiration cytology in thyroid cancer

Introduction Fine-needle aspiration cytology (FNAC) is an effective tool in the diagnostic work-up of patients with thyroid nodules. The aim of our study was to assess the diagnostic sensitivity of FNAC in thyroid cancer (TC) in Sweden by correlating the findings of preoperative FNAC with those obtained through final histology of the surgical specimen. Methods A Swedish nationwide cohort of patients having surgery for TC (n = 2519) from the Scandinavian Quality Register for Thyroid, Parathyroid and Adrenal surgery between 2004 and 2013 was obtained. Data was validated through scrutinizing patient FNAC and histology reports. Results Among the 2519 cases operated with a final diagnosis of TC, the diagnosis was substantiated and validated through the histology report in 2332 cases (92.6%), included in the present study. Among these, 1679 patients (72%) were female and the median age at TC diagnosis was 52.3 years (range 18-94.6). In 353 cases (15.1%) FNAC was not performed at all; whereas in the remaining 1965 cases, the diagnostic sensitivity of FNAC was 81.6%. In lesions > 1 cm, FNAC diagnostic sensitivity reached 86.5%, whereas in lesions < 1 cm, FNAC yielded a sensitivity of 61.5%. Approximately 85% of FNACs (n = 1981/2332) were performed using ultra-sonographic (US) guidance. In TC lesions > 1 cm, the diagnostic sensitivity of US-guided FNAC (n = 1504) was 86.9% as compared to 76.9% in clinically applied FNAC without US utilization (n = 118). Conclusions FNAC is performed in most patients operated for TC in Sweden (85%) and retains its value as a tool in TC diagnostic work-up with an overall sensitivity of 82%, reaching 87% in lesions > 1 cm, that harbor clinically relevant TC.

Investigation of the alterations in miRNA expression levels in thyroid nodules and malignancies

The relationship between preoperative miR-146b and miR-155 expression levels and postoperative pathology results in patients operated on for nodular thyroid disease and thyroid malignancy was investigated. Sixty three patients who were operated on for thyroid nodules diagnosed as benign, malignant and atypia of undetermined significance (AUS) were included in the study. Preoperative miR-146b and miR-155 expression levels of these patients were compared according to postoperative pathology results. Twenty three of the patients were male (36.5%) and 40 patients were female (63.5%). According to the results of fine needle aspiration biopsy (FNAB) taken from the patients in the preoperative period, The number of benign patients was 26 (41.2%), the number of malignant patients was 17 (26.9%), the number of patients reported as suspicion of malignancy was 10 (15.8%), and the number of AUS patients reported was 10 (15.8%). The postoperative pathology of 58.7% (n = 37) of the patients was benign, and the postoperative pathology of 41.3% (n = 26) was malignant. Compared to the group with benign postoperative pathology results, miR-146b expression level significantly increased by 8.08-fold in the group with malignant postoperative pathology results (p < 0.01). Additionally, miR-146b expression level was significantly upregulated by 3.23-fold in AUS patients compared with benign pathology results (p < 0.01). Although a 1.88-fold increase in miR-155 expression level was detected in malignant patients compared to the benign group, it was determined that the expression level of miR-155 significantly increased by 2.36-fold in AUS patients (p < 0.001). Circulating miRNA could discriminate between patients with benign and malignant nodules. Our results suggest that both miR-146b and miR-155 expression levels increased in the group with malignant postoperative pathology results. Additionally, increased miR-155 expression level could be associated with AUS progression. Therefore, miRNAs could be used as preoperative malignancy biomarkers to determine the characteristics of nodules and the decision to undergo surgery.

Critical Appraisal of the 2017 Bethesda System for Reporting Thyroid Cytopathology with Cytohistological Concordance and Estimation of Risk of Malignancy - An Institutional Study

Aim

Bethesda System for reporting thyroid cytopathology established in 2009 was updated for the first time in 2017. Since its introduction very few studies have been done on the utility of recently introduced "The 2017 Bethesda System for Reporting Thyroid Cytopathology" (TBSRTC II) and estimation of risk of malignancy in various categories.

Material and methods

This was a prospective study done on thyroid lesions in which lesions were evaluated cytologically and classified according to TBSRTC II. Histopathological correlation was done, wherever possible. ROM was calculated for each Bethesda category in both ways as per TBSRTC II i.e. with NIFTP and excluding NIFTP from the malignant category.

Results

Using 2017 TBSRTC, 190 cases of thyroid FNACs were classified into 6 diagnostic categories. Cytohistological correlation was available in 60 cases. ROM was calculated which changed only in category III and V as only these two categories showed one case each of NIFTP. However there was an overestimation of ROM in category II and III as there are selection biases and not all thyroid nodules underwent surgical resections.

Conclusion

To conclude, the risk of malignancy calculated in two ways in the recent 2017 Bethesda system may have higher clinical relevance as those lesions with high ROM are defined for surgical excision. Thus we recommend that "The 2017 Bethesda system for Reporting Thyroid Cytopathology" should be implemented uniformly in our country as it provides a homogenous and standardised terminology resulting in better management of patients with thyroid nodular disease.

Central Neck Dissection in Papillary Thyroid Carcinoma: Benefits and Doubts in the Era of Thyroid Lobectomy

INTRODUCTION

Surgery is still the main line of treatment for papillary thyroid cancer (PTC) with a current trend for de-intensified treatment based on an excellent prognosis. The role of a routine prophylactic central neck dissection (PCND) is still debated as its impact on oncologic outcomes has never been cleared by a randomized clinical trial. In this study, we aimed to report our long-standing experience in PCND and its potential contemporary role in the treatment of PTC.

METHODS

A retrospective institutional review was performed on all patients who underwent operation for PTC including PCND between 1998 and 2021. The primary outcomes were the rate of central lymph node metastases (CLNMs), cancer recurrence and incidence of complications. Survivals were analyzed using the Kaplan-Meier estimator and Cox proportional hazard models.

RESULTS

A total of 657 patients were included in this study with a median follow-up of 78 months (48-114 months). Two hundred and one patients presented occult CLNMs (30.6%). The presence of a pathological node represented the unique reason for a completion thyroidectomy and I131 therapy in 12.5% of the population. Age lower than 55 years, microscopic or macroscopic extra-thyroid extension (ETE) and multifocality were independent factors predicting CLNMs. The rate of recurrence in the whole population was 2.7% (18 patients). Five-year and ten-year disease-free survival (DFS) was 96.5% (94.7-97.7) and 93.3% (90.3-95.5), respectively. Two patients relapsed in the central neck compartment (0.3%). Age (>55 years), pathological staging (pT) and extranodal extension (ENE) were independent factors associated with a worse DFS. The rate of temporary and permanent vocal fold palsy was 12.8% and 1.8%, respectively, and did not depend on the type of surgical procedure performed. Hypoparathyroidism was temporary in 42.2% and permanent in 11.9% of the patients. A sub-analysis upon cT1b-T2 patients treated primarily with thyroid lobectomy and ipsilateral PCND demonstrated a 2.6% rate of permanent hypoparathyroidism.

CONCLUSIONS

PCND allows for a high disease-free survival and a proper selection of patients needing adjuvant treatment, in particular, those treated with a unilateral procedure. On the other hand, bilateral approach is burdened by a not-neglectable rate of permanent hypoparathyroidism.

