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Attia AS, Hussein S, Sameh H, Khalil A, Waley AB, Matar I, Sameh R. Diagnostic and prognostic utility of TROP-2, SLP-2, and CXCL12 expression in papillary thyroid carcinoma. Cancer Biomark 2024; 39:211-221. [PMID: 38073379 PMCID: PMC11091596 DOI: 10.3233/cbm-230230] [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: 06/20/2023] [Accepted: 10/30/2023] [Indexed: 01/01/2024]
Abstract
BACKGROUND Papillary thyroid carcinoma (PTC) is the most frequent thyroid malignancy. Histopathological examination is widely accepted as the gold standard test for the diagnosis of PTC. However, the histopathological examination sometimes can't differentiate PTC from other thyroid diseases. Differentiating PTC from other thyroid diseases is essential for a therapeutic approach and prognosis. OBJECTIVES The current study was performed to investigate the utility of TROP-2, SPL-2, and CXCL12 mRNA and protein expression in discriminating PTC from other thyroid diseases that mimic PTC. METHODS The current study was performed on 75 cases of surgically resected thyroid glands. The cases were distributed in two groups: the PTC group and the non-PTC group. The PTC group consisted of 35 cases (25 patients of the classic PTC variant and 10 patients of the PTC follicular variant). The non-PTC group consisted of 40 cases (10 cases were multinodular goiter, 5 cases were Graves' disease, 5 cases were Hashimoto thyroiditis, 15 patients were follicular adenoma (FA) and 5 cases were follicular carcinoma). TROP-2, SPL-2, and CXCL12 mRNA expression were estimated by qRT-PCR, and protein expression was estimated by immunohistochemistry. RESULTS There were upregulated TROP-2, SPL-2, and CXCL12 mRNA and protein expressions in PTC compared to non-PTC (P< 0.001, for each). There was a statistically significant upregulation in the mRNA expression of the three genes among PTC cases with larger tumor sizes (P< 0.001, for each), those with tumor stages III and IV (P= 0.008, 0.002 and < 0.001 respectively), and those with LN metastasis (P< 0.001, for each). Moreover, there was a statistically significant upregulation in CXCL-12 gene expression among PTC cases with extra-thyroid extension (P< 0.001). CONCLUSION mRNA expression of TROP-2, SPL-2, and CXCL12 among PTC cases increased in larger tumor size, tumor stages III and IV, and LN metastasis. Moreover, there was an increase in CXCL-12 gene expression among PTC cases with extra-thyroid extension. Thus, TROP-2, SPL-2, and CXCL12 expressions could be possible diagnostic and prognostic markers in PTC.
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Affiliation(s)
- Amany Selim Attia
- Department of Pathology, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt
| | - Samia Hussein
- Medical Biochemistry and Molecular Biology Department, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt
| | - Hend Sameh
- Medical Biochemistry and Molecular Biology Department, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt
| | - Amr Khalil
- Al Ahrar Oncology Center, Zagazig, Egypt
| | - Ahmad Barakat Waley
- Medical Oncology Department, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt
| | - Ihab Matar
- Surgical Oncology Department, Ismailia Teaching Oncology Hospital, Egypt
| | - Reham Sameh
- Department of Pathology, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt
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Uccella S, Dottermusch M, Erickson L, Warmbier J, Montone K, Saeger W. Inflammatory and Infectious Disorders in Endocrine Pathology. Endocr Pathol 2023; 34:406-436. [PMID: 37209390 PMCID: PMC10199304 DOI: 10.1007/s12022-023-09771-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/03/2023] [Indexed: 05/22/2023]
Abstract
A variety of inflammatory conditions may directly involve the endocrine glands, leading to endocrine dysfunction that can cause severe consequences on patients' health, if left untreated. Inflammation of the endocrine system may be caused by either infectious agents or other mechanisms, including autoimmune and other immune-mediated processes. Not infrequently, inflammatory and infectious diseases may appear as tumor-like lesions of endocrine organs and simulate neoplastic processes. These diseases may be clinically under-recognized and not infrequently the diagnosis is suggested on pathological samples. Thus, the pathologist should be aware of the basic principles of their pathogenesis, as well as of their morphological features, clinicopathological correlates, and differential diagnosis. Interestingly, several systemic inflammatory conditions show a peculiar tropism to the endocrine system as a whole. In turn, organ-specific inflammatory disorders are observed in endocrine glands. This review will focus on the morphological aspects and clinicopathological features of infectious diseases, autoimmune disorders, drug-induced inflammatory reactions, IgG4-related disease, and other inflammatory disorders involving the endocrine system. A mixed entity-based and organ-based approach will be used, with the aim to provide the practicing pathologist with a comprehensive and practical guide to the diagnosis of infectious and inflammatory disorders of the endocrine system.
