The Value of Peripheral Enhancement Pattern for Diagnosing Thyroid Cancer Using Contrast-Enhanced Ultrasound

Ring-Enhancement on CEUS: Is it Useful in the Differential Diagnosis of Solid Thyroid Nodules?

To investigate the efficiency of contrast-enhanced ultrasound (CEUS) features, particularly ring-enhancement patterns, in the differential diagnosis of thyroid nodules. 302 nodules with CEUS ring-enhancement were retrospectively enrolled, including 135 benign and 167 malignant ones. The ring-enhancement patterns were classified into regular and irregular hyper- or hypo-ring enhancement. Comparative analyses of ultrasound (US) and CEUS features between benign and malignant nodules were performed. The diagnostic performances of the ring-enhancement patterns and Chinese Thyroid Imaging Reporting and Data System (C-TIRADS) were compared in nodules with different sizes. Irregular hypo-ring enhancement was much more common in malignancies than that in benign ones, and it was an independent predictor for thyroid malignant nodules. With irregular hypo-ring enhancement as the diagnostic criteria for malignant nodules, the specificity was higher than that of C-TIRADS (85.2% vs. 75.6%, p = .037) while the AUC was comparable (0.845 vs. 0.803, p = .136) in all nodules. When the nodule size was taken into account, the specificity and AUC were both significantly higher than those of C-TIRADS (92.8% vs. 81.1%, p = .021; 0.907 vs. 0.823, p = .026) in nodules ≥10 mm, which can decrease the unnecessary FNA rate. Irregular hypo-ring enhancement was a valuable CEUS feature for the differential diagnosis of thyroid nodules, especially in nodules ≥10 mm.

Diagnostic efficacy of data mining method based on multimodal ultrasound for papillary thyroid carcinoma

Objective

The incidence of papillary thyroid caracinoma (PTC) is increasing year by year. Logistic regression model and Chi-squared automatic interaction (CHAID) decision tree based on multimodal ultrasound were established, and the diagnostic efficiency of the two models in PTC was compared.

Methods

The findings, features and data of routine ultrasound, shear wave elastography (SWE) and contrast-enhanced ultrasonography (CEUS) were prospectively collected in 203 patients. Including: echogenicity, aspect ratio, maximum diameter of tumor, boundary, morphology, focal hyperecho, blood flow grading, maximum elasticity (Emax), minimum elastcity (Emin), mean elasticity (Emean), enhancement degree, enhanced characteristics, distribution of contrast agent, contrast medium arrival time. According to the pathological results, they were divided into PTC group and non-PTC group. CHAID decision tree model and binary Logistic regression model were established, receiver operator characteristic (ROC) curves of the two models were drawn, and diagnostic effectiveness was evaluated by comparing area under curve (AUC).

Results

Logistic regression showed that hypoechoic or very hypoechoic, aspect ratio ≥1, microcalcification and high SWE value were risk factors for PTC (OR 8.604, 2.154, 2.297, 1.067, respectively, P < 0.05). The CHAID decision tree showed echo, aspect ratio, Emax, contrast agent distribution and infusion time combined to diagnose PTC. ROC curve showed that the AUC of PTC predicted by Logistic regression model and CHAID decision tree model was 0.878 and 0.883, respectively, with no statistical significance (z=0.325, P=0.7456).

Conclusion

Both Logistic regression model and CHAID decision tree model can play a good role in the diagnosis of PTC based on multi-modal ultrasound, but the diagnostic efficiency of both models is comparable. In conclusion, these two models provide new insights and ideas for PTC diagnosis.

A comprehensive prediction model for central lymph node metastasis in papillary thyroid carcinoma with Hashimoto's thyroiditis: BRAF may not be a valuable predictor

Purpose

Papillary thyroid carcinoma (PTC) frequently coexists with Hashimoto's thyroiditis (HT), which poses challenges in detecting central lymph node metastasis (CLNM) and determining optimal surgical management. Our study aimed to identify the independent predictors for CLNM in PTC patients with HT and develop a comprehensive prediction model for individualized clinical decision-making.

