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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.
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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.
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Lee JC, Chang P, Grodski S, Yeung M, Johnson W, Serpell J. Temporal analysis of thyroid cancer management in a Melbourne tertiary centre. ANZ J Surg 2016; 89:38-42. [PMID: 27758032 DOI: 10.1111/ans.13792] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 04/20/2016] [Accepted: 07/18/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND The American Thyroid Association (ATA) management guidelines for thyroid cancer were revised in 2009. The aim of this study was to determine if management of thyroid cancer in our institution has changed in accordance with the introduction of the revised ATA guidelines (ATA2009 ), and to compare the characteristics and management of thyroid cancer in a Melbourne endocrine surgery unit over a 7-year period. METHODS All patients treated by the Monash University Endocrine Surgery Unit for thyroid cancer between 2007 and 2013 were divided into two groups - the pre-ATA2009 group (2007-2010) and the post-ATA2009 group (2011-2013). Comparisons were made of the demographics, cytology, pathology, surgical outcome and adjuvant therapy using t-test and chi-squared tests. RESULTS There were 333 patients in the pre-ATA2009 group and 342 patients in the post-ATA2009 group. Fewer non-diagnostic fine-needle aspiration cytology results were identified in the post-ATA2009 group (4% versus 0.9%; P = 0.01), while the rates of other fine-needle aspiration cytology categories were similar. There was a reduction in the use of radioactive iodine ablation in the post-ATA2009 group, both in the proportion of patients being treated (66% versus 48%; P < 0.001) and the dosages used (mean 96 mCi versus 80 mCi; P < 0.01), despite similar tumour size in both groups. CONCLUSION The key changes in practice thought to be attributable to the 2009 revised ATA guidelines were the reduction in the use and dosage of radioactive iodine in the management of differentiated thyroid cancer.
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Affiliation(s)
- James C Lee
- Monash University Endocrine Surgery Unit, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Monash University, Melbourne, Victoria, Australia
| | - Paula Chang
- Monash University Endocrine Surgery Unit, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Simon Grodski
- Monash University Endocrine Surgery Unit, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Monash University, Melbourne, Victoria, Australia
| | - Meei Yeung
- Monash University Endocrine Surgery Unit, The Alfred Hospital, Melbourne, Victoria, Australia
| | - William Johnson
- Monash University Endocrine Surgery Unit, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Monash University, Melbourne, Victoria, Australia
| | - Jonathan Serpell
- Monash University Endocrine Surgery Unit, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Monash University, Melbourne, Victoria, Australia
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Lam E, Vy N, Bajdik C, Strugnell SS, Walker B, Wiseman SM. Synoptic pathology reporting for thyroid cancer: a review and institutional experience. Expert Rev Anticancer Ther 2014; 13:1073-9. [PMID: 24053206 DOI: 10.1586/14737140.2013.825435] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Thyroid cancer surgical pathology reports contain information that is critical for diagnosis, determining completeness of resection, staging and guiding postoperative management. Traditional narrative pathology reporting is prone to errors and omissions with variability in content and completeness. The objective of this review was to evaluate the impact of synoptic reporting on thyroid cancer pathology reporting. Our institutional study of pathology reporting of differentiated thyroid cancers at a Canadian tertiary care institution relative to the College of American Pathologists checklists is also presented and critically evaluates deficiencies in the narrative pathology reporting format.
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Affiliation(s)
- Elaine Lam
- Department of Surgery, St. Paul's Hospital, University of British Columbia, C303 - 1081 Burrard Street, Vancouver, British Columbia, V6Z 1Y6, Canada
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Baynes AL, Del Rio A, McLean C, Grodski S, Yeung MJ, Johnson WR, Serpell JW. Fine-Needle Aspiration of the Thyroid: Correlating Suspicious Cytology Results with Histological Outcomes. Ann Surg Oncol 2014; 21:1653-8. [DOI: 10.1245/s10434-013-3448-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Indexed: 12/30/2022]
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Kakudo K, Kameyama K, Miyauchi A, Nakamura H. Introducing the reporting system for thyroid fine-needle aspiration cytology according to the new guidelines of the Japan Thyroid Association. Endocr J 2014; 61:539-52. [PMID: 24727657 DOI: 10.1507/endocrj.ej13-0494] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The Japan Thyroid Association (JTA) recently published new guidelines for clinical management of thyroid nodules. This paper introduces their diagnostic system for reporting thyroid fine-needle aspiration cytology. There are two points where the new reporting system that differs from existing internationally-accepted ones. The first is the subclassification of the so-called indeterminate category, which is divided into 'follicular neoplasm' and 'others'. The second is the subclassification of follicular neoplasm into 'favor benign', 'borderline' and 'favor malignant'. It is characterized by self-explanatory terminologies as to histological type and probability of malignancy to establish further risk stratification as well as to facilitate communication between clinicians and cytopathologists. The different treatment strategies adopted for thyroid nodules is deeply influenced by the particular diagnostic system used for thyroid cytology. In Western countries all patients with follicular neoplasms are advised to have immediate diagnostic surgery while patients in Japan often undergo further risk stratification without immediate surgery. The JTA diagnostic system of reporting thyroid cytology is designed for further risk stratification of patients with indeterminate cytology. If a surgeon applies diagnostic lobectomy to all patients with follicular neoplasm unselectively, this subclassification of follicular neoplasm has no practical meaning and is unnecessary. Cytological risk stratification of follicular neoplasms is optional and cytopathologists can choose either a simple 6-tier system without stratification of follicular neoplasm or a complicated 8-tier system depending on their experience in thyroid cytology and clinical management.
