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Rationale and Objectives To evaluate the efficacy of microwave ablation (MWA) for benign thyroid nodules (BTNs) and compare trauma and complication rates between MWA and traditional thyroidectomy for BTNs. Materials and Methods 84 patients with BTNs were recruited and followed up at 1, 3, 6, and 12months. 56 and 28 patients chose to undergo MWA (group A) and traditional thyroidectomy (group B), respectively. Efficacy was assessed by volume reduction rate (VRR) and therapeutic success rate (TSR) at each follow-up. Trauma was compared using inflammation response parameters, visual analog scale (VAS) scores, quality of life (QOL) and thyroid function measures at 1, 3, and 6 months. Complications rates were also compared. Results The VRR was 80.70 ± 18.60%, and TSR was 91.70% at 6-months. Furthermore, the VRR increased to 90.45 ± 11.51%, and TSR increased to 100% at 12-months. C-reactive protein levels were significantly higher in group B on the first postoperative day (POD) (3.89 ± 0.86 mg/mL vs 3.39 ± 0.56 mg/mL, p = 0.002). Visual analog scale scores were significantly lower in group A on the first and second POD. Thyroid stimulating hormone levels were significantly lower in group A at three (1.71 ± 1.12uIU/mL vs 2.37 ± 1.24uIU/mL, p = 0.013) and 6-months (1.34 ± 0.70uIU/mL vs 1.97 ± 0.94uIU/mL, p = 0.002). There were no significant between-group differences in QOL and complication rates. Conclusion Microwave ablation shows acceptable and promising efficacy. Compared with thyroidectomy, MWA was associated with less trauma and comparable complication rates.

To assess the application of American College of Radiology Thyroid Imaging Reporting and Data System (ACR-TIRADS) guidelines and the potential reduction of unnecessary fine-needle aspirate (FNA) and cost savings through examination of cytopathological correlation.All ultrasound-guided thyroid FNA performed between December 2017 and July 2019 at our institution were included in this study. Prior to performing each FNA, the nodules were scored according to ACR-TIRADS criteria with subsequent cytology scored according to Bethesda criteria. FNA request forms and preceding diagnostic ultrasound reports were analysed for clinical rationale behind each FNA. Collected data were applied to ACR-TIRADS, American Thyroid Association (ATA) and Korean TIRADS (K-TIRADS) criteria. Rate of reduction of unnecessary thyroid FNA and associated costs were subsequently calculated.A total of 125 patients and 146 nodules were evaluated. A malignancy rate of 7.5% was obtained. Sensitivity and specificity for detection of malignancy were 75% and 41% for ACR-TIRADS, 91% and 26% for ATA and 92% and 19% for K-TIRADS. Reduction in the rate of unnecessary FNA was most superior for ACR-TIRADS at 54.8%. Based on Australian Medicare Benefits Schedule item codes, a total of $18 452.70 might have been saved over the study period had ACR-TIRADS guidelines been uniformly followed.This study highlights the strengths and limitations of guidelines in the investigative pathway of thyroid nodules, including superiority of ACR-TIRADS in reducing the rate of unnecessary FNA. Continued education is needed towards application of guidelines among radiologists and referring clinicians, given the potential to reduce unnecessary FNA and achieve economic savings.

BACKGROUND: Thermoablation is an attractive treatment of thyroid nodules for its minimal-invasiveness. It remains unclear whether results and morbidity meet the patients’ expectations. OBJECTIVE: The aim of the presented study is to show data obtained after microwave thyroid ablation from a patients’ perspective. METHODS: Indications and preoperative diagnosis were chosen according to international guidelines. Thermoablation was achieved using a CE certified microwave system. The procedures heeded the published recommendations of the European Federation of Societies for Ultrasound in Medicine and Biology. Follow-up included ultrasound, laboratory parameters and a standardized questionnaire. RESULTS: Thirty patients were enrolled into the study. All patients reported an improvement of complaints following the procedure. Scar formation occurred in 3 cases (10%) with 0.5 ± 1.3 mm length and 0.4 ± 1.0 mm width. No cosmetic, neurological, vocal or pharyngeal complication occurred. Energy required for non-functioning nodules (n= 15, 50%) was 2.56 ± 3.41 kJ/mL, for autonomous adenoma (n= 8, 27%) 0.96 kJ/mL (p< 0.05, t-test). CONCLUSION: The presented data summarize an initial experience in selected patients and resemble excellent patient reported outcome with minimal morbidity. These preliminary data indicate the majority of patients satisfied with the procedure. Further trials will be required to endorse these findings.

BACKGROUND Few studies have compared the features of thyroid cancer among races and ethnicities. We hypothesized that race and ethnicity may influence the frequency and features of thyroid malignancy in thyroid nodules. METHOD This was a retrospective chart review of patients between 2013 and 2020 who underwent thyroidectomy. RESULTS In the analysis of 2737 patients, thyroid cancer was less prevalent among Blacks (24.0% vs Whites 52.1%, Hispanics 58.7%, Asians 71.7%, and Others 57.9%, p

Introduction About 15% to 30% of thyroid fine-needle aspiration (FNA) nodules have indeterminate cytology. The Afirma (Veracyte Inc, South San Francisco, CA) Gene Expression Classifier (GEC)/Gene Sequencing Classifier (GSC) tests were designed to improve risk stratification of the indeterminate thyroid nodules. This study aimed to evaluate and compare the performance of the Afirma GEC and GSC tests in the indeterminate thyroid lesions. Methods Thyroid FNA cases with indeterminate cytology were searched in the pathology database and only those with available Afirma results were selected for this study. Each patient’s demographic, sonographic, cytologic, molecular, and subsequent surgical follow-up results were collected and analyzed. Results There were 100 cases with indeterminate thyroid FNA results, including 49 cases tested by GEC and 51 cases by GSC. In the GEC group, benign call rate (BCR) was 53% (26 of 49) and the calculated negative predictive value (NPV) and positive predictive value (PPV) were 88% and 47% respectively. In the GSC group, the BCR was 63% (32 of 51) and the calculated NPV and PPV were 100% and 64%, respectively. Whereas only 17% (1 of 6) of benign oncocytic lesions were tested benign by the GEC, 60% (3 of 5) of benign oncocytic nodules were tested benign by the GSC. Conclusion We demonstrated in this study that a little more than half of the indeterminate thyroid nodules had negative Afirma GEC/GSC results and the BCR using the Afirma GSC test was higher than GEC. The Afirma GSC showed higher NPV and PPV than GEC. In addition, the Afirma GSC appeared to be superior for differentiating benign and malignant oncocytic thyroid lesions.

Background The risk of malignancy from nodules with atypia of undetermined significance cytology is estimated between 5% and 15%, though more recent studies suggest rates upwards of 48%. This study sought to characterize preoperative predictors of malignancy to aid in clinical decision-making. Methods We performed a single institution retrospective review of all adult patients with unilateral thyroid nodules demonstrating atypia of undetermined significance cytology between March 1, 2013 and June 1, 2019 who underwent surgical resection (n = 266). Univariate and multivariate logistical analysis was performed using clinical and demographic variables to identify potential preoperative characteristics associated with malignant disease. Results Malignancy was identified on final pathology in 24.7% of patients with atypia of undetermined significance cytology. Age, sex, exposure to ionizing radiation, family history of thyroid cancer, Hashimoto’s disease, Afirma suspicious results, and smoking were not associated with malignancy on both univariate and multivariate analysis. Nodule size >4 cm was independently associated with malignancy risk on both univariate (odds ratio 2.44, 1.09–5.43, P Conclusion The results of this study demonstrate that nodules with atypia of undetermined significance cytology >4 cm are strongly associated with malignancy. We recommend strong consideration of surgery for all patients with thyroid nodules >4 cm and atypia of undetermined significance cytology.

