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Zakka FR, Cipriani NA. To Freeze or Not to Freeze? Recommendations for Intraoperative Examination and Gross Prosection of Thyroid Glands. Surg Pathol Clin 2023; 16:15-26. [PMID: 36739161 DOI: 10.1016/j.path.2022.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The use of intraoperative consultation for indeterminate thyroid lesions is not advocated but is still requested by some surgeons. Obscured cytomorphology and nonrepresentative sampling limit the specificity of intraoperative assessment. Formalin fixation of thyroid glands before sectioning also minimizes artifacts introduced by fresh sectioning. Inking of thyroid may vary based on institutional preferences and information desired by clinical teams. Sectioning may occur in the conventional transverse method or the modified transverse vertical method to more thoroughly evaluate the lesion's periphery. Gross examination of thyroid lesions should always consider possible high-grade features, such as necrosis or extrathyroidal extension.
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Affiliation(s)
- Fouad R Zakka
- Department of Pathology, The University of Chicago, Pritzker School of Medicine, 5841 South Maryland Avenue, MC 6101, Chicago, IL 60637, USA
| | - Nicole A Cipriani
- Department of Pathology, The University of Chicago, Pritzker School of Medicine, 5841 South Maryland Avenue, MC 6101, Chicago, IL 60637, USA.
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2
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The Use of Artificial Intelligence in the Diagnosis and Classification of Thyroid Nodules: An Update. Cancers (Basel) 2023; 15:cancers15030708. [PMID: 36765671 PMCID: PMC9913834 DOI: 10.3390/cancers15030708] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 01/20/2023] [Accepted: 01/20/2023] [Indexed: 01/27/2023] Open
Abstract
The incidence of thyroid nodules diagnosed is increasing every year, leading to a greater risk of unnecessary procedures being performed or wrong diagnoses being made. In our paper, we present the latest knowledge on the use of artificial intelligence in diagnosing and classifying thyroid nodules. We particularly focus on the usefulness of artificial intelligence in ultrasonography for the diagnosis and characterization of pathology, as these are the two most developed fields. In our search of the latest innovations, we reviewed only the latest publications of specific types published from 2018 to 2022. We analyzed 930 papers in total, from which we selected 33 that were the most relevant to the topic of our work. In conclusion, there is great scope for the use of artificial intelligence in future thyroid nodule classification and diagnosis. In addition to the most typical uses of artificial intelligence in cancer differentiation, we identified several other novel applications of artificial intelligence during our review.
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Mao Z, Ding Y, Wen L, Zhang Y, Wu G, You Q, Wu J, Luo D, Teng L, Wang W. Combined fine-needle aspiration and selective intraoperative frozen section to optimize prediction of malignant thyroid nodules: A retrospective cohort study of more than 3000 patients. Front Endocrinol (Lausanne) 2023; 14:1091200. [PMID: 36814578 PMCID: PMC9939476 DOI: 10.3389/fendo.2023.1091200] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 01/06/2023] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Preoperative fine-needle aspiration (FNA) is widely used to differentiate malignant from benign thyroid nodules, while intraoperative frozen sections (FS) are suggested as a systematic supplement for intraoperative decision-making, but limitations still remain for both procedures. METHODS Medical records of 3807 patients with thyroid nodules who underwent both pathological diagnoses (FS and FNA) at our hospital were reviewed. The diagnostic accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of FNA and FS were also evaluated. We further designed an optimal integration scheme (FNA+selective FS) to predict thyroid nodule malignancy. Finally, the efficiency of the proposed integrated diagnostic model was validated using an independent external cohort. RESULTS For distinguishing malignant nodules, FNA had an accuracy of 90.3%, sensitivity of 90.7%, specificity of 85.2%, PPV of 98.8% and NPV of 40.4%. In contrast, the FS represented higher discriminative power (Accuracy, 94.5%; Sensitivity, 94.1%; Specificity, 100%; PPV, 100%; and NPV, 55.6%). we proposed the selective usage of FS (removed nodules with Bethesda category VI from routine FS, ~1/3 of total). The integrated new diagnostic model of FNA plus selective FS (FNA+sFS) achieved accuracy of 96.9%, sensitivity of 97.3%, specificity of 92%, PPV of 99.4%, and NPV of 71.6% (NRI=0.135, 95% CI 0.103-0.167, P <0.001) and was successfully applied to an external cohort (N=554). CONCLUSION Compared with the FNA diagnostic system, FS has an increased ability to distinguish benign and malignant thyroid nodules. The newly proposed integrated diagnostic model of FNA + selective FS can optimize the accuracy of diagnosis.
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Affiliation(s)
- Zhuochao Mao
- Department of Surgical Oncology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yongfeng Ding
- Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Department of Medical Oncology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Liping Wen
- Department of Surgical Oncology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yu Zhang
- Department of Surgical Oncology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Guofa Wu
- Department of General Surgery (Thyroid and Breast Surgery), The People’s Hospital of Haining City, Haining, China
| | - Qihan You
- Department of Pathology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jie Wu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Dingcun Luo
- Department of Surgical Oncology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Lisong Teng
- Department of Surgical Oncology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- *Correspondence: Weibin Wang, ; Lisong Teng,
| | - Weibin Wang
- Department of Surgical Oncology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- *Correspondence: Weibin Wang, ; Lisong Teng,
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Marshall R, Alexander D, Fleming J, Grayson J, Peters G, Buczek E. Utility of intraoperative frozen sections of thyroid tissue in the age of molecular testing. Clin Otolaryngol 2021; 46:991-997. [PMID: 33811452 DOI: 10.1111/coa.13766] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 12/17/2020] [Accepted: 03/14/2021] [Indexed: 01/29/2023]
Abstract
OBJECTIVES Our study aims to examine the correlation between preoperative ultrasound-guided fine-needle aspiration and intraoperative frozen section and examine the clinical benefit of frozen section in the context of the latest national guidelines on the management of differentiated thyroid cancer. STUDY DESIGN A retrospective review of thyroid frozen section from 2012 to2017 at one institution. SETTING Tertiary care centre. PARTICIPANTS/MAIN OUTCOME Patient demographics, fine-needle aspiration results, molecular testing results, frozen section diagnosis (classified as benign, indeterminate, or malignant), final pathologic diagnosis, initial planned surgery, actual surgery performed, need for additional surgery and complications were recorded. Complications included hematoma formation, hypocalcaemia (requiring readmission, symptomatic, or >24-hour stay post op) and recurrent or superior laryngeal nerve damage. RESULTS 728 total patients had an intraoperative frozen section performed. A Thy 4/Bethesda V USGFNA diagnosis (n = 55) significantly correlated with a clinically important intraoperative frozen section (n = 17, P < .01). Intraoperative management was changed by the frozen section 53 times (7.2%). Molecular testing was sent on 92 USGFNA specimens, 80 of which were deemed "suspicious." Of the 49 patients whose management was upstaged intraoperatively, 29 (59%) would not necessitate a completion thyroidectomy under the latest UK and ATA guidelines based on final pathology. CONCLUSION Intraoperative frozen sections rarely alter the pre-surgical plan and indeed may result in expanded surgery that could have been avoided based on latest UK and US guidelines. Molecular testing of indeterminate fine-needle aspiration results does not appear to predict meaningful intraoperative frozen section results.
