Background There is currently insufficient data to validate adult-based US risk stratification systems (RSSs) for the identification of malignant thyroid nodules in a pediatric population. Methods From October 2016 and May 2023, 173 thyroid nodules of pediatric patients (age ≤ 18 years) with definitive pathology results and ultrasound (US) examination within 1 month before surgery or fine-needle aspiration (FNA) biopsy in our institution were enrolled in this study. The clinical and US characteristics of these nodules were retrospectively reviewed and categorized according to the ACR-TIRADS, C-TIRADS, and ATA guidelines. The diagnostic performance of US-based FNA criteria (original and simulating) of the three guidelines in thyroid cancer detection was estimated. Results The three RSSs had similar AUC according to the categories(0.849-0.852, all P > 0.05). When combined with the original FNA criteria of the three RSSs to manage the nodules, the FNA rate of ACR-TIRADS and C-TIRADS were significantly less than ATA guidelines (53.18% vs. 64.63%, P < 0.05, and 52.60% vs. 64.63%, P < 0.05). The missed malignancy rate (MMR) and unnecessary FNA rate (UFR) of ATA guidelines (50.00%, 35.85%) was highest among the three RSSs, followed by the C-TIRADS (37.80%, 19.57%) and the ACR-TIRADS (37.04%, 19.57%). When nodules < 1 cm with the highest category in each RSS biopsied, that is when using the simulating FNA thresholds, the MMR was reduced overall (all P < 0.001), without a change in the UFR (all P > 0.05). All the three RSSs showed a substantial improvement in accuracy and malignant detection rate (all P < 0.05). Conclusion The ACR-TIRADS, C-TIRADS, and ATA guidelines showed high missed malignancy rates when using their original recommended FNA criteria. When nodules < 1 cm with the highest category in each RSS biopsied, the missed malignancy rate of each RSS was decreased. Decreasing the FNA thresholds for highly suspicious malignant nodules may therefore be an effective means of managing malignant thyroid nodules in pediatric patients.
To estimate the feasibility of decreasing the original thresholds for biopsy in the Kwak Thyroid Imaging Reporting and Data System (Kwak TIRADS) and Chinese Thyroid Imaging Reporting and Data System (C TIRADS).This retrospective study included 3,201 thyroid nodules from 2,146 patients with a pathological diagnosis. We lowered the original fine-needle aspiration (FNA) thresholds with the TR4a-TR5 in Kwak and C TIRADSs and calculated the ratio of additional benign-to-malignant nodules being biopsied (RABM). If the RABM is less than 1, the decreased FNA thresholds could be accepted and used to the modified TIRADSs (modified C and Kwak TIRADSs). Then, we estimated and compared the diagnostic performance between the modified TIRADS and the original TIRADS to determine if the decreased thresholds could be an effective strategy.A total of 1,474 (46.0%) thyroid nodules were diagnosed as malignant after thyroidectomy. The TR4c-TR5 in Kwak TIRADS and TR4b-TR5 in C TIRADS had a rational RABM (RABM < 1). The modified Kwak TIRADS had higher sensitivity, a positive predictive value, a negative predictive value, lower specificity, an unnecessary biopsy rate, and a missed malignancy rate compared with the original Kwak TIRADS (94.1% vs. 42.6%, 59.4% vs. 44.6%, 89.9% vs. 52.8%, 45.0% vs. 54.9%, 40.6% vs. 55.4%, and 10.1% vs. 47.1%, respectively, P < 0.05 for all). Similar trends were seen in the modified C TIRADS versus the original C TIRADS (95.1% vs. 38.7%, 61.7% vs. 47.8%, 92.3% vs. 55.0%, 49.7% vs. 64.0%, 38.3% vs. 52.2%, and 7.7% vs. 44.9%, respectively, P < 0.05 for all).The biopsy of all nodules with TR4C-TR5 in the Kwak TIRADS and TR4B-TR5 in the C TIRADS might be an effective strategy. This paper contributes to the contradiction concerning whether to perform FNA for the nodules smaller than 10 mm.
