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A nomogram based on multimodal ultrasound and clinical features for the prediction of central lymph node metastasis in unifocal papillary thyroid carcinoma
Abstract
Objectives
To build a predictive model for central lymph node metastasis (CLNM) in unifocal papillary thyroid carcinoma (UPTC) using a combination of clinical features and multimodal ultrasound (MUS).
Methods
This retrospective study, included 390 UPTC patients who underwent MUS between January 2017 and October 2022 and were divided into a training cohort (n = 300) and a validation cohort (n = 90) based on a cut-off date of June 2022. Independent indicators for constructing the predictive nomogram models were identified using multivariate regression analysis. The diagnostic yield of the 3 predictive models was also assessed using the area under the receiver operating characteristic curve (AUC).
Results
Both clinical factors (age, diameter) and MUS findings (microcalcification, virtual touch imaging score, maximal value of virtual touch tissue imaging and quantification) were significantly associated with the presence of CLNM in the training cohort (all P < .05). A predictive model (MUS + Clin), incorporating both clinical and MUS characteristics, demonstrated favourable diagnostic accuracy in both the training cohort (AUC = 0.80) and the validation cohort (AUC = 0.77). The MUS + Clin model exhibited superior predictive performance in terms of AUCs over the other models (training cohort 0.80 vs 0.72, validation cohort 0.77 vs 0.65, P < .01). In the validation cohort, the MUS + Clin model exhibited higher sensitivity compared to the CLNM model for ultrasound diagnosis (81.2% vs 21.6%, P < .001), while maintaining comparable specificity to the Clin model alone (62.3% vs 47.2%, P = .06). The MUS + Clin model demonstrated good calibration and clinical utility across both cohorts.
Conclusion
Our nomogram combining non-invasive features, including MUS and clinical characteristics, could be a reliable preoperative tool to predict CLNM treatment of UPTC.
Advances in knowledge
Our study established a nomogram based on MUS and clinical features for predicting CLNM in UPTC, facilitating informed preoperative clinical management and diagnosis.
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Objective
Preoperative evaluation of cervical lymph node metastasis (LNM) in papillary thyroid carcinoma (PTC) has been one of the serious clinical challenges. The present study aims at understanding the relationship between preoperative serum thyroglobulin (PS-Tg) and LNM and intends to establish nomogram models to predict cervical LNM.
Methods
The data of 1,324 PTC patients were retrospectively collected and randomly divided into training cohort (n = 993) and validation cohort (n = 331). Univariate and multivariate logistic regression analyses were performed to determine the risk factors of central lymph node metastasis (CLNM) and lateral lymph node metastasis (LLNM). The nomogram models were constructed and further evaluated by 1,000 resampling bootstrap analyses. The receiver operating characteristic curve (ROC curve), calibration curve, and decision curve analysis (DCA) of the nomogram models were carried out for the training, validation, and external validation cohorts.
Results
Analyses revealed that age, male, maximum tumor size >1 cm, PS-Tg ≥31.650 ng/ml, extrathyroidal extension (ETE), and multifocality were the significant risk factors for CLNM in PTC patients. Similarly, such factors as maximum tumor size >1 cm, PS-Tg ≥30.175 ng/ml, CLNM positive, ETE, and multifocality were significantly related to LLNM. Two nomogram models predicting the risk of CLNM and LLNM were established with a favorable C-index of 0.801 and 0.911, respectively. Both nomogram models demonstrated good calibration and clinical benefits in the training and validation cohorts.
Conclusion
PS-Tg level is an independent risk factor for both CLNM and LLNM. The nomogram based on PS-Tg and other clinical characteristics are effective for predicting cervical LNM in PTC patients.
Objectives
To screen out the predictors of central cervical lymph node metastasis (CLNM) for papillary thyroid carcinoma (PTC) and establish a prediction model to guide the operation of PTC patients (cN0).
Methods
Data from 296 PTC patients (cN0) who underwent thyroid operation at the Second Affiliated Hospital of Chongqing Medical University were collected and retrospectively analyzed. They were divided into two groups in accordance with central CLNM or not. Their information, including ultrasound (US) features, BRAFV600E status, and other characteristics of the two groups, was analyzed and compared using univariate and multivariate logistic regression analyses, and the independent predictors were selected to construct a nomogram. The calibration plot, C-index, and decision curve analysis were used to assess the prediction model’s calibration, discrimination, and clinical usefulness.
Results
A total of 37.8% (112/296) of PTC patients had central CLNM, and 62.2% (184/296) did not. The two groups were compared using a univariate logistic regression analysis, and there were no significant differences between the two groups in sex, aspect ratio, boundary, morphology, hypoechoic nodule, thyroid peroxidase antibody, or tumor location (P>0.05), and there were significant differences between age, tumor size, capsule contact, microcalcifications, blood flow signal, thyroglobulin antibodies (TgAb), and BRAF gene status (P<0.05). A multivariate logistic regression analysis was performed to further clarify the correlation of these indices. However, only tumor size (OR=2.814, 95% Cl=1.634~4.848, P<0.001), microcalcifications (OR=2.839, 95% Cl=1,684~4.787, P<0.001) and TgAb (OR=1.964, 95% Cl=1.039~3,711, P=0.038) were independent predictors of central CLNM and were incorporated and used to construct the prediction nomogram. The model had good discrimination with a C-index of 0.715. An ROC curve analysis was performed to evaluate the accuracy of this model. The decision curve analysis showed that the model was clinically useful when intervention was decided in the threshold range of 16% to 80%.
Conclusion
In conclusion, three independent predictors of central CLNM, including tumor size (> 1.0 cm), US features (microcalcifications), and TgAb (positive), were screened out. A visualized nomogram model was established based on the three predictors in this study, which could be used as a basis of central cervical lymph node dissection (CLND) for PTC patients (cN0).
Background
Given the difficulty of accurately determining the central lymph node metastasis (CLNM) status of patients with clinically node-negative (cN0) papillary thyroid carcinoma (PTC) before surgery, this study aims to combine real-time elastography (RTE) and conventional ultrasound (US) features with clinical features. The information is combined to construct and verify the nomogram to foresee the risk of CLNM in patients with cN0 PTC and to develop a network-based nomogram.
Methods
From January 2018 to February 2020, 1,157 consecutive cases of cN0 PTC after thyroidectomy and central compartment neck dissection were retrospectively analyzed. The patients were indiscriminately allocated (2:1) to a training cohort (771 patients) and validation cohort (386 patients). Multivariate logistic regression analysis of US characteristics and clinical information in the training cohort was performed to screen for CLNM risk predictors. RTE data were included to construct prediction model 1 but were excluded when constructing model 2. DeLong’s test was used to select a forecast model with better receiver operator characteristic curve performance to establish a web-based nomogram. The clinical applicability, discrimination, and calibration of the preferable prediction model were assessed.
Results
Multivariate regression analysis showed that age, sex, tumor size, bilateral tumors, the number of tumor contacting surfaces, chronic lymphocytic thyroiditis, and RTE were risk predictors of CLNM in cN0 PTC patients, which constituted prediction model 1. Model 2 included the first six risk predictors. Comparison of the areas under the curves of the two models showed that model 1 had better prediction performance (training set 0.798 vs. 0.733, validation set 0.792 vs. 0.715, p < 0.001) and good discrimination and calibration. RTE contributed significantly to the performance of the prediction model. Decision curve analysis showed that patients could obtain good net benefits with the application of model 1.
Conclusion
A noninvasive web-based nomogram combining US characteristics and clinical risk factors was developed in the research. RTE could improve the prediction accuracy of the model. The dynamic nomogram has good performance in predicting the probability of CLNM in cN0 PTC patients.
Background
The status of lymph nodes in the central compartment is crucial to determining the surgical strategies for papillary thyroid carcinoma (PTC). We aimed to develop a nomogram for predicting central lymph node metastasis (CLNM).
Methods
A total of 886 PTC patients who underwent total thyroidectomy or lobectomy with central neck dissection (CND) from July 2019 to June 2020 were retrospectively retrieved. Clinical and ultrasound features were collected. Univariate and multivariate analysis were performed to determine risk factors of CLNM. A nomogram for predicting CLNM was developed, internal and external calibration was performed for the established model.
