Preoperative serum thyroglobulin as a useful predictive marker to differentiate follicular thyroid cancer from benign nodules in indeterminate nodules

Ultrasound-based nomogram to predict the recurrence in papillary thyroid carcinoma using machine learning

BACKGROUND AND AIMS

The recurrence of papillary thyroid carcinoma (PTC) is not unusual and associated with risk of death. This study is aimed to construct a nomogram that combines clinicopathological characteristics and ultrasound radiomics signatures to predict the recurrence in PTC.

METHODS

A total of 554 patients with PTC who underwent ultrasound imaging before total thyroidectomy were included. Among them, 79 experienced at least one recurrence. Then 388 were divided into the training cohort and 166 into the validation cohort. The radiomics features were extracted from the region of interest (ROI) we manually drew on the tumor image. The feature selection was conducted using Cox regression and least absolute shrinkage and selection operator (LASSO) analysis. And multivariate Cox regression analysis was used to build the combined nomogram using radiomics signatures and significant clinicopathological characteristics. The efficiency of the nomogram was evaluated by receiver operating characteristic (ROC) curves, calibration curves and decision curve analysis (DCA). Kaplan-Meier analysis was used to analyze the recurrence-free survival (RFS) in different radiomics scores (Rad-scores) and risk scores.

RESULTS

The combined nomogram demonstrated the best performance and achieved an area under the curve (AUC) of 0.851 (95% CI: 0.788 to 0.913) in comparison to that of the radiomics signature and the clinical model in the training cohort at 3 years. In the validation cohort, the combined nomogram (AUC = 0.885, 95% CI: 0.805 to 0.930) also performed better. The calibration curves and DCA verified the clinical usefulness of combined nomogram. And the Kaplan-Meier analysis showed that in the training cohort, the cumulative RFS in patients with higher Rad-score was significantly lower than that in patients with lower Rad-score (92.0% vs. 71.9%, log rank P < 0.001), and the cumulative RFS in patients with higher risk score was significantly lower than that in patients with lower risk score (97.5% vs. 73.5%, log rank P < 0.001). In the validation cohort, patients with a higher Rad-score and a higher risk score also had a significantly lower RFS.

CONCLUSION

We proposed a nomogram combining clinicopathological variables and ultrasound radiomics signatures with excellent performance for recurrence prediction in PTC patients.

Diagnostic, Theranostic and Prognostic Value of Thyroglobulin in Thyroid Cancer

Thyroglobulin (Tg) is an iodinated glycoprotein, which is normally stored in the follicular colloid of the thyroid, being a substrate for thyroid hormone production. Since it is produced by well-differentiated thyroid cells, it is considered a reliable tumor marker for patients with differentiated thyroid carcinoma (DTC) during their follow-up after total thyroidectomy and radioiodine ablation. It is used to monitor residual disease and to detect recurrent disease. After total thyroid ablation, unstimulated highly sensitive Tg measurements are sufficiently accurate to avoid exogenous or endogenous thyrotropin (TSH) stimulation and provide accurate diagnostic and prognostic information in the great majority of DTC patients. Adopting sophisticated statistical analysis, i.e., decision tree models, the use of Tg before radioiodine theranostic administration was demonstrated to be useful in refining conventional, pathology-based risk stratification and providing personalized adjuvant or therapeutic radioiodine administrations. The follow-up of DTC patients aims to promptly identify patients with residual or recurrent disease following primary treatment. Our review paper covers the diagnostic, theranostic and prognostic value of thyroglobulin in DTC patients.

Approach to Thyroid Nodules: Diagnosis and Treatment

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.

Nitric oxide, thyroglobulin, and calcitonin: unraveling the nature of thyroid nodules

Background

Thyroid nodules (TN) are localized morphological changes in the thyroid gland and can be benign or malignant.

Objective

The present study investigates the relationships between biochemical markers in serum (s) and their homologs in washout (w) after fine-needle aspiration biopsy (FNAB) of the TN of interest and their correlation with cytology specimen findings.

Methods

We investigated the relationships between serum biochemical markers nitric oxide (NO), thyroglobulin (TG), and calcitonin (CT), their homologs in washout after FNAB of the TN of interest, and cytology findings of biopsy samples classified according to the Bethesda system for thyroid cytopathology in this study, which included 86 subjects.

Results

Washout TG (TGw) level positively correlates with the cytology finding of the biopsy. A higher level of TGw correlates with higher categories of the Bethesda classification and indicates a higher malignant potential. The levels of serum NO (NOs), serum TG (TGs), serum CT (CTs), and washout CT (CTw) do not correlate with the cytology finding of the biopsy, and the higher levels of washout NO (NOw) correspond to the more suspicious ultrasound findings.

Conclusion

The findings of our study suggest that TGw and NOw could be used as potential predictors of malignancy in TN.

Determination of Diagnostic Features of Serum Thyroid Hormones and Thyroglobulin Ratios in Normothyroid Differentiated Thyroid Carcinoma Cases

Objectives

Ultrasonography and fine-needle aspiration biopsy (FNAB) are the gold standard methods in the prediction of benign and malignant thyroid nodules. However, despite being easily applicable, FNAB is an invasive procedure. Less invasive biomarkers should be utilized in the diagnosis of thyroid malignancies. In this study, we aimed to determine the parameters that can be used in the diagnosis of differentiated thyroid cancer (DTC) based on the serum thyroid and thyroglobulin (TG) levels which are routinely checked in patients followed up for thyroid nodules.

Methods

In the study, we evaluated patients who underwent thyroid surgery for nodular diseases between January 2015 and June 2022. Of the 1444 patients evaluated, 919 patients who met the inclusion criteria (normothyroid benign nodular disease or normothyroid DTC) were included in the study. Patients were divided into two groups as benign group (BG) and DTC group (DTCG). We compared patients' pre-operative serum thyroid and TG values and the diagnostic properties of their ratios.

Results

Of the 919 patients included, 517 (56.3%) were in BG and 402 (43.7%) were in DTCG. In DTCG, 318 patients were female and 84 patients were male. The mean age in the DTCG was 47.8 years. Comparison of DTCG and BG revealed a significant difference between T3/T4 ratio (p=0.002), T3/TSH ratio (p≤0.001), T4/TSH ratio (p≤0.001), TG/TSH ratio (p≤0.001), and TSH/TG ratio (p≤0.001). However, evaluation of the specified values by ROC analysis showed that the T3/T4 ratio did not make a significant difference between the two groups (p=0.1), whereas the other values displayed a significant difference (p≤0.001 for T3/TSH, p=0.001 for T4/TSH, p≤0.001 for TG/TSH, and p<0.001 for TSH/TG).

Conclusion

T3/TSH (cutoff =2.183), T4/TSH (cutoff=0.6), and TG/TSH (cutoff=29.67) values were found to be significant tumor markers for the prediction of malignancy in thyroid nodules, and low values were found to be associated with malignancy. TSH/TG (cutoff=0.031) value was also significant in predicting malignancy while high values were found to be associated with malignancy. Thyroid hormone and TG ratios may alter the preferred treatment method for thyroid nodules.

Diagnostic value of cell-free DNA in thyroid cancer: A systematic review and meta-analysis

OBJECTIVE

An increasing number of studies have shown the potential diagnostic value of cell-free DNA (cfDNA) as a new biomarker in the management of thyroid cancer (TC); however, the accuracy of research results is inconsistent. This meta-analysis is the first to synthesize published results and evaluate the application value of circulating cfDNA in the diagnosis of TC.

METHODS

A search strategy was developed according to PICO (P: Patient; I: Intervention; C: Comparison; O: Outcome) principles. We searched 5 databases until October 2022. Original studies that examined cfDNA for the diagnosis of TC and used pathology as the gold standard were included in this meta-analysis. A random-effects model was used to pool the data extracted from individual studies, including the number of patients and the numbers of true positives, false positives, true negatives, and false negatives.

