Ricare, Mary Claire Ida B.

Clinical Question:

Aside from MRI, can neck ultrasound and CT scan be utilized in assessing extrathyroidal extension in
patients with thyroid carcinoma?

Research Question:

In patients with thyroid carcinoma, what is the diagnostic accuracy of neck ultrasound and CT scan in
determining extrathyroidal extension?

Research Journal:

CRITICAL APPRAISAL ON DIAGNOSIS:

1. APPRAISING DIRECTNESS

Research Question Journal

Population Patients with thyroid carcinoma 377 patients with PTC undergoing
total thyroidectomy (with or without
neck dissection) in Seoul National
University Hospital
Intervention Neck Ultrasound, CT scan Neck US vs CT scan vs combined
Comparison Pathological report after surgery
Outcome Extrathyroidal extension Extrathyroidal extension
Methodology Quantitative study Retrospective, quantitative study

2. APRRAISING VALIDITY
a. Was the reference standard an acceptable one?

Yes. Postoperative pathological examination can establish the diagnosis of extrathyroidal extension
(ETE). Pathologic report in the study was uniformly categorized into laterality, multicentricity, tumor size,
TNM staging, gross and/or microscopic ETE, and the presence of nodal metastasis.

b. Was the reference standard interpreted independently from the test in question?

No. Aside from the study being done retrospectively, the results of ultrasound and CT scan
preoperatively influenced the decision in the performance of the surgery. Also, the possibility of ETE before
surgery could be used to decide the extent of surgery and the utilization of postoperative radioactive iodine
(RAI).
 3. APPRAISING RESULTS
a. What were the likelihood ratios of the various test results?

Among 377 patients with PTC, ETE was identified in 174 patients post-surgery. PPV was the highest
in tumor with >50% contact with the adjacent capsule on CT scan (81.8%) and AUC was the highest when
the cutoff criteria was disruption of capsule on US (0.647).

Neck ultrasound result:

Contact with capsule Disruption of capsule

LR(+)= 1.14 LR(-)= 0.36 LR (+)= 1.89 LR (-)= 0.52
Posttest probability (+) = 82% Posttest probability (+) = 88%
Posttest probability (-) = 59% Posttest probability (-) = 68%

Neck CT scan result:

Contact with capsule More than 25% contact More than 50% contact
LR(+)= 1.24 LR(-)= 0.44 LR (+)= 1.27 LR (-)= 0.65 LR (+)= 5.15 LR (-)= 0.8
Posttest probability (+) = 83% Posttest probability (+) = 84% Posttest probability (+) = 95%
Posttest probability (-) = 64% Posttest probability (-) = 72% Posttest probability (-) = 76%

Combined Neck UTZ and CT scan:

Contact with LR(+)= 1.32 LR(-)= 0.07
capsule Posttest probability (+) = 84%
Posttest probability (-) = 22%
Contact More than LR(+)= 1.71 LR(-)= 0.25
with 25% contact Posttest probability (+) = 87%
capsule Posttest probability (-) = 50%
More than LR(+)= 3.22 LR(-)= 0.86
50% contact Posttest probability (+) = 93%
Posttest probability (-) = 77%
 Contact with LR(+)= 1.64 LR(-)= 0.06
capsule Posttest probability (+) = 87%
Posttest probability (-) = 19%
Disruption More than LR(+)= 3.14 LR(-)= 0.10
of capsule 25% contact Posttest probability (+) = 93%
Posttest probability (-) = 28%
More than LR(+)= 8.04 LR(-)= 0.44
50% contact Posttest probability (+) = 97%
Posttest probability (-) = 64%

4. ASSESSING APPLICABILITY
a. Is there any biologic issues affecting applicability?
 Sex- majority of the patients are female with male to female ratio of 1:3.5
 Age- the median age of patients was 49.1 (+/-10.6)
 Pathology- the patients included in the study was only those with PTC. Those with diagnosis other
than PTC were excluded in the study.

b. Is there any socioeconomic issues affecting applicability?

None. Neck ultrasound and CT scan was the most commonly utilized imaging in the country
aside from its availability in public hospitals, it is also cheaper compared to MRI. Although MRI is said
to provide more information when evaluating for extrathyroidal tumor extension but its utilization is more
expensive compared to ultrasound and CT scan.

5. INDIVIDUALIZING THE RESULT

Based on the patient’s history and PE with the consideration of thyroid carcinoma, combination
of neck ultrasound and CT scan can be used as an alternative to MRI in evaluating for presence of
extrathyroidal extension. But there is decreasing efficacy in detecting ETE in using ultrasound or CT scan
alone. Although when using the CT scan alone, there is high probability of determining ETE when the
disruption is >50% contact with the capsule (posttest probability 95%).
In this paper, the pretest probability was set to 80%. In using the ultrasound alone, the LR (+) or
the probability of those having disruption of the thyroid capsule is 1.89 with post-test probability of
having ETE of 88%. Compared to combination of neck UTX and CT scan, the LR (+) of having
disruption of the capsule >25% is 3.14 with posttest probability of 93%. Furthermore, those having
disruption of thyroid capsule >50% have LR (+) of 8.04 with 97% of having extrathyroidal extension.

CONCLUSION:

It is advantageous for surgeons and patients to know the possibility of ETE before surgery, in
order to decide the extent of the surgery (lobectomy/total thyroidectomy or central neck dissection). And
one of the critical determinants for postoperative radioactive iodine (RAI) treatment is the presence of
ETE. Therefore, it is imperative to predict the presence of ETE preoperatively. Although there is some
limitation in CT scan to evaluate tiny thyroid nodule, additional information from the CT scan could
increase the prediction of ETE with US.