Thyroid nodule update on diagnosis and management

Near-Infrared Spectroscopy for Distinguishing Malignancy in Thyroid Nodules

Thyroid nodules are common clinical entities, with a significant proportion being malignant. Early, accurate, and non-invasive tools to differentiate benign and malignant nodules can optimize patient management and reduce unnecessary surgery. This study aimed to evaluate the efficacy and accuracy of near-infrared spectroscopy (NIRS) in distinguishing benign from malignant thyroid nodules. A diffuse reflectance spectrum for a total of 20 thyroid nodule samples (10 samples as colloid goiter and 10 samples as thyroid cancer), were acquired in the wavelength range from 1000 to 2500 nm. Spectral data from NIRS were analyzed by means of principal component analysis (PCA), quadratic discriminant analysis (QDA), and linear discriminant analysis (LDA) to classify and differentiate thyroid nodule samples. The present study found that NIRS effectively distinguished colloid goiter and thyroid cancer using the first two principal components (PCs), explaining 90% and 10% of the variance, respectively. QDA discrimination plot displayed a clear separation between colloid goiter and thyroid cancer with minimal overlap, aligning with reported 95% accuracy. Additionally, applying LDA to seven PCs from PCA achieved a 100% accuracy rate in classifying colloid goiter and thyroid cancer from near-infrared spectral data. In conclusion, NIRS offers a promising, non-invasive complementing diagnostic tool for differentiating benign from malignant thyroid nodules with high accuracy. Future work should integrate these results into predictive model development, emphasizing external validation, alternative performance metrics, and protecting against potential overfitting translation of a machine learning model to a clinical setting.

Machine learning to predict the occurrence of thyroid nodules: towards a quantitative approach for judicious utilization of thyroid ultrasonography

Introduction

Ultrasound is instrumental in the early detection of thyroid nodules, which is crucial for appropriate management and favorable outcomes. However, there is a lack of clinical guidelines for the judicious use of thyroid ultrasonography in routine screening. Machine learning (ML) has been increasingly used on big data to predict clinical outcomes. This study aims to leverage the ML approach in assessing the risk of thyroid nodules based on common clinical features.

Methods

Data were sourced from a Chinese cohort undergoing routine physical examinations including thyroid ultrasonography between 2013 and 2023. Models were established to predict the 3-year risk of thyroid nodules based on patients' baseline characteristics and laboratory tests. Four ML algorithms, including logistic regression, random forest, extreme gradient boosting, and light gradient boosting machine, were trained and tested using fivefold cross-validation. The importance of each feature was measured by the permutation score. A nomogram was established to facilitate risk assessment in the clinical settings.

Results

The final dataset comprised 4,386 eligible subjects. Thyroid nodules were detected in 54.8% (n=2,404) individuals within the 3-year observation period. All ML models significantly outperformed the baseline regression model, successfully predicting the occurrence of thyroid nodules in approximately two-thirds of individuals. Age, high-density lipoprotein, fasting blood glucose and creatinine levels exhibited the highest impact on the outcome in these models. The nomogram showed consistency and validity, providing greater net benefits for clinical decision-making than other strategies.

Conclusion

This study demonstrates the viability of an ML-based approach in predicting the occurrence of thyroid nodules. The findings highlight the potential of ML models in identifying high-risk individuals for personalized screening, thereby guiding the judicious use of ultrasound in this context.

Diagnostic Accuracy of Fine-Needle Aspiration Cytology (FNAC) in Thyroid Nodule Excision Cases

INTRODUCTION

Fine needle aspiration cytology (FNAC) for thyroid nodules has a high diagnostic accuracy, according to several studies worldwide. Patients who experienced preoperative FNAC had more optimal surgical treatment than others who did not perform FNAC. Therefore, achieving an accurate FNAC procedure appears to be an important tool for the proper management of thyroid nodules. We aimed to study the accuracy and challenges of the thyroid FNAC diagnostic tool in the Al-Baha region, Kingdom of Saudi Arabia.

METHODS

The study involves 52 patients with thyroid nodules who underwent preoperative FNAC and postoperative histopathology with the same surgery and pathology team at Al-Baha region in 2022-2023.

RESULTS AND CONCLUSION

The mean age of the included patients was 47.7 years, with a female predominance. The diagnostic accuracy was 90%, and the main cause of inaccurate diagnosis was processing challenges, where the majority of cases were taken on the palpation-only technique, a few cases were ultrasound-guided, and the only technique used in the laboratory was conventional smears. The applied interrater reliability Cohen kappa coefficient (κ) for the clinical-histopathological agreement was "moderate agreement". We recommend using and evaluating more cytological techniques in addition to the currently used conventional smears in pathology laboratories to enhance the efficacy of the FNAC diagnosis of thyroid lesions.

Approach to Thyroid Nodules: Diagnosis and Treatment

Thyroid nodules (TNs) are prevalent and found in up to 50% of individuals. While most TNs are benign, some can be malignant. The evaluation of TNs is crucial to rule out malignancy and identify those requiring surgical intervention. This study aimed to clarify the reported prevalence of TNs, focusing specifically on their various types, assessment and diagnostic processes, current evaluation methods, and evidence-based management. It also provides recommendations for follow-up. TNs are typically found during physical exams or incidentally during imaging procedures. Routine laboratory and clinical evaluations of TNs are common. Ultrasound is the preferred imaging method to determine if a TN needs a biopsy. Fine-needle aspiration (FNA) is crucial in deciding whether surgery or surveillance is necessary. TNs that show suspicious features on the ultrasound may require cytologic analysis to assess the risk of malignancy. The effectiveness of several supplementary molecular tests is still uncertain, although some studies report promising results. The management and treatment approach for TNs primarily depends on the results of FNA cytology and ultrasound characteristics. The optimal treatment strategy for TNs ranges from straightforward follow-ups for low-risk cases to surgical intervention for high-risk patients. Rather than adopting a uniform approach, clinicians should assess each patient on a case-by-case basis using current knowledge and a collaborative, multidisciplinary method.

The Role of Frozen Section Examination in Thyroid Surgery

In endocrine pathology, frozen section (FS) examination is most commonly used for the intraoperative evaluation of thyroid and parathyroid tumors, as well as cervical lymph nodes. In the past, frozen section was considered a fundamental tool in thyroid surgery. However, with advancements in preoperative ultrasound and fine-needle aspiration biopsy (FNAB), there have been increasing queries about its routine use due to the improved preoperative diagnosis. Nowadays, while the use of FS during thyroidectomy has decreased, it is still used as an additional method for different purposes intraoperatively. FS may not always provide definitive results. If FS will alter the surgical plan or extent, it should be applied. Routine FS is not recommended for evaluating thyroid nodules. But in addition to FNAB, if FS results may change the operation plan or extent, they can be utilized. FS should not be applied for thyroid lesions smaller than 1 cm, and the entire lesion should not be frozen for FS. For the assessment of thyroid nodules, the use of FS is recommended based on the Bethesda categories of FNAB. In Bethesda I category nodules, FS may contribute to distinguishing between malignant and benign lesions and guide surgical treatment. In Bethesda II nodules, where the malignancy rate is low, the performance of FNAB and FS can be compared, but it's not recommended due to the lack of a significant contribution to the surgical strategy. The sensitivity of FS in Bethesda III and IV nodules is low; its contribution to the diagnosis is limited, and it does not provide an apparent benefit to treatment; therefore, it is not recommended. In Bethesda V nodules, FS can effectively confirm the malignancy diagnosis, contribute to the surgical strategy, and reduce the possibility of completion thyroidectomy, and accordingly, it is recommended for use. Nonetheless, in Bethesda V nodules with a benign FS report, the malignancy rate remains high, so it should not be used to rule out malignancy. In Bethesda VI nodules, the performance of FS is lower or comparable to FNAB and does not significantly contribute to the treatment strategy; hence, it is not recommended. Particularly in patients with papillary thyroid cancer, intraoperative FS can be effective in detecting extrathyroidal extension and can assist the surgeon in determining the extent of thyroid surgery and central neck dissection. FS has high sensitivity and specificity in evaluating the lymphatic status of the central region intraoperatively and can be used to determine the extent of central compartment node dissection. During thyroidectomy, FS examination can be used in recognizing parathyroid tissue and distinguishing it from fatty tissue, thymus, thyroid, lymph nodes, especially in differentiating metastatic lymph nodes.