RESULTS

A total of 622 patients with TC, 547 patients with benign thyroid nodules, and 98 healthy individuals were included in 20 studies reported in 14 articles. The types of cfDNA included in the research include specific mutations of cfDNA, methylation of cfDNA, the content of cfDNA, and cfDNA index. After rigorous statistical analysis, the pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio, and area under the summary receiver operating characteristic curve were 0.76 (95% confidence interval [CI] 0.62-0.85), 0.87 (95% CI 0.78-0.93), 5.08 (95% CI 3.3-10.3), 0.28 (95% CI 0.17-0.46), 21 (95% CI 9-49), and 0.89 (95% CI 0.86-0.91), respectively. The meta-regression results showed that the number of cfDNAs, cfDNA methylation status, and sample size were the sources of heterogeneity in the specificity of the study. A subgroup analysis showed that the quantitative analysis group (cfDNA level) had a higher diagnostic accuracy than that of the qualitative analysis group (cfDNA methylation, mutation, or integrity index), with a sensitivity of 0.84, specificity of 0.89, and area under the curve of 0.91.

CONCLUSIONS

The results of this meta-analysis suggest that cfDNA has value as an adjunct for the diagnosis of TC. Quantitative detection of cfDNA can achieve relatively high diagnostic accuracy. However, due to heterogeneity, the test results based on cfDNA for TC should be interpreted with caution.

The associations between thyroid-related hormones and the risk of thyroid cancer: An overall and dose-response meta-analysis

Objective

Thyroid cancer (TC) is one of the most common malignant tumours of the endocrine system. Thyroid-stimulating hormone (TSH) is known as being a risk factor for TC, but other thyroid-related hormones are inconsistently associated with TC. The purpose of this study was to comprehensively evaluate the relationships between thyroid-related hormones and the risk of TC.

Methods

This study utilized searches of PubMed, Embase, Web of Science and Cochrane library up to the date of March 31st, 2022. Additionally, we performed a systematic review of related original studies combining overall and dose-response meta-analyses.

Results

A total of 30, 5 and 7 articles were included in the meta-analyses of TSH, Free triiodothyronine (FT3), free thyroxine (FT4) and TC risk with 58437, 6813 and 7118 participants respectively. An increased risk of TC was associated with high TSH exposure (OR=1.28, 95% CI: 1.19-1.37, P < 0.001) in the overall meta-analysis. For every 1 mU/L increase in TSH, the risk of TC increased by 16%. However, in those studies that used healthy subjects as controls, the association was not statistically significant(P=0.62). Additionally, high serum FT3 demonstrated a reduced risk of TC, with a combined OR of 0.86 in the fixed-effect model (95% CI: 0.81-0.90, P < 0.001). In addition, a statistically significant increase in TC risk was found when FT4 concentrations reached a certain threshold (approximately 2.2 ng/dL) in the dose-response meta-analysis.

Conclusions

Significant associations between thyroid-related hormones and the risk of TC were found in this study. Further research is needed to understand the underlying mechanisms.

Clinical Value of Ultrasonography and Serum Markers in Preoperative N Staging of Thyroid Cancer

We aimed to determine factors influencing lymph node metastasis (LNM) and develop a more effective method to assess preoperative N staging. Overall, data of 2130 patients who underwent thyroidectomy for thyroid cancer between 2018 and 2021 were retrospectively analysed. Patients were divided into groups according to pN0, pN1a, and pN1b stages. Pathology was used to analyse the correlation between preoperative serum marker indicators and LNM. Receiver operating characteristic curves were used to compare the diagnostic value of ultrasound (US) examination alone, serum thyroglobulin, age, and combined method for LNM. A significant moderate agreement was observed between preoperative US and postoperative pathology for N staging. Between the pN0 and pN1 (pN1a + pN1b) groups, the differences in free triiodothyronine, anti-thyroid peroxidase antibody, and serum thyroglobulin levels were statistically significant. Among the indicators, serum thyroglobulin was an independent predictor of LNM. The area under the receiver operating characteristic curve was 0.610 for serum thyroglobulin level for predicting LNM, 0.689 for US alone, and 0.742 for the combined method. Both preoperative US and serum thyroglobulin level provide a specific value when evaluating the N staging of thyroid cancer, and the combined method is more valuable in the diagnosis of LNM than US alone.

Ultrasound features and preoperative accuracy of the fine needle aspiration biopsy in detection of thyroid carcinomas

OBJECTIVE

To analyze the ultrasound (US) characteristics and fine needle biopsy (FNAB) of thyroid carcinomas (TCs) prior to surgery and compare with postoperative histopathology and to determine FNAB sensitivity and specificity.

MATERIAL AND METHODS

Retrospective analysis of the US data during 1999-2015 was performed, as well as analysis of FNAB results and using histopathology report as "gold standard" the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of this method was evaluated.

RESULTS

Data revealed that tumors >51 mm were declining by 50% in the period 2011-2015 compared to 2005-2010 or by 18% 2011-2015 compared to 1999-2004 and significant increase was detected in diagnosis of multicentric tumors. The analysis revealed that FNAB has sensitivity = 65.7% CI (0.59% - 0.71%) and specificity = 50% CI (0.43%-0.56%), PPV = 56.9% and NPV = 59.2%.

CONCLUSION

We found increasing detection of smaller TCs, as well as more frequent detection of multicentricity of the neoplastic foci. FNAB results in our study revealed low sensitivity and specificity. Major limitation of the study was inability to exactly separate US guided from non US guided FNAB in evaluation of the sensitivity and specificity, due to retrospective nature of the analysis. Further studies evaluating only US guided FNAB should be performed.

Circulating Biomarkers in Thyroid Cancer

Thyroid cancer is the most important endocrine cancer with increasing incidence. While thyroid cancers, especially papillary thyroid cancers, are known to exhibit generally a favorable outcome with excellent survival rates, some thyroid cancers are more aggressive with a poor prognosis. Several different biomarkers have been introduced for the diagnosis of disease, identification of tumor load, assessment of therapy response, and the detection of recurrence during follow-up of the thyroid cancer patients. This chapter gives a brief overview of the circulating biomarkers used in thyroid cancer patients.

Ultrasonographic and cytologic assessments of follicular neoplasms of the thyroid: Predictive features differentiating follicular carcinoma from follicular adenoma

Background

The preoperative diagnosis of follicular neoplasm of the thyroid is challenging due to difficulties in the assessment of capsular invasion. This study aimed to identify ultrasonographic (US) and cytopathologic features that are characteristic of follicular adenoma and carcinoma to aid in their differential diagnosis.

Methods

A total of 98 surgically resected nodules diagnosed as follicular neoplasms between 2011 and 2012 were analyzed. US findings were reviewed according to the Korean Thyroid Imaging Reporting and Data System (K-TIRADS). Six cytologic features (high cellularity, abundant microfollicles, cell crowding/nuclear overlapping, isolated cells, homogeneous nuclei, abundant colloid) were reviewed quantitatively. The radiologic findings and quantification of cytologic features were correlated with final diagnoses.

Results

In total, 70 (71.4%) and 28 (28.6%) of the nodules were follicular adenomas and follicular carcinomas, respectively. US findings of a heterogeneous echogenicity, speculated/ill-defined margin, and presence of calcifications were significantly associated with follicular carcinoma (p<0.05). Calcifications had a predilection for pericapsular areas than for stromal areas in follicular carcinomas, whereas their location was more varied in follicular adenomas. No cytologic feature was significantly different between follicular adenomas and carcinomas.

Conclusion

Distinct from follicular adenomas, follicular carcinomas are characterized by heterogeneous echogenicity, speculated/ill-defined margin, and presence of calcifications on US. Thus, US findings can be helpful to differentiate between these two follicular neoplasms.

Preoperative platelet distribution width-to-platelet ratio combined with serum thyroglobulin may be objective and popularizable indicators in predicting papillary thyroid carcinoma

Objectives

The incidence of papillary thyroid carcinoma (PTC) has increased more rapidly than that of any other cancer type in China. Early indicators with high sensitivity and specificity during diagnosis are required. To date, there has been a paucity of studies investigating the relationship between preoperative platelet distribution width‐to‐platelet count ratio (PPR) and PTC. This study thus aimed to assess the diagnostic value of PPR combined with serum thyroglobulin (Tg) in patients with PTC.

