Recurrent laryngeal nerve monitoring by flexible laryngoscopy during thyroid radiofrequency ablation in the awake patient.

Objective: Although radiofrequency ablation (RFA) is a safe and effective non-surgical treatment for benign thyroid nodules, injury to the recurrent laryngeal nerve (RLN), is a potential and feared complication. Intermittent voice checks have been proposed to monitor vocal cord (VC) function during RFA, but such assessment is highly subjective and effort-dependent. Methods: We are here reporting the methodological use of flexible laryngoscopy (FL) for VC monitoring during bilateral thyroid RFA treatment. The patient, a 35-year-old woman, was referred to the Endocrinology Unit for subclinical hyperthyroidism due to bilateral autonomously functioning thyroid nodules. Results: At the end of the treatment of the first nodule, the FL performed by an otorhinolaryngologist specialist allowed evaluating VC function and ruling out possible paralysis before proceeding with the contralateral RFA treatment. The patient was awake during the entire procedure and well tolerated the laryngoscopic examination. The TSH serum evaluations performed one month and 9 months after the procedure assessed an euthyroid state (TSH 3.2 mIU/L and 2.8 mIU/L, respectively). Conclusion: During bilateral thyroid RFA the use of FL for VC monitoring treatment resulted in a safe, easy-to-perform, and effective strategy to minimize and anticipate RLN injury risk in the awake patient. The prevention of RLN damage is advisable in the case of single RFA treatment, while it should be strongly recommended when RFA is performed on bilateral nodules.

Cost Effectiveness of Definitive Treatment Strategies for Autonomously Functioning Thyroid Nodules.

OBJECTIVE: Autonomously functioning thyroid nodules (AFTN) can be treated with antithyroid drugs, radioactive iodine (RAI), thyroid lobectomy or radiofrequency ablation (RFA). Although surgery is most definitive, some patients require lifelong hormone supplementation. RFA avoids this sequela, but its efficacy depends on nodule size. This study aims to compare the relative cost-effectiveness of RAI, RFA and lobectomy for treatment of AFTNs. STUDY DESIGN: A Markov analysis model was created to simulate clinical outcomes, costs and utilities for three AFTN treatments: (1) thyroid lobectomy, (2) RAI, and (3) RFA. PATIENTS: This mathematical model was created using published literature and modeling. MEASUREMENTS: Transition probabilities, utilities and costs were extracted from published literature, Medicare, and RedBook. The willingness to pay threshold was set to $100,000 per quality-adjusted life year. The model simulated 2-year outcomes, reflecting RFA literature. Sensitivity analyses were conducted to account for uncertainty in model variables. RESULTS: In the base model, RAI dominated both lobectomy and RFA, with lower estimated cost ($2000 vs. $9452 and $10,087) and higher cumulative utility (1.89 vs. 1.82 and 1.78 quality-adjusted life years). One-way sensitivity analyses demonstrated that relative cost-effectiveness between surgery and RFA was driven by the probability of euthyroidism after RFA and hypothyroidism after lobectomy. RFA becomes more cost-effective than surgery if the rate of euthyroidism after ablation is higher than 69% (baseline 54%). CONCLUSION: Based on published data, RAI is most cost-effective in treating most AFTN. Surgery is more cost-effective than RFA in most scenarios, but RFA may be more resource-efficient for smaller nodules with a high likelihood of complete treatment.

Improving the diagnostic strategy for thyroid nodules: a combination of artificial intelligence-based computer-aided diagnosis system and shear wave elastography.