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Affiliation(s)
- Ryan Marshall
- Department of Otolaryngology Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David Alexander
- Department of Otolaryngology Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jason Fleming
- Department of Otolaryngology Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jessica Grayson
- Department of Otolaryngology Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Glenn Peters
- Department of Otolaryngology Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Erin Buczek
- Department of Otolaryngology Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
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Zhu J, Zheng J, Li L, Huang R, Ren H, Wang D, Dai Z, Su X. Application of Machine Learning Algorithms to Predict Central Lymph Node Metastasis in T1-T2, Non-invasive, and Clinically Node Negative Papillary Thyroid Carcinoma. Front Med (Lausanne) 2021; 8:635771. [PMID: 33768105 PMCID: PMC7986413 DOI: 10.3389/fmed.2021.635771] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 02/15/2021] [Indexed: 11/30/2022] Open
Abstract
Purpose: While there are no clear indications of whether central lymph node dissection is necessary in patients with T1-T2, non-invasive, clinically uninvolved central neck lymph nodes papillary thyroid carcinoma (PTC), this study seeks to develop and validate models for predicting the risk of central lymph node metastasis (CLNM) in these patients based on machine learning algorithms. Methods: This is a retrospective study comprising 1,271 patients with T1-T2 stage, non-invasive, and clinically node negative (cN0) PTC who underwent surgery at the Department of Endocrine and Breast Surgery of The First Affiliated Hospital of Chongqing Medical University from February 1, 2016, to December 31, 2018. We applied six machine learning (ML) algorithms, including Logistic Regression (LR), Gradient Boosting Machine (GBM), Extreme Gradient Boosting (XGBoost), Random Forest (RF), Decision Tree (DT), and Neural Network (NNET), coupled with preoperative clinical characteristics and intraoperative information to develop prediction models for CLNM. Among all the samples, 70% were randomly selected to train the models while the remaining 30% were used for validation. Indices like the area under the receiver operating characteristic (AUROC), sensitivity, specificity, and accuracy were calculated to test the models' performance. Results: The results showed that ~51.3% (652 out of 1,271) of the patients had pN1 disease. In multivariate logistic regression analyses, gender, tumor size and location, multifocality, age, and Delphian lymph node status were all independent predictors of CLNM. In predicting CLNM, six ML algorithms posted AUROC of 0.70–0.75, with the extreme gradient boosting (XGBoost) model standing out, registering 0.75. Thus, we employed the best-performing ML algorithm model and uploaded the results to a self-made online risk calculator to estimate an individual's probability of CLNM (https://jin63.shinyapps.io/ML_CLNM/). Conclusions: With the incorporation of preoperative and intraoperative risk factors, ML algorithms can achieve acceptable prediction of CLNM with Xgboost model performing the best. Our online risk calculator based on ML algorithm may help determine the optimal extent of initial surgical treatment for patients with T1-T2 stage, non-invasive, and clinically node negative PTC.
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Affiliation(s)
- Jiang Zhu
- Department of Endocrine and Breast Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jinxin Zheng
- Department of Breast Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Longfei Li
- Department of Health Statistics, School of Public Health, Chongqing Medical University, Chongqing, China
| | - Rui Huang
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Haoyu Ren
- Department of Endocrine and Breast Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.,Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University, Munich, Germany
| | - Denghui Wang
- Department of Endocrine and Breast Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhijun Dai
- Department of Breast Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Xinliang Su
- Department of Endocrine and Breast Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Christison-Lagay E, Baertschiger RM. Management of Differentiated Thyroid Carcinoma in Pediatric Patients. Surg Oncol Clin N Am 2021; 30:235-251. [PMID: 33706898 DOI: 10.1016/j.soc.2020.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Differentiated thyroid carcinomas are rare in young children but represent almost 10% of all malignancies diagnosed in older adolescents. Differentiated thyroid carcinoma in children is more likely to demonstrate nodal involvement and is associated with higher recurrence rates than seen in adults. Decisions regarding extent of surgical resection are based on clinical and radiologic features, cytology, and risk assessment. Total thyroidectomy and compartment-based resection of involved lymph node basins form the cornerstone of treatment. The use of molecular genetics to inform treatment strategies and the use of targeted therapies to unresectable progressive disease is evolving.
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Affiliation(s)
- Emily Christison-Lagay
- Division of Pediatric Surgery, Department of Surgery, Yale University School of Medicine, 330 Cedar Street, PO Box 208062, New Haven, CT, USA.
| | - Reto M Baertschiger
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Room 1524, 555 University Ave, Toronto, ON M5G 1X8, Canada
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Pediatric differentiated thyroid carcinoma: An update from the APSA Cancer Committee. J Pediatr Surg 2020; 55:2273-2283. [PMID: 32553450 DOI: 10.1016/j.jpedsurg.2020.05.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 04/04/2020] [Accepted: 05/03/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Differentiated thyroid carcinomas (DTCs) are rare in young children but represent almost 10% of all malignancies diagnosed in older adolescents. METHODS This article reviews the recent literature describing surgical therapeutic approaches to pediatric DTC, associated complications, and long-term recurrence and survival outcomes. RESULTS Similar to adult thyroid cancers, pediatric DTCs are more common in females and are associated with thyroid nodules, family history of thyroid cancer, radiation exposure, iodine deficiency, autoimmune thyroid disease, and genetic syndromes. Management of thyroid cancers in children involves ultrasound imaging, fine needle aspiration, and surgical resection with treatment decisions based on clinical and radiological features, cytology and risk assessment. CONCLUSIONS Total thyroidectomy and compartment based resection of clinically involved lymph node basins form the cornerstone of treatment of DTC. There is an evolving literature regarding the use of molecular genetics to inform treatment strategies and the use of targeted therapies to treat iodine refractory and surgically unresectable progressive disease. TYPE OF STUDY Summary review. LEVEL OF EVIDENCE This is a review article of previously published Level 1-5 articles that includes expert opinion (Level 5).
