Tests and procedures used to diagnose thyroid cancer include: Physical exam. Bastin S, Bolland MJ, Croxson MS. Role of Ultrasound in the Assessment of Nodular Thyroid Disease. Thyroid nodules are detected by ultrasonography in up to 68% of healthy patients. We aimed to assess the performance and costs of the American College of Radiology Thyroid Image Reporting And Data System (ACR-TIRADS). ACR TI-RADS FAQ : RADS - Reporting and Data Systems Support Interobserver Agreement of Thyroid Imaging Reporting and Data System (TIRADS) and Strain Elastography for the Assessment of Thyroid Nodules. There remains the need for a highly performing diagnostic modality for clinically important thyroid cancers. The prevalence of incidental thyroid cancer at autopsy is around 10% [3]. Reference article, Radiopaedia.org (Accessed on 05 Mar 2023) https://doi.org/10.53347/rID-21448. We have also estimated the likely costs associated with using the ACR TIRADS guidelines, though for simplicity have not included the costs of molecular testing for indeterminate nodules (which is not readily available in the New Zealand public health system) nor any US follow-up and associated costs. Thyroid nodules are solid or fluid-filled lumps that form within your thyroid, a small gland located at the base of your neck, just above your breastbone. Thyroid nodules - Doctors and departments - Mayo Clinic If a patient was happy taking this small risk (and particularly if the patient has significant comorbidities), then it would be reasonable to do no further tests, including no US, and instead do some safety netting by advising the patient to return if symptoms changed (eg, subsequent clinically apparent nodule enlargement). The other one-half of the cancers that are missed by only doing FNA of TR5 nodules will mainly be in the TR3 and TR4 groups (that make up 60% of the population), and these groups will have a 3% to 8% chance of cancer, depending upon whether the population prevalence of thyroid cancer in those being tested is 5% or 10%. Diag (Basel) (2021) 11(8):137493. Epub 2021 Oct 28. It is interesting to see the wealth of data used to support TIRADS as being an effective and validated tool. These appear to share the same basic flaw as the ACR-TIRADS, in that the data sets of nodules used for their development is not likely to represent the population upon which it is intended for use, at least with regard to pretest probability of malignancy (eg, malignancy rate 12% for Korean TIRADS [26]; 18% and 31% for EU TIRADS categories 4 and 5 [27, 28]). Here at the University of Florida, we are currently recruiting endocrinologists to work with us to help people with thyroid nodules. Chinese thyroid imaging reporting and data system(C-TIRADS); contrast-enhanced ultrasound (CEUS); differentiation; thyroid nodules; ultrasound (US). PLoS ONE. Most nodules and swellings are not cancerous. Recently, the American College of Radiology (ACR) proposed a Thyroid Imaging Reporting and Data System (TI-RADS) for thyroid nodules based on ultrasonographic features. This equates to 2-3 cancers if one assumes a thyroid cancer prevalence of 5% in the real world. If the nodule got a score of 2 in the CEUS schedule, the CEUS-TIRADS category remained the same as before. Jin Z, Zhu Y, Lei Y, Yu X, Jiang N, Gao Y, Cao J. Med Sci Monit. Ultrasound classification of thyroid nodules: does size matter? Treatment of patients with the left lobe of the thyroid gland, tirads 3 Refer to separate articles for the latest systems supported by various professional societies: A TI-RADS was first proposed by Horvath et al. Thyroid Cancer: Diagnosis, Treatment and Follow-Up | IntechOpen By CEUS-TIRADS diagnostic model combining CEUS with C-TIRADS, a total of 127 cases were determined as malignancy (111 were malignant and 16 were benign) and 101 were diagnosed as benign ones (5 were malignant and 96 were benign). A total of 228 thyroid nodules (C-TIRADS 4) were estimated by CEUS. TI-RADS score - Ultrasound Assessment of Thyroid Nodules - GP Voice Very probably benign nodules are those that are both. Diagnostic approach to and treatment of thyroid nodules Any additional test has to perform exceptionally well to surpass this clinicians 95% negative predictive performance, without generating false positive results and consequential harm. A proposal for a thyroid imaging reporting and data system for ultrasound features of thyroid carcinoma. Ultrasound (US) risk-stratification systems for investigation of thyroid nodules may not be as useful as anticipated. However, most of the sensitivity