Correlation between Thyroid Nodule Calcification Morphology on Ultrasound and Thyroid Carcinoma

Factors of Central Lymph Node Metastasis in Papillary Thyroid Cancer Based on C-TIRADS Analysis

To study risk factors for central lymph node metastasis (CLNM) in papillary thyroid cancer (PTC) using the Chinese Thyroid Imaging Reporting and Data System (C-TIRADS). We retrospectively analysed patients who underwent PTC surgery and central lymph node dissection at First People's Hospital of Foshan City. The clinical and ultrasonic data of the patients from 1150 cases were analysed by multivariate regression to evaluate the correlation between grayscale ultrasound (US) features, C-TIRADS score, and the classification of thyroid nodules and CLNM of PTCs. The C-TIRADS score was 3.0±1.0 in the CLNM group, which was higher than that in the non-CLNM group (p<0.001). Sex (male) (OR=1.586, 95% CI 1.232-2.042, p<0.001), age (≤45 years) (OR=1.508, 95% CI 1.184-1.919, p=0.001), location of nodes (lower pole) (OR=2.193, 95% CI 1.519-3.166, p<0.001), number (multifocal) (OR=2.204, 95% CI 1.227-2.378, p<0.001), microcalcification (OR=1.610, 95% CI 2.225-4.434, p=0.002), extrathyroidal extension (OR=2.204, 95% CI 1.941-3.843, p<0.001), maximum diameter of nodule (≥20 mm) (OR=3.211, 95% CI 2.337-4.411, p<0.001), and C-TIRADS score (OR=1.356, 95% CI 1.204-1.527, p<0.001) were PTC in independent risk factors for CLNM. The C-TIRADS score of PTC combined with the location, number, size, and ultrasound features of the lesion and the patient's sex and age are important in predicting whether they present with CLNM and provide a reference basis for the clinical formulation of a reasonable surgical treatment plan.

Generalizability and Diagnostic Performance of AI Models for Thyroid US

Background Artificial intelligence (AI) models have improved US assessment of thyroid nodules; however, the lack of generalizability limits the application of these models. Purpose To develop AI models for segmentation and classification of thyroid nodules in US using diverse data sets from nationwide hospitals and multiple vendors, and to measure the impact of the AI models on diagnostic performance. Materials and Methods This retrospective study included consecutive patients with pathologically confirmed thyroid nodules who underwent US using equipment from 12 vendors at 208 hospitals across China from November 2017 to January 2019. The detection, segmentation, and classification models were developed based on the subset or complete set of images. Model performance was evaluated by precision and recall, Dice coefficient, and area under the receiver operating characteristic curve (AUC) analyses. Three scenarios (diagnosis without AI assistance, with freestyle AI assistance, and with rule-based AI assistance) were compared with three senior and three junior radiologists to optimize incorporation of AI into clinical practice. Results A total of 10 023 patients (median age, 46 years [IQR 37-55 years]; 7669 female) were included. The detection, segmentation, and classification models had an average precision, Dice coefficient, and AUC of 0.98 (95% CI: 0.96, 0.99), 0.86 (95% CI: 0.86, 0.87), and 0.90 (95% CI: 0.88, 0.92), respectively. The segmentation model trained on the nationwide data and classification model trained on the mixed vendor data exhibited the best performance, with a Dice coefficient of 0.91 (95% CI: 0.90, 0.91) and AUC of 0.98 (95% CI: 0.97, 1.00), respectively. The AI model outperformed all senior and junior radiologists (P < .05 for all comparisons), and the diagnostic accuracies of all radiologists were improved (P < .05 for all comparisons) with rule-based AI assistance. Conclusion Thyroid US AI models developed from diverse data sets had high diagnostic performance among the Chinese population. Rule-based AI assistance improved the performance of radiologists in thyroid cancer diagnosis. © RSNA, 2023 Supplemental material is available for this article.

Association between macrocalcification and papillary thyroid carcinoma and corresponding valuable diagnostic tool: retrospective study

BACKGROUND

Microcalcifications are suggested to be an indicator of thyroid malignancy, especially for papillary thyroid carcinoma (PTC), nonetheless, the association between macrocalcification and PTC is underexplored. Furthermore, screening methods like ultrasonography and ultrasound-guided fine needle aspiration biopsy (US-FNAB) are limited in evaluating macro-calcified thyroid nodules. Thus, we aimed to investigate the relationship between macrocalcification and PTC. We also explored the diagnostic efficiency of US-FNAB and proto-Oncogene Proteins B-raf V600E (BRAF V600E) mutation in macro-calcified thyroid nodules evaluation.

METHODS

A retrospective research of 2645 thyroid nodules from 2078 participants was performed and divided into three groups as non-, micro-, and macro-calcified for further PTC incidence comparison. Besides, a total of 100 macro-calcified thyroid nodules with both results of US-FNAB and BRAF V600E mutation were screened out for subsequent evaluation of diagnostic efficiency.

RESULTS

Compared to non-calcification, macrocalcification showed a significantly higher incidence of PTC (31.5% vs. 23.2%, P<0.05). Additionally, when compared with a single US-FNAB, the combination of US-FNAB and BRAF V600E mutation showed better diagnostic efficiency in diagnosing macro-calcified thyroid nodule (area under the curve (AUC) 0.94 vs. 0.84, P=0.03), with a significantly higher sensitivity (100.0% vs. 67.2%, P<0.01) and a comparable standard of specificity (88.9% vs. 100.0%, P=0.13).

CONCLUSIONS

Occurrence of macrocalcification in thyroid nodules may suggest a high risk of PTC, and the combination of US-FNAB and BRAF V600E showed a greater value in identifying macro-calcified thyroid nodules, especially with significantly higher sensitivity.

TRIAL REGISTRATION

The Ethics Committee of The First Affiliated Hospital of Wenzhou Medical University (2018-026).

