Ultrasound criteria of malignancy for cervical lymph nodes in patients followed up for differentiated thyroid cancer

[Diagnosis of lymph node metastases from papillary thyroid carcinoma by measuring thyroglobulin in the puncture needle. Calculation of optimal cut-off point in our series]

Fine-needle aspiration cytology (FNAC), used in suspicious cervical lymph nodes of unknown origin is frequently inconclusive and prone to false negatives. In order to evaluate the usefulness of measuring thyroglobulin in the washing with saline solution of the puncture needle for the diagnosis of metastasis of papillary carcinoma of the thyroid, an optimal thyroglobulin cutting point has to be calculated, being positive or negative depending on whether the thyroglobulin levels are higher or lower than the cutting point. We have retrospectively studied 33 patients (19 women and 14 men) with an average age of 49.3 years, with papillary carcinoma of the thyroid and suspected lymph node metastasis. Of them 16 (47.1%) had a positive FNAC. To determine thyroglobulin predictive capacity with regards to the metastasis of papillary carcinoma of the thyroid a ROC analysis was carried out with an under curve area UCA: 0.987 (CI 95%: 0.808-1.000) obtaining, using Youden's J statistic, 0.4 ng/ml as the thyroglobulin cutting point with best predictive capacity. The study of the relationship between thyroglobulin and the preservation/non-preservation of the thyroid showed statistically significant differences (P=.023). Our results validate 0.4 ng/ml of thyroglobulin as an optimal cutting point of the presence of metastasis of papillary carcinoma of the thyroid in lymph nodes. When reviewing the bibliography, a great diversity of cutting points may be found, which is explained mainly by the great inter-observer and inter-assay variability. That is why we recommend calculating each laboratory's own optimal cutting point; and determine in subsequent studies two cutting points depending on whether or not thyroid is preserved.

Which Ultrasound Characteristics Predict Lymphatic Spread of Papillary Thyroid Cancer?

INTRODUCTION

The 2015 American Thyroid Association guidelines recommend lymph node mapping US in patients with definitive cytological evidence of thyroid cancer. Suspicious lymph node features on imaging including enlarged size (>1 cm in any dimension), architectural distortion, loss of fatty hilum, and microcalcifications often prompt evaluation with fine needle aspiration. There is no universally agreed upon model for determining which ultrasound characteristics most strongly correlate with metastatic disease.

METHODS

A retrospective review of patients with confirmed papillary thyroid cancer (PTC) undergoing lymph node mapping ultrasound from 2013 to 2019 was performed. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value were calculated for each individual ultrasound characteristic as well as for characteristic combinations.

RESULTS

Data from 119 lymph nodes were included. Malignant lymph nodes were more likely to be enlarged (71% versus 61%, P < 0.001) and to have each individual suspicious feature. Loss of fatty hilum had the highest sensitivity (89%) but was not specific (19%) for metastatic disease. Architectural distortion was found to have the highest specificity (87%). A combination of the four features was found to have higher specificity (97%) and PPV (88%) than any individual feature or combination of two/three features.

CONCLUSIONS

A combination of four sonographic features correlates with metastatic PTC to lymph nodes and has the highest specificity and PPV for malignancy. A risk stratification model based on these features may lead to better classification of ultrasound findings in PTC patients with concern for nodal metastases.

Integration of ultrasound-based radiomics with clinical features for predicting cervical lymph node metastasis in postoperative patients with differentiated thyroid carcinoma

OBJECTIVE

The primary objective was to establish a radiomics model utilizing longitudinal +cross-sectional ultrasound (US) images of lymph nodes (LNs) to predict cervical lymph node metastasis (CLNM) following differentiated thyroid carcinoma (DTC) surgery.

METHODS

A retrospective collection of 211 LNs from 211 postoperative DTC patients who underwent neck US with suspicious LN fine needle aspiration cytopathology findings at our institution was conducted between June 2021 and April 2023. Conventional US and clinicopathological information of patients were gathered. Based on the pathological results, patients were categorized into CLNM and non-CLNM groups. The database was randomly divided into a training cohort (n = 147) and a test cohort (n = 64) at a 7:3 ratio. The least absolute shrinkage and selection operator algorithm was applied to screen the most relevant radiomic features from the longitudinal + cross-sectional US images, and a radiomics model was constructed. Univariate and multivariate analyses were used to assess US and clinicopathological significance features. Subsequently, a combined model for predicting CLNM was constructed by integrating radiomics, conventional US, and clinicopathological features and presented as a nomogram.

RESULTS

The area under the curves (AUCs) of the longitudinal + cross-sectional radiomics models were 0.846 and 0.801 in the training and test sets, respectively, outperforming the single longitudinal and cross-sectional models (p < 0.05). In the testing cohort, the AUC of the combined model in predicting CLNM was 0.901, surpassing that of the single US model (AUC, 0.731) and radiomics model (AUC, 0.801).

CONCLUSIONS

The US-based radiomics model exhibits the potential to accurately predict CLNM following DTC surgery, thereby enhancing diagnostic accuracy.

Diagnostic utilities of washout CYFRA 21-1 combined with washout thyroglobulin for metastatic lymph nodes in thyroid cancer: a prospective study

Cervical lymph node (LN) metastasis is common in differentiated thyroid cancer (DTC). This study evaluated the utility of the washout CYFRA 21-1 level, combined with the thyroglobulin (Tg) concentration, in terms of diagnosis of LN metastasis. We prospectively enrolled 53 patients who underwent thyroid surgery to treat DTC with lateral cervical LN metastases. Preoperative ultrasound guided needle localization was used to surgical sampling of specific LNs during the operation. The intraoperative washout Tg and CYFRA 21-1 levels were measured in such LNs. The Tg and CYFRA 21-1 levels differed significantly between metastatic and benign LNs. The cutoff values were 2.63 ng/mL for washout CYFRA 21-1 and 22.62 ng/mL for Tg. Combined use of the washout Tg and CYFRA 21-1 levels afforded the highest diagnostic accuracy (92.5%), better than that of individual markers. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) were 94.6%, 90.0%, 91.4%, 93.8%, respectively. The conjunction of the washout CYFRA21-1 and Tg levels enhances the diagnostic accuracy of LN metastasis in DTC patients. The washout CYFRA 21-1 level may be useful when malignancy is suspected, especially in cases where the cytology and washout Tg findings do not provide definitive results.

To diagnose primary and secondary squamous cell carcinoma of the thyroid with ultrasound malignancy risk stratification

Objectives

This study aimed to investigate the clinico-ultrasound features of primary squamous cell carcinoma of the thyroid (PSCCT) and secondary SCCT (SSCCT) and evaluate the accuracy of fine needle aspiration (FNA) recommendation for SCCT with American College of Radiology-Thyroid Imaging and Reporting Data System (ACR-TIRADS) and Chinese-TIRADS (C-TIRADS).

Materials and methods

We retrieved 26 SCCT patients (11 PSCCT, 15 SSCCT) from our hospital's pathology database (5,718 patients with thyroid malignancy) over 23 years. Medical records and ultrasound data of the 26 patients with 27 SCCTs were analyzed retrospectively, and each SCCT focus was categorized based on the two TIRADSs.

Results

For 26 patients (21 males, 5 females) with an age range of 42-81 years, rapidly enlarging thyroid/neck nodules (18/26, 69.2%), dysphagia (7/26, 26.9%), hoarseness (6/26, 23.1%), dyspnea (5/26, 19.6%), cough (4/26, 15.4%), neck pain (2/26, 7.7%), B symptoms (2/26, 7.7%), and blood in sputum (1/26, 3.8%) were presented at diagnosis. Five asymptomatic patients (5/26, 19.2%) were detected by ultrasound. Hoarseness was more common in PSCCT (5/11, 45.5%) than in SSCCT (1/15, 6.7%) (P=0.032). For 27 SCCTs with a mean size of 3.7 ± 1.3 cm, the ultrasound features consisted of solid (25/27, 92.6%) or almost completely solid composition (2/27, 7.4%), hypoechoic (17/27, 63%) and very hypoechoic echogenicity (10/27, 37%), irregular/lobulated margin with extra-thyroidal extension (27/27, 100%), taller-than-wide shape (13/27, 48.1%), punctate echogenic foci (6/27, 22.2%), hypervascularity (23/27, 85.2%) and involved neck lymph (13/26, 50.0%). A total of 27 SCCTs were evaluated as high malignancy risk stratification (≥TR4 and 4B) by the two TIRADSs and recommended FNA in 96.3-100% (26/27, 27/27). Pathologically, more than half of PSCCTs (7/12, 58.3%) and a quarter of SSCCTs (4/15, 26.7%) were poorly differentiated, while moderately and well-differentiated grades were observed in 5 PSCCTs and 11 SSCCTs (P=0.007). Thirteen patients (50.0%) underwent surgery with radical operation in 5 cases (5/13, 38.5%).

Conclusion

SCCT is an extremely rare and aggressive malignancy with a male predominance. PSCCT and SSCCT had similar clinical and ultrasound features except for tumor differentiation and the symptom of hoarseness. SCCT showed a high malignancy risk stratification in ACR-TIRADS and C-TIRADS, with a high rate of FNA recommendation.

Optimal range of lymph node dissection in patients with unilateral papillary thyroid carcinoma with lateral cervical lymph node metastasis

Background

Whether patients with unilateral papillary thyroid carcinoma (PTC) with lateral cervical lymph node metastasis (LLNM) require prophylactic central regional lymph node dissection (CLND) remains unclear. Herein, we investigated the independent risk factors associated with contralateral central lymph node metastasis (cCLNM) in unilateral PTC with LLNM and analyzed the optimal extent of lymph node dissection by comparing the 5-year recurrence-free survival rates.