PURPOSE: Thyroid nodules are highly prevalent in the general population, posing a clinical challenge in accurately distinguishing between benign and malignant cases. This study aimed to investigate the diagnostic performance of different strategies, utilizing a combination of a computer-aided diagnosis system (AmCAD) and shear wave elastography (SWE) imaging, to effectively differentiate benign and malignant thyroid nodules in ultrasonography. METHODS: A total of 126 thyroid nodules with pathological confirmation were prospectively included in this study. The AmCAD was utilized to analyze the ultrasound imaging characteristics of the nodules, while the SWE was employed to measure their stiffness in both transverse and longitudinal thyroid scans. Twelve diagnostic patterns were formed by combining AmCAD diagnosis and SWE values, including isolation, series, parallel, and integration. The diagnostic performance was assessed using the receiver operating characteristic curve and area under the curve (AUC). Sensitivity, specificity, accuracy, missed malignancy rate, and unnecessary biopsy rate were also determined. RESULTS: Various diagnostic schemes have shown specific advantages in terms of diagnostic performance. Overall, integrating AmCAD with SWE imaging in the transverse scan yielded the most favorable diagnostic performance, achieving an AUC of 72.2% (95% confidence interval (CI): 63.0-81.5%), outperforming other diagnostic schemes. Furthermore, in the subgroup analysis of nodules measuring <2 cm or 2-4 cm, the integrated scheme consistently exhibited promising diagnostic performance, with AUCs of 74.2% (95% CI: 61.9-86.4%) and 77.4% (95% CI: 59.4-95.3%) respectively, surpassing other diagnostic schemes. The integrated scheme also effectively addressed thyroid nodule management by reducing the missed malignancy rate to 9.5% and unnecessary biopsy rate to 22.2%. CONCLUSION: The integration of AmCAD and SWE imaging in the transverse thyroid scan significantly enhances the diagnostic performance for distinguishing benign and malignant thyroid nodules. This strategy offers clinicians the advantage of obtaining more accurate clinical diagnoses and making well-informed decisions regarding patient management.

Radiomics Combined with ACR TI-RADS for Thyroid Nodules: Diagnostic Performance, Unnecessary Biopsy Rate, and Nomogram Construction.

RATIONALE AND OBJECTIVES: To develop a radiomics model with enhanced diagnostic performance, reduced unnecessary fine needle aspiration biopsy (FNA) rate, and improved clinical net benefit for thyroid nodules. METHODS: We conducted a retrospective study of 217 thyroid nodules. Lesions were divided into training (n = 152) and verification (n = 65) cohorts. Three radiomics scores were derived from B-mode ultrasound (B-US) and strain elastography (SE) images, alone and in combination. A radiomics nomogram was constructed by combining high-frequency ultrasonic features and the best-performing radiomics score. The area under the receiver operating characteristic curve (AUC), unnecessary FNA rate, and decision curve analysis (DCA) results for the nomogram were compared to those obtained with the American College of Radiology Thyroid Imaging, Reporting and Data System (ACR TI-RADS) score and the combined TI-RADS+SE+ contrast-enhanced ultrasound (CEUS) advanced clinical score. RESULTS: The three radiomics scores (B-US, SE, B-US+SE) achieved training AUCs of 0.753 (0.668-0.825), 0.761 (0.674-0.838), and 0.795 (0.715-0.871), and validation AUCs of 0.732 (0.579-0.867), 0.753 (0.609-0.892), and 0.752 (0.592-0.899) respectively. The AUC of the nomogram for the entire patient cohort was 0.909 (0.864-0.954), which was higher than that of the ACR TI-RADS score (P < 0.001) and equivalent to the TI-RADS+SE+CEUS score (P = 0.753). Similarly, the unnecessary FNA rate of the radiomics nomogram was significantly lower than that of the ACR TI-RADS score (P = 0.007) and equivalent to the TI-RADS+SE+CEUS score (P = 0.457). DCA also showed that the radiomics nomogram brought more net clinical benefit than the ACR TI-RADS score but was similar to that of the TI-RADS+SE+CEUS score. CONCLUSION: The radiomics nomogram developed in this study can be used as an objective, accurate, cost-effective, and noninvasive method for the characterization of thyroid nodules.

THE IMPACT OF PATIENT ANXIETY AND PAIN PERCEPTION ON THE ADEQUACY OF THYROID FINE-NEEDLE ASPIRATION BIOPSY SAMPLES: A PROSPECTIVE STUDY.

