Comparison of Diagnostic Accuracy of Real-Time Elastography and Shear Wave Elastography in Differentiation Malignant From Benign Thyroid Nodules

The use of real time strain endometrial elastosonography plus endometrial thickness and vascularization flow index to predict endometrial receptivity in IVF treatments: a pilot study

BACKGROUND

The usefulness of endometrium strain elastosonography (SE) for the evaluation of endometrial receptivity in women undergoing in vitro fertilization (IVF) remains controversial. The objective of this prospective, observational study was to evaluate the correlation between endometrial thickness (EMT) and its related strain (ESR) on the day of ovulation triggering (hCG-d) and in vitro fertilization outcomes. Additionally, 3D Power Doppler vascular indices (3DPDVI) were also analysed.

METHODS

We included all the patients undergoing fresh IVF-single blastocyst transfer cycle from January 2021 to August 2021 at our center. On hCG-d, after B-mode scanning was completed to measure the EMT, the mode was changed to elastosonography to evaluate the ESR (ratio between endometrial tissue and the myometrium below). At the end of examination, the Endometrial Volume (EV) and 3DPDVI (vascularization index [VI], flow index [FI] and vascularization flow index [VFI]), were assessed. Statistical analysis was completed using STATA MP16 software.

RESULTS

A total number of 57 women were included. Based on the EMT on hCG-d, women were divided into two groups, Group 1: <7 mm and Group 2 ≥ 7 mm. Women with EMT < 7 mm had a significantly higher ESR (p = 0.004) and lower pregnancy rate (p = 0.04). Additionally, low ESR values were correlated with high VFI values (rho = -0.8; 95% CI = -0.9- -0.6; p < 0.0001) and EMT ≥ 7 mm could be predicted by low ESR (OR = 0.01; 95% CI = 0.01-0.30; p = 0.008, area under the ROC curve: 0.70). After all, in multiple logistic regression analysis, low values of ESR (p = 0.050) and high values of EMT (p = 0.051) on hCG-d had borderline statistical effects on pregnancy rate.

CONCLUSIONS

The ESR may be useful to improve the ultrasound evaluation of the endometrial quality in infertile women candidates to IVF/ICS. Given the small sample size of our study, the usefulness of strain elastosonography in this patients, needs further investigation.

MALİGN VE BENİGN TIROİD NODÜLLERİNİN AYRIMINDA ARFI ELASTOGRAFİ

AMAÇ: Malign ve benign tiroid nodüllerini ayırd etmede “Acoustic Radiation Force Impulse” (ARFI) elastografinin “virtual touch tissue elastografi” modunun tanısal performansını değerlendirmek MATERYAL VE METOD: Çapı &gt; 5 mm olan ikiyüzdört adet solid ve ağırlıklı solid nodül prospektif olarak ultrasonografi, ARFI elastografinin VTQ modu, ince iğne aspirasyon biyopsisi ve endike olduğunda doku patolojisi ile değerlendirildi. Yüzdoksanaltı nodülde üç makaslama dalgası hızı (shear wave velocity-SWV) ölçümü yapıldı. Her bir nodül için SWV oranı, nodülün SWV'sinin ortalama değerinin komşu parankimin ortalama değerine bölünmesiyle hesaplandı. SWV değeri ve SWV oranının tanısal performansı, ROC analizi ile değerlendirildi. SONUÇLAR: Benign ve malign tiroid nodüllerinde normal parankimdeki ortalama SWV değeri sırasıyla 2,13±0,44 m/s, 2,06±0,80 m/s ve 2,06±0,88 m/s idi. SWVoranları benign tiroid nodülleri için 0.97±0.37 ve malign tiroid nodülleri için 1.02±0.40 idi. Ortalama SWV değerleri (t=0,008) (P=0,994) veya SWV oranları (t=0,596; P=0,527) açısından benign ve malign nodüller arasında anlamlı fark yoktu. Maligniteyi öngörmek için herhangi bir cut-off noktası bulunmadı. Alt grup analizinde, SWV ve SWV oranı için AUC'ler, ˂10 mm ve ≥10 mm nodüller arasında önemli ölçüde farklıydı. Bunun dışında herhangi iki grup arasında anlamlı fark saptanmadı (tümü P&gt;0.05). SWV ve SWV oranı için en iyi cut-off noktaları, &lt;10 mm nodüller için sırasıyla SWV için 2.59 m/s ve SWV oranı için 1.0 idi. SONUÇ: ARFİ görüntülemenin VTQ modu, maligniteyi saptamak için iyi bir tanısal performansa sahip değildir ve gereksiz tiroid biyopsilerinin azaltılmasına katkıda bulunamaz.

