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  • Author: Tamas Solymosi x
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Tamas Solymosi Endocrinology and Metabolism Clinic, Bugat Hospital, Gyöngyös, Hungary

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Laszlo Hegedüs Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark

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Steen Joop Bonnema Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark

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Andrea Frasoldati Endocrinology Unit of Arcispedale S. Maria Nuova, Reggio Emilia, Italy

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Laszlo Jambor Department of Radiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary

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Gabor Laszlo Kovacs 1st Department of Medicine, Flohr Ferenc Hospital, Kerepestarcsa, Hungary

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Enrico Papini Regina Apostolorum Hospital in Albano, Rome, Italy

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Karoly Rucz 1st Department of Medicine, University of Pecs, Pecs, Hungary

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Gilles Russ Unité Thyroïde et Tumeurs Endocrines – Pr Leenhardt Hôpital La Pitie Salpetriere, Sorbonne Université, Paris, France

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Zsolt Karanyi Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary

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Endre V. Nagy Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary

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Background: Thyroid nodule image reporting and data systems (TIRADS) provide the indications for fine-needle aspiration (FNA) based on a combination of nodule sonographic features and size. We compared the TIRADS-based recommendations for FNA with those based on the personal expertise of qualified US investigators in the diagnosis of thyroid malignancy. Methods: Seven highly experienced ultrasound (US) investigators from 4 countries evaluated, online, the US video recordings of 123 histologically verified thyroid nodules. Technical resources provided the operators with a diagnostic approach close to the real-world practice. Altogether, 4,305 TIRADS scores were computed. The combined diagnostic potential of TIRADS (TIRSYS) and the personal recommendations of the investigators (PERS) were compared against 3 possible goals: to recognize all malignant lesions (allCA), nonpapillary plus non-pT1 papillary cancers (nPnT1PCA), or stage II-IV cancers (st2-4CA). Results: For allCA and nPnT1PCA, TIRSYS had lower sensitivity than PERS (69.8 vs. 87.2 and 83.5 vs. 92.6%, respectively, p <0.01), while in st2-4CA the sensitivities were the same (99.1 vs. 98.6% and TIRSYS vs. PERS, respectively). TIRSYS had a higher specificity than PERS in all 3 types of cancers (p < 0.001). PERS recommended FNA in a similar proportion of lesions smaller or larger than 1 cm (76.9 vs. 82.7%; ns). Conclusions: Recommendations for FNA based on the investigators’ US expertise demonstrated a better sensitivity for thyroid cancer in the 2 best prognostic groups, while TIRADS methodology showed superior specificity over the full prognostic range of cancers. Thus, personal experience provided more accurate diagnoses of malignancy, missing a lower number of small thyroid cancers, but the TIRADS approach resulted in a similar accuracy for the diagnosis of potentially aggressive lesions while sparing a relevant number of FNAs. Until it is not clearly stated what the goal of the US evaluation is, that is to diagnose all or only clinically relevant thyroid cancers, it cannot be determined whether one diagnostic approach is superior to the other for recommending FNA.

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

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Laszlo Hegedüs Department of Endocrinology, Odense University Hospital, Odense, Denmark

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Agnieszka Czarniecka M. Sklodowska-Curie National Research, Institute of Oncology Gliwice Branch, Gliwice, Poland

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Ralf Paschke Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada

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Gilles Russ Thyroid and Endocrine Tumors Department, Pitié-Salpêtrière Hospital, Sorbonne University GRC N°16, Paris, France

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Fernando Schmitt Faculty of Medicine of University of Porto, CINTESIS@RISE and Institute of Molecular Pathology and Immunology, University of Porto (Ipatimup), Porto, Portugal

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Paula Soares Institute of Investigation and Innovation in Health (I3S), Faculty of Medicine of the University of Porto, Porto, Portugal

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Tamas Solymosi Endocrinology and Metabolism Clinic, Bugat Hospital, Gyöngyös, Hungary

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Enrico Papini Department of Endocrine and Metabolic Diseases, Regina Apostolorum Hospital, Albano, Rome, Italy

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With the widespread use of sensitive imaging techniques, which include neck visualization, a conspicuous number of thyroid nodules emerge and demand attention. Most lesions are benign, asymptomatic, and do not warrant treatment. In the case of cancer diagnosis, most are small, intrathyroidal and indolent neoplasms that can safely be managed conservatively. There is a pronounced need for more cost-effective, risk-adapted approaches to the management of this highly prevalent condition, taking the wishes of the patient into consideration. Thus, the present guidelines aim at providing a clinical practice guide for the initial workup and the subsequent management of adult individuals harboring thyroid nodules. Importantly, these guidelines are not intended to cover the management of thyroid malignancy. The manuscript and the specific recommendations were developed by reconciling the best available research evidence with the knowledge and clinical experience of the panelists and updating aspects of a number of previous European Thyroid Association guidelines.

