Prospective evaluation of thyroid imaging reporting and data system on 4550 nodules with and without elastography

Clinical, ultrasound and anatomopathological concordance of thyroid nodules in Kinshasa: a cross-sectional study

BACKGROUND

The European Thyroid Association Thyroid Imaging Data and Reporting Systems (EU-TIRADS) is widely used in the risk stratification of thyroid nodule malignancy. However, data on the subject in Sub-Saharan Africa are limited. The objective of this study is to evaluate the clinical, sonographic and histopathological concordance of thyroid nodules in the diagnosis of thyroid cancer.

METHODS

This was an analytical cross-sectional study that examined the clinical, ultrasound and pathological data of 61 patients from 4 hospitals in the city province of Kinshasa over a period of 24 months, from June 01, 2020 to May 31, 2022.

RESULTS

Of the 61 patients, their mean age was 47.38 ± 8.8 years. The mean clinical score of the patients was 3.4 ± 0.84 with the extremes ranging from 1 to 5. The majority of the patients were classified as having an intermediate risk, ie 85.2% of the cases. It was noted that 41% of the nodules had a high risk according to the EU-TIRADS score and 8.2% of the nodules were malignant after histopathological analysis. The ROC curves reported at the diagnosis of malignancy show an area under the curve of 0.709 with 95% CI (0.486-0.931), a Youden index of 0.769 for the clinical score, and an area under the curve of 0.830 with 95% CI (0.605-0.995), a Youden index of 0.772 for the EU-TIRADS score.

CONCLUSION

In a low-income country, a well-performed thyroid ultrasound and the well-applied clinical score could be an important tool in the selection of thyroid nodules suspected of malignancy and requiring histopathological examination to avoid excessive acts in the patient.

Immune response and mesenchymal transition of papillary thyroid carcinoma reflected in ultrasonography features assessed by radiologists and deep learning

INTRODUCTION

Ultrasonography (US) features of papillary thyroid cancers (PTCs) are used to select nodules for biopsy due to their association with tumor behavior. However, the molecular biological mechanisms that lead to the characteristic US features of PTCs are largely unknown.

OBJECTIVES

This study aimed to investigate the molecular biological mechanisms behind US features assessed by radiologists and three convolutional neural networks (CNN) through transcriptome analysis.

METHODS

Transcriptome data from 273 PTC tissue samples were generated and differentially expressed genes (DEGs) were identified according to US feature. Pathway enrichment analyses were also conducted by gene set enrichment analysis (GSEA) and ClusterProfiler according to assessments made by radiologists and three CNNs - CNN1 (ResNet50), CNN2 (ResNet101) and CNN3 (VGG16). Signature gene scores for PTCs were calculated by single-sample GSEA (ssGSEA).

RESULTS

Individual suspicious US features consistently suggested an upregulation of genes related to immune response and epithelial-mesenchymal transition (EMT). Likewise, PTCs assessed as positive by radiologists and three CNNs showed the coordinate enrichment of similar gene sets with abundant immune and stromal components. However, PTCs assessed as positive by radiologists had the highest number of DEGs, and those assessed as positive by CNN3 had more diverse DEGs and gene sets compared to CNN1 or CNN2. The percentage of PTCs assessed as positive or negative concordantly by radiologists and three CNNs was 85.6% (231/273) and 7.1% (3/273), respectively.

CONCLUSION

US features assessed by radiologists and CNNs revealed molecular biologic features and tumor microenvironment in PTCs.

The impact of V-flow on preoperative diagnosis of thyroid tumors: individually and as part of multimodal sonographic imaging

V-flow is a dynamic ultrasound technique that visualizes perfusion patterns by displaying dynamic arrows that change in response to the flow of erythrocytes. Furthermore, it provides quantitative values for the maximum and mean velocity of blood flow as well as a percentage value for turbulence. The aim was to enhance the preoperative diagnostic accuracy of thyroid lesions by combining V-flow with established ultrasound modes.B-mode, CCDS, elastography, CEUS, and V-flow were performed on 101 patients. After the ultrasound examination, every nodule was confirmed as benign or malignant via histopathology. The Kruskal-Wallis test, ROC curve, and binary logistic regression were used for the statistical analysis.93 benign regressive thyroid nodules and 8 carcinomas were included in this study. The average mean velocity value for benign lesions was measured at 19.5 cm/s and at 10.7 cm/s for malignant lesions (p = 0.039). The average turbulence percentage was 26.1% for benign nodules and 46.7% for carcinomas (p = 0.016). Carcinomas exhibited a slower and more turbulent perfusion pattern compared to benign tumors. A V-flow-centered system achieves a sensitivity of 100.0% and a specificity of 84.9% in predicting malignancy. This system could have reduced the number of unnecessary thyroid surgeries for benign lesions in our patient group by 70%.The capillary perfusion of thyroid nodules represents a significant indicator of its status. By analyzing the velocity and turbulence level of microvascular blood flow, V-flow offers promising prospects for accurately distinguishing between benign and malignant thyroid lesions. When integrated into a comprehensive multimodal sonographic imaging approach, V-flow further enhances diagnostic accuracy. · V-flow allows for qualitative and quantitative analysis of microvascular perfusion. · Malignant tumors are associated with slower and more turbulent microvascular hemodynamics. · Combining V-flow with other ultrasound modes eases the diagnosis of thyroid carcinomas. · Brandenstein MK, Zhang L, Scharf G et al. The impact of V-flow on preoperative diagnosis of thyroid tumors: individually and as part of multimodal sonographic imaging. Fortschr Röntgenstr 2024; DOI 10.1055/a-2350-0107.

Impact of ultrasound elastography in evaluating Bethesda category IV thyroid nodules with histopathological correlation

Introduction

Fine needle aspiration (FNA) is the gold standard method recommended in the diagnosis of thyroid nodules. Bethesda IV cytology results are identified in 7-9% of nodules investigated through FNA, with reported malignancy rate in a wide range of 10-40%. The recommended treatment is either surgical or risk additional molecular testing before surgery. However, a large number of nodules belonging to this category (60-80%) are observed to be benign after surgical excision, which can put the patient at risk of unnecessary surgical morbidity. This study aimed to assess the diagnostic performance of conventional ultrasound, the ACR TI-RADS score and elastography in cases of Bethesda IV cytology on FNA.

Methods

We evaluated ninety-seven consecutive cases with Bethesda category IV results on FNA by using conventional B-mode ultrasound, qualitative strain or shear-wave elastography (Hitachi Preirus Machine, Hitachi Inc., Japan and Aixplorer Mach 30 Supersonic Imagine, Aix-en-Provence, France) and all nodules were classified according to the ACR TI-RADS system. Conventional ultrasound was used to categorize the nodules as potentially malignant based on the following features: hypoechogenicity, inhomogeneity, a taller than wide shape, irregular margins, presence of microcalcifications, an interrupted thyroid capsule and suspicious cervical lymph nodes. Elastography classified nodules with increased stiffness as suspicious for malignancy.

Results

We considered pathology results as the gold standard diagnosis, finding that 32 out of 97 nodules were carcinomas (33%) and 65 out of 97 were benign nodules (67%). The benign group included twenty cases of non-invasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP). Finally, we compared ultrasound data with pathology results, which showed that nineteen out of the 32 malignant nodules presented with increased stiffness on elastography (p=0.0002). On conventional ultrasound, we found that microcalcifications (p=0.007), hypoechogenicity and irregular margins (p=0.006) are features which can distinguish between benign and malignant nodules with statistical significance.

Discussion

Integrating elastography as a parameter of the ACR TI-RADS score in the evaluation of Bethesda category IV nodules showed a sensitivity of 90.62% in detecting thyroid cancer cases (p=0.006). We can conclude that elastographic stiffness as an addition to high risk features observed on conventional ultrasound improves the detection of malignant nodules in cases with Bethesda IV cytology.

[Elastography in thyroid nodules]

BACKGROUND

Elastography is an imaging method to examine the elasticity of tissue. In the meantime, various elastography methods have been developed, which are subdivided according to the type of stimulus applied. In principle, a distinction should be made between strain elastography (SE) and shear wave elastography (SWE). Both methods provide another means of assessing thyroid disease in addition to conventional B-mode sonography.

OBJECTIVE

The aim is to provide an overview of elastography techniques including physical basics and their importance in the clarification algorithm of thyroid nodules.

MATERIALS AND METHODS

International guidelines and recent publications on elastography were selectively assessed.

RESULTS

Elastography provides additional information compared to conventional B-mode sonography. The change in shear stiffness is the essential physical mechanism for tissue contrast in all elastograms. In addition to the qualitative assessment of elasticity in SE, quantification is possible with SWE. In the international literature, elastography was analyzed as a single method or in comparison or combination with conventional B-mode sonography and especially with standardization using a risk stratification system (RSS, TIRADS). The results are quite controversial. In nodules with unclear findings on fine-needle biopsy (Bethesda III/IV), the combination of morphologic criteria and elastography improved diagnostic accuracy. In particular, the high negative predictive value of soft nodules represents a relevant added value. This strength of the method can play an important role in the clarification of nodules with intermediate malignancy risk or of unclear FNB results. Elastography has previously only been incorporated into French-TIRADS. Although the procedure is mentioned in the EU-TIRADS as a complementary method, integration has not been described. Limitations of the method are idealized basic assumptions, dependence of manufacturer and examiner, and artifacts.

CONCLUSION

Elastography can be a useful adjunct to standard diagnostic procedures in the evaluation of thyroid nodules, especially in nodules with intermediate risk of malignancy and unclear results on fine needle aspiration.

