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Ultrasonographic classification of nodules. From top left, clockwise: grade I, a small round anechoic image (thyroid cyst); grade II, a complex nodule (like a sponge); grade II, multiple echonormal nodules; grade III, a hypoechoic solid nodule with regular border; grade III, cystic mass with solid projection from the cyst wall; and grade IV, a hypoechoic solid nodule with irregular border and microcalcifications.
Source publication
To evaluate the preoperative assessment of thyroid nodules using ultrasound studies and cytology of nodular aspirates.
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.
Nodules larger than 10 mm were...
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Context 1
... indicated in Figure 1, sonographic features alone do not reliably separate benign from malignant thyroid nod- ules. As recently reported by Frates et al, 17 the more cystic a nodule is, the lower the likelihood of cancer. Hypoechoic nodules had a higher rate of malignancy than isoechoic or hyperechoic nodules. The presence of coarse or rim calci- fications increased the likelihood of cancer almost 2-fold, when compared with the malignancy rate for nodules with- out calcification. Punctate microcalcifications increased the likelihood almost 3-fold. Well-defined or poorly defined nodule margins were not significantly associated with pres- ence of thyroid cancer. 17 To assess the likelihood of malignancy as indicated by sonographic characteristics, we combined both the results of ultrasonographic appearance with the cytological diag- nosis after USG-FNAB. As shown in Table 1, in our co- hort of 2468 nodules, grade III and IV sonographic patterns were detected in 1429 nodules. Of these, 261/1276 grade III nodules (20.4%) were cytologically classified as suspi- cious (13.7%) or malignant (6.7%), whereas 88/153 sonographically grade IV nodules (70.5%) were cytologi- cally diagnosed as malignant, and 20/153 as suspicious (13.1%). The combined echographic and cytological score (index score) for patients who subsequently underwent to- tal thyroidectomy is shown in Table 2 the advice of their respective family-practice doctors, and ma- lignancy was confirmed histologically in only 2 patients (3.1%). Patients with a combined score of 5 could be advised to follow a period of observation with or without L-T4 sup- pressive therapy. However, 51/279 (18.4%) of the patients with a score of 5 underwent surgery, and 11.7% (6/51) harbored thyroid malignancy. For patients with higher scores such as index 6, malignancy in the nodules was found in 50.8% (31/ 61), whereas nodules with index scores of over 7 had a 99% (97/98) incidence of thyroid cancer. Thus, sensitivity of the combined sonographic features and cytological results index scores was 94.1% and specificity was 77.5%, with a positive predictive value of 80.5% and a negative predictive value of 93.0%. The accuracy of this numeric scoring was 85.9%. We conclude that the sonographic studies of nodules larger than 10 mm associated with USG-FNAB resulting in a cytological diagnosis comprise a better preoperative diagnosis tool for thyroid nodules as compared to each method individually. However, we were not able to secure a firm indication for score 5 nodules, although about 11% of those could be thyroid cancer. Moreover, nodules with an index score of 6 had a 50% percent chance of being as- sociated with thyroid cancer; in this particular group, our tendency is to indicate thyroid surgery. Finally, a nodule score of 7 or more indicates mandatory thyroid ...
Similar publications
Currently the cytological examination of fine needle aspiration (FNA) biopsies is the standard technique for the pre-operative differential diagnosis of thyroid nodules. However, the results may be non-informative in ~20% of cases due to an inadequate sampling and the lack of highly specific, measurable cytological criteria, therefore ancillary bio...
Citations
... Among malignant tumors in our study, almost 80% were hypoechoic, as already reported by several authors (11,18,(28)(29)(30). The moderate degree hypoechogenicity was the most prevalent among malignant nodules, around 30%, as previously observed by Lee and cols. ...
