851
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Moon HG, Jung EJ, Park ST, Ha WS, Choi SK, Hong SC, Lee YJ, Joo YT, Jeong CY, Choi DS, Ryoo JW. Role Of Ultrasonography in Predicting Malignancy in Patients with Thyroid Nodules. World J Surg 2007; 31:1410-6. [PMID: 17534557 DOI: 10.1007/s00268-007-9013-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The use of ultrasonography (USG) has become an essential part of endocrine surgical practice. We evaluated the value of USG in predicting malignancy of thyroid nodules. The accuracy of USG in 857 patients who underwent fine-needle aspiration (FNA) with or without surgery was analyzed in a prospective setting. The diagnostic accuracy of USG was compared to that of FNA and of combined models in 153 operated patients. The malignancy-predicting value of USG in follicular neoplasms and its relation to nodule size were also investigated. Sensitivity, specificity, and overall accuracy (OA) of USG were 84.9%, 95.5%, and 93.7%, respectively. In operated patients, USG had accuracy comparable to that of FNA and combined models (sensitivity 93.3%, specificity 90.6%, OA 92.0%) regardless of nodule size but showed a significant rate of indeterminate results (29.4%). For follicular neoplasms, the sensitivity, specificity, and OA of USG were 100%, 95.4%, and 96.1%, respectively, with indeterminate results for three malignant nodules (42.8%). This acceptable malignancy-predicting value of USG in thyroid nodules supports the potential role of USG for predicting malignancy in selected patients with thyroid nodules. However, the high rate of indeterminate results precludes it from being a standard independent diagnostic method for the present time.
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Affiliation(s)
- Hyeong-Gon Moon
- Department of Surgery, Postgraduate School of Medicine, Gyeongsang National University, Gyeongsang National University Hospital, Gyeongnam Regional Cancer Center, 90 Chilam-dong, Jinju, Gyeongsangnam-do 660-702, South Korea.
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852
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Bogsrud TV, Karantanis D, Nathan MA, Mullan BP, Wiseman GA, Collins DA, Kasperbauer JL, Strome SE, Reading CC, Hay ID, Lowe VJ. The value of quantifying 18F-FDG uptake in thyroid nodules found incidentally on whole-body PET–CT. Nucl Med Commun 2007; 28:373-81. [PMID: 17414887 DOI: 10.1097/mnm.0b013e3280964eae] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To determine if quantification of [18F]fluorodeoxyglucose (18F-FDG) uptake in a thyroid nodule found incidentally on whole-body 18F-FDG positron emission tomography-computed tomography (PET-CT) can be used to discriminate between malignant and benign aetiology. METHODS A retrospective review of all patients with focally high uptake in the thyroid as an incidental finding on 18F-FDG PET-CT from May 2003 through May 2006. The uptake in the nodules was quantified using the maximum standardized uptake value (SUVmax). The aetiology was determined by cytology and/or ultrasound, or on histopathology. RESULTS Incidental focally high uptake was found in 79/7347 patients (1.1%). In 31/48 patients with adequate follow-up, a benign aetiology was determined. Median SUVmax for the benign group was 5.6, range 2.5-53. Malignancy was confirmed in 15/48 patients. The malignancies were papillary thyroid carcinoma in 12, metastasis from squamous cell carcinoma in one, and lymphoma in two. Median SUVmax for the malignant lesions was 6.4, range 3.5-16. Cytology suspicious for follicular carcinoma was found in 2/48 patients. No statistical difference (P=0.12) was found among the SUVmax between the benign and malignant groups. CONCLUSION Focally high uptake of 18F-FDG in the thyroid as an incidental finding occurred in 1.1% of the patients. Malignancy was confirmed or was suspicious in 17/48 (35%) of the patients that had adequate follow-up. There was no significant difference in the SUVmax between benign and malignant nodules.
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Affiliation(s)
- Trond V Bogsrud
- Division of Nuclear Medicine, Department of Radiology, Mayo Clinic, Rochester, MN 55905, USA
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853
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Tae HJ, Lim DJ, Baek KH, Park WC, Lee YS, Choi JE, Lee JM, Kang MI, Cha BY, Son HY, Lee KW, Kang SK. Diagnostic value of ultrasonography to distinguish between benign and malignant lesions in the management of thyroid nodules. Thyroid 2007; 17:461-6. [PMID: 17542676 DOI: 10.1089/thy.2006.0337] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE We analyzed the sonographic characteristics of thyroid nodules and assessed the diagnostic value of ultrasonography in order to distinguish between benign and malignant lesions in terms of the management of thyroid nodules. DESIGN We retrospectively analyzed the sonographic features of thyroid nodules in 580 patients who had been examined with fine-needle aspiration cytology or who underwent surgery for a thyroid nodule. The sonographic features that suggested malignancy include microcalcifications, an irregular or microlobulated margin, marked hypoechogenicity, and a shape that was taller than it was wide. The presence of one or more of these features indicated classification as category 3 (malignant). The absence of all of these features indicated classification as category 2 (benign). Presence of an anechogenic cystic nodule was classified as category 1 (benign). MAIN OUTCOME Of 124 lesions classified as category 3, 60 of the lesions were malignant. Of 418 lesions classified as category 1 or 2, 409 were benign. The sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy based on the sonographic classification method were 87.0%, 86.5%, 48.4%, 97.8%, and 86.5%, respectively. CONCLUSIONS Our results identified this sonographic classification as a useful tool in the differentiation of malignant nodules from benign nodules. In view of the high negative predictive value of sonographic classification, a more aggressive approach is recommended only for category 3 nodules.
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Affiliation(s)
- Hyun Jung Tae
- Department of Internal Medicine, The Catholic University of Korea, College of Medicine, Seoul, Korea
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854
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Abstract
Thyroid nodules are extremely common in the adult population of the United States, and the incidence of thyroid cancer continues to increase. Preoperative ultrasonography is a crucial component of the work up of thyroid nodules. Recent studies evaluating (18)F-2-fluoro-2-deoxy-D-glucose-positron-emission-tomography, with or without simultaneous computed tomography imaging, are encouraging for its potential utility in thyroid cancer in patients who have an elevated serum thyroglobulin level and a negative (131)I scan.
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Affiliation(s)
- Tracy S Wang
- Department of Surgery, Yale University School of Medicine, Yale-New Haven Hospital, 333 Cedar Street FMB 102, Box 208062, New Haven, CT 06520-8062, USA
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855
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Krause K, Karger S, Schierhorn A, Poncin S, Many MC, Fuhrer D. Proteomic profiling of cold thyroid nodules. Endocrinology 2007; 148:1754-63. [PMID: 17194741 DOI: 10.1210/en.2006-0752] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Cold thyroid nodules (CTNs) represent a frequent endocrine disorder accounting for up to 85% of thyroid nodules in a population living in an iodine-deficient area. Benign CTNs need to be distinguished from thyroid cancer, which is relatively rare. The molecular etiology of benign CTNs is unresolved. To obtain novel insights into their pathogenesis, protein expression profiling was performed in a series of 27 solitary CTNs (10 follicular adenoma and 20 adenomatous nodules) and surrounding normal thyroid tissues using two-dimensional gel electrophoresis combined with mass spectrometry analysis, Western blotting, and immunohistochemistry. The proteome analysis revealed a specific fingerprint of CTNs with up-regulation of three functional systems: 1) thyroid cell proliferation, 2) turnover of thyroglobulin, and 3) H2O2 detoxification. Western blot analysis and immunohistochemistry confirmed the proteome data and showed that CTNs exhibit significant up-regulation of proteins involved in thyroid hormone synthesis yet are deficient in T4-containing thyroglobulin. This is consequential to intranodular iodide deficiency, mainly due to cytoplasmic sodium iodide symporter localization, and portrays the CTN as an activated proliferating lesion with an intranodular hypothyroid milieu. Furthermore, we provide preliminary evidence that up-regulation of H2O2 generation in CTNs could override the antioxidative system resulting in oxidative stress, which is suggested by the finding of raised 8-oxo-guanidine DNA adduct formation in CTNs.
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Affiliation(s)
- Kerstin Krause
- Medical Department III, Universität Leipzig, Leipzig, Germany
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856
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Abstract
In this article the difficulties that face survivors of childhood cancer therapy are presented, and the late effects of such therapy, separated into nonmalignant and malignant late effects, are discussed according to organ system. Recommendations for monitoring the late effects are set forth. A table listing radiation-therapy site and chemotherapeutic agents and selected late effects that result from their use is provided. Finally, a brief recommendation regarding the establishment of a late-effects clinic is also presented.
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Affiliation(s)
- Joseph D Dickerman
- University of Vermont College of Medicine, Department of Pediatrics, 89 Beaumont Ave, Given D201, Burlington, VT 05405-0068, USA.
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857
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Hegedüs L. Can clinical and biochemical criteria augment fine-needle aspiration cytology in the diagnosis of thyroid cancer? NATURE CLINICAL PRACTICE. ENDOCRINOLOGY & METABOLISM 2007; 3:218-9. [PMID: 17245335 DOI: 10.1038/ncpendmet0416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2006] [Accepted: 11/09/2006] [Indexed: 05/13/2023]
Affiliation(s)
- Laszlo Hegedüs
- Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark.
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858
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Abstract
Solitary fibrous tumor (SFT) is a rare spindle-cell neoplasm more commonly involving the pleura, but recognized also in other tissues. Nineteen patients with SFT arising from the thyroid gland have been reported in the literature. The present report reviews these cases and discusses epidemiology, etio-pathogenesis, clinical-pathologic characteristics, differential diagnosis, therapy, and prognosis of thyroid SFT.
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Affiliation(s)
- Giampaolo Papi
- Department of Internal Medicine, Endocrinology Unit, University of Modena and Reggio Emilia, Modena, Italy
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859
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Abstract
Thyroid nodules are rare in children compared to adults. Although most thyroid nodules are benign, the risk of malignancy is greater in pediatric patients. Papillary and follicular cell tumors account for the majority of thyroid neoplasms; Hürthle cell tumors account for less than 5%. Despite being uncommon, malignant Hürthle cell tumors are potentially more aggressive than papillary and follicular cell tumors. Therefore, distinguishing between types of thyroid neoplasms in a timely fashion has implications for prognosis and therapy. We describe a 12-year-old peripubertal girl who presented with a large right-sided thyroid nodule that was subsequently diagnosed as a Hürthle cell adenoma. To our knowledge, she represents the youngest patient with a Hürthle cell neoplasm.