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8
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Staubitz JI, Musholt TJ. [Individualization of the surgical procedure in response to overdiagnosis and overtreatment in differentiated thyroid carcinomas]. DER PATHOLOGE 2020; 40:342-346. [PMID: 31705233 DOI: 10.1007/s00292-019-00699-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Advances in diagnostic methods have led to an early detection of thyroid nodules with debatable malignant potential in numerous cases. This can result in a potential overtreatment of thyroid lesions with very good prognosis. OBJECTIVES To avoid surgical overtreatment, an individualized, risk-adapted management is required that respects the different tumor biology of the underlying histological entities. METHODS The current guidelines of the leading professional societies, the American Thyroid Association (ATA) and the German Association of Endocrine Surgeons (CAEK), were compared and critically studied, to describe risk-adapted, more conservative treatment options for certain types of thyroid neoplasms according to the 2017 WHO definition. RESULTS The German CAEK recommends thyroidectomy as a routine operation in the case of thyroid carcinoma. Exceptions are papillary thyroid microcarcinoma and minimally invasive follicular thyroid carcinoma, which can be treated by lobectomy. The ATA proposes an "active surveillance" for papillary thyroid microcarcinoma and lobectomy in cases of differentiated thyroid carcinoma <4 cm in diameter in the absence of clearly predefined risk factors. CONCLUSIONS The pre- or intraoperative pathological diagnosis of the underlying tumor entity is the key point, which allows for an adaption of the resection strategy for thyroid malignancy. Depending on the type of carcinoma, the current guidelines of international expert societies allow for parenchyma-sparing operations and, according to the ATA, even an "active surveillance."
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Affiliation(s)
- J I Staubitz
- Sektion Endokrine Chirurgie, Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsmedizin Mainz, Johannes Gutenberg-Universität Mainz, Langenbeckstraße 1, 55131, Mainz, Deutschland
| | - T J Musholt
- Sektion Endokrine Chirurgie, Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsmedizin Mainz, Johannes Gutenberg-Universität Mainz, Langenbeckstraße 1, 55131, Mainz, Deutschland.
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Najah H, Tresallet C. Role of frozen section in the surgical management of indeterminate thyroid nodules. Gland Surg 2019; 8:S112-S117. [PMID: 31475098 DOI: 10.21037/gs.2019.04.07] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Indeterminate thyroid nodules (ITNs) correspond to the categories III (atypia of undetermined significance or follicular lesion of undetermined significance) and IV (follicular neoplasm or suspicious for a follicular neoplasm) of the Bethesda system for reporting thyroid cytopathology. Their malignancy risk is 5-15% and 15-30% respectively, imposing surgical treatment for definitive diagnosis. Thus, they represent a diagnostic and therapeutic challenge given the risk of over or under treatment. Several teams continue to perform systematic intraoperative frozen sections (FS) in order to guide the initial extent of surgery and to avoid a two-stage thyroidectomy. FS have a very high specificity and positive predictive value for the diagnosis of malignancy allowing a one-stage total thyroidectomy if the result is positive. However, this attitude is highly controversial; and this review of the literature demonstrates that FS is of little contribution in this setting, due to low sensitivity and high false-negative rates. In fact, for these lesions, a careful and comprehensive evaluation of the tumor capsule is mandatory in order to visualize a capsular or a vascular invasion permitting to make the diagnosis of malignancy. However, this assessment is only possible on permanent section. Moreover, FS can jeopardize the detection of signs of capsular invasion on final pathologic examination. The recent development of molecular testing results in a better preoperative diagnosis, thus reducing even more the need for intraoperative FS. Contrasting with their limited role in Bethesda III and IV categories, FS are useful in guiding the preoperative management of Bethesda V category nodules, given their high negative and positive predictive values. Intraoperative FS of ITNs are of little use and are not recommended systematically. Their use should be restricted to elderly, high anesthetic risk, or poorly compliant patients for whom an eventual subsequent complementary surgery may be problematic.
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Affiliation(s)
- Haythem Najah
- Department of Digestive and Endocrine Surgery, CHU de Bordeaux, Groupe Hospitalier Sud, Hôpital Haut-Lévêque, Centre Magellan, 33604 Pessac cedex, Pessac, France
| | - Christophe Tresallet
- Department of Digestive and Endocrine Surgery, Hôpital de la Pitié-Salpêtrière, Assistance Publique des Hôpitaux de Paris, 47-83, boulevard de l'Hôpital, 75651 Paris cedex 13, Sorbonne université (Pierre et Marie curie Paris 6), Paris, France.,Laboratoire d'imagerie biomédicale (LIB), INSERM U 678, Sorbonne université (Pierre et Marie Curie Paris 6), Paris, France
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Staubitz JI, Musholt PB, Musholt TJ. The surgical dilemma of primary surgery for follicular thyroid neoplasms. Best Pract Res Clin Endocrinol Metab 2019; 33:101292. [PMID: 31434622 DOI: 10.1016/j.beem.2019.101292] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Follicular thyroid carcinoma is the second most prevalent form of differentiated thyroid carcinoma, following papillary thyroid carcinoma. Preoperative diagnosis is hampered by the fact that fine-needle aspiration cytology as well as supplemental molecular analysis cannot unambiguously distinguish between follicular thyroid carcinoma and benign follicular thyroid adenoma. The 2017 WHO classification defines three histological subtypes of follicular thyroid carcinoma: minimally invasive (excellent prognosis), encapsulated angioinvasive, and widely invasive type (higher risk of recurrence and metastatic spread). The fact that definite characterization of follicular neoplasms is predominantly a postoperative histological diagnosis (core criteria: capsular, vascular and adjacent tissue invasion) translates into the challenge for the thyroid surgeon to plan preoperatively for presence of malignancy and, if required, to adapt the surgical strategy according to intraoperative (frozen section) or postoperative histological findings. Until improved tools for pre-/intraoperative diagnosis are available, the malignant potential of a follicular thyroid lesion can be assessed by stratifying the patient according to clinical risk factors (presence of metastases, advanced patient age, tumor size). A stepwise, escalating surgical approach with restricted primary resection (hemithyroidectomy) and completion surgery based on the definite histopathology is another option to solve this dilemma. The currently recommended surgical treatment strategies for FTCs as published by ATA, BTA, CAEK and ESES are discussed. There is consensus that prophylactic lymphadenectomy is not required for FTCs and that hemithyroidectomy is sufficient in low-risk FTCs (capsular invasion only) whereas thyroidectomy with postoperative radioiodine therapy is indicated in high-risk FTCs (angioinvasion; widely invasive FTC).
