Differentiating between benign and malignant thyroid nodules Grani G, Lamartina L, Cantisani V, Maranghi M, Lucia P, Durante C. Interobserver agreement of various thyroid imaging reporting and data systems. Within each risk class, a size threshold is specified above which FNAC is recommended. The nodule in (b) is taller than wide. OR New sonographic criteria for recommending fine-needle aspiration biopsy of nonpalpable solid nodules of the thyroid. Out of these cookies, the cookies that are categorized as necessary are stored on your browser as they are essential for the working of basic functionalities of the website. In several studies, the main suspicious features indicating thyroid malignancy were found to have different diagnostic power among different cohorts, as demonstrated from the ORs in multivariate analysis (17,20,21). While most thyroid nodules are non-cancerous (Benign), ~5% are cancerous. Figure 1. Previous studies have examined the correlation between malignancy and nodule size (25,26). Online ahead of print. When Should you Worry About Thyroid Nodules? 6 Signs to Know Before fine-needle aspiration, two examiners jointly defined all sonographic features considered in risk stratification systems developed by the American Thyroid Association (ATA), the American Association of Clinical Endocrinologists (AACE), the American College of Radiology (ACR TIRADS), the European Thyroid Association (EU-TIRADS), and the Korean Society of Thyroid Radiology (K-TIRADS). the contents by NLM or the National Institutes of Health. The Journey is a blog that addresses the unique hurdles each person faces. and transmitted securely. Find out things like what treatments are available and what happens if there's a recurrence. We aimed to investigate the association of the morphological characteristics of nodular goiters from preoperative US and color Doppler images with malignancy based on pathology. Thyroid nodules are abnormal growths at the base of your neck. Significance of ultrasound features in predicting malignant solid thyroid nodules: need for fine-needle aspiration. (21) found that microcalcifications were a stronger predictor of papillary carcinoma among other US features, following by nodule shape. Thyroid Nodules Located in the Lower Pole Have a Higher Risk of Highly suspicious nodules should have repeat ultrasonography within 612 months, and low-risk and intermediate- risk nodules within 1224 months. It is important to recall that ours was a selected cohort of patients with thyroid nodules: all had been referred to our unit for FNAC, for reasons known only to the referring physician. Australian This website uses cookies to improve your experience while you navigate through the website. Read cancer survivors stories. A curated collection of instructive books. This study was conducted as part of a prospective project aimed at characterizing the performances of the systems most widely used for the sonographic risk stratification of thyroid nodules. official website and that any information you provide is encrypted Any symptom suggestive of invasion, including dysphonia or dysphagia, should raise the suspicion for an underlying malignancy. The new recommendation is that all cytology results should be reported using the Bethesda system for classification of thyroid nodules, which aligns with the Thy classification system adopted by the Royal College of Pathologists in the UK.5 This classification provides an estimate of the malignancy risk for each category and provides a recommended management plan. Before All patients who are suspected of having a thyroid nodule or nodular goitre or in whom a nodule has been incidentally detected on another imaging modality should be referred for ultrasonography of the neck and thyroid. However, the definition of TTW is not consistent across systems (online suppl. Thyroid Ultrasound: a common imaging test used to evaluate the structure of the thyroid gland. The composition of thyroid nodules is an important feature in the assessment of a nodules risk of malignancy. An intraobserver variability of up to 18% in AP diameter evaluations has been described, which may lead to overreporting of this feature. Thyroid nodule sonography: assessment for risk of malignancy Fig. Kamran SC, Marqusee E, Kim MI, Frates MC, Ritner J, Peters H, Benson CB, Doubilet PM, Cibas ES, Barletta J, Cho N, Gawande A, Ruan D, Moore FD Jr., Pou K, Larsen PR, Alexander EK. Thyroid nodules - Symptoms and causes - Mayo Clinic 2Department of Endocrinology, Metabolism and Diabetes Mellitus, Nikea-Piraeus Agios Panteleimon General Hospital, Athens, Greece, 3Endocrine Unit, Alexandra Hospital, Athens, Greece. A taller-than-wide shape was defined as a ratio of 1, calculated by