Han H, Geng W, Zheng F, Huang JJ. Ultrasound-guided thyroid nodule biopsy in esophageal cancer patients with thyroid nodules for surgical decision-making clinical value. World J Gastrointest Surg 2026; 18(5): 118655 [DOI: 10.4240/wjgs.v18.i5.118655]
Corresponding Author of This Article
Juan-Juan Huang, Chief Physician, Department of Color Doppler Ultrasound, The Affiliated Suqian Hospital of Xuzhou Medical University, Longcheng Shijia Residential Area, Sucheng District, Suqian 223800, Jiangsu Province, China. hjjscibg@163.com
Research Domain of This Article
Oncology
Article-Type of This Article
research-article
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Han Han, Juan-Juan Huang, Department of Color Doppler Ultrasound, The Affiliated Suqian Hospital of Xuzhou Medical University, Suqian 223800, Jiangsu Province, China
Han Han, Juan-Juan Huang, Department of Color Doppler Ultrasound, Nanjing Drum Tower Hospital Group Suqian Hospital, Suqian 223800, Jiangsu Province, China
Wei Geng, Department of Ultrasonic Diagnosis, Qingdao Special Servicemen Recuperation Center of PLA Navy, Qingdao 266000, Shandong Province, China
Fang Zheng, Department of Imaging, Army Xiamen Special Service Sanatorium Center, Xiamen 361005, Fujian Province, China
Author contributions: Han H, Geng W contributed to research design, data collection, data analysis, and paper writing; Zheng F, Huang JJ was responsible for research design, funding application, data analysis, reviewing and editing, communication coordination, ethical review, copyright and licensing, and follow-up. All authors have read and approve the final manuscript. Han H and Geng W contributed equally to this work as co-first authors.
Supported by Jiangsu Provincial Young Scientific and Technological Talent Support Project, No. JSTJ-2024-665; and Science Foundation of Suqian City, China.
Institutional review board statement: The research was reviewed and approved by The Nanjing Drum Tower Hospital Group Suqian Hospital.
Informed consent statement: All research participants or their legal guardians provided written informed consent prior to study registration.
Conflict-of-interest statement: No conflict of interest is associated with this work.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Data sharing statement: No other data available.
Corresponding author: Juan-Juan Huang, Chief Physician, Department of Color Doppler Ultrasound, The Affiliated Suqian Hospital of Xuzhou Medical University, Longcheng Shijia Residential Area, Sucheng District, Suqian 223800, Jiangsu Province, China. hjjscibg@163.com
Received: January 9, 2026 Revised: January 26, 2026 Accepted: February 27, 2026 Published online: May 27, 2026 Processing time: 138 Days and 4.1 Hours
Abstract
BACKGROUND
Esophageal cancer is a highly malignant digestive tract tumor with severe consequences, and radical surgery remains its primary treatment modality. Precise preoperative assessment is crucial for identifying suitable candidates for surgery. Some esophageal cancer patients present with concomitant thyroid masses, whose nature directly determines treatment strategy selection. Current conventional imaging methods offer limited specificity for the differential diagnosis of thyroid masses. Ultrasound-guided fine-needle aspiration biopsy (US-FNAB), as a minimally invasive diagnostic technique, can provide cytological evidence; however, its decision-guidance value in this specific patient population remains unclear.
AIM
To investigate the clinical use of US-FNAB in the esophagectomy decision-making process for patients with thyroid lesions and esophageal cancer.
METHODS
This retrospective cohort study included 120 patients with thyroid nodules and esophageal cancer treated between May 2023 and May 2025. They were divided into surgical (n = 85) and non-surgical (n = 35) groups based on esophagectomy status. Clinical data, ultrasound features, fine-needle aspiration biopsy, and pathology results were compared. Binary logistic regression identified independent factors influencing surgical decisions.
RESULTS
No statistically significant differences were found between the two groups in baseline characteristics including age, sex, body mass index, and comorbidities (P > 0.05). However, the non-surgical group had a significantly higher proportion of stage IV esophageal cancer (51.43% vs surgical group, P < 0.05) and thyroid nodules with malignant ultrasound features (e.g., solid composition, hypoechoicity; P < 0.05). Suspected or confirmed thyroid malignancy was also more frequent in the non-surgical group (48.57% vs 7.06%, P < 0.05). Multivariate analysis identified US-FNAB results and esophageal cancer stage as factors influencing non-operative management. Using pathology as the gold standard, US-FNAB showed 90.00% sensitivity, 95.00% specificity, and 94.20% accuracy for diagnosing thyroid malignancy (P < 0.05).
