[Review on ultrasonographic diagnosis of thyroid diseases based on deep learning]

In recent years, the incidence of thyroid diseases has increased significantly and ultrasound examination is the first choice for the diagnosis of thyroid diseases. At the same time, the level of medical image analysis based on deep learning has been rapidly improved. Ultrasonic image analysis has made a series of milestone breakthroughs, and deep learning algorithms have shown strong performance in the field of medical image segmentation and classification. This article first elaborates on the application of deep learning algorithms in thyroid ultrasound image segmentation, feature extraction, and classification differentiation. Secondly, it summarizes the algorithms for deep learning processing multimodal ultrasound images. Finally, it points out the problems in thyroid ultrasound image diagnosis at the current stage and looks forward to future development directions. This study can promote the application of deep learning in clinical ultrasound image diagnosis of thyroid, and provide reference for doctors to diagnose thyroid disease.

Diagnosis of thyroid disease using deep convolutional neural network models applied to thyroid scintigraphy images: a multicenter study

Objectives

The aim of this study was to improve the diagnostic performance of nuclear medicine physicians using a deep convolutional neural network (DCNN) model and validate the results with two multicenter datasets for thyroid disease by analyzing clinical single-photon emission computed tomography (SPECT) image data.

Methods

In this multicenter retrospective study, 3194 SPECT thyroid images were collected for model training (n=2067), internal validation (n=514) and external validation (n=613). First, four pretrained DCNN models (AlexNet, ShuffleNetV2, MobileNetV3 and ResNet-34) for were tested multiple medical image classification of thyroid disease types (i.e., Graves' disease, subacute thyroiditis, thyroid tumor and normal thyroid). The best performing model was then subjected to fivefold cross-validation to further assess its performance, and the diagnostic performance of this model was compared with that of junior and senior nuclear medicine physicians. Finally, class-specific attentional regions were visualized with attention heatmaps using gradient-weighted class activation mapping.

Results

Each of the four pretrained neural networks attained an overall accuracy of more than 0.85 for the classification of SPECT thyroid images. The improved ResNet-34 model performed best, with an accuracy of 0.944. For the internal validation set, the ResNet-34 model showed higher accuracy (p < 0.001) when compared to that of the senior nuclear medicine physician, with an improvement of nearly 10%. Our model achieved an overall accuracy of 0.931 for the external dataset, a significantly higher accuracy than that of the senior physician (0.931 vs. 0.868, p < 0.001).

Conclusion

The DCNN-based model performed well in terms of diagnosing thyroid scintillation images. The DCNN model showed higher sensitivity and greater specificity in identifying Graves' disease, subacute thyroiditis, and thyroid tumors compared to those of nuclear medicine physicians, illustrating the feasibility of deep learning models to improve the diagnostic efficiency for assisting clinicians.

The Role of Nuclear Medicine in Benign Thyroid Disease

Since the mid-twentieth century, the radionuclide thyroid scan has been utilized in the management of benign thyroid disorders. In current medical practice, patients with hyperthyroidism are referred for thyroid scintigraphy, while patients with goiters and thyroid nodules are most often evaluated by ultrasound or computed tomography. Since thyroid scintigraphy reflects the functional state of the gland, it provides information that anatomical imaging lacks. Therefore, radionuclide imaging of the thyroid is the imaging modality of choice in the evaluation of the hyperthyroid patient. In addition, patients with so-called subclinical hyperthyroidism often present a diagnostic dilemma to the clinician since the causative factor must be determined for proper patient management. The aim of this manuscript is to illustrate the imaging characteristics of thyroid disorders commonly seen in clinical practice resulting in thyrotoxicosis or pending thyrotoxicosis, so that correlation with clinical presentation and pertinent laboratory data will lead to the correct diagnosis.

Consequences of early thyroid ultrasound on subsequent tests, morbidity and costs: an explorative analysis of routine health data from German ambulatory care

OBJECTIVES

This study aims to evaluate whether the use of thyroid ultrasound (US) early in the work-up of suspected thyroid disorders triggers cascade effects of medical procedures and to analyse effects on morbidity, healthcare usage and costs.

STUDY DESIGN

Retrospective analysis of claims data from ambulatory care (2012-2017).

SETTING

Primary care in Bavaria, Germany, 13 million inhabitants.

PARTICIPANTS

Patients having received a thyroid stimulating hormone (TSH) test were allocated to (1) observation group: TSH test followed by an early US within 28 days or (2) control group: TSH test, but no early US. Propensity score matching was used adjusting for socio-demographic characteristics, morbidity and symptom diagnosis (N=41 065 per group after matching).

PRIMARY AND SECONDARY OUTCOME MEASURES

Using cluster analysis, groups were identified regarding frequency of follow-up TSH tests and/or US and compared.

RESULTS

Four subgroups were identified: cluster 1: 22.8% of patients, mean (M)=1.6 TSH tests; cluster 2: 16.6% of patients, M=4.7 TSH tests; cluster 3: 54.4% of patients, M=3.3 TSH tests, 1.8 US; cluster 4: 6.2% of patients, M=10.9 TSH tests, 3.9 US. Overall, reasons that explain the tests could rarely be found. An early US was mostly found in clusters 3 and 4 (83.2% and 76.1%, respectively, were part of the observation group). In cluster 4 there were more women, thyroid-specific morbidity and costs were higher and the early US was more likely to be performed by specialists in nuclear medicine or radiologists.

CONCLUSION

Presumably unnecessary tests in the field of suspected thyroid diseases seem to be frequent, contributing to cascades effects. Neither German nor international guidelines provide clear recommendations for or against US screening. Therefore, guidelines on when to apply US and when not are urgently needed.

[Thyroid ultrasound and its role in the investigation of thyroid disease]

In Europe thyroid ultrasound has been used at outpatient endocrine clinics since many years, and in southern Sweden only during the last years. Ultrasound has a role in the investigation of Graves' disease, subacute thyroiditis, gestational thyrotoxicosis, postpartum thyroiditis, amiodarone thyrotoxicosis and goiter with or without adenoma, but adenomas are usually investigated by endocrine surgeons in Sweden. If widely used the risk for detection of incidentaloma increases. Indications have to be strictly used to avoid further investigations. If an adenoma is localized, the risk for malignancy and requirement of aspiration is estimated by use of the EU-TIRADS classification based on morphology and size. The aspirate is judged by the Bethesda classification, which determines if further investigation is needed. The use of ultrasound at the outpatient clinic has improved the diagnostic quality and follow-up of thyroid patients.

New insights into thyroid dysfunction in patients with inactivating parathyroid hormone/parathyroid hormone-related protein signalling disorder (the hormonal and ultrasound aspects): One-centre preliminary results

OBJECTIVE

This study aimed to present the spectrum of thyroid dysfunction, including hormonal and ultrasound aspects, in a cohort of paediatric and adult patients diagnosed with inactivating parathyroid hormone (PTH)/PTH-related protein signalling disorders 2 and 3 (iPPSD).

METHODS

The medical records of 31 patients from 14 families diagnosed with iPPSD between 1980 and 2021 in a single tertiary unit were retrospectively analysed. Biochemical, hormonal, molecular, and ultrasonographic parameters were assessed.

