Publications by authors named "Dong Gyu Na"

115 Publications

Impact of the ultrasonography assessment method on the malignancy risk and diagnostic performance of five risk stratification systems in thyroid nodules.

Endocrine 2021 Sep 17. Epub 2021 Sep 17.

Department of Radiology, GangNeung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Republic of Korea.

Purpose: Ultrasonographic (US) assessment methods may affect the estimated malignancy risk of thyroid nodules. This study aimed to investigate the impact of retrospective and prospective US assessments on the estimated malignancy risk of US features, classified categories, and diagnostic performance of five risk stratification systems (RSSs) in thyroid nodules.

Methods: A total of 3685 consecutive thyroid nodules (≥1 cm) with final diagnoses (retrospective dataset, n = 2180; prospective dataset, n = 1505) were included in this study. We compared the estimated malignancy risk of US features, classified categories, and diagnostic performances of the five common RSSs between retrospective (static US images without cine clips) and prospective datasets of real-time US assessment.

Results: There was no significant difference in the prevalence and histological type of malignant tumours between the two datasets (p ≥ 0.216). The malignancy risk of solid composition and nonparallel orientation was higher and that of microcalcification was lower in the prospective dataset than in the retrospective dataset (p < 0.001, p = 0.018, p = 0.007, respectively). The retrospective US assessment showed slightly higher malignancy risk of intermediate- or high-risk nodules according to the RSSs. Prospective US assessment showed lower specificities and higher unnecessary biopsy rates by all RSSs compared to the retrospective US assessment (p ≤ 0.006, p ≤ 0.045, respectively).

Conclusions: The retrospective US assessment showed higher malignancy risk of microcalcification and some classified categories by RSSs, and overestimated the specificities and underestimated the unnecessary biopsy rates by all RSSs compared to prospective US assessment.
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http://dx.doi.org/10.1007/s12020-021-02795-xDOI Listing
September 2021

Radiofrequency Ablation of Benign Thyroid Nodules: Recommendations from the Asian Conference on Tumor Ablation Task Force - Secondary Publication.

J Med Ultrasound 2021 Apr-Jun;29(2):77-83. Epub 2021 Jun 21.

Department of Ultrasound, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.

Radiofrequency ablation (RFA) is a thermal ablation technique widely used for the management of benign thyroid nodules. To date, five academic societies in various countries have reported clinical practice guidelines, opinion statements, or recommendations regarding the use of thyroid RFA. However, despite some similarities, there are also differences among the guidelines, and a consensus is required regarding safe and effective treatment in Asian countries. Therefore, a task force was organized by the guideline committee of the Asian Conference on Tumor Ablation with the goal of devising recommendations for the clinical use of thyroid RFA. The recommendations in this article are based on a comprehensive analysis of the current literature and the consensus opinion of the task force members.
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http://dx.doi.org/10.4103/JMU.JMU_178_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8330684PMC
June 2021

Korean Thyroid Imaging Reporting and Data System: Current Status, Challenges, and Future Perspectives.

Korean J Radiol 2021 09 1;22(9):1569-1578. Epub 2021 Jun 1.

Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.

The Korean Thyroid Imaging Reporting and Data System (K-TIRADS) is an ultrasound-based risk stratification system for thyroid nodules that has been widely applied for the diagnosis and management of thyroid nodules since 2016. This review article provides an overview of the use of the K-TIRADS compared with other risk stratification systems. Moreover, this review describes the challenges in the clinical application of the K-TIRADS, as well as future development directions toward the personalized management of patients with thyroid nodules.
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http://dx.doi.org/10.3348/kjr.2021.0106DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8390814PMC
September 2021

Comparison of the diagnostic performance of the modified Korean Thyroid Imaging Reporting and Data System for thyroid malignancy with three international guidelines.

Ultrasonography 2021 Oct 5;40(4):594-601. Epub 2021 Apr 5.

Department of Radiology, Research Institute and Hospital, National Cancer Center, Goyang, Korea.

Purpose: This study compared the diagnostic performance of the modified Korean Thyroid Imaging Reporting and Data System (K-TIRADS) for thyroid malignancy with three international guidelines.

Methods: From June to September 2015, 5,708 thyroid nodules (≥1.0 cm) in 5,081 consecutive patients who underwent thyroid ultrasound (US) at 26 institutions were evaluated. The US features of the thyroid nodules were retrospectively reviewed and classified according to all four guidelines. In the modified K-TIRADS, the biopsy size threshold was changed to 2.0 cm for K-TIRADS 3 and 1.0 or 1.5 cm for K-TIRADS 4 (K-TIRADS1.0cm and K-TIRADS1.5cm, respectively). We compared the diagnostic performance and unnecessary fine-needle aspiration biopsy (FNAB) rates for thyroid malignancy between the modified K-TIRADS and three international guidelines.

Results: Of the 5,708 thyroid nodules, 4,597 (80.5%) were benign and 1,111 (19.5%) were malignant. The overall sensitivity was highest for the modified K-TIRADS1.0cm (91.0%), followed by the European (EU)-TIRADS (84.6%), American Association of Clinical Endocrinologists/American College of Endocrinology/Associazione Medici Endocrinologi (AACE/ACE/AME) (80.5%), American College of Radiology (ACR)-TIRADS (76.1%), and modified K-TIRADS1.5cm (76.1%). For large nodules (>2.0 cm), the sensitivity increased to 98.0% in both the modified K-TIRADS1.0cm and K-TIRADS1.5cm. For small nodules (≤2.0 cm), the unnecessary FNAB rate was lowest with the modified K-TIRADS1.5cm (17.6%), followed by the ACR-TIRADS (18.6%), AACE/ACE/AME (19.3%), EU-TIRADS (28.1%), and modified K-TIRADS1.0cm (31.2%).