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Affiliation(s)
- Andrew A Bremer
- Department of Pediatrics, University of California, San Francisco, California, USA
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860
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Abstract
When not to perform fine needle aspiration of a thyroid nodule In summary, FNA of thyroid nodules has become one of the most useful, safe, and accurate tools in the diagnosis of thyroid pathology. Thyroid nodules that should be considered for FNA include any firm, palpable, solitary nodule or nodule associated with worrisome clinical features (rapid growth, attachment to adjacent tissues, new hoarseness, or palpable lymphadenopathy). FNA should also be performed on nodules with suspicious ultrasonographic features (microcalcifications, rounded shape, predominantly solid composition); dominant or atypical nodules in multinodular goiter; complex or recurrent cystic nodules; or any nodule associated with palpable or ultrasonographically abnormal cervical lymph nodes. Finally, FNA should be performed on any abnormal-appearing or palpable cervical lymph nodes. The management of thyroid nodules based on FNA findings is summarized in Table 2. It can be argued that in certain circumstances the results of thyroid FNA do not change the surgical management of a thyroid nodule, and thus preoperative FNA may be unnecessary. These cases include solitary nodules in patients who have a strong family history of thyroid cancer, multiple endocrine neoplasia type II, or radiation to the head and neck. These patients when they have thyroid nodules have at least a 40% risk for thyroid cancer and frequent multifocal or bilateral disease and should undergo total thyroidectomy with or without central neck lymph node dissection. Patients who have multinodular goiter and compressive symptoms, patients who have Graves disease and a thyroid nodule, or patients who have large (greater than 4 cm) or symptomatic unilateral thyroid nodules could also be considered for total thyroidectomy or lobectomy as indicated without preoperative FNA. Finally, patients who have a solitary hyperfunctioning nodule on radioiodine scan and a suppressed TSH have an extremely low incidence of malignancy and may be considered for therapeutic thyroid lobectomy or radioiodine ablation as indicated without undergoing FNA biopsy.
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Affiliation(s)
- Jennifer B Ogilvie
- Division of Surgical Oncology, Section of Endocrine Surgery, University of Pittsburgh Medical Center, 497 Scaife Hall, Pittsburgh, PA 15261-1497, USA
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861
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Tien HC, Tremblay LN, Rizoli SB, Gelberg J, Spencer F, Caldwell C, Brenneman FD. Radiation Exposure From Diagnostic Imaging in Severely Injured Trauma Patients. ACTA ACUST UNITED AC 2007; 62:151-6. [PMID: 17215747 DOI: 10.1097/ta.0b013e31802d9700] [Citation(s) in RCA: 112] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Trauma patients often require multiple imaging tests, including computed tomography (CT) scans. CT scanning, however, is associated with high-radiation doses. The purpose of this study was to measure the radiation doses trauma patients receive from diagnostic imaging. METHODS A prospective cohort study was conducted from June 1, 2004 to March 31, 2005 at a Level I trauma center in Toronto, Canada. All trauma patients who arrived directly from the scene of injury and who survived to discharge were included. Three dosimeters were placed on each patient (neck, chest, and groin) before radiologic examination. Dosimeters were removed before discharge. Surface doses in millisieverts (mSv) at the neck, chest, and groin were measured. Total effective dose, thyroid, breast, and red bone marrow organ doses were then calculated. RESULTS Trauma patients received a mean effective dose of 22.7 mSv. The standard "linear no threshold" (LNT) model used to extrapolate from effects observed at higher dose levels suggests that this would result in approximately 190 additional cancer deaths in a population of 100,000 individuals so exposed. In addition, the thyroid received a mean dose of 58.5 mSv. Therefore, 4.4 additional fatal thyroid cancers would be expected per 100,000 persons. In all, 22% of all patients had a thyroid dose of over 100 mSv (mean, 156.3 mSv), meaning 11.7 additional fatal thyroid cancers per 100,000 persons would result in this subgroup. CONCLUSION Trauma patients are exposed to significant radiation doses from diagnostic imaging, resulting in a small but measurable excess cancer risk. This small individual risk may become a greater public health issue as more CT examinations are performed. Unnecessary CT scans should be avoided.
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Affiliation(s)
- Homer C Tien
- Trauma Program and the Departments of Surgery Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
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862
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Abstract
Thyroid nodules are common, with an estimated incidence of 5%-10% in the United States. The current gold standard for diagnosis is fine needle aspiration biopsy (FNAB). The incidence of indeterminate diagnoses varies from 10% to 25%. Surgical resection is usually indicated to exclude the diagnosis of cancer in these patients. However, only a minority (about 20%) of indeterminate thyroid nodules actually harbor a malignancy, resulting in surgery for diagnostic purposes alone in many patients. The increased detection of benign nodules and microcarcinomas reinforces the need for improved non-operative methods to differentiate benign from malignant disease and discriminate low-risk from high-risk cancers. In this article we present a current, rational diagnostic approach to the patient with a thyroid nodule, evaluate new advances including thyroid genomic and predictor models, and propose the development of prospective trials to incorporate these new additions into clinical decision making. Given how many questions still exist for patients with thyroid nodules, partnership and collaboration, or the "bench to bedside" concept should find its way into most every thyroid surgeon and endocrinologist's lexicon.
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Affiliation(s)
- Jennifer E Rosen
- Department of Surgery, Section of Surgical Oncology, Boston University School of Medicine, 88 East Newton Street D605, Boston, MA 02118, USA.
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863
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Shetty SK, Maher MM, Hahn PF, Halpern EF, Aquino SL. Significance of incidental thyroid lesions detected on CT: correlation among CT, sonography, and pathology. AJR Am J Roentgenol 2006; 187:1349-56. [PMID: 17056928 DOI: 10.2214/ajr.05.0468] [Citation(s) in RCA: 134] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of our study was to determine the prevalence of malignancy in incidental abnormalities of the thyroid gland detected on CT and to determine the relative accuracy of characterizing these abnormalities on CT as compared with sonography and pathology. MATERIALS AND METHODS We searched our department's computerized clinical database for all thoracic and cervical CT scans in which a new abnormality was incidentally identified in the thyroid gland from 1998-2001. Two hundred thirty patients with abnormal findings in the gland on CT subsequently underwent thyroid sonography, and 118 of the 230 patients underwent a diagnostic biopsy or resection. CT and sonographic images were directly reviewed to identify imaging features of each thyroid abnormality, including the location, size, appearance, and presence or absence of calcifications. Associations were evaluated using Fisher's exact test of significance and the Student's t test. The overall rate of malignant and potentially malignant lesions among these incidental abnormalities of the thyroid gland was calculated. RESULTS CT findings matched the sonographic characterization in 122 patients (53.0%), correctly identified the dominant nodule but missed multinodularity in 69 (30.0%) patients, and underestimated the number of nodules in 24 (10.4%) patients. CT overestimated the number of nodules in 5 (2.2%) patients and was false-positive for lesions in 10 patients (4.3%). Ninety-one patients with a single or dominant nodule on CT had pathologic correlation: 7 nodules were malignant, 17 showed malignant potential, and 67 were benign. Of 27 patients with multinodular or enlarged thyroid glands on CT and histopathologic correlation, 2 lesions were malignant and 25 benign. The presence of punctate calcifications on CT significantly correlated to the presence of microcalcifications on sonography (p < 0.02). Benign nodules were significantly smaller (mean, 2.16 +/- 1.01 cm; range, 0.6-4.5 cm) than malignant and potentially malignant nodules (mean, 2.79 +/- 0.99 cm; range, 0.7-4.6 cm) (p = 0.01). Patients 35 years or younger who had a thyroid lesion on CT were more likely to have malignancy (p < 0.01). Overall, among incidentally detected lesions of the thyroid gland, there was at least a 3.9% rate of malignancy (95% CI: 1.8-7.3%) and 7.4% rate of malignant potential (95% CI: 4.4-11.6%). CONCLUSION There is at least an 11.3% prevalence of malignant or potentially malignant lesions among incidental thyroid abnormalities detected on CT. Patients 35 years or younger who have incidental abnormalities have a significantly greater rate of malignancy. No CT feature reliably distinguishes benign from malignant lesions in the thyroid gland. CT underestimates the number of nodules relative to sonography, which suggests that sonography is a useful adjunctive test after the incidental detection of a thyroid abnormality on CT.
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Affiliation(s)
- Sanjay K Shetty
- Department of Radiology, Massachusetts General Hospital, FND 214, 55 Fruit St., Boston, MA 02114, USA.
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864
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Borchhardt KA, Heinzl H, Gessl A, Hörl WH, Kaserer K, Sunder-Plassmann G. Calcitonin concentrations in patients with chronic kidney disease and medullary thyroid carcinoma or c-cell hyperplasia. Kidney Int 2006; 70:2014-20. [PMID: 17051143 DOI: 10.1038/sj.ki.5001888] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
It is currently not known which level of pentagastrin-stimulated calcitonin serum concentration indicates medullary thyroid carcinoma in patients with chronic kidney disease (CKD). We examined CKD stage 3-5 patients who had total thyroidectomy because of a pentagastrin-stimulated calcitonin concentration greater than 100 pg/ml, and tested the diagnostic performance of basal and pentagastrin-stimulated calcitonin levels for differentiating medullary thyroid carcinoma and C-cell hyperplasia in this patient population. A total of 180 CKD patients presented with an elevated calcitonin level and had a pentagastrin stimulation test. Forty patients showed a maximum pentagastrin-stimulated calcitonin concentration greater than 100 pg/ml, and 22 patients had a total thyroidectomy. Seven of these 22 patients presented with a medullary thyroid carcinoma, all other patients showed C-cell hyperplasia. Patients with medullary thyroid carcinoma showed higher unstimulated (212 pg/ml (36-577) vs 42 pg/ml (17-150); P < 0.001) and higher maximum pentagastrin-stimulated calcitonin concentrations (862 pg/ml (431-2423) vs 141 pg/ml (102-471); P < 0.001) as compared to patients with C-cell hyperplasia. The sensitivity (100%) and specificity (93%) estimates suggested that a maximum pentagastrin-stimulated calcitonin concentration greater than 400 pg/ml indicates the presence of medullary thyroid carcinoma in patients with CKD. Receiver-operating characteristic (ROC) analysis revealed an area under the ROC plot of 0.99 for maximum pentagastrin-stimulated calcitonin concentrations. A maximum pentagastrin-stimulated calcitonin concentration greater than 400 pg/ml appears to be a clinically meaningful threshold for thyroidectomy.
