Evaluation Of Thyroid Nodules Research Articles

When Do Physicians Actually Order Neck Ultrasound for Evaluation of Thyroid Nodules?

When Do Physicians Actually Order Neck Ultrasound for Evaluation of Thyroid Nodules?

Concordance of the ACR TI-RADS

BackgroundUltrasonography (US) is the method of choice for evaluating thyroid nodules. In 2017, the American College of Radiology (ACR) created a classification system based on US characteristics. For the system to be adopted, it must be reproducible. ObjectivesTo determine the intraobserver and interobserver variability of the ACR TI-RADS. MethodsCross-sectional study; three radiologists with different levels of experience used the ACR TI-RADS to classify 100 nodules on two occasions one month apart, and we calculated the intraobserver and interobserver variability. ResultsRegarding intraobserver variability, the first radiologist had nearly perfect concordance for composition, echogenicity, shape, and margins and substantial concordance for echogenic foci; the second radiologist had nearly perfect concordance for composition, echogenicity, shape, and margins and substantial concordance for echogenic foci, and the third radiologist had nearly perfect concordance for composition, echogenicity, and shape and substantial concordance for margins and echogenic foci. The interobserver concordance was calculated for the two readings; the concordance was substantial except for shape in the first reading and for echogenicity and margins in the second reading, which had moderate concordance. ConclusionsThe ACR TI-RADS classification system is reproducible.

American Association of Clinical Endocrinology And Associazione Medici Endocrinologi Thyroid Nodule Algorithmic Tool.

The first edition of the American Association of Clinical Endocrinology/American College of Endocrinology/Associazione Medici Endocrinologi Guidelines for the Diagnosis and Management of Thyroid Nodules was published in 2006 and updated in 2010 and 2016. The American Association of Clinical Endocrinology/American College of Endocrinology/Associazione Medici Endocrinologi multidisciplinary thyroid nodules task force was charged with developing a novel interactive electronic algorithmic tool to evaluate thyroid nodules. The Thyroid Nodule App (termed TNAPP) was based on the updated 2016 clinical practice guideline recommendations while incorporating recent scientific evidence and avoiding unnecessary diagnostic procedures and surgical overtreatment. This manuscript describes the algorithmic tool development, its data requirements, and its basis for decision making. It provides links to the web-based algorithmic tool and a tutorial. TNAPP and TI-RADS were cross-checked on 95 thyroid nodules with histology-proven diagnoses. TNAPP is a novel interactive web-based tool that uses clinical, imaging, cytologic, and molecular marker data to guide clinical decision making to evaluate and manage thyroid nodules. It may be used as a heuristic tool for evaluating and managing patients with thyroid nodules. It can be adapted to create registries for solo practices, large multispecialty delivery systems, regional and national databases, and research consortiums. Prospective studies are underway to validate TNAPP to determine how it compares with other ultrasound-based classification systems and whether it can improve the care of patients with clinically significant thyroid nodules while reducing the substantial burden incurred by those who do not benefit from further evaluation and treatment.

Diagnostic accuracy of B-mode ultrasound, ultrasound elastography and diffusion weighted MRI in differentiation of thyroid nodules (prospective study)

