Skip to main content
NCBI home page
International Journal of Clinical Practice logoLink to International Journal of Clinical Practice
. 2022 Sep 13;2022:5056082. doi: 10.1155/2022/5056082

Accuracy of Ultrasound Diagnosis of Benign and Malignant Thyroid Nodules: A Systematic Review and Meta-Analysis

Mei Shi 1, Dandan Nong 2, Minhui Xin 1, Lifei Lin 3,✉
PMCID: PMC9489364  PMID: 36160289

Abstract

Background

Distinguishing between benign and malignant thyroid nodules remains difficult. Ultrasound has been established as a non-invasive and relatively simple imaging technique for thyroid nodules. This study aimed to assess the diagnostic accuracy of conventional ultrasound and ultrasound elastography for the differentiation between benign and malignant thyroid nodules by meta-analyzing published studies.

Methods

Literature was retrieved from the PubMed and Embase databases from inception to May 31, 2022. The literature was screened using inclusion and exclusion criteria. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS2) scale was used to assess the quality of the included literature. Publication bias of the included studies was assessed by Deek's funnel plot. Heterogeneity tests were performed using Cochrane Q statistic and I2 statistic.

Results

Finally, 9 articles were included. The meta-analysis showed that the combined sensitivity and specificity of ultrasound for the diagnosis of thyroid nodules were 0.88 [95% CI (0.83–0.91)] and 0.86 [95% CI (0.79–0.90)], respectively. The area under the curve (AUC) of the summary receiver operating characteristic curve (SROC) was 0.92 [95% CI (0.90–0.94)]. There was no significant publication bias in this study. Discussion. Existing evidence shows that ultrasound has a certain accuracy in diagnosing benign and malignant thyroid nodules, providing a scientific basis for thyroid assessment and diagnosis.

1. Introduction

Thyroid nodules are cystic or solid lumps that are most frequently asymptomatic. Nonetheless, large thyroid nodules have also been shown to interfere with the normal functioning of cardiovascular and respiratory functions [1, 2]. Pathologically, thyroid nodules are dichotomized into benign nodules and malignant nodules. In general, most of the benign thyroid nodules are small in size, mild in symptoms, and have favorable treatment outcomes. Therefore, accurate and effective determination of the nature of nodules is beneficial for clinical treatment planning and assessment of outcomes [3–6]. Currently, the clinical techniques used to distinguish benign and malignant thyroid nodules mainly include ultrasound, computed tomography, and nuclear imaging. Traditional ultrasonography is widely used in clinical practice due to its advantages of safety, low cost, ready availability, and no radiation exposure [7–9]. The ultrasound images of malignant thyroid nodules have the characteristics of irregular shape, unclear edge, inhomogeneous, calcification, low echo, and aspect ratio greater than 1.” However, conventional ultrasound is limited for the diagnosis of malignant thyroid nodules in terms of small thyroid cancers, multiple nodules, and cystic nodules with internal hemorrhage. In addition, there are some thyroid nodules that are not obvious on ultrasound imaging. Thus, several studies have concluded that traditional ultrasound imaging techniques cannot actually meet the needs of current clinical practice [10–12].

Ultrasound elastography, a newly developed dynamic imaging technique, was first proposed by Ophir et al. in 1991 [13] and first applied to thyroid clinical practice by Lyshchik et al. in 2005 [14]. Subsequently, in 2010, Sebag et al. first reported the use of shear-wave elastography (SWE) to diagnose thyroid nodules [15]. In recent years, emerging studies have shown that ultrasound elastography is highly sensitive for differentiation between benign and malignant thyroid nodules and should serve as the first-line imaging modality for patients with thyroid nodule [16, 17].

Therefore, this study evaluated the diagnostic accuracy of conventional ultrasound and ultrasound elastography for the differentiation between benign and malignant thyroid nodules by meta-analyzing published studies.

2. Methods

2.1. Literature Source

Electronic databases, including PubMed and Embase, were searched from inception to May 31, 2022. Keywords used for searching included ultrasonography and thyroid nodule. The combination of medical subject headings and free words was used to search relevant publications. The retrieved literature was checked manually and managed by EndNote X9.

2.2. Inclusion and Exclusion Criteria of Literature

Studies that meet the following criteria were included: (1) the study evaluated the diagnostic utility of conventional ultrasound or ultrasound elastography for patients with thyroid nodules; (2) pathological biopsy was used as the “gold standard” for determination of the benignity or malignancy of the thyroid nodule; and (3) research could directly or indirectly obtain true positive, false positive, false negative, and true negative value. The exclusion criteria were as follows: (1) guidelines, reviews, meetings, reviews, meta-analysis, and other non-original articles; (2) repeated publication; and (3) incomplete data.

