Risk for malignancy of thyroid nodules as assessed by sonographic criteria: the need for biopsy.

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.     

Sonographic diagnosis of thyroid nodules: correlation with the results of sonographically guided fine-needle aspiration biopsy

PURPOSE: To assess the reliability of sonography in differentiating benign from malignant thyroid nodules and selecting lesions for fine-needle aspiration (FNA). METHODS: During a 2-year period, the following 7 sonographic parameters were assessed in 129 patients with thyroid nodules: size, number, echogenicity, echotexure, margin regularity, presence of calcifications, and presence of a hypoechoic rim. Sonographically guided FNA was performed on thyroid nodules 5 mm in diameter. Out of 184 FNAs, we obtained 168 specimens adequate for cytologic analysis and 16 (9%) nondiagnostic specimens. RESULTS: FNA diagnoses included 150 (89%) benign and 18 (11%) malignant nodules. Among 53 solitary nodules, 11 were carcinomas and 42 were benign (p < 0.01). The mean size of the carcinomas was 28 +/- 12 mm versus 18 +/- 10 mm for benign nodules (p < 0.01). The following sonographic features were significantly associated with malignancy: hypoechogenicity, irregular margins, calcifications, and absence of a hypoechoic rim. Differences in echotexure between malignant and benign nodules were not statistically significant. CONCLUSION: Sonographically guided FNA should be performed on thyroid nodules 5 mm in diameter with sonographic characteristics that suggest malignancy.     

Can Color Doppler Sonography Aid in the Prediction of Malignancy of Thyroid Nodules?

OBJECTIVE: To determine whether color Doppler interrogation of a thyroid nodule can aid in the prediction of malignancy. METHODS: We obtained color Doppler images of thyroid nodules undergoing sonographically guided fine-needle aspiration. The color Doppler appearance of each nodule was graded from 0 for no visible flow through 4 for extensive internal flow. The size, sonographic appearance, results of fine-needle aspiration, and surgical pathologic findings, if available, were recorded for each nodule. RESULTS: There were 254 nodules sampled, of which 32 were malignant (all confirmed at surgery) and 177 were benign. Fourteen (43.8%) of the 32 malignant nodules were color type 4, compared with only 26 (14.7%) of the 177 benign nodules (P = .0004, Fisher exact test). Thirteen (40.1%) of the 32 malignant nodules were solid, as were 18 (10.2%) of the 177 benign nodules (P = .006, Fisher exact test). Among solid nodules, the prevalence of malignancy was greater when the nodule was hypervascular (13 [41.9%] of 31) than when the color type was less than 4 (11 [14.7%] of 77; P = .004, Fisher exact test). CONCLUSIONS: Solid hypervascular thyroid nodules have a high likelihood of malignancy (nearly 42% in our series). The color characteristics of a thyroid nodule, however, cannot be used to exclude malignancy, because 14% of solid nonhypervascular nodules were malignant.     

Rates of malignancy in incidentally discovered thyroid nodules evaluated with sonography and fine-needle aspiration.

OBJECTIVE: The purpose of this study was to compare the rate of malignancy in thyroid nodules discovered incidentally on magnetic resonance imaging, computed tomography, and sonography with the rate of malignancy in nonincidentally discovered nodules. METHODS: All thyroid sonographic and fine-needle aspiration (FNA) procedures performed during a 6-month period were retrospectively reviewed. Study indications were categorized as incidental (thyroid nodules found on magnetic resonance imaging, computed tomography, or sonography performed for nonthyroid indications) or nonincidental (studies prompted by abnormal physical examination findings or laboratory values or signs or symptoms suggestive of thyroid disease). Rates of malignancy in patients with incidentally discovered nodules were compared with rates in patients with nonincidental thyroid abnormalities by the Fisher exact test. RESULTS: Of 225 thyroid sonographic studies, 35 (16%) were performed for incidentally discovered thyroid nodules, and 190 (84%) were performed for evaluation of nonincidental thyroid abnormalities. A total of 21 patients (60%) in the incidental group and 90 patients (47%) in the nonincidental group underwent FNA. The rate of malignancy in nodules examined by biopsy in the incidental group was 17% compared with 3% in the nonincidental group (P = .020). Patient sex, multiplicity of nodules, nodule size, echo texture, and presence of calcifications did not differ significantly between the groups. The mean age of patients in the incidental group was significantly higher (61 versus 51 years; P = .007); however, advanced age was not associated with a greater rate of malignancy. CONCLUSIONS: This study identified an unexpectedly high rate of malignancy in incidentally discovered thyroid nodules, suggesting that incidentally discovered thyroid nodules should be evaluated with follow-up thyroid sonography and FNA.     

