The incidental thyroid nodule.

Incidental thyroid nodules that are found on an imaging study performed for reasons other than thyroid pathology represent a common scenario encountered by health care providers. The initial workup for these nodules comprises a thorough history and physical examination, thyroid function tests, a dedicated thyroid ultrasound, and fine-needle aspiration of any suspicious lesions. Management ranges from observation and reassurance to surgical resection and depends on the cytologic diagnosis. In cases of cytologically indeterminate or discordant nodules, surgical excision (lobectomy) offers a definitive diagnosis, although molecular testing or a reasonable period of observation may be useful as less invasive adjuncts. CA Cancer J Clin 2018;68:97-105. © 2018 American Cancer Society.

Contemporary Management of Thyroid Nodules.

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

Blood leukocytes as a non-invasive diagnostic tool for thyroid nodules: a prospective cohort study.

BACKGROUND: Thyroid nodule (TN) patients in China are subject to overdiagnosis and overtreatment. The implementation of existing technologies such as thyroid ultrasonography has indeed contributed to the improved diagnostic accuracy of TNs. However, a significant issue persists, where many patients undergo unnecessary biopsies, and patients with malignant thyroid nodules (MTNs) are advised to undergo surgery therapy. METHODS: This study included a total of 293 patients diagnosed with TNs. Differential methylation haplotype blocks (MHBs) in blood leukocytes between MTNs and benign thyroid nodules (BTNs) were detected using reduced representation bisulfite sequencing (RRBS). Subsequently, an artificial intelligence blood leukocyte DNA methylation (BLDM) model was designed to optimize the management and treatment of patients with TNs for more effective outcomes. RESULTS: The DNA methylation profiles of peripheral blood leukocytes exhibited distinctions between MTNs and BTNs. The BLDM model we developed for diagnosing TNs achieved an area under the curve (AUC) of 0.858 in the validation cohort and 0.863 in the independent test cohort. Its specificity reached 90.91% and 88.68% in the validation and independent test cohorts, respectively, outperforming the specificity of ultrasonography (43.64% in the validation cohort and 47.17% in the independent test cohort), albeit with a slightly lower sensitivity (83.33% in the validation cohort and 82.86% in the independent test cohort) compared to ultrasonography (97.62% in the validation cohort and 100.00% in the independent test cohort). The BLDM model could correctly identify 89.83% patients whose nodules were suspected malignant by ultrasonography but finally histological benign. In micronodules, the model displayed higher specificity (93.33% in the validation cohort and 92.00% in the independent test cohort) and accuracy (88.24% in the validation cohort and 87.50% in the independent test cohort) for diagnosing TNs. This performance surpassed the specificity and accuracy observed with ultrasonography. A TN diagnostic and treatment framework that prioritizes patients is provided, with fine-needle aspiration (FNA) biopsy performed only on patients with indications of MTNs in both BLDM and ultrasonography results, thus avoiding unnecessary biopsies. CONCLUSIONS: This is the first study to demonstrate the potential of non-invasive blood leukocytes in diagnosing TNs, thereby making TN diagnosis and treatment more efficient in China.

The clinical value of artificial intelligence in assisting junior radiologists in thyroid ultrasound: a multicenter prospective study from real clinical practice.

BACKGROUND: This study is to propose a clinically applicable 2-echelon (2e) diagnostic criteria for the analysis of thyroid nodules such that low-risk nodules are screened off while only suspicious or indeterminate ones are further examined by histopathology, and to explore whether artificial intelligence (AI) can provide precise assistance for clinical decision-making in the real-world prospective scenario. METHODS: In this prospective study, we enrolled 1036 patients with a total of 2296 thyroid nodules from three medical centers. The diagnostic performance of the AI system, radiologists with different levels of experience, and AI-assisted radiologists with different levels of experience in diagnosing thyroid nodules were evaluated against our proposed 2e diagnostic criteria, with the first being an arbitration committee consisting of 3 senior specialists and the second being cyto- or histopathology. RESULTS: According to the 2e diagnostic criteria, 1543 nodules were classified by the arbitration committee, and the benign and malignant nature of 753 nodules was determined by pathological examinations. Taking pathological results as the evaluation standard, the sensitivity, specificity, accuracy, and area under the receiver operating characteristic curve (AUC) of the AI systems were 0.826, 0.815, 0.821, and 0.821. For those cases where diagnosis by the Arbitration Committee were taken as the evaluation standard, the sensitivity, specificity, accuracy, and AUC of the AI system were 0.946, 0.966, 0.964, and 0.956. Taking the global 2e diagnostic criteria as the gold standard, the sensitivity, specificity, accuracy, and AUC of the AI system were 0.868, 0.934, 0.917, and 0.901, respectively. Under different criteria, AI was comparable to the diagnostic performance of senior radiologists and outperformed junior radiologists (all P < 0.05). Furthermore, AI assistance significantly improved the performance of junior radiologists in the diagnosis of thyroid nodules, and their diagnostic performance was comparable to that of senior radiologists when pathological results were taken as the gold standard (all p > 0.05). CONCLUSIONS: The proposed 2e diagnostic criteria are consistent with real-world clinical evaluations and affirm the applicability of the AI system. Under the 2e criteria, the diagnostic performance of the AI system is comparable to that of senior radiologists and significantly improves the diagnostic capabilities of junior radiologists. This has the potential to reduce unnecessary invasive diagnostic procedures in real-world clinical practice.

