Thyroid nodules

A combination of risk stratification systems for thyroid nodules and cervical lymph nodes may improve the diagnosis and management of thyroid nodules

Introduction

To assess the performance of the European Thyroid Association Thyroid Imaging and Reporting Data System (EU-TIRADS) and the Korean Thyroid Imaging Reporting and Data System (K-TIRADS), which combine risk stratification systems for thyroid nodules (TN-RSS) and cervical lymph nodes (LN-RSS) in diagnosing malignant and metastatic thyroid cancer in a single referral center.

Methods

We retrospectively analyzed 2,055 consecutive patients who underwent thyroidectomy or fine-needle aspiration (FNA) from January 2021 to December 2022. TNs and LNs were categorized according to the ultrasonography (US) features of EU-TIRADS and K-TIRADS, respectively. The diagnostic performance and postponed malignancy rate (PMR) were compared with those of EU-TIRADS and K-TIRADS. PMR was defined as the number of patients with malignant nodules not recommended for biopsy among patients with cervical LN metastasis.

Results

According to the EU-TIRADS and K-TIRADS, for TN-RSS alone, there were no significant differences in sensitivity, specificity, accuracy, unnecessary FNA rate (UFR), missed malignancy rate (MMR), and PMR between the two TIRADSs (29.0% vs. 28.8%, 50.5% vs. 51.1%, 32.3% vs. 32.2%, 23.6% vs. 23.5%, 88.6% vs. 88.5%, and 54.2% vs. 54.5%, P > 0.05 for all). Combining the LN-RSS increased the diagnostic accuracy (42.7% vs. 32.3% in EU-TIRADS; 38.8% vs. 32.2% in K-TIRADS) and decreased the PMR (54.2% vs. 33.9% in EU-TIRADS; 54.5% vs. 39.3% in K-TIRADS). EU-TIRADS had higher sensitivity and accuracy and lower PMR than K-TIRADS (41.3% vs. 36.7%, 42.7% vs. 38.8%,33.9% vs. 39.3%, P < 0.05 for all).

Conclusions

A combination of TN-RSS and LN-RSS for the management of thyroid nodules may be associated with a reduction in PMR, with enhanced sensitivity and accuracy for thyroid cancers in EU-TIRADS and K-TIRADS. These results may offer a new direction for the detection of aggressive thyroid cancers.

Combining CEUS and ultrasound parameters in thyroid nodule and cancer diagnosis: a TIRADS-based evaluation

Contrast-enhanced ultrasonography (CEUS) has been established as a diagnostic tool for assessing microvascularization, essential for understanding angiogenesis in neoplastic development.

AIM

This study assesses the effectiveness of CEUS as a supplementary tool to TIRADS in enhancing the ultrasound-based diagnosis of thyroid cancer.

METHODS AND MATERIALS

Over one year, 157 nodules in 133 patients, with predominantly solid thyroid nodules, were examined using ultrasound and CEUS and underwent thyroidectomy, allowing for a comparison of ultrasound findings with pathological reports.

RESULTS

Thyroid cancer was identified in 31.21% (49/157) of cases. Significant CEUS high-risk features included inhomogeneous enhancement, enhancement defects, and complete hypoenhancement (AUC 0.818, 0.767, 0.864 respectively). Nodules exhibiting any of these features were classified as high-risk in CEUS. The diagnostic performance of TIRADS improved when combined with CEUS, with AUC increasing from 0.707 to 0.840 and improved sensitivity.

CONCLUSION

The integration of CEUS with TIRADS significantly enhances the diagnostic accuracy and specificity in identifying thyroid cancer. This combination proves to be a more effective method for risk stratification and diagnosis, highlighting the value of CEUS as an adjunctive tool in thyroid cancer evaluation.

Thyroid Nodules: Past, Present & Future

The ability to distinguish benign from malignant thyroid nodules has been a challenge for over a century. Historically, thyroidectomy, as the only definitive method to diagnose thyroid cancer, led to a significant number of thyroid resections for benign disease considering that approximately 90-95% of thyroid nodules are benign. Diagnostic advancements including highly sensitive ultrasonography, fine needle aspiration cytology, molecular studies and future use of artificial intelligence, help distinguish benign from malignant and has significantly reduced the number of unnecessary surgeries for benign nodules. Current and likely future diagnostic improvements have led us to a new conundrum. While decreasing the number of surgeries for benign disease, we are now overdiagnosing and overtreating low-risk subclinical malignancies. Here we describe some of the changes leading to our current state.

Comparative evaluation of shear wave elastography elasticity values in thyroid nodules with cytology results and TI-RADS scoring in differentiation of benign-malignant nodules

PURPOSE

The aim of this prospective study was to investigate the diagnostic performance of shear wave elastography (SWE) in differentiating benign and malignant thyroid nodules and their correlation with the American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS).

METHODS

This prospective study included 370 thyroid nodules in 308 patients aged 18-70 years. All the patients underwent B-mode ultrasound (US), Doppler examination, and SWE and were given an ACR TI-RADS risk score before fine needle aspiration biopsy (FNAB) and/or surgery. The correlation between SWE parameters and ACR TI-RADS categories was investigated statistically and compared with histopathologic results. Additionally, the diagnostic performance of SWE was evaluated to distinguish malignant and benign thyroid nodules.

RESULTS

One hundred and thirty-five of the 370 thyroid nodules were malignant, and 235 nodules were benign. The mean shear wave velocity (SWV) value of the malignant nodules (3.70 ± 0.98 m/s) was statistically higher than that of the benign nodules (2.70 ± 0.37 m/s). The best cutoff value of the mean SWV for differentiating benign and malignant nodules was found to be 2.94 m/s (sensitivity 90.4%, specificity 89.9%, positive predictive value 81.3%, negative predictive value 94.1%, p < 0.001). The average score of the nodules according to the ACR TI-RADS was 3.57 ± 1.83 in benign nodules and 7.38 ± 2.69 in malignant nodules (p ≤ 0.001).

CONCLUSION

This study showed that combining SWE and TI-RADS improves the specificity of TI-RADS alone in differentiating benign and malignant nodules.

Integrated Diagnostics of Thyroid Nodules

Thyroid nodules are common findings, particularly in iodine-deficient regions. Our paper aims to revise different diagnostic tools available in clinical thyroidology and propose their rational integration. We will elaborate on the pros and cons of thyroid ultrasound (US) and its scoring systems, thyroid scintigraphy, fine-needle aspiration cytology (FNAC), molecular imaging, and artificial intelligence (AI). Ultrasonographic scoring systems can help differentiate between benign and malignant nodules. Depending on the constellation or number of suspicious ultrasound features, a FNAC is recommended. However, hyperfunctioning thyroid nodules are presumed to exclude malignancy with a very high negative predictive value (NPV). Particularly in regions where iodine supply is low, most hyperfunctioning thyroid nodules are seen in patients with normal thyroid-stimulating hormone (TSH) levels. Thyroid scintigraphy is essential for the detection of these nodules. Among non-toxic thyroid nodules, a careful application of US risk stratification systems is pivotal to exclude inappropriate FNAC and guide the procedure on suspicious ones. However, almost one-third of cytology examinations are rendered as indeterminate, requiring "diagnostic surgery" to provide a definitive diagnosis. 99mTc-methoxy-isobutyl-isonitrile ([99mTc]Tc-MIBI) and [18F]fluoro-deoxy-glucose ([18F]FDG) molecular imaging can spare those patients from unnecessary surgeries. The clinical value of AI in the evaluation of thyroid nodules needs to be determined.

Thyroid Disorders in Systemic Sclerosis: A Comprehensive Review

Systemic sclerosis, also referred to as scleroderma, is a chronic autoimmune disease that affects both internal organs and the skin. Systemic sclerosis predominantly affects female patients and can coexist with other disorders, including those affecting the thyroid gland. Common symptoms such as fatigue and weight changes can be attributed to either systemic sclerosis or thyroid disease. In this comprehensive review, an extensive analysis is conducted using research from 2002 to 2022, sourced from PubMed. The main focus of this exploration is to understand the intricate relationship between thyroid disorders and systemic sclerosis. We obtained these results by analyzing a number of 32285 patients included in 21 original studies. The existing evidence suggests that there is a higher incidence of elevated TSH levels and hypothyroidism in patients with systemic sclerosis, particularly in females, compared to the general population. This remains true even when comparing patients from iodine-deficient regions. Additionally, there is an increased occurrence of hyperthyroidism in the context of systemic sclerosis, which negatively impacts the prognosis of these patients. Furthermore, thyroid antibodies, predominantly anti-thyroid peroxidase (anti-TPO) antibodies, and autoimmune disorders are more commonly observed in individuals with systemic sclerosis. Although thyroid nodules are not specifically linked to the disease, when considering thyroid volume, it is observed that the thyroid gland in systemic sclerosis patients has a decreased volume, possibly due to fibrosis. Conversely, other studies have revealed that patients without autoimmune thyroid diseases (AITDs) are more likely to have a history of digital ulcers, pulmonary fibrosis detected by computed tomography scan, and a requirement for immunosuppressive medication. The majority of the studies did not establish a connection between thyroid disease in these patients and the occurrence of the limited or diffuse forms of systemic sclerosis, as well as the presence of digital ulcers, calcinosis, pulmonary arterial hypertension, scleroderma renal crisis, Raynaud phenomenon, and various other clinical manifestations.

