Follicular and Hürthle cell thyroid neoplasms. Is frozen-section evaluation worthwhile?

Frozen Section in Diagnosis of Thyroid Swelling: Does It Still Have Role?

Purpose The present study correlates the frozen section diagnosis of thyroid swelling with the histopathological diagnosis and assesses the expression of immunohistochemical markers in malignant thyroid tumours. Also, the study aims to analyse the accuracy and limitations of the frozen section as an intraoperative tool for the diagnosis of thyroid swellings. Method Fifty-three cases of thyroid swelling were included in the study. Frozen section reports were classified as benign, malignant and deferred. A correlation between frozen section and histopathology examination (HPE) reports has been evaluated. The malignant cases confirmed on HPE were subjected to Immunohistochemistry (IHC) with TTF-1, Thyroglobulin, and CK-7. Results Among the 53 patients, 45 (84.9%) were females, and the majority were younger than 40 years (60.37%). On frozen section majority, 42 (79.25%) were benign, while a definitive diagnosis of malignancy was made in six cases (11.32%). On the frozen section, there were no false-positive cases, six true-positive cases, one false-negative case and 46 true-negative cases, with a sensitivity of 85.71%, specificity of 100%, the positive predictive value of 100%, the negative predictive value of 97.87% and diagnostic accuracy of 98.11% respectively. All the six papillary carcinomas and one follicular carcinoma showed immunoreactivity of tumor cells to TTF 1, CK 7 and Thyroglobulin. Conclusion There was a strong correlation between the frozen section and histopathological diagnosis. Still, it is not recommended in routine use for intraoperative diagnosis of thyroid swelling because of various limitations and the high diagnostic accuracy of FNAC. Adequate histopathologic diagnosis of thyroid disease is based on extensive subsampling of the specimen, which is not possible during an intraoperative frozen section procedure. If the frozen section is used, its limitations must be recognized, preferably based on first-hand data.

Cost effectiveness of intraoperative pathology in the management of indeterminate thyroid nodules

Objective This study aims to determine the cost effectiveness of rapid frozen section (RFS) for indeterminate thyroid nodules. Materials and methods A retrospective chart review was conducted between January 2009 and June 2013 at a tertiary care institution. Main outcomes were number needed to treat, RFS efficacy, and cost-savings of avoiding second completion thyroidectomy. Cost-effectiveness was estimated using 2015 Medicare reimbursement rate. Results Out of 1,114 patients undergoing thyroid surgery, 314 had preoperative AUS/FLUS cytopathology and subsequent thyroid lobectomy with RFS. RFS identified 13 of the 32 patients with malignancy resulting in a total thyroidectomy. 19 of the 29 malignancies not detected by RFS were papillary microcarcinomas. Conclusions Completion thyroidectomy was avoided in 1 out of every 24 patients resulting in cost-savings of $ 80.04 per patient. In the era of outpatient thyroid surgery, intraoperative RFS for indeterminate thyroid nodules is cost-effective.

Larger tumor size predicts nodal involvement in patients with follicular thyroid carcinoma

Aims and background

Lymph node metastases are rare in patients with follicular thyroid carcinoma, with an average incidence of 5.5% of all cases reported in the literature. In the present study we focused on the search for risk factors predictive of lymph node involvement in patients with follicular thyroid carcinoma to plan the most appropriate management and follow-up.

Methods and study design

We carried out a cross-sectional study among patients with follicular thyroid carcinoma and lymph node metastasis at diagnosis and patients without lymph node involvement. From January 1998 to April 2008, 930 patients underwent thyroidectomy in our surgical department for a variety of thyroid disorders, 420 (45.2%) of them for a differentiated thyroid carcinoma. The medical records of 55 patients with histological diagnosis of follicular thyroid carcinoma were analyzed.

Results

Four patients (7.3%) had lymph node metastasis from follicular thyroid carcinoma at presentation in both the lateral and central neck compartments. Mean tumor size was significantly greater for follicular thyroid carcinomas with nodal metastasis (5.1 ± 1.4 cm) than for those without nodal involvement (3.0 ± 1.2 cm, P <0.010). Among factors supposed to influence the presence of nodal metastasis at diagnosis (age, gender, tumor size, multifocality, tumor poorly differentiated, tumor widely invasive, vascular invasion, thyroid capsular invasion, and extra thyroid invasion), tumor size larger than 4.0 cm was the only factor retained in the multivariate statistical model.

Conclusions

Lymph node dissection must be planned only in the case of large follicular thyroid carcinomas. Since follicular carcinoma is usually diagnosed postoperatively, more attention should be paid to nodal involvement in the tumor re-staging during follow-up of those patients with tumors larger than 4.0 cm in diameter.

The contemporary utility of intraoperative frozen sections in thyroid surgery

PURPOSE

To determine the accuracy of intraoperative frozen section analysis on thyroidectomy specimens stratified by the Bethesda classification scheme and its utility for intraoperative decision-making.

STUDY DESIGN

Retrospective chart review.

METHODS

A retrospective review was performed on all patients who underwent thyroidectomy or thyroid lobectomy with intraoperative frozen sections at a tertiary care academic center from 2009 to 2015.

RESULTS

There were 74 total patients who underwent partial or total thyroidectomy with intraoperative frozen section analysis of a thyroid nodule whom had previously undergone a thyroid fine needle aspiration of the nodule. The sensitivity, specificity, positive predictive value, and negative predictive value for a thyroid frozen section with respect to its prediction for malignancy was 81%, 95%, 98%, and 66%, respectively, with a diagnostic accuracy of 85%. For 37 patients with an indeterminate cytologic diagnosis on fine needle aspiration (Bethesda categories III-V), the sensitivity, specificity, positive predictive value, and negative predictive value for a thyroid frozen section was 81%, 91%, 95%, and 67%, respectively, with a diagnostic accuracy of 84%. False positives and false negatives resulted in 1 completion thyroidectomy for benign pathology and 3 reoperations for malignancy not discovered on frozen section.

CONCLUSION

While intraoperative frozen sections on thyroid specimens may be helpful if positive, the false negative rate remains high. There appears to be limited value in routine frozen sections to guide clinical management and decision-making in the era of the Bethesda system.

