Functional structure of a high resolution thyroid nodule unit. Economic impact and results of its implementation in an Endocrinology department.

BACKGROUND AND OBJECTIVE: The high incidence of nodular thyroid pathology has led to growing concern about the economic impact that this pathology represents on the healthcare system. There are conclusive data about the cost-effectiveness of high-resolution units for nodular thyroid pathology; however, their implementation is not homogeneous in the Endocrinology and Nutrition services of our country. The objective of the present study was to evaluate the economic impact of the implementation of the high-resolution thyroid nodule unit (HRTNU) in our center. PATIENTS AND METHODS: The present work is a prospective, observational and descriptive study carried out in 1314 patients (82% women, mean age 58 years ds = 11) evaluated at the HRTNU during the period of August 2022-August 2023. Demographic data (age and sex) were analyzed, referral center and consultation type, number of total consultations and neck ultrasound performed, number of fine needle aspiration (FNAB) performed, and cytology results were analyzed. RESULTS: In the period from August 2022 to August 2023, a total of 1314 patients were evaluated (neck ultrasound and clinical consultation) and a total of 133 FNAB were performed, of which only 2.26% were non-diagnostic. Compared to the percentage of unsatisfactory FNAB from the previous year August 2021-July 2022 of 25%, a mean saving of 9931.43 euros was estimated. 84.47% of the patients evaluated for the first time by the HRTNU were discharged, estimating a mean saving of 133,200 euros. CONCLUSIONS: The implementation of a HRTNU at the Endocrinology and Nutrition departments, coordinated with primary and specialized care, is a cost-effectiveness alternative, as it reduces the number of medical consultations and is accompanied by a higher rate of diagnostic FNAB.

Assessment of the American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS™) with modification of the management recommendations for pediatric thyroid nodules.

BACKGROUND: Thyroid nodules are unusual in children, but when present, they carry a higher risk for malignancy, as compared to adults. Several guidelines have been created to address the risk stratification for malignancy of thyroid nodules in adults, but none has been completely validated in children. A few authors have proposed lowering the size threshold to the American College of Radiology Thyroid Imaging, Reporting and Data System (ACR TI-RADS™) management guidelines to decrease missed carcinomas at presentation in children; however, little information is known regarding their accuracy. OBJECTIVE: To assess the performance of proposed modifications of the ACR TI-RADS™ size criteria to guide management decisions in pediatric thyroid nodules and to assess the associated increase in number of fine needle aspiration (FNA) and follow-up exams. MATERIALS AND METHODS: This is a retrospective study of children under 18 years old who underwent ultrasound assessment of a thyroid nodule at a tertiary care pediatric institution between January 2006 and August 2021. The largest dimension, maximum ACR TI-RADS™ score, and final thyroid nodules' diagnoses were documented. The course of action based on the adult ACR TI-RADS™ and after modifying the size threshold for management recommendations was documented and compared. Statistics included descriptive analysis, weighted Kappa statistics, sensitivity, specificity, accuracy, and positive/negative predictive values of the ACR TI-RADS™ presented with 95% confidence intervals (CI) using either Clopper-Pearson or standard logit methods. RESULTS: Of 116 nodules, 18 (15.5%) were malignant. Most malignant nodules (94.4%, n = 17) were ACR TI-RADS™ 4 and ACR TI-RADS™ 5 categories. Based on the adult ACR TI-RADS™ criteria, 24 (24.5%) benign and 15 (83.3%) malignant nodules would have undergone FNA; 14 (14.3%) benign and 3 (16.7%) malignant nodules would have been followed up; and 60 (61.2%) benign and none of malignant nodules would have been dismissed. Three (16.7%) malignant nodules would not have been recommended FNA at presentation, delaying their diagnoses. By lowering the size-threshold criteria of the ACR TI-RADS™ guidelines, no malignancy would have been missed at presentation, but this also resulted in a higher number of FNA from 24 (24.5%) to 36 (36.7%) and follow-up ultrasound exams from 14 (14.3%) to 62 (63.3%). CONCLUSION: Applying potential modifications to the ACR TI-RADS™ guideline lowering the size threshold criteria of the thyroid nodule to guide management decisions for pediatric thyroid nodules can lead to early detection of malignant nodules in children, but at the cost of a significantly increased number of biopsies or ultrasound exams. Further tailoring of the guideline with larger multicentric studies is needed, before warranting its acceptance and general use in the pediatric population.

