Search Results (244)

Background: Pancreatic cancer (PC) has a very poor 5-year survival and prognosis. Even when CT or MRI shows no metastasis, staging laparoscopy(SL) still detects tiny peritoneal deposits in 20–30% of patients, making them ineligible for surgery. SL is invasive, requiring general anesthesia and substantial resources. Endoscopic ultrasound (EUS) allows the observation of the bile ducts, pancreas, and abdominal cavity, and EUS-guided fine-needle aspiration (EUS-FNA) is essential for pathological diagnosis. Reports on using EUS to perform peritoneal lavage cytology are currently not available. We hypothesized that combining EUS-FNA with peritoneal lavage (EUS-lavage technique; EUS-LT) could enhance staging accuracy and avoid unnecessary surgical procedures. Methods: Ten in vivo porcine models underwent EUS-LT. Using a 19G FNA needle, 800 mL saline was instilled into the intraperitoneal cavity and then recovered. Two refinements were introduced sequentially: an ENBD catheter with additional side holes and, subsequently, a side-hole introducer (EndoSheather) that eliminated balloon dilation. The primary endpoint was procedural success. Secondary endpoints included safety, complications, recovered volume, duration of endoscopic procedure, and time required to instill 800 mL. Nonparametric tests compared outcomes across iterations. Results: Ten-model porcine in vivo model series were included, and all procedures were successful. No device malfunctions or unanticipated technical failures; one minor mucosal injury during saline injection resolved after re-puncture. The average procedure time was 31.1 min. Stepwise refinements shortened procedure and infusion times and increased recovered volume. Recovered volume approached the instilled amount in later cases, indicating efficient performance. Conclusions: In this ten-model in vivo series, EUS-LT demonstrated technical feasibility and short-term safety. Full article

Background/Objectives: This study aimed to evaluate the relationship between preoperative clinical, ultrasonographic, and cytologic findings and postoperative histopathology in patients with thyroid nodules, and to determine diagnostic factors associated with malignancy. Materials and Methods: A retrospective analysis was conducted on 100 patients who underwent thyroid surgery between September 2012 and April 2014. Preoperative data—including clinical examination, thyroid function tests, and high-resolution ultrasonography—were compared with fine-needle aspiration biopsy (FNAB) results and final histopathology. Ultrasonographic features (echogenicity, calcification, vascularity, and margin) were analyzed for their association with malignancy. Statistical tests included chi-square, t-test, and correlation analysis (p < 0.05 considered significant). Results: Among 100 patients (79 females, 21 males; mean age 47.5 ± 13.9 years), 29 (29%) had benign and 71 (71%) malignant histopathology. Malignancy was significantly associated with older age (p = 0.025), smaller nodule size (p = 0.019), hypoechogenicity (p = 0.001), microcalcifications (p = 0.014), and irregular margins (p = 0.017). FNAB showed a strong correlation with final histopathology (r = 0.65, p = 0.001). The overall sensitivity and specificity of FNAB were 25.4% and 82.8%, respectively. Conclusions: Hypoechogenicity, microcalcifications, and irregular margins were the most reliable ultrasonographic predictors of malignancy. FNAB remains a highly specific but variably sensitive diagnostic tool, and its accuracy increases when interpreted in conjunction with ultrasonographic findings. Integrating cytology with structured imaging systems such as ACR TI-RADS and Bethesda classification enhances diagnostic precision in thyroid nodule evaluation. Full article