CONCLUSION
US-FNAB guides treatment decisions in esophageal cancer patients with thyroid lesions, avoiding unnecessary surgery for metastases and adjusting plans for combination therapy.
Core Tip: In a study examining treatment decisions for patients with esophageal cancer and thyroid masses, we confirmed that after adjusting for multiple factors in esophageal cancer clinical staging, malignant results from thyroid nodule fine-needle aspiration biopsy remain an independent predictor influencing esophageal resection. This finding demonstrates that ultrasound-guided fine-needle aspiration biopsy can participate in the surgical decision-making pathway by clarifying the nature of thyroid lesions preoperatively. This study supports establishing a standardized pathway within a multidisciplinary diagnostic and treatment framework, encompassing “imaging screening-needle biopsy confirmation-integrated decision-making”, to enhance the precision of therapeutic strategies.
Citation: Han H, Geng W, Zheng F, Huang JJ. Ultrasound-guided thyroid nodule biopsy in esophageal cancer patients with thyroid nodules for surgical decision-making clinical value. World J Gastrointest Surg 2026; 18(5): 118655
Surgical resection is the primary treatment for esophageal cancer, a common malignant tumor of the digestive tract in China[1]. Preoperative imaging tests revealed thyroid space-occupying lesions in a few esophageal cancer patients during the clinical diagnosis and treatment procedure. Thyroid nodules can be classified as benign or malignant based on their pathological features. Benign nodules are mostly nodular goiter, Hashimoto’s thyroiditis, follicular adenoma and other diseases, while malignant nodules are mostly thyroid cancer[2,3]. At present, different treatment plans are adopted for different types of thyroid nodules in clinical practice. Therefore, it is necessary to clarify the nature of thyroid nodules as early as possible, so as to formulate a scientific treatment plan and avoid overtreatment. However, it is often difficult to make a clear diagnosis by relying solely on ultrasound imaging features, and its diagnostic specificity is relatively limited[4]. The recommended minimally invasive diagnostic method for determining the kind of thyroid nodules prior to surgery is ultrasound-guided fine-needle aspiration biopsy (US-FNAB). It has the characteristics of real-time, accuracy and safety, and can effectively obtain cytological or histological evidence points[5,6]. Currently, research on the application value of US-FNAB in the specific population of esophageal cancer with thyroid lesions is still relatively limited. Therefore, systematically exploring the role of US-FNAB in the diagnosis and treatment pathway of patients with esophageal cancer and thyroid lesions is of significant clinical importance in guiding the selection of esophageal cancer resection procedures, determination of surgical extent, and formulation of overall treatment plans. This study aims to explore the diagnostic efficacy of US-FNAB in patients with esophageal cancer and thyroid lesions and its impact on final treatment decisions through a retrospective analysis, in order to provide evidence-based medicine for standardizing the preoperative assessment process and achieving individualized precision surgery for this type of patient.
MATERIALS AND METHODS
Research subjects
Between May 2023 and May 2025, 120 patients with esophageal cancer complicated by thyroid lesions were admitted to our institution. Depending on whether they had an esophagectomy, patients were split into two groups: Those who had surgery (n = 85) and those who did not (n = 35). Inclusion criteria: (1) Pathologically confirmed primary esophageal cancer; (2) Preoperative neck ultrasound examination indicating the presence of a solid or cystic-solid thyroid lesion; (3) Preoperative US-FNAB; and (4) Full clinical and follow-up information. Exclusion criteria: (1) History of thyroid surgery; (2) severe coagulation disorders or inability to tolerate biopsy; (3) Severe cardiopulmonary insufficiency; and (4) Lost to follow-up or with incomplete data.