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Affiliation(s)
- K A Borchhardt
- Department of Medicine III, Division of Nephrology and Dialysis, Medical University Vienna, Vienna, Austria.
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865
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Frates MC, Benson CB, Charboneau JW, Cibas ES, Clark OH, Coleman BG, Cronan JJ, Doubilet PM, Evans DB, Goellner JR, Hay ID, Hertzberg BS, Intenzo CM, Jeffrey RB, Langer JE, Larsen PR, Mandel SJ, Middleton WD, Reading CC, Sherman SI, Tessler FN. Management of Thyroid Nodules Detected at US. Ultrasound Q 2006; 22:231-8; discussion 239-40. [PMID: 17146329 DOI: 10.1097/01.ruq.0000226877.19937.a1] [Citation(s) in RCA: 117] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The Society of Radiologists in Ultrasound convened a panel of specialists from a variety of medical disciplines to come to a consensus on the management of thyroid nodules identified with thyroid ultrasonography (US), with particular focus on which nodules should be subjected to US-guided fine needle aspiration and which thyroid nodules need not be subjected to fine-needle aspiration. The panel met in Washington, DC, October 26-27, 2004, and created this consensus statement. The recommendations in this consensus statement, which are based on analysis of the current literature and common practice strategies, are thought to represent a reasonable approach to thyroid nodular disease.
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Affiliation(s)
- Mary C Frates
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
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866
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Abstract
Clinically, solitary thyroid nodules are common, being present in up to 50% of the elderly population. The majority are benign with thyroid cancer representing an uncommon clinical problem. Investigation should include careful history and examination and thyroid function tests. Toxic or autonomous nodules are rarely malignant and require radionuclide scan for assessment. If euthyroid, then fine needle biopsy provides direct specific information about the cytology of the nodule from which the histology can be inferred. Thyroid 'incidentalomas' are a common management problem. Non-palpable nodules greater than 1.0 to 1.5 cm represent an absolute indication to perform an ultrasound-guided fine needle biopsy. An atypical fine needle biopsy mandates formal diagnostic excision. Because it is not possible to distinguish a follicular carcinoma from a follicular adenoma on cytological grounds alone, this category must simply be interpreted as indicating a follicular tumour and up to 20% will be malignant. Hemithyroidectomy via a 'collar' incision, with submission of the specimen to formal pathological examination, remains the standard of care, with completion total thyroidectomy for cancers other than low risk papillary cancer and 'minimally invasive' follicular cancer without vascular invasion. The issue of whether follicular adenomas can potentially develop into follicular carcinomas has yet to be satisfactorily resolved. The major challenge in the management of the solitary thyroid nodule remains the assessment as to which nodules require surgical excision and which can be followed conservatively.
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Affiliation(s)
- Leigh Delbridge
- University of Sydney, Endocrine Surgical Unit, Department of Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia.
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867
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Cai XJ, Valiyaparambath N, Nixon P, Waghorn A, Giles T, Helliwell T. Ultrasound-guided fine needle aspiration cytology in the diagnosis and management of thyroid nodules. Cytopathology 2006; 17:251-6. [PMID: 16961653 DOI: 10.1111/j.1365-2303.2006.00397.x] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To examine the accuracy of fine needle aspiration cytology (FNAC) in the diagnosis of thyroid nodules and compare the inadequacy rates for ultrasound-guided and freehand FNAC. METHODS A retrospective study of 434 patients with thyroid nodules who underwent diagnostic FNAC over a 2-year period. Cytological diagnoses have been compared with the histological assessment of resection specimens in 69 cases. RESULTS The inadequacy rate was significantly lower from ultrasound guided FNAC (24/373 cases, 6.4%) than from freehand FNAC (8/61 cases, 13.1%) (P = 0.043). Seventy-six percentage of patients had a non-neoplastic cytological diagnosis and, after multidisciplinary review, the patients were reassured and assigned to clinical follow-up. Sixty-seven patients had a resection for cytological appearances consistent with non-neoplastic disease (n = 34), suspicious of follicular neoplasia (n = 23), or suspicious of malignancy (n = 10), and two patients had resections following inadequate cytology with ultrasound appearances suspicious of a neoplasm. The overall accuracy of FNAC analysis for malignancy was 97.0%, with sensitivity 83.3%, specificity 98.0%, positive predictive value 71.4% and negative predictive value 98.4%. The overall accuracy of FNAC analysis for the prediction of neoplasia was 97.5%, with sensitivity 80.5%, specificity 97.8%, positive predictive value 89.2% and negative predictive value 95.9%. Difficulties in cytological diagnosis were associated with lymphoid infiltrates and with degenerative changes in follicular adenomas. CONCLUSION Ultrasound-guided FNAC has a significantly lower yield of inadequate aspirates than palpable FNAC. The ability of FNAC to predict neoplasia in 89% patients and to exclude neoplasia in 95.9% patients makes an important contribution to the multidisciplinary assessment of patients.
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Affiliation(s)
- X J Cai
- Department of Pathology, Radiology and Surgery, Royal Liverpool University Hospital, Liverpool, UK
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868
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Führer D. Molecular determination of benign and malignant thyroid tumors. Expert Rev Endocrinol Metab 2006; 1:763-773. [PMID: 30754153 DOI: 10.1586/17446651.1.6.763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Recent molecular studies have revolutionized our understanding of the pathogenesis of thyroid tumors and particular advances have been made in three areas. First, toxic thyroid nodules, which originate from constitutive activation of thyroid-stimulating hormone receptor/Gs α signaling and represent the dominant cause of thyrotoxicosis in regions with iodine deficiency. Second, papillary thyroid cancer, the most frequent thyroid malignancy, which is characterized by a common fingerprint of constitutive mitogen-activated protein kinase activation. Importantly, this is caused by distinct genetic alterations in radiation-induced (RET/PTC, NTRK and AKAP9/BRAF rearrangements) and sporadic tumors (BRAF and RAS point mutation) and, recently, there exciting in vitro have emerged explaining the structural basis for this. These findings suggest a scenario in which the fate of a thyroid tumor is determined by the specific genetic defect at the beginning. Third, application of microarray analysis in nodular pathologies in which the oncogenic pathway is less clear, notably follicular neoplasia, has led to the identification of a number of promising genetic markers (TFF-3, Gal-3, PLAB, CCND2 and PCKD2) for the diagnostic distinction of follicular adenoma and carcinoma. In addition to the diagnostic perspective, the identification of molecular fingerprints of thyroid tumors opens novel avenues for an improved therapeutic approach; for example, selective antagonism of cell signaling in treatment-refractory thyroid cancer.
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Affiliation(s)
- Dagmar Führer
- a University of Leipzig, III. Medical Department, Ph-Rosenthal-Str. 27, 04103 Leipzig, Germany.
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869
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Chung KW, Yang SK, Lee GK, Kim EY, Kwon S, Lee SH, Park DJ, Lee HS, Cho BY, Lee ES, Kim SW. Detection of BRAFV600E mutation on fine needle aspiration specimens of thyroid nodule refines cyto-pathology diagnosis, especially in BRAF600E mutation-prevalent area. Clin Endocrinol (Oxf) 2006; 65:660-6. [PMID: 17054470 DOI: 10.1111/j.1365-2265.2006.02646.x] [Citation(s) in RCA: 139] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Between 10 and 30% of the fine needle aspiration biopsies (FNABs) of thyroid nodules are diagnosed as 'indeterminate'. A molecular diagnostic method is needed to reduce unnecessary surgery in this group. In Korea, most thyroid cancer is the classic papillary type and the BRAF(V600E) mutation is highly prevalent. AIM To evaluate the role of pre-operative detection of BRAF(V600E) mutation in the FNAB specimens of thyroid nodules in a BRAF(V600E) mutation-prevalent geographical area. PATIENTS AND METHODS In 137 specimens of FNAB (107 papillary thyroid carcinomas (PTC); 3 follicular thyroid carcinomas (FTC); 2 undifferentiated thyroid carcinomas; 25 benign lesions), both direct DNA sequencing and PCR-RFLP were used for detecting the BRAF(V600E) mutation. The sensitivity and specificity were calculated. We analysed the association between BRAF(V600E) mutation and the clinico-pathological parameters. RESULTS The BRAF(V600E) mutation was present in 93 (83%) of 112 thyroid cancers. Direct DNA sequencing showed a sensitivity of 83.0% and a specificity of 96.0%. The sensitivity and specificity of PCR-RFLP were 78.6% and 80.0%, respectively. Among 25 cases with indeterminate FNAB cytology, 8 patients had malignant lesions (5 PTC and 3 FTC). Three (60%) of 5 PTCs and 1 out of 17 benign lesions had BRAF(V600E) mutation (only one false positive case and the definitive pathology showed atypical nodular hyperplasia that could be a premalignant lesion). The diagnostic accuracy of this molecular method in only the 25 indeterminate nodules was 76% (19/25). No mutation was found in 3 FTCs. Among 107 PTCs, there was no significant association of the BRAF(V600E) mutation with the known risk factors. CONCLUSION Detection of the BRAF(V600E) mutation in FNAB specimens refines the FNAB-cytology diagnosis, especially in a BRAF(V600E) mutation-prevalent area. Direct DNA sequencing was a more reliable method than PCR-RFLP for detecting the BRAF(V600E) mutation with a high sensitivity and specificity.
