Risk of malignancy and diagnostic accuracy of fine-needle aspiration biopsy in thyroid nodules with diameters greater than 4 centimeters

ABSTRACT Objective: The risk of malignancy and diagnostic accuracy of fine-needle aspiration biopsy (FNAB) of thyroid nodules (TN) with diameters ≥ 3-4 cm remains controversial. However, some groups have indicated surgical treatment in these patients regardless of the FNAB results. We aimed to evaluate the diagnostic accuracy of the FNAB in systematically resected ≥4 cm TN and if the risk of malignancy is higher in these patients. Subjects and methods: We retrospectively evaluated 138 patients (142 nodules) with TN with diameters ≥4 cm who underwent thyroidectomy. Results: The FNAB results were nondiagnostic/unsatisfactory (ND/UNS) in 2.1% of the cases and benign in 51.4%. They indicated atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS) in 23.9% of cases, follicular neoplasia/suspicious for a follicular neoplasm (FN/SFN) in 9.2%, suspicion of malignancy (SUS) in 8.5%, and malignant in 4.9%. The histopathological analysis after thyroidectomy revealed a thyroid cancer rate of 100% in the FNABs classified as malignant, 33.3% in SUS cases, 7.7% in FN/SFN, 17.6% in AUS/FLUS, and 4.1% in benign FNABs. None of the ND/UNS FNABs were malignant. The global malignancy diagnosis was 14.8% (n = 21). However, the rate of false negatives for FNAB was low (4.1%). Conclusion: We showed that the risk of malignancy in nodules with diameters ≥4 cm was higher compared to the risk of thyroid cancer in TN in general. However, we found a low rate of false-negative cytological results; therefore, our data do not justify the orientation of routine resection for these larger nodules.

Asymptomatic course of overt primary hypothyroidism with a very high peak systolic velocity of the superior thyroid arteries: A case report

This study reports the case of a 59-year-old woman with asymptomatic overt hypothyroidism who presented with signs of increased thyroid exertion involving the autonomic nervous system. These signs included significantly increased peak systolic velocity (PSV) of the superior thyroid arteries (STA) and moderately increased blood flow intensity. The findings suggest an increase in the rate of thyroxine deiodination and the sufficiency of free triiodothyronine (FT3) for the functional needs of the body. The absence of typical symptoms of hypothyroidism may depend on the sufficiency of FT3 in the serum and additional nonhormonal circumstances. Hence, FT3 should always be measured in addition to thyroid-stimulating hormone and free thyroxine levels. When Doppler ultrasound is used, the intensity of blood flow and PSV-STA from both sides should be determined to assess the magnitude of thyroid exertion. Probably, PSV-STA may not be an absolute criterion for the diagnosis of Graves� disease

Hallazgos ecográficos para la determinación de nódulos tiroideos malignos / Ultrasound findings for the determination of malignant thyroid nodules

Resumen Introducción: Los nódulos tiroideos son un crecimiento localizado en el tejido tiroideo, aproximadamente el 8 % son malignos, y el ultrasonido es el método ideal para detectarlos. Objetivo: Determinar cuáles son los hallazgos ecográficos que pueden sugerir una mayor probabilidad de malignidad del nódulo tiroideo. Metodología: Estudio descriptivo de tipo corte transversal en pacientes con nódulo tiroideo en una institución prestadora de salud de Neiva. Resultados: Se evaluaron 63 pacientes con un promedio de edad de 52 años, 95 % fueron femeninos y el 5 % masculinos. El 71 % presentaron nódulos tiroideos benignos, y el 10 % nódulos malignos. En el 100 % de los nódulos tiroideos malignos se encontró vascularidad aumentada, microcalcificaciones, adenopatías asociadas, bordes irregulares y componente sólido, y los hallazgos con respecto a hipoecogenicidad y diámetro anteroposterior mayor al transverso (más alto que ancho), se encontró en el 83 % siendo estadísticamente significativos. La sensibilidad de los hallazgos ecográficos supera el 80 %, excepto la variable "tamaño del nódulo mayor a 1 centímetro". Conclusiones: Los hallazgos ecográficos como adenopatías y el diámetro anteroposterior mayor al transverso son indicadores potenciales de nódulos tiroideos malignos, el tamaño mayor a un centímetro no siempre es predictor de malignidad, sin embargo debido al tamaño de la muestra en nuestro estudio no es posible generalizarlo como un factor determinante para la realización de biopsia, por ende recomendamos el seguimiento de los nódulos teniendo en cuenta los criterios ecográficos de malignidad y la clasificación TIRADS para tomar decisiones con respecto a las biopsias tiroideas.