Associations of Real-Time Ultrasound and Strain and Shear Wave Elastography with Gastrointestinal Organs: A Systematic Review

Ultrasound elastography is gaining attention for its diagnostic potential across various medical fields, and its physical properties make it valuable in modern clinical medicine. However, its specific attributes, especially in the context of recent medical advancements, remain relatively unexplored. This study aimed to identify instrument-specific characteristics and applications of real-time ultrasound elastography, shear wave elastography, and strain elastography, particularly within gastroenterology. Following PRISMA guidelines, the study examined elastography articles on databases like PubMed, resulting in 78 included articles. Data on patient demographics, organ involvement, specificity, sensitivity, accuracy, positive predictive value, and negative predictive value were extracted. Statistical analysis involved SPSS version 21, with significance set at p < 0.05. The majority of patients were male (50.50%), with a mean age of 42.73 ± 4.41 years. Shear wave elastography was the most prevalent technique (48.7%), and liver investigations were predominant in gastroenterology (34.6%). Gastrointestinal applications showed higher sensitivity, positive predictive value, and negative predictive values (p < 0.05) but lower specificity (p < 0.05). Real-time ultrasound elastography exhibited increased specificity, accuracy, and predictive values (p < 0.05). Ultrasound elastography appears more accurate and effective in gastroenterological settings. Nonetheless, its performance depends on instrument-specific and operator-dependent factors. While promising, further studies are necessary to ascertain optimal utilization in both gastrointestinal and non-gastrointestinal conditions.

Diagnostic performance of ultrasound risk stratification systems on thyroid nodules cytologically classified as indeterminate: a systematic review and meta-analysis

PURPOSE

Ultrasound (US) risk stratification systems (RSSs) are increasingly being utilized for the optimal management of thyroid nodules, including those with indeterminate cytology. The goal of this study was to evaluate the category-based diagnostic performance of US RSSs in identifying malignancy in indeterminate nodules.

METHODS

This systematic review and meta-analysis was registered on PROSPERO (CRD42021266195). PubMed, EMBASE, and Web of Science were searched through December 1, 2022. Original articles reporting data on the performance of US RSSs for indeterminate nodules were included. The numbers of nodules classified as true negative, true positive, false negative, and false positive were extracted.

RESULTS

Thirty-three studies evaluating 7,225 indeterminate thyroid nodules were included. The diagnostic accuracy was quantitatively synthesized using a Bayesian bivariate model based on the integrated nested Laplace approximation in R. For the intermediate- to high-risk category, the sensitivity levels of the American College of Radiology, the American Thyroid Association, the European Thyroid Association, the Korean Thyroid Association/Korean Society of Thyroid Radiology, and Kwak et al. were found to be 0.80, 0.72, 0.76, 0.96, and 0.97, respectively. The corresponding specificity measurements were 0.36, 0.50, 0.49, 0.28, and 0.17. Furthermore, for the high-risk category, the sensitivity values were 0.40, 0.46, 0.55, 0.47, and 0.10, while the specificity levels were 0.91, 0.90, 0.71, 0.91, and 0.99, respectively.

CONCLUSION

The overall diagnostic performance of the US RSSs was moderate in the differentiation of indeterminate nodules.

Real-Time Ultrasonography and the Evaluation of Static Images Yield Different Results in the Assessment of EU-TIRADS Categories

The studies on the effectiveness of various TIRADS in the diagnostics of thyroid nodules differ in the method of ultrasound image assessment: real time (rtUS) vs. static ultrasonography (stUS). The aim of the study was to evaluate the impact of those two methods on the categorization of nodules in EU-TIRADS. Three experienced raters assessed 842 nodules in routine rtUS and reassessed with the use of sUS. Reproducibility of the assessment of malignancy risk features and categorization of nodules with EU-TIRADS was estimated with Krippendorff's alpha coefficient (Kα). The reproducibility of EU-TIRADS categories on sUS in relation to rtUS was in range 70.9-76.5% for all raters (Kα: 0.60-0.68) with the highest reproducibility for category 3 (80.0-86.5%) and the lowest for category 5 (48.7-77.8%). There was a total disagreement of the identification of microcalcifications on sUS in relation to rtUS, a strongly variable reproducibility of marked hypoechogenicity (12.5-84.6%, Kα: 0.14-0.48) and a tendency toward more frequent identification of the non-oval shape on sUS. The percentage of agreement for each pair of raters in assigning the EU-TIRADS category on sUS was in the range 71.6-72.3% (Kα: 0.60-0.62). The method of sonographic image evaluation influences the nodule's feature assessment and, eventually, the categorization within EU-TIRADS.

Does a three-degree hypoechogenicity grading improve ultrasound thyroid nodule risk stratification and affect the TI-RADS 4 category? A retrospective observational study

Objective

The aim of this study was to determine whether classifying hypoechogenicity in three degrees (mild, moderate, and marked) could improve the distinction between benign and malignant nodules and whether such an approach could influence Category 4 of the Thyroid Imaging Reporting and Data System (TI-RADS).

Materials and methods

In total, 2,574 nodules submitted to fine needle aspiration, classified by the Bethesda System, were retrospectively assessed. Further, a subanalysis considering solid nodules without any additional suspicious findings (n = 565) was performed with the purpose of evaluating mainly TI-RADS 4 nodules.

Results

Mild hypoechogenicity was significantly less related to malignancy (odds ratio [OR]: 1.409; CI: 1.086-1.829; p = 0.01), compared to moderate (OR: 4.775; CI: 3.700-6.163; p < 0.001) and marked hypoechogenicity (OR: 8.540; CI: 6.355-11.445; p < 0.001). In addition, mild hypoechogenicity (20.7%) and iso-hyperechogenicity (20.5%) presented a similar rate in the malignant sample. Regarding the subanalysis, no significant association was found between mildly hypoechoic solid nodules and cancer.

Conclusion

Stratifying hypoechogenicity into three degrees influences the confidence in the assessment of the rate of malignancy, indicating that mild hypoechogenicity has a unique low-risk biological behavior that resembles iso-hyperechogenicity, but with minor malignant potential when compared to moderate and marked hypoechogenicity, with special influence on the TI-RADS 4 category.

Application of machine learning methods to guide patient management by predicting the risk of malignancy of Bethesda III-V thyroid nodules

OBJECTIVE

Indeterminate thyroid nodules (ITN) are common and often lead to (sometimes unnecessary) diagnostic surgery. We aimed to evaluate the performance of two machine learning methods (ML), based on routinely available features to predict the risk of malignancy (RM) of ITN.

DESIGN

Multi-centric diagnostic retrospective cohort study conducted between 2010 and 2020.

METHODS

Adult patients who underwent surgery for at least one Bethesda III-V thyroid nodule (TN) with fully available medical records were included. Of the 7917 records reviewed, eligibility criteria were met in 1288 patients with 1335 TN. Patients were divided into training (940 TN) and validation cohort (395 TN). The diagnostic performance of a multivariate logistic regression model (LR) and its nomogram, and a random forest model (RF) in predicting the nature and RM of a TN were evaluated. All available clinical, biological, ultrasound, and cytological data of the patients were collected and used to construct the two algorithms.

RESULTS

There were 253 (19%), 693 (52%), and 389 (29%) TN classified as Bethesda III, IV, and V, respectively, with an overall RM of 35%. Both cohorts were well-balanced for baseline characteristics. Both models were validated on the validation cohort, with performances in terms of specificity, sensitivity, positive predictive value, negative predictive value, and area under the receiver operating characteristic curve of 90%, 57.3%, 73.4%, 81.4%, 84% (CI95%: 78.5%-89.5%) for the LR model, and 87.6%, 54.7%, 68.1%, 80%, 82.6% (CI95%: 77.4%-87.9%) for the RF model, respectively.

CONCLUSIONS

Our ML models performed well in predicting the nature of Bethesda III-V TN. In addition, our freely available online nomogram helped to refine the RM, identifying low-risk TN that may benefit from surveillance in up to a third of ITN, and thus may reduce the number of unnecessary surgeries.

Inter-Rater Reliability of Thyroid Ultrasound Risk Criteria: A Systematic Review and Meta-Analysis

OBJECTIVE

The most commonly employed diagnostic criteria for identifying thyroid nodules include Thyroid Imaging and Reporting Data System (TI-RADS) and American Thyroid Association (ATA) guidelines. The purpose of this systematic review and meta-analysis is to determine the inter-rater reliability of thyroid ultrasound criteria.

METHODS

We performed a library search of MEDLINE (Ovid), EMBASE (Ovid), and Web of Science for full-text articles published from January 2005 to June 2022. We included full-text primary research articles that used TI-RADS and/or ATA guidelines to evaluate thyroid nodules in adults. These included studies must have calculated inter-rater reliability using any validated metric. The Quality Appraisal for Reliability Studies (QAREL) was used to assess study quality. We planned for a random-effects meta-analysis, in addition to covariate and publication bias analyses. This study was performed in accordance with Preferred Reporting Items for a Systematic Review and Meta-analysis guidelines and registered prior to conduction (International prospective register of systematic reviews-PROSPERO: CRD42021275072).

RESULTS

Of the 951 articles identified via the database search, 35 met eligibility criteria. All studies were observational. The most commonly utilized criteria were ACR Thyroid Imaging and Reporting Data System (TI-RADS) and/or ATA criteria, while the majority of studies employed Κ statistics. For ACR TI-RADS, the pooled Κ was 0.51 (95% confidence interval [CI]: 0.42, 0.57; n = 7) while for ATA, the pooled Κ was 0.52 (95% CI: 0.37, 0.67; n = 3). Due to the small number of studies, covariate or publication bias analyses were not performed.

CONCLUSION

Ultrasound criteria demonstrate moderate inter-rater reliability, but these findings are impacted by poor study quality and a lack of standardization. Laryngoscope, 133:485-493, 2023.

Accuracy of Ultrasound Scans as Compared to Fine Needle Aspiration Cytology in the Diagnosis of Thyroid Nodules

INTRODUCTION

Thyroid nodules (TNs) are among the more common findings on physical examinations. Due to the fear of the TN harboring malignancy and with the increasing incidence of thyroid cancer, ultrasound (US) scanning is used as an important diagnostic tool in the assessment of a TN. The American College of Radiology's Thyroid Imaging Reporting and Data System (TI-RADS) was established based on specific patterns composed of two or more features. According to the TI-RADS guidelines, a suspicious nodule by US findings should undergo fine-needle aspiration cytology (FNAC), in which results would guide further management.

