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Baugh KA, Yip L, Ramonell KM, Carty SE, McCoy KL. Outcomes of subtotal parathyroidectomy for renal hyperparathyroidism. Surgery 2024; 175:788-793. [PMID: 37945480 DOI: 10.1016/j.surg.2023.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 08/27/2023] [Accepted: 09/05/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Renal hyperparathyroidism due to end-stage kidney disease is associated with considerable morbidity, and when refractory is treated with parathyroidectomy. Recurrent renal hyperparathyroidism is a major surgical complication, yet initial target parathyroid remnant size and outcomes, including rates of recurrence are not well elucidated. METHODS This is a single-institution retrospective cohort study of patients who underwent initial subtotal parathyroidectomy for renal hyperparathyroidism on dialysis, from 1990-2022. The subtotal parathyroidectomy was defined as resection of 3 parathyroid glands ± partial resection of the fourth gland leaving a remnant of ∼75-100 mg, and postresection intraoperative parathyroid hormone goal was 150-250 pg/mL. Clinical data were examined for outcomes. RESULTS Among 204 patients who met inclusion criteria, 139 (68%) had follow-up data; 58% (80/139) were women and median age was 45 years. Surgical complications included 2 hematomas (1.4%), 1 recurrent laryngeal nerve injury (<1%), and no patient required readmission for intravenous calcium. Using a target remnant size of 75-100 mg, recurrent renal hyperparathyroidism was uncommon (14/139, 10%) and arose at a median interval of 58.6 months (range, 8-180). In cases of recurrence, the postresection intraoperative parathyroid hormone level was less likely to drop <250 pg/mL (40%, 4/10 vs nonrecurrence 65%, 80/123; P = .11) with a slightly lower median decrease (70% vs 81% in nonrecurrence, P = .8); however, neither were significant. Recurrence did not occur in the 19 patients who later received kidney transplantation (P = .2). CONCLUSION In subtotal parathyroidectomy for renal hyperparathyroidism, use of a target 75-100 mg remnant size results in low complication rates. Durable cure appears to be more likely with renal transplantation.
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Affiliation(s)
| | - Linwah Yip
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | | | - Sally E Carty
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Kelly L McCoy
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
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Ohori NP, Cuda JM, Bastacky SI, Yip L, Karslioglu-French E, Morariu EM, Ullal J, Ramonell KM, Carty SE, Nikiforov YE, Schoedel KE, Seethala RR. Molecular-derived risk of malignancy and the related positive call rate of indeterminate thyroid cytology diagnoses as quality metrics for individual cytopathologists. Cancer Cytopathol 2024; 132:109-118. [PMID: 37849056 DOI: 10.1002/cncy.22772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 09/16/2023] [Accepted: 09/19/2023] [Indexed: 10/19/2023]
Abstract
BACKGROUND Indeterminate thyroid cytopathology diagnoses represent differing degrees of risk that are corroborated by follow-up studies. However, traditional cytologic-histologic correlation may overestimate the risk of malignancy (ROM) because only a subset of cases undergo resection. Alternatively, some molecular tests provide probability of malignancy data to calculate the molecular-derived risk of malignancy (MDROM) and the positive call rate (PCR). The authors investigated MDROMs and PCRs of indeterminate diagnoses for individual cytopathologists as quality metrics. METHODS This study was approved by the Department of Pathology Quality Improvement Program. Thyroid cytopathology diagnoses and ThyroSeq v3 results were retrieved for each cytopathologist for a 2-year period with at least 3 years of follow-up for the atypia of undetermined significance (AUS), follicular neoplasia (FN), and follicular neoplasia, oncocytic-type (ONC) cytopathologic diagnoses. MDROMs and PCRs were compared with reference ROMs and cytologic-histologic correlation outcomes. RESULTS The overall MDROMs (and ranges for cytopathologists) for the AUS, FN, and ONC categories were 13.4% (range, 5.8%-20.8%), 28.1% (range, 22.1%-36.7%), and 27.0% (range, 19.5%-41.5%), respectively, and most individual cytopathologists' MDROMs were within reference ROM ranges. However, PCRs more effectively parsed the differences in cytopathologists' ROM performance. Although the overall PCRs were not significantly different across cytopathologists (p = .06), the AUS PCRs were quite different (p = .002). By cytologic-histologic correlation, six of 55 resected cases (10.9%) were falsely negative, and there were no false-positive cases. CONCLUSIONS MDROMs and PCRs evaluate concordance with reference ROMs and with one another and provide individual feedback, which potentially facilitates quality improvement.
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Affiliation(s)
- N Paul Ohori
- Department of Pathology, University of Pittsburgh Medical Center-Presbyterian, Pittsburgh, Pennsylvania, USA
| | - Jacqueline M Cuda
- Department of Pathology, University of Pittsburgh Medical Center-Presbyterian, Pittsburgh, Pennsylvania, USA
| | - Sheldon I Bastacky
- Department of Pathology, University of Pittsburgh Medical Center-Presbyterian, Pittsburgh, Pennsylvania, USA
| | - Linwah Yip
- Division of Endocrine Surgery, University of Pittsburgh Medical Center-Presbyterian, Pittsburgh, Pennsylvania, USA
| | - Esra Karslioglu-French
- Division of Endocrinology, University of Pittsburgh Medical Center-Presbyterian, Pittsburgh, Pennsylvania, USA
| | - Elena M Morariu
- Division of Endocrinology, University of Pittsburgh Medical Center-Presbyterian, Pittsburgh, Pennsylvania, USA
| | - Jagdeesh Ullal
- Division of Endocrinology, University of Pittsburgh Medical Center-Presbyterian, Pittsburgh, Pennsylvania, USA
| | - Kimberly M Ramonell
- Division of Endocrine Surgery, University of Pittsburgh Medical Center-Presbyterian, Pittsburgh, Pennsylvania, USA
| | - Sally E Carty
- Division of Endocrine Surgery, University of Pittsburgh Medical Center-Presbyterian, Pittsburgh, Pennsylvania, USA
| | - Yuri E Nikiforov
- Department of Pathology, University of Pittsburgh Medical Center-Presbyterian, Pittsburgh, Pennsylvania, USA
| | - Karen E Schoedel
- Department of Pathology, University of Pittsburgh Medical Center-Presbyterian, Pittsburgh, Pennsylvania, USA
| | - Raja R Seethala
- Department of Pathology, University of Pittsburgh Medical Center-Presbyterian, Pittsburgh, Pennsylvania, USA
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Baugh KA, Liu JB, Yip L, McCoy KL, Carty SE, Ramonell KM. Sex differences in patients with primary hyperparathyroidism. Surgery 2024; 175:65-72. [PMID: 37980200 DOI: 10.1016/j.surg.2023.07.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 06/27/2023] [Accepted: 07/18/2023] [Indexed: 11/20/2023]
Abstract
BACKGROUND Differences in presenting symptoms of primary hyperparathyroidism and outcomes of parathyroidectomy between sexes have been described, but whether these can be assessed by perioperative use of a validated tool, such as the Pasieka Parathyroidectomy Assessment Score, is unknown. METHOD All patients with primary hyperparathyroidism were asked to complete symptom assessment at the preoperative and postoperative visits. The assessment included a query for 13 Pasieka Parathyroidectomy Assessment Score parameters evaluated using a visual analog scale as described by Pasieka (summative score 0-1,300), and general quality of life and wellness. A review of a prospectively maintained database of primary hyperparathyroidism patients (January 2016-December 2019) was performed, and those who had a 6-month cure after initial parathyroidectomy were included. RESULTS The study cohort was mostly women (77%, 541/701). The median preoperative Pasieka Parathyroidectomy Assessment Score was higher in women (155, 0-1,190) than in men (80.5, 0-855, P < .001), although there were similar rates of asymptomatic primary hyperparathyroidism (Pasieka Parathyroidectomy Assessment Score = 0, 12.5% vs 7%, P = .042). After curative parathyroidectomy, women reported a substantial reduction in symptomatology, with Pasieka Parathyroidectomy Assessment Score declining by 35% at initial postoperative visit (median, 155 vs 100, P < .001), further decreasing to 48% by 6 months (155 vs 80, P < .001). The Pasieka Parathyroidectomy Assessment Score in men did change but to a much smaller degree at both the initial postoperative visit (80.5 vs 70; P = .036) and at 6 months (80.5 vs 57.5; P = .048). CONCLUSION When assessed with the Pasieka Parathyroidectomy Assessment Score, improvement in symptoms was clearly demonstrated for women after curative parathyroidectomy. Whether symptom improvement also occurs in men is less apparent but may be due to disparities in the development and validation of outcomes tools in general.
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Affiliation(s)
| | - Jason B Liu
- Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Linwah Yip
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Kelly L McCoy
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Sally E Carty
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
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Liu JB, Carty SE, Yip L. Radiofrequency Ablation of Small Thyroid Cancer-A Solution Looking for a Problem? JAMA Surg 2024; 159:59. [PMID: 37878308 DOI: 10.1001/jamasurg.2023.5195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Affiliation(s)
- Jason B Liu
- Division of Surgical Oncology, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Sally E Carty
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Linwah Yip
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
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Baugh KA, McCoy KL, Leung JH, Carty SE, Ramonell KM, Yip L. Normocalcemic hyperparathyroidism: Intervention to differentiate primary from secondary hyperparathyroidism. Surgery 2024; 175:166-171. [PMID: 37981554 DOI: 10.1016/j.surg.2023.06.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 05/05/2023] [Accepted: 06/20/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Normocalcemic hyperparathyroidism can occur, but surgery should not be considered until common etiologies for secondary hyperparathyroidism are comprehensively excluded. Calcium deficiency is an underrecognized cause of normocalcemic parathyroid hormone elevation, and we aim to determine if the implementation of a preoperative calcium challenge can be used to reduce unnecessary parathyroidectomy. METHODS Consecutive patients referred for parathyroidectomy (1/21-6/22) with normocalcemia (serum calcium <10 mg/dL) and concurrently elevated parathyroid hormone levels were routinely treated with supplemental calcium and vitamin D3, and follow-up laboratory studies were assessed. RESULTS A total of 29/314 (9%) patients had normocalcemic parathyroid hormone elevation with mean calcium, parathyroid hormone, and vitamin D 25OH levels of 9.5 ± 0.3 mg/dL, 109.9 ± 34.9 pg/mL, and 42.7 ± 23.8 ng/mL respectively. Confounding factors included estimated glomerular filtration rate <60 in 2, loop diuretic use in 4, and prior gastric bypass or gastric sleeve surgery in 4. Follow-up biochemical evaluation was available in 27 (92%); results were unchanged in 7 patients (26%); normalization of parathyroid hormone levels with persistently normal calcium levels occurred in 15 (55%), thus confirming secondary hyperparathyroidism and hypercalcemia with elevated parathyroid hormone levels (classic primary hyperparathyroidism) was diagnosed in 5 (19%). Parathyroid exploration has been completed for 3 of 5 patients with classic primary hyperparathyroidism to date. CONCLUSION A preoperative calcium challenge was prospectively initiated in normocalcemic patients with parathyroid hormone elevation, and there was high compliance (92%). Short-interval calcium supplementation revealed ∼50% to have resolved secondary hyperparathyroidism due to insufficient calcium intake, which avoided unnecessary surgery. In contrast, classic patients were unveiled in 20%, allowing for prompt and correct surgical intervention.
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Affiliation(s)
| | - Kelly L McCoy
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Janet H Leung
- Department of Endocrinology, University of Pittsburgh, Pittsburgh, PA
| | - Sally E Carty
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | | | - Linwah Yip
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
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Chiosea S, Hodak SP, Yip L, Abraham D, Baldwin C, Baloch Z, Gulec SA, Hannoush ZC, Haugen BR, Joseph L, Kargi AY, Khanafshar E, Livhits MJ, McIver B, Patel K, Patel SG, Randolph GW, Shaha AR, Sharma J, Stathatos N, van Zante A, Carty SE, Nikiforov YE, Nikiforova MN. Molecular Profiling of 50 734 Bethesda III-VI Thyroid Nodules by ThyroSeq v3: Implications for Personalized Management. J Clin Endocrinol Metab 2023; 108:2999-3008. [PMID: 37071871 PMCID: PMC10583990 DOI: 10.1210/clinem/dgad220] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 03/29/2023] [Accepted: 04/12/2023] [Indexed: 04/20/2023]
Abstract
CONTEXT Comprehensive genomic analysis of thyroid nodules for multiple classes of molecular alterations detected in a large series of fine needle aspiration (FNA) samples has not been reported. OBJECTIVE To determine the prevalence of clinically relevant molecular alterations in Bethesda categories III-VI (BCIII-VI) thyroid nodules. METHODS This retrospective analysis of FNA samples, tested by ThyroSeq v3 using Genomic Classifier and Cancer Risk Classifier at UPMC Molecular and Genomic Pathology laboratory, analyzed the prevalence of diagnostic, prognostic, and targetable genetic alterations in a total of 50 734 BCIII-VI nodules from 48 225 patients. RESULTS Among 50 734 informative FNA samples, 65.3% were test-negative, 33.9% positive, 0.2% positive for medullary carcinoma, and 0.6% positive for parathyroid. The benign call rate in BCIII-IV nodules was 68%. Among test-positive samples, 73.3% had mutations, 11.3% gene fusions, and 10.8% isolated copy number alterations. Comparing BCIII-IV nodules with BCV-VI nodules revealed a shift from predominantly RAS-like alterations to BRAF V600E-like alterations and fusions involving receptor tyrosine kinases (RTK). Using ThyroSeq Cancer Risk Classifier, a high-risk profile, which typically included TERT or TP53 mutations, was found in 6% of samples, more frequently BCV-VI. RNA-Seq confirmed ThyroSeq detection of novel RTK fusions in 98.9% of cases. CONCLUSION In this series, 68% of BCIII-IV nodules were classified as negative by ThyroSeq, potentially preventing diagnostic surgery in this subset of patients. Specific genetic alterations were detected in most BCV-VI nodules, with a higher prevalence of BRAF and TERT mutations and targetable gene fusions compared to BCIII-IV nodules, offering prognostic and therapeutic information for patient management.
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Affiliation(s)
- Simion Chiosea
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Steven P Hodak
- NYU Robert I. Grossman School of Medicine, NYU Langone Health, New York, NY 12297, USA
| | - Linwah Yip
- Division of Endocrine Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Devaprabu Abraham
- Division of Endocrinology, Department of Internal Medicine, University of Utah Health, Salt Lake City, UT 84112, USA
| | - Chelsey Baldwin
- Division of Endocrinology & Metabolism, George Washington University, Washington, DC 20037, USA
| | - Zubair Baloch
- Perelman School of Medicine Department of Pathology, Hospital of the University of Pennsylvania, Philadelphia, PA 19103, USA
| | - Seza A Gulec
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA
| | - Zeina C Hannoush
- Division of Endocrinology, Diabetes and Metabolism. University of Miami, Miller School of Medicine, Miami, FL 33146, USA
| | - Bryan R Haugen
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Lija Joseph
- Lowell General Hospital, Boston University and Tufts University, Lowell, MA 01854, USA
| | - Atil Y Kargi
- Division of Endocrinology, Diabetes and Metabolism. University of Miami, Miller School of Medicine, Miami, FL 33146, USA
| | - Elham Khanafshar
- Department of Pathology, University of California San Francisco, San Francisco, CA 94143, USA
| | - Masha J Livhits
- David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | | | - Kepal Patel
- NYU Robert I. Grossman School of Medicine, NYU Langone Health, New York, NY 12297, USA
| | - Snehal G Patel
- Department of Surgery, Emory University School of Medicine, Atlanta, GA 30342, USA
| | | | - Ashok R Shaha
- Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Jyotirmay Sharma
- Department of Surgery, Emory University School of Medicine, Atlanta, GA 30342, USA
| | | | - Annemieke van Zante
- Department of Pathology, University of California San Francisco, San Francisco, CA 94143, USA
| | - Sally E Carty
- Division of Endocrine Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Yuri E Nikiforov
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Marina N Nikiforova
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
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7
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Daniels KE, Shaffer AD, Garbin S, Squires JH, Vaughan KG, Viswanathan P, Witchel SF, Mollen KP, Yip L, Monaco SE, Duvvuri U, Simons JP. Validity of the American College of Radiology Thyroid Imaging Reporting and Data System in Children. Laryngoscope 2023; 133:2394-2401. [PMID: 36250584 DOI: 10.1002/lary.30425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 09/10/2022] [Accepted: 09/15/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To assess the validity of the American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS) for evaluating thyroid nodules in children. METHODS Patients aged <19 years with thyroid nodule(s) evaluated by ultrasound (US) from 2007-2018 at a tertiary children's hospital were included. Two radiologists scored de-identified thyroid US images using ACR TI-RADS (from 1, "benign" to 5, "highly suspicious"). The radiologists recorded size and rated vascularity for each nodule. Ultrasound findings were compared to pathology results (operative cases, n = 91) and clinical follow-up without disease progression (non-operative cases, n = 15). RESULTS Thyroid images from 115 patients were reviewed. Nine patients were excluded due to the absence of an evaluable nodule. Forty-seven benign and 59 malignant nodules were included. Median age at ultrasound was 15 years (range 0.9-18 years). Twenty (18.9%) patients were male. There was moderate agreement between TI-RADS levels assigned by the two raters (kappa = 0.57, p < 0.001). When the raters' levels were averaged, >3 as the threshold for malignancy correctly categorized the greatest percentage of nodules (68.9%). Eleven (18.6%) malignant nodules received a TI-RADS level of 2 (n = 3) or 3 (n = 8). Sensitivity, specificity, and positive and negative predictive values were 81.4%, 53.2%, 68.6%, and 69.4%, respectively. Although not part of TI-RADS, vascularity was similar between benign and malignant nodules (p = 0.56). CONCLUSION In a pediatric population, TI-RADS can help distinguish between benign and malignant nodules with comparable sensitivity and specificity to adults. However, the positive and negative predictive values suggest TI-RADS alone cannot eliminate the need for FNA. LEVEL OF EVIDENCE 3 Laryngoscope, 133:2394-2401, 2023.
