Stratifying indeterminate cytology thyroid nodules by combining Thyroid Imaging Reporting and Data Systems (TI-RADS) and The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC)

Objective@#To determine the risk of malignancy of Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) indeterminate Thyroid Nodules (Bethesda III, IV and V) by combining cytologic (TSBRTC) and Thyroid Imaging Reporting and Data Systems (TI-RADS) ultrasonographic features based on final histopathology.@*Methods@#Design: Retrospective review of records. Setting: Tertiary Private Training Hospital. Participants: 551 records. @*Results@#Among 81 eligible participants, 59 out of 84 nodules (70.24%) wer malignant on histopathology. The malignancy risk of Bethesda classification was 60.87% (28 out of 46) for Bethesda III, 57.14% (8 out of 14) for Bethesda IV and 95.83% for Bethesda V. The malignancy risk for TI-RADS categories was 0 % (0/1) for TI-RADS 2, 50% (10 out of 20) for TI-RADS 3, 71.05 % for TI-RADS 4 and 91.67 % for TI-RADS 5. The highest risk of malignancy (100%) was associated with [Bethesda IV/TI-RADS 1, 2, and 3], [Bethesda V/TI-RADS 1, 2 and 3 [Bethesda IV and V/TI-RADS 1, 2 and 3] and [Bethesda IV/TI-RADS 5]. The lowest risk of malignancy (33.33%) was associated with [Bethesda III/TI-RADS1, 2 and 3]. A high Bethesda classification (Bethesda V) was almost 5x more likely to have a malignant anatomorphology compared with Bethesda III (p = .05) while a TI-RADS 4 or 5 category was almost 5x more likely to have a malignant anatomorphology compared to TI-RADS 1, 2 or 3 (p = .026).@*Conclusion@#This study showed that TI-RADS scoring is a sensitive diagnostic classification in recognizing patients with thyroid cancer and combining Bethesda classification and TI-RADS scoring increases the sensitivity in the diagnosis of malignant thyroid nodules. A higher likelihood of malignancy is associated with higher Bethesda classification and TI-RADS scoring.

Exophytic and fungating papillary thyroid carcinoma: A rare and complex presentation of a well-differentiated malignancy

@#Papillary thyroid carcinoma is the most common well-differentiated thyroid malignancy accounting for more than 80 to 90% of all thyroid tumors. It has an overall excellent prognosis owing to advances in screening via imaging and ultrasound-guided fine-needle aspiration biopsy, which have facilitated early detection, diagnosis, and surgical treatment followed by adjuvant radioactive iodine therapy. Exceptionally rare cases of papillary thyroid tumors may present with enormous growth due to delayed consultation and, thus, late diagnosis, posing a challenge to definitive management, quality of life, overall survival, and prognosis. We report a case of a 35-year-old woman who presented with a 4-year history of a bleeding exophytic and fungating anterior neck mass. Computed tomography showed a fungating mass arising from the left thyroid lobe that measured 14.1 x 14.0 x 11.1 cm with areas of necrosis and hemorrhage, left internal jugular vein thrombus formation, and compression of the left internal carotid artery. The mass causes a displacement of the trachea to the right side and multiple bilateral cervical lymphadenopathies. The patient was fully aware, and she consented to undergo wide excision, total thyroidectomy, neck dissection, and pectoralis major muscle flap reconstruction. However, she went into arrest intraoperatively attributed to massive pulmonary embolism. Papillary thyroid cancer is well known for its excellent prognosis. However, outcomes may not be favorable and can even be fatal in advanced and extensive cases. Although fungating papillary cancers are rare, they remain more common in the developing countries, where early detection and access to healthcare remains limited. They also represent a big challenge to surgeons. Even if the outcome was not good, we opted to report this case as there were many learning points. If only patients with good and excellent outcomes are reported in the literature, it will overestimate the treatment success of these complex cases.