Introduction Molecular testing has helped clinicians and cytopathologists to further categorize indeterminate thyroid fine needle aspiration (FNA) specimens. The purpose of the present study was to evaluate the accuracy of commercially available molecular tests, review their effects on patient treatment, and correlate the molecular alterations with the histologic findings. Materials and methods A pathology laboratory information system search identified thyroid FNAs performed at our institution between January 1, 2015 and June 30, 2020. The results of surgical follow-up and ancillary molecular testing were collected. We evaluated the accuracy of these tests and whether they could reduce the number of surgeries performed. Results Our laboratory information system search identified 510 cases reported as atypia of undetermined significance, 94 as suspicious for follicular neoplasm, and 44 as suspicious for follicular neoplasm, Hurthle cell type. Of the specimens, 343 had no ancillary molecular testing, 146 were sent for ThyGenX/ThyraMIR, and 136 were sent for ThyroSeq. Of the patients without molecular testing, 50.4% had undergone follow-up surgery compared with 30.8% after ThyGenX/ThyraMIR and 38.2% after ThyroSeq testing, resulting in 38.9% and 24.2% fewer surgeries and an odds ratio of 0.04 (95% confidence interval, 0.00-0.33) and 0.14 (95% confidence interval, 0.01-0.95), respectively. For ThyGenX/ThyraMIR testing, the risk of malignancy for high and moderate to high risk alterations was 80%, 28.6% for moderate and low to moderate risk alterations, and 23.1% for low risk alterations. For ThyroSeq, the risk of malignancy was 87.5% for high risk alterations, 36.8% for intermediate to high risk alterations, 27.3% for intermediate risk alterations, and 0% for low risk alterations. The areas under the curve for ThyGenX/ThyraMIR and ThyroSeq testing were 0.65 and 0.85, respectively. Conclusions These findings suggest that, at our institution, both ThygenX/ThyraMIR and ThyroSeq can be used to effectively stratify cytology specimens based on the risk of malignancy and reduce the number of surgeries performed at our institution.

Rationale and Objective This study is a dedicated 2D-shear wave elastography (2D-SWE) review aimed at systematically eliciting up-to-date evidence of its clinical value in differential diagnosis of benign and malignant thyroid nodules. Methods PubMed, Web of Science, and Scopus databases were searched for studies assessing the diagnostic value of 2D-SWE for thyroid malignancy risk stratification published until December 2016. The retrieved titles and abstracts were screened and evaluated according to the predefined inclusion and exclusion criteria. Methodological quality of the studies was assessed using the Quality Assessment of Studies of Diagnostic Accuracy included in Systematic Review 2 (QUADAS-2) tool. Extracted 2D-SWE diagnostic performance data were meta-analyzed to assess the summary sensitivity, specificity, and area under the receiver operating characteristic curve. Results After stepwise review, 14 studies in which 2D-SWE was used to evaluate 2851 thyroid nodules (1092 malignant, 1759 benign) from 2139 patients were selected for the current study. Study quality on QUADAS-2 assessment was moderate to high. The summary sensitivity, specificity and area under the receiver operating characteristic curve of 2D-SWE for differential diagnosis of benign and malignant thyroid nodules were 0.66 (95% confidence interval [CI]: 0.64–0.69), 0.78 (CI: 0.76–0.80), and 0.851 (Q* = 0.85), respectively. The pooled diagnostic odds ratio, negative likelihood ratio, and positive likelihood ratio were 12.73 (CI: 8.80–18.43), 0.31 (CI: 0.22–0.44), and 3.87 (CI: 2.83–5.29), respectively. Conclusion Diagnostic performance of quantitative 2D-SWE for malignancy risk stratification of thyroid nodules is suboptimal with mediocre sensitivity and specificity, contrary to earlier reports of excellence.

In the setting of cancer pathology, molecular characterization of tumors providing diagnostic and predictive information is acquiring more and more relevance. Moreover, the advent of innovative technologies continuously improves the knowledge of the molecular landscape of tumors and strengthens the links between clinics, tumor pathology and molecular features. In the clinical management of patients with thyroid nodules and thyroid tumors, the aid of molecular testing is encouraged but still not strongly recommended by current guidelines. Also for this reason this field of study is attracting much interest. The nCounter system is a relatively new technology based on a direct hybridization of fluorescent probes to specific nucleic acid targets, followed by digital measurement of signals; the reaction is highly multiplexable and results are robust and reproducible. This review reports and discusses the available data related to the application of this specific technique to thyroid nodules and thyroid tumors samples. The available data indicate that nCounter system represents a solid approach for the research of relevant diagnostic and prognostic biomarkers in thyroid pathology.

Alterations in neck anatomy after thyroid surgery and post-operative fibrosis may be misleading by causing sonoelastographic changes in recurrent tissues in patients with recurrent nodular goiter and so may result in unnecessary biopsies or surgical procedures. Here, the aim was to examine thyroid sonoelastography values in patients developing a recurrence and presenting with recurrent nodular goiter with benign cytology after total or near-total thyroidectomy (T/N-TT). Twenty-nine nodules from 22 patients with a recurrence after T/N-TT whose biopsies were found to be benign constituted the patients, and 23 nodules from 23 participants among the non-operated patients having solitary or multiple thyroid nodules and with age, gender and body mass index values similar to those of the patients constituted our controls. Shear-wave velocity (SWV) values were measured. Average elapsed time after T/N-TT was 11.82 (4:25) y. No difference was detected between the groups in terms of localization and sonographic structures of the nodules. Nodule SWV values were higher in the operated recurrent nodular goiter group than in the controls (2.93 ± 0.87 m/s vs. 2.43 ± 0.33 m/s, respectively, p = 0.011). Because SWV values are high in operated recurrent nodular goiter patients, the utilization of reference sonoelastography values in those with unoperated goiter may yield misleading results in the differentiation of benign and malignant lesions.

BACKGROUND: This study aimed to investigate the ability of quantitative parameter-derived dual-source dual-energy computed tomography (DS-DECT) combined with machine learning to distinguish between benign and malignant thyroid nodules. METHODS: Patients with thyroid nodules and pathological surgical results who underwent preoperative DS-DECT were selected. Quantitative parameter-derived DS-DECT was applied to classify benign and malignant nodules. Then, machine learning and binary logistic regression analysis models were constructed using the DS-DECT quantitative parameters to distinguish between benign and malignant nodules. The receiver operating characteristic curve was used to assess the diagnostic performance. The DeLong test was used to compare the diagnostic efficacy. RESULTS: One hundred and thirty patients with 139 confirmed thyroid nodules were involved in the study. The malignant group had a significantly higher iodine concentration(nodule) (arterial phase) (P=0.001), normalized iodine concentration (arterial phase) (P=0.002), iodine concentration difference (P

Thyroid nodules are common in the general population, with higher prevalence in women and with advancing age. Approximately 5% of thyroid nodules are malignant; the majority of this subset represents papillary thyroid cancer. Ultrasonography is the standard technique to assess the underlying thyroid parenchyma, characterize the features of thyroid nodules, and evaluate for abnormal cervical lymphadenopathy. Various risk stratification systems exist to categorize the risk of malignancy based on the ultrasound appearance of a thyroid nodule. Nodules are selected for fine-needle aspiration biopsy on the basis of ultrasound features, size, and high-risk clinical history. Cytology results are classified by the Bethesda system into six categories ranging from benign to malignant. When cytology is indeterminate, molecular testing can further risk-stratify patients for observation or surgery. Surveillance is indicated for nodules with benign cytology, indeterminate cytology with reassuring molecular testing, or non-biopsied nodules without a benign sonographic appearance. Expected final online publication date for the Annual Review of Medicine, Volume 73 is January 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Thyroid nodules present a serious problem, and mostly they do not carry neoplastic characteristics. Thus, they do not need to be surgically treated. The risk of malignancy varies from 5 to 15 %. Steps to diagnose malignancy should include a careful clinical evaluation, laboratory tests, a thyroid ultrasound exam and a fine-needle aspiration biopsy. Fine-needle aspiration biopsy (FNAB) is the most important diagnostic tool in the assessment of thyroid nodules. Today it is considered the gold standard for malignancy diagnosis in thyroid cancer. In this review we evaluate the role of FNAB and post-operative cytology in the evaluation of thyroid nodules. FNA results are classified as diagnostic (satisfactory) or nondiagnostic (unsatisfactory). Unsatisfactory smears (5–10 %) result from hypocellular specimens usually caused by cystic fluid, bloody smears, or suboptimal preparation. Diagnostic smears are conventionally subclassified into benign, indeterminate, or malignant categories. Benign cytology (60–70 %) is negative for malignancy, and includes cysts, colloid nodule, or Hashimoto thyroiditis. Malignant cytology (5 %) is almost always positive for malignancy, and includes primary thyroid tumors or nonthyroid metastatic cancers. Indeterminate or suspicious specimens (10–20 %) include atypical changes, Hurthle cells or follicular neoplasms. The new Bethesda Cytologic Classification has a 6-category classification, subdividing indeterminate further by risk factors. Considering the increasing worldwide incidence of thyroid microadenomas, recently it is recommended to undergo FNAB under ultrasound guidance even in small (< 1cm) nodules if they are correlated with suspicious ultrasonographic features or suspicious neck lymph nodes. FNAB is a cheap and reliable diagnostic tool that can be used in the selection candidates for surgery and pre-operative diagnosis of thyroid carcinomas. It was concluded that FNAB is the gold standard in the evaluation of thyroid nodules and can prevent many unnecessary surgeries. False-negative FNA cytology remains a concern for clinicians treating patients with thyroid nodules. Post-operative histology give the definitive diagnosis and studies confirm that it has a significant discordance between pre-operative cytology and post-operative histology in patients with thyroid nodule. Cytopathologists should strengthen their criteria for the identification of adenomatous hyperplasia, thyroiditis, cystic lesions or suspicious thyroid nodules to avoid misdiagnoses.

