Incidental thyroid nodules on CT: evaluation of 2 risk-categorization methods for work-up of nodules.
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ABSTRACT: Background and purpose
Thyroid nodules are common incidental findings on CT, but there are no clear guidelines regarding their further diagnostic work-up. This study compares the performance of 2 risk-categorization methods of selecting CT-detected incidental thyroid nodules for work-up.Materials and methods
The 2 categorization methods were method A, based on nodule size ≥10 mm, and method B, a 3-tiered system based on aggressive imaging features, patient age younger than 35 years or nodule size of ≥15 mm. In part 1, the 2 categorization methods were applied to thyroid cancers in the SEER data base of the National Cancer Institute to compare the cancer capture rates and survival. In part two, 755 CT neck scans at our institution were retrospectively reviewed for the presence of ITNs of ≥5 mm, and the same 2 categorization methods were applied to the CT cases to compare the number of patients who would theoretically meet the criteria for work-up. Comparisons of proportions of subjects captured under methods A and B were made by using the McNemar test.Results
For 84,720 subjects in the SEER data base, methods A and B each captured 74% (62,708/84,720 and 62,586/84,720, respectively) of malignancies. SEER subjects who would not have met the criteria for further work-up by both methods had equally excellent 10-year cause-specific and relative survival of >99%. For part 2, the prevalence of ITNs of ≥5 mm at our institution was 133/755 (18%). The number of ITNs that would be recommended for work-up by method A was 57/133 (43%) compared with 31/133 (23%) for method B (P < .0005).Conclusions
Compared with using a 10-mm cutoff, the 3-tiered risk-stratification method identified fewer ITNs for work-up but captured the same proportion of cancers in a national data base and showed no difference in missing high-mortality cancers.
SUBMITTER: Nguyen XV
PROVIDER: S-EPMC7965620 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:Background and purposeVariability in radiologists' reporting styles and recommendations for incidental thyroid nodules can lead to confusion among clinicians and may contribute to inconsistent patient care. Our aim was to describe reporting practices of radiologists for incidental thyroid nodules seen on CT and MR imaging and to determine factors that influence reporting styles.Materials and methodsThis is a retrospective study of patients with incidental thyroid nodules reported on CT and MR imaging between January and December 2011, identified by text search for "thyroid nodule" in all CT and MR imaging reports. The studies included CT and MR imaging scans of the neck, spine, and chest. Radiology reports were divided into those that mentioned the incidental thyroid nodules only in the "Findings" section versus those that reported the incidental thyroid nodules in the "Impression" section as well, because this latter reporting style gives more emphasis to the finding. Univariate and multivariate analyses were performed to identify radiologist, patient, and nodule characteristics that influenced reporting styles.ResultsThree hundred seventy-five patients met the criterion of having incidental thyroid nodules. One hundred thirty-eight (37%) patients had incidental thyroid nodules reported in the "Impression" section. On multivariate analysis, only radiologists' divisions and nodule size were associated with reporting in "Impression." Chest radiologists and neuroradiologists were more likely to report incidental thyroid nodules in the "Impression" section than their abdominal imaging colleagues, and larger incidental thyroid nodules were more likely to be reported in "Impression" (P ≤ .03). Seventy-three percent of patients with incidental thyroid nodules of ≥20 mm were reported in the "Impression" section, but higher variability in reporting was seen for incidental thyroid nodules measuring 10-14 mm and 15-19 mm, which were reported in "Impression" for 61% and 50% of patients, respectively.ConclusionsReporting practices for incidental thyroid nodules detected on CT and MR imaging are predominantly influenced by nodule size and the radiologist's subspecialty. Reporting was highly variable for nodules measuring 10-19 mm; this finding can be partially attributed to different reporting styles among radiology subspecialty divisions. The variability demonstrated in this study further underscores the need to develop CT and MR imaging practice guidelines with the goal of standardizing reporting of incidental thyroid nodules and thereby potentially improving the consistency and quality of patient care.
