Bożena Popowicz

The usefulness of sonographic features in selection of thyroid nodules for biopsy in relation to the nodule's size.

OBJECTIVE To evaluate the efficacy of selected ultrasound (US) features of thyroid focal lesions useful for establishing indications for fine-needle aspiration biopsy (FNAB) with regard to the lesions size. METHODS US imaging features of 1141 thyroid nodules (shape, echogenicity, pattern of blood flow, presence of microcalcifications and the presence of other nodules in the thyroid) and their palpability were compared with the post-operative histopathological outcomes. The efficacy of the selected sets of the features was assessed for small nodules (SN)< or =15 mm and large nodules (LN)>15 mm, as well as separately for nodules< or =10 mm. RESULTS Logistic regression analysis showed that in SN hypoechogenicity (odds ratios, OR: 3.18), microcalcifications (OR: 19.12), solitary occurrence (OR: 3.29) and height-to-width ratio> or =1 (OR: 8.57) were independent risk factors for malignancy. The optimal set of small lesions that should be biopsied includes all lesions presenting at least one of the above-mentioned features (sensitivity 98%, specificity 44%). In the LN group, the selection criteria based on the shape of lesions and hypoechogenicity were less sensitive than in the SN group, but they allowed further reduction in the number of performed FNABs. Large nodules primarily selected for FNAB should be hypoechoic, more tall then wide or contain microcalcifications (sensitivity 84%, specificity 72%). CONCLUSIONS The obtained results provide rationale for using features from the US examination in selecting both small and large nodules for FNAB. In the case of LN, the usefulness of sonographic features is less sensitive, but more specific than in the case of SN.

The fine-needle aspiration biopsy efficacy of small thyroid nodules in the area of recently normalized iodine supply

OBJECTIVE To evaluate the incidence of focal lesions in the thyroid in the area of recently normalized iodine supply as well as to compare the efficacy of fine-needle aspiration biopsy (FNAB) of small (infracentimetric) and large thyroid lesions in this area. METHODS The outcomes of 13,646 ultrasound (US) examinations, 13,437 US-guided FNABs of the thyroid and 1694 results of post-operative histopathological examinations were analysed. RESULTS Infracentimetric nodules (INs < or = 10 mm) were revealed by US examinations in 43.5% of patients; in the majority of the cases (82.2%) INs were multiple. The percentage of revealed carcinomas by aspiration of INs is similar to that observed when large nodules (LNs > 10 mm) are examined cytologically. However, the efficiency of preoperative diagnosis of INs is lower than LNs with respect to both US selection of lesions for FNAB and the percentage of false negative results of FNAB (29.8 vs 5.4%, P<0.001). In post-operative histopathological examination, extrathyroidal extension of thyroid cancers was observed in nearly 30% of microcarcinomas. CONCLUSIONS In endemic or post-endemic areas, the efficiency of FNAB is lower in the case of small lesions than larger ones. In spite of this, the percentage of cytologically revealed carcinomas among small lesions is not lower than larger ones. Thus, it is particularly indicated to follow up small thyroid lesions with repeated US examinations in such areas.

E-cadherin expression is more associated with histopathological type of thyroid cancer than with the metastatic potential of tumors

The aim of this study was to evaluate the relationship between abnormal expression of E-cadherin (E-CAD) and the extracapsular extension of tumors, lymph node involvement and the presence of metastasis in various types of thyroid cancers. Histopathological specimens of 35 benign thyroid lesions and 122 malignant tumors (papillary, follicular, poorly differentiated and undifferentiated cancers) were analyzed. E-CAD immunostaining intensity, its subcellular localization, homogeneity within lesion, and the relation of staining intensity between tumor and surrounding thyroid parenchyma were evaluated. The obtained results show that the variants of differentiated cancers with a poorer prognosis (i.e. tall cell and follicular variants of papillary cancer and widely invasive follicular cancers) present reduced intensity of E-CAD expression, its abnormal localization or heterogeneity of staining more frequently than classical papillary cancers and minimally invasive follicular cancers. However, the assessment of E-CAD expression does not allow the prediction of extrathyroidal growth of thyroid cancers.