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Affiliation(s)
- Kelly E Daniels
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Amber D Shaffer
- Division of Pediatric Otolaryngology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Steven Garbin
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Judy H Squires
- Division of Radiology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kevin G Vaughan
- Division of Radiology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Pushpa Viswanathan
- Division of Endocrinology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Selma F Witchel
- Division of Endocrinology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kevin P Mollen
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Linwah Yip
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Sara E Monaco
- Division of Pediatric Otolaryngology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Laboratory Medicine, Geisinger Medical Center, Danville, PA, USA
| | - Umamaheswar Duvvuri
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jeffrey P Simons
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Division of Pediatric Otolaryngology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Liu JB, Baugh KA, Ramonell K, McCoy KL, Karslioglu-French E, Morariu EM, Ohori NP, Nikiforova MN, Nikiforov YE, Carty SE, Yip L. Molecular Testing Predicts Incomplete Response to Initial Therapy in Differentiated Thyroid Carcinoma without Lateral Neck or Distant Metastasis at Presentation: Retrospective Cohort Study. Thyroid 2023. [PMID: 36974361 DOI: 10.1089/thy.2023.0060] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
BACKGROUND Molecular testing (MT) is emerging as a potential prognostic factor that can be available before treatment of differentiated thyroid carcinoma begins. Among patients eligible for either lobectomy or total thyroidectomy as their initial therapy, our study aim was to assess (1) if conventionally available preoperative factors are associated with incomplete response to initial therapy, and (2) if molecular testing (MT) results can be a surrogate for the ATA Risk Stratification System (RSS) to estimate risk of recurrence. METHODS The data of consecutive thyroid cancer patients without preoperative lateral neck disease or distant metastasis who underwent index thyroidectomy between November 1, 2017 and October 31, 2021 were reviewed. Logistic regression models including preoperative variables such as MT and/or the postoperatively available RSS were constructed to predict disease recurrence, either structural or biochemical. Model discrimination using the c-statistic and goodness-of-fit were compared. RESULTS Among 945 patients studied, 50 (5.2%) recurred with 18-month median follow up. Recurrences were detected in 17 (2.9%), 20 (6.7%), and 13 (22.8%) patients with RSS-Low, -Intermediate, and -High cancers, respectively (p<0.001). In multivariable analysis, only tumor size was associated with recurrence (OR 1.3, 95% CI 1.1-1.5). In a different model analyzing 440 (46.6%) patients with available MT results, recurrence was associated with both larger tumor size (OR 1.4, 95% CI 1.1-1.8) and MT results (p<0.001). Including MT improved the c-statistic by 27%, which was statistically no different than the model incorporating only the RSS (p=0.15). CONCLUSIONS Disease recurrence was observed across all ATA RSS categories in short-term follow-up, and tumor size was the only conventional preoperative factor associated with recurrence. When MT results were incorporated, they not only improved predictive ability beyond tumor size alone, but also yielded similar ability as the gold standard ATA RSS. Thus, MT results might aid the development of novel preoperative risk stratification algorithms.
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Affiliation(s)
- Jason B Liu
- Brigham and Women's Hospital, 1861, Surgery , 75 Francis St. CA-3, Boston, Massachusetts, United States, 02115-6195;
| | - Katherine A Baugh
- University of Pittsburgh, 6614, Surgery, Pittsburgh, Pennsylvania, United States;
| | - Kimberly Ramonell
- University of Pittsburgh, 6614, Pittsburgh, Pennsylvania, United States;
| | - Kelly L McCoy
- University of Pittsburgh, 6614, Surgery, Pittsburgh, Pennsylvania, United States;
| | - Esra Karslioglu-French
- University of Pittsburgh School of Medicine, 12317, Medicine, Falk Medical Building, 3601 5th Ave, Pittsburgh, Pennsylvania, United States, 15213;
| | - Elena Madalina Morariu
- University of Pittsburgh Medical Center, 6595, Endocrinology, 3601 Fifth Ave, Ste 300, Pittsburgh, Pittsburgh, Pennsylvania, United States, 15213;
| | - N Paul Ohori
- University of Pittsburgh, 6614, Pathology, Pittsburgh, Pennsylvania, United States;
| | - Marina N Nikiforova
- University of Pittsburg Medical Center, Pathology, 200 Lothrop Street, Pittsburgh, United States, 15213;
| | - Yuri E Nikiforov
- University of Pittsburgh School of Medicine, 12317, Department of Pathology, 3477 Euler Way, CLB Room 8031, Pittsburgh, Pennsylvania, United States, 15261;
| | - Sally E Carty
- University of Pittsburgh, Surgery, Division of Endocrine Surgery, 101 Kaufmann, 3471 Fifth Avenue, Pittsburgh, United States, 15213
- United States;
| | - Linwah Yip
- University of Pittsburgh, Surgery, 3471 Fifth Ave, Kaufmann Building, Suite 101, Pittsburgh, Pennsylvania, United States, 15213;
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Geisler DL, Karslioglu French E, Yip L, Nikiforova MN, Nikiforov YE, Schoedel KE, Seethala RR, Ohori NP. A thyroid EIF1AX story: how clinical, cytologic, and molecular surveillance led to appropriate management. J Am Soc Cytopathol 2023; 12:105-111. [PMID: 36504010 DOI: 10.1016/j.jasc.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 11/07/2022] [Accepted: 11/14/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Indeterminate thyroid cytology diagnoses are associated with intermediate risks of malignancy. Application of molecular testing (MT) to indeterminate specimens provides additional diagnostic and prognostic information. While a positive or suspicious MT result may prompt surgery, a negative MT result is associated with a low probability of cancer or noninvasive follicular thyroid neoplasm with papillary-like nuclear features and approximates that of a benign cytology diagnosis. Furthermore, ThyroSeq v3 MT has a "currently negative" result for findings with the probability of cancer or noninvasive follicular thyroid neoplasm with papillary-like nuclear feature that is slightly greater than that for the negative ThyroSeq v3 MT result but less than 10%, suggesting active surveillance. In this report, we discuss a case of a patient for whom clinical, cytologic, and molecular surveillance led to timely surgery and management. CLINICAL DETAILS A 53-year-old man with a thyroid isthmus nodule had a fine-needle aspiration cytology diagnosis of atypia of undetermined significance and a subsequent ThyroSeq v3 MT, which revealed an EIF1AX mutation and a "currently negative" MT result. Surveillance with additional fine-needle aspiration samples demonstrated concerning genomic alterations (fluctuating EIF1AX allelic frequency and a non-V600E BRAF mutation), culminating in the conversion to a positive MT result 3 years later. Resection revealed an encapsulated noninvasive, oncocytic solid subtype of papillary thyroid carcinoma with increased mitotic activity. CONCLUSION The case is notable for clinical, cytologic, and molecular surveillance demonstrating sequential pathologic alterations in an indeterminate thyroid nodule with EIF1AX mutation, leading to timely resection of the neoplasm before invasion manifested.
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Affiliation(s)
- Daniel L Geisler
- Department of Pathology, University of Pittsburgh Medical Center-Presbyterian, Pittsburgh, Pennsylvania
| | - Esra Karslioglu French
- Division of Endocrinology and Metabolism, Department of Medicine, University of Pittsburgh Medical Center-Presbyterian, Pittsburgh, Pennsylvania
| | - Linwah Yip
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh Medical Center-Presbyterian, Pittsburgh, Pennsylvania
| | - Marina N Nikiforova
- Department of Pathology, University of Pittsburgh Medical Center-Presbyterian, Pittsburgh, Pennsylvania
| | - Yuri E Nikiforov
- Department of Pathology, University of Pittsburgh Medical Center-Presbyterian, Pittsburgh, Pennsylvania
| | - Karen E Schoedel
- Department of Pathology, University of Pittsburgh Medical Center-Presbyterian, Pittsburgh, Pennsylvania
| | - Raja R Seethala
- Department of Pathology, University of Pittsburgh Medical Center-Presbyterian, Pittsburgh, Pennsylvania
| | - N Paul Ohori
- Department of Pathology, University of Pittsburgh Medical Center-Presbyterian, Pittsburgh, Pennsylvania.
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Liu JB, Ramonell KM, Carty SE, McCoy KL, Schaitkin BM, Karslioglu-French E, Morariu EM, Ohori NP, Seethala RR, Chiosea SI, Nikiforova MN, Nikiforov YE, Yip L. Association of comprehensive thyroid cancer molecular profiling with tumor phenotype and cancer-specific outcomes. Surgery 2023; 173:252-259. [PMID: 36272768 DOI: 10.1016/j.surg.2022.05.048] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 05/03/2022] [Accepted: 05/09/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Molecular testing improves the diagnostic accuracy of thyroid cancer. Whether specific molecular testing results are associated with tumor phenotype or provide prognostic information needs further delineation. METHODS Consecutive thyroid cancer patients after index thyroidectomy with ThyroSeq version 3 (Rye Brook, NY) molecular testing obtained on preoperative fine-needle aspiration or thyroidectomy specimens from patients with thyroid cancer were categorized into 3 molecular risk groups based on detected mutations, fusions, copy number alterations, and/or gene expression alterations and correlated with histopathology and recurrence, defined as biochemical or structural. RESULTS Of 578 patients, 49.9%, 37.5%, and 12.6% had molecular risk group-low, molecular risk group-intermediate, and molecular risk group-high cancers, respectively. With a median 19-month follow-up, 9.1% patients recurred. Compared with molecular risk group-low, molecular risk group-intermediate cancers were diagnosed in younger patients and more often had microscopic extrathyroidal extension, involved margins, and nodal disease. Compared with molecular risk group-intermediate, molecular risk group-high cancers were diagnosed in older patients and more often had gross extrathyroidal extension and vascular invasion. In multivariable analysis, recurrence was more likely in molecular risk group-high cancers than in molecular risk group-intermediate (hazard ratio = 4.0; 95% confidence interval, 1.9-8.6; P < .001) and more likely in molecular risk group-intermediate than in molecular risk group-low (hazard ratio = 5.0; 95% confidence interval, 2.0-12.5; P < .001). CONCLUSION Using modern comprehensive genotyping, the genetic profile of thyroid cancers can be categorized into 3 novel molecular risk groups that were associated with histopathologic phenotype and recurrence in short-term follow-up.
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Affiliation(s)
- Jason B Liu
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, PA
| | - Kimberly M Ramonell
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, PA
| | - Sally E Carty
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, PA
| | - Kelly L McCoy
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, PA
| | | | - Esra Karslioglu-French
- Division of Endocrinology and Metabolism, Department of Medicine, University of Pittsburgh, PA
| | - Elena M Morariu
- Division of Endocrinology and Metabolism, Department of Medicine, University of Pittsburgh, PA
| | - N Paul Ohori
- Division of Molecular and Genomic Pathology, Department of Pathology, University of Pittsburgh, PA
| | - Raja R Seethala
- Division of Molecular and Genomic Pathology, Department of Pathology, University of Pittsburgh, PA
| | - Simion I Chiosea
- Division of Molecular and Genomic Pathology, Department of Pathology, University of Pittsburgh, PA
| | - Marina N Nikiforova
- Division of Molecular and Genomic Pathology, Department of Pathology, University of Pittsburgh, PA
| | - Yuri E Nikiforov
- Division of Molecular and Genomic Pathology, Department of Pathology, University of Pittsburgh, PA
| | - Linwah Yip
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, PA.
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11
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Ramonell KM, Ohori NP, Liu JB, McCoy KL, Furlan A, Tublin M, Carty SE, Yip L. Changes in thyroid nodule cytology rates after institutional implementation of the Thyroid Imaging Reporting and Data System. Surgery 2023; 173:232-238. [PMID: 36244809 DOI: 10.1016/j.surg.2022.06.061] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 05/18/2022] [Accepted: 06/14/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND The American College of Radiology Thyroid Imaging Reporting and Data System for ultrasound classification of malignancy risk was developed to better triage thyroid nodules for fine-needle aspiration biopsy. To examine further, we compared thyroid cytologic classification rates in nodules before and after institutional Thyroid Imaging Reporting and Data System implementation. METHODS Cytology diagnoses by Bethesda criteria (categories I-VI) from January 2014 to October 2021 were retrieved; observed changes in yearly category frequency were analyzed by linear regression; and pooled cohorts of pre- (2014-2018) and post-Thyroid Imaging Reporting and Data System (2019-2021) cytology call rates were compared. RESULTS Overall, 7,413 cytologic specimens were included (range/year 715-1,444). From 2014 to 2021, the proportion of benign (Bethesda category II) diagnosis per year declined stepwise from 49.7% to 19.4%, and atypia of undetermined significance/follicular lesion of undetermined significance (Bethesda category III) increased sequentially from 21.3% to 51.5%. Between 2014 and 2021, Bethesda category III diagnosis increased on average by 4.8% per year (95% confidence internal, 3.29-5.54; P < .001) and Bethesda category II results decreased on average by 4.4% per year (95% confidence interval, 6.29-3.42; P < .001). When comparing pre- and post-Thyroid Imaging Reporting and Data System, the proportion of Bethesda category II cytology results decreased (43.1% vs 21%; P = .001) while Bethesda category III (28.3% vs 47.7%; P = .002) and Bethesda category V (1.1% vs 1.7%; P = .015) results increased. CONCLUSION After implementation of American College of Radiology Thyroid Imaging Reporting and Data System ultrasound criteria, we observed a 2.5-fold decline in the rate of benign cytology and an increase in the proportion of atypia of undetermined significance/follicular lesion of undetermined significance results.
