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Harris M, Zloczower E, Pinhas S, Allon R, Zornitzki T, Malka L, Cohen Y, Lahav Y, Cohen O. Consistency in the Distribution of Bethesda System for Reporting Thyroid Cytology Categories Over 9 Years: A Single Institute, Retrospective Study. Endocr Pract 2024; 30:546-550. [PMID: 38570016 DOI: 10.1016/j.eprac.2024.03.393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 03/07/2024] [Accepted: 03/28/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND The Bethesda System for Reporting Thyroid Cytopathology (BSRTC) has evolved since it was first introduced in 2009 to become a worldwide accepted cytologic analysis reference, due to its simplicity and reproducibility. To date, the consistency of BSRTC throughout time has yet to be investigated. METHODS Retrospective single institution case series with chart review of all patients who underwent fine-needle aspirations for a thyroid nodule in our institution between the years 2010 and 2018 with a documented BSRTC classification. Data collection included demographics, risk factors, sonographic evaluation, nodule size, and final pathology when feasible. The main outcome is the difference in the rates of BSRTC categories benign, atypia of undetermined significance (AUS), follicular neoplasm, suspicious for malignancy, and malignant (BSRTC II-VI, respectively) between the study years. RESULTS A total of 2830 thyroid nodules were included. BSRTC II-VI distribution was 83.9% (2373), 8.2%, (232), 2.7% (75), 3.3% (93), and 2.0% (57), respectively. There was no significant change in the overall trend of each BSRTC category distribution throughout the study. There was a significant increase in the benign cytology rate (BSRTC II) in 2011 compared to 2015 and 2018 (76.4% compared to 88.7% and 87.6%, respectively. P < .005) alongside a significant decline in the AUS category rate (BSRTC III) between the same years (13.0% compared to 4.8% and 5.5%, respectively. P < .005). CONCLUSION BSRTC showed consistency throughout the study across all observed categories. An overlap between AUS and benign may exist, possibly due to the heterogenic definition of AUS as reflected in the 2023 BSRTC subclassification for AUS.
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Affiliation(s)
- Mai Harris
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel; Medical School for International Health, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Elchanan Zloczower
- Department of Otolaryngology, Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel; Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Sapir Pinhas
- Department of Otolaryngology, Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel; Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Raviv Allon
- Department of Otolaryngology, Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel; Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Taiba Zornitzki
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel; Diabetes, Endocrinology and Metabolic Disease Institute, Kaplan Medical Center, Rehovot, Israel
| | - Liron Malka
- Department of Otolaryngology, Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel; Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yonatan Cohen
- Department of Otolaryngology, Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel; Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yonatan Lahav
- Department of Otolaryngology, Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel; Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Oded Cohen
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel; Department of Otolaryngology-Head and Neck Surgery, Samson Assuta Ashdod University Hospital, Ashdod, Israel.
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Martinez Coconubo D, Levy JJ, Kerr DA, Vaickus LJ, Vidis L, Glass RE, Gutmann EJ, Marotti JD, Liu X. Use of molecular testing results to analyze the overuse of atypia of undetermined significance in thyroid cytology. J Am Soc Cytopathol 2023; 12:451-460. [PMID: 37775434 DOI: 10.1016/j.jasc.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 08/31/2023] [Accepted: 09/03/2023] [Indexed: 10/01/2023]
Abstract
INTRODUCTION The suggested atypia of undetermined significance (AUS) rate for thyroid fine-needle aspiration biopsies is 10% or less. Prompted by a high institutional AUS rate, we examined using molecular testing results (MTR) as a potential quality metric tool to reduce the AUS rate. We correlated MTR with AUS cytologic findings, surgical pathology follow-up, and individual pathologist AUS rates. MATERIALS AND METHODS Demographic data, cytologic diagnoses, MTR, and surgical pathology diagnoses were retrospectively obtained. MTR were classified as either positive or negative. AUS rates and MTR proportions were compared among pathologists. The cytomorphologic features of 143 AUS cases were assessed and correlated with MTR. RESULTS Between 2017 and 2022, 710 of 3247 thyroid fine-needle aspirations were classified as AUS, with a yearly average rate of 22% (range = 19%-26%). AUS cases included: 331 (47%) with architectural atypia; 204 (29%) with oncocytic (Hürthle cell) atypia; 99 (14%) with combined architectural and cytologic atypia; and 76 (10%) with isolated cytologic atypia. Most AUS cases with molecular testing had negative MTR (360/492, 73%). AUS with cytologic atypia had higher positive MTR risk (logarithm of odds ratio = 1.27, 95% credible interval [0.5-2.04], P = 0.001). The average positive MTR rate by pathologist was 21.5% (range 0%-35%); higher positive MTR rates had better correlation with subsequent neoplastic/malignant histologic diagnoses. The MTR sensitivity for malignant disease was 89% and the negative predictive value was 91%. CONCLUSIONS MTR analysis reveals the importance of cytologic atypia as a determinant of malignancy risk in AUS cases. Periodic analysis of MTR data alongside individual pathologist AUS rates can help refine diagnostic criteria and potentially reduce AUS overuse.
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Affiliation(s)
- Daniel Martinez Coconubo
- Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire.
| | - Joshua J Levy
- Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire; Departments of Quantitative Biomedical Sciences, Dermatology and Epidemiology, Geisel School of Medicine, Hanover, New Hampshire
| | - Darcy A Kerr
- Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Louis J Vaickus
- Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Laura Vidis
- Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Ryan E Glass
- Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Edward J Gutmann
- Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Jonathan D Marotti
- Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Xiaoying Liu
- Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
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Xing Z, Qiu Y, Zhu J, Su A, Wu W. Diagnostic performance of ultrasound risk stratification systems on thyroid nodules cytologically classified as indeterminate: a systematic review and meta-analysis. Ultrasonography 2023; 42:518-531. [PMID: 37697824 PMCID: PMC10555695 DOI: 10.14366/usg.23055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 06/15/2023] [Accepted: 06/18/2023] [Indexed: 09/13/2023] Open
Abstract
PURPOSE Ultrasound (US) risk stratification systems (RSSs) are increasingly being utilized for the optimal management of thyroid nodules, including those with indeterminate cytology. The goal of this study was to evaluate the category-based diagnostic performance of US RSSs in identifying malignancy in indeterminate nodules. METHODS This systematic review and meta-analysis was registered on PROSPERO (CRD42021266195). PubMed, EMBASE, and Web of Science were searched through December 1, 2022. Original articles reporting data on the performance of US RSSs for indeterminate nodules were included. The numbers of nodules classified as true negative, true positive, false negative, and false positive were extracted. RESULTS Thirty-three studies evaluating 7,225 indeterminate thyroid nodules were included. The diagnostic accuracy was quantitatively synthesized using a Bayesian bivariate model based on the integrated nested Laplace approximation in R. For the intermediate- to high-risk category, the sensitivity levels of the American College of Radiology, the American Thyroid Association, the European Thyroid Association, the Korean Thyroid Association/Korean Society of Thyroid Radiology, and Kwak et al. were found to be 0.80, 0.72, 0.76, 0.96, and 0.97, respectively. The corresponding specificity measurements were 0.36, 0.50, 0.49, 0.28, and 0.17. Furthermore, for the high-risk category, the sensitivity values were 0.40, 0.46, 0.55, 0.47, and 0.10, while the specificity levels were 0.91, 0.90, 0.71, 0.91, and 0.99, respectively. CONCLUSION The overall diagnostic performance of the US RSSs was moderate in the differentiation of indeterminate nodules.
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Affiliation(s)
- Zhichao Xing
- Center of Thyroid and Parathyroid Surgery, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Thyroid and Parathyroid Disease, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu, China
| | - Yuxuan Qiu
- Ultrasound Department, West China Hospital, Sichuan University, Chengdu, China
| | - Jingqiang Zhu
- Center of Thyroid and Parathyroid Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Anping Su
- Center of Thyroid and Parathyroid Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Wenshuang Wu
- Center of Thyroid and Parathyroid Surgery, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Thyroid and Parathyroid Disease, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu, China
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Yang L, Fang B, Ou X, Zhang W, Cai Y. Commemoration and Emotional Sustenance: A Text Analysis of Students' Motivations Behind Online Mourning of Dr Li Wenliang. OMEGA-JOURNAL OF DEATH AND DYING 2023:302228231174492. [PMID: 37163668 DOI: 10.1177/00302228231174492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
As one of the first doctors issued a protective warning to the public, Dr. Li Wenliang was known as "whistleblower" of COVID-19 pandemic. After his death of COVID-19, students entered to his Sina Weibo to display their condolences and sorrow. We conduct text analysis and sentiment classification to investigate the motivation behind online mourning for Dr. Li among students on Sina Weibo. Our results indicate that, a) there always more than one motivation behind online mourning exists in each time period. b) continuing connection and semi-interaction with the deceased is the main motivation when students mourn online. c) there exists positive correlation between the influence of the deceased and the motivation--sharing information with the community of fans and creating social support in a time of loss and social support. d) the motivation--honoring the dead and expressing sadness and resentment can gradually lose over time.
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Affiliation(s)
- Ling Yang
- Department of Geriatrics, Shanghai Fourth People's Hospital Affiliated to Tongji University, Shanghai, China
| | - Bing Fang
- Department of Information Management, School of Management, Shanghai University, Shanghai, China
| | - Xiwen Ou
- Department of Respiratory, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wenjing Zhang
- Department of General Practice, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuyang Cai
- School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Papazian MR, Dublin JC, Patel KN, Oweity T, Jacobson AS, Brandler TC, Givi B. Repeat Fine-Needle Aspiration With Molecular Analysis in Management of Indeterminate Thyroid Nodules. Otolaryngol Head Neck Surg 2023; 168:738-744. [PMID: 35412868 DOI: 10.1177/01945998221093527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 03/22/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To analyze clinical outcomes in a series of indeterminate thyroid nodules (ITNs) with repeat fine-needle aspiration (FNA) biopsy and results of genomic classifier. STUDY DESIGN Historical chart review. SETTING Tertiary care center. METHODS We reviewed FNA samples from subjects with Bethesda III or IV diagnoses from January 2015 to December 2018 at a single institution and selected those with repeat FNA and ThyroSeq testing of the same nodule. Patient demographics, Bethesda classifications, ThyroSeq results, treatment detail, and surgical pathology, when available, were analyzed. RESULTS Ninety-six patients with cytologic diagnosis of ITN, repeat FNA, and ThyroSeq testing were identified. Following repeat FNA, 55 nodules (57%) remained ITN; 40 (42%) were reclassified as benign; and 1 (1%) was reclassified as suspicious for malignancy. In 31 patients with ThyroSeq analysis accompanying initial and repeat FNA, 26 (84%) had the same result on each, while 5 (16%) tested ThyroSeq positive following an initially negative result (κ = 0.24). Most nodules that were downgraded to Bethesda II on repeat FNA (37/40, 93%) were managed nonsurgically. Patients with ThyroSeq-positive results were treated with surgery more often (25/28, 89%) than patients with ThyroSeq-negative results (11/68, 16%; P < .0001). In excised nodules, the prevalence of malignancy and noninvasive follicular thyroid neoplasm with papillary-like nuclear features was 28% (n = 10) and 22% (n = 8), respectively, and all malignancies were low risk. CONCLUSION In this case series, repeat FNA helped patients with ITNs avoid diagnostic surgery through reclassification to benign cytology. The risk of high-risk malignancy in ThyroSeq-positive nodules with repeat indeterminate cytology was low.
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Affiliation(s)
- Michael R Papazian
- Grossman School of Medicine, New York University, New York, New York, USA
| | - Jared C Dublin
- Grossman School of Medicine, New York University, New York, New York, USA
| | - Kepal N Patel
- Division of Endocrine Surgery, Department of Surgery, NYU Langone Medical Center, New York, New York, USA
| | - Thaira Oweity
- Department of Pathology, NYU Langone Medical Center, New York, New York, USA
| | - Adam S Jacobson
- Department of Otolaryngology-Head and Neck Surgery, NYU Langone Medical Center, New York, New York, USA
| | - Tamar C Brandler
- Department of Pathology, NYU Langone Medical Center, New York, New York, USA
| | - Babak Givi
- Department of Otolaryngology-Head and Neck Surgery, NYU Langone Medical Center, New York, New York, USA
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The national rate of malignancy among Bethesda III, IV, and V thyroid nodules is higher than expected: A NSQIP analysis. Surgery 2023; 173:645-652. [PMID: 36229250 DOI: 10.1016/j.surg.2022.06.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/17/2022] [Accepted: 06/20/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND The Bethesda System for Reporting Thyroid Cytopathology was formalized in 2007 to stratify cytologic specimens based on their risk of malignancy. Several studies have reported significant variations between their institutional rate of malignancy compared to the Bethesda System for Reporting Thyroid Cytopathology. The objective of this study was to determine the national rate of malignancy for Bethesda III, Bethesda IV, and Bethesda V thyroid nodules. METHODS From 2016 to 2019, patients with preoperative thyroid cytopathology and pathology results in National Surgical Quality Improvement database were included. The rate of malignancy was compared to the median the Bethesda System for Reporting Thyroid Cytopathology 2017, and risk factors associated with malignancy were identified for Bethesda III, Bethesda IV, and Bethesda V specimens. RESULTS In total, 13,121 patients with preoperative cytopathology and postresection pathology were identified. The national rate of malignancy was significantly higher than the Bethesda System for Reporting Thyroid Cytopathology 2017 for Bethesda III (36.2% vs 12.0%, P < .01), Bethesda IV (36.7% vs 25.0%, P < .01), and Bethesda V (91.1% vs 52.5%, P < .01) specimens. Male sex was significantly associated with malignancy in Bethesda III, Bethesda IV, and Bethesda V nodules (Bethesda III, odds ratio: 1.20, [1.01-1.42]; Bethesda IV, odds ratio: 1.47, [1.27-1.71]; Bethesda V, odds ratio: 1.28, [1.03-1.58]). Younger age was associated with malignancy in Bethesda III patients under 55 (odds ratio: 1.23, [1.06-1.42]), Bethesda IV patients under 42 (odds ratio: 1.23, [1.06-1.43]), and Bethesda V patients aged less than 47 (odds ratio: 1.38, [1.15-1.67]). CONCLUSIONS This is the largest cohort study to describe the national rate of malignancy for Bethesda III, IV, and V specimens in the United States. These results reveal the national rate of malignancy is higher than the implied rate of malignancy reported to patients based on the Bethesda System for Reporting Thyroid Cytopathology. We recommend counseling patients regarding this increased rate of malignancy to set appropriate expectations after surgical intervention.