Comparison of the effects of contrast-enhanced ultrasound and conventional ultrasound-guided radiofrequency ablation on benign thyroid nodules

Objective

To compare the effect of contrast-enhanced ultrasound (CEUS) and conventional ultrasound-guided radiofrequency ablation (RFA) on benign thyroid nodules (BTNs).

Methods

In this retrospective observational study, the data of 72 patients with BTNs who received RFA treatment in The Fourth Affiliated Hospital of Zhejiang University School of Medicine from January 2020 to December 2021 were retrospectively reviewed and selected. The records showed that 34 patients received RFA under the guidance of conventional ultrasound (conventional ultrasound group) and 38 patients received RFA under the guidance of CEUS (CEUS group). The effect of treatment, complications and recurrence of the two groups were compared and analyzed.

Results

There was a smaller volume of thyroid nodules in the two groups immediately post-operation. The incidence of complications was lower in the CEUS group (5.26%) compared to the conventional ultrasound group (23.53%) (P<0.05). The recurrence rate at 6-months (0.00% vs 11.76%) and 12- months (2.63% vs 20.59%) post-operation was lower in the CEUS group compared to the conventional ultrasound group (P<0.05).

Conclusions

Compared with conventional ultrasound, CEUS-guided RFA is effective in treating BTNs, with smaller postoperative nodule volume, reduced occurrence of surgical complications, and reduced recurrence rate of thyroid nodules.

Biomarker Discovery for Early Diagnosis of Papillary Thyroid Carcinoma Using High-Throughput Enhanced Quantitative Plasma Proteomics

The incidence of thyroid cancer (TC) has been increasing over the last 50 years worldwide. A higher rate of overdiagnosis in indolent thyroid lesions has resulted in unnecessary treatment. An accurate detection of TC at an early stage is highly demanded. We aim to develop an enhanced isobaric labeling-based high-throughput plasma quantitative proteomics to identify biomarkers in a discovery cohort. Selected candidates were tested by enzyme-linked immunosorbent assay (ELISA) in the training cohort and validation cohort. In total, 1063 proteins were quantified, and 129 proteins were differentially expressed between patients and healthy subjects. Serum levels of ISG15 and PLXNB2 were significantly elevated in patients with papillary thyroid cancer (PTC) or thyroid adenoma, compared to healthy subjects (p < 0.001) and patients with nodular goiter (p < 0.001). Receiver operating characteristic (ROC) analysis of combined markers (ISG15 and PLXNB2) significantly distinguished PTC from healthy control (HC) subjects. Similar differentiations were also found between thyroid adenoma and HC subjects. Notably, this combined marker could distinguish stage-I PTC from HC subjects (area under the curve (AUC) = 0.872). Our results revealed that ISG15 and PLXNB2 are independent diagnostic biomarkers for PTC and thyroid adenoma, showing a promising value for the early detection of PTC.

Differentiating benign and malignant thyroid nodules: A cross-sectional study on the comparison of diagnostic value of ultrasound elastography and fine needle aspiration biopsy

Background and Aim

This study examines the comparison of ultrasound elastography and fine needle aspiration (FNA) in diagnosing thyroid cancers and investigates the use of elastography as the initial diagnostic test of thyroid cancers to avoid the need for invasive diagnostic tests.

Methods

In this study, 28 patients with 48 thyroid nodules (TNs) who were candidates for FNA or surgery were examined within a period of 18 months. Cut-off and subsequently sensitivity and specificity for elastography results, compared to pathology results as the gold standard, were calculated using the receiver operating characteristic curve (ROC).

Results

Based on ROC, the cut-off point differentiating the tissue stiffness between benign and malignant TNs was 25.400 kilopascal (kPa) (sensitivity of 90.9% and specificity of 78.4%). It was observed that age affects the tissue stiffness; therefore, the cut-off was defined as 65.625 kpa for age groups under 50 years old (sensitivity of 100% and specificity of 100%) and 25.400 kpa for the age group above 50 years old (sensitivity of 88.9% and specificity of 70.4%).

Conclusion

Based on the high sensitivity and specificity of shear wave elastography in the differentiation of benign and malignant TNs, it can be employed as a stand-alone or in combination with other diagnostic techniques to reduce the need for inessential surgical operations. However, future studies or developments are needed on this promising diagnostic technique.

Preoperative Thyroid-Stimulating Hormone Levels and Risk of Thyroid Cancer in Post-thyroidectomy Patients for Thyroid Nodules: A Study From a Tertiary Hospital in Western Saudi Arabia

Background Although serum thyroid-stimulating hormone (TSH) is one of the basic investigations to assess thyroid nodules, its role in thyroid oncogenesis remains unclear. Previous literature has conflicting findings regarding TSH levels and the prediction of malignancy. This study aims to investigate the association between TSH levels and the risk of malignancy and advanced staging in patients who underwent thyroidectomy for nodular thyroid disease. Additionally, it aims to assess if higher TSH correlates with malignancy in Bethesda staging III, IV, and V. Methodology This retrospective cohort study was conducted among participants who underwent near-total/total thyroidectomy or hemithyroidectomy at King Abdulaziz Medical City between 2016 and 2021. Results A total of 378 cases were included, and 50.3% of the cases had malignant nodules in the surgical histopathology findings. The median TSH levels were higher in malignant nodules compared to benign ones (1.64 mIU/L versus 1.49 mIU/L; p < 0.001). Additionally, higher TSH levels were not associated with advanced staging or malignancy in patients with Bethesda stage III-V. Conclusions Higher TSH levels are associated with an increased risk of malignancy in patients with nodular thyroid disease. Using TSH levels as an adjunctive tool for identifying high-risk patients with thyroid nodules would aid in management planning.

Management of Thyroid Nodules

Thyroid nodules are common and the prevalence varies between 4 and 7% by palpation and 19-68% by high-resolution USG. Most thyroid nodules are benign, and the malignancy rate varies between 7 and 15% of patients. Thyroid nodules are detected incidentally during clinical examination or, more often, during imaging studies performed for another reason. All detected thyroid nodules should be evaluated clinically. The main test in evaluating thyroid function is thyroid stimulating hormone (TSH). If the serum TSH level is below the normal reference range, a radionuclide thyroid scan should be performed to determine whether the nodule is hyperfunctioning. If the serum TSH level is normal or high, ultrasonography (US) should be performed to evaluate the nodule. US is the most sensitive imaging method in the evaluation of thyroid nodules. Computed tomography (CT) and magnetic resonance imaging are not routinely used in the initial evaluation of thyroid nodules. There are many risk classification systems according to the USG characteristics of thyroid nodules, and the most widely used in clinical practice are the American Thyroid Association guideline and the American College of Radiology Thyroid Imaging Reporting and Data System. Fine needle aspiration biopsy (FNAB) is the gold standard method in the evaluation of nodules with indication according to USG risk class. In the cytological evaluation of FNAB, the Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) is the most frequently applied cytological classification. TBSRTC is a simplified, 6-category reporting system and was updated in 2023. The application of molecular tests to FNAB specimens, especially those diagnosed with Bethesda III and IV, is increasing to reduce the need for diagnostic surgery. Especially in Bethesda III and IV nodules, different methods are applied in the treatment of nodules according to the malignancy risk of each category, these are follow-up, surgical treatment, radioactive iodine treatment, and non-surgical ablation methods.

[Sociodemographic, clinical and ultrasound characterization of thyroid nodule pathology and its association with malignancy in a Colombian high-complexity center]

BACKGROUND AND OBJECTIVE

Thyroid nodules are among the most frequent conditions, with a 10% risk of malignancy. The objective is to describe the frequency of demographic, clinical, and ultrasonographic characteristics of thyroid nodule pathology in adults and to explore the relationship with tumor malignancy.

METHODS

An analytical, retrospective cross-sectional study in adults with thyroid nodules and nodular fine-needle aspiration performed in adult patients from a Colombian reference center between 2009-2019. Data were obtained from the clinical history, descriptive measures of the patient's demographic, clinical, and ultrasound variables were estimated, and their relationship with the malignancy of the tumor was explored.

