Diagnostic value of cytology, thyroglobulin, and combination of them in fine-needle aspiration of metastatic lymph nodes in patients with differentiated thyroid cancer: A systematic review and network meta-analysis

Diagnostic Efficacy of FNA-Tg in DTC Cervical LN Metastasis and its Impact Factors: A Large Retrospective Study

CONTEXT

Thyroglobulin in needle washout fluid (FNA-Tg) has the advantage of compensating for the low sensitivity of cytological analysis (FNAC) in differentiated thyroid carcinoma (DTC) lymph node (LN) metastasis. However, studies of large data sets to support this view and identify the best cutoff of FNA-Tg are lacking.

OBJECTIVE

Our study aimed to determine the best cutoff of FNA-Tg and explore the impact factors of FNA-Tg.

METHOD

A total of 1106 suspicious LNs from patients treated at West China Hospital from October 2019 to August 2021 were included. Parameters were compared between metastatic and benign LNs, and the best cutoff value of FNA-Tg was identified by ROC curves. The impact factors of FNA-Tg were analyzed.

RESULTS

In the nonsurgery group, after correcting for the effect of age and short diameter of LN, FNA-Tg was the independent risk factor for cervical LN metastasis of DTC (odds ratio [OR]: 1.048; 95% CI, 1.032-1.065). In the surgery group, after correcting for the effects of serum thyrotropin, serum Tg, long diameter of LN, and short diameter of LN, FNA-Tg was the independent risk factor for cervical LN metastasis of DTC (OR: 1.019; 95% CI, 1.006-1.033). The best cutoff value of FNA-Tg was 25.17 μg/L, and the area under the receiver operating characteristic curve, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 0.944, 0.847, 0.978, 0.982, 0.819, and 0.902, respectively. FNA-Tg highly correlated with FNA-TgAb (P < .01; Spearman correlation coefficient = 0.559), but FNA-TgAb positivity did not undermine the diagnostic efficacy of FNA-Tg for DTC LN metastasis.

CONCLUSION

The best cutoff value of FNA-Tg was 25.17 μg/L in diagnosing DTC cervical LN metastasis. FNA-Tg highly correlated with FNA-TgAb, but FNA-TgAb had no influence on the diagnostic efficacy of FNA-Tg.

Thyroglobulin as a Rapid and Cost-Effective Biomarker for Diagnosis of Thyroid Carcinoma Brain Metastasis: A Case Report of a Patient with Metastatic Hurthle Cell Thyroid Carcinoma

BACKGROUND Brain metastasis of papillary thyroid cancer (PTC) is rare. Treatment of these patients is challenging due to the lack of specific guidelines. Early diagnosis is accompanied by immediate treatment and less morbidity. Total resection of brain lesions may be unattainable when they include infiltration of eloquent areas. This report is of an 81-year-old man who had undergone total thyroidectomy for goiter in the past and presented with metastatic papillary thyroid carcinoma (PTC) to the neck after a gap of 16 years. After two years, the patient developed a solitary cystic brain PTC metastasis associated with raised thyroglobulin (Tg) inside the cystic lesion aspirated during brain surgery. CASE REPORT An 81-year-old male patient was admitted for a space-occupying brain lesion in the right frontal lobe. The patient's history included metastatic disease of PTC to the neck with cervical lymph node metastasis and local recurrence after surgery and radioactive iodine-131 treatment. The patient underwent craniotomy and removal of the lesion. The aspirated fluid was sent for cytological examination and measurement of Tg levels, which were interestingly high. Pathology of the brain lesion revealed infiltration of brain parenchyma from a metastatic lesion characterized by eosinophilic cells with irregular contours forming grooves, resulting in cytoplasmic pseudo-inclusions, an oncotic variant of PTC. CONCLUSIONS This report has shown that residual tissue may be present following total thyroidectomy and may be the origin of PTC with metastasis to the brain. The patient in this study suffered from a brain lesion that could be excised. However, aspiration of cystic compartments could provide a rapid diagnosis in patients with non-removable brain lesions.

Preoperative Evaluation of Thyroid Cancer: A Review of Current Best Practices

OBJECTIVE

The incidence of thyroid cancer has significantly increased in recent decades. Although most thyroid cancers are small and carry an excellent prognosis, a subset of patients present with advanced thyroid cancer, which is associated with increased rates of morbidity and mortality. The management of thyroid cancer requires a thoughtful individualized approach to optimize oncologic outcomes and minimize morbidity associated with treatment. Because endocrinologists usually play a key role in the initial diagnosis and evaluation of thyroid cancers, a thorough understanding of the critical components of the preoperative evaluation facilitates the development of a timely and comprehensive management plan. The following review outlines considerations in the preoperative evaluation of patients with thyroid cancer.

