1
|
Velez Torres JM, Vaickus LJ, Kerr DA. Thyroid Fine-Needle Aspiration: The Current and Future Landscape of Cytopathology. Surg Pathol Clin 2024; 17:371-381. [PMID: 39129137 DOI: 10.1016/j.path.2024.04.005] [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: 08/13/2024]
Abstract
Thyroid cytology is a rapidly evolving field that has seen significant advances in recent years. Its main goal is to accurately diagnose thyroid nodules, differentiate between benign and malignant lesions, and risk stratify nodules when a definitive diagnosis is not possible. The current landscape of thyroid cytology includes the use of fine-needle aspiration for the diagnosis of thyroid nodules with the use of uniform, tiered reporting systems such as the Bethesda System for Reporting Thyroid Cytopathology. In recent years, molecular testing has emerged as a reliable preoperative diagnostic tool that stratifies patients into different risk categories (low, intermediate, or high) with varying probabilities of malignancy and helps guide patient treatment.
Collapse
Affiliation(s)
- Jaylou M Velez Torres
- University of Miami Hospital, Miller School of Medicine, 1400 NW 12th Avenue, Room 4078, Miami, FL 33136, USA. https://twitter.com/JaylouVelez
| | - Louis J Vaickus
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756, USA; Geisel School of Medicine at Dartmouth, Hanover, NH 03755, USA
| | - Darcy A Kerr
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756, USA; Geisel School of Medicine at Dartmouth, Hanover, NH 03755, USA.
| |
Collapse
|
2
|
Tjendra Y, Zuo Y, Velez Torres JM. Follicular neoplasms with nuclear atypia versus other types of atypia: Should follicular neoplasms be stratified according to the presence of nuclear atypia? Cancer Cytopathol 2024. [PMID: 39097785 DOI: 10.1002/cncy.22889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2024] [Revised: 06/17/2024] [Accepted: 07/02/2024] [Indexed: 08/05/2024]
Abstract
BACKGROUND The third edition of The Bethesda System (TBS) subclassifies the atypia of undetermined significance (AUS) category on the basis of the presence of nuclear atypia (AUS-Nuclear). This approach is supported by studies showing significant differences in the risk of malignancy (ROM) between AUS-Nuclear and those without (AUS-Other). Although aspirates of follicular neoplasms (FNs) are characterized by marked architectural atypia, TBS recognizes the infrequent occurrence of FNs with mild nuclear atypia (FN-Nuclear). Furthermore, limited studies have shown significant differences in ROM between FN-Nuclear and those without (FN-Other). This study explored potential differences in ROM, molecular-derived risk of malignancy (MDROM), and molecular alterations between FN-Nuclear and FN-Other. METHODS A retrospective database search identified 93 FN aspirates. Cytology slides, molecular reports, and histologic follow-ups were reviewed. Both groups' benign call rate (BCR), positive call rate (PCR), MDROM, and ROM were computed and compared. RESULTS Eighty-six percent of aspirates (80 of 93) comprised FN-Other, whereas 14% (13 of 93) were FN-Nuclear. The BCR and PCR for FN-Other were 51% and 49%, respectively. In contrast, they were 23% and 77% for FN-Nuclear, respectively. The MDROM significantly differed between FN-Other (30%) and FN-Nuclear (56%) (p < .05). HRAS mutation was the most common molecular alteration in FN-Nuclear, whereas mutations in NRAS/KRAS and copy number alterations were more common in FN-Other. The ROM1/ROM2 in FN-Other and FN-Nuclear were 16%/31% and 54%/88%, respectively. CONCLUSIONS These results reveal that FN-Nuclear exhibits significantly higher MDROM and ROM than FN-Other, which provides support for a subclassification scheme for FNs based on the presence of nuclear atypia.
Collapse
Affiliation(s)
- Youley Tjendra
- Department of Pathology and Laboratory Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Yiqin Zuo
- Department of Pathology and Laboratory Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Jaylou M Velez Torres
- Department of Pathology and Laboratory Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| |
Collapse
|
3
|
Sada A, Yip L. The Role of Molecular Markers in Thyroid Cancer Diagnostics and Treatment. Surg Clin North Am 2024; 104:741-749. [PMID: 38944495 DOI: 10.1016/j.suc.2024.02.004] [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: 07/01/2024]
Abstract
Molecular testing for cytologically indeterminate thyroid nodules has demonstrated benefit by reducing the need for diagnostic thyroidectomies and reducing costs. Its use is currently recommended in practice guidelines from the American Thyroid Association and the American Association of Endocrine Surgeons when clinically appropriate. Moreover, there is growing evidence that molecular testing may provide prognostic information and can detect targetable genetic alterations which may expand treatment options for refractory advanced thyroid cancers.
Collapse
Affiliation(s)
- Alaa Sada
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, 3471 Fifth Avenue, Kaufmann Building, Suite 101, Pittsburgh, PA 15213, USA.
| | - Linwah Yip
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, 3471 Fifth Avenue, Kaufmann Building, Suite 101, Pittsburgh, PA 15213, USA. https://twitter.com/l_yip123
| |
Collapse
|
4
|
Rossi ED, Pantanowitz L. Are we ready to bridge classification systems? A comprehensive review of different reporting systems in thyroid cytology. Cytopathology 2024. [PMID: 39056560 DOI: 10.1111/cyt.13411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Revised: 05/27/2024] [Accepted: 06/06/2024] [Indexed: 07/28/2024]
Abstract
The evaluation of thyroid lesions is common in the daily practice of cytology. While the majority of thyroid nodules are benign, in recent decades, there has been increased detection of small and well-differentiated thyroid cancers. Combining ultrasound evaluation with fine-needle aspiration cytology (FNAC) is extremely useful in the management of thyroid nodules. Furthermore, the adoption of specific terminology, introduced by different thyroid reporting systems, has helped effectively communicate thyroid FNAC diagnoses in a clear and understandable way. In 1996, the Papanicolaou Society thyroid cytological classification was introduced. This was followed in 2005 by the first Japanese and then in 2007 by the Bethesda System for Reporting Thyroid Cytopathology, which subsequently underwent two revisions. Other international thyroid terminology classifications include the British, Italian, Australasian and other Japanese cytology systems. This review covers similarities and differences among these cytology classification systems and highlights key points that unify these varied approaches to reporting thyroid FNAC diagnoses.
