Thyroglobulin measurement on fine-needle washout fluids: Influence of sample collection methods

Diagnostic utilities of washout CYFRA 21-1 combined with washout thyroglobulin for metastatic lymph nodes in thyroid cancer: a prospective study

Cervical lymph node (LN) metastasis is common in differentiated thyroid cancer (DTC). This study evaluated the utility of the washout CYFRA 21-1 level, combined with the thyroglobulin (Tg) concentration, in terms of diagnosis of LN metastasis. We prospectively enrolled 53 patients who underwent thyroid surgery to treat DTC with lateral cervical LN metastases. Preoperative ultrasound guided needle localization was used to surgical sampling of specific LNs during the operation. The intraoperative washout Tg and CYFRA 21-1 levels were measured in such LNs. The Tg and CYFRA 21-1 levels differed significantly between metastatic and benign LNs. The cutoff values were 2.63 ng/mL for washout CYFRA 21-1 and 22.62 ng/mL for Tg. Combined use of the washout Tg and CYFRA 21-1 levels afforded the highest diagnostic accuracy (92.5%), better than that of individual markers. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) were 94.6%, 90.0%, 91.4%, 93.8%, respectively. The conjunction of the washout CYFRA21-1 and Tg levels enhances the diagnostic accuracy of LN metastasis in DTC patients. The washout CYFRA 21-1 level may be useful when malignancy is suspected, especially in cases where the cytology and washout Tg findings do not provide definitive results.

Diagnostic strategy of fine needle aspiration cytology of cystic cervical lymph node metastasis from papillary thyroid carcinoma

BACKGROUND

Cystic cervical lymph node metastasis from papillary thyroid carcinoma (CLMPTC) initially presents as cervical cystic lesions, which are often underdiagnosed as other cystic cervical lesions. There is no comprehensive diagnostic strategy of fine needle aspiration (FNA) cytology for CLMPTC.

METHODS

The clinical and FNA cytomorphology data of 87 patients with CLMPTC were analyzed. Thyroglobulin (TG) immunostaining was performed in 40 cases; BRAF V600E mutation was evaluated in 42 cases; the thyroglobulin (Tg) levels of aspiration fluids were assessed in 46 cases. Correspondingly, the data of 42 cases with solid cervical lymph node metastasis from papillary thyroid carcinoma (SLMPTC) and 32 cases with other cystic cervical lesions were collected as controls.

RESULTS

Compared with SLMPTC, CLMPTC has less classical PTC cytomorphology characteristics-for example, nuclear crowding/overlapping, nuclear irregular contours, etc. (p < .05). Additionally, micropapillary architecture and histiocyte-like tumor cells were more often observed in CLMPTC than in SLMPTC (p < .01). The positive rate of TG immunocytochemistry in CLMPTC was 100% (40/40). The positive rate of BRAF V600E mutation in CLMPTC was 81.0% (34/42), which was higher than that in SLMPTC (64.3%; 27/42) (p = .087). The Tg levels in aspiration fluids were significantly higher in CLMPTC (all>500 μg/L) than in other cervical cystic lesions (range: 2.9 μg/L to 40.1 μg/L) (p < .01).

CONCLUSION

To reduce underdiagnoses of CLMPTC, a reasonable diagnostic strategy, as summarized in this study is needed: according to the number of tumor cells, choosing immunocytochemistry (TG) and/or thyroglobulin in fine needle aspirates testing as auxiliary diagnostic measures.

Diagnostic performance of Midkine ratios in fine-needle aspirates for evaluation of Cytologically indeterminate thyroid nodules

Background

Fine-needle aspiration cytology (FNAC) is a basic diagnostic tool for thyroid nodules. However, 15–30% of nodules are cytologically indeterminate. Midkine (MK), a pleiotropic growth factor, is often upregulated in patients with cancers. This study aimed to evaluate the role of MK and its ratios in fine-needle aspirates (FNA) for predicting thyroid malignancy.