BackgroundThe incidence of the thyroid nodules and its detection is increasing rapidly. The most precise method for diagnosis of the nodules of the thyroid is FNAC. But, about 10–20% of specimens of FNAC are indeterminate and non-diagnostic. Therefore, there is a demand for another diagnostic method for evaluating thyroid nodules. Thyroid ultrasound elastography may improve the ability to differentiate malignant from benign thyroid nodules. Few articles were published about the results of DW MRI in thyroid nodules, with its results confirmed that malignant nodules have lower mean ADC values than benign nodules. This study aims to investigate and compare the accuracy of B-mode ultrasound, ultrasound elastography and diffusion-weighted MRI in characterization of the nodules of the thyroid.ResultsThe study included 56 patients with thyroid nodules (36 benign and 20 malignant). Thyroid ultrasound, ultrasound elastography and DWI were done for all patients. Ultrasound-guided FNA Cytological examination (as the gold standard) was done for 48 patients and surgical histopathology was done to 8 patients with non-diagnostic FNAC. The results showed: TIRADS score had sensitivity 90%, specificity 77.8% and accuracy of 82.14%. The elastography score had sensitivity 80%, specificity 88.9% and accuracy 85.7%. The use of the strain ratio had 80% sensitivity, 94.4% specificity and 89.3% accuracy. DWI and ADC value had 100% sensitivity and 94.4% specificity and the accuracy was 96.4% for differentiating malignant from benign thyroid nodules. Multi-parametric analysis by TIRADS and ADC had 100% accuracy.ConclusionUltrasound elastography add valuable data over ultrasound TIRADS. But, diffusion weighted MRI and ADC value has more accuracy in differentiating malignant from benign thyroid nodules. The best performance was achieved by the combination of ACR-TIRADS and ADC value.

Study of serum Micro-RNA 221 Expression in Patients with Thyroid Nodules and Its Relation to Outcome

Abstract A major dilemma in the diagnostic management of thyroid nodules is to determine whether it is a benign or malignant lesion and hence to determine decision for surgery. The majority of individuals with thyroid nodules are asymptomatic. The current first line of evaluation of thyroid nodules encompasses thyroid hormone laboratory tests, and ultrasonography of the thyroid gland, fine-needle aspiration (FNA) biopsy is often used to rule out cancer in thyroid nodules, in 20–30% of cases, however, FNAB yields indeterminate cytological results and suspicious for malignancy. Surgery was classically recommended for such indeterminate nodules for their risk of malignancy, which, overall, is about 25% when confirmed histopathologically upon thyroidectomy. As a result, about 75% of patients with cytologically indeterminate thyroid nodules would undergo unnecessary thyroid surgeries for nodules that prove to be benign only after surgery. Recent advances in research on thyroid carcinogenesis have yielded applications of diagnostic molecular biomarkers and profiling panels in the management of thyroid nodules. Among these markers are MicroRNAs (miRs) are small RNA sequences (19–25 nucleotides) that function to regulate the expression of genes. In this paper we aim to detect a possible of Micro-RNA 221 expression in sera of Patients With thyroid nodules and its relation to outcome after surgery.

The Role of CEUS in the Evaluation of Thyroid Cancer: From Diagnosis to Local Staging.

Ultrasound often represents the first diagnostic step for thyroid nodule evaluation in clinical practice, but baseline US alone is not always effective enough to achieve thyroid nodule characterization. In the last decades new ultrasound techniques, such as CEUS, have been introduced to evaluate thyroid parenchyma as recommended by EFSUMB guidelines, for use in clinical research field, although its role is not yet clear. Several papers show the potential utility of CEUS in the differential diagnosis of benign and malignant thyroid nodules and in the analysis of lymph node involvement in neoplastic pathology. Therefore, we carried out an evaluation of the literature concerning the role of CEUS in three specific areas: the characterization of the thyroid nodule, the evaluation of minimally invasive treatment and loco-regional staging of the lymph node in proven thyroid cancer. According to evidence reported, CEUS can also play an operative role in nodular thyroid pathology as it is able to guide ablation procedures on thyroid nodule and metastatic lymph nodes, to assess the radicality of surgery, to evaluate disease relapse at the level of the margins of ablated regions and to monitor the clinical evolution of necrotic areas in immediate post-treatment setting.

Surgical Outcome and Malignant Risk Factors in Patients With Thyroid Nodule Classified as Bethesda Category III.