Study Objective: The role of transversus thoracic muscle plane blocks (TTMPBs) during cardiac surgery is controversial. We conducted a systematic review to establish the effectiveness of this procedure. Design: Systematic review. We searched PubMed, Embase, Web of Science, CENTRAL, WanFang Data, and the China National Knowledge Infrastructure to June 2022, and followed the GRADE approach to evaluate the certainty of evidence. Study Eligibility Criteria: Eligible studies enrolled adult patients scheduled to undergo cardiac surgery and randomized them to receive a TTMPB or no block/sham block. Main Results: Nine trials that enrolled 454 participants were included. Compared to no block/sham block, moderate certainty evidence found that TTMPB probably reduces postoperative pain at rest at 12h (weighted mean difference [WMD] −1.51 cm on a 10 cm visual analogue scale for pain, 95% CI -2.02 to -1.00; risk difference [RD] for achieving mild pain or less (≤3 cm), 41%, 95%CI 17 to 65) and 24h (WMD −1.07 cm, 95%CI −1.83 to −0.32; RD 26%, 95%CI 9 to 37). Moderate certainty evidence also supported that TTMPB probably reduces pain during movement at 12h (WMD -3.42 cm, 95%CI −4.47 to −2.37; RD 46%, 95%CI 12 to 80) and at 24h (WMD −1.73 cm, 95%CI −3.24 to −0.21; RD 32%, 95%CI 5 to 59), intraoperative opioid use (WMD −28 milligram morphine equivalent [MME], 95%CI −42 to −15), postoperative opioid consumption (WMD −17 MME, 95%CI −29 to −5), postoperative nausea and vomiting (absolute risk difference 255 less per 1000 persons, 95%CI 140 to 314), and ICU length of stay (WMD −13 h, 95%CI −21 to −6). Conclusion: Moderate certainty evidence showed TTMPB during cardiac surgery probably reduces postoperative pain at rest and with movement, opioid consumption, ICU length of stay, and the incidence of nausea and vomiting.
Abstract At present, there is still controversy over whether to perform fine needle aspiration (FNA) on sub-centimeter thyroid nodules with high suspicion of malignancy. Our aim was to estimate the feasibility of reducing the original thresholds for biopsy in American College of Radiology Thyroid Imaging Reporting and Data System (ACR TIRADS) and Artificial Intelligence TIRADS (AI TIRADS). A total of 3201 thyroid nodules with definitive histology obtained were included. Ultrasound categories were assigned according to each TIRADS. We lowered the original FNA thresholds of TR3-TR5 in ACR and AI TIRADS and estimated whether the decreased FNA thresholds could be accepted and used to modified ACR and AI TIRADS. Then, we estimated and compared the diagnostic performance between modified TIRADS and original TRADS to determine if the decreased thresholds could be an effective strategy. 1474 (46.0%) thyroid nodules were diagnosed as malignant after thyroidectomy. Modified ACR TIRADS had higher sensitivity and lower specificity, unnecessary biopsy rate, missed malignancy rate compared with original ACR TIRADS (all P < 0.05). Similar trends were seen in modified AI TIRADS versus original AI TIRADS (all P < 0.05). In conclusion, biopsy of all nodules with TR5 in both ACR TIRADS and AI TIRADS might be an effective strategy, regardless of the nodules dimension. This paper contributes to the contradictory concerning whether perform FNA for the nodules smaller than 10 mm.
Abstract Objective To investigate the diagnostic performances and unnecessary fine needle aspiration (FNA) rates of two point-scale based TIRADS and compare them with a modified version using the ACR TIRADS’ size thresholds. Methods Our Institutional Review Board approved this retrospective study and waived the requirement for informed consent. A total of 2083 thyroid nodules 10 mm or larger in size in 1779 patients with definitive pathological findings were included. Ultrasonography categories were assigned according to each guideline. We applied the ACR TIRADS’ size thresholds for FNA to the C TIRADS and defined it as the modified C TIRADS (mC TIRADS). Diagnostic performances and unnecessary FNA rates were evaluated for the original and modified guidelines. Results Of the original guidelines, the ACR TIRADS had higher specificity, accuracy, and area under the receiver operating characteristic curve (AUC) (51.6%, 67.7%, and 0.723, respectively). When the size threshold of the ACR TIRADS was applied to the C TIRADS, the resultant mC TIRADS had higher specificity and accuracy than the ACR (56.1% vs 51.6%,68.7% vs 67.7%). The mC TIRADS had similar unnecessary FNA rate and AUC with the ACR TIRADS (43.7% and 45%, 0.722 vs 0.723，respectively). The false-negative rate of the C TIRADS was the lowest (2.0%) among all TIRADS. Conclusion The modified C TIRADS incorporating the size thresholds of the ACR showed higher diagnostic performance and a lower unnecessary FNA rate than the original point-scale based TIRADS.