2.3. Literature Screening, Data Extraction, and Quality Evaluation

Literature retrieval, screening, and data extraction were completed by two researchers independently. Two researchers made standardized tables to extract data from the included literature, including research author, research time, country, and type of experiment. The patient data were recorded, including the total number of cases, diagnostic reference standards, and the number of thyroid nodules. The number of true positive, false positive, true negative, and false negative was also extracted from the included studies. The quality of the included literature was evaluated by the Quality Assessment of Diagnostic Accuracy Studies (QUADAS2) scale. Two researchers cross-checked the quality assessment results. If there is any disagreement, the joint judgment result after consultation and discussion shall prevail.

2.4. Statistical Analysis

Stata V 15.0 software was used for statistical analysis. The combined effect quantity, including sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio, was obtained. The diagnostic capability was evaluated by drawing the subject operating characteristic curve (SROC). A larger area under the curve (AUC) often signified higher diagnostic accuracy. Heterogeneity test was performed using I2. In the included literature, P < 0.05 or I2 > 50% indicated high heterogeneity; P > 0.1 or I2 < 25% indicated low heterogeneity; and 25% ≤ I2 ≤ 50% indicated moderate heterogeneity. If the inter-study heterogeneity is high, the random-effects model is used for meta-analysis; otherwise, a fixed-effect model is used for meta-analysis. Publication bias detection was performed using Deek's funnel plots. Two-sided P value < 0.05 denoted statistical significance.

3. Results

3.1. Literature Search Results

After the preliminary search, 480 studies were retrieved. According to the inclusion and exclusion criteria, 43 duplicate studies were excluded. After reading the title and abstract, 323 obviously unrelated studies were excluded. A total of 32 publications were downloaded and read for the full text. Finally, 9 studies were included, as shown in Figure 1.

Figure 1.

Figure 1

Open in a new tab

Flowchart of literature screening. The process of screening meta-analysis into the literature.

3.2. Basic Characteristics of Included Articles

All the 9 included articles were English publications that included 7 prospective single-center studies, 1 prospective multicenter study, and 1 retrospective study. A total of 1436 nodules were included, including 1006 benign nodules and 430 malignant nodules, as shown in Table 1.

Table 1.

The study's basic characteristics and quality score.

Included studies Country TP FP FN TN Type of study
Hong et al. [18] China 43 10 6 86 Prospective study
Trimboli et al. [19] Italy 102 142 24 230 Prospective multicenter study
Liu et al. [20] China 15 7 4 38 Prospective study
Gregory et al. [21] United States 21 13 1 99 Prospective study
Wang et al. [22] China 29 2 3 17 Prospective study
Ragazzoni et al. [23] Italy 34 15 6 77 Prospective study
Lee et al. [24] Korea 63 13 3 151 Retrospective study
Yunus et al. [25] Pakistan 23 12 2 41 Prospective study
Zhang et al. [26] China 42 3 9 50 Prospective study
Open in a new tab

3.3. Quality Evaluation of Included Studies

QUADAS2 scale was used to evaluate the quality of the 9 included articles (Figure 2). The articles we included were all of low risk.

Figure 2.

Figure 2

Open in a new tab

Quality evaluation graph of included studies. Green represents low risk of bias.

3.4. The Results of Meta-Analysis

3.4.1. Heterogeneity Test

All included studies were tested for heterogeneity. There was significant inter-study heterogeneity (I2 = 70%) (Figure 3), so the random-effects model was used for pooled analysis.

Figure 3.

Figure 3

Open in a new tab

Heterogeneity test for ultrasound diagnosis of thyroid nodules.

3.4.2. Consolidation Analysis

The effect quantities of all included studies were statistically analyzed. The combined sensitivity and specificity were 0.88 [95% CI (0.83–0.91)] and 0.86 [95% CI (0.79–0.90)], respectively. The combined positive and negative likelihood ratio was 0.73 [95% CI (0.58–0.88)] and 0.94 [95% CI (0.91–0.97)], respectively (Figures 4–8). The AUC under SROC was 0.92 [95% CI (0.90–0.94)] (Figures 4–8).

Figure 4.

Figure 4

Open in a new tab

The forest plot of sensitivity and specificity in thyroid nodule ultrasound diagnosis.

Figure 5.

Figure 5

Open in a new tab

Subject operating characteristic curve (SROC) for ultrasound diagnosis of thyroid nodules.

Figure 6.

Figure 6

Open in a new tab

Dot plot of likelihood ratio for ultrasound diagnosis of thyroid nodules.