Abstract Introduction: Thyroid nodules are a localized growth in the thyroid tissue, approximately 8% are malignant, and an ultrasound is the ideal method to detect them. Objective: Determine which are the ultrasound findings that may suggest an increased probability of thyroid nodule malignancy. Methodology: Descriptive cross-sectional study amongst patients with thyroid nodule in a healthcare institution in Neiva. Results: A total of 63 patients were evaluated with an average age of 52 years, 95% were female and 5% male. Seventy-one percent had benign thyroid nodules, and 10% malignant nodules. In 100% of malignant thyroid nodules, increased vascularity, microcalcifications, associated adenopathies, irregular borders and solid component were found, and the findings regarding hypoechogenicity and anteroposterior diameter greater than the transverse (higher than wide), were found in 83%, being statistically significant. The sensitivity of ultrasound findings exceeds 80%, except for the variable nodule size greater than 1 centimetre. Conclusions: Ultrasound findings such as adenopathies and anteroposterior diameters greater than the transverse one are potential indicators of malignant thyroid nodules, the size greater than one centimetre is not always a predictor of malignancy; however, due to the size of the sample in our study it is not possible to generalize it as a determining factor for biopsy. Therefore, we recommend monitoring the nodules considering the ultrasound criteria for malignancy and the TIRADS classification to make decisions regarding thyroid biopsies.

Microcalcificaciones en ausencia de nódulo tiroideo identificable por ecografía y su asociación a cáncer de tiroides: a propósito de un caso / Microcalcifications in the absence of identifiable thyroid nodule on sonography and its association with thyroid carcinoma: a case report

La ecografía tiroidea es la principal herramienta diagnóstica en el manejo de los nódulos tiroideos, siendo la presencia de microcalcificaciones un signo de malignidad. Sin embargo, existen escasas publicaciones acerca de la presencia de microcalcificaciones en ausencia de nódulo identificable y su asociación con cáncer de tiroides. Presentamos un caso de una mujer de 26 años, que, tras hallazgo incidental de bocio, se describe en ecografía un tiroides con alteración difusa de su ecogenicidad e imágenes compatibles con microcalcificaciones sin claro nódulo definido en su polo inferior. Tras realización de punción aspiración con aguja fina de la lesión con resultado Bethesda categoría 5, se decide realizar tiroidectomía total, presentando estudio histológico con diagnóstico de carcinoma papilar de tiroides variante clásica con metástasis ganglionares p(T1bN1a). Tras una revisión sistemática, los estudios hasta hoy publicados sugieren que la presencia de microcalcificaciones aisladas sin nódulo identificable debe considerarse un importante factor de riesgo de cáncer de tiroides, especialmente en gente joven, y en aquellas asentadas sobre una tiroiditis de Hashimoto. Por ende, resulta imperativo mantener una alta sospecha ante el hallazgo de este tipo de lesiones, recomendando una valoración exhaustiva de las mismas con la realización de una punción aspiración con aguja fina a todas las lesiones con dichas características.