Molecular testing for thyroid nodules: Where are we now?

Approximately 25% of the fine needle aspiration samples (FNAB) of thyroid nodules are classified as "indeterminate samples", that means, Bethesda III and IV categories. Until the last decade, most of these cases underwent diagnostic surgery, although only a minority (13-34%) confirmed malignancy postoperatively. In view of this, with the objective of improving the preoperative diagnosis in these cases, the molecular tests emerged, which are validated from the diagnostic point of view, presenting good performance, with good diagnostic accuracy, being able to avoid diagnostic surgeries. With the advancement of knowledge of the role of each of the mutations and gene rearrangements in thyroid oncogenesis, molecular markers have left to play only a diagnostic role and have been gaining more and more space both in defining the prognostic role of the tumor, as well as in the indication of target therapy. Thus, the objective of this review is to show how to use the tool of molecular tests, now commercially available in the world, in the management of indeterminate cytological nodules, assessing the pre-test malignancy risk of the nodule, through clinical, ultrasonographic and cytological characteristics, and decide on the benefit of molecular testing for each patient. In addition, to discuss its new and promising prognostic and therapeutic role in thyroid cancer.

Prediction model based on MRI morphological features for distinguishing benign and malignant thyroid nodules.

BACKGROUND: The low specificity of Thyroid Imaging Reporting and Data System (TI-RADS) for preoperative benign-malignant diagnosis leads to a large number of unnecessary biopsies. This study developed and validated a predictive model based on MRI morphological features to improve the specificity. METHODS: A retrospective analysis was conducted on 825 thyroid nodules pathologically confirmed postoperatively. Univariate and multivariate logistic regression were used to obtain ß coefficients, construct predictive models and nomogram incorporating MRI morphological features in the training cohort, and validated in the validation cohort. The discrimination, calibration, and decision curve analysis of the nomogram were performed. The diagnosis efficacy, area under the curve (AUC) and net reclassification index (NRI) were calculated and compared with TI-RADS. RESULTS: 572 thyroid nodules were included (training cohort: n = 397, validation cohort: n = 175). Age, low signal intensity on T2WI, restricted diffusion, reversed halo sign in delay phase, cystic degeneration and wash-out pattern were independent predictors of malignancy. The nomogram demonstrated good discrimination and calibration both in the training cohort (AUC = 0.972) and the validation cohort (AUC = 0.968). The accuracy, sensitivity, specificity, PPV, NPV and AUC of MRI-based prediction were 94.4%, 96.0%, 93.4%, 89.9%, 96.5% and 0.947, respectively. The MRI-based prediction model exhibited enhanced accuracy (NRI>0) in comparison to TI-RADSs. CONCLUSIONS: The prediction model for diagnosis of benign and malignant thyroid nodules demonstrated a more notable diagnostic efficacy than TI-RADS. Compared with the TI-RADSs, predictive model had better specificity along with a high sensitivity and can reduce overdiagnosis and unnecessary biopsies.

US of thyroid nodules: can AI-assisted diagnostic system compete with fine needle aspiration?