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Affiliation(s)
- Silvia Uccella
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanule, Milan, Italy
- Pathology Service IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan, Italy
| | - Matthias Dottermusch
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lori Erickson
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN USA
| | - Julia Warmbier
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kathleen Montone
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA USA
| | - Wolfgang Saeger
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Morovat P, Morovat S, Hosseinpour M, Moslabeh FGZ, Kamali MJ, Samadani AA. Survival-based bioinformatics analysis to identify hub long non-coding RNAs along with lncRNA-miRNA-mRNA network for potential diagnosis/prognosis of thyroid cancer. J Cell Commun Signal 2023; 17:639-655. [PMID: 36149574 PMCID: PMC10409689 DOI: 10.1007/s12079-022-00697-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 09/07/2022] [Indexed: 11/26/2022] Open
Abstract
Thyroid cancer (TC) is the most common endocrine cancer, accounting for 1.7% of all cancer cases. It has been reported that the existing approach to diagnosing TC is problematic. Therefore, it is essential to develop molecular biomarkers to improve the accuracy of the diagnosis. This study aimed to screen hub lncRNAs in the ceRNA network (ceRNET) connected to TC formation and progression based on the overall survival rate. In this study, first, RNA-seq data from the GDC database were collected. A package called edgeR in R programming language was then used to obtain differentially expressed lncRNAs (DElncRNAs), miRNAs (DEmiRNAs), and mRNAs (DEmRNAs) in TC patients' samples compared to normal samples. Second, DEmRNAs were analyzed for their functional enrichment. Third, to identify RNAs associated with overall survival, the overall survival of these RNAs was analyzed using the Kaplan-Meier plotter database to create a survival associated with the ceRNA network (survival-related ceRNET). Next, the GeneMANIA plugin was used to construct a PPI network to better understand survival-related DEmRNA interactions. The survival ceRNET was then visualized with the Cytoscape software, and hub genes, including hub lncRNAs and hub mRNAs, were identified using the CytoHubba plugin. We found 45 DElncRNAs, 28 DEmiRNAs, and 723 DEmRNAs among thyroid tumor tissue and non-tumor tissue samples. According to KEGG, GO and DO analyses, 723 DEmRNAs were mainly enriched in cancer-related pathways. Importantly, the results found that ten DElncRNAs, four DEmiRNAs, and 68 DEmRNAs are associated with overall survival. In this account, the PPI network was constructed for 68 survival-related DEmRNAs, and ADAMTS9, DTX4, and CLDN10 were identified as hub genes. The ceRNET was created by combining six lncRNAs, 109 miRNAs, and 22 mRNAs related to survival using Cytoscape. in this network, ten hub RNAs were identified by the CytoHubba plugin, including mRNAs (CTXND1, XKRX, IGFBP2, ENTPD1, GALNT7, ADAMTS9) and lncRNAs (AC090673.1, AL162511.1, LINC02454, AL365259.1). This study suggests that three lncRNAs, including AL162511.1, AC090673.1, and AL365259.1, could be reliable diagnostic biomarkers for TC. The findings of this study provide a basis for future studies on the therapeutic potential of these lncRNAs.
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Affiliation(s)
- Pejman Morovat
- Department of Medical Biotechnology, School of Medicine, Babol University of Medical Sciences, Babol, Iran
- Student Research Committee, Babol University of Medical Sciences, Babol, Iran
| | - Saman Morovat
- Department of Medical Genetics and Molecular Biology, Faculty of Medicine, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Milad Hosseinpour
- Department of Medical Genetics and Molecular Biology, Faculty of Medicine, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | | | - Mohammad Javad Kamali
- Department of Medical Genetics, School of Medicine, Babol University of Medical Sciences, Babol, Iran
| | - Ali Akbar Samadani
- Guilan Road Trauma Research Center, Guilan University of Medical Sciences, Rasht, Iran.
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Abu-Seadah SS, Attiah SM, Ali MY, Shams Eldin M, El-Kholy MAM. Immunohistochemical Expression of HBME-1 and TROP-2 in Some Follicular-Derived Thyroid Lesions. Asian Pac J Cancer Prev 2023; 24:2305-2311. [PMID: 37505760 PMCID: PMC10676500 DOI: 10.31557/apjcp.2023.24.7.2305] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 07/11/2023] [Indexed: 07/29/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Detecting thyroid tumors depends on histologic characteristics. However, distinguishing malignant from benign thyroid abnormalities may be challenging and contentious, particularly in tumors with a follicular appearance. Therefore, immunohistochemistry might be useful and essential. Immunohistochemical biomarkers, such as human trophoblast cell surface antigen (TROP) and Hector Battifora Mesothelial-1 (HBME-1), have helped diagnose thyroid cancers. In addition, mesothelial cells have an antigen called HBME-1 on their membranes, but its role is unclear. Thyroid epithelial neoplasms have lately been studied, and TROP-2 is a helpful marker of these tumors. Recently, researchers have explored HBME-1 upregulation in benign and malignant thyroid tumors. This research aimed to show that the immunohistochemical biomarkers TROP-2 and HBME-1 might be employed to distinguish malignant from benign follicular-derived thyroid lesions. MATERIALS AND METHODS The research consisted of 50 specimens of various follicular thyroid lesions. From October 2018 to March 2021, blocks of follicular thyroid lesions and clinical information were collected from the Pathology Departments of Al-Azhar University Hospitals. Additionally, the HBME-1 and TROP-2 antigens were stained immunohistochemically. RESULTS Expression of TROP-2 along with HBME-1 distinguished benign from malignant follicular-derived thyroid lesions with respective sensitivities of 74.2 and 87.1% and specificities of 84.2 and 78.9%. Furthermore, positive HBME-1 expression was significantly less prevalent in benign lesions (15.8%) than in malignant lesions (74.2%) (P-value <0.001). Moreover, positive TROP-2 expression was significantly lower in benign lesions (21.1%) than in malignant lesions (87.1%) (P-value <0.001). The P value of <0.001 indicated an extremely strong positive correlation between HBME-1 and TROP-2 expression across all instances investigated. CONCLUSION With high sensitivity and specificity, both HBME-1 and TROP-2 are beneficial in identifying thyroid cancer, particularly papillary carcinoma, and separating malignant follicular-derived thyroid lesions from benign ones.