Conclusion: The modified K-TIRADS1.5cm can reduce the unnecessary FNAB rate for small nodules (1.0-2.0 cm), while maintaining high sensitivity for detecting malignancies >2.0 cm.
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http://dx.doi.org/10.14366/usg.21056DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8446501PMC
October 2021

Which ultrasound image plane is appropriate for evaluating the taller-than-wide sign in the risk stratification of thyroid nodules?

Eur Radiol 2021 Oct 14;31(10):7605-7613. Epub 2021 Apr 14.

Department of Radiology, Gangneung Asan Hospital, University of Ulsan College of Medicine, 38 Bangdong-gil, Sacheon-myeon, Gangneung-si, Gangwon-do, 25440, Republic of Korea.

Objectives: This study aimed to determine the ultrasound (US) image plane appropriate for evaluating the taller-than-wide (TTW) sign in the risk stratification of thyroid nodules using the five widely used risk stratification systems (RSSs).

Methods: A total of 1905 consecutive thyroid nodules with final diagnoses were included. The TTW sign was prospectively assessed in the transverse and longitudinal US image planes. The diagnostic performances of the TTW sign and biopsy criteria by the RSSs for malignancy were compared by sensitivity, specificity, and receiver operating characteristic curve analysis between the two criteria of TTW signs according to image planes (criterion 1, transverse plane; criterion 2, either transverse or longitudinal plane).

Results: Of all 1905 nodules, 1481 (77.7%) were benign and 424 (22.3%) were malignant. The criteria 1 and 2 of TTW signs had similar sensitivities (37.5% and 38.7%) and specificities (94.8% and 94.4%) with minimal differences, and the area under the curve (AUC) of TTW signs for malignancy was not significantly different between criteria 1 and 2 (0.662 and 0.665, p = 0.158, respectively). The sensitivity, specificity, and AUC of biopsy criteria by the five RSSs were not significantly different between criteria 1 and 2 in nodules ≥ 1 cm (p ≥ 0.157, p ≥ 0.317, and p ≥ 0.198, respectively).

Conclusions: The diagnostic performances of the TTW sign and biopsy criteria of the five RSSs were similar between criteria 1 and 2. TTW signs by criterion 1 (transverse plane) may be appropriate in the risk stratification of thyroid nodules.

Key Points: • The diagnostic performance of the taller-than-wide sign by ROC analysis was not significantly different between US image plane criteria (transverse plane vs. either transverse or longitudinal plane). • The diagnostic performances of biopsy criteria for malignancy by the five risk stratification systems were similar between the two taller-than-wide sign criteria. • The taller-than-wide sign using the transverse plane may be appropriate in the risk stratification of thyroid nodules.
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http://dx.doi.org/10.1007/s00330-021-07936-4DOI Listing
October 2021

Five-year follow-up results of thermal ablation for low-risk papillary thyroid microcarcinomas: systematic review and meta-analysis.

Eur Radiol 2021 Sep 13;31(9):6446-6456. Epub 2021 Mar 13.

Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 86 Asanbyeongwon-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea.

Objectives: Confidence in long-term treatment results of thermal ablation for papillary thyroid microcarcinoma (PTMC) is required in comparison with active surveillance. The objective of this meta-analysis is to report 5-year follow-up results of thermal ablation for PTMC.

Methods: Ovid MEDLINE and EMBASE databases were searched through May 30, 2020, for studies reporting outcomes in patients with PTMC treated with thermal ablation and followed up for at least 5 years. Data were extracted and methodological quality was assessed independently by two radiologists according to the PRISMA guidelines.

Results: Three studies, involving 207 patients with 219 PTMCs, met the inclusion criteria through database searches. None of these patients experienced local tumor recurrence, lymph node metastasis, or distant metastasis or underwent delayed surgery during a mean pooled 67.8-month follow-up. Five new tumors appeared in the remaining thyroid gland of four patients, with four of these tumors successfully treated by repeat thermal ablation. The pooled mean major complication rate was 1.2%, with no patient experiencing life-threatening or delayed complications.

Conclusions: Thermal ablation is an excellent local tumor control method in patients with low-risk PTMC, with low major complication rates at 5 years.

Key Points: • No local tumor recurrence, lymph node metastasis, or distant metastasis was noted by thermal ablation during follow-up of 5 years and none underwent delayed surgery. • The pooled mean major complication rate was 1.2%.
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http://dx.doi.org/10.1007/s00330-021-07808-xDOI Listing
September 2021

2020 Imaging Guidelines for Thyroid Nodules and Differentiated Thyroid Cancer: Korean Society of Thyroid Radiology.

Korean J Radiol 2021 05 9;22(5):840-860. Epub 2021 Feb 9.

Department of Radiology, Gangneung Asan Hospital, Ulsan University College of Medicine, Gangneung, Korea.

Imaging plays a key role in the diagnosis and characterization of thyroid diseases, and the information provided by imaging studies is essential for management planning. A referral guideline for imaging studies may help physicians make reasonable decisions and minimize the number of unnecessary examinations. The Korean Society of Thyroid Radiology (KSThR) developed imaging guidelines for thyroid nodules and differentiated thyroid cancer using an adaptation process through a collaboration between the National Evidence-based Healthcare Collaborating Agency and the working group of KSThR, which is composed of radiologists specializing in thyroid imaging. When evidence is either insufficient or equivocal, expert opinion may supplement the available evidence for recommending imaging. Therefore, we suggest rating the appropriateness of imaging for specific clinical situations in this guideline.
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http://dx.doi.org/10.3348/kjr.2020.0578DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8076832PMC
May 2021

Malignancy Risk Stratification of Thyroid Nodules with Macrocalcification and Rim Calcification Based on Ultrasound Patterns.

