Calcification Patterns in Papillary Thyroid Carcinoma are Associated with Changes in Thyroid Hormones and Coronary Artery Calcification

Diagnostic efficiency of existing guidelines and the AI-SONIC™ artificial intelligence for ultrasound-based risk assessment of thyroid nodules

INTRODUCTION

The thyroid ultrasound guidelines include the American College of Radiology Thyroid Imaging Reporting and Data System, Chinese-Thyroid Imaging Reporting and Data System, Korean Society of Thyroid Radiology, European-Thyroid Imaging Reporting and Data System, American Thyroid Association, and American Association of Clinical Endocrinologists/American College of Endocrinology/Associazione Medici Endocrinologi guidelines. This study aimed to compare the efficiency of the six ultrasound guidelines vs. an artificial intelligence system (AI-SONICTM) in differentiating thyroid nodules, especially medullary thyroid carcinoma.

METHODS

This retrospective study included patients with medullary thyroid carcinoma, papillary thyroid carcinoma, or benign nodules who underwent nodule resection between May 2010 and April 2020 at one hospital. The diagnostic efficacy of the seven diagnostic tools was evaluated using the receiver operator characteristic curves.

RESULTS

Finally, 432 patients with 450 nodules were included for analysis. The American Association of Clinical Endocrinologists/American College of Endocrinology/Associazione Medici Endocrinologi guidelines had the best sensitivity (88.1%) and negative predictive value (78.6%) for differentiating papillary thyroid carcinoma or medullary thyroid carcinoma vs. benign nodules, while the Korean Society of Thyroid Radiology guidelines had the best specificity (85.6%) and positive predictive value (89.6%), and the American Thyroid Association guidelines had the best accuracy (83.7%). When assessing medullary thyroid carcinoma, the American Thyroid Association guidelines had the highest area under the curve (0.78), the American College of Radiology Thyroid Imaging Reporting and Data System guidelines had the best sensitivity (90.2%), and negative predictive value (91.8%), and AI-SONICTM had the best specificity (85.6%) and positive predictive value (67.5%). The Chinese-Thyroid Imaging Reporting and Data System guidelines had the best under the curve (0.86) in diagnosing malignant tumors vs. benign tumors, followed by the American Thyroid Association and Korean Society of Thyroid Radiology guidelines. The best positive likelihood ratios were achieved by the Korean Society of Thyroid Radiology guidelines and AI-SONICTM (both 5.37). The best negative likelihood ratio was achieved by the American Association of Clinical Endocrinologists/American College of Endocrinology/Associazione Medici Endocrinologi guidelines (0.17). The highest diagnostic odds ratio was achieved by the American Thyroid Association guidelines (24.78).

DISCUSSION

All six guidelines and the AI-SONICTM system had satisfactory value in differentiating benign vs. malignant thyroid nodules.

A Clinical Predictive Model of Central Lymph Node Metastases in Papillary Thyroid Carcinoma

BACKGROUND

Thyroid carcinoma is one of the most common endocrine tumors, and papillary thyroid carcinoma (PTC) is the most common pathological type. Current studies have reported that PTC has a strong propensity for central lymph node metastases (CLNMs). Whether to prophylactically dissect the central lymph nodes in PTC remains controversial. This study aimed to explore the risk factors and develop a predictive model of CLNM in PTC.

METHODS

A total of 2,554 patients were enrolled in this study. The basic information, laboratory examination, characteristics of cervical ultrasound, genetic test, and pathological diagnosis were collected. The collected data were analyzed by univariate logistic analysis and multivariate logistic analysis. The risk factors were evaluated, and the predictive model was constructed of CLNM.