Collapse
Affiliation(s)
- Esther Diana Rossi
- Division of Anatomic Pathology and Histology, Catholic University of Sacred Heart, Rome, Italy
| | - Liron Pantanowitz
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
5
|
Tumati A, Egan CE, Lee-Saxton YJ, Marshall TE, Lee J, Jain K, Heymann JJ, Gokozan H, Azar SA, Schwarz J, Keutgen XM, Laird AM, Beninato T, Zarnegar R, Fahey TJ, Finnerty BM. Clinical utility of a microRNA classifier in cytologically indeterminate thyroid nodules with RAS mutations: A multi-institutional study. Surgery 2024; 175:234-240. [PMID: 37907382 DOI: 10.1016/j.surg.2023.07.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 06/13/2023] [Accepted: 07/08/2023] [Indexed: 11/02/2023]
Abstract
BACKGROUND Molecular testing guides the management of cytologically indeterminate thyroid nodules. We evaluated the real-world clinical benefit of a commercially available thyroid mutation panel plus microRNA risk classifier in classifying RAS-mutated nodules. METHODS We performed a subgroup analysis of the results of molecular testing of Bethesda III/IV nodules using the ThyGenX/ThyGeNEXT-ThyraMIR platform at 3 tertiary-care centers between 2017 and 2021, defining a positive result as 10% or greater risk of malignancy. RESULTS We identified 387 nodules from 375 patients (70.7% female, median age 59.3 years) who underwent testing. Positive nodules (32.3%) were associated with increased surgical intervention (74.4% vs 14.9%, P < .0001) and carcinoma on surgical pathology (46.4% vs 3.4%, P < .0001) compared to negative modules. RAS mutations were the most common mutations, identified in 71 of 380 (18.7%) nodules, and were classified as ThyraMIR- (28 of 71; 39.4%) or ThyraMIR+ (43 of 71; 60.6%). Among RAS-mutated nodules, there was no significant difference in operative rate (P = .2212) or carcinoma diagnosis (P = .6277) between the ThyraMIR+ and ThyraMIR- groups, and the sensitivity, specificity, negative predictive value, and positive predictive value of ThyraMIR were 64.7%, 34.8%, 40.0%, and 59.5%, respectively. CONCLUSION Although testing positive is associated with malignancy in surgical pathology, the ThyraMIR classifier failed to differentiate between benign and malignant RAS-mutated nodules. Diagnostic lobectomy should be considered for RAS-mutated nodules, regardless of microRNA expression status.
Collapse
Affiliation(s)
- Abhinay Tumati
- Department of Surgery, Weill Cornell Medicine, New York, NY.
| | - Caitlin E Egan
- Department of Surgery, Weill Cornell Medicine, New York, NY. https://twitter.com/CaitlinEgan18
| | - Yeon J Lee-Saxton
- Department of Surgery, Weill Cornell Medicine, New York, NY. https://twitter.com/YeonJooLeeMD
| | - Teagan E Marshall
- Department of Surgery, Weill Cornell Medicine, New York, NY. https://twitter.com/TeaganEMarshall
| | - Joyce Lee
- Department of Surgery, Weill Cornell Medicine, New York, NY
| | - Kavita Jain
- Department of Surgery, Rutgers-Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Jonas J Heymann
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY. https://twitter.com/HeymannJonas
| | - Hamza Gokozan
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY. https://twitter.com/GokozanMD
| | - Sara Abou Azar
- Department of Surgery, Section of Endocrine Surgery, The University of Chicago Medicine, Chicago, IL. https://twitter.com/SaraAbouAzar
| | - Jason Schwarz
- Department of Surgery, Section of Endocrine Surgery, The University of Chicago Medicine, Chicago, IL
| | - Xavier M Keutgen
- Department of Surgery, Section of Endocrine Surgery, The University of Chicago Medicine, Chicago, IL. https://twitter.com/XKeutgen
| | - Amanda M Laird
- Department of Surgery, Rutgers-Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ. https://twitter.com/amlaird
| | - Toni Beninato
- Department of Surgery, Rutgers-Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ. https://twitter.com/BeninatoToni
| | - Rasa Zarnegar
- Department of Surgery, Weill Cornell Medicine, New York, NY. https://twitter.com/RasaZarnegarMD
| | - Thomas J Fahey
- Department of Surgery, Weill Cornell Medicine, New York, NY. https://twitter.com/tjf3endosurg
| | - Brendan M Finnerty
- Department of Surgery, Weill Cornell Medicine, New York, NY. https://twitter.com/FinnertyMD
| |
Collapse
|
6
|
Baumgarten DA. Toward Better Care for Patients with Follicular Thyroid Neoplasms. Radiology 2023; 309:e232985. [PMID: 37987658 DOI: 10.1148/radiol.232985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Affiliation(s)
- Deborah A Baumgarten
- From the Department of Radiology, Mayo Clinic in Florida, 4500 San Pablo Rd S, Jacksonville, FL 32224
| |
Collapse
|
7
|
Lu Y, Guo X, Yang M, Wang K, Cao G, Liu Y, Hou X, Chen L, Liang K. BRAF V600E genetic testing should be recommended for Bethesda III or V thyroid nodules based on fine-needle aspiration. Sci Rep 2023; 13:17129. [PMID: 37816788 PMCID: PMC10564976 DOI: 10.1038/s41598-023-44464-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 10/09/2023] [Indexed: 10/12/2023] Open
Abstract
The preoperative diagnosis of thyroid nodules now routinely includes BRAFV600E genetic testing in most provincial and municipal hospitals in China. This study identified the most suitable patients of thyroid nodule for BRAFV600E genetic testing. We retrospectively collected data of patients from the Hospital Information System that had undergone fine needle aspiration biopsy (FNAB) from May 2019 to December 2021. Data of FNAB, BRAFV600E genetic testing, and post-surgical pathological diagnosis were collected. A total of 12,392 patients were included in this study. Among them, 7,010 patients underwent solely FNAB, while 5,382 patients had both FNAB and BRAFV600E genetic testing. In the FNAB group, 2,065 thyroid nodules were surgically removed, with a 93.12% malignancy rate. In the FNAB + BRAF group, 2,005 nodules were dissected, and the malignancy rate was 98.20%. However, it was evident that in the subgroups, the combination of FNAB and BRAFV600E genetic testing only benefited Bethesda III (p < 0.001) and V (p = 0.001) nodules. Overall, the combination of FNAB with BRAFV600E genetic testing significantly improved the malignancy rate of surgical thyroid nodes at our hospital when compared to FNAB alone. The subgroup analysis showed that BRAFV600E genetic testing only benefited Bethesda III and V nodules. These findings provide a clinical reference for rationally selecting the most suitable population for BRAFV600E genetic testing.
Collapse
Affiliation(s)
- Yiran Lu
- Department of Endocrine and Metabolic Diseases, Qilu Hospital of Shandong University, Jinan, China
| | - Xinghong Guo
- Department of Endocrine and Metabolic Diseases, Qilu Hospital of Shandong University, Jinan, China
- Institute of Endocrine and Metabolic Diseases of Shandong University, Jinan, China
- Key Laboratory of Endocrine and Metabolic Diseases, Shandong Province Medicine & Health, Jinan, China
- Jinan Clinical Research Center for Endocrine and Metabolic Diseases, Jinan, China
| | - Mengmeng Yang
- Department of Endocrine and Metabolic Diseases, Qilu Hospital of Shandong University, Jinan, China
| | - Kewei Wang
- Department of Endocrine and Metabolic Diseases, Qilu Hospital of Shandong University, Jinan, China
| | - Guanglei Cao
- Department of Endocrine and Metabolic Diseases, Qilu Hospital of Shandong University, Jinan, China
| | - Yan Liu
- Department of Endocrine and Metabolic Diseases, Qilu Hospital of Shandong University, Jinan, China
| | - Xinguo Hou
- Department of Endocrine and Metabolic Diseases, Qilu Hospital of Shandong University, Jinan, China
- Institute of Endocrine and Metabolic Diseases of Shandong University, Jinan, China
- Key Laboratory of Endocrine and Metabolic Diseases, Shandong Province Medicine & Health, Jinan, China
- Jinan Clinical Research Center for Endocrine and Metabolic Diseases, Jinan, China
| | - Li Chen
- Department of Endocrine and Metabolic Diseases, Qilu Hospital of Shandong University, Jinan, China.