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Affiliation(s)
| | - Samah Mohamed Attiah
- Department of Pathology, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt.
| | - Mohamed Yousef Ali
- Department of Pathology, Faculty of Medicine for Boys, Al-Azhar University, Cairo, Egypt.
| | - Mohamed Shams Eldin
- Department of Otorhinolaryngology, Faculty of Medicine, Al‐Azhar University, Cairo 1675, Egypt.
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Crescenzi A, Baloch Z. Immunohistochemistry in the pathologic diagnosis and management of thyroid neoplasms. Front Endocrinol (Lausanne) 2023; 14:1198099. [PMID: 37324272 PMCID: PMC10266214 DOI: 10.3389/fendo.2023.1198099] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 05/10/2023] [Indexed: 06/17/2023] Open
Abstract
The use of immunohistochemistry cannot be underestimated in the everyday practice of thyroid pathology. It has evolved over the years beyond the traditional confirmation of thyroid origin to molecular profiling and the prediction of clinical behavior. In addition, immunohistochemistry has served to implement changes in the current thyroid tumor classification scheme. It is prudent to perform a panel of immunostains, and the immunoprofile should be interpreted in light of the cytologic and architectural features. Immunohistochemistry can also be easily performed in the limited cellularity specimen preparation generated from thyroid fine-needle aspiration and core biopsy; however, it will require laboratory validation of immunostains specific to these preparations to avoid diagnostic pitfalls. This review discusses the application of immunohistochemistry in thyroid pathology with a focus on limited cellularity preparations.
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Affiliation(s)
- Anna Crescenzi
- Pathology, University Campus Bio-Medico of Rome, Fondazione Policlinico, Rome, Italy
| | - Zubair Baloch
- Pathology & Laboratory Medicine, University of Pennsylvania Medical Center, Perelman School of Medicine, Philadelphia, PA, United States
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Asghari A, Vosough Z, Khafri S, Sadr Moharrerpour S, Ghorbani H. Scoring System and Diagnosis of Papillary Thyroid Carcinoma Using Human Bone Marrow Endothelium Marker-1, Cytokeratin 19, and Galectin-3. Med J Islam Repub Iran 2023; 37:25. [PMID: 37180862 PMCID: PMC10167649 DOI: 10.47176/mjiri.37.25] [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: 04/05/2022] [Indexed: 03/22/2023] Open
Abstract
Background The increasing incidence of papillary thyroid carcinoma (PTC) and the inadequacy of routine histologic examination in its diagnosis necessitate the application of ancillary studies like immunohistochemistry. This research aimed to investigate the scoring system and diagnosis of PTC with cytokeratin 19 (CK19), human bone marrow endothelium marker-1 (HBME-1), and galectin-3. Methods This experimental laboratory study was performed at Babol University of Medical Sciences, Mazandaran, Iran from April 2017 to March 2019. Neoplastic and nonneoplastic tissue samples of 100 cases with a diagnosis of PTC were selected by convenience sampling. CK19, HBME-1, and galectin-3 immunohistochemistry markers were used on tissue samples. Analysis was performed using the t test and the chi-square test, as well as the receiver operator characteristic (ROC) curve (significance level P < 0.05). Results The CK19 staining was observed in all 100 (100%) non-neoplastic tissues, but HBME-1 and galectin-3 were positive in 36 (36%) and 14 (14%) of non-neoplastic tissues, respectively. The intensity scores of all the markers and their total had significantly different means in PTC and non-neoplastic tissues (P < 0.001). A significant difference was observed between the total score of each marker and the total score of their combination (P < 0.001). The combination of all 3 markers with an 11.5 0 cut-off for the total score showed the most sensitive (0.99) and specific (1.00) results. Conclusion Interpreting CK19, HBME-1, and galectin-3 with the aid of the proposed scoring system was fruitful. HBME-1 and galectin-3 can be used individually or in combination for the diagnosis of PTC.
