Comparison of surgical outcome between conventional open thyroidectomy and endoscopic thyroidectomy through axillo-breast approach

Objective:

Minimally invasive thyroidectomy can be categorized into either video-assisted method or remote access thyroidectomy (RAT). Although RAT provided excellent cosmetic results, some debate about the advantages and disadvantages remains in different countries. Thus, this study aimed to compare the surgical results between endoscopic thyroid surgery and conventional thyroidectomy.

Materials and Methods:

The study retrospectively reviewed the conventional and endoscopic thyroidectomy performed at our institution from September 2011 to July 2012. Overall, 30 patients were recruited for this study. The patients were divided into two groups: Group O (open group, n = 15) and Group E (endoscopic group, n = 15). Postoperative outcomes (including wound pain, swallowing disturbance, and chest wall paresthesia) and complications were analyzed and assessed.

Results:

The endoscopic group was associated with longer operation time and hospital stay. The visual analog scale (VAS) score of surgical wound pain was significantly higher in the open group in 1-week postoperation. However, the VAS score of swallowing disturbance was significantly higher in the endoscopic group in 1-week postoperation. More than half of the patients (53%) had chest wall paresthesia within 1-month postoperation in the endoscopic group. No surgical complications occurred in both groups.

Conclusion:

Although endoscopic thyroidectomy provides excellent cosmetic results in thyroid surgery, higher immediate postoperative pain, and prolonged chest wall paresthesia compared with those in conventional surgery are a concern and warrant careful patient selection.

Identification of serum biomarker panel to differentiate malignant from benign thyroid nodules using multiplex bead assay

BACKGROUND

The challenging target in the workup of thyroid nodule(s) is to exclude or diagnose thyroid cancer efficiently prior to surgical intervention. The present work studied a panel of eight serum biomarkers to differentiate benign from malignant thyroid nodules, aiming at reducing unnecessary thyroidectomy performed for inconclusive preoperative fine needle aspiration cytology. Serum interleukin-5 (IL-5), interleukin-8 (IL-8), hepatocyte growth factor (HGF), epidermal growth factor (EGF), angiopietin (Ang1), nonokine induced by interferon gamma (MIG), galectin (Gal-3), and vitamin D-binding protein (VDRP) were quantified by multiplex bead assay using Luminex xMAP technology. The study was conducted on 60 subjects of three groups (20 each; healthy controls, benign thyroid nodule, and malignant thyroid nodule).

RESULTS

Significant increase of the following biomarkers in the malignant group compared to the benign group was found; IL-8: 29.7 vs 8.75 pg/ml, p < 0.001, EGF: 128.7 vs 6.72 pg/ml, p < 0.001, HGF: 173.2 vs 112.2 pg/ml, p = 0.012, MIG: 776.7 vs 438 pg/ml, p = 0.023, and Ang-1: 95016 vs 33327.5 pg/ml, p = 0.014. No significant differences were detected for IL-5, Gal-3, and VDBP. Serum IL-8 and EGF showed the highest diagnostic performance individually with area under the curve (AUC) 0.849 and 0.848, respectively. The combined biomarker panels of IL-8 and EGF and IL-8, EGF, and MIG have reached a sensitivity and specificity of 95% and 65%, respectively, with a negative predictive value of 92.9%.

CONCLUSIONS

Serum IL-8 and EGF individually or the combined biomarker panel of IL-8, EGF, and MIG are promising tests that can help to exclude malignancy in thyroid nodule workup.

Diagnosis of thyroid nodules for ultrasonographic characteristics indicative of malignancy using random forest

Background

Various combinations of ultrasonographic (US) characteristics are increasingly utilized to classify thyroid nodules. But they lack theories, and heavily depend on radiologists’ experience, and cannot correctly classify thyroid nodules. Hence, our main purpose of this manuscript is to select the US characteristics significantly associated with malignancy and to develop an efficient scoring system for facilitating ultrasonic clinicians to correctly identify thyroid malignancy.

Methods

A logistic regression (LR) model is utilized to identify the potential thyroid malignancy, and the least absolute shrinkage and selection operator (LASSO) method is adopted to simultaneously select US characteristics significantly associated with malignancy and estimate parameters in LR model. Based on the selected US characteristics, we calculate the probability for each of thyroid nodules via random forest (RF) and extreme learning machine (ELM), and develop a scoring system to classify thyroid nodules. For comparison, we also consider eight state-of-the-art methods such as support vector machine (SVM), neural network (NET), etc. The area under the receiver operating characteristic curve (AUC) is employed to measure the accuracy of various classifiers.

Results

The US characteristics: nodule size, AP/T≥1, solid component, micro-calcifications, hackly border, hypoechogenicity, presence of halo, unclear border, irregular margin, and central vascularity are selected as the significant predictors associated with thyroid malignancy via the LASSO LR (LLR). Using the developed scoring system, thyroid nodules are classified into the following four categories: benign, low suspicion, intermediate suspicion, and high suspicion, whose rates of malignancy correctly identified for RF (ELM) method on the testing dataset are 0.0% (4.3%), 14.3% (50.0%), 58.1% (59.1%) and 96.1% (97.7%), respectively.