OBJECTIVES: Artificial intelligence (AI) systems can diagnose thyroid nodules with similar or better performance than radiologists. Little is known about how this performance compares with that achieved through fine needle aspiration (FNA). This study aims to compare the diagnostic yields of FNA cytopathology alone and combined with BRAFV600E mutation analysis and an AI diagnostic system. METHODS: The ultrasound images of 637 thyroid nodules were collected in three hospitals. The diagnostic efficacies of an AI diagnostic system, FNA-based cytopathology, and BRAFV600E mutation analysis were evaluated in terms of sensitivity, specificity, accuracy, and the κ coefficient with respect to the gold standard, defined by postsurgical pathology and consistent benign outcomes from two combined FNA and mutation analysis examinations performed with a half-year interval. RESULTS: The malignancy threshold for the AI system was selected according to the Youden index from a retrospective cohort of 346 nodules and then applied to a prospective cohort of 291 nodules. The combination of FNA cytopathology according to the Bethesda criteria and BRAFV600E mutation analysis showed no significant difference from the AI system in terms of accuracy for either cohort in our multicenter study. In addition, for 45 included indeterminate Bethesda category III and IV nodules, the accuracy, sensitivity, and specificity of the AI system were 84.44%, 95.45%, and 73.91%, respectively. CONCLUSIONS: The AI diagnostic system showed similar diagnostic performance to FNA cytopathology combined with BRAFV600E mutation analysis. Given its advantages in terms of operability, time efficiency, non-invasiveness, and the wide availability of ultrasonography, it provides a new alternative for thyroid nodule diagnosis. CLINICAL RELEVANCE STATEMENT: Thyroid ultrasonic artificial intelligence shows statistically equivalent performance for thyroid nodule diagnosis to FNA cytopathology combined with BRAFV600E mutation analysis. It can be widely applied in hospitals and clinics to assist radiologists in thyroid nodule screening and is expected to reduce the need for relatively invasive FNA biopsies. KEY POINTS: • In a retrospective cohort of 346 nodules, the evaluated artificial intelligence (AI) system did not significantly differ from fine needle aspiration (FNA) cytopathology alone and combined with gene mutation analysis in accuracy. • In a prospective multicenter cohort of 291 nodules, the accuracy of the AI diagnostic system was not significantly different from that of FNA cytopathology either alone or combined with gene mutation analysis. • For 45 indeterminate Bethesda category III and IV nodules, the AI system did not perform significantly differently from BRAFV600E mutation analysis.

Complications of ultrasound-guided thermal ablation of thyroid nodules and associated risk factors: an experience from 9667 cases.

OBJECTIVES: To evaluate the safety of ultrasound-guided thermal ablation (UGTA) for thyroid nodules (TNs) by analysing complications and related risks. MATERIALS AND METHODS: This retrospective, single-centre study reviewed patients who underwent UGTA (microwave or radiofrequency ablation) between January 2018 and March 2023. The incidence of complications was recorded and assessed during and immediately after ablation,1-3 h later, and at 1 month, 3 months, and 6 months. Univariate and multivariate analyses were performed to identify risk factors for hoarseness and haemorrhagic complications. RESULTS: We reviewed 9667 cases in this study. Overall, 4494 (46.49%) cases underwent microwave ablation, while 5173 (53.51%) cases underwent radiofrequency ablation. The overall complication rate was 4.43%. The incidence of major complications was 1.94% (haemorrhage, 1.32%; hoarseness, 0.54%; and symptomatic aseptic necrosis, 0.08%). The incidence of minor complications was 2.45%. A large nodule volume, radiofrequency ablation, hyper-enhancing nodules, benign nodules, higher preoperative blood pressure, hyperthyroidism, and higher ablation power were independent risk factors for haemorrhage. Dorsal nodules and a higher ablation power were independent risk factors for hoarseness. All complications were resolved. CONCLUSION: This study suggests that UGTA is a safe treatment for TNs. Several risk factors for haemorrhage and hoarseness should be considered before performing UGTA. Different ablation modalities should be considered for patients with different conditions. CLINICAL RELEVANCE STATEMENT: Thermal ablation may be a safe treatment for eligible patients with TNs. KEY POINTS: We analysed the complications and risk factors associated with UGTA in 9667 cases. The complication rate was 4.43%; 1.94% were major complications. Risk factors of haemorrhage and hoarseness should be considered. UGTA was a safe method for the treatment of TNs.

Comparative efficacy and safety of radiofrequency ablation and microwave ablation in benign thyroid nodule treatment: a systematic review and meta-analysis.

