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DOI 10.26724/2079-8334-2018-3-65-78-82 UDC 616.441-073.48-037:616.441-006.6
EVALUATION OF THE ULTRASONOGRAPHIC SCALE IN THYROID CANCER RISK
STRATIFICATION
E-mail: marinavolodia@ukr.net.
The purpose of the study was to compare the main known ultrasonographic (USG) scales (TIRADS by Russ, ACR-TIRADS, ATA recommendation and U classification) in predicting of thyroid cancer. A retrospective analysis of patients' cards for 2015-2016 has been carried out, which have undergone an operating treatment for thyroid nodules. There was a significant difference in the prevalence of thyroid cancer among patients with cystic and solid nodes, which was 4.4% and 15.1% respectively (x2=21.082; p<0.001). A significant difference was found between the groups of patients with a detailed preoperative USG (14.8% of cases of thyroid cancer) and patients with incomplete USG (8.0% of cases of cancer: x2=10.388; p=0.002). Papillary microcarcinoma was found practically with the same frequency regardless of the risk groups on USG. The TIRADS by Russ showed the highest statistical indicators in predicting of thyroid cancer: specificity - 88.6%, positive predictive value - 40.0%, accuracy - 81.9%. While the ACR-TIRADS and ATA recommendations had the highest sensitivity rates of 79.2% and 80.2%, and can be used as screening for thyroid cancer.
Key words: thyroid ^ nodules, ultrasonography, diagnostic ^ scales.....................
The paper is a fragment of the research work "Management consideration of patients' with surgical pathology of the abdominal cavity, endocrine system, purulent tissues diseases, using modern technologies to improve the immediate and long-term results and prevent complications ", state registration number 0115U000048.
The number of patients with thyroid nodules (TN), as well as the number of operations on thyroid gland (TG), is steadily increasing [7], and therefore the problem of differential diagnosis of TN with the aim of early detection of malignancy and indications for surgery remains actual. Despite the significant achievements in the field of diagnosis and use of highly informative imaging studies (elastography, magnetic resonance imaging, computer and positron emission tomography), the percentage of benign thyroid pathology among operated patients remains high — 87.2-91.0% [1].
Nowadays, the basic methods of differential diagnosis of TN are ultrasonography (US) and fine-needle aspiration biopsy (FNAB) with subsequent cytological examination [2]. US allows to evaluate such parameters of TN as size, contents, echogenicity, margin, vascularization, presence of fluid, as well as pathological inclusions. However, often US conclusions are bulky, contain a lot of descriptive information, which makes it difficult to interpret and compare.
For the first time, the group of authors from Chile collected and classified data on US of the thyroid gland [3], offering a system with the abbreviation TIRADS (Thyroid Image Reporting and Data System), aimed to stratify TN in the risk of thyroid cancer, and to conduct a more effective selection of patients for FNAB. Subsequently, TIRADS modifications were introduced by a group of researchers from Korea [4] and France [5]. The last, TIRADS by Russ (2011), remains the most popular today, although in 2017 the American College of Radiologists (ACR) published a modified version with abbreviation - ACR TIRADS [6]. Regardless of this, the American Thyroid Association (ATA) and the British Thyroid Association (BTA) have proposed alternative scales for ultrasonographic evaluation of thyroid nodes: ATA recommendation [2] and U classification [8] respectively.
Principles for the classification by the applied scales are similar and based on the analysis of the US pattern of the TNs with the detection of risk factors of thyroid cancer.
The purpose of our study was to compare the main modern ultrasonographic scales (TIRADS by Russ, ACR-TIRADS, ATA recommendation and U classification) in predicting the risk of thyroid cancer.
Material and methods. A retrospective (2015-2016) analysis of patients' data was conducted. All the patients underwent surgical treatment for TNs in Lviv Regional Clinical Hospital surgical department № 3. In addition to general data (patient's age and gender, history of TN), other parameters of thyroid status (TSH, T3, T4, thyroglobulin, antibodies against thyroglobulin and peroxidase antigen) were studied. US determined the number of thyroid nodes, the size of the solitary or dominant node, the presence of the fluid component, lymphadenopathy and other results. Cytological examination after FNAB, the extent of surgery, intraoperative (frozen section) and the final histological verification of the diagnosis were studied.