Korean J Radiol 2021 04 2;22(4):663-671. Epub 2021 Feb 2.

Department of Endoclinology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea.

Objective: To determine the association of macrocalcification and rim calcification with malignancy and to stratify the malignancy risk of thyroid nodules with macrocalcification and rim calcification based on ultrasound (US) patterns.

Materials And Methods: The study included a total of 3603 consecutive nodules (≥ 1 cm) with final diagnoses. The associations of macrocalcification and rim calcification with malignancy and malignancy risk of the nodules were assessed overall and in subgroups based on the US patterns of the nodules. The malignancy risk of the thyroid nodules was categorized as high (> 50%), intermediate (upper-intermediate: > 30%, ≤ 50%; lower-intermediate: > 10%, ≤ 30%), and low (≤ 10%).

Results: Macrocalcification was independently associated with malignancy in all nodules and solid hypoechoic (SH) nodules ( < 0.001). Rim calcification was not associated with malignancy in all nodules ( = 0.802); however, it was independently associated with malignancy in partially cystic or isoechoic and hyperechoic (PCIH) nodules ( = 0.010). The malignancy risks of nodules with macrocalcification were classified as upper-intermediate and high in SH nodules, and as low and lower-intermediate in PCIH nodules based on suspicious US features. The malignancy risks of nodules with rim calcification were stratified as low and lower-intermediate based on suspicious US features.

Conclusion: Macrocalcification increased the malignancy risk in all and SH nodules with or without suspicious US features, with low to high malignancy risks depending on the US patterns. Rim calcification increased the malignancy risk in PCIH nodules, with low and lower-intermediate malignancy risks based on suspicious US features. However, the role of rim calcification in risk stratification of thyroid nodules remains uncertain.
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http://dx.doi.org/10.3348/kjr.2020.0381DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8005340PMC
April 2021

Diagnostic performance of the modified Korean Thyroid Imaging Reporting and Data System for thyroid malignancy according to nodule size: a comparison with five society guidelines.

Ultrasonography 2021 Oct 9;40(4):474-485. Epub 2020 Dec 9.

Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.

Purpose: The aim of this study was to evaluate the diagnostic performance of the modified Korean Thyroid Imaging Reporting and Data System (K-TIRADS) compared with five society risk stratification systems (RSSs) according to nodule size.

Methods: In total, 3,826 consecutive thyroid nodules (≥1 cm) with final diagnoses in 3,088 patients were classified according to five RSSs. The K-TIRADS was modified by raising the biopsy size threshold for low-suspicion nodules and subcategorizing intermediate-suspicion nodules. We assessed the performance of the RSSs as triage tests and their diagnostic accuracy according to nodule size (with a threshold of 2 cm).

Results: Of all nodules, 3,277 (85.7%) were benign and 549 (14.3%) were malignant. In small thyroid nodules (≤2 cm), the American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS) had the highest reduction rate of unnecessary biopsies (76.3%) and the lowest sensitivity (76.1%). The modified K-TIRADS had the second highest reduction rate of unnecessary biopsies (67.6%) and sensitivity (86.6%). The modified K-TIRADS and ACR TI-RADS had the highest diagnostic odds ratios (P=0.165) and the highest areas under the curve (P=0.315). In large nodules (>2 cm), the sensitivity of the ACR TI-RADS for malignancy was significantly lower (88.8%) than the sensitivities of the modified K-TIRADS and other RSSs, which were very high (98.7%-99.3%) (P<0.001).

Conclusion: The modified K-TIRADS allows a large proportion of unnecessary biopsies to be avoided, while maintaining high sensitivity and diagnostic accuracy for small malignant tumors and very high sensitivity for large malignant tumors.
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http://dx.doi.org/10.14366/usg.20148DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8446497PMC
October 2021

Factors to consider when comparing the diagnostic performance of fine-needle aspiration and core-needle biopsy for thyroid nodules.

Authors:
Dong Gyu Na

Endocrine 2021 02 5;71(2):524-525. Epub 2021 Jan 5.

Department of Radiology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung-si Gangwon-do, 25440, Republic of Korea.

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http://dx.doi.org/10.1007/s12020-020-02562-4DOI Listing
February 2021

Radiofrequency ablation of benign thyroid nodules: recommendations from the Asian Conference on Tumor Ablation Task Force.

Ultrasonography 2021 Jan 8;40(1):75-82. Epub 2020 Sep 8.

Department of Ultrasound, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.

Radiofrequency ablation (RFA) is a thermal ablation technique widely used for the management of benign thyroid nodules. To date, five academic societies in various countries have reported clinical practice guidelines, opinion statements, or recommendations regarding the use of thyroid RFA. However, despite some similarities, there are also differences among the guidelines, and a consensus is required regarding safe and effective treatment in Asian countries. Therefore, a task force was organized by the guideline committee of the Asian Conference on Tumor Ablation with the goal of devising recommendations for the clinical use of thyroid RFA. The recommendations in this article are based on a comprehensive analysis of the current literature and the consensus opinion of the task force members.
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http://dx.doi.org/10.14366/usg.20112DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7758103PMC
January 2021

Ultrasonographic echogenicity of normal salivary glands in adults: comparison of submandibular and parotid glands.

Ultrasonography 2021 Jul 21;40(3):342-348. Epub 2020 Aug 21.

Department of Radiology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea.

Purpose: The normal submandibular gland (SMG) and parotid gland (PG) are thought to have similar homogeneous ultrasound (US) hyperechogenicity; however, this has not been extensively investigated. The aim of this study was to determine whether the normal SMG and PG have similar US echogenicity.

