Suspected Thyroid Cancer Research Articles

Diagnostic value of FNA, ultrasound elastography and CEUS in thyroid carcinoma

Background: To investigate the role of fine needle aspiration cytology (FNA), sonoelastography and contrast-enhanced ultrasound (CEUS) in the diagnosis of thyroid carcinoma. Methodology: A total of 150 patients with suspected thyroid cancer admitted to our hospital from January 2019 to December 2021 were selected and divided into group A, group B and group C according to random number table, with 50 cases in each group. FNA was used in group A, ultrasound elastography was used in group B, and CEUS was used in group C. Pathological diagnosis was performed in all patients, and the diagnostic sensitivity, specificity, and accuracy were compared among the three groups. Results: The diagnostic sensitivity, specificity and accuracy of FNA in group A were 90.91%, 70.59% and 84.00%, respectively; the diagnostic sensitivity, specificity and accuracy of ultrasound elastography in group B were 94.12%, 81.25% and 90.00%, respectively; the diagnostic sensitivity, specificity and accuracy of CEUS in group C were 88.57%, 73.33% and 84.00%, respectively; the three groups were compared (P > 0.05). Conclusion: All three diagnostic techniques had a relatively high sensitivity and accuracy in the diagnosis of thyroid carcinoma. Ultrasound elastography had the highest sensitivity and specificity among the three techniques, while FNA and CEUS had similar diagnostic performance. Keywords: Fine needle aspiration cytology; ultrasound elastography; contrast-enhanced ultrasound; thyroid cancer; diagnostic efficacy.

P-68 Misdiagnosed calcitonin negative Medullary thyroid carcinoma as Hurthle cell thyroid adenoma with fine needle aspiration biopsy

Abstract Introduction Medullary carcinoma is a rare thyroid carcinoma, that originates from the malignant proliferation of parafollicular C cells. Medullary thyroid cancer produces calcitonin, and elevated calcitonin level is an essential feature of this tumor, so, most of them are associated with high levels of calcitonin. Calcitonin-negative medullary carcinoma of the thyroid gland is an extremely rare entity and poorly understood primary neuroendocrine carcinoma that is characterized by classic medullary carcinoma of the thyroid morphology without raised serum calcitonin levels. Fine needle biopsy (FNAB) is a diagnostic test done in people with suspected thyroid cancer and it is very important for timely diagnosis and treatment of medullar thyroid cancer, especially when calcitonin levels are in normal range. Clinical Case A 35-year-old woman visited an endocrinologist due to swelling on the left side of the neck. Thyroid ultrasound showed hypoechogenic, heterogenous nodule in the left lobe with dimensions 29×28×35 mm and calcifications. Laboratory tests were normal: thyroid stimulating hormone (TSH) 3,0 mlU/ml; free T4 14,3 pmol/l; anti –thyroid peroxidase antibody (ATPO) 20IU/ml; human thyroglobulin 35IU/ml; calcitonin <2 pg/ml; carcinoembryonic acid (CEA) 0.742ng/ml. The FNAB were performed, with cytological finding for classification group I. Four months after the first biopsy, the FNAB was repeated and Hürthle cells were found, with pronounced degenerative changes as well as pronounced cytological atypia, cytological findings correspond to classification group III. Computed tomography of the neck was performed preoperatively and it showed hypodense nodule (slightly smaller than 4 cm) with numerous calcifications, and no significantly enlarged lymph nodes. Left lobectomy was performed with histopathological findings for Medullary thyroid carcinoma. Immunohistochemical tumor cells were positive for chromogranin A, CD56, focally for thyroglobulin and CK 19, and negative for S-100 and NSE. RET gene mutation analysis was performed and it was negative. Additional diagnostic tests were performed for MEN2A and MEN 2B and they were excluded. Postoperative levels of calcitonin and CEA were in normal range. Conclusion Normal calcitonin levels do not exclude medullar carcinoma. Follow-up and monitoring of the patients with thyroid nodules is very important for timely diagnososis and treatment of medullar carcinoma.

AIUM Practice Parameter for the Performance and Interpretation of Diagnostic Ultrasound of the Thyroid and Extracranial Head and Neck.

AIUM Practice Parameter for the Performance and Interpretation of Diagnostic Ultrasound of the Thyroid and Extracranial Head and Neck.

