1
|
Verma T, Marshall C, Dantey KE, Thompson DV, Banizs A, Finkelstein SD, DelTondo J. The role of the ThyGeNEXT oncogene panel used in combination with the expanded miRNA panel ThyraMIRv2 in Indeterminate thyroid nodules: A large, blinded, real-world, observational study. Cancer Cytopathol 2024. [PMID: 38814813 DOI: 10.1002/cncy.22829] [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: 07/24/2023] [Revised: 04/06/2024] [Accepted: 04/09/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND Molecular analysis of fine-needle aspiration biopsies (FNAB) improves the diagnostic accuracy of cytologically indeterminate thyroid nodules (ITNs). Recently, the use of MPTXv2 has been shown to further improve the accuracy of risk stratification of ITNs. METHODS A total of 338 patient samples with atypia of undetermined significance (n = 260) or follicular neoplasm (n = 78) cytology diagnosis and corresponding surgical outcomes or clinical follow-up, collected between 2016 and 2020 were included. All samples underwent multiplatform testing (MPTXv1), which includes an oncogene panel (ThyGeNEXT®) plus a microRNA risk classifier (ThyraMIR®). A blinded, secondary analysis was performed to assess the added utility of MPTXv2 (ThyraMIR®v2). The average length of follow-up for the surveillance group (n = 248) was 30 months. RESULTS Sensitivity at moderate threshold was 96% and specificity at positive threshold was 99% for MPTXv2. At 14% disease prevalence, the negative predictive value at the moderate threshold was 99% and the positive predictive value at the positive threshold was 89% for MPTXv2. MPTXv2 had fewer patients classified into the moderate-risk group than MPTXv1, which was statistically significant (p < .001). Using surgical resection, the gold standard for outcomes, MPTXv2 showed a statistically greater area under the curve (p = .028) than MPTXv1, demonstrating greater accuracy for MPTXv2. CONCLUSION Both test versions demonstrated robust performance with low false-positive molecular results. Data suggest that incorporation of MPTXv1, and more recently MPTXv2, into clinical practice within our healthcare network resulted in improved accuracy of ITN risk stratification.
Collapse
Affiliation(s)
- Tanvi Verma
- Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Cody Marshall
- Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | | | | | - Anna Banizs
- Interpace Diagnostics, Inc, Parsipanny, New Jersey, USA
| | | | | |
Collapse
|
2
|
Huang Y, Chan SJ, Wright JD, Kuo JH, McManus CM, Lee JA, Kuo EJ. Does the Adoption of Molecular Testing Cause Decreased Thyroidectomy Rates in a National Cohort? A Quasiexperimental Study of High- Versus Low-Adoption States. Thyroid 2024; 34:388-398. [PMID: 38251649 DOI: 10.1089/thy.2023.0651] [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] [Indexed: 01/23/2024]
Abstract
Background: Over the last decade, the utilization of molecular testing (MT) for the evaluation of thyroid nodules has increased. Rates and patterns of adoption of MT and its effect on thyroidectomy rates nationally are unknown. Varying rates of MT adoption at the state level provide an opportunity to study the effects of MT on thyroidectomy rates using a quasiexperimental study design. Methods: We performed a retrospective analysis of American adult patients in the Merative™ MarketScan® Research Databases who underwent thyroid fine-needle aspiration (FNA) from 2011 to 2021. MT included commercially available DNA and RNA platforms and traditional targeted mutational analysis. Interrupted time series analysis was used to evaluate the inflection of MT adoption and thyroidectomy rates after 2015. Difference-in-differences (DID) analysis was used to causally analyze the effect of MT adoption on thyroidectomy rates in high-adoption (at least a 10% increase in MT utilization) versus low-adoption states (no more than 5% increase in MT utilization) from 2015 to 2021. Results: We identified 471,364 patients who underwent thyroid FNA. The utilization of MT increased over the study period from 0.01% [confidence interval, CI: 0.00% to 0.02%] to 10.1% [CI: 9.7% to 10.5%], in 2021, with an immediate (β2 = 1.61, p = 0.002) and deeper (β3 = 0.6, p < 0.001) increase in MT adoption after 2015. Utilization of MT was lower in black patients, the elderly, rural areas, and patients with Medicaid (p < 0.05). Thyroidectomy rates were inversely correlated with MT utilization (r = -0.98, p < 0.0001). From 2015 to 2021, the average MT utilization rate increased from 2.4% to 15.3% in high-adoption states and 1.6% to 5.6% in low-adoption states. In low-adoption states, thyroidectomy rates decreased more but to similar levels (18.5-13.2%) compared with high-adoption states (15.9-13.4%) with an adjusted DID rate of -3.3% [CI -5.6% to -0.8%]. Conclusions: The acceleration in adoption of MT after 2015 likely coincides with the publication of American Thyroid Association guidelines. Black, elderly, and rural patients are less likely to receive MT. Although thyroidectomy rates were inversely correlated with MT utilization, our study suggests that this correlation is not causal. The effect of MT on thyroidectomy rates may be overshadowed by decreasing aggressiveness of thyroid nodule evaluation.
Collapse
Affiliation(s)
- Yongmei Huang
- Department of Obstetrics and Gynecology, Columbia University, New York, New York, USA
| | - Stephanie J Chan
- Department of Surgery, Division of GI/Endocrine Surgery, Columbia University, New York, New York, USA
| | - Jason D Wright
- Department of Obstetrics and Gynecology, Columbia University, New York, New York, USA
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York, USA
| | - Jennifer H Kuo
- Department of Surgery, Division of GI/Endocrine Surgery, Columbia University, New York, New York, USA
| | - Catherine M McManus
- Department of Surgery, Division of GI/Endocrine Surgery, Columbia University, New York, New York, USA
| | - James A Lee
- Department of Surgery, Division of GI/Endocrine Surgery, Columbia University, New York, New York, USA
| | - Eric J Kuo
- Department of Surgery, Division of GI/Endocrine Surgery, Columbia University, New York, New York, USA
| |
Collapse
|
3
|
Alyusuf EY, Alhmayin L, Albasri E, Enani J, Altuwaijri H, Alsomali N, Arafah MA, Alyusuf Z, Jammah AA, Ekhzaimy AA, Alzahrani AS. Ultrasonographic predictors of thyroid cancer in Bethesda III and IV thyroid nodules. Front Endocrinol (Lausanne) 2024; 15:1326134. [PMID: 38405143 PMCID: PMC10884110 DOI: 10.3389/fendo.2024.1326134] [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] [Received: 10/22/2023] [Accepted: 01/23/2024] [Indexed: 02/27/2024] Open
Abstract
Background Bethesda III and IV thyroid nodules continue to be difficult to manage. Although molecular testing may assist in decision-making, it is expensive, not widely available, and not without pitfalls. The objective of this study is to assess whether certain thyroid ultrasonographic features may predict the risk of thyroid cancer in patients with Bethesda III and IV thyroid nodules and be used as additional decision-making tools to complement cytopathological results in deciding on diagnostic thyroidectomy. Methods We retrospectively evaluated the ultrasonographic features of Bethesda categories III and IV thyroid nodules in patients who underwent subsequent thyroidectomy. We used the final histopathological examination of the surgical specimens as the gold-standard test and analyzed individual preoperative ultrasonographic features as predictors of malignancy. Results Of the 278 patients who were diagnosed with Bethesda III and IV thyroid nodules on fine needle aspiration cytology (FNAC), 111 (39.9%) had thyroid cancer, and 167 (59.9%) exhibited benign nodules. The malignancy rate was higher in patients with Bethesda IV nodules (28/50, 56%) than those with Bethesda III nodules (83/228, 36.4%; p=0.016). In univariate analysis, hypoechogenicity (55.6% in malignant vs. 35.3% in benign, p=0.006) and calcifications (54.5 in malignant vs. 35.4% in benign, p=0.008) were significantly different between the benign and malignant pathology groups, whereas the size of the dominant nodule, number of nodules, irregular borders, taller-than-wide shape, and the presence of lymph nodes were comparable between the two groups. These two ultrasonographic features (hypoechogenicity and calcifications) remained significantly associated with the risk of malignancy in multivariate logistic regression analysis (for hypoechogenicity, p=0.014, odds ratio: 2.1, 95% CI:1.0-3.7 and for calcifications, p=0.019, odds ratio: 1.98, 95% CI:1.12-3.50). The sensitivity, specificity, positive and negative predictive values, and accuracy were 31.5%, 83%, 55.6%,64.7%, and 62.6%, for hypoechogenicity, respectively and 32.4%, 82%, 54.5%, 67.8%, and 62%, for calcification, respectively. Conclusions Hypoechogenicity and calcifications in Bethesda III and IV thyroid nodules are strong predictors of thyroid cancer and associated with a two-fold increased risk of malignancy.
Collapse
Affiliation(s)
- Ebtihal Y. Alyusuf
- Division of Endocrinology, Department of Internal Medicine, College of Medicine, King Saud University, King Saud University Medical City, Riyadh, Saudi Arabia
- Division of Endocrinology, Department of Internal Medicine, Salmanyia Medical Complex, Government Hospitals, Manama, Bahrain
| | - Lama Alhmayin
- Department of Internal Medicine, College of Medicine, King Saud University, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Eman Albasri
- Division of Endocrinology, Department of Internal Medicine, College of Medicine, King Saud University, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Jawaher Enani
- Department of Internal Medicine, College of Medicine, King Saud University, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Hessa Altuwaijri
- Department of Internal Medicine, College of Medicine, King Saud University, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Nora Alsomali
- Department of Internal Medicine, College of Medicine, King Saud University, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Maria A. Arafah
- Department of Pathology, College of Medicine, King Saud University, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Zahra Alyusuf
- Department of Radiology, Salmanyia Medical Complex, Government Hospitals, Manama, Bahrain
| | - Anwar A. Jammah
- Division of Endocrinology, Department of Internal Medicine, College of Medicine, King Saud University, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Aishah A. Ekhzaimy
- Division of Endocrinology, Department of Internal Medicine, College of Medicine, King Saud University, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Ali S. Alzahrani
- Division of Molecular Endocrinology, Department of Molecular Oncology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- Department of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| |
Collapse
|
4
|
Slabaugh G, Beltran L, Rizvi H, Deloukas P, Marouli E. Applications of machine and deep learning to thyroid cytology and histopathology: a review. Front Oncol 2023; 13:958310. [PMID: 38023130 PMCID: PMC10661921 DOI: 10.3389/fonc.2023.958310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 10/12/2023] [Indexed: 12/01/2023] Open
Abstract
This review synthesises past research into how machine and deep learning can improve the cyto- and histopathology processing pipelines for thyroid cancer diagnosis. The current gold-standard preoperative technique of fine-needle aspiration cytology has high interobserver variability, often returns indeterminate samples and cannot reliably identify some pathologies; histopathology analysis addresses these issues to an extent, but it requires surgical resection of the suspicious lesions so cannot influence preoperative decisions. Motivated by these issues, as well as by the chronic shortage of trained pathologists, much research has been conducted into how artificial intelligence could improve current pipelines and reduce the pressure on clinicians. Many past studies have indicated the significant potential of automated image analysis in classifying thyroid lesions, particularly for those of papillary thyroid carcinoma, but these have generally been retrospective, so questions remain about both the practical efficacy of these automated tools and the realities of integrating them into clinical workflows. Furthermore, the nature of thyroid lesion classification is significantly more nuanced in practice than many current studies have addressed, and this, along with the heterogeneous nature of processing pipelines in different laboratories, means that no solution has proven itself robust enough for clinical adoption. There are, therefore, multiple avenues for future research: examine the practical implementation of these algorithms as pathologist decision-support systems; improve interpretability, which is necessary for developing trust with clinicians and regulators; and investigate multiclassification on diverse multicentre datasets, aiming for methods that demonstrate high performance in a process- and equipment-agnostic manner.