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Affiliation(s)
- Kimberly M Ramonell
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA.
| | - N Paul Ohori
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA
| | - Jason B Liu
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Kelly L McCoy
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | | | - Mitchell Tublin
- Department of Radiology, University of Pittsburgh, Pittsburgh, PA
| | - Sally E Carty
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Linwah Yip
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
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12
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Skaugen JM, Taneja C, Liu JB, Wald AI, Nikitski AV, Chiosea SI, Seethala RR, Ohori NP, Karslioglu-French E, Carty SE, Nikiforova MN, Yip L, Nikiforov YE. Performance of a Multigene Genomic Classifier in Thyroid Nodules with Suspicious for Malignancy Cytology. Thyroid 2022; 32:1500-1508. [PMID: 35864811 PMCID: PMC9807251 DOI: 10.1089/thy.2022.0282] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Background: Molecular testing is increasingly used to refine the probability of cancer and assess recurrence risk in thyroid nodules with Bethesda III/IV fine needle aspiration (FNA) cytology. However, limited data exist for Bethesda V (suspicious for malignancy [SFM]) samples. This study evaluated the performance of ThyroSeq v3 (TSv3) in thyroid nodules with SFM cytology. Methods: In this single-institution retrospective cohort study, consecutive thyroid FNA samples diagnosed as SFM with TSv3 testing and known surgical outcome were identified. Clinical, pathology, and molecular findings were reviewed. The TSv3 Cancer Risk Classifier was used to determine molecular risk groups (MRGs). For test-negative cases diagnosed as cancer/noninvasive follicular thyroid neoplasm with papillary-like nuclear features, TSv3 was performed on the resected tumors. Results: Among 128 SFM samples studied, 100 (78.1%) were TSv3 positive, and 28 (21.9%) were negative. The cancer prevalence on surgery was 82.8%. Among test-positive samples, 95% were malignant and 5% benign. Among test-negative samples, 17 (60.7%) were benign and 11 (39.3%) malignant. Overall, TSv3 had a sensitivity of 89.6% (confidence interval; CI 82.4-94.1) and a specificity of 77.3% (CI 56.6-89.9). For a cancer prevalence of 50-75% expected in SFM cytology by the Bethesda system, the negative predictive value was expected to range from 71.2% to 88.1% and the positive predictive value from 79.8% to 92.2%. Among test-positive nodules, 20% were MRG-Low (mostly RAS-like alterations), 66% MRG-Intermediate (mostly BRAF-like alterations), and 14% MRG-High. Among patients with cancer, 65 (61.3%) were American Thyroid Association low risk, 25 (23.6%) intermediate risk, and 6 (5.7%) high risk. During the mean follow-up of 51.2 months (range: <1 to 470 months), 12 (13.0%) patients had disease recurrence, which was more common in MRG-High (54.6%) compared with MRG-Intermediate (9.5%) and MRG-Low (0%) cancers (p < 0.001). Upon reexamining tumors with false-negative results, half of evaluable cases had alterations likely missed due to limiting FNA sampling, and the remainder represented low-risk tumors. Potentially targetable alterations were identified in 10 samples. Conclusions: In this large series of SFM thyroid nodules, TSv3 further improved cancer prediction and detected RAS-like, BRAF-like, high-risk, and potentially targetable alterations, all of which may inform more optimal patient management. MRGs were associated with recurrence-free survival, offering potential preoperative cancer risk stratification.
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Affiliation(s)
- John M. Skaugen
- Division of Molecular and Genomic Pathology, Department of Pathology; Department of Pathology; University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Address correspondence to: John M. Skaugen, MD, Department of Pathology, University of Pittsburgh School of Medicine, 3477 Euler Way, Room 7028, Pittsburgh, PA 15213, USA
| | - Charit Taneja
- Division of Endocrinology, Department of Medicine; Department of Pathology; University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jason B. Liu
- Division of Endocrine Surgery, Department of Surgery; and Department of Pathology; University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Abigail I. Wald
- Division of Molecular and Genomic Pathology, Department of Pathology; Department of Pathology; University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Alyaksandr V. Nikitski
- Division of Molecular and Genomic Pathology, Department of Pathology; Department of Pathology; University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Simion I. Chiosea
- Division of Molecular and Genomic Pathology, Department of Pathology; Department of Pathology; University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Division of Anatomic Pathology, Department of Pathology; University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Raja R. Seethala
- Division of Anatomic Pathology, Department of Pathology; University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - N. Paul Ohori
- Division of Anatomic Pathology, Department of Pathology; University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Esra Karslioglu-French
- Division of Endocrinology, Department of Medicine; Department of Pathology; University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Sally E. Carty
- Division of Endocrine Surgery, Department of Surgery; and Department of Pathology; University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Marina N. Nikiforova
- Division of Molecular and Genomic Pathology, Department of Pathology; Department of Pathology; University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Linwah Yip
- Division of Endocrine Surgery, Department of Surgery; and Department of Pathology; University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Yuri E. Nikiforov
- Division of Molecular and Genomic Pathology, Department of Pathology; Department of Pathology; University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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13
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Freeman T, Taneja C, Ohori NP, Wald AI, Skaugen J, Yip L, Kim S, Ferris RL, Nikiforova MN, Roy S, Nikiforov YE. Identifying metastatic renal cell carcinoma in thyroid fine-needle aspirates by molecular testing. Endocr Relat Cancer 2022; 29:657-664. [PMID: 36205930 DOI: 10.1530/erc-22-0195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 10/07/2022] [Indexed: 11/05/2022]
Abstract
Renal cell carcinoma (RCC) is the most common type of cancer found to metastasize to the thyroid gland. These tumors may represent a diagnostic challenge in cytology. However, most RCC tumors carry VHL alterations, which are rare in primary thyroid tumors. The aim of this study was to evaluate the utility of molecular testing in detecting metastatic RCC in thyroid fine-needle aspiration (FNA) samples. From November 2017 until March 2022, thyroid FNA samples with ThyroSeq v3 results showing both VHL alterations and low/absent expression of thyroid cell markers were analyzed. Eighteen samples from 15 patients met the inclusion criteria. On molecular analysis, deleterious VHL mutations were found in nine (50%) nodules, VHL copy number alteration (CNA) in two (11%), and both mutations and CNA in seven (39%). None of the cases showed mutations commonly found in thyroid tumors. The mean age of these patients was 68 (range, 49-89) years with a male to female ratio of 2:1. Eight (53%) patients had multiple thyroid nodules on ultrasound. On cytology, 14 (78%) nodules were diagnosed as Bethesda III, 2 (11%) as Bethesda IV, and 2 (11%) as Bethesda V. At the time of cytology review, the history of RCC, sometimes remote, was available for ten patients. Of the 14 patients with medical history or surgical follow-up available, all had history of RCC or renal mass or revealed metastatic RCC on thyroidectomy. This study demonstrates that molecular testing can reliably identify metastatic RCC in thyroid nodules with indeterminate cytology, which could improve patient management.
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Affiliation(s)
- Tanner Freeman
- Department of Pathology, UPMC, Pittsburgh, Pennsylvania, USA
| | - Charit Taneja
- Division of Endocrinology and Metabolism, UPMC, Pittsburgh, Pennsylvania, USA
| | - N Paul Ohori
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Abigail I Wald
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - John Skaugen
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Linwah Yip
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Seungwon Kim
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Robert L Ferris
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- UPMC Hillman Cancer Center, Department of Oncology, Pittsburgh, Pennsylvania, USA
| | - Marina N Nikiforova
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Somak Roy
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Yuri E Nikiforov
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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14
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Liu JB, Cai J, Dhir M, Paniccia A, Zureikat AH, Ramonell KM, McCoy KL, Carty SE, Yip L. ASO Visual Abstract: Long-Term Outcomes of Patients with Multiple Endocrine Neoplasia Type 1 and Duodenopancreatic Neuroendocrine Neoplasms. Ann Surg Oncol 2022; 29:7818-7819. [PMID: 36109415 DOI: 10.1245/s10434-022-12423-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Affiliation(s)
- Jason B Liu
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Division of Gastrointestinal Surgical Oncology, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jinman Cai
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Mashaal Dhir
- Division of Hepatobiliary Surgery and Surgical Oncology, Department of Surgery, Upstate University Hospital, Syracuse, NY, USA
| | - Alessandro Paniccia
- Division of Gastrointestinal Surgical Oncology, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Amer H Zureikat
- Division of Gastrointestinal Surgical Oncology, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kimberly M Ramonell
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kelly L McCoy
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sally E Carty
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Linwah Yip
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
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15
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Taneja C, Yip L, Morariu EM, Seethala R, Chiosea SI, Ohori NP, Carty SE, Nikiforova MN, Nikiforov YE, Karslioglu-French E. Clinicopathologic Characteristics and Postsurgical Follow-Up of Noninvasive Follicular Thyroid Neoplasm with Papillary-Like Nuclear Features in the Postnomenclature Revision Era. Thyroid 2022; 32:1346-1352. [PMID: 35876443 DOI: 10.1089/thy.2022.0337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Background: Noninvasive encapsulated follicular variant papillary thyroid carcinoma (EFVPTC) was reclassified as "noninvasive follicular thyroid neoplasm with papillary-like nuclear features" (NIFTP) in 2016. Most existing studies that examined outcomes included patients managed as EFVPTC and only retrospectively reclassified as NIFTP. This is the first study to evaluate the clinicopathologic, molecular, and surveillance characteristics of patients diagnosed with NIFTP at the time of surgery and managed based on this diagnosis. Methods: We performed a retrospective cohort study of consecutive cases diagnosed as NIFTP from June 2016 to October 2021 identified from electronic medical records at a large tertiary care institution. Patients with coexisting low-risk thyroid cancers ≥1.0 cm in size or any size aggressive histology were excluded, and review of demographic, clinical, imaging, cytologic, and molecular genetic data was performed. Initial care was delivered according to existing clinical guidelines, with a consensus institutional plan for five-year follow-up after surgery. Results: Among 79 patients with 84 nodules diagnosed as NIFTP after surgery, 83.5% (66/79) were women and the mean age was 51 years (range, 21-84). Mean NIFTP size was 2.4 cm (range 0.15-8.0). On ultrasound, the majority of nodules were categorized as thyroid imaging, reporting and data system TI-RADS 3 (55.3%, 42/76), and TI-RADS 4 (36.8%, 28/76). On cytology, they were typically diagnosed as Bethesda III (69.1%, 47/68) or Bethesda IV (23.5%, 16/68). Molecular testing was performed on 62 nodules, and molecular alterations were found in 93.5% (58/62). The most common alterations identified in NIFTP were RAS mutation (75.4%, 43/57), THADA fusion (12.3%, 7/57), and BRAFK601E mutation (7.0%, 4/57). Fifty-two (65.8%) patients underwent lobectomy and 27 (34.2%) total thyroidectomy, and no patient received completion thyroidectomy. Twenty-one patients (26.5%) had coexisting papillary or follicular microcarcinoma. None of the patients received radioiodine ablation. On a mean follow-up of 28.5 months (range, 6-69 months), no structural or biochemical recurrences were observed. Conclusions: In this large cohort of patients with NIFTP diagnosed at the time of surgery and managed typically by lobectomy with no radioiodine ablation, no evidence of tumor recurrence was identified on a limited follow-up. This finding supports indolent clinical course of NIFTP.
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Affiliation(s)
- Charit Taneja
- Division of Endocrinology and Metabolism, Pittsburgh, Pennsylvania, USA
| | - Linwah Yip
- Division of Endocrine Surgery, Pittsburgh, Pennsylvania, USA
| | - Elena M Morariu
- Division of Endocrinology and Metabolism, Pittsburgh, Pennsylvania, USA
| | - Raja Seethala
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Simion I Chiosea
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - N Paul Ohori
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sally E Carty
- Division of Endocrine Surgery, Pittsburgh, Pennsylvania, USA
| | - Marina N Nikiforova
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Yuri E Nikiforov
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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16
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Yip L, Duh QY, Wachtel H, Jimenez C, Sturgeon C, Lee C, Velázquez-Fernández D, Berber E, Hammer GD, Bancos I, Lee JA, Marko J, Morris-Wiseman LF, Hughes MS, Livhits MJ, Han MA, Smith PW, Wilhelm S, Asa SL, Fahey TJ, McKenzie TJ, Strong VE, Perrier ND. American Association of Endocrine Surgeons Guidelines for Adrenalectomy: Executive Summary. JAMA Surg 2022; 157:870-877. [PMID: 35976622 PMCID: PMC9386598 DOI: 10.1001/jamasurg.2022.3544] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 04/30/2022] [Indexed: 12/14/2022]
Abstract
Importance Adrenalectomy is the definitive treatment for multiple adrenal abnormalities. Advances in technology and genomics and an improved understanding of adrenal pathophysiology have altered operative techniques and indications. Objective To develop evidence-based recommendations to enhance the appropriate, safe, and effective approaches to adrenalectomy. Evidence Review A multidisciplinary panel identified and investigated 7 categories of relevant clinical concern to practicing surgeons. Questions were structured in the framework Population, Intervention/Exposure, Comparison, and Outcome, and a guided review of medical literature from PubMed and/or Embase from 1980 to 2021 was performed. Recommendations were developed using Grading of Recommendations, Assessment, Development and Evaluation methodology and were discussed until consensus, and patient advocacy representation was included. Findings Patients with an adrenal incidentaloma 1 cm or larger should undergo biochemical testing and further imaging characterization. Adrenal protocol computed tomography (CT) should be used to stratify malignancy risk and concern for pheochromocytoma. Routine scheduled follow-up of a nonfunctional adrenal nodule with benign imaging characteristics and unenhanced CT with Hounsfield units less than 10 is not suggested. When unilateral disease is present, laparoscopic adrenalectomy is recommended for patients with primary aldosteronism or autonomous cortisol secretion. Patients with clinical and radiographic findings consistent with adrenocortical carcinoma should be treated at high-volume multidisciplinary centers to optimize outcomes, including, when possible, a complete R0 resection without tumor disruption, which may require en bloc radical resection. Selective or nonselective α blockade can be used to safely prepare patients for surgical resection of paraganglioma/pheochromocytoma. Empirical perioperative glucocorticoid replacement therapy is indicated for patients with overt Cushing syndrome, but for patients with mild autonomous cortisol secretion, postoperative day 1 morning cortisol or cosyntropin stimulation testing can be used to determine the need for glucocorticoid replacement therapy. When patient and tumor variables are appropriate, we recommend minimally invasive adrenalectomy over open adrenalectomy because of improved perioperative morbidity. Minimally invasive adrenalectomy can be achieved either via a retroperitoneal or transperitoneal approach depending on surgeon expertise, as well as tumor and patient characteristics. Conclusions and Relevance Twenty-six clinically relevant and evidence-based recommendations are provided to assist surgeons with perioperative adrenal care.
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Affiliation(s)
- Linwah Yip
- Division of Endocrine Surgery, University of Pittsburgh, Pennsylvania
| | - Quan-Yang Duh
- Department of Surgery, University of California, San Francisco
| | - Heather Wachtel
- Department of Surgery, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia
| | - Camilo Jimenez
- Division of Internal Medicine, Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston
| | - Cord Sturgeon
- Department of Surgery, Section of Endocrine Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Cortney Lee
- Department of Surgery, University of Kentucky College of Medicine, Lexington
| | | | - Eren Berber
- Center for Endocrine Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Gary D Hammer
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Department of Cell & Developmental Biology, University of Michigan, Ann Arbor
- Department of Molecular & Integrative Physiology, University of Michigan, Ann Arbor
| | - Irina Bancos
- Division of Endocrinology, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota
| | - James A Lee
- Department of Surgery, Department of Internal Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | - Jamie Marko
- Department of Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, Maryland
| | | | - Marybeth S Hughes
- Division of Surgical Oncology, Department of Surgery, Eastern Virginia Medical School, Norfolk
| | - Masha J Livhits
- Department of General Surgery, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Mi-Ah Han
- Department of Preventive Medicine, College of Medicine, Chosun University, Gwangju, Korea
| | - Philip W Smith
- Department of Surgery, University of Virginia, Charlottesville
| | - Scott Wilhelm
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Sylvia L Asa
- Department of Pathology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Thomas J Fahey
- Division of Endocrine & Minimally Invasive Surgery, Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York
| | - Travis J McKenzie
- Division of Endocrine and Metabolic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Vivian E Strong
- Department of Surgery, Gastric and Mixed Tumor Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nancy D Perrier
- Section of Surgical Endocrinology, Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
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17
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Liu JB, Cai J, Dhir M, Paniccia A, Zureikat AH, Ramonell KM, McCoy KL, Carty SE, Yip L. Long-Term Outcomes for Patients with Multiple Endocrine Neoplasia Type 1 and Duodenopancreatic Neuroendocrine Neoplasms. Ann Surg Oncol 2022; 29:7808-7817. [PMID: 35963905 DOI: 10.1245/s10434-022-12350-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 07/21/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Liver metastasis from duodenopancreatic neuroendocrine neoplasms (DP-NENs) is a major cause of mortality in multiple endocrine neoplasia type 1 (MEN1) patients, yet much of their natural history is unknown. METHODS This longitudinal, retrospective cohort study analyzed all MEN1 patients with imageable functional (F) and nonfunctional (NF) DP-NENs (1990-2021) for liver metastasis-free survival (LMFS) and overall survival (OS). RESULTS Of 138 patients, 85 (61.6%) had imageable DP-NENs (28 F, 57 NF), and the mean largest tumor size was 1.8 ± 1.4 cm. Multifocality was present in 32 patients (37.7%). Surgery was performed for 49 patients (57.7%). During an 11-year median follow-up period (IQR, 6-17 years), 23 (27.1%) of the patients had liver metastasis, and 19 (22.4%) patients died. Death was attributed to liver metastasis in 60% of cases. The patients with F-DP-NENs versus NF-DP-NENs more often had liver metastasis (46.4% vs. 15.8%; p = 0.002) but had similar 10-year LMFS (80.9 vs. 87.0%; p = 0.44) and OS (82.7 vs. 94.3%; p = 0.69). The patients with NF-DP-NENs had surgery when their tumors were larger (p < 0.001). Tumor size was not associated with liver metastasis (p = 0.89). The average growth rate was 0.04 cm/year (SE, 0.02 cm/year; p = 0.01) during active surveillance for NF-DP-NENs (n = 38). Liver metastasis developed in four patients with tumors smaller than 2 cm. The risk of liver metastasis was independent of surgery (hazard ratio [HR], 0.78; 95% confidence interval [CI], 0.21-2.93; p = 0.72) and death (HR, 0.51; 95% CI, 0.08-3.06; p = 0.46). CONCLUSIONS Although the observed outcomes in this study were better than historical data, small NF-DP-NENs still developed liver metastasis and liver metastasis remains a major cause of death. These results suggest that size as a sole criterion for surgery may be insufficient to predict tumor behavior.