- Institute of Endocrine and Metabolic Diseases of Shandong University, Jinan, China.
- Key Laboratory of Endocrine and Metabolic Diseases, Shandong Province Medicine & Health, Jinan, China.
- Jinan Clinical Research Center for Endocrine and Metabolic Diseases, Jinan, China.
| | - Kai Liang
- Department of Endocrine and Metabolic Diseases, Qilu Hospital of Shandong University, Jinan, China.
- Institute of Endocrine and Metabolic Diseases of Shandong University, Jinan, China.
- Key Laboratory of Endocrine and Metabolic Diseases, Shandong Province Medicine & Health, Jinan, China.
- Jinan Clinical Research Center for Endocrine and Metabolic Diseases, Jinan, China.
| |
Collapse
|
8
|
Uludag M, Unlu MT, Kostek M, Aygun N, Caliskan O, Ozel A, Isgor A. Management of Thyroid Nodules. SISLI ETFAL HASTANESI TIP BULTENI 2023; 57:287-304. [PMID: 37900341 PMCID: PMC10600596 DOI: 10.14744/semb.2023.06992] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 09/13/2023] [Accepted: 09/18/2023] [Indexed: 10/31/2023]
Abstract
Thyroid nodules are common and the prevalence varies between 4 and 7% by palpation and 19-68% by high-resolution USG. Most thyroid nodules are benign, and the malignancy rate varies between 7 and 15% of patients. Thyroid nodules are detected incidentally during clinical examination or, more often, during imaging studies performed for another reason. All detected thyroid nodules should be evaluated clinically. The main test in evaluating thyroid function is thyroid stimulating hormone (TSH). If the serum TSH level is below the normal reference range, a radionuclide thyroid scan should be performed to determine whether the nodule is hyperfunctioning. If the serum TSH level is normal or high, ultrasonography (US) should be performed to evaluate the nodule. US is the most sensitive imaging method in the evaluation of thyroid nodules. Computed tomography (CT) and magnetic resonance imaging are not routinely used in the initial evaluation of thyroid nodules. There are many risk classification systems according to the USG characteristics of thyroid nodules, and the most widely used in clinical practice are the American Thyroid Association guideline and the American College of Radiology Thyroid Imaging Reporting and Data System. Fine needle aspiration biopsy (FNAB) is the gold standard method in the evaluation of nodules with indication according to USG risk class. In the cytological evaluation of FNAB, the Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) is the most frequently applied cytological classification. TBSRTC is a simplified, 6-category reporting system and was updated in 2023. The application of molecular tests to FNAB specimens, especially those diagnosed with Bethesda III and IV, is increasing to reduce the need for diagnostic surgery. Especially in Bethesda III and IV nodules, different methods are applied in the treatment of nodules according to the malignancy risk of each category, these are follow-up, surgical treatment, radioactive iodine treatment, and non-surgical ablation methods.
Collapse
Affiliation(s)
- Mehmet Uludag
- Division of Endocrine Surgery, Department of General Surgery, University of Health Sciences Türkiye, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye
| | - Mehmet Taner Unlu
- Division of Endocrine Surgery, Department of General Surgery, University of Health Sciences Türkiye, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye
| | - Mehmet Kostek
- Division of Endocrine Surgery, Department of General Surgery, University of Health Sciences Türkiye, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye
| | - Nurcihan Aygun
- Division of Endocrine Surgery, Department of General Surgery, University of Health Sciences Türkiye, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye
| | - Ozan Caliskan
- Division of Endocrine Surgery, Department of General Surgery, University of Health Sciences Türkiye, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye
| | - Alper Ozel
- Department of Radiology, University of Health Sciences Türkiye, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye
| | - Adnan Isgor
- Department of General Surgery, Sisli Memorial Hospital, Istanbul, Türkiye
| |
Collapse
|
9
|
Tjendra Y, Kerr DA, Zuo Y, Menendez SG, Jorda M, Gomez-Fernandez C, Velez Torres JM. Probability of malignancy and molecular alterations as determined by ThyroSeq v3 genomic classifier in Bethesda Category IV. Cancer Cytopathol 2023; 131:586-595. [PMID: 37358081 DOI: 10.1002/cncy.22737] [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] [Received: 02/13/2023] [Revised: 05/21/2023] [Accepted: 05/22/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND ThyroSeq molecular testing assesses the probability of malignancy (POM) in thyroid fine-needle aspiration cytology (FNAC) with indeterminate cytology. The aim was to investigate whether Bethesda category IV (BIV) subcategories are associated with specific molecular alterations, molecular-derived risk of malignancy (MDROM), and risk of malignancy (ROM). METHODS FNAC slides, associated ThyroSeq, version 3, Genomic Classifier results, and surgical follow-up were retrieved for BIV nodules. Nodules were subcategorized as follicular neoplasm (FN) with or without cytologic atypia or oncocytic follicular neoplasm (OFN). The MDROM, ROM, and frequency of molecular alterations in FN and OFN were analyzed. p < .05 was considered significant. RESULTS A total of 92 FNAC were identified and subcategorized into 46 FN (15 with and 31 without cytologic atypia) and 46 OFN. The benign call rate and the positive call rate were 49% and 51%, respectively. The MDROM in BIV was 34.3%, trending lower in OFN than in FN. RAS mutations were significantly more frequent in FN when compared to OFN (p = .02). Chromosomal copy number alterations were more often present in OFN than in FN (p < .01). On histologic follow-up, ROM in OFN was trending lower than in FN (p = .1). The most common diagnosis in OFN was oncocytic adenoma, whereas follicular variant papillary thyroid carcinoma was most common in FN. CONCLUSIONS The MDROM and ROM were trending lower in OFN compared with FN, and the molecular alterations differed between OFN and FN subcategories.