Diagnostic Accuracy of American College of Radiology Thyroid Imaging Reporting Data System: A Single-center Cross-sectional Study

Objective

This study aims to evaluate the diagnostic accuracy of the American College of Radiology Thyroid Imaging Reporting Data System (ACR TI-RADS) in identifying nodules that need to undergo fine-needle aspiration biopsy (FNAB) and identify specific thyroid ultrasound characteristics of nodules associated with thyroid malignancy in Filipinos in a single tertiary center.

Methodology

One hundred seventy-six thyroid nodules from 130 patients who underwent FNAB from January 2018 to December 2018 were included. The sonographic features were described and scored using the ACR TI-RADS risk classification system, and the score was correlated to their final cytopathology results.

Results

The calculated malignancy rates for TI-RADS 2 to TI-RADS 5 were 0%, 3.13%, 7.14%, and 38.23%, respectively, which were within the TI-RADS risk stratification thresholds. The ACR TI-RADS had a sensitivity of 89.5% and specificity of 54%, LR + of 1.95 and LR - of 0.194, NPV of 97.7%, PPV of 19.1%, and accuracy of 58%.

Conclusion

The ACR TI-RADS may provide an effective malignancy risk stratification for thyroid nodules and may help guide the decision for FNAB among Filipino patients. The classification system may decrease the number of unnecessary FNABs for nodules with low-risk scores.

Approach to Thyroid Nodules: Diagnosis and Treatment

Thyroid nodules (TNs) are prevalent and found in up to 50% of individuals. While most TNs are benign, some can be malignant. The evaluation of TNs is crucial to rule out malignancy and identify those requiring surgical intervention. This study aimed to clarify the reported prevalence of TNs, focusing specifically on their various types, assessment and diagnostic processes, current evaluation methods, and evidence-based management. It also provides recommendations for follow-up. TNs are typically found during physical exams or incidentally during imaging procedures. Routine laboratory and clinical evaluations of TNs are common. Ultrasound is the preferred imaging method to determine if a TN needs a biopsy. Fine-needle aspiration (FNA) is crucial in deciding whether surgery or surveillance is necessary. TNs that show suspicious features on the ultrasound may require cytologic analysis to assess the risk of malignancy. The effectiveness of several supplementary molecular tests is still uncertain, although some studies report promising results. The management and treatment approach for TNs primarily depends on the results of FNA cytology and ultrasound characteristics. The optimal treatment strategy for TNs ranges from straightforward follow-ups for low-risk cases to surgical intervention for high-risk patients. Rather than adopting a uniform approach, clinicians should assess each patient on a case-by-case basis using current knowledge and a collaborative, multidisciplinary method.

Microwave ablation for large benign thyroid nodules: a proposal for a new approach: "the fluid-motion technique"

INTRODUCTION

Most thyroid nodules are benign, and treatment is primarily indicated for patients with symptoms or cosmetic concerns related to nodular volume. Recently, there has been growing interest in nonsurgical and minimally invasive techniques for the treatment of symptomatic benign thyroid nodules, including microwave ablation (MWA).

AIMS

This study aims to evaluate the effectiveness, efficacy, and safety of ultrasound-guided uncooled MWA in the treatment of benign symptomatic thyroid nodules, using a new ablation technique called the "fluid-motion technique."

MATERIALS AND METHODS

From April 2021 to February 2023, a total of 150 patients with benign thyroid nodules were treated using MWA at the Endocrine Surgery Unit of Pederzoli Hospital, Peschiera del Garda (Italy), with 102 of them being followed-up for at least 6 months.

RESULTS

Before treatment, the mean major diameter was 38.4 ± 10.0 mm, and the mean volume was 13.6 ± 10.5 mL. At 1 month, the mean volume was 6.8 ± 6.2 mL, and at 3 months, it was 4.6 ± 4.1 mL. The mean Volume Reduction Rate (VRR) at 3 months was 61.1 ± 22.0%. Of the nodules, 17 (17%), 65 (66%), and 20 (19%) had volumes ≤ 10, 10.1-20, and ≥ 20.1 mL, respectively. For these nodules, the mean VRR at 3 and 6 months was 55.3 ± 16%, 63.4 ± 24.8%, 72 ± 26.9% and 68.0 ± 11.2%, 73.5 ± 18.3%, and 81.6 ± 15.8%, respectively.

CONCLUSION

Our study shows that ultrasound-guided MWA is an effective and safe minimally invasive treatment for benign thyroid nodules. The goal is to achieve a VRR that can reduce symptoms and improve cosmetic appearance.

Comparison the accuracy of thyroid sono-elastography vs. ultrasound-guided fine needle aspiration cytology with thyroid malignancy diagnosis histopathology

Objective. The intend of the present study was to assess the diagnostic performance of strain elastography in investigating the thyroid nodule malignancy taking the surgical biopsy as a gold standard reference test. Methods. The study included 120 patients with 123 thyroid nodules, of which 67 had total thyroidectomy. The American College of Radiology Thyroid Imaging Reporting and Data Systems (ACR-TIRADS) were evaluated for all nodules. All suspicious nodules were referred for a fine needle aspiration cytology (FNAC) if they fulfilled the required size. Strain elastography was performed for each suspicious nodule. Ultrasound-guided FNAC was performed for all suspicious nodules. Total thyroidectomy was performed in those whom the suspicious nodules were proven by FNAC. Results. Strain ratio had a sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy of 84%, 81%, 95%, 85%, and 84%, respectively, with a cut point 1.96. Elasticity score had a sensitivity, specificity, PPV, NPV, and diagnostic accuracy of 100%, 80%, 95%, 85% and 87%, respectively, with a cut point 0.96. The elasticity score had a statistically significantly odds ratio for detecting the benignity 3.9 C. I (1.6-9.3). Conclusion. Strain elastography has a high diagnostic performance in detecting the malignant as well as benign nodules, thus it can limit the rate of unneeded FNAC or surgery especially among B3 and B4 groups with indeterminate cytology.

Performance of Afirma genomic sequencing classifier and histopathological outcome in Bethesda category III thyroid nodules: Initial versus repeat fine-needle aspiration

BACKGROUND

There is limited data comparing the performance of Afirma Genomic Sequencing Classifier (GSC) in thyroid nodules carrying an initial versus a repeat diagnosis of atypia of undetermined significance (AUS). This study reported an institutional experience in this regard.

MATERIALS AND METHODS

This retrospective study included consecutive thyroid nodules that had an initial or a repeat AUS diagnosis and had a subsequent GSC diagnostic result (benign or suspicious) from 2017 to 2021. All nodules were followed by surgical intervention or by clinical and/or ultrasound monitoring. GSC's benign call rate (BCR), rate of histology-proven malignancy associated with a suspicious GSC result, and diagnostic parameters of GSC were calculated and compared between the two cohorts (initial versus repeat AUS). Statistical significance was defined with a p-value of <.05 for all analysis.

RESULTS

A total of 202 cases fulfilled inclusion criteria, including 67 and 135 thyroid nodules with an initial and a repeat AUS diagnosis, respectively. BCR was 67% and 66% in initial and repeat AUS cohorts, respectively. Rate of histology-proven malignancy associated with a suspicious GSC result were 22% and 24% in initial and repeat AUS cohorts, respectively. Compared with the repeat AUS cohort, the initial AUS cohort showed slightly lower sensitivity (83% vs. 100%), specificity (70% vs. 73%), PPV (23% vs. 24%), NPV (98% vs. 100%), and diagnostic accuracy (72% vs. 75%). Nevertheless, these differences did not reach statistical significance.

CONCLUSION

GSC demonstrated comparable performance in thyroid nodules with a repeat AUS diagnosis versus nodules with an initial AUS diagnosis.

Human exposure to heavy metals and related cancer development: a bibliometric analysis

As notifications on carcinogenicity of heavy metals increase, more and more attention is paid recently to heavy metals exposure. In our study, the human exposure to heavy metals and cancer knowledge epistemology was investigated using bibliometric analysis. The bibliometric data of the research articles were retrieved using following keywords: "heavy metal," "trace element", "cancer", "carcinogen", and "tumor" in the Scopus database. Specifically, 2118 articles published between 1972 and 2023 were found, covering a total of 1473 authors, 252 sources, and 2797 keywords. Retrospective data obtained from 251 documents and 145 journals were further analyzed by performance analysis and techniques of science mapping. The number of studies conducted in this field increased from one article published in 1972 to 18 articles published in 2022 in the study of Michael P Waalkes. The most impactful author regarding the number of published papers was Masoudreza Sohrabi with 7 publications. In the majority of the published papers, the most popular keywords were "cadmium" and "carcinogenicity". However, in recent 4 years, the emphasis has been placed more on epidemiology studies. Our study provides general knowledge about the trend of publication on the role of heavy metals in causing cancer. The leading researchers in the field of the effects of heavy metals on the development of cancer were identified in our studies. Our results might also create a better understanding of new and emerging issues and can be used as a comprehensive road map for future researchers.

