Reevaluating diagnostic categories and associated malignancy risks in thyroid core needle biopsy

As the application of core needle biopsy (CNB) in evaluating thyroid nodules rises in clinical practice, the 2023 Korean Thyroid Association Management Guidelines for Patients with Thyroid Nodules have officially recognized its value for the first time. CNB procures tissue samples preserving both histologic structure and cytologic detail, thereby supplying substantial material for an accurate diagnosis and reducing the necessity for repeated biopsies or subsequent surgical interventions. The current review introduces the risk of malignancy within distinct diagnostic categories, emphasizing the implications of noninvasive follicular thyroid neoplasm with papillary-like nuclear features on these malignancy risks. Prior research has indicated diagnostic challenges associated with follicular-patterned lesions, resulting in notable variation within indeterminate diagnostic categories. The utilization of mutation-specific immunostaining in CNB enhances the accuracy of lesion classification. This review underlines the essential role of a multidisciplinary approach in diagnosing follicular-patterned lesions and the potential of mutation-specific immunostaining to strengthen diagnostic consensus and inform patient management decisions.

Association of High Serum Leptin Level with Papillary Thyroid Carcinoma: A Case-Control Study

Background: Recently, the prevalence of thyroid cancer has increased. Although there are known risk factors for thyroid cancer, none of them can justify this recent increase. In addition to the known risk factors, other risk factors have been proposed. Leptin can be considered as one of these risk factors due to the recent increase in the prevalence of obesity in the population. Leptin is a common factor in obesity and thyroid cancer. Leptin exerts anti-apoptotic and mitogenic effects on cancer cells and also acts as an angiogenic factor. This study aimed to evaluate the serum leptin level in individuals who suffer from papillary thyroid carcinoma (PTC), cases with benign thyroid nodules (BTN), and a healthy group. Materials and Methods: In this study, newly diagnosed patients with PTC, BTNs, as well as euthyroid healthy control subjects without nodules were included. In all these participants, various clinical and laboratory parameters including thyroid function tests and serum leptin levels were measured and compared between the three study groups. For patients with PTC, leptin was assessed 12 weeks after total thyroidectomy. Results: Ninety-one cases with PTC, 90 cases with BTNs, and 88 controls were recruited. Serum leptin levels in the PTC group, benign group, and the control group were 22.34, 17.60, and 13.83 ng/ml, respectively, which was considerably higher in PTC cases compared to those with benign nodules and control group (P<0.001). There was a significant association between leptin with BMI, tumor size, and tumor stage in PTC patients. Also, in patients with BTNs, a correlation between BMI, tumor size, and leptin was observed. Conclusion: Serum leptin levels were considerably higher in cases with PTC than those with BTNs and controls and can be considered as a potential tumor marker for papillary thyroid cancer.

Towards in vivo characterization of thyroid nodules suspicious for malignancy using multispectral optoacoustic tomography

PURPOSE

Patient-tailored management of thyroid nodules requires improved risk of malignancy stratification by accurate preoperative nodule assessment, aiming to personalize decisions concerning diagnostics and treatment. Here, we perform an exploratory pilot study to identify possible patterns on multispectral optoacoustic tomography (MSOT) for thyroid malignancy stratification. For the first time, we directly correlate MSOT images with histopathology data on a detailed level.

METHODS

We use recently enhanced data processing and image reconstruction methods for MSOT to provide next-level image quality by means of improved spatial resolution and spectral contrast. We examine optoacoustic features in thyroid nodules associated with vascular patterns and correlate these directly with reference histopathology.

RESULTS

Our methods show the ability to resolve blood vessels with diameters of 250 μm at depths of up to 2 cm. The vessel diameters derived on MSOT showed an excellent correlation (R2-score of 0.9426) with the vessel diameters on histopathology. Subsequently, we identify features of malignancy observable in MSOT, such as intranodular microvascularity and extrathyroidal extension verified by histopathology. Despite these promising features in selected patients, we could not determine statistically relevant differences between benign and malignant thyroid nodules based on mean oxygen saturation in thyroid nodules. Thus, we illustrate general imaging artifacts of the whole field of optoacoustic imaging that reduce image fidelity and distort spectral contrast, which impedes quantification of chromophore presence based on mean concentrations.

CONCLUSION

We recommend examining optoacoustic features in addition to chromophore quantification to rank malignancy risk. We present optoacoustic images of thyroid nodules with the highest spatial resolution and spectral contrast to date, directly correlated to histopathology, pushing the clinical translation of MSOT.

Comparison of the C-TIRADS, ACR-TIRADS, and ATA guidelines in malignancy risk stratification of thyroid nodules

Background

To compare the diagnostic performance in determining the malignancy of thyroid nodules and the fine needle aspiration (FNA) recommendations of the guidelines set forth by the Superficial Organ and Vascular Ultrasound Group of the Society of Ultrasound in Medicine of the Chinese Medical Association in 2020 [2020 Chinese Thyroid Imaging Reporting and Data System (C-TIRADS)], the American College of Radiology in 2017 (2017 ACR-TIRADS) and the American Thyroid Association in 2015 (2015 ATA guidelines).