benefit is due to the performance in the TR1 and TR2 categories, with sensitivity in just the TR3 and TR4 categories being only 46% to 62%, depending on whether the size cutoffs add value (data not shown). The ROC curves of C-TIRADS, CEUS, and CEUS-TIRADS of 228 nodules in the diagnostic model. In rare cases, they're cancerous. Other similar systems are in use internationally (eg, Korean-TIRADS [14] and EU-TIRADS [15]). Some cancers would not show suspicious changes thus US features would be falsely reassuring. For those that also have 1 or more TR3, TR4, or TR5 nodules on their scan, they cannot have thyroid cancer ruled out by TIRADS because the possibility that their non-TR1/TR2 nodules may be cancerous is still unresolved. It should also be on an intention-to-test basis and include the outcome for all those with indeterminate FNAs. [Clinical Application of the 2021 Korean Thyroid Imaging Reporting and Conclusions: If a guideline indicates that FNA is recommended, it can be difficult to oppose this based on other factors. ACR TIRADS performed poorly when applied across all 5 TR categories, with specificity lower than with random selection (63% vs 90%). Thyroid nodules are lumps that can develop on the thyroid gland. Before All of the C-TIRADS 4 nodules were re-graded by CEUS-TIRADS. Diagnosis and Management of Small Thyroid Nodules: A Comparative Study with Six Guidelines for Thyroid Nodules. doi: 10.1111/j.1754-9485.2009.02060.x Thyroid imaging reporting and data system (TI-RADS). TI-RADS 4b applies to the lesion with one or two of the above signs and no metastatic lymph node is present. eCollection 2022. -, Takano T. Overdiagnosis of Juvenile Thyroid Cancer: Time to Consider Self-Limiting Cancer. For full access to this pdf, sign in to an existing account, or purchase an annual subscription. Radiology. Depending on the constellation or number of suspicious ultrasound features, a fine-needle biopsy is . An official website of the United States government. There are even data showing a negative correlation between size and malignancy [23]. Those working in this field would gratefully welcome a diagnostic modality that can improve the current uncertainty. It is important to validate this classification in different centres. The consequences of these proportions are highly impactful when considering the real-world performance of ACR-TIRADS. Cheng H, Zhuo SS, Rong X, Qi TY, Sun HG, Xiao X, Zhang W, Cao HY, Zhu LH, Wang L. Int J Endocrinol. Thus, the absolute risk of missing important cancer goes from 5% (with no FNAs) to 2.5% using TIRADS and FNA of all TR5, so NNS=100/2.5=40. Ultrasonographic scoring systems such as the Thyroid Imaging Reporting and Data System (TIRADS) are helpful in differentiating between benign and malignant thyroid nodules by offering a risk stratification model. MeSH Endocrinol. In ACR TI-RADS, points in five feature categories are summed to determine a risk level from TR1 to TR5 . Taken as a capsule or in liquid form, radioactive iodine is absorbed by your thyroid gland. We refer to ACR-TIRADS where data or comments are specifically related to ACR TIRADS and use the term TIRADS either for brevity or when comments may be applicable to other TIRADS systems. The https:// ensures that you are connecting to the Yoon JH, Han K, Kim EK, Moon HJ, Kwak JY. Learn how t. Whilst the details of the design of the final validation study can be debated, the need for a well-designed validation study to determine the test characteristics in the real-world setting is a basic requirement of any new test. We found better sensitivity, PPV, and NPV with TIRADS compared with random selection (97% vs 1%, 13% vs 1%, and 99% vs 95%, respectively), whereas specificity and accuracy were worse with TIRADS compared with random selection (27% vs 90%, and 34% vs 85%, respectively (Table 2)[25]. The financial costs and surgical morbidity in this group must be taken into account when considering the cost/benefit repercussions of a test that includes US imaging for thyroid cancer. So, the number needed to scan (NNS) for each additional person correctly reassured is 100 (NNS=100). If one decides to FNA every TR5 nodule, from the original ACR TIRADS data set, 34% were found to be cancerous, but note that this data set likely has double the prevalence of thyroid cancer compared with the real-world population. doi: 10.1007/s12020-020-02441-y The nodules were scored, measured and assigned to one of five TI-RADS levels (TR): TR1 - benign, TR2 - not suspicious, TR3 - mildly suspicious, TR4 - moderately suspicious, TR5 - highly suspicious. It would be unfair to add these clinical factors to only the TIRADS arm or only to the clinical comparator arm, and they would cancel out if added to both arms, hence they were omitted. The actual number of inconclusive FNA results in the real-world validation set has not been established (because that study has not been done), but the typical rate is 30% (by this we mean nondiagnostic [ie, insufficient cells], or indeterminate [ie, atypia of undetermined significance (AUS)/follicular lesion of undetermined significance (FLUS)/follicular neoplasm/suspicious for follicular neoplasm [Bethesda I, III, IV]). Cao H, Fan Q, Zhuo S, Qi T, Sun H, Rong X, Xiao X, Zhang W, Zhu L, Wang L. J Ultrasound Med. Current thyroid cancer trends in the United States, Association between screening and the thyroid cancer epidemic in South Korea: evidence from a nationwide study, 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: the American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer, Thyroid ultrasound and the increase in diagnosis of low-risk thyroid cancer, Korean Society of Thyroid Radiology (KSThR) and Korean Society of Radiology, Ultrasonography diagnosis and imaging-based management of thyroid nodules: revised Korean Society of Thyroid Radiology Consensus Statement and Recommendations, European Thyroid Association Guidelines for Ultrasound Malignancy Risk Stratification of Thyroid Nodules in Adults: the EU-TIRADS, Multiinstitutional analysis of thyroid nodule risk stratification using the American College of Radiology Thyroid Imaging Reporting and Data System, The Bethesda System for reporting thyroid cytopathology: a meta-analysis, The role of repeat fine needle aspiration in managing indeterminate thyroid nodules, The indeterminate thyroid fine-needle aspiration: experience from an academic center using terminology similar to that proposed in the 2007 National Cancer Institute Thyroid Fine Needle Aspiration State of the Science Conference. Cavallo A, Johnson DN, White MG, et al. Thyroid Nodule Characterization: How to Assess the Malignancy Risk. A 38-year-old woman with a nodule in the right-lobe of her thyroid gland. Thyroid Nodules - Diagnosis, Treatment, & More - YouTube This site needs JavaScript to work properly. PPV was poor (20%), NPV was no better than random selection, and accuracy was worse than random selection (65% vs 85%). The common first step when you have a thyroid nodule is to go to your health care provider and get a referral. The process of establishing of CEUS-TIRADS model. A meta-analysis, This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs licence (, Mitoguardin2 is Associated with Hyperandrogenism and Regulates Steroidogenesis in Human Ovarian Granulosa Cells, Factors Associated with Diabetes Distress among Patients with Poorly Controlled Type 2 Diabetes, Serum adiponectin and leptin is not related to skeletal muscle morphology and function in young women, Association Between Metabolic Syndrome Inflammatory Biomarkers and COVID-19 Severity, Long-term outcome of body composition, ectopic lipid and insulin resistance changes with surgical treatment of acromegaly, Volume 7, Issue 4, April 2023 (In Progress), The Journal of Clinical Endocrinology & Metabolism, https://www.uptodate.com/contents/diagnostic-approach-to-and-treatment-of-thyroid-nodules, https://doi.org/10.6084/m9.figshare.11640168.v, http://creativecommons.org/licenses/by-nc-nd/4.0/, Receive exclusive offers and updates from Oxford Academic, 1 in 10 nodules having FNA, assuming pretest probability of cancer of 5%, Negative test being TR1 or TR2; positive test meaning TR3, TR4, or TR5, Positive test meaning TR5; negative test meaning TR1-4, Positive test meaning TR5, TR4 above size cutoff and TR3 above size cutoff; negative test meaning TR1, TR2, TR3 Below Size Cutoff or TR4 below size cutoff, Positive Test Meaning TR5, TR4 Above Size Cutoff and TR3 Above Size Cutoff; negative test meaning TR1, TR2, TR3 below size threshold or TR4 below size cutoff. The TIRADS reporting algorithm is a significant advance with clearly defined objective sonographic features that are simple to apply in practice. TR5 in the data set made up 16% of nodules, in which one-half of the thyroid cancers (183/343) were found. Update of the Literature. The pathological result was papillary thyroid carcinoma. This study aimed to assess the performance and costs of the American College of Radiology (ACR) Thyroid Image Reporting And Data System (TIRADS), by first looking for any important issues in the methodology of its