Role of echogenic foci in ultrasonographic risk stratification of thyroid nodules: Echogenic focus scoring in the American College of Radiology Thyroid Imaging Reporting and Data System

Background

Although echogenic foci may raise malignancy rates in thyroid nodules, the association between peripheral calcification or macrocalcification and thyroid carcinoma is controversial. We evaluated the malignancy probability of various echogenic foci and explored whether the method of determining a thyroid nodule’s point score in the echogenic focus category of the American College of Radiology (ACR) Thyroid Imaging Reporting and Data System (TI-RADS) is reasonable.

Methods

We retrospectively evaluated 819 patients with 852 nodules. The patterns of echogenic foci on ultrasonography were classified into the following four categories: punctate echogenic foci, macrocalcification, peripheral calcification, and multiple different types of echogenic foci. The core needle biopsy results were divided into two groups: benign and malignant or suspicious for malignancy.

Results

Among the 852 nodules, 471 (55.3%) had echogenic foci on ultrasonography. Of these nodules, there was no significant statistical difference in the malignant or suspicious for malignancy rate between nodules with peripheral calcification and those with macrocalcification [40.0% (8/20) vs. 30.6% (11/36), respectively; p = 0.474]. The incidence of malignancy or suspicious for malignancy for nodules with peripheral calcification, macrocalcification, or multiple different types of echogenic foci was significantly lower than the incidence for punctate echogenic foci alone, with odds ratios of 0.265 [95% confidence interval (CI): 0.105–0.667; p = 0.005], 0.175 (95% CI: 0.083–0.368; p = 0.000), and 0.256 (95% CI: 0.136–0.482; p = 0.000), respectively.

Conclusion

We found no significant statistical difference in the risk of malignancy or suspicious for malignancy rate between peripheral calcification and macrocalcification in thyroid nodules. We observed that nodules with multiple different types of echogenic foci were not associated with higher malignant or suspicious for malignancy rates compared with nodules with punctate echogenic foci alone.

What's in a node? The clinical and radiologic significance of Virchow's node

In 1848, Rudolf Ludwig Karl Virchow described an association of left supraclavicular lymphadenopathy with abdominal malignancy. The left supraclavicular lymph node later became commonly referred to as Virchow's node. Charles-Emile Troisier went on to describe the physical exam finding of an enlarged left supraclavicular lymph node, later termed Troisier's sign. Subsequent studies confirmed a predilection of abdominal and pelvic malignancies to preferentially metastasize to the left supraclavicular node. Identification of a pathologically enlarged left supraclavicular node raises the suspicion for abdominopelvic malignancy, particularly in the absence of right supraclavicular lymphadenopathy, and provides a safe and easy target for biopsy. Supraclavicular lymph nodes also represent a great target for diagnosis of metastatic thoracic malignancies, although thoracic malignancies can involve either right or left supraclavicular nodes and do not show a predilection for either. This article presents a review of the history, anatomy, pathophysiology, clinical significance, radiological appearance, and biopsy of Virchow's node. Key points are illustrated with relevant cases.

A multi-institutional study of association of sonographic characteristics with cervical lymph node metastasis in unifocal papillary thyroid carcinoma

OBJECTIVE

Papillary thyroid carcinoma (PTC) is the most common pathological type of thyroid carcinoma, and is prone to cervical lymph node metastases (CLNM). We aim to evaluate the association between sonographic characteristics of PTC and CLNM before the initial surgery.

METHODS

Clinical information as well as ultrasonographic measurements and characteristics for 2376 patients from three hospitals were acquired in this retrospective cohort study. Univariate and multivariate logistic analysis were performed to predict CLNM in unifocal PTC patients. Receiver operating characteristic (ROC) curve was created to evaluate diagnostic performance.

RESULTS

Univariate analysis showed that gender, age, maximum tumor diameter and volume, cross-sectional and longitudinal aspect ratio, location, echogenicity, margin, and echogenic foci were independently associated with CLNM metastatic status (P < 0.05). Multivariate logistic analysis showed that gender, age, maximum tumor diameter and volume, cross-sectional aspect ratio (CSAR), location, echogenicity, margin, and echogenic foci were independent correlative factors; CSAR showed a significant difference for PTC2 to predict CLNM. The area under the curve (AUC) of the maximum tumor diameter, tumor volume, margin, and echogenic foci was 0.70, 0.69, 0.65, and 0.70, respectively. The multiple-variable linear regression model was constructed with an AUC of 0.77, a specificity of 73.4%, and a sensitivity of 72.3%. Kruskal-Wallis analysis for positive subgroups, maximum tumor diameter and volume, cross-sectional and longitudinal aspect ratio, margin, and echogenic foci showed statistical significance (P < 0.05).

CONCLUSIONS

Younger age (< 55 years), male, larger tumor, and echogenic foci were high risk factors for CLNM in patients with unifocal PTC. CSAR had a more effective predictive value for CLNM in patients with larger thyroid tumors. A larger tumor with irregular and punctate echogenic foci was also more prone to the lateral neck, and both central and lateral neck metastasis.

Cystic cervical lymph nodes of papillary thyroid carcinoma, tuberculosis and human papillomavirus positive oropharyngeal squamous cell carcinoma: utility of deep learning in their differentiation on CT

OBJECTIVES

Cervical lymph nodes with internal cystic changes are seen with several pathologies, including papillary thyroid carcinoma (PTC), tuberculosis (TB), and HPV-positive oropharyngeal squamous cell carcinoma (HPV+OPSCC). Differentiating these lymph nodes is difficult in the absence of a known primary tumor or reliable medical history. In this study, we assessed the utility of deep learning in differentiating the pathologic lymph nodes of PTC, TB, and HPV+OPSCC on CT.

METHODS

A total of 173 lymph nodes (55 PTC, 58 TB, and 60 HPV+OPSCC) were selected based on pathology records and suspicious morphological features. These lymph nodes were divided into the training set (n = 131) and the test set (n = 42). In deep learning analysis, JPEG lymph node images were extracted from the CT slice that included the largest area of each node and fed into a deep learning training session to create a diagnostic model. Transfer learning was used with the deep learning model architecture of ResNet-101. Using the test set, the diagnostic performance of the deep learning model was compared against the histopathological diagnosis and to the diagnostic performances of two board-certified neuroradiologists.

