Goiter and thyroid nodules
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Department of Health Sciences, European University Cyprus,
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Division of Endocrinology and Diabetes, “Aghia Sophia” Hospital, Medical School, National and Kapodistrian University of Athens,
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Economides Thyroid & Endocrinology Center,
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Background
Adiposity may be associated with thyroid nodularity. However, its impact on the number of nodules and the risk of malignancy is unclear.
Aim
To evaluate the impact of adiposity on thyroid nodules using body mass index (BMI), ultrasonographic (US) data and cytological data.
Methods
A retrospective cohort study of 310 patients with thyroid nodules was performed. Patients were categorized based on their BMI, and grayscale US data and fine-needle aspiration cytology results were evaluated.
Results
Patients with BMI ≥ 25 kg/m2 were found to have a higher number of thyroid nodules compared to those with BMI < 25 kg/m2 (4.25 ± 2.42 vs 3.66 ± 1.93) (P value = 0.05). Patients with BMI ≥ 25 kg/m2 had more suspicious and malignant cytology than those with BMI < 25 kg/m2 (P value = 0.029). Patients with BMI ≥ 25 kg/m2 had more nodules with intermediate and high suspicion sonographic patterns. However, this did not reach statistical significance.
Conclusion
Overweight and obese patients have a trend for more thyroid nodules and have a higher risk of being diagnosed with thyroid malignancy.
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Objective
To evaluate the current quality of thyroid ultrasound reports in the Community of Madrid.
Methods
Consecutive thyroid ultrasound reports from patients evaluated in the endocrine outpatient clinics of eight academic hospitals in the Community of Madrid were assessed for quality during 2021 and 2022. Descriptions of eight different features were evaluated: number and axes of dimensions, composition, echogenicity, margins, shape, calcifications and category of suspicion. Features were considered adequately reported if described for all nodules ≥1 cm. The number of correctly reported features was compared by year of data capture (2021 vs 2022), specialty of the informant (radiologist vs endocrinologist), and origin of the report (in-house vs outsourced center). The quality of reports for assessing the need for cytological evaluation and/or growth during follow-up was evaluated.
Results
A total of 1234 reports were included, 63% from 2021; 82% were issued by radiologists and 89% were issued in-house. Composition and echogenicity were the most frequently reported (79% and 72%, respectively). The rest of the features were appropriately described in less than half of the reports. Forty percent of the reports were good to select nodules for biopsy, 23% had sufficient data to assess growth during follow-up, and only 13% met both quality criteria. The overall quality of reports was worse in outsourced centers (median number of described features 2 vs 4, P < 0.001) and better when issued by endocrinologists (median number of described features 6 vs 3, P < 0.001).
Conclusions
Most thyroid ultrasound reports issued in the Community of Madrid provide insufficient data to make management decisions regarding thyroid nodules.
Department of Pathology, General University Hospital of Ciudad Real, Ciudad Real, Spain
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Department of Endocrinology and Nutrition, Virgen de la Victoria University Hospital, Málaga, Spain
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The Biomedical Research Institute of Malaga and Platform in Nanomedicine (IBIMA-BIONAND Platform), University of Malaga, Malaga, Spain
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The Biomedical Research Institute of Malaga and Platform in Nanomedicine (IBIMA-BIONAND Platform), University of Malaga, Malaga, Spain
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Department of Pathology, Virgen de la Victoria University Hospital, Málaga, Spain
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Department of Pathology, Virgen de la Victoria University Hospital, Málaga, Spain
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Department of Endocrinology and Nutrition, Virgen de la Victoria University Hospital, Málaga, Spain
The Biomedical Research Institute of Malaga and Platform in Nanomedicine (IBIMA-BIONAND Platform), University of Malaga, Malaga, Spain
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Graphical abstract
Abstract
Objective
The objective of this study was to analyze the evolution in the diagnosis and management of indeterminate thyroid nodules over three time periods.
Methods
In total, 3020 patients with thyroid nodules underwent cytological evaluation during three periods (2006–2008, 2012–2014, 2017–2019). The distribution of diagnostic cytology, risk of malignancy, diagnostic performance indices of fine needle aspiration (FNA), and cytologic–histologic correlation in indeterminate cytology were analyzed.
