Male sex, single nodularity, and young age are associated with the risk of finding a papillary thyroid cancer on fine-needle aspiration cytology in a large series of patients with nodular thyroid disease

Thyrotropin (TSH) and thyroid autoimmunity are predictive factors for the incidental discovery of papillary thyroid microcarcinoma during thyroidectomy

PURPOSE

To identify clinical, biological and pathological risk factors for the incidental discovery of papillary thyroid microcarcinomas (PTMCs) in patients undergoing thyroidectomy for presumed benign conditions.

METHODS

Cross sectional, single center study, involving all consecutive patients (N = 3015) who were submitted to thyroid surgery between 2001-2019. All medical files were retrospectively reviewed. A total of 1961 patients in the benign group and 145 patients in PTMC group were analyzed.

RESULTS

No significant differences in age, sex, body mass index, smoking status, thyroid volume or weight and preoperative thyroxine treatment between benign and PTMC groups were observed. Circulating anti- thyroid antibodies, histological thyroiditis and serum thyrotropin (TSH) were significantly associated with PTMC in univariable analysis. Independent risk factors for incidental PTMC by multivariable analysis where possible (OR: 1.51, 95% CI: 0.99-2.28) and certain (OR: 1.74, 95% CI: 1.09-2.78) thyroid autoimmunity (p = 0.002) and higher serum TSH (OR: 1.25, 95% CI: 1.08-1.45, p = 0.03), whereas thyroid lobectomy was associated with a lower risk of PTMC (OR: 0.40, 95% CI: 0.24-0.67, p < 0.001). The most frequent genetic alteration was BRAFV600E mutation, found in 56.3% of PTMC submitted to DNA sequencing. No association between clinical, biological or histological characteristics of PTMC and BRAFV600E mutation was observed.

CONCLUSIONS

Thyroid autoimmunity and higher preoperative serum TSH level were independent predictors of PTMC incidentally discovered during thyroid surgery. Larger prospective studies are needed to better identify possible risk factors for papillary thyroid carcinoma initiation and progression.

Predictive value of the single most suspicious ultrasound feature in subcentimeter thyroid nodules: a retrospective observational cohort study

PURPOSE

Proper management of subcentimeter thyroid nodules remains challenging for both clinicians and patients. Conducting extensive sonographic research using a safe and inexpensive tool for identifying thyroid nodules is necessary. The aim of this study was to identify whether having the highest-risk ultrasound (US) characteristic suggests that US-guided fine-needle aspiration (FNA) biopsy of subcentimeter nodules is more appropriate for the identification of malignancy than active surveillance (AS) or surgery.

METHODS

The data of patients with highly suspicious subcentimeter thyroid nodules and US characteristic data who underwent surgery were retrospectively examined.

RESULTS

Among a total of 556 subcentimeter nodules, 223 (40.1%) were benign, and 333 (59.9%) were malignant, with a mean maximal nodule size of 8.1 mm. In addition to age younger than 45 years, several US features were significantly associated with malignancy: irregular margins, the presence of microcalcifications, and taller-than-wide shapes (P < 0.001). Multivariate analysis also revealed that a taller-than-wide shape (OR = 8.988, P = 0.0015) was an independent factor associated with malignancy in subcentimeter thyroid nodules. The diagnostic performance of preoperative FNA was classified as a malignancy, with a sensitivity of 98.4%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 76.9%.

CONCLUSIONS

This is one of the few reports based on actual data of the most suspicious US features in subcentimeter thyroid nodules. A taller-than-wide shape US feature is most significantly associated with malignancy. FNA is a simple, accurate, and reliable preoperative method for diagnosing malignant subcentimeter thyroid nodules with highly suspicious US characteristics. AS was less appropriate than FNA for subcentimeter nodules with a taller-than-wide shape, especially in patients ≤ 45 years of age.

Clinical risk factors and cancer risk of thyroid imaging reporting and data system category 4 A thyroid nodules

PURPOSE

Beyond the Thyroid Imaging Reporting and Data System (TIRADS) classification of thyroid nodules, additional factors must be weighed in the decision to perform fine needle aspiration (FNA). In this study, we aimed to identify risk factors for malignancy in patients with ultrasound-classified Chinese-TIRADS (C-TIRADS) 4 A nodules.

METHODS

Patients who underwent thyroid FNA at our institution between May 2021 and September 2022 were enrolled. We collected demographic data, including age, sex, previous radiation exposure, and family history. An in-person questionnaire was used to collect lifestyle data, such as smoking habits and alcohol consumption. Body mass index (BMI) was calculated. The serum levels of thyroid stimulating hormone (TSH), thyroid peroxidase antibody (TPOAb), and thyroglobulin antibody (TGAb) were measured. Prior to FNA, ultrasonic inspection reports were reviewed. The cytologic diagnoses for FNA of thyroid nodules followed the Bethesda System for Reporting Thyroid Cytopathology (2017).

RESULTS

Among the 252 C-TIRADS 4 A nodules, 103 were malignant. Compared to those in the benign group, the patients in the malignant group had a younger age (42.2 ± 13.6 vs. 51.5 ± 14.0 years, P < 0.001). Logistic regression showed that advanced age was associated with a lower risk of malignancy in C-TIRADS 4 A nodules (OR = 0.95, 95% CI 0.93 ~ 0.97, P < 0.001). We demonstrated a decreased risk of malignancy in patients with 48.5 years or older.

CONCLUSION

Advanced age was associated with a decreased risk of malignancy in patients with C-TIRADS 4 A nodules. This study indicated that in addition to sonographic characteristics, patient age should be considered when assessing the risk of malignancy.

Influence of maximum diameter on fine-needle aspiration biopsy outcomes in ACR TI-RADS 5 thyroid nodules

Introduction

Fine needle aspiration (FNA) biopsy is a widely accepted method for diagnosing thyroid nodules. However, the influence of maximum diameter (MD) of ACR TIRADS 5 (TR5) thyroid nodules on the FNA outcomes remains debated. This study examined the influence of MD on the FNA outcomes and investigated the optimal MD threshold for FNA in TR5 nodules.

Methods

We conducted a retrospective analysis of 280 TR5 thyroid nodules from 226 patients who underwent FNA from January to June 2022 in our department. Probably malignant (PM) group was defined as Bethesda V in cytopathology with confirmed BRAF V600E mutation or Bethesda VI, the other cytopathology outcomes were defined as probably benign (PB) group. We examined factors influencing malignant cytopathology outcomes and determined the optimal MD threshold for FNA in TR5 nodules using logistic regression and restricted cubic spline (RCS) analysis.

Results

Among these nodules, 58.2% (163/280) had PM outcomes. The PM group had a significantly larger MD than the PB group [6.5mm (range 5.0-8.4) vs. 5.3mm (range 4.0-7.0), p < 0.001]. In multivariate logistic regression fully adjusted for confounders, MD was significantly associated with PM outcomes [odds ratio 1.16, 95%CI 1.05-1.31; p = 0.042]. The highest quartile of MD had a greater likelihood of PM outcomes compared to the lowest quartile [odds ratio 4.71, 95% CI 1.97-11.69, p = 0.001]. The RCS analysis identified 6.2 mm as the optimal MD threshold for FNA in TR5 nodules.

Conclusion

MD significantly affects the probability of malignant outcomes in FNA of TR5 thyroid nodules. A MD threshold of ≥6.2mm is suggested for FNA in these nodules.

Age-related variation in malignant cytology rates of thyroid nodules: insights from a retrospective observational study assessing the ACR TI-RADS

OBJECTIVE

The influence of age on the malignant cytology rate of thyroid nodules remains uncertain. The American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS) is currently used to guide subsequent investigations of thyroid nodules, regardless of clinical variables. This study aimed to investigate the impact of age on the malignant cytology rates of thyroid nodules and the diagnostic performance of ACR TI-RADS across different age groups.

DESIGN

A retrospective, single-center, observational study.

METHODS

Patients aged ≥ 20 years with thyroid nodules, who underwent fine-needle aspiration biopsy between 2012 and 2019 were evaluated. Ultrasound images were used to obtain the TI-RADS data. Malignancy was determined based on suspicious for malignancy (Bethesda V) and malignant (Bethesda VI) cytology results or malignancy in cell block analysis.

