Persistent Metastatic Thyroid Carcinoma.

The decision to biopsy small thyroid nodules (TNs) is controversial. Careful ultrasound (US) evaluation with shear wave elastography (SWE) of TN and cervical lymph nodes (LNs) may aid in the decision to biopsy and subsequently influence the extent of surgery. A 46-year-old female presented with TNs and hypothyroidism. Her target TN in the left lobe measured 4.8 mm × 4 mm × 4 mm. Fine needle aspiration biopsy of the left TN and a left neck level 6 LN was diagnostic for papillary thyroid carcinoma. In the left lateral neck posterior to the jugular vein, there was a LN with possible microcalcifications that could not be sampled due to vascular proximity. SWE examination showed high velocity suspicious for metastatic disease. In summary, risk stratification for small TNs and cervical LNs can be difficult. SWE can provide valuable information for assessing the risk for malignancy.

Precision Medicine with 3D Ultrasound.

Introduction: A 56-year-old woman was referred for thyroid nodules (TNs) found on a carotid ultrasonography (US). Her laboratories showed a normal thyroid stimulation hormone of 1.530 µIU/mL, normal thyroid hormone levels, and her thyroid antibodies were not elevated. Thyroid 2D US showed an isoechoic solid TN with regular margins measuring 12 × 8 × 10 mm (TR3) in the left thyroid lobe. 3D US demonstrated markedly irregular margins. The nodule volume was 0.52 cm3. Based on current American Thyroid Association and American College of Radiology-Thyroid Imaging, Reporting and Data System (ACR-TIRADS) guidelines, her nodule size would not fit the criteria for fine needle aspiration biopsy (FNAB).1,2 However, because of the irregular margins seen on 3D US, FNAB was offered along with repeat US after 6 months. After considering her options, she requested FNAB. She underwent effective US guided FNAB of the left TN and the cytopathology report indicated follicular neoplasm Bethesda category IV. Subsequently, she had follow-up US guided FNAB for molecular testing with the Afirma's gene sequencing classifier (GSC). The report showed GSC suspicious with an NRAS mutation, indicating a 50% malignancy risk. She elected to have left hemithyroidectomy. The final surgical pathology report demonstrated a 12-mm follicular carcinoma. Materials and Methods: In our thyroid clinic, we utilize conventional 2D US and 3D US to evaluate TN for possible FNAB. Laboratory measurements were performed at Labcorp. Informed consent was given by the patient. The 3D image acquisition follows 2D US examination. The first step in 3D US image acquisition is identifying the target nodule utilizing 2D US. Next, the 3D sweep of the target nodule produces a 3D volume data set and observation of 3D-rendered images generated simultaneously from longitudinal, transverse, and coronal views. A 2D US image displays a TN only on one plane in two dimensions, longitudinal or transverse. The saved 3D volume data set can be viewed and manipulated later. We can reconstruct new images from different angles after the study is completed. The 3D image acquisition direction (front to back versus up to down) will create a different display image and volume slice. The examiner can choose the direction of 3D acquisition before 3D sweep. A 2D US image or machine lacks these qualities. Discussion: This case illuminates recent advances in 3D US imaging and demonstrates that this technology may enhance the value of 2D US in diagnosing malignancy. This technology allows the user to create sequential cross-sectional images through the target nodule. The addition of coronal view to the existing 2D US has been an important contributing factor. Several recent publications have reported that 3D US can improve nodule selection criteria for FNAB.3-5 Our clinic has routinely utilized 3D US technology for the past 4 years. We have learned that this new technology can delineate TN borders more clearly. It not only enhances the observation of structures within but also those attached to the thyroid gland. The target nodule can be rotated and viewed from different angles. The margin irregularities of TNs can be viewed with 3D US in small and large nodules equally. We have found that the 3D US shows the irregular margins of malignant TNs to be more pronounced when compared with high-end 2D US systems. In our experience, the vast majority of benign TNs have regular margins on 3D US. Finally, the 3D volume measurement may provide additional information about the size of TNs for longitudinal follow-up of nodules with benign FNAB. The limitations or challenges of using 3D US in general practice include the cost of the ultrasound machine, lack of reimbursement, and the provider's learning curve. Adding 3D/4D technology to current 2D US does provide more detailed information; however, it requires additional time to complete a thyroid US study. 3D US technology might be more suitable for thyroid clinics or endocrine practices with high patient volumes. Conclusion: We conclude that 3D US can enhance observation of TN margin irregularities and potentially improve nodule selection for FNAB.No competing financial interests exist.Runtime of video: 2 hrs 25 mins 12 secs.

