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Hello and welcome to noom Conference, hosted by modality.

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and previous noom conferences by creating a free account.

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Today we are honored to welcome Dr.

0:24

Shanan Grover for a lecture entitled A CR rads.

0:28

The ultrasound algorithm unraveled step by step. Dr.

0:32

Grover is a distinguished academic radiologist

0:35

with over 40 years of experience in diagnostic

0:37

and interventional radiology.

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She's delivered 250 plus national lectures

0:43

and 80 plus international faculty sessions at forums

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and been recognized with numerous awards.

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She's currently national president of I-F-U-M-B,

0:52

a technical expert to India's NHA

0:56

and a member of RS a's CIRE.

0:59

Her research and clinical expertise span breast women's

1:02

abdominal pediatric

1:03

and oncological imaging

1:05

with a special focus on advanced ultrasound techniques.

1:09

At the end of the lecture, please join Dr.

1:10

Grover in a q and a session

1:12

where she will address questions you have on today's topic.

1:15

Please remember to use that q

1:16

and a feature to submit your questions so we can get to

1:19

as many as we can before our time is up.

1:21

With that, we are ready to begin today's lecture. Dr.

1:24

Grover, please take it from here.

1:27

Good evening, USA. Uh, no.

1:30

Good evening India and good afternoon USA

1:34

and thank Q Ashley

1:38

and the modality online team

1:41

for giving me an opportunity here today.

1:44

And I also thank Dr.

1:47

Sesh Muji for introducing me here today.

1:51

I'll be presenting to you the American College of Radiology,

1:57

A CR Thyroids Thyroid Imaging Reporting

2:01

and Data System.

2:03

The ultrasound algorithm unraveled step by step.

2:09

So before I begin, I wish

2:11

to give you an outline of the lecture.

2:15

Firstly, I will introduce to you the magnitude of disease.

2:21

What are the current dilemmas for biopsy, whether

2:26

to biopsy or not to biopsy the various

2:30

risk stratifications systems that are already available,

2:36

how they evolve and how did the A CR step in.

2:41

And to understand the

2:45

A CR rads, which is the ultrasound algorithm, we have

2:49

to quickly know the normal ultrasound anatomy.

2:53

And after I introduce the anatomy, I will speak

2:57

to you about the RAD lexicon.

3:01

And with that I will have illustrations of the terms

3:05

which are to be used in the A CR RADS algorithm.

3:10

And having done all this,

3:13

I will show you the illustrative cases based on the A CR

3:18

lexicon, which I will introduce to you.

3:21

And on those cases, I will also tell you

3:25

what was the final biopsy outcome.

3:29

And before I close the lecture, I would like to introduce

3:33

some new literature

3:35

and studies which have correlated the A CR RADS

3:40

with the CYTOPATHOLOGY studies

3:42

and the histopathology studies

3:45

because A CR RADS came in 2017

3:49

and these correlating studies have come recently in

3:54

around 2023.

3:56

And with that correlation studies

4:01

and what the literature says, there are some dilemma still

4:06

existing about thyroid nodules.

4:09

So it is my duty to make you aware of these

4:13

and to overcome those dilemmas,

4:15

we have the advances in ultrasound techniques,

4:19

which are the ELASTOGRAPHY

4:21

and contrast announced ultrasound.

4:24

So I will speak to you from our own experience

4:27

where I have worked at Subj Hospital for last 35 years

4:32

and now I'm at Shada University.

4:36

So after we've gone through the lexicon

4:39

and the illustrative cases, what the literature says around

4:43

for the correlation of a CR RADS

4:47

and what is the role of the advanced techniques,

4:49

we will recapitulate everything

4:52

and then look forward to any questions from you.

4:57

Now, uh, firstly the magnitude of the problem.

5:02

Thyroid nodules are common in adults

5:05

and they are identified incidentally in 20

5:10

to 68% of patients

5:13

who have undergone a neck ultrasound, 25%

5:18

of patients who may have undergone a contrast CT

5:22

and maybe 16 to 18% in those patients

5:26

who have undergone MRI.

5:30

Interestingly, in contrast to most diseases

5:35

which are common in male gender, the thyroid diseases

5:39

and thyroid nodules are more common in females.

5:43

And the ratio is four women to one man.

5:47

And the prevalence in females for thyroid nodules

5:52

increases with age.

5:54

And it has been estimated in studies from USA

6:00

that women above 70 years,

6:02

almost half the population may have a incidental

6:07

or a disease existing thyroid nodule,

6:12

which is quite a staggering number.

6:15

Now, how did we get here With so many thyroid nodules,

6:19

it is because the improvements in imaging technologies

6:24

and the increased use of imaging have left,

6:28

have all led to a significant increase in rates

6:32

of nodule detection, resulting in more

6:36

of biopsies, fine needle aspiration, biopsies or cytologies.

6:42

And of course, many of these do turn out

6:46

to be cancerous.

6:49

So having explained to you the magnitude of the problem,

6:55

let us see how this is to be tackled

6:58

as a radiologist practicing ultrasound.

7:01

Now, before the A CR thyroids came in, there were several

7:06

thyroid nodule risk classification systems

7:11

based on ultrasound itself.

7:14

So to begin with, we had the American Thyroid Association

7:19

or the A TA system,

7:23

and they also had published an atlas.

7:26

And then we had the Korean Society of Thyroid Radiology

7:30

or the K thyroids

7:33

in which there was a risk stratification.

7:37

And the need for biopsy was based on the risk stratification

7:43

based on the ultrasound features.

7:46

Then we have the European Thyroid Association

7:51

rads or the EU rads,

7:54

which has come up almost at the same time

7:57

as the A CR RADS around 2017 or 18.

8:02

And they want, and they say that their system

8:06

or the risk stratification system of the European RADS

8:11

has a high negative predictive value.

8:14

Now, uh, all of you being a

8:19

specialist, postgraduate doctors, I don't need

8:21

to explain the importance of high negative predictive value.