Background: Fine-needle aspiration biopsy (FNAB) is the most accurate diagnostic method to assess the malignancy risk of thyroid nodules. However, non-diagnostic results may delay diagnosis, cause unnecessary interventions, and distress patients. Aim: We aimed to determine whether a correlation exists between patients' situational anxiety, pain perception and non-diagnostic cytology results. Methods: The prospective study included patients who underwent thyroid FNAB at the Endocrinology Clinic of Sultan Abdulhamid Training and Research Hospital between 11/2022 and 02/2023. The State-Trait Anxiety Inventory (STAI) questionnaire and visual analogue scale (VAS) assessed situational anxiety and pain in patients undergoing biopsy procedures. We evaluated whether the STAI-S and VAS score is related to non-diagnostic results. Results: Of the 119 patients included in the study, 98 were female, and 21 were male. 25 (21%) nodules were non-diagnostic. The patients' mean STAI-S score before the biopsy was 47.31±12.37, and the mean VAS score after the thyroid biopsy was 2.57±1.51. A statistically significant relation was found between the patient's STAI-S score and VAS score and the cytology result of non-diagnostic (p= 0.001 and p=0.008). In univariate logistic regression, high pre-procedural anxiety (OR:3.09, 95% CI:1.07-8.94, P =0.037) and VAS score (OR:1.57, 95% CI: 1.17-2.10, P =0.002) were associated with non-diagnostic cytology. In multivariate logistic regression analysis, VAS score (OR: 1.59, 95% CI: 1.07-2.34, p=0.019) was still an independent factor related to specimen adequacy. Conclusions: Anxiety level and pain perception during FNAB may be considered risk factors for non-diagnostic cytology. Thus, reducing anxiety and pain may decrease the incidence of non-diagnostic outcomes.

Thermal ablation for Bethesda III and IV thyroid nodules: current diagnosis and management.

The diagnosis and management of Bethesda III and IV thyroid nodules remain clinical dilemmas. Current guidelines from academic societies suggest active surveillance or diagnostic lobectomy. However, the extent of surgery is often inappropriate, and a considerable percentage of patients experience under- or over-treatment. Thermal ablation has gained popularity as a safe and effective alternative treatment option for benign thyroid nodules. This review explores the feasibility of thermal ablation for Bethesda III or IV thyroid nodules, aiming to preserve the thyroid organ and avoid unnecessary surgery. It emphasizes individualized management, the need to consider factors including malignancy risk, clinical characteristics, and sonographic features, and the importance of supplemental tests such as repeat fine needle aspiration cytology, core needle biopsy, molecular testing, and radioisotope imaging.

Small Multi-Gene DNA Panel Can Aid in Reducing the Surgical Resection Rate and Predicting the Malignancy Risk of Thyroid Nodules.

Background: We explored the utility of a small multi-gene DNA panel for assessing molecular profiles of thyroid nodules and influencing clinical decisions by comparing outcomes between tested and untested nodules. Methods: Between April 2022 and May 2023, we prospectively performed fine-needle aspiration (FNA) with gene testing via DNA panel of 11 genes (BRAF, RAS [NRAS, HRAS, KRAS], EZH1, DICER1, EIF1AX, PTEN, TP53, PIK3CA, TERT promoter) in 278 consecutive nodules (panel group). Propensity score-matching (1:1) was performed with 475 nodules that consecutively underwent FNA without gene testing between January 2021 and December 2021 (control group). Results: In the panel group, positive call rate for mutations was 41.7% (BRAF 16.2%, RAS 12.6%, others 11.5%, double mutation 1.4%) for all nodules, and 40.0% (BRAF 4.3%, RAS 19.1%, others 15.7%, double mutation 0.9%) for indeterminate nodules. Benign call rate was 69.8% for all nodules, and 75.7% for indeterminate nodules. In four nodules, additional TP53 (in addition to BRAF or EZH1) or PIK3CA (in addition to BRAF or TERT) mutations were co-detected. Sensitivity, specificity, positive predictive value, and negative predictive value were 80.0%, 53.3%, 88.1%, 38.1% for all nodules, and 78.6%, 45.5%, 64.7%, 62.5% for indeterminate nodules, respectively. Panel group exhibited lower surgical resection rates than the control group for all nodules (27.0% vs. 52.5%, P<0.001), and indeterminate nodules (23.5% vs. 68.2%, P<0.001). Malignancy risk was significantly different between the panel and control groups (81.5% vs. 63.9%, P=0.008) for all nodules. Conclusion: Our panel aids in managing thyroid nodules by providing information on malignancy risk based on mutations, potentially reducing unnecessary surgery in benign nodules or patients with less aggressive malignancies.