OBJECTIVE: Ultrasound-guided thermal ablation, including radiofrequency ablation (RFA) and microwave ablation (MWA), has become one of the main options for treating benign thyroid nodules (BTNs). To assess the efficacy of thermal ablation of BTNs, we performed a systematic review and meta-analysis of relevant studies. MATERIALS AND METHODS: A comprehensive search of MEDLINE, EMBASE, and COCHRANE databases was performed up to September 25, 2023, to identify studies directly comparing RFA and MWA for pathologically proven BTNs and reporting clinical outcomes and complications. Data extraction and quality assessment were independently performed by two radiologists according to PRISMA guidelines. The analysis yielded the serial volume reduction ratios (VRRs) of ablated nodules for up to 12 months, symptom and cosmetic scores, and complications. RESULTS: This analysis included nine studies with 1305 BTNs treated by RFA and 1276 by MWA. VRRs at 1 month, 3 months, and 6 months were similar between RFA and MWA, but RFA showed a significantly higher VRR (83.3%) than MWA (76.9%) at 12 months (p = 0.02). Complication rates showed no significant difference between the two methods. Symptom and cosmetic scores significantly decreased after ablation, without a significant difference between the methods. Subgroup analysis indicated a significantly higher VRR at 12 months for RFA than for MWA for less experienced investigators (≤ 10 years), but no significant difference for more experienced investigators (> 10 years). CONCLUSION: RFA and MWA are both effective and safe methods for treating BTNs. RFA showed a higher VRR at 12 months and seems more suitable for less experienced investigators. CLINICAL RELEVANCE STATEMENT: RFA and MWA are both effective and safe treatments for BTNs, with RFA showing a higher VRR at 12 months. Both methods offer minimally invasive and reliable treatment for thyroid nodules. KEY POINTS: The most effective thermal ablation technique for BTNs remains undetermined. RFA showed a higher VRR at 12 months than MWA. Both techniques are effective for treating thyroid nodules; RFA offers greater benefits, particularly for less experienced investigators.

Efficacy of HIFU for the treatment of benign thyroid nodules: a systematic review and meta-analysis.

OBJECTIVE: Thyroid nodules are common and sometimes associated with cosmetic issues. Surgical treatment has several disadvantages, including visible scarring. High-intensity focused ultrasound (HIFU) is a recent noninvasive treatment for thyroid nodules. The present study aims to evaluate the effectiveness and safety of HIFU for the treatment of benign thyroid nodules. METHODS: We searched PubMed, Embase, and Cochrane Library for studies evaluating the outcomes of HIFU for patients with benign thyroid nodules. We conducted a meta-analysis by using a random effects model and evaluated the volume reduction ratio, treatment success rate, and incidence of treatment-related complications. RESULTS: Thirty-two studies were included in the systematic review. Only 14 studies were used in the meta-analysis because the other 18 involved data collected during overlapping periods. The average volume reduction ratios at 3, 6, and 12 months after treatment were 39.02% (95% CI: 27.57 to 50.47%, I2: 97.9%), 48.55% (95% CI: 35.53 to 61.57%, I2: 98.2%), and 55.02% (95% CI: 41.55 to 68.48%, I2: 99%), respectively. Regarding complications, the incidences of vocal cord paresis and Horner's syndrome after HIFU were 2.1% (95% CI: 0.2 to 4.1%, I2: 14.6%) and 0.7% (95% CI: 0 to 1.9%, I2: 0%), respectively. CONCLUSIONS: HIFU is an effective and safe treatment option for patients with benign thyroid nodules. However, the effects of HIFU on nodules of large sizes and with different properties require further investigation. Additional studies, particularly randomized controlled trials involving long-term follow-up, are warranted. CLINICAL RELEVANCE STATEMENT: Surgical treatment for thyroid nodules often results in permanent visible scars and is associated with a risk of bleeding, nerve injury, and hypothyroidism. High-intensity focused ultrasound may be an alternative for patients with benign thyroid nodules. KEY POINTS: • The success rate of HIFU treatment for thyroid nodules is 75.8% at 6 months. Average volume reduction ratios are 48.55% and 55.02% at 6 and 12 months. • The incidence of complications such as vocal fold paresis, Horner's syndrome, recurrent laryngeal nerve palsy, hypothyroidism, and skin redness is low. • HIFU is both effective and safe as a treatment for benign thyroid nodules.