BackgroundThyroid nodules are a very common finding in the general population. Fine-needle aspiration (FNA) has been recommended as the initial test for the evaluation of thyroid nodules. The trend on reporting as atypia of undetermined significance (AUS) has been significantly increased, but the malignant risk is still controversial among different studies. The aim of this study is to investigate the malignancy risk of thyroid nodules reported as Bethesda category III (AUS/FLUS) on initial FNA.MethodWe reviewed 272 papillary thyroid cancer (PTC) patients with suspicious thyroid nodules who underwent fine-needle aspiration and received surgical treatment during 2019 to 2020.ResultsOne hundred ten (40.4%) patients were diagnosed with PTC. Multivariate analysis showed that microcalcification (p = 0.037, OR = 2.260, 95% CI: 1.051–4.860), shape (p = 0.003, OR = 4.367, 95% CI: 1.629–11.705), diameters (p = 0.002, OR = 0.278, 95% CI: 0.123–0.631), anti-thyroglobulin antibodies (TGAb) (p = 0.002, OR = 0.150, 95% CI: 0.046–0.494), anti-thyroid peroxidase antibody (A-TPO) (p = 0.009, OR = 4.784, 95% CI: 1.486–15.401), and nodule goiter (p < 0.001, OR = 0.100, 95% CI: 0.046–0.217) were independent malignant risk factors in patients with thyroid nodule classified as Bethesda category III.ConclusionIn this study, malignant risk factors in patients with thyroid nodule classified as Bethesda category III were significantly associated with preoperative serum TGAb, A-TPO, microcalcification, irregular shape, and nodule diameters. Nodules with malignant factors should be carefully elevated; surgery may be the better option for those patients.

ACR TI-RADS Recommendations: A Call to Contextualize Radiologists' Recommendations for Thyroid Nodules With the Clinical Scenario.

The American College of Radiology incidental findings and Thyroid Imaging Reporting and Data System (TI-RADS™) committees have provided guidance for reporting findings and providing recommendations for the management of patients with thyroid nodules, and these interventions have significantly reduced performance of unnecessary thyroid biopsies [ 1 Hoang J.K. Langer J.E. Middleton W.D. et al. Managing incidental thyroid nodules detected on imaging: white paper of the ACR Incidental Thyroid Findings Committee. J Am Coll Radiol. 2015; 12: 143-150 Abstract Full Text Full Text PDF PubMed Scopus (179) Google Scholar , 2 Tessler F.N. Middleton W.D. Grant E.G. et al. ACR Thyroid Imaging, Reporting and Data System (TI-RADS): white paper of the ACR TI-RADS Committee. J Am Coll Radiol. 2017; 14: 587-595 Abstract Full Text Full Text PDF PubMed Scopus (711) Google Scholar ]. ACR guidance spans from incidental thyroid nodules detected on cross-sectional imaging and PET to categorization according to thyroid cancer risk for thyroid nodules evaluated on ultrasound with TI-RADS [ 1 Hoang J.K. Langer J.E. Middleton W.D. et al. Managing incidental thyroid nodules detected on imaging: white paper of the ACR Incidental Thyroid Findings Committee. J Am Coll Radiol. 2015; 12: 143-150 Abstract Full Text Full Text PDF PubMed Scopus (179) Google Scholar , 2 Tessler F.N. Middleton W.D. Grant E.G. et al. ACR Thyroid Imaging, Reporting and Data System (TI-RADS): white paper of the ACR TI-RADS Committee. J Am Coll Radiol. 2017; 14: 587-595 Abstract Full Text Full Text PDF PubMed Scopus (711) Google Scholar ]. Evaluation and treatment of thyroid nodules are frequently not the primary concern of patients or of clinicians when they are discovered [ 3 Genere N. Hurtado M.D. Cortes T. et al. Drivers of the decision to biopsy and follow-up of small suspicious thyroid nodules. Endocr Pract. 2020; 26: 857-868 Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar , 4 Singh Ospina N. Iniguez-Ariza N.M. Castro M.R. Thyroid nodules: diagnostic evaluation based on thyroid cancer risk assessment. BMJ. 2020; 368: l6670 Crossref PubMed Scopus (26) Google Scholar ]. Thyroid nodule evaluation may have been born out of testing unrelated to the thyroid and often is ordered by primary care clinicians who are providing care for multiple other issues. Therefore, clinicians are quite appreciative of specific recommendations for thyroid nodule management according to imaging results.

