No apparent damage in the thyroid of transgenic mice expressing antiapoptotic FLIP

Cytogenetic biodosimetry and dose-rate effect after radioiodine therapy for thyroid cancer

This study set out to investigate chromosomal damage in peripheral blood lymphocytes of thyroid cancer patients receiving ¹³¹I for thyroid remnant ablation or treatment of metastatic disease. The observed chromosomal damage was further converted to the estimates of whole-body dose to project the adverse side effects. Chromosomal aberration analysis was performed in 24 patients treated for the first time or after multiple courses. Blood samples were collected before treatment and 3 or 4 days after administration of 2-4 GBq of ¹³¹I. Both conventional cytogenetic and chromosome 2, 4 and 12 painting assays were used. To account for dose-rate effect, a dose-protraction factor was applied to calculate the whole-body dose. The mean dose was 0.62 Gy (95% CI: 0.44-0.77 Gy) in the subgroup of patients treated one time and 0.67 Gy (95% CI: 0.03-1.00 Gy) in re-treated patients. These dose estimates are about 1.7-fold higher than those disregarding the effect of exposure duration. In re-treated patients, the neglected dose-rate effect can result in underestimation of the cumulative whole-body dose by the factor ranging from 2.6 to 6.8. Elevated frequency of chromosomal aberrations observed in re-treated patients before radioiodine therapy allows estimation of a cumulative dose received from all previous treatments.

Cervical lymph node thyroglobulin measurement in washout of fine-needle aspirates for diagnosis of papillary thyroid cancer metastases

BACKGROUND

Patients with papillary thyroid cancer (PTC) and enlarged cervical lymph nodes (CLNs) are usually assessed by fine-needle aspiration biopsy cytology (FNAB-C). Thyroglobulin (Tg) is frequently detected in washout of fine-needle aspirates (FNA) of these lymph nodes. The aim of this study was to evaluate the accuracy of the measurement of FNAB-Tg in the washout of FNAB in combination with FNAB-C to detect CLN metastases in PTC.

METHODS

We retrospectively evaluated 163 surgically proven CLNs. Ultrasound-guided FNAB-C and FNAB-Tg measurements were performed and the ultrasound features were evaluated.

RESULTS

The sensitivity, specificity and accuracy of FNAB-C, FNAB-Tg and FNAB-C/FNAB-Tg in diagnosis of metastatic CLNs were 85.7, 87.8 and 71.6%, were 80.5, 87 and 82.8% and were 97.1, 96.3 and 95.7%, respectively. The diagnostic sensitivity, specificity and accuracy of FNAB-C/FNAB-Tg for metastatic CLNs was significantly higher than that of FNAB-C or FNAB-Tg alone (p < 0.01).

CONCLUSION

Combined US-guided FNAB-C and FNAB-Tg can improve the accuracy for diagnosis of metastatic CLNs in patients with PTC.

FLIP the Switch: Regulation of Apoptosis and Necroptosis by cFLIP

cFLIP (cellular FLICE-like inhibitory protein) is structurally related to caspase-8 but lacks proteolytic activity due to multiple amino acid substitutions of catalytically important residues. cFLIP protein is evolutionarily conserved and expressed as three functionally different isoforms in humans (cFLIP_L, cFLIP_S, and cFLIP_R). cFLIP controls not only the classical death receptor-mediated extrinsic apoptosis pathway, but also the non-conventional pattern recognition receptor-dependent apoptotic pathway. In addition, cFLIP regulates the formation of the death receptor-independent apoptotic platform named the ripoptosome. Moreover, recent studies have revealed that cFLIP is also involved in a non-apoptotic cell death pathway known as programmed necrosis or necroptosis. These functions of cFLIP are strictly controlled in an isoform-, concentration- and tissue-specific manner, and the ubiquitin-proteasome system plays an important role in regulating the stability of cFLIP. In this review, we summarize the current scientific findings from biochemical analyses, cell biological studies, mathematical modeling, and gene-manipulated mice models to illustrate the critical role of cFLIP as a switch to determine the destiny of cells among survival, apoptosis, and necroptosis.

THYRPAN-TM Prototype: New System for Online Telemonitoring of Patients with Thyroid Carcinoma During the Treatment with a High Dose of Radioiodine

BACKGROUND

Our team devised a real-time telemonitoring system (THYRPAN-TM) for measurement of the radiation exposure rate during the hospitalization of patients treated with high doses of radioiodine in the special premises with restricted access ("restricted area" [RA]).

SUBJECTS AND METHODS

The THYRPAN-TM prototype was tested for stability, efficacy, and linearity in a 32-day measurement of a 110 MBq (131)I source. Furthermore, it was tested on 15 patients with differentiated thyroid carcinoma who stayed in the RA for 3 days, following their radioiodine treatment.

RESULTS

Minor deviation from the theoretical values was detected when the (131)I source was measured by the THYRPAN-TM, but only at the beginning of the measurement (7.20%).

CONCLUSIONS

THYRPAN-TM is a stable, user-friendly detection system for the measurement of the exposure rate following radioiodine administration. It enables the telemonitoring of patients, as well as real-time and online measurement of the whole-body burden of (131)I.

