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Adenomatous goiter is surgically confirmed for a 44-year-old woman. (a) Gray-scale US shows solid, isoechoic, well circumscribed, no calcifications, wider than tall, and halo sign in the nodule. (b) Color Doppler US shows type II vascularity in the nodule. Category 4a is classified based on TI-RADS alone, while category 3 is finally classified using the combined method (RS = −1.3). (c) This thyroid nodule is cytologically confirmed to be Bethesda category III by FNA (hematoxylin-eosin stain; original magnification, ×200). (d) This thyroid nodule is surgically confirmed to be an adenomatous goiter by histological specimen (hematoxylin-eosin stain; original magnification, ×200).
Source publication
To investigate the diagnostic performance of combination of ultrasound (US) thyroid imaging reporting and data system (TI-RADS) and a new US scoring system for diagnosing thyroid nodules (TNs) with indeterminate results (Bethesda categories III, IV and V) on fine-needle aspiration (FNA) cytology. 453 patients with 453 cytologically indeterminate TN...
Context in source publication
Context 1
... of RS for scoring system in predicting malignant from benign TNs was 2.0. With this cut-off point, TI-RADS categories were degraded and upgraded in 205 (45.3%, 205/453) and 151 (33.3%, 151/453) TNs respectively, leading to a change in TI-RADS category in 78.6% of all TNs. There was a case which was degraded from TI-RADS category 4a to 3 shown in Fig. 2. For nodules with TI-RADS category 3 and RS less than 2.1 (6.4%, 29/453) or TI-RADS category 5 and RS more than 2.1(15.0%, 68/453), the TI-RADS category was not ...
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Background
In this study, images of 2450 benign thyroid nodules and 2557 malignant thyroid nodules were collected and labeled, and an automatic image recognition and diagnosis system was established by deep learning using the YOLOv2 neural network. The performance of the system in the diagnosis of thyroid nodules was evaluated, and the application...
Background and objective:
Thyroid nodules (TNs) are abnormal growths of thyroid cells that form masses within the thyroid gland. TNs are common, and the importance lies in need to exclude thyroid cancer. This study was intended to evaluate the diagnostic accuracy of ultrasonography for differentiating benign from malignant thyroid lesions in compa...
Advances in the development and improvement of medical technologies and methods of processing medical images make it possible to highlight clinically significant characteristics that were not previously available to classical methods of medical imaging. Ultrasound diagnostics of thyroid gland nodules has a huge potential medical images processing....
Background
Cytologically indeterminate thyroid nodules (ITN) pose a management challenge. Here we analyze if adding ultrasound characteristics to Afirma Genome Sequence Classifier (GSC) results increases GSC diagnostic performance.
Methods
We retrospectively analyzed 237 GSC-tested Bethesda III/IV ITNs between July 2017 and December 2019 and class...
Background: Thyroid nodules are an extremely common disorder. Fine Needle Aspiration (FNA) is the gold standard procedure for thyroid nodules diagnosis and management; it helps clinicians to make a proper therapeutic decision and minimizes the need for unnecessary surgery.
Objective: To assess thyroid FNA sensitivity, specificity, accuracy, Positi...
Citations
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... Third, the various experience of radiologists as commonly described in included studies can induce high heterogeneity. However, difficult cases may be accompanied by the supervision of more experienced radiologists [72]. Additionally, intermediate categories were not tested in ACR TI-RADS, and low agreement in cytologic pathology may be expected [65]. ...
(1) Background: To determine the optimal cut-off values of two risk stratification systems to discriminate malignant thyroid nodules and to compare the diagnostic performance; (2) Methods: True and false positive and negative data were collected, and methodological quality was assessed for forty-six studies involving 39,085 patients; (3) Results: The highest area under the receiver operating characteristic (ROC) curve (AUC) of ACR and Kwak TI-RADS were 0.875 and 0.884. Based on the optimal sensitivity and specificity, the highest accuracy values of ROC curves or diagnostic odds ratios (DOR) were taken as the cut-off values for TR4 (moderate suspicious) and 4B. The sensitivity, specificity, DOR, and AUC by ACR (TR4) and Kwak TI-RADS (4B) for malignancy risk stratification of thyroid nodules were 94.3% and 96.4%; 52.2% and 53.7%; 17.5185 and 31.8051; 0.786 and 0.884, respectively. There were no significant differences in diagnostic accuracy in any of the direction comparisons of the two systems; (4) Conclusions: ACR and Kwak TI-RADS had good diagnostic performances (AUCs > 85%). Although we determined the best cut-off values in individual risk stratification systems based on statistical assessment, clinicians can adjust the optimal cut-off value according to the clinical purpose of the ultrasonography because raising or lowering cut-points leads to reciprocal changes in sensitivity and specificity.
