Guidelines of the French society of endocrinology for the management of thyroid nodules

Radiating blood flow signal: A new ultrasound feature of thyroid carcinoma

OBJECTIVE

To summary radiating blood flow signals and evaluate their diagnostic value in differentiating benign and malignant thyroid nodules.

MATERIALS AND METHODS

We retrospectively recruited consecutive patients undergoing US at 4 hospitals from 2018 to 2022. In a training dataset, the correlations of US features with malignant thyroid nodules were assessed by multivariate logistic analysis. Multivariate logistic regression models involving the ACR TI-RADS score, radiating blood flow signals and their combination were built and validated internally and externally. The AUC with 95% asymptotic normal confidence interval as well as sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) with 95% exact binomial confidence intervals were calculated.

RESULTS

Among 2475 patients (1818 women, age: 42.47 ± 11.57; 657 men, age: 42.16 ± 11.69), there were 3187 nodules (2342 malignant nodules and 845 benign nodules). Radiating blood flow signals were an independent risk factor for diagnosing thyroid carcinoma. In the training set, the AUC of the model using the combination of radiating blood flow signals and the ACR TI-RADS score (0.95 95 % CI: [0.94, 0.97]; P < 0.001) was significantly higher than that of the ACR TI-RADS model (0.91 [0.89, 0.93]). In the two internal validation sets and the external validation set, the AUCs of the combination model were 0.97 [0.96, 0.98], 0.92 [0.88, 0.96], and 0.91 [0.86, 0.95], respectively, and were all significantly higher than that of the ACR TI-RADS score (0.92 [0.90, 0.95], 0.86 [0.81, 0.91], 0.84 [0.79, 0.89]; P < 0.001).

CONCLUSION

Radiating blood flow is a new US feature of thyroid carcinomas that can significantly improve the diagnostic performance vs. the ACR TI-RADS score.

[SFE-AFCE-SFMN 2022 consensus on the management of thyroid nodules: Interest and place of thyroid cytology]

The SFE-AFCE-SFMN 2022 consensus deals with the management of thyroid nodules, a symptom that is a frequent reason for consultation in endocrinology. Thyroid nodules are very common and mostly benign. Thyroid ultrasound and thyroid fine-needle aspiration biopsy (FNAB) are the reference tests for the analysis of these nodules. The aim of this article is to describe for the cytopathologist the key points of the SFE-AFCE-SFMN 2022 consensus involving thyroid cytology: the indications for thyroid FNAB, the technique and analysis, and the management (treatment, follow-up) following this cytological screening examination, a key element in the management of the thyroid nodule.

Agent based modeling in health care economics: examples in the field of thyroid cancer

Although they remain little used in the field of Health Care Economics, Agent Based Models (ABM) are potentially powerful decision-making tools that open up great prospects. The reasons for this lack of popularity are essentially to be found in a methodology that should be further clarified. This article hence aims to illustrate the methodology by means of two applications to medical examples. The first example of ABM illustrates the construction of a Baseline Data Cohort by means of a Virtual Baseline Generator. The aim is to describe the prevalence of thyroid cancer in the French population over the long term according to different scenarios of evolution of this population. The second study considers a setting where the Baseline Data Cohort is an established cohort of (real) patients: the EVATHYR cohort. The aim of the ABM is to describe the long-term costs associated with different scenarios of thyroid cancer management. The results are evaluated using several simulation runs in order to observe the variability of simulations and to derive prediction intervals. The ABM approach is very flexible since several sources of data can be involved and a large variety of simulation models can be calibrated to generate observations according to different evolution scenarios.

The Economic Cost of Thyroid Cancer in France and the Corresponding Share Associated With Treatment of Overdiagnosed Cases

OBJECTIVES

Thyroid cancer incidence in France has increased rapidly in recent decades. Most of this increase has been attributed to overdiagnosis, the major consequence of which is overtreatment. We aimed to estimate the cost of thyroid cancer management in France and the corresponding cost proportion attributable to the treatment of overdiagnosed cases.

METHODS

Multiple data sources were integrated: the mean cost per patient with thyroid cancer was estimated by using the Echantillon Généraliste des Bénéficiaires data set; thyroid cancer cases attributable to overdiagnosis were estimated for 21 departments using data from the French network of cancer registries and extrapolated to the whole country; medical records from 6 departments were used to refine the diagnosis and care pathway.

RESULTS

Between 2011 and 2015, 33 911 women and 10 846 men in France were estimated to be diagnosed of thyroid cancer, with mean cost per capita of €6248. Among those treated, 8114 to 14 925 women and 1465 to 3626 men were due to overdiagnosis. The total cost of thyroid cancer patient management was €203.5 million (€154.3 million for women and €49.3 million for men), of which between €59.9 million (or 29.4% of the total cost, lower bound) and €115.9 million (or 56.9% of the total cost, upper bound) attributable to treatment of overdiagnosed cases.

CONCLUSIONS

The management of thyroid cancer represents not only a relevant clinical and public health problem in France but also a potentially important economic burden. Overdiagnosis and corresponding associated treatments play an important role on the total costs of thyroid cancer management.

Value of TI-RADS and elastography strain ratio in predicting malignant thyroid nodules: experience from a single center in Egypt

Introduction

Thyroid nodules are highly prevalent in the general population; therefore, it is crucial to discriminate benign from malignant nodules. A practical thyroid imaging reporting and data system (TI-RADS) for thyroid nodules and ultrasound elastography are valuable tools not only for characterization of nodules but also for the selection of tumors for fine-needle aspiration cytology (FNAC).

Objective

This study aimed to evaluate the diagnostic accuracy of US evaluation in the prediction of malignant thyroid nodules and evaluate the role of the elastography score, strain ratio (SR), and the TI-RADS scoring system as non-invasive tools in differentiation between malignant and benign thyroid nodules.

Material and methods

A total of 1269 patients were evaluated between February 2017 and April 2020 by a single expert thyroid ultrasound operator. The final diagnosis was achieved from cytological and/or histological evaluation and follow-up for at least 1 year.

Results

There were 1088 females and 181 males with a mean age of 44 ± 10 SD. The final diagnosis was 1197 benign nodules and 72 malignant nodules. Most malignant nodules were scored elastography score 4 (83.3%) and TI-RADS category 5 (86.11%). We found that nodules with antero-posterior to transverse (A-P/T) diameter > 1, have 21 times more risk to be malignant than those with A-P/T diameter < 1, patients with solitary thyroid nodules have 4.5 times to develop malignancy compared to those with multinodular goiter (MNG), nodules with absent halo have 4 times more risk of malignancy. Furthermore, microcalcifications in thyroid nodules increase the risk of malignancy 9 times compared to those without calcifications. SR was found to be an excellent discriminator to differentiate between benign and malignant nodules with P < 0.001. Also, we found that for every unit increase in SR, the risk of malignancy increased by 20%. We reported that the accuracy of ultrasonography in the detection of malignant thyroid nodules had a sensitivity of 89%, specificity of 98%, 70% PPV, and 99.3% NPV, with an overall accuracy of 97.2%.

Conclusion

The application of ultrasonographic non-invasive criteria for thyroid nodules in clinical practice might significantly reduce the number of unnecessary FNAC. Elastography, SR, and TI-RADS classification could be good predictors for malignant thyroid nodules.

Proportion of thyroid cancer and other cancers in the democratic republic of Congo

BACKGROUND

Cancer diagnosis is increasing around the world and in the Democratic Republic of the Congo (DRC). The proportion of thyroid cancer has increased over the past three decades. There are very few studies on cancer epidemiology, and in particular on thyroid cancer in the DRC.

AIM

To establish the most recent proportion of thyroid cancer in the DRC compared to other cancers.

METHODS

This is a retrospective and descriptive study of 6106 consecutive cancer cases listed in the pathological registers of 4 Laboratories in the city of Kinshasa. This study included all cancer cases recorded in the registers between 2005 and 2019.

RESULTS

From a sample of 6106 patients, including all cancer types, 68.3% cases were female and 31.7% were male. Breast and cervical cancer were the most common types of cancer in women and, prostate and skin cancer were the most common types in men. Thyroid cancer was sixth in proportion in women and eleventh in men compared to all cancers. Papillary carcinoma was the most common of thyroid cancers. Rare cancers such as anaplastic and medullary thyroid carcinomas had a proportion of 7% and 2%, respectively.