Detrimental Effects of Increasing Iodine Supply: Iodine-Induced Hyperthyroidism, Following Iodine Prophylaxis

This chapter discusses the epidemiology and etiology of iodine-induced hyperthyroidism (IIH), which follows normalization of iodine supply. The thyroid gland seems to be well adapted to incidents of iodine intake in very high amounts. Still, there is evidence showing that increased intake of iodine may induce clinically relevant problems in some susceptible subjects. These effects are optimally identifiable at population level, as individual responses vary depending on many other factors that are difficult to control. One of the main undesirable consequences of increased iodine intake in a population is a higher incidence of hyperthyroidism. The elevated incidence of IIH, which follows normalization of iodine supply, is transient. The greater the iodine deficiency, the more numerous and clinically more difficult are the cases of hyperthyroidism, which occur after correction of the iodine supply. In fact, IIH, which follows iodine supply normalization, can be viewed as an outcome of iodine deficiency. The deeper the iodine deficiency, the more numerous and more difficult are the IIH cases, which occur after the correction of iodine supply. Also, children form the group that benefits the most from iodine prophylaxis. Some effects of prolonged iodine deficiency, such as the presence of autonomous nodules in the thyroid, seem to be irreversible.

The influence of fine-needle aspiration biopsy of the thyroid gland on the size of the examined nodule and its ultrasound image.

Introduction The aim of the study was to assess the influence of thyroid fine-needle aspiration biopsy (FNAB) on the size and ultrasound (US) features of the lesions and to examine whether the possible effects are persistent. Material and methods One hundred and fifty biopsied and 50 control thyroid nodules underwent two US examinations, 10-20 days and 8-10 weeks after the biopsy. The study took into account lesion volume alterations, both absolute and relative (with reference to its initial value), and the presence of US features of malignancy: hypoechogenicity, microcalcifications, internal blood flow, irregular or blurred margins and suspicious shape of the lesions. The analysis covered only those nodules which immediately after FNAB did not change their appearance owing to cyst fluid evacuation or intranodular hemorrhage. Results The increase of the lesion volume was more frequent in the group of biopsied lesions than the control one (58.0% vs. 24.0%, p < 0.0001) with the highest increase of 61.5%. The mean change percentage, however, was determined below 5% and a tendency of the lesions to resume their initial volume was noticeable. Neither a persistent increase in nodule volume of above 50% nor significant changes in the presence of malignancy suggestive US features were observed after FNAB. None of the biopsied nodules developed any microcalcifications, irregular or blurred margins, internal blood flow, or suspicious shape. Conclusions Fine-needle aspiration biopsy does not cause permanent changes in the US image of biopsied lesions, provided that the sampling technique is appropriate and there are no significant changes observed during the biopsy.

Analysis of clinical significance of equivocal thyroid cytology with a special consideration for FLUS category — five years of new classification of FNA results

INTRODUCTION The diagnostic category of follicular lesion of undetermined significance (FLUS) was intended to allow selection of cases with low risk of malignancy from all smears with indeterminate, suspicious cytology (ISC), which can potentially take advantage from repeat fine-needle aspiration (rFNA). Aim of the study was a comparison of the risk of malignancy related to FLUS nodules and other nodules with ISC: suspected follicular neoplasm (SFN) and suspected malignancy (SM), as well as analysis of the usefulness of assessing ultrasonographic malignancy risk features (UMRF) in nodules with ISC. MATERIAL AND METHODS We analysed UMRF, rFNA, and results of histopathological examination (H) in 441 FLUS, 135 SFN, and 72 SM nodules. RESULTS The frequency of exposing cancer in H in FLUS nodules was 5.9%, and when cytological follow up was also included it was 2.9%. rFNAs made the diagnosis more precise in 72.7% of FLUS, and in 5.2% it was diagnosis/suspicion of cancer. The incidence of cancer in SFN nodules was 8.2%, in SM nodules with suspicion of papillary cancer - 61.1%, and in nodules with suspicion of other or unspecified malignancy - 53.8% (p < 0.0001 FLUS vs. both groups). The presence of calcifications is the only independent UMRF for nodules with ISC (OR 4.7). Features of importance are also microcalcifications (OR 3.8), especially in the SM group, and taller-than-wide-shape (OR 2.2). FLUS and SFN nodules are characterised by particularly low value of assessing suspicious margins; analysis of hypoechogenicity is of low value in SFN nodules, like suspected vascularisation in SFN and SM nodules. CONCLUSIONS The risk of cancer in FLUS and SFN nodules is lower than in SM nodules. rFNAs of FLUS nodules make the diagnosis more precise in more than 70% of cases and are effective in revealing cancers. UMRFs present variable diagnostic value depending on the subcategory of ISC.