Methods

A total of 1001 participants were included in our study. 876 patients who underwent surgery for nodular goiter were divided into the PTC group or benign thyroid nodule (BTN) group according to pathology reports, and 125 healthy controls (HCs) were included. Preoperative hemogram parameters and serum Tg levels were compared among three groups. Receiver operating characteristic (ROC) curve was used to evaluate the value of PPR combined with serum Tg for diagnosing PTC.

Results

Platelet distribution width (PDW) and PPR levels were higher in the PTC group than in the BTN and HC groups (both p < 0.05) but did not significantly differ between the BTN and HC groups. PDW and PPR levels significantly differed in the presence/absence of lymph node metastasis, the presence/absence of capsule invasion (p = 0.005), and TNM stages (p < 0.001). Multivariable analyses indicated that high serum Tg levels [adjusted odds ratio (OR), 1.007; 95% confidence interval (CI), 1.004–1.009; p < 0.001], high neutrophil‐to‐lymphocyte ratio (NLR,adjusted OR, 1.928; 95% CI, 1.619–2.295; p < 0.001), and high PPR (adjusted OR, 1.378; 95% CI, 1.268–1.497; p < 0.001) were independent risk factors for PTC. In ROC analysis, the areas under the curves (AUCs) of serum Tg, PDW, PPR, and NLR for predicting PTC were 0.603, 0.610, 0.706, and 0.685, respectively. PPR combined with serum Tg (PPR + Tg) had a higher diagnostic value (AUC, 0.738; sensitivity, 60%; specificity, 74.7%) compared with PDW + Tg (AUC, 0.656; sensitivity, 64.4%; specificity, 59.9%) and NLR + Tg (AUC, 0.714; sensitivity, 61.6%; specificity, 71.1%).

Conclusions

Preoperative PPR combined with serum Tg may be objective and popularizable indicators for effective predicting PTC.

Thyrotropin/Thyroglobulin ratio in combination with thyroid u/s to assess malignancy risk stratification of thyroid nodules

Objective: we aimed to asses if thyrotropin/thyroglobulin ratio has a significant value in detection of malignant thyroid nodules. Design: Retrospective analysis. Material and Methods: This study included finally 100 subject collected as outpatient’s endocrinology clinic of ALHuessine university hospital or admitted at oncology institute of Tanta. Patients who had history of thyroid diseases or surgery, those with abnormal levels of anti- thyroglobulin antibodies, cases without simultaneous measurement of serum anti Tg., with history of current use of thyroid hormone replacement therapy were excluded from this study. Clinico pathological features, as well as serumTSH, Tg, and TSH/Tg were compared between histopathologically benign and malignant groups. Results: Data related to 100 subjects (40%) normal  and 60(60%) patients  with thyroid nodules were analyzed, 30 patients (50%) were malignant thyroid nodules and 30 patients (50%) were benign.The malignant patients exhibited significantly higher TSH, TSH/Tg, , and a lower Tg compared to the benign patients (p<0.05 for each). Conclusion: Preoperative TSH/Tg could be used as a predictive marker for differ-entiating between benign and malignant thyroid nodules.

Sonographic Features Differentiating Follicular Thyroid Cancer from Follicular Adenoma-A Meta-Analysis

Simple Summary

The risk of thyroid malignancy assessment may include certain ultrasound features. The analysis is lacking for the differentiation of follicular thyroid adenomas and cancers (FTAs and FTCs). Our meta-analysis aimed to identify sonographic features suggesting malignancy in the case of follicular lesions, potentially differentiating FTA and FTC. Based on twenty studies describing sonographic features of 10,215 nodules, we found that the most crucial feature associated with an increased risk of FTC were tumor protrusion (odds ratios—OR = 10.19), microcalcifications or mixed type of calcifications: 6.09, irregular margins: 5.11, marked hypoechogenicity: 4.59, and irregular shape: 3.6.

Abstract

Certain ultrasound features are associated with an increased risk of thyroid malignancy. However, they were studied mainly in papillary thyroid cancers (PTCs); these results cannot be simply extrapolated for the differentiation of follicular thyroid adenomas and cancers (FTAs and FTCs). The aim of our study was to perform a meta-analysis to identify sonographic features suggesting malignancy in the case of follicular lesions, potentially differentiating FTA and FTC. We searched thirteen databases from January 2006 to December 2020 to find all relevant, full-text journal articles written in English. Analyses assessed the accuracy of malignancy detection in case of follicular lesions, potentially differentiating FTA and FTC included the odds ratio (OR), sensitivity, specificity, positive and negative predictive values. A random-effects model was used to summarize collected data. Twenty studies describing sonographic features of 10,215 nodules met the inclusion criteria. The highest overall ORs to increase the risk of malignancy were calculated for tumor protrusion (OR = 10.19; 95% confidence interval: 2.62–39.71), microcalcifications or mixed type of calcifications (coexisting micro and macrocalcifications): 6.09 (3.22–11.50), irregular margins: 5.11 (2.90–8.99), marked hypoechogenicity: 4.59 (3.23–6.54), and irregular shape: 3.6 (1.19–10.92). The most crucial feature associated with an increased risk of FTC is capsule protrusion, followed by the presence of calcifications, irrespectively of their type.

Can preoperative serum thyroglobulin levels predict the risk of malignancy? Results from prospective analysis of biochemical predictors of malignancy in thyroid nodules

Although thyroid nodule is a common presentation, malignancy is rare. The present study investigated biochemical predictors of malignancy in enlarged thyroid. This is a prospective study of all willing patients 18 to 70 years presenting with a complaint of thyroid swelling and who underwent definitive surgery over a period of 19 months. All subjects were initially evaluated with detailed history, physical examination, ultrasonography of neck and fine needle aspiration cytology (FNAC). Preoperative estimation of serum thyroid stimulating hormone (TSH), thyroglobulin (Tg) and anti-thyroglobulin (anti Tg) antibody was obtained. The treatment plan was based on FNAC results and included hemi- or total thyroidectomy. During the study period, 110 patients underwent thyroidectomy, and met the selection criteria, of which 47 patients had malignancy on final histopathology. The majority were females, 30 to 60 years old. Median serum Tg, TSH and anti Tg levels in the benign group were, respectively 29 ng/ml, 1,6 mIU/L and 1,1 IU/ml, whereas in malignant nodules they were 162 ng/ml. 1,7 mIU/L and 0,9 IU/ml. On receiver operating characteristic curve analysis, a Tg cut off value of 53 ng/ml predicted malignancy risk with a sensitivity and specificity of 72% and 73%, respectively (p < 0.001). Our study showed the utility of preoperative Tg in predicting risk of malignancy. Its role should be further explored especially in the backdrop of indeterminate cytology through a larger study.

McGill Thyroid Nodule Score in Differentiating Thyroid Nodules in Total Thyroidectomy Cases of Indeterminate Nodules

Fine-needle aspiration biopsy (FNAB) is the first-line modality in the evaluation of thyroid nodules. However, the results of indeterminate pathology place the thyroid surgeon in difficult management situations. This study evaluates McGill Thyroid Nodule Score (MTNS) to identify thyroid nodules that harbor malignancy in cases of indeterminate FNABs and to guide surgeon about the need and extent of surgery. We conducted a retrospective chart review of 344 patients who underwent total thyroidectomy between January 2013 and January 2018. Patients with FNAB of indeterminate nodules (Bethesda types III, IV, and V) and calculated MTNS were included in the study. Postoperative histopathology was divided into benign and malignant groups. The median and the mean MTNS, the malignancy rate, and the standard deviations were calculated for each subgroup. Of the 344 patient charts reviewed, 106 (30.8%) had an indeterminate FNA biopsy. Eighty-one (76.4%) patients were females and 25 (23.6%) were males. Final pathology revealed malignancy in 69 patients (65.1%). The mean MTNS of patients with malignant pathology (12.81  ± 3.55) was higher than the mean in the benign group (8.32  ± 2.32). 82.4% of thyroid nodules with median MTNS of less than 8 had a benign pathology, and 91.4% of thyroid nodules with median MTNS equal or more than 11 had a malignant pathology (p = 0.002). The rate of malignancy in our series of indeterminate FNABs was 65.1%. The MTNS can be of value to thyroid surgeons in preoperative decision-making when dealing with an indeterminate thyroid nodule.

