Management Of Thyroid Nodules Research Articles

Exploring the Diagnostic Role of Spectral Doppler as a Predictor of Malignancy Within Thyroid Nodules

Objective: In recent years, spectral Doppler has become a valuable diagnostic tool for assessing suspected thyroid nodules. The aim of this study was to assess the clinical use of spectral Doppler in managing thyroid nodules. Materials and Methods: This prospective cohort study included 153 patients who underwent thyroid nodule evaluation, using sonography. Peak systolic velocity, end-diastolic velocity (EDV), resistive index (RI), and pulsatility index (PI) were measured, within the suspected lesions. Results: Among the 209 identified thyroid nodules, 193 (92%) were benign and 16 (7.6%) were malignant. The RI and PI values of malignant nodules were significantly higher than measured within benign nodules. There was also a significant difference in the EDV between benign and malignant nodules ( P = .012). The RI had the highest diagnostic accuracy, with an area under the receiver operating characteristic, area under the curve, of 0.839 (95% confidence interval, 0.748–0.930). The optimal cutoff value for RI was 0.73. The results indicate that the RI with an odds ratio (OR) of 2.64, in the univariate analysis, and an OR of 2.31, in the multivariate analysis, might be successful in predicting a malignant thyroid nodule. Conclusion: This cohort study demonstrated a high sensitivity and specificity for RI and PI as predictors of malignancy in thyroid nodules, with diagnostic cutoff points of 0.73 and 1.37, respectively.

Italian guideline on the management of benign non-hyperfunctioning thyroid nodule causing compressive symptoms

Italian guideline on the management of benign non-hyperfunctioning thyroid nodule causing compressive symptoms

Computer-interpretable guidelines: electronic tools to enhance the utility of thyroid nodule clinical practice guidelines and risk stratification tools.

Clinicians seeking guidance for evaluating and managing thyroid nodules currently have several resources. The principal ones are narrative clinical guidelines and clinical risk calculators. This paper will review the strengths and weaknesses of both. The paper will introduce a concept of computer interpretable guideline, a novel way of transforming narrative guidelines in to a clinical decision support tool that can provide patient specific recommendations at the point of care. The paper then describes an experience of developing an interactive web based computer interpretable guideline for thyroid nodule management, called Thyroid Nodule Management App (TNAPP). The advantages of this approach and the potential barriers for widespread adaptation are discussed.

Surgical Management of Indeterminate Thyroid Nodules across Different World Regions: Results from a Retrospective Multicentric (the MAIN-NODE) Study.

Indeterminate thyroid nodules (ITNs) are characterized by an expected malignancy ranging from 5% to 30%, with most patients undergoing a diagnostic, rather than therapeutic, operation. The aim of our study was to compare the approach to ITNs across different regions of the world. In this retrospective, multicentric, international study, according to the WHO classification, we identified the South East Asian Region (SEAR), the Americas Region (AMR), the Eastern Mediterranean Region (EMR), the Europe Region (EUR), and the Western Pacific Region (WPR). One high-volume thyroid centre was included for each region. Demographic, preoperative, and pathologic data were compared among the different regions. Overall, 5737 patients from five high-volume thyroid centres were included in this study. We found that the proportion of ITNs over the global activity for thyroid disease was higher in the EUR (37.6%) than in the other regions (21.1-23.6%). In the EMR, the patients were significantly younger (with a mean of 43.1 years) than in the other regions (range, 48.8-57.4 years). The proportion of lobectomy was significantly higher in the WPR, where 83.2% (114/137) of patients received this treatment, than in the other regions, where lobectomies were performed in 44.1-58.1% of patients. The pathological diagnosis of malignancy was significantly higher in the SEAR centre, being over 60%, than in centres of the other regions, where it ranged from 26.3% to 41.3%. The occurrence of lymph node metastases was higher in the WPR (27.8%), AMR (26.9%), and EMR (20%) centres than in the EUR and SEAR centres, where it was lower than 10%. In summary, we found in our study different approaches and outcomes in the diagnosis and treatment of ITNs among countries. Overall, almost 60% of patients with ITNs who underwent surgery actually presented a benign disease, potentially undergoing an unnecessary operation.

Thyroid artery embolization of large solitary symptomatic benign thyroid nodules through transradial approach.

