Margaret M. Szabunio

Hashimoto Thyroiditis: Part 1, Sonographic Analysis of the Nodular Form of Hashimoto Thyroiditis

OBJECTIVE The purpose of this article is to analyze the sonographic appearance of nodular Hashimoto thyroiditis. SUBJECTS AND METHODS As part of an ongoing multiinstitutional study, patients who underwent ultrasound examination and fine-needle aspiration of one or more thyroid nodules were analyzed for multiple predetermined sonographic features. Patients completed a questionnaire, including information about thyroid function and thyroid medication. Patients (n = 61) with fine-needle aspiration cytologic results consistent with nodular Hashimoto thyroiditis (n = 64) were included in the study. RESULTS The mean (+/- SD) diameter of nodular Hashimoto thyroiditis was 15 +/- 7.33 mm. Nodular Hashimoto thyroiditis occurred as a solitary nodule in 36% (23/64) of cases and in the setting of five or more nodules in 23% (15/64) of cases. Fifty-five percent (35/64) of the cases of nodular Hashimoto thyroiditis occurred within a sonographic background of diffuse Hashimoto thyroiditis, and 45% (29/64) of cases occurred within normal thyroid parenchyma. The sonographic appearance was extremely variable. It was most commonly solid (69% [42/61] of cases) and hypoechoic (47% [27/58] of cases). Twenty percent (13/64) of nodules had calcifications (seven with nonspecific bright reflectors, four with macrocalcifications, and three eggshell), and 5% (3/64) of nodules had colloid. Twenty-seven percent (17/64) of nodules had a hypoechoic halo. The margins were well defined in 60% (36/60) and ill defined in 40% (24/60) of nodules. On Doppler analysis, 35% (22/62) of nodules were hypervascular, 42% (26/62) were isovascular or hypovascular, and 23% (14/62) were avascular. CONCLUSION The sonographic features and vascularity of nodular Hashimoto thyroiditis were extremely variable.

Simultaneous measurement of deep tissue blood flow and oxygenation using noncontact diffuse correlation spectroscopy flow-oximeter

We report a novel noncontact diffuse correlation spectroscopy flow-oximeter for simultaneous quantification of relative changes in tissue blood flow (rBF) and oxygenation (Δ[oxygenation]). The noncontact probe was compared against a contact probe in tissue-like phantoms and forearm muscles (n = 10), and the dynamic trends in both rBF and Δ[oxygenation] were found to be highly correlated. However, the magnitudes of Δ[oxygenation] measured by the two probes were significantly different. Monte Carlo simulations and phantom experiments revealed that the arm curvature resulted in a significant underestimation (~−20%) for the noncontact measurements in Δ[oxygenation], but not in rBF. Other factors that may cause the residual discrepancies between the contact and noncontact measurements were discussed, and further comparisons with other established technologies are needed to identify/quantify these factors. Our research paves the way for noncontact and simultaneous monitoring of blood flow and oxygenation in soft and vulnerable tissues without distorting tissue hemodynamics.

Hashimoto Thyroiditis: Part 2, Sonographic Analysis of Benign and Malignant Nodules in Patients With Diffuse Hashimoto Thyroiditis

OBJECTIVE The purpose of this article is to compare sonographic features of benign and malignant nodules in patients with diffuse Hashimoto thyroiditis. SUBJECTS AND METHODS As part of an ongoing multiinstitutional study, patients who underwent ultrasound and fine-needle aspiration of one or more thyroid nodules were analyzed for a variety of predetermined sonographic features. Patients with a sonographic appearance consistent with diffuse Hashimoto thyroiditis and with coexisting nodules that could be confirmed to be benign or malignant by fine-needle aspiration or surgical pathologic analysis were included in the study. RESULTS Among nodules within diffuse Hashimoto thyroiditis, 84% (69/82) were benign (35 nodular Hashimoto thyroiditis, 32 nodular hyperplasia, and two follicular adenoma), and 16% (13/82) were malignant (12 papillary carcinoma and one lymphoma). Malignant nodules were more likely to be solid and hypoechoic (62% vs 19%). All types of calcifications were more prevalent among malignant nodules, including microcalcifications (39% vs 0%), nonspecific tiny bright reflectors (39% vs 6%), macrocalcifications (15% vs 3%), and eggshell (15% vs 2%). Benign nodules were more likely to be hyperechoic (46% vs 9%), to have a halo (39% vs 15%), and to lack calcifications (88% vs 23%). Benign nodules more often had ill-defined margins (36% vs 8%). CONCLUSION Sonographic features of benign and malignant nodules within diffuse Hashimoto thyroiditis are generally similar to the features typical of benign and malignant nodules in the general population. If calcifications of any type are added to the list of malignant sonographic features, the decision to biopsy a nodule in patients with diffuse Hashimoto thyroiditis can be based on recommendations that have been published previously.