Figure 7.

Figure 7

Open in a new tab

Positive likelihood ratio for ultrasound diagnosis of thyroid nodules.

Figure 8.

Figure 8

Open in a new tab

Negative likelihood ratio for ultrasound diagnosis of thyroid nodules.

3.4.3. Fagan Nomogram Analysis

A 50% predicted probability was used to simulate the clinical situation. The results showed that the post-test probability of a positive test result was 86%, while the negative likelihood ratio was 0.14 and the negative post-test probability was 1% (Figure 9).

Figure 9.

Figure 9

Open in a new tab

Fagan graph of the accuracy of ultrasonography in diagnosing benign and malignant thyroid nodules.

3.5. Meta-Regression and Subgroup Analysis

There was no significant difference in specificity between articles from China and those that are not (P=0.28). Sensitivity was significantly different between studies in the Chinese group at 0.85 [95% CI (0.78–0.93)] and in the non-Chinese group at 0.90 [95% CI (0.85–0.95)]. The diagnostic sensitivity and specificity of ultrasound elastography were 0.86 [95% CI (0.82, 0.91)] and 0.84 [95% CI (0.76–0.91)], respectively. The sensitivity and specificity of conventional ultrasound diagnosis were 0.84 [95% CI (0.76–0.91)] and 0.89 [95% CI (0.81–0.97)], respectively. There were significant differences in terms of both the sensitivity and specificity (P < 0.05). Diagnosis was a potential factor for heterogeneity. The results are shown in Table 2 and Figure 10.

Table 2.

Univariable meta-regression.

Parameter Category N Sensitivity P1 Specificity P2
China Yes 4 0.85 (0.78–0.93) <0.001 0.90 (0.84–0.97) 0.28
No 5 0.90 (0.85–0.95) — 0.82 (0.75–0.90) —
US-Elastography Yes 6 0.86 (0.82, 0.91) <0.001 0.84 (0.76–0.91) <0.01
No 3 0.84 (0.76–0.91)   0.89 (0.81–0.97) —
Open in a new tab

Figure 10.

Figure 10

Open in a new tab

Univariable meta-regression and subgroup analyses of the accuracy of ultrasound in the diagnosis of benign and malignant thyroid nodules.

3.6. Publication Bias

The results of publication bias detection are shown in Figure 11. The P value for the slope coefficient of Deek's funnel plot is 0.17, indicating no significant publication bias in the included studies.

Figure 11.

Figure 11

Open in a new tab

Publication bias detected by using Deek's funnel plot.

4. Discussion

According to the inclusion criteria, 9 research articles with 1436 thyroid nodules from 1378 patients were selected to analyze the ultrasonic differentiation of benign and malignant thyroid nodules. Since high heterogeneity was observed in the analysis results, the random-effects model was applied in the data analysis. The sensitivity and specificity of ultrasound diagnosis were 0.88 [95% CI (0.83–0.91)] and 0.86 [95% CI (0.79–0.90)], respectively. The combined positive and negative likelihood ratio was 0.73 [95% CI (0.58–0.88)] and 0.94 [95% CI (0.91–0.97)], respectively. Furthermore, the area under the SROC curve of ultrasound diagnosis of thyroid nodules was 0.92 [95% CI (0.90–0.94)]. Therefore, the result demonstrated a good diagnostic efficiency. At the same time, the results of subgroup analysis showed that the diagnostic sensitivity and specificity of ultrasound elastography were 0.86 [95% CI (0.82, 0.91)] and 0.84 [95% CI (0.76–0.91)], respectively. The diagnostic sensitivity and specificity of conventional ultrasound were 0.84 [95% CI (0.76–0.91)] and 0.89 [95% CI (0.81–0.97)], respectively. In addition, there are significant differences in terms of diagnostic sensitivity and specificity between ultrasound elastography and conventional ultrasound, indicating that the diagnosis method may be a potential factor of heterogeneity.

Due to its non-invasiveness, wide availability, and low cost, ultrasonography is still the preferred method for clinical examination of thyroid nodules. In recent years, the Thyroid Imaging Reporting and Data System (TIRADS) risk score has been introduced clinically to standardize the risk assessment of ultrasonographic diagnosis of malignant thyroid nodules [27–30]. The main advantage of the TIRADS score is its high accuracy for identifying suspicious thyroid nodules worthy of cytological examination, thereby achieving early detection while avoiding unnecessary biopsies [31, 32]. However, TIRADS also has some limitations in practical applications in recent years. For instance, thyroid nodules of different classifications may have the same TIRADS score. A study from Italy in 2017 showed that the accuracy of the TIRADS score was approximately 27.2% [33]. In contrast, studies have shown that the specificity and sensitivity of fine-needle aspiration (FNA) in identifying malignant thyroid nodules were about 60%–98% and 54%–90%, respectively. FNA remains one of the gold standards for identifying malignant thyroid nodules [34–37].