Follicular thyroid carcinoma: differences in clinical relevance between minimally invasive and widely invasive tumors

BACKGROUND

Evidence on the biological behavior and clinical courses of minimally invasive and widely invasive follicular thyroid carcinoma (MI-FTC, WI-FTC) is still debatable. The current study was conducted to identify differences between MI and WI tumors and those prognostic parameters influencing late outcome such as local recurrence and survival.

METHODS

From January 1998 to October 2013, 71 patients were operated on in our department because of a FTC. A retrospective cohort study was carried out to compare 42 MI-FTC and 29 WI-FTC. The comparison involved evaluation of patient characteristics, tumor characteristics, tumor staging, and risk assessment.

RESULTS

A diameter greater than 4.0 cm, the presence of vascular invasion, the TNM stage III-IVA, and the high risk at AMES system risk stratification were independent factors significantly related to the presence of a WI-FTC. The only independent predictor of recurrence and disease-free survival at 10-year follow-up was a tumor size greater than 4.0 cm.

CONCLUSIONS

More attention must be paid in the postoperative tumor re-staging of those patients with tumor size larger than 4.0 cm, which was the only parameter predicting recurrence and influencing disease-free survival. Nevertheless, definitive recommendations cannot be made without a longer follow-up.

Follicular nodules (THY3) of the thyroid: we recommend surgery

OBJECTIVE

To determine the need of total thyrodectomy for patients with follicular nodules of thyroid.

SUBJECTS AND METHODS

From January 2005 through June 2008, 2249 consecutive patients (438 males, 1811 females; mean age 54 yr, range 9-87) with thyroid nodules were submitted to 2518 ultrasound-guided fine-needle aspiration (USgFNA) for cytological examination. USgFNA were performed by experienced surgeon (RP) and endocrinologist (RGG) under ultra- sonographyc guidance, using a 10-MHz linear transducer. Liquid-based cytology was used.

RESULTS

All cytological samples were classified in 5 diagnostic classes (THY1, THY2, THY3, THY4, THY5) in agreement with the British Thyroid Association (BTA); 1.4% specimen were classified as THY5, 2.1% as THY4, 7.6% as THY3, 79.5% as THY2 and 9.4% as THY1. In 97% of THY5 patients, malignancy was found. Among THY4 patients, 95.5% were positive for thyroid tumor. Among THY3 patients, malignancy was found in 29.1%. THY3 patients with thyroid tumors were younger than those with benign lesions (46 ± 14.1 yr vs 50 ± 13.8 yr; p<0.05, t test). No statistical difference was found neither in malignancy frequency among men and women nor in mean size of nodules (24 ± 11.8 mm malignant vs 23 ± 9.4 mm benign).

CONCLUSIONS

this study provides evidence that USgFNA offers a very sensitive and accurate method in reducing THY1 samples and in detecting malignancy (>95% both in THY5 and THY4, and >29% in THY3 lesions). Our proposal is to submit to total thyroidectomy all patients with THY5 and THY4 lesions and THY3 thyroid nodule >1 cm.

Approach to the patient with nontoxic multinodular goiter

Thyroid nodules are very common, and although the majority are benign, approximately 5% may harbor malignancy. The evaluation of the patient with solitary thyroid nodule is generally straightforward and will typically include measurement of serum TSH to assess thyroid function and fine-needle aspiration biopsy of the nodule, with or without ultrasound (US) guidance. The approach to the patient with nontoxic multinodular goiter represents a more difficult problem for the clinician. All patients should have serum TSH measured to assess functional thyroid status and US examination to evaluate the number, size, and sonographic features of the nodules and assist in the selection of nodules that may need fine-needle aspiration biopsy. Patients with nodules yielding malignant cytology should be referred for surgery. Given the lack of reliable markers to predict biological behavior of nodules with suspicious (indeterminate) cytology, patients with such nodules are generally advised to have surgery, unless autonomous function of these nodules can be confirmed by scintigraphy. Most of these patients, however, will ultimately prove to have benign follicular tumors. Many patients with benign but large goiters may experience clinical symptoms of pressure, such as dysphagia, choking sensation, or airway obstruction. Such patients will often require surgery for alleviation of symptoms. In the absence of malignancy, asymptomatic patients may be observed. Radioactive iodine, commonly used in many parts of Europe, is safe and effective and may be a reasonable option for many patients. Periodic follow-up with neck palpation and US exam is recommended for all patients.

Thyroid follicular neoplasm: analysis by fine needle aspiration cytology, frozen section, and histopathology

We performed a retrospective analysis of follicular neoplasm data obtained from frozen section examinations of thyroid nodules. A total of 5,660 patients underwent preoperative neck ultrasonography and fine-needle aspiration cytology (FNAC), surgical treatment, and follow-up at a medical institute. Patients with papillary thyroid microcarcinoma were excluded from this study. In 971 cases, frozen section examination was performed during the surgical treatment of follicular neoplasm that was diagnosed via FNAC. Thyroid malignancies were histologically confirmed in 25.1% of cases (244/971). Among the patients with papillary thyroid carcinoma, 45 were diagnosed with the follicular variant of papillary thyroid carcinomas (27.4%). The diagnostic sensitivity of frozen section for the nonfollicular variant of papillary thyroid carcinoma was better than that for the follicular variant of papillary thyroid carcinoma (89.1% versus 78.9%; P = 0.1023). For 12 cases the diagnosis was atypical follicular adenomas. The diagnostic accuracy of frozen section in cases of follicular neoplasm was 76.9% with a sensitivity of 84.8% and a specificity of 98.9%. In conclusion, our analysis revealed high rates of accuracy when using frozen tissue sections for early diagnosis and treatment of follicular neoplasm; thus, an early decision to extent of surgery prevents a risky follow-up surgery.

Indeterminate thyroid nodules: a challenge for the surgical strategy

BACKGROUND

Because no clinical parameter can establish the final status of a cytologically indeterminate thyroid nodule (ITN) or nodal-metastases in case of malignancy, the initial surgical strategy should define an oncologically adequate procedure with low morbidity.

METHODS

The prognostic relevance of sex, age, tumor sizes, multifocality, thyroid function, and recurrence was analyzed in 156 consecutive patients according to the presence of malignancy and nodal metastases. The accuracy of frozen sections to reveal malignancy was determined. Clinical parameters were compared with regard to their ability to identify malignancy and nodal metastases in an ITN to determine an appropriate initial operative strategy.

