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Original Investigation |

Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics:  Results of a Population-Based Study

Rebecca Smith-Bindman, MD1,2,3; Paulette Lebda, MD4; Vickie A. Feldstein, MD1,3; Dorra Sellami, MD5; Ruth B. Goldstein, MD1,3; Natasha Brasic, MD1; Chengshi Jin, PhD2; John Kornak, PhD2
[+] Author Affiliations
1Department of Radiology and Biomedical Imaging, University of California, San Francisco
2Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco
3Department of Epidemiology and Biostatistics, University of California, San Francisco
4Department of Radiology, Cleveland Clinic, Cleveland, Ohio
5California Advanced Imaging Medical Associates, Mills-Peninsula Hospital, San Mateo
JAMA Intern Med. 2013;173(19):1788-1795. doi:10.1001/jamainternmed.2013.9245.
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Importance  There is wide variation in the management of thyroid nodules identified on ultrasound imaging.

Objective  To quantify the risk of thyroid cancer associated with thyroid nodules based on ultrasound imaging characteristics.

Methods  Retrospective case-control study of patients who underwent thyroid ultrasound imaging from January 1, 2000, through March 30, 2005. Thyroid cancers were identified through linkage with the California Cancer Registry.

Results  A total of 8806 patients underwent 11 618 thyroid ultrasound examinations during the study period, including 105 subsequently diagnosed as having thyroid cancer. Thyroid nodules were common in patients diagnosed as having cancer (96.9%) and patients not diagnosed as having thyroid cancer (56.4%). Three ultrasound nodule characteristics—microcalcifications (odds ratio [OR], 8.1; 95% CI, 3.8-17.3), size greater than 2 cm (OR, 3.6; 95% CI, 1.7-7.6), and an entirely solid composition (OR, 4.0; 95% CI, 1.7-9.2)—were the only findings associated with the risk of thyroid cancer. If 1 characteristic is used as an indication for biopsy, most cases of thyroid cancer would be detected (sensitivity, 0.88; 95% CI, 0.80-0.94), with a high false-positive rate (0.44; 95% CI, 0.43-0.45) and a low positive likelihood ratio (2.0; 95% CI, 1.8-2.2), and 56 biopsies will be performed per cancer diagnosed. If 2 characteristics were required for biopsy, the sensitivity and false-positive rates would be lower (sensitivity, 0.52; 95% CI, 0.42-0.62; false-positive rate, 0.07; 95% CI, 0.07-0.08), the positive likelihood ratio would be higher (7.1; 95% CI, 6.2-8.2), and only 16 biopsies will be performed per cancer diagnosed. Compared with performing biopsy of all thyroid nodules larger than 5 mm, adoption of this more stringent rule requiring 2 abnormal nodule characteristics to prompt biopsy would reduce unnecessary biopsies by 90% while maintaining a low risk of cancer (5 per 1000 patients for whom biopsy is deferred).

Conclusions and Relevance  Thyroid ultrasound imaging could be used to identify patients who have a low risk of cancer for whom biopsy could be deferred. On the basis of these results, these findings should be validated in a large prospective cohort.

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Figure.
Thyroid Nodules

A-D, Nodules that are entirely solid. A-C, Nodules with microcalcifications.

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