Springer Nature is making SARS-CoV-2 and COVID-19 research free. View research | View latest news | Sign up for updates

Elastosonographic strain index in thyroid nodules with atypia of undetermined significance

  • 189 Accesses

  • 14 Citations



In this study, we aimed to evaluate the diagnostic accuracy of elastosonography (ESG) scoring and strain ratio in patients who had atypia of undetermined significance (AUS) cytology and underwent surgery for thyroid nodules.

Materials and methods

250 patients were included in this study. They had at least one nodule in thyroid USG, underwent USG-guided FNAC according to the current guidelines and had AUS cytology according to the Bethesda system. Both elastosonographic color scoring and strain index were evaluated.


A total of 270 nodules in 250 patients were evaluated. Histopathologically, 81 (30 %) nodules were malignant and 189 (70 %) were benign. According to the ESG, 10 (3.7 %) nodules were assigned a score of 1, while 13 (4.8 %) nodules were assigned a score of 5. All of the nodules with an ESG score of 1 were histopathologically benign and 92.3 % of the patients with ESG score 5 were in the malignant group. Median SI in the benign histopathologic group was significantly lower compared to malignant group [(2.58 (IQR = 2.35) vs. 14.54 (IQR = 10.71)]. The optimal SI cut-off value to distinguish between the benign and malignant nodules was 6.66, with a sensitivity of 98.77 % and specificity of 96.30 %.


Our study is one of the first studies evaluating the role of SI for discriminating malignant and benign nodules with AUS cytology. Malignant nodules had a significantly higher stiffness compared to benign ones and SI had high sensitivity, specificity, positive predictive value, negative predictive value and accuracy for these nodules. We think SI may be helpful for the presurgical selection of nodules with AUS cytology.

This is a preview of subscription content, log in to check access.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5


  1. 1.

    Shuzhen C (2012) Comparison analysis between conventional ultrasonography and ultrasound elastography of thyroid nodules. Eur J Radiol 81(8):1806–1811

  2. 2.

    Rago T, Scutari M, Santini F, Loiacono V, Piaggi P, Di Coscio G, Basolo F, Berti P, Pinchera A, Vitti P (2010) Real-time elastosonography: useful tool for refining the presurgical diagnosis in thyroid nodules with indeterminate or nondiagnostic cytology. J Clin Endocrinol Metab 95(12):5274–5280

  3. 3.

    Cantisani V, D’Andrea V, Mancuso E, Maggini E, Di Segni M, Olive M, Lodise P, Palermo S, De Antoni S, Redler A, Patrizi G, Porfiri A, Panzironi G, Ricci P (2013) Prospective evaluation in 123 patients of strain ratio as provided by quantitative elastosonography and multiparametric ultrasound evaluation (ultrasound score) for the characterisation of thyroid nodules. Radiol Med 118:1011–1021

  4. 4.

    Merino S, Arrazola J, Cárdenas A, Mendoza M, De Miguel P, Fernández C, Ganado T (2011) Utility and interobserver agreement of ultrasound elastography in the detection of malignant thyroid nodules in clinical care. AJNR Am J Neuroradiol 32(11):2142–2148

  5. 5.

    Nikiforov YE, Ohori NP, Hodak SP, Carty SE, LeBeau SO, Ferris RL, Yip L, Seethala RR, Tublin ME, Stang MT, Coyne C, Johnson JT, Stewart AF, Nikiforova MN (2011) Impact of mutational testing on the diagnosis and management of patients with cytologically indeterminate thyroid nodules: a prospective analysis of 1056 FNA samples. J Clin Endocrinol Metab 96(11):3390–3397

  6. 6.

    Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL, Mandel SJ, Mazzaferri EL, McIver B, Pacini F, Schlumberger M, Sherman SI, Steward DL, Tuttle RM (2009) Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid 19(11):1167–1214

  7. 7.

