Objective To explore the diagnostic efficacy of American Thyroid Association(ATA)guidelines,American College of Radiology Thyroid Imaging Report and Data System(ACR-TIRADS),and Chinese Thyroid Imaging Reporting and Data System(C-TIRADS)alone and combined with BRAFV600E mutation in atypia of undetermined significance/follicular lesion of undetermined significance(AUS/FLUS).Methods A total of 138 patients who underwent ultrasound-guided fine needle aspiration(FNA)in the Chinese PLA General Hospital from January 2020 to May 2023 were selected.The clinicopathological and ultrasound characteristics were retrospectively analyzed for each nodule.Each nodule underwent preoperative BRAFV600E mutation testing and was diagnosed according to the ATA guidelines,ACR-TIRADS,and C-TIRADS.The diagnostic efficacy of ATA guidelines,ACR-TIRADS,and C-TIRADS alone and combined with BRAFV600E mutation was assessed based on the results of histopathological diagnosis.Results The 138 AUS/FLUS thyroid nodules included 45(32.6%)benign ones and 93(67.4%)malignant ones.The patient age(t=1.444,P=0.151),gender(χ2=0.259,P=0.611),and location of nodules(χ2=2.055,P=0.358)had no statistical significance for the differentiation between benign and malignant nodules,while nodule size(Z=2.500,P=0.012),echo(χ2=14.693,P<0.001),composition(χ2=17.075,P<0.001),aspect ratio ≥1(χ2=9.477,P=0.002),and microcalcification(χ2=6.892,P=0.009)were of significance for the differentiation.When applied alone,BRAFV600E mutation showed high specificity(95.56%)and positive predictive value(95.65%).Among the three ultrasound grading systems,ACR-TIRADS had the highest sensitivity(χ2=37.923,P<0.001;χ2=40.462,P<0.001)and accuracy(χ2=81.595,P<0.001;χ2=76.912,P<0.001),while C-TIRADS had the highest specificity(χ2=11.746,P<0.001;χ2=21.235,P<0.001).However,the three systems showed no statistically significant difference in the diagnostic efficiency when applied alone(Z=1.177,P=0.239;Z=0.213,P=0.831;Z=1.016,P=0.310).The combination of BRAFV600E mutation with ACR-TIRADS or C-TIRADS improved the diagnostic efficacy of BRAFV600E mutation in distinguishing the benign and malignant AUS/FLUS nodules(Z=2.107,P=0.035;Z=2.752,P=0.006).The combination of ATA guidelines with BRAFV600E mutation increased the diagnostic accuracy of BRAFV600E mutation(χ2=20.679,P<0.001),while it had no statistically significant difference in distinguishing the benign and malignant AUS/FLUS nodules(Z=1.321,P=0.186).The combination of ATA guidelines,ACR-TIRADS,or C-TIRADS with BRAFV600E mutation improved the diagnostic efficacy of ultrasound grading systems for AUS/FLUS nodules(Z=2.770,P=0.006;Z=2.770,P=0.006;Z=2.890,P=0.004).Specifically,ACR-TIRADS combined with BRAFV600E mutation showed the highest sensitivity(χ2=4.712,P=0.030;χ2=4.712,P=0.030),while C-TIRADS combined with BRAFV600E mutation showed the highest accuracy(χ2=77.627,P<0.001;χ2=85.827,P<0.001).However,there were no statistically significant differences in diagnostic performance between the combinations(Z=1.276,P=0.202;Z=0.808,P=0.419;Z=1.615,P=0.106).Conclusion ATA guidelines,ACR-TIRADS,and C-TIRADS combined with BRAFV600E mutation can improve the diagnostic efficacy of BRAFV600E mutation or ultrasound grading system alone in AUS/FLUS nodules,which can facilitate the further management and treatment of such patients.