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Affiliation(s)
- Jason B Liu
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA.,Division of Gastrointestinal Surgical Oncology, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jinman Cai
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Mashaal Dhir
- Division of Hepatobiliary Surgery and Surgical Oncology, Department of Surgery, Upstate University Hospital, Syracuse, NY, USA
| | - Alessandro Paniccia
- Division of Gastrointestinal Surgical Oncology, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Amer H Zureikat
- Division of Gastrointestinal Surgical Oncology, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kimberly M Ramonell
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kelly L McCoy
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sally E Carty
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Linwah Yip
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
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18
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Karslioglu French E, Nikitski AV, Yip L, Nikiforova MN, Nikiforov YE, Carty SE. Clinicopathological features and outcomes of thyroid nodules with EIF1AX mutations. Endocr Relat Cancer 2022; 29:467-473. [PMID: 35609001 DOI: 10.1530/erc-22-0041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 05/24/2022] [Indexed: 11/08/2022]
Abstract
EIF1AX gene mutations are reported in both benign and malignant thyroid tumors, with unclear outcomes when detected preoperatively. The aim of this study was to determine the features and outcomes of thyroid nodules with various types of mutation identified in cytologic (fine-needle aspiration) samples on preoperative ThyroSeq testing and with surgical outcomes. In this single-institution retrospective study of 31 consecutive patients, 77% were female and nodule size ranged from 1.5 to 9.4 cm with widely varying cytologic and TI-RADS ultrasound categorizations. Among two main mutational hotspots, 55% were located in exon 2 and 45% at the intron 5/exon 6 splice site. On histology, 45% of -positive nodules were cancer/noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) including 19% encapsulated follicular variant papillary thyroid carcinoma, 10% follicular carcinoma, 10% anaplastic carcinoma (ATC), and 7% NIFTP. Almost half (48%) of patients had one or more coexisting mutations, most frequently RAS. The prevalence of cancer/NIFTP was 80% for mutation with coexisting molecular alteration vs 13% with an isolated mutation (P = 0.0002). Cancer probability was associated with mutation type and was 64% for splice-site mutation and 29% for non-splice mutation (P = 0.075). All 3 nodules with EIF1AX+RAS+TERT+TP53 mutations were ATC. In summary, in this study, all nodules with an isolated non-splice mutation were benign, one-third of those with an isolated splice mutation were cancer, and most nodules with coexisting with RAS or other alterations were malignant. These findings suggest that clinical management decisions for patients with EIF1AX-mutant nodules should consider both the type of mutation and its co-occurrence with other genetic alterations.
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Affiliation(s)
- Esra Karslioglu French
- Division of Endocrinology and Metabolism, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Linwah Yip
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Marina N Nikiforova
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Yuri E Nikiforov
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sally E Carty
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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19
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Srivastava P, Da Cruz Paula A, Weigelt B, Pareja F, Reis-Filho JS, Yip L, Pantanowitz L, Seethala RR. Granular cell tumor of thyroid: a case series with molecular characterization highlighting unique pitfalls. Endocrine 2022; 76:395-406. [PMID: 35175560 PMCID: PMC9332905 DOI: 10.1007/s12020-022-03006-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 01/31/2022] [Indexed: 11/24/2022]
Abstract
Primary granular cell tumors (GCTs) of the thyroid are exceptionally rare. We report the clinicopathologic and molecular features of three cases and review the literature. Two patients (20-year-old, Case 1, and 26-year-old, Case 2, black American females) presented with painless masses with a preoperative fine-needle aspiration biopsy (FNAB) diagnosis of "Hürthle cell neoplasm," while one additional patient, 51-year-old white American female (Case 3), presented as an incidental finding within a background of chronic lymphocytic thyroiditis. On resection, morphologic, histochemical and immunohistochemical features were typical of GCT in all cases. Cases 1 and 2 had adequate material for molecular testing and demonstrated a clonal ATP6AP1 p.G381Vfs*15 frameshift mutation (Case 1) and a clonal ATP6AP2 p.L182Pfs*22 frameshift mutation along with a PIK3CA H1047R hotspot mutation (Case 2). All patients showed no evidence of GCT following resection (Cases 1, 3: 96-month follow-up; Case 2: 48-month follow-up). A literature review demonstrates similar clinicopathologic features and indolent course with only rare histologically or clinically aggressive outcomes. On FNAB, lesional cells are frequently miscategorized as Hürthle cells or oncocytes. In summary, GCT of the thyroid is rare but shows similar clinical, morphologic, immunophenotypic and genetic characteristics of GCT of other sites. This unusual site poses unique differential diagnostic pitfalls by mimicking other oncocytic head and neck lesions, particularly thyroid Hürthle cell neoplasms. We confirm that thyroid GCT also harbor V-ATPase component inactivating mutations that characterize these tumors, and that additional PI3K pathway alterations may not necessarily predict aggressive behavior.
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Affiliation(s)
| | | | - Britta Weigelt
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Fresia Pareja
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Linwah Yip
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Raja R Seethala
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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20
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Mollen KP, Shaffer AD, Yip L, Monaco SE, Huyett P, Viswanathan P, Witchel SF, Duvvuri U, Simons JP. Unique Molecular Signatures Are Associated with Aggressive Histology in Pediatric Differentiated Thyroid Cancer. Thyroid 2022; 32:236-244. [PMID: 34915753 DOI: 10.1089/thy.2021.0317] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background: Molecular testing (MT) enhances the diagnostic accuracy of thyroid fine-needle aspiration biopsy, reducing the need for diagnostic lobectomy in adult patients with indeterminate nodules (Bethesda class III/IV). However, little is known about genetic alterations in pediatric thyroid carcinoma (TC). Our aim was to analyze MT results of pediatric differentiated TC (DTC) cases to determine associations with histological and clinical features. Methods: A retrospective review identified all patients (aged <19 years) diagnosed with DTC from 2001 to 2017 at the University of Pittsburgh Medical Center. Histology was rereviewed to confirm diagnosis and identify tissue for MT using next-generation sequencing (ThyroSeq, version 3, TSv3). Correlation with histological and clinical features was analyzed using regression analysis. Results: Of 71 patients with MT results, 62 (87%) patients had papillary TC. All patients were alive at a median follow-up of 6 years (range 18 days to 18 years). Genetic alterations were identified in 65 (92%) patients. These alterations were grouped as BRAF-like point mutations or fusions (39, 55%), RAS-like mutations or fusions (21, 30%), or copy number alterations (5, 7%). On multiple regression analysis accounting for patient sex and tumor size in patients with papillary TC, increased tumor stage (β: 0.234, p < 0.001), multifocal disease (odds ratio [OR]: 3.60, p = 0.042), and lymph node metastases (OR: 6.13, p = 0.044) were associated with BRAF-like gene fusions. When considering individual mutations, ETV6/NTRK3 fusions were associated with increased tumor stage (β: 2.07, p = 0.023) and BRAF-like point mutations were associated with increased likelihood of surgery for recurrence over time (hazard ratio: 19.5, p = 0.004). Conclusions: Among our cohort of pediatric TC patients who underwent comprehensive MT, >90% had an identifiable genetic alteration. Aggressive features were primarily associated with BRAF-like gene fusions. Preoperative MT results may be useful in guiding the extent of the initial operation in pediatric patients (aged <19 years) with TC.
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Affiliation(s)
- Kevin P Mollen
- Department of Surgery and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Amber D Shaffer
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Linwah Yip
- Department of Surgery and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Sara E Monaco
- Department of Laboratory Medicine, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Phillip Huyett
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Pushpa Viswanathan
- Division of Pediatric Endocrinology, Diabetes, and Metabolism, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Selma F Witchel
- Division of Pediatric Endocrinology, Diabetes, and Metabolism, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Umamaheswar Duvvuri
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jeffrey P Simons
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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21
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Shah US, McCoy KL, Kelley ML, Carty SE, Yip L. How and when is multiglandular disease diagnosed in sporadic primary hyperparathyroidism? Surgery 2021; 171:35-39. [PMID: 34924180 DOI: 10.1016/j.surg.2021.09.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 08/31/2021] [Accepted: 09/16/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND In total, ∼15% of patients with sporadic primary hyperparathyroidism have multiglandular disease, which may be suspected preoperatively but can only be confirmed intra or postoperatively. The study aim is to determine how and when patients are diagnosed with multiglandular disease and to what extent different modalities contribute. METHODS Consecutive cases of sporadic primary hyperparathyroidism (2013-2019) undergoing initial exploration were reviewed from a single-institution prospective database. Preoperative single-photon emission tomography/computed tomography and neck ultrasound were routinely performed to help direct either bilateral or unilateral exploration guided by intraoperative parathyroid hormone monitoring using the dual criteria. Multiglandular disease was defined as either resection of >1 enlarged parathyroid or hypercalcemia at ≥6 months after single gland resection. RESULTS Of 1,890 patients with sporadic primary hyperparathyroidism, multiglandular disease was identified in 254 (13.4%); 244 (96.1%) were diagnosed intraoperatively and 10 (3.9%) postoperatively. In these multiglandular disease patients, single gland disease was suggested on single-photon emission tomography/computed tomography in 54.0%, ultrasound in 49.2%, and both were concordant for single gland disease in 29.4%. Intraoperative multiglandular disease diagnosis was prompted by an inadequate intraoperative parathyroid hormone monitoring drop in 38.5%, by surgeon interpretation of imaging in 38.1%, by observing ipsilateral gland enlargement in 11.0%, by finding an initial gland <200 mg in 10.3%, and 2.0% had unexpected multiglandular disease during thyroidectomy. Multiglandular disease was diagnosed by postoperative hypercalcemia in 10 of 254 patients (4.9%). CONCLUSION To avoid failure at parathyroidectomy for primary hyperparathyroidism, expert surgeons use multiple approaches to diagnose and manage multiglandular disease. Preoperative localization studies alone are insufficient, missing multiglandular disease in at least 30% of cases. All examined adjuncts are informative, including intraoperative parathyroid hormone monitoring, imaging, and intraoperative visual cues.
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Affiliation(s)
- Ujas S Shah
- Division of Endocrine Surgery, University of Pittsburgh, PA
| | - Kelly L McCoy
- Division of Endocrine Surgery, University of Pittsburgh, PA
| | | | - Sally E Carty
- Division of Endocrine Surgery, University of Pittsburgh, PA
| | - Linwah Yip
- Division of Endocrine Surgery, University of Pittsburgh, PA.
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22
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Figge JJ, Gooding WE, Steward DL, Yip L, Sippel RS, Yang SP, Scheri RP, Sipos JA, Mandel SJ, Mayson SE, Burman KD, Folek JM, Haugen BR, Sosa JA, Parameswaran R, Tan WB, Nikiforov YE, Carty SE. Do Ultrasound Patterns and Clinical Parameters Inform the Probability of Thyroid Cancer Predicted by Molecular Testing in Nodules with Indeterminate Cytology? Thyroid 2021; 31:1673-1682. [PMID: 34340592 PMCID: PMC8917891 DOI: 10.1089/thy.2021.0119] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background: Molecular testing (MT) is commonly used to refine cancer probability in thyroid nodules with indeterminate cytology. Whether or not ultrasound (US) patterns and clinical parameters can further inform the risk of thyroid cancer in nodules predicted to be positive or negative by MT remains unknown. The aim of this study was to test if clinical parameters, including patient age, sex, nodule size (by US), Bethesda category (III, IV, V), US pattern (American Thyroid Association [ATA] vs. American College of Radiology Thyroid Image Reporting and Data System [TI-RADS] systems), radiation exposure, or family history of thyroid cancer can modify the probability of thyroid cancer or noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) predicted by MT. Methods: We studied 257 thyroid nodules in 232 patients from 10 study centers with indeterminate fine needle aspiration cytology and informative MT results using the ThyroSeq v3 genomic classifier (TSv3). Univariate and multivariate logistic regression was used for data analysis. Results: The presence of cancer/NIFTP was associated with positive TSv3 results (odds ratio 61.39, p < 0.0001). On univariate regression, patient sex, age, and Bethesda category were associated with cancer/NIFTP probability (p < 0.05 for each). Although ATA (p = 0.1211) and TI-RADS (p = 0.1359) US categories demonstrated positive trends, neither was significantly associated with cancer/NIFTP probability. A multivariate regression model incorporating the four most informative non-MT covariates (sex, age, Bethesda category, and ATA US pattern; Model No. 1) yielded a C index of 0.653; R2 = 0.108. When TSv3 was added to Model number 1, the C index increased to 0.888; R2 = 0.572. However, age (p = 0.341), Bethesda category (p = 0.272), and ATA US pattern (p = 0.264) were nonsignificant, and other than TSv3 (p < 0.0001), male sex was the only non-MT parameter that potentially contributed to cancer/NIFTP risk (p = 0.095). The simplest and most efficient clinical model (No. 3) incorporated TSv3 and sex (C index = 0.889; R2 = 0.588). Conclusions: In this multicenter study of thyroid nodules with indeterminate cytology and MT, neither the ATA nor TI-RADS US scoring systems further informed the risk of cancer/NIFTP beyond that predicted by TSv3. Although age and Bethesda category were associated with cancer/NIFTP probability on univariate analysis, in sequential nomograms they provided limited incremental value above the high predictive ability of TSv3. Patient sex may contribute to cancer/NIFTP risk in thyroid nodules with indeterminate cytology.
