| Chart 1 Comparisons of ACR TI-RADS,ATA Guidelines,Kwak TI-RADS,and KTA/KSTh R Guidelines in Malignancy Risk Stratification of Thyroid NodulesObjective To compare the diagnostic performance of Thyroid Imaging Reporting and Data Systems proposed by American College of Radiology(ACR TI-RADS),American Thyroid Association(ATA)guidelines,TI-RADS proposed by Kwak(Kwak TI-RADS),and Korean Thyroid Association/Korean Society of Thyroid Radiology(KTA/KSTh R)guidelines for malignancy risk stratification of thyroid nodules.Methods The study of this chart included 1271 thyroid nodules confirmed by cytological or/and surgical pathological results,of which 535 were benign and 736 were malignant.All nodules were divided into two subgroups according to their maximum diameter: < 10 mm group and ? 10 mm group.Ultrasound images of these thyroid nodules were retrospectively reviewed and categorized according to ACR TI-RADS,ATA guidelines,Kwak TI-RADS and KTA/KSTh R guidelines.The significant predictors and risk scores(RSs)of malignant tumors in suspected ultrasound signs were analyzed.The area under receiver operating characteristic curve(AUC),sensitivity,specificity,Youden index,and accuracy of four thyroid ultrasound classifications for all nodules were compared.Results After multivariate analysis,among the suspicious ultrasound images features,the most significant independent predictor for malignancy was hypoechogenicity/marked hypoechogenicity(OR: 9.37,95% CI: 5.40-16.26),followed by isthmus position(OR:7.40,95% CI:2.47-22.16),solid component(OR:7.39,95%CI:1.70-32.05),microcalcification(OR:5.29,95% CI:3.40-8.25),microlobulated/irregular(OR:4.34,95% CI:3.05-6.16),taller than wide(OR:2.27,95% CI:1.91-2.71)(all P <0.001).The risk score(RS)for malignant tumors was: RS = 2.2 ×(if hypoechogenicity/marked hypoechogenicity)+ 2.0 ×(if solid component)+ 2.0 ×(if isthmus position)+ 1.7 ×(if microcalcification)+ 1.6 ×(if microlobulated/ irregular margin)+ 0.8 ×(if taller than wide).The diagnostic efficacies of the four ultrasound classification systems for ? 10 mm nodules were better than those of < 10 mm nodules(all P <0.05).For all nodules and two subgroups(i.e.nodules < 10 mm group and nodules ?10 mm group),ACR TI-RADS demonstrated higher specificities(all P< 0.05)and lower sensitivities(all P < 0.001)than the other classification systems.In the all nodules group and the nodules < 10 mm group,ACR TI-RADS and Kwak TI-RADS had higher AUC than the other classification systems(all P < 0.01).Conclusions ACR TI-RADS,ATA guidelines,Kwak TI-RADS and KTA/KSTh R guidelines have good diagnostic efficiency in differentiating thyroid nodules,especially for ? 10 mm nodules.ACR TI-RADS and Kwak TI-RADS have better diagnostic performance than ATA guidelines and KTA/KSTh R guidelines in the all nodules group and the nodules < 10 mm group.Chart 2 Comparisons of the Unnecessary Biopsy Rates of the recommended FNA of ACR TI-RADS,ATA Guidelines,Kwak TI-RADS and KTA/KSTh R GuidelinesObjective To compare the unnecessary biopsy rates of the recommended FNA(Fine Needle Aspiration)of ACR TI-RADS,ATA guidelines,Kwak TI-RADS and KTA/KSTh R guidelines when assessing thyroid nodules.The variation of unnecessary biopsy rates in different ultrasound classification systems with changing in nodule size threshold of the recommended FNA were observed.Methods The study of this chart included 638 thyroid nodules with maximum diameter ? 10 mm confirmed by cytological or/and surgical pathological results.The malignancy rates of recommending biopsy nodules,the recommended biopsy rates of malignant nodules and the unnecessary biopsy rates of the recommended FNA of ACR TI-RADS,ATA guidelines,Kwak TI-RADS and KTA/KSTh R guidelines were calculated.The unnecessary biopsy rates of the recommended FNA of ATA guidelines,Kwak TI-RADS and KTA/KSTh R guidelines were compared with that of ACR TI-RADS.In addition to high suspected of ATA guidelines and KTA/KSTh R guidelines and the 5 and 4c of Kwak TI-RADS,nodule sizes of recommending FNA of the other levels of the three ultrasound classification systems were gradually enlarged to establish new recommending FNA models.The malignancy rates of recommending biopsy nodules,the recommending biopsy rates of malignant nodules and the unnecessary biopsy rates under the new models were calculated and compared with those of ACR TI-RADS.The optimal threshold of nodule size for the recommending FNA at each level in the ultrasound classification systems.Results For all thyroid nodules,the unnecessary biopsy rates of the recommended FNA were 24.1%(87/361),46.5%(264/568),40.5%(264/511),47.9%(279/583)for ACR TI-RADS,ATA guidelines,Kwak TI-RADS and KTA/KSTh R guidelines,respectively,and that of ACR TI-RADS was lower than that of ATA guidelines,Kwak TI-RADS and KTA/KSTh R guidelines.For thyroid nodules with ? 