To evaluate whether the categorization methods of risk stratification systems (RSSs) is a decisive factor that influenced the diagnostic performances and unnecessary FNA rates in order to choose optimal RSS for the management of thyroid nodules.From July 2013 to January 2019, 2667 patients with 3944 thyroid nodules had undergone pathological diagnosis after thyroidectomy and/or US-guided FNA. US categories were assigned according to the six RSSs. The diagnostic performances and unnecessary FNA rates were calculated and compared according to the US-based final assessment categories and the unified size thresholds for biopsy proposed by ACR-TIRADS, respectively.A total of 1781 (45.2%) thyroid nodules were diagnosed as malignant after thyroidectomy or biopsy. Significantly lowest specificity and accuracy, along with the highest unnecessary FNA rates were seen in EU-TIRADS for both US categories (47.9%, 70.2%, and 39.4%, respectively, all P < 0.05) and indications for FNA (54.2%, 50.0%, and 55.4%, respectively, all P < 0.05). Diagnostic performances for US-based final assessment categories exhibited similar accuracy for AI-TIRADS, Kwak-TIRADS, C-TIRADS, and ATA guidelines (78.0%, 77.8%, 77.9%, and 76.3%, respectively, all P > 0.05), while the lowest unnecessary FNA rate was seen in C-TIRADS (30.9%) and without significant differences to that of AI-TIRADS, Kwak-TIRADS, and ATA guideline (31.5%, 31.7%, and 33.6%, respectively, all P > 0.05). Diagnostic performance for US-FNA indications showed similar accuracy for ACR-TIRADS, Kwak-TIRADS, C-TIRADS and ATA guidelines (58.0%, 59.7%, 58.7%, and 57.1%, respectively, all P > 0.05). The highest accuracy and lowest unnecessary FNA rate were seen in AI-TIRADS (61.9%, 38.6%) and without significant differences to that of Kwak-TIRADS(59.7%, 42.9%) and C-TIRADS 58.7%, 43.9%, all P > 0.05).The different US categorization methods used by each RSS were not determinant influential factors in diagnostic performance and unnecessary FNA rate. For daily clinical practice, the score-based counting RSS was an optimal choice.
The aim of this study was to explore the diagnostic and therapeutic performances of the artificial intelligence (AI), American College of Radiology (ACR), and Kwak Thyroid Imaging Reporting and Data Systems (TIRADSs) using the size thresholds for fine needle aspiration (FNA) and follow-up defined in the ACR TIRADS.This retrospective study included 3,833 consecutive thyroid nodules identified in 2,590 patients from January 2010 to August 2017. Ultrasound (US) features were reviewed using the 2017 white paper of the ACR TIRADS. US categories were assigned according to the ACR/AI and Kwak TIRADS. We applied the thresholds for FNA and follow-up defined in the ACR TIRADS to the Kwak TIRADS. The diagnostic and therapeutic performances were calculated and compared using the McNemar or DeLong methods.The AI TIRADS had higher specificity, accuracy, and area under the curve (AUC) than did the ACR and Kwak TIRADS (specificity: 64.6% vs. 57.4% and 52.69%; accuracy: 78.5% vs. 75.4% and 73.0%; AUC: 88.2% vs. 86.6% and 86.0%; all P values <0.05). Meanwhile, the AI TIRADS had a lower FNA rate (FNAR), unnecessary FNA rate (UFR), and follow-up rate (FUR) than did the ACR and Kwak TIRADS using the size thresholds of the ACR TIRADS (specificity: 30.9% vs. 34.4% and 36.9%; accuracy: 41.1% vs. 47.8% and 48.7%; AUC: 34.2% vs. 37.7% and 41.0%; all P values <0.05). In addition, the Kwak TIRADS incorporating the size thresholds of the ACR TIRADS was almost similar to the ACR TIRADS in diagnostic and therapeutical performance.The ACR TIRADS can be simplified, which potentially enhances its diagnostic and therapeutic performance. The method of score-based TIRADS (counting in the Kwak TIRADS and weighting in the ACR and AI TIRADS) might not determine the diagnostic and therapeutic performances of the TIRADS. Thus, we propose choosing a straightforward and practical TIRADS in daily practice.
The lack of standardization in risk stratification systems (RSSs) has led to uncertainty in selecting the most effective RSS for diagnosing malignancy risk in thyroid nodules. Therefore, the aim of this study was to compare the diagnostic performance of four current score-based RSSs according to thyroid nodule size, with the goal of determining the most effective RSS and aiding in clinical decision-making.
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