Role of ultrasound in thyroid disorders

Validating the virtual: a deep dive into ultrasound simulator metrics in otorhinolaryngology

PURPOSE

This study aimed to assess the validity of simulation-based assessment of ultrasound skills for thyroid ultrasound.

METHODS

The study collected validity evidence for simulation-based ultrasound assessment of thyroid ultrasound skills. Experts (n = 8) and novices (n = 21) completed a test containing two tasks and four cases on a virtual reality ultrasound simulator (U/S Mentor's Neck Ultrasound Module). Validity evidence was collected and structured according to Messick's validity framework. The assessments being evaluated included built-in simulator metrics and expert-based evaluations using the Objective Structured Assessment of Ultrasound Skills (OSAUS) scale.

RESULTS

Out of 64 built-in simulator metrics, 9 (14.1%) exhibited validity evidence. The internal consistency of these metrics was strong (Cronbach's α = 0.805) with high test-retest reliability (intraclass correlation coefficient = 0.911). Novices achieved an average score of 41.9% (SD = 24.3) of the maximum, contrasting with experts at 81.9% (SD = 16.7). Time comparisons indicated minor differences between experts (median: 359 s) and novices (median: 376.5 s). All OSAUS items differed significantly between the two groups. The correlation between correctly entered clinical findings and the OSAUS scores was 0.748 (p < 0.001). The correlation between correctly entered clinical findings and the metric scores was 0.801 (p < 0.001).

CONCLUSION

While simulation-based training is promising, only 14% of built-in simulator metrics could discriminate between novices and ultrasound experts. Already-established competency frameworks such as OSAUS provided strong validity evidence for the assessment of otorhinolaryngology ultrasound competence.

[Standardized acquisition and documentation of cine loops on conventional thyroid ultrasound]

Ultrasound is the basic imaging method for the assessment of the thyroid gland. Due to the high prevalence of structural disease, the examination procedure is used very frequently in Germany, in many cases in the context of follow-up. The assessment of thyroid pathologies and their dynamics is subjected to relevant inter- and intraobserver variability. Findings that were not identified during live ultrasound cannot be assessed retrospectively. Applying an SOP for the acquisition and documentation of standardized video sequences of ultrasound images (so-called cine loops), allows for a secondary retrospective evaluation of the thyroid gland, taking into account previously acquired images analogous to other cross-sectional imaging methods such as CT or MRI. The cine loops can be acquired by non-physician personnel, stored to the local PACS and used for educational and research purposes.

Preoperative Evaluation of Thyroid Cancer: A Review of Current Best Practices

OBJECTIVE

The incidence of thyroid cancer has significantly increased in recent decades. Although most thyroid cancers are small and carry an excellent prognosis, a subset of patients present with advanced thyroid cancer, which is associated with increased rates of morbidity and mortality. The management of thyroid cancer requires a thoughtful individualized approach to optimize oncologic outcomes and minimize morbidity associated with treatment. Because endocrinologists usually play a key role in the initial diagnosis and evaluation of thyroid cancers, a thorough understanding of the critical components of the preoperative evaluation facilitates the development of a timely and comprehensive management plan. The following review outlines considerations in the preoperative evaluation of patients with thyroid cancer.

METHODS

A clinical review based on current literature was generated by a multidisciplinary author panel.

RESULTS

A review of considerations in the preoperative evaluation of thyroid cancer is provided. The topic areas include initial clinical evaluation, imaging modalities, cytologic evaluation, and the evolving role of mutational testing. Special considerations in the management of advanced thyroid cancer are discussed.

CONCLUSION

Thorough and thoughtful preoperative evaluation is critical for formulating an appropriate treatment strategy in the management of thyroid cancer.

Ultrasonography of the thyroid, parathyroids, and beyond

Background

Ultrasonography has become an essential tool for the evaluation and management of thyroid and parathyroid diseases. Its applications extend beyond neck endocrine conditions to a multitude of pathologies within the head and neck region.

Objectives

Our study aimed to: (1) provide a broad review of neck ultrasonography and key findings in neck endocrine diseases; (2) support skilled performance office-based diagnostic ultrasonography and its varied applications.

Materials and methods

A review of the current literature was supplemented with clinical examples of key ultrasonographic findings.

Results

Current applications and key findings of ultrasonography in the diagnosis and management of neck endocrine conditions are reviewed.

Conclusion

Ultrasonography is a fundamental component in the evaluation and management of neck endocrine diseases. The reader is encouraged to use this review to enhance office-based performance and application of ultrasonography.