CONCLUSION

Newer diagnostic tools led to a surge in cancer diagnoses in the DRC. Thyroid cancer has more than doubled its proportion over the last several decades in the country.

The diagnostic efficacy and inappropriate biopsy rate of ACR TI-RADS and ATA guidelines for thyroid nodules in children and adolescents

BACKGROUND

This study is aimed at evaluating the diagnostic efficacy and unnecessary fine-needle aspiration (FNA) rate of ultrasound-based risk stratification for thyroid nodules in the American College of Radiology (ACR) Thyroid Imaging Reporting and Data System (TI-RADS) and the American Thyroid Association (ATA) risk stratification systems.

METHODS

Children and adolescents with pathology confirmed thyroid nodules were retrospectively included in this study. A total of 217 thyroid nodules from multicenter of Union Medical College Hospital, China Japan Friendship Hospital and Civil Aviation Hospital were included, the diagnostic efficiency and unnecessary FNA rate were calculated according to ACR and ATA guidelines.

RESULTS

Among all thyroid nodules, 139 nodules were malignant, and 78 nodules were benign. Choosing ATA high suspicion and ACR TI-RADS TR5 as benign and malignant cut-off points, the area under the curve and sensitivity of ATA were higher than ACR (AUC: 0.887 vs 0.840, p=0.0037; sensitivity 81.3% vs 71.0%, P <0.049;specificity 96.2% vs 97.4%, p=1.000;specificity both 85.9%); choosing high/intermediate suspicion in ATA and ACR TR4/5 as benign and malignant cut-off points, the two guidelines demonstrated similar diagnostic efficacy (AUC:0.890 vs 0.897, p=0.6038, sensitivity 92.1% vs 93.5%, P =0.817;specificity both 85.9%, p=1.000). The inappropriate FNA rate of ACR guideline was relatively lower (ATA 42.9% vs ACR 27.2%, P <0.001). If ACR TI-RADS TR5 nodules less than 1.0cm were included in the FNA indication, the unnecessary biopsy rate would be further reduced to 17.9%.

CONCLUSION

This study indicated that both ATA and ACR TI-RADS risk stratification systems could provide a feasible differential diagnosis of benign and malignant thyroid nodules, while the ACR risk stratification system demonstrates a lower rate of inappropriate FNA rate. In addition, it was necessary to further study the minimum FNA threshold of thyroid nodules in Children and adolescents in order to reduce the missed biopsy rate of malignant nodules.

The Spectrum of Thyroid Nodules at Kinshasa University Hospital, Democratic Republic of Congo: A Cross-Sectional Study

We analyzed the spectrum of thyroid nodules in patients attending the endocrinology unit care of the Kinshasa University Hospital and assessed their associated factors. We conducted a cross-sectional study, performing descriptive statistics and logistic regression. From the 888 enrolled patients, thyroid nodules were detected in 658 patients (74.1%), as mononodules in 22.5% and multiple nodules in 77.5%. Thyroid function was normal in 71.3% cases, while hyperthyroidism and hypothyroidism were found in 26.1% and 2.6% of cases, respectively. Women were more affected than men (75.1% vs. 63.6%; p = 0.03). Patients with thyroid nodules were older (44 ± 12 vs. 38 ± 12 years; p < 0.001), with a family history of goiter (38.3% vs. 27.4%; p = 0.003) and residence in the iodine-deficient region (51.7% vs. 38.8%; p = 0.012); they had a higher proportion of longer delays to consultation (47% vs. 20%; p < 0.001), but a higher rate of normal thyroid function (85.5% vs. 3 1.3%; p < 0.001). Thyroid nodules were associated with the delay to consultation (for duration ≥ three years, OR: 6.560 [95% CI: 3.525−12.208)], multiparity (present vs. absent: 2.863 [1.475−5.557]) and family history of goiter (present vs. absent: 2.086 [95% CI:1.231−3.534]) in female patients alone. The high frequency of thyroid nodules observed requires measures aimed at early detection in the population, the training of doctors involved in the management and the strengthening of technical platforms in our hospitals.

SFE-AFCE-SFMN 2022 Consensus on the management of thyroid nodules: Introduction to the consensus

The SFE-AFCE-SFMN 2022 consensus deals with the management of thyroid nodules, a condition that is a frequent reason for consultation in endocrinology. In more than 90% of cases, patients are euthyroid, with benign non-progressive nodules that do not warrant specific treatment. The clinician's objective is to detect malignant thyroid nodules at risk of recurrence and death, toxic nodules responsible for hyperthyroidism or compressive nodules warranting treatment. The diagnosis and treatment of thyroid nodules requires close collaboration between endocrinologists, nuclear medicine physicians and surgeons, but also involves other specialists. Therefore, this consensus statement was established jointly by 3 societies: the French Society of Endocrinology (SFE), French Association of Endocrine Surgery (AFCE) and French Society of Nuclear Medicine (SFMN); the various working groups included experts from other specialties (pathologists, radiologists, pediatricians, biologists, etc.). This introductory text explains the reasons for this choice and the methodology used, and gives an overview of the current consensus on the management of the thyroid.

SFE-AFCE-SFMN 2022 Consensus on the management of thyroid nodules: Initial work-up for thyroid nodules

The SFE-AFCE-SFMN 2022 consensus deals with the management of thyroid nodules, a condition that is a frequent reason for consultation in endocrinology. In more than 90% of cases, patients are euthyroid, with benign non-progressive nodules that do not warrant specific treatment. The clinician's objective is to detect malignant thyroid nodules at risk of recurrence and death, toxic nodules responsible for hyperthyroidism or compressive nodules warranting treatment. The diagnosis and treatment of thyroid nodules requires close collaboration between endocrinologists, nuclear medicine physicians and surgeons, but also involves other specialists. Therefore, this consensus statement was established jointly by 3 societies: the French Society of Endocrinology (SFE), French Association of Endocrine Surgery (AFCE) and French Society of Nuclear Medicine (SFMN); the various working groups included experts from other specialties (pathologists, radiologists, pediatricians, biologists, etc.). This section deals with the initial work-up for thyroid nodules in adult patients, including clinical and biological evaluation, standardized ultrasound characterization and EU-TIRADS-based nodule selection for fine-needle aspiration biopsy. Indications for thyroid core-biopsies or open surgical biopsies and for cross-sectional imaging of the neck and upper chest are also mentioned.

The impact of the ultrasound classification on the rate of thyroid surgery indications: a 577 cases series

OBJECTIVES

Nodules of the thyroid gland are common but rarely malignant. Their management can range from simple monitoring to surgery. The use of ultrasound and fine needle aspiration can reduce the rate of unnecessary surgeries. However, there is a risk of false positives and false negatives of malignancy that only pathology can avoid. The objective of this study is to assess the impact of ultrasound classification on the rate of surgical indications.

MATERIAL AND METHODS

Between 2013 and 2017, the ultrasound classification was gradually adopted in our daily practice to become now routine. During this period, we conducted a retrospective study of all the patients who presented to our department for one or more thyroid nodules.

RESULTS

A total of 577 patients were included in the study. We compared two groups, a first where the ultrasound classification was used and a second where this classification was not used. In the end, we found that this classification significantly reduced the surgical indication by 19% while increasing the malignancy detection rate in operated patients by 21%.

CONCLUSIONS

The use of ultrasound classification reduces the indications for surgery while increasing the rate of malignancy in operated patients. The generalization of the use of the ultrasound classification score is strongly recommended in daily practice.

SFE-AFCE-SFMN 2022 consensus on the management of thyroid nodules: Epidemiology and challenges in the management of thyroid nodules

The SFE-AFCE-SFMN 2022 consensus deals with the management of thyroid nodules, a condition that is a frequent reason for consultation in endocrinology. In more than 90% of cases, patients are euthyroid, with benign non-progressive nodules that do not warrant specific treatment. The clinician's objective is to detect malignant thyroid nodules at risk of recurrence and death, toxic nodules responsible for hyperthyroidism or compressive nodules warranting treatment. The diagnosis and treatment of thyroid nodules requires close collaboration between endocrinologists, nuclear medicine physicians and surgeons, but also involves other specialists. Therefore, this consensus statement was established jointly by 3 societies: the French Society of Endocrinology (SFE), French Association of Endocrine Surgery (AFCE) and French Society of Nuclear Medicine (SFMN); the various working groups included experts from other specialties (pathologists, radiologists, pediatricians, biologists, etc.). This section deals with epidemiology and challenges in the management of thyroid nodules.