Materials and methods

We retrospectively analyzed 695 patients with unilateral papillary thyroid carcinoma and lateral cervical lymph node metastasis. Factors including sex, age, multifocal, location of primary tumor, tumor diameter, capsule invasion, thyroid nodular goiter, Hashimoto thyroiditis, ipsilateral central lymph node metastasis(iCLNM), and lateral cervical lymph node metastasis were analyzed using univariate and multivariate logistic regression analyses to explore the independent risk factors of cCLNM. Propensity scores were matched to compare the 5-year recurrence-free survival rates in patients divided by different lymph node metastases and dissections.

Results

Of all patients who underwent bilateral (b)CLND, 52% (149/286) had cCLNM. Receiver operating characteristic (ROC) curve analysis was performed on 286 patients who underwent bCLND, for which a tumor diameter of 20.5 mm and number of LLNM of 3.5 were used as the thresholds for predicting cCLNM. The 5-year recurrence-free survival (RFS) rates in the cCLN-negative and cCLN-positive groups were 98.6% and 91.2%, with statistically significant differences (P=0.034). The 5-year RFS rates showed no significant difference between the ipsilateral (i)CLND and bCLND groups (P=0.235). Multifactorial regression analysis showed that tumor diameter >2 cm, presence of iCLNM, and number of LLNM >3 were independent risk factors of cCLNM.But male sex, young age (<45 years), multifocality, location of primary tumor, capsule invasion, thyroid nodular goiter, and Hashimoto thyroiditis were not associated with cCLNM.

Conclusion

Not all unilateral PTC with LLNM require prophylactic cCLND; however, prophylactic cCLND is necessary in cases which display high-risk factors for cCLNM, including primary diameter >2 cm, iCLNM, and number of LLNM >3.

Clinical features and imaging examination assessment of cervical lymph nodes for thyroid carcinoma

BACKGROUNDS

The purpose of this study is to investigate the relationship between clinical characteristics and cervical lymph node metastasis (LNM) in patients with thyroid carcinoma, as well as estimate the preoperative diagnosis values of ultrasound (US) and contrast enhanced computed tomography (CECT) examinations on the neck for detection of cervical LNM in thyroid carcinoma.

METHODS

A retrospective analysis of 3 026 patients with surgically proven thyroid carcinoma was conducted. Patients' clinical characteristics, including gender, age, tumor size, bilateral lesions, multifocality, adenomatous nodules, Hashimoto's thyroiditis (HT), and extrathyroidal extension, were collected to explore their association with cervical LNM in thyroid carcinoma. Preoperative assessments for central lymph node metastasis (CLNM) and lateral lymph node metastasis (LLNM) were conducted through US and CECT. The diagnostic value of US, CECT and US combined with CECT for detection of LNM located in various cervical compartments was estimated based on the pathological results.

RESULTS

The risk of cervical LNM was higher in thyroid cancer patients who were male, age < 55 years old, tumor size > 10 mm, bilateral lesions, and extrathyroidal extension, while multifocality, adenomatous nodules and HT had no significant effect on LNM. US, CECT and US combined with CECT all had a higher sensitivity to LLNM (93.1%, 57.8%, 95.4%) than to CLNM (32.3%, 29.0%, 43.4%). US and CECT had a high specificity to both CLNM and LLNM (94.3-97.8%).

CONCLUSION

Preoperative clinical characteristics and imaging examinations on patients with thyroid carcinoma are crucial to the evaluation of cervical lymph nodes and conducive to individualizing surgical treatments by clinicians. US combined with CECT are superior to single US or CECT alone in detection of CLNM and LLNM.

Second radioiodine treatment hardly benefits TT-DTC patients with radioiodine-negative metastases on initial post-therapeutic whole-body scans

BACKGROUND

The effect of second 131I treatment (RT) in totally thyroidectomized differentiated thyroid cancer (TT-DTC) patients with true-positive thyroid beds and false-negative metastasis (TB+/M-) on initial post-therapeutic whole-body scan (Rx-WBS) remains unknown.

METHODS

TT-DTC patients with TB+/M- on initial Rx-WBS receiving and not receiving second RT were categorized into group A and group B, respectively, while patients with 131I-avid metastasis receiving second RT were referred to as group C. Biochemical remission (BR) was defined as a decrease of ≥25.0% in thyrotropin-suppressed thyroglobulin (Tgon) level, while the structural response (SR) was determined by the change in the size of the largest lesion.

RESULTS

In total, 145 patients were eligible. In group A, the median Tgon measured 3.3 ng/mL before and 3.0 ng/mL at 4 months after second RT (P=0.307), yielding a decrease in the median Tgon (∆Tgon%) of 13.3%, a BR rate of 36%, and an insignificant SR, which were comparable to those in group B. In group C, however, a median ∆Tgon% of 37.8% and a BR rate of 64% were obtained, which were significantly higher than those in group A (P=0.038 and 0.022, respectively), with SR distributions similar to those in group A. In addition, 131I uptake in the neck was not statistically associated with the detection of metastasis on initial Rx-WBS.

CONCLUSIONS

This controlled study demonstrated a subtle response to second RT in TT-DTC patients with TB+/M- on initial Rx-WBS, representing a meaningful advancement in avoiding ineffective repeated RT.

A prediction model for identifying high-risk lymph node metastasis in clinical low-risk papillary thyroid microcarcinoma

BACKGROUND

The presence of high-volume lymph node metastasis (LNM) and extranodal extension (ENE) greatly increases the risk of recurrence in patients with low-risk papillary thyroid microcarcinoma (PTMC). The goal of this research was to analyze the factors that contribute to high-risk lymph node metastasis in patients with low-risk PTMC.

METHODS

We analyzed the records of 7344 patients who were diagnosed with low-risk PTMC and treated at our center from January 2013 to June 2018.LNM with a high volume or ENE was classified as high-risk lymph node metastasis (hr-LNM). A logistic regression analysis was conducted to identify the risk factors associated with hr-LNM. A nomogram was created and verified using risk factors obtained from LASSO regression analysis, to predict the likelihood of hr-LNM.

RESULTS

The rate of hr-LNM was 6.5%. LASSO regression revealed six variables that independently contribute to hr-LNM: sex, age, tumor size, tumor location, Hashimoto's thyroiditis (HT), and microscopic capsular invasion. A predictive nomogram was developed by integrating these risk factors, demonstrating its excellent performance. Upon analyzing the receiver operating characteristic (ROC) curve for predicting hr-LNM, it was observed that the area under the curve (AUC) had a value of 0.745 and 0.730 in the training and testing groups showed strong agreement, affirming great reliability.

CONCLUSION

Sex, age, tumor size, tumor location, HT, and microscopic capsular invasion were determined to be key factors associated with hr-LNM in low-risk PTMC. Utilizing these factors, a nomogram was developed to evaluate the risk of hr-LNM in patients with low-risk PTMC.

Diagnostic Efficacy of FNA-Tg in DTC Cervical LN Metastasis and its Impact Factors: A Large Retrospective Study

CONTEXT

Thyroglobulin in needle washout fluid (FNA-Tg) has the advantage of compensating for the low sensitivity of cytological analysis (FNAC) in differentiated thyroid carcinoma (DTC) lymph node (LN) metastasis. However, studies of large data sets to support this view and identify the best cutoff of FNA-Tg are lacking.

OBJECTIVE

Our study aimed to determine the best cutoff of FNA-Tg and explore the impact factors of FNA-Tg.

METHOD

A total of 1106 suspicious LNs from patients treated at West China Hospital from October 2019 to August 2021 were included. Parameters were compared between metastatic and benign LNs, and the best cutoff value of FNA-Tg was identified by ROC curves. The impact factors of FNA-Tg were analyzed.

RESULTS

In the nonsurgery group, after correcting for the effect of age and short diameter of LN, FNA-Tg was the independent risk factor for cervical LN metastasis of DTC (odds ratio [OR]: 1.048; 95% CI, 1.032-1.065). In the surgery group, after correcting for the effects of serum thyrotropin, serum Tg, long diameter of LN, and short diameter of LN, FNA-Tg was the independent risk factor for cervical LN metastasis of DTC (OR: 1.019; 95% CI, 1.006-1.033). The best cutoff value of FNA-Tg was 25.17 μg/L, and the area under the receiver operating characteristic curve, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 0.944, 0.847, 0.978, 0.982, 0.819, and 0.902, respectively. FNA-Tg highly correlated with FNA-TgAb (P < .01; Spearman correlation coefficient = 0.559), but FNA-TgAb positivity did not undermine the diagnostic efficacy of FNA-Tg for DTC LN metastasis.

CONCLUSION

The best cutoff value of FNA-Tg was 25.17 μg/L in diagnosing DTC cervical LN metastasis. FNA-Tg highly correlated with FNA-TgAb, but FNA-TgAb had no influence on the diagnostic efficacy of FNA-Tg.

Development and validation of nomograms for predicting the risk of central lymph node metastasis of solitary papillary thyroid carcinoma of the isthmus

BACKGROUND

This study was conducted to develop nomograms and validate them by assessing risk factors for the development of central lymph node metastasis (CLNM) in patients with solitary papillary thyroid carcinoma of the isthmus (PTCI) for predicting the probability of CLNM.

METHODS

Demographic and clinicopathological variables of patients with solitary papillary thyroid carcinoma (PTC) from May 2018 to May 2023 at the First Hospital of Shanxi Medical University were retrospectively analyzed, and the lobar group and the isthmus group were divided according to tumor location. Patients with the same sex, age difference of less than 3 years, and equal gross tumor diameter were selected from the lobar group and compared with the paraisthmic tumor group. Independent risk factors were determined using univariate and multivariate logistic regression analysis. On this basis, clinical predictive nomograms were developed and validated.

RESULTS

Clinical data from 326 patients with solitary PTCI and 660 cases of solitary lobar PTC were used for analysis in our study. The incidence of solitary tumors CLNM located in the median isthmus, paracentral isthmus, and lobes was 69.8%, 40.9%, and 33.6%, respectively. Statistical analysis revealed that gender, age, isthmus location, maximum nodal diameter, the presence of possible CLNM in advance on preoperative ultrasound, chronic lymphocytic thyroiditis, and the lymphocyte/monocyte ratio were independent risk factors for preoperative CLNM in patients with solitary PTCI. Age, isthmus location, chronic lymphocytic thyroiditis, gross tumor diameter, presence of intraoperative extrathyroidal extension, and presence of metastasis in the Delphian lymph node on frozen section were independent risk factors for intraoperative CLNM. The concordance indices of nomograms for preoperative and intraoperative are 0.871 and 0.894 in the training set and 0.796 and 0.851 in the validation set, calibration curve and decision curve analysis also demonstrated the strong reliability and clinical applicability of this clinical prediction model.