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Affiliation(s)
- Abolfazl Asghari
- Department of Pathology, Faculty of Medicine, Babol University of Medical Sciences, Babol, Iran
| | - Zeinab Vosough
- Department of Pathology, Faculty of Medicine, Babol University of Medical Sciences, Babol, Iran
| | - Soraya Khafri
- Department of Biostatistics and Epidemiology, Faculty of Medicine, Babol University of Medical Sciences, Babol, Iran
| | - Sahar Sadr Moharrerpour
- Non-Communicable Pediatric Disease Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
| | - Hossein Ghorbani
- Department of Pathology, Faculty of Medicine, Babol University of Medical Sciences, Babol, Iran
- Clinical Research Development Unit of Rouhani Hospital, Babol University of Medical Sciences, Babol, Iran
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Kılınc E, Gunes P, Doganer A. TROP2 is a Good Indicator for Infiltrative Nature of Carcinoma Rather than Diagnosing Malignancy in Thyroid. Indian J Otolaryngol Head Neck Surg 2022; 74:2560-2568. [PMID: 36452626 PMCID: PMC9702226 DOI: 10.1007/s12070-020-02275-0] [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: 10/08/2020] [Accepted: 11/09/2020] [Indexed: 11/28/2022] Open
Abstract
TROP2 is a glycoprotein which is expressed in carcinomas rather than normal tissues and associated with poor prognosis. Immunohistohemical TROP2 staining was determined to be useful for diagnosing papillary thyroid carcinoma (PTC). In this study, we aimed to find out relationship between TROP-2 expression and the diagnosis of PTC, and clinico pathological parameters. This retrospective study was conducted on 270 cases (145 malignant and 124 benign). All histopathological parameters were re-evaluated blindly. We used 3 different scores for positivity for TROP2 expression (TES: Total estimation score, 5%, IRS:Immunoreactive score). Sensitivity was respectively according to TES, 5%and IRS; 55.5%, 54.1%, 51.4%. Specificity was 98.4% in all different scores. TROP2 positivity was correlated with older age in 5% score and TES. Absence of encapsulation, presence of infiltrating spreading, perineural invasion, extra thyroidal extension, tall cell and/or hobnail differentiation were associated with TROP2 expression in three different scores. Presence of lymphatic invasion was correlated with TROP2 positivity in 5% score and IRS. TROP2 expression was inversely proportional to follicular variant PTC and tumour size in 5% score. TROP-2 is a marker for aggressive behaviour rather than detecting malignancy, but if it stained and not malignant, it may also have potential for determining precursor lesion that demands further studies. Additionally, in 3 different scores, TES was most sensitive, but most variable that had correlation with TROP2 was seen at 5% score.
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Affiliation(s)
- E. Kılınc
- Pathology Department, Kahramanmaras Sutcu Imam University, Kahramanmaras, Turkey
| | - P. Gunes
- Pathology Department, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
| | - A. Doganer
- Biostatistics Department, Kahramanmaras Sutcu Imam University, Kahramanmaras, Turkey
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Song D, Dong F, Zheng J, Luo H, Wei J. Application Value of Color Doppler Ultrasonography Combined with Thyroid Autoantibody Tests in Early Diagnosis of Thyroid Cancer. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:5248230. [PMID: 35529260 PMCID: PMC9068283 DOI: 10.1155/2022/5248230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 03/18/2022] [Accepted: 04/09/2022] [Indexed: 11/17/2022]
Abstract
Objective To explore the application value of color Doppler ultrasonography combined with thyroid autoantibody tests in the early diagnosis of thyroid cancer. Methods The medical data of 100 patients with thyroid nodules treated in our hospital from June 2019 to June 2021 were retrospectively analyzed; all patients received color Doppler ultrasonography and thyroid autoantibody tests before surgery and were divided into the benign lesion group (n = 45) and the malignant lesion group (n = 55) according to the postoperative pathological findings (the gold standard), so as to compare and analyze the application value of color Doppler ultrasonography, thyroid autoantibody tests, and their combination in the early diagnosis of thyroid cancer. Results Compared with the pathological findings, the accuracy rate, sensitivity, specificity, positive predictive value, and negative predictive value of the combined diagnosis were significantly higher than those in the single diagnosis of color Doppler ultrasonography, TgAb test, TPOAb test, and TRAb test (P < 0.05), and by plotting the ROC curves to analyze the effect of these modalities in diagnosing early thyroid diseases, the results showed that the areas under the curve from large to small were combined diagnosis, color Doppler ultrasonography, TgAb test, TPOAb test, and TRAb test. Conclusion Color Doppler ultrasonography has many advantages in the diagnosis of thyroid nodules, such as easy operation, painlessness, noninvasiveness, high efficiency, and repeatable detection, and the high-definition probe is able to show tiny lesions, echogenicity, blood flow signal, and other characteristics of foci. Combining color Doppler ultrasonography with testing thyroid autoantibodies such as TgAb, TPOAb, and TRAb can effectively improve the detection rate of early thyroid cancer, presenting significant reference value and meaning to clinical diagnosis and treatment of thyroid cancer.
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Affiliation(s)
- Danlin Song
- Department of Ultrasound, Shenzhen People's Hospital, 2nd Clinical Medical College of Jinan University, 1st Affiliated Hospital of Southern University of Science and Technology, Shenzhen, 518020 Guangdong, China
| | - Fajin Dong
- Department of Ultrasound, Shenzhen People's Hospital, 2nd Clinical Medical College of Jinan University, 1st Affiliated Hospital of Southern University of Science and Technology, Shenzhen, 518020 Guangdong, China
| | - Jing Zheng
- Department of Ultrasound, Shenzhen People's Hospital, 2nd Clinical Medical College of Jinan University, 1st Affiliated Hospital of Southern University of Science and Technology, Shenzhen, 518020 Guangdong, China
| | - Hui Luo
- Department of Ultrasound, Shenzhen People's Hospital, 2nd Clinical Medical College of Jinan University, 1st Affiliated Hospital of Southern University of Science and Technology, Shenzhen, 518020 Guangdong, China
| | - Jinxi Wei
- Department of Radiology, Shenzhen People's Hospital, 2nd Clinical Medical College of Jinan University, 1st Affiliated Hospital of Southern University of Science and Technology, Shenzhen, 518020 Guangdong, China
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Cazzaniga G, Seminati D, Smith A, Piga I, Capitoli G, Garancini M, L'Imperio V, Fusco N, Pagni F. Lights on HBME-1: the elusive biomarker in thyroid cancer pathology. J Clin Pathol 2022; 75:588-592. [PMID: 35444029 DOI: 10.1136/jclinpath-2022-208248] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 03/31/2022] [Indexed: 11/03/2022]
Abstract
Among the different ancillary immunohistochemical tools that pathologists may employ in thyroid nodules, the so-called Hector Battifora's 'MEsothelioma' 1 (HBME-1) staining is one of the most fascinating, since its real identity is currently unknown. In the present review, the different clinical applications of HBME-1 are analysed, with main emphasis on its role in thyroid pathology with overview on less impactful fields, such as haematopathology or mesothelial lesions. Different acceptable or good diagnostic performances were recorded for HBME-1 in thyroid pathology, being used in routine practice as one of the best tools to screen thyroid malignancy both in terms of sensitivity and specificity. From a speculative point of view, after many attempts to hunt the cryptic target antigen of this antibody, its identity still remains elusive. In this setting, the application of high-throughput technologies (mainly in situ proteomics) may be the exact route to improve the knowledge about the pathophysiology of HBME-1 and to finally unveil its true identity.