RESULTS

A total of 445 patients and 515 nodules were included. The median age was 55 years (IQR 44-64), 86.8% of women, and 54.8% had a single lesion. Percentages of 80.2 and 19.8 were benign and malignant nodules, with a median of 15.7mm (IQR 11-25) and 12.7mm (IQR 8.5-18.3), respectively (p<0.001). Hypothyroidism and levothyroxine consumption were higher in those with malignant nodules (p<0.001). The echographic characteristics were statistically different between the nodules. In the malignant ones, there was a higher frequency of solid composition, hypoechogenicity, and irregular margins. In contrast, in the benign ones, the absence of echogenic focus stood out (p<0.001).

CONCLUSION

The ultrasound characteristics are essential to define the risk of malignancy of a thyroid nodule. Therefore, considering the most frequent ones can help in the most appropriate approach to primary care.

Correlation of Thyroid Fine Needle Aspiration Biopsy With Histopathological Results

Introduction Fine needle aspiration biopsy (FNAB) is an effective method used in the differential diagnosis of thyroid nodules. The Bethesda system has contributed to the determination of clinical approaches by bringing standardization to cytopathology reporting. However, the rate of cytological-histological incompatibility varies between 10% and 30%. Results differ according to clinics in the literature. These results create a need to reevaluate the efficacy and safety of fine needle aspiration biopsy. In this study, we aimed to evaluate the diagnostic accuracy of FNAB of thyroid nodules by correlating the cytopathology results of FNAB with the results of postoperative histopathology. Methods In this retrospective study, thyroid FNAB results and postoperative histopathology results of patients who underwent thyroidectomy operations in our clinic between January 2018 and December 2021 were compared. Accuracy, sensitivity (Sn), specificity (Sp), positive predictive value (PPV), negative predictive value (NPV), false positive rate (FPR), and false negative rate (FNR) were calculated. Cases with nondiagnostic FNAB results were excluded from the calculations. FNAB results with a follicular neoplasm/suspicious for a follicular neoplasm (FN/SFN) and suspicious for malignancy were included in the malignant group. Results A total of 304 patients were included in the study. The male/female ratio was 1:3.3. As a result of the study, malignancy was detected histopathologically in 47 (15.46%) patients. The commonest malignancy detected was papillary carcinoma. According to the Bethesda system, the results were evaluated in six categories. The incidence of malignancy in the Bethesda categories were 0%, 4%, 40%, 69.2%, 100%, and 100%, respectively. Accordingly, the specificity and sensitivity of FNAB for detecting malignancy were 98.7% and 66.6%, respectively. The accuracy was 93.5%. The false positive rate, false negative rate, positive predictive value, and negative predictive value were 1.20%, 33.3%, 91.4%, and 93.8%, respectively. Conclusion Thyroid FNAB is an effective method used with satisfactory reliability in the differential diagnosis of malignancies of thyroid nodules. Still, it has some limitations. This article demonstrates higher rates of malignancy in Bethesda categories III and IV. Therefore, clinical approaches are gaining importance in these categories.

Case report: Thyroid sarcoidosis as a rare localization of the disease: Report of two cases and review of the literature

Sarcoidosis is a multi-systemic disease of unknown etiology that is characterized by the formation of non-necrotizing and non-caseating granulomas in affected organs. Sarcoidosis granulomas can form in any organ, but the lungs and intrathoracic lymph nodes are the most commonly affected. Thyroid involvement in sarcoidosis is very rare, with prevalence estimates of 1–4.5% in case series of autopsied patients with systemic sarcoidosis. It is extremely rare for sarcoidosis to occur solely in the thyroid gland, but it is usually associated with the involvement of other organs, primarily the lungs and lymph nodes. Typical manifestations are diffuse goiter and solitary or multiple thyroid nodules. Thyroid function remains intact in the majority of cases, but sometimes it can result in hypothyroidism or hyperthyroidism. The diagnosis can be made after fine needle aspiration cytology, but usually it is diagnosed as an incidental finding while analyzing thyroidectomy tissue or during autopsy. Oral steroids are the cornerstone of thyroid sarcoidosis management, along with specific endocrinological treatment on some occasions. Given that we found only 71 reports of thyroid sarcoidosis available in the literature, we created and analyzed a cohort of 24 patients with thyroid sarcoidosis who were described in the literature in the 21st century and reported two additional cases of thyroid sarcoidosis.

Cell-free DNA methylation biomarker for the diagnosis of papillary thyroid carcinoma

BACKGROUND

Cell-free DNA (cfDNA) is being explored as biomarker for non-invasive diagnosis of cancer. We aimed to establish a cfDNA-based DNA methylation marker panel to differentially diagnose papillary thyroid carcinoma (PTC) from benign thyroid nodule (BTN).

METHODS

220 PTC- and 188 BTN patients were enrolled. Methylation markers of PTC were identified from patients' tissue and plasma by reduced representation bisulfite sequencing and methylation haplotype analyses. They were combined with PTC markers from literatures and were tested on additional PTC and BTN samples to verify PTC-detecting ability using targeted methylation sequencing. Top markers were developed into ThyMet and were tested in 113 PTC and 88 BTN cases to train and validate a PTC-plasma classifier. Integration of ThyMet and thyroid ultrasonography was explored to improve accuracy.

FINDINGS

From 859 potential PTC plasma-discriminating markers that include 81 markers identified by us, the top 98 most PTC plasma-discriminating markers were selected for ThyMet. A 6-marker ThyMet classifier for PTC plasma was trained. In validation it achieved an Area Under the Curve (AUC) of 0.828, similar to thyroid ultrasonography (0.833) but at higher specificity (0.722 and 0.625 for ThyMet and ultrasonography, respectively). A combinatorial classifier by them, ThyMet-US, improved AUC to 0.923 (sensitivity = 0.957, specificity = 0.708).

INTERPRETATION

The ThyMet classifier improved the specificity of differentiating PTC from BTN over ultrasonography. The combinatorial ThyMet-US classifier may be effective in preoperative diagnosis of PTC.

FUNDING

This work was supported by the grants from National Natural Science Foundation of China (82072956 and 81772850).

Development and validation of the clinical report form for nodular thyroid pathologies

Objective

The aim of this study is to develop and validate a novel clinical report form in the format of a structured interview to enable the characterization of the Portuguese population of the Baixo Vouga region with different subtypes of nodular thyroid pathologies (NTyPs).

Materials and methods

A structured interview was developed and to the best of our knowledge, this is the first structured interview built and validated for that purpose in Portugal.

Results

This structured interview enables the identification of possible correlations between each subtype of nodular lesions and sociodemographic data, consumption habits and lifestyle, endocrine history, and family predisposition.

Conclusion

The novel structured interview will simultaneously, enable a detailed characterization of the group of patients with nodular thyroid lesions and will support future metabolomic studies.

Thyroid nodules: Global, economic, and personal burdens

Thyroid nodules have garnered attention due to changes in population surveillance systems and rising concerns about the associated financial burden on healthcare systems, payers, and patients. In this review, we find that prevalence rates vary widely based on method of detection and may particularly pronounced in asymptomatic patients undergoing routine screening. Incidence rates may be particularly rising in lower-income and middle-income countries and may be declining in higher-income countries. Despite high incidence rates, survival rates continue to be as high as 97% for papillary thyroid cancer. Over the last few decades, thyroid nodule workup and management has grown more sophisticated with the advent of fine-needle aspiration biopsy, specialized biomarkers, and molecular testing. However, gaps remain in risk stratification that can lead to substantial costs of care. Certain molecular tests, such as the Afirma Gene Sequencing Classifier can lead to a cost per diagnosis of $17,873 while achieving only mild decreases in diagnostic lobectomies for patients (11.6% to 9.7% in one study). Out-of-pocket costs associated with thyroid nodule management continue to drive significant financial toxicity for patients, especially for individuals with thyroid cancer. Financial toxicity has been defined as a term that describes how direct and indirect medical costs of cancer care strain patients and households via decreased income, assets, and spending on basic necessities. Recent studies suggest that such toxicity can lead to adverse financial outcomes, such as foreclosure and bankruptcy. Additional cost-effectiveness analyses are needed to improve existing thyroid nodule management systems and new clinical tools are needed to avoid unnecessary workup and management.