目的 探讨美国甲状腺协会(ATA)指南、美国放射学会甲状腺影像报告和数据系统(ACR-TIRADS)和中国甲状腺影像报告和数据系统(C-TIRADS)单独及联合BRAFV600E突变对甲状腺细胞学意义不明确的非典型性或滤泡性病变(AUS/FLUS)的诊断效能。方法 选取2020年1月至2023年5月于中国人民解放军总医院第一医学中心接受细针穿刺并行BRAFV600E基因检测的138个AUS/FLUS结节作为研究对象,回顾性分析甲状腺结节患者的临床病理及超声特征,以组织病理学为金标准,比较ATA指南、ACR-TIRADS、C-TIRADS单独及联合BRAFV600E突变对AUS/FLUS结节的诊断效能。结果 138个AUS/FLUS甲状腺结节中,有45个良性结节(32.6%)和93个恶性结节(67.4%),患者的年龄(t=1.444,P=0.151)、性别(χ2=0.259,P=0.611)及结节的位置(χ2=2.055,P=0.358)对AUS/FLUS结节良恶性的鉴别差异无统计学意义;结节的大小(Z=2.500,P=0.012)、回声(χ2=14.693,P<0.001)、成分(χ2=17.075,P<0.001)、纵横比≥1(χ2=9.477,P=0.002)、微钙化(χ2=6.892,P=0.009)等超声特征对AUS/FLUS结节良恶性的鉴别差异有统计学意义。单独应用时,BRAFV600E突变具有相对较高的特异度(95.56%)和阳性预测值(95.65%);3种超声分级系统中,ACR-TIRADS的灵敏度(χ2=37.923,P<0.001;χ2=40.462,P<0.001)和准确度(χ2=81.595,P<0.001;χ2=76.912,P<0.001)最高,C-TIRADS的特异度(χ2=11.746,P<0.001;χ2=21.235,P<0.001)最高,但单独诊断之间差异均无统计学意义(Z=1.177,P=0.239;Z=0.213,P=0.831;Z=1.016,P=0.310)。联合应用时,BRAFV600E突变与ACR-TIRADS、C-TIRADS联合诊断均提高了BRAFV600E突变对AUS/FLUS结节良恶性的诊断效能(Z=2.107,P=0.035;Z=2.752,P=0.006),ATA指南联合BRAFV600E突变提高了BRAFV600E突变诊断的准确度(χ2=20.679,P<0.001),但对AUS/FLUS结节的良恶性鉴别差异无统计学意义(Z=1.321,P=0.186);ATA指南、ACR-TIRADS及C-TIRAD联合BRAFV600E突变均提高了超声分级系统对AUS/FLUS结节的诊断效能(Z=2.770,P=0.006;Z=2.770,P=0.006;Z=2.890,P=0.004),其中ACR-TIRADS联合诊断的灵敏度(χ2=4.712,P=0.030;χ2=4.712,P=0.030)最高,C-TIRADS联合诊断的准确度(χ2=77.627,P<0.001;χ2=85.827,P<0.001)最高,但联合诊断之间差异无统计学意义(Z=1.276,P=0.202;Z=0.808,P=0.419;Z=1.615,P=0.106)。结论 ATA指南、ACR-TIRADS及C-TIRADS联合BRAFV600E突变可以提高BRAFV600E或超声分级系统单独使用对AUS/FLUS结节的诊断效能,有助于临床对AUS/FLUS结节患者的进一步管理和治疗。.

This study is aimed at evaluating the diagnostic efficacy and unnecessary fine-needle aspiration (FNA) rate of ultrasound-based risk stratification for thyroid nodules in the American College of Radiology (ACR) Thyroid Imaging Reporting and Data System (TI-RADS) and the American Thyroid Association (ATA) risk stratification systems.
Children and adolescents with pathology confirmed thyroid nodules were retrospectively included in this study. A total of 217 thyroid nodules from multicenter of Union Medical College Hospital, China Japan Friendship Hospital and Civil Aviation Hospital were included, the diagnostic efficiency and unnecessary FNA rate were calculated according to ACR and ATA guidelines.