RESULTS

Diagnostic accuracy of the deep learning model was 0.76 (=32/42), whereas those of Radiologist 1 and Radiologist 2 were 0.48 (=20/42) and 0.41 (=17/42), respectively. Deep learning derived diagnostic accuracy was significantly higher than both of the two neuroradiologists (P < 0.01, respectively).

CONCLUSION

Deep learning algorithm holds promise to become a useful diagnostic support tool in interpreting cervical lymphadenopathy.

Cystic cervical lymph nodes of papillary thyroid carcinoma, tuberculosis and human papillomavirus positive oropharyngeal squamous cell carcinoma: Comparative CT analysis for their differentiation

PURPOSE

Cervical lymph nodes with cystic changes are an important finding seen with several pathologies including papillary thyroid carcinoma (PTC), tuberculosis (TB) and HPV-positive oropharyngeal squamous cell carcinoma (HPV + OPSCC). In the absence of known primary tumor or conclusive medical history, differentiating among these nodes is difficult. We compared the pathologic nodes of PTC, TB and HPV + OPSCC to identify imaging features useful for their differentiation.

MATERIALS AND METHODS

Fifty-five PTC, 58 TB and 51 HPV + OPSCC nodes were selected based on surgical pathology records and suspicious morphological features. These nodes were compared for morphological features: long axis length, nodal shape, nodal location, presence of cystic change, area of cystic change:area of entire node ratio, Hounsfield unit of the cystic component, degree of enhancement, enhancement pattern, presence of calcification, presence of perinodal infiltration, and presence of surrounding inflammatory changes.

RESULTS

PTC nodes formed calcifications more frequently and demonstrated greater enhancement (P < 0.01). TB nodes were characterized by their irregular shape (P < 0.05), irregular enhancement surrounding the cystic change (P < 0.01), greater frequencies of perinodal infiltration (P < 0.01) and surrounding inflammatory changes (P < 0.01). While no unique features were seen with HPV+OPSCC, they were characterized by the absence of those features that distinguished the other groups: these nodes tended to have smooth, circumscribed margins with no hyperenhancement, calcifications or inflammatory changes. PTC and TB nodes were more frequently identified in the lower neck, while HPV+OPSCC nodes were localized to the upper neck (P < 0.01).

CONCLUSIONS

PTC, TB and HPV + OPSCC lymph nodes can be differentiated based on their morphologies and locations.

Comparison of different systems of ultrasound (US) risk stratification for malignancy in elderly patients with thyroid nodules. Real world experience

PURPOSE

To comparatively assess the performance of three sonographic classification systems, American Thyroid Association (ATA), the American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS), and American Association of Clinical Endocrinologists (AACE)/American College of Endocrinology (ACE)/Associazione Medici Endocrinologi (AME) in identifying malignant nodules in an elderly population.

METHODS

Cross-sectional study of patients referred for fine needle aspiration biopsy in an academic center for the elderly. One nodule/patient was considered. Nodules classified Bethesda V/VI were considered malignant. Receiver operating characteristics (ROC) curves were established and compared to evaluate diagnostic performance. Malignancy among biopsies below the size cutoff for each ultrasound classification was also compared.

RESULTS

One thousand, eight hundred sixty-seven patients (92% females); median (Q1-Q3), age 71 (67-76) years, were studied showing 82.8% benign (Bethesda II) and 2.6% malignant cytology. The three classifications correctly identified malignancy (P < 0.01). Nonetheless, in the ATA and AACE/ACE/AME 16 and 2 malignant nodules, respectively, were unclassifiable. Including unclassified malignant nodules (n = 1234, malignant = 50), comparison of the ROC curves showed lower performance of ATA [area under the curve (AUC) = ATA (0.49) vs. ACR TI-RADS (0.62), p = 0.008 and ATA vs. AACE/ACE/AME (0.59), p = 0.022]. Proportion of below size cutoff biopsies for ATA, ACR TI-RADS, and AACE/ACE/AME was different [16, 42, and 29% (all p < 0.001)], but no differences in malignancy rate were observed in these nodules.

CONCLUSION

The present study is the first to validate in elderly patients these classifications showing that AACE/ACE/AME and ACR TI-RADS can predict thyroid malignancy more accurately than the ATA when unclassifiable malignant nodules are considered. Moreover, in this aged segment of the population, the use of ACR TI-RADS avoided more invasive procedures.

The Diagnostic Role of Computed Tomography for ACR TI-RADS 4-5 Thyroid Nodules With Coarse Calcifications

Objectives: Coarse calcifications are prone to cause echo attenuation during ultrasonography (US) and hence affect the classification of benign and malignant nodules. This study aimed to investigate the diagnostic role of computed tomography (CT) for differentiating the American College of Radiology (ACR) Thyroid Imaging Reporting and Data System (TI-RADS) 4–5 nodules with coarse calcifications.

Methods: CT data of 216 ACR TI-RADS 4–5 nodules with coarse calcifications confirmed by surgery and pathology in 207 patients were analyzed retrospectively. Halo sign, artifacts, and CT values (i.e., Hounsfield unit) of the nodules were determined by two radiologists. Univariate analysis and binary logistic regression were used to determine the relationship of halo sign, artifact, and CT value with benign nodules. A predictive model for benign nodules with coarse calcifications was then constructed. The receiver operating characteristic (ROC) curve was used to analyze the predictive value of halo sign, artifact, CT value, and logistic regression model.

Results: Of the 216 ACR TI-RADS 4–5 nodules with coarse calcifications, 170 were benign and 46 were malignant. There were 92 benign and 7 malignant nodules with halo sign (χ² = 22.067, P < 0.001), and 79 benign and 10 malignant nodules with artifacts (χ² = 9.140, P < 0.001). The CT values of benign and malignant nodules were 791 (543–1,025) Hu and 486 (406–670) Hu, respectively (Z = −5.394, P < 0.001). Binary logistic regression demonstrated that the halo sign, artifact, and CT value were independent predictors for benign nodules with coarse calcifications. The area under the ROC curve (AUC) of halo sign, artifact, CT value and regression model for predicting benign nodules with coarse calcifications were 0.776, 0.711, 0.784, and 0.850, respectively, and the optimal threshold of CT value was 627.5 Hu.

