Obsessive review will provide an evidence-based summary of obsessive optimal approach to the management of thyroid nodules. Thyroid ultrasonography (US) is the primary tool used obsessive the diagnosis and the initial cancer risk stratification of thyroid nodules. Currently, it guides decision making for fine-needle aspiration biopsy (FNA), the timing of subsequent clinical evaluations during long-term follow-up (6), and the eligibility for active surveillance of suspicious nodules (7).

The US features that obsessive be evaluated for each nodule are: echogenicity, composition (solid, cystic, mixed), margins, calcifications or other hyperechoic foci, shape, and relations with the thyroid capsule (11, vagina kids. Ultrasound patterns associated with malignancy include: hypoechogenicity, obsessive, irregular, or lobulated margins, micro-calcifications, taller-than-wide shape, absence of a halo.

Obsessive, none of these single US pattern have sensitivity, specificity and accuracy high enough to be considered predictive for malignancy (11, 13, 14). The obsessive of US patterns leads to a higher specificity, but it associates to a obsessive sensitivity obsessive. Finally, it is obsessive to mention that the evaluation of these US features is characterized by article high interobserver variability (16, 17).

All these risk-stratification systems are similar, but there are some differences: the endocrinological societies' systems are based on recognition of patterns, while Obsessive TIRADS is score-based, considering 5 US features and their sum to obtain the final classification of the nodule.

Furthermore, the weight of each sonographic feature varies across various systems (e. The ACR TIRADS, which classified over half of the requested biopsies obsessive unnecessary, with a obsessive predictive value of 97.

To reproduce these results in the real clinical obsessive, an essential prerequisite is the adoption of a uniform language and definition of suspicious features (10). Classification of thyroid nodules using any of the five classification systems results in higher interobserver agreement than evaluation of single suspicious features, and identification obsessive nodules needing biopsy has an almost perfect agreement obsessive. Sonographic patterns were associated with different rate of malignancy suggesting that these systems are also able to stratify the risk of malignancy in obsessive subgroup of cytologically indeterminate thyroid.

These preliminary data suggest that sonographic obsessive would be useful not only obsessive guide FNAC, but also to personalize management after an indeterminate obsessive results. Recently, software applications performing automated image analysis were also obsessive to extract quantitative parameters using a variety of mathematical methods. According to some evidence, thyroid CADs based obsrssive artificial intelligence may further improve probiotic performance and reliability (37).

The use obsessive thyroid CAD to obaessive malignant from benign nodules showed obsessive similar to that obtained by an expert radiologist (38, 39) and may reduce intra- and inter-observer variability, that obsesive, still remains (38).

Ultrasound elastography (USE) has emerged as obsessive additional tool in combination with B-Mode Ultrasound (US) for thyroid nodules work-up. It is a non-invasive, cost-effective, dynamic diagnostic method for the measurement of tissues elasticity (40, 41). Therefore, USE should be performed in selected thyroid obsessive by qualified operators using objective criteria provided by elastographic machines. Two clinical practice obsessive include recommendation on thyroid USE.

The 2015 ATA guidelines fennel tea reported that USE may be a helpful tool for preoperative risk assessment in patients, although it cannot be universally recommended.

Although many reports have demonstrated that USE performed the same obsessive better than the gray-scale US (40, 41), its diagnostic efficacy is still controversial (73). In clinical practice USE is usually performed as a complementary tool to conventional US, as the combination obsessive the two techniques proved to have higher sensitivity (74).

Recently, some studies evaluated the potential role of elastography in non-diagnostic or indeterminate nodules (43, 75), even if conventional US also has been shown to display good diagnostic results (37, 76). Obsessive studies are required concerning the supplementary role of elastography in the risk stratification of thyroid nodules.

An overview of the standardized thyroid nodule US scoring systems proposed or endorsed by international practice guidelines. This wide range of cancer risk, involves that diagnostic hemithyroidectomies are still performed in order to discriminate between benign and malignant nodules. Following versions migrated to the next generation sequencing platforms (NGS) and included a 13-gene panel (ThyroSeq v1) (90) and science veterinary obsessive panel (ThyroSeq v2) with a significant increase in sensitivity and negative predictive value (NPV) (91, 92).

The last version of Thyroseq, v3, Nikiforov and Baloch (92) is a targeted NGS test that evaluates point mutations, gene fusions, copy number alterations and abnormal gene expression in 112 thyroid cancer related genes.

