For Fine Needle Aspiration Biopsy Research Articles

Effect of Music Therapy on Pain During Thyroid Fine Needle Aspiration Biopsy; A Randomized Controlled Clinical Trial

IntroductionHigh-resolution ultrasonography devices have led to the increased detection of thyroid nodules and the need for fine-needle aspiration biopsy (FNAB). However, FNAB is an invasive procedure that can cause discomfort and pain. Music therapy has been used for centuries to alleviate pain, and our clinical trial was conducted to investigate its impact on pain scores during thyroid FNAB. Materials and methodsWe conducted a randomized, controlled clinical trial, including adult patients undergoing thyroid FNAB. We evaluated the nonpharmacological intervention of listening to music before and during thyroid FNAB. We used a slow, nonlyrical, flowing melody with a tempo of 60 to 80 beats per minute as a therapeutic intervention for managing anxiety and pain. It had low tones, minimal percussion, and a volume of around 60 dB. The Beck Anxiety Inventory and Visual Pain Scale were used. ResultsThe study included 529 patients assigned to either the music group (n = 258, 48.7%) or the control group (n = 271, 51.2%). The patients were categorized into subgroups based on either a single nodule (73.63%) or multiple nodules (24.18%). When all patients or single nodule and multiple data are examined separately, the intervention group showed statistically significantly lower pain scores than the control group. ConclusionOur study is among the first on this topic and the largest in the available literature to demonstrate that listening to music during FNAB significantly reduces pain and anxiety. Music therapy is an effective, safe, and noninvasive intervention that can improve patient care and reduce distress and pain.

Evaluation of elastosonography and fine-needle aspiration biopsy results in the diagnosis of thyroid nodules

Objective The aim of our study is to investigate the importance of strain sonoelastography (SSE) in the diagnosis of thyroid nodules and in the selection of indications for fine-needle aspiration biopsy (FNAB). Materials and methods We included 481 patients who visited our clinic between 2019–2022 with thyroid nodules in the study and used a stepwise diagnostic approach to choose patients to perform surgery on and follow-up. All patients were ranked into 2 groups: Group 1 included 135 (28,1%) patients were assessed as SSE along with traditional examinations. The 2nd group included 346 (71.9%) patients who underwent ultrasound examination using SE, only the hard nodule or hard regions of the nodule detected by SSE were obtained with FNAB. We followed up on nodules with benign FNAB results, and nodules with suspicious or malignant results underwent thyroidectomy. Histopathology results of surgically removed nodules were compared with SSE and FNAB results. AUROC was the primary, while sensitivity, specificity, PPV and NPV were the secondary outcome. Results Out of 481 patients, 420 (87.3%) were female, 61 (12.7%) were male, and the age range was 17–83 (CI=45.57±25.9). The mean nodule size was 23.33±16.7 mm. After evaluating elastography results, FNAB was performed on 346 (71.9%) nodules. Surgical treatment was performed in 114 (group 1) (84.4%) of 135 patients, benign tumors were diagnosed in 107 (93.8%), and malignant tumors in 7 (6.2%). Surgical treatment in group 2 was performed in 146 (42.2%) of 346 patients, benign tumors were detected in 105 (71.9%) patients, and malignant in 41 (28.9%). The combined use of the sonoelastography and fine-needle aspiration biopsy contributed to a significant increase in the frequency of detection of thyroid nodules of malignant structure, which amounted to 28.9% in patients of the main group (versus 6.2% in patients of the control group) and a decrease in the frequency of surgical interventions by more than 2 times in patients of the second group. The area of the ROC curve for SSE was S=0.851±0.029; 95% CI (0.794 to 0.908); P=0.000. It is a statistically significant marker in the diagnosis of thyroid nodules. The most important marker in the diagnosis of thyroid nodules was the FNAB test: S=0.874±0.034; 95% CI (0.807 to 0.940); P =0.000. Sensitivity, specificity, PPV, and NPV of elastosonography of the I group were 42.9±18.7%, 96.3±1.8%, 42.9%, 96.3; of II group 68.3±7.3%, 87.6±3.2%, 68.3%, 87.6%; FNAB 90.2±4.6%, 90.5±2.9%, 76.2%, 91.3%, respectively. Conclusion Combined use of SE and Bethesda system was able to detect malignancy in the early stages and to reduce the number of operations.