... In contrast, studies have shown that the specificity and sensitivity of fine-needle aspiration (FNA) in identifying malignant thyroid nodules were about 60%-98% and 54%-90%, respectively. FNA remains one of the gold standards for identifying malignant thyroid nodules [34][35][36][37]. ...
Background:
Distinguishing between benign and malignant thyroid nodules remains difficult. Ultrasound has been established as a non-invasive and relatively simple imaging technique for thyroid nodules. This study aimed to assess the diagnostic accuracy of conventional ultrasound and ultrasound elastography for the differentiation between benign and malignant thyroid nodules by meta-analyzing published studies.
Methods:
Literature was retrieved from the PubMed and Embase databases from inception to May 31, 2022. The literature was screened using inclusion and exclusion criteria. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS2) scale was used to assess the quality of the included literature. Publication bias of the included studies was assessed by Deek's funnel plot. Heterogeneity tests were performed using Cochrane Q statistic and I2 statistic.
Results:
Finally, 9 articles were included. The meta-analysis showed that the combined sensitivity and specificity of ultrasound for the diagnosis of thyroid nodules were 0.88 [95% CI (0.83-0.91)] and 0.86 [95% CI (0.79-0.90)], respectively. The area under the curve (AUC) of the summary receiver operating characteristic curve (SROC) was 0.92 [95% CI (0.90-0.94)]. There was no significant publication bias in this study. Discussion. Existing evidence shows that ultrasound has a certain accuracy in diagnosing benign and malignant thyroid nodules, providing a scientific basis for thyroid assessment and diagnosis.
... Several studies have been carried out to evaluate the diagnostic performance of malignancy in TNs with indeterminate cytological results. Most of these studies have used one of the TI-RADS classification systems or were based on the 2015 ATA classification system [26,27]. ...
Purpose:
To evaluate a computer-aided diagnosis (CAD) technique in predicting malignancy for cytologically indeterminate thyroid nodules (TNs) as compared with different experienced radiologists.
Method:
436 patients with 436 cytologically indeterminate TNs on fine-needle aspiration cytology (FNAC) were included and all were confirmed by surgical pathology. They were retrospectively analyzed with respect to ultrasound (US) characteristics using a commercially available CAD system (AmCAD-UT; AmCad BioMed, Taiwan, China) and reviewed by one junior and one senior radiologists.The CAD system and different experienced radiologists stratified the risk of malignancy using ACR TI-RADS category. The diagnostic performance by different experienced radiologists independently and after consulting the CAD (different experienced radiologists + CAD) and by the CAD alone were compared.
Results:
The different experienced radiologists showed significantly higher specificities than the CAD system alone. The combination of radiologist and CAD system showed improved diagnostic performance with an AUC (Area under the curve) of 0.740 in the senior radiologist and 0.677 in the junior radiologist, as compared with CAD (AUC: 0.585) alone (all P < 0.05). The combination of senior radiologist and CAD system had the highest diagnostic performance (AUC: 0.740) and specificity (68.9%) compared to the others (all P < 0.05).
Conclusion:
The CAD system may play the potential role as a decision-making assistant alongside radiologists for differential diagnosis of TNs with indeterminate cytology.
... FNAB presents a specificity of 60 to 98% and sensitivities from 54 to 90% (10,11), so it is not such an accurate exam. In fact, non-diagnostic and indeterminate responses are common (12)(13)(14)(15). Consequentially, on one hand, a significant number of patients have to repeat the procedure with incremented costs and on the other hand, some patients could receive unnecessary thyroid surgery, more for diagnostic than for therapeutic purposes. ...