3D ultrasound guidance for radiofrequency ablation in an anthropomorphic thyroid nodule phantom.

BACKGROUND: The use of two-dimensional (2D) ultrasound for guiding radiofrequency ablation (RFA) of benign thyroid nodules presents limitations, including the inability to monitor the entire treatment volume and operator dependency in electrode positioning. We compared three-dimensional (3D)-guided RFA using a matrix ultrasound transducer with conventional 2D-ultrasound guidance in an anthropomorphic thyroid nodule phantom incorporated additionally with temperature-sensitive albumin. METHODS: Twenty-four phantoms with 48 nodules were constructed and ablated by an experienced radiologist using either 2D- or 3D-ultrasound guidance. Postablation T2-weighted magnetic resonance imaging scans were acquired to determine the final ablation temperature distribution in the phantoms. These were used to analyze ablation parameters, such as the nodule ablation percentage. Further, additional procedure parameters, such as dominant/non-dominant hand use, were recorded. RESULTS: Nonsignificant trends towards lower ablated volumes for both within (74.4 ± 9.1% (median ± interquartile range) versus 78.8 ± 11.8%) and outside of the nodule (0.35 ± 0.18 mL versus 0.45 ± 0.46 mL), along with lower variances in performance, were noted for the 3D-guided ablation. For the total ablation percentage, 2D-guided dominant hand ablation performed better than 2D-guided non-dominant hand ablation (81.0% versus 73.2%, p = 0.045), while there was no significant effect in the hand comparison for 3D-guided ablation. CONCLUSION: 3D-ultrasound-guided RFA showed no significantly different results compared to 2D guidance, while 3D ultrasound showed a reduced variance in RFA. A significant reduction in operator-ablating hand dependence was observed when using 3D guidance. Further research into the use of 3D ultrasound for RFA is warranted. RELEVANCE STATEMENT: Using 3D ultrasound for thyroid nodule RFA could improve the clinical outcome. A platform that creates 3D data could be used for thyroid diagnosis, therapy planning, and navigational tools. KEY POINTS: Twenty-four in-house-developed thyroid nodule phantoms with 48 nodules were constructed. RFA was performed under 2D- or 3D-ultrasound guidance. 3D- and 2D ultrasound-guided RFAs showed comparable performance. Real-time dual-plane imaging may offer an improved overview of the ablation zone and aid electrode positioning. Dominant and non-dominant hand 3D-ultrasound-guided RFA outcomes were comparable.

Current role of interventional radiology in thyroid nodules.

Thyroid nodules are a prevalent health issue in society. Interventional radiological methods are successfully applied for both the diagnosis and treatment of nodules. Diagnostically, a fine-needle aspiration biopsy and a core needle biopsy can be performed to ascertain the benign or malignant nature of a lesion. In recent years, imaging-guided percutaneous treatment methods have become popular in the treatment of thyroid nodules. Aspiration, ablation, and embolization are techniques employed in the treatment process. In this study, we aimed to discuss the current role of interventional radiology in the diagnosis and treatment of thyroid nodules, which occupy an important place in clinical practice.

Federated learning via multi-attention guided UNet for thyroid nodule segmentation of ultrasound images.

Accurate segmentation of thyroid nodules is essential for early screening and diagnosis, but it can be challenging due to the nodules' varying sizes and positions. To address this issue, we propose a multi-attention guided UNet (MAUNet) for thyroid nodule segmentation. We use a multi-scale cross attention (MSCA) module for initial image feature extraction. By integrating interactions between features at different scales, the impact of thyroid nodule shape and size on the segmentation results has been reduced. Additionally, we incorporate a dual attention (DA) module into the skip-connection step of the UNet network, which promotes information exchange and fusion between the encoder and decoder. To test the model's robustness and effectiveness, we conduct the extensive experiments on multi-center ultrasound images provided by 17 local hospitals. The model is trained using the federal learning mechanism to ensure privacy protection. The experimental results show that the Dice scores of the model on the data sets from the three centers are 0.908, 0.912 and 0.887, respectively. Compared to existing methods, our method demonstrates higher generalization ability on multi-center datasets and achieves better segmentation results.

