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Park, Song, Lee, Lee, Jeon, Ko, Kim, and Kang: Diagnostic Performance of Shear Wave Elastography as Add-on Test in Thyroid Nodules: a Systematic Review and Meta-Analysis
Original Article

Int J Thyroidol 2018;11(1):31-40.

Published online: 5 May 2018

DOI: https://doi.org/10.11106/ijt.2018.11.1.31

Diagnostic Performance of Shear Wave Elastography as Add-on Test in Thyroid Nodules: a Systematic Review and Meta-Analysis

Sun-young Park1, Ji Yang Song1, Min Jin Lee1, Kyung Min Lee1, Mi Hye Jeon1, Ryeo Jin Ko1, Seok-Hyun Kim1, Bong Joo Kang2

1Division of New Health Technology Assessment, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea

2Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea

Correspondence: Bong Joo Kang, MD, PhD, Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Korea Tel: 82-2-2258-6253, Fax: 82-2-599-6771, E-mail: lionmain@catholic.ac.kr

Correspondence: Seok-Hyun Kim, MD, PhD, Division of New Health Technology Assessment, National Evidence-based Healthcare Collaborating Agency, Namsan Square (Kukdong B/D) 7F, Toegye-ro, Jung-gu, Seoul 04554, Korea Tel: 82-2-2174-2850, Fax: 82-2-747-4916, E-mail: shkim@neca.re.kr

Received 24 November 201731 January 2018       Accepted 1 February 2018

Copyright © 2018, the Korean Thyroid Association

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creative-commons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

초록

Background and Objectives

The diagnostic performance of shear wave elastography (SWE) combined with ultrasound (US) in the differential diagnosis of thyroid nodules was evaluated.

Materials and Methods

459 articles were collected using KoreaMed, Ovid-MEDLINE, Ovid-EMBASE, and Cochrane Library. The searching words were ‘{(elastography and shear).mp. OR SWE.mp. OR acoustic radiation force impulse.mp. OR ARFI.mp. OR acuson.mp. OR aixplorer.mp.}’. Two authors independently performed article selection and evaluation of the quality of studies with Scottish Intercollegiate Guidelines Network tool.

Results

2582 specimens (thyroid nodules) from 11 studies selected were included in this review. Combined use of US and SWE was reported higher specificity in five literatures, lower specificity in five studies, and no changes in 1 study when compared to US. We performed metaanalysis using data from 10 studies. The pooled sensitivity and specificity of US and SWE group for the differential diagnosis of benign and malignant nodules were 0.91 (I2=83.4%), 0.73 (I2=95.9%). The pooled sensitivity and specificity of US alone group were 0.88 (I2=93.2%), 0.71 (I2=92.7%).

Conclusion

SWE is not effective in the differential diagnosis of thyroid nodules to minimize unnecessary biopsy of nodules. The included studies showed significant heterogeneity of results.

Keywords: Thyroid nodule, Shear wave elastography, Diagnostic performance, Effectiveness

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Fig. 1.
Literature search flow diagram. SWE: shear wave elastography, US: ultrasonography.
ijt-11-31f1.tif
Fig. 2.
Forest plot of sensitivities for SWE＋ US and US. CI: confidential interval, NA: not available, SWE: shear wave elastography, US: ultrasonography, VTI: virtual touch tissue imaging, VTQ: virtual touch tissue quantification
ijt-11-31f2.tif
Fig. 3.
Forest plot of specificities for SWE＋ US and US. CI: confidential interval, NA: not available, SWE: shear wave elastography, US: ultrasonography, VTI: virtual touch tissue imaging, VTQ: virtual touch tissue quantification
ijt-11-31f3.tif
Table 1.
Details of search strategy
No. Search term Searched article
KoreaMed      
Index test 1 Shear wave elastography 25
  2 Shear elastography 26
Related article     1
Ovid MEDLINE      
Patient 1 thyroid$.mp. 191,633
Index test 2 (elastography and shear).mp. 1,154
  3 SWE.mp. 610
  4 acoustic radiation force impulse.mp. 528
  5 ARFI.mp. 481
  6 acuson.mp 378
  7 aixplorer.mp. 26
  8 OR/ 2-7 2,304
Patient & index test 9 1 AND 8 123
Total     123
Ovid EMBASE      
Patient 1 thyroid$.mp. 164,317
Index test 2 (elastography and shear).mp. 2,405
  3 SWE.mp. 1,118
  4 acoustic radiation force impulse.mp. 1,322
  5 ARFI.mp. 1,075
  6 acuson.mp 3,452
  7 aixplorer.mp. 339
  8 OR/ 2-7 7,082
Patient & index test 9 1 AND 8 274
Total     274
Cochrane Library      
Index test 1 Shear wave elastography 61
Total     61