RESULTS

One hundred and eighteen (75.6%) patients underwent (total) thyroidectomy, 37 (23.7%) patients underwent hemithyroidectomy, and 1 patient underwent isthmus resection. Fifty-five (35.3%) patients showed malignancy. First step lymphadenectomy (lymph node dissection along the recurrent laryngeal nerve before removing the thyroid lobe) was performed in 142 patients documenting 10 nodal metastases. Comparing benign and malignant ITN, no association was found for sex (P = .17), age (P = 1.0), tumor sizes (P = .33, P = .12, P = .19 for < or =30 mm, < or =40 mm, and < or =50 mm, respectively), or thyroid function (P = .26). The determination of malignancy by frozen section showed a sensitivity of 30.9% and a specificity of 100%. No permanent hypoparathyroidism or recurrent laryngeal nerve palsy was observed postoperatively.

CONCLUSION

Because of the failure of available clinical parameters to predict malignancy in cytologically ITN, hemithyroidectomy in unilateral goiter and thyroidectomy in bilateral goiter is recommended. Ipsilateral "first step central neck dissection" on the side of ITN offers the advantages of oncologically adequate resection and staging with a low morbidity, as well as avoids reoperation.

How to approach thyroid nodules with indeterminate cytology

BACKGROUND

Ultrasound (US)-guided fine-needle aspiration biopsy (FNAB) is an accurate, reliable, and simple procedure to perform, and it is nowadays accepted as a standard diagnostic method for the differential diagnosis of thyroid nodules. However, a major limitation of US-FNAB is indeterminate cytology results at a thyroid nodule. This study investigated the clinical and US characteristics that predict malignancy, as well as the role of intraoperative frozen sections (FS) in the treatment of thyroid nodules with indeterminate cytology.

METHODS

From September 2002 to December 2007, the medical records of 181 patients (185 nodules) with indeterminate FNAB cytology results were retrospectively reviewed. Among them, 99 patients (M:F = 13:86; mean age, 43.71 years) with 99 thyroid nodules underwent subsequent surgery with pathologic confirmation. Seventy-eight patients (78.8%) underwent intraoperative FS. US findings of the surgically proven thyroid nodules were retrospectively reviewed. US features, clinical characteristics, and FS results were compared to the surgically proven pathologic results.

RESULTS

Nineteen nodules (19.2%) with indeterminate FNAB cytology were diagnosed as malignant. Lesion size varied from 4 to 70 mm (mean, 27.0 mm). Male patients (46.2%) were more significantly associated with malignancy than female patients (15.1%, P < 0.05). Microlobulated or ill-defined margins (87.5%), microcalcifications (50.0%), and taller-than-wide shape (80.0%) were US features showing correlations with malignancy (P < 0.05). Intraoperative FS significantly predicted malignancy (P < 0.05). Of the 78 cases with FS, 29 cases (37.2%) were deferred. Among the remaining 49 cases, 4 (5.1%) were malignant on FS and subsequent surgical pathology. Forty-five cases (57.7%) were diagnosed as benign on FS, but only two cases were diagnosed as malignant on surgical pathology.

CONCLUSIONS

Ultrasound is a feasible method in predicting malignancy in thyroid nodules with indeterminate FNAB cytology. Also, intraoperative FS is a supportive method with high specificity that may guide the treatment of thyroid nodule with indeterminate cytology.

Operative strategy for follicular thyroid cancer in risk groups stratified by pTNM staging

This study determined cancer survival rates and follow-up status at different pTNM stages to stratify risk groups in follicular thyroid carcinoma. Two hundred and fourteen follicular thyroid cancer patients (167 females, 47 males) who underwent surgery and followed-up treatment at a single medical center were enrolled in this retrospective study. Tumors were staged by UICC-TNM criteria (6th edition). Low risk for follicular thyroid cancer was defined as pT1N0M0. (Moderate-risk group) was defined as all other patients in pTNM stage I, and high risk as patients in stages II-IV. After mean follow-up of 9.6+/-0.3 years, 1.6% (2/120), 21.9% (7/32), 5.6% (1/18) and 52.3% (23/44) of patients in pTNM stages I-IV, respectively, died of thyroid cancer. Of 214 follicular thyroid cancer patients, 35 (16.4%), 85 (39.7%) and 94 (43.9%) were defined as low-, moderate- and high-risk groups at the time of surgery. None of the low-risk patients died, and all achieved disease-free status. In the moderate- and high-risk groups, 2.4% (2/85) and 27.7% (26/94) died of thyroid cancer. The moderate- and high-risk groups underwent near-total thyroidectomy and (131)I therapies, and 15 of 107 (14.9%) died of thyroid cancer while 18 (16.8%) had persistent disease at the end of the study period. Multiple regression analysis demonstrated that tumor size, radioactive iodide therapy and post-operative thyroglobulin level significantly differ between the mortality and survival groups. In conclusion, the low-risk follicular thyroid cancer group as defined by pTNM staging had excellent prognosis. Total thyroidectomy and post-operative radioactive iodide therapy are mandatory in moderate- and high-risk groups. Over one-fourth of the follicular thyroid cancer patients in the high-risk group died of thyroid cancer despite aggressive treatment.

Intraoperative pathologic examination: cost effectiveness and clinical value in patients with cytologic diagnosis of cellular follicular thyroid lesion

OBJECTIVE

Routine use of intraoperative pathologic examination (IOPE), including frozen section (FS) and scrape preparation cytology (SPC), during diagnostic thyroid lobectomy continues to be a source of controversy. We sought to better delineate the usefulness and cost-benefit ratio of IOPE in the context of cytologically diagnosed cellular follicular lesion (CFL) or follicular neoplasm (FN).

DESIGN

Records of 205 patients who underwent thyroidectomy for cytologically diagnosed FN or CFL between 1997 and 2005 were retrospectively reviewed. IOPE results, patient demographics, and tumor characteristics were correlated to final histopathologic diagnoses. Sensitivity, specificity, predictive values, accuracy, and costs of IOPE were calculated.

