Background: Thyroid nodules are a common clinical problem, and differentiated thyroid cancer is becoming increasingly prevalent. Since the American Thyroid Association's (ATA's) guidelines for the management of these disorders were revised in 2009, significant scientific advances have occurred in the field. The aim of these guidelines is to inform clinicians, patients, researchers, and health policy makers on published evidence relating to the diagnosis and management of thyroid nodules and differentiated thyroid cancer. Methods: The specific clinical questions addressed in these guidelines were based on prior versions of the guidelines, stakeholder input, and input of task force members. Task force panel members were educated on knowledge synthesis methods, including electronic database searching, review and selection of relevant citations, and critical appraisal of selected studies. Published English language articles on adults were eligible for inclusion. The American College of Physicians Guideline Gr...

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2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer.

Pathologic Basis of Diseaseby Stanley L. Robbins is really the fourth edition of hisPathology. Appropriate updating and addition enhance the otherwise identical format, sequence, writing, and illustrations. So many medical students have benefited from this source that it may be the best known general book in the field. I recommend it even more now. Like his former texts, this will be enjoyed for its readability. He clearly lays out a great deal of information. When he includes minutiae, the reasons are clear and one feels that all the material is pertinent. Robbins keeps the whole field in perspective—that is, he does not dwell so long or so heavily on pathologic anatomy or pathogenesis as to tempt the reader to overlook clinical presentation or prognosis. A great strength of the subject of pathology is that it bonds strongly with many other medical sciences and specialties and thus occupies the

Pathologic Basis of Disease

The Society of Radiologists in Ultrasound convened a panel of specialists from a variety of medical disciplines to come to a consensus on the management of thyroid nodules identified with thyroid ultrasonography (US), with particular focus on which nodules should be subjected to US-guided fine needle aspiration and which thyroid nodules need not be subjected to fine-needle aspiration. The panel met in Washington, DC, October 26–27, 2004, and created this consensus statement. The recommendations in this consensus statement, which are based on analysis of the current literature and common practice strategies, are thought to represent a reasonable approach to thyroid nodular disease. © RSNA, 2005

Management of thyroid nodules detected at US: Society of radiologists in ultrasound consensus conference statement

Purpose: To retrospectively evaluate the diagnostic accuracy of ultrasonographic (US) criteria for the depiction of benign and malignant thyroid nodules by using tissue diagnosis as the reference standard. Materials and Methods: This study had institutional review board approval, and informed consent was waived. From January 2003 through June 2003, 8024 consecutive patients had undergone thyroid US at nine affiliated hospitals. A total of 831 patients (716 women, 115 men; mean age, 49.5 years ± 13.8 [standard deviation]) with 849 nodules (360 malignant, 489 benign) that were diagnosed at surgery or biopsy were included in this study. Three radiologists retrospectively evaluated the following characteristics on US images: nodule size, presence of spongiform appearance, shape, margin, echotexture, echogenicity, and presence of microcalcification, macrocalcification, or rim calcification. A χ2 test and multiple regression analysis were performed. Sensitivity, specificity, and positive and negative predictive...

Benign and malignant thyroid nodules: US differentiation--multicenter retrospective study.

This article provides an overview of the basic principles of percutaneous tumor ablation and describes the equipment and technologic modifications that have been developed to further improve clinical success of this therapy.

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Principles of and Advances in Percutaneous Ablation

Objective. To correlate sonographic and color Doppler characteristics of thyroid nodules with the results of sonographically guided fine-needle aspiration biopsy to establish the relative importance of these features in predicting risk for malignancy. Methods. We retrospectively analyzed the sonographic features of 34 malignant and 36 benign thyroid nodules with respect to size, echogenicity, echo structure, shape, border, calcification, and internal vascularity. Individual features and combinations of features were analyzed for their correlation with benign or malignant disease. A comparative analysis of several authors' previously proposed methods for distinguishing between benign and malignant nodules using sonographic criteria was also performed to determine their sensitivity and specificity in predicting nodule disease within our study data. Results. Nodule size ranged from 0.8 to 4.6 cm in greatest dimension (mean, 1.96 cm; SD, 0.877 cm). The prevalence of malignancy in our study population was estimated to be nearly 5.33%. Intragroup comparison of sonographic features among benign and malignant nodules resulted in identification of intrinsic calcification as the only statistically significant predictor of malignancy (35.3% sensitive and 94.4% specific; P <.005). Presence of a "snowstorm" pattern of calcification was 100% specific for malignancy. Echogenicity, echo structure, shape, border classification, and grade of internal vascularity did not show any significant difference between benign and malignant nodules in this study. Various combinations of features previously suggested to be significant predictors of malignancy were also analyzed and shown to have very little sensitivity or specificity in predicting benign or malignant disease among nodules in our study population. Conclusions. This study indicates that the presence of intrinsic microcalcification is the only statistically reliable criterion on which to base increased suspicion for malignancy in thyroid nodules. Our results indicate the need for biopsy in determining further workup. All nodules that show the presence of intrinsic microcalcification should undergo biopsy, particularly if calcifications have a snowstorm appearance on sonography.