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Affiliation(s)
- Giorgio Cazzaniga
- Department of Medicine and Surgery, Pathology, University of Milano-Bicocca, Monza, Italy
| | - Davide Seminati
- Department of Medicine and Surgery, Pathology, University of Milano-Bicocca, Monza, Italy
| | - Andrew Smith
- Proteomics and Metabolomics Unit, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Isabella Piga
- Proteomics and Metabolomics Unit, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Giulia Capitoli
- Bicocca Bioinformatics Biostatistics and Bioimaging B4 Center, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Mattia Garancini
- Department of Surgery, ASST Monza - San Gerardo Hospital, Monza, Italy
| | - Vincenzo L'Imperio
- Department of Medicine and Surgery, Pathology, University of Milano-Bicocca, Monza, Italy
| | - Nicola Fusco
- Division of Pathology, IEO, European Institute of Oncology IRCCS, Milano, Italy
| | - Fabio Pagni
- Department of Medicine and Surgery, Pathology, University of Milano-Bicocca, Monza, Italy
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Seok JY, Fan X. TROP-2 and 5hmC expression in follicular-patterned thyroid neoplasm emphasizing tiny well-formed papillae. Ann Diagn Pathol 2022; 57:151903. [PMID: 35121239 DOI: 10.1016/j.anndiagpath.2022.151903] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 01/21/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Follicular-patterned thyroid neoplasms (FPTNs), characterized by predominantly follicular growth pattern, represent diverse pathological entities. We aimed to study the nuclear features and the immunoexpression of trophoblast cell-surface antigen 2 (TROP-2) and 5-hydroxymethylcytosine (5hmC) in FPTNs. DESIGN FPTNs were divided into 4 groups: I) noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP), II) encapsulated follicular variant of papillary thyroid carcinoma (FVPTC) with capsular invasion, III) infiltrative FVPTC, and IV) PTC with a predominantly follicular pattern and well-formed papillae (<1%). Nuclear characteristics were evaluated by image analysis. TROP-2 and 5hmC immunostains were analyzed correlating with histological features using QuPath. RESULTS From the group I to II, III, and IV, there is a gradual increase in nuclear atypia in terms of the nuclear area, max caliper, perimeter, circularity, and hematoxylin OD means (corresponding to nuclear enlargement, membrane irregularity, and clearing). A similar trend is observed in the TROP-2 expression. 5hmC expression is highly preserved in groups I, II, and III in contrast to a significant loss in group IV. Group IV tumors show more frequent regional lymph node involvement and the highest BRAF V600E mutation rate. CONCLUSION Among FPTNs, group IV tumors exhibit the most advanced nuclear atypia, highest TROP-2 expression, significant 5HMC expression loss, frequent regional lymph node involvement, and the highest BRAF V600E mutation rate. Our data further support that the presence of any true papillae should be an exclusion criterion for NIFTP. Therefore, well-formed papillae even if very minute (<1% of the tumor) should not be overlooked.
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Affiliation(s)
- Jae Yeon Seok
- Department of Pathology, Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea; Department of Pathology & Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Xuemo Fan
- Department of Pathology & Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
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Lam AK, Lee KTW. Application of Immunohistochemistry in Papillary Thyroid Carcinoma. Methods Mol Biol 2022; 2534:175-195. [PMID: 35670976 DOI: 10.1007/978-1-0716-2505-7_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Immunohistochemistry (IHC) is an economic and precise method to localize the presence of specific protein at cellular level in tissue. Although many papillary thyroid carcinomas do not require IHC to render a diagnosis, there are certain scenarios in which IHC are important. The major diagnostic applications of IHC include confirmation of papillary thyroid carcinoma in sites other than the thyroid, distinguish papillary thyroid carcinoma from other primary thyroid neoplasms in thyroid, and identify papillary thyroid carcinoma from secondary tumors to the thyroid. At research level, IHC could help identify prognostic information, identify underlying genetic alterations, and predict response to treatment in papillary thyroid carcinoma. The understanding of principle and recent advances in IHC will improve the diagnosis and management of patients with thyroid lesions including papillary thyroid carcinoma.
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Affiliation(s)
- Alfred K Lam
- Cancer Molecular Pathology of School of Medicine and Dentistry, Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD, Australia.
- Pathology Queensland, Gold Coast University Hospital, Southport, QLD, Australia.