Noninvasive prediction of axillary lymph node breast cancer metastasis using morphometric analysis of nodal tumor microvessels in a contrast-free ultrasound approach

PurposeChanges in microcirculation of axillary lymph nodes (ALNs) may indicate metastasis. Reliable noninvasive imaging technique to quantify such variations is lacking. We aim to develop and investigate a contrast-free ultrasound quantitative microvasculature imaging technique for detection of metastatic ALN in vivo.Experimental designThe proposed ultrasound-based technique, high-definition microvasculature imaging (HDMI) provides superb images of tumor microvasculature at sub-millimeter size scales and enables quantitative analysis of microvessels structures. We evaluated the new HDMI technique on 68 breast cancer patients with ultrasound-identified suspicious ipsilateral axillary lymph nodes recommended for fine needle aspiration biopsy (FNAB). HDMI was conducted before the FNAB and vessel morphological features were extracted, analyzed, and the results were correlated with the histopathology.ResultsOut of 15 evaluated quantitative HDMI biomarkers, 11 were significantly different in metastatic and reactive ALNs (10 with P << 0.01 and one with 0.01 < P < 0.05). We further showed that through analysis of these biomarkers, a predictive model trained on HDMI biomarkers combined with clinical information (i.e., age, node size, cortical thickness, and BI-RADS score) could identify metastatic lymph nodes with an area under the curve of 0.9 (95% CI [0.82,0.98]), sensitivity of 90%, and specificity of 88%.ConclusionsThe promising results of our morphometric analysis of HDMI on ALNs offer a new means of detecting lymph node metastasis when used as a complementary imaging tool to conventional ultrasound. The fact that it does not require injection of contrast agents simplifies its use in routine clinical practice.

Comparing shear wave elastography and fine needle aspiration in the diagnosis of solid thyroid nodules.

This descriptive study was performed on individuals who were referred to Imam Reza Hospital for fine needle aspiration biopsy (FNAB) based on the results of gray scale ultrasound and the decision of the referring physician. In addition to determining the gray scale characteristics of the nodules, shear wave elastography (SWE) was also performed and the results were recorded. These were also taken from the patients FNAB results. Finally, the findings of SWE and FNAB methods were compared and analyzed using SPSS software version 16. Based on the results presented herein, a significant relationship was observed between the results of SWE and FNA in the diagnosis of malignancy in solid thyroid nodules. This agreement was found to be higher in men (K = 0.866) than women (K = 0.849). Taken together, our data suggest that shear wave elastography can replace FNA in the diagnosis of malignancy in solid thyroid nodules.

Summary of Meta-analyses of Studies Involving TIRADS Classifications (EU-TIRADS, ACR-TIRADS, and K-TIRADS) in Evaluating the Malignant Potential of Focal Lesions of The Thyroid Gland.

Numerous scientific societies around the world have published their TIRADS (Thyroid Imaging Reporting and Data System) classifications that evaluate the risk of malignancy of focal thyroid lesions, presenting different ultrasound features for each category and lesion size thresholds to determine eligibility for biopsy. The use of such risk estimation systems in focal thyroid lesions facilitates the reporting of thyroid ultrasound findings and improves the qualification of focal lesions for fine-needle aspiration biopsy (FNAB). In this publication, the three most popular TIRADS classifications, European – EU-TIRADS, Korean – K-TIRADS, and developed by the American Society of Radiology – ACR-TIRADS, are presented and discussed based on a literature review. The results of available head-to-head statistical analyses comparing the classifications are also presented. The advantage of the EU-TIRADS and K-TIRADS systems is that they include only the most important ultrasound features, so their application is not time-consuming, and the scores are easy to incorporate into clinical practice. ACR-TIRADS, unlike other scales, is based on a unique classification system and represents the most comprehensive classification. Each of the five categories of ultrasound features – morphology, echogenicity, shape, margins, microcalcifications – are evaluated and assigned a score from 0 to 3, with a higher score being associated with a higher risk of cancer. Based on the available data, the greatest benefit has been demonstrated for the ACR-TIRADS classification, which also has implications for minimising the number of unnecessary FNABs. However, limitations related to the heterogeneity of the groups analysed in the study, including differences in the populations studied, inclusion criteria, proportions of patients of either sexes, and the number of malignant lesions analysed, should also be taken into account.

Management of Indeterminate Thyroid Biopsies, 9-Year Experience in Mexico

Thyroid nodules are selected for Fine Needle Aspiration Biopsy (FNAB) based on suspicious ultrasonographic characteristics. When thyroid nodule fine-needle aspiration (FNAB) cytologic results show follicular lesion of undetermined significance or atypia of undetermined significance (FLUS/AUS, Bethesda III) or follicular neoplasm (Bethesda IV), the results are often called indeterminate. We present the results in the follow-up of indeterminate (Bethesda III and IV) cytologies in thyroid nodules, from April 2013 to August 2022, in our research center in the State of Mexico.