Results
Variables (sex, chronic lymphocytic thyroiditis, tumor size, the number of foci, tumor location, margin) significantly associated with CLNM were included in the nomogram. The nomogram showed excellent calibration in the training group and validation group, with area under curves of 0.806 (95% CI, 0.771 to 0.825), and 0.799 (95% CI, 0.778–0.813) respectively.
Conclusion
Through this accurate and easy-to-use nomogram, the possibility of CLNM can be objectively quantified preoperatively. Clinicians can use this nomogram to evaluate the status of lymph nodes in PTC patients and consider prophylactic CND for those with high scores.
Objective
Accurate preoperative identification of cervical lymph node metastasis (CLNM) is essential for clinical management and established of different surgical protocol for patients with papillary thyroid microcarcinoma (PTMC). Herein, we aimed to develop an ultrasound (US) features and clinical characteristics-based nomogram for preoperative diagnosis of CLNM for PTMC.
Method
Our study included 552 patients who were pathologically diagnosed with PTMC between January 2015 and June 2019. All patients underwent total thyroidectomy or lobectomy and divided into two groups: CLNM and non-CLNM. Univariate and multivariate analysis were performed to examine risk factors associated with CLNM. A nomogram comprising the prognostic model to predict the CLNM was established, and internal validation in the cohort was performed.
Results
CLNM and non-CLNM were observed in 216(39.1%) and 336(60.9%) cases, respectively. Seven variables of clinical and US features as potential predictors including male sex (odd ratio [OR] = 1.974, 95% confidence interval [CI], 1.243-2.774; P =0.004), age < 45 years (OR = 4.621, 95% CI, 2.160-9.347; P < 0.001), US-reported CLN status (OR = 1.894, 95% CI, 0.754-3.347; P =0.005), multifocality (OR = 1.793, 95% CI, 0.774-2.649; P =0.007), tumor size ≥ 0.6cm (OR = 1.731, 95% CI,0.793-3.852; P =0.018), ETE (OR = 3.772, 95% CI, 1.752-8.441;P< 0.001) and microcalcification (OR = 2.316, 95% CI, 1.099-4.964; P < 0.001) were taken into account. The predictive nomogram was established by involving all the factors above used for preoperative prediction of CLNM in patients with PTCM. The nomogram model showed an AUC of 0.839 and an accuracy of 77.9% in predicting CLNM. Furthermore, the calibration curve demonstrated a strong consistency between nomogram and clinical findings in prediction CLNM for PTMC.
Conclusions
The nomogram achieved promising results for predicting preoperative CLNM in PTMC by combining clinical and US risk factor. Our proposed prediction model is able to help determine an individual’s risk of CLNM in PTMC, thus facilitate reasonable therapy decision making.
This article provides an update on the global cancer burden using the GLOBOCAN 2020 estimates of cancer incidence and mortality produced by the International Agency for Research on Cancer. Worldwide, an estimated 19.3 million new cancer cases (18.1 million excluding nonmelanoma skin cancer) and almost 10.0 million cancer deaths (9.9 million excluding nonmelanoma skin cancer) occurred in 2020. Female breast cancer has surpassed lung cancer as the most commonly diagnosed cancer, with an estimated 2.3 million new cases (11.7%), followed by lung (11.4%), colorectal (10.0 %), prostate (7.3%), and stomach (5.6%) cancers. Lung cancer remained the leading cause of cancer death, with an estimated 1.8 million deaths (18%), followed by colorectal (9.4%), liver (8.3%), stomach (7.7%), and female breast (6.9%) cancers. Overall incidence was from 2‐fold to 3‐fold higher in transitioned versus transitioning countries for both sexes, whereas mortality varied <2‐fold for men and little for women. Death rates for female breast and cervical cancers, however, were considerably higher in transitioning versus transitioned countries (15.0 vs 12.8 per 100,000 and 12.4 vs 5.2 per 100,000, respectively). The global cancer burden is expected to be 28.4 million cases in 2040, a 47% rise from 2020, with a larger increase in transitioning (64% to 95%) versus transitioned (32% to 56%) countries due to demographic changes, although this may be further exacerbated by increasing risk factors associated with globalization and a growing economy. Efforts to build a sustainable infrastructure for the dissemination of cancer prevention measures and provision of cancer care in transitioning countries is critical for global cancer control.
Background:
Accurate preoperative prediction of cervical lymph node (LN) metastasis in patients with papillary thyroid carcinoma (PTC) provides a basis for surgical decision-making and the extent of tumor resection. This study aimed to develop and validate an ultrasound radiomics nomogram for the preoperative assessment of LN status.
Methods:
Data from 147 PTC patients at the Wuhan Tongji Hospital and 90 cases at the Hunan Provincial Tumor Hospital between January 2017 and September 2019 were included in our study. They were grouped as the training and external validation set. Radiomics features were extracted from shear-wave elastography (SWE) images and corresponding B-mode ultrasound (BMUS) images. Then, the minimum redundancy maximum relevance algorithm and the least absolute shrinkage and selection operator regression were used to select LN status-related features and construct the SWE and BMUS radiomics score (Rad-score). Multivariate logistic regression was performed using the two radiomics scores together with clinical data, and a nomogram was subsequently developed. The performance of the nomogram was assessed with respect to discrimination, calibration, and clinical usefulness in the training and external validation set.
Results:
Both the SWE and BMUS Rad-scores were significantly higher in patients with cervical LN metastasis. Multivariate analysis indicated that the SWE Rad-scores, multifocality, and ultrasound (US)-reported LN status were independent risk factors associated with LN status. The radiomics nomogram, which incorporated the three variables, showed good calibration and discrimination in the training set (area under the receiver operator characteristic curve [AUC] 0.851 [CI 0.791-0.912]) and the validation set (AUC 0.832 [CI 0.749-0.916]). The significantly improved net reclassification improvement and index-integrated discrimination improvement demonstrated that SWE radiomics signature was a very useful marker to predict the LN metastasis in PTC. Decision curve analysis indicated that the SWE radiomics nomogram was clinically useful. Furthermore, the nomogram also showed favorable discriminatory efficacy in the US-reported LN-negative (cN0) subgroup (AUC 0.812 [CI 0.745-0.860]).
Conclusions:
The presented radiomics nomogram, which is based on the SWE radiomics signature, shows a favorable predictive value for LN staging in patients with PTC.
There are about half of papillary thyroid carcinoma (PTC) patients with the experience of central lymph node metastasis (CLNM), while the model to predict high-risk groups of CLNM from PTC patients is uncertain. The aim of this study was to evaluate candidate risk factors of CLNM and identify risk factors of recurrence to guide the postoperative therapeutic decision and follow-up for physicians and patients.A total of 4107 patients(4884 lesions) who underwent lymph node dissection in two hospitals from 2005 to 2014 were evaluated. CLNM risk was stratified and a risk-scoring model was developed on the basis of the identified independent risk factors for CLNM. Cox’s proportional hazards regression model was used to investigate the risk factors for recurrence.CLNM was proved in 37.96% (1559/4107) of patients and 33.96% (1659/4884) of lesions. In the multivariate analysis, Male, Age ≤35 years, Tumor size >0.5 cm,Lobe dissemination (+), Psammoma body (+), Multifocality and Capsule invasion (+) were independent risk predictors of CLNM (P < 0.01). A 14-point risk-scoring model was built to predict the stratified CLNM in PTC patients and the area under receiver operating characteristic curve of the model for the prediction of CLNM was 0.672 (95% CI: 0.656–0.688) (P < 0.01). COX regression model showed that Tumor size >0.5 cm, Lobe dissemination (+), Multifocality and CLNM were significant risk factors associated with poor outcomes. The research suggested that prophylactic CLN dissection could be performed in patients with total score ≥4 according to the risk-scoring model, and more aggressive treatment and more frequent follow-up should be considered for patients with Tumor size >0.5 cm, Lobe dissemination (+), Multifocality and CLNM.
