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Background: The advent and increased use of high-resolution ultrasonography has resulted in improved detection of thyroid nodules. Even with the use of various Thyroid Imaging–Reporting and Data System, accurate imaging diagnosis of malignant thyroid nodules has been suboptimal, which necessitated use of newer modalities like contrast-enhanced ultrasonography alone and in combination for this purpose. Although the combined use of various Thyroid Imaging–Reporting and Data System and contrast-enhanced ultrasonography has turned out to be accurate in many studies, the ideal way to integrate contrast-enhanced ultrasonography into the Thyroid Imaging–Reporting and Data System algorithm is under-investigated. Purpose: To estimate and compare the diagnostic accuracy of American College of Radiology Thyroid Imaging–Reporting and Data System and contrast-enhanced ultrasonography in differentiating benign and malignant nodules alone and in combination. To estimate the diagnostic accuracy of contrast-enhanced ultrasonography in re-categorisation of Thyroid Imaging–Reporting and Data System 3 and Thyroid Imaging–Reporting and Data System 4 thyroid nodules. Materials and methods: This was a prospective cohort study performed in a tertiary care university–based hospital for 3 years. Adult patients with clinical or previous sonographic diagnosis of thyroid nodules were selected. Each of the nodules were assessed using ultrasonography and categorised using American College of Radiology Thyroid Imaging–Reporting and Data System criteria. The lesion was then assessed for contrast-enhanced ultrasonography features. The final diagnosis of the nodules was made using fine needle aspiration cytology. The diagnostic accuracy in diagnosis of malignant thyroid nodules for each of the American College of Radiology Thyroid Imaging–Reporting and Data System and contrast-enhanced ultrasonography alone and in combination was assessed. The diagnostic accuracy of contrast-enhanced ultrasonography in diagnosis of malignant thyroid nodules categorised as Thyroid Imaging–Reporting and Data System 3 and Thyroid Imaging–Reporting and Data System 4 was also assessed. Results: American College of Radiology Thyroid Imaging–Reporting and Data System had a sensitivity, specificity, negative predictive value, positive predictive value and diagnostic accuracy of 86.6%, 54.5%, 17.4%, 97.3% and 57.7%, respectively, in diagnosis of malignant thyroid nodules. Contrast-enhanced ultrasonography had a sensitivity, specificity, negative predictive value, positive predictive value and diagnostic accuracy of 86.6%, 95.4%, 67.9%, 98.4% and 94.4%, respectively, in diagnosis of malignant thyroid nodules. Contrast-enhanced ultrasonography had sensitivity, specificity, negative predictive value, positive predictive value and diagnostic accuracy of 93.3%, 100.0%, 100.0%, 99.2% and 99.3%, respectively, in re-categorisation of Thyroid Imaging–Reporting and Data System 3 and Thyroid Imaging–Reporting and Data System 4 nodules. Conclusion: Contrast-enhanced ultrasonography can play a key role in diagnosis of malignant thyroid nodules which are categorised as indeterminate on grey-scale ultrasound. [ABSTRACT FROM AUTHOR]

Background Many different risk stratification systems have been formulated for thyroid nodules, differing in their fine-needle aspiration cytology (FNAC) indication, suggesting a lack of consensus around the world. Purpose This prospective study was conducted to find the best guideline for risk stratification, for a better malignancy yield, and with reduced rates of negative FNACs among three Thyroid Imaging, Reporting, and Data System (TIRADS) guidelines. Materials and Methods A total of 625 thyroid nodules with conclusive FNAC or histopathological diagnosis were included in the study. Various sonographic parameters were recorded. They were classified into categories as per the three guidelines and compared with FNAC diagnosis. The guidelines were evaluated in terms of sensitivity, specificity, predictive values, and diagnostic accuracy. Sensitivity and specificity were compared by McNemar's test. Results American College of Radiology (ACR) TIRADS had the highest diagnostic accuracy (56.8%), specificity (50.75%), positive predictive value (23.92%), lowest rates of negative FNACs (76.08%), and high negative predictive value (97.84 %). Korean (K) TIRADS had the maximum sensitivity (97.75%), highest negative predictive value (98.44%), and gross malignancy yield. European TIRADS was between the two other guidelines in most parameters with specificity like K TIRADS. Conclusion All the three guidelines are very good screening tools, with comparable high sensitivity. ACR TIRADS is better in terms of specificity and reduced rates of negative FNACs. Including the presence of a suspicious cervical lymph node as a criterion and more frequent follow-up might further improve the diagnostic performance of the guideline. [ABSTRACT FROM AUTHOR]

Thyroid nodules remain a common diagnosis encountered in general and endocrine surgical practice, and thyroid cancer appears to be increasing in incidence in both the United States and worldwide. The understanding of the complex genetics surrounding thyroid neoplasia has increased substantially in recent years and, consequently, has become a consideration in risk stratification, diagnosis, prognosis, and treatment. Molecular genetic analysis of thyroid nodules is now a readily available technology for diagnostic purposes via analysis of fine-needle aspiration biopsy (FNAB) specimens. Although their routine use is controversial, they may aid in selecting which patients require surgery and those who may be safely observed. In the following review, the genetics of the tumorigenesis of thyroid cancer are reviewed, focusing on the most common and clinically relevant of the literally hundreds of known mutations. Following this, the current status of the use of genetic analysis and molecular diagnostics in the workup of thyroid nodules and the diagnosis of differentiated thyroid cancer is explored. Finally, evolving concepts relating to the use of thyroid cancer genetics in individualizing treatment planning, follow-up, and management of recurrent disease is discussed. The goal is to provide the general surgeon with a working knowledge of the most common genetic alterations present in differentiated thyroid cancer, their relevance in clinical practice, and how they impact prognosis and treatment. [ABSTRACT FROM AUTHOR]

Introduction: The Clinical Affairs Committee of the American Thyroid Association has developed this statement to describe recent changes in the billing and coding of ultrasound-guided fine needle aspiration procedures of thyroid nodules, and to raise awareness of the adverse consequences that have arisen as a result. Review: A reduction in payment of ultrasound-guided fine needle aspiration procedures was enacted by the Centers for Medicare and Medicaid Services in 2019. The Clinical Affairs Committee has sought to examine the effects of the change in reimbursement on the care of patients with thyroid diseases. Summary: The historical background of the changes in payment structure for ultrasound-guided fine needle aspiration of thyroid nodules is discussed. The years 2019 and 2020 saw a significant decline in claims for ultrasound-guided fine needle aspiration procedures, concomitant with a shift in the performance of these procedures away from non-facility outpatient settings and a rise in costs to the health care system. Conclusion: Several negative consequences of the decrease in reimbursement for ultrasound-guided fine needle aspiration of thyroid nodules have arisen. This has led to significant concern among clinicians who care for patients with thyroid diseases regarding delays in patient access to care and diagnosis, and a diminished pool of qualified thyroid specialists to perform these procedures in the future.

Aims: 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. Methods: 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. Results: 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. Conclusions: 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. [ABSTRACT FROM AUTHOR]

Background: Early thyroid cancers have excellent long-term outcomes, yet the word "cancer" draws unnecessary apprehension. This study aimed to define when the recommendations for observation and surveillance may be extended to early thyroid cancers at the population level. Methods: Non-metastasized thyroid cancers ≤40 mm diameter were identified from the 1975–2016 Surveillance, Epidemiology and End Results (SEER) database. Causes of death were compared across demographic data. Disease-specific outcomes were compared to the age-adjusted healthy United States (US) population. Survival estimates were computed using Kaplan–Meier and compared using the Cox proportional hazard model. Dynamic benchmarks impacting disease-specific overall survival were determined by decision tree modeling and tested by the Cox model. Results: Of the 28,728 thyroid cancers included in this study, 98.4% underwent some form of thyroid-specific treatment and were followed for a maximum of 10.9 years. This group had a 4.3% mortality rate at the end of follow-up (10.9 years maximum), with 13 times more deaths attributed to competing risks rather than thyroid cancer (stage T1a versus stage T1b, P=1.000; T1 versus T2, P<0.001). Among the untreated T1a or T1b tumors, the risk of disease-specific death was 21 times lower than death due to other causes. There was no significant difference between T1a and T1b tumors nor across sex. The age-adjusted risk of death for the healthy US population was higher than for the population with thyroid cancer. Dynamic categorization demonstrated worsening outcomes up to 73 years, uninfluenced by sex or tumor size. For patients over 73 years of age, only tumors >26 mm impacted outcomes. Conclusion: Based on the current data, T1a and T1b nodules have similar survival outcomes and are not significantly impacted even when left untreated. Multi-institutional prospective studies are needed to confirm these findings so that current observation and surveillance recommendations can be extended to certain T1 thyroid nodules. [ABSTRACT FROM AUTHOR]