This study investigated the efficacy and safety of transradial access (TRA) thyroid artery embolization (TAE) for patients with large solitary symptomatic benign thyroid nodules. Six patients with a total of six nodules (three men and three women; mean age, 36.3 years; age range, 23-45 years) underwent TRA TAE between October 2021 and June 2022 and were subsequently followed up three months later, and their cases were retrospectively reviewed. The associated complications were recorded during and after TRA TAE. The volume change and nodule-related symptom score on a 10-cm visual analogue scale (VAS) between baseline, 1- and 3-month follow-up was analyzed using Wilcoxon signed-rank test. The technical success rate of the TRA TAE was 100% without conversion to transfemoral access. The mean volume of the nodules decreased between baseline (84.1 mL; range, 46.1-170.5 mL), 1-month (38.8 mL; range, 17.6-91.5 mL; P=0.028) and 3-month (14.8 mL; range, 3.95-26.4 mL; P=0.068) at follow-up after TRA TAE. The mean volume reduction rate was 54.9% (range, 45.2-71.8%) at 1-month follow-up and 81.8% (range, 62.0-92.0%) at 3-month follow-up. The VAS score was reduced at 1-month (P=0.028) and at 3-month follow up (P=0.068). Radial artery spasm (n=1) was noted during TRA TAE, and neck pain (n=5) and voice change (n=1) occurred within 1 week after the procedure and resolved with conservative treatment. No major complications were reported. TRA TAE may be a promising alternative therapy for the management of large solitary thyroid nodules.

History of Thyroid Ultrasound.

From low-resolution images in the 1960s to current high-resolution technology, ultrasound has proven to be the initial imaging modality of choice for thyroid application. Point-of-care ultrasound has brought the technology to the thyroid specialist. Combined with physical examination, it provides real-time information regarding goiter, thyroid nodules, and thyroid cancer. Ultrasound-guided fine-needle aspiration biopsy has become the accepted norm, with biopsies rarely performed using palpation alone. Advantages of ultrasound-guided biopsy include precise placement of the needle within the nodule, selective sampling of areas with suspicious features, and accurate direction of the biopsy needle to actively growing viable cells in the periphery of the nodule. Education of endocrinologists in thyroid ultrasound began in the late 1990s and by 2016 more than 6000 clinicians had completed an ultrasound course. Concurrent with this rapid expansion of use of thyroid ultrasound was a rise in the diagnosis of small papillary carcinomas, which might have otherwise remained indolent and undetected. The 2009 American Thyroid Association Guidelines for the Management of Thyroid Nodules and Thyroid Cancer recommended biopsy for all solid hypoechoic nodules measuring larger than 1 cm. Attempting to decrease the frequency of biopsies of low-risk nodules, subsequent guidelines have focused on identifying and selectively biopsying those thyroid nodules at higher risk of clinically significant carcinoma based on ultrasound appearance. A major role for thyroid ultrasound has been in both preoperative staging and mapping to help determine the extent of surgery, as well as postoperative monitoring for locoregional soft tissue or lymph node metastases. With the recognition that the increase in papillary carcinoma was predominantly a result of early diagnosis of small often indolent cancers, active surveillance has become a promising management strategy for papillary thyroid microcarcinomas. Thyroid ultrasound is essential to active surveillance of thyroid cancer. Easy access to high-quality ultrasound studies is a requirement for a successful active surveillance program. Thyroid ultrasound has been used to facilitate interventional procedures, including treatment of thyroid nodules, treatment of recurrent thyroid cancer, and therapy of papillary thyroid microcarcinoma.

Comparison between Fine Needle Aspiration Cytology with Histopathology in the Diagnosis of Thyroid Nodules.

Accurate diagnosis of thyroid nodules is crucial for avoiding unnecessary surgeries and enabling timely treatment. Fine needle aspiration cytology (FNAC) and ultrasound are commonly employed diagnostic techniques, but their reliability is debated. This study aimed to compare the diagnostic accuracy of FNAC and ultrasounds using histopathology as the reference standard. A retrospective review was conducted on 344 patients who underwent thyroidectomy between January 2017 and May 2022. An ultrasound and FNAC were performed before surgery, and histopathological findings were compared. Statistical analyses were conducted to calculate sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), false positive rate, false negative rate, and overall accuracy for each diagnostic method. Among the study population, 38.67% of thyroid tumors were malignant. Ultrasound showed a sensitivity of 68.18%, specificity of 76.55%, PPV of 64.74%, NPV of 79.20%, and overall accuracy of 73.31%. FNAC had a sensitivity of 89.31%, specificity of 48.44%, PPV of 78%, NPV of 68.89%, and accuracy of 75.89%. The correlation coefficient between ultrasound and FNAC was 0.512 (p < 0.0000001). Ultrasound correlated with histopathology with a coefficient of 0.408 (p < 0.0000001), while FNAC with histopathology had a coefficient of 0.304 (p < 0.00001). The correlation coefficient between these three diagnostic methods was 0.423 (p < 0.0001). In the diagnosis of thyroid nodules, both FNAC and ultrasound demonstrated moderate diagnostic accuracy. Ultrasound showed a higher specificity, while FNAC exhibited a higher sensitivity. Combining these techniques may improve diagnostic accuracy. Further research and the development of more reliable diagnostic methods are warranted to optimize the management of thyroid nodules and avoid unnecessary surgeries.