Patients and methods

In this retrospective study, a total of 242 consecutive PTC patients who underwent thyroid surgery and central lymph node dissection between February 2019 and December 2021 were included. 129 patients with HT were enrolled as the case group and 113 patients without HT as control. The results of patients' general information, laboratory examination, ultrasound features, pathological evaluation, and BRAF mutation were collected. Multivariate logistic regression analysis was used to identify independent predictors, and the prediction model and nomogram were developed for PTC patients with HT. The performance of the model was assessed using the receiver operating characteristic curve, calibration curve, decision curve analysis, and clinical impact curve. In addition, the impact of the factor BRAF mutation was further evaluated.

Results

Multivariate analysis revealed that gender (OR = 8.341, P = 0.013, 95% CI: 1.572, 44.266), maximum diameter (OR = 0.316, P = 0.029, 95% CI: 0.113, 0.888), multifocality (OR = 3.238, P = 0.010, 95% CI: 1.319, 7.948), margin (OR = 2.750, P = 0.046, 95% CI: 1.020, 7.416), and thyrotropin receptor antibody (TR-Ab) (OR = 0.054, P = 0.003, 95% CI: 0.008, 0.374) were identified as independent predictors for CLNM in PTC patients with HT. The area under the curve of the model was 0.82, with accuracy, sensitivity, and specificity of 77.5%, 80.3% and 75.0%, respectively. Meanwhile, the model showed satisfactory performance in the internal validation. Moreover, the results revealed that BRAF mutation cannot further improve the efficacy of the prediction model.

Conclusion

Male, maximum diameter > 10mm, multifocal tumors, irregular margin, and lower TR-Ab level have significant predictive value for CLNM in PTC patients with HT. Meanwhile, BRAF mutation may not have a valuable predictive role for CLNM in these cases. The nomogram constructed offers a convenient and valuable tool for clinicians to determine surgical decision and prognostication for patients.

Diagnostic efficacy of the contrast-enhanced ultrasound thyroid imaging reporting and data system classification for benign and malignant thyroid nodules

Background

The contrasted-enhanced ultrasound thyroid imaging reporting and data system (CEUS TI-RADS) is the first international risk stratification system for thyroid nodules based on conventional ultrasound (US) and CEUS. This study aimed to evaluate the diagnostic efficacy of CEUS TI-RADS for benign and malignant thyroid nodules and to assess the related interobserver agreement.

Methods

The study recruited 433 patients who underwent thyroid US and CEUS between January 2019 and June 2023 at the Affiliated Hospital of Guangdong Medical University. A retrospective analysis of 467 thyroid nodules confirmed by fine-needle aspiration (FNA) and/or surgery was performed. Further, a CEUS TI-RADS classification was assigned to each thyroid nodule based on the CEUS TI-RADS scoring criteria for the US and CEUS features of the nodule. The nodules were grouped based on their sizes as follows: size ≤1 cm, group A; size >1 and ≤4 cm, group B; and size >4 cm, group C. Multivariate logistic regression was used to analyze independent risk factors for malignant thyroid nodules. Pathological assessment was the reference standard for establishing the sensitivity (SEN), specificity (SPE), accuracy (ACC), positive predictive value (PPV), and negative predictive value (NPV) of CEUS TI-RADS in diagnosing malignant thyroid nodules. The area under the curve (AUC) in the receiver operating characteristic (ROC) curve analysis was used to compare the diagnostic efficacy of the scoring system in predicting malignancy in three groups of nodules. The intragroup correlation coefficient (ICC) was adopted to assess the interobserver agreement of the CEUS TI-RADS score.