Methods

This retrospective study included patients with thyroid nodules who underwent preoperative FNA and/or thyroidectomy between April 2017 and September 2017. MK levels in FNA washout were measured by enzyme-linked immunosorbent assay, and thyroglobulin (TG) and free thyroxine (FT4) levels in FNA washout were measured by chemiluminescent immunometric assays.

Results

A total of 217 patients with 242 nodules were included in this study. The concentrations of TG, FT4, MK/TG, MK/FT4, and FT4/MK were significantly different between papillary thyroid carcinomas and benign thyroid nodules. Both MK/TG and MK/FT4 ratios were positively correlated with maximum tumor diameter, extrathyroidal extension, and T and N stages. The area under the curve for MK/TG was 0.719 with a cutoff value of 55.57 ng/mg, while the area under the curve for MK/FT4 was 0.677 with a cutoff value of 0.11 μg/pmol. FNAC in combination with MK/FT4 had a higher sensitivity (95% vs. 91%) and accuracy (96% vs. 92%) than FNAC alone for cytologically indeterminate specimens, those of unknown significance, or those suspected of malignancy.

Conclusions

MK/FT4 and MK/TG may have diagnostic utility for evaluation of papillary thyroid carcinomas, particularly for cytologically indeterminate thyroid nodules.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13000-021-01150-y.

The diagnostic value of thyroglobulin in fine-needle aspiration of metastatic lymph nodes in patients with papillary thyroid cancer and its influential factors

Thyroglobulin (Tg) measurement in fine-needle aspiration (FNA-Tg) has proved to be an excellent tool to identify metastatic cervical lymph nodes (CLN) before or after surgery for papillary thyroid cancer (PTC). The diagnostic value of FNA-Tg for metastatic CLN in PTC patients is higher than that of ultrasound (US) and fine-needle aspiration cytology (FNAC), especially for small or cystic LN. The combination of FNAC and FNA-Tg can provide nearly 100% diagnostic sensitivity and specificity for CLN metastasis. However, the cutoff values of FNA-Tg for metastatic CLN have not been standardized, and the reported cutoff values of FNA-Tg range from 0.2 ng/ml to 77 ng/ml because of the differences in study samples, Tg measurement methods, Tg assays kits, etc. Serum anti-thyroglobulin antibody level, serum thyroglobulin level, the presence or absence of thyroid glands, and the characteristics of CLN may be factors affecting the accuracy of FNA-Tg. This review summarizes the recent research on the application of FNA-Tg in the diagnosis of metastatic LN in PTC and provides a reliable basis for the clinical diagnosis of cervical lymph node metastasis.

Lateral neck multilevel fine-needle aspiration cytology and thyroglobulin estimation in papillary thyroid carcinoma

OBJECTIVE

To assess the accuracy of preoperative ultrasound-guided multilevel fine-needle aspiration (FNA) cytology and thyroglobulin (Tg) estimation in mapping metastatic levels in the lateral neck, in patients with papillary thyroid carcinoma (PTC).

METHODS

Patients with PTC clinically metastasizing to the lateral neck who were initially treated at the Peking University Cancer Hospital from June 2018 to September 2020 were included. FNA was performed preoperatively in each suspicious neck level; cytological examination (FNA-C) and Tg measurement of the needle-washout fluid (FNA-Tg) were combined to determine metastasis. FNA-Tg cutoff value was calculated, and the accuracy of FNA at different levels were evaluated.

RESULTS

In total, 111 patients underwent 124 lymph node dissections. The best cutoff value of FNA-Tg for the diagnosis of metastatic level was 1.0 ng/mL. Multilevel FNA showed sensitivity, specificity, positive predictive value, and negative predictive value in predicting single-level metastasis of 100%, 61.0%, 43.9%, and 100%, respectively. In 64 (51.6%) cases, the involved levels diagnosed by FNA were consistent with that diagnosed by postoperative pathology.

