Evidence-based assessment of the role of ultrasonography in the management of benign thyroid nodules

Clinical Characteristics and Predictors Related to the Progression of Multinodular Goiter Causing Tracheal Compression and Deviation: A Report of Two Cases and Review of the Literature

We describe the clinical course of two patients who developed tracheal compression and deviation by multinodular goiter (MNG). Case 1: A 66-year-old woman presented with thyroid swelling. Five years after the initial admission, she was diagnosed with hyperthyroidism by Graves' disease and increased bilateral thyroid lobes compressing the trachea. Thyroglobulin was elevated from 210 to 472 ng/mL. Case 2: A 52-year-old woman presented with thyroid swelling. Five years after the initial admission, the increased right lobe deviated the trachea and compressed the right recurrent laryngeal nerve. Thyroglobulin was elevated from 122 to 392 ng/mL. Two cases and literature review indicated that MNG with >50 mm, solid components, and extension to the mediastinum or paralarynx were risk factors of tracheal compression and deviation. Monitoring thyroglobulin elevation can help predict the clinical course.

Comparison of the Pretzelflex Retractor and Nathanson Retractor in Laparoscopic Sleeve Gastrectomy Surgery

PURPOSE

Retraction of the left lobe of the liver is an important step in most bariatric surgical procedures. The left lobe of the liver may be enlarged, and laceration, hematoma, or necrosis may develop in the liver due to retraction. In this study, the results of use of the Nathanson retractor (NR) and PretzelFlex retractor (PFR) in the patients undergoing laparoscopic sleeve gastrectomy (LSG) were compared.

MATERIALS AND METHODS

The patients who underwent LSG were divided into three groups based on the type of liver retraction device used. Group 1: NR was used fixed during the operation; Group 2: PF retractor was used; Group 3: NR were used only for fundus dissection and when necessary. All groups were evaluated in terms of demographic characteristics, liver function tests, and developing complications.

RESULTS

The study was conducted with a total of 120 consecutive patients. Operation time in the second group was found to be significantly lower than the other two groups (p = 0.009; p = 0.001; p < 0.01). The duration of retractor use in the first group was significantly higher than the other two groups (p = 0.001; p = 0.001; p < 0.01). While aspartate aminotransferase (AST) values were found to be high in Group 1, alanine aminotransferase (ALT) values were found to be high in Groups 1 and 3.

CONCLUSION

PFR has shorter operating and retraction times. It causes less measurable liver damage. Although the NR will be used, intermittent use causes less damage to the liver as in PFR.

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

Background

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

Methods

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

Results

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

Conclusion

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

Diagnostic Accuracy of Ultrasonography in Classifying Thyroid Nodules Compared with Fine-Needle Aspiration

Background

Classifying thyroid lesions is challenging; nonetheless, using ultrasonography may allow for accurate diagnosis, differentiation and management of thyroid lesions and help avoid unnecessary biopsy.

Objectives

The main objective of the study is to determine the diagnostic accuracy of ultrasonography in classifying thyroid nodules compared with fine-needle aspiration.

Materials and Methods

This retrospective study included all 68 patients diagnosed with thyroid nodules at King Fahd Hospital of the University, Al Khobar, Saudi Arabia, between June 1, 2014, and November 30, 2016. Parameters were selected based on the Society of Radiologists in Ultrasound criteria. Ultrasonographic features, namely, nodule margins, echotexture, vascularity and calcifications, and fine-needle aspiration cytology (FNAC) results were reviewed by two radiologists blinded to each other's findings and validated by another experienced interventional radiologist. Ultrasonography results were compared against that of FNAC to calculate sensitivity and positive- and negative-likelihood ratios, and the nodule types were compared using Fisher's exact test.

Results

Of the 68 nodules analyzed, 59 were reported as benign using FNAC (specificity = 95%; P < 0.001). Of these 59, 56 were also reported as benign using ultrasonography. The specificity of ultrasonography in determining benign nodules was 94.9%, and the positive- and negative-likelihood ratios were 13.0 and 0.35, respectively. Six of the nine suspicious nodules were confirmed as malignant using FNAC, and the ultrasonography and FNAC findings were strongly associated (P = 0.001). According to the Society of Radiologists in Ultrasound criteria, FNAC and ultrasonography findings were significantly associated for nodule calcification (P = 0.001) and echogenicity (P = 0.001).