Methods: We included 969 consecutive adult patients with normal salivary glands. The patients were categorized into three age groups: group 1 (19 to 29 years, n=27), group 2 (30 to 49 years, n=273), and group 3 (≥50 years, n=669). The echogenicities of the SMG and PG were prospectively evaluated by an experienced radiologist. Computed tomography (CT) attenuation in Hounsfield units (HUs) was quantitatively measured for the SMG, PG, and sternocleidomastoid muscle in 140 patients.

Results: Relative to the PG, the echogenicity of the SMG was similar in 706 (73.0%) and homogeneously hypoechoic in 263 patients (27.0%). The frequency of SMG hypoechogenicity decreased with increasing age (group 1, 59.3%; group 2, 36.3%; group 3, 22.1%; P<0.001). The CT attenuation levels (in HUs) of the SMG and PG were significantly higher in patients with hypoechoic SMGs than in patients with SMG echogenicity similar to that of the PG (P<0.001).

Conclusion: Hypoechogenicity of the SMG was observed in more than a quarter of this sample of adults with normal salivary glands. The SMG may be inadequate as a reference standard for evaluating thyroid nodule echogenicity in patients with diffuse thyroid disease with decreased echogenicity.
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http://dx.doi.org/10.14366/usg.20070DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8217796PMC
July 2021

Clinical applications of Doppler ultrasonography for thyroid disease: consensus statement by the Korean Society of Thyroid Radiology.

Ultrasonography 2020 Oct 25;39(4):315-330. Epub 2020 Aug 25.

Department of Radiology, GangNeung Asan Hospital, Gangneung, Korea.

Doppler ultrasonography (US) is widely used for the differential diagnosis of thyroid nodules, metastatic cervical lymph nodes in patients with thyroid cancer, and diffuse parenchymal disease, as well as for guidance in various US-guided procedures, including biopsy and ablation. However, controversies remain regarding the appropriate use and interpretation of Doppler US. Therefore, the Korean Society of Thyroid Radiology organized a taskforce to develop a consensus statement on the clinical use of Doppler US for thyroid disease. The review and recommendations in this article are based on a comprehensive analysis of the current literature and the consensus of experts.
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http://dx.doi.org/10.14366/usg.20072DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7515666PMC
October 2020

Diagnostic performance of core needle biopsy as a first-line diagnostic tool for thyroid nodules according to ultrasound patterns: Comparison with fine needle aspiration using propensity score matching analysis.

Clin Endocrinol (Oxf) 2021 03 19;94(3):494-503. Epub 2020 Sep 19.

Division of Biostatistics, Department of R&D Management, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea.

Objective: This study aimed to compare the diagnostic performance of core-needle biopsy (CNB) to fine-needle aspiration (FNA) as a first-line diagnostic tool in initially detected thyroid nodules, according to ultrasound (US) patterns.

Materials And Methods: This study included 778 consecutive nodules from 705 patients who underwent CNB from one institution and 627 nodules from 583 patients who underwent FNA from two institutions. Adjustments for significant differences in patients' characteristics were facilitated via propensity score matching. We compared the diagnostic performance of CNB and FNA for thyroid malignancy according to three diagnostic criteria for all nodules and the US patterns.

Results: A 1:1 matching of 469 patients yielded no significant differences between CNB and FNA for any covariates. CNB showed a significantly higher sensitivity for malignancy than FNA with any criterion (criterion 1: category VI, criterion 2: category V and VI, criterion 3: category IV, V and VI) in overall and high suspicion nodules (90.1-99.5% vs 69.7%-88.3%, all P-values < 0.001) and low/intermediate suspicion nodules, except criterion 1 (61.9%-100% vs 36.4%-45.5%, all P ≤ .016). In ROC curve analysis, the areas under the ROC curve of CNB were significantly higher than those for FNA with any criterion in overall and high suspicion nodules (P < .001) and in low/intermediate suspicion nodules, except criterion 1 (P ≤ .008). CNB had a slightly higher minor complication rate than FNA (0.7% vs 0%, P ≥ .069).

Conclusion: Our study suggests that CNB has a complementary role as an alternative first-line diagnostic tool to FNA for the initial diagnosis of thyroid nodules when performed by an experienced operator.
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http://dx.doi.org/10.1111/cen.14321DOI Listing
March 2021

Re: Clinical significance of isolated macrocalcifications detected by ultrasonography.

Authors:
Dong Gyu Na

Ultrasonography 2020 Oct 19;39(4):409-410. Epub 2020 Jul 19.

Department of Radiology, GangNeung Asan Hospital, Gangneung, Korea.

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http://dx.doi.org/10.14366/usg.20097DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7515664PMC
October 2020

Clinical practice guidelines for radiofrequency ablation of benign thyroid nodules: a systematic review.

Ultrasonography 2021 Apr 8;40(2):256-264. Epub 2020 Jun 8.

Department of Radiology, GangNeung Asan Hospital, Gangneung, Korea.

Purpose: Thermal ablation is a novel treatment alternative for benign thyroid nodules, and one of the most promising thermal ablation techniques is radiofrequency ablation (RFA). Considering the increasing use of thyroid RFA, some scientific societies have proposed clinical practice guidelines. We systemically reviewed and compared these guidelines for thyroid RFA to identify a standard treatment strategy that represents the positions of most societies.

Methods: We searched the MEDLINE and EMBASE databases for studies with human participants that were published in English between January 1, 2000 and August 2, 2019. Studies containing clinical practice guidelines for the RFA of benign thyroid nodules were included. We extracted data regarding indications, pre- and post-procedural evaluations, treatment techniques, and the need to obtain informed consent.

