Value of repeated fine-needle aspiration cytology and cytologic experience on the management of thyroid nodules

Ontological engineering for the definition of a COVID-19 pandemic ontology

COVID-19 has generated a lot of information in different formats, and one of them is in the ontology format. Also, there are previous ontologies from other disciplines that can help to analyze the COVID-19 pandemic. Thus, due to the large quantity of COVID-19 information in the form of ontologies, approaches to ontology integration and interoperability could be beneficial. In this context, this research proposes a new ontology, called COVID-19 Pandemic ontology, which is the product of an ontological engineering process proposed in this research that allows the integration of several ontologies to cover all the aspects of this infectious disease. The ontological engineering process defines tasks of fusion, alignment, and linking for integrating the ontologies. The resulting pandemic ontology provides a simple repository for storing information about the COVID-19, reusing existing ontologies, to offer multiple views about the disease, including the social context. This ontology has been tested in different case studies to prove its capabilities to infer useful information about the COVID-19 pandemic.

Human exposure to bisphenol AF and diethylhexylphthalate increases susceptibility to develop differentiated thyroid cancer in patients with thyroid nodules

Pollutants represent potential threats to the human health, being ubiquitous in the environment and exerting toxicity even at low doses. This study aims at investigating the role of fifteen multiclass organic pollutants, assumed as markers of environmental pollution, most of which exerting endocrine-disrupting activity, in thyroid cancer development. The increasing incidence of differentiated thyroid cancer (DTC) may be related to the rising production and environmental dissemination of pollutants. Fifty-five patients, twenty-seven with diagnosis of benign thyroid nodules and twenty-eight suffering from differentiated thyroid cancer, were enrolled and the concentration levels of seven bisphenols, two phthalates (i.e. di(2-ethylhexyl) phthalate (DEHP) and its main metabolite, mono-(2-ethyl-hexyl) phthalate) (MEHP)), two chlorobenzenes, (1,4-dichlorobenzene and 1,2,4,5-tetrachlorobenzene), and 3 phenol derivatives (2-chlorophenol, 4- nonylphenol, and triclosan) were determined in their serum by using a validated analytical method based on high performance liquid chromatography with ultraviolet tandem fluorescence detection. A significant relationship was found between malignancy and the detection in the serum of both bisphenol AF and DEHP. Indeed, their presence confers a more than fourteen times higher risk of developing differentiated thyroid cancer. Relationship between these two pollutants and the risk of malignancy was dose-independent and not mediated by higher thyroid stimulating hormone levels. Even if a conclusive evidence cannot still be drawn and larger prospective studies are needed, the exposure to low doses of environmental endocrine-disrupting contaminants can be considered consistent with the development of thyroid cancer.

Predictivity of clinical, laboratory and imaging findings in diagnostic definition of palpable thyroid nodules. A multicenter prospective study

PURPOSE

To assess the role of clinical, biochemical, and morphological parameters, as added to cytology, for improving pre-surgical diagnosis of palpable thyroid nodules.

METHODS

Patients with a palpable thyroid nodule were eligible if surgical intervention was indicated after a positive or suspicious for malignancy FNAC (TIR 4-5 according to the 2007 Italian SIAPEC-IAP classification), or two inconclusive FNAC at a ≥3 months interval, or a negative FNAC associated with one or more risk factor. Reference standard was histological malignancy diagnosis. Likelihood ratios of malignancy, sensitivity, specificity, negative (NPV), and positive predictive value (PPV) were described. Multiple correspondence analysis (MCA) and logistic regression were applied.

RESULTS

Cancer was found in 433/902 (48%) patients. Considering TIR4-5 only as positive cytology, specificity, and PPV were high (94 and 91%) but sensitivity and NPV were low (61 and 72%); conversely, including TIR3 among positive, sensitivity and NPV were higher (88 and 82%) while specificity and PPV decreased (52 and 63%). Ultrasonographic size ≥3 cm was independently associated with benignity among TIR2 cases (OR of malignancy 0.37, 95% CI 0.18-0.78). In TIR3 cases the hard consistency of small nodules was associated with malignity (OR: 3.51, 95% CI 1.84-6.70, p < 0.001), while size alone, irrespective of consistency, was not diagnostically informative. No other significant association was found in TIR2 and TIR3.

