A Modified Thyroid Imaging Reporting and Data System (mTI-RADS) For Thyroid Nodules in Coexisting Hashimoto's Thyroiditis

A Prediction Model for Assessing the Efficacy of Thermal Ablation in Treating Benign Thyroid Nodules ≥ 2 cm: A Multi-Center Retrospective Study

OBJECTIVES

To develop and validate a prediction model utilizing clinical and ultrasound (US) data for preoperative assessment of efficacy following US-guided thermal ablation (TA) in patients with benign thyroid nodules (BTNs) ≥ 2 cm.

MATERIALS AND METHODS

We retrospectively assessed 962 patients with 1011 BTNs who underwent TA at four tertiary centers between May 2018 and July 2022. Ablation efficacy was categorized into therapeutic success (volume reduction rate [VRR] > 50%) and non-therapeutic success (VRR ≤ 50%). We identified independent factors influencing the ablation efficacy of BTNs ≥ 2 cm in the training set using multivariate logistic regression. On this basis, a prediction model was established. The performance of model was further evaluated by discrimination (area under the curve [AUC]) in the validation set.

RESULTS

Of the 1011 nodules included, 952 (94.2%) achieved therapeutic success at the 12-month follow-up after TA. Independent factors influencing VRR > 50% included sex, nodular composition, calcification, volume, and largest diameter (all p < 0.05). The prediction equation was established as follows: p = 1/1 + Exp∑[8.113 -2.720 × (if predominantly solid) -2.790 × (if solid) -1.275 × (if 10 mL < volume ≤ 30mL) -1.743 × (if volume > 30 mL) -1.268 × (if with calcification) -2.859 × (if largest diameter > 3 cm) +1.143 × (if female)]. This model showed great discrimination, with AUC of 0.908 (95% confidence interval [CI]: 0.868-0.947) and 0.850 (95% CI: 0.748-0.952) in the training and validation sets, respectively.

CONCLUSIONS

A clinical prediction model was successfully developed to preoperatively predict the therapeutic success of BTNs larger than 2 cm in size following US-guided TA. This model aids physicians in evaluating treatment efficacy and devising personalized prognostic plans.

Autoimmune Thyroid Diseases

Autoimmune thyroid diseases (AITDs) include a wide spectrum of thyroid diseases affecting more commonly women than men. The most frequent forms are Graves' Disease (GD) and Hashimoto's thyroiditis / Autoimmune Thyroiditis (AIT), but there are also other immunogenic destructive forms of thyroiditis, that is, silent and postpartum thyroiditis. In the last decade, AITDs and other inflammatory thyroid diseases related to anti-tumor molecular drugs are more frequently seen due to the widespread use of tyrosine kinase inhibitors (TKIs) and immune checkpoint inhibitors (ICPIs). Autoimmune thyroiditis related to SARS-CoV-2 infection has been a novel entity in recent years. Graves' Disease and AIT may shift from hyperthyroidism to hypothyroidism, which may complicate the differential diagnosis and further treatment strategy. Moreover, all AITDs may manifest with thyrotoxicosis (a clinical condition marked with high serum levels of thyroid hormones) which has to be distinguished from hyperthyroidism (increased thyroid hormone production and secretion as a result of hyperfunctioning thyroid gland) due to different therapeutic approaches. Nuclear medicine techniques, such as radioiodine uptake (RAIU) and thyroid scintigraphy, using 99mTc- pertechnetate (Na[99mTc]TcO4) or 123-Iodine (Na[123I]I), have a crucial role in the differential diagnosis. Measurement of thyroid antibodies, e.g. thyroid peroxidase antibodies (TPO) and thyrotropin receptor antibodies (TRAb), as well as thyroid ultrasound, are complementary methods in the evaluation of thyroid disorders.

Pre-existing Thyroiditis Ameliorates Papillary Thyroid Cancer: Insights From a New Mouse Model

Papillary thyroid cancer (PTC) often co-occurs with Hashimoto's thyroiditis, an association that has long been reported in clinical studies yet remains controversial. Some studies, in fact, have suggested a protective effect of thyroiditis while others have not. We generated a mouse model where PTC and thyroiditis develop in a predictable manner, combining the oncogenic drive of the BRAFv600E mutation (inducible by tamoxifen) to the thyroiditis susceptibility of the NOD.H2h4 strain (inducible by iodine). A total of 113 NOD.H2h4_TPO-CRE-ER_BRAFV600E mice (50 followed throughout lifetime and 63 sacrificed at 16 weeks post tamoxifen) were used to determine whether the PTC phenotype differs when thyroiditis precedes or coincides with the onset of PTC. Mice with pre-existing thyroiditis lived longer (median survival of 28.2 weeks post tamoxifen) than those with concomitant (25.6 weeks) or no (24.5 weeks) thyroiditis (P < 0.01 by Laplace regression). PTC developed less frequently (33%) in the pre-existing thyroiditis group than the concomitant (100%) or no (100%) thyroiditis groups (P < 0.001 by chi-squared) and showed less aggressive histopathological features. The intratumoral mononuclear cell infiltration was more prominent in mice with pre-existing thyroiditis (P = 0.002 vs the other groups) and sustained by a significant expansion of effector memory CD8 + T cells and CD19 + B cells. These findings shed light on the controversial PTC-thyroiditis association and emphasize the contribution of intratumoral T and B lymphocytes to the evolution of PTC.