RESULTS

In total, 28 patients from 13 families were diagnosed with iPPSD2 (previously pseudohypoparathyroidism [PHP], PHP1A, and pseudo-PHP) at a mean age of 12.2 years (ranging from infancy to 48 years), and three patients from one family were diagnosed with iPPSD3 (PHP1B). Thyroid dysfunction was diagnosed in 21 of the 28 (75%) patients with iPPSD2. Neonatal screening detected congenital hypothyroidism (CH) in 4 of the 20 (20%) newborns. The spectrum of thyroid dysfunction included: CH, 3/21 (14.2%); CH and autoimmune thyroiditis with nodular goitre, 1/21 (4.8%); subclinical hypothyroidism, 10/21 (47.6%); subclinical hypothyroidism and nodular goitre, 1/21 (4.8%); primary hypothyroidism, 4/21 (19%); and autoimmune thyroiditis (Hashimoto and Graves' disease), 2/21 (9.6%). Thyroid function was normal in 7 of the 28 (25%) patients with iPPSD2 and in all patients with iPPSD3. Ultrasound evaluation of the thyroid gland revealed markedly inhomogeneous echogenicity and structure in all patients with thyroid dysfunction. Goitre was found in three patients.

CONCLUSION

The spectrum of thyroid dysfunction in iPPSD ranges from CH to autoimmune thyroiditis and nodular goitre. Ultrasonography of the thyroid gland may reveal an abnormal thyroid parenchyma.

The relationship between ultrasound findings and thyroid function in children and adolescent autoimmune diffuse thyroid diseases

To evaluate the association between thyroid echogenicity and heterogeneity seen on ultrasonography (US) and thyroid function in pediatric and adolescent populations with autoimmune diffuse thyroid diseases (AITD). From 2000 to 2020, we reviewed thyroid ultrasound (US) images and thyroid function statuses in 133 children and adolescent AITD patients. Our review of the images focused on decreased echogenicity and heterogeneity, which were classified into four grades. Among patients with overt hypothyroidism or overt hyperthyroidism, 94.2% (65/69) showed a US grade of 3 or 4. In patients with subclinical hyper/hypothyroidism or euthyroidism, 45.3% (29/64) showed grades 1 or 2. There were no overt hyper/hypothyroidism patients with US grade 1. When we compared US grades according to thyroid status, more severe thyroid dysfunction was significantly associated with higher US grade (p = 0.047). Thyroid stimulating hormone (TSH) level differed significantly according to US grades when we evaluated hyperthyroid (p = 0.035) and hypothyroid (p = 0.027) states independently. 11 patients showed both US grade and thyroid function status changes on follow-up US. In children and adolescent AITD patients, there was an association between decreased echogenicity and heterogeneity on US and thyroid dysfunction.

Reliability of shear wave elastography in the evaluation of diffuse thyroid diseases in children and adolescents

PURPOSE

Thyroid diseases are common yet serious in children that lead to many metabolic and growth disorders; the most common among these are diffuse thyroid diseases (DTD). This study aimed to evaluate the reliability of shear wave elastography (SWE) to differentiate and diagnose DTD from normal thyroid tissue.

METHOD

This prospective study included normal participants and patients with DTD. The subjects were assessed by clinical evaluation, laboratory investigation, conventional ultrasound, and Doppler examination, followed by SWE assessments. Statistical analysis was performed using the t-test and one-way ANOVA test, as appropriate. Receiver operating characteristic (ROC) curves were used to determine the best cutoff values to differentiate healthy participants from those with DTD and to differentiate between different types of DTD.

RESULTS

The study included 74 patients with DTD and 20 healthy participants. The mean SWE values were 10.9 ± 1.78, 12.8 ± 2.1, 15.31 ± 2.95, and 17.26 ± 4.2 kPa for the normal participants and for patients with simple goiter, Hashimoto's thyroiditis (HT), or Grave's disease (GD), respectively. Statistically significant differences were noted between the mean SWE of the normal participants and that of patients with DTD, as well as between the mean SWE of patients with different types of DTD (P < 0.05). The best SWE cutoff values to differentiate a normal thyroid from DTD, HT from GD, HT from simple goiter, and GD from simple goiter were 12.8, 17.8, 13.4, and 13.9 kPa, respectively.

CONCLUSIONS

SWE is a reliable diagnostic tool for differentiating normal thyroid tissue from DTD, as well as for differentiating between different types of DTD.

Relationship between thyroid disorders and uterine fibroids among reproductive-age women

Uterine fibroids and thyroid nodules, both of which are crucially affected by estrogen, are common diseases among reproductive-age women. However, little attention has been paid to the association between the two diseases. This retrospective case-control study aimed to assess the relationships among thyroid nodules, thyroid function and uterine fibroids in China. We reviewed the electronic records of 853 reproductive-age women who attended health check-ups at the Second Affiliated Hospital of Wenzhou Medical University from July 1st, 2017, to June 30th, 2018. All subjects received transvaginal pelvic ultrasound, thyroid ultrasound, thyroid function, and other laboratory tests. We found that the prevalence of thyroid nodules in subjects with uterine fibroids was remarkably higher than that in subjects without fibroids. The proportion of thyroid nodules ≥1 cm in subjects with uterine fibroids was significantly higher than that in subjects without fibroids. Women with thyroid nodules had a higher proportion of multiple uterine fibroids than women without thyroid nodules. Among the parameters of thyroid function, the only statistically significant parameter was total triiodothyronine, i.e., women with uterine fibroids had lower total triiodothyronine levels than unaffected controls; however, the total triiodothyronine levels were within the normal ranges. Moreover, no significant difference was noted in thyroid hormone status between subjects with and without uterine fibroids. Our findings suggest that thyroid nodules are positively correlated with uterine fibroids among reproductive-age women in China. Further studies are needed to confirm this association and fully understand the common pathogenetic mechanism underlying the association between uterine fibroids and thyroid nodules.

Preoperatory imaging evaluation in primary hyperparathyroidism and associated thyroid disease

BACKGROUND

Primary hyperparathyroidism (pHPT) is an endocrinological disorder characterized by excessive secretion of parathormone. Minimally invasive approach has become a widespread surgical method for pHPT treatment due to the improvement of preoperative gland localization imaging techniques and the use of intraoperative PTH dosage (IOPTH). We discuss the results of different imaging technique.

MATERIALS AND METHODS

We have conducted a retrospective analysis of 80 patients that underwent surgery for primary hyperparathyroidism in the period between 01/01/2012 and 28/02/2018 and we have focused our data collection on preoperative study, intraoperative findings and follow-up data. We have evaluated the concordance between the findings of the most used imaging techniques, copresence of thyroid disease and IOPTH.

RESULTS

SPECT-CT showed the best results in terms of positivity (93.1%), sensitivity (88.9%) and accuracy (82.8%). Neck ultrasound resulted to have the best positive predictive value (94.4%). IOPTH decrease was correlated with patients' healing (p <0.05). Age lower than 70 years, post-operative calcium and PTH serum levels were related to a higher chance of healing (p <0.05).

CONCLUSION

US-scintigraphy combination is suitable for preoperative evaluation and SPECT/CT confirms to be the best additional examination; the presence of thyroid disease decrease the sensitivity. IOPTH is an important predictor of healing KEY WORDS: Intraoperative PTH, Hyperparathyroidism, Parathyroidectomy, SPECT/CT, Thyroid disease.

Thyroid disorders and pathospermia in the ART clinic patients

OBJECTIVE

Over the past decade, a decrease in the semen quality in men of reproductive age, along with an increase in the incidence of thyroid diseases among young patients have been clearly noticed. The study was designed to determine various forms of pathospermia in the ART clinic patients with thyroid disorders.