Conclusion

LLR together with RF performs better than other methods in identifying malignancy, especially for abnormal nodules, in terms of risk scores. The developed scoring system can well predict the risk of malignancy and guide medical doctors to make management decisions for reducing the number of unnecessary biopsies for benign nodules.

Treating thyroid nodules by radiofrequency: is the delivered energy correlated with the volume reduction rate? A pilot study

OBJECTIVE

Radiofrequency ablation (RFA) was proven as effective in reducing thyroid nodules' volume. However, whether technical procedure aspects could influence the volume reduction rate (VRR) has not been clarified. This retrospective pilot study aimed to analyze the correlation of RFA power, duration, and energy with VRR.

METHODS

During the period from June to December 2018 two primary-care centers treated benign thyroid nodules of adult outpatients according to the same RFA procedure. Technical parameters to be investigated were the following: median power (P_median), effective time of treatment (T_eff), energy calculated as P_median × T_eff (E_calc), and energy delivered per mL as Kcal × 4184 × nodule's volume (E_del). Continuous variables were analyzed by the Mann-Whitney test. Data of 1-year posttreatment follow-up were collected on December 2019 and the correlation of the above parameters with VRR was analyzed by linear regression.

RESULTS

Forty-one nodules were included and their 1-year VRR was 66.6%. RFA was performed with a P_median of 55 W, T_eff 10.24 min, E_calc 31,380 J, and E_del 1473 J/mL. E_del was significantly correlated with VRR (p = 0.014) while P_median, T_eff, and E_calc not. A strong correlation of E_del with VRR was found in nodules <10 mL (p = 0.001) while no significant correlation was observed in nodules >10 mL.

CONCLUSIONS

This study showed that the energy delivered with RFA is the only technical parameter significantly correlated with the VRR of thyroid nodules.

Strategy to reduce unnecessary surgeries in thyroid nodules with cytology of Bethesda category III (AUS/FLUS): a retrospective analysis of 667 patients diagnosed by surgery

PURPOSE

Fine-needle aspiration (FNA) is widely used for the diagnosis of thyroid nodules detected by ultrasonography. However, the cytology of atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS) often leads to unnecessary thyroid surgery. This study aimed to identify a strategy to reduce unnecessary surgeries in patients with AUS/FLUS nodules.

METHODS

Medical records of 667 patients with the cytology of AUS/FLUS who underwent surgery from January 2007 to December 2017 were retrospectively reviewed. Clinicopathological data were analyzed to identify malignant factors in thyroid nodules with AUS/FLUS. Factors were compared between patients with thyroid cancer and those with benign thyroid nodules, using stepwise multivariate logistic regression and decision tree model.

RESULTS

Pathological thyroid cancer was identified in 193 (43.3%) patients. There was a significant difference in malignancy incidence with respect to family history, number of nodules, number of FNAs, ultrasonographic finding, lymphocytic thyroiditis, and BRAFV600E mutation. Multivariate analysis showed that ultrasonography (K-TIRADS 5) was the most influential independent predictor of malignancy in AUS/FLUS (odds ratio = 11.02, p < 0.001), followed by possessing BRAFV600E mutation (odds ratio = 4.54, p < 0.001). This strategy enabled 226 (89.3%) patients to avoid unnecessary surgeries based on the decision tree model. There was no node of repeated FNA in the decision tree model, which reduced the risk of malignancy (odds ratio = 0.35, p = 0.029).

CONCLUSION

K-TIRADS 5 and BRAFV600E mutation were predictive of malignancy in nodules of AUS/FLUS. These factors should be considered in strategies to reduce unnecessary surgeries for AUS/FLUS.

Examination of Malignant Findings of Thyroid Nodules Using Thyroid Ultrasonography

Background

It is important to distinguish benign thyroid nodules from malignant thyroid nodules. Hence, this study aimed to determine the characteristics of patients with thyroid cancer using thyroid ultrasonography.

Methods

We retrospectively examined the ultrasonographic findings of 327 patients with 457 thyroid nodules (age: 59.9 ± 14.3 years; sex, n (%): female 242 (74.0%)) at a single center from 2014 to 2016. Ultrasonography was used to determine the nodule size, shape, border, internal echogenicity, presence of coarse calcifications and microcalcifications within the nodule, internal blood flow and whether the nodule was solid or contained cystic structures. Thyroid fine needle aspiration cytology (FNAC) was performed in all patients. The ultrasonographic findings were compared between patients with benign nodules and those with papillary thyroid carcinoma (PTC). Furthermore, in the analysis of anti-thyroglobulin (Tg) antibody-negative patients with single nodules, values of serum Tg/nodule volume were calculated and compared between patients with benign nodules and those with PTC.

