The nodule was surgically resected because of coexisting thyroid malignancy (nodular hyperplasia by pathology). We found a high incidence of hypoechogenicity (14/44, 31.8%) and eggshell calcification (23/44, 52.3%), as well as a high malignancy rate (65.9%, 29/44). C, Possibly malignant: transverse US image of a right thyroid nodule (1.9 × 2.1 × 2.2 cm) showing an eccentric configuration with an acute angle between the solid and cystic components (arrows) and an isoechoic solid component with a microlobulated margin in a 41-year-old man (nodular hyperplasia by pathology). Physical exam. The US-based diagnostic criteria for solid thyroid nodules were as follows: 1) benign (SN-US class I): solid thyroid nodules with ≥3 US features of benignancy and no malignant or borderline US features; 2) probably benign (SN-US class II): solid thyroid nodules with 1 or 2 US features of benignancy and no malignant or borderline US features; 3) borderline (SN-US class III): solid thyroid nodules with ≥1 borderline US feature and no US features of malignancy, regardless of benign US features; 4) possibly malignant (SN-US class IV): solid thyroid nodules with 1 US feature of malignancy, regardless of borderline or benign US features; 5) malignant (SN-US class V): solid thyroid nodules with ≥2 US features of malignancy, regardless of borderline or benign US features. Thyroid nodules (TNs) occur in 50% of the older adult population; however, only about 5% of TNs are malignant (1, 2).Currently, conventional, gray-scale, B-mode, ultrasound (US) combined with fine-needle biopsy (FNB) cytology is the standard of care for evaluating TNs (3–5).To improve the predictive value of B-mode imaging, classification … This paper presents a computer-aided diagnosis (CAD) system for classifying thyroid nodules in ultrasound images. Each thyroid nodule was prospectively classified into 1 of 5 diagnostic categories following real-time US examination: benign, probably benign, borderline, possibly malignant, and malignant. In contrast, we used real-time US as the diagnostic tool and histopathologic results of resected thyroid nodules as our reference standard. It helps to decide if a thyroid nodule is benign or malignant, combining multiple features on ultrasound. Diagnoses that fall into this category include benign follicular nodules (includes adenomatoid nodules, and colloid nodules), lymphocytic (Hashimoto) thyroiditis, and granulomatous (subacute) thyroiditis. You agree to our use of cookies by continuing to use our site. Recently, Horvath et al22 showed that a US-based reporting system improved patient management and cost-effectiveness by helping avoid unnecessary FNA. In assessing a lump or nodule in your neck, one of your doctor's main goals is to rule out the possibility of cancer. In our Indian scenario however, we face limitation of resources and time. She is a member Editorial Board, Radiology at Specialty Medical Dialogues. D, Possibly malignant: longitudinal US image, in a 60-year-old woman, of a right thyroid nodule (2.0 × 2.5 × 2.7 cm) with isoechogenicity, macrolobulated margin, and taller-than-wide shape (follicular variant of papillary thyroid carcinoma by pathology). A, Benign: longitudinal US image, in a 62-year-old man, of a right thyroid nodule (2.2 × 2.7 × 3.1 cm) with an ovoid shape, isoechogenicity, and smooth margin (nodular hyperplasia by pathology). Of these 1289 nodules, 505 were surgically resected and confirmed by pathology (191 benign and 314 malignant nodules); there were 44 resected solid nodules with a borderline category. Tiered classification schemes for thyroid FNA serve the important purpose of establishing streamlined communication among clinicians involved in the care of patients with thyroid nodules. Thyroid nodules that were diagnosed as benign or probably benign were classified as negative (benign), while those that were diagnosed as possibly malignant and malignant were classified as positive (malignant). The US features of the 44 surgically resected nodules that were classified as borderline by US are listed in Table 4. © 2021 by the American Society of Neuroradiology | Print ISSN: 0195-6108 Online ISSN: 1936-959X. A, Benign: transverse US image of a right isthmic thyroid nodule (1.1 × 1.7 × 1.8 cm) showing an ovoid shape, isoechogenic and smooth-margined solid component, and