Risk for Malignancy of Thyroid Nodules as Assessed by Sonographic Criteria The Need for Biopsy
01 Nov 2004-Journal of Ultrasound in Medicine (American Institute of Ultrasound in Medicine)-Vol. 23, Iss: 11, pp 1455-1464
TL;DR: 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, particularly if calcifications have a snowstorm appearance on sonography.
Abstract: 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.
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Harvard University1, Mayo Clinic2, University of California, San Francisco3, University of Pennsylvania4, Brown University5, University of Texas Health Science Center at Houston6, Duke University7, Thomas Jefferson University8, Stanford University9, Washington University in St. Louis10, University of Texas MD Anderson Cancer Center11, University of Alabama at Birmingham12
TL;DR: 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.
Abstract: 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
1,093 citations
Cites result from "Risk for Malignancy of Thyroid Nodu..."
...The results of these studies are mixed, with some reporting that Doppler US is helpful (3,12,42,43) and others reporting that Doppler US did not improve diagnostic accuracy (13,41,44,45)....
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TL;DR: Shape, margin, echogenicity, and presence of calcification are helpful criteria for the discrimination of malignant from benign nodules; the diagnostic accuracy of US criteria is dependent on tumor size.
Abstract: 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...
956 citations
TL;DR: 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 numberof nodules increases.
Abstract: Context: Controversy remains as to the optimal management of patients with multiple thyroid nodules. Objective: 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. Design: We describe a retrospective observational cohort study that was carried out from 1995 to 2003. Setting: The study was conducted in a tertiary care hospital. Patients: 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. Main Outcome Measures: The main outcome measures were prevalence and distribution of thyroid cancer and the predictive value of demographic and sonographic features. Results: 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 ...
606 citations
Cites background from "Risk for Malignancy of Thyroid Nodu..."
...based on small patient populations (27, 29, 30, 39) or were...
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Harvard University1, Mayo Clinic2, University of California, San Francisco3, University of Pennsylvania4, Brown University5, University of Texas Health Science Center at Houston6, Duke University7, Thomas Jefferson University8, Stanford University9, Washington University in St. Louis10, University of Texas MD Anderson Cancer Center11, University of Alabama at Birmingham12
TL;DR: 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.
Abstract: 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.
509 citations
TL;DR: The Task Force on Thyroid Nodules of the Korean Society of Thyroid Radiology has developed recommendations for the US diagnosis and US-based management of thyroid nodules as mentioned in this paper.
Abstract: The detection of thyroid nodules has become more common with the widespread use of ultrasonography (US). US is the mainstay for detecting and making the differential diagnosis of thyroid nodules as well as for providing guidance for a biopsy. The Task Force on Thyroid Nodules of the Korean Society of Thyroid Radiology has developed recommendations for the US diagnosis and US-based management of thyroid nodules. The review and recommendations in this report have been based on a comprehensive analysis of the current literature, the results of multicenter studies and from the consensus of experts.
439 citations
References
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TL;DR: The aim of the study was to correlate the sonographic and color-Doppler findings with the results of US-guided fine needle aspiration biopsy and of pathologic staging of resected carcinomas to establish the relative importance of US features as risk factors of malignancy and a cost-effective management of nonpalpable thyroid nodules.
Abstract: The aim of the study was to correlate the sonographic [ultrasound (US)] and color-Doppler (CFD) findings with the results of US-guided fine needle aspiration biopsy (FNA) and of pathologic staging of resected carcinomas to establish: 1) the relative importance of US features as risk factors of malignancy; and 2) a cost-effective management of nonpalpable thyroid nodules. Four hundred ninety-four consecutive patients with nonpalpable thyroid nodules (8–15 mm) were evaluated by US, CFD, and US-FNA. Ninety-two patients with inadequate cytology were excluded from the study. All patients with suspicious or malignant cytology underwent surgery, whereas subjects with benign cytology had clinical and US control 6 months later. Thyroid malignancies were observed in 18 of 195 (9.2%) solitary thyroid nodules and in 13 of 207 (6.3%) multinodular goiters. Cancer prevalence was similar in nodules greater or smaller than 10 mm (9.1 vs. 7.0%). Extracapsular growth (pT4) was present in 35.5%, and nodal involvement in 19.4...
1,291 citations
"Risk for Malignancy of Thyroid Nodu..." refers background in this paper
...Border Well defined (3, 4) 0 Poorly defined (1, 2) 1 Shape Regular (round) 0 Irregular (tall or wide) 1 Echo structure Cystic 0 Solid 1 Mixed 2 Echogenicity Isoechoic or hyperechoic 0 Hypoechoic 1 Hypoisoechoic (disregarded) 2 Calcification Absent 0 Fine (few/countable) 1 Other (too numerous to count) 2...
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TL;DR: Considering the high level of sensitivity of the proposed sonographic classification, fine-needle aspiration biopsy should be performed on thyroid nodules classified as positive, regardless of palpability.