MAIN OUTCOME

IOPE correctly identified 3 of 16 follicular carcinomas and 9 of 36 papillary carcinomas. Sensitivity, specificity, and accuracy were 23%, 99%, and 78%, respectively. On univariate analysis, malignancy risk among follicular nodules did not correlate with age, gender, or nodule size. On multivariate analysis, nodule size was predictive of malignancy (p < 0.05). Over the entire patient series, routine IOPE resulted in a net cost savings of $74,304.33.

CONCLUSIONS

IOPE reduced costs and limited the number of completion thyroidectomies necessary. IOPE is specific, cost effective, and of minimal additional risk when performed routinely for patients with CFL or FN.

Role of frozen section associated with intraoperative cytology in comparison to FNA and FS alone in the management of thyroid nodules

AIMS

The utilization of fine needle aspiration (FNA) biopsy is an accurate and cost-effective method in the diagnosis of thyroid diseases. However, the non-diagnostic cases and cases of suspicious carcinoma remain a dilemma, and in these cases thyroidectomy is usually recommended, even if only 15-20% of these patients really need a thyroidectomy. To avoid unnecessary surgical treatment, frozen section (FS) is usually performed. This method is well recognized, but is not useful for the diagnosis of follicular lesions. Therefore, many authors have tried to increase the specificity and sensibility of intraoperative examination, supporting it with an intraoperative cytological technique (IC). To clarify the role of intraoperative exam (FS and IC), also comparing to FNA, we have reviewed our own experiences.

METHODS

In a period covering 6 years (2000-2005), FS was performed in 1,472 cases out of 11,420 total thyroidectomy operations. FS diagnosis and definitive diagnosis, were reviewed and confirmed, moreover, FNA diagnosis and definitive diagnosis were also considered and all intraoperatory cytological slides were reviewed. Diagnostic accuracy was assessed for FNA and FS with or without intraoperative cytology. We compared 1,472 FS diagnoses with their definitive histological diagnosis; 728 FNA out of 1,472 patients with definitive histological diagnosis, and 564 FS associated with IC out of 1,472 patients with definitive diagnosis.

RESULTS

The diagnostic accuracy of these three methods were, respectively, 88.8%, 88.8% and 95.7%.

CONCLUSION

We can assert that FS associated with IC remains the most accurate technique in the surgical management of thyroid nodules.

Surgical Treatment of Solitary Thyroid Nodules Via Fine-Needle Aspiration Biopsy and Frozen-Section Analysis

BACKGROUND

Fine-needle aspiration biopsy (FNAB) and frozen-section analysis of managing solitary thyroid nodules continue to generate considerable controversy.

METHODS

This study was a retrospective review of 619 patients with solitary thyroid nodules who underwent thyroidectomy.

RESULTS

Of 540 FNABs, 35 (6.5%) were positive for malignancy, 276 (51.1%) were benign, and 229 (42.4%) were suspicious. Only 5.1% were false negative, and 11.4% were false positive. Diagnostic FNAB sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy for malignancy were 86.1%, 59.7%, 33.0%, 94.9%, and 64.6%, respectively. Of 569 patients analyzed by frozen section, diagnosis was deferred in 86 (15.1%) patients, and results were positive for malignancy in 92 (16.2%) and benign in 391 (68.7%). No false-positive results were noted, but 2.3% (391) were false negative. Of 86 deferred frozen sections, 11 (12.8%) patients had malignant tumors confirmed by permanent section. Diagnostic frozen-section sensitivity, specificity, PPV, NPV, and accuracy for carcinoma were 82.1%, 100%, 100%, 95.8%, and 96.5%, respectively. Sensitivity, specificity, PPV, NPV, and accuracy for frozen-section analysis for diagnosis of carcinoma in patients with suspicious FNAB were 83.9%, 100%, 100%, 94.9%, and 96.0%, respectively.

CONCLUSIONS

FNAB is a sensitive diagnostic modality in selecting patients who require surgery. Routine use of frozen-section analysis is unwarranted for benign FNAB results. Frozen section is specific and cost-effective in determining the extent of surgery in patients with suspicious or malignant FNABs.

Surgery for thyroid Hürthle cell tumours—a single institution experience

AIMS

The objective of the study was to report a series of patients with Hürthle cell tumours.

METHODS

We reviewed medical records of single institution from January 1982 to December 2002, including follow-up information.

RESULTS

We identified 199 patients with Hürthle cell tumours (HCT), 88 patients with Hürthle cell carcinoma (HCC) and 111 patients with Hürthle cell adenoma (HCA). The HCC group had significantly longer duration of the disease and larger tumours (4.8 vs 3.8 cm) compared with HCA group. Gender appeared to play significant role in patients with HCT (women outnumbered man by 7:1; p < 0.01). Surgical management for 80% of patients with HCA consisted of hemithyroidectomy and total thyroidectomy in 87% patients in the HCC group. Temporary laryngeal nerve palsy and temporary hypoparathyroidismus were not seen in HCA group, in HCC group were confirmed in 2.27 and 3.41%, respectively. Four patients with HCC relapsed and two died of HCC.

CONCLUSIONS

HCC has outlook for favorable outcome when treated radically with total thyroidectomy.

Fine-needle aspiration optimizes surgical management in patients with thyroid cancer

BACKGROUND

Fine-needle aspiration (FNA) is accurate in diagnosing papillary, medullary, and anaplastic thyroid cancer, as well as lymphoma. Although many surgeons routinely perform FNA before surgery, some question whether FNA influences operative management. Therefore, to determine whether FNA affects surgical management in patients with thyroid cancer, we reviewed our experience.

METHODS

A total of 442 consecutive patients underwent thyroid surgery at 1 academic center. Of these, 411 had surgery for an index nodule in the absence of previous radiation or familial thyroid cancer. FNA, operative, and permanent histology findings were reviewed.

RESULTS

The average patient age was 46 years, and 79% were female. A total of 211 patients (51%) had a preoperative FNA, and 71 (17%) had a final diagnosis of cancer. The sensitivity and specificity of FNA for thyroid cancer were 89% and 92%, respectively. In the FNA group, 1 (2.4%) of 41 patients with papillary thyroid cancer required completion thyroidectomy. In contrast, in the no-FNA group, 4 (40%) of 10 patients with papillary thyroid cancer required a second operation. No patient in the FNA group received thyroid resection for lymphoma, whereas three (100%) of three patients with lymphoma in the no-FNA group were treated surgically. A total of 98% of the FNA group, compared with 54% of the no-FNA group, received optimal surgical treatment for thyroid cancer.