OBJECTIVE

This study was carried out to assess the accuracy of US as compared to FNAC in the diagnosis of a thyroid nodule.

METHODOLOGY

This retrospective study involved 213 cases that were sent for FNAC after having done a US scan of the thyroid. Data was gathered from all patient files that were referred for FNAC thyroid between 01/02/2018 and 30/06/2021 in Al-Ahli Hospital in the state of Qatar. The US scans were interpreted and reported according to the TI-RADS criteria. The FNAC samples were interpreted and reported according to the Bethesda System for Reporting Thyroid Cytopathology. Data were tabulated and analyzed with Excel (Microsoft, Redmond, WA, USA) and SPSS version 25 (IBM Corp., Armonk, NY, USA).

RESULTS

The study showed that US had a sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of 73.9%, 72.6%, 24.6% and 95.8%, respectively, with a significant association between the results of US and the results of FNAC (X² (1, n = 213) = 20.295, p < .001) and a significant positive correlation (phi coefficient = .309, p < .001). In addition, the data showed that the odds for having a positive FNAC were 7.519 (95% CI: 2.811, 20.112) times greater for cases with positive US compared with cases with negative US. The relative risk of having a positive FNAC when the US was positive was 5.913 (95% CI: 2.440, 14.332) times greater compared to when the US was negative.

CONCLUSION

While our results showed that US cannot be solely relied on in diagnosing TNs, they did show that US can reliably rule out a malignancy in TNs. Recent studies have been showing increasing accuracy of US in diagnosing TNs and more studies are needed to explore this topic.

Clinical value of molecular markers as diagnostic and prognostic tools to guide treatment of thyroid cancer

OBJECTIVE

Advances in our understanding of the molecular biology of thyroid tumours is being rapidly translated into their clinical management. This review summarizes the current use of molecular testing in thyroid tumours, focusing on their usefulness as diagnostic and prognostic tools to guide treatment with consideration of present limitations.

DESIGN

Considerations about molecular testing applications for the diagnosis and treatment of thyroid tumours are divided into four sections/roles: (1) evaluating cytologically indeterminate thyroid nodules; (2) guiding extent of surgery in indeterminate thyroid nodules; (3) completing histological characterization of thyroid tumours and (4) identifying actionable mutations in advanced progressive thyroid cancers.

RESULTS

Genomic testing can improve the presurgical malignancy risk assessment in indeterminate thyroid nodules. However, a prior in-depth analysis of institutional quality and outcomes of sonographical, cytological and histological characterization of thyroid tumours is necessary. Presently, it remains uncertain whether knowing the molecular profile of a cytologically indeterminate thyroid nodule might be advantageous to modify the extent of initial surgery. Molecular characterization of thyroid tumours can be a valuable adjunct to morphological diagnosis in some challenging cases, such as in low-risk follicular cell-derived neoplasms, or rare tumours. Finally, as selective kinase inhibitors are available, molecular testing in locally advanced/metastatic progressive thyroid cancers should also be integrated into the institutional clinical management pathway to improve outcomes and limit toxicity.

CONCLUSIONS

Molecular testing needs to be implemented into the local evidence-based clinical management thyroid nodule/cancer pathways to improve its diagnostic and prognostic value and to optimize cost-effectiveness.

The impact of the ultrasound classification on the rate of thyroid surgery indications: a 577 cases series

OBJECTIVES

Nodules of the thyroid gland are common but rarely malignant. Their management can range from simple monitoring to surgery. The use of ultrasound and fine needle aspiration can reduce the rate of unnecessary surgeries. However, there is a risk of false positives and false negatives of malignancy that only pathology can avoid. The objective of this study is to assess the impact of ultrasound classification on the rate of surgical indications.

MATERIAL AND METHODS

Between 2013 and 2017, the ultrasound classification was gradually adopted in our daily practice to become now routine. During this period, we conducted a retrospective study of all the patients who presented to our department for one or more thyroid nodules.

RESULTS

A total of 577 patients were included in the study. We compared two groups, a first where the ultrasound classification was used and a second where this classification was not used. In the end, we found that this classification significantly reduced the surgical indication by 19% while increasing the malignancy detection rate in operated patients by 21%.

CONCLUSIONS

The use of ultrasound classification reduces the indications for surgery while increasing the rate of malignancy in operated patients. The generalization of the use of the ultrasound classification score is strongly recommended in daily practice.

The impact of thyroid imaging reporting and data system on the management of Bethesda III thyroid nodules

Objectives

Atypia of undetermined significance (AUS) or follicular lesion of undetermined significance (FLUS) is a heterogeneous category of fine needle aspiration cytology (FNAC); the management of this condition remains controversial. The clinical significance of such patients relies on the exclusion of malignancy. In this study, we aimed to determine the validity of the American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS) (2017) for predicting malignancy in this specific category of patients.

Methods

In this study, we analysed a cohort of patients from our previous retrospective study. This four-year retrospective cohort study included all cases undergoing surgery with a cytological diagnosis of AUS/FLUS. We enrolled 110 cases with documented final histopathological diagnoses and ultrasound examinations.

Results

The study included 83 females (75.5%) and 27 males (24.5%). The overall risk of malignancy (ROM) for AUS/FLUS thyroid nodules was 47.3%. The ROMs of TI-RADS 3 (TR3), TI-RADS 4 (TR4), and TI-RADS 5 (TR5) were 43.5%, 49.4% and 40%, respectively. There was no significant association between TI-RADS and final pathological analysis.

Conclusions

Repeated FNAC with initial AUS/FLUS nodules is crucial. Our findings showed that ACR TI-RADS did not contribute to the cancer risk stratification of AUS/FLUS nodules. A large prospective multi-institutional study is now required to determine the validity of ACR TI-RADS and whether other adjunct clinical, cytological, molecular, or biochemical tools could facilitate the management of patients with these heterogeneous nodules.

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

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

Ultrasound performance using the EU-TIRADS score in the diagnosis of thyroid cancer in Congolese hospitals

The thyroid imaging reporting and data systems by the European Thyroid Association (EU-TIRADS) has been widely used in malignancy risk stratification of thyroid nodules. However, there is a paucity of data in developing countries, especially in Africa, to validate the use of this scoring system. The aim of the study was to assess the diagnostic value of the EU-TIRADS score in Congolese hospitals, using pathological examination after surgery as the gold standard in Congolese hospitals. This retrospective and analytical study examined clinical, ultrasound and pathological data of 549 patients aged 45 ± 14 years, including 468 females (85.2%), operated for thyroid nodule between January 2005 and January 2019. In the present study, only the highest graded nodule according to the EU-TIRADS score in each patient was taken into account for the statistical analyses. So 549 nodules were considered. Nodules classified EU-TIRADS 2 and 3 on the one hand, and, on the other hand, 4 and 5, were considered respectively at low and high risk of malignancy. The sensitivity and specificity of the EU-TIRADS score were calculated. The significance level was set at 5%. Of all patients, 21.7% had malignant nodules. They made 48.4% of the nodules in patients younger than and at 20 years old, and 31.1% in those aged 60 or over. Malignant nodules were more frequent in men than in women (30.9% vs. 20.1%; p = 0.024). Papillary carcinoma (67.2%) and follicular carcinoma (21.8%) were the main types. The malignancy rate was 39.7% and 1.5% among nodules rated EU-TIRADS 4 and 5, and those with EU-TIRADS score 2 and 3, respectively (p < 0.001). The EU-TIRADS score had a sensitivity of 96.6% and a specificity of 59.3%. The ROC curve indicated an area under the curve of 0.862. In a low-income country, a well performed thyroid ultrasound, using the EU-TIRADS score, could be an important tool in the selection of thyroid nodules suspected of malignancy and requiring histopathological examination in the Congolese hospital setting.Trial registration: The research protocol had obtained the favorable opinion of the DRC national health ethics committee no. 197/CNES/BN/PMMF/2020. The data was collected and analyzed anonymously.

Preoperative BRAFV600E mutation detection in thyroid carcinoma by immunocytochemistry

The BRAF^V600E (BRAF) mutation is present in 40-50% of papillary thyroid carcinomas (PTC) and has been associated with more aggressive clinicopathological characteristics of PTC. The aim of this study was to evaluate different methods for preoperative identification of the BRAF mutation in PTC using cytological and histological specimens. Prospectively collected preoperative cytological clots from patients with suspected PTC were tested with BRAF immunocytochemistry (ICC) and the Cobas Test (PCR). In addition, histological specimens were tested with BRAF immunohistochemistry (IHC) and the Cobas Test. All nodules were histologically examined. Fifty-three patients were included in the study. Complete mutation testing was available in 32 patients. The main reason for exclusion was insufficient cell content in the cytological specimen. Twenty-seven nodules were histologically diagnosed as PTC, and 41% (n = 11) of PTCs were BRAF ICC positive. All non-PTC nodules were negative by BRAF ICC. In 26 nodules, all four BRAF tests were concordant, while discordant test results were found in six nodules. ICC was in accordance with the consensus BRAF status in five of these nodules, while BRAF status was undetermined in one nodule. BRAF ICC showed high concordance with the Cobas Test and a low rate of false negative stain. These results indicate that BRAF ICC may be a feasible method for preoperative detection of the BRAF^V600E mutation in patients with PTC.

Risk of malignancy in thyroid nodules with indeterminate (THY3f) cytology

BACKGROUND

Fine-needle aspiration cytology (FNAC) is an integral part of thyroid nodule assessment. Nodules with an indeterminate cytology (THY3a-f) require formal histological assessment to confirm benign or malignant pathology. This study aimed to provide data for an evidence-based approach for management of patients with THY3f nodules.

METHODS

Retrospective review of patients who had a thyroid FNAC reported as suspicious of follicular neoplasm (THY3f) or showing atypia (THY3a) were identified, and clinical, operative and outcomes data were analysed.