Conclusion

The diagnostic specificity of ultrasonography and FNAC in this study are consistent with those reported previously, indicating that ultrasonography reliably classifies thyroid nodules, and thus can assist in the decision-making regarding need for biopsy.

Integration of Sonoelastography Into the TIRADS Lexicon Could Influence the Classification

Aim: Numerous TIRADS (Thyroid Image Reporting and Data System) classifications have been developed, and various ultrasound (US) parameters are employed in different countries. The aim of our study was to introduce risk classification and management in a native population based on the Guidelines of Polish National Societies Diagnostics and Treatment of Thyroid Carcinoma but with the addition of sonoelastography. Materials and Methods: We examined prospectively 208 patients with 305 thyroid lesions employing B-mode ultrasound and sonoelastography (SE). Nodule composition, echogenicity, margins, shape, presence or absence of calcifications, thyroid capsule, nodule size were assessed using B-mode ultrasound. Moreover, sonoelastography results were presented using the Asteria scale. Results: In univariate analysis, the following US features were significantly associated with malignancy: >50% solid /solid component, marked hypoechogenicity, ill-defined margins, micro and macrocalcification, taller-than wide shape, no/partial halo pattern, infiltration of the capsule and an Asteria score of 4. Multivariate logistic regression analysis of B-mode features revealed that ill-defined margins (OR 10.77), markedly hypoechogenicity (OR 5.12), microcalcifications (OR 4.85), thyroid capsule infiltrations (OR 3.2), macrocalcifications (OR 3.01), and hard lesion in SE (OR 6.85) were associated with a higher Odds Ratio (OR) for malignancy. Multivariate logistic regression analysis revealed that combining two features increases the OR and the best combination was irregular margins and Asteria scale 4 (OR 20.21). Adding a third feature did not increase the OR. Conclusions: Sonoelastography increases the value risk of predicted malignancy, with consequent different approach to further clinical investigation and management. A solitary feature (Asteria 4) in a solid tumor can result in its categorization as TIRADS 4, but coexistence with high risk features allows it to be upgraded to TIRADS 5. The irregular margin was the strongest single feature which allowed for the assignment of a solid tumor into TIRADS 5 category. The highest accuracy was found by combining the features of age, margin, echogenicity (markedly hypoechoic), capsule infiltration, microcalcifications and sonoelastography (Asteria 3,4) of the tumors.

Small-Sized Thyroid Cancers-a Single Institutional Experience in India

The incidence of small differentiated thyroid carcinomas is increasing worldwide in the recent years, especially tumours of size less than 2 cm in diameter. In this study, we have analysed the patterns of behaviour of small-sized thyroid carcinomas (<2 cm, T1 tumours) in comparison with large-sized thyroid carcinomas. This is a retrospectively analysed data of patients with thyroid carcinoma. The following parameters were analysed: distribution with regard to age, sex and the presence of metastasis based on radioiodine scan. The following histopathological details were collected: maximal tumour diameter, extrathyroidal extension and lymphovascular invasion. Out of 152 patients, 39 patients were excluded due to the non-availability of complete details. Among the 113 patients of thyroid carcinomas, 43 patients (28%) were presented with small-sized tumours (measuring less than 2 cm). In small-sized thyroid tumours, 21.6% showed extrathyroidal extension. 2.7% of the small-sized thyroid carcinomas showed perineural invasion as compared to 6.3% of the large-sized thyroid carcinomas. Twenty percent of the small-sized thyroid carcinomas showed lymphovascular emboli. 51.2% of the small-sized thyroid carcinomas were presented with nodal metastasis as compared to 40% of the large-sized thyroid carcinomas. 57.5% of the small-sized thyroid carcinomas showed extracapsular extension as compared to 57.8% of the large-sized thyroid carcinomas. Despite small size, thyroid carcinomas have properties to behave aggressively as comparable to large-sized thyroid carcinomas. Taking the above facts into account, the small thyroid cancers should be treated with considerable caution as large thyroid cancers, especially since we have limited tools to predict the preoperative poor prognostic factors.