Collapse
Affiliation(s)
- Youley Tjendra
- Department of Pathology and Laboratory Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Darcy A Kerr
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Yiqin Zuo
- Department of Pathology and Laboratory Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Silvia Gra Menendez
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Merce Jorda
- Department of Pathology and Laboratory Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Carmen Gomez-Fernandez
- Department of Pathology and Laboratory Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Jaylou M Velez Torres
- Department of Pathology and Laboratory Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| |
Collapse
|
10
|
Ali SZ, Baloch ZW, Cochand-Priollet B, Schmitt FC, Vielh P, VanderLaan PA. The 2023 Bethesda System for Reporting Thyroid Cytopathology. Thyroid 2023; 33:1039-1044. [PMID: 37427847 DOI: 10.1089/thy.2023.0141] [Citation(s) in RCA: 33] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
Since the publication of the first edition in 2010, The Bethesda System for Reporting Thyroid Cytopathology has allowed cytopathologists to use a standardized, category-based reporting system for thyroid fine needle aspirations. The third edition builds on the success of the 2 earlier editions and offers several key updates. The most important is the assignment of a single name for each of the 6 diagnostic categories: (i) nondiagnostic; (ii) benign; (iii) atypia of undetermined significance; (iv) follicular neoplasm; (v) suspicious for malignancy; and (vi) malignant. Each of the categories has an implied risk of malignancy (ROM), which has been updated and refined based on data reported after the second edition. The third edition offers an average ROM for each category, in addition to the expected range of cancer risk. The atypia of undetermined significance subcategorization is simplified into 2 subgroups based on the implied ROM and molecular profiling. A discussion of pediatric thyroid disease has been added, and pediatric ROMs and management algorithms are discussed in the relevant sections. Nomenclature has been updated to align with the 2022 World Health Organization Classification of Thyroid Neoplasms. Two new chapters have been added: one that addresses the significant and expanded use of molecular and ancillary testing in thyroid cytopathology, and another that summarizes clinical perspectives and imaging findings in thyroid disease.
Collapse
Affiliation(s)
- Syed Z Ali
- Department of Pathology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Zubair W Baloch
- Department of Pathology and Laboratory Medicine, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania, USA
| | | | - Fernando C Schmitt
- Department of Pathology, Medical Faculty of Porto University, Porto, Portugal
| | - Philippe Vielh
- Department of Pathology, Medipath and the American Hospital of Paris, Paris, France
| | - Paul A VanderLaan
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
11
|
Yang Z, Yao S, Heng Y, Shen P, Lv T, Feng S, Tao L, Zhang W, Qiu W, Lu H, Cai W. Automated diagnosis and management of follicular thyroid nodules based on the devised small-dataset interpretable foreground optimization network deep learning: a multicenter diagnostic study. Int J Surg 2023; 109:2732-2741. [PMID: 37204464 PMCID: PMC10498847 DOI: 10.1097/js9.0000000000000506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 05/10/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Currently, follicular thyroid carcinoma (FTC) has a relatively low incidence with a lack of effective preoperative diagnostic means. To reduce the need for invasive diagnostic procedures and to address information deficiencies inherent in a small dataset, we utilized interpretable foreground optimization network deep learning to develop a reliable preoperative FTC detection system. METHODS In this study, a deep learning model (FThyNet) was established using preoperative ultrasound images. Data on patients in the training and internal validation cohort ( n =432) were obtained from Ruijin Hospital, China. Data on patients in the external validation cohort ( n =71) were obtained from four other clinical centers. We evaluated the predictive performance of FThyNet and its ability to generalize across multiple external centers and compared the results yielded with assessments from physicians directly predicting FTC outcomes. In addition, the influence of texture information around the nodule edge on the prediction results was evaluated. RESULTS FThyNet had a consistently high accuracy in predicting FTC with an area under the receiver operating characteristic curve (AUC) of 89.0% [95% CI 87.0-90.9]. Particularly, the AUC for grossly invasive FTC reached 90.3%, which was significantly higher than that of the radiologists (56.1% [95% CI 51.8-60.3]). The parametric visualization study found that those nodules with blurred edges and relatively distorted surrounding textures were more likely to have FTC. Furthermore, edge texture information played an important role in FTC prediction with an AUC of 68.3% [95% CI 61.5-75.5], and highly invasive malignancies had the highest texture complexity. CONCLUSION FThyNet could effectively predict FTC, provide explanations consistent with pathological knowledge, and improve clinical understanding of the disease.
Collapse
Affiliation(s)
- Zheyu Yang
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine
| | - Siqiong Yao
- School of Life Sciences and Biotechnology, Shanghai Jiao Tong University
| | - Yu Heng
- Department of Otolaryngology, Eye, Ear, Nose and Throat Hospital, Fudan University
| | - Pengcheng Shen
- School of Life Sciences and Biotechnology, Shanghai Jiao Tong University
| | - Tian Lv
- Department of Head, Neck and Thyroid Surgery, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou, People’s Republic of China
| | - Siqi Feng
- Department of General Surgery, Liaoning Cancer Hospital & Institute, Shenyang
| | - Lei Tao
- Department of Otolaryngology, Eye, Ear, Nose and Throat Hospital, Fudan University
| | - Weituo Zhang
- Shanghai Tong Ren Hospital and Clinical Research Institute
- Hong Qiao International Institute of Medicine, Shanghai
| | - Weihua Qiu
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine
- Department of General Surgery, Ruijin Hospital Gubei Campus, Shanghai Jiao Tong University School of Medicine
| | - Hui Lu
- School of Life Sciences and Biotechnology, Shanghai Jiao Tong University
| | - Wei Cai
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine
| |
Collapse
|
12
|
Ali SZ, Baloch ZW, Cochand-Priollet B, Schmitt FC, Vielh P, VanderLaan PA. The 2023 Bethesda System for reporting thyroid cytopathology. J Am Soc Cytopathol 2023; 12:319-325. [PMID: 37438235 DOI: 10.1016/j.jasc.2023.05.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
Since the publication of the first edition in 2010, The Bethesda System for Reporting Thyroid Cytopathology has allowed cytopathologists to use a standardized, category-based reporting system for thyroid fine needle aspirations. The third edition builds on the success of the 2 earlier editions and offers several key updates. The most important is the assignment of a single name for each of the 6 diagnostic categories: (i) nondiagnostic; (ii) benign; (iii) atypia of undetermined significance; (iv) follicular neoplasm; (v) suspicious for malignancy; and (vi) malignant. Each of the categories has an implied risk of malignancy (ROM), which has been updated and refined based on data reported after the second edition. The third edition offers an average ROM for each category, in addition to the expected range of cancer risk. The atypia of undetermined significance subcategorization is simplified into 2 subgroups based on the implied ROM and molecular profiling. A discussion of pediatric thyroid disease has been added, and pediatric ROMs and management algorithms are discussed in the relevant sections. Nomenclature has been updated to align with the 2022 World Health Organization Classification of Thyroid Neoplasms. Two new chapters have been added: one that addresses the significant and expanded use of molecular and ancillary testing in thyroid cytopathology, and another that summarizes clinical perspectives and imaging findings in thyroid disease.