Results

Out of the 467 thyroid nodules, 262 were malignant and 205 were benign. Logistic regression analysis revealed that the independent risk factors for malignant thyroid nodules included punctate echogenic foci (P<0.001), taller-than-wide shape (P=0.015), extrathyroidal invasion (P=0.020), irregular margins/lobulation (P=0.036), hypoechoicity on US (P=0.038), and hypoenhancement on CEUS (P<0.001). The AUC for the CEUS TI-RADS in diagnosing malignant thyroid nodules was 0.898 for all nodules, 0.795 for group A, 0.949 for group B, and 0.801 for group C, with the optimal cutoff values of the CEUS TI-RADS being 5 points, 6 points, 5 points, and 5 points, respectively. Among these groups of nodules, group B had the highest AUC, with the SEN, SPE, ACC, PPV, and NPV for diagnosing malignant nodules being 95.9%, 88.1%, 92.8%, 92.6%, and 93.2%, respectively. The ICC of the CEUS TI-RADS classification between senior and junior physicians was 0.862 (P<0.001).

Conclusions

In summary, CEUS TI-RADS demonstrated significant efficacy in distinguishing thyroid nodules. Nonetheless, there were variations in its capacity to detect malignant nodules across diverse sizes, and it demonstrate optimal performance in 1- to 4-cm nodules. These findings may serve as important insights for clinical diagnoses.

Performance of Intraoperative Contrast-Enhanced Ultrasound (Io-CEUS) in the Diagnosis of Primary Lung Cancer

BACKGROUND

Suspicious tumors of the lung require specific staging, intraoperative detection, and histological confirmation. We performed an intrathoracic, intraoperative contrast-enhanced ultrasound (Io-CEUS) for characterization of lung cancer.

METHODS

Retrospective analysis of prospectively collected data on the application of Io-CEUS in thoracic surgery for patients with operable lung cancer. Analysis of the preoperative chest CT scan and FDG-PET/CT findings regarding criteria of malignancy. Immediately before lung resection, the intrathoracic Io-CEUS was performed with a contrast-enabled T-probe (6-9 MHz-L3-9i-D) on a high-performance ultrasound machine (Loqic E9, GE). In addition to intraoperative B-mode, color-coded Doppler sonography (CCDS), or power Doppler (macrovascularization) of the lung tumor, contrast enhancement (Io-CEUS) was used after venous application of 2.4-5 mL sulfur hexafluoride (SonoVue, Bracco, Italy) for dynamic recording of microvascularization. The primary endpoint was the characterization of operable lung cancer with Io-CEUS. Secondly, the results of Io-CEUS were compared with the preoperative staging.

RESULTS

The study included 18 patients with operable lung cancer, who received Io-CEUS during minimally invasive thoracic surgery immediately prior to lung resection. In the chest CT scan, the mean size of the lung tumors was 2.54 cm (extension of 0.7-4.5 cm). The mean SUV in the FDG-PET/CT was 7.6 (1.2-16.9). All lung cancers were detected using B-mode and power Doppler confirmed macrovascularization (100%) of the tumors. In addition, Io-CEUS showed an early wash-in with marginal and mostly simultaneous central contrast enhancement.

CONCLUSIONS

The intrathoracic application of Io-CEUS demonstrated a peripheral and simultaneous central contrast enhancement in the early phase, which seems to be characteristic of lung cancer. In comparison to preoperative imaging, Io-CEUS was on par with the detection of malignancy and offers an additional tool for the intraoperative assessment of lung cancer before resection.

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.

The Utility of Contrast-Enhanced Ultrasound (CEUS) in Assessing the Risk of Malignancy in Thyroid Nodules

BACKGROUND

Ultrasonography is a primary method used in the evaluation of thyroid nodules, but no single feature of this method predicts malignancy with high accuracy. Therefore, this paper aims to assess the utility of contrast-enhanced ultrasound (CEUS) in the differential diagnosis of thyroid nodules.