Use of the Kwak Thyroid Image Reporting and Data System (K-TIRADS) in differential diagnosis of thyroid nodules: systematic review and meta-analysis

PURPOSE

The purpose of this systematic literature review was to assess the usefulness of the Thyroid Image Reporting and Data System (K-TIRADS) classification proposed by Kwak for differentiation of thyroid nodules.

MATERIAL AND METHODS

Four literature databases were searched for relevant articles through early January 2017. A meta-analysis was performed to calculate pooled sensitivity, specificity, positive likelihood ratio (LR+), negative likelihood ratio (LR-) and diagnostic odds ratio (DOR). The area under the curve (AUC) from the pooled receiver operating characteristic (ROC) was used to assess the usefulness of this classification for differentiation of thyroid nodules. Meta-analysis was conducted by using meta-analysis software.

RESULTS

We analysed six publications describing 10,926 nodules. Pooled sensitivity, specificity, LR+, LR-, DOR, and AUC for pooled ROC were 0.983 (95 % CI 0.976-0.989), 0.552 (95 % CI 0.542-0.562), 2.666 (95 % CI 1.692-4.198), 0.05 (95 % CI 0.035-0.072), 51.020 (95 % CI 15.241-170.79) and 0.938, respectively.

CONCLUSIONS

Kwak TIRADS has high sensitivity and low specificity. Thus, it is very useful to discard the benign cases and to reduce the number of biopsies.

KEY POINTS

• Routine, adequate standardization of thyroid nodules ultrasound classification is mandatory. • Kwak TIRADS parameters are accurate for differentiating focal thyroid lesions. • Kwak TIRADS system is simple to apply. • Kwak TIRADS system may become a useful diagnostic tool.

The utility of thyroid ultrasonography in the management of thyroid nodules

BACKGROUND

Ultrasonography for thyroid nodules is one of the most common imaging tests performed in the general population. Details from ultrasound reports guide biopsies and surgery. This study quantifies the completeness of these reports based on Thyroid Imaging and Reporting System (TI-RADS) criteria and considers their utility in predicting malignant disease.

METHODS

We retrospectively reviewed ultrasound reports for 329 thyroidectomy patients and extracted data elements using the TI-RADS criteria: nodule size, echogenicity, margins, vascularity, solid/cystic composition and the presence or absence of microcalcifications and the halo sign. We assessed the reports to determine whether individual or multiple criteria were associated with malignancy.

RESULTS

More than 97% of reports document nodule size; however, more than 90% of the reports noted only 3 or fewer of the 6 remaining TI-RADS criteria. The presence of microcalcifications was the most sensitive marker of malignancy (> 90%), whereas the documentation of irregular margins was the most specific indicator of malignancy (88%). Overall it was clear that microcalcifications, hypoechogenicity, irregular margins and solid nodules were significantly more likely to be found in malignant neoplasms; their absence predicted benign disease. Because so few reports consistently documented all criteria, the overall ability of thyroid ultrasonography to discriminate between lowerand higher-risk nodules is limited.

CONCLUSION

Although the accuracy of thyroid ultrasonography is good, few ultrasound reports contain the necessary information, as defined by TI-RADS, to predict malignancy and guide management. When reported, microcalcifications and/or irregular margins are the best predictors of malignancy.

Contrast-enhanced ultrasound and real-time elastography in the differential diagnosis of malignant and benign thyroid nodules