Thyroid nodules are very common and found in up to 68% of the general U.S. population on ultrasound. Although thyroidectomy has long been the mainstay of treatment for malignant and symptomatic benign thyroid nodules, various interventional ablative techniques have emerged in the last couple of decades as alternative non-surgical treatment options. Globally, the most widely adopted technique has been ultrasound-guided radiofrequency ablation (RFA). RFA of thyroid nodules was first performed in 2002, and there has been an expanding body of evidence since 2006 showing that RFA and other interventional ablative techniques are effective treatments for benign solid thyroid nodules, toxic adenomas, and thyroid cysts. More recently, evidence has emerged that these techniques may be effective treatment for low-risk thyroid cancer and recurrent disease. Despite these findings, the United States has been slow to adopt these techniques, with only a single publication on RFA more than a decade after the first series was published. EM Rogers' Diffusion of Innovation Theory provides us the appropriate lens to carefully analyze the process of adoption of RFA for thyroid nodules-to understand where we are currently, as well as, the important next steps that must be accomplished in order for RFA and other ablative techniques to be successfully adopted into the management algorithm of thyroid nodules in the United States. [ABSTRACT FROM AUTHOR]

Context Radiofrequency ablation (RFA) has only recently gained popularity in the United States for treatment of thyroid nodules (TNs), with a limited number of patients having undergone the procedure in this country. Objective To evaluate the safety and efficacy of RFA of TNs performed in an outpatient setting in the United States. Methods This is a retrospective, single-center study of 53 patients who underwent RFA of 58 TNs between November 2018 and January 2021. The reduction in volume of nodule, cosmetic and symptomatic improvement, effect on thyroid function, and complications following RFA were assessed. Results Eleven out of 53 patients were excluded from the analysis. A total of 47 benign TNs (23 nonfunctioning thyroid nodules [NFTNs] and 24 autonomously functioning thyroid nodules [AFTNs]), were assessed after RFA. The median reduction in volume was 70.8% after a median follow-up period of 109 days, with symptomatic and cosmetic improvement (P < 0.0001). Compared with larger nodules, smaller nodules had greater volume reduction (P = 0.0266). RFA improved thyrotropin (TSH) in AFTNs (P value = 0.0015) and did not affect TSH in NFTNs (P value = 0.23). There were no major complications; however, 1 patient had self-limited local bleeding and another had transient voice change that recovered in 6 months. Conclusion RFA is a safe and efficacious treatment for symptomatic NFTNs and AFTNs in our population and is especially effective for smaller nodules. RFA should be considered an alternative for TNs in patients who cannot or do not want to undergo surgery. [ABSTRACT FROM AUTHOR]

Background: The American Thyroid Association (ATA) published the 2015 Management Guidelines for patients with thyroid nodules and differentiated thyroid cancer, recommending a shift to less aggressive diagnostic, surgical, and postoperative treatment strategies. At the same time and perhaps related to the new guidelines, there has been a shift to outpatient thyroid surgery. The aim of the current study was to assess physician adherence to these recommendations by identifying and quantifying temporal trends in the rates and indications for thyroid procedures in the inpatient and outpatient settings. Methods: Using the IBM® MarketScan® Commercial database, we identified employer-insured patients in the United States who underwent outpatient and inpatient thyroid surgery from 2007 to 2018. Thyroid surgery was classified as total thyroidectomy (TT), thyroid lobectomy (TL), or a completion thyroidectomy. The surgical indication diagnosis was also determined and classified as either benign or malignant thyroid disease. We compared outpatient and inpatient trends in surgery between benign and malignant thyroid disease both before and after the release of the 2015 ATA guidelines. Results: A total of 220,088 patients who underwent thyroid surgery were included in the analysis. Approximately 80% of TLs were performed in the outpatient setting versus 70% of TTs. Longitudinal analysis showed a statistically significant changepoint for TT proportion occurring in November 2015. The proportion of TT as compared with TL decreased from 80% in September 2015 to 39% by December 2018. For thyroid cancer, there is an increasing trend in performing TL over TT, increasing from 17% in 2015 to 28% by the end of 2018. Conclusions: There was a significant changepoint occurring in November 2015 in the operative and management trends for benign and malignant thyroid disease. [ABSTRACT FROM AUTHOR]

This study aimed to determine the diagnostic accuracy of the American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS) classification and shear-wave elastography (SWE) for the diagnosis of benign and malignant thyroid nodules. This retrospective study enrolled 141 patients (18-84 y of age) undergoing thyroidectomy between January 2015 and August 2020. All statistical analysis was based on pathologic results of patients. The cut-off value was found as category 4 for ACR TI-RADS classification and 5 m/s for shear-wave velocity (Vs) by the receiver operator characteristic curve analysis (area under the curve [AUC] = 0.684, p = 0.020 and AUC = 0.715, p = 0.005, respectively). SWE has higher diagnostic accuracy than the ACR TI-RADS classification system and can improve thyroid nodule discrimination in all sizes of the nodules. Also, the diagnostic performance decreases when the nodule diameter increases. [ABSTRACT FROM AUTHOR]

Objective: The 2017 revised Bethesda System for Reporting Thyroid Cytopathology (BSRTC) included new malignancy rates for each category as well as new management recommendations. Here, we evaluate the malignancy rate and test performance for BSRTC categories in a middle‐sized institution outside the United States (US). Design: Retrospective single centre case series with chart review. Patients: All patients who underwent thyroid surgery with a preoperative BSRTC between the years 2010 and 2018 at our institution. Measurements: In order to assess the malignancy rate for each BSRTC, all medical records were reviewed to collect demographics, nodule's size, BSRTC and final pathology. Results: Three hundred and sixty‐four patients were included, with an overall malignancy rate of 34.3%. The malignancy rate for BSRTC categories I‐VI was as follows: 13.3%, 5.1%, 25.0%, 24.4%, 91.3% and 95.2%, respectively. The most sensitive test was when BSRTC III‐VI were evaluated (91%). Overall best performance (sensitivity, specificity, PPV, NPV and accuracy) was obtained when BSRTC V‐VI were grouped together with a substantial decrease when adding BSRTC III‐IV (90%, 97%, 94%, 95%, 95% vs, respectively, 91%, 73%, 62%, 95%, 79%, respectively). Conclusions: Despite differences from the reported 2017 BSRTC malignancy rates, we demonstrated that the revised 2017 BSRTC management recommendations for thyroid nodules are also valid in smaller non‐US centre, supporting its use globally. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the value of Korean, American, and Chinese ultrasound risk stratification systems combined with BRAF(V600E) mutation in the detection of papillary thyroid carcinoma (PTC)within cytologically indeterminate thyroid nodules (CITNs)., Methods: A single-center retrospective study encompassed 511 CITNs selected from 509 patients between January 2020 and July 2023.Each nodule underwent surgical treatment and was classified according to three distinct systems. Receiver operating characteristic (ROC) curves were plotted using histopathological diagnosis as the reference standard, and diagnostic performance was compared., Results: The three ultrasound stratification systems showed an elevated malignant risk with increasing grades (all P for trend 2  < 0.001). The cut-off values for Korean, American, and Chinese systems were 5, 5, and 4c, and their respective area under the curves (AUCs) were 0.735, 0.778, and 0.783.The combination of BRAF (V600E) mutation significantly enhanced the diagnostic efficacy for the Korean(0.773vs0.735, P < 0.001), American (0.809vs0.778, P < 0.001) and Chinese (0.815vs0.783, P < 0.001) stratification systems in distinguishing CITNs without compromising specificity. When the three stratification systems were applied individually or combined with BRAF (V600E) mutation, the AUCs of the American and Chinese systems were similar (all P > 0.05), both of which were higher than the AUC of the Korean system (all P < 0.05). The American system exhibited higher specificity compared to the Chinese and Korean systems (all P < 0.001), whereas the Chinese system demonstrated higher sensitivity and accuracy when compared to the American and Korean systems (all P < 0.001)., Conclusion: Korean, American and Chinese stratification systems present potential in the differential diagnosis of CITNs. BRAF (V600E) mutation can significantly improve the detection rate of malignant nodules within CTNs, particularly PTC. Notably, the American and Chinese systems demonstrate superior overall diagnostic performance among these systems., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: The aim of the work described here was to develop and validate a predictive nomogram based on combined image features of gray-scale ultrasonography (US), elastosonography (ES) and contrast-enhanced US (CEUS) to differentiate malignant from benign American College of Radiology Thyroid Imaging, Reporting and Data System (ACR TI-RADS) 3-5 thyroid nodules., Methods: Among 2767 thyroid nodules scanned by CEUS in Xijing Hospital between April 2014 and November 2018, 669 nodules classified as ACR TI-RADS 3-5 were included, with confirmed diagnosis and ES examination. Four hundred fifty-five nodules were set as a training cohort and 214 as a validation cohort. Images were categorized as gray-scale US ACR TI-RADS 3, TI-RADS 4 and TI-RADS 5; ES patterns of ES-1 and ES-2; and CEUS patterns of either heterogeneous hypo-enhancement, concentric hypo-enhancement, homogeneous hyper-/iso-enhancement, no perfusion, hypo-enhancement with sharp margin, island-like enhancement or ring-like enhancement. On the basis of multivariate logistic regression analysis, a predictive nomogram model was developed and validated by receiver operating characteristic curve analysis., Results: In the training cohort, ACR TI-RADS 4 and 5, ES-2, heterogeneous hypo-enhancement, concentric hypo-enhancement and homogeneous hyper-/iso-enhancement were selected as predictors of malignancy by univariate logistic regression analysis. A predictive nomogram (combining indices of ACR TI-RADS, ES and CEUS) indicated excellent predictive ability for differentiating malignant from benign lesions in the training cohort: area under the receiver operating characteristic curve (AUC) = 0.93, 95% confidence interval (CI): 0.90-0.95. The prediction nomogram model was determined to have a sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of 0.84, 0.88, 0.91 and 0.81. In the validation cohort, the AUC of the prediction nomogram model was significantly higher than those of the single modalities (p < 0.005) . The AUCs of the validation cohort were 0.93 (95% CI: 0.89-0.96) and 0.93 (95% CI: 0.89-0.97), respectively, for senior and junior radiologists. The prediction nomogram model has a sensitivity, specificity, PPV and NPV of 0.86, 0.87, 0.87 and 0.86., Conclusion: A predictive nomogram model combining ACR TI-RADS, ES and CEUS exhibited potential clinical utility in differentiating malignant from benign ACR TI-RADS 3-5 thyroid nodules., Competing Interests: Conflict of interest The authors declare no conflicts of interest., (Copyright © 2023 World Federation for Ultrasound in Medicine & Biology. Published by Elsevier Inc. All rights reserved.)