Methods

From January 2021 to December 2021, 1,228 thyroid nodules with definitive postoperative histopathology and ultrasound (US) examination within 3 months before surgery in Shantou Central Hospital were enrolled in this study. We collected the data in 2022. The participants formed a consecutive series. The clinical and US features of the nodules were retrospectively reviewed and categorized according to the 2020 C-TIRADS, the 2017 ACR-TIRADS and the 2015 ATA guidelines. The diagnostic performance and unnecessary FNA rates of the three guidelines were calculated.

Results

The 2017 ACR-TIRADS had the highest diagnostic performance [area under the receiver operating characteristic curve (AUROC) 0.938], followed by the 2020 C-TIRADS (AUROC 0.933) and the 2015 ATA guidelines (AUROC 0.928). The ATA guidelines had the highest specificity (93.38%), accuracy (92.10%) and positive predictive value (PPV) (80.56%) among the three guidelines. There were no significant differences in the sensitivity and negative predictive value (NPV) among the three guidelines. The sensitivity, specificity, PPV, NPV and accuracy of the FNA recommendations based on the C-TIRADS were 84.25%, 58.76%, 38.92%, 92.28% and 64.82%, respectively, which were higher than those of the ACR-TIRADS (57.53%, 42.94%, 23.93%, 76.43% and 46.42%, respectively) and the ATA guidelines (62.67%, 13.25%, 18.39%, 53.22% and 25.00%, respectively). Compared with the ACR-TIRADS (76.07%) and the ATA guidelines (81.61%), the C-TIRADS showed advantages in the unnecessary FNA rate (61.08%), especially in nodules larger than 20 mm.

Conclusions

The 2020 C-TIRADS, the 2017 ACR-TIRADS and the 2015 ATA guidelines can effectively predict the malignancy risk of thyroid nodules. Compared with the 2017 ACR-TIRADS and the 2015 ATA guidelines, the 2020 C-TIRADS may offer a meaningful reduction in FNA recommendations with the highest efficacy in distinguishing thyroid carcinoma.

Risk of malignancy and diagnostic accuracy of fine-needle aspiration biopsy in thyroid nodules with diameters greater than 4 centimeters

Objective

The risk of malignancy and diagnostic accuracy of fine-needle aspiration biopsy (FNAB) of thyroid nodules (TN) with diameters ≥ 3-4 cm remains controversial. However, some groups have indicated surgical treatment in these patients regardless of the FNAB results. We aimed to evaluate the diagnostic accuracy of the FNAB in systematically resected ≥4 cm TN and if the risk of malignancy is higher in these patients.

Subjects and methods

We retrospectively evaluated 138 patients (142 nodules) with TN with diameters ≥4 cm who underwent thyroidectomy.

Results

The FNAB results were nondiagnostic/unsatisfactory (ND/UNS) in 2.1% of the cases and benign in 51.4%. They indicated atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS) in 23.9% of cases, follicular neoplasia/suspicious for a follicular neoplasm (FN/SFN) in 9.2%, suspicion of malignancy (SUS) in 8.5%, and malignant in 4.9%. The histopathological analysis after thyroidectomy revealed a thyroid cancer rate of 100% in the FNABs classified as malignant, 33.3% in SUS cases, 7.7% in FN/SFN, 17.6% in AUS/FLUS, and 4.1% in benign FNABs. None of the ND/UNS FNABs were malignant. The global malignancy diagnosis was 14.8% (n = 21). However, the rate of false negatives for FNAB was low (4.1%).

Conclusion

We showed that the risk of malignancy in nodules with diameters ≥4 cm was higher compared to the risk of thyroid cancer in TN in general. However, we found a low rate of false-negative cytological results; therefore, our data do not justify the orientation of routine resection for these larger nodules.

Distant Metastasis as the First Presentation of Thyroid Carcinoma

Introduction

Thyroid carcinoma is the most common endocrine cancer which may manifest with unusual presentations. We addressed distant metastases as the first presentations of thyroid carcinoma in several patients, though previously considered to occur rarely.

Methods

In this case series, 10 patients are introduced with signs and symptoms of distant metastasis. Detailed history, physical examination, laboratory data, and histopathologic final report of thyroid cancer are presented.

Conclusion

Although it seems unusual to discover a distant metastasis without abnormal thyroid examination, several reports of similar findings urge the need to improve screening process. It is prudent to bear in mind these presentations for early detection of thyroid carcinoma.

The Relationship Between American College of Radiology Thyroid Imaging Reporting and Data System (ACR TIRADS) and Fine Needle Aspiration Cytology (FNAC) ; in Geriatric Thyroid Pathologies

 Introduction: The world population is getting older with each passing year.Thyroid cancer is the most common endocrinological cancer and its incidence is increasing in all populations. Although the increase in prevalence has been attributed more to the increased use of imaging methods and to the higher sensitivity of ultrasonography (USG) by some authorities, there are also studies suggesting a real increase.In our study, it was aimed to examine the USG and fine needle aspiration cytology (FNAC) results of thyroid nodules in the geriatric age group and to discuss them in the light of the literature. Methods: Files of 129 geriatric patients with thyroid nodules detected in the University Of Health Sciences Adana City Training and Research Hospital between 2018 and 2020 were retrospectively analyzed.The USG characteristics of the patients were categorized by scoring according to the ACR TIRADS system. FNAC diagnoses were grouped according to the Bethesda classification. Results: According to the ACR TIRADS grading, 4 patients (3.1%) were benign, 58 patients (45%) were not suspicious, 38 patients (29.5%) were mildly suspicious, 25 patients (19.4%) were moderately suspicious, and 4 patients (3.1%) were highly suspicious.In our study, although USG provided very valuable information in the approach to thyroid nodules, no relationship was found between TIRADS in the geriatric age group and FNAC results in our study (p = 0.117). Conclusion: We think that the approach to thyroid nodules in geriatric patients requires closer follow-up not only with USG data but also with clinical and history-based findings.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-022-03215-w.