Ultrasound Guided Thyroid Biopsy

Thyroid nodules are extremely prevalent among older adults, and pose a challenge due to the frequency in which they are incidentally encountered. Approximately 5% of all nodules are malignant. Ultrasound is the first line tool to evaluate thyroid nodules, and can help identify nodules that are high-risk for malignancy. Fine needle aspiration (FNA) is an excellent low-risk procedure used to evaluate suspicious thyroid nodules and identify thyroid malignancy. It is performed with a 22-27-gauge needle under ultrasound guidance. Core needle biopsy (CNB) is usually not required; however, it can be helpful if FNA is non-diagnostic or inconclusive. On-site pathologist evaluation can help determine which patients need additional sampling. CNB is usually performed with a trocar technique using an 18-gauge biopsy device under ultrasound guidance. Complications from thyroid biopsy are rare, and the most common complications are discomfort, small to moderate hematoma, and insufficient sampling. Although rare, a rapidly expanding large hematoma can cause airway compression requiring intubation and surgery to preserve the airway and achieve hemostasis. Following biopsy, approximately 10.8% of thyroid nodules will require surgical excision.

False Negative Rates in Benign Thyroid Nodule Diagnosis: Machine Learning for Detecting Malignancy

BackgroundThyroid nodules are common; up to 67% of adults will show nodules on high-quality ultrasound, and 95% of these nodules are benign. FNA cytology is a crucial step in determining the risk of malignancy, and a false negative diagnosis at this stage delays cancer treatment. The purpose of this study is to develop a predictive model using machine learning which can identify false negative FNA results based on less-invasive clinical data. Materials and methodsWe conducted a retrospective medical record review at one academic and one community center. Inclusion criteria were thyroid nodules evaluated by ultrasound and FNA with a Bethesda II (benign) result or malignancy detected on pathology or FNA. Linear, non–linear, and ensemble models were generated with scikit-learn using 10-fold cross validation with repetition and compared with AUROC. The classification task was the prediction of malignancy using information acquired from less-invasive ultrasound and FNA. ResultsA total of 604 subjects met inclusion criteria; 38 were diagnosed with malignancy. Of all algorithms tested, a Random Forest method achieved the best AUROC (0.64) in separating benign and malignant nodules, though the improvement over other tested algorithms was not statistically significant. ConclusionsA Random Forest model performed better than random chance using readily available data obtained via standard evaluation of thyroid nodules. The diagnostic probability threshold of this model can be varied to minimize false positives at the cost of increasing the number of false negatives. Future studies will prospectively evaluate the model's performance.

Real-world EUROCRINE® registry data challenge the reliability of Bethesda cytopathology for thyroid surgery indication.

Fine-needle aspiration cytology (FNAC) is recommended by international guidelines for the preoperative evaluation of suspicious thyroid nodules >1cm. Despite robust evidence from endocrine centers demonstrating the key role of FNAC results for the indication of surgery, the method is not routinely used in European clinics. The database EUROCRINE®, which was introduced in 2015 with the scope of registering operations of the endocrine system, allows for a large-scale analysis of the current service reality in Europe concerning FNAC use and associated accuracy. Operations performed to "exclude malignancy", registered from January 2015 to December 2018 in EUROCRINE®, were analyzed. Parameters of accuracy were calculated for FNAC. FNAC results were considered "test positive" in the case of Bethesda category IV, V, and VI, since these categories usually prompt surgical interventions in European centers for thyroid surgery. Bethesda category II and III were considered "test negative". Of 8,791 operations, 5,780 had preoperative FNAC (65.7%). The overall malignancy rate was 28.3% (2,488/8,791). Malignancy rates were 68.8% for Bethesda VI, 69.9% for Bethesda V, 32.6% for Bethesda IV, 28.2% for III, 20.2% for Bethesda II, and 24.5% for Bethesda I. After exclusion of papillary microcarcinomas (PTMCs), the sensitivity of FNAC was 71.7% and specificity 43.5%, the positive predictive value was 29.1% and the negative predictive value 82.7%. Although the indication to "exclude malignancy" was the predominant reason that prompted thyroid resection in the present cohort, FNAC was only used in about 65.7% of cases. When performed, FNAC was associated with unexpectedly low accuracy. Interestingly, in Bethesda II, 20.2% of malignant entities were present (13.3% after the exclusion of PTMCs).