Performing stratification of thyroid cancer risk according to following scales (TIRADS by Russ, ACR-TIRADS, ATA recommendation and U classification), the data of preoperative US was evaluated
© V.I. Kolomiytsev, V.N. Marina, 2018
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for the of risk factors presence: hypoechogenicity, irregular margins, presence of calcifications, invasions beyond thyroid gland, enlarged regional lymph nodes, etc. A combination of factors corresponded to respective degree of risk according to selected scales. For example, the hypoechoic tissue nodule of the TG with microcalcifications (2 risk factors) will be classified as TIRADS 4b, U 4, ACR-TIRADS 4 and moderate risk according to ATA recommendation. The obtained data for each scale were analysed and compared their diagnostic capabilities in predicting thyroid cancer. Sensitivity, specificity, positive and negative predictive value and accuracy of the method were determined.
The calculation of the obtained results was performed using SPSS 11.5 for Windows statistical software. Relative data comparison we used x2-test for t-test was used to compare parametric data.
Results of the study and their discussion. Our study involved 1033 patients, who underwent surgery because of TNs, which were detected on US. The study did not include patients who had no TNs on US (diffuse toxic goiter, Hashimoto's thyroiditis, etc.). The average patient's age was 49.2±14.4 years, the prevalence of women was 926 (89.6%). 127 (12.3%) cases of thyroid cancer were diagnosed among all patients. The average size of the solitary or dominant (largest or suspected for malignancy) nodule in case of multinodular goiter was 31.6±14.4 mm in general. Cystic changes (fluid component exceeded 10% of its volume on US) were defined in 271 (26.2%) patients. A significant difference in the prevalence of thyroid cancer among patients with cystic and solid thyroid nodules was detected: 4.4% and 15.1% respectively (x2=21.082; p<0.001).
The duration of the anamnesis varied widely with the median of 24 months (quartile swing - from 4 to 60 months). The level of TSH and other markers of thyroid status did not differ significantly in the groups of patients distributed by age, sex, and the presence of pathological inclusions.
The results of every patient's US were ranked according to selected scales and assigned an appropriate grade of thyroid cancer risk. A significant part of the records - 386 (37.4%) - was not able to be stratified because of the lack of information on US; therefore, they were qualified as "unrated" group and were excluded in the further investigation. The remaining 647 patients were classified according to US findings and were stratified by following scales: TIRADS by Russ, ATA recommendations, U classification, ACR-TIRADS. All the cases were randomly distributed into both groups ("unrated" and "classified"), that was confirmed by similar characteristics: patient's age, sex, duration of anamnesis, etc. The dimensions of the nodule diameters in "unrated" and "classified" groups were similar: 34.6±14.5 mm and 30.0±13.8 mm (t - 4.62; p = 0.0014). There were similar histological findings in both groups, except thyroid cancer (Tab. 1).
Papillary microcarcinoma (PMC) is a papillary thyroid cancer less than 10 mm in diameter, which was accidentally diagnosed, and was found in both groups at almost the same frequency (3.1% and 2.9%). Only among cystic nodules, the incidence of PMC was lower - 1.8%.
Among the 647 patients of "classified" group, the incidence of thyroid cancer was 14.8%, whereas among 386 patients of "unrated" group with insufficient US interpretation, the percentage of cancer was 8.0% (x2=10.388; p=0.002).
Table 1
Histological findings in "classified" and "unrated" groups
^^—Histology Group ^^^^^^^ Colloid goiter n (%) Thyroid adenoma n (%) Thyroid cancer n (%) PMC n (%)
«Classified» (n=647) 393 (60.7%) 127 (19.6%) 96 (14.8%) 19 (2.9%)
«Unrated» (n=386) 271 (70.3%) 75 (19.4%) 31 (8.0%) 12 (3.1%)
This significant statistical difference can be explained by the fact that in "unrated" group the TNs were larger than 30 mm more often, what persuade radiologist to miss fully describe US, but surgeon was inclined to perform operation because of large nodes. In general, the "unrated" group contained a higher number of patients with benign thyroid pathology compared to the "classified" group, which again emphasized the need for detailed description of TN on US for better evaluation of the cancer risk.
After analysis of the histological conclusions of "classified" group (647 patients), results were stratified by following US scales (Tab. 2).
The following main regularities were noted. Prevalence of PMC varied between 2.5-3.8% among different ultrasonographic scales groups, and did not depend on risk group. Colloid goiter was found with a frequency of 60-70% in low risk subgroups by investigated scales with a significant reduction in the frequency (to 20%) in subgroups of moderate and high risk. The same patterns were observed for thyroid adenoma: 20-25% in subgroups with low risk and a decrease in the frequency to 10% in moderate and high risk groups.
