Risk factors associated with thyroid nodular disease in acromegalic patients: A case-cohort study in a tertiary center

INTRODUCTION

Goiter is very common in patients with acromegaly; its development is correlated to the duration of the disease. Thyroid cells express the IGF-1 receptor and the TSH/IGF-1 interaction has been demonstrated to have a synergistic effect in thyroid cell growth. There is a correlation between IGF-1 levels and the thyroid volume of patients with acromegaly. The aim of this study was to evaluate, in a retrospective case-cohort study of patients with acromegaly, the associated risk factors for thyroid nodules disease in this population.

METHODS

This was a case-cohort study matched by age, gender, and growth hormone at diagnosis. Cases consisted of acromegalic patients that developed thyroid nodules during the follow up, and controls consisted in acromegalic patients without thyroid nodules. A Cox proportional hazard estimation was carried out for measure the associated risk factors for thyroid nodules disease in acromegalic patients. A nodular thyroid disease-free survival analysis was estimated using the Kaplan-Meier analysis.

RESULTS

We recruited 49 cases and 56 controls. In a multivariate Cox proportional hazard analysis age and IGF-1 ≥ 2.2 x ULN were significantly related with the presence of thyroid nodules [HR of 2.21 (95% CI; 1.15-4.25, p = 0.01)]. Nodularity-free survival rates in patients who had an IGF-1 X ULN ≥ 2.2 was found to be lower in comparison to those who had IGF-1 X ULN < 2.2, according to a Kaplan-Meier survival analysis.

CONCLUSIONS

Our findings support that exist more probability to develop thyroid nodular disease in patients with acromegaly that present IGF-1 X ULN ≥ 2.2, suggesting a possible direct effect between the time of exposure to the IGF-1 axis hyperactivity and the genesis of thyroid nodules.

Evaluation of thyroid nodules by shear wave elastography: a review of current knowledge

PURPOSE

Shear wave elastography (SWE), as a tool for diagnosing thyroid malignancy, has gathered considerable attention during the past decade. Diverging results exist regarding the diagnostic performance of thyroid SWE.

METHODS

A comprehensive literature review of thyroid SWE was conducted using the terms "Thyroid" and "shear wave elastography" in PubMed.

RESULTS

The majority of studies found SWE promising for differentiating malignant and benign thyroid nodules on a group level, whereas results are less convincing on the individual level due to huge overlap in elasticity indices. Further, there is lack of consensus on the optimum outcome reflecting nodule elasticity and the cut-off point predicting thyroid malignancy. While heterogeneity between studies hinders a clinically meaningful meta-analysis, the results are discussed in a clinical perspective with regard to applicability in clinical practice as well as methodological advantages and pitfalls of this technology.

CONCLUSION

Technological as well as biological hindrances seem to exist for SWE to be clinically reliable in assessing benign and malignant thyroid nodules. Structural heterogeneity of thyroid nodules in combination with operator-dependent factors such as pre-compression and selection of scanning plane are likely explanations for these findings. Standardization and consensus on the SWE acquisition process applied in future studies are needed for SWE to be considered a clinically reliable diagnostic tool for detection of thyroid cancer.

Comparing the rate and extent of malignancy in surgically excised thyroid nodules across race and ethnicity

BACKGROUND

Few studies have compared the features of thyroid cancer among races and ethnicities. We hypothesized that race and ethnicity may influence the frequency and features of thyroid malignancy in thyroid nodules.

METHOD

This was a retrospective chart review of patients between 2013 and 2020 who underwent thyroidectomy.

RESULTS

In the analysis of 2737 patients, thyroid cancer was less prevalent among Blacks (24.0% vs Whites 52.1%, Hispanics 58.7%, Asians 71.7%, and Others 57.9%, p < 0.001). Thyroid cancer in Blacks was less likely to have extrathyroidal extension (9.7% vs Whites 18.6%, Hispanics 25.8%, Asians 18.2%, and Others 17.8%, p = 0.01), overall nodal involvement (12.4% vs Whites 31.1%, Hispanics 37.5%, Asians 36.3%, and Others 30.1%, p < 0.01), and lateral neck metastasis (4.4% vs Whites 10.8%, Hispanics 6.3%, Asians 13.2%, and Others 9.6%, p = 0.02).

CONCLUSIONS

Race and ethnicity may play important roles in the risk of malignancy as well as in the extent of thyroid cancer.

The association between BMI, smoking, drinking and thyroid disease: a cross-sectional study in Wuhan, China

BACKGROUND

There is no clear conclusion on the relationship between thyroid disease and obesity and lifestyle factors such as smoking and drinking. In this study, we analysed the association of body mass index (BMI), smoking and drinking with subclinical hypothyroidism (SHO) and thyroid nodules (TNs) with the results of a cross-sectional survey of urban residents in central China and discussed the potential mechanism linking these predictive factors and the two diseases.

METHODS

This study included 1279 participants who were recruited from a Chinese community in 2011 and 2012. A questionnaire, laboratory examination and ultrasound diagnosis were conducted on these participants. Binary logistic regression analysis was used to analyse these factors.