Results

There were 298 (65.2%) benign nodules, 33 (7.2%) PTCs and 126 (27.6%) others (104 follicular neoplasms, 19 masses of undetermined significance and three other malignant tumors). The nodules diagnosed as PTC had significantly lower internal echogenicity (P < 0.01), more microcalcifications (P < 0.01) and comprised more nodules rich in blood flow (P < 0.05) than benign nodules. Solid nodules were found significantly more in the PTC group (P < 0.01). The serum Tg/nodule volume ratio was significantly higher in the PTC group (P < 0.05).

Conclusions

Findings suggestive of PTC were found from images obtained using thyroid ultrasonography. In the diagnosis of PTC, the frequency of FNAC examinations should be reduced as this method is costly and invasive.

Efficacy and safety of thermal ablation for autonomously functioning thyroid nodules: a systematic review and meta-analysis

BACKGROUND

Although thermal ablation has been regarded as an alternative treatment option for autonomously functioning thyroid nodules (AFTNs), the efficacy of this treatment in patients with AFTNs has not yet been systematically evaluated. In this systematic review and meta-analysis, we aimed to evaluate the efficacy and safety of thermal ablation in the treatment of AFTN, and identify the factors affecting the effectiveness of the treatment.

METHODS

Ovid-MEDLINE and Embase databases were searched for studies reporting the efficacy and safety of thermal ablation for patients with AFTN published up until January 6, 2020. Data extraction and quality assessment were performed by two radiologists according to PRISMA guidelines. The primary and secondary outcomes were to yield the pooled proportions of thyroid-stimulating hormone (TSH) normalization and pooled estimates of volume reduction rate (VRR), respectively. Subgroup analyses were performed to identify factors affecting the treatment efficacy.

RESULTS

This systematic review identified 411 AFTNs treated by thermal ablation in 391 patients in 14 studies. TSH normalization was achieved in 71.2% of patients and the volume reduction rate was 69.4% at a mean follow-up period of 12.8 months. No patients experienced hypothyroidism or a life-threatening complication during follow-up. Subgroup analyses according to nodule volume did not find a significant difference in TSH normalization (p = 0.54) or VRR (p = 0.94).

CONCLUSIONS

Thermal ablation is an effective and safe treatment method for patients with AFTNs. The nodule volume did not affect the efficacy of thermal ablation, and this result should be considered in future thermal ablation guidelines.

KEY POINTS

• Thermal ablation has good efficacy and safety in the treatment of autonomously functioning thyroid nodule. • The efficacy of thermal ablation was not affected by nodule volume.

Rule-based automatic diagnosis of thyroid nodules from intraoperative frozen sections using deep learning

Frozen sections provide a basis for rapid intraoperative diagnosis that can guide surgery, but the diagnoses often challenge pathologists. Here we propose a rule-based system to differentiate thyroid nodules from intraoperative frozen sections using deep learning techniques. The proposed system consists of three components: (1) automatically locating tissue regions in the whole slide images (WSIs), (2) splitting located tissue regions into patches and classifying each patch into predefined categories using convolutional neural networks (CNN), and (3) integrating predictions of all patches to form the final diagnosis with a rule-based system. To be specific, we fine-tune the InceptionV3 model for thyroid patch classification by replacing the last fully connected layer with three outputs representing the patch's probabilities of being benign, uncertain, or malignant. Moreover, we design a rule-based protocol to integrate patches' predictions to form the final diagnosis, which provides interpretability for the proposed system. On 259 testing slides, the system correctly predicts 95.3% (61/64) of benign nodules and 96.7% (148/153) of malignant nodules, and classify 16.2% (42/259) slides as uncertain, including 19 benign and 16 malignant slides, which are a sufficiently small number to be manually examined by pathologists or fully processed through permanent sections. Besides, the system allows the localization of suspicious regions along with the diagnosis. A typical whole slide image, with 80, 000 × 60, 000 pixels, can be diagnosed within 1 min, thus satisfying the time requirement for intraoperative diagnosis. To the best of our knowledge, this is the first study to apply deep learning to diagnose thyroid nodules from intraoperative frozen sections. The code is released at https://github.com/PingjunChen/ThyroidRule.

Suggested amendment of TI-RADS classification of thyroid nodules by shear wave elastography

BACKGROUND

The application of the ultrasound elastography and Thyroid Imaging Reporting and Data System (TI-RADS) classification further expands the scope of ultrasound differential diagnosis between benign and malignant thyroid nodules.

PURPOSE

To investigate the value of the quantitative parameter of ultrasonic shear waves in optimizing the TI-RADS classification of thyroid nodules.

MATERIAL AND METHODS

A total of 168 thyroid nodules, initially classified using TI-RADS and scanned by shear wave elastography (SWE), were retrospectively analyzed. All cases were diagnosed by fine needle aspiration and histology following surgery.

