1
|
Gern J, Arbogast M, Alakus H, Brunner S, Schmidt M, Faust M, Bruns CJ, Schultheis AM, Chiapponi C. Intraoperative thyroid frozen section: indications, results and consequences. Gland Surg 2024; 13:630-639. [PMID: 38845828 PMCID: PMC11150201 DOI: 10.21037/gs-23-105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 02/29/2024] [Indexed: 06/09/2024]
Abstract
Background Frozen section (FS) analysis is strongly influenced by the experience of surgeons and pathologists. We analyzed its performance in a secondary care hospital with surgical and pathologic experience transferred from a university hospital. Methods Indications, results, and consequences of all thyroid FS performed between January 1, 2021 and December 31, 2022 were critically reviewed. Results FS was performed in 90 (26.5%) of 340 procedures. Indications consisted in a suspicious fine needle biopsy in 28 (31.1%) cases, (99m) Technetium-Methoxy-Isobutyl-Isonitrile (MIBI) retaining hypofunctional nodules in 25 (27.8%), the intraoperative appearance in 18 (20%), the sonographic appearance in 18 (20%) and a positron emission tomography (PET) positive result in 1 case (1.1%). Malignancy was diagnosed in 21 (23.3%) and confirmed by final histology in all cases (100%). In the remaining 69 (76.7%) FS displaying no positive malignancy criteria, final histology delivered benign in 62 (89.8%) and malignant diagnoses in 7 cases (10.1%). 25% of thyroid carcinomas could not be diagnosed by FS. FS sensitivity was consequently 75% (95% CI: 55.1-89.3%). All missed malignancies were papillary thyroid carcinomas of follicular variant (fvPTC). FS sensitivity was lowest in MIBI positive hypofunctional nodules (33%) and Bethesda III (50%) as opposed to Bethesda V (92.9%) and to those cases with suspicious sonographic or intraoperative appearance (71.4%). Two-staged surgery was necessary in 10 (15.8%) of carcinomas. Conclusions Sensitivity of FS in a secondary care hospital offering surgical and pathologic experience from a specialized university center is 75% and mainly reduced by the prevalence of fvPTC. Omitting FS in Bethesda III and MIBI positive hypofunctional nodules might improve FS performance.
Collapse
Affiliation(s)
- Jesper Gern
- Department of General, Visceral, Cancer and Transplant Surgery, University Hospital of Cologne, Cologne, Germany
- Department of General and Visceral Surgery, Evangelisches Klinikum Köln Weyertal, Cologne, Germany
- Medical Faculty of the University of Cologne, Cologne, Germany
| | - Michael Arbogast
- Department of General, Visceral, Cancer and Transplant Surgery, University Hospital of Cologne, Cologne, Germany
- Department of General and Visceral Surgery, Evangelisches Klinikum Köln Weyertal, Cologne, Germany
- Medical Faculty of the University of Cologne, Cologne, Germany
| | - Hakan Alakus
- Department of General, Visceral, Cancer and Transplant Surgery, University Hospital of Cologne, Cologne, Germany
- Medical Faculty of the University of Cologne, Cologne, Germany
| | - Stefanie Brunner
- Department of General, Visceral, Cancer and Transplant Surgery, University Hospital of Cologne, Cologne, Germany
- Department of General and Visceral Surgery, Evangelisches Klinikum Köln Weyertal, Cologne, Germany
- Medical Faculty of the University of Cologne, Cologne, Germany
| | - Matthias Schmidt
- Medical Faculty of the University of Cologne, Cologne, Germany
- Department of Nuclear Medicine, University Hospital Cologne, Cologne, Germany
| | - Michael Faust
- Medical Faculty of the University of Cologne, Cologne, Germany
- Policlinic for Endocrinology, Diabetes and Preventive Medicine, University Hospital Cologne, Cologne, Germany
| | - Christiane Josephine Bruns
- Department of General, Visceral, Cancer and Transplant Surgery, University Hospital of Cologne, Cologne, Germany
- Department of General and Visceral Surgery, Evangelisches Klinikum Köln Weyertal, Cologne, Germany
- Medical Faculty of the University of Cologne, Cologne, Germany
| | - Anne Maria Schultheis
- Medical Faculty of the University of Cologne, Cologne, Germany
- Department of Pathology, University Hospital Cologne, Cologne, Germany
| | - Costanza Chiapponi
- Department of General, Visceral, Cancer and Transplant Surgery, University Hospital of Cologne, Cologne, Germany
- Department of General and Visceral Surgery, Evangelisches Klinikum Köln Weyertal, Cologne, Germany
- Medical Faculty of the University of Cologne, Cologne, Germany
| |
Collapse
|
2
|
Uludag M, Cetinoglu I, Unlu MT, Kostek M, Caliskan O, Aygun N. The Role of Frozen Section Examination in Thyroid Surgery. SISLI ETFAL HASTANESI TIP BULTENI 2023; 57:441-450. [PMID: 38268652 PMCID: PMC10805043 DOI: 10.14744/semb.2023.91129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 12/26/2023] [Indexed: 01/26/2024]
Abstract