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Affiliation(s)
- Julia I Staubitz
- Section of Endocrine Surgery, Department of General, Visceral and Transplantation Surgery, University Medicine Mainz, Langenbeckstraße 1, 55131, Mainz, Germany.
| | - Petra B Musholt
- Section of Endocrine Surgery, Department of General, Visceral and Transplantation Surgery, University Medicine Mainz, Langenbeckstraße 1, 55131, Mainz, Germany.
| | - Thomas J Musholt
- Section of Endocrine Surgery, Department of General, Visceral and Transplantation Surgery, University Medicine Mainz, Langenbeckstraße 1, 55131, Mainz, Germany.
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11
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Is Frozen-Section Analysis During Thyroid Operation Useful in the Era of Molecular Testing? J Am Coll Surg 2018; 228:474-479. [PMID: 30582976 DOI: 10.1016/j.jamcollsurg.2018.12.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 12/10/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND With the increased use of molecular testing of thyroid fine-needle biopsies, the frequency and extent of thyroid resection for thyroid nodules has changed. Although the role of frozen-section analysis of the thyroid has been reduced markedly in recent years, many surgeons still routinely use it intraoperatively. We sought to determine the utility of frozen section during thyroidectomy in the era of molecular testing. STUDY DESIGN We reviewed 236 consecutive patients who had thyroidectomy with intraoperative frozen-section analysis at our institution between November 2015 and October 2017. We re-reviewed the preoperative diagnosis, frozen-section diagnosis, final pathology, and whether operative management changed from the initial plan based on frozen section. RESULTS Mean age of the patients was 55.6 ± 14.1 years, and 83% were female. Of the 236 patients, frozen section did not change the intraoperative management in 225 (95%). Of the 11 patients whose thyroid operation was modified, the operation was either too much or not enough in 6 patients. In only 5 (2.1%) patients, frozen-section analysis correctly changed the extent of thyroidectomy. CONCLUSIONS Thyroid frozen-section analysis adds cost and time to thyroid operations without notable benefit. In our cohort, only 2.1% of frozen sections accurately changed intraoperative management. We recommend against its routine use.
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Bollig CA, Gilley D, Lesko D, Jorgensen JB, Galloway TL, Zitsch RP, Dooley LM. Economic Impact of Frozen Section for Thyroid Nodules with "Suspicious for Malignancy" Cytology. Otolaryngol Head Neck Surg 2018; 158:257-264. [PMID: 29292662 DOI: 10.1177/0194599817740328] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective To perform a cost analysis of the routine use of intraoperative frozen section (iFS) among patients undergoing a thyroid lobectomy with "suspicious for malignancy" (SUSP) cytology in the context of the 2015 American Thyroid Association guidelines. Study Design Case series with chart review; cost minimization analysis. Setting Academic. Subjects and Methods Records were reviewed for patients with SUSP cytology who underwent thyroid surgery between 2010 and 2015 in which iFS was utilized. The diagnostic test performance of iFS and the frequency of indicated completion/total thyroidectomies based on the 2015 guidelines were calculated. A cost minimization analysis was performed comparing lobectomy, with and without iFS, and the need for completion thyroidectomy according to costs estimated from 2014 data from Medicare, the Bureau of Labor Statistics, and the Nationwide Inpatient Sample. Results Sixty-five patients met inclusion criteria. The malignancy rate was 61.5%, 45% of which was identified intraoperatively. The specificity and positive predictive value were 100%. The negative predictive value and sensitivity were 83% and 95%, respectively. Completion/total thyroidectomy was indicated for 9% of patients; 83% of these individuals had findings on iFS that would have changed management intraoperatively. Application of the new guidelines would have resulted in a significant reduction in the frequency of conversion to a total thyroidectomy when compared with the actual management (26.1% vs 7.7%, P = .005). Performing routine iFS was the less costly scenario, resulting in a savings of $474 per case. Conclusion For patients with SUSP cytology undergoing lobectomy, routine use of iFS would result in decreased health care utilization.
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Affiliation(s)
- Craig A Bollig
- 1 Department of Otolaryngology-Head and Neck Surgery, School of Medicine, University of Missouri, Columbia, Missouri, USA
| | - David Gilley
- 2 School of Medicine, University of Missouri, Columbia, Missouri, USA
| | - David Lesko
- 2 School of Medicine, University of Missouri, Columbia, Missouri, USA
| | - Jeffrey B Jorgensen
- 1 Department of Otolaryngology-Head and Neck Surgery, School of Medicine, University of Missouri, Columbia, Missouri, USA
| | - Tabitha L Galloway
- 1 Department of Otolaryngology-Head and Neck Surgery, School of Medicine, University of Missouri, Columbia, Missouri, USA
| | - Robert P Zitsch
- 1 Department of Otolaryngology-Head and Neck Surgery, School of Medicine, University of Missouri, Columbia, Missouri, USA
| | - Laura M Dooley
- 1 Department of Otolaryngology-Head and Neck Surgery, School of Medicine, University of Missouri, Columbia, Missouri, USA
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Bollig CA, Lesko D, Gilley D, Dooley LM. The futility of intraoperative frozen section in the evaluation of follicular thyroid lesions. Laryngoscope 2017; 128:1501-1505. [PMID: 28990674 DOI: 10.1002/lary.26937] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 06/22/2017] [Accepted: 08/29/2017] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Investigate the utility of intraoperative frozen section (iFS) in patients with follicular thyroid lesions following publication of the 2015 American Thyroid Association (ATA) guidelines. STUDY DESIGN Retrospective chart review. METHODS Patient demographics, preoperative cytology, frozen pathology, and final pathology were reviewed on patients undergoing thyroid surgery at a tertiary care hospital in which iFS was utilized over a 5-year period. The test performance of iFS and the frequency of indicated completion/total thyroidectomies pre- and postpublication of the 2015 ATA guidelines were calculated. RESULTS One hundred and one patients met inclusion criteria: 54 patients with follicular lesions of undetermined significance (FLUS) and 47 patients with a cytologic diagnosis of suspicious for follicular neoplasm/follicular neoplasm. The malignancy rate was 36%, but only 14% of malignancies were identified on iFS. A definitive benign or malignant diagnosis was given on iFS in only 21% of cases, and operative management was altered in two cases as a result of iFS. There was a statistically significant reduction in the frequency of indicated total/completion thyroidectomies based on high-risk features as a result of the 2015 ATA guidelines compared to prior recommendations (20.8% vs. 5.0%, P = < 0.001). None of these patients had findings on iFS that would have altered management intraoperatively. CONCLUSION Intraoperative frozen section offers minimal diagnostic utility in the evaluation of follicular thyroid lesions. Updates in the 2015 ATA guidelines further diminish its potential to impact management intraoperatively. Significant improvements in its ability to identify malignancies would be needed to justify its use. LEVEL OF EVIDENCE 4. Laryngoscope, 128:1501-1505, 2018.