Background/Objectives: Thyroid nodules are a prevalent condition with a high incidence rate of malignancy. Ultrasound (US)-based risk stratification systems have become widely utilized for the evaluation of thyroid nodules, including the American Thyroid Association (ATA) guidelines, the American College of Radiology Thyroid Imaging Reporting and Data System (ACR-TIRADS), the Korean Society of Thyroid Radiology system (K-TIRADS), and the European Thyroid Association system (EU-TIRADS). Our institution has developed a real-time computerized score for evaluating thyroid nodules. This study aims to systematically compare the diagnostic performance of these systems when applied in real time by otolaryngologists, who integrate dynamic US imaging with physical examination. Methods: Patients with thyroid nodules who underwent US evaluation, US-guided fine-needle aspiration cytology (FNAC), and subsequent thyroidectomy were included. During each examination, otolaryngologists performed real-time risk categorization according to five US-based systems, with immediate scoring based on dynamic sonographic findings. Results: From April 2021 to November 2023, 130 patients were enrolled. For categories 4 and 5, the ATA guidelines had a sensitivity of 96.6% (95% CI: 87.3–100%), specificity of 78.9%, (60.6–97.3%) PPV of 84.6% (70.7–98.5%), NPV of 93.7% (81.9–100%), and accuracy of 88.1% (78.3–97.9%). The sensitivity of the ACR-TIRADS was 95.6% (87.3–100%), the specificity was 78.9% (60.6–97.3%), the PPV was 84.6% (70.7–98.5%), the NPV was 93.7% (81.9–100%), and the accuracy was 88.1% (78.3–97.9%). Both the K-TIRADS and the EU-TIRADS had sensitivities of 95.6% (87.3–100%), specificities of 78.9% (60.6–97.3%), PPVs of 84.6% (70.7–98.5%), NPVs of 93.7% (81.9–100%), and accuracies of 88.1% (78.3–97.9%). The computerized score (>3.3 considered malignant) and TBSRTC (Category 5 or 6) both had sensitivities of 73.9% (56.0–91.9%), specificities of 100%, PPVs of 100%, NPVs of 76.0% (59.3–92.7%), and accuracies of 85.7% (75.1–96.3%). Conclusions: Otolaryngologists can achieve highly accurate diagnostic performance when applying standardized ultrasound-based risk stratification systems, and a real-time computerized scoring system provides highly specific supplemental value for immediate clinical decision-making. Full article

Objectives: Pancreatic cystic lesions (PCLs) are increasingly detected due to the widespread use of imaging techniques. The identification of pancreatic mucinous cysts is especially important since these carry a risk of malignant transformation and require follow-up or surgical resection. The aim of this study was to determine the diagnostic yield of the molecular analysis of K-RAS (Kirsten RAt Sarcoma virus) and GNAS (Guanine Nucleotide-binding protein, Alpha Stimulating protein activity) gene mutations in pancreatic cyst fluid (PCF) obtained by endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA). Methods: In this prospective trial, we assessed the sensitivity, specificity, and positive and negative predictive values of K-RAS and GNAS mutation analysis in differentiating mucinous versus non-mucinous cysts and the subsequent impact on decision-making in daily clinical practice. The reference standard used comprised the combination of morphology on cross-sectional imaging and EUS, string sign, cyst fluid cytology, intracystic carcinoembryonic antigen (CEA), and glucose levels, with subsequent correlation of surgical pathology in resected cases. Fluid samples of 47 cysts obtained by EUS-FNA over a 39-month period were analyzed. Mutation analysis of KRAS (exon 2) was performed in all cases, and additionally, GNAS (exon 8) in 28 cases using Sanger sequencing. Results: 33 out of 47 PCLs were classified as mucinous cysts and 14 as non-mucinous cysts defined using conventional standards, including morphological characteristics, string-sign, cytology, cyst fluid testing, and histology in resected cases. Of these 33 mucinous cysts, KRAS mutation was detected in 14 samples. A further 23 mucinous lesions were additionally tested for GNAS mutation, which was detected in 10 of the 23 cysts. A 42.4% sensitivity for KRAS and 43.5% for GNAS mutation analysis was calculated, with a specificity of 92.9% and 100%, respectively, for detecting mucinous lesions. The clinical management was altered through the genetic testing results in one single case. Conclusions: In this cohort, K-RAS and GNAS mutational analysis in cyst fluid did not improve the detection of mucinous pancreatic cysts significantly after conventional testing. However, the method may be useful due to its high specificity in uncertain cases. Full article