In endocrine pathology, frozen section (FS) examination is most commonly used for the intraoperative evaluation of thyroid and parathyroid tumors, as well as cervical lymph nodes. In the past, frozen section was considered a fundamental tool in thyroid surgery. However, with advancements in preoperative ultrasound and fine-needle aspiration biopsy (FNAB), there have been increasing queries about its routine use due to the improved preoperative diagnosis. Nowadays, while the use of FS during thyroidectomy has decreased, it is still used as an additional method for different purposes intraoperatively. FS may not always provide definitive results. If FS will alter the surgical plan or extent, it should be applied. Routine FS is not recommended for evaluating thyroid nodules. But in addition to FNAB, if FS results may change the operation plan or extent, they can be utilized. FS should not be applied for thyroid lesions smaller than 1 cm, and the entire lesion should not be frozen for FS. For the assessment of thyroid nodules, the use of FS is recommended based on the Bethesda categories of FNAB. In Bethesda I category nodules, FS may contribute to distinguishing between malignant and benign lesions and guide surgical treatment. In Bethesda II nodules, where the malignancy rate is low, the performance of FNAB and FS can be compared, but it's not recommended due to the lack of a significant contribution to the surgical strategy. The sensitivity of FS in Bethesda III and IV nodules is low; its contribution to the diagnosis is limited, and it does not provide an apparent benefit to treatment; therefore, it is not recommended. In Bethesda V nodules, FS can effectively confirm the malignancy diagnosis, contribute to the surgical strategy, and reduce the possibility of completion thyroidectomy, and accordingly, it is recommended for use. Nonetheless, in Bethesda V nodules with a benign FS report, the malignancy rate remains high, so it should not be used to rule out malignancy. In Bethesda VI nodules, the performance of FS is lower or comparable to FNAB and does not significantly contribute to the treatment strategy; hence, it is not recommended. Particularly in patients with papillary thyroid cancer, intraoperative FS can be effective in detecting extrathyroidal extension and can assist the surgeon in determining the extent of thyroid surgery and central neck dissection. FS has high sensitivity and specificity in evaluating the lymphatic status of the central region intraoperatively and can be used to determine the extent of central compartment node dissection. During thyroidectomy, FS examination can be used in recognizing parathyroid tissue and distinguishing it from fatty tissue, thymus, thyroid, lymph nodes, especially in differentiating metastatic lymph nodes.
Collapse
Affiliation(s)
- Mehmet Uludag
- Department of General Surgery, University of Health Sciences Türkiye, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye
| | - Isik Cetinoglu
- Department of General Surgery, University of Health Sciences Türkiye, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye
| | - Mehmet Taner Unlu
- Department of General Surgery, University of Health Sciences Türkiye, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye
| | - Mehmet Kostek
- Department of General Surgery, University of Health Sciences Türkiye, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye
| | - Ozan Caliskan
- Department of General Surgery, University of Health Sciences Türkiye, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye
| | - Nurcihan Aygun
- Department of General Surgery, University of Health Sciences Türkiye, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye
| |
Collapse
|
3
|
Jiang C, Chen Y, Zhang C, Jiang B, Qu C, Dong G, Wang Y, Wang R, Luo Y, Sang J, Su L. Intraoperative frozen section for determining the extent of surgery in papillary thyroid carcinoma: comprehensive risk factor assessment. Gland Surg 2023; 12:1705-1713. [PMID: 38229845 PMCID: PMC10788568 DOI: 10.21037/gs-23-182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 11/02/2023] [Indexed: 01/18/2024]
Abstract
Background There is much debate on the optimal treatment approach of papillary thyroid carcinoma (PTC). Different guidelines base recommendations on various risk factors. While diagnosing the various risk factors is difficult due to the technical limitations, intraoperative frozen section (IFS) may be a feasible method. We aim to real-time evaluate the multiple risk factors, including lymph node metastasis (LNM), extrathyroidal extension (ETE), multifocality using IFS, and then identify a more effective surgical plan, which may help avoid the need for a second surgery and improve prognosis of patients. Methods We retrospectively reviewed the medical records of 364 patients from January 1, 2021 to December 31, 2021. All the patients were initially recommended to undergo a hemithyroidectomy (HT) with isthmusectomy and ipsilateral central compartment neck dissection (CCND). IFS would be executed immediately. Further total thyroidectomies (TTs) would be performed if: (I) results of IFS showed >5 LNM, or (II) there are 1≤ LNM ≤5 but with ETE and/or multifocal carcinoma. The patients were divided and investigated according to the extent of surgery. Results Based on the results of IFS, 72 patients underwent TT. The TT group displayed larger average tumor diameter, greater age, higher average body mass index (BMI), and elevated incidence of hypertension and hyperlipidemia compared to the HT group. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of IFS were 77.61%, 100%, 100%, and 88.46%, respectively. Conclusions IFS is a highly reliable procedure. Comprehensively evaluating central compartment LNM, ETE, and multifocal carcinoma through IFS helps identify a more reasonable surgical option under the current clinical consensus, which may thus help avoid the need for a second surgery.