https://onlinelibrary.wiley.com/doi/pdf/10.7863/jum.2004.23.11.1455

Risk for Malignancy of Thyroid Nodules as Assessed by Sonographic Criteria The Need for Biopsy

Thyroid cancer is the most common endocrine malignancy, accounting for an estimated 22,000 new cases in the United States in 2003 alone.1 Papillary carcinoma is the most common subtype of the well-differentiated thyroid carcinomas (WTC). It has a relative frequency ranging from 75% to 85% among all thyroid cancers, and frequently follows an indolent course, with overall 10-year survival rates reported at 90% to 98%.2–4 Treatment of WTC consists of total or subtotal thyroidectomy, with resection of suspicious lymph nodes in the central compartment. Modified neck dissection is the accepted treatment of patients with lymph node metastasis to the lateral compartments of the neck. Patients with only central compartment lymph node metastasis usually undergo central compartment node dissection only.

The overall recurrence and mortality rates for WTC have been reported at 20.5% and 8.4%, respectively, at a mean follow-up of 11.3 years.5 Patients with thyroid cancer are routinely monitored for recurrence by ultrasound examination of the central and lateral compartments of the neck, along with serum thyroglobulin testing. When thyroid cancer recurs, it is typically found within the surgical bed or in lymph nodes of the central or lateral compartments.4

Factors that have been associated with recurrence include young age at diagnosis, large size of the primary tumor, extracapsular spread, and a known distant metastasis.6 The 2 most common sites for distant metastasis of papillary carcinoma of the thyroid are to the lungs and bone.2 Cases of distant metastatic spread have been reported to occur from 5 to 47 years after initial treatment.7,8 Reported 10-year survival rates for patients with lung and bone metastases are 53% and 15%, respectively.9–11 Following diagnosis of distant metastases, overall mortality rates at 5 and 10 years are 65% and 75%, respectively.12

Recurrence in the central compartment can be either in lymph nodes or in the thyroid bed. A recurrence in the thyroid bed results in increased rates of morbidity and mortality.13 Recurrence in the lateral compartment usually occurs as lymph node metastasis. Surgery is recommended for recurrence in the central or lateral compartments of the neck that can be identified by ultrasonography (US). Reoperative surgery in the central or lateral compartments of the neck in patients who have undergone a previous neck dissection is difficult, however, due to distortion of normal tissue planes by scar tissue formation within the surgical bed, and such operations are subsequently associated with a higher rate of complications.9

Percutaneous radiofrequency ablation (RFA) and percutaneous ethanol (EtOH) injection are relatively new, minimally-invasive techniques that have been widely used as alternatives to surgical treatment in patients with hepatocellular carcinoma or liver metastasis from other malignancies.14 RFA has also shown promise as an effective treatment of metastatic malignancies in bone, lung, and kidney.15–22

RFA and EtOH injection with local anesthesia have recently been reported as alternatives to surgery in patients with local recurrence of WTC.4,15,23,24 In this study, we present our experience with treatment of local WTC recurrence by RFA or EtOH at long-term follow-up. We also report our initial experience using RFA to treat focal distant metastases of WTC.

Radiofrequency ablation and percutaneous ethanol injection treatment for recurrent local and distant well-differentiated thyroid carcinoma.