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Affiliation(s)
- James J. Figge
- Diabetes & Endocrine Care, St. Peter's Health Partners/Trinity Health, Rensselaer, New York, USA
- Address correspondence to: James J. Figge, MD, MBA, Diabetes & Endocrine Care, St. Peter's Health Partners/Trinity Health, 279 Troy Road, Rensselaer, NY 12144, USA
| | - William E. Gooding
- Biostatistics Facility, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania, USA
| | - David L. Steward
- Department of Otolaryngology, Head and Neck Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Linwah Yip
- Division of Endocrine Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Rebecca S. Sippel
- Division of Endocrine Surgery, University of Wisconsin, Madison, Wisconsin, USA
| | - Samantha Peiling Yang
- Endocrinology Division, Department of Medicine, National University Hospital, Singapore, Singapore
- Endocrinology Division, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Randall P. Scheri
- Section of Endocrine Surgery, Department of Surgery, Duke University, Durham, North Carolina, USA
| | - Jennifer A. Sipos
- Division of Endocrinology, Diabetes, and Metabolism, Ohio State University School of Medicine, Columbus, Ohio, USA
| | - Susan J. Mandel
- Division of Endocrinology, Diabetes and Metabolism, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sarah E. Mayson
- Division of Endocrinology, Metabolism and Diabetes, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Kenneth D. Burman
- Endocrinology Section, Department of Medicine, MedStar Washington Hospital Center, Washington, District of Columbia, USA
| | | | - Bryan R. Haugen
- Division of Endocrinology, Metabolism and Diabetes, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Julie A. Sosa
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Rajeev Parameswaran
- Division of Endocrine Surgery, Department of Surgery, National University Hospital, Singapore, Singapore
- Division of Endocrine Surgery, Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Wee Boon Tan
- Division of Endocrine Surgery, Department of Surgery, National University Hospital, Singapore, Singapore
- Division of Endocrine Surgery, Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yuri E. Nikiforov
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sally E. Carty
- Division of Endocrine Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Sally E. Carty, MD, Division of Endocrine Surgery, University of Pittsburgh, 101 Kauffmann, 3471 Fifth Avenue, Pittsburgh, PA 15213, USA
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23
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Yeker RM, Shaffer AD, Viswanathan P, Witchel SF, Mollen K, Yip L, Monaco SE, Duvvuri U, Simons JP. Chronic Lymphocytic Thyroiditis and Aggressiveness of Pediatric Differentiated Thyroid Cancer. Laryngoscope 2021; 132:1668-1674. [PMID: 34687456 PMCID: PMC9033882 DOI: 10.1002/lary.29908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 09/28/2021] [Accepted: 10/12/2021] [Indexed: 11/12/2022]
Abstract
OBJECTIVES/HYPOTHESIS Hashimoto's Thyroiditis (HT) is a common cause of hypothyroidism. Among adults with differentiated thyroid cancer (DTC), HT appears to be associated with less severe disease burden. In the absence of information regarding HT and disease burden among children with DTC, we assessed the relationship between pediatric DTC severity and HT. STUDY DESIGN Retrospective cohort. METHODS Charts from 90 pediatric patients who underwent surgical removal of DTC from 2002 to 2017 at tertiary-care children's hospital were reviewed. Demographic, clinical, surgical, pathology, and outcome details were compared between patients with and without HT. Consistency among diagnostic modalities of HT was also evaluated. RESULTS Median age at presentation was 16.0 years (range 4.2-18.9 years). Twenty-two patients were male (24%). Forty-five patients (50%) had HT based on presence of thyroid autoantibodies and/or surgical pathology findings and 45 patients did not have HT. Patients with HT had increased odds of microcalcifications (odds ratio [OR]: 3.01, P = .031) and decreased odds of palpable nodules (OR: 0.212, P = .024) and T2 lesions (vs. T1) (OR: 0.261, P = .015) compared with non-HT. No significant differences in demographics and the incidence of multifocality, extrathyroidal extension, lymphovascular invasion, lymph node or pulmonary metastases, disease recurrence, or radioactive iodine treatment were found between the two groups. Thyroglobulin/thyroid peroxidase autoantibodies and surgical pathology indicative of HT were concordant in 82.4% (κ = 0.635, P < .001). CONCLUSION HT was present in 50% of children with DTC. Patients with DTC and HT presented with smaller tumors compared to non-HT patients. No significant differences in other markers of disease aggressiveness were found between the two groups. LEVEL OF EVIDENCE 3 Laryngoscope, 2021.
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Affiliation(s)
- Richard M Yeker
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, U.S.A
| | - Amber D Shaffer
- Division of Pediatric Otolaryngology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Pushpa Viswanathan
- Division of Pediatric Endocrinology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, U.S.A
| | - Selma F Witchel
- Division of Pediatric Endocrinology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, U.S.A
| | - Kevin Mollen
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, U.S.A
| | - Linwah Yip
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, U.S.A
| | - Sara E Monaco
- Department of Pathology, UPMC Shadyside Hospital & Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Umamaheswar Duvvuri
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, U.S.A
| | - Jeffrey P Simons
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, U.S.A.,Division of Pediatric Otolaryngology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
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Tao Y, Wang F, Shen X, Zhu G, Liu R, Viola D, Elisei R, Puxeddu E, Fugazzola L, Colombo C, Jarzab B, Czarniecka A, Lam AK, Mian C, Vianello F, Yip L, Riesco-Eizaguirre G, Santisteban P, O’Neill CJ, Sywak MS, Clifton-Bligh R, Bendlova B, Sýkorová V, Zhao S, Wang Y, Xing M. BRAF V600E Status Sharply Differentiates Lymph Node Metastasis-associated Mortality Risk in Papillary Thyroid Cancer. J Clin Endocrinol Metab 2021; 106:3228-3238. [PMID: 34273152 PMCID: PMC8530728 DOI: 10.1210/clinem/dgab286] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
CONTEXT How lymph node metastasis (LNM)-associated mortality risk is affected by BRAF V600E in papillary thyroid cancer (PTC) remains undefined. OBJECTIVE To study whether BRAF V600E affected LNM-associated mortality in PTC. DESIGN, SETTING, AND PARTICIPANTS We retrospectively analyzed the effect of LNM on PTC-specific mortality with respect to BRAF status in 2638 patients (2015 females and 623 males) from 11 centers in 6 countries, with median age of 46 [interquartile range (IQR) 35-58] years and median follow-up time of 58 (IQR 26-107) months. RESULTS Overall, LNM showed a modest mortality risk in wild-type BRAF patients but a strong one in BRAF V600E patients. In conventional PTC (CPTC), LNM showed no increased mortality risk in wild-type BRAF patients but a robustly increased one in BRAF V600E patients; mortality rates were 2/659 (0.3%) vs 4/321 (1.2%) in non-LNM vs LNM patients (P = 0.094) with wild-type BRAF, corresponding to a hazard ratio (HR) (95% CI) of 4.37 (0.80-23.89), which remained insignificant at 3.32 (0.52-21.14) after multivariate adjustment. In BRAF V600E CPTC, morality rates were 7/515 (1.4%) vs 28/363 (7.7%) in non-LNM vs LNM patients (P < 0.001), corresponding to an HR of 4.90 (2.12-11.29) or, after multivariate adjustment, 5.76 (2.19-15.11). Adjusted mortality HR of coexisting LNM and BRAF V600E vs absence of both was 27.39 (5.15-145.80), with Kaplan-Meier analyses showing a similar synergism. CONCLUSIONS LNM-associated mortality risk is sharply differentiated by the BRAF status in PTC; in CPTC, LNM showed no increased mortality risk with wild-type BRAF but a robust one with BRAF mutation. These results have strong clinical relevance.
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Affiliation(s)
- Yubing Tao
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Fei Wang
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Qingdao University, Qingdao, China
- Laboratory for Cellular and Molecular Thyroid Research, Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Xiaopei Shen
- Laboratory for Cellular and Molecular Thyroid Research, Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Guangwu Zhu
- Laboratory for Cellular and Molecular Thyroid Research, Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rengyun Liu
- Laboratory for Cellular and Molecular Thyroid Research, Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David Viola
- Endocrine Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Rossella Elisei
- Endocrine Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Efisio Puxeddu
- Department of Medicine, University of Perugia, Perugia, Italy
| | - Laura Fugazzola
- Division of Endocrinology and Metabolism, IRCCS Istituto Auxologico Italiano, Milan and Department of Pathophysiology and Transplantation, University of Milan, Italy
| | - Carla Colombo
- Division of Endocrinology and Metabolism, IRCCS Istituto Auxologico Italiano, Milan and Department of Pathophysiology and Transplantation, University of Milan, Italy
| | - Barbara Jarzab
- Maria Sklodowska-Curie National Institute of Oncology, Gliwice Branch, Gliwice,Poland
| | - Agnieszka Czarniecka
- Maria Sklodowska-Curie National Institute of Oncology, Gliwice Branch, Gliwice,Poland
| | - Alfred K Lam
- Cancer Molecular Pathology of School of Medicine, Griffith University–Gold Coast, Australia
| | - Caterina Mian
- Department of Medicine, Endocrinology Unit, University of Padua, Padua, Italy
| | | | - Linwah Yip
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Garcilaso Riesco-Eizaguirre
- Department of Endocrinology and Nutrition Hospital Universitario La Paz and Hospital Universitario de Móstoles, Madrid, Spain
- Biomedical Research Institute “Alberto Sols,” Consejo Superior de Investigaciones Científicas and Universidad Autónoma de Madrid, Madrid, Spain
- Ciberonc, Health Institute Carlos III, Madrid, Spain
| | - Pilar Santisteban
- Biomedical Research Institute “Alberto Sols,” Consejo Superior de Investigaciones Científicas and Universidad Autónoma de Madrid, Madrid, Spain
- Ciberonc, Health Institute Carlos III, Madrid, Spain
| | | | - Mark S Sywak
- Endocrine Surgical Unit, University of Sydney, Sydney, Australia
| | | | - Bela Bendlova
- Department of Molecular Endocrinology, Institute of Endocrinology, Prague, Czech Republic
| | - Vlasta Sýkorová
- Department of Molecular Endocrinology, Institute of Endocrinology, Prague, Czech Republic
| | - Shihua Zhao
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yangang Wang
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Mingzhao Xing
- Laboratory for Cellular and Molecular Thyroid Research, Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Correspondence: Mingzhao Xing, Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 333, Baltimore, MD 21207, USA.
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Nikitski AV, Nikiforova MN, Yip L, Karslioglu-French E, Carty SE, Nikiforov YE. Can TP53-mutant follicular adenoma be a precursor of anaplastic thyroid carcinoma? Endocr Relat Cancer 2021; 28:621-630. [PMID: 34264855 DOI: 10.1530/erc-21-0095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 07/15/2021] [Indexed: 11/08/2022]
Abstract
Mutations of the TP53 tumor suppressor gene are highly prevalent in thyroid anaplastic carcinomas (AC) but are also reported in some well-differentiated cancers and even in benign adenomas. The natural history of TP53-mutant adenomas and whether they may represent a precursor for well-differentiated cancer or AC is largely unknown. Similarly, the frequency of TP53 mutations in thyroid nodules found on routine molecular analysis of fine-needle aspiration (FNA) samples is not established. A database on 44,510 FNA samples from thyroid nodules with predominantly indeterminate cytology tested using ThyroSeq v3 was reviewed to identify TP53-mutant cases and analyze their genetic profile and available clinicopathological findings. Among 260 (0.6%) selected thyroid nodules, 36 had an isolated TP53 mutation and 224 carried a combination of TP53 with other genetic alterations. No significant difference was observed between these groups with respect to patient age, gender, nodule size, and spectrum of TP53 mutations. Histopathologically, 86% of the resected nodules with isolated TP53 mutations were benign (mostly adenomas), whereas 82% of nodules carrying TP53 mutations co-occurring with other alterations were cancers (P = 0.001), including de-differentiated AC. TP53-mutant benign tumors and well-differentiated cancers often had scattered single neoplastic cells with bizarre nuclei resembling those comprising AC. Our study demonstrates that a small but distinct proportion of thyroid nodules carry a TP53 mutation, either as a single genetic event or in combination with other alterations. While the latter is mostly cancers prone to dedifferentiation, there is at least a theoretical possibility that TP53-mutated adenomas may represent a precursor for such cancers, including AC.
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Affiliation(s)
| | - Marina N Nikiforova
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Linwah Yip
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Esra Karslioglu-French
- Division of Endocrinology and Metabolism, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sally E Carty
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Yuri E Nikiforov
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Li SR, McCoy KL, Levitt HE, Kelley ML, Carty SE, Yip L. Is routine 24-hour urine calcium measurement useful during the evaluation of primary hyperparathyroidism? Surgery 2021; 171:17-22. [PMID: 34325903 DOI: 10.1016/j.surg.2021.04.055] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/17/2021] [Accepted: 04/30/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Primary hyperparathyroidism and familial hypocalciuric hypercalcemia have similar biochemical profiles, and calcium-to-creatinine-clearance ratio helps distinguish the two. Additionally, 24-hour urine calcium >400 mg/day indicates surgery and guidelines recommend obtaining 24-hour urine calcium preoperatively. Our aim was to assess how 24-hour urine calcium altered care in the evaluation of suspected primary hyperparathyroidism. METHODS Consecutive patients assessed for primary hyperparathyroidism from 2018 to 2020 were reviewed. Primary hyperparathyroidism was diagnosed by 2016 American Association of Endocrine Surgeons Parathyroidectomy Guidelines criteria. 24-hour urine calcium-directed change in care was defined as familial hypocalciuric hypercalcemia diagnosis, surgical deferment for additional testing, or 24-hour urine calcium >400 mg/day as the sole surgical indication. RESULTS Of 613 patients, 565 (92%) completed 24-hour urine calcium and 477 (84%) had concurrent biochemical testing to calculate calcium-to-creatinine-clearance ratio. 24-hour urine calcium was <100 mg/day in 9% (49/565) and calcium-to-creatinine-clearance ratio was <0.01 in 17% (82/477). No patient had confirmed familial hypocalciuric hypercalcemia, although 1 had a CASR variant of undetermined significance. When calcium-to-creatinine-clearance ratio was <0.01, familial hypocalciuric hypercalcemia was excluded by 24-hour urine calcium >100 mg/day (56%), prior normal calcium (16%), renal insufficiency (11%), absence of familial hypercalcemia (3%), normal repeat 24-hour urine calcium (10%), or interfering diuretic (1%). 24-hour urine calcium-directed change in care occurred in 25 (4%), including 4 (1%) who had genetic testing. Four-gland hyperplasia was more common with calcium-to-creatinine-clearance ratio <0.01 (17% vs calcium-to-creatinine-clearance ratio ≥ 0.01, 4%, P < .001), but surgical failure rates were equivalent (P = .24). CONCLUSION 24-hour urine calcium compliance was high, and results affected management in 4%, including productive identification of hypercalciuria as the sole surgical indication in 2 patients. When calcium-to-creatinine-clearance ratio <0.01, clinical assessment was sufficient to exclude familial hypocalciuric hypercalcemia and only 1% required genetic testing. 24-hour urine calcium should be ordered judiciously during primary hyperparathyroidism assessment.
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Affiliation(s)
- Shimena R Li
- Department of Surgery, University of Pittsburgh, PA
| | - Kelly L McCoy
- Department of Surgery, University of Pittsburgh, PA; Division of Endocrine Surgery, University of Pittsburgh, PA
| | - Helena E Levitt
- Department of Medicine, Division of Endocrinology and Metabolism, University of Pittsburgh, PA
| | | | - Sally E Carty
- Department of Surgery, University of Pittsburgh, PA; Division of Endocrine Surgery, University of Pittsburgh, PA
| | - Linwah Yip
- Department of Surgery, University of Pittsburgh, PA; Division of Endocrine Surgery, University of Pittsburgh, PA.
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Somasundar T, Dimick JB, Wong SL, Gosain A, Zheng F, Lee WPA, Yip L, Brahmbhatt TS. Reinventing Yourself Virtually: Fifth Annual Society of Asian Academic Surgeons Virtual Conference. J Surg Res 2021; 267:612-618. [PMID: 34271268 DOI: 10.1016/j.jss.2021.06.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 06/10/2021] [Accepted: 06/10/2021] [Indexed: 10/20/2022]
Abstract
Virtual forms of communication have been integrated into academic surgery now more than ever. The COVID-19 pandemic accelerated its implementation in an effort to support social-distancing. Academic surgery is now learning valuable lessons from early experiences to optimally integrate this communication mode. The Society of Asian Academic Surgeons convened an expert panel during the society's fifth annual meeting that explores these lessons. Realms of virtual communication including meetings, networking, surgery department administration, social media, application processes, and advice for early or mid-career academic surgeons are explored. Virtual conferences pose a new challenge by removing the in-person component that is evident to be integral to networking, collaboration, and all aspects of academic socialization. Strategies such as creating virtual chat rooms, mentor-mentee virtual introductions, and deliberate interactions can enhance the experience. Virtual administrative meetings require special attention to preparation and strategies to insure engagement. Social media can be a valuable tool to integrate into academic careers but special attention needs to be made to utilize it deliberately and not to shy away from our individuality. The interview process can be enhanced when made virtual to give opportunities to those typically disadvantaged in the usual, in-person process.
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Affiliation(s)
- Tharun Somasundar
- Department of Surgery, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Justin B Dimick
- Department of Surgery, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Sandra L Wong
- Department of Surgery, The Geisel School of Medicine at Dartmouth, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Ankush Gosain
- Division of Pediatric Surgery, Department of Surgery, University of Tennessee Health Science Center, Children's Foundation Research Institute, Le Bonheur Children's Hospital, Memphis, Tennessee, USA
| | - Feibi Zheng
- Department of Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, Texas, USA
| | - W P Andrew Lee
- Office of the Provost and Dean, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Linwah Yip
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Tejal S Brahmbhatt
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA.