ARFI: acoustic radiation force impulse, SWE: shear wave elastography

Table 2.
Levels of evidence (SIGN criteria)16,17)
1＋＋ High quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias
1＋ Well conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias
1− Meta-analyses, systematic reviews, or RCTs with a high risk of bias
2＋＋ High quality systematic reviews of case control or cohort studies
  High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal
2＋ Well conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal
2− Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal
3 Non-analytic studies, e.g. case reports, case series
4 Expert opinion

RCT: randomized controlled trial, SIGN: Scottish Intercollegiate Guidelines Network

Table 3.
Main characteristics of selected studies
Authors Country Publication year No. of case Shear wave elastography Reference standard Comparator Level of evidence
Patients/masses Device Parameter Diagnosis criteria
Duan et al.19) China 2016 118/137 Aixplorer E mean 34.5 kPa FNA/surgical US 2−
          E max 53.2 kPa      
Wang et al.20) China 2016 185/215 Aixplorer E mean 26.3 kPa FNA US 2＋＋
          E max 65.0 kPa      
Liu et al.21) China 2015 271/331 Aixplorer E mean 39.3 kPa FNA/surgical US 2＋
          E max 43.8 kPa      
Park et al.22) Korea 2015 453/476 Aixplorer E mean 85.2 kPa FNA/surgical US 2＋
          E max 94.0 kPa      
Kim et al.23) Korea 2013 99/99 Aixplorer E mean 62.0 kPa FNA US 2＋
          E max 65.0 kPa      
Veyrieres et al.24 4) France 2012 148/297 Aixplorer NA 66.0 kPa Surgical US 2＋
Kwak and Kim25 ) Korea 2011 81/81 Aixplorer NA 33.3 kPa FNA US 2＋
Sebag et al.26) France 2010 93/126 Aixplorer NA 65.0 kPa FNA/surgical US 2＋
Xing et al.27) China 2016 86/90 ACUSON VTQ 2.57 m/s Surgical US 2＋
Zhang et al.28) China 2015 556/556 ACUSON VTQ 2.87 m/s FNA US 2＋＋
          VTI 4      
Zhang et al.29) China 2015 154/174 ACUSON VTQ 2.87 m/s Surgical US 2＋
          VTI 4      

FNA: fine-needle aspiration biopsy, NA: not mentioned, US: ultrasonography, VTI: virtual touch tissue imaging, VTQ: virtual touch tissue quantification