Fine-Needle Aspiration versus the CytoCore® Motorized Rotating Needle Device for Thyroid Nodule Biopsies: A Retrospective Cohort Study

INTRODUCTION

Recently, an FDA cleared motorized fine-needle aspiration device (CytoCore®, Praxis Medical) has become available which is designed to reduce sample variability by enabling more consistent sampling due to the rotational drilling action of the device in combination with the standard in and out motion used to access the thyroid nodule with a needle. The rotation of the needle permits the ability to collect a higher quantity of intact cellular material, which is optimal for determining adequacy and, ultimately, for making a diagnosis. The present study compares the diagnostic performance of a motorized fine needle aspiration (FNA) device to a historical cohort of patients biopsied using ultrasound-guided fine needle aspiration (US-FNA).

METHODS

Data from 120 patients with thyroid nodules biopsied using a motorized FNA device was retrospectively analyzed. Patient demographics, lesion characteristics, number of passes, Bethesda category, and cellularity scores were compared to a historical control cohort of 100 patients who underwent US-FNA. Nondiagnostic and indeterminate samples rates for motorized FNA were separately compared to literature controls.

RESULTS

A significantly reduced median number of passes were required with motorized FNA compared to US-FNA (1.48 ± 0.62 vs. 2.64 ± 1.63, p < 0.001). Adequate samples were obtained after the first pass for 58% of biopsies with motorized FNA compared to 11% with US-FNA. The cumulative percentage of adequate samples increased to 98% after two passes for motorized FNA versus 58% for the US-FNA group. The mean cellularity score was also significantly greater for motorized FNA (3.42 ± 0.63 vs. 1.9 ± 0.59; p < 0.001). A determinant diagnosis was possible for a greater number of samples in the motorized FNA group compared to the control group (91.6% vs. 78%; p = 0.05). The motorized FNA also had a lower nondiagnostic rate compared to US-FNA (2.0% vs. 10%) and a lower indeterminate rate compared to published rates associated with the use of FNA (8.3% vs. 20.0%; p = 0.05).

CONCLUSION

The motorized FNA device required less passes to obtain an adequate biopsy than US-FNA. Its use is also associated with obtaining samples with a higher cellularity and lower nondiagnostic and indeterminate sample rates.

RAS-Mutant Follicular Thyroid Tumors: A Continuous Challenge for Pathologists

The classification of thyroid nodules, particularly those with a follicular growth pattern, has significantly evolved. These tumors, enriched with RAS or RAS-like mutations, remain challenging for pathologists due to variables such as nuclear atypia, invasion, mitotic activity, and tumor necrosis. This review addresses the histological correlates of benign, low-risk, and malignant RAS-mutant thyroid tumors, as well as some difficult-to-classify follicular nodules with worrisome features. One prototypical RAS-mutant nodule is non-invasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP). The assessment of nuclear characteristics in encapsulated/well-demarcated non-invasive RAS-mutant follicular-patterned tumors helps distinguish between follicular thyroid adenoma (FTA) and NIFTP. Despite this straightforward concept, questions about the degree of nuclear atypia necessary for the diagnosis of NIFTP are common in clinical practice. The nomenclature of follicular nodules lacking clear invasive features with increased mitotic activity, tumor necrosis, and/or high-risk mutations (e.g., TERT promoter or TP53) remains debated. Invasion, particularly angioinvasion, is the current hallmark of malignancy in RAS-mutant follicular-patterned neoplasms, with follicular thyroid carcinoma (FTC) as the model. Assessing the tumor interface is critical, though full capsule evaluation can be challenging. Multiple levels and NRASQ61R-specific immunohistochemistry can aid in identifying invasion. Controversies around vascular invasion persist, with ancillary stains like CD31, ERG, and CD61 aiding in its evaluation. Moreover, the review highlights that invasive encapsulated follicular variant papillary thyroid carcinoma (IEFVPTC) is closely associated with FTC, suggesting the need for better nomenclature. The concept of "high-grade" differentiated carcinomas, applicable to FTC or IEFVPTC with necrosis and/or high mitotic activity, is also discussed.

Prevalence of malignancy in thyroid nodules with AUS cytopathology: A retrospective cross-sectional study

Background

Category III (AUS; Atypia of Undetermined Significance) of The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) was established to describe thyroid nodule features that are neither benign nor cancerous.

Objectives

This study aims to evaluate the rate of thyroid malignancy in patients diagnosed with AUS at the Armed Forces Hospital Southern Region (AFHSR), Saudi Arabia.

Method

The patients (508) diagnosed with AUS in their thyroid nodules underwent fine-needle aspiration cytology (FNAC). Data were collected through a chart-based approach, reviewing patients' medical records and relevant information.

Results

Among the cases, the majority were females (84.6%). Among the different age groups, individuals between 40 and 50 years had the highest prevalence of thyroid nodules (32.5%). Approximately 27% of patients exhibited tumor sizes larger than 4 cm. FNAC results revealed 16.5% benign, 26% AUS, and 22.4% follicular neoplasm cases. Histopathology indicated 54.1% of benign and 37.2% of malignant cases. Papillary carcinoma accounts for 80.4% of all malignant cases. A significant correlation was observed between FNAC and postoperative histopathology (P value < 0.05). Hypoechoic nodules exhibited 33.9% of malignant cases, and calcification was observed in 25% of the cases. A significant association was found between malignancy and echogenicity and between malignancy and calcification (P value = 0.003 and 0.001, respectively).

Conclusion

The findings of this study identify malignancy in thyroid nodules with AUS cytopathology, particularly in the Southern region of Saudi Arabia. The correlation between pre-surgery FNAC and postoperative histopathology supports FNAC's diagnostic value. Additionally, echogenicity and calcification can potentially contribute to predicting nodule malignancy.

Effects of Implementation of European Thyroid Imaging Reporting and Data System Risk Stratification in a Thyroid Cancer Program in Western Sweden: A Retrospective Cohort Study

OBJECTIVE

The European Thyroid Imaging Reporting and Data System (EU-TIRADS) allows for selective fine needle aspiration cytology (FNAC). In 2017, EU-TIRADS was implemented as part of a nationwide standardized care bundle for thyroid cancer in Western Sweden with a population of approximately 1.7 million. The objective of this study was to investigate the clinical value of EU-TIRADS attempting to reduce the number of unnecessary FNACs in referred patients with thyroid nodules.

METHODS

The study cohort consisted of all patients referred to Sahlgrenska University Hospital due to a palpable, newly detected or growing thyroid nodules or a positron emission tomography-positive finding for examination with thyroid ultrasound and selective cytology between 2018 and 2022. Medical records on EU-TIRADS classification, corresponding FNAC results, and histopathologic diagnosis were retrospectively collected. Adherence to the EU-TIRADS guidelines, use of selective FNAC, and rate of malignancy in patients who underwent surgery were assessed.

RESULTS

In total, 1246 thyroid nodules in 990 patients were evaluated. The distributions of EU-TIRADS 2 to 5 (number [percentage]) for all examined nodules were 63 (5%), 462 (37%), 443 (36%), and 278 (22%), respectively. FNAC was omitted in 7% of the investigated patients. FNAC was performed in 124 nodules (10%) despite not fulfilling the EU-TIRADS criteria or absence of positron emission tomography-positive findings. The rate of malignancy was 33% and 1/50 in patients who underwent "unnecessary" FNAC.

CONCLUSION

Implementation of EU-TIRADS in routine management of thyroid nodules led to the selective use of FNAC; however, the clinical impact was limited. This study provides real-world data on the value and magnitude of diagnostic improvement by implementing EU-TIRADS in clinical practice.

