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AlSaedi AH, Almalki DS, ElKady RM. Approach to Thyroid Nodules: Diagnosis and Treatment. Cureus 2024; 16:e52232. [PMID: 38352091 PMCID: PMC10861804 DOI: 10.7759/cureus.52232] [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] [Accepted: 01/13/2024] [Indexed: 02/16/2024] Open
Abstract
Thyroid nodules (TNs) are prevalent and found in up to 50% of individuals. While most TNs are benign, some can be malignant. The evaluation of TNs is crucial to rule out malignancy and identify those requiring surgical intervention. This study aimed to clarify the reported prevalence of TNs, focusing specifically on their various types, assessment and diagnostic processes, current evaluation methods, and evidence-based management. It also provides recommendations for follow-up. TNs are typically found during physical exams or incidentally during imaging procedures. Routine laboratory and clinical evaluations of TNs are common. Ultrasound is the preferred imaging method to determine if a TN needs a biopsy. Fine-needle aspiration (FNA) is crucial in deciding whether surgery or surveillance is necessary. TNs that show suspicious features on the ultrasound may require cytologic analysis to assess the risk of malignancy. The effectiveness of several supplementary molecular tests is still uncertain, although some studies report promising results. The management and treatment approach for TNs primarily depends on the results of FNA cytology and ultrasound characteristics. The optimal treatment strategy for TNs ranges from straightforward follow-ups for low-risk cases to surgical intervention for high-risk patients. Rather than adopting a uniform approach, clinicians should assess each patient on a case-by-case basis using current knowledge and a collaborative, multidisciplinary method.
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Affiliation(s)
| | | | - Reem M ElKady
- Radiology and Medical Imaging, Taibah University, Al-Madenah, SAU
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Kang S, Kim E, Lee S, Kim JK, Lee CR, Kang SW, Lee J, Jeong JJ, Nam KH, Chung WY. Do large thyroid nodules (≥4 cm) without suspicious cytology need surgery? Front Endocrinol (Lausanne) 2023; 14:1252503. [PMID: 37732121 PMCID: PMC10508984 DOI: 10.3389/fendo.2023.1252503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 08/14/2023] [Indexed: 09/22/2023] Open
Abstract
Background Fine-needle aspiration biopsy (FNAB) is a good diagnostic tool for thyroid nodules; however, its high false-negative rate for giant nodules remains controversial. Many clinicians recommend surgical resection for nodules >4 cm owing to an increased risk of malignancy and an increased false-negative rate. This study aimed to examine the feasibility of this approach and investigate the incidence of malignancy in thyroid nodules >4 cm without suspicious cytology based on medical records in our center. Methods This was a retrospective analysis of 453 patients that underwent preoperative FNAB for nodules measuring >4 cm between January 2017 and August 2022 at Severance Hospital, Seoul. Results Among the 453 patients, 140 nodules were benign and 119 were indeterminate. Among 259 patients, the final pathology results were divided into benign (149) and cancerous (110) groups, and the prevalence of malignancy was 38.9% in the benign group and 55.5% in the indeterminate group. Among the malignancies, follicular carcinoma and follicular variants of papillary carcinoma were observed in 83% of the cytologically benign group and 62.8% of the indeterminate group. Conclusion Preoperative FNAB had high false-negative rates and low diagnostic accuracy in patients with thyroid nodules >4 cm without suspicious cytologic features; therefore, diagnostic surgery may be considered a treatment option.
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Affiliation(s)
- Seokmin Kang
- Department of Surgery, College of Medicine, Severance Hospital, Yonsei University, Seoul, Republic of Korea
| | - Eunjin Kim
- Department of Surgery, College of Medicine, Severance Hospital, Yonsei University, Seoul, Republic of Korea
| | - Sunmin Lee
- Department of Surgery, College of Medicine, Severance Hospital, Yonsei University, Seoul, Republic of Korea
| | - Jin Kyong Kim
- Department of Surgery, College of Medicine, Severance Hospital, Yonsei University, Seoul, Republic of Korea
| | - Cho Rok Lee
- Department of Surgery, Yongin Severance Hospital, Yongin-si, Republic of Korea
| | - Sang-Wook Kang
- Department of Surgery, College of Medicine, Severance Hospital, Yonsei University, Seoul, Republic of Korea
| | - Jandee Lee
- Department of Surgery, College of Medicine, Severance Hospital, Yonsei University, Seoul, Republic of Korea
| | - Jong Ju Jeong
- Department of Surgery, College of Medicine, Severance Hospital, Yonsei University, Seoul, Republic of Korea
| | - Kee-Hyun Nam
- Department of Surgery, College of Medicine, Severance Hospital, Yonsei University, Seoul, Republic of Korea
| | - Woong Youn Chung
- Department of Surgery, College of Medicine, Severance Hospital, Yonsei University, Seoul, Republic of Korea
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Molecular Testing Results for Indeterminate Thyroid Nodules and Social Habits. J Surg Res 2023; 284:245-250. [PMID: 36603517 DOI: 10.1016/j.jss.2022.11.042] [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: 03/01/2022] [Revised: 11/12/2022] [Accepted: 11/20/2022] [Indexed: 01/05/2023]
Abstract
INTRODUCTION The effects of smoking and alcohol use on the risk of thyroid cancer remain unclear. We sought to investigate the association between these social habits, molecular testing results, and the risk of thyroid cancer. METHODS We conducted a retrospective chart review of patients with indeterminate thyroid nodules (Bethesda III and IV) who underwent molecular testing. The frequency of abnormal molecular testing results was compared among patients with varying smoking and alcohol consumption habits. RESULTS Of 460 patients, median age was 51.8 y, 78.3% were female, 60.7% were White, and 79.8% presented with Bethesda III nodules. The rate of malignancy was 42.6% overall; 73.4% of molecular testing was performed with Afirma, 20.1% with ThyroSeq, and 5.0% with ThyGeNEXT. For social habits, 72.2% never smoked and 40.9% never drank alcohol. Never/rare drinkers were less likely to have abnormal results compared to routine drinkers when considering all types of molecular testing together (83.2% versus 91.3%, P = 0.046), as were those who underwent ThyroSeq molecular testing (71.8% versus 94.4%, P = 0.045). Multivariable analysis revealed that being a routine drinker (adjusted OR 2.19, 95% CI 1.08-4.88), having a larger lesion (adjusted OR 0.65, 95% CI 0.54-0.77), being tested by ThyroSeq (adjusted OR 0.41, 95% CI 0.22-0.76), and other commercial panels (adjusted OR 0.12, 95% CI 0.02-0.64) were independent predictors of abnormal molecular testing results. CONCLUSIONS Our patients' social habits may be associated with the molecular testing results of their indeterminate thyroid nodules but not with their surgical pathology results.
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The national rate of malignancy among Bethesda III, IV, and V thyroid nodules is higher than expected: A NSQIP analysis. Surgery 2023; 173:645-652. [PMID: 36229250 DOI: 10.1016/j.surg.2022.06.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/17/2022] [Accepted: 06/20/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND The Bethesda System for Reporting Thyroid Cytopathology was formalized in 2007 to stratify cytologic specimens based on their risk of malignancy. Several studies have reported significant variations between their institutional rate of malignancy compared to the Bethesda System for Reporting Thyroid Cytopathology. The objective of this study was to determine the national rate of malignancy for Bethesda III, Bethesda IV, and Bethesda V thyroid nodules. METHODS From 2016 to 2019, patients with preoperative thyroid cytopathology and pathology results in National Surgical Quality Improvement database were included. The rate of malignancy was compared to the median the Bethesda System for Reporting Thyroid Cytopathology 2017, and risk factors associated with malignancy were identified for Bethesda III, Bethesda IV, and Bethesda V specimens. RESULTS In total, 13,121 patients with preoperative cytopathology and postresection pathology were identified. The national rate of malignancy was significantly higher than the Bethesda System for Reporting Thyroid Cytopathology 2017 for Bethesda III (36.2% vs 12.0%, P < .01), Bethesda IV (36.7% vs 25.0%, P < .01), and Bethesda V (91.1% vs 52.5%, P < .01) specimens. Male sex was significantly associated with malignancy in Bethesda III, Bethesda IV, and Bethesda V nodules (Bethesda III, odds ratio: 1.20, [1.01-1.42]; Bethesda IV, odds ratio: 1.47, [1.27-1.71]; Bethesda V, odds ratio: 1.28, [1.03-1.58]). Younger age was associated with malignancy in Bethesda III patients under 55 (odds ratio: 1.23, [1.06-1.42]), Bethesda IV patients under 42 (odds ratio: 1.23, [1.06-1.43]), and Bethesda V patients aged less than 47 (odds ratio: 1.38, [1.15-1.67]). CONCLUSIONS This is the largest cohort study to describe the national rate of malignancy for Bethesda III, IV, and V specimens in the United States. These results reveal the national rate of malignancy is higher than the implied rate of malignancy reported to patients based on the Bethesda System for Reporting Thyroid Cytopathology. We recommend counseling patients regarding this increased rate of malignancy to set appropriate expectations after surgical intervention.
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How Effective is the Use of Molecular Testing in Preoperative Decision Making for Management of Indeterminate Thyroid Nodules? World J Surg 2022; 46:3043-3050. [PMID: 36167834 DOI: 10.1007/s00268-022-06744-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2022] [Indexed: 01/14/2023]
Abstract
INTRODUCTION We performed Thyroseq v2 molecular testing on indeterminate thyroid nodules and evaluated whether they underwent a management change from the standard of thyroid lobectomy. METHODS We conducted a retrospective analysis of all indeterminate thyroid nodules that underwent Thyroseq v2 molecular testing from 2014 to 2019 at a large academic center. Pathology was reviewed by thyroid cytopathologists. Thyroseq results were reported benign (malignancy probability less than 10%) or suspicious (malignancy probability greater than 30%). The primary endpoint was a management change from a diagnostic lobectomy. RESULTS A total of 142 nodules were included: 113 (80%) Bethesda III and 29 (20%) Bethesda IV. Seventy-three nodules underwent surgical management and 69 did not. We noted a change in management in 64% (91/142) of nodules. Patients who underwent a change in management to no surgery had a significantly higher rate of benign Thyroseq result than those without a change (75.8% vs. 49.0%, p = 0.001). On logistic regression analysis, a benign Thyroseq result was a positive independent predictor of a change to no surgery (OR 3.87, 95% CI 1.69-8.89). Nodule size, multiple nodules, compressive symptoms, and history of hypothyroidism were not significant. Of the 91 patients who underwent a management change, 71% (65/91) did not undergo surgery. On follow-up (average 985 ± 615 days), 12% (8/65) of those nodules were growing or developed suspicious features requiring surgery. CONCLUSIONS Molecular testing helped avoid surgery in almost half our population with indeterminate thyroid nodules, and benign results may help avoid surgery in asymptomatic patients with indeterminate thyroid nodules.
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Advances in Biomarker-Driven Targeted Therapies in Thyroid Cancer. Cancers (Basel) 2021; 13:cancers13246194. [PMID: 34944814 PMCID: PMC8699087 DOI: 10.3390/cancers13246194] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 12/03/2021] [Accepted: 12/06/2021] [Indexed: 02/07/2023] Open
Abstract
Simple Summary This article reviews current treatment practices for thyroid cancer with a focus on novel targeted molecular therapy. Rapidly expanding knowledge of the molecular biology of these cancers coupled with the increased availability of genetic testing has led to exciting paradigm shifts in treatment strategies for these tumor types. We aim to provide up-to-date information on these state-of-the-art therapies as a guide for clinicians who specialize in the treatments of thyroid cancer. Abstract Thyroid cancer is the most common type of endocrine malignancy comprising 2–3% of all cancers, with a constant rise in the incidence rate. The standard first-line treatments for thyroid cancer include surgery and radioactive iodine ablation, and a majority of patients show a good response to these therapies. Despite a better response and outcome, approximately twenty percent of patients develop disease recurrence and distant metastasis. With improved knowledge of molecular dysregulation and biological characteristics of thyroid cancer, the development of new treatment strategies comprising novel targets has accelerated. Biomarker-driven targeted therapies have now emerged as a trend for personalized treatments in patients with advanced cancers, and several multiple receptor kinase inhibitors have entered clinical trials (phase I/II/III) to evaluate their safety and efficacy. Most extensively investigated and clinically approved targeted therapies in thyroid cancer include the tyrosine receptor kinase inhibitors that target antiangiogenic markers, BRAF mutation, PI3K/AKT, and MAPK pathway components. In this review, we focus on the current advances in targeted mono- and combination therapies for various types of thyroid cancer.