Ultrasound evaluation of the lateral neck during the early assessment is helpful in determining the scope of the final operation [38]. Some studies have found that preoperative neck ultrasound has changed the surgical method in 40% of patients [38–40]. At this stage, it is recommended that all patients with suspected thyroid nodules should undergo an ultrasound examination [16]. Hyperechoic/isoechoic (brighter than normal thyroid tissue or with the same echo) nodules are usually benign. Meanwhile, noticeable hypoechoic nodules increase the risk of malignancy [41, 42]. Nodules with mixed cystic and solid components are less likely to be malignant than completely solid nodules [43, 44]. “Taller-than-wide” appearance also increases the risk of malignancy [45, 46]. Intra-nodal calcification has also been reported to increase the likelihood of malignancy [47, 48]. A study of nearly 700 thyroid tumors found that more than half of malignant nodules (63%) lacked intra-nodal vessels on preoperative imaging [49].

Various cancerous processes alter the physical characteristics of affected tissues. Ultrasound sonography is a novel imaging technique that can provide information about tissue hardness [14, 50–55]. With emergence of commercial ultrasound systems, ultrasound elastography has been increasingly applied in various fields to verify its clinical applicability [51, 52, 56–59]. Among the 40 patients examined with ultrasound elastography, 35 of the 40 benign nodules and 9 of the 11 malignant nodules have been correctly classified by ultrasound elastography with pathological examination as the reference standard [60].

The assessment and management of patients with thyroid nodules is no longer a one-size-fits-all proposition. The main challenge in the management of thyroid nodules is to identify malignant nodules while avoiding excessive use of aspirations and surgery at the same time. Therefore, advanced diagnostic methods that can accurately evaluate the benign and malignant thyroid nodules would be desirable. A customized method is advocated, which requires careful evaluation of each nodule to determine the possibility of malignancy [1]. Ultrasound can maximize the detection of clinically relevant thyroid lesions and reduce fine-needle aspiration of benign nodules to reduce over-diagnosis and over-treatment of benign nodules, achieving the best prognosis for patients and minimizing the cost of medical treatment [61].

The 9 studies included in this study have some heterogeneity after analysis, which might affect the reliability of the study conclusions to a certain extent. We suspected that possible reasons for high inter-study heterogeneity were related to small sample size and incomplete publication inclusion since databases other than PubMed and Embase were not searched. In addition, the experience of ultrasound operators would also affect the study results.

In conclusion, ultrasound is still an ideal way to detect thyroid nodules. In the future, additional research is required to improve ultrasonic diagnosis. Meanwhile, it can be combined with other relevant imaging technologies to improve the sensitivity and specificity of ultrasonic diagnosis and reduce unnecessary pathological aspirations. Furthermore, the diagnostic accuracy can be improved by fine-needle aspiration biopsy and other imaging examinations if the lesions are not determined by routine ultrasound.

Acknowledgments

This study was supported by Central South University Xiangya School of Medicine Affiliated Haikou Hospital.

Data Availability

The data used and analyzed during the current study are available from the corresponding author upon request.

Conflicts of Interest

The authors declare that they have no conflicts of interest.

Authors' Contributions

Mei Shi and Dandan Nong contributed equally to this work.