Thyroid ultrasound is the main diagnostic tool in the management of thyroid nodules, with the presence of microcalcifications being a sign of malignancy. However, there are few publications about the presence of microcalcifications in the absence of an identifiable nodule and its association with thyroid cancer. We present a case of a 26-year-old woman who, after an incidental finding of goiter, a thyroid with diffuse echogenicity alteration and images compatible with microcalcifications without a clear nodule defined in the lower pole of the lobe is described on the ultrasound. After performing a fine needle aspiration of the lesion resulting in a Bethesda category 5, a total thyroidectomy was performed, presenting in the histological study a diagnosis of a classic variant of a papillary thyroid carcinoma with lymph node metastases p (T1bN1a). After a systematic review, the studies previously published suggest that the presence of isolated microcalcifications without an identifiable nodule should be considered an important risk factor for thyroid cancer, especially in young people, and in those with a concomitant Hashimoto's thyroiditis. Therefore, it is imperative to maintain a high suspicion of the discovery of this type of lesion, recommending an exhaustive assessment of them with the performance of a fine needle aspiration to all lesions with these features.

Utilidad diagnóstica de la ecografía tiroidea en la evaluación de nódulos tiroideos en niños y adolescentes / Diagnostic utility of thyroid ultrasound ecografy in thyroid nodules evaluation in children and adolescents

AIM: To evaluate the diagnostic utility of ultrasonography and other antecedents and exams usually availables, in the study of patients with thyroid nodules aged 0-20 years. SUBJECTS AND METHODOLOGY: Cross-sectional analytical observational study. We reviewed the data of patients undergoing FNAP (thyroid puncture with a fine needle) and / or thyroidectomy between January 2007 and December 2013. The ultrasound evaluation was performed by 3 specialists. The surgical biopsy was considered an indicator of benignity or malignancy and, in its absence the FNAP (excluding the Bethesda diagnoses 3 and 4). The association between cancer and the different variables was evaluated through binary logistic regression, with measure of association of odds ratio (OR). With the initially significant variables, a multivariate analysis was carried out and a cut-off score was subsequently defined to allow the diagnosis to be discriminated. RESULTS: 104 nodules are included in the analysis (100 patients), 89♀ / 11♂; age x16 ± 2.8; TSH 2.8 uIU / ml ± 5; lymphocytic thyroiditis 30%; pathological anatomy: benign 46 (44%) cancer 58 (56%). Sonographic findings predictive of malignancy were: hypoechogenicity (OR 2.95 p = 0.008) irregular shape (100% CA) non-smooth edges (OR 8.5 p = 0.000) microcalcifications (OR 39 p = 0.000) thick calcifications (OR 18 p = 0.001) and presence of suspicious adenopathy (100% CA). In the TIRADS classification, cases classified as 4 and 5 corresponded to cancer in 50 and 92%. The presence of thyroiditis did not show an insignificant association with malignancy. From the joint analysis of the significant variables, a score with adequate sensitivity and specificity is obtained. CONCLUSIONS: The usefulness of ultrasound as a fundamental examination in the evaluation of the pediatric patient who consults by thyroid nodule is corroborated. Accurately describing their sonographic characteristics and, above all, analyzing them together, allows us to determine an approximate risk of malignancy and define with greater certainty the indication of performing FNAP

Pathologic basis of the sonographic differences between thyroid cancer and noninvasive follicular thyroid neoplasm with papillary-like nuclear features

Ultrasonography is pivotal in triage thyroid biopsy in the era after the identification of noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP). This pictorial essay illustrates the pathologic basis of the sonographic features that distinguish NIFTP from thyroid cancers. In this study, we present the correlations of ultrasonography to ×1 histopathology to assess shape and margin characteristics. Markedly hypoechoic nodules correlate to microfollicular/solid nodules, while isoechoic/hyperechoic thyroid nodules correlate to normofollicular/macrofollicular nodules. The ultrasound findings of NIFTP and minimally invasive encapsulated thyroid cancers are similar. Both are well-circumscribed, oval-to-round nodules with regular margins. Blurred or microlobulated margins indicate infiltrating tumors, while lobulated margins are characteristic of expansile tumors. Overtly invasive encapsulated tumors are characterized by oval-to-round nodules with irregular or lobulated margins. The ultrasound findings for infiltrative thyroid cancers show at least one of the following malignant features: marked hypoechoicity, taller-than-wide shape, microcalcifications, and blurred or microlobulated margins.

