Malignant risk of pediatric Bethesda category III thyroid nodules subcategorized by nuclear atypia and other: A single institution experience.

BACKGROUND: The 2023 Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) divides AUS diagnoses into two major subcategories: atypia of undetermined significance (AUS) nuclear atypia (AUS-N) and other (AUS-O). This study aims to compare the histological outcome and malignant rate of pediatric AUS thyroid nodules classified into AUS-N and AUS-O subcategories. DESIGN: A search of our institutional electronic pathology database for the period from January 2012 to July 2023 was conducted to identify pediatric (<21 years old) thyroid nodules that were interpreted as AUS and subsequently had surgery. Cases were further divided into AUS-N and AUS-O subcategories. Results of follow-up surgical resections were collected. The malignant rate was calculated and compared between AUS-N and AUS-O groups. RESULTS: The study identified 62 thyroid nodules from 58 pediatric patients. Among these nodules, 29 and 33 were subcategorized as AUS-N and AUS-O, respectively. Both groups exhibited a female predominance and displayed a similar nodule size distribution. Histological analysis revealed 15 carcinomas in AUS-N nodules, including 11 cases of classic papillary thyroid carcinoma (PTC) and four cases of follicular type of PTC. In contrast, in the AUS-O group, a total of five carcinomas were documented, including two PTCs and three oncocytic thyroid carcinomas. Notably, the malignant rate of AUS-N nodules (52%) is significantly higher than that of AUS-O nodules (15%) (p = .002). CONCLUSION: In pediatric AUS thyroid nodules, the malignant risk in AUS-N is significantly higher than that in AUS-O. These findings may guide more appropriate clinical triage and/or improve management of pediatric patients with AUS thyroid nodules.

Assessment of malignant risk stratification for microcalcifications interpreted as "amorphous" morphology on mammography: A study based on the 5th edition of breast Imaging Reporting and Data System.

PURPOSE: To investigate the malignant risk stratification of microcalcifications interpreted as amorphous morphology on mammography according to the coexistence of punctate microcalcifications based on the 5th edition of the Breast Imaging Reporting and Data System. METHOD: Between March 2013 and September 2020, 367 microcalcifications interpreted as amorphous morphology on mammography with surgical biopsies were included. The amorphous microcalcifications were classified into a predominantly punctate group (A, <50% of amorphous), a predominantly amorphous group (B, >50% of amorphous), and an only amorphous group (C, 100% of amorphous). The distribution was classified into diffuse, regional, grouped, and linear/segmental. The reference standard was the pathology. The positive predictive values (PPV) were calculated and compared using the Chi-square's test or Fisher's exact test and Kruskal-Wallis test. RESULTS: The overall PPV of microcalcifications interpreted as having an amorphous morphology was 5.2%. The PPV across groups significantly increased in proportion to the amorphous morphology, with 1.0% in group A, 5.6% in group B, and 23.3% in group C (p <.001). Furthermore, the PPV between group A and groups B plus C (10.1%) and groups A plus B (2.8%) and group C were significantly different (p <.001). The PPV of distribution was 0% for diffuse, 4.9% for regional, 5.0% for grouped, and 11.1% for linear/segmental distributions, without statistical significance. CONCLUSIONS: Pure amorphous microcalcifications are suitable for category 4B. However, when they coexist with punctate morphology, the malignant risk decreases suitable for category 4A or lower. When amorphous microcalcifications coexist with a predominantly punctate morphology, follow-up should be considered.

Comparison of Various Ultrasound-Based Malignant Risk Stratification Systems on an Occasion for Assessing Thyroid Nodules in Hashimoto's Thyroiditis.