Incidence, recurrence and mortality among Filipinos with differentiated thyroid cancer: A systematic review / Journal of the ASEAN Federation of Endocrine Societies

Background@#The majority of thyroid malignancies are differentiated thyroid carcinomas (DTCs). We examined the incidence, disease extent, recurrence and disease-specific mortality (DSM) of DTC among Filipinos residing in the Philippines and Filipino immigrants.@*Methodology@# In accordance with the 2020 PRISMA statement, we performed a systematic literature search in MEDLINE, Google Scholar, EBSCO, Cochrane and Clinicaltrials.gov for the period January 1, 1980 until January 27, 2022. Pooled incidence rate ratio and pooled proportions of disease extent, recurrence and DSM were determined.@*Results@#Literature search yielded 1,852 studies. Out of 26 articles retrieved, nine retrospective case controls and cohorts were included. Incidence of DTC was significantly higher in female Filipino immigrants compared with non-Hispanic whites (NHW). Distant metastases and recurrence were more common among Filipinos and Filipino immigrants compared with NHW. Limited data showed higher DSM in Filipino immigrants and NHW than Filipinos, which may be influenced by reporting bias.@*Conclusion@#This review supports the trend of increased incidence and recurrence of DTC among Filipinos, although case registries are essential to confirm these findings. In the setting of the newly released Philippine guidelines for DTC, prospective studies with active long-term follow-up will help detect any changes in the outcomes of DTC among Filipinos.

Behaviour Of Anaplastic Thyroid Carcinoma In Tertiary Care Centre, South India.

INTRODUCTION: Anaplastic thyroid cancer (ATC) is one of the most aggressive solid tumors to affect humans, with a median survival on the order of 3 to 5 months following diagnosis [1]. Recent advances in understanding the genetic and molecular pathogenesis of ATC hold promise for targeted therapy for this disease. METHODS:This retrospective study was conducted for 7 years from 2011 to 2018, included patients who were admitted in the endocrine surgery department in the tertiary hospital with thyroid malignancies. The clinical, operative, cytological, and histological data were tabulated and statistically analyzed. RESULTS: Of the 386 patients analyzed, 350 patients (91.57%) were females and 36 patients were males (9%) (P < 0.001) which shows high significant difference between genders at 0.1% level. Final Histopathology showed papillary thyroid carcinoma in 340 patients, poorly differentiated thyroid carcinoma in 8 patients, anaplastic thyroid carcinoma in 18 patients. Out of 18 patients with anaplastic thyroid carcinoma 8 patients presented with mild dyspnea, 2 patients had dysphagia and 10 patients suffered from hoarseness of voice. The mean patients age were 45 years. 12 patients had intra thyroid tumour, 4 patients had invasion to the strep muscles, 2 patients had adhered to trachea. Overall cause specific mortality rate was 60% at 6 months and 40 % at 12 months. CONCLUSION: The overall prognosis of ATC continues to be poor with the 5 year survival from 5.6 to 11.4% . Age is the most important factor in the patients with ATC

Impact of Nodule Size on Malignancy Risk Differs according to the Ultrasonography Pattern of Thyroid Nodules

OBJECTIVE: To test whether the impact of thyroid-nodule size on the malignancy risk differs according to the ultrasonography (US) patterns of nodules. MATERIALS AND METHODS: This study is a post hoc analysis using data from the Thyroid Imaging Reporting and Data System (TIRADS) multicenter retrospective study which included 2000 consecutive thyroid nodules (≥ 1 cm) with final diagnoses. A total of 2000 consecutive thyroid nodules from 1802 patients (1387 women and 613 men; mean age, 51.2 ± 12.2 years) were enrolled in this study. The malignancy risk of the nodules was assessed according to the nodule size and US patterns (Korean-TIRADS). RESULTS: Overall, the malignancy risk did not increase as nodules enlarged. In high-suspicion nodules, the malignancy rate had no association with nodule size (p = 0.467), whereas in intermediate- or low-suspicion nodules there was a trend toward an increasing malignancy risk as the nodule size increased (p = 0.004 and 0.002, respectively). The malignancy rate of large nodules (≥ 3 cm) was higher than that of small nodules (< 3 cm) in intermediate-suspicion nodules (40.3% vs. 22.6%, respectively; p = 0.001) and low-suspicion nodules (11.3% vs. 7.0%, respectively; p = 0.035). There was a trend toward a decreasing risk and proportion of papillary carcinoma and an increasing risk and proportion of follicular carcinoma or other malignant tumors as nodule size increased (p < 0.001, respectively). CONCLUSION: The impact of nodule size on the malignancy risk differed according to the US pattern. A large nodule size (≥ 3 cm) showed a higher malignancy risk than smaller nodules in intermediate- and low-suspicion nodules.