CONCLUSION

In this study, we concluded that solitary PTCI is more aggressive compared to solitary lobar PTC, and we constructed nomograms and risk stratification to accurately identify patients with solitary PTCI who are at high risk of developing CLNM, which will help clinicians in personalized decision making.

Submandibular solid-cystic mass as the first and sole manifestation of occult thyroid papillary carcinoma: A case report

BACKGROUND

Occult thyroid papillary carcinoma (OTPC) is typically characterized by initial presentation with cervical lymph node metastasis and can be detected through ultrasound. However, the initial and sole manifestation was a submandibular solid-cystic mass. High-frequency ultrasound, enhanced multislice computed tomography (CT) scan, and thyroid function tests revealed no abnormalities, which is relatively uncommon.

CASE SUMMARY

A 24-year-old Chinese female, who studied at a university in Shandong Province, presented to the clinic in June 2019 with a right submandibular mass that she had noticed 2 mo earlier. Clinical examination revealed a 2-cm, nontender, movable solid-cystic mass in the submandibular region, with no palpable thyroid mass observed. Ultrasonography revealed a 2.0 cm × 1.1 cm solid-cystic mass in the right submandibular region, and the thyroid gland showed no abnormalities. CT scan and 131I whole body follow-up scan showed that there were no abnormalities in the thyroid. However, cytology and pathology showed papillary tumor cell clusters, consistent with papillary thyroid carcinoma. Thus, we performed total thyroidectomy and right neck lymph node dissection. The pathology revealed the thyroid was detected as classical thyroid micropapillary carcinoma, and lymph nodes of levels VI central and levels II, III, IV, V on the right side showed no tumor metastasis. The patient was followed up for 2 years without significant recurrence.

CONCLUSION

The presentation of a submandibular solid-cystic mass as the primary and solitary indication of OTPC is relatively uncommon. Fine needle aspiration is advised for evaluating neck masses.

Diffuse Sclerosing Variant of Papillary Thyroid Carcinoma Is Related to a Poor Outcome: A Comparison Study Using Propensity Score Matching

OBJECTIVE

The clinical outcome of diffuse sclerosing variant of papillary thyroid carcinoma (DSV-PTC) remains controversial. We aimed to determine whether DSV-PTC is associated with an increased risk of persistent/recurrent disease.

METHODS

We performed a retrospective cohort study of DSV-PTC and classic variant of papillary thyroid carcinoma (CV-PTC) after postoperative radioactive iodine therapy. We used propensity score matching (1:3 matching ratio) to account for differences between the recipients of DSV-PTC and CV-PTC. Univariate and multivariate analyses were performed to assess the independent factors for persistent/recurrent disease. The Kaplan-Meier curve analyses were used to compare disease-free survival (DFS).

RESULTS

In total, 35 (12.7%) patients with DSV-PTC and 240 (87.3%) patients with CV-PTC were included. After propensity score matching, 35 pairs of patients were selected (DSV-PTC, n = 35; CV-PTC, n = 105). In the matched analysis, a higher proportion of patients with DSV-PTC experienced persistent/recurrent disease than that of those with CV-PTC (25.7% vs 5.7%, P = .003). In the multivariate analyses of clinical and tumor characteristics, only the histologic type of DSV-PTC (odds ratio, 6.288; 95% confidence interval, 1.900-20.811; P = .003) was associated with an increased risk of persistent/recurrent disease. The 5-year DFS rates for the DSV-PTC and CV-PTC groups were 69.2% and 93.6%, respectively. The Kaplan-Meier analysis indicated that the DSV-PTC group (P= .001) had shorter DFS.

CONCLUSION

This propensity score-matched analysis found that the histologic type of DSV-PTC may increase the risk of persistent/recurrent disease.

Preoperative Evaluation of Thyroid Cancer: A Review of Current Best Practices

OBJECTIVE

The incidence of thyroid cancer has significantly increased in recent decades. Although most thyroid cancers are small and carry an excellent prognosis, a subset of patients present with advanced thyroid cancer, which is associated with increased rates of morbidity and mortality. The management of thyroid cancer requires a thoughtful individualized approach to optimize oncologic outcomes and minimize morbidity associated with treatment. Because endocrinologists usually play a key role in the initial diagnosis and evaluation of thyroid cancers, a thorough understanding of the critical components of the preoperative evaluation facilitates the development of a timely and comprehensive management plan. The following review outlines considerations in the preoperative evaluation of patients with thyroid cancer.

METHODS

A clinical review based on current literature was generated by a multidisciplinary author panel.

RESULTS

A review of considerations in the preoperative evaluation of thyroid cancer is provided. The topic areas include initial clinical evaluation, imaging modalities, cytologic evaluation, and the evolving role of mutational testing. Special considerations in the management of advanced thyroid cancer are discussed.

CONCLUSION

Thorough and thoughtful preoperative evaluation is critical for formulating an appropriate treatment strategy in the management of thyroid cancer.

The impact of lymph node ratio on disease recurrence in papillary thyroid microcarcinoma

INTRODUCTION

Lymph node (LN) metastases in papillary thyroid microcarcinomas (microPTCs) are common. The lymph node ratio (LNR) has been proposed as a risk factor for recurrence in papillary thyroid cancer. However, its relevance in microPTC is undetermined.

METHODS

Patients who underwent resection of their microPTC with concomitant LN clearance between 2005 and 2018 were identified. The LNR was calculated as the ratio of positive LNs to the total number of LNs.

RESULTS

Data on 50 patients (36 female [72%]; median age 47 years [range: 19-84]) who underwent LN clearance (28 central [56%] vs 22 central + lateral [44%]) were analysed. Positive LNs were found in over two-thirds of the patients (n = 34; 68%). After a median follow-up of 61 months, 14 patients (28%) had developed recurrence. Positive LNs were not found to impact recurrence-free survival; extranodal extension and an LNR ≥ 0.26 were found to significantly increase the risk of recurrence on unadjusted analyses (p < 0.05).

CONCLUSIONS

LN metastases are frequent among patients with microPTC. A higher LNR seems to be associated with recurrence. Additional studies are needed to further clarify these findings and to assess the possible role of LNR in treatment and surveillance.

Development of a Clinical-Radiomics Nomogram That Used Contrast-Enhanced Ultrasound Images to Anticipate the Occurrence of Preoperative Cervical Lymph Node Metastasis in Papillary Thyroid Carcinoma Patients

Background and Objectives

Papillary thyroid carcinoma (PTC) is a prevalent histological type of thyroid cancer; however, noninvasive assessment of cervical lymph node metastasis (LNM) poses a challenge. This study aims to develop a novel clinical-radiomics nomogram that utilizes ultrasound (US) images to predict the presence of cervical LNM metastasis in patients with PTC.

Methods

A total of 423 patients with PTC were recruited to participate in this study between January 2020 and December 2022, of which 282 were classified into the training group and 141 patients were classified into the validation set. Contrast-enhanced ultrasound (CEUS) and B-mode ultrasound (BMUS) images were subjected to radiomic analysis, leading to the extraction of 912 radiomic features. Thereafter, a radiomics score (Radscore) was developed to effectively integrate the information derived from BMUS and CEUS modalities. Univariate and multivariate backward stepwise logistic regression analysis techniques were used to construct the clinical and clinical-radiomics models, respectively.

Results

The findings revealed that the clinical-radiomics nomogram incorporated age, sex, CEUS Radscore, and US-reported LNM as risk factors. The nomogram demonstrated good performance using data from the training (AUC = 0.891) and validation (AUC = 0.870) sets. The decision curve analysis implied that this nomogram exhibited good clinical utility, which was further supported by the results of the calibration curves and Hosmer-Lemeshow test.

Conclusion

The CEUS Radscore-based clinical radiomics nomogram could serve as a valuable tool for predicting cervical LNM metastasis in patients with PTC, thereby tailoring individualized treatment strategies for them.

Reliable neck sonography of nodal thyroglobulin to diagnose recurrent/persistent disease from papillary thyroid carcinoma

OBJECTIVE

This study evaluates the correlation between the sonographic features and the nodal fine-needle aspiration thyroglobulin (FNA-Tg) in papillary thyroid carcinoma (PTC) patients with the recurrent/persistent lymph node for the purpose of the reasonable selection of lymph nodes.

METHODS

This study prospectively contained PTC patients with the suspicious cervical lymph nodes in one medical center from April 2018 to January 2019. Each suspected lymph node was aspirated with a 22-gauge needle and the value of FNA-Tg was measured as well.

RESULTS

There were 136 lymph nodes related to the disease involved. The FNA-Tg levels of 89 (65.44%) metastatic lymph nodes were significantly higher than those of the benign. The median value of the former was 631.550 ng/mL while the latter was 0.056 ng/mL (p = 0.000). The cut-off value of the metastatic lymph nodes diagnosed by FNA-Tg was 2.71 ng/mL, and 6.5 by FNA-Tg/sTg. The suspicious ultrasonographic features including cystic, hyperechoic content, and lack of hilum were closely related to the high level of FNA-Tg value (p < 0.05). However, the round shape (Solbiati index <2) and calcification were not significantly correlated with the positive FNA-Tg (p > 0.05).

CONCLUSION

FNA-Tg is an effective supplement to fine-needle aspiration (FNA) cytology in the nodal metastasis diagnosis. The FNA-Tg level was much higher in the metastatic lymph nodes. The reliable sonographic features of lymph nodes suggested the positive FNA-Tg were cystic content, hyperechoic content and lack hilum. Solbiati index <2 and calcification did not show an exact correlation with the result of FNA-Tg.