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Alshahrani AS, Alamri AS, Balkhoyor AH, Mahzari MM, Alshieban SS, Majed PM. The Prediction of Malignancy Risk in Thyroid Nodules Classified as Bethesda System Category III (AUS/FLUS) and the Role of Ultrasound Finding for Prediction of Malignancy Risk. Cureus 2021; 13:e17924. [PMID: 34660116 PMCID: PMC8512574 DOI: 10.7759/cureus.17924] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2021] [Indexed: 12/31/2022] Open
Abstract
Objective To predict the risk of malignancy in category III of the Bethesda System for Reporting Thyroid Cytopathology "Atypia of Undetermined Significance/Follicular Lesion of Undetermined Significance (AUS/FLUS)" at King Abdulaziz Medical City, Riyadh, Saudi Arabia. It also intends to determine other possible contributing predictors of malignancy in thyroid nodules such as age, sex, and ultrasound (US) findings. Method This retrospectively designed study included 187 patients (mean age, 43.9 ± 14.1 years) with thyroid nodules, which were diagnosed as AUS/FLUS and all patients included had total thyroidectomy or lobectomy between January 2013 and December 2018 at King Abdulaziz Medical City in Riyadh, Saudi Arabia. The electronic medical records, US images, and final cytopathology and histopathology reports were reviewed and analyzed. Result The overall incidence of AUS/FLUS was (46.5%). Multivariate analysis of US features revealed that malignancy was significantly associated with nodules with irregular margins, microcalcification, multiple numbers (P < 0.001), and hypoechogenicity (P 0.04). Conclusion Despite the high rate of malignancy of nodules AUS/FLUS, it is still consistent with previously reported studies. The highly suspicious ultrasound features (irregular margins, microcalcification, multiple nodules, and hypoechogenicity) could be helpful in the diagnosis of thyroid cancer.
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Affiliation(s)
- Awad S Alshahrani
- Department of Adult Endocrinology, King Abdulaziz Medical City, Riyadh, SAU.,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | | | | | - Moeber M Mahzari
- Department of Adult Endocrinology, King Abdulaziz Medical City, Riyadh, SAU.,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, SAU.,Population Health Research, King Abdullah International Medical Research Center, Riyadh, SAU
| | - Saeed S Alshieban
- Department of Pathology and Laboratory Medicine, King Abdulaziz Medical City, Riyadh, SAU.,College of Applied Medical Sciences, King Saud bin Abdulaziz University for Health Sciences, Riyadh, SAU.,Population Health Research, King Abdullah International Medical Research Center, Riyadh, SAU
| | - Pharaon M Majed
- Department of Pathology and Laboratory Medicine, King Abdulaziz Medical City, Riyadh, SAU
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Nishino M, Mateo R, Kilim H, Feldman A, Elliott A, Shen C, Hasselgren PO, Wang H, Hartzband P, Hennessey JV. Repeat Fine Needle Aspiration Cytology Refines the Selection of Thyroid Nodules for Afirma Gene Expression Classifier Testing. Thyroid 2021; 31:1253-1263. [PMID: 33813868 PMCID: PMC8377518 DOI: 10.1089/thy.2020.0969] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Background: Molecular testing (MT) refines risk stratification for thyroid nodules that are indeterminate for cancer by fine needle aspiration (FNA) cytology. Criteria for selecting nodules for MT vary and remain largely untested, raising questions about the best strategy for maximizing the usefulness of MT while minimizing the harms of overtesting. We used a unique data set to examine the effects of repeat FNA cytology-based criteria for MT on management decisions and nodule outcomes. Methods: This was a study of adults (age 25-90 years; 281 women and 72 men) with cytologically indeterminate (Bethesda III/IV) thyroid nodules who underwent repeat FNA biopsy and Afirma Gene Expression Classifier (GEC) testing (N = 363 nodules from 353 patients) between June 2013 and October 2017 at a single institution, with follow-up data collected until December 2019. Subgroup analysis was performed based on classification of repeat FNA cytology. Outcomes of GEC testing, clinical/sonographic surveillance of unresected nodules, and histopathologic diagnoses of thyroidectomies were compared between three testing approaches: (i) Reflex (MT sent on the basis of the initial Bethesda III/IV FNA), (ii) SemiRestrictive (MT sent if repeat FNA is Bethesda I-IV), and (iii) Restrictive (MT sent only if repeat FNA is Bethesda III/IV) testing approaches. Results: Restricting MT to nodules that remain Bethesda III/IV on repeat FNA would have missed 4 low-risk cancers and 3 noninvasive follicular thyroid neoplasms with papillary-like nuclear features (NIFTP) (collectively 2% of the test population) but would have avoided diagnostic surgery for 42 benign nodules (12% of the test population). The Restrictive testing strategy was more specific (delta 0.126 confidence interval [CI 0.093 to 0.159] and 0.129 [CI 0.097 to 0.161], respectively) but less sensitive (delta -0.339 [CI -0.424 to -0.253] and -0.340 [CI -0.425 to -0.255], respectively) than the Reflex and SemiRestrictive approaches for detecting NIFTP or cancer. Conclusions: Repeat FNA cytology can guide the selection of cytologically indeterminate thyroid nodules that warrant MT. The Restrictive model of performing Afirma GEC only on nodules with two separate biopsies showing Bethesda III/IV cytology would reduce the rate of diagnostic surgery for histologically benign nodules while missing only rare low-risk tumors. Given the low but nontrivial risks of thyroidectomy, the higher specificity of the Restrictive testing approach disproportionately outweighs the potential harms.
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Affiliation(s)
- Michiya Nishino
- Department of Pathology; Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
- Address correspondence to: Michiya Nishino, MD, PhD, Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA
| | - Roselyn Mateo
- Division of Endocrinology, Department of Medicine; Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Holly Kilim
- Division of Endocrinology, Department of Medicine; Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Anna Feldman
- Division of Endocrinology, Department of Medicine; Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Amanda Elliott
- Division of Endocrinology, Department of Medicine; Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Changyu Shen
- Smith Center for Outcomes Research in Cardiology, Department of Medicine; Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Per-Olof Hasselgren
- Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Helen Wang
- Department of Pathology; Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Pamela Hartzband
- Division of Endocrinology, Department of Medicine; Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - James V. Hennessey
- Division of Endocrinology, Department of Medicine; Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
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Schumm MA, Nguyen DT, Kim J, Tseng CH, Chow AY, Shen N, Livhits MJ. Longitudinal Assessment of Quality of Life Following Molecular Testing for Indeterminate Thyroid Nodules. Ann Surg Oncol 2021; 28:8872-8881. [PMID: 34292427 PMCID: PMC8591007 DOI: 10.1245/s10434-021-10375-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 06/13/2021] [Indexed: 11/18/2022]
Abstract
Background Molecular testing can refine the risk of malignancy in cytologically indeterminate thyroid nodules and can reduce the need for diagnostic thyroidectomy. However, quality of life (QOL) in patients mananged with molecular testing is not well studied. Objective We aimed to assess the QOL of patients undergoing surveillance after a benign molecular test result, or thyroidectomy after a suspicious molecular test result. Methods This prospective longitudinal follow-up of the Effectiveness of Molecular Testing Techniques for Diagnosis of Indeterminate Thyroid Nodules randomized trial utilized the Thyroid-Related Patient-Reported Outcome, 39-item version (ThyPro-39) to assess the QOL of patients with indeterminate cytology on thyroid fine needle aspiration (FNA) biopsy. All patients underwent molecular testing at the time of initial FNA. A mixed-effect model was used to determine changes in QOL over time. Results Of 252 eligible patients, 174 completed the assessment (69% response rate). Molecular test results included 72% (n = 124) benign and 28% (n = 50) suspicious. ThyPro-39 scores of benign molecular test patients were unchanged from baseline (following initial FNA and molecular test results) to 18 months of ultrasound surveillance. Baseline symptoms of goiter, anxiety, and depression were more severe for patients with suspicious compared with benign molecular test results. At a median of 8 months after thyroidectomy, suspicious molecular test patients reported improved symptoms of goiter, anxiety, and depression. Conclusion A benign molecular test provides sustained QOL throughout ultrasound surveillance, without worsening anxiety or depression relating to the risk of malignancy. Definitive surgery results in improvement of QOL in patients with suspicious molecular tests.
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Affiliation(s)
- Max A Schumm
- Section of Endocrine Surgery, Department of Surgery, University of California Los Angeles David Geffen School of Medicine, 10833 Le Conte Ave. 72-227 CHS, Los Angeles, CA, 90095, USA.
| | - Dalena T Nguyen
- Section of Endocrine Surgery, Department of Surgery, University of California Los Angeles David Geffen School of Medicine, 10833 Le Conte Ave. 72-227 CHS, Los Angeles, CA, 90095, USA
| | - Jiyoon Kim
- Department of Biostatistics, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Chi-Hong Tseng
- Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA
| | - Amy Y Chow
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of California, Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA
| | - Na Shen
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of California, Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA
| | - Masha J Livhits
- Section of Endocrine Surgery, Department of Surgery, University of California Los Angeles David Geffen School of Medicine, 10833 Le Conte Ave. 72-227 CHS, Los Angeles, CA, 90095, USA
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Hu QL, Schumm MA, Zanocco KA, Yeh MW, Livhits MJ, Wu JX. Cost analysis of reflexive versus selective molecular testing for indeterminate thyroid nodules. Surgery 2021; 171:147-154. [PMID: 34284895 DOI: 10.1016/j.surg.2021.04.050] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/19/2021] [Accepted: 04/23/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Molecular testing is now commonly used to refine the diagnosis of indeterminate thyroid nodules. The purpose of this study is to compare the costs of a reflexive molecular testing strategy to a selective testing strategy for indeterminate thyroid nodules. METHODS A Markov model was constructed to estimate the annual cost of diagnosis and treatment of a real-world cohort of patients with cytologically indeterminate thyroid nodules, comparing a reflexive testing strategy to a selective testing strategy. Model variables were abstracted from institutional clinical trial data, literature review, and the Medicare physician fee schedule. RESULTS The average cost per patient in the reflexive testing strategy was $8,045, compared with $6,090 in the selective testing strategy. In 10,000 Monte Carlo simulations, diagnostic thyroid lobectomy for benign nodules was performed in 2,440 patients in the reflexive testing arm, compared with 3,389 patients in the selective testing arm, and unintentional observation for malignant nodules occurred in 479 patients in the reflexive testing arm, compared with 772 patients in the selective testing arm. The cost of molecular testing had the greatest impact on overall costs, with $1,050 representing the cost below which the reflexive testing strategy was cost saving compared with the selective testing strategy. CONCLUSION In this cost-modeling study, reflexive molecular testing for indeterminate thyroid nodules enabled patients to avoid unnecessary thyroid lobectomy at an estimated cost of $20,600 per surgery avoided.
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Affiliation(s)
- Q Lina Hu
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA.
| | - Max A Schumm
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA. https://twitter.com/@MSchumm90
| | - Kyle A Zanocco
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA. https://twitter.com/@KyleZanocco
| | - Michael W Yeh
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA. https://twitter.com/@michaelyehmd
| | - Masha J Livhits
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA. https://twitter.com/@MashaLivhitsMD
| | - James X Wu
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA. https://twitter.com/@JamesWuMD
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11
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Gorshtein A, Slutzky-Shraga I, Robenshtok E, Benbassat C, Hirsch D. Adherence to Active Surveillance and Clinical Outcomes in Patients with Indeterminate Thyroid Nodules Not Referred for Thyroidectomy. Eur Thyroid J 2021; 10:168-173. [PMID: 33981621 PMCID: PMC8077556 DOI: 10.1159/000509037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 05/30/2020] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE Outcomes of patients with cytologically indeterminate thyroid nodules not referred for thyroidectomy have hardly been investigated. We previously reported outcomes of 322 patients with thyroid nodules classified according to the Bethesda System of Reporting Thyroid Cytology (BSRTC) as indeterminate (B3/B4), of whom 123 (38.2%) underwent thyroidectomy. In the present extension study, we investigated adherence and outcomes in the remaining unoperated 199 patients. METHODS We conducted a file review of 189/199 patients with thyroid nodules cytologically diagnosed as B3 (n = 174) or B4 (n = 15) in 2011-2012 who were conservatively followed at our institution until 2019. RESULTS Among 174 patients with B3 nodules, 140 (80.4%) underwent repeated ultrasound. Nodular growth was detected in 23 (16.4%), and findings remained stable in 105 (75%). Fine-needle aspiration was repeated in 88/174 patients (50.6%), with B2 results in 62 (70.4%) and B3/B4/B5 in 20 (22.7%). Thyroidectomy was performed in 14/174 patients (8%) in the B3 and 5/15 patients (33%) in the B4 group at a median of 5 years' follow-up; thyroid cancer was diagnosed in 4/14 patients (28.5%) and 3/5 patients (60%), respectively. For B3 patients who remained unoperated, none had evidence of thyroid cancer at last follow-up. A reason for avoiding surgery was documented in 6/10 unoperated B4 patients (1 thyroid lymphoma, 3 died of unrelated causes, 2 were considered inoperable due to advanced age). CONCLUSIONS Most patients with initially unoperated B3/B4 nodules adhere, at least partially, to active surveillance. For B3 nodules, subsequent thyroidectomy and thyroid cancer detection are rare events, and patients may be safely managed without using molecular markers. Thyroid cancer is diagnosed in most B4 patients who undergo thyroidectomy in our institution.