To investigate the diagnostic accuracy of ultrasound microcalcifications for the detection of malignancy in thyroid nodules and determine the validity of the concept that ultrasound microcalcification reflects the presence of psammoma body calcification in thyroid nodules.The laboratory information system at University Hospital Galway, a tertiary referral hospital, was used to compile a list of patients who underwent thyroid lobectomy or complete thyroidectomy over a continuous 12-month period with both preoperative ultrasound and postoperative histology available (n=106) from January to December 2019. The haematoxylin and eosin-stained histology slides of each case were sourced and reviewed under light microscopy by a histopathologist to determine the presence of psammoma body calcification within both benign and malignant thyroid nodules. Two radiologists reviewed preoperative thyroid ultrasound images of each case independently and blindly, and reported on the presence of ultrasonographic microcalcification.There was a strong and significant relationship between the presence of preoperative ultrasound microcalcification and thyroid malignancy (p0.001). Ultrasound microcalcification had a high specificity (93%) and positive predictive value (75%) for thyroid malignancy, with a diagnostic accuracy of 76%. Negative predictive value was high at 76.7%, while sensitivity was low at 42.8%. There was a strong and significant association between the presence of preoperative ultrasound microcalcification in thyroid nodules and the presence of pathological psammoma bodies on histology (p0.001).Ultrasound microcalcification has a strong and significant association with malignancy in thyroid nodules. This study supported the theory that ultrasound microcalcification occurs secondary to the presence of psammoma bodies within thyroid nodules.

Purpose: A primary medical relevance of thyroid nodules consists of excluding thyroid cancer, present in approximately 5% of all thyroid nodules. Fine-needle aspiration biopsy (FNAB) has a paramount role in distinguishing benign from malignant thyroid nodules due to its availability and diagnostic performance. Nevertheless, intraoperative frozen section (iFS) is still advocated as a valuable tool for surgery planning, especially for indeterminate nodules. Methods: To compare the FNAB and iFS performances in thyroid cancer diagnosis among nodules in Bethesda Categories (BC) I to VI. The performance of FNAB and iFS tests were calculated using final histopathology results as the gold standard.Results: In total, 316 patients were included in the analysis. Both FNAB and iFS data were available for 272 patients (86.1%). The overall malignancy rate was 30.4%% (n=96). The FNAB sensitivity, specificity, and accuracy for benign (BC II) and malignant (BC V and VI) were 89.5%, 97.1%, and 94.1%, respectively. For all nodules evaluated, the iFS sensitivity, specificity, and accuracy were 80.9%, 100%, and 94.9%, respectively. For indeterminate nodules and follicular lesions (BC III and IV), the iFS sensitivity, specificity, and accuracy were 25%, 100%, and 88.7%, respectively. For BC I nodules, iFS had 95.2% of accuracy.Conclusion: Our results do not support routine iFS for indeterminate nodules or follicular neoplasms (BC III and IV) due to its low sensitivity. In these categories, iFS is not sufficiently accurate to guide the intraoperative management of thyroidectomies. iFS for BC I nodules could be a reasonable option and should be specifically investigated.

BACKGROUND: Radioiodine (131 I) is the treatment of choice for cats with hyperthyroidism. After 131 I, however, euthyroidism is not always achieved, with 5% to 10% of cats remaining persistently hyperthyroid and 20% to 50% developing iatrogenic hypothyroidism. OBJECTIVES: To identify pretreatment factors that may help predict persistent hyperthyroidism and iatrogenic hypothyroidism after treatment of cats using a novel 131 I dosing algorithm. ANIMALS: One thousand and four hundred hyperthyroid cats treated with 131 I. METHODS: Prospective, before-and-after study. Pretreatment predictors (clinical, laboratory, scintigraphic, 131 I dose, 131 I uptake measurements) of treatment failure or iatrogenic hypothyroidism were identified by multivariable logistic regression analysis. RESULTS: Cats that developed iatrogenic hypothyroidism were more likely to be older (odds ratio [OR] = 1.10; 95% confidence interval [CI], 1.04-1.17; P = .001), female (OR = 2.04; 95% CI, 1.54-2.70; P < .001), have detectable serum thyroid-stimulating hormone (TSH) concentrations (OR = 4.19; 95% CI, 2.0-8.81; P < .001), have bilateral thyroid nodules (OR = 1.57; 95% CI, 1.19-2.08; P < .001), have homogeneous, bilateral distribution of 99m Tc-pertechnetate uptake (OR = 2.93; 95% CI, 2.05-4.19; P < .001), have milder severity score (OR = 0.62; 95% CI, 0.49-0.79; P < .001), and have higher 131 I uptake (OR = 2.40; 95% CI, 1.75-3.28; P < .001). In contrast, cats remaining persistently hyperthyroid were more likely to be younger (OR = 0.81; 95% CI, 0.72-0.92; P < .001), have higher severity score (OR = 1.87; 95% CI, 1.51-2.31; P < .001), and have lower 131 I uptake (OR = 3.50; 95% CI, 1.8-6.80; P < .001). CONCLUSIONS AND CLINICAL IMPORTANCE: Age, sex, serum TSH concentration, bilateral and homogeneous 99m Tc-pertechnetate uptake on scintigraphy, severity score, and percent 131 I uptake are all factors that might help predict outcome of 131 I treatment in hyperthyroid cats. Cats with persistent hyperthyroidism had many predictive factors that directly contrasted those of cats that developed 131 I-induced hypothyroidism.

Purpose: Radiofrequency ablation (RFA) and ethanol ablation (EA) are effective and safe for benign symptomatic thyroid nodules (BSTNs). However, relatively little is known about the effects of these procedures on patients’ quality of life (QoL). This prospective, multicenter study evaluated the effects of RFA and EA on changes in thyroid-specific QoL in patients with BSTNs and assessed the volume reduction and safety of these procedures.Methods: Eighty-six consecutive patients with 86 BSTNs were prospectively included from two medical centers. RFA was performed for 55 BSTNs with solidity ≥50% and EA was performed for 31 BSTNs with solidity

Background: The association between Graves’ disease (GD) and co-existing thyroid cancer is still controversial and most of the previously reported data have been based on surgically treated GD patients. This study investigated the clinicopathological findings and prognosis of concomitant thyroid cancer in GD patients in the era of widespread application of ultrasonography.Methods: Data of GD patients who underwent thyroidectomy for thyroid cancer between 2010 and 2019 in three tertiary hospitals in South Korea (Asan Medical Center, Chonnam National University Hwasun Hospital, and Pusan National University Hospital) were collected and analyzed retrospectively. In the subgroup analysis, aggressiveness and clinical outcomes of thyroid cancer were compared nodular GD and non-nodular GD groups according to the presence or absence of the thyroid nodules other than thyroid cancer (index nodules).Results: Of the 15,159 GD patients treated at the hospitals during the study period, 262 (1.7%) underwent thyroidectomy for coexisting thyroid cancer. Eleven patients (4.2%) were diagnosed with occult thyroid cancer and 182 patients (69.5%) had microcarcinomas. No differences in thyroid cancer aggressiveness, ultrasonographic findings, or prognosis were observed between the nodular GD and non-nodular GD groups except the cancer subtype. In the multivariate analysis, only lymph node (LN) metastasis was an independent prognostic factor for recurrent/persistent disease of thyroid cancer arising in GD (P=0.020).Conclusion: The prevalence of concomitant thyroid cancer in GD patients was considerably lower than in previous reports. The clinical outcomes of thyroid cancer in GD patients were also excellent but, more cautious follow-up is necessary for patients with LN metastasis in the same way as for thyroid cancer in non-GD patients.

