Ultrasonographic predictors of thyroid cancer in Bethesda III and IV thyroid nodules

Background

Bethesda III and IV thyroid nodules continue to be difficult to manage. Although molecular testing may assist in decision-making, it is expensive, not widely available, and not without pitfalls. The objective of this study is to assess whether certain thyroid ultrasonographic features may predict the risk of thyroid cancer in patients with Bethesda III and IV thyroid nodules and be used as additional decision-making tools to complement cytopathological results in deciding on diagnostic thyroidectomy.

Methods

We retrospectively evaluated the ultrasonographic features of Bethesda categories III and IV thyroid nodules in patients who underwent subsequent thyroidectomy. We used the final histopathological examination of the surgical specimens as the gold-standard test and analyzed individual preoperative ultrasonographic features as predictors of malignancy.

Results

Of the 278 patients who were diagnosed with Bethesda III and IV thyroid nodules on fine needle aspiration cytology (FNAC), 111 (39.9%) had thyroid cancer, and 167 (59.9%) exhibited benign nodules. The malignancy rate was higher in patients with Bethesda IV nodules (28/50, 56%) than those with Bethesda III nodules (83/228, 36.4%; p=0.016). In univariate analysis, hypoechogenicity (55.6% in malignant vs. 35.3% in benign, p=0.006) and calcifications (54.5 in malignant vs. 35.4% in benign, p=0.008) were significantly different between the benign and malignant pathology groups, whereas the size of the dominant nodule, number of nodules, irregular borders, taller-than-wide shape, and the presence of lymph nodes were comparable between the two groups. These two ultrasonographic features (hypoechogenicity and calcifications) remained significantly associated with the risk of malignancy in multivariate logistic regression analysis (for hypoechogenicity, p=0.014, odds ratio: 2.1, 95% CI:1.0-3.7 and for calcifications, p=0.019, odds ratio: 1.98, 95% CI:1.12-3.50). The sensitivity, specificity, positive and negative predictive values, and accuracy were 31.5%, 83%, 55.6%,64.7%, and 62.6%, for hypoechogenicity, respectively and 32.4%, 82%, 54.5%, 67.8%, and 62%, for calcification, respectively.

Conclusions

Hypoechogenicity and calcifications in Bethesda III and IV thyroid nodules are strong predictors of thyroid cancer and associated with a two-fold increased risk of malignancy.

Islamic Perspectives on Polygenic Testing and Selection of IVF Embryos (PGT-P) for Optimal Intelligence and Other Non-Disease-Related Socially Desirable Traits

In recent years, the genetic testing and selection of IVF embryos, known as preimplantation genetic testing (PGT), has gained much traction in clinical assisted reproduction for preventing transmission of genetic defects. However, a more recent ethically and morally controversial development in PGT is its possible use in selecting IVF embryos for optimal intelligence quotient (IQ) and other non-disease-related socially desirable traits, such as tallness, fair complexion, athletic ability, and eye and hair colour, based on polygenic risk scores (PRS), in what is referred to as PGT-P. Artificial intelligence (AI) and machine learning-based analysis of big data sets collated from genome sequencing of specific human ethnic populations can be used to estimate an individual embryo's likelihood of developing such multifactorial traits by analysing the combination of specific genetic variants within its genome. Superficially, this technique appears compliant with Islamic principles and ethics. Because there is no modification of the human genome, there is no tampering with Allah's creation (taghyīr khalq Allah). Nevertheless, a more critical analysis based on the five maxims of Islamic jurisprudence (qawa'id fiqhiyyah) that are often utilized in discourses on Islamic bioethics, namely qaṣd (intention), yaqın̄ (certainty), ḍarar (injury), ḍarūra (necessity), and `urf (custom), would instead reveal some major ethical and moral flaws of this new medical technology in the selection of non-disease-related socially desirable traits, and its non-compliance with the spirit and essence of Islamic law (shariah). Muslim scholars, jurists, doctors, and biomedical scientists should debate this further and issue a fatwa on this new medical technology platform.

Disparity among Endocrinologists and Gynaecologists in the Diagnosis of Polycystic Ovarian Syndrome

Objectives

This study aimed to compare endocrinologists’ versus gynaecologists’ approaches in using the Rotterdam criteria to diagnose polycystic ovarian syndrome (PCOS).

Methods

This cross-sectional study was conducted at Physiology Department, King Saud University, Riyadh, Saudi Arabia, between December 2017 and April 2018. A validated self-administered questionnaire in English was used to obtain information from endocrinologists and gynaecologists regarding their approaches to diagnosing PCOS. Each group’s diagnostic use of the Rotterdam criteria, association between years of experience and clinical decision-making, clinical features leading to diagnosis and considerations in the diagnosis of biochemical parameters that define hyperandrogenism were evaluated.

Results

A total of 132 physicians were included in this study (response rate: 27%); 77 (58.3%) were endocrinologists and 55 (41.7%) were gynaecologists. Most of the respondents (79.5%) had ≤20 years of experience. A statistically significant difference was detected between the endocrinologists and gynaecologists (98.7% versus 81.8%; P = 0.001) in their consideration of hyperandrogenism in the diagnosis. The gynaecologists relied more on ovarian morphology than the endocrinologists did (76.4% versus 45.5%, P <0.0001). Physicians with more experience used ovarian ultrasonography more compared to those with less experience (P = 0.006).

Conclusion

There was disparity in the diagnostic approaches of endocrinologists, who rely more on androgen levels for diagnosis of PCOS versus gynaecologists, who more frequently use an ovarian morphology assessment. Increased years of experience increased the rate of ultrasonography use for PCOS diagnosis in both groups.