METHODS

The study group comprised 188 adult patients (155 women and 33 men) who preoperatively underwent CEUS of a thyroid nodule classified as Bethesda categories II-VI after fine-needle aspiration biopsy. During the CEUS examination, 1.5 mL of SonoVue contrast was injected intravenously, after which 15 qualitative CEUS enhancement patterns were analysed.

RESULTS

The histopathologic results comprised 65 benign thyroid nodules and 123 thyroid carcinomas. The dominant malignant CEUS features, such as hypo- and heterogeneous enhancement and slow wash-in phase, were evaluated, whereas high enhancement, ring enhancement, and a slow wash-out phase were assessed as predictors of benign lesions. Two significant combinations of B-mode and CEUS patterns were noted, namely, hypoechogenicity with heterogeneous enhancement and non-smooth margins with hypo- or iso-enhancement.

CONCLUSIONS

The preliminary results indicate that CEUS is a useful tool in assessing the risk of malignancy of thyroid lesions. The combination of the qualitative enhancement parameters and B-mode sonographic features significantly increases the method's usefulness.

Diagnostic value of qualitative and quantitative parameters of contrast-enhanced ultrasound for differentiating differentiated thyroid carcinomas from benign nodules

Objective

To explore the diagnostic value of contrast-enhanced ultrasound (CEUS) of qualitative and quantitative parameters for differentiating differentiated thyroid cancers from benign nodules.

Method

A total of 290 thyroid nodules that were pathologically confirmed were enrolled in this study. The univariate analysis was performed for the clinical characteristics and CEUS qualitative and quantitative parameters of the inside and peripheral zone of nodules, including age, gender, nodule size, intensity of enhancement, homogeneity, wash-in and wash-out patterns, margin after CEUS, ring enhancement, peak intensity, sharpness, time to peak(TP), and area under the curve(AUC), and the meaningful indicators in the single-factor analysis were further included in multivariate logistic regression analysis.

Results

Multivariate analysis showed that there were significant differences in age (p=0.031), nodule size (p<0.001), heterogeneous enhancement (p<0.001), hypo-enhancement (p=0.001), unclear margin after CEUS(p=0.007), inside peak (p<0.001), and outside sharpness(p<0.001) between benign and malignant nodules. However, there were no significant differences in gender, ring enhancement, wash-in, wash-out, outside TP, outside AUC between benign and malignant thyroid nodules (P>0.05, for all).

Conclusion

CEUS might be useful in the differential diagnosis of differentiated thyroid cancers and benign nodules, which could provide a certain basis for clinical treatment.

Contrast-enhanced ultrasound (CEUS) characteristics of atypical-enhanced papillary thyroid carcinoma (PTC)

OBJECTIVE

To investigate the diagnostic value of CEUS in atypical-enhanced PTC.

METHODS

The clinical data, qualitative and quantitative parameters of CEUS in 177 Iso/hyper-enhanced thyroid nodules with definite pathological results were retrospectively analyzed in the Lanzhou University Second Hospital from June 2019 to January 2021. And the clinical value of CEUS in the diagnosis of atypical-enhanced PTC was assessed using univariate and multivariate analysis.

RESULTS

Among the 177 thyroid nodules, 59 were benign and 118 were PTC. There were significant differences in age, enhancement border, ring enhancement, speed of wash in, speed of wash out, enhancement pattern, capsule interruption, time to peak, time to wash out, RT, TPH, and TTP (P < 0.05). Multivariate analysis showed unclear enhancement border and concentric enhancement were independent risk factors for the diagnosis of atypical-enhanced PTC by CEUS. The sensitivity, specificity, PPV, NPV, and accuracy of the model in diagnosing atypical-enhanced PTC were 88.1%, 71.2%, 86.0%, 75.0%, and 82.5%, respectively. The area under the curve (AUC) of the receiver operating characteristic (ROC) curve was 0.910.

CONCLUSION

The diagnosis of atypical-enhanced PTC can be better performed by enhancement characteristics and time intensity curve (TIC) of CEUS, which have a good clinical application value.