... Such a relationship between degrees of hypoechogenicity and the ROM can be explained, because the tumor is composed of hypercellular tissues, which leads to cellular compaction and this, combined with the scarcity of colloid, causes lower sound reflection and, therefore, a hypoechoic appearance. Further, fibrosis can also enhance the degree of hypoechogenicity (27,(29)(30)(31). This hypoechogenicity pattern is usually associated with the classical subtype of papillary carcinoma, whereas iso-hyperechoic appearance often occurs in the follicular subtype due to the exclusive or predominantly follicular component over the papillary component, which causes greater sound reflection (31,(35)(36)(37). ...
Objective:
The aim of this study was to determine whether classifying hypoechogenicity in three degrees (mild, moderate, and marked) could improve the distinction between benign and malignant nodules and whether such an approach could influence Category 4 of the Thyroid Imaging Reporting and Data System (TI-RADS).
Materials and methods:
In total, 2,574 nodules submitted to fine needle aspiration, classified by the Bethesda System, were retrospectively assessed. Further, a subanalysis considering solid nodules without any additional suspicious findings (n = 565) was performed with the purpose of evaluating mainly TI-RADS 4 nodules.
Results:
Mild hypoechogenicity was significantly less related to malignancy (odds ratio [OR]: 1.409; CI: 1.086-1.829; p = 0.01), compared to moderate (OR: 4.775; CI: 3.700-6.163; p < 0.001) and marked hypoechogenicity (OR: 8.540; CI: 6.355-11.445; p < 0.001). In addition, mild hypoechogenicity (20.7%) and iso-hyperechogenicity (20.5%) presented a similar rate in the malignant sample. Regarding the subanalysis, no significant association was found between mildly hypoechoic solid nodules and cancer.
Conclusion:
Stratifying hypoechogenicity into three degrees influences the confidence in the assessment of the rate of malignancy, indicating that mild hypoechogenicity has a unique low-risk biological behavior that resembles iso-hyperechogenicity, but with minor malignant potential when compared to moderate and marked hypoechogenicity, with special influence on the TI-RADS 4 category.
... 13 Our findings showed that C+U scoring is a valuable tool in predicting malignancy in a population different from the study of Ianni, et al. 13 Cytological findings were also evaluated in addition to ultrasonographic features in some of these scoring systems. [18][19][20] It has been stated that the use of a combined ultrasonographic-cytological index helps the clinician to decide for management of TNs, especially in TNs with an indeterminate cytology. 18,19 CUT scoring system was evaluated separately in indeterminate thyroid nodules by the same team in 2019 and showed that CUT score could represent a valid aid for the clinician in the management of indeterminate nodules with follicu- International Journal of Hematology and Oncology lar proliferation. ...
... [18][19][20] It has been stated that the use of a combined ultrasonographic-cytological index helps the clinician to decide for management of TNs, especially in TNs with an indeterminate cytology. 18,19 CUT scoring system was evaluated separately in indeterminate thyroid nodules by the same team in 2019 and showed that CUT score could represent a valid aid for the clinician in the management of indeterminate nodules with follicu- International Journal of Hematology and Oncology lar proliferation. 15 The nodules in Btsd1 and Btsd3 categories with a CUT score of higher than 2.5 are suggested to be evaluated for surgery by Ianny, et al. 14 In our study, the recommendation of management of the CUT scoring system for TNs was compared with the histopathological results. ...