Lymphatic Contrast-enhanced US to Improve the Diagnosis of Cervical Lymph Node Metastasis from Thyroid Cancer.

Background The presence of cervical lymph node (LN) metastases (LNMs) affects clinical staging and prognosis of thyroid cancer, but the role of conventional B-mode US is limited for preoperative diagnosis of LNMs. The diagnostic value of lymphatic contrast-enhanced US (LCEUS) in thyroid cancer is still being explored. Purpose To explore the diagnostic performance of LCEUS by means of thyroidal injection of contrast agent in comparison with US in detecting LNMs of suspected thyroid cancer. Materials and Methods In this single-center prospective study conducted from November 2020 to January 2021, consecutive participants with suspected thyroid cancer underwent B-mode US and LCEUS of cervical LNs before biopsy. LNMs were confirmed with fine-needle aspiration cytologic examination, thyroglobulin washout assessment, or histopathologic examination after surgery. The diagnostic performance of LCEUS for cervical LNs was compared with that of conventional B-mode US, and its association with LN size and location was evaluated. Results The final data set included 64 participants (mean age, 45 years ± 12 [SD]; 52 women) with 76 LNs. The sensitivity, specificity, and accuracy of LCEUS for LNM were 97%, 90%, and 93%, respectively, whereas they were 81%, 80%, and 80%, respectively, for LNM at conventional B-mode US. Compared with US, LCEUS had better diagnostic accuracy for the LNs smaller than 1 cm (82% vs 95%; P = .03) and for central neck LNs (level VI) (83% vs 96%; P = .04). Conclusion Lymphatic contrast-enhanced US had better diagnostic performance than conventional B-mode US for detecting cervical LN metastases in suspected thyroid cancer before surgery, especially for LNs smaller than 1 cm and central neck LNs. © RSNA, 2023 See also the editorial by Grant and Kwon in this issue.

Conversion surgery after lenvatinib treatment for anaplastic thyroid carcinoma: a case report

BackgroundAnaplastic thyroid carcinoma (ATC) is the most aggressive form of thyroid carcinoma. Lenvatinib, a multikinase inhibitor, is rarely used in preoperative settings due to adverse effects including delayed wound healing and fistula formation. Herein, we report the use of lenvatinib treatment prior to conversion surgery for the treatment of ATC.Case presentationA 71-year-old woman was referred to our hospital with suspected thyroid cancer with recurrent laryngeal nerve invasion and cervical lymph node metastasis based on the results of ultrasonography. Computed tomography demonstrated the presence of a thyroid tumor invading the trachea and esophagus with no evidence of distant metastasis. Fine needle aspiration of the left cervical lymph node indicated the lymph node metastasis of ATC. As the tumor had widely invaded the trachea and esophagus, unresectable ATC was diagnosed and treatment with lenvatinib was initiated at a dose of 24 mg/day. On day 13 of lenvatinib treatment, the primary tumor and lymph node metastases demonstrated a partial response to therapy. As the tumor was now considered resectable, the decision was made to perform conversion surgery. Total thyroidectomy and left lateral neck node dissection were performed 7 days after the withdrawal of lenvatinib. The patient was discharged on postoperative day 5 with no complications. Histopathological examination demonstrated that the tumor contained the component of papillary thyroid carcinoma, squamoid ATC cells, and granulation tissue. In areas of granulation tissue, atypical cells with spindle-shaped or polygonal morphology, pyknotic nuclei, and scant cytoplasm were observed. Immunohistochemically, these cells were positive for cytokeratin AE1/AE3, TTF-1, and p53 and negative for thyroglobulin and PAX8. Therefore, the areas of granulation tissue observed within tumor samples were also considered ATC that were affected by lenvatinib treatment. In total, approximately 50% of resected tumor comprised ATC, and 70% of them had been changed to granulation tissue.ConclusionsThe findings in the present case indicate that lenvatinib may have significant antitumor effects in preoperative settings. Lenvatinib may represent a promising candidate therapy for unresectable ATC by increasing tumor resectability.