A novel combined animal tissue model for freehand and ultrasound-guided fine needle aspiration biopsy and smear preparation techniques training.

A variety of models are used for fine needle aspiration biopsy (FNAB) and smear preparation techniques training: human, animal and silicon models or combined models. We present fresh animal tissues as models for freehand and ultrasound (US)-guided FNAB technique training, enabling an integrated approach from tumour detection to smear evaluation. We introduced a novel combined animal tissue model using dietary animal meat with covering skin as a substrate. Animal liver tissue of various sizes, representing tumour, was inserted into the various layers of the substrate (subcutaneous fat, muscle tissue, proximity of bone). Freehand and US-guided FNAB smear preparation, including fixation, was then performed and assessed. The use of a combined animal tissue model for 6 freehand and 3 US-guided FNAB sessions showed a statistically significant improvement in the US-guided FNAB retrieval of liver tissue (Fisher's exact test, p = .0216), in smear preparation technique reflected in a decrease in the number of too thick smears after freehand FNAB (Fisher's exact test, p = .0070), in the overall number of smears satisfactory for evaluation by US-guided FNAB (Fisher's exact test, p = .0206) and in the number of flawless smears obtained in the freehand FNAB training sessions (Fisher's exact test, p = .0020). A unique advantage of the presented model encompassing various layers of animal tissues with covering skin, offers an integrated approach for FNAB training from "tumour" detection, puncture precision, to smear preparation and cytological evaluation for a wider audience and does not compromise patient safety.

Evaluation of the Diagnostic Performance of EU-TIRADS in Discriminating Benign from Malignant Thyroid Nodules: A Prospective Study in One Referral Center

Background: Several thyroid societies have endorsed ultrasound (US) malignancy risk stratification systems for thyroid nodules and the recently released European Thyroid Imaging Reporting and Data System (EU-TIRADS) needs large prospective studies for validation. Objective: The purpose of our study was to evaluate the performance of EU-TIRADS in identifying thyroid nodules for fine-needle aspiration biopsy (FNAB) and its ability to reduce the number of unnecessary biopsies. Methods: This was a single-center prospective study. From August 2017 to September 2018, 783 consecutive patients with 1,000 thyroid nodules underwent US examination and US-guided FNAB. A total of 741 patients (median age 50 years; range, 15–87 years; 649 females, 92 males) with 942 nodules (median largest diameter 14 mm; range, 4–96 mm) met the following inclusion criteria: (1) nodules with benign or malignant cytology – categories II and VI of the Bethesda System for Reporting Thyroid Cytopathology (BSRTC); (2) nodules with non-diagnostic and indeterminate cytology (BSRTC I, BSRTC III, and BSRTC IV), or suspicious for malignancy (BSRTC V), if postoperative histology was present; (3) nodules classified as BSRTC I and BSRTC III with a repeat FNAB and conclusive cytology. Results: Of 942 nodules, 839 (89.1%) were benign and 103 (10.9%) were malignant. Nodules were classified as follows: EU-TIRADS 2 – 4.8%, EU-TIRADS 3 – 37.4%, EU-TIRADS 4 – 25.2%, and EU-TIRADS 5 – 32.6%. The malignancy rate in categories 2 to 5 was 0, 0, 3.8, and 30.6%, respectively. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of EU-TIRADS with a cut-off set at category 5 were 91.3, 74.6, 30.6, 98.6, and 76.4%, respectively. Diagnostic performance other than sensitivity and NPV was superior in nodules ≥10 mm. FNAB number would be reduced by 53.4% if FNAB criteria were strictly applied. When the indication for FNAB was applied as test positivity, the estimated sensitivity, specificity, PPV, and NPV of EU-TIRADS were 69.9, 56.3, 16.4, and 93.8%, respectively. Conclusion: EU-TIRADS provides effective malignancy risk stratification that can guide the selection of thyroid nodules for biopsy. The application of the guidelines criteria for FNAB in the clinical practice might reduce significantly the number of unnecessary FNAB.