An artificial neural network for the prediction of the risk of malignancy in category III Bethesda thyroid lesions

BACKGROUND

The diagnosis of cases of atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS) by fine needle aspiration cytology (FNAC) is challenging for both cytopathologists and clinicians. It is extremely difficult to predict the risk of malignancy based on cytological features alone.

AIMS AND OBJECTIVES

In this study, we attempted to construct an artificial neural network (ANN) model to predict the risk of malignancy in FNAC cases of AUS/FLUS in thyroid lesions based on cytological features.

MATERIALS AND METHODS

We included two groups of AUS/FLUS cases: (1) 29 cases of histopathologically proven malignancy, and (2) 32 cases that had either been histopathologically proven to be benign, or for which no progress of malignancy on follow-up had been observed in the last 2 years. Cytological characteristics were analysed semi-quantitatively by two independent observers (TS and PD). Based on these data, we tried to generate an artificial neural network (ANN) model to differentiate between malignant and benign cases. The performance of the ANN was assessed using the confusion matrix and receiving operator curve.

RESULTS

There were 29 malignant cases of AUS/FLUS (histopathologically proven) and 32 benign/follow-up cases in this study. There were 41 cases in the training set, 9 cases in the validation set and 11 cases in the test set. In the test group, the ANN model successfully distinguished between all benign (5/5) and malignant cases (6/6). The area under the receiver operating curve was 1.

CONCLUSION

The present ANN model is well structured and coherent to distinguish malignant from benign outcomes in AUS/FLUS cases on cytology smears with no error. This is an open-ended ANN model, and additional parameters and more cases could be included to make the model more robust.

The Spectrum of Thyroid Nodules at Kinshasa University Hospital, Democratic Republic of Congo: A Cross-Sectional Study

We analyzed the spectrum of thyroid nodules in patients attending the endocrinology unit care of the Kinshasa University Hospital and assessed their associated factors. We conducted a cross-sectional study, performing descriptive statistics and logistic regression. From the 888 enrolled patients, thyroid nodules were detected in 658 patients (74.1%), as mononodules in 22.5% and multiple nodules in 77.5%. Thyroid function was normal in 71.3% cases, while hyperthyroidism and hypothyroidism were found in 26.1% and 2.6% of cases, respectively. Women were more affected than men (75.1% vs. 63.6%; p = 0.03). Patients with thyroid nodules were older (44 ± 12 vs. 38 ± 12 years; p < 0.001), with a family history of goiter (38.3% vs. 27.4%; p = 0.003) and residence in the iodine-deficient region (51.7% vs. 38.8%; p = 0.012); they had a higher proportion of longer delays to consultation (47% vs. 20%; p < 0.001), but a higher rate of normal thyroid function (85.5% vs. 3 1.3%; p < 0.001). Thyroid nodules were associated with the delay to consultation (for duration ≥ three years, OR: 6.560 [95% CI: 3.525−12.208)], multiparity (present vs. absent: 2.863 [1.475−5.557]) and family history of goiter (present vs. absent: 2.086 [95% CI:1.231−3.534]) in female patients alone. The high frequency of thyroid nodules observed requires measures aimed at early detection in the population, the training of doctors involved in the management and the strengthening of technical platforms in our hospitals.

Is conservative management of the indeterminate thyroid nodule [Thy3f or Bethesda category IV] safe?

PURPOSE

The histological diagnosis after diagnostic thyroidectomy for indeterminate thyroid nodules is often non-malignant and some cancers detected are considered 'indolent'. The safety and effectiveness of conservative management in these patients are unclear. The aim of this study was to determine the safety of conservative management of indeterminate thyroid nodules and to explore association between clinical features and pathology in patients undergoing surgery.

METHODS

This is a retrospective cohort study of patients presenting to a single centre over a 4-year period (2013-2016) with thyroid nodules that were considered indeterminate (thy3f in the UK RCPath classification) on cytology. Demographic data, ultrasound features, follow-up details (in those undergoing conservative management) and histology details (in those undergoing surgery) were collected.

RESULTS

Of 164 patients that had Thy3f cytology, 34 were initially managed conservatively; however, 4 of these eventually had surgery (due to patient preference). No patient on conservative management had significant disease progression on ultrasound at a median (interquartile range) of 27 (16-40) months. Of the 134 patients that underwent surgery, 26 had thyroid malignancy. The BTA 'U' classification, gender and age (> 55) were not associated with malignancy in these nodules, but larger nodules (> 40 mm) were more likely to be malignant (p = 0.042).

CONCLUSIONS

Conservative management of indeterminate (Thy3f or Bethesda stage IV) thyroid nodules is safe in the short term and may be indicated in selected cases after appropriate discussion of risks and benefits of surgery.

Can Thyrotropin, Tri-Iodothyronine, and Thyroxine Hormones be Predictors of Cancer in Thyroid Lesions?

Background Thyroid nodules are a common medical problem worldwide. This study aims to investigate and elucidate the relationship between thyroid-stimulating hormone (TSH), thyroxine (T4), and triiodothyronine (T3), and malignant thyroid nodules. Methods This prospective cross-sectional study was conducted at a public specialist hospital in Saudi Arabia from February 2020 to February 2021. All thyroid nodules were scanned using ultrasound imaging, and the largest diameter was measured for each and classified according to the American College of Radiology (ACR) Thyroid Imaging Reporting and Data System (TIRADS) classification system. Thyroid function tests TSH, T3, and T4 were measured. Definitive diagnoses of thyroid nodules were given based on cytology. A one-way analysis of variance (ANOVA) test was used to compare means, and cross-tabulation was used to correlate the variables in the study. Results A total of 222 patients participated in this study; 23.42% were male and 76.57% were females. The mean age was 44.73 ± 13.31 years (range: 18 to 85 years). The percentage of malignancy was 20.6%, 36.3%, and 91.2% in TIRADS 3, TIRADS 4, and TIRADS 5, respectively. A weak positive linear relationship was noted between nodule size and TSH (R²= 0.012). The study demonstrates that TSH increases in malignant nodules more than in benign nodules, while T4 and T3 are decreased in malignant nodules. Conclusion The level of TSH increases in patients with malignant thyroid nodules more than in benign nodules, which can be used as a predictor of malignancy, while T4 and T3 reduced in malignant nodules with an ambiguous relationship.

Combined Shear Wave Elastography and EU TIRADS in Differentiating Malignant and Benign Thyroid Nodules

Although multimodal ultrasound approaches have been suggested to potentially improve the diagnosis of thyroid cancer; the diagnostic utility of the combination of SWE and malignancy-risk stratification systems remains vague due to the lack of standardized criteria. The purpose of the study was to assess the diagnostic value of the combination of grey scale ultrasound assessment using EU TIRADS and shear wave elastography. 121 patients (126 nodules−81 benign; 45 malignant) underwent grey scale ultrasound and SWE imaging of nodules between 0.5 cm and 5 cm prior to biopsy and/or surgery. Nodules were analyzed based on size stratifications: <1 cm (n = 43); 1−2 cm (n = 52) and >2 cm (n = 31) and equivocal cytology status (n = 52), and diagnostic performance assessments were conducted. The combination of EU TIRADS with SWE using the SD parameter; maintained a high sensitivity and significantly improved the specificity of sole EU TIRADS for nodules 1−2 cm (SEN: 72.2% vs. 88.9%, p > 0.05; SPEC: 76.5% vs. 55.9%, p < 0.01) and >2 cm (SEN: 71.4% vs. 85.7%, p > 0.05; SPEC: 95.8% vs. 62.5%, p < 0.01). For cytologically-equivocal nodules; the combination with the SWE minimum parameter resulted in a significant reduction in sensitivity with increased specificity (SEN: 60% vs. 80%; SPEC: 83.4% vs. 37.8%; all p < 0.05). SWE in combination with EU TIRADS is diagnostically efficient in discriminating nodules > 1 cm but is not ideal for discriminating cytologically-equivocal nodules.

Concordance between TIRADS and Cytology in Thyroid Nodule

Introduction

Palpable thyroid nodules are stated in 4 to 7% of individuals. This study was designed to evaluate the relation of Thyroid Imaging Reporting and Data System (TIRADS) and fine-needle aspiration (FNA) based cytology reports in patients with thyroid nodules.