RESULTS

The benign rate of TI-RADS 3 nodules was 76.5%, while the benign rate of TI-RADS 4a nodules was 71.7%. Furthermore, the malignant rate of TI-RADS 4b nodules was 69.7%, while the malignant rate of TI-RADS 4c nodules was 85.7%. In differentiating benign from malignant nodules, the combination of TI-RADS classification and E_mean had the largest area under the receiver operating characteristic curve (AUC). Using an E_mean value of 42.25 kpa as the cut-off point, the malignant rate of TI-RADS 4a nodules decreased from 28.3% to 23.5%, while the malignant rate of TI-RADS 4b nodules increased from 69.7% to 79.4%. Compared to conventional ultrasound alone, the sensitivity, negative predictive value, and AUC of conventional ultrasound combined with SWE in the diagnosis of benign and malignant thyroid nodules significantly improved (P=0.012, 0.029, 0.001).

CONCLUSION

The SWE technique can be used to further determine the benign and malignant nature of TI-RADS 4 lesions, providing further reference for the choice of clinical treatment. The TI-RADS classification system corrected by SWE is more significant in the diagnosis of benign and malignant thyroid nodules.

Usefulness of ultrasound-guided core biopsy in thyroid nodules with inconclusive fine-needle aspiration biopsy findings

OBJECTIVES

To determine the diagnostic performance of ultrasound-guided core-needle biopsy in thyroid nodules after two inconclusive fine-needle aspiration biopsies. To assess the complications of core-needle biopsy. To analyze the reliability of diagnoses obtained with core-needle biopsy. To measure the economic impact of avoiding lobectomies in patients with benign core-needle biopsy findings.

MATERIAL AND METHODS

This retrospective study reviewed 195 core-needle biopsies in 178 patients. To determine the reliability of the core-needle biopsy findings, we compared the diagnosis from the core-needle specimen versus the histologic findings in the surgical specimens when core-needle biopsy findings indicated malignancy or follicular proliferation and versus the stability of the nodule on ultrasound follow-up for one year when core-biopsy findings indicated benignity.

RESULTS

Core-needle biopsy yielded a diagnosis for 179 (91.7%) nodules, of which 122 (62.5%) were classified as benign, 50 (25.6%) as follicular proliferation, and 7 (3.6%) as malignant. The findings were inconclusive for 16 (8.3%) nodules. Minor complications were observed in 4 (2%) patients; no major complications were observed. The sensitivity of core-needle biopsy for the diagnosis of thyroid cancer was low (42.8%) because the technique was unable to detect capsular or vascular invasion, although the specificity and positive predictive value (PPV) were 100%. However, when we considered histologic findings of malignancy and follicular proliferation positive because both require surgical resection, the sensitivity increased to 97.5% and the PPV decreased to 83.3%. There were 79 nodules with ultrasound follow-up for at least one year; 76 (96.2%) had negative core-needle biopsy findings, and 74 (97.3%) of these remained stable. The negative predictive value (NPV) for malignancy of the benign nodules was 98.6%, although no malignant transformation was observed. Nevertheless, the results of the statistical analysis do not allow us to recommend forgoing ultrasound follow-up in patients with benign core-biopsy findings. The cost savings of avoiding lobectomy in patients with benign nodules and stability of the nodule on ultrasound follow-up for at least one year was about 90%.

CONCLUSIONS

Core-needle biopsy of thyroid nodules is effective because it diagnoses more than 90% of nodules with inconclusive findings after fine-needle aspiration biopsy. It is safe if done by experienced professionals. It is reliable because it yields 100% specificity and 100% PPV for malignant nodule, 97.5% sensitivity for the detection of nodules that require surgery, and 98.6% NPV for benign nodules. It is efficient because it reduces the costs of diagnosis compared to lobectomy in benign nodules.

Cost-effectiveness of routine calcitonin screening and fine-needle aspiration biopsy in preoperative diagnosis of medullary thyroid Cancer in the United States

OBJECTIVES

examine the cost-effectiveness of routine Calcitonin (Ctn) screening test in the United States.

MATERIALS AND METHODS

Markov chain model was developed that compares fine-needle aspiration biopsy (FNAB) with Ctn screening vs. FNAB-only in the evaluation of a thyroid nodule with non-highly suspicious findings. Follow-up time was set as 10 years. Costs and probabilities values were obtained from literature, and National Cancer Database. Cost data is expressed in U.S$ and effectiveness is expressed in Quality-adjusted-life-year (QALY). Incremental cost-effectiveness ratio (ICER) was calculated comparing both study arms.

RESULTS

Routine Ctn screening was cost-effective compared to FNAB-only in all tested categories except when cutoff value of 10 pg/ml was applied. Among the tested categories, the application of universal routine Ctn screening with Ctn value > 50 pg/ml considered a positive test produced the most cost-saving scenario. The final accrued cost at the end of 10 years in the FNAB-only arm was $4238.93 with a final effectiveness of 8.717 QALY. While the final cost in the FNAB-with routine Ctn screening was $4345.04 with a final effectiveness of 8.722 QALY. ICER of routine Ctn screening compared to FNAB-only was $23278.61/QALY (<Willing-To-Pay threshold of $50,000/QALY). Based on sensitivity analyses, Ctn testing is cost-effective if the test cost is less than $236.03.

CONCLUSIONS

Routine Ctn screening is a cost-effective strategy in US if the cost is less than $236.03. Although Ctn screening is not perfect in detecting MTC at early stages, it is a cost-effective alternative of discovering MTC after thyroid lobectomy or on follow-up of a thyroid nodule.

