Value of Qualitative and Quantitative Contrast-Enhanced Ultrasound Analysis in Preoperative Diagnosis of Cervical Lymph Node Metastasis From Papillary Thyroid Carcinoma

The application of a clinical-multimodal ultrasound radiomics model for predicting cervical lymph node metastasis of thyroid papillary carcinoma

Background

PTC (papillary thyroid cancer) is a lymphotropic malignancy associated with cervical lymph node metastasis (CLNM, including central and lateral LNM), which compromises the effect of treatment and prognosis of patients. Accurate preoperative identification will provide valuable reference information for the formulation of diagnostic and treatment strategies. The aim of this study was to develop and validate a clinical-multimodal ultrasound radiomics model for predicting CLNM of PTC.

Methods

One hundred sixty-four patients with PTC who underwent treatment at our hospital between March 2016 and December 2021 were included in this study. The patients were grouped into a training cohort (n=115) and a validation cohort (n=49). Radiomic features were extracted from the conventional ultrasound (US), contrast-enhanced ultrasound (CEUS) and strain elastography-ultrasound (SE-US) images of patients with PTC. Multivariate logistic regression analysis was used to identify the independent risk factors. FAE software was used for radiomic feature extraction and the construction of different prediction models. The diagnostic performance of each model was evaluated and compared in terms of the area under the curve (AUC), sensitivity, specificity, accuracy, negative predictive value (NPV) and positive predictive value (PPV). RStudio software was used to develop the decision curve and assess the clinical value of the prediction model.

Results

The clinical-multimodal ultrasound radiomics model developed in this study can successfully detect CLNM in PTC patients. A total of 3720 radiomic features (930 features per modality) were extracted from the ROIs of the multimodal images, and 15 representative features were ultimately screened. The combined model showed the best prediction performance in both the training and validation cohorts, with AUCs of 0.957 (95% CI: 0.918-0.987) and 0.932 (95% CI: 0.822-0.984), respectively. Decision curve analysis revealed that the combined model was superior to the other models.

Conclusion

The clinical-multimodal ultrasound radiomics model constructed with multimodal ultrasound radiomic features and clinical risk factors has favorable potential and high diagnostic value for predicting CLNM in PTC patients.

High-risk habitat radiomics model based on ultrasound images for predicting lateral neck lymph node metastasis in differentiated thyroid cancer

BACKGROUND

This study aims to evaluate the predictive usefulness of a habitat radiomics model based on ultrasound images for anticipating lateral neck lymph node metastasis (LLNM) in differentiated thyroid cancer (DTC), and for pinpointing high-risk habitat regions and significant radiomics traits.

METHODS

A group of 214 patients diagnosed with differentiated thyroid carcinoma (DTC) between August 2021 and August 2023 were included, consisting of 107 patients with confirmed postoperative lateral lymph node metastasis (LLNM) and 107 patients without metastasis or lateral cervical lymph node involvement. An additional cohort of 43 patients was recruited to serve as an independent external testing group for this study. Patients were randomly divided into training and internal testing group at an 8:2 ratio. Region of interest (ROI) was manually outlined, and habitat analysis subregions were defined using the K-means method. The ideal number of subregions (n = 5) was determined using the Calinski-Harabasz score, leading to the creation of a habitat radiomics model with 5 subregions and the identification of the high-risk habitat model. Area under the curve (AUC) values were calculated for all models to assess their validity, and predictive model nomograms were created by integrating clinical features. The internal and external testing dataset is employed to assess the predictive performance and stability of the model.

RESULTS

In internal testing group, Habitat 3 was identified as the high-risk habitat model in the study, showing the best diagnostic efficacy among all models (AUC(CRM) vs. AUC(Habitat 3) vs. AUC(CRM + Habitat 3) = 0.84(95%CI:0.71-0.97) vs. 0.90(95%CI:0.80-1.00) vs. 0.79(95%CI:0.65-0.93)). Moreover, integrating the Habitat 3 model with clinical features and constructing nomograms enhanced the predictive capability of the combined model (AUC = 0.95(95%CI:0.88-1.00)). In this study, an independent external testing cohort was utilized to assess the model's accuracy, yielding an AUC of 0.88 (95%CI: 0.78-0.98).

CONCLUSION

The integration of the High-Risk Habitats (Habitat 3) radiomics model with clinical characteristics demonstrated a high predictive accuracy in identifying LLNM. This model has the potential to offer valuable guidance to surgeons in deciding the necessity of LLNM dissection for DTC.

CLINICAL TRIAL NUMBER

Not applicable.

Automatic tumor segmentation and lymph node metastasis prediction in papillary thyroid carcinoma using ultrasound keyframes

BACKGROUND

Accurate preoperative prediction of cervical lymph node metastasis (LNM) for papillary thyroid carcinoma (PTC) patients is essential for disease staging and individualized treatment planning, which can improve prognosis and facilitate better management.

PURPOSE

To establish a fully automated deep learning-enabled model (FADLM) for automated tumor segmentation and cervical LNM prediction in PTC using ultrasound (US) video keyframes.

METHODS

The bicentral study retrospective enrolled 518 PTC patients, who were then randomly divided into the training (Hospital 1, n = 340), internal test (Hospital 1, n = 83), and external test cohorts (Hospital 2, n = 95). The FADLM integrated mask region-based convolutional neural network (Mask R-CNN) for automatic thyroid primary tumor segmentation and ResNet34 with Bayes strategy for cervical LNM diagnosis. A radiomics model (RM) using the same automated segmentation method, a traditional radiomics model (TRM) using manual segmentation, and a clinical-semantic model (CSM) were developed for comparison. The dice similarity coefficient (DSC) was used to evaluate segmentation performance. The prediction performance of the models was validated in terms of discrimination and clinical utility with the area under the receiver operator characteristic curve (AUC), heatmap analysis, and decision curve analysis (DCA). The comparison of the predictive performance among different models was conducted by DeLong test. The performances of two radiologists compared with FADLM and the diagnostic augmentation with FADLM's assistance were analyzed in terms of accuracy, sensitivity and specificity using McNemar's x2 test. The p-value less than 0.05 was defined as a statistically significant difference. The Benjamini-Hochberg procedure was applied for multiple comparisons to deal with Type I error.

RESULTS

The FADLM yielded promising segmentation results in training (DSC: 0.88 ± 0.23), internal test (DSC: 0.88 ± 0.23), and external test cohorts (DSC: 0.85 ± 0.24). The AUCs of FADLM for cervical LNM prediction were 0.78 (95% CI: 0.73, 0.83), 0.83 (95% CI: 0.74, 0.92), and 0.83 (95% CI: 0.75, 0.92), respectively. It all significantly outperformed the RM (AUCs: 0.78 vs. 0.72; 0.83 vs. 0.65; 0.83 vs. 0.68, all adjusted p-values < 0.05) and CSM (AUCs: 0.78 vs. 0.71; 0.83 vs. 0.62; 0.83 vs. 0.68, all adjusted p-values < 0.05) across the three cohorts. The RM offered similar performance to that of TRM (AUCs: 0.61 vs. 0.63, adjusted p-value = 0.60) while significantly reducing the segmentation time (3.3 ± 3.8 vs. 14.1 ± 4.2 s, p-value < 0.001). Under the assistance of FADLM, the accuracies of junior and senior radiologists were improved by 18% and 15% (all adjusted p-values < 0.05) and the sensitivities by 25% and 21% (all adjusted p-values < 0.05) in the external test cohort.

CONCLUSION

The FADLM with elaborately designed automated strategy using US video keyframes holds good potential to provide an efficient and consistent prediction of cervical LNM in PTC. The FADLM displays superior performance to RM, CSM, and radiologists with promising efficacy.

Diagnostic value of contrast-enhanced ultrasound combined with serum procalcitonin in tuberculous lymph nodes and metastatic lymph nodes

OBJECTIVE

To investigate the value of Contrast-Enhanced Ultrasound (CEUS) combined with Procalcitonin (PCT) in differentiating Tuberculous Lymph Nodes (TLN) from Metastatic Lymph Nodes (MLN).

METHODS

This prospective cohort study included 207 consecutive patients diagnosed with CTL. All patients underwent routine ultrasound and CEUS prior to pathology or laboratory confirmation. Serum indicators were measured by Enzyme-Linked Immunosorbent Assay (ELISA). Predictive modeling was performed by multifactorial logistic regression. Evaluate the diagnostic and calibration performance of the predictive model by drawing Receiver Operating Characteristic (ROC) curves and calibration curves, and using Area Under the Curve (AUC) and Hosmer-Lemeshow (H-L) tests.

RESULTS

The diagnosis of MLN was confirmed pathologically or laboratory in 102 of 207 patients (49.27 %), and 50.8 % were confirmed to be TLN. According to imaging findings of CEUS, TLN was more commonly associated with enhanced concentric performance in the arterial phase (67.65 % vs. 40.95 %) and heterogeneous enhancement pattern in lymph nodes (70.59 % vs. 52.38 %). Peak Intensity (PI) of lesions was higher in patients with MLN. Increased age-enhanced concentric performance in the arterial phase, increased PI, and serum PCT greater than 5.39 ng/mL were independent risk factors for MLN. The prediction model of serum PCT combined with CEUS had a higher diagnostic value for MLN. The H-L test indicated a satisfactory model fit (all p > 0.05), and the calibration curve closely approximates the ideal diagonal.