Collapse
Affiliation(s)
- Greg Slabaugh
- Digital Environment Research Institute, Queen Mary University of London, London, United Kingdom
| | - Luis Beltran
- Barts Health NHS Trust, The Royal London Hospital, London, United Kingdom
| | - Hasan Rizvi
- Barts Health NHS Trust, The Royal London Hospital, London, United Kingdom
| | - Panos Deloukas
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Eirini Marouli
- Digital Environment Research Institute, Queen Mary University of London, London, United Kingdom
- Barts Health NHS Trust, The Royal London Hospital, London, United Kingdom
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| |
Collapse
|
5
|
Martinez Coconubo D, Levy JJ, Kerr DA, Vaickus LJ, Vidis L, Glass RE, Gutmann EJ, Marotti JD, Liu X. Use of molecular testing results to analyze the overuse of atypia of undetermined significance in thyroid cytology. J Am Soc Cytopathol 2023; 12:451-460. [PMID: 37775434 DOI: 10.1016/j.jasc.2023.09.002] [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: 07/02/2023] [Revised: 08/31/2023] [Accepted: 09/03/2023] [Indexed: 10/01/2023]
Abstract
INTRODUCTION The suggested atypia of undetermined significance (AUS) rate for thyroid fine-needle aspiration biopsies is 10% or less. Prompted by a high institutional AUS rate, we examined using molecular testing results (MTR) as a potential quality metric tool to reduce the AUS rate. We correlated MTR with AUS cytologic findings, surgical pathology follow-up, and individual pathologist AUS rates. MATERIALS AND METHODS Demographic data, cytologic diagnoses, MTR, and surgical pathology diagnoses were retrospectively obtained. MTR were classified as either positive or negative. AUS rates and MTR proportions were compared among pathologists. The cytomorphologic features of 143 AUS cases were assessed and correlated with MTR. RESULTS Between 2017 and 2022, 710 of 3247 thyroid fine-needle aspirations were classified as AUS, with a yearly average rate of 22% (range = 19%-26%). AUS cases included: 331 (47%) with architectural atypia; 204 (29%) with oncocytic (Hürthle cell) atypia; 99 (14%) with combined architectural and cytologic atypia; and 76 (10%) with isolated cytologic atypia. Most AUS cases with molecular testing had negative MTR (360/492, 73%). AUS with cytologic atypia had higher positive MTR risk (logarithm of odds ratio = 1.27, 95% credible interval [0.5-2.04], P = 0.001). The average positive MTR rate by pathologist was 21.5% (range 0%-35%); higher positive MTR rates had better correlation with subsequent neoplastic/malignant histologic diagnoses. The MTR sensitivity for malignant disease was 89% and the negative predictive value was 91%. CONCLUSIONS MTR analysis reveals the importance of cytologic atypia as a determinant of malignancy risk in AUS cases. Periodic analysis of MTR data alongside individual pathologist AUS rates can help refine diagnostic criteria and potentially reduce AUS overuse.
Collapse
Affiliation(s)
- Daniel Martinez Coconubo
- Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire.
| | - Joshua J Levy
- Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire; Departments of Quantitative Biomedical Sciences, Dermatology and Epidemiology, Geisel School of Medicine, Hanover, New Hampshire
| | - Darcy A Kerr
- Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Louis J Vaickus
- Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Laura Vidis
- Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Ryan E Glass
- Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Edward J Gutmann
- Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Jonathan D Marotti
- Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Xiaoying Liu
- Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| |
Collapse
|
6
|
McMurtry V, Canberk S, Deftereos G. Molecular testing in fine-needle aspiration of thyroid nodules. Diagn Cytopathol 2023; 51:36-50. [PMID: 36480743 DOI: 10.1002/dc.25035] [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] [Received: 06/01/2022] [Revised: 07/20/2022] [Accepted: 07/22/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Thyroid nodules are commonly faced by clinicians as palpable nodules or incidentally identified on imaging. Nodules that are found to be suspicious by imaging can be biopsied by fine needle aspiration, which can yield material for molecular testing to refine the diagnosis. METHODS The current literature concerning molecular testing in thyroid nodules including available commercial assays was reviewed and summarized. RESULTS/CONCLUSIONS Commonly encountered alterations include mutations in RAS, BRAF, TERT promoter, PTEN, and DICER1 as well as fusions of RET, ALK, PAX8-PPARγ, and NTRK. This article provides a summary of these molecular alterations, commercially available molecular assays, and general considerations for thyroid epithelial malignancies and benign thyroid nodules.
Collapse
Affiliation(s)
- Valarie McMurtry
- Department of Pathology, University of Utah, Salt Lake City, Utah, USA.,ARUP Institute for Experimental Pathology, Salt Lake City, Utah, USA
| | - Sule Canberk
- Instituto de Investigação e Inovação em Saúde (i3S), University of Porto, Porto, Portugal.,Institute of Molecular Pathology and Immunology of the University of Porto (Ipatimup), Porto, Portugal.,Abel Salazar Biomedical Sciences Institute (ICBAS), University of Porto, Porto, Portugal
| | - Georgios Deftereos
- Department of Pathology, University of Utah, Salt Lake City, Utah, USA.,ARUP Institute for Experimental Pathology, Salt Lake City, Utah, USA
| |
Collapse
|
7
|
Dharampal N, Smith K, Harvey A, Paschke R, Rudmik L, Chandarana S. Cost-effectiveness analysis of molecular testing for cytologically indeterminate thyroid nodules. J Otolaryngol Head Neck Surg 2022; 51:46. [PMID: 36544210 PMCID: PMC9773581 DOI: 10.1186/s40463-022-00604-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 10/21/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Thyroid nodules affect up to 65% of the population. Although fine needle aspirate (FNA) cytology is the gold standard for diagnosis, 15-30% of results are indeterminate. Molecular testing may aid in the diagnosis of nodules and potentially reduce unnecessary surgery. However, these tests are associated with significant costs. The objective of this study was to evaluate the cost-effectiveness of Afirma, a commercially available molecular test, in cytologically indeterminate thyroid nodules. METHODS The base case was a solitary thyroid nodule with no additional high-risk features and an indeterminate FNA. Decision tree analysis was performed from the single payer perspective with a 1-year time horizon. Costing data were collected through micro-costing methodology. A probabilistic sensitivity analysis was performed. The primary outcome was the incremental cost effectiveness ratio (ICER) of cost per thyroid surgery avoided. RESULTS Over 1 year, mean cost estimates were $8176.28 with 0.58 effectiveness for the molecular testing strategy and $6016.83 with 0.07 effectiveness for current standard management. The ICER was $4234.22 per surgery avoided. At a willingness-to-pay (WTP) threshold of $5000 per surgery avoided, molecular testing is cost-effective with 63% certainty. CONCLUSION This cost-effectiveness analysis suggests utilizing Afirma for indeterminate solitary thyroid nodules is a cost-effective strategy for avoiding unnecessary thyroid surgery. With a $5000 WTP threshold, molecular testing has a 63% chance of being the more cost-effective strategy. The cost effectiveness varies based on the cost of the molecular test and the value of Afirma for patients with indeterminate thyroid nodules depends on the WTP threshold to avoid unnecessary thyroid surgery.
Collapse
Affiliation(s)
- Navjit Dharampal
- grid.415290.b0000 0004 0465 4685Section of Thoracic Surgery, Providence Cancer Institute, Portland, USA
| | - Kristine Smith
- grid.223827.e0000 0001 2193 0096Department of Otolaryngology, University of Utah, Salt Lake City, USA
| | - Adrian Harvey
- grid.22072.350000 0004 1936 7697Section of General Surgery, Department of Surgery, University of Calgary, Calgary, Canada ,grid.22072.350000 0004 1936 7697Section of Surgical Oncology, Department of Oncology, University of Calgary, Calgary, Canada
| | - Ralf Paschke
- grid.22072.350000 0004 1936 7697Division of Endocrinology, University of Calgary, Calgary, Canada
| | - Luke Rudmik
- grid.22072.350000 0004 1936 7697Section of Otolaryngology, Department of Surgery, University of Calgary, Foothills Medical Centre, North Tower Rm 1012, 1403 29 St NW, Calgary, AB T2N2T9 Canada
| | - Shamir Chandarana
- grid.22072.350000 0004 1936 7697Section of Otolaryngology, Department of Surgery, University of Calgary, Foothills Medical Centre, North Tower Rm 1012, 1403 29 St NW, Calgary, AB T2N2T9 Canada ,grid.22072.350000 0004 1936 7697Section of Surgical Oncology, Department of Oncology, University of Calgary, Calgary, Canada
| |
Collapse
|
8
|
Cipriani NA, Johnson DN, Sarne DH, Angelos P, Reeves W, Antic T. The Significance of RAS-Like Mutations and MicroRNA Profiling in Predicting Malignancy in Thyroid Biopsy Specimens. Endocr Pathol 2022; 33:446-456. [PMID: 36227454 DOI: 10.1007/s12022-022-09734-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/07/2022] [Indexed: 11/03/2022]
Abstract
In cytologically indeterminate thyroid nodules undergoing molecular testing, estimated risk of malignancy is variable. Identification of a non-cancer-specific mutation (RAS-like) confirms a neoplastic process but does not differentiate between benign, malignant, and low-risk neoplasms. This study aims to retrospectively evaluate institutional experience of Interpace (ThyGeNEXT® and ThyraMIR®; Pittsburgh, PA) testing and to determine the rate of malignancy in resected nodules, stratified by mutational analysis and microRNA profile. Of 1917 fine need aspirations, 140 (7.3%) underwent Interpace testing: 47 (33.6%) were molecular-not-benign (harbored mutation, fusion, and/or positive miRNA) and 93 (66.4%) were molecular-benign (no mutations or fusions and negative microRNA). Surgery was spared in 79.6% of molecular-benign and 61.4% of all tested patients. Fifty-four (38.6%) underwent resection. Seventeen (89.5%) of the resected molecular-benign were benign and 2 were malignant. Thirteen (37.1%) of the resected molecular-not-benign were benign, 7 (20%) were noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP), and 15 (42.9%) were malignant (p < 0.05, negative predictive value (NPV) 89.4-95.6%, positive predictive value (PPV) 22.3-42.8%). Most molecular-not-benign (72.3%) had RAS-like mutation. Twenty-three were resected: 3 were malignant and 7 were NIFTP. Nodules with non-RAS-like mutations (BRAF V600E-like, others) were more likely to be malignant than RAS-like (H/N/KRAS, BRAF K601E) (p < 0.05, NPV 86.9-96.5%, PPV 100%). Most nodules had RAS-like mutations and most were benign or low-risk neoplasms (NIFTP). This study supports the role of histologic examination in the distinction of malignancy in RAS-like thyroid neoplasms and underscores the role of molecular testing in risk stratification, patient counseling, and operative management.
Collapse
Affiliation(s)
- Nicole A Cipriani
- Department of Pathology, The University of Chicago, 5841 S. Maryland Ave., MC 6101, Chicago, IL, 60637, USA.
| | | | - David H Sarne
- Department of Medicine, Section of Endocrinology, Diabetes and Metabolism, The University of Chicago, Chicago, IL, USA
| | - Peter Angelos
- Department of Surgery, Section of Endocrine Surgery, The University of Chicago, Chicago, IL, USA
| | - Ward Reeves
- Department of Pathology, The University of Chicago, 5841 S. Maryland Ave., MC 6101, Chicago, IL, 60637, USA
| | - Tatjana Antic
- Department of Pathology, The University of Chicago, 5841 S. Maryland Ave., MC 6101, Chicago, IL, 60637, USA
| |
Collapse
|
9
|
Hu TX, Nguyen DT, Patel M, Beckett K, Douek M, Masamed R, Rhyu J, Kim J, Tseng CH, Yeh MW, Livhits MJ. The Effect Modification of Ultrasound Risk Classification on Molecular Testing in Predicting the Risk of Malignancy in Cytologically Indeterminate Thyroid Nodules. Thyroid 2022; 32:905-916. [PMID: 35611970 DOI: 10.1089/thy.2021.0659] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background: Thyroid nodules with indeterminate cytology are increasingly subjected to molecular testing. We evaluated the diagnostic performances of Afirma Genomic Sequencing Classifier (GSC) and ThyroSeq v3 in thyroid nodules with high versus low/intermediate suspicion ultrasound classification. Methods: In this prospective cohort study, we analyzed all Bethesda III and IV thyroid nodules that underwent fine-needle aspiration biopsies in the University of California Los Angeles Health System from July 2017 to April 2020. All patients underwent molecular testing with Afirma GSC or ThyroSeq v3 as part of an institutional randomized trial (NCT02681328). Nodules were categorized according to the American Thyroid Association (ATA) ultrasound risk classification. The benign call rate and the positive predictive value of molecular testing were compared between ATA high suspicion versus all other categories. Results: A total of 343 patients with 375 indeterminate thyroid nodules were included. The malignancy rate in ATA high suspicion nodules was not significantly increased by a suspicious Afirma GSC result (77.8% for all ATA high suspicion nodules vs. 87.5% for nodules with ATA high suspicion and suspicious Afirma GSC results, positive likelihood ratio [LR] = 2.0, 95% confidence interval [CI 0.5-8.0], p = 1.0) or by a positive ThyroSeq v3 result (80.0% vs. 80.0%, positive LR = 1.0 [CI 1.0-1.0], p = 1.0). The rate of malignancy in ATA low/intermediate suspicion nodules increased from 21.0% to 56.3% with a suspicious Afirma GSC result (positive LR = 4.8 [CI 3.4-6.9], p < 0.0001) and decreased to 3.8% with a benign Afirma GSC result (negative LR = 0.1 [CI 0.07-0.3], p < 0.0001). Similarly, the rate of malignancy in ATA low/intermediate suspicion nodules increased from 24.3% to 66.7% with a positive ThyroSeq v3 result (positive LR = 6.2 [CI 4.0-9.7], p < 0.0001) and decreased to 2.1% with a negative ThyroSeq v3 result (negative LR = 0.07 [CI 0.02-0.3], p < 0.0001). Conclusions: Afirma GSC and ThyroSeq v3 performed well in ruling out malignancy in sonographically low/intermediate suspicion thyroid nodules but has limited diagnostic value in sonographically high suspicion nodules. Molecular testing can prognosticate more aggressive thyroid cancers, which can inform treatment decisions.