The diagnostic value of contrast-enhanced ultrasound (CEUS) or real-time elastography (RTE) alone, as well as a combination of CEUS and RTE, in distinguishing benign from malignant thyroid nodules was investigated. Between August 2012 and June 2014, a total of 97 consecutive patients (50 male and 47 female patients; mean age, 48.6±12.4; age range, 27-70 years) with thyroid nodules referred for surgical treatment were examined by CEUS and RTE. The final diagnosis was obtained based on histological findings. Image analysis of the CEUS and RTE scans was performed. Considering the postoperative pathological results as the golden standard, a receiver operating characteristic (ROC) curve was constructed. Subsequently, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of CEUS alone, RTE alone and CEUS + RTE combination were calculated. Pathological examination showed 66 papillary carcinomas and 43 benign lesions, including 21 adenomas and 22 nodular goiters. The sensitivity, specificity, PPV, NPV and accuracy of CEUS were 81.82, 90.70, 93.10, 90.70 and 85.32%, respectively. In the case of RTE, the sensitivity, specificity, PPV, NPV and accuracy were 80.30, 88.37, 91.38, 88.37 and 83.49%, respectively. Furthermore, the combination of CEUS + RTE had a sensitivity of 95.45%, specificity of 95.35%, PPV of 96.92%, NPV of 95.35% and accuracy of 95.41%. Therefore, the CEUS + RTE combination showed a significantly higher sensitivity and specificity compared with CEUS or RTE alone (all P<0.05). Based on ROC analysis, the area under the curve (AUC) for CEUS, RTE and CEUS + RTE combination was 0.883, 0.863 and 0.959, respectively. The AUC of RTE alone was significantly lower compared with that of the CEUS + RTE combination. In conclusion, our results demonstrate that CEUS + RTE combination significantly increases the diagnostic performance for differential diagnosis of malignant and benign thyroid nodules compared with CEUS or RTE alone.

Thyroid Ultrasound-Guided Fine-Needle Aspiration: The Positive Influence of On-Site Adequacy Assessment and Number of Needle Passes on Diagnostic Cytology Rate

OBJECTIVE

Nondiagnostic cytology is the most important limitation of thyroid ultrasound-guided fine-needle aspiration (US-FNA). This study aimed to identify factors associated with the adequacy rate of thyroid US-FNA.

STUDY DESIGN

Consecutive thyroid US-FNAs (2006-2013) were retrospectively included. Attending radiologists, radiology fellows and radiology residents performed US-FNA, usually involving 2-3 needle passes. In more recent years, rapid on-site adequacy assessment (ROSAA) was performed to ensure specimen adequacy. US characteristics, procedural variations and cytology results were extracted from US and pathology reports and statistically evaluated.

RESULTS

Diagnostic cytology was obtained in 64.6% of 1,381 thyroid US-FNAs. Factors associated with nondiagnostic cytology were ROSAA (74.6% diagnostic cytology, OR 0.55, 95% CI 0.42-0.71), ≥3 clinic visits for US-FNA of the same thyroid nodule (54.7%, OR 1.56, 95% CI 1.16-2.10) and increased intranodular vascularization (51.8%, OR 1.73, 95% CI 1.17-2.57). With ROSAA, an increasing number of needle passes demonstrated improving adequacy rates. The adequacy rate was not operator-dependent.

CONCLUSION

This study demonstrates that ROSAA improves the adequacy rate of thyroid US-FNA. Without ROSAA, we recommend performing at least 3 needle passes. Less diagnostic cytology is obtained from nodules with increased intranodular vascularization or from those undergoing US-FNA ≥3 times.

Well-Differentiated Thyroid Cancer: The Philippine General Hospital Experience

BACKGROUND

Well-differentiated thyroid cancer (WDTC) is the most common form of thyroid malignancy. While it is typically associated with good prognosis, it may exhibit higher recurrence and mortality rates in selected groups, particularly Filipinos. This paper aims to describe the experience of a Philippine Hospital in managing patients with differentiated thyroid cancer.

METHODS

We performed a retrospective cohort study of 723 patients with WDTC (649 papillary and 79 follicular), evaluating the clinicopathologic profiles, ultrasound features, management received, tumor recurrence, and eventual outcome over a mean follow-up period of 5 years.

RESULTS

The mean age at diagnosis was 44±13 years (range, 18 to 82), with a majority of cases occurring in the younger age group (<45 years). Most tumors were between 2 and 4 cm in size. The majority of papillary thyroid cancers (PTCs, 63.2%) and follicular thyroid cancers (FTCs, 54.4%) initially presented as stage 1, with a greater proportion of FTC cases (12.7% vs. 3.7%) presenting with distant metastases. Nodal metastases at presentation were more frequent among patients with PTC (29.9% vs. 7.6%). A majority of cases were treated by complete thyroidectomy, followed by radioactive iodine therapy and thyroid stimulating hormone suppression, resulting in a disease-free state. Excluding patients with distant metastases at presentation, the recurrence rates for papillary and FTC were 30.1% and 18.8%, respectively.