METHODS

A clinical review based on current literature was generated by a multidisciplinary author panel.

RESULTS

A review of considerations in the preoperative evaluation of thyroid cancer is provided. The topic areas include initial clinical evaluation, imaging modalities, cytologic evaluation, and the evolving role of mutational testing. Special considerations in the management of advanced thyroid cancer are discussed.

CONCLUSION

Thorough and thoughtful preoperative evaluation is critical for formulating an appropriate treatment strategy in the management of thyroid cancer.

Cut-off Value for Thyroglobulin Washout Concentration in the Detection of Cervical Lymph Node Metastases in Patients after Thyroidectomy Due to Differentiated Thyroid Cancer

The aim of this study was to establish the cut-off value for the thyroglobulin (Tg) concentration in washout fluid from fine needle aspiration biopsy (FNA-Tg) in the detection of cervical lymph node metastases of differentiated thyroid cancer (DTC). We evaluated the validity and clinical utility of fine needle aspiration biopsy cytology (FNAB-C), FNA-Tg, and the combined method in detecting DTC recurrences. The study included 82 patients after the total thyroidectomy and elective and, in some cases, also selective cervical lymphadenectomy. The majority of patients also underwent subsequent 131I ablative therapy. The patients presented with 1-6 enlarged and/or ultrasonographically suspicious cervical lymph nodes. One to four aspirates of each lymph node were taken, with a total of 297 samples. An FNA-Tg of 4.34 ng/mL was established as the cut-off value for detecting cervical lymph node DTC metastases for the IRMA Brahms DYNO test, Tg-S. FNAB-C is highly specific (91-99%) but not sensitive enough (53-69%) to be used as a standalone method in the detection of cervical lymph node metastases. FNA-Tg is more sensitive (91%), but caution should be taken when selecting patients for surgery with an FNA-Tg higher than the established cut-off value but lower than the serum Tg concentration. To select patients for lymphadenectomy, we recommend using the combined method (FNAB-C and FNA-Tg) with a sensitivity of 96% and specificity of up to 97%. More than one sample should be taken with each fine needle aspiration biopsy (FNAB) to obtain a representative set of samples.

Optimal method for detecting cervical lymph node metastasis from papillary thyroid cancer

PURPOSE

Papillary thyroid cancer (PTC) is often accompanied by cervical lymph node metastases (LNM). This study compared the diagnostic performance of fine needle aspiration (FNA), the combination of FNA and thyroglobulin measurement in the washout (FNA-Tg), and core needle biopsy(CNB) in order to determine the optimal method in detecting cervical LNM from PTC.

METHODS

PTC patients with suspicious cervical lymph nodes, who underwent ultrasonography-guided FNA, or CNB before surgery were retrospectively reviewed between January 2021 and April 2022. Patients' demographics, lymph node size, and results of FNA, FNA-Tg, CNB and surgical pathology were collected. Sensitivitity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy and the area under the curves (AUC) of receiver operating characteristic were obtained.

RESULTS

FNA-Tg had a higher AUC with a threshold of 55 ng/mL than that with a threshold of 1 ng/mL (0.782 vs. 0.636, P = 0.005). The sensitivity of the combination of FNA and FNA-Tg was higher than that of FNA alone (91.3% vs. 81.0%, P = 0.01), but it was not different from that of CNB (91.3% vs. 88.0%, P > 0.05). No significant difference was found in specificity, PPV, NPV, accuracy and AUC among FNA alone, CNB alone, and the combination of FNA and FNA-Tg.

CONCLUSIONS

FNA-Tg is useful to improve the sensitivity of FNA. The diagnostic performance of the combination of FNA and FNA-Tg is better than that of FNA or FNA-Tg alone, but is not different from that of CNB in detecting LNM from PTC.

Lymph node thyroglobulin in the diagnosis of metastases of thyroid carcinoma with the thyroid in situ: A prospective intraoperative study

BACKGROUND

The use of thyroglobulin concentration in washout fluid of fine-needle aspiration (FNA-Tg) is a procedure advocated by international guidelines to diagnose metastatic LN in papillary thyroid cancer. With the increasing use of active follow-up or lobectomy alone for low-risk thyroid cancers, the determination of the diagnostic performance of FNA-Tg in the detection of metastatic PTC when the thyroid is in situ is paramount.

MATERIALS AND METHODS

Prospective study with measurement of Tg in washout fluid obtained from intraoperative fine needle aspiration (FNA) cytology in order to avoid contamination from thyroid tissue and rigorously isolated punctured nodes. Receiver-operating characteristic (ROC) curve and area under the curve (AUC), optimal threshold to discriminate benign and malignant LN, sensitivity and specificity were provided.

