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.

Ultrasonographical, clinical and histopathological features of 1264 nodules with papillary thyroid carcinoma and microcarcinoma based on tumor size

ABSTRACT Objective: We aimed to evaluate the patients diagnosed with papillary thyroid carcinoma (PTC) and papillary thyroid microcarcinoma (PTMC) in terms of clinical, ultrasonographical (US) and histopathological features and their relationships with tumor size. Subjects and methods: We retrospectively evaluated 881 patients who underwent thyroid surgery in our clinic and diagnosed with PTC histopathologically were enrolled the study. Demographic characteristics, US findings and histopathological features were evaluated. Results: In total, 1264 nodules were identified in the 881 patients. The incidentality rates were higher in the PTMC group and also in the ≤ 5 mm group. In total multifocality rate was 32.9%, and was significantly higher in PTMC group than the PTC group. PTC and > 5 mm PTMC groups compared to PTMC and ≤ 5 mm groups respectively, were more aggresive histopathological features. Conclusions: Since the incidentality rates were found significantly more common in our patients with PTMC and those with ≤ 5 mm, ultrasonographic features of the nodules should be evaluated carefully and for cases which are suspicious with US, US-guided fine needle aspiration biopsy (FNAB) should be considered in order to make the correct treatment strategy. Also our study revealed that PTC and > 5 mm PTMC groups compared to PTMC and ≤ 5 mm groups respectively, have more aggresive histopathological features.

Thyroid gland changes in patients with acromegaly

ABSTRACT Objective Acromegaly is characterized by high neoplastic morbidity as a side effect of growth hormone (GH) hypersecretion. Increased incidence of goiter, thyroid carcinoma, and thyroid dysfunction is also reported. The aim of the present study was to find the prevalence of thyroid dysfunction and goiter in patients with acromegaly and determine its relationship to disease activity, disease duration, and the presence of secondary hypothyroidism. Subjects and methods In a cross-sectional study of the period 2008-2012 were included 146 patients with acromegaly (56 men, 90 women) of mean age 50.3 ± 12.4 years. Acromegaly disease activity and thyroid function were evaluated in all patients. Thyroid ultrasonography was performed to calculate thyroid volume and detect the presence of nodular goiter. Results Ninety-one patients were determined to have an active disease, and 55, a controlled disease. The mean thyroid volume in patients without previous thyroid surgery was 37.6 ± 38.8 mL. According to disease activity, thyroid volume was significantly higher in patients with active disease (38.5 ± 45.4 mL vs. 27.2 ± 18.4 mL, p = 0.036). A weak positive correlation was found between thyroid volume and insulin-like growth factor 1 (IGF-1) in the whole group and in females (R = 0.218; p = 0.013, and R = 0.238; p = 0.037, respectively). There was no significant correlation of thyroid volume with disease duration and GH level in the whole group and in both sexes. The patients with secondary hypothyroidism had twofold smaller thyroid volume, relative to the rest of the group. The prevalence of thyroid dysfunction was 39%, with a female to male percentage ratio of 1.73. Goiter was diagnosed in 87% of patients, including diffuse goiter (17.1%) and nodular (69.9%), with no significant difference between patients with active and controlled disease or the presence of secondary hypothyroidism. Conclusions Thyroid volume in patients with acromegaly depends on disease activity and the presence of secondary hypothyroidism as a complication. The increased prevalence of nodular goiter determines the need of regular ultrasound thyroid evaluation in the follow-up of patients with acromegaly. Arch Endocrinol Metab. 2020;64(3):269-75

The application of conventional ultrasonography combined with ultrasonic elastography in the differential diagnosis of thyroid nodules / 医学研究生学报