Results
Only 2.2% of cytology tests were insufficient for a diagnosis. About 86.9% cytology was benign, 1.7% malignant, and 11.4% indeterminate. Indeterminate cytology rates were 15.9% (2006–2008), 10.1% (2012–2014), and 10% (2017–2019). Surgery was performed in 13% of benign cytology, resulting in malignant histology in 2.7%. All malignant and suspicious cytology underwent surgery, with malignancy confirmed in 98% and 77% of cases, respectively.
All ‘indeterminate with atypia’ cytology (2006–2008) and Bethesda IV (2012–2014; 2017–2019) underwent surgery, with malignancy confirmed in 19.6%, 43.8%, and 25.7%, respectively. In the ‘indeterminate without atypia’ category (2006–2008) and Bethesda III (2012–2014; 2017–2019), diagnostic surgery was performed in 57.7%, 78.6%, and 59.4%, respectively, with malignancy confirmed in 3.3%, 20.5%, and 31.6%. The FNA sensitivity was 91.6%, with a negative predictive value greater than 96% in all periods. The specificity exceeded 75% in the last two periods.
Conclusion
The Bethesda system reduces indeterminate cytology and improves the accuracy of FNA diagnosis. We reported a higher proportion of malignancy than expected in Bethesda III, underscoring the importance of having institution-specific data to guide decision-making. However, there is a need for risk stratification tools that allow for conservative management in low-risk cases.
Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy
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Background
Radiofrequency ablation (RFA) is effective in the treatment of thyroid nodules, leading to a 50–90% reduction with respect to baseline. Current guidelines indicate the need for a benign cytology prior to RFA, though, on the other side, this procedure is also successfully used for the treatment of papillary microcarcinomas. No specific indications are available for nodules with an indeterminate cytology (Bethesda III/IV).
Aim
To evaluate the efficacy of RFA in Bethesda III nodules without genetic alterations as verified by means of a custom panel.
Methods
We have treated 33 patients (mean delivered energy 1069 ± 1201 J/mL of basal volume) with Bethesda III cytology, EU-TIRADS 3-4, and negative genetic panel. The mean basal nodular volume was 17.3 ± 10.7 mL.
Results
Considering the whole series, the mean volume reduction rate (VRR) was 36.8 ± 16.5% at 1 month, 59.9 ± 15.5% at 6 months, and 62 ± 15.7% at 1-year follow-up. The sub-analysis done in patients with 1 and 2 years follow-up data available (n = 20 and n = 5, respectively) confirmed a progressive nodular volume decrease. At all-time points, the rate of reduction was statistically significant (P < 0.0001), without significant correlation between the VRR and the basal volume. Neither cytological changes nor complications were observed after the procedure.
Conclusion
RFA is effective in Bethesda III, oncogene-negative nodules, with reduction rates similar to those obtained in confirmed benign lesions. This procedure represents a good alternative to surgery or active surveillance in this particular class of nodules, regardless of their initial volume. A longer follow-up will allow to evaluate further reduction or possible regrowth.
Servizio di Endocrinologia e Diabetologia, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale (EOC), Lugano, Switzerland
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University of Latvia, Faculty of Medicine, Riga, Latvia
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Facoltà di Scienze Biomediche, Università della Svizzera Italiana (USI), Lugano, Switzerland
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Context
Ultrasound-based risk stratification systems (Thyroid Imaging Reporting and Data Systems (TIRADSs)) of thyroid nodules (TNs) have been implemented in clinical practice worldwide based on their high performance. However, it remains unexplored whether different TIRADSs perform uniformly across a range of TNs in routine practice. This issue is highly relevant today, given the ongoing international effort to establish a unified TIRADS (i.e. I-TIRADS), supported by the leading societies specializing in TNs. The study aimed to conduct a direct comparison among ACR-, EU-, and K-TIRADS in the distribution of TNs: (1) across the TIRADS categories, and (2) based on their estimated cancer risk.
Methods
A search was conducted on PubMed and Embase until June 2023. Original studies that sequentially assessed TNs using TIRADSs, regardless of FNAC indication, were selected. General study characteristics and data on the distribution of TNs across TIRADSs were extracted.