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Canton SP, Dadashzadeh E, Yip L, Forsythe R, Handzel R. Automatic Detection of Thyroid and Adrenal Incidentals Using Radiology Reports and Deep Learning. J Surg Res 2021; 266:192-200. [PMID: 34020097 DOI: 10.1016/j.jss.2021.03.060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 03/24/2021] [Accepted: 03/26/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Computed tomography (CT) is commonly performed when evaluating trauma patients with up to 55% showing incidental findings. Current workflows to identify and inform patients are time-consuming and prone to error. Our objective was to automatically identify thyroid and adrenal lesions in radiology reports using deep learning. MATERIALS AND METHODS All trauma patients who presented to an accredited Level 1 Trauma Center between January 2008 and January 2019 were included. Radiology reports of CT scans that included either a thyroid or adrenal gland were obtained. Preprocessing included word tokenization, removal of stop words, removal of punctuation, and replacement of misspellings. A word2vec model was trained using 1.4 million radiology reports. Both training and testing reports were selected at random, manually reviewed, and were considered the gold standard. True positive cases were defined as any lesions in the thyroid or adrenal gland, respectively. Training data was used to create models that would identify reports that contained either thyroid or adrenal lesions. Our primary outcomes were sensitivity and specificity of the models using predetermined thresholds on a separate testing dataset. RESULTS A total of 51,771 reports were identified on 35,859 trauma patients. A total of 1,789 reports were annotated for training and 500 for testing. The thyroid model predictions resulted in a 90.0% sensitivity and 95.3% specificity. The adrenal model predictions resulted in a 92.3% sensitivity and a 91.1% specificity. A total of 240 reports were confirmed to have thyroid incidentals (mean age 69.1 yrs ± 18.9, 35% M) and 214 reports with adrenal incidentals (mean age 68.7 yrs ± 16.9, 50.5% M). CONCLUSIONS Both the thyroid and adrenal models have excellent performance with sensitivities and specificities in the 90s. Our deep learning model has the potential to reduce administrative costs and improve the process of informing patients.
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Affiliation(s)
- Stephen P Canton
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Esmaeel Dadashzadeh
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; University of Pittsburgh Department of Biomedical Informatics, Pittsburgh, Pennsylvania; University of Pittsburgh Department of Surgery, Pittsburgh, Pennsylvania
| | - Linwah Yip
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; University of Pittsburgh Department of Surgery, Pittsburgh, Pennsylvania
| | - Raquel Forsythe
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; University of Pittsburgh Department of Surgery, Pittsburgh, Pennsylvania
| | - Robert Handzel
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; University of Pittsburgh Department of Biomedical Informatics, Pittsburgh, Pennsylvania; University of Pittsburgh Department of Surgery, Pittsburgh, Pennsylvania.
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Doerfler WR, Nikitski AV, Morariu EM, Ohori NP, Chiosea SI, Landau MS, Nikiforova MN, Nikiforov YE, Yip L, Manroa P. Molecular alterations in Hürthle cell nodules and preoperative cancer risk. Endocr Relat Cancer 2021; 28:301-309. [PMID: 33792557 DOI: 10.1530/erc-20-0435] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 03/31/2021] [Indexed: 11/08/2022]
Abstract
Hürthle cell carcinoma (HCC) is a distinct type of thyroid cancer genetically characterized by DNA copy number alterations (CNA), typically of genome haploidization type (GH-type). However, whether CNA also occurs in benign Hürthle cell adenomas (HCA) or Hürthle cell hyperplastic nodules (HCHN), and have diagnostic impact in fine-needle aspiration (FNA) samples, remains unknown. To address these questions, we (1) analyzed 26 HCC, 24 HCA, and 8 HCHN tissues for CNA and other mutations using ThyroSeq v3 (TSv3) next-generation sequencing panel, and (2) determined cancer rate in 111 FNA samples with CNA and known surgical outcome. We identified CNA, more often of the GH-type, in 81% of HCC and in 38% HCA, but not in HCHN. Among four HCC with distant metastasis, all had CNA and three TERT mutations. Overall, positive TSv3 results were obtained in 24 (92%) HCC, including all with ATA high risk of recurrence or metastasis. Among 111 FNA cases with CNA, 38 (34%) were malignant and 73 (66%) benign. A significant correlation between cancer rate and nodule size was observed, particularly among cases with GH-type CNA, where every additional centimeter of nodule size increased the malignancy odds by 1.9 (95% CI 1.3-2.7; P = 0.001). In summary, the results of this study demonstrate that CNA characteristic of HCC also occur in HCA, although with lower frequency, and probability of cancer in nodules with CNA increases with nodule size. Detection of CNA, in conjunction with other mutations and nodule size, is helpful in predicting malignancy in thyroid nodules.
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Affiliation(s)
- William R Doerfler
- Division of Endocrinology and Metabolism, University of Pittsburgh, Pittsburgh, Pennysylvania, USA
| | | | - Elena M Morariu
- Division of Endocrinology and Metabolism, University of Pittsburgh, Pittsburgh, Pennysylvania, USA
| | - N Paul Ohori
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennysylvania, USA
| | - Simion I Chiosea
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennysylvania, USA
| | - Michael S Landau
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennysylvania, USA
| | - Marina N Nikiforova
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennysylvania, USA
| | - Yuri E Nikiforov
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennysylvania, USA
| | - Linwah Yip
- Division of Endocrine Surgery, University of Pittsburgh, Pittsburgh, Pennysylvania, USA
| | - Pooja Manroa
- Division of Endocrinology and Metabolism, University of Pittsburgh, Pittsburgh, Pennysylvania, USA
- Division of Endocrinology, University of Texas Medical Branch, Galveston, Texas, USA
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Yip L, Gooding WE, Nikitski A, Wald AI, Carty SE, Karslioglu-French E, Seethala RR, Zandberg DP, Ferris RL, Nikiforova MN, Nikiforov YE. Risk assessment for distant metastasis in differentiated thyroid cancer using molecular profiling: A matched case-control study. Cancer 2021; 127:1779-1787. [PMID: 33539547 PMCID: PMC8113082 DOI: 10.1002/cncr.33421] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 12/07/2020] [Indexed: 12/16/2022]
Abstract
Background Risk stratification for patients with differentiated thyroid cancer (DTC) is based primarily on pathologic tumor characteristics. Accurate preoperative prognostication could allow for more informed initial surgical recommendations, particularly among patients at a higher risk for distant metastasis (DM). The objective of this study was to characterize the genetic profile of DTC with DM and to validate a molecular‐based risk stratification. Methods A case‐control study design was used to analyze patients who had DTC with DM (n = 62) and a propensity matched cohort of patients who had DTC without DM after at least 5 years of follow‐up using the ThyroSeq version 3 targeted next‐generation sequencing assay. The results were classified into high‐risk, intermediate‐risk, and low‐risk of aggressive disease. Results Most patients who had DTC with DM (66%) had a late‐hit mutation in TERT, TP53, or PIK3CA. After propensity matching by age, tumor size, and sex, the high‐risk molecular profile had strong association with DM (high‐risk vs intermediate‐risk: odds ratio, 25.1; 95% CI, 3.07‐204.4; P < .001; high‐risk vs low‐risk: odds ratio, 122.5; 95% CI, 14.5‐1038.4; P < .001). Overall, molecular risk categories were associated with DM risk, with a concordance index of 0.836 (95% CI, 0.759‐0.913), which remained consistent after internal validation. Within the range of 5% to 10% of DM observed in DTC, the expected probability of DM would be 0.2% to 0.4% for the low‐risk molecular profile, 4.7% to 9.4% for the intermediate‐risk molecular profile, and 19.3% to 33.5% for the high‐risk molecular profile. Conclusions In this matched case‐control study, genetic profiling using an available molecular assay provided accurate and robust risk stratification for DM in patients with DTC. The availability of preoperative prognostication may allow tailoring treatment for patients with DTC. In this matched case‐control study, comprehensive genetic profiling provides accurate and robust risk stratification for distant metastasis in patients with differentiated thyroid cancer. The availability of preoperative prognostication may allow for molecular‐directed treatment recommendations to tailor care for these patients.
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Affiliation(s)
- Linwah Yip
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - William E Gooding
- Biostatistics Facility, University of Pittsburgh Medical Center Hillman Cancer Center, Pittsburgh, Pennsylvania
| | | | - Abigail I Wald
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sally E Carty
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Esra Karslioglu-French
- Division of Endocrinology and Metabolism, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Raja R Seethala
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Dan P Zandberg
- Department of Medicine, Hillman Cancer Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Robert L Ferris
- Department of Otolaryngology, University of Pittsburgh Medical Center, Hillman Cancer Center, Pittsburgh, Pennsylvania
| | | | - Yuri E Nikiforov
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania
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Li SR, Nicholson KJ, Mccoy KL, Carty SE, Yip L. Clinical and Biochemical Features of Pheochromocytoma Characteristic of Von Hippel-Lindau Syndrome. World J Surg 2020; 44:570-577. [PMID: 31773218 DOI: 10.1007/s00268-019-05299-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Approximately 30% of patients with apparent sporadic pheochromocytoma (Pheo) may later prove to have an inherited predisposition syndrome, most commonly Von Hippel-Lindau (VHL) disease. Our aim was to compare the clinical and biochemical features of Pheo in VHL to those in sporadic disease to identify differences that may be used to guide management and surveillance of Pheo in VHL patients. METHODS Data of all patients who had adrenalectomy for histologic Pheo from 2000 to 2018 (QIIRB1749) were retrospectively reviewed. VHL patients were diagnosed by standard clinical criteria and/or genetic testing. Patients were classified as having sporadic Pheo (sPheo) if they had no family/personal history consistent with an associated genetic disorder and/or had negative testing for VHL, MAX, MEN1, NF1, RET and SDHAF2/B/C/D/A mutations. RESULTS Of 175 patients, 38 (22%) had VHL and 137 (78%) had sPheo including 27 (20%) with negative genetic testing. Compared to sPheo, VHL Pheo patients were younger (mean 25.9 vs. 51.2 years, p < 0.001), less symptomatic (55% vs. 72%, p = 0.074), less hypertensive (46% vs. 64%, p = 0.043) and were more likely to have normal plasma metanephrines (85% vs. 25%, p < 0.001). VHL-related Pheos were smaller (median 2.8 cm vs. 4.4 cm, p < 0.001) but more often multifocal (>1 adrenal Pheo) (16% vs. 0%, p < 0.001). Recurrence >6 months from initial resection was common in VHL (40% vs. 0%, p < 0.001), median time to recurrence 15 years, (range 1-38 years). CONCLUSIONS Compared to those with sporadic Pheo, patients with VHL are more likely to be young, asymptomatic and normotensive and to have small, multifocal, normetanephrine-secreting tumors. Because recurrence is common in VHL and arises up to 38 years later, continued surveillance is advised.
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Affiliation(s)
- Shimena R Li
- Department of General Surgery, University of Pittsburgh Medical Center, Kaufman Building, Suite 101, 3471 Fifth Ave, Pittsburgh, PA, 15213, USA
| | - Kristina J Nicholson
- Department of General Surgery, University of Pittsburgh Medical Center, Kaufman Building, Suite 101, 3471 Fifth Ave, Pittsburgh, PA, 15213, USA
| | - Kelly L Mccoy
- Division of Endocrine Surgery, University of Pittsburgh Medical Center, Kaufman Building, Suite 101, 3471 Fifth Ave, Pittsburgh, PA, 15213, USA
| | - Sally E Carty
- Division of Endocrine Surgery, University of Pittsburgh Medical Center, Kaufman Building, Suite 101, 3471 Fifth Ave, Pittsburgh, PA, 15213, USA
| | - Linwah Yip
- Division of Endocrine Surgery, University of Pittsburgh Medical Center, Kaufman Building, Suite 101, 3471 Fifth Ave, Pittsburgh, PA, 15213, USA.
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Yip L, Carty SE, Holder-Murray JM, Recker A, Nicholson KJ, Boisen ML, Esper SA, McCoy KL. A specific enhanced recovery protocol decreases opioid use after thyroid and parathyroid surgery. Surgery 2020; 169:197-201. [PMID: 32690334 DOI: 10.1016/j.surg.2020.04.065] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/21/2020] [Accepted: 04/29/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Enhanced recovery protocols have not been investigated previously for cervical endocrine surgery. The study aim was to determine whether systematic implementation of an enhanced recovery protocol specific for thyroid/parathyroid surgery can improve postoperative outcomes. METHODS A customized enhanced recovery protocol for thyroid/parathyroid surgery was designed and utilized systematically for all patients who underwent parathyroidectomy, thyroid lobectomy, or total thyroidectomy. Outcomes were assessed 12 months before enhanced recovery protocol implementation (n = 464 patients) and after enhanced recovery protocol implementation (n = 654 patients). RESULTS Enhanced recovery protocol implementation was associated with a 72% decrease in mean oral morphine equivalents utilized in-house (before 82 ± 64 versus after 23 ± 28; P < .0001) and many enhanced recovery protocol patients were entirely opioid-free (0.2% vs 21%, P < .0001). When used, the enhanced recovery protocol was associated with a lesser mean amount of ondansetron to treat postoperative nausea and vomiting (5.5 mg ± 3 vs 4.5 ± 2: P < .0001). Duration of stay was short before implementation of the enhanced recovery protocol and did not change substantially after implementation (1.1 days ± 0.7 vs 1.1 ± 0.7; P = .26). CONCLUSION The systematic use of a simple, cervical, endocrine surgery-specific enhanced recovery protocol decreased perioperative opioid use by ~70%, with significantly less postoperative nausea and vomiting. Implementation of a multidisciplinary enhanced recovery protocol may be an important initial step toward limiting opioid overuse during common operative procedures.
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Affiliation(s)
- Linwah Yip
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA.
| | - Sally E Carty
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Jennifer M Holder-Murray
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Arydann Recker
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Kristina J Nicholson
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Michael L Boisen
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Stephen A Esper
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Kelly L McCoy
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
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Ravindra S, French EK, Yip L. MON-LB84 Validation of TI-RADS (Thyroid Imaging, Reporting and Data System) Follow-Up Recommendations. J Endocr Soc 2020. [PMCID: PMC7208667 DOI: 10.1210/jendso/bvaa046.2156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background:Thyroid nodules are exceedingly common, leading to costly interventions for many lesions that ultimately prove benign. Therefore, a reliable, noninvasive method to identify which nodules warrant fine needle aspiration and/or follow-up on the basis of a reasonable likelihood of malignancy is highly desirable. American College of Radiology (ACR) created a standard terminology (lexicon) to describe all thyroid nodules on sonography and standardized TI-RADS risk-stratification system to identify nodules that warrant biopsy and/or follow-up. Many healthcare institutions including UPMC adapted the TI-RADS scoring system in order to identify most clinically significant malignancies while reducing the number of biopsies and follow-up ultrasounds performed on benign nodules. According to ACR, TI-RADS category 3 nodules <1.5 cm and TI-RADS category 4 nodules <1 cm do not warrant follow-up imaging. There are no validation studies on TI-RADS follow-up recommendations. Methods:We completed a retrospective chart review from UPMC endocrine surgery thyroid nodule database from 2002 to 2012. We identified 57 nodules that showed a change in size during follow-up and had surgical data. Patient demographics, nodule baseline TI-RADS category, size, follow-up volume change and histopathological data were recorded. We reviewed ultrasound images and calculated TI-RADS category at baseline and during follow-up. Results:TI-RADS category 1-2 (TR1 and TR2) nodules(n=4) did not show any change in size over an average of 6.5 years confirming the recommendations that TR1 and TR2 nodules do not need follow-up.TI-RADS category (TR3) nodules (n=22) showed an average 225% change in volume over 4 years of follow-up. TR3 nodules <1.5 cm showed 397% volume change; 3 out of 15 (20%) nodules that showed a change in size proved to have thyroid cancer >1cm. TI-RADS category (TR4) nodules(n=31) showed a 786% volume change over 2.6 years of follow-up. TR4 nodules <1 cm, 5/14(35%) proved to have thyroid cancer >1 cm in follow up. Conclusions:TR1 and TR2 nodules did not show thyroid cancer during follow-up validating ACR recommendations not to follow these nodules. 3/15(26.5%) TR3 nodules <1.5 cm that showed a change in volume proved to have thyroid cancer. 5/14(35%) TR4 nodules <1cm that changed in volume were found to have thyroid cancer. Further studies are needed to identify nodules that require follow-up in order to decrease the misdiagnosis of thyroid cancer.
