Goiter and thyroid nodules

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Alessia Cozzolino Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy

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Tiziana Filardi Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy

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Ilaria Simonelli Service of Medical Statistics and Information Technology, Fatebenefratelli Foundation for Health Research and Education, Rome, Italy
Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy

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Giorgio Grani Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy

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Camilla Virili Endocrinology Unit, Department of Medico-Surgical Sciences and Biotechnologies, ‘Sapienza’ University of Rome, Latina, Italy

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Ilaria Stramazzo Endocrinology Unit, Department of Medico-Surgical Sciences and Biotechnologies, ‘Sapienza’ University of Rome, Latina, Italy

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Maria Giulia Santaguida Endocrinology Unit, Department of Medico-Surgical Sciences and Biotechnologies, ‘Sapienza’ University of Rome, Latina, Italy

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Pietro Locantore Endocrinology Unit, Fondazione Policlinico Universitario Agostino Gemelli-IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy

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Massimo Maurici Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy

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Daniele Gianfrilli Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy

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Andrea M Isidori Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy

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Cosimo Durante Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy

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Carlotta Pozza Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy

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on behalf of TALENT Group
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on behalf of TALENT Group

Context

Significant uncertainty exists about the diagnostic accuracy of ultrasonographic (US) features used to predict the risk of thyroid cancer in the pediatric population. Moreover, there are no specific indications for thyroid nodule evaluation in patients during the transition age.

Objective

The meta-analysis aimed to address the following question: which thyroid nodule US features have the highest accuracy in predicting malignancy in the transition age.

Methods

We performed a meta-analysis of observational/cohort/diagnostic accuracy studies dealing with thyroid nodule sonography, reporting US features, and using histology as a reference standard for the diagnosis of malignancy and histology or cytology for the diagnosis of benignity in the transition age (mean/median age 12–21 years).

Results

The inclusion criteria were met by 14 studies, published between 2005 and 2020, including 1306 thyroid nodules (mean size 17.9 mm) from 1168 subjects. The frequency of thyroid cancer was 36.6%. The US features with the highest diagnostic odds ratio (DOR) for malignancy were the presence of suspicious lymph nodes (DOR: 56.0 (95% CI: 26.0–119.0)), a ‘taller than wide’ shape of the nodule (6.0 (95% CI: 2.0–16.0)), the presence of microcalcifications (13.0 (95% CI: 6.0–29.0)) and irregular margins (9.0 (95% CI: 5.0–17.0)). Heterogeneity among the studies was substantial.

Conclusions

Following the diagnosis of a thyroid nodule in the transition age, a thorough US examination of the neck is warranted. The detection of suspicious lymph nodes and/or thyroid nodules with a ‘taller than wide’ shape, microcalcifications, and irregular margins is associated with the highest risk of malignancy in the selection of nodules candidates for biopsy.

Open access
X Y Hu Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada

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J Wu Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada

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P Seal EFW Radiology, Calgary, Alberta, Canada

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S A Ghaznavi Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
Department of Medicine, Section of Endocrinology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada

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C Symonds Department of Medicine, Section of Endocrinology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada

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S Kinnear Department of Medicine, Section of Endocrinology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada

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R Paschke Department of Medicine, Section of Endocrinology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
Departments of Medicine, Oncology, Pathology and Laboratory Medicine, Biochemistry and Molecular Biology, and Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada

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Objectives

There has been slow adoption of thyroid ultrasound guidelines with adherence rates as low as 30% and no population-based studies investigating adherence to guideline-based malignancy risk assessment. We therefore evaluated the impact of adherence to the 2015 ATA guidelines or 2017 ACR-TIRADS guidelines on the quality of thyroid ultrasound reports in our healthcare region.

Methods

We reviewed 899 thyroid ultrasound reports of patients who received fine-needle aspiration biopsy and were diagnosed with Bethesda III or IV nodules or thyroid cancer. Ultrasounds were reported by radiology group 1, group 2, or other groups, and were divided into pre-2018 (before guideline adherence) or 2018 onwards. Reports were given a utility score (0–6) based on how many relevant nodule characteristics were included.