8:26

So we always strive to have an algorithm whereby

8:31

as a radiologist we can

8:34

have confidence in telling the treating clinician

8:37

and the patient whether the

8:40

disease we are looking at is cancerous or non-cancerous.

8:45

So other than the Korean and ra, uh, American RADS

8:49

and the European rads, there was a system known

8:54

as KK rads.

8:55

The co RADS was proposed by a Korean radiologist.

9:01

And then we have these Society

9:03

for Radiologists in ultrasound.

9:06

They also, uh, from USA,

9:08

they also have their own guidelines, which were existing

9:12

from 2005.

9:15

Then we had the American Association

9:18

of Clinical Endocrinology, American College

9:21

of Endocrinology.

9:23

So there was so many risk stratification systems.

9:27

So what should we follow? So what should we follow?

9:32

So why I brought in the co RAD is

9:35

because the Korean, uh, RAD system, which was

9:40

by the Korean radiologist Co.

9:44

He initially published a paper

9:48

studying 3,600 nodules.

9:50

In 2008, he studied

9:53

and it was published in the very prestigious journal called

9:57

Radiology in 2011.

10:00

And now I would like you to

10:02

to pay attention here in the co study which was published in

10:06

the iconic radiology,

10:09

the ultrasound features which quo et all proposed were a

10:14

significant association with malignancy exists.

10:18

If the thyroid nodule has a solid component,

10:22

it has hypo echogenicity

10:25

or it is markedly hypo.

10:30

It is lobulated, it has irregular margins, it has

10:35

microcalcifications and it is taller than wider.

10:38

So now you will see many of these

10:43

findings or these observations

10:46

have been incorporated into the A CR Ts.

10:51

Another important corollary

10:56

or conclusion from quo etal study,

10:58

which was published in 2011, was that as the number

11:03

of suspicious ultrasound features increased,

11:08

the probability and risk of malignancy also increased.

11:14

So if the number of suspicious features increased, the

11:19

possibility of malignancy increased

11:22

to an extent which was found

11:24

to be statistically significant.

11:28

So I have just uh, put this table here to quickly summarize.

11:33

I told you about the American Thyroid Association,

11:36

the Korean thyroids, European Ts,

11:40

and the American College of Radiology rads,

11:43

which we call the A CR rads.

11:47

Now, um, the, as I told you, the

11:52

A CR RADS has adopted a number

11:55

of features from the co rads,

11:57

which is different from the Korean rads otherwise.

12:02

Okay, so now we go on to

12:06

the risk stratification systems was so many.

12:10

So in 2017,

12:12

the A CR TRAC committees were formed to develop

12:17

management guidelines for nodules

12:19

that are discovered incidentally, whether on ultrasound, CT

12:24

MRI or pet, sorry,

12:28

to produce a lexicon

12:30

to describe all thyroid nodules on sonography

12:35

and to develop a standardized

12:38

S risk stratification system based on the lexicon.

12:43

And what is the purpose of the risk stratification system?

12:47

The risk stratification system tells us

12:51

which nodules warrant a biopsy.

12:54

So those of us who are practicing thyroid ultrasound

12:59

would know very well that when you perform ultrasound

13:03

and you discovered a thyroid nodule, they are usually

13:08

more than one in number.

13:10

So harmony to biopsy

13:12

and which ones to biopsy, that is the key role

13:17

of the A CR thyroids and that is what it guides us through.

13:23

This is the normal anatomy I've told you, the thyroid uh,

13:27

classification or risk stratification system.

13:30

So a quick look at the anatomy

13:33

and you perform a transfer scan with a high resolution,

13:37

a transfuser, and you see the right lobe, the left lobe,

13:41

and the isus anterior to the right and left lobes.

13:44

We have the anterior tap muscles

13:47

and posteriorly are the longest coli muscles on

13:51

the left side.

13:52

The esophagus lies posteriorly to the left lobe

13:56

of the thyroid and the longest coli muscles like

14:00

posteriorly and laterally.

14:02

We have the common carotid artery, which is there

14:06

and the internal gilo vein.

14:09

And off the two vessels,

14:11

the internal GI vein is more laterally placed

14:15

and lateral to the anterior strap muscles.

14:18

We have the stern CLEO mastoid muscles.

14:22

Okay, so I was talking about the anatomy,

14:25

which I've explained in the previous slide.

14:28

And this slide in addition shows us the

14:32

vertebral vessels.

14:36

So this is the transverse

14:41

scan of the neck when the patient's neck is patient is

14:45

supine, neck is hyperextended using a high

14:48

resolution transducer.

14:51

Okay, so we've gone over this.

14:53

So we go on to how we should

14:57

measure the normal thyroid gland.

15:00

So the emus is about five millimeter

15:05

or half centimeter in thickness.

15:08

The length of the lobe is around four

15:12

to seven centimeters depending on the height

15:14

and build of the individual.

15:17

And the width is measured on the transfer scan,

15:20

which is about two centimeters.

15:23

So this is how the normal thyroid gland would look like.

15:30

Now why do we follow the A CR rads?

15:33

The reason for following the A CR RADS is

15:37

that compared to other list stratification systems,

15:42

it has a better specificity

15:46

and the number of unnecessary biopsies

15:50

of benign nadu nodules are reduced

15:55

up to 46% in certain studies.

16:00

So that is the importance of following the A CR rads.

16:03

Now, what is this algorithm?

16:06

I would like you all to pay attention here.

16:08

Now basically we have

16:14

1, 2, 3, 4, 5 parameters which we have to

16:19

evaluate on the ultrasound.

16:21

And I have made a mnemonic of my own, I call it the sesame.

16:26

So sesame seeds are so popular now in salads

16:30

and dressings.

16:32

So now it would be easy,

16:34

but here, uh, C is for composition

16:38

of the nodule.

16:41

E is for the e echogenicity of the nodule.

16:46

S is for the shape of the nodule, M is for the margin.

16:51

And the second EI put a footnote focal.