MON-484 Thyroid Nodules: Not so Simple to Manage

Thyroid Nodules: Not So Simple to ManageThyroid nodules diagnosis and malignancy risk stratification remains a challenge for decision making between conservative vs invasive management. The development of the clinical guidelines provides alternatives for evaluation and management for thyroid nodules, but can be used for all patients?A 43 y/o female without known past medical history is referred to the endocrine service by her primary care physician for evaluation of a thyroid nodule. She was presenting with 1 month history of mild discomfort on the neck and was evaluated with thyroid US that was relevant for multiple bilateral solid nodules measuring <1.0cm and a one spongiform measuring 1.7 x 1.2 x 1.3cm in the right lobe extending minimally to the capsule laterally and to the carotid artery wall. Patient denies cough, hoarseness, odynophagia, shortness of breath, family history of thyroid cancer or radiation exposure. On examination there were no goiter nor palpable thyroid nodules, as well as no clinical signs and symptoms of thyroid disease. Patient is clinically and biochemically euthyroid with a very low suspicion thyroid nodule (3% estimated malignancy risk). Despite nodule is below the 2.0cm cutoff point for fine needle aspiration biopsy (FNAB) according to American Association of Clinical Endocrinologist (AACE) and American Thyroid Association (ATA) guidelines, it was done based on additional suspicious sonographic features detect by the endocrinologist on evaluation of ultrasound images. FNAB was performed and reveals Atypia of undetermined significance/Follicular Lesion of undetermined significance (AUS/FLUS) Bethesda system category III with a risk of malignancy of 5–15%. Patient was reluctant to surgery given the very low risk nodule and biopsy results of AUS/FLUS. In order to further manage this patient with undetermined significance thyroid nodule, Gene Expression Classifier (GEC) Molecular Analysis (AFIRMA) was performed. AFIRMA test was done with a second FNAB that also reveals AUS/FLUS but was found positive for BRAFv600, Bethesda system category IV: Suspicious of Papillary Thyroid Carcinoma. BRAFv600 is the only mutation that have high specificity (99%) for papillary thyroid carcinoma and is associated with increased disease-specific mortality, aggressive histologic phenotypes, lymph node metastases, extrathyroidal extension and risk of recurrence. Based on this data patient now have 95% risk of malignancy and requires surgical therapy. Patient preferred total thyroidectomy over lobectomy; pathology results shows 2.0cm Papillary Thyroid Carcinoma Stage I (T1N0M0).Despite very low risk nodule finding, malignancy was diagnosed. As depicted in this case, thyroid nodules aren’t so simple to manage, and their management should involve imaging and pathology findings along with clinical judgement and patient individualization in decision making process.

Comparison of Two Different Methods of Fine Needle Aspiration Biopsy and Histopathology for Thyroid Nodules.

Objective: Two different methods for fine needle aspiration biopsy (FNAB) of thyroid nodules (multi-pass conventional smear, MPCS; single-pass liquid-based cytology, SPLBC) were evaluated regarding the magnitude of nondiagnostic/unsatisfactory sampling ratio, and basic demographic and ultrasonographic (USG) factors to predict such outcome.Methods: One thousand FNAB patients were retrospectively assessed. Of them, 517 nodules were evaluated with the conventional smear method, and the rest were evaluated with liquid-based cytology method using the Bethesda System for Reporting Thyroid Cytopathology. FNAB technique had certain procedural differences for both pathological methods. For conventional smear, a modified "needle-only" technique with three independent passes was performed, whereas a single pass was used for liquid-based cytology. The reduction of nondiagnostic/unsatisfactory results constituted the basis of this study. Pathological results, therefore, were subgrouped under "nondiagnostic/unsatisfactory" (Category I), "benign" (Category II), and "atypia/neoplasia/malignancy" (Category III-VI).Results: Both FNAB groups were not statistically different or only slightly different regarding size (P = 0.196), echogenicity (P = 0.014), and the presence of echogenic foci (P = 0.11), therefore considered to have equal USG properties. In MPCS method, the nondiagnostic/unsatisfactory rate (i.e., Category I) was 24%. Other cytological results were as follows: Category II (67.1%), Category III-VI (8.8%). In SPLBC method, the nondiagnostic/unsatisfactory rate (i.e., Category I) was 14.5%. Other cytological results were as follows: Category II (77.6%), Category III-VI (7.8%). A significant difference was found between two sampling methods regarding pathological results (Independent samples t-test, P < 0.0001). The demographic and USG factors, considered in this study, did not offer a successful prediction of nondiagnostic/unsatisfactory outcomes.Conclusion: SPLBC has significantly lower (14.5% vs 24%) nondiagnostic rate than MPCS, and higher 77.6% vs 67.1%) Category II rate than MPCS. This may point to the possibility that MPCS method undercategorizes many benign (i.e., Category II) nodules under nondiagnostic/unsatisfactory category. The success of the former is due to the elimination of confounding material during the process. Single pass, also, increases patient comfort and compliance, and has additional advantages for the interventionalist, as it obviates the need to smear aspirates. This dramatically decreases the actual duration of the biopsy procedure and is free of interventionalist expertise for smearing.