Video online

The online version of this article contains 11 additional videos. They are provided to illustrate some of the dynamic aspects of US performance. The article and the videos are available online (10.1007/s00106-022-01162-0). The videos can be found in the article back matter as “Electronic Supplementary Material”.

Prediction models constructed for Hashimoto's thyroiditis risk based on clinical and laboratory factors

BACKGROUND

Hashimoto's thyroiditis (HT) frequently occurs among autoimmune diseases and may simultaneously appear with thyroid cancer. However, it is difficult to diagnose HT at an early stage just by clinical symptoms. Thus, it is urgent to integrate multiple clinical and laboratory factors for the early diagnosis and risk prediction of HT.

METHODS

We recruited 1,303 participants, including 866 non-HT controls and 437 diagnosed HT patients. 44 HT patients also had thyroid cancer. Firstly, we compared the difference in thyroid goiter degrees between controls and patients. Secondly, we collected 15 factors and analyzed their significant differences between controls and HT patients, including age, body mass index, gender, history of diabetes, degrees of thyroid goiter, UIC, 25-(OH)D, FT3, FT4, TSH, TAG, TC, FPG, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol. Thirdly, logistic regression analysis demonstrated the risk factors for HT. For machine learning modeling of HT and thyroid cancer, we conducted the establishment and evaluation of six models in training and test sets.

RESULTS

The degrees of thyroid goiter were significantly different among controls, HT patients without cancer (HT-C), and HT patients with thyroid cancer (HT+C). Most factors had significant differences between controls and patients. Logistic regression analysis confirmed diabetes, UIC, FT3, and TSH as important risk factors for HT. The AUC scores of XGBoost, LR, SVM, and MLP models indicated appropriate predictive power for HT. The features were arranged by their importance, among which, 25-(OH)D, FT4, and TSH were the top three high-ranking factors.

CONCLUSIONS

We firstly analyzed comprehensive factors of HT patients. The proposed machine learning modeling, combined with multiple factors, are efficient for thyroid diagnosis. These discoveries will extensively promote precise diagnosis, personalized therapies, and reduce unnecessary cost for thyroid diseases.

Pediatric thyroid ultrasound: a radiologist's checklist

Ultrasonography (US) is the imaging method of choice for evaluating the pediatric thyroid gland, complemented by scintigraphy and thyroid function tests, especially when evaluating children with suspected congenital hypothyroidism, goiter, infectious or autoimmune diseases, or neoplasm. Diagnostic considerations in newborns with congenital hypothyroidism mainly include dysgenesis, dyshormonogenesis, transient hypothyroidism and central (hypophyseal) hypothyroidism. The midline of the neck should be scrutinized for thyroid tissue from the floor of the mouth to the thoracic inlet. Cystic and echogenic ultimobranchial remnants should not be misinterpreted as orthotopic thyroid tissue. Diffuse thyroid diseases affect older children; these comprise Hashimoto and Graves diseases and infectious thyroiditis and exhibit features similar to those in adults. It is important to note that the diffuse sclerosing variant of papillary thyroid cancer can complicate thyroiditis and should not be confused with Hashimoto disease. In children with solid nodules the threshold for fine-needle aspiration biopsy or surgery should be lower compared to adults because of a higher likelihood of malignancy compared with adults. Biopsy should be considered in nodules with suspicious ultrasonographic features, even when smaller than 1 cm. Adult classification systems of thyroid nodules, although useful, are not sufficient to safely discriminate the nodules' likelihood of malignancy in children. We describe key sonographic findings and suggest a standard checklist that might be considered while performing and interpreting thyroid US in neonates and children.

Papillary Thyroid Carcinoma as a Lateral Neck Cyst: A Cystic Metastatic Node versus an Ectopic Thyroid Tissue

Papillary thyroid carcinoma is the most common thyroid malignancy and frequently metastasizes to regional lymph nodes. Occasionally, metastatic lymph nodes are palpable without the evidence of primary tumour. Papillary thyroid carcinoma of lateral neck cyst is a rare condition. It may arise from thyroid primary which underwent cystic degeneration or true malignant transformation of ectopic thyroid tissue. Herein, we reported two cases with preoperative diagnosis of benign lateral neck cyst but postoperative histopathological results showed primary papillary thyroid carcinoma. Ultrasonography and computed tomography of the neck in both cases showed no significant thyroid lesion. However, the patient in Case  2 was subjected for total thyroidectomy and histopathological results showed the origin of primary tumour. In conclusion, thorough investigations including total thyroidectomy are indicated in cases of papillary thyroid carcinoma of lateral neck cyst. This practice is to ensure that this type of thyroid cancer can be detected earlier because it has a very good prognosis if treated earlier.