16:55

So the second E stands for E echogenic focal.

17:00

Now how do we evaluate the composition E echogenicity

17:05

shape margin and e echogenic foci?

17:08

I will be going into this step by step,

17:12

but at the outset I must tell you that from

17:16

the first four CESM,

17:21

from these, we have to choose one parameter

17:26

from each of these

17:27

and then give the score

17:30

as recommended in the RAD stable A CR RAD stable,

17:34

this is available on the internet as well.

17:37

And this is their trademark showing the thyroid gland.

17:42

And then the last one the

17:47

we have to add score for

17:51

all the parameters which are applicable.

17:54

So one parameter from the first four

17:58

and all parameters from the echogenic foci.

18:03

So we, so at the outset, remember five

18:08

ses, E-C-E-S-M-E, one from each

18:12

and from the last one all which apply.

18:16

So having said this, the next point

18:20

to be understood is that harmony, many categories

18:24

or rads do we have.

18:28

So we have here five.

18:32

So the first one is benign TR one,

18:36

it should have zero points in all these columns.

18:40

TR two is non suspicious.

18:44

Again, it's like a benign category, but it has two points.

18:49

Then the TR three mildly suspicious has three points.

18:55

TR four moderately suspicious has four to six points,

18:59

and T five has seven or more points.

19:03

Then you will categorize the nodule as tard pipe.

19:08

So you will add one point from each of these columns

19:12

and as many points which apply from the last column.

19:16

And then you add up the score

19:18

and the total score

19:19

to be remembered is 0 2, 3, 4.

19:24

So 2, 3, 4 is for two, three and four

19:28

and seven is for five.

19:30

So this you have to remember

19:32

or keep the table in front of you

19:34

because there is so much to remember.

19:37

So we can use it. So the

19:41

features are associated with the,

19:44

or the score is associated with the malignancy risk.

19:48

Now I'll tell you that

19:52

there is no risk in

19:57

TR one, TR two

19:59

and TR three which has a score of zero two and three.

20:04

But any nodule which is TR four is one which has a score

20:09

of four to six.

20:10

And any nodule would score

20:13

more than seven fits into TR five,

20:15

which is highly suspicious.

20:18

Now the idea is that I told you there are

20:22

so many nodules whether to do any biopsy

20:26

or not to do, which nodule to biopsy.

20:29

So we have T card guidelines by the A CR,

20:33

the TR one

20:34

and two do not need any FNA

20:38

or biopsy in TR three

20:43

because it is a mildly suspicious nodule, you have

20:48

to biopsy only if the maximum diameter is

20:53

more than 2.5, any dimension is more than 2.5,

20:58

then it is recommended for biopsy.

21:00

If it is less than one point between 1.5 to 2.5, you have

21:05

to just do a imaging surveillance follow up.

21:09

Now in the TR four, the

21:15

straight out four biopsy is comes down.

21:19

So for a 1.5 centimeter in maximum diameter nodule,

21:24

a biopsy is recommended

21:26

and a follow-up only for a nodule,

21:30

which is 1 2, 1 0.5 centimeters in size.

21:34

And going on to TR five.

21:36

If the score for the nodule with all those features

21:39

that I named goes to give you a score seven

21:43

or more, then the nodule deserves a biopsy.

21:47

Even if the score is one centimeter

21:51

and some investigators say that you may like

21:55

to biopsy it,

21:57

if it is even 0.5 centimeters, I'll come

22:01

to those details a little later.

22:04

But first we have to remember zero is one,

22:08

two is 2, 3 3

22:10

and four to six is four, seven is five.

22:13

Now another rule to be remembered here is

22:16

that the nodules which fall into TR one, two

22:20

and three are considered to be benign

22:23

unless proven otherwise.

22:25

And the nodules which fall into four

22:27

and five are to be considered malignant

22:30

unless proven otherwise.

22:33

Okay, so which are those features?

22:37

These features are

22:39

as I told you in the quo paper in 2011,

22:44

solid components in the nodule, low echogenicity,

22:50

taller than wider nodule, irregular margins

22:53

and calcifications.

22:55

These are all the red flag signs for malignancy.

22:59

Now another important concept which

23:04

I want to bring across is that

23:07

the Bethesda system is what the cytopathologists follow

23:12

and we follow the A CR rads.

23:16

So it is called T, the

23:20

beza BS system

23:23

R reporting thyroid cytopathology.

23:26

It is called T-B-S-R-T-C.

23:29

And this is a standardized reporting system

23:33

of all the thyroid PY, needle aspiration biopsies.

23:38

And it is found to be highly reproducible

23:41

and it has a good clinical significance.

23:45

And then staging does not go parallel to us.

23:50

But since they use this method as radiologists, we have

23:54

to be conversant with

23:56

what language they will be talking to us about.

23:59

So for one, they say, now non-diagnostic two is benign,

24:04

three is eight, type but not malignant.

24:07

Four is a follicular neoplasm, five is suspicious

24:12

for malignancy, six is malignant.

24:15

So just to make you familiar, they might talk

24:17

to you on those parameters, but we have to remember one, two

24:22

and three rads are benign, most likely four

24:25

and five are likely to be malignant.

24:29

Now how do you characterize the nodule

24:34

for the composition

24:36

and how do you characterize for genicity?

24:39

How do you decide whether it's taller than wider?

24:42

How do you look at the margins?

24:44

So instead of looking at this table which is available in

24:47

the book, I would like to show you the cases.

24:52

Now for the first one C

24:55

or composition, if it is a completely

25:00

cystic looking nodule, look at this arrowhead here,

25:03

then you give zero points

25:06

and a spongy form is when it has got at least

25:10

50% of cystic spaces.

25:15

Then again, it is given zero points.

25:18

So for the composition, the nodule may be either cystic,

25:21

it may be spongiform if it is mixed.

25:26

So if there is more than 50% of

25:30

a solid component there, give it

25:32

as a mixed nodule one point.