3-D Ultrasound and Thyroid Cancer Diagnosis: A Prospective Study.

This study tests the hypothesis that evaluation of thyroid nodule (TN) margin irregularities by three-dimensional ultrasound (3-D-US) distinguishes benign from malignant TNs with greater sensitivity and specificity than two-dimensional ultrasound (2-D-US). We prospectively evaluated 344 TNs using both 2-D-US and 3-D-US followed by fine needle aspiration biopsy. TNs were divided into four groups based on the 3-D-US appearance of the margins. Bi-variate and multi-variate analyses were used. Surgical pathology confirmed 44 thyroid cancers in 40 patients. For 2-D-US, irregular margins and micro-calcifications (p < 0.001) were found more frequently in malignant TNs. Irregular margins on 2-D-US had a sensitivity and specificity of 61.4% and 79.3%, respectively. Irregular margins on 3-D-US had a sensitivity and specificity of 86.4% and 83.3%, respectively. Sensitivity, specificity, positive and negative predictive values were higher for irregular margins on 3-D-US than micro-calcifications and irregular margins on 2-D-US. Evaluation of TN margins by 3-D-US distinguished benign from malignant TNs with greater sensitivity and specificity than 2-D-US.

Precision Medicine with 3D Ultrasound.

Introduction: Currently, B-mode ultrasound (US) is the primary imaging modality in diagnosing thyroid nodules (TNs). B-mode is a two-dimensional US (2D US) imaging display. Recent studies suggest a role for strain and shear wave elastography for evaluating TN as well. Three-dimensional US (3D-US) has the potential to enhance the diagnostic accuracy and precision for thyroid cancer (TC) detection. Materials and Methods: An experienced ultrasonographer (G.A.) evaluated the patient using the following techniques: B-mode, strain and shear wave elastography, and 3D-US followed by fine needle aspiration biopsy (FNAB). Laboratory measurements were performed at LabCorp. Informed consent was obtained. Case: A 28-year-old woman referred for hypothyroidism. Her primary doctor initiated levothyroxine 50 mcg daily 6 months prior. At the time of her visit, her thyroid stimulating hormone (TSH) was 2.8 (0.45-4.5 uIU/mL) and both thyroid peroxidase and thyroglobulin antibodies were elevated, suggestive of Hashimoto's thyroiditis. Her thyroid US showed a heterogeneous gland with an isoechoic TN in the right lobe measuring 7.7 × 6.3 × 7 mm. Strain elastography showed diffuse and patchy tissue stiffness throughout the gland, suggestive of tissue fibrosis caused by Hashimoto's thyroiditis. This study did not distinguish target TN from the surrounding tissue. Shear wave elastography of the TN revealed moderately increased stiffness compared with surrounding tissue. The shear wave velocity (SWV) measurement for the TN was 3.1 m/s. 3D-US examination demonstrated an isoechoic TN with irregular margins, and the volume was 0.119 cm3. FNAB of the TN was performed. Cytopathology was diagnostic for papillary thyroid cancer (PTC), Bethesda Category VI. Subsequent total thyroidectomy confirmed a 7 mm PTC with positive surgical margins caused by thyroid capsule invasion and no clear-cut evidence of extra-thyroid extension. Discussion: This case showcases the recent technological advances in TN imaging. Our objective is to provide an improved approach to TN management. The American College of Radiology Thyroid Imaging Reporting and Data System stratifies the malignancy risk of TN primarily based on the size and B-mode US features. This model does not recommend FNAB for any TN <10 mm regardless of malignancy risk.1 This is our observation that with 3D-US the size cutoff of TN might not be an issue as with B-mode or elastography. Irregularities of the TN can be seen with 3D-US with small and large nodules equally. The finding of irregular margins on 3D-US and consulting with the patient lead us to perform FNAB. Recent publications in the journal of VideoEndocrinology showed utilizations of 3D-US in diagnosing parathyroid adenomas and TNs. 3D-US technology improves view of the target lesion by adding a third dimension, coronal view, to the transverse and longitudinal views of B-mode US.2,3 B-mode imaging provides excellent view of TNs. However, it has a low sensitivity for predicting TC.4 Prospective TN studies have demonstrated that adding elastography to B-mode imaging improves sensitivity of US technology for detecting TC.5-10 In a prospective study with 707 TN, we showed that a single cutoff analysis for predicting malignancy in TNs, a maximum SWV of 3.54 m/s had the best sensitivity. The mean SWV for benign nodules was 2.71 m/s. The mean SWV for malignant nodules was 3.96 m/s.6 In this particular case strain and shear wave were not as helpful. The discrepancy between the two systems has been described in cases with severe Hashimoto's thyroiditis associated with tissue fibrosis.6 In our experience, the presence of autoimmune thyroid disease increases the risk for malignancy. Recent publications reported an association between differentiated TC and autoimmune thyroid disease and/or TSH when all Bethesda classifications were included.11-13 Conclusion: 3D-US technology in conjunction with B-mode may improve diagnostic accuracy in detecting TC. No competing financial interests exist. Runtime of video: 2 mins 30 secs.