Malign ve benign tiroid nodüllerinin ayrımında ARFI elastografi

Aim: To examine the diagnostic performance of virtual touch tissue quantification (VTQ) mode of Acoustic Radiation Force Impulse (ARFI) elastography imaging in differentiating benign and malignant thyroid nodules. Materials and Methods: Two hundred four solid and mostly solid nodules >5mm were prospectively evaluated with ultrasonography, VTQ mode of ARFI elastography, fine needle aspiration biopsy, and when indicated with tissue pathology. Three shear-wave velocities (SWV) measurements were done in 196 nodules. The SWV ratio for each nodule was calculated as the mean value of the SWV of the nodule divided by the mean value of the adjacent parenchyma. The diagnostic performance of SWV value and SWV-ratio were assessed by a receiver-operating characteristic (ROC) curve analysis. Results: The mean SWV value in the normal parenchyma, in benign and malign thyroid nodules, were 2.13±0.44 m/s, 2.06±0.80 m/s, and 2.06±0.88 m/s respectively. The SWV-ratios were 0.97±0.37 for benign thyroid nodules and 1.02±0.40 for malignant thyroid nodules. There was no significant difference between benign and malign nodules in terms of mean SWV values (t=0.008) (P=0.994) or SWV-ratios (t =0.596; P=0.527). No cut-off point was found to predict malignancy. In subgroup analysis, AUCs for the SWV and SWV-ratio were significantly different between nodules ˂10 mm and those ≥10 mm, but not with any other two groups (all P>0.05) (Table-2). The cutoff points for the differential diagnosis were 2.59 m/s for SWV and 1.0 for SWV- ratio respectively for nodules

Diagnostic Accuracy of Strain Ultrasound Elastography in Thyroid Lesions Compared to Fine-Needle Aspiration Cytology

Introduction

Strain ultrasound-guided elastography (USE) could be used to differentiate malignant from benign thyroid lesions if its sensitivity and specificity are significantly high. Data on whether to rely on USE in differentiating thyroid nodules are unavailable, and fine-needle aspiration cytology (FNAC) remains the gold standard. However, FNAC carries a significant financial burden on hospitals and psychological stress on patients. Therefore, we conducted this study to determine the diagnostic accuracy of strain USE in thyroid lesions.

Methodology

We conducted a descriptive cross-sectional study at the Radiology Department, Benazir Bhutto Hospital, Rawalpindi, from December 6, 2020, to June 5, 2021. The study included adult patients aged between 20 to 70 years who were referred with thyroid nodules or lesions found clinically or on routine neck ultrasound. The study excluded patients who had previous history of surgery or previously diagnosed with malignant thyroid lesions and recurrent thyroid nodules. Strain USE was performed on thyroid nodules, and the degree of strain was color-coded on a scale from red (soft, greatest elasticity) to green (intermediate, average strain) to blue (hard, no elasticity/strain). Lesions were given an elasticity score on a five-point scale. The lesion was given a score of one if the entire lesion was uniformly shaded in green. A lesion with mosaic pattern of green and blue was scored as two. A score of three denoted a lesion with green periphery and blue center on strain elastography. A score of four indicated uniform blue in the entire lesion, with green in the lesion's periphery. The highest score of five was given if the lesion and its surroundings demonstrated blue color. Ultrasound-guided FNAC of the thyroid nodules was performed following USE. Data was analyzed using IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp. Mean ± standard deviation for calculating quantitative variables. Frequencies and percentages were calculated for qualitative variables. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy of strain USE was calculated taking FNAC as gold standard. We also conducted a receiver operating characteristic curve analysis to quantify the diagnostic accuracy of strain USE in thyroid lesions.

Results

The study included 207 adult patients (117 women, 56.52%; 90 men, 43.48%). The study population's mean age was 50.0 ± 11.8 years (range, 20 to 70 years). Most patients (56.52%) were aged 46 to 70 years. FNAC confirmed malignant thyroid nodules in 100 cases (true positive), and nine cases (false positive) had no malignant lesions on FNAC. In USE-negative patients, 91 were true negative, while seven were false negative. Strain USE's overall sensitivity was 93.46%, specificity was 91.0%, PPV was 91.74%, NPV was 92.86%, and diagnostic accuracy was 92.27% compared to the gold standard FNAC.

Conclusions

Strain USE in thyroid lesions is a noninvasive modality of choice with high diagnostic accuracy and has dramatically improved our ability to diagnose malignant thyroid nodules preoperatively. Strain USE also helps the surgeons in proper decision-making. Strain USE should be used routinely in all patients with thyroid lesions to help diagnose malignant thyroid nodules preoperatively and inform proper surgical and treatment plans.

Metastasis of Mixed Adenoneuroendocrine Carcinoma of the Uterine Cervix to Thyroid Gland

The thyroid metastasis from cervical cancer is extremely rare compared to other organs. It is sometimes difficult to distinguish primary tumors from metastases, as most metastatic thyroid nodules are asymptomatic. In this case, a 54-year-old woman had undergone radical hysterectomy due to cervical tumor of stage IB1 mixed adenoneuroendocrine carcinoma (MANEC) 5 years ago. After 3 years, ultrasound examination revealed a suspicious malignant nodule in the left lobe of thyroid gland at regular postoperative follow-up. This patient had no obvious clinical symptoms. The ultrasonography (US)-guided core needle biopsy (CNB) of the thyroid nodule was performed on the patient. The immunohistochemistry analyses revealed that it was poorly differentiated small-cell neuroendocrine carcinoma (SCNEC). Subsequently, the patient underwent left hemithyroidectomy plus isthmusectomy. The postoperative pathology and immunohistochemistry, combining with clinical history, confirmed that the thyroid nodule was a metastasis from cervical MANEC. Conventional chemotherapy and regular follow-up were carried out after the operation. The patient was readmitted 1 year later for pancreatic metastatic lesions and died 1 month after surgery. Early detection of metastatic cancer is potentially helpful, and when necessary, ultrasound-guided puncture biopsy can be utilized to further diagnose metastatic thyroid cancer.