RESULTS

A total of 1023 nodules from 921 patients (88.2% female) were analyzed. The median age was 58.5 (interquartile range [IQR], 41.1-66.6) years, and the median nodule size was 2.4 (IQR, 1.7-3.6) cm. Stratification by age revealed a decreasing prevalence of malignant cytology across subgroups of 20-39, 40-59, and ≥60 years (10.7%, 8.5%, and 3.7%, respectively; P = .002). After adjusting for sex, multinodularity, nodule size, and ACR TI-RADS category, we observed that each year of age reduced the OR for malignant cytology by 3.0% (95% CI: 0.7%-5.3%; P = .011). When comparing the subgroups of 20-39 and ≥60 years, the malignant cytology rate decreased by half in TI-RADS 4 (from 21.4% to 10.4%) and two-thirds in TI-RADS 5 (from 64.7% to 22.6%).

CONCLUSIONS

Our study demonstrated that as patient age increased, the rate of malignant cytology in thyroid nodules decreased. Moreover, age significantly influences the malignancy rates of thyroid nodules classified according to the ACR TI-RADS.

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.

Incorporation of a machine learning pathological diagnosis algorithm into the thyroid ultrasound imaging data improves the diagnosis risk of malignant thyroid nodules

Objective

This study aimed at establishing a new model to predict malignant thyroid nodules using machine learning algorithms.

Methods

A retrospective study was performed on 274 patients with thyroid nodules who underwent fine-needle aspiration (FNA) cytology or surgery from October 2018 to 2020 in Xianyang Central Hospital. The least absolute shrinkage and selection operator (lasso) regression analysis and logistic analysis were applied to screen and identified variables. Six machine learning algorithms, including Decision Tree (DT), Extreme Gradient Boosting (XGBoost), Gradient Boosting Machine (GBM), Naive Bayes Classifier (NBC), Random Forest (RF), and Logistic Regression (LR), were employed and compared in constructing the predictive model, coupled with preoperative clinical characteristics and ultrasound features. Internal validation was performed by using 10-fold cross-validation. The performance of the model was measured by the area under the receiver operating characteristic curve (AUC), accuracy, precision, recall, F1 score, Shapley additive explanations (SHAP) plot, feature importance, and correlation of features. The best cutoff value for risk stratification was identified by probability density function (PDF) and clinical utility curve (CUC).

Results

The malignant rate of thyroid nodules in the study cohort was 53.2%. The predictive models are constructed by age, margin, shape, echogenic foci, echogenicity, and lymph nodes. The XGBoost model was significantly superior to any one of the machine learning models, with an AUC value of 0.829. According to the PDF and CUC, we recommended that 51% probability be used as a threshold for determining the risk stratification of malignant nodules, where about 85.6% of patients with malignant nodules could be detected. Meanwhile, approximately 89.8% of unnecessary biopsy procedures would be saved. Finally, an online web risk calculator has been built to estimate the personal likelihood of malignant thyroid nodules based on the best-performing ML-ed model of XGBoost.

Conclusions

Combining clinical characteristics and features of ultrasound images, ML algorithms can achieve reliable prediction of malignant thyroid nodules. The online web risk calculator based on the XGBoost model can easily identify in real-time the probability of malignant thyroid nodules, which can assist clinicians to formulate individualized management strategies for patients.

Solitary and multiple thyroid nodules as predictors of malignancy: a systematic review and meta-analysis

BACKGROUND

The debate on whether or not there is a difference in the incidence of thyroid cancer between the patients with Solitary thyroid Nodule (STN) and Multinodular Goiter (MNG) has been constantly present for the last few decades. With newer studies yielding mixed results, it was imperative to systematically compile all available literature on the topic.

METHODS

PubMed/MEDLINE, Cochrane Central, ScienceDirect, GoogleScholar, International Clinical Trials registry, and reference lists of the included articles were systematically searched for article retrieval. No filter was applied in terms of time, study design, language or country of publication. Rigorous screening as per PRISMA guidelines was undertaken by 2 independent reviewers in order to identify the articles that were most relevant to the topic.

RESULTS

Twenty-two studies spanning from 1992 to 2018 were included in this analysis and encompassed 50,321 patients, 44.2% of which belonged to the STN subgroup and 55.37% to the MNG subgroup. MNG was found to be associated with a significantly lower risk of thyroid cancer (OR = 0.76; 95% CI 0.61-0.96) when compared with STN. Papillary carcinoma was the most frequently occurring carcinoma across both groups, followed by follicular and medullary carcinomas. A subgroup analysis was performed to assess the efficacy of the two most commonly employed diagnostic tools i.e. surgery and fine needle aspiration cytology (FNAC), however it yielded nonsignificant results, indicating a comparable usefulness of the two. Another subgroup analysis run on the basis of the presumed iodine status of the participants also yielded nonsignificant results.

CONCLUSION

There is a higher incidence of thyroid cancer among patients of STN, however, given the low quality of existing evidence on the topic, it is crucial to conduct larger studies that can establish association with a greater precision.

The Italian Consensus for the Classification and Reporting of Thyroid Cytology: Cytohistologic and molecular correlations on 37,371 nodules from a single institution

BACKGROUND

The Italian Consensus for the Classification and Reporting of Thyroid Cytology (ICCRTC) includes six diagnostic categories (TIR 1/1C, TIR 2, TIR 3A, TIR 3B, TIR 4, and TIR 5), each indicating a different risk of malignancy. The objective of this monocentric retrospective study was to evaluate the distribution of the ICCRTC classes at the authors' institution and assess their cytohistologic correlations.

METHODS

The authors retrospectively collected 37,371 consecutive cytologic reports of thyroid nodules and described the clinical-pathologic features of the different cytologic categories. The cytologic diagnoses also were compared with histologic outcomes in a subset of patients.

RESULTS

The cytologic classes were distributed as follows: nondiagnostic, 15.6%; benign, 66.5%; low-risk indeterminate, 10% (TIR 3A); high-risk indeterminate, 3.5% (TIR 3B); suspicious, 1.7%; and malignant, 2.6%. According to histology, the risk of malignancy was very high in the nondiagnostic category (29.8%), with young male patients more exposed to malignancy, and it was relatively high among benign (7.8%) and indeterminate nodules (32.5% in TIR 3A; 52.1% in TIR 3B), mainly because of the high prevalence of follicular architecture in malignant tumors. On histology, the malignancy rates were 92.4% and 99.3% for the suspicious and malignant categories, respectively; aggressive variants of papillary thyroid carcinoma were mostly diagnosed in these categories.

CONCLUSIONS

In this series, nondiagnostic nodules showed high prevalence and, surprisingly, high malignancy rates. Malignant tumors with follicular architecture represented a diagnostic pitfall in benign and indeterminate nodules. The suspicious and malignant categories had high specificity for malignancy. Importantly, the ICCRTC had high reliability for identifying preoperatively aggressive histotypes of thyroid carcinoma.

The Inverse Association of Serum Magnesium with Papillary Thyroid Cancer in Thyroid Nodules: a Cross-Sectional Survey Based on Thyroidectomy Population

Magnesium is considered to play a role in preventing cancer. However, the association between serum magnesium and papillary thyroid cancer (PTC) remains unknown. We retrospectively reviewed records of all patients who underwent thyroidectomy with thyroid nodules confirmed pathologically as benign nodule or PTC at our institution from January 2016 to December 2020. Data including demographic characteristics, laboratory tests, and pathological features were analyzed in 5709 adult patients eventually. The subjects with benign nodules had a higher mean serum magnesium level than those with PTC (P < 0.001), and the proportions of PTCs decreased across quartiles of serum magnesium within the normal range. After adjustment for confounders, patients with the lowest quartile of serum magnesium had a higher prevalence of PTC than those with the highest quartile (OR = 1.421, 95%CI: 1.125-1.795, P for trend = 0.005), and the risk of PTC was 0.863 (95%CI: 0.795-0.936) for a per-SD change in serum magnesium. The contribution of serum magnesium remained in subgroup analysis (P for interaction for all analyses > 0.05). Based on the ROC curve, the cut-off value of serum magnesium used to differentiate benign nodules from PTCs was 935 μmol/L. Combining serum magnesium with other clinical indicators can improve the efficacy of predicting PTC. Our results showed that lower serum magnesium within the normal range was associated with a greater risk of PTC among patients with thyroid nodules considering thyroidectomy. Serum magnesium may be an independent protective factor against PTC and provide additional information on the odds of malignancy in uncertain thyroid nodules in combination with other clinical factors.