Prognostic factors in thyroid carcinomas: a 17-year outcome study

Objectives The aim of our study was to evaluate the survival rate of all thyroid carcinomas (TCs) diagnosed in the 1999-2015 period in the Republic of North Macedonia and to analyze the prognostic influence of several characteristics on development of distant metastases, as well as to analyze the prognostic effect of seven clinical and constitutional features on mortality. Material and methods A retrospective analysis of medical data from all TCs diagnosed in 1999-2015 was performed. The survival rate of all types of TCs was estimated using the Kaplan Meier method. Univariate and multivariate logistic regression analysis was applied for evaluation of the predictive role of seven clinical and constitutional characteristics for development of distant metastases, and the univariate Cox-proportional model was applied for evaluation of the predictors for mortality. Results A total of 422 TC cases were diagnosed in the 17-year period, with an average survival time of 212.99 months. Results of the univariate regression analysis showed that dimension at initial ultrasound and histopathological type of tumor were significantly predictive variables for distant metastases. Multifocal tumors vs. unifocal tumors < 15 mm significantly increased the probability of distant metastases by 7.401 (p = 0.005, 95% CI = 1.817-30.190) times. Age, initial lymph node involvement, number of radioiodine therapies, and histopathology of the tumor were selected as independent significant predictors for mortality. Conclusion Our results showed an excellent overall prognosis of thyroid tumors in the Macedonian population. The dimension of the tumor, multifocality, and histopathological type were the most relevant prognostic predictive features for development of distant metastases.

The association of preoperative thyroid-stimulating hormone level and the risk of differentiated thyroid cancer in patients with thyroid nodules: A systematic review and meta-analysis

BACKGROUND

This systematic review and meta-analysis was conducted to determine the value of preoperative thyroid-stimulating hormone (TSH) levels in assessing the risk of differentiated thyroid cancer (DTC) in patients with thyroid nodules.

METHODS

This meta-analysis included 23,799 subjects (15,406 non-Chinese and 8,393 Chinese) with thyroid nodules. Multivariate and individual adjusted odds ratios (OR) were calculated for a 1 mU/L increase in preoperative TSH levels to determine the risk of malignant DTC.

RESULTS

The OR for DTC in relation to preoperative TSH levels was significant in Chinese (1.25 [1.11, 1.40], Z = 3.67, p = 0.0002) and non-Chinese subjects (1.12 [1.03, 1.22], Z = 2.72, p = 0.006). The overall random-effects model indicated that there was a significantly increased risk for DTC in patients with thyroid nodules (OR 1.16 [1.06, 1.27], Z = 3.29, p = 0.007).

CONCLUSIONS

A significant association between higher TSH levels and risk of DTC was observed in both population groups investigated, with higher ORs for Chinese subjects.

Preoperative prediction of non-invasive follicular thyroid neoplasm with papillary-like nuclear features: a Canadian single-Centre experience

Background

An international group of experts recommended reclassifying non-invasive follicular variant of papillary thyroid cancers (FVPTC) as ‘non-invasive follicular thyroid neoplasm with papillary-like nuclear features’ (NIFTP) in April 2016. The purpose of this study was to establish preoperative clinical, laboratory, ultrasonographic, and cytological variables, which can differentiate NIFTP from FVPTC.

Methods

We conducted a retrospective chart review of consecutive patients from a single institution evaluated between January 2012 and December 2017. 203 adult patients underwent lobectomy or total thyroidectomy for a FVPTC during that period. Each patient’s medical chart was reviewed and information on pre-operative variables was recorded. An expert pathologist reviewed all surgical specimens and reclassified a subset of FVPTC as NIFTP according to the specific criteria.

Results

Overall, 44 patients were included in the NIFTP group and 159 in the non-NIFTP group. Mean age was 50.1 years in the NIFTP group and 50.7 in the non-NIFTP group. Most patients were female (86.4% (38/44) in the NIFTP group vs 79.8% (127/159) in the non-NIFTP group). More patients underwent lobectomy in the NIFTP group (50% (22/44) vs 16.4% (26/159) in the non-NIFTP group, p = < 0.0001). Less patients received radioactive iodine in the NIFTP group (31.8% (14/44) vs 52.2% (83/159) in the non-NIFTP group, p = 0.0177). Preoperative thyroglobulin levels were lower in NIFTP patients (Median 25.55 mcg/L +/− 67.8 vs 76.06 mcg/L +/− 119.8 in Non-NIFTP, p = 0.0104). NIFTP nodules were smaller (Mean size 22.97 mm +/− 12.3 vs 25.88 mm +/− 11.2 for non-NIFTP, p = 0.0448) and more often solid than non-NIFTP (93.2% (41/44) vs 74.8% (119/159) for non-NIFTP, p = 0.0067). 2017 ACR TIRADS nodule category of 1–4 on ultrasound had a negative predictive value and a sensitivity of 100% for NIFTP. ROC Curve Analysis demonstrated that a preoperative thyroglobulin level of 31.3 mcg/L had a sensitivity of 75% and a specificity of 62.5% to differentiate NIFTP from non-NIFTP cancers.

Conclusion

Lower preoperative thyroglobulin levels, smaller nodule size, solid texture and 2017 ACR TIRADS Category of 1–4 are more strongly associated with NIFTP than FVPTC and can favour less invasive surgical options such as lobectomy.

Development and validation of a preoperative prediction model for follicular thyroid carcinoma

OBJECTIVE

The low pre- and intraoperative diagnostic rates in follicular thyroid carcinoma (FTC) often lead to inadequate surgical resection and necessitate further completion surgery. Therefore, the preoperative prediction of FTC in thyroid nodules is essential. DESIGN AND PATIENT: Patients were categorized into two data sets: the modelling data set, which included 3649 patients admitted to our centre between January 2014 and December 2016, and the validation data set, which included 1253 patients admitted between January and December 2017. Patient data from the FTC and non-FTC groups were initially included in a modelling data set to establish a preoperative prediction model. This model was subsequently employed in a validation data set for external validation of the predictive value. The positivity rate for FTC predicted by the model was compared with that of the intraoperative frozen sections.

RESULTS

The preoperative serum thyroglobulin level, nodule diameter, calcification status, solidity and blood supply were selected as predictors for the model. The regression equation was as follows: Y = 0.010 × (thyroglobulin level) + 0.556 × (nodule diameter) + 0.675 × (calcification status) + 2.355 × (nodule component) + 1.072*(blood flow) - 9.787. The model positively predicted FTC at values of Y ≥ -4.11. The accuracy, sensitivity, specificity, positive likelihood ratio and negative likelihood ratio of the prediction model were 89.2%, 90.2%, 87.7%, 39.2 and 0.11, respectively. External validation of the model demonstrated acceptable results. The positive prediction rate of the model was 90.7% (78/86), which was significantly higher than that of the intraoperative frozen sections (10.5% [9/86]; P < 0.0001).

CONCLUSIONS

We successfully established and validated a simple and reliable preoperative prediction model for FTC using the preoperative thyroglobulin level and ultrasonographic features of the thyroid nodules. This model may improve the preoperative evaluation of FTC in clinical settings and facilitate the development of a reasonable surgical programme for FTC.

Follicular thyroid cancer and Hürthle cell carcinoma: challenges in diagnosis, treatment, and clinical management

Follicular thyroid cancer is the second most common differentiated thyroid cancer histological type and has been overshadowed by its more common counterpart-papillary thyroid cancer-despite its unique biological behaviour and less favourable outcomes. In this Review, we comprehensively review the literature on follicular thyroid cancer to provide an evidence-based guide to the management of these tumours, to highlight the lack of evidence behind guideline recommendations, and to identify changes and challenges over the past decades in diagnosis, prognosis, and treatment. We highlight that correct identification of cancer in indeterminate cytological samples is challenging and ultrasonographic features can be misleading. Despite certain unique aspects of follicular thyroid cancer presentation and prognosis, no specific recommendations exist for follicular thyroid cancer and Hürthle cell carcinoma in evidence-based guidelines. Efforts should be made to stimulate additional research in this field.

