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Paspala A, Bompetsi G, Paschou SA, Charalambopoulos A, Pikoulis E, Peppa M, Nastos C. The value of preoperative molecular testing in the management of Bethesda V and Bethesda VI thyroid tumors. Hormones (Athens) 2024:10.1007/s42000-024-00597-0. [PMID: 39225945 DOI: 10.1007/s42000-024-00597-0] [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] [Received: 08/30/2023] [Accepted: 08/23/2024] [Indexed: 09/04/2024]
Abstract
The incidence of thyroid cancer has increased over recent years due to the fact that several diagnostic tools, such as neck ultrasound and fine-needle aspiration, are being ever more widely adopted. Lately, another modality which might provide significant information preoperatively on the aggressiveness of a thyroid tumor, its prognosis, and its recurrence rate is molecular testing. We reviewed the literature with regard to the role of preoperative molecular testing in patients with Bethesda V and Bethesda VI thyroid nodules and its impact on choice of the optimal treatment strategy. Several molecular mutations and alterations are associated with thyroid cancer and its biological behavior, such as BRAF-V600E, RET, and TERT promoter. Although the value of preoperative molecular testing for indeterminate nodules (Bethesda III and Bethesda IV) have been analyzed in numerous studies, the impact of preoperative molecular testing on Bethesda V and Bethesda VI thyroid nodules is not adequately described in the current literature. The preoperative recognition of specific molecular mutations, such as BRAFV600E and TERT promoter mutation, might provide more individualized management for thyroid cancer patients by altering the surgical approach and the extent of surgery for patients diagnosed with a more aggressive or iodine-resistant subtype of thyroid cancer.Thyroid cancer is characterized by multiple genetic mutations and alterations and, as a result, preoperative molecular testing of malignant nodules could be a very useful tool for surgeons, enabling them to decide on the most appropriate surgical approach for each patient.
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Affiliation(s)
- Anna Paspala
- Department of Surgery, Evgenideio Hospital, Papadiamantopoulou 20, Athens, 115 28, Greece.
| | - Georgia Bompetsi
- 3rd Department of Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Stavroula A Paschou
- Endocrine Unit and Diabetes Centre, Department of Clinical Therapeutics, School of Medicine, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Anestis Charalambopoulos
- 3rd Department of Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Emmanuil Pikoulis
- 3rd Department of Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Melpomeni Peppa
- Endocrine Unit, 2nd Propaedeutic Department of Internal Medicine & Research Institute, National & Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Constantinos Nastos
- 3rd Department of Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
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Lukas J, Hintnausova B, Sykorova V, Syrucek M, Maly M, Lukas D, Duskova J. Clinical and molecular genetic analysis of cytologically uncertain thyroid nodules in patients with thyroid disease. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2023. [PMID: 38058193 DOI: 10.5507/bp.2023.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND The current requirement is to establish the preoperative diagnosis accurately as possible and to achieve an adequate extent of surgery. The aim of this study was to define the preoperative clinical and molecular genetic risks of malignancy in indeterminate thyroid nodules (Bethesda III and IV) and to determine their impact on the surgical strategy. METHODS Prospectively retrospective analysis of 287 patients provided the basis of preoperative laboratory examination, sonographic stratification of malignancy risks and cytological findings. Molecular tests focused on pathogenic variants of genes associated with thyroid oncogenesis in cytologically indeterminate nodules (Bethesda III and IV). The evaluation included clinical risk factors: positive family history, radiation exposure and growth in size and/or number of nodules. RESULTS Preoperative FNAB detected 52 cytologically indeterminate nodules (28.7%) out of 181 patients. Postoperative histopathological examination revealed malignancy in 12 cases (23.7%) and there was no significant difference between Bethesda III and IV categories (P=0.517). Clinical risk factors for malignancy were found in 32 patients (61.5%) and the presence of at least one of them resulted in a clearly higher incidence of malignancy than their absence (31.3% vs. 10.0%, respectively). Pathogenic variants of genes were detected in 12/49 patients in Bethesda III and IV, and in 4 cases (33.3%) thyroid carcinoma was revealed. The rate of malignancies was substantially higher in patients with pathogenic variants than in those without (33.3% vs. 16.2%, respectively). CONCLUSIONS Our experience implies that molecular genetic testing is one of several decision factors. We will continue to monitor and enlarge our patient cohort to obtain long-term follow-up data.
