scholarly journals Thyroid Multimodal Ultrasound Evaluation—Impact on Presurgical Diagnosis of Intermediate Cytology Cases

2020 ◽  
Vol 10 (10) ◽  
pp. 3439
Author(s):  
Andreea Borlea ◽  
Dana Stoian ◽  
Laura Cotoi ◽  
Ioan Sporea ◽  
Fulger Lazar ◽  
...  
Keyword(s):  
Color Doppler ◽  
Final Analysis ◽  
Needle Aspiration ◽  
Pathology Report ◽  
Cancer Prevalence ◽  
Ultrasound Evaluation ◽  
Risk Of Malignancy ◽  
3D Color Doppler ◽  
Prevalence Of Cancer

Fine needle aspiration (FNA) is recommended as the final evaluation in diagnosing thyroid nodules. Intermediate cytology is observed in about 15%–25% of the FNA results and has divergent recommendations: follow-up or surgery, either hemi- or total thyroidectomy. The present study aimed to assess the benefit of multimodal ultrasound (US) evaluation in clarifying the attitude in cases with intermediate cytology on FNA. Sixty-four successive cases with Bethesda III or IV cytology results were evaluated using two-dimensional B-mode US (2B), qualitative strain elastography, as well as planar and volumetric (3D) color Doppler using both a linear multifrequency probe and a linear volumetric probe (Hitachi Preirus Machine, Hitachi Inc. Japan). The analyzed nodules were all categorized as low, intermediate, or high risk, based on the following US criteria: taller-than-wide shape, marked hypoechogenicity, irregular borders, inhomogeneity, microcalcifications, or the presence of suspicious adenopathy. Elastographic criteria included stiff lesions, while volumetric Doppler criteria included moderate and marked perinodular vascularization, as suspicious for malignancy. The gold standard for the analysis was the result of the pathology report after thyroidectomy. Our results showed that the prevalence of cancer was 25% (16 cases). In five cases, borderline follicular neoplasia was identified, group which requires watchful waiting. These lesions were also considered as malignant in the final analysis, with a total number of 21 neoplasm cases. Sixteen of the 21 malignant nodules presented with high stiffness, while 15/21 had increased perinodular vascularization. Eight of the 21 cases displayed both important stiffness and perinodular vascularization. Cancer prevalence increased both with severity of stiffness (9.0%–15.0%–66.6%–80.0%) and intensity of vascularization in the adjacent perinodular parenchyma (18.2%–27.7%–35.29%–50.0%). Combining the use of grayscale US, elastography, and 3D Doppler in the evaluation of intermediate cytology cases showed a sensitivity of 85.7%, a specificity of 88.3%, and an accuracy of 90.3% in detecting thyroid cancer cases. We can conclude that the identification of highly suspicious US characteristics observed in 2B, qualitative elastography, and volumetric Doppler increases the risk of malignancy.

Classification of Male Breast Lesions According to the IAC Yokohama System for Reporting Breast Cytopathology

2020 ◽  
pp. 1-8
Author(s):  
Melissa Oosthuizen ◽  
Rubina Razack ◽  
Jenny Edge ◽  
Pawel Tomasz Schubert
Keyword(s):  
Predictive Value ◽  
Best Practice ◽  
Internal Audit ◽  
Needle Aspiration ◽  
Male Breast ◽  
Histopathological Diagnosis ◽  
Breast Lesions ◽  
Risk Of Malignancy ◽  
Sensitivity Specificity

<b><i>Objective:</i></b> This study aims to determine the diagnostic utility of the International Academy of Cytology (IAC) Yokohama System for reporting breast cytopathology in lesions of the male breast. <b><i>Study Design:</i></b> Fine-needle aspiration biopsy (FNAB) reports between 2015 and 2019 were retrospectively recategorized according to the 5-tiered IAC Yokohama Reporting System. Our database yielded a total of 1,532 FNAB reports from breast lesions, obtained from 1,350 male patients. The risk of malignancy (ROM) and diagnostic performance of FNAB were determined using follow-up histopathological diagnosis and/or clinical follow-up, where available, for each category. <b><i>Results:</i></b> The category distribution were as follows: inadequate, 40%; benign, 57%; atypical, 0.6%; suspicious for malignancy, 0.7%; and malignant, 1.6%. The ROM in each category was nondiagnostic, 11%; benign, 3%; atypical, 28%; suspicious for malignancy, 56%; and malignant, 100%. The sensitivity, specificity, positive predictive value, and negative predictive value were recorded as 63, 100, 100, and 84.6% respectively, when only malignant cases were considered as positive tests. <b><i>Conclusion:</i></b> This study validates the IAC Yokohama System for reporting male breast cytopathology. In accordance with the aim of the Yokohama System to establish best practice guidelines for reporting breast cytopathology, this comprehensive scheme facilitates comparisons between local and international institutions. The ROM acts as an internal audit for quality assurance within one’s own laboratory and provides guidance for clinical management. It highlights inefficiencies such as high inadequacy rates for category 1 and also features strengths with impressive specificity for categories 4 and 5.