A Practical CEUS Thyroid Reporting System for Thyroid Nodules

Background The role of contrast-enhanced US (CEUS) in reducing unnecessary biopsies of thyroid nodules has received little attention. Purpose To construct and externally validate a thyroid imaging reporting and data system (TI-RADS) based on nonenhanced US and CEUS to stratify the malignancy risk of thyroid nodules. Materials and Methods This retrospective study evaluated 756 patients with 801 thyroid nodules who underwent nonenhanced US, CEUS, and fine-needle aspiration and received a final diagnosis from January 2018 to December 2019. Qualitative US features of the thyroid nodules were analyzed with univariable and multivariable logistic regression to construct a CEUS TI-RADS. The CEUS TI-RADS was validated with use of internal cross-validation and external validation. Results A total of 801 thyroid nodules in 590 female (mean age, 44 years ± 13) and 166 male (mean age, 47 years ± 13 [SD]) patients were included. Independent predictive US features included nodule composition at CEUS, echogenicity, nodule shape, nodule margin, echogenic foci, extrathyroidal extension, enhancement direction, peak intensity, and ring enhancement. The CEUS TI-RADS showed a higher area under the receiver operating characteristic curve of 0.93 (95% CI: 0.92, 0.95; P < .001 in comparison with all other systems), a biopsy yield of malignancy of 66% (157 of 239 nodules), and an unnecessary biopsy rate of 34% (82 of 239 nodules). In the external validation, the area under the receiver operating characteristic curve, biopsy yield of malignancy, and unnecessary biopsy rate of CEUS TI-RADS were 0.89 (95% CI: 0.84, 0.92), 61% (65 of 106 nodules), and 39% (41 of 106 nodules) for the first external validation set and 0.90 (95% CI: 0.85, 0.94), 57% (56 of 99 nodules), and 43% (43 of 99 nodules) for the second external validation set. Conclusion A contrast-enhanced US (CEUS) thyroid imaging reporting and data system was created with thyroid nodule malignancy risk stratification according to the simplified regression coefficients of nonenhanced US and qualitative features of CEUS. Clinical trials registration no. ChiCTR2000028712 Published under a CC BY 4.0 license. Online supplemental material is available for this article.

Epidemiological, Clinical, Ultrasonographic and Cytological Characteristics of Thyroid Nodules in an Afro-Caribbean Population: A Series of 420 Patients

Simple Summary

This study describes the epidemiological, clinical and ultrasound characteristics of malignancy in thyroid nodules and evaluates the value of cytology in the diagnosis of malignancy in an Afro-Caribbean population. Our results revealed that none of the standard ultrasound criteria of malignancy were significantly predictive of cancer, but hypoechogenicity and central vascularity were frequently found in malignant nodules. These results could increase awareness and guide practitioners in their diagnostic approach and management of thyroid nodules in Afro-Caribbean populations. Bethesda system-based cytology revealed low sensitivity in analyzing the risk of malignancy in this population. The high prevalence of papillary microcarcinomas may explain the inconclusive ultrasound and cytological results.

Abstract

The incidence of thyroid cancer is increasing worldwide. The aim of this study is to describe the epidemiological, clinical and ultrasound characteristics of malignancy in thyroid nodules and to evaluate the predictive value of the Bethesda system for thyroid cytology in the diagnosis of malignancy in an Afro-Caribbean population. We conducted a retrospective study in Martinique involving 420 patients with a diagnosis of thyroid nodules between 2011 and 2014. Of the 192/420 (45.7%) patients operated on for thyroid nodules, 9% had thyroid cancer. All patients with thyroid cancer were obese women with a mean age of 50 years. The final histological examination revealed papillary microcarcinomas in 61% of cases and papillary carcinomas in 39% of cases. Thyroid cytology alone had a low sensitivity (22.2%) and positive predictive value (15.4%) for the diagnosis of malignancy, with a good specificity (91.1%) and negative predictive value (94.2%). None of the standard ultrasound criteria of malignancy were significantly predictive of cancer, but hypoechogenicity and central vascularity were frequently found in malignant nodules. These epidemiological, clinical and ultrasound results could increase awareness and guide practitioners in their diagnostic approach and management of thyroid nodules in an Afro-Caribbean population. Bethesda system-based cytology revealed lower sensitivity in analyzing the risk of malignancy in this population. The high prevalence of papillary microcarcinomas may explain the inconclusive ultrasound and cytological results.

The Diagnostic Efficacy of the American College of Radiology (ACR) Thyroid Imaging Report and Data System (TI-RADS) and the American Thyroid Association (ATA) Risk Stratification Systems for Thyroid Nodules

BACKGROUND

This study is aimed at evaluating the diagnostic efficacy of ultrasound-based risk stratification for thyroid nodules in the American College of Radiology (ACR) Thyroid Imaging Reporting and Data System (TI-RADS) and the American Thyroid Association (ATA) risk stratification systems.

METHODS

286 patients with thyroid cancer were included in the tumor group, with 259 nontumor cases included in the nontumor group. The ACR TI-RADS and ATA risk stratification systems assessed all thyroid nodules for malignant risks. The diagnostic effect of ACR and ATA risk stratification system for thyroid nodules was evaluated by receiver operating characteristic (ROC) analysis using postoperative pathological diagnosis as the gold standard.

RESULTS

The distributions and mean scores of ACR and ATA rating risk stratification were significantly different between the tumor and nontumor groups. The lesion diameter > 1 cm subgroup had higher malignant ultrasound feature rates detected and ACR and ATA scores. A significant difference was not found in the ACR and ATA scores between patients with or without Hashimoto's disease. The area under the receiver operating curve (AUC) for the ACR TI-RADS and the ATA systems was 0.891 and 0.896, respectively. The ACR had better specificity (0.90) while the ATA system had higher sensitivity (0.92), with both scenarios having almost the same overall diagnostic accuracy (0.84).

CONCLUSION

Both the ACR TI-RADS and the ATA risk stratification systems provide a clinically feasible thyroid malignant risk classification, with high thyroid nodule malignant risk diagnostic efficacy.

Comparative Study of ACR TI-RADS and ATA 2015 for Ultrasound Risk Stratification of Thyroid Nodules

OBJECTIVE

To study the adoption rate of the American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS) scoring system over a 3-year period in a community setting and compare its performance with that of the American Thyroid Association 2015 (ATA 2015) ultrasound risk scoring system.

STUDY DESIGN

Case series with prospective data collection and retrospective chart review.

SETTING

Large community-based practice with multiple satellite offices and a dedicated thyroid ultrasound clinic.

METHODS

All patients referred to the thyroid clinic between January 2018 and December 2020 for ultrasound-guided fine-needle biopsy were assigned an ATA 2015 risk score in a prospective manner immediately prior to biopsy. ACR TI-RADS scores were recorded through retrospective chart review of the radiologist report. Performance of the 2 systems was compared with cytology as the gold standard.

RESULTS

A total of 949 nodules underwent biopsy, of which 236 had available data for both scoring systems. There was a 33.8% increase in adoption of the ACR TI-RADS over the 3-year study period. The ATA 2015 guidelines yielded sensitivity and specificity of 81.6% and 54.5%, respectively, as opposed to 73.7% and 27.0% for the ACR TI-RADS.

CONCLUSION

In our community, there has been a gradual increase in adoption of the ACR TI-RADS, although the ATA 2015 risk scoring system has performed better.

Long-Term Outcome of Lobectomy for Thyroid Cancer

INTRODUCTION

Recent guidelines of the American Thyroid Association (ATA) suggest that a lobectomy may be sufficient to treat low- to intermediate-risk patients with thyroid tumors ≤40 mm, without extrathyroidal extension or lymph node metastases. The present study aimed to evaluate long-term recurrence after lobectomy for differentiated thyroid cancer and to analyze factors associated with recurrence.

METHODS

In this retrospective cohort study, patients who underwent a lobectomy for thyroid cancer in a tertiary center between 1970 and 2010 were included. The outcome was the proportion of pathology-confirmed thyroid cancer recurrence, assessed in the whole cohort or in subgroups according to tumor size (≤ or >40 mm).