RESULTS

Between 2018 and 2020, 200 patients (167F:33M, median age 51 years (range:18-86 years)) had a THY3f cytology. Most presented with a palpable nodule (n=104; 68.4%). Overall, 152 (76.0%;130F:23M) underwent surgery and 31 (20.4%) were found to have a thyroid carcinoma (22 follicular carcinomas, 7 papillary carcinomas, 1 medullary thyroid carcinoma and 1 metastatic renal carcinoma). An additional incidental carcinoma (size: 0.7-13mm) was found in seven (4.6%). Among those with cancer, a completion thyroidectomy and radioactive iodine treatment was indicated in nine (<6% of the entire cohort). Previously suggested risk factors for malignancy, eg male gender, large tumour size (>4cm) or age, were not found to be associated with increased risk. During the same period, THY3a cytology was reported in 53 patients, of whom 29 underwent diagnostic surgery and 4 patients were found to have a thyroid cancer (follicular, n=3 and medullary, n=1).

CONCLUSION

One in five patients with features suspicious of a follicular neoplasm (THY3f) has a thyroid carcinoma. This risk is much lower for THY3a. This study reinforces the current recommendation for thyroid surgery in all patients with a reliable THY3f cytology, as no further stratifying risk factors could be identified.

Elastographic Evaluation of Thyroid Nodules in Children and Adolescents with Hashimoto’s Thyroiditis and Nodular Goiter with Reference to Cytological and/or Histopathological Diagnosis

There are data indicating the coexistence of papillary thyroid carcinoma and autoimmune thyroiditis (AIT) in children. The aim of the study was elastographic evaluation of thyroid nodules in children and adolescents with AIT and nodular goiter in relation to cytological and/or histopathological diagnosis. We examined 215 children (57 boys and 158 girls) with 261 thyroid nodules (143 non-AIT and 118 AIT). All study participants underwent a conventional ultrasound examination with elastography followed by fine needle aspiration biopsy (FNAB). Abnormal Strain Ratio (SR ≥ 5) was observed in 36 non-AIT nodules and 15 AIT nodules. Papillary thyroid carcinoma was diagnosed in 5 patients (2% of all investigated nodules). SR of malignant thyroid nodules was statistically higher in comparison to SR of benign nodules both in the group of non-AIT (6 ± 4 vs. 3.67 ± 2.62, p = 0.024) and AIT nodules (6.3 ± 0.01 vs. 2.92 ± 1.89, p = 0.047). Comparison of non-AIT and AIT benign nodules revealed that SR was higher in non-AIT nodules (3.67 ± 2.62 vs. 2.92 ± 1.89, p = 0.01). We observed a strong positive correlation (R = 1) between TSH concentration and SR ratio in the group of all malignant thyroid nodules. Autoimmune inflammatory process of the thyroid gland does not limit the use of elastography in the diagnosis of thyroid nodules in children.

Multiparametric Sonographic Imaging of Thyroid Lesions: Chances of B-Mode, Elastography and CEUS in Relation to Preoperative Histopathology

Simple Summary

As the incidence of thyroid lesions in Europe is rising, more and more people affected by thyroid pathologies seek treatment in a clinic. Every suspicious thyroid nodule needs to be confirmed as benign or malignant in order to be treated correctly. Unnecessary invasive diagnostics and thyroid surgery should be avoided. The aim of this retrospective study was to improve the distinction between benign and malignant nodules by using new high-performance multiparametric ultrasound examination techniques. By analyzing 122 thyroid nodules we created a score-based system combining B-mode, shear-wave elastography and contrast-enhanced ultrasound malignancy criteria. This system allows for a quite accurate detection of thyroid carcinomas with a sensitivity of 95% and specificity of 75.49%. Shear-wave elastography and contrast-enhanced ultrasound can detect unique malignancy features, which cannot be found in B-mode. Therefore, these criteria would present a relevant addition to the B-mode TI-RADS classification.

Abstract

Background: The aim was to improve preoperative diagnostics of solid non-cystic thyroid lesions by using new high-performance multiparametric ultrasound examination techniques. Methods: Multiparametric ultrasound consists of B-mode, shear-wave elastography and contrast enhanced ultrasound (CEUS) including Time-Intensity-Curve (TIC) analysis. A bolus of 1–2.4 mL Sulfur Hexafluorid microbubbles was injected for CEUS. Postoperative histopathology was the diagnostic gold standard. Results: 116 patients were included in this study. 102 benign thyroid nodules were diagnosed as well as 20 carcinomas. Suspicious B-mode findings like microcalcifications, a blurry edge and no homogeneous sonomorphological structure were detected in 60, 75 and 80% of all carcinomas but only in 13.7, 36.3 and 46.1% of all benign lesions. The average shear-wave elastography measurements of malignant lesions (4.6 m/s or 69.8 kPa centrally and 4.2 m/s or 60.1 kPa marginally) exceed the values of benign nodules. Suspicious CEUS findings like a not-homogeneous wash-in and a wash-out were detected almost twice as often in carcinomas. Conclusion: Multiparametric ultrasound offers new possibilities for the preoperative distinction between benign and malignant thyroid nodules. A score based system of B-mode, shear-wave and CEUS malignancy criteria shows promising results in the detection of thyroid carcinomas. It reaches a sensitivity of 95% and specificity of 75.49%.

The reliability of TIRADS classification in predicting thyroid malignancy based on ultrasound findings in Mosul city

Introduction and Aim: Ultrasound of the thyroid gland is a routine procedure. Nodules are the most common disorders seen and analyzed by ultrasound. The study purpose was to show how accurate ultrasonography was at identifying benign from malignant nodules using (Thyroid Imaging Reporting and Data System TIRADS) categories. High-frequency ultrasonography scanning of the neck and thyroid glands offers useful information and anatomical images.  Materials and Methods: This study involved 495 patients who were subjected to a thyroid ultrasound imaging from December 2019 to December 2020. The ultrasound and evaluation was performed by a professional Radiologist by means of a transducer with linear-array (between 5 - 12 MHz) (DC-30, Shenzhen Mindray Bio-Medical Electronics Co., Ltd). Nodules detected were evaluated for composition, echogenicity, boundary, shape and echogenic foci. Each attribute was recorded using the standardized scoring system provided by the ACR Thyroid Imaging Reporting and Data System (ACR TI-RADS). The scores obtained, were used in classifying the nodules as TI-RADS 1, 2, 3, 4a, 4b, and 5 to define risk levels of malignant nodule.  Results: TIRADS approach was used to assess the thyroid ultrasound data obtained and the nodules categorized created on ultrasound features such as irregular edges, shape, tall rather wide, hypo echogenic, calcified, and vascular. The TIRAD 3 category was the most common accounting for about 251 cases (52.73 percent of the calculated diagnostic results, which included specificity (50%), sensitivity (96.59%), positive (97.21%) and negative (55.17%) predictive values. The study revealed 26 (4.25%) of the nodules to be cancerous. Conclusion: Since the TIRADS system of categorization is a good technique for predicting malignancies in thyroid nodules, we employ ultrasound as the first diagnostic tool for efficiently finding and classifying thyroid nodules.

DIAGNOSIS OF ENDOCRINE DISEASE: Usefulness of genetic testing of fine-needle aspirations for diagnosis of thyroid cancer

OBJECTIVE

Genetic testing is increasingly used to diagnose or rule out thyroid cancer in indeterminate fine-needle aspirations. This review evaluates the usefulness of these methods with considerations of advantages and limitations.

DESIGN

Given the diagnostic problem associated with the increasing incidental detection of indeterminate thyroid nodules in the context of thyroid cancer overtreatment, we consider the conditions and respective necessary settings for the role of genetic testing to improve presurgical malignancy risk stratification.

METHODS

We review diagnostic pathway requirements and commercially available molecular tests with their respective advantages and disadvantages and discuss the prerequisites required for local application and implementation including quality assurance for local ultrasound and cytopathology practices.

RESULTS

Recent improvements in available molecular diagnostic tests have brought high sensitivity and specificity in initial validation studies, but whether these promising results translate to other clinical settings depends on the quality of the local thyroid nodule diagnostic pathway.

CONCLUSIONS

Genetic testing can meaningfully improve presurgical malignancy risk assessment, but more work is needed to implement and use genetic testing effectively in local settings.

The European Institute of Oncology Thyroid Imaging Reporting and Data System for Classification of Thyroid Nodules: A Prospective Study

Background: To evaluate the performance, quality and effectiveness of “IEO-TIRADS” in assigning a TI-RADS score to thyroid nodules (TN) when compared with “EU-TIRADS” and the US risk score calculated with the S-Detect software (“S-Detect”). The primary objective is the evaluation of diagnostic accuracy (DA) by “IEO-TIRADS”, “S-Detect” and “EU-TIRADS”, and the secondary objective is to evaluate the diagnostic performances of the scores, using the histological report as the gold standard. Methods: A radiologist collected all three scores of the TNs detected and determined the risk of malignancy. The results of all the scores were compared with the histological specimens. The sensitivity (SE), specificity (SP), and diagnostic accuracy (DA), with their 95% confidence interval (95% CI), were calculated for each method. Results: 140 TNs were observed in 93 patients and classified according to all three scores. “IEO-TIRADS” has an SE of 73.6%, an SP of 59.2% and a DA of 68.6%. “EU-TIRADS” has an SE of 90.1%, an SP of 32.7% and a DA of 70.0%. “S-Detect” has an SE of 67.0%, an SP of 69.4% and a DA of 67.9%. Conclusion: “IEO-TIRADS” has a similar diagnostic performance to “S-Detect” and “EU-TIRADS”. Providing a comparable DA with other reporting systems, IEO-TIRADS holds the potential of being applied in clinical practice.