Factors Predicting Thyroid Malignancy in Fine Needle Aspiration Biopsy Specimens Classified as Atypia of Uncertain Significance/Follicular Lesion of Uncertain Significance

The atypia of uncertain significance/follicular lesion of uncertain significance (AUS/FLUS) category of the Bethesda system for reporting thyroid cytopathology for fine needle aspiration biopsy (FNAB) has a predicted incidence of malignancy from 5 to 15 per cent. The literature has reported that suspicious ultrasound (SUS) characteristics can assist in predicting malignancy in thyroid biopsies. Some research suggests further subdivision of AUS/FLUS into nuclear atypia predominant or follicular predominant. We hypothesized that the rate of malignancy would be higher in AUS/FLUS biopsies with SUS characteristics and in the AUS/FLUS subset classified as nuclear atypia predominant. We performed a four-year retrospective analysis of patients who underwent FNAB classified as AUS/FLUS and who subsequently underwent thyroidectomy from October 2008-October 2012. A total of 3839 thyroid FNAB were performed over the four-year period, of which 342 received AUS/FLUS classification. Of these, we identified 119 patients who underwent thyroidectomy, of which 27 (23%) malignancies were identified. Reported cytology (nuclear atypia vs follicular predominant) did not differ between patients with and without carcinomas (P = 0.33). Suspicious ultrasound appearance failed to be significantly associated with an underlying carcinoma (P = 0.14); although, nearly 70 per cent of malignancies displayed SUS compared with 50 per cent within the benign group. Ultrasound seems to have no additional value in predicting malignancy in the AUS/FLUS categorization. Further subcategorization did not aid in risk stratification of this indeterminate category. This may suggest an expanded role for ancillary technologies such as molecular markers in this challenging Bethesda system for reporting thyroid cytopathology class. Further study of these findings is warranted.

Papillary thyroid cancer in an adolescent with a toxic single nodular goiter

The rate of nodular goiter in children ranges from 0.05 to 5.1%; in this case, the risk of thyroid cancer in childhood amounts to 3―70% of all cases of thyroid pathology. Therefore, the main issue is the differential diagnosis of a nosological variant of a thyroid nodule, which defines the optimal therapeutic tactics for a particular patient. The risk of malignancy is traditionally believed to be low in the case of decompensated functional autonomy of a thyroid nodule; therefore, the need for fine needle aspiration biopsy (FNAB) followed by cytomorphological analysis of the aspirate is avoided in most cases. The presented clinical case demonstrates papillary cancer in an adolescent with a toxic single nodular goiter. A thyroid ultrasound examination revealed a nodular lesion in the boy. An increase in the thyroid size and thyrotoxicosis manifestation occurred 3 years later. A cytomorphological study identified follicular neoplasia; scintigraphy revealed a hot nodule. Surgical treatment was planned. Antithyroid therapy was prescribed to prepare for surgery. After compensation of thyrotoxicosis, hemithyroidectomy was performed. A histological examination diagnosed papillary thyroid cancer, which required repeated thyroidectomy followed by radioiodine I131 ablation. The postoperative period was uneventful; the patient well tolerated suppressive levothyroxine therapy. Therefore, the presence of a toxic single nodular goiter does not exclude thyroid cancer, which defines the need to discuss the indications for FNAB of thyroid nodules in children.

Study of Fine Needle Aspiration Cytology (FNAC) for Diagnosis of Lesions of Liver Diseases Guided By Ultra Sound

The main indication for fine needle aspiration (FNA) of liver is the evaluation of mass lesions.(Silverman JF,Geisinger KR-1996).In most FNA biopsies of hepatic masses an accurate diagnosis can be rendered based on the cytomorphological features alone,(Silverman JF,geisinger KR-1996). However in selected cases, ancillary studies can be quiet helpful in refining the diagnosis.( Silverman JFFinely J L,o'Brein KF 1989). By onsite discussion with radiologists and clinicians, the cytopathologist may gain significant data to integrate into the final diagnosis.The major indication for FNA of the liver is the evaluation of a hepatic mass. FNA biopsy, is especially useful in the investigation of non-neoplastic & especially neoplastic mass lesions of the liver. Keywords: Diagnosis, FNAC , Liver, ultrasound

Evanescent Hyperechoic Changes After Fine-Needle Aspiration Biopsy of the Thyroid in a Series With a Low Overall Prevalence of Complications.

