Graves’ disease (GD) is the most common cause of thyrotoxicosis and the second most common autoimmune thyroid disorder. It is characterized by the presence of circulating thyroid-stimulating hormone receptor autoantibodies responsible for hyperthyroidism. Ultimately, GD causes elevated serum free-thyroxine (fT4) and/or free-triiodothyronine (fT3) levels, and suppressed thyroid-stimulating hormone (TSH) levels. It usually affects middle-aged women(1–3).
Ultrasonography and Doppler ultrasonography are widely utilized techniques in the diagnosis and follow-up of diffuse thyroid diseases. Color and power Doppler US are well-known techniques to demonstrate the vascularity of tissues. While Doppler US techniques are cost-effective and useful noninvasive methods to evaluate tissue vascularization, they are inferior in the evaluation of small microvessels with a slow blood flow(4). Also, artifacts related to motion (e.g. in pediatric patients, caused by breathing) can be an important limitation to using these techniques. Conventional Doppler US techniques utilize a wall filter to remove motion artifacts, resulting in a loss of low-velocity flow. On the other hand, the evaluation of tissue vascularization using these conventional Doppler US techniques remains a qualitative assessment(5–7).
Superb microvascular imaging (SMI) is applied as a novel technique to assess tissue vascularization, with two types being available: monochrome SMI (mSMI) and color superb microvascular imaging (cSMI). The cSMI mode shows simultaneously the traditional grayscale US with color-encoded Doppler signals. The mSMI mode raises the visibility of vascular structures by eliminating the background signals(8,9). Superb microvascular imaging technique can reduce motion artifacts and shows slow blood flow in microvessels(10,11). The vascularization index (VI) is a quantitative parameter that can be obtained with cSMI. It indicates the ratio of blood flow within the tissue (a ratio of colored pixels to all of the pixels within the region of interest), and correspond to a percentage(12,13).
Our primary aims were to investigate the VI values of the thyroid parenchyma with cSMI in patients with GD, and compare them with the VI values of healthy participants. Additionally, we performed a correlation analysis between the VI values and laboratory and grayscale US parameters.
The present study was prospectively conducted at our institution between July and December 2019 after the approval of the local Research Ethics Committee. Written informed consent was taken from all of the study participants.
All of the subjects were consecutive patients treated at an endocrinology outpatient clinic, including both followed-up patients with the diagnosis of GD and newly diagnosed with GD. GD diagnosis was based on elevated thyroid hormone and autoantibody levels, and clinical evidence of thyrotoxicosis. After determining that the thyroid hormone levels were within normal limits, volunteer individuals were also referred for cSMI examination from the endocrinology outpatient clinic, so that they could be included in the control group. The exclusion criteria of the study were Hashimoto’s thyroiditis, multinodular goiter, history of thyroid gland operation, or radioactive iodine treatment. All laboratory tests were done within one week before the cSMI examination. The normal reference ranges of the laboratory parameters were as follows: 2.3–4.4 pg/mL (fT3), 0.89–1.7 ng/dL (fT4), 0.56–5.5 mIU/L (TSH), 0–40 IU/mL (anti-thyroglobulin antibody; TgAbs), and 0–34 IU/mL (anti-thyroid peroxidase antibody; TPOAbs), 1.6–60 ng/mL Tg.
All the cSMI examinations in both groups were performed blindly by a radiologist with 14 years of experience in the US, and four years of experience in cSMI, using a 4–14 MHz linear probe (Toshiba Aplio 500, Canon Medical Systems Corporation, Tokyo, Japan). The longest three dimensions of each thyroid lobe were measured to calculate the volume. The total thyroid volume was calculated by summing up volumes of both thyroid lobes. Grayscale US images of the submandibular and thyroid glands were recorded to evaluate the echogenicity.
After the initial grayscale US evaluation, all subjects were examined with the cSMI technique using a pulse repetition frequency (PRF) set at 120–180 Hz. During the examination, the patients were asked to breathe normally. To measure the VI, the thyroid gland was examined in the cSMI mode for five seconds, after which the image was frozen. The VI measurements were performed on cSMI images with a free region of interest by manually drawing the margins of the whole thyroid gland. The highest three VI values were noted. Next, the average of the three measurements was calculated (Fig. 1). The VI measurements were performed by the same procedure separately for the right and left lobes on the longitudinal and transverse planes (Fig. 2).
The obtained images were transferred to our picture archiving communication system (PACS). The VI values of both lobes on the longitudinal plane were summed and divided into two to calculate a mean VI value for the longitudinal plane. Transverse plane mean VI values were calculated by the same procedure. In the next stage, the mean longitudinal and transverse plane VI values were summed and divided into two to calculate the VI of the whole gland.