The Value of Thyroid Ultrasound Computer-Aided Diagnosis System in the Evaluation of Thyroid Nodules With Concurrent Hashimoto's Thyroiditis.

To investigate the value of computer-aided diagnosis (CAD) system in assessing thyroid nodules concurrent with Hashimoto's thyroiditis (HT). Totally 148 patients with 193 thyroid nodules were enrolled. A radiologist assessed the nodules using a thyroid ultrasound CAD system. Additionally, the nodules were evaluated by one experienced radiologist alone, and one training radiologist without and with CAD assistance. The diagnostic performance was compared between the CAD system and the experienced radiologist, and the training radiologist without and with CAD assistance. The CAD system demonstrated a similar sensitivity to that of the experienced radiologist in diagnosing thyroid cancers (89.8% versus 92.4%, P > .05). The specificity and accuracy of the CAD system were lower than that of the experienced radiologist in assessing the nodules with diffusedly altered glands (specificity, 60.0% versus 81.7%, P=.007; accuracy, 77.5% versus 88.1%, P=.011). With CAD assistance, the training radiologist had improved sensitivity and accuracy that increased to 87.9% and 86.8% in classifying nodules with sonographically evident HT (both P=.012). The CAD system has comparable sensitivity, but lower specificity compared with the experienced radiologist in diagnosing thyroid malignancies concurrent with HT. For a radiologist with less experience, the CAD system can help improve the diagnostic performance by increasing sensitivity and accuracy in assessing thyroid nodules with diffusely altered parenchyma.

Diagnostic Accuracy of Five Different Classification Systems for Thyroid Nodules: A Prospective, Comparative Study.

To compare the diagnostic performance of five different thyroid ultrasound classification systems, and determine which system is optimal for evaluating thyroid nodules and reducing the unnecessary biopsy rate. In this prospective study, 1,010 nodules referred for biopsy during a 2-year period were classified using five classification systems: the Kwak Thyroid Imaging Reporting and Data System (Kwak TI-RADS), the European TI-RADS (EU TI-RADS, the Korean TI-RADS (K TI-RADS), the American College of Radiology TI-RADS (ACR TI-RADS), and the American Thyroid Association (ATA) classification. After fine needle aspiration biopsy, all classifications were compared for all nodules and also particularly for nodules sized 1-3 cm. Sensitivity, specificity, and interobserver agreement were evaluated for each classification system. Of the 939 nodules (after exclusion of Bethesda 3 nodules) finally classified according to the surgical histopathology and cytology results, 73 (7.8%) were malignant and 866 nodules were benign (92.2%). The sensitivity was highest (94.5%) for the ACR TI-RADS and lowest for the Kwak TI-RADS (69%). After exclusion of small (<1 cm) and large nodules (>3 cm); while sensitivity was highest for ATA (97.8%), ACR TI-RADS was the second best classification (91.3%). There was substantial agreement among all classification systems except the Kwak TI-RADS (fair agreement). The ACR TI-RADS was the most sensitive ultrasound risk stratification system for all nodules, while the Kwak TI-RADS was the most specific, ie, the most capable of excluding benign nodules based on the combined cytological and histopathological results. ATA and ACR-TIRADS were the most sensitive classification systems for nodules 1 to 3 cm in size. The ACR TI-RADS had higher sensitivity than the Bethesda classification system when compared according to the histopathological results.