Preoperative Thyroid-Stimulating Hormone Levels and Risk of Thyroid Cancer in Post-thyroidectomy Patients for Thyroid Nodules: A Study From a Tertiary Hospital in Western Saudi Arabia

Background Although serum thyroid-stimulating hormone (TSH) is one of the basic investigations to assess thyroid nodules, its role in thyroid oncogenesis remains unclear. Previous literature has conflicting findings regarding TSH levels and the prediction of malignancy. This study aims to investigate the association between TSH levels and the risk of malignancy and advanced staging in patients who underwent thyroidectomy for nodular thyroid disease. Additionally, it aims to assess if higher TSH correlates with malignancy in Bethesda staging III, IV, and V. Methodology This retrospective cohort study was conducted among participants who underwent near-total/total thyroidectomy or hemithyroidectomy at King Abdulaziz Medical City between 2016 and 2021. Results A total of 378 cases were included, and 50.3% of the cases had malignant nodules in the surgical histopathology findings. The median TSH levels were higher in malignant nodules compared to benign ones (1.64 mIU/L versus 1.49 mIU/L; p < 0.001). Additionally, higher TSH levels were not associated with advanced staging or malignancy in patients with Bethesda stage III-V. Conclusions Higher TSH levels are associated with an increased risk of malignancy in patients with nodular thyroid disease. Using TSH levels as an adjunctive tool for identifying high-risk patients with thyroid nodules would aid in management planning.

An update on the management of thyroid nodules: rationalising the guidelines

BACKGROUND

Guidance for the management of thyroid nodules has evolved over time, from initial evaluation based predominantly on clinical grounds to now including the established role of ultrasound and fine needle aspiration cytology in their assessment. There is, however, significant variation in the management of thyroid nodules depending on which national guidelines are followed. In addition, there are certain clinical situations such as pregnancy and paediatric thyroid nodules that have differing evaluation priorities.

OBJECTIVES

This review aimed to provide an overview of currently accepted practices for the initial investigation and subsequent management of patients with thyroid nodules for the non-specialist. The review also addresses areas of variance between the systems in common clinical use, as well as newer, evolving technologies, including molecular testing in the evaluation of malignancy in thyroid nodules.

Differentiating Thyroid Follicular Adenoma from Follicular Carcinoma via G-Protein Coupled Receptor-Associated Sorting Protein 1 (GASP-1)

Follicular neoplasms are classified as benign or malignant depending on the presence or absence of capsular and/or vascular invasion. Due to incomplete capsular penetration or equivocal vascular invasion, the evaluation of these features can be challenging using histologic examination. In the current study, we analyzed the involvement of G-protein coupled receptor-associated sorting protein 1 (GASP-1) in the development and progression of thyroid neoplasms. Affinity-purified anti-GASP-1 polyclonal antibodies were used for routine immunohistochemistry (IHC) analysis. Thyroid tissue microarrays containing normal thyroid tissue, follicular adenoma, follicular carcinoma, papillary thyroid carcinoma, and anaplastic carcinoma were analyzed. We found that the level of GASP-1 expression can differentiate follicular adenoma from follicular carcinoma. When numerous cases were scored for GASP-1 expression by a board-certified pathologist, we found that GASP-1 expression is 7-fold higher in thyroid malignant neoplasms compared to normal thyroid tissue, and about 4-fold higher in follicular carcinoma compared to follicular adenoma. In follicular adenoma tissues, we observed the presence of many mini-glands that are enriched in GASP-1 and some mini-glands contain as few as three cells. GASP-1 IHC also possesses several advantages over the conventional H&E and can be used to identify early thyroid cancer and monitor cancer progression.

Determination of Diagnostic Features of Serum Thyroid Hormones and Thyroglobulin Ratios in Normothyroid Differentiated Thyroid Carcinoma Cases

Objectives

Ultrasonography and fine-needle aspiration biopsy (FNAB) are the gold standard methods in the prediction of benign and malignant thyroid nodules. However, despite being easily applicable, FNAB is an invasive procedure. Less invasive biomarkers should be utilized in the diagnosis of thyroid malignancies. In this study, we aimed to determine the parameters that can be used in the diagnosis of differentiated thyroid cancer (DTC) based on the serum thyroid and thyroglobulin (TG) levels which are routinely checked in patients followed up for thyroid nodules.

Methods

In the study, we evaluated patients who underwent thyroid surgery for nodular diseases between January 2015 and June 2022. Of the 1444 patients evaluated, 919 patients who met the inclusion criteria (normothyroid benign nodular disease or normothyroid DTC) were included in the study. Patients were divided into two groups as benign group (BG) and DTC group (DTCG). We compared patients' pre-operative serum thyroid and TG values and the diagnostic properties of their ratios.

Results

Of the 919 patients included, 517 (56.3%) were in BG and 402 (43.7%) were in DTCG. In DTCG, 318 patients were female and 84 patients were male. The mean age in the DTCG was 47.8 years. Comparison of DTCG and BG revealed a significant difference between T3/T4 ratio (p=0.002), T3/TSH ratio (p≤0.001), T4/TSH ratio (p≤0.001), TG/TSH ratio (p≤0.001), and TSH/TG ratio (p≤0.001). However, evaluation of the specified values by ROC analysis showed that the T3/T4 ratio did not make a significant difference between the two groups (p=0.1), whereas the other values displayed a significant difference (p≤0.001 for T3/TSH, p=0.001 for T4/TSH, p≤0.001 for TG/TSH, and p<0.001 for TSH/TG).

Conclusion

T3/TSH (cutoff =2.183), T4/TSH (cutoff=0.6), and TG/TSH (cutoff=29.67) values were found to be significant tumor markers for the prediction of malignancy in thyroid nodules, and low values were found to be associated with malignancy. TSH/TG (cutoff=0.031) value was also significant in predicting malignancy while high values were found to be associated with malignancy. Thyroid hormone and TG ratios may alter the preferred treatment method for thyroid nodules.

Diagnostic performance of the EU TI-RADS and ACR TI-RADS scoring systems in predicting thyroid malignancy

INTRODUCTION

Several ultrasound scoring systems have been developed to stratify the risk of malignancy of thyroid nodules, including ACR (American College of Radiology) and EU (European) TI-RADS. This study aimed to assess the diagnostic performance of these two classifications using histology as a reference standard.

METHODS

It was a single-centre, retrospective study including 156 patients who underwent thyroidectomy. Ultrasound data of 198 nodules (99 malignant nodules and 99 benign nodules) were analysed. Both classifications were applied for all nodules.

RESULTS

Ultrasound criteria associated with malignancy were solid composition (OR=7.81; p < 10^-3 ), hypoechoic character (OR=16.42; p < 10^-3 ), irregular contours (OR=7.47; p < 10^-3 ), taller-than-wide shape (OR=3.58; p = 0.02), microcalcifications (OR=3.02; p = .006) and the presence of cervical adenopathy (OR=3.89; p = .006). The prevalence of malignancy was 15.5%, 69% and 76.9% for EU TI-RADS categories 3, 4 and 5, respectively. It was 33.3%, 57% and 91.1% for ACR TI-RADS categories 3, 4 and 5, respectively. For category 5, EU TI-RADS and ACR TI-RADS had sensitivities of 60% and 41%, specificities of 82% and 96%, respectively. For categories 4 and 5 combined, the diagnostic performance of these two classification systems became comparable with a sensitivity of 89% and 86% for EU-TIRADS and ACR-TIRADS, respectively. The area under the ROC curve was 0.81 for the EU TI-RADS classification and 0.82 for the ACR TI-RADS classification.

CONCLUSIONS

EU TI-RADS and ACR TI-RADS scoring systems seem to be comparable in predicting malignancy in thyroid nodules.

Unusual Clinical Manifestations of Thyroid Carcinoma

Thyroid cancer is considered the most common endocrine malignancy, with the most frequent presentation of differentiated thyroid cancer being a neck swelling or an incidental finding of a thyroid nodule on imaging. In this case series, we describe three cases of thyroid cancer with unusual clinical manifestations. The first case describes a patient who underwent parathyroidectomy for primary hyperparathyroidism and was found to have papillary thyroid cancer on a cervical lymph node biopsy. While this may be coincidental, the literature raises the question of whether there may be an association. The second case describes a patient who presents with a suspicious thyroid nodule and was subsequently diagnosed with follicular thyroid cancer on biopsy. This raises the question of performing thyroidectomy early in patients with a suspicious thyroid nodule but a false negative biopsy. The third case describes a patient with a scalp lesion found to have poorly differentiated thyroid carcinoma, a rare presentation of this form of cancer.

Performance of European Thyroid Imaging Reporting and Data System in Stratifying Malignancy Risk of Thyroid Nodules: A Prospective Study

Background

There is a limited number of studies reporting the performance of European Thyroid Imaging Reporting and Data System (EU-TIRADS) guideline in identifying thyroid nodule malignancy. We aimed to evaluate diagnostic accuracy of EU-TIRADS regardless of thyroid nodule size.

Methods

During August 2019-November 2021, subjects with thyroid nodules were prospectively included. Sonographic characteristics were recorded and scored as per EU-TIRADS guideline. Finally, fine-needle aspiration (FNA) was performed, and cytological findings were reported.

Results

Totally, 1266 thyroid nodules from 984 subjects were assessed, of which 295 nodules were smaller than 10 mm and 971 nodules were 10 mm or larger. Among nodules <10 mm, prevalence rates of malignancy for EU-TIRADS classes 2-5 were 0.0%, 3.7%, 20.6%, and 40.9%, respectively; these rates among nodules ≥10 mm were 2.3%, 4.0%, 19.3%, and 43.2%, respectively. The accuracy values of EU-TIRADS class 5 and EU-TIRADS class 4 or 5 in diagnosis of malignancy for nodules <10 mm were 86.4% and 79.7%, respectively; these rates for nodules ≥10 mm were 83.8% and 76.3%, respectively. Hypoechogenicity, microcalcification, ill-defined and irregular margins were predictors for malignancy regardless of thyroid nodule size.