dividing the anteroposterior diameter by the transverse diameter. Eighty-two nodules were excluded from the analysis because their maximum diameter was >1 cm, and 282 were excluded due to an inconclusive (nondiagnostic or indeterminate) diagnosis. Radiology. This cookie is used for setting an unique ID for the visitor which helps to get the accurate number of specific visitor on the website. a This nodule would fulfill the current definition only (TTW ratio = 1.15); however, applying TIRADS, it would still be submitted to biopsy, being predominantly solid, partially hypoechoic, with lobulated margins. Thyroid nodules size and prediction of cancer. The https:// ensures that you are connecting to the Keywords: Thyroid; malignancy; microcalcifications; nodule . The diagnostic value of a new ultrasonographic method for the measurement of a taller-than-wide shape of benign and malignant thyroid nodules. This category only includes cookies that ensures basic functionalities and security features of the website. If the TSH level is normal or elevated, FNA should be performed. MeSH To improve reproducibility and simplify reporting, sonographic systems for risk stratification of thyroid nodules have been developed by several scientific societies [1, 2, 3, 4, 5], and their diagnostic performance has been explored and validated in numerous studies [18, 24, 25, 26, 27, 28, 29, 30, 31, 32]. Serum TSH, ultrasonography and FNA remain the initial investigations in general practice, with radionuclide scans reserved for patients with low TSH. In some studies, a nodule is called a cyst only if it is predominantly cystic on ultrasonography, but in others, the term is applied to nodules that have any areas of cystic degeneration, which may include up to 50 percent of thyroid nodules. This study indicates that in a clinical sample of patients with nodular goiters referred to our center, the majority of nodules with papillary carcinomas had a taller-than-wide shape, significantly higher than that of benign. Of the 471 lesions, 125 (26.5%) were classified as malignant, and 346 (73.5%) were classified as benign. For example, marked hypoechogenicity, microcalcifications, irregular margins, intranodular vascular images and low elasticity have been associated with malignancy (4,9-13). Thyroid Ultrasound Reporting Lexicon: White Paper of the ACR Thyroid Imaging, Reporting and Data System (TIRADS) Committee. Ann Intern Med 1997;126(3):22631. Before The primary goal of a GP is to differentiate between a benign and a malignant nodule. Research studies and new treatments available. If your doctor found a hypoechoic nodule during an ultrasound, they may simply do some additional testing to make sure there's . Clin Endocrinol 2014;81(Suppl 1):1122. The accuracy of thyroid nodule ultrasound to predict thyroid cancer: systematic review and meta-analysis. Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. Remonti LR, Kramer CK, Leito CB, Pinto LC, Gross JL. AACE/ACE/AME, American Association of Clinical Endocrinologists/American College of Endocrinology/Associazione Medici Endocrinologi; ACR, American College of Radiology; ATA, American Thyroid Association; EU-TIRADS, European Thyroid Imaging Reporting and Data Systems; K-TIRADS, Korean Thyroid Imaging Reporting and Data Systems; TTW, taller-than-wide shape. Thyroid cancer is an increasingly prevalent malignancy throughout the world. Thyroid nodules are also classified according to their shape, and are broken into categories: taller than wide or wider than tall. Ha EJ, Moon WJ, Na DG, Lee YH, Choi N, Kim SJ, et al. Hyperplastic Ultrasound risk evaluation of thyroid nodules that are "unspecified" in Ultrasonography. Ultrasound is the first-line imaging modality for assessment of thyroid nodules found on clinical examination or incidentally on another imaging modality. Use the tools and advice inside and adapt them for your family. Thyroid, nodule, shape, microcalcifications, malignancy. As a large proportion of incidentalomas will be under 1 cm, it is important they are managed according to the guidelines, to avoid over-investigation. material, see www.karger.com/doi/10.1159/000504219), the five sonographic systems most widely used to estimate the probability of thyroid nodule malignancy define TTW nodules as those with an anteroposterior (AP) diameter that exceeds the transverse (T) diameter [1, 2, 3, 4, 5], without specifying any minimum magnitude for the excess. Management of indeterminate cytology can be complex. Shin JH, Baek JH, Chung J, Ha EJ, Kim JH, Lee YH, et al.Korean Society of Thyroid Radiology (KSThR) and Korean Society of Radiology Ultrasonography Diagnosis and Imaging-Based Management of Thyroid Nodules: Revised Korean Society of Thyroid Radiology