25:35

And if it is completely solid, call it a solid

25:39

and call it two points.

25:40

So I told you from the first parameters C

25:44

or composition, you have to give only one of the one point

25:49

or one uh parameter to be marked out of

25:53

all those which are applicable, only a single one has

25:56

to be marked and the score will be given then coming

26:01

to the E echogenicity, how to give the score here

26:05

if it is qu, now the e echogenicity is compared

26:09

to the normal adjoining parent.

26:13

So zero points if it is very unequal.

26:16

If it is hyper, it is one point.

26:20

If it is hypo echoic compared

26:23

to the adjoining parenchyma here it is very qu.

26:27

Here it is hypo two points.

26:31

And if it is very hypo

26:33

and becomes hypo to the adjoining strap muscle,

26:37

then it becomes three points.

26:39

So this quake is almost like a cystic nodule,

26:44

so that remains zero.

26:45

But once it is hyper hypo

26:49

or very hypo, then the score points keep on increasing.

26:53

So this is the second parameter, E

26:56

sesame seeds composition echogenicity.

26:58

We've looked at this. Now look at the shape

27:02

now taller than wider.

27:05

Here there is a concept which has to be understood.

27:09

We perform the ultrasound when the patient is lying down.

27:14

So we use earth transfers image.

27:17

When the transfers ultrasound is being performed,

27:22

then the ultrasound beam is

27:28

running vertical to the thyroid gland.

27:33

So at that time, if you want to measure height at that time,

27:37

the measurement should be parallel to the beam

27:42

and for the width it'll be perpendicular.

27:45

So when you imagine the patient

27:47

and your transducer there, then you will be able

27:50

to understand this concept.

27:52

Now having understood this, that it,

27:55

the measurements should be parallel to sound beam for height

27:59

and perpendicular to the sound beam forward.

28:03

So for the height, if the nodule is taller than wider,

28:07

it gets three points.

28:08

And if it's wider than taller, it has zero points.

28:12

So this is the third parameter S.

28:15

Now coming to the margins, this will be easy to understand.

28:20

So a smooth margins gives you a score of zero

28:24

lobulated margins like we have over here is two points

28:29

and another case with lobulated margins.

28:32

Here we can see lobulated margins.

28:34

Here, this makes it again two points.

28:38

And if there is extension beyond the thyroid capsule

28:43

into the overlying strap muscle,

28:45

then this is extra thyroidal extension which gives

28:49

it three points.

28:51

So what we have seen is storm composition, e genicity,

28:56

shape and margins.

28:59

So we have looked how to give the scoring in all these.

29:02

Now let us see the last one in which we said we have

29:06

to give all the scores which apply.

29:09

So in e cogenic foci, let us see here,

29:13

this module has got no echogenic focus.

29:16

So zero points here we can see some

29:20

comit tail artifacts.

29:21

Again, these are zero points.

29:24

If there is a carve linear

29:26

or a rim like calcification, it gets two points.

29:29

And if there are multiple ate

29:34

e echogenic, then it gets three points.

29:38

So zero Again, the C tail artifacts are considered

29:43

to be solid calcification.

29:45

That's why they give the tail like artifacts here,

29:48

which you see here where the arrow heads are also put.

29:52

So these are considered benign.

29:54

So that is why it is given zero points.

29:56

If it has rim, it is two

29:59

and if it has multiple punctate, it's three.

30:02

And why it it'll be like this.

30:05

Why should you give more score?

30:07

And if you have both rim

30:10

and punctate, then the score will be three plus two five

30:13

from the echogenic foci column.

30:19

So uh, briefly I'll explain

30:22

that the comal artifact is due to a reverberation artifact

30:27

and they are due to SAM bodies in the

30:30

colloid nodules.

30:32

That is why they are considered benign foca.

30:35

And we give zero points here.

30:38

So it is a colloid calcification.

30:40

Whereas if you have micro calcification for

30:44

those radiologists, colleagues

30:46

who do breast imaging also they will understand

30:49

that micro calcification you immediately correlate

30:52

with malignancy.

30:54

And in breast

30:55

and in thyroid gland we correlate micro calcification

31:00

with the papillary carcinoma of the thyroid.

31:04

But with the micro calcification,

31:07

if you get a com tail also you may see a combination,

31:11

but the micro calcification correlates most often

31:14

with papillary thyroid carcinoma.

31:18

Now you can see the echogenic focus here

31:21

and you can see your tail.

31:23

That is what is meant by the com tail artifact.

31:27

And this is a proven case

31:28

of a colloid goer from our own collection

31:31

at Subhan Hospital.

31:34

Now as I was telling you, the multiple

31:38

microcalcifications, I've marked them here.

31:40

These are all in favor

31:42

of the papini carcinoma of the thyroid.

31:46

So the, this picture

31:48

and this picture I want you to remember,

31:50

the com tail goes in favor of benignity

31:53

where the multiple punctate microcalcifications go in favor

31:57

of papillary carcinoma.

32:00

So again, I'm repeating choose one from composition,

32:05

choose one from Genicity, choose one from shape,

32:08

choose one from margin and from e echogenic.

32:11

Choose all that apply.

32:14

And the categories are

32:16

0, 1, 2, 4, 2, 3, 4, 3, 4 to six is four

32:21

and more than seven, seven or more is five.

32:25

So we've gone through this table.

32:27

So and I've illustrated the cases,

32:29

so I won't explain this now,

32:32

but from this table I want to explain

32:37

what is important to be learned.

32:39

This we have learned that we have to add all the points

32:42

and how many points are given that all I have gone over.

32:46

But here I want to tell you what is the risk of malignancy?

32:50

It has been found TR one is 0.3, tier two is 1.5,

32:54

tier three is 4.8, tier four is 9.1

32:58

and TR five is 35%.

33:01

This is some of the literature available

33:03

because we don't have very large bodies of work.

33:06

As I told you, there are so many ACRs, uh, so many RADS

33:11

and A CR RADS is also relatively new and young.