Differentiation of Thyroid Nodules With Macrocalcifications

Objective. The purpose of this study was to determine which types of macrocalcifications are associated with thyroid carcinoma and to assess the role of other suspicious sonographic findings in thyroid nodules with macrocalcifications. Methods. Our Institutional Review Board approved this retrospective study, and informed consent was not required. We reviewed sonographic findings of thyroid nodules in 722 patients that underwent thyroid surgery in our institution between March 2006 and August 2006. Sonographic results were grouped into 3 types of macrocalcifications. Each lesion was evaluated on the basis of other suspicious sonographic criteria, including marked hypoechogenicity, irregular or microlobulated margins, and a taller‐than‐wide shape. Sensitivity and specificity based on sonographic criteria were calculated and compared among the subtypes of macrocalcifications. Results. One hundred seventy‐four nodules showed macrocalcifications; 116 were malignant, and 58 were benign. Among the macrocalcification categories, solitary calcifications were more common in benign thyroid lesions, whereas coarse calcifications not otherwise specified were more common in malignant lesions (P < .05). Although the risk of malignancy was 17.2% in cases with no suspicious sonographic findings, the risk of malignancy was up to 82.8% in cases with at least 1 of the sonographic criteria (P < .05). On the basis of the suspicious sonographic criteria, the overall sensitivity was 82.8%. There was no statistically significant difference in sensitivity among the macrocalcification subtypes (P > .05). Conclusions. Suspicious sonographic features such as marked hypoechogenicity, irregular or microlobulated margins, and a taller‐than‐wide shape can play important roles in differentiating benign and malignant thyroid nodules with macrocalcifications.     

Intraobserver and interobserver agreement of grayscale typical ultrasonographic patterns for the diagnosis of ovarian cancer

The purpose of this study was to evaluate the intraobserver and interobserver agreement for identifying ovarian malignancy using typical grayscale ultrasonographic patterns. Digitally stored grayscale sonographic images from a random sample of 98 women with an adnexal mass submitted to surgery after a grayscale transvaginal sonography were evaluated by five different examiners with different degrees of experience in three European university departments of obstetrics and gynecology. Masses in which the echo features were highly characteristic of a benign pathology were categorized as benign. Any cystic mass containing excrescences, thick septations, multiple irregular septations or solid component in which the echo architecture was not highly suggestive of benign histology was categorized as malignant. Intraobserver and interobserver agreement according to the level of experience were assessed by calculating the kappa index. Of the 98 cases randomly selected, 28 (29%) were malignant masses and 70 (71%) were benign. Intraobserver agreement was good or very good for all examiners with different degrees of experience (kappa = 0.72 to 1). Interobserver agreement was good for all expert operators (kappa = 0.69 to 0.75). Interobserver agreement between experts and highly experienced operators was moderate or good (kappa = 0.51 to 0.63). Interobserver agreement between the moderately experienced operator and experts was fair to moderate (kappa = 0.29 to 0.46). Interobserver agreement between moderately and highly experienced operators was fair (kappa = 0.33). Our results indicate that ultrasonographic malignant patterns are reproducible, even in moderately experienced examiners, although more experience is associated with better interobserver agreement.     

