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Antonia TD, Maria LI, Ancuta-Augustina GG. Preoperative evaluation of thyroid nodules - Diagnosis and management strategies. Pathol Res Pract 2023; 246:154516. [PMID: 37196471 DOI: 10.1016/j.prp.2023.154516] [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: 02/20/2023] [Accepted: 05/06/2023] [Indexed: 05/19/2023]
Abstract
Thyroid cancer is the most common endocrine malignancy, with increasing incidence over the past few decades. Fine needle aspiration (FNA) biopsy is the gold standard for preoperative diagnosis of thyroid malignancies. Nevertheless, this method renders indeterminate results in up to 30% of the cases. Therefore, these patients are often referred to unnecessary surgery to establish the diagnosis. To improve the accuracy of preoperative diagnosis, several other ways, such as ultrasonography, elastography, immunohistochemical analysis, genetic testing, and core needle biopsy, have been developed and can be used either in association with or as an alternative to FNA. This review aims to evaluate all these diagnostic tools to determine the most appropriate way of managing thyroid nodules and subsequently improve the selection of cases referred to surgery.
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Affiliation(s)
- Tapoi Dana Antonia
- Carol Davila University of Medicine and Pharmacy, Department of Pathology, Bucharest, Romania; University Emergency Hospital, Department of Pathology, Bucharest, Romania
| | - Lambrescu Ioana Maria
- Carol Davila University of Medicine and Pharmacy, Department of Cellular and Molecular Biology and Histology, Bucharest, Romania; Victor Babes National Institute of Pathology, Bucharest, Romania.
| | - Gheorghisan-Galateanu Ancuta-Augustina
- Carol Davila University of Medicine and Pharmacy, Department of Cellular and Molecular Biology and Histology, Bucharest, Romania; CI Parhon National Institute of Endocrinology, Bucharest, Romania
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DiGennaro C, Vahdatzad V, Jalali MS, Toumi A, Watson T, Gazelle GS, Mercaldo N, Lubitz CC. Assessing Bias and Limitations of Clinical Validation Studies of Molecular Diagnostic Tests for Indeterminate Thyroid Nodules: Systematic Review and Meta-Analysis. Thyroid 2022; 32:1144-1157. [PMID: 35999710 PMCID: PMC9595633 DOI: 10.1089/thy.2022.0269] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background: Molecular tests for thyroid nodules with indeterminate fine needle aspiration results are increasingly used in clinical practice; however, true diagnostic summaries of these tests are unknown. A systematic review and meta-analysis were completed to (1) evaluate the accuracy of commercially available molecular tests for malignancy in indeterminate thyroid nodules and (2) quantify biases and limitations in studies that validate those tests. Summary: PubMed, EMBASE, and Web of Science were systematically searched through July 2021. English language articles that reported original clinical validation attempts of molecular tests for indeterminate thyroid nodules were included if they reported counts of true-negative, true-positive, false-negative, and false-positive results. We performed screening and full-text review, followed by assessment of eight common biases and limitations, extraction of diagnostic and histopathological information, and meta-analysis of clinical validity using a bivariate linear mixed-effects model. Forty-nine studies were included. Meta-analysis of Afirma Gene expression classifiers (GEC; n = 38 studies) revealed a sensitivity of 0.92 (confidence interval: 0.90-0.94), specificity of 0.26 (0.20-0.32), negative likelihood ratio (LR-) of 0.32 (0.23-0.44), positive LR+ of 1.24 (1.15-1.35), and area under the curve (AUC) of 0.83 (0.74-0.89). Afirma Genomic Sequencing Classifier (GSC; n = 10) had a sensitivity of 0.94 (0.89-0.96), specificity of 0.38 (0.27-0.50), LR- of 0.18 (0.10-0.30), LR+ of 1.52 (1.28-1.87), and AUC of 0.91 (0.62-0.92). ThyroSeq v1 and v2 (n = 10) had a sensitivity of 0.86 (0.82-0.90), specificity of 0.74 (0.59-0.85), LR- of 0.19 (0.13-0.26), LR+ of 3.52 (2.08-5.92), and AUC of 0.86 (0.81-0.90). ThyroSeq v3 (n = 6) had a sensitivity of 0.92 (0.86-0.95), specificity of 0.41 (0.18-0.69), LR- of 0.24 (0.09-0.62), LR+ of 1.67 (1.09-2.98), and AUC of 0.90 (0.63-0.92). Fourteen percent of studies conducted a blinded histopathologic review of excised thyroid nodules, and 8% made the decision to go to surgery blind to molecular test results. Conclusions: Meta-analyses reveal a high diagnostic accuracy of molecular tests for thyroid nodule assessment of malignancy risk; however, these studies are subject to several limitations. Limitations and their potential clinical impacts must be addressed and, when feasible, adjusted for using valid statistical methodologies.
