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      Advanced Ultrasound Application – Impact on Presurgical Risk Stratification of the Thyroid Nodules

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          Current major guidelines recommend risk stratification of the thyroid nodules, after each diagnostic evaluation, in order to focus attention on potentially risky nodules. The main aim of our study was to evaluate the performance of combined advanced ultrasound techniques in this process, compared with conventional stratification models, in order to reduce unnecessary fine-needle biopsies, respectively, surgery.

          Material and Methods

          We evaluated 261 cases (261 nodules) using conventional ultrasound (2B), real-time Doppler evaluation (4D) respectively, real-time elastography, using a linear multifrequency probe and a linear volumetric probe (Hitachi Prerius Machine, Hitachi Inc, Japan). All the nodules were classified using a risk stratification model comprising seven conventional US characteristics, two 4 D characteristics and a color map RTE aspect. The results were compared with the pathology results, considered the golden standard diagnosis.


          The prevalence of malignant nodules was 21.83% (57 cases). Conventional risk classification generated: 106 low-risk cases, 113 intermediate-risk and 42 high-risk cases. Our proposed risk classification changes the conventional risk classification with a risk upgrade in 27 cases and with a risk downgrade in 69 cases. The diagnostic quality of the combined risk stratification model was better, considering a low-risk category predictive for benignancy and a high category predictive for malignancy: Sensitivity: 80.88% versus 49.01%, respectively, Specificity: 91.22% versus 54.38. The diagnostic power differences were observed regardless of the nodule size.


          Advanced ultrasound techniques did add diagnostic value in the presurgical risk assessment of the thyroid nodules.

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          Most cited references 28

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          Prevalence and distribution of carcinoma in patients with solitary and multiple thyroid nodules on sonography.

          Controversy remains as to the optimal management of patients with multiple thyroid nodules. The objective of this study was to determine the prevalence, distribution, and sonographic features of thyroid cancer in patients with solitary and multiple thyroid nodules. We describe a retrospective observational cohort study that was carried out from 1995 to 2003. The study was conducted in a tertiary care hospital. Patients with one or more thyroid nodules larger than 10 mm in diameter who had ultrasound-guided fine needle aspiration (FNA) were included in the study. The main outcome measures were prevalence and distribution of thyroid cancer and the predictive value of demographic and sonographic features. A total of 1985 patients underwent FNA of 3483 nodules. The prevalence of thyroid cancer was similar between patients with a solitary nodule (175 of 1181 patients, 14.8%) and patients with multiple nodules (120 of 804, 14.9%) (P = 0.95, chi(2)). A solitary nodule had a higher likelihood of malignancy than a nonsolitary nodule (P < 0.01). In patients with multiple nodules larger than 10 mm, cancer was multifocal in 46%, and 72% of cancers occurred in the largest nodule. Multiple logistic regression analysis of statistically significant features demonstrates that the combination of patient gender (P < 0.02), whether a nodule is solitary vs. one of multiple (P < 0.002), nodule composition (P < 0.01), and presence of calcifications (P < 0.001) can be used to assign risk of cancer to each individual nodule. Risk ranges from a 48% likelihood of malignancy in a solitary solid nodule with punctate calcifications in a man to less than 3% in a noncalcified predominantly cystic nodule in a woman. In a patient with one or more thyroid nodules larger than 10 mm in diameter, the likelihood of thyroid cancer per patient is independent of the number of nodules, whereas the likelihood per nodule decreases as the number of nodules increases. For exclusion of cancer in a thyroid with multiple nodules larger than 10 mm, up to four nodules should be considered for FNA. Sonographic characteristics can be used to prioritize nodules for FNA based on their individual risk of cancer.
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            American Association of Clinical Endocrinologists, Associazione Medici Endocrinologi, and EuropeanThyroid Association Medical Guidelines for Clinical Practice for the Diagnosis and Management of Thyroid Nodules.

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              Increased incidence of differentiated thyroid carcinoma and detection of subclinical disease.

              Recent reports from North America and Europe have documented an annual increase in the incidence of differentiated thyroid carcinoma. We sought to investigate the relation between rates of detection, tumour size, age and sex. Using the Ontario Cancer Registry, we identified 7422 cases of differentiated thyroid carcinoma diagnosed from Jan. 1, 1990, to Dec. 31, 2001. We obtained pathology reports for a random 10% of the 7422 patients for each year of the study period. The sample represented all Cancer Care Ontario regions. We compared the size of the patients' tumours by year, sex and age. As expected, the incidence of differentiated thyroid carcinoma increased over the 12-year period. A significantly higher number of small (< or = 2 cm), nonpalpable tumours were resected in 2001 than in 1990 (p = 0.001). The incidence of tumours 2-4 cm in diameter remained stable. When we examined differences in tumour detection rates by age and sex, we observed a disproportionate increase in the number of small tumours detected among women and among patients older than 45 years. Our findings suggest that more frequent use of medical imaging has led to an increased detection rate of small, subclinical tumours, which in turn accounts for the higher incidence of differentiated thyroid carcinoma. This suggests that we need to re-evaluate our understanding of the trends in thyroid cancer incidence.

                Author and article information

                Ther Clin Risk Manag
                Ther Clin Risk Manag
                Therapeutics and Clinical Risk Management
                21 January 2020
                : 16
                : 21-30
                [1 ]2nd Department of Internal Medicine, “Victor Babes” University of Medicine , Timisoara, Romania
                [2 ]Dr. D Center for Ultrasound in Endocrinology , Timisoara, Romania
                [3 ]2nd Department of Surgery, “Victor Babes” University of Medicine , Timisoara, Romania
                [4 ]Department of Physiopathology, “Victor Babes” University of Medicine , Timisoara, Romania
                [5 ]Department of Obstetrics Gynecology, “Victor Babes” University of Medicine , Timisoara, Romania
                [6 ]Department of Obstetrics Gynecology, “Gr. T. Popa” University of Medicine , Iasi, Romania
                Author notes
                Correspondence: Dan Navolan Department of Obstetrics Gynecology, “Victor Babes” University of Medicine and Pharmacy Timisoara , P-ta Eftimie Murgu, Nr. 2, Timisoara300011, Romania Email navolan@yahoo.com
                Viviana Ivan 2nd Department of Internal Medicine, “Victor Babes” University of Medicine and Pharmacy Timisoara , P-ta Eftimie Murgu, Nr. 2, Timisoara300011, RomaniaTel +40 722 960 911Fax +40 256 020 1890 Email ivanmvivi@yahoo.com
                © 2020 Stoian et al.

                This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms ( https://www.dovepress.com/terms.php).

                Page count
                Figures: 6, Tables: 4, References: 46, Pages: 10
                “This research was funded by a research grant: grant number: SMIS 45997/21.01.2014- “Cresterea calitatii actului medical prin valorificarea potentialului IT” funder: Guvernul Romaniei, Ministerul Comunicatiilor si societatii informationale, axa POS CCE.
                Original Research


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