A comparison of the 2 thermal ablation procedures for the management of benign thyroid nodules.

In recent years, ultrasound (US)-guided thermal ablation techniques have come to the fore as minimally invasive alternatives to surgery. The purpose of this study was to assess the effectiveness and safety of radiofrequency ablation or microwave ablation procedures in patients with benign thyroid nodules. This retrospective and single-centre study consisted of 55 patients and 62 benign thyroid nodules that were treated either with radiofrequency ablation (RFA) or microwave ablation (MWA) in our hospital between January 2020 and March 2022. All the patients were at high risk for surgery or with symptomatic TNs and who refused surgery. The TNs diagnosed as benign from the fine-needle aspiration biopsy were evaluated in terms of volume reduction, symptom, and cosmetic scores. In addition, these 2 treatment modalities were compared to each other. Out of 55 patients, 44 (80%) were female and were aged between 24 and 97 years with a median age of 50 years. RFA was applied to 54.5% (n = 30) of the participants, and MWA was applied to 46.5% (n = 25). The volume reduction rate (VRR) after RFA and MWA at the first month was 63.4 ± 14.2 and 65.7 ± 13, respectively. No significant difference was detected between the 2 groups in terms of VRR (p = 0.51). In addition, the mean symptom and cosmetic scores decreased significantly in both procedures, and there was a significant difference due to the symptom score change in the RFA group compared to the MWA group. Of all the patients, one patient experienced haematoma in the RFA, and one patient had transient voice change in the MWA group. No life-threatening complications were noted. In the treatment of benign symptomatic thyroid nodules, both RFA and MWA are options worthy of consideration in terms of efficacy and safety.

Comparison of the diagnostic accuracy of K-TIRADS and EU-TIRADS guidelines for detection of thyroid malignancy on ultrasound

IntroductionThis retrospective study compared the diagnostic accuracy of histopathologically proven thyroid nodules between the Korean Thyroid Imaging Reporting and Data System (K-TIRADS) and the European Thyroid Imaging Reporting and Data System (EU-TIRADS) guidelines for the management of thyroid nodules characterized by ultrasonography. Material and methodsFor thyroid nodules resected from 2018 to 2021 at our institution, static ultrasound images of each nodule were reviews and stratify into both systems. Agreement between above two classifications was compared based on histopathological results. ResultsA total 403 thyroid nodules from 213 patients were evaluated. Each nodule was characterized by ultrasonography and stratified into K-TIRADS and EU-TIRADS classifications. The diagnostic accuracy was as follows: K-TIRADS sensitivity 85.3% (95% CI, 78.7–91.9) specificity 76.8% (95% CI, 72.1–81.7), positive predictive value 57.8% (95% CI, 50.1–65.4) negative predictive value 93.4% (95% CI, 90.3–96.5); EU-TIRADS sensitivity 86.2% (95% CI, 79.7–92.7), specificity 75.5% (95% CI, 70.6–80.4), positive predictive value 56.6% (95% CI, 49.1–64.2), negative predictive value 93.7% (95% CI, 90.6–96.8). Excellent agreement in risk stratifications between both systems was found (kappa 0.86). ConclusionsUltrasound thyroid nodules categorized by either by K-TIRADS or EU-TIRADS are useful to predicting malignancy and perform risk stratification with similar results. Implications for practiceThis study confirmed that both K-TIRADS and EU-TIRADS have high diagnostic accuracy and both guidelines may be used as an effective tool for management planning of patients with thyroid nodules in daily clinical practice.