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Affiliation(s)
- Kennichi Kakudo
- Department of Pathology, Nara Hospital Kinki University Faculty of Medicine, Ikoma 630-0293, Japan
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Wong SL, Grodski S, Yeung MJ, Serpell JW. Anti-thyroid antibodies as a predictor of thyroid cancer. ANZ J Surg 2013; 85:849-53. [DOI: 10.1111/ans.12453] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2013] [Indexed: 01/30/2023]
Affiliation(s)
- Sze Ling Wong
- Endocrine Surgery Unit; Monash University; Alfred Hospital; Melbourne Victoria Australia
| | - Simon Grodski
- Endocrine Surgery Unit; Monash University; Alfred Hospital; Melbourne Victoria Australia
| | - Meei J. Yeung
- Endocrine Surgery Unit; Monash University; Alfred Hospital; Melbourne Victoria Australia
| | - Jonathan W. Serpell
- Endocrine Surgery Unit; Monash University; Alfred Hospital; Melbourne Victoria Australia
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Chiu CG, Yao R, Chan SK, Strugnell SS, Bugis S, Irvine R, Anderson D, Walker B, Jones SJ, Wiseman SM. Hemithyroidectomy is the preferred initial operative approach for an indeterminate fine needle aspiration biopsy diagnosis. Can J Surg 2012; 55:191-8. [PMID: 22630062 DOI: 10.1503/cjs.034510] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Fine needle aspiration biopsy represents the critical initial diagnostic test used for evaluation of thyroid nodules. Our objectives were to determine the cytological distribution, the utility of clinicopathologic characteristics for predicting malignancy and the true proportion of cancer among individuals who presented with indeterminate cytology and had undergone thyroid surgery for suspicion of cancer. METHODS We retrospectively reviewed 1040 consecutive primary thyroid operations carried out over an 8-year period at a tertiary care endocrine referral centre. Follicular neoplasm (FN), Hürthle cell neoplasm (HN), neoplasms suspicious for but not diagnostic of papillary carcinoma (IP) and neoplasms with cellular atypia (IA) were reviewed. RESULTS In all, 380 individuals presented with cytologically indeterminate thyroid nodules. Of these, 252 (66%) patients had FN, 47 (12%) HN, 44 (12%) IP, 26 (7%) IA and 11 (4%) had mixed diagnoses. Biopsied lesions were found to be malignant on pathological evaluation in 102 (27%) patients: 49 (19%) with FN, 11 (23%) HN, 28 (64%) IP and 9 (35%) with IA. Hemithyroidectomy was adequate definitive treatment in 196 of 225 (87%) patients with FN and 39 of 42 (93%) with HN. Significant associations with a cancer diagnosis were identified for smaller tumour size in patients with FN (p = 0.004) and right thyroid lobe location in patients with IP (p = 0.012), although these factors were nonsignificant in the corrected analyses for multiple comparisons. CONCLUSION In a review of the experience at a Canadian centre, 4 operations were carried out to identify each cancer, and hemithyroidectomy was the optimal initial and definitive surgical approach for most patients.
