1. 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

2. 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

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

4. 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

5. ELASTOGRAPHY TECHNIQUE

6. 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

7. 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 %

8. Elastography diagram of Asteria (2008)

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

10. 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

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

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

13. 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

14. 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 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.

15. 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%

16. 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%)

17. 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

18. 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%

19. 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%)

20. Figure 5: TIRADS classification
RESULTS & DISCUSSIONS
Grade 4: 12 patients (16,6%)
Figure 5: TIRADS classification
TIRADS 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)

21. 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.

22. 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.

23. 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

24. 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%.

25. 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%.

26. 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%

27. 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%

28. 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%.

29. THANK YOU!