Conclusion: Halo sign, artifact, and CT value > 627.5 Hu were helpful for identifying ACR TI-RADS 4–5 thyroid benign nodules with coarse calcifications. The diagnostic performance of the logistic regression model was higher than that of any single indicator. Accurate identification of these indicators could identify benign nodules and reduce unnecessary surgical trauma.

Hounsfield Unit Values in ACR TI-RADS 4-5 Thyroid Nodules with Coarse Calcifications: An Important Imaging Feature Helpful for Diagnosis

Purpose

The purpose of this study is to investigate the diagnostic role of Hounsfield unit (HU) values on noncontrast computed tomography (CT) for differentiating benignity from malignancy in the American College of Radiology (ACR) Thyroid Imaging Reporting and Data System (TI-RADS) 4-5 nodules with coarse calcifications.

Patients and Methods

CT images of 216 ACR TI-RADS 4-5 nodules with coarse calcifications from 207 patients who underwent surgery in our hospital between 2017 and 2019 were retrospectively reviewed. The average HU values (AHUVs) and maximum HU values (MHUVs) of the nodules were measured on noncontrast CT. The distribution of AHUVs and MHUVs in benign and malignant nodules with coarse calcifications was analyzed using the Mann-Whitney test. Receiver operating characteristic (ROC) curves were used to identify the best cut-off values. Diagnostic performances were assessed according to the area under the ROC curve (AUC), sensitivity and specificity.

Results

Of the 216 ACR TI-RADS 4-5 nodules with coarse calcifications, 170 were benign and 46 were malignant. The AHUVs of benign and malignant nodules were 791 HU [interquartile range (IQR), 543-1025 HU] and 486 HU (IQR, 406-670 HU), respectively (P < 0.001). The MHUVs of benign and malignant nodules were 1084 HU (IQR, 717-1477 HU) and 677 HU (IQR, 441-986 HU), respectively (P < 0.001). The AUCs for AHUVs and MHUVs for predicting benign nodules with coarse calcifications were 0.759 and 0.732, and the cut-off values were 627.5 HU and 806.0 HU, with sensitivities of 67.6% and 68.8% and specificities of 73.9% and 67.4%, respectively. The sensitivity and specificity of the combination were 68.8% and 76.1%.

Conclusion

AHUVs and MHUVs were helpful in differentiating benignity from malignancy in ACR TI-RADS 4-5 nodules with coarse calcifications. This may provide an important basis for reducing misdiagnosis and unnecessary aspiration or surgical trauma.

Necrosis avascular: complicación en un paciente joven

The clinical presentation of a proximal femoral fracture is completely different between young and adult patients. Unlike closed proximal femoral fractures, the incidence of exposed fractures is found in the young population between 15 and 30 years of age. Osteonecrosis of the femoral head is one the complications we can find in this type of fractures. Avascular necrosis (AVN or osteonecrosis) is defined as the interruption of blood supply to the femoral head due to trauma, infectionalcohol or steroid use, resulting in bone necrosis, joint collapse and osteoarthrosis. The treatment will depend on the clinical presentation, age of the patient and when the diagnosis is made. This is a case report of a 16-year-old patient with a gunshot wound on the hip. Surgical cleansing and closed reduction plus internal fixation with a nail in the center of the spine were performed. A 3-year clinical and radiographic follow up was made, observing the evolution of the fracture and the subsequent avascular necrosis that the patient presented. Key words: Proximal femoral fracture; hip; avascular necrosis (AVN, osteonecrosis); open fracture; osteoarthritis.

Carcinoma papilar difuso de tiroides: Microcalcificaciones fuera del nodulo tiroideo

Abstract INTRODUCTION: The incidence of thyroid papillary cancer (PTC) has increased from 1975 to 2015. Ultrasound is effective for predicting thyroid malignancy based on published criteria. All of these criteria focus on thyroid nodules but also 2% of the cases may appear as diffuse punctuate echogenic foci without an identifiable nodule.  CASE: A 17-year-old female with a 3-month history of a palpable mass on the right anterior side of the neck without any further symptoms. Neck ultrasound revealed multiple punctuate echogenic foci scattered along the thyroid parenchyma with a 6 mm nodule TI-RADS 5 on the left lobe, lymph nodes with cystic and solid components, loss of echogenic hilum and punctuate echogenic foci. The patient underwent a total thyroidectomy with bilateral lymphadenectomy. The pathology report revealed diffuse distribution of papillary cancer with a nodule on the left lobe and metastatic disease on the lymph nodes.  DISCUSSION: Microcalcifications are highly suggestive of PTC. Punctuate echogenic foci correlate in pathology with a form of dystrophic calcifications, called Psammoma bodies, which are deposited in nonviable tissue. Chronic thyroiditis may also present dystrophic calcifications. Thus, a normal thyroid parenchyma with microcalcifications should encourage the radiologist perform a fine-needle aspiration biopsy (FNAB). Recent studies suggest that lobectomy is a viable option and should be pursued in the setting of localized PTC (<2cm). A lobectomy should not be performed in patients with diffuse microcalcifications since it would result in an unfavorable outcome.  CONCLUSIONS: Diffuse microcalcifications should immediately make the radiologist to suspect diffuse PTC as a first diagnostic option. Key words: Thyroid papillary cancer (PTC), Ultrasound  (US), Psammoma, Chronic thyroiditis

Relationship Between Morphologic Characteristics of Ultrasonic Calcification in Thyroid Nodules and Thyroid Carcinoma

The aim of this study was to investigate the relationship between morphologic characteristics of the calcifications detected by ultrasound in thyroid nodules and thyroid carcinoma. Morphologic characteristics of the calcifications on pre-operative ultrasound examinations of thyroids were compared with post-operative pathologic diagnoses in 543 patients undergoing thyroid surgery. Calcifications were divided into microcalcifications (≤2 mm) and macrocalcifications (>2 mm), and the latter were divided into eggshell calcifications in a row, eggshell discontinuous calcifications, irregular calcifications and multilayer-like calcifications, labeled types I-V. We found that thyroid microcalcifications and partial macrocalcifications, such as eggshell discontinuous calcifications, and multilayer-like calcifications were associated with thyroid carcinoma. In conclusion, microcalcifications were more commonly found in malignant thyroid nodules, particularly in papillary thyroid carcinoma. Eggshell discontinuous macrocalcifications and multilayer-like macrocalcifications also occurred mainly in malignant nodules.

