Search Results (48)

Background: Thyroid nodules are common in the general population, and up to 15% may be malignant. Patients with transfusion-dependent thalassemia (TDT) are predisposed to endocrine complications, raising concern for thyroid malignancy. This study compared surveillance strategies between TDT patients and healthy controls (HCs). Methods: This cross-sectional study used thyroid ultrasonography (US) to identify and characterize thyroid nodules in patients with TDT and HCs. Nodule assessment was performed using the Thyroid Imaging Reporting and Data System and the Italian Consensus for the Classification and Reporting of Thyroid Cytology for FNAs. Rates of indicated but unperformed FNAs and confirmed thyroid cancer cases were recorded. Statistical comparisons were performed using Fisher’s exact and chi-squared tests. Results: A total of 156 TDT and 101 HCs underwent thyroid US. Nodules were detected in 35.2% of TDT patients and 34.6% of HCs, with no difference in prevalence. Nodules were smaller in TDT patients, but suspicious ultrasound features and cancer prevalence were similar. Furthermore, 33.3% of TDT patients vs. 4.5% of HCs did not undergo indicated FNA (p = 0.021). Conclusions: Thyroid nodule prevalence and malignancy risk were comparable in TDT patients and HCs. A higher proportion of TDT patients missed indicated FNA procedures, revealing a critical gap in surveillance. Enhanced adherence to guideline-based follow-up is needed in thalassemia care. 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

Purpose: This study aimed to compare: the performance of K-TIRADS, EU-TIRADS and ACR TIRADS when used by observers with different levels of experience compared with the gold standard of cytology, and to evaluate the diagnostic performance of CAD (computer-aided design) compared with TI-RADS systems. Methods and Materials: In total, 323 thyroid nodules were evaluated in patients who were candidates for needle aspiration. Three observers with different levels of experience evaluated the diagnostic accuracy of three risk stratification systems (ACR TI-RADS, EU-TIRADS and K-TIRADS) and CAD software (S-Detect, made by Samsung) in characterizing the nodules. The results were compared with cytology examination. All nodules were characterized in terms of shape, margins, composition, calcifications, size, echogenicity and microcalcifications, and by stratifying individual nodules by using the three TIRADS systems; then S-detect software was applied and the data were compared with each other and with the gold standard. Results: Through cytology, 308 benign and 33 malignant nodules were identified. ACR-TIRADS showed a sensitivity of 100%, a specificity of 86%, a positive predictive value of 43% and a negative predictive value of 100%. EU-TIRADS showed a sensitivity of 100%, a specificity of 79%, a positive predictive value of 33% and a negative predictive value of 100%. K-TIRADS showed a sensitivity of 100%, a specificity of 89%, a positive predictive value of 50% and a negative predictive value of 100%. S-Detect combined with EU-TIRADS showed a high agreement (>95%) with the gold standard. Conclusions: K-TIRADS’s positive predictive power was slightly better than the other TIRADS, suggesting greater accuracy in correctly diagnosing positive cases. S-DETECT combined with EU-TIRADS has similar results to S-Detect with ACR- and K-TIRADS in terms of sensitivity, specificity and negative predictive power. However, it has a slightly better positive predictive power, suggesting greater accuracy in correctly diagnosing positive cases than the ACR- and K-TIRADS classification systems. In general, S-Detect cannot yet be considered a substitute for the human observer but only as an important support for human evaluation and an excellent and fast help to provide a comprehensive and complete report. Clinical Relevance/Application: S-Detect is a valuable tool for characterizing thyroid nodules when integrated with radiologist evaluation. It is also an important support tool for less experienced observers. Particularly interesting is the approach of use in integrated combination of the K-TIRADS by the human observer with S-Detect using EU-TIRADS, which could increase the overall diagnostic efficiency of the systems. Full article