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Affiliation(s)
- Alexander Gorshtein
- Endocrine Institute, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- *Alexander Gorshtein, Endocrinology and Metabolism Institute, Rabin Medical Center, 39 Ze'ev Jabotinsky St., IL–49100 Petach Tikva (Israel),
| | - Ilana Slutzky-Shraga
- Endocrine Institute, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eyal Robenshtok
- Endocrine Institute, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Carlos Benbassat
- Endocrine Institute, Shamir Medical Center (Formerly Assaf Harofeh Medical Center), Beer Yaakov, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dania Hirsch
- Endocrine Institute, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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12
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Silaghi CA, Lozovanu V, Georgescu CE, Georgescu RD, Susman S, Năsui BA, Dobrean A, Silaghi H. Thyroseq v3, Afirma GSC, and microRNA Panels Versus Previous Molecular Tests in the Preoperative Diagnosis of Indeterminate Thyroid Nodules: A Systematic Review and Meta-Analysis. Front Endocrinol (Lausanne) 2021; 12:649522. [PMID: 34054725 PMCID: PMC8155618 DOI: 10.3389/fendo.2021.649522] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 04/13/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Molecular tests are being used increasingly as an auxiliary diagnostic tool so as to avoid a diagnostic surgery approach for cytologically indeterminate thyroid nodules (ITNs). Previous test versions, Thyroseq v2 and Afirma Gene Expression Classifier (GEC), have proven shortcomings in malignancy detection performance. OBJECTIVE This study aimed to evaluate the diagnostic performance of the established Thyroseq v3, Afirma Gene Sequencing Classifier (GSC), and microRNA-based assays versus prior iterations in ITNs, in light of "rule-in" and "rule-out" concepts. It further analyzed the impact of noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) reclassification and Bethesda cytological subtypes on the performance of molecular tests. METHODS Pubmed, Scopus, and Web of Science were the databases used for the present research, a process that lasted until September 2020. A random-effects bivariate model was used to estimate the summary sensitivity, specificity, positive (PLR) and negative likelihood ratios (NLR), and area under the curve (AUC) for each panel. The conducted sensitivity analyses addressed different Bethesda categories and NIFTP thresholds. RESULTS A total of 40 eligible studies were included with 7,831 ITNs from 7,565 patients. Thyroseq v3 showed the best overall performance (AUC 0.95; 95% confidence interval: 0.93-0.97), followed by Afirma GSC (AUC 0.90; 0.87-0.92) and Thyroseq v2 (AUC 0.88; 0.85-0.90). In terms of "rule-out" abilities Thyroseq v3 (NLR 0.02; 95%CI: 0.0-2.69) surpassed Afirma GEC (NLR 0.18; 95%CI: 0.10-0.33). Thyroseq v2 (PLR 3.5; 95%CI: 2.2-5.5) and Thyroseq v3 (PLR 2.8; 95%CI: 1.2-6.3) achieved superior "rule-in" properties compared to Afirma GSC (PLR 1.9; 95%CI: 1.3-2.8). Evidence for Thyroseq v3 seems to have higher quality, notwithstanding the paucity of studies. Both Afirma GEC and Thyroseq v2 performance have been affected by NIFTP reclassification. ThyGenNEXT/ThyraMIR and RosettaGX show prominent preliminary results. CONCLUSION The newly emerged tests, Thyroseq v3 and Afirma GSC, designed for a "rule-in" purpose, have been proved to outperform in abilities to rule out malignancy, thus surpassing previous tests no longer available, Thyroseq 2 and Afirma GEC. However, Thyroseq v2 still ranks as the best rule-in molecular test. SYSTEMATIC REVIEW REGISTRATION http://www.crd.york.ac.uk/PROSPERO, identifier CRD42020212531.
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Affiliation(s)
- Cristina Alina Silaghi
- Department of Endocrinology, “Iuliu Hatieganu” University of Medicine and Pharmacy Cluj-Napoca, Cluj-Napoca, Romania
| | - Vera Lozovanu
- Department of Endocrinology, “Iuliu Hatieganu” University of Medicine and Pharmacy Cluj-Napoca, Cluj-Napoca, Romania
- *Correspondence: Vera Lozovanu, ; Raluca Diana Georgescu,
| | - Carmen Emanuela Georgescu
- Department of Endocrinology, “Iuliu Hatieganu” University of Medicine and Pharmacy Cluj-Napoca, Cluj-Napoca, Romania
| | - Raluca Diana Georgescu
- International Institute for the Advanced Studies of Psychotherapy and Applied Mental Health, Babeş-Bolyai University, Cluj-Napoca, Romania
- *Correspondence: Vera Lozovanu, ; Raluca Diana Georgescu,
| | - Sergiu Susman
- Department of Morphological Sciences-Histology, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
- Department of Pathology, IMOGEN Research Center, Cluj-Napoca, Romania
| | - Bogdana Adriana Năsui
- Department of Community Health, “Iuliu Hatieganu” University of Medicine and Pharmacy Cluj-Napoca, Cluj-Napoca, Romania
| | - Anca Dobrean
- International Institute for the Advanced Studies of Psychotherapy and Applied Mental Health, Babeş-Bolyai University, Cluj-Napoca, Romania
- Department of Clinical Psychology and Psychotherapy, Babeş-Bolyai University, Cluj-Napoca, Romania
| | - Horatiu Silaghi
- Department of Surgery V, “Iuliu Hatieganu” University of Medicine and Pharmacy Cluj-Napoca, Cluj-Napoca, Romania
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13
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Marin F, Murillo R, Diego C, Jodar E, Acevedo A. The impact of repeat fine-needle aspiration in thyroid nodules categorized as atypia of undetermined significance or follicular lesion of undetermined significance: A single center experience. Diagn Cytopathol 2020; 49:412-417. [PMID: 33252841 DOI: 10.1002/dc.24676] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 11/04/2020] [Accepted: 11/19/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Atypia of undetermined significance (AUS) or follicular lesion of undetermined significance (FLUS) is the most controversial category of the Bethesda System. The present study was conducted to compare the histological findings in a series of thyroid nodules diagnosed with AUS/FLUS after single or repeat fine needle aspiration (FNA) cytology. METHODS Retrospective analysis of our institution's series of 514 patients with an initial diagnosis of AUS/FLUS between 11/2011 and 02/2020. RESULTS Of 4887 FNA samples, 11.8% were classified as AUS/FLUS. Of patients with an initial AUS/FLUS diagnosis, 11.5% (59/514) underwent surgery after a single FNA, 55.4% (285/514) had a repeat FNA, and 32.7% (168/514) were either observed or lost to follow-up. Surgical pathology was available in 123 cases (23.9%), and malignancy was confirmed in 32.5% (40/123) cases, with similar rates in the single 32.2% (19/59) and repeat FNA 32.8% (21/64) groups. Repeat FNA reclassified 78.9% of the AUS/FLUS cases to a different category: 57.2% were reclassified as benign, 10.5% as follicular neoplasm, and 5.6% as suspicious for malignancy or malignant. The rates of nonneoplastic benign lesions were 52.5% (31/59) and 31.2% (20/64) in the single and repeat FNA groups, respectively (P = .018). The rates of follicular adenomas were higher when repeat FNA was performed (23/64, 35.9%) compared with a single FNA (9/59; 15.2%) (P = .013). CONCLUSION In this series, a repeat FNA in cases of AUS/FLUS increased detection of follicular adenomas but not the detection of malignancy. Repeat FNA reduced the rate of benign nonneoplastic lesions by 40% in the surgical samples.
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Affiliation(s)
- Fernando Marin
- Department of Endocrinology, Hospital Universitario Quironsalud, Madrid, Spain.,Medical Sciences School, Universidad Europea, Madrid, Spain
| | - Raquel Murillo
- Department of Pathology, Hospital Universitario Quironsalud, Madrid, Spain
| | - Cristina Diego
- Department of Pathology, Hospital Universitario Quironsalud, Madrid, Spain
| | - Esteban Jodar
- Department of Endocrinology, Hospital Universitario Quironsalud, Madrid, Spain.,Medical Sciences School, Universidad Europea, Madrid, Spain
| | - Agustín Acevedo
- Department of Pathology, Hospital Universitario Quironsalud, Madrid, Spain
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14
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Ooi LY, Nga ME. Atypia of undetermined significance/follicular lesion of undetermined significance: Asian vs. non-Asian practice, and the Singapore experience. Gland Surg 2020; 9:1764-1787. [PMID: 33224854 DOI: 10.21037/gs-20-555] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The Bethesda System for Reporting Thyroid Cytopathology has paved the way for comparisons of the practice of thyroid cytology in many different regions. However, there have been comparatively few studies documenting differences between Asian and non-Asian practice. Here, we aim to compare a few key parameters between the two regions, focusing on the indeterminate category of atypia of undetermined significance (AUS)/follicular lesion of undetermined significance (FLUS). We compared its incidence, resection rates (RRs), risk of malignancy (ROM), rate of repeat fine needle aspiration (rFNA), ROMs of cytomorphologic subcategories of nuclear atypia (AUS-N) vs. architectural atypia (AUS-A), and, finally, the incidence of papillary thyroid carcinoma (PTC) vs. follicular neoplasms (FNs) in resected AUS/FLUS cases in Asian and non-Asian regions. Where possible, these metrics were compared with the Singapore experience from a tertiary referral institution. While the incidence of AUS/FLUS was similar in both regions, we found geographical differences in the RRs and ROMs, which may reflect a higher collective threshold for surgery in Asian countries. However, both cohorts showed higher ROMs in the AUS-N subcategory as compared to the AUS-A subcategory, supporting the subclassification of the AUS/FLUS based on the presence of nuclear atypia. We also observed a higher incidence of AUS-N coupled with a higher incidence of PTC in resected AUS/FLUS nodules in Asian cohorts, while AUS-A and follicular-patterned neoplasms featured more prominently in the non-Asian cohorts. These incidences may account for the starkly different molecular approaches that we noted-in Asian (chiefly Korean and Chinese) centers, BRAF mutational analysis was favored, while gene panels and gene expression classifiers were more frequently applied in non-Asian centers (chiefly in the United States of America). Overall, the data from Singapore appears more closely aligned to non-Asian trends, despite its geographical location in Southeast Asia and its predominantly Asian population. We conclude that there is significant heterogeneity in the outcomes of the AUS/FLUS categories between and within regions, which is only partially explained by regional variations, and may also reflect different regional diagnostic and management practices. This highlights the importance of understanding the local context in the interpretation of indeterminate Bethesda categories, rather than adopting a "one-size fits all" approach.
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Affiliation(s)
- Li Yin Ooi
- Department of Pathology, National University Hospital, Singapore
| | - Min En Nga
- Department of Pathology, National University Hospital, Singapore
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15
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Wong CW, Schumm MA, Zhu CY, Tseng CH, Arasu A, Han J, Livhits MJ. Quality of Life Following Molecular Marker Testing for Indeterminate Thyroid Nodules. Endocr Pract 2020; 26:960-966. [PMID: 33471700 DOI: 10.4158/ep-2020-0101] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 04/18/2020] [Indexed: 01/26/2023]
Abstract
OBJECTIVE Thyroid cancer has a disproportionately negative effect on the quality of life (QOL) compared to malignancies with a worse prognosis. The QOL of patients with indeterminate thyroid nodules has not been previously evaluated. We aimed to assess the impact of molecular test results on the QOL of patients with indeterminate thyroid nodules. METHODS A short version of the Thyroid-Related Patient-Reported Outcome (ThyPro-39) was used to assess the QOL of patients who underwent thyroid fine needle aspiration (FNA) biopsy throughout UCLA Health from May, 2016, to June, 2017. All patients with indeterminate biopsy results underwent molecular testing with either Afirma Gene Expression Classifier or ThyroSeq v2 at the time of the initial biopsy. The QOL associated with symptoms of goiter, anxiety, depression, and impaired daily life were analyzed. RESULTS Of 825 consented patients, 366 completed the assessment (44.4% response rate). FNA results included 76% benign, 7% malignant, and 17% indeterminate. There were no differences in QOL between patients with a benign FNA and patients with an indeterminate result with benign molecular testing. In patients with an indeterminate FNA, symptoms of goiter (20.5 versus 10.4; P = .033) and depression (33.3 versus 21.0; P = .026) were worse for patients with suspicious versus benign molecular test results; however, no significant differences were observed in anxiety or impaired daily life. CONCLUSION A benign molecular test result may provide reassurance for patients with indeterminate thyroid nodules that the risk of malignancy is low. Long-term follow-up is necessary to determine if benign molecular test results maintain improved QOL.
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Affiliation(s)
- Calvin W Wong
- Section of Endocrine Surgery, Department of Surgery, University of California, Los Angeles David Geffen School of Medicine, Los Angeles, California
| | - Max A Schumm
- Division of General Surgery, Department of Surgery, University of California, Los Angeles David Geffen School of Medicine, Los Angeles, California
| | - Catherine Y Zhu
- Division of General Surgery, Department of Surgery, University of California, Los Angeles David Geffen School of Medicine, Los Angeles, California
| | - Chi-Hong Tseng
- Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California
| | - Aarthi Arasu
- Division of Endocrinology - Diabetes, and Metabolism, Department of Medicine, University of California David Geffen School of Medicine, Los Angeles, California
| | - Jennifer Han
- Division of Endocrinology - Diabetes, and Metabolism, Department of Medicine, University of California David Geffen School of Medicine, Los Angeles, California
| | - Masha J Livhits
- Section of Endocrine Surgery, Department of Surgery, University of California, Los Angeles David Geffen School of Medicine, Los Angeles, California.
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16
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Suh YJ, Choi YJ. Strategy to reduce unnecessary surgeries in thyroid nodules with cytology of Bethesda category III (AUS/FLUS): a retrospective analysis of 667 patients diagnosed by surgery. Endocrine 2020; 69:578-586. [PMID: 32297204 DOI: 10.1007/s12020-020-02300-w] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 03/30/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE Fine-needle aspiration (FNA) is widely used for the diagnosis of thyroid nodules detected by ultrasonography. However, the cytology of atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS) often leads to unnecessary thyroid surgery. This study aimed to identify a strategy to reduce unnecessary surgeries in patients with AUS/FLUS nodules. METHODS Medical records of 667 patients with the cytology of AUS/FLUS who underwent surgery from January 2007 to December 2017 were retrospectively reviewed. Clinicopathological data were analyzed to identify malignant factors in thyroid nodules with AUS/FLUS. Factors were compared between patients with thyroid cancer and those with benign thyroid nodules, using stepwise multivariate logistic regression and decision tree model. RESULTS Pathological thyroid cancer was identified in 193 (43.3%) patients. There was a significant difference in malignancy incidence with respect to family history, number of nodules, number of FNAs, ultrasonographic finding, lymphocytic thyroiditis, and BRAFV600E mutation. Multivariate analysis showed that ultrasonography (K-TIRADS 5) was the most influential independent predictor of malignancy in AUS/FLUS (odds ratio = 11.02, p < 0.001), followed by possessing BRAFV600E mutation (odds ratio = 4.54, p < 0.001). This strategy enabled 226 (89.3%) patients to avoid unnecessary surgeries based on the decision tree model. There was no node of repeated FNA in the decision tree model, which reduced the risk of malignancy (odds ratio = 0.35, p = 0.029). CONCLUSION K-TIRADS 5 and BRAFV600E mutation were predictive of malignancy in nodules of AUS/FLUS. These factors should be considered in strategies to reduce unnecessary surgeries for AUS/FLUS.