The predictive value of sonographic images of follicular lesions – a comparison with nodules unequivocal in FNA – single centre prospective study

BackgroundTo determine the diagnostic efficacy of ultrasonographic malignancy risk features (UMRFs) in follicular lesions (FL) in a population with low risk of malignancy in FL and to compare it with a similar analysis in a group of patients with unequivocal cytology (UC): benign lesion (BL) or malignant neoplasm (MN).MethodsPresence of UMRFs (hypoechogenicity, solid echostructure, taller-than-wide shape, pathological vascularization, irregular margins, microcalcifications and macrocalcifications) and their sets were assessed in 322 FL: 202 follicular lesions of undetermined significance (FLUS) and 120 suspicious for follicular neoplasm (SFN) and 300 nodules with UC: 200 BL and 100 MN, subsequently evaluated histopathologically.ResultsCancers were confirmed in 100% nodules in MN group (89.0% of them were papillary carcinomas - PTC), in 6.4% FLUS nodules (69.2% PTC), and in 10.8% SFN nodules (30.8% PTC). In the UC group all UMRFs occurred more frequently in cancers than in benign lesions. In the FL group only calcifications were found in cancers more frequently – macro and microcalcifications together: 34.6 vs. 11.5% (p = 0.001) and isolated macrocalcifications: 26.0 vs. 6.8% (p = 0.001); the presence of those features increased the basic risk of malignancy in FL more than 2 times. The presence of at least 2 of the following URMFs: hypoechogenicity, solid echostructure, any type of calcifications and suspected shape, additionally improved sensitivity.ConclusionsEvaluation of UMRFs in FLs is less effective than in nodules with UC, and its effectiveness decreases parallel to the decrease in percentage of PTCs among malignant neoplasms and to the increase of the percentage of adenomas among benign nodules. The presence of macrocalcifications in such FLs significantly increases the basic risk of malignancy in these nodules.

The efficiency of elastography in the diagnostics of follicular lesions and nodules with an unequivocal FNA result

INTRODUCTION The aim was to assess the usefulness of strain elastography (SEG) in the diagnostics of two groups of thyroid nodules (TNs): follicular lesions (FL) with low malignancy risk (< 20.0%) and low percentage of papillary carcinomas (PTCs) among cancers as well as TNs with unequivocal cytology (UC) and high percentage of PTCs among cancers. MATERIAL AND METHODS 168 TNs were analysed and eventually surgically treated: 100 UC (50 benign and 50 malignant - 90.0% PTCs) and 68 FL (60 benign, 8 malignant - 50.0% PTCs). Elasticity score (ES) and strain ratio (SR) were evaluated, and their effectiveness was compared with the evaluation of the number of ultrasound malignancy risk features (NoUMRFs). RESULTS In the UC group the evaluation of mean values of SR and ES in both sections (meanSR, meanES) was more efficient than NoUMRFs analysis (AUC: 0.903 and 0.869 vs. 0.754, p < 0.05). The following thresholds: meanSR ≥ 2.01, meanES ≥ 2.5, NoUMRFs ≥ 2, were related to the increased malignancy risk in nodules (OR: 45.0; 23.2; 5.4, respectively), but only meanSR ≥ 2.01 was an independent risk factor (OR: 20.3; SEN: 86.0%, SPC: 88.0%). In the FL group, only the evaluation of tSR (SR assessed in transverse section) had the value of AUC > 0.7, and only the set of features: tSR ≥ 1.7 and NoUMRFs ≥ 1 increased the malignancy risk in nodules (OR: 12.0; SEN: 75.0%, SPC: 75.0%). CONCLUSIONS SEG is more reliable than conventional US in the diagnostics of TNs. The efficacy of SEG decreases with lowering percentage of PTCs among cancers. But in FL nodules SEG may support the selection of nodules for surgical treatment.

Repeat FNA Significantly Lowers Number of False Negative Results in Patients with Benign Nodular Thyroid Disease and Features of Chronic Thyroiditis

Purpose. The aim of the study was to compare the risk of thyroid malignancy and efficacy of repeat FNA in patients with thyroid nodules diagnosed cytologically as benign lesion (BL) with features of chronic thyroiditis (BL-CT) and BL without CT features (BL-nCT). Methods. The analysis included 917 patients with BL-CT and 7046 with BL-nCT in the first FNA. Repeat biopsy was carried out in 787 patients of BL-CT and 5147 of BL-nCT; 218 patients of BL-CT and 2462 of BL-nCT were operated; in 88 cases of BL-CT and 563 of BL-nCT both ways of follow-up were available. Results. Outcome of repeat cytology implied surgery more frequently in patients with BL-CT than with BL-nCT—3.2% versus 1.9%, P < 0.05. Incidence of cancer (including incidentalomas) was higher in patients with BL-CT operated after one benign cytology than in patients with two benign FNA outcomes: 10.8% versus 1.6%, P < 0.05. In patients with BL-nCT that difference was not significant: 3.2% versus 2.6%. Conclusions. Patients with thyroid nodules diagnosed as BL with CT features have higher risk of malignancy than patients with BL without CT features. Repeat biopsy significantly lowers percentage of FN results in patients with BL-CT in the first FNA.