Materials and Methods

In this retrospective cross-sectional study, individuals with thyroid nodules who were selected for ultrasonographic-guided FNA enrolled in this study. Demographic data, radiologic assessment, and cytology report were gathered based on hospital medical records. TIRADS grading of the nodules was assessed for each nodule. Cytology was performed on all samples. Sensitivity and specificity were calculated by comparing cytology with ACR-TIRADS and also cytology with TIRADS 4-5 cut-off point as a radiologic malignant lesion.

Results

172 patients were studied, 151 of whom were female and 21 were male. The mean age of the patients was 49.46 years. Most of the patients had TIRADS 4 (53.5%) followed by 3 (31.4%), and 5 (11.6%). 151 patients (87.8%) had a benign lesion in cytology. Of them, 118 had colloid nodules. There was a statistically significant relation between TIRADS and cytology (p-value<0.001). Sensitivity, specificity, AUC, and positive and negative predictive value for ACR-TIRADS classification were 76.19%, 47.54%, 0.619, 20.00%, and 92.06%, respectively. These values for cut-off "4-5" classification was 86.36%, 38.00%, 0.622, 16.96%, and 95.00%.

Conclusions

According to the significant concordance between TIRADS and cytology, as shown in the results of our study, it seems that TIRADS could be used to decrease the amount of unnecessary FNA in individuals with thyroid nodules.

Association of Fine-Needle Aspiration of Thyroid Nodules With Final Histopathology in Diagnosing Thyroid Malignancy: A Single Institute Retrospective Study

Background Fine needle aspiration cytology (FNAC) is the gold standard for detecting thyroid nodules. It is a cost-efficient approach that affords prompt and accurate evaluation. It is crucial in deciding to treat patients with suspected malignancy of thyroid nodules that might have thyroid surgery. According to findings in cytology, patients may be observed when the cytology is benign, and surgery can be performed if the cytology is malignant, which leads to a reduction in the incidence of unneeded surgery. Aim The current study aims to assess the concordance between FNAC of thyroid nodules with final histopathology and identify the different types of detected thyroid lesions. Methodology A retrospective record-based study reviewed the medical files of all patients presenting to the Armed Forces Hospital, Southern region, with suspected thyroid nodules from April 2018 to January 2020. Data were extracted using pre-structured data extraction sheet to avoid inconsistency. Data extracted included patients' demographic data, swelling laterality, size, ultrasound, and histopathological findings.  Results The baseline characteristics of studied samples in the present study: Forty-seven samples had a mean age of 44.27 (SD=±13.5) years, and 85.1% were female gender. The study showed that 12.5% of benign samples were lymphocytic in histopathology, 25% suspicious for follicular neoplasm samples were benign multi-nodular goiter in histopathology, and all 100% of samples suspicious for malignancy were malignant in final histopathology. Conclusions The current study showed that the malignancy rate of the examined nodules was not uncommon in FNAC and histopathology. Where papillary carcinoma was the most detected malignancy, the diagnosis of malignancy using FNAC is a cost-efficient approach that affords prompt and accurate evaluation. Once diagnosed, these cases should be subjected to surgery.

Ultrasound-Guided Fine Needle Aspiration of Deep Thyroid Nodule: Is There a Correlation between the Nodule’s Depth and Nondiagnostic Results?

Objective

To evaluate whether thyroid nodule depth correlates with nondiagnostic results in ultrasound-guided fine needle aspiration cytopathology.

Background

Many factors correlate with nondiagnostic ultrasound-guided fine needle aspiration cytology (FNAC) results, including older age, macrocalcification, small-sized nodules, aspirin medication, and cystic portion in more than 50% of the thyroid nodules. However, there are few studies which have examined whether there is a relationship between the depth of nodules and the percentage of nondiagnostic results in cytology (Bethesda category I). We conducted this study in order to investigate if such a correlation exists.

Materials and Methods

FNAC was performed on 283 thyroid nodules between January 2019 and December 2020. Cytological analyses of the nodules were reviewed and sorted as nondiagnostic and diagnostic according to the Bethesda score. Patient files and ultra sound (US) scans were reviewed for clinical information (such as age, sex, and ethnic group) and sonographic features of nodules (such as depth, size, cystic portion, type of calcification, and echogenicity) and were compared between the nondiagnostic and diagnostic nodule results. The depth of a nodule was calculated as the shortest distance from the skin to the most superficial border of the nodule in the axial plane, using our medical center's computer program, which allows reviewing all saved shots of the US scan.

Results

Age, sex, and ethnicity were not significantly different between the nondiagnostic group and the diagnostic group (p > 0.05). Nodule diameter, cystic portion, calcification, and echogenicity were also not associated with the frequency of nondiagnostic results. The depth of nodules ≥9 mm was correlated with nondiagnostic US-guided FNA cytological results (OR = 2.55, p=0.018).

Conclusions

Deep thyroid nodules correlated with nondiagnostic US-guided FNA cytological results. Further studies are needed for optimizing the approach to deep thyroid nodules in order to improve the efficacy of FNA in deep thyroid nodules.

US-guided FNA techniques for thyroid nodules is the short axis better than the long axis?

BACKGROUND

Ultrasound-guided fine needle aspiration cytology (FNAC US) has been proven to be an accurate and efficient tool in thyroid nodule evaluation. Thyroid nodule aspiration can be acquired with either of two techniques: the short axis, in which only the tip of the needle is observed, and the long axis, in which the entire length of the needle is observed. Our retrospective study aimed to compare the adequacy of the two techniques.

METHODS

FNAC US was performed in 538 thyroid nodules between January 2019 and December 2021. Data on the technique and the diagnostic accuracy were collected.

RESULTS

A total of 273 nodules were aspirated using the long axis technique, and 265 nodules were aspirated using the short axis technique. The diagnostic adequacies of the long axis technique were significantly higher than those of the short axis technique (92 % versus 86 %, respectively, p < 0.025).

CONCLUSION

In our study, the long axis technique provided more accurate cytological evaluation than the short axis technique.

LEVEL OF EVIDENCE

level 3.

Association of patient characteristics, ultrasound features, and molecular testing with malignancy risk in Bethesda III–V thyroid nodules

Objective

To evaluate the role of patient characteristics, ultrasound findings, and molecular testing in predicting risk of malignancy in Bethesda III, IV, and V thyroid nodules.

Design

Single institution retrospective review of 230 patients with Bethesda III, IV, and V cytopathology undergoing thyroidectomy between 2009 and 2018.

Setting

Private and public tertiary urban university hospitals at the same academic institution.

Subjects and methods

Patients who underwent thyroidectomy with Bethesda III, IV, and V nodules were included. Patient demographics, presence of underlying thyroid disease, nodule size, sonographic features, gene expression results, and surgical procedure were documented. Correlation between these variables and final histopathologic diagnosis of malignancy was analyzed.

Results

The 230 patients (103 Bethesda III, 64 Bethesda IV, and 63 Bethesda V) were included for analysis. Bethesda III nodules harbored malignancy in 26.2% of cases compared with 26.6% of Bethesda IV nodules and 82.5% of Bethesda V nodules. On multivariate analysis, age was inversely correlated with a diagnosis of malignancy (OR: 0.98, 95% confidence interval [CI]: 0.96–0.99, p = .03) Although the presence of microcalcifications was positively associated with cancer (OR: 2.31, CI: 1.24–4.29, p = .008) The co‐occurrence of microcalcifications and irregular margins was associated with a higher odds of malignancy (OR: 4.42, 95% CI: 1.32–14.93, p = .016), whereas the combination of microcalcifications, irregular margins, and hypoechogenicity was associated with the greatest cancer risk (OR: 5.52, 95% CI: 1.12–27.78, p = .036).

Conclusions

The presence of microcalcifications in thyroid nodules categorized as Bethesda III–V is an independent risk factor for malignancy. The combination of microcalcifications, irregular margins, and hypoechogenicity is associated with a greater malignancy risk in nodules indeterminate for thyroid cancer on cytopathology.