Correlation between the Bethesda system for thyroid nodules and post-thyroidectomy histopathological diagnosis

Thyroid nodules are a common clinical condition. Thyroid nodules may be identified with ultrasonography in roughly 50% of the population. The risk of malignancy varies between 4 and 15% of the nodules. Fine needle aspiration (FNA) with a cytopathology report using the Bethesda system is the most utilized methods to diagnose thyroid carcinoma. A retrospective, descriptive study was performed to investigate the correlation between the cytopathology of the FNA biopsies, and the final histopathology after thyroidectomy. A total of 128 nodules in 128 patients were studied; 24 males and 104 females. In the Bethesda category I, a 67% malignancy rate was reported, Bethesda II 14%, Bethesda III 28% for follicular lesions and 15% for atypia, Bethesda IV 36%, Bethesda V 79% and Bethesda VI 100%. The Bethesda system has been widely adopted internationally and has become an unassailable tool for the pathologist and clinicians for the evaluation and management of thyroid nodules. Since its implementation in the ABC Medical Center, the Bethesda system has granted the institution with favorable and reproducible results.

Evaluation of the Reliability of US-based TI-RADS in Predicting Thyroid Malignancy

Thyroid nodules are a common and prevalent problem encountered in every day clinical practice. Ultrasound (US) is considered to be the initial imaging modality used in the evaluation of thyroid nodules. The TI-RADS (Thyroid Image Reporting and Data system) is an US-based system used to categorize thyroid nodules and stratify their malignant risk in the aim to standardize reporting and simplify communication among practitioners. The aim of this study is to compare the TI-RADS classification of thyroid nodules on ultrasound with the findings of fine-needle aspiration cytology (FNAC) reported using the Bethesda system. A retrospective study of 59 thyroid nodules that underwent single radiologist bedside neck and thyroid US over a period of one year between January 2020 – January 2021 was performed. The US findings were based on the TI-RADS and all the nodules were eventually subjected to US-guided FNAC. Clinico-pathological retrospective analysis was performed by comparing TI-RADS findings to the Bethesda FNAC classification. Comparing TI-RADS results with the Bethesda system of classification, the risk of malignancy for TI-RADS 2, TI-RADS 3, TI-RADS 4, and TI-RADS 5 were 0%, 10%, 50%, and 100%, respectively. A significant association was noted between the TI-RADS and Bethesda system of classification (P &lt; 0.001). We derived 91.3% sensitivity, 88.9% specificity, 84% positive predictive value, and 94.1% negative predictive value for our study. There is a strong correlation between thyroid sonographic reporting using the TI-RADS and Bethesda cytological classification system for thyroid nodules. The TI-RADS classification is an effective method for risk stratification of thyroid nodules into categories predictive of their malignant potential. This aims to guide further management and facilitate the selection process for fine-needle aspiration biopsy, thus avoiding unnecessary procedures.

Thyroid Nodules Located in the Lower Pole Have a Higher Risk of Malignancy than Located in the Isthmus: A Single-Center Experience.

Purpose The aim of our study is to investigate whether thyroid nodules (TNs) localization has value as a predictor of malignancy. Ultrasonography provides very valuable information in the evaluation of TNs, but it does not correlate perfectly with histopathologic findings. Therefore, studies that will include new diagnostic methods that can improve these unknowns can be welcomed gratefully. Methods This study was carried out retrospectively in a tertiary care center from September 2016 to January 2020. The study included 862 adult patients who have one or more nodules. Ultrasonography of characteristics of nodules such as echogenicity, content, margins, calcifications, size, and localization was recorded. Fine-needle aspiration biopsy (FNAB) was performed on dominant and suspicious 1142 nodules. Results The patients were composed of 692 (80.3%) females and 170 (19.7%) males. Compared to nodules located in the isthmus; the malignancy risk increased 8.39 (OR: 8.39 (2.34–30.12), p = 0.001) times in the lower pole, 4.27 (OR: 4.27 (1.16–15.72), p = 0.029), times in the middle pole, 8.09 (OR: 8.09 (2.11–30.94), p = 0.002) times in the upper pole, and 7.63 (OR: 7.63 (1.95–29.81), p = 0.003) times in the nodules covering the whole of the lobe. Although the most nodular location was in the middle pole, the risk of malignancy was less than that in the lower and upper poles. Conclusions Unlike the other localization studies, we found a higher risk of malignancy in the lower and similarly upper thyroid poles. Besides well-defined malignancy indicators in the literature and guidelines, localization information is promising for this purpose in the future.