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Affiliation(s)
- Catherine DiGennaro
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Vahab Vahdatzad
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Mohammad S. Jalali
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Asmae Toumi
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Tina Watson
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - G. Scott Gazelle
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nathaniel Mercaldo
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Carrie Cunningham Lubitz
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
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Stewardson P, Eszlinger M, Paschke R. DIAGNOSIS OF ENDOCRINE DISEASE: Usefulness of genetic testing of fine-needle aspirations for diagnosis of thyroid cancer. Eur J Endocrinol 2022; 187:R41-R52. [PMID: 35900312 DOI: 10.1530/eje-21-1293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 07/04/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Genetic testing is increasingly used to diagnose or rule out thyroid cancer in indeterminate fine-needle aspirations. This review evaluates the usefulness of these methods with considerations of advantages and limitations. DESIGN Given the diagnostic problem associated with the increasing incidental detection of indeterminate thyroid nodules in the context of thyroid cancer overtreatment, we consider the conditions and respective necessary settings for the role of genetic testing to improve presurgical malignancy risk stratification. METHODS We review diagnostic pathway requirements and commercially available molecular tests with their respective advantages and disadvantages and discuss the prerequisites required for local application and implementation including quality assurance for local ultrasound and cytopathology practices. RESULTS Recent improvements in available molecular diagnostic tests have brought high sensitivity and specificity in initial validation studies, but whether these promising results translate to other clinical settings depends on the quality of the local thyroid nodule diagnostic pathway. CONCLUSIONS Genetic testing can meaningfully improve presurgical malignancy risk assessment, but more work is needed to implement and use genetic testing effectively in local settings.
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Affiliation(s)
- Paul Stewardson
- Arnie Charbonneau Cancer Institute, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Markus Eszlinger
- Departments of Oncology, Pathology and Laboratory Medicine, Biochemistry and Molecular Biology, University of Calgary Cumming School of Medicine, Universitätsklinikum Halle, Institute of Pathology
| | - Ralf Paschke
- Departments of Medicine, Oncology, Pathology and Laboratory Medicine, Biochemistry and Molecular Biology, and Arnie Charbonneau Cancer Institute, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
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White MK, Thedinger WB, Dhingra JK. Long-term Follow-up of Cytologically Indeterminate Thyroid Nodules Found Benign on Molecular Testing: A Validation Study. OTO Open 2022; 6:2473974X221083542. [PMID: 35321424 PMCID: PMC8935552 DOI: 10.1177/2473974x221083542] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 02/08/2022] [Indexed: 11/16/2022] Open
Abstract
Objective Molecular testing has revolutionized management of indeterminate thyroid nodules (Bethesda categories III and IV). Few studies have attempted to validate the negative predictive value of molecular tests. Using long-term observation as a surrogate for surgical resection, we sought to examine the false-negative rate of “benign” indeterminate thyroid nodules on molecular testing. Study Design Case series with retrospective data collection and chart review. Setting Large community-based practice with multiple satellite offices. Methods All patients with thyroid nodules that underwent ultrasound-guided fine-needle aspiration biopsy between 2013 and 2019 were evaluated through retrospective analysis. Cytologically indeterminate nodules reflexively underwent molecular testing to guide clinical management. Observation was recommended for lesions with benign molecular testing, and these nodules were followed clinically and by ultrasound. Results A total of 2011 nodules underwent fine-needle aspiration, of which 280 (14%) were indeterminate thyroid nodules. Of those 280 nodules, 100 (36%) were benign on molecular testing. Three samples were excluded from analysis due to patient deaths from unrelated causes. Surgical resection was recommended in 16 of the 97 nodules (17%), with the majority due to size and compressive symptoms. Histopathology was available in 14 nodules that underwent surgery, with 1 demonstrating minimally invasive follicular carcinoma. Conclusion While molecular testing is safe to use in guiding management of indeterminate thyroid nodules, consideration of individualized clinical factors and close long-term follow-up remains paramount.
