7:8 907–913F O Valen im e al. Thy oid ollicula lesions
diagnosis
RESEARCH
Follicula hy oid lesions: is he e a
disc imina o y po en ial in he compu e ized
nuclea analysis?
Flá iaO Valen im1, Bá ba aP Coelho1, HélioA Mio 2, Ca olineY Hayashi1, DaniloTA Jaune1,
C is ianoC Oli ei a3, Ma iângelaEA Ma ques3, JoséVicen e Taglia ini4, EmanuelC Cas ilho4,
Paula Soa es5,6,7 and GláuciaMFS Maze o1
1In e nal Medicine Depa men , Bo uca u Medical School, Sao Paulo S a e Uni e si y (Unesp), Bo uca u, São Paulo, B azil
2Depa men o De ma ology, Bo uca u Medical School, Sao Paulo S a e Uni e si y (Unesp), Bo uca u, São Paulo, B azil
3Pa hology Depa men , Bo uca u Medical School, Sao Paulo S a e Uni e si y (Unesp), Bo uca u, São Paulo, B azil
4O ola yngology and Head and Neck Su ge y Depa men , Bo uca u Medical School, Sao Paulo S a e Uni e si y (Unesp), Bo uca u, São Paulo, B azil
5i3S - Ins i u o de In es igação e Ino ação em Saúde, Uni e sidade do Po o, Po o, Po ugal
6Cance Signaling and Me abolism G oup, Ins i u e o Molecula Pa hology and Immunology o he Uni e si y o Po o (IPATIMUP), Po o, Po ugal
7Depa men o Pa hology, Medical Facul y, Uni e si y o Po o, Po o, Po ugal
Co espondence should be add essed o G M F S Maze o: [email p o ec ed]
Abs ac
Backg ound: Compu e ized image analysis seems o ep esen a p omising diagnos ic
possibili y o hy oid umo s. Ou aim was o e alua e he disc imina o y diagnos ic
e iciency o compu e ized image analysis o cell nuclei om his ological ma e ials o
ollicula umo s.
Me hods: We s udied pa a in-embedded ma e ials om 42 ollicula adenomas
(FA), 47 ollicula a ian s o papilla y ca cinomas (FVPC) and 20 ollicula ca cinomas
(FC) by he so wa e ImageJ. Based on he nuclea mo phome y and ch oma in ex u e,
he samples we e classi ied as FA, FC o FVPC using he Classi ica ion and Reg ession
T ees me hod.
Resul s: We obse ed high diagnos ic sensi i i y and speci ici y a es (FVPC: 89.4% and
100%; FC: 95.0% and 92.1%; FA: 90.5 and 95.5%, espec i ely). When he umo s we e
compa ed by pai s (FC s FA, FVPC s FA), 100% o he cases we e classi ied co ec ly.
Conclusion: The compu e ized image analysis o nuclea ea u es showed o be a use ul
diagnos ic suppo ool o he his ological di e en ia ion be ween ollicula adenomas,
ollicula a ian s o papilla y ca cinomas and ollicula ca cinomas.
In oduc ion
The di e en ial diagnosis o hy oid ollicula lesions
includes bo h benign umo s, such as ollicula adenoma
(FA) and malignan umo s, such as ollicula ca cinoma
(FC) and ollicula a ian o papilla y ca cinoma
(FVPC). This diagnosis can be di icul , especially
conside ing FA and FC, in which he dis inc ion depends
on de ec ing ascula and/o capsula in asion and
demands ho ough e alua ion o he his ological ma e ial
(1). Thus, bo h incomple e lesion excision, lacking a
sample o he in il a ed umo capsule po ion, and he
ex a ime equi ed o assess he en i e umo ex ension
hinde he di e en ial diagnosis be ween FA and FC (2)
and can make i un easible.
Changes in nuclea mo phome y and ch oma in
ex u e a e classically desc ibed by pa hologis s as
ac o s ha di e en ia e no mal issues om neoplasms.