Epidemiological, Clinical, Ultrasonographic and Cytological Characteristics of Thyroid Nodules in an Afro-Caribbean Population: A Series of 420 Patients

Simple Summary

This study describes the epidemiological, clinical and ultrasound characteristics of malignancy in thyroid nodules and evaluates the value of cytology in the diagnosis of malignancy in an Afro-Caribbean population. Our results revealed that none of the standard ultrasound criteria of malignancy were significantly predictive of cancer, but hypoechogenicity and central vascularity were frequently found in malignant nodules. These results could increase awareness and guide practitioners in their diagnostic approach and management of thyroid nodules in Afro-Caribbean populations. Bethesda system-based cytology revealed low sensitivity in analyzing the risk of malignancy in this population. The high prevalence of papillary microcarcinomas may explain the inconclusive ultrasound and cytological results.

Abstract

The incidence of thyroid cancer is increasing worldwide. The aim of this study is to describe the epidemiological, clinical and ultrasound characteristics of malignancy in thyroid nodules and to evaluate the predictive value of the Bethesda system for thyroid cytology in the diagnosis of malignancy in an Afro-Caribbean population. We conducted a retrospective study in Martinique involving 420 patients with a diagnosis of thyroid nodules between 2011 and 2014. Of the 192/420 (45.7%) patients operated on for thyroid nodules, 9% had thyroid cancer. All patients with thyroid cancer were obese women with a mean age of 50 years. The final histological examination revealed papillary microcarcinomas in 61% of cases and papillary carcinomas in 39% of cases. Thyroid cytology alone had a low sensitivity (22.2%) and positive predictive value (15.4%) for the diagnosis of malignancy, with a good specificity (91.1%) and negative predictive value (94.2%). None of the standard ultrasound criteria of malignancy were significantly predictive of cancer, but hypoechogenicity and central vascularity were frequently found in malignant nodules. These epidemiological, clinical and ultrasound results could increase awareness and guide practitioners in their diagnostic approach and management of thyroid nodules in an Afro-Caribbean population. Bethesda system-based cytology revealed lower sensitivity in analyzing the risk of malignancy in this population. The high prevalence of papillary microcarcinomas may explain the inconclusive ultrasound and cytological results.

Malignancy risk of thyroid nodules: quality assessment of the thyroid ultrasound report

Background

Thyroid nodules are a challenge in clinical practice and thyroid ultrasonography is essential for assessing the risk of malignancy. The use of ultrasound-based malignancy risk classification systems has been recommended by several scientific societies but radiologist’s adherence to these guidelines may vary. The authors aimed to analyze the quality of the information provided by the thyroid ultrasound report, to assess the malignancy risk of thyroid nodules, in Portugal.

Methods

Multicenter and retrospective study, conducted in three of the five Portuguese NUTS2 corresponding to about 88.3% of the mainland population. We included 344 consecutive unselected participants aged ≥ 18 years who underwent thyroid ultrasonography in 2019. The description of six features of the dominant thyroid nodule was analyzed: maximum size, shape, margins, composition, echogenicity and echogenic foci. A utility score, including these six features, was used as an indicator of the report’s quality. A score of 4 was considered as a minimum value.

Results

Maximum diameter was reported for all nodules. Shape, margins, composition, echogenicity and echogenic foci were reported in 8.1%, 25.0%, 76.5%, 53.2% and 20.9%, respectively. Only 21.8% of the nodules had a score ≥ 4. At least one of four suspicious features, including marked hypoechogenicity, microcalcifications, irregular margins and non-oval shape, was identified in 8.7% of the nodules. Cervical lymph nodes’ status was reported in 93% of the exams. The risk category was only reported in 7.8% of the participants.

Conclusion

The adherence of Portuguese radiologists to a standardized reporting model and to an ultrasound-based malignancy risk stratification system is still low and has implications for the correct characterization of the malignancy risk of nodules and the decision to perform fine-needle aspiration biopsy.

Risk Stratification of Thyroid Nodules: From Ultrasound Features to TIRADS

Simple Summary

Thyroid nodules are a frequent clinical issue. Their incidence has increased mainly due to the widespread use of neck ultrasound scans. Most thyroid nodules are asymptomatic, incidentally discovered, and benign at cytology. Thyroid ultrasound is the most sensitive diagnostic tool to evaluate patients with nodular thyroid disease. It is therefore important to use the ultrasound features to select nodules that require a fine-needle aspiration cytology.

Abstract

Thyroid nodules are common in iodine deficient areas, in females, and in patients undergoing neck irradiation. High-resolution ultrasonography (US) is important for detecting and evaluating thyroid nodules. US is used to determine the size and features of thyroid nodules, as well as the presence of neck lymph node metastasis. It also facilitates guided fine-needle aspiration (US-FNA). The most consistent US malignancy features of thyroid nodules are spiculated margins, microcalcifications, a taller-than-wide shape, and marked hypoechogenicity. Increased nodular vascularization is not identified as a predictor of malignancy. Thyroid elastosonography (USE) is also used to characterize thyroid nodules. In fact, a low elasticity of nodules at USE has been related to a higher risk of malignancy. According to their US features, thyroid nodules can be stratified into three categories: low-, intermediate-, and high-risk nodules. US-FNA is suggested for intermediate and high-risk nodules.

Risk factors and diagnostic prediction models for papillary thyroid carcinoma

Thyroid nodules (TNs) represent a common scenario. More accurate pre-operative diagnosis of malignancy has become an overriding concern. This study incorporated demographic, serological, ultrasound, and biopsy data and aimed to compare a new diagnostic prediction model based on Back Propagation Neural Network (BPNN) with multivariate logistic regression model, to guide the decision of surgery. Records of 2,090 patients with TNs who underwent thyroid surgery were retrospectively reviewed. Multivariate logistic regression analysis indicated that Bethesda category (OR=1.90, P<0.001), TIRADS (OR=2.55, P<0.001), age (OR=0.97, P=0.002), nodule size (OR=0.53, P<0.001), and serum levels of Tg (OR=0.994, P=0.004) and HDL-C (OR=0.23, P=0.001) were statistically significant independent differentiators for patients with PTC and benign nodules. Both BPNN and regression models showed good accuracy in differentiating PTC from benign nodules (area under the curve [AUC], 0.948 and 0.924, respectively). Notably, the BPNN model showed a higher specificity (88.3% vs. 73.9%) and negative predictive value (83.7% vs. 45.8%) than the regression model, while the sensitivity (93.1% vs. 93.9%) was similar between two models. Stratified analysis based on Bethesda indeterminate cytology categories showed similar findings. Therefore, BPNN and regression models based on a combination of demographic, serological, ultrasound, and biopsy data, all of which were readily available in routine clinical practice, might help guide the decision of surgery for TNs.

Peripheral Blood Inflammatory Markers Can Predict Benign and Malignant Thyroid Nodules

OBJECTIVE

Inflammation is related to the occurrence and development of various cancers. This study was designed to explore the role of peripheral blood platelet count, neutrophil-lymphocyte ratio (NLR), platelet count-lymphocyte count ratio (PLR), systemic inflammation index (SII), and other inflammatory markers in predicting benign and malignant Thyroid Imaging Reporting and Data System (TI-RADS) grade 3 thyroid nodules.

METHODS

In this retrospective study, 514 patients with TI-RADS grade 3 thyroid nodules were enrolled. According to the pathological results, the patients were divided into the benign and malignant nodule groups. We compared the clinical characteristics between the two groups and analysed the influencing factors for malignant thyroid nodules by univariate and stepwise multivariate logistic regression analyses and then analysed the cutoff value of each influencing factor according to the receiver operating characteristic curve.

RESULTS

The leukocyte count, neutrophil count, platelet count, NLR, PLR, and SII of the malignant nodule group were significantly higher than those of the benign nodule group (P < 0.05), the age and the diameter of nodule of the malignant nodule group were significantly smaller than those of the benign nodule group (P < 0.05). After excluding the influence of confounding factors, SII (odds ratio (OR) = 1.006; 95% confidence interval (CI) = 1.003-1.008; P < 0.001), PLR (odds ratio (OR) = 0.981; 95% confidence interval (CI) = 0.981-0.992; P < 0.05), leukocyte count (odds ratio (OR) = 0.654; 95% confidence interval (CI) = 0.466-0.892; P < 0.05), and age (OR = 0.969; 95% CI = 0.954-0.985; P < 0.001) were independent risk factors for malignant thyroid nodules, and the cutoff value of SII and PLR in predicting benign and malignant thyroid nodules were 545.63 × 10⁹/L and 138.63.

