Radiofrequency ablation and thyroid nodules: updated systematic review

PURPOSE

In the thyroid gland, radiofrequency ablation (RFA) is being applied to both benign nodules and cancers internationally, while interest is also growing in the West. Benign thyroid nodules (BTNs) may be candidates for intervention when symptoms develop. For differentiated thyroid cancers (DTC), surgery is currently the first-line treatment. However, for candidates with high surgical risk or those who refuse to undergo repeated surgery, newer techniques such as RFA are an option. Surgery is associated with complications including hypothyroidism, voice change, hypocalcemia, and a scar. RFA has been used in Asian and European institutions as an alternative to surgery, but is relatively new in North America. Although RFA is not associated with significant complications, few randomized control trials have assessed its efficacy. The studies to date suggest a low rate of severe complications and a small need for thyroid hormone replacement following RFA. Further large-scale studies focusing on a Western population are needed. The aim of this review is to evaluate the evidence with respect to the current studies and data about the safety and efficacy of radiofrequency ablation for the management of BTNs and DTC.

METHODS

We systematically searched the PubMed/MEDLINE, EMBASE, Clinical Queries, and Web of Science databases, for articles published up to April 30th, 2020.

RESULTS

Total of 75 studies that met the inclusion criteria were included in the review. Thirty-five studies focused on RFA use for solid nodules, 12 studies on predominantly cystic nodules, 10 for autonomously functioning thyroid nodules, and 18 studied were published on differentiated thyroid cancer.

CONCLUSIONS

RFA seems to be an effective and safe alternative to surgery in high-risk surgical patients with thyroid cancers and for selected BTNs. Additional trials with longer follow-up in North American patients are needed to validate its full role in the armamentarium of thyroid ologists.

Korean Thyroid Imaging Reporting and Data System: Current Status, Challenges, and Future Perspectives

The Korean Thyroid Imaging Reporting and Data System (K-TIRADS) is an ultrasound-based risk stratification system for thyroid nodules that has been widely applied for the diagnosis and management of thyroid nodules since 2016. This review article provides an overview of the use of the K-TIRADS compared with other risk stratification systems. Moreover, this review describes the challenges in the clinical application of the K-TIRADS, as well as future development directions toward the personalized management of patients with thyroid nodules.

Improving the diagnosis of AUS/FLUS thyroid nodules using an algorithm with combination of BRAFV600E mutation analysis and ultrasound pattern-based risk stratification

PURPOSE

To propose a diagnostic algorithm for improving the diagnosis of atypia of undetermined significance or follicular lesion of undetermined significance (AUS/FLUS) thyroid nodules.

METHODS

This study retrospectively enrolled 77 consecutive patients with 81 AUS/FLUS nodules who underwent preoperative BRAFV600E mutation analysis. A new diagnostic algorithm was proposed that BRAFV600E mutation analysis for the Fine-needle aspiration cytology specimen was firstly carried out, in which positive BRAFV600E mutation indicated malignancy and classification of the nodules with negative BRAFV600E mutation was further performed based on ultrasound pattern-based risk stratification of American Thyroid Association Guidelines. The diagnostic performance of the new diagnostic algorithm was evaluated.

RESULTS

The sensitivity, specificity, positive predictive value, negative predictive value, accuracy, and area under the receiver operating characteristic curve (AUROC) of new diagnostic algorithm were 94.6%, 84.0%, 91.4%, 86.9%, 90.1%, and 0.893, respectively. The proposed diagnostic algorithm significantly increased the diagnostic performances (AUROC: 0.893 vs. 0.837 and 0.795), sensitivity (94.6% vs. 71.4% and 75.0%), and accuracy (90.1% vs. 79.0% and 77.8%) compared with BRAFV600E mutation analysis alone and ultrasound pattern-based risk stratification alone (all P < 0.05).

CONCLUSION

The proposed diagnostic algorithm is helpful for improving the diagnosis of AUS/FLUS nodules, which might be as a routine approach.

Kinase-inhibitors for iodine-refractory differentiated thyroid cancer: still far from a structured therapeutic algorithm

The kinase-inhibitors (KIs) sorafenib and lenvatinib demonstrated efficacy in iodine-refractory DTC upon phase III studies. However, evidence allowing a punctual balance of benefits and risks is poor. Furthermore, the lack of a direct comparison hampers to establish the proper sequence of administration. However, some insights may provided: a) indirect comparison between phase III trials showed milder toxicity for sorafenib, which should be preferred in case of cardiovascular comorbidities; b) prospective evidence of efficacy in KIs pre-treated patients is available only for lenvatinib, which should be used as second-line. Promising activity was found for the majority of other tested KIs, but no placebo-controlled trials are available. Emerging, but still early, frontiers include the restoration of iodine-sensitivity and the selective activity on pathogenic mutations. In conclusion, the use of KIs in iodine-refractory DTC is far from a structured therapeutic algorithm.