PTC-MAS: A Deep Learning-Based Preoperative Automatic Assessment of Lymph Node Metastasis in Primary Thyroid Cancer

BACKGROUND

Identifying cervical lymph node metastasis (LNM) in primary thyroid cancer preoperatively using ultrasound is challenging. Therefore, a non-invasive method is needed to assess LNM accurately.

PURPOSE

To address this need, we developed the Primary Thyroid Cancer Lymph Node Metastasis Assessment System (PTC-MAS), a transfer learning-based and B-mode ultrasound images-based automatic assessment system for assessing LNM in primary thyroid cancer.

METHODS

The system has two parts: YOLO Thyroid Nodule Recognition System (YOLOS) for obtaining regions of interest (ROIs) of nodules, and LMM assessment system for building the LNM assessment system using transfer learning and majority voting with extracted ROIs as input. We retained the relative size features of nodules to improve the system's performance.

RESULTS

We evaluated three transfer learning-based neural networks (DenseNet, ResNet, and GoogLeNet) and majority voting, which had the area under the curves (AUCs) of 0.802, 0.837, 0.823, and 0.858, respectively. Method III preserved relative size features and achieved higher AUCs than Method II, which fixed nodule size. YOLOS achieved high precision and sensitivity on a test set, indicating its potential for ROIs extraction.

CONCLUSIONS

Our proposed PTC-MAS system effectively assesses primary thyroid cancer LNM based on preserving nodule relative size features. It has potential for guiding treatment modalities and avoiding inaccurate ultrasound results due to tracheal interference.

A Nod to the Nodes: An Overview of the Role of Central Neck Dissection in the Management of Papillary Thyroid Carcinoma

Lymph node metastasis in thyroid cancer is common and associated with an increased risk of locoregional recurrence (LRR). Although therapeutic central neck dissection is well established, prophylactic central node dissection (pCND) for microscopic occult nodal involvement is controversial and recommendations are based on low-level evidence. The potential benefits of pCND such as reducing LRR and re-operation, refining staging, and improving surveillance are enthusiastically debated and the decision to perform pCND must be weighed up against the increased risks of complications.

Correlation between Sonographic Features and Central Neck Lymph Node Metastasis in Solitary Solid Papillary Thyroid Microcarcinoma with a Taller-Than-Wide Shape

Purpose: This study aimed to investigate the correlation between sonographic features and central neck lymph node metastasis (CNLM) in solitary solid papillary thyroid microcarcinoma (PTMC) with a taller-than-wide shape. Methods: A total of 103 patients with solitary solid PTMC with a taller-than-wide shape on ultrasonography who underwent surgical histopathological examination were retrospectively selected. Based on the presence or absence of CNLM, patients with PTMC were divided into a CNLM (n = 45) or nonmetastatic (n = 58) group, respectively. Clinical findings and ultrasonographic features, including a suspicious thyroid capsule involvement sign (STCS, which is defined as PTMC abutment or a disrupted thyroid capsule), were compared between the two groups. Additionally, postoperative ultrasonography was performed to assess patients during the follow-up period. Results: Significant differences were observed in sex and the presence of STCS between the two groups (p < 0.05). The specificity and accuracy of the male sex for predicting CNLM were 86.21% (50/58 patients) and 64.08% (66/103 patients), respectively. The sensitivity, specificity, positive predictive value (PPV), and accuracy of STCS for predicting CNLM were 82.22% (37/45 patients), 70.69% (41/58 patients), 68.52% (37/54 patients), and 75.73% (78/103 patients), respectively. The specificity, PPV, and accuracy of the combination of sex and STCS for predicting CNLM were 96.55% (56/58 patients), 87.50% (14/16 patients), and 67.96% (70/103 patients), respectively. A total of 89 (86.4%) patients were followed up for a median of 4.6 years, with no patient having recurrence as detected on ultrasonography and pathological examination. Conclusions: STCS is a useful ultrasonographic feature for predicting CNLM in patients with solitary solid PTMC with a taller-than-wide shape, especially in male patients. Solitary solid PTMC with a taller-than-wide shape may have a good prognosis.

The risk of central nodal metastasis based on prognostic factors of the differentiated thyroid carcinoma: a systematic review and meta-analysis study

BACKGROUND AND AIM

Despite improving the 10-year disease-free-survival, prophylactic central neck dissection (pCND) in differentiated thyroid carcinoma (DTC) should only be considered in patients with high risk factors for lymph node (LN) metastasis due to the increases in the risk of postoperative complications. Our aim was to identify the risk factors for central lymph node metastasis (CLNM) in DTC.

METHOD

We searched PubMed, Scopus, Web of science, Cochrane library for eligible studies from inception to November 1, 2021 and a systematic review and meta-analysis were carried out to identify the risk factors for CLNM in DTC.

RESULTS

We included 41 studies with total of 27,741 patients in this study. The pooled results in this meta-analysis showed that these risk factors were significantly associated with CLNM: age < 45 years (odds ratio (OR) 1.64, 95% confidence interval (CI) 1.34-1.99, p < 0.00001), male sex (OR 1.73, 95% CI 1.54-1.93, p < 0.00001), multifocality (OR 1.87, 95% CI 1.59-2.19, p < 0.00001), bilateral disease (OR 1.43, 95% CI 1.15-1.78, p < 0.001), capsular invasion (OR 1.67, 95% CI 1.10-2.54, p < 0.02), lymphovascular invasion (OR 4.89, 95% CI 2.76-8.66, p < 0.00001) and extra-thyroidal extension (OR 2.43, 95% CI 1.97-3.00, p < 0.00001). In addition, young age (< 45 years), male sex, multifocality, and extra-thyroidal extension were significantly associated with large-volume CLNM in clinically N0 DTC patients. However, the presence of Hashimoto's thyroiditis was not a predictors of large-volume CLNM.

CONCLUSION

Young age (< 45 years), male sex, bilateral disease, multifocality, capsular invasion, lymphovascular invasion and extra-thyroidal extension are significantly associated with CLNM and pCND would be expected to have a higher yield in patients with these risk factors.

Nomogram to differentiate benign and malignant thyroid nodules in the American College of Radiology Thyroid Imaging Reporting and Data System level 5

OBJECTIVES

To develop and validate a nomogram for differentiating benign and malignant thyroid nodules of American College of Radiology (ACR) Thyroid Imaging Reporting and Data System (TI-RADS) level 5 (TR5) and improving the performance of the guideline.

METHODS

From May 2018 to December 2019, 640 patients with TR5 nodules were retrospectively included in the primary cohort. Univariate and multivariable analyses were performed to determine the risk factors for thyroid cancer. A nomogram was established on the basis of multivariable analyses; the performance of the nomogram was evaluated with respect to discrimination, calibration, and clinical usefulness. The nomogram model was also compared to the ACR score model. External validation was performed and the independent validation cohort contained 201 patients from April 2021 to January 2022.

RESULTS

Multivariable analyses showed that age, tumour location, multifocality, concomitant Hashimoto's disease, neck lymph node status reported by ultrasound (US) and ACR score were the independent risk factors for thyroid cancer (all p < .05). The nomogram showed good discrimination, with an area under the curve (AUC) of 0.786 (95% confidence interval [CI]: 0.742-0.830) and 0.712 (95% CI: 0.615-0.809) in the primary cohort and external validation cohort, respectively. Decision curve analysis demonstrated the clinical usefulness of the model. Compared to the ACR score model, the nomogram showed higher AUC (0.786 vs. 0.626, p < .001) and specificity (0.783 vs. 0.391).

CONCLUSIONS

The presented nomogram model, based on age, tumour features and ACR score, can differentiate benign and malignant thyroid nodules in TR5 and had a high specificity.

Guideline for the Surgical Management of Locally Invasive Differentiated Thyroid Cancer From the Korean Society of Head and Neck Surgery

The aim of this study was to develop evidence-based recommendations for determining the surgical extent in patients with locally invasive differentiated thyroid cancer (DTC). Locally invasive DTC with gross extrathyroidal extension invading surrounding anatomical structures may lead to several functional deficits and poor oncological outcomes. At present, the optimal extent of surgery in locally invasive DTC remains a matter of debate, and there are no adequate guidelines. On October 8, 2021, four experts searched the PubMed, Embase, and Cochrane Library databases; the identified papers were reviewed by 39 experts in thyroid and head and neck surgery. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess the quality of evidence, and to develop and report recommendations. The strength of a recommendation reflects the confidence of a guideline panel that the desirable effects of an intervention outweigh any undesirable effects, across all patients for whom the recommendation is applicable. After completing the draft guidelines, Delphi questionnaires were completed by members of the Korean Society of Head and Neck Surgery. Twenty-seven evidence-based recommendations were made for several factors, including the preoperative workup; surgical extent of thyroidectomy; surgery for cancer invading the strap muscles, recurrent laryngeal nerve, laryngeal framework, trachea, or esophagus; and surgery for patients with central and lateral cervical lymph node involvement. Evidence-based guidelines were devised to help clinicians make safer and more efficient clinical decisions for the optimal surgical treatment of patients with locally invasive DTC.

Active surveillance in differentiated thyroid cancer: a strategy applicable to all treatment categories response

Currently, the differentiated thyroid cancer (DTC) management is shifted toward a tailored approach based on the estimated risks of recurrence and disease-specific mortality. While the current recommendations on the management of metastatic and progressive DTC are clear and unambiguous, the management of slowly progressive or indeterminate disease varies according to different centers and different physicians. In this context, active surveillance (AS) becomes the main tool for clinicians, allowing them to plan a personalized therapeutic strategy, based on the risk of an unfavorable prognosis, and to avoid unnecessary treatment. This review analyzes the main possible scenarios in treated DTC patients who could take advantage of AS.