Objective: This study aims to evaluate the diagnostic accuracy of the American College of Radiology Thyroid Imaging Reporting Data System (ACR TI-RADS) in identifying nodules that need to undergo fine-needle aspiration biopsy (FNAB) and identify specific thyroid ultrasound characteristics of nodules associated with thyroid malignancy in Filipinos in a single tertiary center., Methodology: One hundred seventy-six thyroid nodules from 130 patients who underwent FNAB from January 2018 to December 2018 were included. The sonographic features were described and scored using the ACR TI-RADS risk classification system, and the score was correlated to their final cytopathology results., Results: The calculated malignancy rates for TI-RADS 2 to TI-RADS 5 were 0%, 3.13%, 7.14%, and 38.23%, respectively, which were within the TI-RADS risk stratification thresholds. The ACR TI-RADS had a sensitivity of 89.5% and specificity of 54%, LR + of 1.95 and LR - of 0.194, NPV of 97.7%, PPV of 19.1%, and accuracy of 58%., Conclusion: The ACR TI-RADS may provide an effective malignancy risk stratification for thyroid nodules and may help guide the decision for FNAB among Filipino patients. The classification system may decrease the number of unnecessary FNABs for nodules with low-risk scores., Competing Interests: The authors declared no conflict of interest., (© 2024 Journal of the ASEAN Federation of Endocrine Societies.)

Background: Risk stratification systems for thyroid nodules are limited by low specificity. The fine-needle aspiration (FNA) biopsy size thresholds and stratification criteria are based on evidence from the literature and expert consensus. Our aims were to investigate the optimal FNA biopsy size thresholds in the American College of Radiology (ACR) Thyroid Imaging Reporting and Data System (TI-RADS) and artificial intelligence (AI) TI-RADS and to revise the stratification criteria in AI TI-RADS. Methods: A total of 2596 thyroid nodules (in 2511 patients) on ultrasound examination with definite pathological diagnoses were retrospectively identified from January 2017 to September 2021 in 6 participating Chinese hospitals. The modified criteria for ACR TI-RADS were as follows: (1) no FNA for TR3; (2) FNA threshold for TR4 increased to 2.5 cm. The modified criteria for AI TI-RADS were as follows: (1) 6-point nodules upgraded to TR5; (2) no FNA for TR3; (3) FNA threshold for TR4 increased to 2.5 cm. The diagnostic performance and the unnecessary FNA rate (UFR) of modified versions were compared with the original ACR TI-RADS. Results: Compared with the original ACR TI-RADS, the modified ACR (mACR) TI-RADS yielded higher specificity (73% vs. 46%), accuracy (74% vs. 51%), area under the receiver operating characteristic curve (AUC; 0.80 vs. 0.70), and lower UFR (25% vs. 48%; all p  < 0.001), although the sensitivity was slightly decreased (87% vs. 93%, p  = 0.057). Compared with the original ACR TI-RADS, the modified AI (mAI) TI-RADS yielded higher specificity (73% vs. 46%), accuracy (75% vs. 51%), AUC (0.81 vs. 0.70), and lower UFR (24% vs. 48%; all p  < 0.001), although the sensitivity tended to be slightly decreased (89% vs. 93%, p  = 0.13). There was no significant difference between the mACR TI-RADS and mAI TI-RADS in the diagnostic performance and UFR (all p  > 0.05). Conclusions: The revised FNA thresholds and the stratification criteria of the mACR TI-RADS and mAI TI-RADS may be associated with improvements in specificity and accuracy, without significantly sacrificing sensitivity for malignancy detection.

Background: Care for patients with thyroid nodules is complex and multidisciplinary, and research demonstrates variation in care. The objective was to develop clinical guidelines and quality metrics to reduce unwarranted variation and improve quality. Methods: Multidisciplinary expert consensus and modified Delphi approach. Source documents were workflow algorithms from Kaiser Permanente Northern California and Cancer Care of Ontario based on the 2015 American Thyroid Association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer. Results: A consensus‐based, unified preoperative, perioperative, and postoperative workflow was developed for North American use. Twenty‐one panelists achieved consensus on 16 statements about workflow‐embedded process and outcomes metrics addressing safety, access, appropriateness, efficiency, effectiveness, and patient centeredness of care. Conclusion: A panel of Canadian and United States experts achieved consensus on workflows and quality metric statements to help reduce unwarranted variation in care, improving overall quality of care for patients diagnosed with thyroid nodules. [ABSTRACT FROM AUTHOR]

Objectives: To assume the ideal cut-off values and diagnostic performance of two thyroid imaging reporting and data systems published by the Korean Thyroid Association/Korean Society of Thyroid Radiology (Korean TI-RADS) and the American Thyroid Association (ATA TI-RADS)., Methods: Eighteen studies with 25,422 patients from PubMed, SCOPUS, Embase, Web of Science, and Cochrane Library databases up to August 2022. True and false positive and negative values with characteristics were extracted., Results: The highest area under the receiver operating characteristic curve (AUC) was 0.893 and 0.887 for Korean and ATA TI-RADS. High suspicion was judged as the best cut-off value with the highest AUC based on optimal sensitivity and specificity. In determining the risk of malignant thyroid nodules, high suspicion in Korean and ATA TI-RADS showed sensitivity as 71.3% and 73.5%, specificity as 7.9% and 86.4%, diagnostic odds ratios as 20.0289 and 20.9076, AUC as 0.893 and 0.887. There was no significant difference when directly comparing the diagnostic accuracy of both TI-RADS., Conclusion: The two risk stratification systems had good diagnostic performance with high AUC and no significant differences. The ideal cut-off can depend on the medical condition or thyroid nodules, because the changes of cut-off point may reciprocally alter sensitivity and specificity., (© 2023. Italian Society of Medical Radiology.)