Role of elastography strain ratio and TIRADS score in predicting malignant thyroid nodule

OBJECTIVE

Ultrasonography (US) is the most accurate and cost-effective imaging method in diagnosis of thyroid nodules. A practical thyroid imaging reporting and data system (TIRADS) for thyroid nodules has been proposed to classify nodules of the thyroid gland to solve the problem of nodule selection for fine needle aspiration cytology (FNAC). Real-time elastography and strain ratio (SR) is a method used to assess the stiffness and predict the malignancy of thyroid nodules. The objective of this study was to assess the role of elastography and SR and the TIRADS scoring system in discriminating malignant from benign thyroid nodules.

METHODS

From 2015 to 2018 at Cairo University Hospital, a series of 409 patients with thyroid nodules was referred to undergo thyroid ultrasound. Categorization of each nodule according to the TIRADS ranged from 1 to 5. The qualitative elastography score and semiquantitative SR of the nodules were evaluated. Final diagnosis was done by either post-thyroidectomy histopathological examination or US-guided FNAC.

RESULTS

Our study included 409 patients with thyroid nodules. Their mean age was 39 ± 10 SD; 36 were males and 373 were females. There were 22 malignant nodules and 387 benign nodules. There were statistical differences between benign and malignant nodules regarding TIRADS classification, SR, anteroposterior/transverse ratio, degree of echogenicity, border, presence of calcification, and absence of halo sign (P < 0.001). The elastic properties of thyroid nodules proved to be a good discriminator between malignant and benign nodules (P- < 0.001) at a cut off value of > 2.32 with 95.2% sensitivity and 86.5% specificity. For every unit increase in SR, the risk of malignancy increased by nearly 2 times. Patients with irregular borders had nearly 17 times increased risk of malignancy than those with regular borders.

CONCLUSION

Elastography and SR proved to be of high significant value in discriminating benign from malignant nodules, so we recommend adding it to the TIRADS classification.

Hydrodissection: A Novel Approach for Safe Core Needle Biopsy of Small High-Risk Subcapsular Thyroid Nodules

PURPOSE

To evaluate the safety and effectiveness of core needle biopsy (CNB) under the assistance of hydrodissection (HDS).

MATERIALS AND METHODS

Of 2325 patients requiring biopsy of thyroid lesions, 21 high-risk patients with subcapsular nodules smaller than 10 mm were recruited into this study. All patients underwent HDS with 0.9% saline solution followed by ultrasound (US)-guided CNB with an 18-gauge semi-automated biopsy needle. The separation success rate (SSR) of the HDS, technical success rate (TSR) of CNB, histopathologic success rate (HSR), and complications were assessed.

RESULTS

Both the SSR of HDS and TSR of CNB were 100% (21/21). The HSR of the thyroid nodules was 85.7% (18/21). No major complications were recorded.

CONCLUSION

HDS before CNB can successfully lead to safe biopsy of small subcapsular thyroid nodules.

LEVEL OF EVIDENCE

Level 4, Case Series.

Exploring physicians and patients' perspectives for current interventions on thyroid nodules using a MCDA method

BACKGROUND

The detection of thyroid cancer has rapidly increased over last few decades without an increase in disease specific mortality. Several studies claim that the diagnose of thyroid nodules through routine ultrasound imaging is often the trigger for cascade effects leading to unnecessary follow-up over many years or to invasive treatment. The objective of this study was to explore physicians' and patients' insights and preferences regarding the current interventions on thyroid nodules.

METHODS

An online survey was developed using a comprehensive multi-criteria decision analysis (MCDA) framework, the EVIdence based Decision-Making (EVIDEM). The EVIDEM core model used in this study encompassed 13 quantitative criteria and four qualitative criteria. Participants were asked to provide weights referring to what matters most important in general for each criterion, performance scores for appraising the interventions on thyroid nodules and their consideration of impact of contextual criteria. Normalized weights and standardized scores were combined to calculate a value contribution across all participants, additionally differences across physicians and patients' group were explored.

RESULTS

48 patients and 31 physicians were included in the analysis. The value estimate of the interventions on thyroid nodules reached 0.549 for patients' group and 0.5 was reported by the physicians' group, compared to 0.543 for all participants. The highest value contributor was 'Comparative effectiveness' (0.073 ± 0.020). For the physicians' group, 'Comparative safety' (0.050 ± 0.023) was given with higher value. And for the patients' group, 'Type of preventive benefits' (0.059 ± 0.022) contributed more positively to the value estimation. 51% participants considered 'Population priorities and access' having a negative impact on the interventions of nodules.66% participants thought that the 'system capacity' had a negative impact.

CONCLUSION

Our study shows participants' preferences on each criterion, i.e., physician indicated keeping the interventions safe and effective more important, patients indicated quality of life after receiving interventions more important. Through comparison among participants, differences have been highlighted, which can make better communication between physicians and patients. This study provides a supportive decision-making for healthcare providers when they explored the interventions on thyroid nodules.

Retrospective analysis of the ultrasound features of resected thyroid nodules

PURPOSE

Several ultrasound (US) risk stratification systems (US-RSSs) have been proposed to stratify the risk of malignancy (ROM) of thyroid nodules. This risk might be overestimated due to selection bias and comparison with the cytological report alone. Our study aimed to compare ROM and diagnostic performance of three guidelines (ATA, AACE/ACE/AME, EUTIRADS) and evaluate the changes in unnecessary biopsy according to the nodule size cutoff for biopsy, using histology as gold standard.