Increasing diagnosis of thyroid papillary carcinoma follicular variant in south-east Anatolian region: comparison of characteristics of classical papillary and follicular variant thyroid cancers

We aimed to compare ratios of thyroid cancers diagnosed in our regional reference hospital Pathology Center in Sanliurfa city located in southeast Anatolia, and evaluate the characteristics related with follicular variant papillary thyroid carcinoma (FVPTC). We re-evaluated the specimens of last 5 years thyroidectomies by same five pathologists, by same criteria and immunohistochemical evaluation. Chi-square test was used to compare characteristics of classical pure papillary thyroid carcinomas and FVPTC groups. Stepwise multiple regression analysis was used to evaluate the factors related with presence of FVPTC. Among 400 thyroidectomies, there were 105 papillary thyroid carcinoma, 42 of them with pure PTC, and 56 with FVPC, also seven with other variants. There was increase in ratios of FVPTC/PTC between 2010 and 2011 (68.4 vs 76.7%, p < 0.005). Radius, vascular invasion, and extrathyroidal invasion showed statistically significant difference between pure PTC and FVPTC. In regression analysis radius (p = 0.001, OR = 2.611; 95%CI, 2.010-3.391), age (p = 0.018, OR = 0.959; 95%CI, 0.927-0.993), and multicentricity (p = 0.044, OR = 0.403; 95%CI, 0.167-0.975) were related with presence of FVPTC. Besides, further need for studies to understand whether total prevalence of FVPTC is higher in this region, and the related factors, our study showed that the ratio of FVPTC/PTC is higher in our reference hospital. Age of the patients and the radius and multicentricity of the nodules could be alarming factors for us to suspect for FVPTC.

Expression and localization of the sodium/iodide symporter (NIS) in testicular cells

Administration of radioiodine (I(131)) is currently exploited for both diagnostic and therapeutic treatment of thyroid cancer. Few data are available on the sodium/iodide symporter (NIS) expression in human testis, a particular important prerequisite to predict radioiodine accumulation in the gonads of males with thyroid cancer exposed to such a treatment. In this study, we analyzed the expression of NIS in mouse, rat and human normal testis in different stages of development. By using a quantitative RT-PCR, Western blot and immunohistochemical analysis, NIS mRNA and protein were measured in both fetal and adult testicular tissues. NIS transcript was detected in both fetal and adult testis, although its expression levels were approximately 10-fold less than in thyroid gland. Western blot analysis and immunohistochemistry showed the presence of NIS protein in germinal and Leydig cells, but not in Sertoli cells with prevalent expression in the cytosol compartment of the cells. Our study demonstrates that NIS transcript and protein are expressed in normal testis. Further studies will demonstrate whether it may act as the transporter of radioiodine in normal testis of male patients with thyroid cancer.

Decreasing tumor size of thyroid cancer in Germany: institutional experience 1995-2009

OBJECTIVE

Decreasing tumor size in a population over time is widely interpreted as a measure of effectiveness of cancer screening programs. Nonetheless, thyroid cancer size is rarely analyzed as a function of time. This study aimed to explore secular trends of thyroid cancer diameter in Germany.

DESIGN

Retrospective analysis of 1644 thyroid cancer patients from a large referral center for thyroid cancer (1995-2009).

METHODS

Calculation of largest tumor diameters for each type of cancer as a function of time periods and birth cohorts.

RESULTS

Over the past 25 years, subdivided into 5-year periods by year of thyroidectomy (1985-1989; 1990-1994; 1995-1999; 2000-2004; 2005-2009), tumor diameters diminished from 25 to 16 mm (P=0.025) for medullary thyroid cancer and from 28 to 18 mm (P=0.017) for papillary thyroid cancer. This reduction was greater for hereditary medullary thyroid cancer (from 27 to 11 mm; P=0.088) than sporadic medullary thyroid cancer (from 23 to 19 mm; P=0.11). No decline was observed for follicular thyroid cancer (means of 45 to 42 mm; P=0.52). From the first (1921-1940) to the most recent birth cohort (1981-2000), tumor size fell from 22 to 10 mm (P<0.001) for medullary thyroid cancer, from 24 to 22 mm (P<0.001) for papillary thyroid cancer, and from 49 to 38 mm (P=0.011) for follicular thyroid cancer. The reduction of medullary thyroid cancers affected exclusively patients with hereditary disease (from 20 to 7 mm; P<0.001).

CONCLUSION

The consistency and robustness of these data signify powerful secular trends toward smaller papillary, follicular, and medullary thyroid cancers. The causes and consequences of these trends warrant further investigation.

Thyrotropin serum concentrations in patients with papillary thyroid microcancers

BACKGROUND

Recent studies have shown that elevated serum thyrotropin (thyroid-stimulating hormone [TSH]) concentrations are associated with an increased risk of differentiated thyroid cancers in patients with nodular goiter. Therefore, the measurement of TSH concentrations might support the clinical estimation of cancer risk, especially in patients with thyroid nodules that are too small for fine-needle aspiration biopsies. Thus, the objective of this study was to compare preoperative serum TSH concentrations in patients with papillary thyroid microcarcinoma (PTMC) and individuals in whom the presence of even small differentiated thyroid cancers was excluded by thorough histological examination of the thyroid after total thyroidectomy because of medullary thyroid carcinoma or c-cell hyperplasia.