RESULTS

a total of 58 lymph nodes from 32 patients were analyzed. ROC analysis defined the optimal cutoff values of FNA-Tg at 60 ng/ml for the diagnosis of malignant LNs in patients with a thyroid in situ. Sensitivity and specificity were 75% (95% confidence interval 57.89-86.75) and 87.5% (95%CI: 69-95.66), respectively.

CONCLUSION

Our results support the hypothesis that the Tg-FNA threshold for a safe diagnosis of LN metastasis in PTC is higher in presence of a thyroid gland in situ. The use of lower thresholds could result in false positive results and lead to unnecessary surgery.

Detection of thyroglobulin in fine-needle aspiration for diagnosis of metastatic lateral cervical lymph nodes in papillary thyroid carcinoma: A retrospective study

Objective

We analysed the diagnostic performance of thyroglobulin in fine-needle aspiration (FNA-Tg) in the suspicious lateral cervical lymph nodes (CLNs) in patients with papillary thyroid cancer (PTC), proposed the best cutoff value and discussed the factors that may affect the diagnostic value of FNA-Tg.

Methods

In the present study, a retrospective analysis of 403 patients with PTC with 448 suspected lateral CLNs metastasis from October 2019 to May 2021 was performed. The cutoff value according to the receiver operating characteristic (ROC) curve was determined, and the Wilcoxon rank-sum test was used to evaluate the correlation between FNA-Tg and factors.

Results

According to the ROC curve, the cutoff value of FNA-Tg was 3.69 ng/ml (sensitivity, 92.48%; specificity, 75.00%). Patients who underwent total thyroidectomy were excluded. Compared with US and FNAC, the diagnostic performance of FNA-Tg was the greatest, especially for small CLNs (diameter ≤ 1 cm), cystic CLNs, and patients with Hashimoto’s thyroiditis (HT). Moreover, FNA-Tg levels were correlated with the presence of HT (p = 0.003), the anti-thyroglobulin antibody (Tg-Ab) (p < 0.001), the ratio of metastatic lateral CLNs (p = 0.004) and Tg assay kits (p < 0.001).

Conclusions

FNA-Tg measurement is sensitive enough for diagnosing lateral CLN metastases from PTC, but its diagnostic value is compromised by a number of factors.

Value of thyroglobulin combined with ultrasound-guided fine-needle aspiration cytology for diagnosis of lymph node metastasis of thyroid carcinoma

BACKGROUND

Surgery for thyroid carcinoma offers a good prognosis; however, cervical lymph node metastasis may occur in the early stage. An effective diagnostic method can accurately guide clinical surgical planning and the scope of lymph node dissection, ultimately improving patient prognosis.

AIM

To explore the diagnostic value of fine-needle aspiration of thyroglobulin (FNA-Tg) combined with ultrasound (US)-guided fine-needle aspiration cytology for cervical lymph node metastasis in thyroid carcinoma.

METHODS

We enrolled 209 pathologically confirmed thyroid carcinoma patients who visited our hospital between Jan 2017 and Dec 2020. Patients were tentatively diagnosed with cervical lymph node enlargement using preoperative US. They underwent US-guided fine-needle aspiration cytology and FNA-Tg. The value of single and combined application of the two methods for the diagnosis of cervical lymph node metastasis was calculated. The factors affecting FNA-Tg for diagnosis were analyzed using univariate and multivariate methods.

RESULTS

FNA-Tg values were significantly higher among patients with positive cervical lymph node metastasis. The sensitivity and specificity of US-guided fine-needle aspiration cytology, FNA-Tg, and US-guided fine-needle aspiration cytology + FNA-Tg were 85.48% and 90.59%, 83.06% and 87.06%, and 96.77% and 91.76%, respectively. The area under the receiver operating characteristic curve for US-guided fine-needle aspiration cytology, FNA-Tg, and the two combined, was 0.880, 0.851, and 0.943, respectively. A long diameter/short diameter ratio < 2, an insufficient number of acquired cells, a low serum thyroglobulin level, and an absence of typical metastatic US features increased the risk of cervical lymph node metastasis in thyroid carcinoma patients misdiagnosed using FNA-Tg.

CONCLUSION

The diagnostic value of FNA-Tg for detecting cervical lymph node metastasis is not high; however, combined with US-guided fine-needle aspiration cytology, it is significantly improved.