Anesthesia for thyroid surgery in heart transplant patients - first case study in Serbia

Introduction. The number of patients in the world who have undergone heart transplantation is increasing, with better and longer survival rates, and therefore the number of patients who undergo various surgical interventions after transplantation is also increasing. This presents a challenge for anaesthesiologists. Case outline. A 45-year-old female patient underwent a total thyroidectomy due to suspected thyroid cancer. She had a heart transplant three years earlier. Preoperative preparation included evaluation of cardiac function, consultative examinations by a transplant cardiologist, laboratory and other diagnostic procedures, as well as a detailed analysis of all 20 medications that the patient uses in daily therapy. Common drugs were used for premedication and general endotracheal anaesthesia, with careful dose titration. Medicines were also prepared for the occurrence of heart rhythm disorders, bearing in mind that the heart is denervated, but there was no need for their use. The operation and postoperative course went smoothly and on the third postoperative day the patient was discharged from the hospital in good general condition. Conclusion. Preoperative preparation, anaesthesia, and postoperative treatment of this patient represented a challenge for our team, which was successfully overcome, considering that this is the first case of operative treatment of a patient with a transplanted heart in Serbia.

Shear Wave Ultrasonic Elastometry in Diagnostics of Metastatic Lymph Nodes in Neck Thyroid Cancer

Purpose: Determination of informative value of a new method of ultrasound tomography, based on the properties of elasticity of soft tissues, in the differential diagnosis of metastatic lesions of the lymph nodes of the neck thyroid cancer.Material and methods: To assess the capabilities of shear wave ultrasound elastometry in the diagnosis of metastatic lesions of the lymph nodes in thyroid cancer, a study was carried out with 45 patients with suspected thyroid cancer. The work was performed by devices Acuson S2000 Siemens, Avius hi vision Hitachi using a linear sensor with a frequency of 5–12 MHz. For each object of the study, from 5 to 10 measurements of the shear wave velocity in m / s were made, depending on the size of the lymph nodes.Results: Reliable results were obtained in the group of altered lymph nodes (statistical significance p < 0.05). Interquartile intervals and the most common values of shear wave velocities do not overlap: in metastases — 2.20– 3.36 m/s, with hyperplasia of lymph nodes — 0.70–1.88 m/s, and medians show a significant difference in velocities: metastases — 3.00 m/s, hyperplastic lymph nodes 1.38 m/s.Conclusions: Shear wave elastography objectifies ultrasound studies, obtaining specific indicators of shear wave velocity in the areas of interest, and can be used as an additional diagnostic tool in the differential diagnosis of metastatic and hyperplastic lymph nodes.

Identification of soluble tissue-derived biomarkers from human thyroid tissue explants maintained on a microfluidic device.

Although a large cohort of potential biomarkers for thyroid cancer aggressiveness have been tested in various formats in recent years, to the best of our knowledge, thyroglobulin and calcitonin remain the only two established biomarkers associated with thyroid cancer management. Our group has recently validated a novel means of maintaining live, human ex vivo thyroid tissue within a tissue-on-chip format. The present pilot study aimed to interrogate the tissue effluent, containing all the soluble markers released by the tissue samples maintained within the devices' tissue chamber, for the presence of markers potentially associated with thyroid cancer aggressiveness. Culture effluent from tissue samples harvested from 19 individual patients who had undergone thyroidectomy for the treatment of suspected thyroid cancer was assessed, first using a proteome profiler™ angiogenesis array kit. Patients were subcategorised as 'aggressive' if they possessed a minimum of N1b level metastases, whilst 'non-aggressive' samples were T3 or lower without evidence of multifocality; and contralateral healthy thyroid tissue was harvested for comparative studies. Levels of Serpin-F1, vascular endothelial growth factor, Thrombospondin-1 and chemokine (C-C motif) ligand were significantly altered and, thus, were further investigated using ELISA to allow for quantitative analysis. The concentration of serpin-F1 was significantly increased in the effluent of aggressive thyroid cancer tissue when compared with levels released by both non-aggressive and benign samples. The present study demonstrated the usability of microfluidic technology for the analysis of the ex vivo tissue secretome in order to identify novel biomarkers.