Sonographic Differentiation of Thyroid Nodules With Eggshell Calcifications

Objective. The purpose of this study was to assess the role of known suspicious sonographic findings and to find other additional sonographic findings to differentiate benign and malignant thyroid nodules with “eggshell” calcifications. Methods. Our Institutional Review Board approved this retrospective study, and informed consent was not required. We reviewed sonographic findings of thyroid nodules in 795 patients who underwent thyroid surgery in our institution between August 2006 and February 2007. Ninety‐three thyroid nodules with eggshell calcifications in 92 patients were included in this study. Each lesion was evaluated for known suspicious sonographic criteria, including marked hypoechogenicity, irregular or microlobulated margins, and a taller‐than‐wide shape, as well as 2 additional sonographic findings: a hypoechoic halo and disruption of eggshell calcifications (halo and disrupted calcification rim). The sensitivity and specificity based on the sonographic criteria were calculated and compared among the 2 types of criteria. Results. Among the 93 thyroid nodules, 59 were malignant and 34 were benign. The halo and disrupted calcification rim showed higher sensitivity (62.7% and 76.3%, respectively) than any of the known suspicious sonographic criteria (40.7%, 35.6%, and 55.9%). The combination of both the halo and the disrupted calcification rim showed significantly higher sensitivity (93.2%) than the combination of the known suspicious sonographic criteria (78%; P < .05), although both had the same specificity (64.7%). Conclusions. In thyroid nodules with eggshell calcifications but no other calcifications, the findings of a peripheral halo and disruption of the eggshell calcifications may be more useful sonographic predictors of malignancy than hypoechogenicity, microlobulated margins, and a taller‐than‐wide shape.     

Intranodular Vascularity May Be Useful in Predicting Malignancy in Thyroid Nodules with the Intermediate Suspicion Pattern of the 2015 American Thyroid Association Guidelines

The aim of the study described here was to determine whether vascularity patterns on Doppler ultrasonography (US) differentiate benign and malignant thyroid nodules with the intermediate suspicion pattern based on the 2015 American Thyroid Association guidelines. A total of 411 benign or malignant thyroid nodules from 406 patients with intermediate-suspicion US features were retrospectively collected. Univariate and multivariate logistic regression analyses with the generalized estimating equation were used to identify factors predicting malignancy, and odds ratios with 95% confidence intervals were calculated. The vascularity patterns significantly differed between the benign (353 of 411, 85.9%) and malignant (58 of 411, 14.1%) nodules (p = 0.005). Only intranodular vascularity was significantly associated with malignancy on univariate analysis (p = 0.006) and was an independent predictor of malignancy on multivariate analysis (p = 0.004). In conclusion, intranodular vascularity on Doppler US may be useful for predicting malignancy in thyroid nodules with the intermediate-suspicion pattern.     

甲状腺木乃伊结节的常规超声、声触诊组织量化成像及超声造影表现

目的探讨常规超声、声触诊组织量化成像(VTIQ)及超声造影(CEUS)在鉴别甲状腺木乃伊结节中的临床价值。方法选取23例甲状腺木乃伊良性结节患者(木乃伊结节组)和17例甲状腺乳头状癌患者(PTCs组),应用常规超声、VTIQ及CEUS获取结节的大小、形态、边界、回声、钙化、声影、黑白双层晕环征、血流、剪切波速度(SWV)及CEUS各参数,并进行比较分析,绘制受试者工作特征(ROC)曲线获得SWV的截断值,计算曲线下面积。采用Logistic回归分析获得木乃伊结节的独立影响因素。结果木乃伊结节组与PTCs组血流信号、SWV值、增强模式、峰值强度比<1、曲线下面积比<1比较差异均有统计学意义(均P<0.05),其余特征比较差异均无统计学意义。ROC曲线分析显示以SWV值3.69 m/s为截断值,其诊断甲状腺木乃伊结节的敏感性82.4%,特异性52.2%,曲线下面积0.673。Logistic回归分析显示黑白双层晕环征和峰值强度比<1是甲状腺木乃伊结节的独立影响因素(OR=27.589、40.877,P=0.012、0.007)。结论熟悉和掌握木乃伊结节的超声特征,并结合既往超声检查的结果,有助于鉴别甲状腺木乃伊结节。常规超声、VTIQ及CEUS对甲状腺木乃伊结节的鉴别诊断均具有重要价值。     

Quantitative analysis of tumor vascularity in benign and malignant solid thyroid nodules.