Collapse
Affiliation(s)
- Theodore X Hu
- Section of Endocrine Surgery, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California, USA
| | - Dalena T Nguyen
- Section of Endocrine Surgery, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California, USA
| | - Maitraya Patel
- Department of Radiology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California, USA
| | - Katrina Beckett
- Department of Radiology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California, USA
| | - Michael Douek
- Department of Radiology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California, USA
| | - Rinat Masamed
- Department of Radiology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California, USA
| | - Jane Rhyu
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California, USA
| | - Jiyoon Kim
- Department of Biostatistics, Fielding School of Public Health at University of California Los Angeles, Los Angeles, California, USA
| | - Chi-Hong Tseng
- Department of Medicine, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California, USA
| | - Michael W Yeh
- Section of Endocrine Surgery, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California, USA
| | - Masha J Livhits
- Section of Endocrine Surgery, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California, USA
| |
Collapse
|
10
|
FDG-PET/CT in indeterminate thyroid nodules: cost-utility analysis alongside a randomised controlled trial. Eur J Nucl Med Mol Imaging 2022; 49:3452-3469. [PMID: 35435497 PMCID: PMC9308600 DOI: 10.1007/s00259-022-05794-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 04/03/2022] [Indexed: 11/04/2022]
Abstract
PURPOSE To evaluate cost-effectiveness of an [18F]FDG-PET/CT-driven diagnostic workup as compared to diagnostic surgery, for thyroid nodules with Bethesda III/IV cytology. [18F]FDG-PET/CT avoids 40% of futile diagnostic surgeries for benign Bethesda III/IV nodules. METHODS Lifelong societal costs and quality-adjusted life years (QALYs) were assessed for 132 patients participating in a randomised controlled multicentre trial comparing [18F]FDG-PET/CT to diagnostic surgery. The observed 1-year trial results were extrapolated using a Markov model. The probability of cost-effectiveness was estimated using cost-effectiveness acceptability curves, taking uncertainty about sampling, imputation, and parameters into account. RESULTS The observed 1-year cost difference of [18F]FDG-PET/CT as compared to diagnostic surgery was - €1000 (95% CI: - €2100 to €0) for thyroid nodule-related care (p = 0.06). From the broader societal perspective, the 1-year difference in total societal costs was - €4500 (- €9200 to €150) (p = 0.06). Over the modelled lifelong period, the cost difference was - €9900 (- €23,100 to €3200) (p = 0.14). The difference in QALYs was 0.019 (- 0.045 to 0.083) at 1 year (p = 0.57) and 0.402 (- 0.581 to 1.385) over the lifelong period (p = 0.42). For a willingness to pay of €50,000 per QALY, an [18F]FDG-PET/CT-driven work-up was the cost-effective strategy with 84% certainty. CONCLUSION Following the observed reduction in diagnostic surgery, an [18F]FDG-PET/CT-driven diagnostic workup reduced the 1-year thyroid nodule-related and societal costs while sustaining quality of life. It is very likely cost-effective as compared to diagnostic surgery for Bethesda III/IV nodules. TRIAL REGISTRATION NUMBER This trial is registered with ClinicalTrials.gov: NCT02208544 (5 August 2014), https://clinicaltrials.gov/ct2/show/NCT02208544 .
Collapse
|
11
|
Rossi ED, Locantore P, Bruno C, Dell’Aquila M, Tralongo P, Curatolo M, Revelli L, Raffaelli M, Larocca LM, Pantanowitz L, Pontecorvi A. Molecular Characterization of Thyroid Follicular Lesions in the Era of "Next-Generation" Techniques. Front Endocrinol (Lausanne) 2022; 13:834456. [PMID: 35634500 PMCID: PMC9134849 DOI: 10.3389/fendo.2022.834456] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 03/29/2022] [Indexed: 12/26/2022] Open
Abstract
It is unequivocally recognized that thyroid nodules are frequently detected in the adult population and mostly characterized by benign lesions (up to 70% of them), with only 5%-15% malignant lesions. The evaluation of thyroid lesions with fine-needle aspiration cytology (FNAC) represents one of the first and most useful diagnostic tools in the definition of their nature. Despite the fact that the majority of thyroid lesions are correctly diagnosed as either benign (70%-75%) or malignant (5%-10%) entities, the remaining nodules (20%-25%) represent the "gray zone" of follicular lesions, which belong to indeterminate categories, according to the different classification systems. This indeterminate group of lesions includes both benign and malignant entities, which cannot be easily discriminate with morphology alone. In these last decades, the increasing role of molecular testings, feasibly performed on cytological material combined with the discoveries of specific genetic alterations in the field of thyroid pathology, has opened the pace to their more accurate and specific contribution on cytology. In fact, in 2015, in the revised management guidelines for patients with thyroid nodules and well-differentiated thyroid cancers (WDTCs), the American Thyroid Association (ATA) confirmed the performance of molecular testing in thyroid indeterminate cytology, and the same performance was addressed in recent update of the management of thyroid nodules in the second edition of the Bethesda system for reporting thyroid cytopathology (TBSRTC). In the current review, we discuss the role of molecular tests for the different thyroid diagnostic categories of the Bethesda system for reporting thyroid cytopathology, mostly focusing our attention on the follicular and indeterminate lesions.
Collapse
Affiliation(s)
- Esther Diana Rossi
- Division of Anatomic Pathology and Histology, Fondazione Policlinico Universitario “Agostino Gemelli” - IRCCS, Rome, Italy
- *Correspondence: Esther Diana Rossi,
| | - Pietro Locantore
- Division of Endocrinology, Fondazione Policlinico Universitario “Agostino Gemelli” - IRCCS, Rome, Italy
| | - Carmine Bruno
- Division of Endocrinology, Fondazione Policlinico Universitario “Agostino Gemelli” - IRCCS, Rome, Italy
| | - Marco Dell’Aquila
- Division of Anatomic Pathology and Histology, Fondazione Policlinico Universitario “Agostino Gemelli” - IRCCS, Rome, Italy
| | - Pietro Tralongo
- Division of Anatomic Pathology and Histology, Fondazione Policlinico Universitario “Agostino Gemelli” - IRCCS, Rome, Italy
| | - Mariangela Curatolo
- Division of Anatomic Pathology and Histology, Fondazione Policlinico Universitario “Agostino Gemelli” - IRCCS, Rome, Italy
| | - Luca Revelli
- Division of Endocrine Surgery, Fondazione Policlinico Universitario “Agostino Gemelli”- IRCCS, Rome, Italy
| | - Marco Raffaelli
- Division of Endocrine Surgery, Fondazione Policlinico Universitario “Agostino Gemelli”- IRCCS, Rome, Italy
| | - Luigi Maria Larocca
- Division of Anatomic Pathology and Histology, Fondazione Policlinico Universitario “Agostino Gemelli” - IRCCS, Rome, Italy
| | - Liron Pantanowitz
- Department of Pathology, University of Michigan, Ann Arbor, MI, United States
| | - Alfredo Pontecorvi
- Division of Endocrinology, Fondazione Policlinico Universitario “Agostino Gemelli” - IRCCS, Rome, Italy
| |
Collapse
|
12
|
Lynch CA, Bethi M, Tang A, Lee P, Steward D, Holm TM. Thyroid nodules >4 cm with atypia of undetermined significance cytology independently associate with malignant pathology. Surgery 2021; 171:725-730. [PMID: 34742567 DOI: 10.1016/j.surg.2021.08.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 08/10/2021] [Accepted: 08/12/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND The risk of malignancy from nodules with atypia of undetermined significance cytology is estimated between 5% and 15%, though more recent studies suggest rates upwards of 48%. This study sought to characterize preoperative predictors of malignancy to aid in clinical decision-making. METHODS We performed a single institution retrospective review of all adult patients with unilateral thyroid nodules demonstrating atypia of undetermined significance cytology between March 1, 2013 and June 1, 2019 who underwent surgical resection (n = 266). Univariate and multivariate logistical analysis was performed using clinical and demographic variables to identify potential preoperative characteristics associated with malignant disease. RESULTS Malignancy was identified on final pathology in 24.7% of patients with atypia of undetermined significance cytology. Age, sex, exposure to ionizing radiation, family history of thyroid cancer, Hashimoto's disease, Afirma suspicious results, and smoking were not associated with malignancy on both univariate and multivariate analysis. Nodule size >4 cm was independently associated with malignancy risk on both univariate (odds ratio 2.44, 1.09-5.43, P < .03) and multivariate (odds ratio 2.96, 1.27-6.87, P < .02) analysis. CONCLUSION The results of this study demonstrate that nodules with atypia of undetermined significance cytology >4 cm are strongly associated with malignancy. We recommend strong consideration of surgery for all patients with thyroid nodules >4 cm and atypia of undetermined significance cytology.
Collapse
Affiliation(s)
- Caroline A Lynch
- The University of Cincinnati College of Medicine, Cincinnati, OH
| | - Mridula Bethi
- The University of Cincinnati College of Medicine, Cincinnati, OH
| | - Alice Tang
- The University of Cincinnati, Department of Otolaryngology-Head and Neck Surgery, Cincinnati, OH
| | - Paul Lee
- The University of Cincinnati, Department of Pathology, Cincinnati, OH
| | - David Steward
- The University of Cincinnati, Department of Otolaryngology-Head and Neck Surgery, Cincinnati, OH
| | - Tammy M Holm
- The University of Cincinnati College of Medicine, Cincinnati, OH; The University of Cincinnati, Department of Surgery, Cincinnati, OH.
| |
Collapse
|
13
|
Hu QL, Schumm MA, Zanocco KA, Yeh MW, Livhits MJ, Wu JX. Cost analysis of reflexive versus selective molecular testing for indeterminate thyroid nodules. Surgery 2021; 171:147-154. [PMID: 34284895 DOI: 10.1016/j.surg.2021.04.050] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/19/2021] [Accepted: 04/23/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Molecular testing is now commonly used to refine the diagnosis of indeterminate thyroid nodules. The purpose of this study is to compare the costs of a reflexive molecular testing strategy to a selective testing strategy for indeterminate thyroid nodules. METHODS A Markov model was constructed to estimate the annual cost of diagnosis and treatment of a real-world cohort of patients with cytologically indeterminate thyroid nodules, comparing a reflexive testing strategy to a selective testing strategy. Model variables were abstracted from institutional clinical trial data, literature review, and the Medicare physician fee schedule. RESULTS The average cost per patient in the reflexive testing strategy was $8,045, compared with $6,090 in the selective testing strategy. In 10,000 Monte Carlo simulations, diagnostic thyroid lobectomy for benign nodules was performed in 2,440 patients in the reflexive testing arm, compared with 3,389 patients in the selective testing arm, and unintentional observation for malignant nodules occurred in 479 patients in the reflexive testing arm, compared with 772 patients in the selective testing arm. The cost of molecular testing had the greatest impact on overall costs, with $1,050 representing the cost below which the reflexive testing strategy was cost saving compared with the selective testing strategy. CONCLUSION In this cost-modeling study, reflexive molecular testing for indeterminate thyroid nodules enabled patients to avoid unnecessary thyroid lobectomy at an estimated cost of $20,600 per surgery avoided.
Collapse
Affiliation(s)
- Q Lina Hu
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA.
| | - Max A Schumm
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA. https://twitter.com/@MSchumm90
| | - Kyle A Zanocco
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA. https://twitter.com/@KyleZanocco
| | - Michael W Yeh
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA. https://twitter.com/@michaelyehmd
| | - Masha J Livhits
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA. https://twitter.com/@MashaLivhitsMD
| | - James X Wu
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA. https://twitter.com/@JamesWuMD
| |
Collapse
|
14
|
Abstract
OBJECTIVES To assessed the current practices for the management of thyroid nodules in the Gulf Cooperation Council (GCC) countries. Methods: We conducted a descriptive web-based survey to physicians and surgeons involved in the management of thyroid nodules. The survey included questions on referral, ultrasound (US) reporting, fine needle aspiration (FNA), management of thyroid nodules including the approach for indeterminate FNA results, and usage of molecular testing. Results: A total of 311 responders, 155 (49.8%) were endocrinologists. Results showed that referrals and US report lack a number of valuable information including family history (84.9%) and high-risk US features (92.9%). Approximately 263 (84.6%) preferred to include a scoring system or protocol to assess the nodule risk in US report. Approximately 193 (62.1%) sent the patient to interventional radiologists for FNA. Almost half (n=147, 47.3%) repeat the FNA in 2-3 months if the FNA result was a follicular lesion or atypia of undetermined significance and 142 (45.7%) opted for lobectomy for follicular neoplasm or suspicious of follicular neoplasm result. Only 44 (14.1%) performed molecular testing; however, 174 (55.9%) preferred it available. Significant variations in the approach were seen between endocrinologists versus non-endocrinologists. Conclusion: Practices variation in the management of thyroid nodules mandate a common practical guideline. Molecular testing is a preferable test for indeterminate FNA results by most of the responders though it is not widely available.