Background/Objectives: Thyroid nodules are commonly found through sensitive imaging methods like ultrasonography. While most nodules are benign and asymptomatic, certain characteristics may indicate malignancy, prompting fine needle aspiration biopsy. Factors like age and gender affect cancer risk, complicating ultrasound-based risk systems. We aimed to determine whether the cytological malignancy rate of thyroid nodules could be adjusted for several clinical parameters. Methods: Data from patients aged 18 and above with thyroid nodules assessed via fine needle aspiration (FNA) were retrospectively reviewed. Malignancy classification was based on cytopathology and histopathology results. The study examined how various clinical parameters, adjusted for the ACR TI-RADS category, affected thyroid nodule malignancy rates, including age, sex, Body Mass Index (BMI), nodule size, presence of autoimmunity, and thyroxine therapy. Additionally, we analyzed the performance of ACR TI-RADS in predicting malignant cytology across different age subgroups of thyroid nodules. Results: The study included 1128 thyroid nodules from 1001 adult patients, with a median age of 48 years and predominantly female (76.68%). Malignancy rates varied across ACR TI-RADS categories, with higher rates associated with larger nodules and younger age groups. Age emerged as a significant predictor of malignancy, with a consistent decrease in the odds ratio for malignant cytology with advancing age across all ACR TI-RADS categories, indicating its potential utility in risk assessment alongside nodule size and sex. Conclusions: Raising the size threshold for recommending FNA of TR3-3 nodules and incorporating patients’ age and gender into the evaluation process could enhance the system’s accuracy in assessing thyroid nodules and guiding clinical management decisions. Full article

Objectives: Oncocyte-rich indeterminate thyroid nodules (O-ITNs) present diagnostic and management challenges due to overlapping features between benign and malignant lesions and differing cytological classifications. This study aimed primarily to assess the ultrasound (US) characteristics and US-based risk of O-ITNs using the American College of Radiology Thyroid Imaging Reporting And Data Systems (ACR TI-RADS). A secondary objective was to compare the Bethesda System for Reporting Thyroid Cytopathology (BSRTC) and Italian Consensus for the Classification and Reporting of Thyroid Cytology (ICCRTC) cytological systems regarding classification and clinical management implications for O-ITNs. Methods: A retrospective study was conducted on 177 ITNs (TIR3A and TIR3B) evaluated between June 2023 and December 2024 at CTO-Alesini, Rome (Italy). Nodules were assessed with US, cytology, and histology. Oncocyte predominance was defined as >70% oncocytes on fine-needle aspiration (FNA). US features were analyzed according to ACR TI-RADS. Nodules were reclassified by BSRTC, and potential differences in clinical case management (CCM) were analyzed. Results: O-ITNs comprised 47.5% of the sample. Compared to non-O-ITNs, O-ITNs were larger and more frequently showed low-risk US features, including a higher prevalence of ACR TI-RADS 3 nodules. However, no progressive increase in the risk of malignancy (ROM) was observed across ACR TI-RADS classes within O-ITNs. Histological malignancy was identified in 47.1% of O-ITNs, a lower proportion compared to non-O-ITNs, though the difference was not statistically significant. Classification discordance with potential management impact was lower in O-ITNs (20.2%) than in non-O-ITNs (38.7%). Conclusions: O-ITNs typically exhibit benign-appearing US features and lower classification discordance between BSRTC and ICCRTC, yet US risk stratification fails to differentiate malignancy risk within O-ITNs. A tailored approach integrating cytology and cautious US interpretation is essential for optimal O-ITN management. Full article