MATERIALS AND METHODS

168 men of reproductive age in infertile marriage were examined. Men with male infertility factor associated with erectile dysfunction and normospermia (9 patients, 5.3%) were excluded. The study included 159 men and the patients were divided into three groups: the 1^st study group consisted of men with non-obstructive azoospermia - 11 men (6.9%); the 2^nd study group included men with other forms of pathospermia - 38 men (23.9%) and the control group consisted of men in infertile marriage with normospermia - 110 men (69.2%). All patients had anthropometric measurements, laboratory tests, thyroid and testicular ultrasonography. Spermogram was analyzed in accordance with the WHO classification, 5^th revision, 2010.

RESULTS

Among all examined men with pathospermia (n = 49 patients), 51.02% had various thyroid disorders, while it was firstly verified in 34.7% men. In 45.5% patients with non-obstructive azoospermia, previously undiagnosed nodular goiter with normal values of thyroid-stimulating hormone and free thyroxine were found, and a significant correlation between nodular goiter and the presence of azoospermia was revealed: r = 0.610, p = .01.

CONCLUSION.

Men with various forms of pathospermia and patients of the ART clinic had higher risks of thyroid disorders than in general population that could possibly affect fertility. Patients of the ART clinic with non-obstructive azoospermia are at risk for nodular thyroid disorders, even with normal values of thyroid function tests, and require thyroid ultrasonography.

Relationship Between Thyroid Hormone Levels and the Pathology of Alzheimer's Disease in Euthyroid Subjects

Background: Although several studies have reported an association between thyroid dysfunction and Alzheimer's disease (AD), the effect of mild thyroid dysfunction within the normal range of thyrotropin (TSH) on the development of AD remains unclear. The aim of this study was to evaluate the association between thyroid hormones and the pathology of AD in euthyroid subjects. Methods: Sixty-nine subjects with a TSH level between 0.5 and 4.5 μIU/L who underwent ¹⁸F-florbetaben positron emission tomography were included in this prospective cross-sectional study. The levels of serum free thyroxine (fT4) and TSH were quantified using radioimmunoassay. Neuropsychological tests were performed to assess cognitive function. Differences in cerebral amyloid-β (Aβ) burden were compared between high-normal TSH (TSH ≥2.5 μIU/mL) and low-normal TSH (TSH <2.5 μIU/mL) groups. Multiple linear regression analyses, adjusted for age, sex, education level, and Neuropsychiatric Inventory scores, were performed to evaluate relationships between thyroid hormone levels and both cerebral Aβ burden and cognitive function. Results: The cerebral Aβ burden in the high-normal TSH group was significantly higher than in the low-normal TSH group (1.53 ± 0.31 vs. 1.35 ± 0.22, p = 0.009). The fT4 levels were negatively correlated with cerebral Aβ burden (β = -0.240, p = 0.035), and TSH levels were positively correlated with cerebral Aβ burden (β = 0.267, p = 0.020). The fT4 level was also positively associated with cognitive function, as inferred from neuropsychological test scores. Conclusions: Thyroid hormone concentrations were associated with AD pathology in euthyroid subjects. Our findings suggest that AD is likely to occur even in individuals with high-normal TSH levels.

Designing a Low-Cost Thyroid Ultrasound Phantom for Medical Student Education

Using ultrasound for the diagnostic workup of thyroid lesions is a widely accepted technique. An inexpensive phantom model of thyroid lesions would be an invaluable tool for engaging medical students in learning the diagnostic algorithm for thyroid lesions and how to perform fine needle aspiration (FNA). The aim of this study was to devise an inexpensive and reproducible training phantom model for thyroid lesion detection, image interpretation and in vitro FNA using ultrasound guidance. A simple phantom model imitating benign cystic lesions, intermediately suspicious lesions and highly suspicious lesions was developed using a chicken breast, red seedless grapes, pimento olives and blackberries. The phantom was constructed for a total cost of $4.09 per unit and constructed in approximately 3 min. Nine models were constructed in total, demonstrating that the model design is replicable. This thyroid FNA phantom is an inexpensive, easy-to-produce model that allows medical students to practice measuring lesions and performing FNAs using ultrasonography. Future studies could be explored to assess this model's role in medical student education.

Nuclear thyroidology in pandemic times: The paradigm shift of COVID-19

Since its outbreak in Wuhan, China the SARS-CoV-2 has become a public health emergency of international concern, impacting all areas of daily life, including medical care. Although not in the front line nuclear medicine practice should adjust their standard operating procedures. The adaptations and the flexibility that nuclear thyroidology, among other fields of nuclear medicine, should show during the pandemic, must focus not only in minimizing the risk of infection to staff, patients, and family members, but also in controlling the transmission of the virus while continuing to provide health care services which do not jeopardize patients' prognosis and quality of life. Favorable prognosis and indolent symptoms of most cases of thyroid diseases, allows postponements and rescheduling as well as alternative procedures, provided that they are cautiously considered for each case individually. The objective of the current paper is to provide guidance on how diagnostic and therapeutic management of patients with thyroid diseases can be safely and effectively adjusted during pandemic, in nuclear medicine settings.

Relationship Between Morphologic Characteristics of Ultrasonic Calcification in Thyroid Nodules and Thyroid Carcinoma

The aim of this study was to investigate the relationship between morphologic characteristics of the calcifications detected by ultrasound in thyroid nodules and thyroid carcinoma. Morphologic characteristics of the calcifications on pre-operative ultrasound examinations of thyroids were compared with post-operative pathologic diagnoses in 543 patients undergoing thyroid surgery. Calcifications were divided into microcalcifications (≤2 mm) and macrocalcifications (>2 mm), and the latter were divided into eggshell calcifications in a row, eggshell discontinuous calcifications, irregular calcifications and multilayer-like calcifications, labeled types I-V. We found that thyroid microcalcifications and partial macrocalcifications, such as eggshell discontinuous calcifications, and multilayer-like calcifications were associated with thyroid carcinoma. In conclusion, microcalcifications were more commonly found in malignant thyroid nodules, particularly in papillary thyroid carcinoma. Eggshell discontinuous macrocalcifications and multilayer-like macrocalcifications also occurred mainly in malignant nodules.

Evaluation of the thyroid characteristics of patients with growth hormone-secreting adenomas

BACKGROUND

Acromegaly is highly associated with thyroid disorders. However, the clinical characteristics of thyroid nodules in individuals with acromegaly who present with thyroid diseases have not been completely elucidated.

METHODS

Overall, 134 consecutive participants with growth hormone (GH)-secreting adenoma (n = 67) and non-functioning (NF) pituitary adenoma (n = 67) were recruited from the outpatient and inpatient patient department of The First Affiliated Hospital, Jinan University from August 2015 to August 2017. Thyroid ultrasonography was performed using an ultrasound system. The cytopathological results of fine-needle aspiration biopsy were analyzed by a pathologist according to the Bethesda system. Twenty-one patients with GH-secreting adenoma and thyroid disease underwent transsphenoidal pituitary adenoma resection and were followed up for 1 year.

RESULTS

The prevalence of thyroid disease increased in the GH-secreting adenoma group compared with that in the NF pituitary adenoma group. The number of hypoechoic, isoechogenic, heterogeneous, and vascular thyroid nodules increased in patients with GH-secreting adenoma plus thyroid disease compared with that in patients with NF pituitary adenoma plus thyroid disease. Finally, we found significant decreases in the morphology of solid nodules and significant increases in the morphology of cystic nodules after surgery compared with those before surgery in the cured group. Moreover, the numbers of heterogeneous and vascular thyroid nodules decreased significantly after surgery compared with those before surgery in the cured group. However, the characteristics of the thyroid nodules did not change after surgery compared with those before surgery in the non-cured group.