Results: Of the 83 studies found, four studies were included, and one study was added after searching the bibliographies of those articles. The five included studies were guidelines developed by the Korean Society of Thyroid Radiology, a group of experts from Italian scientific societies, the Italian Working Group on Minimally Invasive Treatments of the Thyroid, the United Kingdom's National Institute for Health and Clinical Excellence, and a group of four professional Austrian thyroid associations. Indications, pre- and post-procedural evaluations, and techniques were similar across studies; however, differences in each of these categories were found.

Conclusion: While the reviewed guidelines are similar with regard to major categories, international guidelines for the RFA of benign thyroid nodules should be established in the future.
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http://dx.doi.org/10.14366/usg.20015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7994735PMC
April 2021

Assessing the diagnostic performance of thyroid biopsy with recommendations for appropriate interpretation.

Ultrasonography 2021 Apr 19;40(2):228-236. Epub 2020 May 19.

Department of Radiology and the Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

Purpose: The diagnostic performance of thyroid biopsy is influenced by several factors, including differences in the Bethesda categorization for malignancy, the inclusion or exclusion of non-diagnostic results, the definition used for the final diagnosis, and the definition of an inconclusive diagnosis. The purpose of this study was to provide an understanding of the factors influencing the diagnostic performance of thyroid biopsy.

Methods: We collected data retrospectively between January and December 2013 from a cohort of 6,762 thyroid nodules from 6,493 consecutive patients who underwent biopsy. In total, 4,822 nodules from 4,553 patients were included. We calculated the biopsy sensitivity according to the inclusion of different Bethesda categories in the numerator and the exclusion of non-diagnostic results, as well as the diagnostic accuracy according to different definitions of a benign diagnosis. We obtained the conclusive and inconclusive diagnosis rates.

Results: The sensitivity increased when more Bethesda categories were included in the numerator and when non-diagnostic results were excluded. When a benign thyroid nodule diagnosis was defined as benign findings on surgical resection, concordant benign results on at least two occasions, or an initial benign biopsy result and follow-up for more than 12 months, the accuracy was higher than when the diagnosis was based on surgical resection alone (91.1% vs. 68.7%). A higher conclusive diagnosis rate was obtained when Bethesda categories I and III were considered inconclusive than when Bethesda categories I, III and IV were considered inconclusive (78.3% vs. 72.8%, P<0.001).

Conclusion: Understanding the concepts presented herein is important in order to appropriately interpret the diagnostic performance of thyroid biopsy.
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http://dx.doi.org/10.14366/usg.19099DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7994740PMC
April 2021

Malignancy risk of thyroid nodules with nonshadowing echogenic foci.

Ultrasonography 2021 Jan 19;40(1):115-125. Epub 2020 Apr 19.

Department of Pathology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea.

Purpose: This study was conducted to determine the malignancy risk and diagnostic value of various types of nonshadowing echogenic foci (NEF) in the risk stratification of thyroid nodules.

Methods: A total of 1,018 consecutive thyroid nodules (≥1 cm) with final diagnoses were included. The presence of NEF was determined and types of NEF were classified according to the presence of a comet tail artifact (CTA), location, and size through a prospective evaluation. The associations with malignancy, malignancy risk, and diagnostic value of various types of NEF were assessed.

Results: Intrasolid punctate NEF without CTA was the only type of NEF that was an independent predictor of malignancy (P<0.001). The malignancy risk of intrasolid punctate NEF without CTA was substantially higher in solid hypoechoic nodules than in isoechoic or nonsolid nodules (71.3% vs. 9.2%, P<0.001). In solid hypoechoic nodules, slightly increased sensitivity (70.8% vs. 67.9%) for malignancy and a similar malignancy risk (71.4% vs. 71.3%) were observed for intrasolid punctate NEF (with or without CTA) and intrasolid punctate NEF without CTA, respectively. NEF with CTA at the margin of the cystic component was not associated with malignancy or benignity in nonsolid nodules (P>0.05).

Conclusion: Intrasolid punctate NEF without CTA was the only independent predictor of malignancy. However, solid hypoechoic nodules with intrasolid punctate NEF should be classified as high-suspicion nodules regardless of coexisting CTA. Other types of NEF had no added value for detecting malignancy compared to intrasolid punctate NEF without CTA.
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http://dx.doi.org/10.14366/usg.20012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7758109PMC
January 2021

Thyroid Nodules with Isolated Macrocalcifications: Malignancy Risk of Isolated Macrocalcifications and Postoperative Risk Stratification of Malignant Tumors Manifesting as Isolated Macrocalcifications.

Korean J Radiol 2020 05;21(5):605-613

Department of Radiology, GangNeung Asan Hospital, Gangneung, Korea.

Objective: To determine the malignancy risk of isolated macrocalcifications (a calcified nodule with complete posterior acoustic shadowing) detected on ultrasonography (US) and to evaluate the postoperative American Thyroid Association (ATA) risk stratification of malignant tumors manifesting as isolated macrocalcifications.

Materials And Methods: A total of 3852 thyroid nodules (≥ 1 cm) of 3061 consecutive patients who had undergone biopsy between January 2011 and June 2018 were included in this study. We assessed the prevalence, malignancy rate, and size distribution of isolated macrocalcifications and evaluated the histopathologic features and postoperative ATA risk stratification of malignant tumors manifesting as isolated macrocalcifications.

Results: Isolated macrocalcifications were found in 38 (1.2%) of the 3061 patients. Final diagnosis was established in 30 (78.9%) nodules; seven malignant tumors were diagnosed as papillary thyroid carcinomas (PTCs). The malignancy rate of the isolated macrocalcifications was 23.3% in the 30 nodules with final diagnoses and 18.4% in all nodules. Among the six surgically-treated malignant tumors, five (83.3%) had an extrathyroidal extension (ETE) (minor ETE 1, gross ETE 4), and two (33.3%) had macroscopic lymph node metastasis. Four (66.7%) malignant tumors were categorized as high-risk tumors, one as an intermediate-risk tumor, and one as a low-risk tumor using the ATA risk stratification. Histopathologically, out of the six malignant tumors, ossifications were noted in four (66.7%) and predominant calcifications in two (33.3%).