Collapse
Affiliation(s)
- Syed Z Ali
- Department of Pathology, The Johns Hopkins Medical Institutions, Baltimore, Maryland.
| | - Zubair W Baloch
- Department of Pathology and Laboratory Medicine, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania
| | | | - Fernando C Schmitt
- Department of Pathology, Medical Faculty of Porto University, Porto, Portugal
| | - Philippe Vielh
- Department of Pathology, Medipath and the American Hospital of Paris, Paris, France
| | - Paul A VanderLaan
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
13
|
Kim NE, Raghunathan RS, Hughes EG, Longstaff XR, Tseng CH, Li S, Cheung DS, Gofnung YA, Famini P, Wu JX, Yeh MW, Livhits MJ. Bethesda III and IV Thyroid Nodules Managed Nonoperatively After Molecular Testing With Afirma GSC or Thyroseq v3. J Clin Endocrinol Metab 2023; 108:e698-e703. [PMID: 36995878 PMCID: PMC10438873 DOI: 10.1210/clinem/dgad181] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/14/2023] [Accepted: 03/27/2023] [Indexed: 03/31/2023]
Abstract
CONTEXT Molecular testing has improved risk stratification and increased nonoperative management for patients with indeterminate thyroid nodules, but data on the long-term outcomes of current molecular tests Afirma Gene Sequencing Classifier (GSC) and Thyroseq v3 are limited. OBJECTIVE To determine the rate of delayed operation and the false negative rate of the Afirma GSC and Thyroseq v3 in Bethesda III and IV thyroid nodules. METHODS Prospective follow-up of a single center, randomized, clinical trial comparing the performance of Afirma GSC and Thyroseq v3 in the diagnosis of indeterminate thyroid nodules at the University of California, Los Angeles (UCLA). Consecutive participants who underwent thyroid biopsy in the UCLA health system with Bethesda III and IV cytology from August 2017 to November 2019. The main outcome measure was false negative rate of molecular testing. RESULTS Of 176 indeterminate nodules with negative or benign molecular test results, 14 (8%) nodules underwent immediate resection, with no malignancies found on surgical pathology. Nonoperative management with active surveillance was pursued for 162 (92%) nodules with benign or negative test results. The median surveillance was 34 months (range 12-60 months), and 44 patients were lost to follow-up. Of 15 nodules resected during surveillance, 1 malignancy was found (overall false negative rate of 0.6%). This was a 2.7 cm minimally invasive Hurthle cell carcinoma that initially tested negative with Thyroseq v3 and underwent delayed resection due to sonographic growth during surveillance. CONCLUSIONS The majority of Bethesda III/IV thyroid nodules with negative or benign molecular test results are stable over 3 years of follow-up. These findings support the high sensitivity of current molecular tests and their role in ruling out malignancy in indeterminate thyroid nodules.
Collapse
Affiliation(s)
- Na Eun Kim
- Department of Surgery, Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA 90095, USA
| | - Rajam S Raghunathan
- Department of Surgery, Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA 90095, USA
| | - Elena G Hughes
- Department of Surgery, Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA 90095, USA
| | - Xochitl R Longstaff
- Department of Surgery, Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA 90095, USA
| | - Chi-Hong Tseng
- Division of General Internal Medicine and Health Services Research, University of California, Los Angeles, Los Angeles, CA 90095, USA
| | - Shanpeng Li
- Department of Biostatistics, University of California, Los Angeles, CA 90095, USA
| | - Dianne S Cheung
- Division of Endocrinology, Diabetes and Metabolism, UCLA David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA
| | - Yaroslav A Gofnung
- Division of Endocrinology, Diabetes and Metabolism, UCLA David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA
| | - Pouyan Famini
- Division of Endocrinology, Diabetes and Metabolism, UCLA David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA
| | - James X Wu
- Department of Surgery, Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA 90095, USA
| | - Michael W Yeh
- Department of Surgery, Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA 90095, USA
| | - Masha J Livhits
- Department of Surgery, Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA 90095, USA
| |
Collapse
|
14
|
Rossi ED, Baloch Z. The Impact of the 2022 WHO Classification of Thyroid Neoplasms on Everyday Practice of Cytopathology. Endocr Pathol 2023; 34:23-33. [PMID: 36797454 DOI: 10.1007/s12022-023-09756-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/10/2023] [Indexed: 02/18/2023]
Abstract
This review outlines how the alterations in the 5th edition of the WHO Classification of Endocrine and Neuroendocrine Tumors of the thyroid gland are likely to impact thyroid cytopathology. It is important to note that WHO subclassifies thyroid tumors into several new categories based on increased comprehension of the cell of origin, pathologic features (including cytopathology), molecular classification, and biological behavior. The 3rd edition of the Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) will debut in the near future and will include changes in diagnostic category designations. The changes in the 5th edition of the WHO will in some instances subtly, and in other instances significantly, impact the cytological diagnoses. Moreover, these changes will also affect other thyroid FNA classification schemes used internationally for classifying thyroid FNA specimens.
Collapse
Affiliation(s)
- Esther Diana Rossi
- Division of Anatomic Pathology and Histology- Fondazione, Policlinico Universitario A.Gemelli-IRCCS, Largo Agostino Gemelli, 8 - 00168 , Rome, Italy
| | - Zubair Baloch
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, 19104, USA.
| |
Collapse
|
15
|
Carty SE. Invited commentary: Real-time thyroid nodule care. Surgery 2023; 173:180-182. [PMID: 36357229 DOI: 10.1016/j.surg.2022.09.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 09/27/2022] [Accepted: 09/28/2022] [Indexed: 11/09/2022]
Affiliation(s)
- Sally E Carty
- Department of Surgery, Division of Endocrine Surgery, University of Pittsburgh, Pittsburgh, PA.
| |
Collapse
|
16
|
Follicular Neoplasm of Thyroid Revisited: Current Differential Diagnosis and the Impact of Molecular Testing. Adv Anat Pathol 2023; 30:11-23. [PMID: 36102526 DOI: 10.1097/pap.0000000000000368] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The diagnosis of "follicular neoplasm" (FN) in thyroid cytopathology has a long history that originated not long after the practice of fine-needle aspiration (FNA) of thyroid nodules. From the outset, this interpretive category was intended to convey a set of differential diagnoses rather than a precise diagnosis, as key diagnostic features, such as capsular and vascular invasion, were not detectable on cytology preparations. Cytologic-histologic correlation studies over the past several decades have shown that FN interpretation can be applied to the spectrum of nonneoplastic tumors to carcinomas. Most tumors classified as FN include follicular adenoma, follicular carcinoma, noninvasive follicular thyroid tumor with papillary-like nuclear features, and follicular variant of papillary thyroid carcinoma. Less common entities that may be classified as FN on FNA include hyalinizing trabecular tumor (HTT), poorly differentiated thyroid carcinoma, medullary carcinoma, and nonthyroidal lesions such as parathyroid tissue, paraganglioma, and metastatic tumors. Advances in our ability to detect characteristic molecular alterations (eg, GLIS gene rearrangements for hyalinizing trabecular tumor) in FNA samples may assist in the identification of some of these entities. In this review, we summarize the pathophysiology, history, and evolution of the terminology and the current differential diagnosis according to the recently published 2022 World Health Organization classification, molecular testing, and management of nodules classified as FN.