A Local and Global Feature Disentangled Network: Toward Classification of Benign-Malignant Thyroid Nodules From Ultrasound Image

Thyroid nodules are one of the most common nodular lesions. The incidence of thyroid cancer has increased rapidly in the past three decades and is one of the cancers with the highest incidence. As a non-invasive imaging modality, ultrasonography can identify benign and malignant thyroid nodules, and it can be used for large-scale screening. In this study, inspired by the domain knowledge of sonographers when diagnosing ultrasound images, a local and global feature disentangled network (LoGo-Net) is proposed to classify benign and malignant thyroid nodules. This model imitates the dual-pathway structure of human vision and establishes a new feature extraction method to improve the recognition performance of nodules. We use the tissue-anatomy disentangled (TAD) block to connect the dual pathways, which decouples the cues of local and global features based on the self-attention mechanism. To verify the effectiveness of the model, we constructed a large-scale dataset and conducted extensive experiments. The results show that our method achieves an accuracy of 89.33%, which has the potential to be used in the clinical practice of doctors, including early cancer screening procedures in remote or resource-poor areas.

Clinical diagnostic value of American College of Radiology thyroid imaging report and data system in different kinds of thyroid nodules

BACKGROUND

To evaluate the diagnostic value of American College of Radiology (ACR) score and ACR Thyroid Imaging Report and Data System (TI-RADS) for benign nodules, medullary thyroid carcinoma (MTC) and papillary thyroid carcinoma (PTC) through comparing with Kwak TI-RADS.

METHODS

Five hundred nine patients diagnosed with PTC, MTC or benign thyroid nodules were included and classified into the benign thyroid nodules group (n = 264), the PTC group (n = 189) and the MTC group (n = 56). The area under the curve (AUC) values were analyzed and the receiver operator characteristic (ROC) curves were drawn to compare the diagnostic efficiencies of ACR score, ACR TI-RADS and KWAK TI-RADS on benign thyroid nodules, MTC and PTC.

RESULTS

The AUC values of ACR score, ACR TI-RADS and Kwak TI-RADS for distinguishing malignant nodules from benign nodules were 0.914 (95%CI: 0.886-0.937), 0.871 (95%CI: 0.839-0.899) and 0.885 (95%CI: 0.854-0.911), respectively. In distinguishing of patients with MTC from PTC, the AUC values of ACR score, ACR TI-RADS and Kwak TI-RADS were 0.650 (95%CI: 0.565-0.734), 0.596 (95%CI: 0.527-0.664), and 0.613 (95%CI: 0.545-0.681), respectively. The AUC values of ACR score, ACR TI-RADS and Kwak TI-RADS for the discrimination of patients with MTC, PTC or benign nodules from patients without MTC, PTC or benign nodules were 0.899 (95%CI: 0.882-0.915), 0.865 (95%CI: 0.846-0.885), and 0.873 (95%CI: 0.854-0.893), respectively.

CONCLUSION

The ACR score performed the best, followed ex aequo by the ACR and Kwak TI-RADS in discriminating patients with malignant nodules from benign nodules and patients with MTC from PTC.

Suspected Malignant Thyroid Nodules in Children and Adolescents According to Ultrasound Elastography and Ultrasound-Based Risk Stratification Systems-Experience from One Center

The risk of malignancy in thyroid nodules correlates with the presence of ultrasonographic features. In adults, ultrasound risk-classification systems have been proposed to indicate the need for further invasive diagnosis. Furthermore, elastography has been shown to support differential diagnosis of thyroid nodules. The purpose of our study was to assess the application of the American Thyroid Association (ATA), British Thyroid Association (BTA) ultrasound risk-classification systems and strain elastography in the management of thyroid nodules in children and adolescents from one center. Seventeen nodules with Bethesda III, IV, V and VI were selected from 165 focal lesions in children. All patients underwent ultrasonography and elastography followed by fine needle aspiration biopsy. Ultrasonographic features according to the ATA and BTA stratification systems were assessed retrospectively. The strain ratio in the group of thyroid nodules diagnosed as malignant was significantly higher than in benign nodules (6.07 vs. 3.09, p = 0.036). According to the ATA guidelines, 100% of malignant nodules were classified as high suspicion and 73% of benign nodules were assessed as low suspicion. Using the BTA U-score classification, 80% of malignant nodules were classified as cancerous (U5) and 20% as suspicious for malignancy (U4). Among benign nodules, 82% were classified as indeterminate or equivocal (U3) and 9% as benign (U2). Our results suggest that application of the ATA or BTA stratification system and elastography may be a suitable method for assessing the level of suspected malignancy in thyroid nodules in children and help make a clinical decision about the need for further invasive diagnosis of thyroid nodules in children.

External validation of AIBx, an artificial intelligence model for risk stratification, in thyroid nodules

BACKGROUND

Artificial intelligence algorithms could be used to risk-stratify thyroid nodules and may reduce the subjectivity of ultrasonography. One such algorithm is AIBx which has shown good performance. However, external validation is crucial prior to clinical implementation.

MATERIALS AND METHODS

Patients harboring thyroid nodules 1-4 cm in size, undergoing thyroid surgery from 2014 to 2016 in a single institution, were included. A histological diagnosis was obtained in all cases. Medullary thyroid cancer, metastasis from other cancers, thyroid lymphomas, and purely cystic nodules were excluded. Retrospectively, transverse ultrasound images of the nodules were analyzed by AIBx, and the results were compared with histopathology and Thyroid Imaging Reporting and Data System (TIRADS), calculated by experienced physicians.

RESULTS

Out of 329 patients, 257 nodules from 209 individuals met the eligibility criteria. Fifty-one nodules (20%) were malignant. AIBx had a negative predictive value (NPV) of 89.2%. Sensitivity, specificity, and positive predictive values (PPV) were 78.4, 44.2, and 25.8%, respectively. Considering both TIRADS 4 and TIRADS 5 nodules as malignant lesions resulted in an NPV of 93.0%, while PPV and specificity were only 22.4 and 19.4%, respectively. By combining AIBx with TIRADS, no malignant nodules were overlooked.

CONCLUSION

When applied to ultrasound images obtained in a different setting than used for training, AIBx had comparable NPVs to TIRADS. AIBx performed even better when combined with TIRADS, thus reducing false negative assessments. These data support the concept of AIBx for thyroid nodules, and this tool may help less experienced operators by reducing the subjectivity inherent to thyroid ultrasound interpretation.

Non-Marked Hypoechogenic Nodules: Multicenter Study on the Thyroid Malignancy Risk Stratification and Accuracy Based on TIRADS Systems Comparison

Background and Objectives: The aim of the study was to evaluate the predictive value of the ultrasound criterion “non-marked hypoechogenicity” for malignancy and to determine whether classification of these nodules as TIRADS 3 could improve the overall accuracy of consequently adjusted M-TIRADS score. Materials and Methods: A total of 767 patients with 795 thyroid nodules were subject to ultrasonography examination and ultrasound-guided fine needle aspiration biopsy. Nodules were classified by Kwak TIRADS and modified (M-TIRADS) categories 4A, 4B, and 5 according to number of suspicious US features (marked hypoechogenicity, microlobulated or irregular margins, microcalcifications, taller-than-wide shape, metastatic lymph nodes). Non-marked hypoechoic nodules were classified as TIRADS 3. Results: Thyroid nodules were classified as TIRADS 2, 3, 4A, 4B, and 5 in 14.5, 57.5, 14.2, 8.1, and 5.7%, respectively. Only histopathologic results (125 nodules underwent surgery) and highly specific cytology results (Bethesda II, VI) were accepted as a standard of reference, forming a sub-cohort of 562/795 nodules (70.7%). Malignancy was found in 7.7%. Overall, M-TIRADS showed sensitivity/specificity of 93.02/81.31%, and for PPV/NPV, these were 29.2/99.29%, respectively (OR—18.62). Irregular margins showed the highest sensitivity and specificity (75.68/93.74%, respectively). In TIRADS 3 category, 37.2% nodules were isoechoic, 6.6% hyperechoic, and 52.2% hypoechoic (there was no difference of malignancy risk in hypoechoic nodules between M-TIRADS and Kwak systems—0.9 vs. 0.8, respectively). Accuracy of M-TIRADS classification in this cohort was 78.26% vs. 48.11% for Kwak. Conclusions: The non-marked hypoechoic nodule pattern correlated with low risk of malignancy; classification of these nodules as TIRADS 3 significantly improved the predictive value and overall accuracy of the proposed M-TIRADS scoring with malignancy risk increase in TIRADS 4 categories by 20%; and no significant alteration of malignancy risk in TIRADS 3 could contribute to reducing overdiagnosis, obviating the need for FNA.

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.

Comparison of thyroid nodule FNA rates recommended by ACR TI-RADS, Kwak TI-RADS and ATA guidelines

OBJECTIVES

To compare the differences among the thyroid imaging reporting and data system (TI-RADS) proposed by American College of Radiology (ACR TI-RADS), TI-RADS proposed by Kwak (Kwak TI-RADS), and American Thyroid Association (ATA) guidelines in the specificity, sensitivity and the unnecessary FNA rate (the UFR, the false positive rate) of recommended fine needle aspiration (FNA), and to observe the changes of the UFR in the KwakTI-RADS and ATA guidelines with the recommended FNA nodule size threshold.

METHODS

The specificities, sensitivities and UFRs of recommended FNA in the ACR TI-RADS, ATA guidelines and Kwak TI-RADS were calculated and compared. The nodule sizes for recommended FNA of ATA guidelines and Kwak TI-RADS were systematically varied to establish new FNA thresholds. The specificities, sensitivities and UFRs of recommended FNA under the new models were calculated and compared to those in the ACR TI-RADS.

RESULTS

For all thyroid nodules, the UFRs in the ACR TI-RADS, ATA guidelines and Kwak TI-RADS were 26.3%, 47.4% and 40.0%, respectively. The UFR in the ACR TI-RADS was lower than that in the others, and the specificity of recommended FNA in the ACR TI-RADS(73.7%) was higher than that in the others (all P < 0.001), but the sensitivity of recommended FNA in the ACR TI-RADS(89.3%) was lower than that in the others (all P < 0.001). When nodule sizes threshold of the recommended FNA for ATA guidelines Intermediate Suspicion, Low Suspicion, and Very Low Suspicion, and Kwak TI-RADS grade 4b and 4a were gradually increased, the UFRs gradually decreased.