And finally, from 3.3 to 70% in
the incidence of thyroid cancer clearly increased in all the above-mentioned scales high risk subgroups.
Table 2
TIRADS by Russ
Risk group Histology ——^^^^ 3 (n=324) 4a (n=210) 4b (n=95) 5 (n=10)
Colloid goiter 227 (70.1%) 123 (58.6%) 37 (39.0%) 2 (20%)
Thyroid adenoma 67 (20.7%) 42 (20.0%) 14 (14.7%) 1 (10%)
Thyroid cancer 19 (5.9%) 35 (16.7%) 35 (36.8%) 7 (70%)
PMC 9 (2.8%) 7 (3.3%) 3 (3.2%) -
Others 11 (3.4%) 11 (5.2%) 8 (8.4%) -
U Classification
Risk group Histology ——^^^^ 2 (n=159) 3 (n=346) 4 (n=132) 5 (n=10)
Colloid goiter 114 (71.7%) 227 (65.6%) 52 (39.4%) 2 (20%)
Thyroid adenoma 33 (20.8%) 73 (21.1%) 20 (15.2%) 1 (10%)
Thyroid cancer 6 (3.8%) 36 (10.4%) 47 (35.6%) 7 (70%)
PMC 4 (2.5%) 10 (2.9%) 5 (3.8%) -
Others 6 (3.8%) 9 (2.6%) 13 (9.8%) -
ATA recommendations
——^^^^ Risk group Histology —— Very low (n=9) Low (n=344) Moderate (n=238) High (n=56)
Colloid goiter 7 (77.8%) 243 (70.6%) 126 (52.9%) 19 (34%)
Thyroid adenoma 2 (22.2%) 79 (23%) 46 (19.3%) 7 (12.5%)
Thyroid cancer - 19 (5.5%) 48 (20.2%) 29 (51.8%)
PMC - 10 (2.9%) 9 (3.8%) -
Others - 10 (2.9%) 17 (7.1%) 10 (1.8%)
ACR TIRADS
——^^^^ Risk group Histology —— 2 (n=90) 3 (n=251) 4 (n=285) 5 (n=21)
Colloid goiter 71.1% 69.3% 53.0% 28.6%
Thyroid adenoma 22.2% 20.7% 18.2% 14.3%
Thyroid cancer 3.3% 7.2% 22.5% 57.1%
PMC 3.3% 3.6% 3.2% -
Others 4.4% 2.8% 6.0% -
| | | - groups of moderate and high cancer risk
For evaluation the effectiveness of each US scales, two groups of the highest risk were selected on each of the investigated scales: "4b" and "5" grades for TIRADS by Russ; "4" and "5" ACR-TIRADS and U classification; as well as "the moderate" and "high-risk" scale for the ATA recommendation.
In order to predict thyroid cancer and differentiate from benign pathology, specificity, positive predictive value and total accuracy were chosen among statistical parameters (Tab. 3).
The highest specificity of thyroid cancer prediction was found in the TIRADS by Russ and U classification - 88.6% and 84.0% respectively. In assessing the positive predictive value, TIRADS by Russ and U classification, showed higher results among others - 40.0 and 38.0%. Also, these scales showed the highest accuracy of the method: TIRADS by Russ - 81.9% and U classification - 79.9%. The results can be explained by the fact that the ACR-TIRADS and ATA recommendations include more cases of benign thyroid disease in subgroups of moderate to high risk, so the percentage of thyroid cancer is
lower, and the specificity and accuracy of thyroid cancer prediction were lower compared to TIRADS by Russ and U classification. On another hand, ACR-TIRADS and ATA recommendations scales showed higher sensitivity and could be recommended as screening for thyroid cancer.
Table 3
Statistical parameters of ultrasonographic scales in prediction of thyroid cancer
~--------- Parameter Scale Sensitivity Specificity Positive predictive value Accuracy
TIRADS by Russ 43.8% 88.6% 40.0% 81.9%
U classification 56.3% 84.0% 38.0% 79.9%
АТА recommendation 80.2% 60.6% 26.2% 63.5%
ACR-TIRADS 79.2% 58.3% 24.8% 61.4%
Besides that TIRADS by Russ scale showed better statistical results in the prediction of thyroid cancer, in our opinion, it is more convenient for practical use among the investigated scales as well.