Results
Seven studies, reporting a total of 41,332 TNs, were included in the analysis. The prevalence of ACR-TIRADS 1–2 was significantly higher than that of EU-TIRADS 2 and K-TIRADS 2, with no significant difference observed among intermediate- and high-risk categories of TIRADSs. According to malignancy risk estimation, K-TIRADS often classified TNs as having more severe risk, ACR-TIRADS as having moderate risk, and EU-TIRADS classified TNs as having lower risk.
Conclusion
ACR-, EU-, and K-TIRADS assess TNs similarly across their categories, with slight differences in low-risk classifications. Despite this, focusing on cancer risk estimation, the three TIRADSs assess TNs differently. These findings should be considered as a prerequisite for developing the I-TIRADS.
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Objective
This study aims to analyze the diagnostic utility of multiple repeat FNA on thyroid nodules with initially benign diagnosis.
Methods
In a 5-year period, 1658 thyroid nodules with initially benign FNAs were retrospectively reviewed and followed for subsequent resection and repeat biopsy.
Results
Out of 2150 thyroid nodules, 1658 (77.1%) were diagnosed as benign on FNAs. The average age at diagnosis was 57.4 years (range: 11–93 years), and most were females (83.8%). Repeat FNA was performed on 183 benign nodules, of which 141 (8.5%) were sampled a second time and 42 (2.5%) had two or more repeat samplings. For the benign nodules without repeat FNAs, 124 had benign resection. Of cases with one-time repeat FNA, most (n = 101) remained benign on repeat FNAs, 13 of which were benign on resection. Eleven had atypical repeat FNAs, five were resected, four of which were benign and one was atypical follicular neoplasm with HRAS and TERT promoter mutations. Of cases with multiple repeat FNA, most (n = 35) were still benign on repeat FNAs, one had benign resection. Two had atypical repeat biopsies, one was PTC on resection with CCD6::RET fusion. The positive predictive value significantly decreased from 41.1% on single FNA to 8.3% on one-time repeat (P < 0.001) and 16.7% on multiple repeat (P = 0.002). The total cost for the work-up of previously benign nodules was $285,454.
Conclusions
Repeat FNA biopsies did not provide an additional diagnostic value in the evaluation of benign thyroid nodules, and often led to unwarranted follow-up procedures and significantly increased health-care cost.
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Objective
Few studies use all nodule burdens to specify the prognosis of multinodular goiter (MNG) following radiofrequency ablation (RFA), so this study addresses this question for MNG after completely ablating dominant nodules.
Methods
The RFA indications for MNG include 2–5 benign nodules with over 50% normal tissue on ultrasound, 1–3 well-defined benign dominant nodules on cytology, largest diameter ≥20 mm and/or with clinical complaints, and patient refusal or unable to undergo surgery. A retrospective study of 185 MNG patients with completely ablated dominant nodules in a single-session RFA was conducted. The efficacy and complications were evaluated at 1, 6, 12 months, and yearly thereafter. Based on retreatment risks, progressive disease (PD), stable disease (SD), and complete relief (CR) were introduced to assess all nodule load changes. PD was clarified as having new/non-target nodules that newly appeared to ACR TI-RADS≥4, or new/enlarged non-target nodules ≥1 cm.
Results
The initial ablation ratios of target nodules were 100% at one month. During a mean 22.38 ± 13.75 months (range, 12–60 months), the volume reduction rate of ablated nodules was 98.25% at 24 months without regrowth. Cosmetic and symptomatic scores decreased to 1 and 0, respectively, after 48 months. Of the patients, 9.7% (18/185) had PD and the retreatment rate was 2.2% (4/185). The complication rate was 2.7% (5/185).
Conclusion
RFA provides cosmetic and symptomatic relief for an average of two years. RFA is a useful minimally invasive treatment modality for selected MNG patients.
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Objectives
The aim was to evaluate the clinical, ultrasound (US) and, when indicated, the cytological and histological characteristics of autonomously functioning thyroid nodules (AFTN) in consecutive patients.