Diagnostic Value of AngioPLUS Microvascular Imaging in Thyroid Nodule Diagnosis Using Quantitative and Qualitative Vascularity Grading

This study investigated the diagnostic value of the Angio Planewave Ultrasensitive (AngioPLUS) Doppler ultrasound in improving the efficacy of grey scale ultrasound in thyroid nodule diagnosis. The EU TIRADS was used for the grey scale ultrasound assessment of 94 thyroid nodules. conventional Doppler and AngioPLUS Doppler ultrasound images were evaluated using qualitative vascularity grading, where predominant central vascularity indicated malignancy-suspicion, and quantitative regional vascularity assessment, where predominant peripheral vascularity using a ratio vascularity index (RVI) of > 1 indicated benign disease. Diagnostic performance outcomes of sole and combination approaches were calculated based on final pathologic results. Using sole EU TIRADS and AngioPLUS + power Doppler imaging (APDI) based on qualitative vascularity and RVI, the results were a sensitivity of 83.3% vs. 83.3 vs. 66.7% and a specificity of 50% vs. 81.3% vs. 73.4, respectively. EU TIRADS combined with APDI significantly improved the specificity using both qualitative vascularity and RVI assessment approaches (84.4% and 81%, respectively, p < 0.05); and slightly reduced the sensitivity (76.7% and 58.1%). For cytologically-equivocal thyroid nodules, the combination approach using qualitative vascularity assessment outperformed the EU TIRADS (sensitivity: both were 88.9%; specificity: 77.4% vs. 38.7%, p < 0.05; and AUROC: 0.83 vs. 0.62, p < 0.05). APDI combined with EU TIRADS is diagnostically efficient in stratifying thyroid nodules, particularly cytologically-equivocal nodules.

Detection of differentiated thyroid carcinoma in exhaled breath with an electronic nose

This proof-of-principle study investigates the diagnostic performance of the Aeonose in differentiating malignant from benign thyroid diseases based on volatile organic compound analysis in exhaled breath. All patients with a suspicious thyroid nodule planned for surgery, exhaled in the Aeonose. Definitive diagnosis was provided by histopathological determination after surgical resection. Breath samples were analyzed utilizing artificial neural networking. About 133 participants were included, 48 of whom were diagnosed with well-differentiated thyroid cancer. A sensitivity of 0.73 and a negative predictive value (NPV) of 0.82 were found. The sensitivity and NPV improved to 0.94 and 0.95 respectively after adding clinical variables via multivariate logistic regression analysis. This study demonstrates the feasibility of the Aeonose to discriminate between malignant and benign thyroid disease. With a high NPV, low cost, and non-invasive nature, the Aeonose may be a promising diagnostic tool in the detection of thyroid cancer.

The Pattern of Thyroid Malignancy and Its Associated Characteristics Among United Arab Emirates Population With More Focus on Patients in the Bethesda III Category

Introduction: Thyroid cancer is the most prevalent endocrine cancer worldwide. It is the second most common type of cancer among United Arab Emirates (UAE) women and ranks as the sixth most common type of cancer overall among the UAE population. There are limited studies in the UAE related to thyroid malignancy. This study aimed to determine the pattern of thyroid malignancy among the UAE population and its associated characteristics, with more emphasis on patients categorized as Bethesda III by cytopathology, and furthermore, to determine the significance of advanced diagnostic methods in the assessment of thyroid nodules.

Methods: A retrospective review of the electronic medical charts of adult patients (age 18 and above) who were diagnosed with a thyroid nodule by ultrasound during the years 2019 and 2020. It is a comparative study of different variables associated with thyroid nodules and thyroid malignancy.

Results: A total of 1072 patients were diagnosed with thyroid nodules upon initial ultrasound. We had 174 patients diagnosed with thyroid malignancy, constituting 16% (95% CI 0.14-0.19) of the total study population. 78% of the thyroid malignancy patients were women as compared to men, and this difference was statistically significant (p=0.042). Non-UAE nationals comprised 61% of the population diagnosed with thyroid malignancy (95% CI 1.37-2.68). Malignancy was found to be more common in patients with multinodular goiter, in the 30 to 39-year age group, and in patients with high ultrasound and Bethesda grades. From the total study population, 140 patients had cytology reports in the Bethesda III category. Thyroid malignancy was found in 30 patients with Bethesda III, and this comprised 17% of the total population who were diagnosed with thyroid malignancy.

Conclusion: Despite being a single-center study, it highlights the percentage of thyroid malignancy and its associated factors among the UAE population. Thyroid ultrasound grading and Bethesda classification guide physicians in risk stratification, but it remains challenging in patients who fall into the Bethesda III category. Intervention versus regular follow-up should not depend on a single value but on the overall clinical picture and the use of advanced diagnostic methods.

Pediatric Thyroid Nodules: Ultrasound Characteristics as Indicators of Malignancy

Objective

Pediatric thyroid nodules are uncommon but carry a 25% malignancy risk. Adult patients have well-established ultrasound characteristics that are predictive of malignancy, but these are not clearly defined in pediatric patients. We reviewed a case series of pediatric thyroid nodules.

Study Design

Retrospective chart review.

Setting

Tertiary children’s hospital.

Method

Institutional review board approval was obtained. This case series with chart review includes all pediatric thyroid nodules with ultrasounds from 2006 to 2016 at 2 pediatric tertiary care centers.

Results

An overall 112 pediatric thyroid nodules were analyzed. The mean patient age was 14.3 years; there was a female:male ratio of 4:1; and 94% were Caucasian. Seventeen percent (20/112) of nodules were malignant. In patients with malignant nodules, the average presenting age was 15.5 years, with a female:male ratio of 5.6:1. Seventy percent of malignant nodules had accompanying microcalcifications, 55% had abnormal lymph nodes, and 45% had irregular margins. In the benign nodules, 11% had microcalcifications, 12% had abnormal lymph nodes, and 26% had irregular margins. The presence of microcalcifications (odds ratio, 19.1 [95% CI, 6.0-61.0]; P < .0001), abnormal lymph nodes (odds ratio, 9.0 [95% CI, 3.0-26.6]; P = .0001), and size >3.5 cm (odds ratio, 5.8 [95% CI, 1.5-22.5]; P = .01) was associated with thyroid cancer. Irregular margins were not statistically significant (odds ratio, 2.3 [95% CI, 0.86-6.3]; P = .9).

Conclusions

Our data suggest that abnormal lymph nodes, microcalcifications, and size >3.5 cm could be predictors of malignancy in the pediatric population and influence clinical decision making.

A Study of Thyroid Fine Needle Aspiration of Follicular Adenoma in the "Atypia of Undetermined Significance" Bethesda Category Using Digital Image Analysis

Background

Originally designed for computerized image analysis, ThinPrep is underutilized in that role outside gynecological cytology. It can be used to address the inter/intra-observer variability in the evaluation of thyroid fine needle aspiration (TFNA) biopsy and help pathologists to gain additional insight into thyroid cytomorphology.

Methods

We designed and validated a feature engineering and supervised machine learning-based digital image analysis method using ImageJ and Python scikit-learn . The method was trained and validated from 400 low power (100x) and 400 high power (400x) images generated from 40 TFNA cases.

Result

The area under the curve (AUC) for receiver operating characteristics (ROC) is 0.75 (0.74–0.82) for model based from low-power images and 0.74 (0.69–0.79) for the model based from high-power images. Cytomorphologic features were synthesized using feature engineering and when performed in isolation, they achieved AUC of 0.71 (0.64–0.77) for chromatin, 0.70 (0.64–0.73) for cellularity, 0.65 (0.60–0.69) for cytoarchitecture, 0.57 (0.51–0.61) for nuclear size, and 0.63 (0.57–0.68) for nuclear shape.

Conclusion

Our study proves that ThinPrep is an excellent preparation method for digital image analysis of thyroid cytomorphology. It can be used to quantitatively harvest morphologic information for diagnostic purpose.

Breast and thyroid cancer: A multicenter study with Accrual to Clinical Trials Network

OBJECTIVE

To investigate a possible link between breast and thyroid cancer.

METHODS

A multicenter retrospective review of patients in the electronic medical records of six Accrual to Clinical Trial (ACT) institutions with both breast cancer and thyroid carcinoma. Each center queried its data using a predefined data dictionary. Information on thyroid and breast cancer included dates of diagnosis, histology, and patient demographics.

RESULTS

A random-effects model was used. There were 4.24 million women's records screened, 44 605 with breast cancer and 11 846 with thyroid cancer. The relative risks observed at each institution ranged from 0.49 to 13.47. The combined risk ratio (RR) estimate was 1.77 (95% confidence interval: 0.50-5.18).