Various scoring systems in order to predict the malignancy risk in thyroid nodules (TNs) have been developed. CUT is one of the novel scoring systems. In this study, we aimed to evaluate its performance in predicting the malignancy risk in TNs and validity in the presence of Hashimoto's thyroiditis (HT). We retrospectively evaluated a total of 252 TNs with a fine needle aspiration biopsy. The CUT scores (Clinical, Ultrasonographic, and Thyroid Cytological scoring system) of the nodules were compared with ATA, ACR-TIRADS and KWAK-TIRADS scores and the histopathology of the nodules. Patients with HT were also compared with m-TIRADS classification. The CUT scores of nodules with malignant histopathology were significantly higher than the benign nodules (3.59 vs. 4.63, p< 0.001). The area values under the ROC curve of ACR-TIRADS, KWAK-TIRADS, ATA and CUT scoring systems were similar and significantly higher than the reference line [ACR-TIRADS, AUC was 0.762 (95% CI: 0.702-0.822, p< 0.001); KWAK-TIRADS, AUC was 0.759 (95% CI: 0.699-0.819, p< 0.001); CUT score, AUC was 0.759 (95% CI: 0.700-0.819, p< 0.001); ATA, AUC was 0.748 (95% CI: 0.687-0.810, p< 0.001)]. The areas under the ROC curve were similar when the efficiency of the CUT score was compared with m-TIRADS [CUT score, AUC was 0.772 (95% CI: 0.669-0.876, p< 0.001); m-TIRADS, AUC was 0.770 (95% CI: 0.667-0.874; p< 0.001)] in patients with HT. Our study showed that CUT scoring system was as effective as other scoring systems in predicting the risk of malignancy in thyroid nodules. Furthermore, CUT score is also effective in the presence of HT.
... It is important to remember, however, that each thyroid nodule carries an independent risk of cancer development [45]. That is why US evaluation may indicate the need to complement the assessment with a cytological analysis [46]. ...
Ultrasonography (US) is an important diagnostic tool in evaluating thyroid diseases in pediatric patients. This pictorial essay reviews the application of various ultrasound techniques such as B-Mode ultrasound and color Doppler, elastography and contrast enhanced ultrasound (CEUS) in children and adolescents in various thyroid pathologies including congenital thyroid abnormalities, diffuse thyroid diseases (DTD), focal thyroid lesions and thyroid malignancy.
... Additionally, the vascular distribution of thyroid nodules is a very complex issue. In the literature it is common to find reports of malignant nodules "poor on the number of veins" as well as "hypervascularized benign nodules" [37][38][39]. Khadra et al. [40] mentioned that several reports have proposed that increased vascular flow may be associated with malignancy in thyroid nodules and at the same time others have described no correlation between the presence of vascular flow and risk of malignancy. They performed a metaanalysis of the literature until 2016 in order to determine whether the vascularity of a thyroid nodule can aid or not in the prediction of malignancy. ...
... The fat tissue layer varies among individuals. Fat thickness is associated with the Body Mass Index (BMI) and can be measured by Ultrasound (US) examinations [37,38]. Three sizes of nodules, with the diameters shown in Figure 4 and four fat layers of thickness (0, 0.3, 0.6, and 1.2 cm) were considered (as shown in Figure 5). ...
According to experts and medical literature, healthy thyroids and thyroids containing benign nodules tend to be less inflamed and less active than those with malignant nodules. It seems to be a consensus that malignant nodules have more blood veins and more blood circulation. This may be related to the maintenance of the nodule’s heat at a higher level compared with neighboring tissues. If the internal heat modifies the skin radiation, then it could be detected by infrared sensors. The goal of this work is the investigation of the factors that allow this detection, and the possible relation with any pattern referent to nodule malignancy. We aim to consider a wide range of factors, so a great number of numerical simulations of the heat transfer in the region under analysis, based on the Finite Element method, are performed to study the influence of each nodule and patient characteristics on the infrared sensor acquisition. To do so, the protocol for infrared thyroid examination used in our university’s hospital is simulated in the numerical study. This protocol presents two phases. In the first one, the body under observation is in steady state. In the second one, it is submitted to thermal stress (transient state). Both are simulated in order to verify if it is possible (by infrared sensors) to identify different behavior referent to malignant nodules. Moreover, when the simulation indicates possible important aspects, patients with and without similar characteristics are examined to confirm such influences. The results show that the tissues between skin and thyroid, as well as the nodule size, have an influence on superficial temperatures. Other thermal parameters of thyroid nodules show little influence on surface infrared emissions, for instance, those related to the vascularization of the nodule. All details of the physical parameters used in the simulations, characteristics of the real nodules and thermal examinations are publicly available, allowing these simulations to be compared with other types of heat transfer solutions and infrared examination protocols. Among the main contributions of this work, we highlight the simulation of the possible range of parameters, and definition of the simulation approach for mapping the used infrared protocol, promoting the investigation of a possible relation between the heat transfer process and the data obtained by infrared acquisitions.