Background/Objectives: Both benign and malignant thyroid lesions present as nodules. While thyroid nodules are less common in the pediatric population than in adults, their malignancy rates are considerably higher. Although the 10 mm cut-off for fine-needle aspiration cytology (FNAC) is commonly used for both adults and children, there is limited information regarding subcentimeter thyroid nodules in the pediatric population. The majority of published studies have focused on nodules measuring 1 cm or greater. This study aimed to compare the cytological diagnosis, ultrasonographic features, and histopathological outcomes of thyroid nodules in pediatric patients (under 21 years old), stratified by size (≤10 mm vs. >10 mm). Methods: We conducted a retrospective, single-center cohort study, evaluating 108 thyroid nodules from 98 patients. Nodule sizes were categorized into two groups, and their features were correlated with findings from FNAC using the Bethesda System for Reporting Thyroid Cytopathology and subsequent surgical histopathology. The risk of malignancy (ROM) was calculated for each Bethesda category. Results: A total of 108 nodules were evaluated, with 35 (32.4%) measuring ≤ 10 mm. The overall malignancy rate was 12%, with 14.3% in the ≤10 mm group and 11% in the >10 mm group. The difference was not statistically significant, and this finding indicates that small nodules can also harbor malignancy. Notably, all cases categorized as suspicious for malignancy or malignant by FNAC were confirmed to be malignant on histopathology (ROM = 100%). The Atypia of Undetermined Significance (AUS) category exhibited a malignancy rate of 60%, which is significantly higher than the rates reported in previous studies. Ultrasonographic features such as hypoechogenicity and microcalcifications were more prevalent in malignant nodules but lacked statistical significance. Conclusions: Our findings demonstrate that pediatric thyroid nodules, including those ≤10 mm, have a notable risk of malignancy. The high rate of malignancy in the AUS category suggests that the current Bethesda criteria, primarily designed for adults, may require re-evaluation for pediatric cases due to known differences in genetic profiles and disease behavior. Consequently, these pathological findings clearly demonstrate that FNAC indications in children should not be based solely on nodule size, and that a multidisciplinary approach guided by pediatric-specific guidelines should inform clinical management. Full article

Background: The diagnostic process for probable benign breast lesions involves a 1–40% upgrade rate to malignancy when biopsy (cytology and/or histology) is compared with surgery. In a previously conducted clinical randomized trial, we aimed to examine diagnostic discrepancies between prior biopsy results and subsequent vacuum-assisted excision (VAE). Methods: This study is a post hoc analysis of the Swedish VAE randomized trial. Patients were enrolled between November 2019 and August 2022. All patients who underwent a biopsy before VAE were included in this study. Pathology reports from the initial biopsy, VAE, surgical excision, and recurrence were collected. In addition, we conducted clinical follow-up, including imaging, for at least 2 years. Results: The study population included 169 patients with 169 lesions, of whom 71 underwent fine-needle aspiration cytology (FNA), and 126 underwent core-needle biopsy (CNB) before VAE. The diagnostic discrepancy between FNA and VAE was 38% (27/71). The discrepancy between CNB and VAE was 29% (37/126). The upgrade rate to cancer was 7% (5/71) for FNA and 5% (6/126) for CNB. In the CNB group, the highest upgrade rate to cancer occurred in patients with prior atypical ductal hyperplasia (ADH) on CNB (3/12, 25%). Conclusions: The upgrade rate in histopathological diagnosis between prior CNB and VAE was high (15%), and even higher when comparing FNA with VAE (24%). Our findings support avoiding FNA for BI-RADS 3 and 4a lesions and suggest that multi-round VAE may be a safe and effective alternative to surgery for selected cases, particularly those with ADH on CNB. Full article

Accurate preoperative assessment of thyroid nodules remains challenging, particularly in indeterminate cytological categories. Integrating molecular testing into cytology could improve diagnostic precision, enable timely intervention, and support better risk stratification and patient management. This proof-of-concept study evaluated the feasibility of performing molecular testing on fine-needle aspiration cytology (FNAC) samples processed on CytoMatrix, a three-dimensional synthetic scaffold designed to capture and preserve cellular material. Thirty-three thyroid FNAC specimens were processed on CytoMatrix, and cytological diagnoses were mirrored to the 2023 Bethesda System for Reporting Thyroid Cytopathology and correlated with final histopathology. DNA was extracted from paraffin-embedded CytoMatrix sections and analyzed for the BRAF V600E mutation. Adequate DNA for molecular testing was obtained in 30 of 33 cases (90%), and BRAF V600E mutations were detected in three papillary thyroid carcinoma samples. DNA adequacy and yield were consistent across Bethesda III–V categories, with insufficiency limited to low-cellularity Bethesda III cases. CytoMatrix enables reliable DNA recovery and targeted molecular testing without compromising cytological evaluation. This integrated cytomolecular workflow provides a feasible approach for combining cytological and molecular data in thyroid FNAC, supporting personalized and timely diagnostic management. Full article