Deep learning to assist composition classification and thyroid solid nodule diagnosis: a multicenter diagnostic study.

OBJECTIVES: This study aimed to propose a deep learning (DL)-based framework for identifying the composition of thyroid nodules and assessing their malignancy risk. METHODS: We conducted a retrospective multicenter study using ultrasound images from four hospitals. Convolutional neural network (CNN) models were constructed to classify ultrasound images of thyroid nodules into solid and non-solid, as well as benign and malignant. A total of 11,201 images of 6784 nodules were used for training, validation, and testing. The area under the receiver-operating characteristic curve (AUC) was employed as the primary evaluation index. RESULTS: The models had AUCs higher than 0.91 in the benign and malignant grading of solid thyroid nodules, with the Inception-ResNet AUC being the highest at 0.94. In the test set, the best algorithm for identifying benign and malignant thyroid nodules had a sensitivity of 0.88, and a specificity of 0.86. In the human vs. DL test set, the best algorithm had a sensitivity of 0.93, and a specificity of 0.86. The Inception-ResNet model performed better than the senior physicians (p < 0.001). The sensitivity and specificity of the optimal model based on the external test set were 0.90 and 0.75, respectively. CONCLUSIONS: This research demonstrates that CNNs can assist thyroid nodule diagnosis and reduce the rate of unnecessary fine-needle aspiration (FNA). CLINICAL RELEVANCE STATEMENT: High-resolution ultrasound has led to increased detection of thyroid nodules. This results in unnecessary fine-needle aspiration and anxiety for patients whose nodules are benign. Deep learning can solve these problems to some extent. KEY POINTS: • Thyroid solid nodules have a high probability of malignancy. • Our models can improve the differentiation between benign and malignant solid thyroid nodules. • The differential performance of one model was superior to that of senior radiologists. Applying this could reduce the rate of unnecessary fine-needle aspiration of solid thyroid nodules.

Volume reduction rate of radiofrequency ablation in ≤ 2 cm Bethesda IV thyroid nodules.

OBJECTIVE: This prospective observational study aimed to evaluate the efficacy of radiofrequency ablation (RFA) in treating ≤ 2 cm thyroid nodules with Bethesda IV cytology and C-TIRADS 4A categorization. Additionally, the factors influencing the completed absorption of ablation (CAA) were examined. METHODS: A total of 62 cases with 62 nodules underwent ultrasound-guided RFA and were included in the study. The volume reduction rate (VRR), CAA, and incomplete absorption of ablation (IAA) were assessed at the 1st, 3rd, 6th, and subsequent 6-month follow-ups. Clinical and ultrasound features were compared between the CAA and IAA groups at the 12th month follow-up. RESULTS: The average VRR at the 1st, 3rd, 6th, 12th month, and last follow-up were -88.6%, 16.0%, 59.7%, 82.0%, and 98.2%, respectively. More than half of the nodules achieved a 90% VRR after 1 year of RFA, with 88.7% demonstrating CAA at the end of the study (follow-up duration of 14 to 63 months). Nodules with grade 3 vascularity and those associated with chronic thyroiditis showed delayed CAA at the 12th month follow-up (p = 0.036 and 0.003, respectively). CONCLUSION: RFA is an effective technique for treating ≤ 2 cm thyroid nodules with Bethesda IV cytology and C-TIRADS 4A categorization. Nodules with grade 3 blood supply and patients with chronic thyroiditis exhibited an impact on the completed absorption following RFA. CLINICAL RELEVANCE STATEMENT: Our study has shown that radiofrequency ablation is an effective treatment for ≤ 2 cm thyroid nodules classified as Bethesda IV cytology. However, we identified that high vascularity of the nodule and chronic thyroiditis are adverse factors affecting the completed absorption of the ablation. KEY POINTS: •Radiofrequency ablation (RFA) is an effective technique for treatment of ≤ 2 cm Bethesda IV category thyroid nodules. •Higher blood supply and chronic thyroiditis influence the completed absorption after RFA.

Thyroid Cancer-Related Fear & Anxiety in Patients With Benign Thyroid Nodules: A Mixed-Methods Study.