Factors affecting the false negativity of fine-needle aspiration biopsy in thyroid nodules with indeterminate cytology

Purpose: False negative results of fine needle aspiration biopsies (FNAB) remain one of the most important problems in the management of thyroid nodules. The aim of this study was to evaluate the factors affecting the false negative results of FNAB, especially in thyroid nodules with indeterminate cytology.&#x0D; Materials and Methods: Patients with thyroid nodules who underwent FNAB and subsequent thyroidectomy between January 2017 and January 2020 were included in the study. FNAB was performed on suspicious nodules according to the TIRADS classification. Nodules with "atypia/follicular lesion of undetermined significance (AUS/FLUS)", "non-diagnostic (ND)" cytology or "follicular neoplasm/suspicious for follicular neoplasm (FN/SFN)" according to FNAB were defined as "indeterminate cytology (IC)". Nodules were analyzed in two groups. Nodules with false negative FNAB were included in Group-1, while nodules with true positive and true negative FNAB were included in Group-2. Demographic and clinical data, pathologic results and genetic profiles of the patients were statistically compared for all patients and IC group separately.&#x0D; Results: The results of FNAB and final pathology were discordant in 94 patients (Group-1) and concordant in 233 patients (Group-2). In the IC subgroup, 56 of 95 patients were in IC/Group-1 and 39 patients were in IC/Group-2. The accuracy of FNAB was statistically significantly higher in the presence of extrathyroidal extension (71.4% vs. 30.8%), perineural/lymphovascular invasion (60.0% vs. 29.6%), classical variants (68.5% vs. 50.7%), non-encapsulated tumors (67.9% vs. 50.0%) and multicentricity (47.2% vs. 24.1%). In the IC group, the presence of thyroiditis (75.0% vs. 49.2%) and high serum Anti-TPO levels (60.0% vs. 30.7%) increased the rate of false negativity on FNAB. High serum Neutrophil to Lymphocyte Ratio (NLR) and small tumor size also increase the false negativity of FNAB, especially in IC group patients.&#x0D; Conclusion: The diagnostic accuracy of FNAB is increased in classical variant tumors and in tumors expected to be aggressive due to presence of extra-thyroidal extension, perineural/lymphovascular invasion, non-encapsulated tumors and multicentricity. It should be kept in mind that the false negative results of FNAB increase in the presence of thyroiditis, high level of serum anti-TPO and high level of NLR.

Diagnostic performance of ultrasound risk stratification systems on thyroid nodules cytologically classified as indeterminate: a systematic review and meta-analysis.

Ultrasound (US) risk stratification systems (RSSs) are increasingly being utilized for the optimal management of thyroid nodules, including those with indeterminate cytology. The goal of this study was to evaluate the category-based diagnostic performance of US RSSs in identifying malignancy in indeterminate nodules. This systematic review and meta-analysis was registered on PROSPERO (CRD42021266195). PubMed, EMBASE, and Web of Science were searched through December 1, 2022. Original articles reporting data on the performance of US RSSs for indeterminate nodules were included. The numbers of nodules classified as true negative, true positive, false negative, and false positive were extracted. Thirty-three studies evaluating 7,225 indeterminate thyroid nodules were included. The diagnostic accuracy was quantitatively synthesized using a Bayesian bivariate model based on the integrated nested Laplace approximation in R. For the intermediate- to high-risk category, the sensitivity levels of the American College of Radiology, the American Thyroid Association, the European Thyroid Association, the Korean Thyroid Association/Korean Society of Thyroid Radiology, and Kwak et al. were found to be 0.80, 0.72, 0.76, 0.96, and 0.97, respectively. The corresponding specificity measurements were 0.36, 0.50, 0.49, 0.28, and 0.17. Furthermore, for the high-risk category, the sensitivity values were 0.40, 0.46, 0.55, 0.47, and 0.10, while the specificity levels were 0.91, 0.90, 0.71, 0.91, and 0.99, respectively. The overall diagnostic performance of the US RSSs was moderate in the differentiation of indeterminate nodules.