US-Elastography With Different Techniques for Thyroid Nodule Characterization: Systematic Review and Meta-analysis

Background

Thyroid nodules are frequent in adult population and thyroid cancer incidence has increased dramatically over the past three decades. The aim of this systematic review and meta-analysis was to evaluate the US-Elastosonography (USE) diagnostic performance in assessing the thyroid nodules malignancy risk.

Methods

PubMed and Embase databases were searched from January 2011 to July 2021. We extracted data from selected studies and calculated the overall diagnostic accuracy of qualitative USE, semi-quantitative USE and quantitative USE. Summary receiver operating characteristic (ROC) curve was elaborated to show the results. All statistical tests were performed using Metadisc and Medcal software package.

Results

Finally 72 studies with 13,505 patients and 14,015 thyroid nodules (33% malignant) undergoing elastography were included. The pooled sensitivity, specificity and AUC were 84%, 81%, and 0.89 respectively for qualitative USE; 83%, 80%, and 0.93 for semi-quantitative USE and 78%, 81% and 0.87, for quantitative USE. The qualitative and semiquantitative USE present very similar diagnostic accuracy values and both better than the quantitative USE.

Conclusions

USE is a useful imaging tool for thyroid nodule characterization. In accordance with recent guidelines and meta-analyses, the USE could be used daily in thyroid nodule malignancy risk stratification.

Systematic Review Registration

PROSPERO: CRD42021279257.

Elastography and Doppler May Bring a New Perspective to TIRADS, Altering Conventional Ultrasonography Dominance

RATIONALE AND OBJECTIVES

The main aim of ultrasonography (US) examining thyroid nodules is to differentiate malignant nodules from benign nodules. Several professional societies and groups of investigators have defined guidelines such as Thyroid Imaging Reporting and Data System (TIRADS) to provide the standardized language and approach to thyroid nodules. This study is aimed to investigate the compatibility of such classification systems with the pathological diagnosis of nodules and evaluate the contribution of the Shear-wave elastography (SWE) and Doppler ultrasonography (DUS) findings.

MATERIALS AND METHODS

This is a prospective study. Patients with thyroid US exams between December 2017 and April 2019 were included. In the study, eligible 210 nodules from 210 patients were enrolled. For stratification, the conventional B-mode US, SWE and DUS were performed. According to Kwak, American College of Radiology (ACR), and European (EU)-TIRADS, Nodules were classified separately, and a new scoring system whose the criteria was put defined in the study has developed.

RESULTS

For SWE; Emean cut-off value was 33 kPa with a sensitivity and specificity of 95,6% (95% CI: 0,85-0,98) and 95% (95% CI:0,90-0,97) respectively (p <0.001). For spectral DUS; resistivity index (RI) cut-off value was 0.64 with a sensitivity and specificity of 73,3% (95% CI:0,59-0,83) and 80% (95% CI:0,73-0,85) respectively (p <0.001). Kwak TIRADS, American College of Radiology TIRADS, EU-TIRADS, and new system were compared by ROC curve analysis. The new system has the highest sensitivity, specificity, PPV, NPV, accuracy, and AUC compared to others.

CONCLUSIONS

The new scoring system has shown that SWE and DUS findings may alter the categorization in TIRADS and increase sensitivity and specificity.

Real-Time Elastography: A Web-Based Nomogram Improves the Preoperative Prediction of Central Lymph Node Metastasis in cN0 PTC

BACKGROUND

Given the difficulty of accurately determining the central lymph node metastasis (CLNM) status of patients with clinically node-negative (cN0) papillary thyroid carcinoma (PTC) before surgery, this study aims to combine real-time elastography (RTE) and conventional ultrasound (US) features with clinical features. The information is combined to construct and verify the nomogram to foresee the risk of CLNM in patients with cN0 PTC and to develop a network-based nomogram.

METHODS

From January 2018 to February 2020, 1,157 consecutive cases of cN0 PTC after thyroidectomy and central compartment neck dissection were retrospectively analyzed. The patients were indiscriminately allocated (2:1) to a training cohort (771 patients) and validation cohort (386 patients). Multivariate logistic regression analysis of US characteristics and clinical information in the training cohort was performed to screen for CLNM risk predictors. RTE data were included to construct prediction model 1 but were excluded when constructing model 2. DeLong's test was used to select a forecast model with better receiver operator characteristic curve performance to establish a web-based nomogram. The clinical applicability, discrimination, and calibration of the preferable prediction model were assessed.

RESULTS

Multivariate regression analysis showed that age, sex, tumor size, bilateral tumors, the number of tumor contacting surfaces, chronic lymphocytic thyroiditis, and RTE were risk predictors of CLNM in cN0 PTC patients, which constituted prediction model 1. Model 2 included the first six risk predictors. Comparison of the areas under the curves of the two models showed that model 1 had better prediction performance (training set 0.798 vs. 0.733, validation set 0.792 vs. 0.715, p < 0.001) and good discrimination and calibration. RTE contributed significantly to the performance of the prediction model. Decision curve analysis showed that patients could obtain good net benefits with the application of model 1.

CONCLUSION

A noninvasive web-based nomogram combining US characteristics and clinical risk factors was developed in the research. RTE could improve the prediction accuracy of the model. The dynamic nomogram has good performance in predicting the probability of CLNM in cN0 PTC patients.

Diagnostic performance of C-TIRADS combined with SWE for the diagnosis of thyroid nodules

OBJECTIVE

To explore the value of the optimal parameters of shear wave elastography (SWE) to enhance the identification of benign and malignant thyroid nodules by C-TIRADS.