Among all thyroid nodules, 139 nodules were malignant, and 78 nodules were benign. Choosing ATA high suspicion and ACR TI-RADS TR5 as benign and malignant cut-off points, the area under the curve and sensitivity of ATA were higher than ACR (AUC: 0.887 vs 0.840, p=0.0037; sensitivity 81.3% vs 71.0%, P <0.049;specificity 96.2% vs 97.4%, p=1.000;specificity both 85.9%); choosing high/intermediate suspicion in ATA and ACR TR4/5 as benign and malignant cut-off points, the two guidelines demonstrated similar diagnostic efficacy (AUC:0.890 vs 0.897, p=0.6038, sensitivity 92.1% vs 93.5%, P =0.817;specificity both 85.9%, p=1.000). The inappropriate FNA rate of ACR guideline was relatively lower (ATA 42.9% vs ACR 27.2%, P <0.001). If ACR TI-RADS TR5 nodules less than 1.0cm were included in the FNA indication, the unnecessary biopsy rate would be further reduced to 17.9%.
This study indicated that both ATA and ACR TI-RADS risk stratification systems could provide a feasible differential diagnosis of benign and malignant thyroid nodules, while the ACR risk stratification system demonstrates a lower rate of inappropriate FNA rate. In addition, it was necessary to further study the minimum FNA threshold of thyroid nodules in Children and adolescents in order to reduce the missed biopsy rate of malignant nodules.

Incidental thyroid nodules are commonly detected on ultrasonography (US). This has contributed to the rapidly rising incidence of low-risk papillary thyroid carcinoma over the last 20 years. The appropriate diagnosis and management of these patients is based on the risk factors related to the patients as well as the thyroid nodules. The Korean Society of Thyroid Radiology (KSThR) published consensus recommendations for US-based management of thyroid nodules in 2011 and revised them in 2016. These guidelines have been used as the standard guidelines in Korea. However, recent advances in the diagnosis and management of thyroid nodules have necessitated the revision of the original recommendations. The task force of the KSThR has revised the Korean Thyroid Imaging Reporting and Data System and recommendations for US lexicon, biopsy criteria, US criteria of extrathyroidal extension, optimal thyroid computed tomography protocol, and US follow-up of thyroid nodules before and after biopsy. The biopsy criteria were revised to reduce unnecessary biopsies for benign nodules while maintaining an appropriate sensitivity for the detection of malignant tumors in small (1-2 cm) thyroid nodules. The goal of these recommendations is to provide the optimal scientific evidence and expert opinion consensus regarding US-based diagnosis and management of thyroid nodules.

The objective was to evaluate the diagnostic value of clinical examination and complementary imaging in the exploration of a breast lump or microcalcifications occurring in a postmenopausal woman taking hormonal replacement therapy (HRT), based on a systematic review of the literature in order to make recommendations for HRT management.
A literature review was conducted using Medline, Cochrane Library data and international recommendations in French and English until 2020.
In the presence of a clinical breast mass in postmenopausal women, there is no clinical evidence to rule out cancer. A double evaluation by mammography and ultrasound is recommended and allows the imaging to be classified into 5 BI-RADS categories. The diagnostic management of masses classified BI-RADS 4 and 5 should be based on percutaneous sampling, with microbiopsy being the first step. A total of four situations may arise: 1. Clinical examination has detected a breast mass, but there is no imaging abnormality. In this case, the imaging NPV is high (>96%). If the clinical lesion increases in size, a tissue biopsy should be performed, while continued routine breast screening is recommended if the lesion remains stable and HRT can be continued. 2. Clinical examination, mammography, and ultrasound are in favour of a cyst. Simple cysts can be punctured if painful. There is no contraindication to continuing HRT in the case of simple cysts. Management options for complicated and complex cysts are no different from those offered to women without HRT. Continuation of HRT must consider their histological nature. 3. Clinical examination, mammography, and ultrasonography suggest a benign solid tumour. The management of these benign breast lesions (fibroadenoma…) is not different in women taking an HRT and there is no contraindication to continue the HRT. 4: Clinical examination, imaging and microbiopsy diagnose a malignant tumour. It is imperative that the HRT be stopped, whatever the hormonal dependence of the tumour and whether it is invasive or in situ. The management of the cancerous tumour must consider the updated breast cancer treatment guidelines. In the presence of microcalcifications, the course of action to be taken depends on the BI-RADS classification, established according to the morphology and arrangement of the calcifications. In case of suspicious microcalcifications (BI-RADS 4 or 5), a guided macrobiopsy should be performed. Diagnostic and therapeutic management in these patients is no different from that offered to women without HRT. Discontinuation of HRT is necessary in cases of malignancy (in situ or invasive cancer).
