Evaluation of role of sonoelastography in solitary thyroid nodule with pathological correlation

Suresh Phatak; Shraddha Jain; Kaustubh Madurwar; Sakshi Daga; Soumya Jain; Rishab Gupta

doi:10.4103/jdmimsu.jdmimsu_131_19

ORIGINAL ARTICLE

Year : 2020 | Volume : 15 | Issue : 3 | Page : 372-375

Evaluation of role of sonoelastography in solitary thyroid nodule with pathological correlation

Suresh Phatak¹, Shraddha Jain², Kaustubh Madurwar¹, Sakshi Daga¹, Soumya Jain¹, Rishab Gupta¹
¹ Department of Radiodiagnosis, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi(M), Wardha, Maharashtra, India
² Department of ENT, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi(M), Wardha, Maharashtra, India

Date of Submission	03-Sep-2019
Date of Decision	15-Sep-2020
Date of Acceptance	30-Sep-2020
Date of Web Publication	1-Feb-2021

Correspondence Address:
Dr. Suresh Phatak
Department of Radiodiagnosis, Jawaharlal Nehru Medical College, Sawangi, Wardha, Maharashtra
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jdmimsu.jdmimsu_131_19

Abstract

Aims: To evaluate the role of sonoelastography in solitary thyroid nodule with a pathological correlation. Subjects and Methods: This was a prospective observational study conducted in patients presenting with solitary thyroid nodule. It was carried out in AVBRH Hospital, Sawangi, Wardha, during July 2016–June 2019. One hundred and two patients were included in the study. Most of them were female patients. Most of the patients were in the age group of 41–50 years followed by 31–40 years. Results: Sonoelastography shows good sensitivity, specificity, positive predictive value, negative predictive value, and accuracy in identifying thyroid pathology. Conclusions: Sonoelastography is a new imaging modality which is helpful in characterization of thyroid nodule and shows significant accuracy in differentiating benign from malignant lesion.

Keywords: Elastography, malignant, thyroid nodule, ultrasound

How to cite this article:
Phatak S, Jain S, Madurwar K, Daga S, Jain S, Gupta R. Evaluation of role of sonoelastography in solitary thyroid nodule with pathological correlation. J Datta Meghe Inst Med Sci Univ 2020;15:372-5

How to cite this URL:
Phatak S, Jain S, Madurwar K, Daga S, Jain S, Gupta R. Evaluation of role of sonoelastography in solitary thyroid nodule with pathological correlation. J Datta Meghe Inst Med Sci Univ [serial online] 2020 [cited 2021 Mar 4];15:372-5. Available from: http://www.journaldmims.com/text.asp?2020/15/3/372/308541

Introduction

A thyroid nodule is defined as abnormal growth of cells within the thyroid gland that represents a common clinical entity in about 4%–8% of adults during palpation and about 41% by ultrasound (US) examination and may be in about 50% of autopsy studies.^[1] The incidence of malignancy is estimated to be approximately 5% in thyroid nodules.^[2] It is very important to differentiate malignant nodules from benign which do not require surgery and the challenge is to evaluate the thyroid nodule and decide which patient should proceed for biopsy.^{[3],[4],[5],[6]} US elastography noninvasively evaluates the tissue stiffness by measuring its deformation degree in response to applied stress. Its salient principle is that on application of compression, the softer parts of tissues tend to deform easily than the harder ones and thus tissue stiffness can be determined objectively.^[7],[8] A prospective study is done to evaluate the role of sonoelastography in solitary thyroid nodule with pathological correlation.

Subjects and Methods

A total number of 102 patients with solitary thyroid nodules (62 females and 40 males) were involved in this study. It was carried out in AVBRH Hospital Sawangi, Wardha, from July 2016 to June 2019. The institutional ethical committee approved this study and informed consent was obtained from all patients.

The inclusion criteria

All patients presenting with solitary thyroid nodule.

The exclusion criteria

Multinodular thyroid mass
Large nodule (>5 cm)
Postoperative patients
Patients with known pathological diagnosis.

Imaging was performed using Aloka Hitachi US machine (Arietta 70 S) with a 12–18 MHz linear array probe and strain elastography.

Conventional B-mode US image was obtained first to assess the morphologic appearance of the thyroid nodule including the nodule size, margins, echogenicity, and calcification.

After conventional B-mode US image acquisition, elastography was obtained. Patients lie on supine position. A transducer was placed on neck, and after locating thyroid nodule, gentle manual compression was applied and elastograms were obtained. Stiff tissues were displayed in dark-blue color, whereas soft and most deformed tissues were seen in green color.

Evaluation based on elastography scores

Each nodule was assigned an elastography score based on a four-point scale according to the classification proposed by Itoh et al.^[9]

Score 1: Low stiffness over the entire nodules (entirely green)
Score 2: Low stiffness over most of the nodule (almost green with blue spots)
Score 3: High stiffness over most of the nodule (almost blue with green spots)
Score 4: High stiffness over the entire nodule (entirely blue).