Graves’ disease (GD) is the most common cause of pediatric hyperthyroidism. In children and adolescents the clinical GD course is different from this seen in adults, due to low remission rate and high prevalence of adverse events related to treatment with antithyroid drugs (ATDs). The majority of patients in this group require definitive therapy. As in adults, there are two treatment options – thyroid ablation with radioactive iodine (RAI) or surgery with preferred procedure of total thyroidectomy (TT). The choice of definitive therapy depends on many important factors such as children‘s age, effectiveness of the first- line ATD treatment, presence of ATDs side effects, presence of large goiter or thyroid nodules and concomitant diseases. The following paper provides the current guidelines on GD management in children and compares the efficacy of both definitive treatment methods as well as the acute and long-term complication rates, which must be taken into account to choose the optimal therapeutic option.

Rationale and Objectives This study aims to evaluate the diagnostic accuracy, inter-reader, and intra-reader variability of the ACR Thyroid Imaging Reporting and Data System (TI-RADS) for risk-stratification of indeterminate thyroid nodules using next generation genetic sequencing and tissue histology as a reference standard. Materials and Methods Retrospective chart review was performed on all patients who underwent thyroid ultrasound for a nodule with subsequent fine-needle aspiration ± surgical resection from January 2017 to August 2018. Four radiologists with expertise in thyroid ultrasound assessed imaging twice, ≥1 month apart. Results of cytology and next generation genetic sequencing were used as a reference standard for high versus low risk of malignancy in each nodule. Inter-reader reliability between readers and intra-reader reliability between replicate self-reads for TI-RADS categorization were assessed. Univariate analysis, kappa statistics, and receiver operating characteristic curve were calculated. Results One hundred and thirty six nodules across 121 patients met inclusion criteria. 84.6% of patients were female and average age was 55.8 ± 14.1 years. One hundred and eighteen of 135 nodules (87%) had indeterminate cytology (Bethesda III or IV). One of 23 high-risk mutations was identified in 30.1% (42) of the nodules. Of the 52 patients who had surgery, 24 (47.1%) had confirmed malignant disease on surgical pathology. Inter-reader reliability between the four radiologists was marginal, κ = 0.293. Intra-reader reliability ranged from marginal to good, κ = 0.337 to κ = 0.560, respectively. The area under the receiver operating characteristic curve was 0.509, and no optimal TI-RADS Level for identifying high-risk nodules existed. Conclusion The ACR TI-RADS classification system performs with low inter-reader and intra-reader reliability when assessing the genetic risk of nodules with indeterminate cytology.

Background The Bethesda System for Reporting Thyroid Cytopathology has 6 diagnostic categories, each with an implied cancer risk of malignancy (ROM). Bethesda III, defined as atypia or follicular lesions of undetermined significance (AUS/FLUS) on fine needle aspiration (FNA), has an indeterminate ROM. This study investigates the utility of Afirma Gene Expression Classifier (GEC) and Thyroid Sequencing (ThyroSeq) molecular testing to predict malignancy in AUS/FLUS thyroid nodules. Methods A retrospective review of prospectively collected data of 1457 patients with index thyroid nodules who underwent FNA and thyroidectomy at a single academic institution was performed. Use of GEC or ThyroSeq for AUS/FLUS thyroid nodules was examined. GEC testing was reported benign or suspicious for malignancy whereas ThyroSeq testing was reported on a spectrum of low, intermediate or high ROM. Descriptive statistics were utilized to compare the ROM among AUS/FLUS thyroid nodules. Results Of 1457 patients with FNA thyroid cytology, 359 (25%) corresponded to AUS/FLUS results. There were 132 (37%) patients with GEC testing and 88 (24%) had ThyroSeq testing. ROM without GEC or ThyroSeq testing was 49%, whereas ROM with suspicious GEC was 55%. ROM with positive ThyroSeq was 73%. Among ThyroSeq patients, 43 had intermediate-risk mutations with 60% malignancy, and 23 had high-risk mutations with 96% malignancy (P Conclusion Surgical patients with AUS/FLUS thyroid nodules have a high ROM. High-risk ThyroSeq testing may have some utility in predicting malignancy, but GEC and intermediate-risk TGC results have limited value. Surgeons should carefully consider the utility of molecular tests to determine surgical resection.

Background. Gitelman syndrome (GS) is an inherited salt-losing renal tubulopathy characterized by hypokalemic metabolic alkalosis with hypomagnesemia and hypocalciuria. Patients can be asymptomatic until late adolescence or adulthood, and hence may be discovered incidentally during presentation with other illnesses. GS has been described in association with thyroid disorders and should be considered in patients with hyperthyroidism and persistent hypokalemia, especially in those with associated hypomagnesemia and hypocalciuria. Case summary. In this report, we describe an 18-year-old female who presented with hyperemesis gravidarum and thyrotoxicosis, and was incidentally found to have GS, confirmed by the sequence analysis of SLC12A3. Conclusions. Thyroid dysfunctions, such as hypothyroidism, thyrotoxicosis, and thyroid nodules, may develop during pregnancy. A structural homology between the beta-human chorionic gonadotropin and thyroid stimulating hormone molecules, as well as their receptors is probably the basis for the transient thyrotoxicosis crisis during pregnancy. Since hyperemesis in pregnancy can also lead to hypokalemia and alkalosis, a high index of suspicion for GS during pregnancy is required for timely diagnosis and management.

To report a new feature of contrast-enhanced ultrasound (CEUS) and its diagnostic performance for the prediction of papillary thyroid carcinoma (PTC).This retrospective study was conducted from October 2018 to March 2019, including 276 patients with 308 thyroid nodules who underwent CEUS examinations prior to surgery (90 patients, 122 nodules) or fine needle aspiration (186 patients, 186 nodules). Quantitative analysis of CEUS features was performed using time-intensity curves. After surgery, tissue sections stained with HE and an anti-CD34 primary antibody were used to characterize the cell number and microvessel density. The nodules were divided into retention and non-retention groups.There were 168 malignant nodules and 140 benign nodules. The contrast-agent retention (CAR) feature was only observed in 52 papillary carcinomas. The CAR feature showed the sensitivity of 30.9% albeit the high specificity of 100%, for the diagnosis of thyroid cancers. The maximum slope coefficient of the washout index was significantly lower in the retention group than in the non-retention group (P 0.001). The enhancement intensity during the late stage of enhancement index was significantly higher in the retention group than in the non-retention group (P 0.001). The cell number and microvessel density in nodules with CAR features were higher (P 0.001, P = 0.004).The combination of the retention pattern of the CEUS observed herein with other CEUS features may be a useful tool to improve the diagnostic of the PTC.

Our objective was to provide the various sonographic characteristics of clinically atypical subacute thyroiditis (CAST) in distinguishing CAST from papillary thyroid carcinomas (PTCs) by using conventional ultrasound (US) and contrast-enhanced ultrasound (CEUS). Forty-six CAST patients and 50 PTC patients were enrolled in this study. We evaluated the size, shape, margin, echogenicity, calcification, vascularity and CEUS parameters for each nodule. The final diagnosis of CAST was confirmed via fine-needle aspiration (FNA) or surgery. Of the 46 CASTs, 13 (28.3%) were confirmed by surgery to be benign, and 33 (71.7%) were proven by FNA to be benign. Univariate analysis indicated that compared with PTCs, CAST lesions more frequently had wider-than-taller shapes, blurred margins, the absence of microcalcifications, peripheral high echogenicity, the absence of internal vascularity, hypo-enhancement, centrifugal perfusion and a peak intensity index

Although nearly half of thyroid nodules with Bethesda V cytology (suspicious for malignancy) may be benign or harbor low-grade neoplasms that can be sufficiently treated with lobectomy, many patients with Bethesda V cytology continue to be treated with total thyroidectomy. The objectives of this study were to establish whether cytomorphologic and ultrasonographic features can determine appropriate surgery for thyroid nodules with Bethesda V cytology and how often patients are overtreated with total instead of partial thyroidectomy.Utilizing a 10-y prospective database starting January 1, 2004, cytomorphologic and ultrasonographic features of thyroid nodules with Bethesda V cytology were reviewed. Overtreatment was defined as total thyroidectomy when histopathology revealed benign nodule, noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) or a unilateral4 cm low risk cancer.Sixty-three patients were included in the study. Seventeen (27%) had benign, 14 (22%) NIFTP, and 32 (51%) malignant nodules. On cytology, nuclear pseudoinclusions, and on ultrasound, taller-than-wide configuration, were more common in malignant than benign or NIFTP nodules. Among 56 patients who underwent total thyroidectomy, 14 and 11 had a benign or NIFTP nodule, respectively, and 13 had a unilateral4 cm low risk cancer, suggesting that 68% (38/56) were overtreated.Total thyroidectomy for Bethesda V thyroid nodules may result in overtreatment in more than half of the patients. Although certain cytomorphologic and ultarsonographic features may be helpful in determining appropriate surgery for Bethesda V thyroid nodules, additional characteristics are needed to reduce overtreatment of these nodules.