Objective The increased use of high-resolution ultrasound (US) for thyroid disease has markedly increased the detection rate of nonpalpable thyroid nodules .The objective of this study was to investigate the diagnostic value of conventional ultrasonography, ultrasonic elastography(UE) and combined application of both in the differential diagnosis of thyroid nodules. Methods A retrospective analysis was made on 105 patients with 160 histologically proved thyroid nodules from September 2014 and August 2015 in our hospital.The receiver operating characteristic ( ROC) curve analysis was made on Thyroid Imaging Repor-ting and Data System ( TI-RADS) score, elastography score and the score of combined application.The area under curve ( AUC) was calculated and compared to select the best cut-off value in order to work out the respective diagnostic efficacy of 3 methods and Kappa consistence check with pathologic results . Results In ROC curve analysis, AUC of combination score(0.930, 95%CI:0.890-0.969) was higher than those of TI-RADS score(0.855, 95%CI:0.794-0.915) and elasticity score(0.845, 95%CI:0.780-0.909), and the difference was statistically significant (Z=2.20, 2.03, P<0.05) .Taking TI-RADS score≥4, elastography score≥3, and combination score≥7 as the limitation to diagnose ma-lignant thyroid nodules, the specificity and PPV of combination score(94.3%, 95%CI:0.867-0.979;91.7%, 95%CI:0.809-0.969) were higher than those of TI-RADS score(78.4%, 95%CI:0.681-0.862;84.7%, 95%CI:0.692-0.886) and e-lasticity score(81.8%, 95%CI:0.719-0.889;78.7%,95%CI:0.674-0.870).Kappa value of combination score(0.718, 95%CI:0.610-0.826) was higher than that of TI-RADS score(0.586, 95%CI:0.461-0.711) and elasticity score(0.635, 95%CI:0.515-0.755). Conclusion Conventional ultrasonography and UE are mutual complementation, and the application of conventional ultrasonography combined with UE has higher value than single examination in the differential diagnosis of thyroid nodules.

Delayed Surgery for Parathyroid Adenoma Misdiagnosed as a Thyroid Nodule and Treated with Radiofrequency Ablation

Primary hyperparathyroidism occurs as a result of isolated parathyroid adenoma in 80% to 85% of all cases. A 99mtechnetium (99mTc) sestamibi scan or neck ultrasonography is used to localize the neoplasm prior to surgical intervention. A 53-year-old female was referred for the exclusion of metabolic bone disease. She presented with low back pain that had persisted for the past 6 months and elevated serum alkaline phosphatase (1,253 IU/L). Four years previously, she had been diagnosed at a local hospital with a 2.3-cm thyroid nodule, which was determined to be pathologically benign. Radiofrequency ablation was performed at the same hospital because the nodule was still growing during the follow-up period 2 years before the visit to our hospital, and the procedure was unsuccessful in reducing the size of the nodule. The results of the laboratory tests in our hospital were as follows: serum calcium, 14.6 mg/dL; phosphorus, 3.5 mg/dL; and intact parathyroid hormone (iPTH), 1,911 pg/mL. Neck ultrasonography and 99mTc sestamibi scan detected a 5-cm parathyroid neoplasm in the left lower lobe of the patient's thyroid; left parathyroidectomy was performed. This case indicated that thyroid ultrasonographers and pathologists need to be experienced enough to differentiate a parathyroid neoplasm from a thyroid nodule; 99mTc sestamibi scan, serum calcium, and iPTH levels can help to establish the diagnosis of parathyroid neoplasm.

Thyroid nodules in acromegaly / Nódulos tiroideanos na acromegalia

OBJECTIVE: We made a prospective study evaluating the prevalence of thyroid nodular disease in acromegalic patients. SUBJECTS AND METHODS: Thyroid ultrasound and ultrasound-guided fine needle aspiration biopsy were performed when nodules were detected. Nodules were characterized by cytology and histopathology. RESULTS: We found high prevalence of nodular thyroid disorder, 23/34 (67%) in acromegalic patients. High risk and malignant cytology were significantly higher in acromegalic patients than in our non-acromegalic population (25% vs. 9%). Differentiated thyroid carcinoma was present in 11% of the acromegalic patients. CONCLUSIONS: We strongly recommend periodic thyroid evaluation by ultrasound in patients with acromegaly. Fine needle aspiration biopsy should be performed in nodules larger than 10 mm, and in all suspicious nodules, regardless of the size.