Hemithyroidectomy in Papillary Thyroid Cancers: A Prospective, Single Institutional Surgical Audit and Contemplating on the Clinical Implications of 2015 American Thyroid Association Guidelines

Papillary thyroid carcinoma (PTC) contributes to 88% of thyroid malignancies and its extent of surgical management has been a topic of debate in the past 2 decades. American thyroid association (ATA) recommendations have been periodically updated for its robust and evidence-based management. We present our experience in implementing 2015 ATA guidelines, assessment of surgical outcomes of hemithyroidectomy in PTC ≤ 4 cm and contemplating on the potential clinical implications of 2015 ATA guidelines. A prospective study in a cohort of Bethesda class V and VI PTC with nodule ≤ 4 cm who underwent Hemithyroidectomy between 2012 and 2020. Data on thyroid nodule evaluation, management, histopathology and follow up were used for risk stratification. Of 37 patients, 27 (72.9%) were low risk and 10 (37%) were intermediate risk ATA group. 4 (40%) intermediate risk patients had structural incomplete response and underwent completion thyroidectomy. 1 (2.7%) out of 4 completion surgery patients required adjuvant radio-ablation iodine (RAI) and 3 patients were under surveillance. Overall, 2 (5.4%) of 37 patients, 1 each from low and intermediate groups were given remnant RAI in view of aggressive histology, old age and unwillingness for a completion surgery. During follow up of 4.94 ± 2.4 years, 35 (94.5%) showed excellent response and 2 (5.4%) showed biochemical incomplete response. The difference in RFS between two groups was statistically significant with p < 0.001. Thyroid preserving surgery combined with real time risk stratification seems appropriate for low and intermediate risk PTC ≤ 4 cm.

Association between macrocalcification and papillary thyroid carcinoma and corresponding valuable diagnostic tool: retrospective study

BACKGROUND

Microcalcifications are suggested to be an indicator of thyroid malignancy, especially for papillary thyroid carcinoma (PTC), nonetheless, the association between macrocalcification and PTC is underexplored. Furthermore, screening methods like ultrasonography and ultrasound-guided fine needle aspiration biopsy (US-FNAB) are limited in evaluating macro-calcified thyroid nodules. Thus, we aimed to investigate the relationship between macrocalcification and PTC. We also explored the diagnostic efficiency of US-FNAB and proto-Oncogene Proteins B-raf V600E (BRAF V600E) mutation in macro-calcified thyroid nodules evaluation.

METHODS

A retrospective research of 2645 thyroid nodules from 2078 participants was performed and divided into three groups as non-, micro-, and macro-calcified for further PTC incidence comparison. Besides, a total of 100 macro-calcified thyroid nodules with both results of US-FNAB and BRAF V600E mutation were screened out for subsequent evaluation of diagnostic efficiency.

RESULTS

Compared to non-calcification, macrocalcification showed a significantly higher incidence of PTC (31.5% vs. 23.2%, P<0.05). Additionally, when compared with a single US-FNAB, the combination of US-FNAB and BRAF V600E mutation showed better diagnostic efficiency in diagnosing macro-calcified thyroid nodule (area under the curve (AUC) 0.94 vs. 0.84, P=0.03), with a significantly higher sensitivity (100.0% vs. 67.2%, P<0.01) and a comparable standard of specificity (88.9% vs. 100.0%, P=0.13).

CONCLUSIONS

Occurrence of macrocalcification in thyroid nodules may suggest a high risk of PTC, and the combination of US-FNAB and BRAF V600E showed a greater value in identifying macro-calcified thyroid nodules, especially with significantly higher sensitivity.

TRIAL REGISTRATION

The Ethics Committee of The First Affiliated Hospital of Wenzhou Medical University (2018-026).

Does a three-degree hypoechogenicity grading improve ultrasound thyroid nodule risk stratification and affect the TI-RADS 4 category? A retrospective observational study

Objective

The aim of this study was to determine whether classifying hypoechogenicity in three degrees (mild, moderate, and marked) could improve the distinction between benign and malignant nodules and whether such an approach could influence Category 4 of the Thyroid Imaging Reporting and Data System (TI-RADS).

Materials and methods

In total, 2,574 nodules submitted to fine needle aspiration, classified by the Bethesda System, were retrospectively assessed. Further, a subanalysis considering solid nodules without any additional suspicious findings (n = 565) was performed with the purpose of evaluating mainly TI-RADS 4 nodules.

Results

Mild hypoechogenicity was significantly less related to malignancy (odds ratio [OR]: 1.409; CI: 1.086-1.829; p = 0.01), compared to moderate (OR: 4.775; CI: 3.700-6.163; p < 0.001) and marked hypoechogenicity (OR: 8.540; CI: 6.355-11.445; p < 0.001). In addition, mild hypoechogenicity (20.7%) and iso-hyperechogenicity (20.5%) presented a similar rate in the malignant sample. Regarding the subanalysis, no significant association was found between mildly hypoechoic solid nodules and cancer.