Thyroid Nodule Characterization: Overview and State of the Art of Diagnosis with Recent Developments, from Imaging to Molecular Diagnosis and Artificial Intelligence

Ultrasound (US) is the primary tool for evaluating patients with thyroid nodules, and the risk of malignancy assessed is based on US features. These features help determine which patients require fine-needle aspiration (FNA) biopsy. Classification systems for US features have been developed to facilitate efficient interpretation, reporting, and communication of thyroid US findings. These systems have been validated by numerous studies and are reviewed in this article. Additionally, this overview provides a comprehensive description of the clinical and laboratory evaluation of patients with thyroid nodules, various imaging modalities, grayscale US features, color Doppler US, contrast-enhanced US (CEUS), US elastography, FNA biopsy assessment, and the recent introduction of molecular testing. The potential of artificial intelligence in thyroid US is also discussed.

Validating the Modified McGill Thyroid Nodule Score for Assessment of Preoperative Risk of Pediatric Thyroid Malignancy

OBJECTIVE

The McGill Thyroid Nodule Score (MTNS) is a preoperative tool used to predict the risk for well-differentiated thyroid cancer in adults. It was developed by a multidisciplinary team using established evidence-based risk factors for thyroid cancer. The modified McGill Thyroid Nodule Score (mMTNS) was developed to predict malignancy risk in children. A pilot study suggested the mMTNS was able to assess malignancy risk in children with indeterminate cytology on fine needle aspiration (FNA). This study seeks to validate these findings.

METHODS

Retrospective chart review identified subjects who underwent FNA biopsy and subsequent resection. Each patient was assigned a score to compare to final pathology. Statistical analysis was performed with SPSS. All tests were 2-tailed and statistical significance defined p < 0.05. Logistic regression used to determine predictive values of scores.

RESULTS

46 patients ≤21 years of age underwent resection of a thyroid nodule. Female predominance of 85% (n = 39). 78% (n = 36) of patients had palpable nodule. 65% (n = 30) found to have benign pathology and 35% (n = 16) found to have malignancy. Malignant nodules associated with greater mean mMTNS compared to benign [13.63 vs 7.23]. An mMTNS greater >12 had sensitivity of 86.7%, specificity of 90.3%, positive predictive value of 81.3%, and negative predictive value of 93.3%.

CONCLUSION

Our data suggests the mMTNS continues to be a useful adjunct in predicting malignancy risk of pediatric thyroid nodules. An mMTNS >12 has a high risk for malignancy, which can aid in counseling and clinical decision making, particularly when there is indeterminate cytology on FNA.

LEVEL OF EVIDENCE

IV.

Diagnostic values of SurePath liquid-based cytology versus conventional smear in thyroid aspiration samples: A 13-year experience at a single institution

BACKGROUND

Fine needle aspiration cytology (FNAC) is the most useful tool in the diagnosis of thyroid nodules. Liquid-based cytology (LBC) is replacing the conventional smear (CS) for evaluation of thyroid FNAC. In our institution, thyroid FNAC preparation was changed from CS to LBC SurePath in July 2016. This study aimed to compare the diagnostic value of SurePath with that of CS in thyroid lesions.

METHODS

A total of 35,406 samples of thyroid FNAC (11,438 CS and 23,968 SurePath), collected from January 2010 to December 2022, were included in this study. We also examined the malignant rate using the surgical pathology diagnosis as the gold standard.

RESULTS

The distribution of TBSRTC cytological categories was equivalent between CS and SurePath. The rate of nondiagnostic/unsatisfactory category was higher in CS compared to SurePath (43.4% vs. 22.3%; p < .05). After routine use of SurePath, the surgical resection rate was reduced from 12.0% to 8.6% (p < .05) and the malignant rate increased from 32.2% to 41.5% (p < .05). The sensitivities of CS and SurePath were 71.0% and 82.0%, respectively, and the specificities were 99.0% and 97.3%, respectively, whereas the positive predictive values were 97.8% and 96.8%, respectively, and the negative predictive values were 85.0% and 84.6%, respectively. Diagnostic accuracy of CS and SurePath were 88.5% and 89.7% respectively.

CONCLUSION

SurePath can increase the sample adequacy, increase the sensitivity and reduce the workload and avoid unnecessary surgeries with similar accuracy to CS.

Welcoming the new, revisiting the old: a brief glance at cytopathology reporting systems for lung, pancreas, and thyroid

This review addresses new reporting systems for lung and pancreatobiliary cytopathology as well as the most recent edition of The Bethesda Reporting System for Thyroid Cytopathology. The review spans past, present, and future aspects within the context of the intricate interplay between traditional morphological assessments and cutting-edge molecular diagnostics. For lung and pancreas, the authors discuss the evolution of reporting systems, emphasizing the bridge between past directives and more recent collaborative efforts of the International Academy of Cytology and the World Health Organization in shaping universal reporting systems. The review offers a brief overview of the structure of these novel systems, highlighting their strengths and pinpointing areas that require further refinement. For thyroid, the authors primarily focus on the third edition of The Bethesda System for Reporting Thyroid Cytopathology, also considering the two preceding editions. This review serves as an invaluable resource for cytopathologists, offering a panoramic view of the evolving landscape of cytopathology reporting and pointing out the integrative role of the cytopathologist in an era of rapid diagnostic and therapeutic advancements.

Molecular Pathology of Thyroid Tumors: Old Problems and New Concepts

The molecular signatures of many thyroid tumors have been uncovered. These discoveries have translated into clinical practice and are changing diagnostic and tumor classification paradigms. Here, the findings of recent studies are presented with special emphasis on how molecular insights are impacting the understating of RAS mutant thyroid nodules, Hürthel cell neoplasms, and unusual thyroid tumors, such as hyalinizing trabecular tumor, secretory carcinoma of the thyroid, and sclerosing mucoepidermoid carcinoma with eosinophilia. In addition, the utility of detecting actionable molecular alterations by immunohistochemistry in advanced and aggressive thyroid cancer is also discussed.

Cancer rates and characteristics of thyroid nodules with macrocalcification

AIMS

The aim of this study was to determine the malignant potential of thyroid nodules with macrocalcifications and to evaluate the role of other sonographic findings in the diagnosis of malignancy in thyroid nodules besides macrocalcifications.

METHODS

The findings of 8250 patients who applied to our outpatient clinic and underwent thyroid ultrasonography(US) between 2008 and 2021 were retrospectively reviewed. We included a total of 296 patients with 296 macrocalcified nodules (macrocalcification group) and an age- and sex matched group of 300 patients (control group) with the cytopathologic and/or histopathologic data of fine-needle aspiration biopsy (FNAB) of thyroid nodules without calcification. Demographic characteristics of these patients, US characteristics of the nodules, and thyroid function tests were recorded. Cytopathological data of FNAB were classified according to BETHESDA.

RESULTS

The malignancy rate was 14.2% (42/296) in the macrocalcification group and 5.3% (16/300) in the control group (p < 0.001). There was no significant relationship between interrupted peripheral calcification and malignancy. Hypoechoic or markedly hypoechoic appearance, irregular border, solid structure, presence of accompanying pathological lymphadenopathy on sonographic examination and upper and middle zone localization were other sonographic features that increased the risk of malignancy of a nodule. The presence of autoimmunity was not found to be associated with the risk of malignancy. TSH and calcitonin levels of malignant nodules were higher than benign nodules. There was no significant difference between gender and malignancy. In the univariate analysis, it was found that the presence of macrocalcification increased the risk of malignancy 2.935 times. (OR:2.935, p < 0.001.95% CI for OR 1.611-5.349) In addition, being younger, being in the high TIRADS category, and being in the upper and middle zones were factors that increased the risk of malignancy. Gender, TSH level, nodule volume and structure were not associated with malignancy. However, after multivariate analysis, factors that significantly increased the risk of malignancy were younger age, higher TIRADS category, and nodule localization.