-18-0237
Key Wo ds
adenoca cinoma
ollicula
ca cinoma
papilla y
cell nucleus
his ology
hy oid neoplasms
Endoc ine Connec ions
(2018) 7, 907–913
ID: 18-0237
78
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F O Valen im e al. Thy oid ollicula lesions
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Mo phological analysis o cell nuclei by his ology may
p o ide da a abou cellula physiology and con ibu e
o he es ablishmen o he diagnosis and p ognosis
o neoplas ic lesions (3). Compu e ized image analysis
is an objec i e and highly ep oducible ool in daily
p ac ice and has p o en o be a p omising esou ce o
assessing hy oid lesions. Mo e widely used o assessing
his ological ma e ial (1, 4, 5, 6, 7, 8, 9, 10), compu e ized
image analysis enables he de ec ion o e y sub le nuclea
changes (11), whose in es iga ion could also p o ide da a
o cy ological ma e ial analysis (11, 12, 13).
Howe e , speci ically o ollicula -pa e ned umo s,
nuclea pa ame e s ha can co ec ly di e en ia e
malignan om benign lesions ha e no ye been
es ablished. This could be pa ly due o he small numbe
o samples analyzed in p e ious s udies, o absence o
no maliza ion o he esul s by nuclea dimension and
o he assessmen o ew nuclea pa ame e s (1, 11, 13).
Hence, he objec i e o his s udy was o e alua e he
disc imina o y diagnos ic e iciency o compu e ized
image analysis o cell nuclei in his ological ma e ials
ob ained om FA, FC and FVPC.
Ma e ials and me hods
Design, pa ien s and his ological ma e ial p ocessing
This c oss-sec ional s udy used compu e ized image
analysis o compa e he nuclea mo phome y and
ch oma in ex u e ea u es o hy oid umo issues and
heal hy hy oid issue (Fig.1) and o assess i s diagnos ic
accu acy. When making models using machine lea ning
me hods, o e i ing should always be conside ed.
The e o e, he ideal in hose cases would be o e alua e a
la ge sample and o di ide i in o a aining g oup, which
de elops he e alua ion algo i hm, and a alida ion g oup,
which applies he de eloped algo i hm and measu es i s
pe o mance. This is a p elimina y s udy, in which he
aining was ca ied ou esul ing in he de elopmen o
he algo i hm o be alida ed la e .
S o ed his ological ma e ials o 103 pa ien s wi h
his opa hological diagnoses o FA, FC and FVPC
we e analyzed. The pa ien s had unde gone o al
hy oidec omy be ween 1993 and 2016 a he Clinics
Hospi al o Bo uca u School o Medicine. The s udy
popula ion was i s cha ac e ized by gende and age.
Nex , wo expe ienced pa hologis s (MEAM and CCO)
assessed he hy oid issue o con i m he diagnoses based
on his opa hological pa ame e s (14). A o al o 109
umo s om 103 pa ien s we e included: 42 FA, 47 FVPC
and 20 FC (six pa ien s p esen ed wo lesions: i e had
FA and FVPC and one had FA and FC). Tissue adjacen o
he benign umo s (FA) was used as ep esen ing no mal
hy oid issue (NT). Th ee mic on sec ions we e cu om
pa a in-embedded ep esen a i e issue samples and
s ained wi h hema oxylin-eosin (HE).
This s udy was app o ed by he Resea ch E hics
Commi ee o Bo uca u School o Medicine – Unesp –
unde p o ocol numbe 635,459, issued on May 05, 2014.
Image acquisi ion
The slides we e scanned and pho og aphed
(43× magni ica ion; PANORAMIC MIDI II – 3D His ech,
Japan; h p://3dhis ech.com/panno amic_midi) and
numbe ed andomly. Two o h ee pho os we e cap u ed
Figu e1
Thy oid issues analyzed: no mal hy oid (A),
ollicula adenoma (B), ollicula a ian o
papilla y ca cinoma (C), and ollicula ca cinoma
(D). Hema oxylin-eosin s aining, ×20.
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F O Valen im e al. Thy oid ollicula lesions
diagnosis
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om each slide. Thy oid neoplasms may be qui e
he e ogeneous and choosing a slide a ea o pho og aph
could esul in di e en nuclea ep esen a i eness.
The e o e, he pho og aphs we e cap u ed om he
mos ep esen a i e a eas p esen ing a highe numbe o
nuclei, and he bes pho o o each slide was chosen o
be analyzed, based on he judgmen o wo expe ienced
pa hologis s (MEAM and CCO).