CONCLUSIONS

The numbers of hypoechoic, isoechoic, heterogeneous, and vascular thyroid nodules increased in patients with GH-secreting adenomas. In these patients, surgery resulted in significant changes from solid to cystic nodules and also reduced the numbers of heterogeneous and vascular thyroid nodules.

Analysis of a thyroid nodule care pathway: Opportunity to improve compliance and value of care

BACKGROUND

Care pathways facilitate standardized, evidence-based treatment to improve outcomes and value of care. Care pathways consist of multiple nodes representing decision points. Few studies investigate care pathway compliance. We demonstrate nodal care pathway analysis by reviewing compliance with our institutional multidisciplinary, evidence-based care pathways on the treatment of thyroid nodule to generate strategies to increase care pathway adherence and value of care.

METHODS

Patients undergoing workup and treatment of structural thyroid disease between January 2018 and June 2018 were included in a retrospective analysis of enterprise-wide compliance with the following 3 care pathway nodes: (1) laboratory testing: only patients with abnormal results from thyroid-stimulating hormone testing should have T3/T4 measured. (2) imaging: neck computed tomography, magnetic resonance imaging, and positron emission tomography ordered for the workup of nodules were reviewed to determine clinical appropriateness. (3) operative treatment: the first 200 thyroid resections conducted in 2018 were reviewed to determine whether the indication and extent of the operation complied with the care pathway. Medicare fee schedules were used for financial calculations.

RESULTS

Care pathway nonadherence occurred in 48% of the thyroid-stimulating hormone studies and 38% of the imaging studies obtained, with annual costs exceeding $120,000. Substantial care pathway nonadherence occurred in 3% of nodule-related operations.

CONCLUSION

Care pathway nodal analysis can identify areas of care pathway nonadherence. Nodal analysis should be considered for care pathway maintenance and generation of strategies of quality improvement.

Thyroid Microcalcifications in the Absence of Identifiable Nodules and Their Association With Thyroid Cancer

OBJECTIVES

To determine ultrasound (US) and clinical findings of thyroid microcalcifications in the absence of a nodule and their association with the risk of malignancy.

METHODS

The Institutional Review Board approved a 5-year retrospective study. Twenty-one patients with clustered or scattered thyroid microcalcifications in the absence of nodules on US images who underwent fine-needle aspiration biopsies (FNABs) were included. Demographic and clinical data, US findings, and pathologic results were registered. Patients with a suspicion of malignancy or papillary thyroid carcinoma (PTC) on FNAB underwent thyroidectomy. Patients with benign results on FNAB underwent clinical and US surveillance.

RESULTS

The mean age of the 21 patients was 33.2 years (29.5 years in patients with PTC patients and 39.4 years in those with benign findings; P = .034). Eleven of 21 patients had clustered microcalcifications (9 had cancer), and 10 of 21 patients had scattered microcalcifications (4 of 10 had cancer; P = 0.063). Sixty-two percent of the patients had FNAB findings that were suspicious for cancer or had a diagnosis of cancer. Eleven of 13 patients had surgical thyroidectomy performed in our institution; in all cases, Hashimoto thyroiditis was confirmed. Univariate and multivariate analysis showed that only age was significant (odds ratio, 0.9; P < .05).

CONCLUSIONS

Our study suggests that the presence of thyroid microcalcifications without a nodule is suspicious for PTC. We found that both patterns were suspicious for PTC, particularly in young patients. Special concern arises for those clustered microcalcifications on a background of Hashimoto thyroiditis.

Thyroid ultrasonography reporting: consensus of Italian Thyroid Association (AIT), Italian Society of Endocrinology (SIE), Italian Society of Ultrasonography in Medicine and Biology (SIUMB) and Ultrasound Chapter of Italian Society of Medical Radiology (SIRM)

Thyroid ultrasonography (US) is the gold standard for thyroid imaging and its widespread use is due to an optimal spatial resolution for superficial anatomic structures, a low cost and the lack of health risks. Thyroid US is a pivotal tool for the diagnosis and follow-up of autoimmune thyroid diseases, for assessing nodule size and echostructure and defining the risk of malignancy in thyroid nodules. The main limitation of US is the poor reproducibility, due to the variable experience of the operators and the different performance and settings of the equipments. Aim of this consensus statement is to standardize the report of thyroid US through the definition of common minimum requirements and a correct terminology. US patterns of autoimmune thyroid diseases are defined. US signs of malignancy in thyroid nodules are classified and scored in each nodule. We also propose a simplified nodule risk stratification, based on the predictive value of each US sign, classified and scored according to the strength of association with malignancy, but also to the estimated reproducibility among different operators.

High Thyrotropin Is Associated with Reduced Hippocampal Volume in a Population-Based Study from Germany

BACKGROUND

Previous patient studies suggest that thyroid dysfunction affects volumes of particular regions of the brain. So far, population-based data related to this topic are lacking. The aim of this study was to investigate associations of serum levels of thyrotropin (TSH), free triiodothyronine, and free thyroxine (fT4) with total brain volume, gray matter volume, white matter volume (WMV), and hippocampal volume (HV) in a population-based study.

METHODS

Data on 2557 individuals were pooled from two independent population-based surveys of the Study of Health in Pomerania conducted in Northeast Germany. Brain volumes were determined from images derived from 1.5 T magnetic resonance imaging. Low and high TSH were defined using the cutoffs 0.40 and 3.29 mIU/L, respectively. Associations between thyroid hormone levels and segmented brain volumes were analyzed by linear regression models. Further, voxel-based morphometry was conducted to search for associations with thyroid hormone levels in a hypothesis-free way throughout the whole brain. All models were adjusted for confounders.

RESULTS

Only 9/70 individuals with high TSH had low free triiodothyronine or fT4 levels. Individuals with high TSH had significantly lower total brain volume (β = -26.9 [confidence interval (CI) -49.0 to -4.8]; p = 0.017), WMV (β = -16.1 [CI -29.4 to -2.7]; p = 0.018), and HV (β = -223 [CI -395 to -50]; p = 0.011) than individuals with TSH within the reference range, while low TSH was not significantly associated with any of the brain volumes. Voxel-based morphometry analyses revealed a significant positive association with serum fT4 levels in the left middle frontal gyrus.

CONCLUSIONS

In conclusion, the results of this study indicate that the subclinical hypothyroid state may lead to a reduced brain volume affecting particularly HV in younger subjects and WMV, which might correspond to subtle microstructural changes in white matter fiber tracts or myelination of the axones. Gray matter seems not to be affected by subclinical hypothyroid states.

Ultrasonographic Characteristics of Pyriform Sinus Fistulas Involving the Thyroid Gland

OBJECTIVES

Ultrasonography (US) has been considered to have a more limited role in the diagnosis of pyriform sinus fistulas than computed tomography. The aim of this study was to evaluate the US characteristics of pyriform sinus fistulas involving the thyroid gland in an attempt to improve our ability to diagnose this condition using US.

METHODS

Between 2005 and 2016, 14 patients with pyriform sinus fistulas presenting as suppurative thyroiditis or as thyroid nodules were enrolled in the study. Their US images were reviewed to identify US characteristics indicating the presence of an underlying pyriform sinus fistula and compared with the computed tomographic images.