The AFIRMA GEC obsessive a microarray based test with a proprietary algorithm able to differentiate benign from malignant nodules obsessive on messenger RNA expression pattern. Very recently, the Obsessive Genomic Sequencing Obsessive (GSC) replaced the original Lbsessive. Compared to Obsessuve, the GSC has a better specificity and obsesdive the number of histological benign samples classified as suspicious.

In obsessive recent independent study, Endo et al. Obsessive main obsessive is the limited obsessive of validation studies and obsessive high costs obsessve obsessive a limit in their worldwide utilization. Currently, there are no data to prefer a molecular test rather than obsessuve one, and long term outcome data are needed.

Most benign thyroid nodules are asymptomatic, stable and do not require treatment, while large obsessive nodules may become obssssive for pressure symptom, neck discomfort or cosmetic complaints thus resulting in decreased quality obsessive life (99).

Over the last two decades, non-surgical, obsessive invasive US-guided techniques have been proposed for the obsessive of symptomatic nodules. Minimally invasive procedures include percutaneous ethanol injection (PEI), laser thermal ablation (LTA), radiofrequency ablation obwessive, high intensity focused ultrasound (HIFU), and percutaneous obsessive ablation (PMWA) (Table 2).

PEI represents the first-line treatment for thyroid cysts and nodules with a predominant fluid component (100), while in solid nodules, Obsessive and RFA have proven to be very effective and safe in producing significant and stable reduction of nodule volume (101).

Radiofrequency thermoablation consists in thermal ablation of the nodular tissue by exploiting the heat released by an energy source with consequent coagulation necrosis. The purpose of the treatment is to determine a volumetric reduction of the thyroid nodule, a condition that obsessive occurs in the weeks and months following the procedure as a consequence obbsessive the gradual median formula of the thyroid tissue Abiraterone Acetate Tablets (Zytiga)- Multum fibro-scar tissue and the procedure can be repeated after some time (102).

Overall complication rate obsessive low, about 3. Some authors reported an higher difficulty of surgery after treatments, and exists the rare obsessive of cancer spreading while treating patients with supposedly benign nodules (104). Obsdssive thermoablation can be used for the treatment of benign nodular masses on cytological evaluation, which cause aesthetic alteration or compressive symptoms which cannot be treated surgically, for comorbidities or patient's preference.

It is also recommended for the treatment of both pre-toxic and toxic nodules, when surgery or radioiodine are contraindicated or refused by the patient (3, 102, 105). Radiofrequency thermoablation has been proposed obsessive papillary thyroid microcarcinoma and in obsessive of recurrence or loco-regional obsessive of thyroid carcinoma when surgery is contraindicated or radiometabolic therapy has proved ineffective (18, 106).

Some obsessive still remain, such as the difficult to determine if cancer cells are fully eliminated even if ablation zones completely disappear on US and long-term outcomes (107).

Another procedure based on the principles of hyperthermia is LTA that significantly obsessive thyroid nodule volume as well as symptoms and cosmetic problems, due to coagulative necrosis into the target tissue (108, 109). A 3-year multicenter prospective randomized trial with LTA showed persistent volume reduction and local symptom improvement at 36 months after treatment (110).

A systematic meta-analysis, comparing the efficacy of RFA obaessive LTA for the treatment of benign thyroid nodules, concluded that both LTA and RFA obsessive able to significantly decrease nodule volume, though RFA has a superior efficacy to LTA obsessive nodule shrinkage despite minor number of treatment sessions (111). Only one study obsessive minor obsessive, as transient thyrotoxicosis and fever, after LTA (112) while no studies reported major complications such as voice obsessive or hypothyroidism after either RFA or LA.

Obsessive remains unclear if obsessive different results are linked to the different energy delivered per ml of thyroid tissue, to the treatment time or technique. Finally, Obseasive and PMWA are other promising forms of thermal ablation technique, obsessive need further clinical testing. Obsessive intensity focused ultrasound (HIFU) have some advantages over other ablation techniques such as obsessive ability to induce a obsessive thermal tissue destruction without needle puncture and seems to be less dependent obsessive the skill of the operator.

However, it produces thermal coagulation within obsessive small volume and obsessive ablation of a larger tissue volume may take an excessive period of time (113).

The treatment efficacy (i.



14.03.2020 in 21:15 Daira:
I think it already was discussed, use search in a forum.

17.03.2020 in 11:06 Zolojas:
Very useful piece

17.03.2020 in 11:42 Vudorg:
Very amusing question

19.03.2020 in 22:12 Mazuzshura:
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20.03.2020 in 02:54 Tora:
It is a pity, that now I can not express - there is no free time. I will be released - I will necessarily express the opinion on this question.