Collapse
Affiliation(s)
- Chaoyu Jiang
- Division of Thyroid Surgery, Department of General Surgery, Nanjing Drum Tower Hospital, the Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Yongzhao Chen
- Nanjing Drum Tower Hospital Clinical College of Nanjing University of Chinese Medicine, Nanjing, China
| | - Chen Zhang
- Division of Thyroid Surgery, Department of General Surgery, Nanjing Drum Tower Hospital, the Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Bo Jiang
- Division of Thyroid Surgery, Department of General Surgery, Nanjing Drum Tower Hospital, the Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Cheng Qu
- Division of Thyroid Surgery, Department of General Surgery, Nanjing Drum Tower Hospital, the Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Guanqun Dong
- Medical School of Southeast University Nanjing Drum Tower Hospital, Nanjing, China
| | - Yanxue Wang
- Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Ru Wang
- Division of Thyroid Surgery, Department of General Surgery, Nanjing Drum Tower Hospital, the Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Yuqian Luo
- Department of Pathology and Laboratory Medicine, Nanjing Drum Tower Hospital and Jiangsu Key Laboratory for Molecular Medicine, Nanjing, China
| | - Jianfeng Sang
- Division of Thyroid Surgery, Department of General Surgery, Nanjing Drum Tower Hospital, the Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Lei Su
- Division of Thyroid Surgery, Department of General Surgery, Nanjing Drum Tower Hospital, the Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| |
Collapse
|
4
|
Dralle H, Weber F, Machens A, Brandenburg T, Schmid KW, Führer-Sakel D. [Hemithyroidectomy or total thyroidectomy for low-risk papillary thyroid cancer? : Surgical criteria for primary and secondary choice of treatment in an interdisciplinary treatment concept]. CHIRURGIE (HEIDELBERG, GERMANY) 2023; 94:79-92. [PMID: 36121448 DOI: 10.1007/s00104-022-01726-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/23/2022] [Indexed: 01/21/2023]
Abstract
The increase in small intrathyroid papillary thyroid cancer (PTC) observed worldwide over the past two decades, with no increase in cancer-specific mortality, has challenged the previous concept of total thyroidectomy as a one-size-fits-all panacea. After exclusion of papillary microcarcinomas, a systematic review of 20 clinical studies published since 2002, which compared hemithyroidectomy (HT) to total thyroidectomy (TT), found comparable long-term oncological outcomes for low-risk papillary thyroid cancer (LRPTC) 1-4 cm in diameter, whereas postoperative complication rates were markedly lower for HT. To refine individual treatment plans, HT should be combined with ipsilateral central lymph node dissection and intraoperative frozen section analysis for staging. Based on recent evidence from studies and in consideration of individual risk factors, patients with LRPTC can be offered the concept of HT as an alternative to the standard TT. A prerequisite for the treatment selection and decision is a comprehensive patient clarification of the possible advantages and disadvantages of both approaches.
Collapse
Affiliation(s)
- H Dralle
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Sektion Endokrine Chirurgie, Universitätsmedizin Essen, Universität Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Deutschland.