References

  • 1.Grani G., Sponziello M., Pecce V., Ramundo V., Durante C. Contemporary thyroid nodule evaluation and management. Journal of Clinical Endocrinology and Metabolism . 2020;105(9):2869–2883. doi: 10.1210/clinem/dgaa322. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Pemayun T. G. D. Current diagnosis and management of thyroid nodules. Acta Med Indones . 2016;48(3):247–257. [PubMed] [Google Scholar]
  • 3.Wong R., Farrell S. G., Grossmann M. Thyroid nodules: diagnosis and management. Medical Journal of Australia . 2018;209(2):92–98. doi: 10.5694/mja17.01204. [DOI] [PubMed] [Google Scholar]
  • 4.Perri F., Giordano A., Pisconti S., et al. Thyroid cancer management: from a suspicious nodule to targeted therapy. Anti-Cancer Drugs . 2018;29(6):483–490. doi: 10.1097/cad.0000000000000617. [DOI] [PubMed] [Google Scholar]
  • 5.Singaporewalla R. M., Hwee J., Lang T. U., Desai V. Clinico-pathological correlation of thyroid nodule ultrasound and cytology using the TIRADS and bethesda classifications. World Journal of Surgery . 2017;41(7):1807–1811. doi: 10.1007/s00268-017-3919-5. [DOI] [PubMed] [Google Scholar]
  • 6.Bauer A. J. Thyroid nodules in children and adolescents. Current Opinion in Endocrinology Diabetes and Obesity . 2019;26(5):266–274. doi: 10.1097/med.0000000000000495. [DOI] [PubMed] [Google Scholar]
  • 7.Gild M. L., Chan M., Gajera J., Lurie B., Gandomkar Z., Clifton-Bligh R. J. Risk stratification of indeterminate thyroid nodules using ultrasound and machine learning algorithms. Clinical Endocrinology . 2022;96(4):646–652. doi: 10.1111/cen.14612. [DOI] [PubMed] [Google Scholar]
  • 8.Hou J., Li M., Peng X., Li Y., Liu L. The effect of Hashimoto’s thyroiditis on the diagnostic efficacy of ultrasound-guided fine needle aspiration cytology for thyroid nodules ≥ 1 cm. Lin Chung Er Bi Yan Hou Tou Jing Wai Ke Za Zhi . 2021;35(9):807–812. doi: 10.13201/j.issn.2096-7993.2021.09.008. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9.Jiang S., Xie Q., Li N., Chen H., Chen X. Modified models for predicting malignancy using ultrasound characters have high accuracy in thyroid nodules with small size. Frontiers in Molecular Biosciences . 2021;8 doi: 10.3389/fmolb.2021.752417.752417 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Li L., Chen X., Li P., Liu Y., Ma X., Ye Y. Q. The value of ultrasound-guided fine-needle aspiration cytology combined with puncture feeling in the diagnosis of thyroid nodules. Acta Cytologica . 2021;65(5):368–376. doi: 10.1159/000517168. [DOI] [PubMed] [Google Scholar]
  • 11.Li L., Qiu X. Safety and efficacy of ultrasound-guided radiofrequency ablation for benign nonfunctional thyroid nodules in children: a retrospective study of 62 patients with over four years of follow-up. Thyroid . 2022;32(5):525–535. doi: 10.1089/thy.2021.0454. [DOI] [PubMed] [Google Scholar]
  • 12.Maddaloni E., Briganti S. I., Crescenzi A., et al. Usefulness of color Doppler ultrasonography in the risk stratification of thyroid nodules. Eur Thyroid J . 2021;10(4):339–344. doi: 10.1159/000509325. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Ophir J., Cespedes I., Ponnekanti H., Yazdi Y., Li X. Elastography: a quantitative method for imaging the elasticity of biological tissues. Ultrasonic Imaging . 1991;13(2):111–134. doi: 10.1016/0161-7346(91)90079-w. [DOI] [PubMed] [Google Scholar]
  • 14.Lyshchik A., Higashi T., Asato R., et al. Thyroid gland tumor diagnosis at US elastography. Radiology . 2005;237(1):202–211. doi: 10.1148/radiol.2363041248. [DOI] [PubMed] [Google Scholar]
  • 15.Sebag F., Vaillant-Lombard J., Berbis J., et al. Shear wave elastography: a new ultrasound imaging mode for the differential diagnosis of benign and malignant thyroid nodules. Journal of Clinical Endocrinology and Metabolism . 2010;95(12):5281–5288. doi: 10.1210/jc.2010-0766. [DOI] [PubMed] [Google Scholar]