Value of Trans-lymphatic Contrast-enhanced Ultrasound in the Diagnosis of Cervical Lymph Node Metastasis of Thyroid Cancer

Objective To explore the value of trans-lymphatic contrast-enhanced ultrasound(CEUS)in the diagnosis of cervical lymph node metastasis of thyroid cancer. Methods The patients with suspected thyroid cancer underwent conventional ultrasound and trans-lymphatic CEUS examinations before the biopsy.The differences in ultrasound and CEUS characteristics of cervical lymph nodes between the metastatic group and the non-metastatic group were compared,and pathological results were regarded as the golden standard. Results Twenty patients had thyroid cancer,including 12 cases with lymph node metastasis and 8 cases without metastasis.The diagnostic sensitivity(91.7% vs. 75.0%)and accuracy(90.0% vs.80.0%)of trans-lymphatic CEUS were higher than those of conventional ultrasound.The normal lymph nodes presented homogeneous enhancement,while the metastatic lymph nodes showed heterogeneous or non-enhancement during the trans-lymphatic CEUS examination.Conclusion As a new modality of ultrasound,trans-lymphatic CEUS contributes to the diagnosis of cervical lymph node metastasis of thyroid cancer and supplements the deficiencies of conventional ultrasound.

Communicating with residents about 10years of scientific progress in understanding thyroid cancer risk in children after the Fukushima Dai-ichi Nuclear Power Station accident.

ABSTRACTAfter the Fukushima Dai-ichi Nuclear Power Station (FDNPS) accident in 2011, radiation-related risk of childhood thyroid cancer remains a matter of concern among residents living in areas affected by radioactive plumes. As a countermeasure to that, the Fukushima Prefectural Government—in conjunction with Fukushima Medical University—began the Fukushima Thyroid Examination (FTE) campaign in 2011. As 116 definite or suspected thyroid cancer cases were found after the first round of FTE and the total number of cases was >240 as of June 2020, residents’ concerns have deepened. Some researchers claim that these cases are radiation-induced, while others claim a screening effect (because FTE uses high-resolution ultrasound equipment) and express concern about over-diagnosis. Researchers therefore must address two conflicting issues: one is to elucidate radiation effects on thyroid cancer, which requires continuation of FTE; the other is to solve ethical problems associated with FTE. As to over-diagnosis, surgeons claim that early diagnosis benefits children by reducing the side-effects of treatment and prolonging disease-free survival, while cancer epidemiologists claim that early diagnosis will result in overtreatment without reducing the death rate. ‘To receive FTE or not’ and ‘to stop FTE or not’ are ongoing dilemmas for children (and their parents) and other stakeholders, respectively. To facilitate building a consensus among stakeholders, I overview recent findings about dose reconstruction, the dose–response relationship of thyroid cancer, over-diagnosis, and the natural history of thyroid cancer, all of which contribute to judging the risk–benefit balance of thyroid screening.

Secular Trends in Ablation Therapy for Graves’ Disease: An Analysis of a 15-Year Experience at a Tertiary Hospital in South Korea

Ablation therapy, such as radioactive iodine (RAI) therapy or thyroidectomy, is generally used as the second-line treatment for Graves’ disease (GD) in Asia. This study investigated changes in the clinical characteristics and outcomes of ablation therapies for GD over 15 years. Patients who underwent ablation therapy between 2001 and 2015 at a single tertiary hospital were included. Among the 10,991 GD patients treated over this 15-year period, 1357 (12.3%) underwent ablation therapy, and the most common reason was intractable GD. The proportion of patients who underwent any type of ablation therapy significantly decreased from 9.0% (2001–2005) to 7.7% (2011–2015). However, the proportion of patients who underwent surgery significantly increased from 1.1% (2001–2005) to 2.4% (2011–2015), and the proportion of patients who received ablation therapy due to suspected thyroid cancer increased from 5% to 13% over time. With a median follow-up duration of 6.2 years, remission was achieved in 86% and 98% of patients in the RAI and surgery groups, respectively, and these rates remained stable over time. In conclusion, although the proportion of patients who underwent ablation therapy for GD decreased during 15 years, the proportion of those who underwent surgery increased in association with the increased rate of suspected thyroid cancers.

Contrast-enhanced ultrasound: a valuable modality for extracapsular extension assessment in papillary thyroid cancer.