Breast cancer rarely metastasizes to the parotid gland. Early recognition in patients with a history of malignancy is critical for timely diagnosis and treatment. We report the case of a 60-year-old female who presented with a two-month history of a left periauricular mass, 18 months after completing treatment for breast carcinoma. Despite the patient’s oncologic history, initial evaluation by our maxillofacial surgery service showed no evidence of distant metastasis, and we initially ruled out metastatic disease. Clinical evaluation, contrast-enhanced computed tomography (CT), fine-needle aspiration cytology (FNAC), PET-CT, and histopathological analysis were performed. Given the persistent and progressive nature of the mass, surgical excision was undertaken to obtain a definitive diagnosis and provide local control. Immunohistochemical analysis of the resected mass and adjacent node confirmed metastatic breast carcinoma infiltrating the parotid parenchyma and an intra-parotid lymph node, with strong positivity for progesterone receptor (PR) and carcinoembryonic antigen (CEA). Unfortunately, several months later, the patient developed pulmonary metastases and subsequently died. Full article

Fine-needle aspiration cytology (FNAC) is the cornerstone of thyroid nodule evaluation, standardized by the Bethesda System. However, indeterminate categories (Bethesda III–IV) remain a major challenge, often leading to unnecessary surgery or delayed molecular testing. Deep learning (DL) has recently emerged as a promising adjunct in thyroid cytopathology, with applications spanning triage support, Bethesda category classification, and integration with molecular data. Yet, routine adoption is limited by preanalytical variability (staining, slide preparation, Z-stack acquisition, scanner heterogeneity), annotation bias, and domain shift, which reduce generalizability across centers. Most studies remain retrospective and single-institution, with limited external validation. This article provides a technical overview of DL in thyroid cytology, emphasizing preanalytical sources of variability, architectural choices, and potential clinical applications. We argue that standardized datasets, multicenter prospective trials, and robust explainability frameworks are essential prerequisites for safe clinical deployment. Looking forward, DL systems are most likely to enter practice as diagnostic co-pilots, Bethesda classifiers, and multimodal risk-stratification tools. With rigorous validation and ethical oversight, these technologies may augment cytopathologists, reduce interobserver variability, and help transform thyroid cytology into a more standardized and data-driven discipline. Full article

Background/Objectives: Medullary thyroid carcinoma (MTC) poses diagnostic challenges due to its sonographic similarity to benign nodules and the modest sensitivity of conventional ultrasound (US) and TIRADS-based risk stratification. Elastography, using strain (SE) and shear-wave (SWE) techniques, has demonstrated high accuracy in papillary thyroid carcinoma (PTC) but remains underexplored in MTC. This study investigates whether elastographic stiffness measurements can enhance diagnostic precision for MTC when combined with conventional US. Methods: We retrospectively analyzed 20 nodules confirmed as MTC by pathology after surgical resection (January 2013–June 2024) and evaluated via conventional US, SE, and SWE at a specialized endocrinology center. Elasticity scores (ES) and Emean/Emax values were compared with US features, TIRADS categories, calcitonin levels, nodule size, and lymph node status. Results: Qualitative SE showed a mean ES of 3.2 (55% ES 4, 20% ES 3), while 87.5% of nodules exceeded an SWE Emean cutoff of 30.5 kPa, indicating increased stiffness in most MTC nodules and outperforming TIRADS, where only 60% were high-risk. Moderate correlations were found between calcitonin and nodule size (r = 0.52, p = 0.018) and between ES and size (r = 0.48, p = 0.034), but calcitonin did not correlate with ES (r = 0.07, p = 0.768). Nodules with suspicious lymph nodes showed higher Emean and ES trends, though not significant. Conclusions: Elastography identifies increased stiffness in MTC, challenging its “soft” classification, and improves risk stratification beyond TIRADS. We suggest integrating elastography as a complementary tool alongside TIRADS to guide fine-needle aspiration, without replacing calcitonin or cytology. Prospective multicenter studies are needed to validate thresholds and optimize multimodal risk assessment in MTC. Full article