Rare presentation of metastatic renal cell carcinoma to thyroid gland: A case report

Introduction

Renal cell carcinoma is known to cause metastasis to unusual sites, but metastasis to the thyroid gland is a rare occurrence, not only that, but 20 years after complete recovery is almost nonexistent.

Case presentation

We are presenting here a case of 79-year-old female who presented to us for asymptomatic progressive thyroid nodule. She had history of right nephrectomy for renal cell carcinoma 20 years ago. Ultrasound guided fine needle aspiration biopsy (FNAB) of the thyroid was non-diagnostic. Total thyroidectomy of the patient was performed, and histopathological evaluation of the specimen revealed the swelling to be of metastatic in nature secondary to renal cell carcinoma.

Discussion

Despite thyroid metastasis being rare, FNAB can prove to be useful tool for diagnosis of thyroid tumors and metastases and can be inconclusive in some cases. Therefore, immunohistochemistry can prove beneficial in diagnosis such cases.

Conclusion

The diagnosis of renal cell carcinoma metastasis is made after immunohistochemical evaluation of the thyroidectomy specimen with thyroidectomy proving to be the modality of treatment for such cases with no further radiation therapy and a yearly follow up plan to screen for other lesions.

•

Renal cell carcinoma is one of the most common malignany to metastasize to thyroid.

•

Metastatic etiology should always be considered in thyroid nodule patient with history of renal cell carcinoma.

•

Diagnosis is mainly by immunohistochemical analysis.

•

Surgery has a significant mortality benefit.

Postoperative thyroid hormone supplementation rates following thyroid lobectomy

BACKGROUND

Thyroid lobectomy is performed for symptomatic benign nodules, indeterminate nodules, or low-risk well differentiated thyroid cancer. We aimed to determine factors associated with thyroid stimulating hormone over goal (TH) following lobectomy.

METHODS

We performed a retrospective single-institution cohort study of patients undergoing thyroid lobectomy from January 2016 to December 2017. TH was defined as need for thyroid hormone in accordance with guidelines. Univariate and multivariate logistic regression analysis was performed.

RESULTS

One hundred patients were included and 47% developed. TH: 73% of those with cancer, 38% with benign pathology (p = 0.002). Patients with TH were more likely to have thyroiditis 26% versus 3.8% (p = 0.002); higher preoperative TSH: mean 1.88mIU/L (SD 1.17) versus 1.16mIU/L (SD 0.77) (p = 0.0002), and smaller remnant thyroid lobe adjusted for body surface area 2.99ml/m2 versus 3.72ml/m2 (p = 0.003).

CONCLUSIONS

After thyroid lobectomy, TH is associated with preoperative TSH level, thyroiditis, remnant thyroid volume, and malignancy. The majority of patients with final pathology of carcinoma will require thyroid hormone supplementation to achieve TSH goal.

Pitfalls in Thyroid Cytopathology

Fine-needle aspiration (FNA) is among the first diagnostic tools used in the evaluation of thyroid nodules. It has the ability to triage patients with benign and malignant lesions, thus defining the optimum clinical and/or surgical management. The Bethesda System for Reporting Thyroid Cytopathology has found worldwide acceptance. Thyroid FNA offers high positive predictive value (97%-99%), with sensitivities and specificities of 65% to 99% and 72% to 100%, respectively. Nonetheless, many potential diagnostic pitfalls exist that can lead to false-positive and/or false-negative results. This article discusses several of the potential pitfalls in the cytologic evaluation of thyroid lesions.

Central hypothyroidism or subclinical hyperthyroidism: can they be confused with each other?

SUMMARY

Isolated, adult-onset central hypothyroidism is very rare, and its diagnosis can be challenging. A 42-year-old patient was referred for evaluation of a 2.8 cm thyroid nodule. She referred symptoms that could be attributed to hypothyroidism and thyroid tests showed low TSH and normal-low levels of free T4. However, evaluation of the remaining pituitary hormones and pituitary MRI were normal, yet a radionuclide scanning revealed that the thyroid nodule was 'hot' and the tracer uptake in the remaining thyroid tissue was suppressed. Interpretation of these studies led to a misdiagnosis of subclinical hyperthyroidism and the patient was treated with radioiodine. Soon after treatment, she developed a frank hypothyroidism without appropriate elevation of TSH and the diagnosis of central hypothyroidism was made a posteriori. Long term follow-up revealed a progressive pituitary failure, with subsequent deficiency of ACTH and GH. This case should alert to the possibility of overlooking central hypothyroidism in patients simultaneously bearing primary thyroid diseases able to cause subclinical hyperthyroidism.

LEARNING POINTS

Although rarely, acquired central hypothyroidism can occur in the absence of other pituitary hormone deficiencies. In these cases, diagnosis is challenging, as symptoms are unspecific and usually mild, and laboratory findings are variable, including low, normal or even slightly elevated TSH levels, along with low or low-normal concentrations of free T4. In cases with low TSH levels, the coexistence of otherwise common disorders able to cause primary thyroid hyperfunction, such as autonomous nodular disease, may lead to a misdiagnosis of subclinical hyperthyroidism.