Collapse
Affiliation(s)
- Anwar A Jammah
- Division of Endocrinology, Department of Medicine, King Saud University Medical City, King Saud University, Riyadh, Kingdom of Saudi Arabia. E-mail.
| |
Collapse
|
15
|
Van Den Heede K, Tolley NS, Di Marco AN, Palazzo FF. Differentiated Thyroid Cancer: A Health Economic Review. Cancers (Basel) 2021; 13:cancers13092253. [PMID: 34067214 PMCID: PMC8125846 DOI: 10.3390/cancers13092253] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 05/03/2021] [Accepted: 05/05/2021] [Indexed: 12/22/2022] Open
Abstract
Simple Summary This review reflects on health economic considerations associated with the increasing diagnosis and treatment of differentiated thyroid cancer. Analysis of different relevant health economic topics, such as overdiagnosis, overtreatment, surgical costs, and costs of follow-up are being addressed. Several unanswered research questions such as optimising molecular markers for diagnosis, active surveillance of primary tumours, and improved risk stratification and survivorship care all influence future healthcare expenditures. Abstract The incidence of differentiated thyroid cancer (DTC) is rising, mainly because of an increased detection of asymptomatic thyroid nodularity revealed by the liberal use of thyroid ultrasound. This review aims to reflect on the health economic considerations associated with the increasing diagnosis and treatment of DTC. Overdiagnosis and the resulting overtreatment have led to more surgical procedures, increasing health care and patients’ costs, and a large pool of community-dwelling thyroid cancer follow-up patients. Additionally, the cost of thyroid surgery seems to increase year on year even when inflation is taken into account. The increased healthcare costs and spending have placed significant pressure to identify potential factors associated with these increased costs. Some truly ground-breaking work in health economics has been undertaken, but more cost-effectiveness studies and micro-cost analyses are required to evaluate expenses and guide future solutions.
Collapse
Affiliation(s)
- Klaas Van Den Heede
- Department of Endocrine & Thyroid Surgery, Hammersmith Hospital, London W12 0HS, UK; (N.S.T.); (A.N.D.M.); (F.F.P.)
- Department of General and Endocrine Surgery, OLV Hospital, 9300 Aalst, Belgium
- Correspondence:
| | - Neil S. Tolley
- Department of Endocrine & Thyroid Surgery, Hammersmith Hospital, London W12 0HS, UK; (N.S.T.); (A.N.D.M.); (F.F.P.)
- Department of Surgery and Cancer, Imperial College, London SW7 2AZ, UK
| | - Aimee N. Di Marco
- Department of Endocrine & Thyroid Surgery, Hammersmith Hospital, London W12 0HS, UK; (N.S.T.); (A.N.D.M.); (F.F.P.)
- Department of Surgery and Cancer, Imperial College, London SW7 2AZ, UK
| | - Fausto F. Palazzo
- Department of Endocrine & Thyroid Surgery, Hammersmith Hospital, London W12 0HS, UK; (N.S.T.); (A.N.D.M.); (F.F.P.)
- Department of Surgery and Cancer, Imperial College, London SW7 2AZ, UK
| |
Collapse
|
16
|
Bakker L, Aarts J, Uyl-de Groot C, Redekop W. Economic evaluations of big data analytics for clinical decision-making: a scoping review. J Am Med Inform Assoc 2021; 27:1466-1475. [PMID: 32642750 PMCID: PMC7526472 DOI: 10.1093/jamia/ocaa102] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 04/06/2020] [Accepted: 05/11/2020] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE Much has been invested in big data analytics to improve health and reduce costs. However, it is unknown whether these investments have achieved the desired goals. We performed a scoping review to determine the health and economic impact of big data analytics for clinical decision-making. MATERIALS AND METHODS We searched Medline, Embase, Web of Science and the National Health Services Economic Evaluations Database for relevant articles. We included peer-reviewed papers that report the health economic impact of analytics that assist clinical decision-making. We extracted the economic methods and estimated impact and also assessed the quality of the methods used. In addition, we estimated how many studies assessed "big data analytics" based on a broad definition of this term. RESULTS The search yielded 12 133 papers but only 71 studies fulfilled all eligibility criteria. Only a few papers were full economic evaluations; many were performed during development. Papers frequently reported savings for healthcare payers but only 20% also included costs of analytics. Twenty studies examined "big data analytics" and only 7 reported both cost-savings and better outcomes. DISCUSSION The promised potential of big data is not yet reflected in the literature, partly since only a few full and properly performed economic evaluations have been published. This and the lack of a clear definition of "big data" limit policy makers and healthcare professionals from determining which big data initiatives are worth implementing.
Collapse
Affiliation(s)
- Lytske Bakker
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, Netherlands.,Institute for Medical Technology Assessment, Erasmus University, Rotterdam, Netherlands
| | - Jos Aarts
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, Netherlands
| | - Carin Uyl-de Groot
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, Netherlands.,Institute for Medical Technology Assessment, Erasmus University, Rotterdam, Netherlands
| | - William Redekop
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, Netherlands.,Institute for Medical Technology Assessment, Erasmus University, Rotterdam, Netherlands
| |
Collapse
|
17
|
Thyroid and Molecular Testing. Advances in Thyroid Molecular Cytopathology. JOURNAL OF MOLECULAR PATHOLOGY 2021. [DOI: 10.3390/jmp2020008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Thyroid nodules are a common finding in the adult population including the fact that more than 50% of individuals, over the age of 60, have thyroid nodules. The majority have been mostly detected with ultrasonography and 10% by palpation. The majority of these nodules are benign, whereas 5–15% of them are malignant. The pre-operative diagnosis of cancer is a critical challenge in order to ensure that each patient can be treated with the best tailored management with a reduction of unnecessary surgery for benign lesions. Fine needle aspiration cytology (FNAC) represents the first and most important diagnostic tool for the evaluation of thyroid lesions. According to the literature, FNAC is able to render a conclusive diagnosis in up to 70–80% of all cases. For the remaining 20–30% of nodules, cytological diagnoses fall into the category of indeterminate lesions mostly due to the lack of specific morphological features. According to the Bethesda system for reporting thyroid cytopathology (TBSRTC), indeterminate lesions can be sub-stratified into three different subcategories including “atypia of undetermined significance/follicular lesion of undetermined significance-AUS/FLUS”; “follicular or Hürthle cell neoplasm/suspicious for follicular or Hürthle cell neoplasm-FN/SFN”; and “suspicious for malignancy-SFM”. Many of these indeterminate lesions undergo repetition or diagnostic lobectomy. Nonetheless, the majority of these cases will have a benign diagnosis due to the fact that the rate of cancer ranges between 6 and 30%. It stands to reason that the application of ancillary technique, mostly molecular testing, emerged as a critical additional tool for those thyroid indeterminate lesions. Since the early 1990s, material collected from cytological samples yields sufficient and adequate cells for the detection of point mutation or gene fusions. Nonetheless, the further availability of new sequencing technologies such as next-generation sequencing (NGS) has led to more comprehensive molecular applications adopted now in clinical use. The current review investigates the multiple advances in the field of molecular testing applied in thyroid cytology.
Collapse
|
18
|
Zanocco KA, Wang MM, Yeh MW, Livhits MJ. Selective use of Molecular Testing Based on Sonographic Features of Cytologically Indeterminate Thyroid Nodules: A Decision Analysis. World J Surg 2020; 44:393-401. [PMID: 31538250 DOI: 10.1007/s00268-019-05177-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Molecular diagnostics can allow some patients with indeterminate thyroid nodule cytopathology to avoid diagnostic hemithyroidectomy; however, the testing is costly. We hypothesized that molecular testing with the intention of preventing unnecessary diagnostic hemithyroidectomy would be cost-effective if this test was applied selectively based on sonographic risk of malignancy. METHODS A Markov model was constructed depicting a 40-year-old patient with a cytologically indeterminate thyroid nodule. Molecular testing of fine needle aspiration material was compared to a strategy of immediate diagnostic hemithyroidectomy. Data from a single tertiary-referral health system were reviewed to estimate the outcomes of molecular testing of indeterminate nodules stratified by the American Thyroid Association sonographic classification system. Other outcome probabilities and their utilities were derived from literature review. Costs were estimated with Medicare reimbursement data. A $100,000/QALY threshold for cost-effectiveness was applied. Sensitivity analysis was employed to examine uncertainty in the model's assumptions. RESULTS Of 123 patients who underwent molecular testing for indeterminate cytology, 12 (9.8%) were classified as high sonographic suspicion, 49 (40%) were intermediate suspicion, and 62 (50%) were low or very low suspicion. Molecular testing was only cost-effective when the pretest probability of a negative test was greater than 31%. The model was most sensitive to the cost of molecular testing and the quality adjustment factor for hypothyroidism. CONCLUSIONS In hypothetical modeling, molecular testing is only cost-effective for cytologically indeterminate thyroid nodules with sonographic features that are intermediate or low suspicion for malignancy. In nodules with high sonographic suspicion, molecular testing is rarely negative and appears to add minimal value.
Collapse
Affiliation(s)
- Kyle A Zanocco
- Section of Endocrine Surgery, David Geffen School of Medicine at UCLA, 108333 Le Conte Ave., 72-222 CHS, Los Angeles, CA, 90095, USA.
| | - Max M Wang
- Section of Endocrine Surgery, David Geffen School of Medicine at UCLA, 108333 Le Conte Ave., 72-222 CHS, Los Angeles, CA, 90095, USA
| | - Michael W Yeh
- Section of Endocrine Surgery, David Geffen School of Medicine at UCLA, 108333 Le Conte Ave., 72-222 CHS, Los Angeles, CA, 90095, USA
| | - Masha J Livhits
- Section of Endocrine Surgery, David Geffen School of Medicine at UCLA, 108333 Le Conte Ave., 72-222 CHS, Los Angeles, CA, 90095, USA
| |
Collapse
|
19
|
Fazeli SR, Zehr B, Amraei R, Toraldo G, Guan H, Kindelberger D, Lee S, Cerda S. ThyroSeq v2 Testing: Impact on Cytologic Diagnosis, Management, and Cost of Care in Patients with Thyroid Nodule. Thyroid 2020; 30:1528-1534. [PMID: 32349630 DOI: 10.1089/thy.2019.0191] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Background: Novel molecular tests (MTs), such as ThyroSeq, may improve the management of thyroid nodules with indeterminate cytologic diagnoses; however, the impact of these tests on cost and outcome of management is unknown. Here, we evaluated the impact of ThyroSeq testing on the cytopathologic diagnosis, management, and cost of care in patients with thyroid nodules. Methods: In a retrospective study, using actual patient cohorts, the outcome and cost of management of patients with thyroid nodules seen before the introduction of ThyroSeq v2 at our institution (standard of care [StC] cohort) were compared with those seen after the introduction of this test (MT cohort). Results: A total of 773 consecutive patients entered the study (393 StC, 380 MT). The incidence of cytologically benign nodules decreased from 71.0% (StC) to 53.2% (MT) and those of atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS) and follicular neoplasm/suspicious for follicular neoplasm (FN/SFN) increased from 8.9% (StC) to 21.3% (MT) and from 3.1% (StC) to 6.3% (MT), respectively. The overall rate of surgery did not change significantly (23.4% in StC vs. 23.2% in MT). Among patients who underwent surgery, the rate of overtreatment (surgeries performed on histologic benign nodules without clinical indication: compressive symptoms, hyperthyroidism resistant to medication, and nodule size >4 cm) slightly decreased from 18.8% (StC) to 16.7% (MT). The rate of malignancy decreased from 45.5% (StC) to 37.9% (MT) in AUS/FLUS and increased from 40.0% to 53.8% in FN/SFN. However, the overall rate of malignancy remained equal (47.8% in StC vs. 47.7% in MT). The average cost of care per patient in the AUS/FLUS and FN/SFN categories increased from $6,566 (StC) to $8,444 (MT) and from $9,313 (StC) to $10,253 (MT), respectively. Similarly, the overall average cost of care of a patient who underwent thyroid fine-needle aspiration increased from $3,088 (StC) to $4,282 (MT). Finally, the average cost per thyroid cancer detected increased from $26,312 (StC) to $38,746 (MT). Conclusions: Introduction of ThyroSeq v2 resulted in a shift toward indeterminate cytology results. The institutional rate of surgery, overtreatment, and malignancy did not change significantly. Lack of decrease in the rate of surgery along with the additional cost of ThyroSeq v2 increased the overall cost of care of patients including those with indeterminate cytology results.