METHODS

The study was a retrospective cross-sectional analysis. Thirty-three patients with PTMC who had undergone a hemi- or total thyroidectomy and 54 subjects with medullary thyroid carcinoma or c-cell hyperplasia in whom a total thyroidectomy had been performed between 1994 and 2008 were included. Exclusion criteria were the intake of medication that might affect thyroid function and previous thyroid cancer or thyroid surgery.

RESULTS

The mean TSH value was comparable between patients with PTMCs (1.40 +/- 0.92 mLU/L, 95% CI = 1.07-1.72) and the control group (1.43 +/- 1.44 mLU/L; 95% CI = 1.04-1.82, p = 0.912). There was a positive trend in correlation between nodule size and TSH levels in patients with PTMC (p = 0.066).

CONCLUSIONS

TSH is not elevated in subjects with PTMCs, indicating that it is not likely involved in the de novo oncogenesis of these small cancers. However, TSH might rather play a role in the progression of preexisting PTMCs.

Clinical risk factors associated with cervical lymph node recurrence in papillary thyroid carcinoma

BACKGROUND

Recurrence of regional cervical lymph nodes in patients with papillary thyroid carcinoma (PTC) is not uncommon, and is an important factor affecting the quality of life. The aims of this study are to investigate the risk factors that are associated with regional lymph node recurrence by comparing a group of patients with regional lymph node recurrence with a group without lymph node recurrence, and to analyze the clinical characteristics of recurrent regional lymph nodes in PTC.

METHODS

A retrospective analysis was performed on 189 patients who underwent surgery for PTC. By comparing a group with recurrent cervical lymph nodes (n = 33) with a group without recurrent cervical lymph nodes (n = 156), the risk factors for cervical lymph node recurrence were investigated and the clinical characteristics of recurrent cervical lymph nodes were analyzed.

RESULTS

Tumor size >2 cm, presence of extrathyroid tumor spread, high T stage, and presence of lymph node metastasis were associated with regional lymph node recurrence in univariate analysis (p < 0.05). Among them, only the N stage was significantly associated with regional recurrence in multivariate analysis (p < 0.05). The disease-free survival period was shorter in the lymph node metastasis-positive group, and the 10-year disease-free survival rate was 77.8% in the lymph node metastasis-negative group and 57.9% in the lymph node metastasis-positive group (p < 0.05). Among 130 patients without lymph node metastasis, regional recurrence occurred in 13 patients (10%), and the frequent levels of regional recurrence were levels II-IV of ipsilateral neck. In the patients with lymph node metastasis, the frequent levels were levels IV-VI of ipsilateral side and level II of the contralateral side.

CONCLUSION

Considering the low incidence of regional lymph node recurrence and the levels with frequent regional recurrence in patients without lymph node metastasis, elective neck dissection in all cases of total thyroidectomy may be immoderate. However, if any risk factors for regional recurrence, including large tumor size, presence of extrathyroid spread, high T stage, and presence of lymph node metastasis, are detected by preoperative and intraoperative evaluation, a systematic compartment-oriented lymphadenectomy should be considered because of the high possibility of regional recurrence.

Unexpected effect of furosemide on radioiodine urinary excretion in patients with differentiated thyroid carcinomas treated with iodine 131

BACKGROUND

In patients receiving (131)I for therapeutic purposes, diuretics are frequently used in an attempt to accelerate elimination of unbound radioiodine, reduce its adverse effects, and shorten the hospital stay. The aims of our study were to investigate the influence of furosemide therapy on urinary excretion of (131)I in patients with differentiated thyroid cancer (DTC), referred to radioiodine ablation after thyroidectomy, and to investigate whether diuretics are useful in daily practice in patients with DTC.

METHODS

Forty-three patients with DTC who had normal renal function and low (131)I uptake in cervical region (3.55 +/- 3.45%) were included in this study. The furosemide (20 mg) and potassium chloride (250 mg) were given orally to 23 patients 3 hours after the (131)I administration, and then q8h for 3 days. Twenty patients did not receive either furosemide or potassium chloride. After (131)I administration, the patients collected their urine for 3 days, and radioactivity of urine sample from each micturition was expressed as percentage of the administered dose. Radioactivity of blood samples was measured after 72 hours, and the values were corrected for decay of (131)I and expressed in relation to the administered dose. Initial whole-body measurement (immediately after (131)I administration) and the whole-body measurement after 72 hours were recorded for all patients. The 72-hour whole-body measurement was corrected for decay of (131)I, and expressed as a percentage of the initial whole-body measurement.

RESULTS

Urinary excretion of (131)I was significantly lower in the patients who were taking furosemide and potassium chloride compared with the control group. The whole-body measurements after 72 hours (13.22 +/- 6.55% vs. 8.24 +/- 3.39% of the initial; p < 0.01, respectively) and the blood radioactivity (34.66 +/- 24.84 vs. 11.64 +/- 8.32 cpm/mL per 1 MBq of administered (131)I, p < 0.01) were found to be unexpectedly higher in the patients who were taking furosemide and potassium chloride compared with the control group.

