Identifying and Predicting Diverse Patterns of Benign Nodule Growth.

CONTEXT: The natural history of benign thyroid nodules is typically characterized by slow growth and minimal risk of malignant transformation. Available data have, to date, been unable to elucidate the diversity of benign nodule growth patterns over time nor predictive of which patients follow which pattern. OBJECTIVE: We aimed to better define the diverse patterns of benign nodule behavior and their predictors. METHODS: We prospectively studied 389 consecutive patients with solitary, solid, cytologically benign thyroid nodules ≥1 cm and follow-up ultrasound for at least 4 years. Demographic, sonographic, biochemical data were collected at initial evaluation, and subsequent growth patterns were identified over the follow-up. Predictors of growth at initial evaluation and 3 years of follow-up were defined. RESULTS: The mean (±SD) follow-up was 7.7 (±2.7) years. Three distinct growth patterns were identified: A) stagnant nodules with average growth rate < 0.2 mm/year; B) slow-growing nodules with a rate 0.2 to 1.0 mm/year; and C) fast-growing nodules increasing > 1.0 mm/year. Fast-growing nodules represented 17.2% of the cohort, and were more frequent in patients younger than 50 years (OR 2.2 [1.2-4.1], P = 0.016), and in larger nodules (2.0-2.9 cm, OR 3.5 [1.7-7.1], P = 0.001; >3.0 cm, OR 4.4 [1.8-10.4], P = 0.001 vs reference 1-1.9 cm). In a multiple regression model, nodule growth at 3 years at an average growth rate over 0.2 mm/year over 3 years since initial evaluation was an independent predictor of longer-term fast nodule growth, even after adjusting for age, biological sex, TSH level, and nodule size (P < 0.001). CONCLUSION: The natural history of benign nodule growth is diverse, with over 80% of nodules demonstrating minimal to no growth long-term. Nearly 20% of cytologically benign nodules may exhibit a fast, continued growth pattern, which can be predicted by the 3-year growth rate pattern. These findings can help inform decision making for tailored benign nodule follow-up and monitoring.

Clinical experience following implementation of routine SPECT-CT imaging following 131-iodine administration for thyroid cancer.

Background: Planar scintigraphy has long been indicated in patients receiving I-131 therapy for thyroid cancer to determine the anatomic location of metastases. We studied our experience upon implementing additional single-photon emission (SPECT)-CT scanning in these patients. Method: We performed a retrospective study of consecutive adult patients with newly diagnosed thyroid cancer treated with I-131 between 2011 and 2017. Radiologic findings detected with planar scintigraphy alone vs those identified with SPECT-CT scanning were primary endpoints. Result: In this study, 212 consecutive patients with thyroid cancer were analyzed in two separate cohorts (107 planar scintigraphy alone and 105 planar scintigraphy with SPECT-CT). The addition of SPECT-CT resulted in more findings, both thyroid-related and incidental. However, we identified only 3 of 21 cases in which SPECT-CT provided an unequivocal additional benefit by changing clinical management beyond planar scintigraphy alone. No difference in the detection of distant metastatic disease or outcome was identified between cohorts. Conclusion: Synergistic SPECT-CT imaging in addition to planar nuclear scintigraphy adds limited clinical value to thyroid cancer patients harboring a low risk of distant metastases, while frequently identifying clinically insignificant findings. These data from a typical cohort of patients receiving standard thyroid cancer care provide insight into the routine use of SPECT-CT in such patients.

Thyroid Nodule Shape Independently Predicts Risk of Malignancy.

CONTEXT: Predictive models of thyroid nodule cancer risk are presently based upon nodule composition, echogenicity, margins, and the presence of microcalcifications. Nodule shape has shown promise to be an additive factor helping determine the need for nodule biopsy. OBJECTIVE: We sought to determine if calculation of a nodule's spherical shape independently associates with cancer risk. METHODS: This prospective cohort study, conducted at a single large academic healthcare system in the United States, included patients with 1 or 2 clinically relevant thyroid nodules (predominantly solid and over 1 cm) presenting for diagnostic evaluation. Thyroid ultrasound, cytological evaluation with fine-needle biopsy, and/or histopathological examination on occasion of thyroid surgery were performed. We calculated the nodule's long to short ratio (spherical shape), and its association with tissue proven benign or malignant endpoints. RESULTS: The long to short nodule ratio was significantly lower in malignant compared to benign nodules indicating greater risk of malignancy in more spherical nodules (1.63 ±â€…0.38 for malignant nodules vs 1.74 ±â€…0.47 for benign, P < 0.0001). The risk of malignancy continually increased as the long to short ratio approached a purely spherical ratio of 1.0 (ratio > 2.00, 14.6% cancer; ratio 1.51-2.00, 19.7%; ratio 1.00-1.50, 25.5%, P < 0.0001). In multiple regression analysis, younger age, male sex, and nodule's spherical shape were each independently associated with cancer risk. CONCLUSION: The more a thyroid nodule is spherically shaped, as indicated by a long to short ratio approaching 1.0, the greater its risk of malignancy. This was independent of age, sex, and nodule size. Incorporating a nodule's sphericity in the risk stratification systems may improve individualized clinical decision making.