RESULTS

A total of 295 patients were included, and these were followed-up for a mean (standard deviation, SD) 19.1 (7.8) years (5,649 patient-years); 61 (20.7%) were male and the mean (SD) age at diagnosis was 39.7 (12) years. Histological subtype was papillary in 263 (89.2%) patients and mean cancer size was 22.9 (16.9) mm. According to the 2015 ATA guidelines, 271 (91.9%) cancers had a low risk of recurrence and 24 (8.1%) an intermediate risk. A reoperation was performed in 54 patients (18.3%) and recurrence was confirmed in 40 (13.6%), diagnosed for 55% of cases more than 10 years after their initial surgery. Among recurrent patients, 14 (4.8% of the cohort) were operated for a contralateral papillary thyroid microcarcinoma and 26 (8.8% of the cohort) for a locoregional or metastatic recurrence. Non-suspicious nodular recurrences were monitored without reoperation in 53 (18.0%) patients. At the end of follow-up, 282 (95.6%) patients were in remission. Tumors with locoregional or metastatic recurrence were more frequent among tumors with aggressive histology (19.2 vs. 4.1%, p = 0.015) and of intermediate risk category (28.6 vs. 7.1%, p = 0.018). Tumors >40 mm, which would have been treated by thyroidectomy according to the 2015 ATA guidelines criteria, were found in 34 (11.5%) patients and were associated with a higher frequency of recurrence (20.6 vs. 7.3%, p = 0.024) and less remission (85.3 vs. 96.9%, p = 0.001).

CONCLUSION

The outcome of thyroid cancer treated by lobectomy is very good, particularly for cancer ≤40 mm. A prolonged follow-up is required due to the risk of late recurrence.

Partial Versus Total Thyroidectomy: What Influences Most Surgeons' Decision? Analysis of a Nationwide Cohort of 375,810 Patients Over 10 Years

National and international guidelines about thyroid surgery seem to be moving more and more towards less radical surgical procedures but everyday practice does not seem to always align with them. We describe for the first time the role of non-surgical parameters in the surgeon's choice for thyroid surgery.

OBJECTIVE

To describe thyroid surgery and to identify the factors leading to either a total or a partial thyroidectomy regardless of the severity of the thyroid disease.

SUMMARY BACKGROUND DATA

National and international guidelines about thyroid surgery seem to be moving more and more towards less radical surgical procedures but everyday practice does not seem to always align with them.

METHODS

We based this nationwide retrospective cohort study on a national database that compiles discharge abstracts for every admission for thyroidectomy to French acute healthcare facilities (PMSI database 2010 to 2019).

RESULTS

In this study, 375,810 patients (male: 23%; age = 53 ± 15 y) had a thyroidectomy (partial: 28%) for cancer (17%), hyperthyroidism (16%), non-functioning goiter (64%) or other (3%). We noticed a global trend toward more partial thyroidectomy (p < 0.001) with a significant increase in the proportion of lobectomy in the post-ATA recommendations' period (p < 0.001) as well as in the "French Levothyrox crisis" period, in which we saw an unexpected rise of adverse events notifications associated with the marketing of a new formula of Levothyrox (p < 0.001) amid widespread media coverage. In a multivariate analysis, we also identified that complete resection was more frequently performed in centers with a caseload > 40/y (p < 0.001, OR = 1.48), for obese patients (BMI> 30 kg/m2; p < 0.001, OR = 1.42), and according to the indication of surgery (OR benign = 1, OR cancer = 2.25, OR hyperthyroidism = 4.13).

CONCLUSION

We describe for the first time the role of non-surgical parameters in the surgeon's choice for thyroid surgery.

Active Surveillance for Papillary Thyroid Microcarcinoma in a Population with Restrictive Diagnostic Workup Strategies

Background: The worldwide incidence of papillary thyroid carcinoma (PTC) has increased. Efforts to reduce overtreatment follow two approaches: limiting diagnostic workup of low-risk thyroid nodules and pursuing active surveillance (AS) after diagnosis of microscopic PTC (mPTC). However, most studies on AS have been performed in countries with a relatively high proportion of overdiagnosis and thus incidental mPTC. The role of AS in a population with a restrictive diagnostic workup protocol for imaging and fine-needle aspiration remains unknown. Therefore, the aim of this study was to describe the proportion and characteristics of patients with mPTC in the Netherlands and to describe the potential candidates for AS in a situation with restrictive diagnostic protocols since 2007. Methods: All operated patients with an mPTC in the Netherlands between 2005 and 2015 were identified from the Netherlands Cancer Registry database. Three groups were defined: (Group 1) mPTC with preoperative distant or lymph node metastases, (Group 2) mPTC in pathology report after thyroid surgery for another indication, and (Group 3) patients with a preoperative high suspicious thyroid nodule or proven mPTC (Bethesda 5 or 6). Only patients in Group 3 were considered potential candidates for AS. Results: A total of 1018 mPTC patients were identified. Group 1 consisted of 152 patients with preoperatively discovered metastases. Group 2 consisted of 667 patients, of whom 16 (2.4%) had lymph node metastases. There were 199 patients in Group 3, of whom 27 (13.6%) had lymph node metastases. After initial treatment in Group 3, 3.5% (7/199) of the patients had recurrence. Conclusions: Restrictive diagnostic workup strategies of patients with small thyroid nodules lead to limited patients eligible for AS and a higher incidence of lymph node metastases. We believe that there is limited additive value for AS in countries with restrictive diagnostic workup guidelines such as in the Netherlands. However, if an mPTC is encountered, AS can be offered on an individual basis.

Management of thyroid cancer: results from a German and French patient survey

OBJECTIVE

Various national and international guidelines for the management of thyroid cancer exist. The aim of this survey was to evaluate whether patients experience differences regarding the management of thyroid cancer in Germany and in France.

METHODS

An online survey addressing diagnosis, treatment, aftercare, and information needs of thyroid cancer survivors was set up by the German and the French nationwide thyroid cancer self-help organizations. The survey consisted of up to 70 questions depending on the given answers. Descriptive statistics and univariate comparisons, if appropriate, for comparing thyroid cancer survivors in Germany and France were performed.

RESULTS

In total, 1254 thyroid cancer survivors took part in the survey, of whom 1005 were included in the analysis, 618 from Germany and 387 from France. Remarkable differences between the two countries were observed regarding waiting times, diagnostics, surgical complications, radioiodine treatment, and aftercare of the patients. A high disease burden and lack of information regarding the condition and its treatment were reported in both countries.

CONCLUSION

This large survey showed that despite various guidelines for the management of thyroid cancer, thyroid cancer survivors' experiences are noticeably different between two big European countries. Lack of information and unmet needs are still tasks to be addressed in order to optimize thyroid cancer care.

Progression of incidence and estimate of net survival from papillary thyroid cancers diagnosed between 2008 and 2016 in France

BACKGROUND

After several decades of increasing incidence of papillary thyroid cancer (PTC), a change in this trend has been recently observed, particularly in the United States. This is attributed to the impact of new guidelines for the management of thyroid disease. The objective of this study was to describe the recent situation in France in terms of incidence and survival, taking account of tumor size.

METHODS

Data from the FRANCIM network cancer registries, covering around 25% of the French metropolitan population, were analyzed. Distribution according to tumor size was determined in terms of frequency, trends in incidence and spatial distribution for the period 2008-2016. Analysis of net survival considered gender, age and tumor size.

RESULTS

Cancers of size≤5mm were predominant in patients diagnosed between 55 and 74 years of age. Incidence of≤5mm tumors in women and of 5-10mm tumors in men began declining in the early 2010s. Incidence of 10-20mm and 20-40mm tumors in men increased significantly throughout the period 2008-2016. For both men and women, the incidence of the largest tumors (>40mm) also increased, but not significantly. The spatial distribution of incidence showed great heterogeneity. Net survival was generally high, although decreasing with age and tumor size.

CONCLUSION

The recent epidemiological situation in France is consistent with the hypothesis of recent progress in medical management of thyroid pathologies. Variations in incidence should be monitored for both small (<10mm) and larger tumors, and notably>40mm tumors. Net survival is generally high, although decreasing with age and tumor size.