  • 16.Haugen B. R., Alexander E. K., Bible K. C., et al. 2015 American thyroid association management Guidelines for adult patients with thyroid nodules and differentiated thyroid cancer: the American thyroid association Guidelines task force on thyroid nodules and differentiated thyroid cancer. Thyroid . 2016;26(1):1–133. doi: 10.1089/thy.2015.0020. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17.Radzina M., Ratniece M., Putrins D. S., Saule L., Cantisani V. Performance of contrast-enhanced ultrasound in thyroid nodules: review of current state and future perspectives. Cancers . 2021;13(21):p. 5469. doi: 10.3390/cancers13215469. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18.Hong Y., Liu X., Li Z., Zhang X., Chen M., Luo Z. Real-time ultrasound elastography in the differential diagnosis of benign and malignant thyroid nodules. Journal of Ultrasound in Medicine . 2009;28(7):861–867. doi: 10.7863/jum.2009.28.7.861. [DOI] [PubMed] [Google Scholar]
  • 19.Trimboli P., Guglielmi R., Monti S., et al. Ultrasound sensitivity for thyroid malignancy is increased by real-time elastography: a prospective multicenter study. Journal of Clinical Endocrinology and Metabolism . 2012;97(12):4524–4530. doi: 10.1210/jc.2012-2951. [DOI] [PubMed] [Google Scholar]
  • 20.Liu B. X., Xie X. Y., Liang J. Y., et al. Shear wave elastography versus real-time elastography on evaluation thyroid nodules: a preliminary study. European Journal of Radiology . 2014;83(7):1135–1143. doi: 10.1016/j.ejrad.2014.02.024. [DOI] [PubMed] [Google Scholar]
  • 21.Gregory A., Bayat M., Kumar V., et al. Differentiation of benign and malignant thyroid nodules by using comb-push ultrasound shear elastography: a preliminary two-plane view study. Academic Radiology . 2018;25(11):1388–1397. doi: 10.1016/j.acra.2018.02.025. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22.Wang Y., Dan H. J., Dan H. Y., Li T., Hu B. Differential diagnosis of small single solid thyroid nodules using real-time ultrasound elastography. Journal of International Medical Research . 2010;38(2):466–472. doi: 10.1177/147323001003800210. [DOI] [PubMed] [Google Scholar]
  • 23.Ragazzoni F., Deandrea M., Mormile A., et al. High diagnostic accuracy and interobserver reliability of real-time elastography in the evaluation of thyroid nodules. Ultrasound in Medicine and Biology . 2012;38(7):1154–1162. doi: 10.1016/j.ultrasmedbio.2012.02.025. [DOI] [PubMed] [Google Scholar]
  • 24.Lee Y. J., Kim D. W., Park Y. M., et al. Comparison of sonographic and cytological diagnoses of solid thyroid nodules: emphasis on the discordant cases. Diagnostic Cytopathology . 2015;43(12):953–959. doi: 10.1002/dc.23363. [DOI] [PubMed] [Google Scholar]
  • 25.Yunus M., Ahmed Z. Significance of ultrasound features in predicting malignant solid thyroid nodules: need for fine-needle aspiration. Journal of Pakistan Medical Association . 2010;60(10):848–853. [PubMed] [Google Scholar]
  • 26.Zhang J., Liu B. J., Xu H. X., et al. Prospective validation of an ultrasound-based thyroid imaging reporting and data system (TI-RADS) on 3980 thyroid nodules. International Journal of Clinical and Experimental Medicine . 2015;8(4):5911–5917. [PMC free article] [PubMed] [Google Scholar]
  • 27.Kwak J. Y., Han K. H., Yoon J. H., et al. Thyroid imaging reporting and data system for US features of nodules: a step in establishing better stratification of cancer risk. Radiology . 2011;260(3):892–899. doi: 10.1148/radiol.11110206. [DOI] [PubMed] [Google Scholar]
  • 28.Russ G., Bonnema S. J., Erdogan M. F., Durante C., Ngu R., Leenhardt L. European thyroid association Guidelines for ultrasound malignancy risk stratification of thyroid nodules in adults: the EU-TIRADS. European Thyroid Journal . 2017;6(5):225–237. doi: 10.1159/000478927. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 29.Tessler F. N., Middleton W. D., Grant E. G., et al. ACR thyroid imaging, reporting and data system (TI-RADS): white paper of the ACR TI-RADS committee. Journal of the American College of Radiology . 2017;14(5):587–595. doi: 10.1016/j.jacr.2017.01.046. [DOI] [PubMed] [Google Scholar]
  • 30.Castellana M., Grani G., Radzina M., et al. Performance of EU-TIRADS in malignancy risk stratification of thyroid nodules: a meta-analysis. European Journal of Endocrinology . 2020;183(3):255–264. doi: 10.1530/eje-20-0204. [DOI] [PubMed] [Google Scholar]