Conclusion: The US pattern of isolated macrocalcifications (≥ 1 cm) showed an intermediate malignancy risk (at least 18.4%). All malignant tumors were PTCs, and most showed an aggressive behavior and a high or intermediate postoperative ATA risk.
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http://dx.doi.org/10.3348/kjr.2019.0523DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7183826PMC
May 2020

Diagnostic Efficacy and Safety of Core Needle Biopsy as a First-Line Diagnostic Method for Thyroid Nodules: A Prospective Cohort Study.

Thyroid 2020 08 28;30(8):1141-1149. Epub 2020 Apr 28.

Department of Pathology, Ewha Clinical Laboratory, Seoul, Korea.

The diagnostic role of ultrasonography (US)-guided core needle biopsy (CNB) as a first-line diagnostic method for thyroid nodules remains controversial. This study was performed to determine the diagnostic efficacy and safety of CNB as a first-line diagnostic method for thyroid nodules. From February 2016 to January 2018, CNB was prospectively performed by an experienced radiologist in all consecutive patients with thyroid nodules indicated for fine-needle aspiration (FNA). Three patients refused this protocol. Finally, 212 consecutive patients with 248 thyroid nodules were enrolled in this prospective study. Combined CNB/FNA was selectively performed in 43 patients. The diagnostic efficacy of CNB was evaluated by the rate of inconclusive results (nondiagnostic or indeterminate results), and its feasibility was estimated by calculating the successful biopsy rate and by measuring the procedure time from the time of the initial skin puncture to the last withdrawal of the biopsy needle from the skin. The safety of the procedure was evaluated by the major and minor complication rates. A US evaluation was performed before and after manual self-compression to assess for hemorrhage at the biopsy site, and delayed complications were assessed 5-7 days after the biopsy. Any hemorrhage that did not require hospitalization was classified as a minor complication. CNB was performed once ( = 125, 50.4%), twice ( = 122, 49.2%), or three times ( = 1, 0.4%) per nodule. The diagnostic results of CNB were as follows: nondiagnostic (0.8%), benign (63.3%), indeterminate (10.1%), follicular neoplasm (3.2%), suspected malignancy (2.4%), and malignancy (20.1%); the rate of inconclusive results was 10.9%. The successful biopsy rate of CNB was 100%, and the median procedure time was 102 seconds (interquartile range 51-181 seconds). There were no major or delayed complications. There were 6 cases (2.8%) of minor complications, which included 2 cases (0.9%) with symptomatic hematomas and 4 cases (1.9%) with asymptomatic small hematomas. The findings confirm that CNB is effective in reducing the rate of inconclusive results and it is safe. CNB may be used as an alternative first-line diagnostic method for thyroid nodules by an experienced operator.
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http://dx.doi.org/10.1089/thy.2019.0444DOI Listing
August 2020

Distribution and malignancy risk of six categories of the pathology reporting system for thyroid core-needle biopsy in 1,216 consecutive thyroid nodules.

Ultrasonography 2020 Apr 16;39(2):159-165. Epub 2020 Jan 16.

Department of Radiology, Human Medical Imaging and Intervention Center, Seoul, Korea.

Purpose: The purpose of this study was to present the distribution of lesions among the six categories of the pathology reporting system for thyroid core-needle biopsy (CNB), along with the range of malignancy risk of each category based on different diagnostic criteria for benignity in a clinical cohort.

Methods: For 1,216 consecutive nodules (≥1 cm) of 1,125 patients who underwent CNB at two hospitals, the diagnostic results based on the six categories of thyroid CNB were analyzed. Patients were divided into three groups according to prior fine-needle aspiration (FNA) status: second-line CNB for nodules where prior FNA yielded nondiagnostic or unsatisfactory results (n=57), second-line CNB for nodules with prior FNA results of atypia/follicular lesion of undetermined significance (AUS/FLUS) (n=303), and first-line CNB (n=856).

Results: The proportion of nodules in each CNB category and the range of the malignancy rate for each category was as follows, in order from category I to VI: 1.8%, 23.1%-75.0%; 57.9%, 0.7%-16.7%; 16.0%, 13.2%-46.7%; 8.8%, 53.8%-56.8%; 2.0%, 100%; and 13.5%, 100%. First-line CNB was associated with a higher rate of conclusive diagnoses (category II, IV, or VI) (725 of 856, 84.7%) than second-line CNB with prior nondiagnostic or AUS/FLUS FNA results (241 of 360, 66.9%; P<0.001).

Conclusion: The overall distribution of nodules across the six categories of thyroid CNB and the ranges of malignancy risk for those categories were presented in a clinical cohort. First-line CNB tended to produce a higher rate of conclusive results than second-line CNB with prior inconclusive FNA results.
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http://dx.doi.org/10.14366/usg.19056DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7065982PMC
April 2020

2019 Practice guidelines for thyroid core needle biopsy: a report of the Clinical Practice Guidelines Development Committee of the Korean Thyroid Association.

J Pathol Transl Med 2020 Jan 15;54(1):64-86. Epub 2020 Jan 15.

Department of Internal Medicine, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea.