INTRODUCTION: Thyroid cancer diagnosis often evokes strong negative emotions in patients, yet little is understood about such responses in those with benign thyroid nodules. This study explored the impact of a hypothetical cancer diagnosis, the provision of treatment information, and emotional support from surgeons on patients with benign nodules. METHODS: Patients within 30 d of a thyroid nodule biopsy were asked to imagine their nodule was cancerous and write down their feelings about this diagnosis. They then viewed a video depicting a patient-surgeon discussion of thyroid cancer treatment options, with or without added emotional support (1:1 randomized allocation). Validated measures assessed anxiety and thyroid cancer-related fear before and after video-viewing. Thematic analysis evaluated participants' feelings about the hypothetical diagnosis. RESULTS: Of 221 eligible patients, 118 participated (53.4%). While participants state anxiety increased after performing the thought exercise and watching the video (9 [6, 11]-12 [8, 14]; P < 0.001), thyroid cancer-related fear decreased over the same period (27 [22, 30]-25 [20, 29]; P < 0.001). Emotional support by the surgeon in the video did not affect anxiety or fear. Themes that emerged from participants imagining they have thyroid cancer included information seeking, trust in medicine, cancer experience, thyroid cancer knowledge, apprehension about surgery, and impact on family. CONCLUSIONS: Patients with recently diagnosed benign thyroid nodules experience heightened anxiety when contemplating thyroid cancer. Provision of treatment and disease information mitigates cancer-related fear, while emotional support does not. Offering patients with thyroid nodules information about thyroid cancer before biopsy may offer emotional benefits.

CT-Based Radiomics Models for Differentiation of Benign and Malignant Thyroid Nodules: A Multicenter Development and Validation Study.

BACKGROUND. CT is increasingly detecting thyroid nodules. Prior studies indicated a potential role of CT-based radiomics models in characterizing thyroid nodules, although these studies lacked external validation. OBJECTIVE. The purpose of this study was to develop and validate a CT-based radiomics model for the differentiation of benign and malignant thyroid nodules. METHODS. This retrospective study included 378 patients (mean age, 46.3 ± 13.9 [SD] years; 86 men, 292 women) with 408 resected thyroid nodules (145 benign, 263 malignant) from two centers (center 1: 293 nodules, January 2018 to December 2022; center 2: 115 nodules, January 2020 to December 2022) who underwent preoperative multiphase neck CT (noncontrast, arterial, and venous phases). Nodules from center 1 were divided into training (n = 206) and internal validation (n = 87) sets; all nodules from center 2 formed an external validation set. Radiologists assessed nodules for morphologic CT features. Nodules were manually segmented on all phases, and radiomic features were extracted. Conventional (clinical and morphologic CT), noncontrast CT radiomics, arterial phase CT radiomics, venous phase CT radiomics, multiphase CT radiomics, and combined (clinical, morphologic CT, and multiphase CT radiomics) models were established using feature selection methods and evaluated by ROC curve analysis, calibration-curve analysis, and decision-curve analysis. RESULTS. The combined model included patient age, three morphologic features (cystic change, "edge interruption" sign, abnormal cervical lymph nodes), and 28 radiomic features (from all three phases). In the external validation set, the combined model had an AUC of 0.923, and, at an optimal threshold derived in the training set, sensitivity of 84.0%, specificity of 94.1%, and accuracy of 87.0%. In the external validation set, the AUC was significantly higher for the combined model than for the conventional model (0.827), noncontrast CT radiomics model (0.847), arterial phase CT radiomics model (0.826), venous phase CT radiomics model (0.773), and multiphase CT radiomics model (0.824) (all p < .05). In the external validation set, the calibration curves indicated the lowest (i.e., best) Brier score for the combined model; in the decision-curve analysis, the combined model had the highest net benefit for most of the range of threshold probabilities. CONCLUSION. A combined model incorporating clinical, morphologic CT, and multiphase CT radiomics features exhibited robust performance in differentiating benign and malignant thyroid nodules. CLINICAL IMPACT. The combined radiomics model may help guide further management for thyroid nodules detected on CT.

Thyroid involvement in cystic echinococcosis: a systematic review.