Knowledge, Attitude and Practice of Filipino Surgeons Regarding Clinical Practice Guidelines on Thyroid Nodules and Malignancy: A PCS-PSGS -PAHNSI Collaborative Study

Rationale: In 2008, the Philippine College of Surgeons in collaboration with the Philippine Society of General Surgeons and the Philippine Academy of Head and Neck Surgeons, Inc. had published Evidence-based Clinical Practice Guidelines (CPG) on the Diagnosis and Management of Thyroid Nodules. This was followed by an update in 2013 with a focus on important diagnostic and therapeutic management issues concerning thyroid malignancy. The objective of this study was to assess knowledge gaps and behavioral patterns among users with respect to these CPGs. Methods: A validated 30 item survey assessing knowledge of, attitudes towards, and adherence to the recommendations of different Evidence based Clinical Practice Guidelines was administered to general surgery residents, PSGS fellows, and otorhinolaryngology residents and consultants performing thyroidectomies. Results: There were 343 assessable forms. Of the respondents, 276 (80.47%) were general surgeons, 33 (9.62%) were otorhinolaryngologists. There were 66 (19.24%) consultants, and 277 (80.76%) residents. Otorhinolaryngologists were less aware of the local CPGs than their GS counterparts. GS Residents, compared to their consultants, were more aware of the American Thyroid Association guidelines than the local guidelines. Among all respondents, the local guidelines had about equal preference for usage as the American Thyroid Association guidelines. There were no statistically significant differences on the level of knowledge and attitudes among the respondents. Conclusions: The level of awareness about the PCS Thyroid Guidelines needs to be improved. The dissemination process needs to be reviewed and ensure that all stakeholders will be reached. Key words: thyroid, clinical practice guidelines

Multimodality US versus Thyroid Imaging Reporting and Data System Criteria in Recommending Fine-Needle Aspiration of Thyroid Nodules.

Background Current guidelines recommend the use of conventional US for risk stratification and management of thyroid nodules. However, fine-needle aspiration (FNA) is often recommended in benign nodules. Purpose To compare the diagnostic performance of multimodality US (including conventional US, strain elastography, and contrast-enhanced US [CEUS]) with the American College of Radiology Thyroid Imaging Reporting and Data System (TI-RADS) in the recommendation of FNA for thyroid nodules to reduce unnecessary biopsies. Materials and Methods In this prospective study, 445 consecutive participants with thyroid nodules from nine tertiary referral hospitals were recruited between October 2020 and May 2021. With univariable and multivariable logistic regression, the prediction models incorporating sonographic features, evaluated with interobserver agreement, were constructed and internally validated with bootstrap resampling technique. In addition, discrimination, calibration, and decision curve analysis were performed. Results A total of 434 thyroid nodules confirmed at pathologic analysis (259 malignant thyroid nodules) in 434 participants (mean age, 45 years ± 12 [SD]; 307 female participants) were included. Four multivariable models incorporated participant age, nodule features at US (proportion of cystic components, echogenicity, margin, shape, punctate echogenic foci), elastography features (stiffness), and CEUS features (blood volume). In recommending FNA in thyroid nodules, the highest area under the receiver operating characteristic curve (AUC) was 0.85 (95% CI: 0.81, 0.89) for the multimodality US model, and the lowest AUC was 0.63 (95% CI: 0.59, 0.68) for TI-RADS (P < .001). At the 50% risk threshold, 31% (95% CI: 26, 38) of FNA procedures could be avoided with multimodality US compared with 15% (95% CI: 12, 19) with TI-RADS (P < .001). Conclusion Multimodality US had better performance in recommending FNA to avoid unnecessary biopsies than the TI-RADS. Clinical trial registration no. NCT04574258 © RSNA, 2023 Supplemental material is available for this article.

Clinico-cytopathological subcategorization in thyroid nodules of atypia of undetermined significance/follicular lesion of undetermined significance using the TIRADS and Bethesda classifications.