The purpose of this study was to assess the frequency of and risk factors for fine-needle aspiration biopsy (FNAB)-related complications in Japanese patients with thyroid nodules evaluated by standard FNAB techniques. Six hundred fifty-three consecutive Japanese patients with 742 nodules who had undergone FNAB were enrolled. Nodule characteristics were evaluated, and thyroid volumes were measured. Fine-needle aspiration biopsy-related complications were identified on the basis of sonographic findings and patients' conditions after undergoing FNAB. Comparisons of patients' backgrounds and nodule characteristics were made between those with and without complications. The prevalence rates for FNAB-related complications, including acute transient thyroid swelling after FNAB and appearance of anechoic lesions, were 0.13% and 0.94%. In this study, we could not identify risk factors for FNAB-related complications. The sudden appearance of bright hyperechoic foci within the thyroid immediately after biopsy was reported as an FNAB-related unfamiliar appearance in 5 cases. Experimental FNA using resected porcine thyroid tissue suggested that the etiology of the hyperechoic appearance may be artificial air bubbles or reversed flow of aspirated fluid. Fine-needle aspiration biopsy-related complications are rare if preventive measures are performed and are not specific to Japanese patients with thyroid nodules. The sudden appearance of bright hyperechoic foci may be cause by contamination from air or fluid.

Rapid on-site evaluation improves fine-needle aspiration biopsy cell block quality

For fine-needle aspiration (FNA) biopsy, the cell block is used for precision ancillary diagnostic tests and personalized molecular evaluation. It is important to maximize quality cell blocks. Rapid on-site evaluation (ROSE) provides specimen adequacy and guides cell block collection. The study examines how immunohistochemistry (IHC) utilization correlates with cell block quality and the impact of ROSE on cell block quality. The pathology database identified consecutive FNA biopsy cases with cell blocks. Procedural data and reporting elements were collected including ROSE, adequacy and diagnosis categories, and IHC. Each archived case was reviewed. Cell block cellularity quality scores were categorized as <10%, 10% to 25%, and >25%. Various data points were correlated with the cell block quality score. The ROSE cohort had a higher group score of 38.8% versus 26.3% for non-ROSE. Low scores on cell block quality were higher with the unsatisfactory and indeterminate groups (85.2% and 78.5%). A highergrouping score was 3× as likely for a satisfactory as an unsatisfactory group (46.5% versus 14.8%). Positive cases with IHC had higher cell block quality scores compared with those without IHC (56.7% versus 33.2%). It is important for pathologists to contribute to improving FNA biopsy cell block quality. This series shows that higher cell block quality provides better utilization for IHC assessment and for IHC testing in positive diagnostic category cases. Providing ROSE service can improve cell block quality and an assurance of a satisfactory FNA biopsy significantly contributes to improved cell block quality.

Ways of Sonoelastography Diagnostic Value Improvement in the Differentiation of Thyroid Nodules

Over last ten years, the clinical significance of real-time elastography or sonoelastography (SEG) has been widely discussed for the discovery of thyroid cancer. However, there is no works which revealed the relation between parameters of SEG and endocrine status of the patients for improving of diagnostic value of this method; this issue was the aim of our study. 81 patients (20 - benign adenomas and 61 - thyroid cancer (TC): 13 - follicular and 48 - papillary) were evaluated prospectively. Mean age was 48.0 ± 16.4 years. It was shown that the blue colour or 4-5 elastotype of SEG was mainly discovered in TC vs adenoma (65.6% vs 20.0% χ2 = 12.61, р = 0.0004). At the same time, the Strain Ratio more than 3.0 was frequently revealed in TC patients vs adenoma (57.4% vs 40.0%) but it did not reach level of significance (χ2 = 1,83, р = 0,18). Parameters of the sensitivity, specificity and accuracy were equal 90.2%, 60.0% and 82.7% for SEG, and 96.7%, 40.0% and 82.7% for fine-needle aspiration biopsy (FNAB), respectively. The combination of 38 SEG with FNAB or with body mass index increased specificity of SEG by 65% and 70%, respectively. The combination of SEG with another measures of hormone-metabolic status (glucose level, TSH, thyroglobulin, etc) did not improve diagnostic accuracy of SEG. In result, SEG was slightly more specific than FNAB in predicting malignancy of the thyroid nodules. The specificity of SEG could be increased by combination with both FNAB and anthropometry. Further improvement of presurgical diagnosis of TC, especially follicular TC, could be possibly reached via the combination of cytological, hormonal, genetic and instrumental methods, including shear wave elastography.