The Kolmogorov-Smirnov test was used to determine the normal distribution of continuous variables. Categorical variables were expressed as raw numbers, and numeric variables were expressed as mean ± SD for normalized variables, and median (min–max) for non-normalized variables. Comparisons between the GD and control groups were performed using the Mann-Whitney U test for quantitative variables, and the Chi2 test for qualitative variables, as appropriate. The VI values according to the lobe and measurement plane were compared with the Wilcoxon test. The Spearman correlation analysis was performed for the laboratory values and the VI values. The receiver operating characteristic (ROC) curve analysis was used to determine the best cutoff value to discriminate patients with GD. A
The GD group included 37 patients (27 F, 10 M), and the control group consisted of 40 patients (29 F, 11 M). The two groups were age and sex-matched (
Variables | Graves disease subgroups | Graves disease ( |
Control group ( |
||
---|---|---|---|---|---|
New diagnosis ( |
Follow up ( |
||||
|
2 M / 9 F | 8 M / 18 F | 10 M / 27 F | 11 M / 29 F | |
|
37.7 ± 8.7 | 41.4 ± 10.9 | 40.3 ± 10.3 | 40.9 ± 11.5 | |
|
4.4 (3-12) | 4.2 (1.7-7.8) | 4.4 (1.7-12) | 3 (1.2-7.3) | |
|
|
12.4 (4.5-31.1) | 9 (4.4-32.6) | 10.3 (4.4-32.6) | 5.8 (2.5-23.4) |
|
11.1 (2.2-21.3) | 7.3 (3-46.5) | 8.5 (2.2–46.5) | 5.6 (2.8-17.8) | |
|
23 (6.7-50.8) | 16.2 (7.4-79.1) | 19.4 (6.7-79.1) | 11.5 (5.3-31.2) | |
|
|
0.01 (0.01-0.18) | 1.07 (0.01-4.67) | 0.12 (0.01–4.67) | 2.24 (0.56-4.14) |
|
2.2 (0.88-7.47) | 1.16 (0.89-3.04) | 1.23 (0.88-7.47) | 3.27 (2.67–4.1) | |
|
6.2 (2.76-28.1) | 3.37 (2.59-11.2) | 3.63 (2.59-28.1) | 1.28 (0.9-1.69) | |
|
|
91.3 (11.7-600) | 110 (10-600) | 108.4 (10-600) | - |
|
47 (21.6-591) | 89.2 (10.9-1478) | 78.6 (10.9-1478) | - |
While Graves disease and control groups were age and sex-matched groups, thyroid volumes and hormone levels were significantly different between both groups (
Whilst TSH, fT3, and fT4 levels were significantly different between new diagnosis and follow up groups (
The median of the thyroid volume values obtained in the GD group was significantly higher than those in the control group (
In the GD group, the VI values were significantly higher than in the control group (median values for total thyroid 12 vs 5.04, respectively;
Vascularization index of | Measurement plane/lobe | Graves disease subgroups | Graves disease ( |
Control group ( |
|
---|---|---|---|---|---|
New diagnosis ( |
Follow up ( |
||||
|
Transverse (T) | 15.2 (2.5-30) | 13 (2.9–41.2) | 13.2 (2.5-41.2) | 4.8 (0.7-10.1) |
Longitudinal (L) | 13 (1.35-29.2) | 11.6 (0.7-32.8) | 11.8 (0.7-32.8) | 5.8 (1.6-12) | |
(T+L)/2 | 13.3 (3.1-29.6) | 12.3 (3-35.05) | 12.4 (3-35.05) | 5.15 (1.75-9.65) | |
|
Transverse | 9.5 (4.6-25) | 12.1 (1.5-29.1) | 12.1 (1.5-29.1) | 4.8 (0.8-10) |
Longitudinal | 12.6 (4.9-31.3) | 9.9 (1.7-29.4) | 11.5 (1.7-31.3) | 5.4 (0.3-15.6) | |
(T+L)/2 | 11.4 (5.2-28.5) | 11.2 (1.6-29.2) | 11.4 (1.6-29.2) | 5 (0.5-12.8) | |
|
(R+L)/2 | 13.05 (4.6-27.5) | 13.1 (2.95-35.1) | 13.05 (2.95-35.1) | 4.8 (0.75-10) |
|
(R+L)/2 | 11.2 (4.5-30.2) | 12.2 (1.2-29.1) | 11.95 (1.2-30.2) | 5.05 (1.55-11.7) |
|
(R+L)/2 | 11.9 (4.7-28.9) | 12.1 (2.3-32.1) | 12 (2.3-32.1) | 5.04 (1.1-10.8) |
All the VI values were significantly different between the control group and Graves disease, new diagnosis, follow up groups (
All the VI values were similar between new diagnosis and follow up groups (
Comparison of VI values |
|
|
---|---|---|
Right transverse | Right longitudinal | 0.61 |
Left transverse | Left longitudinal | 0.96 |
Right transverse | Left transverse | 0.28 |
Right longitudinal | Left longitudinal | 0.25 |
Right average | Total thyroid | 0.14 |
Left average | Total thyroid | 0.13 |
Right average | Left average | 0.14 |
Transverse average | Longitudinal average | 0.67 |
Transverse average | Total thyroid | 0.6 |
Longitudinal average | Total thyroid | 0.67 |
Wilcoxon test
The Spearman correlation analysis between the total thyroid VI values and laboratory tests is listed in Tab. 4. While there was a negative correlation between the VI values and TSH, fT4 levels (
Correlation analysis between |
|
Spearman’s rho | |
---|---|---|---|
|
|
0.001* | -0.426 |
|
0.018* | -0.270 | |
|
0.001* | 0.67 | |
|
0.28 | 0.179 | |
|
0.36 | -0.155 | |
|
0.004* | 0.327 | |
|
0.001* | 0.466 |
The echogenicity of the thyroid gland was compared with the echogenicity of the submandibular gland in patients with GD, and classified as either hypoechoic, isoechoic or hyperechoic. The echogenicity of the thyroid gland was not correlated with the VI values in the GD group (Tab. 5).