US-FNAB inspection
The position, size, and blood flow of the thyroid nodule are ascertained by scanning the patient's neck with a GELOGIQ E11 color ultrasound diagnostic device prior to the biopsy. Based on the scan results, a biopsy plan is formulated, and a suitable diameter needle is selected. The puncture site is marked on the neck. After marking the puncture point, a sterile glove is placed over the ultrasound probe, and the puncture site and surrounding area are disinfected. After disinfection, the area is draped. The needle is inserted along the predetermined puncture point to the location of the thyroid nodule, and then withdrawn and lifted 5-10 times. During the puncture, one physician is responsible for the puncture, and the ultrasound probe is used to explore around the puncture site to observe whether the needle direction and depth are appropriate. At the same time, the needle hub needs to be observed during the withdrawal and lifting. Once a small amount of red tissue fluid is observed on the needle hub, the withdrawal and lifting should be stopped, and the needle should be slowly withdrawn. After the needle is withdrawn, the aspirated sample is transferred to a pre-prepared glass slide and fixed by another physician before being sent to the pathology department for examination.
Judgment criteria
US-FNAB results are categorized as benign, malignant, suspected malignant, indeterminate, and undiagnostic or unsatisfactory. Bethesda classification of thyroid tumors: Category I: Inadequate or non-diagnostic specimen; benign lesions go into category II; atypical lesions of unknown importance fall into category III; follicular tumors or suspected follicular tumors fall into category IV; suspected malignant tumors fall into category V; and malignant tumors fall into category VI.
Observation indicators
(1) Clinical data: Gender, age, body mass index (BMI), history of diabetes, history of hypertension, location of esophageal cancer tumor, clinical stage and pathological type. Clinical staging criteria for esophageal cancer: Stage I tumor is confined to the esophageal wall and its thickness does not exceed 5 mm; stage II tumor thickness exceeds 5 mm, does not invade surrounding tissues and has no distant metastasis; stage III tumor thickness exceeds 5 mm, invades adjacent tissues and mediastinal lymph nodes, but has not metastasized to distant sites; stage IV tumor thickness exceeds 5 mm, invades surrounding tissues and has distant metastasis; (2) Ultrasound characteristics of thyroid nodules: Nodule nature, echogenicity, calcification, boundary, size; (3) US-FNAB results; and (4) Pathological results.
Statistical analysis
Software called SPSS 21.0 was used to analyze the data. For group comparisons, independent samples t-tests were employed, and continuous data were represented as mean ± SD. Percentages (%) were utilized to express categorical data, and χ2 tests were employed to compare groups. Potential influencing factors in patients who did not have an esophagectomy were examined using univariate analysis. Binary logistic regression analysis also included variables with statistically significant differences. Statistical significance was defined as a P value of less than 0.05.
RESULTS
Comparison of clinical data between the two groups
The two groups were compared in terms of clinical data. Age, sex, BMI, history of diabetes, history of hypertension, location of esophageal cancer tumor, and pathological type did not change statistically significantly between the two groups (P > 0.05); the non-surgical group had 18 patients (51.43%) with clinical stage IV esophageal cancer, which was 2 patients (2.35%) higher than the surgical group (P < 0.05) (Table 1).
Table 1 Comparison of clinical data between the two groups, n (%).
Thyroid nodule ultrasonography features in the two groups are compared
As shown in Table 2, there was no statistically significant difference in calcifications between the two groups of thyroid nodules (P > 0.05); However, the proportions of solid nodules, hypoechoic nodules, nodules with indistinct borders, and nodules with a length-to-width ratio ≥ 1 were all higher in the non-surgical group than in the surgical group (P < 0.05).
Table 2 Thyroid nodule ultrasonography features in the two groups are compared, n (%).
In the non-surgical group, 17 cases (48.57%) were suspected malignant or malignant, which was higher than 6 cases (7.06 %) in the surgical group. Among them, 12 cases (34.29%) were diagnosed as malignant, which was significantly higher than 2 cases (2.35%) in the surgical group. Table 3 indicates that the difference was statistically significant (P < 0.05).
Table 3 Comparison of the two groups' ultrasound-guided fine-needle aspiration biopsy results, n (%).
Analysis of specific causes in the non-surgical group
In the non-surgical group, 42.86% (15/35) of patients gave up radical surgery because the US-FNAB confirmed that the thyroid gland was a metastatic lesion. In the remaining patients, advanced metastasis (28.57%) or physical condition (17.14%) were the main limiting factors (Table 4).
Table 4 Analysis of specific causes in the non-surgical group (n = 35), n (%).