Investigation of thyroid nodules: A practical algorithm and review of guidelines

BACKGROUND

High resolution ultrasound has led to early detection of subclinical tumors and drastic increase in incidence of thyroid malignancy. To achieve a balance in appropriate investigation without perpetuating an overdiagnosis phenomenon, a concise set of evidence-based recommendations to stratify risk is required.

METHODS

We sought to assemble an evidence-based diagnostic algorithm and accompanying pictorial review for workup of thyroid nodules that summarizes the most recent guidelines. In addition, we conducted a literature search and analysis of our imaging databases.

RESULTS

Although many imaging features of benign and malignant nodules can be nonspecific, others, such as microcalcifications, lymphadenopathy, and peripheral invasion, are highly suggestive of malignancy. The predictive values of salient imaging characteristics are presented.

CONCLUSION

Evidence-based guidelines are available such that a cost-effective algorithm for thyroid nodule workup can be devised. Conservative management with a focus on periodic monitoring is the working clinical consensus on the approach to thyroid nodules.

An overall and dose-response meta-analysis for thyrotropin and thyroid cancer risk by histological type

Thyrotropin (TSH) is thought as a risk factor for thyroid cancer. However, the effect of serum TSH might depend on histological types of thyroid cancer. We searched for related studies including serum TSH as an exposure and thyroid cancer as a result in PUBMED, EMBASE and Chinese National Knowledge Infrastructure up to April 21, 2016. This meta-analysis included 22 articles with 53,538 participants. When comparing all histological thyroid cancer, the pooled odds ratios of thyroid cancer in patients with nodules was found to increase significantly with higher serum TSH concentrations for differentiated thyroid carcinoma (1.88 vs .1.48, P = 0.0000) and papillary thyroid carcinoma (2.08 vs. 1.48, P = 0.0006). Each 1 mU/L increase of serum TSH was associated with 14% greater risk of thyroid cancer for all histological thyroid cancer, 16% for differentiated thyroid carcinoma and 22% for papillary thyroid carcinoma. In addition, high serum TSH was associated with a reduced risk for follicular thyroid carcinoma (OR = 0.73, 95% CI: 0.52, 1.02). This meta-analysis suggested high serum TSH concentration is risky for papillary thyroid carcinoma but not for follicular thyroid carcinoma.

Preoperative serum thyroglobulin predicts initial distant metastasis in patients with differentiated thyroid cancer

Differentiated thyroid cancer (DTC) generally has a favorable prognosis. However, a small percentage of patients suffer from initial distant metastasis (DM). To date, there is no effective predictor for the presence of initial DM. The aim of this study was to determine if preoperative serum thyroglobulin (Tg) level could predict initial DM in DTC. We reviewed an institutional thyroid cancer database from October 1994 to February 2016. To determine the Tg cutoff for predicting initial DM, 4,735 patients who were diagnosed with DTC were included in this study. Fifty-seven patients (1.2%) were identified as having DTC with initial DM. Median preoperative Tg level was 328.4 ng/ml in the initial DM group and 10.0 ng/ml in the non-DM group. Initial DM was the most important factor affecting serum Tg level (β = 2,049.32 ± 103.40; P < 0.001). The Tg cutoff level that distinguished overall DM with the greatest accuracy was 63.4 ng/ml [area under the ROC curve 0.914, sensitivity 84.2%, specificity 90.6%, negative likelihood ratio (LR) 0.17, and positive LR 8.97]. Preoperative Tg levels were useful for predicting initial DM of DTC. Measurement of serum Tg in patients with DTC may guide preoperative staging evaluation and initial treatment.

2016 Russian clinical practice guidelines for differentiated thyroid cancer diagnosis and treatment

В представленных клинических рекомендациях обсуждаются современные подходы к диагностике и лечению дифференцированного рака щитовидной железы у взрослых. Изменения в настоящей редакции Клинических рекомендаций касаются показаний к пункционной биопсии, скринингового определения концентрации кальцитонина, унификации заключений цитологического исследования, новых подходах к послеоперационной динамической стратификации риска рецидива, показаний к супрессивной и заместительной терапии, таргетной терапии йоднегативных форм дифференцированного рака щитовидной железы.

Preoperative serum thyroglobulin and changes in serum thyroglobulin during TSH suppression independently predict follicular thyroid carcinoma in thyroid nodules with a cytological diagnosis of follicular lesion

BACKGROUND

Fine-needle aspiration biopsy (FNAB) cannot distinguish a follicular thyroid carcinoma (FTC) from a follicular adenoma in follicular lesions. We designed this study to determine whether the preoperative thyroglobulin (Tg) and change in serum Tg during thyroid-stimulating hormone (TSH) suppression can predict FTC in thyroid nodules with a cytological diagnosis of follicular lesion.

METHODS

Among 854 patients who underwent thyroid surgery, the 198 patients who presented with thyroid nodules with a cytological diagnosis of follicular lesion were analyzed. Predictive factors for malignancy were evaluated using multivariate logistic regression models. Subgroup analyses of patients with TSH suppression therapy by levothyroxine were also conducted.

RESULTS

Thirty-two patients (16%) had FTC, and 166 patients had confirmed benign nodules. The median preoperative serum Tg levels were significantly higher in patients with FTC compared to those with benign pathology (449 vs. 34 ng/mL, p < 0.001). The serum Tg (odds ratios (OR) 10.311, p < 0.001) and tumor volume (OR 4.500, p = 0.035) were found to be independent predictors for FTC in all patients with a cytological diagnosis of follicular lesion. Forty-eight patients received TSH suppression therapy. When we performed subgroup analyses on the patients with TSH suppression therapy, decrease less than 15% in serum Tg during TSH suppression was found to be an independent predictor of FTC (OR 13.918, p = 0.018).

CONCLUSION

Preoperative serum Tg and changes in serum Tg during TSH suppression independently predict FTC in thyroid nodules with a cytological diagnosis of follicular lesion.

Thyroid nodule update on diagnosis and management

Thyroid nodules are common. The clinical importance of thyroid nodules is related to excluding malignancy (4.0 to 6.5% of all thyroid nodules), evaluate their functional status and assess for the presence of pressure symptoms. Incidental thyroid nodules are being diagnosed with increasing frequency in the recent years with the use of newer and highly sensitive imaging techniques. The high prevalence of thyroid nodules necessitates that the clinicians use evidence-based approaches for their assessment and management. New molecular tests have been developed to help with evaluation of malignancy in thyroid nodules. This review addresses advances in thyroid nodule evaluation, and their management considering the current guidelines and supporting evidence.

Evaluation and management of thyroid nodules in children

PURPOSE OF REVIEW

The review is focused on new information about the presentation and management of thyroid nodules in children and adolescents.

RECENT FINDINGS

Palpable thyroid nodules are uncommon in children but many children have nodules detected by radiologic imaging. How to evaluate them, when to suspect thyroid cancer, and how best to follow apparently benign nodules has become an area of great interest. The American Thyroid Association recently published treatment guidelines for children with thyroid nodules and cancers but much has been learned since that publication.

SUMMARY

Personal and family history, ultrasound features, and fine needle aspiration cytology are used to determine the risk of cancer in thyroid nodules, which are then managed according to cancer risk.

Can preoperative thyroglobulin antibody levels be used as a marker for well differentiated thyroid cancer?

Background

It has been reported that thyroglobulin antibody are more frequently elevated in patients with thyroid cancercompared to general population. This study aims at evaluating whether preoperative thyroglobulin antibody (TgAb) levels increase the likelihood that a thyroid nodule is malignant.

Methods

A retrospective review of 586 patients who underwent thyroidectomy was conducted. Demographic data, TgAb levels, and final histopathology were recorded. Patients were divided into two groups: TgAb positive (defined as TgAb ≥ 30 IU/ml) and TgAb low/negative (defined as TgAb < 30).

Results

Preoperative TgAb levels were available in 405 patients. There were 353 (87 %) patients in the TgAblow/negative group (malignancy rate: 50.42 %) and 52 (13 %) patients in the TgAb positive group (malignancy rate: 65.38 %). The sensitivity, specificity, positive predictive value and negative predictive value of TgAb ≥ 30 IU/ml for thyroid malignancy were 16.04 %, 90.67 %, 65.38 % and 49.58 %, respectively. The relative risk of having a malignant thyroid nodule when the TgAb titers were≥30 IU/ml was 1.30 (CI1.04-1.62) and the odds ratio was 1.86 (CI 1.01-3.41). Both the Pearson chi-square test (p = 0.024) and Fisher’s exact test (p = 0.017) yielded statistical significance between the two groups.