Purpose: To compare the diagnostic performance and unnecessary ultrasound-guided fine-needle aspiration (US-FNA) biopsy rate of the 2015 American Thyroid Association (ATA), 2016 Korean Society of Thyroid Radiology (KSThR), and 2017 American College of Radiology (ACR) guidelines for patients with and without Hashimoto's thyroiditis (HT). Patients and Methods: This retrospective study included 716 nodules from 696 consecutive patients, which were classified using the categories defined by the three guidelines: ATA, KSThR, and ACR. The malignancy risk in each category was calculated and the diagnostic performance and unnecessary fine-needle aspiration (FNA) rates of the three guidelines were compared. Results: In total, 426 malignant and 290 benign nodules were identified. Patients with malignant nodules had lower total thyroxine levels and higher thyroid-stimulating hormone, thyroid peroxidase antibody, and thyroglobulin antibody levels than those without malignant nodules (all P<0.01). The margin difference was significant in non-HT patients (P<0.01), but comparable in HT patients (P=0.55). The calculated malignancy risks of high and intermediate suspicion nodules in the ATA and KSThR guidelines and moderately suspicious nodules in the ACR guidelines were significantly lower in non-HT patients compared with HT patients (P<0.05). The ACR guidelines showed the lowest sensitivity, highest specificity, and lowest unnecessary FNA rates in patients with and without HT. Compared to non-HT patients, HT patients had significantly lower unnecessary FNA rates (P<0.01). Conclusion: HT was associated with a higher malignancy rate of thyroid nodules with intermediate suspicion according to the ATA, KSThR, and ACR guidelines. The three guidelines, especially ACR, were likely to be more effective and could allow a greater reduction in the percentage of benign nodules biopsied in patients with HT.

Ki67 for evaluating the prognosis of gastrointestinal stromal tumors: A systematic review and meta-analysis.

Overexpression of Ki67 is observed in tumor cells, and it has been suggested to be a marker for cancer prognosis. However, the relationship between Ki67 expression and the risk of recurrence of gastrointestinal stromal tumors (GISTs) remains poorly defined. In the present study, a meta-analysis was used to examine the associations between Ki67 levels and GIST recurrence. Studies reporting GIST and Ki67 were found by searching Cochrane Library, PubMed and Embase until October 14, 2021. The Newcastle-Ottawa Scale (NOS) was used to verify the quality of the evidence. Totally, 1682 patient cases were included. The odds ratio (OR) estimates and 95% confidence interval (CI) for each publication were determined by a fixed-effects (Mantel-Haenszel) model. A total of 20 studies that fulfilled the inclusion criteria were finally included in the analysis. The average score of quality evaluation was 6.4 points according to NOS. It was found that Ki67 levels were significantly higher in the NIH L group compared with the NIH VL group (OR: 0.51; 95% CI: 0.26-0.99; P=0.04; P heterogeneity=0.44). There was also greater Ki67 overexpression in the NIH I group compared with the NIH L group (OR: 0.45, 95% CI: 0.31-0.65; P<0.0001; P heterogeneity=0.32), while Ki67 levels were greater in the NIH H group than in the NIH I group (OR: 0.20; 95% CI: 0.15-0.28; P<0.00001; P heterogeneity=0.56). In conclusion, Ki67 overexpression may be a useful marker of the risk of recurrent GIST transformation.

Adnexal Torsion Due to Borderline Mucinous Tumor of the Gonad in a Prepubertal Girl with Mixed Gonadal Dysgenesis (45,X/46,XY) and a Turner Phenotype.

BACKGROUND: Turner syndrome (TS) is a sex chromosome condition characterized by complete or partial loss of the X chromosome. Patients with mixed gonadal dysgenesis (45,X/46,XY) and a Turner phenotype are predisposed to gonadoblastoma with malignant transformation. CASE: We present the case of a TS patient with 45,X/46,XY with 2 episodes of left adnexal torsion (AT). Biopsies during detorsion showed benign mucinous cystadenoma. Pathology following bilateral gonadectomy revealed a left gonad with mucinous borderline tumor and right gonad with gonadoblastoma, both of which have malignant potential. SUMMARY AND CONCLUSION: Gonadectomy is recommended in XY gonadal dysgenesis to decrease risk of malignant transformation from gonadoblastoma. Although rare in pediatric patients, ovarian malignancies have been identified among AT cases. To our knowledge, we present the first case of AT due to borderline ovarian mucinous tumor of the ovary and contralateral gonadoblastoma in a patient with mixed gonadal dysgenesis (45,X/46,XY) and a Turner phenotype.