33:16

So as the body of work

33:17

and research ads, we will have more information.

33:21

But the thumb rule is up till three, we consider them benign

33:25

and four and five we consider them malignant,

33:29

although you will find that TR five is only 35%.

33:32

But I will tell you that like we have with the rads,

33:36

which came for ovary in 2020, so that also the

33:41

RADS five is considered more than 50%,

33:43

we don't have any rads which tells us the risk

33:46

of malignancy 90%.

33:48

So even 35% is a significant number.

33:53

So, and the other thing I told you,

33:56

the first two had no FNA more than 2.543 is a

34:00

cutoff more than 1.5 40

34:04

or four for three more than 2.5 for four more than 1.5

34:09

and for five more than one centimeter.

34:11

So the risk for doing a biopsy keeps on reducing

34:17

as the PR category goes on increasing.

34:22

So I think you understood it still here now.

34:26

Now if you have so many nodules,

34:29

so the A CR also recommends a worksheet,

34:33

you have a worksheet which can be downloaded

34:36

and kept with you and you have to localize the nodule

34:39

as whether it's lying anterior or lateral, what is its size.

34:44

And with on the right lobe,

34:47

left lobe nodule one, nodule two.

34:50

So it is recommended that you describe maximum

34:54

of only four nodules, which are largest insights.

34:59

Okay? And the biopsy should be done also

35:03

from the four largest nodules,

35:06

which if there are multiple nodes.

35:10

Okay, having said all this, let us see some

35:15

illustrative cases.

35:17

Now we already set the size threshold for FNA increases

35:22

as the T level increases

35:24

and those which are below the threshold for biopsy,

35:29

it is re recommended

35:30

as I already told you from the a CR table that they have

35:35

to be under imaging surveillance.

35:37

And the moment they attain the uh,

35:40

reach the site which needs a biopsy,

35:43

then they should undergo a biopsy.

35:46

And it is actually a fine needle aspiration.

35:49

And what the pathologist actually give us is

35:52

the cytopathology.

35:54

And that is why they talk about the bethea classification.

35:58

And whereas when you have a surgical resection,

36:02

then you will get a histopathology.

36:04

So this aspect also has to be very clear.

36:09

So, so routine biopsy

36:14

for the thyroids five,

36:16

even though the cutoff is one centimeter, some thyroid

36:21

investigators adequate, they advocate

36:24

that active surveillance

36:27

or a partial lobectomy should be done even if the micro

36:32

carcinoma is five to nine millimeters.

36:35

But this is recommended when there is a mutual

36:40

consent of the treating clinician and the patient.

36:45

And some investigators believe we follow a CR rads

36:49

and you undertake a biopsy

36:52

and resection only if the micro carcinoma is more than 10

36:57

millimeters and some believe five

37:00

to nine should also undergo biopsy and undergo resection.

37:04

So there is a bit of a controversy

37:07

for the thyroids five when the papillary mark carcinoma

37:12

is being considered.

37:15

So as I said, it's a shared decision between the physician

37:20

and the patient.

37:22

Now let us come to the active examples,

37:26

which I have to show you.

37:29

So here we have a young female who's 25 years old.

37:33

She came with a prominent thyroid gland

37:36

and she was very worried about it.

37:39

So we see a nodule in the left lobe of the thyroid.

37:43

So how do we classify it is that we have the it,

37:48

the left lobe, it's a com is cystic, it is zero

37:52

and equate zero wider than taller.

37:55

It is not margins are smooth.

37:57

So basically the score is zero

37:59

and we set for a score of zero.

38:01

It is RADS one, no FACS to be done.

38:05

Patient undergoes only regular surveillance.

38:10

Now here we have another case who's also a young female.

38:14

We have a pongy form nodule in which we uh,

38:18

already gave you the definition that it has multiple

38:22

cystic components

38:24

and it has a sponge-like appearance.

38:28

So what is the score?

38:31

The composition is zero and EQU is zero wider than taller.

38:35

We don't have any score margins remain smooth in this sune.

38:40

The E echogenic foca absent total score is zero.

38:43

Again, it is RADS one.

38:45

So again in the RADS one no or no FA is to be done.

38:50

And if the patient is worried, you can

38:53

undertake a follow up imaging surveillance.

38:57

Now let us look at another case here.

39:01

Here we have another patient who's 25 years female

39:05

thyroid, right?

39:07

Lobe of thyroid is prominent. She came for the ultrasound.

39:10

We see uh, nodule over here which is partly

39:14

solid, partly cystic.

39:16

And what do we see here? The e echogenicity is very hypo.

39:22

The shape taller than wider is not there.

39:25

But the very hypo equate I told you goes for a score of two

39:29

and we saw it as a bit of vascularity here

39:33

and I'm just adding here that the

39:36

sheer wave elastography showed us that it's a soft nodule.

39:40

I'll come to that later. That's not part of RAD so far.

39:44

The elastography and contrast.

39:46

So the total score that we have for all the parameters here,

39:50

there's no micro calcification or e echogenic focus.

39:53

So the score remained two because only very hypo eic.

39:57

So it is RADS two.

39:59

But the patient was very, very uh, concerned

40:04

and she insisted on having a biopsy.

40:06

Though it is not recommended in this case

40:09

because she said there was a close relative

40:12

who had a thyroid cancer.

40:14

And it turned out that we were right, the thyroids too,

40:18

it was only a colloid nodule in this patient.

40:23

It is not recommended,

40:24

but the patient insisted so we could not do anything

40:28

but help her out.

40:30

Another female here we have a right thyroid nodule.

40:35

We see it has got a composition which is mixed.

40:38

So when you have solid, you have to give us four of two.

40:42

It is mildly hyper equate

40:45

to the adjoining currently muscle score of one,

40:49

but it is not looking wider than taller.

40:52

So score is zero, margins are seeming smooth.

40:55

So it is zero eco for absent.

40:59

So score is three

41:01

and with a score of three, the tarara is three.