Preoperative Ultrasound is Not Useful for Identifying Nodal Metastasis in Melanoma Patients Undergoing Sentinel Node Biopsy: Preoperative Ultrasound in Clinically Node-Negative Melanoma

BackgroundSentinel lymph node biopsy (SLNB) is widely used in melanoma. Identifying nodal involvement preoperatively by high-resolution ultrasound may offer less invasive staging. This study assessed feasibility and staging results of clinically targeted ultrasound (before lymphoscintigraphy) compared to SLNB.MethodsFrom 2005 to 2009, a total of 325 patients with melanoma underwent ultrasound before SLNB. We reviewed demographics and histopathologic characteristics, then compared ultrasound and SLNB results. Sensitivity, specificity, and positive and negative predictive value were determined.ResultsA total of 325 patients were included, 58% men and 42% women with a median age of 58 (range 18–86) years. A total of 471 basins were examined with ultrasound. Only six patients (1.8%) avoided SLNB by undergoing ultrasound-guided fine-needle aspiration of involved nodes, then therapeutic lymphadenectomy. Sixty-five patients (20.4%) had 69 SLNB positive nodal basins; 17 nodal basins from 15 patients with positive ultrasounds were considered truly positive. Forty-five SLNB positive basins had negative ultrasounds (falsely negative). Seven node-positive basins did not undergo ultrasound because of unpredicted drainage. A total of 253 patients with negative SLNBs had negative ultrasounds in 240 nodal basins (truly negative) but falsely positive ultrasounds occurred in 40 basins. Overall, sensitivity of ultrasound was 33.8%, specificity 85.7%, positive predictive value 36.5%, and negative predictive value 84.2%. Sensitivity and specificity improved somewhat with increasing Breslow depth. Sensitivity was highest for the neck, but specificity was highest for the groin.ConclusionsRoutine preoperative ultrasound in clinically node-negative melanoma is impractical because of its low sensitivity. Selected patients with thick or ulcerated lesions may benefit. Because of variable lymphatic drainage patterns, preoperative ultrasound without lymphoscintigraphic localization will provide incomplete evaluation in many cases.

Noncontact diffuse correlation tomography of human breast tumor.

Abstract. Our first step to adapt our recently developed noncontact diffuse correlation tomography (ncDCT) system for three-dimensional (3-D) imaging of blood flow distribution in human breast tumors is reported. A commercial 3-D camera was used to obtain breast surface geometry, which was then converted to a solid volume mesh. An ncDCT probe scanned over a region of interest on the mesh surface and the measured boundary data were combined with a finite element framework for 3-D image reconstruction of blood flow distribution. This technique was tested in computer simulations and in vivo human breasts with low-grade carcinoma. Results from computer simulations suggest that relatively high accuracy can be achieved when the entire tumor is within the sensitive region of diffuse light. Image reconstruction with a priori knowledge of the tumor volume and location can significantly improve the accuracy in recovery of tumor blood flow contrasts. In vivo imaging results from two breast carcinomas show higher average blood flow contrasts (5.9- and 10.9-fold) in the tumor regions compared to the surrounding tissues, which are comparable with previous findings using diffuse correlation spectroscopy. The ncDCT system has the potential to image blood flow distributions in soft and vulnerable tissues without distorting tissue hemodynamics.

Multiinstitutional Analysis of Thyroid Nodule Risk Stratification Using the American College of Radiology Thyroid Imaging Reporting and Data System

OBJECTIVE Guidelines for managing thyroid nodules are highly dependent on risk stratification based on sonographic findings. The purpose of this study is to evaluate the risk stratification system used by the American College of Radiology Thyroid Imaging Reporting and Data System (TIRADS). MATERIALS AND METHODS Patients with thyroid nodules who underwent sonography and fine-needle aspiration were enrolled in a multiinstitutional study. The sonographic nodule features evaluated in the study were composition, echogenicity, margins, and echogenic foci. Images were reviewed by two radiologists who were blinded to the results of cytologic analysis. Nodules were assigned points for each feature, and the points were totaled to determine the final TIRADS level (TR1-TR5). The risk of cancer associated with each point total and final TIRADS level was determined. RESULTS A total of 3422 nodules, 352 of which were malignant, were studied. The risk of malignancy was closely associated with the composition, echogenicity, margins, and echogenic foci of the nodules (p < 0.0001, in all cases). An increased aggregate risk of nodule malignancy was noted as the TIRADS point level increased from 0 to 10 (p < 0.0001) and as the final TIRADS level increased from TR1 to TR5 (p < 0.0001). Of the 3422 nodules, 2948 (86.1%) had risk levels that were within 1% of the TIRADS risk thresholds. Of the 474 nodules that were more than 1% outside these thresholds, 88.0% (417/474) had a risk level that was below the TIRADS threshold. CONCLUSION The aggregate risk of malignancy for nodules associated with each individual TIRADS point level (0-10) and each final TIRADS level (TR1-TR5) falls within the TIRADS risk stratification thresholds. A total of 85% of all nodules were within 1% of the specified TIRADS risk thresholds.