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MESH Headings
- Adenocarcinoma, Follicular/genetics
- Adult
- Aged
- Biopsy, Fine-Needle
- Carcinoma, Papillary/ethnology
- Carcinoma, Papillary/genetics
- Carcinoma, Papillary/pathology
- Carcinoma, Papillary, Follicular/genetics
- DNA Mutational Analysis
- DNA, Neoplasm/analysis
- Diagnosis, Differential
- Female
- Humans
- Korea
- Male
- Middle Aged
- Point Mutation
- Polymorphism, Restriction Fragment Length
- Prospective Studies
- Proto-Oncogene Proteins B-raf/genetics
- Sensitivity and Specificity
- Thyroid Neoplasms/ethnology
- Thyroid Neoplasms/genetics
- Thyroid Neoplasms/pathology
- Thyroid Nodule/ethnology
- Thyroid Nodule/genetics
- Thyroid Nodule/pathology
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Affiliation(s)
- Ki-wook Chung
- Research Institute and Hospital, National Cancer Centre, Goyang, Gyeonggi, Korea
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870
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Boelaert K, Horacek J, Holder RL, Watkinson JC, Sheppard MC, Franklyn JA. Serum thyrotropin concentration as a novel predictor of malignancy in thyroid nodules investigated by fine-needle aspiration. J Clin Endocrinol Metab 2006; 91:4295-301. [PMID: 16868053 DOI: 10.1210/jc.2006-0527] [Citation(s) in RCA: 291] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Thyroid nodules and goiter are common, and fine-needle aspiration biopsy (FNAB) is the first investigation of choice in distinguishing benign from malignant disease. OBJECTIVE The objective of the study was to assess whether simple clinical and biochemical parameters can predict the likelihood of thyroid malignancy in subjects undergoing FNAB. DESIGN The design was a prospective cohort. SETTING The study was conducted at a single secondary/tertiary care clinic. PARTICIPANTS One thousand five hundred consecutive patients without overt thyroid dysfunction (1304 females and 196 males, mean age 47.8 yr) presenting with palpable thyroid enlargement between 1984 and 2002 were evaluated by FNAB of the thyroid. INTERVENTION(S) There were no interventions. MAIN OUTCOME MEASURES Goiter type was assessed clinically and classified as diffuse in 183, multinodular in 456, or solitary nodule in 861 cases. Serum TSH concentration at presentation was measured in a sensitive assay in patients presenting after 1988 (n = 1183). The final cytological or histological diagnosis was determined after surgery (n = 553) or a minimum 2-yr clinical follow-up period (mean 9.5 yr, range 2-18 yr). RESULTS The overall sensitivity and specificity of FNAB in predicting malignancy were 88 and 84%, respectively. The risk of diagnosis of malignancy rose in parallel with the serum TSH at presentation, with significant increases evident in patients with serum TSH greater than 0.9 mU/liter, compared with those with lower TSH. Binary logistic regression analysis revealed significantly increased adjusted odds ratios (AORs) for the diagnosis of malignancy in subjects with serum TSH 1.0-1.7 mU/liter, compared with TSH less than 0.4 mU/liter [AOR 2.72, 95% confidence interval (CI) 1.02-7.27, P = 0.046], with further increases evident in those with TSH 1.8-5.5 mU/liter (AOR 3.88, 95% CI 1.48-10.19, P = 0.006, compared with TSH < 0.4 mU/liter) and greater than 5.5 mU/liter (AOR 11.18, 95% CI 3.23-8.63, P < 0.001, compared with TSH < 0.4 mU/liter). Males (AOR 1.8, 95% CI 1.04-3.1, P = 0.04), younger patients (AOR 1.1, 95% CI 1.01-1.15, P = 0.025), and those with clinically solitary nodules (AOR 2.53, 95% CI 1.5-4.28, P = 0.001) were also at increased risk. Based on these findings, a formula to predict the risk of the diagnosis of thyroid malignancy in individual patients, taking into account their gender, age, goiter type determined clinically, and serum TSH, was calculated. CONCLUSIONS The risk of malignancy in a thyroid nodule increases with serum TSH concentrations within the normal range. In addition to patient's gender, age, and goiter type, the serum TSH concentration at presentation is an independent predictor of the presence of thyroid malignancy. We propose that these simple clinical and biochemical factors can serve as an adjunct to FNAB in predicting risk of malignancy.
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Affiliation(s)
- K Boelaert
- Division of Medical Sciences, University of Birmingham, Queen Elizabeth Hospital, Edgbaston, Birmingham B15 2TH, United Kingdom.
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871
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Brunaud L, Ayav A, Chatelin J, Klein M, Bresler L, Boissel P. [Is radionuclide imaging still usefull for thyroid nodule management? A surgical point of view]. ANNALES DE CHIRURGIE 2006; 131:514-7. [PMID: 16930528 DOI: 10.1016/j.anchir.2006.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2006] [Accepted: 06/22/2006] [Indexed: 05/11/2023]
Abstract
Preoperative management of thyroid nodule is still controversial. Since 25 years ago, preoperative evaluation of thyroid nodule has been modified and improved. The aim of this study was to review, from a surgical point of view, the role of radionuclide imaging results in the management of patients with thyroid nodules.
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Affiliation(s)
- L Brunaud
- Service de chirurgie générale et endocrinienne, hôpital Brabois-Adultes, CHU de Nancy, 11, allée du Morvan, 54511 Vandoeuvre-lès-Nancy, France.
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872
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Abstract
BACKGROUND Thyroid nodules are common, yet treatment modalities range from observation to surgical resection. Because thyroid nodules are frequently found incidentally during routine physical examination or imaging performed for another reason, physicians from a diverse range of specialties encounter thyroid nodules. Clinical decision making depends on proper evaluation of the thyroid nodule. METHODS The current literature was reviewed and synthesized. RESULTS Current evidence allows the formulation of recommendations and a general algorithm for evaluating the incidental thyroid nodule. CONCLUSIONS Only a small percentage of thyroid nodules require surgical management. Diagnosis and treatment selection require a risk stratification by history, physical examination, and ancillary tests. Nodules causing airway compression or those at high risk for carcinoma should prompt evaluation for surgical treatment. In nodules larger than 1 cm, fine-needle aspiration biopsy is central to the evaluation as it is accurate, low risk, and cost effective. Subcentimeter nodules, often found incidentally on imaging obtained for another purpose, can usually be evaluated by ultrasonography. Other laboratory and imaging evaluations have specific and more limited roles. An algorithm for the evaluation of the thyroid nodule is presented.
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Affiliation(s)
- Christopher D Lansford
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan Health System, Ann Arbor, MI 48109, USA
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873
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Lubitz CC, Ugras SK, Kazam JJ, Zhu B, Scognamiglio T, Chen YT, Fahey TJ. Microarray analysis of thyroid nodule fine-needle aspirates accurately classifies benign and malignant lesions. J Mol Diagn 2006; 8:490-8; quiz 528. [PMID: 16931590 PMCID: PMC1867621 DOI: 10.2353/jmoldx.2006.060080] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Current preoperative diagnostic procedures for thyroid nodules rely mainly on the cytological interpretation of fine-needle aspirates (FNAs). DNA microarray analysis has been shown to reliably distinguish benign and malignant thyroid nodules in surgically resected specimens, but its diagnostic potential in thyroid FNA has not been examined. In the present study, the expression profiles of 50 benign thyroid lesions and papillary thyroid carcinoma tissue samples were compared, generating a list of 25 differentially expressed genes from this training set. A test set of 22 FNA specimens was evaluated by unsupervised hierarchical cluster analysis using this gene list, and the results were compared to FNA cytology. FNA specimens were found to fall into three clusters: malignant (n = 10), benign (n = 7), and indeterminate (n = 5). The benign and malignant groups showed complete concordance with the final histological diagnosis except for one histologically benign lesion, which was rediagnosed as follicular variant of papillary thyroid carcinoma on histological review. Paired analysis between FNA and matched tissues samples illustrated adequate sampling with FNA. These results illustrate that microarray analysis of FNA is feasible and has the potential to improve the accuracy of FNA in categorizing benign from malignant lesions beyond routine cytological evaluation.
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Affiliation(s)
- Carrie C Lubitz
- Department of Surgery, Weill Cornell Medical College, Room A-983, 510 East 70th St., New York, NY 10021, USA.
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874
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Premawardhana LDKE, Lazarus JH. Management of thyroid disorders. Postgrad Med J 2006; 82:552-8. [PMID: 16954449 PMCID: PMC2585732 DOI: 10.1136/pgmj.2006.047290] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2006] [Accepted: 04/10/2006] [Indexed: 02/03/2023]
Abstract
Autoimmune thyroid disease is the predominant form of thyroid dysfunction in the developed world. Although its precise cause is currently unclear, principles of management have been established. There is a vigorous debate about the management of the increasingly commonly recognised subclinical forms of thyroid dysfunction despite recent recommendations. Nodular thyroid disease and thyroid carcinoma have received wide attention. The effects of drugs and pregnancy on thyroid function have also been investigated widely. This short review attempts to give an overview and clarify the current management of common thyroid disorders.
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875
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Frates MC, Benson CB, Doubilet PM, Kunreuther E, Contreras M, Cibas ES, Orcutt J, Moore FD, Larsen PR, Marqusee E, Alexander EK. Prevalence and distribution of carcinoma in patients with solitary and multiple thyroid nodules on sonography. J Clin Endocrinol Metab 2006; 91:3411-7. [PMID: 16835280 DOI: 10.1210/jc.2006-0690] [Citation(s) in RCA: 412] [Impact Index Per Article: 22.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
CONTEXT Controversy remains as to the optimal management of patients with multiple thyroid nodules. OBJECTIVE The objective of this study was to determine the prevalence, distribution, and sonographic features of thyroid cancer in patients with solitary and multiple thyroid nodules. DESIGN We describe a retrospective observational cohort study that was carried out from 1995 to 2003. SETTING The study was conducted in a tertiary care hospital. PATIENTS Patients with one or more thyroid nodules larger than 10 mm in diameter who had ultrasound-guided fine needle aspiration (FNA) were included in the study. MAIN OUTCOME MEASURES The main outcome measures were prevalence and distribution of thyroid cancer and the predictive value of demographic and sonographic features. RESULTS A total of 1985 patients underwent FNA of 3483 nodules. The prevalence of thyroid cancer was similar between patients with a solitary nodule (175 of 1181 patients, 14.8%) and patients with multiple nodules (120 of 804, 14.9%) (P = 0.95, chi(2)). A solitary nodule had a higher likelihood of malignancy than a nonsolitary nodule (P < 0.01). In patients with multiple nodules larger than 10 mm, cancer was multifocal in 46%, and 72% of cancers occurred in the largest nodule. Multiple logistic regression analysis of statistically significant features demonstrates that the combination of patient gender (P < 0.02), whether a nodule is solitary vs. one of multiple (P < 0.002), nodule composition (P < 0.01), and presence of calcifications (P < 0.001) can be used to assign risk of cancer to each individual nodule. Risk ranges from a 48% likelihood of malignancy in a solitary solid nodule with punctate calcifications in a man to less than 3% in a noncalcified predominantly cystic nodule in a woman. CONCLUSIONS In a patient with one or more thyroid nodules larger than 10 mm in diameter, the likelihood of thyroid cancer per patient is independent of the number of nodules, whereas the likelihood per nodule decreases as the number of nodules increases. For exclusion of cancer in a thyroid with multiple nodules larger than 10 mm, up to four nodules should be considered for FNA. Sonographic characteristics can be used to prioritize nodules for FNA based on their individual risk of cancer.