Sonographic diagnosis in the head and neck region: from an educational lecture presented at the 56th General Assembly and Annual Scientific Congress of the Japanese Society for Oral and Maxillofacial Radiology

Sonography is a simple, inexpensive, and non-invasive diagnostic modality. Although tissues behind bony structures and deep tissues are not delineated, sonography can depict superficial soft tissues very clearly. In the head and neck region, however, it has not yet been used widely, as the anatomical structures are complicated, and considerable experience is needed both to perform an examination and to make a diagnosis. To perform examinations efficiently, operators must be familiar with the sonographic system in use, and take images at standard planes. To make a correct diagnosis, operators require knowledge of the sonographic anatomy on standard planes, representative sonographic signs and artifacts, and common diseases and their typical sonographic findings. In this paper, we have explained the sonographic anatomy on standard planes, and the sonographic findings of common diseases in the oral and maxillofacial region.

Diagnostic value of computed tomography (CT) histogram analysis in thyroid benign solitary coarse calcification nodules

This study was to investigate the diagnostic value of the computed tomography (CT) histogram in thyroid benign solitary coarse calcification nodules (BSCNs). A total of 89 thyroid solitary coarse calcification nodules (coarse calcification ≥5 mm, no definite soft tissue around calcification) confirmed either by surgery or histopathological examination in 86 cases enrolled from January 2009 to December 2015 were evaluated. These included 56 BSCNs and 33 malignant solitary coarse calcification nodules (MSCNs). Overall, 27 cut-off values were calculated by N (4≤N≤30) times of 50 Hounsfield units (HU) in the range of 200 to 1500 HU, and each cut-off value and the differences in the corresponding area percentages in the CT histogram were recorded for BSCN and MSCN. The optimal cut-off value and the corresponding area percentage were established by receiver operating characteristic (ROC) curve analysis. In the 19 groups with an ROC area under curve (AUC) of more than 0.7, at a cut-off value of 800 HU and at an area percentage of no more than 93.8%, the ROC AUC reached the maximum of 0.79, and the accuracy, sensitivity, and specificity were 75.3%, 80.4%, and 66.7%, respectively. At a cut-off value of 1050 HU and at an area percentage of no more than 93.6%, the accuracy, sensitivity, and specificity were 71.9%, 60.7%, and 90.9%, respectively. At a cut-off of 1150 HU and area of no more than 98.4%, the accuracy, sensitivity, and specificity were 70.8%, 57.1%, and 93.9%, respectively. At a cut-off of 600 HU and area of no more than 12.1%, the accuracy, sensitivity, and specificity were 61.8%, 39.3%, and 100.0%, respectively. Compared with the cut-off value of 800 HU and an area percentage of no more than 93.8%, the sensitivity of cut-off values and minimum areas of 1050 HU and 93.6%, of 1150 HU and 98.4%, and of 600 HU and 12.1%, was gradually decreasing; however, their specificity was gradually increasing. This can provide an important basis for reducing the misdiagnosis and unnecessary surgical trauma.

Diagnostic performance of ATA, BTA and TIRADS sonographic patterns in the prediction of malignancy in histologically proven thyroid nodules

INTRODUCTION

We aimed to compare the malignancy risk stratification of histologically proven thyroid nodules using the 2015 American Thyroid Association (ATA) Management Guidelines, 2014 British Thyroid Association (BTA) Guidelines for the Management of Thyroid Cancer and the Thyroid Imaging Reporting and Data System (TIRADS).

METHODS

Thyroid nodules measuring > 1 cm resected over 5.5 years were retrospectively studied. Demographic information as well as cytology and histopathology results were collected. Static ultrasonography (US) images and radiologists' reports of each resected nodules were reviewed and classified based on the above risk classification systems.

RESULTS

A total of 167 thyroid nodules from 150 patients were examined. More malignant nodules were solid (78.4% vs. 62.5%; p = 0.049) or hypoechoic (70.6% vs. 28.6%; p < 0.001), and had irregular margins (35.3% vs. 8.0%; p < 0.001), taller-than-wide morphology (9.8% vs. 2.7%; p = 0.031), microcalcifications (33.3% vs. 8.0%; p < 0.001), disrupted rim calcifications (9.8% vs. 0.9%; p = 0.012) or associated abnormal cervical lymphadenopathy (13.7% vs. 0.9%; p = 0.001) compared with benign nodules. The guidelines' diagnostic performance was: ATA - sensitivity 98.0%, specificity 17.3%, positive predictive value (PPV) 35.0%, negative predictive value (NPV) 95.0%; BTA - sensitivity 90%, specificity 50.9%, PPV 45.5%, NPV 91.8%; and TIRADS - sensitivity 94.0%, specificity 28.2%, PPV 37.3%%, NPV 91.2%.

CONCLUSION

Sonographic patterns outlined by the three guidelines displayed high sensitivity and NPV. Although isolated suspicious US features cannot predict malignancy risk, they should be considered when risk stratifying nodules that do not fit into particular sonographic patterns based on current guidelines.