CONCLUSION

Overall, PTC among Filipinos was associated with a more aggressive and recurrent behavior. FTC among Filipinos appeared to behave similarly with other racial groups.

Triage of patients with AUS/FLUS on thyroid cytopathology: effectiveness of the multimodal diagnostic techniques

The management of patients with thyroid cytopathologic diagnosis of atypia (or follicular lesion) of undetermined significance (AUS/FLUS) is a complex clinical problem. The purpose of this study was to develop a practical triage scheme based on multiple diagnostic tests in general use. We performed a retrospective cohort study involving 15,335 consecutive patients with a referral diagnosis of thyroid nodule between April 2011 and March 2015 using an institutional database. We obtained 904 patients with an initial cytopathologic diagnosis of AUS/FLUS who underwent repeat fine‐needle aspiration or core needle biopsy, 388 of whom had a corresponding histopathological diagnosis for excised index lesions. The diagnostic performance of ultrasound (US) findings, repeat biopsy, and BRAF^V600E mutation in cytopathologic specimens were evaluated individually or as a set. Of the 388 resected AUS/FLUS cases, 338 (87.1%) were thyroid cancer. The positive likelihood ratios (LRs) for BRAF^V600E mutation and repeat biopsy result of suspicious for malignant cell (SMC) or worse were 11.6 (95% CI = 1.7–77.8) and 13.7 (95% CI = 4.6–41.0), respectively. The absence of suspicious findings on US combined with cytologic result of less than SMC or negative BRAF^V600E mutation produced negative LRs ranging from 0.06 to 0.15, corresponding to negative predictive values of over 90% in both primary and referral settings. For patients with AUS/FLUS cytopathology, clinical decision making can be guided by a simple triage scheme based on US findings, repeat biopsy, or BRAF^V600E mutation.

Meta-analysis of thyroid imaging reporting and data system in the ultrasonographic diagnosis of 10,437 thyroid nodules

BACKGROUND

The meta-analysis was performed to review the diagnostic accuracy of ultrasound reporting and data system in the diagnosis of thyroid nodules.

METHODS

We identified the diagnostic accuracy of ultrasound reporting and data system in 5 databases. Meta-analyses were used in selected studies to obtain pooled sensitivity, specificity, and summary receiver operating characteristic (ROC) curves. Fixed or random-effects models were performed to analyze our data.

RESULTS

Twelve eligible studies were identified, including 10,437 thyroid nodules. A pooled sensitivity of 0.79 (95% confidence interval [CI] = 0.77-0.81) and a pooled specificity of 0.71 (95% CI = 0.70-0.72) of ultrasound reporting system in differentiated diagnosis of thyroid nodules were shown in meta-analyses. Subgroup analyses showed that the most important factor of heterogeneity in studies was the final diagnostic references (histological and cytological standards or only histological results).

CONCLUSION

The thyroid imaging reporting and data system has a good sensitivity and specificity in diagnosis of patients with thyroid nodules.

German Association of Endocrine Surgeons practice guideline for the surgical management of malignant thyroid tumors

INTRODUCTION

Over the past years, the incidence of thyroid cancer has surged not only in Germany but also in other countries of the Western hemisphere. This surge was first and foremost due to an increase of prognostically favorable ("low risk") papillary thyroid microcarcinomas, for which limited surgical procedures are often sufficient without loss of oncological benefit. These developments called for an update of the previous practice guideline to detail the surgical treatment options that are available for the various disease entities and tumor stages.

METHODS

The present German Association of Endocrine Surgeons practice guideline was developed on the basis of clinical evidence considering current national and international treatment recommendations through a formal expert consensus process in collaboration with the German Societies of General and Visceral Surgery, Endocrinology, Nuclear Medicine, Pathology, Radiooncology, Oncological Hematology, and a German thyroid cancer patient support organization.