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Affiliation(s)
- Jindrich Lukas
- Department of Otolaryngology - Head and Neck Surgery, Na Homolce Hospital, Prague, Czech Republic
- Ear, Nose, and Throat Department Faculty of Medicine in Pilsen, Charles University in Prague, Czech Republic
| | - Barbora Hintnausova
- Department of Internal Medicine, Endocrinology Centre, Na Homolce Hospital, Prague, Czech Republic
| | - Vlasta Sykorova
- Institute of Endocrinology, Department of Molecular Endocrinology, Prague, Czech Republic
| | - Martin Syrucek
- Department of Pathology, Na Homolce Hospital, Prague, Czech Republic
| | - Marek Maly
- Department of Biostatistics, National Institute of Public Health, Prague, Czech Republic
| | | | - Jaroslava Duskova
- Institute of Pathology, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
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Effect of Having Concurrent Mutations on the Degree of Aggressiveness in Patients with Thyroid Cancer Positive for TERT Promoter Mutations. Cancers (Basel) 2023; 15:cancers15020413. [PMID: 36672362 PMCID: PMC9856260 DOI: 10.3390/cancers15020413] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 12/30/2022] [Accepted: 01/05/2023] [Indexed: 01/11/2023] Open
Abstract
This study aimed to examine whether concurrent mutations with a TERT promoter mutation are associated with a greater likelihood of more aggressive disease than a TERT promoter mutation alone. The medical records of 1477 patients who underwent thyroid surgery at two tertiary hospitals between 2017 and 2022 were reviewed. Twenty-four patients had TERT promoter mutations based on molecular profile testing. Clinicodemographic data, mutational profiles, and histopathological features were assessed. Descriptive analysis, Fisher's exact test, and binary logistic regression were performed. Seven patients had single-gene TERT promoter mutations, and 17 had concurrent mutations, including BRAF V600E, HRAS, NRAS, PIK3CA, and EIF1AX. The overall prevalence of malignancy was 95.8%, of which 78.3% were aggressive thyroid cancers. There was a statistically significant association between concurrent mutations and disease aggressiveness. The odds of having aggressive disease were 10 times higher in patients with a TERT promoter mutation and a concurrent molecular alteration than in those with a TERT promoter mutation alone. This is an important finding for thyroid specialists to consider when counseling patients concerning risk stratification and management options.
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Surgical Outcomes of Thyroid Nodules Positive for Gene Expression Alterations Using ThyroSeq V3 Genomic Classifier. Cancers (Basel) 2022; 15:cancers15010049. [PMID: 36612045 PMCID: PMC9817510 DOI: 10.3390/cancers15010049] [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: 11/16/2022] [Revised: 12/13/2022] [Accepted: 12/20/2022] [Indexed: 12/24/2022] Open
Abstract
ThyroSeq V3 (TsV3) tests for various genetic alterations, including gene expression alterations (GEAs), to improve diagnostic accuracy and clinical decision-making for indeterminate thyroid nodules. This study aimed to clarify the clinico-pathological features and outcomes of GEA-positive thyroid nodules, which have not yet been well-described in the literature. A retrospective chart review was performed whereby patients were included if they underwent thyroid surgery between January 2018 and May 2022 at two McGill University teaching hospitals and their surgery was preceded by pre-operative molecular TsV3 testing. In total, 75 of the 328 patients with thyroid nodules (22.9%) who underwent molecular testing and surgery were GEA-positive. On surgical pathology, GEA-positive nodules showed a significantly higher malignancy rate compared to their GEA-negative counterparts (90.7% vs. 77.7%, respectively, p = 0.011). Among those that were malignant, 48.5% had at least one aggressive pathological feature, including histological subtype, extra-thyroidal extension, or lymph node metastasis. BRAF V600E mutation had a significantly greater association with aggressive malignant GEA-positive nodules compared to non-aggressive ones (p < 0.001). This study demonstrates that GEA may be an effective diagnostic and prognostic tool for thyroid nodule management. However, further investigation is needed to characterize the clinico-pathological features of GEA in isolation and in association with other gene alterations.