Standardized Imaging and Reporting for Thyroid Ultrasound: Korean Society of Thyroid Radiology Consensus Statement and Recommendation

Ultrasonography (US) is a primary imaging modality for diagnosing nodular thyroid disease and has an essential role in identifying the most appropriate management strategy for patients with nodular thyroid disease. Standardized imaging techniques and reporting formats for thyroid US are necessary. For this purpose, the Korean Society of Thyroid Radiology (KSThR) organized a task force in June 2021 and developed recommendations for standardized imaging technique and reporting format, based on the 2021 KSThR consensus statement and recommendations for US-based diagnosis and management of thyroid nodules. The goal was to achieve an expert consensus applicable to clinical practice.

Incorporation size of lymph node metastasis focus and pre-ablation stimulated Tg could more effectively predict clinical outcomes in differentiated thyroid cancer patients without distant metastases

BACKGROUND

The size of lymph node metastasis (LNM) and pre-ablation stimulated Tg (ps-Tg) were key predictors of clinical prognosis in differentiated thyroid cancer (DTC) patients, however, very few studies combine the above two as predictors of clinical prognosis of DTC patients.

METHODS

Persistent/recurrent disease and clinicopathologic factors were analyzed in 543 DTC patients without distant metastases who underwent LN dissection, near-total/total thyroidectomy, and radioiodine ablation.

RESULTS

In the multivariate analysis, size of LNM, ps-Tg, and the activity of ¹³¹I significantly correlated with long-term remission. The optimal cutoff size of LNM 0.4 cm-1.4 cm (intermediate-risk patients) and >1.4cm (high-risk patients) increased the recurrence risk (hazard ratio [95% CI], 4.674 [2.881-7.583] and 13.653 [8.135-22.913], respectively). Integration of ps-Tg into the reclassification risk stratification showed that ps-Tg ≤ 10.0 ng/mL was relevant to a greatly heightened possibility of long-term remission (92.2%-95.4% in low-risk patients, 67.3%-87.0% in intermediate-risk patients, and 32.3%-57.7% in high-risk patients).

CONCLUSION

The cutoff of 0.4 cm and 1.4 cm for a definition of size of LNM in DTC patients without distant metastases can reclassify risk assessment, and incorporating ps-Tg could more effectively predict clinical outcomes and modify the postoperative management plan.

Risk factors and prediction model of level II lymph node metastasis in papillary thyroid carcinoma

Introduction

Surgical management of lateral lymph nodes in papillary thyroid carcinoma, especially at level II, remains controversial. This study aimed to investigate the risk factors for level II lymph node metastasis in patients with papillary thyroid carcinoma and establish a prediction model to estimate the metastatic risk.

Materials and methods

A total of 768 patients with papillary thyroid carcinoma underwent thyroidectomy and central plus lateral lymph node dissection, including levels VI, II, III, and IV, at the First Affiliated Hospital of Chongqing Medical University from January 2016 to December 2018. Data on the clinicopathological characteristics were collected and analyzed. Univariate and multivariate analyses were performed to identify risk factors for level II lymph node metastasis. Subsequently, a predictive model was established based on the results of the multivariate analyses.

Results

The level II lymph node metastatic rate was 34.11% with the following features: largest tumor diameter >20 mm (Odds ratio=1.629, P=0.026), located in the upper pole (Odds ratio=4.970, P<0.001), clinical lymph node-positive (clinical central lymph node-positive: Odds ratio=1.797; clinical lateral lymph node-positive: Odds ratio=1.805, P=0.008), vascular invasion (Odds ratio=6.759, P=0.012), and rate of central lymph node metastasis (Odds ratio=2.498, P<0.001). Level III lymph node metastasis (Odds ratio=2.749, P<0.001) and level IV lymph node metastasis (Odds ratio=1.732, P=0.007) were independent of level II lymph node metastasis predictors. The prediction model's areas under the receiver operating characteristic curve were 0.815 and 0.804, based on bootstrapping validation. Level II lymph node metastasis was associated with the tumor-free survival rate of patients with papillary thyroid carcinoma (P<0.001).

Conclusions

Largest tumor diameter >20 mm, located in the upper pole, clinical lymph node-positive, vascular invasion, rate of central lymph node metastasis, and levels III and IV lymph node metastases were independent level II lymph node metastasis predictors. We developed a prediction model for level II lymph node metastasis. Overall, level II lymph node metastasis dissection should be individualized according to clinicopathological data both preoperatively and intraoperatively.

SFE-AFCE-SFMN 2022 Consensus on the management of thyroid nodules: Initial work-up for thyroid nodules

The SFE-AFCE-SFMN 2022 consensus deals with the management of thyroid nodules, a condition that is a frequent reason for consultation in endocrinology. In more than 90% of cases, patients are euthyroid, with benign non-progressive nodules that do not warrant specific treatment. The clinician's objective is to detect malignant thyroid nodules at risk of recurrence and death, toxic nodules responsible for hyperthyroidism or compressive nodules warranting treatment. The diagnosis and treatment of thyroid nodules requires close collaboration between endocrinologists, nuclear medicine physicians and surgeons, but also involves other specialists. Therefore, this consensus statement was established jointly by 3 societies: the French Society of Endocrinology (SFE), French Association of Endocrine Surgery (AFCE) and French Society of Nuclear Medicine (SFMN); the various working groups included experts from other specialties (pathologists, radiologists, pediatricians, biologists, etc.). This section deals with the initial work-up for thyroid nodules in adult patients, including clinical and biological evaluation, standardized ultrasound characterization and EU-TIRADS-based nodule selection for fine-needle aspiration biopsy. Indications for thyroid core-biopsies or open surgical biopsies and for cross-sectional imaging of the neck and upper chest are also mentioned.

2022 European Thyroid Association Guidelines for the management of pediatric thyroid nodules and differentiated thyroid carcinoma

At present, no European recommendations for the management of pediatric thyroid nodules and differentiated thyroid carcinoma (DTC) exist. Differences in clinical, molecular, and pathological characteristics between pediatric and adult DTC emphasize the need for specific recommendations for the pediatric population. An expert panel was instituted by the executive committee of the European Thyroid Association including an international community of experts from a variety of disciplines including pediatric and adult endocrinology, pathology, endocrine surgery, nuclear medicine, clinical genetics, and oncology. The 2015 American Thyroid Association Pediatric Guideline was used as framework for the present guideline. Areas of discordance were identified, and clinical questions were formulated. The expert panel members discussed the evidence and formulated recommendations based on the latest evidence and expert opinion. Children with a thyroid nodule or DTC require expert care in an experienced center. The present guideline provides guidance for healthcare professionals to make well-considered decisions together with patients and parents regarding diagnosis, treatment, and follow-up of pediatric thyroid nodules and DTC.

Clinical Value of Ultrasonography and Serum Markers in Preoperative N Staging of Thyroid Cancer

We aimed to determine factors influencing lymph node metastasis (LNM) and develop a more effective method to assess preoperative N staging. Overall, data of 2130 patients who underwent thyroidectomy for thyroid cancer between 2018 and 2021 were retrospectively analysed. Patients were divided into groups according to pN0, pN1a, and pN1b stages. Pathology was used to analyse the correlation between preoperative serum marker indicators and LNM. Receiver operating characteristic curves were used to compare the diagnostic value of ultrasound (US) examination alone, serum thyroglobulin, age, and combined method for LNM. A significant moderate agreement was observed between preoperative US and postoperative pathology for N staging. Between the pN0 and pN1 (pN1a + pN1b) groups, the differences in free triiodothyronine, anti-thyroid peroxidase antibody, and serum thyroglobulin levels were statistically significant. Among the indicators, serum thyroglobulin was an independent predictor of LNM. The area under the receiver operating characteristic curve was 0.610 for serum thyroglobulin level for predicting LNM, 0.689 for US alone, and 0.742 for the combined method. Both preoperative US and serum thyroglobulin level provide a specific value when evaluating the N staging of thyroid cancer, and the combined method is more valuable in the diagnosis of LNM than US alone.

Sonographic Diagnosis of Cervical Lymph Node Metastasis in Patients with Thyroid Cancer and Comparison of European and Korean Guidelines for Stratifying the Risk of Malignant Lymph Node

OBJECTIVE

To evaluate the ultrasonography (US) features for diagnosing metastasis in cervical lymph nodes (LNs) in patients with thyroid cancer and compare the US classification of risk of LN metastasis between European and Korean guidelines.

MATERIALS AND METHODS

From January 2014 to December 2018, US-guided fine-needle aspiration was performed on 836 LNs from 714 patients for the preoperative nodal staging of thyroid cancer. The US features of LNs were retrospectively reviewed for the following features: size, presence of hilum, margin, orientation, cystic change, punctate echogenic foci (PEF), large echogenic foci, eccentric cortical thickening, abnormal vascularity, and cortical hyperechogenicity. A multiple logistic regression analysis was performed to identify the independent US features for the diagnosis of metastatic LNs. The diagnostic performance of independent US features was subsequently evaluated. LNs were categorized according to the Korean Thyroid Imaging Reporting and Data System (K-TIRADS) and European Thyroid Association (ETA) guidelines, and the correlation between the two sets of classifications was assessed.

RESULTS

Absence of the hilum, presence of cystic changes, PEF, abnormal vascularity, and cortical hyperechogenicity were independent US features of metastatic LNs. Cystic changes, PEF, abnormal vascularity, and cortical hyperechogenicity showed high specificity (86.8%-99.6%). The absence of the hilum had the highest sensitivity yet low specificity (66.4%). When LNs were classified according to the ETA guidelines and K-TIRADS, they yielded similar categorizations of malignancy risks and were strongly correlated (Spearman coefficient, 0.9766 [95% confidence interval, 0.973-0.979]). According to the ETA guidelines, 9.8% (82/836) of LNs were classified as "not specified."

CONCLUSION

Absence of hilum, cystic changes, PEF, abnormal vascularity, and cortical hyperechogenicity were independent US features suggestive of metastatic LNs in thyroid cancer. Both K-TIRADS and the ETA guidelines provided similar risk stratification for metastatic LNs with a high correlation; however, the ETA guidelines failed to classify 9.8% of LNs into a specific risk stratum. These results may provide a basis for revising LN classification in future guidelines.