Objective To evaluate whether women during early pregnancy with 'hypothyroidism' symptoms are at risk of biochemically defined hypothyroidism. The 2017 Guidelines of the American Thyroid Association ( ATA) recommend case-finding on the basis of symptoms to identify these women during pregnancy, while evidence is lacking. Design Construct validation of a thyroid hypofunction symptom checklist during the first trimester of pregnancy comparing high scores with biochemically defined hypothyroidism. Patients A total of 2198 healthy pregnant women from an iodine-sufficient area in 2013-2014. Measurements Completion of a draft questionnaire with 'classical' symptoms of hypothyroidism at 12 weeks of gestation. The 2.5th and 97.5th percentiles of TSH and fT4 during pregnancy in TPO-Ab-negative (<35 kU/L) women were used to define euthyroid women and those with overt (clinical) and subclinical hypothyroidism. The prevalence of overt (subclinical) hypothyroidism was compared between women with high symptom scores and those with low symptom scores. Results According to fT4 and TSH cut-offs (0.23-4.0 mIU/L and 11.5-18.0 pmol/L, respectively), there were 15 women with 'to treat hypofunction' (overt hypothyroidism or TSH >10 mIU/L) and 68 women with subclinical hypothyroidism. Questionnaire construct validation revealed a 12-item hypothyroid checklist with normally distributed scores. The cut-off indicating high scores of OH was set at 1 SD > mean. Women with high symptom scores did not present more often with biochemically defined thyroid hypofunction. Conclusion This study does not support the ATA recommendation that pregnant women who require levothyroxine therapy can be identified by case-based screening of women with symptoms of thyroid disease. [ABSTRACT FROM AUTHOR]

Objective: To compare the diagnostic efficacy of the Chinese Thyroid Imaging Reporting and Data Systems (C-TIRADS) with the well-accepted ACR-TIRADS guidelines in identifying benign from malignant thyroid nodules., Methods: A total of 2064 nodules were collected from 1627 patients undergoing thyroid ultrasonography in our center between October 2019 and November 2021. Nodules were divided into two groups: "≥1 cm" and "<1 cm". Ultrasound features of each nodule were observed and recorded by two physicians with more than 15 years of experience and classified according to the ACR-TIRADS and C-TIRADS guidelines, respectively., Results: The area under the curve of the ACR-TIRADS guideline was higher than that of the C-TIRADS guideline (0.922, P = 0.017), the specificity and positive predictive value of the C-TIRADS guideline were higher (81.64%, 88.72%, all P < 0.05), which was more significant in the subgroup of nodules <1 cm (P = 0.001). In addition, there was no statistical difference between the two guidelines in the diagnostic efficacy indicators for nodules ≥1 cm. The ACR-TIRADS effectively reduced unnecessary biopsies compared with the C-TIRADS (P < 0.05)., Conclusions: There was high agreement between the two guidelines for the diagnosis of thyroid nodules, C-TIRADS guidelines had a higher specificity and simplicity while were inferior to the ACR-TIRADS guidelines in terms of reducing the number of biopsies., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: The most commonly employed diagnostic criteria for identifying thyroid nodules include Thyroid Imaging and Reporting Data System (TI-RADS) and American Thyroid Association (ATA) guidelines. The purpose of this systematic review and meta-analysis is to determine the inter-rater reliability of thyroid ultrasound criteria., Methods: We performed a library search of MEDLINE (Ovid), EMBASE (Ovid), and Web of Science for full-text articles published from January 2005 to June 2022. We included full-text primary research articles that used TI-RADS and/or ATA guidelines to evaluate thyroid nodules in adults. These included studies must have calculated inter-rater reliability using any validated metric. The Quality Appraisal for Reliability Studies (QAREL) was used to assess study quality. We planned for a random-effects meta-analysis, in addition to covariate and publication bias analyses. This study was performed in accordance with Preferred Reporting Items for a Systematic Review and Meta-analysis guidelines and registered prior to conduction (International prospective register of systematic reviews-PROSPERO: CRD42021275072)., Results: Of the 951 articles identified via the database search, 35 met eligibility criteria. All studies were observational. The most commonly utilized criteria were ACR Thyroid Imaging and Reporting Data System (TI-RADS) and/or ATA criteria, while the majority of studies employed Κ statistics. For ACR TI-RADS, the pooled Κ was 0.51 (95% confidence interval [CI]: 0.42, 0.57; n = 7) while for ATA, the pooled Κ was 0.52 (95% CI: 0.37, 0.67; n = 3). Due to the small number of studies, covariate or publication bias analyses were not performed., Conclusion: Ultrasound criteria demonstrate moderate inter-rater reliability, but these findings are impacted by poor study quality and a lack of standardization. Laryngoscope, 133:485-493, 2023., (© 2022 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: Artificial intelligence (AI) is broadly defined as the ability of machines to apply human-like reasoning to problem solving. Recent years have seen a rapid growth of AI in many disciplines. This review will focus on AI applications in the assessment of thyroid nodules. Summary: AI encompasses two related computational techniques: machine learning, in which computers learn by observing data provided by humans, and deep learning, which employs neural networks that mimic brain structure and function to analyze data. Some experts believe the way AI systems reach a conclusion should be transparent, or explainable, while others disagree. Most AI platforms in thyroid disease have focused on malignancy risk stratification of nodules. To date, four have been approved by the United States Food and Drug Administration. While the results of validation studies have been mixed, there is ample evidence that AI can exceed the performance of some humans, particularly physicians with less experience. AI has also been applied to assessment of lymph nodes and cytopathology specimens. Conclusions: Adoption of AI in thyroid disease will require vendors to demonstrate that their software works as intended, is readily usable in real-world settings, and is cost effective. AI platforms that perform best in head-to-head comparisons will dominate and spur wider adoption.

The aim of the study was to explore the value of 3-D shear wave elastography (SWE) in differentiating malignant from benign thyroid nodules. A total of 188 patients with 216 nodules who underwent conventional ultrasound, 2-D SWE and 3-D SWE were included in this study. All patients underwent surgical excision, and the pathological results were the gold standard. Receiver operating characteristic (ROC) curves of the American College of Radiology's Thyroid Imaging Reporting and Data System (ACR TI-RADS), 2-D SWE and 3-D SWE were plotted, and the areas under the curves (AUCs) were compared using a Z-test. There were 62 benign thyroid nodules and 154 malignant thyroid nodules in this study. Young's modulus (E min , E mean , E max , E sd ) values of thyroid malignant nodules in different sections of 2-D SWE and 3-D SWE were significantly higher than those of thyroid benign nodules (p < 0.001). The AUC of E max in 2-D SWE transverse sections was significantly lower than that in 3-D SWE transverse sections and 3-D SWE sagittal sections (0.768 vs. 0.831 and 0.844, p < 0.05). The AUC of 3-D S-E max combined with ACR TI-RADS was 0.859; the specificity increased from 54.84% to 85.71%, and the diagnostic accuracy increased from 74.54% to 85.19%, compared with ACR TI-RADS. The difference was statistically significant (p < 0.05). Three-dimensional SWE combined with ACR TI-RADS for the diagnosis of thyroid nodules significantly improved the diagnostic ability of ACR TI-RADS, and was significantly better than 2-D SWE combined with ACR TI-RADS., Competing Interests: Conflict of interest disclosure No conflict of interest exists in the submission of this article, and the article is approved by all authors for publication., (Copyright © 2022 World Federation for Ultrasound in Medicine & Biology. Published by Elsevier Inc. All rights reserved.)