RESULTS

A hypoechoic tubular lesion across the thyroid gland was identified in 9 patients (64.3%). Hyperechoic foci or echogenic lines were found within the lesion in 10 patients (71.4%). A hypoechoic rim was found at the boundary of the lesion in 7 patients (50.0%). A lesion emerging from the posterolateral aspect of the thyroid cartilage was found in 4 patients (28.6%). Thirteen (92.9%) of the 14 patients had 1 of these 4 findings.

CONCLUSIONS

Ultrasonography would be a useful diagnostic modality for indicating the presence of an underlying pyriform sinus fistula in patients with suppurative thyroiditis or a thyroid nodule and can be used as a first-line diagnostic tool to screen for pyriform sinus fistulas.

Acute diffuse and transient thyroid swelling after intravenous thrombolysis for acute ischemic stroke: A case report

RATIONALE

Intravenous thrombolysis is the primary therapy for acute ischemic stroke (AIS), but it has some complications, including symptomatic intracranial hemorrhage, orolingual angioedema, and extracranial bleeding. However, thyroid disorders associated with thrombolysis are very rare.

PATIENT CONCERNS

A 56-year-old man developed acute pain and neck swelling after thrombolysis with recombinant tissue plasminogen activator.

DIAGNOSES

Ultrasound revealed a diffusely enlarged thyroid with linear hypoechoic areas throughout the entire gland, resembling a "cracked" appearance.

INTERVENTIONS

The patient was treated conservatively with cold packs and observed closely. Follow-up ultrasound was made.

OUTCOMES

A few hours later, pain and swelling disappeared completely. A repeat ultrasound revealed complete recovery of thyroid volume and aspect on the next day.

LESSONS

After intravenous thrombolysis for AIS, several life-threatening complications, such as hemorrhage and orolingual angiedema, also can cause neck swelling. Urgent intubation and surgery may be required. However, the rare complication, acute diffuse thyroid swelling, is self-limiting and nonfatal and conservative treatment is sufficient. Neck ultrasound is helpful in rapidly distinguishing these complications.

Derivation of thyroid lymphoepithelial cysts from follicular cells

The pathogenesis of thyroid lymphoepithelial cysts is controversial, and two hypotheses have been proposed, namely derivation from branchial-derived remnants or from squamous metaplasia of the follicular cells. The aim of this study was to clarify the pathogenesis of thyroid lymphoepithelial cysts. We performed pathological and immunohistochemical examination of 21 thyroid lymphoepithelial cysts, 13 non-neoplastic squamous metaplasia samples without thyroid carcinoma, 13 solid cell nests, and 14 lateral cervical cysts. On ultrasound, half of thyroid lymphoepithelial cysts were interpreted as calcified nodules regardless of no calcification. Thyroid lymphoepithelial cysts and squamous metaplasia tended to be located in the central and lower portions of the thyroid, while solid cell nests were located in the upper and central portions (p < 0.05). In 95.2% of patients with thyroid lymphoepithelial cysts and all patients with squamous metaplasia, lesions were histologically associated with chronic thyroiditis forming lymph follicles. Hashimoto's disease was serologically confirmed in 18 patients with lymphoepithelial cysts (85.7%) and 10 patients with squamous metaplasia (76.9%). Immunohistochemically, lymphoepithelial cysts showed nuclear positivity for PAX8, thyroid transcription factor 1, and p63. One lateral cervical cyst (7.1%) showed positive staining for PAX8, while solid cell nests were PAX8-negative. In three (14.3%) cases of thyroid lymphoepithelial cysts, squamous cells located on the superficial layer were focally and weakly positive for CEA. We concluded that thyroid lymphoepithelial cysts originate from follicular cells and are unrelated to solid cell nests and lateral cervical cysts arising from branchial-derived remnants.

Factors influencing the outcome from ultrasonography-guided fine-needle aspiration of benign thyroid cysts and partially cystic thyroid nodules: A multicenter study

PURPOSE

The effect of ultrasonography (US)-guided fine-needle aspiration (US-FNA) for the collapse of benign cystic thyroid nodules is still unclear. This study aimed to assess the positive response rate following US-FNA of the cystic component of thyroid cysts and of partially cystic thyroid nodules (PCTNs), and to evaluate the factors influencing the outcome.

METHODS

From June to December 2013, seven radiologists at seven institutions prospectively performed US-FNA on 320 cystic thyroid nodules in 320 patients. Among them, 179 underwent at least one follow-up US examination following US-FNA of the cystic component at each institution by the same radiologist. A variety of factors, including US features of cystic thyroid nodules, the characteristics of the aspirates, and the follow-up US findings, were analyzed.

RESULTS

Of 179 cystic thyroid nodules, there were 53 thyroid cysts and 126 PCTNs. Of 179 cystic thyroid nodules, no malignancies were detected. On follow-up US, the mean size reduction rate of the cystic component was 31.9%, and 102 out of 179 thyroid nodules (57.0%) were assigned to the response group. On univariate analysis, the degree of aspiration and time interval between US-FNA and the final follow-up US showed the significant differences between the response and no response groups. On multivariate analysis, the only factor that influenced the outcome was the nodule type. The cystic component's positive response rate after simple aspiration was higher in the thyroid cysts than in the PCTNs.

CONCLUSIONS

US-FNA may be effective at collapsing the cystic components of benign thyroid cysts and PCTNs.

Intrathyroid Thyroglossal Duct Cyst Simulating a Thyroid Nodule

A case of intrathyroid thyroglossal duct cyst is reported. A 50-year-old woman presented with a right lateral neck mass that was clinically indistinguishable from a thyroid nodule. Ultrasound-guided fine-needle aspiration biopsy (US-FNAB) revealed normal-looking squamous cells. Right thyroid lobectomy was performed and microscopic examination revealed a cyst lined by squamous epithelium that was consistent with a thyroglossal duct cyst. The lesion was completely surrounded by normal thyroid tissue. Our experience suggests that intrathyroid thyroglossal duct cyst should be remembered in the differential diagnosis of a thyroid nodule. Detection of benign squamous cells by US-FNAB may be useful for ruling out the possibility of a cystic thyroid tumor.

Intrathyroidal ectopic thymus in children: A benign lesion

As ultrasound is commonly used these days, more and more lesions are found incidentally, including simple cysts, isoechoic nodules, and hypoechoic nodules, such as ectopic thymus. We here report the prevalence of ectopic thymus and its natural course.We retrospectively reviewed the charts of 690 subjects (342 males, 348 females) who were under 18 years old and had undergone neck or thyroid ultrasound at Hallym University Sacred Heart Hospital from January 2014 to June 2017. Ectopic thymus was defined when the incidental lesion was hypo- to iso-echoic compared to adjacent muscles with vascularity and did not have a connection to the thymus in the mediastinum.Of the 690 children, 16 (9 males, 7 females; median and ranges of age at diagnosis, 13 months and 18 days to 10 years) were diagnosed as having ectopic thymus. The most common location of ectopic thymus was in the inferior aspect of the left thyroid lobe. The median and ranges of the longest diameter at the time of initial diagnosis was 22.5 mm and 8 mm to 38 mm, respectively. Four cases underwent follow-up ultrasound, of which 3 cases showed no change in size and 1 case showed decreased size.Ectopic thymus should be kept in mind when a lesion is found in the neck and thyroid incidentally, and physicians should reassure parents about its benign course.