Background: A globus sensation is one of the most common complaints in otolaryngological practice. Patients with no associated abnormalities detected during the usual examinations performed in ENT clinics, are being diagnosed with globus sensation. Cervical ultrasonography is usually not performed in ENT clinics; however, it is useful in screening diseases of the subcutaneous tissue/organs, whose detection is not possible with the routine ENT examinations. The purpose of our study was to elucidate whether cervical ultrasound examination identifies abnormalities in patients with globus sensation. Methods: A single-centre retrospective cohort study. Cervical ultrasonographic examinations were performed on patients with globus sensation at the Department of Otolaryngology, Head and Neck Surgery of Tottori university hospital, a tertiary care centre, from January 2013 to September 2017. The subjects were 74 patients who complained of globus sensation with no abnormality in general otolaryngological examination including laryngoscopy. Results: Ultrasonography detected structural abnormalities in 60.8% of the patients with globus sensation: thyroid disorders in 41 patients, including: 35 patients with thyroid nodules, 4 patients with Hashimoto’s disease, 1 patient with Grave’s disease, and 1 patient with subacute thyroiditis; Sjögren syndrome in 2 patients; and cervical lipoma in 1 patient. Furthermore, 2 patients with thyroid disorders had concomitant esophageal cancer. Conclusion: Cervical ultrasonography identified thyroid disorders in patients with globus sensation, despite the normal ENT status. Therefore, it would be appropriate to adopt cervical ultrasonography as a routine examination at ENT clinics for patients with globus sensation.

In an assessment of risk for differentiated thyroid cancer (DTC) in individuals with human papillary thyroid cancer (PTC) and thyroid nodules a cohort prospective study was undertaken to establish the significance of preoperative thyroid-stimulating hormone (TSH) levels. Confirmed histologically PTC cases in one tertiary care center, and matched healthy individuals were tested for TSH, T3, T4 and T4 free total. The ORs and 95% confidence intervals have been calculated using conditional logistic regression models (CI). The blood TSH levels were related to the higher risk of PTC for men (OR,0,09; 95% Ci, 04–0,21, 95% CI and women) compared with the middle tertile of the TSH levels in the normal range (OR,0,07; 95 percent CI, 0,04–0,1). Over the normal range of TSH levels, an elevated PTC risks were connected amongst women (OR 0,09; 95% CI, 0,04–0,21) but not amongst men (OR,0,07; 95% CI, 0,04–0,1). With an increase in TSH level in the normal range between men and women, the risk for PTC reduced (Ptrend=0.041 and 0.0001). The risk of PTC related to TSH levels has been dramatically elevated above the normal range for men and TSH values below the normal range for women.

Background The Thyroid Imaging Reporting and Data System (TIRADS) was created to assess risk of thyroid nodules through ultrasound. Plenty classifications methods for thyroid nodules have already been created, but none of them have yet achieved global utilization. This study analyzed the performance of the American College of Radiology (ACR) TIRADS, its reproducibility and the impact of its utilization as a screening method in a large Cancer Center cohort. Methods Thyroid nodules which underwent fine-needle aspiration (FNA) in a 1-year period were selected, with their ultrasound images retrospectively classified according to the ACR TI-RADS. Cytological evaluation of the nodules and final histology (whenever available) was used to assess risk of neoplasm (RON) and risk of malignancy (ROM) associated to each ACR-TIRADS category. Further analyses were also carried out according to recommendation or not of FNA by the ACR-TIRADS and nodule size. Inter-observer agreement for the system was also assessed. Results A total of 1112 thyroid nodules were included. RON for each category according to final cytological diagnosis was 0% for TR1 and TR2, 2.1% for TR3; 15.6% for TR4 and 68.9% for TR5. No significant difference was observed between the RON of the categories for cases above or below 1.0 cm. Nodules that met the criteria for FNA had 3 times greater chance of a positive outcome. Substantial agreement (kappa 0.77) was seen between two different observers. Conclusions ACR TI-RADS scoring system has demonstrated to be an accurate method to stratify thyroid nodules in a Cancer Center, with a high reproducibility.

Background A number of ultrasound risk stratification systems (RSSs) of thyroid nodule, often labeled as TIRADS (Thyroid Imaging Reporting and Data System), have been proposed. As a consequence, an increasing number of studies have been published on this topic. This systematic review was undertaken to answer specific questions in this field: how many articles and what type of studies have been published, which TIRADSs/RSSs have preferably been discussed, and what is the geographic distribution of the publications. Methods The study was conducted according to PRISMA. A specific search algorithm was used. Defined selection criteria were applied. Results 502 studies were finally included. The number of publications about TIRADSs/RSSs has increased over the time, being the Horvath TIRADS the most evaluated one. The first author of the article was from China in one fourth of cases. Conclusions The number of scientific articles focused on TIRADSs/RSSs is high and it has been importantly increased over the time.

Introduction: DICER1 syndrome is characterized by increased susceptibility to malignancies, mostly occurring in childhood. The range of phenotypic effects of DICER1 variants is under investigation, and the syndrome’s phenotypic spectrum is steadily widening. We report on three Italian families showing heterogeneous clinical presentation and reduced penetrance in family members. Case descriptions: Patient 1 is a 10-year-old girl with a Sertoli-Leydig cell tumor. Although family history was unremarkable, genetic testing identified a DICER1 germline variant, inherited from her healthy father. Benign thyroid nodules were subsequently diagnosed in both the proband and her father. Patient 2 is an 8-month-old boy with type 1 pleuropulmonary blastoma. His sister developed a nephroblastoma at age 2 years. A DICER1 novel variant was identified in both siblings and their healthy father. Patient 3 is a 22-year-old man who developed a spinal extramedullary intradural mass diagnosed as rhabdomyosarcoma with a peculiar tubular, gland-like component. Tumor testing revealed two pathogenic DICER1 variants, one of which was confirmed to be germline and identified in his 17-year-old healthy brother and in his father, who showed multiple thyroid nodules. Conclusions: Among our patients, three developed tumors most frequently associated with DICER1 syndrome (i.e. pleuropulmonary blastoma, nephroblastoma, and Sertoli-Leydig cell tumor). One developed a peculiar sarcoma of the spinal cord not previously described in DICER1 syndrome. Genetic testing in relatives highlighted the paternal origin and reduced penetrance in all families, with thyroid benign lesions as the most common features in otherwise unaffected individuals.

Introduction and objective: The present review work aims to assess the mutual influence that pregnancy may have on the progression of differentiated thyroid carcinoma as well as the influence that differentiated thyroid carcinoma may have on pregnancy. Synthesis: Thyroid cancer appears frequently in women at reproductive age and during pregnancy. Since the most common presentation is as a thyroid nodule, proper management of this condition constitutes a priority while pregnancy. Thyroid ultrasound and ultrasound-guided FNA are fundamental tools for both correct diagnosis and monitoring thyroid nodules. Also, differentiated thyroid carcinoma can happen during pregnancy in at least three different settings (newly diagnosed, papillary thyroid microcarcinoma under active surveillance, and differentiated thyroid carcinoma previously treated before pregnancy) that must be approached in different ways. Usually, pregnancy does not present any additional risk for the prognosis of differentiated thyroid carcinomas. Furthermore, differentiated thyroid carcinoma does not appear to have a negative influence on the progression of pregnancy for either the mother or the fetus. The treatment of choice for new-onset carcinomas is surgery, which should be postponed after delivery whenever possible or carried out in the second trimester in the most aggressive cases. Papillary microcarcinomas do not appear to be significantly influenced by pregnancy and do not require special monitoring during gestation. For previously treated carcinomas, pregnancy does not worsen the prognosis in most cases either. Only those classified as having an incomplete structural response require special attention in their follow-up. Treatment with the appropriate doses of levothyroxine to achieve the most appropriate TSH levels for the risk situation is another of the fundamental cornerstones in the management of differentiated thyroid carcinoma. Finally, treatment with I-131, if necessary, is formally contraindicated during pregnancy and lactation. Introducción y objetivo: el presente trabajo de revisión pretende valorar la influencia mutua que puedan tener la gestación sobre la progresión del carcinoma diferenciado de tiroides, así como la influencia que el carcinoma diferenciado de tiroides pueda tener sobre la gestación. Síntesis: El cáncer de tiroides aparece con frecuencia en mujeres en edad reproductiva y durante el embarazo. Dado que la presentación más común es en forma de nódulo tiroideo, el manejo adecuado de esta patología constituye una prioridad durante la gestación. La ecografía tiroidea y la PAAF guiada por ecografía son herramientas fundamentales tanto para el correcto diagnóstico como para el seguimiento de los nódulos tiroideos. Además, el carcinoma diferenciado de tiroides puede presentarse durante el embarazo en al menos tres escenarios diferentes (recién diagnosticado, microcarcinoma papilar de tiroides bajo vigilancia activa y carcinoma diferenciado de tiroides tratado previamente antes del embarazo) que deben abordarse de distintas maneras. Por lo general, el embarazo no presenta ningún riesgo adicional para el pronóstico de los carcinomas diferenciados de tiroides. Además, el carcinoma diferenciado de tiroides no parece tener una influencia negativa en la progresión del embarazo ni para la madre ni para el feto. El tratamiento de elección de los carcinomas de nueva aparición es la cirugía, que debe posponerse hasta después del parto siempre que sea posible o realizarse en el segundo trimestre en los casos más agresivos. Los microcarcinomas papilares no parecen estar significativamente influenciados por el embarazo y no requieren un seguimiento especial durante la gestación. Para los carcinomas tratados previamente, el embarazo tampoco empeora el pronóstico en la mayoría de los casos. Solo aquellos clasificados como de respuesta estructural incompleta requieren especial atención en su seguimiento. El tratamiento con las dosis correctas de levotiroxina para conseguir los niveles de TSH más adecuados a la situación de riesgo, constituye otro de los pilares fundamentales en el manejo del carcinoma diferenciado de tiroides. Finalmente, el tratamiento con I-131, si fuera necesario, está formalmente contraindicado durante el embarazo y la lactancia.