| S-EPMC7965682 | biostudies-literature
Project description:Rationale and objectivesThe study aimed to determine whether the addition of the Fleischner Society guidelines to chest computed tomography (CT) reports identifying incidental pulmonary nodules affects follow-up care.Patients and methodsBeginning in 2008, a template containing the Fleischner Society guidelines was added at the interpreting radiologist's discretion to chest CT reports describing incidental solid pulmonary nodules at our institution. The records of all medical centers in Olmsted county were used to capture the complete medical history of local patients >35 years old diagnosed with a pulmonary nodule from April 1, 2008 to October 1, 2011. Patients with a history of cancer or previously diagnosed nodule, or who died before follow-up, were excluded. Patients were categorized according to whether they did ("template group") or did not ("control group") have the template added. Nodule size and smoking history were used to determine recommended follow-up care. Differences in follow-up were compared between groups using Pearson's chi-square test.ResultsA total of 510 patients (276 in the template group, 234 in the control group) were included in the study. Only 198 patients (39%) received their recommended follow-up care. Template group patients were significantly more likely to receive recommended follow-up care compared to control group patients (45% vs 31%, P = .0014). Most patients whose management did not adhere to Fleischner Society guidelines did not receive a recommended follow-up chest CT (210 out of 312, 67%).ConclusionsThe addition of the Fleischner Society guidelines to chest CT reports significantly increases the likelihood of receiving recommended follow-up care for patients with incidental pulmonary nodules. Additional education is needed to improve appropriate guideline utilization by radiologists and adherence by ordering providers.
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Project description:PurposeAs ~25% of cytologically indeterminate thyroid nodules harbour malignancy, diagnostic lobectomy is still performed in many cases. 18FDG PET/CT rules out malignancy in visually negative nodules; however, none of the currently available interpretation criteria differentiates malignant from benign 18FDG-avid nodules. We evaluated the ability of PET metrics and radiomics features (RFs) to predict final diagnosis of 18FDG-avid cytologically indeterminate thyroid nodules.MethodsSeventy-eight patients were retrospectively included. After volumetric segmentation of each thyroid lesion, 4 PET metrics and 107 RFs were extracted. A logistic regression was performed including thyroid stimulating hormone, PET metrics, and RFs to assess their predictive performance. A linear combination of the resulting parameters generated a radiomics score (RS) that was matched with cytology classes (Bethesda III and IV) and compared with final diagnosis.ResultsTwo RFs (shape_Sphericity and glcm_Autocorrelation) differentiated malignant from benign lesions. A predictive model integrating RS and cytology classes effectively stratified the risk of malignancy. The prevalence of thyroid cancer increased from 5 to 37% and 79% in accordance with the number (score 0, 1 or 2, respectively) of positive biomarkers.ConclusionsOur multiparametric model may be useful for reducing the number of diagnostic lobectomies with advantages in terms of costs and quality of life for patients.
| S-EPMC8763930 | biostudies-literature
Project description:This study assesses the role of [18F] FDG PET/CT, fine needle aspiration (FNA) cytology and ultrasound in the 1-2% of patients with focally positive thyroid nodules on FDG PET/CT. All FDG PET/CT scans with focally increased thyroid FDG PET/CT uptake performed over 37 months in one institution were matched to patients undergoing thyroid FNA. Diffuse FDG PET/CT uptake patients were excluded. A total of 47 patients showed focally increased thyroid uptake. Consistent with previous studies, 18 (38.2%) patients had malignancy-12 primary thyroid carcinoma, 1 parathyroid carcinoma, 3 metastatic carcinoma to the thyroid and 2 lymphoma. A total of 15 (31.9%) lesions categorized as non-malignant contained Hürthle cells/oncocytes. A total of 14 lesions (29.8%) had focally increased FDG PET/CT uptake with no specific cytological or histopathological cause identified. No focally PET avid Hürthle cell/oncocytic lesions were found to be malignant. Exclusion of oncocytic lesions increased the calculated risk of malignancy (ROM) of focally PET avid nodules from 38% to 68%. It may be useful to exclude focally FDG PET/CT avid Hürthle cell/oncocytic lesions, typically reported as follicular neoplasm or suspicious for a follicular neoplasm, Hürthle cell type (Oncocytic) type, RCPath Thy 3F: Bethesda IV or sometimes Thy 3a: Bethesda III FNAs) from ROM calculations. Oncocytic focally PET/CT FDG avid lesions appear of comparatively lower risk of malignancy and require investigation or operation but these lesions should be readily identified by FNA cytology on diagnostic work up of focally PET avid thyroid nodules.