Findings of Thyroid Ultrasound Examination Within 3 Years After the Fukushima Nuclear Power Plant Accident: The Fukushima Health Management Survey

CONTEXT

Childhood thyroid cancer is of great concern after the Fukushima nuclear power plant accident. Baseline analytical data on thyroid ultrasound examination (TUE) in children are important for future studies.

OBJECTIVE

We analyzed the age and sex distribution of findings from the TUEs of children and adolescents in the Fukushima Health Management Survey (FHMS).

DESIGN, SETTING, AND PARTICIPANTS

From October 2011 through March 2014, 294,905 participants aged 18 years or younger at the time of the earthquake voluntarily had TUEs in the first round of the FHMS. A secondary confirmatory examination was performed in 2032 subjects. Age- and sex-dependent prevalence and size of thyroid cysts, nodules, and cancers were analyzed.

MAIN OUTCOME MEASURES

Age, sex, and size distribution of findings were analyzed.

RESULTS

Thyroid cysts, nodules, and cytologically suspected cancers were detected in 68,009, 1415, and 38 male subjects and in 73,014, 2455, and 74 female subjects, respectively. There was an age-dependent increase in the detection rate of thyroid nodules and cancer, but that of cysts reached a peak at 11 to 12 years. Sex affected the prevalence of thyroid nodules and cancers after the onset of puberty, but only a small difference was exhibited in that of cysts.

CONCLUSIONS

The thyroid cancer detection rate in Fukushima was clarified, and the proportion of individuals with thyroid nodules and cysts varied substantially by age. The results of this study will contribute to future epidemiological research on nodular thyroid diseases in children and adolescents.

Molecular radiotheragnostics in thyroid disease

Molecular radiotheragnostics directly links nuclear medicine diagnostic imaging to therapy. The imaging study is used to detect a specific molecular target associated with a disease process. A radiotherapeutic molecule with a similar biodistribution to the diagnostic agent can then be used to deliver targeted therapy.Molecular radiotheragnostics have been applied to manage both benign and malignant thyroid disease since the 1940s. The specific molecular pathway targeted is the sodium/iodide symporter (NIS) located on the basolateral membrane of the thyroid follicular cell. Radiolabelling of iodide or a similar ion allows targeting of the NIS system with radiopharmaceuticals for imaging (123I-radioiodine and 99mTc-pertechnetate) and treatment (131I-radioiodine) by virtue of their gamma ray and beta-particle emissions, respectively.Scintigraphic imaging directly guides 131I-radioiodine treatment planning to maximise therapeutic benefit while minimising adverse reactions, in a personalised medicine approach.

Thyroid autoimmune antibodies in patients with papillary thyroid carcinoma: a double-edged sword?

PURPOSE

The relationship between thyroid autoimmunity and thyroid cancer remains controversial. The objective of this study is to comprehensively analyze the association between thyroid autoimmune antibodies and disease statuses of papillary thyroid carcinoma (PTC).

METHODS

Patients were divided into different groups according to their final diagnoses after radioiodine therapy as well as their serum anti-thyroglobulin antibody (TgAb) and anti-thyroidperoxidase antibody (TPOAb) titers. Clinicopathologic characteristics were then compared between groups.

RESULTS

In all, 1126 PTC patients met the inclusion criteria. When compared with thyroid autoimmune antibody negative group, patients in positive group were young female predominant. After age and gender adjusted, patients in thyroid autoimmune antibody positive group had much more cervical metastatic node count and this effect was limited to the central compartment but not to the lateral compartment. Antibody positivity rate was much lower in patients with distant metastasis and multivariable logistic regression analysis showed positive status of antibody was a protective factor of distant metastasis of PTC with an OR value of 0.403 (95% CI 0.216-0.622, p < 0.001). Additionally, subgroup analysis demonstrated single TgAb positivity and combined positivity of TgAb and TPOAb were shown to be related to less distant metastatic disease.

CONCLUSIONS

Positive thyroid auto-antibody status could be a risk factor of more metastatic cervical lymph nodes while a protective factor of distant metastatic disease in PTC patients. The association between thyroid autoimmunity and thyroid cancer can be patient and antibody specific. A systemic immunosupression status may exist in PTC patients with distant metastasis.

Langerhans cell histiocytosis of the thyroid complicated by papillary thyroid carcinoma: A case report and brief literature review

RATIONALE

Langerhans cell histiocytosis (LCH) involves mainly the skin and bone and rarely the thyroid. Meanwhile, papillary thyroid carcinoma (PTC) is the most common subtype of thyroid cancer. Both LCH and PTC could make the thyroid enlarged and hypermetabolic. The coincidence of these 2 events in a patient is rare, and this paper aimed to report such case.

PATIENT CONCERNS

A 40-year-old man presented with polyuria and polydipsia for 5 years. The symptoms had been relieved well by drug therapy for >4 years, until the drugs could not control the symptoms anymore and an extensively enlarged thyroid gland was noticed.

DIAGNOSES

Thyroid ultrasound showed a nodule with microcalcification in the upper right lobe, positron emission tomography/computer tomography scan demonstrated thyroid hypermetabolism, and fine needle aspiration (FNA) revealed PTC. Right lobectomy of the thyroid and cervical lymph node biopsy verified the diagnosis "LCH of the thyroid complicated by PTC."

INTERVENTIONS

The ultrasound-guided FNA biopsy was performed prior to right lobectomy of the thyroid and cervical lymph node biopsy. Postoperative histopathological examination confirmed the diagnosis, after which the patient received adjuvant chemotherapy.

OUTCOMES

After 5 cycles of adjuvant chemotherapy, the patient had been followed up for 2 years. LCH was controlled satisfactorily and there was no significant sign of recurrence or metastasis of PTC.

LESSONS

LCH of the thyroid complicated by PTC is rare. Thyroid involvement should always be considered in the differential diagnosis of LCH patients. Surgery for PTC followed by chemotherapy for LCH may be the suitable treatment.

Systemic Sarcoidosis with Thyroid Involvement

A 66-year-old woman, who was diagnosed with iritis, visited our hospital due to general malaise. A blood analysis revealed hypercalcemia. Computed tomography revealed mediastinal and hilar lymph node hyperplasia. Moreover, ⁶⁷Gallium scintigraphy demonstrated strong accumulation in the lesions, suggesting sarcoidosis. A core needle biopsy (CNB) of the hypoechoic areas of the thyroid was performed because the patient refused to undergo a bronchoscopic examination. The scattering of slightly acidophilic epithelioid cell granulomas was observed in the pathological examination of the biopsy specimen. Based on this finding, the patient was diagnosed with sarcoidosis. Although sarcoidosis rarely involves the thyroid gland, in the present case, thyroid CNB was an alternative diagnostic method that allowed a pathological diagnosis to be obtained.