OBJETIVO: Realizamos um estudo prospectivo avaliando a prevalência de patologia nodular tireói­dea em 34 pacientes acromegálicos. SUJEITOS E MÉTODOS: Avaliamos os pacientes com ecografia tireóidea e punção biópsia com agulha fina quando se detectavam nódulos. RESULTADOS: Encontramos uma alta prevalência de patologia nodular tireóidea 23/34 (67%) em acromegálicos. A citologia tireóidea de alto risco e maligna foi significativamente mais elevada em pacientes acromegálicos que em uma população não acromegálica (25% vs. 9%). O grupo acromegálico apresentou carcinoma diferenciado de tireoides em 11%. CONCLUSÕES: Recomendamos fortemente a ecografia periódica tireóidea em pacientes acromegálicos. Uma punção biópsia aspirativa com agulha fina deve ser realizada em presença de nódulos tireóideos maiores que 10 mm e daqueles com critérios ecográficos suspeitos de malignidade, independentemente do tamanho deles.

Sonographic Analysis of the Nodular Form of Hashimoto Thyroiditis / 대한내분비외과학회지

PURPOSE: There are relatively few results from studies on nodular Hashimoto's thyroiditis. In addition, some Hashimoto's thyroiditis patients present with irregular symptoms, making the distinction from malignant thyroid nodule difficult. Therefore, we performed analyses on ultrasonographic findings of nodular Hashimoto's thyroiditis. METHODS: A retrospective follow-up study was performed on 76 patients (88 nodules) diagnosed with Hashimoto's thyroiditis after undergoing fine needle aspiration biopsy from January 2009 to December 2010. A frequency analysis was performed to investigate the most common ultrasonographic findings of nodular Hashimoto's thyroiditis. In addition, patients were divided into two groups based on the presence or absence of extensive Hashimoto's thyroiditis on the parenchyma, and ultrasonographic findings were compared and analyzed for nodules in each group. RESULTS: The study was performed on 76 patients and 88 nodules. The majority of nodular Hashimoto's thyroiditis were found to be solid on ultrasonography, and echogenicity was mostly hypoechoic, with prominent hypoechoic findings being more common. Most nodules did not have a rim surrounding the margins, and absence of accompanying calcification was also noted. The comparison and analysis of ultrasonographic findings of two patient groups that were divided based on the presence or absence of Hashimoto's thyroiditis across the parenchyma, revealed no significant difference. CONCLUSION: Most nodular Hashimoto's thyroiditis cases do not present with calcification or rims and frequently present as solid and hypoechoic. It can be concluded that such findings are consistent regardless of whether there is accompanying extensive changes at the thyroid parenchyma associated with Hashimoto's thyroiditis.

Thyroid hormonal disturbances related to treatment of hepatitis C with interferon-alpha and ribavirin

OBJECTIVE: To characterize thyroid disturbances induced by interferon-alpha and ribavirin therapy in patients with chronic hepatitis C. INTRODUCTION: Interferon-alpha is used to treat chronic hepatitis C infections. This compound commonly induces both autoimmune and non-autoimmune thyroiditis. METHODS: We prospectively selected 26 patients with chronic hepatitis C infections. Clinical examinations, hormonal evaluations, and color-flow Doppler ultrasonography of the thyroid were performed before and during antiviral therapy. RESULTS: Of the patients in our study, 54 percent had no thyroid disorders associated with the interferon-alpha therapy but showed reduced levels of total T3 along with a decrease in serum alanine aminotransferase. Total T4 levels were also reduced at 3 and 12 months, but free T4 and thyroid stimulating hormone (TSH) levels remained stable. A total of 19 percent of the subjects had autoimmune interferon-induced thyroiditis, which is characterized by an emerge of antithyroid antibodies or overt hypothyroidism. Additionally, 16 percent had non-autoimmune thyroiditis, which presents as destructive thyroiditis or subclinical hypothyroidism, and 11 percent remained in a state of euthyroidism despite the prior existence of antithyroidal antibodies. Thyrotoxicosis with destructive thyroiditis was diagnosed within three months of therapy, and ultrasonography of these patients revealed thyroid shrinkage and discordant change in the vascular patterns. DISCUSSION: Decreases in the total T3 and total T4 levels may be related to improvements in the hepatocellular lesions or inflammatory changes similar to those associated with nonthyroidal illnesses. The immune mechanisms and direct effects of interferon-alpha can be associated with thyroiditis. CONCLUSION: Interferon-alpha and ribavirin induce autoimmune and non-autoimmune thyroiditis and hormonal changes (such as decreased total T3 and total T4 levels), which occur despite stable free T4 and TSH levels. A thyroid hormonal evaluation, including the analysis of the free T4, TSH, and antithyroid antibody levels, should be mandatory before therapy, and an early re-evaluation within three months of treatment is necessary as an appropriate follow-up.