scholarly journals Correlation study of thyroid nodule cytopathology and histopathology at two institutions in Jordan

CytoJournal ◽  
2018 ◽  
Vol 15 ◽  
pp. 24 ◽  
Author(s):  
Niveen Abdullah ◽  
Manar Hajeer ◽  
Loay Abudalu ◽  
Maher Sughayer
Keyword(s):  
Test Performance ◽  
Predictive Value ◽  
Diagnostic Category ◽  
Needle Aspiration ◽  
Correlation Study ◽  
Follicular Neoplasm ◽  
Risk Of Malignancy ◽  
Thyroid Fna ◽  
Undetermined Significance

Background: Fine-needle aspiration (FNA) plays a fundamental role in determining the appropriate management for patients presenting with thyroid nodules. Aims: The aims of this study are to evaluate thyroid FNA test performance parameters through a cytohistological correlation. Materials and Methods: A retrospective analysis of all thyroid FNAs received over a period of 18 months was carried out. The findings were compared to their subsequent definite diagnoses on surgical specimens as well as to their follow-up repeat FNA results. A total of 499 thyroid FNAs were collected and reviewed against The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC). The percentage of each diagnostic category was calculated, and the implied risk of malignancy was determined by comparing the cytology results to their definite diagnoses obtained on the resection specimens. Analytical procedures were performed using Microsoft Excel. Results: Out of 499 thyroid FNAs, a benign interpretation was found in 273 patients (54.7%), atypia of undetermined significance in 81 (16.2%), follicular neoplasm in 20 (4%), suspicious for malignancy in 36 (7.2%), malignant in 32 (6.4%) and were nondiagnostic in 57 patients (11.4%). Only 101 patients (20.2%) underwent surgical resection and 47 (9.4%) underwent a follow-up FNA. After cytohistological correlation, FNA test performance, calculated by excluding the inadequate and undetermined categories revealed test sensitivity, specificity, and diagnostic accuracy of 95.6%, 54.8%, and 78.9%, respectively. The positive predictive value was 75.4%, and the negative predictive value was 89.5%. Conclusions: Our results are comparable to those previously published figures. The rate of atypia of undetermined significance/follicular lesion of undetermined significance is higher than what is currently recommended in TBSRTC.

Application of the Milan System for Reporting Salivary Gland Cytopathology: A 10-Year Experience in a Single Japanese Institution

2020 ◽  
pp. 1-9
Author(s):  
Yukiya Hirata ◽  
Kayoko Higuchi ◽  
Koichi Tamashiro ◽  
Keisuke Koja ◽  
Yuiko Yasutomi ◽  
...  
Keyword(s):  
Salivary Gland ◽  
Predictive Value ◽  
Diagnostic Category ◽  
Needle Aspiration ◽  
Salivary Gland Neoplasm ◽  
Published Evidence ◽  
Risk Of Malignancy ◽  
Categorization System ◽  
Sensitivity Specificity