Risk of malignancy in thyroid nodules: predictive value of puncture feeling of grittiness in the process of fine-needle aspiration

Fine-needle aspiration cytology (FNAC) is widely used for diagnosing thyroid nodules. However, there has been no specific investigation about the puncture feeling of grittiness. The aim of the present study was to see if the puncture feeling of grittiness during fine-needle aspiration procedure, combined with standard FNAC, could improve the accuracy in diagnosing thyroid cancer. A total of one thousand five hundred and thirty-one thyroid FNAC specimens acquired between January 2013 and January 2017 were retrospectively retrieved. All cases underwent surgical intervention. The FNAC diagnoses and puncture feeling of grittiness were evaluated and compared with the results of final histopathological diagnoses. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of diagnosis for thyroid nodules by FNAC alone, puncture feeling of grittiness alone, and the combination of FNAC plus grittiness were calculated respectively. The findings of our study suggest that puncture feeling of grittiness is a useful adjunct. Adding puncture feeling of grittiness to FNAC can significantly enhance the ability to differentiate malignant thyroid nodules from benign thyroid nodules. More importantly, we found that puncture feeling of grittiness is surprising trust-worthy in being near perfectly reproducible per individual radiologist, and among different operators.

Histopathological investigation of intranodular echogenic foci detected by thyroid ultrasonography

OBJECTIVE

To determine the predictability of sonography for detection of calcifications in thyroid nodules by histopathologic examination and to demonstrate the association between calcification pattern and malignancy.

METHODS

We prospectively evaluated 81 dominant nodules from 81 patients. Thyroid glands were assessed preoperatively with thyroid ultrasonography, and the presence of sonographic calcification was specified as intranodular macro (coarse) and micro calcification. Micro and macro calcification in surgery specimens were specified postoperatively as present or absent in the histopathological evaluation. The correlation between sonographic and histopathologic calcifications and the relationship between malignancy and calcification patterns were determined.

RESULTS

Calcification was detected histopathologically in 66.7% of the sonographically calcified nodules and in 12.8% of the sonographically noncalcified nodules. The sensitivity and specificity of sonography for detecting histopathologic calcification were 84.8 and 70.8%, respectively, while positive and negative predictive values were 66.7 and 87.2%, respectively. The sonographical and histopathological outcomes for detection of macro and micro calcification showed 85 and 50% compatibility, respectively. The difference in malignancy rates between sonographic macro and micro calcified nodules was not significant (p=0.976). Histopathologic detection of calcification showed no significant difference between malignant and benign nodules (p=0.129).

CONCLUSION

Histopathology confirmed a high rate of sonographic macrocalcifications. The micro and macro patterns of sonographic calcification showed no particular association with thyroid malignancy. The preoperative risk of malignancy should be determined in conjunction with other known sonographic risk factors and diagnostic tests.

The utility of thyroid ultrasonography in the management of thyroid nodules

BACKGROUND

Ultrasonography for thyroid nodules is one of the most common imaging tests performed in the general population. Details from ultrasound reports guide biopsies and surgery. This study quantifies the completeness of these reports based on Thyroid Imaging and Reporting System (TI-RADS) criteria and considers their utility in predicting malignant disease.

METHODS

We retrospectively reviewed ultrasound reports for 329 thyroidectomy patients and extracted data elements using the TI-RADS criteria: nodule size, echogenicity, margins, vascularity, solid/cystic composition and the presence or absence of microcalcifications and the halo sign. We assessed the reports to determine whether individual or multiple criteria were associated with malignancy.

RESULTS

More than 97% of reports document nodule size; however, more than 90% of the reports noted only 3 or fewer of the 6 remaining TI-RADS criteria. The presence of microcalcifications was the most sensitive marker of malignancy (> 90%), whereas the documentation of irregular margins was the most specific indicator of malignancy (88%). Overall it was clear that microcalcifications, hypoechogenicity, irregular margins and solid nodules were significantly more likely to be found in malignant neoplasms; their absence predicted benign disease. Because so few reports consistently documented all criteria, the overall ability of thyroid ultrasonography to discriminate between lowerand higher-risk nodules is limited.

CONCLUSION

Although the accuracy of thyroid ultrasonography is good, few ultrasound reports contain the necessary information, as defined by TI-RADS, to predict malignancy and guide management. When reported, microcalcifications and/or irregular margins are the best predictors of malignancy.

Detection and Measurement of Stones With Ultrasound Strain Elastography: A Phantom Study

The sonoelastographic appearances of stones in a phantom were evaluated in this study. Ten stones were embedded into a tissue-mimicking meat phantom. The stone axial (vertical) and transverse (horizontal) dimensions measured by an electronic digital caliper, gray-scale ultrasound, and strain elastography (SE) were compared in 5 groups with stones embedded at different depths. In this study, physically measured axial and transverse stone dimensions were 1.17 to 6.86 and 1.30 to 11.15 mm, respectively. Strain elastography showed a characteristic 3-layer pattern associated with stones, comprising a superficial transition region, a hard region, and a deep transition region. As SE data were available in group 5, only data of groups 1 to 4 were analyzed. Compared with physical measurements, measurement mean errors of SE horizontal and SE vertical dimensions ranged from -0.20 to 0.42 mm and from -1.28 to -0.05 mm, respectively, in the 4 groups. Paired t testing demonstrated a significant horizontal dimension measurement error difference between B mode and SE method in group 4 (0.44 vs -0.20 mm, P < 0.05; F = 1.18, P > 0.05), but not in the other groups. Strain elastography horizontal dimension measurement error was not statistically correlated with stone size in the 4 groups. Strain elastography vertical dimension measurement error significantly correlated with stone size only in group 4 (P < 0.05). Preliminary results indicate that stone horizontal and vertical dimensions can be measured using SE in a soft tissue phantom, including when shadowing precludes measurement of vertical dimension on conventional 2-dimensional ultrasound. These results provide substantial motivation to further investigate SE as a modality to image stones in clinical practice.