Ultrasonography-Based Classification and Reporting System for the Malignant Risk of Thyroid Nodules

OBJECTIVE

The aim of this study was to test the predictive value of a Thyroid Imaging Reporting and Data System (TI-RADS) for malignant thyroid nodules.

METHODS

Ultrasonographic data was examined for 910 thyroid nodules with histopathologically confirmed diagnoses. Nodules were placed into incomplete (category 0) or complete final categories (1, 2, 3a, 3b, 3c, 4, or 5) based on the presence and number of ultrasonographic features of malignancy, and the predictive value for the malignancy of nodules in categories 2-4 was assessed.

RESULTS

The overall rate of malignancy among thyroid nodules included in the study was 59.34%. The rate of malignancy gradually increased according to TI-RADS categories as follows: category 2, 5.4%; category 3 (a-c), 36% to 92%; and category 4, 99.0%. When nodules of category 2 were counted as benign, the reliability of the TI-RADS classification for determining the risk of malignancy was as follows; sensitivity, 98.15%; specificity, 47.84%; positive predictive value, 73.31%; negative predictive value, 94.65%; and odds ratio, 48.61.

CONCLUSIONS

The TI-RADS classification used in this study is relatively simple and provides a reliable measure of the risk of malignancy of thyroid nodules.

Sonographic scoring of solid thyroid nodules: effects of nodule size and suspicious cervical lymph node

Introduction

Ultrasound is the most frequently used imaging method to evaluate thyroid nodules. Sonographic characteristics of thyroid nodules which are concerning for malignancy are important to define the need for fine needle aspiration biopsy or open surgery.

Objective

To evaluate malignancy risk of solid thyroid nodules through sonographic scoring. The effects of nodule size ≥2 cm and associated pathologic cervical lymph node in scoring were examined in addition to generally excepted suspicious features.

Methods

Medical data of 123 patients underwent thyroid surgery were reviewed, and 89 patients (58 females, 31 males) were included in the study. The presence and absence of each suspicious sonographic feature of thyroid nodules were scored as 1 and 0, respectively. Total ultrasound score was obtained by adding the positive ultrasound findings. Differently from the literature, nodule size ≥2 cm and associated pathologic cervical node were added in scoring criteria. The diagnostic performance of nodule characteristics for malignancy and the effect of total US score to discriminate malignant and benign disease were calculated.

Results

A significant relationship was found between malignancy and hypoechogenity, border irregularity, intranodular vascularity, and microcalcification (p < 0.05). Pathologic cervical node was observed predominantly in association with malignant nodules. Positive predictive value of suspicious cervical node for malignancy was 67%, similar to microcalcification. Nodule size ≥2 cm was not distinctive for diagnosis of malignancy. The number of suspicious sonographic features obtained with receiver operating characteristic analysis to discriminate between malignant and benign disease was three.

Conclusion

Sonographic scoring of thyroid nodules is an effective method for predicting malignancy. The authors suggest including associated pathologic node in the scoring criteria. Further studies with larger cohorts will provide more evidence about its importance in sonographic scoring.

Elastography Evaluation of Benign Thyroid Nodules in Patients Affected by Hashimoto's Thyroiditis

The aim of the present prospective study was to evaluate the predictive value of elastography in benign thyroid nodules of patients affected by Hashimoto's thyroiditis (HT). From January 2011 to January 2012, 242 nodules in patients affected by HT were submitted to fine needle aspiration cytology (FNAC). All of the patients underwent sonography and elastography performed before FNAC. 230 (95%) nodules were benign, 8 papillary cancers, and 4 follicular lesions. Score 1 was found in 79.1% of benign lesions (sensitivity 79.1%; specificity 66.7%; PPV 97.8%; NPV 14.3%; accuracy 78.5%; p < 0.05). In order to evaluate the outcome of thyroid ultrasound echogenicity in relation to elastography features of nodule(s), all the patients with benign nodules were stratified according to their hypoechoic pattern of thyroid (mild-moderate and severe). Following stratification score 1 was found in 84.2% of benign nodules (sensitivity 75.0%; specificity 88.9%; PPV 27.3%; NPV 98.4%; accuracy 88.2%; p < 0.0001) of patients with a mild-moderate ultrasound thyroid hypoechogenicity, whereas it was found in 60% of benign nodules (p = 0.715) of patients with a marked thyroid hypoechogenicity. Elastography appears to have limited value in detecting thyroid cancer in patients affected by Hashimoto's thyroiditis with severe hypoechoic thyroid tissue.