COMPARISON OF DIAGNOSTIC PERFORMANCE BETWEEN THE AMERICAN COLLEGE OF RADIOLOGY THYROID IMAGING REPORTING AND DATA SYSTEM AND AMERICAN THYROID ASSOCIATION GUIDELINES: A SYSTEMATIC REVIEW

Objective: We aimed to compare the diagnostic accuracy of the American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS) with the American Thyroid Association (ATA) guidelines in risk stratification of thyroid nodules. Methods: We performed a computerized search of Medline, EMBASE, Web of Science, Cochrane Library, and Google Scholar to identify eligible articles published before July 31, 2019. We included studies providing head-to-head comparison between ACR TI-RADS and ATA guidelines, with fine-needle aspiration biopsy cytology results or pathology results as the reference standard. Quality assessment of included studies was conducted using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Summary estimates of sensitivity and specificity were calculated by bivariate modeling and hierarchical summary receiver operating characteristic modeling. We also performed multiple subgroup analyses and meta-regression. Results: Twelve original articles with 13,000 patients were included, involving a total of 14,867 thyroid nodules. The pooled sensitivity of ACR TI-RADS and ATA guidelines was 0.84 (95% confidence interval [CI], 0.76-0.89) and 0.89 (95% CI, 0.80-0.95), with specificity of 0.67 (95% CI, 0.56-0.76) and 0.46 (95% CI, 0.29-0.63), respectively. There were no significant differences between the two classification criteria in terms of both sensitivity (P = .26) and specificity (P = .05). For five studies providing direct comparison of ACR TI-RADS, ATA guidelines, and Korean TI-RADS, our analyses showed that the Korean TI-RADS yielded the highest sensitivity (0.89; 95% CI, 0.82-0.94), but at the cost of a significant decline in specificity (0.23; 95% CI, 0.17-0.30). Conclusion: Both classification criteria demonstrated favorable sensitivity and moderate specificity in the stratification of thyroid nodules. However, use of ACR TI-RADS could avoid a large number of biopsies at the cost of only a slight decrease in sensitivity. Abbreviations: ACR = American College of Radiology; ATA = American Thyroid Association; FNAB = fine-needle aspiration biopsy; HSROC = hierarchical summary receiver operating characteristic; SROC = summary receiver operating characteristic; TI-RADS = Thyroid Imaging Reporting and Data System; US = ultrasonography.

Influence of Care Pathway on Thyroid Nodule Surgery Relevance: A Historical Cohort Study

Background: Guidelines recommend using fine-needle aspiration cytology (FNAC) to guide thyroid nodule surgical indication. However, the extent to which these guidelines are followed remains unclear. This study aimed to analyze the quality of the preoperative care pathway and to evaluate whether compliance with the recommended care pathway influenced the relevance of surgical indications. Methods: Nationwide historical cohort study based on data from a sample (1/97th) of French health insurance beneficiaries. Evaluation of the care pathway of adult patients operated on between 2012 and 2015 during the year preceding thyroid nodule surgery. The pathway containing only FNAC was called “FNAC”, the pathway including an endocrinology consultation (ENDO) with FNAC was called “FNAC+ENDO”, whereas the no FNAC pathway was called “NO FNAC”. The main outcome was the malignant nature of the nodule. Results: Among the 1080 patients included in the study, “FNAC+ENDO” was found in 197 (18.2%), “FNAC” in 207 (19.2%), and “NO FNAC” in 676 (62.6%) patients. Cancer diagnosis was recorded in 72 (36.5%) “FNAC+ENDO” patients and 66 (31.9%) “FNAC” patients, against 119 (17.6%) “NO FNAC” patients. As compared to “NO FNAC”, the “FNAC+ENDO” care pathway was associated with thyroid cancer diagnosis (OR 2.67, 1.88–3.81), as was “FNAC” (OR 2.09, 1.46–2.98). Surgeries performed in university hospitals were also associated with thyroid cancer diagnosis (OR 1.61, 1.19–2.17). Increasing the year for surgery was associated with optimal care pathway (2015 vs. 2012, OR 1.52, 1.06–2.18). Conclusions: The recommended care pathway was associated with more relevant surgical indications. While clinical guidelines were insufficiently followed, compliance improved over the years.

Ultrasound Classification of Thyroid Nodules: A Systematic Review

Ultrasound (US) based classification systems exist for the stratification of thyroid nodules based on the risk for malignancy. This systematic review aimed to assess the evidence for the performance of US-based thyroid nodule classification systems through correlation with fine needle aspiration biopsy (FNAB). PubMed and Scopus were searched using keywords that included ‘ultrasound classification’, ‘thyroid nodules’, ‘fine needle aspiration’, and ‘malignancy’. Inclusion criteria were as follows: studies/reviews reporting on US imaging for the classification of thyroid nodules. Exclusion criteria were as follows: no comparison between US imaging findings and histology reports based on FNAB, no full English text available/accessible. The database searches identified 66 publications. After evaluation, 12 studies met the inclusion criteria. Two US-based classification systems for thyroid nodules were assessed: the Thyroid Imaging Reporting and Data System (TIRADS) and the American Thyroid Association (ATA) guidelines. For TIRADS, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) ranged from 70.6% to 97.4%, 29.3% to 90.4%, 23.3% to 64.3%, and 87.1% to 99.0%, respectively. The median sensitivity, specificity, PPV, and NPV for TIRADS was 90.0%, 57.4%, 49.0%, and 91.0%, respectively. One study comparing TIRADS with the ATA guidelines demonstrated that TIRADS was superior in terms of sensitivity, whereas the ATA guidelines were superior in terms of specificity and PPV. The high sensitivity and NPV of the US-based TIRADS classification system have excellent utility for correctly classifying nodules as positive for malignant disease and for predicting the absence of malignant disease. The paucity of studies assessing the ATA guidelines highlights avenues for further research comparing TIRADS with other systems of thyroid nodule classification.

Learnability and reproducibility of ACR Thyroid Imaging, Reporting and Data System (TI-RADS) in postgraduate freshmen

PURPOSE

The Thyroid Imaging, Reporting and Data System (TI-RADS) from the American College of Radiology (ACR) has been used since 2017 for the evaluation of thyroid nodules. The purpose of this study is to assess the learnability and reproducibility of TI-RADS in postgraduate freshmen.

METHODS

This was a retrospective study involving 400 nodules with a final diagnosis following ultrasound (US) examination. The nodules were randomized into eight groups (50/group). Three postgraduate freshmen and three experts evaluated the nodules according to ACR TI-RADS without knowledge of the final diagnosis. After evaluating each group, training was carried out based on the inconsistencies of the freshmen/experts. Training was stopped after 200 nodules because the κ value showed almost perfect concordance. Three months later, the 50 nodules of Group 4 (the last evaluated group) were re-evaluated to assess the reproducibility of ACR TI-RADS.

RESULTS

The diagnostic accuracy of the three postgraduate freshmen increased from 60%, 48%, and 46% in Group 1 to 80%, 78%, and 72% in Group 4 (P= 0.029, 0.002, and 0.008), respectively. After training, the diagnostic accuracy of the postgraduate freshmen was close to that of the experts (84%). For the US features, the postgraduate freshmen were consistent with the experts (all κ > 0.6). When re-evaluating Group 4 three months later, the five features had substantial to almost perfect agreement for the same researcher (all κ > 0.7).

CONCLUSION

Based on experts' consensus, ACR TI-RADS can be learned well, and its reproducibility is excellent.

Ultrasound and cytological characteristics of non-invasive follicular thyroid neoplasm with papillary-like nuclear features compared to papillary carcinomas

INTRODUCTION

NIFTP (non-invasive follicular thyroid neoplasm with papillary-like nuclear features, formerly non-invasive encapsulated follicular variant of papillary thyroid carcinoma) has been removed from the carcinoma category because of its indolent character and good prognosis. This change impacts clinical and surgical management, since these tumors no longer require total thyroidectomy, or complementary radioactive iodine therapy for <4cm tumor. The aim of the present study was to identify preoperative ultrasound and cytological differences between NIFTP and papillary thyroid carcinoma (PTC).

MATERIALS AND METHODS

A retrospective study included 81 patients who underwent total thyroidectomy or thyroid lobectomy with histologic diagnosis of PTC, NIFTP or invasive follicular variant of PTC (IFVPTC) between January 1st, 2016 and May 31st, 2018. Ultrasound and cytological data were analyzed and compared between NIFTP and non-NIFTP (PTC and invasive follicular variant of PTC).