CONCLUSION

CEUS combined with serum PCT has better clinical application value in the differential diagnosis of TLN and MLN.

Sonographic characteristics of thyroid nodules with a Halo

OBJECTIVE

To investigate the sonographic characteristics of thyroid nodules with a halo, explore the value of contrast-enhanced ultrasound (CEUS) combined with fine needle aspiration (FNA) in identifying nodules with a halo, and predict the risk of metastasis by analyzing the pathological features of the halo.

METHODS

A retrospective analysis was conducted on 185 postoperative cases of thyroid nodules accompanied by halos between January 2019 and December 2022. After describing the ultrasound characteristics of the thyroid nodules and their halos, all patients were divided into three groups, the first group (group I = CEUS only) of patients underwent CEUS, the second group (group II = CEUS + FNA) underwent FNA based on the first group, and the third group (group III = FNA only) underwent FNA directly. The CEUS and FNA results were graded using the Chinese Thyroid Imaging Report and Data System (C-TIRADS) and Bethesda Reporting System for Thyroid Cytopathology, respectively. Those graded below C-TIRADS 4b or Bethesda IV were defined as benign, and the results of FNA were referenced when the two methods were combined. The surgical pathology results were used as the gold standard. We plotted working curves to compare the diagnostic efficacy of CEUS and FNA alone and in combination in the diagnosis of thyroid nodules with halos. The pathological features of the halo were analyzed and the number of patients with cervical lymph node metastases was recorded.

RESULTS

One hundred and sixty patients met the requirements. Benign nodules were mainly characterized by a thin (0.75 ± 0.31 mm) and uniform halo with good integrity, while malignant nodules had a thicker (1.48 ± 0.51 mm) halo with uneven and irregular margins (P < 0.05). The sensitivity and specificity were highest when the cutoff value was 1.09 mm, with 76.08% and 84.29%, respectively. The halos of benign nodules were mostly hyper- or iso-enhanced, whereas the halos of malignant nodules were predominantly hypo-enhanced (P < 0.05). The areas under the curve (AUCs) for CEUS, FNA, and CEUS + FNA were 0.751(95% CI = 0.642-0.841), 0.863(95% CI = 0.767-0.929), and 0.918(95% CI = 0.834-0.967), respectively. Cervical lymph node metastasis occurred in only 13 (11.5%) malignant nodes with halos. The primary pathological components of the halo around malignant nodules were almost reactive hyperplastic fibrous tissue.

CONCLUSION

The halo surrounding malignant thyroid nodules is thicker, with uneven and irregular margins, and shows hypo-enhancement on CEUS. Combining CEUS with FNA improves the diagnostic efficacy of thyroid nodules with halos. The reactive hyperplastic fibrous halo may be one of the reasons why malignant nodules are less likely to metastasize.

Investigating the Involvement of Mediastinal Lymph Nodes in Patients with Papillary Thyroid Carcinoma

Background

Papillary thyroid carcinoma (PTC) is also the most common endocrine malignancy. In the present study, we aimed to evaluate the metastasis pattern of upper mediastinal lymph node involvement in patients with PTC.

Materials and Methods

This is a descriptive cross-sectional study that was performed in 2020 in Isfahan, Iran, on 73 patients with PTC who were candidates for total thyroidectomy. Demographic data including age and gender were collected. The frequency distribution of upper mediastinal lymph node involvements and their relationships with mass size, gender, and age, location of tumor in the thyroid gland and involvement of lateral lymph nodes in the neck were evaluated.

Results

The mean mass size was 17.27 mm. The most involved thyroid lobe in patients with upper mediastinal lymph node involvement was the right lobe (16.5%). In terms of mediastinal lymph node involvement, there were no significant relationships between the two sexes (P = 0.161), primary mass size (P = 0.151), and thyroid mass location (P = 0.739) with mediastinal lymph node involvement. There was a significant relationship between lateral lymph node involvement of the neck (P = 0.007) and age groups (P = 0.042) with involvement of the upper mediastinal lymph nodes. Based on our results, the upper mediastinal lymph node involvement was more frequent among patients under 40 years of age.

Conclusion

Upper mediastinal lymph node metastasis in PTC was significantly more frequent in cases with younger ages (lower than 40 years) and involvements of lateral lymph nodes in the neck.

Score based on contrast-enhanced ultrasound predict central lymph node metastasis in papillary thyroid cancer

Objectives

To investigate the association between contrast-enhanced ultrasound (CEUS) features of PTC and central lymph node metastasis (CLNM) and to develop a predictive model for the preoperative identification of CLNM.

Methods

This retrospective study evaluated 750 consecutive patients with PTC from August 2020 to April 2023. Conventional ultrasound and qualitative CEUS features were analyzed for the PTC with or without CLNM using univariate and multivariate logistic regression analysis. A nomogram integrating the predictors was constructed to identify CLNM in PTC. The predictive nomogram was validated using a validation cohort.

Results

A total of 684 patients were enrolled. The 495 patients in training cohort were divided into two groups according to whether they had CLNM (pCLNM, n= 191) or not (nCLNM, n= 304). There were significant differences in terms of tumor size, shape, echogenic foci, enhancement direction, peak intensity, and score based on CEUS TI-RADS between the two groups. Independent predictive US features included irregular shape, larger tumor size (≥ 1.0cm), and score. Nomogram integrating these predictive features showed good discrimination and calibration in both training and validation cohort with an AUC of 0.72 (95% CI: 0.68, 0.77) and 0.79 (95% CI: 0.72, 0.85), respectively. In the subgroup with larger tumor size, age ≤ 35 years, irregular shape, and score > 6 were independent risk factors for CLNM.

Conclusion

The score based on preoperative CEUS features of PTC may help to identify CLNM. The nomogram developed in this study provides a convenient and effective tool for clinicians to determine an optimal treatment regimen for patients with PTC.

Differential diagnosis of cervical lymphadenopathy: Integration of postvascular phase of contrast-enhanced ultrasound and predictive nomogram model

BACKGROUND

Distinguishing benign from malignant cervical lymph nodes is critical yet challenging. This study evaluates the postvascular phase of contrast-enhanced ultrasound (CEUS) and develops a user-friendly nomogram integrating demographic, conventional ultrasound, and CEUS features for accurate differentiation.

METHODS

We retrospectively analyzed 395 cervical lymph nodes from 395 patients between January 2020 and December 2022. The cohort was divided into training and validation sets using stratified random sampling. A predictive model, based on demographic, ultrasound, and CEUS features, was created and internally validated.

RESULTS

The training set included 280 patients (130 benign, 150 malignant nodes) and the validation set 115 patients (46 benign, 69 malignant). Relative hypoenhancement in the postvascular phase emerged as a promising indicator for MLN, with sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 96.7 %,52.3 %, 70.0 %, 93.2 %, and 76.1 %, respectively in the training set and 95.7 %, 52.2 %, 75.0 %, 88.9 %, and 74.8 % in the validation set. Age over 50 years, history of malignancy, short-axis diameter greater than 1.00 cm, focal hyperechogenicity, ill-defined borders, and centripetal perfusion were also identified as independent MLN indicators. The nomogram prediction model showed outstanding accuracy, with an area under the curve (AUC) of 0.922 (95 % CI: 0.892-0.953) in the training set and 0.914 (95 % CI: 0.864-0.963) in the validation set.

CONCLUSION

Relative hypoenhancement in the postvascular phase of CEUS, combined with demographics and ultrasound features, is effective for identifying MLNs. The developed prediction model, with a user-friendly nomogram, can facilitate clinical decision-making.

Risk factor analysis and prediction model for papillary thyroid carcinoma with lymph node metastasis

Objective

We aimed to identify the clinical factors associated with lymph node metastasis (LNM) based on ultrasound characteristics and clinical data, and develop a nomogram for personalized clinical decision-making.

Methods

A retrospective analysis was performed on 252 patients with papillary thyroid carcinoma (PTC). The patient's information was subjected to univariate and multivariate logistic regression analyses to identify risk factors. A nomogram to predict LNM was established combining the risk factors. The performance of the nomogram was evaluated using receiver operating characteristic (ROC) curve, calibration curve, cross-validation, decision curve analysis (DCA), and clinical impact curve.

Results

There are significant differences between LNM and non-LNM groups in terms of age, sex, tumor size, hypoechoic halo around the nodule, thyroid capsule invasion, lymph node microcalcification, lymph node hyperechoic area, peak intensity of contrast (PI), and area under the curve (AUC) of the time intensity curve of contrast (P<0.05). Age, sex, thyroid capsule invasion, lymph node microcalcification were independent predictors of LNM and were used to establish the predictive nomogram. The ROC was 0.800, with excellent discrimination and calibration. The predictive accuracy of 0.757 and the Kappa value was 0.508. The calibration curve, DCA and calibration curve demonstrated that the prediction model had excellent net benefits and clinical practicability.

Conclusion

Age, sex, thyroid capsule invasion, and lymph node microcalcification were identified as significant risk factors for predicting LNM in patients with PTC. The visualized nomogram model may assist clinicians in predicting the likelihood of LNM in patients with PTC prior to surgery.

Diagnostic value of contrast-enhanced ultrasonography in the preoperative evaluation of lymph node metastasis in papillary thyroid carcinoma: a single-center retrospective study

BACKGROUND

Contrast-enhanced ultrasound (CEUS) has been recently used for the assessment of cervical lymph node metastasis (LNM) to guide surgical operation in patients with papillary thyroid carcinoma (PTC). However, the specificity and sensitivity of CEUS reported from previous studies are not consistent. The objective of this study was to evaluate the diagnostic value of CEUS for the metastasis of cervical lymph nodes in PTC patients based on data from one regional central hospital.