a centrally and eccentrically located cystic component in a 30-year-old woman. For solid nodules and PCTNs, the sensitivity, specificity, positive and negative predictive values, and accuracy of US diagnosis were 86.1 and 66.7, 90.0 and 88.9, 94.3 and 75.0, 77.3 and 84.2, and 87.5% and 81.5%, respectively, based on 505 surgical specimens and excluding the 42 solid borderline nodules. With many thyroid nodules being incidentally detected, it is important to identify as many malignant nodules as possible while excluding those that are highly likely to be benign from fine needle aspiration (FNA) biopsies or surgeries. The ACR-TIRAD uses ultrasound data and a point system based on There are several limitations to our study. The aim of this study was to assess the diagnostic efficacy of a US-based classification system for solid and PCTNs through a prospectively designed study. The American College of Radiology TI-RADS has five different categories for nodule appearance -- composition, echogenicity, shape, margins and echogenic foci.The point total determines the nodule's ACR TI-RADS level, which ranges from … The thyroid is part of the endocrine system, which is made up of glands that secrete various hormones into the bloodstream. However, the former has not gained equal popularity in usage among radiologists. Diagnostic indices of US diagnoses for the resected nodules, Diagnostic indices of individual US classes for 505 resected nodules. Abnormalities detected by ultrasound, nodules are particularly common in the thyroid gland. Kim et al1 believed that US features predicting malignant solid nodules include marked hypoechogenicity, microcalcifications, microlobulated margin, and taller-than-wide shape. •Sonographically, a thyroid nodule can be described as a discrete lesion distinguishable from the adjacent normal thyroid parenchyma. Classification system for US-based diagnosis of thyroid nodules. The classification of thyroid nodules using ultrasound (US) imaging is done using the Thyroid Imaging Reporting and Data System (TIRADS) guidelines that classify nodules … The criteria underlying the US diagnosis of PCTNs were as follows: 1) benign (PCTN-US class I): PCTNs with ≥3 US features of benignancy and no features of malignancy; 2) probably benign (PCTN-US class II): PCTNs with 1 or 2 US features of benignancy and no features of malignancy; 3) possibly malignant (PCTN-US class III): PCTNs with 1 US feature of malignancy, regardless of other benign features; 4) malignant (PCTN-US class IV): PCTNs with ≥2 US features of malignancy, regardless of other benign features. B, Probably benign: transverse US image, in a 31-year-old woman, of a large left thyroid nodule (3.2 × 4.9 × 7.3 cm) with an ovoid shape, inhomogeneous isoechogenicity, and macrolobulated margin (trabecular variant of follicular adenoma by pathology). An estimated two-thirds of adults have nodules in the thyroid gland, with most either benign or resulting in a slow-growing cancer that is not life-threatening. The diagnostic indices of individual US diagnostic classes for the resected nodules are shown in Table 3. The other classification method is the TNM classification (tumor-node-metastasis) method developed by the America… Solid nodules were classified by using all 5 categories, and PCTNs were classified by all except the borderline category. We do not capture any email address. It consists of guidelines regarding whether a thyroid nodule should be followed up on ultrasound or to should be biopsied. Classification: Thy1: Non-diagnostic (inadequate or where technical artefact precludes interpretation; smears must contain 6 or more groups of at least 10 thyroid follicular cells to be considered adequate). Representative sonographic images of the 4 diagnostic categories for PCTNs. Keywords Thyroid nodules, British Thyroid Association, U-grade, thyroid nodule classification, reproducibility Introduction The incidence of thyroid nodules is 40% in the general population (increasing with age). Thyroid lesions found on CT or ultrasound scan for non-thyroid reasons are the most common endocrine incidentalomas. The diagnostic efficacy of thyroid US when borderline nodules were excluded did not differ significantly from that when the same nodules were reclassified as malignant (P = .389, McNemar test), but it significantly