Management of Incidental Thyroid Nodules.

Thyroid nodules are widely prevalent, and often discovered incidentally. Malignancy rates are low for incidental thyroid nodules, and overall outcomes are favorable regardless of diagnosis. Patients with thyroid nodules should be evaluated with TSH levels followed by ultrasound of the thyroid and cervical lymph nodes. It is important to recognize sonographic features suspicious for thyroid malignancy and obtain biopsies when indicated according to major society guidelines. The Bethesda System for Reporting Thyroid Cytopathology along with molecular testing can help guide management decisions regarding thyroid nodules. Surgical resection and other emerging technologies are safe and effective for the treatment of thyroid nodules needing intervention.

Comparison of efficacy and safety of different minimally invasive therapies for thyroid nodules: A network meta-analysis.

OBJECTIVE: This study aimed to compare efficacy and safety of minimally invasive therapies such as radiofrequency ablation (RFA), microwave ablation (MWA), ethanol ablation (EA), and laser ablation (LA) for thyroid nodules through network meta-analysis (NMA). METHODS: This study searched PubMed, Web of Science, Embase, and The Cochrane Library databases to collect randomized controlled trials (RCTs) or cohort studies comparing efficacy and safety of different minimally invasive therapies for thyroid nodules. Newcastle-Ottawa Scale (NOS) was implemented to assess quality of included cohort studies, and Cochrane risk of bias assessment tool was utilized to evaluate quality of included RCTs. Eligible studies contained at least one of the following clinical outcome measures: volume reduction rate (VRR), symptom score, cosmetic score, nodule regrowth rate, and complication rate. STATA software was utilized for NMA. RESULTS: Sixteen eligible studies (4 RCTs, 11 retrospective cohort studies, 1 prospective cohort study) involved 4094 patients. NMA results revealed that RFA group had the highest VRR at 1 months and 12 months. There were no significant differences in symptom scores and cosmetic scores among all treatment methods, with the lowest symptom scores and cosmetic scores in RFA group. LA group had a significantly higher nodule regrowth rate than RFA and MWA groups, with the lowest in RFA group. There were no significant differences in complication rate among all treatment methods. CONCLUSION: RFA had the highest VRR for thyroid nodules, and it excelled in symptom scores, cosmetic scores, and nodule regrowth rates.

Assessment of ChatGPT's adherence to ETA-thyroid nodule management guideline over two different time intervals 14 days apart: in binary and multiple-choice queries.

OBJECTIVE: Artificial intelligence (AI) has significant potential in healthcare, particularly in providing decision-support in specialized domains like thyroid nodule management. This study assesses the effectiveness of ChatGPT-v4, an advanced AI model, in aligning with the European Thyroid Association (ETA) - 2023 guidelines. METHODS: The study utilized a structured questionnaire comprising 100 questions, divided into true/false and multiple-choice formats, reflecting real-world clinical scenarios in thyroid nodule management. These questions encompassed diagnostic criteria, treatment options, follow-up protocols, and patient counseling. ChatGPT response was evaluated for accuracy, consistency, and comprehensiveness using a six-point Likert scale. The assessment occurred initially and was repeated after 14 days. RESULTS: In the binary queries, the AI model showed an ability to correct some initially incorrect responses. However, there was a noticeable regression in certain responses. 8 of the 11 previously non-compliant responses remained unchanged, while 3 non-compliant responses were rectified. Conversely, 6 initially compliant answers transitioned to non-compliance after 14 days. In multiple-choice queries, the AI's performance was more consistent. A majority of the responses, 43 (86% of the total), were initially correct and maintained their correctness upon re-assessment. However, 4 responses that were initially incorrect remained unchanged, and 3 correct responses shifted to non-compliance over time. CONCLUSION: ChatGPT exhibited improving potential as a clinical support tool in thyroid nodule management altgouh it showed varied performance for binary and multiple-choice questions. CLINICAL TRIAL REGISTRATION: N/A.

Effect of Music Therapy on Pain During Thyroid Fine Needle Aspiration Biopsy; A Randomized Controlled Clinical Trial.