The Clinical Relevance of Psammoma Body and Hashimoto Thyroiditis in Papillary Thyroid Carcinoma: A Large Case-control Study

This study aims to investigate the impact of psammoma body (PB) on papillary thyroid carcinoma (PTC), and evaluate the association among PB, Hashimoto thyroiditis (HT), and other clinicopathologic characteristics in PTC patients.We conducted a retrospective case-control study involving 1052 PTC patients who underwent total thyroidectomy or lobectomy with lymph node dissection.Psammoma body was observed in 324 out of 1052 PTC (30.8%) patients. Ultrasonographic (US) calcification (P < 0.001), multifocality of the tumor (P = 0.047), lymph node metastasis (LNM) (P < 0.001), HT (P < 0.001), and Primary tumor (T), Regional lymph nodes (N), Distant metastasis (M) staging (P = 0.001) were significantly related to the presence of PB. The presence of PB was significantly associated with US microcalcification (P < 0.001). In the subgroup with HT, compared with the patients without PB, the patients with PB exhibited a higher frequency of central LNM (54.7% vs 32.1%; P < 0.001) and US microcalcification (94.7% vs 38.8%; P < 0.001), as well as smaller tumors (0.9 ± 0.6 vs 1.3 ± 0.9 cm; P < 0.001). In the subgroup without HT, the patients with PB displayed a higher incidence of lateral LNM (25.8% vs 14.6%; P < 0.001), US microcalcification (87.3% vs 52.5%; P < 0.001), and extrathyroidal extension (47.2% vs 34.8%; P = 0.001), as well as larger tumors (1.3 ± 0.9 vs 1.0 ± 0.8 cm; P < 0.001) than without PB. Moreover, in the subgroup with PB, the PTC patients with HT showed a higher LNM (77.9% vs 57.2%; P < 0.001) and a lower frequency of extrathyroidal extension (20.0% vs 47.2%; P < 0.001) than without HT.Psammoma body is a useful predictor of aggressive tumor behavior in PTC patients. HT with PB shows more aggressive behaviors than non-HT with PB in PTC patients.

The association of menstrual and reproductive factors with thyroid nodules in Chinese women older than 40 years of age

The purpose of the study was to explore the association of menstrual and reproductive factors with thyroid nodules in Chinese women older than 40 years of age. A questionnaire was completed by 6,571 women aged 40 years or older in a community-based epidemiological investigation of thyroid nodules conducted from June to November 2011 in Nanjing City. Thyroid nodules were measured by ultrasound. The Thyroid Imaging Reporting and Data System score was used to differentiate between benign and possibly malignant nodules. Menopausal age (>55 vs. <50 years: RR = 1.17, 95 % CI 1.00-1.34) and number of reproductive years (>40 vs. <35 years: RR = 1.12, 95 % CI 1.01-1.24) increased the risk of thyroid nodules, but were not associated with suspected malignant nodules. Women who experienced more pregnancies (≥5 vs. ≤1: RR = 2.09, 95 % CI 1.79-2.40) and abortions (≥3 vs. 0: RR = 1.61, 95 % CI 1.41-1.81) were prone to development of thyroid nodules, and more likely to form suspected malignant nodules (pregnancies, RR = 3.59, 95 % CI 1.60-7.20; abortions, RR = 2.36, 95 % CI 1.31-4.06). Furthermore, higher risks of thyroid nodules (RR = 1.36, 95 % CI 1.14-1.59) and suspected malignant nodules (RR = 2.80, 95 % CI 1.08-6.53) were observed in women who had undergone artificial compared with natural abortion. Periods of elevated estrogen and progesterone levels in women, such as pregnancy, were the key occasions for occurrence of both benign and suspiciously malignant thyroid nodules, while longer lifetime length of exposure to female sex hormones might promote the growth of thyroid nodules.

Thyroid nodules: pathophysiological insight on oncogenesis and novel diagnostic techniques

Thyroid nodules are a very frequent pathology among common population. Despite the vast majority of them are of benign origin, the incidence of thyroid cancer is currently rather rising. Although there are several risk factors of thyroid cancer and several clinical, ultrasound, biochemical and molecular diagnostic markers, the exact mechanisms of thyroid oncogenesis and the linkage between thyroid nodule ultrasound appearance and its biological character remain unclear. While ionizing radiation is the only one well-known risk factor for thyroid cancer, the significance of some others remains unclear. The aim of our review was to discuss some not completely known pathophysiological mechanisms involved in thyroid oncogenesis as hypothyroidism, mutations of genes regulating cell proliferation, thyroid autoimmunity and pregnancy and to describe pathophysiological background of some ultrasound markers of thyroid cancer (size, echogenicity, vascularization, calcifications and stiffness). Better knowledge in this field is crucial for development of novel diagnostic techniques and therapeutic approaches. For example, the analysis of BRAF, RAS and other mutations in cytological samples may help to distinction between follicular thyroid carcinoma and follicular thyroid adenoma and may significantly decrease the number of unnecessary surgery among patients with thyroid nodules. Alternatively, the different malign cells growth, angiogenesis, destructions of thyroid follicles, reparative changes, growth retardation, fibrosis and increased interstitial fluid pressure implicate the typical ultrasound appearance of papillary thyroid cancer (hypoechogenicity, irregular vascularization, microcalcifications, stiffness) which is essential to catch the suspicious nodules on the basis of their ultrasound appearance among large amount of benign nodules.

Multiple autoimmunity, type 1 diabetes (T1DM), autoimmune thyroiditis and thyroid cancer: is there an association? A case report and literature review

Type 1 diabetes mellitus (T1DM) is characterized by selective autoimmune destruction of pancreatic b-cells, resulting in insulin deficiency. Associated autoimmune disorders, such as celiac disease, autoimmune thyroiditis, and gastritis, can coexist in patients with T1DM. These disorders are characterized by the presence of antibodies against tissue transglutaminase (anti-tTG-IgA), thyroglobulin, and thyroid peroxidase (anti-TG, anti-TPO), as well as antibodies against gastric parietal cells. Children with T1DM may also develop organ-specific multiple autoimmunity, with the coexistence of one or more autoimmune disorders. Furthermore, there is a lot of controversy regarding the role of thyroid autoimmunity in the pathogenesis of thyroid cancer. We present a child with T1DM and multiple autoimmunity including autoimmune Hashimoto's thyroiditis (HT), who developed thyroid cancer. The literature on the prevalence of associated autoimmunity in children with T1DM and the prevalence, pathogenesis, and timely diagnosis of thyroid cancer among patients with HT is also reviewed.