OBJECTIVE: The purpose of our study was to analyze the accuracy of quantitative analysis of tumor vascularity on power Doppler sonograms in differentiating malignant and benign solid thyroid nodules using tumor histologic evaluation as the reference standard. Methods. Eighty-six solid thyroid tumors (46 malignant and 40 benign) in 56 consecutive patients (mean age +/- SD, 53.1 +/- 11.6 years; 12 male and 44 female) referred for the surgical treatment were included in our study. Visual and qualitative analysis of patterns of nodule vascularity was performed for all tumors. Quantification of the power Doppler sonograms was performed with normalized and weighted vascular indices (VIs). The accuracy of sonographic criteria for thyroid cancer was evaluated with univariate analysis. Results. Among benign thyroid tumors, there was a statistically significant increase in the levels of intranodular vascularization with an increase in tumor size (P < .001). In all tumors, increased intranodular vascularization showed 65.2% sensitivity, 52.5% specificity, and 58.9% overall accuracy in differentiation between benign and malignant thyroid lesions. In tumors smaller than 2 cm, it had 65.5% sensitivity, 85.7% specificity, and 72.1% overall accuracy. Quantitative analysis of tumor vascularity significantly overperformed visual analysis of power Doppler patterns (P < .05). Among thyroid lesions with diameters of less than 2 cm, a normalized VI of greater than 0.14 had 72.4% sensitivity, 100% specificity, and 86.2% overall accuracy. A weighted VI of greater than 0.24 showed compatible results, with 69.0% sensitivity, 100% specificity, and 84.5% overall accuracy. CONCLUSIONS: Our study indicates that in small thyroid nodules, quantitative analysis of tumor vascularity has benefits over visual inspection and can be useful in differentiation between benign and malignant thyroid tumors.     

High diagnostic accuracy and interobserver reliability of real-time elastography in the evaluation of thyroid nodules

Elastography is a new diagnostic tool in the evaluation of thyroid nodules. Aim of the study was to evaluate the accuracy and reliability of elastography in discriminating thyroid lesions and the interobserver variability. One hundred thirty-two nodules in 115 patients selected for thyroid surgery underwent conventional ultrasound and elastographic evaluation. Elastography score was divided in four categories (totally elastic nodule, mainly elastic, mainly rigid and totally rigid) according to signal distribution. Three independent operators conducted the study. Final histology showed 92 benign nodules and 40 malignant. On elastography, 77/92 benign nodules were classified as score 1 or 2 and 34/40 malignant nodules as score 3 or 4 (sensitivity 85%, specificity 83.7%, positive predictive value [PPV] 69.3%, negative predictive value [NPV] 92.7%). Rate of concordance between operators was good (K test: 0.64, p < 0.0001). Simple to use, with good interobserver agreement, elastography has all the requisites to become an important complement of conventional US examination in the near future.     

Ultrasound grading of thyroid nodules using the BTA U-scoring guidelines – Is there evidence of intra-and interobserver variability?