RESULTS

Fourteen NIFTPs, 67 PTCs, including 20 IFVPTCs, were included. In comparison with non-NIFTP PTC, nodules in NIFTP were more often isoechoic (69.2% vs. 17.4%; P=0.0007), with smooth borders (92.3% vs. 31.1%; P=0.0001) and TI-RADS score 2, 3 or 4a. Cytologically, NIFTPs were mainly in categories AUS/FLUS, FN and SusM of the Bethesda System for Reporting Thyroid Cytopathology. Only nuclear pseudo-inclusions were significantly associated with non-NIFTP (P=0.0031).

CONCLUSION

NIFTP appears non-suspect on preoperative ultrasound and indeterminate on cytology. These differences with respect to PTC can guide diagnosis and surgical treatment.

The Added Value of Operator's Judgement in Thyroid Nodule Ultrasound Classification Arising From Histologically Based Comparison of Different Risk Stratification Systems

Objective: Several ultrasound classifications for thyroid nodules were proposed but their accuracy is still debated, since mainly estimated on cytology and not on histology. The aim of this study was to test the diagnostic accuracy and the inter-classification agreement of AACE/ACE-AME, American Thyroid Association (ATA), British Thyroid Association (BTA), and Modena Ultrasound Thyroid Classification (MUT) that stratifies malignancy risk considering also the clinician subjective impression. Methods: A prospective study collecting thyroid nodule features at ultrasound and histological diagnosis was conducted. Ultrasound features were collected following a preformed checklist in candidates for surgery because of indeterminate, suspicious, or malignant cytology. All the nodules, besides the cytologically suspicious one, were blinded analyzed. MUT score was applied prospectively, and the others retrospectively. Sensitivity, specificity, diagnostic cut-off value, and accuracy of each classification were calculated. The overall agreement between classifications was tested by Bland-Altman, and agreement between single nodule analysis by different classifications by Weighted Cohen's Kappa. Results: In classifying a total of 457 nodules, MUT has the highest accuracy (AUC 0.808) and specificity (89%), followed by ATA and BTA, and finally by AACE/ACE-AME. ATA, BTA, and MUT are highly interchangeable. Considering agreement between single nodule analyses, ATA and BTA had the best (κ = 0.723); AACE/ACE-AME showed slight agreement with BTA (κ = 0.177) and MUT (κ = 0.183), and fair agreement with ATA (κ = 0.282); MUT had fair agreement with both ATA (κ = 0.291) and BTA (κ = 0.271). Conclusion: Classifications have an acceptable overall diagnostic accuracy, improved using a less rigid system that takes into consideration operator subjective impression.

Prediction of thyroid nodule malignancy using thyroid imaging reporting and data system (TIRADS) and nodule size

OBJECTIVES

Thyroid imaging reporting and data system (TIRADS) is a combination of ultrasonographic features developed to help physicians in predicting the malignancy risk of thyroid nodules based on sonographic characteristics. Thyroid nodule size is another factor in determining whether a nodule is malignant. The aim of this study was detecting the predictive value of TIRADS and nodule size based on Bethesda classification in prognostication of malignancy.

METHODS

This was a cross-sectional study of 239 patients with thyroid nodules. The patients underwent ultrasonography using TIRADS classification and FNA biopsy based on Bethesda categorization. The results were analyzed using SPSS with the cut off points and predictive values measured.

RESULTS

TIRADS ≥4 could detect malignant nodules with a sensitivity of 91.67% and specificity of 52.8%. An inverse relationship was observed between nodule size and malignancy risk and cutoff point of 12 mm was found for detecting malignant nodules.

CONCLUSIONS

Thyroid nodules with TIRADS 4 and 5 and diameter lower than 12 mm, are highly suspicious for malignancy and should be considered as indications for fine needle aspiration biopsy.

ADVANCES IN KNOWLEDGE

The study suggests TIRADS and thyroid nodule size as sensitive predictors of malignancy.

Treatment of adult Graves' disease

Treatment strategy in Graves' disease firstly requires recovery of euthyroid status by antithyroid therapy. Treatment modalities, precautions, advantages and side-effects are to be discussed with the patient. No particular treatment modality has demonstrated superiority. Pregnancy or pregnancy project affects choice of treatment and monitoring. Graves' orbitopathy is liable to be aggravated by iodine-131 treatment and requires pre-treatment assessment. Iodine-131 treatment aims at achieving hypothyroidism. Thyroid surgery for Graves' disease should preferably be performed by an expert team. In case of recurrence of hyperthyroidism, the various treatment options should be discussed with the patient. Empiric treatment of thyroid dermopathy uses local corticosteroids in occlusive dressing.

Early corrected serum calcium value can predict definitive calcium serum level after total thyroidectomy in asymptomatic patients

INTRODUCTION

Hypocalcemia is the most common complication of thyroidectomy, requiring supplementation as well as prolonged hospitalization. Our study's objective was to determine a corrected calcium (CCa) level on day 1 after thyroidectomy predictive of no calcium and vitamin supplementation.

MATERIALS AND METHODS

A single-center prospective study conducted between January 2012 and July 2015 in 396 patients, consisting of 331 cases of total thyroidectomy, with seven completion surgeries. The data collected were age, sex, type of thyroid surgery, etiology, anatomical pathological analysis, and the need for calcium and vitamin supplementation therapy as well as its duration. CCa levels were analyzed 20 and 30 h after surgery then on days 2 and 3. To determine a cut-off value for CCa, a ROC curve analysis was performed. The population was described in terms of numbers and associated percentages for categorical variables, and mean.

RESULTS

Mean CCa on 20 h after surgery was 2.09 mmol/L (p < 0.001) and 30 h was 2.06 mmol/L p = 0.02. CCa of less than 2.13 mmol/L was predictive of calcium and vitamin supplementation with 56% sensitivity and 97% specificity. On the evening of day 1, the cut-off value for CCa was 2.06 mmol/L with 67% sensitivity and 65% specificity.

CONCLUSION

This prospective study confirms that CCa on the first morning after surgery is reliable when it is more than 2.13 mmol/L. In total, analyzing CCa on day 1 after total thyroidectomy allows the discharge of 70% of patients on the first day after surgery, with no risk of hypocalcemia.

Malignancy rate of focal thyroid incidentaloma detected by FDG PET-CT: results of a prospective cohort study

OBJECTIVE

To evaluate the malignancy rate of focal thyroid incidentaloma (fTI) in a population of patients undergoing a 18F-fluorodeoxyglucose positron emission tomography-computed tomography (FDG PET-CT) for a non-thyroid purpose.

DESIGN

We conducted a prospective cohort study from January 2013 to November 2014. All consecutive patients referred for a FDG PET-CT were prospectively screened. Patients with known neoplastic thyroid disease were excluded from the analysis. All patients presenting one or more fTI and who accepted to benefit from a complementary thyroid ultrasonography (US) were included and managed according to the French endocrine society consensus. Prevalence of fTI in our population and malignancy rate was assessed.

RESULTS

During the inclusion period, 10,171 patients were referred for a FDG PET-CT in our center. Fifty-three patients presenting a known thyroid disease were excluded. Among the remaining 10,118 patients, 127 (1.3%) with 131 fTI were individualized. US could not be performed in 37 patients. The remaining 90 patients (92 fTI) were explored by US ± fine-needle aspiration biopsy (FNAB). US results demonstrated a nodule aspect in 80 cases of which 60 benefited from FNAB. Nineteen of 92 fTI underwent surgery with 10 malignant lesions among the 60 patients performing both US and FNAB.

CONCLUSION

The prevalence of fTI discovered on FDG PET-CT in our population was 1.3% with 10 malignant lesions among the 60 patients performing both US and FNAB.

Diagnostic accuracy of Thyroid Imaging Reporting and Data System in the prediction of malignancy in nodules with atypia and follicular lesion of undetermined significance cytologies

OBJECTIVE

Thyroid Imaging Reporting and Data System (TIRADS) is a simple and reliable reporting system for the prediction of malignancy. We aimed to determine the role of TIRADS in the prediction of malignancy in subcategories of Bethesda Category III, atypia of undetermined significance (AUS) and follicular lesion of undetermined significance (FLUS).