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Hu QL, Schumm MA, Zanocco KA, Yeh MW, Livhits MJ, Wu JX. Cost analysis of reflexive versus selective molecular testing for indeterminate thyroid nodules. Surgery 2021; 171:147-154. [PMID: 34284895 DOI: 10.1016/j.surg.2021.04.050] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/19/2021] [Accepted: 04/23/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Molecular testing is now commonly used to refine the diagnosis of indeterminate thyroid nodules. The purpose of this study is to compare the costs of a reflexive molecular testing strategy to a selective testing strategy for indeterminate thyroid nodules. METHODS A Markov model was constructed to estimate the annual cost of diagnosis and treatment of a real-world cohort of patients with cytologically indeterminate thyroid nodules, comparing a reflexive testing strategy to a selective testing strategy. Model variables were abstracted from institutional clinical trial data, literature review, and the Medicare physician fee schedule. RESULTS The average cost per patient in the reflexive testing strategy was $8,045, compared with $6,090 in the selective testing strategy. In 10,000 Monte Carlo simulations, diagnostic thyroid lobectomy for benign nodules was performed in 2,440 patients in the reflexive testing arm, compared with 3,389 patients in the selective testing arm, and unintentional observation for malignant nodules occurred in 479 patients in the reflexive testing arm, compared with 772 patients in the selective testing arm. The cost of molecular testing had the greatest impact on overall costs, with $1,050 representing the cost below which the reflexive testing strategy was cost saving compared with the selective testing strategy. CONCLUSION In this cost-modeling study, reflexive molecular testing for indeterminate thyroid nodules enabled patients to avoid unnecessary thyroid lobectomy at an estimated cost of $20,600 per surgery avoided.
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Affiliation(s)
- Q Lina Hu
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA.
| | - Max A Schumm
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA. https://twitter.com/@MSchumm90
| | - Kyle A Zanocco
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA. https://twitter.com/@KyleZanocco
| | - Michael W Yeh
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA. https://twitter.com/@michaelyehmd
| | - Masha J Livhits
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA. https://twitter.com/@MashaLivhitsMD
| | - James X Wu
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA. https://twitter.com/@JamesWuMD
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Higher EU-TIRADS-Score Correlated with BRAF V600E Positivity in the Early Stage of Papillary Thyroid Carcinoma. J Clin Med 2021; 10:jcm10112304. [PMID: 34070605 PMCID: PMC8199205 DOI: 10.3390/jcm10112304] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/10/2021] [Accepted: 05/20/2021] [Indexed: 01/21/2023] Open
Abstract
The data demonstrating a correlation between sonographic markers of malignancy of thyroid cancer (TC) and its genetic status are scarce. This study aimed to assess whether the addition of genetic analysis at the preoperative step of TC patients' stratification could aid their clinical management. The material consisted of formalin-fixed paraffin-embedded tumor fragments of 49 patients who underwent thyroidectomy during the early stages of papillary TC (PTC). Tumor DNA and RNA were subjected to next-generation sequencing (NGS) on Ion Proton using the Oncomine™ Comprehensive Assay panel. We observed a significant correlation between BRAF V600E and a higher EU-TIRADS score (p-value = 0.02) with a correlation between hypoechogenicity and taller-than-wide tumor shape in analysed patients. There were no other significant associations between the identified genetic variants and other clinicopathological features. For TC patient's stratification, a strong suspicion of BRAF V600E negativity in preoperative management of TC patients could limit the over-treatment of asymptomatic, very low-risk, indolent disease and leave room for active surveillance.
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A Novel Nanoproteomic Approach for the Identification of Molecular Targets Associated with Thyroid Tumors. NANOMATERIALS 2020; 10:nano10122370. [PMID: 33260544 PMCID: PMC7761166 DOI: 10.3390/nano10122370] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 11/23/2020] [Accepted: 11/25/2020] [Indexed: 12/24/2022]
Abstract
A thyroid nodule is the most common presentation of thyroid cancer; thus, it is extremely important to differentiate benign from malignant nodules. Within malignant lesions, classification of a thyroid tumor is the primary step in the assessment of the prognosis and selection of treatment. Currently, fine-needle aspiration biopsy (FNAB) is the preoperative test most commonly used for the initial thyroid nodule diagnosis. However, due to some limitations of FNAB, different high-throughput “omics” approaches have emerged that could further support diagnosis based on histopathological patterns. In the present work, formalin-fixed paraffin-embedded (FFPE) tissue specimens from normal (non-neoplastic) thyroid (normal controls (NCs)), benign tumors (follicular thyroid adenomas (FTAs)), and some common types of well-differentiated thyroid carcinoma (follicular thyroid carcinomas (FTCs), conventional or classical papillary thyroid carcinomas (CV-PTCs), and the follicular variant of papillary thyroid carcinomas (FV-PTCs)) were analyzed. For the first time, FFPE thyroid samples were deparaffinized using an easy, fast, and non-toxic method. Protein extracts from thyroid tissue samples were analyzed using a nanoparticle-assisted proteomics approach combined with shotgun LC-MS/MS. The differentially regulated proteins found to be specific for the FTA, FTC, CV-PTC, and FV-PTC subtypes were analyzed with the bioinformatic tools STRING and PANTHER showing a profile of proteins implicated in the thyroid cancer metabolic reprogramming, cancer progression, and metastasis. These proteins represent a new source of potential molecular targets related to thyroid tumors.
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The Clinical Utility of Molecular Testing in the Management of Thyroid Follicular Neoplasms (Bethesda IV Nodules). Ann Surg 2020; 272:621-627. [PMID: 32773640 DOI: 10.1097/sla.0000000000004130] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE FN present a management quandary as they are often benign but may also be aggressive TC. Consensus recommendations have historically advised thyroidectomy for definitive diagnosis. Although MT have robust benefit in hypothetical cost analyses, under current management guidelines a real-time study of their clinical utility in FN is awaited. We investigate if MT use for FN directs appropriate thyroidectomy for TC while triaging to surveillance nodules that are likely benign. METHODS Data were analyzed for 389 consecutive patients managed from 11/14 to 9/19 for 405 FN, excluding oncocytic neoplasms. TC was defined as same-nodule histologic malignancy. When obtained, MT was performed using ThyroSeq (TS) v2 or 3. RESULTS With a mean nodule size of 2.7 ± 1.3 cm, MT was used in 89% and was positive in 39%. When MT was positive, thyroidectomy was more often utilized (91% v. MT- 27%; P < 0.001) and more likely for histologic TC (70% vs 16%, P < 0.001). With preoperative MT, all American Thyroid Association intermediate, high-risk, and medullary TC were positive whereas all MT- malignancies were low-risk. With TSv3, ultrasound surveillance was more likely for MT- FN (90% vs TSv2 65%, P < 0.001), and occurred for a total of 174 MT- FN. With mean follow-up of 24.6 months, 82% remained stable in size. CONCLUSIONS MT use for FN increased the surgical yield of cancer by 4-fold, identified all potentially aggressive malignancies, and allowed apparently safe nonoperative surveillance for >80% of MT-negative patients. Thyroid nodule MT optimizes patient outcomes sufficiently to justify its incorporation into routine practice.
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Classification of Thyroid Tumors Based on Mass Spectrometry Imaging of Tissue Microarrays; a Single-Pixel Approach. Int J Mol Sci 2020; 21:ijms21176289. [PMID: 32878024 PMCID: PMC7503764 DOI: 10.3390/ijms21176289] [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: 07/14/2020] [Revised: 08/23/2020] [Accepted: 08/28/2020] [Indexed: 12/29/2022] Open
Abstract
The primary diagnosis of thyroid tumors based on histopathological patterns can be ambiguous in some cases, so proper classification of thyroid diseases might be improved if molecular biomarkers support cytological and histological assessment. In this work, tissue microarrays representative for major types of thyroid malignancies—papillary thyroid cancer (classical and follicular variant), follicular thyroid cancer, anaplastic thyroid cancer, and medullary thyroid cancer—and benign thyroid follicular adenoma and normal thyroid were analyzed by mass spectrometry imaging (MSI), and then different computation approaches were implemented to test the suitability of the registered profiles of tryptic peptides for tumor classification. Molecular similarity among all seven types of thyroid specimens was estimated, and multicomponent classifiers were built for sample classification using individual MSI spectra that corresponded to small clusters of cells. Moreover, MSI components showing the most significant differences in abundance between the compared types of tissues detected and their putative identity were established by annotation with fragments of proteins identified by liquid chromatography-tandem mass spectrometry in corresponding tissue lysates. In general, high accuracy of sample classification was associated with low inter-tissue similarity index and a high number of components with significant differences in abundance between the tissues. Particularly, high molecular similarity was noted between three types of tumors with follicular morphology (adenoma, follicular cancer, and follicular variant of papillary cancer), whose differentiation represented the major classification problem in our dataset. However, low level of the intra-tissue heterogeneity increased the accuracy of classification despite high inter-tissue similarity (which was exemplified by normal thyroid and benign adenoma). We compared classifiers based on all detected MSI components (n = 1536) and the subset of the most abundant components (n = 147). Despite relatively higher contribution of components with significantly different abundance and lower overall inter-tissue similarity in the latter case, the precision of classification was generally higher using all MSI components. Moreover, the classification model based on individual spectra (a single-pixel approach) outperformed the model based on mean spectra of tissue cores. Our result confirmed the high feasibility of MSI-based approaches to multi-class detection of cancer types and proved the good performance of sample classification based on individual spectra (molecular image pixels) that overcame problems related to small amounts of heterogeneous material, which limit the applicability of classical proteomics.
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Nylén C, Mechera R, Maréchal-Ross I, Tsang V, Chou A, Gill AJ, Clifton-Bligh RJ, Robinson BG, Sywak MS, Sidhu SB, Glover AR. Molecular Markers Guiding Thyroid Cancer Management. Cancers (Basel) 2020; 12:cancers12082164. [PMID: 32759760 PMCID: PMC7466065 DOI: 10.3390/cancers12082164] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 07/31/2020] [Accepted: 08/03/2020] [Indexed: 12/12/2022] Open
Abstract
The incidence of thyroid cancer is rapidly increasing, mostly due to the overdiagnosis and overtreatment of differentiated thyroid cancer (TC). The increasing use of potent preclinical models, high throughput molecular technologies, and gene expression microarrays have provided a deeper understanding of molecular characteristics in cancer. Hence, molecular markers have become a potent tool also in TC management to distinguish benign from malignant lesions, predict aggressive biology, prognosis, recurrence, as well as for identification of novel therapeutic targets. In differentiated TC, molecular markers are mainly used as an adjunct to guide management of indeterminate nodules on fine needle aspiration biopsies. In contrast, in advanced thyroid cancer, molecular markers enable targeted treatments of affected signalling pathways. Identification of the driver mutation of targetable kinases in advanced TC can select treatment with mutation targeted tyrosine kinase inhibitors (TKI) to slow growth and reverse adverse effects of the mutations, when traditional treatments fail. This review will outline the molecular landscape and discuss the impact of molecular markers on diagnosis, surveillance and treatment of differentiated, poorly differentiated and anaplastic follicular TC.
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Affiliation(s)
- Carolina Nylén
- Endocrine Surgical Unit, Royal North Shore Hospital, Northern Sydney Local Health District, St. Leonards, NSW 2065, Australia; (C.N.); (R.M.); (M.S.S.); (S.B.S.)
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Solna L1:00, 171 76 Stockholm, Sweden
| | - Robert Mechera
- Endocrine Surgical Unit, Royal North Shore Hospital, Northern Sydney Local Health District, St. Leonards, NSW 2065, Australia; (C.N.); (R.M.); (M.S.S.); (S.B.S.)
- Department of Visceral Surgery, Clarunis University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland
| | - Isabella Maréchal-Ross
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2006, Australia; (I.M.-R.); (V.T.); (A.C.); (A.J.G.); (R.J.C.-B.); (B.G.R.)
| | - Venessa Tsang
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2006, Australia; (I.M.-R.); (V.T.); (A.C.); (A.J.G.); (R.J.C.-B.); (B.G.R.)
- Department of Endocrinology, Royal North Shore Hospital, University of Sydney, St. Leonards, NSW 2065, Australia
| | - Angela Chou
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2006, Australia; (I.M.-R.); (V.T.); (A.C.); (A.J.G.); (R.J.C.-B.); (B.G.R.)
- NSW Health Pathology, Department of Anatomical Pathology, Royal North Shore Hospital, University of Sydney, St. Leonards, NSW 2065, Australia
| | - Anthony J. Gill
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2006, Australia; (I.M.-R.); (V.T.); (A.C.); (A.J.G.); (R.J.C.-B.); (B.G.R.)
- NSW Health Pathology, Department of Anatomical Pathology, Royal North Shore Hospital, University of Sydney, St. Leonards, NSW 2065, Australia
| | - Roderick J. Clifton-Bligh
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2006, Australia; (I.M.-R.); (V.T.); (A.C.); (A.J.G.); (R.J.C.-B.); (B.G.R.)
- Department of Endocrinology, Royal North Shore Hospital, University of Sydney, St. Leonards, NSW 2065, Australia
- Cancer Genetics Unit, Kolling Institute, Sydney, NSW 2010, Australia
| | - Bruce G. Robinson
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2006, Australia; (I.M.-R.); (V.T.); (A.C.); (A.J.G.); (R.J.C.-B.); (B.G.R.)