IntroductionU-score ultrasound classification (graded U1-U5) is widely used to grade thyroid nodules based on benign and malignant sonographic features. It is well established that ultrasound is an operator-dependent imaging modality and thus more susceptible to subjective variances between operators when using imaging-based scoring systems. We aimed to assess whether there is any intra- or interobserver variability when U-scoring thyroid nodules and whether previous thyroid ultrasound experience has an effect on this variability.MethodsA total of 14 ultrasound operators were identified (five experienced thyroid operators, five with intermediate experience and four with no experience) and were asked to U-score images from 20 thyroid cases shown as a single projection, with and without Doppler flow. The cases were subsequently rescored by the 14 operators after six weeks. The first and second round U-scores for the three operator groups were then analysed using Fleiss’ kappa to assess interobserver variability and Cochran’s Q test to determine any intraobserver variability.ResultsWe found no significant interobserver variability on combined assessment of all operators with fair agreement in round 1 (Fleiss’ kappa = 0.30, p <0.0001) and slight agreement in round 2 (Fleiss’ kappa = 0.19, p < 0.0001). Cochran’s Q test revealed no significant intraobserver variability in all 14 operators between round 1 and round 2 (all p>0.05).ConclusionsWe found no statistically significant inter- or intraobserver variability in the U-scoring of thyroid nodules between all participants reinforcing the validity of this scoring method in clinical practice, allaying concerns regarding potential subjective biases in reporting.     

Sonographic Features of the Follicular Variant of Papillary Thyroid Carcinoma

Objective. The purpose of this study was to evaluate the sonographic findings of the follicular variant of papillary thyroid carcinoma (FVPTC) and to assess the role of preoperative fine‐needle aspiration biopsy (FNAB). Methods. The sonographic findings of 27 thyroid nodules in 26 patients (2 male and 24 female; mean age, 45 years) with surgically proven FVPTC were reviewed retrospectively. Findings were categorized according to the echogenicity, margin, shape, and presence of microcalcifications. Malignant findings included marked hypoechogenicity, irregular or microlobulated margins, a taller‐than‐wide shape, and microcalcifications. Thyroid nodules with a single malignant finding as described above were classified as malignant. All patients underwent sonographically guided FNAB, and the sensitivity of the cytologic results was calculated. Results. Lesion sizes varied from 3 to 34 mm (mean, 15.2 mm), and lesions were most commonly solid (23 [85.2%]), hypoechoic (14 [51.9%]), and oval (17 [63%]) with well‐defined margins (14 [51.9%]) and no microcalcifications (23 [85.2%]). Eighteen lesions (66.7%) were correctly classified as malignant, whereas 9 (33.3%) were classified as benign on the basis of sonographic criteria. Twenty‐four samples were adequate for cytologic examination, and 3 were inadequate. Twenty‐one of 24 diagnostic cytologic results (87.5%) were suspicious for papillary carcinoma (5 of 21 [20.8%]) or malignant (16 of 21 [66.7%]), whereas 3 lesions (12.5%) had benign results. The sensitivity of FNAB was 77.8% (21 of 27). Conclusions. The follicular variant of papillary thyroid carcinoma tends to have relatively benign sonographic features, such as hypoechogenicity, well‐defined margins, an oval shape, and no microcalcifications, but most lesions were correctly classified as malignant by both sonography and FNAB. The possibility of FVPTC should be considered when thyroid nodules with a relatively benign sonographic appearance have suspicious or malignant FNAB results     

Ultrasonic evaluation of benign and malignant nodules in echographically multinodular thyroids

In 165 patients with ultrasound findings of multinodular thyroids in whom thyroid resection was performed, sonographic features and pathohistologic findings of removed nodules were analyzed. Of 426 nodules removed, 70 were carcinomas and 356 benign. Carcinomas are more often hypoechogenic (p < 0.01) and contain nodular calcifications (p < 0.01), while benign nodules are more often iso-hyperechogenic (p < 0.01), showing intranodular cystic degenerative changes (p < 0.01), showing intranodular cystic degenerative changes (p < 0.01) and perinodular hypoechogenic rim (p < 0.01). Mean diameter of carcinomatous nodules is lwoer than in benign nodules (p = 0.022). The relative proportion of malignant nodules is highest in the upper halves of thyroid lobes (p < 0.01). Although certain sonographic signs increase the likelihood of a given lesion being malignant or benign, the lack of absolute specificity in the ultrasound evaluation of thyroid nodules was confirmed. © 1994 John Wiley & Sons, Inc.     