Diagnostic value of ultrasound elastography and conventional ultrasound for thyroid nodules: a meta-analysis

Background

Thyroid nodular disease is a common disorder. Ultrasonography has emerged as a powerful tool for the diagnosis of thyroid disease owing to its high operational simplicity, non-invasiveness and reproducibility. This study aimed to systematically evaluate the value of ultrasound elastography and conventional ultrasound for the diagnosis of thyroid nodules.

Methods

The PubMed, EMBASE, Cochrane Library, China National Knowledge Infrastructure, Wanfang and VIP databases were searched systematically. RevMan 5.3 software was used to draw a risk bias map, and Stata 16.0 was used to plot a sensitivity and specificity forest map. A summary receiver operating characteristics (SROC) curve was plotted, and the area under the curve (AUC) was calculated. Meta-regression was used to explore the sources of heterogeneity.

Results

The sensitivity of conventional ultrasonography for detecting thyroid nodules was 0.55 [95% confidence interval (CI): 0.45-0.65], the specificity was 0.90 (95% CI: 0.87-0.93), the positive likelihood ratio was 5.8 (95% CI: 3.8-8.9), the negative likelihood ratio was 0.49 (95% CI: 0.39-0.6), and the AUC was 0.86 (95% CI: 0.82-0.88). The sensitivity of ultrasonic elastography for detecting thyroid nodules was 0.67 (95% CI: 0.60-0.73), the specificity was 0.93 (95% CI: 0.90-0.95), the positive likelihood ratio was 9.1 (95% CI: 6.3-13.3), the negative likelihood ratio was 0.36 (95% CI: 0.29-0.44), and the AUC was 0.89 (95% CI: 0.86-0.91). The sensitivity of conventional ultrasound combined with ultrasonic elastography for detecting thyroid nodules was 0.88 (95% CI: 0.84-0.90), the specificity of the combined approach was 0.96 (95% CI: 0.93-0.98), the positive likelihood ratio was 23.3 (95% CI: 12.4-43.6), the negative likelihood ratio was 0.13 (95% CI: 0.10-0.17), and the AUC was 0.92 (95% CI: 0.90-0.94). Age, region, research type, conventional ultrasound evaluation criteria and elastography evaluation criteria had specific effects on sensitivity and specificity when detecting thyroid nodules.

Conclusions

Conventional ultrasound can be used as a routine examination technique for the differential diagnosis of benign and malignant thyroid nodules, while ultrasound elastography can improve the sensitivity and specificity of the diagnosis. The diagnostic value of conventional ultrasound combined with ultrasound elastography is higher than that of a single diagnostic method.

Value of CEUS features in diagnosing thyroid nodules with halo sign on B-mode ultrasound

BACKGROUND

The results of halo sign in the differential diagnosis of thyroid nodules were conflicting, and the value of contrast-enhanced ultrasound (CEUS) in characterization of thyroid nodules with halo has not been fully evaluated. This study was therefore designed to investigate the value of contrast-enhanced ultrasound features in the differential diagnosis of thyroid nodules with halo sign on B-mode ultrasound.

MATERIAL AND METHODS

Seventy-four consecutive thyroid nodules with halo sign on B-mode ultrasound were pathologically confirmed by surgery or fine needle aspiration, including 43 benign and 31 malignant lesions. All these lesions underwent pre-operative CEUS examination. The CEUS features, including enhanced time, enhanced intensity and homogeneity, and presence of enhancing ring, were compared between benign and malignant ones.

RESULTS

Enhanced intensity was significant different between benign and malignant lesions with halo. Hypo-enhancement was more frequently detected in malignant nodules than that in benign ones, compared with iso-enhancement and hyper-enhancement (p = 0.013, and = 0.014, respectively). Detection rate of high-enhancing ring was significantly higher in benign nodules than that in malignant group (p = 0.001). While in nodules > 10 mm, only high-enhancing ring was the distinguishing feature between benign and malignant nodules.