METHODS

The two-dimensional ultrasonography images and SWE images of 515 patients with a total of 586 thyroid nodules were retrospectively analyzed. The nodules were divided into the D ≤10 mm and D >10 mm groups according to size and were graded by C-TIRADS. With the pathological results as the gold standard, the receiver operating characteristic (ROC) curves were drawn, and the area under the curve (AUC) was calculated to compare the diagnostic performances of C-TIRADS, SWE, and the combination of the two on the benign and malignant thyroid nodules.

RESULTS

The ROC showed that the AUC of the maximum elastic modulus (0.875) was higher than that of the mean elastic modulus (0.798) and elasticity ratio (0.772), with an optimal cutoff point of 51 kPa, which was the optimal parameter to distinguish the malignant from the benign nodules (P < 0.001). In the D ≤10 mm group, the AUC of TIRADS combined with SWE (0.955) was elevated by 0.172 compared with the application of C-TIRADS alone (0.783), and the difference was statistically significant (P < 0.05). In the D >10 mm group, the AUC of TIRADS combined with SWE (0.904) was elevated by 0.076 compared with the application of C-TIRADS alone (0.828), and the difference was statistically significant (P < 0.05). Among all nodules, the application of C-TIRADS alone had a sensitivity of 88.14%, a specificity of 74.56%, and an accuracy of 85.50% in diagnosing benign and malignant thyroid nodules, while the sensitivity, specificity, and accuracy were 93.22%, 90.35%, and 92.66%, respectively, in combination with SWE.

CONCLUSION

The diagnostic performance of SWE in combination with TIRADS was better than that of SWE or C-TIRADS alone. Here, SWE enhanced the diagnostic performance of C-TIRADS for the benign and malignant thyroid nodules, most significantly for nodules with D ≤10 mm.

Diagnostic accuracy of B-mode ultrasound, ultrasound elastography and diffusion weighted MRI in differentiation of thyroid nodules (prospective study)

Background

The incidence of the thyroid nodules and its detection is increasing rapidly. The most precise method for diagnosis of the nodules of the thyroid is FNAC. But, about 10–20% of specimens of FNAC are indeterminate and non-diagnostic. Therefore, there is a demand for another diagnostic method for evaluating thyroid nodules. Thyroid ultrasound elastography may improve the ability to differentiate malignant from benign thyroid nodules. Few articles were published about the results of DW MRI in thyroid nodules, with its results confirmed that malignant nodules have lower mean ADC values than benign nodules. This study aims to investigate and compare the accuracy of B-mode ultrasound, ultrasound elastography and diffusion-weighted MRI in characterization of the nodules of the thyroid.

Results

The study included 56 patients with thyroid nodules (36 benign and 20 malignant). Thyroid ultrasound, ultrasound elastography and DWI were done for all patients. Ultrasound-guided FNA Cytological examination (as the gold standard) was done for 48 patients and surgical histopathology was done to 8 patients with non-diagnostic FNAC. The results showed: TIRADS score had sensitivity 90%, specificity 77.8% and accuracy of 82.14%. The elastography score had sensitivity 80%, specificity 88.9% and accuracy 85.7%. The use of the strain ratio had 80% sensitivity, 94.4% specificity and 89.3% accuracy. DWI and ADC value had 100% sensitivity and 94.4% specificity and the accuracy was 96.4% for differentiating malignant from benign thyroid nodules. Multi-parametric analysis by TIRADS and ADC had 100% accuracy.

Conclusion

Ultrasound elastography add valuable data over ultrasound TIRADS. But, diffusion weighted MRI and ADC value has more accuracy in differentiating malignant from benign thyroid nodules. The best performance was achieved by the combination of ACR-TIRADS and ADC value.

Evaluation of thyroid nodules by shear wave elastography: a review of current knowledge

PURPOSE

Shear wave elastography (SWE), as a tool for diagnosing thyroid malignancy, has gathered considerable attention during the past decade. Diverging results exist regarding the diagnostic performance of thyroid SWE.

METHODS

A comprehensive literature review of thyroid SWE was conducted using the terms "Thyroid" and "shear wave elastography" in PubMed.

RESULTS

The majority of studies found SWE promising for differentiating malignant and benign thyroid nodules on a group level, whereas results are less convincing on the individual level due to huge overlap in elasticity indices. Further, there is lack of consensus on the optimum outcome reflecting nodule elasticity and the cut-off point predicting thyroid malignancy. While heterogeneity between studies hinders a clinically meaningful meta-analysis, the results are discussed in a clinical perspective with regard to applicability in clinical practice as well as methodological advantages and pitfalls of this technology.

CONCLUSION

Technological as well as biological hindrances seem to exist for SWE to be clinically reliable in assessing benign and malignant thyroid nodules. Structural heterogeneity of thyroid nodules in combination with operator-dependent factors such as pre-compression and selection of scanning plane are likely explanations for these findings. Standardization and consensus on the SWE acquisition process applied in future studies are needed for SWE to be considered a clinically reliable diagnostic tool for detection of thyroid cancer.