Background and Objectives: Indeterminate thyroid nodules (Bethesda III and IV) are a common clinical entity that present a diagnostic challenge due to their intermediate risk of malignancy. This study aimed to evaluate the role of ultrasound in risk stratification and malignancy prediction to support clinical decision-making and reduce unnecessary surgical interventions. Materials and Methods: This retrospective multicenter cohort study included patients aged ≥18 years who underwent thyroid surgery between 2016 and 2022 at four centers in the Eastern Province of Saudi Arabia. Only nodules with indeterminate cytology (Bethesda III or IV) were included. Data collected included demographic characteristics, thyroid function, ultrasound features, cytology results, and histopathological findings. Results: A total of 679 patients with 733 nodules were reviewed. Of these, 206 patients with 223 indeterminate nodules were included (median age: 42 years; 88.3% female). The overall malignancy rate was 46.6%. Independent predictors of malignancy included solid hypoechoic composition (OR = 2.26, p = 0.012), microcalcifications (OR = 3.07, p = 0.002), lymph node involvement (OR = 2.43, p = 0.021), American Thyroid Association (ATA) intermediate to high suspicion category (OR = 1.9, p = 0.018), and Thyroid Imaging Reporting and Data Systems (TI-RADS) categories 4–5 (OR = 2.3, p = 0.003). Solid hypoechoic nodules showed 82.3% specificity and 63.0% positive predictive value (PPV); microcalcifications demonstrated 84.1% specificity and 68.4% PPV; lymph node involvement had 87.6% specificity and 68.9% PPV. The ATA and TI-RADS classifications showed higher sensitivity (63.5% and 68.0%, respectively), but lower specificity (53.1% and 52.8%, respectively). Conclusions: Ultrasound features, particularly solid hypoechoic composition, microcalcifications, and lymph node involvement, as well as ATA and TI-RADS classifications, were independent predictors of malignancy in indeterminate thyroid nodules. Although ATA and TI-RADS offered higher sensitivity, individual features demonstrated greater specificity and PPV. These findings support the use of ultrasound risk stratification to guide surgical decisions in high-risk cases and suggest that additional diagnostic evaluation may be appropriate for low-risk nodules. Full article

Background/Objectives: Thyroid nodules are commonly observed in neck ultrasonography. Most nodules are benign; hence, several nodules require biopsy to accurately identify the malignant ones. Numerous risk classification guidelines have been developed for thyroid nodules, varying in their indications for fine-needle aspiration biopsy (FNAB). The aim of this study is to evaluate the performances of three internationally recognized thyroid imaging reporting and data systems (TIRADS) for risk stratification of malignancy in comparison to one another. Methods: A total of 225 thyroid nodules with definitive FNAB cytology or histopathological diagnoses were included in this study. Various ultrasound (US) features were classified into categories based on three TIRADS editions. The guidelines were assessed regarding sensitivity, specificity, predictive values, and diagnostic accuracy to compare diagnostic value. Results: The American College of Radiology (ACR)-TIRADS demonstrated the best diagnostic accuracy (63.1%), the highest specificity (58.7%) and positive predictive value (36.3%), among three different TIRADS systems. Korean (K)-TIRADS exhibited the highest sensitivity (94.2%), negative predictive value (96.1%), and the most favorable negative likelihood ratio (0.13). The European (EU)-TIRADS had a sensitivity of 90.4%, specificity of 48.6%, and diagnostic accuracy of 58.2%, ranking between the other two guidelines across most parameters. Conclusions: The rigorous use of the guidelines established by each of the three TIRADS systems would have markedly reduced the number of FNABs performed. The comparison of the three guidelines in our study indicated that they are effective screening methods for identifying malignant thyroid nodules. Among them, K-TIRADS showed the most effective diagnostic performance in sensitivity, while ACR-TIRADS yielded the best specificity. Full article