To evaluate the diagnostic accuracy of preoperative contrast-enhanced ultrasound (CEUS) to detect extracapsular extension (ECE) and identify the relationship between ECE and nodule enhancement patterns in patients with papillary thyroid cancer (PTC). Patients with suspected thyroid cancer underwent ultrasound (US) and CEUS examinations. The US and CEUS features of the PTC nodules and thyroid capsule were recorded and classified individually. The accuracy of US and CEUS in detecting ECE was compared individually, and its relationship with various tumour enhancement patterns was analysed. The presence or absence of ECE and cervical lymph node metastasis (LNM) was confirmed pathologically. The final dataset included 119 patients with 124 PTC nodules. Seventy-two (60.5%) of these patients with PTC had no ECE (including 38 patients with single capsule invasion), while the remaining 52 had ECE. A significant difference was found in nodules with non-capsule invasion, single capsule invasion, and ECE between the cervical LNM and non-LNM groups (p < 0.01). Receiver operating characteristic curve analysis demonstrated that area under the curve (AUC) of ECE for cervical LNM was higher than that of capsule invasion (71.9% vs. 49.6%). Moreover, the CEUS images acquired to detect ECE showed higher AUC values than those of US images (79.4% vs. 65.8%) (p = 0.02). Among the PTC nodules with differential enhancement, hyper-enhanced nodules had the highest incidence of capsule invasion (41.9%), while hypo-enhanced ones had a higher incidence of ECE (47.4%). Compared with conventional US, CEUS is a more valuable and non-invasive imaging modality to detect ECE. • Single capsular invasion was a poor predictor of cervical lymph node metastasis, while extracapsular extension assessments were clinically significant for predicting cervical lymph node metastasis. • CEUS is better than conventional US in detecting extracapsular extension in papillary thyroid carcinoma (AUC: 79.4% vs. 65.8%) (p = 0.02). • Among the thyroid papillary carcinoma nodules with differential enhancement, hyper-enhanced nodules had the highest incidence of single capsule invasion (41.9%), while hypo-enhanced ones had a higher incidence of ECE (47.4%).

Metastasis of cancer from Merkel cells to the thyroid gland

Introduction. Merkel cell carcinoma (MCC) is a rare and aggressive neuroendocrine skin cancer. Aim. Herein described is a case of hypertensive patient, after removal of Merkel cancer of the left gluteus skin (2011), after pulmonary embolism (2013), with degenerative changes of the spine and uterine myoma, chronically treated with Warfarin, because of suspected thyroid cancer. Description of the case. A 70-year-old woman case after removing Merkel cancer of the left buttock skin (2011), after pulmonary embolism (2013), with degenerative changes of the spine and uterine fibroids treated chronically with Warfarin because of suspected thyroid cancer is described. Conclusion. Increasing evidence of Merkel cell carcinoma with immunodeficiency and neoplasia, and the management and outcome of these patients requires study.

Diagnostic value of circulating cell-free mtDNA in patients with suspected thyroid cancer: ND4/ND1 ratio as a new potential plasma marker

Thyroid cancer is the most common endocrine malignancy, and its incidence continues to rise. For clinicians with cancer patients, choosing and interpreting diagnostic laboratory studies has become increasingly important. Previously, changes in plasma free mitochondrial DNA levels have been found in colorectal, breast, lung, and urinary cancers, and have demonstrated diagnostic value. In this study, we investigated whether the occurrence and development of thyroid cancer might be predicted using mtDNA copy number (ND1), mtDNA integrity (ND4/ND1) and levels of cell-free nDNA (GAPDH). We analyzed ND1, ND4, and GAPDH levels in plasma and blood cells from 75 patients with thyroid cancer, 40 patients with nodular goiter, and 107 normal controls using real-time PCR. Although both the thyroid nodule and thyroid cancer patients had significantly increased ND1 levels, the ND4/ND1 ratio in the thyroid cancer group was higher than the thyroid nodule group (P < 0.05), and significantly higher than the normal control group (P < 0.01). Plasma levels of nuclear DNA (GAPDH) in the thyroid cancer group were also higher compared to normal (P < 0.05). These results indicate that increased intactness of plasma free mtDNA is associated with increased levels of plasma cell-free nDNA, and that the ND4/ND1 ratio has the potential to be a new detection indicator in thyroid cancer. Furthermore, we classified thyroid cancer patients according to clinical data including age, tumor size, and metastasis. We found significantly higher levels of GAPDH in malignant tissues. Because ND4/ND1 correlated with plasma GAPDH in the plasma studies, this also suggests a potential relationship between ND4 intactness and thyroid tumor tissue size. Taken together, our findings suggest a tumor-specific process involving increased release of intact mtDNA, detectable in the plasma, which differentiates normal patients from patients with thyroid cancer.