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Affiliation(s)
- Mary C Frates
- Thyroid Section, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, 75 Francis Street, PBB-B4, Boston, Massachusetts 02115, USA
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876
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Døssing H, Bennedbaek FN, Hegedüs L. Effect of ultrasound-guided interstitial laser photocoagulation on benign solitary solid cold thyroid nodules: one versus three treatments. Thyroid 2006; 16:763-8. [PMID: 16910878 DOI: 10.1089/thy.2006.16.763] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Interstitial laser photocoagulation (ILP) is a safe and effective procedure when inducing thyroid nodule necrosis. In this prospective randomized study, we evaluated a possible dose-response relationship as well as patient satisfaction. DESIGN Thirty euthyroid outpatients with a cytologically benign solitary solid and scintigraphically cold thyroid nodule causing local discomfort were assigned to one session of ILP (ILP-1) (n = 15) or three monthly ILP sessions (ILP-3) (n = 15) and followed for 6 months. ILP was performed under continuous ultrasound (US)--guidance and with an output power of 2.5-3.5 W. Thyroid nodule volume was assessed by US. Pressure and cosmetic complaints were evaluated on a visual analogue scale. MAIN OUTCOME In the ILP- 1 group, thyroid nodule volume decreased from 10.1 +/- 4.3 mL (mean +/- standard deviation [SD]) to 5.7 +/- 3.2 mL (p = 0.0004), and in the ILP-3 group from 10.8 +/- 5.5 mL to 4.6 +/- 3.0 mL (p = 0.0005) during follow-up. The overall mean difference between the two groups was 13%, corresponding to an improved mean thyroid nodule volume reduction of 30% (p = 0.03). In both groups subjective symptoms were significantly reduced, and without difference between the two groups (p = 0.7). No major side effects were seen in either group. CONCLUSION As a nonsurgical therapeutic option, ILP-1 approximately halves thyroid nodule volume with concomitant symptom relief. There is little incremental effect of additional ILP treatment, which should be limited to patients with large nodules or limited nodule reduction after the first treatment.
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Affiliation(s)
- Helle Døssing
- Department of Oto-Rhino-Laryngology and Neck Surgery, Odense University Hospital, Odense, Denmark.
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877
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Carroll NM, Carty SE. Promising molecular techniques for discriminating among follicular thyroid neoplasms. Surg Oncol 2006; 15:59-64. [PMID: 16949814 DOI: 10.1016/j.suronc.2006.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
To guide the extent of thyroidectomy for indeterminate follicular neoplasm (FN), clinicians have long sought ways to differentiate follicular adenoma from carcinoma pre- or intraoperatively. Several promising molecular techniques have recently appeared including loss of heterozygosity analysis and molecular profiling microarray analysis. These new tools may also prove useful in determining prognosis, thus and allow a paradigm change in current management of the thyroid nodule.
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Affiliation(s)
- Nancy M Carroll
- Department of Surgery, Section of Endocrine Surgery, University of Pittsburgh School of Medicine, 497 Scaife Hall, Pittsburgh PA 15261, USA
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878
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Amabile G, Rotondi M, De Chiara G, Silvestri A, Di Filippo B, Bellastella A, Chiovato L. Low-energy interstitial laser photocoagulation for treatment of nonfunctioning thyroid nodules: therapeutic outcome in relation to pretreatment and treatment parameters. Thyroid 2006; 16:749-55. [PMID: 16910876 DOI: 10.1089/thy.2006.16.749] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Interstitial laser photocoagulation (ILP) is a recently proposed therapeutic procedure for the ablation of benign thyroid nodules, which has already proven to be safe and effective. However, results supporting the routine use of ILP are still limited. DESIGN The aim of the study was to evaluate the efficacy and safety of ILP treatment in benign nonfunctioning thyroid nodules and to establish whether the therapeutic outcome may be predicted by any clinical parameter at baseline. Twenty-three patients with either a solitary nodule or a dominant nodule within a multinodular goiter underwent ILP and were evaluated 1 and 3 months later. In order to assess the efficacy of low-energy ILP, the procedure was performed with an output power of 3 W, delivering a mean energy of 33.4 +/- 12.7 Joule/mL of nodule volume, which is much lower than previously reported. MAIN OUTCOME Nodule volume significantly decreased after ILP as assessed after 1 and 3 months (analysis of variance; F = 5.37; p = 0.007). Patients with multinodular goiter showed a greater reduction at 3 months compared with patients bearing a solitary thyroid nodule (38.6 +/- 5.3 vs. 30.9 +/- 6.5%; p < 0.01). Age, sex, ultrasound pattern (isoechogenous/hypoechogenous), pretreatment volume, number of ILP treatments, and total energy delivered did not show any significant correlation with treatment outcome. CONCLUSIONS Our results demonstrate that ILP can produce a significant reduction of thyroid nodule volume even when a much lower energy than previously reported is delivered. ILP constitutes a minimally invasive technique, which can be carried out on an outpatient basis and could represent a valid nonsurgical alternative for thyroid nodule management. Dominant nodules within a multinodular goiter appear to be more responsive to ILP compared with solitary thyroid nodules.
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879
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Døssing H, Bennedbaek FN, Hegedüs L. Beneficial effect of combined aspiration and interstitial laser therapy in patients with benign cystic thyroid nodules: a pilot study. Br J Radiol 2006; 79:943-7. [PMID: 16822801 DOI: 10.1259/bjr/40698061] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The aim of this study was to evaluate the effect of combined cyst aspiration and ultrasound-guided interstitial laser photocoagulation (ILP) on recurrence rate and the volume of benign cystic thyroid nodules. 10 euthyroid outpatients with a solitary and cytologically benign partially cystic thyroid nodule causing local discomfort were assigned to cyst aspiration followed by ultrasound-guided ILP and followed for 12 months. The ILP was performed under continuous ultrasound-guidance and with an output power of 2.5-3.5 W. The volume of the nodules was assessed by means of ultrasound and determination of the amount of aspirated cyst fluid, thereby calculating the volume of the solid part. Follow-up included ultrasound and determination of thyroid function. Pressure and cosmetic complaints were evaluated on a visual analogue scale. The median initial volume of the cystic nodule decreased from 9.6 ml [6.8;15.5 (quartiles)] to 3.5 ml [2.7;9.0 (quartiles)] (p = 0.0001), and the median cyst volume from 3.0 ml [2.0;6.0 (quartiles)] to 0 ml [0;0.5 (quartiles)] (p = 0.0001) during follow-up. Recurrence of the cystic part was defined as a cyst volume > 1 ml. In eight of 10 patients there was no recurrence of the cystic part. Both pressure symptoms and cosmetic complaints were significantly reduced. The only side effect was mild pain or tenderness for a few days. Our study suggests that complete cyst aspiration and subsequent ultrasound-guided ILP of benign cystic thyroid nodules is a feasible and safe technique, resulting in a significant reduction in the volume of both the solid and the cystic component. A large-scale prospective randomized study is warranted.
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Affiliation(s)
- H Døssing
- Department of Oto-rhino-laryngology and Neck Surgery, Odense University Hospital, Odense C, Denmark.
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880
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Chuang SC, Hashibe M, Yu GP, Le AD, Cao W, Hurwitz EL, Rao JY, Neugut AI, Zhang ZF. Radiotherapy for primary thyroid cancer as a risk factor for second primary cancers. Cancer Lett 2006; 238:42-52. [PMID: 16039041 DOI: 10.1016/j.canlet.2005.06.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2005] [Revised: 06/04/2005] [Accepted: 06/10/2005] [Indexed: 11/25/2022]
Abstract
Although radiation is considered a risk factor for thyroid cancer, the potential relationship between radiation therapy and the risk of second primary cancer among patients with first primary thyroid cancer has not been evaluated. We identified 26,639 patients with first primary thyroid cancer in the Surveillance, Epidemiology, and End Results (SEER) database from 1973 to 2000. Information on radiation therapy as well as second primary cancers was recorded in SEER. The proportional hazards model was utilized to estimate adjusted risk ratios (RRs) and their 95% confidence intervals (CIs) to assess the potential association between radiation therapy for thyroid cancer and the risk of second primary cancers. With 270,674.33 person-years of follow-up, 1,896 (7.1%) of the 26,639 patients with first primary thyroid cancer developed second primary cancers. Among the second primaries, 35 occurred in the thyroid. No obvious association was observed between radiation therapy and the overall risk of second primary cancer after ten years of follow-up (RR=1.07, 95% CI=0.88-1.30). However, an increased risk was seen for several cancers, including upper digestive system cancers (RR=1.66, 95% CI=1.07-2.57) and myeloid malignancies (RR=3.26, 95% CI=1.39-7.67). Radiation therapy was associated with reduced second cancer risks for thyroid cancer (RR=0.18, 95% CI=0.04-0.76). Beam radiation might be important to the digestive system, radioactive implants might be associated with the male genital system, radioisotopes might have an effect on myeloid malignancies, and combined beam radiation with radioactive implants or radioisotopes might be related to the increased risk of respiratory system cancers. This study suggests that radiation therapy for patients with first primary thyroid cancer might be associated with an increased risk of developing a second primary cancer in the upper digestive system and second primary myeloid malignancies. Radiation therapy for adult patients with thyroid cancer might be associated with a reduced risk of second primary thyroid cancer.
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Affiliation(s)
- Shu-Chun Chuang
- Department of Epidemiology, UCLA School of Public Health and Jonsson Comprehensive Cancer Center, 71-225 CHS, Box 951772, Los Angeles, CA 90095, USA
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881
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Abstract
Thyroid nodules are present in 4-10% of the adult population. However, less than 1% of all cancers occur in the thyroid gland. Thyroid nodules are usually an incidental finding in a routine clinical or an ultrasound examination of the neck performed for some other reason. Differentiating a benign nodule, which may require no specific treatment, from a malignant nodule presents a diagnostic dilemma. An individualized approach to a patient with history, risk factors and fine needle cytology is warranted. Molecular markers and immunohistochemical studies done on thyroid nodule cytology may help in differentiating benign from malignant. This article presents a review of the literature for the diagnosis and management of the thyroid nodule.
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Affiliation(s)
- Rajiv V Datta
- Division of Surgical Oncology and Head & Neck Surgery, South Nassau Cancer Center, 1 S. Central Avenue, Valley Stream, New York 11791, USA.