  • 31.Grani G., Lamartina L., Ascoli V., et al. Reducing the number of unnecessary thyroid biopsies while improving diagnostic accuracy: toward the “right” TIRADS. Journal of Clinical Endocrinology and Metabolism . 2019;104(1):95–102. doi: 10.1210/jc.2018-01674. [DOI] [PubMed] [Google Scholar]
  • 32.Li W., Wang Y., Wen J., Zhang L., Sun Y. Diagnostic performance of American college of radiology TI-RADS: a systematic review and meta-analysis. American Journal of Roentgenology . 2021;216(1):38–47. doi: 10.2214/ajr.19.22691. [DOI] [PubMed] [Google Scholar]
  • 33.Negro R., Attanasio R., Grimaldi F., Frasoldati A., Guglielmi R., Papini E. A. A 2016 Italian survey about Guidelines and clinical management of thyroid nodules. European Thyroid Journal . 2017;6(2):75–81. doi: 10.1159/000453032. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 34.Grani G., Calvanese A., Carbotta G., et al. Intrinsic factors affecting adequacy of thyroid nodule fine-needle aspiration cytology. Clinical Endocrinology . 2013;78(1):141–144. doi: 10.1111/j.1365-2265.2012.04507.x. [DOI] [PubMed] [Google Scholar]
  • 35.Grani G., Lamartina L., Ascoli V., et al. Ultrasonography scoring systems can rule out malignancy in cytologically indeterminate thyroid nodules. Endocrine . 2017;57(2):256–261. doi: 10.1007/s12020-016-1148-6. [DOI] [PubMed] [Google Scholar]
  • 36.He Y. P., Xu H. X., Zhao C. K., et al. Cytologically indeterminate thyroid nodules: increased diagnostic performance with combination of US TI-RADS and a new scoring system. Scientific Reports . 2017;7(1):p. 6906. doi: 10.1038/s41598-017-07353-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 37.Dighe M., Barr R., Bojunga J., et al. Thyroid ultrasound: state of the art. Part 2 - focal thyroid lesions. Med Ultrason . 2017;19(2):195–210. doi: 10.11152/mu-999. [DOI] [PubMed] [Google Scholar]
  • 38.Marqusee E., Benson C. B., Frates M. C., et al. Usefulness of ultrasonography in the management of nodular thyroid disease. Annals of Internal Medicine . 2000;133(9):696–700. doi: 10.7326/0003-4819-133-9-200011070-00011. [DOI] [PubMed] [Google Scholar]
  • 39.Kouvaraki M. A., Shapiro S. E., Fornage B. D., et al. Role of preoperative ultrasonography in the surgical management of patients with thyroid cancer. Surgery . 2003;134(6):946–954. doi: 10.1016/s0039-6060(03)00424-0. [DOI] [PubMed] [Google Scholar]
  • 40.Stulak J. M., Grant C. S., Farley D. R., et al. Value of preoperative ultrasonography in the surgical management of initial and reoperative papillary thyroid cancer. Archives of Surgery . 2006;141(5):489–494. doi: 10.1001/archsurg.141.5.489. [DOI] [PubMed] [Google Scholar]
  • 41.Li W., Zhu Q., Jiang Y., et al. Partially cystic thyroid nodules in ultrasound-guided fine needle aspiration: prevalence of thyroid carcinoma and ultrasound features. Medicine (Baltimore) . 2017;96(46) doi: 10.1097/md.0000000000008689.e8689 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 42.Jeh S. K., Jung S. L., Kim B. S., Lee Y. S. Evaluating the degree of conformity of papillary carcinoma and follicular carcinoma to the reported ultrasonographic findings of malignant thyroid tumor. Korean Journal of Radiology . 2007;8(3):192–197. doi: 10.3348/kjr.2007.8.3.192. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 43.Kim D. S., Kim Jh, Na D. G., et al. Sonographic features of follicular variant papillary thyroid carcinomas in comparison with conventional papillary thyroid carcinomas. Journal of Ultrasound in Medicine . 2009;28(12):1685–1692. doi: 10.7863/jum.2009.28.12.1685. [DOI] [PubMed] [Google Scholar]
  • 44.Henrichsen T. L., Reading C. C., Charboneau J. W., Donovan D. J., Sebo T. J., Hay I. D. Cystic change in thyroid carcinoma: prevalence and estimated volume in 360 carcinomas. Journal of Clinical Ultrasound . 2010;38(7):361–366. doi: 10.1002/jcu.20714. [DOI] [PubMed] [Google Scholar]
  • 45.Chen S. P., Hu Y. P., Chen B. Taller-than-wide sign for predicting thyroid microcarcinoma: comparison and combination of two ultrasonographic planes. Ultrasound in Medicine and Biology . 2014;40(9):2004–2011. doi: 10.1016/j.ultrasmedbio.2014.03.023. [DOI] [PubMed] [Google Scholar]