41:05

So in RAD three it is mildly suspicious. We did a ELAs.

41:10

It was looking like a benign nodule.

41:14

Again, this patient was very concerned

41:17

but we were not keen to do it.

41:19

But the FNAC was done, it again was a

41:23

benign colloid nodule.

41:25

So two cases we saw, which was zero and it was RADS one

41:30

and next case we saw was RADS two.

41:33

This one was scored three.

41:34

So this was three was again benign.

41:36

So as I told you, the nodules

41:40

1, 2, 3 are likely to be benign.

41:42

Let us see another patient here.

41:45

We have a very large nodule on the right side

41:49

and it is extending almost into the,

41:53

and I have marked it with the arrow heads here

41:56

and we can see that it has got largely solid.

41:59

So score is two, it is hyper equate to some

42:03

of the RET parent.

42:05

So score one is added for the E echogenicity

42:09

wider than taller.

42:10

It is not. It has smooth margins. There is no loation.

42:15

And the total score here was three.

42:18

And again in three we think of benign.

42:22

So we said it is benign,

42:23

but since the nodule was very large, it merited a biopsy

42:28

and it turned out to be a benign follicular

42:32

adenoma in this patient.

42:34

So this is what we have seen RADS one, two

42:37

and three examples of now going on further

42:42

here we have another large nodule which is

42:46

largely solid.

42:48

And here we can see that the score we have to give is two

42:52

and it has got hyper echoic compared

42:56

to the normal parenchyma and some hypo echoic area.

42:59

So for the composition we've given two

43:04

for the echogenicity we give one

43:06

and here we can see it is taller than wider.

43:10

So it has to be measured when the patient has the beam.

43:17

The measurement is when the scan is to the ultrasound beam,

43:21

so taller than wider, we gave a score of three.

43:25

The margins were not lobulated.

43:28

We can see that there are smooth margins

43:31

and there are no genic focal.

43:33

So the score here came up to B three and one four

43:37

and actually the score is six.

43:39

So it is third TS score nodule.

43:43

But when it was biopsied,

43:45

because the LO nodule was very large in size, that came out

43:48

to be a benign colloid nodule.

43:51

So the four and five are expected to be malignant,

43:54

but sometimes we can have the outliers.

43:58

Now let us look at another nodule here, which is

44:01

also taller than wider smooth.

44:04

And it has got hyper equ.

44:07

So two for the solid components, hyper equ,

44:11

it gives one taller than wider, gives a score of three.

44:15

So the total score came out to be six and it is four.

44:19

And although this was a small nodule small,

44:22

the four also meditated a biopsy

44:25

and the previous one turned out to be a colloid one.

44:29

But here the RADS four in this case turned out

44:33

to be a papillary carcinoma.

44:35

So as I'm repeating the RADS four score four to six

44:39

and above six, that is seven

44:41

and above all needs, uh, merits, uh, biopsy.

44:45

And the cutoff is 1.5 for the four

44:48

and one for the five and 2.5 for the three.

44:53

Now let us look at another case here.

44:56

Here I had shown you the

44:58

microcalcifications very large nodules.

45:00

So score is two for E echogenicity we have hyper

45:04

and hyper quick.

45:06

So we put two, it is not taller than wider.

45:09

The margins are of course very lobulated and irregular

45:13

and it has these multiple echogenic FOI which gives

45:17

it a score of three.

45:19

So here the total became four and two, six and three nine.

45:23

So above seven. So here it is RADS five.

45:27

So this was under uh, highly suspicious for malignancy,

45:31

histopathology proven it to be her pap carcinoma.

45:36

Now another patient here, here are a very large nodule.

45:41

We don't have any micro calcification.

45:44

It is not taller than wider.

45:46

We have hyper echogenicity solid company,

45:50

but the rest, the margins are mildly ated over here.

45:54

So the score came out to be five,

45:57

so two one and two five.

46:00

So RADS four, it was mildly suspicious, but

46:04

because it was in RADS four

46:06

and it was a very large one, more than 1.5 cutoff is 1.5

46:11

efficacy was done.

46:12

And unfortunately this came out to be medullary carcinoma.

46:17

And compared to papillary,

46:18

the medullary carcinoma has a worse prognosis.

46:22

Now one more case here.

46:25

We have a older patient who's around 50,

46:29

uh, plus 57 years large du.

46:33

So solid, hyper quick, taller than wider.

46:37

We can make out here. Total score is six RADS four,

46:41

but again this turned out to be

46:44

anaplastic carcinoma after biopsy.

46:47

So the four can also have a lot of cancers in

46:51

that group as I have shown you.

46:54

So this one I have already talked about

46:56

so I will not repeat it.

46:58

So now we have gone through all the examples.

47:02

So I am also coming to the closing time

47:06

of my talk.

47:08

I would like to add here that the diagnostic performance

47:13

of a CR RADS

47:15

and the European RADS were

47:19

examined by a group of workers,

47:22

which was published in Diagnostic

47:24

and interventional Radiology in 2021.

47:28

And these workers are from Turkey

47:31

and they found that the diagnostic performance

47:34

of the European RADS

47:36

and the CR RADS were almost equal.

47:40

And the RADS four

47:42

and five categories were found to be malignant,

47:44

as I have been telling you.

47:47

But they also added from the statistical

47:52

analysis of their work that if you presume only RADS pipe

47:57

as malignant, then you have the increase in specificity

48:02

of this algorithm,

48:04

but it lowers the sensitivity

48:07

and the negative predictive value.

48:10

So then what the A CR RAD says is definitely

48:14

better because you also include RADS for, and

48:19

therefore you get a good negative predictive value.

48:22

Also if you include RADS four as likely

48:26

to be malignant.

48:30

Now, uh, this same study, they said that the

48:35

benign nodules, almost 15%

48:39

of the nodules, which are in the benign category

48:44

or 16% can later turn out to be malignant.

48:48

But the uh, important thing

48:52

to understand here is

48:54

that the A CR RADS also gives you a

48:57

guideline for the follow up.