Each year, the American Cancer Society estimates the numbers of new cancer cases and deaths that will occur in the United States and compiles the most recent data on population‐based cancer occurrence. Incidence data (through 2016) were collected by the Surveillance, Epidemiology, and End Results Program; the National Program of Cancer Registries; and the North American Association of Central Cancer Registries. Mortality data (through 2017) were collected by the National Center for Health Statistics. In 2020, 1,806,590 new cancer cases and 606,520 cancer deaths are projected to occur in the United States. The cancer death rate rose until 1991, then fell continuously through 2017, resulting in an overall decline of 29% that translates into an estimated 2.9 million fewer cancer deaths than would have occurred if peak rates had persisted. This progress is driven by long‐term declines in death rates for the 4 leading cancers (lung, colorectal, breast, prostate); however, over the past decade (2008‐2017), reductions slowed for female breast and colorectal cancers, and halted for prostate cancer. In contrast, declines accelerated for lung cancer, from 3% annually during 2008 through 2013 to 5% during 2013 through 2017 in men and from 2% to almost 4% in women, spurring the largest ever single‐year drop in overall cancer mortality of 2.2% from 2016 to 2017. Yet lung cancer still caused more deaths in 2017 than breast, prostate, colorectal, and brain cancers combined. Recent mortality declines were also dramatic for melanoma of the skin in the wake of US Food and Drug Administration approval of new therapies for metastatic disease, escalating to 7% annually during 2013 through 2017 from 1% during 2006 through 2010 in men and women aged 50 to 64 years and from 2% to 3% in those aged 20 to 49 years; annual declines of 5% to 6% in individuals aged 65 years and older are particularly striking because rates in this age group were increasing prior to 2013. It is also notable that long‐term rapid increases in liver cancer mortality have attenuated in women and stabilized in men. In summary, slowing momentum for some cancers amenable to early detection is juxtaposed with notable gains for other common cancers.
Purpose:
To evaluate the diagnostic accuracy of real-time neck computed tomography (CT)-guided ultrasonography (US) in detecting cervical neck lymph node metastasis (LNM) in patients with papillary thyroid cancer (PTC).
Methods:
We retrospectively reviewed data from 176 patients (mean age, 43 years; range, 23 to 74 years) with surgically confirmed PTC who underwent preoperative US, neck CT, and neck CTguided US. We then compared the sensitivities and diagnostic accuracies of each of the three above modalities in detecting cervical LNM.
Results:
Preoperative US showed 17.3% sensitivity and 58.5% diagnostic accuracy in detecting central LNM compared with 64.3% sensitivity and 89.2% diagnostic accuracy in detecting lateral neck LNM. Neck CT showed 23.5% sensitivity and 55.7% diagnostic accuracy in detecting central LNM and 71.4% sensitivity with 90.9% diagnostic accuracy in detecting lateral neck LNM. CT-guided US exhibited 37.0% sensitivity and 63.1% diagnostic accuracy in detecting central LNM compared with 92.9% sensitivity and 96.0% diagnostic accuracy in detecting lateral LNM. CT-guided US showed higher diagnostic accuracy with superior sensitivity in detecting central and lateral LNM than did US (P<0.001, P=0.011) and CT (P=0.026, P=0.063).
Conclusion:
Neck CT-guided US is a more accurate technique with higher sensitivity for detecting cervical LNM than either US or CT alone. Therefore, our data indicate that neck CT-guided US is an especially useful technique in preoperative examinations.
Papillary thyroid microcarcinoma (PTMC) has been increasing, without a consensus for the management of this condition. In the present study, we analyzed the clinicopathological features of patients with PTMC to examine the impact of initial therapy and establish appropriate treatment. A total of 2,018 patients with PTMC were enrolled at a single university hospital. Of them, 1,245 patients (61.8%) underwent total thyroidectomy, and 1,838 patients (91.3%) underwent central lymph node (LN) dissection. Five-and 10-yr recurrence rates were 3.2% and 4.6%, respectively. In univariate analysis, the prognostic factors for recurrence were N stage, the number of LN metastases, and extrathyroidal extension. However, multivariate analysis revealed LN metastases and N stage as the only significant prognostic factors after adjusting for confounding factors (P < 0.001). Additionally, multivariate analysis of a subgroup consisting of PTMC patients without N1b revealed the number of central LN metastases as the only significant factor. Therefore, intraoperative examination for central LN metastasis may discriminate high or low risk group.
Background:
Central compartment lymph node metastases in papillary thyroid carcinoma (PTC) are difficult to detect preoperatively, and the role of routine or prophylactic central compartment lymph node dissection (CLND) in managing PTC remains controversial. The aim of this project was to create a nomogram able to predict the occurrence of central compartment lymph node metastasis using readily available preoperative clinical characteristics.
Methods:
Records from patients undergoing total thyroidectomy and lymph node dissection for PTC in the period 1968-2012 were analyzed. Nodal status was based on results of serial hematoxylin and eosin (H&E) examination. Age, sex, tumor size, tumor site, and multifocality were included in a multivariable logistic regression model to predict lymph node metastasis. A coefficient-based nomogram was developed and validated using an external patient cohort.
Results:
The study population included 914 patients (80% females) with an average central compartment nodal yield of eight per patient. Central compartment lymph node metastases were present in 390 patients (42.7%). The variables with the strongest predictive value were age (p<0.001), male sex (p<0.001), increasing tumor size (p<0.001), and tumor multifocality (p<0.05). The nomogram had good discrimination with a concordance index of 76.4% [95% confidence interval 73.3-79.4], supported by an external validation point estimate of 61.5% [95% confidence interval 49.5-73.6]. An online calculator and smartphone application were developed for point of care use.
Conclusions:
A validated nomogram utilizing readily available preoperative variables has been developed to give a predicted probability of central lymph node metastases in patients presenting with PTC. This nomogram may help guide surgical decision making in PTC.
Objective:
Virtual touch tissue quantification (VTQ) of acoustic radiation force impulse (ARFI) is a new quantitative technique to measure tissue stiffness. The study was aimed to assess the usefulness of VTQ in the diagnosis of thyroid nodules.
Methods:
173 pathologically proven thyroid nodules in 142 patients were included and all were examined by conventional ultrasound (US), conventional elasticity imaging (EI) and VTQ of ARFI. The tissue stiffness for VTQ was expressed as shear wave velocity (SWV) (m/s). Receiver-operating characteristic curve (ROC) analyses were performed to assess the diagnostic performance. Intra- and inter-observer reproducibility of VTQ measurement was assessed.
Results:
The SWVs of benign and malignant thyroid nodules were 2.34±1.17 m/s (range: 0.61-9.00 m/s) and 4.82±2.53 m/s (range: 2.32-9.00 m/s) respectively (P<0.001). The mean SWV ratios between each nodule and the adjacent thyroid tissue were 1.19±0.67 (range: 0.31-6.87) for benign and 2.50±1.54 (range: 0.85-6.69) for malignant nodules (P<0.001). ROC analyses indicated that the area under the curve was 0.861 (95% CI : 0.804, 0.918) (P<0.001) for SWV and 0.831(95% CI : 0.761, 0.900)(P<0.001) for the SWV ratio. The cutoff points for the differential diagnosis were 2.87 m/s for SWV and 1.59 for SWV ratio. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value for EI were 65.9%, 66.7%, 66.5%, 40.3%, and 85.1%, respectively, and were 63.6%-75%, 82.2%-88.4%, 80.3%-82.1%, 58.9%-65.1%, and 87.7%-90.5%, respectively, for VTQ. The diagnostic value of VTQ is the highest for nodules >20 mm and lowest for those ≤10 mm. The correlation coefficients were 0.904 for intraobserver measurement and 0.864 for interobserver measurement.
Conclusions:
VTQ of ARFI provides quantitative and reproducible information about the tissue stiffness, which is useful for the differentiation between benign and malignant thyroid nodules. The diagnostic performance of VTQ is higher than that of conventional EI.