RESULTS

Overweight (BMI ≥ 25 kg/m²) was closely related to SHO and TNs in univariate and multivariate logistic regression analyses. Smoking had a protective effect on SHO and TNs, while drinking had a protective effect on TNs in univariate logistic regression and multivariate logistic regression with some covariates, but there was no significant difference between smoking and drinking and the two kinds of thyroid diseases in multivariate logistic regression analysis with all the covariates. In subgroup analysis, BMI ≥ 25 kg/m2 was significantly associated with SHO in people with positive thyroid antibodies (odds ratio (OR) = 2.221, 95 % confidence interval (CI): 1.168-4.184, P = 0.015) and smokers (OR = 2.179, 95 % CI: 1.041-4.561, P = 0.039). BMI ≥ 25 kg/m2 was significantly associated with TNs in people over 60 years old (OR = 2.069, 95 % CI: 1.149-3.724, P = 0.015) and drinkers (OR = 3.065, 95 % CI: 1.413-6.648, P = 0.005). Drinking alcohol had a protective effect on TNs in smokers (OR = 0.456, 95 % CI: 0.240-0.865, P = 0.016) and people with BMI ≥ 25 kg/m² (OR = 0.467, 95 % CI: 0.236-0.925, P = 0.029). No significant association was found between smoking and the two thyroid diseases in different subgroups.

CONCLUSIONS

Obesity is a risk factor for both TNs and SHO, especially in elderly individuals and people with positive thyroid autoantibodies. Obesity and metabolic syndrome may be more associated with TNs than SHO. Smoking may have a protective effect on thyroid disease, while drinking may have a protective effect only on TNs.

Accuracy of shear wave elastography in characterization of thyroid nodules in children and adolescents

BACKGROUND

Thyroid nodules are an important health problem in children and adolescents. They possess a higher risk of malignancy in comparison to adults. This fact forms a great dilemma for clinicians. The aim of this study was to evaluate the reliability of shear wave elastography (SWE) as a non-invasive technique in the characterization of thyroid nodules in children and adolescents.

METHODS

This prospective study included 56 patients with thyroid nodules. All the patients underwent clinical assessment, laboratory investigations, ultrasound, and Doppler examination, followed by an SWE assessment. Statistical analysis was performed and the best cut-off value to differentiate benign from malignant nodules was determined using the ROC curve and AUC.

RESULTS

Seventy-two nodules were detected in the examined patients (ages ranged from 11 to 19 years, with mean age of 14.89 ± 2.3 years). Fifty-eight nodules (80.6%) were benign, and fourteen nodules (19.4%) were malignant (histopathologically proved). Highly suspicious criteria for prediction of malignancy by ultrasound and Doppler were hypoechoic echopattern, internal or internal and peripheral vascularity, microcalcifications, taller-than-wide dimensions, irregular outlines, and absence of halo (p < 0.05). The diagnostic performance for their summation was 70.69% sensitivity, 82.8% specificity, 80.45% accuracy, a 63.79% positive predictive value (PPV), and 87.9% negative predictive values (NPV). Regarding SWE, our results showed that 42.2 kPa was the best cut-off value, with AUC = 0.921 to differentiate malignant from benign nodules; the diagnostic performance was 85.71% sensitivity, 94.83% specificity, 93.06% accuracy, 76.9% PPV, and 93.2% NPV.

CONCLUSION

Shear wave elastography is a non-invasive technique that can assist in the diagnosis of malignant thyroid nodules among children and adolescents.

Analysis of the correlation between high iodized salt intake and the risk of thyroid nodules: a large retrospective study

BACKGROUND

Currently, whether daily excess iodized salt intake increases the risk of thyroid nodules and even thyroid cancer remains controversial. Our research group aimed to provide a theoretical basis for the clinical guidance of daily iodized salt intake and the prevention of thyroid nodules through a retrospective analysis of the correlation between daily iodized salt intake and the risk of thyroid nodules and thyroid cancer in Hunan, China.

METHODS

This study retrospectively analyzed the data of subjects who underwent a physical examination at the Health Management Center, Third Xiangya Hospital of Central South University, between January 1, 2017, and December 31, 2019. Subjects enrolled in this study underwent thyroid ultrasonography and tests to urine routines and liver and kidney function, and all subjects completed a questionnaire survey. The daily iodized salt intake of the study subjects was estimated based on spot urine methods (Tanaka). A multivariate logistic regression model was used to analyze the relationship between daily iodized salt intake and thyroid nodules and thyroid cancer.

RESULTS

Among the 51,637 subjects included in this study, the prevalence of thyroid nodules was 40.25%, and the prevalence of thyroid cancer was 0.76%; among all enrolled subjects, only 3.59% had a daily iodized salt intake less than 5 g. In addition, we found that a daily intake of more than 5 g of iodized salt was not only an independent risk factor for the occurrence of thyroid nodules (odds ratio (OR): 2.08, 95% confidence interval (CI): 1.86-2.31, p < 0.001) but also an independent risk factor for the occurrence of thyroid cancer (OR: 5.81, 95% CI: 1.44-23.42, p = 0.012). A pooled analysis showed a significantly higher risk of thyroid nodules in subjects aged > 60 years with a daily iodized salt intake of more than 5 g compared to subjects aged < 60 years with a daily iodized salt intake of no more than 5 g (OR: 4.88, 95% CI: 4.29-5.54, p < 0.001); the risk of thyroid cancer was not significantly different between subjects aged > 60 years with a daily iodized salt intake of more than 5 g and those aged < 60 years with a daily iodized salt intake of no more than 5 g (OR: 2.15, 95% CI: 0.52-8.95, p = 0.281). The risk of thyroid nodules was not increased in physically active subjects with a daily iodized salt intake of more than 5 g compared to physically inactive subjects with a daily iodized salt intake of no more than 5 g (OR: 1.12, 95% CI: 0.97-1.28, p = 0.111). The same protective effect of physical activity was observed for thyroid cancer in subjects whose daily iodized salt intake exceeded 5 g. The risk of thyroid nodules was reduced for subjects with an education level of postgraduate and above, even when the daily iodized salt intake exceeded 5 g, compared to those with high school education and below and a daily iodized salt intake of no more than 5 g (OR: 0.79, 95% CI: 0.66-0.93, p = 0.005); however, a protective effect of education level on the occurrence of thyroid cancer was not observed. Independent risk factors affecting daily iodized salt intake greater than 5 g included age, triglycerides, family history of tumors, physical activity, and marital status.