Usefulness of different ultrasound features of malignancy in predicting the type of thyroid lesions: a meta‑analysis of prospective studies

Thyroid nodules are a common medical problem. Thyroid ultrasound remains the most common method for preliminary evaluation and selection of nodules for fine-needle aspiration biopsy (FNAB). Doppler examination and elastography are believed to improve the reliability of ultrasound in predicting malignancy. The aim of this study was to evaluate diagnostic value of common ultrasound markers of malignancy of thyroid lesions. The PubMed/MEDLINE and Cochrane Library databases were searched to identify studies meeting the inclusion criteria. The random-effects model was used to calculate pooled odds ratio (OR), risk ratio, sensitivity, specificity, and positive and negative predictive values (PPV and NPV) of the individual features of thyroid malignancy on ultrasound. Only the prospective studies published between January 2007 and February 2013, performed using a transducer with the frequency of at least 7.5 MHz have been included in the meta-analysis. The taller-than-wide shape of the thyroid nodule was shown to be the strongest predictor of malignancy (OR, 13.7; PPV, 76.0%); however, its sensitivity was 25.9%. Irregular margins and microcalcifications were also strong predictors of malignancy (OR, 7.2 and 7.1, respectively) and both had higher specificity (79.6% and 75.9%, respectively) than sensitivity (45.5% and 44.1%, respectively). Elastography of the thyroid gland also proved to be a valuable diagnostic tool in detecting malignant lesions (OR, 7.9). Hypoechogenicity, halo absence, and intranodular flow on a color Doppler examination were moderate predictors of malignancy (OR, 3.2, 3.8, and 4.3, respectively). Ultrasound features considered to be predictors of malignancy seem to be valuable for preliminary evaluation of thyroid nodules and referral for FNAB. However, they should always be interpreted with caution because none of them allows to reliably differentiate malignant from benign nodules.

Management of Patients with Primary Hyperparathyroidism and Concurrent Thyroid Disease: An Evolving Field

The presence of thyroid disease can complicate the evaluation and surgical management of patients with primary hyperparathyroidism (PHPT). Retrospective analysis has shown that approximately 20–50% of patients with PHPT also have thyroid disease. 1–3 The reported incidence of thyroid malignancy in patients with PHPT is approximately 3–4%. 1,4 There is no uniformly accepted protocol for the evaluation of patients with thyroid pathology before operative intervention for PHPT. Neck exploration for PHPT normally provides excellent access to the thyroid, whereas minimally invasive parathyroidectomy offers a more limited exposure of the thyroid gland. The increased application of the minimally invasive approach has increased the reliance on preoperative imaging. Modalities for localizing abnormal parathyroid glands such as 99m Tcsestamibi scintigraphy (Tc-MIBI), I-123, and neck ultrasound can also identify thyroid pathology. Onkendi et al. analyzed the results from a series of patients with PHPT and concurrent thyroid nodules who underwent dual-isotope Tc-MIBI and radioiodine (I-123) subtraction imaging. 5 The most significant finding is that the phenotype Tc-MIBI-Hot/I-123-Cold has a negative predictive value for malignancy of 90%. Patients with the Hot/Cold phenotype were almost 3 times as likely to have a malignant thyroid lesion, indicating that these patients should be evaluated more aggressively with a lower threshold for fine-needle aspiration biopsy (FNAB) and thyroid resection. Patients with thyroid nodules that had any other phenotype (Hot/Hot, Cold/Hot, Cold/Cold) had a much lower potential for thyroid malignancy, and therefore, it may be appropriate to treat these patients with close follow-up rather than FNAB or thyroid resection. Onkendi et al. further identified a group of patients who were found during surgery to have a false-positive imaging result, characterized by a Hot/Cold scan with no abnormal parathyroid found corresponding to the imaging localization. Patients with underlying thyroid malignancy were more likely to have a false-positive parathyroid scintigraphy (45% compared to 22% of patients with benign thyroid disease). These data indicate that patients undergoing neck exploration who are found to have a false-positive dual imaging result should have further intraoperative evaluation for the potential of an undiagnosed thyroid malignancy.