Diagnosis of Parathyroid Adenomas with New Ultrasound Imaging Modalities.

Ultrasound technology is becoming an integral part of diagnosing parathyroid adenomas. Careful ultrasound evaluation with b-mode, shear wave elastography, and three-dimensional (3D) of parathyroid adenomas may improve localization and outcome. Introduction: A 60-year-old woman was referred for the evaluation of hyperparathyroidism. This patient gave her informed consent. She had a history of hypothyroidism and thyroid nodules. She was being treated with levothyroxine 50 mcg daily. Routine testing revealed hypercalcemia. The serum calcium was 11.2 (nL range 8.7-10.2 mg/dL), creatinine was 0.69 (nL range 0.57-1.00 mg/dL), intact parathyroid hormone (PTH) was 70 (nL range 15-65 pg/mL), phosphorus was 2.7 (nL range 2.5-4.5 mg/dL), vitamin D was 38.7 (30-100 ng/mL), and 24 hours urine calcium was 362.9 (100-300 mg/24 hour). The neck ultrasound showed two lesions one superior/posterior and the other in the inferior/posterior aspect of the right thyroid lobe measuring 11.6 × 4.4 × 9.7 mm and 14.6 × 5.0 × 10.0 mm, respectively. Both lesions resembled parathyroid adenomas. Shear wave velocity (SWV) measurements for the superior and inferior lesions were 1.67 and 1.77 m/second, respectively. For the adjacent thyroid tissue SWV was 2.3 m/second, significantly higher. 3D ultrasound examination demonstrated a polar artery in both lesions. A sestamibi scan showed a probable right parathyroid adenoma and she was referred for surgery. She was found to have two right parathyroid adenomas in the superior and inferior poles corresponding with the ultrasound finding. Intraoperative PTH level decreased from 139.9 to 17 pg/mL postresection. Six weeks after surgery, her calcium and PTH were normal. Materials and Methods: This patient was evaluated in our clinic with ultrasound imaging, including b-mode, shear wave elastography (SWE), and 3D ultrasound. Discussion: Most patients with primary hyperparathyroidism have a single parathyroid adenoma. Other causes include glandular hyperplasia, multiple adenomas, and parathyroid carcinoma.1,2 This case shows two parathyroid adenomas in the neck posterior to the right thyroid lobe. The role of ultrasound in diagnosing parathyroid adenomas is becoming more prominent because of improved technology, low cost, and noninvasive nature. With this case we illustrate that SWE can be an added value to b-mode ultrasound in diagnosing parathyroid adenomas. Our previous publication in the Journal of European Radiology reported that SWV measurement of parathyroid adenomas may enhance other sonographic parameters to predict the diagnosis. In our view, parathyroid adenomas appear to have a more homogenous texture and lower tissue stiffness when compared with the thyroid gland.3 This case confirms our prior findings. It can be challenging to differentiate parathyroid adenomas from lymph nodes (LNs) and ectopic thyroid tissue at level 6, with b-mode ultrasound. A combination of 3D ultrasound images with 3D color Doppler (CD) might improve our ability to identify the polar artery and enhance differentiation from LN. 3D technology might improve the view by adding coronal view to current b-mode that comprises of transverse and longitudinal views. This is a preliminary report, and more studies need to be done. Conclusion: Combining multiple image modalities, including b-mode, shear wave elastography, and 3D technology, may improve our ability to identify parathyroid adenomas. Parathyroid adenomas have a lower SWV compared with thyroid tissue. 3D ultrasound technology may enhance view of polar artery when adding 3D CD. This challenging case illustrates the utility of these additional modalities. No competing financial interests exist. Runtime of video: 1 min, 52 secs.

