Degenerating Thyroid Nodules: Ultrasound Diagnosis, Clinical Significance, and Management

Thyroid pyocele with systemic sepsis: a rare clinical scenario

A late middle-aged woman presented with a large, painful neck mass, with a history of rapid increase of size since 1 week and associated voice change, dyspnoea and odynophagia. Prior radiological investigation showed a multiloculated cystic mass in the left thyroid lobe. Fine needle aspiration revealed a predominant cluster of neutrophils. Blood investigations showed leucocytosis and high blood glucose levels suggestive of sepsis. The patient underwent surgical drainage of the thyroid abscess with total thyroidectomy which was managed through multidisciplinary teamwork between surgeons, haematologists, endocrinologists and anaesthesiologists. In addition, urine culture and thyroid pus culture both showed Escherichia coli growth suggestive of bacterial sepsis. The patient was treated successfully and made a complete recovery following surgery with normalisation of voice.

Diagnostic significance of clay-like materials aspirated from thyroid nodules

Objective

The simplest way to determine the adequacy of aspirated materials is the on-site gross visual assessment of aspirated materials. However, few studies have examined the gross findings of thyroid aspirates. This study aimed to clarify the diagnostic significance of clay-like material aspirated from thyroid nodules.

Material and Methods

We reviewed 69,848 thyroid nodules that underwent aspiration cytology at Kuma Hospital between January 2007 and August 2021. Among them, 355 (0.5%) nodules with aspirated materials described as clay-like materials were retrospectively examined.

Results

Among 355 nodules, 322 (90.7%) were categorized as cystic fluid or benign. The aspirated materials were mainly composed of non-epithelial components, including colloid or proteinaceous materials, foamy histiocytes, and degenerative red blood cells. In original ultrasound reports, the incidence of intermediate and high suspicion was 11.0%. Malignant cells were observed in 21 nodules (5.9%), one-third of which were papillary thyroid carcinomas. The materials aspirated from papillary and follicular thyroid carcinomas exhibited necrotic carcinoma cells derived from infarcted areas. The overall risk of malignancy was 3.9%. The risk of malignancy in nodules interpreted as highly suspicious on ultrasound examination was 37.5%.

Conclusion

As clay-like materials aspirated from thyroid nodules were considered sufficient specimens, the recognition contributes to avoiding unnecessary second punctures. The presence of clay-like materials was indicative of the colloid and/or blood components of benign cystic lesions, or, more rarely, of infarcted carcinoma. The ultrasound examination results tended to overestimate nodules. We should reaffirm that on-site gross visual assessment of aspirated materials is a fast and reasonably accurate predictor of the on-site adequacy of the samples.

Contrast-enhanced ultrasound improves the potency of fine-needle aspiration in thyroid nodules with high inadequate risk

Background

This study aims to determine the clinical value of contrast enhanced ultrasound (CEUS) for fine-needle aspiration (FNA) of high inadequate risky thyroid nodules.

Methods

During April 2018 and April 2021, consecutive 3748 thyroid nodules underwent FNA were retrospectively analyzed. CEUS guided FNA (CEUS-FNA) was applied in 115 nodules with high inadequate risk in Lingnan Campus. Ten nodules underwent CEUS-FNA presented non-enhancing, and would be further analyzed independently. Other 105 partial or total enhancing nodules were included as CEUS-FNA group, and 210 nodules with high inadequate risk in Tianhe Campus were match as the US-FNA control group. FNA specimens were collected for liquid-based preparation. Cytological results were classified following the Bethesda System for Reporting Thyroid Cytopathology.

Results

The overall FNA specimen inadequate rate in our center was 6.6%. All of the ten non-enhancing nodules under CEUS have an inadequate result in cytopathological analyzes. The subsequent postoperative pathology and follow-up ultrasonography showed the non-enhancing nodules were benign or stable without further malignant features. Total specimen inadequate rate of high inadequate risk thyroid nodules in CEUS-FNA group was significantly lower than US-FNA group (6.7% vs. 16.7%, P = 0.014). Further stratified analyzed shown that FNA under US guidance, the inadequate rates in cystic, predominantly cystic, predominantly solid and solid sub-groups were 28.1%, 17.1%, 10.0% and 9.2% (P = 0.019). In contrast, the inadequate rates in cystic, predominantly cystic, predominantly solid and solid sub-groups were 7.4%, 6.7%, 5.6% and 6.7% (P = 0.996) in CEUS-FNA group.

Conclusions

CEUS can improve the specimen adequacy of FNA in high inadequate risk thyroid nodules by avoiding unnecessary FNAs of the non-enhancing nodules, and accurately locating the viable tissue and precise guidance in real-time. CEUS is a recommend modality for FNA guidance of high inadequate risk thyroid nodules.

Effect of the size of benign thyroid degenerative nodules on ACR TI-RADS categories

PURPOSE

Our study aimed to identify ultrasound characteristics of benign thyroid degenerative nodules and reveal the correlation between their sizes and 2017 ACR Thyroid Imaging Reporting and Data System (TI-RADS) categories.

METHODS

A total of 174 thyroid degenerative nodules were divided into three groups: 0.5-1 cm group (70 nodules), 1-2 cm group (27 nodules), and > 2 cm group (77 nodules). The ultrasound appearance of each nodule was evaluated, and the ACR TI-RADS scores and levels of the nodules were also calculated and compared among the three groups.

RESULTS

The ultrasound appearance of degenerative nodules of different sizes is diversified, and the 0.5-1 cm group tended to have more malignant features and higher TI-RADS scores and categories. The scatterplot of Spearman correlation showed a significant negative correlation between the nodule sizes and TI-RADS categories.