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Affiliation(s)
- Michelle K. White
- Department of Otolaryngology–Head and Neck Surgery, Tufts Medical Center, Boston, Massachusetts, USA
| | | | - Jagdish K. Dhingra
- Department of Otolaryngology–Head and Neck Surgery, Tufts Medical Center, Boston, Massachusetts, USA
- ENT Specialists, Inc, Brockton, Massachusetts, USA
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Figge JJ, Gooding WE, Steward DL, Yip L, Sippel RS, Yang SP, Scheri RP, Sipos JA, Mandel SJ, Mayson SE, Burman KD, Folek JM, Haugen BR, Sosa JA, Parameswaran R, Tan WB, Nikiforov YE, Carty SE. Do Ultrasound Patterns and Clinical Parameters Inform the Probability of Thyroid Cancer Predicted by Molecular Testing in Nodules with Indeterminate Cytology? Thyroid 2021; 31:1673-1682. [PMID: 34340592 PMCID: PMC8917891 DOI: 10.1089/thy.2021.0119] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background: Molecular testing (MT) is commonly used to refine cancer probability in thyroid nodules with indeterminate cytology. Whether or not ultrasound (US) patterns and clinical parameters can further inform the risk of thyroid cancer in nodules predicted to be positive or negative by MT remains unknown. The aim of this study was to test if clinical parameters, including patient age, sex, nodule size (by US), Bethesda category (III, IV, V), US pattern (American Thyroid Association [ATA] vs. American College of Radiology Thyroid Image Reporting and Data System [TI-RADS] systems), radiation exposure, or family history of thyroid cancer can modify the probability of thyroid cancer or noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) predicted by MT. Methods: We studied 257 thyroid nodules in 232 patients from 10 study centers with indeterminate fine needle aspiration cytology and informative MT results using the ThyroSeq v3 genomic classifier (TSv3). Univariate and multivariate logistic regression was used for data analysis. Results: The presence of cancer/NIFTP was associated with positive TSv3 results (odds ratio 61.39, p < 0.0001). On univariate regression, patient sex, age, and Bethesda category were associated with cancer/NIFTP probability (p < 0.05 for each). Although ATA (p = 0.1211) and TI-RADS (p = 0.1359) US categories demonstrated positive trends, neither was significantly associated with cancer/NIFTP probability. A multivariate regression model incorporating the four most informative non-MT covariates (sex, age, Bethesda category, and ATA US pattern; Model No. 1) yielded a C index of 0.653; R2 = 0.108. When TSv3 was added to Model number 1, the C index increased to 0.888; R2 = 0.572. However, age (p = 0.341), Bethesda category (p = 0.272), and ATA US pattern (p = 0.264) were nonsignificant, and other than TSv3 (p < 0.0001), male sex was the only non-MT parameter that potentially contributed to cancer/NIFTP risk (p = 0.095). The simplest and most efficient clinical model (No. 3) incorporated TSv3 and sex (C index = 0.889; R2 = 0.588). Conclusions: In this multicenter study of thyroid nodules with indeterminate cytology and MT, neither the ATA nor TI-RADS US scoring systems further informed the risk of cancer/NIFTP beyond that predicted by TSv3. Although age and Bethesda category were associated with cancer/NIFTP probability on univariate analysis, in sequential nomograms they provided limited incremental value above the high predictive ability of TSv3. Patient sex may contribute to cancer/NIFTP risk in thyroid nodules with indeterminate cytology.