Background and Objective: Thyroid imaging reporting and data system (TI-RADS) is developed to determine the risk of malignancy in patients with thyroid nodules. The aim of this study was to determine the diagnostic accuracy of TI-RADS classification for diagnosing malignant thyroid nodules taking Fine needle aspiration cytology (FNAC) as a gold standard in the local population. Methods: In this cross-sectional validation study, 201 patients presenting with thyroid nodules at the Department of Radiology, Bakhtawar Amin Hospital Multan, Pakistan from July 2020 to December 2020 were included. In all patients, thyroid nodules were evaluated on grey scale (B-mode) modality. TI-RADS score was calculated for each patient. Patients with TI-RADS score 4 and 5 were labelled as having malignant nodules. After that FNAC samples were taken and sent for histopathologic evaluation of thyroid nodules. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of TI-RADS taking FNAC as a gold standard were determined. Results: The mean age of the patients was 47.8 ± 4.5 years; there were 129 (67.2%) women and 72 (35.82%) men. There were 42 patients who tested true positive and 36 patients tested false positive and 12 patients were false negative and 111 patients true negative. The TIRADS sensitivity was 77.8%, specificity was 75.5%, PPV was 53.8%, and NPV 90.2%. the diagnostic accuracy was 76.1%. Conclusion: Differentiating benign thyroid nodules from malignant using the TI-RADS score has a high diagnostic accuracy. Our study results support the TIRADS as a first-line imaging evaluation for diagnosis of thyroid malignancy.

Background: Thyroid fine needle aspiration (T-FNA) is a mainstay in management of thyroid nodules. However, the preparation of T-FNA specimens varies across institutions. Prior studies have compared diagnostic rates between different specimen preparations of T-FNA specimens and their associated advantages and disadvantages. However, few have compared the rates of all diagnostic categories of The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) between liquid-based preparations (LBPs) and a combination of LBP and conventional smear (CS) preparations. Our study compares TBSRTC diagnostic rates between these 2 cohorts and correlates cytologic diagnoses with subsequent thyroid resections to evaluate rates of neoplasia (RON) and malignancy (ROM). Methods: 584 consecutive thyroid FNA specimens were collected and stratified by preparation type (ThinPrep [TP] vs. CS & TP). Diagnostic rates for each TBSRTC diagnostic category were calculated. The institution’s electronic medical records database was searched for histologic diagnoses of previously sampled thyroid nodules to evaluate the RON and ROM. Results: Of 584 thyroid FNA specimens, 73 (12.5%) and 511 (87.5%) were evaluated by TP only and CS & TP, respectively, reflecting the predominance of rapid on-site evaluation (ROSE) with CS for T-FNAs at our institution. Of the TP only and CS & TP cohorts, 29 (39.7%) and 98 (19.2%) had subsequent resections, respectively. The frequency of non-diagnostic cases was lower in the CS & TP cohort (12.7% vs. 26%). While the diagnostic rate of follicular lesion of undetermined significance was similar for both cohorts, SFN categorization was only utilized in the CS & TP cohort (1.5% vs. 0%). Although RON and ROM were similar between cohorts in many of the TBSRTC categories, there was a higher RON associated with non-diagnostic specimens in the TP only cohort when the denominator included all non-diagnostic cases. Conclusion: The combination of CS and LBP may potentially decrease the non-diagnostic rate of T-FNA specimens as well as the number of passes required for diagnosis, particularly with ROSE. Evaluation of morphologic features highlighted in conventional smears may facilitate diagnostic categorization in the “suspicious for follicular neoplasm” category.

To report the results of a multicenter retrospective evaluation of the clinical outcomes of thermal ablation (TA) in a large series of autonomously functioning thyroid nodules (AFTN) with a follow-up protracted up to 3 years.Patients treated with single TA for an AFTN in Italy were included. Changes in nodule volume, TSH values, and ongoing anti-thyroid therapy were assessed at the 2-, 6-, 12-, 24-, and 36-month follow-up controls. Complications and need of any additional therapy after TA were also registered.A total of 361 patients (244 females, 117 males, median age 58 years, IQR 46-70 years) were included. Nodule volume was significantly reduced at all time points (p 0.001) (median volume reduction 58% at 6-month and 60% at 12-month). Serum TSH values increased significantly at all time points. After TA, anti-thyroid therapy was withdrawn in 32.5% of patients at 2 months, in 38.9% at 6 months, and in 41.3% at 12 months. A significant difference in the rate of patients who withdrawn medical therapy at 12 months was registered between small ( 10 mL) (74%), medium (49%), or large ( 30 mL) nodules (19%). A single major complication occurred (0.25%). Additional treatments were needed in 34/361 (9.4%) of cases including 4 (1.1%) surgical treatment.Image-guided thermal ablation offers a further safe and effective therapeutic option in patients with AFTN. Clinical outcomes are significantly more favorable in small than in large size AFTN.• Thermal ablations (TA) can be safely and effectively used in patients with autonomously functioning thyroid nodules (AFTN). • TA results in a clinically significant nodule volume reduction that is paralleled by TSH level normalization and anti-thyroid drug therapy discontinuation (after TA anti-thyroid therapy was withdrawn in 41.3% at 12 months). • Clinical outcomes after TA are more favorable in small nodules, and when a large amount of thyroid nodule tissue is ablated.

Introduction Hurthle cells are modified follicular thyroid cells, whose development and proliferation have been related to different stimuli inducing cellular stress. Most thyroid aspirates containing Hurthle cells are classified as indeterminate, although the specific risk of malignancy for this subtype of atypia remains unclear. The aim of our study was to assess if the presence of Hurthle cells in indeterminate thyroid nodules correlates with the risk of malignancy. We further evaluated if this risk can be modified by the presence of an underlying Hashimoto's thyroiditis. Materials and methods We retrospectively analyzed all indeterminate thyroid nodules that were surgically treated at our institution between January 2010 and March 2019. For each nodule, we inferred the presence of Hurthle cells in the cytological report. Cytological findings were then correlated with histological reports. Results 354 indeterminate thyroid nodules were included in the study. The rate of malignancy resulted significantly lower in nodules exhibiting Hurthle cells compared to those negative for this cellular pattern (11.4% vs 22.5%, p = 0.01). Although there was no difference in the rate of malignancy in the whole population according to the presence or absence of Hashimoto's thyroiditis (21.5 vs 18.5%, p = 0.63), the significantly lower prevalence of malignant lesions in nodules with Hurthle cells was confirmed only in the presence of a histologically documented Hashimoto's thyroiditis (6.2% vs 32%, p = 0.005). Conclusions The finding of Hurthle cells in indeterminate thyroid nodules is associated with a low risk of malignancy in patients with an underlying Hashimoto's thyroiditis. The clinical management of these lesions may therefore be more conservative.