BACKGROUND: Thyroid Hydatid Cyst (THC), a pathological state induced by the larval form of Echinococcus granulosus, represents a multifaceted clinical entity with nonspecific symptoms, making both diagnosis and treatment intricate. The current understanding of THC's attributes is somewhat limited. To gain a broader perspective on the disease's clinical and epidemiological characteristics, we have systematically reviewed the existing literature. METHODS: We performed an extensive review of articles on THC across four key scientific databases: PubMed, Scopus, Web of Science, and Google Scholar. Our study encompassed all patients diagnosed with THC through post-surgical pathology or Fine Needle Aspiration Cytology (FNAC) examinations, extracting clinical, epidemiological, and therapeutic data of THC patients from publications up to October 2023. RESULTS: From 770 articles, 57 met our criteria, detailing 75 THC patients. The gender ratio was 2.36 females per one male. The patients averaged 36.1 years old, with common symptoms including neck mass, hoarseness, shortness of breath, and dysphagia. The left lobe was involved in most patients, and only 21.3% had extrathyroidal involvement. Cysts averaged 36.4 mm in diameter, with cystic nodules being the most frequent imaging finding (91.2%). Serological tests were performed for 42.6% of cases, of which 62.5% were positive. Surgery was undertaken in 71 patients (94.6%). CONCLUSION: Cystic echinococcosis (CE) of the thyroid should be considered as part of the differential diagnosis in patients with cervicofacial mass, especially in endemic countries. The present study provides reliable data to improve our understanding of the features of the disease for a better diagnosis and management.

Comparison of clinical and patient-reported outcomes in patients with benign euthyroid solitary nodules after ultrasound-guided percutaneous microwave ablation and endoscopic thyroidectomy.

BACKGROUND: Percutaneous ultrasound-guided microwave ablation (MWA) for benign solid thyroid nodules is the newest modality for treatment. However, the differences in treatment outcomes between MWA and endoscopic thyroidectomy vestibular approach (TOETVA) for patients with benign euthyroid solitary nodules remain unknown. We are sharing initial results from our prospective study. METHODS: Prospective study between January 2022 and December 2023 was conducted and data were noted at 3 time points in patients planned for treatment (Preoperative, 1 week, and 12 months). Main outcome measures were clinical outcome and comparison of thyroid-related quality of life using the ThyPRO-39hin and swallowing-related quality of life using the SWAL-QoL. RESULTS: Of the 36 included patients, 20 patients underwent TOETVA and 16 underwent MWA. Both the groups were comparable in terms of demographic and clinicopathological profiles. The nodule volume reduction rate of patients at 12 months after MWA was 75.10% and 100% for TOETVA. The mean preoperative ThyPRO-39hin and SWAL-QoL scores were comparable in all domains between the two groups. Mean ThyPRO-39hin and SWAL-QoL scores on postoperative day 7 were significantly better in the MWA group in domains impaired social life (p < 0.0001) and impaired daily life (p = 0.0002). However, at the end of 12 months, mean ThyPRO-39hin and SWAL-QoL scores became significantly better in the TOETVA group as compared to the MWA group. CONCLUSION: Our findings suggest that transoral endoscopic thyroidectomy results in significant superior clinical outcome, thyroid-related quality of life, and swallowing-related quality of life in the long term.

Molecular Profiling for Bethesda III to VI Nodules: Results of a Multicenter International Retrospective Study.

OBJECTIVE: Molecular testing is a well-established tool that assists in the management of thyroid nodules. We describe our experience using molecular testing of thyroid nodules with Bethesda III to VI cytology. METHODS: This is a retrospective multicenter, multinational study of thyroid nodules that underwent preoperative molecular profiling with ThyGenX/ThyGeNEXT or ThyroSeq V3 between 2015 and 2022. The clinical characteristics and mutational profiles of tumors were compared. Collected data included demographics, cytology results, surgical pathology, and molecular alterations. Molecular alterations were categorized into 3 main phenotypes: BRAF-like, RAS-like, and non-BRAF-non-RAS (NBNR). RESULTS: Overall, 784 patients who had surgery were included, of which 603 (76.2%) were females. The most common histologic type was papillary thyroid cancer (PTC) with 727 (91.9%) cases. In total, 205 (28.2%) cases showed an aggressive subtype of PTC (eg, tall cell and hobnail). BRAF-like alterations were most likely to be found in Bethesda V and VI nodules and show extrathyroidal extension (ETE), nodal disease, and/or aggressive subtypes of PTC (P < .001 for all). RAS-like alterations were more commonly found in Bethesda III and IV nodules and were less likely to show ETE, nodal disease, and/or aggressive histology (P < .001 for all). NBNR alterations were more commonly found in Bethesda III and IV nodules and were less likely to show ETE, nodal disease, and/or aggressive subtypes of PTC. However, they were rarely but significantly associated with poorly differentiated thyroid cancer (P < .005). CONCLUSION: Molecular testing of thyroid nodules can help determine the likelihood of malignancy and classify nodules into several tumor phenotypes, predicting their behaviors and potentially allowing for a more tailored treatment. NBNR alterations should be managed with caution.