RESULTS

The practice guideline for the surgical management of malignant thyroid tumors includes recommendations regarding preoperative workup; classification of locoregional nodes and terminology of surgical procedures; frequency, clinical, and histopathological features of occult and clinically apparent papillary, follicular, poorly differentiated, undifferentiated, and sporadic and hereditary medullary thyroid cancers, thyroid lymphoma and thyroid metastases from primaries outside the thyroid gland; extent of thyroidectomy; extent of lymph node dissection; aerodigestive tract resection; postoperative follow-up and surgery for recurrence and distant metastases.

CONCLUSION

These evidence-based recommendations for surgical therapy reflect various "treatment corridors" that are best discussed within multidisciplinary teams and the patient considering tumor type, stage, progression, and inherent surgical risk.

A randomized trial of hemithyroidectomy versus Dunhill for the surgical management of asymmetrical multinodular goiter

OBJECTIVE

To assess the immediate and long-term clinical results of 2 different surgical procedures for the treatment of asymmetrical multinodular goiter (AMG).

BACKGROUND

Half of the patients presenting with a single benign thyroid nodule have contralateral subclinical disease. There is a controversy whether these patients should be treated with hemithyroidectomy (HMT) or with a more extensive procedure.

METHODS

Adult patients with a benign unilateral dominant nodule and contralateral nodule(s) with a diameter of less than 10 mm detected on neck ultrasonography were randomized to HMT or Dunhill (DUN). Rates of complications, remnant growth, incidental carcinoma, and reoperation were assessed.

RESULTS

A total of 118 patients (F/M:110/8, mean age 43 years) were included and randomized: 65 to HMT and 53 to DUN. After randomization, 28 patients were excluded leaving 47 HMT and 43 DUN long-term (55 ± 35 months) evaluable patients. Mean nodule size was 38 and 6 mm for the dominant and contralateral nodules, respectively. No differences were found in operative time, accidental parathyroidectomy, parathyroid autotransplantation, or wound complications. Transient hypocalcemia was more common in DUN (30% vs 8%; P < 0.001). No permanent complications were observed. At the last follow-up visit, thyroid-stimulating hormone was similar in both groups. Remnant growth (20 vs 0%; P < 0.001), appearance of new nodules (55 vs 14%; P < 0.001), and overall reoperation rate (9.2 vs 1.8%, P = 0.2) were more common in HMT, mostly because of undiagnosed cancer requiring completion thyroidectomy. Thirty percent of HMTs developed hypothyroidism and required long-term T4 supplementation.

CONCLUSIONS

DUN appears superior to HMT for the treatment of AMG in terms of early reoperation for missed carcinomas and disease progression. Both procedures have a similarly uneventful postoperative course.

Avoiding unnecessary fine-needle aspiration cytology by accuractely predicting the benign nature of thyroid nodules using ultrasound

Objective:

The objective of this study was to describe a reliable ultrasound based index scoring system based on ultraound characteristics to identify benign thyroid nodules and avoid unnecessary fine needle aspiration cytology.

Materials and Methods:

Patients undergoing ultrasound-guided fine-needle aspiration cytology (FNAC) for thyroid nodules were evaluated prospectively. A total of 284 patients were evaluated from November 2005 to November 2011. There were 284 nodules. Any solid or partly solid focal nodule in the thyroid gland was included in the study. Cysts with no solid component were excluded. We used LOGIQ 9 (GE Healthcare) scanner equipped with a 10--14 MHz linear matrix transducer with color and power Doppler capability. Four US characteristics were evaluated, i.e., nodule margins, echo texture, vascularity, and calcification. Fine needle aspiration (FNA) was performed on all nodules. The nodules were labeled benign or suspicious using an ultrasound index score and the results compared with FNAC. Follicular neoplasms on fine-needle aspiration cytology were further assessed by excision biopsy and histology. Cytology/histology was used as the final diagnosis.

Results:

In total 284 nodules were analyzed. All the 234 nodules in US labeled benign category were proven to be benign on cytology/histology. Therefore the specificity of ultrasound in labeling a nodule benign was 100%. Twenty of the 50 nodules that were suspicious on US were malignant. The most significant US differentiating characteristics were nodule margins, vascularity, and microcalcification.