The purpose of this study was to correlate the presence and patterns of distribution of B-flow imaging (BFI) twinkling signs within thyroid nodules with the histologic evidence of microcalcifications and the results of the sonographically guided fine-needle aspiration to establish their role in predicting the risk of malignancy.
Between September 2006 and December 2007, 343 consecutive patients with 479 suspected nodules (maximum diameter > 9 mm) were enrolled in this prospective study. Sonographic and BFI examinations were performed with a commercially available real-time sonography system, and all patients also underwent a cytologic evaluation. Written informed consent was obtained from all patients. Patients with suspicious or malignant cytologic features underwent surgery.
On histologic examination, 66 of 479 nodules were malignant (59 papillary thyroid carcinoma, 1 Hürthle cell carcinoma, and 6 follicular carcinoma). All sonographic characteristics, which were potential predictors of thyroid malignancy (microcalcifications, hypoechogenicity, absence of a halo, and a predominantly solid composition), were found in different percentages in both histologically verified malignant and benign nodules. For BFI, pattern 3 (> or = 4 signs and distance > 2 mm) was the most predictive factor for malignancy (specificity, 99.6%; sensitivity, 65.2%), whereas pattern 2 (> or = 4 signs and distance < 2 mm) was a positive factor because it was detected only in benign lesions, with a positive predictive of 0.
Our results indicate that BFI can overcome the limits of the traditional B-mode and color Doppler sonographic features in the diagnosis of thyroid nodules. This technique provides maximum specificity levels both in the case of benign nodules with pattern 2 and in the case of malignant nodules with pattern 3.
To evaluate the long-term outcomes and prognostic value of our sonographically based surgical approach to the lateral neck for recurrences in papillary thyroid cancer (PTC).
Retrospective medical chart review.
Tertiary cancer institution.
The study population comprised 331 consecutive patients primarily treated for papillary thyroid carcinoma (PTC) at a tertiary cancer institution between 1996 and 2003. The lateral neck compartments were surgically addressed only in the presence of abnormalities on ultrasonography (US).
Recurrence-free interval and overall, disease-specific, and recurrence-free survival.
There were 112 male and 219 female patients, with a median age of 44.7 years (range, 11-87 years). The median follow-up time for the series was 77.9 months (range, 12.7-148.7 months). Preoperative US abnormalities were found in the right neck in 13.3%, in the left neck in 12.3%, and bilaterally in 11.2%; all of these patients underwent a lateral neck dissection at the time of the thyroidectomy. There were 11 recurrences in the series (0.3%), with a median time to presentation of 22.8 months (range, 6.0-55.3 months). Predictors of lateral neck disease-free interval were T stage and distant disease at presentation (P = .01 and P < .001, respectively) and the sonographic status of the ipsilateral and central neck (P = .001 and P < .001). The number of abnormal neck compartments in US correlated with the risk of regional failure (P = .01). The presence of US abnormalities in the lateral neck decreased the 10-year disease-specific survival from 98.3% to 66.9% (P < .001).
Preoperative US is an excellent outcome predictor for lateral neck disease-free interval and for disease-specific survival in PTC. Sonographically based surgical approach provides excellent long-term regional control and validates current treatment guidelines.
Objective:
In the present study, we compared the results of conventional ultrasonography (US) and colour flow Doppler sonography (CFDS) with those of US guided fine needle aspiration biopsy (FNAB) and of pathologic staging of resected thyroid nodules, to assess the relative importance of US and CFDS in discriminating malignant thyroid nodules.
Subjects and study design:
We retrospectively reviewed records of 230 patients submitted to US-guided FNAB before surgery for solitary, not hot thyroid nodules. Before US guided FNAB, they were examined with conventional US and CFDS. Conventional US evaluated nodule size, echogenicity, presence of halo sign and microcalcifications. CFDS evaluated the vascular pattern classified as types I, II and III. Twenty-seven patients with inadequate cytology were excluded from this study (11.7%).
Results:
Two hundred and three patients underwent surgery. At histology a thyroid carcinoma was found in 36 patients (17.7%) and a benign nodule was observed in 167 patients (82.3%). We did not find any difference in cancer prevalence between nodules with a primary tumour size < or =1 cm and those >1 cm (17.6 vs. 17.7%; p = 0.99). A solid echo texture was not statistically significant to suggest malignancy (p = 0.32). Microcalcifications were seen in 83.3% (30/36) of malignant nodules and in 33.5% (56/167) of benign nodules. These results were statistically significant (p < 0.0001). The type III flow as determined by CFDS was a statistically significant criterion to suggest malignant disease (p < 0.005). The most predictive findings of malignancy on conventional US was the combination of microcalcifications plus the absence of halo sign (sensitivity 75%, specificity 71.9%, p < 0.0001). The combination of an absence of halo sign on conventional US and a type III pattern on CFDS presented the higher sensitivity (83.3%) for malignancy with a specificity of 43.7%. Microcalcifications on US in combination with a type III CFDS pattern showed a lesser sensitivity (80.6%) with an improved specificity (75.4%). In our opinion, the better balanced combination of US and CFDS features was the absence of halo sign plus microcalcifications and a type III CDFS pattern (sensitivity 72.2%, specificity 77.2%).
Conclusions:
The combination of conventional US and CFDS provides benefits in increasing the screening sensitivity and accuracy in distinguishing malignant thyroid nodules.
Objectives:
To establish a nomogram for predicting central lymph node metastasis (CLNM) based on the preoperative clinical and multimodal ultrasound (US) features of papillary thyroid carcinoma (PTC) and cervical LNs.
Methods:
Overall, 822 patients with PTC were included in this retrospective study. A thyroid tumor ultrasound model (TTUM) and thyroid tumor and cervical LN ultrasound model (TTCLNUM) were constructed as nomograms to predict the CLNM risk. Areas under the curve (AUCs) evaluated model performance. Calibration and decision curves were applied to assess the accuracy and clinical utility.
Results:
For the TTUM training and test sets, the AUCs were 0.786 and 0.789 and bias-corrected AUCs were 0.786 and 0.831, respectively. For the TTCLNUM training and test sets, the AUCs were 0.806 and 0.804 and bias-corrected AUCs were 0.807 and 0.827, respectively. Calibration and decision curves for the TTCLNUM nomogram exhibited higher accuracy and clinical practicability. The AUCs were 0.746 and 0.719 and specificities were 0.942 and 0.905 for the training and test sets, respectively, when the US tumor size was ≤ 8.45 mm, while the AUCs were 0.737 and 0.824 and sensitivity were 0.905 and 0.880, respectively, when the US tumor size was > 8.45 mm.
Conclusion:
The TTCLNUM nomogram exhibited better predictive performance, especially for the CLNM risk of different PTC tumor sizes. Thus, it serves as a useful clinical tool to supply valuable information for active surveillance and treatment decisions.
Key points:
• Our preoperative noninvasive and intuitive prediction method can improve the accuracy of central lymph node metastasis (CLNM) risk assessment and guide clinical treatment in line with current trends toward personalized treatments. • Preoperative clinical and multimodal ultrasound features of primary papillary thyroid carcinoma (PTC) tumors and cervical LNs were directly used to build an accurate and easy-to-use nomogram for predicting CLNM. • The thyroid tumor and cervical lymph node ultrasound model exhibited better performance for predicting the CLNM of different PTC tumor sizes. It may serve as a useful clinical tool to provide valuable information for active surveillance and treatment decisions.
Objective
To investigate the relationship between shear wave elastography (SWE) elasticity indices of papillary thyroid carcinoma (PTC) and central lymph node metastasis (CLNM) and to evaluate the value of SWE combined with gray-scale ultrasound (US) for predicting preoperative CLNM.
Method
This study included 172 patients with a pathology diagnosis of PTC who underwent preoperative gray-scale US and SWE evaluation. Patients were divided into CLNM-positive and CLNM-negative groups. We analyzed the association between SWE elasticity indices (Emax, Emean and Emin) and CLNM, compared the diagnostic efficacy of gray-scale US alone versus SWE combined with gray-scale US for predicting CLNM, and analyzed the influence of Hashimoto's thyroiditis (HT) on the diagnostic efficacy of CLNM.