A Scoring System for Assessing the Risk of Malignant Partially Cystic Thyroid Nodules Based on Ultrasound Features.

OBJECTIVE: To assess the ultrasound (US) features of partially cystic thyroid nodules (PCTNs) and to establish a scoring system to further improve the diagnostic accuracy. METHODS: A total of 262 consecutive nodules from September 2017 to March 2020 were included in a primary cohort to construct a scoring system. Moreover, 83 consecutive nodules were enrolled as an validation cohort from May 2018 to August 2020. All nodules were determined to be benign or malignant according to the pathological results after surgery or ultrasound-guided fine-needle aspiration (US-FNA). The US images and demographic characteristics of the patients were analyzed. The ultrasound features of PCTNs were extracted from primary cohort by two experienced radiologists. The features extracted were used to develop a scoring system using logistic regression analysis. Receiver operating characteristic (ROC) curves were applied to evaluate the diagnostic efficacy of the scoring system in both the primary cohort and validation cohort. In addition, the radiologists evaluated the benign and malignant PCTNs of the validation cohort according to the ACR TI-RADS guidelines and clinical experience, and the accuracy of their diagnosis were compared with that of the scoring system. RESULTS: Based on the eight features of PCTNs, the scoring system showed good differentiation and reproducibility in both cohorts. The scoring system was based on eight features of PCTNs and showed good performance. The area under the curve (AUC) was 0.876 (95% CI, 0.830 - 0.913) in the primary cohort and 0.829(95% CI, 0.730 - 0.903) in the validation cohort. The optimal cutoff value of the scoring system for the diagnosis of malignant PCTNs was 4 points, with a good sensitivity of 71.05% and specificity of 87.63%. The scoring system (AUC=0.829) was superior to radiologists (AUC= 0.736) in diagnosing PCTNs and is a promising method for clinical application. CONCLUSIONS: The scoring system described herein is a convenient and clinically valuable method that can diagnose PCTNs with relatively high accuracy. The use of this method to diagnose PCTNs, which have been previously underestimated, will allow PCTNs to receive reasonable attention, and assist radiologist to confidently diagnose the benignity or malignancy.

Abbreviated Magnetic Resonance Imaging With Breath-Hold Three-Dimensional Magnetic Resonance Cholangiopancreatography: Assessment of Malignant Risk of Pancreatic Intraductal Papillary Mucinous Neoplasm.

BACKGROUND: For surveillance of pancreatic intraductal papillary mucinous neoplasms (IPMNs), magnetic resonance imaging (MRI)/magnetic resonance cholangiopancreatography (MRCP) is preferred over computed tomography, but the long acquisition time limits its use. PURPOSE: To investigate the diagnostic performance of abbreviated MRI with breath-hold (BH) three-dimensional MRCP (abbreviated MRI-BH) for malignant risk assessment of pancreatic IPMN. STUDY TYPE: Retrospective. POPULATION: Two hundred and thirty-five patients with IPMNs (M:F = 115:120; mean age ± SD, 66 ± 9 years; typical imaging features with ≥2-year stability [N = 172] and histopathologically confirmed [N = 63]). FIELD STRENGTH/SEQUENCE: 3.0 T/ abbreviated MRI-BH (single-shot fast spin-echo, T1W fat-suppressed gradient-echo sequence, and BH-3D-MRCP). ASSESSMENT: Abbreviated MRI-BH was reviewed by three reviewers, and its diagnostic performance was assessed using the predetermined scoring system. The diagnostic performance for the mural nodule detection was assessed. Additionally, diagnostic performance of abbreviated MRI was compared with that of full-sequence MRI. STATISTICAL TESTS: Area under the receiver operating characteristic curve (AUC) with z-test, and linear-weighted kappa values. RESULTS: Thirty-five patients had malignant IPMN. At a cut-off score ≥3, AUCs of abbreviated MRI-BH for detecting malignant IPMN were 0.959 for reviewer 1, 0.962 for reviewer 2, and 0.956 for reviewer 3. The sensitivity of reviewers 1, 2, and 3 was 97.1% for all, and the specificity was 85.5%, 86.0%, and 85.0%, respectively. Regarding mural nodule detection (N = 22), abbreviated MRI-BH demonstrated a sensitivity of 95.5% and a specificity of 88.3% for reviewer 1, a sensitivity of 86.4% and a specificity of 92.0% for reviewer 2, and a sensitivity of 86.4% and a specificity of 89.2% for reviewer 3. There were no significant differences between AUC of abbreviated MRI-BH and that of full-sequence MRI in the three reviewers (P > 0.05). DATA CONCLUSION: Abbreviated MRI-BH showed good diagnostic performance for detecting malignant IPMNs by using a predetermined scoring system. LEVEL OF EVIDENCE: 3 TECHNICAL EFFICACY STAGE: 2.