A rigorous multidisciplinary approach is necessary for the exploration of a breast mass or microcalcifications in a postmenopausal woman.

A multi-society expert panel recently published evidence-based guidelines and recommendations for the primary diagnosis and classification of lymphoma, which included a public comment period. The guideline concludes: \"primary diagnosis and classification of lymphoma can be achieved with a variety of specimens.\" The guideline recommends that fine-needle aspiration biopsy (FNAB) cytomorphology not be used without ancillary testing, and that either flow cytometry or immunohistochemical immunophenotyping be performed for any type of specimen. Either excisional or core biopsy should be obtained when there is a high suspicion of lymphoma, and excision is recommended when feasible for Hodgkin lymphoma primary diagnosis. The use of cerebrospinal fluid to diagnose central nervous system lymphoma is discussed. For any patient with initial negative biopsy or fluid specimens and a high suspicion of lymphoma, additional tissue samples should be obtained. Additional molecular testing and good practice statements are summarized in the guideline. Cytopathologists should continue to advocate for judicious use of lymph node FNAB as an excellent triage tool that may require additional tissue biopsy for definitive diagnosis.

The American Society of Clinical Oncology (ASCO)-endorsed College of American Pathologists guideline recommends high-risk human papillomavirus (HPV) testing for metastatic squamous cell carcinoma (SCC) of lymph nodes level II/III of unknown primary. Herein, the performance of HPV-RNA in situ hybridisation (ISH) in detection of HPV-related SCC is evaluated implementing the ASCO guideline recommendations.
Eighty head and neck (HN) SCC fine needle aspirations, which utilized HPV-RNA ISH/P16, were evaluated at Johns Hopkins Hospital (2015-2018) to investigate their performance and concordance with histology. The results were compared to a prior study of 59 HNSCCs, which HPV-DNA ISH.
Of the 80 reviewed fine needle aspirations, 65 (50 male, 15 female) were included. The mean age was 63.2 ± 14.0 years. The most common site was neck lymph nodes (47, 72.3%). Fifty-five cases (84.6%) were accompanied by concurrent core biopsy, and 48 cases (59.4%) had surgical follow-ups. HPV-RNA ISH was positive in 44 (67.7%), and P16 was strongly positive in 46 (70.8%). The HPV-RNA ISH/ P16 concordance rate was 92.3% on cytology material. The cytology/surgical concordance rate for HPV-RNA ISH was 88.9% (16/18). There was a discordance between the results in five cases (7.7%; HPV-RNA ISH-/P16+).
HPV-RNA ISH is a robust and reliable method for detecting HPV-related HNSCC on cytology material showing concordance rate of 92.3% between HPV-RNA ISH and P16, which is a sensitive but non-specific marker. Compared to HPV-DNA ISH, HPV-RNA ISH reproducibly identifies HPV-related HNSCC with fewer discrepancies between cytology and histology. The findings of this study are in agreement with the ASCO recommendations.