Thyroid nodules are widespread in the United States and the rest of the world, with a prevalence ranging from 19 to 68%. The problem with nodules is whether they are malignant or benign. Ultrasonography is currently recommended as the initial modality for evaluating thyroid nodules. However, obtaining a good diagnosis from ultrasound imaging depends entirely on the radiologists levels of experience and other circumstances. There is a tremendous demand for automated and more reliable methods to screen ultrasound images more efficiently. This research proposes an efficient and quick detection deep learning approach for thyroid nodules. An open and publicly available dataset, Thyroid Digital Image Database (TDID), is used to determine the robustness of the suggested method. Each image is formatted into a pyramid tile-based data structure, which the proposed VGG-16 model evaluates to provide segmentation results for nodular detection. The proposed method adopts a top-down approach to hierarchically integrate high- and low-level features to distinguish nodules of varied sizes by employing fuse features effectively. The results demonstrated that the proposed method outperformed the U-Net model, achieving an accuracy of 99%, and was two times faster than the competitive model. [ABSTRACT FROM AUTHOR]

Objectives: To compare the differences among the thyroid imaging reporting and data system (TI-RADS) proposed by American College of Radiology (ACR TI-RADS), TI-RADS proposed by Kwak (Kwak TI-RADS), and American Thyroid Association (ATA) guidelines in the specificity, sensitivity and the unnecessary FNA rate (the UFR, the false positive rate) of recommended fine needle aspiration (FNA), and to observe the changes of the UFR in the KwakTI-RADS and ATA guidelines with the recommended FNA nodule size threshold., Methods: The specificities, sensitivities and UFRs of recommended FNA in the ACR TI-RADS, ATA guidelines and Kwak TI-RADS were calculated and compared. The nodule sizes for recommended FNA of ATA guidelines and Kwak TI-RADS were systematically varied to establish new FNA thresholds. The specificities, sensitivities and UFRs of recommended FNA under the new models were calculated and compared to those in the ACR TI-RADS., Results: For all thyroid nodules, the UFRs in the ACR TI-RADS, ATA guidelines and Kwak TI-RADS were 26.3%, 47.4% and 40.0%, respectively. The UFR in the ACR TI-RADS was lower than that in the others, and the specificity of recommended FNA in the ACR TI-RADS(73.7%) was higher than that in the others (all P < 0.001), but the sensitivity of recommended FNA in the ACR TI-RADS(89.3%) was lower than that in the others (all P < 0.001). When nodule sizes threshold of the recommended FNA for ATA guidelines Intermediate Suspicion, Low Suspicion, and Very Low Suspicion, and Kwak TI-RADS grade 4b and 4a were gradually increased, the UFRs gradually decreased., Conclusions: The UFRs of FNA recommended by the Kwak TI-RADS and ATA guidelines were higher than that of the ACR TI-RADS, and were affected by the recommended FNA nodule size threshold., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Objective: We aimed to compare the thyroid ultrasound risk stratification systems (RSSs) of the American College of Radiology (ACR) Thyroid Imaging Reporting and Data System (TI-RADS), European TI-RADS, Korean TI-RADS, and American Thyroid Association (ATA), American Association of Clinical Endocrinologists, American College of Endocrinology, and Associazione Medici Endocrinologi guidelines to differentiate benign from malignant thyroid nodules and to avoid unnecessary fine needle aspiration (FNA)., Methods: The records of 1143 nodules ≥1 cm that underwent FNA biopsy and thyroidectomy between 2012 and 2020 at our institution were reviewed. Ultrasound categories and FNA recommendation indications of 5 international RSSs were compared with histopathological findings as benign or malignant. The ultrasound categories and recommended FNA indications, the proportion of the avoidable FNA procedures, and false negative rates (FNRs) by different systems were compared with each other., Results: Of the 1143 nodules, 45% had thyroid malignancy. FNA recommendation and ultrasound risk classification of ATA guidelines had the highest area under curves of 0.619, and 0.715, respectively. ACR TI-RADS, American Association of Clinical Endocrinologists/American College of Endocrinology/Associazione Medici Endocrinologi guidelines, European TI-RADS, ATA guidelines, and Korean TI-RADS would have avoided FNA for 34.7%, 31%, 25.7%, 20%, and 6% of nodules with an FNR of 24%, 28.5%, 22%, 7.2%, and 1.9%, respectively., Conclusion: Our findings showed that all RSSs classified the nodules appropriately for malignancy. ATA guidelines had the highest area under curves and a low FNR, whereas ACR TI-RADS would have spared more patients from FNA with a high FNR., (Copyright © 2021 AACE. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2021 AACE. Published by Elsevier Inc. All rights reserved.)

The American Thyroid Association guidelines on thyroid nodules and differentiated thyroid cancer, published in 2009, provide valuable recommendations based on current evidence. Inevitably, controversies and uncertainties will continue to challenge clinicians and patients. On topics where evidence is not clear-cut, judgement may be coloured by pre-existing practises and the structure of the health service in each country, so one has to be aware of the pitfalls of transferring recommendations to one’s own practise. [Copyright &y& Elsevier]

Purpose: This study aims to compare three guidelines according to their diagnostic accuracy in the management of thyroid nodules.Methods: A total of 540 patients with 597 thyroid nodules were enrolled in this study. Sonographic images were classified and scored with the American Thyroid Association (ATA-2015), American College of Radiology (ACR), and European Thyroid Association (EU) Thyroid Imaging, Reporting, and Data Systems (ACR-TIRADS and EU-TIRADS) guidelines. Fine-needle aspiration biopsy (FNAB) was performed, and cytopathological results were reported with the Bethesda system. Outcomes of these three classification systems were then correlated with Bethesda results.Results: FNAB procedures revealed a total of 447 benign and 45 malignant nodules. With guideline dedicated FNAB criteria; 38 malignant nodules could have been diagnosed with ATA-2015, which is followed by 34 nodules with ACR-TIRADS, and 31 nodules with EU-TIRADS. Nonetheless, 301 benign nodules would have been biopsied with ATA-2015, 143 benign nodules with ACR-TIRADS, 222 benign nodules with EU-TIRADS. The accuracy rate was found to be highest with ACR-TIRADS (59.93 %); while 55.20 % with ATA-2015 and 51.25 % with EU-TIRADS. The sensitivity and specificity ratios of these guidelines were as follows; ATA-2015 (82.22, 53.47), ACR-TIRADS (48.89, 60.63), and EU-TIRADS (86.67, 48.99). A total of 23 nodules (3.8 %) could not be classified with ATA-2015.Conclusion: Diagnostic strengths, unnecessary recommended FNAB rates, and categorization capabilities differ among various guidelines. Clinicians and interventional radiologists should keep in mind these features in the management of thyroid nodules. [ABSTRACT FROM AUTHOR]

Objectives: examine the cost-effectiveness of routine Calcitonin (Ctn) screening test in the United States.Materials and Methods: Markov chain model was developed that compares fine-needle aspiration biopsy (FNAB) with Ctn screening vs. FNAB-only in the evaluation of a thyroid nodule with non-highly suspicious findings. Follow-up time was set as 10 years. Costs and probabilities values were obtained from literature, and National Cancer Database. Cost data is expressed in U.S$ and effectiveness is expressed in Quality-adjusted-life-year (QALY). Incremental cost-effectiveness ratio (ICER) was calculated comparing both study arms.Results: Routine Ctn screening was cost-effective compared to FNAB-only in all tested categories except when cutoff value of 10 pg/ml was applied. Among the tested categories, the application of universal routine Ctn screening with Ctn value > 50 pg/ml considered a positive test produced the most cost-saving scenario. The final accrued cost at the end of 10 years in the FNAB-only arm was $4238.93 with a final effectiveness of 8.717 QALY. While the final cost in the FNAB-with routine Ctn screening was $4345.04 with a final effectiveness of 8.722 QALY. ICER of routine Ctn screening compared to FNAB-only was $23278.61/QALY (Conclusions: Routine Ctn screening is a cost-effective strategy in US if the cost is less than $236.03. Although Ctn screening is not perfect in detecting MTC at early stages, it is a cost-effective alternative of discovering MTC after thyroid lobectomy or on follow-up of a thyroid nodule. [ABSTRACT FROM AUTHOR]