Diagnosis of Thyroid Nodule with New Ultrasound Imaging Modalities.

Introduction: B-mode ultrasound (US) technology is an integral part of diagnosing and assessing risk stratification of thyroid nodules (TNs). The addition of shear wave elastography and three-dimensional (3D) US imaging may improve risk stratification for thyroid cancer (TC). Materials and Methods: The patient was evaluated in our clinic with US imaging including B-mode, shear wave elastography, 3D-US, and fine needle aspiration biopsy (FNAB). Laboratory measurements were performed at LabCorp. The patient gave informed consent. Case: A 20-year-old female referred for hypothyroidism who was on levothyroxine 25µg daily. Her thyroid-stimulating hormone (TSH) was 3.870 (0.45-4.5 µIU/mL). Thyroid peroxidase antibody and thyroglobulin antibody were elevated, suggestive of Hashimoto's thyroiditis. Her thyroid ultrasongraph showed a heterogeneous thyroid gland with a hypoechoic TN in the right lobe measuring 9.2 × 8.9 × 9 mm. Shear wave elastography examination was suggestive of a hard TN. The shear wave velocity (SWV) measurements for the target TN was 3.9 m/s. 3D-US examination demonstrated a hypoechoic TN with irregular margins and a volume of 0.322 cm3. FNAB of right TN was performed. The cytopathology was read as malignant (Bethesa Category VI), diagnostic for papillary thyroid cancer (PTC). She underwent total thyroidectomy. Surgical pathology report showed an 8 mm PTC in the right lobe and 2 mm PTC in the left lobe with a background of Hashimoto's thyroiditis. There were 3/10 positive lymph nodes (LNs) for metastases. The largest metastatic LN measured 5 mm at level 6. Discussion: This case illustrates recent advances in US technology. For decades, clinicians relied on B-mode US to assess the risk for TC. This case illustrates important challenges and advances in US technology. Current ACR-TIRADS guideline for TN management is based on B-mode US features and TN size.1 In our experience, including additional factors such as elastography, 3D-US, and laboratory evaluation helps to improve our diagnostic accuracy. In this case, her laboratory was suggestive of autoimmune thyroid disease. This information was helpful to put this patient in a higher risk category. Recent large studies reported an association between differentiated TC and autoimmune thyroid disease and/or TSH when all Bethesda classifications were included.2-4 Shear wave elastography examination showed that this TN had a high SWV, suggestive of a hard TN, which is suspicious for malignancy. Several recent publications have reported that elastography can assess the malignant potential of TN.5-10 In our prospective study, we reported that in a single cutoff analysis for predicting malignancy in TNs, a maximum SWV of 3.54 m/s had the best sensitivity. With greater SWV values, specificity increased but sensitivity decreased.6 3D-US technology enhances our ability to visualize the target lesion because of adding a new dimension, coronal view, to the existing B-mode that consists of transverse and longitudinal views. In this case, irregular margins of the TN are seen much better with 3D-US. This is a preliminary report, and more studies need to be done. Conclusion: Adding SWE and 3D-US technology to B-mode US may enhance our ability for risk stratification for TN before FNAB. 3D-US may improve our ability to visualize the margins of TN. No competing financial interests exist. Runtime of video: 2 mins 5 secs.

Shear wave elastography and Afirma™ gene expression classifier in thyroid nodules with indeterminate cytology: a comparison study.