Conclusion

EU-TIRADS could provide an acceptable malignancy risk stratification that is helpful for better distinguishing benignity from malignancy, as well as preventing unnecessary FNA biopsies, in thyroid nodules irrespective of their size.

Triple Assessment in Diagnosis of Thyroid Nodules and Its Comparison With Histopathology

BACKGROUND

 Thyroid nodules are more common than previously realised, and the rate of prevalence is hugely impacted by the method of detection and their easy access. No single test is sufficient to access the thyroid nodule at any given time. Hence this necessitates the need for clinicians to use an evidence-based protocol for their assessment and diagnosis.

AIMS AND OBJECTIVE

 To determine the likelihood of malignancy in individuals who have thyroid nodules of any size, by a) performing a triple assessment, including a history and physical examination, an ultrasound of the neck and fine needle aspiration and cytology (FNAC) b) predicting the percentage of correlation between findings of malignancy on FNAC and final histopathological diagnosis c) identifying and validate individual risk factors in the clinical examination and ultrasound imaging that point towards a nodule being malignant Methods: Patients presenting with thyroid nodules in a clinically euthyroid state were studied over a time period of 18 months. Seventy-five patients were included in this study. Patients having external cytology and ultrasonography reports were reassessed if they consented to the study. If the pathologists thought the smears were sufficient, slide reviews were accepted. A senior consultant conducted the clinical evaluation. Prior to doing the FNACs, the designated radiologist performed the majority of the ultrasonograms. If the physicians believed it was necessary, ultrasound-guided FNACs were performed. According to Bethesda criteria, the cytology was reported. The outcome of the histopathological analysis was used as the gold standard for diagnosis in this investigation.

RESULT

Out of 75 patients included in the study, the older age group (50-70) patients had mostly malignant lesions (92%). In the younger age group (20-39), about 77% had benign lesions. Benign lesions were more common in females than males according to the histopathology study. Seventy-three percent of fixed swellings turned out to be malignant. About 86% of patients who had extrathyroidal extension ended up being found to have malignant lesions but even 41% of patients who didn't have any extrathyroidal extension also turned out to be having malignant lesions. However, the presence of pressure symptoms didn't necessarily translate to being an indicator of malignancy. Ninety-seven percent of patients who had punctate microcalcifications turned out to have malignant lesions. Hypoechogenicity on imaging also is an important marker of malignancy, with about 87% of patients who had hypoechogenicity having malignant lesions proven on histopathology. All the patients who had solid lesions on imaging were proven to have malignant lesions. About 77% of patients who had cystic features ended up having benign lesions. Hence, it is a very significant marker. Intranodular vascularity, taller than wider lesions and positive lymph nodes on imaging were proven to have malignant lesions. FNAC is an important diagnostic tool. It is made out that the reporting of FNAC more or less matched the histopathological diagnosis in almost all categories.

CONCLUSION

 There are definite correlations in the role of triple assessment as a standard protocol in the diagnosis of thyroid nodules and guiding its management.

Development and validation of the clinical report form for nodular thyroid pathologies

Objective

The aim of this study is to develop and validate a novel clinical report form in the format of a structured interview to enable the characterization of the Portuguese population of the Baixo Vouga region with different subtypes of nodular thyroid pathologies (NTyPs).

Materials and methods

A structured interview was developed and to the best of our knowledge, this is the first structured interview built and validated for that purpose in Portugal.

Results

This structured interview enables the identification of possible correlations between each subtype of nodular lesions and sociodemographic data, consumption habits and lifestyle, endocrine history, and family predisposition.

Conclusion

The novel structured interview will simultaneously, enable a detailed characterization of the group of patients with nodular thyroid lesions and will support future metabolomic studies.

Contrast-enhanced ultrasound and shear wave elastography in the diagnosis of ACR TI-RADS 4 and 5 category thyroid nodules coexisting with Hashimoto's thyroiditis

Objective

This study aims to evaluate the value of contrast-enhanced ultrasound (CEUS), shear wave elastography (SWE), and their combined use in the differentiation of American College of Radiology (ACR) thyroid imaging reporting and data system (TI-RADS) 4 and 5 category thyroid nodules coexisting with Hashimoto's thyroiditis (HT).

Materials and methods

A total of 133 pathologically confirmed ACR TI-RADS 4 and 5 category nodules coexisting with HT in 113 patients were included; CEUS and SWE were performed for all nodules. The sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), accuracy, and the area under the receiver operating characteristic curve (AUC) of the SWE, CEUS, and the combined use of both for the differentiation of benign and malignant nodules were compared, respectively.

Results

Using CEUS alone, the sensitivity, specificity, PPV, NPV, and accuracy were 89.2%, 66.0%, 81.3%, 78.6%, and 80.5%, respectively. Using SWE alone, Emax was superior to Emin, Emean, and Eratio for the differentiation of benign and malignant nodules with the best cutoff Emax >46.8 kPa, which had sensitivity of 65.1%, specificity of 90.0%, PPV of 91.5%, NPV of 60.8%, and accuracy of 74.4%, respectively. Compared with the diagnostic performance of qualitative CEUS or/and quantitative SWE, the combination of CEUS and SWE had the best sensitivity, accuracy, and AUC; the sensitivity, specificity, PPV, NPV, accuracy, and AUC were 94.0%, 66.0%, 82.1%, 86.8%, 83.5%, and 0.80 (95% confidence interval: 0.713, 0.886), respectively.

Conclusion

In conclusion, CEUS and SWE were useful for the differentiation of benign and malignant ACR TI-RADS 4 and 5 category thyroid nodules coexisting with HT. The combination of CEUS and SWE could improve the sensitivity and accuracy compared with using CEUS or SWE alone. It could be a non-invasive, reliable, and useful method to differentiate benign from malignant ACR TI-RADS 4 and 5 category thyroid nodules coexisting with HT.

Artificial Intelligence for Pre-operative Diagnosis of Malignant Thyroid Nodules Based on Sonographic Features and Cytology Category

BACKGROUND

Current diagnosis and classification of thyroid nodules are susceptible to subjective factors. Despite widespread use of ultrasonography (USG) and fine needle aspiration cytology (FNAC) to assess thyroid nodules, the interpretation of results is nuanced and requires specialist endocrine surgery input. Using readily available pre-operative data, the aims of this study were to develop artificial intelligence (AI) models to classify nodules into likely benign or malignant and to compare the diagnostic performance of the models.

METHODS

Patients undergoing surgery for thyroid nodules between 2010 and 2020 were recruited from our institution's database into training and testing groups. Demographics, serum TSH level, cytology, ultrasonography features and histopathology data were extracted. The training group USG images were re-reviewed by a study radiologist experienced in thyroid USG, who reported the relevant features and supplemented with data extracted from existing reports to reduce sampling bias. Testing group USG features were extracted solely from existing reports to reflect real-life practice of a non-thyroid specialist. We developed four AI models based on classification algorithms (k-Nearest Neighbour, Support Vector Machine, Decision Tree, Naïve Bayes) and evaluated their diagnostic performance of thyroid malignancy.

RESULTS

In the training group (n = 857), 75% were female and 27% of cases were malignant. The testing group (n = 198) consisted of 77% females and 17% malignant cases. Mean age was 54.7 ± 16.2 years for the training group and 50.1 ± 17.4 years for the testing group. Following validation with the testing group, support vector machine classifier was found to perform best in predicting final histopathology with an accuracy of 89%, sensitivity 89%, specificity 83%, F-score 94% and AUROC 0.86.

CONCLUSION

We have developed a first of its kind, pilot AI model that can accurately predict malignancy in thyroid nodules using USG features, FNAC, demographics and serum TSH. There is potential for a model like this to be used as a decision support tool in under-resourced areas as well as by non-thyroid specialists.

Prevalence and Associated Predictors of Hypertension in Adult Patients with Thyroid Nodules at the Royal Commission Hospital, Kingdom of Saudi Arabia

Background

Hypertension and thyroid nodules (TNs) are common medical problems that are increasing in prevalence globally. Hence, we conducted this study to assess the prevalence and associated predictors of hypertension in adult patients with TNs at the Royal Commission Hospital, Kingdom of Saudi Arabia (KSA).

Methods

A retrospective study was conducted between 1 January 2015 and 31 December 2021. Patients with documented TNs based on the Thyroid Imaging Reporting and Data System (TI-RADS) were recruited to assess the prevalence and associated risk factors for hypertension.

Result

Three hundred ninety-one patients with TNs were recruited for this study. The median (interquartile range, IQR) age was 46.00 (20.0) years, and 332 (84.9%) of the patients were females. The median (IQR) body mass index (BMI) was 30.26 (7.71) kg/m². There was a high prevalence of hypertension (22.5%) in adult patients with TNs. In the univariate analysis, there were significant associations between diagnosed hypertension in patients with TNs and age, sex, diabetes mellitus (DM), bronchial asthma, triiodothyronine (FT3), total cholesterol and high-density lipoprotein (HDL). In the multivariate analysis, age (OR = 1.076 [95% CI 1.048 - 1.105]), sex (OR = 2.28 [95% CI 1.132 - 4.591]), DM (OR = 0.316 [95% CI 0.175 - 0.573]) and total cholesterol levels (OR = 0.820 [95% CI 0.694 - 0.969]) were significantly associated with hypertension.