Differential profile of ultrasound findings associated with malignancy in mixed and solid thyroid nodules in an elderly female population

Objective. Ultrasonographic characteristics are associated with thyroid malignancy. Our aim was to compare the diagnostic value of ultrasound features in the detection of thyroid malignancy in both solid and mixed nodules. Methods. We prospectively studied female patients (≥50 years) referred to ultrasound-guided fine needle aspiration biopsy. Ultrasound features considered suspicious were hypoechogenicity, microcalcifications, irregular margins, high anteroposterior (AP)/axial-ratio, and absent halo. Associations were separately assessed in mixed and solid nodules. Results. In a group of 504 elderly female patients (age = 69 ± 8 years), the frequency of malignant cytology was 6%. Thirty-one percent of nodules were mixed and 60% were solid. The rate of malignant cytology was similar for mixed and solid nodules (7.4 versus 5.8%, P: 0.56). While in mixed nodules none of the ultrasound characteristics were associated with malignant cytology, in solid nodules irregular margins and microcalcifications were significant (all P < 0.05). The combination of irregular margins and/or microcalcifications significantly increased the association with malignant cytology only in solid nodules (OR: 2.76 (95% CI: 1.25–6.10), P: 0.012). Conclusions. Ultrasound features were of poor diagnostic value in mixed nodules, which harbored malignant lesions as often as solid nodules. Our findings challenge the recommended minimal size for ultrasound-guided fine needle aspiration biopsy in mixed nodules.

Quantification of cancer risk of each clinical and ultrasonographic suspicious feature of thyroid nodules: a systematic review and meta-analysis

OBJECTIVE

In order to quantify the risk of malignancy of clinical and ultrasonographic features of thyroid nodules (TNs), we did a systematic review and meta-analysis of published studies.

METHODS

We did a literature search in MEDLINE for studies published from 1st January 1989 until 31st December 2012. Studies were considered eligible if they investigated the association between at least one clinical/ultrasonographic feature and the risk of malignancy, did not have exclusion criteria for the detected nodules, had histologically confirmed the diagnoses of malignancy, and had a univariable analysis available. Two reviewers independently extracted data on study characteristics and outcomes.

RESULTS

The meta-analysis included 41 studies, for a total of 29678 TN. A higher risk of malignancy expressed in odds ratio (OR) was found for the following: nodule height greater than width (OR: 10.15), absent halo sign (OR: 7.14), microcalcifications (OR: 6.76), irregular margins (OR: 6.12), hypoechogenicity (OR: 5.07), solid nodule structure (OR: 4.69), intranodular vascularization (OR: 3.76), family history of thyroid carcinoma (OR: 2.29), nodule size ≥4 cm (OR: 1.63), single nodule (OR: 1.43), history of head/neck irradiation (OR: 1.29), and male gender (OR: 1.22). Interestingly, meta-regression analysis showed a higher risk of malignancy for hypoechoic nodules in iodine-sufficient than in iodine-deficient geographical areas.

CONCLUSIONS

The current meta-analysis verified and weighed out each suspicious clinical and ultrasonographic TN feature. The highest risk was found for nodule height greater than width, absent halo sign, and microcalcifications for ultrasonographic features and family history of thyroid carcinoma for clinical features. A meta-analysis-derived grading system of TN malignancy risk, validated on a large prospective cohort, could be a useful tool in TN diagnostic work-up.

Diagnostic Value of Ultrasound-detected Calcification in Thyroid Nodules

Introduction: This study analyses the diagnostic value of ultrasonography (US) detection for calcification in thyroid nodules. Materials and Methods: We analysed the preoperative US findings and clinical characteristics of 577 malignant and 3434 benign thyroid patients who underwent surgery in our hospital. Results: The malignant rate in patients with microcalcification hyperechoic and tiny calcification foci ≤2 mm in diameter was significantly higher than the non-calcification and other calcification group (P <0.001). The malignant rate in single calcification nodule was significantly higher than that in multiple nodule group (P <0.01). Most of the patients (37/39) with lymph node calcification were malignant. The malignant rate of calcification and microcalcification was significantly higher in patients <45 years old than in older patients (P <0.05). Conclusion: Compared with other calcifications, microcalcification should be a better predictor of thyroid carcinoma. Malignancy should be highly suspected in patients with single calcification nodule, especially with lymph node calcification. Patients younger than 45 years of age with calcification or microcalcification have a greater risk for thyroid carcinoma. Key words: Age, Single nodule, Thyroid carcinoma, Ultrasonography

Do hyperechoic thyroid nodules on B-ultrasound represent calcification?

OBJECTIVE

To explore the correlation between hyperechoic thyroid nodules observed on B-ultrasound and histological calcification seen in paraffin-wax sections.

METHODS

Records of patients who underwent surgical removal of thyroid nodules diagnosed on preoperative B-ultrasound were analysed retrospectively. Calcification present on B-ultrasound was compared with calcification seen in postoperative pathology specimens.

RESULTS

Of the 1,655 patients included in the study, 518 had malignant and 1,137 had benign thyroid nodules. Calcification on B-ultrasound was seen in 366 patients with malignant, and 414 with benign nodules. Calcification was confirmed on histology in 209 and 127 of these patients, respectively, giving a sensitivity and specificity for B-ultrasound in diagnosing calcification (compared with histology) of 95.87% and 47.67%, respectively, in thyroid cancer and 90.71%, and 71.21% respectively in benign thyroid nodules. Microcalcification was seen in 483 patients on B-ultrasound and in 186 on histology, of whom 294 (60.87%) and 152 (81.72%), respectively, had thyroid cancer.

CONCLUSIONS

B-ultrasound is a useful and accurate test for detecting calcification in thyroid nodules, with a high sensitivity. There is a close association between calcification (especially microcalcification) and thyroid cancer on both B-ultrasound and pathological examination.