Timing of thyroid ultrasonography in the etiological investigation of congenital hypothyroidism

ABSTRACT Objectives To describe the findings of thyroid ultrasonography (T-US), its contribution to diagnose congenital hypothyroidism (CH) and the best time to perform it. Subjects and methods Forty-four patients with CH were invited to undergo T-US and 41 accepted. Age ranged from 2 months to 45 years; 23 patients were females. All were treated with L-thyroxine; 16 had previously undergone scintigraphy and 30 had previous T-US, which were compared to current ones. Results At the current T-US, the thyroid gland was not visualized in its normal topography in 10 patients (24.5%); 31 T-US showed topic thyroid, 17 with normal or increased volume due to probable dyshormonogenesis, 13 cases of hypoplasia and one case of left-lobe hemiagenesis. One patient had decreased volume due to central hypothyroidism. Scintigraphy scans performed 3-4 years earlier showed 100% agreement with current results. Comparisons with previous T-US showed concordant results regarding thyroid location, but a decrease in current volume was observed in eight due to the use of L-thyroxine, calling the diagnosis of hypoplasia into question. Conclusions The role of T-US goes beyond complementing scintigraphy results. It allows inferring the etiology of CH, but it must be performed in the first months of life. An accurate diagnosis of CH will be attained with molecular study and the T-US can guide this early assessment, without therapy withdrawal.

Non invasive assessment of malignancy in solitary non palpable thyroid nodules: A comparative and complimentary evaluation of grey scale ultrasound and color doppler parameters –Way towards a new scoring system?

Objectives: To assess the comparative as well as collective role of various grey scale (GS) ultrasonography (USG) and color doppler (CD) parameters in distinguishing benign from malignant thyroid nodules. To suggest a scoring system for predicting malignancy in thyroid nodules using this array of parameters. Methods: 140 patients with non palpable thyroid nodules were examined by five GS USG and three CD parameters. The results were compared with histopathological examination and evaluated statistically. Each GS and CD parameter was evaluated individually as well as collectively, comparatively. Total score was calculated by assigning each of these eight parameters a score of 0 to 2. Results: Scoring used in this study showed sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy of 87.5%, 90.6%, 70%, 96.7% and 80% respectively. These parameters were 85.4%, 86.2%, 60%, 96%, 80% for CD and 69.2%, 71.9%, 50%, 85.2% and 64% for GS. Two GS USG features showing p value < 0.05 were poorly defined margins and thick incomplete halo while on CD Resistivity index (RI) was found to be very highly significant (p < 0.0001) and Pulsatility index (PI) was highly significant (p < 0.001). Conclusion: Scoring system proposed in this study proved better than GS or CD individually for predicting malignancy in thyroid nodules. Amongst various GS and CD parameters RI showed highest statistical significance. Overall CD showed better accuracy, sensitivity, specificity than GS USG.

Can Ultrasound Be as a Surrogate Marker for Diagnosing a Papillary Thyroid Cancer? Comparison with BRAF Mutation Analysis

