Abstract：
BACKGROUND: Thyroid nodules are unusual in children, but when present, they carry a higher risk for malignancy, as compared to adults. Several guidelines have been created to address the risk stratification for malignancy of thyroid nodules in adults, but none has been completely validated in children. A few authors have proposed lowering the size threshold to the American College of Radiology Thyroid Imaging, Reporting and Data System (ACR TI-RADS™) management guidelines to decrease missed carcinomas at presentation in children; however, little information is known regarding their accuracy.
OBJECTIVE: To assess the performance of proposed modifications of the ACR TI-RADS™ size criteria to guide management decisions in pediatric thyroid nodules and to assess the associated increase in number of fine needle aspiration (FNA) and follow-up exams.
METHODS: This is a retrospective study of children under 18 years old who underwent ultrasound assessment of a thyroid nodule at a tertiary care pediatric institution between January 2006 and August 2021. The largest dimension, maximum ACR TI-RADS™ score, and final thyroid nodules\' diagnoses were documented. The course of action based on the adult ACR TI-RADS™ and after modifying the size threshold for management recommendations was documented and compared. Statistics included descriptive analysis, weighted Kappa statistics, sensitivity, specificity, accuracy, and positive/negative predictive values of the ACR TI-RADS™ presented with 95% confidence intervals (CI) using either Clopper-Pearson or standard logit methods.
RESULTS: Of 116 nodules, 18 (15.5%) were malignant. Most malignant nodules (94.4%, n = 17) were ACR TI-RADS™ 4 and ACR TI-RADS™ 5 categories. Based on the adult ACR TI-RADS™ criteria, 24 (24.5%) benign and 15 (83.3%) malignant nodules would have undergone FNA; 14 (14.3%) benign and 3 (16.7%) malignant nodules would have been followed up; and 60 (61.2%) benign and none of malignant nodules would have been dismissed. Three (16.7%) malignant nodules would not have been recommended FNA at presentation, delaying their diagnoses. By lowering the size-threshold criteria of the ACR TI-RADS™ guidelines, no malignancy would have been missed at presentation, but this also resulted in a higher number of FNA from 24 (24.5%) to 36 (36.7%) and follow-up ultrasound exams from 14 (14.3%) to 62 (63.3%).
CONCLUSIONS: Applying potential modifications to the ACR TI-RADS™ guideline lowering the size threshold criteria of the thyroid nodule to guide management decisions for pediatric thyroid nodules can lead to early detection of malignant nodules in children, but at the cost of a significantly increased number of biopsies or ultrasound exams. Further tailoring of the guideline with larger multicentric studies is needed, before warranting its acceptance and general use in the pediatric population.
OBJECTIVE: To assess the performance of proposed modifications of the ACR TI-RADS™ size criteria to guide management decisions in pediatric thyroid nodules and to assess the associated increase in number of fine needle aspiration (FNA) and follow-up exams.
METHODS: This is a retrospective study of children under 18 years old who underwent ultrasound assessment of a thyroid nodule at a tertiary care pediatric institution between January 2006 and August 2021. The largest dimension, maximum ACR TI-RADS™ score, and final thyroid nodules\' diagnoses were documented. The course of action based on the adult ACR TI-RADS™ and after modifying the size threshold for management recommendations was documented and compared. Statistics included descriptive analysis, weighted Kappa statistics, sensitivity, specificity, accuracy, and positive/negative predictive values of the ACR TI-RADS™ presented with 95% confidence intervals (CI) using either Clopper-Pearson or standard logit methods.
RESULTS: Of 116 nodules, 18 (15.5%) were malignant. Most malignant nodules (94.4%, n = 17) were ACR TI-RADS™ 4 and ACR TI-RADS™ 5 categories. Based on the adult ACR TI-RADS™ criteria, 24 (24.5%) benign and 15 (83.3%) malignant nodules would have undergone FNA; 14 (14.3%) benign and 3 (16.7%) malignant nodules would have been followed up; and 60 (61.2%) benign and none of malignant nodules would have been dismissed. Three (16.7%) malignant nodules would not have been recommended FNA at presentation, delaying their diagnoses. By lowering the size-threshold criteria of the ACR TI-RADS™ guidelines, no malignancy would have been missed at presentation, but this also resulted in a higher number of FNA from 24 (24.5%) to 36 (36.7%) and follow-up ultrasound exams from 14 (14.3%) to 62 (63.3%).