Consensus Statement and Recommendations. Trajman A, Luiz RR. Continuous variables were compared using the Mann-Whitney U-test, while discrete variables were compared using the chi-square or Fisher's exact test, as appropriate. A pounding heart. For each sonographic risk stratification system, the indication for FNAC under each of the test conditions (i.e., current vs. proposed definition of TTW) was defined as a test positivity. The difficulty arises when the ultrasound or cytological findings are unclear; these patients should be under the care of an endocrinologist. Partially cystic nodule with eccentric solid areas, Solid hypoechoic nodule with smooth margins. Diagnostic value of conventional ultrasound combined with contrast-enhanced ultrasonography in thyroid imaging reporting and data system (TI-RADS) 3 and 4 thyroid micronodules. Grey-Scale Analysis Improves the Ultrasonographic Evaluation of Thyroid Nodules. reported an OR for malignant nodules of 8.6 for those with taller-than-wide shape (17). Additionally, a significant number of carcinomas had micro-calcifications, but the most important finding was the coexistence of micro-calcifications in nodules with a taller-than-wide shape which represented the one third of our malignant nodules. Descriptive statistics are reported as the median and interquartile range (IQR) for continuous variables, and frequency and percentage for categorical variables. Solid hypoechoic nodule The AUCs of shape, microcalcifications and the combination of both were 0.671, 0.721 and 0.649 respectively, demonstrating relatively good accuracy, showing the combination also to be as useful as the shape or the presence of microcalcifications alone in predicting malignancy. In our study, nodules with taller-than-wide shape or shape combined with microcalcifications were the best predictors of malignancy. Bible KC, et al. Malignancy rate of the various classes of the five sonographic risk stratification systems, applying the current and proposed definition of TTW shape. doi: 10.1089/thy.2015.0275. Helen J. Karga, MD, Ph.D., Medical Diagnosis Group, Aristidou and Gynosati, Koropi, 19004, Attiki, Greece. The mechanism of the taller-than-wide sign is no or minimal compressibility of a thyroid mass by the ultrasound probe, which occurs more frequently in malignant masses than in benign masses. A receiver operating characteristic curve analysis was performed to assess the diagnostic performance of the US features distinguishing benign from malignant thyroid nodules. This might mean that smaller nodules with taller-than-wide shape are more often malignant than larger ones. Metastasis. All conventional and power color Doppler US of thyroid nodules were performed using a 6-12 MHz linear array transducer, logic 7 (KPI Healthcare Inc. Yorba Linda, CA, USA). The study was approved by the Institutional Scientific Committee (00/16.10.2017). ScoreLevelInterpretationSuggested Action0 pointsTIRADS 1Benignno FNA2 pointsTIRADS 2Not suspiciousno FNA3 pointsTIRADS 3Mildly suspiciousFNA if > 2.5 cm Follow if > 1.546 pointsTIRADS 4Moderately suspicious FNA if > 1.5 Follow if > 1 7 pointsTIRADS 5Highly suspiciousFNA if > 1 cm Follow if > 0.5. This cookie is used for counting the new visitors to the website by assigning a unique visitor ID. It should also be noted that the size of malignant nodules was significantly lower than that of benign ones, reflecting the strong negative correlation between the nodule size and taller-than-wide shape. Accuracy of Ultrasound Diagnosis of Benign and Malignant Thyroid Nodules: A Systematic Review and Meta-Analysis. Management guidelines for both thyroid nodules and thyroid cancer have been published and updated by a number of societies internationally. Vol 16 Issue 6 p.3-4 | American Thyroid Association They are discovered either clinically or using sensitive imaging techniques (3). Int J Clin Pract. Haugen BR, Alexander EK, Bible KC, Doherty GM, Mandel SJ, Nikiforov YE, et al. Thyroid nodules are common lesions and are being diagnosed with increasing frequency (1,2). MEN2 is associated with medullary thyroid cancer and FNMTC, which effects two or more first degree relatives and can occur in isolation or as part of a syndrome such as familial adenomatous polyposis, Cowdens syndrome, Gardners syndrome and Carneys complex type 1. We hypothesized that the mechanism of the "taller-than-wide sign" is no or minimal compressibility of a malignant thyroid mass by the ultrasound probe, whereas compressibility is seen more frequently in benign than malignant masses. Ultrasound images of the thyroid gland tend to have specific characteristics that can convey information about the health of the thyroid and the presence of disease. The most widely