CONCLUSIONS

FNA is a sensitive and specific test for the diagnosis of thyroid cancer, allowing definitive initial surgery and avoiding unnecessary procedures. Therefore, we recommend routine use of preoperative thyroid FNA, even in those patients in whom a resection is already planned.

Surgical Treatment of Hurthle Cell Tumors of the Thyroid

Hurthle cell tumors are relatively rare thyroid tumors and their management and prognosis is controversial. We retrospectively review 135 Hurthle cell adenomas and 28 Hurthle cell carcinomas of the thyroid surgically treated at our institute. No significant difference was found between the adenoma and carcinoma groups in patient age, gender, and tumor size. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of fine-needle aspiration cytology (FNAC) in detecting malignancy were 87.5%, 19.3%, 31.2%, 18.6%, and 88.0%. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of frozen section in detecting malignancy of the thyroid gland were 40.0%, 100.0%, 92.9%, 100.0%, and 92.0%. Most of the adenomas were treated with procedures no less invasive than lobectomy/isthmusectomy. Meanwhile, most of the carcinoma patients underwent total thyroidectomy. Operative morbidity occurred in six patients (3.8%), including transient recurrent laryngeal nerve palsy in three patients, damage to the external branch of the superior laryngeal nerve in two patients, and transient hypocalcemia in one patient. No recurrence of Hurthle cell adenomas was noted. Five adenoma patients died of causes unrelated to their Hurthle cell tumors, but no carcinoma patients died during the follow-up period. In conclusion, clinical factors and FNAC are not helpful in the differentiation between adenoma and carcinoma. Unilateral Hurthle cell adenoma can be treated by lobectomy/isthmusectomy, and Hurthle cell carcinoma can be treated by total thyroidectomy with minimal operative morbidity.

PPARgamma staining as a surrogate for PAX8/PPARgamma fusion oncogene expression in follicular neoplasms: clinicopathological correlation and histopathological diagnostic value

The PAX8/PPARgamma (PPFP) fusion-oncogene is moderately specific for follicular thyroid carcinomas (FTC). It remains unknown whether this can be translated into improved diagnosis, classification, or outcome prediction. We studied a cohort of well-characterized follicular adenomas (FA), FTC, and Hurthle cell carcinomas (HCC) from patients with complete clinical follow-up, to determine whether PPARgamma immunohistochemistry (as a surrogate of PAX8/PPARgamma expression) helps to distinguish FA from FTC and to assess its diagnostic accuracy as an adjunct to frozen section. We also correlated PPARgamma staining with clinical outcomes to assess its role as a prognostic marker.PPARgamma staining was more common in FTC (31 of 54; 57%) than in HCC (one of 23; 4%) or FA (four of 31; 13%) (P < 0.000001). Adjunctive use of PPARgamma immunohistochemistry improved diagnostic sensitivity of intraoperative frozen section from 84% to 96% (P < 0.05) but reduced specificity from 100% to 90% (P < 0.05). PPARgamma staining was associated with favorable prognostic indicators (female gender, better tumor differentiation, and lesser risk of metastases).PPARgamma staining may be helpful in the differential diagnosis of FA, FTC, and HCC, particularly when diagnostic sensitivity of histomorphology is reduced (e.g. during intraoperative frozen section). PPARgamma staining also shows an association with favorable prognosis and may have a role in risk stratification.

Role of intraoperative frozen section in the management of thyroid nodules

BACKGROUND

The role of intraoperative frozen section in the management of thyroid nodules is controversial. Its potential benefit is to facilitate one-stage total thyroidectomy. Most literature on this topic originates from overseas tertiary referral centres with a high percentage of cancer cases and a fully resourced frozen section service. The aim of the present study was to review all patients undergoing frozen section at a typical general surgical department in New Zealand (North Shore Hospital, Auckland) to see how often frozen section altered surgical strategy.

METHODS

A retrospective review of all frozen sections between November 1999 and June 2003 was performed. Patient records, operation notes and pathology reports were reviewed.

RESULTS

Forty-seven sequential frozen sections were included in the study. Thirteen patients had thyroid carcinoma (five follicular, three Hurthle cell, and five papillary). In only one patient did the result of an intraoperative frozen section result in a total thyroidectomy being performed instead of a thyroid lobectomy. The reason for this was the rare condition of Riedel's thyroiditis. In no patients did frozen section detect a cancer that was not diagnosed on preoperative fine-needle aspirate biopsy.

CONCLUSION

The present review found little benefit in performing intraoperative frozen section in this setting. As a diagnostic test the cost of frozen section (NZ $200 for each frozen section) needs to be weighed against its low clinical benefit.

Current Strategies for Surgical Management and Adjuvant Treatment of Childhood Papillary Thyroid Carcinoma

Childhood papillary thyroid carcinoma is associated with more locally aggressive and more frequent distant disease than its adult counterpart. Recurrence rates tend to be higher in children, but cause-specific mortality remains low. Optimal initial treatment of childhood papillary thyroid carcinoma should include total or near-total thyroidectomy and central compartment node clearance. Modified neck dissections should be performed for biopsy-proven lateral neck disease. Every effort should be made to maintain parathyroid and laryngeal nerve function. Radical neck dissections are to be avoided. Radioiodine remnant ablation (RRA), appropriate thyroid hormone suppressive therapy (THST), and judicious use of therapeutic doses of (131)I are applied to achieve a disease-free status, which is most often confirmed by negative neck ultrasonography, negative whole-body scan (either withdrawal or recombinant human thyroid-stimulating hormone-stimulated), and extremely low levels of serum thyroglobulin. Appropriate utilization of (131)I, THST, repeat surgery, external beam radiotherapy, and rarely chemotherapy may provide long-term palliation and some cures in patients with recurrent/persistent disease. Follow-up should be lifelong, and the care of children after age 17 should subsequently be transferred to adult-care endocrinologists with expertise in managing thyroid neoplasia. Optimal surgical management can be achieved if adequate operations are routinely carried out by "high-volume" thyroid surgeons with expertise in the care of children. Nowhere is a multidisciplinary approach (endocrinologists, surgeons, nuclear medicine physicians, pediatricians, pathologists, oncologists) more critical than in the long-term management of papillary thyroid carcinoma that presents during childhood.