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Affiliation(s)
| | | | - Linwah Yip
- University of Pittsburgh, Pittsburgh, PA, USA
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Nikiforova MN, Nikitski A, Tebbets J, Tolino L, Manroa P, Yip L, Nikiforov YE. OR21-02 Impact of Nodule Size on the Probability of Hurthle Cell Carcinoma and Other Cancers in Thyroid Nodules with Multiple Chromosomal Copy Number Alterations. J Endocr Soc 2020. [PMCID: PMC7208849 DOI: 10.1210/jendso/bvaa046.1766] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Fine-needle aspiration (FNA) of thyroid nodules yields indeterminate cytological diagnosis in ~20% of cases, confounding patient management. This includes Hurthle cell nodules, which typically yield Bethesda IV and III cytology. Chromosomal copy number alterations (CNA) are known to occur in thyroid tumors, particularly in Hurthle cell carcinomas (HCC) as well as in other typically follicular-patterned tumors including papillary thyroid carcinomas (PTC) and poorly differentiated thyroid carcinomas (PDTC). The aim of this study was to evaluate thyroid nodules tested positive for CNA but negative for all other genomic alterations using ThyroSeq v3 NGS assay in order to establish the probability of cancer in these nodules and find whether it is influenced by the pattern of CNA and nodule size. We evaluated 111 nodules with multiple CNA detected by ThyroSeq in FNA samples and available surgical pathology outcome. Of those, 69 (62%) nodules showed CNA changes consistent with genome near-haploidization (GNH) whereas 42 (38%) nodules had multiple chromosomal losses and gains (CLG). Nodule size ranged from 0.5-10.2 cm; cytology was Bethesda III in 54%, Bethesda IV in 43%, and Bethesda V-VI in 3% of cases, with Hurthle cells mentioned in the cytology report in 64% of cases. On surgical pathology, 38 (34%) of these nodules were malignant (including 24 HCC, 8 PTC, and 5 oncocytic PDTC) and 73 (66%) were benign (including 43 Hurthle cell and 18 follicular adenomas). No significant difference was observed in probability of malignancy between the two patterns of CNA (p=0.41). However, a significant correlation between the nodule size and probability of cancer was found (p=0.006). In specific CNA groups, correlation between cancer and nodule size remained significant for nodules with GNH pattern (P=0.0002), but not with CLG pattern (p=0.449). Specifically, cancer probability in nodules with GNH pattern and <2 cm in size was 14% (all cancers minimally-invasive), 2.0-2.9 cm was 33%, 3.0-3.9 cm was 50%, 4-4.9 cm was 67%, and ≥5 cm was 80%. Among high-risk cancers (widely-invasive or angioinvasive HCC, PDTC), all 10 tumors had the GNH pattern (p=0.01) and average nodule size of 4.9 cm (range, 2.1-8.5 cm). These findings suggest that CNA of both types are frequently found in Hurthle cell tumors, and probability of cancer in nodules with CNA and no other mutations increases with larger nodule size. This may help to refine the pre-operative assessment of cancer probability and risk of more aggressive disease and offer more tailored management to these patients.
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Affiliation(s)
| | | | - Jessica Tebbets
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Lindsey Tolino
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Pooja Manroa
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Linwah Yip
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Figge JJ, Gooding WE, Burman KD, Mayson S, Scheri RP, Sipos JA, Sippel RS, Steward DL, Yang SP, Yip L, Nikiforov YE, Carty SE. MON-LB79 Do Ultrasound Patterns and Clinical Parameters Modify the Probability of Thyroid Cancer Predicted by Molecular Testing in Thyroid Nodules With Indeterminate Cytology? J Endocr Soc 2020. [PMCID: PMC7209362 DOI: 10.1210/jendso/bvaa046.2118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background: Molecular testing (MT) is commonly used to refine cancer probability in thyroid nodules with indeterminate cytology. Whether or not ultrasound (US) patterns and clinical parameters can further modify the risk of cancer in nodules predicted to be positive or negative by molecular testing remains unknown. Aim: To test if clinical parameters, including age, gender, nodule size (by US), Bethesda category (III, IV, V), US pattern (American Thyroid Association [ATA] system vs American College of Radiology TIRADS), radiation exposure, and family history of thyroid cancer (TC) can modify the probability of TC or NIFTP predicted by MT in thyroid nodules with indeterminate cytology. Methods: We studied 257 thyroid nodules from 10 study centers with fine-needle aspiration (FNA) yielding indeterminate cytology and informative MT results using the ThyroSeq v3 genomic classifier (TSv3). Univariate and multivariate logistic regression were used for data analysis. Results: In this group of thyroid nodules, out of all parameters studied using univariate regression, patient gender, age, and Bethesda category were significantly associated with TC/NIFTP probability (P<0.05 for each). The ATA US patterns showed a positive trend (P=0.1211), whereas TIRADS was not predictive (P=0.3135). A multivariate regression model incorporating the four most informative covariates (gender, age, Bethesda category, and ATA US patterns) (model #1) yielded a C index=0.653; R2=0.108. Male gender and Bethesda category V significantly increased risk, and age demonstrated a nonlinear risk profile. When TSv3 was added to model #1, the C index increased to 0.888; R2=0.572. However, age (P=0.341), Bethesda category (P=0.272), and the ATA US patterns (P=0.264) had limited predictive ability in comparison with TSv3, which dominated the predictive performance (P<0.001). Gender was the only parameter showing tendency for significance beyond MT (P=0.095). The most parsimonious model incorporated gender and TSv3 (C index=0.889; R2=0.588). Conclusions: While often useful in selecting thyroid nodules for FNA, neither the ATA US nor the TIRADS scoring systems were informative in further predicting TC/NIFTP in thyroid nodules with indeterminate FNA cytology. Although age and Bethesda category were associated with TC/NIFTP probability on univariate analysis, they had limited incremental value above the high predictive ability of TSv3. Gender was the only parameter with potential contribution to predicting TC/NIFTP in addition to MT.
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Affiliation(s)
- James J Figge
- Department of Medicine, Division of Endocrinology, St Peter’s Hospital, Albany, NY, USA
| | - William E Gooding
- Biostatistics Facility, UPMC Hillman Cancer Center, Pittsburgh, PA, USA
| | - Kenneth D Burman
- Department of Medicine, Endocrinology Section, Medstar Washington Hospital Center, Washington, DC, USA
| | - Sarah Mayson
- Division of Endocrinology, Metabolism and Diabetes, University of Colorado Denver-Anschutz Medical Campus, Aurora, CO, USA
| | | | - Jennifer A Sipos
- Division of Endocrinology, Diabetes and Metabolism, Ohio State University, Columbus, OH, USA
| | - Rebecca S Sippel
- Division of Endocrine Surgery, University of Wisconsin, Madison, WI, USA
| | - David L Steward
- Department of Otolaryngology, Head and Neck Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Samantha Peiling Yang
- Endocrinology Division, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Linwah Yip
- Division of Endocrine Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Yuri E Nikiforov
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sally E Carty
- Division of Endocrine Surgery, University of Pittsburgh, Pittsburgh, PA, USA
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Affiliation(s)
- Linwah Yip
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
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Mallick R, Nicholson KJ, Yip L, Carty SE, McCoy KL. Factors associated with late recurrence after parathyroidectomy for primary hyperparathyroidism. Surgery 2020; 167:160-165. [DOI: 10.1016/j.surg.2019.05.076] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 04/25/2019] [Accepted: 05/01/2019] [Indexed: 10/25/2022]
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Steward DL, Carty SE, Sippel RS, Yang SP, Sosa JA, Sipos JA, Figge JJ, Mandel S, Haugen BR, Burman KD, Baloch ZW, Lloyd RV, Seethala RR, Gooding WE, Chiosea SI, Gomes-Lima C, Ferris RL, Folek JM, Khawaja RA, Kundra P, Loh KS, Marshall CB, Mayson S, McCoy KL, Nga ME, Ngiam KY, Nikiforova MN, Poehls JL, Ringel MD, Yang H, Yip L, Nikiforov YE. Performance of a Multigene Genomic Classifier in Thyroid Nodules With Indeterminate Cytology: A Prospective Blinded Multicenter Study. JAMA Oncol 2019; 5:204-212. [PMID: 30419129 PMCID: PMC6439562 DOI: 10.1001/jamaoncol.2018.4616] [Citation(s) in RCA: 254] [Impact Index Per Article: 50.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Question Can the diagnosis of benign disease or cancer in thyroid nodules with indeterminate cytology be established by molecular testing instead of diagnostic surgery? Findings This prospective, blinded, multicenter cohort study of a multigene genomic classifier (ThyroSeq v3) test included 257 indeterminate cytology thyroid nodules with informative test results. It demonstrated a high sensitivity (94%) and reasonably high specificity (82%), with 61% of the nodules yielding a negative test result and only 3% residual cancer risk in these nodules. Meanings Up to 61% of patients with indeterminate cytology thyroid nodules may avoid diagnostic surgery by undergoing multigene genomic classifier testing. Importance Approximately 20% of fine-needle aspirations (FNA) of thyroid nodules have indeterminate cytology, most frequently Bethesda category III or IV. Diagnostic surgeries can be avoided for these patients if the nodules are reliably diagnosed as benign without surgery. Objective To determine the diagnostic accuracy of a multigene classifier (GC) test (ThyroSeq v3) for cytologically indeterminate thyroid nodules. Design, Setting, and Participants Prospective, blinded cohort study conducted at 10 medical centers, with 782 patients with 1013 nodules enrolled. Eligibility criteria were met in 256 patients with 286 nodules; central pathology review was performed on 274 nodules. Interventions A total of 286 FNA samples from thyroid nodules underwent molecular analysis using the multigene GC (ThyroSeq v3). Main Outcomes and Measures The primary outcome was diagnostic accuracy of the test for thyroid nodules with Bethesda III and IV cytology. The secondary outcome was prediction of cancer by specific genetic alterations in Bethesda III to V nodules. Results Of the 286 cytologically indeterminate nodules, 206 (72%) were benign, 69 (24%) malignant, and 11 (4%) noninvasive follicular thyroid neoplasms with papillary-like nuclei (NIFTP). A total of 257 (90%) nodules (154 Bethesda III, 93 Bethesda IV, and 10 Bethesda V) had informative GC analysis, with 61% classified as negative and 39% as positive. In Bethesda III and IV nodules combined, the test demonstrated a 94% (95% CI, 86%-98%) sensitivity and 82% (95% CI, 75%-87%) specificity. With a cancer/NIFTP prevalence of 28%, the negative predictive value (NPV) was 97% (95% CI, 93%-99%) and the positive predictive value (PPV) was 66% (95% CI, 56%-75%). The observed 3% false-negative rate was similar to that of benign cytology, and the missed cancers were all low-risk tumors. Among nodules testing positive, specific groups of genetic alterations had cancer probabilities varying from 59% to 100%. Conclusions and Relevance In this prospective, blinded, multicenter study, the multigene GC test demonstrated a high sensitivity/NPV and reasonably high specificity/PPV, which may obviate diagnostic surgery in up to 61% of patients with Bethesda III to IV indeterminate nodules, and up to 82% of all benign nodules with indeterminate cytology. Information on specific genetic alterations obtained from FNA may help inform individualized treatment of patients with a positive test result.
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Affiliation(s)
- David L Steward
- Department of Otolaryngology, Head and Neck Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Sally E Carty
- Division of Endocrine Surgery, University of Pittsburgh, Pittsburgh, Pennslyvania
| | | | - Samantha Peiling Yang
- Endocrinology Division, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Julie A Sosa
- Section of Endocrine Surgery, Department of Surgery, Duke Cancer Institute and Duke Clinical Research Institute, Duke University, Durham, North Carolina.,Department of Surgery, University of California, San Francisco
| | - Jennifer A Sipos
- Division of Endocrinology, Diabetes, and Metabolism, The Ohio State University School of Medicine, Columbus
| | - James J Figge
- Diabetes & Endocrine Care, St Peter's Health Partners, Rensselaer, New York
| | - Susan Mandel
- Division of Endocrinology, Diabetes and Metabolism, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Bryan R Haugen
- Division of Endocrinology, Metabolism and Diabetes, University of Colorado School of Medicine, Aurora
| | - Kenneth D Burman
- Department of Medicine, Endocrinology Section, MedStar Washington Hospital Center, Washington, DC
| | - Zubair W Baloch
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Ricardo V Lloyd
- Department of Pathology and Laboratory Medicine, University of Wisconsin, Madison
| | - Raja R Seethala
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - William E Gooding
- Biostatistics Facility, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania
| | - Simion I Chiosea
- Department of Medicine, Endocrinology Section, MedStar Washington Hospital Center, Washington, DC
| | - Cristiane Gomes-Lima
- Department of Medicine, Endocrinology Section, MedStar Washington Hospital Center, Washington, DC
| | - Robert L Ferris
- Departments of Otolaryngology and Immunology, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania
| | - Jessica M Folek
- Diabetes & Endocrine Care, St Peter's Health Partners, Rensselaer, New York
| | - Raheela A Khawaja
- Division of Endocrinology, Diabetes, and Metabolism, The Ohio State University School of Medicine, Columbus
| | - Priya Kundra
- Department of Medicine, Endocrinology Section, MedStar Washington Hospital Center, Washington, DC
| | - Kwok Seng Loh
- Department of Otolaryngology-Head and Neck Surgery, National University Hospital, Singapore
| | - Carrie B Marshall
- Department of Pathology, University of Colorado School of Medicine, Aurora, Colorado
| | - Sarah Mayson
- Division of Endocrinology, Metabolism and Diabetes, University of Colorado School of Medicine, Aurora
| | - Kelly L McCoy
- Division of Endocrine Surgery, University of Pittsburgh, Pittsburgh, Pennslyvania
| | - Min En Nga
- Department of Pathology, National University Hospital, Singapore
| | - Kee Yuan Ngiam
- Department of General Surgery, University Surgical Cluster, National University Hospital, Singapore
| | | | - Jennifer L Poehls
- Division of Endocrinology, Diabetes & Metabolism, University of Wisconsin, Madison
| | - Matthew D Ringel
- Division of Endocrinology, Diabetes, and Metabolism, The Ohio State University School of Medicine, Columbus
| | - Huaitao Yang
- Department Pathology, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Linwah Yip
- Division of Endocrine Surgery, University of Pittsburgh, Pittsburgh, Pennslyvania
| | - Yuri E Nikiforov
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania
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Kim KJ, Kim SG, Tan J, Shen X, Viola D, Elisei R, Puxeddu E, Fugazzola L, Colombo C, Jarzab B, Czarniecka A, Lam AK, Mian C, Vianello F, Yip L, Riesco-Eizaguirre G, Santisteban P, O'Neill CJ, Sywak MS, Clifton-Bligh R, Bendlova B, Sýkorová V, Xing M. BRAF V600E status may facilitate decision-making on active surveillance of low-risk papillary thyroid microcarcinoma. Eur J Cancer 2019; 124:161-169. [PMID: 31790974 DOI: 10.1016/j.ejca.2019.10.017] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 10/05/2019] [Accepted: 10/21/2019] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Conservative active surveillance has been proposed for low-risk papillary thyroid microcarcinoma (PTMC), defined as ≤1.0 cm and lacking clinical aggressive features, but controversy exists with accepting it as not all such PTMCs are uniformly destined for benign prognosis. This study investigated whether BRAF V600E status could further risk stratify PTMC, particularly low-risk PTMC, and can thus help with more accurate case selection for conservative management. METHODS This international multicenter study included 743 patients treated with total thyroidectomy for PTMC (584 women and 159 men), with a median age of 49 years (interquartile range [IQR], 39-59 years) and a median follow-up time of 53 months (IQR, 25-93 months). RESULTS On overall analyses of all PTMCs, tumour recurrences were 6.4% (32/502) versus 10.8% (26/241) in BRAF mutation-negative versus BRAF mutation-positive patients (P = 0.041), with a hazard ratio (HR) of 2.44 (95% CI (confidence interval), 1.15-5.20) after multivariate adjustment for confounding clinical factors. On the analyses of low-risk PTMC, recurrences were 1.3% (5/383) versus 4.3% (6/139) in BRAF mutation-negative versus BRAF mutation-positive patients, with an HR of 6.65 (95% CI, 1.80-24.65) after adjustment for confounding clinical factors. BRAF mutation was associated with a significant decline in the Kaplan-Meier recurrence-free survival curve in low-risk PTMC. CONCLUSIONS BRAF V600E differentiates the recurrence risk of PTMC, particularly low-risk PTMC. Given the robust negative predictive value, conservative active surveillance of BRAF mutation-negative low-risk PTMC is reasonable whereas the increased recurrence risk and other well-known adverse effects of BRAF V600E make the feasibility of long-term conservative surveillance uncertain for BRAF mutation-positive PTMC.