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Affiliation(s)
- Yong Joon Suh
- Department of Breast and Endocrine Surgery, Hallym University Sacred Heart Hospital, Anyang, 14068, Republic of Korea.
| | - Yeon Ju Choi
- Research Cooperation Center, Hallym University, Chuncheon, 24252, Republic of Korea
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17
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Valerio E, Pastorello RG, Calsavara V, Porfírio MM, Engelman GG, Francisco Dalcin J, Bovolim G, Domingos T, De Brot L, Saieg M. Should we wait 3 months for a repeat aspiration in non-diagnostic/indeterminate thyroid nodules? A cancer centre experience. Cytopathology 2020; 31:525-532. [PMID: 32656878 DOI: 10.1111/cyt.12887] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 06/15/2020] [Accepted: 07/08/2020] [Indexed: 01/21/2023]
Abstract
INTRODUCTION The Bethesda System recommends repeat fine needle aspiration (rFNA) as a management option for nodules classified under the non-diagnostic (ND) and atypia of undetermined significance (AUS/FLUS) categories. We evaluated the impact of an rFNA in diagnostic resolution and the role of early (≤3 months) vs delayed (more than 3 months) rFNA of nodules initially diagnosed as ND and AUS/FLUS. METHODS We retrospectively collected all thyroid FNA performed in a 4-year period with repeat aspiration. For cases initially signed out as ND or AUS/FLUS, diagnostic resolution was defined as a change to a Bethesda System category other than these two on rFNA. Comparison and regression models were fitted to identify the impact of time of rFNA on diagnostic resolution. RESULTS In total, 184 cases were initially assigned as ND and 143 as AUS/FLUS, with overall diagnostic resolution rates for the reassessment of these nodules calculated at 70.1% and 62.9%, respectively. For ND cases, time of rFNA was not significantly associated with diagnostic resolution (P > .05). For AUS/FLUS nodules, however, repeat aspiration performed in more than 3 months after the initial diagnosis was 2.5 times more likely to achieve a resolution in diagnosis than early rFNA (P = .024). CONCLUSIONS Repeat aspiration of ND and AUS/FLUS nodules helped define diagnosis for the majority of cases, being highly effective in determining correct patient management. For AUS/FLUS nodules, repeat aspiration performed more than 3 months after the initial diagnosis was associated with a higher diagnostic resolution.
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Affiliation(s)
- Ediel Valerio
- Department of Pathology, A.C. Camargo Cancer Center, São Paulo, Brazil
| | | | - Vinicius Calsavara
- Department of Epidemiology and Statistics, A.C. Camargo Cancer Center, São Paulo, Brazil
| | | | | | | | - Graziele Bovolim
- Department of Pathology, A.C. Camargo Cancer Center, São Paulo, Brazil
| | - Tábata Domingos
- Department of Pathology, A.C. Camargo Cancer Center, São Paulo, Brazil
| | - Louise De Brot
- Department of Pathology, A.C. Camargo Cancer Center, São Paulo, Brazil
| | - Mauro Saieg
- Department of Pathology, A.C. Camargo Cancer Center, São Paulo, Brazil.,Department of Pathology, Santa Casa Medical School, São Paulo, Brazil.,Department of Pathology, Fleury Laboratories, São Paulo, Brazil
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18
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Vuong CD, Watson WB, Kwon DI, Mohan SS, Perez MN, Lee SC, Simental AA. Cost effectiveness of intraoperative pathology in the management of indeterminate thyroid nodules. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2020; 64:356-361. [PMID: 32609146 PMCID: PMC10522076 DOI: 10.20945/2359-3997000000263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 02/07/2020] [Indexed: 11/23/2022]
Abstract
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.
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Affiliation(s)
- Christopher D Vuong
- Department of Otolaryngology- Head and Neck Surgery, Loma Linda University Medical Center, Loma Linda, California, United States
| | - WayAnne B Watson
- Loma Linda School of Medicine, Loma Linda University Medical Center, Loma Linda, California, United States
| | - Daniel I Kwon
- Department of Otolaryngology-Head and Neck Surgery, University of Southern California, Los Angeles, California, United States
| | - Sonia S Mohan
- Department of Pathology, Laboratory Medicine, Loma Linda University Medical Center, Loma Linda, California, United States
| | - Mia N Perez
- Department of Pathology, Laboratory Medicine, Loma Linda University Medical Center, Loma Linda, California, United States
| | - Steve C Lee
- Department of Otolaryngology- Head and Neck Surgery, Loma Linda University Medical Center, Loma Linda, California, United States
| | - Alfred A Simental
- Department of Otolaryngology- Head and Neck Surgery, Loma Linda University Medical Center, Loma Linda, California, United States
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19
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The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Thyroid Disease in Adults. Ann Surg 2020; 271:e21-e93. [PMID: 32079830 DOI: 10.1097/sla.0000000000003580] [Citation(s) in RCA: 231] [Impact Index Per Article: 57.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To develop evidence-based recommendations for safe, effective, and appropriate thyroidectomy. BACKGROUND Surgical management of thyroid disease has evolved considerably over several decades leading to variability in rendered care. Over 100,000 thyroid operations are performed annually in the US. METHODS The medical literature from 1/1/1985 to 11/9/2018 was reviewed by a panel of 19 experts in thyroid disorders representing multiple disciplines. The authors used the best available evidence to construct surgical management recommendations. Levels of evidence were determined using the American College of Physicians grading system, and management recommendations were discussed to consensus. Members of the American Association of Endocrine Surgeons reviewed and commented on preliminary drafts of the content. RESULTS These clinical guidelines analyze the indications for thyroidectomy as well as its definitions, technique, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Fine Needle Aspiration Biopsy Diagnosis, Molecular Testing, Indications, Extent and Outcomes of Surgery, Preoperative Care, Initial Thyroidectomy, Perioperative Tissue Diagnosis, Nodal Dissection, Concurrent Parathyroidectomy, Hyperthyroid Conditions, Goiter, Adjuncts and Approaches to Thyroidectomy, Laryngology, Familial Thyroid Cancer, Postoperative Care and Complications, Cancer Management, and Reoperation. CONCLUSIONS Evidence-based guidelines were created to assist clinicians in the optimal surgical management of thyroid disease.
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20
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Neck Mass that Moves with Swallowing. Surgery 2020. [DOI: 10.1007/978-3-030-05387-1_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Stewart R, Leang YJ, Bhatt CR, Grodski S, Serpell J, Lee JC. Quantifying the differences in surgical management of patients with definitive and indeterminate thyroid nodule cytology. Eur J Surg Oncol 2019; 46:252-257. [PMID: 31648951 DOI: 10.1016/j.ejso.2019.10.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 09/16/2019] [Accepted: 10/05/2019] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Thyroid nodules are increasingly common. Despite being an essential pre-operative diagnostic tool, up to 30% of fine needle aspirate cytology (FNAC) yields a non-definitive diagnosis. This study aimed to quantify differences in surgical management of patients with definitive and indeterminate thyroid nodule cytology, and determine if clinical factors can improve cytological diagnosis. MATERIALS AND METHODS Patients who underwent thyroidectomy for nodules from 2001 to 2015 were recruited. Those with benign and malignant preoperative cytology were included in the "definitive diagnosis" (DC) group; patients with all other preoperative cytology results were included in the "indeterminate diagnosis" (IC) group. We compared demographics and procedures between these groups. Clinical factors and demographics were also compared between patients with benign and malignant histology in the IC group. RESULTS A total of 3821 cases were included. A significantly larger proportion of the IC patients had a hemithyroidectomy (IC 69% vs. DC 39%, p < 0.001) initially, and also had a significantly higher rate of two-stage surgery compared to the DC group (IC 17% vs. DC 11%, p < 0.001). Patients in the DC group were twice as likely to undergo concurrent central lymph node dissection for papillary and medullary cancers than the IC group (p < 0.001). Overall, up to 60% of IC patients had been over- or under-treated at initial surgery. The clinical factors examined were not significantly associated with higher risk of malignancy in IC patients. CONCLUSION This study highlights the potential for improved preoperative diagnosis to streamline decision making for surgical management of patients with thyroid nodules.
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Affiliation(s)
- Rose Stewart
- Monash University Endocrine Surgery Unit, Alfred Hospital, Melbourne, Australia
| | - Yit Jern Leang
- Monash University Endocrine Surgery Unit, Alfred Hospital, Melbourne, Australia
| | - Chhavi Raj Bhatt
- Monash University Endocrine Surgery Unit, Alfred Hospital, Melbourne, Australia; Department of Epidemiology and Preventive Medicine, School of Public Health and Preventative Medicine, Monash University, Melbourne, Australia; Department of Emergency Medicine, Monash Health, Melbourne, Australia
| | - Simon Grodski
- Monash University Endocrine Surgery Unit, Alfred Hospital, Melbourne, Australia; Department of Surgery, Monash University, Melbourne, Australia; Department of Surgery, Monash Health, Melbourne, Australia
| | - Jonathan Serpell
- Monash University Endocrine Surgery Unit, Alfred Hospital, Melbourne, Australia; Department of Surgery, Monash University, Melbourne, Australia
| | - James C Lee
- Monash University Endocrine Surgery Unit, Alfred Hospital, Melbourne, Australia; Department of Surgery, Monash University, Melbourne, Australia; Department of Surgery, Monash Health, Melbourne, Australia.
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22
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Li F, Pan D, Wu Y, Peng J, Li Q, Gui X, Ma W, Yang H, He Y, Chen J. Ultrasound characteristics of thyroid nodules facilitate interpretation of the malignant risk of Bethesda system III/IV thyroid nodules and inform therapeutic schedule. Diagn Cytopathol 2019; 47:881-889. [PMID: 31211509 PMCID: PMC6772092 DOI: 10.1002/dc.24248] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 05/19/2019] [Accepted: 05/23/2019] [Indexed: 12/15/2022]
Abstract
Background This study was designed to explore whether ultrasound of thyroid nodules facilitates the interpretation of the malignant risk of Bethesda III/IV thyroid nodules to inform further therapies. Methods We reviewed patient records in which the results of ultrasound‐guided fine‐needle aspiration (US‐FNA) were classified by the Bethesda III/IV in our institution between January 2016 and June 2018. Studies were retrieved from PubMed, Cochrane Central Register of Controlled Trials, ISI Web of Science, Science Direct, Wiley Online Library, EMBASE, China National Knowledge Infrastructure, WanFang, and Chinese VIP. The odds ratio (OR) was used to measure associations between risk factors and thyroid nodule malignancy. Results Fifty‐nine cases of Bethesda III/IV with corresponding surgeries were included, and the malignancy risk was 54.2%. Meta‐analysis revealed irregular borders, solitary nodules, hypoechogenicity, microcalcifications, and being taller than wide, all of which increased the malignancy risk of thyroid nodules. Combined ORs for these factors were 4.08 (95% CI: 2.34‐7.14, P < .001), 2.18 (95% CI: 1.39‐3.42, P = .001), 2.02 (95% CI: 1.35‐3.01, P = .001), 3.21 (95% CI: 2.26‐4.56, P < .001), and 4.35 (95% CI: 3.07‐6.15, P < .001), respectively. Conclusion As the risk of malignancy for papillary thyroid carcinoma (PTC) is high, when any one of the five ultrasound features of malignancy were confirmed, repeated FNA is recommended to confirm PTC‐type malignancy, even though nodules were Bethesda III/IV classification. However, repeated FNA should be avoided when none of these ultrasound features are identified because repeated FNA does not contribute to identifying non‐PTC type malignancies, such as follicular thyroid carcinoma and poorly differentiated thyroid carcinoma.
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Affiliation(s)
- Fu Li
- Department of Gastrointestinal Surgery, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, People's Republic of China
| | - Denghua Pan
- Department of Ultrasonography, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, People's Republic of China
| | - Yuquan Wu
- Department of Ultrasonography, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, People's Republic of China
| | - Jinbo Peng
- Department of Ultrasonography, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, People's Republic of China
| | - Qing Li
- Department of Ultrasonography, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, People's Republic of China
| | - Xiaolong Gui
- Department of Gastrointestinal Surgery, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, People's Republic of China
| | - Wei Ma
- Department of Pathology, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, People's Republic of China
| | - Hong Yang
- Department of Ultrasonography, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, People's Republic of China
| | - Yun He
- Department of Ultrasonography, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, People's Republic of China
| | - Junqiang Chen
- Department of Gastrointestinal Surgery, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, People's Republic of China
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Allen L, Al Afif A, Rigby MH, Bullock MJ, Trites J, Taylor SM, Hart RD. The role of repeat fine needle aspiration in managing indeterminate thyroid nodules. J Otolaryngol Head Neck Surg 2019; 48:16. [PMID: 30894222 PMCID: PMC6425601 DOI: 10.1186/s40463-019-0338-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 03/05/2019] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND The Bethesda System is the most widely used for reporting fine needle aspiration (FNA) cytology. It recommends a repeat FNA (rFNA) when initial results are category I or III. It is unclear how often rFNA provides additional diagnostic information. We sought to investigate its utility at our institution. METHODS A retrospective chart review was performed of patients who had a category I or III FNA result and underwent rFNA of the same thyroid nodule between 2013 and 2015 at the QE II Health Sciences Centre in Nova Scotia, Canada. Results of initial FNA and ultrasound characteristics, rFNA, demographic data, surgical details, and pathology were collected. RESULTS A total of 237 patients (474 thyroid FNAs) were included. Most initial FNAs were category I (82%), the remainder category III (18%). rFNA yielded a different category 60% of the time. However, 60% remained category I or III. rFNA results of benign or malignant were found in 40% of cases; 1% were SFN/SFM. Twenty-seven percent of patients had surgery after rFNA; of those 68% had category I or III rFNA results. Of all nodules that underwent surgery, 46% were malignant, including 32% with category I rFNA results, and 42% category III. CONCLUSIONS rFNA for category I and III nodules provided a definitive diagnosis in only 40% of cases, which is important for patient counseling. Malignancy rates at our centre were higher for these categories than predicted by Bethesda. Clinical management should consider institution specific malignancy rates, patient factors, and ultrasound findings.
