VALUES OF ELASTOGRAPHY IN DIAGNOSIS OF THYROID CANCER 103 Military Hospital DEPARTMENT OF FUNCTIONAL EXPLORATION VALUES OF ELASTOGRAPHY IN DIAGNOSIS OF THYROID CANCER M.D. Nguyen Minh Hai

INTRODUCTION - Thyroid nodules are very common hormone disease, only after diabetes - The incidence of nodules through clinical examination is only at 4-7 %. - Ultrasound diagnosis brings up the rate to 19-67% - More than 90% of thyroid nodule is benign and 5-10% is malignant  Need to diagnose early and carry out surgery to patients diagnosed with malignant thyroid nodules

PURPOSES OF THE STUDY Evaluated some clinical characteristics, 2D ultrasound and thyroid elastography of tumors Some values thyroid elastography in diagnosis of malignant tumors

OVERVIEW 2D Ultrasound Elastography Pathology - Golden standard to diagnosis - Invasive method - Depends on the number of nodules 2D Ultrasound - Major diagnostic method - Noninvasive procedure - Directional diagnosis of cancer Elastography - Provide more basis to diagnose cancer - Assess the biophysical characteristics of tissue

ELASTOGRAPHY TECHNIQUE

Hypoechogenicity or marked hypoechogenicity TIRADS PARAMETERS Kwak (2011) determined TIRADS based on following 5 maglinant suggestive signs: Solid nodule Hypoechogenicity or marked hypoechogenicity Microlobulated or irregular margins Microcalcifications, with diameter < 0,5mm Taller-than-wide shape TIRADS: Thyroid image reporting and data system

TIRADS Characteristics Mag. rate 1 Normal No focal lesions 0% 2 Benign lesions - follicle, spongiform follicle - Nodes with macrocalcification and clear border - Nodes with hyperechogenicity 3 Possibly benign isoechoic or hypoechoic, clear margin, peripheral blood perfusion 1,7 % 4 4A Low possibility of being malignant 1 malignant sign 3,3 % 4B Midium possibility of being malignant 2 malignant signs 9,2 % 4C High possibility of being malignant 3 or 4 malignant signs 44,4 - 72,4% 5 Very high possibility of being maglinant All 5 malignant signs or tissue diagnosis or Nodal metastases 87,5 %

Elastography diagram of Asteria (2008)

RESEARCH METHODOLOGY SUBJECTS 72 patients examined or under treatment for thyroid nodules from 10/2015 - 11/2016 Undertook ultrasound scan at the department of functional diagnosis- 103 Military Hospital Tissue diagnosis at the department of Histology –103 Military Hospital

RESEARCH METHODOLOGY Research methodology: cross-sectional study RESEARCH CONTENTS Clinical examination, identify location, density, displacement characteristics of tumors, identify related lympho nodes 2D ultrasound, color Doppler: Assess echogenicity, border, size, blood circulation Elastography of tumors: assess the Elastography parameters

EQUIPMENT Ultrasound scanner Logic S8 (GE – U.S.A) Elastography Program Linear transducer with 6 - 15 MHz.

Measurement parameters - Average elasticity of lesions: E2 - The elasticity of benign parenchyma : E1 Elasticity ratio (SR - strain ratio) SR = E2 / E1

RESEARCH METHODOLOGY Measure elasticity parameter Data processing: Data are analyzed by SPSS 16.0, percentage, average value, sensitivity level, specificity, the accuracy of the method compared with the outcome of pathology analysis

Table 1. Some clinical characteristics of patients RESULTS & DISCUSSIONS Table 1. Some clinical characteristics of patients Parameter N = 72 % Age (Average) 47,31 ± 12,91   Gender Male 4 5,6 Female 68 94,4 Physical examination of thyroid nodules Number One 41 56,9 More than one 31 43,1 Location Right lobe 28 38,9 Left lobe 16 22,2 Both side Density of tumors Soft 42 58,3 Hard, solid, less movement 30 41,7 Cervical lymph nodes Yes 6 8,3 No 66 91,7 * Trần Ngọc Dũng (2010) studied 1181 patients with thyroid carcinoma nodules, aged average 41,3 ± 8,9 years old, out of which aged 30-49 years old (45,97%) * Nguyễn Hữu Thịnh (2012) studied 44 patients with thyroid cancer, aged average 45 years old, female accounts for 81,8%, clinical examination suggested 40,9% of being malignant.

Figure 1: Distribution of patients with thyroid cancer by gender RESULTS & DISCUSSIONS Figure 1: Distribution of patients with thyroid cancer by gender *Trịnh Thị Thu Hồng: studied 146 patients thyroid multi-nodules: Female/Male: 9/1 *Nguyễn Tài Dũng (2005) studied 32 patients special thyroid cancer: Female 84,4%,; Male 15,6%

Figure 2: Distribution of nodules by location on lobes of thyroid RESULTS & DISCUSSIONS Figure 2: Distribution of nodules by location on lobes of thyroid *Trần Ngọc Dũng (2010) tumors on right lobe (44,4%), left lobe (37,3%), both lobes (18,3%)

Table 2. 2D ultrasound results Lesion structure n = 72 % Structure Solid 50 69,4 Cyst 3 4,2 Combination 19 26,4 Echogenicity hypoechogenicity 21 29,2 isoechoic 26 36,1 Heterogeneity 25 34,7 Shape Taller than wide 8 11,1 Wider than tall 64 88,9 Calcification Micro-calcification 10 13,9 Macro-calcification 11 15,3 Margin Irregular 36 50,0 Regular