CONCLUSION

This study showed that peripheral blood SII, PLR, leukocyte count and age were independent risk factors for malignant thyroid nodules, and the combination of these can better predict benign and malignant thyroid nodules, which can further guide the diagnosis and treatment of TI-RADS grade 3 thyroid nodules.

Prevalence and predictors of thyroid cancer among thyroid nodules: a retrospective cohort study of 1,000 patients

INTRODUCTION

Thyroid cancer is increasing in incidence globally due either to early detection (overestimation) or true increment. A recent debate concerns multinodular goitre (MNG) or toxic goitres which have classically been considered at a lower risk for cancer.

METHODS

In this study, we enrolled retrospectively all patients with nodular goitre treated at our tertiary hospital and analysed their data with the aim of detecting the rate of cancer among different types of nodular goitre. We also studied predictors of incidental malignancy among thyroidectomies.

RESULTS

A predilection for solitary thyroid nodules (STNs) was found in women of younger age, with STNs tending to be larger in comparison with MNG in the same age group. However, both types of nodules were at equal risk of harbouring malignancy. Thyroid Imaging Reporting and Data System (TI-RADS) and Bethesda scores were the only dependent predictors of malignancy within thyroid nodules.

CONCLUSION

The authors recommend management of both STNs and MNG using the same algorithm.

Factors Associated with Malignancy in Patients with Maximal Thyroid Nodules ≥2 Cm

Purpose

The relationship between large thyroid nodules and the risk of malignancy is controversial. This study aimed to examine the relationship between thyroid nodule size and the risk of malignancy of maximal thyroid nodules ≥2 cm and the risk of accompanied by occult thyroid carcinoma.

Methods

This was a retrospective study of patients who underwent near-total or total thyroidectomy for thyroid nodules from January 2016 to January 2019 at the First Affiliated Hospital,Zhejiang University School of Medicine. Clinical, biochemical, and pathological characteristics were examined for association with malignancy using univariable, multivariable, and receiver operating characteristic curve analyses.

Results

Finally, 367 patients (277 females (75.5%) and 90 males (24.5%)) with a mean age of 49.0±13.5 years were included. Multivariable logistic regression analysis showed that age (OR=0.959, 95% CI: 0.939–0.979, P<0.001), Hashimoto’s thyroiditis (OR=2.437, 95% CI: 1.162–5.112, P=0.018), the diameter of maximal nodule (small) (OR=0.706, 95% CI: 0.541–0.919, P=0.010), and punctate echogenic foci (OR=2.837, 95% CI: 1.598–5.286, P<0.001) were independently associated with malignancy. Of 223 patients who had non-suspicious malignant nodules (TI-RADS <4), 12.7% (n=29) patients showed malignancy at postoperative pathology. Only age was associated with occult PTC in the univariable analyses (OR=0.962, 95% CI: 0.934–0.991, P=0.011). When TPOAb was used as a continuous variable for statistical analysis, it showed a significant difference in the ROC curve, and the results showed TPOAb >31.4 mIU/L was more associated with occult PTC (P=0.006). A predictive model including four independent risk factors of malignancy showed an optimal discriminatory accuracy (area under the curve, AUC) of 0.783 (95% CI=0.732–0.833).

Conclusion

Relatively young age (<54.5 years), Hashimoto’s thyroiditis, the diameter of the maximal nodule, and punctate echogenic foci were independently associated with thyroid malignancy in patients with maximal thyroid nodules ≥2 cm. Young age (<54.5 years) and TPOAb >31.4 mIU/L were associated with occult PTC.

Clinical profile and management of primary thyroid cancer in patients with nodular goitre at the Douala General Hospital, Cameroon

Introduction

thyroid cancer (TC) is considered to have become the fastest growing cancer in terms of incidence worldwide. Despite literature reporting a prevalence of 5-10% in clinically identified thyroid nodules, Cameroon still has limited data on the profile of TCs in patients with Nodular Goitres (NGs). The Objective were to describe the epidemiological, diagnostic and therapeutic profiles of TCs in patients with nodular goitres at the Douala General Hospital (DGH).

Methods

this was a retrospective cross-sectional analysis of patient records with diagnoses of NGs, over 11 years (2006 to 2016) at the DGH.

Results

overall, 187 patients (mean age= 46.8±13.9 years, men=27 (14.4%)) were included; 43 (23%) cancers were identified. The most common histological type was papillary cancer (50%). Nodule size of >4cm and hypoechogenicity were independently associated with malignancy. Most patients presented with TNM stage II (47.4%) and well-differentiated cancers were considered to be predominantly at low-risk according to MACIS (55%) and AMES (74%) scores. Surgery was offered to 95.3% of patients.

Conclusion

TCs are frequent in patients with NGs with papillary cancer dominating. A high index of suspicion should be held if a nodule is >4cm and/or is hypoechogenic. Prognostic studies are needed to describe the outcome of TCs in our setting.

Fine-Needle Aspiration Cytology and Histological Types of Thyroid Cancer in the Elderly: Evaluation of 9070 Patients from a Single Referral Centre

Simple Summary

Elderly patients have a high prevalence of thyroid nodules, and their management should consider the presence of comorbidities, which are frequent in this age group. In this retrospective monocentric study, we analyzed data of more than 13,000 nodules in order to highlight differences between the elderly and the general population in terms of cytological and histological diagnoses. Thyroid nodules in the elderly are more often benign than in younger patients. Nevertheless, in case of malignancy, follicular-derived well-differentiated tumors are almost always diagnosed in younger patients. Instead, elderly patients more often have tumors with aggressive histotypes. In addition, even in presence of well-differentiated tumors, elderly patients present a higher rate of high-risk pathological features.

Abstract

Background. The prevalence of thyroid nodules increases with age. Their management takes into account the presence of co-morbidities, which are frequent among the elderly. We sought to highlight the differences between the elderly and the general population in cytological and histological diagnoses. Methods. In this retrospective cohort study, we gathered 13,747 nodule data and compared cytological and histological diagnoses between patients aged over 65 years and a control group. Results. Elderly patients had a higher prevalence of cytologically benign nodules and, consequently, they were less frequently subject to surgery. However, there were no differences in terms of malignancy-risk after surgery. At histology, elderly patients often presented aggressive histology such as medullary thyroid carcinoma, poorly-differentiated and anaplastic cancer, tall cell variant of papillary thyroid carcinoma and Hürthle cell carcinoma. Even in presence of well-differentiated cancer, older patients had higher rates of local invasiveness, lateral lymph node involvement and vascular invasion. Conclusion. Thyroid nodules in elderly patients represent a challenging entity since they are very often benign, but, in case of malignancy, aggressive histotypes and high-risk features are more frequent. Therefore, presurgical characterization of nodules in older patients is crucial and might require strict monitoring.

Prevalence and risk factors for thyroid cancer in patients with multinodular goitre

BACKGROUND

Rates of thyroid cancer in patients with multinodular goitre (MNG) vary widely, from 3 per cent in older studies to 35 per cent in more recent studies. The purpose of the present study was to evaluate the prevalence of thyroid cancer in patients operated on for MNG, and to determine risk factors for incidental thyroid malignancy.

METHODS

A prospectively developed database of all patients who underwent thyroidectomy for a benign MNG at the high-volume endocrine surgery unit of a tertiary referral university hospital was interrogated.

RESULTS

A total of 3233 patients were analysed, separated into three groups according to their functional thyroid status (hypothyroid, hyperthyroid or euthyroid). There were 2788 women (86.2 per cent); the mean patient age was 56.4 years and mean preoperative disease duration was 106.2 months. Incidental thyroid cancer was identified in 1026 patients (31.7 per cent), of which 917 (89.4 per cent) were papillary cancers. Multivariable regression analysis identified functional thyroid status, younger age, male sex, smaller adenoma size, smaller thyroid glands, Hashimoto's thyroiditis and chronic non-specific thyroiditis as independent risk factors for thyroid cancer.

CONCLUSION

MNG was associated with a considerable rate of incidental thyroid cancer, which has been underestimated. A variety of factors should be taken into account when considering the malignant potential of a presumed benign MNG.