CONCLUSIONS

The combination of cytology with clinical and ultrasonographic parameters may improve diagnostic definition of palpable thyroid nodules. However, the need for innovative diagnostic tools is still high.

[Repeated fine-needle aspiration cytology for the diagnosis and follow-up of thyroid nodules]

INTRODUCTION

The recently-proposed Bethesda reporting system has offered clinical recommendations for each category of reported thyroid cytology, including repeated fine-needle aspiration (FNA) for non-diagnostic and atypia/follicular lesions of undetermined significance, but there are no sound indications for repeated examination after an initial benign exam.

OBJECTIVE

To investigate the clinical validity of repeated FNA in the management of patients with thyroid nodules.

METHOD

The present study evaluated 412 consecutive patients who had repeated aspiration biopsies of thyroid nodules after an initial non-diagnostic, atypia/follicular lesion of undetermined significance, or benign cytology.

RESULTS

The majority of patients were female (93.5%) ranging from 13 to 83 years. Non-diagnostic cytology was the most common indication for a repeated examination in 237 patients (57.5%), followed by benign (36.8%), and A/FLUS (5.6%) cytology. A repeated examination altered the initial diagnosis in 70.5% and 78.3% of the non-diagnostic and A/FLUS patients, respectively, whereas only 28.9% of patients with a benign cytology presented with a different diagnosis on a sequential FNA.

CONCLUSIONS

Repeat FNA is a valuable procedure in cases with initial non-diagnostic or A/FLUS cytology, but its routine use for patients with an initial benign examination appears to not increase the expected likelihood of a malignant finding.

Repeat FNA Significantly Lowers Number of False Negative Results in Patients with Benign Nodular Thyroid Disease and Features of Chronic Thyroiditis

Purpose. The aim of the study was to compare the risk of thyroid malignancy and efficacy of repeat FNA in patients with thyroid nodules diagnosed cytologically as benign lesion (BL) with features of chronic thyroiditis (BL-CT) and BL without CT features (BL-nCT). Methods. The analysis included 917 patients with BL-CT and 7046 with BL-nCT in the first FNA. Repeat biopsy was carried out in 787 patients of BL-CT and 5147 of BL-nCT; 218 patients of BL-CT and 2462 of BL-nCT were operated; in 88 cases of BL-CT and 563 of BL-nCT both ways of follow-up were available. Results. Outcome of repeat cytology implied surgery more frequently in patients with BL-CT than with BL-nCT-3.2% versus 1.9%, P < 0.05. Incidence of cancer (including incidentalomas) was higher in patients with BL-CT operated after one benign cytology than in patients with two benign FNA outcomes: 10.8% versus 1.6%, P < 0.05. In patients with BL-nCT that difference was not significant: 3.2% versus 2.6%. Conclusions. Patients with thyroid nodules diagnosed as BL with CT features have higher risk of malignancy than patients with BL without CT features. Repeat biopsy significantly lowers percentage of FN results in patients with BL-CT in the first FNA.

Thyroid nodule management: clinical, ultrasound and cytopathological parameters for predicting malignancy

Although fine-needle aspiration cytology is considered to be the reference method for evaluating thyroid nodules, the results are inaccurate in approximately 10-30% of cases. Several studies have attempted to predict the risk of malignancy in thyroid nodules based on age, nodularity, thyrotropin values, thyroid autoimmune disease, hot/cold nodule status, and ultrasound parameters. However, no consensus has been found, and none of these parameters has significantly affected patient management. The management of indeterminate thyroid nodules and re-biopsies of nodules with initially benign cytological results remain important and controversial topics of discussion. The Bethesda cytological system and several studies on the use of molecular markers to predict malignancy from cytological samples of thyroid nodules need further clarification. More in-depth discussions among and continuous education of the specialists involved in treating thyroid disease are necessary to improve the management of these patients. This review aims to examine the clinical, laboratory, ultrasound, and scintigraphic parameters that can be used for thyroid nodule management.