CONCLUSION

Our results demonstrated that furosemide given as an adjuvant medication in patients with DTC causes a significant decrease in urinary excretion of radioiodine and its higher blood concentration. Therefore, furosemide should not be recommended as an adjuvant therapy to radioiodine ablation in patients with DTC previously iodine depleted by low-iodine diet.

Identification of a neck lump as a lymph node metastasis from an occult contralateral papillary microcarcinoma of the thyroid: key role of thyroglobulin assay in the fine-needle aspirate

BACKGROUND

Thyroglobulin (Tg) assay of material from fine-needle aspiration of neck masses can help distinguish neck masses of thyroid origin from other masses. We describe its utility in a patient with an unusual constellation of findings, a neck lump identified as a lymph node metastasis from a contralateral occult papillary thyroid carcinoma (PTC).

SUMMARY

A 56-year-old woman was referred to our center for evaluation of a 15-mm right lateral cervical neck mass which was strongly hypoechoic, not homogenous and contained several microcalcifications. There was no family history of thyroid disease, the patient was euthyroid and was not taking medications for thyroid disorders. On physical examination the thyroid was slightly enlarged and was normal on ultrasound except for a 1 x 3 mm hypoechoic nodule in the middle of the left lobe. Ultrasound-guided fine-needle aspiration biopsy (FNAB) of the right lateral cervical mass was performed with the Tg concentration of the FNAB washout liquid being >300 ng/mL and the cytology showing lymphoid elements mixed with polymorphous epithelial cells with atypical nuclei, suggesting lymph node metastasis from a cancer of epithelial origin. A lymph node metastasis from a papillary thyroid microcarcinoma (micro-PTC) was the presumptive diagnosis with the preoperative staging being Tx N1b. The patient underwent total thyroidectomy and bilateral lymph node dissection. At pathology, the right cervical mass was confirmed as lymph node metastasis of a PTC, and a unifocal micro-PTC was found in the middle left lobe. The patient was readmitted for a therapeutic (131)I dose (4810 MBq). At the time of (131)I administration, the whole-body scan showed only minimal thyroid bed uptake and serum Tg was <1 ng/mL. She was maintained on l-thyroxine treatment (150 microg/d). Five year later she did not have evidence of recurrent or residual PTC.

CONCLUSIONS

We describe the first case of contralateral lymph node metastasis from a unifocal micro-PTC identified by the detection of high Tg levels in the wash-out liquid of FNAB.

Two patients with highly aggressive macrofollicular variant of papillary thyroid carcinoma

BACKGROUND

The macrofollicular variant of papillary thyroid carcinoma (MFV-PTC) is an unusual type of thyroid carcinoma with histological features that can be confused with nodular goiter or follicular adenoma. It generally has a good prognosis and low incidence of metastases. We report two patients with highly aggressive MFV-PTC including bone metastases, one of whom died of their disease.

SUMMARY

The first patient was a 59-year-old woman with an occipital mass diagnosed histologically as papillary thyroid carcinoma (PTC), follicular variant. There were multiple bone lesions on computed tomography. Ten years earlier a biopsy of a thyroid nodule had been negative for malignant cells. Thyroidectomy showed a 3-cm nodule in the thyroid, diagnosed as MFV-PTC. Iodine 131 whole body scan showed uptake in the skull, ribs, thoracic and lumbar spine, and pelvic bones. The second patient was an 81-year-old man with a history of right thyroid nodule treated by total thyroidectomy with a postoperative diagnosis of adenomatous goiter. Three years later he developed a right shoulder mass, histologically diagnosed as follicular variant of PTC. The original thyroidectomy specimen was reviewed and reclassified as MFV-PTC. The patient developed new bone and lung metastases. Three treatments with (131)I were not effective. He died of metastatic thyroid cancer.

CONCLUSIONS

To our knowledge these are the first cases of MFV-PTC reported with bone metastasis. Although MFV-PTC usually has a good prognosis these cases highlight the importance of careful histopathological examination for MFV-PTC in thyroidectomy specimens that may appear to be seemingly benign nodular thyroid disease.

Diagnostic benefit of thyroglobulin measurement in fine-needle aspiration for diagnosing metastatic cervical lymph nodes from papillary thyroid cancer: correlations with US features

OBJECTIVE

Our goals were to determine the added value of fine-needle aspiration biopsy (FNAB)-thyroglobulin (Tg) measurements over FNAB-cytology alone for diagnosing metastatic nodes, and to determine whether the ultrasound features of lymph nodes can be used to identify lymph nodes that may benefit from FNAB-Tg measurement in patients with papillary thyroid cancer.

MATERIALS AND METHODS

We retrospectively evaluated 76 surgically proven cervical lymph nodes. Twenty-nine patients were awaiting surgery and 18 patients had undergone thyroid surgery for papillary thyroid cancer. Ultrasound-guided FNAB and Tg measurements were performed and the ultrasound features were evaluated.

RESULTS

The accuracies, sensitivities, and specificities of FNAB-cytology, FNAB-Tg, and combined FNAB-Tg/cytology were 90%, 80%, and 100%; 92%, 95%, and 90%; and 93%, 96%, and 90%, respectively. The diagnostic sensitivity of FNAB-Tg for metastatic nodes was significantly higher than that of FNAB-cytology (p = 0.011). Furthermore, combined FNAB-Tg/cytology significantly increased sensitivity (p = 0.002) and accuracy (p = 0.03) as compared with FNAB-cytology.