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Affiliation(s)
- Laura Allen
- Faculty of Medicine, Dalhousie University, 1459 Oxford Street, Halifax, Nova Scotia, B3H 4R2, Canada
| | - Ayham Al Afif
- Dalhousie University Division of Otolaryngology - Head & Neck Surgery, QEII Health Sciences Centre, 3rd floor Dickson Building, 5820 University Avenue, Halifax, NS, B3H 1Y9, Canada
| | - Matthew H Rigby
- Dalhousie University Division of Otolaryngology - Head & Neck Surgery, QEII Health Sciences Centre, 3rd floor Dickson Building, 5820 University Avenue, Halifax, NS, B3H 1Y9, Canada
| | - Martin J Bullock
- Department of Pathology, Dalhousie University, Sir Charles Tupper Medical Building, Room 11B, 5850 College Street, PO Box 15000, Halifax, NS, B3H 4R2, Canada
| | - Jonathan Trites
- Dalhousie University Division of Otolaryngology - Head & Neck Surgery, QEII Health Sciences Centre, 3rd floor Dickson Building, 5820 University Avenue, Halifax, NS, B3H 1Y9, Canada
| | - S Mark Taylor
- Dalhousie University Division of Otolaryngology - Head & Neck Surgery, QEII Health Sciences Centre, 3rd floor Dickson Building, 5820 University Avenue, Halifax, NS, B3H 1Y9, Canada
| | - Robert D Hart
- Department of Surgery, Section of Otolaryngology - Head and Neck Surgery, University of Calgary, 1007 North Tower, Foothills Medical Centre, 1403 29th Street NW, Calgary, AB, T2N 2T9, Canada.
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24
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Pastorello RG, Destefani C, Pinto PH, Credidio CH, Reis RX, Rodrigues TDA, Toledo MCD, De Brot L, Costa FDA, Nascimento AG, Pinto CAL, Saieg MA. The impact of rapid on‐site evaluation on thyroid fine‐needle aspiration biopsy: A 2‐year cancer center institutional experience. Cancer Cytopathol 2018; 126:846-852. [DOI: 10.1002/cncy.22051] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 07/23/2018] [Accepted: 07/25/2018] [Indexed: 12/17/2022]
Affiliation(s)
| | - Camila Destefani
- Department of Pathology A.C. Camargo Cancer Center Sao Paulo Brazil
| | - Pedro H. Pinto
- Department of Pathology A.C. Camargo Cancer Center Sao Paulo Brazil
- Department of Pathology Base Hospital Federal District Brazil
| | | | - Rafael X. Reis
- Department of Pathology A.C. Camargo Cancer Center Sao Paulo Brazil
| | | | | | - Louise De Brot
- Department of Pathology A.C. Camargo Cancer Center Sao Paulo Brazil
| | | | | | | | - Mauro A. Saieg
- Department of Pathology A.C. Camargo Cancer Center Sao Paulo Brazil
- Department of Pathology Santa Casa Medical School Sao Paulo Brazil
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25
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Fine-needle aspiration biopsy of thyroid nodules: Is routine ultrasound-guidance necessary? Surgery 2018; 164:789-794. [DOI: 10.1016/j.surg.2018.04.047] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 04/13/2018] [Accepted: 04/30/2018] [Indexed: 12/26/2022]
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26
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Gay S, Schiaffino S, Santamorena G, Massa B, Ansaldo G, Turtulici G, Giusti M, At The Policlinico San Martino Genoa TT. Role of Strain Elastography and Shear-Wave Elastography in a Multiparametric Clinical Approach to Indeterminate Cytology Thyroid Nodules. Med Sci Monit 2018; 24:6273-6279. [PMID: 30194820 PMCID: PMC6140375 DOI: 10.12659/msm.909870] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background In thyroid nodules with indeterminate cytology, further clinical assessment aimed at ruling out malignancy is often mandatory. Ancillary imaging techniques and genetic mutation analysis can improve the risk stratification of such lesions, thereby facilitating the clinician’s decision to undertaken surgery or simple follow-up. The aim of this study was to evaluate the diagnostic performance of shear-wave elastography (SW), strain elastography (ELX 2/1), conventional ultrasound (US), contrast-enhanced ultrasound (CEUS), and BRAF V600E mutation analysis in the aforementioned lesions. Material/Methods We enrolled 81 patients, each with 1 indeterminate-cytology thyroid nodule. Thyroid function, thyroperoxidase antibodies and calcitonin were known in each case. SW, ELX 2/1, US, CEUS, and BRAF mutation analysis were subsequently performed, followed by a second FNAB. If the lesion was not downgraded to benign, surgery was recommended and histological reports collected. Results There were 28 nodules (34%) that proved benign on the second FNAB; 38 nodules (47%) underwent surgery (17 benign, 21 malignant), and 15 nodules (19%) refused surgery. The only techniques related to histological outcome were US (AUC=0,766), ELX 2/1 (AUC=0.701), and BRAF analysis (AUC=0.762). ELX 2/1 and SW reports were not correlated with each other (P=0.45). A scoring system taking into account all the variables considered performed better than the single variables alone (AUC=0.831). Conclusions In indeterminate-cytology thyroid lesions, repeating FNAB can avoid unnecessary surgery. ELX 2/1 seems to perform better than SW in distinguishing malignancy; these techniques could, however, be complementary in describing such lesions. A multiparametric approach appears the most accurate in predicting nodule histology.
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Affiliation(s)
- Stefano Gay
- Endocrine Unit, Policlinico San Martino, Genoa, Italy
| | | | | | - Barbara Massa
- Cyto-Histopathological Unit, Policlinico San Martino, Genova, Italy
| | | | - Giovanni Turtulici
- Interventional Radiology Unit, Ospedale Evangelico Internazionale, Genoa, Italy
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27
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Kouba E, Ford A, Brown CG, Yeh C, Siegal GP, Manne U, Eltoum IE. Detection of BRAF V600E Mutations With Next-Generation Sequencing in Infarcted Thyroid Carcinomas After Fine-Needle Aspiration. Am J Clin Pathol 2018; 150:177-185. [PMID: 29868707 DOI: 10.1093/ajcp/aqy045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES Fine-needle aspiration (FNA) of thyroid lesions may result in infarction and diagnostic difficulties on subsequent thyroidectomy specimens. Next-generation sequencing (NGS) methods for detection of hallmark driver BRAF V600E mutations may help characterize such tumors in which histologic alterations preclude definitive tissue diagnosis. METHODS Thyroidectomy specimens with both malignant FNA diagnoses and resultant infarction were identified from our institutional database. NGS methods were used to detect BRAF V600E mutations in the infarcted thyroid carcinomas. RESULTS Nine thyroid carcinomas with infarction were characterized as BRAF-like papillary thyroid carcinoma based on molecular driver categorization and histologic diagnosis. BRAF V600E mutations were detected in the infarcted tissue in four (67%) of six lesions. CONCLUSIONS We demonstrate detection of hallmark BRAF V600E mutations by NGS within infarcted tissue of thyroid carcinomas after FNA. This suggests a potential ancillary method of characterizing infarcted thyroid carcinomas whose altered histology may be nondiagnostic.
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Affiliation(s)
- Erik Kouba
- Department of Pathology, University of Alabama–Birmingham, Birmingham, AL
| | | | | | | | - Gene P Siegal
- Department of Pathology, University of Alabama–Birmingham, Birmingham, AL
| | - Upender Manne
- Department of Pathology, University of Alabama–Birmingham, Birmingham, AL
| | - Isam-Eldin Eltoum
- Department of Pathology, University of Alabama–Birmingham, Birmingham, AL
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Grani G, Lamartina L, Durante C, Filetti S, Cooper DS. Follicular thyroid cancer and Hürthle cell carcinoma: challenges in diagnosis, treatment, and clinical management. Lancet Diabetes Endocrinol 2018; 6:500-514. [PMID: 29102432 DOI: 10.1016/s2213-8587(17)30325-x] [Citation(s) in RCA: 110] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 09/06/2017] [Accepted: 09/07/2017] [Indexed: 12/16/2022]
Abstract
Follicular thyroid cancer is the second most common differentiated thyroid cancer histological type and has been overshadowed by its more common counterpart-papillary thyroid cancer-despite its unique biological behaviour and less favourable outcomes. In this Review, we comprehensively review the literature on follicular thyroid cancer to provide an evidence-based guide to the management of these tumours, to highlight the lack of evidence behind guideline recommendations, and to identify changes and challenges over the past decades in diagnosis, prognosis, and treatment. We highlight that correct identification of cancer in indeterminate cytological samples is challenging and ultrasonographic features can be misleading. Despite certain unique aspects of follicular thyroid cancer presentation and prognosis, no specific recommendations exist for follicular thyroid cancer and Hürthle cell carcinoma in evidence-based guidelines. Efforts should be made to stimulate additional research in this field.
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Affiliation(s)
- Giorgio Grani
- Dipartimento di Medicina Interna e Specialità Mediche, University of Rome, Sapienza, Rome, Italy
| | - Livia Lamartina
- Dipartimento di Medicina Interna e Specialità Mediche, University of Rome, Sapienza, Rome, Italy
| | - Cosimo Durante
- Dipartimento di Medicina Interna e Specialità Mediche, University of Rome, Sapienza, Rome, Italy
| | - Sebastiano Filetti
- Dipartimento di Medicina Interna e Specialità Mediche, University of Rome, Sapienza, Rome, Italy
| | - David S Cooper
- Division of Endocrinology, Diabetes, and Metabolism, The Johns Hopkins School of Medicine, Baltimore, MD, USA.
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29
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Hong SH, Lee H, Cho MS, Lee JE, Sung YA, Hong YS. Malignancy Risk and Related Factors of Atypia of Undetermined Significance/Follicular Lesion of Undetermined Significance in Thyroid Fine Needle Aspiration. Int J Endocrinol 2018; 2018:4521984. [PMID: 30154840 PMCID: PMC6091291 DOI: 10.1155/2018/4521984] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 07/04/2018] [Indexed: 01/21/2023] Open
Abstract
Atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS) in thyroid fine needle aspiration (FNA) is a challenging category. The malignancy risk is different by multiple factors and subsequent management strategy is inconclusive. Therefore, we analyzed the malignancy risk of AUS/FLUS according to radiological and clinical features. A total of 687 nodules that had been initially diagnosed as AUS/FLUS were retrospectively reviewed from 6365 thyroid FNAs between 2011 and 2014. The ultrasonographic (US) features were categorized using the Korean Thyroid Imaging Reporting and Data System. Radiological and clinical features were compared according to the second FNA results or histologically confirmed results from surgery. Repeat FNA was performed on 248 (36%) nodules, and 49 (7%) nodules underwent immediate surgery. Among the 248 nodules subjected to repeated FNA, 49 (20%) nodules were diagnosed again as AUS/FLUS, 123 (50%) were found to be benign, and 47 (19%) were diagnosed as follicular neoplasm, suspicious for malignancy or malignant. Among histologically confirmed nodules, the US features were more unfavorable in malignant nodules, and hypo- or anechogenicity was associated with a higher risk of malignancy after adjusting for age, size, and other US features (P < 0.01). In conclusion, we observed that malignant nodules tended to show unfavorable US features, especially hypo- or anechogenicity. Age, sex, and thyroid function were not significantly associated with malignancy risk. We also found out that malignancy risk was not different between the group which underwent immediate operation following the AUS/FLUS diagnosis and the group which underwent repeated FNA after the initial diagnosis.
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Affiliation(s)
- So-hyeon Hong
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Hyejin Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Min-Sun Cho
- Department of Pathology, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Jee Eun Lee
- Department of Radiology, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Yeon-Ah Sung
- Division of Endocrinology and Metabolism, Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Young Sun Hong
- Division of Endocrinology and Metabolism, Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
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Saieg MA, Barbosa B, Nishi J, Ferrari A, Costa F. The impact of repeat FNA in non-diagnostic and indeterminate thyroid nodules: A 5-year single-centre experience. Cytopathology 2017; 29:196-200. [PMID: 29205587 DOI: 10.1111/cyt.12508] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2017] [Indexed: 01/21/2023]
Abstract
INTRODUCTION FNA is a well-established method for the preoperative diagnosis of thyroid nodules, but limitations still reside among non-diagnostic and indeterminate samples. The objective of the present study was to assess the impact of repeat FNA in thyroid nodules primarily classified as non-diagnostic and indeterminate, with the evaluation of the diagnostic resolution rate after the reassessment of the nodule. METHODS We retrospectively collected all cases of thyroid FNA at our institution in the last 5 years that had one or more repeat aspirations of the same nodule, calculating the percentage of samples with change in the diagnostic category. Additional collected data included sex, age and interval between the repeat aspirations. RESULTS One hundred and seventy-eight specimens from 167 patients (140 female, 27 male) with a median age of 56 years (range 11-90) were included in the study. Among the 86 cases primarily classified as non-diagnostic, 25 (29.1%) remained in the same category after the first reassessment and only 18 (20.9%) after the second repeat aspiration. Among the 40 indeterminate cases, only 10 (25%) retained their status after the second aspiration, with no change after the third assessment. CONCLUSION Repeat aspiration of non-diagnostic and indeterminate thyroid nodules had a positive impact in both groups, with diagnostic resolution rates of 80% and 75%, respectively. The present study therefore endorses the use of such strategy for the initial follow-up of nodules with no definite diagnosis, especially in low-resource centres with limited access to modern molecular technologies.
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Affiliation(s)
- M A Saieg
- Department of Pathology, Santa Casa Medical School, Sao Paulo, Brazil.,Department of Pathology, AC Camargo Cancer Center, Sao Paulo, Brazil.,Municipal University of São Caetano, São Caetano do Sul, Brazil
| | - B Barbosa
- Department of Pathology, Santa Casa Medical School, Sao Paulo, Brazil
| | - J Nishi
- Municipal University of São Caetano, São Caetano do Sul, Brazil
| | - A Ferrari
- Municipal University of São Caetano, São Caetano do Sul, Brazil
| | - F Costa
- Municipal University of São Caetano, São Caetano do Sul, Brazil
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Cohen O, Tzelnick S, Lahav Y, Schindel D, Halperin D, Yehuda M. Selection of Atypia/Follicular Lesion of Unknown Significance Patients for Surgery Versus Active Surveillance, Without Using Genetic Testing: A Single Institute Experience, Prospective Analysis, and Recommendations. Thyroid 2017; 27:928-935. [PMID: 28463595 DOI: 10.1089/thy.2016.0237] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Atypia/follicular lesion of unknown significance (AUS/FLUS) has variable rates of malignancy. The recommended management includes active surveillance (AS), repeated fine-needle aspiration (RFNA), diagnostic surgery, or genetic testing for malignancy. The objective of this study was to assess the management of AUS/FLUS patients in a dedicated thyroid clinic without implementing genetic testing. METHODS This was a single institute cohort study of all patients aged ≥18 years who underwent ultrasound-guided FNA thyroid biopsies between January 2009 and January 2013 and were followed until January 2016. The median follow-up time was 4.6 years (range 3.2-6.8 years). Forty-eight (57%) patients were referred to AS, and 36 (43%) patients were referred for diagnostic surgery. Thirty-six (75%) patients from the AS group underwent RFNA. An additional eight patients from the AS group subsequently underwent diagnostic surgery. RESULTS Malignancies were found in 15/44 (34%) diagnostic surgical samples, and benign cytologies were found in 61.1% of the RFNAs. Analysis of adherence to follow-up in the 36 AS patients showed an adherence rate of only 53%, with males tending to comply better than females did (31.6% vs. 5.8%, respectively; p = 0.052), especially males in their sixth decade of life. CONCLUSIONS Genetic tests for AUS/FLUS patients are accepted today as complementary evaluations in many well-developed health systems. Yet, when these tests are not feasible due to financial or availability issues, careful management of AUS/FLUS patients may still offer good results in the selection of patients for surgery or AS. The present results also indicate that compliance to follow-up schedules is a major consideration when selecting patients for AS.