Context: DICER1 mutations are found in multinodular goiter and differentiated thyroid carcinoma in children, and can be a manifestation of DICER1 syndrome, but the prevalence of DICER1 mutations and their significance in adult-onset thyroid nodules is unknown., Objective: Determine (1) the prevalence of DICER1 hotspot mutations in thyroid nodules; (2) the frequency of a second DICER1 pathogenic variant in thyroid nodules with DICER1 hotspot mutations; (3) the prevalence of other thyroid cancer driver mutations in thyroid nodules with and without DICER1 hotspot mutations., Methods: Population-based study of 14 993 consecutive fine needle aspiration biopsies of thyroid nodules evaluated by ThyroSeq v3. From 214 DICER1 hotspot-positive cases, we selected 61, matched to DICER1 hotspot-negative nodules. We performed full sequencing of all exons and exon-intron boundaries of DICER1., Setting: Commercial and university-based laboratories in the United States and Canada., Results: Among 14 993 thyroid nodules, 214 (1.4%) revealed a DICER1 hotspot mutation. A second pathogenic/likely pathogenic variant in DICER1 was found in 45/59 (76%) DICER1 hotspot-positive nodules studied while no other DICER1 variant was identified in the DICER1 hotspot-negative group by full DICER1 sequencing. Other alterations in thyroid-related genes were significantly more frequent in DICER1 hotspot-negative nodules (32/61) than in DICER1 hotspot--positive nodules (4/59) (P < .0001)., Conclusion: DICER1 alterations occur in a proportion of adult thyroid nodules and appear mutually exclusive with alterations in other thyroid cancer-related genes. DICER1 hotspot mutations occur with a second hit in most cases and could suggest occult DICER1 syndrome in adults with thyroid nodules., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Endocrine Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: 18 F-Fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) positive (PET+) cytologically indeterminate thyroid nodules (ITNs) have variable cancer risk in the literature. The benign call rate (BCR) of Afirma Gene Classifier (Gene Expression Classifier, GEC, or Genome Sequence Classifier, GSC) in (PET +) ITNs is unknown., Methods: This is a retrospective study at our institution of all patients with (PET+) ITNs (Bethesda III/IV) from 1 January 2010 to 21 May 2019 who underwent Afirma testing and/or surgery or repeat FNA with benign cytology., Results: Forty-five (PET+) ITNs were identified: 31 Afirma-tested (GEC = 20, GSC = 11) and 14 either underwent surgery (n = 13) or repeat FNA (Benign cytology) (n = 1) without Afirma. The prevalence of cancer and noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) including only resected nodules and ITN with repeat benign FNA (n = 33) was 36.4% (12/33). Excluding all Afirma "suspicious" non-resected ITNs and assuming all Afirma "benign" ITNs were truly benign, that prevalence was 28.6% (12/42). The BCR with GSC was 64% compared to 25% with GEC (p = 0.056). Combining GSC/GEC-tested ITNs, the BCR was higher in ITNs demonstrating low/very low-risk sonographic pattern by the American Thyroid Association (ATA) classification and ITNs scoring <4 by the American College of Radiology Thyroid Imaging, Reporting and Data System (ACR-TI-RADS) than ITNs with higher sonographic pattern/score (p = 0.025)., Conclusions: The prevalence of cancer/NIFTP in (PET+) ITNs was 28.6-36.4% depending on the method of calculation. The BCR of Afirma GSC was 64%. Combining Afirma GEC/GSC-tested ITNs, BCR was higher in ITNs with a lower risk sonographic pattern., (© 2021 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.)

Thyroid nodules are a common clinical problem encountered in an endocrine practice. More and more thyroid nodules are now being detected on unrelated imaging studies, leading to an increased diagnosis of low-risk thyroid cancers. There is therefore a greater emphasis on risk assessment based on clinical and sonographic features to avoid morbidity secondary to unnecessary therapy. Molecular diagnostics are also being widely used to further characterize indeterminate nodules. The American Thyroid Association and American College of Radiology-Thyroid Imaging Reporting and Data System guidelines are the most commonly used in clinical practice for risk assessment., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: To comparatively assess the performance of three sonographic classification systems, American Thyroid Association (ATA), the American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS), and American Association of Clinical Endocrinologists (AACE)/American College of Endocrinology (ACE)/Associazione Medici Endocrinologi (AME) in identifying malignant nodules in an elderly population., Methods: Cross-sectional study of patients referred for fine needle aspiration biopsy in an academic center for the elderly. One nodule/patient was considered. Nodules classified Bethesda V/VI were considered malignant. Receiver operating characteristics (ROC) curves were established and compared to evaluate diagnostic performance. Malignancy among biopsies below the size cutoff for each ultrasound classification was also compared., Results: One thousand, eight hundred sixty-seven patients (92% females); median (Q1-Q3), age 71 (67-76) years, were studied showing 82.8% benign (Bethesda II) and 2.6% malignant cytology. The three classifications correctly identified malignancy (P < 0.01). Nonetheless, in the ATA and AACE/ACE/AME 16 and 2 malignant nodules, respectively, were unclassifiable. Including unclassified malignant nodules (n = 1234, malignant = 50), comparison of the ROC curves showed lower performance of ATA [area under the curve (AUC) = ATA (0.49) vs. ACR TI-RADS (0.62), p = 0.008 and ATA vs. AACE/ACE/AME (0.59), p = 0.022]. Proportion of below size cutoff biopsies for ATA, ACR TI-RADS, and AACE/ACE/AME was different [16, 42, and 29% (all p < 0.001)], but no differences in malignancy rate were observed in these nodules., Conclusion: The present study is the first to validate in elderly patients these classifications showing that AACE/ACE/AME and ACR TI-RADS can predict thyroid malignancy more accurately than the ATA when unclassifiable malignant nodules are considered. Moreover, in this aged segment of the population, the use of ACR TI-RADS avoided more invasive procedures.

Background: International thyroid nodule and cancer management guidelines generally fail to take into account potential limitations in diagnostic and treatment resources., Methods: Thyroid cancer specialists from the African Head and Neck Society and American Head & Neck Society Endocrine Section developed guidelines for diagnosis and management of thyroid nodules and cancer in low resource settings. Recommendations were based on literature review and expert opinion, with level of evidence defined., Results: Using the ADAPTE process, diagnostic and treatment algorithms were adapted from the National Comprehensive Cancer Network (NCCN). Low resource settings were simulated by systematically removing elements such as availability of laboratory testing, hormone replacement, imaging, and cytopathology from NCCN guidelines., Conclusions: Successful management of thyroid nodules and cancer in low resource settings requires adaptation of treatment methodologies. These guidelines define specific scenarios where either more or less aggressive intervention for thyroid pathology may be advisable based on limited available resources., (© 2020 The Authors. Head & Neck published by Wiley Periodicals, Inc.)

Numerous sets of guidelines have been proposed regarding ultrasound of thyroid nodules. None has been universally accepted. American College of Radiology-Thyroid Imaging, Reporting and Data System (ACR-TIRADS) has been promoted as an improvement to existing guidelines such as the 2015 revised American Thyroid Association (ATA) guidelines. This commentary compares and contrasts these two guidelines. Adoption of TI-RADS is likely to result in large-scale, costly surveillance without clear benefit. Replacement of 2015 revised ATA guidelines by TI-RADS is not justified. The shortcomings that exist in the ATA guidelines can be addressed as described in this commentary., (© 2019 Wiley Periodicals, Inc.)

Objective: To investigate the concordance of three international guidelines: the Korean Thyroid Association/Korean Society of Thyroid Radiology, American Thyroid Association, and American College of Radiology for thyroid nodules classified by ultrasonography (US) and the diagnostic performance of simulated size criteria for malignant biopsies., Materials and Methods: A total of 2586 thyroid nodules (≥ 1 cm) were collected from two multicenter study datasets. The classifications of the thyroid nodules were based on three different guidelines according to US categories for malignancy risk, and the concordance rate between the different guidelines was calculated for the classified nodules. In addition, the diagnostic performance of criteria related to four different simulated biopsy sizes was evaluated., Results: The concordance rate of nodules classified as high- or intermediate-suspicion was high (84.1-100%), but low-suspicion or mildly-suspicious nodules exhibited relatively low concordance (63.8-83.8%) between the three guidelines. The differences in sensitivity, specificity, and accuracy between the guidelines were 0.7-19.8%, 0-40.9%, and 0.1-30.5%, respectively, when the original biopsy criteria were applied. The differences decreased to 0-5.9%, 0-10.9%, and 0.1-8.2%, respectively, when simulated, similar biopsy size criteria were applied. The unnecessary biopsy rate calculated with the original criteria (0-33.8%), decreased with the simulated biopsy size criteria (0-8.7%)., Conclusion: We found a high concordance between the three guidelines for high- or intermediate-suspicion nodules, and the diagnostic performance of the biopsy criteria was approximately equivalent for each simulated size criterion. The difference in diagnostic performance between the three guidelines is mostly influenced by the various size thresholds for biopsies., Competing Interests: The authors have no potential conflicts of interest to disclose., (Copyright © 2020 The Korean Society of Radiology.)