Methods
A prospective, single-centre study was conducted between March 2018 and September 2021. In total, 901 consecutive patients were referred for thyroid workup and of 67 AFTN were evaluated. All enrolled patients underwent 99mTcO4 − scintigraphy, additional 123I scintigraphy only in case of normal serum TSH, evaluation of thyroid function, US examination using European Thyroid Imaging and Reporting Data System (EU-TIRADS), and US-guided fine needle aspiration (FNA) cytology when indicated. All indeterminate FNA samples were subjected to DNA sequencing analysis.
Results
More than half of the evaluated patients with AFTN were euthyroid; median serum TSH was 0.41 (IQR: 0.03–0.97) mU/L. The median AFTN size measured by US was 27.0 (IQR: 21.1–35.0) mm. 28.4% of AFTN were classified as EU-TIRADS score 3 and 71.6% as EU-TIRADS score 4, indicating that the majority of AFTN had intermediate risk for malignancy according to US. Out of the 47 AFTN subjected to cytological evaluation, 24 (51%) yielded indeterminate FNA results. DNA sequencing revealed pathogenic TSHR and GNAS mutations in 60% of cases. No malignancy was detected at final histology in surgically excised AFTN (n = 12).
Conclusions
Of the 67 AFTN evaluated in this study, 50% presented with normal serum TSH, 70% displayed ultrasound features suggesting an intermediate malignancy risk and 50% of the AFTN submitted to cytology yielded indeterminate results. No malignant AFTN was detected.
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Introduction
Thyroid metastasis from clear cell renal cell carcinoma (ccRCC) is relatively rare, so ultrasound doctors lack experience with the disease, which can easily lead to misdiagnosis. We describe three cases of thyroid metastasis from ccRCC detected 12, 8, and 7 years after nephrectomy.
Case presentation
The first patient, a 78-year-old woman, was admitted to our institution for hoarseness and progressive dyspnea. Ultrasonography revealed bilateral thyroid nodules and abnormal cervical lymph nodes. Fine-needle aspiration biopsy (FNAB) and core needle biopsy (CNB) of the thyroid was nondiagnostic. The other two patients, a 54-year-old man and a 65-year-old man, were admitted to our institution for a goiter pressing on the trachea. In each case, ultrasonography revealed a partially cystic nodule of the left lobe of the thyroid gland. Histological examination of three patients after thyroidectomy showed thyroid metastasis from ccRCC.
Discussion/Conclusion
For patients with a history of ccRCC, long-term follow-up and routine thyroid ultrasonography should be performed. If a new thyroid nodule is found during the examination, metastases should be highly suspected. FNAB should be performed, even if benign ultrasound features seem to be in evidence. If the diagnosis of FNAB is incorrect and inconclusive, CNB should be performed.
Nursing Department, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
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Introduction
Given the high prevalence of thyroid nodules and the potential for malignancy, it is imperative to understand the various factors that contribute to their development. This study aimed to explore the relationship between metabolic syndrome, lifestyle, and thyroid nodules in adult men in southern China.
Methods
This study enrolled a total of 183,990 subjects at a medical examination center in a general hospital in southern China between January 1, 2015, and December 31, 2020. Multivariate logistic regression analysis was utilized to evaluate the relationship between metabolic syndrome, lifestyle factors, and thyroid nodules. Furthermore, structural equation modeling elucidated the intricate relationships among these variables.
Results
The prevalence of thyroid nodules among Chinese adult males was 14.9%. Several factors were identified as risk factors for thyroid nodules, including advanced age, irregular meal time, smoking or quitting smoking, quitting drinking, heavy manual labor, hypertension, diabetes, dyslipidemia and centripetal obesity, and those belonging to ethnic minorities and drinking alcohol were found to be protective factors against thyroid nodules. Structural equation modeling highlighted metabolic syndrome's mediating role amidst lifestyle influences on thyroid nodules.
Conclusion
The prevalence of thyroid nodules in Chinese adult males is relatively moderate to low. The factors identified in this study can help clinicians identify high-risk patients and develop targeted screening strategies for the timely detection of thyroid nodules. However, further mechanistic research and longitudinal studies are necessary to explore the underlying causes and establish causal relationships.