development, and then illustrating the performance of TIRADS for the initial decision for or against FNA, compared with an imagined Thus, the absolute risk of missing important cancer goes from 4.5% to 2.5%, so NNS=100/2=50. The challenge of appropriately balancing the risks of missing an important cancer versus the chance of causing harm and incurring significant costs from overinvestigation is major. -, Zhou J, Yin L, Wei X, Zhang S, Song Y, Luo B, et al. ; Korean Society of Thyroid Radiology (KSThR) and Korean Society of Radiology. The diagnostic performance of CEUS-TIRADS was significantly better than CEUS and C-TIRADS. Its not something that happens every day, but every day. Whereas using TIRADS as a rule-in cancer test would be the finding that a nodule is TR5, with a sufficiently high chance of cancer that further investigations are required, compared with being TR1-4. 2021 Oct 30;13(21):5469. doi: 10.3390/cancers13215469. However, there are ethical issues with this, as well as the problem of overdiagnosis of small clinically inconsequential thyroid cancer. With the right blood tests, you can see if you have a thyroid nodule, and if so, you can treat it with radioactive iodine. If one assumes that in the real world, 25% of the patients have a TR1 or TR2 nodule, applying TIRADS changes the pretest 5% probability of cancer to a posttest risk of 1%, so the absolute risk reduction is 4%. These patients are not further considered in the ACR TIRADS guidelines. The first time Tirads 3 after cytology is benign, but you do not say how many mm and after 3 months of re-examination, it was . The cost of seeing 100 patients and only doing FNA on TR5 is at least NZ$100,000 (compared with $60,000 for seeing all patients and randomly doing FNA on 1 in 10 patients), so being at least NZ$20,000 per cancer found if the prevalence of thyroid cancer in the population is 5% [25]. It is also relevant to note that the change in nodule appearance over time is poorly predictive of malignancy. Objectives: 2022 Jul;41(7):1753-1761. doi: 10.1002/jum.15858. Horvath E, Majlis S, Rossi R et-al. . Bessey LJ, Lai NB, Coorough NE, Chen H, Sippel RS. The financial cost depends on the health system involved, but as an example, in New Zealand where health care costs are modest by international standards in the developed world, compared with randomly selecting 1 in 10 nodules for FNA, using ACR TIRADS would result in approximately NZ$140,000 spent for every additional patient correctly reassured that he or she does not have thyroid cancer [25]. Advances in knowledge: The study suggests TIRADS and thyroid nodule size as sensitive predictors of malignancy. Eur. A recent meta-analysis comparing different risk stratification systems included 13,000 nodules, mainly from retrospective studies, had a prevalence of cancer of 29%, and even in that setting the test performance of TIRADS was disappointing (eg, sensitivity 74%, specificity 64%, PPV 43%, NPV 84%), and similar to our estimated values of TIRADS test performance [38]. sharing sensitive information, make sure youre on a federal Your email address will not be published. Clinical Application of C-TIRADS Category and Contrast-Enhanced Ultrasound in Differential Diagnosis of Solid Thyroid Nodules Measuring 1 cm. 2018;287(1):29-36. We are here imagining the consequence of 100 patients presenting to the thyroid clinic with either a symptomatic thyroid nodule (eg, a nodule apparent to the patient from being palpable or visible) or an incidentally found thyroid nodule. The test that really lets you see a nodule up close is a CT scan. Unauthorized use of these marks is strictly prohibited. A TR5 cutoff would have NNS of 50 per additional cancer found compared with random FNA of 1 in 10 nodules, and probably a higher NNS if one believes that clinical factors can increase FNA hit rate above the random FNA hit rate. Perhaps the most relevant positive study is from Korea, which found in a TR4 group the cancer rate was no different between nodules measuring between 1-2 cm (22.3%) and those 2-3 cm (23.5%), but the rate did increase above 3 cm (40%) [24]. ectomy, Parotid gland surgery, Transoral laser microsurgery, Transoral robotic surgery, Oral surgery, Parotid gland tumor, Skin cancer, Tonsil cancer, Throat cancer, Salivary gland tumor, Salivary gland cancer, Thyroid nodule, Head and neck cancer, Laryngeal cancer, Tongue . They are found . Findings of a large, prospective multicenter study from Egypt, published in the August 2019 issue of the European Journal . Copyright 2022 Zhu, Chen, Zhou, Ma and Huang. 