1. The use of ultrasonographic stratification scale for prediction of thyroid cancer can improve the patient's selection for surgical treatment, increase the prevalence of thyroid cancer among operated patients, and reduce the number of operations for benign pathology.
2. Papillary microcarcinoma of thyroid gland occurs randomly with a frequency of 2.5%-3.8% among all subgroups, and is not predictable by ultrasonographic scales.
3. Thyroid cancer is significantly more common among solid nodes than cystic, 15.1% and 4.4%, respectively.
4. The TIRADS by Russ scale showed the highest specificity (88.6%), positive predictive value (40.0%) and accuracy (81.9%) for prediction of thyroid cancer and is the most convenient for use in practice.
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ПОР1ВНЯЛЬНА ОЦ1НКА УЛЬТРАСОНОГРАФ1ЧНИХ ШКАЛ В СТРАТИФ1КАЦП ПРОГНОЗУ РИЗИКУ
РАКУ ЩИТОПОД1БНО1 ЗАЛОЗИ Коломшцев В.1., Марша В.Н. , Лукавецький О.В.,
Довгань Ю.П. Метою дослщження було nopiBMHra основних вщомих ультpасoнoгpафiчних (УСГ) шкал (TIRADS за Russ, ACR-TIRADS, АТА recommendation та U classification) у прогнозуванш ризику раку щитoпoдiбнoI залози (ЩЗ). Проведено ретроспективний аналiз стащонарних карт пащенив за 2015-2016 рр., яю перенесли операцшне лкування з приводу вузлових утворень ЩЗ. Вiдмiченo значну piзницю у поширеност раку ЩЗ серед пащенив iз юстозними i солщними вузлами, яка склала 4,4% та 15,1% вщповщно (х2
СРАВНИТЕЛЬНАЯ ОЦЕНКА УЛЬТРАСОНОГРАФИЧЕСКИХ ШКАЛ В СТРАТИФИКАЦИИ ПРОГНОЗА РИСКА РАКА ЩИТОВИДНОЙ ЖЕЛЕЗЫ Коломийцев В.И., Марина В.Н., Лукавецкий А.В., Довгань Ю.П.
Целью исследования было сравнение основных известных ультразвуковых шкал (TIRADS за Russ, ACR-TIRADS, АТА recommendation и U classification) в прогнозировании риска рака щитовидной железы (ЩЖ). Проведен ретроспективный анализ стационарных карт пациентов за 2015-2016 гг., которые были оперированы в связи с узловыми образованиями ЩЖ. Отмечено значительную разницу в распространенности рака ЩЖ среди пациентов с кистозными и солидными узлами, которая составила 4,4% и 15,1% соответственно (х2=21.082, р<0,001).
=21.082; р<0,001). Виявлено суттеву рiзницю мiж групами пащенив i3 детальною передоперацшною УСГ (14,8% випадюв раку ЩЗ) i пацiентами з неповним описом УСГ (8,0% випадюв раку: х2=10,388; р=0,002). Папiлярна мiкрокарцинома ЩЗ за результатами УСГ зпдно дослiджуваних шкал зустрiчалася практично з однаковою частотою незалежно вiд груп ризику. Шкала TIRADS за Russ показала найвищi серед дослщжуваних шкал статистичнi показники у виявлеш раку ЩЗ: специфiчнiсть - 88,6%, позитивне прогностичне значення - 40,0%, дiагностичну цiннiсть методу - 81,9%. В той час як шкали ACR-TIRADS i АТА recommendation володши найвищими показниками чутливост - 79.2% i 80.2% i можуть бути використаш в якост скринiнгу раку ЩЗ.
Ключовi слова: вузли щитоподiбноï залози, ультрасонографiя, дiагностичнi шкали.
Стаття надшшла: 11.04.18 р.
Выявлено существенное различие между группами пациентов с детальным предоперационным ультразвуковым исследованием (УЗИ) (14,8% случаев рака ЩЖ) и пациентами с неполным описанием УЗИ (8,0% случаев рака: Х2=10,388, р=0,002). Папиллярная микрокарцинома ЩЗ встречалась практически с одинаковой частотой независимо от групп риска по результатам УЗИ. Шкала TIRADS за Russ показала самые высокие статистические показатели в прогнозировании рака ЩЖ: специфичность - 88,6%, положительное прогностическое значение - 40,0%, диагностическую ценность метода - 81,9%. В то же время шкалы ACR-TIRADS и АТА recommendation продемонстрировали высокие значения показателей чувствительности (79.2% и 80.2%) и могут быть использованы в качестве скрининга рака ЩЖ.