Conclusion

There is a high prevalence of hypertension in patients with TNs. Age, female sex, DM and elevated total cholesterol are significant predictors of hypertension in adult patients with TNs.

The crossroad between autoimmune disorder, tissue remodeling and cancer of the thyroid: The long pentraxin 3 (PTX3)

Thyroid is at the crossroads of immune dysregulation, tissue remodeling and oncogenesis. Autoimmune disorders, nodular disease and cancer of the thyroid affect a large amount of general population, mainly women. We wondered if there could be a common factor behind three processes (immune dysregulation, tissue remodeling and oncogenesis) that frequently affect, sometimes coexisting, the thyroid gland. The long pentraxin 3 (PTX3) is an essential component of the humoral arm of the innate immune system acting as soluble pattern recognition molecule. The protein is found expressed in a variety of cell types during tissue injury and stress. In addition, PTX3 is produced by neutrophils during maturation in the bone-marrow and is stored in lactoferrin-granules. PTX3 is a regulator of the complement cascade and orchestrates tissue remodeling and repair. Preclinical data and studies in human tumors indicate that PTX3 can act both as an extrinsic oncosuppressor by modulating complement-dependent tumor-promoting inflammation, or as a tumor-promoter molecule, regulating cell invasion and proliferation and epithelial to mesenchymal transition, thus suggesting that this molecule may have different functions on carcinogenesis. The involvement of PTX3 in the regulation of immune responses, tissue remodeling and oncosuppressive processes led us to explore its potential role in the development of thyroid disorders. In this review, we aimed to highlight what is known, at the state of the art, regarding the connection between the long pentraxin 3 and the main thyroid diseases i.e., nodular thyroid disease, thyroid cancer and autoimmune thyroid disorders.

Solitary and multiple thyroid nodules as predictors of malignancy: a systematic review and meta-analysis

BACKGROUND

The debate on whether or not there is a difference in the incidence of thyroid cancer between the patients with Solitary thyroid Nodule (STN) and Multinodular Goiter (MNG) has been constantly present for the last few decades. With newer studies yielding mixed results, it was imperative to systematically compile all available literature on the topic.

METHODS

PubMed/MEDLINE, Cochrane Central, ScienceDirect, GoogleScholar, International Clinical Trials registry, and reference lists of the included articles were systematically searched for article retrieval. No filter was applied in terms of time, study design, language or country of publication. Rigorous screening as per PRISMA guidelines was undertaken by 2 independent reviewers in order to identify the articles that were most relevant to the topic.

RESULTS

Twenty-two studies spanning from 1992 to 2018 were included in this analysis and encompassed 50,321 patients, 44.2% of which belonged to the STN subgroup and 55.37% to the MNG subgroup. MNG was found to be associated with a significantly lower risk of thyroid cancer (OR = 0.76; 95% CI 0.61-0.96) when compared with STN. Papillary carcinoma was the most frequently occurring carcinoma across both groups, followed by follicular and medullary carcinomas. A subgroup analysis was performed to assess the efficacy of the two most commonly employed diagnostic tools i.e. surgery and fine needle aspiration cytology (FNAC), however it yielded nonsignificant results, indicating a comparable usefulness of the two. Another subgroup analysis run on the basis of the presumed iodine status of the participants also yielded nonsignificant results.

CONCLUSION

There is a higher incidence of thyroid cancer among patients of STN, however, given the low quality of existing evidence on the topic, it is crucial to conduct larger studies that can establish association with a greater precision.

Malignancy risk stratification of thyroid nodules smaller than 10 mm with ACR-TIRADS, K-TIRADS, and ATA-2015 guidelines: a prospective study

Background

Small thyroid nodules (≤ 10 mm) are common findings in thyroid ultrasonography. The first purpose of this study was to compare the performance of three guidelines in the diagnosis of malignancy for small thyroid nodules. The second aim was to find the ultrasonographic characteristics potentially associated with the risk of malignancy. This prospective cross-sectional study was performed on the patients with a diagnosis of small thyroid nodules (≤ 10 mm), who were rereferred to the radiologists for sonography and FNA. Sonographic features were recorded and scored according to the American College of Radiology-Thyroid Imaging Reporting and Data System (ACR-TIRADS), American Thyroid Association (ATA-2015), and Korean-TIRADS (K-TIRADS). Finally, FNA was conducted and cytological findings were reported.

Results

In total, 287 thyroid nodules from 256 subjects (64 men and 192 women) were finally included in the study. The accuracy of ACR-TIRADS categories TR5 and TR4/5 was 88.9% and 72.1%, respectively. This rate for ATA-2015 classes high suspicion and intermediate suspicion/high suspicion was 88.9% and 82.6%, respectively. For K-TIRADS classes 5 and 4/5, the diagnostic accuracy was 89.6% and 82.9%, respectively. Significant direct associations were found between malignancy and punctate echogenic foci (odds ratio [OR] = 6.46), hypoechogenicity (OR = 6.39), ill-defined margin (OR = 4.38), and irregular margin (OR = 7.33).

Conclusion

The differences in the strength of the three guidelines in the prediction of the malignancy should be considered by clinicians and radiologists in the management of thyroid nodules smaller than 10 mm.

Can Thyrotropin, Tri-Iodothyronine, and Thyroxine Hormones be Predictors of Cancer in Thyroid Lesions?

Background Thyroid nodules are a common medical problem worldwide. This study aims to investigate and elucidate the relationship between thyroid-stimulating hormone (TSH), thyroxine (T4), and triiodothyronine (T3), and malignant thyroid nodules. Methods This prospective cross-sectional study was conducted at a public specialist hospital in Saudi Arabia from February 2020 to February 2021. All thyroid nodules were scanned using ultrasound imaging, and the largest diameter was measured for each and classified according to the American College of Radiology (ACR) Thyroid Imaging Reporting and Data System (TIRADS) classification system. Thyroid function tests TSH, T3, and T4 were measured. Definitive diagnoses of thyroid nodules were given based on cytology. A one-way analysis of variance (ANOVA) test was used to compare means, and cross-tabulation was used to correlate the variables in the study. Results A total of 222 patients participated in this study; 23.42% were male and 76.57% were females. The mean age was 44.73 ± 13.31 years (range: 18 to 85 years). The percentage of malignancy was 20.6%, 36.3%, and 91.2% in TIRADS 3, TIRADS 4, and TIRADS 5, respectively. A weak positive linear relationship was noted between nodule size and TSH (R²= 0.012). The study demonstrates that TSH increases in malignant nodules more than in benign nodules, while T4 and T3 are decreased in malignant nodules. Conclusion The level of TSH increases in patients with malignant thyroid nodules more than in benign nodules, which can be used as a predictor of malignancy, while T4 and T3 reduced in malignant nodules with an ambiguous relationship.

Clinical Value of Ultrasonography and Serum Markers in Preoperative N Staging of Thyroid Cancer

We aimed to determine factors influencing lymph node metastasis (LNM) and develop a more effective method to assess preoperative N staging. Overall, data of 2130 patients who underwent thyroidectomy for thyroid cancer between 2018 and 2021 were retrospectively analysed. Patients were divided into groups according to pN0, pN1a, and pN1b stages. Pathology was used to analyse the correlation between preoperative serum marker indicators and LNM. Receiver operating characteristic curves were used to compare the diagnostic value of ultrasound (US) examination alone, serum thyroglobulin, age, and combined method for LNM. A significant moderate agreement was observed between preoperative US and postoperative pathology for N staging. Between the pN0 and pN1 (pN1a + pN1b) groups, the differences in free triiodothyronine, anti-thyroid peroxidase antibody, and serum thyroglobulin levels were statistically significant. Among the indicators, serum thyroglobulin was an independent predictor of LNM. The area under the receiver operating characteristic curve was 0.610 for serum thyroglobulin level for predicting LNM, 0.689 for US alone, and 0.742 for the combined method. Both preoperative US and serum thyroglobulin level provide a specific value when evaluating the N staging of thyroid cancer, and the combined method is more valuable in the diagnosis of LNM than US alone.

Performance of Afirma genomic sequencing classifier and histopathological outcome are associated with patterns of atypia in Bethesda category III thyroid nodules

BACKGROUND

Data on Afirma's genomic sequencing classifier (GSC) performance in atypia of undetermined significance (AUS) subcategories is limited. This study investigated GSC performance in AUS nodules with architectural atypia (AUS-A), cytological atypia (AUS-C), architectural and cytological atypia (AUS-AC), and predominantly Hürthle cells (AUS-HC).

METHODS

This study retrieved consecutive thyroid nodules having a recurrent cytologic diagnosis of AUS with qualifiers and a concurrent GSC diagnostic result. All nodules were followed by either surgical intervention or clinical and/or ultrasound monitoring (≥6 months). GSC benign call rate (BCR), rate of histology-proven malignancy, and diagnostic parameters of GSC were calculated for individual AUS subcategories. Statistical analysis was performed using the Fisher exact test.