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Bandargal S, Chen T, Pusztaszeri MP, Forest VI, da Silva SD, Payne RJ. Prognostic Indicators of EIF1AX-Mutated Thyroid Tumor Malignancy and Cancer Aggressiveness. Cancers (Basel) 2022; 14:cancers14246097. [PMID: 36551583 PMCID: PMC9776054 DOI: 10.3390/cancers14246097] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 12/05/2022] [Accepted: 12/09/2022] [Indexed: 12/14/2022] Open
Abstract
The risk of malignancy (ROM) of EIF1AX-mutated thyroid nodules has been theorized to be contingent on the position of the mutation within the gene and the presence of co-existing mutations. However, due to EIF1AX's low mutation frequency, sample sizes currently reported in the literature are too diminutive to appraise the clinical utility of molecular diagnostic testing. The objective of this study was to elucidate prognostic indicators of EIF1AX-mutated thyroid tumors and cancer aggressiveness by examining a large cohort of cytologically indeterminate thyroid nodules (CITNs) that underwent molecular testing and subsequent surgical resection. This is a multicenter study involving 764 subtotal and total thyroidectomy patients that underwent preoperative molecular testing at two quaternary care hospitals. A five-year retrospective review was performed on the 42 charts of patients that opted for surgery following a positive EIF1AX mutation on ThyroseqV3 results from January 2018 to May 2022. Patient demographics, cytopathology results, molecular testing results, and postoperative histopathology were reviewed. Of the 42 surgically resected nodules that harbored an EIF1AX mutation, 16 (38.1%) were benign, six (14.3%) were non-invasive follicular thyroid neoplasms with papillary-like nuclear features (NIFTPs) or well-differentiated thyroid neoplasms of uncertain malignant potential (WDT-UMPs), and 20 (47.6%) were malignant. An isolated EIF1AX mutation conferred a ROM of 47.6%, whereas the ROM for nodules with at least one additional molecular alteration was 72.7%. The ROM increased to 100% for nodules with at least one additional molecular alteration and the A113_splice site mutation. Six malignant nodules were aggressive, with five having variegated components of poorly differentiated thyroid carcinoma (PDTC). EIF1AX-mutated thyroid nodules are more susceptible to malignancy in the presence of the A113_splice site mutation and when co-mutated with RAS and/or TP53. This deleterious amalgam is associated with aggressive disease and renders these nodules PDTC. A preoperative molecular test finding of an EIF1AX mutation can be a useful tool for thyroid specialists to optimize clinical management.