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

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

Effect of Preeclampsia on Ultrastructure of Thyroid Gland, Hepatic Type 1 Iodothyronine Deiodinase, and Thyroid Hormone Levels in Rats

Background

Although hypothyroidism during pregnancy may develop grave outcomes for both mothers and offspring, management of which is still a challenge due to the insufficient understanding of this disease. The close correlation between hypothyroidism and preeclampsia is well documented, suggesting that preeclampsia is a potential risk factor for the development of maternal hypothyroidism. However, the exact role of preeclampsia in gestational hypothyroidism is still obscure.

Objective

In this study, we explored the possible mechanisms of the effect of preeclampsia on thyroid function of maternal rats.

Methods

Thirty pregnant rats were randomly divided into normal pregnancy control (NOP), preeclampsia (PE), and preeclampsia supplemented with amlodipine besylate (PEAml). NG-Nitro-L-arginine-methyl ester was used to induce preeclamptic symptoms. On gestational day 21, rats were sacrificed, and then, the ultrastructure of the thyroid gland, type 1 iodothyronine deiodinase (Dio1) expression, and serum-free thyroxine (FT₄), free triiodothyronine (FT₃), and thyroid stimulation hormones (TSH) were assessed.

Results

Compared to NOP rats, results of PE rats showed that thyroid follicular cells' ultrastructure was damaged; both hepatic Dio1 mRNA and protein levels were decreased. Interestingly, these changes were ameliorated in PEAml rats. Additionally, FT₄, FT₃, and TSH levels have no significant differences among groups.

Conclusion

These findings indicated that preeclampsia could disrupt synthesis, secretion, and metabolism function of thyroid hormones by damaging thyroid follicular cells and interfering Dio1 expression.

The diagnostic challenge of coexistent sarcoidosis and thyroid cancer - a retrospective study

BACKGROUND

Sarcoid lesions may mimic metastatic disease or recurrence in thyroid cancer (TC) patients as both diseases may affect the lungs and lymph nodes. We present the first study to systematically evaluate the clinical course of patients with (TC) after adjuvant radioactive iodine therapy (RIT) and concomitant sarcoidosis of the lung or the lymph nodes.

METHODS

We screened 3285 patients and retrospectively identified 16 patients with TC (11 papillary thyroid cancer (PTC), 3 follicular thyroid cancer (FTC), 1 oncocytic PTC, 1 oncocytic FTC) and coexisting sarcoidosis of the lung and/or the lymph nodes treated at our institute. All patients had undergone thyroidectomy and initial adjuvant RIT. Challenges in diagnosing and the management of these patients were evaluated during long term follow-up (median 4.9 years (0.8-15.0 years)).

RESULTS

Median age at first diagnosis of TC was 50.1 years (33.0-71.5 years) and of sarcoidosis 39.4 years (18.0-63.9 years). During follow-up, physicians were able to differentiate between SA and persistent or recurrent TC in 10 of 16 patients (63%). Diagnosis was complicated by initial negative thyroglobulin (Tg), positive Tg antibodies and non-specific imaging findings. Histopathology can reliably distinguish between SA and TC in patients with one suspicious lesion.

CONCLUSION

Physicians should be aware of the rare coexistence of sarcoidosis and TC. Lymphadenopathy and pulmonary lesions could be metastases, sarcoidosis or even a mix of both. Therefore, this rare patient group should receive a thorough work up including histopathological clarification and, if necessary, separately for each lesion.

Thyroglobulin Measurement in Needle Aspiration for Detection of Recurrences and Neck Metastases in Patients with Differentiated Thyroid Carcinoma: Significance of Anti-Tg Antibodies

The worldwide incidence of differentiated thyroid cancer (DTC) has increased in recent decades, likely due to frequent use of cervical ultrasonography (US) and US-guided fine needle aspiration biopsy (FNA)., US is performed during follow-up after thyroidectomy, and US-guided FNA with cytology is used if suspicious cervical lymph nodes (LN) or thyroid bed masses are detected. Knowing that serum anti-Tg antibodies (sTgAb) affect the use of serum Tg (sTg) as a tumor marker, the aim of our study was to assess the usefulness of Tg determination in needle aspirates (FNA-Tg) in presence of sTgAb. This retrospective study included 149 patients with DTC and 159 aspirations of suspicious LN and thyroid bed masses. As expected, there was a negative correlation between sTg and sTgAb levels (p<0.05), while FNA-Tg levels had a positive correlation with FNA-TgAb levels (p<0.05). Furthermore, we found a positive correlation between sTg and FNA-Tg levels (p<0.05), but not between sTgAb and FNA-TgAb or sTgAb and FNA-Tg. In conclusion, these results show that FNA-Tg values were not affected by sTgAb and that FNA-Tg measurement were highly effective in detecting cervical DTC metastases. However, combined use with cytology is suggested for neck evaluation because cytology could reveal metastases from other tumor sites.