Background/Objectives: Guidelines for the risk stratification of thyroid nodules are based on certain well-recognized sonographic features of nodules. However, significant variations in reported sensitivity and specificity values are observed due to the overlap of imaging characteristics between benign and malignant nodules. Additionally, differences in ultrasound (US) equipment and the varying experience levels of radiologists performing the imaging procedures contribute to these discrepancies. Inevitably, there are also interobserver differences. The aim of this study was to investigate interobserver agreement on these criteria using the international thyroid imaging reporting and data system (I-TIRADS) thyroid evaluation framework, independently assessed by three residents and one consultant. Methods: We included 393 patients who underwent ultrasound-guided fine needle aspiration biopsy (FNAB) within four months. In each case, longitudinal and transverse video images of the thyroid gland, neck chain, and biopsied nodules were recorded. The evaluations of the parameters defined in the I-TIRADS dictionary were then performed by a radiologist with 15 years of experience and radiology assistants with 3, 3, and 2 years of experience, respectively, blinded to the images, pathology data, and patient demographics. The parameters evaluated included composition, echogenicity, margin, direction of growth, calcification, extension beyond the thyroid, and lymph node. An interobserver comparison between the US lexicon classifications of thyroid nodules was then performed. Results: The results of our study showed that the highest level of consensus was observed in the ‘mixed predominantly cystic’ classification, indicating a solid consistency between the assessors (κ = 0.729). Conversely, the subcategories ‘Solid’, ‘Mixed Predominantly Solid’ and ‘Spongiform’ showed moderate agreement, while the “Pure Cyst” subcategory exhibited the lowest level of agreement among the assessors (κ = 0.292). Agreement among the three radiology assistants was strong concerning the evaluation of nodule composition, growth direction, and lymph node assessment. In contrast, a moderate level of consensus was noted regarding the assessment of extrathyroidal extension, margins, and echogenicity. Notably, the parameter exhibiting moderate agreement across all readers was the presence of echogenic foci or calcifications. Conclusions: the reproducibility observed in the parameters defined within the lexicon supports its potential to enhance consistency and interobserver agreement in thyroid nodule assessment. Full article

Background: Mediastinal mass syndrome represents a major threat to respiratory and cardiovascular integrity, with difficult evidence-based risk stratification for interdisciplinary management. Methods: We conducted a narrative review concerning risk stratification and difficult airway management of patients presenting with a large mediastinal mass. This is supplemented by a case report illustrating our individual approach for a patient presenting with a subtotal tracheal stenosis due to a large cyst of the thyroid gland. Results: We identified numerous risk stratification grading systems and only a few case reports of regional anesthesia techniques for extracorporeal membrane oxygenation patients. Clinical Case: After consultation with his general physician because of exertional dyspnea and stridor, a 78-year-old patient with no history of heart failure was advised to present to a cardiology department under the suspicion of decompensated heart failure. Computed tomography imaging showed a large mediastinal mass that most likely originated from the left thyroid lobe, with subtotal obstruction of the trachea. Prior medical history included the implantation of a dual-chamber pacemaker because of a complete heart block in 2022, non-insulin-dependent diabetes mellitus type II, preterminal chronic renal failure with normal diuresis, arterial hypertension, and low-grade aortic insufficiency. After referral to our hospital, an interdisciplinary consultation including experienced cardiac anesthesiologists, thoracic surgeons, general surgeons, and cardiac surgeons decided on completing the resection via median sternotomy after awake cannulation for veno-venous extracorporeal membrane oxygenation via the right internal jugular and the femoral vein under regional anesthesia. An intermediate cervical plexus block and a suprainguinal fascia iliaca compartment block were performed, followed by anesthesia induction with bronchoscopy-guided placement of the endotracheal tube over the stenosed part of the trachea. The resection was performed with minimal blood loss. After the resection, an exit blockade of the dual chamber pacemaker prompted emergency surgical revision. The veno-venous extracorporeal membrane oxygenation was explanted after the operation in the operating room. The postoperative course was uneventful, and the patient was released home in stable condition. Conclusions: Awake veno-venous extracorporeal membrane oxygenation placed under local anesthetic infiltration with regional anesthesia techniques is a feasible individualized approach for patients with high risk of airway collapse, especially if the mediastinal mass critically alters tracheal anatomy. Compressible cysts may represent a subgroup with easy passage of an endotracheal tube. Interdisciplinary collaboration during the planning stage is essential for maximum patient safety. Prospective data regarding risk stratification for veno-venous extracorporeal membrane oxygenation cannulation and effectiveness of regional anesthesia is needed. Full article