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Affiliation(s)
- Craig A Bollig
- Department of Otolaryngology-Head and Neck Surgery, University of Missouri School of Medicine, Columbia, Missouri, U.S.A
| | - David Lesko
- University of Missouri School of Medicine, Columbia, Missouri, U.S.A
| | - David Gilley
- University of Missouri School of Medicine, Columbia, Missouri, U.S.A
| | - Laura M Dooley
- Department of Otolaryngology-Head and Neck Surgery, University of Missouri School of Medicine, Columbia, Missouri, U.S.A
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Divarcı E, Çeltik Ü, Dökümcü Z, Ergün O, Özok G, Özen S, Şimşek DG, Darcan Ş, Çetingül N, Oral A, Ertan Y, Demirağ B, Çelik A. Management of Childhood Thyroid Nodules: Surgical and Endocrinological Findings in a Large Group of Cases. J Clin Res Pediatr Endocrinol 2017; 9:222-228. [PMID: 28387647 PMCID: PMC5596803 DOI: 10.4274/jcrpe.4272] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE The management of childhood thyroid nodules is still a big challenge for clinicians. In this study, we aimed to present our surgical and endocrinological experience in more than one hundred pediatric cases. METHODS A retrospective analysis of patients admitted with a thyroid nodule between 2006 and 2014 was performed. Detailed ultrasonography and fine-needle aspiration biopsy (FNAB) were the cornerstones of the diagnostic approach. RESULTS One hundred-three children (72 female, 31 male) with a mean age of 13.1±3.6 years (3-18 years) were admitted to our center. Management strategy was surgery in 58 patients and follow-up in 45 patients. Mean nodule size was 17±12.7 mm (2-45 mm). The diagnoses were listed as benign solitary nodule (48 patients), thyroid carcinoma (26 patients), multinodular goiter (23 patients), Hashimoto thyroiditis (4 patients), and Graves' disease (2 patients). Surgical procedures were nodulectomy/lobectomy (32 patients), total thyroidectomy (TT) (13 patients), or TT+ neck dissection (13 patients). The rate of malignancy was 25% in the total group and 44% in the surgery group. The malignancy rate was higher in patients younger than 12 years compared to older children (41% vs. 17%, p=0.040). Metastasis was seen in 38% of the malignant nodules. Postoperative complications were transient hypocalcemia (8%), permanent hypocalcemia (1.7%), and unilateral vocal cord paralysis (1.7%). Recurrence or mortality was not encountered in the 5.4±1.2-year follow-up period. CONCLUSION Thyroid nodule in a child requires an aggressive diagnostic approach due to increased risk of malignancy and metastasis. Intraoperative frozen section examination must be done as a useful adjunct to determine the surgical strategy. Incidence of complications is small in thyroid surgery when performed by experienced surgeons.
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Affiliation(s)
- Emre Divarcı
- Ege University Faculty of Medicine, Department of Pediatric Surgery, İzmir, Turkey
,* Address for Correspondence: Ege University Faculty of Medicine, Department of Pediatric Surgery, İzmir, Turkey GSM: +90 535 726 87 63 E-mail:
| | - Ülgen Çeltik
- Ege University Faculty of Medicine, Department of Pediatric Surgery, İzmir, Turkey
| | - Zafer Dökümcü
- Ege University Faculty of Medicine, Department of Pediatric Surgery, İzmir, Turkey
| | - Orkan Ergün
- Ege University Faculty of Medicine, Department of Pediatric Surgery, İzmir, Turkey
| | - Geylani Özok
- Ege University Faculty of Medicine, Department of Pediatric Surgery, İzmir, Turkey
| | - Samim Özen
- Ege University Faculty of Medicine, Division of Pediatric Endocrinology, İzmir, Turkey
| | - Damla Gökşen Şimşek
- Ege University Faculty of Medicine, Division of Pediatric Endocrinology, İzmir, Turkey
| | - Şükran Darcan
- Ege University Faculty of Medicine, Division of Pediatric Endocrinology, İzmir, Turkey
| | - Nazan Çetingül
- Ege University Faculty of Medicine, Division of Pediatric Oncology, İzmir, Turkey
| | - Aylin Oral
- Ege University Faculty of Medicine, Department of Nuclear Medicine, İzmir, Turkey
| | - Yeşim Ertan
- Ege University Faculty of Medicine, Department of Pathology, İzmir, Turkey
| | - Bengü Demirağ
- Dr. Behçet Uz Children’s Hospital, Division of Pediatric Oncology, İzmir, Turkey
| | - Ahmet Çelik
- Ege University Faculty of Medicine, Department of Pediatric Surgery, İzmir, Turkey
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Roychoudhury S, Souza F, Gimenez C, Glass R, Cocker R, Chau K, Kohn N, Das K. Utility of intraoperative frozen sections for thyroid nodules with prior fine needle aspiration cytology diagnosis. Diagn Cytopathol 2017; 45:789-794. [PMID: 28603866 DOI: 10.1002/dc.23765] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Revised: 05/03/2017] [Accepted: 05/17/2017] [Indexed: 11/09/2022]
Abstract
INTRODUCTION The objective of this study was to evaluate the role of intraoperative frozen section (IFS) in determining the course of surgery in thyroid nodules with a prior fine needle aspiration (FNA) biopsy diagnosis. In addition, reliability of FNA interpretation to guide surgical management without IFS was investigated. MATERIAL AND METHODS This is a retrospective study of all patients who had a FNA biopsy, IFS, and final pathology performed on a thyroid nodule over a 9 month period. The extent of surgery at the time of the IFS was recorded. Subsequent change in surgical procedure following the IFS diagnosis was noted in each of the Bethesda diagnostic categories. RESULTS 55% of the cases were deferred at IFS overall, with 68 and 86% in Bethesda III and IV categories, respectively. Overall, there was a change in management in 6% of cases. CONCLUSIONS Our study does not support the use of IFS for nodules with prior FNA interpretation of Bethesda II, III, IV and VI as management was not significantly changed. IFS is of value for nodules with prior FNA diagnosis of Bethesda I for interpretation of nodule, and Bethesda V for planning surgery. A confirmatory diagnosis could not be rendered at IFS for lesions with follicular architecture, which comprised most of the cases in Bethesda III and IV.