Thyroid Nodule Characterization: How to Assess the Malignancy Risk. Update of the Literature

Ultrasound (US) is the first imaging modality for thyroid parenchyma evaluation. In the last decades, the role of ultrasound has been improved with the introduction of new US software, such as contrast-enhanced ultrasound (CEUS) and US-elastography (USE). USE is nowadays recognized as an essential part of the multiparametric ultrasound (MPUS) examination, in particular for the indeterminate thyroid nodule with possible fine-needle aspiration cytology (FNAC) number reduction; even if further and larger studies are needed to validate it. More controversial is the role of CEUS in thyroid evaluation, due to its high variability in sensitivity and specificity. Semi-automatic US systems based on the computer-aided diagnosis (CAD) system are producing interesting results, especially as an aid to less experienced operators. New knowledge on the molecular mechanisms involved in thyroid cancer is allowing practitioners to identify new genomic thyroid markers that could reduce the number of "diagnostic" thyroidectomies. We have therefore drawn up an updated representation of the current evidence in the literature for thyroid nodule multiparametric ultrasound (MPUS) evaluation with particular regard to USE, the US CAD system and CEUS.

TIRADS, SRE and SWE in INDETERMINATE thyroid nodule characterization: Which has better diagnostic performance?

Purpose

To assess Strain Ratio (SRE) and Shear Wave Elastography (SWE) accuracy alone and with TIRADS classification, for the risk stratification of indeterminate thyroid nodules.

Materials and methods

128 Patients with 128 indeterminate nodules candidates for thyroidectomy underwent preoperative staging neck ultrasound and were classified according to K-TIRADS score. After TIRADS evaluation, semi-quantitative (SRE) and quantitative (SWE expressed in kPa) elastosonography were performed and relative diagnostic performances, alone and in combination, were compared through ROC curves analysis. In order to maximize the SRE and SWE sensitivity and specificity, their cut-off values were calculated using the Liu test. Bonferroni test was used to evaluate statistically significant differences with a p value < 0.05.

Results

Sensitivity, specificity, PPV and NPV were, respectively, 71.4%, 82.4%, 62.5%, 87.5% for K-TIRADS baseline US, 85.7%, 94.1%, 85.7%, 94.1% for SRE and 57.1%, 79.4%, 53.3%, 81.8% for SWE (kPa expressed). SRE evaluation showed the best diagnostic accuracy compared to the SWE (kPa expressed) (p < 0.05) and to the K-TIRADS (p > 0.05). The association of SRE with conventional ultrasound with K-TIRADS score increased sensitivity (92.9% vs 71.4%) but decreased the specificity than conventional US alone (76.5% vs 82.4%).

Conclusion

Strain Elastosonography can be associated with K-TIRADS US examination in the thyroid nodule characterization with indeterminate cytology; in fact, adding the SRE to K-TIRADS assessment significantly increases its sensitivity and negative predictive value. However, further multicenter studies on larger population are warranted.

Variation of Shear Wave Elastography With Preload in the Thyroid: Quantitative Validation

OBJECTIVES

Thyroid shear wave elastography (SWE) has been shown to have advantages compared to biopsy or other imaging modalities in the evaluation of thyroid nodules. However, studies show variability in its assessment. The objective of this study was to evaluate whether stiffness measurements of the normal thyroid, as estimated by SWE, varied due to preload force or the pressure applied between the transducer and the patient.

METHODS

In this study, a measurement system was attached to the ultrasound transducer to measure the applied load. Shear wave elastographic measurements were obtained from the left lobe of the thyroid at applied transducer forces between 2 and 10 N. A linear mixed-effects model was constructed to quantify the association between the preload force and stiffness while accounting for correlations between repeated measurements within each participant. The preload force effect on elasticity was modeled by both linear and quadratic terms to account for a possible nonlinear association between these variables.

RESULTS

Nineteen healthy volunteers without known thyroid disease participated in the study. The participants had a mean age ± SD of 36 ± 8 years; 74% were female; 74% had a normal body mass index; and 95% were white non-Hispanic/Latino. The estimated elastographic value at a 2-N preload force was 16.7 kPa (95% confidence interval, 14.1-19.3 kPa), whereas the value at 10 N was 29.9 kPa (95% confidence interval, 24.9-34.9 kPa).

CONCLUSIONS

The preload force was significantly and nonlinearly associated with SWE estimates of thyroid stiffness. Quantitative standardization of preload forces in the assessment of thyroid nodules using elastography is an integral factor for improving the accuracy of thyroid nodule evaluation.

Intrathyroidal Ectopic Thymus and Sonoelastographic Findings

BACKGROUND

Intrathyroidal ectopic thymus (IET) can be misdiagnosed as thyroid nodules.

PURPOSE

To evaluate the sonoelastographic findings of IET in pediatric population.

METHODS

Twelve children who had been examined with ultrasound (US) and strain elastography between December 2012 and December 2019 were included in this retrospective study. The patients' demographics and ultrasonographic findings including the location, margin, shape, diameters, volume, structure, vascularity, and elastography values of the lesions were evaluated.

RESULTS

Twelve lesions were detected in 12 asymptomatic patients (3 females and 9 males) with a mean age of 4.67 ± 2.27 years. The most common location of the IET was in posterior part and middle third of thyroid, and the most common appearance on US was a well-defined, ovoid-shaped, and predominantly hypoechoic solid lesion with punctate/linear branching hyperechogenities. The lesions were mostly hypovascular on Doppler US. The mean strain ratio on elastography was found to be 1.10 ± 0.04. In the follow-up of 7 patients with available information, there was not any significant change in size or appearance of IET on US.

