Abstract
BackgroundThe standard management in patients with thyroid nodules is to assess the risk of malignancy, based on cytological examination. On the other hand, there are thyroid patterns of ultrasound (US) image, associated with an increased risk of malignancy.The aim of our study was to create a diagnostic algorithm that would employ both data from US examination (expressed by a total score, according to our scoring system) and FNAB results, classified according to Bethesda system (The Bethesda System for Reporting Thyroid Cytopathology - TBSRTC categories).Material and methods100 thyroid cancer foci (94 papillary carcinomas, 4 medullary carcinomas, 2 undifferentiated carcinomas) and 100 benign focal lesions were selected during postoperative histopathological examination of thyroid glands excised during surgery from 111 patients. The corresponding US images of each lesion – performed in the course of preoperative diagnostics – were evaluated for the presence of seven (7) different features in US image, suggesting a malignant character of lesion, viz. vascularity, i.e., the increased central intranodular blood flows, microcalcifications, “taller-than-wide” orientation, solid composition, hypoechogenicity, irregular margin and either absence of peripheral halo or the presence of outer shell of uneven thickness, surrounding the lesion. The sensitivity, specificity, positive predictive values, negative predictive values and odds ratios for each US feature were calculated.ResultsIn US image of the analyzed cancer foci, we obtained the following values of odds ratio for each of the above mentioned features suggesting malignancy: “taller-than-wide” orientation - odds ratio - 301.0, microcalcifications - 24.67, increased intranodular vascularity - 20.44, hypoechogenicity - 18.61, irregular margins - 7.81, absence of halo - 5.88, and solid composition - 4.16.Taking into account our own experience and the present data, in juxtaposition with the opinions of other authors, we propose a division of US features into 3 groups of different prognostic importance, expressed by a total score calculated based on our scoring system. Accordingly, microcalcifications, “taller-than-wide” orientation, the increased intranodular vascularity, and hypoechogenicity constitute one group - each of the features in this group is awarded 1 point. In turn, the characteristics of minor prognostic importance, such as irregular margin, absence of halo, solid composition, and large size (a diameter longer than 3.0 cm) - are associated with the granting 0.5 points each. The most important prognostic features – a rapid growth (enlargement) of nodules/focal lesions and a presence of pathologically altered lymph nodes are associated with the granting 3 points for each.Our scoring system can be applied in order to better assessment of thyroid US patterns in whole. In patients with a total score ranging from 0 < 4 points there is US pattern of a low risk of malignancy, with ≥ 4 < 7 points - intermediate risk, and in patients with a score ≥ 7 points – a high risk in question.ConclusionComplementary use of our scoring system and FNAB TBSRTC categories can help to make optimal clinical decisions as regards the selection of treatment strategy.
Highlights
The standard management in patients with thyroid nodules is to assess the risk of malignancy, based on cytological examination
The aim of our study was to create an algorithm that would employ both data from US examination and fine needle aspiration biopsy (FNAB) results, classified according to Bethesda recommendations (The Bethesda System for Reporting Thyroid Cytopathology - TBSRTC categories), in order to optimise diagnostic and therapeutic management in case of nodules/US focal lesions in the thyroid [6]
100 thyroid cancer foci (94 papillary carcinomas, 4 medullary carcinomas, 2 undifferentiated carcinomas) and 100 benign focal lesions were selected during postoperative histopathological examination of thyroid glands excised during surgery carried out in 111 patients, aged 23 to 79 years
Summary
The standard management in patients with thyroid nodules is to assess the risk of malignancy, based on cytological examination. It allows to visualize 10 times more US lesions than the number of palpable nodules detected during the physical examination [1,2,3] It creates diagnostic and therapeutic dilemmas, dominated by the question: what is the most proper medical management – observation and careful monitoring of existing nodule, or – the opposite - referring the patients for surgery. Even though the biopsy is considered by many doctors as a basis for further monitoring, performing FNAB of any identified lesions may not be prudent [4,5] It happens that FNAB confirms the benign nature of the lesion and, it is quite frequently repeated (often many times) in spite of the fact that US image pattern does not change during a long-term observation. The endocrinologist - while diagnosing the thyroid nodule - cannot forget a question of fundamental importance – what is a bigger threat to the patients – observation, i.e., monitoring of lesion and live with the existing thyroid nodule or subjecting the patient to surgical treatment of his/her thyroid
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