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Affiliation(s)
- Connie G Chiu
- St. Paul's Hospital, Department of Surgery, University of British Columbia, Vancouver, BC
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Raj MD, Grodski S, Martin SA, Yeung M, Serpell JW. The role of fine-needle aspiration cytology in the surgical management of thyroid cancer. ANZ J Surg 2011; 80:827-30. [PMID: 20969692 DOI: 10.1111/j.1445-2197.2010.05343.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Diagnosis of thyroid malignancy relies on clinical assessment, imaging and fine-needle aspiration cytology 'FNAC' of thyroid nodules. The purpose of this study was to evaluate how effective synoptically reported FNAC is in clinical practice in diagnosing thyroid cancer. We also examined the effectiveness of using preoperative FNAC results to plan the type of operation for treating thyroid cancer. METHOD A retrospective case series of all patients undergoing thyroid surgery from 1993 to 2008 was analysed. All data were collected prospectively and recorded in a dedicated endocrine surgery database. Data analysed included age, sex, preoperative FNAC result, type of surgery, final histology and complications. Cytology was reported based on a five-tiered classification system. RESULTS There were 1373 patients in total and 125 patients with a final diagnosis of thyroid cancer. Female to male ratio was 3:1. Cytology reported as 'malignant' was confirmed as thyroid cancer in 100% of the cases. Of the patients, 47% with 'suspicious' cytology report and 14% with 'follicular/indeterminate' cytology report had a final diagnosis of cancer. Thyroid cancer subtypes were 90 patients with papillary thyroid cancer 'PTC', 24 with follicular 'FTC', eight with medullary 'MTC' and two with anaplastic cancer. Cytology was suggestive of cancer in 89% of the patients with PTC >10 mm, 75% with FTC and 88% with MTC. Transient hypocalcaemia was the commonest complication occurring in 7.2%. There were no cases of permanent hypoparathyroidism. Recurrent laryngeal nerve neuropraxia occurred in 2.4% with a permanent palsy occurring in 0.8%. There were three cancer-related deaths. CONCLUSIONS Preoperative synoptically reported FNAC is effective when used in diagnosing and planning surgery for thyroid cancer.
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Affiliation(s)
- Mariolyn D Raj
- Monash University Endocrine Surgery Unit, The Alfred Hospital, Prahran, Victoria, Australia
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Raj MD, Grodski S, Woodruff S, Yeung M, Paul E, Serpell JW. Diagnostic lobectomy is not routinely required to exclude malignancy in thyroid nodules greater than four centimetres. ANZ J Surg 2011; 82:73-7. [DOI: 10.1111/j.1445-2197.2011.05667.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Marchevsky AM, Walts AE, Bose S, Gupta R, Fan X, Frishberg D, Scharre K, Zhai J. Evidence-based evaluation of the risks of malignancy predicted by thyroid fine-needle aspiration biopsies. Diagn Cytopathol 2010; 38:252-9. [PMID: 19813257 DOI: 10.1002/dc.21185] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
A National Cancer Institute (NCI) "Thyroid Fine-Needle Aspiration (FNA) State of the Science Conference" recently proposed standardized nomenclature and "risks of malignancies" associated with various diagnostic categories. We evaluated the evidence levels of the data used by NCI to predict malignancy risks and whether those estimates had clinical validity in our patient population.Eight hundred seventy-nine patients underwent thyroid FNA during 2006. FNA diagnoses were translated into NCI diagnostic categories, and 2-year follow-up retrospective information was obtained. Four percentages of malignancies were calculated for each diagnostic category using follow-up information from FNA, thyroidectomy, both, and all patients as denominators. 95% confidence intervals (CI) were estimated for all proportions, and results were analyzed with chi-square statistics. "Relative risk" calculations were performed using the percentage of malignancies in the entire population under study as a denominator.Most of the studies cited by the NCI provided incomplete and variable level III evidence based mainly on surgical follow-up. Among our patients, the percentages of malignancies calculated with follow-up data from all patients as the denominator were similar to the "risk estimates" proposed by the NCI, but estimates based on surgical follow-up overestimated the probability of thyroid malignancy for patients with FNA diagnosis of "benign" and "follicular lesions of undetermined significance" (FLUS). Relative risk and 95% CI calculations suggested that the NCI classification could be simplified into three categories: "benign," "FLUS + neoplasm," and "suspicious + malignant."
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Affiliation(s)
- A M Marchevsky
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA90048, USA.