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882
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Sakorafas GH, Peros G, Farley DR. Thyroid nodules: Does the suspicion for malignancy really justify the increased thyroidectomy rates? Surg Oncol 2006; 15:43-55. [PMID: 16950080 DOI: 10.1016/j.suronc.2006.07.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Thyroid nodules are frequently diagnosed today, mainly due to the wide use of neck ultrasonography (US). The majority of these are benign; suspicion for malignancy is an indication for surgery, while benign thyroid nodules may be managed conservatively. There is evidence that a large percentage of patients with thyroid nodules (many diagnosed incidentally) are over-treated. Careful and accurate identification of patients with thyroid nodules highly suspicious for underlying malignancy would allow a more reasonable therapeutic approach and would result in a reduction of the number of unnecessary thyroidectomies. Fine-needle aspiration cytology (FNAC), in conjunction with high-resolution thyroid US, are currently the most accurate and cost-effective diagnostic approach for the evaluation of patients with nodular thyroid disease. Radionuclide thyroid scanning should be used selectively. By increasing the use of FNAC, it is expected that the number of unnecessary thyroidectomies will be further diminished, thereby avoiding over-treatment, without exposing the patients to the risk of under-treatment for a highly curable cancer. However, accurate preoperative diagnosis of thyroid cancer within a thyroid nodule is not always possible and, although the problem of unnecessary surgery can further be diminished, it cannot be completely eliminated.
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Affiliation(s)
- George H Sakorafas
- Fourth Department of Surgery, Athens University, Medical School, Attikon University Hospital, Athens, Greece.
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883
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Abstract
Ultrasonography is the most important imaging tool in the diagnosis of thyroid disease. The results of real-time B-imaging of the thyroid gland along with physical signs and basal TSH can aid in the diagnosis of thyroid dysfunction, of for instance, a small, hypoechogenic gland in Hashimoto's and radiation thyroiditis, or an enlarged, hypoechogenic and pulsating gland in Graves' disease. Although recent improvements in technology have increased sensitivity of colored duplexsonography, certain sonographic differentiation of benign and malignant lesions as well as of active (hormone secreting) and inactive nodules is not yet possible. Diagnostic interpretation of ultrasonographic findings is feasible only when the history of the patient, physical examination and the laboratory evaluation are taken into account. Ultrasound detects thyroid nodules, is useful for following nodule size, in guiding fine needle biopsies and in the aspiration of cysts. Highly experienced investigators in ultrasound can assist preoperatively in the localization of parathyroid adenomas in primary and tertiary hyperthyroidism (when followed by (99m)Tc szintigraphy plus SPECT).
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Affiliation(s)
- B Braun
- Klinikum am Steinenberg, Kreiskliniken, 72710, Reutlingen.
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884
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Gharib H, Papini E, Valcavi R, Baskin HJ, Crescenzi A, Dottorini ME, Duick DS, Guglielmi R, Hamilton CR, Zeiger MA, Zini M. American Association of Clinical Endocrinologists and Associazione Medici Endocrinologi medical guidelines for clinical practice for the diagnosis and management of thyroid nodules. Endocr Pract 2006; 12:63-102. [PMID: 16596732 DOI: 10.4158/ep.12.1.63] [Citation(s) in RCA: 381] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Thyroid nodules are common and are frequently benign. Current data suggest that the prevalence of palpable thyroid nodules is 3% to 7% in North America; the prevalence is as high as 50% based on ultrasonography (US) or autopsy data. The introduction of sensitive thyrotropin (thyroid-stimulating hormone or TSH) assays, the widespread application of fine-needle aspiration (FNA) biopsy, and the availability of high-resolution US have substantially improved the management of thyroid nodules. This document was prepared as a collaborative effort between the American Association of Clinical Endocrinologists (AACE) and the Associazione Medici Endocrinologi (AME). Most Task Force members are members of AACE. We have used the AACE protocol for clinical practice guidelines, with rating of available evidence, linking the guidelines to the strength of recommendations. Key observations include the following. Although most patients with thyroid nodules are asymptomatic, occasionally patients complain of dysphagia, dysphonia, pressure, pain, or symptoms of hyperthyroidism or hypothyroidism. Absence of symptoms does not rule out a malignant lesion; thus, it is important to review risk factors for malignant disease. Thyroid US should not be performed as a screening test. All patients with a palpable thyroid nodule, however, should undergo US examination. US-guided FNA (US-FNA) is recommended for nodules > or = 10 mm; US-FNA is suggested for nodules < 10 mm only if clinical information or US features are suspicious. Thyroid FNA is reliable and safe, and smears should be interpreted by an experienced pathologist. Patients with benign thyroid nodules should undergo follow-up, and malignant or suspicious nodules should be treated surgically. A radioisotope scan of the thyroid is useful if the TSH level is low or suppressed. Measurement of serum TSH is the best initial laboratory test of thyroid function and should be followed by measurement of free thyroxine if the TSH value is low and of thyroid peroxidase antibody if the TSH value is high. Percutaneous ethanol injection is useful in the treatment of cystic thyroid lesions; large,symptomatic goiters may be treated surgically or with radioiodine. Routine measurement of serum calcitonin is not recommended. Suggestions for thyroid nodule management during pregnancy are presented. We believe that these guidelines will be useful to clinical endocrinologists, endocrine surgeons, pediatricians, and internists whose practices include management of patients with thyroid disorders. These guidelines are thorough and practical, and they offer reasoned and balanced recommendations based on the best available evidence.
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885
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Scarpato R, Antonelli A, Ballardin M, Cipollini M, Fallahi P, Tomei A, Traino C, Barale R. Analysis of chromosome damage in circulating lymphocytes of radiological workers affected by thyroid nodules. Mutat Res 2006; 606:21-6. [PMID: 16713331 DOI: 10.1016/j.mrgentox.2006.02.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2005] [Revised: 02/09/2006] [Accepted: 02/22/2006] [Indexed: 01/12/2023]
Abstract
The aim of our study was to assess whether or not thyroid nodularity in combination with occupational exposure to low levels of ionising radiation would be correlated with chromosome damage in peripheral lymphocytes. Conventional chromosome-aberration analysis was performed on a group of 92 hospital workers with or without thyroid nodules. On the basis of measurements of their exposure levels, the workers were classified into a low (mean total level=0.03 mSv), medium (mean total level=1.04 mSv) or high (mean total level=8.60 mSv) exposure category. Our results indicate that among workers with thyroid nodules, the high-exposed workers showed significantly higher levels of both total (2.35+/-0.34 per 100 cells) and chromosome-type aberrations (1.46+/-0.20 per 100 cells) than medium-exposed (0.98+/-0.42 and 0.68+/-0.25 per 100 cells, respectively) or low-exposed workers (1.11+/-0.29 and 0.58+/-0.17 per 100 cells, respectively). Workers without thyroid nodules had comparable frequencies of chromosome aberrations among the three exposure categories. To our knowledge, this is the first study revealing a slight, but significant increase of chromosome damage in peripheral lymphocytes from hospital workers who developed thyroid nodules under conditions of occupational exposure to radiation well below the threshold limit for the workplace. The existence of a possible association between chromosome aberrations and development of thyroid nodularity will be discussed.
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Affiliation(s)
- Roberto Scarpato
- Dipartimento di Scienze dell'Uomo e dell'Ambiente, University of Pisa, Via San Giuseppe 22, 56100, Pisa, Italy
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886
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Scissons RP, Hoskins M, Gillis JC. Incidence of Visualized Thyroid Abnormalities During Carotid Duplex Evaluations. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2006. [DOI: 10.1177/8756479306287941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The objective of this study was to determine the incidence of thyroid abnormalities detected in patients referred for clinically indicated carotid duplex Doppler sonography examinations. Data from 327 consecutive initial carotid sonography examinations performed at two institutions were analyzed. Institution A was a vascular surgery office in the eastern United States; Institution B was a multispecialty clinic in the western United States. Visualized thyroid abnormalities in Institution A represented 51 of 192 patients (27%); females had the majority (65%), and 18% (9/51) described a prior history of thyroid disease. Thyroid anomalies in Institution B were 47 of 135 patients (35%), with near-equal gender distribution (49% female; 51% male), and 26% (12/47) had a prior history of thyroid disease. Most affected patients were not aware of their thyroid abnormalities. The reporting of incidental findings may seriously affect patient management and therefore should not be overlooked.
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Affiliation(s)
- Robert P. Scissons
- Bend Memorial Clinic Vascular Laboratory, 1501 NE Medical Center Drive, Bend, OR 97701
| | - Megan Hoskins
- Bend Memorial Clinic Vascular Laboratory, Bend, Oregon
| | - Joseph C. Gillis
- Vascular Laboratory, Providence Surgical Care, Providence, Rhode Island
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887
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Papi G, Corsello SM, Cioni K, Pizzini AM, Corrado S, Carapezzi C, Fadda G, Baldini A, Carani C, Pontecorvi A, Roti E. Value of routine measurement of serum calcitonin concentrations in patients with nodular thyroid disease: A multicenter study. J Endocrinol Invest 2006; 29:427-37. [PMID: 16794366 DOI: 10.1007/bf03344126] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND The routine measurement of serum calcitonin (CT) has been proposed for patients with nodular thyroid disease (NTD), to detect unsuspected medullary thyroid carcinoma (MTC) before surgery. OBJECTIVE To assess the prevalence of hypercalcitoninemia and MTC in NTD patients; to compare the ability of CT measurement and fine needle aspiration cytology (FNAC) to predict MTC; to identify age groups of NTD patients who should be better candidates than others to undergo routine measurement of CT. PATIENTS AND METHODS 1425 consecutive patients, referred from April 1, 2003, through March 31, 2004, to four Italian endocrine centers due to NTD, were grouped depending on age, and underwent basal and, in some cases, pentagastrin (Pg)-stimulated CT measurement, FNAC and, when indicated, surgery. Serum CT concentrations were measured by an immunoluminometric assay (ILMA). RESULTS Hypercalcitoninemia was found in 23 out of 1425 patients. MTC was discovered in 9 patients, all >40 yr old and showing high CT levels. Sensitivity of basal and Pg-stimulated CT to predict MTC before surgery was 100% for both tests, whereas specificity was 95 and 93%, respectively. CT specificity reached 100% when a cutoff value of 20 pg/ml was taken. FNAC showed an overall 86% sensitivity. When >10 mm MTC nodules were considered, FNAC sensitivity approached 100%. On the contrary, a correct cytological diagnosis was obtained in only one out of five patients with <10 mm MTC nodules (microMTC); in one patient with histologically proved microMTC, FNAC even demonstrated a benign lesion. Hypercalcitoninemia or MTC were associated with chronic thyroiditis in 30 or 33% of cases, respectively. C-cell hyperplasia was found in 57% of hypercalcitoninemic patients without MTC. CONCLUSIONS Basal CT measurement detects elevated CT values in 1.6% of NTD patients. Although CT is not a specific marker of MTC, its routine measurement represents a useful tool in the pre-operative evaluation of NTD patients, particularly those >40 yr old presenting with nodules <10 mm, even when FNAC does not show malignant features. To our knowledge, this is the first trial using ILMA to assess the ability of pre-operative CT measurement to predict MTC in a large series of NTD patients.