Comparison of Performance Characteristics of American College of Radiology TI-RADS, Korean Society of Thyroid Radiology TIRADS, and American Thyroid Association Guidelines

OBJECTIVE The American College of Radiology (ACR) Thyroid Imaging Reporting and Data System (TI-RADS) provides guidelines to practitioners who interpret sonographic examinations of thyroid nodules. The purpose of this study is to compare the ACR TI-RADS system with two other well-established guidelines. MATERIALS AND METHODS The ACR TI-RADS, the Korean Society of Thyroid Radiology (KSThR) Thyroid Imaging Reporting and Data System (TIRADS), and the American Thyroid Association guidelines were compared using 3422 thyroid nodules for which pathologic findings were available. The composition, echogenicity, margins, echogenic foci, and size of the nodules were assessed to determine whether a recommendation would be made for fine-needle aspiration or follow-up sonography when each system was used. The biopsy yield of malignant findings, the yield of follow-up, and the percentage of malignant and benign nodules that would be biopsied were determined for all nodules and for nodules 1 cm or larger. RESULTS The percentage of nodules that could not be classified was 0%, 3.9%, and 13.9% for the ACR TI-RADS, KSThR TIRADS, and ATA guidelines, respectively. The biopsy yield of malignancy was 14.2%, 10.2%, and 10.0% for nodules assessed by the ACR TI-RADS, KSThR TIRADS, and ATA guidelines, respectively. The percentage of malignant nodules that were biopsied was 68.2%, 78.7%, and 75.9% for the ACR TI-RADS, the KSThR TIRADS, and the ATA guidelines, respectively, whereas the percentage of malignant nodules that would be either biopsied or followed was 89.2% for the ACR TI-RADS. The percentage of benign nodules that would be biopsied was 47.1%, 79.7%, and 78.1% for the ACR TI-RADS, the KSThR TIRADS, and the ATA guidelines, respectively. The percentage of benign nodules that would be either biopsied or followed was 65.2% for the ACR TI-RADS. CONCLUSION The ACR TI-RADS performs well when compared with other well-established guidelines.

Pre-SN Ultrasound-FNAC for Lymph Node Metastases in Melanoma Patients: A Reply

We thank Drs. Voit, van Akkooi, Catalano, and Eggermont—unquestioned pioneers in this field—for their interest in our paper, and we are pleased to have the opportunity to address several key points mentioned in their letter. We believe that our conclusions are sound and neither premature nor misleading. Specifically, we concluded that ‘‘preoperative ultrasound without lymphoscintigraphic localization will provide incomplete evaluation in many cases.’’ So, we agree that targeting ultrasound with lymphoscintigraphy might increase the sensitivity of ultrasound. However, as we discussed and others have found, targeted ultrasound does not necessarily guarantee improved sensitivity. Furthermore, there are major practical hurdles involved in obtaining lymphoscintigraphy plus ultrasonography, with or without fine needle aspiration cytology (FNAC), and performing a sentinel lymph node biopsy (SLNB) the same or the following day with a definitive FNAC report available for the surgeon. This approach is not feasible in our Comprehensive Cancer Center, where we see nearly 2000 new patients with cutaneous malignancies per year, and we believe that it is neither feasible nor cost-effective for most hospitals in the United States or abroad. Hence, we stand by our conclusion that ‘‘routine preoperative ultrasound in clinically node-negative melanoma is impractical because of its low sensitivity.’’ Importantly, this conclusion is identical to that of Thompson et al., who found that the sensitivity of ultrasound was only 8% based on an interim analysis of the prospective MSLT-II clinical trial. The MSLT-II protocol was amended so that preoperative ultrasound is no longer performed for patients entering the trial. Voit et al. voiced their disappointment that we did not utilize their ultrasound morphology criteria, although these specific criteria were not published until 2010, 1 year after our last patient was evaluated. In fact, even today, there are no uniformly accepted criteria for sonographic lymph node evaluation in the literature. A recent systematic review concluded that the diagnostic criteria used in the literature to diagnose lymph node malignancy with ultrasound were frequently vague and contradictory and emphasized the need for validating proposed criteria in large series with histologic confirmation. Even though Voit et al. published a 65% detection rate of sentinel node metastases using targeted ultrasound-guided FNAC (86% for metastases [ 1 mm in greatest dimension, 46% for metastases 0.1–1 mm, and 23% in for metastases \ 0.1 mm) using their morphology criteria, these results have as yet neither been reproduced nor validated. Previous publications from Voit’s group acknowledged the singleinstitution nature of their studies and stated that the peripheral perfusion criterion needs further validation as an early sign of nodal metastasis in multicenter prospective trials, which we heartily support. Finally, while Voit et al. mention the ability to identify metastases as small as 0.4 mm in their letter, the current limits of reliable detection in most hands are more like 4–6 mm. Most nodal metastases diagnosed today are far smaller than this. In the interim analysis of MSLT-II previously cited, sentinel node metastases found by ultrasound had a median cross-sectional area of 6.11 mm, whereas the median cross-sectional area of metastases with negative ultrasounds was 0.16 mm. Although the size of the nodal Society of Surgical Oncology 2017

3-D Blood Flow Imaging of Breast Tumor Using Noncontact Diffuse Correlation Tomography: Computer Simulations

Computer simulations with different tissue geometries were conducted to investigate the potential of a novel noncontact diffuse correlation tomography (NC-DCT) system for 3-D imaging of blood flow contrast in breast tumors.