Factors Predicting Malignancy of H�rthle Cell Tumors of the Thyroid: Influence on Surgical Treatment

Controversy still exists about the ability to differentiate between malignant and benign Hürthle cell tumors (HCTs) before and during surgery. Diagnostic difficulties make surgical decisions debatable. The aim of this study was to evaluate factors predicting the malignancy of HCT and to plan its appropriate management. From January 1998 to May 2003 a series of 41 patients underwent thyroidectomy in our surgical department because of HCT. A cross-sectional study of 23 patients with carcinoma and 18 patients with adenoma was carried out: demographic data, tumor characteristics, diagnostic results of fine-needle aspiration cytology (FNAC), frozen section (FS), MIBI scan scintigraphy, surgical indications, and treatment were evaluated. The mean tumor size was significantly greater for carcinomas than adenomas (3.1 vs. 1.9 cm; p = 0.006). Threshold sizes of more than 3.0 cm and 4.0 cm, respectively, were significant for predicting malignancy ( p = 0.025 and p = 0.012). Conversely, 47.8% of carcinomas had a diameter smaller than 3.0 cm. FNAC and FS sensitivities for carcinoma detection were 23.8% and 33.3%, respectively. The positive uptake on MIBI scan imaging was likely to be similarly malignant or benign. Because of the lack of accuracy of all diagnostic studies for predicting malignancy, all oxyphilic cell nodules should be referred to surgery. Different tumor sizes cannot be the only factor on which to base a surgical decision. Therefore, because of diagnostic uncertainties, we believe that an experienced surgeon can safely perform total thyroidectomy in all patients with an HCT.

Utility of frozen-section examination for diagnosis of malignancy associated with multinodular goiter

BACKGROUND

Frozen-section examination (FSE) has traditionally been used for the intraoperative diagnosis of thyroid cancer. However, the utility of the technique is now controversial, especially in multinodular goiter (MNG), on which there are few studies. The aim of this study was to analyze the utility of FSE for ruling out malignancy in patients undergoing surgery for MNG.

PATIENTS AND METHODS

FSE was performed in 197 patients with MNGs undergoing surgery for suspected malignancy, either preoperatively (n = 145; 74%) or intraoperatively (n = 52; 26%), and where the preoperatively planned surgical technique was partial resectional surgery. The FSE diagnosis was classified as benign, suggestive of malignancy, or malignant. The following FSE parameters were calculated for diagnosing MNG-associated carcinoma: true- and false-positives and true- and false-negatives, sensitivity, specificity, positive and negative predictive values, and diagnostic accuracy. The chi2 and Student's t tests were applied.

RESULTS

The FSE revealed benignity in 191 cases (97%), suggested malignancy in 3 (1.5%), and were malignant in the remaining 3. The final histology revealed 16 carcinomas (8%), of which only 3 were detected by FSE. Only tumor size was a factor significantly associated with FSE carcinoma detection (p = 0.0012). The sensitivity of the technique for detecting carcinoma was 19%, specificity, 100%; positive predictive value, 100%; negative predictive value, 93%; and diagnostic accuracy, 93%.

CONCLUSIONS

FSE should not be used routinely in the management of MNG, and considering its low rate of sensitivity for detecting malignancy, the decision on the extent of the thyroidectomy should be based on other factors and explorations.

The utility of frozen section evaluation for follicular thyroid lesions

BACKGROUND

Because fine-needle aspiration cannot reliably discriminate between benign and malignant follicular thyroid lesions, some surgeons use intraoperative frozen section (FS) to guide operative management. To determine the utility of FS for these lesions, we reviewed our institutional experience.

METHODS

Between 1994 and 2001, 152 patients underwent surgical resection for follicular neoplasms.

RESULTS

The mean age of the patients was 47 years, and 76% were female. Forty-one (32%) FSs were reported as benign, 5 (4%) as malignant, and 3 (2%) as indeterminate, and in 80 (62%), the diagnosis was "follicular lesion, deferred to permanent histology." On paraffin section, all patients with malignant FSs had thyroid cancer, and all 41 patients with benign FSs had benign lesions. Thus, FS for diagnosis of follicular thyroid cancer had a sensitivity, specificity, positive predictive value, and accuracy of 67%, 100%, 100%, and 96%, respectively. In most cases (64%), FS rendered no additional information at the time of operation. Therefore, the cost per useful FS was $7800, which is higher than the charge of a completion thyroidectomy (approximately $6000).

CONCLUSIONS

FS analysis for follicular lesions seems to be highly specific and accurate. However, because of the low sensitivity, routine use of FS is not cost-effective in patients with follicular thyroid lesions.

Fine-needle aspiration of the thyroid and correlation with histopathology in a contemporary series of 240 patients

BACKGROUND

False-positive, false-negative, and indeterminate fine-needle aspiration (FNA) biopsy results complicate the management of patients with thyroid nodules.

METHODS

Thyroid FNA results from 240 consecutive patients (seen 1991 to 2002) were categorized into four groups: positive for malignancy, negative for malignancy, indeterminate for malignancy, and nondiagnostic. Indeterminate results included follicular neoplasm, Hürthle cell neoplasm, and suspicious for papillary carcinoma. The FNA results were compared with histopathologic analysis after thyroidectomy.

RESULTS

The FNA results were 76 (32%) positive for malignancy, 53 (22%) negative for malignancy, 100 (42%) indeterminate for malignancy, and 11 (5%) nondiagnostic. There were 3 (4%) false-positive and 2 (4%) false-negative FNA results. Among the 100 indeterminate FNA results, carcinoma was found in 11 (15%) of 73 follicular neoplasms, 2 (20%) of 10 Hürthle cell neoplasms, and 14 (82%) of 17 suspicious for papillary carcinoma. For the 73 patients with follicular neoplasms, nodule diameter >2 cm was associated with an increased risk of malignancy (P <0.03).