Serum Selenium Level in Thyroid Cancer: A Case-Control Study.

Background: Despite the implementation of national iodine supplementation programs, structural thyroid diseases are still highly prevalent in most countries. Thus, the link between trace elements other than iodine, such as selenium, and thyroid diseases should be investigated. Methods: In this case-control study, adult patients with newly diagnosed papillary thyroid carcinoma, benign thyroid nodules, and healthy euthyroid controls without nodules were recruited. Thyroid function tests and serum selenium levels were assessed and compared between groups. The One-way ANOVA test was used to assess the mean difference of numerical variables among the three studied groups (PTC, Benign nodule, and healthy control group). In addition, a post-hoc comparison was conducted based on Bonferroni correction for a pairwise comparison of these three groups. Results: Data from 182 patients with papillary thyroid carcinoma (PTC), 185 patients with benign thyroid nodules, and 180 healthy individuals as a control group were analyzed. The mean serum selenium levels in the PTC, benign thyroid nodules, and control group were 94.9, 121.6, and 134.3 µg/l, respectively (P < 0.001). There was a significant relationship between the cancer stage and selenium level in the PTC group. Patients in higher stages of cancer had a lower mean of selenium (P < 0.001). In univariate logistic regression, TSH and selenium were significant variables for PTC compared with patients with benign thyroid nodules. Each unit increase in selenium reduces the chance of PTC by about 6%. Conclusion: The low levels of selenium were associated with PTC. Also, serum selenium levels were inversely correlated with the stage of thyroid cancer.

Risk Stratification of Thyroid Nodules Diagnosed as Bethesda Category III by Ultrasound, Size, and Cytology.

OBJECTIVE: This study aimed to evaluate the performance of an integrated risk stratification system (RSS) based on ultrasound (US) RSSs, nodule size, and cytology subcategory for diagnosing malignancy in thyroid nodules initially identified as Bethesda category III on fine-needle aspiration. MATERIALS AND METHODS: This retrospective study was conducted at two institutions and included consecutive patients with Bethesda category III nodules, and final diagnoses confirmed by repeat biopsy or surgery. A total of 320 Bethesda category III nodules (≥1 cm) from 309 patients (223 female and 86 male; mean age, 50.9 ± 12.0 years) were included. The malignancy risk of Bethesda category III nodules and predictors of malignancy were assessed according to US RSSs, nodule size, and cytology subcategory. The diagnostic performances of US-size cytology (USC) RSS and US RSS alone for malignancy were compared. RESULTS: The intermediate or high suspicion US category independently increased the malignancy risk in all US RSSs (P ≤ 0.001). Large nodule size (≥3 cm) independently increased the malignancy risk of low- or intermediate suspicion US category nodules. Additionally, the atypia of undetermined significance cytology subcategory independently increased the malignancy risk of low suspicion US category nodules in most US RSSs. The area under the receiver operating characteristic curve of the USC RSSs was greater than that of the US RSSs alone (P < 0.048). Malignancy was not found in the very low risk category of USC RSS. CONCLUSION: The diagnostic performance of USC RSS for malignancy was superior to that of US RSS alone in Bethesda category III nodules. Malignancy can be ruled out in the very low-risk category of USC RSS.

Correlation between ultrasonographic and cytologic features of thyroid nodules: a single-center cross-sectional study.