- Department of Endocrinology, Royal North Shore Hospital, University of Sydney, St. Leonards, NSW 2065, Australia
- Cancer Genetics Unit, Kolling Institute, Sydney, NSW 2010, Australia
| | - Mark S. Sywak
- Endocrine Surgical Unit, Royal North Shore Hospital, Northern Sydney Local Health District, St. Leonards, NSW 2065, Australia; (C.N.); (R.M.); (M.S.S.); (S.B.S.)
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2006, Australia; (I.M.-R.); (V.T.); (A.C.); (A.J.G.); (R.J.C.-B.); (B.G.R.)
| | - Stan B. Sidhu
- Endocrine Surgical Unit, Royal North Shore Hospital, Northern Sydney Local Health District, St. Leonards, NSW 2065, Australia; (C.N.); (R.M.); (M.S.S.); (S.B.S.)
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2006, Australia; (I.M.-R.); (V.T.); (A.C.); (A.J.G.); (R.J.C.-B.); (B.G.R.)
- Cancer Genetics Unit, Kolling Institute, Sydney, NSW 2010, Australia
| | - Anthony R. Glover
- Endocrine Surgical Unit, Royal North Shore Hospital, Northern Sydney Local Health District, St. Leonards, NSW 2065, Australia; (C.N.); (R.M.); (M.S.S.); (S.B.S.)
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2006, Australia; (I.M.-R.); (V.T.); (A.C.); (A.J.G.); (R.J.C.-B.); (B.G.R.)
- The Kinghorn Cancer Centre, Garvan Institute of Medical Research, Faculty of Medicine, St. Vincent’s Clinical School, University of New South Wales Sydney, Sydney, NSW 2010, Australia
- Correspondence: ; Tel.: +61-2-9463-1477
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The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Thyroid Disease in Adults. Ann Surg 2020; 271:e21-e93. [PMID: 32079830 DOI: 10.1097/sla.0000000000003580] [Citation(s) in RCA: 222] [Impact Index Per Article: 55.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To develop evidence-based recommendations for safe, effective, and appropriate thyroidectomy. BACKGROUND Surgical management of thyroid disease has evolved considerably over several decades leading to variability in rendered care. Over 100,000 thyroid operations are performed annually in the US. METHODS The medical literature from 1/1/1985 to 11/9/2018 was reviewed by a panel of 19 experts in thyroid disorders representing multiple disciplines. The authors used the best available evidence to construct surgical management recommendations. Levels of evidence were determined using the American College of Physicians grading system, and management recommendations were discussed to consensus. Members of the American Association of Endocrine Surgeons reviewed and commented on preliminary drafts of the content. RESULTS These clinical guidelines analyze the indications for thyroidectomy as well as its definitions, technique, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Fine Needle Aspiration Biopsy Diagnosis, Molecular Testing, Indications, Extent and Outcomes of Surgery, Preoperative Care, Initial Thyroidectomy, Perioperative Tissue Diagnosis, Nodal Dissection, Concurrent Parathyroidectomy, Hyperthyroid Conditions, Goiter, Adjuncts and Approaches to Thyroidectomy, Laryngology, Familial Thyroid Cancer, Postoperative Care and Complications, Cancer Management, and Reoperation. CONCLUSIONS Evidence-based guidelines were created to assist clinicians in the optimal surgical management of thyroid disease.
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Singh Ospina N, Iñiguez-Ariza NM, Castro MR. Thyroid nodules: diagnostic evaluation based on thyroid cancer risk assessment. BMJ 2020; 368:l6670. [PMID: 31911452 DOI: 10.1136/bmj.l6670] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Thyroid nodules are extremely common and can be detected by sensitive imaging in more than 60% of the general population. They are often identified in patients without symptoms who are undergoing evaluation for other medical complaints. Indiscriminate evaluation of thyroid nodules with thyroid biopsy could cause a harmful epidemic of diagnoses of thyroid cancer, but inadequate selection of thyroid nodules for biopsy can lead to missed diagnoses of clinically relevant thyroid cancer. Recent clinical guidelines advocate a more conservative approach in the evaluation of thyroid nodules based on risk assessment for thyroid cancer, as determined by clinical and ultrasound features to guide the need for biopsy. Moreover, newer evidence suggests that for patients with indeterminate thyroid biopsy results, a combined assessment including the initial ultrasound risk stratification or other ancillary testing (molecular markers, second opinion on thyroid cytology) can further clarify the risk of thyroid cancer and the management strategies. This review summarizes the clinical importance of adequate evaluation of thyroid nodules, focuses on the clinical evidence for diagnostic tests that can clarify the risk of thyroid cancer, and highlights the importance of considering the patient's values and preferences when deciding on management strategies in the setting of uncertainty about the risk of thyroid cancer.
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Affiliation(s)
- Naykky Singh Ospina
- Division of Endocrinology, Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Nicole M Iñiguez-Ariza
- Department of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - M Regina Castro
- Division of Endocrinology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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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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Huang BL, Chabot JA, Lee JA, Kuo JH. A stepwise analysis of the diagnostic algorithm for the prediction of malignancy in thyroid nodules. Surgery 2019; 167:28-33. [PMID: 31515126 DOI: 10.1016/j.surg.2019.05.079] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 05/16/2019] [Accepted: 05/21/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND The evaluation of the malignancy risk of thyroid nodules involves clinical factors, sonographic characteristics, cytopathology, and molecular profiling. Altogether, this algorithm can be costly and time consuming. We evaluated the stepwise contribution of each diagnostic step toward an accurate prediction of malignancy. METHODS A retrospective study of dominant nodules of 137 patients who underwent surgical excision was performed. A baseline logistic regression model for predicting malignancy was regressed on clinical factors. In a stepwise fashion, the 2015 American Thyroid Association ultrasound risk stratification, Bethesda classification of fine-needle aspiration biopsies, and molecular profiling were added to the baseline model and the significance of each step analyzed using likelihood ratio test. Receiver operating characteristic curves were calculated for each model. RESULTS The addition of American Thyroid Association risk stratification and Bethesda classification to preceding models were statistically significant (P < .001). The addition of molecular profiling (as a strategy independent of a particular test) was not significant (P = .812). The areas under the curve of the baseline model and models sequentially including American Thyroid Association stratification, cytopathology, and molecular profiling were 0.76, 0.85, 0.91, and 0.91, respectively. CONCLUSION Clinical factors, sonographic characteristics, and cytopathology are sufficiently accurate in predicting malignancy risk of most thyroid nodules.
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Affiliation(s)
- Bernice L Huang
- Division of GI and Endocrine Surgery, Columbia University, New York, NY
| | - John A Chabot
- Division of GI and Endocrine Surgery, Columbia University, New York, NY
| | - James A Lee
- Division of GI and Endocrine Surgery, Columbia University, New York, NY
| | - Jennifer H Kuo
- Division of GI and Endocrine Surgery, Columbia University, New York, NY.
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The Diagnostic Performance of Afirma Gene Expression Classifier for the Indeterminate Thyroid Nodules: A Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2019; 2019:7150527. [PMID: 31531363 PMCID: PMC6720051 DOI: 10.1155/2019/7150527] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 06/25/2019] [Accepted: 07/07/2019] [Indexed: 01/07/2023]
Abstract
Background Approximately 15 to 30% of thyroid nodules evaluated by fine-needle aspiration (FNA) were classified as indeterminate; the accurate diagnostic molecular tests of these nodules remain a challenge. We aimed to evaluate the diagnostic performance of Afirma gene expression classifier (GEC) for the indeterminate thyroid nodules (ITNs). Methods Studies published from January 2005 to December 2018 were systematically reviewed. The gold reference standard relied on the histopathologic results diagnosis from thyroidectomy surgical specimens. MetaDisc software was used to investigate the pooled sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), diagnostic odds ratio (DOR), and summary receiver operating characteristic (SROC) curves. Results A total of 18 studies involving 5290 patients with 3290 cases of ITNs were included. Collected data revealed that the pooled sensitivity of GEC was 95.5% (95% CI 93.3%–97.0%, p < 0.001), the specificity was 22.1% (95% CI 19.4%-24.9%, p < 0.001), the NPV was 88.2% (95% CI 0.833–0.921, p < 0.001), the PPV was 44.3% (95% CI 0.416–0.471, p < 0.001), and the DOR was 5.25 (95% CI 3.42–8.04, p= 0.855). Conclusion The GEC has quite high sensitivity of 95.5% but low specificity of 22.1%. The high sensitivity makes it probable to rule out malignant nodules. Thus, over half of nodules with GEC-suspicious results still require further validation like molecular markers, diagnostic surgery, or long follow-up, which limits its use in future clinical practice.
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Gawin M, Wojakowska A, Pietrowska M, Marczak Ł, Chekan M, Jelonek K, Lange D, Jaksik R, Gruca A, Widłak P. Proteome profiles of different types of thyroid cancers. Mol Cell Endocrinol 2018; 472:68-79. [PMID: 29183805 DOI: 10.1016/j.mce.2017.11.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 10/20/2017] [Accepted: 11/23/2017] [Indexed: 12/21/2022]
Abstract
Proteomics profiling of tissue specimens representative for major types of thyroid cancers: papillary (classical and follicular variant), follicular, anaplastic and medullary, as well as benign follicular adenoma, was performed using shotgun LC-MS/MS approaches. A combination of Orbitrap and MALDI-TOF approach allowed to identify protein products of 3700 unique genes and revealed large differences between medullary, anaplastic and epithelium-derived differentiated cancers (papillary and follicular). Proteins characteristic for medullary and anaplastic cancers included factors associated with neuroendocrine functions and factors typically associated with advanced malignancies, respectively. Proteomes of different types of epithelium-derived differentiated cancers and follicular adenoma were compared using multi-enzyme LC-MS/MS approach, which revealed products of 4800 unique genes. A comparable overall similarity of follicular cancers to both variants of papillary cancers was found. Moreover, follicular adenoma showed higher overall similarity to follicular cancer than to either variant of papillary cancer. Proteins discriminating differentiated thyroid neoplasms included factors associated with lipid and hormone metabolism, regulation of gene expression and maintenance of DNA structure. Importantly, proteome data matched several features of transcriptome and metabolome profiles of thyroid cancers contributing to systems biology of this malignancy.
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Affiliation(s)
- Marta Gawin
- Maria Sklodowska-Curie Institute - Oncology Center, Gliwice Branch, ul. Wybrzeze Armii Krajowej 15, 44-101 Gliwice, Poland
| | - Anna Wojakowska
- Maria Sklodowska-Curie Institute - Oncology Center, Gliwice Branch, ul. Wybrzeze Armii Krajowej 15, 44-101 Gliwice, Poland
| | - Monika Pietrowska
- Maria Sklodowska-Curie Institute - Oncology Center, Gliwice Branch, ul. Wybrzeze Armii Krajowej 15, 44-101 Gliwice, Poland
| | - Łukasz Marczak
- Institute of Bioorganic Chemistry, Polish Academy of Sciences, ul. Noskowskiego 12/14, 61-704 Poznań, Poland
| | - Mykola Chekan
- Maria Sklodowska-Curie Institute - Oncology Center, Gliwice Branch, ul. Wybrzeze Armii Krajowej 15, 44-101 Gliwice, Poland
| | - Karol Jelonek
- Maria Sklodowska-Curie Institute - Oncology Center, Gliwice Branch, ul. Wybrzeze Armii Krajowej 15, 44-101 Gliwice, Poland
| | - Dariusz Lange
- Maria Sklodowska-Curie Institute - Oncology Center, Gliwice Branch, ul. Wybrzeze Armii Krajowej 15, 44-101 Gliwice, Poland
| | - Roman Jaksik
- Institute of Automatic Control, Faculty of Automatic Control, Electronics and Computer Science, Silesian University of Technology, ul. Akademicka 16, 44-100 Gliwice, Poland
| | - Aleksandra Gruca
- Institute of Informatics, Faculty of Automatic Control, Electronics and Computer Science, Silesian University of Technology, ul. Akademicka 16, 44-100 Gliwice, Poland
| | - Piotr Widłak
- Maria Sklodowska-Curie Institute - Oncology Center, Gliwice Branch, ul. Wybrzeze Armii Krajowej 15, 44-101 Gliwice, Poland.