Diagnostic value and cost considerations of routine fine-needle aspirations in the follow-up of thyroid nodules with benign readings

BACKGROUND

Fine-needle aspiration (FNA) is the most accurate tool to identify malignancy in solitary thyroid nodules. Although some recommend routinely repeating FNA for nodules that are initially read as benign, there is no consensus. We evaluated clinical relevancy and considered costs of routine follow-up FNA in nodules initially read as benign.

METHODS

We reviewed the records of all 739 patients who underwent FNA of solitary thyroid nodules at our institution from 1988 to 2004. A total of 815 aspirations were required to obtain satisfactory specimens. According to their physicians practice, some patients had a "follow-up biopsy" after an initially benign FNA reading as a matter of routine (Group I approach) or if their clinical status changed (Group II approach). The outcome information for at least 4 years after the initial FNA in these two groups was compared. In addition, hypothetical costs relating to both methods for deciding whether to do a follow-up FNA were considered.

RESULTS

The initial FNA was benign in 576 (78%), suspicious for follicular neoplasms in 106 (14.4%), and malignant in 57 patients (7.7%). Follow-up FNA was performed in 292 patients with initially benign lesions, 235 in Group I approach and 57 in Group II approach. The FNA diagnosis according to Group I approach remained benign on follow-up biopsy in 96.2% (226/235), was altered to follicular neoplasm in 3% (7/235), and was suspicious for malignancy in 0.8% (2/235). When following Group II approach, the follow-up FNA was benign in 93% (53/57), undetermined in 1.7% (1/57), and showed follicular neoplasm in 5.3% (3/57). Combining Groups I and II methods, 5 of 292 patients had a malignant nodule on histological examination, a false-negative rate of 1.7% for the initial FNA, but without a difference in prevalence of thyroid malignancy between the groups. Cost-consequence analysis showed no benefit in routine follow-up FNA after initially benign FNA readings.

CONCLUSIONS

Routine follow-up FNA in patients whose initial FNA is benign has a low diagnostic upgrading value and is relatively costly. In patients whose initial FNA is benign, we recommend the FNA be repeated only if clinically suspicious signs or complaints develop.

Is a five-category reporting scheme for thyroid fine needle aspiration cytology accurate? Experience of over 18,000 FNAs reported at the same institution during 1998-2007

OBJECTIVE

Fine needle aspiration (FNA) has long been recognized as an essential technique for the evaluation of thyroid nodules. Although specific cytological patterns have been recognized, a wide variety of reporting schemes for thyroid FNA results have been adopted. This study reports our experience with a five-category reporting scheme developed in-house based on a numeric score and applied to a large series of consecutive thyroid FNAs. It focuses mainly on the accuracy of thyroid FNA as a preoperative test in a large subset of histologically distinct thyroid lesions.

METHODS

During the 1998-2007 period, 18,359 thyroid ultrasound-guided FNAs were performed on 15,269 patients; FNA reports were classified according to a C1-C5 reporting scheme: non-diagnostic (C1), benign (C2), indeterminate (C3), suspicious (C4), and malignant (C5).

RESULTS

Non-diagnostic (C1) and indeterminate (C3) FNA results totalled 2,230 (12.1%) and 1,461 (7.9%), respectively, while suspicious (C4) and malignant (C5) results totalled 238 (1.3%) and 531 (2.9%), respectively. Histological results were available in 2,047 patients, with thyroid malignancy detected in 840. Positive predictive value of FNA was 98.1% with a 49.0 likelihood ratio (LR) of malignancy in patients with a C4/C5 FNA report.

CONCLUSIONS

This five-category scheme for thyroid FNA is accurate in discriminating between the virtual certainty of malignancy associated with C5, a high rate (92%) of malignancy associated with C4, and a 98% probability of a histological benign diagnosis associated with C2. Further sub-classifications of C3 may improve the accuracy of the diagnostic scheme and may help in recognizing patients eligible for a 'wait and see' management.

Value of repeated fine needle aspirations of the thyroid: an analysis of over ten thousand FNAs

OBJECTIVE

Fine needle aspiration (FNA) has been accepted as the diagnostic method of choice in the initial evaluation of thyroid nodules. However, the value of repeated FNAs in the long-term follow-up of lesions initially diagnosed as benign is being questioned. Do the findings on initial FNA really spare patients thyroidectomy or do they only postpone it? The purpose of the present study is our attempt to answer this question.