Figure 3: Distribution of lesion characteristics by 2D echoic pattern RESULTS & DISCUSSIONS Figure 3: Distribution of lesion characteristics by 2D echoic pattern * Ng. Hữu.Thịnh (2011): studied 44 patients with thyroid nodules, hypoechogenicity nodules: 47,7%. * Trần Văn Tuấn (2010): studied 54 patients with thyroid nodules: hypoechogenicity 57,4%, hyperechogenicity 27,8%

RESULTS & DISCUSSIONS Figure 4: Distribution of lesion characteristics by calcification images * Ng. Hữu.Thịnh (2012) : calcification: 31,8%; * Trịnh Thị Thu Hồng: studied 146 patients with thyroid multi nodular cancer: micro calcification (8,2%), macro-calcification (22,4%), non-calcification (69,4%)

Figure 5: TIRADS classification RESULTS & DISCUSSIONS Grade 4: 12 patients (16,6%) Figure 5: TIRADS classification TIRADS 2 - 3 included 60 patients (83,3%), have not found images suggesting malignant sign. 12 patients (16,6%) had 1 to 4 malignant signs of TIRADS 4. (These patients was referred for FNA)

RESULTS & DISCUSSIONS Elasticity classification n = 72 Percentage (%) Table 3. Results of sample of tumor elastography Elasticity classification n = 72 Percentage (%) ES 1 (soft) 4 5,6 ES 2 (soft – hard) 35 48,6 ES 3 (hard) 28 38,9 ES 4 (very hard) 5 6,9 The results showed, 33/72 patients (45,8%) have hard and very hard tumors (ES3-ES4), all of these case are suggested to be malignant tumors. However, these are only qualitative parameter, diagnostic value is not high.

Figure 6: Distribution of elastography of lesions by colour diagram RESULTS & DISCUSSIONS Figure 6: Distribution of elastography of lesions by colour diagram The results showed: 33/72 patients (45,8%) have hard and very hard tumors (ES3-ES4), all of these case are suggested to be malignant tumors. However, these are only qualitative parameter, diagnostic value is not high.

Table 4. Parameters of elasticity RESULTS & DISCUSSIONS Table 4. Parameters of elasticity Parameters N = 72 Min Max E1 1,19 ± 0,54 0,6 3,3 E2 2,6 ± 0,98 1,0 4,6 SR (E2/E1) 2,51 ±1,18 5,7 SR ≥ 2,5 23 patients (31,9 %) < 2,5 49 patients (68,1%) - Sahin et al. (2014) SR > 2,45 suggests thyroid cancer on elastography

Table 5. Sensitivity, Specificity by elastography RESULTS & DISCUSSIONS Table 5. Sensitivity, Specificity by elastography GPB Elastography Malignant Benign Total ES3 -ES4 (hard tumor - Malignant) 10 13 23 ES1-ES2 (soft tumor-benign) 2 47 49 12 60 72 - Sensitivity: 83,3%. - Specificity: 78,3%. - Accuracy level: 79,1%.

Table 6. Sensitivity level, specification by SR elasticity ratio Results & discussion Table 6. Sensitivity level, specification by SR elasticity ratio GPB SR elasticity ratio Malignant Benign Total SR ≥ 2,5 ( Malignant ) 11 12 23 SR < 2,5 ( Benign ) 1 48 49 60 72 - Sensitivity: 91,6%. - Specificity: 80%. - Accuracy level: 81,9%. Sahin et al. (2014) SR > 2,45 is diagnostic sign of thyroid cancer on elastography. Sensitivity level: 73,9% and Specificity: 73%.

Results & discussion Table 7. Sensitivity level, Specification according TIRADS, ES and SR elasticity ratio Pathology parenchyma 2D ultrasound+ elasticity Malignant Benign Total TIRADS 4 + ES 3,4+ SR ≥ 2.5 (Malignant) 11 1 12 TIRADS 2-3+ES 2,3+ SR < 2.5 (benign ) 59 60 72 Sensitivity level: 91,7%. Specification: 98,3%. Accuracy level: 98,3%. Gilles Russ (2013): 2D ultrasound, TIRADS if combined with tissue ultrasound elastography will increase the sensitivity level of thyroid cancer diagnosis up to 98,5%

CONCLUSIONS Clinical characteristics, 2D ultrasound and elastography Studying on 72 patients with thyroid nodules by thyroid elastography, we have concluded that: Clinical characteristics, 2D ultrasound and elastography Clinical characteristics : Density of hard, solid, less moving tumors: 41,7% One nodule: 56,9% Cervical lymph node: 8,3% 2D ultrasound parameters: Irregular margin: 50% Hypoechogenicity: 29,2% Taller than wide shape: 11,1% Micro-calcification nodes: 13,9% Elastography parameters: Colour codes ES3 - ES4 (hard and very hard tumors): 45,8%

CONCLUSIONS 2. Technical values of elastography in thyroid cancer diagnosis - Elastography values: Sensitivity level 83,3%. Specification 78,3%. - Elastography combined with 2D ultrasound and TIRADS classification: Sensitivity level 91,7%. Specificity: 98,3%. Accuracy: 98,3%.

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