CONCLUSION

In our study, the malignancy rate was higher in the macrocalcification group than in the control group. However, no correlation was found after multivariate analysis. In the multivariate analysis, younger age, higher TIRADS category, and nodules located in the upper and middle zone were other factors associated with malignancy. There was no association between peripheral interrupted calcification and malignancy risk.

Consistency in the Distribution of Bethesda System for Reporting Thyroid Cytology Categories Over 9 Years: A Single Institute, Retrospective Study

BACKGROUND

The Bethesda System for Reporting Thyroid Cytopathology (BSRTC) has evolved since it was first introduced in 2009 to become a worldwide accepted cytologic analysis reference, due to its simplicity and reproducibility. To date, the consistency of BSRTC throughout time has yet to be investigated.

METHODS

Retrospective single institution case series with chart review of all patients who underwent fine-needle aspirations for a thyroid nodule in our institution between the years 2010 and 2018 with a documented BSRTC classification. Data collection included demographics, risk factors, sonographic evaluation, nodule size, and final pathology when feasible. The main outcome is the difference in the rates of BSRTC categories benign, atypia of undetermined significance (AUS), follicular neoplasm, suspicious for malignancy, and malignant (BSRTC II-VI, respectively) between the study years.

RESULTS

A total of 2830 thyroid nodules were included. BSRTC II-VI distribution was 83.9% (2373), 8.2%, (232), 2.7% (75), 3.3% (93), and 2.0% (57), respectively. There was no significant change in the overall trend of each BSRTC category distribution throughout the study. There was a significant increase in the benign cytology rate (BSRTC II) in 2011 compared to 2015 and 2018 (76.4% compared to 88.7% and 87.6%, respectively. P < .005) alongside a significant decline in the AUS category rate (BSRTC III) between the same years (13.0% compared to 4.8% and 5.5%, respectively. P < .005).

CONCLUSION

BSRTC showed consistency throughout the study across all observed categories. An overlap between AUS and benign may exist, possibly due to the heterogenic definition of AUS as reflected in the 2023 BSRTC subclassification for AUS.

Identifying potential breath biomarkers for early diagnosis of papillary thyroid cancer based on solid-phase microextraction gas chromatography-high resolution mass spectrometry with metabolomics

INTRODUCTION

Thyroid cancer incidence rate has increased substantially worldwide in recent years. Fine needle aspiration biopsy (FNAB) is currently the golden standard of thyroid cancer diagnosis, which however, is invasive and costly. In contrast, breath analysis is a non-invasive, safe and simple sampling method combined with a promising metabolomics approach, which is suitable for early cancer diagnosis in high volume population.

OBJECTIVES

This study aims to achieve a more comprehensive and definitive exhaled breath metabolism profile in papillary thyroid cancer patients (PTCs).

METHODS

We studied both end-tidal and mixed expiratory breath, solid-phase microextraction gas chromatography coupled with high resolution mass spectrometry (SPME-GC-HRMS) was used to analyze the breath samples. Multivariate combined univariate analysis was applied to identify potential breath biomarkers.

RESULTS

The biomarkers identified in end-tidal and mixed expiratory breath mainly included alkanes, olefins, enols, enones, esters, aromatic compounds, and fluorine and chlorine containing organic compounds. The area under the curve (AUC) values of combined biomarkers were 0.974 (sensitivity: 96.1%, specificity: 90.2%) and 0.909 (sensitivity: 98.0%, specificity: 74.5%), respectively, for the end-tidal and mixed expiratory breath, indicating of reliability of the sampling and analysis method CONCLUSION: This work not only successfully established a standard metabolomic approach for early diagnosis of PTC, but also revealed the necessity of using both the two breath types for comprehensive analysis of the biomarkers.

Validation of the Bethesda System for Reporting Thyroid Cytopathology in a Danish tertiary centre

INTRODUCTION

The Bethesda System for Reporting Thyroid Cytopathology (BSRTC) is used to categorise thyroid fine-needle aspiration (FNA). The aim of this study was to validate the BSRTC in a consecutive cohort and to evaluate the derived management in terms of performing repeat FNA or thyroid surgery.

METHODS

Results of thyroid FNAs assessed at the Department of Pathology, Aarhus University Hospital, in the period 2016-2019 were retrieved from The Danish Pathology Registry. FNA category according to the BSRTC along with the histological diagnosis (if available) were linked to the individual patient.

RESULTS

In total, 3,669 biopsies were included from 2,873 thyroid nodules in 2,547 patients. Repeat FNA was performed in 23.6% of nodules. The majority of primary FNAs were Benign (BSRTC II; 52.4%). Non-diagnostic (ND) (BSRTC I) was found in 26.3% and BSRTC III-VI were found in 3.6-7.5%. Compared with the first with the last FNA, the frequency of Benign (BSRTC II) increased (61.3%), whereas the frequency of ND (BSRTC I) decreased (14.8%). Surgery was performed in 38.2% (n = 1,097) of nodules. The malignancy rate of 11.5% correlated positively with the BSRTC category, being 2.8% in Benign (BSRTC II) and 95.7% in Malignant (BSRTC VI).

CONCLUSIONS

The malignancy rates in the BSRTC categories were in accordance with reports from other countries. Since the BSRTC ensures a standardised and concise communication of cytopathology assessments, application of the BSRTC for thyroid nodule management in a Danish setting is recommended.

FUNDING

None.

TRIAL REGISTRATION

Not relevant.

Molecular Testing for Bethesda III Thyroid Nodules: Trends in Implementation, Cytopathology Call Rates, Surgery Rates, and Malignancy Yield at a Single Institution

Background: Molecular testing (MT) has become standard practice to more accurately rule out malignancy in indeterminate Bethesda III (BIII) thyroid lesions. We sought to assess the adoption of this technology and its impact on cytology reporting, malignancy yield, and rates of surgery across community and academic sites affiliated with a tertiary medical center. Methods: We performed a retrospective cross-sectional study including all fine-needle aspirations (FNAs) analyzed at our institution from 2017 to 2021. We analyzed trends in MT utilization by platform and by community or academic site. We compared BIII call rates, MT utilization rates, rates of subsequent surgery, and malignancy yield on final pathology before and after MT became readily available using chi-square analysis and linear regression. Results: A total of 8960 FNAs were analyzed at our institution from 2017 to 2021. There was broad adoption of MT across both community and academic sites. There was a significant increase in both the BIII rate and the utilization of MT between the pre- and post-MT periods (p < 0.001 and p < 0.001). There was no significant change in the the malignancy yield on final pathology (57.1% vs. 50.0%, p = 0.347), while the positive predictive value of MT decreased from 85% to 50% (p = 0.008 [confidence interval 9.5-52.5% decrease]). Conclusions: The use of MT increased across the institution over the study period, with the largest increase seen after a dedicated pass for MT was routinely collected. This increased availability of MT may have led to an unintended increase in the rates of BIII lesions, MT utilization, and surgery for benign nodules. Physicians who use MT should be aware of potential consequences of its adoption to appropriately counsel patients.