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Affiliation(s)
- Sudarshana Roychoudhury
- Department of Pathology, Hofstra Northwell Health School of Medicine, Lake Success, New York
| | - Fabiola Souza
- Department of Pathology, Hofstra Northwell Health School of Medicine, Lake Success, New York
| | - Cecilia Gimenez
- Department of Pathology, Hofstra Northwell Health School of Medicine, Lake Success, New York
| | - Ryan Glass
- Department of Pathology, Hofstra Northwell Health School of Medicine, Lake Success, New York
| | - Rubina Cocker
- Department of Pathology, Hofstra Northwell Health School of Medicine, Lake Success, New York
| | - Karen Chau
- Department of Pathology, Hofstra Northwell Health School of Medicine, Lake Success, New York
| | - Nina Kohn
- Department of Biostatistics Manhasset, The Feinstein Institute for Medical Research, New York
| | - Kasturi Das
- Department of Pathology, Hofstra Northwell Health School of Medicine, Lake Success, New York
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Abstract
PURPOSE OF REVIEW The review is focused on new information about the presentation and management of thyroid nodules in children and adolescents. RECENT FINDINGS Palpable thyroid nodules are uncommon in children but many children have nodules detected by radiologic imaging. How to evaluate them, when to suspect thyroid cancer, and how best to follow apparently benign nodules has become an area of great interest. The American Thyroid Association recently published treatment guidelines for children with thyroid nodules and cancers but much has been learned since that publication. SUMMARY Personal and family history, ultrasound features, and fine needle aspiration cytology are used to determine the risk of cancer in thyroid nodules, which are then managed according to cancer risk.
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Kennedy JM, Robinson RA. Thyroid Frozen Sections in Patients With Preoperative FNAs: Review of Surgeons' Preoperative Rationale, Intraoperative Decisions, and Final Outcome. Am J Clin Pathol 2016; 145:660-5. [PMID: 27124950 DOI: 10.1093/ajcp/aqw042] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES We wished to discover (1) in what circumstances surgeons wished to request frozen sections (FSs) on thyroid nodules having a prior fine needle aspiration (FNA) and the preoperative plan in these cases; (2) what the surgeons did with the information provided by FS and (3) in what types of cases was value added with the FS. METHODS A retrospective chart review was performed of 121 consecutive patients receiving an intraoperative FS diagnosis on a thyroid nodule, all of which had been evaluated with a preoperative FNA. RESULTS The medical record documented rationale for the request in 83% of cases. The most common reason for a FS request of a nodule was whether a planned hemithyroidectomy should proceed to a total thyroidectomy (TT). This scenario led to a TT in 9% of patients with a FNA diagnosed as benign thyroid nodule, 16% diagnosed as follicular neoplasm/suspicious for follicular neoplasm and 69% diagnosed as suspicious for malignancy. CONCLUSIONS The stated rationale for FSs in patients with preoperative FNA was not supported by patient outcome in most cases. There may be some utility for FSs in lesions with a suspicious for malignancy preoperative FNA diagnosis.
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Affiliation(s)
- John M Kennedy
- From the Department of Pathology, University of Iowa, Iowa City
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18
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Truran P, Harrison B. Central neck dissection in the treatment of well-differentiated thyroid cancer. INTERNATIONAL JOURNAL OF ENDOCRINE ONCOLOGY 2015. [DOI: 10.2217/ije.15.19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Therapeutic central compartment neck dissection (CCND) is required for confirmed nodal metastasis in patients with differentiated thyroid cancer. The need for routine prophylactic CCND in patients with papillary thyroid cancer is controversial. This article presents the current evidence to inform the debate against the background of the recommendations of US and British thyroid cancer guidelines. Potential advantages of pCCND include reduced local recurrence, preventing the need for further central compartment surgery and improved staging. Opponents claim that there is no proven patient benefit and that there is increased risk of recurrent laryngeal nerve injury and hypocalcemia.
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Affiliation(s)
- Peter Truran
- Sheffield Teaching Hospitals, Royal Hallamshire Hospital, Sheffield, South Yorkshire S10 2JF, UK
| | - Barney Harrison
- Sheffield Teaching Hospitals, Royal Hallamshire Hospital, Sheffield, South Yorkshire S10 2JF, UK
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Cohen MA, Patel KR, Gromis J, Kutler DI, Kuhel WI, Stater BJ, Schulman A, Hoda RS, Scognamiglio T. Retrospective evaluation of frozen section use for thyroid nodules with a prior fine needle aspiration diagnosis of Bethesda II-VI: The Weill Cornell Medical College experience. World J Otorhinolaryngol Head Neck Surg 2015; 1:5-10. [PMID: 29204534 PMCID: PMC5698504 DOI: 10.1016/j.wjorl.2015.09.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2015] [Indexed: 11/20/2022] Open
Abstract
Objective To evaluate the Weill Cornell Medical College (WCMC)/New York Presbyterian Hospital (NYPH) experience with intraoperative frozen (IOF) section in the management of thyroid nodules with a fine needle aspiration (FNA) diagnosis of Bethesda II–VI and to analyze the cost and pathology benefit it provides. Methods The surgical and cytopathology files at WCMC/NYPH were searched within the time period of January 2008 to May 2013. A total of 435 thyroid specimens were identified for which both an FNA and subsequent IOF section was performed. The FNA was correlated with the locations of the resected nodule and the nodule frozen for intraoperative diagnosis. The results of the FNA were compared to the IOF section diagnosis and final diagnosis (FD). Results Among 435 cases, the FNA diagnosis was Bethesda II: 149 cases, Bethesda III: 170 cases, Bethesda IV: 91 cases, Bethesda V: 19 cases, and Bethesda VI: 6 cases. There were a total of 83 carcinomas identified on FD, which included 69 papillary thyroid carcinomas (PTCs), 12 follicular carcinomas, and 2 poorly differentiated carcinomas. The preoperative FNA diagnosis for these carcinomas was as follows: Bethesda II, 11/149 (7.4%), Bethesda III, 24/170 (14%), Bethesda IV, 26/91 (29%), Bethesda V, 16/19 (84%), and Bethesda VI, 6/6 (100%). IOF section contributed to the diagnosis of malignancy in 16/429 (4%) cases: 1/149 (0.7%) Bethesda II, 5/170 (3%) Bethesda III, 2/91 (1.1%) Bethesda IV, and 8/19 (42%) Bethesda V. The diagnosis of malignancy was confirmed in the 6 Bethesda VI cases by IOF section. There were no false positives on IOF section. IOF had a sensitivity and specificity of 26% and 100%, respectively. Conclusion The role of IOF section is limited in the evaluation of thyroid nodules. IOF section is most useful for nodules with an FNA diagnosis of Bethesda V lesions. The diagnosis of follicular variant of PTC remains difficult on frozen section.