Classification
Number of examples
Stage IV was determined due to clear distant metastases outside the thyroid gland (such as to the liver, lungs, and bones)
10 (28.57)
Metastatic cancer was diagnosed through thyroid biopsy
15 (42.86)
Due to severe comorbidities/cardiopulmonary inability to tolerate major surgery
6 (17.14)
Because the patient or their family subjectively refuses surgery
A multifactorial analysis of the variables influencing the choice to have an esophagectomy
“Whether or not esophagectomy was performed” was included as the dependent variable in a multivariate logistic regression analysis based on “clinical stage (IV = 1, I-III = 2)” and “US-FNAB outcome (Bethesda V-VI = 1, I-IV = 2)”. The results showed that clinical stage and US-FNAB outcome were influencing factors for patients not undergoing esophagectomy (Table 5).
Table 5 A multifactorial analysis of the variables influencing the choice to have an esophagectomy.
The value of US-FNAB in diagnosing thyroid malignancies
In identifying thyroid cancers, US-FNAB has a sensitivity of 90.00%, specificity of 95.00%, accuracy of 94.20%, positive predictive value of 78.26%, and negative predictive value of 97.94%, using pathological test results as the gold standard (Table 6).
Table 6 The diagnostic value of ultrasound-guided fine-needle aspiration biopsy for thyroid malignancies.
The esophagus mucosal epithelium is the source of esophageal cancer. The main pathological types are squamous cell carcinoma and adenocarcinoma[7]. Due to the rich lymphatic drainage network of the esophagus, the tumor is prone to lymph node metastasis, and often due to the insidious early symptoms, about half of the patients are already in the middle and late stages when diagnosed[8,9]. Treatment strategies depend on accurate clinical staging. In the early stage, endoscopic treatment or direct surgery can be performed. In the locally advanced stage, comprehensive treatment with surgery as the core is usually adopted. In the late stage, systemic drug treatment and palliative treatment are the main treatments[10]. The clinical manifestations of thyroid nodules mainly depend on their size and functional status[11,12]. Small nodules often have no obvious symptoms, but as the nodules enlarge and compress surrounding tissues, they can cause a series of local symptoms such as a foreign body sensation in the throat, difficulty breathing, and difficulty swallowing[13,14]. Clinically, they are primarily separated into benign and malignant nodules based on their pathological characteristics. Asymptomatic benign nodules usually only require regular follow-up observation, while nodules that have caused obvious symptoms or have malignant characteristics need to be considered for interventions such as surgical resection. Drug treatment can also be used as an adjunct[15,16]. Therefore, determining the type of thyroid nodules early and accurately is crucial for developing sensible treatment strategies and enhancing patient outcomes.
This study found that malignant US-FNAB results reshape decision-making through two mechanisms: If confirmed as metastatic thyroid carcinoma to the esophagus, it provides definitive evidence of distant metastasis, directly upgrading esophageal cancer staging to stage IV. This fundamentally precludes curative surgery, shifting the approach to systemic therapy and avoiding major trauma from ineffective surgery that offers no survival benefit. If diagnosed as primary thyroid carcinoma, it prompts the multidisciplinary team to shift focus toward integrating surgical strategies-choosing between simultaneous combined radical resection or staged surgery-to achieve optimal management of dual primary cancers[17,18]. For Bethesda Class III nodules, given that patients are about to undergo major esophageal cancer surgery, we typically recommend repeating US-FNAB after 3-6 months of ultrasound follow-up, or combining it with thyroid globulin testing in the aspirate to aid in assessment. If the repeat biopsy remains inconclusive or there is high clinical suspicion, molecular marker testing will be performed for risk re-stratification. For Bethesda Category IV nodules, due to their significantly elevated malignant risk and the inability to exclude malignancy in follicular tumors through cytology alone, our approach is more proactive. After thorough patient consultation, we generally recommend diagnostic thyroid lobectomy to obtain definitive paraffin-embedded histopathology, particularly when concurrent esophageal cancer surgery is planned. At present, clinical decision-making in such cases is challenging. Conventional preoperative assessment methods have limitations. Computed tomography and magnetic resonance imaging (MRI) have limited detection rates and feature display capabilities for thyroid micronodules with a diameter of less than 1 cm, and MRI is not suitable for bedside assessment of critically ill or emergency patients[19,20]. The recommended imaging assessment technique for thyroid nodules is ultrasound examination. Based on the sonographic characteristics of the nodules and the condition of the cervical lymph nodes, it can assist in determining whether the nodules are benign or cancerous. Risk stratification is guided by the commonly used ultrasonography thyroid imaging report and data system