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Tamas Solymosi Endocrinology and Metabolism Clinic, Bugat Hospital, Gyöngyös, Hungary
Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary

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Laszlo Hegedűs Department of Endocrinology, Odense University Hospital, Odense, Denmark

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

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Andrea Frasoldati Endocrinology Unit of Arcispedale S Maria Nuova, Reggio Emilia, Italy

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Laszlo Jambor Department of Radiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary

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Zsolt Karanyi Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary

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Gabor L Kovacs 1st Department of Medicine, Flohr Ferenc Hospital, Kistarcsa, Hungary

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Enrico Papini Regina Apostolorum Hospital in Albano, Rome, Italy

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Karoly Rucz 1st Department of Medicine, University of Pecs, Pecs, Hungary

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Gilles Russ Unité Thyroïde et Tumeurs Endocrines – Pr Leenhardt Hôpital La Pitie Salpetriere, Sorbonne Université, Paris, France

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Endre V Nagy Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary

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Objective

Thyroid nodule ultrasound characteristics are used as an indication for fine-needle aspiration cytology, usually as the basis for Thyroid Imaging Reporting and Data System (TIRADS) score calculation. Few studies on interobserver variation are available, all of which are based on analysis of preselected still ultrasound images and often lack surgical confirmation.

Methods

After the blinded online evaluation of video recordings of the ultrasound examinations of 47 consecutive malignant and 76 consecutive benign thyroid lesions, 7 experts from 7 thyroid centers answered 17 TIRADS-related questions. Surgical histology was the reference standard. Interobserver variations of each ultrasound characteristic were compared using Gwet’s AC1 inter-rater coefficients; higher values mean better concordance, the maximum being 1.0.

Results

On a scale from 0.0 to 1.0, the Gwet’s AC1 values were 0.34, 0.53, 0.72, and 0.79 for the four most important features in decision-making, i.e. irregular margins, microcalcifications, echogenicity, and extrathyroidal extension, respectively. The concordance in the discrimination between mildly/moderately and very hypoechogenic nodules was 0.17. The smaller the nodule size the better the agreement in echogenicity, and the larger the nodule size the better the agreement on the presence of microcalcifications. Extrathyroidal extension was correctly identified in just 45.8% of the cases.

Conclusions

Examination of video recordings, closely simulating the real-world situation, revealed substantial interobserver variation in the interpretation of each of the four most important ultrasound characteristics. In view of the importance for the management of thyroid nodules, unambiguous and widely accepted definitions of each nodule characteristic are warranted, although it remains to be investigated whether this diminishes observer variation.

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Karoly Rucz Department of Endocrinology, Siofok Hospital, Siofok, Hungary

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Laszlo Hegedűs Department of Endocrinology, Odense University Hospital, Odense, Denmark

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

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Andrea Frasoldati Endocrinology Unit of Arcispedale S. Maria Nuova, Reggio Emilia, Italy

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Laszlo Jambor Institute of Medical Imaging, Faculty of Medicine, University of Debrecen, Debrecen, Hungary

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Gabor Laszlo Kovacs 1st Department of Medicine, Flohr Ferenc Hospital, Kistarcsa, Hungary

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Enrico Papini Regina Apostolorum Hospital in Albano, Rome, Italy

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Gilles Russ Unité Thyroïde et Tumeurs Endocrines - Pr Leenhardt Hôpital La Pitie Salpetriere, Sorbonne Université, Paris, France

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Zsolt Karanyi Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary

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Endre V Nagy Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary

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Tamas Solymosi Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary

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Objective

The ultrasound evaluation of thyroid nodules (TNs) in patient selection for fine needle aspiration (FNA) requires both uniformly accepted definitions of each nodule characteristic and extensive experience from the examiner. We hypothesized that nodule echogenicity alone may provide comparable performance to more complex approaches in patient selection for FNA.

Patients and methods

Seven highly experienced investigators from four countries evaluated, online, the ultrasound (US) video recordings of 123 histologically verified TN by answering 17 nodule characteristics-related questions. The diagnostic performances of five TN image reporting and data systems (TIRADS) were compared to making decisions based solely on the echogenicity of the nodule for indicating FNA in 110 nodules ≥10 mm.

Results

In the 10–20 mm size range, the sensitivities and specificities of the five TIRADS systems in identifying malignant nodules were 80.5–91.0% and 31.4–50.9%, respectively. Had FNA been recommended for all hypoechoic nodules, disregarding other US characteristics, comparable sensitivity and specificity (87.5% and 43.4%, respectively) were obtained. Compared to nodules >20 mm, a higher proportion of cancers were hypoechoic in the 10–20 mm size range (87.2% vs 77.8%, P = 0.05). In the 10–20 mm size range, compared to hypoechoic nodules, a significantly lower proportion of isoechoic nodules demonstrated suspicious findings (70.7% vs 30.0%, P < 0.05).

Conclusion

In contrast to >20 mm diameter nodules, the recommendation of FNA may rely on a single US feature, echogenicity, in the 10–20 mm size range. If independently confirmed in larger cohorts, this may simplify nodule evaluation in this size range.

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