Ultrasound-guided core needle biopsy (CNB) has been increasingly used for the pre-operative diagnosis of thyroid nodules. Since the Korean Society of the Thyroid Radiology published the 'Consensus Statement and Recommendations for Thyroid CNB' in 2017 and the Korean Endocrine Pathology Thyroid CNB Study Group published 'Pathology Reporting of Thyroid Core Needle Biopsy' in 2015, advances have occurred rapidly not only in the management guidelines for thyroid nodules but also in the diagnostic terminology and classification schemes. The Clinical Practice Guidelines Development Committee of the Korean Thyroid Association (KTA) reviewed publications on thyroid CNB from 1995 to September 2019 and updated the recommendations and statements for the diagnosis and management of thyroid nodules using CNB. Recommendations for the resolution of clinical controversies regarding the use of CNB were based on expert opinion. These practical guidelines include recommendations and statements regarding indications for CNB, patient preparation, CNB technique, biopsy-related complications, biopsy specimen preparation and processing, and pathology interpretation and reporting of thyroid CNB.
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http://dx.doi.org/10.4132/jptm.2019.12.04DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6986975PMC
January 2020

CT features of thyroid nodules with isolated macrocalcifications detected by ultrasonography.

Ultrasonography 2020 Apr 23;39(2):130-136. Epub 2019 Oct 23.

Department of Radiology, Yonsei University College of Medicine, Seoul, Korea.

Purpose: A thyroid nodule with an isolated macrocalcification is visualized as a calcified nodule with complete posterior shadowing on ultrasonography (US). This study aimed to determine the computed tomography (CT) features of isolated macrocalcifications detected using US.

Methods: This study included 20 patients who had thyroid nodules with isolated macroalcifications and underwent neck CT or chest CT. The patients were enrolled from a sample of 82 patients with isolated macrocalcifications detected by US drawn from 7,142 consecutive patients who underwent thyroid biopsy at two institutions. We evaluated the CT features of nodules with isolated macrocalcifications and categorized them as central or rim calcifications. We assessed the nodule size and the frequency of nondiagnostic fine-needle aspiration (FNA) results and malignant tumors according to the CT features of isolated macrocalcifications.

Results: CT scans showed central calcifications in 18 (90.0%) and rim calcifications in two (10.0%) of the 20 nodules with isolated macrocalcifications. Among the 18 nodules with central isolated macrocalcifications, complete compact calcification was found in six nodules and partial coarse calcification in 12 nodules. In 18 nodules with central isolated macrocalcifications, the nondiagnostic FNA rate and frequency of malignant tumors were not significantly different between complete and partial central calcifications (P=0.620 and P=0.999, respectively). Malignant tumors were only found in nodules with central isolated macrocalcifications.

Conclusion: The majority of nodules with isolated macrocalcifications showed central calcifications on CT. Thyroid nodules with isolated macrocalcifications detected by US should not be classified as having a type of rim or peripheral calcification.
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http://dx.doi.org/10.14366/usg.19045DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7065983PMC
April 2020

Concordance of Three International Guidelines for Thyroid Nodules Classified by Ultrasonography and Diagnostic Performance of Biopsy Criteria.

Korean J Radiol 2020 01;21(1):108-116

Department of Radiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea.

Objective: To investigate the concordance of three international guidelines: the Korean Thyroid Association/Korean Society of Thyroid Radiology, American Thyroid Association, and American College of Radiology for thyroid nodules classified by ultrasonography (US) and the diagnostic performance of simulated size criteria for malignant biopsies.

Materials And Methods: A total of 2586 thyroid nodules (≥ 1 cm) were collected from two multicenter study datasets. The classifications of the thyroid nodules were based on three different guidelines according to US categories for malignancy risk, and the concordance rate between the different guidelines was calculated for the classified nodules. In addition, the diagnostic performance of criteria related to four different simulated biopsy sizes was evaluated.

Results: The concordance rate of nodules classified as high- or intermediate-suspicion was high (84.1-100%), but low-suspicion or mildly-suspicious nodules exhibited relatively low concordance (63.8-83.8%) between the three guidelines. The differences in sensitivity, specificity, and accuracy between the guidelines were 0.7-19.8%, 0-40.9%, and 0.1-30.5%, respectively, when the original biopsy criteria were applied. The differences decreased to 0-5.9%, 0-10.9%, and 0.1-8.2%, respectively, when simulated, similar biopsy size criteria were applied. The unnecessary biopsy rate calculated with the original criteria (0-33.8%), decreased with the simulated biopsy size criteria (0-8.7%).

Conclusion: We found a high concordance between the three guidelines for high- or intermediate-suspicion nodules, and the diagnostic performance of the biopsy criteria was approximately equivalent for each simulated size criterion. The difference in diagnostic performance between the three guidelines is mostly influenced by the various size thresholds for biopsies.
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http://dx.doi.org/10.3348/kjr.2019.0215DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6960308PMC
January 2020

Ultrasound malignancy risk stratification of thyroid nodules based on the degree of hypoechogenicity and echotexture.

Eur Radiol 2020 Mar 15;30(3):1653-1663. Epub 2019 Nov 15.

Division of Endocrinology and Metabolism, Department of Internal Medicine, Gangneung Asan Hospital, College of Medicine, University of Ulsan, Gangneung, 25440, Republic of Korea.

Objectives: The ultrasound (US) lexicon of nodule echogenicity and echotexture is one of the major differences among various risk stratification systems of thyroid nodules. This study aimed to stratify the US malignancy risk of thyroid nodules based on their degree of hypoechogenicity and echotexture.

Material And Methods: This retrospective study included a total of 2255 consecutive thyroid nodules (≥ 1 cm) with final diagnoses (malignancy rate, 13%) from 2011 to 2016. Thyroid nodules were stratified according to the US degree of hypoechogenicity (mild, moderate, or marked hypoechogenicity) and echotexture (homogeneous vs. heterogeneous). The calculated malignancy risk was compared between each category.

