2022 Expert consensus on the use of laser ablation for papillary thyroid microcarcinoma.

OBJECTIVE: With the aim of standardizing and improving the use of ultrasound-guided PLA on PTMC, a panel of experts from China and Italy, jointly issued this expert consensus on the clinical use of PLA for low-risk PTMC. METHODS: This expert consensus was developed by Chinese and Italian experts who have specific competence and expertise in this area. An evidence-based approach combining the knowledge and practical experience of the panelists was utilized. RESULTS: Twenty-six expert consensus recommendations were developed, spanning topics including the indications and contraindications of PLA for PTMC, physician training, preoperative preparation of patients, intraoperative technical procedures, possible complications, efficacy assessment, follow-up strategy, the approach to new PTMC and metastatic lymph nodes after treatment, thyroid-stimulating hormone inhibition therapy, and quality control of the entire procedure. CONCLUSION: We summarized practical recommendations about standardized and improved PLA treatment for PTMC.

The values of shear wave elastography in avoiding repeat fine-needle aspiration for thyroid nodules with nondiagnostic and undetermined cytology.

OBJECTIVE: To evaluate the value of shear wave elastography (SWE) in avoiding repeat fine-needle aspiration of thyroid nodules with nondiagnostic and undetermined cytology. METHODS: A total of 232 thyroid nodules with nondiagnostic (n = 132) and undetermined (n = 100) cytology underwent ultrasound (US) and SWE, followed by repeat ultrasound (US)-guided fine-needle aspiration cytology (FNAC). The final diagnosis was based on cytological or pathological findings. The US and SWE characteristics of benign and malignant nodules were compared using the χ2 -test. The receiver operating characteristic (ROC) curves of the thyroid imaging reporting and data system (TI-RADS) categories from the US and the EMean and ESD from the SWE were graphed, and the areas under the curves (AUCs) were compared using a Z test. RESULTS: There were significant differences between the benign and malignant nodules in terms of the echogenicity, shape, margin, calcification and TI-RADS categories (all P < 0.05). The differences were significant between the malignant and benign nodules for EMean [(34.57 ± 14.81) kPa vs. (19.18 ± 7.09) kPa] and ESD [(13.68 ± 13.01) kPa vs. (3.97 ± 2.58) kPa] (both P < 0.001). Though the difference in the AUCs of EMean (0.864) and ESD (0.876) was not significant (P = 0.745), they both had higher diagnostic performances in comparison with TI-RADS categories (0.762) (all P < 0.05). Moreover, ESD attained a sensitivity of 100% with a relatively higher specificity of 49.75% when its cut-off value was 3.3 kPa. CONCLUSIONS: Shear wave elastography is a promising imaging method for reducing repeat FNAC for benign thyroid nodules with nondiagnostic and undetermined cytology when using ESD as an index.

Preoperative Axillary Ultrasound in the Selection of Patients With a Heavy Axillary Tumor Burden in Early-Stage Breast Cancer: What Leads to False-Positive Results?

OBJECTIVES: To determine whether imaging and clinicopathologic features could predict false-positive axillary ultrasound (US) results in the selection of patients with breast cancer who had a heavy axillary tumor burden (≥3 tumor-involved nodes). METHODS: Among 788 patients with histologically confirmed invasive breast cancer at Ruijin Hospital from October 2014 to September 2015, 162 patients (cT1-T2, cN0) with 167 axillae had suspicious axillary US findings. Ultrasound findings were considered suspicious for metastasis if cortical thickening of greater than 3 mm or effacement of the fatty hilum was present. The false-positive rate of suspicious axillary US results for identifying 3 or more positive lymph nodes in the final pathologic examination was calculated. Univariate and multivariate analyses were used to evaluate imaging and clinicopathologic factors related to the false-positive results. RESULTS: Axillary US showed a false-positive rate of 60.5% (101 of 167) in the patients with breast cancer and a heavy nodal burden. By logistic regression analyses, we found false-positive axillary US results more frequently in patients who had a T1 stage tumor (P = .005), an estrogen receptor/progesterone receptor-negative tumor (P < .001), solitary suspicious nodes identified on axillary US (P < .001), and a cortical thickness of the most suspicious lymph node of 3.5 mm or less (P = .015). CONCLUSIONS: Imaging and clinicopathologic features can be used to identify axillae with less than 3 metastatic nodes in patients with early-stage breast cancer who have positive axillary US results. In the post-American College of Surgeons Oncology Group Z0011 trial era, conducting a secondary evaluation either clinically or by axillary imaging before the use of a US-guided biopsy of suspicious nodes can potentially avoid the additional morbidity of axillary lymph node dissection and reduce the preoperative workload.