Collapse
Affiliation(s)
- Shoreh R Fazeli
- Department of Pathology & Laboratory Medicine at Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts, USA
| | - Bradley Zehr
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Razie Amraei
- Department of Pathology & Laboratory Medicine at Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts, USA
| | - Gianluca Toraldo
- Lahey Hospital and Medical Center Endocrinology, Burlington, Massachusetts, USA
| | - Haixia Guan
- Section of Endocrinology, Diabetes and Nutrition, Department of Medicine, Boston University Medical Center, Boston, Massachusetts, USA
| | - David Kindelberger
- Department of Pathology, Harvard Vanguard Medical Associates Atrius Health, Boston, Massachusetts, USA
| | - Stephanie Lee
- Section of Endocrinology, Diabetes and Nutrition, Department of Medicine, Boston University Medical Center, Boston, Massachusetts, USA
| | - Sandra Cerda
- Department of Pathology & Laboratory Medicine at Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts, USA
| |
Collapse
|
20
|
Kumar N, Gupta R, Gupta S. Molecular testing in diagnosis of indeterminate thyroid cytology: Trends and drivers. Diagn Cytopathol 2020; 48:1144-1151. [PMID: 32501611 DOI: 10.1002/dc.24522] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 05/13/2020] [Accepted: 05/19/2020] [Indexed: 12/11/2022]
Abstract
Fine needle aspiration (FNA), the cornerstone of diagnosis in thyroid swellings, fails to render a definitive diagnosis in about 20% to 30% of cases that are reported as indeterminate on cytology. Since the clinical management in thyroid rests on the risk of malignancy (ROM) in a given nodule, this distinction between "benign" and "possibly malignant" assumes paramount clinical importance. Over the last two decades, tremendous progress has been achieved in our understanding of the molecular basis of thyroid pathologies leading to identification of several genetic alterations that could potentially be exploited for diagnostic, prognostic and therapeutic purposes. An array of molecular tests has hit the markets aiming to predict the ROM in thyroid nodules. A deeper understanding of the strengths and limitations of these tests is imperative to be able to judiciously choose the right molecular test in a given case for maximum clinical benefit. This narrative review provides an overview of current status of molecular testing in the evaluation of thyroid nodules encompassing the current status and applications of these tests in diagnostic, prognostic and therapeutic areas along with a brief insight into the future developments in this field.
Collapse
Affiliation(s)
- Neeta Kumar
- Department of Pathology, Faculty of Dentistry, Jamia Millia Islamia (Central University), New Delhi, India
| | - Ruchika Gupta
- Division of Cytopathology, ICMR-National Institute of Cancer Prevention and Research, Noida, India
| | - Sanjay Gupta
- Division of Cytopathology, ICMR-National Institute of Cancer Prevention and Research, Noida, India
| |
Collapse
|
21
|
Franco AT, Labourier E, Ablordeppey KK, Surrey LF, Mostoufi-Moab S, Isaza A, Adzick NS, Kazahaya K, Kumar G, Bauer AJ. miRNA expression can classify pediatric thyroid lesions and increases the diagnostic yield of mutation testing. Pediatr Blood Cancer 2020; 67:e28276. [PMID: 32196952 DOI: 10.1002/pbc.28276] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 02/27/2020] [Accepted: 02/28/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND Genetic alterations in multiple cell signaling pathways are involved in the molecular pathogenesis of thyroid cancer. Oncogene mutation testing and gene-expression profiling are routinely used for the preoperative risk management of adult thyroid nodules. In this study, we evaluated the potential value of miRNA biomarkers for the classification of pediatric thyroid lesions. PROCEDURE Double-blind case-control study with 113 resected pediatric lesions: 66 malignant and 47 benign. Quantitative and qualitative molecular data generated with a 10-miRNA expression panel (ThyraMIR) and a next-generation sequencing oncogene panel (ThyGeNEXT) were compared with clinicopathological parameters. RESULTS miRNAs were differentially expressed in benign versus malignant tumors with distinct expression patterns in different histopathology categories. The 10-miRNA classifier identified 39 (59%) malignant lesions with 100% specificity. A positive classifier score was associated with lymph node metastasis, extrathyroidal extension and intrathyroidal spread. Genetic alterations associated with increased risk for malignancy were detected in 35 (53%) malignant cases, 20 positive for point mutations in BRAF, HRAS, KRAS, NRAS, PIK3CA, or TERT and 15 positive for gene rearrangements involving ALK, NTRK3, PPARG, or RET. The 10-miRNA classifier correctly identified 11 mutation-negative malignant cases. The performance of the combined molecular test was 70% sensitivity and 96% specificity with an area under the curve of 0.924. CONCLUSIONS These data suggest that the regulatory miRNA pathways underlying thyroid tumorigenesis are similar in adults and children. miRNA expression can identify malignant lesions with high specificity, augment the diagnostic yield of mutation testing, and improve the molecular classification of pediatric thyroid nodules.
Collapse
Affiliation(s)
- Aime T Franco
- Division of Endocrinology and Diabetes, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | | | - Lea F Surrey
- Division of Anatomic Pathology and Genomic Diagnostics, Department of Pathology and Laboratory Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sogol Mostoufi-Moab
- Division of Endocrinology and Diabetes, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Division of Oncology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Amber Isaza
- Division of Endocrinology and Diabetes, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - N Scott Adzick
- Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ken Kazahaya
- Department of Otorhinolaryngology: Head and Neck Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Otorhinolaryngology/Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Andrew J Bauer
- Division of Endocrinology and Diabetes, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| |
Collapse
|
22
|
Qichang W, Jinming S, Lu L, Bin J, Renjie W, Xiuying Z. Comparison of 18F-FDG-PET and 18F-FDG-PET/CT for the diagnostic performance in thyroid nodules with indeterminate cytology: A meta-analysis. Medicine (Baltimore) 2020; 99:e20446. [PMID: 32481449 DOI: 10.1097/md.0000000000020446] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUNDS We performed a meta-analysis to compare F-FDG-PET and F-FDG-PET/CT for the diagnostic performance in thyroid nodules with indeterminate cytology by Bethesda classification. METHODS PubMed and Embase databases were searched for eligible studies from the earliest available date of indexing through September 2019. Only studies with clearly stated histopathology confirmation were included. Publication bias was assessed by Deeks funnel plot. The pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, positive predictive value, negative predictive value, and diagnostic odds ratio was determined by random-effect analysis, respectively. All diagnostic estimate indexes were determined separately for PET alone and PET/CT and were compared pair-wisely using Z-test. RESULTS We included 214 patients from five PET alone studies and 420 patients from 8 PET/CT studies in this meta-analysis. The range of the prevalence of malignancy was 11% to 27% for PET alone studies (Median, 20%) and 4% to 50% for PET/CT studies (Median, 24%). The sensitivity (0.95 vs 0.73, P < .01), negative likelihood ratio (0.20 vs 0.53, P = .04) and negative predictive value (0.99 vs 0.91, P < .01) of PET alone are significantly better than those of PET/CT. For PET/CT, Fagan nomogram indicated that when the pre-test probability was set at 24%, the negative post-test probability could decrease to 12%. CONCLUSION This meta-analysis reveals that in evaluating thyroid nodules with indeterminate cytology by Bethesda classification, the rule-out performance of F-FDG-PET is significantly better than F-FDG-PET/CT, although the latter represents a more objective and accurate technique. We hypothesize that the lack of precise localization of suspicious FDG uptake in the neck region may have contributed to this overvaluation for PET alone studies, and advocate that future studies be performed with PET/CT rather than PET alone to avoid misinterpretation and overvaluation in this scenario.
Collapse
Affiliation(s)
- Wan Qichang
- Department of Nuclear Medicine, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Shen Jinming
- Department of Intensive Care, Xinyu People's Hospital, Xinyu, China
| | - Li Lu
- Department of Nuclear Medicine, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Ji Bin
- Department of Nuclear Medicine, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Wang Renjie
- Department of Nuclear Medicine, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Zheng Xiuying
- Department of Discipline Inspection, The Second Affiliated Hospital of Mudanjiang Medical University, Mudanjiang, China
| |
Collapse
|
23
|
Khan TM, Zeiger MA. Thyroid Nodule Molecular Testing: Is It Ready for Prime Time? Front Endocrinol (Lausanne) 2020; 11:590128. [PMID: 33162941 PMCID: PMC7581778 DOI: 10.3389/fendo.2020.590128] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 09/22/2020] [Indexed: 12/19/2022] Open
Abstract
Cytologically indeterminate thyroid nodules remain a diagnostic and clinical challenge, and molecular testing has been advocated and advanced as a diagnostic modality to help guide treatment. While studies have expounded on the improved diagnostic certainty with these tests, data demonstrating meaningful clinical impact and supporting their routine use is still limited at best. In this review, we discuss the limitations regarding diagnostic accuracy, impact on surgical decision-making and outcomes, and cost-effectiveness of molecular testing. By highlighting the limitations of these tests, we aim to promote more thoughtful utilization of these tools in the management of thyroid nodules going forward.
Collapse
|
24
|
Stewart R, Leang YJ, Bhatt CR, Grodski S, Serpell J, Lee JC. Quantifying the differences in surgical management of patients with definitive and indeterminate thyroid nodule cytology. Eur J Surg Oncol 2019; 46:252-257. [PMID: 31648951 DOI: 10.1016/j.ejso.2019.10.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 09/16/2019] [Accepted: 10/05/2019] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Thyroid nodules are increasingly common. Despite being an essential pre-operative diagnostic tool, up to 30% of fine needle aspirate cytology (FNAC) yields a non-definitive diagnosis. This study aimed to quantify differences in surgical management of patients with definitive and indeterminate thyroid nodule cytology, and determine if clinical factors can improve cytological diagnosis. MATERIALS AND METHODS Patients who underwent thyroidectomy for nodules from 2001 to 2015 were recruited. Those with benign and malignant preoperative cytology were included in the "definitive diagnosis" (DC) group; patients with all other preoperative cytology results were included in the "indeterminate diagnosis" (IC) group. We compared demographics and procedures between these groups. Clinical factors and demographics were also compared between patients with benign and malignant histology in the IC group. RESULTS A total of 3821 cases were included. A significantly larger proportion of the IC patients had a hemithyroidectomy (IC 69% vs. DC 39%, p < 0.001) initially, and also had a significantly higher rate of two-stage surgery compared to the DC group (IC 17% vs. DC 11%, p < 0.001). Patients in the DC group were twice as likely to undergo concurrent central lymph node dissection for papillary and medullary cancers than the IC group (p < 0.001). Overall, up to 60% of IC patients had been over- or under-treated at initial surgery. The clinical factors examined were not significantly associated with higher risk of malignancy in IC patients. CONCLUSION This study highlights the potential for improved preoperative diagnosis to streamline decision making for surgical management of patients with thyroid nodules.
Collapse
Affiliation(s)
- Rose Stewart
- Monash University Endocrine Surgery Unit, Alfred Hospital, Melbourne, Australia
| | - Yit Jern Leang
- Monash University Endocrine Surgery Unit, Alfred Hospital, Melbourne, Australia
| | - Chhavi Raj Bhatt
- Monash University Endocrine Surgery Unit, Alfred Hospital, Melbourne, Australia; Department of Epidemiology and Preventive Medicine, School of Public Health and Preventative Medicine, Monash University, Melbourne, Australia; Department of Emergency Medicine, Monash Health, Melbourne, Australia
| | - Simon Grodski
- Monash University Endocrine Surgery Unit, Alfred Hospital, Melbourne, Australia; Department of Surgery, Monash University, Melbourne, Australia; Department of Surgery, Monash Health, Melbourne, Australia
| | - Jonathan Serpell
- Monash University Endocrine Surgery Unit, Alfred Hospital, Melbourne, Australia; Department of Surgery, Monash University, Melbourne, Australia
| | - James C Lee
- Monash University Endocrine Surgery Unit, Alfred Hospital, Melbourne, Australia; Department of Surgery, Monash University, Melbourne, Australia; Department of Surgery, Monash Health, Melbourne, Australia.
| |
Collapse
|
25
|
Nicholson KJ, Roberts MS, McCoy KL, Carty SE, Yip L. Molecular Testing Versus Diagnostic Lobectomy in Bethesda III/IV Thyroid Nodules: A Cost-Effectiveness Analysis. Thyroid 2019; 29:1237-1243. [PMID: 31407625 PMCID: PMC7366255 DOI: 10.1089/thy.2018.0779] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Background: Molecular tests (MT) using gene expression and/or mutational analysis have been developed to reduce the need for diagnostic surgery for indeterminate (Bethesda III/IV) thyroid nodules. Prior cost-effectiveness studies have shown mixed results but none has included the recent and more comprehensive versions of the two commonly utilized MT. The aim of this study is to compare the cost-effectiveness of diagnostic lobectomy (DL), the Afirma Gene Sequencing Classifier (GSC), and ThyroSeq version 3 (TSv3). Methods: A decision tree from the payer perspective was created using a base case of a 40-year-old euthyroid woman with a solitary 2 cm Bethesda III or IV thyroid nodule. In this model, all patients in the DL arm had lobectomy, which was also performed for patients with positive MT, while those with negative MT underwent 20 years of surveillance. The outcome was a correct diagnosis, defined as malignant histology after DL or 20 years of nodule stability after negative MT. Costs were obtained from the Centers for Medicare & Medicaid Services (CMS) data and existing literature, and probabilities were obtained from the literature. Sensitivity analysis was performed for costs, pretest probability of malignancy, and performance parameters. Results: The cost per correct diagnosis was $14,277 for TSv3, $17,873 for GSC, and $38,408 for DL. TSv3 was preferred over both GSC and DL. One-way sensitivity analysis between TSv3 and GSC demonstrated that the results were robust to variations in cost, cancer prevalence, and length of surveillance. In the two-way sensitivity analysis, TSv3 was preferred over GSC at all considered test costs, and in probabilistic sensitivity analysis, TSv3 was the preferred management strategy in 68.5% of cases. Conclusions: In hypothetical modeling to determine whether surgery versus MT is optimal for indeterminate (Bethesda III/IV) nodules, either of the major MT was considerably more cost-effective than DL, although TSv3 was more likely to be cost-effective than GSC. Use of either MT adjunct should be strongly considered in the absence of other indications for thyroidectomy.