Conclusions

In this study, patients with preoperative TgAb ≥ 30 IU/ml had a higher rate of malignancy when compared topatients with TgAb < 30 IU/ml. This suggests that an elevated TgAb level may indicate that a thyroid nodule is at an increased risk for malignancy.

2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer

BACKGROUND

Thyroid nodules are a common clinical problem, and differentiated thyroid cancer is becoming increasingly prevalent. Since the American Thyroid Association's (ATA's) guidelines for the management of these disorders were revised in 2009, significant scientific advances have occurred in the field. The aim of these guidelines is to inform clinicians, patients, researchers, and health policy makers on published evidence relating to the diagnosis and management of thyroid nodules and differentiated thyroid cancer.

METHODS

The specific clinical questions addressed in these guidelines were based on prior versions of the guidelines, stakeholder input, and input of task force members. Task force panel members were educated on knowledge synthesis methods, including electronic database searching, review and selection of relevant citations, and critical appraisal of selected studies. Published English language articles on adults were eligible for inclusion. The American College of Physicians Guideline Grading System was used for critical appraisal of evidence and grading strength of recommendations for therapeutic interventions. We developed a similarly formatted system to appraise the quality of such studies and resultant recommendations. The guideline panel had complete editorial independence from the ATA. Competing interests of guideline task force members were regularly updated, managed, and communicated to the ATA and task force members.

RESULTS

The revised guidelines for the management of thyroid nodules include recommendations regarding initial evaluation, clinical and ultrasound criteria for fine-needle aspiration biopsy, interpretation of fine-needle aspiration biopsy results, use of molecular markers, and management of benign thyroid nodules. Recommendations regarding the initial management of thyroid cancer include those relating to screening for thyroid cancer, staging and risk assessment, surgical management, radioiodine remnant ablation and therapy, and thyrotropin suppression therapy using levothyroxine. Recommendations related to long-term management of differentiated thyroid cancer include those related to surveillance for recurrent disease using imaging and serum thyroglobulin, thyroid hormone therapy, management of recurrent and metastatic disease, consideration for clinical trials and targeted therapy, as well as directions for future research.

CONCLUSIONS

We have developed evidence-based recommendations to inform clinical decision-making in the management of thyroid nodules and differentiated thyroid cancer. They represent, in our opinion, contemporary optimal care for patients with these disorders.

Evaluation of Serum Vascular Adhesion Protein-1 as a Potential Biomarker in Thyroid Cancer

Vascular adhesion protein-1 (VAP-1) is a glycoprotein that mediates tissue-selective lymphocyte adhesion. The prognostic value of VAP-1 has been determined in gastric cancer. The aim of this study was to evaluate the changes and the predictive value of serum VAP-1 in patients with thyroid cancer. A total of 126 patients with thyroid nodules and 53 healthy controls participated in this study. The patients were further divided into subgroup 1 (69 cases with benign thyroid nodules) and subgroup 2 (57 cases with thyroid cancer). Serum VAP-1 was measured by time-resolved immunofluorometric assay. Diagnostic value of presurgical VAP-1 for thyroid cancer was conducted by receiver operating characteristic (ROC) curves. Serum levels of VAP-1 were significantly lower in thyroid cancer group than in healthy control and benign thyroid nodule groups. VAP-1 concentrations negatively correlated with serum thyroglobulin (Tg) levels in thyroid cancer patients (r = -0.81; p < 0.001). The optimum cut-off value of VAP-1 was 456.6 ng/mL with a 77.4% specificity and 66.7% sensitivity for thyroid cancer diagnosis. Serum VAP-1 decreased in thyroid cancer patients and VAP-1 could be a potential useful adjunct biomarker in the diagnosis of thyroid cancer.

Shear-Wave Elastography for the Preoperative Risk Stratification of Follicular-patterned Lesions of the Thyroid: Diagnostic Accuracy and Optimal Measurement Plane

PURPOSE

To evaluate the diagnostic accuracy of shear-wave elastography (SWE) for the diagnosis of malignancy in follicular lesions and to identify the optimal SWE measurement plane.

MATERIALS AND METHODS

The institutional review board approved this HIPAA-compliant, single-institution, prospective pilot study. Subjects scheduled for surgery after a previous fine-needle aspiration report of "atypia of undetermined significance" or "follicular lesion of undetermined significance," "suspicion for follicular neoplasm," or "suspicion for Hurthle cell neoplasm," were enrolled after obtaining informed consent. Subjects underwent conventional ultrasonography (US), Doppler evaluation, and SWE preoperatively, and their predictive value for thyroid malignancy was evaluated relative to the reference standard of surgical pathologic findings.

RESULTS

Thirty-five patients (12 men, 23 women) with a mean age of 55 years (range, 23-85 years) and a fine-needle aspiration diagnosis of atypia of undetermined significance or follicular lesion of undetermined significance (n = 16), suspicion for follicular neoplasm (n = 14), and suspicion for Hurthle cell neoplasm (n = 5) were enrolled in the study. Male sex was a statistically significant (P = .02) predictor of malignancy, but age was not. No sonographic morphologic parameter, including nodule size, microcalcification, macrocalcification, halo sign, taller than wide dimension, or hypoechogenicity, was associated with malignancy. Similarly, no Doppler feature, including intranodular vascularity, pulsatility index, resistive index, or peak-systolic velocity, was associated with malignancy. Higher median SWE tissue Young modulus estimates from the transverse insonation plane were associated with malignancy, yielding an area under the receiver operating characteristic curve of 0.81 (95% confidence interval: 0.62, 1.00) for differentiation of malignant from benign nodules. At a cutoff value of 22.3 kPa, sensitivity, specificity, positive predictive value, and negative predictive value of 82%, 88%, 75%, and 91%, respectively, were observed.

CONCLUSION

This prospective pilot study indicates that SWE may be a valuable tool in preoperative malignancy risk assessment of follicular-patterned thyroid nodules.

Preoperative Serum Thyrotropin to Thyroglobulin Ratio Is Effective for Thyroid Nodule Evaluation in Euthyroid Patients

OBJECTIVE

This study was designed to assess the efficiency of the serum thyrotropin to thyroglobulin ratio for thyroid nodule evaluation in euthyroid patients.

STUDY DESIGN

Cross-sectional study.

SETTING

Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China.

SUBJECTS AND METHODS

Retrospective analysis was performed for 400 previously untreated cases presenting with thyroid nodules. Thyroid function was tested with commercially available radioimmunoassays. The receiver operating characteristic curves were constructed to determine cutoff values. The efficacy of the thyrotropin:thyroglobulin ratio and thyroid-stimulating hormone for thyroid nodule evaluation was evaluated in terms of sensitivity, specificity, positive predictive value, positive likelihood ratio, negative likelihood ratio, and odds ratio.

RESULTS

In receiver operating characteristic curve analysis, the area under the curve was 0.746 for the thyrotropin:thyroglobulin ratio and 0.659 for thyroid-stimulating hormone. With a cutoff point value of 24.97 IU/g for the thyrotropin:thyroglobulin ratio, the sensitivity, specificity, positive predictive value, positive likelihood ratio, and negative likelihood ratio were 78.9%, 60.8%, 75.5%, 2.01, and 0.35, respectively. The odds ratio for the thyrotropin:thyroglobulin ratio indicating malignancy was 5.80. With a cutoff point value of 1.525 µIU/mL for thyroid-stimulating hormone, the sensitivity, specificity, positive predictive value, positive likelihood ratio, and negative likelihood ratio were 74.0%, 53.2%, 70.8%, 1.58, and 0.49, respectively. The odds ratio indicating malignancy for thyroid-stimulating hormone was 3.23.

CONCLUSION

Increasing preoperative serum thyrotropin:thyroglobulin ratio is a risk factor for thyroid carcinoma, and the correlation of the thyrotropin:thyroglobulin ratio to malignancy is higher than that for serum thyroid-stimulating hormone.