Increased thyroid malignancy in patients with primary hyperparathyroidism.

BackgroundMultiple studies have reported the increased incidence of thyroid cancer in patients with primary hyperparathyroidism (PHPT). However, the underlying risk factors of concomitant thyroid cancer in patients with PHPT remain unknown. The primary aim of this study was to examine the records of patients with PHPT to identify characteristics that correlated with the presence of coexisting thyroid nodules, and which may have an implication for the prediction of thyroid cancer.MethodsMedical records of consecutive patients with PHPT (n = 318) were reviewed from January 2010 to September 2020 in two tertiary medical centers in China. Patient clinicopathological and biological data were collected and analyzed.ResultsOf a total of 318 patients with PHPT, 105 (33.0%) patients had thyroid nodules and 26 (8.2%) patients were concomitant with thyroid cancer. A total of 38 thyroid nodules taken from 26 patients were pathologically assessed to be well-differentiated papillary thyroid carcinoma (PTC), with 81% being papillary thyroid microcarcinoma (PTMC). In 79% (30/38) of these cancers, thyroid nodules were considered suspicious following preoperative ultrasound. Multinomial logistic regression analysis revealed that female gender was associated with increased risk of thyroid nodules (OR = 2.13, 95% CI: 1.13–3.99, P = 0.019), while lower log-transformed parathyroid hormone levels were an independent predictor of thyroid cancer in patients with PHPT (OR = 0.50, 95% CI: 0.26–0.93, P = 0.028).ConclusionIn conclusion, we observed a relatively high prevalence of thyroid cancer in our cohort of Chinese patients with PHPT. Evaluation of thyroid nodules by preoperative ultrasound may be advisable in patients with PHPT, particularly for females and patients with modestly elevated serum parathyroid hormone levels.

Update on the Evaluation of Thyroid Nodules.

Thyroid nodules (TN) are prevalent in the general population and represent a common complaint in clinical practice. Most are asymptomatic and are associated with a 7%-15% risk of malignancy (1). Methods: PubMed and Medline were searched for articles with a focus on the epidemiology, diagnosis, and management of TN over the past 5 y. Results: The increase in frequency of imaging has led to a rise in the incidence of incidentally diagnosed TN. The initial evaluation of a TN includes assessing thyroid function, clinical risk factors, and neck imaging. Ultrasound remains the gold standard for assessing TN morphology, and biopsy is the standard method for determining whether a TN is benign. Recently published risk stratification systems using morphologic characteristics on ultrasonography have been effective in reducing the number of unnecessary biopsies. Advances in molecular testing have reduced the number of surgical procedures performed for diagnostic purposes on asymptomatic TN with indeterminate cytology. Scintigraphy is the first-line study for assessing a hyperfunctioning nodule. Many TN can be followed clinically or with serial ultrasound after the initial diagnosis. Surgical intervention is warranted when local symptoms are present, in patients with clinical risk factors, as well as in most situations with malignant cytology. Active surveillance is an option in cases of micropapillary thyroid cancer. Emerging nonsurgical approaches for treating TN include ethanol ablation for TN; sclerotherapy for thyroid cysts; and thermal techniques, such as radiofrequency ablation, laser ablation, microwaves, and high-intensity focused ultrasound. Conclusion: Most TN are benign and can be safely monitored. The indications for biopsy and frequency of imaging should be tailored on the basis of risk stratification. Treatment options should be individualized for each patient's particular situation. Active surveillance should be considered in certain cases of papillary microcarcinoma.