- Faculty of Medicine, University of Queensland, Herston, QLD, Australia.
| | - Katherine Ting-Wei Lee
- Cancer Molecular Pathology of School of Medicine and Dentistry, Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD, Australia
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Immunohistochemistry Helps to Distinguish Noninvasive Follicular Thyroid Neoplasm with Papillary-like Nuclear Features/Noninvasive Encapsulated Follicular Variant of Papillary Thyroid Carcinoma with Other Follicular Thyroid Lesions. Medicina (B Aires) 2021; 57:medicina57111246. [PMID: 34833464 PMCID: PMC8624760 DOI: 10.3390/medicina57111246] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 11/12/2021] [Accepted: 11/12/2021] [Indexed: 12/31/2022] Open
Abstract
Background and Objectives: We aimed to assess the diagnostic value of various immunohistochemical (IHC) markers and panels for differentiation among benign follicular nodules (BFNs), noninvasive follicular thyroid neoplasms with papillary-like nuclear features (NIFTPs), noninvasive encapsulated follicular variants of papillary thyroid carcinoma (NEFVPTCs), and infiltrative FVPTC (IFVPTC). Materials and Methods: Sixty-three cases were classified as BFNs, NIFTPs, NEFVPTCs, or IFVPTCs and were evaluated using the following markers: CK19, CD56, galectin-3, CITED1, HBME-1, VE1, and TROP-2. Results: The IHC results for NIFTP and NEFVPTC exhibited no statistically significant differences. In differentiating IFVPTCs from BFNs and NIFTPs/NEFVPTCs, galectin-3 and TROP-2 were the markers with the highest sensitivity plus high specificity, respectively. In various combinations, panel co-expression of two markers, including galectin-3 and/or HBME-1 and/or TROP-2, and the combination of galectin-3 and TROP-2 co-expression could achieve 100% in all aspects. In terms of discrimination of BFNs from NIFTP/NEFVPTC, CK19 was the single most sensitive marker (81.3%), while CD56 was the most specific (100%). The panel consisting of CK19 and/or HBME-1 exhibited the greatest sensitivity (96.9%), but the panel with CD56 and/or HBME-1 exhibited the greatest specificity (90.5%). Conclusions: Our results broaden the use of IHC markers for differential diagnoses among the four groups of follicular-based lesions. In addition, the similar IHC profiles of NIFTP and NEFVPTC also suggest the original criterion of <1% papillae within tumors, providing a reliable NIFTP diagnosis. Their close relationship may represent a spectrum of progressing neoplasia.
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Gupta S, Dey P. Diagnostic challenges in the gray-zone lesions of fine-needle aspiration cytology. Cytojournal 2021; 18:23. [PMID: 34754322 PMCID: PMC8571265 DOI: 10.25259/cytojournal_66_2020] [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: 10/03/2020] [Accepted: 05/31/2021] [Indexed: 11/10/2022] Open
Abstract
Fine-needle aspiration cytology (FNAC) is an excellent technique for rapid diagnosis due to its speed, accuracy, and cost-effectiveness. However, there are many gray-zone areas in cytology that needs attention. These lesions in the aspiration cytology can be overcome by applying the selective use of the series of tests. This review discusses the diagnostic challenges in the gray-zone areas in FNAC. It emphasizes the use of selective ancillary techniques to solve the problems in this area.
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Affiliation(s)
- Shruti Gupta
- Department of Cytology and Gynaecological Pathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Pranab Dey
- Department of Cytology and Gynaecological Pathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Xiong Y, Li X, Liang L, Li D, Yan L, Li X, Di J, Li T. Application of biomarkers in the diagnosis of uncertain samples of core needle biopsy of thyroid nodules. Virchows Arch 2021; 479:961-974. [PMID: 34308507 PMCID: PMC8572826 DOI: 10.1007/s00428-021-03161-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 07/10/2021] [Accepted: 07/12/2021] [Indexed: 11/25/2022]
Abstract
Core needle biopsy (CNB) is now more frequently used for the preoperative diagnosis of thyroid nodules. Based on morphology alone, 5–20% of CNB samples cannot be determined as malignant or benign. Compared to fine-needle biopsy (FNB), samples collected by CNB are more accessible for various tests. Therefore, studying biomarkers’ application in distinguishing uncertain CNB samples of thyroid nodules is a practical need. Patients of thyroid nodules with both CNB and matched resected specimens were reviewed. Cases classified as indeterminate lesions, follicular neoplasms, and suspicious for malignancy were retrieved. All CNB samples were stained by immunohistochemistry (IHC) using antibodies against CK19, galectin-3, HBME-1, and CD56 and detected by next-generation sequencing (NGS) using an OncoAim® thyroid cancer multigene assay kit (Singlera Genomics) that detected 26 genes. Taking the resected specimens’ classification as the gold standard, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy of a single biomarker, and various combinations for discriminating malignancy from benignity were calculated. The sensitivity, specificity, PPV, NPV, and accuracy for preoperative malignancy evaluation were as follows. In the cohort of non-follicular-neoplasm-lesions (non-FN-lesion), they were 95.16%, 53.85%, 90.77%, 70.00%, and 88.00% for CK19; 95.16%, 38.46%, 88.06%, 62.50%, and 85.33% for galectin-3; 77.42%, 76.92%, 94.12%, 41.67%, and 58.00% for HBME-1; 66.13%, 100.00%, 100.00%, 38.24%, and 72.00% for CD56; 90.32%, 92.31%, 98.25%, 66.67%, and 90.67% for NGS; and 88.71%, 92.30%, 98.21%, 63.16%, and 89.33% for integrated IHC. In the cohort of follicular neoplasms (FN), they were 30.43%, 77.77%, 77.77%, 30.43%, and 43.75% for CK19; 73.91%, 66.67%, 85.00%, 50.00%, and 71.88% for galectin-3; 26.09%, 88.89%, 85.71%, 32.00%, and 43.75% for HBME-1; 26.09%, 100.00%, 100.00%, 34.62%, and 46.88% for CD56; 52.17%, 88.89%, 92.31%, 42.11%, and 62.50% for NGS; 82.61%, 66.67%, 86.36%, 60.00%, and 78.13% for integrated IHC; and 100%, 66.67%, 88.46%, 100%, and 90.63% for integrated IHC-NGS. The application of biomarkers in distinguishing uncertain CNB samples of thyroid nodules is available and capable. CD56 negative or NGS positive suggests malignancy strongly for both FN and non-FN-lesion, which may be used as a “rule in” tool. The negative predictive value of the integrated IHC and the integrated IHC-NGS implies a high possibility to be benign for non-FN-lesion and FN separately, which can work as a “rule out” tool. Considering the balance of specificity and sensitivity, NGS is the best for non-FN-lesion and the integrated IHC-NGS is the best for FN.