Results
SWE elasticity values Emax, Emean and Emin were significantly higher in CLNM-positive patients (P=0.000, 0.000 and 0.003, respectively). The AUC of Emax was higher than that of other SWE indices for predicting CLNM (AUC = 0.749; 95% CI = 0.676–0.822). In multivariate analysis, microcalcification (OR = 5.254; 95% CI = 2.496–11.061), extrathyroidal extension (OR = 4.210; 95% CI = 1.423–12.456), multifocality (OR = 3.084; 95% CI = 1.190–7.991) and Emax >59.0 kpa (OR = 4.934; 95% CI = 2.318–10.500) were independent risk factors for predicting CLNM. The AUC of SWE combined with gray-scale US for predicting CLNM (AUC = 0.825; 95% CI = 0.760–0.879) was significantly higher (P = 0.011) than that for gray-scale US alone (AUC = 0.774; 95% CI = 0.704–0.834). There was no significant difference in AUC between the HT and non-HT subgroups in predicting CLNM (0.798 vs. 0.833, P = 0.640).
Conclusions
SWE can be used to predict CLNM in PTC patients. SWE combined with gray-scale US can improve the prediction of CLNM.
Objective
The incidence of papillary thyroid carcinoma (PTC) increases yearly. Central lymph node metastasis (CLNM) is common in PTC. Many studies have addressed ipsilateral CLNM; however, few studies have evaluated contralateral CLNM. The purpose of this study is to investigate the high-risk factors of lymph node metastasis in the contralateral central compartment of cT1 stage in PTC.
Methods
In total, 369 unilateral PTC (cT1N0) patients who underwent total-thyroidectomy with bilateral central lymph node dissection (CLND) between 2013 and 2016 in our hospital were retrospectively enrolled. Univariate and multivariate analyses identified the high-risk factors for contralateral CLNM of PTC.
Results
The total metastasis rate of the ipsilateral central neck compartment was 31.71% (117/369). The total metastasis rate of the contralateral central neck compartment was 8.13% (30/369). The multivariate analysis showed that multifocality (p = 0.009), ipsilateral CLNM (p＜0.001), number of ipsilateral CLNM ＞2 (p = 0.006), tumor located at the inferior pole (p = 0.032) and tumor diameter ＞ 1 cm (p = 0.029) were independent risk factors for contralateral CLNM at cT1 stage in PTC, with odds ratios (ORs) of,4.132 (95% confidence intervals (CI): 1.430–11.936) ，8.591 (95% CI: 3.200–23.061) ，0.174 (95% CI: 0.050–0.601) ，0.353 (95% CI: 0.136–0.917)and 0.235 (95% CI: 0.064–0863), respectively.
Conclusion
The combinational use of these risk factors will help surgeons devise an appropriate surgical plan preoperatively. This information could provide reference for the readers who are interested and help to determine the optimal extent of CLND in patients with PTC, especially for cT1b patients.
Background
There has been an ongoing debate concerning the predictors of contralateral paratracheal lymph nodes metastasis (LNM) in unilateral papillary thyroid cancer (PTC). This study aimed to explore the value of pretracheal–laryngeal lymph nodes (LNs) in frozen section in predicting contralateral paratracheal LNM.
Methods
A total of 242 patients with unilateral PTC were enrolled in this prospective study. Patients who underwent total thyroidectomy and bilateral central lymph nodes dissection (LND) were divided into two groups according to positive or negative contralateral paratracheal LNs. Patients’ demographics and clinicopathological features were compared between the two groups. Validity indexes and consistency of pretracheal–laryngeal LNs in frozen sections were calculated.
Results
LNM rates in central, ipsilateral paratracheal, pretracheal–laryngeal, and contralateral paratracheal regions were 55.37%, 47.03%, 23.55% and 14.05%, respectively. Only pretracheal–laryngeal LNM, regardless of whether detected in frozen or paraffin sections, were independent risk factors for contralateral paratracheal LNM (OR = 2.707; 95% CI 1.062–6.902; P = 0.037 in frozen section; OR = 3.072; 95% CI 1.248–7.560; P = 0.015 in paraffin section). The sensitivity, specificity, false-negative rate, false-positive rate, accuracy rate, and Kappa value of pretracheal–laryngeal LNM in frozen sections for predicting pretracheal–laryngeal LNM were 87.72%, 100%, 12.28%, 0%, 97.11% and 0.916 respectively, while those for predicting contralateral paratracheal LNM were 85,29%, 89.90%, 14.71%, 10.10%, 89.22%, and 0.618 respectively.
Conclusion
Pretracheal–laryngeal LNs in frozen section accurately predicted contralateral paratracheal LNM, which could allow the identification of patients who can benefit from an extended central LND.
Objectives
To develop a nomogram based on postoperative clinical and ultrasound findings to quantify the probability of central compartment lymph node metastases (CLNM).MethodsA total of 952 patients with histologically confirmed papillary thyroid carcinoma (PTC) were included in this retrospective study and assigned to three groups based on sex and age. The strongest predictors for CLNM were selected according to ultrasound imaging features, and an ultrasound (US) signature was constructed. By incorporating clinical characteristics, a predictive model presented as a nomogram was developed, and its performance was assessed with respect to calibration, discrimination and clinical usefulness.ResultsPredictors contained in the nomogram included US signature, US-reported LN status and age. The US signature was constructed with tumour size and microcalcification. The nomogram showed excellent calibration in the training dataset, with an AUC of 0.826 (95% CI, 0.765–0.887) for male patients, 0.818 (95% CI, 0.746–0.890) for young females and 0.808 (95% CI, 0.757–0.859) for elder females. For male and young female patients, application of the nomogram to the validation cohort revealed good discrimination, with AUCs of 0.813 (95% CI, 0.722–0.904) and 0.814 (95% CI, 0.712–0.915), respectively. Conversely, for elderly female patients, the nomogram failed to show good performance with an AUC of 0.742 (95% CI, 0.661–0.823).Conclusion
This ultrasound-based nomogram may serve as a useful clinical tool to provide valuable information for treatment decisions, especially for male and younger female patients.Key Points
• Age, gender, US-reported LN status and US signature were the strongest predictors of CLNM in PTC patients and informed the development of a predictive nomogram.
• Microcalcification was the strongest predictor in the US signature, as CLMN was identified in approximately 92% of patients characterised by diffuse microcalcification.
• Stratified by sex and age, this nomogram achieved good performance in predicting CLNM, especially in male and young female patients. This prediction tool may be useful as an imaging marker for identifying CLNM preoperatively in PTC patients and as a guide for personalised treatment.
Background:
To evaluate the association of preoperative clinical and sonographic features with central lymph node metastasis (CLNM) in patients with clinically node-negative (cN0) papillary thyroid carcinoma (PTC) without capsule invasion.
Methods:
Clinical and sonographic features of 635 cN0 PTC nodules without capsule invasion were retrospectively reviewed. CLNM was confirmed by pathology. Univariate and multivariate analyses were performed to analyze the predicting factors associated with CLNM in cN0 PTC without capsule invasion.
Results:
In the 635 cN0 PTC nodules without capsule invasion, age ≤36 years, male, tumor size >8 mm, the distance between the tumor and the capsule ≤1.1 mm and calcification were independently associated with CLNM (P < .05).
Conclusions:
CLNM was associated with age, sex, tumor size, the distance between the tumor and the capsule, and calcification in cN0 PTC without capsule invasion. Preoperative assessment of risk factors could help to select PTC patients who benefit from surgery.
Background:
Large-volume lymph node metastasis (LNM) is associated with poor clinical outcomes in papillary thyroid microcarcinoma (PTMC) patients. However, sensitivity in the detection of central neck LNM on preoperative neck ultrasonography (US) is believed to be low. The aim of this study is to investigate the preoperative clinical factors associated with large-volume LNM in clinical N0 PTMC patients.