INTRODUCTION: High-resolution ultrasonography devices have led to the increased detection of thyroid nodules and the need for fine-needle aspiration biopsy (FNAB). However, FNAB is an invasive procedure that can cause discomfort and pain. Music therapy has been used for centuries to alleviate pain, and our clinical trial was conducted to investigate its impact on pain scores during thyroid FNAB. MATERIALS AND METHODS: We conducted a randomized, controlled clinical trial, including adult patients undergoing thyroid FNAB. We evaluated the nonpharmacological intervention of listening to music before and during thyroid FNAB. We used a slow, nonlyrical, flowing melody with a tempo of 60 to 80 beats per minute as a therapeutic intervention for managing anxiety and pain. It had low tones, minimal percussion, and a volume of around 60 dB. The Beck Anxiety Inventory and Visual Pain Scale were used. RESULTS: The study included 529 patients assigned to either the music group (n = 258, 48.7%) or the control group (n = 271, 51.2%). The patients were categorized into subgroups based on either a single nodule (73.63%) or multiple nodules (24.18%). When all patients or single nodule and multiple data are examined separately, the intervention group showed statistically significantly lower pain scores than the control group. CONCLUSION: Our study is among the first on this topic and the largest in the available literature to demonstrate that listening to music during FNAB significantly reduces pain and anxiety. Music therapy is an effective, safe, and noninvasive intervention that can improve patient care and reduce distress and pain.

A Multi-dimensional Data Mining-based Study on the Prescriptions Developed by Professor Xu Zhiyin in Treating Thyroid Nodules.

OBJECTIVES: In this study, we employed a multi-dimensional data mining approach to examine the clinical instances where Professor Xu Zhiyin treated thyroid nodules. Our aim is to understand the patterns of symptoms, underlying causes, and treatment approaches used for thyroid nodules. By doing so, the intention is to distill the essential aspects, compile Professor Xu Zhiyin's clinical insights, and investigate his scholarly perspectives. METHODS: Professor Xu Zhiyin's clinical diagnoses and treatments spanning from 2009 to 2019 were entered into Microsoft Excel. Subsequently, the collected data was imported into the Medcase V5.2 system to facilitate data mining. Various techniques, such as frequency-based method, association rule analysis, and clustering, including a decentralized system clustering approach, were employed on a set of 346 cases involving patients with thyroid nodules that conformed to the specified criteria. The primary focus was on extracting insights regarding symptoms and the underlying causes from the medical records. By integrating these findings with Professor Xu Zhiyin's clinical expertise, we examined and summarized the outcomes of the data mining process. RESULTS: The fundamental prescriptions were successfully extracted using the techniques for mining across multiple dimensions. Utilizing the scattered grouping of these prescriptions and with reference to the cluster analysis of the frequency-linked system, the fundamental prescriptions proposed by Professor Xu Zhiyin for addressing thyroid nodules encompass the following ingredients: Glycyrrhiza uralensis Fisch, Cortex Moutan, Paeoniae radix rubra, Curcuma longa L., Radix Curcumae, persica seed, Citri Reticulatae Viride Pericarpium, Pinellia ternata, Spica Prunellae, Ostreae concha, Gleditsia sinensis spine, Tuckahoe and Radix Codonopsis. CONCLUSION: The fundamental prescriptions were acquired using the frequency approach, association rule technique, k-means clustering approach, and systematic clustering approach. The research findings corroborate one another, demonstrating that Professor Xu Zhiyin's approach to distinguishing and treating thyroid nodules is embodied in distinct prescriptions tailored to specific diseases.

A Narrative Review of the 2023 Korean Thyroid Association Management Guideline for Patients with Thyroid Nodules.

The 2023 Korean Thyroid Association (KTA) Management Guideline for Patients with Thyroid Nodules constitute an update of the 2016 KTA guideline for thyroid nodules and cancers that focuses specifically on nodules. The 2023 guideline aim to offer updated guidance based on new evidence that reflects the changes in clinical practice since the 2016 KTA guideline. To update the 2023 guideline, a comprehensive literature search was conducted from January 2022 to May 2022. The literature search included studies, reviews, and other evidence involving human subjects that were published in English in MEDLINE (PubMed), Embase, and other relevant databases. Additional significant clinical trials and research studies published up to April 2023 were also reviewed. The limitations of the current evidence are discussed, and suggestions for areas in need of further research are identified. The purpose of this review is to provide a summary of the 2023 KTA guideline for the management of thyroid nodules released in May 2023 and to give a balanced insight with comparison of recent guidelines from other societies.