Correlation of TIRADS scoring in thyroid nodules with preoperative fine needle aspiration biopsy and postoperative specimen pathology

INTRODUCTION

The aim of our study is to determine the value of Thyroid Imaging Reporting and Data Systems (TIRADS) scoring in predicting malignancy in thyroid nodules by examining its relationship with fine needle aspiration biopsy and postoperative histopathological results.

MATERIALS AND METHODS

In this study, patients who underwent surgery after ultrasonographic examination and fine needle aspiration biopsy for thyroid nodules at the General Surgery Clinic of Çukurova University Faculty of Medicine between January 2014 and November 2021 were retrospectively analyzed. The thyroid ultrasonography and fine needle aspiration biopsy of the included patients were performed by a clinician with 15 years of experience. The ultrasonographic features of the nodules were re-evaluated by the same clinician, and the American College of Radiology (ACR) TIRADS score was determined. Fine needle aspiration biopsy results were grouped according to Bethesda criteria. Postoperative histopathological examination results were divided into two groups: benign and malignant. The ACR TIRADS score was compared with fine needle aspiration biopsy and histopathological results. The performance of the ACR TIRADS score in predicting malignancy was determined.

RESULTS

79.8% of the 397 patients were female, and the mean age was 50.9 ± 12.8 years. The mean diameter of the nodules was 27.4 ± 15.8 mm. There was a significant, positive, but weak correlation between ACR TIRADS and Bethesda (p < 0.001) (r = 0.33). When the ACR TIRADS score was compared with histopathological results, it was found that the rate of malignancy increased as the TIRADS score increased (p < 0.001). The rates of malignancy diagnosis were 0% for TR1, 13.2% for TR2, 21.7% for TR3, 50.3% for TR4, and 72.4% for TR5. The area under the receiver operating characteristic curve for TIRADS in predicting malignancy was 0.747 (95% CI: 0.699-0.796, p < 0.001). TIRADS can distinguish malignancy with 75% accuracy. The optimal cutoff point was determined as TR4 with 80.3% sensitivity and 60.8% specificity.

CONCLUSION

The ACR TIRADS scoring system is an effective risk classification system for thyroid nodules, providing 75% accuracy in predicting malignancy, with 80.3% sensitivity and 60.8% specificity values.

An old friend, a new insight: Calcitonin measurement in serum and aspiration needle washout fluids significantly increases the early and accurate detection of medullary thyroid cancer

BACKGROUND

The sensitivity of cytological (CY) evaluation after fine-needle aspiration (FNA) for detecting medullary thyroid carcinoma (MTC) is a subject of controversy. The routine use of serum calcitonin (CT) in patients with thyroid nodules is not universally adopted. The authors conducted CT screening of FNA washout fluid (FNA-CT) to address the diagnostic challenges. The objective was to assess the contributions of serum CT, FNA cytology (FNA-CY), and FNA-CT to the diagnosis.

METHODS

Between February 2019 and June 2022 (group 1), the authors prospectively screened the CT of patients with thyroid nodules. Both FNA-CY and FNA-CT were performed for patients with persistently elevated CT values. The sensitivity of FNA-CY, serum CT, and FNA-CT for accurate diagnosis was evaluated. Additionally, the authors retrospectively examined data from patients with thyroid nodules before CT screening (2008-2019) (group 2). They compared the characteristics of MTC patients in groups 1 and 2.

RESULTS

MTC was identified in 30 patients (0.25%) in group 1 and 19 (0.07%) in group 2. A FNA-CT cutoff value of 4085.5 pg/mL detected MTC with a sensitivity of 96.8%, and a serum CT cutoff value of 28.3 pg/mL detected MTC with a sensitivity of 86.7%. In contrast, FNA-CY detected MTC with a sensitivity of 42.4%. In group 1, 18 patients (60%) with MTC were diagnosed with microcarcinoma, whereas only two patients (10.5%) in group 2 had microcarcinoma.

CONCLUSIONS

This study detected MTC earlier by routinely measuring serum CT in all patients with nodular thyroid disease and performing FNA-CT in those with elevated values. FNA-CT and serum CT sensitivities were significantly higher than those of FNA-CY. This study revealed different FNA-CT cutoff values compared to other studies, emphasizing the need for determining clinic-specific cutoff values.

Impact of fine-needle aspiration cytology in thyroidectomy extent and associated surgical morbidity in thyroid cancer

PURPOSE

To assess the impact of fine-needle aspiration cytology (FNAC) in the extent of surgery in patients with thyroid cancer (TC) and the associated surgical morbidity in primary and completion setting.

METHODS

A Swedish nationwide cohort of patients having surgery for TC (n = 2519) from the Scandinavian Quality Register for Thyroid, Parathyroid and Adrenal surgery between 2004 and 2013 was obtained. Data was validated through scrutinizing FNAC and histology reports.

RESULTS

Among the 2519 cases operated for TC, the diagnosis was substantiated and validated through the histology report in 2332 cases (92.6%). Among these, 1679 patients (72%) were female, and the median age at TC diagnosis was 52.3 years (range 18-94.6). Less than total thyroidectomy (LTT) was undertaken in 944 whereas total thyroidectomy (TT) in 1388 cases. The intermediate FNAC categories of atypia of undetermined significance/follicular lesion of undetermined significance (AUS/ FLUS), as well as suspicion for follicular neoplasm (SFN) lesions were more often encountered in LTT (n = 314, 33.3%) than TT (n = 63, 4.6%), whereas FNACs suspicion for malignancy and/or malignancy were overrepresented in TT (n = 963, 69.4%). Completion thyroidectomies were undertaken in 553 patients out of 944 that initially had LTT. In 201 cases with cancer lesions > 1 cm, other than FTC (Follicular TC)/ HTC (Hürthle cell TC) subjected to primary LTT, inadequate procedures were undertaken in 81 due to absent, Bethesda I or II FNAC categories, preoperatively. Complications at completion of surgery in this particular setting were 0.5% for RLN palsy (n = 1) and 1% (n = 2) for hypoparathyroidism 6 months postoperatively. The overall postoperative complication rate was higher in primary TT vs. LTT for RLN palsy (4.8% [n = 67] vs. 2.4% [n = 23]; p = 0.003) and permanent hypoparathyroidism (6.8% [n = 95] vs. 0.8% [n = 8]; p < 0.0001).

CONCLUSIONS

FNAC results appear to affect surgical planning in TC as intermediate FNAC categories lead more often to LTT. Overall, inadequate procedures necessitating completion surgery are encountered in up to 15% of TC patients subjected to LTT due to absent, inconclusive, or misleading FNAC, preoperatively. However, completion of thyroidectomy in this setting did not yield significant surgical morbidity. Primary LTT is a safer primary approach compared to TT in respect of RLN palsy and permanent hypoparathyroidism complication rates; therefore, primary TT should probably be reserved for lesions > 1 cm or even larger with suspicion for malignancy or malignant FNAC.

Thyroid Imaging Reporting and Data Systems: Applicability of the "Taller than Wide" Criterium in Primary/Secondary Care Units and the Role of Thyroid Scintigraphy

BACKGROUND

To examine the applicability of the "taller than wide" (ttw) criterium for risk assessment of thyroid nodules (TNs) in primary/secondary care units and the role of thyroid scintigraphy therein.