DESIGN & PATIENTS

A total of 461 nodules with AUS cytology in 450 patients and 179 nodules with FLUS cytology in 168 patients were included. Ultrasonography (US) features and postoperative histopathology results were documented. Every suspicious US feature was scored as 1 and 0 according to the presence or not, respectively. TIRADS category of each nodule was determined.

RESULTS

In AUS subcategory, histopathologically malignant nodules had significantly different TIRADS categories compared to benign nodules (P = 0·001), but this was not the case in FLUS subcategory (P = 0·121). In AUS group, malignant nodules had significantly higher prevalance of microcalcification, hypoechogenicity and anteroposterior/transverse ratio than benign ones (P < 0·001, P < 0·001 and P = 0·003, respectively) and TIRADS categories of 4c and 5 were more frequent in malignant nodules (P < 0·05). Microcalcification, hypoechogenicity and TIRADS were found to be associated with malignancy in multivariate logistic regression analysis in this subcategory. TIRADS category ≥4c was associated with malignancy (AUC ± SE: 0·584 ± 0·028). In FLUS subcategory, there was no significant difference between histopathologically malignant and benign nodules with respect to suspicious US features (P > 0·05, all).

CONCLUSION

TIRADS seems to be useful in predicting malignancy and planning further management in the AUS subcategory, but not quite so in the FLUS subcategory.

Thyroid lobectomy is an effective option for unilateral benign nodular disease

OBJECTIVE

The use of thyroid lobectomy in the treatment of unilateral, benign nodules is limited by the potential of nodular recurrence in the remaining lobe. This study aimed to assess the rate and clinical impact of nodular recurrence in the contralateral lobe after thyroid lobectomy and to identify predictive factors of recurrence.

DESIGN

Single-centre retrospective study.

PATIENTS

Records of patients that underwent lobectomy for unilateral thyroid nodules between 1991 and 2010 were reviewed and 270 patients were included. Exclusion criteria were: presence of contralateral nodule(s) ≥5 mm on preoperative ultrasound, diagnosis of cancer necessitating completion thyroidectomy or pseudonodules. Recurrence was defined as the occurrence of nodule(s) ≥5 mm in the remaining lobe on at least one postoperative ultrasound. A set of clinical, imaging, histological and biochemical parameters was tested as predictors of recurrence using logistic regression.

RESULTS

After a median follow-up of 78 months (range, 12-277 months), the global recurrence rate was 42% and recurrence of nodules of a size ≥1 cm occurred in 19%. Reoperation rate was 1·1%. 90% of patients were treated postoperatively by levothyroxine. Median time to nodular recurrence was 4 years. Preoperative contralateral lobe volume and resected thyroid weight were identified as significant predictors of recurrence (P = 0·045 and P = 0·03 respectively).

CONCLUSIONS

Thyroid lobectomy is an effective therapeutic strategy for unilateral, benign nodules, resulting in a low rate of clinically relevant nodular relapse in a mildly iodine-deficient area. Patients with uninodular disease and a contralateral lobe of normal size are particularly good candidates for lobectomy.

A Multicenter Prospective Validation Study for the Korean Thyroid Imaging Reporting and Data System in Patients with Thyroid Nodules

OBJECTIVE

To validate a new risk stratification system for thyroid nodules, the Korean Thyroid Imaging Reporting and Data System (K-TIRADS), using a prospective design.

MATERIALS AND METHODS

From June 2013 to May 2015, 902 thyroid nodules were enrolled from four institutions. The type and predictive value of ultrasonography (US) predictors were analyzed according to the combination of the solidity and echogenicity of nodules; in addition, we determined malignancy risk and diagnostic performance for each category of K-TIRADS, and compared the efficacy of fine-needle aspiration (FNA) with a three-tier risk categorization system published in 2011.

RESULTS

The malignancy risk was significantly higher in solid hypoechoic nodules, as compared to partially cystic or isohyperechoic nodules (each p < 0.001). The presence of any suspicious US features had a significantly higher malignancy risk (73.4%) in solid hypoechoic nodules than in partially cystic or isohyperechoic nodules (4.3-38.5%; p < 0.001). The calculated malignancy risk in K-TIRADS categories 5, 4, 3, and 2 nodules were 73.4, 19.0, 3.5, and 0.0%, respectively; and the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for malignancy were 95.5, 58.6, 44.5, 96.9, and 69.5%, respectively, in K-TIRADS categories 4 and 5. The efficacy of FNA for detecting malignancy based on K-TIRADS was increased from 18.6% (101/544) to 22.5% (101/449), as compared with the three-tier risk categorization system (p < 0.001).

CONCLUSION

The proposed new risk stratification system based on solidity and echogenicity was useful for risk stratification of thyroid nodules and the decision for FNA. The malignancy risk of K-TIRADS was in agreement with the findings of a previous retrospective study.

Ultrasonography Diagnosis and Imaging-Based Management of Thyroid Nodules: Revised Korean Society of Thyroid Radiology Consensus Statement and Recommendations

The rate of detection of thyroid nodules and carcinomas has increased with the widespread use of ultrasonography (US), which is the mainstay for the detection and risk stratification of thyroid nodules as well as for providing guidance for their biopsy and nonsurgical treatment. The Korean Society of Thyroid Radiology (KSThR) published their first recommendations for the US-based diagnosis and management of thyroid nodules in 2011. These recommendations have been used as the standard guidelines for the past several years in Korea. Lately, the application of US has been further emphasized for the personalized management of patients with thyroid nodules. The Task Force on Thyroid Nodules of the KSThR has revised the recommendations for the ultrasound diagnosis and imaging-based management of thyroid nodules. The review and recommendations in this report have been based on a comprehensive analysis of the current literature and the consensus of experts.

Thyroid Imaging Reporting and Data System Risk Stratification of Thyroid Nodules: Categorization Based on Solidity and Echogenicity

BACKGROUND

Although ultrasonography (US) has an essential role in assessing the malignancy risk of thyroid nodules, a malignancy risk-stratification system has not been established. The purpose of this study was to develop a clinically feasible US risk-stratification system--the Thyroid Imaging Reporting and Data System (TIRADS)--primarily based on the solidity and echogenicity of thyroid nodules.

METHODS

From January 2010 to May 2011, a total of consecutive 2000 thyroid nodules (≥ 1 cm) with final diagnoses were enrolled from the database of low and high cancer volume institutions (1000 nodules from each institution). For the development of TIRADS, the type and predictive value of US predictors in the groups categorized by solidity and echogenicity were analyzed, and the US predictors were integrated and categorized according to the malignancy risk.

RESULTS

The suspicious US features of microcalcification, taller than wide shape, and spiculated/microlobulated margin were independently predictive of malignancy in the solid or hypoechoic nodule group (p < 0.001, respectively). Meanwhile, only microcalcification was independently predictive of malignancy in the partially cystic nodule group (p = 0.006), and microcalcification and spiculated/microlobulated margin were independently predictive of malignancy in the iso- and hyperechoic nodule group (p = 0.002 and p = 0.015, respectively). Although the presence of any suspicious US features had a high malignancy risk in the group of solid hypoechoic nodules, it had an intermediate malignancy risk in the group of partially cystic or iso- and hyperechoic nodules. The malignancy risk of thyroid nodules was stratified into five TIRADS categories by integrating the type and predictive values of US predictors based on solidity and echogenicity.

CONCLUSION

The malignancy risk of thyroid nodules can be stratified by TIRADS according to US patterns by combining solidity, echogenicity, and suspicious US features. The proposed risk-stratification system based on solidity and echogenicity will be useful for risk stratification and management decision of thyroid nodules.

Clinical impact of BRAF mutation on the diagnosis and prognosis of papillary thyroid carcinoma: a systematic review and meta-analysis

BACKGROUND

The possible role of BRAF(V) (600E) mutation in the diagnosis and prognosis of papillary thyroid carcinoma (PTC) remains controversial. A systematic review to investigate the diagnostic and prognostic role of BRAF(V) (600E) mutation in patients with PTC is urgently needed.

METHODS

A systematic review of relevant literatures was performed in PubMed, EMBASE and CENTRAL. The incremental accuracy (IA) of fine needle aspiration biopsy plus BRAF(V) (600E) mutation analysis over fine needle aspiration biopsy alone, and the statistical data about the association of BRAF(V) (600E) mutation and the prognosis of PTC (risk ratios (RR) for dichotomous data, standard mean differences for continuous data and hazard ratios (HRs) for disease-free survival (DFS) were pooled. Subgroup analysis was performed to explain the heterogeneities.