| S-EPMC7761140 | biostudies-literature
Project description:ObjectiveThis study assessed the health-related quality of life (HRQoL) in patients undergoing 2-[18F]fluoro-2-deoxy-D-glucose (FDG)-PET/CT for an indeterminate (Bethesda III/IV) thyroid nodule. FDG-PET/CT accurately rules out malignancy and prevents 40% of futile diagnostic surgeries in these nodules.DesignSecondary analyses of HRQoL data from a randomised controlled multicentre trial (NCT02208544) in 126 patients from 15 hospitals in the Netherlands were done.MethodsLongitudinal HRQoL assessment was performed using the EuroQol 5-dimension 5-level (EQ-5D-5L), the RAND 36-item Health Survey v2.0 (RAND-36), and the Thyroid Patient-Reported Outcome (ThyPRO) questionnaire on baseline, 3, 6, and 12 months, relative to the date of the FDG-PET/CT scan.ResultsPatients who were randomised to active surveillance following an FDG-negative nodule instead of diagnostic surgery reported stable HRQoL scores throughout the year. Univariate analysis indicated better HRQoL for patients undergoing surveillance than surgical patients with benign histopathology on multiple physical and psychosocial domains. Univariate within-group analysis suggested both temporary and continued HRQoL deteriorations in patients with benign histopathology over time. Multivariate within-group analysis demonstrated no significant longitudinal HRQoL changes in patients undergoing active surveillance. In contrast, in patients with benign histopathology, worse HRQoL was observed with regard to ThyPRO cognitive impairment (P = 0.01) and cosmetic complaints (P = 0.02), whereas goitre symptoms (P < 0.001) and anxiety (P = 0.04) improved over time. In patients with malignant histopathology, anxiety also decreased (P = 0.05).ConclusionsThe reassurance of a negative FDG-PET/CT resulted in sustained HRQoL throughout the first year of active surveillance. Diagnostic surgery for a nodule with benign histopathology resulted in more cognitive impairment and physical problems including cosmetic complaints, but improved goitre symptoms and anxiety. Anxiety was also reduced in patients with malignant histopathology.
| S-EPMC9346328 | biostudies-literature
Project description:BackgroundManagement recommendations for thyroid nodules rely primarily on the cytological diagnosis. However, 25% of biopsies render an indeterminate cytology for which management decision is more challenging due to heterogeneity of the specimens. This study aimed to stratify the cancer risk through subcategorization of indeterminate cytology.MethodsThe indeterminate cytological specimens (Bethesda-III or IV) of 518 thyroid nodules consecutively evaluated at our academic cancer center between October 2008 and September 2015, blinded to the histological outcome, were retrospectively reviewed. Cytological specimens were subclassified into four groups: aspirates exhibiting nuclear atypia (n?=?158; 31%); architectural atypia (n?=?222; 43%); oncocytic features (n?=?120; 23%); or other types of atypia (n?=?18; 3%). The prevalence of malignancy and odds ratio for malignancy were calculated in 323 nodules with histological confirmation.ResultsThe prevalence of malignancy was 26% overall (20% in Bethesda-III and 29% in Bethesda-IV; p?=?0.07), and 47%, 12%, 24%, and 25% for aspirates with nuclear atypia, architectural atypia, oncocytic features, or other types of atypia, respectively. The OR of nuclear atypia over architectural atypia was 6.4 (3.4-12.2; p?<?0.001), and 2.7 over oncocytic features (1.4-5.1; p?=?0.01), whereas the OR of architectural atypia over oncocytic features was 0.4 (0.2-0.9; p?=?0.03). Results were similar for Bethesda-III and IV aspirates when analyzed independently. Furthermore, cytological subcategories improved cytology-histology correlation, as they were associated with distinct profiles of histological diagnoses (p?<?0.001).ConclusionsCytological subcategories can effectively stratify the risk of malignancy of thyroid nodules with indeterminate cytology and improve cytology-histology correlation.