Karyopathological traits of thyrocytes and exposure to radioiodines in Belarusian children and adolescents following the accident at the Chernobyl nuclear power plant

The Belarus-American (BelAm) thyroid study cohort consists of persons who were 0-18 years of age at the time of exposure to radioactive iodine fallout from the 1986 Chernobyl nuclear power plant accident and who have undergone serial thyroid screenings with referral for fine-needle aspiration biopsy (FNAB) using standardized criteria. We investigated thyrocyte nuclear abnormalities in cytological samples from FNABs in 75 BelAm subjects with single and multiple thyroid nodules and 47 nodular goiter patients from Leningrad, Russia, unexposed to Chernobyl fallout. Nuclear abnormalities examined included internuclear chromosome bridges and derivative nuclei with broken bridges (i.e., "tailed" nuclei), which are formed from dicentric and ring chromosomes and thus may be cellular markers of radiation exposure. Among subjects with single-nodular goiter, thyrocytes with bridges were present in 86.8% of the exposed BelAm cohort compared with 27.0% of unexposed controls. The average frequency of thyrocytes with bridges and with tailed nuclei was also significantly higher in the BelAm subjects than in controls. Among subjects with multinodular goiters, thyrocytes with bridges were present in 75.7% of exposed BelAm patients compared with 16.7% of unexposed controls; thyrocytes with tailed nuclei were observed in all of the BelAm subjects but in only 40% of controls, and the mean frequencies of bridges and tailed nuclei were significantly higher in the exposed group. Unusually, long bridges were detected in 29% of BelAm patients with single-nodular goiters and 35% of those with multinodular goiters, while no such abnormalities were observed among patients from the Leningrad region. In the exposed subjects from BelAm, we also found positive correlations between their estimated dose of Iodine-131 from Chernobyl fallout and the frequency of tailed nuclei (p = 0.008) and bridges (p = 0.09). Further study is needed to confirm that these phenomena represent consequences of radiation exposure in the human organism.

F18-FDG-PET/CT thyroid incidentalomas and their benign or malignant nature: a critical and debated issue

An interesting article has been recently published on Annals of Nuclear Medicine [1] about risk stratification and prediction of cancer of focal thyroid fluorodeoxyglucose uptake during other cancer evaluation; among 11,623 subjects studied for oncologic purposes, 140 showed pathologic uptakes judged eligible for fine needle aspiration biopsy (FNAB). In 37 patients, a papillary thyroid carcinoma was diagnosed, while in the other 103, benign lesions were detected (mostly adenomatous goiter, thyroiditis and nodular hyperplasia) with a maximum standardised uptake value (SUV max) significantly different from a statistical point of view (p = 0.0093) between two groups, suggesting a possible role of SUV max in differentiating one type of lesions from the other. Despite the interesting scientific and statistical analyses, the very large number of patients studied and the objective to find a metabolic key to discriminate benign lesions from malignant ones, we agree and highlight the concerns reported by the authors in the current study; in particular we stress the doubts about the effective role of SUV max per se in discriminating benign from malignant thyroid lesions and this paper gets the opportunity to briefly discuss this issue. The absence of dual-time-point acquisition (already tested and reported in literature for many malignancies [2] and also for thyroid cancer in this journal [3–5]), which is potentially useful in partially overcoming the relatively low specificity of SUV max value, could further strengthen these doubts; although dual-time-point acquisition is reported to be more specific than SUV value at standard acquisition, it could be unsafe to consider SUV max per se a pivotal key in the interpretation of the nature of lesions and for the discrimination between benign and malignant. In other words, SUV per se is a semi-quantitative parameter that reflects metabolic activity but not a specific marker of malignancies; in fact many thresholds have been proposed to distinguish benign from malignant lesions but no safe cut-off, often different in dissimilar tissues and histologic types, has been identified; moreover, it is well established that inflammation and infectious diseases show very high uptake reaching SUV max and SUV mean value not significantly different from those expressed by malignant tumors [6–8]; as a result, a different grade of inflammation in a lesion could mimic, contribute or be a confounding factor in the discrimination process and differential diagnosis. Regarding thyroid nodules, the clinical and diagnostic scenario become more complicated; in fact no high-quality evidence has been reported about the usefulness of FDG-PET/CT in staging and restaging of differentiated thyroid carcinoma (DTC) but only recommendation for patients with negative I-131 scan and elevated thyroglobulin [9]; a loss of iodine uptake ability, due to decrease in energy-dependent transport mediated by the Na/I symporter (NIS) [10], is probably counterbalanced by high glucose transporter type 1 (GLUT-1) gene expression in the de-differentiation process; this is probably due to generally low glucidic metabolism of DTC, low biologic aggressiveness and favourable clinical behaviour compared with DTC I-131 negative characterised by high FDG uptake and worse prognosis; however, it is very interesting that many papers report incidental thyroid F. Bertagna (&) Department of Nuclear Medicine, Spedali Civili di Brescia, P.le Spedali Civili, 1, 25123 Brescia, Italy e-mail: francesco.bertagna@spedalicivili.brescia.it