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Affiliation(s)
- Oded Cohen
- 1 Department of Otolaryngology-Head and Neck Surgery, Kaplan Medical Center, Hadassah School of Medicine, Hebrew University in Jerusalem , Rehovot, Israel
| | - Sharon Tzelnick
- 1 Department of Otolaryngology-Head and Neck Surgery, Kaplan Medical Center, Hadassah School of Medicine, Hebrew University in Jerusalem , Rehovot, Israel
| | - Yonatan Lahav
- 1 Department of Otolaryngology-Head and Neck Surgery, Kaplan Medical Center, Hadassah School of Medicine, Hebrew University in Jerusalem , Rehovot, Israel
| | - Doron Schindel
- 1 Department of Otolaryngology-Head and Neck Surgery, Kaplan Medical Center, Hadassah School of Medicine, Hebrew University in Jerusalem , Rehovot, Israel
| | - Doron Halperin
- 1 Department of Otolaryngology-Head and Neck Surgery, Kaplan Medical Center, Hadassah School of Medicine, Hebrew University in Jerusalem , Rehovot, Israel
| | - Moshe Yehuda
- 1 Department of Otolaryngology-Head and Neck Surgery, Kaplan Medical Center, Hadassah School of Medicine, Hebrew University in Jerusalem , Rehovot, Israel
- 2 Department of Otolaryngology-Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Sackler School of Medicine, Tel-Aviv University , Tel-Aviv, Israel
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Karatzas T, Vasileiadis I. Authors' reply to the Letter to Editor "Thyroglobulin antibodies may serve as predictive marker for papillary thyroid carcinoma in indeterminate cytology: Acceptable or not?". Am J Surg 2017; 216:178-179. [PMID: 28237046 DOI: 10.1016/j.amjsurg.2017.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 01/18/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Theodore Karatzas
- Second Department of Propedeutic Surgery, Medical School, University of Athens, Laikon General Hospital, Athens, Greece
| | - Ioannis Vasileiadis
- Department of Otolaryngology/Head and Neck Surgery, Venizeleio - Pananeio General Hospital, Herakleion, Greece; Department of Otolaryngology - Head and Neck Surgery, Royal London Hospital, Barts and the London Trust, London, United Kingdom.
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Manning AM, Yang H, Falciglia M, Mark JR, Steward DL. Thyroid Ultrasound-Guided Fine-Needle Aspiration Cytology Results: Observed Increase in Indeterminate Rate over the Past Decade. Otolaryngol Head Neck Surg 2017; 156:611-615. [PMID: 28118554 DOI: 10.1177/0194599816688190] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Objectives To evaluate changes in distribution of reported thyroid nodule fine-needle aspiration (FNA) cytopathology results since implementation of the Bethesda classification and revised 2015 American Thyroid Association (ATA) guidelines for selecting nodules for biopsy. Study Design Retrospective review. Setting Tertiary academic medical center. Subjects and Methods Evaluation of ultrasound (US)-guided thyroid FNA by a single surgeon using 2015 ATA nodule selection criteria and Bethesda reporting on 211 thyroid nodules in a 1-year period (2015). Comparison is made to an earlier sample wherein any nodule >1 cm underwent US FNA with cytology reported prior to Bethesda consensus (2006). Results The current cohort involved mostly women (79%); nodules ranged from 1 to 7 cm (mean ± SEM, 2.4 ± 0.07 cm). Mean ± SEM age was 53.5 ± 1.1 years. Bethesda reporting yielded 6% nondiagnostic, 57% benign, 3% malignant, and 34% indeterminate (27% atypia of undetermined significance [AUS]/follicular lesion of undetermined significance [FLUS], 4% follicular neoplasm [FN]/Hürthle neoplasm [HN], and 2% suspicious for malignancy [SFM]). The malignancy rate in indeterminate nodules was 26% (18% AUS/FLUS, 33% FN/HN, and 80% SFM). Age, sex, or nodule size did not correlate with indeterminate cytology. The comparator sample of 447 nodules had significantly different distribution, with 7% nondiagnostic, 80% benign, 5% malignant, and 8% indeterminate ( P < .00001). Conclusion We observed a significantly increased proportion of indeterminate cytology and corresponding decrease in benign nodules compared with an earlier sample, predominately from an increase in AUS/FLUS. Multiple factors are likely involved, including selection of sonographically suspicious nodules for biopsy based upon 2015 ATA guidelines coupled with cytopathological interpretation by a new generation of cytopathologists trained in the era of Bethesda reporting; further study is required to make a definitive conclusion.
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Affiliation(s)
- Amy M Manning
- 1 Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati (UC) College of Medicine, Cincinnati, Ohio, USA
| | - Huaitao Yang
- 2 Department of Pathology and Laboratory Medicine. University of Cincinnati (UC) College of Medicine, Cincinnati, Ohio, USA
| | - Mercedes Falciglia
- 3 Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine. University of Cincinnati (UC) College of Medicine, Cincinnati, Ohio, USA
| | - Jonathan R Mark
- 1 Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati (UC) College of Medicine, Cincinnati, Ohio, USA
| | - David L Steward
- 1 Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati (UC) College of Medicine, Cincinnati, Ohio, USA.,3 Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine. University of Cincinnati (UC) College of Medicine, Cincinnati, Ohio, USA
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Abstract
The detection of thyroid nodules, consisting of different diseases, represents a common finding in population. Their evaluation and diagnosis are mostly achieved with fine-needle aspiration cytology (FNAC). Even though the majority of thyroid nodules are correctly diagnosed, a total of 25% to 30% of them are classified "indeterminate" comprising lesions with varying risk of malignancy and different types of management. Although the number of thyroid FNACs, including small lesions, is increasing due to the reliance upon sonographic and cytologic interpretations, there are issues concerning cytomorphologic interpretation and interobserver reproducibility. Different classification systems have tried to better define the criteria for inclusion in specific categories and to therefore reduce the rate of indeterminate diagnoses such as atypia of undetermined significance, follicular neoplasms, and suspicious for malignancy. However, the support of ancillary techniques (eg, immunocytochemistry and molecular analysis) are reshaping morphologic diagnoses made on materials obtained from FNAC.
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Jooya A, Saliba J, Blackburn A, Tamilia M, Hier MP, Mlynarek A, Forest VI, Rochon L, Florea A, Wang H, Payne RJ. The role of repeat fine needle aspiration in the management of indeterminate thyroid nodules. J Otolaryngol Head Neck Surg 2016; 45:51. [PMID: 27756425 PMCID: PMC5070180 DOI: 10.1186/s40463-016-0164-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 10/10/2016] [Indexed: 01/21/2023] Open
Abstract
Background Management decisions are not straightforward when the Ultrasound Guided Fine Needle Aspiration (USFNA) demonstrates a Bethesda score of either category III or IV, and a diagnostic hemi-thyroidectomy or a repeat USFNA (r-USFNA) could be performed. The aim of this study is to assess the effectiveness of r-USFNA in the management of indeterminate thyroid nodules by evaluating the likelihood of obtaining a definite diagnosis. Methods We reviewed the medical records of all patients with thyroid nodules between 2011 and 2015 at the Jewish General Hospital (Montreal, Canada). Three hundred fifty-one patients who had undergone a surgical procedure (hemi or total thyroidectomy) and a diagnosis of B3 or B4 on the primary USFNA (p-USFNA) were included in the study. Ninety-six of the included patients also had a repeat USFNA prior to the surgery. Demographic data, type of procedure, and McGill Thyroid Nodule Score (MTNS) were obtained from the medical records. Malignancy rates were calculated based on the final surgical histopathology report. Results Upon r-USFNA, an average 76 % of patients did not change Bethesda categories, 7.4 % downgraded to a benign category. The results showed that, on an average 17.3 % of patients with p-USFNA of B3 and 20 % of patients with p-USFNA of B4, upgraded to a malignant or suspicious for malignancy category, thus changing the clinical management to total thyroidectomy. Our data demonstrates that r-USFNA facilitates choosing the correct surgery of total thyroidectomy in about 20 % of nodules that have upgraded from B3/B4 to a more definite malignant category. Conclusions r-USFNA in patients with indeterminate diagnoses (B3 or B4) increases categorization into more definite categories. Approximately 20 % of patients are found to have malignant thyroid nodules and suspicious for malignancy thyroid nodules upon repeating the biopsy, hence a diagnostic hemi-thyroidectomy was avoided and a more definitive surgery could be performed. Furthermore, repeat USFNA results in a fewer number of hemi-thyroidectomy and completion thyroidectomy procedures.
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Affiliation(s)
- Alborz Jooya
- Department of Otolaryngology - Head and Neck Surgery - Jewish General Hospital, McGill University, 3755 Chemin de la Côte-Sainte-Catherine, Room E-903, Montréal, H3T 1E2, QC, Canada
| | - Joe Saliba
- Department of Otolaryngology - Head and Neck Surgery - Jewish General Hospital, McGill University, 3755 Chemin de la Côte-Sainte-Catherine, Room E-903, Montréal, H3T 1E2, QC, Canada
| | - Audrey Blackburn
- Department of Otolaryngology - Head and Neck Surgery - Jewish General Hospital, McGill University, 3755 Chemin de la Côte-Sainte-Catherine, Room E-903, Montréal, H3T 1E2, QC, Canada
| | - Michael Tamilia
- Division of Endocrinology, Jewish General Hospital - McGill University, Montreal, QC, Canada
| | - Michael P Hier
- Department of Otolaryngology - Head and Neck Surgery - Jewish General Hospital, McGill University, 3755 Chemin de la Côte-Sainte-Catherine, Room E-903, Montréal, H3T 1E2, QC, Canada
| | - Alex Mlynarek
- Department of Otolaryngology - Head and Neck Surgery - Jewish General Hospital, McGill University, 3755 Chemin de la Côte-Sainte-Catherine, Room E-903, Montréal, H3T 1E2, QC, Canada
| | - Véronique-Isabelle Forest
- Department of Otolaryngology - Head and Neck Surgery - Jewish General Hospital, McGill University, 3755 Chemin de la Côte-Sainte-Catherine, Room E-903, Montréal, H3T 1E2, QC, Canada
| | - Louise Rochon
- Department of Pathology, Jewish General Hospital - McGill University, Montreal, QC, Canada
| | - Anca Florea
- Department of Pathology, Jewish General Hospital - McGill University, Montreal, QC, Canada
| | - Hangjun Wang
- Department of Pathology, Jewish General Hospital - McGill University, Montreal, QC, Canada
| | - Richard J Payne
- Department of Otolaryngology - Head and Neck Surgery - Jewish General Hospital, McGill University, 3755 Chemin de la Côte-Sainte-Catherine, Room E-903, Montréal, H3T 1E2, QC, Canada.
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Kim SJ, Roh J, Baek JH, Hong SJ, Shong YK, Kim WB, Song DE. Risk of malignancy according to sub-classification of the atypia of undetermined significance or follicular lesion of undetermined significance (AUS/FLUS) category in the Bethesda system for reporting thyroid cytopathology. Cytopathology 2016; 28:65-73. [DOI: 10.1111/cyt.12352] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2016] [Indexed: 01/21/2023]
Affiliation(s)
- S. J. Kim
- Department of Pathology; Asan Medical Center; University of Ulsan College of Medicine; Seoul Korea
| | - J. Roh
- Department of Pathology; Asan Medical Center; University of Ulsan College of Medicine; Seoul Korea
| | - J. H. Baek
- Department of Radiology; Asan Medical Center; University of Ulsan College of Medicine; Seoul Korea
| | - S. J. Hong
- Department of Surgery; Asan Medical Center; University of Ulsan College of Medicine; Seoul Korea
| | - Y. K. Shong
- Department of Internal Medicine; Asan Medical Center; University of Ulsan College of Medicine; Seoul Korea
| | - W. B. Kim
- Department of Internal Medicine; Asan Medical Center; University of Ulsan College of Medicine; Seoul Korea
| | - D. E. Song
- Department of Pathology; Asan Medical Center; University of Ulsan College of Medicine; Seoul Korea
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A Pilot Study of Galectin-3, HBME-1, and p27 Triple Immunostaining Pattern for Diagnosis of Indeterminate Thyroid Nodules in Cytology With Correlation to Histology. Appl Immunohistochem Mol Morphol 2016; 23:481-90. [PMID: 25221953 PMCID: PMC4530731 DOI: 10.1097/pai.0000000000000106] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Supplemental Digital Content is available in the text. Indeterminate thyroid nodules form a heterogenous group of lesions that constitute 5% to 30% of thyroid cytology diagnoses. We introduce a triple immunostaining protocol for subtyping. Galectin-3, HBME-1, and p27 triple immunostaining, performed on destained cytology slides and formalin-fixed paraffin-embedded tissue, was developed and applied to 51 patients retrospectively with preoperative cytologic diagnoses of follicular lesion of undetermined significance (n=40), atypia of undetermined significance (n=6), and suspicious for follicular neoplasm (n=5). The malignant rate in this series was 43.1% (22/51). A hierarchal evaluation algorithm was generated based on digital image quantitation of triple-stained histologic sections, and applied to both cytology and histology specimens. Fifty of 51 cytology cases have triple staining validated by internal controls. In cytology specimens, the individual sensitivities and specificities of p27, Galectin3, and HBME1 for cancer with 95% confidence interval are: 86.2% (0.674, 0.955)/66.7% (0.431, 0.845); 77.3% (0.542, 0.913)/72.4% (0.525, 0.866); and 72.7% (0.496, 0.884)/93.1% (0.758, 0.988), respectively. Sensitivity is increased to 95.5% (0.751, 0.998), but specificity is decreased to 69.0% (0.490, 0.840), if Galectin3 and HBME1 are both used in combination as markers for malignancy. However, the level of specificity is increased to 86.2% (0.674, 0.955) and sensitivity remains high 100% (0.808, 1) if in addition, using the Galectin3/HBME1:p27 ratio (ratio ≥2 indicating malignancy) for 2 or 3 markers positive cases. Thus, the triple staining method on cytology slides and histology sections shows a similar sensitivity/specificity/positive predictive value/negative predictive value of 100.0%/86.2%/84.0%/100.0% and 95.5%/86.2%/84.0%/96.2%, respectively (P=0.92). Overall, p27 is the most frequent single positive marker (19/50, 38% in cytology), consistent with benign nature of most indeterminate thyroid nodules. Galectin-3 and HBME-1 colocalization (positive in the same cell) was demonstrated in thyroid cancer in 45.5% (10/22) of histology sections, but in none of the normal thyroid tissues and benign thyroid lesions. This supports the notion that synchronous activation of Galectin-3 and HBME-1 occurs in thyroid malignancy and is highly specific for malignancy. We have demonstrated the performance and pattern of triple immunostaining for subtyping indeterminate thyroid nodules. Further studies and validation in different larger populations are warranted.