<b><i>Objective:</i></b> The Milan System for Reporting Salivary Gland Cytopathology (MSRSGC) is a recently published evidence-based categorization system for salivary gland fine-needle aspiration (FNA). We applied MSRSGC to Japanese cases and evaluated its utility. <b><i>Study Design:</i></b> A total of 480 FNA cases were reviewed. We recategorized each case into one of the MSRSGC categories. The risk of neoplasm (RON) and the risk of malignancy (ROM) for each diagnostic category in MSRSGC, and the sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) for malignancy and for neoplasms were calculated for cases with histological follow-up. In addition, the overall ROM (O-ROM) was calculated for all FNA cases. <b><i>Results:</i></b> RON, ROM, and O-ROM rates were as follows – non-diagnostic: 51.3, 5.1, and 1.0%; non-neoplastic: 0, 0, and 0%; atypia of undetermined significance: 83.9, 12.9, and 7.3%; neoplasm, benign: 100, 0, and 0%; salivary gland neoplasm of uncertain malignant potential: 100, 32.1, and 23.7%; suspicious for malignancy: 100, 85.7, and 60%; and malignant: 100, 100, 81.8%. The sensitivity, specificity, and accuracy with (without) indeterminate cases for malignancy were 65 (100), 99 (99), 92% (99%) and PPV and NPV were 96 and 100%, respectively, and those for neoplasms were 84 (100), 100 (100), 85% (100%), and PPV and NPV were 100 and 100%, respectively. <b><i>Conclusions:</i></b> The MSRSGC is useful for stratification of ROM and for promoting the performance of salivary gland FNA. The MSRSGC could be easily introduced in Japan and may improve the Japanese salivary gland FNA status.

The Milan System for Reporting Salivary Gland Cytopathology: Assessment of Cytohistological Concordance and Risk of Malignancy

2020 ◽  
pp. 1-13
Author(s):  
Shilpy Jha ◽  
Suvradeep Mitra ◽  
Suvendu Purkait ◽  
Amit Kumar Adhya
Keyword(s):  
Salivary Gland ◽  
Predictive Value ◽  
Malignant Tumors ◽  
Minor Salivary Gland ◽  
Treatment Protocol ◽  
Needle Aspiration ◽  
Histopathological Diagnosis ◽  
Wide Range ◽  
Risk Of Malignancy

<b><i>Introduction:</i></b> The Milan System for Reporting Salivary Gland Cytopathology (MSRSGC) was proposed by the American Society of Cytopathology and the International Academy of Cytology to bring uniformity in the reporting system and the treatment protocol. A wide range of risk of malignancy for each category has been reported by various authors by applying the system. <b><i>Aim:</i></b> We intend to study the cytohistological concordance and the ROM for each of the diagnostic categories of the Milan system. <b><i>Materials and Methods:</i></b> The study included 292 cases of fine-needle aspiration cytology (FNAC) of salivary gland lesions over a period of 3 years. The diagnosis of these cases was reclassified into the 6 categories of the Milan system. The cytohistological concordance and ROM for each category of the Milan system were calculated based on the clinical and histopathological follow-up. <b><i>Results:</i></b> The patients’ age ranged from 3 to 81 years with the mean of 42.65 ± 16.3 years. The cases included 189 (64.7%) parotid, 82 (28.1%) submandibular, and 21 (7.2%) cases of minor salivary gland swellings. Follow-up histopathological diagnosis for 102 cases was available. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated to be 64.28, 97.01, 90, 86.67, and 87.37%, respectively. After reclassification, the number of cases in each category was as follows: category I: 31 (10.62%), category II: 80 (27.4%), category III: 2 (0.68%), category IVA: 143 (48.97%), category IVB: 1 (0.34%), category V: 13 (4.45%), and category VI: 22 (7.53%). The calculated ROM was as follows: category I: 42.86%, category II: 26.67%, category III: 100% category IVA: 10.17%, category IVB: 0%, category V: 71.42%, category VI: 100%. <b><i>Conclusion:</i></b> FNAC is an excellent procedure to differentiate benign from malignant tumors, and MSRSGC is a useful system for risk assessment and deciding the further treatment protocol. Our findings also suggest that in addition to the surgical follow-up, inclusion of the clinical and radiological follow-up may be a better strategy for calculation of ROM, especially for categories I and II.

scholarly journals Medullary thyroid carcinoma and pregnancy

2021 ◽  
Vol 16 (S3) ◽  
pp. 6-9
Author(s):  
Andreea Elena DUMITRU ◽  
◽  
Corina GICĂ ◽  
Anca Marina CIOBANU ◽  
Brînduşa Ana CIMPOCA-RAPTIS ◽  
...  
Keyword(s):  
Thyroid Carcinoma ◽  
Medullary Thyroid Carcinoma ◽  
Relevant Information ◽  
Needle Aspiration ◽  
Hereditary Disease ◽  
Thyroid Tumor ◽  
Medullary Thyroid ◽  
Ultrasound Evaluation ◽  
Regional Metastases