Rates of diagnostic and therapeutic procedures in a cohort of patients undergoing first endocrine consultation for thyroid nodular disease.

PURPOSE: This study aimed to evaluate the rates of necessary diagnostic and therapeutic procedures in a cohort of patients undergoing their first endocrine consultation for thyroid nodular disease. METHODS: This was an observational study conducted between January 1 and June 30, 2023, on patients undergoing their first endocrine consultation for thyroid nodular disease. Data were collected, including age, thyroid-stimulating hormone (TSH) concentration, reasons for performing thyroid ultrasound (US), and thyroid US reports. The US was performed at the time of the endocrine consultation according to the American College of Radiology Thyroid Imaging, Reporting and Data System (ACR-TIRADS) risk stratification system. Patients underwent further investigations/treatment or simple US follow-up as necessary. RESULTS: A total of 373 patients with thyroid nodules were evaluated. Reasons for undergoing thyroid US were unrelated to suspected thyroid disease in 126 (33.8%), incidentalomas in 91 (24.4%), dysfunction or positivity for thyroid antibodies in 67 (18%), symptoms or visible nodules in 61 (16.3%), and family history of thyroid disease in 28 (7.5%). A total of 193 diagnostic or therapeutic procedures were performed in 133 (35.7%) patients [fine-needle aspiration (FNA): 121 (62.7%), surgery: 28 (14.5%), percutaneous ethanol injection: 20 (10.4%), scintigraphy: 10 (5.2%); thermal ablation: 7 (3.6%), and radioactive treatment: 7 (3.6%)]. CONCLUSIONS: In the present study only one-third of the patients undergoing endocrine consultation with first detected thyroid nodules required any diagnostic or therapeutic procedures.

[SFE-AFCE-SFMN 2022 consensus on the management of thyroid nodules: Interest and place of thyroid cytology]. / Consensus SFE-AFCE-SFMN 2022 sur la prise en charge des nodules thyroïdiens : intérêt et place de la cytologie thyroïdienne.

The SFE-AFCE-SFMN 2022 consensus deals with the management of thyroid nodules, a symptom that is a frequent reason for consultation in endocrinology. Thyroid nodules are very common and mostly benign. Thyroid ultrasound and thyroid fine-needle aspiration biopsy (FNAB) are the reference tests for the analysis of these nodules. The aim of this article is to describe for the cytopathologist the key points of the SFE-AFCE-SFMN 2022 consensus involving thyroid cytology: the indications for thyroid FNAB, the technique and analysis, and the management (treatment, follow-up) following this cytological screening examination, a key element in the management of the thyroid nodule.

Thyroid Nodules: Emerging Trends in Detection and Visualization based on Citespace.

BACKGROUND: Thyroid nodule (TN) is a highly prevalent clinical endocrine disease. Many countries have formed guidelines on the prevention and treatment of TN based on extensive research. However, there is a scarcity of TN-related literature based on bibliometrics. OBJECTIVES: This study aimed to evaluate the scientific achievements and progress of TN research from a global perspective by investigating the literature for 20 years through bibliometrics. METHODS: We searched the literature on TN in the core collection of the Web of Science database from 2002 to 2021 and used the Citespace software to analyze the co-authorship, co-citation, and co-occurrence of countries, institutions, authors, keywords, and co-cited literature. RESULTS: We retrieved 12319 documents related to TN. The literature on TN has been growing since 2002. The United States has contributed the largest proportion of TN papers (20.64%), followed by China, Italy, and South Korea. The United States ranked first in terms of centrality (0.38). Haugen BR, Gharib H, and Cibas ES are the top three most cited authors. The papers published in Thyroid were cited most frequently (7952 times). The most prominent keywords were management, cancer, fine needle aspiration, diagnosis, malignant tumor, thyroid cancer, ultrasound, biopsy, benign, surgery, ablation, and cytology. All keywords could be divided into three categories: diagnosis stratification, treatment, and cancer. As far as potential hot spots are concerned, the keywords that have recently burst strongly and are still continuing are: "Association Guideline" (2018-2021), "Radiofrequency Ablation" (2017-2021), "Classification" (2019-2021), and "Data System" (2017-2021). CONCLUSION: Based on the current trends, the number of publications on TN will continue to increase. The United States is the most active contributor to research in this field. Previous literature focused on stratification, cancer, surgery, and ablation, and there were different opinions on the stratification of diagnosis. There were relatively few studies on pathogenesis and treatment using medicine. More focus will be placed on association guidelines, radiofrequency ablation, classification, and data system, which may be the next popular topics in TN research.