CONCLUSION

Combined FNAB-Tg/cytology is significantly more sensitive and accurate at detecting metastatic nodes than FNAB-cytology alone. FNAB-Tg was better at diagnosing metastases in small lymph nodes.

Diagnosis and reporting of follicular-patterned thyroid lesions by fine needle aspiration

Over the past 3 decades, fine needle aspiration (FNA) has developed as the most accurate and cost-effective initial method for guiding the clinical management of patients with thyroid nodules. Thyroid FNA specimens containing follicular-patterned lesions are the most commonly encountered and include various forms of benign thyroid nodules, follicular carcinomas, and the follicular variant of papillary thyroid carcinoma. Based primarily upon the cytoarchitectural pattern, FNA is used as a screening test for follicular-patterned lesions to identify the majority of patients with benign nodules who can be managed without surgical intervention. The terminology and reporting of thyroid FNA results have been problematic due to significant variation between laboratories, but the recent multidisciplinary NCI Thyroid FNA State of the Science Conference has provided a seven-tiered diagnostic solution. A key element of this approach is the category "atypical cells of undetermined significance" (ACUS) which is used for those aspirates which cannot be easily classified as benign, suspicious, or malignant. Lesions in this category represent approximately 3-6% of thyroid FNAs and have a risk of malignancy intermediate between the "benign" category and the "suspicious for a follicular neoplasm" category. The recommended follow-up for an ACUS diagnosis is clinical correlation and in most cases, repeat FNA sampling.

Outcome after high-dose radioiodine therapy for advanced differentiated thyroid carcinoma in childhood

OBJECTIVE

To evaluate the clinical outcome in childhood patients receiving postoperative high-dose radioiodine therapy for advanced differentiated thyroid carcinoma.

METHOD

Patients under 18 years old with neck diseases (n = 4) or distant metastases (n = 10) received postoperative radioiodine ablation and repeated treatments for a median of 2 (0.8 10) years with an averaged activity of 25.0 (7.0 72.2) GBq.

RESULTS

Partial remission was achieved in 6, stable disease in 6 and progressive disease in 2 patients, without severe side effects except for two Grade 1 and one Grade 2 WHO haematological toxicity. The median survival time from diagnosis to the last treatment sessions was 5.3 (range, 0.7 14.5) years.

CONCLUSION

High-dose radioiodine treatment was well tolerated with satisfactory outcome in childhood patients with advanced differentiated thyroid carcinoma.

Predictive value of recombinant human TSH stimulation and neck ultrasonography in differentiated thyroid cancer patients

BACKGROUND

Serum thyroglobulin (Tg) stimulation by recombinant human TSH (rhTSH), in combination with neck ultrasonography (US), is an important tool in the first follow-up of differentiated epithelial cell thyroid carcinoma (DTC) patients. The objective of this study was to investigate if a second rhTSH stimulation, performed 2-3 years later, is of clinical utility in the follow-up of these patients.

METHODS

One hundred and one consecutive ambulatory DTC patients were studied. The great majority of them (89/101) were low-risk patients, being stage I or II at tumor node metastasis (TNM) staging classification. All study patients had been treated by surgery and radioiodine ablation, and exhibited, at first rhTSH follow-up, either undetectable Tg (<or=1 ng/mL) (rhTSH1-Tg-, n = 89 patients considered as free of disease) or low Tg (>1-5 ng/mL) (rhTSH1-Tg+, n = 12 patients considered with uncertain prognosis), with no US evidence of residual disease. In all patients, serum Tg measurement after a second rhTSH stimulation and neck US were performed.

RESULTS

At the second follow-up, all 89 rhTSH1-Tg-patients showed a negative US, and Tg became low positive only in one case, whereas it remained undetectable in the other patients. The overall negative predictive value of rhTSH1-Tg- was, then, 98.9%. Out of the remaining 12 patients (i.e., rhTSH1-Tg+ patients), 2 showed disease persistence/recurrence (with a positive predictive value of rhTSH1-Tg+ of 16.7%) and 6 became Tg-.

CONCLUSIONS

A second rhTSH stimulation is useless in DTC patients who were rhTSH-Tg and imaging negative at first follow-up, while it is suggested in patients with detectable, although low, rhTSH-Tg levels at first follow-up: in the absence of clinical or US evidence of disease persistence, these patients should not be retreated by radioiodine, but simply scheduled for a later rhTSH stimulation.

A diagnostic predictor model for indeterminate or suspicious thyroid FNA samples

BACKGROUND

The management of patients with thyroid fine-needle aspiration (FNA) specimens that are neither benign nor malignant still remains problematic. Efforts to improve their management have focused on identifying risk factors that predict malignancy. This study seeks to identify clinical and tumor characteristics that predict thyroid malignancy among patients with indeterminate or suspicious FNA and to develop a diagnostic predictor model.