A thyroid nodule is managed according to the clinical context, ultrasound (US) findings, and fine needle aspiration (FNA) results. Most thyroid nodules are benign; however, nodule classification is crucial to avoid unnecessary thyroid surgery. We conducted this study to compare the findings of fine-needle aspiration cytology (FNAC) expressed using the Bethesda system with the features of thyroid US classified using the EU-TIRADS classification to assess the risk of malignancy. A descriptive and analytical study involving 99 patients with thyroid nodules followed up in the Department of Endocrinology-Diabetology and Nutrition. Data were collected from medical records and analyzed using SPSS software V21. FNA was performed on 121 nodules using the BETHESDA system. These nodules were classified as malignant, suspicious for follicular neoplasm, and suspicious for malignancy in 5.8%, 5%, and 1.7% of cases, respectively. As for the EU-TIRADS 2017 classification, 59.5% of benign nodules were classified as EU-TIRADS III, whereas 66.7% of malignant nodules were classified as EU-TIRADS V and significantly related to malignant prediction (P = 0.000). The size of nodules was significantly correlated to the risk of malignancy (P = 0.013). Seventy-five percent of nodules with central vascularity were malignant (P = 0.012). Irregularity of nodule contours was significantly associated with the risk of malignancy, as 30% of nodules with irregular contours were Bethesda VI (P = 0.003). Hypoechogenicity was found in 77.8% of malignant nodules (P = 0.004). Additionally, only 9.2% of the nodules were taller than wide, of which 37.5% were malignant (P = 0.012). For a safe management strategy, US-guided FNAC should be performed on each suspicious thyroid nodule, given the correlation between EU-TIRADS classification features and the risk of malignancy.

Investigating the optimal maximum diameter of benign thyroid nodules for thermal ablation on the basis of complete disappearance rate.

OBJECTIVE: Thermal ablation (TA) is a safe and effective treatment for benign thyroid nodules (BTNs). However, there has been no consensus on the optimal maximum diameter (MD) of BTNs for TA. This study aimed to identify the optimal MD of BTNs for TA based on complete disappearance rate after TA. MATERIALS AND METHODS: This retrospective study included 639 BTNs treated with TA from June 2014 to January 2022. The complete disappearance rate of BTNs after TA was summarized, related influencing factors were explored, and the optimal MD of BTNs for TA was identified. RESULTS: At the final follow-up (median: 40 months, range: 24-95 months), the overall volume reduction rate was 95.4 ± 9.0%, and 50.5% of the BTNs (323/639) completely disappeared. The MD was significantly negatively correlated with complete disappearance (odds ratio 0.89, 95% confidence interval 0.87-0.92; p < 0.001). Calcification, comet-tail artifacts, multilocular cysts, and composition of BTNs, as well as diabetes were negatively correlated with complete disappearance. Restricted cubic spline indicated that an MD of 25.0 mm was the optimal threshold of BTNs for TA, which was confirmed by subgroup logistic regression analysis. Compared with BTNs with MD ≤ 25.0 mm, those with MD > 25.0 mm had a greater complication rate (6.5% vs. 2.4%, p = 0.012). CONCLUSIONS: The MD of BTNs was negatively correlated with complete disappearance after TA; an MD > 25.0 mm indicated a reduced likelihood of complete disappearance compared with an MD ≤ 25.0 mm. An MD of 25.0 mm is an appropriate threshold of BTNs for TA on the basis of complete disappearance rate.

Cold Agglutinin Disease: A Rare Paraneoplastic Manifestation of a Thyroid Malignancy.

A paraneoplastic syndrome is the presence of signs and symptoms due to cancer, but it is not a consequence of the mass effect of a tumour. It typically occurs in middle-aged to older patients with solid tumors (lung, breast, and ovaries), and hematological malignancies (leukemia and lymphoma). Autoimmune hemolytic anaemia is also a well-defined paraneoplastic phenomenon in lymphoproliferative disorders and rare solid tumour malignancies such as renal cell carcinoma, ovarian dermoid cysts, thymus cell cancer, Kaposi sarcoma, and cancers of the breast, pancreas, thyroid, and prostate. Most of the time, it is warm and is rarely cold type. We present a case of cold-type autoimmune hemolytic anaemia, presented as paraneoplastic manifestations of a thyroid malignancy.

Redo Thyroidectomy: Updated Insights.