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Crothers BA, Tench WD, Schwartz MR, Bentz JS, Moriarty AT, Clayton AC, Fatheree LA, Chmara BA, Wilbur DC. Guidelines for the reporting of nongynecologic cytopathology specimens. Arch Pathol Lab Med 2009; 133:1743-56. [PMID: 19886707 DOI: 10.5858/133.11.1743] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2009] [Indexed: 11/06/2022]
Abstract
CONTEXT Gynecologic cytology terminology and report formatting have been nationally standardized since the implementation of The Bethesda System of 1988, but standard reporting for nongynecologic cytology has never been formally addressed on the same scale. OBJECTIVES To promote patient safety through uniform reporting in nongynecologic cytology (including fine-needle aspiration cytology) and to improve communication between laboratories and health care providers. DATA SOURCES Sources include the College of American Pathologists Cytopathology Resource Committee; the College of American Pathologists Council on Scientific Affairs Ad Hoc Committee on Pathology Report Standardization; the College of American Pathologists Laboratory Accreditation Program inspection checklists; the Joint Commission for Accreditation of Healthcare Organizations; and the Clinical Laboratory Improvement Amendments of 1988. CONCLUSIONS We describe the major elements of quality nongynecologic cytology reporting and discuss areas of controversy in cytology reporting. Standardized nongynecologic specimen reporting will expand the concept of common report elements already widely implemented in gynecologic cytology reporting. The intent is to improve communication with the health care team while remaining in compliance with federal mandates and accreditation guidelines.
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Affiliation(s)
- Barbara A Crothers
- Department of Pathology and Area Laboratory Services, Walter Reed Army Medical Center, Washington, District of Columbia 20307-5001, USA.
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Kang HP, Devine LJ, Piccoli AL, Seethala RR, Amin W, Parwani AV. Usefulness of a synoptic data tool for reporting of head and neck neoplasms based on the College of American Pathologists cancer checklists. Am J Clin Pathol 2009; 132:521-30. [PMID: 19762529 DOI: 10.1309/ajcpqzxr1nmf2vdx] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
The primary source of information that clinicians use when evaluating and managing patients with cancer is the surgical pathology report. Omission of critical information from the report is a recognized problem in pathology, especially considering the expanding amount of information, such as molecular diagnostics data, that is now routinely included in reports. To standardize surgical pathology reports, the College of American Pathologists (CAP) introduced the CAP checklists. In 2004, the American College of Surgeons Commission on Cancer mandated that 90% of pathology reports indicating a cancer diagnosis at participating centers contain all scientifically validated or regularly used data elements. The University of Pittsburgh Medical Center has implemented synoptic reporting based on the CAP checklists for all major tumor types. We report our experience with synoptic reporting on head and neck neoplasms, demonstrating, in particular, how this can be customized according to needs of each institution.
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Affiliation(s)
- Hyunseok P. Kang
- Department of Pathology and Laboratory Medicine, Roswell Park Cancer Institute, Buffalo, NY
| | - Lisa J. Devine
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA
| | - Anthony L. Piccoli
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA
| | - Raja R. Seethala
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Waqas Amin
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA
| | - Anil V. Parwani
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA
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Agarwal A, Kocjan G. FNAC thyroid reporting categories: value of using the British Thyroid Association (Thy 1 to Thy 5) thyroid FNAC reporting guidelines. Cytopathology 2009; 20:133-4. [PMID: 19207303 DOI: 10.1111/j.1365-2303.2008.00625.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Abstract
Thyroid nodules are common, with up to 8% of the adult population having palpable nodules. With the use of ultrasound, up to 10 times more nodules are likely to be detected. Increasing numbers of nodules are being detected serendipitously because of the rising use of imaging to investigate unrelated conditions. The primary aim in investigating a thyroid nodule is to exclude the possibility of malignancy, which occurs in about 5% of nodules. This begins with a thorough history, including previous exposure to radiation and any family history of thyroid cancer or other endocrine diseases. Clinical examination of the neck should focus on the thyroid nodule and the gland itself, but also the presence of any cervical lymphadenopathy. Biochemical assessment of the thyroid needs to be followed by thyroid ultrasound, which may demonstrate features that are associated with a higher chance of the nodule being malignant. Fine-needle aspiration biopsy is crucial in the investigation of a thyroid nodule. It provides highly accurate cytologic information about the nodule from which a definitive management plan can be formulated. The challenge remains in the management of nodules that fall under the "indeterminate" category. These may be subject to more surgical intervention than is required because histological examination is the only way in which a malignancy can be excluded. Surgery followed by radioactive iodine ablation is the mainstay of treatment for differentiated thyroid cancers, and the majority of patients can expect high cure rates.
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Affiliation(s)
- Meei J Yeung
- The Alfred Hospital, Monash University Endocrine Surgery Unit, Melbourne, Australia.
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