Objective: To evaluate the diagnostic value of the 2015ATA, 2017ACR and 2016KTA/KSThR ultrasound model for indeterminate thyroids nodules. Method: Four hundred and sixty-four patients with thyroid nodules that were initially diagnosed as indeterminate thyroids nodules by fine needle aspiration(FNA) cytology were included in this study. The clinical data and two-dimensional ultrasonographic features were compared between the benign and malignant nodules. The two-dimensional ultrasound images of all nodules were sorted by the 2015ATA, 2017ACR and 2016KTA/KSThR guideline ultrasound model grading criteria, and the malignant risk of different grading were calculated. In order to calculate the diagnosis and other indicators, the optimal threshold drawing from ROC curve was drawn to obtain the cut-off value of 2015ATA, 2017ACR and 2016KTA/KSThR. Result: ①There was no significant difference in age, sex and nodule size between benign and malignant nodules(P>0.05), and there also was no significant difference in irregular margin, microcalcification between benign and malignant nodules.②The sensitivity of the 2015ATA ultrasound model was 87.9%, slightly lower than that of the 2016KTA/KSThR and 2017ACR guidelines(P>0.05).The specificity of 2015ATA was 63.9%, which was significantly higher than that of 2016KTA/KSThR and 2017ACR guidelines(P<0.05). There was no significant difference between 2015ATA ultrasound model and 2016KTA/KSThR guide ultrasound for the accuracy(P>0.05), but the accuracy of 2015ATA ultrasound model was significantly higher than that of 2017ACR guide(P<0.05).③The area under the curve of 2015ATA was slightly lower than that of 2016KTA/KSThR(0.889 VS 0.902, P>0.05) and significantly higher than that of 2017ACR(0.889 VS 0.854, P<0.05). Conclusion: 2015ATA has high specificity and accuracy and moderate sensitivity for the diagnosis of benign and malignant indeterminate thyroids nodules, which is helpful for the clinical evaluation and management of such nodules.
目的：探讨2015ATA、2016KTA/KSThR及2017ACR三种指南模式对性质不明确的甲状腺结节的诊断效能。方法：选取464例经细针穿刺（FNA）细胞学诊断为不明确意义的甲状腺结节患者作为研究对象，分析并比较良恶性结节的临床资料及二维超声特征，对所有结节的二维超声图像分别行2015ATA、2016KTA/KSThR及2017ACR三种指南超声模式分级，计算得出各分级结节的恶性风险，使用受试者工作特征曲线计算得出3种超声模型鉴别不明确意义的良恶性结节的最佳诊断界点，并根据诊断界点得出诊断效能等指标。结果：①在良恶性结节之间，患者的年龄、性别及结节大小差异无统计学意义（P>0.05）；不规则边界、微钙化等超声特征对结节良恶性的鉴别差异无统计学意义；②2015ATA超声模式诊断不明确意义的甲状腺结节的敏感性为87.9%，均略低于2016KTA/KSThR和2017ACR指南超声模式，差异无统计学意义（P>0.05）。2015ATA的特异性为63.9%，均明显高于2016KTA/KSThR和2017ACR指南超声模式（P<0.05）；其准确性与2016KTA/KSThR指南超声模式相近，差异无统计学意义（P>0.05），但明显高于2017ACR指南超声模式（P<0.05）；③2015ATA诊断不明确意义的甲状腺结节的曲线下面积为0.889，略低于2016KTA/KSThR（0.902），差异无统计学意义（P>0.05），但却略高于2017ACR（0.854），差异有统计学意义（P<0.05）。结论：2015ATA指南对不确定意义的甲状腺结节良恶性的诊断具有较高的特异性和准确性以及适度的敏感性，有助于临床有效地评估和管理此类结节。.

To appraise the quality of current guidelines on fine needle aspiration biopsy (FNAB) of thyroid nodules for adults using the AGREE II quality assessment tool.
We conducted an online search for guidelines on FNAB of thyroid nodules published between 2013 and October 2018. They were evaluated by four independent reviewers previously trained to apply the AGREE II instrument, which is organized into items and domains. A fifth independent reviewer calculated scores for each domain and guideline as well as inter-appraiser agreement.