METHODS

This retrospective observational study included 146 consecutive patients who underwent surgery after US and cytological characterization. We analyzed the effectiveness and accuracy of three US-RSSs.

RESULTS

46.6% of nodules were diagnosed as malignant. Applying US-RSS, the percentage of nodules that should have been analyzed by biopsy was 84.25% with ATA, 69.86% with EUTIRADS and 64.38% with AACE/ACE/AME systems. The ROM was 94.9%, 86.0%, 87.0% for high-risk category, 36.4%, 32.0%, 35.4% for intermediate-risk category and 22.9%, 0.0%, 22.9% for low-risk category by ATA, AACE/ACE/AME and EUTIRADS systems, respectively. EUTIRADS and AACE/ACE/AME systems were more accurate in differentiating malignant from benign cases. ATA score was the more sensitive US-RSS to identify malignant tumors within the high-risk category. About the unnecessary biopsies, in the intermediate-risk category, the application of the size criterion helps to increase specificity in all systems.

CONCLUSIONS

The US categorization of low and high-risk thyroid nodules using current US-RSSs helps alone to determine the optimal treatment option. Nodule size remains relevant to recommend biopsy for the intermediate-risk category.

Multiparametric Ultrasound Evaluation of the Thyroid: Elastography as a Key Tool in the Risk Prediction of Undetermined Nodules (Bethesda III and IV)-Histopathological Correlation

The purpose of this study was to select thyroid nodules most at risk for malignancy among those cytologically undetermined by fine-needle aspiration biopsy (FNAB), using B-mode, color duplex Doppler and 2-D shear wave shear wave elastography (2-D-SWE). This was a prospective diagnostic accuracy study with 62 Bethesda III/IV nodules according to FNAB (atypia/follicular lesion of undetermined significance or follicular neoplasia/Hürthle cell neoplasm). Ultrasonography (US) data were compared with resection histologic results, revealing 35 of 62 benign nodules (56.4%) and 27 of 62 carcinomas (43.6%). Conventional US was uses to evaluate nodule echogenicity, dimensions, contours, presence of halo and microcalcifications. Doppler US was used to assess the vascularization (exclusively or predominantly peripheral or central) and mean resistance index of three nodule arteries. Elastography was used to evaluate the nodule elastographic pattern; mean nodule deformation index; deformation ratio between nodule and adjacent thyroid parenchyma; and mean deformation ratio between nodule and pre-thyroid musculature (MDR). Statistical analysis included χ², Fisher's exact, Student's t, Mann-Whitney tests and multivariable analysis by multiple logistic regression. Areas under the receiver operating characteristic curves (AUC-ROCs) were used for accuracy analysis. Fifty-eight participants (54.7 ± 14.0 y, 51 women) were studied. The parameters that were statistically significant to the univariate analysis were hypo-echogenicity, nodule diameter greater than width and all parameters analyzed from Doppler and elastography. Multivariate analysis revealed that the MDR (in kPa) was the best parameter for risk analysis of indeterminate nodules. Nodules with MDRs >1.53 exhibited a greater chance of malignancy (AUC-ROC = 0.98). We conclude that 2-D-SWE is able to select malignant nodules among those cytologically indeterminate, thus avoiding unnecessary surgery in these cytologic groups.

Comparison of five thyroid ultrasound stratification systems for differentiation of benign and malignant nodules and to avoid biopsy using histology as reference standard

OBJECTIVE

We aimed at to compare the thyroid ultrasound risk stratification systems (RSSs) of the American College of Radiology (ACR) Thyroid Imaging Reporting and Data System (TI-RADS), European (EU) TI-RADS, Korean (K) TI-RADS, and American Thyroid association (ATA) guidelines and American Association of Clinical Endocrinologists (AACE), American College of Endocrinology (ACE) and Associazione Medici Endocrinologi (AME) guidelines to differentiate benign from malignant thyroid nodules and to avoid unnecessary FNA.

METHODS

The records of 1143 nodules ≥1 cm which underwent fine needle aspiration biopsy (FNA) and thyroidectomy between 2012 and 2020 at our institution were reviewed. Ultrasound categories and FNA recommendation indications of five international RSSs were compared with histopathological finding as benign or malignant. The ultrasound categories and recommended FNA indications and the proportion of the avoidable FNA procedures, and false negative rates (FNR) by different systems were compared with each other.

RESULTS

Of the 1143 nodules, 45% had thyroid malignancy. FNA recommendation and ultrasound risk classification of ATA guidelines had the highest area under curves (AUCs) of 0.619, and 0.715, respectively. ACR TI-RADS, AACE/ACE/AME guidelines, EU TI-RADS, ATA guidelines and K TI-RADS would have avoided 34.7%, 31%, 25.7%, 20%, 6% nodules from FNA with a FNR of 24%, 28.5%, 22%, 7.2%, and 1.9%, respectively.

CONCLUSION

Our findings showed that all RSSs classified the nodules appropriately for malignancy. ATA guidelines had the highest AUC and a low FNR, whereas ACR TI-RADS would have spared more patients from FNA with a high FNR.

Application of the Bethesda System for Reporting Thyroid Cytopathology in the Pediatric Population

OBJECTIVES

We aimed to provide the Asian experience with the Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) in pediatric thyroid nodules.