Methods:
In all, 2329 clinical N0 PTMC patients who underwent total thyroidectomy with prophylactic central lymph node (LN) dissection were evaluated. The LNM status of these patients was divided into three groups by the number of metastatic nodes: no LNM, small-volume LNM (≤5 metastatic LNs), and large-volume LNM (>5 metastatic LNs). The correlations between age, sex, and other clinical factors and large-volume LNM were evaluated.
Results:
Large-volume LNM was found in 94 (4.0%) patients. Young (<40 years old) and male patients tended to have large-volume LNM (p for trend <0.001). Young age (odds ratio [OR] = 2.69 [confidence interval (CI) 1.64-4.32], p < 0.001) and male sex (OR = 5.79 [CI 3.67-9.10], p < 0.001) were independent risk factors for large-volume LNM in multivariate analyses. The prevalence of large-volume LNM ranged from 24% in male patients <40 years of age to only 2% in female patients aged ≥40 years. Multifocal tumors and presence of extrathyroidal extension were also considered risk factors for large-volume LNM.
Conclusions:
Large-volume LNM was more frequently found in young (<40 years) and male patients. These findings support the notion that surgery rather than observation may be favored in young and male clinically LN negative PTMC patients as a primary therapeutic option.
Purpose of review:
Thyroid cancer incidence and mortality trends have been identified as being consistent with overdiagnosis, and several recent efforts have been made to mitigate this problem.
Recent findings:
Major guidelines for thyroid nodule management recommend against general biopsy of nodules less than 1 cm in size. Data supporting the safety of active surveillance of low-risk thyroid cancers is now recognized. Tumors previously labeled as encapsulated follicular variant papillary thyroid cancers are now recommended to be called noninvasive follicular thyroid neoplasm with papillary-like nuclear features.
Summary:
Workup, diagnostic, and management of papillary thyroid cancer are changing rapidly to accommodate the recognition that many thyroid cancers are low risk and do not require aggressive, immediate intervention.
Thyroid nodules are a frequent finding on neck sonography. Most nodules are benign; therefore, many nodules are biopsied to identify the small number that are malignant or require surgery for a definitive diagnosis. Since 2009, many professional societies and investigators have proposed ultrasound-based risk stratification systems to identify nodules that warrant biopsy or sonographic follow-up. Because some of these systems were founded on the BI-RADS(?) classification that is widely used in breast imaging, their authors chose to apply the acronym TI-RADS, for Thyroid Imaging, Reporting and Data System. In 2012, the ACR convened committees to (1) provide recommendations for reporting incidental thyroid nodules, (2) develop a set of standard terms (lexicon) for ultrasound reporting, and (3) propose a TI-RADS on the basis of the lexicon. The committees published the results of the first two efforts in 2015. In this article, the authors present the ACR TI-RADS Committee's recommendations, which provide guidance regarding management of thyroid nodules on the basis of their ultrasound appearance. The authors also describe the committee's future directions.
Thyroid nodules are very common, and thyroid cancer is currently the fifth leading cancer diagnosis in women. The American Thyroid Association has led the development and revision of guidelines for the management of patients with thyroid nodules and differentiated thyroid cancer (DTC). The most current revision was published in the January 2016 issue of the journal Thyroid. The current guidelines have 101 recommendations, with 8 figures and 17 tables that are hopefully helpful to those treating patients with thyroid nodules and cancer. The primary goals of the American Thyroid Association Guidelines Task Force were to use the current evidence to guide recommendations and yet be as helpful and practical as possible within the scope and strength of the evidence. The current review focuses on new and significantly revised recommendations that may very well change clinical practice. The author notes 3 new basic principles that have emerged in this guidelines revision: 1) the management of thyroid nodules, including the decision to perform a fine-needle aspiration biopsy as well as follow-up decision making, will be heavily influenced by the newly developed sonographic risk pattern; 2) the long-term management of DTC along with thyroid-stimulating hormone target goals will be heavily influenced by the 4 categories of “response to therapy”; and 3) the management of patients with radioactive iodine-refractory DTC will be divided into 4 basic decision-making groups: patients who should undergo monitoring, patients who should undergo directed therapies, patients who should undergo systemic therapies, and patients who should be offered entry into clinical trials. Cancer 2016.
Background and objectives:
Central compartment neck dissection (CCND) is recommended for patients with papillary thyroid carcinoma (PTC). However, whether to perform contralateral CCND remains unclear. An individualized estimation of the contralateral central neck metastasis (CNM) risk would assist in the tailoring of treatment for PTC patients.
Methods:
Consecutive patients who underwent bilateral CCND for unilateral PTC between 2012 and 2014 in a tertiary center were identified. The clinicopathological data of 142 patients were analyzed retrospectively. The variables that had clinical significance in the final multivariate logistic regression model were built into a nomogram to assess the risk of metastasis of the contralateral central compartment. This model was internally validated using bootstrap resampling.
Results:
This nomogram demonstrated good calibration and discrimination, with a concordance index of 0.834 (bootstrap corrected, 0.824). The variables with the greatest influence on the risk of contralateral CNM in this model included tumor size, the number of positive lymph nodes, and extranodal extension in the ipsilateral central neck.
Conclusions:
This nomogram integrates three variables to estimate an individualized risk of contralateral CNM in unilateral PTC patients. This model may assist in individual decision-making regarding contralateral CCND and help avoid the over- and under-treatment of PTC. J. Surg. Oncol. © 2016 Wiley Periodicals, Inc.
Objectives:
To evaluate the diagnostic performance of a new method of combined two-dimensional shear wave elastography (i.e. virtual touch imaging quantification, VTIQ) and ultrasound (US) Breast Imaging Reporting and Data System (BI-RADS) in the differential diagnosis of breast lesions.
Materials and methods:
From September 2014 to December 2014, 276 patients with 296 pathologically proven breast lesions were enrolled in this study. The conventional US images were interpreted by two independent readers. The diagnosis performances of BI-RADS and combined BI-RADS and VTIQ were evaluated, including the area under the receiver operating characteristic curve (AUROC), sensitivity and specificity. Observer consistency was also evaluated.
Results:
Pathologically, 212 breast lesions were benign and 84 were malignant. Compared with BI-RADS alone, the AUROCs and specificities of the combined method for both readers increased significantly (AUROC: 0.862 vs. 0.693 in reader 1, 0.861 vs. 0.730 in reader 2; specificity: 91.5 % vs. 38.7 % in reader 1, 94.8 % vs. 47.2 % in reader 2; all P < .05). The Kappa value between the two readers for BI-RADS assessment was 0.614, and 0.796 for the combined method.
Conclusion:
The combined VTIQ and BI-RADS had a better diagnostic performance in the diagnosis of breast lesions in comparison with BI-RADS alone.
Key points:
• Combination of conventional ultrasound and elastography distinguishes breast cancers more effectively. • Combination of conventional ultrasound and elastography increases observer consistency. • BI-RADS weights more than the 2D-SWE with an increase in malignancy probability.
Objectives:
To investigate the value of combined conventional ultrasound (US), strain elastography (SE) and acoustic radiation force impulse (ARFI) elastography for prediction of cervical lymph node metastasis (CLNM) in papillary thyroid cancer (PTC).
Methods:
A consecutive series of 203 patients with 222 PTCs were preoperatively evaluated by US, SE, and ARFI including virtual touch tissue imaging (VTI) and virtual touch tissue quantification (VTQ). A multivariate analysis was performed to predict CLNM by 22 independent variables. Receiver operating characteristic (ROC) curve analysis was used to evaluate the diagnostic performance.
Results:
Multivariate analysis demonstrated that VTI area ratio (VAR) > 1 was the best predictor for CLNM, followed by abnormal cervical lymph node (ACLN), capsule contact, microcalcification, capsule involvement, and multiple nodules (all P < 0.05). ROC analyses of these characteristics showed the areas under the curve (Az), sensitivity, and specificity were 0.600-0.630, 47.7 %-93.2 %, and 26.9 %-78.4 % for US, respectively; and they were 0.784, 83.0 %, and 73.9 %, respectively, for VAR > 1. As combination of US characteristics with and without VAR, the Az, sensitivity, and specificity were 0.803 and 0.556, 83.0 % and 100.0 %, and 77.6 % and 11.2 %, respectively (P < 0.001).