Reproducibility of endometrial vascular patterns in endometrial disease as assessed by transvaginal power Doppler sonography in women with postmenopausal bleeding.

OBJECTIVE: The purpose of this study was to assess the intraobserver and interobserver agreement for identifying different endometrial vascular patterns using power Doppler sonography in women with postmenopausal bleeding and a thickened endometrium. METHODS: Digitally stored sonographic images from a random sample of 65 patients with postmenopausal bleeding and a thick endometrium (>5 mm) on B-mode sonography and evaluated by transvaginal power Doppler sonography for assessment of endometrial blood flow mapping were evaluated by 5 different examiners with different levels of expertise in Doppler sonography. Intraobserver and interobserver agreement according to the level of experience were assessed by calculating the kappa index. RESULTS: Intraobserver agreement was good or very good for all experienced examiners (kappa = 0.78-0.96) and moderate (kappa = 0.52) for the inexperienced examiner. Interobserver agreement was moderate among all experienced examiners (kappa = 0.45-0.80). The inexperienced examiner showed fair or moderate interobserver agreement (kappa = 0.32-0.45). CONCLUSIONS: Our results indicate that endometrial blood flow mapping using transvaginal power Doppler sonography is acceptably reproducible. More experience was associated with better intraobserver and interobserver agreement.     

Quantitative Evaluation of Vascularity Using 2-D Power Doppler Ultrasonography May Not Identify Malignancy of the Thyroid

The purpose of this study was to evaluate the usefulness of a quantitative vascular index in predicting thyroid malignancy. A total of 1309 thyroid nodules in 1257 patients (mean age: 50.2 y, range: 18–83 y) were included. The vascularity pattern and vascular index (VI) measured by quantification software for each nodule were obtained from 2-D power Doppler ultrasonography (US). Gray-scale US + vascularity pattern was compared with gray-scale US + VI with respect to diagnostic performance. Of the 1309 thyroid nodules, 927 (70.8%) were benign and 382 (29.2%) were malignant. The area under the receiver operating characteristics curve (A_z) for gray-scale US (0.82) was significantly higher than that for US combined with vascularity pattern (0.77) or VI (0.70, all p < 0.001). Quantified VIs were higher in benign nodules, but did not improve the performance of 2-D US in diagnosing thyroid malignancy.     

Radiologic and pathologic findings of nonpalpable thyroid carcinomas detected by ultrasonography in a medical screening center.

OBJECTIVE: The purpose of this study was to investigate the ultrasonographic and pathologic findings of nonpalpable thyroid carcinomas and reliable guidelines for fine-needle aspiration (FNA). METHODS: Our study was approved by our Institutional Review Board, and written informed consent was waived. Between April 2004 and June 2006, screening ultrasonography was performed for 16,352 self-referred patients in the health care center. Among 1325 nonpalpable thyroid nodules in 1009 patients, pathologic results of FNA revealed 823 benign, 154 indeterminate, 198 nondiagnostic, and 150 malignant nodules. Fifty-eight malignant thyroid nodules (39 microcarcionomas and 19 carcinomas >1 cm, confirmed by both FNA and thyroidectomy) in 55 patients and 82 benign nodules (confirmed by both FNA and follow-up over 2 years) in 75 patients were included for the analysis. Three radiologists retrospectively analyzed the ultrasonographic features of these nonpalpable thyroid nodules for echogenicity, shape, margin, calcification, degree of cystic changes, and size. We compared the radiologic and pathologic findings between microcarcinomas and carcinomas larger than 1 cm for extra-capsular invasion, lymph node metastasis, bilaterality, and multicentricity using univariate analysis. RESULTS: Marked hypoechogenicity, an irregular shape, a taller-than-wide shape, a well-defined spiculated margin, microcalcification, and an entirely solid nature were significant predictors for malignancy (P < .05), whereas a cutoff value of 1 cm in the longest diameter was not significant (P = .184). However, extracapsular invasion (P = .024) and lymph node metastasis (P = .019) were observed more frequently in carcinomas larger than 1 cm (73.7% and 42.1%, respectively) than in microcarcinomas (38.5% and 12.8%). CONCLUSIONS: Ultrasonographic findings suggesting malignancy should be preferentially considered as indicators for FNA, regardless of size, in nonpalpable thyroid nodules. However, extracapsular invasion and lymph node metastasis are closely related to the size of the thyroid nodule.     