METHODS

The diagnostic value of CEUS in preoperative LNM of PTC patients was concluded by comparing the results of CEUS on lymph node status with postoperative pathology examination. In addition, this study conducted hierarchical analysis of PTC patients to explore whether tumor size, different lymph node regions, and Hashimoto's thyroiditis influence the assessment of CEUS.

RESULTS

This research study ultimately enrolled 965 PTC patients, including 266 males and 699 females with a mean age of 42.27 ± 11.34 years. A total of 527 patients were considered clinical-node negative, and 438 were clinical-node positive before surgery. The specificity, sensitivity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of CEUS in the assessment of LNM in PTC patients were 56.00%, 71.00%, 57.06%, 69.76% and 62.59%, respectively. For central and lateral lymph nodes, the accuracy of CEUS in PTC patients was 49.43% and 54.30%, respectively. In addition, it was shown that the accuracy of CEUS in PTC patients with Hashimoto's thyroiditis (HT) slightly decreased to 58.44%, and the accuracy of CEUS in PTC patients with non-HT in turn increased to 64.17%. The accuracy of CEUS in non-papillary thyroid microcarcinoma (PTMC) and PTMC patients was 65.68% and 61.24%, respectively. The accuracy of CEUS in predicting central LNM was significantly different between PTC patients with or without HT (P < 0.001) in this study but not for lateral lymph nodes (P = 0.114).

CONCLUSION

The accuracy of CEUS in the assessment of LNM in PTC is not consistently satisfactory, especially for central lymph nodes, small tumor diameters, or patients with HT. More diagnostic technologies for abnormal lymph nodes should be considered in PTC patients.

International Expert Consensus on US Lexicon for Thyroid Nodules

Multiple US-based systems for risk stratification of thyroid nodules are in use worldwide. Unfortunately, the malignancy probability assigned to a nodule varies, and terms and definitions are not consistent, leading to confusion and making it challenging to compare study results and craft revisions. Consistent application of these systems is further hampered by interobserver variability in identifying the sonographic features on which they are founded. In 2018, an international multidisciplinary group of 19 physicians with expertise in thyroid sonography (termed the International Thyroid Nodule Ultrasound Working Group) was convened with the goal of developing an international system, tentatively called the International Thyroid Imaging Reporting and Data System, or I-TIRADS, in two phases: (phase I) creation of a lexicon and atlas of US descriptors of thyroid nodules and (phase II) development of a system that estimates the malignancy risk of a thyroid nodule. This article presents the methods and results of phase I. The purpose herein is to show what has been accomplished thus far, as well as generate interest in and support for this effort in the global thyroid community.

Multi-modality parathyroid imaging: A shifting paradigm

The goal of parathyroid imaging in hyperparathyroidism is not diagnosis, rather it is the localization of the cause of hyperparathyroidism for planning the best therapeutic approach. Hence, the role of imaging to accurately and precisely localize the abnormal parathyroid tissue is more important than ever to facilitate minimally invasive parathyroidectomy over bilateral neck exploration. The common causes include solitary parathyroid adenoma, multiple parathyroid adenomas, parathyroid hyperplasia and parathyroid carcinoma. It is highly imperative for the radiologist to be cautious of the mimics of parathyroid lesions like thyroid nodules and lymph nodes and be able to differentiate them on imaging. The various imaging modalities available include high resolution ultrasound of the neck, nuclear imaging studies, four-dimensional computed tomography (4D CT) and magnetic resonance imaging. Contrast enhanced ultrasound is a novel technique which has been recently added to the armamentarium to differentiate between parathyroid adenomas and its mimics. Through this review article we wish to review the imaging features of parathyroid lesions on various imaging modalities and present an algorithm to guide their radiological differentiation from mimics.

The Dark Side of Ultrasound Imaging in Parathyroid Disease

The diagnosis of parathyroid diseases by imaging still has some intrinsic technical limitations due to the differential diagnosis of different structures of the neck that mimic the parathyroid glands. In this view, ultrasound (US) is an established, low-cost, and non-invasive imaging technique that still represents the first-line approach for evaluating patients with parathyroid disease. The objective of this article is to provide a comprehensive review of the applications of USs in clinical practice, discussing the histopathological and US characteristics of the parathyroid glands in normal and pathological conditions, the advantages of preoperative imaging, and novel updates on the most useful and currently available multiparameter US techniques.

Using ultrasound radiomics analysis to diagnose cervical lymph node metastasis in patients with nasopharyngeal carcinoma

OBJECTIVE

This study aimed to explore the clinical value of ultrasound radiomics analysis in the diagnosis of cervical lymph node metastasis (CLNM) in patients with nasopharyngeal carcinoma (NPC).

METHODS

A total of 205 cases of NPC CLNM and 284 cases of benign lymphadenopathy with pathologic diagnosis were retrospectively included. Grayscale ultrasound (US) images of the largest section of every lymph node underwent feature extraction. Feature selection was done by maximum relevance minimum redundancy (mRMR) algorithm and multivariate logistic least absolute shrinkage and selection operator (LASSO) regression. Logistic regression models were developed based on clinical features, radiomics features, and the combination of those features. The AUCs of models were analyzed by DeLong's test.

RESULTS

In the clinical model, lymph nodes in the upper neck, larger long axis, and unclear hilus were significant factors for CLNM (p < 0.001). MRMR and LASSO regression selected 7 significant features for the radiomics model from the 386 radiomics features extracted. In the validation dataset, the AUC value was 0.838 (0.776-0.901) in the clinical model, 0.810 (0.739-0.881) in the radiomics model, and 0.880 (0.826-0.933) in the combined model. There was not a significant difference between the AUCs of clinical models and radiomics models in both datasets. DeLong's test revealed a significantly larger AUC in the combined model than in the clinical model in both training (p = 0.049) and validation datasets (p = 0.027).

CONCLUSION

Ultrasound radiomics analysis has potential value in screening meaningful ultrasound features and improving the diagnostic efficiency of ultrasound in CLNM of patients with NPC.

KEY POINTS

• Radiomics analysis of gray-scale ultrasound images can be used to develop an effective radiomics model for the diagnosis of cervical lymph node metastasis in nasopharyngeal carcinoma patients. • Radiomics model combined with general ultrasound features performed better than the clinical model in differentiating cervical lymph node metastases from benign lymphadenopathy.

Nomogram incorporating preoperative clinical and ultrasound indicators to predict aggressiveness of solitary papillary thyroid carcinoma

Objective

To construct a nomogram based on preoperative clinical and ultrasound indicators to predict aggressiveness of solitary papillary thyroid carcinoma (PTC).

Methods

Preoperative clinical and ultrasound data from 709 patients diagnosed with solitary PTC between January 2017 and December 2020 were analyzed retrospectively. Univariate and multivariate logistic regression analyses were performed to identify the factors associated with PTC aggressiveness, and these factors were used to construct a predictive nomogram. The nomogram's performance was evaluated in the primary and validation cohorts.

Results

The 709 patients were separated into a primary cohort (n = 424) and a validation cohort (n = 285). Univariate analysis in the primary cohort showed 13 variables to be associated with aggressive PTC. In multivariate logistic regression analysis, the independent predictors of aggressive behavior were age (OR, 2.08; 95% CI, 1.30-3.35), tumor size (OR, 4.0; 95% CI, 2.17-7.37), capsule abutment (OR, 2.53; 95% CI, 1.50-4.26), and suspected cervical lymph nodes metastasis (OR, 2.50; 95% CI, 1.20-5.21). The nomogram incorporating these four predictors showed good discrimination and calibration in both the primary cohort (area under the curve, 0.77; 95% CI, 0.72-0.81; Hosmer-Lemeshow test, P = 0.967 and the validation cohort (area under the curve, 0.72; 95% CI, 0.66-0.78; Hosmer-Lemeshow test, P = 0.251).

Conclusion

The proposed nomogram shows good ability to predict PTC aggressiveness and could be useful during treatment decision making.

Advances in knowledge

Our nomogram-based on four indicators-provides comprehensive assessment of aggressive behavior of PTC and could be a useful tool in the clinic.

Microbubble contrast agent SonoVue: An efficient medium for the preoperative lymphatic mapping of thyroid carcinoma

Objective: To assess the value of microbubble contrast agent SonoVue in the thorough preoperative lymphatic mapping of patients with thyroid carcinoma, including the lymphatic drainage region, the detection of sentinel lymph node (SLN), and the diagnosis of lymph node metastasis (LNM). Materials and methods: 55 patients with 62 thyroid malignancies proved by surgical pathology (59 papillary thyroid carcinomas and three medullary thyroid carcinomas) who underwent preoperative lymphatic contrast-enhanced ultrasound (LCEUS) with microbubble contrast agent SonoVue were enrolled. All LNM were confirmed by pathology. The location of thyroid lesions, ultrasonic features of lymph nodes, lymphatic drainage region, and detection of SLN were assessed. The diagnostic performance (sensitivity, specificity, positive predictive value, negative predictive value and accuracy) of different parameters for the LNM diagnosis was calculated. Results: SonoVue effectively demonstrated the lymphatic drainage region for all enrolled thyroid carcinomas. The most common lymphatic drainage region for thyroid carcinomas was region VI (93.55%), followed by region III (62.90%), region IV (48.39%) and region II (4.84%). When divided by the lesion location, the most common lymphatic drainage regions for the nodule in isthmus, superior lobe and inferior lobe of the thyroid were region VI, region III, and region VI respectively. SLN was detected in 96.77% (60/62) of cases. The two cases without SLN demonstration had pathologically proven LNM. The most common sonographic sign of LNM was perfusion defect (54.17%). The diagnostic accuracy of SonoVue in central and lateral compartment LNM was 86.67% and 91.67%, respectively. Conclusion: Microbubble contrast agent SonoVue is a valuable imaging contrast medium for thorough preoperative lymphatic mapping in patients with thyroid carcinoma, including the lymphatic drainage region, the detection of SLN, and the diagnosis of LNM. LCEUS with SonoVue alone has limitations of false negatives when there is lymphatic vessel obstruction and may need to be combined with other ultrasound modalities.