19 (11): 1257-64. to propose a simpler TI-RADS in 2011 2. Many of these papers share the same fundamental problem of not applying the test prospectively to the population upon which it is intended for use. TIRADS Management Guidelines in the Investigation of Thyroid Nodules The authors suggested, as with BI-RADS, that biopsy candidates were those nodules categorized as TI-RADS category 4 or 5, meaning demonstrating at least one suspicious sonographic feature. Symptoms and Causes Diagnosis and Tests Management and Treatment Prevention Outlook / Prognosis Living With Frequently Asked Questions Overview TI-RADS 1: normal thyroid gland TI-RADS 2: benign nodule TI-RADS 3: highly probable benign nodule TI-RADS 4a: low suspicion for malignancy TI-RADS 4b: high suspicion for malignancy TI-RADS 5: malignant nodule with more than two criteria of high suspicion Imaging features TI-RADS 2 category Constantly benign patterns include simple cyst Thyroid nodules are common, affecting around one-half of the population and become increasingly common with advancing age [1, 2]. Now you can go out and get yourself a thyroid nodule. Please enable it to take advantage of the complete set of features! The optimal investigation and management of the 84% of the population harboring the remaining 50% of cancer remains unresolved. Such guidelines do not detail the absolute risk of finding or missing a cancer, nor the often excellent outcome of the treatment of thyroid cancer, nor the potential for unnecessary operations. Zhonghua Yi Xue Za Zhi. and transmitted securely. To illustrate the effect of the size cutoffs we have given 2 examples, 1 where the size cutoffs are not discriminatory and the cancer rate is the same above and below the size cutoff, and the second example where the cancer risk of the nodule doubles once the size goes above the cutoff. TI-RADS 1: Normal thyroid gland. The problem is that many people dont know that they have a thyroid nodule, so they dont know how to treat it. 2020 Chinese Guidelines for Ultrasound Malignancy Risk Stratification of Thyroid Nodules: The. In CEUS analysis, it reflected as equal arrival time, iso-enhancement, homogeneity, and diffuse enhancement, receiving a score of 0 in the CEUS model. Anti-thyroid medications. The specificity of TIRADS is high (89%) but, perhaps surprisingly, is similar to randomly selecting of 1 in 10 nodules for FNA (90%). We have detailed the data set used for the development of ACR TIRADS [16] in Table 1, plus noted the likely cancer rates in the real world if one assumes that the data set cancer prevalence (10.3%) is double that in the population upon which the test is intended to be used (pretest probability of 5%). Results: Among the 228 C-TIRADS 4 nodules, 69 were determined as C-TIRADS 4a, 114 were C-TIRADS 4b, and 45 were C-TIRADS 4c. Risk Stratification of Thyroid Nodules Using the Thyroid Imaging Given that ACR TIRADS test performance is at its worst in the TR3 and TR4 groups, then the cost-effectiveness of TIRADS will also be at its worst in these groups, in particular because of the false-positive TIRADS results. Lin JD, Chao TC, Huang BY, Chen ST, Chang HY, Hsueh C. Bongiovanni M, Crippa S, Baloch Z, et al. Using ACR-TIRADS as a rule-in test to identify a higher risk group that should have FNA is arguably a more effective application. We assessed a hypothetical clinical comparator where 1 in 10 nodules are randomly selected for fine needle aspiration (FNA), assuming a pretest probability of clinically important thyroid cancer of 5%. This causes the nodules to shrink and signs and symptoms of hyperthyroidism to subside, usually within two to three months. We first estimate the performance of ACR TIRADS guidelines recommended approach to the initial decision to perform FNA, by using TR1 or TR2 as a rule-out test, or using TR5 as a rule-in test because applying TIRADS at the extremes of pretest cancer risk (TR1 and TR2 for lowest risk, and TR5 for highest risk), is most likely to perform best. They're common, almost always noncancerous (benign) and usually don't cause symptoms. So, for 100 scans, if FNA is done on all TR5 nodules, this will find one-half of the cancers and so will miss one-half of the cancers. Quite where the cutoff should be is debatable, but any cutoff below TR5 will have diminishing returns and increasing harms. Dr. Ron Karni, Chief of the Division of Head and Neck Surgical Oncology at McGovern Medical School at UTHealth Houston discusses Thyroid Nodules. EU-TIRADS 1 category refers to a US examination where no thyroid nodule is