CONCLUSIONS

Daily intake of more than 5 g of iodized salt increased the risk of thyroid nodules and thyroid cancer, while increased physical activity and education level reduced the risk of thyroid nodules and thyroid cancer caused by iodized salt intake.

Thyroid and COVID-19: a review on pathophysiological, clinical and organizational aspects

BACKGROUND

Thyroid dysfunction has been observed in patients with COVID-19, and endocrinologists are requested to understand this clinical issue. Pandemic-related restrictions and reorganization of healthcare services may affect thyroid disease management.

OBJECTIVE AND METHODS

To analyze and discuss the relationship between COVID-19 and thyroid diseases from several perspectives. PubMed/MEDLINE, Google Scholar, Scopus, ClinicalTrial.gov were searched for this purpose by using free text words and medical subject headings as follows: "sars cov 2", "covid 19", "subacute thyroiditis", "atypical thyroiditis", "chronic thyroiditis", "hashimoto's thyroiditis", "graves' disease", "thyroid nodule", "differentiated thyroid cancer", "medullary thyroid cancer", "methimazole", "levothyroxine", "multikinase inhibitor", "remdesivir", "tocilizumab". Data were collected, analyzed, and discussed to answer the following clinical questions: "What evidence suggests that COVID-19 may induce detrimental consequences on thyroid function?"; "Could previous or concomitant thyroid diseases deteriorate the prognosis of COVID-19 once the infection has occurred?"; "Could medical management of thyroid diseases influence the clinical course of COVID-19?"; "Does medical management of COVID-19 interfere with thyroid function?"; "Are there defined strategies to better manage endocrine diseases despite restrictive measures and in-hospital and ambulatory activities reorganizations?".

RESULTS

SARS-CoV-2 may induce thyroid dysfunction that is usually reversible, including subclinical and atypical thyroiditis. Patients with baseline thyroid diseases are not at higher risk of contracting or transmitting SARS-CoV-2, and baseline thyroid dysfunction does not foster a worse progression of COVID-19. However, it is unclear whether low levels of free triiodothyronine, observed in seriously ill patients with COVID-19, may worsen the disease's clinical progression and, consequently, if triiodothyronine supplementation could be a tool for reducing this burden. Glucocorticoids and heparin may affect thyroid hormone secretion and measurement, respectively, leading to possible misdiagnosis of thyroid dysfunction in severe cases of COVID-19. High-risk thyroid nodules require a fine-needle aspiration without relevant delay, whereas other non-urgent diagnostic procedures and therapeutic interventions should be postponed.

DISCUSSION

Currently, we know that SARS-CoV-2 could lead to short-term and reversible thyroid dysfunction, but thyroid diseases seem not to affect the progression of COVID-19. Adequate management of patients with thyroid diseases remains essential during the pandemic, but it could be compromised because of healthcare service restrictions. Endocrine care centers should continuously recognize and classify priority cases for in-person visits and therapeutic procedures. Telemedicine may be a useful tool for managing patients not requiring in-person visits.

Real-life use of BRAF-V600E mutation analysis in thyroid nodule fine needle aspiration: consequences on clinical decision-making

PURPOSE

This study aimed to evaluate the real-life use of BRAF-V600E mutation analysis in washout liquid from thyroid nodule fine needle aspiration (FNA), and the consequences of genetic result on clinical decision-making.

METHODS

We retrospectively considered subjects tested for BRAF-V600E among those attending the Endocrinology Unit of Modena for FNA between 2014 and 2018. Washing fluid was collected together with cytological sample and stored at -20 °C. If the clinician deemed it necessary, the sample was thawed, DNA extracted, and genetic test performed by high-resolution melting technique. We collected data on cytology according to the Italian Consensus for the cytological classification of thyroid nodules, type of surgery (when performed), histology, and adverse events.

RESULTS

Out of 7112 subjects submitted to FNA, BRAF analysis was requested for 683 (9.6%). Overall, 896 nodules were analyzed: 74% were indeterminate at cytology, mainly TIR3A (low risk). Twenty-two nodules were mutant (BRAF+). Only 2% of indeterminate, mainly TIR3B, were BRAF+. Based on final histological diagnosis, BRAF test had high specificity (100%) but poor sensitivity (21%), also in indeterminate nodules. Mutant subjects underwent more extensive surgery compared to wild type (p = 0.000), with frequent prophylactic central lymph node dissection. One third had local metastases. Higher prevalence of hypoparathyroidism was found in BRAF+ compared to wild type (p = 0.018).

CONCLUSIONS

The analysis of BRAF-V600E outside of gene panels has low sensitivity, especially in indeterminate nodules, and a positive result could lead to more extensive surgery with greater risk of hypoparathyroidism and questionable clinical utility.