METHODS

German bicenter study performed in a setting of primary/secondary care. Patient recruitment and analysis in center A was conducted in a prospective manner. In center B, patient data were retrieved from a database that was originally generated by prospective data collection. TNs were assessed by ultrasound and thyroid scans, mostly fine needle biopsy and occasionally surgery and others. In center A, only patients who presented for the first time were included. The inclusion criterion was any TN ≥ 10 mm that had at least the following two sonographic risk features: solidity and a ttw shape. In center B, consecutive patients who had at least ttw and hypofunctioning nodules ≥ 10 mm were retrieved from the above-mentioned database. The risk of malignancy was determined according to a mixed reference standard and compared with literature data.

RESULTS

In center A, 223 patients with 259 TNs were included into the study. For further analysis, 200 nodules with a reference standard were available. The overall malignancy rate was 2.5% (upper limit of the 95% CI: 5.1%). After the exclusion of scintigraphically hyperfunctioning nodules, the malignancy rate increased slightly to 2.8% (upper limit of the 95% CI: 5.7%). Malignant nodules exhibited sonographic risk features additional to solidity and ttw shape more often than benign ones. In addition to the exclusion of hyperfunctioning nodules, when considering only nodules without additional US risk features, i.e., exclusively solid and ttw-nodules, the malignancy rate decreased to 0.9% (upper limit 95% CI: 3.7%). In center B, from 58 patients, 58 ttw and hypofunctioning TNs on thyroid scans with a reference standard were available. Malignant nodules from center B were always solid and hypoechoic. The overall malignancy rate of hypofunctioning and ttw nodules was 21%, with the lower limit of the 95% CI (one-sided) being 12%.

CONCLUSIONS

In primary/secondary care units, the lowest TIRADS categories for indicating FNB, e.g., applying one out of five sonographic risk features, may not be appropriate owing to the much lower a priori malignancy risk in TNs compared to tertiary/quaternary care units. Even the combination of two sonographic risk features, "solidity" and "ttw", may only be appropriate in a limited fashion. In contrast, the preselection of TNs according to hypofunctioning findings on thyroid scans clearly warranted FNB, even when applying only one sonographic risk criterion ("ttw"). For this reason, thyroid scans in TNs may not only be indicated to rule out hyperfunctioning nodules from FNB but also to rule in hypofunctioning ones.

Ultrasound Features and Performance of Afirma Gene Sequencing Classifier in Cytologically Indeterminate Thyroid Nodules

Background

Cytologically indeterminate thyroid nodules (ITN) pose a management challenge. Here we analyze if adding ultrasound characteristics to Afirma Genome Sequence Classifier (GSC) results increases GSC diagnostic performance.

Methods

We retrospectively analyzed 237 GSC-tested Bethesda III/IV ITNs between July 2017 and December 2019 and classified them by American Thyroid Association (ATA) and the Thyroid Imaging Reporting and Data System (TIRADS) of the American College of Radiology.

Results

The benign call rate was higher in Bethesda III ITNs with TIRADS <5 vs TIRADS 5 (89% vs 68%. P = .015). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of GSC in ATA high-risk Bethesda III ITNs vs lower were 100% vs 80% (P = 1), 89.5% vs 91.5% (P = .67), 66.7% vs 25% (P = .13), and 100% vs 99.2% (P = 1), respectively, and for TIRADS 5 vs <5 were 100% vs 80% (P = 1), 88.2% vs 91.4% (P = .65), 71.4% vs 23.5% (P = .06), and 100% vs 99.3% (P = 1). The sensitivity, specificity, PPV, and NPV of GSC in high-risk ATA Bethesda IV ITNs vs lower were 66.7% vs 100% (P = .42), 83.3% vs 85.7% (P = 1), 66.7% vs 64.3% (P = 1), and 83.3% vs 100% (P = .3), respectively, and for TIRADS 5 vs <5 were 66.7% vs 90% (P = .42), 88.9% vs 83.8% (P = 1), 66.7% vs 60% (P = 1), and 88.9% vs 96.9% (P = .39).

Conclusion

Sensitivity, specificity, NPV, and PPV of GSC were not significantly different in ATA high-risk and TIRADS 5 ITNs compared to ATA < high-risk and TIRADS 1-4 ITNs.

Examining the impact of several factors including COVID-19 on thyroid fine-needle aspiration biopsy

OBJECTIVE

The study explores various factors, including coronavirus disease 2019 (COVID-19) history and vaccination status, that influence the classification value of ultrasonography-guided thyroid fine needle aspiration biopsy (TFNAB) by comparing non-diagnostic (Bethesda-I) and diagnostic (Bethesda II-VI) results.

METHODS

We conducted a retrospective observational study in a high-volume tertiary care center involving patients who underwent TFNAB from November 2022 to April 2023. The study retrospectively analyzed the cytopathology of 482 thyroid nodules. Patients were categorized into non-diagnostic (n = 136) and Diagnostic groups (n = 346) based on TFNAB. A comprehensive set of parameters was examined, including demographic, anthropometric and clinical data, thyroid ultrasonography findings, COVID-19 history and immunization status.

RESULTS

The mean age was 55.1 ± 12.1 years in the non-diagnostic group and 53.5 ± 13 years in the Diagnostic group (p = .223). 75.7% (n = 103) of the non-Diagnostic group and 82.9% (n = 287) of the Diagnostic group were male (p = .070). The mean nodule longitudinal diameter of the Diagnostic group was significantly higher than that of the non-diagnostic group (p = .015). The TIRADS score of the nodules showed a statistical difference between the groups (p = .048). The groups had no significant differences regarding other ultrasonographic parameters and COVID-19-related variables.

CONCLUSION

It can be assumed that when the longitudinal diameter of the thyroid nodule is small and in TIRADS categories other than the TIRADS3 category, TFNAB is less likely to be diagnostic. However, future research may be needed to confirm these findings and uncover any long-term effects of COVID-19 or vaccines on thyroid nodule diagnostics.

Thyroid US-guided FNA techniques: A prospective,randomized controlled study

BACKGROUND

Thyroid nodules are common in the general population. Ultrasonography is the most efficient diagnostic approach to evaluate thyroid nodules. The US FNAC procedure can be performed using either the short axis (perpendicular), or a long axis (parallel) approach to visualize the needle as it is advanced toward the desired nodule. The main aim of this study was to compare the percentage of non-diagnostic results between the long and short axis approach.

METHODS

A prospective study that included a randomized controlled trial and was divided into two arms-the short axis and the long axis-was conducted. A total of 245 thyroid nodules were collected through the fine needle aspiration cytology, performed with ultrasound, from march 2021 to march 2022. The patient's demographic information were collected and also nodules characteristics.

RESULTS

Of 245 nodules sampled, 122 were sampled with the long axis method, while 123 with the short axis method. There is not significantly less non diagnostic approach with either method compared to the other (11.5 % vs 16.3 % respectively).

DISCUSSION

Previous studies came to the conclusion that the long axis method yields fewer non diagnostic samples. This study evaluated the two FNA approaches which were proceeded by the same physician who is expert in both techniques.

CONCLUSION

The US FNAC performed in the long axis approach will not produce more conclusive results and less non diagnostic results (Bethesda category 1) than the short axis approach one.