The history of thyroid ultrasound: Past, present, and future directions.

The rapid evolution of ultrasound (US) technology has dramatically changed the medical field. Ideally suited for evaluation of anatomic disorders of the thyroid, coupled with its ease of use at the bedside, US has become an essential tool for Endocrinologists over the last 50 years. This noninvasive technology provides a sensitive and specific instrument for malignancy risk prediction of thyroid nodules, surveillance for recurrent thyroid cancer, and diagnosis of autoimmune thyroid disorders. While US has proven invaluable for such diagnostic purposes, its extensive use also has resulted in important negative consequences. This review will discuss the evolution of US equipment for the evaluation of thyroid disorders, its use in interventional procedures, and the unintended outcomes from the widespread adoption of this technology. Finally, this article will explore the potential future applications for US technology and its related advancements.

Thyroid Nodules: Past, Present, and Future.

BACKGROUND: Over the past millennia, the evaluation and management of thyroid nodules has essentially remained the same with thyroidectomy as the only reliable method to identify malignancy. However, in the last 30 years, technological advances have significantly improved diagnostic management of thyroid nodules. Advances in imaging have allowed development of a reliable risk- based stratification system to identify nodules at increased risk of malignancy. At the same time, sensitive imaging has caused collateral damage to the degree that we are now identifying and treating many small, low risk nodules with little to no clinical relevance. OBJECTIVE: To review the history of thyroid nodule evaluation with emphasis on recent changes and future pathways. METHODS: Literature review and discussion. RESULTS: Thyroid ultrasound remains the best initial method to evaluate the thyroid gland for nodules. Different risk-of-malignancy protocols have been developed and introduced by different societies, reporting methods have been developed and improved each, with goals of improving the ability to recognize nodules requiring further intervention and minimizing excessive monitoring of those who do not. Once identified, cytological evaluation of nodules further enhances malignancy identification with molecular markers assisting in ruling out malignancies in indeterminate nodules preventing unneeded intervention. And all societies have urged avoidance of overdiagnosis and overtreatment of low-risk cancers of little to no clinical relevance. CONCLUSION: In this review, we describe advancements in nodule evaluation and management, while emphasizing caution in overdiagnosing and overtreating low-risk lesions without clinical importance.

Combining Image Similarity and Predictive Artificial Intelligence Models to Decrease Subjectivity in Thyroid Nodule Diagnosis and Improve Malignancy Prediction.

OBJECTIVES: To evaluate the efficacy of combining predictive artificial intelligence (AI) and image similarity model to risk stratify thyroid nodules, using retrospective external validation study. METHODS: Two datasets were used to determine efficacy of the AI application. One was Stanford dataset ultrasound images of 192 nodules between April 2017 and May 2018 and the second was private practice consisting of 118 thyroid nodule images between January 2018 and December 2023. The nodules had definitive diagnosis by cytology or surgical pathology. The AI application was used to predict the diagnosis and American College of Radiology Thyroid Imaging and Data System (ACR TI-RADS) score. RESULTS: In the Stanford dataset, the AI application predicted malignancies with sensitivity of 1.0 and specificity of 0.55. Positive predictive value (PPV) was 0.18 and negative predictive value (NPV) was 1.0. The Area Under the Curve - Receiver Operating Characteristic was 0.78. ACR TI-RADS based clinical recommendation had a polychoric correlation of 0.67. In the private dataset, the AI application predicted malignancies with sensitivity of 0.91 and specificity of 0.95. PPV was 0.8 and NPV was 0.98. The area under the curve - receiver operating characteristic was 0.93 and accuracy was 0.94. ACR TI-RADS based score had a polychoric correlation of 0.94. CONCLUSION: The AI application showed good performance for sensitivity and NPV between the two datasets and demonstrated potential for 61.5% reduction in the need for fine needle aspiration and strong correlation to ACR TI-RADS. However, PPV was variable between the datasets possibly from variability in image selection and prevalence of malignancy. If implemented widely and consistently among various clinical settings, this could lead to decreased patient burden associated with an invasive procedure and possibly to decreased health care spending.