CONCLUSIONS

Enhanced intensity and high-enhancing ring may be helpful in the differential diagnosis of thyroid nodules with halo sign on B-mode ultrasound.

Performance of Contrast-Enhanced Ultrasound in Thyroid Nodules: Review of Current State and Future Perspectives

Ultrasound has been established as a baseline imaging technique for thyroid nodules. The main advantage of adding CEUS is the ability to assess the sequence and intensity of vascular perfusion and hemodynamics in the thyroid nodule, thus providing real-time characterization of nodule features, considered a valuable new approach in the determination of benign vs. malignant nodules. Original studies, reviews and six meta-analyses were included in this article. A total of 624 studies were retrieved, and 107 were included in the study. As recognized for thyroid nodule malignancy risk stratification by US, for acceptable accuracy in malignancy a combination of several CEUS parameters should be applied: hypo-enhancement, heterogeneous, peripheral irregular enhancement in combination with internal enhancement patterns, and slow wash-in and wash-out curve lower than in normal thyroid tissue. In contrast, homogeneous, intense enhancement with smooth rim enhancement and "fast-in and slow-out" are indicative of the benignity of the thyroid nodule. Even though overlapping features require standardization, with further research, CEUS may achieve reliable performance in detecting or excluding thyroid cancer. It can also play an operative role in guiding ablation procedures of benign and malignant thyroid nodules and metastatic lymph nodes, and providing accurate follow-up imaging to assess treatment efficacy.

Value of Conventional Ultrasonography with Contrast-Enhanced Ultrasonography in the Differential Diagnosis of Partial Cystic Thyroid Nodules

The value of contrast-enhanced ultrasonography (CEUS) in the diagnosis of malignant partial cystic thyroid nodules (PCTNs) remains unclear. Thus, in the present study, the data of patients with pathologically proven PCTNs who underwent CEUS in the Chinese PLA General Hospital from January 2016 to February 2019 were retrospectively reviewed, and the imaging characteristics of benign and malignant PCTNs were compared. A total of 177 PCTNs were enrolled in this study, including 58 (32.7%) malignant nodules and 119 (67.2%) benign nodules. Six characteristics significantly differed between malignant PCTNs and benign PCTNs in univariate comparison: position of the solid portion (χ² = 17.937, p < 0.001), microcalcifications (χ² = 81.382, p < 0.001), boundaries (χ² = 45.486, p < 0.001), echogenicity (χ² = 11.152, p = 0.004), intensity of enhancement (χ² = 40.656, p < 0.001) and uniformity of enhancement (χ² = 19.933, p < 0.001). Among these, microcalcifications, boundaries, position of the solid portion, and uniformity of enhancement were independent risk factors in the multivariate comparison. A logistic regression model for predicting benign and malignant PCTNs was established with a sensitivity, specificity, positive predictive value, negative predictive value and accuracy of 89.0% (95% confidence interval [CI]: 0.788-0.961), 91.0% (95% CI: 0.830-0.946), 81.0% (95% CI: 0.715-0.881), 95.0% (95% CI: 0.892-0.974) and 90.0% (95% CI: 0.844-0.938), respectively. The area under the receiver operating characteristic curve was 0.967 (95% CI: 0.944-0.990), which was significantly higher than that of conventional ultrasound only (0.747, 95% CI: 0.663-0.831, Z = 2.090, p = 0.0366). CEUS can be used in the diagnosis of PCTNs, and the four characteristics of malignant PCTNs proven by our study were microcalcifications, unclear boundaries, eccentric distributions of the solid parts and heterogeneous enhancement.

Contrast-Enhanced Ultrasound in the Differential Diagnosis and Risk Stratification of ACR TI-RADS Category 4 and 5 Thyroid Nodules With Non-Hypovascular

Objective

This study aims to investigate the value of contrast-enhanced ultrasound (CEUS) in the differential diagnosis and risk stratification of ACR TI-RADS category 4 and 5 thyroid nodules with non-hypovascular.