Detection of thyroglobulin in fine-needle aspiration for diagnosis of metastatic lateral cervical lymph nodes in papillary thyroid carcinoma: A retrospective study

Objective

We analysed the diagnostic performance of thyroglobulin in fine-needle aspiration (FNA-Tg) in the suspicious lateral cervical lymph nodes (CLNs) in patients with papillary thyroid cancer (PTC), proposed the best cutoff value and discussed the factors that may affect the diagnostic value of FNA-Tg.

Methods

In the present study, a retrospective analysis of 403 patients with PTC with 448 suspected lateral CLNs metastasis from October 2019 to May 2021 was performed. The cutoff value according to the receiver operating characteristic (ROC) curve was determined, and the Wilcoxon rank-sum test was used to evaluate the correlation between FNA-Tg and factors.

Results

According to the ROC curve, the cutoff value of FNA-Tg was 3.69 ng/ml (sensitivity, 92.48%; specificity, 75.00%). Patients who underwent total thyroidectomy were excluded. Compared with US and FNAC, the diagnostic performance of FNA-Tg was the greatest, especially for small CLNs (diameter ≤ 1 cm), cystic CLNs, and patients with Hashimoto’s thyroiditis (HT). Moreover, FNA-Tg levels were correlated with the presence of HT (p = 0.003), the anti-thyroglobulin antibody (Tg-Ab) (p < 0.001), the ratio of metastatic lateral CLNs (p = 0.004) and Tg assay kits (p < 0.001).

Conclusions

FNA-Tg measurement is sensitive enough for diagnosing lateral CLN metastases from PTC, but its diagnostic value is compromised by a number of factors.

Contrast-enhanced ultrasound-based nomogram for predicting malignant involvements among sonographically indeterminate/suspicious cervical lymph nodes in patients with differentiated thyroid carcinoma

This prospective study was aimed at assessing the value of nomograms based on conventional and contrast-enhanced ultrasound (CEUS) features in the pre-operative diagnosis of sonographically indeterminate/suspicious lymph node metastasis (LNM) in patients with differentiated thyroid carcinoma (DTC). A total of 72 cervical LNs from 47 patients with DTC from January to June 2018 were included in the primary data set, and 30 LNs from 15 patients with DTC from July to August 2018 were included in the external validation data set. The LNs of the included patients were preoperatively evaluated by conventional ultrasound (US) and CEUS. Each included LN was labeled by puncture localization with carbon nanoparticle suspension injection (Canalin) under US guidance and dissected separately to ensure the one-to-one correspondence between ultrasonic features and pathology status. Univariate logistic regression analysis was used to identify risk factors for LNM. A nomogram was used to construct a prediction model for cervical metastatic LNs. Round shape, absence of hilar structure, peripheral or mixed blood flow and centripetal or mass enhancement were risk factors for lymph node metastases. The area under the receiver operating characteristic curve of the nomogram model based on conventional US and CEUS features was 0.93 (95% confidence interval: 0.872-0.985), which was superior to that of the nomogram based on conventional US features(0.85, 95% confidence interval: 0.707-0.989). CEUS features can provide incremental benefit in the diagnosis of LNM among DTC cohorts. Nomograms based on conventional US and CEUS features can predict LN status with high accuracy.

Diagnostic accuracy of ultrasound, CT and their combination in detecting cervical lymph node metastasis in patients with papillary thyroid cancer: a systematic review and meta-analysis

OBJECTIVES

To determine the diagnostic accuracy of ultrasound (US), CT and their combination in detecting cervical lymph node metastasis (CLNM) in patients with papillary thyroid cancer (PTC).

METHODS

Medline (via PubMed), Web of Science, Embase were searched to identify studies published till 5 December 2021 that used US and CT to detect CLNM in patients with PTC. The primary outcomes were sensitivity, specificity and diagnostic ORs in neck-level-based (lymph nodes are analysed by neck level) or patient-based (lymph nodes are analysed by patient) analysis. Secondary outcomes were sensitivity, specificity and DORs in the central and lateral compartments.

RESULTS

Fourteen studies (6167 patients with 11 601 neck lymph nodes) met the inclusion criteria. Based on the neck-level-based analysis, the pooled sensitivity, specificity and DORs were 0.35 (95% CI 0.34 to 0.37), 0.95 (95% CI 0.94 to 0.95) and 13.94 (95% CI 9.34 to 20.82) for US, were 0.46 (95% CI 0.44 to 0.47), 0.88 (95% CI 0.87 to 0.89) and 7.24 (95% CI 5.46 to 9.62) for CT, were 0.51 (95% CI 0.49 to 0.52), 0.85 (95% CI 0.84 to 0.86), 6.01 (95% CI 3.84 to 9.40) for the combination of US and CT. In the patient-based analysis, the pooled estimates of sensitivity, specificity and DOR were 0.41 (95% CI 0.36 to 0.46), 0.92 (95% CI 0.89 to 0.94) and 7.56 (95% CI 4.08 to 14.01) for US, were 0.49 (0.44 to 0.54), 0.91 (0.89 to 0.94), 9.40 (5.79 to 15.27) for CT, and were 0.64 (95% CI 0.57 to 0.71), 0.83 (95% CI 0.77 to 0.88), 8.59 (95% CI 5.37 to 13.76) for the combination of US and CT.

DISCUSSION

These findings suggest US, with a DOR almost twice that of CT in the neck-level-based analysis, was superior to CT in detecting CLNM in patients with PTC, especially in the lateral compartment. The combination of US and CT increased the sensitivity from 41%-49% for the individual modalities to 64% for combined modalities in the patient-based analysis.

The Old and the New in Subacute Thyroiditis: An Integrative Review

Subacute thyroiditis (SAT) is the most common cause of neck pain and thyrotoxicosis. Although this disease was recognized already by the end of the 18th century, new concepts regarding pathogenesis have emerged in recent years. Moreover, in the last two years, literature on SAT has increased significantly due to articles describing the possible connection with coronavirus disease 2019 (COVID-19). This integrative review depicts old and new concepts of this disease, proposing a detailed overview of pathogenesis, a practical approach to diagnosis and treatment, and a thorough description of the latest discoveries regarding the association of SAT with COVID-19.

Clinical application of a 5G-based telerobotic ultrasound system for thyroid examination on a rural island: a prospective study

PURPOSE

To evaluate the feasibility of a 5G-based telerobotic ultrasound (US) system for thyroid examination on a rural island.

METHODS

From September 2020 to March 2021, this prospectively study enrolled a total of 139 patients (average age, 58.6 ± 12.7 years) included 33 males and 106 females, who underwent 5G-based telerobotic thyroid US examination by a tele-doctor at Shanghai Tenth People's Hospital and a conventional thyroid US examination at Chongming Second People's Hospital 84 km away. The clinical feasibility of 5G-based telerobotic US for thyroid examination were evaluated in terms of safety, duration, US image quality, diagnostic results, and questionnaire survey.

RESULTS

92.8% of patients had no examination-related complaints. The average duration of the 5G-based telerobotic US examination was similar as that of conventional US examination (5.57 ± 2.20 min vs. 5.23 ± 2.1 min, P = 0.164). The image quality of telerobotic US correlated well with that of conventional US (4.63 ± 0.60 vs. 4.65 ± 0.61, P = 0.102). There was no significant difference between two types of US examination methods for the diameter measurement of the thyroid, cervical lymph nodes, and thyroid nodules. Two lymphadenopathies and 20 diffuse thyroid diseases were detected in two types of US methods. 124 thyroid nodules were detected by telerobotic US and 127 thyroid nodules were detected by conventional US. Among them, 122 were the same thyroid nodules. In addition, there were good consistency in the US features (component, echogenicity, shape, and calcification) and ACR TI-RADS category of the same thyroid nodules between telerobotic and conventional US examinations (ICC = 0.788-0.863). 85.6% of patients accepted the telerobotic US, and 87.1% were willing to pay extra fee for the telerobotic US.

CONCLUSION

The 5G-based telerobotic US system can be a routine diagnostic tool for thyroid examination for patients on a rural island.

68Ga-DOTA-FAPI-04 PET/CT imaging in radioiodine-refractory differentiated thyroid cancer (RR-DTC) patients

OBJECTIVE

This study aimed to assess the potential of ⁶⁸Ga-DOTA-FAPI-04 PET/CT for the detection of the radioiodine-refractory differentiated thyroid cancer (RR-DTC) lesions.

METHODS

We analyzed the ⁶⁸Ga-DOTA-FAPI-04 PET/CT imaging data of 24 RR-DTC patients (7 men and 17 women; 49.6 ± 10.5 year). Clinical data were collected including history, last post-therapeutic radioiodine whole body scan, contemporary CT, thyroglobulin, and antithyroglobulin. Target lesions were selected and measured by the RECIST 1.1. The mean growth rates of the target lesions in the past 6 months were recorded. Tumor uptake of lesions were quantified by SUVmax and the tumor-to-background ratios. The correlation between SUVmax and target lesion growth rate and thyroglobulin was analyzed.

RESULTS

On patient-based analysis, positive metastases were detected in 87.5% (21/24) patients. Except for the lymph node (LN) metastasis of 3 patients (patient 6, 12 and 17#) and the lung metastasis of another 3 patients (patient 9, 13 and 21#), most of the lesions were positive on ⁶⁸Ga-DOTA-FAPI-04 PET/CT images, including LN metastasis and distant metastasis such as lung, bone and pleura. There were altogether 33 target lesions including 30 lung metastases and 3 LN metastases with the mean SUVmax and the growth rate were 4.25 and 6.51%, respectively. SUVmax was statistically associated with the growth rates of the target lesions (p = 0.047). No statistically significant correlation was found between the SUVmax and the serum thyroglobulin levels (p = 0.139).

CONCLUSIONS

⁶⁸Ga-DOTA-FAPI-04 PET/CT has a promising detection rate for RR-DTC metastasis. The FAPI uptake of the tumor may provide a potential therapeutic target for RR-DTC.