Ultrasonographic Assessment of Differential Diagnosis Between Degenerating Cystic Thyroid Nodules and Papillary Thyroid Microcarcinomas.

PURPOSE: To enhance the diagnostic accuracy of conventional ultrasonography in differentiating papillary thyroid microcarcinomas (PTMCs) from degenerating cystic thyroid nodules mimicking malignancy (under 10 mm in diameter). METHODS: A retrospective analysis of hypoechoic thyroid nodules under 10 mm between 162 cases of degenerating cystic thyroid nodules confirmed by ultrasound-guided fine-needle aspiration (US-FNA) and 150 cases of PTMCs confirmed by both US-FNA and postoperative pathology were performed in the aspects of shape, margin, calcification, and vascularity. RESULTS: Significant differences were observed in the aspects of shape, rim calcification, and vascularity (P < 0.05) between two groups in condition of solid hypoechogenicity. An ovoid-to-round regular shape, rim calcification, and no intrinsic blood flow were the statistically significant features for the depiction of a benign degenerating cystic nodule, while a taller-than-wide shape and peripheral or intranodular blood flow were that of a malignancy. Multiple stepwise logistic regression analysis demonstrated each of them as an independent predictor of malignancy (P < 0.05). CONCLUSIONS: Shape, rim calcification, and vascularity are efficient criteria to distinguish degenerating cystic thyroid nodules mimicking malignancy from PTMCs in cases of solid hypoechogenic nodules under 10 mm. Such criteria should be acknowledged in cases of solid hypoechogenic thyroid nodules to help guide for the need of US-FNA.

Clinicopathologic Factors and Thyroid Nodule Sonographic Features for Predicting Central Lymph Node Metastasis in Papillary Thyroid Microcarcinoma: A Retrospective Study of 1204 Patients.

OBJECTIVES: Preoperative prediction of lymph node metastasis is of clinical importance for the surgical treatment of thyroid tumor. The purpose of this study was to evaluate clinicopathologic factors and thyroid nodule sonographic features predictive of central lymph node metastasis in papillary thyroid microcarcinoma. METHODS: Clinicopathologic factors and thyroid nodule sonographic features of 1204 patients with papillary thyroid microcarcinoma were retrospectively reviewed from January 2014 to June 2015. Central lymph node dissection was performed on each patient. Univariate and multivariate analyses were performed to analyze the clinicopathologic factors and thyroid nodule sonographic features associated with central lymph node metastasis in papillary thyroid microcarcinoma. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated to assess the relevance of all potential predictive factors. RESULTS: Central lymph node metastasis was detected in 395 of the 1204 patients (32.81%). By univariate and multivariate analyses, younger age (≤43 years), male sex, larger tumor size (≥7 mm), multifocal papillary thyroid microcarcinoma and microcalcification were independently associated with central lymph node metastasis in papillary thyroid microcarcinoma (P < .05). The ORs were 1.920 (95% CI, 1.476-2.499), 1.665 (95% CI, 1.234-2.247), 1.534 (95% CI, 1.177-2.000), 2.120 (95% CI, 1.563-2.877), and 4.109 (95% CI, 3.118-5.414), respectively. CONCLUSIONS: Central lymph node metastasis is highly prevalent in papillary thyroid microcarcinoma. Younger age (≤43 years), male sex, larger tumor size (≥7 mm), multifocal papillary thyroid microcarcinoma, and microcalcification were independent predictors of central lymph node metastasis. Surgeons and radiologists need to pay more attention to patients with papillary thyroid microcarcinoma who have these risk predictors.

Axillary Staging of Early-Stage Invasive Breast Cancer by Ultrasound-Guided Fine-Needle Aspiration Cytology: Which Ultrasound Criteria for Classifying Abnormal Lymph Nodes Should Be Adopted in the Post-ACOSOG Z0011 Trial Era?