Conclusion:

Our results show that US can accurately characterize benign thyroid nodules using an index scoring system and therefore preclude FNAC in these patients.

Investigating the value of fine needle aspiration cytology in thyroid cancer

Background:

Current guidance recommends the use of fine needle aspiration cytology (FNAC) as an essential investigation in patients presenting with a thyroid lump. Current literature suggests that the sensitivity of FNAC in thyroid nodules ranges between 80-90%. However, only very few studies have looked specifically at the sensitivity of FNAC in solely thyroid cancer patients.

Aims:

The aim of our study was to investigate the value of FNAC as a first-line investigation in patients with thyroid cancer. We aimed specifically to assess the sensitivity of FNAC within this group.

Materials and Methods:

Patients diagnosed with thyroid cancer between 2000-08 were identified from a local histopathology database. Sixty-seven case notes were retrieved, retrospectively reviewed and analyzed. Analysis included results of FNAC, ultrasound scanning and final histopathological diagnosis.

Results:

Analysis of the 56 patients who underwent FNAC revealed that a cytological grading of thy3 or greater was only given to 31 cases (55.3%).

Conclusion:

In this study, FNAC findings of thy3 or greater were reported only in 55.3% of proven thyroid cancer cases. This study highlights the greater diagnostic difficulties of thyroid cancer compared to other thyroid nodules. Our findings suggest that clinicians must interpret the results of this initial investigation with caution and consider the routine use of ultrasound scanning to help guide FNAC.

Is one benign fine needle aspiration enough?

BACKGROUND

Fine needle aspiration (FNA) is used to diagnose thyroid nodules, but the follow-up of benign FNA is unclear. We sought to determine whether routine repeat FNAs after initial benign FNA reduces false negatives.

METHODS

We identified 265 patients who had at least one benign FNA that either progressed to surgery or had at least one repeat FNA. We reviewed their ultrasonography, FNA cytology, and surgical pathology.

RESULTS

Of 127 patients with initial benign FNA that had surgery, 13 had a malignancy, yielding a 10.2% false-negative rate. Of 22 patients who had surgery after at least two benign FNAs, one had a malignancy, yielding a 4.5% false-negative rate. Initially benign cytology (Bethesda II) was upgraded to a cytology requiring surgical intervention (Bethesda IV-VI) in 7 of 129 (5.4%) patients after two FNAs. Suspicious features on ultrasound, including size >4 cm, calcifications, or increased vascularity were found in 90% of patients with a false-negative FNA.

CONCLUSIONS

The overall false-negative rate of thyroid FNAs is 10.2%, which is reduced to 4.5% with a second benign FNA. Ninety percent of patients with a false-negative FNA had suspicious sonographic features. Reaspiration should be considered in patients with sonographically suspicious nodules.

Head and neck ultrasound: why now?

This article provides an overview of ultrasound and the techniques for its use by otolaryngologists in diagnosing and treating neck masses and lesions. Head and neck ultrasound is extremely useful in diagnosing neck masses and lesions and in facilitating many procedures that are commonly performed on the head and neck. Although in the past these studies were generally performed by radiologists, clinicians are now able to perform high-quality ultrasound studies and ultrasound-guided procedures in the head and neck. Given the advanced knowledge of head and neck anatomy and disease processes that otolaryngologists possess, head and neck ultrasound offers a logical and valuable extension of the physical examination. Recent improvements in ultrasound resolution, portability, and affordability have provided an excellent impetus for otolaryngologists to incorporate ultrasound into their office and operative practices.

Role of ultrasound in thyroid disorders

Thyroid ultrasonography has established itself as a popular and useful tool in the evaluation and management of thyroid disorders, both malignant and benign. Although its use has traditionally been the domain of radiologists, surgeons and endocrinologists are increasingly integrating this technology into their daily clinical and operative practice. This article provides an overview of the relevant uses and indications for ultrasound in various thyroid diseases, describes characteristic ultrasound findings in these diseases, and reviews the relevant literature and guidelines concerning its uses.