Medullary thyroid carcinoma (MTC) is a rare neuroendocrine tumor of the parafollicular cells of the thyroid gland. The tumor occurs, either sporadically or in a hereditary form, as a component of the type 2 multiple endocrine neoplasia (MEN) syndromes, MEN2A and MEN2B, both with an autosomal dominant transmission. Due to its higher aggressiveness and urgency to treat, it poses a challenge when diagnosed during pregnancy. We performed a literature review searching medical databases as UpToDate and PubMed for relevant information about diagnosis, impact, treatment, and outcome of medullary thyroid carcinoma during pregnancy. Diagnosis of MTC is established by clinical and ultrasound evaluation, followed by a fine needle aspiration biopsy. Further analyses decide whether it is a sporadic or a hereditary disease. Surgery offers the curative solution, but careful postoperative follow-up is needed for the best outcome. The decision for surgery is taken considering the DNA mutation of RET oncogene and pregnancy status. A premature planned delivery is associated with potential complications for the newborn, but it is recommended when maternal status worsens. Conclusions. Complete resection of the thyroid tumor and any local and regional metastases is the only curative solution. Timing of the intervention is extremely important to decrease fetal outcomes. Close follow-up during the postoperative period, by both biochemical and imaging methods, is needed.

Improving Malignancy Prediction in AUS/FLUS Pediatric Thyroid Nodules with the Aid of Ultrasound

2020 ◽  
Vol 93 (4) ◽  
pp. 239-244
Author(s):  
Shruthi Arora ◽  
Jane Khoury ◽  
Andrew T. Trout ◽  
Janet Chuang
Keyword(s):  
Predictive Value ◽  
Lower Risk ◽  
Thyroid Nodules ◽  
Pediatric Population ◽  
Retrospective Chart Review ◽  
Needle Aspiration ◽  
Risk Category ◽  
American Thyroid Association ◽  
Risk Of Malignancy

<b><i>Introduction:</i></b> The standard workup of thyroid nodules concerning for malignancy includes fine-needle aspiration (FNA). In 2015, the American Thyroid Association (ATA) guidelines for the management of pediatric thyroid nodules recommended that all nodules with a Bethesda III cytology undergo surgical resection. <b><i>Objectives:</i></b> To correlate a Bethesda III cytology with histologic and clinical outcomes to determine the relevance of the ATA recommendations, and to evaluate whether Thyroid Imaging Reporting and Data System (TI-RADS) scoring could identify Bethesda III nodules at a lower risk of malignancy. <b><i>Methods:</i></b> A retrospective chart review of patients who had undergone thyroid nodule FNA from 2008 to 2018 was performed. Malignancy rates were determined for each Bethesda category. The reference standard was histopathology or 2-year follow-up of imaging outcomes for nonoperative cases. Ultrasound exams of Bethesda III nodules were reviewed and TI-RADS scores assigned. <b><i>Results:</i></b> A total of 143 FNA samples from 128 patients were identified. The mean age was 14.9 years (range 7–22). Twenty-two (15%) of the FNA samples were Bethesda III; the malignancy rate was 38%. A TI-RADS score was assigned in 20 of the 22 Bethesda III nodules. ROC analysis found an optimal cut-off for malignancy prediction of ≥7 points (risk category TR5). The negative predictive value was 85.7% (95% CI 35.9–99.6) and the positive predictive value was 83.3% (95% CI 57.2–98.2). <b><i>Conclusion:</i></b> Although, at baseline, thyroid nodules with a Bethesda III classification carry a moderate risk of malignancy in the pediatric population, TI-RADS scoring can identify nodules with a lower risk within this group. If validated by larger studies, this can inform decision making and reduce unneeded surgery.

scholarly journals Imaging-Cytology Correlation of Thyroid Nodules with Initially Benign Cytology

2014 ◽  
Vol 2014 ◽  
pp. 1-8 ◽  
Author(s):  
Shin Hye Hwang ◽  
Ji Min Sung ◽  
Eun-Kyung Kim ◽  
Hee Jung Moon ◽  
Jin Young Kwak
Keyword(s):  
Thyroid Nodules ◽  
False Negative ◽  
Needle Aspiration ◽  
Malignancy Rate ◽  
Negative Results ◽  
False Negative Results ◽  
Significant Difference ◽  
Risk Of Malignancy ◽  
Us Findings