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Affiliation(s)
- G Papi
- Department of Internal Medicine, University of Modena and Reggio Emilia, Modena, Italy.
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888
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Sakorafas GH, Peros G. Thyroid nodule: A potentially malignant lesion; optimal management from a surgical perspective. Cancer Treat Rev 2006; 32:191-202. [PMID: 16580137 DOI: 10.1016/j.ctrv.2006.02.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2005] [Revised: 01/15/2006] [Accepted: 02/13/2006] [Indexed: 11/25/2022]
Abstract
Thyroid nodules are very common lesions, frequently detected by modern imaging methods (mainly ultrasonography). Despite that most thyroid nodules represent benign lesions, a small but significant percentage of them are malignant. Surgery is indicated when there is underlying malignancy (or suspicion for), pressure symptoms, or for cosmetic reasons. Total/near total thyroidectomy is the most radical procedure, which achieves cure, avoids the possibility of reoperation in the future (completion thyroidectomy), and facilitates postoperative management of the patient with underlying malignancy. Simple observation and thyroid hormone suppressive therapy are acceptable management options for patients with presumably benign thyroid nodules. Radioiodine therapy may be used for the management of patients with hyperfunctioning ("hot") thyroid nodules. Ablation of thyroid nodules (sclerosing therapy [alcohol injection] and laser photocoagulation) have been used for the in situ destruction of thyroid nodules; ablation therapy is currently viewed as experimental therapeutic method. Careful evaluation is required in order to avoid both overtreatment (mainly unnecessary surgery) as well as undertreatment of these potentially malignant, but highly curable lesions.
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Affiliation(s)
- George H Sakorafas
- 4th Department of Surgery, Athens University, Medical School ATTIKON University Hospital, Greece.
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889
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Levine RA. Value of Doppler Ultrasonography in Management of Patients with Follicular Thyroid Biopsy Specimens. Endocr Pract 2006; 12:270-4. [PMID: 16772198 DOI: 10.4158/ep.12.3.270] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To perform a statistical evaluation with use of Bayes' theorem, evaluating the prognostic value of Doppler flow analysis, to determine the probability of cancer in thyroid nodules with a prior follicular biopsy specimen. METHODS The medical literature was reviewed to identify studies in which ultrasonographic Doppler flow analysis was performed on thyroid nodules with a prior fine-needle aspiration biopsy sample showing follicular cytologic features. For inclusion in the study, all nodules must have had pathologic confirmation of the final diagnosis. The pretest probability of cancer was considered to be the incidence of carcinoma within the population studied. The posttest or conditional probability was calculated by using Bayes' theorem. RESULTS Two well-designed prospective studies met the criteria for inclusion. The sensitivity of demonstration of intranodular flow by Doppler analysis for detection of thyroid carcinoma ranged from 80% to 86%. The specificity of intranodular flow indicating cancer ranged from 85% to 89%. The incidence of thyroid cancer (pretest probability) ranged from 12% to 14%. Application of Bayes' theorem indicated that the posttest probability of thyroid cancer declined to 3% when no central intranodular flow was present and increased to nearly 50% in the presence of intranodular flow. CONCLUSION Doppler flow analysis, when performed on thyroid nodules with follicular cytologic findings on fine-needle aspiration biopsy, can provide extremely useful information regarding the probability of malignant involvement. This information can be used in the decision-making process about the need for, and the extent of, surgical resection of follicular lesions.
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Affiliation(s)
- Robert A Levine
- The Thyroid Center of New Hampshire and Dartmouth Medical College, Nashua, New Hampshire, USA
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890
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Metzger ML, Howard SC, Hudson MM, Gow KW, Li CS, Krasin MJ, Merchant T, Kun L, Shelso J, Pui CH, Shochat SJ, McCarville MB. Natural history of thyroid nodules in survivors of pediatric Hodgkin lymphoma. Pediatr Blood Cancer 2006; 46:314-9. [PMID: 16086425 DOI: 10.1002/pbc.20541] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Survivors of Hodgkin lymphoma and other patients who receive neck irradiation are at increased risk of thyroid cancer. Ultrasonography provides an inexpensive and non-invasive method of thyroid screening, but the clinical significance of thyroid nodules detected by ultrasound screening is uncertain. PROCEDURE We reviewed the demographics, clinical characteristics, method of detection, and outcome of patients who developed thyroid nodules after treatment for pediatric Hodgkin lymphoma at our institution. One radiologist reviewed all imaging studies. RESULTS Sixty-seven children treated for Hodgkin lymphoma from 1962 to 2001 developed thyroid nodules. The study group represented 9,024 person-years of follow-up after the diagnosis of Hodgkin lymphoma and 581 person-years after diagnosis of a thyroid nodule. A median of 10.5 years (range, 0.2-24.8 years) elapsed between the diagnoses of Hodgkin lymphoma and thyroid nodule(s). All but one patient had received neck irradiation for Hodgkin lymphoma, with a median thyroid radiation dose of 35 Gy (range, 12-45 Gy). Thyroid nodules were found to be malignant in seven patients (10%), at a median of 16.2 years (range, 8.4-23.7 years) after diagnosis of Hodgkin lymphoma. Only one malignancy was found through screening ultrasonography. All patients with thyroid cancer remained disease-free at 0.4-16.2 years of follow-up. CONCLUSIONS Thyroid nodules are common in Hodgkin lymphoma survivors treated with neck irradiation, but the majority of these lesions have an indolent clinical course and do not undergo malignant transformation. Only patients with a palpable mass or clinical symptoms need more extensive evaluation, including Doppler-flow ultrasonography and fine-needle aspiration.
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Affiliation(s)
- Monika L Metzger
- Department of Hematology-Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
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891
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Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL, Mandel SJ, Mazzaferri EL, McIver B, Sherman SI, Tuttle RM. Management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid 2006; 16:109-42. [PMID: 16420177 DOI: 10.1089/thy.2006.16.109] [Citation(s) in RCA: 1291] [Impact Index Per Article: 71.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- David S Cooper
- Sinai Hospital of Baltimore and Johns Hopkins University School of Medicine, MD, USA
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892
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Wiseman SM, Baliski C, Irvine R, Anderson D, Wilkins G, Filipenko D, Zhang H, Bugis S. Hemithyroidectomy: the optimal initial surgical approach for individuals undergoing surgery for a cytological diagnosis of follicular neoplasm. Ann Surg Oncol 2006; 13:425-32. [PMID: 16485160 DOI: 10.1245/aso.2006.03.089] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2005] [Accepted: 08/29/2005] [Indexed: 01/29/2023]
Abstract
BACKGROUND The primary objective of this study was to determine the true proportion and optimal surgical approach for individuals undergoing thyroid operation for a suspicion of cancer based on a fine-needle aspiration biopsy diagnosis of a follicular neoplasm (FN). A secondary objective of this study was to determine whether patient characteristics could assist the clinician in predicting malignancy in this FN patient cohort. METHODS A retrospective chart, pathology, and cytology review of 370 consecutive primary thyroid operations was performed over a 4-year period at a tertiary care referral center. Clinical patient data were evaluated as an adjunct for predicting malignancy in the FN patient cohort. Univariate and multivariate analyses were used to investigate the association and the predictability. RESULTS A total of 80 (22%) of the 370 patients underwent hemithyroidectomy to rule out cancer based on clinical presentation with a fine-needle aspiration biopsy diagnosis of FN. Fifteen (19%) of the FN cases were diagnosed as cancer by histological analysis (4 follicular carcinomas and 11 papillary carcinomas). Hemithyroidectomy was considered adequate treatment for 77 patients (96%). No patient characteristic significantly predicted the presence of cancer by either univariate or multivariate analysis. CONCLUSIONS Overall, in the FN patient population, five hemithyroidectomies were performed to identify each cancer, and no further operation was required in 96% of patients. New diagnostic tools are needed to reduce the number of operations performed for benign pathology in patients with nodular thyroid disease and a needle biopsy diagnosis of FN.
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Affiliation(s)
- Sam M Wiseman
- Department of Surgery, St. Paul's Hospital, University of British Columbia, C303-1081 Burrard Street, Vancouver, British Columbia, V6Z 1Y6, Canada.
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893
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Frates MC, Benson CB, Charboneau JW, Cibas ES, Clark OH, Coleman BG, Cronan JJ, Doubilet PM, Evans DB, Goellner JR, Hay ID, Hertzberg BS, Intenzo CM, Jeffrey RB, Langer JE, Larsen PR, Mandel SJ, Middleton WD, Reading CC, Sherman SI, Tessler FN. Management of thyroid nodules detected at US: Society of Radiologists in Ultrasound consensus conference statement. Radiology 2006; 237:794-800. [PMID: 16304103 DOI: 10.1148/radiol.2373050220] [Citation(s) in RCA: 760] [Impact Index Per Article: 42.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The Society of Radiologists in Ultrasound convened a panel of specialists from a variety of medical disciplines to come to a consensus on the management of thyroid nodules identified with thyroid ultrasonography (US), with particular focus on which nodules should be subjected to US-guided fine needle aspiration and which thyroid nodules need not be subjected to fine-needle aspiration. The panel met in Washington, DC, October 26-27, 2004, and created this consensus statement. The recommendations in this consensus statement, which are based on analysis of the current literature and common practice strategies, are thought to represent a reasonable approach to thyroid nodular disease.