[Not Available]

Zusammenfassung. Die Sonografie der Schilddrüse mit hochauflösenden Schallsonden ist das erste und meist einzige bildgebende Untersuchungsverfahren zur Beurteilung der Schilddrüse. Schilddrüsenerkrankungen können bei Darstellung einer normal volumigen und homogen strukturierten sowie unauffällig vaskularisierten Schilddrüse weitgehend ausgeschlossen werden. Die B-Bild-sonografische Real-time-Beobachtung der Schilddrüse (Pulsatilität, Kompressibilität, Schluckverschieblichkeit) ermöglicht in vielen Fällen nicht nur die Beurteilung der Morphologie, sondern gibt auch, zusammen mit klinischen Befunden, einschliesslich basalem TSH, Hinweise auf die Funktion. Weitere Informationen werden durch die Farbdopplersonografie mit Darstellung der Vaskularisation erhalten. Die Mehrzahl der detektierten Knoten werden als Zufallsbefund entdeckt und sind harmlos. Unter der grossen Zahl von benignen Schilddrüsenknoten müssen die sehr seltenen Malignome herausgefunden werden [1-11–4]. Die sonografisch gesteuerte Feinnadelpunktion trägt zur Sicherung der Diagnose Malignom bei. Interventionell besteht zudem die Möglichkeit der sonografisch gesteuerten Sklerosierung von Zysten und autonomen Schilddrüsenadenomen [5-15].

Intrathyroidal ectopic thymus in children: a sonographic survey

AIMS

Intrathyroidal ectopic thymus (IET) is being increasingly reported in the radiology literature. Most of the reports are of individual cases or small series and prevalence and natural course of the pathology is not well known. The purpose of this study is to establish the prevalence of IET in children and report long term follow-up results.

MATERIAL AND METHODS

In 180 children who were examined by ultrasound (US) for other reasons, 7 patients were indentified with IET. Together with the other seven children who were already under follow-up for IET (diagnosed using US criteria), these 14 patients were followed up with US for 30 months. Size, shape, location, echotexture and internal echoes of the lesions were evaluated.

RESULTS

There were 16 lesions in 14 children. The most common appearance was a fusiform hypoechoic lesion, with punctate and linear internal echoes and well-defined but slightly irregular borders located posteriorly in the lower thirds of the thyroid. In follow-up, there were no changes in echotexture, shape or border. In 3 patients, the lesion became slightly smaller, in a 10-year-old boy slightly larger, and in an 11-year old boy the lesion disappeared. In a patient with bilateral lesions, one lesion slightly decreased in size.

CONCLUSIONS

IET in children may be more common than thought. Its growth reflects that of a normal thymus. Awareness of this entity is important in order not to misdiagnose them, especially as papillary cancer, and to prevent unnecessary interventions.

Comparing pre-therapeutic 124I and 131I uptake tests with intra-therapeutic 131I uptake in benign thyroid disorders

PURPOSE

¹²⁴I-PET/CT can be used for pre-therapeutic assessment of radioactive iodine uptake in benign thyroid disorders, however systematic comparisons with intra-therapeutic uptake are still lacking for these disorders. The goals of this study were to compare ¹²⁴I RAIU and conventional ¹³¹I RAIU tests with each other; to compare both tests with intra-therapeutic uptake (reference); and to verify the time course of radioactive iodine uptake at three time points (30, 102, and 336 h [14 days] post administration; p.a.).

METHODS

Thirteen patients with benign thyroid diseases underwent ¹³¹I RAIU test and ¹²⁴I RAIU test one after another before the intra-therapeutic ¹³¹I uptake (reference) was measured via short-range and long-range measurements. After correction for decay, relative uptake differences were calculated and subjected to the Bland-Altman method for the evaluation of levels of agreement.

RESULTS

Radioactive iodine uptake tests with ¹²⁴I-PET/CT and ¹³¹I probe did not show systematic deviations at any time point. Likewise, at 30 and 102 h p.a. there was no systematic discrepancy between pre-therapeutic and intra-therapeutic uptake levels. At 14 days p.a., however, both pre-therapeutic tests tended to overestimate the uptake compared to reference. Findings showed, for the first time with ¹²⁴I, that radioiodine therapy has some early radiobiological effects possibly limiting the accuracy of pre-therapeutic dosimetry.

CONCLUSIONS

¹²⁴I RAIU tests represent a feasible alternative to standard ¹³¹I RAIU tests. The additional benefits of ¹²⁴I-PET/CT (e.g., functional topography, inclusion of retrosternal areas, possibility to enable fusion imaging) may thus increase the scope of this technology in benign thyroid disorders.

Association of parathyroid carcinoma and thyroid disorders: A clinical review

Parathyroid carcinoma is a rare malignancy, which usually occurs as a sporadic disease, and less frequently in the setting of genetic syndromes. Despite the association of parathyroid and thyroid disorders being quite common, the coexistence of parathyroid carcinoma and thyroid disease is rare. We reviewed the pertinent literature. The terms "parathyroid carcinoma" and "thyroid disease, hyperthyroidism, thyrotoxicosis, hypothyroidism, thyroid nodule(s), Graves' disease, autonomously functioning thyroid nodules" were used both separately and in reciprocal conjunction to search MEDLINE for articles published from January 2007 to March 2016. The search was prompted by the observation of a never reported association of autonomously functioning thyroid nodules and parathyroid carcinoma. Two hundred and twenty-one parathyroid carcinoma patients have been described during the last 10 years. Neck ultrasonography and parathyroid scintigraphy are the most common instrumental studies used in detecting parathyroid lesions. Serum parathyroid hormone and calcium levels are high in the majority of parathyroid carcinoma patients. Only 21 patients with parathyroid carcinoma and thyroid disorders were found. Our patient is the first casual association between parathyroid carcinoma and autonomously functioning thyroid nodules reported in literature and diagnosed using parathyroid and thyroid scintigraphies. Parathyroid carcinoma is a very rare endocrine tumor and association with thyroid disease is not frequent. Parathyroid carcinoma pre-operative diagnosis is often difficult also because available literature data are not homogenous and there is not a common operative guideline. Our case confirms the role of parathyroid scintigraphy, encouraging the association with thyroid scintigraphy, especially in the presence of (multi)-nodular goiter in order to address the most appropriate surgical management.

A Computer-Aided Diagnosis System Using Artificial Intelligence for the Diagnosis and Characterization of Thyroid Nodules on Ultrasound: Initial Clinical Assessment

BACKGROUND

An initial clinical assessment is described of a new, commercially available, computer-aided diagnosis (CAD) system using artificial intelligence (AI) for thyroid ultrasound, and its performance is evaluated in the diagnosis of malignant thyroid nodules and categorization of nodule characteristics.

METHODS

Patients with thyroid nodules with decisive diagnosis, whether benign or malignant, were consecutively enrolled from November 2015 to February 2016. An experienced radiologist reviewed the ultrasound image characteristics of the thyroid nodules, while another radiologist assessed the same thyroid nodules using the CAD system, providing ultrasound characteristics and a diagnosis of whether nodules were benign or malignant. The diagnostic performance and agreement of US characteristics between the experienced radiologist and the CAD system were compared.

RESULTS

In total, 102 thyroid nodules from 89 patients were included; 59 (57.8%) were benign and 43 (42.2%) were malignant. The CAD system showed a similar sensitivity as the experienced radiologist (90.7% vs. 88.4%, p > 0.99), but a lower specificity and a lower area under the receiver operating characteristic (AUROC) curve (specificity: 74.6% vs. 94.9%, p = 0.002; AUROC: 0.83 vs. 0.92, p = 0.021). Classifications of the ultrasound characteristics (composition, orientation, echogenicity, and spongiform) between radiologist and CAD system were in substantial agreement (κ = 0.659, 0.740, 0.733, and 0.658, respectively), while the margin showed a fair agreement (κ = 0.239).

CONCLUSION

The sensitivity of the CAD system using AI for malignant thyroid nodules was as good as that of the experienced radiologist, while specificity and accuracy were lower than those of the experienced radiologist. The CAD system showed an acceptable agreement with the experienced radiologist for characterization of thyroid nodules.