... However, TIRADS have limitations: there are many and different TIRADS with similar but non-overlapping classifications, accuracy is far less than 100% they are rarely used in real-life practice [in about 27.2% of the Italian reports (90)]. Therefore, fine-needle aspiration cytology (FNAC) still represents the gold-standard technique for classification of thyroid nodules, due to its high specificity (60-98%) to identify malignant thyroid nodules, but with variable sensitivity (54-90%) (10)(11)(12)(13)(14)91). ...
Background
Thyroid nodules are frequent in adult population and thyroid cancer incidence has increased dramatically over the past three decades. The aim of this systematic review and meta-analysis was to evaluate the US-Elastosonography (USE) diagnostic performance in assessing the thyroid nodules malignancy risk.
Methods
PubMed and Embase databases were searched from January 2011 to July 2021. We extracted data from selected studies and calculated the overall diagnostic accuracy of qualitative USE, semi-quantitative USE and quantitative USE. Summary receiver operating characteristic (ROC) curve was elaborated to show the results. All statistical tests were performed using Metadisc and Medcal software package.
Results
Finally 72 studies with 13,505 patients and 14,015 thyroid nodules (33% malignant) undergoing elastography were included. The pooled sensitivity, specificity and AUC were 84%, 81%, and 0.89 respectively for qualitative USE; 83%, 80%, and 0.93 for semi-quantitative USE and 78%, 81% and 0.87, for quantitative USE. The qualitative and semiquantitative USE present very similar diagnostic accuracy values and both better than the quantitative USE.
Conclusions
USE is a useful imaging tool for thyroid nodule characterization. In accordance with recent guidelines and meta-analyses, the USE could be used daily in thyroid nodule malignancy risk stratification.
Systematic Review Registration
PROSPERO: CRD42021279257.
... Other recent studies investigated the impact of different dimensional cutoffs, e.g., ≤2 and >2 cm, on the final performances of the available US systems, showing a range of values quite close to the ones obtained in the present cohort with the ACR and EU-TIRADS systems [8,29]. An innovative approach was proposed in 2017 by He et al., creating a new algorithm that significantly increased the predictive performance of US features [30]. In our case series, we found no improvement in diagnostic accuracy by combining either ACR or EU-TIRADS and the cytology class. ...
Objective: The American College of Radiology (ACR) and the European Thyroid Association (EU) have proposed two scoring systems for thyroid nodule classification. Here, we compared the ability of the two systems in triaging thyroid nodules for fine-needle aspiration (FNA) and tested the putative role of an approach that combines ultrasound features and cytology for the detection of malignant nodules. Design and Methods: The scores obtained with the ACR and EU Thyroid Imaging Reporting and Data Systems (TIRADS) from a prospective series of 480 thyroid nodules acquired from 435 subjects were compared to assess their performances in FNA triaging on the final cytological diagnosis. The US features that showed the highest contribution in discriminating benign nodules from malignancies were combined with cytology to improve its diagnostic performance. Results: FNA was recommended on 46.5% and 51.9% of the nodules using the ACR and EU-TIRADS scores, respectively. The ACR system demonstrated a higher specificity as compared to the EU-TIRADS (59.0% vs. 52.4%, p = 0.0012) in predicting >TIR3A/III (SIAPEC/Bethesda) nodules. Moreover, specific radiological features (i.e., echogenic foci and margins), combined with the cytological classes improved the specificity (97.5% vs. 91%, p < 0.0001) and positive predictive values (77.5% vs. 50.7%, p < 0.0001) compared to cytology alone, especially in the setting of indeterminate nodules (TIR3A/III and TIR3B/IV), maintaining an excellent sensitivity and negative predictive value. Conclusions: The ACR-TIRADS system showed a higher specificity compared to the EU-TIRADS in triaging thyroid nodules. The use of specific radiological features improved the diagnostic ability of cytology.
... Fine-needle aspiration cytology (FNAC) still represents the gold-standard technique for thyroid nodule classification, due to its high specificity (60-98%); however, the variable reported sensitivity (ranging between 54 and 90%) should be taken in consideration [10][11][12][13][14]. ...
... However, it should be taken in account that cytology itself has a reported specificity of 60-98% and a highly variable sensitivity (54-90%), but with considerable non-diagnostic reports [10][11][12][13][14]. ...