CONCLUSIONS

The UFRs of FNA recommended by the Kwak TI-RADS and ATA guidelines were higher than that of the ACR TI-RADS, and were affected by the recommended FNA nodule size threshold.

Ambiguous and Incomplete: Natural Language Processing Reveals Problematic Reporting Styles in Thyroid Ultrasound Reports

OBJECTIVE

 Natural language processing (NLP) systems convert unstructured text into analyzable data. Here, we describe the performance measures of NLP to capture granular details on nodules from thyroid ultrasound (US) reports and reveal critical issues with reporting language.

METHODS

 We iteratively developed NLP tools using clinical Text Analysis and Knowledge Extraction System (cTAKES) and thyroid US reports from 2007 to 2013. We incorporated nine nodule features for NLP extraction. Next, we evaluated the precision, recall, and accuracy of our NLP tools using a separate set of US reports from an academic medical center (A) and a regional health care system (B) during the same period. Two physicians manually annotated each test-set report. A third physician then adjudicated discrepancies. The adjudicated "gold standard" was then used to evaluate NLP performance on the test-set.

RESULTS

 A total of 243 thyroid US reports contained 6,405 data elements. Inter-annotator agreement for all elements was 91.3%. Compared with the gold standard, overall recall of the NLP tool was 90%. NLP recall for thyroid lobe or isthmus characteristics was: laterality 96% and size 95%. NLP accuracy for nodule characteristics was: laterality 92%, size 92%, calcifications 76%, vascularity 65%, echogenicity 62%, contents 76%, and borders 40%. NLP recall for presence or absence of lymphadenopathy was 61%. Reporting style accounted for 18% errors. For example, the word "heterogeneous" interchangeably referred to nodule contents or echogenicity. While nodule dimensions and laterality were often described, US reports only described contents, echogenicity, vascularity, calcifications, borders, and lymphadenopathy, 46, 41, 17, 15, 9, and 41% of the time, respectively. Most nodule characteristics were equally likely to be described at hospital A compared with hospital B.

CONCLUSIONS

 NLP can automate extraction of critical information from thyroid US reports. However, ambiguous and incomplete reporting language hinders performance of NLP systems regardless of institutional setting. Standardized or synoptic thyroid US reports could improve NLP performance.

Conventional ultrasound, color Doppler, TI-RADS, and shear wave elastography for thyroid nodule differentiation: a study of efficacy compared with the histopathology results

Background

Although a minority of the thyroid nodules is malignant, usually the invasive diagnostic procedures are warranted. This prospective study aims to assess the diagnostic performance of the US criteria in addition to the TI-RADS score and the SWE for the differentiation between the benign and malignant thyroid nodules as a potential surrogate for the invasive procedures.

Results

Ninety-nine patients with thyroid nodules (79 females and 20 males, with a mean age of 45.9 ± 7.7 years; 30–69 years) were enrolled in this study and underwent conventional ultrasound, color Doppler, TI-RADS scoring, and shear wave elastography (SWE); the findings were correlated to the histopathological results.

Our results revealed a significant increase in SWE elasticity indices (EIs) and presence of color Doppler signals in malignant nodules as compared with the benign ones (ρ < 0.05). Combined TI-RADS and SWE as well as TI-RADS and color Doppler imaging had given a better sensitivity for detection of malignancy.

Conclusion

Elasticity indices had shown a significantly high diagnostic performance that is almost approaching the histopathological results. Combined SWE, color Doppler and TI-RADS, as a sum of findings, could effectively differentiate between benign and malignant thyroid nodules. Furthermore, it had offered a non-invasive tool for accurate risk stratification of malignant nodules.

Analysis of vascularization in thyroid gland nodes with superb microvascular imaging (SMI) and CD34 expression histology: a pilot study

Background

The Doppler sonography technique known as "superb microvascular imaging" (SMI) is advancing sonographic micro vascularization imaging in various disciplines. In this study, we aimed to determine whether SMI could reliably reproduce the blood flow in thyroid nodes and whether malignancy could be diagnosed, based on vascularization properties. Immunhistochemical staining by CD34 and SMI where used to determine the vascularization of nodes in terms of quantified vascularization parameters gained by computational evaluation.

Methods

We used image analysis programs to investigate whether the quantitative value for vascularization strength in the thyroid node, measured with SMI, was correlated with the actual degree of vascularization, determined microscopically. We included 16 patients that underwent thyroid resections. We prepared thyroid gland tissue slices for immunohistochemistry and labelled endothelial cells with CD34 to visualize blood vessels microscopically. We used image analysis programs, ImageJ, to quantify SMI Doppler sonographic measurements and CellProfiler to quantify CD34 expression in histological sections. We evaluated the numeric values for diagnostic value in node differentiation. Furthermore, we compared these values to check for correlations.

Results

Among the 16 nodes studied, three harboured malignant tumours (18.75%): two papillary and one follicular carcinoma. Among the 13 benign lesions (81.25%), four harboured follicular adenomas. Malignant and benign nodes were not significantly different in sonographic (0.88 ± 0.89 vs. 1.13 ± 0.19; p = 0.2790) or immunohistochemical measurements of vascularization strength (0.05 ± 0.05 vs. 0.08 ± 0.06; p = 0.2260).

Conclusion

We found a positive, significant correlation (r = 0.55588; p = 0.0254) between SMI (quantitative values for vascularization strength) and immunohistochemistry (CD34 staining) evaluations of thyroid nodes.

Evaluation of thyroid nodules by shear wave elastography: a review of current knowledge

PURPOSE

Shear wave elastography (SWE), as a tool for diagnosing thyroid malignancy, has gathered considerable attention during the past decade. Diverging results exist regarding the diagnostic performance of thyroid SWE.

METHODS

A comprehensive literature review of thyroid SWE was conducted using the terms "Thyroid" and "shear wave elastography" in PubMed.

RESULTS

The majority of studies found SWE promising for differentiating malignant and benign thyroid nodules on a group level, whereas results are less convincing on the individual level due to huge overlap in elasticity indices. Further, there is lack of consensus on the optimum outcome reflecting nodule elasticity and the cut-off point predicting thyroid malignancy. While heterogeneity between studies hinders a clinically meaningful meta-analysis, the results are discussed in a clinical perspective with regard to applicability in clinical practice as well as methodological advantages and pitfalls of this technology.

CONCLUSION

Technological as well as biological hindrances seem to exist for SWE to be clinically reliable in assessing benign and malignant thyroid nodules. Structural heterogeneity of thyroid nodules in combination with operator-dependent factors such as pre-compression and selection of scanning plane are likely explanations for these findings. Standardization and consensus on the SWE acquisition process applied in future studies are needed for SWE to be considered a clinically reliable diagnostic tool for detection of thyroid cancer.

Macrocalcifications Do Not Alter Malignancy Risk Within the American Thyroid Association Sonographic Pattern System When Present in Non-High Suspicion Thyroid Nodules

Background: The American Thyroid Association Sonographic Pattern System (ATASPS) depicts five levels of suspicion for malignancy based on the sonographic appearance of a thyroid nodule. However, 3-37% of nodules are non-classifiable when the combination of grayscale findings is not depicted by the ATASPS. The only calcifications included in the ATASPS are in solid hypoechoic high suspicion (HS) nodules and include both microcalcifications and peripheral interrupted calcifications with soft tissue extrusion. Non-hypoechoic nodules with these and other calcification patterns, which we defined as non-high suspicion calcifications (NHSC), are not classifiable by ATASPS. We assessed the effect of assigning an ATASPS risk level to nodules with NHSC based on analysis of their other grayscale features. Methods: A retrospective review of 728 consecutively biopsied nodules was performed. Nodules were classified by ATASPS as HS, intermediate suspicion (IS), low suspicion (LS), or very low suspicion (VLS); other nodules with patterns not described by ATASPS were non-classifiable (NC). If NC was due to NHSC, the nodule was assigned an ATASPS by analysis of grayscale features alone. Cytology and pathology results were correlated with assigned ATASPS level. Results: A NC pattern was observed in 144 of the 728 nodules (20%). Of these, 101/144 (70%) had NHSC and the assigned ATASPS was IS (n = 18), LS (n = 62) and VLS (n = 21). The distribution of cytology diagnoses within this group was similar to classifiable nodules (IS p = 0.13, LS p = 0.55, VLS p = 0.44). The majority of NHSC (n = 92, 91%) were macrocalcifications (large central or linear dystrophic calcifications); however, 9 LS pattern nodules had punctate echogenic foci, possibly representing microcalcifcations, with an estimated cancer prevalence of 19% (vs. 10% for total LS group, p = 0.24). The remaining NC nodules (43/144, 30%) included solid nodules with heterogeneous echogenicity (n = 30) or presence of a complete circumferential rim calcification, limiting further sonographic assessment (n = 13). Malignancy was identified in 11 out of 43 (26%) of these [9/30 (30%) heterogeneous solid and 2/13 (15%) with complete rim calcifications]. Conclusions: Macrocalcifications accounted for the majority of NHSC and these did not alter the expected ATASPS malignancy risk based on grayscale features.

Characteristics of different histological subtypes of thyroid nodules classified with 99mTc-methoxy-isobutyl-isonitrile imaging and Thyroid Imaging Reporting And Data System

INTRODUCTION

Thyroid Imaging Reporting And Data System (TIRADS) is helpful for risk stratification of thyroid nodules. However, there is a lack of data for TIRADS classification of different histological subtypes [classical papillary thyroid cancer (PTC), follicular variant of papillary thyroid cancer (FVPTC), and follicular thyroid cancer (FTC)], and benign thyroid nodules (follicular adenoma, oncocytic adenoma, and multinodular goiter (MNG)]. Methoxy-isobutyl-isonitrile (MIBI) imaging has a high negative predictive value for the exclusion of thyroid malignancy in hypofunctioning thyroid nodules. The aim of this analysis was to compare malignant and benign subtypes of thyroid nodule using three TIRADS and MIBI imaging.