48:59

So if the RADS three is

49:04

more than 2.5,

49:06

but if the 1.5 of RAD three is followed up

49:10

and it increases in size, then you have to do the biopsy.

49:14

So anyway, the conclusion of these workers was

49:17

that both the risk stratification systems are good,

49:21

but in India we are following the RADS or ads.

49:24

So we are mostly following the American system

49:27

and I believe the uh, noon conference also has a lot

49:31

of American radiologists.

49:33

So I think that uh,

49:35

we are very relevant here when we follow the A CR rads.

49:39

Now, uh, the other thing about literature which I wanted

49:43

to add is, uh, whether these uh, ACR

49:48

RADS recommendations are concordant with the BETHEA scoring.

49:53

Now I told you the BETHEA scoring is for the cytology,

49:57

whereas the histopathology we get only from the resection

50:01

or the thyroidectomy.

50:04

So their storing goes on a different path

50:07

and ours goes on a different path.

50:09

But we have to be aware of this nomenclature.

50:13

So now we have workers who published from uh, Singapore

50:18

and they published in JAMA network open in September, 2023.

50:22

They studied 4 46 nodule, uh, patients with six 30 nodules.

50:28

And as I told you the ACR R rads, they found that

50:32

the score three or RADS three had high concordance

50:36

and negative predictive value with even the BEZA scores

50:40

and with the histopathology and with four

50:43

and five they had a good correlation

50:46

for the cancer detection with the histopathology.

50:50

So that was another study which in a way supported the A

50:54

CR thyroids.

50:56

So, uh, in their study they said already, which we know

51:00

that less than 2.5 have lower risk of cancer

51:03

and the patients with biopsy or for the four

51:07

and five categories, we already already discussed that,

51:10

that if it is five less than one centimeters, some

51:14

thyroid experts prefer to have a biopsy

51:18

and intersection earlier.

51:20

But because of this mild uh, overlap

51:25

between four and five,

51:27

there are some gray areas which are being, you know, uh,

51:32

attended by some of the Asian investigators

51:35

by performing the sheer wave elastography.

51:39

And they have found that the nodules

51:42

above 85.2 kilo pascals shared wave are likely

51:46

to be malignant.

51:48

Whereas we did our own study

51:50

and we are going to publish this paper as we

51:53

take a lower threshold of 74 kilo pascals,

51:57

then the sensitivity

51:59

and specificity reaches above 91

52:03

to 96%.

52:04

So anyway, what the literature says is 85,

52:08

we are saying 74,

52:10

but it's not too much of a earth shaking difference.

52:13

But elastography can help us share wave elastography

52:18

as I've shown that the blue color

52:20

and the uh, the she wave velocity here was um,

52:29

this was a very low she wave velocity only two kilo PA

52:34

46 kilopascals.

52:35

So this was a benign nodule

52:38

and uh, this was correlating very well.

52:43

And then even with the strain elastography, we found

52:46

that you can find out that uh, you know,

52:48

benign nodules have low strain ratios

52:52

and low, um, you know, um,

52:55

size ratios which are below one.

52:58

So even the elastography can help us if you want

53:02

to be more confident.

53:03

But so far it has not been adopted into the A CR rads.

53:09

Now looking at this patient, which I showed you,

53:11

which turned out to be a papillary carcinoma,

53:14

just I'll show you that here.

53:16

When we did the elastography, we found that the value

53:21

for the kilo pascal was 92.

53:24

And I told you that the literature cutoff is 82

53:28

and sometimes if it is above 90

53:30

or a hundred, the machine does not give you a reading.

53:33

The machine that we had,

53:35

so this was correlating the elastography cut, uh,

53:38

correlates very well.

53:40

And then we also did some work on

53:43

contrast enhanced ultrasound.

53:45

So the,

53:48

we use a sono view contrast

53:51

and we compare the enhancement of the nodule

53:56

and the remaining parenchyma

53:58

and we can see that if there is a slow washing wash

54:03

in the lesion, then it is likely to be in a benign lesion.

54:08

So this was the ROI in the normal perma,

54:11

an ROI in the hypo coic nodule.

54:15

On the other hand, if you have a nodule,

54:18

which you are su uh, you know,

54:20

seeing a enhancement in the solid component,

54:24

then it is likely to be a malignant nodule.

54:27

And these nodules have a very fast time to pick of

54:31

around nine seconds and a early washout.

54:34

So this we all know from a lot of literature we read,

54:38

so I not uh, spend more time on it.

54:41

I'll, my time is ending for the lecture duration.

54:45

So I'll quickly summarize that.

54:47

There are five major features for evaluation.

54:51

So I have used the mnemonic of sesame though it,

54:56

the first one is C, so esme is C for

55:01

contents, genicity contents

55:04

or composition, E for genicity, S for shape, M for margins.

55:09

The second E is four

55:11

genic foci assign one value from each

55:15

of the contents, genicity shape and margins

55:20

and all the values that apply from the last column in the

55:24

genic foci one score zero is RADS one,

55:29

score two is two, three is three, four to six is four.

55:33

And more than seven is RAs five and four

55:37

and five are considered malignant unless proven otherwise.

55:41

And we know the, the threshold for biopsy

55:45

in RAs three is more than 2.5, 1.5.

55:48

You follow up threshold for biopsy in four is 1.5

55:53

and between one and 1.5 you do imaging follow up.

55:57

And if the nodule is RADS five,

56:02

then the threshold for biopsy is

56:06

five millimeter according to certain workers.

56:09

As for the RADS recommendation,

56:12

it's one centimeter.

56:15

So then these have to undergo biopsy

56:18

and the features that we learned was solid components

56:24

very low E echogenicity taller than wider irregular margins

56:28

and calcification are red flag signs for malignancy because

56:33

whenever we have solid components we give two score low

56:36

echogenicity two scores taller than wider.

56:38

We straightaway give three for irregular, we give two

56:42

for the microcalcifications we give three.