Evolving approaches in paediatric thyroid cytopathology: A review

The guidelines for the workup of thyroid nodules have been established in adult populations and secondarily applied to paediatric populations. In particular, The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) is commonly applied to both adult and paediatric thyroid nodules. However, as paediatric nodules have distinct molecular drivers and behavioural trajectories, there is renewed interest in diagnostic and management strategies that are paediatric specific. Here, we review key differences between paediatric and adult thyroid cancer and recent literature evaluating the use of TBSRTC in paediatric populations.

Factors for second non-diagnostic ultrasound-guided fine-needle aspiration cytology in thyroid nodules

INTRODUCTION

Results in fine-needle aspiration cytology (FNAC) of thyroid nodules may be non-diagnostic (ND). In these cases, it is recommended to repeat the FNAC. The aim of our study was to evaluate the influence of demographic, clinical and ultrasound (US) characteristics in the recurrence of an ND result in thyroid nodule FNAC.

METHODS

A retrospective study of ND thyroid nodule FNAC was performed for the period 2017-2020. Demographic and clinical data (age, gender, cervical radiotherapy, presence of Hashimoto's thyroiditis, and TSH value) and US characteristics (nodule size, echogenicity, composition and microcalcifications) were collected at first ND FNAC.

RESULTS

Out of 230 nodules with first ND FNAC (83% women; mean age 60.2±14.1 years), 195 (84.8%) underwent a second FNAC: 121 benign, 63 non-diagnostic, 9 indeterminate and 2 malignant. Nine (3.9%) underwent surgery, only 1 of which showed malignant histology and 26 (11.3%) remained under US monitoring. Demographically, patients with second ND FNAC were older (63.4±14 vs. 59±14 years; P=0.032). Females had lower risk of second ND FNAC (OR, 0.4, 0.2-0.9; P=0.016); risk of second ND FNAC was higher in patients treated with anticoagulant/antiplatelet drugs (OR, 2.2, 1.1-4.7; P=0.03). Previous cervical radiotherapy, family history of thyroid cancer, Hashimoto's thyroiditis and TSH value did not influence the risk of second ND FNAC. On US, nodule echogenicity differed significantly between the ND and diagnostic FNAC, with greater risk of an ND result in hypoechogenic nodules. Microcalcification increased the risk of ND FNAC (OR 2.2, 1.1-4.5; P=0.03). Nodule composition and size did not significantly differ according to ND or diagnostic second FNAC.

CONCLUSION

Male gender, advanced age, anticoagulant/antiplatelet drug therapy, hypoechogenic nodules and microcalcified nodules are likely factors for second ND FNAC. Nodules with two ND FNACs were rarely malignant, and a more conservative approach in these cases is not unsafe.

Prediction of cytology-histology discrepancy when Bethesda cytology reports benign results for thyroid nodules in women: with special emphasis on pregnancy

Objectives: Benign category of Bethesda classification is generally well known to carry a false-negative rate of 0-3%. The current study was designed to investigate the rate of false-negative cytology in patients who underwent thyroidectomy for presumably benign thyroid diseases. Predictive risk factors for false results and malignancy were evaluated along with cytology-histology discrepant cases.Materials and methods: Females who underwent thyroidectomy between May 2014 and December 2022 were included. Demographics, ultrasound (US) features, fine-needle aspiration (FNA) diagnosis, surgical indications and outcomes, final histology reports, risk factors, and malignancy rate were recorded. Cytology-histology discrepant cases were further evaluated for interpretation errors and risk factors. Statistical analyses were performed using Fisher's exact and Mann-Whitney U tests.Results: Of 581 women with a benign thyroid disease who underwent thyroidectomy, 91 was diagnosed as incidental carcinoma (15.6%) and most was T1a (4.9 ± 2.7 mm, 95.6%). Final histology reports revealed mostly papillary carcinoma (93.4%). Predictors of malignancy such as age, family history, previous radiation exposure, and iodine-deficient diet did not help in risk stratification (p > 0.05, for each). However, FNA taken during pregnancy was determined as a risk factor (n = 7, 7.6%, p < 0.05) since it may cause a delay in diagnosis. Cytology-histology discrepant cases were seen to be mostly due to sampling errors (45%, p < 0.05), followed by misinterpretations (37.3%, p < 0.05). There was no reason for discrepancy in 17.5%, and this was linked to inherent nature of thyroid nodule with overlapping cytologic features. Best identifiable risk factor for misinterpretation was pregnancy as well (n = 5, 14.7%, p < 0.05).Conclusions: Risk of malignancy in a presumably benign thyroid disease should not be ignored. Radiology-cytology correlation by an experienced dedicated team may help in decreasing sampling errors. Physiologic changes caused by pregnancy may shade malignant transformation in thyrocytes, and it would be appropriate to be cautious about benign FNA taken during this period.

Should we reconsider high-risk features in thyroid ultrasonography?

OBJECTIVE

Round shape is generally considered to reduce the risk of malignancy according to recent guidelines. On the contrary, according to some reports, spherically shaped thyroid nodules are associated with a higher risk of malignancy. Thus, we aimed to evaluate the malignancy risk of solid round isoechoic nodules detected at thyroid ultrasonography and compare it with that of solid ovoid isoechoic nodules.

METHODS

Between 2017 and 2022, solitary solid round isoechoic nodules with diameters ³10 and £25 mm at thyroid ultrasonography were retrospectively selected and enrolled in the study. Age, size, nodule volume, serum thyrotropin levels, thyroid antibody levels, and cytopathological and histopathological results were recorded.

RESULTS

A total of 457 solitary solid isoechoechoic nodules from 457 patients (262 females and 195 males; median age, 59 [31-70] years) were selected, of which 203 were solid round isoechoic nodules, and 254 were solid ovoid isoechoic nodules. A total of 54 surgical operations were performed on 457 nodules, and 31 of them resulted in malignancy. From the 31 malignant results, 25 originated from solid round isoechoic nodules and the remaining 6 originated from solid ovoid isoechoic nodules (p<0.025).

CONCLUSION

We found that round nodules have higher malignancy rates than ovoid nodules. We think that ultrasonographic risk stratification systems used to target the most suitable nodules for the necessary biopsies can be dynamically updated, and sphericity can be added as a parameter in patient-based decision-making.

Nontargeted Native Renal Biopsy Adequacy: Preintervention Data From a Province-Wide, Multicentre, and Interdepartmental Audit

Background

Nontargeted renal biopsy is essential to diagnosis, classification, and prognostication of medical renal disease. Inadequate biopsies delay diagnosis, expose the patient to repeated biopsy, and increase costs.

Objective

The purpose of this project is to characterize nontargeted renal biopsy specimen adequacy and identify areas for improvement.

Design

This project was designed as a clinical audit of specimen adequacy rates of nontargeted renal biopsies from 13 hospitals, as well as a questionnaire of radiology and pathology department staff regarding current practices surrounding renal biopsies.

Setting

Retrospective analysis of 2188 adult native renal biopsies was performed from January 1, 2018, to September 9, 2021, across 13 hospitals.

Patients

Adult patients with medical renal disease undergoing a nontargeted renal biopsy were included.

Methods

Retrospective analysis of 2188 adult native renal biopsies was performed from January 1, 2018, to September 9, 2021, across 13 hospitals. Adequacy was divided into 4 categories based on number of glomeruli received: ideally adequate (≥25 glomeruli), minimally adequate (15-24), suboptimal (<15 and diagnosis rendered), and inadequate (<15 and no diagnosis rendered). Two targets were chosen; target 1, to achieve a combined suboptimal and inadequate rate ≤ 10%, and target 2, to attain an ideally adequate rate ≥80%. Radiology department heads in the province were surveyed on biopsy equipment, technique, technologist support, and feasibility of possible interventions to enhance biopsy adequacy. Pathology department staff were surveyed on their education and experience.