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Nabhan F, Porter K, Lupo MA, Randolph GW, Patel KN, Kloos RT. Heterogeneity in Positive Predictive Value of RAS Mutations in Cytologically Indeterminate Thyroid Nodules. Thyroid 2018; 28:729-738. [PMID: 29665745 DOI: 10.1089/thy.2017.0635] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND RAS mutations are common in the available mutational analysis of cytologically indeterminate (Cyto-I) thyroid nodules. However, their reported positive predictive value (PPV) for cancer is widely variable. The reason for this variability is unknown, and it causes clinical management uncertainty. A systematic review was performed, evaluating the PPV for cancer in RAS mutation positive Cyto-I nodules, and variables that might affect residual heterogeneity across the different studies were considered. METHODS PubMed was searched through February 22, 2017, including studies that evaluated at least one type of RAS mutation in Cyto-I nodules, including any (or all) of the Bethesda III/IV/V categories or their equivalents and where the histological diagnosis was available. The PPV residual heterogeneity was investigated after accounting for Bethesda classification, blindedness of the histopathologist to the RAS mutational status, Bethesda category-specific cancer prevalence for each study, and which RAS genes and codons were tested. This was studied using five meta-regression models fit to different sets of Bethesda classification categories: Bethesda III, IV, or V (III/IV/V); Bethesda III or IV (III/IV); Bethesda III only; Bethesda IV only; and Bethesda V only. RESULTS Of 1831 studies, 23 were eligible for data inclusion. Wide ranges of PPV were found at 0-100%, 28-100%, and 0-100% in Bethesda III, IV, and V, respectively. Residual heterogeneity remained moderately high for PPV after accounting for the above moderators for Bethesda III/IV/V (21 studies; I2 = 59.5%) and Bethesda III/IV (19 studies; I2 = 66.0%), with significant Cochran's Q-test for residual heterogeneity (p < 0.001). Among individual Bethesda categories, residual heterogeneity was: Bethesda III (eight studies; I2 = 89.0%), IV (12 studies; I2 = 53.5%), and V (10 studies; I2 = 34.4%), with significant Cochran's Q-test for Bethesda III (p < 0.001) and IV (p = 0.04). CONCLUSION The PPV of RAS mutations in Bethesda III and IV categories is quite heterogeneous across different studies, creating low confidence in the accuracy of a single estimate of PPV. Clinicians must appreciate this wide variability when managing a RAS-mutated Cyto-I nodule. Future studies should seek to resolve this unexplained variability.
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Affiliation(s)
- Fadi Nabhan
- 1 Division of Endocrinology, Diabetes, and Metabolism, The Ohio State University and Arthur G. James Cancer Center, Columbus, Ohio
| | - Kyle Porter
- 2 Center for Biostatistics, Division of Human Genetics, The Ohio State University and Arthur G. James Cancer Center, Columbus, Ohio
| | - Mark A Lupo
- 3 Thyroid and Endocrine Center of Florida , Sarasota, Florida
| | - Gregory W Randolph
- 4 Department of Otolaryngology Harvard Medical School Boston, Massachusetts
| | - Kepal N Patel
- 5 Division of Endocrine Surgery, NYU Langone Medical Center , New York, New York
| | - Richard T Kloos
- 6 Department of Medical Affairs, Veracyte, Inc. , South San Francisco, California
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Valderrabano P, Khazai L, Thompson ZJ, Leon ME, Otto KJ, Hallanger-Johnson JE, Wadsworth JT, Chung CH, Centeno BA, McIver B. Impact of oncogene panel results on surgical management of cytologically indeterminate thyroid nodules. Head Neck 2018; 40:1812-1823. [PMID: 29624786 DOI: 10.1002/hed.25165] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 11/15/2017] [Accepted: 02/14/2018] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND The impact of oncogene panel results on the surgical management of indeterminate thyroid nodules (ITNs) is currently unknown. METHODS Surgical management of 649 patients consecutively evaluated from October 2008 to April 2016 with a single nodule biopsied and indeterminate cytology (193 evaluated with and 456 without oncogene panels) was assessed and compared. Histological features of 629 consecutively resected ITNs (164 evaluated with and 465 without oncogene panels) were also characterized and compared. RESULTS Oncogene panel evaluation was associated with higher rates of total thyroidectomy (45% vs 28%; P = .006), and central lymph node dissection (19% vs 12%; P = .03) without increasing the yield of malignancy or decreasing the rate of completion thyroidectomy. Most malignancies (64%), including 83% of those with driver mutation identified, were low-risk cancers for which a lobectomy could have been sufficient initial treatment. CONCLUSION Current oncogene panel results seem insufficient to guide the surgical extent of solitary ITNs.
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Affiliation(s)
- Pablo Valderrabano
- Department of Head and Neck-Endocrine Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Laila Khazai
- Department of Anatomic Pathology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Zachary J Thompson
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Marino E Leon
- Department of Anatomic Pathology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Kristen J Otto
- Department of Head and Neck-Endocrine Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Julie E Hallanger-Johnson
- Department of Head and Neck-Endocrine Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - J Trad Wadsworth
- Department of Head and Neck-Endocrine Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Christine H Chung
- Department of Head and Neck-Endocrine Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Barbara A Centeno
- Department of Anatomic Pathology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Bryan McIver
- Department of Head and Neck-Endocrine Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
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de Koster EJ, de Geus-Oei LF, Dekkers OM, van Engen-van Grunsven I, Hamming J, Corssmit EPM, Morreau H, Schepers A, Smit J, Oyen WJG, Vriens D. Diagnostic Utility of Molecular and Imaging Biomarkers in Cytological Indeterminate Thyroid Nodules. Endocr Rev 2018; 39:154-191. [PMID: 29300866 DOI: 10.1210/er.2017-00133] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 12/27/2017] [Indexed: 12/21/2022]
Abstract
Indeterminate thyroid cytology (Bethesda III and IV) corresponds to follicular-patterned benign and malignant lesions, which are particularly difficult to differentiate on cytology alone. As ~25% of these nodules harbor malignancy, diagnostic hemithyroidectomy is still custom. However, advanced preoperative diagnostics are rapidly evolving.This review provides an overview of additional molecular and imaging diagnostics for indeterminate thyroid nodules in a preoperative clinical setting, including considerations regarding cost-effectiveness, availability, and feasibility of combining techniques. Addressed diagnostics include gene mutation analysis, microRNA, immunocytochemistry, ultrasonography, elastosonography, computed tomography, sestamibi scintigraphy, [18F]-2-fluoro-2-deoxy-d-glucose positron emission tomography (FDG-PET), and diffusion-weighted magnetic resonance imaging.The best rule-out tests for malignancy were the Afirma® gene expression classifier and FDG-PET. The most accurate rule-in test was sole BRAF mutation analysis. No diagnostic had both near-perfect sensitivity and specificity, and estimated cost-effectiveness. Molecular techniques are rapidly advancing. However, given the currently available techniques, a multimodality stepwise approach likely offers the most accurate diagnosis, sequentially applying one sensitive rule-out test and one specific rule-in test. Geographical variations in cytology (e.g., Hürthle cell neoplasms) and tumor genetics strongly influence local test performance and clinical utility. Multidisciplinary collaboration and implementation studies can aid the local decision for one or more eligible diagnostics.
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Affiliation(s)
- Elizabeth J de Koster
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Lioe-Fee de Geus-Oei
- Department of Radiology, Section of Nuclear Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Olaf M Dekkers
- Department of Endocrinology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Jaap Hamming
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Eleonora P M Corssmit
- Department of Endocrinology, Leiden University Medical Center, Leiden, the Netherlands
| | - Hans Morreau
- Department of Pathology, Leiden University Medical Center, Leiden, the Netherlands
| | - Abbey Schepers
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Jan Smit
- Department of Endocrinology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Wim J G Oyen
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, the Netherlands.,Division of Radiotherapy and Imaging, Institute of Cancer Research, and Department of Nuclear Medicine, Royal Marsden Hospital, London, United Kingdom
| | - Dennis Vriens
- Department of Radiology, Section of Nuclear Medicine, Leiden University Medical Center, Leiden, the Netherlands
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Haymart MR. Is BRAF V600E Mutation the Explanation for Age-Associated Mortality Risk in Patients With Papillary Thyroid Cancer? J Clin Oncol 2018; 36:433-434. [PMID: 29240539 DOI: 10.1200/jco.2017.76.2583] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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23
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Sahli ZT, Smith PW, Umbricht CB, Zeiger MA. Preoperative Molecular Markers in Thyroid Nodules. Front Endocrinol (Lausanne) 2018; 9:179. [PMID: 29720964 PMCID: PMC5915469 DOI: 10.3389/fendo.2018.00179] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 04/03/2018] [Indexed: 12/12/2022] Open
Abstract
The need for distinguishing benign from malignant thyroid nodules has led to the pursuit of differentiating molecular markers. The most common molecular tests in clinical use are Afirma® Gene Expression Classifier (GEC) and Thyroseq® V2. Despite the rapidly developing field of molecular markers, several limitations exist. These challenges include the recent introduction of the histopathological diagnosis "Non-Invasive Follicular Thyroid neoplasm with Papillary-like nuclear features", the correlation of genetic mutations within both benign and malignant pathologic diagnoses, the lack of follow-up of molecular marker negative nodules, and the cost-effectiveness of molecular markers. In this manuscript, we review the current published literature surrounding the diagnostic value of Afirma® GEC and Thyroseq® V2. Among Afirma® GEC studies, sensitivity (Se), specificity (Sp), positive predictive value (PPV), and negative predictive value (NPV) ranged from 75 to 100%, 5 to 53%, 13 to 100%, and 20 to 100%, respectively. Among Thyroseq® V2 studies, Se, Sp, PPV, and NPV ranged from 40 to 100%, 56 to 93%, 13 to 90%, and 48 to 97%, respectively. We also discuss current challenges to Afirma® GEC and Thyroseq® V2 utility and clinical application, and preview the future directions of these rapidly developing technologies.
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Affiliation(s)
- Zeyad T. Sahli
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Philip W. Smith
- Department of Surgery, University of Virginia, Charlottesville, VA, United States
| | - Christopher B. Umbricht
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Martha A. Zeiger
- Department of Surgery, University of Virginia, Charlottesville, VA, United States
- *Correspondence: Martha A. Zeiger,
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Duh QY, Busaidy NL, Rahilly-Tierney C, Gharib H, Randolph G. A Systematic Review of the Methods of Diagnostic Accuracy Studies of the Afirma Gene Expression Classifier. Thyroid 2017; 27:1215-1222. [PMID: 28741442 DOI: 10.1089/thy.2016.0656] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND The Afirma® Gene Expression Classifier (GEC) risk stratifies The Bethesda System for the Reporting of Thyroid Cytopathology class III/IV (indeterminate) thyroid nodules (ITNs) as suspicious for malignancy or benign. Several authors have published studies describing the diagnostic accuracy of the GEC. However, the quality of these methods has not been rigorously examined. SUMMARY In this study, MEDLINE and EMBASE were searched for studies published between January 1, 2010, and June 30, 2016, examining the sensitivity, specificity, negative predictive value, and positive predictive value of the GEC. The Quality of Diagnostic Accuracy Studies 2 was customized to evaluate the methods of included studies in each of four domains: nodule selection, index test execution, reference standard assignment, and flow and timing. Signaling questions were used to identify sources of potential bias in calculation of diagnostic accuracy, and issues of applicability were assessed. Three panelists applied the Quality of Diagnostic Accuracy Studies 2 tool to each study included, and divergence was resolved in conference. In 12 studies evaluated, the most common methodologic flaw was lack of reference standard diagnosis assignment to un-excised GEC-benign ITNs. Exclusion of these ITNs from the analyses resulted in unreliable estimates of specificity and negative predictive value. Other flaws identified included restriction to ITNs that had already been selected for referral for thyroidectomy or lobectomy. CONCLUSIONS Future studies should define and assign a "true negative" label to GEC-benign nodules that do not develop malignant signs or symptoms during a pre-specified period of follow-up, and these nodules should be included in calculations of diagnostic accuracy.
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Affiliation(s)
- Quan-Yang Duh
- 1 Section of Endocrine Surgery, Department of Surgery, University of California San Francisco Medical Center , San Francisco, California
| | - Naifa L Busaidy
- 2 Department of Endocrine Neoplasia and Hormonal Disorders, University of Texas MD Anderson Cancer Center , Houston, Texas
| | - Catherine Rahilly-Tierney
- 3 Department of Medicine, Harvard Medical School , Boston, Massachusetts
- 4 Strategic Research Partners , LLC, Falmouth, Massachusetts
| | - Hossein Gharib
- 5 Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic College of Medicine , Rochester, Minnesota
| | - Gregory Randolph
- 3 Department of Medicine, Harvard Medical School , Boston, Massachusetts
- 6 Department of Otolaryngology, Divisions of Thyroid and Parathyroid Surgery, Massachusetts Eye and Ear Infirmary , Boston, Massachusetts
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Eszlinger M, Lau L, Ghaznavi S, Symonds C, Chandarana SP, Khalil M, Paschke R. Molecular profiling of thyroid nodule fine-needle aspiration cytology. Nat Rev Endocrinol 2017; 13:415-424. [PMID: 28361927 DOI: 10.1038/nrendo.2017.24] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
The differential diagnosis and malignancy risk stratification of thyroid nodules requires multidisciplinary expertise and knowledge of both local ultrasonography practices and the local malignancy rates for a given fine-needle aspiration (FNA) result. Even in such a multidisciplinary setting, FNA cytology has the inherent limitation that indeterminate cytology results cannot distinguish between follicular adenomas, follicular thyroid carcinomas or follicular variant papillary thyroid carcinomas. Accumulating evidence suggests that this limitation can be overcome by using molecular diagnostic approaches. In this Review, we present the advantages and disadvantages of the different molecular diagnostic methodologies, which can be divided into two approaches: those that 'rule out' malignancy (to reduce the overtreatment of benign nodules) and those that 'rule in' malignancy (to optimize surgical planning). We identify microRNA classifiers as potential additional markers for use in a two-step diagnostic approach, consider the potential implications of the reclassification of noninvasive encapsulated follicular variant papillary thyroid carcinomas to noninvasive follicular thyroid neoplasms with papillary-like nuclear features and discuss the cost-effectiveness of molecular testing. Molecular FNA diagnostics is an important complementary addition to FNA cytology that could substantially reduce unnecessary surgery and better define the need for appropriate surgery in patients who have thyroid nodules with indeterminate FNA cytology.