Bethesda category III - atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS) is a heterogeneous class of the Bethesda system for thyroid nodules. In order to clarify the therapeutic road for clinicians, this category was subclassified based on the cytopathological features. In this study, we evaluated the risk of malignancy, surgical outcome, demographic characteristics, and correlation of ultrasound features with the final outcome in patients with thyroid nodules based on AUS/FLUS subclassification. After evaluating 867 thyroid nodules from three different centers, 70 (8.07%) were initially diagnosed as AUS/FLUS. The cytopathologists re-interpreted the FNA samples and subclassified them into five subcategories: architectural atypia, cytologic atypia, cytologic and architectural atypia, and Hürthle cell AUS/FLUS, and atypia, which was not specified. Based on the suspicious ultrasound features, an appropriate ACR TI-RADS score was allocated to each nodule. Finally, the malignancy rate, surgical outcomes, and ACR TI-RADS scores were evaluated among Bethesda category III nodules. Among the 70 evaluated nodules, 28 (40%) were subclassified as Hürthle cell AUS/FLUS, 22 (31.42%) as cytologic and architectural atypia, 8 (11.42%) as architectural atypia, 7 (10%) as cytologic atypia, and 5 (7.14%) as atypia which was not specified. The overall malignancy rate was 34.28%, and the architectural atypia and Hürthle cell nodules displayed lower malignancy compared to other groups (P-Value<0.05). Utilizing ACR TI-RADS scores showed no statistical significance between Bethesda III subcategorization and ACR TI-RADS scores. However, ACR TI-RADS can be a reliable predictor for Hürthle cell AUS/FLU nodules. ACR TI-RADS helps evaluate malignancy only in the Hürthle cell AUS/FLUS subcategory of AUS/FLUS. Besides, cytopathological reporting based on the suggested AUS/FLUS subclassification could help clinicians take appropriate measures to manage thyroid nodules.

Evaluation and management of pediatric thyroid nodules and thyroid cancer at a single institution after adoption of the American Thyroid Association 2015 guidelines.

The study purpose is to correlate clinical findings with rates of differentiated thyroid cancer (DTC) ina cohort of children presenting with thyroid nodules atasingle institution since the adoption of the 2015 American Thyroid Association (ATA) Guidelines Task Force on Pediatric Thyroid Cancer. Clinical, radiographic, and cytopathologic findings were retrospectively analyzed in a pediatric cohort (≤19 years) identified with ICD-10 codes for thyroid nodules and thyroid cancer from January 2017 until May 2021. We analyzed 183 patients with thyroid nodules. The mean patient age was 14 years (interquartile range 11-16) with a female (79.2 %) and white Caucasian (78.1 %) predominance. The overall DTC in our pediatric patient cohort was 12.6 % (23 out of 183). Most of the malignant nodules measured from 1-4 cm (65.2 %) with TI-RADS score of≥4 (69.6 %). Among the fine-needle aspiration results (n=49), the highest frequency of DTC was within the malignant category (16.33 %), followed by suspicious for malignancy (6.12 %), then atypia or follicular lesion of undetermined significance (8.16 %), and lastly follicular lesion or neoplasm and benign with 4.08 % and 2.04 % respectively. Of the forty-four thyroid nodules that underwent surgical intervention, pathology was remarkable for 19 papillary thyroid carcinoma (43.18 %) and 4 follicular thyroid carcinoma (9.09 %). Based on the analysis of our pediatric cohort in the southeast region at a single institution, adoption of the 2015 ATA guidelines could lead to an increased accuracy in detecting DTC while reducing the number of patients requiring interventions, such as FNA biopsy and/or surgeries. Further, based on our small cohort, it would be reasonable for thyroid nodules 1 cm or less to be monitored clinically with physical exam and ultrasonography, with further therapeutic or diagnostic intervention considered based on concerning features or parental shared decision making.

Comparative Study of C-TIRADS, ACR-TIRADS, and EU-TIRADS for Diagnosis and Management of Thyroid Nodules

Chinese Thyroid Imaging Reporting and Data Systems (C-TIRADS) was developed to provide a more simplified tool for stratifying thyroid nodules. Here we aimed to validate the efficacy of C-TIRADS in distinguishing benign from malignant and in guiding fine-needle aspiration biopsies in comparison with the American College of Radiology TIRADS (ACR-TIRADS) and European TIRADS (EU-TIRADS). This study retrospectively included 3438 thyroid nodules (≥10mm) in 3013 patients (mean age, 47.1 years±12.9) diagnosed between January 2013 and November 2019. Ultrasound features of the nodules were evaluated and categorized according to the lexicons of the three TIRADS. We compared these TIRADS by using the area under the receiver operating characteristic curve (AUROC), the area under the precision-recall curve (AUPRC), sensitivity, specificity, net reclassification improvement (NRI), and unnecessary fine-needle aspiration biopsy (FNAB) rate. Of the 3438 thyroid nodules, 707 (20.6%) were malignant. C-TIRADS showed higher discrimination performance (AUROC, 0.857; AUPRC, 0.605) than ACR-TIRADS (AUROC, 0.844; AUPRC, 0.567) and EU-TIRADS (AUROC, 0.802; AUPRC, 0.455). The sensitivity of C-TIRADS (85.3%) was lower than that of ACR-TIRADS (89.1%) but higher than that of EU-TIRADS (78.4%). The specificity of C-TIRADS (76.9%) was similar to that of EU-TIRADS (78.9%) and higher than that of ACR-TIRADS (69.5%). The unnecessary FNAB rate was lowest with C-TIRADS (21.2%), followed by ACR-TIRADS (41.7%) and EU-TIRADS (58.3%). C-TIRADS obtained significant NRI for recommending FNAB over ACR-TIRADS (19.0%, P<0.001) and EU-TIRADS (25.5%, P<0.001). C-TIRADS may be a clinically applicable tool to manage thyroid nodules, which warrants thorough tests in other geographic settings.