differed from that obtained when the same nodules with a borderline US diagnosis were reclassified as benign (P = .001, McNemar test). A method has been developed by the National Cancer Institute (NCI) to address terminology and other issues related to thyroid fine-needle aspiration (FNA), called "The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC)". Thy2: Non-neoplastic (features consistent with a nodular goitre or thyroiditis). Thyroid nodules are common and occur in up to 50% of the adult population; however, less than 7% of thyroid nodules are malignant. US diagnoses, cytologic diagnoses in initial US-FNA, and histopathologic results in 505 resected thyroid nodulesa. Solid nodules were classified by using all 5 categories, and PCTNs were classified by all except the borderline category. Of 1289 thyroid nodules, 1193 (92.6%; solid [94.5%, 997/1055] and PCTN [83.8%, 196/234]) were adequately sampled by US-FNA. High-resolution ultrasonography (US) is commonly used to evaluate the thyroid gland, but US is frequently misperceived as unhelpful for ... U1 – U5 Classification Thyroid nodules can be defined as abnormal cell growth in the thyroid gland and can be either benign or malignant. What are thyroid nodules? solid or fluid-filled lumps that form within your thyroid, a small gland located at the base of your neck, just above your breastbone. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer, Ultrasonography and ultrasound-based management of thyroid nodules: consensus statement and recommendations, US-guided fine-needle aspiration biopsy of thyroid nodules: adequacy of cytologic material and procedure time with and without immediate cytologic analysis, Nondiagnostic fine needle aspiration biopsy of the thyroid gland: a diagnostic dilemma, How to approach thyroid nodules with indeterminate cytology, Sonographic differentiation of partially cystic thyroid nodules: a prospective study, Metastatic cervical nodes in papillary carcinoma of the thyroid: ultrasound and histological correlation, Cystic appearance of cervical lymph nodes is characteristic of metastatic papillary thyroid carcinoma, Accurate and simple method of diagnosing thyroid nodules by the modified technique of ultrasound-guided fine-needle aspiration biopsy, Thyroid imaging reporting and data system for US features of nodules: a step in establishing better stratification of cancer risk, An ultrasonogram reporting system for thyroid nodules stratifying cancer risk for clinical management, Differentiation of benign and malignant solid thyroid nodules using an US classification system, Sonographic differentiation of thyroid nodules with eggshell calcifications, Sonography of thyroid nodules with peripheral calcifications, Evaluating the degree of conformity of papillary carcinoma and follicular carcinoma to the reported ultrasonographic findings of malignant thyroid tumor, Clinical evaluation of color Doppler imaging for the differential diagnosis of thyroid follicular lesions, Assessment of MR Imaging and CT in Differentiating Hereditary and Nonhereditary Paragangliomas, Convolutional Neural Network to Stratify the Malignancy Risk of Thyroid Nodules: Diagnostic Performance Compared with the American College of Radiology Thyroid Imaging Reporting and Data System Implemented by Experienced Radiologists, The Pharyngolaryngeal Venous Plexus: A Potential Pitfall in Surveillance Imaging of the Neck, Thanks to our 2020 Distinguished Reviewers, © 2012 by American Journal of Neuroradiology. AI Thyroid Nodule Classification Could Reduce Biopsies by 50%. B, Probably benign: transverse US image of a right thyroid nodule (1.9 × 2.4 × 2.5 cm) showing an eccentric configuration with a blunt angle between the solid and cystic components (arrows) and an isoechoic solid component with a smooth margin in a 36-year-old woman. In 3/6127 cases thyroid papillary carcinoma was diagnosed prior to ultrasound examination due to surgical excision of There are various methods for classifying a thyroid nodule. Cytology was termed “indeterminate” in the specimens with atypical cells or follicular cells of undetermined significance. First, 784 thyroid nodules were not surgically confirmed and were not included in the calculation of the diagnostic efficacy of US diagnosis. The cytologic analysis was categorized as follows: 1) inadequate (Bethesda