Methods

From January 2016 to December 2019 in our hospital, 217 ACR TI-RADS category 4 and 5 nodules with non-hypovascular in 210 consecutive patients were included for a derivation cohort. With surgery and/or fine-needle aspiration (FNA) as a reference, conventional ultrasound (US) features and CEUS features were analyzed. Multivariate logistic regression analysis was used to screen the independent risk factors and establish a risk predictive model. Between January 2020 and March 2021, a second cohort of 100 consecutive patients with 101 nodules were included for an external validation cohort. The model was converted into a simplified risk score and was validated in the validation cohort. The area under the receiver operating characteristic curves (AUC) were used to assess the models’ diagnostic performance.

Results

Micro-calcification, irregular margin, earlier wash-out, centripetal enhancement, and absence of ring enhancement were independent risk factors and strongly discriminated malignancy in the derivation cohort (AUC = 0.921, 95% CI 0.876–0.953) and the validation cohort (0.900, 0.824–0.951). There was no significant difference (P = 0.3282) between the conventional US and CEUS in differentiating malignant non-hypovascular thyroid nodules, but a combination of them (the predictive model) had better performance than the single method (all P <0.05), with a sensitivity of 87.0%, specificity of 86.2%, and accuracy of 86.6% in the derivation cohort. The risk score based on the independent risk factors divided non-hypovascular thyroid nodules into low-suspicious (0–3 points; malignancy risk <50%) and high-suspicious (4–7 points; malignancy risk ≥ 50%), the latter with nodule ≥10mm was recommended for FNA. The risk score showed a good ability of risk stratification in the validation cohort. Comparing ACR TI-RADS in screening suitable non-hypovascular nodules for FNA, the risk score could avoid 30.8% benign nodules for FNA.

Conclusions

CEUS is helpful in combination with conventional US in differentiating ACR TI-RADS category 4 and 5 nodules with non-hypovascular. The risk score in this study has the potential to improve the diagnosis and risk stratification of non-hypovascular thyroid nodules.

"Double-Flash": An Innovative Method to Diagnose Papillary Thyroid Microcarcinomas

The aim of the study was to investigate the diagnostic ability of an innovative method called "Double-Flash" during contrast-enhanced ultrasound (CEUS) examination in papillary thyroid microcarcinomas. A total of 43 nodules measuring <10 mm and with definite pathology confirmed by surgery or fine-needle aspiration biopsy (FNAB) were included in this study. The bottom of "Flash" was pressed in the 40th and 60th seconds, respectively, defined as "Double-Flash." The curve of reperfusion was evaluated and the diagnostic value of "Double-Flash" was compared with that of CEUS. Pathologic results obtained by surgery or FNAB revealed there were 27 malignant and 16 benign nodules. The sensitivity, specificity and accuracy of CEUS were 70.0%, 53.8% and 65.1%. With "Double-Flash," the sensitivity, specificity and accuracy were 92.3%, 82.3% and 88.4%, respectively. The difference was statistically significant. Higher diagnostic ability is obtained with "Double-Flash." The parameter based on the new method could improve the diagnostic performance of quantitative diagnosis in CEUS. The change in the perfusion curve after "Flash" may be a strong indicator of malignancy.

Contrast-enhanced ultrasound for the differential diagnosis of thyroid nodules: An updated meta-analysis with comprehensive heterogeneity analysis