PURPOSE: To compare shear wave elastography (SWE) and Afirma™ gene expression classifier (GEC) for diagnosis of malignancy in thyroid nodules (TNs) with Bethesda Classification (BC) III or IV indeterminate cytology. METHODS: This preliminary single-center prospective study was approved by the Institutional Review Board. We evaluated 151 consented patients with 151 indeterminate TNs (123 BC III, 28 BC IV) on fine-needle aspiration biopsy (FNAB). B-mode ultrasound, vascularity, and SWE were performed prior to FNAB. TN stiffness was measured as shear wave velocity (SWV) in meters per second (m/s). The stiffest area of the TN was selected for SWV measurement. GEC testing was performed with a second FNAB. Surgery was recommended for GEC-suspicious TNs, or GEC-benign TNs with two or more worrisome B-mode US features. RESULTS: Surgical pathology confirmed 31 malignant TNs. Among the GEC-suspicious group, 28 of 59 TNs were malignant. The SWV value of ≥3.59 m/s was the best cut-off for malignancy risk based on the receiver operating curve (ROC). Twenty-six malignant TNs had SWV ≥ 3.59 m/s. The sensitivity and specificity for SWV ≥ 3.59 m/s were 83.9 and 79.2%, respectively. Positive predictive value (PPV) was 51.0% and negative predictive value (NPV) was 95.0%. For the GEC-suspicious group, sensitivity, specificity, PPV, and NPV were 90.3, 74.2, 47.5, and 96.7%, respectively. In multivariate analysis, SWV and GEC-suspicious were significant predictors of malignancy, but B-mode features and vascularity were not. CONCLUSION: This preliminary study indicates that SWE and GEC are independent predictors of malignancy in TNs with BC III or IV.

Shear Wave Elastography and Cervical Lymph Nodes: Predicting Malignancy.

This prospective study evaluates the accuracy of virtual touch imaging quantification (VTIQ), a non-invasive shear wave elastography method for measuring cervical lymph nodes (LN) stiffness in differentiating benign from malignant LN. The study evaluated 270 LN in 236 patients with both conventional B-mode ultrasound and VTIQ shear wave elastography before fine-needle aspiration biopsy (FNAB). LN stiffness was measured as shear wave velocity (SWV) in m/s. Surgical resection was advised for FNAB results that were not clearly benign. Surgical pathology confirmed 54 malignant LN. The receiver operating curve (ROC) identified a single cut-off value of 2.93 m/s as the maximum SWV for predicting a malignant cervical LN. The sensitivity and specificity were 92.59% and 75.46%, respectively. Positive predictive value (PPV) was 48.54% and negative predictive value (NPV) was 97.60%. LN stiffness measured by VTIQ-generated shear wave elastography is an independent predictor of malignancy.

Shear wave elastography and parathyroid adenoma: A new tool for diagnosing parathyroid adenomas.

OBJECTIVES: This study prospectively determines the shear wave elastography characteristics of parathyroid adenomas using virtual touch imaging quantification, a non-invasive ultrasound based shear wave elastography method. METHODS: This prospective study examined 57 consecutive patients with biochemically proven primary hyperparathyroidism and solitary parathyroid adenoma identified by ultrasound and confirmed by at least one of the following: surgical resection, positive Technetium-99m Sestamibi Scintigraphy (MIBI) scan, or fine needle aspiration biopsy with positive PTH washout (performed only in MIBI negative patients). Vascularity and shear wave elastography were performed for all patients. Parathyroid adenoma stiffness was measured as shear wave velocity in meters per second. RESULTS: The median (range) pre-surgical value for PTH and calcium were 58pg/mL (19, 427) and 10.8mg/dL (9.5, 12.1), respectively. 37 patients had positive MIBI scan. 20 patients had negative MIBI scan but diagnosis was confirmed with positive PTH washout. 42 patients underwent parathyroidectomy, and an adenoma was confirmed in all. The median (range) shear wave velocity for all parathyroid adenomas enrolled in this study was 2.02m/s (1.53, 2.50). The median (range) shear wave velocity for thyroid tissue was 2.77m/s (1.89, 3.70). The shear wave velocity of the adenomas was independent of adenoma size, serum parathyroid hormone concentration, or plasma parathyroid hormone concentration. CONCLUSIONS: Tissue elasticity of parathyroid adenoma is significantly lower than thyroid tissue. B-mode features and distinct vascularity pattern are helpful tools in diagnosing parathyroid adenoma with ultrasound. Shear wave elastography may provide valuable information in diagnosing parathyroid adenoma.

Thyroid Nodules and Shear Wave Elastography: A New Tool in Thyroid Cancer Detection.