Abstract: OBJECTIVE. The purpose of our study was to provide new sonographic criteria for fine-needle aspiration biopsy of nonpalpable solid thyroid nodules.MATERIALS AND METHODS. Sonographic scans of 155 nonpalpable thyroid nodules in 132 patients were prospectively classified as having positive or negative findings. Sonographic findings that suggested malignancy included microcalcifications, an irregular or microlobulated margin, marked hypoechogenicity, and a shape that was more tall than it was wide. If even one of these sonographic features was present, the nodule was classified as positive (malignant). If a nodule had none of the features described, it was classified as negative (benign). The final diagnosis of a lesion as benign (n = 106) or malignant (n = 49) was confirmed by fine-needle aspiration biopsy and follow-up (>6 months) in 83 benign nodules, by fine-needle aspiration biopsy and surgery in 44 malignant and 15 benign lesions, and by surgery alone in five malignant and eight benign lesions. The sens...
1,010 citations
TL;DR: According to the study, OPC can be regarded as a normal finding which should not be treated when incidentally found and in order to avoid unnecessary operations it is suggested that incidentally found small OPCs were called occult papillary tumor instead of carcinoma.
Abstract: The thyroids from 101 consecutive autopsies from Finland were subserially sectioned at 2- to 3-mm intervals. From 36 thyroids, 52 foci of occult papillary carcinoma (OPC) were found, giving a prevalence rate of 35.6%, the highest reported rate in the world. The rate was higher, although not significantly, in males (43.3%) than in females (27.1%), but it did not correlate to the age of the patients. Twenty-six glands contained one tumor focus and ten glands contained two to five tumor foci. Only a minority of the smallest tumors can be detected with the method used. The probable number of OPCs over 0.15 mm in diameter was calculated to be about 300 in this material. The tumor diameter varied from 0.15 mm to 14.0 mm, with 67% of tumors under 1.0 mm. The smallest tumors were usually circumscribed and were composed almost solely of follicles. Larger tumors had more papillary structures and were often invasive. Fibrosis and, in the largest OPCs, lymphocytic reaction were seen around the invasive islands. All tumors were positively stained for thyroglobulin and all but one of the tumors stained positively for epidermal keratin. OPC appears to arise from follicular cells of normal follicles. Apparently the great majority of the tumors remain small and circumscribed and even from those few tumors that grow larger and become invasive OPCs only a minimal proportion will ever become a clinical carcinoma. According to the study, OPC can be regarded as a normal finding which should not be treated when incidentally found. In order to avoid unnecessary operations it is suggested that incidentally found small OPCs (less than 5 mm in diameter) were called occult papillary tumor instead of carcinoma.
864 citations
TL;DR: The data indicate that thyroid abnormalities are very common incidental findings, emphasizing the need for a conservative approach when such lesions are encountered incidentally.
Abstract: Background: Thyroid nodules are commonly identified on autopsy examination. There are relatively few descriptions, however, of the frequency with which thyroid nodules are encountered incidentally during the course of other investigations. Method: Prospective study to examine the prevalence of thyroid nodules in asymptomatic North American subjects, with palpation findings compared with findings on high-resolution ultrasonography. Results: Palpable nodules were identified in 21 (21%) of 100 subjects, with nine solitary nodules (9%) and 12 multiple nodules (12%). In comparison, only 33 subjects were found to be free of any nodules by ultrasonography. Of the 67 subjects with abnormal ultrasound findings, 22 had solitary nodules (22%) and 45 had multiple nodules (45%). The prevalence of nodules was greater in women (72%) than in men (41%) ( P Conclusions: The data indicate that thyroid abnormalities are very common incidental findings, emphasizing the need for a conservative approach when such lesions are encountered incidentally. (Arch Intern Med. 1994;154:1838-1840)
740 citations
"Risk for Malignancy of Thyroid Nodu..." refers background in this paper
...Border Well defined (3, 4) 0 Poorly defined (1, 2) 1 Shape Regular (round) 0 Irregular (tall or wide) 1 Echo structure Cystic 0 Solid 1 Mixed 2 Echogenicity Isoechoic or hyperechoic 0 Hypoechoic 1 Hypoisoechoic (disregarded) 2 Calcification Absent 0 Fine (few/countable) 1 Other (too numerous to count) 2...
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TL;DR: Long-term follow-up showed that all patients were alive and without disease or were dead without proof of thyroid-related disease and occult papillary thyroid carcinoma with or without nodal metastasis is a nonlethal and curable disease when treated by conservative surgical means.
Abstract: Retrospective review was undertaken of 137 patients with occult papillary carcinoma of the thyroid (lesions less than or equal to 1.5 cm in diameter) who were operated on at the Mayo Clinic, Rochester, Minn, between 1926 and 1955. Mean follow-up period was 25.3 years. Operations were conservative. No patient underwent bilateral total lobectomy. For 55 patients with lymph node involvement, lymphadenectomy generally involved selective node excision or modified neck dissection. Subsequent surgery was required in 12 patients; modified radical neck dissection was necessary in only four. No operative deaths occurred. Long-term follow-up showed that all patients were alive and without disease or were dead without proof of thyroid-related disease. Thus, occult papillary thyroid carcinoma with or without nodal metastasis is a nonlethal and curable disease when treated by conservative surgical means. Radical surgical or medical extirpation of all thyroid tissue is unnecessary in the treatment of this disease.
494 citations