CONCLUSION

IET should be considered in the differential diagnosis of the lesions within the thyroid. The first step to accurately diagnose an IET is to consider it in the differential diagnosis. In addition to US, strain elastography findings can be used to distinguish IETs from papillary thyroid cancers which can have similar US appearance, and help avoid unnecessary biopsies.

Web-Based Ultrasonic Nomogram Predicts Preoperative Central Lymph Node Metastasis of cN0 Papillary Thyroid Microcarcinoma

BACKGROUND

Many clinicians are facing the dilemma about whether they should apply the active surveillance (AS) strategy for managing Clinically Node-negative (cN0) PTMC patients in daily clinical practice. This research plans to construct a dynamic nomogram based on network, connected with ultrasound characteristics and clinical data, to predict the risk of central lymph node metastasis (CLNM) in cN0 PTMC patients before surgery.

METHODS

A retrospective analysis of 659 patients with cN0 PTMC who had underwent thyroid surgery and central compartment neck dissection. Patients were randomly (2:1) divided into the development cohort (439 patients) and validation cohort (220 patients). The group least absolute shrinkage and selection operator (Group Lasso) regression method was used to select the ultrasonic features for CLNM prediction in the development cohort. These features and clinical data were screened by the multivariable regression analysis, and the CLNM prediction model and web-based calculator were established. Receiver operating characteristic, calibration curve, Clinical impact curve and decision curve analysis (DCA) were used to weigh the performance of the prediction model in the validation set.

RESULTS

Multivariable regression analysis showed that age, tumor size, multifocality, the number of contact surface, and real-time elastography were risk factors that could predict CLNM. The area under the curve of the prediction model in the development and validation sets were 0.78 and 0.77, respectively, with good discrimination and calibration. A web-based dynamic calculator was built. DCA proved that the prediction model had excellent net benefits and clinical practicability.

CONCLUSIONS

The web-based dynamic nomogram incorporating US and clinical features was able to forecast the risk of preoperative CLNM in cN0 PTMC patients, and has good predictive performance. As a new observational indicator, NCS can provide additional predictive information.

Elastography for the diagnosis of high-suspicion thyroid nodules based on the 2015 American Thyroid Association guidelines: a multicenter study

BACKGROUND

An accurate diagnosis for high-suspicion nodules based on the 2015 American Thyroid Association (ATA) guidelines would reduce unnecessary invasive examinations. Elastography is a useful tool for discriminating benign and malignant thyroid nodules. The aim of this study is to investigate the diagnostic efficiency of elastography for high-suspicion thyroid nodules based on the 2015 ATA guidelines in the Chinese population.

METHODS

Thyroid nodules with high-suspicion characteristics based on the 2015 ATA guidelines were subjected to conventional ultrasound (US) and ultrasound strain elastography (USE) examinations at 12 hospitals from 4 geographic regions across China. Cytology/histology of thyroid nodules was used as a reference method. Receiver operating characteristic (ROC) curves were plotted to evaluate the diagnostic performance of the elasticity score (ES) and strain ratio (SR). Logistic regression analysis was used to determine the predictors of malignancy.

RESULTS

Overall, a total of 1445 thyroid nodules (834 malignant, 611 benign) from 12 centers were included in the final analysis. The areas under the curve of the ES and SR were 0.828 and 0.732, respectively. The sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) of the ES were 92.4, 60.7, 79.0, 76.3 and 85.5%, respectively, and those of the SR were 81.1, 50.1, 68.9, 65.9 and 67.9%, respectively. The combination of the Thyroid Imaging Reporting and Data System (TI-RADS) and ES led to a significant increase in the sensitivity and NPV (97.1 and 91.9%, respectively) compared with the TI-RADS alone. Logistic regression analysis showed that microcalcifications (OR = 5.290), taller than wide (OR = 12.710), irregular margins (OR = 10.117), extrathyroidal extension (ETE; OR = 6.412), the ES (OR = 3.741) and the SR (OR = 1.083) were independent predictors of malignant thyroid nodules. The sensitivity, specificity, accuracy, PPV and NPV of the ES were all superior in nodules ≥1 cm than in those < 1 cm (95.0% vs 90.4, 68.8% vs 56.8, 85.9% vs 74.4, 85.2% vs 69.9, and 87.8% vs 84.2%, respectively).

CONCLUSIONS

Elastography combined with the ES is a valuable tool for the assessment of high-suspicion thyroid nodules based on the 2015 ATA guidelines, especially in nodules ≥1 cm.

Ultrasound Real-Time Tissue Elastography Improves the Diagnostic Performance of the ACR Thyroid Imaging Reporting and Data System in Differentiating Malignant from Benign Thyroid Nodules: A Summary of 1525 Thyroid Nodules

BACKGROUND

To explore the correlation between the ultrasound elasticity score (ES) of real-time tissue elastography (RTE) and the malignant risk stratification of the Thyroid Imaging Reporting and Data System (TI-RADS) and to evaluate the added value of RTE to TI-RADS in differentiating malignant nodules from benign ones.

METHODS

A total of 1,498 patients (885 women and 613 men; mean age of 43.5 ± 12.4 years) with 1,525 confirmed thyroid nodules (D = maximum diameter, D ≤ 2.5 cm) confirmed by fine-needle aspiration (FNA) and/or surgery were included. The nodules were divided into four groups based on their sizes (D ≤ 0.5 cm, 0.5 < D ≤ 1.0 cm, 1.0 < D ≤ 2.0 cm, and 2.0 < D ≤ 2.5 cm). We assigned an ES of RTE and malignant risk stratification of the TI-RADS category to each nodule. The correlation between the ES of RTE and the malignant risk stratification of TI-RADS category was analyzed by the Spearman's rank correlation. The diagnostic performances of RTE, TI-RADS, and their combination were compared by the receiver operator characteristic (ROC) analysis.