Warthin’s tumor is a benign salivary gland neoplasm that can exhibit intense FDG uptake, potentially mimicking malignant lesions on oncologic imaging. We report a case of a 78-year-old man undergoing staging for suspected lung cancer, in whom a hypermetabolic lesion was incidentally detected in the left parotid gland on [¹⁸F]FDG PET/CT. Correlation with prior salivary scintigraphy, MRI, and CT supported the likelihood of Warthin’s tumor, which was subsequently confirmed by fine-needle aspiration cytology. This case illustrates how multimodality imaging can provide complementary diagnostic information that helps characterize the parotid lesion, but not replace cytologic confirmation. Recognition of characteristic imaging features, an understanding of each modality’s diagnostic strengths and limitations, and cytologic confirmation when indicated are essential to avoid misinterpretation and optimize patient management. Full article

Early diagnosis of pancreatic cancer, particularly in intraductal papillary mucinous neoplasm (IPMN), remains challenging despite advances in imaging and biomarkers. Pancreatic adenocarcinoma (PDAC) has a high mortality rate; therefore, its early detection and adequate interventions are necessary to improve the disease outcome. Most IPMNs are asymptomatic and discovered incidentally. Magnetic resonance imaging (MRI) is a preferred tool for diagnosing malignant IPMNs, with a sensitivity of 90.7–94.1% and a specificity of 84.7–87.2% in detecting mural nodules > 5 mm, a strong predictor of high-risk lesions. Radiomics further enhances diagnostic accuracy (sensitivity 91–96%, specificity 78–81%), especially when combined with CA 19-9, which has lower sensitivity (73–90%) but higher specificity (79–95%). Computed tomography (CT), though less effective for small mural nodules, remains widely used; its accuracy improves with radiomics and clinical variables (sensitivity 90.4%, specificity 74%). Conventional endoscopic ultrasonography (EUS) shows lower performance (sensitivity 60%, specificity 80%), but its advanced variations have improved outcomes. Contrast-enhanced EUS (CE-EUS) visualizes mural nodules with more than 90% sensitivity and involvement of the main pancreatic duct, with a sensitivity of 83.5% and a specificity of 87%. EUS–fine-needle aspiration (EUS-FNA) allows cyst fluid analysis; however, CEA, glucose, and KRAS/GNAS mutations show poor value for malignancy risk. Cytology has low sensitivity (28.7–64.8%) but high specificity (84–94%) in diagnostic malignant changes and strongly affects further management. EUS–through-the-needle biopsy (EUS-TTNB) yields high diagnostic accuracy (sensitivity 90%, specificity 95%) but carries a range of 2–23% adverse events, which limits its wide use. EUS–confocal laser endomicroscopy (EUS-nCLE) provides real-time microscopic evaluation, detecting malignant IPMN with a sensitivity of 90% and a specificity of 73%, though its availability is limited. New emerging biomarkers available in cyst fluid or blood include mucins, miRNA panels (sensitivity 66.7–89%, specificity 89.7–100%), lipidomics, and cancer metabolite profiling, with diagnostic accuracy approaching 89–91%. Pancreatoscopy (POP) enables direct main pancreatic duct (MPD) visualization and biopsy with a sensitivity of 64–100% and a specificity of 75–100%, though adverse events occur in around 12% cases. Combining advanced imaging, EUS-based tissue acquisition, and novel biomarkers holds promise for earlier and more accurate detection of malignant IPMN, potentially improving PDAC outcomes. Full article