Ultrasound (US) is the first imaging modality for thyroid parenchyma evaluation. In the last decades, the role of ultrasound has been improved with the introduction of new US software, such as contrast-enhanced ultrasound (CEUS) and US-elastography (USE). USE is nowadays recognized as an essential part of the multiparametric ultrasound (MPUS) examination, in particular for the indeterminate thyroid nodule with possible fine-needle aspiration cytology (FNAC) number reduction; even if further and larger studies are needed to validate it. More controversial is the role of CEUS in thyroid evaluation, due to its high variability in sensitivity and specificity. Semi-automatic US systems based on the computer-aided diagnosis (CAD) system are producing interesting results, especially as an aid to less experienced operators. New knowledge on the molecular mechanisms involved in thyroid cancer is allowing practitioners to identify new genomic thyroid markers that could reduce the number of "diagnostic" thyroidectomies. We have therefore drawn up an updated representation of the current evidence in the literature for thyroid nodule multiparametric ultrasound (MPUS) evaluation with particular regard to USE, the US CAD system and CEUS.
... Both US and fineneedle aspiration cytology (FNAC) play instrumental roles in the diagnosis and managements of thyroid nodules. Highresolution US is a morphological imaging technique that can facilitate the diagnosis of thyroid nodules (3,4) and is recommended as the first choice for detecting differentiated thyroid carcinoma (DTC) in the 2015 American Thyroid Association (ATA) guidelines (5). US-guided FNAC is the most accurate method in the management of thyroid nodules (6,7) and provides direct indications for surgery based on a worldwide consensus. ...
Background:
When sonographic suspicious malignant thyroid nodules initially proven to be inconsistent by aspiration, repeat fine-needle aspiration cytology (FNAC) is commonly recommended. Although FNAC is simple and reliable, it is also an invasive operation with inevitable false negative results. To determine which sonographic features and histogram parameters based on gray-scale ultrasonic images need repeat aspiration.
Methods:
All of the nodules were suspicious for malignancy by preoperative ultrasound (US), and their initial FNAC findings indicated Bethesda category II, or III. Histogram analyses were performed for gray-scale ultrasonic images. Mean, variance, skewness, kurtosis, percentiles (1st, 10th, 50th, 90th, 99th), and sonographic features were compared between pathological benign nodules and malignant ones. Thereafter, receiver operator characteristic (ROC) curves were analyzed for the valuable indicators.
Results:
One hundred and nineteen consecutive patients with 123 histopathologically diagnosed focal thyroid nodules were included in the cohort. The factors associated with malignancy were taller-than-wide shape [odds ratio (OR) =15.165; 95% confidence interval (CI): 3.157-72.854], irregular margins (OR =11.492; 95% CI: 1.747-75.573), microcalcifications (OR =5.107; 95% CI: 1.455-17.927) and skewness (OR =25.800; 95% CI: 1.034-76.422). The skewness of malignant thyroid nodules is higher than that of benign thyroid nodules and has an area under the curve (AUC) of 0.776 in the diagnosis.
Conclusions:
For thyroid nodules suspicious on US but not on cytology, skewness, together with taller-than-wide shape, irregular margins and microcalcifications might be a promising marker for clinicians to perform repetitive FNACs.
... In cases of intermediate cytology, there are results showing that the sonographic characteristics should influence the further management of these cases [28] by considering molecular diagnostic tests or surgery [29]. ...
Fine needle aspiration (FNA) is recommended as the final evaluation in diagnosing thyroid nodules. Intermediate cytology is observed in about 15%–25% of the FNA results and has divergent recommendations: follow-up or surgery, either hemi- or total thyroidectomy. The present study aimed to assess the benefit of multimodal ultrasound (US) evaluation in clarifying the attitude in cases with intermediate cytology on FNA. Sixty-four successive cases with Bethesda III or IV cytology results were evaluated using two-dimensional B-mode US (2B), qualitative strain elastography, as well as planar and volumetric (3D) color Doppler using both a linear multifrequency probe and a linear volumetric probe (Hitachi Preirus Machine, Hitachi Inc. Japan). The analyzed nodules were all categorized as low, intermediate, or high risk, based on the following US criteria: taller-than-wide shape, marked hypoechogenicity, irregular borders, inhomogeneity, microcalcifications, or the presence of suspicious adenopathy. Elastographic criteria included stiff lesions, while volumetric Doppler criteria included moderate and marked perinodular vascularization, as suspicious for malignancy. The gold standard for the analysis was the result of the pathology report after thyroidectomy. Our results showed that the prevalence of cancer was 25% (16 cases). In five cases, borderline follicular neoplasia was identified, group which requires watchful waiting. These lesions were also considered as malignant in the final analysis, with a total number of 21 neoplasm cases. Sixteen of the 21 malignant nodules presented with high stiffness, while 15/21 had increased perinodular vascularization. Eight of the 21 cases displayed both important stiffness and perinodular vascularization. Cancer prevalence increased both with severity of stiffness (9.0%–15.0%–66.6%–80.0%) and intensity of vascularization in the adjacent perinodular parenchyma (18.2%–27.7%–35.29%–50.0%). Combining the use of grayscale US, elastography, and 3D Doppler in the evaluation of intermediate cytology cases showed a sensitivity of 85.7%, a specificity of 88.3%, and an accuracy of 90.3% in detecting thyroid cancer cases. We can conclude that the identification of highly suspicious US characteristics observed in 2B, qualitative elastography, and volumetric Doppler increases the risk of malignancy.