METHODS

The records of 639 patients with an indeterminate or suspicious thyroid FNA between January 1995 and April 2005 were reviewed. Patient and tumor characteristics were evaluated for their potential to predict malignancy in the final surgical histopathology. A diagnostic predictor model was designed based on statistically significant predictors. Patients seen between April 2005 and April 2007 were used to validate the model.

RESULTS

Patient age, nodule size, and FNA cytopathology were identified as risk factors. Patients at extremes of age were at increased risk. Patients 50 years of age had the lowest risk of malignancy. For patients less than age 50, the risk increased 3% for each year decrease in age (p = 0.001). After 50, the risk increased 3.4% for each year increase in age (p = 0.016). Nodules 2.5 cm had the lowest likelihood of malignancy. For smaller nodules, the risk increased 53% per cm decrease in size (p < 0.001). For larger nodules, the risk increased 39% per cm increase (p < 0.001). Patients with FNA cytology suspicious for papillary thyroid carcinoma had the greatest risk of malignancy (p < 0.001).

CONCLUSIONS

A predictor model was created using the variables age, nodule size, and FNA cytology to predict thyroid malignancy.

Cultured murine thyroid epithelial cells expressing transgenic Fas-associated death domain-like interleukin-1beta converting enzyme inhibitory protein are protected from fas-mediated apoptosis

The antiapoptotic molecule Fas-associated death domain-like IL-1beta-converting enzyme inhibitory protein (FLIP) inhibits Fas-mediated apoptosis by blocking activation of caspase-8. We previously showed that expression of transgenic FLIP on thyroid epithelial cells (TECs) of DBA/1 and CBA/J mice promoted earlier resolution of granulomatous experimental autoimmune thyroiditis in vivo. This study was undertaken to directly determine whether transgenic FLIP expressed on cultured TECs can protect TECs from Fas-mediated apoptosis in vitro. The results indicate that cultured TECs from DBA/1 and CBA/J mice can be sensitized in vitro by interferon-gamma and TNF-alpha to undergo Fas-mediated apoptosis. Transgenic overexpression of FLIP protected cultured TECs of FLIP transgene (Tg)+ DBA/1 and CBA/J mice from Fas-mediated apoptosis, and FLIP small interfering RNA transfection of cultured TECs of FLIP Tg+ DBA/1 and CBA/J mice abolished the protective effect. These in vitro results are consistent with our previous in vivo studies using DBA/1 and CBA/J FLIP Tg+ mice and provide direct support for the hypothesis that transgenic expression of FLIP promotes resolution of granulomatous experimental autoimmune thyroiditis by protecting TECs from apoptosis.

Is the management of thyroid nodules and differentiated thyroid cancer in accordance with recent consensus guidelines? - Results of a national survey

OBJECTIVE

To assess approaches to patients with a potentially malignant thyroid nodule and patients with differentiated thyroid carcinoma and compare them with the European Consensus and Guidelines by the American Thyroid Association.

DESIGN

A survey of the 388 active members of the Belgian Thyroid Club.

METHODS

A questionnaire addressing the management of an index case and four clinical variations (including variations in the size of the tumour and histological type). The index case was a 40-year-old euthyroid woman with a 3-cm solitary thyroid nodule. Fine-needle aspiration (FNA) cytology showed cellular aspirates with numerous follicular cells and no colloid.

RESULTS

The overall response rate was 41%. For the index case, respondents favoured a right lobectomy. Variations in size and histopathology of the nodule altered the management. In the case of a papillary thyroid carcinoma (PTC) of 3 cm in diameter, a total thyroidectomy and prophylactic central lymph node dissection was preferred. After a lobectomy showing a 3.5-cm follicular thyroid carcinoma (FTC), completion surgery followed by radioiodine administration was the most frequent proposal. For the follow-up of the index case with a low-risk disease, determination of serum thyroglobulin (Tg) after recombinant human TSH (rhTSH) administration was considered by the majority of respondents. For the follow-up of a clinical variation with residual disease, immediate planning of a new treatment was (mistakenly) not considered by a majority of respondents.

CONCLUSIONS

In most cases, respondents were in accordance with the guidelines, although there were some unexpected variations.

A thyroid thriller: acute transient and symmetric goiter after fine-needle aspiration of a solitary thyroid nodule

OBJECTIVE

To report a case of a patient who developed an acute and transient, tender, and bilateral swelling of the thyroid that occurred during fine-needle aspiration (FNA) of a solitary nodule in the left thyroid lobe; to add accurate ultrasound measurements to support our clinical observation; and to analyze a possible underlying mechanism of this rare condition. RESULTS AND CLINICAL FOLLOW-UP: The calculated thyroid volume increased from 23 to 57 mL before and at 4 minutes, respectively, after the needle aspiration, but the thyroid volume returned to prediagnostic level after 4 hours. Cytology, serum calcitonin, and histology were concordant, and the nodule was diagnosed as a medullary thyroid carcinoma. Immunohistochemistry was positive for calcitonin, chromogranin, and the very potent vasodilator calcitonin gene-related peptide (CGRP).

CONCLUSION

This is a rare case of acute and transient thyroid swelling during a common procedure as FNA of a thyroid nodule. This is the first case with documented acute volume expansion quantified by ultrasound measurements supporting our clinical observation, which is in accordance with two historical case reports. The clinical and ultrasound data support the hypothesis of vasodilation as the underlying mechanism, possibly evoked by the release of the vasodilator CGRP.