Computer-interpretable guidelines: electronic tools to enhance the utility of thyroid nodule clinical practice guidelines and risk stratification tools.

Clinicians seeking guidance for evaluating and managing thyroid nodules currently have several resources. The principal ones are narrative clinical guidelines and clinical risk calculators. This paper will review the strengths and weaknesses of both. The paper will introduce a concept of computer interpretable guideline, a novel way of transforming narrative guidelines in to a clinical decision support tool that can provide patient specific recommendations at the point of care. The paper then describes an experience of developing an interactive web based computer interpretable guideline for thyroid nodule management, called Thyroid Nodule Management App (TNAPP). The advantages of this approach and the potential barriers for widespread adaptation are discussed.

Cytology and Histology of Thyroid Nodules: Exploring Novel Insights in the Molecular Era for Enhanced Patient Management.

Significant advancements have been made over the past decade in our understanding of thyroid cancers, encompassing histomorphology, cytology, and ancillary techniques, particularly molecular tests. As a result, it is now feasible to put forth a comprehensive histo/cytomolecular approach to treating these tumors, thereby offering patients treatments that are precisely tailored to their unique circumstances.

Current controversies in the management of patients with indeterminate thyroid nodules.

The management of cytologically indeterminate thyroid nodules remains debatable as their malignancy is difficult to establish. Most nodules have benign postoperative histology, but an accurate assessment of their proclivity for malignant transformation is crucial. Numerous studies have investigated the effects of various tools, including clinical, radiological, and cytological features, as well as biochemical and molecular markers, on the management of these heterogeneous nodules. Collectively, strategies aim to treat malignant nodules and avoid unnecessary surgery for asymptomatic benign nodules. Currently, no clear guidelines for the optimal management of cytologically indeterminate thyroid nodules exist to determine whether a conservative approach with long-term observation or surgical intervention should be selected. Thus, personalized approaches have been recommended. Large-scale multicenter prospective studies are needed to elucidate controversial issues. As this topic has not been comprehensively covered based on publications from the Gulf region, this review aims to shed light on remaining controversies.

[Exploration and management of thyroid nodules]. / Exploration et prise en charge des nodules thyroïdiens.

EXPLORATION AND MANAGEMENT OF THYROID NODULES. Most thyroid nodules are benign (95%) and can benefit from clinical and ultrasound monitoring. Cancers (approximately 5% of nodules) could be suspected, particularly in subjects whose neck was irradiated, in cases of a hard, irregular, evolving nodule, or with very high serum calcitonin (> 100 pg/ml). It is crucial to recognize cancers when nodules exceed the supracentimeter stage. Thyroid ultrasonography is the most common, handy, safe, and cost-effective tool to image thyroid nodules. It classifies thyroid nodules according to the EU-TIRADS score, which comprises 5 categories associated with an increasing risk of malignancy. An ultrasound-guided fine needle aspiration (FNA) biopsy is performed only in nodules staged EU-TIRADS classes 5, 4, and 3 over 1, 1.5, and 2 cm, respectively. Cytologic analysis of FNA material classifies thyroid nodules according to the Bethesda system into 6 classes, each with its own prognostic value. The difficulties in cytological evaluation are related to the uninterpretable (Bethesda I) and indeterminate (especially III and IV) results, for which have to be discussed opportunities of reassessment and follow-up by scintiscans and cytological molecular markers. Management is imperfectly codifiable: from surveillance in the absence of suspicious elements initially to total thyroidectomy in their presence.