Latin American Thyroid Society recommendations for the management of thyroid nodules / Recomendações da Sociedade Latino-Americana de Tireoide no manejo de nódulos tireoideos

Several guidelines on diagnosis and treatment of thyroid nodules and cancer have recently been published. However, recommended practices are not always appropriate to different settings or countries. The aim of this consensus was to develop Clinical Guidelines for evaluation and management of patients with thyroid nodules applicable to Latin American countries. The panel was composed by 13 members of the Latin American Thyroid Society involved with research and management of thyroid nodules and cancer from different medical centers in Latin America. The consensus was produced based on the expert opinion of the panel with use of principles of evidence-based medicine. Following a group meeting, a first draft based on the expert opinion of the panel was elaborated and later circulated among panel members for further revision. After revision, this document was submitted to all LATS members for commentaries and considerations and finally revised and refined by the authors. The final recommendations represent state of the art on management of thyroid nodules applied to all Latin American countries.

Vários consensos têm sido publicados acerca do diagnóstico e do tratamento de nódulos e câncer da tireoide. Entretanto, as recentes recomendações nem sempre são apropriadas para diferentes regiões ou países. O objetivo deste trabalho foi oferecer uma série de recomendações para a avaliação e conduta de pacientes portadores de nódulos tireoideos aplicáveis a todos os países da América Latina. O trabalho foi realizado por um comitê composto por 13 membros da Sociedade Latino-Americana de Tireoide envolvidos com pesquisa e manejo de pacientes portadores de nódulos e carcinoma diferenciado da tireoide, de diferentes centros médicos da América Latina. As recomendações foram estabelecidas, após consenso, utilizando as opiniões especializadas de cada membro e os princípios da medicina baseada em evidência. Após a primeira reunião do grupo, um primeiro documento foi elaborado e encaminhado a todos os membros para revisão. Posteriormente, o documento foi enviado aos membros da Sociedade Latino-Americana de Tireoide para avaliação, sugestões e comentários. A versão final, elaborada após refinada revisão de todos os autores, representa o estado da arte no diagnóstico e na conduta de nódulos tireoideos, aplicáveis a todos os países da América Latina.

Recommendations of the Latin American Thyroid Society on diagnosis and management of differentiated thyroid cancer / Recomendações da Sociedade Latino-Americana de Tireoide para diagnóstico e manejo do carcinoma diferenciado de tireoide

The aims of these recommendations were to develop clinical guidelines for evaluation and management of patients with differentiated thyroid cancer applicable to Latin American countries. The panel was composed by 13 members of the Latin American Thyroid Society (LATS) involved with research and management of thyroid cancer from different medical centers in Latin America. The recommendations were produced on the basis of the expert opinion of the panel with use of principles of Evidence-Based Medicine. Following a group meeting, a first draft based on evidences and the expert opinions of the panel was elaborated and, later, circulated among panel members, for further revision. After, this document was submitted to the LATS members, for commentaries and considerations, and, finally, revised and refined by the authors. The final recommendations presented in this paper represent the state of the art on management of differentiated thyroid cancer applied to all Latin American countries.

Estas recomendações tiveram por objetivo o desenvolvimento de diretrizes para avaliação e manejo de pacientes com câncer diferenciado da tiroide em países latino-americanos. Um painel composto por 13 membros da Sociedade Latino-Americana de Tireoide (SLAT) - que estavam envolvidos em pesquisas, e eram peritos no cuidado do paciente com câncer da tiroide e provenientes de diferentes centros médicos latino-americanos - utilizou os princípios da Medicina Baseada em Evidências para produzir esse consenso. Após uma primeira reunião, um texto inicial foi elaborado, baseado em evidências e opiniões dos especialistas do painel e, posteriormente, circulado entre os membros do painel, para revisão. Após a revisão, o documento foi enviado aos membros da SLAT para comentários e considerações e, finalmente, revisado e refinado pelos autores. As recomendações finais aqui apresentadas demonstram o estado da arte no manejo do câncer diferenciado da tireoide aplicadas aos países latino-americanos.