Objectives: The aim of this study was to investigate the preoperative clinical and hematologic variables, including the neutrophil-to-lymphocyte ratio (NLR), that can be used to predict malignancy in patients with atypia of undetermined significance (AUS) thyroid nodules; we further aimed to develop a machine learning-based prediction model. Methods: We enrolled 280 patients who underwent surgery for AUS nodules at the Wonju Severance Christian Hospital between 2018 and 2022. A logistic regression-based model was trained and tested using cross-validation, with the performance evaluated using metrics such as the area under the receiver operating characteristic curve (AUROC). Results: Among the 280 patients, 116 (41.4%) were confirmed to have thyroid malignancies. Independent predictors of malignancy included age, tumor size, and the Korean Thyroid Imaging Reporting and Data System (K-TIRADS) classification, particularly in patients under 55 years of age. The addition of NLR to these predictors significantly improved the malignancy prediction accuracy in this subgroup. Conclusions: Incorporating NLR into preoperative assessments provides a cost-effective, accessible tool for refining surgical decision making in younger patients with AUS nodules. Full article

Background: Thyroid nodules are common yet remain a diagnostic challenge. While ultrasound and Thyroid Imaging Reporting and Data Systems (TIRADS) are accepted as standard, the use of thyroid scintigraphy in euthyroid patients is debated. The European Association of Nuclear Medicine advocates it, whereas the American Thyroid Association and European Thyroid Association do not. However, it has not been evaluated whether scintigraphy adds value to TIRADS in a multimodal approach. Our study addresses this gap by assessing the impact of integrated pertechnetate scintigraphy on TIRADS accuracy. Methods: The diagnostic performance of ACR-TIRADS, EU-TIRADS, pertechnetate scintigraphy, and multimodal models were retrospectively analyzed for 322 nodules (231 benign, 91 malignant) in 208 euthyroid patients with histopathology as a reference. Generalized estimating equations were used for statistical analysis. Results: On scintigraphy, 210 nodules were hypofunctional, 99 isofunctional, and 13 hyperfunctional. The AUC for thyroid scintigraphy, ACR-TIRADS, and EU-TIRADS were 0.6 (95% CI: 0.55–0.66), 0.83 (95% CI: 0.78–0.88), and 0.78 (95% CI: 0.72–0.83). Integrating scintigraphy with ACR-TIRADS and EU-TIRADS slightly increased diagnostic accuracy (AUC 0.86 vs. 0.83, p = 0.039 and AUC 0.80 vs. 0.78, p = 0.008) and adjusted the malignancy probability for intermediate risk TIRADS categories, with iso- or hyperfunctioning nodules in ACR-TIRADS-TR4 or EU-TIRADS-4 showing comparable malignancy probabilities as hypofunctioning nodules in TR3 or EU-TIRADS-3, respectively. Conclusions: Integrating thyroid scintigraphy with ACR- or EU-TIRADS moderately improves diagnostic performance, potentially benefiting management, especially in complex cases like multinodular goiter or indeterminate FNA. Further research is warranted to validate these findings and explore their clinical implications. Full article

The American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS) stratifies patients with thyroid nodules for further evaluation. We evaluated the accuracy of this risk stratification and compared it with that of fine-needle aspiration cytology (FNAC) and final pathology. The nodules (n = 381) of 329 patients (mean age, 45.5 y; 251 female) who underwent thyroid surgery from January 2021 to September 2023 were retrospectively analyzed for the ACR TI-RADS, FNAC, and final pathology results. The nodules were categorized according to risk of malignancy as 75.9% ACR TI-RADS 5, 72.6% ACR TI-RADS 4, 38.9% ACR TI-RADS 3, and 33.3% ACR TI-RADS 2. Considering ACR TI-RADS 5 and 4 as high-risk categories, the sensitivity, specificity, positive-predictive value, and negative-predictive value of the ACR TI-RADS categories were 77.9%, 57.3%, 73.8%, and 62.8%, respectively. With both ACR TI-RADS and FNAC high-risk categories combined, the sensitivity and specificity improved to 82.4% and 58.6%, respectively. The ACR TI-RADS score effectively predicts malignancy in higher-risk categories; however, some malignant cases were found within lower-risk categories, implying the need for careful utilization of this system. Combining high-risk ACR TI-RADS and FNAC results improves the diagnostic accuracy of thyroid nodules. Confirmation from further prospective studies is required. Full article