    Gharib H, Papini E, Paschke R, Duick DS, Valcavi R, Hegedüs L, Vitti P (2010) AACE/AME/ETA Task Force on Thyroid Nodules. American Association of Clinical Endocrinologists, Associazione Medici Endocrinologi, and European Thyroid Association medical guidelines for clinical practice for the diagnosis and management of thyroid nodules. J Endocrinol Invest 33:1–50

  8. 8.

    Moon HJ, Sung JM, Kim EK, Yoon JH, Youk JH, Kwak JY (2012) Diagnostic performance of gray-scale US and elastography in solid thyroid nodules. Radiology 262(3):1002–1013

  9. 9.

    Moon HJ, Kim EK, Yoon JH, Kwak JY (2012) Clinical implication of elastography as a prognostic factor of papillary thyroid microcarcinoma. Ann Surg Oncol 19(7):2279–2287

  10. 10.

    Unlütürk U, Erdoğan MF, Demir O, Güllü S, Başkal N (2012) Ultrasound elastography is not superior to grayscale ultrasound in predicting malignancy in thyroid nodules. Thyroid 22(10):1031–1038

  11. 11.

    Cantisani V, D’Andrea V, Biancari F, Medvedyeva O, Di Segni M, Olive M, Patrizi G, Redler A, De Antoni EE, Masciangelo R, Frezzotti F, Ricci P (2012) Prospective evaluation of multiparametric ultrasound and quantitative elastosonography in the differential diagnosis of benign and malignant thyroid nodules: preliminary experience. Eur J Radiol 81(10):2678–2683

  12. 12.

    Lippolis PV, Tognini S, Materazzi G, Polini A, Mancini R, Ambrosini CE, Dardano A, Basolo F, Seccia M, Miccoli P, Monzani F (2011) Is elastography actually useful in the presurgical selection of thyroid nodules with indeterminate cytology? J Clin Endocrinol Metab 96(11):E1826–E1830

  13. 13.

    Ning CP, Jiang SQ, Zhang T, Sun LT, Liu YJ, Tian JW (2012) The value of strain ratio in differential diagnosis of thyroid solid nodules. Eur J Radiol 81(2):286–291

  14. 14.

    Chaudhary V, Bano S (2012) Imaging of the thyroid: recent advances. Indian J Endocrinol Metab 16(3):371–376

  15. 15.

    Ophir J, Céspedes I, Ponnekanti H, Yazdi Y, Li X (1991) Elastography: a quantitative method for imaging the elasticity of biological tissues. Ultrason Imaging 13(2):111–134

  16. 16.

    Lyshchik A, Higashi T, Asato R, Tanaka S, Ito J, Mai JJ, Pellot-Barakat C, Insana MF, Brill AB, Saga T, Hiraoka M, Togashi K (2005) Thyroid gland tumor diagnosis at US elastography. Radiology 237(1):202–211

  17. 17.

    Xing P, Wu L, Zhang C, Li S, Liu C, Wu C (2011) Differentiation of benign from malignant thyroid lesions: calculation of the strain ratio on thyroid sonoelastography. J Ultrasound Med 30(5):663–669

  18. 18.

    Cakir B, Aydin C, Korukluoğlu B, Ozdemir D, Sisman IC, Tüzün D, Oguz A, Güler G, Güney G, Kuşdemir A, Sanisoglu SY, Ersoy R (2011) Diagnostic value of elastosonographically determined strain index in the differential diagnosis of benign and malignant thyroid nodules. Endocrine 39(1):89–98

  19. 19.

    Rago T, Santini F, Scutari M, Pinchera A, Vitti P (2007) Elastography: new developments in ultrasound for predicting malignancy in thyroid nodules. J Clin Endocrinol Metab 92(8):2917–2922

  20. 20.

    Rago T, Vitti P (2008) Role of thyroid ultrasound in the diagnostic evaluation of thyroid nodules. Best Pract Res Clin Endocrinol Metab 22(6):913–928

  21. 21.

    Bojunga J, Herrmann E, Meyer G, Weber S, Zeuzem S, Friedrich-Rust M (2010) Real-time elastography for the differentiation of benign and malignant thyroid nodules: a meta-analysis. Thyroid 20(10):1145–1150

  22. 22.

