The Use of Demographic, Ultrasonographic and Scintigraphic Data in the Diagnostic Approach of Thyroid Nodules

Abstract

Introduction: Thyroid nodules are a common diagnostic challenge mainly because of the need to exclude thyroid malignancy. The aim of this study was to evaluate the usefulness of demographic, ultrasonographic and scintigraphic findings in differentiating benign from malignant thyroid lesions in patients presenting with thyroid nodules.

Materials and Methods: 941 patients, who presented with palpable thyroid nodules and underwent at least one fine-needle aspiration biopsy (FNAB), were retrospectively evaluated.

Results: The thyroid was assessed by ultrasonography (US) in 796 patients and by scintigraphy (SC) in 774 patients. The final diagnostic outcome was established after surgery (n=183) or after a minimum of one-year clinical follow-up period. Higher rates of malignancy were observed in male gender (p<0.001), in patients presenting with a solitary nodule in US (p<0.001), in nodules with maximum diameter ≥4.5 cm in US (p=0.024) and in nodules detectable by SC (p=0.006). There were no statistical differences in the rates of malignancy among cystic, solid or mixed nodules in US or among “hot”, “warm” or “cold” nodules in SC.

Conclusions: Male gender, solitary nodule and nodule diameter ≥4.5 cm can serve as adjuncts to FNAB in predicting the risk of thyroid malignancy in patients presenting with thyroid nodules.

fine needle aspiration biopsy (FNAB) - multinodular goiter - thyroid malignancy - thyroid nodule - thyroid scintigraphy - thyroid ultrasonography