Conclusion

Stratifying hypoechogenicity into three degrees influences the confidence in the assessment of the rate of malignancy, indicating that mild hypoechogenicity has a unique low-risk biological behavior that resembles iso-hyperechogenicity, but with minor malignant potential when compared to moderate and marked hypoechogenicity, with special influence on the TI-RADS 4 category.

[Evaluation of accuracy of pathological diagnosis based on thyroid core needle biopsy]

OBJECTIVE

To explore the protocol for diagnosing thyroid nodules based on core needle biopsy (CNB) and study the biomarkers' application in distinguishing indeterminate samples.

METHODS

Patients with thyroid nodules treated at Peking University First Hospital from 2015 to 2020 were reviewed. In the study, 598 cases with CNB and matched resected specimens were retrieved. According to "diagnostic categories of thyroid CNB" proposed by the Korean Endocrine Pathology Thyroid Core Needle Biopsy Study Group, the CNB samples were diagnosed as follows: Ⅰ, unsatisfactory; Ⅱ, benign; Ⅲ, indeterminate; Ⅳ, follicular neoplasm; Ⅴ, suspicious for malignancy; and Ⅵ, malignant. The samples of CNB Ⅲ were stained by immunohistochemistry (IHC) using antibodies against CK19, Galectin-3, HBME-1, and CD56, and detected by next-generation sequencing (NGS) using an OncoAim^® thyroid cancer multigene assay kit (Singlera Genomics) that detected 26 genes. Taking the resected specimens' classification as the gold standard, the predictive value of CNB for determining the malignancy of thyroid nodules and the biomarkers for distinguishing the samples of CNB Ⅲ was calculated.

RESULTS

The study included 598 patients, of which none were CNB Ⅰ, 40 cases were CNB Ⅱ, 40 cases were CNB Ⅲ, 32 cases were CNB Ⅳ, 35 cases were CNB Ⅴ, and 451 cases were CNB Ⅵ. The predictive value of CNB Ⅳ for determining follicular neoplasm was sensitivity (Sen) 100.00% and specificity (Sep) 100.00%, CNB Ⅴ-Ⅵ for determining malignancy was Sen 94.55% and Sep 100.00%, CNB Ⅱ for determining benign lesions was Sen 75.00% and Sep 99.80%. The predictive value of biomarkers for determining malignancy in cases of CNB Ⅲ was Sen 96.30% and Sep 92.31% by NGS, and Sen 81.48% and Sep 92.30% by IHC.

CONCLUSION

The Korean "diagnostic categories of thyroid CNB", which considers the histological specificity of CNB samples and the habits of clinicians, have strong operability, high diagnosis rate, and high clinical value. Under this framework, the cases of CNB Ⅵ should be treated with surgical operation, the cases of CNB Ⅴ-Ⅵ are recommended to be treated as malignant neoplasms, and the major cases of CNB Ⅱ could be followed up without worrisome except the one considered malignant by ultrasound. The value of biomarkers in distinguishing the cases of CNB Ⅲ is significant.

Segmentation of thyroid glands and nodules in ultrasound images using the improved U-Net architecture

BACKGROUND

Identifying thyroid nodules' boundaries is crucial for making an accurate clinical assessment. However, manual segmentation is time-consuming. This paper utilized U-Net and its improved methods to automatically segment thyroid nodules and glands.

METHODS

The 5822 ultrasound images used in the experiment came from two centers, 4658 images were used as the training dataset, and 1164 images were used as the independent mixed test dataset finally. Based on U-Net, deformable-pyramid split-attention residual U-Net (DSRU-Net) by introducing ResNeSt block, atrous spatial pyramid pooling, and deformable convolution v3 was proposed. This method combined context information and extracts features of interest better, and had advantages in segmenting nodules and glands of different shapes and sizes.

RESULTS

DSRU-Net obtained 85.8% mean Intersection over Union, 92.5% mean dice coefficient and 94.1% nodule dice coefficient, which were increased by 1.8%, 1.3% and 1.9% compared with U-Net.

CONCLUSIONS

Our method is more capable of identifying and segmenting glands and nodules than the original method, as shown by the results of correlational studies.

Colorectal cancer metastases in thyroid: case report and literature review

BACKGROUND

The thyroid gland is an uncommon site for metastatic deposits from non-thyroid malignancies, occurring in only 1.4 - 3% of surgical specimens where malignancy is suspected. It is even rarer for the source of thyroid metastases to be of colorectal origin. In most cases reported, colorectal metastases in the thyroid occurs many years later after the primary colorectal cancer has been diagnosed and treated. In this unique case, a primary sigmoid carcinoma metastasised to the thyroid gland and presented synchronously as a thyroid nodule.

CASE PRESENTATION

We describe a case of a 64-year-old Caucasian woman who presented with clinical features of metastatic cancer of unknown origin. Her medical history included underlying hyperthyroidism. She had a large pelvic mass adjacent to the sigmoid colon, a left lower lobe lung mass and a suspicious nodule in the left thyroid lobe. A fine-needle aspiration biopsy of the thyroid nodule was performed, which remarkably showed malignant cells originating from primary colorectal cancer on immunohistochemical staining. The patient was managed with palliative chemotherapy given the poor prognosis due to disseminated colorectal malignancy.