CONCLUSIONS: Applying potential modifications to the ACR TI-RADS™ guideline lowering the size threshold criteria of the thyroid nodule to guide management decisions for pediatric thyroid nodules can lead to early detection of malignant nodules in children, but at the cost of a significantly increased number of biopsies or ultrasound exams. Further tailoring of the guideline with larger multicentric studies is needed, before warranting its acceptance and general use in the pediatric population.
摘要：
背景：甲状腺结节在儿童中并不常见，但是当存在时，他们患恶性肿瘤的风险更高，与成年人相比。已经制定了一些指南来解决成人甲状腺结节恶性肿瘤的风险分层。但没有一个在儿童中得到完全验证。一些作者向美国放射学甲状腺成像学院提出了降低尺寸阈值的建议，报告和数据系统（ACRTI-RADS™）管理指南，以减少儿童中漏诊的癌；然而，关于它们的准确性知之甚少。
目的：评估ACRTI-RADS™尺寸标准的拟议修改的性能，以指导小儿甲状腺结节的管理决策，并评估细针穿刺（FNA）和随访检查的相关数量增加。
方法：这是一项回顾性研究，研究对象是2006年1月至2021年8月在三级儿科护理机构接受甲状腺结节超声评估的18岁以下儿童。最大的维度,ACRTI-RADS™最大评分,并记录最终的甲状腺结节诊断。记录并比较了基于成人ACRTI-RADS™和修改管理建议的大小阈值后的行动过程。统计包括描述性分析，加权Kappa统计，灵敏度,特异性，准确度,ACRTI-RADS™的阳性/阴性预测值使用Clopper-Pearson或标准logit方法以95%置信区间(CI)呈现。
结果：在116个结节中，18例（15.5%）为恶性。大多数恶性结节（94.4%，n=17）是ACRTI-RADS™4和ACRTI-RADS™5类。根据成人ACRTI-RADS™标准，24个（24.5％）良性和15个（83.3％）恶性结节将进行FNA；14个（14.3％）良性和3个（16.7％）恶性结节将被随访；60个（61.2％）良性和没有恶性结节将被驳回。三个（16.7％）恶性结节在介绍时不会被推荐FNA，延迟诊断。通过降低ACRTI-RADS™指南的尺寸阈值标准，在演示时不会遗漏恶性肿瘤，但这也导致FNA数量从24例(24.5%)增加到36例(36.7%),随访超声检查从14例(14.3%)增加到62例(63.3%).
结论：对ACRTI-RADS™指南进行潜在修改，降低甲状腺结节的大小阈值标准，以指导儿童甲状腺结节的管理决策，可导致儿童恶性结节的早期发现。但代价是活检或超声检查的数量大大增加。需要通过更大的多中心研究进一步调整指南，在保证其在儿科人群中的接受和普遍使用之前。
目的：评估ACRTI-RADS™尺寸标准的拟议修改的性能，以指导小儿甲状腺结节的管理决策，并评估细针穿刺（FNA）和随访检查的相关数量增加。
方法：这是一项回顾性研究，研究对象是2006年1月至2021年8月在三级儿科护理机构接受甲状腺结节超声评估的18岁以下儿童。最大的维度,ACRTI-RADS™最大评分,并记录最终的甲状腺结节诊断。记录并比较了基于成人ACRTI-RADS™和修改管理建议的大小阈值后的行动过程。统计包括描述性分析，加权Kappa统计，灵敏度,特异性，准确度,ACRTI-RADS™的阳性/阴性预测值使用Clopper-Pearson或标准logit方法以95%置信区间(CI)呈现。
结果：在116个结节中，18例（15.5%）为恶性。大多数恶性结节（94.4%，n=17）是ACRTI-RADS™4和ACRTI-RADS™5类。根据成人ACRTI-RADS™标准，24个（24.5％）良性和15个（83.3％）恶性结节将进行FNA；14个（14.3％）良性和3个（16.7％）恶性结节将被随访；60个（61.2％）良性和没有恶性结节将被驳回。三个（16.7％）恶性结节在介绍时不会被推荐FNA，延迟诊断。通过降低ACRTI-RADS™指南的尺寸阈值标准，在演示时不会遗漏恶性肿瘤，但这也导致FNA数量从24例(24.5%)增加到36例(36.7%),随访超声检查从14例(14.3%)增加到62例(63.3%).
结论：对ACRTI-RADS™指南进行潜在修改，降低甲状腺结节的大小阈值标准，以指导儿童甲状腺结节的管理决策，可导致儿童恶性结节的早期发现。但代价是活检或超声检查的数量大大增加。需要通过更大的多中心研究进一步调整指南，在保证其在儿科人群中的接受和普遍使用之前。