Evaluation based on strain ratio

The strain ratio (normal tissue-to-lesion strain ratio) of each nodule was calculated by dividing the strain value of the normal tissue by that of the nodule.^[10] Higher values indicate possibility of malignancy.

Pathological diagnosis

Pathological examination of all thyroid nodules was used as the diagnostic standard of reference.

Ethical clearance

The Institutional Ethics Committee of DMIMSDU has approved the Research work proposed to be carried out at Jawaharlal Nehru Medical College, Sawangi(M), Wardha. Date: 30^th Jan 2016 with Reference no DMIMS(DU)/IEC/2016/265

Results

Most of the patients (31.37%) were in the age group of 41–50 years, followed by 31–40 years of age. Most patients included in study were female (66.66%). Nodular goiter was the most common pathology in thyroid nodules followed by thyroiditis and adenoma. In case of thyroid carcinoma, papillary carcinomas were maximum in number. In sonographic features of thyroid nodule, majority of nodules were more than 2 cm in size, with regular margins and showing hyperechoic echotexture. In case of intraparenchymal calcifications, fine calcifications were more common than coarse calcifications. In elastography score of thyroid nodules, a score of 1–2 was seen in majority of benign nodules [Figure 1], whereas a score of 3–4 dominated in case of malignant nodules [Figure 2]. In strain ratio, benign lesions had strain ratio between 0.84 and 3.5, whereas malignant lesions showed strain ratio values between 3.8 and 50.33, indicating that malignant lesions have significant higher values. Cystic lesions typically showed blue–green–red pattern on elastography [Figure 3]. Final diagnosis was based on pathological correlation. In case of thyroid ultrasonography, false positive cases were 2 and false negative cases were 8. In case of sonoelastography, false positive cases were 2 and false negative cases were 3. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of sonography were 91.76%, 82.35%, 96.30%, 66.67%, and 90.20%, respectively. In case of sonoelastography, sensitivity, specificity, PPV, NPV, and accuracy were 96.51%, 87.50%, 97.65%, 82.35%, and 95.10%, respectively [Table 1],[Table 2],[Table 3],[Table 4],[Table 5],[Table 6],[Table 7],[Table 8].

Figure 1: A well-defined hyperechoic nodule in the right lobe of thyroid with hypoechoic peripheral halo showing mostly green and red (score I by Itoh et al.) and strain ratio of 0.84 indicating benign lesion, adenoma on fine-needle aspiration cytology

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Figure 2: A hypoechoic nodule in left lobe of thyroid with microcalcifications. On elastography, it shows mostly blue color (Stiff tissue) with some green in periphery (signifying score III by Itoh et al.). Strain ratio was 50.33 indicating malignant lesion. Fine-needle aspiration cytology report was papillary carcinoma

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Figure 3: A complex lesion in the left lobe of thyroid showing debris, thin septa, and fluid level. On elastography, typical blue–green–red appearance is seen indicating cyst. Hemorrhagic cyst confirmed on aspiration

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Table 1: Age of patients

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Table 2: Sex incidence

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Table 3: Pathological diagnosis of solitary thyroid nodules

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Table 4: Thyroid solitary nodule ultrasonography features

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Table 5: Elastography score of thyroid nodules

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Table 6: Comparison between ultrasonography, elastography and pathological diagnosis

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Table 7: Thyroid ultrasonography

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Table 8: Ultrasound elastography

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Discussion

EL-Hariri et al. concluded in 2014 that the scores of 1 and 2 with Itoh criteria were significantly seen in benign nodules, whereas scores of 3 and 4 were significantly seen in malignant nodules. Our study also shows a similar pattern in thyroid nodules.^[11] Eltyib et al. in 2014 concluded that on real-time US elastography, majority of benign nodules had a score of 1 or 2, whereas maximum malignant nodules had a score of 3 to 5.^[12] Khamis et al. in 2017 concluded that both conventional US and strain elastography score have the best diagnostic performance with sensitivity, specificity, PPV, NPV, and accuracy accounting for 80%, 97%, 57%, 99%, and 96%, respectively.^[13] In our study, sonoelastography sensitivity, specificity, PPV, NPV, and accuracy were 96.51%, 87.50%, 97.65%, 82.35%, and 95.10%, respectively, which shows better sensitivity and comparable accuracy. In 2014, Kura et al. concluded that the elastography strain ratio allowed ruling out malignant nodules with a strain ratio of =2 and a NPV of 99%, improving the selection of patients for fine-needle aspiration cytology. The increase in the elastography strain ratio was associated with a higher probability of malignant thyroid pathology, although no cutoff value could be established because of the low number of cases with Bethesda V–VI nodules.^[14] In our study also, we have seen the similar trend.^{[15],[16],[17],[18],[19],[20]}

Conclusions

Sonoelastography is a new imaging modality, which is helpful in characterization of thyroid nodule and shows significant accuracy in differentiating benign from malignant lesion.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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