Comparison of diagnostic performance between C-TIRADS and ACR-TIRADS for malignancy risk stratification of thyroid nodules / 中华超声影像学杂志

Objective:To validate the Chinese version of Thyroid Imaging Report and Data System (C-TIRADS) for the malignancy risk stratification assessment of thyroid nodules, and compare with the American College of Radiology TIRADS(ACR-TIRADS) for diagnostic performance.Methods:A total of 1 306 patients with 1 389 thyroid nodules in the First Affiliated Hospital of Hainan Medical University from January 2015 to March 2021 were reviewed and assessed for diagnostic performance according to the C-TIRADS and the ACR-TIRADS, respectively, and the histopathological results were taken as golden standard.Results:The 1 389 thyroid nodules consisted of 973 benign nodules and 416 malignant nodules. The C-TIRADS 4C and ACR-TIRADS 5 had the highest accuracies and were taken respectively as the optimized cut-off values for diagnosis.The sensitivity, specificity, positive and negative predictive values and AUC by C-TIRADS 4C and ACR-TIRADS 5 for thyroid nodule evaluation were 87.39%, 89.92%, 75.00%, 95.38%, 0.89, and 85.58%, 91.88%, 81.84%, 93.71%, 0.89, respectively(all P>0.05). Conclusions:The C-TIRADS and ACR-TIRADS have good diagnostic performance for the malignancy risk stratification of thyroid nodules, and C-TIRADS 4C has comparable diagnostic performance to ACR-TIRADS 5.

Potential association between oral mucosal nevus and melanoma: A preliminary clinicopathologic study.

OBJECTIVES: To assess potential association between oral nevi (ON) and nevus-associated melanoma (NAM), in which melanoma cells coexist with nevus cells. METHODS: A total of 74 ON patients and 7 NAM patients were retrospectively reviewed. Comparative and regression analyses of clinical and histological data were performed between two groups. RESULTS: The mean age of the patients with ON was 36.5 years compared with that of 54.7 years of the patients with NAM (p = .008). Gender ratio was female predominance for ON (1.64:1 ratio) and male predominance for NAM (6:1 ratio). The most common location of ON and NAM was the palate (31.1%) and gingiva (71.4%), respectively. Univariate regression analysis revealed that elderly male patients (≥60 years) with junctional ON located on the gingiva correlate with higher risk of melanoma. Multivariate analysis revealed that junctional type of ON was an independent factor (adjusted OR, 38.32; 95% CI, 3.20-458.64; p = .004) associated significantly with increased risk for melanoma. CONCLUSIONS: The preliminary study for the first time elucidated the clinicopathologic features of a Chinese series of ON and evaluated the potential association between ON and NAM with a limited sample size. Further large multicenter studies are needed to confirm the findings.