Validation of Four Thyroid Ultrasound Risk Stratification Systems in Patients with Hashimoto's Thyroiditis; Impact of Changes in the Threshold for Nodule's Shape Criterion

Simple Summary

Thyroid Imaging Reporting and Data Systems (TIRADS) optimize the selection of thyroid nodules for cytological examination. There is a question: is the effectiveness of these systems affected by morphological changes to thyroid parenchyma that are visible in the course of Hashimoto’s thyroiditis (HT)? This question is very important because of the increased risk of malignancy in thyroid nodules in patients with HT. We investigated widely accepted ultrasound malignancy risk features with a special consideration of the suspected nodule’s shape in patients with and without HT. We also validated EU-TIRADS, K-TIRADS, ACR-TIRADS, and ATA guidelines in both groups and evaluated the impact of changes in the threshold for nodule’s shape criterion on the diagnostic value of these TIRADS. The presence of Hashimoto’s thyroiditis did not exert any significant adverse implications for the efficiency of examined TIRADS. The impact of changes in the threshold for nodule’s shape criterion was the highest for EU-TIRADS.

Abstract

The aim of the study was to validate thyroid US malignancy features, especially the nodule’s shape, and selected Thyroid Imaging Reporting and Data Systems (EU-TIRADS; K-TIRADS; ACR-TIRADS, ATA guidelines) in patients with or without Hashimoto’s thyroiditis (HT and non-HT groups). The study included 1188 nodules (HT: 358, non-HT: 830) with known final diagnoses. We found that the strongest indications of nodule’s malignancy were microcalcifications (OR: 22.7) in HT group and irregular margins (OR:13.8) in non-HT group. Solid echostructure and macrocalcifications were ineffective in patients with HT. The highest accuracy of nodule’s shape criterion was noted on transverse section, with the cut-off value of anteroposterior to transverse dimension ratio (AP/T) close to 1.15 in both groups. When round nodules were regarded as suspicious in patients with HT (the cut-off value of AP/T set to ≥1), it led to a three-fold increase in sensitivity of this feature, with a disproportionally lower decrease in specificity and similar accuracy. Such a modification was effective also for cancers other than PTC. The diagnostic effectiveness of analyzed TIRADS in patients with HT and without HT was similar. Changes in the threshold for AP/T ratio influenced the number of nodules classified into the category of the highest risk, especially in the case of EU-TIRADS.

The Presence of Hypoechoic Micronodules in Patients with Hashimoto's Thyroiditis Increases the Risk of an Alarming Cytological Outcome

The aim of the study was to identify a possible relation between various ultrasonographic (US) appearances of Hashimoto's thyroiditis (HT) and the risk of obtaining an alarming cytology of coexisting nodules. The study included 557 patients with HT, who had been referred for fine needle aspiration biopsy (FNA). We divided US patterns of HT (UP-HT) into eight groups: (a) Hypoechoic (compared to submandibular glands), homogeneous/fine echotexture; (b) hypoechoic, heterogeneous/coarse echotexture; (c) marked hypoechoic (darker than strap muscles), heterogeneous/coarse echotexture; (d) heterogeneous echotexture with hyperechoic, fibrous septa; (e) multiple, discrete marked hypoechoic areas (sized as 1 to 6 mm); (f) normoechoic pseudo-nodular areas; (g) echostructure similar to connective tissue; (h) thyroid parenchyma with no signs of HT. Indications for a surgical treatment resulting from the FNA outcome (categories IV-VI of Bethesda System for Reporting Thyroid Cytopathology) were identified only in patients with variants b, c, and e of UP-HT, but merely the "multiple, discrete marked hypoechoic areas" variant significantly increased the odds of obtaining such cytology (OR:5.7). The presence of the "normoechoic pseudo-nodular areas" variant significantly increased the odds for the benign cytology (OR:1.7). There are significant differences in the frequency of obtaining an alarming cytology in relation to the UP-HT variant.