Image analysis
The images we e analyzed by wo esea che s who did
no know he his opa hological diagnosis o he samples
(blind analysis). The diame e s o he umo s in each
slide we e measu ed in cen ime e s, and he nuclei we e
analyzed by he ee so wa e ImageJ (h p://imagej.ne /
Downloads). The so wa e u ns colo images in o black
and whi e images con aining 256 shades o g ay (16 bi s),
which allows be e analysis o ch oma in compac ion
and elimina es colo -based di e ences be ween he
samples (10). The nuclei in he edi ed pho og aphs
we e manually selec ed and analyzed indi idually.
Agglome a ed o o e lapping nuclei we e excluded. A
pilo s udy de e mined he minimum numbe o nuclei
ha should be analyzed in each pho og aph – any hing
abo e ha minimum would no a ec he esul s o he
s a is ical analysis. Six y nuclei pe pho og aph would be
su icien (da a no shown) based on a s anda d e o o
5% o each a iable. Thus, a o al o 9060 nuclei we e
assessed, including he NT samples.
Fo each selec ed nucleus, he p og am p o ides a
lis o mo phome ic and ex u e pa ame e s, allowing
he use o selec he pa ame e s o in e es o nuclea
assessmen (16). We also calcula ed seconda y indica o s
( a ia ion coe icien s) ela ed o hese pa ame e s. Hence,
mo phome ic assessmen included: a ea, pe ime e s,
ci cula i y, la ge diame e (Fe e ), a io be ween la ge
and smalle diame e (Aspec Ra io, AR), index a ea
pe Fe e , a io be ween pe ime e and a ea (P/A), a io
be ween a ea and Fe e (a ea/Fe e ) and index pe ime e /
a ea. The selec ed ex u e ea u es we e mean and median
g ay in ensi y (exp essed in a scale o 256 shades o g ay,
in which highe numbe s mean ligh e nuclei: 0 = black;
255 = whi e), s anda d de ia ion o g ay in ensi y (STDEV),
oughness (RA), egula i y o nuclea memb ane (Round),
solidi y, ac al dimension (F ac al), en opy and a io
be ween g ay in ensi y and a ea (g ay in ensi y/a ea).
The calcula ed seconda y indica o s we e coe icien o
a ia ion (CV) o a ea, CV-Mean in ensi y, CV-STDEV,
CV-Pe ime e , CV-Ci cula i y, CV-Fe e , CV-Median
in ensi y, CV-AR, CV-Round, CV-Solidi y, CV-F ac al,
CV-En opy, CV-Pe ime e /a ea and CV-RA. The so wa e
exp essed hese pa ame e s as pixels, which we e la e
ans o med in o mic ons.
Compa ison and classi ica ion o he umo s
The umo and he heal hy hy oid issues we e ini ially
compa ed o mo phome ic and ex u al aspec s o
ch oma in. La e , umo s wi h his ological diagnoses
o FA, FC and FVPC we e analyzed o hese nuclea
pa ame e s wi h he Classi ica ion and Reg ession T ees
(CRT) me hod, which p o ided a eclassi ica ion o hem.
The diagnosis p o ided by he CRT was hen compa ed o
he his ological diagnosis, hus e alua ing he me hod's
abili y o co ec ly classi y hese lesions. Since he majo
doub when acing a ollicula pa e n umo esides in
di e en ia ing benign om malignan lesions, he umo s
we e also analyzed by pai s (malign s benign: FC s FA,
FVPC s FA).