CONCLUSIONS

Colorectal adenocarcinoma metastases can rarely present as a metastatic thyroid nodule. Fine-needle aspiration should be performed in suspicious thyroid nodules and may be the least invasive way of identifying a metastatic colorectal or other non-thyroidal malignancy in patients presenting with an unknown primary. The pathologist should be vigilant to this possibility and specific immunohistochemical markers should be used to ensure accurate diagnosis. In thyroid metastases, the prognosis is ultimately determined by the primary tumour but thyroidectomy still has a role in alleviating compressive symptoms and can potentially improve survival in selected cases.

Radiofrequency ablation of benign thyroid nodules: the value of anterolateral hydrodissection

PURPOSE

This study aimed to evaluate the technical feasibility, efficacy, and safety of anterolateral hydrodissection (ALHD) in radiofrequency ablation (RFA) for benign thyroid nodules.

METHODS

Between November 2019 and April 2020, 39 patients underwent 41 sessions of RFA with the ALHD technique to treat benign thyroid nodules. ALHD was performed with cold (0°C-4°C) 5% dextrose solution during RFA to minimize pain and secure sufficient safety margins from critical neck structures. The initial ablation ratio (IAR) was measured to assess the technique's efficiency. Ultrasound examinations, symptoms, and cosmetic scores were evaluated pre-procedure and at 6 and 12 months post-procedure. Procedure-related pain during RFA and complications were recorded.

RESULTS

The mean index nodule volume was 20.5±21.6 mL. ALHD was technically feasible in all patients. The mean IAR was 90.7%±8.3%, and significant reductions in mean nodule volume were noted at 6- and 12-month follow-ups (P<0.001, 63.9%±19.0%, and 76.3%±18.9%, respectively). Symptom and cosmetic scores showed significant improvements at 6- and 12-month follow-ups (P<0.001). Pain during the procedure was well-controlled with ALHD in all patients. After the initial use of 5-10 mL of lidocaine at the start of the procedure, no further lidocaine injection was given to any patient. Transient voice change was observed in one patient, but the patient recovered spontaneously within 30 minutes.

CONCLUSION

The ALHD technique was technically feasible and effective in all patients, achieving a mean IAR of 90.7%. The ALHD technique also had a pain-relieving effect, resulting in only low amounts of lidocaine administration being required during the procedure.

Predicting malignancy in thyroid nodules based on conventional ultrasound and elastography: the value of predictive models in a multi-center study

BACKGROUND

This study aimed to establish predictive models based on features of Conventional Ultrasound (CUS) and elastography in a multi-center study to determine appropriate preoperative diagnosis of malignancy in thyroid nodules with different risk stratification based on 2017 Thyroid Imaging Reporting and Data System by the American College of Radiology (ACR TI-RADS) guidelines.

METHODS

Five hundred forty-eight thyroid nodules from three centers pathologically confirmed by the cytology or histology were retrospectively enrolled in the study, which were examined by CUS and elastography before fine needle aspiration (FNA) and surgery. Characteristics of CUS of thyroid nodules were reviewed according to 2017 ACR TI-RADS. Binary logistic regression analysis was used to develop the prediction models based on the different risk stratification of CUS features and elastography which were statistically significant. Values of predictive models were evaluated regarding the discrimination and calibration.

RESULTS

Binary logistic regression showed that patients' age, taller-than-wider, lobulated or irregular boundary, extra-thyroid extension, microcalcification and the elastic parameter of Virtual touch tissue imaging quantification (VTIQ) max were independent predictors for thyroid malignancy (p < 0.05) in the ACR model and showed the area under the curve (AUC) in training (0.912) and validation cohort (internal and external: 0.877 vs 0.935). Predictive models showed predictors in ACR TR4 and TR5 for malignancy and diagnostic performance of AUC in training, internal and external validation cohort respectively: the VTIQ max (p < 0.001) with AUC of 0.809 vs 0.842 vs 0.705 and the age, taller than wide, VTIQ max variables with AUC of 0.859 vs 0.830 vs 0.906 in validation cohort. All predictive models have better calibration capabilities (p > 0.05).

CONCLUSIONS

Predictive models combined CUS and elastography features would aid clinicians to make appropriate preoperative diagnosis of thyroid nodules among different risk stratification. The elastography parameter of VTIQ max has the priority in distinguishing thyroid malignancy with moderately suspicious (ACR TR4).

Combined fine-needle aspiration with core needle biopsy for assessing thyroid nodules: a more valuable diagnostic method?

PURPOSE

This study aimed to evaluate the diagnostic value of combined fine-needle aspiration (FNA) with core needle biopsy (CNB) in thyroid nodules.

METHODS

FNA and CNB were performed simultaneously on 703 nodules. We compared the proportions of inconclusive results and the diagnostic performance for malignancy among FNA, CNB, and combined FNA/CNB for different nodule sizes.

RESULTS

Combined FNA/CNB showed lower proportions of inconclusive results than CNB for all nodules (2.8% vs. 5.7%, P<0.001), nodules ≤1.0 cm (4.9% vs. 7.3%, P=0.063), nodules >1.0 cm (2.0% vs. 5.0 %, P<0.001), nodules ≤1.5 cm (3.8% vs. 7.9 %, P<0.001), and nodules >1.5 cm (2.1% vs. 3.9 %, P=0.016). The sensitivity of combined FNA/CNB in predicting malignancy was significantly higher than that of CNB (89.0% vs. 80.0%, P<0.001) and FNA (89.0% vs. 58.1%, P<0.001) for all nodules. Within American College of Radiology Thyroid and Imaging Reporting and Data System grades 4-5, in the subgroup of nodules ≤1.5 cm, combined FNA/ CNB showed the best sensitivity in predicting malignancy (91.4%), significantly higher than that of CNB (81.0%, P<0.001) and FNA (57.8%, P<0.001). However, in the subgroup of nodules >1.5 cm, the difference between combined FNA/CNB and CNB was not significant (84.2% vs. 78.9%, P=0.500).