Introduction: The standard workup of thyroid nodules concerning for malignancy includes fine-needle aspiration (FNA). In 2015, the American Thyroid Association (ATA) guidelines for the management of pediatric thyroid nodules recommended that all nodules with a Bethesda III cytology undergo surgical resection., Objectives: To correlate a Bethesda III cytology with histologic and clinical outcomes to determine the relevance of the ATA recommendations, and to evaluate whether Thyroid Imaging Reporting and Data System (TI-RADS) scoring could identify Bethesda III nodules at a lower risk of malignancy., Methods: A retrospective chart review of patients who had undergone thyroid nodule FNA from 2008 to 2018 was performed. Malignancy rates were determined for each Bethesda category. The reference standard was histopathology or 2-year follow-up of imaging outcomes for nonoperative cases. Ultrasound exams of Bethesda III nodules were reviewed and TI-RADS scores assigned., Results: A total of 143 FNA samples from 128 patients were identified. The mean age was 14.9 years (range 7-22). Twenty-two (15%) of the FNA samples were Bethesda III; the malignancy rate was 38%. A TI-RADS score was assigned in 20 of the 22 Bethesda III nodules. ROC analysis found an optimal cut-off for malignancy prediction of ≥7 points (risk category TR5). The negative predictive value was 85.7% (95% CI 35.9-99.6) and the positive predictive value was 83.3% (95% CI 57.2-98.2)., Conclusion: Although, at baseline, thyroid nodules with a Bethesda III classification carry a moderate risk of malignancy in the pediatric population, TI-RADS scoring can identify nodules with a lower risk within this group. If validated by larger studies, this can inform decision making and reduce unneeded surgery., (© 2020 S. Karger AG, Basel.)

Background: The 2015 American Thyroid Association (ATA) clinical practice guidelines (CPGs) on management of thyroid nodules (TNs) and differentiated thyroid cancer (DTC) in adults were developed to inform clinicians, patients, researchers, and health policy makers about the best available evidence, and its limitations, relating to management of these conditions. Methods: We conducted a cross-sectional electronic survey of ATA members' perspectives of these CPGs, using a standardized survey (Clinician Guidelines Determinant Questionnaire) developed by the Guidelines International Network. A survey link was electronically mailed to members in February of 2019, with reminders sent to nonrespondents 2 and 5 weeks later. Data were descriptively summarized, after excluding missing responses. Results: The overall response rate was 19.8% (348/1761). The effective response rate was 20.2% (348/1720), after excluding a recently deceased member and individuals who had either invalid e-mail addresses or whose e-mails were returned. Of the respondents, 37.9% (132/348) were female, 60.4% (209/346) were endocrinologists, 27.5% (95/346) were surgeons, and 3.5% (12/346) were nuclear medicine specialists. The majority of respondents (71.9%; 250/348) were at a mid- or advanced-career level, and more than half were in academia (57.5%; 195/339). The majority (69.8%; 243/348) practiced in North America. The vast majority of respondents indicated that the CPGs explained the underlying evidence (92.3%; 298/323) and 92.9% (300/323) agreed or strongly agreed with the content. Most respondents stated that they regularly used the CPGs in their practice (83.0%; 268/323). Most respondents (83.0%; 268/323) also agreed or strongly agreed that the recommendations were easy to incorporate in their practice. The most popular CPG format was an electronic desktop file (78.8%; 252/320). Shorter more frequent CPGs were favored by 55.0% (176/320) of respondents, and longer traditional CPGs were favored by 39.7% (127/320). Conclusions: The clinical content and evidence explanations in the adult TN and DTC CPGs are widely accepted and applied among ATA survey respondents. Future ATA CPG updates need to be optimized to best meet users' preferences regarding format, frequency, and length.

For a long time, the diagnosis and treatment of pediatric thyroid nodules and cancer (PTNC) are mainly referred to adults. In recent years, it has been found that there are great differences between PTNC and TNC in adults. In 2015, the American Thyroid Association released the first Management Guidelines for Children with Thyroid Nodules and Differentiated Thyroid Cancer. In the guidelines, the characteristics of PTNC were described, and clear management strategies were provided. In this paper, we mainly interpret the surgical part of the guidelines and also review the associated research progress in recent years.

Purpose: To compare the value of Thyroid Imaging Reporting and Data Systems proposed by Kwak (KWAK-TIRADS) and ACR (ACR TI-RADS) and 2015 American Thyroid Association (ATA) guidelines in the diagnosis of surgically resected thyroid nodules., Methods: From January 2015 to December 2015, 2544 thyroid nodules in 1758 patients who underwent thyroidectomy at our center were included. The KWAK-TIRADS category, ACR TI-RADS and ultrasound (US) pattern based on ATA guidelines were assigned to each thyroid nodule. Nodules were divided into groups according to their maximal diameter further., Results: Of all the nodules, 863 (33.9%) were benign, whereas 1681 (66.1%) were malignant. The malignancy percentage of ACR TI-RADS category 1, 2, 3, 4, and 5 were 0%, 1.3%, 9.1%, 52.5%, and 88.8%, respectively. KWAK-TIRADS and ATA guidelines showed a better diagnostic efficiency than ACR TI-RADS (P < 0.01). ACR TI-RADS demonstrated a higher specificity (79.7%, P < 0.05), whereas the ATA US pattern had a higher sensitivity (95.5%, P < 0.01). The TIRADS (KWAK-TIRADS and ACR TI-RADS) category and ATA guidelines performed better in differentiating nodules >1 cm. KWAK-TIRADS showed better diagnostic efficiency than the other methods in differentiating nodules >1 cm (AUC: 0.92, P < 0.01)., Conclusions: KWAK-TIRADS and ATA guidelines provide a better diagnostic efficiency than ACR TI-RADS. The TIRADS (KWAK-TIRADS and ACR TI-RADS) category and ATA guidelines perform better in differentiating nodules >1 cm than nodules ≤1 cm. KWAK-TIRADS perform better in differentiating nodules >1 cm than other methods.

Background: The American Thyroid Association (ATA) management guidelines for patients with thyroid nodules and differentiated thyroid cancer (DTC) are highly influential practice recommendations. The latest revision appeared in 2015 ("ATA 2015"). These guidelines were developed predominantly by North American experts. European experts frequently have different perspectives, given epidemiological, technological/methodological, practice organization, and medicolegal differences between the respective regions., Summary: Divergent viewpoints were the focus of an invited symposium organized by the European Association of Nuclear Medicine involving 17 European thyroidologists, four ATA Guidelines Taskforce members, and an audience of 200 international experts. The group discussed the preoperative assessment of thyroid nodules, surgery and the role of pathology, radioiodine (RAI) therapy (RAIT), the assessment of initial therapy and dynamic risk stratification, and the treatment of persistent disease, recurrences, and advanced thyroid cancer. The dialogue resulted in this position paper contrasting European and ATA 2015 perspectives on key issues. One difference pertains to the permissiveness of ATA 2015 regarding lobectomy for primary tumors ≤4 cm. European panelists cited preclusion of RAIT, potential need for completion thyroidectomy, frequent inability to avoid chronic thyroid hormone replacement, and limitations of supportive evidence as arguments against widely applying lobectomy. Significant divergence involved ATA 2015's guidance regarding RAIT. European panelists favored wider use of postoperative RAIT than does ATA 2015. Rationales included the modality's association with favorable patient outcomes and generally limited toxicity, and lack of high-quality evidence supporting withholding RAIT. Additionally, European panelists favored recombinant human thyrotropin (rhTSH) in more settings than does ATA 2015, citing avoidance of hypothyroid morbidity and quality-of-life impairment, without apparent sacrifice in oncologic outcomes. Based on clinical evidence plus theoretical advantages, European experts advocated dosimetric versus fixed-activity RAIT approaches for advanced DTC. European panelists noted that the ATA 2015 risk-stratification system requires information sometimes unavailable in everyday practice. ATA 2015 recommendations regarding RAI-refractory DTC should consider potential palliative benefits of RAIT in patients who also have RAI-susceptible lesions., Conclusions: European panelists suggested modifications to approximately one-third of ATA 2015 recommendations. Varying European and ATA 2015 perspectives can stimulate analysis and discussion of the literature and performance of primary research to resolve discrepant recommendations and potentially improve patient outcomes.