CONCLUSION

FNA-Tg improves the diagnostic performance of FNA-C in lateral neck lymph node metastases. However, limited accuracy was obtained for preoperative multilevel FNA in predicting the extent of metastasis in the lateral compartment.

Pediatric differentiated thyroid carcinoma: An update from the APSA Cancer Committee

BACKGROUND

Differentiated thyroid carcinomas (DTCs) are rare in young children but represent almost 10% of all malignancies diagnosed in older adolescents.

METHODS

This article reviews the recent literature describing surgical therapeutic approaches to pediatric DTC, associated complications, and long-term recurrence and survival outcomes.

RESULTS

Similar to adult thyroid cancers, pediatric DTCs are more common in females and are associated with thyroid nodules, family history of thyroid cancer, radiation exposure, iodine deficiency, autoimmune thyroid disease, and genetic syndromes. Management of thyroid cancers in children involves ultrasound imaging, fine needle aspiration, and surgical resection with treatment decisions based on clinical and radiological features, cytology and risk assessment.

CONCLUSIONS

Total thyroidectomy and compartment based resection of clinically involved lymph node basins form the cornerstone of treatment of DTC. There is an evolving literature regarding the use of molecular genetics to inform treatment strategies and the use of targeted therapies to treat iodine refractory and surgically unresectable progressive disease.

TYPE OF STUDY

Summary review.

LEVEL OF EVIDENCE

This is a review article of previously published Level 1-5 articles that includes expert opinion (Level 5).

Clinical application of the ultrasound-guided fine needle aspiration for thyroglobulin measurement to diagnose lymph node metastasis from differentiated thyroid carcinoma-literature review

Papillary thyroid carcinoma (PTC) generally has a good prognosis, but disease recurs in 25% to 30% of PTC patients and significantly reduces the survival rate. Lymph node metastasis (LNM) is reported in 20% to 50% of PTC patients, mainly in the neck, and 20% originates from recurrence. LNM of papillary thyroid carcinoma are a plausible prognostic factor to determine disease recurrence. Currently, fine needle lymph node aspiration for cytology (LN-FN-cytology) is the best modality to diagnose LNM but is limited by diagnostic sensitivity and sample error. Fine needle lymph node aspiration for thyroglobulin measurement (LN-FNA-Tg) could offer a reliable and quantitative diagnostic method for LNM. The combination of LN-FNA-cytology and LN-FNA-Tg could achieve almost 100% diagnostic sensitivity and specificity for LNM. Both treatment guidelines of the American Thyroid Association and European Thyroid Association recommend LN-FNA-Tg to diagnose LNM after total thyroidectomy. Diagnostic accuracy of the LN-FNA-Tg depends on optimal equipment, scanning protocol, skill, and experience of operators. Normal saline is mainly used for aspiration needle wash-out and buffer solution. And radioimmunoassay or immunoradiometric assay are widely used for the LN-FNA-Tg measurement. So far, there is no consensus about the diagnostic threshold of LN-FNA-Tg for positive LNM, but high LN-FNA-Tg, especially higher than 10 ng/mL, strongly favors LNM.

CYFRA 21-1 in Lymph Node Fine Needle Aspiration Washout Improves Diagnostic Accuracy for Metastatic Lymph Nodes of Differentiated Thyroid Cancer