CONCLUSION

There was no association between the risk of developing thyroid cancer and being a breast cancer survivor compared to no history of breast cancer, but the range of relative risks among the participating institutions was wide. Our findings warrant further study of more institutions with larger sample size. Additionally, further analysis of the significance of regional RR differences may be enlightening.

Thyroid Cancer Diagnostics Related to Occupational and Environmental Risk Factors: An Integrated Risk Assessment Approach

There are still many questions remaining about the etiopathogenesis of thyroid cancer, the most common type of endocrine neoplasia. Numerous occupational and environmental exposures have been shown to represent important risk factors that increase its incidence. Updated information about thyroid cancer diagnostics related to occupational and environmental risk factors is reviewed here, considering an integrated risk assessment approach; new data concerning thyroid cancer etiology and pathogenesis mechanisms, diagnostic biomarkers and methodologies, and risk factors involved in its pathogenesis are presented. A special emphasis is dedicated to specific occupational risk factors and to the association between environmental risk agents and thyroid cancer development. The occupational environment is taken into consideration, i.e., the current workplace and previous jobs, as well as data regarding risk factors, e.g., age, gender, family history, lifestyle, use of chemicals, or radiation exposure outside the workplace. Finally, an integrative approach is presented, underlying the need for an accurate Risk Assessment Matrix based on a systematic questionnaire. We propose a complex experimental design that contains different inclusion and exclusion criteria for patient groups, detailed working protocols for achieving coherent and sustainable, well-defined research stages from sample collection to the identification of biomarkers, with correlations between specific oncometabolites integrated into the Risk Assessment Matrix.

Metabolic Profile Characterization of Different Thyroid Nodules Using FTIR Spectroscopy: A Review

Thyroid cancer’s incidence has increased in the last decades, and its diagnosis can be a challenge. Further and complementary testing based in biochemical alterations may be important to correctly identify thyroid cancer and prevent unnecessary surgery. Fourier-transform infrared (FTIR) spectroscopy is a metabolomic technique that has already shown promising results in cancer metabolome analysis of neoplastic thyroid tissue, in the identification and classification of prostate tumor tissues and of breast carcinoma, among others. This work aims to gather and discuss published information on the ability of FTIR spectroscopy to be used in metabolomic studies of the thyroid, including discriminating between benign and malignant thyroid samples and grading and classifying different types of thyroid tumors.

Assessment of diagnostic value of preoperative elastography in thyroid nodules having indeterminate cytology results

Background/aim

The management of nodules with indeterminate cytology [atypia of undetermined significance (AUS), follicular lesion of undetermined significance (FLUS), follicular neoplasm (FN), suspicious for a follicular neoplasm (SFN), and suspicious for malignancy (SM)] results is controversial. To assess the role of the elastography technique in the diagnosis of malignancy in the subtypes of indeterminate thyroid nodules.

Materials and methods

We included 132 patients with indeterminate cytology who underwent thyroid surgery. Sensitivity, specificity, area under the curve, and optimal cut-off points were calculated with receiver operating characteristic (ROC) analysis for elastography score (ES) and strain index (SI).

Results

Malignancy was observed in 27/95 (28.4%) of the AUS-FLUS cytology and 12/24 (50%) of FN, SFN cytology. All of the 13 patients (100 %) with SM are found to be malignant on histology. In the FLUS group, nodules with ES greater or equal to 3, the presence of malignancy was higher 17/41 (41.5%) when compared with nodules with ES smaller than 39/46 (19.6 %) (p = 0.023). In the SFN group, 2 of 2 nodules with an ES score of 4 and 1 of 1 nodule with an ES score of 5 were malignant. In the FLUS group, 4 of 10 nodules with an ES score of 4 and 2 of 2 nodules with an ES score of 5 were malignant.

Conclusion

Thyroid elastography may reduce unnecessary surgery for both patients with AUS/FLUS and selected SFN cytology. Elastography appears to be helpful in follicular variants and other types of papillary thyroid cancer, however, not in follicular thyroid cancer.

Evaluation of a Clinical Pathway for Thyroid Nodular Disease: Timings and Delays in the Diagnosis and Treatment of Thyroid Cancer

Background: Due to the high prevalence of nodular thyroid disease in the general population and the need to rule out malignant tumours, a clinical pathway for nodular thyroid disease was created at our tertiary-level hospital. Our study aimed to quantify timings and delays in diagnosis and treatment in this clinical pathway, specifically for patients who were diagnosed with thyroid cancer. Methods: A retrospective review was conducted of patients who were newly diagnosed with thyroid cancer and who had been previously evaluated in the clinical pathway for nodular thyroid disease at our institution during 2015–2017. Patient demographics, previous diagnostic studies, cytological results, tumour details and key dates were analysed to identify wait times in diagnosis and treatment. Results: Forty patients with thyroid cancer were included. The diagnostic delay had a median time of 60 days, and the treatment delay was dependent on cytopathological results. The main cause for delay in the diagnostic phase was the timing of the thyroid ultrasound performed by the radiology department. In the treatment phase, patients with a cytological result of Bethesda III, V or VI underwent surgery at the suggested time, while those in the Bethesda II or IV category did not. Conclusions: The major delay found in the diagnostic phase was the timing of the thyroid ultrasound performed by the radiology department. We are not suggesting that this step must be eliminated, though the implementation of routine ultrasonography in a thyroid clinic can help identify patients who need more urgent evaluation for fine needle aspiration cytology. In our hospital, decision for surgery is based mainly on the cytopathological report. Imaging studies and/or molecular testing could be considered to reduce treatment delays.

Bilateral thyroid adenomas in an alpaca

A 7-year-old neutered male alpaca (Vicugna pacos) was presented for evaluation of a 3-year history of large, bilateral, firm ventral cervical masses causing esophageal and tracheal impingement. Ultrasound examination, radiographic evaluation, histopathological findings, and magnetic resonance imaging confirmed the masses to be bilateral thyroid adenomas. Conservative medical treatment by unilateral chemical ablation, using 10% formalin by aspiration technique, was performed on the left mass. Chemical ablation proved to be effective in decreasing the size of the mass, with no apparent adverse effects. To our knowledge, this case is the first known report of bilateral thyroid adenomas in an alpaca, a condition previously described in humans, horses, dogs, and cats.

Different sonographic features of peripheral thyroid nodule calcification and risk of malignancy: a prospective observational study

Purpose

To investigate the association of peripheral calcification, as well as its sonographic features, with thyroid nodule malignancy.

Material and methods

This study was prospectively conducted during 2015-2020 on patients diagnosed with thyroid nodule undergoing ultrasound-guided fine-needle aspiration in Shahid Beheshti teaching hospital or private offices in Babol, northern Iran. The ultrasonographic characteristics of the nodules, as well as the cytological findings, were recorded. Regression analysis was used to assess the relationship between sonographic results and malignancy. We also used receiver operator characteristics (ROC) analysis to estimate the ability of ultrasound to predict the characteristic features of malignancy, as estimated by the area under the curve (AUC).

Results

A total of 1857 thyroid nodules were finally included, of which 84 were peripherally calcified nodules. There was a significant positive association between the nodule malignancy and peripheral calcification (OR = 2.23, 95% CI: 1.13-4.35). In the nodules with peripheral calcification, significant positive associations were seen between malignancy and lobulated margin (OR = 3.85, 95% CI: 1.02-14.54) and solid composition (OR = 4.05, 95% CI: 0.99-16.53). The ROC analysis indicated that AUC for lobulated margin and solid composition was 63.8% and 66.5%, respectively, in predicting malignant thyroid nodules.

Conclusion

The findings showed that peripheral calcification on sonography can be a potential indicator of malignant thyroid nodules. Also, the presence of lobulated margin and/or solid composition, besides peripheral calcification, can be helpful in better distinguishing malignant from benign nodules.

A double mutation of BRAF L597Q and V600E in situ and solitary brain metastasis of occult papillary thyroid carcinoma: A case report

RATIONALE

The rare BRAF L597Q (c.T1790A) point mutation has been previously reported in childhood acute lymphoblastic leukemia. We present the first rare case of occult papillary thyroid carcinoma with BRAF L597Q mutation in a Tibetan patient.