[Thyroid nodules: The Guidelines of the American Thyroid Association from a European Perspective]

In Germany and in other regions with former iodine deficiency, thyroid nodules and nodular goiter are still much more frequent than in the U.S.A. The American Thyroid Association (ATA) has published 2015 revised guidelines for patients with thyroid nodules and differentiated thyroid cancer. For evaluation of suspected thyroid nodules the authors describe high, intermediate, low and very low suspicion pattern and recommend further fine needle aspiration cytology, depending on the pattern and the size of the nodule. The high suspicion pattern includes irregular margins of the nodule, which may be an important criterion for malignancy of solitary nodules. In nodular goiters with multiple nodules grown together and without clear margins, frequently observed in former iodine deficiency regions, irregular margins may not be a significant criterion for malignancy. Another pattern, hypoechogenicity, which is frequently seen in benign nodules in former iodine deficiency areas, is also not a clear criterion for malignancy. Only strong hypoechogenicity may indicate malignancy. Another difference relates to the recommendation of scintigraphy that according to the guideline is restricted to patients with decreased TSH. In regions with former iodine deficiency, it has been demonstrated that thyroid autonomy may be present even if TSH is in the lower normal range. Therefore, in Germany scintigraphy is recommended for preoperative evaluation of all patients with thyroid nodules or nodular goiter.

Is patient age associated with risk of malignancy in a ≥4 cm cytologically benign thyroid nodule?

BACKGROUND

Current data regarding the risk of malignancy in a large thyroid nodule with benign fine-needle aspiration biopsy(FNAB) is conflicting. We investigated the impact of patient age on the risk of malignancy in nodules≥4 cm with benign cytology.

METHODS

We performed a single-institution retrospective review of patients who underwent surgery from 07/2008-08/2019 for a cytologically benign thyroid nodule ≥4 cm. The relationship between malignant histopathology and patient and ultrasound features was assessed with multivariable logistic regression.

RESULTS

Of 474 nodules identified, 25(5.3%) were malignant on final pathology. In patients <55 years old, 21/273(7.7%) nodules were malignant, compared to 4/201(2.0%) in patients ≥55. Patient age ≥55 was independently associated with significantly lower risk of malignancy(OR:0.2,95%CI:0.1-0.7,p = 0.011). Increasing nodule size >4 cm and high-risk ultrasound features were not associated with risk of malignancy(OR:1.0,95%CI:0.7-1.4,p = 0.980, and OR:9.6,95%CI:0.9-107.8,p = 0.066, respectively).

CONCLUSIONS

Patients <55 years old are 3.7-fold more likely to have a falsely benign FNA biopsy in a nodule≥4 cm.

Positive central lymph-nodes are underdiagnosed in patients with Bethesda V cytology in an endemic goiter region

Background

Fine needle aspiration (FNA) is a significant diagnostic procedure for detecting malignancy in patients with nodular thyroid disease. A high proportion of patients with cytological diagnosed follicular neoplasia (Bethesda IV and V) ultimately have thyroid cancer. The aim of this study was to evaluate the incidence of preoperatively undiagnosed central lymph node metastasis in patients with multinodular goiter (MNG).

Methods

Patients who underwent FNA and were classified as Bethesda IV/V were included. Applying a radical approach, all patients underwent (hemi)thyroidectomy and prophylactic unilateral central neck dissection.

Results

During our study period 2009-2013, 60 patients (19.7%) were classified as Bethesda IV and 21 (6.9%) Bethesda V. Final histopathological results revealed malignancy in 35 (43.2%) of 81 Bethesda IV/V nodules. Of the nodules classified as Bethesda IV, 20 (33.3%) showed malignancy in the final histology. Ten patients (16.7%) had papillary micro-carcinoma (mPTC, <10 mm), 4 (6.6%) PTC and 6 (10%) follicular thyroid cancer. Fifteen of 21 (71.4%) Bethesda V nodules were revealed as PTC of whom seven (33.3%) patients also had lymph-node metastases.

Conclusions

While 33.3% of the patients with PTC, preoperatively classified as Bethesda V, had previously undetected positive lymph-nodes, only one patient with Bethesda IV had lymph-node metastasis.

Lymph node metastasis around the entrance point to recurrent laryngeal nerve in papillary thyroid carcinoma

There are few reports on the lymph nodes of entrance point to recurrent laryngeal nerve (LN-epRLN) in patients with papillary thyroid carcinoma (PTC). Thus, we investigated the clinical significance of LN-epRLN and implications it may have. An observational analysis of 878 consecutive patients with PTC who underwent thyroidectomy from April 2016 to March 2017 was conducted. We explored the surrounding tissue of laryngeal entry point, during routine central lymph node dissection (CLND). The lymph node specimens were sent separately for routine histopathological examination. Thereafter, complications and follow-ups were recorded. LN-epRLNs were found in 73 of the 878 patients, with the metastatic rate of 3.76%. Univariate and multivariate analysis showed central lymph node metastases can serve as independent predictors for LN-epRLN metastasis. In summary, we confirmed the significance of LN-epRLN in metastasis and recurrence, which required precise anatomy and thorough CLND. In PTC patients, especially in suspicious presence of central cervical lymph node metastasis, attention should be given to excising the nodal tissue at the laryngeal entry point.

Thyroid nodules: diagnostic evaluation based on thyroid cancer risk assessment

Thyroid nodules are extremely common and can be detected by sensitive imaging in more than 60% of the general population. They are often identified in patients without symptoms who are undergoing evaluation for other medical complaints. Indiscriminate evaluation of thyroid nodules with thyroid biopsy could cause a harmful epidemic of diagnoses of thyroid cancer, but inadequate selection of thyroid nodules for biopsy can lead to missed diagnoses of clinically relevant thyroid cancer. Recent clinical guidelines advocate a more conservative approach in the evaluation of thyroid nodules based on risk assessment for thyroid cancer, as determined by clinical and ultrasound features to guide the need for biopsy. Moreover, newer evidence suggests that for patients with indeterminate thyroid biopsy results, a combined assessment including the initial ultrasound risk stratification or other ancillary testing (molecular markers, second opinion on thyroid cytology) can further clarify the risk of thyroid cancer and the management strategies. This review summarizes the clinical importance of adequate evaluation of thyroid nodules, focuses on the clinical evidence for diagnostic tests that can clarify the risk of thyroid cancer, and highlights the importance of considering the patient's values and preferences when deciding on management strategies in the setting of uncertainty about the risk of thyroid cancer.

Prediction of thyroid nodule malignancy using thyroid imaging reporting and data system (TIRADS) and nodule size

OBJECTIVES

Thyroid imaging reporting and data system (TIRADS) is a combination of ultrasonographic features developed to help physicians in predicting the malignancy risk of thyroid nodules based on sonographic characteristics. Thyroid nodule size is another factor in determining whether a nodule is malignant. The aim of this study was detecting the predictive value of TIRADS and nodule size based on Bethesda classification in prognostication of malignancy.

METHODS

This was a cross-sectional study of 239 patients with thyroid nodules. The patients underwent ultrasonography using TIRADS classification and FNA biopsy based on Bethesda categorization. The results were analyzed using SPSS with the cut off points and predictive values measured.

RESULTS

TIRADS ≥4 could detect malignant nodules with a sensitivity of 91.67% and specificity of 52.8%. An inverse relationship was observed between nodule size and malignancy risk and cutoff point of 12 mm was found for detecting malignant nodules.

CONCLUSIONS

Thyroid nodules with TIRADS 4 and 5 and diameter lower than 12 mm, are highly suspicious for malignancy and should be considered as indications for fine needle aspiration biopsy.

ADVANCES IN KNOWLEDGE

The study suggests TIRADS and thyroid nodule size as sensitive predictors of malignancy.

Association of exposure to multiple metals with papillary thyroid cancer risk in China

Papillary thyroid cancer (PTC) has inflicted huge threats to the health of mankind. Metal pollution could be a potential risk factor of PTC occurrence, but existing relevant epidemiological researches are limited. The current case-control study was designed to evaluate the relationships between exposure to multiple metals and the risk of PTC. A total of 262 histologically confirmed PTC cases were recruited. Age- and gender-matched controls were enrolled at the same time. Urine samples were used as biomarkers to reflect the levels of environmental exposure to 13 metals. Conditional logistic regression models were adopted to assess the potential association. Single-metal and multi-metal models were separately conducted to evaluate the impacts of single and co-exposure to 13 metals. The increased concentration of urinary Cd, Cu, Fe, and Pb quartiles was found significant correlated with PTC risk. We also found the decreased trends of urinary Se, Zn, and Mn quartiles with the ORs for PTC. These dose-response associations between Pb and PTC were observed in the single-metal model and remained significant in the multi-metal model (OR_25-50th=1.39, OR_50-75th=3.32, OR_>75th=7.62, p for trend <0.001). Our study suggested that PTC was positively associated with urinary levels of Cd, Cu, Fe, Pb, and inversely associated with Se, Zn, and Mn. Targeted public health policies should be made to improve the environment and the recognition of potential risk factors. These findings need additional studies to confirm in other population.