Postoperative thyroid hormone supplementation rates following thyroid lobectomy

BACKGROUND

Thyroid lobectomy is performed for symptomatic benign nodules, indeterminate nodules, or low-risk well-differentiated thyroid cancer. We aimed to determine factors associated with need for thyroid hormone supplementation following thyroid lobectomy.

METHODS

We performed a retrospective single-institution cohort study of patients undergoing thyroid lobectomy from January 2016 to December 2017. Thyroid hormone supplementation was assessed postoperatively based on guidelines for thyroid stimulating hormone (TSH) level goal for benign (0.5-4.5mIU/L) or malignant (<2mIU/L) final pathology. Univariate and multivariate logistic regression analysis was performed.

RESULTS

One hundred patients were included and overall 47% required thyroid hormone supplementation after thyroid lobectomy: 73% of those with cancer, 38% with benign pathology (p = 0.002). Patients requiring thyroid hormone supplementation were more likely to have thyroiditis 26% versus 3.8% of those who remained euthyroid (p = 0.002); have a higher preoperative TSH: mean 1.88mIU/L (SD 1.17) versus 1.16mIU/L (SD 0.77) (p = 0.0002), and have a smaller remnant thyroid lobe adjusted for body surface area 2.99ml/m2 versus 3.72ml/m2 (p = 0.003).

CONCLUSIONS

After thyroid lobectomy, the need for thyroid hormone supplementation is associated with higher preoperative TSH level, thyroiditis, remnant thyroid volume, and malignancy on final pathology. The majority of patients with final pathology of carcinoma will require thyroid hormone supplementation to achieve TSH goal. For patients with benign pathology after thyroid lobectomy the majority will not require thyroid hormone supplementation to achieve TSH goal.

Limitations of ultrasound in predicting bilaterality vs unilaterality of well-differentiated carcinoma of the thyroid

PURPOSE

The purpose of this study is to assess the efficacy of ultrasonography in the differentiation of a bilateral and a unilateral WDTC to help physicians decide on performing a total or a partial thyroidectomy.

MATERIALS AND METHODS

Retrospective chart review of all patients diagnosed with papillary thyroid carcinoma following a total thyroidectomy or a complete thyroidectomy between January 2013 and December 2015 at the Department of Otorhinolaryngology and Head and Neck Surgery in Soroka University Medical Center in southern Israel. The preoperative ultrasound images of the thyroid were compared to the final pathology in the contralateral lobe.

RESULTS

Seventy seven patients (77) were included in this study, There was no correlation between the sonography in the contralateral lobe and the malignancy on that side (p = 0.479). US had a 39% false negative rate and 69% false positive rate.

CONCLUSION

The patients with a well-differentiated carcinoma of the thyroid, a benign nodule detected sonographically in the contralateral lobe should not bear a high weight in decision making regarding the extent of surgery.

Ultrasound risk stratification systems for thyroid nodule: between lights and shadows, we are moving towards a new era

Ultrasound (US) has long played a major role in the assessment of thyroid nodules and their risk of malignancy, and its importance has been further enhanced over the past decade by the development of a number of US-based risk stratification systems (US-RSSs), referred to in some cases as TIRADS (Thyroid Imaging Reporting And Data Systems). The high-risk categories of all currently available US-RSSs display strong associations to cytological diagnostic classes of "malignant/suspicious-for-malignancy" and the low-risk classes are clearly associated to "not neoplastic/benign" cytology. The introduction of these systems has elevated the diagnostic performance of US to a level approaching that of fine-needle aspiration (FNA) cytology. The time seems ripe to exploit this new level of accuracy to reduce the number of FNAs for nodules likely to be benign (i.e., sonographically classified as low-risk with no suspicious clinical features). In the near future, US-RSS could also become the main tool for diagnosing papillary thyroid cancers. The establishment of a new "international TIRADS"-currently in progress-will be critical to guide us towards a new era.

2020 European Thyroid Association Clinical Practice Guideline for the Use of Image-Guided Ablation in Benign Thyroid Nodules

Standard therapeutic approaches for benign thyroid lesions that warrant intervention are surgery for cold and either surgery or radioiodine for autonomously functioning thyroid nodules (AFTN). Image-guided thermal ablation (TA) procedures are increasingly proposed as therapy options for selected clinical conditions. Due to mounting scientific evidence and widening availability, ETA considered it appropriate to develop guidelines for the use of TA in adult patients. TA procedures are well tolerated, but a dedicated training of the operators is required and information on possible complications needs to be shared with the patients. The following factors should be considered when weighing between observation, surgery, and TA for benign thyroid nodules. In solid non-hyperfunctioning nodules, TA induces a decrease in thyroid nodule volume, paralleled by improvement in symptoms. Nodule re-growth is possible over time and may necessitate repeat treatment, or surgery, in a dialogue with the patient. In AFTN, radioactive iodine is the first-line treatment, but TA may be considered in young patients with small AFTN due to higher probability of restoring normal thyroid function and avoidance of irradiation. In cystic nodules, ethanol ablation (EA) is the most effective and least expensive treatment. TA may be considered for cystic lesions that relapse after EA or have a significant residual solid component following drainage and EA. TA should be restricted to benign lesions that cause symptoms or cosmetic concern. Presently, laser and radiofrequency ablation are the most thoroughly assessed techniques, with similar satisfactory clinical results. Microwaves and high-intensity focused ultrasound therapy options remain to be fully evaluated.