Super-Resolution Ultrasound Localization Microscopy of Microvascular Structure and Flow for Distinguishing Metastatic Lymph Nodes - An Initial Human Study

PURPOSE

Detecting and distinguishing metastatic lymph nodes (LNs) from those with benign lymphadenopathy are crucial for cancer diagnosis and prognosis but remain a clinical challenge. A recent advance in super-resolution ultrasound (SRUS) through localizing individual microbubbles has broken the diffraction limit and tracking enabled in vivo noninvasive imaging of vascular morphology and flow dynamics at a microscopic level. In this study we hypothesize that SRUS enables quantitative markers to distinguish metastatic LNs from benign ones in patients with lymphadenopathy.

MATERIALS AND METHODS

Clinical contrast-enhanced ultrasound image sequences of LNs from 6 patients with lymph node metastasis and 4 with benign lymphadenopathy were acquired and motion-corrected. These were then used to generate super-resolution microvascular images and super-resolved velocity maps. From these SRUS images, morphological and functional measures were obtained including micro-vessel density, fractal dimension, mean flow speed, and Local Flow Direction Irregularity (LFDI) measuring the variance in local flow direction. These measures were compared between pathologically proven reactive and metastasis LNs.

RESULTS

Our initial results indicate that the difference in the indicator of flow irregularity (LFDI) derived from the SRUS images is statistically significant between the two groups. The LFDI is 60% higher in metastatic LNs compared with reactive nodes.

CONCLUSION

This pilot study demonstrates the feasibility of super-resolution ultrasound for clinical imaging of lymph nodes and the potential of using the irregularity of local blood flow directions afforded by SRUS for the characterization of LNs.

Diagnostic value of multiple diagnostic methods for lymph node metastases of papillary thyroid carcinoma: A systematic review and meta-analysis

OBJECTIVE

This study compared the diagnostic value of various diagnostic methods for lymph node metastasis (LNM) of papillary thyroid carcinoma (PTC) through network meta-analysis.

METHODS

In this experiment, databases such as CNKI, Wanfang, PubMed, and Web of Science were retrieved according to the Cochrane database, Prisma, and NMAP command manual. A meta-analysis was performed using STATA 15.0, and the value of the surface under the cumulative ranking curve (SUCRA) was used to determine the most effective diagnostic method. Quality assessments were performed using the Cochrane Collaboration's risk of bias tool, and publication bias was assessed using Deeks' funnel plot.

RESULTS

A total of 38 articles with a total of 6285 patients were included. A total of 12 diagnostic methods were used to study patients with LNM of PTC. The results showed that 12 studies were direct comparisons and 8 studies were indirect comparisons. According to the comprehensive analysis of the area of SUCRA, US+CT(86.8) had the highest sensitivity, FNAC had the highest specificity (92.4) and true positive predictive value (89.4), and FNAC+FNA-Tg had higher negative predictive value (99.4) and accuracy (86.8). In the non-invasive method, US+CT had the highest sensitivity, and the sensitivity (SEN) was [OR=0.59, 95% confidence interval (CI): (0.30, 0.89]. Among the invasive methods, the combined application of FNAC+FNA-Tg had higher diagnostic performance. The sensitivity was [OR=0.62, 95% CI: (0.26, 0.98)], the specificity (SPE) was [OR=1.12, 95% CI: (0.59, 1.64)], the positive predictive value was [OR=0.98, 95% CI: (0.59, 1.37)], the negative predictive value was [OR=0.64, 95% CI (0.38, 0.90)], and the accuracy was [OR=0.71, 95% CI: (0.31, 1.12)].

CONCLUSION

In the non-invasive method, the combined application of US+CT had good diagnostic performance, and in the invasive method, the combined application of FNAC+FNA-Tg had high diagnostic performance, and the above two methods were recommended.

Application value of contrast-enhanced ultrasound in preoperative localization of microwave ablation for primary hyperparathyroidism

BACKGROUND

Ultrasonography (US) and ^99m Technetium-sestamibi scintigraphy (^99m Tc-MIBI) are currently first-line imaging modalities to localize parathyroid adenomas with sensitivities of 80% and 84%, respectively. Therefore, finding other modalities to further improve the diagnostic accuracy for preoperative localization is critically needed.

PURPOSE

To evaluate the application value of contrast-enhanced ultrasound (CEUS) in the preoperative localization of microwave ablation (MWA) for primary hyperparathyroidism (PHPT).

METHODS

Between December 2012 and May 2021, 100 PHPT patients (34 males and 66 females; mean age, 56.31 ± 13.43 years; age range, 25-85 years) with 130 suspected parathyroid nodules were enrolled. US, CEUS, and ^99m Tc-MIBI were performed for the localization of pathological parathyroid glands. All patients were performed MWA under ultrasound guidance. All the suspected parathyroid nodules underwent core needle biopsy under ultrasound guidance during MWA to confirm the pathology. The diagnostic performance of all the imaging tests was analyzed in comparison with the pathological results.

RESULTS

A total of 130 nodules suspected to be of parathyroid origin from preoperative localization images were confirmed by pathological results, of which 116 were of parathyroid origin, and 14 were not of parathyroid origin. The sensitivity, specificity, accuracy, and the area under receiver operating characteristic curve of CEUS in the localization of pathological parathyroid glands were 100%, 92.86%, 99.23%, and 0.964, which were significantly higher than those of US (93.10%, 42.86%, 87.69%, and 0.680) and ^99m Tc-MIBI (81.90%, 42.86%, 77.69%, and 0.624) (p < 0.05). The sensitivity and accuracy of CEUS were 100% and 97.22%, which were higher than those of ^99m Tc-MIBI (65.62% and 63.89%) or US (75.00% and 72.22%) in patients with multiple parathyroid glands (p < 0.05). For smaller parathyroid adenomas (≤2 cm in diameter), the sensitivities of CEUS in locating hyperfunctioning parathyroid glands were 100%, which was significantly higher than that of ^99m Tc-MIBI (73.68% and 84.31%, p < 0.05).

CONCLUSIONS

CEUS is a valuable preoperative localization method for PHPT patients performed MWA, especially for the patients with smaller pathological parathyroid gland and multiple glandular lesions.

A Combination of Contrast-Enhanced Ultrasound and Thyroglobulin Level in Fine-Needle Aspirates Improves Diagnostic Accuracy for Metastatic Lymph Nodes of Papillary Thyroid Carcinoma

OBJECTIVE

To evaluate the diagnostic performance of contrast-enhanced ultrasound (CEUS) combined with thyroglobulin (Tg) levels in fine-needle aspirates (FNA) washout fluid (FNA-Tg) in diagnosing cervical lymph node (LN) metastasis in papillary thyroid cancer (PTC) patients.

METHODS

Data from 190 LNs in 167 patients suspected of metastasis from the US between November 2018 and September 2020 were included. All subjects underwent FNA, CEUS, and FNA-Tg examinations. The final outcomes were confirmed by histopathological or cytological examination or follow-up imaging. Data were analyzed using the Wilcoxon rank-sum or chi-squared test. The diagnostic efficacy of FNA, CEUS, and FNA-Tg in diagnosing LNs was compared.

RESULTS

A cutoff value of 6.15 ng/ml (AUC 0.925, 95% confidence interval (CI) 0.885-0.966) successfully identified metastatic LNs. FNA missed 58 LN metastases, of these, 94.8% (55/58) were correctly diagnosed using the combination of CEUS and FNA-Tg. FNA-Tg showed higher sensitivity (90.2%), NPV (86.1%) and accuracy (88.9%) than either FNA (48.2, 57.4 and 69.5%, respectively) or CEUS (82.1, 67.7 and 70.5%, respectively) alone. The combination of CEUS, FNA and FNA-Tg resulted in maximal sensitivity (100%) and NPV (100%) but reduced specificity (51.3%) and overall diagnostic accuracy (80.0%). After adding FNA-Tg to discordant samples between CEUS and FNA, 81.9% of LNs (77/94) were correctly diagnosed.

CONCLUSIONS

The combination of FNA, FNA-Tg and CEUS was found to be a promising imaging tool in detecting metastatic LNs in PTC patients.

Ultrasonic Characterization of Primary Squamous Cell Carcinoma of the Thyroid

OBJECTIVES

To identify the ultrasonographic characteristics of primary squamous cell carcinoma of the thyroid (PSCCT), and to assess the value of the 2015 American Thyroid Association (ATA) guideline and 2017 American College of Radiology (ACR) Thyroid Imaging, Reporting and Data System (TI-RADS) in the evaluation of this disease.