Objective. To determine the role of imaging-cytology correlation in reducing false negative results of fine-needle aspiration (FNA) at thyroid nodules.Methods. This retrospective study included 667 nodules 1 cm or larger in 649 patients diagnosed as benign at initial cytologic evaluation and that underwent follow-up ultrasound (US) or FNA following a radiologist’s opinion on concordance between imaging and cytologic results. We compared the risk of malignancy of nodules classified into subgroups according to the initial US features and imaging-cytology correlation.Results. Among included nodules, 11 nodules were proven to be malignant (1.6%) in follow-up FNA or surgery. The malignancy rate was higher in nodules with suspicious US features (11.4%) than in nodules without suspicious US features (0.5%,P<0.001). When a thyroid nodule had discordant US findings on image review after having benign FNA results, malignancy rate increased to 23.3%, significantly higher than that of nodules with suspicious US features (P<0.001). However, no significant difference was found in the risk of malignancy between the nodules without suspicious US features (0.5%) and imaging-cytology concordant nodules (0.6%,P=0.438).Conclusions. Repeat FNA can be effectively limited to patients with cytologically benign thyroid nodules showing discordance in imaging-cytology correlation after initial biopsy, which reduces unnecessary repeat aspirations.

scholarly journals Benign Aspirates on Follow-Up FNA May Be Enough in Patients with Initial Atypia of Undetermined Significance/Follicular Lesion of Undetermined Significance

2014 ◽  
Vol 2014 ◽  
pp. 1-8 ◽  
Author(s):  
Ga Ram Kim ◽  
Jung Hyun Yoon ◽  
Eun-Kyung Kim ◽  
Hee Jung Moon ◽  
Jin Young Kwak
Keyword(s):  
Thyroid Nodules ◽  
Surgical Excision ◽  
Needle Aspiration ◽  
Risk Of Malignancy ◽  
Benign Nodules ◽  
Benign Thyroid Nodules ◽  
Benign Thyroid ◽  
Undetermined Significance

Background.Management of thyroid nodules with benign aspirates following atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS) is not well established. We reviewed the risk of malignancy and the role of ultrasound (US) features among thyroid nodules with benign results following initial AUS/FLUS diagnoses.Methods.From December 2009 to February 2011, a total of 114 nodules in 114 patients diagnosed as benign on follow-up fine-needle aspiration (FNA) after AUS/FLUS results were included in our study. Eight among 114 nodules were confirmed pathologically and 106 were clinically observed by a follow-up FNA or US. Suspicious US features were defined as markedly hypoechogenicity, irregular or microlobulated margin, presence of microcalcifications, and taller than wide shape.Results.There were 110 (96.5%) benign nodules and 4 (3.5%) malignant nodules. Two (4.8%) among 42 nodules without suspicious US features and 2 (2.8%) out of 72 nodules with suspicious US features were confirmed as malignancy, but there were no significant associations between the malignancy rate and US features (P=0.625).Conclusion.Clinical follow-up instead of surgical excision or continuous repeat FNA may be enough for benign thyroid nodules after AUS/FLUS. The role of US features might be insignificant in the management of these nodules.

Diagnostic performance of thyroid multimodal-imaging comprehensive risk stratification scoring (TMC-RSS) system in characterising thyroid nodules.

2017 ◽  
Vol 35 (15_suppl) ◽  
pp. e17588-e17588 ◽  
Author(s):  
Abhishek Mahajan ◽  
Richa Vaish ◽  
Supreeta Arya ◽  
Nilesh Sable ◽  
Shilpa Pande ◽  
...  
Keyword(s):  
Multimodal Imaging ◽  
Diagnostic Performance ◽  
Thyroid Nodules ◽  
Color Doppler ◽  
Cumulative Risk ◽  
Final Analysis ◽  
Expert Radiologist ◽  
Risk Of Malignancy ◽  
Mean Size ◽  
Degree Of Confidence