Ultrasonographic, cytologic and genetic diagnosis of thyroid cancers / 대한내과학회지

Thyroid nodules are very common in adults, but only small fraction of them are malignant. The primary aim in investigating a thyroid nodule is to exclude the possibility of malignancy, which occurs in about 5% of nodules. Thyroid ultrasonography (US) provides not only anatomic details of the nodule, but also features of nodules that increase the likelihood of malignancy. Hypoechogenicity, ill-defined margin, microcalcifications, taller-than-wide shape, and associated pathologic cervical lymphadenopathies are important US features, suggesting thyroid cancer. These findings are helpful in risk stratification of the nodules and in deciding which nodule should be sampled in multinodular goiter. Fine-needle aspiration cytology (FNA) is the most accurate diagnostic test for most thyroid nodules, but the challenge remains in indeterminate cytologic category and inadequate samples. US-guided FNA can improve the diagnostic yield by reducing non-diagnostic specimens, and especially useful in thyroid nodules that are impalpable, posteriorly located, densely-calcified, or mixed solid-cystic. There has been significant progress in biomarkers that could improve the accuracy of FNA and predict disease aggressiveness. Physicians caring for patients with thyroid nodules need to develop a rational, cost-effective approach to ordering and interpreting imaging and diagnostic tests in the evaluation of the thyroid nodule.

The Usefulness of Preoperative Thyroid Ultrasonography Performed by Surgeons / 대한내분비외과학회지

PURPOSE: Although the diagnostic accuracy of thyroid cancer by fine needle aspiration cytology (FNAC) is increasing, there are some nodules for which ultrasonography and FNAC show indeterminant. The purpose of this study was to determine the usefulness of thyroid ultrasonography by the surgeon prior to operation METHODS: Forty-nine patients who underwent thyroid operations between June 2006 and January 2007 were selected for this study. Thyroid ultrasonography was performed on each patient.And we recorded and analyzed the shape and the margin of the nodule, internal echogeneiety, heterogeneiety, the presence of microcalcification, height versus width, and the presence of level VI lymph node larger than 3 mm, assigning each a score of 1, 2 or 3. RESULTS: The average score was 17.1. Assuming an average score over 14 is considered to be malignant, the sensitivity, specificity, positive predictive value, and negative predictive value were 95.6%, 88.9%, 91.7%, 94.1% respectively. Statistically significant characteristics of malignancy were the shape and the margin of the nodule, internal echogeneiety, microcalcification, taller than wide shape and the presence of enlarged VI lymph nodes. The heterogeneiety had no significant P value. CONCLUSION: When malignancy cannot be confirmed even after repeated FNAC, preoperative ultrasonograpy performed by surgeons can be a reliable test and helpful for operations.

An Analysis of the Ultrasound Findings of False Negative Cases for an Initial Ultrasound-guided Fine Needle Aspiration Biopsy (FNAB)

PURPOSE: To analyze the ultrasonographic (US) findings of thyroid nodules that yielded false negative results after an initial ultrasound-guided fine needle aspiration biopsy (FNAB). MATERIALS AND METHODS: Between August 2003 and February 2006, 389 patients with 405 thyroid nodules received a repeat US-guided FNAB. We retrospectively reviewed the US findings, cytology results and postsurgical pathological results. The cytology diagnoses were classified as benign, a suspicious malignancy, a follicular neoplasm, a papillary carcinoma, and a non-diagnostic result. The US findings of the thyroid nodules were analyzed with regard to size, internal content, shape, margin, echogenecity, and calcification pattern. RESULTS: Of the 405 thyroid nodules, 17 nodules were false negative. The major US findings of these nodules were a solid internal component in 16 nodules, hypoechogenicity or marked hypoechogenicity in 14 nodules, microcalcifications in 12 nodules, an ovoid to round shape in 9 nodules and a well-defined smooth margin in 9 nodules. CONCLUSION: An repeat US-guided FNAB should be performed if the thyroid nodules have one of the malignant US features such as hypoechogenecity or marked hypoechogenecity, a microcalcification, a taller than wide shape or a well-defined spiculate margin although the cytology results indicated a benign lesion. In addition, thyroid nodules with findings of a well-defined smooth margin, ovoid to round shape, and solid internal component might also be subject to a repeat US-guided FNAB to exclude a malignancy.