... Additionally, the vascular distribution of thyroid 58 nodules is a very complex issue. In the literature is common to find reports of 59 malignant nodules "poor on the number of veins" as well as "hypervascularized benign 60 nodules" [35,36]. Patients with thyroid nodules have different body constitutions, 61 summarized by the relationship between body mass (weight) and height. ...
... The fat tissue layer varies among 184 individuals. Fat thickness is associated with the body mass index (BMI) and can be 185 measured by ultrasound (US) examinations [35,36]. Three sizes of nodules as shown in 186 Fig. 2 and four fat layer thickness (0, 0.3, 0.6, and 1.2 cm) were considered (as shown in 187 Fig. 3). ...
According to experts and medical literature, a healthy thyroid gland, or a thyroid containing benign nodules, tend to be less inflamed and less active than one with malignant nodules. It seems to be a consensus that malignant nodules have more blood veins and it may be related to the maintenance of high and constant temperatures. Investigation of these characteristics, detectable by infrared sensors, and answering if they constitute patterns of malignancy are the aims of this work. Experiments considering biological heat transfer analysis by Finite Element numerical simulations are used to show the influence of nodule and patient characteristics on the identification of malignancy of thyroid nodule by thermography. The used and approved protocol for infrared examination are analyzed and simulated during all its phase that is on transient and steady state behavior, in order to verify how and when their influence can be really recognized in patients. Simulation results and the analysis of infrared exams show that the tissues between the skin and the thyroid, as well as the nodule size, have influence in superficial temperatures. Other thermal parameters of thyroid nodules are also investigated and show little influence on surface temperatures. These characteristics must be considered in nodular infrared analysis and diagnosis by thermography. The infrared examinations of patients that meet the hypotheses related to the vascularization of the nodule confirm the numerical results. All details of the physical parameters used in the simulations, characteristics of the nodules, and their complete thermal examinations are public and available, turning possible that the presented simulation could be compared with other types of heat transfer solutions. This study is a concrete contribution to the answer of under what conditions thermography can be useful in the identification of thyroid nodules.
Author summary
Thyroid nodules are very common health problems. These nodules may have different characteristics, and some of them could influence the temperature of the region. Many works in the medical literature report that the healthy thyroid and even benign nodules tend to be less inflamed and active than malignant nodules and therefore should exhibit some variation in patterns of behavior related to the temperature variation between them. The focus of this work is to analyze some parameters of the nodules and details of the patients that can influence the identification and diagnosis of thyroid nodules by infrared images. To reach the objective, simulations of bioheat transfer in the neck (using a simple neck geometry and Finite Elements Analysis in COMSOL Multiphysics Software) and real infrared examinations (performed with a FLIR Infrared Camera model SC620 and a proposed protocol) were analyzed. Our results show the thermal insulation effect of the neck fat tissue, and that the effect of nodule sizes can be decremented by a thicker layer of fat. The analysis of the nodule parameters as blood perfusion rate and metabolic heat, which could be related with the nodule vascularization (an important condition related with malignancy), suggest that the thermal effects of thyroid nodules on the neck surface are not sufficient to differentiate benign from malign, and for this other features or methods must be considered.
... The most important aspect of this disease, for both, patients and their health care providers, is to determine its nature, allowing for timely and appropriate management. Currently, FNAC is the gold standard for triage [27]. ...
Purpose:
To assess the reliability of a simple, accessible, cost-effective rule-out tool, for use in triaging patients with Bethesda IV nodules to appropriate surgery.