The Mcgill thyroid nodule score - does it help with indeterminate thyroid nodules?

BACKGROUND

Ultrasound guided fine-needle aspiration (USFNA) biopsy of thyroid nodules often gives a result of indeterminate pathology, placing thyroid specialists in difficult management situations. The aim of this study is to evaluate the incidence of malignancy in patients undergoing surgery and to correlate these results with the McGill Thyroid Nodule Score (MTNS).

METHODS

We performed a retrospective study comparing USFNA results, MTNS and histopathology of patients undergoing thyroid surgery between 2010 and 2012. Pre-operative USFNA results were divided into three subgroups: benign, indeterminate and suspicious for/malignant. The indeterminate USFNA subgroup comprised of Bethesda type III (atypia of undetermined significance) and Bethesda type IV (follicular neoplasms, including Hurthle cell neoplasms) lesions. Post-operative histopathology was divided into benign or malignant groups.

RESULTS

Of the 437 patient charts reviewed, 57.0% had an indeterminate USFNA biopsy. Within the indeterminate group, the malignancy rate was 39.8%. For indeterminate USFNA, the median MTNS was 7 (32% risk of malignancy) for benign nodules and 9 (63% risk of malignancy) for malignant nodules on post-operative histopathology (p < 0.05).

CONCLUSION

The rate of malignancy in operated patients with an indeterminate USFNA result was 39.8%. The MTNS can be of value to thyroid specialists in pre-operative decision-making when dealing with an indeterminate result of a thyroid nodule on USFNA.

Identification of Intermediate- to High-Risk Papillary Thyroid Carcinoma Patients Who May Be Safely Managed without the Performance of Delayed Stimulated Thyroglobulin Measurements following Total Thyroidectomy and Radioactive Iodine Therapy

Background. The measurement of stimulated thyroglobulin (sTg) after total thyroidectomy and remnant radioactive iodine (RAI) ablation is the gold standard for monitoring disease status in patients with papillary thyroid carcinomas (PTCs). The aim of this study was to determine whether sTg measurement during follow-up can be avoided in intermediate- and high-risk PTC patients. Methods. A total of 346 patients with PTCs with an intermediate or high risk of recurrence were analysed. All of the patients underwent total thyroidectomy as well as remnant RAI ablation and sTg measurements. Preoperative and postoperative parameters were included in the analysis. Results. Among the preoperative parameters, age below 45 years and preoperative Tg above 19.4 ng/mL were significant risk factors for predicting detectable sTg during follow-up. Among the postoperative parameters, thyroid capsular invasion, lymph node metastasis, and ablative Tg above 2.9 ng/mL were independently correlated with a detectable sTg range. The combination of ablative Tg less than 2.9 ng/mL with pre- and postoperative independent risk factors for detectable sTg increased the negative predictive value for detectable sTg up to 98.5%. Conclusions. Based on pre- and postoperative parameters, a substantial proportion of patients with PTCs in the intermediate- and high-risk classes could avoid aggressive follow-up measures.

How sensitive (second-generation) thyroglobulin measurement is changing paradigms for monitoring patients with differentiated thyroid cancer, in the absence or presence of thyroglobulin autoantibodies

PURPOSE OF REVIEW

To discuss new insights regarding how sensitive (second-generation) thyroglobulin immunometric assays (TgIMAs), (functional sensitivities ≤0.10 μg/L) necessitate different approaches for postoperative thyroglobulin monitoring of patients with differentiated thyroid cancer (DTC), depending on the presence of thyroglobulin autoantibodies (TgAbs).

RECENT FINDINGS

Reliable low-range serum thyroglobulin measurement has both enhanced clinical utility and economic advantages, provided TgAb is absent (∼75% DTC patients). Basal [nonthyroid-stimulating hormone (TSH) stimulated] TgIMA measurement obviates the need for recombinant human TSH stimulation because basal TgIMA below 0.20 μg/L has comparable negative predictive value (>95%) to recombinant human TSH-stimulated thyroglobulin values below the cutoff of 2 μg/L. Now that radioiodine remnant ablation is no longer considered necessary to treat low-risk DTC, the trend and doubling time of low basal thyroglobulin values arising from postsurgical thyroid remnants have recognized prognostic significance. The major limitation of TgIMA testing is interference by TgAb (∼25% DTC patients), causing TgIMA underestimation that can mask disease. When TgAb is present, the trend in TgAb concentrations (measured by the same method) can serve as the primary (surrogate) tumor-marker and be augmented by thyroglobulin measured by a TgAb-resistant class of method (radioimmunoassay or liquid chromatography-tandem mass spectrometry).

SUMMARY

The growing use of TgIMA measurement is changing paradigms for postoperative DTC monitoring. When TgAb is absent, it is optimal to monitor the basal TgIMA trend and doubling time (using the same method) in preference to recombinant human TSH-stimulated thyroglobulin testing. When TgAb is present, interference renders TgIMA testing unreliable and the trend in serum TgAb concentrations per se (same method) can serve as a (surrogate) tumor-marker.

Diagnostic Value of Preoperative Serum Thyroglobulin Measurement for the Diagnosis of Malignancy in Follicular or Hürthle Cell Neoplasms of the Thyroid Gland

<title>Abstract</title><sec><title>Objectives</title><p>The aim of this retrospective study was whether serum Tg predicts malignancy in follicular or Hürthle-cell neoplasms on fine needle aspiration.</sec><sec><title>Methods</title><p>A chart review of 111 patients (90 females, 21 males; mean age 46.8 ± 11.9 years) with follicular or Hürthle-cell neoplasms on fine needle aspiration, who were surgically treated between Sep. 2001 and Sep. 2011, was performed. Predictive factors for malignancy were identified by the chi-squared test and multivariate logistic regression.</sec><sec><title>Results</title><p>There were no differences between 41 malignant and 70 benign lesions in serum Tg or any of the normalized indexes. Receiver-operator characteristic analysis revealed no cutoff value. Lesions with serum Tg levels greater than 500 g/L had no significant difference. And also there were no independent predictors of malignancy by multivariate logistic regression.</sec><sec><title>Conclusions</title><p>In this study, the author found that serum Tg has poor accuracy for predicting malignancy in follicular or Hürthle cell neoplasms on fine needle aspiration.</sec>

Serum thyroglobulin improves the sensitivity of the McGill Thyroid Nodule Score for well-differentiated thyroid cancer

BACKGROUND

The McGill Thyroid Nodule Score (MTNS) is a scoring system devised to help physicians to assess the preoperative risk that a thyroid nodule is malignant. It uses 22 different known risk factors for thyroid cancer (radiation exposure, microcalcifications on ultrasound, positive HBME-1 stain on biopsy, etc.) and attributes a percentage risk that the nodule is malignant. Recently, preoperative thyroglobulin (Tg) levels have been shown to correlate with the risk of malignancy. The aim of this study was to incorporate Tg levels into the already established MTNS.

METHODS

This is a retrospective analysis of 184 thyroidectomy patients at the McGill University Thyroid Cancer Center. Patients with preoperative Tg levels were included in the study, and patients with incidental papillary microcarcinoma without extrathyroidal extent on final pathology were excluded. MTNS scores were calculated for all patients. Preoperative Tg levels of 75 ng/mL added one point to the MTNS, and levels of 187.5 ng/mL added two points. The new system is named MTNS+.

RESULTS

Malignancy rates were calculated for each MTNS+ score. Patients with a score of 0-1 were <5% at risk of malignancy. The malignancy rate for scores of 2-3 was 14.29%, followed by 28.95% for scores of 4-6, 32.65% for scores of 7-8, 64.86% for scores of 9-11, 71.43% for scores of 12-14, 78.57% for scores of 15-18, and 92.31% for scores of 19-22. All patients (five of five) with an MTNS+ score of 23 or more had a malignant final pathology result. Patients with scores greater than eight had a relative risk of 2.5 [CI 1.79-3.49] of malignancy compared to patients with lower scores. MTNS+ showed good specificity at higher scores, with 89%, 96%, and 100% at scores above 11, 14, and 20 respectively. Compared to MTNS, adding Tg levels did not improve positive predictive values (PPV) or specificity, but improved sensitivity by 7.89% for scores greater than eight, and by up to 10.48% for scores greater than seven.