TRIAL REGISTRY

NIH Clinical Trials.gov (NCT04499365).

Validation of Ultrasound Risk Stratification Systems for Cervical Lymph Node Metastasis in Patients with Thyroid Cancer

Simple Summary

Ultrasound (US) malignancy risk stratification systems (RSS) for cervical lymph nodes (LNs) have not been fully established in patients with thyroid cancer. In this study, we assessed the malignancy risks of each US feature and risk category from the Korean Society of Thyroid Radiology (KSThR) and the European Thyroid Association (ETA). Both systems effectively classified malignancy risks; however, 15.1% of LNs were unclassifiable in ETA RSS. Suspicious US features of hyperechogenicity, cystic change, echogenic foci, and abnormal vascularity were independently associated with metastasis. When the primary tumor characteristics were assessed, tumor multiplicity was associated with metastasis in the indeterminate LN group. We refined this system and proposed an RSS based on the KSThR system for cervical LNs in patients with thyroid cancer.

Abstract

A malignancy risk stratification system (RSS) for cervical lymph nodes (LNs) has not been fully established. This study aimed to validate the current RSS for the diagnosis of cervical LN metastasis in thyroid cancer. In total, 346 LNs from 282 consecutive patients between December 2006 and June 2015 were included. We determined the malignancy risk of each ultrasound (US) feature and performed univariable and multivariable logistic regression analyses. Each risk category from the Korean Society of Thyroid Radiology (KSThR) and the European Thyroid Association (ETA) was applied to calculate malignancy risks. The effects of size, number of suspicious features, and primary tumor characteristics were analyzed to refine the current RSS. Suspicious features including echogenic foci, cystic change, hyperechogenicity, and abnormal vascularity were independently predictive of malignancy (p ≤ 0.045). The malignancy risks of probably benign, indeterminate, and suspicious categories were 2.2–2.5%, 26.8–29.0%, and 85.8–87.4%, respectively, according to the KSThR and ETA criteria. According to the ETA criteria, 15.1% of LNs were unclassifiable. In indeterminate LNs, multiplicity of the primary tumor was significantly associated with malignancy (odds ratio, 6.53; p = 0.004). We refined the KSThR system and proposed a US RSS for LNs in patients with thyroid cancer.

Papillary thyroid microcarcinoma with contralateral lymphatic skip metastasis and breast cancer: A case report

BACKGROUND

The recognized pattern of cervical lymph node metastasis (CLNM) of papillary thyroid carcinoma involves a stepwise route. Contralateral lymph node skip metastasis is very rare. In addition, the patient in our case report also suffered from a breast carcinoma accompanied by left supraclavicular lymphadenopathy, which made it difficult to distinguish the origin of the CLNM. Based on this case, we recommended that more detailed physical and imaging examinations are needed for patients with uncommon cervical lymphatic metastasis of primary cancer.

CASE SUMMARY

A 53-year-old women was admitted to the hospital for a neck mass in the left cervical region that had existed for 2 mo. The neck mass was suspected to be an enlarged lateral LN originating from papillary thyroid microcarcinoma of the contralateral thyroid lobe, according to ultrasound and ultrasound-guided fine needle aspiration biopsy. The patient underwent total thyroidectomy and radical cervical LN dissection. Postoperative pathology confirmed the diagnosis of papillary thyroid microcarcinoma with contralateral lymphatic skip metastasis. Unfortunately, a breast cancer was discovered 4 mo later, which was accompanied by ipsilateral supraclavicular LN metastasis. She accepted neoadjuvant chemotherapy and subsequent left modified radical mastectomy for treatment. The patient is currently receiving postoperative radiotherapy, and no local recurrence was observed in the 6-mo follow-up after surgery.

CONCLUSION

We present a rare case of papillary thyroid microcarcinoma with contralateral lymphatic skip metastasis and breast cancer with supraclavicular lymphatic metastasis.

Papillary thyroid cancer: the value of bilateral diagnostic lymphadenectomy

Purpose

Papillary thyroid carcinoma (PTC) spreads early to lymph nodes (LN). However, prophylactic central (CND) and lateral neck dissection (LND) is controversially discussed in patients with clinically negative nodes (cN0). The preoperative prediction of LN metastasis is desirable as re-operation is associated with higher morbidity and poor prognosis. The study aims to analyse possible benefits of a systemic bilateral diagnostic lateral lymphadenectomy (DLL) for intraoperative LN staging.

Methods

Preoperative prediction of LN metastasis by conventional ultrasound (US) was correlated with the results of DLL and intra-/postoperative complications in 118 consecutive patients with PTC (cN0) undergoing initial thyroidectomy and bilateral CND and DLL.

Results

Lateral LNs (pN1b) were positive in 43/118 (36.4%) patients, including skip lesions (n = 6; 14.0%). Preoperative US and intraoperative DLL suspected lateral LN metastasis in 19/236 (TP: 8.1%) and 54/236 (TP: 22.9%) sides at risk, which were confirmed by histology. Sixty-seven out of 236 (FN: 28.4%) and 32/236 (FN: 13.6%) sides at risk with negative preoperative US and intraoperative DLL lateral LN metastasis were documented. DLL was significantly superior compared to US regarding sensitivity (62.8% vs 22.1%; p < 0.002), positive predictive value (100% vs 76.0%), negative predictive value (82.4% vs 68.2%), and accuracy (86.4% vs 69.1%), but not specificity (100% vs 96.0%; p = 0.039). DLL-related complications (haematoma) occurred in 6/236 [2.5%] sides at risk, including chylous fistula in 2/118 [1.7%] patients.

Conclusion

DLL can be recommended for LN staging during initial surgery in patients with PTC to detect occult lateral LN metastasis not suspected by US in order to plan lateral LN dissection.

Nomograms based on preoperative multimodal ultrasound of papillary thyroid carcinoma for predicting central lymph node metastasis

OBJECTIVES

To establish a nomogram for predicting central lymph node metastasis (CLNM) based on the preoperative clinical and multimodal ultrasound (US) features of papillary thyroid carcinoma (PTC) and cervical LNs.

METHODS

Overall, 822 patients with PTC were included in this retrospective study. A thyroid tumor ultrasound model (TTUM) and thyroid tumor and cervical LN ultrasound model (TTCLNUM) were constructed as nomograms to predict the CLNM risk. Areas under the curve (AUCs) evaluated model performance. Calibration and decision curves were applied to assess the accuracy and clinical utility.

RESULTS

For the TTUM training and test sets, the AUCs were 0.786 and 0.789 and bias-corrected AUCs were 0.786 and 0.831, respectively. For the TTCLNUM training and test sets, the AUCs were 0.806 and 0.804 and bias-corrected AUCs were 0.807 and 0.827, respectively. Calibration and decision curves for the TTCLNUM nomogram exhibited higher accuracy and clinical practicability. The AUCs were 0.746 and 0.719 and specificities were 0.942 and 0.905 for the training and test sets, respectively, when the US tumor size was ≤ 8.45 mm, while the AUCs were 0.737 and 0.824 and sensitivity were 0.905 and 0.880, respectively, when the US tumor size was > 8.45 mm.

CONCLUSION

The TTCLNUM nomogram exhibited better predictive performance, especially for the CLNM risk of different PTC tumor sizes. Thus, it serves as a useful clinical tool to supply valuable information for active surveillance and treatment decisions.

KEY POINTS

• Our preoperative noninvasive and intuitive prediction method can improve the accuracy of central lymph node metastasis (CLNM) risk assessment and guide clinical treatment in line with current trends toward personalized treatments. • Preoperative clinical and multimodal ultrasound features of primary papillary thyroid carcinoma (PTC) tumors and cervical LNs were directly used to build an accurate and easy-to-use nomogram for predicting CLNM. • The thyroid tumor and cervical lymph node ultrasound model exhibited better performance for predicting the CLNM of different PTC tumor sizes. It may serve as a useful clinical tool to provide valuable information for active surveillance and treatment decisions.

The influence of thyroid status, serum Tg, TSH, and TgAb on FNA-Tg in cervical metastatic lymph nodes of papillary thyroid carcinoma

OBJECTIVE

Papillary thyroid carcinoma is treated in China mostly with surgery, including total ablation, lobectomy, and lobe and isthmus resection. Therefore, whether thyroid status affects the FNA-Tg cutoff value in the diagnosis of cervical lymph node metastasis deserves our attention. In addition, we investigated the influence of serum Tg, TSH, and TgAb on the accuracy of using FNA-Tg for diagnosis.

METHODS

Our retrospective analysis included 189 suspected cervical lymph nodes, and we determined whether the cutoff value of FNA-Tg was affected by thyroid status, sTg, sTSH, and sTgAb.

RESULTS

In thyroid present cases, the optimal cutoff value of FNA-Tg was 2.3 ng/ml (sensitivity 96.2%, specificity 100%), and in the thyroid absent cases, the optimal cutoff value of FNA-Tg was 0.7 ng/ml (sensitivity 97.6%, specificity 96.0%). Although serum Tg, TSH, and TgAb were weakly correlated with FNA-Tg values, they did not affect the diagnostic performance of the optimal cutoff value of FNA-Tg according to thyroid status.

CONCLUSIONS

The optimal cutoff value of FNA-Tg should be selected according to the thyroid status (2.3 ng/ml for thyroid present cases and 0.7 ng/ml for thyroid absent cases) to ensure the efficient diagnosis of cervical metastatic lymph nodes of papillary thyroid carcinoma. It was determined that sTg, sTSH, and sTg-Ab cannot influence the diagnostic performance of FNA-Tg. The combination method of FNA-Tg and FNAC is the most optimal choice for the diagnosis of lymph nodes metastasis.