Comparisons of ACR TI-RADS, ATA guidelines, Kwak TI-RADS, and KTA/KSThR guidelines in malignancy risk stratification of thyroid nodules

OBJECTIVE

To compare the diagnostic performance and the unnecessary biopsy rates for recommending fine needle aspiration (FNA) of Thyroid Imaging Reporting and Data Systems proposed by American College of Radiology (ACR TI-RADS), American Thyroid Association (ATA) guidelines, TI-RADS proposed by Kwak (Kwak TI-RADS), and Korean Thyroid Association/Korean Society of Thyroid Radiology (KTA/KSThR) guidelines for malignancy risk stratification of thyroid nodules (TNs).

METHODS

The study included 1271 TNs whose cytologic results or surgical pathologic findings were available. Ultrasound images of these TNs were retrospectively reviewed and categorized according to the four guidelines. The diagnostic performances and the unnecessary biopsy rates for recommending FNA of the four guidelines were evaluated.

RESULTS

After multivariate analysis, the most significant independent predictor for malignancy was hypoechogenicity/marked hypoechogenicity (OR: 9.37, 95% CI: 5.40-16.26) (P < 0.001) among the suspicious ultrasound images features. For all nodules and two subgroups (i.e. nodules <10 mm group and nodules ≥10 mm group), ACR TI-RADS demonstrated higher specificities (all P < 0.05) and lower sensitivities (all P < 0.001) than the other guidelines. In the all nodules group and the nodules<10 mm group, ACR TI-RADS and Kwak TI-RADS had higher Azs than the other guidelines (all P < 0.01). The unnecessary biopsy rates for recommending FNA of ACR TI-RADS in the all nodules (≥10 mm) group and the subgroup (10∼19 mm) were all lower than those of the others guidelines (P < 0.001 for all). For the subgroup (≥20 mm), the unnecessary biopsy rate of ACR was lower than that of ATA guidelines and KTA/KSThR guidelines (P < 0.001).

CONCLUSIONS

The four guidelines have good diagnostic efficiency in differentiating TNs. ACR TI-RADS and Kwak TI-RADS have better diagnostic performance than the other guidelines in the all nodules group and the nodules<10 mm group. Considering the comprehensive diagnostic efficacy and unnecessary biopsy rate, ACR TI-RADS is a more desirable classification guideline in clinical practice.

Evaluation of thyroid nodules with coexistent Hashimoto's thyroiditis according to various ultrasound-based risk stratification systems：A retrospective research

PURPOSES

To investigate the efficiency of Thyroid Imaging Reporting and Data System (TI-RADS) proposed by KWAK, the American College of Radiology, and the 2015 American Thyroid Association (ATA) guidelines for thyroid nodules with Hashimoto's thyroiditis (HT) and to determine whether HT influence the diagnostic performance of these risk-stratification systems.

METHODS

A total of 101 nodules with HT and 101 nodules with non-HT were retrospectively analyzed by ultrasound-based diagnostic classifications and compared with histopathological results. The areas under the receiver operating characteristic curve (AUCs) were calculated for comparative analysis.

RESULTS

In the HT group, KWAK TI-RADS has the best sensitivity (91.67%), while ACR TI-RADS has the highest specificity (82.93%) and accuracy (81.19%). The AUCs of ACR TI-RADS, ATA guidelines, and KWAK TI-RADS were 0.844, 0.782, and 0.830, respectively. In the non-HT group, the sensitivity and specificity of three risk-stratification systems had no significant difference. The AUCs of ACR TI-RADS, ATA guidelines, and KWAK TI-RADS were 0.872, 0.839, and 0.874, respectively. No significant difference was found in diagnostic effectiveness of the same systems with both contexts.

CONCLUSIONS

ACR TI-RADS performed the most effective for thyroid nodules in HT, whereas KWAK TI-RADS was the best for those in non-HT. Both of TI-RADS (ACR and KWAK) provided higher diagnostic effectiveness than ATA guidelines in HT or in non-HT. Moreover, HT could not affect the diagnostic performance of these risk-stratification systems.

Trypanocidal and leishmanicidal activity of six limonoids

Six limonoids [kotschyienone A and B (1, 2), 7-deacetylgedunin (3), 7-deacetyl-7-oxogedunin (4), andirobin (5) and methyl angolensate (6)] were investigated for their trypanocidal and leishmanicidal activities using bloodstream forms of Trypanosoma brucei and promastigotes of Leishmania major. Whereas all compounds showed anti-trypanosomal activity, only compounds 1–4 displayed anti-leishmanial activity. The 50% growth inhibition (GI₅₀) values for the trypanocidal and leishmanicidal activity of the compounds ranged between 2.5 and 14.9 μM. Kotschyienone A (1) was found to be the most active compound with a minimal inhibition concentration (MIC) value of 10 μM and GI₅₀ values between 2.5 and 2.9 μM. Only compounds 1 and 3 showed moderate cytotoxicity against HL-60 cells with MIC and GI₅₀ values of 100 μM and 31.5–46.2 μM, respectively. Compound 1 was also found to show activity against intracellular amastigotes of L. major with a GI₅₀ value of 1.5 μM. The results suggest that limonoids have potential as drug candidates for the development of new treatments against trypanosomiasis and leishmaniasis.