CONCLUSIONS

False-negative FNA results are uncommon, supporting the practice of observation in most of these patients. Among those with indeterminate biopsy results, high-risk subgroups include patients with FNA results suspicious for papillary carcinoma and follicular neoplasms >2 cm.

The value of frozen section in intraoperative surgical management of thyroid follicular carcinoma

BACKGROUND

Preoperative and intraoperative diagnosis of follicular carcinoma (FC), resulting in one-stage surgical treatment of follicular thyroid tumors, is an important issue in thyroid surgery.

METHODS

In the 10-year period there were 4158 operations performed on thyroid gland. There were 1559 patients with follicular tumors, 70 (4.4%) of them having FC. We analyzed the groups of patients with FC determined on frozen section (FS) and permanent section (PS) according to duration of clinical symptoms, ultrasound (US) examination, tumor size, patient gender and age, intensity of invasion, localization, and multiple or solitary occurrence of tumor.

RESULTS

FC was diagnosed in 39 (55.7%) patients on frozen section (FS). Among the encapsulated (minimal invasion) carcinomas, the FS was accurate in 19 of 33 (57.6%) FC and in 5 of 15 (27.8%) Hürthle cell carcinomas (HCC); among extensively invasive carcinoma in 11 of 14 (78.6%) FC and in 4 of 5 (80.0%) HCC. FC was significantly more common in men (p <.001) and in the right lobe (p <.05). We did not find statistically significant differences concerning duration of symptoms, US examination, tumor size, patient age, and multiple or solitary occurrence of the tumor between the patients with FC diagnosed on FS and the patients with FC diagnosed on PS.

CONCLUSIONS

The intraoperative diagnosis of FC is difficult. Although the percentage of false-negative results was relatively high (44.3%), there were no false-positive results. This means that the second operation was avoided in 55.7% of the patients, and no unnecessary thyroidectomies were performed. FS biopsy is an important method in surgery of follicular tumors. Improved technical support and the ability to analyze a greater number of slides will increase the accuracy of the method.

Diagnostic value of frozen section examination in thyroid nodule--surgery at the Shariati Hospital (1997-2000)

INTRODUCTION

There is controversy regarding the use and accuracy of frozen section (FS) in managing thyroid nodules. We compared the diagnostic value of FS with that of permanent histopathology examination and fine needle aspiration (FNA).

MATERIALS AND METHODS

Permanent, FS, and FNA sample reports were compared in 214 patients between 1997 and 2000. FS, FNA, and permanent pathology (gold standard) results were compared using McNemar's test.

RESULTS

160 women and 54 men (mean age: 42.3 +/- 5.4 yr) took part in the study; 163 patients (76%) had benign and 51 (24%) malignant lesions; 76% of our thyroid cancer cases were papillary, 13.5% follicular, 6% medullary carcinoma, 4% Hürthle cell carcinoma, and 0.5% anaplastic carcinoma. FNA yielded definite results in 150 patients (sensitivity 72%, specificity 96%, and precision 90%). In 64 patients with equivocal FNA, FS was performed (sensitivity 36%, specificity 73%, and precision 85%). The observed difference between FNA and FS was not statistically significant.

DISCUSSION

When FNA results are inconclusive, FS does not provide any further information. In suspected cases of papillary, undifferentiated, or medullary carcinomas, FS can confirm FNA findings and guide surgical therapy.

Radioactive iodine lobe ablation as an alternative to completion thyroidectomy for follicular carcinoma of the thyroid

We performed a retrospective record review of patients who received large lobar remnant ablation after surgery for well-differentiated thyroid carcinoma including 30 with papillary carcinoma, 14 with follicular carcinoma, and 6 with Hürthle cell carcinoma. We compared these 50 patients to a group of patients who underwent total or near-total thyroidectomy for well-differentiated thyroid carcinoma. The ablation group was treated with single outpatient doses of 29.9 mCi (131)I to prepare for whole-body radioiodine scanning. Subsequent serum thyrotropin (TSH) concentration during thyroid hormone withdrawal was greater than 25 microU/mL in 94% of patients. The mean TSH in this population (76 microU/mL) was not statistically different from a group of 50 patients who underwent total or near-total thyroidectomy (mean, TSH 71 microU/ml p = 0.84). Twenty-four hour radioiodine uptake post-29.9 mCi (131)I ablation was less than 1% in 80% of patients. The mean radioiodine uptake (0.8%) in the lobe ablation population was significantly lower than in patients treated with total thyroidectomy (mean, 2.4%, p < 0.001). There was minimal morbidity after 29.9 mCi (131)I ablation of large lobar remnants. Outpatient 29.9 mCi (131)I ablation is a safe, effective, and less costly alternative to completion thyroidectomy in selected patients. Although we included patients with both papillary and follicular carcinoma in our review, we recommend this method for patients with minimally invasive follicular carcinoma requiring whole body scanning, even with large postsurgical remnants in place.

Can Fine-Needle Aspiration Biopsy of Thyroid Nodule Help in Determining the Extent of Surgery in Follicular and Hurthle Cell Neoplasm at a Community Teaching Institution?

Fine-needle aspiration biopsy (FNAB) was used to evaluate cold thyroid nodules in 179 patients treated between 1990 and 1998. The purpose of this study was to see whether FNAB findings of follicular or Hurthle cells could help in planning the extent of thyroid surgery. Group I patients (47) had findings suggestive of follicular or Hurthle cell neoplasm. Group II patients (132) had inconclusive results. In group I FNAB was 100 per cent correct in diagnosing follicular or Hurthle cell neoplasm with a high percentage of malignant findings (malignancy 85 per cent and benign adenoma 15 per cent). In Group II malignancy was found in 16 per cent and benign pathology in 84 per cent. Women were more likely to have malignancy than men. The average age was over 50 years in patients with either malignant or benign nodules. In addition there was no significant difference in average size of benign or malignant nodules (2.9 vs 2.6 cm respectively). When an FNAB finding was suggestive of neoplasm malignancy was found in 85 per cent. On the other hand when an FNAB was inconclusive malignancy was present in 16 per cent. Thus we conclude that using FNAB finding can guide surgical resection and recommend performing total or subtotal thyroidectomy when FNAB is suggestive of neoplasm and lobectomy when FNAB is inconclusive.