Methods:
The diagnostic tool was assembled by combining the negativity for suspicious ultrasound features (irregular margins, microcalcification, and a taller-than-wide orientation), and mutational marker negativity (BRAF and NRAS). The tool, (US-/mutation-), was tested on 167 patients with solitary Bethesda IV nodules. The primary outcome was its negative predictive value (NPV) for lesions requiring total thyroidectomy (TT). The impact of mutational marker negativity, as part of the tool, was evaluated by comparing the NPV of (US-/mutation-) to that of (US-/mutation+).
Results:
10 out of 167 lesions were positive for a mutational marker. These underwent TT, and only 2/10 (20%) were benign, on final histology. In 6/8 malignant lesions, TT was concordant with current clinical guidelines. 157 patients comprised the negative study cohort, for both mutational markers and suspicious US features. These underwent thyroid lobectomy, and 17 cases resulted in malignancy, only 8 of which required completion thyroidectomy. Accordingly, the NPV of (US-/mutation-) for malignancy was 89% (140/157), and 95% (149/157) for malignancy requiring TT. However, the NPV of (US-/mutation+) was 20% for malignancy, and 40% for malignancy requiring TT. These differences were statistically significant (89% vs. 20%; p < 0.0001, and 95% vs. 40%; p < 0.0001).
Conclusion:
US-/mutation- is a reliable rule-out tool, with sufficient diagnostic accuracy to spare patients, with Bethesda IV nodules, an overly radical TT.
... Malignant nodules are detected in 3 to 28% of excised nodules by ultrasonography (standard, Doppler, elastography), by evaluation with the TIRADS system, by thermography, Fine Needle Aspiration Biopsy (FNB), by the BETHESDA criteria, and by molecular examination [8][9][10][11][12][13][14]. ...
... Although previous attempts have been made to create a scoring system that integrates risk factors associated with thyroid cancer [7][8][9][10][11][12][13][14][15][16][17][18][19], none of them was based on the evidence of a comprehensive meta-analysis of published studies on the clinical and US features of TN that are associated with higher MR. ...
... Considering the need to combine several features in attributing a MR to a TN [3], several authors have formulated scoring systems or nomograms (mostly based on US pattern/features) aiming to reach a good accuracy in predicting the risk of a TN to be malignant [7][8][9][10][11][12][13][14][15][16][17][18][19]. For this purpose, some authors have proposed a score based on US features alone [7][8][9][10][11][12][13], while others have combined US features with cytology [14,15]. ...
... Considering the need to combine several features in attributing a MR to a TN [3], several authors have formulated scoring systems or nomograms (mostly based on US pattern/features) aiming to reach a good accuracy in predicting the risk of a TN to be malignant [7][8][9][10][11][12][13][14][15][16][17][18][19]. For this purpose, some authors have proposed a score based on US features alone [7][8][9][10][11][12][13], while others have combined US features with cytology [14,15]. Focused on the US pattern of the TN, separate teams [10][11][12][13] suggested thyroid imaging reporting and data system (TI-RADS), a risk stratification of the TN based on defined US pattern categories bearing different MR, devised from the breast imaging reporting and data system (BI-RADS). ...
The purpose of this study is to develop a new cancer risk score for preoperative assessment of thyroid nodules (TN) trying to reduce unnecessary thyroidectomies. On the basis of a recent meta-analysis of published literature, we assigned a matching value to the clinical (C) and ultrasonographic (U) features of TN with increased malignancy risk (MR). The created "CUT" score derived from "C+U" score, (CU[1-10] ), along with the five-tiered "T" (T[1-5] ), represents the cytologic result of the fine-needle aspiration. The C+U score was prospectively applied to 683 consecutive patients with 705 TN and validated through a ROC curve analysis. The CUT score was correlated with the histopathological diagnoses of 110 surgically resected TN. Fifty-five histologically benign TN had a mean C+U score of 2.4 versus 5.7 of 55 malignant TN (p < 0.001). Three categories were identified: low risk for C+U score ≤2.5 (MR: 9 %), intermediate risk for C+U score ≥2.75 and ≤5 (MR: 38 %), and high risk for C+U score ≥5.25 (MR: 95 %). Sensitivity and specificity were, respectively, 95 and 60 % for a cut-off value >2.5, and 69 and 96 % for >5. The "CUT" score can be easily applied, aiding clinicians in the evaluation of TN, especially in cases with indeterminate or repeated non-diagnostic FNA.