| | - F Weber
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Sektion Endokrine Chirurgie, Universitätsmedizin Essen, Universität Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Deutschland
| | - A Machens
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Sektion Endokrine Chirurgie, Universitätsmedizin Essen, Universität Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Deutschland
| | - T Brandenburg
- Klinik für Endokrinologie, Diabetologie und Stoffwechsel, Universitätsmedizin Essen, Universität Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Deutschland
| | - K W Schmid
- Institut für Pathologie, Universitätsmedizin Essen, Universität Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Deutschland
| | - D Führer-Sakel
- Klinik für Endokrinologie, Diabetologie und Stoffwechsel, Universitätsmedizin Essen, Universität Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Deutschland
| |
Collapse
|
5
|
Schmidt M, Bartenstein P, Bucerius J, Dietlein M, Drzezga A, Herrmann K, Lapa C, Lorenz K, Musholt TJ, Nagarajah J, Reiners C, Sahlmann CO, Kreissl MC. Individualized treatment of differentiated thyroid cancer: The value of surgery in combination with radioiodine imaging and therapy - A German position paper from Surgery and Nuclear Medicine. Nuklearmedizin 2022; 61:87-96. [PMID: 35299276 DOI: 10.1055/a-1783-8154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
A consensus statement about indications for post-surgical radioiodine therapy (RIT) in differentiated thyroid cancer patients (DTC) was recently published by the European Thyroid Association (ETA) 1. This publication discusses indications for RIT on the basis of an individual risk assessment. Many of the conclusions of this consensus statement are well founded and accepted across the disciplines involved. However, especially from the perspective of nuclear medicine, as the discipline responsible for indicating and executing RIT, some of the recommendations may require further clarification with regard to their compatibility with established best practice and national standards of care. Assessment of the indications for RIT is strongly dependent on the weighing up of benefits and risks. On the basis of longstanding clinical experience in nuclear medicine, RIT represents a highly specific precision medicine procedure of proven efficacy with a favorable side-effect profile. This distinguishes RIT significantly from other adjuvant oncological therapies and has resulted in the establishment of this procedure as a usually well-tolerated, standard safety measure. With regard to its favorable risk/benefit ratio, this procedure should not be unnecessarily restricted, in the interest of offering reassurance to the patients. Both patients' interests and regional/national differences need to be taken into account. We would therefore like to comment on the recent consensus from the perspective of authors and to provide recommendations based on the respective published data.
Collapse
Affiliation(s)
- Matthias Schmidt
- Department of Nuclear Medicine, Faculty of Medicine, University Hospital of Cologne, Cologne, Germany.,Thyroid Committee, German Society of Nuclear Medicine (DGN e. V.).,Guideline Committee, German Society of Nuclear Medicine (DGN e. V.)
| | - Peter Bartenstein
- Department of Nuclear Medicine, University Hospital, LMU Munich, Munich, Germany.,Guideline Committee, German Society of Nuclear Medicine (DGN e. V.)
| | - Jan Bucerius
- Department of Nuclear Medicine, University Medical Center Göttingen, Göttingen, Germany
| | - Markus Dietlein
- Department of Nuclear Medicine, Faculty of Medicine, University Hospital of Cologne, Cologne, Germany.,Guideline Committee, German Society of Nuclear Medicine (DGN e. V.)
| | - Alexander Drzezga
- Department of Nuclear Medicine, Faculty of Medicine, University Hospital of Cologne, Cologne, Germany
| | - Ken Herrmann
- Department of Nuclear Medicine, University Hospital Essen, University of Duisburg-Essen and German Cancer Consortium (DKTK), Essen, Germany
| | - Constantin Lapa
- Nuclear Medicine, Faculty of Medicine, University of Augsburg, Augsburg, Germany.,Member of the Board, German Society of Nuclear Medicine (DGN e. V.)
| | - Kerstin Lorenz
- Department of Visceral, Vascular and Endocrine Surgery, Martin Luther University of Halle Wittenberg, Faculty of Medicine, Halle, Germany.,Member of the surgical working group for endocrinology (CAEK) of the German society for general and visceral surgery (DGAV)
| | - Thomas J Musholt
- Section of Endocrine Surgery, Department of General, Visceral and Transplantation Surgery, University Medical Center, Johannes Gutenberg University Mainz, Mainz, Germany.,Member of the surgical working group for endocrinology (CAEK) of the German society for general and visceral surgery (DGAV)
| | - James Nagarajah
- Department of Medical Imaging, Nuclear Medicine, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, Netherland.,Thyroid Committee, German Society of Nuclear Medicine (DGN e. V.).,Guideline Committee, German Society of Nuclear Medicine (DGN e. V.)
| | - Christoph Reiners
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Carsten O Sahlmann
- Department of Nuclear Medicine, University Medical Center Göttingen, Göttingen, Germany.,Thyroid Committee, German Society of Nuclear Medicine (DGN e. V.)
| | - Michael C Kreissl
- Division of Nuclear Medicine, Department of Radiology and Nuclear Medicine, Otto von Guericke University, Magdeburg, Germany.,Thyroid Committee, German Society of Nuclear Medicine (DGN e. V.)
| |
Collapse
|