Microvascular imaging in diffuse thyroid disease: diagnostic performance of subtraction ultra-micro angiography
6 affiliations
- 1Department of Doctoral Studies, Victor Babes University of Medicine and Pharmacy
- 2Center for Advanced Ultrasound Evaluation, Dr. D Medical Center
- 3Center for Molecular Research in Nephrology and Vascular Disease, “Victor Babes” University of Medicine and Pharmacy
- 4Discipline of Endocrinology, Second Department of Internal Medicine, University of Medicine and Pharmacy “Victor Babes”
- 51st Department of Surgery, Victor Babes University of Medicine and Pharmacy
- 6Second Clinic of General Surgery and Surgical Oncology, Emergency Clinical Municipal Hospital
Abstract
Background: Quantitative assessment of thyroid microvascularity may improve the ultrasound evaluation of diffuse autoimmune thyroid disease, particularly when conventional Doppler findings overlap. This prospective single-center study investigated whether subtraction Ultra-Micro Angiography (sUMA), quantified using the color pixel percentage (CPP) index, differentiates chronic autoimmune thyroiditis (CAT) from Graves’ disease (GD) and healthy thyroid parenchyma.
Methods: A total of 179 participants were included: 84 controls, 74 with newly diagnosed, untreated CAT, and 21 with newly diagnosed, untreated GD. All participants underwent standardized B-mode ultrasonography followed by sUMA using the same ultrasound platform and linear transducer. Three CPP sUMA measurements were obtained in each thyroid lobe, and the lobe medians were averaged to obtain the whole-gland CPP sUMA value. Interlobar and group differences, correlations, multivariable associations, apparent ROC performance, bootstrap cut-off distributions, and repeated stratified five-fold internal validation were analyzed.
Results: CPP sUMA values did not differ significantly between the right and left lobes. Mean CPP sUMA increased progressively from controls (23.25 ± 6.02%) to CAT (50.49 ± 13.58%) and GD (79.90 ± 8.86%). In CAT, CPP sUMA correlated positively with thyroid volume and TSH and inversely with FT4 and was significantly higher in overt than in subclinical disease. In GD, CPP sUMA correlated positively with FT3, FT4, and TSI. Differences between the diagnostic groups remained significant after adjustment for age, sex, BMI, and thyroid volume. Apparent ROC analysis showed high discrimination between CAT and controls (AUC 0.980; cut-off >31.55%; sensitivity 93.2%; specificity 90.5%) and between GD and CAT (AUC 0.966; cut-off >62.00%; sensitivity 100%; specificity 78.4%). GD and controls were completely separated in the analyzed cohort. During internal validation, mean accuracy was 88.5% for CAT versus controls, 82.0% for GD versus CAT, and 98.9% for GD versus controls.
Conclusion: CPP sUMA provided a quantitative tissue-level estimate of thyroid microvascularity and maintained high discriminatory performance during internal validation. However, the proposed cut-offs are hypothesis-generating and require confirmation in larger multicenter cohorts using different ultrasound platforms. Once externally validated, CPP sUMA may complement thyroid function testing, antibody assays, and conventional ultrasound in the assessment of autoimmune diffuse thyroid disease.
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BibTeX
@article{bunceanu2026microvascular,
title = {{Microvascular imaging in diffuse thyroid disease: diagnostic performance of subtraction ultra-micro angiography}},
author = {Stefania Bunceanu and Andreea Bena and Octavian Constantin Neagoe and Roxana Pui and Diana Raluca Streinu and Marco Marian and Dana Stoian},
journal = {Frontiers in Endocrinology},
year = {2026},
month = oct,
doi = {10.3389/fendo.2026.1892757},
url = {https://www.frontiersin.org/articles/10.3389/fendo.2026.1892757/full},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Microvascular imaging in diffuse thyroid disease: diagnostic performance of subtraction ultra-micro angiography
AU - Stefania Bunceanu
AU - Andreea Bena
AU - Octavian Constantin Neagoe
AU - Roxana Pui
AU - Diana Raluca Streinu
AU - Marco Marian
AU - Dana Stoian
PY - 2026
DA - 2026/10/27
JO - Frontiers in Endocrinology
DO - 10.3389/fendo.2026.1892757
UR - https://www.frontiersin.org/articles/10.3389/fendo.2026.1892757/full
AB - Background: Quantitative assessment of thyroid microvascularity may improve the ultrasound evaluation of diffuse autoimmune thyroid disease, particularly when conventional Doppler findings overlap. This prospective single-center study investigated whether subtraction Ultra-Micro Angiography (sUMA), quantified using the color pixel percentage (CPP) index, differentiates chronic autoimmune thyroiditis (CAT) from Graves’ disease (GD) and healthy thyroid parenchyma. Methods: A total of 179 participants were included: 84 controls, 74 with newly diagnosed, untreated CAT, and 21 with newly diagnosed, untreated GD. All participants underwent standardized B-mode ultrasonography followed by sUMA using the same ultrasound platform and linear transducer. Three CPP sUMA measurements were obtained in each thyroid lobe, and the lobe medians were averaged to obtain the whole-gland CPP sUMA value. Interlobar and group differences, correlations, multivariable associations, apparent ROC performance, bootstrap cut-off distributions, and repeated stratified five-fold internal validation were analyzed. Results: CPP sUMA values did not differ significantly between the right and left lobes. Mean CPP sUMA increased progressively from controls (23.25 ± 6.02%) to CAT (50.49 ± 13.58%) and GD (79.90 ± 8.86%). In CAT, CPP sUMA correlated positively with thyroid volume and TSH and inversely with FT4 and was significantly higher in overt than in subclinical disease. In GD, CPP sUMA correlated positively with FT3, FT4, and TSI. Differences between the diagnostic groups remained significant after adjustment for age, sex, BMI, and thyroid volume. Apparent ROC analysis showed high discrimination between CAT and controls (AUC 0.980; cut-off >31.55%; sensitivity 93.2%; specificity 90.5%) and between GD and CAT (AUC 0.966; cut-off >62.00%; sensitivity 100%; specificity 78.4%). GD and controls were completely separated in the analyzed cohort. During internal validation, mean accuracy was 88.5% for CAT versus controls, 82.0% for GD versus CAT, and 98.9% for GD versus controls. Conclusion: CPP sUMA provided a quantitative tissue-level estimate of thyroid microvascularity and maintained high discriminatory performance during internal validation. However, the proposed cut-offs are hypothesis-generating and require confirmation in larger multicenter cohorts using different ultrasound platforms. Once externally validated, CPP sUMA may complement thyroid function testing, antibody assays, and conventional ultrasound in the assessment of autoimmune diffuse thyroid disease.
SN - 1664-2392
ER -