Automated diagnosis and management of follicular thyroid nodules based on the devised small-datasets interpretable foreground optimization network deep learning: A multicenter diagnostic study.

Currently, follicular thyroid carcinoma (FTC) has relatively low incidence with a lack of effective preoperative diagnostic means. To reduce the need for diagnostic invasive procedures and to address information deficiencies inherent in a small-dataset, we utilized interpretable foreground optimization network deep learning to develop a reliable preoperative FTC detection system. In this study, a deep learning model (FThyNet) was established using preoperative ultrasound images. Data on patients in training and internal validation cohort (n=432) were obtained from XXX Hospital, China. Data on patients in external validation cohort (n=71) were obtained from four other clinical centers. We evaluated the predictive performance of FThyNet and its ability to generalize across multiple external centers and compared the results yielded with assessments from physicians directly predicting FTC outcomes. In addition, the influence of texture information around the nodule edge on the prediction results was evaluated. FThyNet had a consistently high accuracy in predicting FTC with area under the receiver operating characteristic curve (AUC) of (89.0% [95% CI 87.0-90.9]). Particularly, the AUC for grossly invasive-FTC reached 90.3%, which was significantly higher than that of the radiologists (56.1% [95% CI 51.8-60.3]). The parametric visualization study found that those nodules with blurred edges and relatively distorted surrounding textures were more likely to have FTC. Furthermore, edge texture information played an important role in FTC prediction with an AUC of (68.3% [95% CI 61.5-75.5]), and highly invasive malignancies had the highest texture complexity. FThyNet could effectively predict FTC, provide explanations consistent with pathological knowledge, and improve clinical understanding of the disease.

Integration of Artificial Intelligence Decision Aids to Reduce Workload and Enhance Efficiency in Thyroid Nodule Management

To optimize the integration of artificial intelligence (AI) decision aids and reduce workload in thyroid nodule management, it is critical to incorporate personalized AI into the decision-making processes of radiologists with varying levels of expertise. To develop an optimized integration of AI decision aids for reducing radiologists' workload while maintaining diagnostic performance compared with traditional AI-assisted strategy. In this diagnostic study, a retrospective set of 1754 ultrasonographic images of 1048 patients with 1754 thyroid nodules from July 1, 2018, to July 31, 2019, was used to build an optimized strategy based on how 16 junior and senior radiologists incorporated AI-assisted diagnosis results with different image features. In the prospective set of this diagnostic study, 300 ultrasonographic images of 268 patients with 300 thyroid nodules from May 1 to December 31, 2021, were used to compare the optimized strategy with the traditional all-AI strategy in terms of diagnostic performance and workload reduction. Data analyses were completed in September 2022. The retrospective set of images was used to develop an optimized integration of AI decision aids for junior and senior radiologists based on the selection of AI-assisted significant or nonsignificant features. In the prospective set of images, the diagnostic performance, time-based cost, and assisted diagnosis were compared between the optimized strategy and the traditional all-AI strategy. The retrospective set included 1754 ultrasonographic images from 1048 patients (mean [SD] age, 42.1 [13.2] years; 749 women [71.5%]) with 1754 thyroid nodules (mean [SD] size, 16.4 [10.6] mm); 748 nodules (42.6%) were benign, and 1006 (57.4%) were malignant. The prospective set included 300 ultrasonographic images from 268 patients (mean [SD] age, 41.7 [14.1] years; 194 women [72.4%]) with 300 thyroid nodules (mean [SD] size, 17.2 [6.8] mm); 125 nodules (41.7%) were benign, and 175 (58.3%) were malignant. For junior radiologists, the ultrasonographic features that were not improved by AI assistance included cystic or almost completely cystic nodules, anechoic nodules, spongiform nodules, and nodules smaller than 5 mm, whereas for senior radiologists the features that were not improved by AI assistance were cystic or almost completely cystic nodules, anechoic nodules, spongiform nodules, very hypoechoic nodules, nodules taller than wide, lobulated or irregular nodules, and extrathyroidal extension. Compared with the traditional all-AI strategy, the optimized strategy was associated with increased mean task completion times for junior radiologists (reader 11, from 15.2 seconds [95% CI, 13.2-17.2 seconds] to 19.4 seconds [95% CI, 15.6-23.3 seconds]; reader 12, from 12.7 seconds [95% CI, 11.4-13.9 seconds] to 15.6 seconds [95% CI, 13.6-17.7 seconds]), but shorter times for senior radiologists (reader 14, from 19.4 seconds [95% CI, 18.1-20.7 seconds] to 16.8 seconds [95% CI, 15.3-18.3 seconds]; reader 16, from 12.5 seconds [95% CI, 12.1-12.9 seconds] to 10.0 seconds [95% CI, 9.5-10.5 seconds]). There was no significant difference in sensitivity (range, 91%-100%) or specificity (range, 94%-98%) between the 2 strategies for readers 11 to 16. This diagnostic study suggests that an optimized AI strategy in thyroid nodule management may reduce diagnostic time-based costs without sacrificing diagnostic accuracy for senior radiologists, while the traditional all-AI strategy may still be more beneficial for junior radiologists.