METHODS

Eight patients with 9 PSCCTs over a 20-year study period were enrolled. Ultrasonic characteristics including nodule echogenicity, composition, shape, margin, calcification, size, vascularity, and cervical lymphadenopathy were reviewed. All nodules were then evaluated by 2017 ACR TI-RADS and 2015 ATA guidelines.

RESULTS

The average size of PSCCTs was 3.87 ± 1.41 cm. All PSCCTs were hypoechoic or very hypoechoic, solid nodules with intranodular vascularity. The average resistive index (RI) was 0.84 ± 0.18. Near half of PSCCTs (44.4%) demonstrated extrathyroidal extension. Taller-than-wide signs and cervical lymphadenopathy were observed in 33.3% of PSCCTs, and microcalcification was observed in 11.1% of them. All PSCCTs were classified as high suspicion patterns by 2015 ATA and recommended for fine-needle aspiration (FNA). Six PSCCTs (66.7%) were classified as grade 5 by 2017 ACR TI-RADS, while the remaining were grade 4. 88.9% of PSCCTs were recommended for FNA based on 2017 ACR TI-RADS.

CONCLUSION

PSCCT has certain ultrasonic features, including relatively large, hypoechoic, or very hypoechoic solid nodules with intranodular vascularity and extrathyroidal extension. Both 2015 ATA and 2017 ACR TI-RADS could identify PSCCT as suspicious for malignancy.

Multiparametric Ultrasound of Cervical Lymph Node Metastases in Head and Neck Cancer for Planning Non-Surgical Therapy

Background: We aimed to evaluate multiparametric ultrasound, to achieve a better understanding of the baseline characteristics of suspected cervical lymph node metastases in head and neck cancer before induction chemotherapy or chemoradiation. Methods: From February 2020 to April 2021, our complete ultrasound examination protocol was carried out on clinically evident malignant lymph nodes of histologically proven HNSCC in the pre-therapeutic setting. Results: A total of 13 patients were eligible for analysis. Using elastography, irregular clear hardening in areas in the center of the lymph node could be detected in all cases. Elastographic Q-analysis showed a significantly softer cortex compared to the center and surrounding tissue. The time–intensity curve analysis showed high values for the area under the curve and a short time-to-peak (fast wash-in) in all cases compared to the surrounding tissue. A parametric evaluation of contrast enhanced the ultrasound in the early arterial phase and showed an irregular enhancement from the margin in almost all investigated lymph nodes. These results show that the implementation of comprehensive, multiparametric ultrasound is suitable for classifying suspected lymph node metastasis more precisely than conventional ultrasound alone in the pre-therapeutic setting of HNSCC. Thus, these parameters may be used for improvements in the re-staging after chemoradiation or neoadjuvant therapy monitoring, respectively.

Contrast-enhanced ultrasound (CEUS) in characterization of inconclusive cervical lymph nodes: a meta-analysis and systematic review

Lymph node metastases are common in malignant neoplasms of head and neck. Since cervical lymph nodes (cLN) are localized superficially, ultrasound (US) represents the primary imaging modality. The aim of the study is to report the value of US and contrast-enhanced ultrasound (CEUS) and their diagnostic confidence in the characterization of inconclusive cLN. A systematic review was performed using the literature data base PubMed. Results were filtered (published in a peer-reviewed journal, full-text available, published within the last ten years, species human, English or German full-text) and inclusion criteria were clearly defined (cohort with lymphadenopathy or malignancy in head and neck ≥ 50 patients, histological confirmation of malignant imaging findings, performance of CEUS as outcome variable). The results were quantified in a meta-analysis using a random-effects model. Overall, five studies were included in qualitative and quantitative analysis. The combination of non-enhanced US and CEUS enlarges the diagnostic confidence in the characterization of lymph nodes of unclear dignity. The pooled values for sensitivity and specificity in the characterization of a malignant cervical lymph node using US are 76% (95%-CI 66-83%, I2 = 63%, p < 0.01) and 80% (95%-CI 45-95%, I2 = 92%, p < 0.01), compared to 92% (95%-CI 89-95%, I2 = 0%, p = 0.65) and 91% (95%-CI 87-94%, I2 = 0%, p = 0.40) for the combination of US and CEUS, respectively. Consistent results of the included studies show improved diagnostic performance by additional CEUS. Nevertheless, more prospective studies are needed to implement CEUS in the diagnostic pathway of cLN.

Ultrasound-based radiomics analysis for preoperative prediction of central and lateral cervical lymph node metastasis in papillary thyroid carcinoma: a multi-institutional study

Background

An accurate preoperative assessment of cervical lymph node metastasis (LNM) is important for choosing an optimal therapeutic strategy for papillary thyroid carcinoma (PTC) patients. This study aimed to develop and validate two ultrasound (US) nomograms for the individual prediction of central and lateral compartment LNM in patients with PTC.

Methods

A total of 720 PTC patients from 3 institutions were enrolled in this study. They were categorized into a primary cohort, an internal validation, and two external validation cohorts. Radiomics features were extracted from conventional US images. LASSO regression was used to select optimized features to construct the radiomics signature. Two nomograms integrating independent clinical variables and radiomics signature were established with multivariate logistic regression. The performance of the nomograms was assessed with regard to discrimination, calibration, and clinical usefulness.

Results

The radiomics scores were significantly higher in patients with central/lateral LNM. A radiomics nomogram indicated good discrimination for central compartment LNM, with an area under the curve (AUC) of 0.875 in the training set, the corresponding value in the validation sets were 0.856, 0.870 and 0.870, respectively. Another nomogram for predicting lateral LNM also demonstrated good performance with an AUC of 0.938 and 0.905 in the training and internal validation cohorts, respectively. The AUC for the two external validation cohorts were 0.881 and 0.903, respectively. The clinical utility of the nomograms was confirmed by the decision curve analysis.

Conclusion

The nomograms proposed here have favorable performance for preoperatively predicting cervical LNM, hold promise for optimizing the personalized treatment, and might greatly facilitate the decision-making in clinical practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12880-022-00809-2.

Application Value of Color Doppler Ultrasonography Combined with Thyroid Autoantibody Tests in Early Diagnosis of Thyroid Cancer

Objective

To explore the application value of color Doppler ultrasonography combined with thyroid autoantibody tests in the early diagnosis of thyroid cancer.

Methods

The medical data of 100 patients with thyroid nodules treated in our hospital from June 2019 to June 2021 were retrospectively analyzed; all patients received color Doppler ultrasonography and thyroid autoantibody tests before surgery and were divided into the benign lesion group (n = 45) and the malignant lesion group (n = 55) according to the postoperative pathological findings (the gold standard), so as to compare and analyze the application value of color Doppler ultrasonography, thyroid autoantibody tests, and their combination in the early diagnosis of thyroid cancer.

Results

Compared with the pathological findings, the accuracy rate, sensitivity, specificity, positive predictive value, and negative predictive value of the combined diagnosis were significantly higher than those in the single diagnosis of color Doppler ultrasonography, TgAb test, TPOAb test, and TRAb test (P < 0.05), and by plotting the ROC curves to analyze the effect of these modalities in diagnosing early thyroid diseases, the results showed that the areas under the curve from large to small were combined diagnosis, color Doppler ultrasonography, TgAb test, TPOAb test, and TRAb test.

Conclusion

Color Doppler ultrasonography has many advantages in the diagnosis of thyroid nodules, such as easy operation, painlessness, noninvasiveness, high efficiency, and repeatable detection, and the high-definition probe is able to show tiny lesions, echogenicity, blood flow signal, and other characteristics of foci. Combining color Doppler ultrasonography with testing thyroid autoantibodies such as TgAb, TPOAb, and TRAb can effectively improve the detection rate of early thyroid cancer, presenting significant reference value and meaning to clinical diagnosis and treatment of thyroid cancer.

Application Value of Real-Time Ultrasonic Elastograph with Serum Human Epididymis Protein 4, Interleukin-33, and Carbohydrate Antigen 153 in Diagnosis of Early Cervical Cancer

Objective

To explore the application value of real-time ultrasonic elastograph (USE) with serum human epididymis protein 4 HE4, interleukin-33 (IL-33), and carbohydrate antigen 153 (CA153) in the diagnosis of early cervical cancer.

Methods

A total of 120 cervical cancer patients treated in our hospital (06, 2019-06, 2021) and meeting the study criteria were screened and divided into the benign group (BG, n = 70) and malignant group (MG, n = 50) according to their final diagnostic results, and healthy females who received physical examination in our hospital in the same period were selected as the control group (CG, n = 60). Patients in the three groups received real-time USE and detection of serum HE4, IL-33, and CA153 so as to analyze the diagnostic value of single examination and combined examination in diagnosing early cervical cancer.

Results

The patients' real-time USE score, E _max, E _mean, and elastic fibers were significantly higher in the MG than those in the BG (P < 0.05), and the patients' real-time USE E _min, stroma ratio and collagen fibers were significantly lower in the MG than those in the BG (P < 0.05); the HE4, IL-33, and CA153 levels were obviously higher in the MG than those in the BG (P < 0.05) and were significantly higher in the BG than those in the CG (P < 0.05); the positive detection rate of combining real-time USE with serum HE4, IL-33, and CA153 was higher than that of single examination, and the diagnostic accuracy rate, sensitivity, specificity, positive predictive value, and negative predictive value of the combined examination were significantly higher than those of single examination (P < 0.05); according to the diagnostic efficacy of single examination and combined examination in diagnosing early cervical cancer by ROC curve, it was combined diagnosis > real-time USE > HE4 > CA153 > IL-33.