Results: There was no significant difference of malignancy risk between the homogeneous markedly hypoechoic and moderately hypoechoic nodules (p ≥ .18). However, the malignancy risks of markedly and moderately hypoechoic nodules were significantly higher than those of mildly hypoechoic nodules (p < .001). Heterogeneous predominantly hypoechoic thyroid nodules showed a significantly higher malignancy risk than predominantly iso- or hyperechoic thyroid nodules (p < .001). There were no significant differences of malignancy risk between heterogeneous predominantly hypoechoic and homogeneous hypoechoic nodules according to the degree of hypoechogenicity (p ≥ .12) and between heterogeneous predominantly iso- or hyperechoic nodules and homogeneous iso- or hyperechoic thyroid nodules (p = .36).

Conclusions: The malignancy risk of nodule hypoechogenicity is stratified as mild vs. moderate to marked hypoechogenicity, and the malignancy risk of nodules with heterogeneous echotexture is stratified by the predominant echogenicity of the nodules.

Key Points: • Thyroid nodule echogenicity is categorized as marked, moderate, or mild hypoechogenicity and iso- or hyperechogenicity with the reference standard of adjacent thyroid tissue and anterior neck muscles. • The malignancy risk of thyroid nodule echogenicity is stratified as iso- or hyperechoic vs. mild vs. moderate or marked hypoechogenicity. • The malignancy risk of nodules with heterogeneous echotexture is stratified by the predominant echogenicity.
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http://dx.doi.org/10.1007/s00330-019-06527-8DOI Listing
March 2020

Similarities and Differences Between Thyroid Imaging Reporting and Data Systems.

AJR Am J Roentgenol 2019 08 27;213(2):W76-W84. Epub 2019 Mar 27.

1 Department of Radiology, GangNeung Asan Hospital, Gangneung-si Gangwon-do, 25440, Korea.

The purposes of this study were to identify the similarities and differences among the Korean Thyroid Imaging Reporting and Data System (TIRADS), American College of Radiology (ACR) TI-RADS, and European TIRADS and to compare the diagnostic performance of sonographic fine-needle aspiration (FNA) criteria for detecting malignant thyroid nodules. This study included 2274 consecutively evaluated thyroid nodules 1 cm or larger in 1836 patients with final diagnoses from January 2011 to December 2016. US features of the nodules were retrospectively reviewed and classified according to three published guidelines from international societies. We compared the US lexicons, categories, and diagnostic performance of the FNA criteria for malignant nodules among the three reporting systems. Of the 2274 thyroid nodules, 1974 (86.8%) were benign and 300 (13.2%) were malignant; 93.7% of all malignancies were papillary carcinoma. Most of the US lexicons were similar among the three systems except for the definition of echogenicity of a nodule of mixed echogenicity in European TIRADS. Although the categories had strong correlations ( = 0.777-0.877, all < 0.001) among the three systems, significant differences were observed in categories 5, 4, and 3 of nodules (all < 0.001) and in the sensitivity, specificity, and rate of unnecessary FNA of the FNA criteria for malignancy (all < 0.001). Although the three systems had similarities in most US lexicons, significant differences were observed in the classified categories and diagnostic performance of the FNA criteria for malignancy.
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http://dx.doi.org/10.2214/AJR.18.20510DOI Listing
August 2019

Ethanol Ablation of the Thyroid Nodules: 2018 Consensus Statement by the Korean Society of Thyroid Radiology.

Korean J Radiol 2019 04;20(4):609-620

Department of Radiology, Kangbuk Samsung Hospital, Sungkyunkwan University, Seoul, Korea.

Minimally invasive treatment of symptomatic thyroid nodules is now commonplace. Ethanol ablation (EA) of thyroid cystic nodules has been performed since the 1990s, but there is no global consensus or guideline. Although various limitations of EA have been described, recommendations for practical application are necessary. Therefore, the Task Force Committee of the Korean Society of Thyroid Radiology initiated the present consensus statement and here we provide recommendations for the role of EA in the management of symptomatic thyroid nodules. These recommendations are based on evidence to date from the literature and expert opinion.
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http://dx.doi.org/10.3348/kjr.2018.0696DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6424836PMC
April 2019

Deep convolutional neural network models for the diagnosis of thyroid cancer.

Lancet Oncol 2019 03;20(3):e130

Department of Radiology, GangNeung Asan Hospital, Gangwon-do, South Korea.

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http://dx.doi.org/10.1016/S1470-2045(19)30086-5DOI Listing
March 2019

Validation of web-based thyroid imaging reporting and data system in atypia or follicular lesion of undetermined significance thyroid nodules.

Head Neck 2019 07 24;41(7):2215-2224. Epub 2019 Feb 24.

Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea.

Background: Atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS) show variable malignancy risk. We validated the web-based predictive models and the scoring system by the American College of Radiology (ACR) for AUS/FLUS nodules to stratify the malignancy risk.

Methods: From January 2011 to November 2014, 275 consecutive nodules diagnosed as AUS/FLUS were enrolled. The discrimination and calibration ability of a web-based scoring with inclusion of biopsy result and sonographic features, old web-based scoring model without biopsy result, and ACR models were assessed.

Results: The areas under the receiver operating characteristic curve of the validation set were 0.670 for the new web-based model, 0.710 for the old web-based model, and 0.732 for the ACR scoring risk-stratification model. All models were well calibrated.

Conclusion: The web-based scoring risk-stratification model using the combined information of ultrasonography features and biopsy result for AUS/FLUS nodules to stratify malignancy risk presents an acceptable predictive accuracy.
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http://dx.doi.org/10.1002/hed.25677DOI Listing
July 2019
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