OBJECTIVES: Ultrasound (US)-guided fine-needle aspiration cytology (FNAC) is able to identify patients with extensive node involvement before surgery. In this study, we aimed to establish the optimal US criterion to identify abnormal lymph nodes on US-guided FNAC for detection of patients with 3 or more metastatic axillary nodes. METHODS: A total of 445 axillae from 443 patients with histologically confirmed invasive breast cancer (cT1-2 cN0) were examined with US at Ruijin Hospital from August 2013 to August 2014. Ultrasound-guided FNAC was performed on suspicious nodes when the cortex was eccentrically or concentrically thickened to greater than 2 mm; 269 axillae (60.4%) met the criterion and underwent US-guided FNAC. We retrospectively analyzed the US characteristics of axillary lymph nodes, the US-guided FNAC results, and the extent of axillary nodal involvement. For diagnostic performance, the sensitivity, specificity, and receiver operating characteristic curves were obtained. RESULTS: Eighty-six patients (19.4%) were confirmed to have 3 or more positive lymph nodes by pathologic analysis. There was a significant association between the morphologic change in the most suspicious node and the extent of axillary nodal involvement (P < .001). When we applied the cutoff point (cortical thickness >3.5 mm) at which the maximal sum of sensitivity and specificity for diagnosis of 3 or more axillary lymph node metastases was achieved, we found that the sensitivity and specificity were 75.6% and 82.7%, respectively. When combining this criterion with US-guided FNAC of the most suspicious nodes, the sensitivity and specificity were 64.2% and 94.5%, and 36.1% of cases could be spared an unnecessary 1-step axillary lymph node dissection. CONCLUSIONS: Cortical thickness of greater than 3.5 mm in the most suspicious nodes is appropriately predictive of patients with 3 or more tumor-involved axillary nodes. When this criterion for US-guided FNAC was adopted, a group of patients with 1 or 2 metastatic nodes could be spared unnecessary 1-step axillary lymph node dissection.

Correlation between Echo-Tracking Parameters and In Vitro Measurements of Arterial Contraction and Relaxation in Rats Fed a High-Cholesterol Diet.

BACKGROUND: Echo-tracking (ET) is a new technique that allows the assessment of arterial function and stiffness. This study aimed to ascertain the utility of the echo-tracking (ET) technique to assess vascular stiffness in rats with hypercholesterolemia and atherosclerosis. MATERIAL AND METHODS: ET was used to measure the arterial stiffness of the aorta in cholesterol-fed Sprague-Dawley rats (group T1, n=10, for 4 weeks; group T2, n=10, for 12 weeks) and normal control rats (group C1, n=10; group C2, n=10). In vitro isometric tension experiments were used to measure the maximum contractile tension (MCT) and maximum relaxation percentage (MRR%) of aortic rings. Indicators of arterial stiffness and aortic MCT and MRR% were compared between groups using linear regression analysis. Light microscopic evaluation was used to demonstrate atherosclerotic changes in the aorta. RESULTS: The rat models were successfully induced; pathological examination of the aortas showed significant atherosclerosis in group T2, but not in groups C1, C2, or T1. The arterial stiffness parameters obtained using ET and aortic rings in vitro showed significant impairments in T1 and T2 rats compared with C1 and C2 controls (all P<0.05 vs. controls). In addition, these impairments were greater in the T2 group than in the T1 group (all P<0.05). Finally, MRR% correlated with the distensibility coefficient (r=0.396, P=0.012), arterial compliance (r=0.317, P=0.047), stiffness parameter b (r=-0.406, P=0.009) and one-point pulse wave ß (r=-0.434, P=0.005). CONCLUSIONS: These results suggest that ET could be used to evaluate the changes in arterial wall elasticity associated with atherosclerosis and hypercholesterolemia.

Evaluation of Thyroid Nodules by a Scoring and Categorizing Method Based on Sonographic Features.

OBJECTIVES: To assess sonographic features of thyroid nodules associated with malignancy and to establish a scoring and categorizing method based on sonographic features. METHODS: A total of 2445 patients with 2445 thyroid nodules were included and divided into 2 groups: benign (1493 cases) and malignant (952 cases). First, 10 sonographic features, including shape, border, margin, internal content, echogenicity, microcalcifications, posterior echo, halo, vascularization distribution, and vascularization degree, were defined, and all nodules were retrospectively evaluated. Second, the features associated with malignancy were selected by statistical analysis and were assigned weightings according to their odds ratios. Third, a total score for each nodule was obtained after the assigned weightings of the suspicious features were summed. Fourth, the malignancy rate of each total score was calculated. Then a modified version of the Thyroid Imaging Reporting and Data System (TI-RADS) was established with reference to the American College of Radiology's Breast Imaging Reporting and Data System. RESULTS: Seven independent features associated with malignancy were a taller-than-wide shape, an obscure border, an irregular margin, solid internal content, marked hypoechogenicity and hypoechogenicity, microcalcifications, and an internal vascularization distribution. The TI-RADS included 5 categories with different malignancy rates: category 3 (<2%), 4A (2%-5%), 4B (5%-50%), 4C (50%-90%), and 5 (≥ 90%). CONCLUSIONS: A modified version of TI-RADS was established on the basis of the sonographic features with different weightings according to the relative risk of malignancy. This system could be of great use in predicting the nature of thyroid nodules in a quantified and standardized way and also helping clinicians decide on the clinical management.