Background: Obesity has been proposed as a risk factor for differentiated thyroid carcinoma (DTC), though findings in the literature remain conflicting. While some studies suggest an association between elevated body mass index (BMI) and thyroid malignancy, others attribute this link to diagnostic bias. The Calabria region in Southern Italy, historically affected by iodine deficiency and endemic goiter, offers a valuable population for investigating this relationship. Objective: This study aimed to evaluate the association between obesity and clinical, sonographic, and cytological characteristics of thyroid nodules in a Calabrian cohort undergoing fine-needle aspiration biopsy (FNAB). Methods: This retrospective observational study included 1192 patients evaluated at a single endocrine referral center between 2015 and 2024. Patients were stratified by BMI (<30 vs. ≥30 kg/m²). Demographic, biochemical, ultrasound, and cytological data were collected and analyzed. Cytological results were classified according to the SIAPEC 2014 system. Results: Obese patients had significantly larger thyroid nodules in terms of anteroposterior and transverse diameters, as well as overall volume (p < 0.05). However, the distribution of high-risk cytological categories (TIR 3B, TIR 4, and TIR 5) did not differ significantly between obese and non-obese patients (9.4% in both groups). Multivariate analysis confirmed that BMI was not an independent predictor of malignancy risk (OR 0.988; p = 0.723), whereas younger age was inversely associated with malignancy. Conclusions: Obesity appears to influence thyroid nodule size but does not constitute an independent risk factor for cytological malignancy. BMI should not influence indications for FNAB or subsequent treatment decisions. Thyroid nodule management should instead rely on ultrasound risk stratification and cytological findings. Special attention should be given to younger patients as they may carry a higher malignancy risk. Full article

Background/Objectives: This study aimed to evaluate the effectiveness of core needle biopsy (CNB) by comparing its diagnostic yield to fine needle aspiration cytology (FNAC) across primary and secondary examinations. Methods: This retrospective review analyzed medical records of patients who visited Soonchunhyang University Cheonan Hospital between January 2021 and August 2023 for thyroid nodule evaluation. Demographic data and the malignancy risk of thyroid nodules were collected based on the 2021 Korean Thyroid Imaging Reporting and Data System. FNAC and CNB results, classified using the Bethesda system for reporting thyroid cytopathology and diagnostic categories for thyroid CNB, were categorized as either “conclusive” or “inconclusive.” The rates of conclusive results in the primary examination and nodules transitioning from inconclusive to conclusive results during the secondary examination were analyzed. Finally, the diagnostic yields of FNAC and CNB were assessed using histopathological findings from surgically excised nodules. Results: The rate of nodules classified as “conclusive” was significantly higher in the CNB group than that in the FNAC group. Among nodules subjected to secondary examination, only the group with FNAC followed by CNB demonstrated a significant improvement in the rate of transition from inconclusive to conclusive results. Although FNAC and CNB showed comparable sensitivity and accuracy, the specificity of CNB was greater than that of FNAC. Conclusions: This study confirms the clinical utility of CNB by demonstrating its higher rate of conclusive results than FNAC. Future prospective studies, including cost–benefit analyses, are warranted to further define the indications for CNB. Full article

Background and Objectives: To identify clinical, ultrasound (US) and real-time elastography (RTE) characteristics indicative of malignancy in small thyroid lesions. Materials and Methods: 141 consecutive patients with incidentally discovered solid thyroid nodules (diameter ≤ 10 mm) by neck US were assessed, and RTE was performed. The nodules were classified per American (ACR-TIRADS) and European (EU-TIRADS) criteria; US-guided FNA was conducted on EU-TIRADS 5 nodules. The US and RTE features of nodules classified as benign (Bethesda II) or malignant (Bethesda V and VI) were compared. Results: 41 nodules were classified as EU-TIRADS 5. Their Fine Needle Aspiration (FNA) cytology was Bethesda II (n = 11), III-IV (n = 3), V (n = 10) or VI (n = 17). Bethesda V–VI patients had a higher rate of autoimmune thyroiditis (p = 0.015) and higher ACR-scoring points (p < 0.001) compared with Bethesda II. The elastography ratio was equal between the groups (p = 0.584). In logistic regression analysis, ACR-scoring points predicted FNA results, with an area under the curve (AUC) of 0.993 (sensitivity 92.6% and specificity of 100%). The clinical model (age, body mass index, sex, autoimmunity, L-thyroxine treatment, nodule diameter, elastography ratio) achieved an AUC of 0.744. A “mixed” model, combining clinical characteristics with the ACR scoring points, achieved perfect performance (AUC = 1.000), predicting FNA results with 100% sensitivity and specificity. Conclusions: The proposed “mixed model” can predict Bethesda V–VI in thyroid nodules <10 mm, allowing for the selection of those needing further evaluation. Full article