S a is ical analysis
The equencies o emales by umo diagnosis we e
compa ed by he chi-squa e es . The pa ien s’ ages, g ea e
umo diame e and nuclea pa ame e s we e exp essed as
medians and qua iles (p25–p75) and compa ed by he
K uskal–Wallis es . Based on he s udy nuclea ea u es, he
umo s we e eclassi ied by he CRT me hod and woing
algo i hm (impu i y measu e). This s a is ical me hod
cons uc s a ee model, wi h p edic i e cha ac e o he
da a, ha s a s om a oo and b anches ou , om nodes
ha use cu -o s o he pa ame e s analyzed, p o ided
by he model i sel (17). The sensi i i y, speci ici y and
a ea unde he ecei e ope a o cha ac e is ic (ROC)
cu e (AUC) we e calcula ed o each umo o de e mine
he alidi y o he classi ica ion me hod. The a ious
nuclea mo phome ic and ex u e pa ame e s we e also
co ela ed wi h g ea e umo diame e using Spea man’s
ho coe icien . The so wa e IBM SPSS/Windows ( e sion
22) pe o med all s a is ical analyses using a signi icance
le el o 5%.
Resul s
FC pa ien s we e olde (P = 0.04) han FVPC pa ien s
and hei umo s had la ge diame e s (P = 0.001) han
FVPC. The FA did no di e om he o he umo s in
hese pa ame e s. No signi ican di e ences we e p esen
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F O Valen im e al. Thy oid ollicula lesions
diagnosis
9107:8
conce ning he gende dis ibu ion acco ding o diagnosis
(P = 0.41) (Table 1). Tumo diame e was no associa ed
wi h he s udy mo phome ic and ex u e pa ame e s
(Supplemen a y Table 1, see sec ion on supplemen a y
da a gi en a he end o his a icle), excep o he
CV-STDEV pa ame e s, which we e weakly nega i ely
co ela ed ( = −0.24; P = 0.02). The e o e, he esul s we e
no co ec ed by umo diame e .
All he s udied p ima y nuclea pa ame e s di e ed
signi ican ly (P < 0.05) (Table 2 and Supplemen a y
Table 2) be ween he di e en lesions, bu no he
seconda y indica o s ( a ia ion coe icien s) CV-A ea
(P = 0.08), CV-STDEV (P = 0.24), CV-Fe e (P = 0.22), and
CV-AR (P = 0.05) (Supplemen a y Table2).
When he nuclea pa ame e s o he h ee umo s we e
analyzed by he CRT eg ession model (Fig.2) based on
he CV-RA pa ame e s, he esul ing global classi ica ion
ma ched he ac ual diagnoses in 90.8% o he cases, wi h
sensi i i ies o 95, 90.5 and 89.4% o FC, FA and FVPC,
espec i ely (Supplemen a y Table 3). The speci ici ies
and AUC we e 92.1–100% and 0.93–0.95, espec i ely
(Table3). When only FC and FA we e analyzed, co ec
global classi ica ion was achie ed o 100% o he umo s
(Fig.3 and Supplemen a y Table4). Likewise, when only
FVPC and FA we e analyzed, co ec global classi ica ion
was also achie ed o 100% o he cases (Supplemen a y
Fig.1 and Supplemen a y Table5).
Discussion
Nume ous s udies ha e a emp ed o de e mine an
e icien and accu a e diagnos ic me hod o ollicula -
pa e ned hy oid nodules (2). One o he echniques
ha has been used o his pu pose is compu e ized
image analysis o cell nuclei (4, 5, 7, 8, 12, 18, 19, 20, 21),
which has p o en p omising bu no en i ely conclusi e.
This p elimina y s udy uses compu e ized image
analysis o cell nuclei and a classi ica ion me hod,
which p o ed capable o co ec ly iden i ying high
pe cen ages o FA, FC and FVPC by image analysis
ob ained om he his ological ma e ials. Assessmen
o hese h ee ollicula -pa e ned umo s enabled us o
co ec ly globally classi y mo e han 90% o he cases.
Addi ionally, high sensi i i ies (be ween 89.4% and 95%),
Table 1 Gene al da a o 109 umo s in 103 pa ien s.
Pa ame e
Diagnosis o he umo s
P
FA FVPC FC
Pa ien s* (n) 36 47 20 –
Women (n (%)) 34 (94.4) 44 (93.6) 15 (75.0) 0.41
Age (yea s)†54 (44; 60)ab 52 (39; 59)ª 61 (46; 73)b0.04
La ge
diame e (cm)†
2.5 (1.2; 3.5)ab 1.5 (1; 3)a 3.5 (3; 4.2)b 0.001
*Only he wo s diagnosis was conside ed. †Median (25 h pe cen ile, 75 h
pe cen ile). S a is ical es : K uskal–Wallis. Di e en le e s mean
s a is ical di e ence (b > a; P < 0.05).