Ultrasonographic evaluation of thyroid nodules in 900 patients: comparison among ultrasonographic, cytological, and histological findings

Ultrasonography is the most useful tool for detection and evaluation of thyroid nodules. In this study, we present our classification system for ultrasonographic evaluation, which has been routinely performed since 1995. Of 1244 nodules identified by ultrasonography in 900 patients, 1145 nodules demonstrating adequate specimens on fine-needle aspiration biopsy were enrolled in the study. We stratified these nodules into classes 1 to 5 with intermediate steps of 0.5 for classes 2 to 5. Nodules classified as 3.5 or greater were evaluated as malignant, those classified as 3 were evaluated as borderline, and those classified as 2.5 or lower were evaluated as benign. Of 233 nodules evaluated as malignant, 179 (76.8%) were cytologically confirmed as malignant. Furthermore, 145 of 159 nodules (91.2%) classified as 4 or greater were cytologically diagnosed as carcinoma. Of 710 nodules evaluated as benign, 683 (96.1%) were cytologically confirmed as benign. Two hundred fifty-five nodules of 210 patients were surgically resected and pathologically examined. In this series, the positive predictive value of ultrasonographic evaluation of malignancy was 97.2%. These findings suggest that our classification system is simple and useful to facilitate ultrasonographic evaluation of thyroid nodules.

Expression of transgenic FLIP on thyroid epithelial cells inhibits induction and promotes resolution of granulomatous experimental autoimmune thyroiditis in CBA/J mice

Granulomatous experimental autoimmune thyroiditis (G-EAT) is induced by transfer of thyroglobulin-primed in vitro activated splenocytes. Thyroid lesions reach maximal severity 20 d later, and inflammation resolves or progresses to fibrosis by d 60, depending on the extent of thyroid damage at d 20. Depletion of CD8+ T cells inhibits G-EAT resolution. We showed that expression of Fas-associated death domain-like IL-1beta-converting enzyme inhibitory protein (FLIP) transgene (Tg) on thyroid epithelial cells (TECs) of DBA/1 mice had no effect on G-EAT induction but promoted earlier resolution of G-EAT. However, when CBA/J wild-type donor cells were transferred to transgenic CBA/J mice expressing FLIP on TECs, they developed less severe G-EAT than FLIP Tg- littermates. Both strains expressed similar levels of the FLIP Tg, but endogenous FLIP was up-regulated to a greater extent on infiltrating T cells during G-EAT development in DBA/1 compared with CBA/J mice. After transient depletion of CD8+ T cells, FLIP Tg+ and Tg- CBA/J recipients both developed severe G-EAT at d 20. Thyroid lesions in CD8-depleted Tg+ recipients were resolving by d 60, whereas lesions in Tg- littermates did not resolve, and most were fibrotic. FLIP Tg+ recipients had increased apoptosis of CD3+ T cells compared with Tg- recipients. The results indicate that transgenic FLIP expressed on TECs in CBA/J mice promotes G-EAT resolution, but induction of G-EAT is inhibited unless CD8+ T cells are transiently depleted.

The role of apoptosis in thyroid autoimmunity

There is increasing evidence showing that apoptosis plays a role in the development of the autoimmune thyroid diseases-Hashimoto's (lymphocytic) thyroiditis (HT) and Graves' disease (GD). The immune pathogenesis of HT and GD is not yet fully understood, but evidence points toward several steps. A defect in CD4(+)CD25(+) T regulatory cells breaks the immunological tolerance of the host and induces an abnormal production of cytokines, which facilitates the initiation of apoptosis. Though apoptosis appears to play a role in the pathogenesis of both HT and GD, the mechanisms that mediate these processes appear different. The induction of apoptosis in HT results in the destruction of thyrocytes, while apoptosis in the GD leads to damage of thyroid-infiltrating lymphocytes. The differences in the apoptotic mechanisms produce two very different forms of thyroid autoimmune responses, eventually developing into HT and GD, respectively.

Murine FLIP transgene expressed on thyroid epithelial cells promotes resolution of granulomatous experimental autoimmune thyroiditis in DBA/1 mice

Granulomatous experimental autoimmune thyroiditis (G-EAT) is induced by mouse thyroglobulin-sensitized splenocytes activated in vitro with mouse thyroglobulin and interleukin-12. In wild-type (WT) DBA/1 recipients of WT donor splenocytes, thyroid lesions reach maximal severity at day 20, with ongoing inflammation and extensive fibrosis at day 60. Our previous studies indicated the site of expression of FLIP and Fas ligand [thyroid epithelial cells (TECs) versus inflammatory cells] differed in mice when lesions would resolve or progress to fibrosis. To test the hypothesis that expression of FLIP by TECs would promote earlier G-EAT resolution in DBA/1 mice, transgenic (Tg) DBA/1 mice expressing FLIP on TECs were generated. In FLIP Tg(+) and Tg(-) littermate recipients of WT donor splenocytes, G-EAT severity was comparable at day 20, but fibrosis was decreased, and many lesions resolved by day 60 in Tg(+) but not Tg(-) recipients. FLIP and Fas ligand were primarily expressed by TECs in Tg(+) recipients and by inflammatory cells in Tg(-) recipients at day 60. Apoptosis of inflammatory cells was greater, and expression of proinflammatory cytokines was decreased in thyroids of Tg(+) compared with Tg(-) recipients. These results are consistent with the hypothesis that transgenic expression of FLIP on thyroid epithelial cells promotes earlier resolution of granulomatous experimental autoimmune thyroiditis.