    Cibas ES, Ali SZ (2009) NCI thyroid FNA state of the science conference. The Bethesda system for reporting thyroid cytopathology. Am J Clin Pathol 132(5):658–665

  23. 23.

    Broome JT, Solorzano CC (2011) The impact of atypia/follicular lesion of undetermined significance on the rate of malignancy in thyroid fine-needle aspiration: evaluation of the Bethesda system for reporting thyroid cytopathology. Surgery 150(6):1234–1241

  24. 24.

    Cantisani V, Ulisse S, Guaitoli E, De Vito C, Caruso R, Mocini R, D’Andrea V, Ascoli V, Antonaci A, Catalano C, Nardi F, Redler A, Ricci P, De Antoni E, Sorrenti S (2012) Q-elastography in the presurgical diagnosis of thyroid nodules with indeterminate cytology. PLoS One 7(11):e50725

  25. 25.

    Kagoya R, Monobe H, Tojima H (2010) Utility of elastography for differential diagnosis of benign and malignant thyroid nodules. Otolaryngol Head Neck Surg 143(2):230–234

  26. 26.

    Gharib H, Papini E, Paschke R, Duick DS, Valcavi R, Hegedüs L, Vitti P (2010) AACE/AME/ETA task force on thyroid nodules. American Association of Clinical Endocrinologists, Associazione Medici Endocrinologi, and European Thyroid Association Medical guidelines for clinical practice for the diagnosis and management of thyroid nodules: executive summary of recommendations. Endocr Pract 16(3):468–475

  27. 27.

    Gharib H, Papini E, Paschke R (2008) Thyroid nodules: a review of current guidelines, practices, and prospects. Eur J Endocrinol 159(5):493–505

  28. 28.

    Itoh A, Ueno E, Tohno E, Kamma H, Takahashi H, Shiina T, Yamakawa M, Matsumura T (2006) Breast disease: clinical application of US elastography for diagnosis. Radiology 239(2):341–350

  29. 29.

    DeLellis RA, Williams ED (2004) Thyroid and parathyroid tumors. In: DeLellis RA, Lloyd R, Heitz PU, Eng C (eds) WHO classification of tumors, pathology and genetics—tumors of endocrine organs. IARC Press, Lyon, pp 49–97

  30. 30.

    Bonzanini M, Amadori P, Morelli L, Fasanella S, Pertile R, Mattiuzzi A, Marini G, Niccolini M, Tirone G, Rigamonti M, Dalla Palma P (2011) Subclassification of the “grey zone” of thyroid cytology; a retrospective descriptive study with clinical, cytological, and histological correlation. J Thyroid Res 2011, Article ID 251680

  31. 31.

    Bongiovanni M, Krane JF, Cibas ES, Faquin WC (2012) The atypical thyroid fine-needle aspiration: past, present, and future. Cancer Cytopathol 120(2):73–86

  32. 32.

    Rago T, Di Coscio G, Basolo F, Scutari M, Elisei R, Berti P, Miccoli P, Romani R, Faviana P, Pinchera A, Vitti P (2007) Combined clinical, thyroid ultrasound and cytological features help to predict thyroid malignancy in follicular and Hupsilonrthle cell thyroid lesions: results from a series of 505 consecutive patients. Clin Endocrinol (Oxf) 66(1):13–20

Download references

Conflict of interest

The authors B. Cakir, R. Ersoy, F. N. Cuhaci, C. Aydin, B. Polat, M. Kılıc, and A. Yazgan declare that they have no conflict of interest.

Author information

Correspondence to F. N. Cuhaci.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Cakir, B., Ersoy, R., Cuhaci, F.N. et al. Elastosonographic strain index in thyroid nodules with atypia of undetermined significance. J Endocrinol Invest 37, 127–133 (2014). https://doi.org/10.1007/s40618-013-0005-1

Download citation


  • Atypia of undetermined significance (AUS)
  • Elastosonography (ESG)
  • Strain index (SI)
  • Thyroid nodule
  • Malignancy