A Cohort Analysis of Clinical and Ultrasound Variables Predicting Cancer Risk in 20,001 Consecutive Thyroid Nodules

Abstract

Context Assessing thyroid nodules for malignancy is complex. The impact of patient and nodule factors on cancer evaluation is uncertain. Objectives To determine precise estimates of cancer risk associated with clinical and sonographic variables obtained during thyroid nodule assessment. Design Analysis of consecutive adult patients evaluated with ultrasound-guided fine-needle aspiration for a thyroid nodule ≥1 cm between 1995 and 2017. Demographics, nodule sonographic appearance, and pathologic findings were collected. Main Outcome Measures Estimated risk for thyroid nodule malignancy for patient and sonographic variables using mixed-effect logistic regression. Results In 9967 patients [84% women, median age 53 years (range 18 to 95)], thyroid cancer was confirmed in 1974 of 20,001 thyroid nodules (9.9%). Significant ORs for malignancy were demonstrated for patient age <52 years [OR: 1.82, 95% CI (1.63 to 2.05), P < 0.0001], male sex [OR: 1.68 (1.45 to 1.93), P < 0.0001], nodule size [OR: 1.30 (1.14 to 1.49) for 20 to 19 mm, OR: 1.59 (1.34 to 1.88) for 30 to 39 mm, and OR: 1.71 (1.43 to 2.04) for ≥40 mm compared with 10 to 19 mm, P < 0.0001 for all], cystic content [OR: 0.43 (0.37 to 0.50) for 25% to 75% cystic and OR: 0.21 (0.15 to 0.28) for >75% compared with predominantly solid, P < 0.0001 for both], and the presence of additional nodules ≥1 cm [OR: 0.69 (0.60 to 0.79) for two nodules, OR: 0.41 (0.34 to 0.49) for three nodules, and OR: 0.19 (0.16 to 0.22) for greater than or equal to four nodules compared with one nodule, P < 0.0001 for all]. A free online calculator was constructed to provide malignancy-risk estimates based on these variables. Conclusions Patient and nodule characteristics enable more precise thyroid nodule risk assessment. These variables are obtained during routine initial thyroid nodule evaluation and provide new insights into individualized thyroid nodule care.

Clinical, Pathological, and Molecular Characteristics Correlating to the Occurrence of Radioiodine Refractory Differentiated Thyroid Carcinoma: A Systematic Review and Meta-Analysis

“…Generally, a large tumor size is a useful feature for indicating the worse prognosis of PTC (27,28), but it remains unknown in RR-DTC. Here, we drew the opposite conclusion.…”

Thyroid nodules: diagnostic evaluation based on thyroid cancer risk assessment

“…Models that integrate multiple clinical and radiological variables can enhance our estimation of risk of thyroid cancer before FNA. However, as a result of better diagnostic performance, they mostly rely on ultrasound risk assessment 4122123…”

The gray zone of thyroid nodules: Using a nomogram to provide malignancy risk assessment and guide patient management

“…Although extensive attention has been paid to defining the risk of thyroid malignancy due to specific clinical, radiologic, or cytologic findings, relatively few studies have attempted to integrate this data 16‐22 . Angell et al used a combination of histology and cytology outcomes where they considered all benign cytology results equivalent to a benign histology result.…”

“…Although there is a potential bias in our cohort due to its restriction to surgically managed nodules, it is challenging to better define outcome; of note, some related studies have evaluated clinical and sonographic variables against cytologic (rather than histologic) outcome, but this approach is suboptimal and prohibits the use of cytology as an input variable 16,24,25 . Alternately, while long‐term clinical follow‐up and/or “benign” FNA molecular testing might be utilized as outcome surrogates for non‐surgically managed nodules, they each have significant limitations, notably, the variable accuracy of the different available molecular tests and the slow progression of most thyroid cancers.…”