DESIGN

Retrospective review of cytology reports of patients who underwent thyroidal FNAs at Washington Hospital Center from January 1998 through April 2006. All statistical analyses were done using the statistical package Splus.

MAIN OUTCOME

Patients who had thyroid nodules diagnosed as benign on FNA performed at our institution had a 90% probability of a benign diagnosis (with 95% confidence interval [0.87, 0.92]), when they underwent surgery. When the benign cytologic diagnosis was confirmed on a repeat aspiration, this probability increased to 98% (with 95% confidence interval [0.94, 1.0]).

CONCLUSIONS

Repeated thyroidal FNAs yielding benign diagnoses are nearly always accurate (98%), and therefore the patients can be followed safely without undergoing surgery, unless an unfavorable clinical change occurs.

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

BACKGROUND

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Fine needle aspiration biopsy of thyroid nodules

BACKGROUND

Fine needle aspiration biopsy (FNA) is a routine diagnostic technique for evaluating thyroid nodules. Many reports in adults consider that FNA is superior to thyroid ultrasonography (USG) and radionuclide scanning (RS). Only five studies have been published on FNA of childhood thyroid nodules.

AIMS

To investigate the reliability of FNA in the evaluation and management of thyroid nodules, and compare the results of FNA, USG, and RS with regard to final histopathological diagnosis.

METHODS

FNA was performed in 46 children with thyroid nodules after USG and RS examination. We investigated the sensitivity, specificity, accuracy, and positive and negative predictive values of USG, RS, and FNA in their management.

RESULTS

Six patients who had malignant or suspicious cells on FNA examination underwent immediate surgery. The other 40 patients received medical treatment according to their hormonal status. Fifteen of these nodules either disappeared or decreased in number and/or size. Surgery was performed in 25 patients who did not respond to therapy. Statistical analysis revealed sensitivity, specificity, accuracy, and positive and negative predictive values respectively as follows: 60%, 59%, 59%, 15%, and 92% for USG; 30%, 42%, 39%, 12%, and 68% for SC; 100%, 95%, 95%, 67%, and 100% for FNAB.

CONCLUSION

FNAB is as reliable in children as in adults for definitive diagnosis of thyroid nodules. Using this technique avoids unnecessary thyroid surgery in children.

Role of repeated fine-needle aspiration of thyroid nodules with benign cytologic features

OBJECTIVE

To determine the role of repeated fine-needle aspiration (FNA) biopsy in the evaluation of thyroid nodules initially classified as benign.

METHODS

We retrospectively reviewed data on 235 patients with clinically palpable thyroid nodules who underwent a repeated FNA biopsy after an initially benign diagnosis. All the nodules were evaluated and biopsies were obtained by the same endocrinologist. Cytodiagnoses were divided into four major categories: inadequate, benign, suspicious, or malignant.

RESULTS

The study cohort consisted of 211 female and 24 male patients with a mean age of 47.1 years. The repeated FNA cytodiagnoses were as follows: 204 (86.8%) remained benign and 19 (8.1%), 11 (4.7%), and 1 (0.4%) became inadequate, suspicious, and malignant, respectively. All patients with benign or inadequate cytologic results on repeated FNA who underwent thyroid surgical resection had benign histologic findings (N = 23). The mean follow-up period between the initial and the last benign FNA cytodiagnosis in the 186 patients without surgical intervention was 1,078 days (2.95 years). Nine of 11 patients with suspicious cytologic results underwent a thyroid surgical procedure, which revealed a benign lesion in 7 and malignant disease in 2 (18%). The other two patients with suspicious cytologic findings had a 13-year clinical follow-up without any clinical evidence of a thyroid malignant lesion. The only patient with malignant cytologic findings on repeated FNA (a 76-year-old woman) refused surgical treatment and was lost to follow-up.

CONCLUSION

Although the yield of finding a malignant lesion on repeated FNA biopsy in the follow-up of a presumably benign thyroid nodule may be low, rebiopsy reduces the rate of false-negative diagnosis from an average of 5.2% to <1.3%.