Context.— Follicular thyroid nodules can be a source of diagnostic difficulties, particularly when they display atypical features commonly associated with malignancy, such as nuclear grooves. Objective.— To differentiate lesions with atypical features from similar-appearing benign and malignant lesions. Design.— Eighteen cases of atypical follicular thyroid nodules characterized by a solid growth pattern and prominent longitudinal nuclear grooves were studied and examined for clinicopathologic characteristics. Results.— The lesions occurred in 16 women and 2 men aged 36 to 88 years and measured from 0.2 to 1.5 cm. The tumors were well circumscribed and noninvasive, and histologically characterized by a predominantly solid growth pattern with rare scattered follicles or a combination of solid growth pattern with minor follicular areas. A striking feature seen in all cases was the occurrence of longitudinal nuclear grooves. Immunohistochemical stains showed negativity for cytokeratin 19 (CK19) and HBME-1 in 8 cases; in the other 10, there was focal positivity for HBME-1 in 4 cases and diffuse positivity in 6. All cases were negative for galectin-3 and for CK19, with the exception of 1 case, which was CK19+/HBME-1−. Next-generation sequencing of 16 cases with a 161-gene panel detected 14 single nucleotide variants in 12 cases, predominantly NRAS and HRAS mutations. Clinical follow-up ranging from 18 to 72 months (median, 43.7 months) did not disclose any evidence of recurrence or metastases. Conclusions.— We interpret these lesions as low-grade, indolent follicular proliferations that need to be distinguished from papillary thyroid carcinoma, follicular adenoma, and noninvasive follicular thyroid neoplasms with papillary-like nuclear features.

To conduct a meta-analysis to compare the short-term outcomes of transoral thyroidectomy vestibular approach (TOTVA) with non-transoral endoscopic thyroidectomy (NTET). MEDLINE, EMBASE, science citation index expanded, and the Cochrane Central Register of Controlled Trials in the Cochrane Library from January 2007 to January 2021 were searched for relevant literature. The evaluated endpoints were intra-operative and post-operative outcomes. Ten eligible, non-randomized comparative studies involving 1677 patients were included. Meta-analysis results revealed that TOTVA was associated with significantly longer operative time [weighted mean differences (WMD), 22.60; 95%confidence interval (CI), 7.51–37.69; P = 0.003]. No significant differences were found between TOTVA group and NTET group in terms of post-operative outcomes. TOTVA appears to be an equally feasible and safe surgical procedure as NTET for patients with benign thyroid nodules and selected differentiated thyroid carcinomas.

Thyroid abnormalities are well reported following childhood treatment for Hodgkin Lymphoma (HL). Limited information exists for adult patients and after modern treatments. We analyzed risks of thyroid disorders in 237 female participants treated at the Royal Marsden Hospital 1970-2015. Multivariable analyses of risk according to treatment and time-related factors, survival analyses, and Cox regression modeling were undertaken. Overall, 33.8% of patients reported thyroid disorders (hypothyroidism 30.0% and thyroid nodules 6.8%). Cumulative prevalence was 42.9% by 40 years follow-up. Risks were greatest after supradiaphragmatic radiotherapy (RR = 5.0, p

Background This study aims to report the results of a pioneering clinical study using the single-port transaxillary robotic thyroidectomy (START) for 200 patients with thyroid tumor and to introduce our novel two-step retraction method. Methods START was performed on consecutive 200 patients using the da Vinci Single-Port (SP) robot system from January 2019 to September 2020 at the Yonsei University Health System, Seoul, Korea. The novel two-step retraction technique, in which a 3.5 cm long incision is made along the natural skin crease, was used for the latter 164 patients. The surgical outcome and invasiveness of the SP two-step retraction method were analyzed. Results Among the 200 cases who underwent START, 198 were female and 2 were male, with a mean age of 34.7 (range: 13–58 years). Thyroid lobectomy was performed for 177 patients and total thyroidectomy was performed for 23 patients. Ten patients had benign thyroid nodules, whereas the other 190 had thyroid malignancy. The mean body mass index (BMI) was 22.2 ± 3.7 kg/m2 (range: 15.9–37.0 kg/m2). All of the operations were performed successfully without any open conversions, and patients were discharged on postoperative day 3 or 4 without significant complication. The mean operative time for thyroid lobectomy with the two-step retraction method was 116.69 ± 23.23 min, which was similar to that in the conventional robotic skin flap method (115.33 ± 17.29 min). We could minimize the extent of the robotic skin flap dissection with the two-step retraction method. Conclusions START is a practical surgical method. By employing the new two-step retraction method, we can maximize the cosmetic and functional benefits for patients and reduce the workload fatigue of surgeons by increasing robotic dependency.

Introduction: Ultrasound (USG) is the most commonly used imaging method to evaluate thyroid nodules. The sonographic features of thyroid nodules are very important to determine whether the nodule is benign or malignant. Fine Needle Aspiration Cytology (FNAC) is the gold standard to determine whether the nodule is benign or malignant. Objective: The purpose of this study was to compare ultrasound and color Doppler features of thyroid nodules with ultrasound-guided FNAC results to determine the relative importance of these features in predicting the risk of malignancy. Methodology: This prospective cross-sectional study was conducted in Birat medical college teaching hospital in Tankisinuwari, Morang, Nepal. The study was conducted from September 2019 to April 2021. In total sixty-one patients with thyroid nodules were evaluated for sonographic characteristics. Finally, USG guided FNA for cytopathological examination was performed. Both descriptive and inferential statistics were used to analyze the result. Results: Out of the 61 patients, 34 (55.7%) were females and 27 (44.2%) were males. Majority of the malignant nodules were solid 11 (91.6%), whereas cystic and mixed nodules were predominantly seen in benign nodules 18 (36.7%) and 30 (61.2%) respectively. In malignant nodules 10 (83.3%) were heterogeneous and 2 (16.6%) were isoechoic. In benign nodules 29 (59.1%) were heterogeneous and 15 (30.6%) were anechoic with comet-tail artifact and 5 (10.2%) were isoechoic. Among 12 malignant cases, internal and peripheral vascularity were equally present in six cases each. Benign nodules showed peripheral vascularity in 48 (97.9%) and internal vascularity was noted in only one nodule. All of the malignant nodules showed calcification. None of the benign nodules showed micro-calcification. In malignant cases, cervical lymph nodes were present in 7 (58.3%) and absent in 5 (41.6%). In benign cases, cervical lymph nodes were present in 4 (8.1%) and absent in 45 (91.83%). Conclusion: The ultrasound features associated with malignancy in thyroid nodules are predominantly solid component, presence of micro-calcifications and internal vascularity. Enlarged cervical lymph nodes are good predictors for malignancy. USG guided FNAC confirms the suspicious features of thyroid nodules seen on USG.

Was ist neu? Diagnose und Prognose Calcitonin ist ein sensitiver und spezifischer Tumormarker zur Früherkennung und Verlaufskontrolle des MTC. Daneben kommt dem Ultraschall der Schilddrüse eine entscheidende Rolle zu. Rolle des RET-Proto-Onkogens Das medulläre Schilddrüsenkarzinom (MTC) nimmt seinen Ursprung aus den parafollikulären Calcitonin-produzierenden C-Zellen. Es macht nur ca. 3–8 % aller Schilddrüsenkarzinome aus. Aktivierende Mutationen im RET (rearranged during transfection)-Gen liegen bei etwa 25 % der Patienten in der Keimbahn vor, werden aber auch beim sporadischen MTC als somatische Mutationen in ca. 60 % der Fälle beobachtet. Bei metastasierter Erkrankung findet sich in 90 % eine RET-Mutation. RET-Mutationen gelten als Treibermutationen und schließen weitere Treibermutationen weitestgehend aus. Seltener sind somatische Mutationen der RAS-Gene. Chirurgische Therapie Die chirurgische Resektion ist bis heute der einzige kurative Therapieansatz. Entscheidend für eine frühzeitige Diagnosestellung ist die Bestimmung des Serum-Calcitonins bei Nachweis von Schilddrüsenknoten. Die chirurgische Therapie steht auch bei der Behandlung lokoregionärer Rezidive oder lokal angehbarer Metastasen im Zentrum. Systemtherapie Bei irresektabel fortgeschrittener und progredienter Erkrankung mit signifikanter Tumorlast kann eine systemische Therapie erforderlich werden. Neuerdings ist die Kenntnis einer RET-Mutation im Tumorgewebe therapeutisch relevant, da mit den selektiven RET-Inhibitoren Selpercatinib und zukünftig Pralsetinib neue, effektive und gut verträgliche Systemtherapien zur Verfügung stehen. Ihr Einsatz ist nach Vortherapie mit einem der Multityrosinkinase-Inhibitoren Vandetanib oder Cabozantinib zugelassen und wird derzeit in der Erstlinientherapie in klinischen Studien untersucht.