PURPOSE: We investigated the merit of ultrasound (US) features and BRAF(V600E) mutation as an additional study of cytology and compared the diagnostic performances of cytology alone, cytology with US correlation, cytology with BRAF(V600E) mutation, and a combination of cytology, US, and BRAF(V600E) mutation all together. MATERIALS AND METHODS: This study included 185 patients (mean age, 48.4 years; range 20-77 years) with 191 thyroid nodules who underwent US-guided fine-needle aspiration (FNA) with an additional BRAF(V600E) mutation test. Three radiologists highly experienced in thyroid imaging retrospectively reviewed US images and classified each nodule into two categories (positive for malignancy or negative for malignancy). Interobserver variability (IOV) of US assessment between the three readers was estimated using the generalized kappa statistic of Landis and Koch. We also calculated the diagnostic performances of these studies. RESULTS: There were 131 cases of malignancy (131/191, 68.6%) and 60 cases of benign nodules (60/191, 31.4%). In terms of IOV of US assessment, the generalized kappa value was 0.242, indicating fair agreement was reached. The combination of cytology with BRAF(V600E) showed higher specificity (100%) and positive predictive value (PPV) (100%) compared to the combination of cytology, BRAF(V600E), and US (specificity 28.3%, 66.7%, 68.3%; PPV 74.6%, 86.6%, 86.8%, respectively; p<0.001). However, cytology with BRAF(V600E) showed lower sensitivity (84.7%) than cytology with BRAF(V600E) and US (96.2%, 98.5%, 95.4%, respectively; p<0.001). CONCLUSION: Considering the diagnostic performance and low reproducibility of US, the combination of FNA with BRAF(V600E) is the most reliable and objective method for diagnosing thyroid malignancy.

Can Ultrasound Be as a Surrogate Marker for Diagnosing a Papillary Thyroid Cancer? Comparison with BRAF Mutation Analysis

PURPOSE: We investigated the merit of ultrasound (US) features and BRAF(V600E) mutation as an additional study of cytology and compared the diagnostic performances of cytology alone, cytology with US correlation, cytology with BRAF(V600E) mutation, and a combination of cytology, US, and BRAF(V600E) mutation all together. MATERIALS AND METHODS: This study included 185 patients (mean age, 48.4 years; range 20-77 years) with 191 thyroid nodules who underwent US-guided fine-needle aspiration (FNA) with an additional BRAF(V600E) mutation test. Three radiologists highly experienced in thyroid imaging retrospectively reviewed US images and classified each nodule into two categories (positive for malignancy or negative for malignancy). Interobserver variability (IOV) of US assessment between the three readers was estimated using the generalized kappa statistic of Landis and Koch. We also calculated the diagnostic performances of these studies. RESULTS: There were 131 cases of malignancy (131/191, 68.6%) and 60 cases of benign nodules (60/191, 31.4%). In terms of IOV of US assessment, the generalized kappa value was 0.242, indicating fair agreement was reached. The combination of cytology with BRAF(V600E) showed higher specificity (100%) and positive predictive value (PPV) (100%) compared to the combination of cytology, BRAF(V600E), and US (specificity 28.3%, 66.7%, 68.3%; PPV 74.6%, 86.6%, 86.8%, respectively; p<0.001). However, cytology with BRAF(V600E) showed lower sensitivity (84.7%) than cytology with BRAF(V600E) and US (96.2%, 98.5%, 95.4%, respectively; p<0.001). CONCLUSION: Considering the diagnostic performance and low reproducibility of US, the combination of FNA with BRAF(V600E) is the most reliable and objective method for diagnosing thyroid malignancy.

Nódulo tiroideo, enfoque y manejo. Revisión de la literatura / Approach and management of thyroid nodule. A literature review

Introducción: el nódulo tiroideo es un hallazgo común en la actualidad, cuya incidencia viene en aumento. El objetivo principal durante la evaluación es distinguir el nódulo benigno del maligno. Materiales y métodos: se hizo una revisión narrativa de la literatura mediante búsqueda en Ovid, Medline y Lilacs desde 1950 a 2010. Resultados: la mayoría de los nódulos tiroideos son benignos, solo 4% a 8% de los casos pueden ser malignos. Los nódulos mayores de un centímetro se deben estudiar mediante aspirado con aguja fina; sin embargo, se deben tener en cuenta las características clínicas del paciente y las características ecográficas del nódulo. Entre los factores de riesgo asociados a la presencia de nódulo están la edad por encima de 45 años, el sexo femenino y el tabaquismo. No se recomienda la medición de marcadores tumorales en el estudio de los pacientes con nódulo tiroideo. Conclusión: la ecografía de tiroides y el aspirado con aguja fina son los métodos diagnósticos más importantes en la evaluación del nódulo tiroideo y han permitido cambiar las conductas terapéuticas disminuyendo el número de tiroidectomías innecesarias. El tratamiento y el pronóstico dependen de los factores de riesgo y de los hallazgos citológicos y patológicos.