Iodine Nutrition and the Prevalence Status of Thyroid Nodules in the Population: a Cross-sectional Survey in Heilongjiang Province, China

The aim of this study was to determine the iodine nutritional status and the epidemiological characteristics of thyroid nodules (TNs) in the adult population of Heilongjiang Province. From December 2017 to December 2018, a total of 3661 adults aged 20-70 years were selected through probability proportional to size (PPS) sampling for a cross-sectional survey. During the field epidemiological investigation, each participant received a questionnaire survey and thyroid ultrasonography examination. The iodine concentrations in casual urine specimens and household edible salt were measured. The household coverage of iodized salt was 86.56%. The median urinary iodine concentration (MUIC) in the adult population in Heilongjiang Province was 161.57 μg/L (25th-75th percentile: 100.35-245.15 μg/L). The prevalence of TNs was 36.88%, and the prevalence in females was significantly higher than that in males (41.25% vs 32.50%, χ² = 11.841, P < 0.01). The prevalence of TNs increased with age (χ²_trend = 49.80, P < 0.001). The prevalence of multiple TNs increased with age (χ²_trend = 48.709, P < 0.001). There was no significant difference in the MUIC between healthy control group and those with TNs (Z = - 1.386, P = 0.166). The female, age (40-49 age group, 50-59 age group, 60-70 age group), BMI (obesity, overweight), history of hypertension, history of diabetes, and smoking history were all independent risk factors that affected the occurrence of TNs. The iodine nutritional status of the adult population in Heilongjiang Province was adequate. The prevalence of TNs was higher in middle-aged and elderly women, so these individuals should be the focus of the prevention and treatment of thyroid nodule disease.

Prevalence and associated metabolic factors for thyroid nodules: a cross-sectional study in Southwest of China with more than 120 thousand populations

OBJECTIVE

To explore the prevalence and its associated metabolic factors of thyroid nodules (TNs) among subjects who participated in the physical examinations in Chongqing, China.

METHODS

The participants from the Health Management Center of JinShan Hospital of Chongqing Medical University, between September 2015 and May 2020, were included in this study. All of the participants underwent thyroid ultrasonography, anthropometric measurements, and serum examinations. Differences in the TNs prevalence were compared with the chi-square test or Wilcoxon rang-sum test. Multivariable logistic regression analyses were used to estimate the metabolic factors associated with TNs and multiple thyroid nodules (MTNs).

RESULTS

Of the included 121,702 participants, 41,547 had TNs, and 20,899 had MTNs, with the prevalence of 34.1 and 17.0 %, respectively. Women had a significantly higher prevalence of TNs than men (40.6 % vs. 29.8 %; χ² = 1517.33, P < 0.001), and TNs prevalence was gradually increased with age (P for trend < 0.001). Female gender, advanced age, and metabolic factors including central obesity, hypertension, diabetes and fatty liver were positively associated with TNs; BMI, hyperlipoidemia and hyperuricemia were not independent risk factors of TNs. While female gender, advanced age, central obesity, hypertension and diabetes were independent risk factors of MTNs.

CONCLUSIONS

The prevalence of thyroid nodules was relatively high. The associated factors identified in this study could help the clinicians to detect the high-risk patients and make targeted screening strategies for the preventing of the occurrence of TNs.

Prevalence and predictors of thyroid cancer among thyroid nodules: a retrospective cohort study of 1,000 patients

INTRODUCTION

Thyroid cancer is increasing in incidence globally due either to early detection (overestimation) or true increment. A recent debate concerns multinodular goitre (MNG) or toxic goitres which have classically been considered at a lower risk for cancer.

METHODS

In this study, we enrolled retrospectively all patients with nodular goitre treated at our tertiary hospital and analysed their data with the aim of detecting the rate of cancer among different types of nodular goitre. We also studied predictors of incidental malignancy among thyroidectomies.

RESULTS

A predilection for solitary thyroid nodules (STNs) was found in women of younger age, with STNs tending to be larger in comparison with MNG in the same age group. However, both types of nodules were at equal risk of harbouring malignancy. Thyroid Imaging Reporting and Data System (TI-RADS) and Bethesda scores were the only dependent predictors of malignancy within thyroid nodules.

CONCLUSION

The authors recommend management of both STNs and MNG using the same algorithm.

False Negative Rates in Benign Thyroid Nodule Diagnosis: Machine Learning for Detecting Malignancy

BACKGROUND

Thyroid nodules are common; up to 67% of adults will show nodules on high-quality ultrasound, and 95% of these nodules are benign. FNA cytology is a crucial step in determining the risk of malignancy, and a false negative diagnosis at this stage delays cancer treatment. The purpose of this study is to develop a predictive model using machine learning which can identify false negative FNA results based on less-invasive clinical data.

MATERIALS AND METHODS

We conducted a retrospective medical record review at one academic and one community center. Inclusion criteria were thyroid nodules evaluated by ultrasound and FNA with a Bethesda II (benign) result or malignancy detected on pathology or FNA. Linear, non-linear, and ensemble models were generated with scikit-learn using 10-fold cross validation with repetition and compared with AUROC. The classification task was the prediction of malignancy using information acquired from less-invasive ultrasound and FNA.

RESULTS

A total of 604 subjects met inclusion criteria; 38 were diagnosed with malignancy. Of all algorithms tested, a Random Forest method achieved the best AUROC (0.64) in separating benign and malignant nodules, though the improvement over other tested algorithms was not statistically significant.