Collapse
|
17
|
DiGennaro C, Vahdatzad V, Jalali MS, Toumi A, Watson T, Gazelle GS, Mercaldo N, Lubitz CC. Assessing Bias and Limitations of Clinical Validation Studies of Molecular Diagnostic Tests for Indeterminate Thyroid Nodules: Systematic Review and Meta-Analysis. Thyroid 2022; 32:1144-1157. [PMID: 35999710 PMCID: PMC9595633 DOI: 10.1089/thy.2022.0269] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background: Molecular tests for thyroid nodules with indeterminate fine needle aspiration results are increasingly used in clinical practice; however, true diagnostic summaries of these tests are unknown. A systematic review and meta-analysis were completed to (1) evaluate the accuracy of commercially available molecular tests for malignancy in indeterminate thyroid nodules and (2) quantify biases and limitations in studies that validate those tests. Summary: PubMed, EMBASE, and Web of Science were systematically searched through July 2021. English language articles that reported original clinical validation attempts of molecular tests for indeterminate thyroid nodules were included if they reported counts of true-negative, true-positive, false-negative, and false-positive results. We performed screening and full-text review, followed by assessment of eight common biases and limitations, extraction of diagnostic and histopathological information, and meta-analysis of clinical validity using a bivariate linear mixed-effects model. Forty-nine studies were included. Meta-analysis of Afirma Gene expression classifiers (GEC; n = 38 studies) revealed a sensitivity of 0.92 (confidence interval: 0.90-0.94), specificity of 0.26 (0.20-0.32), negative likelihood ratio (LR-) of 0.32 (0.23-0.44), positive LR+ of 1.24 (1.15-1.35), and area under the curve (AUC) of 0.83 (0.74-0.89). Afirma Genomic Sequencing Classifier (GSC; n = 10) had a sensitivity of 0.94 (0.89-0.96), specificity of 0.38 (0.27-0.50), LR- of 0.18 (0.10-0.30), LR+ of 1.52 (1.28-1.87), and AUC of 0.91 (0.62-0.92). ThyroSeq v1 and v2 (n = 10) had a sensitivity of 0.86 (0.82-0.90), specificity of 0.74 (0.59-0.85), LR- of 0.19 (0.13-0.26), LR+ of 3.52 (2.08-5.92), and AUC of 0.86 (0.81-0.90). ThyroSeq v3 (n = 6) had a sensitivity of 0.92 (0.86-0.95), specificity of 0.41 (0.18-0.69), LR- of 0.24 (0.09-0.62), LR+ of 1.67 (1.09-2.98), and AUC of 0.90 (0.63-0.92). Fourteen percent of studies conducted a blinded histopathologic review of excised thyroid nodules, and 8% made the decision to go to surgery blind to molecular test results. Conclusions: Meta-analyses reveal a high diagnostic accuracy of molecular tests for thyroid nodule assessment of malignancy risk; however, these studies are subject to several limitations. Limitations and their potential clinical impacts must be addressed and, when feasible, adjusted for using valid statistical methodologies.
Collapse
Affiliation(s)
- Catherine DiGennaro
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Vahab Vahdatzad
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Mohammad S. Jalali
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Asmae Toumi
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Tina Watson
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - G. Scott Gazelle
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nathaniel Mercaldo
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Carrie Cunningham Lubitz
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| |
Collapse
|
18
|
Goldfarb M, Dinauer C. Differences in the management of thyroid nodules in children and adolescents as compared to adults. Curr Opin Endocrinol Diabetes Obes 2022; 29:466-473. [PMID: 35777975 DOI: 10.1097/med.0000000000000754] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To describe recent advances in the diagnosis and management of thyroid nodules in both children and adults, highlighting differences between the two groups. RECENT FINDINGS Thyroid nodules are less common in children than adults but the risk of malignancy is higher. Screening recommendations for patients with certain genetic syndromes or specific risk factors for thyroid nodules and cancer continue to evolve ultrasound is the most appropriate imaging modality for evaluating thyroid nodules in all patients, but radiographic risk stratification systems validated in adults have not been extensively studied in children. Criteria for proceeding to fine needle aspiration (FNA) biopsy differ some between children and adults, with nodule size being less of a consideration in young patients. Molecular testing continues to improve the diagnostic capabilities of FNA for all age groups, but options for pediatric thyroid nodules are currently limited. In children, only oncogene panels are validated and their exact utility, along with miRNA classifiers, is an evolving area of study. For adults, data support selection of a specific molecular test based on ultrasound characteristics and pretest probability of malignancy. Multiple series have shown that fusion mutations are more common in pediatric thyroid nodules, while point mutations are seen more often in adult thyroid nodules. Molecular data help guide management recommendations regarding the need for surgery when FNA is indeterminate, but clinical use is still being refined. Radiofrequency ablation is a nonoperative approach that has gained significant traction for the treatment of symptomatic benign nodules in adults, but data are currently extremely limited in children. SUMMARY There are difference in the diagnosis and treatment of thyroid nodules in adults and children, the nuances of which are important for clinical management.
Collapse
Affiliation(s)
- Melanie Goldfarb
- Center for Endocrine Tumors, Saint Johns Cancer Institute at Providence Saint Johns Health Center, Santa Monica
| | - Catherine Dinauer
- Section of Pediatric Endocrinology, Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut, USA
| |
Collapse
|
19
|
Rajab M, Payne RJ, Forest VI, Pusztaszeri M. Molecular Testing for Thyroid Nodules: The Experience at McGill University Teaching Hospitals in Canada. Cancers (Basel) 2022; 14:cancers14174140. [PMID: 36077677 PMCID: PMC9454567 DOI: 10.3390/cancers14174140] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 08/24/2022] [Accepted: 08/25/2022] [Indexed: 11/16/2022] Open
Abstract
In the past few decades, molecular characterization of thyroid cancer has made significant progress and is able to identify thyroid-cancer-related molecular markers that can then be applied clinically for improved decision making. The aim of this review is to provide a general overview about the molecular markers (mutations and alterations) of thyroid cancers, present several molecular tests, and discuss the clinical applications of identifying these markers supported by the clinical experience of several high-volume thyroid cancer specialists at the McGill university hospitals in Montreal, Canada. Our group experience showed that molecular testing can reclassify more than half of the patients with indeterminate thyroid nodules (Bethesda III and IV) into benign and spare these patients from unnecessary diagnostic surgery. Furthermore, it can help optimize the initial management in thyroid cancers with no evidence of high risk of recurrence of disease preoperatively. While routine molecular testing is not firmly established for thyroid FNA specimens that are suspicious or positive for malignancy (Bethesda V and VI), knowledge of a thyroid nodule’s molecular risk group profile in such cases, together with its clinical and radiologic features, can help select the optimal surgical options (lobectomy versus upfront total thyroidectomy and central neck dissection), as demonstrated by our studies.