Sonographic Features of Ductal Carcinoma In Situ of the Breast With Microinvasion: Correlation With Clinicopathologic Findings and Biomarkers.

OBJECTIVES: To compare the sonographic results, clinicopathologic characteristics, and biomarkers in pure ductal carcinoma in situ (DCIS) of the breast and DCIS with microinvasion. METHODS: A total of 218 patients with pathologically proven DCIS based on sonography in our hospital (2009-2013) were retrospectively enrolled. Clinicopathologic characteristics and biomarkers were examined. Grayscale sonographic results were investigated according to the American College of Radiology Breast Imaging Reporting and Data System lexicon, and color Doppler sonography was used to assess the vascularization distribution and degree. All variables were compared by univariate and multivariate logistic regression analyses. RESULTS: All patients were female, with a mean age of 55.3 years (range, 32-78 years). One hundred sixty patients with 160 lesions had pure DCIS, and 58 patients with 58 lesions had DCIS with microinvasion. Ductal carcinoma in situ with microinvasion was more likely to have sentinel lymph node metastases, larger tumors, a higher tumor grade, human epidermal growth factor receptor 2 positivity, and a high Ki-67 index (all P < .05). Univariate analysis showed that DCIS with microinvasion was more likely to be hypoechoic with microcalcifications, have a mixed vascularization distribution (equal peripheral and internal blood flow signals), and have a high degree of vascularization (at least 2 penetrating vessels; all P < .05). Multivariate analysis indicated that the presence of microcalcifications and a high degree of vascularization were significantly and independently associated with microinvasion (both P < .001). CONCLUSIONS: Our findings suggest that DCIS with microinvasion is more likely to have microcalcifications and a high degree of vascularization than pure DCIS. Patients with these sonographic features are more likely to have a high tumor grade, sentinel lymph node metastases, larger tumors, a high Ki-67 index, and human epidermal growth factor receptor 2 positivity.

Three-dimensional contrast-enhanced sonography in the assessment of breast tumor angiogenesis: correlation with microvessel density and vascular endothelial growth factor expression.

OBJECTIVES: The purpose of this study was to differentiate perfusion and vascular characteristics between benign and malignant breast lesions by 3-dimensional contrast-enhanced sonography and evaluate their correlation with microvessel density and vascular endothelial growth factor (VEGF) expression for further clinical exploration. METHODS: Three-dimensional contrast-enhanced sonography was performed in 183 patients with breast lesions, and sonographic characteristics were carefully observed for further analysis. The mean microvessel density and VEGF expression were measured by immunohistochemical analysis. RESULTS: Pathologic results showed 35 benign and 148 malignant cases. Malignancy and benignity differed significantly in peripheral vessel characteristics (number, distribution, course, degree of dilatation, and penetrating vessels), rim perfusion and coarseness degree, intratumoral perfusion type, and intratumoral vessel dilatation (P< .05) but not the presence of peripheral and intratumoral vessels and intratumoral perfusion (P > .05). The specificity of penetrating vessels was 88.6% for diagnosing malignancy. The sensitivity, specificity, and accuracy of rim perfusion coarseness were 90.2%, 70.4%, and 85.3% respectively. The sensitivity of the intratumoral perfusion type was 77.8%, whereas the specificity of intratumoral vessel dilatation was 88.9%. Microvessel density and VEGF expression were significantly correlated with perfusion and vascular characteristics (P < .05), except the presence of peripheral vessels, rim perfusion, and intratumoral perfusion (P> .05). The presence of intratumoral vessels was related to VEGF (P< .05) but not microvessel density (P > .05). CONCLUSIONS: Three-dimensional contrast-enhanced sonographic characteristics were statistically different between benign and malignant breast lesions. Some of them also correlated significantly with microvessel density and VEGF expression and therefore have potential for objective evaluation of tumor angiogenesis.

Blood flow resistance in lesion vessels and normal host vessels evaluated by pulsed Doppler ultrasound.