A new ultrasound nomogram for differentiating benign and malignant thyroid nodules

OBJECTIVE

The Thyroid Imaging Reporting and Data System (TI-RADS) is commonly used for risk stratification of thyroid nodules. However, this system has a poor sensitivity and specificity. The aim of this study was to build a new model based on TI-RADS for evaluating ultrasound image patterns that offer improved efficacy for differentiating benign and malignant thyroid nodules.

DESIGN AND PATIENTS

The study population consisted of 1092 participants with thyroid nodules.

MEASUREMENTS

The nodules were analysed by the TI-RADS and the new model. The prediction properties and decision curve analysis of the nomogram were compared between the two models.

RESULTS

The proportions of thyroid cancer and benign disease were 36.17% and 63.83%. The new model showed good agreement between the prediction and observation of thyroid cancer. The nomogram indicated excellent prediction properties with an area under the curve (AUC) of 0.946, sensitivity of 0.884 and specificity of 0.917 for training data as well as a high sensitivity, specificity, negative predictive value and positive predictive value for the validation data also. The optimum cut-off for the nomogram was 0.469 for predicting cancer. The decision curve analysis results corroborated the good clinical applicability of the nomogram and the TI-RADS for predicting thyroid cancer with wide and practical ranges for threshold probabilities.

CONCLUSIONS

Based on the TI-RADS, we built a new model using a combination of ultrasound patterns including margin, shape, echogenic foci, echogenicity and nodule halo sign with age to differentiate benign and malignant thyroid nodules, which had high sensitivity and specificity.

Influence of Hashimoto Thyroiditis on the Development of Thyroid Nodules and Cancer in Children and Adolescents

It is unclear whether patients with Hashimoto thyroiditis (HT) are predisposed to develop thyroid nodules and/or thyroid cancer. The objective of our study was therefore to assess the prevalence of thyroid nodules and/or cancer in patients with HT and to look for possible prognostic factors. A retrospective survey of 904 children/adolescents with HT (709 females, 195 males) regularly followed in nine Italian centers of pediatric endocrinology was performed. Median period of follow-up was 4.5 years (1.2 to 12.8 years). We evaluated free T4, TSH, thyroid peroxidase antibody (TPOAb), thyroglobulin antibodies, and thyroid ultrasound yearly. One hundred seventy-four nodules were detected, with an annual incidence rate of 3.5%. Ten nodules were malignant (8 papillary and 2 papillary follicular variant), giving a 5.7% prevalence of cancer among patients with nodules. The severity of hypoechogenity at ultrasound, TPOAb, and free T4 serum concentrations were predictive for the appearance of new nodules. Furthermore, a positive correlation was observed between TPOAb titer and the development of thyroid cancer. In conclusion, HT seems to influence the development of thyroid nodules, but not cancer in children and adolescents.

Intraoperative carbon nanoparticles mapping in secondary total thyroidectomy for recurrent thyroid nodules: Results of a 8-criterion case-match study (case control study)

BACKGROUND

The extent of total thyroidectomy in the management of multinodular goiter remains unclear. Compared to primary thyroidectomy, secondary total thyroidectomy is more difficult to perform and carries a significantly higher risk of postoperative complications such as recurrent laryngeal nerve (RLN) palsy or hypoparathyroidism. In this study, we aimed to evaluate the efficacy and safety of intraoperative carbon nanoparticle (CN) mapping in patients undergoing secondary total thyroidectomy.

METHODS

We performed a case-matched analysis of a prospectively maintained database using 8 specific criteria to compare perioperative outcomes after primary total thyroidectomy to those after secondary total thyroidectomy with intraoperative CN mapping. The criteria included age, sex, operative procedure, RLN/parathyroid glands (PGs) exploration, preoperative vocal cord calcium abnormalities, and pathological results. Thirty-five patients underwent secondary total thyroidectomy with intraoperative CN mapping due to recurrent thyroid nodules or development of nodules suspicious for malignancy after subtotal thyroidectomy. Fifty exact matches for all 8 criteria were identified from the database in our previous study, which included records of 3078 primary thyroidectomies without CNs. Perioperative outcomes, surgical technique, and complications were analyzed.

RESULTS

The RLNs were successfully identified in all 35 patients. Among three patients that experienced slight hoarseness, one had an RLN end-to-end anastomosis with subsequent improvement in the during the 12-month follow-up period. Two patients experienced changes in vocal tone, but recovered after several months. Two patients underwent parathyroid auto-transplantations, and subsequently presented with transient hypocalcaemia. Their symptoms gradually remitted within one year. Except for mean operation time, there were no statistically significant differences in complications between the primary total thyroidectomies and the secondary total thyroidectomy with CNs.

CONCLUSIONS

Intraoperative CN mapping, expert knowledge of the jugular anatomy, and standardized resection procedures can minimize the incidence of complications such as RLN palsy and hypoparathyroidism after secondary total thyroidectomy.

The risk of thyroid carcinoma in multinodular goiter compared to solitary thyroid nodules: A retrospective analysis of 600 patients

Background

It is generally believed that multinodular goiter (MNG) is associated with a lower risk of malignancy compared to solitary thyroid nodules (STN). This will be the null hypothesis in this retrospective study and we aim to prove or reject it.

Methods

Medical files and histopathology reports of 600 patients who underwent thyroidectomy over 4-year period were reviewed. Data including patient' age, gender, presentation, ultrasonography, FNAC, surgical procedures, final histopathologic diagnosis and stage of malignant tumors were collected and analyzed. The primary end point was assessment of risk of thyroid carcinoma in patients with MNG compared to those with STN. Secondary endpoints included demographic differences and prognosis.

Results

There were 459 females (76.5%). Mean age was 44.3 ± 14.5 years (range 14-85). After exclusion of 33 patients, 224 (39.5%) had STN and 343 (60.5%) had MNG. The prevalence of thyroid cancer was 41.1% (92/224) in STN compared to 29.2% (100/343) in MNG (Chi-Square = 8.593, p < 0.01). However, on multiple logistic regression analysis this correlation was found insignificant (p = 0.640). Only male gender (p = <0.000005) and preoperative impression of malignancy (p = 0.000082) were significantly associated with thyroid carcinoma.

Conclusion

The risk of thyroid carcinoma in STN and MNG was similar. Male gender was identified as a risk factor for thyroid cancer while age, number and size of nodules were not.

Thyroid Nodule Management: Thyroid-Stimulating Hormone, Ultrasound, and Cytological Classification System for Predicting Malignancy

Background/objectives:

Thyroid nodule (TN) is a common thyroid disorder globally, and the incidence has been increasing in recent decades. The objective of this study was to determine the contribution of thyroid-stimulating hormone (TSH), ultrasound (US), and cytological classification system for predicting malignancy among the surgically excised nodules.

Design and methods:

A retrospective analysis was performed between January 2012 and December 2014, using data drawn from 1188 patients (15-90 years), who had 1433 TN and fine-needle aspiration in Prince Sultan Military Medical City, Saudi Arabia. After reviewing all the thyroid cytopathological slides and US reports, classification was done based on the Bethesda System for Reporting Thyroid Cytology and the Thyroid Imaging Reporting and Data System (TI-RADS).