  • 46.Moon H. J., Kwak J. Y., Kim E. K., Kim M. J. A taller-than-wide shape in thyroid nodules in transverse and longitudinal ultrasonographic planes and the prediction of malignancy. Thyroid . 2011;21(11):1249–1253. doi: 10.1089/thy.2010.0372. [DOI] [PubMed] [Google Scholar]
  • 47.Taki S., Terahata S., Yamashita R., et al. Thyroid calcifications: sonographic patterns and incidence of cancer. Clinical Imaging . 2004;28(5):368–371. doi: 10.1016/s0899-7071(03)00190-6. [DOI] [PubMed] [Google Scholar]
  • 48.Arpaci D., Ozdemir D., Cuhaci N., et al. Evaluation of cytopathological findings in thyroid nodules with macrocalcification: macrocalcification is not innocent as it seems. Arquivos Brasileiros de Endocrinologia & Metabologia . 2014;58(9):939–945. doi: 10.1590/0004-2730000003602. [DOI] [PubMed] [Google Scholar]
  • 49.Yang G. C. H., Fried K. O. Most thyroid cancers detected by sonography lack intranodular vascularity on color Doppler imaging: review of the literature and sonographic-pathologic correlations for 698 thyroid neoplasms. Journal of Ultrasound in Medicine . 2017;36(1):89–94. doi: 10.7863/ultra.16.03043. [DOI] [PubMed] [Google Scholar]
  • 50.Cochlin D. L., Ganatra R. H., Griffiths D. F. Elastography in the detection of prostatic cancer. Clinical Radiology . 2002;57(11):1014–1020. doi: 10.1053/crad.2002.0989. [DOI] [PubMed] [Google Scholar]
  • 51.Giuseppetti G. M., Martegani A., Di Cioccio B., Baldassarre S. Elastosonography in the diagnosis of the nodular breast lesions: preliminary report. Radiologia Medica, La . 2005;110(1-2):69–76. [PubMed] [Google Scholar]
  • 52.Itoh A., Ueno E., Tohno E., et al. Breast disease: clinical application of US elastography for diagnosis. Radiology . 2006;239(2):341–350. doi: 10.1148/radiol.2391041676. [DOI] [PubMed] [Google Scholar]
  • 53.Lyshchik A., Higashi T., Asato R., et al. Cervical lymph node metastases: diagnosis at sonoelastography--initial experience. Radiology . 2007;243(1):258–267. doi: 10.1148/radiol.2431052032. [DOI] [PubMed] [Google Scholar]
  • 54.39th Annual Meeting of the European Thyroid Association. European Thyroid Journal . 2016;5 doi: 10.1159/000517526. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 55.Magri F., Chytiris S., Chiovato L. The role of elastography in thyroid ultrasonography. Current Opinion in Endocrinology Diabetes and Obesity . 2016;23(5):416–422. doi: 10.1097/med.0000000000000274. [DOI] [PubMed] [Google Scholar]
  • 56.Săftoiu A., Vilmann P., Hassan H., Gorunescu F. Analysis of endoscopic ultrasound elastography used for characterisation and differentiation of benign and malignant lymph nodes. Ultraschall in der Medizin . 2006;27(6):535–542. doi: 10.1055/s-2006-927117. [DOI] [PubMed] [Google Scholar]
  • 57.Janssen J., Schlörer E., Greiner L. EUS elastography of the pancreas: feasibility and pattern description of the normal pancreas, chronic pancreatitis, and focal pancreatic lesions. Gastrointestinal Endoscopy . 2007;65(7):971–978. doi: 10.1016/j.gie.2006.12.057. [DOI] [PubMed] [Google Scholar]
  • 58.Săftoiu A., Vilmann P., Ciurea T., et al. Dynamic analysis of EUS used for the differentiation of benign and malignant lymph nodes. Gastrointestinal Endoscopy . 2007;66(2):291–300. doi: 10.1016/j.gie.2006.12.039. [DOI] [PubMed] [Google Scholar]
  • 59.Bae U., Dighe M., Dubinsky T., Minoshima S., Shamdasani V., Kim Y. Ultrasound thyroid elastography using carotid artery pulsation: preliminary study. Journal of Ultrasound in Medicine . 2007;26(6):797–805. doi: 10.7863/jum.2007.26.6.797. [DOI] [PubMed] [Google Scholar]
  • 60.Rubaltelli L., Corradin S., Dorigo A., et al. Differential diagnosis of benign and malignant thyroid nodules at elastosonography. Ultraschall in der Medizin . 2009;30(2):175–179. doi: 10.1055/s-2008-1027442. [DOI] [PubMed] [Google Scholar]
  • 61.Melany M., Chen S. Thyroid cancer: ultrasound imaging and fine-needle aspiration biopsy. Endocrinology and Metabolism Clinics of North America . 2017;46(3):691–711. doi: 10.1016/j.ecl.2017.04.011. [DOI] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data used and analyzed during the current study are available from the corresponding author upon request.

Articles from International Journal of Clinical Practice are provided here courtesy of Wiley

RESOURCES