METHODS

Retrospective analysis of MIBI imaging studies. Hypofunctioning thyroid nodules were classified with Kwak-TIRADS, EU-TIRADS, and K-TIRADS. MIBI imaging was visually categorized.

RESULTS

We included 242 thyroid nodules (32 malignant, 19 PTC, 7 FVPTC, and 6 FTC). When using Kwak-TIRADS 4C and 5 as a marker for high-risk nodules, we found 85.5% of the follicular adenoma, 80.8% of the MNG, 100% of the oncocytic adenoma, 100% of the FTC, 57.1% of the FVPTC, and 42.2% of the PTC to be below this cutoff. All PTC and FVPTC were MIBI-positive, 83% of the FTC, 78% of the follicular adenoma, 75% of the oncocytic adenoma, and 60% of the MNG were MIBI-positive.

CONCLUSION

TIRADS is useful to detect PTC, but FVPTC and FTC may be missed. MIBI imaging seems to be more suitable to detect FVPTC and FTC. However, neither TIRADS nor MIBI imaging are able to differentiate between follicular adenoma and FTC or FVPTC.

The New Era of TIRADSs to Stratify the Risk of Malignancy of Thyroid Nodules: Strengths, Weaknesses and Pitfalls

Simple Summary

The aim of this review is to provide the reader with a comprehensive overview of thyroid imaging and reporting data systems used for thyroid nodules, so as to understand how nodules are scored with all existing systems. Both ultrasound based risk stratification systems and indications for fine-needle aspirations are described. Systems are compared by analyzing their strengths and weaknesses. Studies show satisfactory sensitivities and specificities for the diagnosis of malignancy for all systems, and none of them have shown a real significant advantage over the others in terms of raw diagnostic value. Interobserver agreement is also very similar for all systems, fairly adequate to robust. Dimensional cut-offs for fine-needle aspiration are quite similar and all RSSs seem to reduce effectively the number of unnecessary FNAs. Merging all existing systems in a common international one is desirable.

Abstract

Since 2009, thyroid imaging reporting and data systems (TI-RADS) have been playing an increasing role in the field of thyroid nodules (TN) imaging. Their common aims are to provide sonologists of varied medical specialties and clinicians with an ultrasound (US) based malignancy risk stratification score and to guide decision making of fine-needle aspiration (FNA). Schematically, all TI-RADSs scores can be classified as either pattern-based or point-based approaches. The main strengths of these systems are their ability (i) to homogenize US TN descriptions among operators, (ii) to facilitate and shorten communication on the malignancy risk of TN between sonologists and clinicians, (iii) to provide quantitative ranges of malignancy risk assessment with high sensitivity and negative predictive values, and (iv) to reduce the number of unnecessary FNAs. Their weaknesses are (i) the remaining inter-observer discrepancies and (ii) their insufficient sensitivity for the diagnosis of follicular cancers and follicular variant of papillary cancers. Most common pitfalls are degenerating shrinking nodules and confusion between individual and coalescent nodules. The benefits of all TI-RADSs far outweigh their shortcomings, explaining their rising use, but the necessity to improve and merge the different existing systems remains.

Ultrasonography and Fine-Needle Aspiration in Indeterminate Thyroid Nodules: A Systematic Review of Diagnostic Test Accuracy

OBJECTIVES/HYPOTHESIS

Sonographic risk criteria may assist in further prognostication of indeterminate thyroid nodules (ITNs). Our aim was to determine whether sonographic criteria could further delineate the post-test probability of malignancy in ITNs.

STUDY DESIGN

Meta-analysis of diagnostic test accuracy.

METHODS

A systematic review of Web of Science, MEDLINE, EMBASE, and CINAHL was performed from inception to April 15, 2021. Eligible studies included those which reported ultrasonographic evaluations with the American Thyroid Association (ATA) or the Thyroid Imaging Reporting and Data System (TIRADS) in adult patients with ITNs. ATA or TIRADS were scored as low (negative) or high (positive) malignancy risk using a previously validated binary classification. Primary outcomes included pooled sensitivity, specificity, likelihood ratios, and diagnostic odds ratio for all sonographic criteria. Studies were appraised using Quality Assessment of Diagnostic Accuracy Studies and the data were pooled using bivariate random-effects models.

RESULTS

Seventeen studies were included in the analysis. For Bethesda III, ATA had a specificity (0.90, 95% confidence interval (CI): 0.74-0.94), but a sensitivity of 0.52 (95% CI: 0.25-0.77). Conversely, K-TIRADS had the highest sensitivity (0.78, 95% CI: 0.62-0.89) with a specificity of 0.53 (95% CI: 0.31-0.74). Furthermore, American College of Radiology and EU TIRADS had specificities of 0.60 (95% CI: 0.36-0.80) and 0.81 (95% CI: 0.73-0.87) with sensitivities of 0.70 (95% CI: 0.37-0.90) and 0.38 (95% CI: 0.20-0.60), respectively. There were few studies with Bethesda IV nodules.

CONCLUSIONS

Though dependent on malignancy rates, Bethesda III nodules with low-suspicion TIRADS features may benefit from clinical observation, whereas nodules with high-suspicion ATA features may require molecular testing and/or surgery.

LEVEL OF EVIDENCE

NA Laryngoscope, 2021.

Role of elastography strain ratio and TIRADS score in predicting malignant thyroid nodule

OBJECTIVE

Ultrasonography (US) is the most accurate and cost-effective imaging method in diagnosis of thyroid nodules. A practical thyroid imaging reporting and data system (TIRADS) for thyroid nodules has been proposed to classify nodules of the thyroid gland to solve the problem of nodule selection for fine needle aspiration cytology (FNAC). Real-time elastography and strain ratio (SR) is a method used to assess the stiffness and predict the malignancy of thyroid nodules. The objective of this study was to assess the role of elastography and SR and the TIRADS scoring system in discriminating malignant from benign thyroid nodules.

METHODS

From 2015 to 2018 at Cairo University Hospital, a series of 409 patients with thyroid nodules was referred to undergo thyroid ultrasound. Categorization of each nodule according to the TIRADS ranged from 1 to 5. The qualitative elastography score and semiquantitative SR of the nodules were evaluated. Final diagnosis was done by either post-thyroidectomy histopathological examination or US-guided FNAC.

RESULTS

Our study included 409 patients with thyroid nodules. Their mean age was 39 ± 10 SD; 36 were males and 373 were females. There were 22 malignant nodules and 387 benign nodules. There were statistical differences between benign and malignant nodules regarding TIRADS classification, SR, anteroposterior/transverse ratio, degree of echogenicity, border, presence of calcification, and absence of halo sign (P < 0.001). The elastic properties of thyroid nodules proved to be a good discriminator between malignant and benign nodules (P- < 0.001) at a cut off value of > 2.32 with 95.2% sensitivity and 86.5% specificity. For every unit increase in SR, the risk of malignancy increased by nearly 2 times. Patients with irregular borders had nearly 17 times increased risk of malignancy than those with regular borders.

CONCLUSION

Elastography and SR proved to be of high significant value in discriminating benign from malignant nodules, so we recommend adding it to the TIRADS classification.

Validating the 'CUT score' risk stratification tool for indeterminate thyroid nodules using the Bethesda system for reporting thyroid cytopathology

PURPOSE

Managing intermediate thyroid nodules remains challenging. The CUT score is an Italian metanalysis-based cytologic (SIAPEC-IAP) scoring system, designed to assist clinicians. However, it was never evaluated against the Bethesda system for reporting thyroid cytopathology (BSRTC). This study aims to validate its utility for BSRTC III and IV nodules in a non-Italian population.

METHODS

We collected all BSRTC III and IV thyroid nodules with a documented final pathology between 2010 and 2020. We calculated the C + U components of the CUT score using retrospective clinical (C) data collection and reevaluation of preoperative sonography (U) examination. The cytology (T) component which originally referred to the five-tiered SIAPEC-IAP cytologic classification was replaced by the corresponding BSRTC categories. Optimal test performances were calculated using receiver operating characteristic (ROC) curve analysis. Data were analyzed twice with considering of NIFTP as benign and as malignant.

RESULTS

After exclusions, 62 nodules from 61 patients were included (50% BSRTC III, 50% BSRTC IV). Malignant nodules demonstrated a significantly higher C + U score compared with benign in both categories. The C + U cutoff value for BSRTC III was 5.25 (sensitivity and specificity of 69.23% and 66.67%, respectively, AUC = 0.72, p-value = 0.016), and 5.75 for BSRTC IV (sensitivity and specificity of 85.7% and 76.5%, respectively, AUC = 0.84, p-value < 0.001).

CONCLUSION

Our study suggests that the CUT score is applicable for both BSRTC III and IV nodules, and highlights the need for internal validations, since the cutoffs found were higher than previously reported.

Risk-stratification of thyroid nodules examined by 18FDG-PET/CT while ensuring congruity between imaging and histopathological localization

PURPOSE

The risk of malignancy (ROM) in FDG-avid thyroid incidentalomas varies between studies, which may be contributed by discordance between the anatomical localization depicted on ¹⁸FDG-PET/CT and by histopathological examination. The purpose was to ensure anatomical congruity between the index tumour identified by ¹⁸FDG-PET/CT and the histopathological examination, in order to assess the risk of malignancy (ROM) in PET-positive and PET-negative thyroid nodules. Further, preoperative characteristics indicative of thyroid malignancy were identified.

METHODS

Thirty-two patients referred to thyroid surgery were prospectively included. ¹⁸FDG-PET/CT, fine-needle aspiration biopsy and thyroid ultrasonography examination were performed in all participants. The exact anatomical localization of the index nodule was established by histopathological examination to ensure concordance with the ¹⁸FDG-PET/CT finding.