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Project description:PurposeTo evaluate cost-effectiveness of an [18F]FDG-PET/CT-driven diagnostic workup as compared to diagnostic surgery, for thyroid nodules with Bethesda III/IV cytology. [18F]FDG-PET/CT avoids 40% of futile diagnostic surgeries for benign Bethesda III/IV nodules.MethodsLifelong societal costs and quality-adjusted life years (QALYs) were assessed for 132 patients participating in a randomised controlled multicentre trial comparing [18F]FDG-PET/CT to diagnostic surgery. The observed 1-year trial results were extrapolated using a Markov model. The probability of cost-effectiveness was estimated using cost-effectiveness acceptability curves, taking uncertainty about sampling, imputation, and parameters into account.ResultsThe observed 1-year cost difference of [18F]FDG-PET/CT as compared to diagnostic surgery was - €1000 (95% CI: - €2100 to €0) for thyroid nodule-related care (p = 0.06). From the broader societal perspective, the 1-year difference in total societal costs was - €4500 (- €9200 to €150) (p = 0.06). Over the modelled lifelong period, the cost difference was - €9900 (- €23,100 to €3200) (p = 0.14). The difference in QALYs was 0.019 (- 0.045 to 0.083) at 1 year (p = 0.57) and 0.402 (- 0.581 to 1.385) over the lifelong period (p = 0.42). For a willingness to pay of €50,000 per QALY, an [18F]FDG-PET/CT-driven work-up was the cost-effective strategy with 84% certainty.ConclusionFollowing the observed reduction in diagnostic surgery, an [18F]FDG-PET/CT-driven diagnostic workup reduced the 1-year thyroid nodule-related and societal costs while sustaining quality of life. It is very likely cost-effective as compared to diagnostic surgery for Bethesda III/IV nodules.Trial registration numberThis trial is registered with ClinicalTrials.gov: NCT02208544 (5 August 2014), https://clinicaltrials.gov/ct2/show/NCT02208544 .
| S-EPMC9308600 | biostudies-literature
Project description:ObjectivesThis study aims to assess the performance of radiomics approaches based on 3D computed tomography (CT), clinical and semantic features in predicting the pathological classification of thymic epithelial tumors (TETs).MethodsA total of 190 patients who underwent surgical resection and had pathologically confirmed TETs were enrolled in this retrospective study. All patients underwent non-contrast-enhanced CT (NECT) scans and contrast-enhanced CT (CECT) scans before treatment. A total of 396 hand-crafted radiomics features of each patient were extracted from the volume of interest in NECT and CECT images. We compared three clinical features and six semantic features (observed radiological traits) between patients with TETs. Two triple-classification radiomics models (RMs), two corresponding clinical RMs, and two corresponding clinical-semantic RMs were built to identify the types of the TETs. The area under the receiver operating characteristic curve (AUC) and accuracy (ACC) were useful to evaluate the different models.ResultsOf the 190 patients, 83 had low-risk thymoma, 58 had high-risk thymoma, and 49 had thymic carcinoma. Clinical features (Age) and semantic features (mediastinal fat infiltration, mediastinal lymph node enlargement, and pleural effusion) were significantly different among the groups(P < 0.001). In the validation set, the NECT-based clinical RM (AUC = 0.770 for low-risk thymoma, 0.689 for high-risk thymoma, and 0.783 for thymic carcinoma; ACC = 0.569) performed better than the CECT-based clinical-semantic RM (AUC = 0.785 for low-risk thymoma, 0.576 for high-risk thymoma, and 0.774 for thymic carcinoma; ACC = 0.483).ConclusionsNECT-based and CECT-based RMs may provide a non-invasive method to distinguish low-risk thymoma, high-risk thymoma, and thymic carcinoma, and NECT-based RMs performed better.Advances in knowledgeRadiomics models may be used for the preoperative prediction of the pathological classification of TETs.