CONCLUSIONS

A Random Forest model performed better than random chance using readily available data obtained via standard evaluation of thyroid nodules. The diagnostic probability threshold of this model can be varied to minimize false positives at the cost of increasing the number of false negatives. Future studies will prospectively evaluate the model's performance.

Improving Malignancy Prediction in AUS/FLUS Pediatric Thyroid Nodules with the Aid of Ultrasound

INTRODUCTION

The standard workup of thyroid nodules concerning for malignancy includes fine-needle aspiration (FNA). In 2015, the American Thyroid Association (ATA) guidelines for the management of pediatric thyroid nodules recommended that all nodules with a Bethesda III cytology undergo surgical resection.

OBJECTIVES

To correlate a Bethesda III cytology with histologic and clinical outcomes to determine the relevance of the ATA recommendations, and to evaluate whether Thyroid Imaging Reporting and Data System (TI-RADS) scoring could identify Bethesda III nodules at a lower risk of malignancy.

METHODS

A retrospective chart review of patients who had undergone thyroid nodule FNA from 2008 to 2018 was performed. Malignancy rates were determined for each Bethesda category. The reference standard was histopathology or 2-year follow-up of imaging outcomes for nonoperative cases. Ultrasound exams of Bethesda III nodules were reviewed and TI-RADS scores assigned.

RESULTS

A total of 143 FNA samples from 128 patients were identified. The mean age was 14.9 years (range 7-22). Twenty-two (15%) of the FNA samples were Bethesda III; the malignancy rate was 38%. A TI-RADS score was assigned in 20 of the 22 Bethesda III nodules. ROC analysis found an optimal cut-off for malignancy prediction of ≥7 points (risk category TR5). The negative predictive value was 85.7% (95% CI 35.9-99.6) and the positive predictive value was 83.3% (95% CI 57.2-98.2).

CONCLUSION

Although, at baseline, thyroid nodules with a Bethesda III classification carry a moderate risk of malignancy in the pediatric population, TI-RADS scoring can identify nodules with a lower risk within this group. If validated by larger studies, this can inform decision making and reduce unneeded surgery.

Molecular Testing Has Limited Utility in the Surgical Evaluation of Bethesda III Thyroid Nodules

BACKGROUND

The Bethesda System for Reporting Thyroid Cytopathology has 6 diagnostic categories, each with an implied cancer risk of malignancy (ROM). Bethesda III, defined as atypia or follicular lesions of undetermined significance (AUS/FLUS) on fine needle aspiration (FNA), has an indeterminate ROM. This study investigates the utility of Afirma Gene Expression Classifier (GEC) and Thyroid Sequencing (ThyroSeq) molecular testing to predict malignancy in AUS/FLUS thyroid nodules.

METHODS

A retrospective review of prospectively collected data of 1457 patients with index thyroid nodules who underwent FNA and thyroidectomy at a single academic institution was performed. Use of GEC or ThyroSeq for AUS/FLUS thyroid nodules was examined. GEC testing was reported benign or suspicious for malignancy whereas ThyroSeq testing was reported on a spectrum of low, intermediate or high ROM. Descriptive statistics were utilized to compare the ROM among AUS/FLUS thyroid nodules.

RESULTS

Of 1457 patients with FNA thyroid cytology, 359 (25%) corresponded to AUS/FLUS results. There were 132 (37%) patients with GEC testing and 88 (24%) had ThyroSeq testing. ROM without GEC or ThyroSeq testing was 49%, whereas ROM with suspicious GEC was 55%. ROM with positive ThyroSeq was 73%. Among ThyroSeq patients, 43 had intermediate-risk mutations with 60% malignancy, and 23 had high-risk mutations with 96% malignancy (P < 0.01).

CONCLUSION

Surgical patients with AUS/FLUS thyroid nodules have a high ROM. High-risk ThyroSeq testing may have some utility in predicting malignancy, but GEC and intermediate-risk TGC results have limited value. Surgeons should carefully consider the utility of molecular tests to determine surgical resection.

Performance of afirma gene sequencing classifier versus gene expression classifier in thyroid nodules with indeterminate cytology

INTRODUCTION

About 15% to 30% of thyroid fine-needle aspiration (FNA) nodules have indeterminate cytology. The Afirma (Veracyte Inc, South San Francisco, CA) Gene Expression Classifier (GEC)/Gene Sequencing Classifier (GSC) tests were designed to improve risk stratification of the indeterminate thyroid nodules. This study aimed to evaluate and compare the performance of the Afirma GEC and GSC tests in the indeterminate thyroid lesions.

METHODS

Thyroid FNA cases with indeterminate cytology were searched in the pathology database and only those with available Afirma results were selected for this study. Each patient's demographic, sonographic, cytologic, molecular, and subsequent surgical follow-up results were collected and analyzed.

RESULTS

There were 100 cases with indeterminate thyroid FNA results, including 49 cases tested by GEC and 51 cases by GSC. In the GEC group, benign call rate (BCR) was 53% (26 of 49) and the calculated negative predictive value (NPV) and positive predictive value (PPV) were 88% and 47% respectively. In the GSC group, the BCR was 63% (32 of 51) and the calculated NPV and PPV were 100% and 64%, respectively. Whereas only 17% (1 of 6) of benign oncocytic lesions were tested benign by the GEC, 60% (3 of 5) of benign oncocytic nodules were tested benign by the GSC.