Blood flow rate in the microcirculation is proportional to the arteriole-venule pressure difference and inversely proportional to the blood flow resistance (BFR). Generally, the BFR studies to date have focused on using invasive methods and were carried out in non-physiological conditions. Moreover, few studies have been concerned with the relationships of BFR between the tumor vessels and the normal host vessels. The present study investigated the BFR in malignant lesion vessels, benign lesion vessels and normal host vessels in physiological conditions using pulsed Doppler ultrasound as a tool and the thyroid as a model, A total of 133 patients with thyroid nodules were included in the study. The results revealed that most of the BFR parameters were higher in malignant lesion vessels than in benign lesion vessels (P=0.001-0.029), as well as lower in normal host vessels than in malignant or benign lesion vessels (P=0.000-0.017); Low to moderate significant positive correlations of BFR between benign lesion vessels and normal host vessels were also found (r=0.358-0.480, P=0.000 for all). Finally and interestingly, low negative correlations between the malignant nodule sizes and some of the BFR parameters were revealed, though these correlations were not statistically significant (r=-0.205--0.261, P=0.108-0.211). Our results suggested that pulsed Doppler ultrasound could be successfully used to measure BFR in physiological conditions and to reveal the BFR relationship between lesion vessels and normal host vessels, as well as the relationship between the lesion sizes and the BFR.

Differences in sonographic features of papillary thyroid carcinoma between neck lymph node metastatic and nonmetastatic groups.

OBJECTIVES: The purpose of this study was to assess the differences in sonographic features of papillary thyroid carcinoma between neck lymph node metastatic and non-metastatic groups. METHODS: A total of 155 patients with 155 papillary thyroid carcinoma nodules were included and divided into two groups: with neck lymph node metastases (52 cases) and without neck lymph node metastases (103 cases). The size, shape, border, margin, halo, internal architecture, echogenicity, echo homogeneity, calcifications, and contact extent between the nodule border and thyroid capsule were evaluated by gray scale sonography, and color Doppler sonography was applied to assess the vascularization distribution and vascularization degree in the nodules. The peak systolic velocity, pulsatility index, resistive index, peak systolic velocity difference, pulsatility index difference, and resistive index difference were measured by pulsed Doppler sonography in 80 lesions. The differences in the sonographic features of papillary thyroid carcinoma between the metastatic and nonmetastatic groups were investigated. RESULTS: The differences in the size, percentage of the nodule border that contacted the thyroid capsule, calcifications, vascularization degree, and resistive index difference of the lesions were statistically significant between the metastatic and nonmetastatic groups (P < .05). CONCLUSIONS: Our findings suggest that a larger size, a greater contact percentage, combined microcalcifications and macrocalcifications, a higher blood supply, and a higher resistive index difference were significantly more common in the metastatic group compared to the nonmetastatic group.

The feasibility and efficacy of ultrasound-guided percutaneous laser ablation for multifocal papillary thyroid microcarcinoma.

Objective: The aim of this study was to evaluate the feasibility and efficacy of percutaneous laser ablation (PLA) for patients with multifocal papillary thyroid microcarcinoma (PTMC). Materials and methods: A cohort of patients who underwent ultrasound (US)-guided PLA for primary PTMC were enrolled in this study. The patients were divided into a multifocal PTMC (multi-PTMC) group and a unifocal PTMC (uni-PTMC) group. Before PLA, conventional US and contrast-enhanced ultrasound (CEUS) were performed to evaluate the PTMC and cervical lymph nodes. The operation time, energy, power, amount of isolation liquid, and complications during PLA were recorded. Patients were followed up at 2 days, 1 month, 3 months, and 6 months, and every 6 months after that. Volume reduction rate (VRR), local tumor recurrence, and lymph node metastasis after PLA were observed. Results: The study included 12 patients with 26 PTMCs and 60 patients with 60 PTMCs. The operation time, total energy, and amount of isolation liquid in the multi-PTMC group were more than those in the uni-PTMC group (p = 0.000, 0.007, and 0.020, respectively). The mean follow-up durations in multi-PTMC and uni-PTMC groups were 19.75 ± 11.46 months (6-36 months) and 16.33 ± 10.01 months (4-40 months), with a similar VRR of the ablated lesions in the two groups. One and three cases with newly developed PTMCs were observed in the multi-PTMC group and the uni-PTMC group during follow-up, respectively. There was no regrowth of treated lesions, lymph node metastasis, or distant metastasis. At the end of the follow-up, all the ablated lesions in the two groups completely disappeared or only remained scar strips. Conclusion: PLA is a safe and effective technique for treating multifocal PTMC, which might be an alternative technique for patients who are not eligible or are unwilling to undergo surgery.