Role of fine-needle aspiration biopsy and frozen-section evaluation in the surgical management of thyroid nodules

BACKGROUND

The role of routine frozen section (FS) in the surgical management of thyroid nodules remains uncertain. This study reviewed the role of FS in the presence of an adequate fine-needle aspiration biopsy (FNAB).

METHODS

FNAB and FS were evaluated in 206 patients who had surgery for a thyroid nodule. Cytological specimens were classified as benign, malignant or suspicious. The FS diagnoses were benign, malignant or deferred.

RESULTS

A cytological diagnosis was obtained in 93 nodules; the remaining 113 were classified as suspicious, of which 21 were malignant on definitive examination. The overall accuracy of FNAB was 53 per cent. FS evaluation identified 165 lesions as benign; the diagnosis was deferred until definitive histological evaluation in only eight. The overall accuracy, therefore, was 96 per cent. Routine use of FS was cost-effective; lowering the number of reoperations led to an estimated saving of about 40 per cent.

CONCLUSION

These data suggest that FS remains an important tool in the surgical management of thyroid nodules and can reduce the number of patients requiring reoperation.

Hürthle cell tumor of the thyroid: analysis of 188 cases

We reviewed 188 cases of Hürthle cell tumor of the thyroid (HCT) between 1982 and 1996. There were 160 women and 28 men with a mean age of 51.8 years. Thirty-one of the patients had cancer, and the others had adenoma. Age, size of the primary tumor, and preoperative thyroglobulin level were not significantly different in the cancer and adenoma patients. The gender ratio, however, was significantly different (p < 0.05). Recurrent HCT was observed in three patients with adenoma. Two patients had subcutaneous recurrence (suspected implantation), and the other patient had recurrence in the residual thyroid gland. All patients with recurrence of adenoma underwent partial lobectomy at the initial operation. Three cancer patients had recurrent disease. Locoregional recurrence was observed in one patient and distant metastases in two patients (lung in one, lung and bone in one). One of the patients with distant metastasis died from the disease, and the other is alive with the disease. Tumor implantation was observed in patients with adenoma, so intraoperative handling of the tumor requires care. It also means that this tumor, even though benign, is aggressive in terms of proliferative activity. All patients with Hürthle cell tumor should be treated by total lobectomy at least. The outcome of the cancer patients was not as poor as in previous reports.

Randomized prospective evaluation of frozen-section analysis for follicular neoplasms of the thyroid

OBJECTIVE

To evaluate the clinical utility of frozen section in patients with follicular neoplasms of the thyroid in a randomized prospective trial.

SUMMARY BACKGROUND DATA

The finding of a follicular neoplasm on fine-needle aspiration prompts many surgeons to perform intraoperative frozen section during thyroid lobectomy. However, the focal distribution of key diagnostic features of malignancy contributes to a high rate of noninformative frozen sections.

METHODS

The series comprised 68 consecutive patients with a solitary thyroid nodule in whom fine-needle aspiration showed a follicular neoplasm. Patients were excluded for bilateral or nodal disease, extrathyroidal extension, or a definitive fine-needle aspiration diagnosis. Final pathologic findings were compared with frozen sections, and cost analyses were performed.

RESULTS

Sixty-one patients met the inclusion criteria. Twenty-nine were randomized to the frozen-section group and 32 to the non-frozen-section group. In the non-frozen-section group, one patient was excluded when gross examination of the specimen was suggestive of malignancy and a directed frozen section was diagnostic of follicular carcinoma. Frozen-section analysis rendered a definitive diagnosis of malignancy in 1 of 29 (3.4%) patients, who then underwent a one-stage total thyroidectomy. In the remaining 28 patients, frozen section showed a "follicular or Hürthle cell neoplasm." Permanent histology demonstrated well-differentiated thyroid cancer in 6 of these 28 patients (21%). Of the 31 patients in the non-frozen-section group, 3 (10%) showed well-differentiated thyroid carcinoma on permanent histology. Complications were limited to one transient unilateral vocal cord dysfunction. All but one patient had a 1-day hospital stay. There were no significant differences between the groups in surgical time or total hospital charges; however, the charge per informative frozen section was approximately $12,470.

CONCLUSIONS

For the vast majority of patients (96.4%) with follicular neoplasms of the thyroid, frozen section is neither informative nor cost-effective.

Role of fine-needle aspiration biopsy and frozen section analysis in the surgical management of thyroid tumors

INTRODUCTION

The role of fine-needle aspiration (FNA) and frozen section (FS) in the management of thyroid neoplasms continues to generate considerable controversy. We reviewed our recent experience to determine the clinical utility of FNA and FS in our surgical management and intraoperative decision-making.

METHODS

All patients who had operations for thyroid disease between January 1996 and June 1999 were identified in our prospective database. Completion and incidental thyroidectomies were excluded. Data obtained from the pathology files included FNA, FS, and the final histologic diagnosis.

RESULTS

Five hundred sixty-four patients, including 409 women (73%), with a median age of 50 years (range, 6-94) were identified, of whom 293 (52%) had cancer diagnosed on permanent sections. Three hundred twenty-nine patients (58%) had evaluable FNA, of which 91 (28%) were benign, 94 were malignant (28%), and 144 (44%) were suspicious (46% of these were malignant on final). Frozen section was performed in 397 (70%) patients; of these samples, 170 (43%) were found to be benign, 106 (27%) were malignant, and 121 (30%) were deferred (46% malignant on final). Fine-needle aspiration positively identified 51% of confirmed malignancies; 13% of patients with malignancy had a benign FNA result. Total thyroidectomy was performed in 64% of malignant tumors and 29% of benign thyroid disease (P < .001). Logistic regression revealed no association of extent of surgery with FNA results. A frozen section positive for malignancy was associated with total thyroidectomy (P < .001, RR 6 [CI 3-10]), and a negative frozen section report was associated with lobectomy (P < .05, RR 0.5 [CI 0.3-0.96]). Frozen sections results altered the preoperative plan in only 29 patients (5%).

CONCLUSION

Results of preoperative FNA had no direct impact on the selection of the surgical procedure in this selected cohort. Intraoperative FS added very little to surgical management. The majority of thyroid operations at this institution are planned and performed based on known prognostic factors and intraoperative findings.