PATIENT CONCERNS

A 57-year-old male patient presented with a protruding mass on the left forehead for 2 years and numbness in the right limb for 3 weeks.

DIAGNOSES

The patient had a double mutation of BRAF L597Q and V600E in 2 separate lesions at thyroid and brain, the immunohistochemical staining showed that the cytokeratin (CK), thyroglobulin (Tg) and thyroid transforming factor-1 (TTF-1) were immunoreactive. All the findings supported the diagnosis of solitary brain metastasis of occult papillary thyroid carcinoma.

INTERVENTIONS

The patient underwent left frontal lobe metastasis (thyroid cancer) resection that involved craniectomy and artificial skull repair.

OUTCOMES

During the 24-month follow-up, no postoperative complications or recurrence and metastasis were found.

LESSONS

This is the first case of solitary brain metastasis of occult papillary thyroid carcinoma with double mutation of BRAF L597Q and V600E in 2 separate lesions reported in the literature. Our study extends the disease spectrum of occult papillary thyroid carcinoma and suggests that the BRAF L597Q mutation might play a specific role in inducing the solitary brain metastasis of occult papillary thyroid carcinoma in a Chinese Tibetan patient, but the detailed molecular mechanism remains to be confirmed by a large number of functional experiments and clinical research.

Transverse and Longitudinal Ultrasound Location of Thyroid Nodules and Risk of Thyroid Cancer

BACKGROUND

The high prevalence of thyroid nodules demands accurate assessment tools to avoid unnecessary biopsies. Prior studies demonstrated a correlation between the longitudinal location of thyroid nodules and the likelihood of malignancy. No study has evaluated the predictive value of transverse location on ultrasonography with malignancy.

METHODS

We retrospectively reviewed the records of thyroid nodules that underwent fine-needle aspiration over 13 years, including demographics, risk factors, nodule sonographic features, location, and surgical pathology. Univariate and multivariable logistic regression models were used to evaluate the risk of malignancy.

RESULTS

Of the 668 thyroid nodules, 604 were analyzed with a definitive diagnosis. Thirty-seven nodules were malignant, representing a prevalence of 6.1%. In the longitudinal plane, the upper pole nodules carried the highest incidence of malignancy (14.9%). In the transverse plane, the highest incidence of malignancy occurred in nodules located laterally (12.5%) and anterior-laterally (11.8%). Compared with the upper pole, the odds of malignancy were significantly lower for lower pole (odds ratio [OR] = 0.26, 95% confidence interval [CI]: 0.09-0.70) and midlobe nodules (OR = 0.31, 95% CI: 0.12-0.83). In the transverse plane, posteriorly situated nodules carried a significantly lower risk of malignancy (OR = 0.07, 95% CI: 0.01-0.69). Multiple logistic regression confirmed these associations after adjusting for age, sex, family history, radiation exposure, nodule size, and sonographic characteristics.

CONCLUSION

Both the transverse and longitudinal planes were independent predictors of cancer in thyroid nodules. Lateral, anterior-lateral, and upper pole nodules carried the highest risk and posterior nodules had the lowest risk of malignancy.

The diagnostic value of ultrasonography in detection of different types of thyroid nodules

Background

This article discusses the importance of high frequency ultrasonography in detection of different types of thyroid nodules considering only the histopathological examination of the surgical specimens as the final diagnosis. We studied 50 patients referred to ENT clinic with a thyroid nodule. Ultrasonography and ultrasound-guided fine-needle aspiration biopsy were done to all the patients. Thyroid surgery was done according to FNAB results.

Result

From 50 thyroid specimens, the US could predict the malignancy in 18 specimens. By histopathology, only 16 specimens were malignant, and 34 were benign thyroid disease. The sensitivity, specificity, and accuracy of US were 100%, 94.12%, and 96% respectively. The most suspicious ultrasongraphic feature was microcalcification followed by taller than wider (T ˃ W).

Conclusion

High frequency ultrasound is a very important tool to predict the malignant possibility during thyroid nodule evaluation.

The Keap1/Nrf2 Signaling Pathway in the Thyroid-2020 Update

The thyroid gland has a special relationship with oxidative stress. On the one hand, like all other tissues, it must defend itself against reactive oxygen species (ROS). On the other hand, unlike most other tissues, it must also produce reactive oxygen species in order to synthesize its hormones that contribute to the homeostasis of other tissues. The thyroid must therefore also rely on antioxidant defense systems to maintain its own homeostasis in the face of continuous self-exposure to ROS. One of the main endogenous antioxidant systems is the pathway centered on the transcription factor Nuclear factor erythroid 2-related factor 2 (Nrf2) and its cytoplasmic inhibitor Kelch-like ECH-associated protein 1 (Keap1). Over the last few years, multiple links have emerged between the Keap1/Nrf2 pathway and thyroid physiology, as well as various thyroid pathologies, including autoimmunity, goiter, hypothyroidism, hyperthyroidism, and cancer. In the present mini-review, we summarize recent studies shedding new light into the roles of Keap1/Nrf2 signaling in the thyroid.

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.

Diagnostic accuracy of preoperative palpation- versus ultrasound-guided thyroid fine needle aspiration cytology: an observational study

BACKGROUND

Thyroid fine needle aspiration (FNA) is the mainstay for diagnosis of malignancy, and is an integral part of current thyroid nodule assessment. The present study analyzes the diagnostic accuracy of palpation-directed versus ultrasound guided fine-needle aspiration in patients who underwent surgery for thyroid nodules.

METHODS

A retrospective chart review of all consecutive patients who had FNA biopsy (palpation or ultrasound guided) of thyroid nodules and underwent thyroid gland surgery between 1998 and 2014 was conducted. The FNA findings of the palpation-guided and ultrasound-guided groups were compared for baseline characteristics. Moreover, the diagnostic accuracy of FNA findings and surgical histopathology results were analyzed.

RESULTS

A total of 1174 patients were included in the study with a mean age of 46.3 ± 11.7 years and the majority were females (75.5%). Among the study population, 392 (33.4%) patients underwent US-guided FNA; 570 (48.6%) had palpation-guided FNA in clinic and no FNA was done in 212 (18%) cases. Patients underwent US-guided FNA were more likely to have suspicion of malignancy (p = 0.001), and had indeterminate findings (p = 0.001). On the other hand, palpation-guided FNA group had significantly higher frequency of benign cytology (p = 0.001). With respect to the suspicion for malignancy as well as malignancy, the US-guided group had a similar diagnostic accuracy in comparison to the palpation group. The proportion of malignancy finding on US-guided FNA (8.9%) was higher than the palpation-guided FNA (6.4%) that had been confirmed on postoperative histopathological examination (p = 0.95).

CONCLUSION

The present study demonstrates higher sensitivity of US-guided thyroid FNA biopsies over palpation-guided FNA for the suspicion of malignancy; however, the accuracy is comparable. Moreover, both groups showed more postoperative malignancy in the benign and unsatisfactory categories than predicted in the Bethesda system. Further prospective studies are needed to underpin a realistic correlation between FNA and final histopathology reports.

Data-Driven Analysis of Radiologists' Behavior for Diagnosing Thyroid Nodules

Thyroid nodule has been a common and serious threaten to human health. With the identification and diagnosis of thyroid nodules in the general population, large volumes of examination reports in clinical practice have been accumulated. They provide data basics of analyzing radiologists' behavior of diagnosing thyroid nodules. To conduct data-driven analysis of radiologists' behavior, an experimental framework is designed based on belief rule base, which is essentially a white box for knowledge representation and uncertain reasoning. Under the framework, with 2744 examination reports of thyroid nodules in the period from January 2012 to February 2019 that have been collected from a tertiary hospital located in Hefei, Anhui, China, experimental results are obtained from conducting missing validation, self-validation, and mutual validation. Three principles are then concluded from the results and corresponding analysis. The first is that missing features on some criteria are considered as benign ones by default, the second is that there is generally inconsistency between the recorded features on criteria and the overall diagnosis, and the third is that different radiologists have different diagnostic preferences. These three principles reflect three diagnostic behavioral characteristics of radiologists, namely reliability, inconsistency, and independence. Based on the three principles and radiologists' behavioral characteristics, managerial insights in a general case are concluded to make the findings in this study available in other situations.