Collapse
Affiliation(s)
- Kristina J. Nicholson
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mark S. Roberts
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, Department of Health Policy and Management, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kelly L. McCoy
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sally E. Carty
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Linwah Yip
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Address correspondence to: Linwah Yip, MD, Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, 3471 Fifth Avenue Ste 101, Pittsburgh, PA 15213
| |
Collapse
|
26
|
Sistrunk JW, Shifrin A, Frager M, Bardales RH, Thomas J, Fishman N, Goldberg P, Guttler R, Grant E. Clinical impact of testing for mutations and microRNAs in thyroid nodules. Diagn Cytopathol 2019; 47:758-764. [PMID: 31013001 PMCID: PMC6766884 DOI: 10.1002/dc.24190] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 04/02/2019] [Indexed: 11/29/2022]
Abstract
Background We report results of a multicenter clinical experience study examining the likelihood of patients with indeterminate thyroid nodules to undergo surgery or have malignant outcome based on multiplatform combination mutation and microRNA testing (MPT). Methods MPT assessed mutations in BRAF, HRAS, KRAS, NRAS, and PIK3CA genes, PAX8/PPARγ, RET/PTC1, and RET/PTC3 gene rearrangements, and the expression of 10 microRNAs. Baseline clinical information at the time of MPT and clinical follow‐up records were reviewed for 337 patients, of which 80% had negative MPT results. Kaplan Meier analysis for cumulative probability of survival without having a surgical procedure or malignant diagnosis over the course of patient follow‐up was determined for MPT results of 180 patients, among which only 14% had malignancy. Results A negative MPT result in nodules with Bethesda III or IV cytology (2009) conferred a high probability of non‐surgical treatment, with only 11% expected to undergo surgery and a high probability of survival without malignancy (92%) for up to 2 years follow up. A positive MPT result conferred a 57% probability of malignancy and was an independent risk factor for undergoing surgical treatment (Hazard Ratio [HR] 9.2, 95% confidence intervals 5.4‐15.9, P < .0001) and for malignancy (HR 13.4, 95% confidence intervals 4.8‐37.2, P < .0001). For nodules with weak driver mutations, positive microRNA test results supported high risk of cancer while negative results downgraded cancer risk. Conclusion MPT results are predictive of real‐world decisions to surgically treat indeterminate thyroid nodules, with those decisions being appropriately aligned with a patient's risk of malignancy over time.
Collapse
Affiliation(s)
| | - Alexander Shifrin
- Department of Surgery, Jersey Shore University Medical Center, Neptune, New Jersey
| | - Marc Frager
- East Coast Medical Associates, Boca Raton, Florida
| | - Ricardo H Bardales
- Precision Pathology/Outpatient Pathology Associates, Sacramento, California
| | | | - Norman Fishman
- Diabetes & Endocrinology Specialists, Chesterfield, Missouri
| | | | | | - Edward Grant
- Department of Radiology, University of Southern California, Keck School of Medicine, Los Angeles, California
| |
Collapse
|
27
|
Banizs AB, Silverman JF. The utility of combined mutation analysis and microRNA classification in reclassifying cancer risk of cytologically indeterminate thyroid nodules. Diagn Cytopathol 2018; 47:268-274. [DOI: 10.1002/dc.24087] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 08/15/2018] [Accepted: 09/10/2018] [Indexed: 01/11/2023]
Affiliation(s)
- Anna B. Banizs
- Department of Pathology; Allegheny General Hospital; Pittsburgh Pennsylvania
| | - Jan F. Silverman
- Department of Pathology; Allegheny General Hospital; Pittsburgh Pennsylvania
| |
Collapse
|
28
|
Dinan MA, Li Y, Reed SD, Sosa JA. INITIAL ADOPTION OF RECOMBINANT HUMAN THYROID-STIMULATING HORMONE FOLLOWING THYROIDECTOMY IN THE MEDICARE THYROID CANCER PATIENT POPULATION. Endocr Pract 2018; 25:31-42. [PMID: 30383499 DOI: 10.4158/ep-2018-0253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Recombinant human thyroid-stimulating hormone (rhTSH) has been approved for diagnostic (1998) and therapeutic (2008) indications in conjunction with radioactive iodine (RAI) administration post-thyroidectomy. Potential benefits of rhTSH, including avoidance of hypothyroidism side effects and shorter, less costly hospital stays, have not been assessed at the population level within the United States. In this study we quantify utilization, outcomes, and associated costs of rhTSH within the nationally representative Surveillance, Epidemiology, and End Results (SEER)-Medicare patient population. METHODS We conducted a retrospective analysis of beneficiaries aged >65 years diagnosed within the SEER-Medicare data with differentiated thyroid cancer. Endpoints examined included ( 1) rhTSH utilization in the 2 years post-thyroidectomy (patients diagnosed 1996-2011 [utilization cohort]) and ( 2) comparison of resource utilization and costs as a function of rhTSH receipt in the 30 days prior to and 1 year following therapeutic RAI administration (patients diagnosed 2008-2011 [resource use cohort]). All costs were adjusted to reflect 2013 dollars. RESULTS A total of 6,482 patients met inclusion criteria, of which, 1,363 (21.0%) received rhTSH. Receipt varied by region and was higher in the South (18%), Northeast (28%), and West (44%) compared to the Midwest (10%), and lower in census tracts in the bottom quartile of high school education rates (odds ratio 0.68, 95% confidence interval [CI] 0.55-0.83). rhTSH receipt was not associated with patient sex, age, comorbidities, or stage. Post-therapeutic RAI, 1,444 patients were assessed for resource utilization (2008-2011). The average cost of rhTSH was $905 per patient, with $2,483 being spent on average among patients who received rhTSH in association with therapeutic RAI. rhTSH receipt was not significantly associated with total inpatient days or number of outpatient and emergency department visits. Multivariable analyses showed similar overall costs among patients who did versus did not receive rhTSH (cost ratio [CR] 0.96, 95% CI 0.86-1.09), partially due to increased mean outpatient costs ($5,213 vs. $4,190) being offset by lower inpatient costs ($3,493 vs. $6,143). Overall costs were significantly higher in multivariable analyses among patients with distant metastatic disease (CR 1.92, 95% CI 1.58-2.32) and multiple comorbidities (CR 2.15, 95% CI 1.83-2.53). CONCLUSION rhTSH recipients had higher outpatient, lower inpatient, and similar total Medicare payments as those not receiving rhTSH in conjunction with RAI, lending support to the use of rhTSH as a cost-neutral treatment option from the payer perspective. ABBREVIATIONS CI = confidence interval; CMS = Centers for Medicare & Medicaid Services; CR = cost ratio; HCPCS = Healthcare Common Procedure Coding System; IQR = interquartile range; mCi = millicurie; OR = odds ratio; PET = positron emission tomography; RAI = radioactive iodine; rhTSH = recombinant human thyroid-stimulating hormone; RR = risk ratio; SEER = Surveillance, Epidemiology, and End Results.
Collapse
|
29
|
Rivas AM, Nassar A, Zhang J, Casler JD, Chindris AM, Smallridge R, Bernet V. ThyroSeq ®V2.0 Molecular Testing: A Cost-Effective Approach for the Evaluation of Indeterminate Thyroid Nodules. Endocr Pract 2018; 24:780-788. [PMID: 30084677 DOI: 10.4158/ep-2018-0212] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Approximately 15 to 30% of thyroid nodules have indeterminate cytology. Many of these nodules are treated surgically, but only 5 to 30% are malignant. Molecular testing can further narrow the risk of malignancy of these nodules. Our objective was to assess the cost effectiveness of ThyroSeq®V2.0 compared to diagnostic thyroidectomy for the evaluation of indeterminate nodules. METHODS Cytology and histopathology slides of Bethesda category III and IV (suspicious for follicular neoplasia [SFN]) nodules obtained between January 1, 2014 and November 30, 2016 were re-reviewed by 2 endocrine cytopathologists. Costs for a diagnostic approach using ThyroSeq® were calculated and compared to those of diagnostic thyroidectomy. RESULTS We included 8 Bethesda category III nodules that underwent ThyroSeq® and 8 that underwent diagnostic surgery. Of those submitted for ThyroSeq®, 4 were positive for mutations and underwent thyroid surgery. The average cost per nodule evaluated was $14,669 using ThyroSeq®, compared to $23,338 for diagnostic thyroid surgery. The cost per thyroid cancer case detected was $58,674 using ThyroSeq® compared to $62,233 for diagnostic thyroid surgery. We included 13 nodules Bethesda category IV that underwent ThyroSeq® and 11 that underwent diagnostic surgery. Of those submitted for ThyroSeq®, 6 were positive for mutation and underwent thyroid surgery. The average costs per nodule evaluated were $14,641 using ThyroSeq® and $24,345 using diagnostic thyroidectomy. The cost per thyroid cancer case detected was $31,721 when using ThyroSeq® compared to $53,560 for diagnostic thyroidectomy. CONCLUSION The use of ThyroSeq® in our institution is cost effective compared to diagnostic thyroid surgery for the evaluation of Bethesda categories III and IV (SFN) nodules. ABBREVIATIONS FNA = fine-needle aspiration; GEC = gene expression classifier; NIFTP = noninvasive follicular thyroid neoplasm with papillary-like nuclear features; PTC = papillary thyroid cancer; SFN = suspicious for follicular neoplasia.
Collapse
|
30
|
Deaver KE, Haugen BR, Pozdeyev N, Marshall CB. Outcomes of Bethesda categories III and IV thyroid nodules over 5 years and performance of the Afirma gene expression classifier: A single-institution study. Clin Endocrinol (Oxf) 2018; 89:226-232. [PMID: 29791966 DOI: 10.1111/cen.13747] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 05/09/2018] [Accepted: 05/14/2018] [Indexed: 12/26/2022]
Abstract
OBJECTIVE The second edition Bethesda System for Reporting Thyroid Cytology estimates 6%-18% malignancy rate of category III (B3) and 10%-40% for category IV (B4) nodules; however, reported malignancy rates have considerable variability among institutions. Use of molecular classifiers (including Afirma Gene Expression Classifier, GEC) can be utilized in management of thyroid nodules. Our objective was to analyse malignancy rates of B3 and B4 nodules and determine clinical outcomes of GEC Benign nodules. METHODS A retrospective analysis of 2019 thyroid FNAs was performed at the University of Colorado from 2011 to 2015, including molecular, surgical and clinical follow-up. RESULTS Of 2019 FNAs analysed, 231 (11.4%) were diagnosed as B3 and 80 (4.0%) as B4. GEC was obtained in 54.1% of B3 cases, with nearly half (48.8%) having a Benign result. Surgery was performed in 40.7% B3 cases with a 24.5% malignancy rate, ranging 8%-38% by year. In the B4 group, 52.5% underwent molecular testing with 28.6% as GEC Benign. About 68.8% of B4 cases underwent surgery with a 20% malignancy rate, ranging 0%-42% by year. Seventy-three GEC Benign cases were reviewed: 5 (6.8%) underwent surgery, with none demonstrating malignancy in the target nodule. Size remained stable for most GEC Benign nodules: 75.9% (B3) and 71.4% (B4) with no malignancy on repeat FNA. CONCLUSIONS Our 5-year review demonstrated that malignancy rates of B3 and B4 nodules showed year-to-year variability. We suggest that clinicians use a multi-year average of their institution's malignancy rates to optimally manage patients. Follow-up for GEC Benign cases thus far supports their indolent nature.