METHODS

Consecutive thyroid fine-needle aspirates (patient age, ≤18 years) were retrospectively collected from 7 tertiary centers in 5 Asian countries.

RESULTS

Of 194,364 thyroid aspirates, 0.6% were pediatric cases (mean age, 15.0 years). Among 827 nodules with accessible follow-up, the resection rate and risk of malignancy (ROM) were 36.3% and 59.0%, respectively. Malignant nodules (n = 179) accounted for 59.7% of resected nodules and 21.6% of all thyroid nodules with available follow-up. Compared with the published adult series, pediatric nodules had a higher resection rate and ROM, particularly in the indeterminate categories.

CONCLUSIONS

Our study demonstrates that Asian pediatric thyroid nodules had higher ROM than those from adults. The prototypic outputs of TBSRTC may need to be adjusted in the pediatric population.

The value of the Demetics ultrasound-assisted diagnosis system in the differential diagnosis of benign from malignant thyroid nodules and analysis of the influencing factors

OBJECTIVES

To evaluate the value of Demetics and to explore whether Demetics can help radiologists with varying years of experience in the differential diagnosis of benign from malignant thyroid nodules.

METHODS

The clinical application value of Demetics was assessed by comparing the diagnostic accuracy of radiologists before and after applying Demetics. This retrospective analysis included 284 thyroid nodules that underwent pathological examinations. Two different combined methods were applied. Using method 1: the original TI-RADS classification was forcibly upgraded or downgraded by one level when Demetics classified the thyroid nodules as malignant or benign. Using method 2: the TI-RADS and benign or malignant classification of the thyroid nodules were flexibly adjusted after the physician learned the Demetics' results.

RESULTS

Demetics exhibited a higher sensitivity than did junior radiologist 1 (p_D1 = 0.029) and was similar in sensitivity to the two senior radiologists. Demetics had a higher AUC than both junior radiologists (p_D1 = 0.042, p_D2 = 0.038) and an AUC similar to that of the senior radiologists. The sensitivity (p = 0.035) and AUC (p = 0.031) of junior radiologist 1 and the specificity (p < 0.001) and AUC (p = 0.026) of junior radiologist 2 improved with combined method 1. The AUC of junior radiologist 2 improved with combined method 2 (p = 0.045). The factors influencing the diagnostic results of Demetics include sonographic signs (echogenicity and echogenic foci), contrast of the image, and nodule size.

CONCLUSION

Demetics exhibited high sensitivity and accuracy in the differential diagnosis of benign from malignant thyroid nodules. Demetics could improve the diagnostic accuracy of junior radiologists.

KEY POINTS

• Demetics exhibited a high sensitivity and accuracy in the differential diagnosis of benign from malignant thyroid nodules. • Demetics could improve the diagnostic accuracy of junior radiologists in the differential diagnosis of benign from malignant thyroid nodules. • Factors influencing the diagnostic results of Demetics include the sonographic signs (echogenicity and echogenic foci), contrast of the image, and nodule size.

Comparison of the diagnostic performance of the modified Korean Thyroid Imaging Reporting and Data System for thyroid malignancy with three international guidelines

Purpose

This study compared the diagnostic performance of the modified Korean Thyroid Imaging Reporting and Data System (K-TIRADS) for thyroid malignancy with three international guidelines.

Methods

From June to September 2015, 5,708 thyroid nodules (≥1.0 cm) in 5,081 consecutive patients who underwent thyroid ultrasound (US) at 26 institutions were evaluated. The US features of the thyroid nodules were retrospectively reviewed and classified according to all four guidelines. In the modified K-TIRADS, the biopsy size threshold was changed to 2.0 cm for K-TIRADS 3 and 1.0 or 1.5 cm for K-TIRADS 4 (K-TIRADS_1.0cm and K-TIRADS_1.5cm, respectively). We compared the diagnostic performance and unnecessary fine-needle aspiration biopsy (FNAB) rates for thyroid malignancy between the modified K-TIRADS and three international guidelines.

Results

Of the 5,708 thyroid nodules, 4,597 (80.5%) were benign and 1,111 (19.5%) were malignant. The overall sensitivity was highest for the modified K-TIRADS_1.0cm (91.0%), followed by the European (EU)-TIRADS (84.6%), American Association of Clinical Endocrinologists/American College of Endocrinology/Associazione Medici Endocrinologi (AACE/ACE/AME) (80.5%), American College of Radiology (ACR)-TIRADS (76.1%), and modified K-TIRADS_1.5cm (76.1%). For large nodules (>2.0 cm), the sensitivity increased to 98.0% in both the modified K-TIRADS_1.0cm and K-TIRADS_1.5cm. For small nodules (≤2.0 cm), the unnecessary FNAB rate was lowest with the modified K-TIRADS_1.5cm (17.6%), followed by the ACR-TIRADS (18.6%), AACE/ACE/AME (19.3%), EU-TIRADS (28.1%), and modified K-TIRADS_1.0cm (31.2%).

Conclusion

The modified K-TIRADS_1.5cm can reduce the unnecessary FNAB rate for small nodules (1.0-2.0 cm), while maintaining high sensitivity for detecting malignancies >2.0 cm.