All thyroid ultrasound evaluations are not equal: sonographers specialized in thyroid cancer correctly label clinical N0 disease in well differentiated thyroid cancer

BACKGROUND

Ultrasound (US) is a standard preoperative study in thyroid cancer. Accurate identification of lymph node (LN) disease in the central neck by US is debated, leading some surgeons to perform prophylactic central dissection. The purpose of this study was to evaluate if US performed by a surgeon with specialization in thyroid sonography correctly determined clinical N0 status.

METHODS

Retrospective identification of cN0 thyroid cancer patients from a prospectively maintained database was performed. Exclusion criteria included LN dissection with thyroidectomy or missing preoperative US. Demographics and outcomes were reviewed. Patients were categorized by who performed the thyroid US (surgeon vs. non-surgeon). Additional radioactive iodine (RAI) treatments or subsequent positive pathology defined recurrence.

RESULTS

From 2005 to 2012, 177 patients met criteria. Forty-eight patients had surgeon US versus 129 patients with non-surgeon US. Groups were equivalent in age, gender, and tumor size. Forty-six percent had a preoperative diagnosis of cancer, whereas 19 % had benign and 35 % had indeterminate diagnoses. Surgeon US documented LN status more frequently (69 vs. 20 %, p < 0.01). RAI treatment and dose were equivalent. RAI uptake was lower with surgeon US (0.06 % ± 0.02 vs. 0.20 % ± 0.03, p < 0.01). Recurrence rates were higher in non-surgeon US (12 vs. 0 %, p = 0.01). Median time to recurrence was 11 months.

CONCLUSIONS

Surgeons with thyroid US expertise correctly identify patients as N0, which may eliminate the need for prophylactic LN dissection without increasing risk of early recurrence. Because not all thyroid cancers are diagnosed preoperatively, US examination of the thyroid should include routine evaluation of the cervical LNs.

Ultrasound findings of subacute thyroiditis: a single institution retrospective review

BACKGROUND

High resolution ultrasonography features have also been described as having a useful supporting role in the diagnosis of subacute granulomatous thyroiditis (ST), and images are generally characterized by heterogeneous hypoechoic areas of the affected tissue with lack of flow on color Doppler US.

PURPOSE

To determine the sonographic features of subacute granulomatous thyroiditis.

MATERIAL AND METHODS

We reviewed the medical records of patients referred at the Endocrine and Metabolic Unit of our Institution between January 2010 and December 2011.

RESULTS

A total of 7520 patients were evaluated in our department between January 2010 and December 2011. Among them, 22 (0.3%) patients had a diagnosis of ST (19 women and 3 men, 45.4 ± 9.7 year; range, 33-62 years). Ultrasound examination showed bilateral ST in 64% of patients. Thyroid volume was 13.2 ± 7.7 mL, without difference if ST was unilateral (13.2 ± 7.1 mL) or bilateral (13.9 ± 8.3 mL). On grayscale US, heterogeneous diffusely or focally marked hypoechoic areas, like "lava flow", were found in all the lesions.

CONCLUSION

Our data confirm the high sensitivity of US in the diagnosis of ST: diffuse hypoechoic and confluent areas with the characteristic features like "lava flow".

Ultrasound elastography as an objective diagnostic measurement tool for lymphoedema of the treated breast in breast cancer patients following breast conserving surgery and radiotherapy

BACKGROUND.: Lymphoedema of the operated and irradiated breast is a common complication following early breast cancer treatment. There is no consensus on objective diagnostic criteria and standard measurement tools. This study investigates the use of ultrasound elastography as an objective quantitative measurement tool for the diagnosis of parenchymal breast oedema. PATIENTS AND METHODS.: The elasticity ratio of the subcutis, measured with ultrasound elastography, was compared with high-frequency ultrasound parameters and subjective symptoms in twenty patients, bilaterally, prior to and following breast conserving surgery and breast irradiation. RESULTS.: Elasticity ratio of the subcutis of the operated breast following radiation therapy increased in 88.9% of patients, was significantly higher than prior to surgery, unlike the non operated breast and significantly higher than the non operated breast, unlike preoperative results. These results were significantly correlated with visibility of the echogenic line, measured with high-frequency ultrasound. Big preoperative bra cup size was a significant risk factor for the development of breast oedema. CONCLUSIONS.: Ultrasound elastography is an objective quantitative measurement tool for the diagnosis of parenchymal breast oedema, in combination with other objective diagnostic criteria. Further research with longer follow-up and more patients is necessary to confirm our findings.