This study determines the performance of virtual touch imaging quantification (VTIQ), a non-invasive shear wave elastography method for measuring thyroid nodule (TN) stiffness, in distinguishing benign from malignant TNs. This prospective study evaluates 707 TNs in 676 patients with fine-needle aspiration biopsy (FNAB). Before FNAB, both conventional B-mode ultrasound and shear wave elastography were performed. Surgical resection was recommended for FNAB results that were not clearly benign. Surgical pathology confirmed 82 malignant TNs. The receiver operating curve identified a single cut-off of 3.54 m/s as the maximum shear wave velocity (SWV) for predicting thyroid cancer (TC). The sensitivity and specificity were 79.27% and 71.52%, respectively. Positive predictive value (PPV) was 26.75% and negative predictive value (NPV) was 96.34%. Compared with B-mode US features for predicting malignancy, SWV ≥3.54 m/s has a higher sensitivity, specificity, PPV and NPV. TN stiffness measured by VTIQ-generated shear wave elastography is an independent predictor of TC.

Performance of elastography for the evaluation of thyroid nodules: a prospective study.

BACKGROUND: In the ultrasound evaluation of masses, elastography measures stiffness, which may predict malignancy. Studies of small or selected subgroups suggest that elastography may be useful in the evaluation of thyroid nodules (TNs). We prospectively tested the hypothesis that TN stiffness, as measured by strain elastography (SE), is an independent predictor of thyroid cancer (TC) in unselected TNs. METHODS: In 706 unselected patients with 912 TNs meeting the ATA criteria for a fine-needle aspiration biopsy (FNAB), we first performed conventional thyroid ultrasound and SE. Nodule stiffness was graded from least to most stiff by an elastography score (ES) of ES 0 to ES 3. Surgical resection was recommended for FNAB results that were not clearly benign. Bivariate and multivariate regression analyses identified the independent predictors of TC. RESULTS: There were 86 malignant TNs. ES was a significant predictor of TC (p=0.0001). The prevalence of TC was 57 of the 158 TNs (36.1%) for the ES 3 group, 12 of the 158 TNs (7.7%) for the ES 2 group, 16 of the 565 TNs (2.8%) for the ES 1 group, and 1 of the 33 TNs (3%) for the ES 0 group. By multivariate regression analysis, the independent predictors of TC were ES, microcalcifications, hypoechogenicity, and isthmus location. The positive predictive value (PPV) of ES was 36.1%, which was similar to the PPV of microcalcifications (35.9%), but greater compared with hypoechogenicity (13.6%) and isthmus location (16.9%). The negative predictive value (NPV) of ES was 97.2%, which was better than any other predictor for malignancy. CONCLUSIONS: We conclude that TN stiffness measured by elastography is an independent predictor of TC with a PPV that is equal to or greater than that of conventional ultrasonographic characteristics. NPV was greater than any other predictor of malignancy.

Autoimmune thyroid disease: a risk factor for thyroid cancer.

OBJECTIVE: To examine the relationship between clinical markers of autoimmune thyroid disease and the risk of thyroid cancer in patients with thyroid nodules. METHODS: A retrospective cohort analysis was performed in a single clinical practice. In 2,500 consecutive patients, fine-needle aspiration biopsy (FNAB) was performed on all 3,658 ultrasonography-positive thyroid nodules that were ≥ 1.0 cm in diameter or ≥ 0.5 cm in diameter with ultrasound features suspicious for thyroid cancer. Serum concentrations of thyroglobulin antibodies (TgAb), thyroid peroxidase antibodies, and thyroid-stimulating hormone were measured before FNAB. Diagnosis of thyroid cancer was based on pathologic analysis of thyroidectomy tissue. Associations of thyroid cancer with the independent variables were determined by multivariate logistic regression analysis and reported as the adjusted odds ratio (OR) with the 95% confidence interval (CI). RESULTS: There were 202 patients with malignant thyroid nodules, 51 patients with microscopic unsuspected thyroid cancer distal to the nodule under investigation (found at thyroidectomy), and 2,247 patients with benign thyroid nodules. To evaluate the association of clinical markers for autoimmune thyroid disease with thyroid cancer, we included all 253 patients with thyroid cancer in the malignant cohort. Thyroid cancer was associated with elevated levels of TgAb (OR = 1.57; CI = 1.11 to 2.23) and age <55 years (OR = 2.01; CI = 1.45 to 2.78), and a strong trend was demonstrated for association with male sex (OR = 1.45; CI = 0.99 to 2.12). Thyroid cancer was not associated with elevated levels of thyroid peroxidase antibodies. CONCLUSION: In patients who have thyroid nodules with indications for FNAB, elevated levels of TgAb are associated with thyroid cancer.