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Affiliation(s)
- James J. Figge
- Diabetes & Endocrine Care, St. Peter's Health Partners/Trinity Health, Rensselaer, New York, USA
- Address correspondence to: James J. Figge, MD, MBA, Diabetes & Endocrine Care, St. Peter's Health Partners/Trinity Health, 279 Troy Road, Rensselaer, NY 12144, USA
| | - William E. Gooding
- Biostatistics Facility, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania, USA
| | - David L. Steward
- Department of Otolaryngology, Head and Neck Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Linwah Yip
- Division of Endocrine Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Rebecca S. Sippel
- Division of Endocrine Surgery, University of Wisconsin, Madison, Wisconsin, USA
| | - Samantha Peiling Yang
- Endocrinology Division, Department of Medicine, National University Hospital, Singapore, Singapore
- Endocrinology Division, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Randall P. Scheri
- Section of Endocrine Surgery, Department of Surgery, Duke University, Durham, North Carolina, USA
| | - Jennifer A. Sipos
- Division of Endocrinology, Diabetes, and Metabolism, Ohio State University School of Medicine, Columbus, Ohio, USA
| | - Susan J. Mandel
- Division of Endocrinology, Diabetes and Metabolism, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sarah E. Mayson
- Division of Endocrinology, Metabolism and Diabetes, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Kenneth D. Burman
- Endocrinology Section, Department of Medicine, MedStar Washington Hospital Center, Washington, District of Columbia, USA
| | | | - Bryan R. Haugen
- Division of Endocrinology, Metabolism and Diabetes, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Julie A. Sosa
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Rajeev Parameswaran
- Division of Endocrine Surgery, Department of Surgery, National University Hospital, Singapore, Singapore
- Division of Endocrine Surgery, Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Wee Boon Tan
- Division of Endocrine Surgery, Department of Surgery, National University Hospital, Singapore, Singapore
- Division of Endocrine Surgery, Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yuri E. Nikiforov
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sally E. Carty
- Division of Endocrine Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Sally E. Carty, MD, Division of Endocrine Surgery, University of Pittsburgh, 101 Kauffmann, 3471 Fifth Avenue, Pittsburgh, PA 15213, USA
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Onken AM, VanderLaan PA, Hennessey JV, Hartzband P, Nishino M. Combined molecular and histologic end points inform cancer risk estimates for thyroid nodules classified as atypia of undetermined significance. Cancer Cytopathol 2021; 129:947-955. [PMID: 34314102 DOI: 10.1002/cncy.22489] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 06/09/2021] [Accepted: 06/11/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Thyroid nodules classified as atypia of uncertain significance (AUS) on fine-needle aspiration cytology are heterogeneous. Prior studies reported a higher risk of noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP)/cancer among AUS nodules that had cytologic (AUS-C) versus architectural (AUS-A) atypia; however, such studies were generally confined to resected cohorts, introducing bias into risk calculations. The authors hypothesized that combined histologic and molecular end points would permit clinically meaningful calculations of NIFTP/malignancy risk among AUS nodules. METHODS The study consisted of 279 thyroid nodules classified as AUS on initial fine-needle aspiration and tested by the Afirma Gene Expression Classifier (GEC) between June 2013 and October 2017. Results of GEC testing and histopathologic diagnoses were stratified by AUS classifiers. The AUS-A category was further subclassified as 1) hypocellular microfollicular or 2) cellular with mixed but predominantly microfollicular architecture. NIFTP/cancer risk was calculated for each subgroup, with the inclusion of unresected nodules that had benign GEC results as low-risk end points comparable to histologically benign nodules. RESULTS When only histologic end points were considered, there was no difference in NIFTP/cancer risk (25% vs 23%; P = .82). By using molecular and histologic end points, AUS cases with cytologic atypia trended toward higher NIFTP/cancer risk than AUS-A cases (14% vs 6%; P = .06). Furthermore, AUS-A cases showed a trend toward lower NIFTP/cancer risk for hypocellular microfollicular aspirates (3%) compared with cellular samples that had mixed/predominantly microfollicular architecture (13%; P = .18). CONCLUSIONS The inclusion of unresected benign GEC nodules in risk-of-malignancy calculations provides more accurate results, which may be helpful for informing patient management as well as quality improvement in the cytopathology laboratory.