Effectiveness of Lymphatic Contrast Enhanced Ultrasound in the diagnosis of Cervical Lymph node metastasis from papillary thyroid carcinoma

Cervical lymph node metastasis (CLNM) is common in patients with papillary thyroid carcinoma (PTC), which is responsible for tumor staging and surgical strategy. The accurate preoperative identification of CLNM is essential. In this study, twenty consecutive patients with PTC received a parenchyma injection of Sonazoid followed by contrast enhanced ultrasound (CEUS) to identify CLNM. The specific lymphatic CEUS (LCEUS) signs for diagnosing CLNM were summarized, which were further compared with the resected specimens to get the pathological basis. After the injection of contrast agent, lymphatic vessel and lymph node (LN) could be exclusively displayed as hyperperfusion on LCEUS. The dynamic perfusion process of contrast agent in CLNM over time can be clearly visualized. Perfusion defect and interruption of bright ring were the two characteristic LCEUS signs in diagnosing CLNM. After comparing with pathology, perfusion defect was correlated to the metastatic foci in medulla and interruption of bright ring was correlated to the tumor seeding in marginal sinus (all p values < 0.001). The diagnostic efficacies of these two signs were high (perfusion defect vs. interruption of bright ring: AUC, 0.899, 95% CI 0.752–1.000 vs. 0.904, 0.803–1.000). LCEUS has advantages in identifying CLNM from PTC. The typical LCEUS signs of CLNM correlated with pathology.

A Risk Stratification Model for Metastatic Lymph Nodes of Papillary Thyroid Cancer: A Retrospective Study Based on Sonographic Features

BACKGROUND

Papillary thyroid carcinoma (PTC) has a high probability of cervical lymph node (LN) metastasis. The aim of the study was to develop an ultrasound risk stratification model to standardize the diagnosis of metastatic LNs of PTC.

METHODS

Patients with suspicious thyroid nodules who underwent US examination and US guided fine-needle aspiration for cervical LNs were retrospectively collected. Univariate and multivariate logistic regression analyses were performed to assess the independent risk factor of metastatic LNs. According to the OR value of correlated indicators in logistic regression analysis, a risk stratification model was established.

RESULTS

A total of 653 LNs were included. The independent risk factors of metastatic LNs were long-axis diameter/short-axis ≤ 2 (OR=1.644), absence of hilum (OR=1.894), hyperechogenicity (OR=5.375), calcifications (OR=6.201), cystic change (OR=71.818), and abnormal flow (OR=3.811) (P<0.05 for all). The risk stratification model and malignancy rate were as follows: 0-2 points, malignancy rate of 10.61%, low suspicion; 3-5 points, malignancy rate of 50.49%, intermediate suspicion, ≥6 points, malignancy rate of 84.81%, high suspicion. The area under the receiver operating characteristic curve for the model was 0.827 (95% CI 0.795-0.859).

CONCLUSIONS

Our established risk stratification model can effectively evaluate metastatic LNs in the patients with suspicious thyroid nodules, and it might provide a new strategy choice for clinical practice.

Ultrasonic Characteristics Improve Prediction of Central Lymph Node Metastasis in cN0 Unifocal Papillary Thyroid Cancer

BACKGROUND

Prediction of central lymph node metastasis (CLNM) is vital for clinical decision-making processes in clinically N0 (cN0) unifocal papillary thyroid carcinoma (PTC), but the sensitivity of preoperative detection of CLNM is limited. The aim of the present study was to determine whether there are ultrasonic (US) characteristics associated with CLNM.

METHODS

In total, 1657 PTC patients (514 men and 1143 women) were enrolled in the present study between January 2018 and May 2021. The patients met the following inclusion criteria based on preoperative detection: suspected nodule confirmed as PTC by biopsy; the nodule was unifocal and less than 4 cm in diameter; no prior neck radiation exposure; no extrathyroidal extension; and no CLNM or distant metastases on imaging. All the enrolled patients underwent total thyroidectomy with prophylactic central lymph node dissection (CLND). A postoperative pathological diagnosis was made.

RESULTS

CLNM was found in 58.4% of male patients and 36.9% of female patients. In univariate analysis, size, adjacent anterior capsule, distance to the lower pole and color Doppler flow imaging (CDFI) were considered risk factors for the male and female groups (p < 0.05). In multivariate analyses, size, adjacent anterior capsule, distance to the lower pole and CDFI were independent risk factors for male patients. For females, the independent risk factors included size, adjacent anterior capsule, distance to the lower pole and CDFI.

CONCLUSION

In the present cohort, US imaging characteristics, including size, adjacent anterior capsule, distance to the lower pole and CDFI, were identified to be potentially beneficial in preoperative clinical decision-making processes for cN0 unifocal PTC patients.

Comprehensive analysis of the effect of Hashimoto's thyroiditis on the diagnostic efficacy of preoperative ultrasonography on cervical lymph node lesions in papillary thyroid cancer

PURPOSE

Hashimoto's thyroiditis often leads to reactive hyperplasia of the central compartment lymph nodes in papillary thyroid carcinoma (PTC) patients. However, the effect and clinical significance of Hashimoto's thyroiditis (HT) on ultrasonography evaluation for cervical lymph node (LN) lesions remain unknown. This study aims to investigate the effect of Hashimoto's thyroiditis on the diagnostic efficacy of preoperative ultrasonography on cervical lymph node lesions in PTC patients.

PATIENTS AND METHODS

This study consecutively enrolled 1,874 PTC patients who underwent total thyroidectomy and radical cervical lymph node dissection between January 2010 and December 2021. Eligible patients were categorized as with HT and without HT. The diagnostic performance of preoperative ultrasonography for cervical LN lesions (including central LNs and lateral LNs) was evaluated between PTC patients with HT and those without HT, respectively.

RESULTS

Among the 1,874 PTC patients, 790 (42.1%) had central cN+ and 1,610 (85.9%) had lateral cN+. Compared with PTC patients without HT, the preoperative US for central LNs displays a higher false-positive rate (27.9% vs. 12.2%, p <0.001) and a lower specificity (72.1% vs. 87.8%, p < 0.001) in PTC patients with HT. Moreover, in PTC patients with HT, the ratio of the absence of fatty hilum in central LNs without metastasis was higher than in PTC patients without HT (13.02% vs. 7.46%, p = 0.013). However, no such differences were observed in lateral LNs.

CONCLUSION

HT will interfere with the preoperative US evaluation for central LNs and increase the incidence of the absence of fatty hilum in central benign LNs. When PTC patients have concomitant HT, clinicians should thoroughly evaluate the central LNs, thereby decreasing the incidence of misdiagnosis and unnecessary surgery.

Related factor analysis for predicting large-volume central cervical lymph node metastasis in papillary thyroid carcinoma

The aim of this study was to investigate the factors related to large-volume central cervical lymph node metastasis (LNM) in papillary thyroid carcinoma. A retrospective study of 340 patients with 642 papillary thyroid carcinoma nodules who underwent thyroidectomy in Peking Union Medical College Hospital between 2011 and 2015 was conducted. These nodules were divided into two groups by the number of central cervical lymph node metastases: large-volume central cervical LNM (>5 metastatic lymph nodes, n = 129) and no central cervical LNM (n = 211). We evaluated the correlations between gender, age, chronic lymphocytic thyroiditis, thyroid ultrasonographic features, and large-volume central cervical LNM. We found that younger age (≤40 years) (OR = 3.796, 95% CI = 2.842, 5.070), male gender (OR = 4.005, 95% CI = 2.858, 5.61), and ultrasonographic features such as tumor macroaxis size (OR = 2.985, 95% CI = 1.581, 5.633), tumor located in the isthmus (OR = 7.578, 95% CI = 4.863, 11.810), ill-defined margin (OR = 3.008, 95% CI = 1.986, 4.556), microcalcification (OR = 2.155, 95% CI = 1.585, 2.929), and abnormal cervical lymph nodes (OR = 13.753, 95% CI = 9.278, 20.385) were independent risk factors for large-volume central cervical LNM in papillary thyroid carcinoma, while chronic lymphocytic thyroiditis (OR = 0.248, 95% CI = 0.172, 0.358) was a protective factor. Younger age (≤40 years), male sex, and ultrasonographic features such as tumor macroaxis size, tumor located in the isthmus, ill-defined margin, microcalcification, and abnormal cervical lymph nodes were independent risk factors for large-volume central cervical LNM in papillary thyroid carcinoma, while chronic lymphocytic thyroiditis can be considered a protective factor. Our results provide a reference for adjusting clinical treatment approaches.

BRAF V600E mutation is associated with aggressive features in papillary thyroid carcinomas ≤ 1.5 cm

Background

While some studies suggest that the BRAF V600E mutation correlates with a high-risk phenotype in papillary thyroid microcarcinoma (PTMC), more evidence is necessary before this mutation can be used to help guide decision making in the management of small thyroid nodules. This study investigated whether BRAF V600E mutation is associated with aggressive features in PTMC (≤ 1 cm) and small PTC (1–1.5 cm).

Methods

Retrospective chart review was performed on 121 patient cases. Patients who underwent thyroid surgery for PTMC (≤ 1 cm) or small PTC (1–1.5 cm) were included if molecular testing was done for BRAF V600E mutation. Two study groups were created based on tumour size: PTMC (n = 55) and small PTC (n = 66). The groups were analysed for the presence of a BRAF V600E mutation and aggressive features, including macroscopic extrathyroidal extension (ETE), lymph node metastasis (LNM), and high-risk histological features (tall cell, columnar cell, hobnail, solid/trabecular, and diffuse sclerosing). The Fischer exact test was used to calculate statistical significance.

Results

BRAF V600E mutations were detected in 43.6% of PTMC and 42.4% of small PTC. Of the mutated PTMC nodules, 54.1% demonstrated aggressive characteristics as compared to 19.4% of the non-mutated PTMCs (p = 0.010). Of the mutated small PTC tumours, 82.1% had aggressive features. In contrast, 28.9% of the non-mutated small PTCs showed aggressive features (p < 0.001).

Conclusions

Our findings demonstrate an association between a BRAF V600E mutation and aggressive features in PTMC (≤ 1 cm) and small PTC (1–1.5 cm). Therefore, determining the molecular status of these thyroid nodules for the presence of BRAF V600E can help guide patient management.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s40463-021-00543-9.