Conclusion

Combined examination of real-time USE and serum HE4, IL-33, and CA153 has higher diagnostic value in diagnosing early cervical cancer, which can obviously improve the diagnostic accuracy rate of cervical cancer.

Value of Contrast-Enhanced Ultrasound in the Preoperative Evaluation of Papillary Thyroid Carcinoma Invasiveness

Objective

To evaluate the diagnostic performance of preoperative contrast-enhanced ultrasound (CEUS) in the detection of extracapsular extension (ECE) and cervical lymph node metastasis (LNM) of papillary thyroid carcinoma (PTC) and the added value of CEUS in the evaluation of PTC invasiveness to conventional ultrasound (US).

Materials and Methods

A total of 62 patients were enrolled retrospectively, including 30 patients with invasive PTCs (Group A, ECE or LNM present) and 32 patients with non-invasive PTCs (Group B). All patients underwent US and CEUS examinations before surgery. US and CEUS features of PTCs and lymph nodes were compared between groups. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of US, CEUS, and the combination of the two in the detection of ECE and LNM of PTCs were calculated. Logistic regression was used to analyze relationships between variables.

Results

The PTC size was larger in group A on both US and CEUS (P = 0.001, P = 0.003). More PTCs showed hyper-enhancement in group A (P = 0.013) than in group B. More PTCs had >25% contact between PTC and the thyroid capsule and discontinued capsule on US and CEUS (all P < 0.05) in group A than in group B. More absent hilum and calcification of lymph nodes were observed in group A (both P < 0.05) than in group B on US. More centripetal perfusion and enlarged lymph nodes were observed in group A (both P < 0.05) than in group B on CEUS. CEUS alone and US combined with CEUS manifested higher diagnostic accuracy (79.0%) than US alone (72.6%) in the detection of ECE. The combination of US and CEUS manifested the highest diagnostic accuracy (95.2%) than CEUS alone (90.3%) and US alone (82.2%) in the detection of LNM. Diagnoses of ECE and LNM by the combination of US and CEUS were independent risk factors for PTC invasiveness [odds ratio (OR) = 29.49 and 97.20, respectively; both P = 0.001].

Conclusion

CEUS or US combined with CEUS is recommended for the detection of PTC ECE, while the combination of US and CEUS is most recommended for LNM detection. CEUS plays an essential role in the preoperative evaluation of PTC invasiveness.

Analysis of the Relevance of the Ultrasonographic Features of Papillary Thyroid Carcinoma and Cervical Lymph Node Metastasis on Conventional and Contrast-Enhanced Ultrasonography

Background

Preoperative prediction of lymph node metastases has a major impact on prognosis and recurrence for patients with papillary thyroid carcinoma (PTC). Thyroid ultrasonography is the preferred inspection to guide the appropriate diagnostic procedure.

Purpose

To investigate the relationship between PTC and cervical lymph node metastasis (CLNM, including central and lateral LNM) using both conventional ultrasound (US) and contrast-enhanced ultrasound (CEUS).

Material and Methods

Our study retrospectively analyzed 379 patients diagnosed with PTC confirmed by surgical pathology at our hospital who underwent US and CEUS examinations from October 2016 to March 2021. Individuals were divided into two groups: the lymph node metastasis group and the nonmetastasis group. The relationship between US and CEUS characteristics of PTC and CLNM was analyzed. Univariate and multivariable logistic regression methods were used to identify the high-risk factors and established a nomogram to predict CLNM in PTC. Furthermore, we explore the frequency of CLNM at each nodal level in PTC patients.

Results

Univariate analysis indicated that there were significant differences in gender, age, tumor size, microcalcification, contact with the adjacent capsule, multifocality, capsule integrity and enhancement patterns in CEUS between the lymph node metastasis group and the nonmetastasis group (all P<0.05). Multivariate regression analysis showed that tumor size ≥1 cm, age ≤45 years, multifocality, and contact range of the adjacent capsule >50% were independent risk factors for CLNM in PTC, which determined the nomogram. The diagnostic model had an area under the curve (AUC) of 0.756 (95% confidence interval, 0.707-0.805). And calibration plot analysis shown that clinical utility of the nomogram. In 162 PTC patients, the metastatic rates of cervical lymph nodes at levels I-VI were 1.9%, 15.4%, 35.2%, 34.6%, 15.4%, 82.1%, and the difference was statistically significant (P<0.001).

Conclusion

Our study indicated that the characteristics of PTC on ultrasonography and CEUS can be used to predict CLNM as a useful tool. Preoperative analysis of ultrasonographical features has important value for predicting CLNM in PTCs. The risk of CLNM is greater when tumor size ≥1 cm, age ≤45 years, multifocality, contact range of the adjacent capsule >50% are present.

Value of Contrast-Enhanced Ultrasound for Evaluation of Cervical Lymph Node Metastasis in Papillary Thyroid Carcinoma

The aim of the study was to evaluate the diagnostic value of contrast-enhanced ultrasound (CEUS) in distinguishing between benign and malignant cervical lymph nodes (LNs) in patients with papillary thyroid carcinoma (PTC). Two hundred and one cervical LNs (157 metastatic from PTC and 44 benign) were evaluated using conventional ultrasonography (US) and CEUS before biopsy or surgery. Histopathology was used as the gold standard. We evaluated the size, long axis/short axis ratio (L/S), fatty hilum, hyper-echogenicity, calcification, cystic change, peripheral vascularity and CEUS parameters for each lymph nodule. The CEUS parameters included enhancement type, homogeneity, perfusion type, ring enhancement, peak intensity (PI) index and area under the curve (AUC) index. Univariate analysis demonstrated that compared with benign LNs, malignant LNs more frequently had L/S < 2, absence of a fatty hilum, presence of hyper-echogenicity, presence of calcification, peripheral vascularity, hyper-enhancement, heterogeneous enhancement, centripetal perfusion, ring enhancement, PI index > 1 and AUC index > 1 on preoperative US and CEUS. Binary logistic regression analysis demonstrated that hyper-enhancement, centripetal perfusion, and ring enhancement are independent CEUS characteristics related to malignant LNs for their differentiation from benign LNs (all p < 0.05). Our study indicated that preoperative CEUS characteristics may serve as a useful tool to identify malignant cervical LNs from benign cervical LNs.

Contrast-enhanced ultrasound characteristics of preoperative central cervical lymph node metastasis in papillary thyroid carcinoma

This study evaluated the preoperative diagnostic value of lymph node ultrasonography in distinguishing between benign and malignant central cervical lymph nodes (CCLNs) in patients with papillary thyroid carcinoma (PTC). A total of 176 patients who had PTC with 216 CCLNs (49 benign and 155 malignant) were enrolled in this study and preoperatively imaged by ultrasonography, including conventional ultrasound (US) and contrast-enhanced ultrasound (CEUS). We evaluated the ultrasonography parameters for each lymph node. Binary logistic regression analysis indicated that multifocality of PTC and the absence of Hashimoto's thyroiditis are independent clinical features related to patients with PTC who also have malignant CCLNs. For preoperative ultrasonography features, heterogeneous enhancement and centripetal perfusion are independent ultrasonographic features to identify malignant and benign CCLNs. This study demonstrated that preoperative CEUS characteristics help to distinguish malignant CCLNs from benign CCLNs.

The value of contrast-enhanced ultrasound for the diagnosis of metastatic cervical lymph nodes of papillary thyroid carcinoma: A systematic review and meta-analysis

To investigate the diagnostic efficiency of contrast-enhanced ultrasound (CEUS) for the diagnosis of cervical lymph nodes metastasis (CLNM) of papillary thyroid carcinoma (PTC), eight available datasets of seven qualified articles before March 31, 2021 were included after a comprehensive search. Meta-analysis results showed that CEUS demonstrated acceptable diagnostic performance in the diagnosis of CLNM of PTC. Furthermore, meta-regression analysis was conducted to identify the reasons for heterogeneity and the results indicated that the criteria of CEUS for the diagnosis of CLNM in PTC need to be unified.