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Affiliation(s)
- Yan Xiong
- Department of Pathology, Peking University First Hospital, 7 Xishiku Street, Xicheng District, Beijing, 100034, China.
| | - Xin Li
- Department of Pathology, Peking University First Hospital, 7 Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Li Liang
- Department of Pathology, Peking University First Hospital, 7 Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Dong Li
- Department of Pathology, Peking University First Hospital, 7 Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Limin Yan
- Department of Pathology, Tangshan Gongren Hospital, 27 Wenhua Road, Lubei District, Tangshan, 063000, Hebei, China
| | - Xueying Li
- Department of Biostatistics, Peking University First Hospital, 7 Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Jiting Di
- Department of Pathology, Peking University First Hospital, 7 Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Ting Li
- Department of Pathology, Peking University First Hospital, 7 Xishiku Street, Xicheng District, Beijing, 100034, China
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Seok JY, Astvatsaturyan K, Peralta-Venturina MD, Lai J, Fan X. TROP-2, 5hmC, and IDH1 Expression in Anaplastic Thyroid Carcinoma. Int J Surg Pathol 2020; 29:368-377. [PMID: 33289434 DOI: 10.1177/1066896920978597] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Anaplastic thyroid carcinoma (ATC), a highly aggressive malignancy, has no effective treatment to date. Trophoblast cell-surface antigen 2 (TROP-2), a transmembrane glycoprotein, has been suggested to be a promising novel target for sacituzumab govitecan, an antibody-drug conjugate. 5-Hydroxymethylcytosine (5hmC) has a role in tumor suppression and promoting modification. Additionally, isocitrate dehydrogenase 1 (IDH1) mutations are strongly associated with increased overall survival in gliomas and worse prognosis in leukemias. This study attempts to evaluate the immunoexpression of TROP-2, 5hmC, and IDH1 in ATCs and to determine their potential impact in targeted therapy. METHODS Twenty-four ATCs were retrieved, with 9 cases that occurred de novo and 15 cases derived from either papillary thyroid carcinoma (PTC) or follicular thyroid carcinoma (FTC). Sections were immunostained with TROP-2, 5hmC, and IDH1 antibodies, and evaluated using the QuPath program. The t tests were performed using SPSS software. RESULTS TROP-2 was detected in 12 ATCs with 9 cases demonstrating a high expression and in all PTC components, and absent in all FTC components of secondary ATCs. 5hmC expression was moderately reduced in PTC and FTC components and markedly reduced in ATC. The entire cohort showed a total absence of IDH1. CONCLUSIONS Increased TROP-2 immunoexpression in some ATCs supports that these patients may potentially benefit from an antibody-drug conjugate therapy targeting TROP-2. Markedly reduced 5hmC expression suggests that 5hmC may be used as potential therapeutic targets for ATC. The total lack of IDH1 R132H mutation by immunostain indicates that it has no prognostic and therapeutic value in ATC.
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Affiliation(s)
- Jae Yeon Seok
- Department of Pathology, Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea.,Department of Pathology & Laboratory Medicine, 548288Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Kristine Astvatsaturyan
- Department of Pathology & Laboratory Medicine, 548288Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | - Jinping Lai
- 23542Kaiser Permanente Sacramento Medical Center, Sacramento, CA, USA
| | - Xuemo Fan
- Department of Pathology & Laboratory Medicine, 548288Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Zhang B, Gao S, Li R, Li Y, Cao R, Cheng J, Guo Y, Wang E, Huang Y, Zhang K. Tissue mechanics and expression of TROP2 in oral squamous cell carcinoma with varying differentiation. BMC Cancer 2020; 20:815. [PMID: 32854652 PMCID: PMC7450929 DOI: 10.1186/s12885-020-07257-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 08/04/2020] [Indexed: 12/15/2022] Open
Abstract
Background Trophoblast cell surface antigen 2 (TROP2) is overexpressed in many squamous cell carcinomas and promotes tumor development and invasion. The association between TROP2 expression and occurrence and development of oral squamous cell carcinoma (OSCC) remains to be understood. Methods We investigated the role of TROP2 in OSCC patients using a combination of biophysical approaches. A total of 108 OSCC patient specimens with varying degrees of differentiation were subjected to hematoxylin and eosin staining, immunohistochemistry, Kaplan-Meier survival curve analysis, and atomic force microscopy to analyze TROP2 expression, morphology, and mechanical properties of OSCC tissues. Results TROP2 was overexpressed in 34% of poorly differentiated OSCC samples. High levels of TROP2 were associated with 10.2% survival rate lower than 45.4% and patient age (odds ratio [OR] = 0.437, P = 0.039, 95% confidence interval [CI, 0.198–0.966]), tumor size (OR = 13.148, P = 0.000, 95% CI [5.060–34.168]), and TNM stage (OR = 0.141, P = 0.000, 95% CI [0.082–0.244]). Average surface roughness of low, medium, and highly differentiated OSCC tissues were 448.9 ± 54.8, 792.7 ± 83.6, and 993.0 ± 104.3 nm, respectively. The Pearson coefficient revealed a negative association between tumor stiffness and TROP2 expression (r = − 0.84, P < 0.01). Conclusion Overexpression of TROP2 negatively associated with patient survival, degree of tumor differentiation, and tissue mechanics. Taken together, our findings demonstrated that TROP2 may be an indicator of OSCC differentiation leading to the altered mechanical properties of OSCC tissues.