found; there is no need for FNAB. Thyroid nodules - Symptoms and causes - Mayo Clinic . Frontiers | Differentiation of Thyroid Nodules (C-TIRADS 4) by Unable to process the form. Therefore, for every 25 patients scanned (100/4=25) and found to be either TR1 or TR2, 1 additional person would be correctly reassured that they do not have thyroid cancer. Management of nodules with initially nondiagnostic results of thyroid fine-needle aspiration: can we avoid repeat biopsy? Sometimes a physician may refer you to a specialist (doctor) at a clinic that specializes in thyroid cancer. In 2013, Russ et al. Attempts to compare the different TIRADS systems on data sets that are also not reflective of the intended test population are similarly flawed (eg, malignancy rates of 41% [29]). The current ACR TIRADS system changed from that assessed during training, with the addition of the taller-than-wide and size criteria, which further questions the assumption that the test should perform in the real world as it did on a the initial training data set. spiker54. This approach likely performs better than randomly selecting 1 in 10 nodules for FNA, but we intentionally made assumptions that would favor the performance of ACR TIRADS to illustrate that if a poor clinical comparator cannot clearly be beaten, then the clinical value that such new systems bring is correspondingly poor. At best, only a minority of the 3% of cancers would show on follow-up imaging features suspicious for thyroid cancer that correctly predict malignancy. Until a well-designed validation study is completed, the performance of TIRADS in the real world is unknown. Alternatively, if random FNAs are performed in 1 in 10 nodules, then 4.5 thyroid cancers (4-5 people per 100) will be missed. The process of validation of CEUS-TIRADS model. The system is sometimes referred to as TI-RADS Kwak 6. The gold test standard would need to be applied for comparison. The chance of finding a consequential thyroid cancer during follow-up is correspondingly low. The arrival time, enhancement degree, enhancement homogeneity, enhancement pattern, enhancement ring, and wash-out time were analyzed in CEUS for all of the nodules. 4. Metab. A study that looked at all nodules in consecutive patients (eg, perhaps FNA of every nodule>10 mm) would be required to get an accurate measure of the cancer prevalence in those nodules that might not typically get FNA. K-TIRADS category was assigned to the thyroid nodules. If one accepts that the pretest probability of a patient presenting with a thyroid nodule having an important thyroid cancer is 5%, then clinicians who tell every patient they see that they do not have important thyroid cancer will be correct 95% of the time. The high prevalence of thyroid nodules combined with the generally indolent growth of thyroid cancer present a challenge for optimal patient care. Accessibility Once the test is considered to be performing adequately, then it would be tested on a validation data set. eCollection 2020 Apr 1. Thyroid surgery, Microvascular reconstruction, Neck surgery, Reconstructive surgery, Facial reconstruction, Parathyroid. The summary of test performance of random selection, ACR TIRADS as a rule-out test, ACR TIRADS as a rule-in test, and ACR TIRADS applied across all TIRADS categories are detailed in Table 2, and the full data, definitions, and calculations are given elsewhere [25]. This is a specialist doctor who specializes in the treatment and diagnosis of thyroid cancer. As it turns out, its also very accurate and detailed. Using TR5 as a rule-in test was similar to random selection (specificity 89% vs 90%). TIRADS does not perform to this high standard. First, 10% of FNA or histology results were excluded because of nondiagnostic findings [16]. Im on a treatment plan with my oncologist, my doctor, and Im about to start my next round of treatments. Thyroid nodules could be classified into one of 10 ultrasound patterns, which had a corresponding TI-RADS category. TIRADS 5: probably malignant nodules (malignancy >80%). The Thyroid Imaging Reporting and Data System (TI-RADS) of the American College of Radiology (ACR) was designed in 2017 with the intent to decrease biopsies of benign nodules and improve overall . A normal finding in Finland. Data sets with a thyroid cancer prevalence higher than 5% are likely to either include a higher proportion of small clinically inconsequential thyroid cancers or be otherwise biased and not accurately reflect the true population prevalence.
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