CONCLUSION

Regardless of nodule size, combined FNA/CNB tended to yield lower proportions of inconclusive results than CNB or FNA alone and exhibited higher performance in diagnosing malignancy. The combined FNA/CNB technique may be a more valuable diagnostic method for nodules ≤1.5 cm and nodules with a risk of malignancy than CNB and FNA alone.

Value of CEUS combined with feeding artery ablation in the microwave ablation of large solid benign thyroid nodules

OBJECTIVES

To investigate the value of contrast-enhanced ultrasound (CEUS) combined with feeding artery ablation in the microwave ablation (MWA) of large solid benign thyroid nodules (LSBTNs) with a diameter ≥ 4 cm.

METHODS

We retrospectively analyzed 122 patients with LSBTN ≥ 4 cm in diameter treated with MWA. During evaluations before and after MWA, 53 patients who underwent conventional ultrasound examination were classified as the routine group, and 69 patients who underwent CEUS combined with feeding artery ablation were classified as the union group. The differences in ablation energy required per milliliter (AERPM), complication rate, regrowth rate, and volume reduction rate (VRR) were compared between the two groups.

RESULTS

The AERPM of the union group was significantly less than that of the routine group (956.3 ± 38.5 J/mL vs. 1025.9 ± 121.5 J/mL, p < 0.001). The complication rate of the routine group was significantly higher than that of the union group (13.2% vs. 2.9%, p = 0.031). The regrowth rate of the routine group (22.6%, 12/53) was significantly higher than that of the union group (7.2%, 5/69) (p = 0.015). At the 1st, 3rd, 6th, 12th, 18th, and 24th month after ablation, the mean VRRs of the routine group were significantly less than those of the union group, with p values of < 0.001, < 0.001, 0.002, 0.007, 0.013, and < 0.001, respectively.

CONCLUSIONS

The application of CEUS combined with feeding artery ablation in the MWA of LSBTNs is helpful to reduce the regrowth rate, improve the ablation efficiency, and reduce bleeding.

KEY POINTS

• CEUS combined with feeding artery ablation in MWA of LSBTNs is helpful to reduce regrowth rate. • CEUS combined with feeding artery ablation can help improve ablation efficiency than conventional ultrasound in LSBTNs. • CEUS combined with feeding artery ablation helps reduce the incidence of bleeding during MWA.

When and why patients drop out from benign thyroid nodules follow-up: a single centre experience

PURPOSE

Drop-out in clinical long-term follow-up is a general problem that is potentially harmful to patients. No data about patients that drop out from thyroid ultrasound follow-up is available literature. The aim of the present retrospective study was to evaluate the characteristics of patients that dropped out from ultrasound thyroid nodule follow-up.

PATIENTS AND METHODS

We reviewed medical records of all consecutive patients who underwent a fine needle aspiration from January 2007 to March 2009 in our department. All the patients with benign nodule(s) were recommended annual ultrasounds; patients who had dropped out from follow-up were included and a telephone interview was obtained to evaluate the reasons for dropping out.

RESULTS

289/966 (30%) of patients with benign nodules dropped out during follow-up; 94% of them within the first 5 years. Phone interviews were obtained from 201/289 (70%) of the patients. In the 57% of cases, the main declared reason for dropping out was nodular dimension stability during the first 2-3 years; 8.7% of them had forgotten about the appointment; 6.4% of subjects claimed to check only serum TSH, and 3.2% stated that they would undergo an ultrasound only if the nodule(s) were symptomatic. Finally, 10.7% patients continued follow-up in other centres.

CONCLUSION

we showed that a third of patients miss their thyroid ultrasound follow-ups, and that the major cause is the low perceived threat coming from the disease. As a certain amount of drop-out is inevitable, attempting to reinforce our patients' awareness regarding their own health state is mandatory.

TRIAL REGISTRATION

Trial registration: no. 4084.

Thyroid region prior guided attention for ultrasound segmentation of thyroid nodules

Ultrasound segmentation of thyroid nodules is a challenging task, which plays an vital role in the diagnosis of thyroid cancer. However, the following two factors limit the development of automatic thyroid nodule segmentation algorithms: (1) existing automatic nodule segmentation algorithms that directly apply semantic segmentation techniques can easily mistake non-thyroid areas as nodules, because of the lack of the thyroid gland region perception, the large number of similar areas in the ultrasonic images, and the inherently low contrast images; (2) the currently available dataset (i.e., DDTI) is small and collected from a single center, which violates the fact that thyroid ultrasound images are acquired from various devices in real-world situations. To overcome the lack of thyroid gland region prior knowledge, we design a thyroid region prior guided feature enhancement network (TRFE+) for accurate thyroid nodule segmentation. Specifically, (1) a novel multi-task learning framework that simultaneously learns the nodule size, gland position, and the nodule position is designed; (2) an adaptive gland region feature enhancement module is proposed to make full use of the thyroid gland prior knowledge; (3) a normalization approach with respect to the channel dimension is applied to alleviate the domain gap during the training process. To facilitate the development of thyroid nodule segmentation, we have contributed TN3K: an open-access dataset containing 3493 thyroid nodule images with high-quality nodule masks labeling from various devices and views. We perform a thorough evaluation based on the TN3K test set and DDTI to demonstrate the effectiveness of the proposed method. Code and data are available at https://github.com/haifangong/TRFE-Net-for-thyroid-nodule-segmentation.