Reproducibility and Interobserver Agreement of Different Thyroid Imaging and Reporting Data Systems (TIRADS)

INTRODUCTION

A number of classification systems (TIRADS) have been developed to estimate the likelihood of malignancy in thyroid nodules, but their reproducibility is yet to be assessed. We evaluated the interobserver variability and diagnostic performance of the TIRADS in Kwak's modification (Kw-TIRADS) and European TIRADS (EU-TIRADS).

METHODS

Two independent specialists, blinded concerning the morphology of the nodules, evaluated ultrasound images of 153 thyroid nodules identified in 149 patients at multiple time points.

RESULTS

The interobserver agreement (Cohen's κ) was 0.52 and 0.67 for Kw-TIRADS and EU-TIRADS, respectively, and rated as substantial. There were strong correlations between Kw-TIRADS and EU-TIRADS for the two observers with Spearman's coefficients of 0.731 (p = 0.00025) and 0.661 (p = 0.0012), respectively. Sensitivity of Kw-TIRADS for the diagnosis of thyroid cancer was 95-92.31% and that of EU-TIRADS was 92.31-89.74%, with specificity of about 60% for both TIRADS.

CONCLUSION

Despite the wide variability in the description of single ultrasonographic features, both Kw-TIRADS and EU-TIRADS may be a useful diagnostic tool in clinical practice.

Incidence of microcarcinoma and non-microcarcinoma in ultrasound-found thyroid nodules

BACKGROUNDS

The incidence of thyroid nodules is increasing year by year around the world. However, ultrasound is not recommended as a screening test for the general population or patients with a normal thyroid on palpation by the American Association of Clinical Endocrinologists (AACE). In practice, some individuals with normal thyroid palpation have nodules that can just be found out by ultrasound. No studies have directly described the risk of nodules found by ultrasound or by palpation up to now. More evidence is needed to carry out for helping us balance the over diagnosis and missed diagnosis of malignant lesions. Therefore, we carried out a retrospective study to investigate the incidence of malignant lesions in ultrasound-found nodules in a large cohort.

METHODS

We conducted a retrospective analysis involving 2957 patients who underwent thyroid ultrasound evaluation and fine-needle aspiration (FNA) between Jan 2013 and Dec 2019. The cytologic examinations were analyzed based on the Bethesda system. For nodules suspected to be follicular neoplasm or other malignant tumors by cytological tests, patients were recommended for surgery and histopathology examinations.

RESULTS

Compared with palpation-found nodules, ultrasound-found nodules were presenting less as purely cystic nodules (10.1 % vs. 39.9 %, x² = 355.69, p = 0.000), smaller size (17.5 ± 9.9 mm vs. 28.0 ± 12.5 mm, t = 23.876 p = 0.000), and higher TI-RADS score (5.5 ± 2.9 vs. 3.4 ± 3.3, t = 18.084, p = 0.000), respectively. More ultrasound-found nodules were diagnosed as carcinoma by histology examinations [136 (11.2 %) nodules found by ultrasound vs. 68 (3.9 %) by palpation, x² = 59.737, p = 0.000], and 88 (64.7 %) nodules found by ultrasound were non-microcarcinoma. Among the malignant nodules confirmed by histopathology, a higher proportion of microcarcinoma was detected in ultrasound-found nodules [35.3 % (48/136) vs. 16.2 % (11/68), x² = 8.183, p = 0.004].

CONCLUSIONS

In view of the results observed in our research, malignant nodules were more common in nodules screened out by ultrasound, and nearly two thirds of them were non-microcarcinoma. We suggest the recommendation against screening thyroid nodules by ultrasound needs to be re-evaluated.

Relationship between thyroid disorders and uterine fibroids among reproductive-age women

Uterine fibroids and thyroid nodules, both of which are crucially affected by estrogen, are common diseases among reproductive-age women. However, little attention has been paid to the association between the two diseases. This retrospective case-control study aimed to assess the relationships among thyroid nodules, thyroid function and uterine fibroids in China. We reviewed the electronic records of 853 reproductive-age women who attended health check-ups at the Second Affiliated Hospital of Wenzhou Medical University from July 1st, 2017, to June 30th, 2018. All subjects received transvaginal pelvic ultrasound, thyroid ultrasound, thyroid function, and other laboratory tests. We found that the prevalence of thyroid nodules in subjects with uterine fibroids was remarkably higher than that in subjects without fibroids. The proportion of thyroid nodules ≥1 cm in subjects with uterine fibroids was significantly higher than that in subjects without fibroids. Women with thyroid nodules had a higher proportion of multiple uterine fibroids than women without thyroid nodules. Among the parameters of thyroid function, the only statistically significant parameter was total triiodothyronine, i.e., women with uterine fibroids had lower total triiodothyronine levels than unaffected controls; however, the total triiodothyronine levels were within the normal ranges. Moreover, no significant difference was noted in thyroid hormone status between subjects with and without uterine fibroids. Our findings suggest that thyroid nodules are positively correlated with uterine fibroids among reproductive-age women in China. Further studies are needed to confirm this association and fully understand the common pathogenetic mechanism underlying the association between uterine fibroids and thyroid nodules.