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Affiliation(s)
- Allison M Onken
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Paul A VanderLaan
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - James V Hennessey
- Division of Endocrinology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Pamela Hartzband
- Division of Endocrinology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Michiya Nishino
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
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Patel SG, Carty SE, Lee AJ. Molecular Testing for Thyroid Nodules Including Its Interpretation and Use in Clinical Practice. Ann Surg Oncol 2021; 28:8884-8891. [PMID: 34275048 DOI: 10.1245/s10434-021-10307-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 05/31/2021] [Indexed: 01/09/2023]
Abstract
Despite advances in imaging and biopsy techniques, the management of thyroid nodules often remains a diagnostic and clinical challenge. In particular, patients with cytologically indeterminate nodules often undergo diagnostic thyroidectomy although only a minority of patients are found to have thyroid malignancy on final pathology. More recently, several molecular testing platforms have been developed to improve the stratification of cancer risk for patients with cytologically indeterminate thyroid nodules. Based on numerous studies demonstrating its accuracy, molecular testing has been incorporated as an important diagnostic adjunct in the management of indeterminate thyroid nodules in the National Comprehensive Cancer Network Guidelines as well as in the American Thyroid Association (ATA) and American Association of Endocrine Surgeons (AAES) guidelines. This overview describes the currently available molecular testing platforms and highlights the published data to date on the clinical validity and utility of molecular testing in the contemporary management of thyroid nodules.
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Affiliation(s)
- Snehal G Patel
- Department of Surgery, Division of General Surgery, Emory University, Atlanta, GA, USA
| | - Sally E Carty
- Department of Surgery, Division of Endocrine Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Andrew J Lee
- Department of Surgery, Division of Surgical Oncology, University of Pittsburgh, Pittsburgh, PA, USA.
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Zhu CY, Donangelo I, Gupta D, Nguyen DT, Ochoa JE, Yeh MW, Livhits MJ. Outcomes of Indeterminate Thyroid Nodules Managed Nonoperatively after Molecular Testing. J Clin Endocrinol Metab 2021; 106:e1240-e1247. [PMID: 33394039 DOI: 10.1210/clinem/dgaa887] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Indexed: 01/27/2023]
Abstract
CONTEXT Molecular testing to refine the diagnosis of cytologically indeterminate thyroid nodules has become increasingly popular, but data on long-term durability of test results and the rate of delayed operation are limited. OBJECTIVE Determine the delayed rate of surgical resection in indeterminate nodules with benign/negative molecular testing and the risk of false-negative molecular test results. DESIGN Prospective follow-up of the Gene Expression Classifier vs Targeted Next-Generation Sequencing in the Management of Indeterminate Thyroid Nodules randomized controlled trial comparing the diagnostic test performance of Afirma Gene Expression Classifier and ThyroSeq v2. SETTING University of California, Los Angeles. PARTICIPANTS Patients who underwent thyroid biopsy with indeterminate (Bethesda III/IV) cytology (April 2016 to July 2017). INTERVENTION Ultrasound surveillance. MAIN OUTCOME MEASURE False-negative rate of molecular testing. RESULTS Of 95 indeterminate nodules with negative/benign molecular test results, 12 nodules underwent immediate resection (11 benign nodules, 1 noninvasive follicular thyroid neoplasm nodule with papillary-like nuclear features). Nonoperative management was pursued for 83 (87.4%) nodules. The median surveillance was 26.7 months. Ten nodules were resected during surveillance and malignancy was identified in 4 nodules (overall false-negative rate of 5.8%). In the 4 malignant nodules that underwent delayed operation, surgery was prompted by sonographic changes during surveillance. CONCLUSIONS The majority of indeterminate nodules with negative molecular testing have a stable clinical course over 3 years of follow-up, but our finding of a 6% false-negative rate highlights the importance of continuing sonographic surveillance. Long-term studies are needed to determine the optimal length of follow-up.