Thyroid Ultrasound Reports: Deficiencies and Recommendations

OBJECTIVE

Thyroid ultrasound plays a major role in the clinical management of patients with thyroid nodules. Comprehensive reporting enables malignant risk stratification and biopsy decisions. In this study, we aimed at a systematic evaluation of the content and completeness of thyroid radiology reports.

METHODS

A retrospective study was undertaken. A total of 200 thyroid ultrasound reports of examinations performed over a 1-year period were reviewed. After excluding 18 reports, the remaining 182 were evaluated for the inclusion of the following nodule characteristics: size, 3-axis dimensions, location, presence or absence of five signs suspicious of malignancy, namely microcalcification, hypoechogenecity, irregular margin, height-to-width ratio, and intranodular vascularity.

RESULTS

While all reported nodules could be stratified easily as being more or less than 1 cm in size, only 23.6% of these nodules were reported in 3 dimensions, and 33.5% of the nodules were specifically localized. For any described nodule, the frequency of reporting on echogenicity was 50%, on vascularity 19.2%, on margin 10.4%, on calcifications 9.3%, and no report contained a description of the height-to-width ratio. The cumulative frequency of reporting on one characteristic per nodule was 84%, of two characteristics 27%, three characteristics 4.4%, and no report included ≥4 characteristics per nodule.

CONCLUSION

Despite easily accessible templates, reporting of thyroid nodule sonogram continues to be incomplete and inconsistent. This in turn constitutes a waste of a significant tool that could otherwise help in making timely informed medical decisions and in providing a significant platform for patients' future follow-up.

Malignancy risk stratification of thyroid nodules: comparisons of four ultrasound Thyroid Imaging Reporting and Data Systems in surgically resected nodules

To compare the efficiency of four different ultrasound (US) Thyroid Imaging Reporting and Data Systems (TI-RADS) in malignancy risk stratification in surgically resected thyroid nodules (TNs). The study included 547 benign TNs and 464 malignant TNs. US images of the TNs were retrospectively reviewed and categorized according to the TI-RADSs published by Horvath E et al. (TI-RADS H), Park et al. (TI-RADS P), Kwak et al. (TI-RADS K) and Russ et al. (TI-RADS R). The diagnostic performances for the four TI-RADSs were then compared. At multivariate analysis, among the suspicious US features, marked hypoechogenicity was the most significant independent predictor for malignancy (OR: 15.344, 95% CI: 5.313-44.313) (P < 0.05). Higher sensitivity was seen in TI-RADS H, TI-RADS K, TI-RADS R comparing with TI-RADS P (P < 0.05 for all), whereas the specificity, accuracy and area under the ROC curve (Az) of TI-RADS P were the highest (all P < 0.05). Higher specificity, accuracy and Az were seen in TI-RADS K compared with TI-RADS R (P = 0.003). With its higher sensitivity, TI-RADS K, a simple predictive model, is practical and convenient for the management of TNs in clinical practice. The study indicates that there is a good concordance between TI-RADS categories and histopathology.

Cytologically indeterminate thyroid nodules: increased diagnostic performance with combination of US TI-RADS and a new scoring system

To investigate the diagnostic performance of combination of ultrasound (US) thyroid imaging reporting and data system (TI-RADS) and a new US scoring system for diagnosing thyroid nodules (TNs) with indeterminate results (Bethesda categories III, IV and V) on fine-needle aspiration (FNA) cytology. 453 patients with 453 cytologically indeterminate TNs were included in this study. Multivariate analyses were performed to construct the scoring system. The diagnostic performances of TI-RADS and the combined method were evaluated and compared. Multivariate analyses revealed that marked hypoechogenicity, taller than wide shape and absence of halo sign were independent predictors for malignancy in cytologically indeterminate TNs. Scoring system was thereafter defined as follows: risk score (RS) = 3.2 x (if marked hypoechogenicity) + 2.8 x (if taller than wide shape) + 1.3 x (if absence of halo sign). Compared with TI-RADS alone, the areas under the receiver operating characteristic curves (AUC), specificity, accuracy and positive predictive value (PPV) of the combined method increased significantly with 0.731 versus 0.569, 48.5% versus 14.1%, 76.2% versus 62.3%, and 70.9% versus 59.9%, respectively (all P < 0.05). The combination of TI-RADS and new US scoring system showed superior diagnostic performances in predicting malignant TNs with indeterminate FNA cytology results in comparison with TI-RADS alone.