Efficacy of Lauromacrogol Injection for Ablation of Benign Predominantly Cystic Thyroid Nodules and Related Factors: A Prospective Study.

OBJECTIVE: To prospectively evaluate the efficacy of lauromacrogol injection for ablation (LIA) of benign predominantly cystic thyroid nodules and its related factors. MATERIALS AND METHODS: A total of 142 benign predominantly cystic thyroid nodules (median volume, 12.5 mL; range, 0.4-156 mL) in 137 patients (male:female sex ratio, 36:101; mean age ± standard deviation [SD], 49 ± 13 years) were treated with LIA after being confirmed as benign via cytology. The volume reduction rate (VRR) of the nodules and cosmetic score were evaluated during follow-up at 1, 3, and 6 months after treatment and every 6 months thereafter. A VRR of ≥ 50% at the 12-month follow-up was considered to indicate effective treatment. The associations between the clinical factors and nodular ultrasound features, including the initial nodule volume, proportion of solid components, vascularity grade and ineffective treatment (VRR of < 50% at the 12-month follow-up), and regrowth were analyzed. RESULTS: All patients completed follow-up for at least 12 months. The average ± SD follow-up period was 32 ± 11 months (range, 12-54 months). The effective treatment rate was 73.2% (104/142), while the regrowth rate was 12.0% (17/142) at the last follow-up. Grade 2-3 intranodular vascularity in the solid components of the nodules was the only independent factor associated with ineffective treatment, with an odds ratio (reference category, grade 0-1) of 3.054 (95% confidence interval, 1.148-8.127) (p = 0.025). CONCLUSION: LIA is an effective treatment for predominantly cystic thyroid nodules. Grade 2-3 intranodular vascularity in the solid components of nodules is the only independent risk factor for ineffective LIA.

Long-term follow-up ultrasonography surveillance in a large cohort of patients with papillary thyroid carcinoma.

OBJECTIVE: This study aimed to investigate the predictive factors as well as the time and age course of recurrence/persistence in a large cohort of postoperative patients with papillary thyroid carcinoma (PTC) based on the long-term ultrasonography (US) follow-up data. METHODS: Between January 2007 and December 2016, 3106 patients underwent surgery for PTC and at least two postoperative US follow-up examination over more than three years. Tumor recurrence/persistence was confirmed based on the follow-up US data and histopathological results. Univariate and multivariate analyses were performed to evaluate the predictive factors of tumor recurrence/persistence. Kaplan-Meier survival analysis was used to evaluate the recurrence-/persistence-free survival curve based on the US results. RESULTS: A total of 321(10.3%) patients developed tumor recurrence/persistence during 54.3 months of mean follow-up (range 36-135 months), including 268(83.5%) cases of lymph node recurrence/persistence, 37 (11.5%) cases of non-lymph node recurrence/persistence, and 16(5%) cases of both types. Recurrence/persistence was observed using US examination at a mean interval of 23.6 ± 21.6 months (range 1-135 months) after surgery and peak incidence was observed 1-2 years after initial treatment. Younger (20-30 years old) and older (70-80 years old) patients had a higher proportion of tumor recurrence/persistence. Multifocality, advanced T and advanced N stages were independent risk factors of tumor recurrence/persistence. CONCLUSION: Tumor recurrence/persistence of PTC usually occurs during the early postoperative period. For patients with multifocal cancer, advanced T and N stage, the US surveillance examination should be cautiously performed, especially in younger and older patients.

Gail Model Improves the Diagnostic Performance of the Fifth Edition of Ultrasound BI-RADS for Predicting Breast Cancer: A Multicenter Prospective Study.