used classification system for thyroid nodules is named the TIRADS. It should also be pointed out that marked hypoechogenecity was common in our malignant nodules, with an OR of 6.5, higher than previously reported (24) indicating an increased risk of malignancy, whereas intranodular vascularity or ill-defined margins were adequate for determining a high risk of malignancy. Hoang JK, Middleton WD, Farjat AE, Langer JE, Reading CC, Teefey SA, et al. General New York: Humana Press, 2018. Yin A, Lu Y, Xu F, Zhao Y, Sun Y, Huang M, Li X. Radiologie (Heidelb). Xue E, Zheng M, Zhang S, Huang L, Qian Q, Huang Y. Ultrasonography-based classification and reporting system for the malignant risk of thyroid nodules. Additionally, we found a strong negative correlation between size and taller-than-wide shape of a thyroid nodule (r=0.41, p<0.001). Conclusion: Among the important indicators of thyroid malignancy, taller-than-wide nodules with microcalcifications are most likely to be malignant. Currently available sonographic risk stratification systems for thyroid nodules were developed to more accurately identify those for which fine-needle aspiration cytology (FNAC) can safely be deferred [1, 2, 3, 4, 5]. These cookies will be stored in your browser only with your consent. The margins can be categorized as: smooth, ill-defined, lobulated or irregular. The quantitative evaluation, however, would avoid confusion about the TTW and taller-than-long shape (the latter is defined as an AP diameter longer than the longitudinal one) that some earlier studies considered a single entity (online suppl. If the nodule was resected, the final diagnosis was based on surgical histology. Children and teenagers have unique interests and learn differently compared to adults. Campanella P, Ianni F, Rota CA, Corsello SM, Pontecorvi A. Quantification of cancer risk of each clinical and ultrasonographic suspicious feature of thyroid nodules: a systematic review and meta-analysis. Not only is the morbidity associated with a missed diagnosis potentially significant, but given the prevalence of the condition, excessive or unnecessary investigations lead to a significant economic burden on the healthcare system. We determined in which ultrasonography (US) plane a taller-than-wide shape is most predictive of malignancy. DOI: 10.1177/01945998211051310 Abstract Objective: To evaluate nodule height-to-width ratio as a continuous variable predicting likelihood of thyroid malignancy. The assessment of a thyroid nodules margins is very important. and transmitted securely. Your doctor will decide the best treatment course for you based on classification of the nodule(s) identified. Comparison of the current and proposed definition of TTW shape; McNemar test. This means that the coexistence of microcalcifications in taller-than-wide nodules provides strong evidence of malignancy, although the absence of this profile cannot exclude malignancy. A thyroid biopsy is called fine-needle . Vol 5 Issue 3 p.5 | American Thyroid Association 1). The https:// ensures that you are connecting to the The study described below was undertaken to explore this possibility. Full details on the procedures used for sonographic assessment, risk stratification, and FNAC examination of the nodules have been published elsewhere [11, 17, 18]. K.D.P: study concept and design, data analysis and interpretation, statistical analysis and article writing; H.J.K: study concept design, data analysis and interpretation and critical revision of the article; C.C.E., I.A.I., K.S.M., N.I.K. While the ultrasound is being performed, a doctor can place a needle into any concerning structures and sample cells for a biopsy (called an ultrasound-guided biopsy) which will be examined under the microscope. Using this definition in risk stratification systems will increase their specificity, reducing the number of suggested biopsies without significantly diminishing their overall diagnostic performance. Paajanen I, Metso S, Jaatinen P, Kholov I. Thyroid FNA diagnosis in a real-life setting: Experience of the implementation of the Bethesda system in Finland. Nodules classified as very low risk and <1cm have been shown to grow very little over five years and do not require routine ultrasonographic follow-up.1,6. In summary, all nodule sonographic features were collected: diameters, margins, composition, echogenicity, presence of calcifications and other hyperechoic foci, and suspected extrathyroidal extension. Thirty-nine nodules were histologically confirmed as anaplastic thyroid cancer (n = 1); follicular thyroid cancer (n = 1); follicular-variant papillary thyroid cancer (n = 6); medullary thyroid cancer (n = 2); papillary thyroid cancer (n = 26); and metastases from