FA, ollicula adenoma; FC, ollicula ca cinoma; FVPC, ollicula a ian o
papilla y ca cinoma.
Table 2 Mo phome ic and ex u al p ima y pa ame e s, acco ding o he his ological ma e ial e alua ed.
Pa ame e
His opa hologic ma e ial*
P**
NT FA FVPC FC
A ea (µm2) 40 (34.77; 46.2) 44.91 (38.15; 55.2) 59.73 (46.91; 73.16) 64.35 (50.56; 69.54) 0.00
Mean g ay in ensi y†59.1 (53.05; 65.26) 55.35 (45.53; 68.06) 83.71 (66.31; 94.92) 78.04 (57.91; 85.31) 0.00
STDEV 41.15 (36.6; 45.1) 34.6 (29.31; 41.85) 44.28 (36.45; 51.54) 38.17 (33.34; 43.54) 0.00
Pe ime e (µm) 24.38 (23.15; 26.82) 26.59 (24.17; 29.69) 30.22 (27.62; 34.73) 32.55 (28.01; 35.13) 0.00
Ci cula i y 0.85 (0.8; 0.87) 0.83 (0.8; 0.86) 0.79 (0.7; 0.87) 0.78 (0.72; 0.84) 0.00
Fe e (µm) 8.74 (8.35; 9.85) 9.31 (8.73; 10.39) 10.66 (9.88; 12.15) 11.14 (9.47; 12.01) 0.00
Median g ay in ensi y†47 (39; 53.5) 43.25 (38; 58.5) 74.5 (57.5; 86.5) 71.25 (48; 81.25) 0.00
AR 1.38 (1.27; 1.46) 1.27 (1.24; 1.39) 1.32 (1.26; 1.41) 1.28 (1.23; 1.35) 0.02
Round 0.73 (0.68; 0.78) 0.78 (0.72; 0.81) 0.75 (0.7; 0.79) 0.78 (0.74; 0.81) 0.02
Solidi y 0.93 (0.92; 0.94) 0.93 (0.92; 0.94) 0.92 (0.89; 0.94) 0.92 (0.9; 0.93) 0.04
F ac al 2.36 (2.33; 2.38) 2.39 (2.36; 2.43) 2.46 (2.43; 2.48) 2.43 (2.34; 2.44) 0.00
En opy 5.27 (4.76; 5.73) 4.68 (2.27; 5.17) 4.65 (4.34; 5.04) 4.35 (4.06; 4.61) 0.00
Pe ime e /a ea (µm) 0.6 (0.58; 0.66) 0.58 (0.53; 0.63) 0.5 (0.47; 0.62) 0.52 (0.49; 0.56) 0.00
RA 130.9 (124.4; 142.2) 133.8 (121.6; 152.2) 105.0 (93.1; 123.4) 107.8 (98.7; 135.8) 0.00
A ea/ e e (µm) 4.52 (4.11; 4.79) 4.93 (4.36; 5.21) 5.62 (4.58; 6.01) 5.58 (5.22; 6.05) 0.00
G ay in ensi y/a ea (unidades/µm2) 0.13 (0.12; 0.16) 0.12 (0.1; 0.14) 0.12 (0.12; 0.15) 0.12 (0.1; 0.14) 0.02
*Median (pe cen ile 25; pe cen ile 75). **Signi ican di e ences (be ween he ou g oups): P < 0.05; s a is ical es : K uskal–Wallis. †Exp essed in a scale
o 256 shades o g ay, in which highe numbe s mean ligh e nuclei (0 = black; 255 = whi e).
AR, Aspec Ra io; FA, ollicula adenoma; FC, ollicula ca cinoma; FVPC, ollicula a ian o papilla y ca cinoma; µm: mic ome e ; NT, no mal hy oid;
RA, oughness; STDEV, s anda d de ia ion o g ay in ensi y.
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F O Valen im e al. Thy oid ollicula lesions
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9117:8
speci ici ies (be ween 92.1% and 100%) and AUC
(be ween 0.93 and 0.95) we e ob ained when he
assessmen me hod was used o classi ying umo ype.