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Affiliation(s)
- Saruchi Bandargal
- Faculty of Medicine, McGill University, Montreal, QC H3G 2M1, Canada
| | - Tanya Chen
- Department of Otolaryngology–Head and Neck Surgery, University of Toronto, Toronto, ON M5S, Canada
| | | | - Véronique-Isabelle Forest
- Department of Otolaryngology–Head and Neck Surgery, McGill University, Jewish General Hospital, Montreal, QC H3T 1E2, Canada
| | - Sabrina Daniela da Silva
- Department of Otolaryngology–Head and Neck Surgery, McGill University, Jewish General Hospital, Montreal, QC H3T 1E2, Canada
| | - Richard J. Payne
- Department of Otolaryngology–Head and Neck Surgery, McGill University, Jewish General Hospital, Montreal, QC H3T 1E2, Canada
- Department of Otolaryngology–Head and Neck Surgery, McGill University, Royal Victoria Hospital, Montreal, QC H4A 3J1, Canada
- Correspondence:
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Rajab M, Payne RJ, Forest VI, Pusztaszeri M. Molecular Testing for Thyroid Nodules: The Experience at McGill University Teaching Hospitals in Canada. Cancers (Basel) 2022; 14:cancers14174140. [PMID: 36077677 PMCID: PMC9454567 DOI: 10.3390/cancers14174140] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 08/24/2022] [Accepted: 08/25/2022] [Indexed: 11/16/2022] Open
Abstract
In the past few decades, molecular characterization of thyroid cancer has made significant progress and is able to identify thyroid-cancer-related molecular markers that can then be applied clinically for improved decision making. The aim of this review is to provide a general overview about the molecular markers (mutations and alterations) of thyroid cancers, present several molecular tests, and discuss the clinical applications of identifying these markers supported by the clinical experience of several high-volume thyroid cancer specialists at the McGill university hospitals in Montreal, Canada. Our group experience showed that molecular testing can reclassify more than half of the patients with indeterminate thyroid nodules (Bethesda III and IV) into benign and spare these patients from unnecessary diagnostic surgery. Furthermore, it can help optimize the initial management in thyroid cancers with no evidence of high risk of recurrence of disease preoperatively. While routine molecular testing is not firmly established for thyroid FNA specimens that are suspicious or positive for malignancy (Bethesda V and VI), knowledge of a thyroid nodule’s molecular risk group profile in such cases, together with its clinical and radiologic features, can help select the optimal surgical options (lobectomy versus upfront total thyroidectomy and central neck dissection), as demonstrated by our studies.
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Affiliation(s)
- Mohannad Rajab
- Department of Otolaryngology—Head and Neck Surgery, Jewish General Hospital, McGill University, 3755 Côte-Sainte-Catherine Road, Montreal, QC H3T 1E2, Canada
- Departments of Otolaryngology—Head and Neck Surgery, Royal Victoria Hospital, McGill University, 1001 Decarie Blvd, Montreal, QC H4A 3J1, Canada
- Department of Otolaryngology—Head and Neck Surgery, King Faisal Specialist Hospital & Research Center, Al Madinah Al Munawwarah 42523, Saudi Arabia
| | - Richard J. Payne
- Department of Otolaryngology—Head and Neck Surgery, Jewish General Hospital, McGill University, 3755 Côte-Sainte-Catherine Road, Montreal, QC H3T 1E2, Canada
- Departments of Otolaryngology—Head and Neck Surgery, Royal Victoria Hospital, McGill University, 1001 Decarie Blvd, Montreal, QC H4A 3J1, Canada
| | - Véronique-Isabelle Forest
- Department of Otolaryngology—Head and Neck Surgery, Jewish General Hospital, McGill University, 3755 Côte-Sainte-Catherine Road, Montreal, QC H3T 1E2, Canada
| | - Marc Pusztaszeri
- Department of Pathology, Jewish General Hospital, McGill University, 3755 Côte-Sainte-Catherine Road, Montreal, QC H3T 1E2, Canada
- Correspondence: ; Tel.: +1-(514)-340-8222 (ext. 4197)
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Semsar-Kazerooni K, Morand GB, Payne AE, da Silva SD, Forest VI, Hier MP, Pusztaszeri MP, Tamilia M, Payne RJ. Mutational status may supersede tumor size in predicting the presence of aggressive pathologic features in well differentiated thyroid cancer. J Otolaryngol Head Neck Surg 2022; 51:9. [PMID: 35246262 PMCID: PMC8895819 DOI: 10.1186/s40463-022-00559-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 01/17/2022] [Indexed: 12/14/2022] Open