Real-time Ultrasound Elastography in the Differential Diagnosis of Benign and Malignant Thyroid Nodules

Abstract Background: Elastosonography is a promising noninvasive technique that developed in recent years for evaluating thyroid nodules. It assesses nodule stiffness or displacement depending on the applied force to differentiate malignant from benign thyroid nodules. Objectives: The aim of this study was to evaluate the diagnostic utility of real-time ultrasound (US) elastography in the differentiation the benign from malignant thyroid nodules. Patients and Methods: A prospective study was carried out on 40 patients attending the US unit/radiology in Al-Imamein Al-Kadhimein Medical City in Baghdad, Iraq, from September 2018 to August 2019. All patients were examined by B-mode US, color Doppler, and real-time elastography by Voluson-E6 US machine. Final diagnoses were obtained from histological and/or cytological evaluation. Results: The mean age of 40 patients was 43.7 ± 11.7 years, with a range of 25–70 years. Twenty-eight (70%) of them were female and 12 (30%) were male. Of the 40 lesions, 34 (85%) were benign and 6 (15%) were malignant lesions. Malignant thyroid nodules were significantly hypoechoic, with irregular margin, taller than wider, showed microcalcification, and exhibited a significant increase in vascularity with varying rates of sensitivity and specificity. Orientation (taller than wider) was the most US predictive pattern of malignancy with sensitivity, specificity, and accuracy of 66.7%, 100%, and 92.5%, respectively. The mean ± standard deviation of the strain ratio (SR) of all nodules was 2.7 ± 2.1 (range: 0.4–13.5) with significant result. The optimal SR cutoff value was &gt;2.5 and showed to have a sensitivity of 100%, a specificity of 88.2%, a positive predictive value of 67%, a negative predictive value of 100%, and an accuracy rate of 90%. Conclusion: Elastosonography can assist in the differential diagnosis of malignant and benign thyroid nodules, as strain elastosonography improves the diagnostic performance in differentiating the benign and malignant thyroid nodules. SR is higher in malignant than benign nodules.

The role of fine-needle aspiration biopsy and post-operative histology in the evaluation of thyroid nodules

Thyroid nodules present a serious problem, and mostly they do not carry neoplastic characteristics. Thus, they do not need to be surgically treated. The risk of malignancy varies from 5 to 15 %. Steps to diagnose malignancy should include a careful clinical evaluation, laboratory tests, a thyroid ultrasound exam and a fine-needle aspiration biopsy. Fine-needle aspiration biopsy (FNAB) is the most important diagnostic tool in the assessment of thyroid nodules. Today it is considered the gold standard for malignancy diagnosis in thyroid cancer. In this review we evaluate the role of FNAB and post-operative cytology in the evaluation of thyroid nodules. FNA results are classified as diagnostic (satisfactory) or nondiagnostic (unsatisfactory). Unsatisfactory smears (5–10 %) result from hypocellular specimens usually caused by cystic fluid, bloody smears, or suboptimal preparation. Diagnostic smears are conventionally subclassified into benign, indeterminate, or malignant categories. Benign cytology (60–70 %) is negative for malignancy, and includes cysts, colloid nodule, or Hashimoto thyroiditis. Malignant cytology (5 %) is almost always positive for malignancy, and includes primary thyroid tumors or nonthyroid metastatic cancers. Indeterminate or suspicious specimens (10–20 %) include atypical changes, Hurthle cells or follicular neoplasms. The new Bethesda Cytologic Classification has a 6-category classification, subdividing indeterminate further by risk factors. Considering the increasing worldwide incidence of thyroid microadenomas, recently it is recommended to undergo FNAB under ultrasound guidance even in small (&lt; 1cm) nodules if they are correlated with suspicious ultrasonographic features or suspicious neck lymph nodes. FNAB is a cheap and reliable diagnostic tool that can be used in the selection candidates for surgery and pre-operative diagnosis of thyroid carcinomas. It was concluded that FNAB is the gold standard in the evaluation of thyroid nodules and can prevent many unnecessary surgeries. False-negative FNA cytology remains a concern for clinicians treating patients with thyroid nodules. Post-operative histology give the definitive diagnosis and studies confirm that it has a significant discordance between pre-operative cytology and post-operative histology in patients with thyroid nodule. Cytopathologists should strengthen their criteria for the identification of adenomatous hyperplasia, thyroiditis, cystic lesions or suspicious thyroid nodules to avoid misdiagnoses.