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Karatzas T, Vasileiadis I, Zapanti E, Charitoudis G, Karakostas E, Boutzios G. Thyroglobulin antibodies as a potential predictive marker of papillary thyroid carcinoma in patients with indeterminate cytology. Am J Surg 2016; 212:946-952. [PMID: 27324384 DOI: 10.1016/j.amjsurg.2015.12.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Revised: 11/14/2015] [Accepted: 12/02/2015] [Indexed: 10/21/2022]
Abstract
BACKROUND We investigated the efficacy of thyroglobulin antibodies (TgAb) in detecting malignancy in indeterminate thyroid nodules and evaluated the possible association between TgAb and autoimmunity in papillary thyroid carcinoma (PTC). METHODS This retrospective, nonrandomized study included 1,646 patients who had undergone preoperative fine-needle aspiration biopsy to evaluate their thyroid nodules, and then standard total thyroidectomy. Of 194 patients (11.8%) with indeterminate nodules, 61 (31.4%) had PTC and 133 (68.6%) had benign nodules at the final histologic examination. RESULTS Univariate analysis showed that multifocality (P = .002), bilaterality (P = .003), lymph-node metastasis (P = .030), and capsule penetration (P = .003) were significantly associated with positive TgAb in patients with indeterminate cytology and histopathologic diagnosis of PTC. The multivariate analysis showed that TgAb positivity (P < .001) and preoperative thyroid-stimulating hormone levels (P = .022) were independent predictive factor for PTC diagnosis in patients with indeterminate cytology. CONCLUSIONS Preoperative TgAb could be a marker for PTC in patients with indeterminate thyroid nodules, increasing diagnostic accuracy. TgAb positivity could also influence the clinical assessment and subsequent selection of total thyroidectomy.
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Affiliation(s)
- Theodore Karatzas
- Second Department of Propedeutic Surgery, Medical School, University of Athens, Laikon General Hospital, Athens, Greece
| | - Ioannis Vasileiadis
- Department of Otolaryngology/Head and Neck Surgery, Venizeleio - Pananeio General Hospital, Herakleion, Greece; Department of Otolaryngology - Head and Neck Surgery, Royal London Hospital, Barts and the London Trust, London, UK.
| | - Evangelia Zapanti
- Endocrine Unit, First Department of Internal Medicine, Medical School, University of Athens, Laikon General Hospital, Athens, Greece
| | - Georgios Charitoudis
- Department of Otolaryngology/Head and Neck Surgery, Venizeleio - Pananeio General Hospital, Herakleion, Greece
| | - Efthimios Karakostas
- Department of Otolaryngology/Head and Neck Surgery, Venizeleio - Pananeio General Hospital, Herakleion, Greece
| | - Georgios Boutzios
- Endocrine Unit, Department of Pathophysiology, Medical School, University of Athens, Laikon General Hospital, Athens, Greece
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Pyo JS, Sohn JH, Kang G. Core Needle Biopsy Is a More Conclusive Follow-up Method Than Repeat Fine Needle Aspiration for Thyroid Nodules with Initially Inconclusive Results: A Systematic Review and Meta-Analysis. J Pathol Transl Med 2016; 50:217-24. [PMID: 27077724 PMCID: PMC4876081 DOI: 10.4132/jptm.2016.02.15] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 02/12/2016] [Accepted: 02/15/2016] [Indexed: 01/21/2023] Open
Abstract
Background: This study investigated the appropriate management of thyroid nodules with prior non-diagnostic or atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS) through a systematic review and meta-analysis. Methods: This study included 4,235 thyroid nodules from 26 eligible studies. We investigated the conclusive rate of follow-up core needle biopsy (CNB) or repeat fine needle aspiration (rFNA) after initial fine needle aspiration (FNA) with non-diagnostic or AUS/FLUS results. A diagnostic test accuracy (DTA) review was performed to determine the diagnostic role of the follow-up CNB and to calculate the area under the curve (AUC) on the summary receiver operating characteristic (SROC) curve. Results: The conclusive rates of follow-up CNB and rFNA after initial FNA were 0.879 (95% confidence interval [CI], 0.801 to 0.929) and 0.684 (95% CI, 0.627 to 0.736), respectively. In comparison of the odds ratios of CNB and rFNA, CNB had more frequent conclusive results than rFNA (odds ratio, 5.707; 95% CI, 2.530 to 12.875). Upon subgroup analysis, follow-up CNB showed a higher conclusive rate than rFNA in both initial non-diagnostic and AUS/FLUS subgroups. In DTA review of followup CNB, the pooled sensitivity and specificity were 0.94 (95% CI, 0.88 to 0.97) and 0.88 (95% CI, 0.84 to 0.91), respectively. The AUC for the SROC curve was 0.981, nearing 1. Conclusions: Our results show that CNB has a higher conclusive rate than rFNA when the initial FNA produced inconclusive results. Further prospective studies with more detailed criteria are necessary before follow-up CNB can be applied in daily practice.
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Affiliation(s)
- Jung-Soo Pyo
- Department of Pathology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin Hee Sohn
- Department of Pathology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Guhyun Kang
- Department of Pathology, Inje University Sanggye Paik Hospital, Seoul, Korea
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Caleo A, Landolfi L, Vitale M, Di Crescenzo V, Vatrella A, De Rosa G, Peluso AL, Zeppa P. The diagnostic accuracy of fine-needle cytology of Hurthle cell lesions; A comprehensive cytological, clinical and ultrasonographic experience. Int J Surg 2016; 28 Suppl 1:S65-9. [DOI: 10.1016/j.ijsu.2015.12.049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2015] [Revised: 05/13/2015] [Accepted: 05/25/2015] [Indexed: 01/31/2023]
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Koh J, Kim EK, Kwak JY, Yoon JH, Moon HJ. Repeat fine-needle aspiration can be performed at 6 months or more after initial atypia of undetermined significance or follicular lesion of undetermined significance results for thyroid nodules 10 mm or larger. Eur Radiol 2016; 26:4442-4448. [PMID: 26965502 DOI: 10.1007/s00330-016-4311-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 02/22/2016] [Accepted: 02/26/2016] [Indexed: 01/21/2023]
Abstract
OBJECTIVES To investigate whether repeat ultrasound-guided fine-needle aspiration (US-FNA) in initial atypia of undetermined significance or follicular lesion of undetermined significance (AUS/FLUS) results could be performed 6 months after or more. METHODS A total of 221 AUS/FLUS ≥10 mm with any follow-up were grouped according to the first follow-up interval at less than 6 months (group 1, n = 87) and 6 months or more (group 2, n = 134). Clinical features, final assessment of ultrasound (US) or the Thyroid Imaging Reporting and Data System (TIRADS), tumour size, extrathyroidal extension and lymph node metastasis in malignancies were compared. RESULTS Thirty-four (15.4 %) were malignant. Age, gender, size, final assessment, TIRADS and malignancy rate were not significantly different between the two groups (p = 0.660, 0.691, 0.502, 0.237, 0.819 and 0.420). Tumour size, extrathyroidal extension and lymph node metastasis were not significantly different between the two malignancy groups (p = 0.770, 0.611 and 0.068). Two of 10 nodules with increased size were malignancies found at 7.1 and 25.0 months. None of 33 nodules (14.9 %) with decreased size at a median 10 months were malignant. CONCLUSIONS Repeat US-FNA performed on nodules ≥10 mm at 6 months or more after initial AUS/FLUS results can reduce unnecessary repeat US-FNAs without progression of malignancy. KEY POINTS • Follow-up intervals of AUS/FLUS did not affect the malignancy rate • Tumour stage was not different according to the follow-up intervals • None of the nodules with decreased size were malignant • Repeat US-FNA can be performed at ≥6 months after initial AUS/FLUS.
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Affiliation(s)
- Jieun Koh
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea, 120-752
| | - Eun-Kyung Kim
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea, 120-752
| | - Jin Young Kwak
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea, 120-752
| | - Jung Hyun Yoon
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea, 120-752
| | - Hee Jung Moon
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea, 120-752.
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Hirsch D, Robenshtok E, Bachar G, Braslavsky D, Benbassat C. The Implementation of the Bethesda System for Reporting Thyroid Cytopathology Improves Malignancy Detection Despite Lower Rate of Thyroidectomy in Indeterminate Nodules. World J Surg 2016; 39:1959-65. [PMID: 25809059 DOI: 10.1007/s00268-015-3032-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The Bethesda system for reporting thyroid cytopathology (TBSRTC) was developed in 2009 to standardize the terminology for interpreting fine-needle aspiration (FNA) specimens. METHODS A historical prospective case series design was employed. The study group included patients with a thyroid nodule classified as TBSRTC AUS/FLUS (B3) or FN/SFN (B4) in 2011-2012 in a tertiary university-affiliated medical center. Rates of surgery and malignancy detection were compared to our pre-TBSRTC (1999-2000) study. RESULTS Of 3927 nodules aspirated, 575 (14.6%) were categorized as B3/B4. Complete data were available for 322. Thyroidectomy was performed in 123 (38.2%) cases: 66/250 (26.4%) B3 and 57/72 (79.2%) B4. Differentiated thyroid cancer was found in 66 (53.7%) patients: 30/66 (45.5%) B3 and 36/57 (63.2%) B4 (p=0.075). Operated patients were younger than the non-operated (B3: 52.4±16 vs. 59.7±13 years, p=0.009; B4: 51.7±15 vs. 60.5±14 years, p=0.042), and operated B3 nodules were larger than the non-operated (27.2 vs. 22.2 mm, p=0.014). Additional FNA was done in 160 patients (49.7%): 137/250 (54.8%) B3 and 23/72 (31.9%) B4 (p=0.002). The additional B3 nodules aspirations yielded a diagnosis of B2 in 84 patients (61.3%), B3 in 48 (35%), and B4 in 5 (3.6%). Of the 23 repeated B4 aspirations, B2 was reported in 5 (21.7%), B3 in 12 (52.2%), B4 in 4 (17.4%), and B6 in 2 (8.7%). The number of aspirated nodules was twice that reported in 1999-2000. The rate of indeterminate nodules increased from 6 to 14.6%, the surgery rate decreased from 52.3 to 38.2%, and the accuracy of malignancy diagnosis increased from 25.9 to 53.7%. CONCLUSIONS The application of TBSRTC significantly improves diagnostic accuracy for indeterminate thyroid nodules, leading to higher rates of malignancy detection despite lower rates of thyroidectomies.
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Affiliation(s)
- Dania Hirsch
- Endocrine Institute, Rabin Medical Center, 49100, Petach Tikva, Israel,
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Brandler TC, Aziz MS, Coutsouvelis C, Rosen L, Rafael OC, Souza F, Jelloul FZ, Klein MA. Young investigator challenge: Atypia of undetermined significance in thyroid FNA: Standardized terminology without standardized management-a closer look at repeat FNA and quality measures. Cancer Cytopathol 2016; 124:37-43. [DOI: 10.1002/cncy.21648] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Revised: 10/02/2015] [Accepted: 10/19/2015] [Indexed: 01/21/2023]
Affiliation(s)
- Tamar C. Brandler
- Department of Pathology; Hofstra North Shore-LIJ School of Medicine; Lake Success New York
| | - Mohamed S. Aziz
- Department of Pathology; Hofstra North Shore-LIJ School of Medicine; Lake Success New York
| | | | - Lisa Rosen
- Department of Biostatistics; Hofstra North Shore-LIJ School of Medicine; Lake Success New York
| | - Oana C. Rafael
- Department of Pathology; Hofstra North Shore-LIJ School of Medicine; Lake Success New York
| | - Fabiola Souza
- Department of Pathology; Hofstra North Shore-LIJ School of Medicine; Lake Success New York
| | - Fatima-Zahra Jelloul
- Department of Pathology; Hofstra North Shore-LIJ School of Medicine; Lake Success New York
| | - Melissa A. Klein
- Department of Pathology; Hofstra North Shore-LIJ School of Medicine; Lake Success New York
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Bobanga ID, McHenry CR. Evaluation and management of thyroid nodules with atypia/follicular lesion of undetermined significance on fine-needle aspiration. INTERNATIONAL JOURNAL OF ENDOCRINE ONCOLOGY 2015. [DOI: 10.2217/ije.15.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Since the introduction of the Bethesda System for Reporting Thyroid Cytopathology in 2008, the management of thyroid nodules has become more standardized, with clearly defined algorithms based on risk of malignancy for each of the six cytologic categories. However, the management of a thyroid nodule with a fine-needle aspiration biopsy classified as Bethesda III, or atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS), remains controversial due to the cytologic heterogeneity and the variability in the reported rates of malignancy. In this review, the history and rationale for the new Bethesda III category is examined, the reported incidence and risk of malignancy from published studies is reviewed and recommendations for management of patients with a thyroid nodule and AUS/FLUS are provided. Recent advances in molecular analysis and their role in the evaluation of patients with AUS/FLUS are also discussed.