Contrast-Enhanced Ultrasound Qualitative and Quantitative Characteristics of Parathyroid Gland Lesions

Background and Objectives: preoperative differentiation of enlarged parathyroid glands may be challenging in conventional B-mode ultrasound. The aim of our study was to analyse qualitative and quantitative characteristics of parathyroid gland lesions, using multiparametric ultrasound protocol—B-mode, Colour Doppler (CD), and contrast-enhanced ultrasound (CEUS)—and to evaluate correlation with morphology in patients with hyperparathyroidism (HPT). Materials and Methods: consecutive 75 patients with 88 parathyroid lesions and biochemically confirmed HPT prior to parathyroidectomy were enrolled in the prospective study. B-mode ultrasound, CD, and CEUS were performed with the subsequent qualitative and quantitative evaluation of acquired data. We used 1 mL or 2 mL of intravenous ultrasound contrast agent during the CEUS examination. Correlation with post-surgical morphology was evaluated. Results: seventy parathyroid adenomas were hypoechoic and well contoured with increased central echogenicity (44.3%), peripheral-central vascularization (47%), and polar feeding vessel (100%). Twelve hyperplasias presented with similar ultrasound appearance and were smaller in volume (p = 0.036). Hyperplasias had a tendency for homogenous, marked intense enhancement vs. peripherally enhanced adenomas with central wash-out in CEUS after quantitative analysis. No significant difference was observed in contrasting dynamics, regardless of contrast media volume use (1 mL vs. 2 mL). We achieved 90.9% sensitivity and 72.7% specificity, 93% positive predictive value (PPV), 87.3% negative predictive value (NPV), and 87.3% accuracy in the differentiation of parathyroid lesions prior to post-processing. In a quantitative lesion analysis, our sensitivity increased up to 98%, specificity 80%, PPV 98%, and NPV 80% with an accuracy of 96.4%. Conclusions: CEUS of parathyroid lesions shows potential in the differentiation of adenoma from hyperplasia, regardless of the amount of contrast media injected. The quantitative analysis improved the sensitivity and specificity of differentiation between parathyroid lesions. Hyperplasia was characterized by homogeneous enhancement, fast uptake, and homogeneous wash-out appearance; adenoma—by peripheral uptake, central wash-out, and reduced hemodynamics. The use of CEUS quantification methods are advised to improve the ultrasound diagnostic role in suspected parathyroid lesions.

Ultrasound-Based Radiomic Nomogram for Predicting Lateral Cervical Lymph Node Metastasis in Papillary Thyroid Carcinoma

RATIONALE AND OBJECTIVES

Accurate preoperative identification of lateral cervical lymph node metastasis (LNM) is important for decision-making and clinical management of patients with papillary thyroid carcinoma (PTC). The aim of this study was to develop an ultrasound (US)-based radiomic nomogram to preoperatively predict the lateral LNM in PTC patients.

METHODS

In this retrospective study, a total of 886 patients were enrolled and randomly divided into 2 groups. Radiomic features were extracted from the preoperative US images. A radiomic signature was constructed using the least absolute shrinkage and selection operator algorithm in the training set. Multivariate logistic regression was performed to develop the radiomic nomogram, which incorporating the radiomic signature and the selected clinical characteristics. The performance of the nomogram was assessed by its discrimination, calibration, and clinical usefulness in both the training and validation sets.

RESULTS

The radiomic signature was significantly associated with the lateral LNM in both cohorts (p< 0.001). The nomogram that consisted of radiomic signature, US-reported cervical lymph node (CLN) status, and CT-reported CLN status demonstrated good discrimination and calibration in the training and validation sets with an AUC of 0.946 and 0.914, respectively. The decision curve analysis indicated that the radiomic nomogram was worthy of clinical application.

CONCLUSION

The radiomic nomogram proposed here has good performance for noninvasively predicting the lateral LNM and might be used to facilitate clinical decision-making and potentially improve the survival outcome in selected patients.

Diagnostic Test Accuracy of Ultrasonography vs Computed Tomography for Papillary Thyroid Cancer Cervical Lymph Node Metastasis: A Systematic Review and Meta-analysis

Importance

The use of ultrasonography (US) vs cross-sectional imaging for preoperative evaluation of papillary thyroid cancer is debated.

Objective

To compare thyroid US and computed tomography (CT) in the preoperative evaluation of papillary thyroid cancer for cervical lymph node metastasis (CLNM), as well as extrathyroidal disease extension.

Data Sources

MEDLINE and Embase were searched from January 1, 2000, to July 18, 2020.

Study Selection

Studies reporting on the diagnostic accuracy of US and/or CT in individuals with treatment-naive papillary thyroid cancer for CLNM and/or extrathyroidal disease extension were included. The reference standard was defined as histopathology/cytology or imaging follow-up. Independent title and abstract review (2515 studies) followed by full-text review (145 studies) was completed by multiple investigators.

Data Extraction and Synthesis

PRISMA guidelines were followed. Methodologic and diagnostic accuracy data were abstracted independently by multiple investigators. Risk of bias assessment was conducted using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool independently and in duplicate. Bivariate random-effects model meta-analysis and multivariable meta-regression modeling was used.

Main Outcomes and Measures

Diagnostic test accuracy of US and CT of the neck for lateral and central compartment CLNM, as well as for extrathyroidal disease extension, determined prior to study commencement.

Results

A total of 47 studies encompassing 31 942 observations for thyroid cancer (12 771 with CLNM; 1747 with extrathyroidal thyroid extension) were included; 21 and 26 studies were at low and high risk for bias, respectively. Based on comparative design studies, US and CT demonstrated no significant difference in sensitivity (73% [95% CI, 64%-80%] and 77% [95% CI, 67%-85%], respectively; P = .11) or specificity (89% [95% CI, 80%-94%] and 88% [95% CI, 79%-94%], respectively; P = .79) for lateral compartment CLNM. For central compartment metastasis, sensitivity was higher in CT (39% [95% CI, 27%-52%]) vs US (28% [95% CI, 21%-36%]; P = .004), while specificity was higher in US (95% [95% CI, 92%-98%]) vs CT (87% [95% CI, 77%-93%]; P < .001). Ultrasonography demonstrated a sensitivity of 91% (95% CI, 81%-96%) and specificity of 47% (95% CI, 35%-60%) for extrathyroidal extension.

Conclusions and Relevance

The findings of this systematic review and meta-analysis suggest that further study is warranted of the role of CT for papillary thyroid cancer staging, possibly as an adjunct to US.

2021 Korean Thyroid Imaging Reporting and Data System and Imaging-Based Management of Thyroid Nodules: Korean Society of Thyroid Radiology Consensus Statement and Recommendations

Incidental thyroid nodules are commonly detected on ultrasonography (US). This has contributed to the rapidly rising incidence of low-risk papillary thyroid carcinoma over the last 20 years. The appropriate diagnosis and management of these patients is based on the risk factors related to the patients as well as the thyroid nodules. The Korean Society of Thyroid Radiology (KSThR) published consensus recommendations for US-based management of thyroid nodules in 2011 and revised them in 2016. These guidelines have been used as the standard guidelines in Korea. However, recent advances in the diagnosis and management of thyroid nodules have necessitated the revision of the original recommendations. The task force of the KSThR has revised the Korean Thyroid Imaging Reporting and Data System and recommendations for US lexicon, biopsy criteria, US criteria of extrathyroidal extension, optimal thyroid computed tomography protocol, and US follow-up of thyroid nodules before and after biopsy. The biopsy criteria were revised to reduce unnecessary biopsies for benign nodules while maintaining an appropriate sensitivity for the detection of malignant tumors in small (1-2 cm) thyroid nodules. The goal of these recommendations is to provide the optimal scientific evidence and expert opinion consensus regarding US-based diagnosis and management of thyroid nodules.

Reassessing the Value of Contrast-Enhanced Ultrasonography in Differential Diagnosis of Cervical Tuberculous Lymphadenitis and Lymph Node Metastasis of Papillary Thyroid Carcinoma

Aim

We aimed to evaluate the ability of contrast-enhanced ultrasonography (CEUS) to perform differential diagnosis of cervical tuberculous lymphadenitis and lymph node metastasis from papillary thyroid cancer (PTC).

Methods

We analyzed 102 enlarged cervical lymph nodes as diagnosed by conventional ultrasound (US) and CEUS. The US and CEUS enhancement pattern and the time intensity curve (TIC) of the metastatic lymph nodes or tuberculous lymph nodes were compared following standard pathological protocols. The TIC included peak time (TTP), peak intensity (PI), and area under the gamma curve (AUC).

Results

Pathological results demonstrated that 48 out of the 102 enlarged lymph nodes were lymph node metastasis from PTC, while 54 were tuberculous lymphadenitis. There was statistically significant differences in hyperechoic islands, pulse-like enhancement, and asynchronous enhancement between tuberculous lymphadenitis and lymph node metastasis (P < 0.05), but their diagnostic sensitivity and specificity were unsatisfactory. In addition, our data did not show statistically significant difference in enhancement direction, enlarged range on CEUS, and perfusion defect (P > 0.05). Similarly, quantitative parameters such as PI, TTP, and AUC did not yield significant differences between the groups.

Conclusion

Taken together, the present results demonstrate that CEUS can provide valuable information on lymph node blood flow, which can be used to identify tuberculous lymphadenitis and lymph node metastasis of PTC.

The Role of CEUS in the Evaluation of Thyroid Cancer: From Diagnosis to Local Staging

Ultrasound often represents the first diagnostic step for thyroid nodule evaluation in clinical practice, but baseline US alone is not always effective enough to achieve thyroid nodule characterization. In the last decades new ultrasound techniques, such as CEUS, have been introduced to evaluate thyroid parenchyma as recommended by EFSUMB guidelines, for use in clinical research field, although its role is not yet clear. Several papers show the potential utility of CEUS in the differential diagnosis of benign and malignant thyroid nodules and in the analysis of lymph node involvement in neoplastic pathology. Therefore, we carried out an evaluation of the literature concerning the role of CEUS in three specific areas: the characterization of the thyroid nodule, the evaluation of minimally invasive treatment and loco-regional staging of the lymph node in proven thyroid cancer. According to evidence reported, CEUS can also play an operative role in nodular thyroid pathology as it is able to guide ablation procedures on thyroid nodule and metastatic lymph nodes, to assess the radicality of surgery, to evaluate disease relapse at the level of the margins of ablated regions and to monitor the clinical evolution of necrotic areas in immediate post-treatment setting.

