Autonomously hyperfunctioning cystic nodule harbouring thyroid carcinoma – Case report and literature review

Lima, Maria João; Soares, Virgínia Lúcia Fontes; Koch, Pedro; Silva, Artur M. S.; Taveira‐Gomes, António

doi:10.1016/j.ijscr.2018.01.002

Cited by 14 publications

(5 citation statements)

References 16 publications

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“…Indeed, one patient with follicular thyroid cancer, cared for in our institution (not included in the study population), initially presented with a hyperfunctional nodule which turned out to be malignant. Some studies such as a review by Mirfakhraee et al report malignancy rates of up to 3.1% for hyperfunctional nodules [27][28][29]. Further studies evaluating the malignancy rate of hyperfunctional nodules seem warranted.…”

Section: Discussionmentioning

confidence: 99%

Prevalence of hyperfunctioning thyroid nodules among those in need of fine needle aspiration cytology according to ATA 2015, EU-TIRADS, and ACR-TIRADS

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Pixberg

et al. 2020

Eur J Nucl Med Mol Imaging

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Purpose Given the large number of patients with thyroid nodules, improvement of the specificity of current ultrasound-based thyroid nodule classification systems (ATA, EU-TIRADS, and ACR-TIRADS) is warranted to reduce the number of diagnostic thyroidectomies. Thyroid scintigraphy has been shown to demonstrate hyperfunctional nodules, associated with a low malignancy risk, in euthyroid patients. However, it is not known if thyroid scintigraphy could improve specificity of current classification systems. The aim of this study, therefore, was to determine the frequency of hyperfunctional nodules among those nodules in need of fine needle aspiration cytology (FNA) according to current classification systems and to test if nodule functional status is associated with sonographic features. Methods Five hundred sixty-six euthyroid patients (TSH 0.55-4.20 μU/ml) presenting for thyroid nodule workup including thyroid sonography and scintigraphy at our department between 09/2013 and 02/2018 were included in this retrospective study. All nodules > 10 mm were classified according to ATA, EU-TIRADS, and ACR-TIRADS and correlated to their functional status as assessed by 99m Tc-pertechnetate scintigraphy. Results Ultrasound detected 1029 thyroid nodules ≥ 10 mm, including 545 nodules ≥ 15 mm. Prevalence of hyperfunctional nodules among those with recommendation for FNA according to ATA 2015, EU-TIRADS, and ACR-TIRADS was 6.4%, 6.9%, and 6.5% for nodules ≥ 10 mm and 7.2%, 7.6%, and 7.5% only considering nodules ≥ 15 mm. No sonographic feature was correlated to hyperfunctionality of nodules. Conclusion In euthyroid patients, thyroid scintigraphy demonstrates hyperfunctionality, which cannot be predicted by ultrasound, in up to 6.9% of nodules in need of FNA according to ultrasound-based classifications. Given the known low risk of malignancy in hyperfunctional nodules, thyroid scintigraphy can lower the frequency of fine needle aspirations and-potentially-the frequency of diagnostic hemithyroidectomies in euthyroid patients.

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Section: Discussionmentioning

confidence: 99%

Prevalence of hyperfunctioning thyroid nodules among those in need of fine needle aspiration cytology according to ATA 2015, EU-TIRADS, and ACR-TIRADS

Noto

Eveslage

Pixberg

et al. 2020

Eur J Nucl Med Mol Imaging

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“…They concluded that a total reliance on fine-needle biopsy without performing scintigraphy would result in surgery for benign nodules suspected of being malignant and may increase the surgical morbidity (29). Moreover, a systematic exclusion of malignancy in HTNs with fine-needle biopsy is presumed to not be cost-effective (30). Furthermore, HTNs cannot reliably be identified or excluded by the thyroid-stimulating hormone (TSH) level alone (31).…”

mentioning

confidence: 99%

Risk Stratification of Thyroid Nodules Using the Thyroid Imaging Reporting and Data System (TIRADS): The Omission of Thyroid Scintigraphy Increases the Rate of Falsely Suspected Lesions