Sonographic scoring of solid thyroid nodules: effects of nodule size and suspicious cervical lymph node / Escore ultrassonográfico de nódulos sólidos de tireoide: efeitos do tamanho do nódulo e de linfonodo cervical suspeito

Abstract Introduction Ultrasound is the most frequently used imaging method to evaluate thyroid nodules. Sonographic characteristics of thyroid nodules which are concerning for malignancy are important to define the need for fine needle aspiration biopsy or open surgery. Objective To evaluate malignancy risk of solid thyroid nodules through sonographic scoring. The effects of nodule size ≥2 cm and associated pathologic cervical lymph node in scoring were examined in addition to generally excepted suspicious features. Methods Medical data of 123 patients underwent thyroid surgery were reviewed, and 89 patients (58 females, 31 males) were included in the study. The presence and absence of each suspicious sonographic feature of thyroid nodules were scored as 1 and 0, respectively. Total ultrasound score was obtained by adding the positive ultrasound findings. Differently from the literature, nodule size ≥2 cm and associated pathologic cervical node were added in scoring criteria. The diagnostic performance of nodule characteristics for malignancy and the effect of total US score to discriminate malignant and benign disease were calculated. Results A significant relationship was found between malignancy and hypoechogenity, border irregularity, intranodular vascularity, and microcalcification (p < 0.05). Pathologic cervical node was observed predominantly in association with malignant nodules. Positive predictive value of suspicious cervical node for malignancy was 67%, similar to microcalcification. Nodule size ≥2 cm was not distinctive for diagnosis of malignancy. The number of suspicious sonographic features obtained with receiver operating characteristic analysis to discriminate between malignant and benign disease was three. Conclusion Sonographic scoring of thyroid nodules is an effective method for predicting malignancy. The authors suggest including associated pathologic node in the scoring criteria. Further studies with larger cohorts will provide more evidence about its importance in sonographic scoring.

Resumo Introdução A ultrassonografia é o método imagiológico mais frequentemente usado na avaliação de nódulos tireoidianos. As características ultrassonográficas dos nódulos tireoidianos que dizem respeito à malignidade são importantes para a definição da necessidade de uma biópsia por aspiração com agulha fina ou uma cirurgia aberta. Objetivo Avaliar o risco de malignidade de nódulos tireoidianos sólidos por meio de escore ultrassonográfico, verificar os efeitos de nódulos ≥ 2 cm, em associação com linfonodo cervical patológico, além de características suspeitas geralmente omitidas. Método Foram revisados dados médicos de 123 pacientes tratados com cirurgia da tireoide. Foram incluídos no estudo 89 pacientes (58 mulheres, 31 homens). Presença e ausência de cada característica ultrassonográfica suspeita de nódulo tireoidiano receberam pontuações de 1 e 0, respectivamente. O escore ultrassonográfico total foi obtido pela soma dos achados ultrassonográficos positivos. Diferentemente da literatura, nódulos ≥ 2 cm e nodo cervical patológico associado foram acrescentados nos critérios de pontuação. Foram calculados o valor diagnóstico das características dos nódulos para malignidade e o efeito do escore ultrassonográfico total na diferenciação entre doença maligna vs. benigna. Resultados Foi encontrada uma associação significante entre malignidade e hipoecogenicidade, irregularidade das margens, vascularidade intranodular e microcalcificação (p < 0,05). Nodo cervical patológico foi observado predominantemente em associação com nódulos malignos. O valor preditivo positivo de nodo cervical suspeito para malignidade foi de 67%, similar ao achado para microcalcificação. Diâmetro de nódulo ≥ 2 cm não foi fator diferenciador para diagnóstico de malignidade. O número de características ultrassonográficas suspeitas obtido com a análise da curva de características de operação do receptor (receiver operating characteristic, ROC) para discriminação entre doença maligna vs. benigna foi igual a 3. Conclusão O escore ultrassonográfico dos nódulos tireoidianos é método efetivo para predição de malignidade. Sugerimos a inclusão de nódulo patológico associado aos critérios de pontuação. Futuros estudos com coortes maiores proporcionarão mais evidências sobre sua importância no escore ultrassonográfico.