Background While some studies suggest that the BRAF V600E mutation correlates with a high-risk phenotype in papillary thyroid microcarcinoma (PTMC), more evidence is necessary before this mutation can be used to help guide decision making in the management of small thyroid nodules. This study investigated whether BRAF V600E mutation is associated with aggressive features in PTMC (≤ 1 cm) and small PTC (1–1.5 cm). Methods Retrospective chart review was performed on 121 patient cases. Patients who underwent thyroid surgery for PTMC (≤ 1 cm) or small PTC (1–1.5 cm) were included if molecular testing was done for BRAF V600E mutation. Two study groups were created based on tumour size: PTMC (n = 55) and small PTC (n = 66). The groups were analysed for the presence of a BRAF V600E mutation and aggressive features, including macroscopic extrathyroidal extension (ETE), lymph node metastasis (LNM), and high-risk histological features (tall cell, columnar cell, hobnail, solid/trabecular, and diffuse sclerosing). The Fischer exact test was used to calculate statistical significance. Results BRAF V600E mutations were detected in 43.6% of PTMC and 42.4% of small PTC. Of the mutated PTMC nodules, 54.1% demonstrated aggressive characteristics as compared to 19.4% of the non-mutated PTMCs (p = 0.010). Of the mutated small PTC tumours, 82.1% had aggressive features. In contrast, 28.9% of the non-mutated small PTCs showed aggressive features (p Conclusions Our findings demonstrate an association between a BRAF V600E mutation and aggressive features in PTMC (≤ 1 cm) and small PTC (1–1.5 cm). Therefore, determining the molecular status of these thyroid nodules for the presence of BRAF V600E can help guide patient management. Graphical Abstract

OBJECTIVE To compare 2 ultrasound-based risk stratification systems in malignancy risk assessment of thyroid nodules and the clinical applicability of these guidelines in Brazil. METHODS We retrospectively reviewed the ultrasound findings of 314 patients (473 thyroid nodules) who underwent fine-needle aspiration (FNA) biopsy and/or surgery between February 2018 and March 2019. All nodules were classified using 2 systems: the Thyroid Imaging, Reporting, and Data System (TIRADS) of the American College of Radiology (ACR-TIRADS) and the TIRADS of the European Thyroid Association (EU-TIRADS). Both risk stratification systems were analyzed. We identified the diagnostic predictive values that yielded optimal sensitivity, specificity, positive predictive value, negative predictive value, and accuracy. RESULTS Of the 473 nodules, all underwent FNA, and histopathology was performed for 332 nodules. The agreement between the ACR-TIRADS and EU-TIRADS results and that between cytology and histopathology findings was 92.6% (kappa = 0.84) and 86.7% (kappa = 0.73), respectively. The area under the curve for the ACR-TIRADS and EU-TIRADS was 0.871 and 0.828, respectively (P < .001). The EU-TIRADS had the best sensitivity and negative predictive value, whereas the ACR-TIRADS had the best specificity, positive predictive value, and accuracy. Of the 473 nodules studied, only 158 (33.4%) followed the FNA size criteria suggested by the ACR-TIRADS. CONCLUSION ACR-TIRADS and EU-TIRADS had good diagnostic performances. However, most aspirated nodules did not follow the TIRADS indication; thus, the overuse of FNA as a diagnostic tool was observed.

Objective Longitudinal studies have investigated the effects of changing iodine status on thyroid disorders, but the effect of a transition from more than adequate iodine to adequate iodine on national changes in prevalence adjusted for changing risk factors remains unclear. Design Two repeat nationwide surveys were conducted from 2009–2010 to 2015–2017 to assess changes in thyroid disorder prevalence and iodine status in China. Methods A multistage stratified random sampling method was used to obtain a nationally representative sample of urban adults aged 18 and older in mainland China in 2009 (n = 14 925) and 2015 (n = 12 553). Changes in thyroid disorder prevalence, urinary iodine concentration (UIC), and thyroid-stimulating hormone (TSH) levels were assessed. Logistic regression models were used to examine changes in prevalence over time. Results The median UIC decreased significantly from 219.7 to 175.9 μg/L (P < 0.0001). The weighted prevalence of overt hyperthyroidism, subclinical hyperthyroidism, Graves’ disease, and goitre decreased between 2009 and 2015 in the overall population (P < 0.05 for all). Despite no significant changes in subclinical hyperthyroidism or hypothyroidism or anti-thyroid peroxidase or anti-thyroglobulin antibody positivity prevalence, a significant increase in thyroid nodule prevalence (P < 0.0001) was found in the overall population. The 2.5th TSH percentile increased by 0.15 mIU/L (95% CI: 0.01 to 0.30 mIU/L, P = 0.04) from 2009 to 2015. Conclusions With the iodine status transition from more than adequate to adequate, thyroid disorder (except for thyroid nodules) prevalence remained stable or even decreased after adjusting for confounding factors among adults in mainland China between 2009 and 2015. Additional studies are needed to explore the reasons for the increased thyroid nodule prevalence.

Thyroid nodules may be discovered in a variety of settings. Familiarity with their management is important for medical specialists. Workup should start with history and physical examination, proceed to laboratory studies, and then to imaging. Nodules are selected for fine needle aspiration (FNA) biopsy based on imaging criteria. Most nodules can be accurately diagnosed on cytopathology, but some may require additional molecular testing to evaluate risk of malignancy. Patients with malignant lesions require additional investigation before referral to an experienced thyroid surgeon. Those who have benign lesions may require monitoring by periodic ultrasound to identify nodules requiring reevaluation.

Background: The management of cytologically indeterminate thyroid nodules is challenging for clinicians. This study aimed to compare the diagnostic performance of the Korean Thyroid Imaging Reporting and Data Systems (K-TIRADS) with that of the American College of Radiology (ACR)-TIRADS for predicting the malignancy risk of indeterminate thyroid nodules.Methods: Thyroid nodules diagnosed by fine-needle aspiration (FNA) followed by surgery or core needle biopsy at a single referral hospital were enrolled.Results: Among 200 thyroid nodules, 78 (39.0%) nodules were classified as indeterminate by FNA (Bethesda category III, IV, and V), and 114 (57.0%) nodules were finally diagnosed as malignancy by surgery or core needle biopsy. The area under the curve (AUC) was higher for FNA than for either TIRADS system in all nodules, while all three methods showed similar AUCs for indeterminate nodules. However, for Bethesda category III nodules, applying K-TIRADS 5 significantly increased the risk of malignancy compared to a cytological examination alone (50.0% vs. 26.5%, P=0.028), whereas applying ACR-TIRADS did not lead to a change.Conclusion: K-TIRADS and ACR-TIRADS showed similar diagnostic performance in assessing indeterminate thyroid nodules, and K-TIRADS had beneficial effects for malignancy prediction in Bethesda category III nodules.

OBJECTIVE: To evaluate diagnostic value of Thyroid Imaging Reporting and Data System published by American College of Radiology (ACR TI-RADS) in 2017, ultrasound-guided fine-needle aspiration (US-FNA), and the combination of both methods in differentiation between benign and malignant thyroid nodules. METHODS: The data of US-FNA and ACR TI-RADS are collected from 159 patients underwent thyroid surgery in our hospital, which include a total of 178 thyroid nodules. A Bethesda System for Reporting Thyroid Cytopathology category of ≥IV and an ACR TI-RADS category ≥4 are regarded as diagnosis standards for malignancy in US-FNA and ACR TI-RADS, respectively. The pathological results after surgery are considered as the gold standard. The sensitivity, specificity, accuracy, positive predictive value and negative predictive value of the ACR TI-RADS, US-FNA and the combination of both methods for the differential diagnosis of thyroid nodules are calculated, respectively. RESULTS: The sensitivity, specificity and accuracy of ACR TI-RADS are 85.4%, 37.5%and 72.5%, respectively. The sensitivity, specificity and accuracy of US-FNA are 70.0%, 100%and 78.1%, respectively. After combining these two methods, the sensitivity, specificity and accuracy increase to 99.23%, 37.50%and 82.58%, respectively. The sensitivity of ACR TI-RADS is higher than that of US-FAN, and the sensitivity of combining these two methods is also higher than that of using ACR TI-RADS and US-FNA alone. CONCLUSION: The established ACR TI-RADS can help in selecting the target during nodule puncture, while the combination of ACR TI-RADS and US-FAN can further improve diagnostic ability for detecting malignant thyroid nodules.