Purpose: To evaluate the impact of video sequences (cine-loops) on the interobserver agreement (IOA) using risk stratification systems (RSSs) for thyroid nodules (TNs). Methods: Twenty TNs were randomly selected from a large database and evaluated by twelve experienced observers using five different RSSs (Kwak-, ACR-, EU-, Korean-TIRADS, ATA Guidelines). In the first step, the evaluation was conducted based on static ultrasound (US) images in two planes (“static”). Six months later, these cases were reevaluated by the same observers using video sequences in two planes (“cine-loops”). Fleiss’ kappa (κ) was calculated for the IOA analyses. Results: IOA on static was moderate with κ values of 0.46, 0.42, 0.40, 0.45, and 0.38 for the Kwak-, ACR-, EU-, Korean-TIRADS, and ATA Guidelines, respectively, while the IOA on cine-loops was fair with κ values of 0.41, 0.38, 0.37, 0.36, and 0.34 for the Kwak-, ACR-, EU-, Korean-TIRADS, and ATA Guidelines, respectively. The overall IOA was superior in static images versus cine-loops (p = 0.024). Among other findings, the subgroup analyses (related to age, gender, US certificates, number of thyroid US per week, and RSSs experience) particularly showed that the experience of the observers in using RSSs had a significant influence on the IOA. Conclusions: The overall IOA (all twelve observers and all five RSSs) was superior on static US images in comparison to cine-loops. Furthermore, the overall IOA of the five US features revealed superior κ values of the static images over cine-loops. However, this impact was significantly lower when the observers were highly experienced in the use of US RSSs of TNs. Full article

Ultrasound (US) is the primary tool for evaluating patients with thyroid nodules, and the risk of malignancy assessed is based on US features. These features help determine which patients require fine-needle aspiration (FNA) biopsy. Classification systems for US features have been developed to facilitate efficient interpretation, reporting, and communication of thyroid US findings. These systems have been validated by numerous studies and are reviewed in this article. Additionally, this overview provides a comprehensive description of the clinical and laboratory evaluation of patients with thyroid nodules, various imaging modalities, grayscale US features, color Doppler US, contrast-enhanced US (CEUS), US elastography, FNA biopsy assessment, and the recent introduction of molecular testing. The potential of artificial intelligence in thyroid US is also discussed. Full article

Thyroid Ultrasound (US) is the primary method to evaluate thyroid nodules. Deep learning (DL) has been playing a significant role in evaluating thyroid cancer. We propose a DL-based pipeline to detect and classify thyroid nodules into benign or malignant groups relying on two views of US imaging. Transverse and longitudinal US images of thyroid nodules from 983 patients were collected retrospectively. Eighty-one cases were held out as a testing set, and the rest of the data were used in five-fold cross-validation (CV). Two You Look Only Once (YOLO) v5 models were trained to detect nodules and classify them. For each view, five models were developed during the CV, which was ensembled by using non-max suppression (NMS) to boost their collective generalizability. An extreme gradient boosting (XGBoost) model was trained on the outputs of the ensembled models for both views to yield a final prediction of malignancy for each nodule. The test set was evaluated by an expert radiologist using the American College of Radiology Thyroid Imaging Reporting and Data System (ACR-TIRADS). The ensemble models for each view achieved a mAP0.5 of 0.797 (transverse) and 0.716 (longitudinal). The whole pipeline reached an AUROC of 0.84 (CI 95%: 0.75–0.91) with sensitivity and specificity of 84% and 63%, respectively, while the ACR-TIRADS evaluation of the same set had a sensitivity of 76% and specificity of 34% (p-value = 0.003). Our proposed work demonstrated the potential possibility of a deep learning model to achieve diagnostic performance for thyroid nodule evaluation. Full article