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Affiliation(s)
- Marc A. Cohen
- Department of Otolaryngology—Head and Neck Surgery, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, NY 10065, USA
- Corresponding author. Tel.: +1 646 962 2286; fax: +1 646 962 0030.
| | | | | | - David I. Kutler
- Department of Otolaryngology—Head and Neck Surgery, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, NY 10065, USA
| | - William I. Kuhel
- Department of Otolaryngology—Head and Neck Surgery, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, NY 10065, USA
| | - Brian J. Stater
- Department of Otolaryngology—Head and Neck Surgery, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, NY 10065, USA
| | - Aaron Schulman
- Department of Endocrinology, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, NY 10065, USA
| | - Rana S. Hoda
- Department of Pathology & Laboratory Medicine, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, NY 10065, USA
| | - Theresa Scognamiglio
- Department of Pathology & Laboratory Medicine, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, NY 10065, USA
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20
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Slijepcevic N, Zivaljevic V, Marinkovic J, Sipetic S, Diklic A, Paunovic I. Retrospective evaluation of the incidental finding of 403 papillary thyroid microcarcinomas in 2466 patients undergoing thyroid surgery for presumed benign thyroid disease. BMC Cancer 2015; 15:330. [PMID: 25925164 PMCID: PMC4423135 DOI: 10.1186/s12885-015-1352-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 04/23/2015] [Indexed: 12/22/2022] Open
Abstract
Background The aim of our study was to investigate the incidence of papillary thyroid microcarcinoma (PTMC) in patients operated for benign thyroid diseases (BTD) and its relation to age, sex, extent of surgery and type of BTD. Methods Retrospective study of 2466 patients who underwent thyroid surgery for BTD from 2008 to 2013. To determine independent predictors for PTMC we used three separate multivariate logistic regression models (MLR). Results There were 2128 (86.3%) females and 338 (13.7%) males. PTMC was diagnosed in 345 (16.2%) females and 58 (17.2%) males. Age ranged from 14 to 85 years (mean 54 years). Sex and age were not related to the incidence of PTMC. The overall incidence of PTMC was 16.3%. The highest incidence was in Hashimoto thyroiditis (22.7%, χ2 = 10.80, p < 0.001); and in patients with total/near-total thyroidectomy (17.7%, χ2 = 7.05, p < 0.008). The lowest incidence (6.6%, χ2 = 9.96, p < 0.001) was in a solitary hyperfunctional thyroid nodule (SHTN). According to MLR, Hashimoto thyroiditis (OR 1.54, 95% CI 1.15-2.05, p < 0.003) and SHTN (OR 0.43, 95% CI 0.21-0.87, p < 0.019) are independent predictors. Since the extent of surgery was an independent predictor (OR 1.45, 95% CI 1.10-1.92, p = 0.009) for all BTD, and sex and age were not; when the MLR model was adjusted for them, Graves disease (OR 0.72, 95% CI 0.53-0.99, p < 0.041) also proved to be an independent predictor. Conclusions Sex and age are not statistically related to the incidence of PTMC in BTD. The incidence of PTMC is higher in Hashimoto thyroiditis and patients with total/near-total thyroidectomy; and lower in patients with a SHTN and Graves disease.
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Affiliation(s)
- Nikola Slijepcevic
- Centre for endocrine surgery, Clinical Centre of Serbia, Koste Todorovica 8, Belgrade, 11000, Serbia.
| | - Vladan Zivaljevic
- Centre for endocrine surgery, Clinical Centre of Serbia, Koste Todorovica 8, Belgrade, 11000, Serbia. .,School of Medicine, University of Belgrade, Dr Subotica 8, Belgrade, 11000, Serbia.
| | - Jelena Marinkovic
- School of Medicine, University of Belgrade, Dr Subotica 8, Belgrade, 11000, Serbia. .,Institute of Medical Statistics and Informatics, School of Medicine, University of Belgrade, Dr Subotica 8, Belgrade, Serbia.
| | - Sandra Sipetic
- School of Medicine, University of Belgrade, Dr Subotica 8, Belgrade, 11000, Serbia. .,Institute of Epidemiology, School of Medicine, University of Belgrade, Visegradska 26a, Belgrade, 11000, Serbia.
| | - Aleksandar Diklic
- Centre for endocrine surgery, Clinical Centre of Serbia, Koste Todorovica 8, Belgrade, 11000, Serbia. .,School of Medicine, University of Belgrade, Dr Subotica 8, Belgrade, 11000, Serbia.
| | - Ivan Paunovic
- Centre for endocrine surgery, Clinical Centre of Serbia, Koste Todorovica 8, Belgrade, 11000, Serbia. .,School of Medicine, University of Belgrade, Dr Subotica 8, Belgrade, 11000, Serbia.