Results:

A total of 1188 patients’ medical records were reviewed for this study, among them 311 patients had undergone surgical intervention (253 patients had single nodule and 58 had 2 nodules), with a total of 369 nodules. However, as 54 nodules on the US were either unavailable or unclear, the 315 remaining nodules were analyzed, revealing 30.2% (n = 95) malignancy overall. Patients with TSH values of >4.5 mIU/L (38.2%), TN <1 cm (48.8%), TI-RADS category 5 (75.6%), and Bethesda category VI (88.9%) revealed a higher percentage of malignancy. From the univariate analysis using the χ² test, significant relationship between the TSH, nodule size, TI-RADS, and the Bethesda category between the malignant and benign nodules emerged. The regression analysis showed that patients with a TSH value of 0.5 to 4.5 mIU/L (odds ratio [OR]: 2.96), TSH >4.5 mIU/L (OR: 6.54) had higher risk for malignancy than those with a TSH value of ≤0.4 mIU/L. Thyroid nodules with sizes of 1 to 1.9 cm (OR: 1.12), 2 to 2.9 cm (OR: 0.74), 3-3.9 cm (OR: 1.21), and ≥4 cm (OR: 0.52) were found to have no association with the risk of malignancy. Compared with TI-RADS 2 patients, those with categories 4B (OR: 1.35) and 5 (OR: 2.3) were found to be at higher risk of malignancy. Similarly, Bethesda IV (OR: 2.72), V (OR: 8.47), and VI (OR: 20; P < .02) category patients had a higher risk for malignancy than those in Bethesda class I. Among the study population, the papillary thyroid carcinoma was the most common type of thyroid cancer (86, 90.5%) followed by 7.4% (n = 7) of follicular thyroid carcinoma, 1.05% (n = 1) of anaplastic carcinoma, and 1.05% (n = 1) of medullary thyroid carcinoma.

Conclusions:

A predictive model for risk of malignancy using a combining characteristic of the TSH, US, and cytological classification systems could assist the clinicians in minimizing exposing the patients with TNs to nonessential invasive procedures.

Increased Cancer Risk in Younger Patients with Thyroid Nodules Diagnosed as Atypia of Undetermined Significance

Background: The objective of this study was to determine if patient age and/or gender significantly alter the risk of thyroid malignancy in the Bethesda System for Reporting Thyroid Cytopathology (BSRTC) diagnostic categories.

Methods: A retrospective review of 291 sequential patients that underwent thyroid nodule fine needle aspiration biopsy (FNAB) and subsequent surgery at a single center was carried out. Cases were grouped according to age (55 years and older versus younger than 55 years) and gender. The cancer risk was calculated for each BSRTC diagnostic group. A p-value <0.05 was not considered statistically significant.

Results: The study population was composed of 291 patients (227 females and 64 males). Histopathology diagnosed cancer in 113 cases (39%). The cancer risk was significantly increased in cases with a BSRTC diagnosis of atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS) in patients younger than 55 years of age (36.8% vs 7.4%, p=0.0082).

Conclusions: Though thyroid cancer was significantly more common in males (p=0.021), gender did not significantly influence specific BRSTC diagnostic category cancer risk estimation. A BSRTC AUS/FLUS diagnosis is associated with an increased cancer risk in younger patients.

The role of fine-needle aspiration in the thyroid nodules of elderly patients

We assess the role of thyroid fine needle aspiration cytology(FNAC) in our series of elderly patients. The growing subset of people aged older than 70 years has shown an increased incidence of thyroid diseases which need to be studied in order to reduce the percentage of surgical treatments in patients with higher likelihood of co-morbidities and associated life risk. We compared Follicular/Indeterminate Neoplasms(FN) and suspicious of malignancy(SM) with pediatric and adult cohorts. We discussed the role of immunocytochemistry-ICC to refine diagnoses. Four hundred and eighty out of 3539FNACs(13.5%) in elderly patients, were surgical followed-up. They included: 35Inadequate, 188benign(BL), 164FN/AUS, 49SM and 44positive for malignancy (PM). All PM and 95.7%BL were histological confirmed. The malignant rate was 24.3% mostly diagnosed as papillary thyroid carcinomas. An ICC panel (HBME-1 and Galectin-3) was carried out on liquid based cytology (LBC) and performed on FN/AUS, SM and PM. We found concordant positive ICC in 69.3%malignancies and concordant negative ICC in 97.6%benign follicular adenomas. Among FNs, 42.9%malignant histologic cases had concordant positivity whilst 97.4%benign histology had negative panel. Thyroid FNAC shows high feasibility in elderly patients. ICC helps in reducing the number of useless thyroidectomies and providing a more adequate clinical and/or surgical selection in elderly patients.

Adequate sampling of multiple thyroid nodules by fine-needle aspiration

BACKGROUND

Recommendations regarding how many nodules to biopsy with thyroid fine-needle aspiration vary.

METHODS

The authors reviewed fine-needle aspiration specimens of 12,763 nodules from 10,506 patients and correlated them with the number of nodules biopsied.

RESULTS

Compared with patients in whom only a single nodule was biopsied, patients in whom multiple nodules were biopsied were found to be significantly younger, more likely female, and to have larger tumors, and those tumors were more often papillary (all P<.001). On fine-needle aspiration, patients who had multiple nodules biopsied were more often diagnosed with benign findings (P<.001), but usually had no significant difference in the risk of malignancy associated with any cytologic diagnosis. Performing biopsy in 3 nodules detected all carcinomas in the current series. Combining all cases in the literature demonstrated that performing only 3 biopsies in a patient with at least 4 suspicious nodules had a risk of malignancy of 1.2%.

CONCLUSIONS

Biopsy of 3 different nodules in patients with multiple nodules appears to lower the risk of malignancy to that of a benign fine-needle aspiration specimen. Although exceptions can occur, cytologists may be able to improve the accuracy of their diagnoses by focusing predominantly on identifying papillary carcinoma after the first 2 nodules have been biopsied. Cancer Cytopathol 2017;125:848-53. © 2017 American Cancer Society.

Clinical impact of molecular techniques for the presurgical diagnosis of differentiated thyroid cancer diagnosis

The gold standard for the presurgical diagnosis of thyroid cancer is fine needle aspiration cytology. In about 30% of cases a final diagnosis is not obtained and surgical treatment is required for diagnostic/therapeutic purposes. To avoid unnecessary thyroidectomies, methods based on molecular markers analysis have been explored over the last 10 years. Areas covered: The present review introduces the limits of the cytological diagnosis of thyroid nodules and describes the molecular techniques for the presurgical diagnosis of these nodules focusing on the use of the Thyroseq-V2 (Rule in) and Afirma (Rule out) tests. Expert commentary: These two types of tests have been clinically applied and validated; however they are still confined to specialized laboratories, either academic or private, and not yet routinely used. The evidence of a positive cost-benefit analysis should encourage to set up molecular pathology laboratories to apply new molecular testing(s). In the meantime, clinical judgment, which must take into consideration several parameters including the age of the patient, the size and number of the nodule(s), the ultrasound pattern and the risk level for malignancy, should guide the decision to operate or to follow up the evolution of the nodule.

Risk of Malignancy in Thyroid Incidentaloma is Not Increased in Overweight or Obese Patients, but in Young Patients

Thyroid incidentaloma is defined as an unsuspected, asymptomatic thyroid lesion that is discovered on an imaging study or during an operation unrelated to the thyroid gland. We aim to evaluate the relationship between overweight or obese and risk of malignancy in patients with thyroid incidentaloma detected by F18-flurodeoxyglucose positron emission tomography/computed tomography and factors to predict risk of malignancy in thyroid incidentaloma. From January 2010 to December 2013, a total of 238 patients were eligible for this study. Using the Bethesda system for reporting thyroid cytopathology, categories I-III were defined as a nonmalignancy and categories V-VI were defined as a malignancy. When patients with body mass index (BMI) of less than 23 and 23 or more were divided into two groups of normal and overweight or obese, risk of malignancy of thyroid incidentaloma was not significantly different between two groups (P = 0.1812). In logistic regression analysis, age was the only variable that showed a significant association with malignancy of thyroid incidentaloma (odds ratio 0.9608, P = 0.0021). However, none of sex, height, weight, and BMI was predictor of malignancy of thyroid incidentaloma. We demonstrated that being overweight or obese did not increase rate of malignancy in patients with thyroid incidentaloma.