A tribute to Ernest L. Mazzaferri, MD and the lasting impact that he had on thyroid cancer care ten years after his death.

This viewpoint highlights the contributions of Dr. Ernest Mazzaferri, a prominent figure in the field of thyroid cancer care, who made significant contributions to the diagnosis and treatment of this disease. Dr. Mazzaferri's first paper on thyroid cancer, published in 1977, established fundamental principles that remain fundamental to differentiated thyroid cancer management. He was an advocate of total thyroidectomy and of postoperative radioiodine therapy and contributed to improving thyroid fine needle aspiration techniques. Dr. Mazzaferri's leadership in developing guidelines for the management of thyroid cancer and thyroid nodules has been influential and widely accepted. His groundbreaking work established a systematic and data-driven approach to the diagnosis and treatment of thyroid cancer that continues to shape the field of thyroid cancer care today. This Viewpoint reflects on his lasting impact ten years after his death.

Ultrasonography-based radiomics and computer-aided diagnosis in thyroid nodule management: performance comparison and clinical strategy optimization.

To compare ultrasonography (US) feature-based radiomics and computer-aided diagnosis (CAD) models for predicting malignancy in thyroid nodules, and to evaluate their utility for thyroid nodule management. This prospective study included 262 thyroid nodules obtained between January 2022 and June 2022. All nodules previously underwent standardized US image acquisition, and the nature of the nodules was confirmed by the pathological results. The CAD model exploited two vertical US images of the thyroid nodule to differentiate the lesions. The least absolute shrinkage and operator algorithm (LASSO) was applied to choose radiomics features with excellent predictive properties for building a radiomics model. Ultimately, the area under the receiver operating characteristic curve (AUC) and calibration curves were assessed to compare diagnostic performance between the models. DeLong's test was used to analyze the difference between groups. Both models were used to revise the American College of Radiology Thyroid Imaging Reporting and Data Systems (ACR TI-RADS) to provide biopsy recommendations, and their performance was compared with the original recommendations. Of the 262 thyroid nodules, 157 were malignant, and the remaining 105 were benign. The diagnostic performance of radiomics, CAD, and ACR TI-RADS models had an AUC of 0.915 (95% confidence interval (CI): 0.881-0.947), 0.814 (95% CI: 0.766-0.863), and 0.849 (95% CI: 0.804-0.894), respectively. DeLong's test showed a statistically significant between the AUC values of models (p < 0.05). Calibration curves showed good agreement in each model. When both models were applied to revise the ACR TI-RADS, our recommendations significantly improved the performance. The revised recommendations based on radiomics and CAD showed an increased sensitivity, accuracy, positive predictive value, and negative predictive value, and decreased unnecessary fine-needle aspiration rates. Furthermore, the radiomics model's improvement scale was more pronounced (33.3-16.7% vs. 33.3-9.7%). The radiomics strategy and CAD system showed good diagnostic performance for discriminating thyroid nodules and could be used to optimize the ACR TI-RADS recommendation, which successfully reduces unnecessary biopsies, especially in the radiomics model.