Computer-Aided Diagnosis Systems in Diagnosing Malignant Thyroid Nodules on Ultrasonography: A Systematic Review and Meta-Analysis

BACKGROUND

Computer-aided diagnosis (CAD) systems are being applied to the ultrasonographic diagnosis of malignant thyroid nodules, but it remains controversial whether the systems add any accuracy for radiologists.

OBJECTIVE

To determine the accuracy of CAD systems in diagnosing malignant thyroid nodules.

METHODS

PubMed, EMBASE, and the Cochrane Library were searched for studies on the diagnostic performance of CAD systems. The diagnostic performance was assessed by pooled sensitivity and specificity, and their accuracy was compared with that of radiologists. The present systematic review was registered in PROSPERO (CRD42019134460).

RESULTS

Nineteen studies with 4,781 thyroid nodules were included. Both the classic machine learning- and the deep learning-based CAD system had good performance in diagnosing malignant thyroid nodules (classic machine learning: sensitivity 0.86 [95% CI 0.79-0.92], specificity 0.85 [95% CI 0.77-0.91], diagnostic odds ratio (DOR) 37.41 [95% CI 24.91-56.20]; deep learning: sensitivity 0.89 [95% CI 0.81-0.93], specificity 0.84 [95% CI 0.75-0.90], DOR 40.87 [95% CI 18.13-92.13]). The diagnostic performance of the deep learning-based CAD system was comparable to that of the radiologists (sensitivity 0.87 [95% CI 0.78-0.93] vs. 0.87 [95% CI 0.85-0.89], specificity 0.85 [95% CI 0.76-0.91] vs. 0.87 [95% CI 0.81-0.91], DOR 40.12 [95% CI 15.58-103.33] vs. DOR 44.88 [95% CI 30.71-65.57]).

CONCLUSIONS

The CAD systems demonstrated good performance in diagnosing malignant thyroid nodules. However, experienced radiologists may still have an advantage over CAD systems during real-time diagnosis.

Can the unnecessary operations for suspected thyroid nodules be avoided by the combined use of the strain ratio and elastography score?

Introduction

Only 5%–15% of thyroid surgical specimens are reported as malignant. Most of the operations are performed due to suspicion of malignancy as a result of fine needle aspiration biopsy but invasiveness, non-diagnostic results and potential repeat biopsies are disadvantages of fine needle aspiration biopsy.

Objective

The aim of this study was to investigate the effectiveness of simultaneously using both the strain ratio and elasticity score in the differential diagnosis of thyroid nodules, as well as to assess the compatibility of these two methods.

Methods

A total of 144 nodules were included in the study. The final histopathologic diagnosis was used as the reference standard. The area under the curve sensitivity, specificity, and cut-off values of the strain ratio and elasticity score were determined using receiver operating characteristic curve analysis. The compatibility and comparison of strain ratio and elasticity score were also performed.

Results

Twenty eight nodules (19.4%) were malignant. The strain ratio and elasticity score results were found to be significantly successful in predicting thyroid malignancy (p < 0.001 for both). Moreover, the area under the curve for the strain ratio and elasticity score were found to be 0.944 and 0.960, respectively. The diagnostic accuracy of the elasticity score was found to be superior to that of the strain ratio, but this difference was not statistically significant (p = 0.456). When the compatibility of the strain ratio and elasticity score was examined, the two evaluations were revealed to be statistically consistent with each other (Kappa = 0.767; p < 0.001). When the strain ratio and the elasticity score were used together, the specificity of capturing the correct diagnosis increased from 84.5% to 93.1%.

Conclusion

When the strain ratio an elasticity score were used together for the differential diagnosis of thyroid nodules, more accurate results were obtained. Thus, combining both methods may be a promising alternative to fine needle aspiration biopsy in order to prevent unnecessary surgical interventions for suspected thyroid nodules.

Is thyroid core needle biopsy a valid compliment to fine-needle aspiration?

Fine-needle aspiration (FNA) has long been considered the first and an important diagnostic tool in the evaluation of thyroid nodules. The advantages of FNA include simplicity, safety, cost-effectiveness, high diagnostic accuracy, and low complication rate. Nevertheless, limitations associated with FNA include a substantial rate of inconclusive results and indeterminate interpretations. Therefore, core needle biopsy (CNB) of the thyroid gland has been proposed as a complementary or even alternate diagnostic method to evaluate thyroid nodules. Although controversial, a growing number of researchers have reported CNB to be an effective and safe sampling method for thyroid nodules, especially for cases with inadequate or indeterminate FNA yields. Skeptics highlight local pain and bleeding risk. Supporters highlight the potential likelihood of overcoming FNA limitations by obtaining a larger amount of tissue and using architecture and cellular details to guide possible ancillary testing. This review evaluates the indications, advantages, and disadvantages of CNB as compared with FNA of the thyroid gland.