other solid tumors (n = 3). Practice, Formerly Australian Family Physician (AFP). These cookies do not store any personal information. These studies included large nodules (>3 cm) and size correlated with the FNAB results and other US findings but not with the shape as evaluated in our study. A taller-than-wide (TTW) shape is a suspicious feature of thyroid nodules commonly defined as an anteroposterior/transverse diameter (AP/T) ratio >1. Perros P, Boelaert K, Colley S, et al. False-negative fine needle aspiration cytology results delay treatment and adversely affect outcome in patients with thyroid carcinoma. Russ G, Bonnema SJ, Erdogan MF, Durante C, Ngu R, Leenhardt L. European Thyroid Association Guidelines for Ultrasound Malignancy Risk Stratification of Thyroid Nodules in Adults: the EU-TIRADS. High-resolution ultrasonography (US) is a powerful tool for detecting thyroid lesions and identify nodules even with a size of a few millimeters (4,5). While the majority of patients will be euthyroid, a suppressed TSH level indicates a hyperfunctioning nodule, which t, if confirmed, has an exceedingly small risk of malignancy.1 Further evaluation of a patient with suppressed TSH levels is best managed by an endocrinologist. However, TTW rates using both definitions are unchanged by these exclusions. Thyroid nodules are fourfold more frequent in women when compared to men. In conclusion, adopting an arbitrary definition of TTW as an AP/T diameter ratio 1.2 would reduce the number of indicated biopsies according to five widely used sonographic risk stratification systems and improve specificity without negatively influencing overall diagnostic performance. The frequency of the ultrasonic sound waves cannot be heard by humans. It appears to be a variation of the _gat cookie which is used to limit the amount of data recorded by Google on high traffic volume websites. Yeh MW, Demicran O, Ituarte P, Clark OH. WHAT ARE THE IMPLICATIONS OF THIS STUDY? Currently, US-guided fine-needle aspiration biopsy (FNAB) remains the gold standard within the diagnostic procedures in the workup of thyroid nodules. Websites, online advocacy groups and forums. It is recommended that the thyroid nodule is not imaged in isolation on ultrasonography.1. In cases of indeterminate cytology, because of the increased risk of malignancy, referral to a thyroid surgeon for hemi-thyroidectomy is recommended over a repeated FNA.8,9. LaFranchi SH. Background The final diagnosis was based on histopathology in 145 nodules in 120 patients, and cytology in the remaining patients. Brito JP, Gionfriddo MR, Al Nofal A, Boehmer KR, Leppin AL, Reading C, et al. An intraobserver variability of up to 18% in AP diameter evaluations has been described, which may lead to overreporting of this feature. Gharib H, editor. The cookie is set by GDPR cookie consent to record the user consent for the cookies in the category "Functional". Can vascularity at power Doppler US help predict thyroid malignancy. Grani G, Lamartina L, Biffoni M, Giacomelli L, Maranghi M, Falcone R, et al. Diagnostic Performances of the ACR-TIRADS System in Thyroid Nodules DOI: 10.1089/thy.2010.0372 Abstract Background: A "taller-than-wide" shape is associated with thyroid malignancy, but taller-than-wide in which plane is most accurate is unclear. 1). Serum thyroglobulin levels are neither sensitive nor specific for the detection of thyroid cancer and should not be ordered in the evaluation of thyroid nodules.1 Serum calcitonin levels are expensive to obtain and should only be requested when a medullary thyroid carcinoma issuspected. A little inspiration can go far. However, a significant number of cases give false-negative, nondiagnostic, indeterminate or suspicious results that are difficult for clinicians to assess (6-8). In our work, the combination of microcalcifications and taller-than-wide shape was an independent predictor of malignancy and although the sensitivity was only approximately 30%, the specificity was 100%, since none of the benign nodules with taller-than-wide shape were found to have microcalcifications. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Durante C, Costante G, Lucisano G, et al. When considering only technically satisfactory specimens, the diagnostic accuracy of FNA when performed by an experienced operator is approximately 95%, although this figure is dependent on how each cytology category is used in the calculation4 The decision to perform FNA of a nodule depends on the sonographic pattern and size (Figure1, Table 2). Malignancy Risk Stratification of Thyroid Nodules: Comparison between the Thyroid Imaging Reporting and Data System and the 2014 American Thyroid Association Management Guidelines. These cookies help provide information on metrics the number of visitors, bounce rate, traffic source, etc. Criterion 1, a taller-than-wide shape in either transverse or longitudinal plane, was most accurate and sensitive for predicting thyroid malignancy among the three criteria. Table 1), and because it depends on the measurement (or at least the estimate) of nodule diameters, it is subjected to inter- and even intraobserver variability. Aviva S . There are 4 variants of papillary thyroid cancer: classic, follicular, tall-cell and noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP). Sonographically Estimated Risks of Malignancy for Thyroid Nodules Computed with Five Standard Classification Systems: Changes over Time and Their Relation to Malignancy. Hypoechoic thyroid nodule: What does it mean and risk of cancer? The US findings were re-evaluated and interpreted by two radiologists with more than 20-year experience who were blinded to the final pathology results. Ultrasounds cannot be used to image any areas hidden behind bone (such as inside the head) because the sound waves cannot travel through bone. Size [odds ratio (OR)=0.93, 95% confidence interval (CI)=0.89-0.98; p=0.002], taller-than-wide shape (OR=25.3; 95% CI=5.4-118.9; p<0.001), microcalcifications (OR=4.9, 95% CI=2.5-9.5; p<0.001), hypoechogenicity (OR=4.5, 95% CI=2-10.3; p<0.001) of thyroid nodules were the only variables independently associated with thyroid malignancy (Table II). An intraobserver variability of up to 18% in AP diameter evaluations has been described, which may lead to overreporting of this feature. Wang Y, Nie F, Liu T, Yang D, Li Q, Li J, Song A. This probe is responsible for producing the sound waves and taking pictures. FNA, fine-needle aspiration; TSH, thyroid-stimulating hormone. Microcalcifications are one of the most specific US findings . The current and proposed definitions have a sensitivity of 26.2 and 11.9% (p = 0.03) and a specificity of 83.8 and 95.5% (p < 0.001). Dry skin. Number of avoided biopsies, missed malignancies, sensitivity, specificity, and AUROC curve according to five sonographic risk stratification systems, applying the current and proposed definition of TTW shape. The cookies store information anonymously and assign a randomly generated number to identify unique visitors. Rago T, Scutari M, Loiacono V, Santini F, Tonacchera M, Torregrossa L, Giannini R, Borrelli N, Proietti A, Basolo F, Miccoli P, Piaggi P, Latrofa F, Vitti P. Low elasticity of thyroid nodules on ultrasound elastography is correlated with malignancy, degree of fibrosis and high expression of galectin-3 and fibronectin-1. Please enable it to take advantage of the complete set of features! 2009; 94:1748-1751. doi: 10.1210/jc.2008-1724. Cappelli C, Castellano M, Pirola I, Gandossi E, De Martino E, Cumetti D, Agosti B, Rosei EA. The majority of thyroid nodules encountered in general practice will have benign cytology and can be monitored with a repeat ultrasound scan at a time interval determined by the sonographic features (Figure 2). In our study, one limitation included a lack of a large number of nodules more than 4 cm in size. For thyroid cancer, the gold standard initial imaging test is an ultrasound. Additionally, Capelli et al. An official website of the United States government. Zheng LL, Ma SY, Zhou L, Yu C, Xu HS, Xu LL, Li SY. WHAT ARE THE IMPLICATIONS OF THIS STUDY? Thyroidectomy: surgery to remove the entire thyroid gland. However, these systems still rely on the recognition of specific suspicious features. Endocrine. 2015 American Thyroid Association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer: The American Thyroid Association Guidelines task force on thyroid nodules and differentiated thyroid cancer. Predictive Value of Malignancy of Thyroid Nodule Ultrasound Classification Systems: A Prospective Study. The sensitivity, specificity, positive predictive value, negative predictive value, and area under the receiver operating characteristic curve (Az) were compared among the three criteria. Fig. Hence malignant nodules can be taller than they are wide (Fig. The incidence of thyroid nodules has increased in recent years, with detection in up to 65% of the general population, which may be due in part to the increased use of US [1, 2].Approximately 7-15% of thyroid nodules are thyroid cancer, which accounts for approximately 3% of all cancers and is the most common endocrine malignancy [].Thyroid US has been recognized as the most useful tool for . Prevalence of thyroid nodules and their associated clinical parameters: a large-scale, multicenter-based health checkup study. A p-value of less than 0.05 was considered as statistically significant.
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