Validation of CK-19 and HBME-1 Expression Pattern in FNACs to Supplement Morphological Evaluation for Preoperative Diagnosis of Thyroid Lesions.

Aim: Fine Needle Aspiration Cytology is the cost effective, quick and minimally invasive method for the initial evaluation of thyroid nodule. But it poses a diagnostic challenge in differentiating benign follicular adenoma from follicular carcinoma and follicular variant of papillary carcinoma as they have similar cytological appearance. Present study focused on the identification of a biological marker for the differential diagnosis of thyroid malignancy in indeterminate cases. Place and Duration of the Study: Division of cancer Research, Regional Cancer Centre, Kerala, India, between August 2009 to September 2014. Methodology: Immunohistochemistry was performed using Ret (Rearranged during transfection), Hector Battifora Mesothelial Cell Antigen-1 (HBME-1), Cytokeratin-19 (CK-19), Keratan sulphate (KS), Thyroid peroxidase (TPO), Estrogen receptor (ER) and Progesterone receptor (PR) on cell block prepared from FNA material and corresponding tissue sections on 153 samples. Western blot analysis of ER and PR was performed in surgically excised fresh tissue specimens. Results: The present study found that HBME-1 is highly significant (P < .001) for the differential diagnosis with a diagnostic accuracy of 95.96%. Ret immunostaining may serve as good indicator of PTC whereas its sensitivity is very low in other lesions. The diagnostic accuracy of CK-19 was 90.91%. Intense positive staining of TPO was noted in majority of follicular epithelial cells of benign lesions (42.42%). Females had an increased prevalence in our study population so we examined the estrogen and progesterone receptors status in thyroid lesions. The specificity of KS, ER and PR are very low for the differentiation of adenoma from carcinomas of the thyroid. Conclusion: Present study found that the combination of two markers may give a more accurate way in the differentiation of thyroid nodules in problematic cases. So we suggest morphological evaluation along with immunocytochemistry of HBME-1 and CK19 can help the differential diagnosis of thyroid lesions in FNAs.

Axillary Lymph Node Metastasis from Thyroid Malignancy: Unusual Presentation with Ominous Implications.

Lymph node metastases to cervical group of nodes occur frequently in well-differentiated thyroid carcinoma. Metastasis to axillary lymph nodes however, is exceptional, leading to diagnostic and management dilemma. While presenting a case of thyroid malignancy with axillary lymph node metastasis, the literature is reviewed for similar cases to analyze their clinico-pathological features, investigations, management and outcome. Fifteen cases have been reported so far. Majority of these patients were female (male: female ratio 6:9) and their mean age was 54.5 years. Axillary lymph node metastases occurred concurrently or as recurrent disease after initial treatment of primary disease in about equal number of these patients. The predominant histological type was papillary carcinoma and 83.3% of these were poorly differentiated. Visceral metastases to lungs and bones were often seen. Despite treating these patients with thyroidectomy, lymph node clearance and adjuvant therapy, 40% of them died; some within one year and among the 60% who were alive, 30% still had active disease. Conclusion: Axillary lymph node metastasis from thyroid cancer, even though rare should be considered in the differential diagnosis in patients presenting with axillary mass and thyroid malignancy. Based on the limited number of cases reported in the literature it appears that it is generally a manifestation of the aggressive nature of this tumor with overall poor outcome.