Benefits of thyrotropin suppression versus the risks of adverse effects in differentiated thyroid cancer

BACKGROUND

Despite clinical practice guidelines for the management of differentiated thyroid cancer (DTC), there are no recommendations on the optimal serum thyrotropin (TSH) concentration to reduce tumor recurrences and improve survival, while ensuring an optimal quality of life with minimal adverse effects. The aim of this review was to provide a risk-adapted management scheme for levothyroxine (L-T4) therapy in patients with DTC. The objective was to establish which patients require complete suppression of serum TSH levels, given their risk of recurrent or metastatic DTC, and how potential adverse effects on the heart and skeleton, induced by subclinical hyperthyroidism, in concert with advanced age and comorbidities, may influence the degree of TSH suppression.

SUMMARY

A risk-stratified approach to predict the rate of recurrence and death from thyroid cancer was based on the recently revised American Thyroid Association guidelines. A stratified approach to predict the risk from the adverse effects of L-T4 was devised, taking into account the age of the patient, as well as the presence of preexisting cardiovascular and skeletal risk factors that might predispose to the development of long-term adverse cardiovascular or skeletal outcomes, particularly increased heart rate and left ventricular mass, atrial fibrillation, and osteoporosis. Nine potential patient categories can be defined, with differing TSH targets for both initial and long-term L-T4 therapy.

CONCLUSION

Before deciding on the degree of TSH suppression during initial and long-term L-T4 treatment in patients with DTC, it is necessary to consider the aggressiveness of DTC, as well as the potential for adverse effects induced by iatrogenic subclinical hyperthyroidism. More aggressive TSH suppression is indicated in patients with high-risk disease or recurrent tumor, whereas less aggressive TSH suppression is reasonable in low-risk patients. In patients with high-risk DTC and an equally high risk of adverse effects, long-term treatment with L-T4 therapy should be individualized and balanced against the potential for adverse effects. In patients with an intermediate risk for thyroid cancer recurrence and a high risk of adverse effects of therapy, the degree of TSH suppression should be reevaluated during the follow-up period. Normalization of serum TSH is advisable for long-term treatment of disease-free elderly patients with DTC and significant comorbidities.

Surgical management of well-differentiated thyroid cancer: state of the art

Nonmedullary well-differentiated thyroid cancer (WDTC) comprises a group of tumors including papillary thyroid carcinoma (PTC) and follicular thyroid carcinoma (FTC), with Hürthle cell carcinoma being a subtype of follicular carcinoma. This article reviews the epidemiology, pathogenesis, preoperative and diagnostic evaluation, imaging, and staging of WDTC. Different approaches to therapy and follow-up care are discussed. The prognosis for WDTC remains good and most patients can expect to be cured of their disease.

Benefits of laparoscopic peritoneal lavage for complicated sigmoid diverticulitis

BACKGROUND

The traditional therapy for perforated sigmoid diverticulitis with peritonitis is emergency colectomy usually with colostomy. We report laparoscopic exploration with peritoneal lavage as an alternative in seven patients who required emergency surgery for diverticulitis.

METHODS

Six patients presented with diffuse peritonitis and one with a failure of percutaneous therapy. All patients were explored laparoscopically and the peritoneal cavity was lavaged with saline in addition to receiving intravenous antibiotics. Patient demographics, clinical response, length of stay, and complications were recorded.

RESULTS

Six patients had resolution of peritonitis resolved and patients were discharged from the hospital. One of these patients who developed a pelvic abscess required a percutaneous drainage postoperatively. This patient ultimately returned 3 months later with recurrent symptoms and underwent colectomy with primary anastomosis. One patient failed to improve initially and underwent colectomy with primary anastomosis on the same admission. Five patients subsequently had elective sigmoid resections, four laparoscopic and one open. Mean length of stay was 7.7 days. There was no mortality.

CONCLUSION

We conclude that laparoscopic exploration and peritoneal lavage can be performed safely in patients with diffuse, purulent peritonitis. Using this approach, most patients with purulent peritonitis can avoid emergent laparotomy with the risk of colostomy, and the need for a second surgery.