Results

Group 1 had a pre-2018 utility score of 3.62 and 39.4% classification reporting rate, improving to 5.77 and 97.0% among 2018-onwards reports. Group 2 had a pre-2018 score of 2.8 and reporting rate of 11.5%, improving to 5.58 and 93.3%. Other radiology groups had a pre-2018 score of 2.49 and reporting rate of 32.2%, improving to 3.28 and 61.8%. Groups 1 and 2 had significantly higher utility scores and reporting rates in their 2018-onward reports when compared to other groups’ 2018-onward reports, pre-2018 group 1 reports, and pre-2018 group 2 reports.

Conclusions

Dedicated adherence to published thyroid ultrasound reporting guidelines can lead to improvements in report quality. This will reduce diagnostic ambiguity and improve clinician’s decision-making, leading to overall reductions in unnecessary FNA biopsy and diagnostic surgery.

Open access
Muhammad Fahad Arshad Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
University of Sheffield, Sheffield, UK

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Amardass Dhami Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK

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Gillian Quarrell Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK

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Saba Prakash Balasubramanian Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
University of Sheffield, Sheffield, UK

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Objective

Post-surgical hypoparathyroidism (PoSH) usually settles within few months after thyroid surgery, but several patients require long-term supplementation with calcium/activated vitamin D. When PoSH persists beyond 6 months, it is considered ‘chronic’ or ‘permanent’, however, late recovery has been reported. The aim of this study was to determine the frequency of late recovery and explore factors predicting late recovery of parathyroid function.

Methods

Adult patients undergoing total/completion thyroidectomy between 2009 and 2018 were included in this retrospective cohort observational study. The records of patients with evidence of PoSH were reviewed to identify those with persisting PoSH at 6 months. Demographic, biochemical, surgical, pathological, and clinical follow-up data were collected and analysed.

Results

Out of 911 patients undergoing thyroidectomy, 270 were identified with PoSH. Of these, 192 were started on supplements and 138 (71.9%) recovered within 6 months. Of the remaining 54 patients, 35 had ongoing PoSH with median (range) follow-up of 3.4 (0.5–11.1) years. Nineteen patients were weaned off supplements and achieved remission at median (range) follow-up of 1.3 (0.6–4.8) years. All of those who recovered had a PTH of ≥1.6 pmol/L at 6 months. There was no difference in age, gender, diagnosis, type, and extent of surgery between those who did and did not show late recovery.

Conclusions

Recovery from PoSH is common beyond 6 months, raising the question whether a 6-month threshold to define ‘long-term’ PoSH is appropriate. The chances of recovery are high (~50%) in patients with PTH level ≥1.6 pmol/L at 6 months, where attempts at weaning may be focussed.

Open access
Kristine Z Swan Department of ORL, Head- and Neck Surgery, Aarhus University Hospital, Aarhus, Denmark

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Johnson Thomas Department of Endocrinology, Mercy Hospital, Springfield, Missouri, USA

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Viveque E Nielsen Department of ORL, Head- and Neck Surgery, Odense University Hospital, Odense, Denmark

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Marie Louise Jespersen Department of Pathology, Aarhus University Hospital, Aarhus, Denmark

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Steen J Bonnema Department of Endocrinology, Odense University Hospital, Odense, Denmark

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Background

Artificial intelligence algorithms could be used to risk-stratify thyroid nodules and may reduce the subjectivity of ultrasonography. One such algorithm is AIBx which has shown good performance. However, external validation is crucial prior to clinical implementation.

Materials and methods

Patients harboring thyroid nodules 1–4 cm in size, undergoing thyroid surgery from 2014 to 2016 in a single institution, were included. A histological diagnosis was obtained in all cases. Medullary thyroid cancer, metastasis from other cancers, thyroid lymphomas, and purely cystic nodules were excluded. Retrospectively, transverse ultrasound images of the nodules were analyzed by AIBx, and the results were compared with histopathology and Thyroid Imaging Reporting and Data System (TIRADS), calculated by experienced physicians.