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Affiliation(s)
- Baoping Zhang
- Department (Hospital) of Stomatology, Lanzhou University, Donggang west Road 199, Lanzhou, 730000, Gansu, China.,Institute of Biomechanics and Medical Engineering, Lanzhou University, Lanzhou, 730000, China
| | - Shuting Gao
- Department (Hospital) of Stomatology, Lanzhou University, Donggang west Road 199, Lanzhou, 730000, Gansu, China
| | - Ruiping Li
- Department (Hospital) of Stomatology, Lanzhou University, Donggang west Road 199, Lanzhou, 730000, Gansu, China
| | - Yiting Li
- Department (Hospital) of Stomatology, Lanzhou University, Donggang west Road 199, Lanzhou, 730000, Gansu, China
| | - Rui Cao
- Department (Hospital) of Stomatology, Lanzhou University, Donggang west Road 199, Lanzhou, 730000, Gansu, China
| | - Jingyang Cheng
- Department (Hospital) of Stomatology, Lanzhou University, Donggang west Road 199, Lanzhou, 730000, Gansu, China
| | - Yumeng Guo
- Department (Hospital) of Stomatology, Lanzhou University, Donggang west Road 199, Lanzhou, 730000, Gansu, China
| | - Errui Wang
- Department (Hospital) of Stomatology, Lanzhou University, Donggang west Road 199, Lanzhou, 730000, Gansu, China
| | - Ying Huang
- Department (Hospital) of Stomatology, Lanzhou University, Donggang west Road 199, Lanzhou, 730000, Gansu, China
| | - Kailiang Zhang
- Department (Hospital) of Stomatology, Lanzhou University, Donggang west Road 199, Lanzhou, 730000, Gansu, China.
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Armanious H, Adam B, Meunier D, Formenti K, Izevbaye I. Digital gene expression analysis might aid in the diagnosis of thyroid cancer. ACTA ACUST UNITED AC 2020; 27:e93-e99. [PMID: 32489258 DOI: 10.3747/co.27.5533] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background Thyroid cancer represents approximately 90% of endocrine cancers. Difficulties in diagnosis and low inter-observer agreement are sometimes encountered, especially in the distinction between the follicular variant of papillary thyroid carcinoma (fvptc) and other follicular-patterned lesions, and can present significant challenges. In the present proof-of-concept study, we report a gene-expression assay using NanoString nCounter technology (NanoString Technologies, Seattle, WA, U.S.A.) that might aid in the differential diagnosis of thyroid neoplasms based on gene-expression signatures. Methods Our cohort included 29 patients with classical papillary thyroid carcinoma (ptc), 13 patients with fvptc, 14 patients with follicular thyroid carcinoma (ftc), 14 patients with follicular adenoma (fa), and 14 patients without any abnormality. We developed a 3-step classifier that shows good correlation with the pathologic diagnosis of various thyroid neoplasms. Step 1 differentiates normal from abnormal thyroid tissue; step 2 differentiates benign from malignant lesions; and step 3 differentiates the common malignant entities ptc, ftc, and fvptc. Results Using our 3-step classifier approach based on selected genes, we developed an algorithm that attempts to differentiate thyroid lesions with varying levels of sensitivity and specificity. Three genes-namely SDC4, PLCD3, and NECTIN4/PVRL4-were the most informative in distinguishing normal from abnormal tissue with a sensitivity and a specificity of 100%. One gene, SDC4, was important for differentiating benign from malignant lesions with a sensitivity of 89% and a specificity of 92%. Various combinations of genes were required to classify specific thyroid neoplasms. Conclusions This preliminary proof-of-concept study suggests a role for nCounter technology, a digital gene expression analysis technique, as an adjunct assay for the molecular diagnosis of thyroid neoplasms.
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Affiliation(s)
- H Armanious
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB.,Alberta Public Laboratories, University of Alberta, Edmonton, AB
| | - B Adam
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB.,Alberta Public Laboratories, University of Alberta, Edmonton, AB
| | - D Meunier
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB.,Alberta Public Laboratories, University of Alberta, Edmonton, AB
| | - K Formenti
- Alberta Public Laboratories, University of Alberta, Edmonton, AB
| | - I Izevbaye
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB.,Alberta Public Laboratories, University of Alberta, Edmonton, AB
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