20 mm,the unnecessary biopsy rate of the recommended FNA of ACR TI-RADS and Kwak TI-RADS was about 60%,that of ATA guidelines and KTA/KSTh R guidelines was nearly 80%,and that of each ultrasound classification system was higher than that of < 20 mm nodules(all P < 0.05).when nodule sizes threshold of the recommending FNA of ATA guidelines,Kwak TI-RADS,and KTA/KSTh R guidelines were increased gradually,the unnecessary biopsy rates decreased gradually.The nodule size optimum thresholds of recommending FNA were as follows: ATA guidelines High Suspicion ? 10 mm,Intermediate Suspicion ? 15 mm,Low Suspicion ? 25 mm,Very Low Suspicion without FNA,Kwak TI-RADS 5 ? 10 mm,4c ? 10 mm,4b ? 15 mm,4a ? 15 mm,KTA/KSTh R guidelines High Suspicion ?10 mm,Intermediate Suspicion ? 15 mm,Low Suspicion ? 25 mm,Benign without FNA.Conclusions The unnecessary biopsy rates of the recommended FNA of ATA,Kwak TI-RADS and KTA/KSTh R guidelines are higher than that of ACR TI-RADS,and are influenced by the nodule size threshold of recommending FNA.Considering the current problem of overdiagnosis of thyroid nodules,ACR TI-RADS is more clinically worthy of application in recommending FNA,especially for larger thyroid nodules(? 20 mm).The nodule size thresholds of recommending FNA of ATA guidelines,Kwak TI-RADS,and KTA/KSTh R guidelines may consider to increase appropriately.Chart 3 The Value of SWE,FNA and BRAF Gene Detection in ACR TI-RADS4 and 5 Thyroid NodulesObjective To study the diagnostic value of SWE(shear wave elastography),FNA(ultrasound-guided fine needle aspiration)and BRAF gene detection(BRAFV600E gene mutation detection)in ACR TI-RADS 4 and 5 thyroid nodules.Methods The diagnostic efficacy of SWE,FNA-alone and FNA combination with BRAF gene detection in ACR TI-RADS 4 and 5 thyroid nodules confirmed by operation and pathology were analyzed,and the differences between them were compared,retrospectively.The ROC curve was drawn to determine the best cut-off value of SWE Emax.Thyroid nodules were divided into the SWE negative group and the SWE positive group according to the best cut-off value.The differences of diagnostic efficiency between the SWE negative group and the SWE positive group in FNA-alone and in combination with BRAF gene detection were analyzed.Results The ROC curve showed that the best cut-off value of SWE Emax was40.9kpa,and the area under ROC curve(AUC)was 0.847(0.805~0.889).SWE diagnosed 166 benign and 294 malignant thyroid nodules.The sensitivity,specificity and accuracy were 76.3%(270/354),77.4%(82/106)and 76.5%(352/460),respectively.FNA-alone diagnosed 106 benign nodules,148 intermediate ones and 206 malignant ones.The sensitivity,specificity and accuracy were 58.2%(206/354),90.6%(96/106)and 67.8(312/460),respectively.FNA combination with BRAF gene detection diagnosed 98 benign nodules,24 intermediate ones and 338 malignant ones.The sensitivity,specificity and accuracy were 95.5%(338/354),90.6%(96/106)and94.3%(434/460),respectively.In the SWE negative group(SWE Emax < 40.9 k Pa),there were 82 cases of benign and 84 cases of malignant confirmed by operation and pathology.The diagnostic accuracy of FNA-alone and FNA combination with BRAF gene detection were 67.5%(112/166)and 90.4%(150/166),respectively.In the SWE positive group(SWE Emax ? 40.9 k Pa),there were 24 cases of benign and 270 cases of malignant confirmed by operation and pathology.The diagnostic accuracy of FNA-alone and FNA combination with BRAF gene detection was 64.6%(190/294)and 96.6%(284/294),respectively.In the SWE negative group and the SWE positive group,there was no significant difference in the diagnostic accuracy of FNA-alone(x2 = 0.38,P = 0.537),but there was a significant difference in the diagnostic accuracy of FNA combination with BRAF gene detection(x2 = 7.74,P = 0.005).After combination BRAF gene detection,the diagnostic accuracy of the SWE negative group and the SWE positive group increased by 22.9%(38/166)and 32.0%(94/294),respectively,with statistically significant difference(x2 = 4.276,P = 0.039).Conclusions For ACR TI-RADS 4 and 5 thyroid nodules,SWE and FNA have high diagnostic efficiency.FNA combination with BRAF gene detection further improves the diagnostic sensitivity and accuracy of FNA,especially for the SWE positive nodules. |
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