Malignancy risk of hyperfunctioning thyroid nodules compared with non-toxic nodules: systematic review and a meta-analysis

Background

Hyperfunctioning or hot nodules are thought to be rarely malignant. As such, current guidelines recommend that hot nodules be excluded from further malignancy risk stratification. The objective of this systematic review and meta-analysis is to compare the malignancy risk in hot nodules and non-toxic nodules in observational studies.

Methods

Ovid MEDLINE Daily and Ovid MEDLINE, EMBASE, Scopus, and Web of Science databases were searched. Observational studies which met all of the following were included: (1) use thyroid scintigraphy for nodule assessment, (2) inclusion of both hyperfunctioning and non-functioning nodules based on scintigraphy, (3) available postoperative histopathologic nodule results, (4) published up to November 12, 2020 in either English or French. The following data was extracted: malignancy outcomes include malignancy rate, mapping of the carcinoma within the hot nodule, inclusion of microcarcinomas, and presence of gene mutations.

Results

Among the seven included studies, overall incidence of malignancy in all hot thyroid nodules ranged from 5 to 100% in comparison with non-toxic nodules, 3.8–46%. Odds of malignancy were also compared between hot and non-toxic thyroid nodules, separated into solitary nodules, multiple nodules and combination of the two. Pooled odds ratio (OR) of solitary thyroid nodules revealed a single hot nodule OR of 0.38 (95% confidence interval (CI) 0.25, 0.59), toxic multinodular goiter OR of 0.51 (95% CI 0.34, 0.75), and a combined hot nodule OR of 0.45 (95% CI 0.31, 0.65). The odds of malignancy are reduced by 55% in hot nodules; however, the incidence was not zero.

Conclusions

Odds of malignancy of hot nodules is reduced compared with non-toxic nodules; however, the incidence of malignancy reported in hot nodules was higher than expected. These findings highlight the need for further studies into the malignancy risk of hot nodules.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13044-021-00094-1.

Choosing the best algorithm among five thyroid nodule ultrasound scores: from performance to cytology sparing-a single-center retrospective study in a large cohort

OBJECTIVE

Incidental diagnosis of thyroid nodules, and therefore of thyroid cancer, has definitely increased in recent years, but the mortality rate for thyroid malignancies remains very low. Within this landscape of overdiagnosis, several nodule ultrasound scores (NUS) have been proposed to reduce unnecessary diagnostic procedures. Our aim was to verify the suitability of five main NUS.

METHODS

This single-center, retrospective, observational study analyzed a total number of 6474 valid cytologies. A full clinical and US description of the thyroid gland and nodules was performed. We retrospectively applied five available NUS: KTIRADS, ATA, AACE/ACE-AME, EUTIRADS, and ACRTIRADS. Thereafter, we calculated the sensitivity, specificity, PPV, and NPV, along with the number of possible fine-needle aspiration (FNA) sparing, according to each NUS algorithm and to clustering risk classes within three macro-groups (low, intermediate, and high risk).

RESULTS

In a real-life setting of thyroid nodule management, available NUS scoring systems show good accuracy at ROC analysis (AUC up to 0.647) and higher NPV (up to 96%). The ability in FNA sparing ranges from 10 to 38% and reaches 44.2% of potential FNA economization in the low-risk macro-group. Considering our cohort, ACRTIRADS and AACE/ACE-AME scores provide the best compromise in terms of accuracy and spared cytology.

CONCLUSIONS

Despite several limitations, available NUS do appear to assist physicians in clinical practice. In the context of a common disease, such as thyroid nodules, higher accuracy and NPV are desirable NUS features. Further improvements in NUS sensitivity and specificity are attainable future goals to optimize nodule management.

KEY POINTS

• Thyroid nodule ultrasound scores do assist clinicians in real practice. • Ultrasound scores reduce unnecessary diagnostic procedures, containing indolent thyroid microcarcinoma overdiagnosis. • The variable malignancy risk of the "indeterminate" category negatively influences score's performance in real-life management of thyroid lesions.

SWE combined with ACR TI-RADS categories for malignancy risk stratification of thyroid nodules with indeterminate FNA cytology

OBJECTIVES

To compare the diagnostic efficacy of shear wave elastography (SWE) comnined with ACR TI-RADS categories for malignancy risk stratification of thyroid nodules with interminate FNA cytology.

METHODS

The clinical data, sonographic features, ACR TI-RADS grading and shear wave elastography images of 193 patients of surgical pathologically proven thyroid nodules with interminate FNA cytology were retrospectively analyzed. The diagnostic efficacy of ACR TI-RADS categories, the maximum Young's modulus (Emax) of SWE and the combination of the two were calculated respectively.

RESULTS

The ROC curves were drawn using surgical pathology results as the gold standard. The ROC curves indicated that the cut-off value of ACR TI-RADS and Emax of SWE was TR5 and 41.2 kPa respectively, and the area under the ROC curve (AUC) was 0.864 (95% CI: 0.879-0.934) and 0.858 (95% CI: 0.796-0.920) respectively. The diagnostic sensitivity, specificity and accuracy of ACR TI-RADS was 81.4% (127/156), 84.8% (31/37), and 81.9% (158/193), respectively. That of SWE Emax was 80.8% (126/156), 78.4% (29/37), and 80.3% (155/193), respectively. After SWE combined with ACR TI-RADS, the sensitivity, specificity and accuracy was 94.2% (147/156), 75.7% (28/37), and 90.7% (175/193), respectively.