56:45

So all these definitely add up to give us a higher score

56:49

and place the nodule in a higher category.

56:53

So these are the uh, broad outlines on which the

56:58

RADS works and I already introduced to you the BEA system

57:03

and the FNAC

57:06

or cytology will be categorized as per beza.

57:09

And when you have the surgery

57:11

or the section, it'll be categorized

57:15

with the histopathology.

57:17

And I've already told you about those studies which have

57:20

been done and the last study in JAMA Network Open says

57:25

that ACR ROS is a good robust system

57:29

and it gives us a good negative

57:33

and positive predictive value as such.

57:37

But there is still scope for using the ELA

57:41

and CUS as I said, which is being investigated more in Asia.

57:46

And we are also going to come up with a manuscript which has

57:49

to be sent for publication.

57:52

So, um, the, this is

57:57

what I have to say and we have learned how to go about it

58:02

and the Asian workers are working on the elastography

58:05

and the the contrast ultrasound.

58:09

And at the end of the day, what we deliver

58:11

to our cancer patients really affects their longevity

58:16

and their disease survival.

58:19

But no individual can work himself or herself.

58:23

It is always a team.

58:25

So at the end of my lecture I thank all the patients

58:30

who have learned so much and gained so much experience from,

58:34

but I also thank my peers and my residents

58:38

and students as well who always continue to give us a lot

58:43

of enthusiasm to keep on learning and remaining up to date.

58:48

And one small thank you to MRI online, Ashley

58:53

and her team and also to Dr.

58:56

Sesh Buji for introducing me to this platform.

59:01

Thank you very much. I look forward to any questions.

59:06

Thank you so much Dr. Grover for that lecture.

59:08

That was great. We have time for a couple questions

59:13

and we've got a few in here.

59:15

So I'm gonna read, read out a couple to you,

59:19

what words do you use in the impression when a nodule is

59:23

below size criteria for both biopsy

59:26

or continued surveillance?

59:29

Sorry, What words do you use in the impression when

59:34

a nodule is below size criteria for both biopsy

59:38

or continued surveillance?

59:40

Uh, what uh, will I write in my report? Right?

59:44

So on the size of the nodule

59:47

and the category in which the nodule I have categorized,

59:52

like I told you, if it is a RAs four nodule, then I have

59:57

to recommend for uh, RADS three nodule.

60:01

I have to recommend if it is more than 2.5 centimeters

60:05

inside and uh, RADS four I have to recommend for uh,

60:10

FNA if it is more than 1.5

60:12

and a RADS five, I have to recommend

60:15

for FNA if it is more than one centimeter.

60:19

So let me go back to that slide from the RAD site

60:26

that will explain it again.

60:28

It is available on the RAD site as well.

60:34

So, so the

60:39

size, the category of the nodule is based on the points,

60:44

but the FNAC is based on the category

60:49

plus the size of the nodule.

60:55

Great. This is another question about how you report out.

60:59

How do you report nodules

61:01

that have been previously biopsied?

61:04

And what about benign lesions that grow

61:08

The previously biopsied nodules?

61:11

We don't have any guidelines to say

61:14

that these cannot be categorized.

61:17

So we would use the same guidelines to categorize them.

61:24

I think you answered this one.

61:25

What do you do with nodules one centimeter or less?

61:29

Do you still give ty rads classifications to these nodules

61:33

Which are One centimeter or less?

61:37

Depends on the category I said

61:39

because if it is a RADS one

61:43

or two, nothing has to be done for those.

61:46

So we still can give them a category like I showed you my

61:49

first two or three cases and if they are RADS three, four

61:54

or five depending on the size of the nodule,

61:58

again I'm repeating so I can again go to the slideshow.

62:03

So more than 2.5 it'll need a biopsy.

62:08

If it is 1.5 to 2.5,

62:11

it needs some imaging surveillance follow up.

62:14

If it is RADS four category

62:16

and the size is more than 1.5,

62:21

it'll need a biopsy recommended for biopsy.

62:24

If it is between one to 1.5, we keep following it up

62:29

and more than one centimeter.

62:31

If it is in that's five at one centimeter,

62:34

it is a threshold for the biopsy.

62:36

And if it is 0.5 centimeters we should follow up though.

62:40

This last one, uh, has some uh,

62:45

overlap in the viewpoints of some thyroid surgeons

62:50

who do not want to, uh, leave the patient alone

62:54

with a one centimeter nodule

62:56

and would like to biopsy it at 0.5 centimeters.

63:01

But the rads a CR RAD says one centimeter

63:05

is the cutoff.

63:07

So we cannot decide for only the size.

63:11

We have to see the category plus the size,

63:15

then come to a conclusion.

63:19

Okay, we'll do one more.

63:21

How do you determine solid versus mixed? Solid and cystic?

63:25

If the nodule is 98% solid, do you call it solid or mixed?

63:31

More than 50%. We determine it to be solid.

63:35

I showed that at the beginning when I illustrated the cases.

63:39

If this is mixed, then it has got solid

63:43

and stic both.

63:45

I hope my, uh, slides are visible. Ashley,

63:48

I actually don't see them. I

63:49

think you stopped sharing them if you wanna

63:50

quickly share them again.

63:54

Okay. So I had shown this slide that if there is a solid

63:59

and a cystic component, then it is categorized as mixed

64:05

and the score given for the composition

64:07

for a mixed nodule is score one.

64:11

But if it is largely solid, more than 50% is solid,

64:16

then we'll give the score as solid

64:18

and the score is two months or two points.

64:24

Excellent. Well thank you so much Dr. Grover.

64:28

We're gonna wrap today's noon conference.

64:30

We really appreciate your time in this lecture.

64:34

Thank you so much.

64:36

Thank you. And thank you for everyone else

64:37

for participating and for asking such great questions.

64:41

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64:43

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64:45

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64:46

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64:50

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64:52

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64:54

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64:58

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65:00

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65:02

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65:04

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65:07

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