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Affiliation(s)
- Iuliana D Bobanga
- Department of Surgery, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA
| | - Christopher R McHenry
- Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH 44109, USA
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Celik B, Whetsell CR, Nassar A. Afirma GEC and thyroid lesions: An institutional experience. Diagn Cytopathol 2015; 43:966-70. [PMID: 26466552 DOI: 10.1002/dc.23378] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 07/29/2015] [Accepted: 09/24/2015] [Indexed: 01/21/2023]
Abstract
BACKGROUND Thyroid fine-needle aspiration (FNA) is used to assess appropriate management of nodular thyroid lesions safely, but Bethesda category III (atypia of undetermined significance/follicular lesion of undetermined significance) and category IV (follicular neoplasm/suspicious for follicular neoplasm) lesions are problematic. This study aimed to evaluate the Afirma Gene Expression Classifier (GEC) results for lesions in those categories. METHODS Medical records of patients with thyroid FNA and GEC results were obtained from archived material. Results were compared to thyroidectomy histologic diagnoses. RESULTS Among 66 patients with FNA results (47 women and 19 men aged 26-89 years [mean, 59.4 years]), surgical reports were available for 38. Afirma GEC results were "nondiagnostic" for 10 of 66 (15.2%), "benign" for 22 (33.3%), and "suspicious" for 34 (51.5%). Surgical diagnosis was available for 38 of 66 patients (57.6%); GEC results for 6 (15.8%) of these were "nondiagnostic," 27 (71.0%) were "suspicious," and 5 (13.2%) were "benign." One of 6 (16.7%) samples with "nondiagnostic" results, 1 of 5 (20%) with "benign" results, and 15 of 27 (55.6%) with "suspicious" results were malignant on histology. Papillary carcinoma was the most common tumor type (15 of 38; 39.5%). CONCLUSIONS Afirma GEC results minimize the number of unnecessary operations. Afirma GEC testing may be reserved for FNAs with a category III diagnosis on follow-up cytologic examination. We recommend a conservative approach for "suspicious" Afirma GEC results if Hürthle cells are seen with FNA.
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Affiliation(s)
- Betul Celik
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, Florida
| | - Chantel R Whetsell
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, Florida
| | - Aziza Nassar
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, Florida
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Straccia P, Rossi ED, Bizzarro T, Brunelli C, Cianfrini F, Damiani D, Fadda G. A meta-analytic review of the Bethesda System for Reporting Thyroid Cytopathology: Has the rate of malignancy in indeterminate lesions been underestimated? Cancer Cytopathol 2015; 123:713-22. [DOI: 10.1002/cncy.21605] [Citation(s) in RCA: 120] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 07/23/2015] [Accepted: 07/23/2015] [Indexed: 12/30/2022]
Affiliation(s)
- Patrizia Straccia
- Division of Anatomic Pathology and Histology, “Agostino Gemelli” School of Medicine, Catholic University; Rome Italy
| | - Esther Diana Rossi
- Division of Anatomic Pathology and Histology, “Agostino Gemelli” School of Medicine, Catholic University; Rome Italy
| | - Tommaso Bizzarro
- Division of Anatomic Pathology and Histology, “Agostino Gemelli” School of Medicine, Catholic University; Rome Italy
| | - Chiara Brunelli
- Division of Anatomic Pathology and Histology, “Agostino Gemelli” School of Medicine, Catholic University; Rome Italy
| | - Federica Cianfrini
- Division of Anatomic Pathology and Histology, “Agostino Gemelli” School of Medicine, Catholic University; Rome Italy
| | - Domenico Damiani
- Division of Anatomic Pathology and Histology, “Agostino Gemelli” School of Medicine, Catholic University; Rome Italy
| | - Guido Fadda
- Division of Anatomic Pathology and Histology, “Agostino Gemelli” School of Medicine, Catholic University; Rome Italy
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Norlén O, Charlton A, Sarkis LM, Henwood T, Shun A, Gill AJ, Delbridge L. Risk of malignancy for each Bethesda class in pediatric thyroid nodules. J Pediatr Surg 2015; 50:1147-9. [PMID: 25783310 DOI: 10.1016/j.jpedsurg.2014.10.046] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Revised: 10/01/2014] [Accepted: 10/14/2014] [Indexed: 01/17/2023]
Abstract
PURPOSE The Bethesda classification for cytology is used to classify thyroid nodules into one of six categories, and for each category there is an implied cancer risk and also recommendation for management. Despite lack of data in children, the American thyroid association promotes the use of the same management guidelines as in adults. Our aim was to study the risk of malignancy for each Bethesda class in children with thyroid nodules. METHODOLOGY We included all patients ≤18years of age that had underwent a thyroid fine needle aspiration (FNA) at one of two centers between January 1998 and July 2013. FNA results were reclassified according to the Bethesda criteria. Histological, repeat cytological, radiological and clinical follow-up were recorded. RESULTS Fifty-six patients (66 nodules) underwent FNB. Mean age was 13.6 years. Numbers of nodules reported as BI-BVI were 7, 38, 11, 4, 3 and 3, respectively. Follow-up was achieved for 55 (83%) nodules. Twelve (18%) nodules were malignant by histology and revealed papillary (n=7), follicular (n=3) or insular thyroid cancer (n=2), The proportion of nodules with malignancy for BI-BVI was: 0%, 0%, 18%, 100%, 100% and 100%. CONCLUSION The rate of malignancy in thyroid nodules in children seems to be higher than reported in adults. The Bethesda criteria seem to accurately identify benign nodules, but other categories have a very high rate of malignancy and BIII nodules pose a particular challenge.
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Affiliation(s)
- Olov Norlén
- University of Sydney Endocrine Surgery Unit, Royal North Shore Hospital, Australia; Department of Surgical Sciences, Uppsala University, Sweden
| | - Amanda Charlton
- Department of Histopathology, Children's Westmead Hospital, Australia
| | - Leba M Sarkis
- Department of Anatomical Pathology, Royal North Shore Hospital and University of Sydney, Australia
| | - Tony Henwood
- Department of Histopathology, Children's Westmead Hospital, Australia
| | - Albert Shun
- Department of Surgery, Children's Westmead Hospital, Australia
| | - Anthony J Gill
- Department of Anatomical Pathology, Royal North Shore Hospital and University of Sydney, Australia
| | - Leigh Delbridge
- University of Sydney Endocrine Surgery Unit, Royal North Shore Hospital, Australia
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Nassar A, Reynolds JP, Kerr SE, Jenkins SM, Lackore KA, Bernet V. Survey of cytopathologists and cytotechnologists for the clinical impact of the use of atypia or follicular lesion of undetermined significance. Cytojournal 2015. [PMID: 26195986 PMCID: PMC4485319 DOI: 10.4103/1742-6413.159246] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Background: The cytologic diagnosis of atypia of undetermined significance or follicular lesion of undetermined significance (AUS/FLUS) is controversial because of variation in how it is applied in practice, as well as uncertainty about patient management. We aimed to assess the percentage of thyroid fine-needle aspiration biopsies (FNABs) with AUS/FLUS diagnoses in different North American and European practice settings (e.g. community, academic, etc.), assess whether patients were managed according to current guidelines, and determine patient outcomes. Materials and Methods: A detailed questionnaire survey was posted in secure websites used separately by cytopathologists and cytotechnologists. The questionnaire was posted from August 1 through December 31, 2013. Results: Endocrinologists and cytopathologists performed 51.7% and 37.1% of thyroid FNABs, respectively. The Bethesda reporting system for thyroid FNAB was used in 90% of practices. The rate of AUS/FLUS varied widely among institutions, with 46.1% of represented institutions reporting AUS/FLUS rates of 3–10%. The median follow-up rate of patients with an initial AUS/FLUS diagnosis was 70% (range, 10–100%). For the majority of represented institutions (86.4%), patients with initial AUS/FLUS diagnosis had follow-up with endocrinologists. Of repeat AUS/FLUS thyroid FNABs, a median of 52% was considered benign, and 18% were suspicious of or positive for malignancy (median, 10% and 7.5%, respectively). Conclusions: Reporting of the AUS/FLUS category varied widely among different institutions. The median follow-up rate was lower than published guidelines. The most common follow-up diagnosis was benign thyroid nodule. Improved standardization of cytologic criteria should be adopted to reduce such variation.
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Affiliation(s)
- Aziza Nassar
- Address: Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, Florida, USA
| | - Jordan P Reynolds
- Department of Pathology and Laboratory Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sarah E Kerr
- Division of Anatomic Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sarah M Jenkins
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Kandace A Lackore
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Victor Bernet
- Division of Endocrinology, Mayo Clinic, Jacksonville, Florida, USA
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Kamaya A, Lewis GH, Liu Y, Akatsu H, Kong C, Desser TS. Atypia of undetermined significance and follicular lesions of undetermined significance: sonographic assessment for prediction of the final diagnosis. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2015; 34:767-774. [PMID: 25911708 DOI: 10.7863/ultra.34.5.767] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVES To determine whether radiologic assessment of thyroid nodules can potentially help guide clinical management after a cytologic diagnosis of atypia of undetermined significance or a follicular lesion of undetermined significance. METHODS We identified 41 patients with 41 thyroid nodules initially diagnosed as atypia or follicular lesions of undetermined significance on fine-needle aspiration that were subsequently definitively diagnosed by either surgical resection or repeated fine-needle aspiration. All sonograms of nodules were reviewed by 2 blinded board-certifiedradiologists. Lesions were assessed in 3 ways: (1) Mayo pattern classification as benign, indeterminate, or worrisome for malignancy (Ultrasound Q 2005; 21:157-165); (2) thyroid imaging reporting and data system scores (scale of 1-5) based on 2 different previously published scoring criteria (Park et al [Thyroid 2009; 19:1257-1264] and Kwak et al [Radiology 2011; 260:892-899]); and (3) binary classification as benign or malignant. RESULTS Of the 41 nodules, 25 had benign histologic findings, and 16 were malignant. Mayo pattern classification was 100% accurate for the benign score. Lesions with a Mayo score of indeterminate were malignant in 21% of cases (6 of 28) and benign in 79% (22 of 28). Lesions with a Mayo score of malignant were malignant in 91% of cases (10 of 11) and benign in 9% (1 of 11). Thyroid imaging reporting and data system scores had area under the receiver operating characteristic curve values of 0.827 for Park scores and 0.822 for Kwak scores. Radiologist binary classification of thyroid nodules showed 88% overall accuracy. CONCLUSIONS Radiologist assessment of thyroid nodules in cases of atypia of undetermined significance or follicular lesions of undetermined significance is highly predictive of the final diagnosis and can help guide management of thyroid nodules of these pathologic types.
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Affiliation(s)
- Aya Kamaya
- Departments of Radiology (A.K., T.S.D.), Pathology (G.H.L., C.K.), and Medicine and Endocrinology (H.A.), Stanford University Medical Center, Stanford, California USA; and Department of Biomedical Informatics, Stanford University, Stanford, California USA (Y.L.).
| | - Gloria Huang Lewis
- Departments of Radiology (A.K., T.S.D.), Pathology (G.H.L., C.K.), and Medicine and Endocrinology (H.A.), Stanford University Medical Center, Stanford, California USA; and Department of Biomedical Informatics, Stanford University, Stanford, California USA (Y.L.)
| | - Yi Liu
- Departments of Radiology (A.K., T.S.D.), Pathology (G.H.L., C.K.), and Medicine and Endocrinology (H.A.), Stanford University Medical Center, Stanford, California USA; and Department of Biomedical Informatics, Stanford University, Stanford, California USA (Y.L.)
| | - Haruko Akatsu
- Departments of Radiology (A.K., T.S.D.), Pathology (G.H.L., C.K.), and Medicine and Endocrinology (H.A.), Stanford University Medical Center, Stanford, California USA; and Department of Biomedical Informatics, Stanford University, Stanford, California USA (Y.L.)
| | - Christina Kong
- Departments of Radiology (A.K., T.S.D.), Pathology (G.H.L., C.K.), and Medicine and Endocrinology (H.A.), Stanford University Medical Center, Stanford, California USA; and Department of Biomedical Informatics, Stanford University, Stanford, California USA (Y.L.)
| | - Terry S Desser
- Departments of Radiology (A.K., T.S.D.), Pathology (G.H.L., C.K.), and Medicine and Endocrinology (H.A.), Stanford University Medical Center, Stanford, California USA; and Department of Biomedical Informatics, Stanford University, Stanford, California USA (Y.L.)
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Park VY, Kim EK, Kwak JY, Yoon JH, Moon HJ. Malignancy risk and characteristics of thyroid nodules with two consecutive results of atypia of undetermined significance or follicular lesion of undetermined significance on cytology. Eur Radiol 2015; 25:2601-7. [PMID: 25740802 DOI: 10.1007/s00330-015-3668-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Revised: 02/09/2015] [Accepted: 02/12/2015] [Indexed: 01/21/2023]
Abstract
PURPOSE To evaluate the malignancy risk and characteristics of thyroid nodules with two "Atypia of Undetermined Significance" or "Follicular Lesion of Undetermined Significance" (AUS/FLUS) results, and compare characteristics of malignancies with two AUS/FLUS results to those with one AUS/FLUS result. METHODS Of 441 thyroid nodules with initial AUS/FLUS results, 236 underwent repeat fine-needle-aspiration (FNA), with 58 obtaining repeated AUS/FLUS results. Thyroid Imaging Reporting and Data System (TIRADS) categories were assigned, and clinico-pathological characteristics were compared between benign and malignant nodules and between malignancies with two consecutive AUS/FLUS results and those with one AUS/FLUS result. RESULTS Thirty-one percent (18/58) of nodules with two AUS/FLUS results and 58.1% (18/31) of confirmed nodules were malignant. Age, gender, nodule size, ultrasound features and TIRADS categories did not differ between benign and malignant nodules or between malignancies with one and two AUS/FLUS results. Malignancies with two AUS/FLUS results had a higher proportion of a follicular variant of papillary thyroid carcinoma (PTC) (46.7% vs. 13.6%, P = 0.009). CONCLUSIONS Thyroid nodules with two AUS/FLUS results had a high malignancy risk of at least 31.0% and a higher proportion of a follicular variant of PTC. Surgery should be considered regardless of ultrasound features. KEY POINTS • Thyroid nodules with two consecutive AUS/FLUS results had a high malignancy risk. • Ultrasound features are less useful in nodules with two AUS/FLUS results. • The follicular variant of PTC is more frequent in malignancies with two AUS/FLUS results.
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Affiliation(s)
- Vivian Youngjean Park
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea, 120-752
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