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Affiliation(s)
- Catherine Y Zhu
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Ines Donangelo
- Division of Endocrinology, Diabetes, and Metabolism, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Deepashree Gupta
- Division of Endocrinology, Diabetes, and Metabolism, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Dalena T Nguyen
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Joana E Ochoa
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Michael W Yeh
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Masha J Livhits
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
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Endo M, Porter K, Long C, Azaryan I, Phay JE, Ringel MD, Sipos JA, Nabhan F. Features of Cytologically Indeterminate Molecularly Benign Nodules Treated With Surgery. J Clin Endocrinol Metab 2020; 105:5890166. [PMID: 32772084 PMCID: PMC7497819 DOI: 10.1210/clinem/dgaa506] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 08/03/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Most cytologically indeterminate thyroid nodules (ITNs) with benign molecular testing are not surgically removed. The data on clinical outcomes of these nodules are limited. METHODS We retrospectively analyzed all ITNs where molecular testing was performed either with the Afirma gene expression classifier or Afirma gene sequencing classifier between 2011 and 2018 at a single institution. RESULTS Thirty-eight out of 289 molecularly benign ITNs were ultimately resected. The most common reason for surgery was compressive symptoms (39%). In multivariable modeling, patients aged <40 years, nodules ≥3 cm, presence of an Afirma suspicious nodule other than the index nodule, and compressive symptoms were associated with higher surgery rates with hazard ratios for surgery of 3.5 (P < 0.001), 3.2 (P < 0.001), 16.8 (P < 0.001), and 7.31 (P < 0.001), respectively. Of resected nodules, 5 were malignant. False-negative rate (FNR) was 1.7%, presuming all unresected nodules were truly benign and 13.2% restricting analysis to resected cases. The FNR was significantly higher in nodules with a high-risk sonographic appearance for cancer (American Thyroid Association high-risk classification and American College of Radiology Thyroid Imaging Reporting and Data Systems score of 5) compared with nodules with all other sonographic categories (11.8% vs 1.1%; P = 0.03 and 11.1% vs 1.1%; P = 0.02, respectively). CONCLUSIONS Younger age, larger nodule size, presence of an Afirma suspicious nodule other than the index nodule, and compressive symptoms were associated with a higher rate of surgery. The FNR of benign Afirma was significantly higher in nodules with high-risk sonographic features.
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Affiliation(s)
- Mayumi Endo
- Division of Endocrinology, Diabetes, and Metabolism, The Ohio State University and Arthur G. James Cancer Center, Columbus, Ohio
- Division of Metabolism, Endocrinology, and Nutrition, University of Washington, Seattle, Washington
| | - Kyle Porter
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University, Columbus, Ohio
| | - Clarine Long
- The Ohio State University, College of Medicine, Columbus, Ohio
| | - Irina Azaryan
- Division of Endocrinology, Diabetes, and Metabolism, The Ohio State University and Arthur G. James Cancer Center, Columbus, Ohio
| | - John E Phay
- Department of Surgery, The Ohio State University Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio
| | - Matthew D Ringel
- Division of Endocrinology, Diabetes, and Metabolism, The Ohio State University and Arthur G. James Cancer Center, Columbus, Ohio
| | - Jennifer A Sipos
- Division of Endocrinology, Diabetes, and Metabolism, The Ohio State University and Arthur G. James Cancer Center, Columbus, Ohio
| | - Fadi Nabhan
- Division of Endocrinology, Diabetes, and Metabolism, The Ohio State University and Arthur G. James Cancer Center, Columbus, Ohio
- Correspondence and Reprint Requests: Fadi Nabhan, MD, Division of Endocrinology, Diabetes and Metabolism, The Ohio State University, 1581 Dodd Drive, Columbus, OH 43210, USA. E-mail:
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10
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Khan TM, Zeiger MA. Thyroid Nodule Molecular Testing: Is It Ready for Prime Time? Front Endocrinol (Lausanne) 2020; 11:590128. [PMID: 33162941 PMCID: PMC7581778 DOI: 10.3389/fendo.2020.590128] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 09/22/2020] [Indexed: 12/19/2022] Open
Abstract
Cytologically indeterminate thyroid nodules remain a diagnostic and clinical challenge, and molecular testing has been advocated and advanced as a diagnostic modality to help guide treatment. While studies have expounded on the improved diagnostic certainty with these tests, data demonstrating meaningful clinical impact and supporting their routine use is still limited at best. In this review, we discuss the limitations regarding diagnostic accuracy, impact on surgical decision-making and outcomes, and cost-effectiveness of molecular testing. By highlighting the limitations of these tests, we aim to promote more thoughtful utilization of these tools in the management of thyroid nodules going forward.
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