RESULTS

A total of 67 studies were included. The pooled IA was 2% (95% confidence interval (CI): 0·5-4%). The pooled RR for gender, multifocality, lymph node metastasis, extrathyroidal invasion and pathological stage was 1·11 (95% CI: 0·98-1·25), 1·17 (95% CI: 1·09-1·24), 1·36 (95% CI: 1·20-1·53), 1·60 (95% CI: 1·41-1·82), and 1·49 (95% CI: 1·33-1·68), respectively. The pooled standard mean differences for age and tumour size were 0·14 (95% CI: 0·04-0·23) and 0·21 (95% CI: 0·1-0·32), respectively. The pooled HR for DFS was 1·96 (95% CI: 1·62-2·37). Subgroup analysis showed that these statistical results were affected by the geographical background of patients, study design and detection methods.

CONCLUSIONS

BRAF(V) (600E) mutation analysis can not only be used in the diagnosis of PTC, but can also predict its prognosis.

Thyroid nodules with minimal cystic changes have a low risk of malignancy

PURPOSE

The goal of this study was to determine the risk of malignancy of thyroid nodules with minimal cystic changes.

METHODS

A total of consecutive 1,000 thyroid nodules (≥1 cm) with final diagnoses from twoinstitutions were included in this study. The risk of malignancy of thyroid nodules was analyzed according to the internal content, which was categorized as purely solid, minimally cystic (cystic changes ≤10%), and partially cystic (cystic changes >10%). We also assessed the risk of malignancy of nodules with minimal cystic changes depending on echogenicity and presence of any suspicious ultrasonografic (US) features.

RESULTS

The overall frequency of purely solid, minimally cystic, and partially cystic noduleswas 730/1,000 (73%), 61/1,000 (6.1%), and 209/1,000 (20.9%), respectively, with risks ofmalignancy of 14.8% (108/730), 3.3% (2/61), and 3.3% (7/209), respectively. The risk ofmalignancy of nodules with minimal cystic changes was significantly lower than that of purelysolid nodules (P=0.013). The risk of malignancy of nodules with minimal cystic changes was also lower than that of purely solid nodules in the group of hypoechoic nodules (P=0.063) and in the group of nodules with suspicious US features (P=0.028), but was not significantly different from that of partially cystic nodules regardless of echogenicity or the presence of suspicious US features (P≥0.652).

CONCLUSION

Thyroid nodules with minimal cystic changes have a low risk of malignancy, similar to that of partially cystic nodules regardless of echogenicity or the presence of suspicious US features. The US lexicon could define solid nodules as nodules with purely solid internal content in order to enhance the accuracy of estimated risks of malignancy.

Computerized analysis of calcification of thyroid nodules as visualized by ultrasonography

OBJECTIVE

The purpose of this study is to quantify computerized calcification features from ultrasonography (US) images of thyroid nodules in order to determine the ability to differentiate between malignant and benign thyroid nodules.

METHODS

We designed and implemented a computerized analysis scheme to quantitatively analyze the US features of the calcified thyroid nodules from 99 pathologically determined calcified thyroid nodules. Univariate analysis was used to identify features that were significantly associated with tumor malignancy, and neural-network analysis was performed to classify tumors as benign or malignant. The diagnostic performance of the neural network was evaluated using receiver operating characteristic (ROC) analysis, where in the area under the ROC curve (Az) summarized the diagnostic performance of specific calcification features.

RESULTS

The performance values for each calcification feature were as follows: ratio of calcification distance=0.80, number of calcifications=0.68, skewness=0.82, and maximum intensity=0.75. The combined value of the four features was 0.84.With a threshold of 0.64, the Az value of calcification features was 0.83 with a sensitivity of 83.0%, specificity of 82.4%, and accuracy of 82.8%.

CONCLUSIONS

These results support the clinical feasibility of using computerized analysis of calcification features from thyroid US for differentiating between malignant and benign nodules.

Thyroid nodules with atypia or follicular lesions of undetermined significance (Bethesda Category III): importance of ultrasonography and cytological subcategory

BACKGROUND

One possible result of fine-needle aspiration (FNA) in patients with thyroid nodules is "follicular lesion of undetermined significance" (FLUS) or "atypia of undetermined significance" (AUS). The risk of malignancy is relevant information to define appropriate management, and knowledge of predictors of malignancy in these nodules is therefore important. The objective of this prospective study was to evaluate clinical, laboratory, ultrasonographic, and cytological predictors of malignancy in patients with thyroid nodules and FLUS/AUS cytology.

METHODS

The sample consisted of 150 patients with thyroid nodules and an indication for FNA whose cytology was classified as FLUS/AUS according to the Bethesda classification criteria.

RESULTS

In the second FNA, cytology was nondiagnostic in 2 (1.3%) nodules and benign in 54 (36%), FLUS/AUS cytology persisted in 73 (48.6%), and cytology was suspicious for follicular neoplasm in 11 (7.3%) and for malignancy in 10 (6.6%). The rate of malignancy was 22.6%. Clinical and laboratory data or nodule size were not predictors of malignancy. The rate of malignancy was lower in nodules initially classified as FLUS (10.8% versus 41.3% with AUS). Ultrasonography (US) was also useful for predicting malignancy, with sensitivity, specificity, and positive and negative predictive values of 79.4%, 90.5%, 71%, and 93.75%, respectively. Different malignancy rates were obtained when the two parameters, cytological subcategory and US, were combined: (i) 3.9% for nodules nonsuspicious on US and FLUS, (ii) 11.4% for nonsuspicious nodules with AUS, (iii) 46.6% for suspicious nodules with FLUS, and (iv) 87% for suspicious nodules with AUS.

CONCLUSIONS

The combination of cytological subcategory (FLUS or AUS) and US provides different risks of malignancy for nodules initially classified as Bethesda category III.

TSH measurement is not an appropriate screening test for autonomous functioning thyroid nodules: a retrospective study of 368 patients

OBJECTIVE

Based on the assumption that normal TSH concentration rules out the presence of autonomous functioning thyroid nodules (AFTNs), clinical guidelines on the management of thyroid nodules only recommend a thyroid scan if TSH concentration is subnormal. However, the proportion of AFTN presenting with a normal TSH is unknown. Our objective is therefore to determine the proportion of AFTNs with a normal TSH level to ascertain whether a normal TSH really rules out an AFTN.

DESIGN

Retrospective study on 368 patients with an AFTN.

METHODS

Thyroid scans with a diagnosis of AFTN were reviewed retrospectively by one of us (R Moreno-Reyes), blinded to the clinical data. The diagnosis of solitary AFTN was confirmed in 368 patients. Among them, we selected 217 patients based on the absence of another thyroid nodule >10 mm, the absence of medical conditions able to interfere with thyroid function, and the completeness of the data.

RESULTS

The proportion of AFTNs with normal TSH was 49%. This proportion increased to 71% in patients for whom thyroid scan was performed in the workup of a thyroid nodule.

CONCLUSIONS

Our data suggest that serum TSH is not an effective screening tool to diagnose AFTNs. Using 'TSH-only' screening, as recommended by the majority of guidelines, the diagnosis of AFTN would have been missed in 71% of our patients in the workup of a thyroid nodule. Thyroid scan remains the gold standard for detecting AFTN and should be considered before performing fine-needle aspiration cytology (FNAC), as the reliability of FNAC in an unsuspected AFTN remains unclear.

Patient information ahead of thyroid surgery. Guidelines of the French Society of Oto-Rhino-Laryngology and Head and Neck Surgery (SFORL)

OBJECTIVE

The authors present the guidelines of the French Society of Oto-Rhino-Laryngology and Head and Neck Surgery (SFORL) on patient information ahead of thyroid surgery.

METHODS

A multidisciplinary medical team was tasked with a scientific literature review on this topic. The texts retrieved were analyzed by an independent committee. A joint meeting drew up the final guidelines. The strength of the recommendations (grade A, B or C) was based on levels of evidence.

RESULTS

It is recommended that the results of preoperative exploration and the indications for surgery should be explained to the patient. Patients should be informed as to the type of surgery, surgical objectives, risks and consequences. It is mandatory to obtain the patient's written consent before surgery.

CONCLUSION

Appropriate medical information is a critical step in patient management.