Concordance of the ACR TI-RADS

BACKGROUND

Ultrasonography (US) is the method of choice for evaluating thyroid nodules. In 2017, the American College of Radiology (ACR) created a classification system based on US characteristics. For the system to be adopted, it must be reproducible.

OBJECTIVES

To determine the intraobserver and interobserver variability of the ACR TI-RADS.

METHODS

Cross-sectional study; three radiologists with different levels of experience used the ACR TI-RADS to classify 100 nodules on two occasions one month apart, and we calculated the intraobserver and interobserver variability.

RESULTS

Regarding intraobserver variability, the first radiologist had nearly perfect concordance for composition, echogenicity, shape, and margins and substantial concordance for echogenic foci; the second radiologist had nearly perfect concordance for composition, echogenicity, shape, and margins and substantial concordance for echogenic foci, and the third radiologist had nearly perfect concordance for composition, echogenicity, and shape and substantial concordance for margins and echogenic foci. The interobserver concordance was calculated for the two readings; the concordance was substantial except for shape in the first reading and for echogenicity and margins in the second reading, which had moderate concordance.

CONCLUSIONS

The ACR TI-RADS classification system is reproducible.

Intermixed medullary and papillary thyroid cancer in a patient with renal cell carcinoma

SUMMARY

We report a rare case of concurrent medullary thyroid cancer (MTC) and papillary thyroid cancer (PTC) with intermixed disease in several of the lymph node (LN) metastases in a patient who was subsequently diagnosed with clear cell renal cell carcinoma (RCC). A 56 year old female presented with dysphagia and was found to have a left thyroid nodule and left superior cervical LN with suspicious sonographic features. Fine needle aspiration biopsy (FNAB) demonstrated PTC in the left thyroid nodule and MTC in the left cervical LN. Histopathology demonstrated multifocal PTC with 3/21 LNs positive for metastatic PTC. One LN in the left lateral neck dissection exhibited features of both MTC and PTC within the same node. In the right lobe, a 0.3 cm focus of MTC with extra-thyroidal extension was noted. Given persistent calcitonin elevation, a follow-up ultrasound displayed an abnormal left level 4 LN. FNAB showed features of both PTC and MTC on the cytopathology itself. The patient underwent repeat central and left radical neck dissection with 3/6 LNs positive for PTC in the central neck and 2/6 LNs positive for intermixed PTC and MTC in the left neck. There was no evidence of distant metastases on computed tomography and whole body scintigraphy, however a 1.9 x 2.5 cm enhancing mass within the right inter-polar kidney was discovered. This lesion was highly suspicious for RCC. Surgical pathology revealed a 2.5 cm clear cell RCC, Fuhrman grade 2/4, with negative surgical margins. She continues to be observed with stable imaging of her triple malignancies.

LEARNING POINTS

Mixed medullary-papillary thyroid neoplasm is characterized by the presence of morphological and immunohistochemical features of both medullary and papillary thyroid cancers within the same lesion. Simultaneous occurrence of these carcinomas has been previously reported, but a mixed disease within the same lymph node is an infrequent phenomenon. Prognosis of mixed medullary-papillary thyroid carcinomas is determined by the medullary component. Therefore, when PTC and MTC occur concurrently, the priority should be given to the management of MTC, which involves total thyroidectomy and central lymph node dissection. Patients with thyroid cancer, predominantly PTC, have shown higher than expected rates of RCC. To our knowledge, this is the first report describing the combination of MTC, PTC, and RCC in a single patient.

Intranodular Vascularity May Be Useful in Predicting Malignancy in Thyroid Nodules with the Intermediate Suspicion Pattern of the 2015 American Thyroid Association Guidelines

The aim of the study described here was to determine whether vascularity patterns on Doppler ultrasonography (US) differentiate benign and malignant thyroid nodules with the intermediate suspicion pattern based on the 2015 American Thyroid Association guidelines. A total of 411 benign or malignant thyroid nodules from 406 patients with intermediate-suspicion US features were retrospectively collected. Univariate and multivariate logistic regression analyses with the generalized estimating equation were used to identify factors predicting malignancy, and odds ratios with 95% confidence intervals were calculated. The vascularity patterns significantly differed between the benign (353 of 411, 85.9%) and malignant (58 of 411, 14.1%) nodules (p = 0.005). Only intranodular vascularity was significantly associated with malignancy on univariate analysis (p = 0.006) and was an independent predictor of malignancy on multivariate analysis (p = 0.004). In conclusion, intranodular vascularity on Doppler US may be useful for predicting malignancy in thyroid nodules with the intermediate-suspicion pattern.