Fine needle aspiration cytology (FNAC) and washout thyroglobulin (Tg) measurements are the standard for evaluating a metastatic lymph node (LN) in thyroid cancer. However, patients rarely benefit from these procedures due to false results. This study aims to identify a reliable biomarker that significantly improves the diagnosis of metastatic LNs, in addition to FNAC and washout Tg. This study analyzed 130 LNs that were suspected to have metastases on thyroid ultrasonography, from June 2016 to December 2017. All subjects underwent FNAC, washout Tg measurements and a new biomarker, washout Cytokeratin fragment 21-1 (CYFRA 21-1) measurement. The final LN outcomes were confirmed by surgical histology, repeat FNAC, or follow-up image. The diagnostic values of the presence of washout CYFRA 21-1 for diagnosing metastatic LNs were evaluated according to final LN outcomes. Among the 130 LNs, 42 were metastatic lesions and 88 were benign. The washout CYFRA 21-1 levels were significantly higher in metastatic LNs than in benign LNs. In contrast to the findings of washout Tg, washout CYFRA 21-1 showed little overlap between benign and malignant LNs, and its diagnostic cutoff values were not affected by surgery. The combinations of FNAC and washout CYFRA 21-1 showed higher sensitivity (91.9%), specificity (96.5%), negative predictive value (98.8%), and diagnostic accuracy (94.2%) than FNAC with washout Tg. The combination of FNAC, washout Tg, and washout CYFRA 21-1 showed the best sensitivity (98.8%). When washout CYFRA 21-1 was applied to the discordant results that were observed between FNAC and washout Tg, 20 of 22 LNs were correctly diagnosed. Washout CYFRA 21-1 measurements in thyroid LNs provide a diagnostic modality.

Measurement of thyroglobulin, calcitonin, and PTH in FNA washout fluids

Different imaging tools, circulating endocrine markers, and fine-needle aspiration (FNA) cytology are of great importance in the diagnosis and follow-up of different thyroid and parathyroid diseases. Sometimes, however, they are conflicting or inconclusive: interestingly, measuring endocrine markers (i.e. thyroglobulin, calcitonin, parathyroid hormone) in fluids from FNA proved to be a very useful complementary diagnostic tool in such cases. The determination of endocrine markers in fluids other than serum/plasma has been developed in the last years. Although studies have reported overall satisfactory results, a good standardization of procedures has not yet been reached, and further efforts should be made in order to better define pre-analytical, analytical, and post-analytical aspects. Here we reviewed critically the literature on the measurement of FNA endocrine markers, focusing on laboratory issues, such as preparation of the sample, choice of solution, and technical features of determination of these markers. Indeed, information for use of FNA-Tg, FNA-CT, and FNA-PTH in clinical practice was also provided.

Any detectable thyroglobulin in lymph node biopsy washouts suggests local recurrence in differentiated thyroid cancer

The sensitivity of local recurrence detection in differentiated thyroid cancer (DTC) is increased by measuring thyroglobulin in needle washouts from lymph node fine-needle aspiration biopsies (FNA-Tg). Recent studies have proposed minimum diagnostic threshold values for FNA-Tg and have reported interference from Tg antibodies (Tg Ab), leading to low or false-negative results. The aim of this study was to assess the utility of FNA-Tg in the diagnosis of local DTC recurrence in patients referred to a single pathology service used by our tertiary teaching hospital, the first such study in an Australian cohort. Data were collected from the pathology service database for FNA-Tg over an 18-month period, and the results of 69 FNA-Tg samples from 57 patients were obtained. FNA-Tg findings were compared with cytology and histology when patients proceeded to surgery. Using the functional sensitivity as the cut-off, detectable FNA-Tg (≥0.9 μg/l) had a sensitivity of 95.7%, specificity of 50% and positive predictive value of 95.7%. Our results suggest that detectable FNA-Tg leads to histological confirmation of local nodal DTC recurrence and would support a decision to proceed to surgery. Serum Tg Ab can, however, interfere with FNA-Tg measurements. Thus, we now recommend routine use of FNA-Tg washouts in all lymph node FNA biopsies for the detection of DTC recurrence.

Thyroglobulin in lymph node fine-needle aspiration washout: a systematic review and meta-analysis of diagnostic accuracy

CONTEXT

The thyroglobulin measurement in the needle washout after fine-needle aspiration (FNA) has been reported to increase the sensitivity of FNA in identifying lymph node (LN) metastases from differentiated thyroid cancer (DTC).

OBJECTIVE

The aim of the study was to estimate the diagnostic accuracy of this technique.

DATA SOURCES

To identify eligible studies, we searched electronic databases for original articles in English from 1975 through 2013.