Introduction: Thyroid nodules are commonly found, and their incidence is increasing. The main objective during the evaluation of these nodules is to determine if they are benign or malignant. Materials and methods: We made a narrative review of the literature by searching Ovid, Medline and Lilacs from 1950 to 2010. Results: Most thyroid nodules are benign, but in 4% to 8% of cases they may be malignant, hence the importance of appropriate study and management. Nodules larger than 1 cm should undergo fine needle aspirate; however, the clinical features of the patient and the characteristics of the nodule on ultrasound assessment should always be taken into account. The following are risk factors associated with the presence of thyroid nodules: age over 45 years, female gender and smoking. The measurement of tumor markers in the initial study of patients with thyroid nodule is not recommended. Conclusion: Ultrasound and thyroid fine needle aspirate are the most important diagnostic methods in the evaluation of thyroid nodules, because they enable to make changes in therapeutic decisions thus decreasing the number of unnecessary thyroidectomies. Treatment and prognosis of thyroid nodules will depend on the patient's risk factors and the cytological and pathological findings.

Core Needle Biopsy of Thyroid Nodules: Consensus Statement and Recommendations

Core needle biopsy is a complementary diagnostic method of fine needle aspiration for patients with thyroid nodules. The Task Force Committee of the Korean Society of Thyroid Radiology has developed recommendations for diagnosis of thyroid nodules and recurrent thyroid cancers using core needle biopsy. These recommendations are based on evidence from the current literature and expert consensus.

Remarkable calcifications in medullary thyroid carcinoma / Journal of the ASEAN Federation of Endocrine Societies

@#Various patterns of calcifications may be seen in thyroid cancers on ultrasonography (USG) of thyroid.1 Coarse calcifications seen in medullary thyroid carcinoma (MTC) are generally associated with posterior shadowing on thyroid ultrasound.2 We briefly report this case of MTC with an emphasis on its radiological features.

Radiofrequency Ablation of Benign Thyroid Nodules and Recurrent Thyroid Cancers: Consensus Statement and Recommendations

Radiofrequency ablation is a new non-surgical treatment modality for patients with benign thyroid nodules and recurrent thyroid cancers. The Task Force Committee of the Korean Society of Thyroid Radiology has developed recommendations for the treatment of benign thyroid nodules and recurrent thyroid cancers using radiofrequency ablation. These recommendations are based on evidence from the current literature and expert consensus.

Diagnostic Approaches to Patients with Thyroid Nodules

Thyroid nodules are epidemic with the rising use of high-resolution thyroid ultrasonography for health screening. The primary aim in investigating a thyroid nodule is to exclude the possibility of malignancy, which occurs in about 5% of nodules. Initial history taking and physical examination should focus on the clinical risk factors associated with thyroid cancer. Measurement of thyroid stimulating hormone (TSH) is the only biochemical test routinely needed to exclude autonomously functioning nodules. Thyroid ultrasonography-guided fine needle aspiration biopsy (US-FNA) is the most accurate standard diagnostic test for most thyroid nodules. Ultrasonographic features of nodules associated with increased risk of thyroid cancers include hypoechogenicity, microcalcification, irregular spiculated margin, taller-than-wide, Doppler signal in the nodules, and suspicious cervical lymphadenopathies. These findings are helpful in risk stratification of the nodules and in deciding which nodule should be sampled in multinodular goiters. The success of the procedure heavily depends on the experience and expertise of the clinicians. Knowledge on basic US-FNA techniques and some tricks is very important to improve overall diagnostic yields. Practically critical issues related to US-FNA are emphasized based on several guidelines and author's experiences.