Cytopathology reports from fine needle aspirations of the thyroid gland: can they be improved?

Many endocrinologists are dissatisfied with the cytopathology reports from thyroidal aspirates and unsure of how to proceed with the management of their patients. Endocrinologists and cytopathologists should have a symbiotic or complementary professional relationship if patients are going to be well served. The endocrinologist has responsibilities to the pathologist and vice versa. If the endocrinologist performs the thyroidal fine needle aspirations (FNAs), he or she must provide the pathologist with adequate specimens (in terms of quantity or number of cells) that are well smeared so that cells are well preserved and accurate cytologic diagnosis may be rendered. Also, pertinent clinical history and reasonable differential diagnoses should be stated. The pathologist has responsibilities to the endocrinologist. He or she should strive constantly to provide a clear and definite diagnosis. Cytologic reports must be in a "clinical language." By this I mean a language the clinician can understand. The pathologist should not merely provide morphologic descriptions without any clinical meaning. Here I provide my views and suggestions on improving cytopathology reports based on over 30 years' experience of performing and reporting thyroidal FNAs.

The BRAF mutation is useful for prediction of clinical recurrence in low-risk patients with conventional papillary thyroid carcinoma

BACKGROUND

The activating BRAF(V600E) mutation is the most common genetic alteration reported in papillary thyroid carcinoma (PTC). While some reports suggest the BRAF(V600E) mutation is associated with factors predicting a poor prognosis and recurrence, this remains a controversial issue.

AIM

To determine whether the presence of the BRAF(V600E) mutation is a prognostic indicator for clinical recurrence in low-risk patients with conventional PTC.

PATIENTS AND METHODS

The study involved 203 conventional PTC patients who underwent total or near-total thyroidectomy followed by immediate 131I ablation of the remnants. Patients with antithyroglobulin antibodies and those with extracervical metastases at presentation were excluded. DNA was extracted from paraffin-embedded tumour specimens, and the presence of the BRAF(V600E) mutation was evaluated using PCR amplification and direct sequencing.

RESULTS

The BRAF(V600E) mutation was found to be present in 149 (73.4%) of 203 patients. The BRAF(V600E) mutation was correlated with male gender (P = 0.006) and with tumour size (P = 0.005). While there appeared to be an association between the BRAF(V600E) mutation and extrathyroid extension, this did not reach statistical significance (P = 0.062). During follow-up of the 203 patients (median 7.3 years; range 0.7-10.0 years), 36 (18%) patients experienced recurrence. While univariate analysis showed the BRAF(V600E) mutation was associated with tumour recurrence (21% with mutation vs 7% without mutation; P = 0.037), this association was not shown following multivariate analyses adjusting for the clinicopathological prognostic factors of age, gender, tumour size, extrathyroid extension, multifocality and lymph node metastasis.

CONCLUSIONS

Although the BRAF(V600E) mutation was found to be associated with a higher clinical recurrence of disease in low-risk conventional PTC patients, it was not an independent predictor.

Validation of a five-tier cytodiagnostic system for thyroid fine needle aspiration biopsies using cytohistologic correlation

OBJECTIVE

Approximately 70-80% of thyroid fine needle aspiration biopsies (FNAB) can distinguish benign from malignant thyroid nodules. However, much interpretive diagnostic difficulty arises with the remaining 20-30% of cases. These problematic thyroid aspirations have been placed in various diagnostic categories, which collectively have led to confusion and a negative impact on the clinical management of patients with thyroid nodules. We present our experience using a five-tier system, including the diagnostic terminology: benign, indeterminate, suspicious, malignant, and unsatisfactory.

DESIGN

Thyroid FNABs were diagnosed using a five-tier system from 200 consecutive patients and the subsequent surgical excisions were correlated.

MAIN OUTCOME

Overall, there was an excellent association between the five diagnostic categories and predicting benign versus neoplastic thyroid nodules (LR = 96.06, X(2) = 76.49, and phi = 0.618, df = 4, p < 0.0001). A negative cytologic diagnosis carries a negative predictive value of 92%, while an indeterminate, suspicious, and malignant cytologic diagnosis carries a positive predictive value of 50, 71, and 100% respectively. The estimated sensitivity for an indeterminate, suspicious, or malignant cytologic diagnosis varied from 70 to 89%, while the specificity increased from 57 to 92 to 100%, respectively.

CONCLUSIONS

The data presented shows that the five diagnostic categories of thyroid FNAB are excellent at distinguishing benign from neoplastic thyroid nodules. Both the indeterminate and suspicious categories, while not statistically different from each other in predicting benign from neoplasia, are statistically different from obviously benign and obviously malignant categories. These results support the need for an indeterminate and/or suspicious category.