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Project description:PurposeThe aim of this study was to evaluate racial/ethnic disparities in follow-up adherence for incidental pulmonary nodules (IPNs) using a cascade-of-care framework, representing the multistage pathway from IPN diagnosis to timely follow-up adherence.MethodsA cohort of 1,562 patients diagnosed with IPNs requiring follow-up in a tertiary health care system in 2016 were retrospectively identified. Racial/ethnic disparities in follow-up adherence were examined by developing a multistep cascade-of-care model (provider communication, follow-up examination ordering and scheduling, adherence) to identify where patients were most likely to fall off the path toward adherence. Racial/ethnic adherence disparities were measured using descriptive statistics and multivariate modeling, controlling for sociodemographic, communication, and health characteristics.ResultsAmong 1,562 patients whose IPNs required follow-up, unadjusted results showed that nonwhite patients were less likely to meet each step on the cascade than White patients: for provider-patient IPN communication, 55% among Black patients and 80% among White patients; for follow-up ordering and scheduling, 42% and 41% among Black patients and 66% and 64% among White patients; and for timely adherence, 29% among Black patients and 54% among White patients. Adjusting for provider communication, sociodemographic, and health characteristics, Black patients had increased odds of never adhering to and delaying follow-up compared with White patients (odds ratios, 1.30 [95% confidence interval, 0.90-1.89] and 2.51 [95% confidence interval, 1.54-4.09], respectively).ConclusionsThese findings demonstrate substantial racial/ethnic disparities in IPN follow-up adherence that persist after adjusting for multiple characteristics. The cascade of care demonstrates where on the adherence pathway patients are at risk for falling off, enabling specific targets for health policy and clinical interventions. Radiologists can play a key role in improving IPN follow-up via increased patient care involvement.
| S-EPMC7655670 | biostudies-literature
Project description:PurposeTo evaluate whether quantitative [18F]FDG-PET/CT assessment, including radiomic analysis of [18F]FDG-positive thyroid nodules, improved the preoperative differentiation of indeterminate thyroid nodules of non-Hürthle cell and Hürthle cell cytology.MethodsProspectively included patients with a Bethesda III or IV thyroid nodule underwent [18F]FDG-PET/CT imaging. Receiver operating characteristic (ROC) curve analysis was performed for standardised uptake values (SUV) and SUV-ratios, including assessment of SUV cut-offs at which a malignant/borderline neoplasm was reliably ruled out (≥ 95% sensitivity). [18F]FDG-positive scans were included in radiomic analysis. After segmentation at 50% of SUVpeak, 107 radiomic features were extracted from [18F]FDG-PET and low-dose CT images. Elastic net regression classifiers were trained in a 20-times repeated random split. Dimensionality reduction was incorporated into the splits. Predictive performance of radiomics was presented as mean area under the ROC curve (AUC) across the test sets.ResultsOf 123 included patients, 84 (68%) index nodules were visually [18F]FDG-positive. The malignant/borderline rate was 27% (33/123). SUV-metrices showed AUCs ranging from 0.705 (95% CI, 0.601-0.810) to 0.729 (0.633-0.824), 0.708 (0.580-0.835) to 0.757 (0.650-0.864), and 0.533 (0.320-0.747) to 0.700 (0.502-0.898) in all (n = 123), non-Hürthle (n = 94), and Hürthle cell (n = 29) nodules, respectively. At SUVmax, SUVpeak, SUVmax-ratio, and SUVpeak-ratio cut-offs of 2.1 g/mL, 1.6 g/mL, 1.2, and 0.9, respectively, sensitivity of [18F]FDG-PET/CT was 95.8% (95% CI, 78.9-99.9%) in non-Hürthle cell nodules. In Hürthle cell nodules, cut-offs of 5.2 g/mL, 4.7 g/mL, 3.4, and 2.8, respectively, resulted in 100% sensitivity (95% CI, 66.4-100%). Radiomic analysis of 84 (68%) [18F]FDG-positive nodules showed a mean test set AUC of 0.445 (95% CI, 0.290-0.600) for the PET model.ConclusionQuantitative [18F]FDG-PET/CT assessment ruled out malignancy in indeterminate thyroid nodules. Distinctive, higher SUV cut-offs should be applied in Hürthle cell nodules to optimize rule-out ability. Radiomic analysis did not contribute to the additional differentiation of [18F]FDG-positive nodules.Trial registration numberThis trial is registered with ClinicalTrials.gov: NCT02208544 (5 August 2014), https://clinicaltrials.gov/ct2/show/NCT02208544 .
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