Conclusions:
ARFI elastography shows superior performance over conventional US, particularly when combined with US, in predicting CLNM in PTC patients.
Key points:
• Conventional ultrasound is useful in predicting cervical lymph node metastasis preoperatively. • Virtual touch tissue imaging area ratio is the strongest predicting factor. • Predictive performance is markedly improved by combining ultrasound characteristics with VAR. • Acoustic radiation force impulse elastography may be a promising complementary tool.
Background:
Papillary thyroid cancer (PTC) is the most common thyroid malignancy, with a strong predilection for lymph node metastasis, most commonly to the central neck compartment (level VI). Few studies have evaluated lymph node metastasis in multifocal PTC, and the role of level VI dissection in the management of PTC remains controversial. This retrospective analysis evaluated the rate of level VI lymph node positivity in multifocal PTC, as compared with unifocal disease, in order to inform surgical decision making better.
Methods:
Patients with PTC who underwent total or hemi-thyroidectomy plus level VI lymph node dissection at the authors' institution between January 2008 and June 2014 were included (N=227). The number and laterality of PTC foci, lymphovascular invasion (LVI), extrathyroidal extension (ETE), and positive/total number of level VI lymph nodes were recorded. Fisher's exact test was used to determine univariate associations, and multivariate analysis was done by logistical regression.
Results:
There was an association between the number of PTC foci and level VI node positivity (p<0.001), with an odds ratio (OR) of 2.355 in patients with three or more tumor foci (p=0.026). The OR for central neck metastasis was 1.088 with each additional focus of PTC (p=0.018). The risk of level VI node positivity in the presence of one or two foci was only 19%, with no appreciable difference between one and two foci. This risk increased in the presence of between three and nine foci (38%), and 10 or more foci (88%). Level VI node positivity was associated with ETE (p<0.001), LVI (p<0.001), and size of the largest focus (p<0.001). There was no association between level VI lymph node positivity and male sex (p=0.089), bilaterality (p=0.276), or age (p=0.076).
Conclusions:
There is a significant association between multifocal PTC and level VI lymph node positivity, increasing proportionally with the number of foci. These findings recognize multifocality as a sign of tumor aggressiveness, as evidenced by a higher propensity for lymph node metastasis.
Most of unilateral papillary thyroid carcinoma (PTC) metastasize to ipsilateral paratracheal lymph nodes (LNs) while some had contralateral paratracheal LN involved. The aim of this study was to analyze the predictive factors of contralateral paratracheal LN metastasis in unilateral PTC.
Data on 332 patients with unilateral PTC who underwent total/near total thyroidectomy and bilateral central neck dissection (CND) with/without lateral neck dissection were collected retrospectively. Patients' demographics, the extent of surgeries, and the pathological status of LNs and primary tumor were analyzed.
A total of 332 patients (67 male and 265 female) were included. Contralateral paratracheal LN metastasis was found in 68 (68/332, 20.5%) patients. Tumor size (>1 cm) (P < .001), capsular/extracapsular invasion (P < .001), pretracheal/prelaryngeal LN metastasis (P < .001), lateral neck LN metastasis (P < .001) and ipsilateral paratracheal LN metastasis (P < .001) was significantly associated with contralateral paratracheal LN metastasis on univariate analysis. Multivariate analysis showed that tumor size (>1 cm) (P = .013), capsular/extracapsular invasion (P = .009), pretracheal/prelaryngeal LN metastasis (P = .021) and lateral neck LN metastasis (P = .002) were independent risk factors of contralateral paratracheal LN metastasis.
Primary tumor size >1 cm, capsular/extracapsular invasion, pretracheal/prelaryngeal LN metastasis and lateral neck LN metastasis are predictive factors of contralateral paratracheal LN metastasis in unilateral PTC, which may help to determine the optimal extent of CND in patients with PTC.
Copyright © 2015. Published by Elsevier Ltd.
Background:
Central lymph node (CLN) metastasis in papillary thyroid carcinoma (PTC) is common and being able to predict CLN metastasis helps surgeons determine individualized therapy. However, the relationship between contralateral CLN metastasis and the total number of positive lymph nodes (LNs) in the combined prelaryngeal and pretracheal region remains unclear. This study aimed to investigate whether the total number of positive LNs in the combined prelaryngeal and pretracheal region has clinical significance as a predictor for contralateral CLN metastasis.
Methods:
We prospectively enrolled 153 consecutive patients with unifocal PTC >1.0 cm without ultrasonographic evidence of nodal metastasis who underwent total thyroidectomy and prophylactic bilateral CLN dissection from July 2011-May 2013. Patients were divided into three groups according to the total number of positive LNs in the combined prelaryngeal and pretracheal region.
Results:
Rates of metastasis to ipsilateral and contralateral central compartments in PTC >1.0 cm were 84.3% and 24.2%, respectively. Multivariate analysis showed that ≥3 positive LNs in the combined prelaryngeal and pretracheal region were an independent predictive factor of contralateral CLN metastasis (P < 0.001; odds ratio, 8.585). After a mean follow-up of 24.1 mo, none of these patients had a recurrence in the central or lateral compartment.
Conclusions:
Occult metastasis is highly prevalent in the ipsilateral central neck of patients with PTC >1.0 cm, and the total number of prelaryngeal and pretracheal LNs metastases may be a useful indicator to predict contralateral CLN metastasis in patients with unifocal PTC.
Purpose:
To evaluate conventional ultrasonography (US), US elasticity imaging (EI), and acoustic radiation force impulse (ARFI) imaging in thyroid nodule malignancy prediction.
Materials and methods:
This prospective study was institutional review board approved; informed consent was obtained. Study included 375 patients (mean age, 51 years; range, 18-75 years) with 441 pathologically proven thyroid nodules. In 281 women (mean age, 50 years; range, 18-75 years) and 94 men (mean age, 53 years; range, 18-74 years), conventional US, EI, Virtual Touch tissue imaging (VTi; Siemens, Mountain View, Calif), and Virtual Touch tissue quantification (VTq; Siemens) of ARFI imaging were performed for each nodule. Multivariate logistic regression analysis was performed to assess 17 independent variables for malignancy prediction. Diagnostic performance was evaluated with receiver operating characteristic (ROC) curve analysis.
Results:
There were 325 benign and 116 malignant nodules. Marked hypoechogenicity (odds ratio [OR]: 83.88; 95% confidence interval [CI]: 17.81, 394.99) was the strongest independent predictor for thyroid malignancy, followed by shape taller than wide (OR: 8.69; 95% CI: 2.87, 26.31), VTi (OR: 6.54; 95% CI: 3.61, 11.88), moderate hypoechogenicity (OR: 3.98; 95% CI: 1.13, 14.05), poorly defined margin (OR: 3.27; 95% CI: 1.22, 8.77), female sex (OR: 2.55; 95% CI: 1.33, 4.91), coarse background of surrounding thyroid tissue (OR: 2.01; 95% CI: 1.12, 3.62), and VTq (OR: 1.78; 95% CI: 1.28, 2.47) (all P < .05). EI was not significantly associated with thyroid malignancy (P = .855). Area under the ROC curve (Az) for VTq and VTi was higher than that with other significant independent variables. Az, sensitivity, and specificity were 0.91 (95% CI: 0.87, 0.94) and 0.86 (95% CI: 0.82, 0.90), 80% and 71.6%, and 93.8% and 83.4%, respectively, for VTi and VTq. VTq of at least 2.87 m/sec and VTi of at least grade IV were the best cutoff values for malignant thyroid nodules.
Conclusion:
ARFI imaging is promising for malignant thyroid nodule prediction, with higher diagnostic performance than conventional US or EI. ARFI can be used to supplement conventional US to diagnose thyroid nodules in patients referred for surgery.
Objectives
Acoustic radiation force impulse elastography is a newly developed ultrasound elasticity imaging technique that included both Virtual Touch tissue quantification and Virtual Touch tissue imaging (VTI; Siemens Medical Solutions, Mountain View, CA). This study aimed to evaluate the usefulness of VTI in differentiating malignant from benign thyroid nodules.