Ключевые слова: узлы щитовидной железы, ультразвуковое исследование, диагностические шкалы.
Рецензент Старченко 1.1.
DOI 10.26724/2079-8334-2018-3-65-82-86 УДК 618.2/3:618.15-002:576.8.073.3
ДИНАМ1КА М1КРОЕКОЛОГЧНИХ ПОКАЗНИК1В СТАТЕВИХ ШЛЯХ1В У ВАГ1ТНИХ З ЗАПАЛЬНИМИ ЗАХВОРЮВАННЯМИ РЕПРОДУКТИВНО1 СИСТЕМИ
E-mail: microbiki@gmail.com
У ваптних жшок з запальними захворюваннями статевих шляхiв вщбуваеться формування иатолопчиого мжробюцеиозу 3i змшою сшввщношения облкатио! та факультативно! частин резидентно! мкрофлори. В po6oTi проведена оцшка структури бактерiальних асоцiацiй та вивчена динамiка змш мiж аеробним та анаеробним компонентами мкробюцеиозу статевих шляхiв у 98 ваптних жшок з запальними захворюваннями репродуктивно! системи у рiзнi иерюди вагiтностi. Одержанi данi свiдчать, що мiкробiоценоз статевих шляхiв у жшок з запальними захворюваннями у рiзнi термши вагiтностi характеризуеться формуванням бактерiальних комплексiв та вiдрiзняeться рiзною частотою иатолопчиих проявiв (анаеробний вагiноз, аеробний вапшт, кандидоз). У жiнок з запальними захворюваннями статевих шляхiв в першому та другому триместрi ваптиосп в спектрi мiкрофлори пiхви збшьшуеться питома вага ентеробактерiй, аеробних грампозитивних коюв, а також анаеробiв з патогенними властивостями. В третьому триместрi ваптиост в структурi мiкробних асощацш рееструвалась тенденцiя до зниження рiвня транзиторно! факультативно-аеробно! мiкрофлори та збшьшеиия анаеробiв.
Ключов! слова: BariTHicTb, мкрофлора nixBH, статев1 шляхи, заиальш захворювання.
Одшею з важливих проблем сучасного акушерства е шфекцшш ускладнення перебпу ваптносп та полопв у жшок [9,12]. Етюлопчними чинниками шфекцшних ускладнень ваптносп найчастше е представники умовно-патогенно! мшрофлори (факультативно-анаеробно! або обл1гатно-анаеробно!). 3i статевих шлях1в ваптних переважно видшяються мшрооргашзми с1мейств Enterobacteriacea та Streptococcacea, з меншою частотою стафiлококи - Staphylococcus spp. [2,7]. В умовах активно! пролiферацi! умовно-патогенно! мiкрофлори (УПМ) на rai зниження iмунореактивностi оргашзму може виникати запальний процес. Запалення супроводжуеться змшою ендокринно! функцi! яечниюв, структурними та функцiональними порушеннями ендометрiя та його рецепторного апарата, що може призвести до переривання ваптностг Реалiзацiя iнфекцiйного запалення визначаеться не тшьки зростанням рiвня мiкробно! колошзацп статевих шляхiв, але i присутшстю факторiв iмунно! системи: природних антимшробних пептидiв, в тому числi Р-дефензишв 1,4, iнгiбiторiв секреторно! лейкоцитарно! протеази, лактоферрина, лiзоцима [5].
В нормi по мiрi прогресування вагiтностi збшьшуеться рiвень колонiзацi! статевих шляхiв лактобацилами та знижуються показники висiву транзиторно! умовно-патогенно! мшрофлори [1,8]. У ваптних шд впливом гормонiв збiльшуеться синтез глшогена в епiтелiальних клiтинах, що сприяе збiльшенню кiлькiсного рiвня захисно! мiкрофлори, для яко! глiкоген е поживним субстратом. У жшок з патолопчним перебиюм вагiтностi збiльшуються кшьюсш показники висiву мiкроорганiзмiв, якi здатш продукувати бiологiчнi активнi речовини [6,10]. Ц речовини можуть спричиняти патолопчш змiни в органах фетоплацентарно! системи, зокрема грати значну роль в розвитку запального процесу. Окремi УП мшрооргашзми синтезують фосфолiпази, якi ддать на
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