Enfoque del paciente con nódulo tiroideo: [revisión] / Approach of patient with thyroid nodule: [review]

Un nódulo tiroideo solitario clínicamente es una lesión discreta, dentro de una glándula tiroidea que a la palpación es normal. Aunque los nódulos tiroideos son un problema clínico común, la gran minoría de ellos son malignos y pocas veces requieren manejo quirúrgico. Una aproximación sistemática en su evaluación es de suma importancia con el fi n de evitar procedimientos quirúrgicos innecesarios. Los factores que favorecen la presencia de malignidad incluyen entre otros la historia de irradiación en cuello, crecimiento rápido nodular, sexo masculino, menores de 20 años o mayores de 70 años, historia familiar de cáncer de tiroides o características sugestivas de neoplasia endocrina múltiple. La incidencia de cáncer en aquellos con características clínicas sugestivas de malignidad es muy alta, pero la mayoría de los pacientes no tienen dichas características. Los recientes avances en el uso generalizado de la biopsia por aspiración con aguja fina, la aplicación de la ecografía de alta resolución y los ensayos de medición de la hormona estimulante de tiroides, han originado un importante avance en el diagnóstico y manejo de los nódulos tiroideos. La biopsia por aspiración con aguja fina es crucial en la investigación de un nódulo tiroideo, provee una información citológica con alta exactitud acerca del nódulo, proporcionando un plan de manejo que puede ser formulado. Los principales cambios surgen en el manejo del nódulo que cae dentro de la categoría de “indeterminado”. Éstos pacientes pueden ser sometidos a más procedimientos quirúrgicos, los cuáles son necesarios, ya que el análisis histopatológico es el único medio a través del cual la malignidad puede excluirse. El manejo del nódulo tiroideo permanece controversial, la presente revisión tiene como objetivo el enfoque del diagnóstico y manejo del nódulo tiroideo solitario que es detectado al examen físico...

A clinically solitary thyroid nodule is a discrete swelling within an otherwise palpable normal thyroid gland. Although thyroid nodules are common, few are malignant and require surgical treatment. A systematic approach to their evaluation is important to avoid unnecessary surgery. Factors that favor malignancy include history of neck irridation, rapid tumor growth, male sex, age younger than 20 years or older than 70 years, a family history of thyroid cancer or features suggestive of multiple endocrine neoplasia. The incidence of cancer in those with clinical suggestive of malignancy is high, but most patients do not have these features. The recent developments such as the widespread use of fine-needle aspiration biopsy, the application of high-resolution ultrasonography and sensitive thyroid-stimulating hormone assays have resulted in important advances in the diagnosis and management of thyroid nodules. Fine-needle aspiration biopsy is crucial in the investigation of a thyroid nodule. It provides highly accurate cytologic information about the nodule from which a definitive management plan can be formulated. The challenge remains in the management of nodules that fall under the “indeterminate” category. These may be subject to more surgical intervention than is required because histological examination is the only way in which a malignancy can be excluded. The management of a solitary thyroid nodule remains controversial. This review will focus on the management of a solitary thyroid nodule that is detected on physical examination...

Preoperative assessment of thyroid nodules: role of ultrasonography and fine needle aspiration biopsy followed by cytology

PURPOSE:To evaluate the preoperative assessment of thyroid nodules using ultrasound studies and cytology of nodular aspirates. SUBJECTS AND METHODS: 2,468 patients with thyroid nodules were examined from 1999 to 2005. All patients were clinically examined and underwent ultrasonography followed by fine-needle aspiration biopsy (FNAB) and cytology. RESULTS:Nodules larger than 10 mm were classified ultrasonographically in a 4-tier system and received a score according to the criterion of possible malignancy. Cytological examinations were conducted independently by 2 cytologists and classified as benign (score 1), indeterminate (score 2), suspicious (score 3), and malignant (score 6). Combining both scores, an index was generated that would indicate a higher probability of malignancy (benign, doubtful, suspicious, and malignant). Thyroid surgery was performed in 274 patients. Of those, 115 patients had a score of 2 to 5 and only 8 had a histological diagnosis of thyroid cancer (6.9 percent). For patients with a score of 5 (n = 51), 11.5 percent had a malignant lesion, and 51 percent of the 61 patients with a score of 6 had confirmed thyroid cancer. Of the 98 patients with a combined score of 7 to 10, 99 percent had a histological confirmation of malignancy. CONCLUSIONS: The index score had a sensitivity of 94.1 percent and specificity of 77.5 percent. The overall accuracy was 85.8 percent. Therefore, we concluded that this methodology may improve the preoperative diagnosis of thyroid cancer in nodules larger than 10 mm. Association with other methods such as color Doppler echography, serum TSH concentration, galectin-3 expression analysis, and FDG/PET scan would be useful in avoiding the higher costs of thyroid surgical procedures.