Clinicopathological, Biochemical, and Sonographic Features of Thyroid Nodule Predictive of Malignancy among Adult Filipino Patients in a Tertiary Hospital in the Philippines

BACKGROUND: Thyroid nodules may harbor cancer in 5% to 15% of cases. Specific clinical and sonographic features predictive of malignancy have been investigated in various populations, but due to differences in epidemiology, risk factors and iodine nutrition status, these predictors may not be valid in the Philippines. This study determined the clinicopathological, biochemical, and sonographic features of thyroid nodules predictive of malignancy among adult Filipino patients at the University of the Philippines-Philippine General Hospital (UP-PGH). METHODS: We reviewed the medical records of Filipino patients > or =19 years of age who underwent thyroid surgery in UP-PGH from 2008 to 2011. RESULTS: A total of 837 of 1,670 patients (50.1%) were enrolled in the study, which included 417 benign and 420 malignant tumors. The mean age at diagnosis was 38+/-11 years, with female predominance. Multiple logistic regression analysis showed that the presence of a hard or firm nodule (odds ratio [OR], 58.8, P<0.001; OR, 12.8, P<0.001), presence of microcalcifications (OR, 11.1; P<0.001), irregular margins on ultrasound (OR, 4.5; P<0.001), and absence of associated symptoms (OR, 2.3; P<0.002) increased significantly the likelihood of thyroid malignancy. CONCLUSION: Similar to international data, the absence of associated symptoms, firm to hard thyroid nodules, and the presence of microcalcifications and irregular margins were significant predictors of thyroid malignancy.

Indications for Fine Needle Aspiration in Thyroid Nodules

Thyroid nodules are a common clinical problem with the widespread use of ultrasonography. Fine needle aspiration (FNA) is the mainstay for diagnosing a thyroid malignancy. There have been several guidelines on when to perform FNA in thyroid nodules. This review is based on several published recommendations and helps physicians easily understand the factors favoring FNA.

Elastography for Thyroid Nodules: The Comparison of Diagnostic Performance on Transverse and Longitudinal Planes

PURPOSE: To evaluate the diagnositc performance of elastography for thyroid nodules on the transverse and longitudinal planes. MATERIALS AND METHODS: Gray scale ultrasonography (US), elastography on transverse and longitudinal planes, and fine needle aspiration biopsy for 78 thyroid nodules (malignant: 34 cases, benign: 44 cases) were performed. According to the Asteria criteria of elastography, scores 1 and 2 were classfied as probably benign and scores 3 and 4 were classifeid as suspicious. Strain ratios on transverse and longitudinal planes were measured. Sensitivity, specificity, positive predictive value, negative predictive value, accuracy, and Az value (under the receiver operating characteristics curve) of elastography on transverse and longitudinal planes were calculated and compared. RESULTS: Scores 3 and 4 were more frequently seen in malignant nodules on the longitudinal plane (p value = 0.007), but not significantly seen on the transverse plane (p value = 0.160). Sensitivity, specificity, positive predictive value, negative predictive value, accuracy, and the Az value of elastography on the longitudinal plane were higher than those on the transverse plane, although Az values on the transverse and longtudinal planes were not statistically significant. CONCLUSION: Diagnostic performance of thyroid elastography, especially sensitivity, were higher on the longitudinal plane than the transverse plane.

Hurthle cell carcinoma: a rare variant of thyroid malignancy.

Hurthle cell carcinoma is a rare entity of differentiated thyroid carcinoma. Modality of treatment is controversial due to the nature and rarity of the disease. However, total thyroidectomy followed by adjuvant treatment is prudent in this variant of thyroid malignancy in view of its aggressive nature. We report a case of Hurthle cell carcinoma of thyroid in an elderly male in which the pre operative diagnosis was follicular carcinoma. The outline of management is discussed.

Cranial metastases from thyroid malignancy

1. The statistical incidence, pathology, symptomatology, and diagnosis of cranial metastases from malignancies of the thyroid gland are discussed2. Four cases of such metastases are reported. (Summary)