class I), 2) benign (Bethesda class II), 3) indeterminate (Bethesda class III), 4) follicular neoplasm (Bethesda class IV), 5) suspicious for malignancy (Bethesda class V), and 6) positive for malignancy (Bethesda class VI). High-resolution thyroid US has been widely used in the evaluation of thyroid nodules, resulting in the establishment and general acceptance of certain characteristics that mark benign and malignant thyroid nodules.1⇓⇓⇓⇓⇓⇓⇓⇓–10 On the basis of previous studies, US findings suggestive of a solid malignant nodule include marked hypoechogenicity, spiculated margin, microcalcifications, and a taller-than-wide shape.1⇓⇓⇓⇓⇓⇓–8,10,11 Malignant US findings of a PCTN are considered different from those of a solid nodule and include an eccentric configuration with an acute angle, microcalcifications, macrolobulation or irregularity of the free margin, perinodular infiltration, and a centripetal vascularity in the pedicle.9,17 Several researchers have suggested that associated cervical lymphadenopathy with intranodal cystic components or microcalcifications should be added to this list as one of the malignant US features of both solid nodules and PCTNs.13,17⇓–19. #### Summary points Thyroid nodules are common: 4-7% of the adults have a palpable nodule, and up to 50-70% will have nodules on high definition ultrasonography, which may cause considerable concern to patients. RESULTS: One thousand fifty-five solid nodules and 234 PCTNs were prospectively classified as benign (n = 435 and 179), probably benign (n = 213 and 25), borderline (n = 94 and 0), possibly malignant (n = 115 and 15), and malignant (n = 198 and 15), respectively. All 1036 patients underwent US-FNA; collectively, they had 1289 nodules (nodule size range, 0.5–9.8 cm; mean size, 1.5 cm). A P value < .05 was considered statistically significant. Thyroid nodule: an abnormal growth of thyroid cells that forms a lump within the thyroid. Thank you for your interest in spreading the word on American Journal of Neuroradiology. A thyroid nodule is an unusual growth (lump) of thyroid cells in the thyroid gland. A total of 505 thyroid nodules (451 solid nodules and 54 PCTNs) were surgically resected due to cytologic malignancy in the initial US-FNA (n = 281), the presence of coexisting thyroid malignancy (n = 91), cytologic malignancy in the repeat US-FNA (n = 15), indeterminate cytology (n = 35), follicular neoplasm cytology (n = 15), the presence of a large palpable mass with benign cytology (n = 49), or patient request (n = 19). But your doctor will also want to know if your thyroid is functioning properly. The nodules that we classified as borderline had a high incidence of malignancy (65.9%, 29/44). The American College of Radiology TI-RADS has five different categories for nodule appearance -- composition, echogenicity, shape, margins and echogenic foci.The point total determines the nodule's ACR TI-RADS level, which ranges from TR1, benign, to TR5, high suspicion of malignancy. C, Borderline: longitudinal US image, in a 47-year-old woman, of a right thyroid nodule (1.0 × 1.2 × 1.6 cm) with hypoechogenicity, smooth margin, and an ovoid shape (oncocytic variant of follicular adenoma by pathology). Each thyroid nodule was prospectively classified into 1 of 5 diagnostic categories following real-time US examination: benign, probably benign, borderline, possibly malignant, and malignant. This paper presents a computer-aided diagnosis (CAD) system for classifying thyroid nodules in ultrasound images. Real-time thyroid US was performed by an experienced radiologist by using a high-resolution sonographic instrument (iU 22; Philips Healthcare, Bothell, Washington) equipped with a 12- to 5-MHz linear probe. A universally established international terminology most likely represents an … However, thyroid ultrasonography is prone to subjective interpretations and interobserver variabilities. Disclaimer: This site is primarily intended for healthcare professionals. In addition, all diagnostic indices were high regardless of exclusion or inclusion of borderline nodules. We obtained informed written consent from all patients, and the study was approved by the institutional review board. The health content on Medical Dialogues and its subdomains is created and/or edited by our, Ultrasound classification of thyroid nodules : Role of TI-RADS, Website Last Updated On : 13 May 2020 8:24 AM GMT, We use cookies for analytics, advertising and to improve our site. © 2020 Minerva Medical Treatment Pvt Ltd, • Email: info@medicaldialogues.in• Phone: 011 - 4372 0751. Nodules that grow larger or produce symptoms may eventually need medical care. for the American Thyroid Association (ATA) Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer. Specimens were considered suspicious for malignancy if they demonstrated features of a malignant neoplasm that were quantitatively or qualitatively insufficient to make a definite diagnosis of malignancy. These diagnoses typically do not require surgical intervention. TI-RADS classification of thyroid nodules based on a score modified according to ultrasound criteria for malignancy 140 carcinomas were papillary (n = 25), follicular (n = 15), oxy-philic (n = 2) or medullary (n = 2). The author is MD (Radiodiagnosis) and is Senior Resident, Dept of Radiology in All India Institute of Medical Sciences, AIIMS Patna. It has been suggested that 4-7% of the UK population have palpable nodules, with the American Thyroid Association stating that in an iodine-replete part of the world, such as the UK, 5% of women and 1% of men will have them, as … The cytologic results were deemed inadequate when fewer than 6 clusters of thyroid follicular cells containing no identifiable colloid were observed in a preparation. They reported that the sensitivity, specificity, positive and negative predictive values, and accuracy of US diagnosis were 93.8, 66.0, 56.1 95.9, and 74.8%, respectively when cytopathologic diagnoses of 155 solid nodules were used as a reference standard. According to a recent study (2018) published in AJR a ‘’Web-Based Tool for Standardized Reporting of Thyroid Ultrasound Studies’’ could be useful in characterization,and follow-up of thyroid nodules. Thyroid Imaging, Reporting and Data System, or TI-RADS, is formulated after the American College of Radiology's BI-RADS, a widely accepted risk stratification system for breast lesions which has been further modified by ACR( American College of Radiology) in 2017. They may be hyperplastic or tumorous, but only a small percentage of thyroid tumors are malignant. The US features of a malignant PCTN included an eccentric configuration of the main solid or cystic component with an acute angle, microcalcifications, macrolobulation or irregularity of the free margin, perinodular infiltration, a centripetal vascularity in the pedicle, and associated cervical lymphadenopathy showing intranodal cystic components or microcalcifications. Small, asymptomatic nodules are common, and often go unnoticed. US findings and histopathologic results in 44 resected nodules with borderline US categorya. In addition, solid thyroid nodules were prospectively classified into 1 of 5 categories (SN-US classes I–V), and PCTNs were grouped into 1 of 4 categories according to their US features (PCTN-US classes I–IV). Nodular goiter, nodular goiter with hyperplastic nodules, colloid nodules, cyst contents with or without benign follicular cells, and lymphocytic thyroiditis were classified as benign cytology. For PCTNs, the US features of a benign nodule included a configuration that was either concentric or eccentric with a blunt angle, a smooth free margin, peripheral or no vascularity, a spongiform appearance or daughter cysts in the solid component, intranodular comet-tail artifacts, and isoechogenicity. Furthermore, after we divided the nonborderline resected nodules into solid and PCTN categories, 451 solid nodules were included in the analysis. This site complies with the HONcode standard for trustworthy health information: verify here. U3 (indeterminate) solid homogenous markedly hyperechoic nodule with halo (follicular lesions) hypoechoic with equivocal echogenic foci or cystic change mixed or central vascularity The US features of the 23 nodules with eggshell calcification were retrospectively reviewed. The usefulness of hypoechogenicity, macrocalcifications, and centrally predominant vascularity as characteristics that predict malignancy for solid nodules has been debated.2⇓⇓⇓⇓⇓–8,11⇓–13,24,25 Nonetheless, we used these characteristics to classify nodules as borderline malignancy. On the basis of retrospective US image analysis, 14 malignant nodules