Purpose: The aim of this study was to compare the diagnostic performance of ultrasound (US)-based risk-stratification systems for thyroid nodules in the 2015 American Thyroid Association (ATA) guidelines with those of the 2016 Korean Thyroid Association (KTA)/Korean Society of Thyroid Radiology (KSThR) and 2017 American College of Radiology (ACR) guidelines., Methods: From June 2013 to May 2015, a total of 902 consecutive thyroid nodules were enrolled in four institutions, and their US features were retrospectively reviewed and classified using the categories defined by the three guidelines. The malignancy risk of each category, as defined by all three risk-stratification systems, was calculated, and the diagnostic performance of the fine-needle aspiration (FNA) indications of the ATA guidelines were compared to those of the KTA/KSThR and ACR guidelines., Results: Of all nodules, 636 (70.5%) were benign and 266 (29.5%) malignant. The calculated malignancy risks for ATA categories 5, 4, 3, 2, and 1 nodule(s) were 71.7, 21.5, 2.6, 3.8, and 0%. Of all nodules, 7.6% (69/902) did not meet the ATA pattern criteria, but the malignancy risk was calculated to be 10.1% (7/69). The ATA guidelines afforded significantly higher diagnostic sensitivity (95.0%) than the ACR guidelines (80.2%; p = 0.001) but a lower specificity (38.1 vs. 68.9%; p < 0.001). On the other hand, the ATA guidelines exhibited a lower diagnostic sensitivity than the KTA/KSThR guidelines (100.0%; p = 0.07) but a higher specificity (28.2%; p < 0.001). The unnecessary FNA rate was the lowest when the ACR guidelines were used (25.8%), followed by the ATA (51.2%) and KTA/KSThR (59.4%) guidelines., Conclusion: The 2015 ATA guidelines afford relatively moderate sensitivity and an unnecessary FNA rate for thyroid cancer detection compared to the 2016 KTA/KSThR and 2017 ACR guidelines. US practitioners require a deep understanding of the benefits and risks of the US-based FNA criteria of different guidelines and potential impact on the diagnosis of low-risk thyroid cancers.

Objective: The American College of Radiology (ACR) Thyroid Imaging Reporting and Data System (TI-RADS) provides guidelines to practitioners who interpret sonographic examinations of thyroid nodules. The purpose of this study is to compare the ACR TI-RADS system with two other well-established guidelines., Materials and Methods: The ACR TI-RADS, the Korean Society of Thyroid Radiology (KSThR) Thyroid Imaging Reporting and Data System (TIRADS), and the American Thyroid Association guidelines were compared using 3422 thyroid nodules for which pathologic findings were available. The composition, echogenicity, margins, echogenic foci, and size of the nodules were assessed to determine whether a recommendation would be made for fine-needle aspiration or follow-up sonography when each system was used. The biopsy yield of malignant findings, the yield of follow-up, and the percentage of malignant and benign nodules that would be biopsied were determined for all nodules and for nodules 1 cm or larger., Results: The percentage of nodules that could not be classified was 0%, 3.9%, and 13.9% for the ACR TI-RADS, KSThR TIRADS, and ATA guidelines, respectively. The biopsy yield of malignancy was 14.2%, 10.2%, and 10.0% for nodules assessed by the ACR TI-RADS, KSThR TIRADS, and ATA guidelines, respectively. The percentage of malignant nodules that were biopsied was 68.2%, 78.7%, and 75.9% for the ACR TI-RADS, the KSThR TIRADS, and the ATA guidelines, respectively, whereas the percentage of malignant nodules that would be either biopsied or followed was 89.2% for the ACR TI-RADS. The percentage of benign nodules that would be biopsied was 47.1%, 79.7%, and 78.1% for the ACR TI-RADS, the KSThR TIRADS, and the ATA guidelines, respectively. The percentage of benign nodules that would be either biopsied or followed was 65.2% for the ACR TI-RADS., Conclusion: The ACR TI-RADS performs well when compared with other well-established guidelines.

Background: Pediatric thyroid nodules are more likely to be malignant compared to those in adults and may have different concerning ultrasound (US) features. Recent adult guidelines stratify malignancy risk by US features. Our aim is to (1) describe and confirm US features that predict pediatric malignancy, and (2) apply the Adult American Thyroid Association (ATA) Risk Stratification Guidelines to a large pediatric cohort., Methods: We identified 112 children with 145 thyroid nodules from 1996 to 2015. Two blinded pediatric radiologists independently read all US images, described multiple features, and reported their overall impression: benign, indeterminate, or malignant. Each nodule was assigned an ATA risk stratification category. Radiologists' impressions and ATA risk stratification were compared to histology and cytology results., Results: Multiple US features including a solid composition, presence of microcalcifications, irregular margins, increased blood flow, and hypoechogenicity were associated with increased odds of malignancy. ATA risk stratification correlated with the radiologists' overall impression (p < 0.001). The sensitivity for detecting malignancy was comparable between both ATA stratification (91%) and the radiologists' overall impression (90%). The specificity of the radiologists' malignant overall impression (80%) was better compared to the ATA high risk stratification (54%)., Conclusions: At our institution, pediatric radiologists' overall impressions had similar sensitivity but better specificity for detecting malignancy than the ATA risk stratification tool by our convention. However, neither US-based methods perfectly discriminated benign from malignant nodules, supporting the continued need for fine needle aspiration for suspicious nodules. Further work is needed to develop an US-based scoring system specific to pediatric patients., (© 2018 S. Karger AG, Basel.)

Background: Despite the importance of ultrasound imaging in thyroid disease care, ultrasound reports vary greatly in the features described. It is essential that ultrasound reports contain and present all components necessary for a clinical decision in a reader-friendly format., Methods: One hundred ninety thyroid and neck ultrasound reports were scored using the universal ultrasound report template developed by Su et al, along with the American Thyroid Association (ATA) and the American Association of Clinical Endocrinologists/Associazione Medici Endocrinologi/European Thyroid Association (AACE/AME/ETA) guidelines. All ultrasounds were performed on patients seen between August and November 2015 by a single surgeon (M.L.U), and originated from a variety of physicians and institutions., Results: An average of 30.9% of Su et al's criteria was satisfactorily included in the reports. Similar results were reached when the ATA and the AACE/AME/ETA guidelines were applied as scoring templates., Conclusion: Our results reveal the wide variation in ultrasound reporting. The standardization of ultrasound reporting would help to improve physicians' ability to properly diagnose and manage patients with thyroid disease., (© 2017 Wiley Periodicals, Inc.)

Objective: The aim of this study was to validate the American Thyroid Association (ATA) sonographic risk assessment of thyroid nodules., Methods: The ATA sonographic risk assessment was prospectively applied to 206 thyroid nodules selected for ultrasound-guided fine-needle aspiration (US-FNA), and analyzed with The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC), as well as surgical pathology for the subset undergoing surgical excision., Results: The analysis included 206 thyroid nodules averaging 2.4 cm (range 1-7 cm; standard error of the mean 0.07). Using the ATA US pattern risk assessment, nodules were classified as high (4%), intermediate (31%), low (38%), and very low (26%) risk of malignancy. Nodule size was inversely correlated with sonographic risk assessment, as lower risk nodules were larger on average (p < 0.0001). Malignancy rates determined by cytology/surgical pathology were high 100%, intermediate 11%, low 8%, and very low 2%, which were closely aligned with ATA malignancy risk estimates (high 70-90%, intermediate 10-20%, low 5-10%, and very low 3%). ATA US pattern risk assessment also appropriately predicted the proportion of nodules classified as malignant or suspicious for malignancy through TBSRTC classification-high (77%), intermediate (6%), low (1%), and very low 0%-as well as benign TBSRTC classification-high (0%), intermediate (47%), low (61%), and very low (70%) (p < 0.0001). Malignancy rates of surgically excised, cytologically indeterminate nodules followed ATA sonographic risk stratification (high 100%, intermediate 21%, low 17%, and very low 12%; p = 0.003)., Conclusion: This prospective study supports the new ATA sonographic pattern risk assessment for selection of thyroid nodules for US-FNA based upon TBSRTC and surgical pathology results. In the setting of indeterminate cytopathology, nodules categorized as atypia of undetermined significance/follicular lesion of undetermined significance with ATA high-risk sonographic patterns have a high likelihood of being malignant.