The purpose of this study was to evaluate the sonographic features of thyroid nodules suspicious for malignancy with standard examination in B-mode and Color Doppler associated with modern tech- niques such as ultrasound RTE (Real Time Elastosonography) and BFI (B-flow imaging) in correlation with the results of the sonographically guided fine-needle aspiration to establish their role in predicting the risk of malignancy. Between November 2012 and January 2014, 354 consecutive patients (age range, 18e73 years; mean age ± SD, 41.2 ± 9.2 years; 90 male and 264 female) with 493 suspected nodules (maximum diameter > 9 mm) were enrolled in this prospective study. Sonographic, elastosonographic and BFI examinations were performed with a commercially available real-time ultrasound system, and all patients also underwent a cytologic evaluation. Patients with sus- picious or malignant cytologic features underwent surgery. On histologic examination, 71 of 493 nodules were malignant (62 papillary thyroid carcinoma, 1 Hürthle cell carcinoma, and 8 follicular carcinoma). All sonographic characteristics, which were potential predictors of thyroid malignancy (microcalcifications, hypoechogenicity, absence of a halo, and a pre- dominantly solid composition), were found in different percentages in both histologically verified ma- lignant and benign nodules. For BFI, pattern 3 (!4 signs and distance > 2 mm) was the most predictive factor for malignancy (specificity, 99.6%; sensitivity, 65.2%), whereas pattern 2 (!4 signs and distance < 2 mm) was a positive factor because it was detected only in benign lesions. For the RTE, scores 1e2 were detected in 68% of benign nodules, while scores 3e4 in 94% of malignant nodules. Our results indicate that Elastosonography and BFI can overcome the limits of the traditional B-mode and color Doppler sonographic features in the diagnosis of thyroid nodules. This techniques provides maximum specificity levels both in the case of benign nodules and in the case of malignant nodules.
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