STUDY SELECTION

Studies that enrolled participants with suspicious neck LNs during thyroid nodule workup or thyroid cancer follow-up were included.

DATA EXTRACTION

Working independently, authors used a standard form to extract data. For quality assessment, QUADAS2 guidelines were applied.

DATA SYNTHESIS

Including all the selected studies (24 studies, 2865 LNs) in the pooled analysis, overall sensitivity was 95.0% (95% confidence interval [CI], 93.7-96.0%), specificity was 94.5% (95% CI, 93.2-95.7%), and diagnostic odds ratio (DOR) was 338.91 (95% CI, 164.82-696.88) with significant heterogeneity (inconsistency [I(2)] = 65.7%; heterogeneity, P < .001). Stratifying different populations and including only patients with thyroid gland (410 LNs), pooled sensitivity was 86.2% (95% CI, 80.9-90.5%), specificity was 90.2% (85.1-94.0%), and DOR was 56.621 (22.535-142.26; I(2) = 37.3%; heterogeneity, P = .121). Including only patients after thyroidectomy (1007 LNs), pooled sensitivity was 96.9% (95% CI, 94.9-98.2%), specificity was 94.1% (91.7-96.0%), and DOR was 407.65 (198.67-836.46; I(2) = 0.0%; heterogeneity, P = .673).

CONCLUSIONS

Thyroglobulin measurement in washout from LN FNA has high accuracy in early detection of nodal metastases from DTC. The technique is simple, but a better standardization of criteria for patient selection, analytical methods, and cutoff levels is required.

Thyroglobulin in the washout fluid of lymph-node biopsy: what is its role in the follow-up of differentiated thyroid carcinoma?

BACKGROUND

The clinical evaluation of enlarged local lymph nodes (LNs) is difficult at the beginning and throughout the follow-up of differentiated thyroid carcinoma (DTC). Although the examination of samples collected from LNs by fine-needle aspiration biopsy cytology (FNAB-C) is extremely specific for the diagnosis of metastases, its sensitivity is low, especially in paucicellular samples.

SUMMARY

The measurement of thyroglobulin (Tg) in the fine-needle aspiration biopsy (FNAB) washout fluid (FNAB-Tg) increases the diagnostic performance of cytology to up to 100% sensitivity and specificity. However, the application of FNAB-Tg is currently hindered by the absence of methodological standardization, a lack of definite cutoff points, and the ongoing debate regarding its accuracy in nonthyroidectomized patients, those with elevated serum Tg, and those with circulating anti-Tg antibodies.

CONCLUSION

FNAB-Tg improves the diagnostic performance of FNAB-C in LN metastases, even when the latter is unable to diagnose the metastases. For that reason, FNAB-Tg should be included in the monitoring of DTC.

Cervical lymph node metastases from thyroid cancer: does thyroglobulin and calcitonin measurement in fine needle aspirates improve the diagnostic value of cytology?

Background

Measurement of thyroglobulin (Tg) protein in the washout of the needle used for fine needle aspiration biopsy cytology (FNAB-C) has been shown to increase the sensitivity of FNAB-C in identifying cervical lymph node (CLN) metastasis from well-differentiated thyroid cancer (TC). In this study, we evaluated whether routine measurement of Tg protein (FNAB-Tgp), Tg mRNA (FNAB-Tgm) and calcitonin (CT) mRNA (FNAB-CTm) in the FNAB washout of CLN increases the accuracy of FNAB-C in the diagnosis of suspicious metastatic CLN.

Methods

In this prospective study 35 CLN from 28 patients were examined. Histology showed metastatic papillary TC (PTC) in 26 CLN, metastatic medullary TC (MTC) in 3 CLN, metastatic anaplastic TC (ATC) in 3 CLN and 3 metastatic CLN from extra-thyroidal cancers.