References

• 1 AACE, AME, Task Force on Thyroid Nodules . American Association of Clinical Endocrinologists and Associazione Medici Endocrinologi medical guidelines for clinical practice for the diagnosis and management of thyroid nodules.  Endocr Pract. 2006;  12 63-102
• 2 Abdel-Razzak M, Christie JH. Thyroid carcinoma in an autonomously functioning nodule.  J Nucl Med. 1979;  20 1001-1002
• 3 Belfiore A, La Rosa GL, La Porta GA, Giuffrida D, Milazzo G, Lupo L, Regalbuto C, Vigneri R. Cancer risk in patients with cold thyroid nodules: relevance of iodine intake, sex, age, and multinodularity.  Am J Med. 1992;  93 363-369
• 4 Carpi A, Mechanick JI, Nicolini A, Rubello D, Iervasi G, Bonazzi V, Giardino R. Thyroid nodule evaluation: what have we really learned from recent clinical guidelines?.  Biomed Pharmacother. 2006;  60 393-395
• 5 Castro MR, Gharib H. Continuing controversies in the management of thyroid nodules.  Ann Intern Med. 2005;  142 926-931
• 6 Cerise EJ, Randall S, Ochsner A. Carcinoma of the thyroid and nontoxic nodular goiter.  Surgery. 1952;  31 552-561
• 7 Chow LS, Gharib H, Goellner JR, Heerden JA van. Nondiagnostic thyroid fine-needle aspiration cytology: management dilemmas.  Thyroid. 2001;  11 1147-1151
• 8 Clark OH, Okerlund MD, Cavalieri RR, Greenspan FS. Diagnosis and treatment of thyroid, parathyroid, and thyroglossal duct cysts.  J Clin Endocrinol Metab. 1979;  48 983-988
• 9 Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL, Mandel SJ, Mazzaferri EL, MacIver B, Sherman SI, Tuttle RM. Management guidelines for patients with thyroid nodules and differentiated thyroid cancer.  Thyroid. 2006;  16 109-142
• 10 Crile Jr G. Treatment of thyroid cysts by aspiration.  Surgery. 1966;  59 210-212
• 11 los Santos ET de, Keyhani-Rofagha S, Cunningham JJ, Mazzaferri EL. Cystic thyroid nodules. The dilemma of malignant lesions.  Arch Intern Med. 1990;  150 1422-1427
• 12 dell’Erba L, Gerundini P, Caputo M, Bagnasco M. Association of hyperfunctioning thyroid adenoma with thyroid cancer presenting as “trapping only” nodule at 99mTcO4- scintigraphy.  J Endocrinol Invest. 2003;  26 1124-1127
• 13 Ezzat S, Sarti DA, Cain DR, Braunstein GD. Thyroid incidentalomas. Prevalence by palpation and ultrasonograhy.  Arch Intern Med. 1994;  154 1838-1840
• 14 Franklyn JA, Daykin J, Young J, Oates GD, Sheppard MC. Fine needle aspiration cytology in diffuse or multinodular goitre compared with solitary thyroid nodules.  BMJ. 1993;  307 240
• 15 Frates MC, Benson CB, Charboneau JW, Cibas ES, Clark OH, Coleman BG, Cronan JJ, Doubilet PM, Evans DB, Goellner JR, Hay ID, Hertzberg BS, Intenzo CM, Jeffrey RB, Langer JE, Larsen PR, Mandel SJ, Middleton WD, Reading CC, Sherman SI, Tessler FN. Management of thyroid nodules detected at US: Society of Radiologists in Ultrasound consensus conference statement.  Radiology. 2005;  237 794-800
• 16 Frates MC, Benson CB, Doubilet PM, Kunreuther E, Contreras M, Cibas ES, Orcutt J, Moore Jr FD, Larsen PR, Marqusee E, Alexander EK. Prevalence and distribution of carcinoma in patients with solitary and multiple thyroid nodules on sonography.  J Clin Endocrinol Metab. 2006;  91 3411-3417
• 17 Gharib H, Goellner JR. Fine-needle aspiration biopsy of the thyroid: an appraisal.  Ann Intern Med. 1993;  118 282-289
• 18 Giuffrida D, Gharib H. Controversies in the management of cold, hot, and occult thyroid nodules.  Am J Med. 1995;  99 642-650
• 19 Haber RS. Role of ultrasonography in the diagnosis and management of thyroid cancer.  Endocr Pract. 2000;  6 396-400
• 20 Hammer M, Wortsman J, Folse R. Cancer in cystic lesions of the thyroid.  Arch Surg. 1982;  117 1020-1023
• 21 Hegedus L. Thyroid ultrasound.  Endocrinol Metab Clin North Am. 2001;  30 339-360
• 22 Hegedus L, Bonnema SJ, Bennedbaek FN. Management of simple nodular goiter: current status and future perspectives.  Endocr Rev. 2003;  24 102-132
• 23 Hegedus L, Karstrup S. Ultrasonography in the evaluation of cold thyroid nodules.  Eur J Endocrinol. 1998;  138 30-31
• 24 Hoving J, Piers DA, Vermey A, Oosterhuis JW. Carcinoma in hyperfunctioning thyroid nodule in recurrent hyperthyroidism.  Eur J Nucl Med. 1981;  6 131-132
• 25 Iannuccilli JD, Cronan JJ, Monchik JM. Risk for malignancy of thyroid nodules as assessed by sonographic criteria: the need for biopsy.  J Ultrasound Med. 2004;  23 1455-1464
• 26 Izquierdo R, Arekat MR, Knudson PE, Kartun KF, Khurana K, Kort K, Numann PJ. Comparison of palpation-guided versus ultrasound-guided fine-needle aspiration biopsies of thyroid nodules in an outpatient endocrinology practice.  Endocr Pract. 2006;  12 609-614
• 27 Khan O, Ell PJ, Maclennan KA, Kurtz A, Williams ES. Thyroid carcinoma in an autonomously hyperfunctioning thyroid nodule.  Postgrad Med J. 1981;  57 172-175
• 28 Leenhardt L, Hejblum G, Franc B, Fediaevsky LD, Delbot T, Le GD, Menegaux F, Guillausseau C, Hoang C, Turpin G, Aurengo A. Indications and limits of ultrasound-guided cytology in the management of nonpalpable thyroid nodules.  J Clin Endocrinol Metab. 1999;  84 24-28