CONCLUSION

The 2017 ACR TI-RADS, which recommends fine-needle aspiration according to the nodule size and category, is still useful in managing these nodules, and following the clinical recommendations of ACR TI-RADS is necessary.

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.

Obstetrics and Gynecology Acute Abdomen Clinical Diagnosis and Differential Value of Ultrasonography

Acute abdomen in obstetrics and gynecology is a common disease in clinical emergency, most of the patients have the characteristics of complex condition and rapid progress, and need to be treated through clinical diagnosis. There are many traditional diagnosis methods, but the accuracy is not ideal. Ultrasound is a widely used imaging technique in recent years, which has the characteristics of simple operation and high accuracy, so it is favored by doctors and patients in obstetrics and gynecology. In this study, 200 patients with acute abdomen in obstetrics and gynecology were selected, and the results of pathological examination were taken as the gold standard to evaluate the clinical value of ultrasound examination. As a result, the misdiagnosed ultrasound group was significantly lower after the diagnosis than in the normal group, the difference was significant (P < 0.05). Therefore, the use of ultrasound imaging, the clinical diagnosis of acute abdominal diseases in gynecology and obstetrics achieves a clear diagnostic effect, improves the diagnostic accuracy of patients with acute abdominal disease in the clinical. It is very important for the development of targeted therapeutic programmes.

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.

Malignancy Analyses of Thyroid Nodules in Patients Subjected to Surgery with Cytological- and Ultrasound-Based Risk Stratification Systems

The fine needle aspiration (FNA) cytology is the gold standard for the preoperative diagnosis of thyroid cancer. However, up to 30% of FNA examinations yield nondiagnostic or indeterminate results and this complicates patient management. Clinical features and ultrasound (US) patterns, including US risk stratification systems, could be useful in the preoperative diagnostic workup and prediction of malignancy, but the evidences are not univocal. Methods: 400 consecutive patients subjected to thyroid surgery were retrospectively enrolled at our institution in Calabria, Southern Italy. Preoperative US and FNA cytological descriptions, formulated according to the “Italian consensus for reporting thyroid fine-needle aspiration cytology” (ICCRTC) classification and three US risk stratification systems (those developed by the American Association of Clinical Endocrinologists, American College of Endocrinology and Associazione Medici Endocrinologi (AACE/ACE/AME), American Thyroid Association (ATA), and American College of Radiology (ACR-TIRADS)), were collected, along with histological results. Results: 147 thyroid cancer cases, in large majority papillary carcinomas, were detected on final histological examination. Almost two-thirds of patients subjected to thyroid surgery for either benign or malignant lesions were female. Patient’s age ≤20 years and between 21–30 years were clinical features associated with increased risk of thyroid cancer in logistic regression analyses. US features associated with thyroid cancer included irregular margins, solid composition, microcalcifications, and marked hypoechogenicity. The AACE/ACE/AME, ATA, and ACR-TIRADS risk categories, corresponding to specific US patterns, were strong predictors of malignancy in both genders, but not in nodules with indeterminate cytology. A measured difference between the longitudinal (L) and the anteroposterior (AP) diameter >5 mm, a proxy for a parallel-oriented oval shape of a nodule, emerged as a robust protective factor against thyroid cancer (OR 0.288 (95%CI 0.817–0.443); p < 0.001), regardless of cytological risk. Conclusions: Some, but not all, well-established predictors of TC have been confirmed in this study. Controversy surrounds the diagnostic performance of US risk stratification systems for the detection of thyroid cancer in the subgroup of nodules with indeterminate cytology, suggesting their use only to set the thresholds for FNA. A measured difference between L and AP diameters >5 mm may represent an additional and practical tool for ruling out malignancy in thyroid nodules, with the potential to reduce unnecessary surgical procedures.

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.

Thyroid Ultrasound: Diffuse and Nodular Disease

Thyroid ultrasound with gray-scale and color Doppler is the most helpful imaging modality to differentiate normal thyroid parenchyma from diffuse or nodular thyroid disease by evaluating glandular size, echogenicity, echotexture, margins, and vascularity. The various causes of diffuse thyroid disease often have overlapping sonographic imaging features. Thyroid nodules may be hyperplastic or neoplastic, with most due to benign hyperplastic changes in architecture and benign follicular adenomas; only a small percentage are malignant. A systematic approach to nodule morphology that includes evaluation of composition, echogenicity, margin, shape, and any echogenic foci can guide decision to biopsy or follow nodules.

2019 Practice guidelines for thyroid core needle biopsy: a report of the Clinical Practice Guidelines Development Committee of the Korean Thyroid Association

Ultrasound-guided core needle biopsy (CNB) has been increasingly used for the pre-operative diagnosis of thyroid nodules. Since the Korean Society of the Thyroid Radiology published the ‘Consensus Statement and Recommendations for Thyroid CNB’ in 2017 and the Korean Endocrine Pathology Thyroid CNB Study Group published ‘Pathology Reporting of Thyroid Core Needle Biopsy’ in 2015, advances have occurred rapidly not only in the management guidelines for thyroid nodules but also in the diagnostic terminology and classification schemes. The Clinical Practice Guidelines Development Committee of the Korean Thyroid Association (KTA) reviewed publications on thyroid CNB from 1995 to September 2019 and updated the recommendations and statements for the diagnosis and management of thyroid nodules using CNB. Recommendations for the resolution of clinical controversies regarding the use of CNB were based on expert opinion. These practical guidelines include recommendations and statements regarding indications for CNB, patient preparation, CNB technique, biopsy-related complications, biopsy specimen preparation and processing, and pathology interpretation and reporting of thyroid CNB.