RESULTS

A total of 135 AUS nodules fulfilled inclusion criteria, including 79 AUS-A, 9 AUS-C, 29 AUS-AC, and 18 AUS-HC. BCR was 72.2%, 66.7%, 44.8%, and 77.8% in AUS-A, AUS-C, AUS-AC, and AUS-HC, respectively. AUS-A showed a greater BCR than AUS-AC (p &lt; .05). All GSC-benign nodules were considered benign on clinical or surgical follow-up. Among GSC-suspicious nodules, histology-proven malignancies represented 4.5% of AUS-A, 0% of AUS-C, 56.3% of AUS-AC, and 25.0% of AUS-HC cases. AUS-AC demonstrated a higher malignant rate compared with AUS-A (p &lt; .05). GSC offers 100% NPV and a wide range (5%-56%) of PPV across all AUS subcategories. AUS-AC demonstrated a greater PPV compared with AUS-A (p &lt; .05).

CONCLUSION

BCR of GSC and malignant rates associated with suspicious GSC may differ in various AUS subcategories. GSC-suspicious nodules with both architectural and cytologic atypia are more likely to be malignant. These findings may improve clinical triage and/or management of patients with AUS thyroid nodules.

Prevalence of thyroid nodules and its association with water iodine among Chinese men and women

BACKGROUND

Because of the large change in iodine nutrition and other lifestyle in China, there is concern that thyroid nodules (TNs) may become epidemic. However, few data are currently available on the national prevalence of TNs. In addition, whether excess iodine in drinking water is associated with an increased risk of TNs, following universal salt iodization, has been less studied. We aim to estimate a national prevalence of TNs and its association with drinking water iodine.

METHODS

We conducted a national survey of 9,381,032 adults, aged 18 years or older, from 30 provinces and municipalities in China, who underwent a thyroid ultrasound test from January 2018 to December 2018. Crude and standardized prevalence of TNs were estimated. We further evaluated the ecological association between province- or city-specific iodine levels in drinking water and the prevalence of TNs using linear regression.

RESULTS

The age-standardized prevalence of TNs in men, women, and both sexes were 29.8%, 44.7%, and 37.1%, respectively. The prevalence increased with age from 22.7% (18-30 years) to 71.5% (≥70 years), and body mass index from 26.1% (<18.5 kg/m2) to 40.8% (≥28 kg/m2). Participants living in the eastern, northern, and northeastern regions had a higher prevalence of TNs (ranged from 38.7% to 43.7%) than those in other regions (ranged from 30.1% to 35.5%). The coastal residents (40.1%) had a higher prevalence of TNs than those in inlanders (35.4%). Higher levels of iodine in drinking water were linearly associated with increased prevalence of TNs, with Pearson correlation coefficients of 0.47 (P < 0.01) in men, 0.40 (P = 0.03) in women, and 0.46 (P = 0.01) in overall participants.

CONCLUSION

This was a nationwide prevalence study of TNs in China, showing that TNs were common health problems, and increased concentration of iodine in drinking water was associated with a higher prevalence of TNs.

Battle of the axes: simulation-based assessment of fine needle aspiration biopsies for thyroid nodules

Importance

Ultrasound-guided fine-needle aspiration biopsies (UGFNA) play a crucial role in the diagnosis of thyroid nodules. There are two techniques for performing an UGFNA: short-axis technique and long-axis technique. There is sparsity in the literature regarding the differences between these two techniques.

Objective

To compare the efficiency between long-axis and short-axis thyroid UGFNA techniques in trainees. Our secondary outcomes were to define the comfort level and learning curves of trainees.

Design

A longitudinal prospective cohort study, completed from December 2018 to November 2019, using the Blue Phantom Thyroid Model© for UGFNA. Face and construct validity of the model were verified. Residents completed UGFNA on an assigned nodule using both long-axis and short-axis techniques, the order of which was sequentially allocated. The rate and time to successful biopsy were obtained for both techniques. Biopsy attempts were repeated to establish learning curves.

Setting

Single-center study.

Participants

Fourteen Otolaryngology—Head & Neck Surgery residents at the University of Toronto.

Main outcome measure

Biopsy success and efficiency for novice learners completing UGFNA on a simulated thyroid model using long-axis and short-axis techniques.

Results

A trend towards higher odds of successful biopsy using the long-axis technique with no difference in procedure duration was observed (OR = 2.2, p = 0.095, CI = 0.87–5.39). Learning curve graphs appeared heterogenous according to trainee level. Trainees found the long-axis technique easier to perform (10/14, 71%), and the simulator valuable for learning (12/14, 86%).

Conclusion

Thyroid UGFNA using the long-axis technique may have an increased success rate and is generally favored by trainees for being easier to perform. Thyroid simulators have the potential to increase learner comfort and efficiency with UGFNA.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s40463-022-00587-5.

“Elastic Stretch Cavity Building” System in Endoscopic Thyroidectomy of Giant Thyroid Tumors

Objective

To analyze the clinical characteristics of patients with large thyroid tumors underwent endoscopic thyroidectomy using the “elastic stretch cavity builder” system.

Methods

This retrospective case series study included thyroid tumor patients admitted to the Ningbo Medical Center Li Hui li Hospital between September 2017 and November 2021. The self-developed “elastic stretch cavity builder” was used to elastically lift the anterior cervical flap, combined with low-pressure (3 mmHg) high-flow CO2 inflation, and create a working cavity for endoscopic thyroidectomy.

Results

This study included 13 patients for analysis. The endoscopic thyroidectomy duration was 92-170 min (mean, 123 ± 24min). The maximum transverse plane diameter of the glands was 5.0-6.2 cm (mean, 5.3 ± 0.3 cm). The maximum sagittal plane diameter was 6.8-10.0 cm (mean, 7.6 ± 0.9 cm). After the “elastic stretch cavity builder” lifted the cervical flap, the height of the subcutaneous region was increased by 1.3 ± 0.2cm without affecting cervical activity. There was no residual scar in the anterior cervical skin puncture hole. All patients were satisfied with the cosmetic with the cosmetic satisfaction score was 3.4 ± 0.5.

Conclusion

The novel mixed cavity building model established by the “elastic stretch cavity builder” might provide the surgeon with additional longitudinal cervical operating space while improving the stability of the space and saving human effort.

Thyrotropin/Thyroglobulin ratio in combination with thyroid u/s to assess malignancy risk stratification of thyroid nodules

Objective: we aimed to asses if thyrotropin/thyroglobulin ratio has a significant value in detection of malignant thyroid nodules. Design: Retrospective analysis. Material and Methods: This study included finally 100 subject collected as outpatient’s endocrinology clinic of ALHuessine university hospital or admitted at oncology institute of Tanta. Patients who had history of thyroid diseases or surgery, those with abnormal levels of anti- thyroglobulin antibodies, cases without simultaneous measurement of serum anti Tg., with history of current use of thyroid hormone replacement therapy were excluded from this study. Clinico pathological features, as well as serumTSH, Tg, and TSH/Tg were compared between histopathologically benign and malignant groups. Results: Data related to 100 subjects (40%) normal  and 60(60%) patients  with thyroid nodules were analyzed, 30 patients (50%) were malignant thyroid nodules and 30 patients (50%) were benign.The malignant patients exhibited significantly higher TSH, TSH/Tg, , and a lower Tg compared to the benign patients (p<0.05 for each). Conclusion: Preoperative TSH/Tg could be used as a predictive marker for differ-entiating between benign and malignant thyroid nodules.

Utility of Fine-Needle Aspirations to Diagnose Pediatric Thyroid Nodules

INTRODUCTION

Risk of malignancy for pediatric thyroid nodules classified according to The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) is not well defined. Correlations between risk of malignancy and ancillary clinical data remain inconclusive. We report a single institutional experience of fine-needle aspiration (FNA) to improve upon current management paradigm of thyroid nodules.

METHODS

A retrospective chart review of 575 thyroid nodules was performed of 324 patients who underwent 340 FNAs between 2008 and 2018 at the Children's Hospital of Philadelphia. Demographics, ultrasound (US) characteristics, FNA cytology, surgical pathology, and ancillary data were reviewed.

RESULTS

The rate of malignancy according to TBSRTC was 0.0% for category I, 0.8% for category II, 15.6% for category III, 54.5% for category IV, 100.0% for category V, and 100.0% for category VI. The cumulative Thyroid Imaging Reporting and Data System (TI-RADS) score was significantly correlated with benign and malignant nodules on pathology (p < 2.2e-16). Distribution of TI-RADS for cytologically indeterminate nodules with benign or malignant pathology revealed significant differences for composition (p = 3.20e-8) and echogenic foci (p = 0.005) but not for echogenicity (p = 0.445), shape (p = 0.160), margins (p = 0.220), and size (p = 0.105). Distributions of thyroid-stimulating hormone levels between benign and malignant patients was significant (p = 1.58e-3).

CONCLUSIONS

Nodules with TI-RADS scores >3 should undergo FNA, irrespective of size; surgical resection is recommended for nodules classified as TBSRTC category IV and V due to high risk of malignancy. US surveillance instead of FNA can be performed for nodules with TI-RADS scores ≤3.

The Pattern of Thyroid Malignancy and Its Associated Characteristics Among United Arab Emirates Population With More Focus on Patients in the Bethesda III Category

Introduction: Thyroid cancer is the most prevalent endocrine cancer worldwide. It is the second most common type of cancer among United Arab Emirates (UAE) women and ranks as the sixth most common type of cancer overall among the UAE population. There are limited studies in the UAE related to thyroid malignancy. This study aimed to determine the pattern of thyroid malignancy among the UAE population and its associated characteristics, with more emphasis on patients categorized as Bethesda III by cytopathology, and furthermore, to determine the significance of advanced diagnostic methods in the assessment of thyroid nodules.