Oncologic Imaging of the Lymphatic System: Current Perspective with Multi-Modality Imaging and New Horizon

The lymphatic system is an anatomically complex vascular network that is responsible for interstitial fluid homeostasis, transport of large interstitial particles and cells, immunity, and lipid absorption in the gastrointestinal tract. This network of specially adapted vessels and lymphoid tissue provides a major pathway for metastatic spread. Many malignancies produce vascular endothelial factors that induce tumoral and peritumoral lymphangiogenesis, increasing the likelihood for lymphatic spread. Radiologic evaluation for disease staging is the cornerstone of oncologic patient treatment and management. Multiple imaging modalities are available to access both local and distant metastasis. In this manuscript, we review the anatomy, physiology, and imaging of the lymphatic system.

Preoperative Prediction of Cervical Nodal Metastasis in Papillary Thyroid Carcinoma: Value of Quantitative Dual-Energy CT Parameters and Qualitative Morphologic Features

OBJECTIVE. The purpose of our study was to assess the value of combining quantitative dual-energy CT (DECT) parameters with qualitative morphologic parameters for the preoperative prediction of cervical nodal metastasis from papillary thyroid carcinoma (PTC). MATERIALS AND METHODS. Thirty-five patients with pathologically proven PTC underwent single-phase contrast-enhanced DECT before thyroidectomy and cervical lymphadenectomy. Analyses of quantitative DECT parameters and qualitative morphologic features of metastatic and benign lymph nodes (LNs) were independently performed. The diagnostic performances of using only quantitative parameters, only morphologic features, and their combination for predicting cervical nodal metastasis were statistically calculated with ROC curves and logistic regression models. RESULTS. A total of 206 LNs, 80 metastatic and 126 benign, were included. The best single performer in DECT was the normalized iodine concentration in the venous phase, which had low sensitivity (62.5%) but high specificity (85.7%), for diagnosing metastatic cervical LNs. On the other hand, the best single performer in qualitative morphologic parameters was using the criterion of shortest diameter of greater than 5 mm, which had low specificity (69.8%) but high sensitivity (86.3%). Combining these two parameters improved the AUC, sensitivity, and specificity to 0.846, 86.3%, and 72.2%, respectively. The combination of multiple quantitative DECT parameters and all morphologic data further improved AUC, sensitivity, and specificity to 0.878, 87.5%, and 73.8%, respectively, which was significant compared with the use of any single parameter. CONCLUSION. The combination of quantitative DECT parameters with morphologic data improves performance in the preoperative diagnosis of metastatic cervical LNs in patients with PTC.

Combination of Lymphatic and Intravenous Contrast-Enhanced Ultrasound for Evaluation of Cervical Lymph Node Metastasis from Papillary Thyroid Carcinoma: A Preliminary Study

The aim of this prospective study was to evaluate the value of the combination of lymphatic contrast-enhanced ultrasound (LCEUS) and intravenous contrast-enhanced ultrasound (IVCEUS) for the identification of cervical lymph node metastasis (CLNM) from papillary thyroid carcinoma (PTC). From November 2018 to March 2019, 24 consecutive patients with PTC were evaluated. All patients underwent routine US, LCEUS and IVCEUS. Pathology was used as the gold standard. After injection of a contrast agent into the thyroid parenchyma, lymphatic vessels and lymph nodes (LNs) could be exclusively displayed as hyper-enhancement on LCEUS. Benign LNs displayed a complete bright ring (100%) and homogeneous perfusion (88.9%) on LCEUS, while displaying centrifugal perfusion (66.7%) and homogenous enhancement (88.9%) on IVCEUS. Perfusion defects (94.9%) and interruption of the bright ring (71.8%) were the two characteristic LCEUS signs for diagnosing CLNM. On IVCEUS, CLNM appeared as centripetal perfusion (59.0%) and heterogeneous enhancement (59.0%). After comparison with pathology, perfusion defect was correlated to the metastatic foci in the medulla and interruption of the bright ring to the tumor seeding in the marginal sinus (all p values <0.05). LCEUS had more value (area under the receiver operating characteristic curve [AUC] = 0.850, 95% confidence interval [CI]: 0.682-1.000) in diagnosing CLNM than IVCEUS (AUC = 0.692, 95% CI: 0.494-0.890) and routine US (AUC = 0.581, 95% CI: 0.367-0.796). The combination of LCEUS and IVCEUS has the highest diagnostic value (AUC = 0.863, 95% CI: 0.696-1.000). LCEUS had higher diagnostic value than IVCEUS and US for CLNM from PTC. The combination of LCEUS and IVCEUS has the highest diagnostic value for CLNM.

Clinical Utility of Contrast-enhanced Ultrasound for the Diagnosis of Lymphadenopathy

This meta-analysis aimed to evaluate the diagnostic accuracy of contrast-enhanced ultrasonography (CEUS) in identifying lymphazdenopathy. PubMed, Web of Science, Embase and the Cochrane Library were searched for relevant articles through September 2020. A total of 16 articles, which included 1787 participants, were analyzed. The summary sensitivity, specificity, positive likelihood ratio (LR), negative LR and diagnostic odds ratio of CEUS for diagnosing lymphadenopathy were 0.88 (0.86-0.90), 0.90 (0.88-0.92), 6.04 (3.67-9.95), 0.15 (0.10-0.21) and 47.38 (23.45-95.66), respectively. The summary receiver operating characteristic (SROC) area under the curve (AUC) was 0.9405. After omitting outliers identified in a bivariate box plot and forest plot, heterogeneity was decreased, and the pooled sensitivity and specificity were 0.87 (0.84-0.90) and 0.87 (0.84-0.90), respectively. Furthermore, the SROC AUC was 0.9327. In conclusion, CEUS has the potential to be a valuable tool for characterizing lymphadenopathy and could provide clinical decision support.

Ultrasound and Contrast-Enhanced Ultrasound Characteristics Associated With cN1 and Microscopic pN1 in Papillary Thyroid Carcinoma

OBJECTIVES

Lymph node metastases (LNMs) could be stratified into clinical N1 (cN1) and microscopic pN1 (pathological N1), which bear different biological behavior and prognosis. Our study aimed to investigate the associations between LNMs and primary tumor's US (ultrasound) and CEUS (contrast-enhanced ultrasound) characteristics based on the stratification of LNMs into cN1 and microscopic pN1 in papillary thyroid carcinoma (PTC).

METHODS

From August 2019 to May 2020, 444 consecutive PTC patients who underwent preoperative neck US and CEUS evaluation were included. According to regional lymph node status, the patients were classified into cN1 group versus cN0 (clinical N0) group and microscopic pN1 group versus pN0 (pathological N0) group. For multiple PTCs, the largest one was selected for the evaluation of US, CEUS and clinical features. Univariate and multivariate analyses were performed to determine independent predictors of cN1 and microscopic pN1.

RESULTS

85 cN1 versus 359 cN0 patients and 117 microscopic pN1 versus 242 pN0 patients were analyzed. Multivariate logistic regression analysis showed that <55-years-old (OR: 2.56 (1.08-6.04), male [OR: 2.18 (1.22-3.91)], large size [OR: 2.59 (1.71-3.92)], calcification [OR: 3.88 (1.58-9.51)], and hyper-enhancement [OR: 2.78 (1.22-6.30)] were independent risk factors of cN1, while <55-years-old [OR: 1.91 (1.04-3.51)], large size [OR: 1.56 (1.003-2.42)], multifocality [OR: 1.67 (1.04-2.66)] were independent risk factors of microscopic pN1.

CONCLUSIONS

For patients with PTC, young age, male, large size, calcification, and hyper-enhancement were independent predictors of cN1, while young age, large size and multifocality were independent predictors of microscopic pN1.

Homogeneity Parameter in Contrast-Enhanced Ultrasound Imaging Improves the Classification of Abnormal Cervical Lymph Node after Thyroidectomy in Patients with Papillary Thyroid Carcinoma

Objective

To explore the conventional and contrast-enhanced ultrasound (CEUS) features of cervical lymph node metastasis (CLNM) in papillary thyroid carcinoma (PTC) patients postoperatively and analyze its pathological basis.

Materials and Methods

Conventional and CEUS were performed in 86 abnormal cervical lymph nodes (ACLNs) from 56 PTC patients who had received thyroidectomy. Then, fine-needle aspiration (FNA) was taken to confirm pathological results, a multivariate analysis was performed to correlate the sonographic features of the CLNM, and then an equation for CLNM was established.

Results

Fifty-four lymph nodes were confirmed to be metastasis of PTC by FNA. Intensity at peak time, homogeneity, and color flow patterns, cystic change, or microcalcification and echogenicity were significantly associated with CLNM. Multivariate analysis showed three strongest features (homogeneity, intensity of peak, and cystic change or calcification) to be significantly associated with the evidence of CLNM. Then, the equation was established with the following significant predictive factors: P = 1/1 + exp∑[−3.213 + 2.77 ∗ cystic or calcification + 0.13 ∗ CDFI patterns + 3.65 ∗ homogeneity + 2.43 ∗ intensity at peak time].

Conclusion

Depiction of a heterogeneous hyperenhancement of cervical lymph nodes within CEUS studies and cystic change or microcalcification in conventional ultrasound were identified as predictive for metastatic lymph node invasion, and the equation was more accurate for predicting CLNM compared to single B-mode ultrasound and CEUS feature.