classification[21,22]. However, conventional ultrasound examination is mainly used for preliminary screening. Improving the diagnostic specificity of nodules with overlapping benign and malignant characteristics is necessary to prevent misdiagnosis or missed diagnosis[23]. In recent years, ultrasound elastography can quantitatively assess the hardness characteristics of nodules, while artificial intelligence technology can perform in-depth feature analysis on ultrasound images. Combining the two is anticipated to enhance the capacity to detect nodules that are challenging for traditional ultrasound to describe, optimizing puncture indications and provide a more trustworthy foundation for clinical decision-making. However, the relevant fusion technology is still in the exploratory stage, and its reliability and universality in clinical application still need more medical evidence to support it[24,25]. US-FNAB is currently a key technology for clarifying the nature of thyroid nodules before surgery. This method precisely directs the puncture needle into the target lesion under real-time ultrasound monitoring to retrieve cytological specimens for pathological examination. This can significantly increase the accuracy of diagnosis and serve as a crucial foundation for clinical decision-making[26,27]. US-FNAB provides a high sensitivity and specificity for the identification of malignant thyroid nodules, according to studies[28]. In line with the findings of this study, we discovered that US-FNAB has a sensitivity of 90.00%, a specificity of 95.00%, an accuracy of 94.20%, a positive predictive value of 78.26%, and a negative predictive value of 97.94% in the identification of malignant thyroid lesions. US-FNAB has the advantages of minimal trauma, fewer complications, and high sample satisfaction. It can not only reduce the false negative rate, but also preserve the cellular structure layer, which is of great significance for subsequent histological classification[29].
Multivariate analysis revealed that clinical staging of esophageal cancer and US-FNAB results are independent factors influencing whether patients with esophageal cancer and thyroid lesions ultimately undergo radical esophagectomy. The 35 non-surgical patients can be categorized into three groups based on the primary determinant for not undergoing radical surgery: (1) Advanced patients directly deemed inoperable due to confirmed non-thyroid distant metastases (e.g., liver, lung metastases), totaling 10 cases (28.57%). For this group, radical surgery is not an appropriate option regardless of the nature of the thyroid nodule. US-FNAB results primarily served as supplementary confirmation or adjunctive diagnosis in these cases; (2) Patients who declined surgery due to severe comorbidities or personal preference, totaling 10 cases (28.57%). Their decision-making showed relatively weak association with tumor staging or thyroid nodule characteristics; and (3) Patients diagnosed with malignancy via US-FNAB, where this result was the primary basis for altering treatment decisions, totaled 15 cases (42.86% of the non-surgical group, 12.50% of all patients). The primary esophageal cancer was predominantly clinically staged as stage II or III, with no distant metastases detected by conventional imaging. US-FNAB findings provided cytological evidence of metastatic thyroid carcinoma or high suspicion, prompting multidisciplinary teams to reclassify the disease as stage IV. This overturned the initially planned radical esophagectomy. In other words, within this study cohort, preoperative thyroid nodule evaluation and biopsy may have spared over 10% of patients scheduled for surgery from undergoing a highly invasive thoracotomy for esophageal cancer resection that would not have conferred survival benefit. Therefore, combining US-FNAB results with the clinical stage of esophageal cancer can greatly impact the final treatment plan in the preoperative evaluation of patients with thyroid lesions and esophageal cancer, preventing needless surgery or postponing essential comprehensive treatment. This study has some limitations: The sample size is small, particularly in terms of the number of thyroid cancer cases; it is a single-center retrospective study, which may be prone to selection bias. Future research could involve prospective, multi-center studies to establish more reliable clinical decision-making models and explore the application value of new technologies such as ultrasound elastography and artificial intelligence-assisted diagnostic systems in preoperative evaluation.
CONCLUSION
In conclusion, for patients scheduled for esophagectomy, preoperative neck ultrasound and US-FNAB for suspicious nodules should be considered important evaluation steps. For early-stage esophageal cancer combined with a benign thyroid nodule on US-FNAB, esophagectomy can be performed as scheduled, and the thyroid issue can be addressed later. However, an individualized comprehensive treatment sequence or plan must be created for patients with advanced esophageal cancer or early-stage esophageal cancer with a malignant thyroid nodule on US-FNAB. This plan may include non-surgical treatment strategies for both thyroid and esophageal cancers, staged surgery, or simultaneous surgery.
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