Ultrasonographic classification for evaluating malignant risk of cervical lymphadenopathy / 中国医学影像技术

Objective: To establish ultrasonographic (US) classification criterion for evaluating malignant risk of cervical enlarged lymph nodes (LN). Methods: Four US indexes of 882 cervical enlarged LN were retrospectively studied, including echogenicity of hilum, intranodal echogenicity, intranodal vascular pattern and the ratio of long axis to short axis (L/S),and each LN was given scores. US classification criterion was proposed according to the differences of the percentage of malignant LN in each score group. Results: The score range of US criterion was from 0 to 7. The percentage of malignant LN increased with the scores increasing (P<0.05), so did OR values of malignant risk. US classification diagnostic criterion for cervical enlarged LN was as follows: grade 1 (0 score), very low malignant risk, malignant percentage was less than 3.70%; grade 2 (1-2 score), low malignant risk, malignant percentage was (14.91±4.63)%; grade 3 (3-4 score ), moderate malignant risk, malignant percentage was (43.89±0.64)%; grade 4 (5-7 score), high malignant risk, malignant percentage was (77.84±9.15)%. Taken "grade 4" as the cut-off value for differentiating benign and malignant LN, the sensitivity was 78.97%, specificity was 72.51%, Youden's index was 0.515,accuracy was 76.08%, and the AUC was 0.791. Conclusion: US classification based on US score criterion can differentiate benign and malignant LN and evaluate the malignant risk of cervical enlarged LN.

Prediction of risk of malignancy of gastrointestinal stromal tumors by endoscopic ultrasonography.

BACKGROUND/AIMS: The accurate preoperative prediction of the risk of malignancy of gastrointestinal stromal tumors (GISTs) is difficult. The aim of this study was to determine whether tumor size and endoscopic ultrasonography (EUS) features can preoperatively predict the risk of malignancy of medium-sized gastric GISTs. METHODS: Surgically resected, 2 to 5 cm gastric GIST patients were enrolled and retrospectively reviewed. EUS features, such as heterogeneity, hyperechoic foci, calcification, cystic change, hypoechoic foci, lobulation, and ulceration, were evaluated. Tumors were grouped in 1 cm intervals. The correlations of tumor size or EUS features with the risk of malignancy were evaluated. RESULTS: A total of 75 patients were enrolled. The mean tumor size was 3.43±0.92 cm. Regarding the risk of malignancy, 51 tumors (68%) had a very low risk, and 24 tumors (32%) had a moderate risk. When the tumors were divided into three groups in 1 cm intervals, the proportions of tumors with a moderate risk were not different between the groups. The preoperative EUS features also did not differ between the very low risk and the moderate risk groups. CONCLUSIONS: Tumor size and EUS features cannot be used to preoperatively predict the risk of malignancy of medium-sized gastric GISTs. A preoperative diagnostic modality for predicting risk of malignancy is necessary to prevent the overtreatment of GISTs with a low risk of malignancy.

Prediction of Risk of Malignancy of Gastrointestinal Stromal Tumors by Endoscopic Ultrasonography

BACKGROUND/AIMS: The accurate preoperative prediction of the risk of malignancy of gastrointestinal stromal tumors (GISTs) is difficult. The aim of this study was to determine whether tumor size and endoscopic ultrasonography (EUS) features can preoperatively predict the risk of malignancy of medium-sized gastric GISTs. METHODS: Surgically resected, 2 to 5 cm gastric GIST patients were enrolled and retrospectively reviewed. EUS features, such as heterogeneity, hyperechoic foci, calcification, cystic change, hypoechoic foci, lobulation, and ulceration, were evaluated. Tumors were grouped in 1 cm intervals. The correlations of tumor size or EUS features with the risk of malignancy were evaluated. RESULTS: A total of 75 patients were enrolled. The mean tumor size was 3.43+/-0.92 cm. Regarding the risk of malignancy, 51 tumors (68%) had a very low risk, and 24 tumors (32%) had a moderate risk. When the tumors were divided into three groups in 1 cm intervals, the proportions of tumors with a moderate risk were not different between the groups. The preoperative EUS features also did not differ between the very low risk and the moderate risk groups. CONCLUSIONS: Tumor size and EUS features cannot be used to preoperatively predict the risk of malignancy of medium-sized gastric GISTs. A preoperative diagnostic modality for predicting risk of malignancy is necessary to prevent the overtreatment of GISTs with a low risk of malignancy.