CONCLUSIONS

ACR TI-RADS classification system and shear wave elastography had high diagnostic efficacy for thyroid nodules with interminate FNA cytology. The combination of the two could improve diagnostic sensitivity and accuracy, and could help to differentiate benign and malignant thyroid nodules with interminate FNA cytology.

The importance of using fine-needle aspiration cytology in the diagnosis of thyroid nodules

Background

Thyroid nodules are common diseases, frequent in middle-aged women; only 5%–30% are malignant. Fine needle aspiration cytology is a simple, rapid and non invasive diagnostic test, performed to predict malignancy and avoid unnecessary surgery.

The aim of this study is to evaluate the accuracy of fine needle aspiration in the management of thyroid lesions.

Materials and methods

Our study was retrospective, including all cases of thyroid fine needle aspiration between January 2010 and December 2017, which were verified by microscopic examination, Data was obtained from the files of Pathology and ENT Department of Farhat Hached Hospital of Sousse and from nuclear medicine department of Sahloul Hospital of Sousse, Tunisia.

Results

A total of 58 cases were studied, the main age was 40 ± 15,57 years and the sex ratio was 0.03 with female predominance. Concordance between fine needle aspiration and histology was seen in 45 cases. The sensitivity was 60% and the specificity was 100%. The negative and positive predictive values were 100 and 92%, respectively. The concordance index Kappa was of 0.67.

Conclusion

Thyroid fine needle aspiration in experienced hands is an easily performed diagnostic procedure with very little associated risk. It should be performed in suspect nodules for treatment stratification.

-

The thyroid nodules are a frequent disease.

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We present a serie case of 58 thyroid nodules to enhance the importance of using of fine needle cytology to predict malignancy and avoid unnecessary surgery.

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We describe clinical, gross and microscopic examinations for diagnosis and treatment.

Ultrasonic thyroid nodule detection method based on U-Net network

OBJECTIVE

Aiming at the time consuming processing of existing thyroid nodule detection and difficulty in feature extraction, U-Net-based thyroid nodule detection is proposed to perform computed aided diagnosis.

METHOD

This paper proposes a mark-guided ultrasound deep network segmentation model of thyroid nodules. By comparing with VGG19, Inception V3, DenseNet 161, segmentation accuracy, segmentation edge and network operation time, it is found that the algorithm in this paper has relative advantages.

RESULTS

U-Net network-based ultrasound thyroid nodules segmented the nodule area overlapped with the manually depicted nodule area close to 100%, the segmentation accuracy rate was as high as 0.9785, and the U-Net segmentation result was closer to the manually depicted nodule. The accuracy of U-Net segmentation of the thyroid is about 3% higher than the other three networks.

CONCLUSION

The segmentation of nodules based on U-Net proposed in this paper significantly improves the segmentation accuracy of thyroid nodules with a small training data set, and provides a comprehensive reference for clinical diagnosis and treatment.

Diagnostic and prognostic value of a 7-panel mutation testing in thyroid nodules with indeterminate cytology: the SWEETMAC study

PURPOSE

The aim of this prospective study (ClinicalTrials.gov: NCT01880203) was to evaluate the diagnostic and prognostic value of a 7-panel mutation testing in the aspirates of thyroid nodules with indeterminate cytology (IC).

METHODS

Eligible patients had a thyroid nodule ≥15 mm with IC (Bethesda III-V) for which surgery had been recommended. Detection of BRAF and RAS mutations was performed using pyrosequencing and RET/PTC and PAX8/PPARγ rearrangements using Real-Time quantitative reverse transcription-polymerase chain reaction (RT-PCR).

RESULTS

Among 131 nodules with IC, 21 (16%) were malignant including 20 differentiated cancers and one thyroid lymphoma. Molecular abnormalities were identified in 15 nodules with IC corresponding to 10 malignant and 5 benign tumours. BRAF mutation was detected in 4 nodules all corresponding to classic PTC, and PAX8/PPARγ rearrangement in 2 HCC. In contrast, RAS mutation was identified in eight nodules, of which four were malignant, and one RET/PTC3 rearrangement in a follicular adenoma. This data resulted in an accuracy of 88%, sensitivity of 48%, specificity of 95%, positive-predictive value of 67%, and negative-predictive value of 91%. After a 56 month's follow-up, the proportion of excellent response was similar in patients with molecular alterations (67%) and those without (60%).

CONCLUSIONS

By increasing the overall risk of cancer from 16 to 67% in mutated nodules and by diminishing it to 9% in wild-type, this study confirms the relevance of the 7-panel mutation testing in the diagnostic of nodules with IC. Genetic testing, however, did not predict outcome in the cancer patient subgroup.

Evaluation of the Diagnostic Performance of EU-TIRADS in Discriminating Benign from Malignant Thyroid Nodules: A Prospective Study in One Referral Center

BACKGROUND

Several thyroid societies have endorsed ultrasound (US) malignancy risk stratification systems for thyroid nodules and the recently released European Thyroid Imaging Reporting and Data System (EU-TIRADS) needs large prospective studies for validation.