... Also, there was significant inverse correlation between geriatric index of comorbidity and free T4. DISCUSSION Elderly individuals often have thyroid disorders which pass unnoticed [20] , especially in associations with other diseases. In the elderly, thyroid disorders may manifest with different misleading clinical features. ...
Background: the study was undertaken with an objective to study the spectrum of thyroid dysfunction in elderly and to correlate comorbidity with abnormal thyroid function. Methods: a total of 246 subjects aged more than 60 years, admitted to General Medicine or attended the outpatient clinic who were presented with vague symptoms like easy fatigability and lethargy, were subjected to detailed clinical examination and thyroid function testing by biochemical means. Results: a total of 246 patients were included in the study. Thyroid disorders were present in 51.2%. Clinical hypothyroidism in 8.13%, subclinical hypothyroidism in 4.88% cases, hyperthyroidism in 3.3% and Low tri-iodothyronine (T3) syndrome in about one third of our patients were noted. There were no correlation between the thyroid hormones and most of clinical and laboratory parametes. The prevalence of abnormal thyroid patterns were significantly high in patients with comorbidities in comparison to those without. Conclusions: Elderly patients especially those with comorbidity have high prevalence of thyroid dysfunction. Clinical diagnosis is difficult to make because of vague symptomology and comorbid diseases. So, high clinical suspicion and thyroid function tests always helps in diagnosing the disease.
... Routine assessment of the thyroid with ultrasonography (in association with the analysis of the vascularization with color Doppler) had a great impact in endocrinology practice [47]. This methodology is widely disseminated due to the greater availability of high-resolution equipment, relatively affordable devices, little or no discomfort for the patient, and the absence of ionizing radiation. ...
... Also, experts disagree on the role of ultrasound to identify malignant features in thyroid nodules. In our view, the use of already established criteria such as the absence of a halo, undefined borders, presence of microcalcifications, marked hypoechogenicity, and central vascular flow at Doppler evaluation may indicate the need to complement the assessment with a cytological analysis [47]. Reported mean specificities for predicting malignancy are 67 % for marked hypoechogenicity, 70 % for microcalcifications (small, intranodular, punctate, hyperechoic spots with scanty or no posterior acoustic shadowing), 70 % for irregular or microlobulated margins, and about 80 % for chaotic arrangement or intranodular vascular images [48,49]. ...
Goiter, an enlargement of the thyroid gland, is a common problem in clinical practice associated with iodine deficiency, increase in serum thyroid-stimulating hormone (TSH) level, natural goitrogens, smoking, and lack of selenium and iron. Evidence suggests that heredity also has an important role in the etiology of goiter. The current classification divides goiter into diffuse and nodular, which may be further subdivided into toxic (associated with symptoms of hyperthyroidism, suppressed TSH or both), or nontoxic (associated with a normal TSH level). Nodular thyroid disease with the presence of single or multiple nodules requires evaluation due to the risk of malignancy, toxicity, and local compressive symptoms. Measurement of TSH, accurate imaging with high-resolution ultrasonography or computed tomography, and fine-needle aspiration biopsy are the appropriate methods for evaluation and management of goiter. This review discusses the clinical presentation, diagnostic evaluation, and treatment considerations of nontoxic diffuse and nodular goiters.