RESULTS

The ES of RTE and the malignant risk stratification of TI-RADS showed a strong correlation in the size intervals of 0.5 < D ≤ 1.0 cm, 1.0 < D ≤ 2.0 cm, and 2.0 < D ≤ 2.5 cm (r = 0.768, 0.711, and 0.743, respectively). The diagnostic performance of their combination for each size interval was always better than RTE or TI-RADS alone (for all, P < 0.001).

CONCLUSIONS

Overall, The ES of RTE was strongly correlated with the malignant risk stratification of TI-RADS. The diagnostic performance of the combination of RTE and TI-RADS outperformed RTE or TI-RADS alone. Therefore, RTE may be an adjunctive tool to the current TI-RADS system for differentiating malignant from benign thyroid nodules.

Machine Learning-Assisted System for Thyroid Nodule Diagnosis

Background: Ultrasound (US) examination is helpful in the differential diagnosis of thyroid nodules (malignant vs. benign), but its accuracy relies heavily on examiner experience. Therefore, the aim of this study was to develop a less subjective diagnostic model aided by machine learning. Methods: A total of 2064 thyroid nodules (2032 patients, 695 male; M_age = 45.25 ± 13.49 years) met all of the following inclusion criteria: (i) hemi- or total thyroidectomy, (ii) maximum nodule diameter 2.5 cm, (iii) examination by conventional US and real-time elastography within one month before surgery, and (iv) no previous thyroid surgery or percutaneous thermotherapy. Models were developed using 60% of randomly selected samples based on nine commonly used algorithms, and validated using the remaining 40% of cases. All models function with a validation data set that has a pretest probability of malignancy of 10%. The models were refined with machine learning that consisted of 1000 repetitions of derivatization and validation, and compared to diagnosis by an experienced radiologist. Sensitivity, specificity, accuracy, and area under the curve (AUC) were calculated. Results: A random forest algorithm led to the best diagnostic model, which performed better than radiologist diagnosis based on conventional US only (AUC = 0.924 [confidence interval (CI) 0.895-0.953] vs. 0.834 [CI 0.815-0.853]) and based on both conventional US and real-time elastography (AUC = 0.938 [CI 0.914-0.961] vs. 0.843 [CI 0.829-0.857]). Conclusions: Machine-learning algorithms based on US examinations, particularly the random forest classifier, may diagnose malignant thyroid nodules better than radiologists.

Role of Strain Elastography and Shear-Wave Elastography in a Multiparametric Clinical Approach to Indeterminate Cytology Thyroid Nodules

Background

In thyroid nodules with indeterminate cytology, further clinical assessment aimed at ruling out malignancy is often mandatory. Ancillary imaging techniques and genetic mutation analysis can improve the risk stratification of such lesions, thereby facilitating the clinician’s decision to undertaken surgery or simple follow-up. The aim of this study was to evaluate the diagnostic performance of shear-wave elastography (SW), strain elastography (ELX 2/1), conventional ultrasound (US), contrast-enhanced ultrasound (CEUS), and BRAF V600E mutation analysis in the aforementioned lesions.

Material/Methods

We enrolled 81 patients, each with 1 indeterminate-cytology thyroid nodule. Thyroid function, thyroperoxidase antibodies and calcitonin were known in each case. SW, ELX 2/1, US, CEUS, and BRAF mutation analysis were subsequently performed, followed by a second FNAB. If the lesion was not downgraded to benign, surgery was recommended and histological reports collected.

Results

There were 28 nodules (34%) that proved benign on the second FNAB; 38 nodules (47%) underwent surgery (17 benign, 21 malignant), and 15 nodules (19%) refused surgery. The only techniques related to histological outcome were US (AUC=0,766), ELX 2/1 (AUC=0.701), and BRAF analysis (AUC=0.762). ELX 2/1 and SW reports were not correlated with each other (P=0.45). A scoring system taking into account all the variables considered performed better than the single variables alone (AUC=0.831).

Conclusions

In indeterminate-cytology thyroid lesions, repeating FNAB can avoid unnecessary surgery. ELX 2/1 seems to perform better than SW in distinguishing malignancy; these techniques could, however, be complementary in describing such lesions. A multiparametric approach appears the most accurate in predicting nodule histology.

Comparison of Strain Elastography, Shear Wave Elastography, and Conventional Ultrasound in Diagnosing Thyroid Nodules

Objective:

The purpose of this study is to compare the diagnostic performances of strain elastography (SE), shear wave elastography (SWE), and traditional ultrasound (US) features in diagnosing thyroid nodules.

Subjects and Methods:

This study included 185 adult patients with thyroid nodules who underwent conventional gray-scale US, SE, and SWE. SE was scored using a four-pattern elastographic scoring (ES) system. SWE values were presented as mean SWE values and standard derivation using Young's modules. The optimal cutoff values of the mean SWE values for predicting malignancy were determined using receiver operating characteristic (ROC) curve analysis. We used logistic regression models to test elastography as a novel significant predictor for the diagnosis of malignant nodules. The diagnostic performance of elastography parameters was compared with a traditional trained model.