Methods
This study included 192 consecutive patients with thyroid nodules (n = 219) who underwent surgery for compressive symptoms or suspicion of malignancy. Tissue stiffness on VTI elastography was scored from 1 (soft) to 6 (hard). The VTI scores between malignant and benign thyroid nodules were compared. The intraobserver and interobserver agreement for VTI elastography was also assessed.
Results
On VTI elastography: score 1 was found in 84 nodules (all benign); score 2 in 37 nodules (3 papillary carcinomas and 34 benign nodules); score 3 in 25 nodules (1 medullary carcinoma, 6 papillary carcinomas, and 18 benign nodules); score 4 in 53 nodules (50 papillary carcinomas and 3 benign nodules); score 5 in 17 nodules (14 papillary carcinomas and 3 benign nodules); and score 6 in 3 nodules (all papillary carcinomas). A VTI elasticity score of 4 or greater was highly predictive of malignancy ( P < .01), and the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 87.0% (67 of 77), 95.8% (136 of 142), 91.8% (67 of 73), 93.1% (136 of 146), and 92.7% (203 of 219), respectively. The κ values were 0.69 for intraobserver agreement and 0.85 for interobserver agreement.
Conclusions
Virtual Touch tissue elasticity imaging has great potential as an adjunctive tool combined with conventional sonography for differential diagnosis between benign and malignant thyroid nodules.
A firm and hard thyroid nodule on palpation is known to be associated with an increased risk of thyroid malignancy. Elastography has been introduced to evaluate the tissue hardness objectively. We investigated the clinical implications of elastography as a prognostic factor in patients with papillary thyroid microcarcinoma.
Elastography images were classified according to Rago scores of 1-5. Malignancies with Rago scores of 4 or 5 were considered as "hard" and remaining malignancies as "soft." Clinicopathologic characteristics were compared between patients with hard or soft malignancies according to the extrathyroidal extension and central and lateral lymph node metastasis by using chi-square tests, Fisher's exact test, and independent t tests. Odds ratios with 95% confidence intervals were calculated for evaluating the factors for predicting extrathyroidal extension and central and lateral lymph node metastasis.
A hard malignancy on the Rago score was significantly associated with pathologic extrathyroidal extension compared with a soft malignancy (P=0.001). The odds ratio of a hard malignancy on the Rago score for predicting extrathyroidal extension was 5.060 (95% confidence interval, 1.565-16.358). A hard malignancy on Rago scores was not associated with central or lateral lymph node metastasis.
A hard malignancy on the Rago score of elastography was an independent factor for predicting pathologic extrathyroidal extension on pathology.
To retrospectively evaluate the diagnostic performance of power Doppler ultrasonography (US) in depicting vascularity and to determine whether the combination of vascularity and suspicious gray-scale US features is more useful in predicting thyroid malignancy than are gray-scale features alone.
This was an institutional review board-approved retrospective study, with waiver of informed consent. A total of 1083 thyroid nodules in 1024 patients (median age, 51 years; range, 16-83 years), consisting of 886 women (median age, 50 years; range, 16-83 years) and 138 men (median age, 53 years; range, 19-74 years), were included. Nodules with marked hypoechogenicity, noncircumscribed margins, microcalcifications, and taller-than-wide shape were classified as suspicious according to gray-scale US criteria. Vascularity was classified as none, peripheral, and intranodular. The diagnostic performance of gray-scale and power Doppler US features was compared and classified as follows: criterion 1, any single suspicious gray-scale US feature; criterion 2, addition of any vascularity as one of the suspicious features to criterion 1; criterion 3, addition of peripheral vascularity to criterion 1; criterion 4, addition of intranodular vascularity to criterion 1; criterion 5, addition of no vascularity to criterion 1; criterion 6, American Association of Clinical Endocrinologists and Associazione Medici Endocrinology guidelines--all hypoechoic nodules with at least one of the following US features: irregular margins, intranodular vascular spots, taller-than-wide shape, or microcalcifications.
Of 1083 nodules, 814 were benign and 269 were malignant. Intranodular vascularity was frequently seen in benign nodules and no vascularity was more frequent in malignant nodules (P < .0001, respectively). The area under the receiver operating characteristic curve (A(z)) of criterion 1 was superior (A(z) = 0.851) to that of criteria 2 (A(z) = 0.634), 3 (A(z) = 0.752), 4 (A(z) = 0.733), 5 (A(z) = 0.718), and 6 (A(z) = 0.806) (P < .0001).
Vascularity itself or a combination of vascularity and gray-scale US features was not as useful as the use of suspicious gray-scale US features alone for predicting thyroid malignancy.
There is still no complete agreement about the proper treatment of differentiated thyroid cancer (DTC).
All patients (n=130) with DTC in a defined population, treated with surgery between 1985 and 1999, were carefully followed up (median 13.1 years). Fifty three were operated with subtotal and 77 with total thyroidectomy. Twenty seven percent of the patients in the subtotal group and 56% of those in the total thyroidectomy group had postoperative radioiodine ablation. Thirty nine patients had papillary cancers incidentally detected during surgery for benign disorders (median size 7 (1-30) mm). Living patients answered the Swedish version of the SF-36 health survey.
Eleven of 106 patients considered tumour-free after primary surgery developed recurrences during follow-up. Fifteen patients (12%) died from DTC but only one within stage I-II (1.2%). No patient below 50 years of age at diagnosis died from DTC. Only three of 29 patients with isolated loco-regional spreading of their disease at the time of diagnosis have died from thyroid cancer. There was no statistically significant difference in the 10 year cancer-specific survival rate between those operated with subtotal or total thyroidectomy--irrespective of stage. Survival rate was significantly better for papillary than for follicular cancer. Mental and physical quality of life among patients treated for DTC were similar to the healthy Swedish population.
Patients with DTC stage I-II (according to TNM) or low-risk (according to AMES) have an excellent prognosis. Treatment as well as follow-up should not be exaggerated.
Preoperative neck ultrasonography (US) may detect nodal metastases of papillary thyroid carcinoma (PTC) but its utility in detecting metastases at specific neck subsites and levels is not known. We therefore evaluated preoperative US in detecting cervical metastases of PTC according to neck subsites and levels.
Preoperative US was performed in 133 new patients to detect metastases at three central cervical subsites and five lateral cervical levels. All patients underwent total thyroidectomy and bilateral central neck dissection. Thirty-four patients with lateral nodal metastases underwent modified radical neck dissection.
Lymph node metastases to the central and lateral cervical compartments were identified in 57.9% and 25.6%, respectively. The sensitivity and specificity of US for detecting central nodal metastasis were 61.0% and 92.8%, respectively. In the lateral neck, US detected non-palpable lymph node metastases in 6 of 34 patients (17.6%). Overall, US was >85.0% specific at all cervical subsites and levels.
Preoperative US may detect cervical metastases of PTC and may assist in determining the necessity and extent of neck dissection in PTC patients.
Acoustic radiation force impulse (ARFI) imaging involves the mechanical excitation of tissue using localized, impulsive radiation force. This results in shear-wave propagation away from the region of excitation. Using a single diagnostic transducer on a modified commercial ultrasound (US) scanner with conventional beam-forming architecture, repeated excitations with multiple look directions facilitate imaging shear-wave propagation. Direct inversion methods are then applied to estimate the associated Young's modulus. Shear-wave images are generated in tissue-mimicking phantoms, ex vivo human breast tissue and in vivo in the human abdomen. Mean Young's modulus values of between 3.8 and 5.6 kPa, 11.7 kPa and 14.0 kPa were estimated for fat, fibroadenoma and skin, respectively. Reasonable agreement is demonstrated between structures in matched B-mode and reconstructed modulus images. Although the relatively small magnitude of the displacement data presents some challenges, the reconstructions suggest the clinical feasibility of radiation force induced shear-wave imaging.
2015 American Thyroid Association Management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer: what is new and what has changed?
- BR. Haugen