RESULTS

The multivariate logistic analysis showed that Age (p < 0.001), Gender (p < 0.001), Multifocality (p < 0.001), BRAF (p = 0.027), and Tumor size (p < 0.001) were associated with CLNM. The receiver operating characteristic curve (ROC curve) showed high efficiency with an area under the ROC (AUC) of 0.781 in the training group. The calibration curve and the calibration of the model were evaluated. The decision curve analysis (DCA) for the nomogram showed that the nomogram can provide benefits in this study.

CONCLUSION

The predictive model of CLNM constructed and visualized based on the evaluated risk factors was confirmed to be a practical and convenient tool for clinicians to predict the CLNM in PTC.

Ultrasound in active surveillance for low-risk papillary thyroid cancer: imaging considerations in case selection and disease surveillance

Active surveillance (AS) of small, low-risk papillary thyroid cancers (PTCs) is increasingly studied in prospective observational studies. Ultrasound is the primary imaging modality for case selection. While researchers have put forward selection criteria for PTCs based on size, absence of suspicious lymph nodes and tumor location, there are limited reported data highlighting inherent ultrasound limitations and guidelines for case selection and follow-up. We report our experience including imaging limitations encountered in the ongoing AS prospective observational study for PTCs measuring < 2 cm at our institute. We define disease progression as an increase in size of > 3 mm in the largest dimension of nodule or evidence of metastatic disease or extrathyroidal extension. Accurate, consistent and reproducible measurements of PTCs are essential in risk stratifying patients for the option of AS or disease progression. Interobserver discrepancy, shadowing from coarse calcification and background parenchyma heterogeneity or thyroiditis can limit accurate PTC size assessment and therefore hinder patient eligibility evaluation or AS follow-up. Following the ACR Thyroid Imaging, Reporting and Data System (TI-RADS) protocol of three-axes technique to measure a thyroid nodule enables reproducibility of measurements. In patients with multi-nodular goiter, accurate identification and labeling of the PTC is important to avoid mistaking with adjacent benign nodules at follow-up. Ultrasound assessment for extrathyroid extension of PTC, and relationship of PTC to trachea and the anatomic course of the recurrent laryngeal nerve are important considerations in evaluation for AS eligibility.

Nomogram prediction for the involution of the ablation zone after radiofrequency ablation treatment in patients with low-risk papillary thyroid carcinoma

OBJECTIVES

To construct a prognostic nomogram to predict the involution of the ablation zone for patients with low-risk papillary thyroid carcinoma (PTC) who underwent radiofrequency ablation (RFA) treatment.

METHODS

Data from 204 patients with low-risk PTC without extrathyroidal extension or cervical lymph node or distant metastasis who underwent RFA treatment were collected from January 2018 to January 2019. Clinicopathological and imaging characteristics were analyzed. The prognostic factors associated with the involution of the ablation zone within 12 months after RFA were identified by logistic analysis, and the nomogram was established. Calibration curve and decision curve analysis were used to evaluate the nomogram performance.

RESULTS

Of the 204 patients included in this study, the ablation zone in 78 (38%) patients did not completely disappear in the 12 months after RFA. Four variables, including sex (odds ratio [OR], 3.303; 95% confidence interval [CI], 1.418-8.418; p = 0.008), age (OR, 1.045; 95% CI, 1.012-1.081; p = 0.009), calcification size (OR, 1.666; 95% CI, 1.041-2.701; p = 0.035), and RFA energy (OR, 2.902; 95% CI, 1.333-6.683; p = 0.009), were found to be closely associated with ablation zone non-disappearance at 12 months after RFA by multivariate analysis. A nomogram model was constructed, and its accuracy was well validated (C-index = 0.787).

CONCLUSIONS

This study constructed and validated a risk model that could accurately predict the involution of the ablation zone after RFA for patients with PTC. This could provide clinicians with useful resource to guide patient counseling regarding tumor prognosis after RFA.