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894
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Redman R, Zalaznick H, Mazzaferri EL, Massoll NA. The impact of assessing specimen adequacy and number of needle passes for fine-needle aspiration biopsy of thyroid nodules. Thyroid 2006; 16:55-60. [PMID: 16487014 DOI: 10.1089/thy.2006.16.55] [Citation(s) in RCA: 119] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Fine-needle aspiration biopsy (FNAB) of thyroid nodules is a safe, cost-effective procedure but the rates of inadequate cytology specimens range from approximately 1% to 15%. This study tests the hypothesis that ultrasonographically (US) guided FNAB and onsite assessment of cytology improves the adequacy rate of FNAB. A retrospective analysis was performed on 693 thyroid FNAB specimens obtained with and without ultrasound guidance and with or without onsite cytology assessment. Overall, 29 specimens (4%) were inadequate for diagnosis. Among 163 cystic nodules and 530 solid nodules, inadequacy rates were 15% (n = 24) and 1% (n = 5) respectively (p = 0.0001). An onsite assessment of cytology for adequacy was done in 550 cases (83%), which was more accurately performed by a cytopathologist (97%) than a cytotechnologist (93%, p = 0.015). With US-guided FNAB, 3% of the cytology specimens were inadequate, compared to a 7% rate when US was not done (p = 0.003). The mean number of needle punctures necessary for an adequate specimen was 3.8 +/- 0.06 (median, 3.0; range, 1-11), which was different among various types of doctors, ranging from 3.2 +/- 0.07 to 5.4 +/- 0.12 (p = 0.001 analysis of variance [ANOVA]). The fewest number of needle passes to achieve an adequate specimen were required by university endocrinologists and pathologists working together (average, 3.2 +/- 0.07; median, 3.0; range, 1-11). Sample inadequacy rate varied significantly among physician groups, ranging from 3% to 18% (p = 0.0001 ANOVA). Stepwise regression analysis showed that onsite assessment of cytology, US-guided FNAB (p = 0.16), and cystic nature of the nodule (p < 0.0001 for all) correlated with adequacy of the specimen. We conclude that US-guided FNAB with onsite evaluation of cytology specimens substantially increases the adequacy of cytology specimens and decreases the number of required needle passes, which ultimately reduces patient discomfort and diagnostic errors, thus raising the question as to whether this should eventually become the standard of care. We believe this is a goal that training programs should strive to achieve.
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Affiliation(s)
- Rachel Redman
- Department of Pathology, University of Florida, Gainesville, Florida 32610-0275, USA
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895
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Lee MT, Wang CY, Chang TC. Graves' Hyperthyroidism with Incidental Ossified Nodular Lesion. J Med Ultrasound 2006. [DOI: 10.1016/s0929-6441(09)60065-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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896
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Goggins W, Daniels GH, Tsao H. Elevation of thyroid cancer risk among cutaneous melanoma survivors. Int J Cancer 2005; 118:185-8. [PMID: 16049985 DOI: 10.1002/ijc.21300] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Recent molecular studies have identified recurrent BRAF mutations in both cutaneous melanoma and thyroid malignancies. This relatively selective shared genetic vulnerability raises the possibility that these 2 tumors are connected through a common undisclosed pathogenic mechanism. To assess for possible associations between these 2 genetically related tumors at the population level, we calculated standardized incidence ratios (SIRs) for thyroid cancer (TC) among cutaneous melanoma (CM) survivors and CM among TC survivors using the National Cancer Institute's Surveillance, Epidemiology and End Result (SEER) database. Between 1973 and 2000, there were 73,274 and 27,138 cases of CM and TC cases, respectively. Overall, we found a 2.17-fold increase (p < 0.0000001) in the risk of TC after a diagnosis of CM. This augmented risk of TC is somewhat higher for males, for those diagnosed more recently and for the first 3 years after the CM diagnosis. We also detected a considerably smaller and borderline significant increased risk of CM (25%, p = 0.063) among the post-TC survivors. Of note, TC patients who received radiation therapy had a 57% increased risk of a subsequent CM (p = 0.034). Our study documents a strong unilateral risk of TC after CM. More studies are clearly needed to better delineate this mechanism.
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Affiliation(s)
- William Goggins
- Centre for Epidemiology and Biostatistics, School of Public Health, Chinese University of Hong Kong, Hong Kong, China
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897
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Milas M, Stephen A, Berber E, Wagner K, Miskulin J, Siperstein A. Ultrasonography for the endocrine surgeon: A valuable clinical tool that enhances diagnostic and therapeutic outcomes. Surgery 2005; 138:1193-200; discussion 1200-1. [PMID: 16360408 DOI: 10.1016/j.surg.2005.08.032] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2005] [Revised: 08/16/2005] [Accepted: 08/27/2005] [Indexed: 11/26/2022]
Abstract
BACKGROUND Surgeon-performed ultrasonography (U/S) has revolutionized many subspecialties by broadening the diagnostic and interventional scope of practice. We report our experience on the impact of surgeon-performed U/S in an endocrine surgery practice. METHODS Prospectively maintained records of patients from November 1999 to November 2004 were reviewed to establish patterns and outcomes of U/S practice. Surgeon-performed neck U/S was done routinely at the initial clinic visit and incorporated into resident/fellow education. RESULTS A total of 5703 U/S were performed on endocrine patients with thyroid 42%, parathyroid 57%, and adrenal 1% disorders. Diagnostic fine-needle aspiration biopsy (FNA) was achieved with low sampling errors (<7%). When U/S identified thyroid nodules coexisting with hyperparathyroidism, preoperative FNA correctly established benign thyroid diagnosis and minimized need for thyroidectomy. U/S successfully imaged abnormal parathyroid glands when (99)Tc-sestamibi scans were negative. U/S data significantly changed treatment plans in nearly two thirds of thyroid cancer patients. Surgical residents readily mastered essential U/S skills. CONCLUSIONS Surgeon-performed U/S is a highly specific tool for identification of endocrine disease in the neck. It is learned readily and performed accurately, and functions as an informative extension of physical examination. Because it substantially benefits patient care and impacts surgical decision making, neck U/S is recommended highly as a valuable adjunct to endocrine surgical practice.
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Affiliation(s)
- Mira Milas
- Department of General Surgery, Cleveland Clinic Foundation, OH 44195, USA.
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898
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Vierhapper H, Niederle B, Bieglmayer C, Kaserer K, Baumgartner-Parzer S. Early diagnosis and curative therapy of medullary thyroid carcinoma by routine measurement of serum calcitonin in patients with thyroid disorders. Thyroid 2005; 15:1267-72. [PMID: 16356091 DOI: 10.1089/thy.2005.15.1267] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
To identify patients with medullary thyroid carcinoma (MTC) at a potentially curable stage of the disease, serum concentrations of calcitonin (hCT) were determined in 14,000 patients (including 10,158 patients with thyroid nodules) referred to a thyroid outpatient clinic. Excluding patients in whom elevated basal hCT concentrations had already been known at the time of their referral, 507 patients with thyroid nodules presented basal concentrations of hCT of more than 10 pg/ml. Following stimulation by IV pentagastrin (0.5 microg/kg BW), hCT concentrations of more than 100 pg/ml were seen in 103 patients. This group included 32 new cases of MTC (29 patients with sporadic MTC and 3 new index cases of the familial form) and 43 patients with C cell hyperplasia (CCH). Among the 3,843 patients without thyroid nodules, 2 were found to harbor sporadic MTC while 4 had CCH. As compared to 1.1 cases of MTC per 1,000 patients with nodular thyroid diseases diagnosed in our institution before hCT screening was begun, 3.2 cases of MTC per 1,000 patients were identified when hCT was determined in all patients with thyroid nodules. The determination of hCT in all patients with thyroid nodular disease facilitates the timely diagnosis of MTC, thus providing the chance of curative surgery.
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Affiliation(s)
- H Vierhapper
- Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Austria.
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899
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Slapa RZ, Slowinska-Srzednicka J, Szopinski KT, Jakubowski W. Gray-scale three-dimensional sonography of thyroid nodules: feasibility of the method and preliminary studies. Eur Radiol 2005; 16:428-36. [PMID: 16155720 DOI: 10.1007/s00330-005-2903-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2005] [Revised: 07/28/2005] [Accepted: 08/18/2005] [Indexed: 11/25/2022]
Abstract
The aim of the study was differential evaluation of new and classical sonographic features of benign thyroid nodules and thyroid cancer with three-dimensional gray-scale sonography and evaluation of the effectiveness of the thin-slice surface rendered images in comparison with multiplanar reformation (MPR) presentation. Fifty-four thyroid nodules were interactively evaluated with thin-slice smooth surface rendering: shape in the c-plane (parallel to the probe) and evaluation of echogenicity, margins and calcification/microcalcification-like echogenic foci in the a-plane (plane of the probe). Evaluation of the level of agreement in readers' interpretation and between sonographic techniques was performed using the kappa statistic. Surface rendering permitted visualization of the shape of the nodule in the c-plane in all cases, in contrast to only up to 48% of cases in MPR evaluation. Lobulated nodule shape in the c-plane was 82-100% sensitive and 47-53% specific in diagnosis of carcinoma. Surface rendered images showed more calcification/microcalcification-like echogenic foci than MPR ones. The level of agreement between the observers in the evaluation of features of thyroid nodules and the agreement between features of thyroid nodules on MPR and surface-rendered images showed at least moderate reproducibility (kappa>or=0.41). Three-dimensional thin-slice surface rendering sonography appears to be a feasible and effective method for thyroid nodule evaluation.
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MESH Headings
- Adult
- Aged
- Biopsy, Needle
- Calcinosis/diagnostic imaging
- Calcinosis/pathology
- Calcinosis/surgery
- Carcinoma, Medullary/diagnostic imaging
- Carcinoma, Medullary/pathology
- Carcinoma, Medullary/surgery
- Carcinoma, Papillary/diagnostic imaging
- Carcinoma, Papillary/pathology
- Carcinoma, Papillary/surgery
- Feasibility Studies
- Female
- Goiter, Nodular/diagnostic imaging
- Goiter, Nodular/pathology
- Goiter, Nodular/surgery
- Humans
- Image Processing, Computer-Assisted/methods
- Imaging, Three-Dimensional/methods
- Magnetic Resonance Imaging
- Male
- Middle Aged
- Observer Variation
- Sensitivity and Specificity
- Software
- Thyroid Gland/diagnostic imaging
- Thyroid Gland/pathology
- Thyroid Neoplasms/diagnostic imaging
- Thyroid Neoplasms/pathology
- Thyroid Neoplasms/surgery
- Thyroid Nodule/diagnostic imaging
- Thyroid Nodule/pathology
- Thyroid Nodule/surgery
- Thyroidectomy
- Ultrasonography/methods
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Affiliation(s)
- Rafal Z Slapa
- Department of Diagnostic Imaging, Medical Faculty II, Medical University of Warsaw, ul. Kondratowicza 8, 03-242, Warsaw, Poland.
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Abstract
This article describes an approach to some of the commonly encountered, "classic pattern," appearances of both benign and malignant thyroid nodules that are seen in day-to-day practice. These appearances include specific nodules that commonly need fine needle aspiration (FNA)/biopsy, and other nodules that do not usually need FNA/biopsy.
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Affiliation(s)
- Carl C Reading
- Department of Radiology, Division of Ultrasonography, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA.
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