Point of Care Measurement of Body Mass Index and Thyroid Nodule Malignancy Risk Assessment.

Background: Large scale epidemiology studies have suggested obesity may increase the risk of thyroid cancer, though no prospective analyses using real-world measurement of BMI at a time proximate to initial thyroid nodule evaluation have been performed. Methods: We performed a prospective, cohort analysis over 3 years of consecutive patients presenting for thyroid nodule evaluation. We measured BMI proximate to the time of initial evaluation and correlated this with the final diagnosis of benign or malignant disease. We further correlated patient BMI with aggressivity of thyroid cancer, if detected. Results: Among 1,259 consecutive patients with clinically relevant nodules, 199(15%) were malignant. BMI averaged 28.6 kg/m2 (SD: 6.35, range:16.46-59.26). There was no correlation between the measurement of BMI and risk of thyroid cancer (p=0.58) as mean BMI was 28.9 kg/m2 and 28.6 kg/m2 in cancerous and benign cohorts, respectively. Similarly, BMI did not predict aggressive thyroid cancer (p=0.15). While overall nodule size was associated with increased BMI (p<0.01), these data require further validation as obesity may hinder nodule detection until large. Conclusion: In contrast to findings published from large scale association studies drawn from national databases, these prospective data of consecutive patients presenting for nodule evaluation detect no association of obesity (as measured by BMI) with thyroid cancer. Real time measurement of BMI at the time of thyroid nodule evaluation does not contribute to cancer risk assessment.

Dental core training in oral and maxillofacial surgery: a United Kingdom survey of on-call provision.

Introduction Dental core training posts within oral and maxillofacial surgery (OMFS) units often include on-call provision. There is a lack of current data demonstrating the variation of dental core trainee (DCT) involvement in on-call. This variation may influence trainees' experience of training.Aim To examine the provision of on-call cover in OMFS units across the United Kingdom, including trainee involvement, supervision and training.Method Online surveys were distributed in August 2019 to all DCTs, educational supervisors (ESs) and training programme directors (TPDs) in OMFS units to understand trainee involvement in on-call provision, including levels of supervision and perceived educational benefit.Results In total, 167 trainees responded from 69 OMFS units. Responses were received from 102 ESs/TPDs. All trainees experienced on call, with over 75% covering night shifts. Trainees reported minimal difference between support within hours and out of hours (OOH). Qualitative data from trainees and supervisors highlighted the educational value of on-call within normal hours. However, limited supervised training opportunities were reported OOH.Conclusion This survey highlights the educational value of on-call within hours. The perceived level of support does not vary significantly between normal hours and OOH. Some concerns were expressed regarding OOH supervision and prolonged on-call periods.

Post-qualification dental training. Part 2: is there value of training within different clinical settings?

Introduction Upon completion of dental foundation training (DFT), a number of dental graduates apply for further training known as dental core training (DCT). Alternatively, there are two-year integrated training pathways within both primary and secondary care; known as longitudinal dental foundation training (LDFT). There is a lack of evidence supporting LDFT and how this compares to DFT and DCT.Aim To explore perceptions and experiences of three post-qualification dental training pathways (DFT, DFT+DCT1, LDFT) and understand how this training prepares trainees for independent clinical practice and their future career.Method A qualitative study from an interpretivist stance, theoretical sampling was carried out until data saturation was achieved; 36 individual in-depth semi-structured interviews of trainees and supervisors were conducted. The development of codes and generation of sub-themes resulted in major themes grounded within the data of participants.Results Seven major themes were generated: training pathway choice, skill development, career development, identity, team, setting and training programme.Conclusion The second part of this short series provides an understanding of how the different training pathways prepare trainees for independent clinical practice and their future careers; in particular how training in different clinical settings can promote interprofessional collaboration and appreciation of patient care pathways.

Post-qualification dental training. Part 1: perceptions of different dental foundation and dental core training pathways.

Introduction Upon completion of dental foundation training (DFT), a number of dental graduates apply for further training known as dental core training (DCT). Alternatively, there are two-year integrated training pathways within both primary and secondary care; known as longitudinal dental foundation training (LDFT). There is a lack of evidence supporting LDFT and how this compares to DFT and DCT.Aim To explore perceptions and experiences of three post-qualification dental training pathways (DFT, DFT+DCT1, LDFT) and understand how this training prepares trainees for independent clinical practice and their future career.Method A qualitative study, employing a 'grounded theory' approach. Theoretical sampling was carried out until data saturation was achieved; 36 individual in-depth semi-structured interviews of trainees and supervisors were conducted. Data analysis was iterative and inductive. The development of codes and generation of sub-themes resulted in major themes grounded within the data of participants. Results Seven major themes were generated: training pathway choice, skill development, career development, identity, team, setting and training programme.Conclusion The first part of this short series provides an understanding of perceptions of the different training pathways and factors considered when choosing a training pathway; in particular the impact of the recruitment process, peer opinion and service pressures.