Change of Age Distribution of Childhood and Adolescent Thyroid Cancer after the Fukushima Nuclear Accident Compared with the Chernobyl Cases

Background and Methods: Comparison of age patterns of childhood and adolescent childhood thyroid cancer after the nuclear accidents in Fukushima and Chernobyl is often used as a criterion of radiationinduced thyroid cancer in Fukushima. The Fukushima Health Management Survey reports that thyroid cancers in Fukushima are unlikely to be radiation-induced, and one reason for the conclusion was no case was found in the age of 0-5 years at exposure. Published data on the health effects of the Chernobyl accident were analysed to assess whether there was one age pattern common in Chernobyl to be used as a criterion of radiation-induced thyroid cancer. Various age distributions of thyroid cancer as to the age at exposure and age at diagnosis, which depend on the country and the extent of radiation contamination, were studied as a function of years after exposure. Results and Conclusion: The highest incidence of thyroid cancer for infants aged 0-4 at exposure was observed only in Belarus. The high incidence of age group 0-4 AE became apparent only after 12 years from the accident in Ukraine and Russia. Age distribution of diagnosed or suspected thyroid cancer cases in Fukushima by age at exposure shifts to younger age side, average age from 14.9 to 8.3 years in 9 years after the accident. This trend agrees with the one in Ukraine and Russia. Because there is no common age pattern in Chernobyl, we should better not use age pattern as a simple criterion of radiation-induced thyroid cancer.

Thyroid cancer: retrospective study of patients with surgical treatment (a single-center experience)

Introduction. Nodular goiter is one of the most common endocrine disorder, and thyroid cancer takes a leading place among malignancy of the endocrine system. The aim of our study is to evaluate the prevalence and risk factors of thyroid cancer. Materials and methods: this is a retrospective case-control study that included 140 patients operated with suspected thyroid cancer according to a cytological study of fine needle aspirates in single center in 2018. All patients underwent preoperative cytological examination with interpretation of the results according to the Bethesda system, thyroid ultrasound examination, thyroid status assessment. The results of the cytological examination, as well as clinical and laboratory data were compared with the data of histological analysis. Results: According to the preoperative cytological study, 76 nodules were reported as Bethesda IV, 4 – Bethesda III, 32 – Bethesda VI, 28 – Bethesda V. According to the results of a histological examination, thyroid cancer was confirmed in 70% of patients: in 89,3% of Bethesda V and 100% in the Bethesda VI group, 52,6% of Bethesda IV, 25% of the Bethesda III. The risk of nodule malignancy was associated with such ultrasound signs as hypoechoicity, calcifications and irregular contours. Conclusions: the improvement of the methods of preoperative diagnosis of thyroid cancer should help to choose the optimal surgical strategy, reduce the number of diagnostic and repeated thyroidectomy.

Trends in the Surgical Management of Known or Suspected Differentiated Thyroid Cancer at a Single Institution, 2010-2018.

Background: The surgical management of nodular thyroid disease has been influenced by the advent of molecular diagnostics and recent guidelines recommending a more conservative approach to low-risk thyroid tumors. The purpose of this study was to assess practice changes arising from the early adoption of current literature within a single high-volume center. Methods: A retrospective cohort study of all patients evaluated or surgically treated for known or suspected thyroid cancer at a single institution was performed (2010-2018). We analyzed the yield of diagnostic thyroidectomy for indeterminate (Bethesda III and IV) nodules, the choice of initial operation for likely malignant (Bethesda V and VI) nodules, and the rate of completion thyroidectomy. The Cochran-Armitage test was used to assess the significance of any observed trends. Results: Of 2497 patients who underwent initial thyroidectomy from 2010 to 2018, 1791 patients had a tissue diagnosis of suspected or known thyroid cancer by cytopathology (Bethesda III-VI) or surgical pathology (differentiated thyroid cancer). In patients with likely malignant nodules but no clinical evidence of invasive or metastatic disease, the proportion managed with total thyroidectomy plus prophylactic neck dissection fell from 50% to 10% (p = 0.007). The proportion with likely malignant nodules managed definitively with thyroid lobectomy rose from 2% to 19% (p < 0.001). The rate of completion thyroidectomy for thyroid cancer found in the initial lobectomy specimen declined from 73% to 26% (p < 0.001). Among all patients with cytologically indeterminate nodules (n = 1036), we observed a decrease in the rate of diagnostic thyroidectomy from 67% to 35% over the study period (p = 0.015). Conclusions: The early adoption of new diagnostic technology and management guidelines has manifested in a less aggressive surgical approach to known or suspected thyroid cancer. Long-term follow-up will be required to assess oncologic and patient-centered outcomes arising from this modern strategy.