e17588 Background: A univocal ultrasound (US) classification system for characterising thyroid nodules is still lacking. The aim was to create an algorithm (TMC-RSS) using US features in combination with Color Doppler (CD), TIRADS, elastography (ES) and test its diagnostic performance. Methods: Analysis of prospectively collected data over 10 months. All studies were performed on single equipment using standard US protocol with TIRADS scoring. Gold standard was pathology. 340 nodules in 260 patients of which 316 nodules included for final analysis. 148 (46.8%) benign and 168 (53.2%) Malignant. TMC-RSS Multiple Logistic Regression Model. Malignant characteristics:Plus (+) 3 points for: ES score 3/4, malignant nodes. (+) 1 point for: Taller than wider, microcalcification, hypoechogenicity, solid composition, ill-defined margins, central +/- peripheral vascularity. (+) 0.5 point for: irregular halo, size > 1 cm. Benign characteristics:Minus (-) 3 points for: Purely cystic, ES score-1; (-) 1 point for: spongiform, comet tail artefact, complete halo. (-) 0.5 point for: peripheral vascularity. Final TMC-RSS Score calculated by addition of all the points. Results: Mean age was 47.3 yrs. Mean size was 2.3 +/- 1.5 cm. Diagnostic performance of combined US, ES, TIRADS and CD (sensitivity: 96%, specificity: 95%, PPV: 95%, NPV: 96%, kappa: 0.911) was significantly higher (p < .001) than either combination of US, TIRADS, ES, CD. On multivariate analysis all US features except taller than wider were independent predictor of malignancy (p < .01). TMC-RSS Model had 90% sensitivity, 89% specificity and 91% accuracy for characterising nodules. On the ROC curve the cut-off for best performance of TMC-RSS score was 5.75. The cumulative risk of malignancy based on TMC-RSS score was 2.4% for score < 3, 18% for score ≥ 3 - < 6 and 80% for score ≥ 6. Conclusions: The proposed TMC-RSS is easy-to-use, robust, reproducible and provides higher degree of confidence to a non-expert radiologist. It can be the first step in standardization of reporting lexicon to allow effective communication between the radiologists, pathologists, and clinicians; helping avoid unnecessary interventions.

SPONTANEOUS THYROID NODULE HEMORRHAGE IN THE EMERGENCY DEPARTMENT

2020 ◽  
Vol 26 (2) ◽  
pp. 192-196 ◽  
Author(s):  
Marcello Covino ◽  
Pietro Princi ◽  
Giulio De Luca ◽  
Annemilia Del Ciello ◽  
Benedetta Simeoni ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Emergency Department ◽  
Thyroid Nodule ◽  
Thyroid Disease ◽  
Rare Event ◽  
Needle Aspiration ◽  
Urgent Surgery ◽  
Ultrasound Evaluation ◽  
Clinical Records

Objective: Spontaneous thyroid gland hemorrhage is a rare event. The present retrospective study considered its clinical impact and management in a referral center. Methods: Clinical records of adult patients accessed in the last 10 years (2009–2018) in the Emergency Department of Policlinico Gemelli IRCCS were reviewed to study patients with spontaneous thyroid nodule hemorrhage. All demographic and radiologic or surgical parameters were included, with special attention to the characteristics of thyroid disease and clinical management. Results: Among the 631,129 adults who were registered during the period considered, 59 consecutive patients were included in the study. The mean age was 48.3 ± 14.3 years, with a prevalence of females. The main symptoms were acute neck pain, dyspnea, and dysphagia. All patients underwent ultrasound evaluation; computed tomography scan was performed on only 3 patients, finding one case of active intranodular bleeding requiring urgent surgery. Six patients required hospitalization; the others were discharged and referred for ambulatory endocrinology follow-up. Among them, 7 patients underwent surgery in the next 6 months, with malignant disease found in 3 cases (5.1%). Conclusion: Intrathyroidal spontaneous hemorrhage is a rare event, occurring in multinodular as well as in single-nodule thyroid disease. Although the clinical course is mostly benign, this condition should be carefully evaluated as, in rare circumstances, active bleeding could induce airway obstruction with the need for emergency surgery. Patients should be referred to endocrinology ambulatory follow-up because bleeding could arise as the first sign of malignant lesions in some cases. Abbreviations: CT = computed tomography; ED = emergency department; FNA = fine-needle aspiration; US = ultrasound

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