Results

The overall accuracy of FNAB-C was 84.4%, reaching 95.7% when the analysis was restricted to PTC. Both FNAB-Tgp and FNAB-Tgm compared favorably with FNAB-C and shown diagnostic performances not statistically different from that of FNAB-C. However, FNAB-Tgp and FNAB-Tgm/FNAB-CTm were found useful in cases in which cytology results were inadequate or provided diagnosis inconsistent with patient's clinical parameters.

Conclusions

We demonstrated that FNAB-C, Tg/CT mRNA and Tg protein determination in the fine-needle washout showed similar accuracy in the diagnosis of metastatic CLN from TC. The results of this study suggest that samples for Tg protein and Tg/CT mRNA measurements from CLN suspicious for metastatic TC should be collected, but their measurements should be restricted to cases in which FNAB-C provides uninformative or inconsistent diagnosis with respect to patient's clinical parameters.

Lymph node thyroglobulin measurement in diagnosis of neck metastases of differentiated thyroid carcinoma

Aim. Enlarged cervical lymph nodes (LNs) in patients with thyroid cancer are usually assessed by fine-needle aspiration cytology (FNAC). Thyroglobulin (Tg) is frequently elevated in malignant FNAC needle wash specimens (FNAC-Tg). The objectives of the study were to (1) determine an appropriate diagnostic cut-off for FNAC-Tg levels (2) compare FNAC and FNAC-Tg results in a group of 108 patients affected by differentiated thyroid carcinoma (DTC). Methods. A total of 126 consecutive FNACs were performed on enlarged LNs and the final diagnosis was confirmed by surgical pathology examination or clinical follow-up. The best FNAC-Tg cut-off level was selected by receiver operating curve analysis, and diagnostic performances of FNAC and FNAC-Tg were compared. Results. The rate of FNAC samples adequate for cytological examination was 77% in contrast FNAC-Tg available in 100% of aspirates (P < .01). The sensitivity, specificity, and accuracy of FNAC were 71%, 80%, 74%, 100%, 80%, and 94%, respectively. The most appropriate cut-off value for the diagnosis of thyroid cancer metastatic LN was 1.1 ng/mL (sensitivity 100%, specificity 100%). Conclusions. The diagnostic performance of needle washout FNAC-Tg measurement with a cut-off of 1.1 ng/mL compared favorably with cytology in detecting DTC node metastases.

Measurement of human epidermal growth factor receptor type-2 extracellular domain and cancer antigen 15-3 levels in needle washout fluid: a potential adjunct to the cytological diagnosis of breast cancer

To determine whether the measurement of biomarkers in the needle washout fluid after fine needle aspiration cytology could strengthen cytological diagnosis, 29 benign lesions, 26 ductal carcinomas in situ (DCIS), and 95 invasive carcinomas of the breast were analyzed. Immediately after the aspiration samples were expelled onto glass slides, the needle was rinsed out with 2 ml of saline. Human epidermal growth factor receptor two extracellular domain (HER2-ECD) and cancer antigen 15-3 (CA 15-3) in the washout fluid were measured using chemiluminescence. The measuring limit for HER2-ECD (0.5 ng/ml) and that for CA 15-3 (4 U/ml) were used as the cutoff values, respectively. The proportion of patients with positive HER2-ECD values was 6.9% in cases of benign lesions, 26.9% in DCIS, and 10.5% in invasive carcinomas. The proportion of patients with positive CA 15-3 values was 6.9% in cases of benign lesions, 42.3% in DCIS, and 10.5% in invasive carcinomas. The proportion of patients with any biomarker elevation was 6.9% in cases of benign lesions, 46.2% in DCIS, and 15.8% in invasive carcinomas. Thus, biomarker elevation was most frequent in cases of DCIS, followed by invasive carcinomas (P < 0.01). HER2-ECD values over 6 ng/ml or CA 15-3 values over 25 U/ml were seen exclusively in cases of DCIS or invasive ductal carcinomas with an extensive intraductal component. If the biomarker status is included, 5 of 12 cases of DCIS with equivocal cytology categories would be upgraded. Further clinicopathological validation is necessary before applying this new approach to the clinical setting.