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Affiliation(s)
- Markus Eszlinger
- Department of Oncology, Cumming School of Medicine, University of Calgary, Tom Baker Cancer Centre, 1331 - 29th Street NW, Calgary, Alberta T2N 4N2, Canada
- Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Health Research Innovation Centre, 3280 Hospital Drive, Calgary, Alberta T2T 4Z6, Canada
| | - Lorraine Lau
- Division of Endocrinology, Department of Medicine, Cumming School of Medicine, University of Calgary, Richmond Road Diagnostic and Treatment Centre, 1820 Richmond Road SW, Calgary, Alberta T2T 5C7, Canada
| | - Sana Ghaznavi
- Division of Endocrinology, Department of Medicine, Cumming School of Medicine, University of Calgary, Richmond Road Diagnostic and Treatment Centre, 1820 Richmond Road SW, Calgary, Alberta T2T 5C7, Canada
| | - Christopher Symonds
- Division of Endocrinology, Department of Medicine, Cumming School of Medicine, University of Calgary, Richmond Road Diagnostic and Treatment Centre, 1820 Richmond Road SW, Calgary, Alberta T2T 5C7, Canada
| | - Shamir P Chandarana
- Department of Oncology, Cumming School of Medicine, University of Calgary, Tom Baker Cancer Centre, 1331 - 29th Street NW, Calgary, Alberta T2N 4N2, Canada
- Department of Surgery, Cumming School of Medicine, University of Calgary, Foothills Medical Centre, North Tower 1012, 1403 - 29th Street NW, Calgary, Alberta T2N 2T9, Canada
| | - Moosa Khalil
- Department of Pathology and Laboratory Medicine, University of Calgary, Foothills Medical Centre, McCaig Tower, 1403 - 29th Street NW, Calgary, Alberta T2N 2T9, Canada
| | - Ralf Paschke
- Department of Oncology, Cumming School of Medicine, University of Calgary, Tom Baker Cancer Centre, 1331 - 29th Street NW, Calgary, Alberta T2N 4N2, Canada
- Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Health Research Innovation Centre, 3280 Hospital Drive, Calgary, Alberta T2T 4Z6, Canada
- Division of Endocrinology, Department of Medicine, Cumming School of Medicine, University of Calgary, Richmond Road Diagnostic and Treatment Centre, 1820 Richmond Road SW, Calgary, Alberta T2T 5C7, Canada
- Department of Medicine, Cumming School of Medicine, University of Calgary, North Tower 9th floor, 1403 - 29th Street NW, Calgary, Alberta T2N 2T9, Canada
- Department of Biochemistry and Molecular Biology, Cumming School of Medicine, University of Calgary, Health Research Innovation Centre, 3280 Hospital Drive, Calgary, Alberta T2N 4Z6, Canada
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Mungan S, Ersoz S, Saygin I, Sagnak Z, Cobanoglu U. Nuclear morphometric findings in undetermined cytology: A possible clue for prediction of BRAF mutation in papillary thyroid carcinomas. Endocr Res 2017; 42:138-144. [PMID: 27911099 DOI: 10.1080/07435800.2016.1255895] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE To investigate the possible relationship between the nuclear morphometric characteristics (nuclear perimeter, roundness, nuclear area, and nuclear shape) and BRAF mutation status in papillary thyroid carcinoma cases with a prior diagnosis of undetermined cytology. MATERIALS AND METHODS Total thyroidectomy specimens obtained from 48 patients with papillary thyroid carcinoma with a prior diagnosis of undetermined cytology were included. Morphometric analysis under light microscopy included measurements of the perimeter, shape factor, nuclear area, and roundness of thyrocyte nuclei from the cytological smear preparations. Mutational analysis, including immunohistochemistry and polymerase chain reaction, was performed in formalin fixed paraffin embedded tissue blocks. RESULTS BRAF V600E mutation was detected in 7 of 48 cases (14.5%). The nuclear perimeter and nuclear area in mutated cases were significantly higher than the wild type (p = 0.005). Shape factor (p = 0.681) and roundness (p = 0.752) values did not significantly differ between the wild-type and mutant groups. No significant relationship was evident between BRAF expression and BRAF point mutation. CONCLUSION In cases with positivity for BRAF mutation, the nuclear perimeter and nuclear area were significantly increased. These findings suggest that morphometric variables are predictive markers for papillary thyroid carcinoma cases with positivity for BRAF mutation. However, further trials on larger series are warranted to understand the significance and predictive value of nuclear morphometric analysis in these circumstances.
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Affiliation(s)
- Sevdegul Mungan
- a Department of Pathology, Faculty of Medicine , Karadeniz Technical University , Trabzon , Turkey
| | - Safak Ersoz
- a Department of Pathology, Faculty of Medicine , Karadeniz Technical University , Trabzon , Turkey
| | - Ismail Saygin
- a Department of Pathology, Faculty of Medicine , Karadeniz Technical University , Trabzon , Turkey
| | - Zeynep Sagnak
- a Department of Pathology, Faculty of Medicine , Karadeniz Technical University , Trabzon , Turkey
| | - Umit Cobanoglu
- a Department of Pathology, Faculty of Medicine , Karadeniz Technical University , Trabzon , Turkey
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Clinkscales W, Ong A, Nguyen S, Harruff EE, Gillespie MB. Diagnostic Value of RAS Mutations in Indeterminate Thyroid Nodules. Otolaryngol Head Neck Surg 2017; 156:472-479. [PMID: 28116986 DOI: 10.1177/0194599816685697] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Objectives To determine the diagnostic value of HRAS, KRAS, and NRAS mutations in fine-needle aspiration biopsies of thyroid nodules that are nondiagnostic on cytology. Data Sources PubMed, Scopus, Embase, CINAHL. Review Methods Two authors independently searched the data sources. To be included, studies reported the RAS mutational status and postoperative histopathologic diagnosis of nodules that exhibited indeterminate cytology after fine-needle aspiration biopsy. Data were extracted to calculate sensitivity, specificity, and positive/negative predictive values of any HRAS, KRAS, or NRAS mutation. A meta-analysis was performed to generate pooled values for each parameter. Results A total of 7 studies with a combined 1025 patients met inclusion criteria. The pooled sensitivity of a RAS mutation for detecting cancer was 0.343 (95% confidence interval [95% CI], 0.198-0.506), while the pooled specificity was 0.935 (95% CI, 0.882-0.973). The weighted averages for positive predictive value and negative predictive value were 78.0% and 64.0%, respectively, with 68.0% accuracy. The positive likelihood ratio was 4.235 (95% CI, 1.506-11.910), and the negative likelihood ratio was 0.775 (95% CI, 0.630-0.953). Conclusion Our data suggest that testing for any RAS mutation is unlikely to change the clinical management of thyroid nodules that have indeterminate cytology. While a RAS mutation may rule in malignancy, the sensitivity of testing is low enough to merit further mutational analysis, repeat fine-needle aspiration, or surgical excision, even in the presence of a negative test.
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Affiliation(s)
- William Clinkscales
- 1 Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Adrian Ong
- 1 Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Shaun Nguyen
- 1 Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Elizabeth Emily Harruff
- 1 Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Marion Boyd Gillespie
- 1 Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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Castelblanco E, Zafon C, Maravall J, Gallel P, Martinez M, Capel I, Bella MR, Halperin I, Temprana J, Iglesias C, Puig-Domingo M, Robledo M, Matias-Guiu X, Mauricio D. APLP2, RRM2, and PRC1: New Putative Markers for the Differential Diagnosis of Thyroid Follicular Lesions. Thyroid 2017; 27:59-66. [PMID: 27796194 DOI: 10.1089/thy.2016.0094] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Current methods based on fine-needle aspiration biopsy (FNAB) are not sufficient to distinguish among follicular thyroid lesions, follicular adenoma (FA), follicular thyroid carcinoma (FTC), and the follicular variant of papillary thyroid cancer (FVPTC). Furthermore, none of the immunohistochemical markers currently available are sensitive or specific enough to be used in the clinical setting, necessitating a diagnostic hemithyroidectomy. The aim of this study was to identify proteins of value for differential diagnosis between benign and malignant thyroid follicular lesions. METHODS This retrospective analysis is based on an assessment of the immunoexpression of 19 proteins on 81 benign thyroid lesions (FA) and 50 malignant tumors (FTC/FVPTC). The resulting expression profile allowed the design of a scoring system model to improve the differential diagnosis of benign and malignant thyroid lesions. The model was validated using an independent series of 69 FA and 40 FTC and an external series of 40 nodular hyperplasias, and was further tested in a series of 38 FNAB cell blocks. RESULTS A model based on the nuclear and cytoplasmic expression of APLP2, RRM2, and PRC1 discriminated between benign and malignant lesions with 100% sensitivity in both main and validation groups, with specificities of 71.3% and 50.7%, respectively. For the nodular hyperplasia series, specificity reached 94.8%. Finally, in FNAB samples, the sensitivity was 100% and the specificity was 45% for discrimination between benign and malignant lesions. CONCLUSIONS These findings suggest that the identified APLP2, RRM2, and PRC1 signature could be useful for distinguishing between benign (FA) and malignant (FTC and FVPTC) tumors of the thyroid follicular epithelium.