Incidental thyroid nodules on thoracic contrast-enhanced computed tomography in clinical practice during a 10-year period: Characteristics, clinical outcomes, and factors contributing to further evaluation

The purposes of this study were to assess the prevalence, malignancy rate, and characteristics of incidental thyroid nodules (ITNs), and to identify factors that contribute the additional workup by ultrasound.The medical records and imaging features of ITNs reported via thoracic computed tomography (CT) were retrospectively reviewed to determine the size, multiplicity, attenuation, shape, and presence of calcification. To identify the factors associated with additional workup, we compared the workup and non-workup groups in terms of nodule characteristics, indications, and CT slices. We identified factors that could distinguish malignant ITNs from non-malignant nodules.A total of 60,921 thoracic CT scans met the inclusion criteria, and ITNs were reported using formal radiology in 2733 patients (4.5%). Among all patients with reported ITNs, 546 (20.0%) underwent further workup. Of these patients, 62 (2.3%, 62/2773) were diagnosed with malignant nodules. Multivariable analysis identified multiple factors associated with additional workup, including female sex, younger age, larger nodule size, calcification, anteroposterior to transverse dimension ratio >1, heterogeneous attenuation in the nodule, and scanning indications such as infection or screening. However, only calcification was associated with malignant nodules (odds ratio [OR] = 2.313; 95% confidence interval [CI], 1.301-4.113).We observed discordance between the numbers of reported ITNs and case with additional workup and identified multiple factors associated with additional workup. We have, therefore, demonstrated a need for reliable subsequent evaluation guidelines and note that the appearance of calcification in an ITN on imaging may be a factor indicating the need for additional workup.

Diagnostic accuracy of ultrasound-guided fine needle aspiration biopsy for thyroid malignancy: systematic review and meta-analysis

PURPOSE

To systematically appraise and summarize the available evidence about the diagnostic accuracy of ultrasound-guided fine needle aspiration biopsy (USFNA) for thyroid malignancy, and to explore the integration of these estimates with the probability of thyroid malignancy before USFNA.

METHODS

A comprehensive search of multiple databases from each database's inception to August 2014 was performed. Eligible studies included those that evaluated patients with thyroid nodules who underwent USFNA and subsequent evaluation by histopathology or long-term follow-up.

RESULTS

We identified 32 studies at moderate risk of bias evaluating the USFNA diagnostic characteristics for the diagnosis of thyroid malignancy. Results were imprecise and inconsistent across trials. The pooled likelihood ratio (LR) of thyroid malignancy for a benign USFNA result was 0.09 (95 % CI 0.06, 0.14; I (2) = 33 %), whereas the pooled LR for a malignant result was 197 (95 % CI, 68, 569; I (2) = 77 %). In the case of a suspicious for follicular neoplasm result, the pooled LR for malignancy was 0.6 (95 % CI, 0.4, 1.0; I (2) = 84 %) and 8.3 (95 % CI, 3.6, 19.2; I (2) = 89) for a result of suspicious for malignancy.

CONCLUSION

The available evidence regarding the diagnostic accuracy of USFNA warrants only limited confidence due to risk of bias, imprecision, and inconsistency. However, some USFNA results (benign, malignant) are likely very helpful, by significantly changing the pre-test probability of thyroid cancer.

Negative Fine-Needle Aspiration in Patients with Goiter: Should We Doubt It?

BACKGROUND

Epidemiologic studies demonstrated higher incidence of thyroid cancer in patients with multinodular goiters compared to the general population. The aim of this study was to evaluate the risk of finding significant thyroid cancer in patients undergoing thyroidectomy for presumed benign disease.

METHODS

The records of 273 patients operated for indications other than cancer or indeterminate cytology were reviewed and analyzed.

RESULTS

202 (74%) patients had a preoperative fine-needle aspiration (FNA) performed. FNA was benign in 96% of patients and non-diagnostic in 4%. Malignancy was unexpectedly found in 50 (19%) patients. Papillary carcinoma constituted 94% of cancers and 86% of cancers were incidental microcarcinomas. Only 7 (2.6%) patients of the entire cohort had tumors greater than 1 cm, of those only 3 had a previous benign FNA (false-negative rate 1.5%).

CONCLUSIONS

The rate of significant thyroid cancer found unexpectedly in resected goiters is extremely low. A negative FNA excludes significant cancer with near certainty.

Obesity Does Not Modify the Risk of Differentiated Thyroid Cancer in a Cytological Series of Thyroid Nodules

BACKGROUND

A possible impact of obesity on the risk of thyroid cancer has been postulated in some studies, but it remains controversial.

OBJECTIVE

To investigate the association between obesity and differentiated thyroid carcinoma in a population of unselected patients subjected to fine-needle aspiration cytology (FNAC) for thyroid nodules.

METHODS

We retrospectively evaluated the results of FNAC of thyroid nodules in 4,849 patients (3,809 females and 1,040 males; mean age 55.9 ± 14.1 years). Patients were stratified according to their body mass index (BMI). There were 1,876 (38.7%) normal-weight patients (BMI 18-24.9), 1,758 (36.2%) overweight (BMI 25-29.9), 662 (13.7%) grade 1 obese (BMI 30-34.9), 310 (6.4%) grade 2 obese (BMI 35-39.9) and 243 (5.0%) grade 3 obese (BMI >40).

RESULTS

The prevalence of suspicious or malignant nodules (Thy4/Thy5) did not differ across the 5 BMI groups, i.e. it was 6.8% in normal-weight patients, 6.3% in overweight patients, 6.3% in grade 1 obese patients, 4.0% in grade 2 obese patients and 4.2% in grade 3 obese patients (p = 0.29). The prevalence of Thy4/Thy5 nodules did not differ when males and females were evaluated separately (p = 0.22 and p = 0.12, respectively). A significant, lower rate of Thy4/5 cytology was observed in female patients with grade 2-3 obesity (odds ratio 0.51; 95% confidence interval 0.284-0.920; p = 0.009).

CONCLUSIONS

The results of this study, in a retrospective series of patients with thyroid nodules, do not confirm previous findings reporting an association between obesity and differentiated thyroid carcinoma. Thus, obese patients with nodular thyroid disease should be managed the same as normal-weight patients.

Risk of Thyroid Cancer in Euthyroid Asymptomatic Patients with Thyroid Nodules with an Emphasis on Family History of Thyroid Cancer

Objective

To determine the factors associated with thyroid cancer, focusing on first-degree family history and ultrasonography (US) features, in euthyroid asymptomatic patients with thyroid nodules.

Materials and Methods

This retrospective study included 1310 thyroid nodules of 1254 euthyroid asymptomatic patients who underwent US-guided fine-needle aspiration biopsy between November 2012 and August 2013. Nodule size and clinical risk factors–such as patient age, gender, first-degree family history of thyroid cancer, multiplicity on US and serum thyroid stimulating hormone (TSH) levels–were considered together with US features to compare benign and malignant nodules. Multiple logistic regression analysis was performed to assess the risk of thyroid malignancy according to clinical and US characteristics.

Results

Although all of the clinical factors and US findings were significantly different between patients with benign and malignant nodules, a solitary lesion on US (p = 0.041–0.043), US features and male gender (p < 0.001) were significant independent risk factors for thyroid malignancy in a multivariate analysis. Patient age, a first-degree family history of thyroid cancer and high normal serum TSH levels did not independently significantly increase the risk of thyroid cancer. However, multicollinearity existed between US assessment and patient age, first-degree family history of thyroid cancer and serum TSH values.

Conclusion

Ultrasonography findings should be the primary criterion used to decide the management of euthyroid asymptomatic patients with thyroid nodules. The concept of first-degree family history as a risk factor for thyroid malignancy should be further studied in asymptomatic patients.

Thyroid Hormones, Autoantibodies, Ultrasonography, and Clinical Parameters for Predicting Thyroid Cancer

Our objective was to evaluate thyroid nodule malignancy prediction using thyroid function tests, autoantibodies, ultrasonographic imaging, and clinical data. We conducted a retrospective cohort study in 1400 patients with nodular thyroid disease (NTD). The thyroid stimulating hormone (TSH) concentration was significantly higher in patients with differentiated thyroid cancer (DTC) versus benign thyroid nodular disease (BTND) (p = 0.004). The receiver operating characteristic curve of TSH showed an AUC of 0.58 (95% CI 0.53-0.62, p = 0.001), sensitivity of 74%, and specificity of 57% at a cut-off of 1.59 mIU/L. There was an incremental increase in TSH concentration along with the increasing tumor size (p < 0.001). Thyroglobulin antibody (TgAb) concentration was associated with an increased risk of malignancy (p = 0.029), but this association was lost when the effect of TSH was taken into account (p = 0.11). Thyroid ultrasonographic characteristics, including fewer than three nodules, hypoechoic appearance, solid component, poorly defined margin, intranodular or peripheral-intranodular flow, and punctate calcification, can be used to predict the risk of thyroid cancer. In conclusion, our study suggests that preoperative serum TSH concentration, age, and ultrasonographic features can be used to predict the risk of malignancy in patients with NTD.