Echogenicity of thyroid parenchyma | GD group ( |
VI values of total thyroid Median (min–max) |
---|---|---|
|
7 (18.9%) | 12.26 (5.7-32.1) |
|
20 (54.1%) | 10.75 (2.3-22.8) |
|
10 (27%) | 16.77 (4.5-28.9) |
ROC curves of the VI values were obtained to discriminate patients with GD (Fig. 4). The cutoff values of the VI suggestive of GD are shown in Tab. 6 with appropriate sensitivity, specificity, AUC, and 95% confidence interval values. A cutoff value of 6.3 for the total thyroid VI was distinguishing GD patients with 83.8% sensitivity and 70% specificity.
VI values | Cutoff value | Sensitivity, % | Specificity, % | AUC | 95% Confidence interval | |
---|---|---|---|---|---|---|
Lower bound | Upper bound | |||||
Transverse average | 6.3 | 83.8 | 82.5 | 0.872 | 0.786 | 0.958 |
Longitudinal average | 7.25 | 78.4 | 75 | 0.852 | 0.761 | 0.944 |
Total thyroid | 6.3 | 83.8 | 70 | 0.872 | 0.785 | 0.958 |
The cSMI technique can be a complementary tool in the diagnosis of GD, demonstrating the quantitative blood flow via the VI. A cutoff value of 6.3 for the total thyroid VI could discriminate GD patients with 83.8% sensitivity and 70% specificity. There was no significant difference between the VI values of different measurement planes (transverse vs longitudinal) and lobes (right vs left). According to these results, one can reliably reduce the duration of VI measurement by cSMI. Instead of obtaining a few measurements to calculate an average VI value for the whole thyroid gland, only one VI value obtained from the longitudinal or transverse plane of a single lobe may be utilized in the diagnosis of GD in the daily routine. Also, we showed that VIs were not significantly different between newly diagnosed patients and GD patients under follow-up. Furthermore, we reported the VI values of the thyroid gland in healthy subjects [median (min–max); 5.04 (1.1–10.8)].
Superb microvascular imaging technique can be utilized to evaluate the vascularity of various organs such as the testis, parotid gland, palatine tonsil, breast, liver, peripheral arteries, and lymph nodes beside the thyroid gland(5,8,9,14–19). Although SMI is largely studied to assess the vascularization of the previously mentioned organs, the VI is utilized in a minority of these studies. In the literature, there are five papers evaluating thyroid gland vascularity based on the VI by cSMI(12,13,20–22). Bayramoğlu
The VI measurements by cSMI were different in the mentioned studies. Bayramoğlu
Whilst no significant correlation was revealed between the VI and autoantibody levels in our study, Bayramoglu
The present study has some limitations. First of all, the study population is relatively small. The diagnosis of GD was based on laboratory parameters and clinical findings instead of tissue sampling. We did not compare SMI and conventional Doppler US techniques to evaluate the vascularization of the thyroid gland. Autoantibody levels were not measured in the asymptomatic group. However, the grayscale US evaluation of the thyroid parenchyma was normal in the participants with normal thyroid hormone levels. As a final limitation, the evaluation of the parenchymal echogenicity of the thyroid gland by comparison with the submandibular gland echogenicity could be influenced by diseases of the salivary gland.
As a conclusion, patients with GD had quantitatively higher VI values than the control group. Utilizing cSMI can be a promising non-invasive diagnostic tool with high sensitivity and specificity rates to identify patients with GD.