Results

Adequacy was as follows: ideally adequate 64.7%, minimally adequate 26.0%, suboptimal 7.9%, and inadequate 1.4%. The province (and 8/13 hospitals) met target 1 for native biopsies (9.3%). Two hospitals achieved target 2 for native biopsies. A key finding was that the 2 hospitals with the lowest target 1 scores did not have a technologist present at biopsy.

Limitations

Survey data was used to assess biopsy technique at each hospital, and specific technique for each biopsy was not recorded. As such, a multivariate statistical analysis of specimen adequacy rates was not feasible. Data on complications was not collected.

Conclusions

Preintervention the province was at target for limiting inadequate and suboptimal native biopsies. There was a substantial shortfall in the ideally adequate rate from the proposed target. Using insight from survey data, interventions with the greatest expected impact were identified and those that are feasible given limited resources will be implemented to improve sample adequacy.

Trial Registration

Not registered.

The Incidence Trend and Management of Thyroid Cancer-What Has Changed in the Past Years: Own Experience and Literature Review

Because of ambiguous and widely debated observations concerning the incidence, trend, and management of TC, we performed this analysis. We drew attention to some events, such as "cancer screening activity", introduction of noninvasive follicular neoplasm with papillary-like nuclear features (NIFTP) to TC types, possibility of papillary thyroid microcarcinoma (PTMC) active surveillance (AS), occurrence of personalized medicine in TC management, and, finally, COVID-19 pandemic time. Because of the opinion that all changes have been made mostly by PTC, we compared it to the remaining types of TC in terms of incidence, clinical and pathological characteristics, and treatment. We analyzed patients treated in a single surgical center in eastern Europe (Poland). The prevalence of TC significantly increased from 5.15% in 2008 to 13.84% in 2015, and then significantly decreased to 1.33% in 2022 when the COVID-19 pandemic lasted (p < 0.0001). A similar trend was observed for PTC, when the incidence significantly increased to 13.99% in 2015 and then decreased to 1.38% in 2022 (p < 0.0001). At that time, the NIFTP category was introduced, and observation of PTMC began. The prevalence of FTC and MTC also increased until 2015 and then decreased. Significant differences in age, types of surgery, necessity of reoperation, and pTNM between PTCs and other types of TCs were observed. The average age was significantly lower in PTC patients than in patients with the remaining types of TC (p < 0.0001). Four milestones, including NIFTP introduction, the possibility of PTMC AS, personalized cancer medicine, and the COVID-19 pandemic, may have influenced the general statistics of TC.

Stratifying High-Risk Thyroid Nodules Using a Novel Deep Learning System

INTRODUCTION

The current ultrasound scan classification system for thyroid nodules is time-consuming, labor-intensive, and subjective. Artificial intelligence (AI) has been shown to increase the accuracy of predicting the malignancy rate of thyroid nodules. This study aims to demonstrate the state-of-the-art Swin Transformer to classify thyroid nodules.

MATERIALS AND METHODS

Ultrasound images were collected prospectively from patients who received fine needle aspiration biopsy for thyroid nodules from January 2016 to June 2021. One hundred thirty-nine patients with malignant thyroid nodules were enrolled, while 235 patients with benign nodules served as controls. Images were fed to Swin-T and ResNeSt50 models to classify the thyroid nodules.

RESULTS

Patients with malignant nodules were younger and more likely male compared to those with benign nodules. The average sensitivity and specificity of Swin-T were 82.46% and 84.29%, respectively. The average sensitivity and specificity of ResNeSt50 were 72.51% and 77.14%, respectively. Receiver operating characteristics analysis revealed that the area under the curve of Swin-T was higher (AUC=0.91) than that of ResNeSt50 (AUC=0.82). The McNemar test evaluating the performance of these models showed that Swin-T had significantly better performance than ResNeSt50.Swin-T classifier can be a useful tool in helping shared decision-making between physicians and patients with thyroid nodules, particularly in those with high-risk characteristics of sonographic patterns.

Weighty Matters: The Obesity-Thyroid Nodule Connection Unveiling the Impact of Obesity on Thyroid Cancer Risk

Background and Objectives: The effect of obesity on the development/progression of thyroid nodules with uncertain cytology is unknown. Therefore, our objective was to assess the role of body mass index (BMI) in predicting malignancy in patients with atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS) nodules. Materials and Methods: We retrospectively analyzed 113 patients with available BMI data and final histopathology of benign or differentiated thyroid cancer. Patients were classified into four groups based on BMI: <18.5 (underweight), 18.5-24.9 (normal weight), 25-29.9 (overweight), and ≥30 (obesity) kg/m2. The association between risk of malignancy and BMI was examined for all data and subgroups based on nodule size, sex, and age. Results: Overall, 44.2% were obese, 36.3% were ≥45 years, and 75.4% were women. Final pathological results showed malignant nodules in 52 patients (46%) and benign nodules in 61 patients (54%) (mean age: 41 ± 11.6 vs. 39.9 ± 11.7 years; p = 0.62). Men had more malignant nodules than benign nodules (32.7% vs. 16.4%, p < 0.05). Overall, no significant correlation was identified between the risk of thyroid cancer and BMI, and the risk of malignancy was not significantly different between obese men and women (p = 0.4). However, in individuals with BMI < 30 kg/m2 (non-obese group), malignant nodules were more frequent in men than in women (71% vs. 41%, p = 0.04). No significant difference was observed in mean nodule size between the benign and malignant groups. Furthermore, BMI was not related to increased risk of malignancy in multiple logistic regression models using all data, even after controlling for confounding variables (odds ratio, 0.99, 95% confidence interval: 0.93-1.06, p = 0.87) or when stratifying by sex. Conclusions: Our study showed no correlation between obesity and thyroid cancer in patients with AUS/FLUS. Moreover, men had more malignant nodules than benign nodules. Further well-designed prospective studies are required to confirm our findings.

Real-Time Ultrasonography and the Evaluation of Static Images Yield Different Results in the Assessment of EU-TIRADS Categories

The studies on the effectiveness of various TIRADS in the diagnostics of thyroid nodules differ in the method of ultrasound image assessment: real time (rtUS) vs. static ultrasonography (stUS). The aim of the study was to evaluate the impact of those two methods on the categorization of nodules in EU-TIRADS. Three experienced raters assessed 842 nodules in routine rtUS and reassessed with the use of sUS. Reproducibility of the assessment of malignancy risk features and categorization of nodules with EU-TIRADS was estimated with Krippendorff's alpha coefficient (Kα). The reproducibility of EU-TIRADS categories on sUS in relation to rtUS was in range 70.9-76.5% for all raters (Kα: 0.60-0.68) with the highest reproducibility for category 3 (80.0-86.5%) and the lowest for category 5 (48.7-77.8%). There was a total disagreement of the identification of microcalcifications on sUS in relation to rtUS, a strongly variable reproducibility of marked hypoechogenicity (12.5-84.6%, Kα: 0.14-0.48) and a tendency toward more frequent identification of the non-oval shape on sUS. The percentage of agreement for each pair of raters in assigning the EU-TIRADS category on sUS was in the range 71.6-72.3% (Kα: 0.60-0.62). The method of sonographic image evaluation influences the nodule's feature assessment and, eventually, the categorization within EU-TIRADS.