Abstract
Background In clinical practice, thyroid tumor size plays a critical role in the staging of thyroid malignancies and in the selection of nodules that should undergo ultrasound-guided fine-needle aspiration. Thyroid tumor size is influenced by the elapsed time since the beginning of oncogenesis and by the presence of somatic mutations driving growth, such as BRAFV600E mutations, associated with aggressive phenotypes, and RAS-like mutations, associated with more indolent behavior. Although large nodules are often considered to be more alarming, the true impact of tumor size on prognosis remains controversial. The aim of this study was to assess the relationship between mutational status, tumor size and aggressiveness, with emphasis on BRAFV600E and RAS-like mutations. Method We conducted a multicentric retrospective chart review in Montréal, Canada, of all patients who underwent thyroid surgery between January 2016 and December 2020, with well-differentiated thyroid cancer on final pathology, and who had undergone molecular testing revealing the presence of BRAFV600E mutations or RAS-like mutations (NRAS, HRAS or KRAS). Results We included 214 cases. There were 117 (54.7%) cases of BRAFV600E and 97 (45.3%) cases of RAS-like mutations. The BRAFV600E group was statistically associated with a smaller mean tumor size when compared with the RAS group of 1.55 cm and 2.04 cm, respectively. In a multivariate model, tumors with BRAFV600E mutations were also more likely to display aggressive pathological features, including extra-thyroidal extension, lymph node metastasis, columnar cell features, tall cell histology, or hobnail histology (OR 26.69; 95% CI 11.15–70.81). In contrast, tumor size was not associated with pathologic aggressive features on multivariate analysis (OR 0.81; 95% CI 0.54–1.22). Conclusion This study demonstrates that thyroid tumors expressing BRAFV600E mutations correlate with aggressive pathologic features more than tumors expressing RAS-like mutations. When comparing tumors with BRAFV600E and RAS-like mutations, the former were found to be smaller. As a result of this finding, this study suggests that molecular alterations may better predict aggressive pathologic features than the size of the tumor. Graphical abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1186/s40463-022-00559-9.
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Affiliation(s)
| | - Grégoire B Morand
- Faculty of Medicine, McGill University, Montréal, QC, Canada.,Department of Otolaryngology-Head and Neck Surgery, Jewish General Hospital, McGill University, 3755 Côte-Sainte-Catherine Road, Montréal, QC, H3T 1E2, Canada
| | | | - Sabrina D da Silva
- Faculty of Medicine, McGill University, Montréal, QC, Canada.,Department of Otolaryngology-Head and Neck Surgery, Jewish General Hospital, McGill University, 3755 Côte-Sainte-Catherine Road, Montréal, QC, H3T 1E2, Canada
| | - Véronique-Isabelle Forest
- Faculty of Medicine, McGill University, Montréal, QC, Canada.,Department of Otolaryngology-Head and Neck Surgery, Jewish General Hospital, McGill University, 3755 Côte-Sainte-Catherine Road, Montréal, QC, H3T 1E2, Canada
| | - Michael P Hier
- Faculty of Medicine, McGill University, Montréal, QC, Canada.,Department of Otolaryngology-Head and Neck Surgery, Jewish General Hospital, McGill University, 3755 Côte-Sainte-Catherine Road, Montréal, QC, H3T 1E2, Canada
| | - Marc P Pusztaszeri
- Faculty of Medicine, McGill University, Montréal, QC, Canada.,Department of Pathology, Jewish General Hospital, McGill University, Montréal, QC, Canada
| | - Michael Tamilia
- Faculty of Medicine, McGill University, Montréal, QC, Canada.,Division of Endocrinology and Metabolism, Jewish General Hospital, McGill University, Montréal, QC, Canada
| | - Richard J Payne
- Faculty of Medicine, McGill University, Montréal, QC, Canada. .,Department of Otolaryngology-Head and Neck Surgery, Jewish General Hospital, McGill University, 3755 Côte-Sainte-Catherine Road, Montréal, QC, H3T 1E2, Canada.
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