Duodenal Metastases of an Angiosarcoma of the Thyroid Gland

A 71-year-old man presented to the emergency department with melena and severe anemia. One month earlier tinzaparin had been started because of atrial fibrillation. Another 3 months earlier thyroidectomy had been performed for suspected thyroid cancer. Angiosarcoma of the thyroid gland was diagnosed in the resection specimen and palliative chemotherapy with paclitaxel was started because of lung metastasis. Endoscopy revealed multiple reddish lesions with slightly raised margins in the duodenum (Figure A).

Positive rate and accuracy of ultrasound-guided fine-needle aspiration cytology for detecting suspected thyroid carcinoma nodules of different sizes

To analyze the accuracy and positive rate of ultrasound-guided fine-needle aspiration (US-FNA) cytology for detecting suspected thyroid cancer nodules of different sizes. A total of 591 patients with 594 suspected malignant thyroid nodules received examinations with US-FNA cytology. Based on their size, the nodules were divided into group I (4-5 mm), group II (6-10 mm), group III (&gt;10 mm). With the results of pathology as the standard, we analyzed the results of US-FNA cytology for detecting thyroid carcinoma in terms of its accuracy, indeterminate rate, positive predictive value and negative predictive value for nodules of different sizes. The positive rates in group I, group II and group III were 39.2% (40/102), 48.2% (172/357) and 65.2% (88/135), respectively, similar between groups I and II (P=0.107) and differed significantly between groups I and III (P=0.000) and between groups II and III (P=0.001). The accuracy, indeterminate rate, positive predictive value and negative predictive value in the 3 groups were 95.5% (21/22), 97.1% (100/103), and 94.4% (51/54); 2.9% (3/102), 2.8% (10/357), and 1.5% (2/135); 100%, 100%, and 98%; 66.7%, 57.1%, and 33.3%, respectively, showing no significant differences among the 3 groups. The size of the thyroid nodules can affect the positive rate but does not have significant effects on the accuracy, indeterminate rate, positive predictive value or negative predictive value of US-FNA cytology.

Diagnostic Performance of Neck Ultrasonography in the Preoperative Evaluation for Extrathyroidal Extension of Suspicious Thyroid Nodules.

A preoperative neck ultrasound (US) is recommended for all patients with suspected thyroid cancer, to identify features potentially changing surgical extent. The extrathyroidal extension (ETE) is considered an indication for total thyroidectomy, but there is limited consensus on its US definition, and the interobserver reliability is low. This study aimed to evaluate the predictive value of neck US for ETE before surgery and to estimate the diagnostic performance of different US findings, evaluated during real-time examinations. Patients referred to surgery between November 1, 2015, and May 31, 2019, for a suspicious thyroid cancer underwent a preoperative neck US, with systematic assessment for ETE. Three definitions were tested: very restrictive (capsular disruption with suspicious images of surrounding tissues invasion), restrictive (including also capsular abutment with evidence of capsular disruption), and nonrestrictive (capsular abutment is sufficient). Histopathology report of ETE involving at least soft tissues was considered positive. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. The study cohort included 128 patients, with 102 (79.7%) confirmed malignancies, and 44 (43.1%) histological ETE. The nonrestrictive definition had good sensitivity (86.4%) but low specificity (29.8%), with an NPV of 80.6%; the restrictive definition had higher specificity (81%), while the very restrictive had specificity and PPV of 100%. A more extensive surgical approach should not be based on US suspicion of ETE alone, with the possible exception of gross invasion appearance. The absence of any sign of ETE, on the other hand, has a substantial negative predictive value.