Table 4.
Diagnostic accuracy of ultrasonography and combining shear wave elastography with ultrasonography
Authors Year No. of nodules Ultrasonography Shear wave elastography and ultrasonography
Se Sp PPV NPV Accuracy Parameter Diagnosis criteria Se Sp PPV NPV Accuracy
Device: Aixplorer
Duan et al.19) 2016 137 0.89 0.90 0.82 0.93 0.90 E max 53.2 kPa 0.96∗ 0.95∗ 0.90∗ 0.98∗ 0.95
E mean 34.5 kPa
Wang et al.20) 2016 215 0.82 0.76 0.94 0.48 0.81 E max 65.0 kPa 0.88 0.58 0.91 0.50 0.82
E mean 26.3 kPa 0.94 0.50 0.90 0.63 0.86
Liu et al.21) 2015 331 0.76 0.83 0.66 0.89 0.81 E max 43.8 kPa 0.87∗ 0.74∗ 0.59∗ 0.93∗ 0.78∗
E mean 39.3 kPa
Park et al.22) 2015 476 1.00 0.43 0.87 0.96 0.88 E max 94.0 kPa 0.95 0.55 0.89 0.74 0.87
E mean 85.2 kPa 0.95 0.57 0.90 0.74 0.87
Kim et al.23) 2013 99 0.91 0.60 0.38 0.96 0.67 E max 65.0 kPa 0.52 0.73 0.34 0.81 0.69
E mean 62.0 kPa 0.52 0.80 0.41 0.86 0.74
Veyrieres et al.24) 2012 297 0.77 0.58 0.20 0.95 0.60 E max 66.0 kPa 0.97 0.55 0.23 0.99 0.60
Kwak and Kim25) 2011 81 0.83 0.76 0.58 0.92 0.78 NA 33.3 kPa∗ 0.96∗ 0.48∗ 0.48∗ 0.97∗ 0.62∗
Sebag et al.26) 2010 126 0.52 0.97 0.82 0.88 0.87 NA 65.0 kPa∗ 0.82∗ 0.97∗ 0.88∗ 0.95∗ 0.94∗
Device: ACUSON
Xing et al.27) 2016 90 0.78 0.78 0.70 0.84 0.78 VTQ 2.57 m/s 1.00 0.56 0.60 1.00 0.73
Zhang et al.28) 2015 556 0.91 0.71 0.62 0.94 0.78 VTQ 2.87 m/s 0.85 0.92 0.85 0.92 0.90
VTI 4 (1-6) 0.80 0.82 0.69 0.89 0.81
Zhang et al.29) 2015 174 0.97 0.76 0.54 0.99 0.80 VTI 4 (1-6) 0.92 0.85 0.64 0.97 0.87

NA: not mentioned, NPV:negative predictive value, PPV: positive predictive value, Se: sensitivity, VTI: virtual touch tissue imaging, VTQ: virtual touch tissue quantification, Sp: specificity

∗ No reported which parameter was used.

Table 5.
Pooled diagnostic accuracy of US and combining SWE with US
Pooled sensitivity Pooled specificity Pooled SROC
Aixplorer, E max (5 articles)      
US (n=1,418) 0.90 (95% CI 0.88-0.93) 0.65 (95% CI 0.62-0.69) 0.82 (±0.05)
  I2=95.8% I2=93.8%  
SWE＋ US (n=1,418) 0.91 (95% CI 0.89-0.93) 0.63 (95% CI 0.60-0.67) 0.78 (±0.05)
  I2=88.9% I2=84.4%  
Aixplorer, E mean (3 articles)      
US (n=790) 0.94 (95% CI 0.92-0.96) 0.55 (95% CI 0.49-0.62) 0.84 (±0.04)
  I2=96.9% I2=85.3%  
SWE＋ US (n=790) 0.93 (95% CI 0.91-0.95) 0.64 (95% CI 0.57-0.70) 0.79 (±0.04)
  I2=93.0% I2=85.9%  
Aixplorer, NA (2 articles)      
US (n=207) 0.66 (95% CI 0.51-0.79) 0.89 (95% CI 0.83-0.94) 0.50 (±0.00)
  I2=81.7% I2=94.0%  
SWE＋ US (n=207) 0.88 (95% CI 0.76-0.95) 0.79 (95% CI 0.72-0.85) 0.50 (±0.00)
  I2=61.4% I2=98.2%  
ACUSON, VTQ (2 articles)      
US (n=646) 0.89 (95% CI 0.84-0.93) 0.72 (95% CI 0.68-0.76) 0.50 (±0.00)
  I2=79.9% I2=0.0%  
SWE＋ US (n=646) 0.88 (95% CI 0.82-0.92) 0.88 (95% CI 0.84-0.91) 0.50 (±0.00)
  I2=90.5% I2=97.7%  
ACUSON, VTI (2 articles)      
US (n=730) 0.93 (95% CI 0.88-0.96) 0.73 (95% CI 0.68-0.76) 0.50 (±0.00)
  I2=51.7% I2=0.0%  
SWE＋ US (n=730) 0.82 (95% CI 0.76-0.87) 0.83 (95% CI 0.79-0.86) 0.50 (±0.00)
  I2=75.2% I2=0.0%  

CI: confidential interval, SROC: the summary receiver operating characteristic curve, SWE: shear wave elastography, US: ultrasonography, VTI: virtual touch tissue imaging, VTQ: virtual touch tissue quantification

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