Impact of ultrasound elastography in evaluating Bethesda category IV thyroid nodules with histopathological correlation

Abstract

Introduction: Fine needle aspiration (FNA) is the gold standard method recommended in the diagnosis of thyroid nodules. Bethesda IV cytology results are identified in 7-9% of nodules investigated through FNA, with reported malignancy rate in a wide range of 10-40%. The recommended treatment is either surgical or risk additional molecular testing before surgery. However, a large number of nodules belonging to this category (60-80%) are observed to be benign after surgical excision, which can put the patient at risk of unnecessary surgical morbidity. This study aimed to assess the diagnostic performance of conventional ultrasound, the ACR TI-RADS score and elastography in cases of Bethesda IV cytology on FNA.

Methods: We evaluated ninety-seven consecutive cases with Bethesda category IV results on FNA by using conventional B-mode ultrasound, qualitative strain or shear-wave elastography (Hitachi Preirus Machine, Hitachi Inc., Japan and Aixplorer Mach 30 Supersonic Imagine, Aix-en-Provence, France) and all nodules were classified according to the ACR TI-RADS system. Conventional ultrasound was used to categorize the nodules as potentially malignant based on the following features: hypoechogenicity, inhomogeneity, a taller than wide shape, irregular margins, presence of microcalcifications, an interrupted thyroid capsule and suspicious cervical lymph nodes. Elastography classified nodules with increased stiffness as suspicious for malignancy.

Results: We considered pathology results as the gold standard diagnosis, finding that 32 out of 97 nodules were carcinomas (33%) and 65 out of 97 were benign nodules (67%). The benign group included twenty cases of non-invasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP). Finally, we compared ultrasound data with pathology results, which showed that nineteen out of the 32 malignant nodules presented with increased stiffness on elastography (p=0.0002). On conventional ultrasound, we found that microcalcifications (p=0.007), hypoechogenicity and irregular margins (p=0.006) are features which can distinguish between benign and malignant nodules with statistical significance.

Discussion: Integrating elastography as a parameter of the ACR TI-RADS score in the evaluation of Bethesda category IV nodules showed a sensitivity of 90.62% in detecting thyroid cancer cases (p=0.006). We can conclude that elastographic stiffness as an addition to high risk features observed on conventional ultrasound improves the detection of malignant nodules in cases with Bethesda IV cytology.

Keywords: ACR TI-RADS; Bethesda IV cytology; fine needle aspiration; follicular neoplasm; thyroid elastography; thyroid nodule; thyroid ultrasound.

Figure 1

The selection process of the cases.

Figure 2

The area under the receiver operating characteristic curve for microcalcifications, hypoechogenicity and irregular margins.

Figure 3

The area under the receiver operating characteristic curve for ACR TI-RADS and elastography.

Figure 4

Multiparametric ultrasound-based evaluation: (A) B-mode image on the right - solid, oval, inhomogeneous, hypoechoic thyroid nodule with smooth margins, ACR-TIRADS 4, strain elastography color-map on the left - stiff in elastography (color code blue), asteria 4, ACR-TIRADS + elasography score 5, Histopathology: NIFTP. (B) B-mode image on the right - solid, oval, inhomogeneous, isoechoic thyroid nodule with smooth margins, ACR-TIRADS 3, strain elastography color-map on the left - mostly soft in elastography (code green), asteria 2, ACR-TIRADS + elasography score 3, Histopathology: NIFTP. (C) B-mode image on the bottom - solid, oval, inhomogeneous, hypoechoic thyroid nodule with ill-defined margins, ACR-TIRADS 4, SWE elastography color-map on the upper side of the image - stiff in elastography (code red), asteria 4, ACR-TIRADS + elasography score 5, Histopathology: Follicular thyroid carcinoma. (D) B-mode image on the bottom - solid, oval, homogeneous, hypoechoic thyroid nodule with smooth, lobulated margins, ACR-TIRADS 5, SWE elastography color-map on the upper side of the image - mostly soft in elastography (code blue-yellow), asteria 2, ACR TIRADS + elasography remains score 5, Histopathology: Follicular adenoma.