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Affiliation(s)
- Esmeralda Castelblanco
- 1 Department of Endocrinology and Nutrition, Health Sciences Research Institute and University Hospital Germans Trias i Pujol , Badalona, Spain
- 2 Centre for Biomedical Research on Diabetes and Associated Metabolic Diseases (CIBERDEM) , ISCIII, Badalona, Spain
- 3 Consortium for the study of thyroid cancer (CECaT) , Badalona, Spain
| | - Carles Zafon
- 2 Centre for Biomedical Research on Diabetes and Associated Metabolic Diseases (CIBERDEM) , ISCIII, Badalona, Spain
- 3 Consortium for the study of thyroid cancer (CECaT) , Badalona, Spain
- 4 Diabetes and Metabolism Research Unit (VHIR) and Department of Endocrinology, University Hospital Vall d'Hebron and Autonomous University of Barcelona , Barcelona, Spain
| | - Javier Maravall
- 3 Consortium for the study of thyroid cancer (CECaT) , Badalona, Spain
- 5 Department of Endocrinology and Nutrition, University Hospital Arnau de Vilanova and University of Lleida , Biomedical Research Institute of Lleida, Lleida, Spain
| | - Pilar Gallel
- 6 Department of Pathology and Molecular Genetics, University Hospital Arnau de Vilanova and University of Lleida , Biomedical Research Institute of Lleida, Lleida, Spain
| | - Montserrat Martinez
- 7 Biostatistics and Epidemiology Unit, Biomedical Research Institute of Lleida , Lleida, Spain
| | - Ismael Capel
- 3 Consortium for the study of thyroid cancer (CECaT) , Badalona, Spain
- 8 Department of Endocrinology and Nutrition, University Hospital Parc Taulí Sabadell , Barcelona, Spain
| | - Maria Rosa Bella
- 3 Consortium for the study of thyroid cancer (CECaT) , Badalona, Spain
- 9 Department of Pathology, University Hospital Parc Taulí Sabadell , Barcelona, Spain
| | - Irene Halperin
- 3 Consortium for the study of thyroid cancer (CECaT) , Badalona, Spain
- 10 Department of Endocrinology and Nutrition, University Hospital Clinic Barcelona , Barcelona, Spain
| | - Jordi Temprana
- 3 Consortium for the study of thyroid cancer (CECaT) , Badalona, Spain
- 11 Department of Pathology, Vall d'Hebron University Hospital and Autonomous University of Barcelona , Barcelona, Spain
| | - Carmela Iglesias
- 3 Consortium for the study of thyroid cancer (CECaT) , Badalona, Spain
- 11 Department of Pathology, Vall d'Hebron University Hospital and Autonomous University of Barcelona , Barcelona, Spain
| | - Manel Puig-Domingo
- 1 Department of Endocrinology and Nutrition, Health Sciences Research Institute and University Hospital Germans Trias i Pujol , Badalona, Spain
- 2 Centre for Biomedical Research on Diabetes and Associated Metabolic Diseases (CIBERDEM) , ISCIII, Badalona, Spain
- 3 Consortium for the study of thyroid cancer (CECaT) , Badalona, Spain
| | - Mercedes Robledo
- 12 Hereditary Endocrine Cancer Group, Spanish National Cancer Centre , Madrid, Spain
- 13 Centre for Biomedical Research on Rare Diseases (CIBERER) , ISCIII, Madrid, Spain
| | - Xavier Matias-Guiu
- 6 Department of Pathology and Molecular Genetics, University Hospital Arnau de Vilanova and University of Lleida , Biomedical Research Institute of Lleida, Lleida, Spain
| | - Didac Mauricio
- 1 Department of Endocrinology and Nutrition, Health Sciences Research Institute and University Hospital Germans Trias i Pujol , Badalona, Spain
- 2 Centre for Biomedical Research on Diabetes and Associated Metabolic Diseases (CIBERDEM) , ISCIII, Badalona, Spain
- 3 Consortium for the study of thyroid cancer (CECaT) , Badalona, Spain
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Pietrowska M, Diehl HC, Mrukwa G, Kalinowska-Herok M, Gawin M, Chekan M, Elm J, Drazek G, Krawczyk A, Lange D, Meyer HE, Polanska J, Henkel C, Widlak P. Molecular profiles of thyroid cancer subtypes: Classification based on features of tissue revealed by mass spectrometry imaging. BIOCHIMICA ET BIOPHYSICA ACTA-PROTEINS AND PROTEOMICS 2016; 1865:837-845. [PMID: 27760391 DOI: 10.1016/j.bbapap.2016.10.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 10/07/2016] [Accepted: 10/11/2016] [Indexed: 02/08/2023]
Abstract
Determination of the specific type of thyroid cancer is crucial for the prognosis and selection of treatment of this malignancy. However, in some cases appropriate classification is not possible based on histopathological features only, and it might be supported by molecular biomarkers. Here we aimed to characterize molecular profiles of different thyroid malignancies using mass spectrometry imaging (MSI) which enables the direct annotation of molecular features with morphological pictures of an analyzed tissue. Fifteen formalin-fixed paraffin-embedded tissue specimens corresponding to five major types of thyroid cancer were analyzed by MALDI-MSI after in-situ trypsin digestion, and the possibility of classification based on the results of unsupervised segmentation of MALDI images was tested. Novel method of semi-supervised detection of the cancer region of interest (ROI) was implemented. We found strong separation of medullary cancer from malignancies derived from thyroid epithelium, and separation of anaplastic cancer from differentiated cancers. Reliable classification of medullary and anaplastic cancers using an approach based on automated detection of cancer ROI was validated with independent samples. Moreover, extraction of spectra from tumor areas allowed the detection of molecular components that differentiated follicular cancer and two variants of papillary cancer (classical and follicular). We concluded that MALDI-MSI approach is a promising strategy in the search for biomarkers supporting classification of thyroid malignant tumors. This article is part of a Special Issue entitled: MALDI Imaging, edited by Dr. Corinna Henkel and Prof. Peter Hoffmann.
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Affiliation(s)
- Monika Pietrowska
- Center for Translational Research and Molecular Biology of Cancer, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology Gliwice Branch, ul. Wybrzeze Armii Krajowej 15, 44101 Gliwice, Poland
| | - Hanna C Diehl
- Medizinisches Proteom-Center, Ruhr-University Bochum, Universitätsstraße 150, 44801 Bochum, Germany
| | - Grzegorz Mrukwa
- Faculty of Automatic Control, Electronics and Computer Science, Silesian University of Technology, ul. Akademicka 16, 44100 Gliwice, Poland
| | - Magdalena Kalinowska-Herok
- Center for Translational Research and Molecular Biology of Cancer, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology Gliwice Branch, ul. Wybrzeze Armii Krajowej 15, 44101 Gliwice, Poland
| | - Marta Gawin
- Center for Translational Research and Molecular Biology of Cancer, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology Gliwice Branch, ul. Wybrzeze Armii Krajowej 15, 44101 Gliwice, Poland
| | - Mykola Chekan
- Center for Translational Research and Molecular Biology of Cancer, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology Gliwice Branch, ul. Wybrzeze Armii Krajowej 15, 44101 Gliwice, Poland
| | - Julian Elm
- Medizinisches Proteom-Center, Ruhr-University Bochum, Universitätsstraße 150, 44801 Bochum, Germany
| | - Grzegorz Drazek
- Faculty of Automatic Control, Electronics and Computer Science, Silesian University of Technology, ul. Akademicka 16, 44100 Gliwice, Poland
| | - Anna Krawczyk
- Faculty of Automatic Control, Electronics and Computer Science, Silesian University of Technology, ul. Akademicka 16, 44100 Gliwice, Poland
| | - Dariusz Lange
- Center for Translational Research and Molecular Biology of Cancer, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology Gliwice Branch, ul. Wybrzeze Armii Krajowej 15, 44101 Gliwice, Poland
| | - Helmut E Meyer
- Medizinisches Proteom-Center, Ruhr-University Bochum, Universitätsstraße 150, 44801 Bochum, Germany; Leibniz-Institut für Analytische Wissenschaften - ISAS - e.V., Bunsen-Kirchhoff-Straße 11, 44139 Dortmund, Germany
| | - Joanna Polanska
- Faculty of Automatic Control, Electronics and Computer Science, Silesian University of Technology, ul. Akademicka 16, 44100 Gliwice, Poland.
| | - Corinna Henkel
- Medizinisches Proteom-Center, Ruhr-University Bochum, Universitätsstraße 150, 44801 Bochum, Germany; Leibniz-Institut für Analytische Wissenschaften - ISAS - e.V., Bunsen-Kirchhoff-Straße 11, 44139 Dortmund, Germany.
| | - Piotr Widlak
- Center for Translational Research and Molecular Biology of Cancer, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology Gliwice Branch, ul. Wybrzeze Armii Krajowej 15, 44101 Gliwice, Poland.
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Wei Y, Zhou X, Liu S, Wang H, Liu L, Liu R, Kang J, Hong K, Wang D, Yuan G. Novel and Practical Scoring Systems for the Diagnosis of Thyroid Nodules. PLoS One 2016; 11:e0163039. [PMID: 27654865 PMCID: PMC5031406 DOI: 10.1371/journal.pone.0163039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Accepted: 09/01/2016] [Indexed: 01/04/2023] Open
Abstract
Objective The clinical management of patients with thyroid nodules that are biopsied by fine-needle aspiration cytology and yield indeterminate results remains unsettled. The BRAF V600E mutation has dubious diagnostic value due to its low sensitivity. Novel strategies are urgently needed to distinguish thyroid malignancies from thyroid nodules. Design This prospective study included 504 thyroid nodules diagnosed by ultrasonography from 468 patients, and fine-needle aspiration cytology was performed under ultrasound guidance. Cytology and molecular analysis, including BRAF V600E, RET/PTC1 and RET/PTC3, were conducted simultaneously. The cytology, ultrasonography results, and mutational status were gathered and analyzed together. Predictive scoring systems were designed using a combination of diagnostic parameters for ultrasonography, cytology and genetic analysis. The utility of the scoring systems was analyzed and compared to detection using the individual methods alone or combined. Result The sensitivity of scoring systema (ultrasonography, cytology, BRAF V600E, RET/PTC) was nearly identical to that of scoring systemb (ultrasonography, cytology, BRAF V600E); these were 91.0% and 90.2%, respectively. These sensitivities were significantly higher than those obtained using FNAC, genetic analysis and US alone or combined; their sensitivities were 63.9%, 70.7% and 87.2%, respectively. Scoring systemc (ultrasonography, cytology) was slightly inferior to the former two scoring systems but still had relatively high sensitivity and specificity (80.5% and 95.1%, respectively), which were significantly superior to those of single cytology, ultrasonography or genetic analysis. In nodules with uncertainty cytology, scoring systema, scoring systemb and scoring systemc could elevate the malignancy detection rates to 69.7%, 69.7% and 63.6%, respectively. Conclusion These three scoring systems were quick for clinicians to master and could provide quantified information to predict the probability of malignant nodules. Scoring systemb is recommended for improving the detection rate among nodules of uncertain cytology.
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Affiliation(s)
- Ying Wei
- Department of Internal Medicine, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xinrong Zhou
- Department of Internal Medicine, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Siyue Liu
- Department of Internal Medicine, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Hong Wang
- Molecular Diagnostic Laboratory, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Limin Liu
- Department of surgical cytology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Renze Liu
- Department of surgical cytology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Jinsong Kang
- Department of surgical cytology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Kai Hong
- Department of ultrasonic, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Daowen Wang
- Department of Internal Medicine, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, Hubei, China.,Molecular Diagnostic Laboratory, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Gang Yuan
- Department of Internal Medicine, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, Hubei, China
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Halászlaki C, Tóbiás B, Balla B, Kósa JP, Horányi J, Bölöny E, Nagy Z, Speer G, Járay B, Székely E, Istók R, Székely T, Putz Z, Dank M, Lakatos P, Takács I. PREDICTIVE VALUE OF SOMATIC MUTATIONS FOR THE DEVELOPMENT OF MALIGNANCY IN THYROID NODULES BY CYTOPATHOLOGY. Endocr Pract 2016; 22:1081-7. [PMID: 27214302 DOI: 10.4158/ep151057.or] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE The purpose of our prospective longitudinal study was to evaluate the predictive efficacy of genetic testing for malignancies in fine-needle aspiration biopsy samples that are cytologically benign at the time of biopsy. METHODS A total of 779 aspirated cytological samples collected from thyroid nodules of 626 patients were included in a 3-year follow-up study. Consecutive patients with cytologically benign thyroid nodules by the Bethesda System for Reporting Thyroid Cytopathology were enrolled in the study. At enrollment, somatic 1-point nucleotide polymorphisms of BRAF and RAS family genes were tested by melting-point analysis, while RET/PTC and PAX8/PPAR-gamma rearrangements were examined by real-time polymerase chain reaction. The genetic test was considered to be positive if a somatic mutation was found. Malignant cytopathologic diagnoses were confirmed by histopathology. RESULTS In samples collected from 779 thyroid nodules, there were 39 BRAF, 33 RAS mutations, and 1 RET/PTC rearrangements found at the beginning of the study. No PAX8/PPAR-gamma rearrangement was identified. There were 52 malignant thyroid tumors removed during follow-up, out of which 24 contained a somatic mutation. The specificity of the presence of somatic mutations for malignancies was as high as 93.3%, and sensitivity was 46.2%. The negative predictive value of genetic testing reached 96.0%. CONCLUSION Our results show that our set of genetic tests can predict the appearance of malignancy in benign thyroid nodules (at the beginning of follow-up) with high specificity and strong negative predictive value. ABBREVIATIONS BRAF = v-raf murine sarcoma viral oncogene homolog B1 FLUS = follicular lesion of undetermined significance FNAB = fine-needle aspiration biopsy FTC = follicular thyroid carcinoma HRAS = homologous to the oncogene from the Harvey rat sarcoma virus KRAS = homologous to the oncogene from the Kirsten rat sarcoma virus NRAS = first isolated from a human neuroblastoma/neuroblastoma RAS = viral oncogene homolog PAX8 = paired box 8 PCR = polymerase chain reaction PPAR-gamma = peroxisome proliferator-activated receptor gamma PTC = papillary thyroid carcinoma RAS = rat sarcoma RET = rearranged during transfection tyrosine-kinase proto-oncogene SM = somatic mutation SNP = single-nucleotide polymorphism.