RESULTS

Forty thyroid nodules were included. Malignancy was identified in 10 of 28 PET-positive nodules and in 1 of 12 PET-negative nodules, resulting in a ROM of 36% and 8%, respectively. A Hurtle cell neoplasm was found in 50% of patients with a benign nodule and a PET-positive scan. One PET-negative nodule represented a papillary microcarcinoma. In PET-positive nodules, hypoechogenicity, irregular margins, and pathological lymph nodes on thyroid ultrasonography were characteristics associated with malignancy.

CONCLUSIONS

In this study-ensuring anatomical congruity between PET-findings and the histopathological examination-the risk of malignancy in PET-positive thyroid nodules was 36%. A low ROM was seen in thyroid nodules without suspicious ultrasonographic findings, independent of the ¹⁸FDG-PET/CT result.

TRIAL REGISTRATION NUMBER

NCT02150772 registered 14th of April 2014.

Shear Wave Elastography Combined with Thyroid Imaging Report and Data System for Risk Stratification of Thyroid Nodule Malignant Tumor

Benign and malignant thyroid cancer diagnosis is crucial. Our study intends to evaluate the role of shear wave elastography (SWE) and thyroid imaging report and data system (TI-RADS) in diagnosing the benign and malignant thyroid nodules. 100 thyroid nodules patients were recruited and evaluated by SWE and TI-RADS before fine needle biopsy and/or surgery. The maximum elastic index (Emax), mean elasticity index of thyroid nodules (Emean), minimum elastic index (Emin) and elastic ratio (ER) was measured and compared between different imaging. Ultrasound diagnosis showed solid nodules with significant hypoechoic, unclear boundary, and microcalcification. TI-RADS value was measured based on suspected ultrasound features. Combination of SWE and TI-RADS was performed. Among the 100 nodules, 38 were benign (38.0%), 62 were malignant (62.0%), and malignant nodules had significantly elevated SWE and TI-RADS compared with benign nodules (P < 0.001). The optimal SWE threshold for Emax was 51.95 kPa, with a sensitivity of 81.44% and specificity of 83.19%. There were two methods for combining SWE and TI-RADS. One was sequential detection, with a specificity of 95.80%, positive similarity ratio of 18.16 and PPV of 96.73%; the other was parallel detection method with a sensitivity of 94.85%, negative similarity ratio of 0.07 and PPV of 90.00%. Our results suggest that combination of SWE and TI-RADS might be applied to identify benign and malignant thyroid cancers.

Evaluation of the Diagnostic Performance of EU-TIRADS in Discriminating Benign from Malignant Thyroid Nodules: A Prospective Study in One Referral Center

BACKGROUND

Several thyroid societies have endorsed ultrasound (US) malignancy risk stratification systems for thyroid nodules and the recently released European Thyroid Imaging Reporting and Data System (EU-TIRADS) needs large prospective studies for validation.

OBJECTIVE

The purpose of our study was to evaluate the performance of EU-TIRADS in identifying thyroid nodules for fine-needle aspiration biopsy (FNAB) and its ability to reduce the number of unnecessary biopsies.

METHODS

This was a single-center prospective study. From August 2017 to September 2018, 783 consecutive patients with 1,000 thyroid nodules underwent US examination and US-guided FNAB. A total of 741 patients (median age 50 years; range, 15-87 years; 649 females, 92 males) with 942 nodules (median largest diameter 14 mm; range, 4-96 mm) met the following inclusion criteria: (1) nodules with benign or malignant cytology - categories II and VI of the Bethesda System for Reporting Thyroid Cytopathology (BSRTC); (2) nodules with non-diagnostic and indeterminate cytology (BSRTC I, BSRTC III, and BSRTC IV), or suspicious for malignancy (BSRTC V), if postoperative histology was present; (3) nodules classified as BSRTC I and BSRTC III with a repeat FNAB and conclusive cytology.

RESULTS

Of 942 nodules, 839 (89.1%) were benign and 103 (10.9%) were malignant. Nodules were classified as follows: EU-TIRADS 2 - 4.8%, EU-TIRADS 3 - 37.4%, EU-TIRADS 4 - 25.2%, and EU-TIRADS 5 - 32.6%. The malignancy rate in categories 2 to 5 was 0, 0, 3.8, and 30.6%, respectively. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of EU-TIRADS with a cut-off set at category 5 were 91.3, 74.6, 30.6, 98.6, and 76.4%, respectively. Diagnostic performance other than sensitivity and NPV was superior in nodules ≥10 mm. FNAB number would be reduced by 53.4% if FNAB criteria were strictly applied. When the indication for FNAB was applied as test positivity, the estimated sensitivity, specificity, PPV, and NPV of EU-TIRADS were 69.9, 56.3, 16.4, and 93.8%, respectively.

CONCLUSION

EU-TIRADS provides effective malignancy risk stratification that can guide the selection of thyroid nodules for biopsy. The application of the guidelines criteria for FNAB in the clinical practice might reduce significantly the number of unnecessary FNAB.

The associated factors for spontaneous intranodular hemorrhage of partially cystic thyroid nodules: A retrospective study of 101 thyroid nodules

ABSTRACT

Spontaneous intranodular hemorrhaging in benign partially cystic thyroid nodules was reported to cause neck swelling, difficulty swallowing, and other oppressive symptoms attributed to their growing progressively at high rates. In our study, the risk factors for hemorrhaging in these nodules were investigated.We retrospectively analyzed benign partial cystic thyroid nodules from September 2017 to December 2019, and divided them into 2 groups according to the occurrence of intranodular hemorrhage. Age, gender, follow-up time nodules initial maximum diameter, blood supply, spongiform content, nodules solid components, and internal solid portion were compared between the 2 groups at the first ultrasound examination. Chi-Squared and multivariate analysis were performed to evaluate the association of hemorrhage with clinical and ultrasonographic characteristics. ROC analysis was performed to evaluate the utility of factors in predicting hemorrhage.There were 59 occurrences of intranodular hemorrhage, which were associated with abundant blood supply, spongiform contents, and unsmooth margin of the internal solid portion. After multivariate analysis, abundant blood supply, and spongiform content were independent predictors for hemorrhage. In ROC analysis integrating these predictors, the sensitivity was 62.7% and specificity was 95.2% with the AUC 0.881.Partially cystic thyroid nodules with abundant blood supply, non-smooth margin of the internal solid portion and a spongiform internal content were apt to spontaneous intranodular hemorrhaging, which can be recognized as soon as possible by ultrasound.

Development and validation of a Web-based malignancy risk-stratification system of thyroid nodules

OBJECTIVES

Previous publications on risk-stratification systems for malignant thyroid nodules were based on conventional ultrasound only. We aimed to develop a practical and simplified prediction model for categorizing the malignancy risk of thyroid nodules based on clinical data, biochemical data, conventional ultrasound and real-time elastography.

DESIGN

Retrospective cohort study.

PATIENTS

A total of 2818 patients (1890 female, mean age, 45.5 ± 13.2 years) with 2850 thyroid nodules were retrospectively evaluated between April 2011 and October 2016. 26.8% nodules were malignant.

MEASUREMENTS

We used a randomly divided sample of 80% of the nodules to perform a multivariate logistic regression analysis. Cut-points were determined to create a risk-stratification scoring system. Patients were classified as having low, moderate and high probability of malignancy according to their scores. We validated the models to the remaining 20% of the nodules. The area under the curve (AUC) was used to evaluate the discrimination ability of the systems.

RESULTS

Ten variables were selected as predictors of malignancy. The point-based scoring systems with and without elasticity score achieved similar AUCs of 0.916 (95% confidence interval [CI]: 0.885-0.948) and 0.906 (95% CI: 0.872-0.941) when validated. Malignancy risk was segmented from 0% to 100.0% and was positively associated with an increase in risk scores. We then developed a Web-based risk-stratification system of thyroid nodules (http: thynodscore.com).

CONCLUSION

A simple and reliable Web-based risk-stratification system could be practically used in stratifying the risk of malignancy in thyroid nodules.

Comparison of Multimodal Ultrasound Imaging with Conventional Ultrasound Risk Stratification Systems in Presurgical Risk Stratification of Thyroid Nodules

BACKGROUND

Ultrasonography (US) is an indispensable tool in the management of thyroid nodules, not only for assessing tumor characteristics but also to assign risk of malignancy and guide in management. Various guidelines and US-based risk stratification systems have been proposed for this purpose. This study aims to compare the diagnostic performances of multimodal US-based risk scores (French TIRADS, TMC-RSS) with conventional US-based scoring systems (Korean TIRADS, ACR-TIRADS, ATA risk stratification).

MATERIAL AND METHODS

A total of 168 nodules from 139 patients were studied and categorized in each of the risk stratification systems. Sensitivity, specificity, positive and negative predictive values, and accuracy of each system were computed. ROC curves were plotted and area under curve (AUC) for each scoring system noted.

RESULTS

Thirty five (21%) of the 168 nodules were malignant on final histopathological examination. TMC-RSS fared the best in predicting malignant nodules with a sensitivity of 96.2% and specificity of 88.6%, while the PPV and NPV were 97% and 86.1%, respectively. The AUC for TMC-RSS was 0.924 (95% CI, 0.860-0.988; P < 0.001).

CONCLUSION

Multimodal US-based risk stratification incorporating non-grayscale characteristics in addition to conventional systems like the TMC-RSS improves the diagnostic performance of ultrasound imaging of thyroid nodules.

A Review of the Pathology, Diagnosis and Management of Colloid Goitre

Colloid goitres are a common, benign lesion of the thyroid gland, that involve a diffuse or nodular pattern. An important feature of colloid goitre is the contained colloid material inside and the comet-tail artefacts, which show up on ultrasound. However, some cases of colloid goitre do not show a comet-tail sign and sometimes these artefacts need to be distinguished from microcalcifications in malignant lesions. This review discusses the epidemiology, pathophysiology, clinical manifestations, ultrasound features and management of colloid goitres.