The risk of post-operatory hypothyroidism and hypocalcaemia, along with recurrent laryngeal nerve injury, is lower following a less-than-total thyroidectomy; however, a previously unsuspected carcinoma or a disease progression might be detected after initial surgery, hence indicating re-intervention as mandatory (so-called "redo" surgery) with completion. This decision takes into consideration a multidisciplinary approach, but the surgical technique and the actual approach is entirely based on the skills and availability of the surgical team according to the standard protocols regarding a personalised decision. We aimed to introduce a review of the most recently published data, with respect to redo thyroid surgery. For the basis of the discussion, a novel vignette on point was introduced. This was a narrative review. We searched English-language papers according to the key search terms in different combinations such as "redo" and "thyroid", alternatively "thyroidectomy" and "thyroid surgery", across the PubMed database. Inclusion criteria were original articles. The timeframe of publication was between 1 January 2020 and 20 July 2024. Exclusion criteria were non-English papers, reviews, non-human studies, case reports or case series, exclusive data on parathyroid surgery, and cell line experiments. We identified ten studies across the five-year most recent window of PubMed searches that showed a heterogeneous spectrum of complications and applications of different surgeries with respect to redo interventions during thyroid removal (e.g., recurrent laryngeal nerve monitoring during surgery, other types of incision than cervicotomy, the use of parathyroid fluorescence, bleeding risk, etc.). Most studies addressing novel surgical perspectives focused on robotic-assisted re-intervention, and an expansion of this kind of studies is expected. Further studies and multifactorial models of assessment and risk prediction are necessary to decide, assess, and recommend redo interventions and the most adequate surgical techniques.

A model based on C-TIRADS combined with SWE for predicting Bethesda I thyroid nodules.

Objectives: This study aimed to explore the performance of a model based on Chinese Thyroid Imaging Reporting and Data Systems (C-TIRADS), clinical characteristics, and shear wave elastography (SWE) for the prediction of Bethesda I thyroid nodules before fine needle aspiration (FNA). Materials and methods: A total of 267 thyroid nodules from 267 patients were enrolled. Ultrasound and SWE were performed for all nodules before FNA. The nodules were scored according to the 2020 C-TIRADS, and the ultrasound and SWE characteristics of Bethesda I and non-I thyroid nodules were compared. The independent predictors were determined by univariate analysis and multivariate logistic regression analysis. A predictive model was established based on independent predictors, and the sensitivity, specificity, and area under the curve (AUC) of the independent predictors were compared with that of the model. Results: Our study found that the maximum diameter of nodules that ranged from 15 to 20 mm, the C-TIRADS category <4C, and E max <52.5 kPa were independent predictors for Bethesda I thyroid nodules. Based on multiple logistic regression, a predictive model was established: Logit (p) = -3.491 + 1.630 × maximum diameter + 1.719 × C-TIRADS category + 1.046 × E max (kPa). The AUC of the model was 0.769 (95% CI: 0.700-0.838), which was significantly higher than that of the independent predictors alone. Conclusion: We developed a predictive model for predicting Bethesda I thyroid nodules. It might be beneficial to the clinical optimization of FNA strategy in advance and to improve the accurate diagnostic rate of the first FNA, reducing repeated FNA.

Cervical plexus block enhanced pain control for unilateral thermal ablation of thyroid nodules.

Background: Despite being minimally invasive, thermal ablation (TA) of thyroid nodules may still cause significant pain during and shortly afterwards. Conventional analgesia relies on perithyroidal local anesthesia (PLA) with or without sedation. The use of cervical plexus block (CPB) has been extensively studied in thyroidectomy, but never studied in TA of the thyroid gland. This study examined whether adding ultrasound-guided CPB to PLA and sedation could further reduce post-operative pain in unilateral TA of thyroid nodules. Methods: Consecutive patients aged ≥18 years undergoing unilateral radiofrequency ablation (RFA) or microwave ablation (MWA) of thyroid nodules were reviewed. Group I patients did not receive CPB, and Group II patients received CPB by bupivacaine injection between the sternocleidomastoid muscle (SCM) and prevertebral fascia on the treatment side. Pain was charted immediately and 4 hours after ablation using a numeric rating scale (NRS) of 0-10. The Quality-of-Recovery-9 (QoR9) questionnaire was completed. Results: Over an 18-month period, 100 patients underwent unilateral thyroid ablation (Group I, n=50; Group II, n=50). Comparable baseline patient demographics, nodule characteristics, ablation parameters were noted (P>0.05). Significantly lower immediate NRS {1 [0-3] vs. 4 [1.3-6], P<0.001}, 4-hour NRS {1 [0-3] vs. 2 [0-4], P=0.04}, and more zero immediate NRS (44% vs. 14%, P=0.001) was observed in Group II. Total QoR9 scores were comparable {16 [12-17] vs. 15 [12-17], P=0.72}. No adverse events occurred. All patients were discharged within the same day. Conclusions: Adding ultrasound-guided CPB further enhanced pain control following unilateral TA of thyroid nodules, without compromising quality of recovery or same-day discharge.