Collapse
Affiliation(s)
- Kelsi E Deaver
- Division of Endocrinology, Metabolism & Diabetes, University of Colorado School of Medicine, Aurora, CO, USA
| | - Bryan R Haugen
- Division of Endocrinology, Metabolism & Diabetes, University of Colorado School of Medicine, Aurora, CO, USA
- University of Colorado Cancer Center, Aurora, CO, USA
| | - Nikita Pozdeyev
- Division of Endocrinology, Metabolism & Diabetes, University of Colorado School of Medicine, Aurora, CO, USA
| | - Carrie B Marshall
- Department of Pathology, University of Colorado School of Medicine, Aurora, CO, USA
| |
Collapse
|
31
|
Amendoeira I, Maia T, Sobrinho-Simões M. Non-invasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP): impact on the reclassification of thyroid nodules. Endocr Relat Cancer 2018; 25:R247-R258. [PMID: 29439059 DOI: 10.1530/erc-17-0513] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 02/08/2018] [Indexed: 12/19/2022]
Abstract
The 2017 edition of the WHO book on Classification of Tumours of Endocrine Organs includes a new section entitled 'Other encapsulated follicular-patterned thyroid tumours', in which the newly created NIFTP (non-invasive follicular thyroid neoplasm with papillary-like nuclear features) is identified and described in detail. Despite deleting the word 'carcinoma' from its name, NIFTP is not a benign tumor either and is best regarded as a neoplasm with 'very low malignant potential'. The main goal of the introduction of NIFTP category is to prevent overdiagnosis and overtreatment. Sampling constraints, especially when dealing with heterogeneous and/or large nodules, and difficulties in the invasiveness evaluation, are the major weaknesses of the histological characterization of NIFTP. At the cytological level, NIFTP can be separated from classic papillary carcinoma (cPTC) but not from encapsulated, invasive follicular variant PTC. The impact of NIFTP individualization for cytopathology is the drop of rates of malignancy for each Bethesda category in general and for indeterminate categories in particular. The biggest impact will be seen in institutions with a high frequency of FVPTC. The introduction of NIFTP has changed the utility of predictive values of molecular tests because RAS mutations and PAX8-PPARg rearrangements are frequently detected in NIFTP. This turns less promising the application of mutation detection panels as indicators of malignancy and will probably contribute to switch to a rule-out approach of molecular testing. Selection for surgery will go on being determined by a combined detection of clinical, cytological and ultrasound suspicious features.
Collapse
Affiliation(s)
- Isabel Amendoeira
- Department of Pathology, Centro Hospitalar S. João, Porto, Portugal
- Department of Pathology, Medical Faculty of the University of Porto, Porto, Portugal
- Ipatimup - Institute of Molecular Pathology and Immunology, University of Porto, Porto, Portugal
| | - Tiago Maia
- Department of Pathology, Centro Hospitalar S. João, Porto, Portugal
- Department of Pathology, Medical Faculty of the University of Porto, Porto, Portugal
| | - Manuel Sobrinho-Simões
- Department of Pathology, Centro Hospitalar S. João, Porto, Portugal
- Department of Pathology, Medical Faculty of the University of Porto, Porto, Portugal
- Ipatimup - Institute of Molecular Pathology and Immunology, University of Porto, Porto, Portugal
- I3S - Institute of Investigation and Innovation in Health, Porto, Portugal
| |
Collapse
|
32
|
de Koster EJ, de Geus-Oei LF, Dekkers OM, van Engen-van Grunsven I, Hamming J, Corssmit EPM, Morreau H, Schepers A, Smit J, Oyen WJG, Vriens D. Diagnostic Utility of Molecular and Imaging Biomarkers in Cytological Indeterminate Thyroid Nodules. Endocr Rev 2018; 39:154-191. [PMID: 29300866 DOI: 10.1210/er.2017-00133] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 12/27/2017] [Indexed: 12/21/2022]
Abstract
Indeterminate thyroid cytology (Bethesda III and IV) corresponds to follicular-patterned benign and malignant lesions, which are particularly difficult to differentiate on cytology alone. As ~25% of these nodules harbor malignancy, diagnostic hemithyroidectomy is still custom. However, advanced preoperative diagnostics are rapidly evolving.This review provides an overview of additional molecular and imaging diagnostics for indeterminate thyroid nodules in a preoperative clinical setting, including considerations regarding cost-effectiveness, availability, and feasibility of combining techniques. Addressed diagnostics include gene mutation analysis, microRNA, immunocytochemistry, ultrasonography, elastosonography, computed tomography, sestamibi scintigraphy, [18F]-2-fluoro-2-deoxy-d-glucose positron emission tomography (FDG-PET), and diffusion-weighted magnetic resonance imaging.The best rule-out tests for malignancy were the Afirma® gene expression classifier and FDG-PET. The most accurate rule-in test was sole BRAF mutation analysis. No diagnostic had both near-perfect sensitivity and specificity, and estimated cost-effectiveness. Molecular techniques are rapidly advancing. However, given the currently available techniques, a multimodality stepwise approach likely offers the most accurate diagnosis, sequentially applying one sensitive rule-out test and one specific rule-in test. Geographical variations in cytology (e.g., Hürthle cell neoplasms) and tumor genetics strongly influence local test performance and clinical utility. Multidisciplinary collaboration and implementation studies can aid the local decision for one or more eligible diagnostics.
Collapse
Affiliation(s)
- Elizabeth J de Koster
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Lioe-Fee de Geus-Oei
- Department of Radiology, Section of Nuclear Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Olaf M Dekkers
- Department of Endocrinology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Jaap Hamming
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Eleonora P M Corssmit
- Department of Endocrinology, Leiden University Medical Center, Leiden, the Netherlands
| | - Hans Morreau
- Department of Pathology, Leiden University Medical Center, Leiden, the Netherlands
| | - Abbey Schepers
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Jan Smit
- Department of Endocrinology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Wim J G Oyen
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, the Netherlands.,Division of Radiotherapy and Imaging, Institute of Cancer Research, and Department of Nuclear Medicine, Royal Marsden Hospital, London, United Kingdom
| | - Dennis Vriens
- Department of Radiology, Section of Nuclear Medicine, Leiden University Medical Center, Leiden, the Netherlands
| |
Collapse
|
33
|
Angell TE, Vyas CM, Barletta JA, Cibas ES, Cho NL, Doherty GM, Gawande AA, Howitt BE, Krane JF, Marqusee E, Strickland KC, Alexander EK, Moore FD, Nehs MA. Reasons Associated with Total Thyroidectomy as Initial Surgical Management of an Indeterminate Thyroid Nodule. Ann Surg Oncol 2018. [DOI: 10.1245/s10434-018-6421-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
|
34
|
Sahli ZT, Smith PW, Umbricht CB, Zeiger MA. Preoperative Molecular Markers in Thyroid Nodules. Front Endocrinol (Lausanne) 2018; 9:179. [PMID: 29720964 PMCID: PMC5915469 DOI: 10.3389/fendo.2018.00179] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 04/03/2018] [Indexed: 12/12/2022] Open
Abstract
The need for distinguishing benign from malignant thyroid nodules has led to the pursuit of differentiating molecular markers. The most common molecular tests in clinical use are Afirma® Gene Expression Classifier (GEC) and Thyroseq® V2. Despite the rapidly developing field of molecular markers, several limitations exist. These challenges include the recent introduction of the histopathological diagnosis "Non-Invasive Follicular Thyroid neoplasm with Papillary-like nuclear features", the correlation of genetic mutations within both benign and malignant pathologic diagnoses, the lack of follow-up of molecular marker negative nodules, and the cost-effectiveness of molecular markers. In this manuscript, we review the current published literature surrounding the diagnostic value of Afirma® GEC and Thyroseq® V2. Among Afirma® GEC studies, sensitivity (Se), specificity (Sp), positive predictive value (PPV), and negative predictive value (NPV) ranged from 75 to 100%, 5 to 53%, 13 to 100%, and 20 to 100%, respectively. Among Thyroseq® V2 studies, Se, Sp, PPV, and NPV ranged from 40 to 100%, 56 to 93%, 13 to 90%, and 48 to 97%, respectively. We also discuss current challenges to Afirma® GEC and Thyroseq® V2 utility and clinical application, and preview the future directions of these rapidly developing technologies.
Collapse
Affiliation(s)
- Zeyad T. Sahli
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Philip W. Smith
- Department of Surgery, University of Virginia, Charlottesville, VA, United States
| | - Christopher B. Umbricht
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Martha A. Zeiger
- Department of Surgery, University of Virginia, Charlottesville, VA, United States
- *Correspondence: Martha A. Zeiger,
| |
Collapse
|
35
|
Roth MY, Witt RL, Steward DL. Molecular testing for thyroid nodules: Review and current state. Cancer 2017; 124:888-898. [DOI: 10.1002/cncr.30708] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 03/02/2017] [Accepted: 03/06/2017] [Indexed: 12/12/2022]
Affiliation(s)
- Mara Y. Roth
- Division of Metabolism, Endocrinology, and Nutrition, Department of Medicine; University of Washington; Seattle Washington
| | - Robert L. Witt
- Department of Otolaryngology; Thomas Jefferson University; Philadelphia Pennsylvania
- Multidisciplinary Head and Neck Clinic, Helen F. Graham Cancer Center; Newark Delaware
| | - David L. Steward
- Department of Otolaryngology; University of Cincinnati; Cincinnati Ohio
| |
Collapse
|
36
|
Thyroid hormone regulates hematopoiesis via the TR-KLF9 axis. Blood 2017; 130:2161-2170. [PMID: 28972010 DOI: 10.1182/blood-2017-05-783043] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 09/06/2017] [Indexed: 12/21/2022] Open
Abstract
Congenital hypothyroidism (CH) is one of the most prevalent endocrine diseases, for which the underlying mechanisms remain unknown; it is often accompanied by anemia and immunodeficiency in patients. Here, we created a severe CH model together with anemia and T lymphopenia to mimic the clinical features of hypothyroid patients by ethylnitrosourea (ENU) mutagenesis in Bama miniature pigs. A novel recessive c.1226A>G transition of the dual oxidase 2 (DUOX2) gene was identified as the causative mutation. This mutation hindered the production of hydrogen peroxide (H2O2) and thus contributed to thyroid hormone (TH) synthesis failure. Transcriptome sequencing analysis of the thymuses showed that Krüppel-like factor 9 (KLF9) was predominantly downregulated in hypothyroid mutants. KLF9 was verified to be directly regulated by TH in a TH receptor (TR)-dependent manner both in vivo and in vitro. Furthermore, knockdown of klf9 in zebrafish embryos impaired hematopoietic development including erythroid maturation and T lymphopoiesis. Our findings suggest that the TR-KLF9 axis is responsible for the hematopoietic dysfunction and might be exploited for the development of novel therapeutic interventions for thyroid diseases.
Collapse
|
37
|
Witt RL. In reference to Does mutational analysis influence the management of differentiated thyroid cancers? Laryngoscope 2017; 128:E84. [PMID: 28865093 DOI: 10.1002/lary.26811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 06/15/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Robert L Witt
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania; the Department of Biological Sciences, University of Delaware; and the Department of Surgery, Head & Neck Clinic, Helen F. Graham Cancer Center, Christiana Care, Newark, Delaware, U.S.A
| |
Collapse
|
38
|
Al-Abbadi MA, Shareef SQ, Yousef MM, Almasri NM, Mustafa HE, Aljawad H, Ali JA, Groves A, Alsaihati Y. A follow-up study on thyroid aspirates reported as atypia of undetermined significance/follicular lesion of undetermined significance and follicular neoplasm/suspicious for follicular neoplasm: A multicenter study from the Arabian Gulf region. Diagn Cytopathol 2017; 45:983-988. [DOI: 10.1002/dc.23805] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 08/14/2017] [Accepted: 08/16/2017] [Indexed: 01/21/2023]
Affiliation(s)
| | | | | | | | - Huda E. Mustafa
- Sheikh Khalifa Medical City; Abu Dhabi United Arab Emirates
- Department of Pathology; Sheikh Khalifa Medical City; Abu Dhabi United Arab Emirates
- Department of Laboratory Medicine and Internal Medicine; Sheikh Khalifa Medical City; Abu Dhabi United Arab Emirates
| | | | | | - Alan Groves
- Sheikh Khalifa Medical City; Abu Dhabi United Arab Emirates
| | | |
Collapse
|
39
|
Shapiro S, Pharaon M, Kellermeyer B. Cost-effectiveness of Gene Expression Classifier Testing of Indeterminate Thyroid Nodules Utilizing a Real Cohort Comparator. Otolaryngol Head Neck Surg 2017; 157:596-601. [PMID: 28828911 DOI: 10.1177/0194599817725709] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Objective To predict the cost-effectiveness of implementing routine gene expression classifier testing for thyroid nodules with indeterminate fine-needle aspiration cytology, by utilizing a real cohort of patients as a comparator. Study Design Cost-effectiveness analysis of a retrospective cohort compared with a simulated cohort. Setting Tertiary academic medical center. Subjects and Methods We reviewed the records of all patients who underwent ultrasound-guided fine-needle aspiration from 2010 to 2014 at a tertiary academic medical center. All patients with Bethesda class III or IV cytopathology had the details of their management catalogued over the subsequent 2 years of care. These patients were assigned to the standard-of-care arm of the study. We compared the third-party payer costs of care and the proportion of patients who underwent surgery with a simulated cohort who underwent gene expression classifier testing after an initial indeterminate fine-needle aspiration (molecular test arm). Results The cost of managing 1 nodule over 2 years was $2399 higher (range, $397-$4399) for the molecular test group than the standard of care group. The molecular test group had a 13.1% decrease (base parameters; range, 0.73%-45.09%) in the number of patients undergoing surgery. Conclusion When applied to a real cohort of patients, routine gene expression classifier is predicted to reduce the number of patients undergoing surgery but will increase cost of care. Cost-effectiveness is heavily dependent on prevalence of malignancy and gene expression classifier specificity.