Collapse
Affiliation(s)
- Mohannad Rajab
- Department of Otolaryngology—Head and Neck Surgery, Jewish General Hospital, McGill University, 3755 Côte-Sainte-Catherine Road, Montreal, QC H3T 1E2, Canada
- Departments of Otolaryngology—Head and Neck Surgery, Royal Victoria Hospital, McGill University, 1001 Decarie Blvd, Montreal, QC H4A 3J1, Canada
- Department of Otolaryngology—Head and Neck Surgery, King Faisal Specialist Hospital & Research Center, Al Madinah Al Munawwarah 42523, Saudi Arabia
| | - Richard J. Payne
- Department of Otolaryngology—Head and Neck Surgery, Jewish General Hospital, McGill University, 3755 Côte-Sainte-Catherine Road, Montreal, QC H3T 1E2, Canada
- Departments of Otolaryngology—Head and Neck Surgery, Royal Victoria Hospital, McGill University, 1001 Decarie Blvd, Montreal, QC H4A 3J1, Canada
| | - Véronique-Isabelle Forest
- Department of Otolaryngology—Head and Neck Surgery, Jewish General Hospital, McGill University, 3755 Côte-Sainte-Catherine Road, Montreal, QC H3T 1E2, Canada
| | - Marc Pusztaszeri
- Department of Pathology, Jewish General Hospital, McGill University, 3755 Côte-Sainte-Catherine Road, Montreal, QC H3T 1E2, Canada
- Correspondence: ; Tel.: +1-(514)-340-8222 (ext. 4197)
| |
Collapse
|
20
|
Figge JJ, Gooding WE, Steward DL, Yip L, Sippel RS, Yang SP, Scheri RP, Sipos JA, Mandel SJ, Mayson SE, Burman KD, Folek JM, Haugen BR, Sosa JA, Parameswaran R, Tan WB, Nikiforov YE, Carty SE. Do Ultrasound Patterns and Clinical Parameters Inform the Probability of Thyroid Cancer Predicted by Molecular Testing in Nodules with Indeterminate Cytology? Thyroid 2021; 31:1673-1682. [PMID: 34340592 PMCID: PMC8917891 DOI: 10.1089/thy.2021.0119] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background: Molecular testing (MT) is commonly used to refine cancer probability in thyroid nodules with indeterminate cytology. Whether or not ultrasound (US) patterns and clinical parameters can further inform the risk of thyroid cancer in nodules predicted to be positive or negative by MT remains unknown. The aim of this study was to test if clinical parameters, including patient age, sex, nodule size (by US), Bethesda category (III, IV, V), US pattern (American Thyroid Association [ATA] vs. American College of Radiology Thyroid Image Reporting and Data System [TI-RADS] systems), radiation exposure, or family history of thyroid cancer can modify the probability of thyroid cancer or noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) predicted by MT. Methods: We studied 257 thyroid nodules in 232 patients from 10 study centers with indeterminate fine needle aspiration cytology and informative MT results using the ThyroSeq v3 genomic classifier (TSv3). Univariate and multivariate logistic regression was used for data analysis. Results: The presence of cancer/NIFTP was associated with positive TSv3 results (odds ratio 61.39, p < 0.0001). On univariate regression, patient sex, age, and Bethesda category were associated with cancer/NIFTP probability (p < 0.05 for each). Although ATA (p = 0.1211) and TI-RADS (p = 0.1359) US categories demonstrated positive trends, neither was significantly associated with cancer/NIFTP probability. A multivariate regression model incorporating the four most informative non-MT covariates (sex, age, Bethesda category, and ATA US pattern; Model No. 1) yielded a C index of 0.653; R2 = 0.108. When TSv3 was added to Model number 1, the C index increased to 0.888; R2 = 0.572. However, age (p = 0.341), Bethesda category (p = 0.272), and ATA US pattern (p = 0.264) were nonsignificant, and other than TSv3 (p < 0.0001), male sex was the only non-MT parameter that potentially contributed to cancer/NIFTP risk (p = 0.095). The simplest and most efficient clinical model (No. 3) incorporated TSv3 and sex (C index = 0.889; R2 = 0.588). Conclusions: In this multicenter study of thyroid nodules with indeterminate cytology and MT, neither the ATA nor TI-RADS US scoring systems further informed the risk of cancer/NIFTP beyond that predicted by TSv3. Although age and Bethesda category were associated with cancer/NIFTP probability on univariate analysis, in sequential nomograms they provided limited incremental value above the high predictive ability of TSv3. Patient sex may contribute to cancer/NIFTP risk in thyroid nodules with indeterminate cytology.
Collapse
Affiliation(s)
- James J. Figge
- Diabetes & Endocrine Care, St. Peter's Health Partners/Trinity Health, Rensselaer, New York, USA
- Address correspondence to: James J. Figge, MD, MBA, Diabetes & Endocrine Care, St. Peter's Health Partners/Trinity Health, 279 Troy Road, Rensselaer, NY 12144, USA
| | - William E. Gooding
- Biostatistics Facility, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania, USA
| | - David L. Steward
- Department of Otolaryngology, Head and Neck Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Linwah Yip
- Division of Endocrine Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Rebecca S. Sippel
- Division of Endocrine Surgery, University of Wisconsin, Madison, Wisconsin, USA
| | - Samantha Peiling Yang
- Endocrinology Division, Department of Medicine, National University Hospital, Singapore, Singapore
- Endocrinology Division, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Randall P. Scheri
- Section of Endocrine Surgery, Department of Surgery, Duke University, Durham, North Carolina, USA
| | - Jennifer A. Sipos
- Division of Endocrinology, Diabetes, and Metabolism, Ohio State University School of Medicine, Columbus, Ohio, USA
| | - Susan J. Mandel
- Division of Endocrinology, Diabetes and Metabolism, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sarah E. Mayson
- Division of Endocrinology, Metabolism and Diabetes, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Kenneth D. Burman
- Endocrinology Section, Department of Medicine, MedStar Washington Hospital Center, Washington, District of Columbia, USA
| | | | - Bryan R. Haugen
- Division of Endocrinology, Metabolism and Diabetes, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Julie A. Sosa
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Rajeev Parameswaran
- Division of Endocrine Surgery, Department of Surgery, National University Hospital, Singapore, Singapore
- Division of Endocrine Surgery, Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Wee Boon Tan
- Division of Endocrine Surgery, Department of Surgery, National University Hospital, Singapore, Singapore
- Division of Endocrine Surgery, Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yuri E. Nikiforov
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sally E. Carty
- Division of Endocrine Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Sally E. Carty, MD, Division of Endocrine Surgery, University of Pittsburgh, 101 Kauffmann, 3471 Fifth Avenue, Pittsburgh, PA 15213, USA
| |
Collapse
|
21
|
Patel SG, Carty SE, Lee AJ. Molecular Testing for Thyroid Nodules Including Its Interpretation and Use in Clinical Practice. Ann Surg Oncol 2021; 28:8884-8891. [PMID: 34275048 DOI: 10.1245/s10434-021-10307-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 05/31/2021] [Indexed: 01/09/2023]
Abstract
Despite advances in imaging and biopsy techniques, the management of thyroid nodules often remains a diagnostic and clinical challenge. In particular, patients with cytologically indeterminate nodules often undergo diagnostic thyroidectomy although only a minority of patients are found to have thyroid malignancy on final pathology. More recently, several molecular testing platforms have been developed to improve the stratification of cancer risk for patients with cytologically indeterminate thyroid nodules. Based on numerous studies demonstrating its accuracy, molecular testing has been incorporated as an important diagnostic adjunct in the management of indeterminate thyroid nodules in the National Comprehensive Cancer Network Guidelines as well as in the American Thyroid Association (ATA) and American Association of Endocrine Surgeons (AAES) guidelines. This overview describes the currently available molecular testing platforms and highlights the published data to date on the clinical validity and utility of molecular testing in the contemporary management of thyroid nodules.