CONCLUSION

We demonstrated in this study that a little more than half of the indeterminate thyroid nodules had negative Afirma GEC/GSC results and the BCR using the Afirma GSC test was higher than GEC. The Afirma GSC showed higher NPV and PPV than GEC. In addition, the Afirma GSC appeared to be superior for differentiating benign and malignant oncocytic thyroid lesions.

The Value of Ultrasound-Guided Fine-Needle Aspiration Cytology Combined with Puncture Feeling in the Diagnosis of Thyroid Nodules

INTRODUCTION

There are few studies on the role of puncture feeling in thyroid nodules during ultrasound-guided fine-needle aspiration cytology (US-FNAC), although it is expected to become a new predictive technique. We aimed to analyze the importance of puncture feeling in combination with US-FNAC and investigate whether it can be used as an indicator to predict the nature of thyroid nodules.

MATERIALS AND METHODS

From January 1, 2018, to October 31, 2020, a total of 623 thyroid nodules were included. Puncture feeling was classified as "soft," "hard," or "hard with grittiness." The correlation between puncture feeling and postoperative pathology and the diagnostic value of FNAC combined with puncture feeling were analyzed, and the influence of thyroid nodule size on puncture feeling, FNAC, and FNAC combined with puncture feeling was studied. We further explored the correlation between puncture feeling and histopathology in Bethesda III and IV thyroid nodules.

RESULTS

There was a significant correlation between puncture feeling and postoperative pathology (p < 0.001). The sensitivity, negative predictive value, and total coincidence rate of US-FNAC combined with puncture feeling for the diagnosis of thyroid nodules were higher than those of US-FNAC alone (96.1, 83.6, and 94.7% vs. 89.0, 65.5, and 89.7%, respectively). Thyroid nodule size was the influencing factor for puncture feeling, FNAC, and FNAC combined with puncture feeling (p < 0.05 for all). The area under the curve for puncture feeling, FNAC, and FNAC combined with puncture feeling for thyroid nodules of size ≤1 cm was greater than for modules of size >1 cm. Puncture feeling was of great value in diagnosing Bethesda III thyroid nodules (p < 0.001), and all Bethesda IV thyroid nodules had puncture feeling of soft.

CONCLUSION

Puncture feeling is of great value during US-FNAC. "Hard" and "hard with grittiness" were indicators for malignancy, while "soft" indicated that the thyroid nodule was likely to be benign. The diagnostic value of US-FNAC combined with puncture feeling for thyroid nodules is higher than US-FNAC alone, especially when nodule size is ≤1 cm. Puncture feeling is of great value in predicting the nature of Bethesda III thyroid nodules.

Comparison of ACR TI-RADS, Kwak TI-RADS, ATA guidelines and KTA/KSThR guidelines in combination with SWE in the diagnosis of thyroid nodules

OBJECTIVE

To compare the diagnostic efficacy of ACR TI-RADS, Kwak TI-RADS, ATA guidelines and KTA/KSThR guidelines in combination with shear wave elastography (SWE) for thyroid nodules.

METHODS

The retrospective study included 566 thyroid nodules with maximum diameter≥5 mm which confirmed by FNA cytology or/and surgical pathology. The sensitivity, specificity, accuracy, Youden index of diagnosis of thyroid nodules by ACR TI-RADS, Kwak TI-RADS, ATA guidelines, KTA/KSThR guidelines and SWE were calculated. The ROC curve was drawn to determine the cut-off values of the four ultrasound classification systems and SWE Emax. The diagnostic efficacy of the four ultrasound classification systems in combination with SWE were calculated and compared with those of pre-combination.

RESULTS

The ROC curves indicated that the cut-off value of ACR TI-RADS, Kwak TI-RADS, ATA guidelines, KTA/KSThR guidelines and Emax of SWE was TR5, 4c, high-suspicion, high-suspicion, and 41.7 kPa, respectively, and the area under the ROC curve (AUC) was 0.907(0.879-0.934), 0904(0.876-0.932), 0.894(0.863-0.924), 0.888(0.856-0.919), 0.886(0.859-0.913), respectively. After combination with SWE, the the sensitivities of the four ultrasound classification systems for the diagnosis of nodules were improved, and the differences were statistically significant (all P≤0.001); the specificities were decreased, but the differences were not statistically significant (all P > 0.05); the accuracies were improved, but only the difference of ACR TI-RADS was statistically significant (x2 = 4.45, P = 0.035); the differences in the AUCs were not significant (all P > 0.05).

CONCLUSIONS

The four ultrasound classification systems and SWE all had high performance in the diagnosis of thyroid nodules. The four classification systems in combination with SWE were all beneficial to the differential diagnosis of nodules, and ACR TI-RADS in combination with SWE was more effective, especially for TR3 and TR4 nodules.

Validation of TIRADS ACR Risk Assessment of Thyroid Nodules in Comparison to the ATA Guidelines

Objectives:

The prevalence of thyroid nodules in adults, detected by ultrasound (US), is reported as high as 68%. US-guided fine-needle aspiration biopsy (FNAB) is the test of choice used to determine the nature of the nodules. However, not more than 15% are found to be malignant. Reducing the number of unnecessary FNAB while identifying clinically significant malignant nodules is imperative. There are several guidelines suggested for risk stratification of thyroid nodules by US. The aim of our study was to validate and compare Thyroid Imaging Reporting and Data System (TIRADS) American College of Radiology (ACR) and American Thyroid Association (ATA) risk stratification, specifically pertaining to reduction of unnecessary biopsies.