A New Marker for Diagnosis of Thyroid Papillary Cancer

Objective. The purpose of this study was to correlate the presence and patterns of distribution of B‐flow imaging (BFI) twinkling signs within thyroid nodules with the histologic evidence of microcalcifications and the results of the sonographically guided fine‐needle aspiration to establish their role in predicting the risk of malignancy. Methods. Between September 2006 and December 2007, 343 consecutive patients with 479 suspected nodules (maximum diameter >9 mm) were enrolled in this prospective study. Sonographic and BFI examinations were performed with a commercially available real‐time sonography system, and all patients also underwent a cytologic evaluation. Written informed consent was obtained from all patients. Patients with suspicious or malignant cytologic features underwent surgery. Results. On histologic examination, 66 of 479 nodules were malignant (59 papillary thyroid carcinoma, 1 Hürthle cell carcinoma, and 6 follicular carcinoma). All sonographic characteristics, which were potential predictors of thyroid malignancy (microcalcifications, hypoechogenicity, absence of a halo, and a predominantly solid composition), were found in different percentages in both histologically verified malignant and benign nodules. For BFI, pattern 3 (≥ 4 signs and distance >2 mm) was the most predictive factor for malignancy (specificity, 99.6%; sensitivity, 65.2%), whereas pattern 2 (≥ 4 signs and distance <2 mm) was a positive factor because it was detected only in benign lesions, with a positive predictive of 0. Conclusions. Our results indicate that BFI can overcome the limits of the traditional B‐mode and color Doppler sonographic features in the diagnosis of thyroid nodules. This technique provides maximum specificity levels both in the case of benign nodules with pattern 2 and in the case of malignant nodules with pattern 3.     

Thyrotoxic periodic paralysis: sonographic appearances of the thyroid

PURPOSE: The aim of the study was to describe the sonographic appearances of the thyroid in patients with thyrotoxic periodic paralysis (TPP). METHODS: Of the 25 patients diagnosed with TPP between January 1, 1998, and December 31, 2001, as identified by a search of our patient database, 13 had undergone sonography of the thyroid. We retrospectively reviewed the clinical records and thyroid sonograms of these 13 patients. The sonograms were assessed subjectively for thyroid size, echogenicity, vascularity, and the presence of solid nodules and cysts. RESULTS: Sonography showed abnormality of the thyroid in all 13 patients. In 11 patients (85%), sonography showed widespread hypoechogenicity (compared with the muscle) whose distribution was diffuse (6 patients) or patchy (5 patients) and diffusely distributed areas of hypervascularity (type 1 pattern). All 11 of these patients had a clinical diagnosis of Graves' disease. One patient (8%) had multinodular goiter and enlargement of the thyroid with multiple heterogeneous solid nodules and cysts (type 2 pattern); the clinical diagnosis was toxic multinodal goiter. One patient (8%) had a combination of type 1 and type 2 patterns and a clinical diagnosis of Graves' disease. CONCLUSIONS: The sonographic abnormalities of the thyroid in patients with TPP reflect the common underlying causes of thyrotoxicosis in the general population. The sonographic appearances associated with Graves' disease (type 1 pattern) were the most common abnormality detected. No sonographic features specific to TPP were identified.