EXPLORATION ET PRISE EN CHARGE DES NODULES THYROÏDIENS. La plupart des nodules thyroïdiens sont bénins (95 %) et peuvent bénéficier d'une surveillance clinique et échographique. La malignité (5 % des nodules environ) est à suspecter, particulièrement chez les sujets dont le cou a été irradié, en cas de nodule dur, irrégulier, évolutif, avec une calcitoninémie très élevée (supérieure à 100 pg/mL). C'est au stade de nodule supracentimétrique qu'il importe de reconnaître les cancers. L'échographie est l'examen d'imagerie de référence ; elle permet de classer les nodules selon le score EU-TIRADS, composé de cinq catégories associées à un risque croissant de malignité. Les ponctions échoguidées en vue de l'analyse cytologique sont réservées aux catégories EU-TIRADS 5, 4 et 3 de plus de 1, 1,5 et 2 cm respectivement. Les caractéristiques cytologiques sont présentées selon la nomenclature de Bethesda en six classes dont chacune quantifie aussi le risque de malignité, en complément des données échographiques. Les difficultés de l'évaluation cytologique sont liées aux résultats ininterprétables (Bethesda I) et indéterminés (surtout Bethesda III et IV) pour lesquels se discutent l'opportunité de la réévaluation et de la surveillance, des scintigraphies dites de seconde intention, et également des marqueurs moléculaires sur le produit de cytoponction. La prise en charge est imparfaitement codifiable : de la surveillance en l'absence d'éléments suspects initialement à la thyroïdectomie totale en leur présence.

Artificial Intelligence in Thyroidology: A Narrative Review of the Current Applications, Associated Challenges, and Future Directions.

Background: The use of artificial intelligence (AI) in health care has grown exponentially with the promise of facilitating biomedical research and enhancing diagnosis, treatment, monitoring, disease prevention, and health care delivery. We aim to examine the current state, limitations, and future directions of AI in thyroidology. Summary: AI has been explored in thyroidology since the 1990s, and currently, there is an increasing interest in applying AI to improve the care of patients with thyroid nodules (TNODs), thyroid cancer, and functional or autoimmune thyroid disease. These applications aim to automate processes, improve the accuracy and consistency of diagnosis, personalize treatment, decrease the burden for health care professionals, improve access to specialized care in areas lacking expertise, deepen the understanding of subtle pathophysiologic patterns, and accelerate the learning curve of less experienced clinicians. There are promising results for many of these applications. Yet, most are in the validation or early clinical evaluation stages. Only a few are currently adopted for risk stratification of TNODs by ultrasound and determination of the malignant nature of indeterminate TNODs by molecular testing. Challenges of the currently available AI applications include the lack of prospective and multicenter validations and utility studies, small and low diversity of training data sets, differences in data sources, lack of explainability, unclear clinical impact, inadequate stakeholder engagement, and inability to use outside of the research setting, which might limit the value of their future adoption. Conclusions: AI has the potential to improve many aspects of thyroidology; however, addressing the limitations affecting the suitability of AI interventions in thyroidology is a prerequisite to ensure that AI provides added value for patients with thyroid disease.

Genetic Considerations in the Tumorigenesis, Diagnosis, and Treatment of Differentiated Thyroid Cancer: Current State of the Science.

Thyroid nodules remain a common diagnosis encountered in general and endocrine surgical practice, and thyroid cancer appears to be increasing in incidence in both the United States and worldwide. The understanding of the complex genetics surrounding thyroid neoplasia has increased substantially in recent years and, consequently, has become a consideration in risk stratification, diagnosis, prognosis, and treatment. Molecular genetic analysis of thyroid nodules is now a readily available technology for diagnostic purposes via analysis of fine-needle aspiration biopsy (FNAB) specimens. Although their routine use is controversial, they may aid in selecting which patients require surgery and those who may be safely observed. In the following review, the genetics of the tumorigenesis of thyroid cancer are reviewed, focusing on the most common and clinically relevant of the literally hundreds of known mutations. Following this, the current status of the use of genetic analysis and molecular diagnostics in the workup of thyroid nodules and the diagnosis of differentiated thyroid cancer is explored. Finally, evolving concepts relating to the use of thyroid cancer genetics in individualizing treatment planning, follow-up, and management of recurrent disease is discussed. The goal is to provide the general surgeon with a working knowledge of the most common genetic alterations present in differentiated thyroid cancer, their relevance in clinical practice, and how they impact prognosis and treatment.