CONCLUSION

This study shows that adding Tg to the MTNS increases the sensitivity of this scoring system. Moreover, it suggests that a combined scoring system such as the MTNS+ can accurately stratify the risk of well-differentiated malignancy in patients with thyroid nodules.

Markedly elevated thyroglobulin levels in the preoperative thyroidectomy patient correlates with metastatic burden

BACKGROUND

Thyroglobulin (Tg) is a marker of tumor recurrence during thyroid cancer follow-up. While helpful in the postoperative setting, the clinical significance of preoperative Tg measurements remains unclear. The aim of the study was to determine if preoperative Tg levels are indicative of underlying malignancy or burden of metastatic disease.

METHODS

A retrospective review of a prospectively collected database at an academic medical center of all thyroidectomy patients with a measured preoperative Tg level was conducted. Patients were grouped by Tg level into quartiles for initial univariate analysis, followed by multivariable analysis of variance.

RESULTS

Between 2007 and 2012, 611 patients met criteria. Quartile breakdown was as follows: ≤19 ng/mL, 19.1-54 ng/mL, 54.1-151 ng/mL, and >151 ng/mL. Patients' age and gender were equivalent. Hashimoto's thyroiditis was most common in the lowest Tg group (24% versus 11%-12%, P < 0.01). While cancer was more common in the low Tg, metastatic disease was most common in the high Tg group. Specimen weight increased with increasing Tg levels (P < 0.01). Body mass index, gland weight, cancer, and Hashimoto's and metastatic disease were entered into a multivariable analysis. Only gland weight and metastatic disease correlated with Tg levels (both P < 0.001). All patients with Tg > 5000 ng/mL had metastatic disease (n = 6).

CONCLUSIONS

Although preoperative Tg levels are not associated with a diagnosis of cancer, they are associated with the presence of metastatic disease. All patients with a Tg > 5000 ng/mL had significant disease burden. In patients with concern for metastatic disease, preoperative serum Tg may be a useful marker to aid decision making.

Predictive factors of malignancy in thyroid nodules with a cytological diagnosis of follicular neoplasm

In cases of follicular neoplasm identified by thyroid fine-needle aspiration (FNA), surgery is required to achieve a precise diagnosis. We investigated potential clinical factors for the preoperative prediction of malignancy in thyroid nodules with a cytological diagnosis of follicular neoplasm. We retrospectively reviewed the data of 97 patients who were diagnosed with follicular neoplasm by FNA and had undergone surgery at the Korea Cancer Center Hospital between April 2010 and April 2012. Age, sex, laboratory data (such as thyroid-stimulating hormone, free T4, thyroglobulin (Tg), and Tg antibody), and ultrasonographic findings were reviewed from the electronic medical records. Of 97 patients, 50 (51.5 %) were diagnosed with benign nodules, 16 (16.5 %) with follicular thyroid carcinoma (FTC), and 31 (32.0 %) with papillary thyroid carcinoma (PTC). In comparison with the features of benign nodules, FTC presented with a large nodule size, high serum Tg level, isoechogenicity, calcifications, and peripheral halo, whereas PTC exhibited traits similar to those of benign nodules, except for high serum Tg level and the presence of calcifications on ultrasonography. Therefore, a high serum Tg level (≥75 ng/mL) and calcification were the only significant predictive factors for malignancy in case of follicular neoplasm (p < 0.01). Serum Tg levels and the presence of calcification on ultrasonography are important clinical features to predict malignancy in thyroid nodules with cytological diagnosis of follicular neoplasm.

Lobectomy in follicular thyroid neoplasms' treatment

BACKGROUND

The purpose of this study is to evaluate the suitability of lobectomy with isthmectomy (LwI) in treatment of Follicular Thyroid Neoplasms (FTN), considering malignancy incidence and postoperative complications.

METHODS

192 patients (165 females; 27 males) who underwent LwI for FTN from 01/2005 to 12/2007 were retrospectively evaluated: clinical and pathological features, surgical complications and five year outcome. Inclusion criteria were cytological Bethesda category III and IV or histological follicular adenoma/carcinoma or follicular variant of papillary carcinoma). Metastatic disease or previous thyroidal surgery patients were excluded.

RESULTS

Mean age was 48.68 ± 14.93 yrs. Overall malignancy occurred in 88 patients (45.83%) and 80 (41.67%) underwent thyroidectomy completion (TC), mainly by index lesion's malignancy. Forty-one (21.35%) in LwI and 31 (38.75%) in TC specimens had associated malignancy, mainly papillary microcarcinomas. High preoperative Thyroid-Stimulating Hormone (TSH), histological multinodularity and, in cytology category IV, younger age, were significantly associated to malignancy. Permanent recurrent laryngeal nerve lesion occurred in 0.58% in Lwl and 1.52% in TC, and temporary dysphonia occurred in 9.25% and 6.06% (LwI and TC respectively). No LwI patients presented hypoparathyroidism whereas 3.03% in TC had temporary symptoms. In LwI, 36.70% developed hypothyroidism. Higher preoperative TSH was associated with hypothyroidism development.

CONCLUSIONS

LwI was inappropriate in 40.10% patients with malignancy who required TC and 23.12% had no functional benefit because post-LwI hypothyroidism. Nodular relapse was reported in at least 23/113 LwI patients (20.35%). We propose total thyroidectomy for patients with FTN preoperative TSH higher than 2.16 mU/L and, in Bethesda category IV, less than 39.5yrs.

Biomarkers for anti-angiogenic therapy in cancer

Angiogenesis, the development of new vessels from existing vasculature, plays a central role in tumor growth, survival, and progression. On the molecular level it is controlled by a number of pro- and anti-angiogenic cytokines, among which the vascular endothelial growth factors (VEGFs), together with their related VEGF-receptors, have an exceptional position. Therefore, the blockade of VEGF signaling in order to inhibit angiogenesis was deemed an attractive approach for cancer therapy and drugs interfering with the VEGF-ligands, the VEGF receptors, and the intracellular VEGF-mediated signal transduction were developed. Although promising in pre-clinical trials, VEGF-inhibition proved to be problematic in the clinical context. One major drawback was the generally high variability in patient response to anti-angiogenic drugs and the rapid development of therapy resistance, so that, in total, only moderate effects on progression-free and overall survival were observed. Biomarkers predicting the response to VEGF-inhibition might attenuate this problem and help to further individualize drug and dosage determination. Although up to now no definitive biomarker has been identified for this purpose, several candidates are currently under investigation. This review aims to give an overview of the recent developments in this field, focusing on the most prevalent tumor species.

Incidental thyroid carcinoma diagnosed after total thyroidectomy for benign thyroid diseases: incidence and association with thyroid disease type and laboratory markers

Objective. Currently, total thyroidectomy (TT) is widely used to treat benign thyroid diseases and thyroid carcinoma. The differential diagnosis between benign and malignant thyroid disorders and the potential identification of thyroid microcarcinomas with biochemical markers remain controversial. This retrospective study aimed to estimate the prognostic validity of thyroid autoantibodies, thyroglobulin (Tg), and the thyroid disease type in diagnostic approaches regarding the co-existence of incidental thyroid carcinoma (ITC) with benign thyroid diseases. Methods. A cohort of 228 patients was treated with TT for benign thyroid disorders between 2005 and 2010. Thyroid autoantibodies and Tg were preoperatively estimated. Patients were classified according to the preoperative and histologically established diagnoses, and the median values of the biochemical markers were compared between the groups. Results. ITC was detected in 33/228 patients and almost exclusively in the presence of nontoxic thyroid disorders (P = 0.014). There were no statistically significant differences in the median values of the biochemical markers between the benign and malignant groups. There was also no significant association between ITC and chronic lymphocytic thyroiditis. Conclusions. The co-existence of ITC with benign and especially nontoxic thyroid diseases is significant, and treatment of these disorders with TT when indicated can lead to the identification and definitive cure of microcarcinomas. Further studies are required to establish precise markers with prognostic validity for TC diagnosis.