Hypothesis: For patients with primary hyperparathyroidism and patients with 2 localization studies showing the same single location of parathyroid disease, use of intraoperative parathyroid hormone (IOPTH) measurement does not significantly increase the success of minimally invasive parathyroidectomy. Design: Retrospective cohort study. Setting: Experience of 2 academic centers over 5 years (at Brigham and Women's Hospital, Boston, Mass) and almost 4 years (at Rhode Island Hospital, Providence). Patients: A total of 569 patients with primary hyperparathyroidism who underwent technetium Tc 99m sestamibi (MIBI) parathyroid imaging and neck ultrasonography (US). Main Outcome Measures: Incidence of correct prediction of location and extent of disease. Results: In 322 patients (57%), MIBI and US imaging identified the same single site of disease. In 319 (99%) of these 322 patients, surgical exploration confirmed a parathyroid adenoma at that site, and the IOPTH levels normalized on removal. In 3 (1%) of the 322 patients, IOPTH measurement identified unsuspected additional disease. In 3 (1%) of the remaining 319 patients, IOPTH-guided removal of a single adenoma failed to correct hypercalcemia. Therefore, the failure rate of surgery in patients with positive MIBI and positive US imaging was 1% with IOPTH measurement and 2% without IOPTH measurement (P=.50). In 201 (35%) of the 569 patients, only 1 of the 2 studies recognized an abnormality or the studies disagreed on location. In these cases, either MIBI imaging or US imaging (if MIBI imaging was negative) failed to predict the correct site or extent of disease in 76 (38%) of the 201 patients (P<.001 vs concordant studies). Conclusions: In primary hyperparathyroidism, concordant preoperative localization with MIBI and US imaging is highly accurate. Use of IOPTH measurement in these cases adds only marginal benefit. When only 1 of the 2 studies identifies disease or the studies conflict, however, IOPTH measurement remains essential during minimally invasive parathyroidectomy.

https://jamanetwork.com/journals/jamasurgery/articlepdf/398297/sne50007.pdf

Reassessment of Parathyroid Hormone Monitoring During Parathyroidectomy for Primary Hyperparathyroidism After 2 Preoperative Localization Studies

Sensitivity and specificity of eight CT signs in the preoperative diagnosis of internal mesenteric hernia following Roux-en-Y gastric bypass surgery

To define effectiveness and safety of CT-guided radiofrequency ablation (RFA) of renal tumours and prognostic indicators for treatment success. Patients with a single treatment of a solitary, biopsy-proven renal tumour with intent to cure over a 14-year period were included (n = 203). Probability of residual disease over time, complication rates and all-cause mortality were assessed in relation to multiple variables. Mean tumour size was 2.5 cm (range 1.0–6.0). Mean follow-up was 34.1 months (range 1–131). There was an increase in likelihood of residual disease for tumours ≥3.5 cm (P < 0.05), clear cell subtype of renal cell carcinoma (P ≤ 0.005) and maximum treatment temperature ≤70 °C (P < 0.05). There was a decrease in likelihood of residual disease for exophytic tumours (P = 0.01) and no difference based on age, gender, tumour location or type of radio freqency (RF) electrode used. Major complications occurred in 3.9 %. Median post-treatment survival was 7 years for patients with tumours <4 cm, and 5-year overall survival was 80 %. Probability of minor complication increased with tumour size (P = 0.03), as did all-cause mortality (P = 0.005). CT-guided RFA is safe and effective for early-stage renal cancer, particularly for exophytic tumours measuring <3.5 cm. Overall 5-year survival with tumours <4 cm is comparable to partial nephrectomy. • Prognostic indicators for success of CT-guided RFA of renal tumours are reported.
 • Tumour size ≥3.5 cm confers an increased risk for residual tumour.
 • Clear cell renal cell carcinoma subtype confers increased risk for residual tumour.
 • Tmax <70 °C within the ablation zone confers increased risk for residual tumour.
 • Exophytic tumours have a lower probability of residual disease.

Effectiveness and safety of computed tomography-guided radiofrequency ablation of renal cancer: a 14-year single institution experience in 203 patients

Jason D. Iannuccilli

Papers

Risk for Malignancy of Thyroid Nodules as Assessed by Sonographic Criteria The Need for Biopsy

Radiofrequency ablation and percutaneous ethanol injection treatment for recurrent local and distant well-differentiated thyroid carcinoma.

Reassessment of Parathyroid Hormone Monitoring During Parathyroidectomy for Primary Hyperparathyroidism After 2 Preoperative Localization Studies

Sensitivity and specificity of eight CT signs in the preoperative diagnosis of internal mesenteric hernia following Roux-en-Y gastric bypass surgery

Effectiveness and safety of computed tomography-guided radiofrequency ablation of renal cancer: a 14-year single institution experience in 203 patients