et al. 2018

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Thyroid nodules are a common finding, especially in iodine-deficient regions. Ultrasonographic scoring systems such as Thyroid Imaging Reporting And Data System (TIRADS) are helpful in differentiating between benign and malignant thyroid nodules by offering a risk stratification model. Depending on the constellation or number of suspicious ultrasound features, a fine needle biopsy (FNB) is recommended. However, none of the previously published TIRADS considered the functional status of the nodules. Hyperfunctioning thyroid nodules (HTN) were presumed to exclude malignancy with a very high negative predictive value. Particularly in regions where the iodine supply is lower, the majority of HTN are seen in patients with normal TSH levels. Therefore, thyroid scintigraphy is essential for the detection of HTN. We investigated whether TIRADS identifies HTN as non-suspicious. We evaluated 615 HTN (23.2±10.0 mm at maximum diameter in 582 patients ( = 442 female, 57.7±13.2 years, and = 140 male, 60.1 ±12.7 years) detected byTc Pertechnetate or Iodine scintigraphy. Prior to evaluating the scintigraphic appearance, all nodules were analyzed prospectively with sonography, using the TIRADS model referenced in Kwak et al., wherein fine needle biopsy is recommended for TIRADS 4A or higher. We also investigated two subgroups, 42 nodules with available histology as well as 117 patients with subclinical or overt hyperthyroidism. Whereas 15.9% of the nodules were classified as TIRADS 3 or lower and <0.1% as TIRADS 5, most of the nodules were classified as TIRADS 4A (29.3%), 4B (29.3%), and 4C (24.9%), respectively. Altogether, more than 80% of the autonomous thyroid nodules were classified as TIRADS 4A or higher which would result in a recommendation of fine needle biopsy. Focusing on those 117 HTN that were already associated with hyperthyroid laboratory values, the rates were similar: 81.2% were categorized as TIRADS 4A or higher (4A: 33.3%, 4B: 29.9%, 4C:17.1%, 5: 0.9%). In the subgroup of patients who underwent thyroid surgery, all nodules were benign, confirming the known NPV of HTN with regard to malignancy exclusion. Integration of thyroid scintigraphy into the TIRADS model is essential to prevent unnecessary FNB and thyroid surgery.

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“…However, whereas FNAC has become the gold standard for preoperative clarification of sonomorphologically suspicious TN, the role of scintigraphy is controversially defined in international guidelines [11,[22][23][24][25]. Scintigraphy is not considered to have a significant impact on the assessment of the risk of malignancy of TN despite the fact that it has been shown to almost rule out malignancy in cases of autonomously hyperfunctioning TN [26][27][28]. Furthermore, hyperfunctioning TN cannot be reliably identified or excluded by laboratory assessment alone [29,30].…”

Section: Discussionmentioning

confidence: 99%

The FUSION iENA Study: Comparison of I-124-PET/US Fusion Imaging with Conventional Diagnostics for the Functional Assessment of Thyroid Nodules by Multiple Observers

et al. 2019

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Aim To investigate the value of I-124 positron emission tomography (PET) / ultrasound (US) fusion imaging in comparison to conventional diagnostics (CD) of Thyroid nodules (TN) by multiple observers. Methods Digital patient case files (PCF) of patients that received CD and I-124-PET/US in clinical routine were prepared containing cine-loops of the examinations. All physicians with nuclear medicine specialty from Germany, Austria, and Switzerland were invited to participate. 106 acquired observers completed 7.2 ± 1.8 (median: 8, range: 4–14) randomly assigned PCF (CD only or CD+PET/US). They assessed the TN function, stated their confidence in functional assessment, and suggested a treatment course for each TN. Results 68 PCF of 34 patients comprising 66 TN ≥ 1 cm (= 1.94 TN/patient) were created. A total of 748 (11.2/TN), and 751 ratings (11.4/TN) were recorded for CD only, and CD+PET/US, respectively. The functional assessment revealed more hyper- or hypofunctioning (524 vs. 320, p < 0.0001) and less indifferent or not rateable (209 vs. 428, p < 0.0001) TN in CD+PET/US vs. CD only. The observers’ confidence in functional assessment was superior in CD+PET/US (p < 0.0001). Furthermore, the ratings were carried out more homogeneous in CD+PET/US (p < 0.0001). Fewer suggestion of follow up (p < 0.0001), and more (p < 0.0001) suggestion of invasive treatments (fine-needle aspiration & surgery) was observed in CD+PET/US. Radioiodine therapy was more often (p = 0.0036), and thyroid medication less often (p = 0.0167) advised in CD+PET/US. Conclusion Functional assessment of equivocal TN shows frequent failures in CD, underestimating the incidence of hyper- and hypofunctioning lesions. Confidence in functional assessment significantly increases with additional PET/US. This influences the proposed treatment course.

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Autonomously hyperfunctioning cystic nodule harbouring thyroid carcinoma – Case report and literature review

Abstract: HighlightsHyperthyroidism cannot rule out thyroid cancer.Published cases of autonomously functioning thyroid carcinomas are increasing.In hyperthyroid patients, carcinoma should always be considered as differential diagnosis.

Cited by 14 publications

References 16 publications

Prevalence of hyperfunctioning thyroid nodules among those in need of fine needle aspiration cytology according to ATA 2015, EU-TIRADS, and ACR-TIRADS

Prevalence of hyperfunctioning thyroid nodules among those in need of fine needle aspiration cytology according to ATA 2015, EU-TIRADS, and ACR-TIRADS

Risk Stratification of Thyroid Nodules Using the Thyroid Imaging Reporting and Data System (TIRADS): The Omission of Thyroid Scintigraphy Increases the Rate of Falsely Suspected Lesions

The FUSION iENA Study: Comparison of I-124-PET/US Fusion Imaging with Conventional Diagnostics for the Functional Assessment of Thyroid Nodules by Multiple Observers

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