The diagnostic accuracy of contrast-enhanced ultrasound (CEUS) for distinguishing malignant thyroid nodules from benign thyroid nodules remains controversial. This meta-analysis was performed to evaluate the overall diagnostic value of CEUS for the characterization of thyroid nodules. Relevant studies were identified by searching PubMed, Embase and the Cochrane Library until August 1th 2019 to assess the overall diagnostic accuracy of CEUS. 37 eligible studies were included in the present meta-analysis. The pooled sensitivity, specificity, positive likelihood rate, negative likelihood rate and diagnostic odds ratio of CEUS were 0.87, 0.83, 5.38, 0.17 and 38.94, respectively, with the AUC of 0.9263. Subgroup analysis showed the heterogeneity was greatly reduced in small nodules group (≤ 1 cm) (I2 = 0.0%), while heterogeneity was still observed in the group of variable sizes group (I2 = 69.5%). However, meta-regression analysis revealed that only diagnostic criterion was the major source of heterogeneity (p = 0.0259). The risk of publication bias was negligible (p = 0.35). CEUS exhibited high accuracy for the identification of thyroid nodules and might provide additional perfusion information for the current US imaging reporting systems.

Update on thyroid ultrasound: a narrative review from diagnostic criteria to artificial intelligence techniques

Objective

Ultrasound imaging is well known to play an important role in the detection of thyroid disease, but the management of thyroid ultrasound remains inconsistent. Both standardized diagnostic criteria and new ultrasound technologies are essential for improving the accuracy of thyroid ultrasound. This study reviewed the global guidelines of thyroid ultrasound and analyzed their common characteristics for basic clinical screening. Advances in the application of a combination of thyroid ultrasound and artificial intelligence (AI) were also presented.

Data sources

An extensive search of the PubMed database was undertaken, focusing on research published after 2001 with keywords including thyroid ultrasound, guideline, AI, segmentation, image classification, and deep learning.

Study selection

Several types of articles, including original studies and literature reviews, were identified and reviewed to summarize the importance of standardization and new technology in thyroid ultrasound diagnosis.

Results

Ultrasound has become an important diagnostic technique in thyroid nodules. Both standardized diagnostic criteria and new ultrasound technologies are essential for improving the accuracy of thyroid ultrasound. In the standardization, since there are no global consensus exists, common characteristics such as a multi-feature diagnosis, the performance of lymph nodes, explicit indications of fine needle aspiration, and the diagnosis of special populations should be focused on. Besides, evidence suggests that AI technique has a good effect on the unavoidable limitations of traditional ultrasound, and the combination of diagnostic criteria and AI may lead to a great promotion in thyroid diagnosis.

Conclusion

Standardization and development of novel techniques are key factors to improving thyroid ultrasound, and both should be considered in normal clinical use.

Combination of contrast-enhanced ultrasound and strain elastography to assess cytologically non-diagnostic thyroid nodules

The aim of the present study was to investigate the benefits of combining contrast-enhanced ultrasound (CEUS) and strain elastography (SE) for the diagnosis of thyroid nodules with non-diagnostic fine-needle aspiration cytology (FNAC) results. Between October 2013 and March 2017, CEUS and SE were performed in 226 patients (236 thyroid nodules) with non-diagnostic FNAC results prior to thyroidectomy. The diagnostic value of CEUS, SE and their combination (CEUS+SE) in distinguishing malignant from benign thyroid nodules was evaluated, using surgical pathology as a reference. Receiver operating characteristic curve analysis was used to assess the diagnostic performance of CEUS, SE and CEUS+SE in determining malignant thyroid nodules. Subsequently, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of CEUS, SE and CEUS + SE were calculated. The malignancy rate in patients with thyroid nodules and non-diagnostic FNAC results was 26.3% in the present study. The sensitivity, specificity, PPV, NPV, accuracy and area under the curve in predicting malignant thyroid nodules were 80.6, 85.6, 66.7, 92.5, 84.3 and 0.831%, respectively, using SE alone; 59.7, 95.9, 84.1, 86.9, 86.4 and 0.778%, respectively, using CEUS alone; and 83.9, 89.1, 73.6, 94.5, 88.1 and 0.865%, respectively, using the combination of CEUS and SE. Overall, the combination of CEUS with SE resulted in higher sensitivity, NPV and accuracy in the diagnosis of cytologically non-diagnostic thyroid nodules compared with CEUS or SE alone.