... Few studies have addressed the role of sonographic scores in indeterminate thyroid nodules [ Table 4]. [10][11][12][13][14] The presence of marked hypoechogenicity, taller-than-wide, punctate echogenic foci and extra-thyroidal extension each carry three points and likely to push the sonographic phenotype into a TR4 or TR5 nodules. Maia et al. studied the combination of the TI-RADS score with the Bethesda system to stratify malignancy risk in 136 indeterminate thyroid nodules, showing a negative predictive value of 90% in nodules classified as Bethesda III and TI-RADS 3 and 4a scores, and a higher risk of malignancy (75-77%) in nodules scored as TI-RADS 4b and 5 with Bethesda IV and V. [14] While individual risk stratification of BETH scoring and TR scoring has been studied in indeterminate thyroid nodules, there is not much literature in combining these two risk scores. ...
Context:
Given the lack of easy access to molecular markers for indeterminate thyroid nodules (Bethesda (BETH) category III, IV), the clinician can either decide to get a second opinion from an expert high-volume thyroid cytopathologist, redo the FNAC after a period of 3-6 months, or send the patient for a diagnostic hemithyroidectomy. Reviewing the sonographic risk features is also one way of triaging these nodules. The ACR-TIRADS (TR) is an objective method of sonographic risk assessment and is superior to other forms of sonographic classification.
Aim:
We propose combining the scoring of the TR category and BETH category (both expressed as a numerical value and summated) and look at the score which could potentially guide the clinician in deciding whom to send for surgery.
Settings and design:
Observational prospective collection of consecutive patient data from the thyroid FNAC clinic.
Statistical analysis used:
The BETH categories were represented numerically and summated with the TR category. The categorical outcome variables of benign and malignant nodules and the summated score was analyzed using the Kruskal-Wallis test.
Results:
We analyzed 450 FNAC data, out of which 403 were thyroid nodule aspirates. Out of these nodules, 96 of them underwent surgery and 64% of these nodules were malignant on final histopathology (malignant = 62 and benign = 34). The mean size of the benign nodules was 3.6 ± 2.2 cm compared to 2.8 ± 1.8 cm of the malignant nodules. After excluding those with BETH 1 (n = 4), the mean BETH-TR score for benign nodules was 6 ± 1.4 and malignant nodules 9.4 ± 2.1 (P < 0.0001). The BETH-TR score progressively increased from 7.3 ± 0.92 in follicular thyroid cancers (FTC) to 8.6 ± 1.4 in follicular variant papillary thyroid cancer (FVPTC) to 10 ± 1.3 in classic papillary thyroid cancers (PTC). Among the indeterminate nodules (BETH III and IV; n = 40), the BETH-TR score of benign nodules was 6.75 ± 1 and malignant nodules was 7.5 ± 0.72 (P value = 0.01). A BETH-TR score ≥7 gave a sensitivity of 92% specificity of 74% and correctly identified malignant nodules in 86% of cases (likelihood ratio 3.5; ROC area: 0.8841; CI 0.79-0.94).
Conclusion:
A combined sonocytological BETH-TR score is one way to triage the management of indeterminate thyroid nodules. A BETH-TR score ≥7 gave a sensitivity of 92% specificity of 74% and correctly identified malignant nodules in 86% of cases.