Six sets of guidelines were included, respectively, provided by the American Thyroid Association (ATA), the American Association of Clinical Endocrinologists/American College of Endocrinology/Associazione Medici Endocrinologi (AACE/ACE/AME), the Korean Society of Thyroid Radiology (KSThR), the European Thyroid Association (ETA), the American College of Radiology (ACR) and the Korean Society of Radiology and National Evidence-Based Healthcare Collaborating Agency (KSR/NECA). Five out of the six guidelines (ATA, AACE/ACE/AME, ETA, ACR and KSR/NECA) reached a high level of overall quality, having at least five domain scores >60%. An average level of overall quality was achieved in one case (KSThR recommendations). Inter-appraiser agreement ranged from moderate to excellent.
Overall, the quality of guidelines on FNAB of thyroid nodules is satisfactory when evaluated using the AGREE II instrument.

OBJECTIVE: Some authors have found little or no diagnostic benefit from repeated biopsy of benign thyroid nodules. However, to our knowledge, integration of Thyroid Imaging Reporting and Data System (TIRADS) guidelines with one biopsy for sufficient benign thyroid nodule diagnosis has not been previously described. We investigated malignancy rate and probability by using various malignancy stratification systems in initially biopsy-proven benign nodules and sought to determine their clinical relevance in management of benign thyroid nodules.
METHODS: This retrospective study collected 6762 thyroid nodules from 6493 consecutive patients who underwent biopsy between January 2013 and December 2013. The initial biopsy with ≥1 year of follow-up was used as the gold standard for benign diagnosis. For our study purpose, we analyzed 2747 (57.0%, 2747 of 4822, 532 women, 2111 men; 229 malignant and 2518 benign) thyroid nodules diagnosed by initial biopsy with 28.2 ± 9.1 (range, 12-41) months of follow-up. We calculated the malignancy probability of thyroid nodules by using various malignancy risk stratification systems.
RESULTS: The overall calculated thyroid malignancy rate was 8.3% (229 of 2747). Initially biopsy-proven benign nodules exhibited a ≤3.0% malignancy probability when assessed as \"low suspicion\" by Korean-TIRADS (K-TIRADS), \"low suspicion\" by the ATA guideline, and \"very probably benign\" by the French TIRADS guideline and gave a score of ≤3 by the web-based TIRADS.
CONCLUSIONS: When initially biopsy-proven benign nodules exhibit a \"low suspicion\" US pattern and low malignancy probability, as stratified by various TIRADS guidelines, imaging surveillance instead of second biopsy is warranted.
CONCLUSIONS: • One biopsy is sufficient for initially biopsy-proven benign nodules. • Repetitive biopsy is necessary for imaging-pathology mismatched nodules. • Scoring risk stratification permits personalized management.

Thyroid ultrasound (US) is a key examination for the management of thyroid nodules. Thyroid US is easily accessible, noninvasive, and cost-effective, and is a mandatory step in the workup of thyroid nodules. The main disadvantage of the method is that it is operator dependent. Thyroid US assessment of the risk of malignancy is crucial in patients with nodules, in order to select those who should have a fine needle aspiration (FNA) biopsy performed. Due to the pivotal role of thyroid US in the management of patients with nodules, the European Thyroid Association convened a panel of international experts to set up European guidelines on US risk stratification of thyroid nodules. Based on a review of the literature and on the American Association of Clinical Endocrinologists, American Thyroid Association, and Korean guidelines, the panel created the novel European Thyroid Imaging and Reporting Data System, called EU-TIRADS. This comprises a thyroid US lexicon; a standardized report; definitions of benign and low-, intermediate-, and high-risk nodules, with the estimated risks of malignancy in each category; and indications for FNA. Illustrated by numerous US images, the EU-TIRADS aims to serve physicians in their clinical practice, to enhance the interobserver reproducibility of descriptions, and to simplify communication of the results.