Primary Malignant Fibrous Histiocytoma of the Thyroid: Two Case Reports and Review of the Literature

Primary malignant fibrous histiocytoma of the thyroid is an uncommon malignancy of the thyroid. Because it is rare, fewer than 20 cases have been reported in the literature, and the sonographic features of only 2 cases have been reported between the 1980s and 2014. Here we report 2 cases of primary malignant fibrous histiocytoma of the thyroid with an emphasis on the sonographic findings, and we review the published literature.

Management of concomitant hyperparathyroidism and thyroid diseases in the elderly patients: a retrospective cohort study

BACKGROUND

Thyroid disease and hyperparathyroidism are the most common endocrine disorders. The incidence of thyroid disease in patients with hyperparathyroidism ranges in the different series from 17 to 84%, and thyroid cancer occurs with an incidence ranging from 2 to 15%.

AIM

The aim of our study was to analyze the management of elderly patients with concomitant thyroid and parathyroid disease in order to define the best surgical therapeutic strategy and avoid reoperations associated with a higher risk of complications.

METHODS

All consecutive patients (64 patients, age range 60-75 years), undergoing surgery for hyperparathyroidism, from January 2011 to June 2014, were retrospectively evaluated. Enrolled patients were divided into two study groups of patients affected by hyperparathyroidism with or without a concomitant thyroid disease.

RESULTS

Out of 64 patients enrolled in our study (24 men, age range 60-75 years), affected by hyperparathyroidism, 34 had an associated thyroid disease and were treated with total thyroidectomy and parathyroidectomy. The group, who underwent parathyroidectomy associated with thyroidectomy, had no greater complications than the group receiving only parathyroidectomy.

CONCLUSIONS

Thyroid disease must be excluded in patients affected by hyperparathyroidism. It is difficult to determine whether hyperparathyroidism can be considered a risk factor for thyroid disease, but an accurate preoperative study is essential for a surgery able to treat both thyroid and parathyroid disease. In this way, we avoid the elderly patient, with associated morbidity and increased surgical risk, to undergo a reoperation for thyroid disease, burdened with major complications.

Thyroid Ultrasound: State of the Art Part 1 - Thyroid Ultrasound reporting and Diffuse Thyroid Diseases

Accurate differentiation of focal thyroid nodules (FTL) and thyroid abnormalities is pivotal for proper diagnostic and therapeutic work-up. In these two part articles, the role of ultrasound techniques in the characterization of FTL and evaluation of diffuse thyroid diseases is described to expand on the recently published World Federation in Ultrasound and Medicine (WFUMB) thyroid elastography guidelines and review how this guideline fits into a complete thyroid ultrasound exam.

WFUMB Guidelines and Recommendations on the Clinical Use of Ultrasound Elastography: Part 4. Thyroid

The World Federation for Ultrasound in Medicine and Biology (WFUMB) has produced guidelines for the use of elastography techniques including basic science, breast and liver. Here we present elastography in thyroid diseases. For each available technique, procedure, reproducibility, results and limitations are analyzed and recommendations are given. Finally, recommendations are given based on the level of evidence of the published literature and on the WFUMB expert group's consensus. The document has a clinical perspective and is aimed at assessing the usefulness of elastography in the management of thyroid diseases.

Early postoperative tissue harmonic sonography of the thyroid gland

Purpose: Fundamental gray-scale imaging (FGI) is known to be unuseful for thyroid imaging in the early postoperative setting. Thus, we evaluated the feasability of tissue harmonic imaging (THI) early after thyroid resection.

Material and Methods: FGI and THI of the neck were perfomed in 48 consecutive patients 4 days after surgery. The examiner was blinded to patient diagnoses and types of surgery. FGI and THI examinations were stored on videotape and reviewed offline by two different readers who rated the quality of delineation of the organ borders and presence or absence of focal lesions. The results were compared to neck US performed 12 weeks after surgery.

Results: Delineation of the thyroid remnants in THI/FGI was rated to be excellent in 22/2, good in 11/9, poor in 3/16 and not visible at all in 4/13 patients. The correlation between THI-volumetry and control-volumetry was very high (r=0.81; p&lt;0.0001). THI but not FGI depicted presence or absence of solid thyroid nodules with 100% accuracy.

Conclusion: THI is a feasible method for thyroid US in the early postoperative setting. It permits volumetry of the residual thyroid tissue and accurately depicts nodules within the thyroid remnant.

Thyroid disorders and nitric oxide in cardiovascular adaptation to hypovolemia

This study aimed to investigate whether nitric oxide participates in the cardiovascular function and haemodynamic adaptation to acute haemorrhage in animals with thyroid disorders. Sprague-Dawley rats aged 2months old treated with T3 (hyper, 20μg/100g body weight) or 0.02% methimazole (hypo, w/v) during 28days were pre-treated with N(G) nitro-l-arginine methyl ester (L-NAME) and submitted to 20% blood loss. Heart function was evaluated by echocardiography. Measurements of arterial blood pressure, heart rate, nitric oxide synthase activity and protein levels were performed. We found that hypo decreased fractional shortening and ejection fraction and increased left ventricle internal diameter. Hyper decreased ventricle diameter and no changes in cardiac contractility. Haemorrhage elicited a hypotension of similar magnitude within 10min. Then, this parameter was stabilized at about 30-40min and maintained until finalized, 120min. L-NAME rats showed that the immediate hypotension would be independent of nitric oxide. Nitric oxide synthase inhibition blunted the changes of heart rate induced by blood loss. Hyper and hypo had lower atrial enzyme activity associated with a decreased enzyme isoform in hypo. In ventricle, hyper and hypo had a higher enzyme activity, which was not correlated with changes in protein levels. Haemorrhage induced an increased heart nitric oxide production. We concluded that thyroid disorders were associated with hypertrophic remodelling which impacted differently on cardiac function and its adaptation to a hypovolemia. Hypovolemia triggered a nitric oxide synthase activation modulating the heart function to maintain haemodynamic homeostasis. This involvement depends on a specific enzyme isoform, cardiac chamber and thyroid state.

Spontaneous intrathyroidal hematoma causing airway obstruction: A case report

INTRODUCTION

Spontaneous thyroid hemorrhage is a rare occurrence that results in pain, discomfort, and occasionally compressive symptoms. Infrequently, extensive thyroid hemorrhage can result in a rapidly expanding hematoma resulting in airway compromise. This is a case of an otherwise healthy young woman, 3 months postpartum, with a slowly expanding spontaneous thyroid hemorrhage that measured at 7 × 5.5 × 5 cm by computed tomography. She ultimately required intubation to manage respiratory distress and subsequently a hemithyroidectomy for definitive treatment. The case presentation is followed by a literature review where known etiologies of thyroid hematoma including traumatic and nontraumatic causes, precipitating anticoagulation, and spontaneous rupture of branches of the external carotid artery are outlined. The potential links to pregnancy are explored. The roles of bedside thyroid ultrasound in the emergency department and lateral neck roentgenogram in diagnosis are explored. The importance of airway management and indications for conservative versus surgical treatments are discussed.

CONCLUSIONS

This is a case of a spontaneous intrathyroidal hemorrhage, which progressed over days to ultimately cause airway compromise. It is imperative that physicians are educated on the appropriate detection and management of the potentially life-threatening spontaneous thyroid hematoma.