Methods: A retrospective review of the electronic medical charts of adult patients (age 18 and above) who were diagnosed with a thyroid nodule by ultrasound during the years 2019 and 2020. It is a comparative study of different variables associated with thyroid nodules and thyroid malignancy.

Results: A total of 1072 patients were diagnosed with thyroid nodules upon initial ultrasound. We had 174 patients diagnosed with thyroid malignancy, constituting 16% (95% CI 0.14-0.19) of the total study population. 78% of the thyroid malignancy patients were women as compared to men, and this difference was statistically significant (p=0.042). Non-UAE nationals comprised 61% of the population diagnosed with thyroid malignancy (95% CI 1.37-2.68). Malignancy was found to be more common in patients with multinodular goiter, in the 30 to 39-year age group, and in patients with high ultrasound and Bethesda grades. From the total study population, 140 patients had cytology reports in the Bethesda III category. Thyroid malignancy was found in 30 patients with Bethesda III, and this comprised 17% of the total population who were diagnosed with thyroid malignancy.

Conclusion: Despite being a single-center study, it highlights the percentage of thyroid malignancy and its associated factors among the UAE population. Thyroid ultrasound grading and Bethesda classification guide physicians in risk stratification, but it remains challenging in patients who fall into the Bethesda III category. Intervention versus regular follow-up should not depend on a single value but on the overall clinical picture and the use of advanced diagnostic methods.

Ultrasound findings of the thyroid gland in children and adolescents

Ultrasonography (US) is an important diagnostic tool in evaluating thyroid diseases in pediatric patients. This pictorial essay reviews the application of various ultrasound techniques such as B-Mode ultrasound and color Doppler, elastography and contrast enhanced ultrasound (CEUS) in children and adolescents in various thyroid pathologies including congenital thyroid abnormalities, diffuse thyroid diseases (DTD), focal thyroid lesions and thyroid malignancy.

Metabolic Profile Characterization of Different Thyroid Nodules Using FTIR Spectroscopy: A Review

Thyroid cancer’s incidence has increased in the last decades, and its diagnosis can be a challenge. Further and complementary testing based in biochemical alterations may be important to correctly identify thyroid cancer and prevent unnecessary surgery. Fourier-transform infrared (FTIR) spectroscopy is a metabolomic technique that has already shown promising results in cancer metabolome analysis of neoplastic thyroid tissue, in the identification and classification of prostate tumor tissues and of breast carcinoma, among others. This work aims to gather and discuss published information on the ability of FTIR spectroscopy to be used in metabolomic studies of the thyroid, including discriminating between benign and malignant thyroid samples and grading and classifying different types of thyroid tumors.

Benign thyroid nodules respond to a single administration of 0.3mg recombinant human thyrotropin with highly variable volume increase

INTRODUCTION

The nature of thyroid nodules is heterogenous. Most of them are benign and, in the absence of pressure symptoms of adjunct structures, no treatment is needed. Our objective was to investigate the acute effects of a low dose of recombinant human TSH (rhTSH) on the volume of benign thyroid nodules.

METHODS

we studied 27 nodules (14 isoechoic and 13 hypoechoic) in 15 (11 women and 4 men; mean age: 51.0 ± 15.9 years) consecutive patients with one to three well-separated asymptomatic benign thyroid nodules. All subjects were euthyroid, with negative thyroid antibodies, and none received levothyroxine. The total thyroid volume and thyroid nodule volume were sonographically determined by two independent examiners (P.B. and M.M.) before, 48 hours and 6 months post intramuscular (IM) administration of 0.3mg rhTSH, and the mean values of the two examiners' measurements were used; thyroid function tests were obtained at the same time points.

RESULTS

The mean volume of isoechoic nodules increased by 57.3%, of hypoechoic nodules by 46.6% and of the surrounding thyroid parenchyma by 70.4% 48 hours post-rhTSH; mean volumes had returned to baseline levels 6 months later. A large variance in the volume change responses was observed. The relative change in nodule volume (defined as the percent change in nodule volume divided by the percent change in the surrounding parenchyma) from baseline to 48 hours was significantly higher in isoechoic versus hypoechoic nodules (p<0.05).

CONCLUSIONS

A single dose of 0.3 mg rhTSH transiently increased the volume of benign thyroid nodules. The increase was more pronounced in isoechoic nodules and had a great variability. Our findings could be useful in the management of benign thyroid nodules, by helping in understanding which nodules would be more responsive to TSH suppression therapy.

Reliability of a computer-aided system in the evaluation of indeterminate ultrasound images of thyroid nodules

INTRODUCTION

Computer-aided diagnostic (CAD) programs for malignancy risk stratification from ultrasound (US) imaging of thyroid nodules are being validated both experimentally and in real-world practice. However, they have not been tested for reliability in analyzing difficult or unclear images.

METHODS

US images with indeterminate characteristics were evaluated by five observers with different experience in US examination and by a commercial CAD program. The nodules, on which the observers widely agreed, were considered concordant and, if there was little agreement, not concordant or difficult to assess. The diagnostic performance of the readers and the CAD program was calculated and compared in both groups of nodule images.

RESULTS

In the group of concordant thyroid nodules (n = 37), the clinicians and the CAD system obtained similar levels of accuracy (77.0% vs 74.2%, respectively; P = 0.7) and no differences were found in sensitivity (SEN) (95.0% vs 87.5%, P = 0.2), specificity (SPE) (45.5 vs 49.4, respectively; P = 0.7), positive predictive value (PPV) (75.2% vs 77.7%, respectively; P = 0.8), nor negative predictive value (NPV) (85.6 vs 77.7, respectively; P = 0.3). When analyzing the non-concordant nodules (n = 43), the CAD system presented a decrease in accuracy of 4.2%, which was significantly lower than that observed by the experts (19.9%, P = 0.02).

CONCLUSIONS

Clinical observers are similar to the CAD system in the US assessment of the risk of thyroid nodules. However, the AI system for thyroid nodules AmCAD-UT® showed more reliability in the analysis of unclear or misleading images.

Incidental thyroid carcinoma: Correlation between FNAB cytology and pathological examination in 1093 cases

OBJECTIVE

To investigate Incidental Thyroid Carcinoma (ITC) by comparing the results of Fine Needle Aspiration Biopsy (FNAB) cytology and the postoperative pathological findings.

METHODS

Data of 1479 patients who underwent total thyroidectomy were retrieved. Three hundred eighty-six patients were excluded due to insufficient data. Each surgical specimen studied received two histopathological diagnoses: the local diagnosis ‒ for the same area in which the FNAB was performed; and the final diagnosis, which includes a study of the entire surgical specimen.

RESULTS

A thousand and ninety-three patients were investigated. FNAB result was malignant in 187 patients, benign in 204, suspicious or indeterminate in 668 cases, and inconclusive in 34 cases. The prevalence of ITC was 15.1%. Most of the ITC in this series was less than 0.5 cm. The incidence of ITC was higher in Bethesda III (17.5% ITC) and IV (19% ITC) than in Bethesda II cases (1.5% false negatives and 9% ITC).

CONCLUSION

Although the incidence of false-negative results in Bethesda II nodules is only 1.5%, 9% of these patients had ITC in the thyroid parenchyma outside the nodule that underwent preoperative FNAB. The incidence of ITC in the same scenario was even higher in Bethesda III (17.5%) and Bethesda IV cases (19%). Ultrasonography-guided FNAB is an excellent method for the assessment of thyroid nodules. However, biopsy sites should be carefully selected. Despite the high incidence of incidentalomas, total thyroidectomy should not always be the treatment of choice due to its rare but potentially serious complications. The findings of the present study can assist future clinical decisions towards active surveillance strategies for the management of papillary thyroid carcinoma.

Correlation between fine-needle aspiration cytology, cell block cytology, and histopathology in the diagnosis of thyroid lesions

Context:

Fine-needle aspiration cytology is considered the gold standard screening test in the evaluation of a thyroid nodule. We studied whether cell block cytology can be used in addition to conventional smears for the evaluation of tissue from fine-needle aspirations or fluid aspirations and also compared it with histopathological diagnosis.

Aims:

The primary aim of this study was to know the utility of cell blocks in the diagnosis of thyroid lesions.

Settings and Design:

This was a prospective observational study conducted from June 2018 to September 2020 at a tertiary Care Hospital in Eastern India. Ethical approval was obtained from the Ethics Committee of the institution. Patients above 18 years who presented with goiter were included in the study. Thirty patients were enrolled in the study after informed consent.

Methods and Material:

Smears prepared from the aspirates were stained with Leishman-Giemsa (LG) and Pap stain. The remnant from the needle hub was transferred to a sterile container. Cell blocks were prepared from the remnants. Smears were scored based on cell obscuration by blood, cellularity, cell degeneration, and cell architecture. The results were compared with histopathology.

Statistical Analysis Used:

Data were recorded using Microsoft Excel. Descriptive statistics, frequency, and proportion were used to describe demographic variables.