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Aragon Han P, Kim HS, Cho S, Fazeli R, Najafian A, Khawaja H, McAlexander M, Dy B, Sorensen M, Aronova A, Sebo TJ, Giordano TJ, Fahey TJ, Thompson GB, Gauger PG, Somervell H, Bishop JA, Eshleman JR, Schneider EB, Witwer KW, Umbricht CB, Zeiger MA. Association of BRAF V600E Mutation and MicroRNA Expression with Central Lymph Node Metastases in Papillary Thyroid Cancer: A Prospective Study from Four Endocrine Surgery Centers. Thyroid 2016; 26:532-42. [PMID: 26950846 PMCID: PMC4827320 DOI: 10.1089/thy.2015.0378] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Studies have demonstrated an association of the BRAF(V600E) mutation and microRNA (miR) expression with aggressive clinicopathologic features in papillary thyroid cancer (PTC). Analysis of BRAF(V600E) mutations with miR expression data may improve perioperative decision making for patients with PTC, specifically in identifying patients harboring central lymph node metastases (CLNM). METHODS Between January 2012 and June 2013, 237 consecutive patients underwent total thyroidectomy and prophylactic central lymph node dissection (CLND) at four endocrine surgery centers. All tumors were tested for the presence of the BRAF(V600E) mutation and miR-21, miR-146b-3p, miR-146b-5p, miR-204, miR-221, miR-222, and miR-375 expression. Bivariate and multivariable analyses were performed to examine associations between molecular markers and aggressive clinicopathologic features of PTC. RESULTS Multivariable logistic regression analysis of all clinicopathologic features found miR-146b-3p and miR-146b-5p to be independent predictors of CLNM, while the presence of BRAF(V600E) almost reached significance. Multivariable logistic regression analysis limited to only predictors available preoperatively (molecular markers, age, sex, and tumor size) found miR-146b-3p, miR-146b-5p, miR-222, and BRAF(V600E) mutation to predict CLNM independently. While BRAF(V600E) was found to be associated with CLNM (48% mutated in node-positive cases vs. 28% mutated in node-negative cases), its positive and negative predictive values (48% and 72%, respectively) limit its clinical utility as a stand-alone marker. In the subgroup analysis focusing on only classical variant of PTC cases (CVPTC), undergoing prophylactic lymph node dissection, multivariable logistic regression analysis found only miR-146b-5p and miR-222 to be independent predictors of CLNM, while BRAF(V600E) was not significantly associated with CLNM. CONCLUSION In the patients undergoing prophylactic CLNDs, miR-146b-3p, miR-146b-5p, and miR-222 were found to be predictive of CLNM preoperatively. However, there was significant overlap in expression of these miRs in the two outcome groups. The BRAF(V600E) mutation, while being a marker of CLNM when considering only preoperative variables among all histological subtypes, is likely not a useful stand-alone marker clinically because the difference between node-positive and node-negative cases was small. Furthermore, it lost significance when examining only CVPTC. Overall, our results speak to the concept and interpretation of statistical significance versus actual applicability of molecular markers, raising questions about their clinical usefulness as individual prognostic markers.
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Affiliation(s)
- Patricia Aragon Han
- Endocrine Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Hyun-seok Kim
- Endocrine Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Soonweng Cho
- Endocrine Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Roghayeh Fazeli
- Endocrine Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alireza Najafian
- Endocrine Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Hunain Khawaja
- Endocrine Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Melissa McAlexander
- Department of Molecular and Comparative Pathobiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Benzon Dy
- Departments of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Meredith Sorensen
- Division of Endocrine Surgery, University of Michigan Health System, Ann Arbor, Michigan
| | - Anna Aronova
- Endocrine Surgery Section, Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York
| | - Thomas J. Sebo
- Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Thomas J. Giordano
- Departments of Pathology and Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan
| | - Thomas J. Fahey
- Endocrine Surgery Section, Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York
| | | | - Paul G. Gauger
- Division of Endocrine Surgery, University of Michigan Health System, Ann Arbor, Michigan
| | - Helina Somervell
- Endocrine Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Justin A. Bishop
- Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - James R. Eshleman
- Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Eric B. Schneider
- Endocrine Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kenneth W. Witwer
- Department of Molecular and Comparative Pathobiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christopher B. Umbricht
- Endocrine Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Martha A. Zeiger
- Endocrine Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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Trimboli P, Treglia G, Condorelli E, Romanelli F, Crescenzi A, Bongiovanni M, Giovanella L. BRAF-mutated carcinomas among thyroid nodules with prior indeterminate FNA report: a systematic review and meta-analysis. Clin Endocrinol (Oxf) 2016; 84:315-20. [PMID: 25920006 DOI: 10.1111/cen.12806] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Revised: 04/02/2015] [Accepted: 04/21/2015] [Indexed: 01/02/2023]
Abstract
BACKGROUND Several molecular analyses have been investigated for risk stratification of thyroid nodules, with a particular focus on the V600E mutation of the BRAF gene [BRAF(V600E)]. To date, there is no high-level evidence supporting or refuting a role for BRAF analysis in thyroid nodules with prior indeterminate cytology. To obtain more robust evidence, we reviewed and meta-analysed data from published articles. RESEARCH DESIGN AND METHODS A comprehensive literature search of the PubMed/MEDLINE, Embase and Scopus databases was conducted using the terms 'BRAF', 'thyroid' and 'indeterminate'. The search was updated until March 2015, and references of the retrieved articles were also screened. Only original articles reporting BRAF mutation testing within nodules with indeterminate FNA were eligible for inclusion. RESULTS The literature search revealed 82 articles, of which 8 were eligible for the study. Five studies were prospective and three retrospective. The majority of authors analysed BRAF mutations in FNA samples which were classified by the British or Bethesda system. Of the initial series of studies, a pooled number of 1361 cases were achieved of which 43 were BRAF mutated. Overall, the BRAF mutation rate was 4·6% (95% CI: 1-10·8%), ranging from 0 to 22·9%. When we included only histological series, 978 thyroid nodules were found. Of these, 245 were cancers. CONCLUSIONS A very low rate of lesions with indeterminate cytology are BRAF mutated. Thus, the role of this biomarker to detect or exclude cancers in patients with such FNA reports is marginal and should be reconsidered in guidelines.
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Affiliation(s)
- Pierpaolo Trimboli
- Section of Endocrinology and Diabetology, Ospedale Israelitico, Rome, Italy
- Department of Nuclear Medicine and Thyroid Centre, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Giorgio Treglia
- Department of Nuclear Medicine and Thyroid Centre, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Emma Condorelli
- Section of Endocrinology and Diabetology, Ospedale Israelitico, Rome, Italy
| | | | - Anna Crescenzi
- Section of Pathology, University Hospital Campus Bio Medico, Rome, Italy
| | | | - Luca Giovanella
- Department of Nuclear Medicine and Thyroid Centre, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
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Santhanam P, Khthir R, Gress T, Elkadry A, Olajide O, Yaqub A, Driscoll H. Gene expression classifier for the diagnosis of indeterminate thyroid nodules: a meta-analysis. Med Oncol 2016; 33:14. [PMID: 26749587 DOI: 10.1007/s12032-015-0727-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 12/31/2015] [Indexed: 12/30/2022]
Abstract
Prior studies demonstrate that a novel genomic test, the gene expression classifier (GEC), could identify a benign gene expression signature in those nodules with indeterminate cytology with a negative predictive value of greater than 95 %. Examine the performance of the AFIRMA gene expression classifier in predicting benign and malignant nodules in patients with cytologically indeterminate nodules. MEDLINE and EMBASE search for studies meeting eligibility criteria between January 1, 2005, and August 30, 2015. A total of 58 studies identified. After excluding duplicates, case reports, reviews, commentary, insufficient data, a total of seven studies selected for analysis. We combined individual patient data from seven studies that examined the GEC test for indeterminate thyroid nodules. The reference standard for determination of benign or malignant nodules was the histopathology of the thyroidectomy specimen. A QUADAS-2 report for all studies included in the final analysis was tabulated for risk of bias and applicability. The pooled sensitivity of the GEC was 95.7 % (95 % CI 92.2-97.9, I (2) value 45.4 %, p = 0.09), and the pooled specificity was 30.5 % (95 % CI 26.0-35.3, I (2) value 92.1 %, p < 0.01). Overall, the diagnostic odds ratio was 7.9 (95 % CI 4.1-15.1). Patients with benign GEC were not followed long enough to ascertain the actual false-negative rates of the index test. Our meta-analysis revealed a high pooled sensitivity and a low specificity for the AFIRMA-GEC test for indeterminate thyroid nodules. This makes it an excellent tool to rule out malignancy.
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Affiliation(s)
- Prasanna Santhanam
- Section of Endocrinology, Department of Internal Medicine, Byrd Clinical Center, Joan C Edwards School of Medicine, Marshall University, 1249 15th Street, Suite 3046, Huntington, WV, 25701, USA.
| | - Rodhan Khthir
- Section of Endocrinology, Department of Internal Medicine, Byrd Clinical Center, Joan C Edwards School of Medicine, Marshall University, 1249 15th Street, Suite 3046, Huntington, WV, 25701, USA
| | - Todd Gress
- Department of Clinical and Translational Sciences and Department of Internal Medicine, Joan C Edwards School of Medicine, Marshall University, Huntington, WV, 25701, USA
| | - Ayman Elkadry
- Section of Endocrinology, Department of Internal Medicine, Byrd Clinical Center, Joan C Edwards School of Medicine, Marshall University, 1249 15th Street, Suite 3046, Huntington, WV, 25701, USA
| | - Omolola Olajide
- Section of Endocrinology, Department of Internal Medicine, Byrd Clinical Center, Joan C Edwards School of Medicine, Marshall University, 1249 15th Street, Suite 3046, Huntington, WV, 25701, USA
| | - Abid Yaqub
- Division of Endocrinology, Department of Internal Medicine, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Henry Driscoll
- Section of Endocrinology, Department of Internal Medicine, Byrd Clinical Center, Joan C Edwards School of Medicine, Marshall University, 1249 15th Street, Suite 3046, Huntington, WV, 25701, USA
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Aragon Han P, Weng CH, Khawaja HT, Nagarajan N, Schneider EB, Umbricht CB, Witwer KW, Zeiger MA. MicroRNA Expression and Association with Clinicopathologic Features in Papillary Thyroid Cancer: A Systematic Review. Thyroid 2015; 25:1322-9. [PMID: 26414548 DOI: 10.1089/thy.2015.0193] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Studies have suggested that microRNAs (miR) may be useful prognostic markers and are associated with aggressive clinicopathologic features in papillary thyroid cancer (PTC). This systematic review examined associations between miRs and aggressive clinicopathologic features in PTC. METHODS A literature search was performed within the PubMed, Embase, Cochrane, Web of Science, and Scopus databases for papers published prior to November 24, 2014. The search was performed by combining the concepts "thyroid tumor" with "microRNA" and by using "and" as the Boolean operator. Upon retrieval of candidate studies, full-text publications were reviewed in their entirety and selected if they examined the prognostic significance between miR expression and established aggressive clinicopathologic features of PTC. RESULTS Fifteen studies from 13 unique groups that included 807 patients were reviewed. Most of the studies were retrospective, and none included patients who had undergone routine central lymph node dissection. Expression levels of miRs-21, -34b, -130b, -135b, -146b, -151, -181b, -199b-5p, -221, -222, -451, -623, -1271, -2861, and let-7e showed significant association with at least one aggressive feature, such as large tumor size, extrathyroidal extension, multifocality, lymphovascular invasion, lymph node metastases, distant metastasis, advanced American Joint Cancer Committee stage, and presence of the BRAF(V600E) mutation. Herein we summarize the literature with regard to these associations. CONCLUSION Further studies are needed to investigate whether miRs are independent predictors of aggressive clinicopathologic features before it can be recommended that miR expression levels should be incorporated into the management algorithm for patients with PTC. A well-designed prospective study is needed to assess these potential associations.
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Affiliation(s)
- Patricia Aragon Han
- 1 Endocrine Surgery Section, Department of Surgery, The Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Chien-Hsiang Weng
- 1 Endocrine Surgery Section, Department of Surgery, The Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Hunain T Khawaja
- 1 Endocrine Surgery Section, Department of Surgery, The Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Neeraja Nagarajan
- 2 Johns Hopkins Surgery Center for Outcomes Research, Department of Surgery, The Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Eric B Schneider
- 2 Johns Hopkins Surgery Center for Outcomes Research, Department of Surgery, The Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Christopher B Umbricht
- 1 Endocrine Surgery Section, Department of Surgery, The Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Kenneth W Witwer
- 3 Department of Molecular and Comparative Pathobiology, The Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Martha A Zeiger
- 1 Endocrine Surgery Section, Department of Surgery, The Johns Hopkins University School of Medicine , Baltimore, Maryland
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Fnais N, Soobiah C, AL-Qahtani K, Hamid JS, Perrier L, Straus SE, Tricco AC. Diagnostic value of fine needle aspiration BRAFV600E mutation analysis in papillary thyroid cancer: a systematic review and meta-analysis. Hum Pathol 2015; 46:1443-54. [DOI: 10.1016/j.humpath.2015.06.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 05/20/2015] [Accepted: 06/03/2015] [Indexed: 01/15/2023]
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Bhatia P, Abd Elmageed ZY, Friedlander P, Aslam R, Kandil E. The utility of molecular markers in pre-operative assessment of thyroid nodules. Future Oncol 2015; 11:2343-50. [PMID: 26260812 DOI: 10.2217/fon.15.135] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
The pre-operative diagnosis of thyroid tumors is determined by gold standard fine needle aspiration (FNA) biopsy. This has been widely accepted and offers the most cost-effective approach for evaluation of thyroid nodules. However, its diagnostic accuracy can pose a challenging scenario to surgeons. These diagnostic difficulties may subject patients to unnecessary thyroidectomies for benign thyroid nodules. Thus, additional molecular tests are needed to improve the sensitivity and specificity of FNA. The role of molecular markers is being proposed to predict the type and risk of malignancy to abate the need for diagnostic thyroidectomies. This review discusses their utility and validity in pre-operative diagnosis of thyroid nodules and how these markers can enhance the accuracy of FNA cytology.