Value of Combining Clinical Factors, Conventional Ultrasound, and Contrast-Enhanced Ultrasound Features in Preoperative Prediction of Central Lymph Node Metastases of Different Sized Papillary Thyroid Carcinomas

Purpose

Early and accurate preoperative diagnosis of central lymph node metastasis (CLNM) is crucial to improve surgical management of patients with clinical lymph node-negative papillary thyroid carcinoma (PTC). Towards improving diagnosis of CLNM, we assessed the value of combining preoperative clinical characteristics, conventional ultrasound, and contrast-enhanced ultrasound (CEUS) in preoperative prediction of CLNM of different sized PTCs.

Patients and Methods

Patients were divided according to tumor size: a PTC group (>10 mm) and a papillary thyroid microcarcinoma (PTMC) group (≤10 mm). We retrospectively analyzed the clinical and ultrasonographic features of 120 PTC patients and 165 PTMC patients. Multivariate logistic regression analysis was used to screen independent risk factors and establish prediction models. Receiver operating characteristic curves were used to determine the best cut-off values for continuous variables and assess the performance of prediction models.

Results

Independent risk predictors of CLNM for the PTC group were extrathyroidal extension in CEUS (OR=7.923), tumor size >14 mm (OR=5.491), and multifocality (OR=3.235). For the PTMC group, the independent risk factors were the distance from the thyroid capsule =0 mm (OR=4.629), male (OR=3.315), tumor size >5 mm (OR=3.304), and microcalcification (OR=2.560). The predictive model of combined method had better performance in predicting CLNM of PTC compared with models based on CEUS and conventional ultrasound alone (area under the curve: 0.832 vs 0.739, P=0.0011; 0.832 vs 0.678, P=0.0012). For PTMC, comparing with CEUS, the combined method and conventional ultrasound performed better than CEUS alone in predicting CLNM (area under the curve: 0.783 vs 0.636, P=0.0016; 0.738 vs 0.636, P=0.0196).

Conclusion

The predictive models of combined method obtained from significant preoperative clinical and ultrasonographic features can potentially improve the preoperative diagnosis and individual treatment of CLNM in patients with PTC and PTMC. CEUS may be helpful in predicting CLNM of PTC, but CEUS would be ineffective in predicting CLNM of PTMC.

Association of Hyperparathyroidism and Papillary Thyroid Cancer: A Multicenter Retrospective Study

BACKGROUND

Concomitant papillary thyroid cancer (PTC) and hyperparathyroidism (HPT) have been reported in several studies. Our study aimed to investigate the incidence of concomitant PTC in HPT patients upon preoperative diagnosis and present a clinical opinion on detecting thyroid malignancy in case of parathyroidectomy.

METHODS

Patients who underwent parathyroidectomy between January 2009 and December 2019 in two medical centers were included. Of the 279 participants 154 were diagnosed as primary hyperparathyroidism (pHPT) and 125 as secondary hyperparathyroidism (sHPT). The incidence of concomitant PTC and its clinical characteristics were compared with 98 patients who underwent thyroidectomy and were diagnosed with classical PTC during the same period.

RESULTS

Concurrent PTC was detected in 14 patients (9.1%) with pHPT and in nine patients (7.2%) with sHPT. Ten (71.4%) and seven (77.8%) PTCs were microcarcinomas in the pHPT and sHPT cases respectively. In the pHPT patients, vitamin D was lower in the pHPT+PTC group (13.0±3.7 ng/mL) than in the pHPT-only group (18.5±10.4 ng/mL; P=0.01). Vitamin D levels were also lower in the sHPT+PTC group (12.3±5.6 ng/mL) than in the sHPT-only group (18.0±10.2 ng/mL; P=0.12). In the concomitant PTC group, lymph node ratio was higher than in the classical PTC group (P=0.00).

CONCLUSION

A high prevalence of concomitant PTC was seen in patients with pHPT and sHPT. Those concomitant PTCs were mostly microcarcinomas and had more aggressive features, suggesting that efforts should be made to detect concomitant malignancies in the preoperative parathyroidectomy evaluation.