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Perros P, Boelaert K, Colley S, Evans C, Evans RM, Gerrard Ba G, Gilbert J, Harrison B, Johnson SJ, Giles TE, Moss L, Lewington V, Newbold K, Taylor J, Thakker RV, Watkinson J, Williams GR. Guidelines for the management of thyroid cancer. Clin Endocrinol (Oxf) 2014; 81 Suppl 1:1-122. [PMID: 24989897 DOI: 10.1111/cen.12515] [Citation(s) in RCA: 732] [Impact Index Per Article: 73.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Petros Perros
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne
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22
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Poller DN, Glaysher S, Agrawal A, Caldera S, Kim D, Yiangou C. BRAF V600 co-testing in thyroid FNA cytology: short-term experience in a large cancer centre in the UK. J Clin Pathol 2014; 67:684-9. [PMID: 24873948 DOI: 10.1136/jclinpath-2014-202348] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
AIMS To ascertain whether BRAF V600 mutational analysis is useful for diagnosis of thyroid cancer in thyroid fine needle aspirate (FNA). METHODS Over 8 months thyroid FNAs reported as Thy 3F (neoplasm possible/suggestive of follicular neoplasm), Thy4 (suspicious of malignancy) and Thy 5 (malignant) were tested for BRAF V600 mutation and managed as malignant if mutations were present. RESULTS Of 207 FNAs from 176 patients, 5 were Thy 5, 19 Thy 4, 36 Thy 3f, 13 Thy 3a, 84 Thy 2 and 50 Thy 1. 11 Thy 3f, 15 Thy 4 and 3 Thy 5 FNAs were tested for BRAF V600 mutation. 0 Thy 3F cases, 6 Thy 4 and 1 Thy 5 (24% of the total tested) showed evidence of mutation. Four patients with BRAF V600 mutation underwent surgery to remove all thyroid tissue, two patients received a lobectomy and one patient is awaiting thyroidectomy. All patients with BRAF V600 mutation were found to have malignancy on final histology, with a diagnostic sensitivity for malignancy excluding coincidental microcarcinoma of 43% and specificity of 100%. CONCLUSIONS BRAF V600 mutational analysis can enable single-stage total thyroidectomy for carcinoma if gene mutation is present in preoperative FNA. BRAF V600 co-testing may reduce the need for completion thyroidectomy with implied cost savings and lower patient morbidity associated with completion thyroidectomy when the cytology is inconclusive but where BRAF V600 mutation is identified in preoperative thyroid FNA.
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Affiliation(s)
- David N Poller
- Departments of Pathology and Surgery, Queen Alexandra Hospital, Portsmouth, UK
| | - Sharon Glaysher
- Departments of Pathology and Surgery, Queen Alexandra Hospital, Portsmouth, UK
| | - Avi Agrawal
- Portsmouth Acute Hospitals, Portsmouth, Hampshire, UK
| | | | - Dae Kim
- Portsmouth Acute Hospitals, Portsmouth, Hampshire, UK
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Ustun B, Chhieng D, Van Dyke A, Carling T, Holt E, Udelsman R, Adeniran AJ. Risk stratification in follicular neoplasm: a cytological assessment using the modified Bethesda classification. Cancer Cytopathol 2014; 122:536-45. [PMID: 24753500 DOI: 10.1002/cncy.21425] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 02/28/2014] [Accepted: 03/11/2014] [Indexed: 01/05/2023]
Abstract
BACKGROUND The 2007 Bethesda classification for thyroid cytology defines follicular neoplasm as a category of cases with cellular specimens demonstrating abundant follicular cells arranged in a microfollicular pattern with little or no colloid. The current recommendation for the management of these cases is diagnostic lobectomy. There has been great difficulty and variability in triaging and reporting follicular neoplasm. To increase diagnostic accuracy, at the study institution, this category is subclassified further into 3 categories: 1) microfollicular-patterned neoplasm (MN); 2) Hürthle cell neoplasm (HN); and 3) follicular lesion with some features suggestive of but not diagnostic of the follicular variant of papillary thyroid carcinoma (FL). The authors reviewed the cases of follicular neoplasm observed over a period of 5 years to document the follow-up trend using this modified classification. METHODS A search of the cytology records was performed for the period between January 2008 and December 2012. All thyroid fine-needle aspiration cases were reviewed and those with a diagnosis of follicular neoplasm (including Hürthle cell neoplasm) were identified. Correlating follow-up surgical pathology reports were reviewed. RESULTS A total of 399 cases of follicular neoplasm with surgical follow-up were identified. Malignancy was identified in 32% of all cases of follicular neoplasm and was found to be disproportionately higher in the FL category (73%). A cytological diagnosis of FL is more likely to be called malignant (73%) than benign neoplastic (9%) or benign nonneoplastic (18%). A cytological diagnosis of MN or HN is more likely to be benign neoplastic (46% and 46%, respectively) than malignant (29% and 26%, respectively) or benign nonneoplastic (25% and 28%, respectively). Of the cytological features examined, 2 (nuclear enlargement and nuclear grooves) were significantly associated with the follicular variant of papillary thyroid carcinoma. CONCLUSIONS The results of the current study clearly indicate that follicular lesions with even subtle nuclear atypia have a high positive predictive value for malignancy and therefore should be distinguished from other follicular lesions because these cases require more aggressive surgical management. The current study also raises an important issue concerning the current thyroid classification based on the 2007 Bethesda classification for thyroid cytology. Future thyroid fine-needle aspiration classification schemes should consider subclassifying follicular neoplasms for the purpose of risk stratification.
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Affiliation(s)
- Berrin Ustun
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut
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Romero-Rojas AE, Diaz-Perez JA, Mastrodimos M, Chinchilla SI. Follicular thyroid carcinoma with signet ring cell morphology: fine-needle aspiration cytology, histopathology, and immunohistochemistry. Endocr Pathol 2013; 24:239-45. [PMID: 24068558 DOI: 10.1007/s12022-013-9271-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Thyroid follicular neoplasms with signet ring cell morphology represent a challenging cytological and histopathologic diagnosis. The low frequency of these neoplasms and their broad differential diagnosis contribute to this difficult scenario. Here, we present an exceptionally rare case of thyroid follicular carcinoma with signet ring cell morphology in a 62-year-old female. We analyze the characteristics in fine-needle aspiration cytology, histopathology, and immunohistochemistry and compare our results in a discussion with previous literature reports.
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25
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Dhyani M, Faquin W, Lubitz CC, Daniels GH, Samir AE. How to interpret thyroid fine-needle aspiration biopsy reports: a guide for the busy radiologist in the era of the Bethesda Classification System. AJR Am J Roentgenol 2013; 201:1335-9. [PMID: 24261375 DOI: 10.2214/ajr.13.10537] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Fine-needle aspiration biopsy (FNAB) is the current primary test to risk stratify thyroid nodules. However, in up to one third of biopsies, cytology is indeterminate. The Bethesda System for Reporting Thyroid Cytopathology categorizes thyroid cytology findings into six groups, with each group assigned a putative malignancy risk. This article reviews the Bethesda System, emphasizing the key facts necessary to understand thyroid biopsy results and effectively manage patients after FNAB. CONCLUSION It is important to diagnose and stratify the risk of malignancy in thyroid nodules. A working knowledge of the Bethesda System permits accurate, evidence-based risk stratification of patients with thyroid nodules and thereby facilitates their management. Because it is a uniform diagnostic approach, the Bethesda System allows comparisons of different management strategies across different institutions.
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Affiliation(s)
- Manish Dhyani
- 1 Department of Radiology, Abdominal Imaging & Intervention, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, White 270, Boston, MA 02114
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