Gi en he diagnos ic unce ain y be ween FC and FA (2),
we analyzed he alidi y o he classi ica ion me hod o
hese wo umo s and co ec ly diagnosed 100% o he
samples. Simila ly, when only FVPC and FA we e assessed,
100% o he samples we e classi ied co ec ly.
O he s udies ha used compu e ized nuclea image
analysis o assess hy oid umo s epo ed co ec global
classi ica ion a es o 62–100% (1, 5). The easons o
classi ica ion a e a iabili y may in ol e he sample size,
he numbe and ype o he nuclea pa ame e s e alua ed
and he in e e ence o o he ac o s, such as hose ela ed
o he umo s s udied. Indeed, small sample sizes and
assessmen o ew nuclea pa ame e s may a ec he esul s
(1). The p esen s udy assessed 109 umo s, a easonably
obus numbe , and 33 nuclea pa ame e s, including
mo phome ic and ex u e ea u es, and seconda y nuclea
indica o s, which enabled mo e accu a e analysis o each
nucleus, and consequen ly, o each umo . Appa en ly, he
a e o co ec umo diagnosis inc eases wi h he numbe
o s udied pa ame e s (7, 11).
Some nuclea pa ame e s included in he p esen
s udy ha e al eady been used by o he au ho s and p o ed
p omising o he inal cha ac e iza ion o he a ious
ollicula lesions (4, 5, 8, 19, 22). None heless, s udies
using seconda y indica o s (CV) we e no ound. In he
p esen s udy, seconda y indica o s con ibu ed o he high
pe cen ages o co ec classi ica ion in he CRT eg ession
model. O he p oblems ha could a ec he esul s a e he
inclusion o high umo sub ype di e si y and dis ega ding
he ac o umo size, ha is, no co ec ing nuclea
pa ame e s by size (1, 7, 11), which could limi he use ulness
o he me hod o lesions o ce ain diame e s (11, 13). The
p esen s udy assessed only ollicula -pa e ned umo s.
Al hough FCs had g ea e diame e s, umo dimension was
no associa ed wi h nuclea pa ame e s, sugges ing ha
umo size does no in luence nuclea a iables. Thus, ou
esul s sugges ha he me hod may be used in hy oid
umo s ega dless o hei dimensions.
Figu e2
Classi ica ion by he me hod Classi ica ion and Reg ession T ees (CRT), wi h algo i hm o woing, o he ollicula adenomas (FA), ollicula ca cinomas
(FC) and ollicula a ian o papilla y ca cinomas (FVPC), om he e alua ed nuclea pa ame e s. The numbe s and le e s o he low cha a e
explained in he able. AR, Aspec Ra io; CV, coe icien o a ia ion; DX, diagnosis; RA, oughness; PERIM, Pe ime e ; STDEV, s anda d de ia ion o g ay
in ensi y.
Table 3 Validi y o he use o compu ed nuclea
mo phome y analysis, wi h he Classi ica ion and Reg ession
T ees (CRT) analysis, as a classi ica o y me hod.
Tumo s
FA FVPC FC
Sensi i i y (%) 90.5 89.4 95.0
Speci ici y (%) 95.5 100.0 92.1
PPV (%) 92.7 100.0 73.1
NPV (%) 94.1 92.5 98.8
A ea unde he ROC cu e 0.93 0.95 0.94
FA, ollicula adenomas; FC, ollicula ca cinomas; FVPC, ollicula a ian
o papilla y ca cinoma; NPV, nega i e p edic i e alue; PPV, posi i e
p edic i e alue.