Material and Methods:

The study included 281 nodules in 245 patients who underwent FNAB between May 2018 and June 2019. Statistical analysis was performed only on 235 nodules that according to the TIRADS ACR and/ or ATA guidelines were eligible for FNAB. Data collected included nodule characteristics with corresponding TIRADS and ATA grading and cytological results using Bethesda scoring.

Results:

An agreement was found between the two criteria methods in 58.2% (137/235) of the cases. In 35.3% (83/235), ATA recommended FNAB while TIRADS did not. The specificity for ATA criteria was 7% (15/221) and for TIRADS was 37% (81/221). The sensitivity was 100% (14/14) for ATA and 86% (12/14) for TIRADS.

Conclusion:

Application of ACR TIRADS criteria can reduce the number of US-guided FNAB performed on benign nodules compared to ATA criteria, by 35%, with a cost of only two missed carcinomas that remained on further follow-up.

Thyroid nodules in xeroderma pigmentosum patients: a feature of premature aging

PURPOSE

Xeroderma pigmentosum (XP) is an autosomal recessive disease with defective DNA repair, a markedly increased risk of skin cancer, and premature aging. Reports from North Africa have described thyroid nodules in XP patients, but thyroid nodule prevalence has never been determined in XP patients enrolled in our natural history study at the National Institutes of Health (NIH).

METHODS

We performed thyroid ultrasound examinations on all 29 XP patients examined from 2011 to 2019 and assessed nodule malignancy using the Thyroid Imaging Reporting and Data System. Thyroid nodule prevalence was also obtained from comparison cohorts. DNA sequencing was performed on thyroid tissue from XP patients who had surgery for thyroid cancer.

RESULTS

Thyroid nodules were identified in 18/29 XP patients (62%). The median age of patients with thyroid nodules in our XP cohort (20 years) was younger than that of three comparison groups: 36 years (California study-208 subjects), 48 years (Korean study-24,757 subjects), and 52 years (NIH-682 research subjects). Multiple (2-4) thyroid nodules were found in 12/18 (67%) of the patients with nodules. Autopsy examination revealed follicular adenomas in 4/8 (50%) additional XP patients. DNA sequencing revealed rare mutations in two other XP patients with papillary thyroid cancer.

CONCLUSIONS

XP patients have an increased incidence of thyroid nodules at an early age in comparison to the general population. These finding confirm another premature aging feature of XP.

Usefulness of Color Doppler Ultrasonography in the Risk Stratification of Thyroid Nodules

INTRODUCTION

Thyroid ultrasound (US) is crucial for clinical decision in the management of thyroid nodules. In this cross-sectional study, we aimed to test if the evaluation of thyroid nodules' vascularization could improve the risk stratification ability of the American College of Radiology (ACR) TI-RADS classification system.

METHODS

A total of 873 thyroid nodules undergoing fine-needle aspiration were classified according to ACR TI-RADS US classification. Three types of vascularization were identified: type 0, no vascular signals; type 1, peripheral vascular signals; type 2, peripheral and intralesional vascular signals. Cytology specimens were evaluated conforming to the Italian Reporting System for Thyroid Cytology, and TIR3b, TIR4, and TIR5 were defined as high risk for malignancy. Odds ratios (ORs) with 95% confidence intervals (CI) and the areas under the receiver operating characteristic curves (ROC-AUC) for high-risk cytology categories were calculated.

RESULTS

The 3 vascular patterns were differently distributed within the cytology categories: 52.4% of TIR1c, 15.9% of TIR2, 5.9% of TIR3a, 6.7% of TIR3b, 12.5% of TIR4, and 28.9% of TIR5 nodules had no vascular signals (p < 0.001). Nodule vascularity alone was not associated with a higher risk of malignant cytology (OR [95% CI] 0.75 [0.43-1.32], p = 0.32), without differences between peripheral (OR [95% CI] 0.65 [0.35-1.20]) and intranodular (OR [95% CI] 0.88 [0.48-1.62]) vascularization (p = 0.22). The ROC-AUC (95% CI) for the diagnosis of malignant cytology was similar when considering TI-RADS classification alone (0.736 [0.684-0.786]) and when considering TI-RADS classification plus the presence/absence of vascular signals (0.736 [0.683-0.789], p value for differences between the ROC-AUCs: 0.91). Among TR1, TR2, and TR3 TI-RADS classes, no nodules without vascular signals showed a malignant cytology, allowing the identification of nodules with benign cytology with 100% specificity within these US classes.

CONCLUSIONS

Color Doppler study of thyroid nodules does not improve the risk stratification ability of the ACR TI-RADS US classification system.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The impact of TI-RADS in detecting thyroid malignancies: a prospective study

INTRODUCTION

Thyroid ultrasonography (US) is the first-step noninvasive and easily accessible diagnostic method widely used in the detection and characterization of nodular thyroid disease. We aimed to develop a TI-RADS, which is easy to apply and only relies on the counting of suspicious criteria. In order to measure the reliability of the system, we investigated its correlation with fine needle aspiration biopsy (FNAB) and post-surgery histological results.

MATERIALS AND METHODS

In this prospective study, 242 patients who had undergone FNAB with simultaneous cytopathologist in the radiology department between April and August 2016 were analyzed. Before FNAB, the thyroid gland was re-evaluated with US, and TI-RADS classification was made. Demographic characteristics, family thyroid cancer history and radiotherapy history to the neck region were noted.