Collapse
Affiliation(s)
- Scott Shapiro
- Department of Otolaryngology–Head and Neck Surgery, West Virginia University, Morgantown, West Virginia, USA
| | - Majed Pharaon
- Department of Pathology, West Virginia University, Morgantown, West Virginia, USA
| | - Brian Kellermeyer
- Department of Otolaryngology–Head and Neck Surgery, West Virginia University, Morgantown, West Virginia, USA
| |
Collapse
|
40
|
González HE, Martínez JR, Vargas-Salas S, Solar A, Veliz L, Cruz F, Arias T, Loyola S, Horvath E, Tala H, Traipe E, Meneses M, Marín L, Wohllk N, Diaz RE, Véliz J, Pineda P, Arroyo P, Mena N, Bracamonte M, Miranda G, Bruce E, Urra S. A 10-Gene Classifier for Indeterminate Thyroid Nodules: Development and Multicenter Accuracy Study. Thyroid 2017; 27:1058-1067. [PMID: 28521616 PMCID: PMC5564024 DOI: 10.1089/thy.2017.0067] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND In most of the world, diagnostic surgery remains the most frequent approach for indeterminate thyroid cytology. Although several molecular tests are available for testing in centralized commercial laboratories in the United States, there are no available kits for local laboratory testing. The aim of this study was to develop a prototype in vitro diagnostic (IVD) gene classifier for the further characterization of nodules with an indeterminate thyroid cytology. METHODS In a first stage, the expression of 18 genes was determined by quantitative polymerase chain reaction (qPCR) in a broad histopathological spectrum of 114 fresh-tissue biopsies. Expression data were used to train several classifiers by supervised machine learning approaches. Classifiers were tested in an independent set of 139 samples. In a second stage, the best classifier was chosen as a model to develop a multiplexed-qPCR IVD prototype assay, which was tested in a prospective multicenter cohort of fine-needle aspiration biopsies. RESULTS In tissue biopsies, the best classifier, using only 10 genes, reached an optimal and consistent performance in the ninefold cross-validated testing set (sensitivity 93% and specificity 81%). In the multicenter cohort of fine-needle aspiration biopsy samples, the 10-gene signature, built into a multiplexed-qPCR IVD prototype, showed an area under the curve of 0.97, a positive predictive value of 78%, and a negative predictive value of 98%. By Bayes' theorem, the IVD prototype is expected to achieve a positive predictive value of 64-82% and a negative predictive value of 97-99% in patients with a cancer prevalence range of 20-40%. CONCLUSIONS A new multiplexed-qPCR IVD prototype is reported that accurately classifies thyroid nodules and may provide a future solution suitable for local reference laboratory testing.
Collapse
Affiliation(s)
- Hernán E. González
- Department of Surgical Oncology, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - José R. Martínez
- Department of Surgical Oncology, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Sergio Vargas-Salas
- Department of Surgical Oncology, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Antonieta Solar
- Department of Anatomic Pathology, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Loreto Veliz
- Department of Physiology, Faculty of Biological Sciences, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Francisco Cruz
- Department of Radiology, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Tatiana Arias
- Department of Radiology, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Soledad Loyola
- Department of Radiology, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Eleonora Horvath
- Department of Radiology, Clínica Alemana de Santiago, Universidad del Desarrollo, Santiago, Chile
| | - Hernán Tala
- Department of Radiology, Clínica Alemana de Santiago, Universidad del Desarrollo, Santiago, Chile
| | - Eufrosina Traipe
- Instituto Oncológico Fundación Arturo López Pérez, Santiago, Chile
| | - Manuel Meneses
- Instituto Oncológico Fundación Arturo López Pérez, Santiago, Chile
| | - Luis Marín
- Instituto Oncológico Fundación Arturo López Pérez, Santiago, Chile
| | - Nelson Wohllk
- Department of Endocrinology, Hospital del Salvador, Universidad de Chile, Santiago, Chile
| | - René E. Diaz
- Department of Endocrinology, Hospital del Salvador, Universidad de Chile, Santiago, Chile
| | - Jesús Véliz
- Department of Endocrinology, Hospital del Salvador, Universidad de Chile, Santiago, Chile
| | - Pedro Pineda
- Sección Endocrinología y Diabetes, Departamento de Medicina, Hospital Clínico Universidad de Chile, Santiago, Chile
| | | | | | | | | | | | - Soledad Urra
- Department of Surgical Oncology, Pontificia Universidad Católica de Chile, Santiago, Chile
| |
Collapse
|
41
|
Eszlinger M, Lau L, Ghaznavi S, Symonds C, Chandarana SP, Khalil M, Paschke R. Molecular profiling of thyroid nodule fine-needle aspiration cytology. Nat Rev Endocrinol 2017; 13:415-424. [PMID: 28361927 DOI: 10.1038/nrendo.2017.24] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
The differential diagnosis and malignancy risk stratification of thyroid nodules requires multidisciplinary expertise and knowledge of both local ultrasonography practices and the local malignancy rates for a given fine-needle aspiration (FNA) result. Even in such a multidisciplinary setting, FNA cytology has the inherent limitation that indeterminate cytology results cannot distinguish between follicular adenomas, follicular thyroid carcinomas or follicular variant papillary thyroid carcinomas. Accumulating evidence suggests that this limitation can be overcome by using molecular diagnostic approaches. In this Review, we present the advantages and disadvantages of the different molecular diagnostic methodologies, which can be divided into two approaches: those that 'rule out' malignancy (to reduce the overtreatment of benign nodules) and those that 'rule in' malignancy (to optimize surgical planning). We identify microRNA classifiers as potential additional markers for use in a two-step diagnostic approach, consider the potential implications of the reclassification of noninvasive encapsulated follicular variant papillary thyroid carcinomas to noninvasive follicular thyroid neoplasms with papillary-like nuclear features and discuss the cost-effectiveness of molecular testing. Molecular FNA diagnostics is an important complementary addition to FNA cytology that could substantially reduce unnecessary surgery and better define the need for appropriate surgery in patients who have thyroid nodules with indeterminate FNA cytology.
Collapse
Affiliation(s)
- Markus Eszlinger
- Department of Oncology, Cumming School of Medicine, University of Calgary, Tom Baker Cancer Centre, 1331 - 29th Street NW, Calgary, Alberta T2N 4N2, Canada
- Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Health Research Innovation Centre, 3280 Hospital Drive, Calgary, Alberta T2T 4Z6, Canada
| | - Lorraine Lau
- Division of Endocrinology, Department of Medicine, Cumming School of Medicine, University of Calgary, Richmond Road Diagnostic and Treatment Centre, 1820 Richmond Road SW, Calgary, Alberta T2T 5C7, Canada
| | - Sana Ghaznavi
- Division of Endocrinology, Department of Medicine, Cumming School of Medicine, University of Calgary, Richmond Road Diagnostic and Treatment Centre, 1820 Richmond Road SW, Calgary, Alberta T2T 5C7, Canada
| | - Christopher Symonds
- Division of Endocrinology, Department of Medicine, Cumming School of Medicine, University of Calgary, Richmond Road Diagnostic and Treatment Centre, 1820 Richmond Road SW, Calgary, Alberta T2T 5C7, Canada
| | - Shamir P Chandarana
- Department of Oncology, Cumming School of Medicine, University of Calgary, Tom Baker Cancer Centre, 1331 - 29th Street NW, Calgary, Alberta T2N 4N2, Canada
- Department of Surgery, Cumming School of Medicine, University of Calgary, Foothills Medical Centre, North Tower 1012, 1403 - 29th Street NW, Calgary, Alberta T2N 2T9, Canada
| | - Moosa Khalil
- Department of Pathology and Laboratory Medicine, University of Calgary, Foothills Medical Centre, McCaig Tower, 1403 - 29th Street NW, Calgary, Alberta T2N 2T9, Canada
| | - Ralf Paschke
- Department of Oncology, Cumming School of Medicine, University of Calgary, Tom Baker Cancer Centre, 1331 - 29th Street NW, Calgary, Alberta T2N 4N2, Canada
- Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Health Research Innovation Centre, 3280 Hospital Drive, Calgary, Alberta T2T 4Z6, Canada
- Division of Endocrinology, Department of Medicine, Cumming School of Medicine, University of Calgary, Richmond Road Diagnostic and Treatment Centre, 1820 Richmond Road SW, Calgary, Alberta T2T 5C7, Canada
- Department of Medicine, Cumming School of Medicine, University of Calgary, North Tower 9th floor, 1403 - 29th Street NW, Calgary, Alberta T2N 2T9, Canada
- Department of Biochemistry and Molecular Biology, Cumming School of Medicine, University of Calgary, Health Research Innovation Centre, 3280 Hospital Drive, Calgary, Alberta T2N 4Z6, Canada
| |
Collapse
|
42
|
Feller-Kopman D, Liu S, Geisler BP, DeCamp MM, Pietzsch JB. Cost-Effectiveness of a Bronchial Genomic Classifier for the Diagnostic Evaluation of Lung Cancer. J Thorac Oncol 2017; 12:1223-1232. [PMID: 28502850 DOI: 10.1016/j.jtho.2017.04.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 04/14/2017] [Accepted: 04/23/2017] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The use of a bronchial genomic classifier has been shown to improve the diagnostic accuracy of bronchoscopy for suspected lung cancer by identifying patients who may be more suitable for radiographic surveillance as opposed to invasive procedures. Our objective was to assess the cost-effectiveness of bronchoscopy plus a genomic classifier versus bronchoscopy alone in the diagnostic work-up of patients at intermediate risk for lung cancer. METHODS A decision-analytic Markov model was developed to project the costs and effects of two competing strategies by using test performance from the Airway Epithelial Gene Expression in the Diagnosis of Lung Cancer-1 and Airway Epithelial Gene Expression in the Diagnosis of Lung Cancer-2 studies. The diagnostic accuracy of noninvasive and invasive follow-up, as well as associated adverse event rates, were derived from published literature. Procedure costs were based on claims data and 2016 inpatient and outpatient reimbursement amounts. The model projected the number of invasive follow-up procedures, 2-year costs and quality-adjusted life-years (QALYs) by strategy, and resulting incremental cost-effectiveness ratio discounted at 3% per annum. RESULTS Use of the genomic classifier reduced invasive procedures by 28% at 1 month and 18% at 2 years, respectively. Total costs and QALY gain were similar with classifier use ($27,221 versus $27,183 and 1.512 versus 1.509, respectively), resulting in an incremental cost-effectiveness ratio of $15,052 per QALY. CONCLUSIONS Our analysis suggests that the use of a genomic classifier is associated with meaningful reductions in invasive procedures at about equal costs and is therefore a high-value strategy in the diagnostic work-up of patients at intermediate risk of lung cancer.
Collapse
Affiliation(s)
- David Feller-Kopman
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland.
| | - Shan Liu
- Wing Tech, Inc., Menlo Park, California; Department of Industrial and Systems Engineering, University of Washington, Seattle, Washington
| | - Benjamin P Geisler
- Wing Tech, Inc., Menlo Park, California; Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
| | - Malcolm M DeCamp
- Northwestern University Feinberg School of Medicine, Division of Thoracic Surgery, Chicago, Illinois
| | | |
Collapse
|
43
|
Molinaro E, Elisei R, Romei C. Clinical impact of molecular techniques for the presurgical diagnosis of differentiated thyroid cancer diagnosis. Expert Rev Endocrinol Metab 2017; 12:207-214. [PMID: 30063461 DOI: 10.1080/17446651.2017.1320217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The gold standard for the presurgical diagnosis of thyroid cancer is fine needle aspiration cytology. In about 30% of cases a final diagnosis is not obtained and surgical treatment is required for diagnostic/therapeutic purposes. To avoid unnecessary thyroidectomies, methods based on molecular markers analysis have been explored over the last 10 years. Areas covered: The present review introduces the limits of the cytological diagnosis of thyroid nodules and describes the molecular techniques for the presurgical diagnosis of these nodules focusing on the use of the Thyroseq-V2 (Rule in) and Afirma (Rule out) tests. Expert commentary: These two types of tests have been clinically applied and validated; however they are still confined to specialized laboratories, either academic or private, and not yet routinely used. The evidence of a positive cost-benefit analysis should encourage to set up molecular pathology laboratories to apply new molecular testing(s). In the meantime, clinical judgment, which must take into consideration several parameters including the age of the patient, the size and number of the nodule(s), the ultrasound pattern and the risk level for malignancy, should guide the decision to operate or to follow up the evolution of the nodule.
Collapse
Affiliation(s)
- Eleonora Molinaro
- a Endocrine Unit, Department of Clinical and Experimental Medicine , University of Pisa , Pisa , Italy
| | - Rossella Elisei
- a Endocrine Unit, Department of Clinical and Experimental Medicine , University of Pisa , Pisa , Italy
| | - Cristina Romei
- a Endocrine Unit, Department of Clinical and Experimental Medicine , University of Pisa , Pisa , Italy
| |
Collapse
|
44
|
Labourier E. Efficiency versus effectiveness: impact of molecular testing on healthcare costs and clinical outcome of patients with indeterminate thyroid nodules. Med Oncol 2016; 33:79. [PMID: 27307224 DOI: 10.1007/s12032-016-0792-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 06/08/2016] [Indexed: 11/29/2022]
|