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F O Valen im e al. Thy oid ollicula lesions
diagnosis
9127:8
This s udy has some limi a ions. A i s limi a ion
would be he applicabili y o he echnique, which
is somewha ime demanding as i equi es nuclea
image analysis. Howe e , he ime equi ed o such
ask a ies be ween indi iduals and dec eases wi h
expe ience, un il i pla eaus a abou 30 min pe case
in ou expe ience. This s udy’s esul s could encou age
he de elopmen o au oma ed sys ems o op imize
slide selec ion ime and analysis. Ano he limi a ion
would be he size o ees and numbe o kno s esul ing
om CRT model analysis. La ge ees may no be
use ul and may be associa ed wi h o e i ing, he eby
p o iding no explana o y powe . Howe e , he ees
p esen ed he e could be conside ed only o mode a e
size. Mo eo e , as dis inguishing umo s h ough
pa hological cha ac e is ics is di icul , i is expec ed
ha he a iables o igina ed om hose cha ac e is ics
migh also be di icul o e alua e, which in ol es a
g ea e numbe o kno s. Ano he limi a ion ega ds he
sample size, which could s ill be conside ed no la ge
enough, al hough o he s udies ha e al eady ob ained
meaning ul esul s wi h e en smalle sample sizes (1).
In addi ion, he numbe o nuclei assessed was based
on a pilo s udy ha de e mined he minimum sample
size, and his pa ame e can be u he op imized. I is
impo an o emphasize ha his is a p elimina y s udy,
in which he e alua ion algo i hm was de eloped. The
nex s ep will consis o selec ing a much la ge sample
o alida e he obse ed esul s.
Despi e he limi a ions lis ed abo e, he high
sensi i i y and speci ici y o he me hod used by he
p esen s udy makes i an impo an ool o aiding
he his ological diagnosis o ollicula -pa e ned cases.
In addi ion, hese p elimina y esul s s imula e he
implemen a ion o u u e s udies wi h dis inc designs,
which could include mo e umo sub ypes, such as
he ecen ly p oposed NIFTP (nonin asi e ollicula
hy oid neoplasm wi h papilla y-like nuclea ea u es)
(23, 24); he explo a ion o clinical, labo a o ial,
and p ognos ic a iables (25); and he e alua ion o
nuclea mo phome ic and ch oma in ex u e
cha ac e is ics also o he ollicula lesions om
cy ological samples.
In conclusion, compu e ized image analysis o
nuclea ea u es showed o be a p omising diagnos ic
suppo ool o he his ological di e en ia ion be ween
FA, FC and FVPC, wi h high sensi i i y and speci ici y.
The e o e, his inexpensi e, ep oducible and ope a o -
independen me hod migh ep esen a aluable
diagnos ic suppo ool o he assessmen o ollicula -
pa e ned umo s and pa icula ly, o di e en ia ing
FA om FC. Howe e , due o he conside a ions and
limi a ions men ioned abo e, he p elimina y esul s
p esen ed in his s udy should ye be alida ed, and
hen con i med by independen g oups. Mo eo e , o he
s udies a e needed o assess he applicabili y o hese
indings in cy ological ma e ials wi h inde e mina e
diagnosis.
Figu e3
Classi ica ion by he me hod Classi ica ion and Reg ession T ees (CRT), wi h algo i hm o woing, o he ollicula adenomas (FA) and ollicula
ca cinomas (FC), om he e alua ed nuclea pa ame e s. The numbe s and le e s o he low cha a e explained in he able. AR, Aspec Ra io; CIRC,
ci cula i y; CV, coe icien o a ia ion; DX, diagnosis; PERIM, pe ime e .
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F O Valen im e al. Thy oid ollicula lesions
diagnosis
9137:8
Supplemen a y da a
This is linked o he online e sion o he pape a h ps://doi.o g/10.1530/
EC-18-0237.
Decla a ion o in e es
The au ho s decla e ha he e is no con lic o in e es ha could be
pe cei ed as p ejudicing he impa iali y o he esea ch epo ed.
Funding
This s udy ecei ed inancial suppo om Fundação de Ampa o à Pesquisa
do Es ado de São Paulo (FAPESP; p ocess numbe 2014/10028-2), and
PIBIC/PROPE-Unesp (p ocess numbe 33347).
Acknowledgmen s
The au ho s hank o Fundação de Ampa o à Pesquisa do Es ado de São
Paulo (FAPESP; p ocess numbe 2014/10028-2), and PIBIC/PROPE-Unesp
(p ocess numbe 33347) o he esea ch suppo and o Ma cos Robe o
F anchi and Luiz Fe nando F anchi o he help in p ocessing he
his ological ma e ial.
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Accep ed 3 July 2018
Accep ed P ep in published online 4 July 2018
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