RESULTS

Of the 242 patients, 17.3% were male (42 males/200 females). US-guided FNAB was applied to all patients. Mean age was 50 ± 13 years (min: 19, max: 82). Both FNAB and final post-surgery histology results showed that sex and age were not statistically significantly associated with malignancy (p = 0.193) TI-RADS criteria and FNAB results revealed a statistically significant association between irregular contours, the state of anteroposterior diameter being longer than transverse diameter, microcalcifications, marked hypoechogenicity, and malignancy (p < 0,05). Thirty patients were TI-RADS ≥ 4, 206 patients were TI-RADS ≤ 3 and there was a significant correlation between TI-RADS and Bethesda classification (p = 0.001). In addition, statistically significant associations were found between malignancy and family history of thyroid cancer (p = 0.035) and radiotherapy history to the neck region (p = 0.01).

CONCLUSION

TI-RADS system after nodule identification is based only on the counting of suspicious criteria. It will be safe and effective to recommend follow-up with low score TI-RADS, benign characters and insufficient FNAB results, and thus, unnecessary thyroidectomy operations will be prevented. It will be easier for surgeons to recommend surgery and persuade the patients for it when patients have high TI-RADS scores. TI-RADS has high power in detecting malignancy by recommending biopsy of suspicious nodules.

Testing of mutations on thyroid nodules with indeterminate cytology: A prospective study of 112 patients in Argentina

BACKGROUND

The study of genetic mutations in thyroid nodules makes it possible to improve the preoperative diagnosis of and reduce unnecessary surgeries on benign nodules. In this study, we analysed the impact of implementing a 7-gene mutation panel that enables mutations to be detected in BRAF and RAS (H/N/K) and the gene fusions PAX8/PPARG, RET/PTC1 and RET/PTC2, in a population in northern Argentina.

METHOD

We performed a prospective analysis of 112 fine needle aspirations diagnosed as having indeterminate cytology according to the Bethesda classification system. These include the Bethesda III or atypia of unknown significance/follicular lesion of unknown significance and Bethesda IV or follicular neoplasm/suspicious for follicular neoplasm categories. The mutations of the 7-gene panel were analysed and this information was linked to the available histology and ultrasound monitoring.

RESULTS

The BRAF V600E and RET/PTC1 mutations were associated with carcinoma in 100% of cases (n=8), whereas only 37.5% (n=3) of the nodules with RAS and 17% (n=1) with PAX8/PPARG mutations were associated with carcinoma. From the histological diagnosis and ultrasound monitoring of patients, we can estimate that this panel has a sensitivity of 86% in detecting malignant carcinoma, a specificity of 77%, a positive predictive value (PPV) of 54% and a negative predictive value (NPV) of 94%. In this study, it was possible to reduce the number of surgeries by 48% in the patients analysed.

CONCLUSION

The implementation of the mutation panel allowed the appropriate surgical strategy to be selected for each patient, the number of two-step surgeries to be reduced, and active follow-up to be established in low-risk patients.

Ultrasound of Thyroid Nodules and the Thyroid Imaging Reporting and Data System

Benign or malignant thyroid nodules are common in adults. Fine needle aspiration biopsy is the gold standard for diagnosis. Most thyroid nodules are benign. Ultrasound imaging is the optimal noninvasive imaging modality to determine which nodules demonstrate malignant features. The American College of Radiology Thyroid Imaging Reporting and Data System committee published a standardized approach to classifying nodules on ultrasound. The ultrasound features in this system are categorized as benign, minimally suspicious, moderately suspicious, or highly suspicious for malignancy. Applying the Thyroid Imaging Reporting and Data System results in a meaningful decrease in the number of thyroid nodules biopsied.

Rates of lymphocytic thyroiditis and ultrasound features of citologically-interrogated thyroid nodules based on the area of residence in a Sicily province

PURPOSE

To verify the prevalence of autoimmune thyroiditis (AIT) and the ultrasound characteristics (composition and volume) of thyroid nodules with respect to the area of residence in the province of Messina, some areas having environmental issues.

METHODS

Fine-needle aspiration-interrogated nodules (n = 902) of 809 patients were evaluated upon stratification into 8 areas of residence.

RESULTS

Overall, women were younger than men (55.3 ± 14.0 vs. 58.6 ± 12.6 years, P = 0.0083). Patients residing in three areas (one hosting two garbage dumps, one hosting a petrochemical complex and a thermoelectrical power plant, and one hosting several ceramic factories [CFA]) were younger than those residing in the city of Messina (MEA) (52.9 ± 13.4 vs. 57.7 ± 13.6 years, P < 0.0001). Also, patients residing in those three areas had a greater rate of AIT, diagnosed either ultrasonographically/serologically (22.2% of patients) or cytologically (26.3% of nodules), compared with MEA (11.7% of patients, P = 0.0007 or 20.2% of nodules, P = 0.0815). Rates of AIT ranged 12.5-28.6% in the remaining four areas. Overall, nodules in women were smaller than in men (3.6 ± 5.7 vs. 6.1 ± 9.4 ml, P = 0.0006). Compared with the other seven areas, patients living in CFA had the largest nodules (6.8 ± 6.8 ml, P = 0.0040-0.0291), with the nodule volume being inversely correlated to patient's age (r = -0.4955, P = 0.0431).

CONCLUSION

Rates of AIT and associated ultrasound features of thyroid nodules vary in different areas of our province. Further studies correlating these rates and features with exposure to specific toxicants are warranted.