Results:

The majority of the patients (23.3%) were in their third decade of life, followed by 16.7% of the patients in their fourth and fifth decades. The patient age ranged from 25 to 80 years, with a mean age of 50.83 years and a standard deviation of 16.72. The largest number of patients were females accounting for 80% (24/30) of the total participants. The majority of the patients (36.7%) (11/30) had thyroid gland enlargement for a period of 15 days to three months. 14% of the participants were not able to recall its duration. The majority (60%) (18/30) had left lobe lesions, followed by 33.3% (10/30) who had right lobe lesions, and 6.7% (2/30) who had bilateral lobe swelling. The mean size of the lesion was 2.84 cm. 50% were found to be Bethesda II lesions, while 13.3% were Bethesda IV, and 36.7% were found to be Bethesda VI lesions. The cell block score (7) was found to be better compared to Fine Needle Aspiration Cytology (FNAC) (4.7). Tissue Coagulum Clot and Clot Scrape methods were found to yield better results compared to the Cytocentrifuge method. The P value was found to be significant (<0.001).

Conclusions:

Cell blocks were found to improve the cell morphology compared to FNAC alone and can be used as an adjunct to FNAC in the diagnosis of various thyroid lesions.

Accuracy of Ultrasound Diagnosis of Thyroid Nodules Based on Artificial Intelligence-Assisted Diagnostic Technology: A Systematic Review and Meta-Analysis

BACKGROUND

Ultrasonography (US) is the most common method of identifying thyroid nodules, but US images require an experienced surgeon for identification. Many artificial intelligence (AI) techniques such as computer-aided diagnostic systems (CAD), deep learning (DL), and machine learning (ML) have been used to assist in the diagnosis of thyroid nodules, but whether AI techniques can improve the diagnostic accuracy of thyroid nodules still needs to be explored.

OBJECTIVE

To clarify the accuracy of AI-based thyroid nodule US images for differentiating benign and malignant thyroid nodules.

METHODS

A search strategy of "subject terms + key words" was used to search PubMed, Cochrane Library, Embase, Web of Science, China Biology Medicine (CBM), and China National Knowledge Infrastructure (CNKI) for studies on AI-assisted diagnosis of thyroid nodules based on US images. The summarized receiver operating characteristic (SROC) curve and the pooled sensitivity and specificity were used to assess the performance of the diagnostic tests. The quality assessment of diagnostics accuracy studies-2 (QUADAS-2) tool was used to assess the methodological quality of the included studies. The Review Manager 5.3 and Stata 15 were used to process the data. Subgroup analysis was based on the integrity of data collection.

RESULTS

A total of 25 studies with 17,429 US images of thyroid nodules were included. AI-assisted diagnostic techniques had better diagnostic efficacy in the diagnosis of benign and malignant thyroid nodules: sensitivity 0.88 (95% CI: (0.85-0.90)), specificity 0.81 (95% CI: 0.74-0.86), diagnostic odds ratio (DOR) 30 (95% CI: 19-46). The SROC curve indicated that the area under the curve (AUC) was 0.92 (95% CI: 0.89-0.94). Threshold effect analysis showed a Spearman correlation coefficient: 0.17 < 0.5, suggesting no threshold effect for the included studies. After a meta-regression analysis of 4 different subgroups, the results showed a statistically significant effect of mean age ≥50 years on heterogeneity. Compared with studies with an average age of ≥50 years, AI-assisted diagnostic techniques had higher diagnostic performance in studies with an average age of <50 years (0.89 (95% CI: 0.87-0.92) vs. 0.80 (95% CI: 0.73-0.88)), (0.83 (95% CI: 0.77-0.88) vs. 0.73 (95% CI: 0.60-0.87)).

CONCLUSIONS

AI-assisted diagnostic techniques had good diagnostic efficacy for thyroid nodules. For the diagnosis of <50 year olds, AI-assisted diagnostic technology was more effective in diagnosis.

Can sonographic features of microcalcification predict thyroid nodule malignancy? a prospective observational study

Background

The aim of this study was to investigate the diagnostic accuracy of microcalcification, as well as its associated sonographic features, for prediction of thyroid nodule malignancy.

We prospectively assessed the patients with thyroid nodule, who underwent ultrasound-guided fine-needle aspiration during 2017–2020 in Babol, northern Iran. The ultrasonographic characteristics of the nodules, as well as their cytological results, were recorded. We used regression analysis to evaluate the relation between sonographic findings and nodule malignancy. A receiver operator characteristics (ROC) analysis was also used to estimate the ability of ultrasound to predict the characteristic features of malignancy, as estimated by the area under the curve (AUC).

Results

Overall, 1129 thyroid nodules were finally included in the study, of which 452 (40%) had microcalcification. A significant positive association was found between nodule malignancy and microcalcification in both univariate (OR=3.626, 95% CI 2.258–5.822) and multivariable regression analyses (OR=1.878, 95% CI 1.095–3.219). In the nodules with microcalcification, significant positive relations were seen between malignancy and hypoechogenicity (OR=3.833, 95% CI 1.032–14.238), >5 microcalcification number (OR=3.045, 95% CI 1.328–6.982), irregular margin (OR=3.341, 95% CI 1.078–10.352), and lobulated margin (OR=5.727, 95% CI 1.934–16.959). The ROC analysis indicated that AUC for hypoechogenicity, >5 microcalcification number, irregular margin, and lobulated margin were 60%, 62%, 55%, and 60%, respectively, in predicting malignant thyroid nodules.

Conclusion

The findings indicated that microcalcification can be a potential predictor of thyroid nodule malignancy. Also, the presence of irregular or lobulated margins, multiple intranodular microcalcification (>5 microcalcifications), and/or hypoechogenicity can improve the ability of microcalcification in distinguishing malignant from benign nodules.

The role of ultrasound measurements and cosmetic scoring in evaluating the effectiveness of ethanol ablation in cystic thyroid nodules

BACKGROUND

A minimally invasive approach has been adopted to treat benign cystic nodules in recent years, with ethanol ablation (EA) being used as a more common method in routine treatment. For this study, we aimed to investigate the change of nodule volumes and cosmetic scores before and after EA in benign thyroid nodules and the effectiveness of treatment. Therefore, ultrasound data and cosmetic scores of pure cystic, mixed-type and spongy-type benign thyroid nodules undergoing EA in the last two years were reviewed retrospectively.

METHODS

Archive scanning was performed for all cases that were proven benign by fine-needle aspiration biopsy (FNAB) and who underwent EA. In all 46 patients included in the study, thyroid FNAB was performed. Ultrasound images were available to assess the size and volumes at pretreatment and 3 and 6 months after EA. The cosmetic scores obtained before the procedure and at 6 months after EA were compared.

RESULTS

There was a statistically significant difference when the sizes and volumes of the nodules were compared at pretreatment, 3 and 6 months follow-up (P < .001). The mean pretreatment cosmetic score was 3.09, and at 6 months, it was 1.20, with a statistically significant difference (P < .001).

CONCLUSIONS

Recently, a minimally invasive approach has been adopted in the treatment of benign cystic nodules, with ethanol ablation becoming more common in routine treatment. Therefore, ethanol ablation is very valuable in minimising complications that may arise from surgery.

Hospital-Based Ultra-Sonographic Prevalence and Spectrum of Thyroid Incidentalomas in Pakistani Population

Introduction: Thyroid incidentalomas (TIs) are clinically asymptomatic nodules found accidentally during imaging studies ordered for some other reasons. Being easily accessible, non-invasive, and inexpensive, thyroid ultrasound (US) is a key investigation in the management of thyroid nodules.

Methods: This ultrasound-based cross-sectional study was performed in the radiology department of a major tertiary care hospital. Every second patient visiting the emergency department was a potential candidate for a thyroid ultrasound. Patients having ages greater than 20 years were included in the study.

Results: A total of 250 patients were included in the study. Out of these, 175 were female and 75 were male. The majority (54.80%) were in the age group 21-30 years. Nodules were found in 65 (26%) patients and in the majority of cases (67.7%) they were multiple in number. Associated lymphadenopathy was seen in only one patient. Thyroid nodules were more common in females as compared to males (75.38% versus 24.62%). According to Thyroid Imaging and Reporting Data System (TI-RADS) classification, the majority of the nodules were falling in TI-RADS 1 (74%) followed by TI-RADS 3 (9.60%) and 4A (8.80%).

Conclusion: The thyroid nodules are more commonly seen in females as compared to males. A significant association is seen between the frequency of thyroid nodules and increasing age. The majority of thyroid nodules fall in TI-RADS 1 category followed by TI-RADS 3 and 4A.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

A Rare Case of Thyroid Metastasis Secondary to Hidden Undiagnosed Lung Adenocarcinoma

The majority of thyroid lesions are primary in origin while secondary metastases to thyroid are considered a rare incidence. However, presentation of such cases with no signs of lung cancer can be extremely challenging to diagnose. Here, we present a 64-year-old man, an ex-smoker of 70 pack-years, who presented with a complaint of hoarseness of voice with associated dyspnea, choking episodes, weight loss, and hemoptysis. With no investigation abnormalities indicating lung adenocarcinoma, he was transferred to the Otolaryngology Department as being suspicious of thyroid cancer. A laryngoscopy demonstrated an immobile right vocal cord and pooling of secretions while a computed tomography (CT) scan showed a right thyroid lobe nodule, upper mediastinal lymphadenopathy, and pleural effusion. The patient underwent a total thyroidectomy. Biopsies from the lymph nodes and lung were obtained, and all demonstrated lung adenocarcinoma. Thus, a diagnosis of primary lung adenocarcinoma with thyroid and mediastinal lymph nodes metastases was established. Despite being a rare clinical presentation, thyroid metastasis should be considered and evaluated for a primary origin according to the associated clinical history and presentation.