Development of machine learning models to predict papillary carcinoma in thyroid nodules: The role of immunological, radiologic, cytologic and radiomic features.

OBJECTIVE: Approximately 30 % of thyroid nodules yield an indeterminate diagnosis through conventional diagnostic strategies. The aim of this study was to develop machine learning (ML) models capable of identifying papillary thyroid carcinomas using preoperative variables. METHODS: Patients with thyroid nodules undergoing thyroid surgery were enrolled in a retrospective monocentric study. Six 2-class supervised ML models were developed to predict papillary thyroid carcinoma, by sequentially incorporating clinical-immunological, ultrasonographic, cytological, and radiomic variables. RESULTS: Out of 186 patients, 92 nodules (49.5 %) were papillary thyroid carcinomas in the histological report. The Area Under the Curve (AUC) ranged from 0.41 to 0.61 using only clinical-immunological variables. All ML models exhibited an increased performance when ultrasound variables were included (AUC: 0.95-0.97). The addition of cytological (AUC: 0.86-0.97) and radiomic (AUC: 0.88-0.97) variables did not further improve ML models' performance. CONCLUSION: ML algorithms demonstrated low accuracy when trained with clinical-immunological data. However, the inclusion of radiological data significantly improved the models' performance, while cytopathological and radiomics data did not further improve the accuracy. LEVEL OF EVIDENCE: Level 4.

Incidental Thyroid Nodules on Computed Tomography: A Systematic Review and Meta-Analysis Examining Prevalence, Follow-Up, and Risk of Malignancy.

Background: The increased utilization of computed tomography (CT) has led to a higher detection rate of thyroid incidentalomas. Currently, there are no widely agreed-upon guidelines for managing these incidentalomas. This study aims to investigate the prevalence, follow-up practices, and malignancy rates of thyroid incidentalomas detected by CT. Methods: We conducted a comprehensive search of PubMed, Embase, and Cochrane databases to identify relevant studies published before April 12, 2024 (PROSPERO #42024535501). Studies reporting on the prevalence, follow-up, and risk of malignancy (ROM) of thyroid incidentalomas detected by CT were included. Combined outcomes were analyzed using pooled proportion with a random-effects model. The risk of bias was assessed using the Cochrane risk-of-bias tool for randomized trials (RoB 2) and the Newcastle-Ottawa Scale tool. Subgroup analyses were conducted based on characteristics including size of the incidentaloma, CT area, and age of the study population. Results: Thirty-eight studies involving 195,959 patients were included in the prevalence analysis, revealing a prevalence of thyroid incidentalomas on CT of 8.3% (confidence interval [CI], 7.4-9.3). The prevalence was higher in neck CT (16.5%, CI, 11.0-22.1) compared with chest CT (6.6%, CI, 5.3-7.9). Multiple incidentalomas were found in 27.0% (CI, 12.9-41.1) of patients. Of the nodules, 46.3% (CI, 32.3-60.3) were ≥1 cm, and 28.6% (CI, 19.9-37.3) were ≥1.5 cm. Thyroid ultrasounds, biopsies, and surgeries were performed in 34.9% (CI, 26.1-43.7), 28.4% (CI, 19.9-36.9), and 8.2% (CI, 2.1-14.4) of cases, respectively. Additionally, 25 studies with 6272 patients reported a ROM of 3.9% (CI, 3.0-4.9) for thyroid incidentalomas detected on CT. A higher ROM was observed in incidentalomas ≥1 cm (11.7%, CI, 3.9-19.4) and ≥1.5 cm (24.9%, CI, 0-52.7) compared with those <1 cm (0.1%, CI, 0-0.8) and <1.5 cm (0%, CI, 0-0.2). Conclusions: Most thyroid incidentalomas identified on CT are benign. Implementing a collaborative protocol between radiologists and thyroid specialists to manage high-risk thyroid incidentalomas can ensure appropriate follow-up and optimal patient care.