Collapse
Affiliation(s)
- Snehal G Patel
- Department of Surgery, Division of General Surgery, Emory University, Atlanta, GA, USA
| | - Sally E Carty
- Department of Surgery, Division of Endocrine Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Andrew J Lee
- Department of Surgery, Division of Surgical Oncology, University of Pittsburgh, Pittsburgh, PA, USA.
| |
Collapse
|
22
|
Zhu CY, Donangelo I, Gupta D, Nguyen DT, Ochoa JE, Yeh MW, Livhits MJ. Outcomes of Indeterminate Thyroid Nodules Managed Nonoperatively after Molecular Testing. J Clin Endocrinol Metab 2021; 106:e1240-e1247. [PMID: 33394039 DOI: 10.1210/clinem/dgaa887] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Indexed: 01/27/2023]
Abstract
CONTEXT Molecular testing to refine the diagnosis of cytologically indeterminate thyroid nodules has become increasingly popular, but data on long-term durability of test results and the rate of delayed operation are limited. OBJECTIVE Determine the delayed rate of surgical resection in indeterminate nodules with benign/negative molecular testing and the risk of false-negative molecular test results. DESIGN Prospective follow-up of the Gene Expression Classifier vs Targeted Next-Generation Sequencing in the Management of Indeterminate Thyroid Nodules randomized controlled trial comparing the diagnostic test performance of Afirma Gene Expression Classifier and ThyroSeq v2. SETTING University of California, Los Angeles. PARTICIPANTS Patients who underwent thyroid biopsy with indeterminate (Bethesda III/IV) cytology (April 2016 to July 2017). INTERVENTION Ultrasound surveillance. MAIN OUTCOME MEASURE False-negative rate of molecular testing. RESULTS Of 95 indeterminate nodules with negative/benign molecular test results, 12 nodules underwent immediate resection (11 benign nodules, 1 noninvasive follicular thyroid neoplasm nodule with papillary-like nuclear features). Nonoperative management was pursued for 83 (87.4%) nodules. The median surveillance was 26.7 months. Ten nodules were resected during surveillance and malignancy was identified in 4 nodules (overall false-negative rate of 5.8%). In the 4 malignant nodules that underwent delayed operation, surgery was prompted by sonographic changes during surveillance. CONCLUSIONS The majority of indeterminate nodules with negative molecular testing have a stable clinical course over 3 years of follow-up, but our finding of a 6% false-negative rate highlights the importance of continuing sonographic surveillance. Long-term studies are needed to determine the optimal length of follow-up.
Collapse
Affiliation(s)
- Catherine Y Zhu
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Ines Donangelo
- Division of Endocrinology, Diabetes, and Metabolism, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Deepashree Gupta
- Division of Endocrinology, Diabetes, and Metabolism, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Dalena T Nguyen
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Joana E Ochoa
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Michael W Yeh
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Masha J Livhits
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| |
Collapse
|
23
|
Yip L, Gooding WE, Nikitski A, Wald AI, Carty SE, Karslioglu-French E, Seethala RR, Zandberg DP, Ferris RL, Nikiforova MN, Nikiforov YE. Risk assessment for distant metastasis in differentiated thyroid cancer using molecular profiling: A matched case-control study. Cancer 2021; 127:1779-1787. [PMID: 33539547 PMCID: PMC8113082 DOI: 10.1002/cncr.33421] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 12/07/2020] [Indexed: 12/16/2022]
Abstract
Background Risk stratification for patients with differentiated thyroid cancer (DTC) is based primarily on pathologic tumor characteristics. Accurate preoperative prognostication could allow for more informed initial surgical recommendations, particularly among patients at a higher risk for distant metastasis (DM). The objective of this study was to characterize the genetic profile of DTC with DM and to validate a molecular‐based risk stratification. Methods A case‐control study design was used to analyze patients who had DTC with DM (n = 62) and a propensity matched cohort of patients who had DTC without DM after at least 5 years of follow‐up using the ThyroSeq version 3 targeted next‐generation sequencing assay. The results were classified into high‐risk, intermediate‐risk, and low‐risk of aggressive disease. Results Most patients who had DTC with DM (66%) had a late‐hit mutation in TERT, TP53, or PIK3CA. After propensity matching by age, tumor size, and sex, the high‐risk molecular profile had strong association with DM (high‐risk vs intermediate‐risk: odds ratio, 25.1; 95% CI, 3.07‐204.4; P < .001; high‐risk vs low‐risk: odds ratio, 122.5; 95% CI, 14.5‐1038.4; P < .001). Overall, molecular risk categories were associated with DM risk, with a concordance index of 0.836 (95% CI, 0.759‐0.913), which remained consistent after internal validation. Within the range of 5% to 10% of DM observed in DTC, the expected probability of DM would be 0.2% to 0.4% for the low‐risk molecular profile, 4.7% to 9.4% for the intermediate‐risk molecular profile, and 19.3% to 33.5% for the high‐risk molecular profile. Conclusions In this matched case‐control study, genetic profiling using an available molecular assay provided accurate and robust risk stratification for DM in patients with DTC. The availability of preoperative prognostication may allow tailoring treatment for patients with DTC. In this matched case‐control study, comprehensive genetic profiling provides accurate and robust risk stratification for distant metastasis in patients with differentiated thyroid cancer. The availability of preoperative prognostication may allow for molecular‐directed treatment recommendations to tailor care for these patients.
Collapse
Affiliation(s)
- Linwah Yip
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - William E Gooding
- Biostatistics Facility, University of Pittsburgh Medical Center Hillman Cancer Center, Pittsburgh, Pennsylvania
| | | | - Abigail I Wald
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sally E Carty
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Esra Karslioglu-French
- Division of Endocrinology and Metabolism, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Raja R Seethala
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Dan P Zandberg
- Department of Medicine, Hillman Cancer Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Robert L Ferris
- Department of Otolaryngology, University of Pittsburgh Medical Center, Hillman Cancer Center, Pittsburgh, Pennsylvania
| | | | - Yuri E Nikiforov
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|