RATIONALE AND OBJECTIVES: The sonographic appearance of benign and malignant breast nodules overlaps to some extent, and we aimed to assess the performance of the Gail model as an adjunctive tool to ultrasound (US) Breast Imaging Reporting and Data System (BI-RADS) for predicting the malignancy of nodules. MATERIALS AND METHODS: From 2018 to 2019, 2607 patients were prospectively enrolled by 35 health care facilities. An individual breast cancer risk was assessed by the Gail model. Based on B-mode US, color Doppler, and elastography, all nodules were evaluated according to the fifth edition of BI-RADS, and these nodules were all confirmed later by pathology. RESULTS: We demonstrated that the Gail model, age, tumor size, tumor shape, growth orientation, margin, contour, acoustic shadowing, microcalcification, presence of duct ectasia, presence of architectural distortion, color Doppler flow, BI-RADS, and elastography score were significantly related to breast cancer (all p < 0.001). The sensitivity, specificity, positive predictive value, negative predictive value, accuracy, and area under the curve (AUC) for combining the Gail model with the BI-RADS category were 95.6%, 91.3%, 85.0%, 97.6%, 92.8%, and 0.98, respectively. Combining the Gail model with the BI-RADS showed better diagnostic efficiency than the BI-RADS and Gail model alone (AUC 0.98 vs 0.80, p < 0.001; AUC 0.98 vs 0.55, p < 0.001) and demonstrated a higher specificity than the BI-RADS (91.3% vs 59.4%, p < 0.001). CONCLUSION: The Gail model could be used to differentiate malignant and benign breast lesions. Combined with the BI-RADS category, the Gail model was adjunctive to US for predicting breast lesions for malignancy. For the diagnosis of malignancy, more attention should be paid to high-risk patients with breast lesions.

The Utility of the Fifth Edition of the BI-RADS Ultrasound Lexicon in Category 4 Breast Lesions: A Prospective Multicenter Study in China.

RATIONALE AND OBJECTIVES: The objective of this study was to evaluate the utility of the fifth edition of the Breast Imaging-Reporting and Data System (BI-RADS) in clinical breast radiology by using prospective multicenter real-time analyses of ultrasound (US) images. MATERIALS AND METHODS: We prospectively studied 2049 female patients (age range, 19-86 years; mean age 46.88 years) with BI-RADS category 4 breast masses in 32 tertiary hospitals. All the patients underwent B-mode, color Doppler US, and US elastography examination. US features of the mass and associated features were described and categorized according to the fifth edition of the BI-RADS US lexicon. The pathological results were used as the reference standard. The positive predictive values (PPVs) of subcategories 4a-4c were calculated. RESULTS: A total of 2094 masses were obtained, including 1124 benign masses (54.9%) and 925 malignant masses (45.1%). For BI-RADS US features of mass shape, orientation, margin, posterior features, calcifications, architectural distortion, edema, skin changes, vascularity, and elasticity assessment were significantly different for benign and malignant masses (p< 0.05). Typical signs of malignancy were irregular shape (PPV, 57.2%), spiculated margin (PPV, 83.7%), nonparallel orientation (PPV, 63.9%), and combined pattern of posterior features (PPV, 60.6%). For the changed or newly added US features, the PPVs for intraductal calcifications were 80%, 56.4% for internal vascularity, and 80% for a hard pattern on elastography. The associated features such as architectural distortion (PPV, 89.3%), edema (PPV, 69.2%), and skin changes (PPV, 76.2%) displayed high predictive value for malignancy. The rate of malignant was 7.4% (72/975) in category 4a, 61.4% (283/461) in category 4b, and 93.0% (570/613) in category 4c. The PPV for category 4b was higher than the likelihood ranges specified in BI-RADS and the PPVs for categories 4a and 4c were within the acceptable performance ranges specified in the fifth edition of BI-RADS in our study. CONCLUSION: Not only the US features of the breast mass, but also associated features, including vascularity and elasticity assessment, have become an indispensable part of the fifth edition of BI-RADS US lexicon to distinguish benign and malignant breast lesions. The subdivision of category 4 lesions into categories 4a, 4b, and 4c for US findings is helpful for further assessment of the likelihood of malignancy of breast lesions.

Determinants of arterial properties in Chinese type-2 diabetic patients compared with population-based controls.

OBJECTIVE: To our knowledge, few studies compared the association of brachial-ankle pulse wave velocity (baPWV) with cardiovascular risk factors among Chinese with type-2 diabetes mellitus and non-diabetic controls. This study addresses this issue. METHODS: We measured baPWV (OMRON VP1000) in 413 diabetic patients from Shanghai city (mean age: 58.7 years; 57% women) and 354 controls randomly recruited from the population of JingNing county, Zhejiang Province. We used stepwise multiple regression to identify covariables of baPWV and introduced interaction terms in the models to compare slopes. We expressed association sizes for continuous variables for a 1-SD increase in the dependent variable. RESULTS: Adjusted baPWV was higher in diabetic patients than controls (1678 vs 1583 cm/sec; P= 0.018). In diabetic patients, baPWV was independently correlated with female sex (-61 cm/sec; P = 0.061), age (+107 cm/sec; P < 0.0001), height (-51 cm/sec; P = 0.012), systolic pressure (+99 cm/sec; P < 0.0001), and the HDL-to-total cholesterol ratio (-38 cm/sec; P = 0.0004). In controls, the explanatory variables were female sex (-74 cm/sec; P = 0.045), age (+138 cm/sec; P < 0.0001), height (-262 cm/sec; P < 0.0001), systolic pressure (+202 cm/sec; P < 0.0001), but not the HDL-to-total cholesterol ratio (P = 0.48). Explained variance of baPWV was 34% and 61% in diabetic patients and controls, respectively. The associations of baPWV with age, height and systolic pressure were steeper (P < 0.04) in controls than diabetic patients. CONCLUSION: Sex, age, height and systolic pressure were the main determinants of baPWV in Chinese, irrespective of whether they had diabetes or not, but these associations were tighter in population-based controls without diabetes.