with an eggshell calcification had either an interrupted eggshell (10/14, 71.4%) or a thick hypoechoic outer rim (7/14, 50%), which concurs with studies that suggest that these 2 findings predict malignancy in eggshell-calcified nodules.24,25 Nevertheless, large-scale studies are needed to correctly predict the risk of malignancy in borderline nodules because of the high possibility that the 50 nonresected borderline nodules were benign in this study. We used the criterion recommended by the Korean Society of Thyroid Radiology to determine which nodules were eligible for US-FNA examination (largest diameter, ≥5 mm) rather than the American Thyroid Association guidelines (largest diameter, ≥10 mm).13 For each sample, smears were prepared on 4–6 slides, fixed in 95% ethanol, and were examined after Papanicolaou staining. Solid nodules were classified by using all 5 categories, and PCTNs were classified by all except the borderline category. E, Malignant: longitudinal US image in a 36-year-old woman of a left thyroid nodule (1.1 × 1.2 × 1.3 cm) with a round shape, marked hypoechogenicity, microlobulated margin, microcalcifications, and associated lymph nodes with intranodal cystic component or microcalcifications in the left inferior perithyroidal region (arrows) (classic type of papillary thyroid carcinoma by pathology). 39-42, http://www.uab.edu/news/research/item/8429-uab-led-blue-ribbon-committee-creates-ultrasound-scoring-system-for-thyroid-nodules-to-reduce-unnecessary-biopsies. Among these resected nodules, there were 299 papillary thyroid carcinomas, 9 follicular thyroid carcinomas, 3 medullary thyroid carcinomas, 1 anaplastic thyroid carcinoma, 1 metastasis due to renal cell carcinoma, 1 poorly differentiated carcinoma, 23 follicular adenomas, and 168 nodular hyperplasias. The US criteria that we used in this study for assessment of solid nodules were based on a number of previous studies,1⇓⇓⇓⇓⇓⇓–8 but different US criteria for PCTNs were predicated on the theory that a malignant PCTN originates from the wall of a thyroid cyst.20 Some US features that are associated with malignancy in a solid thyroid nodule include marked hypoechogenicity, a spiculated margin, microcalcifications, taller-than-wide shape, and associated cervical lymphadenopathy with intranodal cystic components or microcalcifications,1⇓⇓⇓⇓⇓⇓⇓⇓–10,18,19 whereas those associated with malignant PCTNs have an eccentric configuration with an acute angle, microcalcifications within a solid component, macrolobulated or irregular free margin of the solid component, perinodular infiltration, a centripetal vascularity in the pedicle, and associated cervical lymphadenopathy with intranodal cystic components or microcalcifications.9,17⇓–19 In addition, the possibility of malignancy or benignancy for thyroid nodules is considered to be related to the number of malignant or benign US features.17,21,22 In particular, Kwak et al21 examined the risk stratification of thyroid malignancy by using similar US features such as those used in our study; this study showed that the risk of malignancy increased with an increase in the number of suspicious US features. D, Malignant: longitudinal US image of a left thyroid nodule (0.9 × 1.0 × 1.1 cm) showing an eccentric configuration with an acute angle between the solid and cystic components (arrows) and some microcalcifications in the solid component in a 36-year-old woman (classic type of papillary thyroid carcinoma by pathology). Two eggshell nodules simultaneously showed 2 subfindings: 1 nodule showed interrupted eggshell and thick hypoechoic outer rim and the other nodule showed thickening of eggshell and a thick hypoechoic outer rim. Therefore, large-scale multicenter studies are recommended to ensure reproducibility. This helps clinicians to choose the right thyroid nodule for thyroid biopsy. Previously, we used an US-based classification to demonstrate that prospective studies that used 5 US categories for solid thyroid nodules and 4 US categories for PCTNs have a high diagnostic efficacy.17,23 However, this study showed the diagnostic accuracy of US for thyroid nodules on a larger scale, correlated these with histopathologic results, and attempted to use a different US classification system for solid nodules versus PCTNs.
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