OBJECTIVE

The purpose of our study was to evaluate the performance of EU-TIRADS in identifying thyroid nodules for fine-needle aspiration biopsy (FNAB) and its ability to reduce the number of unnecessary biopsies.

METHODS

This was a single-center prospective study. From August 2017 to September 2018, 783 consecutive patients with 1,000 thyroid nodules underwent US examination and US-guided FNAB. A total of 741 patients (median age 50 years; range, 15-87 years; 649 females, 92 males) with 942 nodules (median largest diameter 14 mm; range, 4-96 mm) met the following inclusion criteria: (1) nodules with benign or malignant cytology - categories II and VI of the Bethesda System for Reporting Thyroid Cytopathology (BSRTC); (2) nodules with non-diagnostic and indeterminate cytology (BSRTC I, BSRTC III, and BSRTC IV), or suspicious for malignancy (BSRTC V), if postoperative histology was present; (3) nodules classified as BSRTC I and BSRTC III with a repeat FNAB and conclusive cytology.

RESULTS

Of 942 nodules, 839 (89.1%) were benign and 103 (10.9%) were malignant. Nodules were classified as follows: EU-TIRADS 2 - 4.8%, EU-TIRADS 3 - 37.4%, EU-TIRADS 4 - 25.2%, and EU-TIRADS 5 - 32.6%. The malignancy rate in categories 2 to 5 was 0, 0, 3.8, and 30.6%, respectively. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of EU-TIRADS with a cut-off set at category 5 were 91.3, 74.6, 30.6, 98.6, and 76.4%, respectively. Diagnostic performance other than sensitivity and NPV was superior in nodules ≥10 mm. FNAB number would be reduced by 53.4% if FNAB criteria were strictly applied. When the indication for FNAB was applied as test positivity, the estimated sensitivity, specificity, PPV, and NPV of EU-TIRADS were 69.9, 56.3, 16.4, and 93.8%, respectively.

CONCLUSION

EU-TIRADS provides effective malignancy risk stratification that can guide the selection of thyroid nodules for biopsy. The application of the guidelines criteria for FNAB in the clinical practice might reduce significantly the number of unnecessary FNAB.

Value of image-pro plus for assisting virtual touch tissue imaging in the diagnosis of thyroid nodules

PURPOSE

The value of virtual touch tissue imaging (VTI) with support of Image-Pro Plus (IPP) for diagnosing malignant thyroid tumors was assessed in the present study.

METHODS

In this retrospective study, we enrolled 160 patients with 198 thyroid nodules. TI-RADS, VTI grade, and VTI with support of IPP (VTI-IPP) were underwent for each nodule. With the pathological diagnosis as the gold standard, the receiver-operating characteristic curve (ROC) was drawn to evaluate the diagnostic performance of VTI-IPP, VTI, TI-RADS, VTI-IPP combinate with TI-RADS in thyroid carcinoma.

RESULTS

VTI-IPP score >2, VTI score >3, TI-RADS score >1, and VTI-IPP combine with TI-RADS score >4 expressed the highest diagnostic value for malignant thyroid nodules, the areas under the curve (AUC) were 0.939, 0.905, 0.925, and 0.967, respectively. The combination indicated the largest AUC, compared with VTI-IPP and TI-RADS, respectively (P = 0.0054 and 0.0009). The performance of VTI-IPP in diagnosing thyroid carcinomas was better than VTI (P = 0.0321).

CONCLUSION

Compare with VTI, VTI-IPP exhibited more excellent value in distinguishing between benign and malignant thyroid nodules. The value of malignant thyroid nodules diagnosis can be improved when VTI-IPP combines with TI-RADS.

Trends in the epidemiology of thyroid diseases in Bulgaria since the year 2000-a review of the literature

This review attempts to summarize data on the prevalence of thyroid pathology in the Bulgarian population over a period of 20 years. Thyroid dysfunction was studied in two population-based studies (2006 and 2012). In the first, hypothyroidism was found in 6.3% and hyperthyroidism in 3.7% of the participants. The second study found overt and subclinical hypothyroidism in 3.2% and 4.5%, respectively, of females, and in 1.1% and 2% of males. TPOAb levels were elevated in 23% of females and in 9.6% of males. Nodules were found using ultrasound (US) in 23.4% of the participants in the 2006 study (in 30.1% of females and 15.0% of males), while the 2012 study showed 24.4% (32.1% of females and 15.7% of males). Recent data regarding prevalence of thyroid carcinoma in the Bulgarian population are lacking. Between 4 and 6% of thyroid biopsies produce results which have markers for malignancy. Four studies were carried out to address urinary iodine excretion levels in schoolchildren and three for those in pregnant women. Although median urinary iodine was in the iodine-sufficient range, a rising proportion of women had low urinary excretion. In the studies involving schoolchildren, excessive iodine excretion was also observed. The major strength of this review is the combination of data from different publications to give an overall baseline of thyroid epidemiology in Bulgaria. Further work is needed to map the recent trends regarding thyroid pathology in Bulgaria and the complete epidemiological dataset.