Risk-predicted dual nomograms consisting of clinical and ultrasound factors for downgrading BI-RADS category 4a breast lesions - A multiple centre study.

Purpose: To develop and to validate a risk-predicted nomogram for downgrading Breast Imaging Reporting and Data System (BI-RADS) category 4a breast lesions. Patients and Methods: We enrolled 680 patients with breast lesions that were diagnosed as BI-RADS category 4a by conventional ultrasound from December 2018 to June 2019. All 4a lesions were randomly divided into development and validation groups at the ratio of 3:1. In the development group consisting of 499 cases, the multiple clinical and ultrasound predicted factors were extracted, and dual-predicted nomograms were constructed by multivariable logistic regression analysis, named clinical nomogram and ultrasound nomogram, respectively. Patients were twice classified as either "high risk" or "low risk" in the two nomograms. The performance of these dual nomograms was assessed by an independent validation group of 181 cases. Receiver Operating Characteristic (ROC) curve and diagnostic value were calculated to evaluate the applicability of the new model. Results: After multiple logistic regression analysis, the clinical nomogram included 2 predictors: age and the first-degree family members with breast cancer. The area under the curve (AUC) value for the clinical nomogram was 0.661 and 0.712 for the development and validation groups, respectively. The ultrasound nomogram included 3 independent predictors (margins, calcification and strain ratio), and the AUC value in this nomogram was 0.782 and 0.747 in the development and validation groups, respectively. In the development group of 499 patients, approximately 50.90% (254/499) of patients were twice classified "low risk", with a malignancy rate of 1.18%. In the validation group of 181 patients, approximately 47.51% (86/181) of patients had been twice classified as "low risk", with a malignancy rate of 1.16%. Conclusions: A dual-predicted nomogram incorporating clinical factors and imaging characteristics is an applicable model for downgrading the low-risk lesions in BI-RADS category 4a and shows good stability and accuracy, which is useful for decreasing the rate of invasive examinations and surgery.

Qualitative Evaluation of Virtual Touch Imaging Quantification: A Simple and Useful Method in the Diagnosis of Breast Lesions.

OBJECTIVE: To test the value of qualitative virtual touch imaging quantification (VTIQ) features in differentiating benign from malignant breast lesions. METHODS: From November 2016 to August 2017, 230 lesions were subjected to conventional US and virtual touch imaging quantification before biopsy. The maximum shear wave velocity (SWVmax) was measured using a standardized method. Qualitative VTIQ features, including the "stiff rim" sign and color pattern classification, were assessed according to a binary classification. The sensitivity, specificity and area under the receiver operating curve (AUC) of Breast Imaging Reporting and Data System (BI-RADS), SWVmax, qualitative VTIQ features, and combined data were compared. RESULTS: Among the 230 breast lesions, 150 were benign and 80 were malignant. Compared to the benign lesions, the malignant ones had higher SWVmax values and were more likely to show the "stiff rim" sign and VTIQ pattern 2 (P <0.001 for all). The AUC value was 0.885 for the qualitative VTIQ combination (the presence of the "stiff rim" sign and/or the display of VTIQ pattern 2), similar to that for SWVmax (P=0.472). BI-RADS combined with the qualitative VTIQ combination and with SWVmax yielded similar results, including significantly higher AUC values (P = 0.018 and 0.014, respectively), significantly higher specificities (P<0.001 for both), and nonsignificantly decreased sensitivities (P = 0.249 for both) compared to BI-RADS alone. CONCLUSION: The dual-category classification of qualitative VTIQ features according to the presence of the "stiff rim" sign and/or the classification of VTIQ pattern 2 is a simple and useful method that may be representative of quantitative VTIQ parameters in the evaluation of breast masses.