• 29 Levine RA. Something old and something new: a brief history of thyroid ultrasound technology.  Endocr Pract. 2004;  10 227-233
• 30 Lyshchik A, Moses R, Barnes SL, Higashi T, Asato R, Miga MI, Gore JC, Fleischer AC. Quantitative analysis of tumor vascularity in benign and malignant solid thyroid nodules.  J Ultrasound Med. 2007;  26 837-846
• 31 Ma MK, Ong GB. Cystic thyroid nodules.  Br J Surg. 1975;  62 205-206
• 32 Marqusee E, Benson CB, Frates MC, Doubilet PM, Larsen PR, Cibas ES, Mandel SJ. Usefulness of ultrasonography in the management of nodular thyroid disease.  Ann Intern Med. 2000;  133 696-700
• 33 Mazzaferri EL. Management of a solitary thyroid nodule.  N Engl J Med. 1993;  328 553-559
• 34 McHenry C, Smith M, Lawrence AM, Jarosz H, Paloyan E. Nodular thyroid disease in children and adolescents: a high incidence of carcinoma.  Am Surg. 1988;  54 444-447
• 35 Miller JM, Zafar SU, Karo JJ. The cystic thyroid nodule. Recognition and management.  Radiology. 1974;  110 257-261
• 36 Nelson RL, Wahner HW, Gorman CA. Rectilinear thyroid scanning as a predictor of malignancy.  Ann Intern Med. 1978;  88 41-44
• 37 Pacini F, Schlumberger M, Dralle H, Elisei R, Smit JW, Wiersinga W. European consensus for the management of patients with differentiated thyroid carcinoma of the follicular epithelium.  Eur J Endocrinol. 2006;  154 787-803
• 38 Polyzos SA, Kita M, Avramidis A. Thyroid nodules – Stepwise diagnosis and management.  Hormones (Athens). 2007;  6 101-119
• 39 Polyzos SA, Kita M, Efstathiadou Z, Poulakos P, Slavakis A, Sofianou D, Flaris N, Leontsini M, Kourtis A, Avramidis A. Serum thyrotropin concentration as a biochemical predictor of thyroid malignancy in patients presenting with thyroid nodules.  J Cancer Res Clin Oncol. 2008;  , (doi: 10.1007/s00432-008-0373-7)
• 40 Polyzos SA, Kita M, Goulis DG, Benos A, Flaris N, Leontsini M, Avramidis A. Epidemiologic analysis of thyroid fine needle aspiration biopsis over a period of 18 years (1987–2004).  Exp Clin Endocrinol Diabetes. 2008;  , (doi: 10.1055/s-2008-1058082)
• 41 Rago T, Vitti P, Chiovato L, Mazzeo S, De LA, Miccoli P, Viacava P, Bogazzi F, Martino E, Pinchera A. Role of conventional ultrasonography and color flow-doppler sonography in predicting malignancy in ‘cold’ thyroid nodules.  Eur J Endocrinol. 1998;  138 41-46
• 42 Reschini E, Catania A, Ferrari C, Bergonzi M, Paracchi A, Raineri P. Comparison of pertechnetate and radioiodine thyroid scintiscans in thyroid disease.  J Nucl Biol Med. 1993;  37 12-17
• 43 Reschini E, Ferrari C, Castellani M, Matheoud R, Paracchi A, Marotta G, Gerundini P. The trapping-only nodules of the thyroid gland: prevalence study.  Thyroid. 2006;  16 757-762
• 44 Rojeski MT, Gharib H. Nodular thyroid disease. Evaluation and management.  N Engl J Med. 1985;  313 428-436
• 45 Rosen IB, Provias JP, Walfish PG. Pathologic nature of cystic thyroid nodules selected for surgery by needle aspiration biopsy.  Surgery. 1986;  100 606-613
• 46 Sakorafas GH, Giotakis J, Stafyla V. Papillary thyroid microcarcinoma: a surgical perspective.  Cancer Treat Rev. 2005;  31 423-438
• 47 Schneider AB, Bekerman C, Leland J, Rosengarten J, Hyun H, Collins B, Shore-Freedman E, Gierlowski TC. Thyroid nodules in the follow-up of irradiated individuals: comparison of thyroid ultrasound with scanning and palpation.  J Clin Endocrinol Metab. 1997;  82 4020-4027
• 48 Solbiati L, Volterrani L, Rizzatto G, Bazzocchi M, Busilacci P, Candiani F, Ferrari F, Giuseppetti G, Maresca G, Mirk P. The thyroid gland with low uptake lesions: evaluation by ultrasound.  Radiology. 1985;  155 187-191
• 49 Tollin SR, Mery GM, Jelveh N, Fallon EF, Mikhail M, Blumenfeld W, Perlmutter S. The use of fine-needle aspiration biopsy under ultrasound guidance to assess the risk of malignancy in patients with a multinodular goiter.  Thyroid. 2000;  10 235-241
• 50 Tunbridge WM, Evered DC, Hall R, Appleton D, Brewis M, Clark F, Evans JG, Young E, Bird T, Smith PA. The spectrum of thyroid disease in a community: the Whickham survey.  Clin Endocrinol (Oxf). 1977;  7 481-493
• 51 Tuttle RM, Lemar H, Burch HB. Clinical features associated with an increased risk of thyroid malignancy in patients with follicular neoplasia by fine-needle aspiration.  Thyroid. 1998;  8 377-383
• 52 Vander JB, Gaston EA, Dawber TR. The significance of nontoxic thyroid nodules. Final report of a 15-year study of the incidence of thyroid malignancy.  Ann Intern Med. 1968;  69 537-540
• 53 Walfish PG, Hazani E, Strawbridge HT, Miskin M, Rosen IB. Combined ultrasound and needle aspiration cytology in the assessment and management of hypofunctioning thyroid nodule.  Ann Intern Med. 1977;  87 270-274
• 54 Yoon DY, Lee JW, Chang SK, Choi CS, Yun EJ, Seo YL, Kim KH, Hwang HS. Peripheral calcification in thyroid nodules: ultrasonographic features and prediction of malignancy.  J Ultrasound Med. 2007;  26 1349-1355

1 This paper is a synopsis of the work submitted for the Master in Sciences (M.Sc.) in “Medical Research Technology” (Medical School, Aristotle University of Thessaloniki, Greece).

Correspondence