Results

Out of 329 patients, 257 nodules from 209 individuals met the eligibility criteria. Fifty-one nodules (20%) were malignant. AIBx had a negative predictive value (NPV) of 89.2%. Sensitivity, specificity, and positive predictive values (PPV) were 78.4, 44.2, and 25.8%, respectively. Considering both TIRADS 4 and TIRADS 5 nodules as malignant lesions resulted in an NPV of 93.0%, while PPV and specificity were only 22.4 and 19.4%, respectively. By combining AIBx with TIRADS, no malignant nodules were overlooked.

Conclusion

When applied to ultrasound images obtained in a different setting than used for training, AIBx had comparable NPVs to TIRADS. AIBx performed even better when combined with TIRADS, thus reducing false negative assessments. These data support the concept of AIBx for thyroid nodules, and this tool may help less experienced operators by reducing the subjectivity inherent to thyroid ultrasound interpretation.

Open access
J L Reverter Endocrinology and Nutrition Service, Germans Trias i Pujol Hospital and Research Institute, Badalona, Spain
Department of Medicine, Autonomous University of Barcelona, Barcelona, Spain

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L Ferrer-Estopiñan Endocrinology and Nutrition Service, Germans Trias i Pujol Hospital and Research Institute, Badalona, Spain
Department of Medicine, Autonomous University of Barcelona, Barcelona, Spain

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F Vázquez Endocrinology and Nutrition Service, Germans Trias i Pujol Hospital and Research Institute, Badalona, Spain
Department of Medicine, Autonomous University of Barcelona, Barcelona, Spain

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S Ballesta Endocrinology and Nutrition Service, Germans Trias i Pujol Hospital and Research Institute, Badalona, Spain
Department of Medicine, Autonomous University of Barcelona, Barcelona, Spain

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S Batule Endocrinology and Nutrition Service, Germans Trias i Pujol Hospital and Research Institute, Badalona, Spain
Department of Medicine, Autonomous University of Barcelona, Barcelona, Spain

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A Perez-Montes de Oca Endocrinology and Nutrition Service, Germans Trias i Pujol Hospital and Research Institute, Badalona, Spain
Department of Medicine, Autonomous University of Barcelona, Barcelona, Spain

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C Puig-Jové Endocrinology and Nutrition Service, Germans Trias i Pujol Hospital and Research Institute, Badalona, Spain
Department of Medicine, Autonomous University of Barcelona, Barcelona, Spain

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M Puig-Domingo Endocrinology and Nutrition Service, Germans Trias i Pujol Hospital and Research Institute, Badalona, Spain
Department of Medicine, Autonomous University of Barcelona, Barcelona, Spain

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Introduction

Computer-aided diagnostic (CAD) programs for malignancy risk stratification from ultrasound (US) imaging of thyroid nodules are being validated both experimentally and in real-world practice. However, they have not been tested for reliability in analyzing difficult or unclear images.

Methods

US images with indeterminate characteristics were evaluated by five observers with different experience in US examination and by a commercial CAD program. The nodules, on which the observers widely agreed, were considered concordant and, if there was little agreement, not concordant or difficult to assess. The diagnostic performance of the readers and the CAD program was calculated and compared in both groups of nodule images.

Results

In the group of concordant thyroid nodules (n = 37), the clinicians and the CAD system obtained similar levels of accuracy (77.0% vs 74.2%, respectively; P = 0.7) and no differences were found in sensitivity (SEN) (95.0% vs 87.5%, P = 0.2), specificity (SPE) (45.5 vs 49.4, respectively; P = 0.7), positive predictive value (PPV) (75.2% vs 77.7%, respectively; P = 0.8), nor negative predictive value (NPV) (85.6 vs 77.7, respectively; P = 0.3). When analyzing the non-concordant nodules (n = 43), the CAD system presented a decrease in accuracy of 4.2%, which was significantly lower than that observed by the experts (19.9%, P = 0.02).

Conclusions

Clinical observers are similar to the CAD system in the US assessment of the risk of thyroid nodules. However, the AI system for thyroid nodules AmCAD-UT® showed more reliability in the analysis of unclear or misleading images.

Open access