Analysis of 5 years' experience of a head and neck surgeon with radiofrequency ablation for benign thyroid nodule

PURPOSE

This study reports the long-term efficacy, safety, complications and management of radiofrequency ablation (RFA) for benign thyroid nodule performed over 5 years by a head and neck surgeon.

MATERIALS AND METHODS

We studied 287 consecutive patients who underwent RFA between March 2011 and January 2021. Pre- and postoperative thyroid nodule volumes were measured and volume reduction rate was calculated using ultrasonography (USG). Subjective symptom scores and cosmetic scores were investigated. Complications and their managements were analyzed. Complications and their management were investigated. Follow-up USG was performed at 6 and 12 months after RFA, and annually thereafter.

RESULTS

The mean volume reduction was 75.2 ± 23.8 % after 6 months and 91.9 ± 14.8 % after 5 years. All of nodule volume, and the cosmetic and symptom scores, decreased significantly postoperatively, and these scores were maintained to 5 years. Minor complications occurred in 15 of 287 (5.2 %) patients; there were no major complications. Injection laryngoplasty was performed for three patients with vocal cord paralysis. Two patients underwent open thyroid surgery because of nodule regrowth.

CONCLUSIONS

RFA is a safe and effective treatment without major complication for more than five years. Minor complications were managed by the head-and-neck surgeon personally.

A Triumvirate:: Correlating Thyroid Cytopathology, Molecular Testing, and Histopathology

Risk stratification is essential in the preoperative evaluation and management of thyroid nodules, most of which are benign. Advances in DNA and RNA sequencing have shed light on the molecular drivers of thyroid cancer. Molecular testing of cytologically indeterminate nodules has helped refine risk stratification, triage patients for surgery, and determine the extent of surgery. Molecular platforms with high negative predictive values can help identify nodules that may be spared surgery and can be managed conservatively. Here we discuss the importance of integrating cytomorphologic, molecular, and histologic features to help avoid errors and improve patient management.

Diagnostic value of ultrasound elastography and conventional ultrasound for thyroid nodules: a meta-analysis

Background

Thyroid nodular disease is a common disorder. Ultrasonography has emerged as a powerful tool for the diagnosis of thyroid disease owing to its high operational simplicity, non-invasiveness and reproducibility. This study aimed to systematically evaluate the value of ultrasound elastography and conventional ultrasound for the diagnosis of thyroid nodules.

Methods

The PubMed, EMBASE, Cochrane Library, China National Knowledge Infrastructure, Wanfang and VIP databases were searched systematically. RevMan 5.3 software was used to draw a risk bias map, and Stata 16.0 was used to plot a sensitivity and specificity forest map. A summary receiver operating characteristics (SROC) curve was plotted, and the area under the curve (AUC) was calculated. Meta-regression was used to explore the sources of heterogeneity.

Results

The sensitivity of conventional ultrasonography for detecting thyroid nodules was 0.55 [95% confidence interval (CI): 0.45-0.65], the specificity was 0.90 (95% CI: 0.87-0.93), the positive likelihood ratio was 5.8 (95% CI: 3.8-8.9), the negative likelihood ratio was 0.49 (95% CI: 0.39-0.6), and the AUC was 0.86 (95% CI: 0.82-0.88). The sensitivity of ultrasonic elastography for detecting thyroid nodules was 0.67 (95% CI: 0.60-0.73), the specificity was 0.93 (95% CI: 0.90-0.95), the positive likelihood ratio was 9.1 (95% CI: 6.3-13.3), the negative likelihood ratio was 0.36 (95% CI: 0.29-0.44), and the AUC was 0.89 (95% CI: 0.86-0.91). The sensitivity of conventional ultrasound combined with ultrasonic elastography for detecting thyroid nodules was 0.88 (95% CI: 0.84-0.90), the specificity of the combined approach was 0.96 (95% CI: 0.93-0.98), the positive likelihood ratio was 23.3 (95% CI: 12.4-43.6), the negative likelihood ratio was 0.13 (95% CI: 0.10-0.17), and the AUC was 0.92 (95% CI: 0.90-0.94). Age, region, research type, conventional ultrasound evaluation criteria and elastography evaluation criteria had specific effects on sensitivity and specificity when detecting thyroid nodules.

Conclusions

Conventional ultrasound can be used as a routine examination technique for the differential diagnosis of benign and malignant thyroid nodules, while ultrasound elastography can improve the sensitivity and specificity of the diagnosis. The diagnostic value of conventional ultrasound combined with ultrasound elastography is higher than that of a single diagnostic method.

The value of second opinions on thyroid nodule management provided via direct-to-consumer telemedicine service

PURPOSE

Second medical opinions (SMO) can improve patient outcomes and change medical decision-making. The purpose was to determine the concordance of initial management of thyroid nodules for patients seeking SMO to established management guidelines.