OBJETIVO: Avaliar a possibilidade de diagnóstico pré-operativo de nódulos da tireóide (de diâmetro superior a 10mm) usando ultra-sonografia da glândula tireóide e citologia de punção aspirativa por agulha fina guiada pela ultra-sonografia. CASUíSTICA E MÉTODOS: Nódulos tireóideos (maiores que 10mm) foram classificados ultra-sonograficamente em graus de I a IV e escores numéricos de 1 a 4, de acordo com crescente possibilidade de malignidade. O exame citológico, subseqüentemente, classificou os nódulos como benigno (escore 1) indeterminado (escore 2) suspeito (escore 3) e maligno (escore 6). Somando-se os escores obtidos nas duas metodologias obtém-se um índice considerado benigno (índice combinado 2-4), duvidoso (índice combinado 5) suspeito para malignidade (índice combinado 6) e elevada probabilidade de malignidade (índice combinado 7 a 10). Cirurgia da Tireóide foi realizada em 274 pacientes, dos quais 64 apresentavam índice de 2-4; destes, apenas 2 pacientes (3,1 por cento) apresentaram comprovação histológica de câncer. Em pacientes com índice 5 (n= 51), 11,8 por cento apresentaram câncer de tireóide e, em 61 pacientes com índice 6, (n= 31), 51 por cento tiveram diagnóstico confirmado de malignidade. O índice combinado de 7-10 (n= 98) apresentou 99 por cento de pacientes com câncer de tireóide. CONCLUSÕES: O índice combinado apresentou sensibilidade de 94,1 por cento e especificidade de 77,5 por cento. A precisão desta metodologia foi de 85,8 por cento. Concluímos que o índice combinado pode ser útil no diagnóstico pré-cirúrgico do nódulo tireóideo, mormente se associado com outras metodologias como a ecografia com Doppler colorido, nível elevado de TSH sérico, análise de expressão de galectina-3 e imagens por FDG/PET.

The Diagnosis of Hashimoto Thyroiditis: A Report of 45 Cases / 中国医师杂志

Objective To investigate the clinical manifestation and diagnosis of Hashimoto thyroiditis (HT). Methods 45 HT patients diagnosed by fine needle aspiration cytology (FNAC) were enrolled in this study. Their medical history, clinical parameters, data of laboratory examination, colour doppler ultrasonic image and FNAC were analyzed. Results This disease was more common in women than in men, and most of cases occurred during 35～50 years old. Almost all cases had the symptoms of thyromegaly and laryngopharynx malaise. The patients had normal thyroid function, hypothyroidism or hyperthyroidism. The levels of both antithyroid globulin antibody and antithyroid microsome antibody increased in 39 cases. The ultrasonic imaging features of thyroid were such as following: diffusive nonhomogenous hypoecho pattern in 19 cases, numerous hypoecho micronodes in 15 cases, hyperecho micronodes in 3 cases, and hyperecho bandlike echo pattern with swelling of neck lymph nodes in 8 cases. Conclusion Diagnosis of HD should put emphasis on a complete medical history, physical examination and necessary laboratory tests. Antithyroid auto-antibody assay and thyroid ultrasonic examination were very important for diagnosis of HD, and FNAC may be indispensable in suspected cases.