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Affiliation(s)
- Parisha Bhatia
- Department of Surgery, Tulane University School of Medicine, Tulane University School of Medicine, New Orleans, LA 70112, USA
| | - Zakaria Y Abd Elmageed
- Department of Surgery, Tulane University School of Medicine, Tulane University School of Medicine, New Orleans, LA 70112, USA
| | - Paul Friedlander
- Department of Otolaryngology, Tulane University School of Medicine, Tulane University School of Medicine, New Orleans, LA 70112, USA
| | - Rizwan Aslam
- Department of Otolaryngology, Tulane University School of Medicine, Tulane University School of Medicine, New Orleans, LA 70112, USA
| | - Emad Kandil
- Department of Surgery, Tulane University School of Medicine, Tulane University School of Medicine, New Orleans, LA 70112, USA.,Department of Otolaryngology, Tulane University School of Medicine, Tulane University School of Medicine, New Orleans, LA 70112, USA
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Brauner E, Holmes BJ, Krane JF, Nishino M, Zurakowski D, Hennessey JV, Faquin WC, Parangi S. Performance of the Afirma Gene Expression Classifier in Hürthle Cell Thyroid Nodules Differs from Other Indeterminate Thyroid Nodules. Thyroid 2015; 25:789-96. [PMID: 25962906 DOI: 10.1089/thy.2015.0049] [Citation(s) in RCA: 98] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND The recently introduced Afirma gene expression classifier (AGEC) provides binary results (benign or suspicious) to guide management of cytologically indeterminate thyroid nodules. The AGEC is intended to reduce unnecessary surgeries for benign nodules, and management algorithms favor surgery for suspicious results. Limited data are available on the performance of this test for Hürthle cell nodules (HCNs). This study hypothesized that a predominance of Hürthle cells leads to an increased rate of suspicious AGEC results with a potential for overtreatment, despite a relatively low risk of malignancy. METHODS The pathology databases from three tertiary care facilities were queried from 2010 to 2014 for fine-needle aspirates (FNAs) diagnosed as suspicious for Hürthle cell neoplasm (SHCN) or atypia of undetermined significance/follicular lesion of undetermined significance concerning for Hürthle cell neoplasm (AFHCN). Cytology diagnoses were rendered internally prior to AGEC testing. The patient demographics, FNA diagnosis, AGEC result, surgical procedure, and pathologic outcomes were recorded. RESULTS The cohort consisted of 134 patients with HCNs. Prior to AGEC availability, 62 patients underwent surgery: 81% (50/62) of patients had surgery, and 34% (17/50) of the resected index nodules were malignant. After introduction of the AGEC, 72 patients underwent AGEC testing: 65% (47/72) of patients had surgery, and 13% (6/46) of the resected nodules were malignant. Thirty-two percent (23/72) of patients had a benign AGEC result and did not undergo surgery, and 4% (3/72) had surgery despite a benign AGEC result with benign final pathology, whereas 63% (45/72) of patients had suspicious AGEC results, with 96% of these patients (43/45) undergoing surgery, and 14% (6/43) of these index nodules were malignant. CONCLUSIONS While 32% of tested patients declined surgery based on a benign AGEC, 86% of patients with suspicious AGEC findings had unnecessary surgery, reflecting a substantially lower rate of malignancy from what was previously reported for all indeterminate nodules. Given the approximate pretest malignancy risk of 25-35% for an FNA diagnosis of SHCN or AFHCN, a suspicious AGEC diagnosis does not increase the probability of malignancy in an HCN, and patients should be counseled accordingly.
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MESH Headings
- Adenocarcinoma, Follicular/diagnosis
- Adenocarcinoma, Follicular/genetics
- Adenoma, Oxyphilic
- Adult
- Aged
- Biopsy, Fine-Needle
- Carcinoma/diagnosis
- Carcinoma/genetics
- Carcinoma, Neuroendocrine/diagnosis
- Carcinoma, Neuroendocrine/genetics
- Carcinoma, Papillary
- Cohort Studies
- Diagnosis, Differential
- Female
- Gene Expression Profiling
- Gene Expression Regulation, Neoplastic
- Humans
- Male
- Middle Aged
- Oxyphil Cells/metabolism
- Oxyphil Cells/pathology
- Retrospective Studies
- Thyroid Cancer, Papillary
- Thyroid Neoplasms/diagnosis
- Thyroid Neoplasms/genetics
- Thyroid Nodule/diagnosis
- Thyroid Nodule/genetics
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Affiliation(s)
- Eran Brauner
- 1 Department of Surgery, Massachusetts General Hospital , Boston, Massachusetts
| | - Brittany J Holmes
- 2 Department of Pathology, Massachusetts General Hospital , Boston, Massachusetts
| | - Jeffrey F Krane
- 3 Department of Pathology, Brigham and Women's Hospital , Boston, Massachusetts
| | - Michiya Nishino
- 4 Department of Pathology, Beth Israel Deaconess Medical Center , Boston, Massachusetts
| | - David Zurakowski
- 5 Departments of Surgery and Anesthesia, Boston Children's Hospital , Boston, Massachusetts
| | - James V Hennessey
- 6 Department of Medicine, Beth Israel Deaconess Medical Center , Boston, Massachusetts
| | - William C Faquin
- 2 Department of Pathology, Massachusetts General Hospital , Boston, Massachusetts
| | - Sareh Parangi
- 1 Department of Surgery, Massachusetts General Hospital , Boston, Massachusetts
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Prescott JD, Zeiger MA. TheREToncogene in papillary thyroid carcinoma. Cancer 2015; 121:2137-46. [DOI: 10.1002/cncr.29044] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Revised: 08/21/2014] [Accepted: 08/26/2014] [Indexed: 01/19/2023]
Affiliation(s)
- Jason D. Prescott
- Endocrine Surgery, Department of Surgery; The Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Martha A. Zeiger
- Endocrine Surgery, Department of Surgery; The Johns Hopkins University School of Medicine; Baltimore Maryland
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VandenBussche CJ, Olson MT, Adams C, Ali SZ. Cytotechnologist performance for screening microfollicular atypia in indeterminate thyroid fine-needle aspirates. Acta Cytol 2014; 58:432-8. [PMID: 25341367 DOI: 10.1159/000367882] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 08/25/2014] [Indexed: 01/25/2023]
Abstract
INTRODUCTION We previously identified a high level of accuracy among our cytotechnologists (CTs) for identifying nuclear atypia in thyroid fine-needle aspiration (FNA) specimens. Herewith, we present our CT performance at screening for microfollicular atypia. METHODS 8,814 thyroid FNA specimens were identified in our archives, all screened by 1 of 11 CTs and signed out by a cytopathologist. A subsample of cases was categorized either as atypia of uncertain significance (AUS) with microfollicular proliferation (AUS-F) or suspicious for a follicular neoplasm (SFN). RESULTS The agreement rate was low between CTs and cytopathologists for SFN and AUS-F. Only 55.8% of SFN screening diagnoses were upheld; 27.9% were downgraded to AUS, 10.4% were downgraded to benign, and 5% were upgraded. Of AUS-F screening diagnoses, 35.5% were upheld, 33.7% were downgraded to benign, and 20.2% were upgraded to SFN. Among all cases, two-step discrepancies were uncommon. CONCLUSION Most disagreements were one-category discrepancies between AUS-F and SFN. The evaluation of microfollicular atypia is challenging given that certain follicular lesions cannot be definitively diagnosed on cytology, a high level of subjectivity is involved in the interpretation of such lesions, and the presence of nuclear or Hurthle cell atypia may complicate the diagnosis.
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Lastra RR, Pramick MR, Crammer CJ, LiVolsi VA, Baloch ZW. Implications of a suspicious afirma test result in thyroid fine-needle aspiration cytology: An institutional experience. Cancer Cytopathol 2014; 122:737-44. [DOI: 10.1002/cncy.21455] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 05/27/2014] [Accepted: 05/28/2014] [Indexed: 01/21/2023]
Affiliation(s)
- Ricardo R. Lastra
- Department of Pathology and Laboratory Medicine; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania
| | - Michelle R. Pramick
- Department of Pathology and Laboratory Medicine; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania
| | - Cody J. Crammer
- Department of Pathology and Laboratory Medicine; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania
| | - Virginia A. LiVolsi
- Department of Pathology and Laboratory Medicine; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania
| | - Zubair W. Baloch
- Department of Pathology and Laboratory Medicine; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania
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Najafian A, Zeiger MA. Role of molecular diagnostic markers in the management of indeterminate and suspicious thyroid nodules. INTERNATIONAL JOURNAL OF ENDOCRINE ONCOLOGY 2014. [DOI: 10.2217/ije.13.4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Incidental thyroid nodules are commonly found during routine neck examination. Fine needle aspiration (FNA) followed by cytological examination is currently considered as the most reliable method for evaluation of thyroid nodules. However, 10–40% of FNA results are inconclusive, and are reported as indeterminate or suspicious. Approximately 20% of indeterminate or suspicious nodules are malignant. Therefore, there has been an increasing trend in use of molecular markers as an adjunctive measure for more accurate preoperative diagnosis of indeterminate or suspicious nodules. Molecular markers can be used alone or as a part of molecular panels. Although some investigations revealed promising findings regarding the potential use of molecular markers in the management of thyroid nodules, their true impact on management of patients with indeterminate nodules is still unclear.
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Affiliation(s)
- Alireza Najafian
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Martha A Zeiger
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
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Proietti A, Borrelli N, Giannini R, Romani R, Di Coscio G, Quilici F, Rago T, Miccoli P, Vitti P, Basolo F. Molecular characterization of 54 cases of false-negative fine-needle aspiration among 1347 papillary thyroid carcinomas. Cancer Cytopathol 2014; 122:751-9. [PMID: 24913568 DOI: 10.1002/cncy.21454] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Revised: 05/12/2014] [Accepted: 05/27/2014] [Indexed: 11/11/2022]
Abstract
BACKGROUND Fine-needle aspiration (FNA) has been widely accepted as the most crucial step in the preoperative assessment of thyroid nodules, but the false-negative rates are generally reported to be between 3.6% and 10.2%. To lower the overall incidence of this false-negative testing, new reporting systems encourage the molecular testing of thyroid nodules. However, to the authors' knowledge, the role of molecular testing in false-negative FNA has not yet been evaluated. METHODS In total, 1347 consecutive papillary thyroid carcinomas (PTCs) with both cytological and histological diagnoses were collected from the same center. A blinded revision of the false-negative cases was performed. An analysis of the BRAF and Ras genes in the false-negative cases was then performed. RESULTS The false-negative rate at the time of primary FNA diagnosis was 4.8% (65 of 1347 cases). False-negative cases were 15 follicular variant PTCs, 2 classical variant, and 1 solid variant that lacked peculiar PTC cytomorphological features. Adequate cellular material for molecular analysis was available only in 54 of the 65 false-negative cases. Mutations were found in 6 cases (11%), and Ras alterations were present in 16 cases (29.6%). The addition of molecular analysis decreased the false-negative rate to 0.4% (5 of 1347 cases). CONCLUSIONS The results of the current study confirm the feasibility of BRAF and Ras analysis in routine FNA. However, when the false-negative FNA rate is low, the cost-benefit analysis of the detection of BRAF and Ras mutations should be carefully evaluated. Consequently, the authors suggest that preoperative molecular assessment could be helpful for benign nodules, but only in the presence of clinical suspicion of malignancy.
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Affiliation(s)
- Agnese Proietti
- Department of Surgical, Medical, Molecular Pathology and Critical Area, Unit of Pathological Anatomy, University of Pisa, Pisa, Italy
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Ahmed A, Novak AB, Farhat Sheerin A, Boonyaarunnate T, Ali SZ, Olson MT. Accuracy of cytotechnologist evaluation of specimen adequacy and screening interpretation of malignancy in fine-needle aspiration of the liver. Acta Cytol 2014; 58:367-72. [PMID: 25115188 DOI: 10.1159/000364853] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 05/09/2014] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To evaluate the performance of cytotechnologists in assessing the adequacy and accuracy of the preliminary diagnosis for fine-needle aspirates of the liver. STUDY DESIGN We retrospectively analyzed 10 years of data and found 589 cases of ultrasound-guided fine-needle aspiration (FNA) of the liver with on-site evaluation of adequacy (OSEA). All the OSEA were performed by the cytopathologist because OSEA of liver FNA is not performed by cytotechnologists at our institution at present. After OSEA, the material was seen by cytotechnologists who rendered an adequacy assessment and preliminary diagnosis. We calculated the adequacy and accuracy statistics and compared the performance of the cytotechnologists with the OSEA and final interpretation. RESULTS There was no statistically significant difference in adequacy downgrade rate for cytotechnologist versus cytopathologist assessment during the study period (5 vs. 3%, p = 0.06). A total agreement of 88% was noted in overall diagnosis with 97% agreement in malignant cases. CONCLUSION Cytotechnologists assess the adequacy of liver FNA accurately and there is therefore potential for them to perform OSEA for liver FNA.
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Affiliation(s)
- Aadil Ahmed
- Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Md., USA
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