MATERIALS AND METHODS

Cases of patients consulting a single provider via telemedicine for SMO on the workup and management of thyroid nodule(s) were reviewed from September 2011 to February 2022. The primary outcome was the overall rate of adherence to 2015 ATA guidelines (correct/incorrect) and complete agreement (yes/no) between SMO and initial treatment team.

RESULTS

Most sought a second opinion for treatment options. Only 14 (29.2 %) cases had followed all the guidelines correctly. Living in North America compared to Asia (10/18 vs. 4/25, p = 0.004) and consulting endocrinology (11/21 vs. 3/26, p = 0.004) was associated with correct following of all guidelines. The most common violations of the guidelines were a lack of Bethesda scoring in pathology reports (31.8 %) and inappropriate initial FNA (25.5 %). The SMO was in complete agreement with the initial treatment recommendation in 31 cases (64.6 %), in partial agreement in 12 cases (25 %), and in disagreement in 5 cases (10.4 %).

CONCLUSIONS

In our study, adherence to guidelines was low. However, the SMO agreed with the workup and management of most patients, as most of this discordance with guidelines did not affect the overall treatment. The virtual second opinion consult was valuable in addressing patient-specific concerns, explaining additional treatment options, and, in a few cases, recommending against inappropriate surgical intervention.

Classification regularized dimensionality reduction improves ultrasound thyroid nodule diagnostic accuracy and inter-observer consistency

PROBLEM

Convolutional Neural Networks (CNNs) for medical image analysis usually only output a probability value, providing no further information about the original image or inter-relationships between different images. Dimensionality Reduction Techniques (DRTs) are used for visualization of high dimensional medical image data, but they are not intended for discriminative classification analysis.

AIM

We develop an interactive phenotype distribution field visualization system for medical images to accurately reflect the pathological characteristics of lesions and their similarity to assist radiologists in diagnosis and medical research.

METHODS

We propose a novel method, Classification Regularized Uniform Manifold Approximation and Projection (UMAP) referred as CReUMAP, combining the advantages of CNN and DRT, to project the extracted feature vector fused with the malignant probability predicted by a CNN to a two-dimensional space, and then apply a spatial segmentation classifier trained on 2614 ultrasound images for prediction of thyroid nodule malignancy and guidance to radiologists.

RESULTS

The CReUMAP embedding correlates well with the TI-RADS categories of thyroid nodules. The parametric version that embeds external test dataset of 303 images in presence of the training data with known pathological diagnosis improves the benign and malignant nodule diagnostic accuracy (p-value = 0.016) and confidence (p-value = 1.902 × 10^-6) of eight radiologists of different experience levels significantly as well as their inter-observer agreements (kappa≥0.75). CReUMAP achieve 90.8% accuracy, 92.1% sensitivity and 88.6% specificity in test set.

CONCLUSION

CReUMAP embedding is well correlated with the pathological diagnosis of thyroid nodules, and helps radiologists achieve more accurate, confident and consistent diagnosis. It allows a medical center to generate its locally adapted embedding using an already-trained classification model in an updateable manner on an ever-growing local database as long as the extracted feature vectors and predicted diagnostic probabilities of the correspondent classification model can be outputted.

Diagnostic Performance of Ultrasound-Based Risk Stratification Systems for Thyroid Nodules: A Systematic Review and Meta-Analysis

BACKGRUOUND

This study investigated the diagnostic performance of biopsy criteria in four society ultrasonography risk stratification systems (RSSs) for thyroid nodules, including the 2021 Korean (K)-Thyroid Imaging Reporting and Data System (TIRADS).

METHODS

The Ovid-MEDLINE, Embase, Cochrane, and KoreaMed databases were searched and a manual search was conducted to identify original articles investigating the diagnostic performance of biopsy criteria for thyroid nodules (≥1 cm) in four widely used society RSSs.

RESULTS

Eleven articles were included. The pooled sensitivity and specificity were 82% (95% confidence interval [CI], 74% to 87%) and 60% (95% CI, 52% to 67%) for the American College of Radiology (ACR)-TIRADS, 89% (95% CI, 85% to 93%) and 34% (95% CI, 26% to 42%) for the American Thyroid Association (ATA) system, 88% (95% CI, 81% to 92%) and 42% (95% CI, 22% to 67%) for the European (EU)-TIRADS, and 96% (95% CI, 94% to 97%) and 21% (95% CI, 17% to 25%) for the 2016 K-TIRADS. The sensitivity and specificity were 76% (95% CI, 74% to 79%) and 50% (95% CI, 49% to 52%) for the 2021 K-TIRADS1.5 (1.5-cm size cut-off for intermediate-suspicion nodules). The pooled unnecessary biopsy rates of the ACR-TIRADS, ATA system, EU-TIRADS, and 2016 K-TIRADS were 41% (95% CI, 32% to 49%), 65% (95% CI, 56% to 74%), 68% (95% CI, 60% to 75%), and 79% (95% CI, 74% to 83%), respectively. The unnecessary biopsy rate was 50% (95% CI, 47% to 53%) for the 2021 K-TIRADS1.5.

CONCLUSION

The unnecessary biopsy rate of the 2021 K-TIRADS1.5 was substantially lower than that of the 2016 K-TIRADS and comparable to that of the ACR-TIRADS. The 2021 K-TIRADS may help reduce potential harm due to unnecessary biopsies.