Results:

Malignant thyroid nodules were stiffer for SE (ES patterns 1 and 2/3 and 4) and mean SWE values (4/17; 51.0 ± 24.4 kPa) than for benign nodules (114/50; 33.1 ± 25.2 kPa) (P < 0.01). In ROC curve analyses, a mean SWE value of 32 kPa was the optimal cutoff point, with diagnostic performance measures of 81% sensitivity, 65% specificity, a 23% positive predictive value (PPV), and 96% negative predictive value (NPV). In multivariate logistic regression, the mean SWE value (≥32 kPa) was an independent predictor for malignancy (odds ratio: 16.8; 95% confidence interval [CI]: 3.6–78.3). However, after the addition of SE and SWE to traditional US features, the C-statistic was not significantly increased compared to the traditional model (0.88, 95% CI: 0.81–0.94 vs. 0.91, 0.85–0.97, P = 0.4).

Conclusion:

In this study, we confirmed SWE as an independent predictor for malignant thyroid nodules. However, in comparing the new extended elastography model to our previous prediction model, the new extended model showed no significant difference in the diagnostic performance.

Real-time elastography evaluation of differential penetrating liver trauma in a rabbit model

BACKGROUND

Real-time ultrasound elastography (RTE) is used to examine liver fibrosis and benign and malignant lesions, but its use for the diagnosis of liver trauma has not been examined. The purpose of this study was to examine the use of RTE for the evaluation of differential penetrating liver trauma in a rabbit model.

MATERIAL AND METHODS

Eighty New Zealand rabbits were divided into 2 groups. In one group, a single incision (type "-" lesion) was made, and in the other group a hash mark incision (type "#" lesion) was made (about 0.5cm in depth; 1.0-2.0cm in length). RTE was performed at 10, 30, and 60min after injury.

RESULTS

There were no differences in mean RTE scores between the 2 types of lesions at 10 and 30min. However, the mean values for the 2 types of lesions increased from 10min to 60min (type '-' lesion: 0.88±0.32 to 2.06±0.88; type '#' lesion: 0.89±0.34 to 2.63±1.16). At 60min, the mean elasticity score in the type '#' lesion group was significantly higher than in the type '-' lesion group (P<.001). Strain ratios were not different between the groups at each time point, but in each group the values decreased from the 10min time point to the 60min time point (P-value for the trends, <.001).

CONCLUSIONS

RTE may be able to distinguish mild or severe penetrating liver trauma at 60min or more after injury.

Diagnostic Value of Virtual Touch Tissue Imaging Quantification for Evaluating Median Nerve Stiffness in Carpal Tunnel Syndrome

OBJECTIVES

To measure the shear wave velocity (SWV) of the median nerve by Virtual Touch tissue imaging quantification (VTIQ; Siemens AG, Erlangen, Germany) through the beginning of the carpal tunnel and to determine whether VTIQ could be used to diagnose carpal tunnel syndrome.

METHODS

This study recruited 49 consecutive patients (72 wrists) with a definitive diagnosis of carpal tunnel syndrome and 23 healthy volunteers (46 wrists). We measured the median nerve diameter and cross-sectional area by 2-dimensional sonography and the SWV by VTIQ. The interobserver variability was analyzed, and diagnostic values were evaluated by drawing a receiver operating characteristic curve.

RESULTS

The median nerve SWV was significantly higher in the carpal tunnel syndrome group (3.857 m/s) than the control group (2.542 m/s; P < .05). A 3.0-m/s SWV cutoff value revealed sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 83.3%, 91.3%, 93.8%, 77.8%, and 86.4%, respectively. The interobserver agreement was excellent for the SWV measurements.

CONCLUSIONS

The median nerve SWV at the carpal tunnel inlet is significantly higher in patients with carpal tunnel syndrome, for whom VTIQ appears to be a highly reproducible diagnostic technique.

Evaluation of Optic Nerve with Strain and Shear Wave Elastography in Patients with Behçet's Disease and Healthy Subjects

The objective of this study was to investigate the elasticity characteristics of the optic nerve using strain and shear wave elastography in patients with Behçet's disease and to compare the results with those of healthy volunteers. Forty-six optic nerves from patients with Behçet's disease and 54 optic nerves from healthy volunteers were investigated prospectively in this study using strain and shear wave elastography. There was a statistically significant difference in terms of elasticity patterns between patients and healthy volunteers (p < 0.001). Elastographic images of healthy volunteers revealed most optic nerves to be type 3 (51.8%); however, type 2 (40.7%) and type 1 (7.5%) were also observed. Elastographic examination of Behçet's disease patients revealed type 2 in 52.2%, type 1 in 43.5% and type 3 in 4.3% of patients. Statistically significant differences were observed between patients and healthy volunteers in the analysis of shear wave elastography values (p < 0.001). Receiver operating characteristic curve analysis was perfect (0.933) (95% CI = 0.885-0.980), and a cutoff value of 16.5 kPa shear had very high sensitivity and specificity for the patient group. Strain and shear wave elastography findings for the optic nerves of patients with Behçet's disease were significantly different from those for healthy volunteers.

Erratum: Comparison of Diagnostic Accuracy of Real-Time Elastography and Shear Wave Elastography in Differentiation Malignant From Benign Thyroid Nodules: Erratum

[This corrects the article on p. e2312 in vol. 94, PMID: 26717367.].