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Affiliation(s)
- Kyeong J Kim
- Laboratory for Cellular and Molecular Thyroid Research, Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul 02841, South Korea
| | - Sin G Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul 02841, South Korea
| | - Jie Tan
- Laboratory for Cellular and Molecular Thyroid Research, Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Xiaopei Shen
- Laboratory for Cellular and Molecular Thyroid Research, Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - David Viola
- Section of Endocrinology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Rossella Elisei
- Section of Endocrinology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Efisio Puxeddu
- Department of Internal Medicine, University of Perugia, Perugia, Italy
| | - Laura Fugazzola
- Division of Endocrine and Metabolic Diseases, IRCCS Instituto Auxologico Italiano, and Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Carla Colombo
- Division of Endocrine and Metabolic Diseases, IRCCS Instituto Auxologico Italiano, and Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Barbara Jarzab
- Maria Sklodowska-Curie Institute-Oncology Center, Gliwice Branch, Gliwice, Poland
| | - Agnieszka Czarniecka
- Maria Sklodowska-Curie Institute-Oncology Center, Gliwice Branch, Gliwice, Poland
| | - Alfred K Lam
- Cancer Molecular Pathology of School of Medicine and Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia
| | - Caterina Mian
- Department of Medicine, Endocrinology Unit, University of Padua, Italy
| | | | - Linwah Yip
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Garcilaso Riesco-Eizaguirre
- Department of Endocrinology and Nutrition Hospital Universitario La Paz and Hospital, Universitario De Mostoles, 28029 Madrid, Spain; Biomedical Research Institute "Alberto Sols", Consejo Superior De Investigaciones Cientificas and Univeridad Autonoma de Madrid, 28029, Madrid, Spain; Ciberonc, Health Institute Carlos III, 28029 Madrid, Spain
| | - Pilar Santisteban
- Biomedical Research Institute "Alberto Sols", Consejo Superior De Investigaciones Cientificas and Univeridad Autonoma de Madrid, 28029, Madrid, Spain; Ciberonc, Health Institute Carlos III, 28029 Madrid, Spain
| | | | - Mark S Sywak
- Endocrine Surgical Unit, The University of Sydney, Sydney, Australia
| | | | - Bela Bendlova
- Department of Molecular Endocrinology, Institute of Endocrinology, Prague, Czech Republic
| | - Vlasta Sýkorová
- Department of Molecular Endocrinology, Institute of Endocrinology, Prague, Czech Republic
| | - Mingzhao Xing
- Laboratory for Cellular and Molecular Thyroid Research, Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
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Panebianco F, Nikitski AV, Nikiforova MN, Kaya C, Yip L, Condello V, Wald AI, Nikiforov YE, Chiosea SI. Characterization of thyroid cancer driven by known and novel ALK fusions. Endocr Relat Cancer 2019; 26:803-814. [PMID: 31539879 PMCID: PMC7002208 DOI: 10.1530/erc-19-0325] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 09/19/2019] [Indexed: 12/13/2022]
Abstract
ALK fusions are found in various tumors, including thyroid cancer, and serve as a diagnostic marker and therapeutic target. Spectrum and outcomes of ALK fusions found in thyroid nodules and cancer are not fully characterized. We report a series of 44 ALK-translocated thyroid neoplasms, including 31 identified preoperatively in thyroid fine-needle aspirates (FNA). The average patients' age was 43 years (range, 8-76 years); only one with radiation history. All 19 resected thyroid nodules with ALK fusion identified preoperatively were malignant. Among nodules with known surgical pathology (n = 32), 84% were papillary thyroid carcinomas (PTCs) and 16% poorly differentiated thyroid carcinomas (PDTCs). PTCs showed infiltrative growth with follicular architecture seen exclusively (30%) or in combination with papillary and/or solid growth (37%). Tumor multifocality was seen in 10 (31%) PTC cases. Most PDTC had a well-differentiated PTC component. Lymph node metastases were identified in 10/18 (56%) patients with neck dissection. The most common ALK fusion partners were STRN (n = 22) and EML4 (n = 17). In five cases, novel ALK fusion partners were discovered. All five PDTCs carried STRN-ALK fusion. On follow-up, ten patients were free of disease at 2-108 months, whereas two patients with PDTC died of disease. In summary, ALK fusion-positive thyroid carcinomas are typically infiltrative PTC with common follicular growth, which may show tumor dedifferentiation associated with increased mortality. Compared to EML4-ALK, STRN-ALK may be more common in PDTC, and ~10% of ALK fusions occur to rare gene partners. When ALK fusion is detected preoperatively in FNA samples, malignancy should be expected.
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Affiliation(s)
- Federica Panebianco
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Alyaksandr V Nikitski
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Marina N Nikiforova
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Cihan Kaya
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Linwah Yip
- Division of Endocrine Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Vincenzo Condello
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Abigail I Wald
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Yuri E Nikiforov
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Simion I Chiosea
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Yip L, McCoy KL, Carty SE. Remembering the Hippocratic Oath in Surgical Training. JAMA Surg 2019; 154:958-959. [PMID: 31389976 DOI: 10.1001/jamasurg.2019.3013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Linwah Yip
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kelly L McCoy
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sally E Carty
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
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Felmingham C, Yip L, Tam M, Nixon RL. Allergy to sunscreen and leave-on facial products is not a likely causative mechanism in frontal fibrosing alopecia: perspective from contact allergy experts. Br J Dermatol 2019; 182:481-482. [PMID: 31369143 DOI: 10.1111/bjd.18380] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- C Felmingham
- Skin and Cancer Foundation - Occupational Dermatology Research and Education Centre, Carlton, VIC, Australia
| | - L Yip
- Bulimba Dermatology, Brisbane, QLD, Australia
| | - M Tam
- Skin and Cancer Foundation, Carlton, VIC, Australia.,St Vincent's Hospital, Fitzroy, VIC, Australia
| | - R L Nixon
- Skin and Cancer Foundation - Occupational Dermatology Research and Education Centre, Carlton, VIC, Australia
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Landau MS, Pearce TM, Carty SE, Wolfe J, Yip L, McCoy KL, LeBeau SO, Tublin ME, Ohori NP. Comparison of the collection approaches of 2 large thyroid fine-needle aspiration practices reveals differing advantages for cytology and molecular testing adequacy rates. J Am Soc Cytopathol 2019; 8:243-249. [PMID: 31543223 DOI: 10.1016/j.jasc.2019.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 03/16/2019] [Accepted: 03/22/2019] [Indexed: 01/21/2023]
Abstract
INTRODUCTION At our institution, almost all thyroid fine-needle aspiration (FNA) procedures are performed by either Endocrinology or Radiology personnel. In this study, we compared the cytology and molecular adequacy rates of these 2 thyroid FNA practices, which differ on several aspects of specimen procurement. MATERIALS AND METHODS All thyroid FNA specimens from Endocrinology and Radiology practices between September 2008 and December 2016 were included. Over this time frame, the molecular testing modality transitioned from polymerase chain reaction (PCR)-based (7-gene panel era) to next generation sequencing (NGS)-based (ThyroSeq era). In measuring cytology adequacy, the Bethesda System unsatisfactory rate was determined. Molecular adequacy was categorized as Optimal, Limited Thyroid Epithelial Cells, Limited Nucleic Acids, or Failed. These parameters were compared for the 2 practices. RESULTS The study cohorts comprised 5810 specimens from Endocrinology and 4597 from Radiology. More Endocrinology specimens were satisfactory for cytology diagnosis than those from Radiology (94.7% versus 90.0%, P < 0.001). For molecular adequacy, fewer Endocrinology specimens were optimal than specimens from Radiology for both the 7-gene panel era (76.2% versus 82.9%, P < 0.001) and the ThyroSeq era (88.1% versus 91.9%, P = 0.049). CONCLUSIONS The 2 thyroid FNA practices varied inversely in their adequacy rates for cytology and molecular testing. Had one practice been superior for both cytology and molecular adequacy, a recommendation for the method of choice would have been straightforward. However, our results show that optimization of FNA practice for the current practice of thyroid cytology requires further investigation due to the complex nature of specimen procurement.
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Affiliation(s)
- Michael S Landau
- Division of Anatomic Pathology, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
| | - Thomas M Pearce
- Division of Anatomic Pathology, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Sally E Carty
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jenna Wolfe
- Division of Anatomic Pathology, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Linwah Yip
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Kelly L McCoy
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Shane O LeBeau
- Division of Endocrinology and Metabolism, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Mitchell E Tublin
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - N Paul Ohori
- Division of Anatomic Pathology, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Nicholson KJ, Smith KJ, McCoy KL, Carty SE, Yip L. A comparative cost-utility analysis of postoperative calcium supplementation strategies used in the current management of hypocalcemia. Surgery 2019; 167:137-143. [PMID: 31515122 DOI: 10.1016/j.surg.2019.05.077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 04/24/2019] [Accepted: 05/01/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Symptomatic hypocalcemia is a common complication of total thyroidectomy. Management strategies include responsive treatment initiation for symptoms or prevention by routine or parathyroid hormone-directed calcium supplementation. The comparative cost-effectiveness of even the most often utilized strategies is unclear. METHODS A Markov cohort model was created to compare routine supplementation with calcium alone (RS), postoperative parathyroid hormone-based selective supplementation with calcium and calcitriol (SS), and no supplementation (NS) in asymptomatic patients. Patients could remain asymptomatic or develop symptomatic hypocalcemia, managed with outpatient oral supplementation or intravenous calcium infusion and administered either inpatient or outpatient. Effectiveness was measured in quality-adjusted life years. Sensitivity analyses were performed to test model parameter assumptions. RESULTS RS was the preferred strategy, costing $329/patient and resulting in 0.497 quality-adjusted life years, which was only marginally better compared to SS ($373 for 0.495 quality-adjusted life years). NS was most costly at $4,955 for 0.491 quality-adjusted life years. Preference for RS over SS was sensitive to the probability of developing symptoms and the probability of symptom treatment with intravenous supplementation. On probabilistic sensitivity analysis, RS was preferred in 75.4% of scenarios. CONCLUSION After total thyroidectomy, a preventative calcium supplementation strategy should be strongly considered. In this data-driven theoretical model, RS was the least costly option and resulted in an incremental gain in quality-adjusted life years.
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Affiliation(s)
- Kristina J Nicholson
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, PA
| | | | - Kelly L McCoy
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, PA
| | - Sally E Carty
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, PA
| | - Linwah Yip
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, PA.
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Abstract
Background: Molecular tests (MT) using gene expression and/or mutational analysis have been developed to reduce the need for diagnostic surgery for indeterminate (Bethesda III/IV) thyroid nodules. Prior cost-effectiveness studies have shown mixed results but none has included the recent and more comprehensive versions of the two commonly utilized MT. The aim of this study is to compare the cost-effectiveness of diagnostic lobectomy (DL), the Afirma Gene Sequencing Classifier (GSC), and ThyroSeq version 3 (TSv3). Methods: A decision tree from the payer perspective was created using a base case of a 40-year-old euthyroid woman with a solitary 2 cm Bethesda III or IV thyroid nodule. In this model, all patients in the DL arm had lobectomy, which was also performed for patients with positive MT, while those with negative MT underwent 20 years of surveillance. The outcome was a correct diagnosis, defined as malignant histology after DL or 20 years of nodule stability after negative MT. Costs were obtained from the Centers for Medicare & Medicaid Services (CMS) data and existing literature, and probabilities were obtained from the literature. Sensitivity analysis was performed for costs, pretest probability of malignancy, and performance parameters. Results: The cost per correct diagnosis was $14,277 for TSv3, $17,873 for GSC, and $38,408 for DL. TSv3 was preferred over both GSC and DL. One-way sensitivity analysis between TSv3 and GSC demonstrated that the results were robust to variations in cost, cancer prevalence, and length of surveillance. In the two-way sensitivity analysis, TSv3 was preferred over GSC at all considered test costs, and in probabilistic sensitivity analysis, TSv3 was the preferred management strategy in 68.5% of cases. Conclusions: In hypothetical modeling to determine whether surgery versus MT is optimal for indeterminate (Bethesda III/IV) nodules, either of the major MT was considerably more cost-effective than DL, although TSv3 was more likely to be cost-effective than GSC. Use of either MT adjunct should be strongly considered in the absence of other indications for thyroidectomy.
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Affiliation(s)
- Kristina J. Nicholson
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mark S. Roberts
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, Department of Health Policy and Management, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kelly L. McCoy
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sally E. Carty
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Linwah Yip
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Address correspondence to: Linwah Yip, MD, Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, 3471 Fifth Avenue Ste 101, Pittsburgh, PA 15213
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Borrelli N, Panebianco F, Condello V, Barletta JA, Kaya C, Yip L, Nikiforova MN, Nikiforov YE. Characterization of Activating Mutations of the MEK1 Gene in Papillary Thyroid Carcinomas. Thyroid 2019; 29:1279-1285. [PMID: 31407636 PMCID: PMC6913803 DOI: 10.1089/thy.2019.0065] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background: Genetic alterations activating the mitogen-activated protein kinase (MAPK) signaling pathway, most commonly BRAF and RAS mutations, are common in papillary thyroid carcinoma (PTC). Somatic mutations of the MEK gene, also known as mitogen-activated protein kinase kinase 1 (MAP2K1), coding for a signaling protein downstream of BRAF, have been found in several cancer types. The goal of this study was to investigate if functional MEK1 mutations occur in thyroid cancer (TC). Methods: We analyzed MEK1 mutation status in a series of 101 PTCs lacking other known driver mutations using Sanger sequencing and targeted next-generation sequencing. In addition, 64 follicular and Hürthle cell carcinomas and 32 follicular adenomas were studied. The occurrence of MEK1 mutations was evaluated using another series of thyroid tumors studied by targeted next-generation sequencing. Western blot and RNA-seq analyses were performed on selected tumors. Results: We detected MEK1 mutations in 2/101 (2%) PTCs that otherwise had no known genetic alterations, in 0/64 follicular and Hürthle cell carcinomas, and in 0/32 follicular adenomas. Two positive tumors carried the same in-frame deletion p.L98_I103del; K104I (c.292_309del18; c.311A>T) located in exon 3 of the gene. One additional MEK1 mutation was identified following routine molecular tumor profiling. The tumor had an in-frame deletion p.I99_K104del (c.294_311del18) also located in exon 3. Western blot analysis of one of the tumors showed activation of the MAPK pathway. Using RNA-seq analysis to evaluate changes in gene expression, these tumors were RAS-like and showed a high thyroid differentiation score. Phenotypically, the MEK1-positive PTCs were all encapsulated and had a predominantly or exclusively follicular architecture, being diagnosed as a classic papillary type with a significant follicular pattern ( × 2) or follicular variant PTC ( × 1). Follow-up was available for 2 patients, with no evidence of disease found 2 and 10 years postsurgery. Conclusions: In this study, we report the occurrence of functional MEK1 mutations in PTC. All mutations are in-frame deletions in exon 3 of MEK1, representing another mechanism of activation of the MAPK pathway in papillary carcinomas with a predominantly follicular growth pattern.
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Affiliation(s)
- Nicla Borrelli
- Department of Pathology and Laboratory Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Federica Panebianco
- Department of Pathology and Laboratory Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Vincenzo Condello
- Department of Pathology and Laboratory Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Justine A. Barletta
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Cihan Kaya
- Department of Pathology and Laboratory Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Linwah Yip
- Division of Endocrine Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Marina N. Nikiforova
- Department of Pathology and Laboratory Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Yuri E. Nikiforov
- Department of Pathology and Laboratory Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Address correspondence to: Yuri E. Nikiforov, MD, PhD, Department of Pathology and Laboratory Medicine, School of Medicine, University of Pittsburgh, Clinical Lab Building, Room 8031, 3477 Euler Way, Pittsburgh, PA 15213
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Nicholson KJ, Teng CY, McCoy KL, Carty SE, Yip L. Completion thyroidectomy: A risky undertaking? Am J Surg 2019; 218:695-699. [PMID: 31345503 DOI: 10.1016/j.amjsurg.2019.07.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/22/2019] [Accepted: 07/16/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Completion thyroidectomy (cT) is sometimes necessary after thyroid lobectomy (TL), and it remains controversial whether 2-stage thyroidectomy adds operative risk. This study compares complication rates for TL, total thyroidectomy (TT), and cT. METHODS Using a cohort design, we reviewed 100 consecutive cases each of TL, TT, and cT. Complications examined included reoperation for hematoma, temporary/permanent recurrent laryngeal nerve (RLN) dysfunction, and hypoparathyroidism. RESULTS Two patients had reoperation for hematoma, both in the TT cohort (p = 0.33). No patients in any cohort had permanent hypoparathyroidism or RLN injury, but transient RLN paresis occurred in three (3%) TL, two (2%) TT, and no (0%) cT patients (p = 0.38). Transient hypoparathyroidism occurred in 3% following TT versus 0% after cT (p = 0.12). Overall complication rate was higher after TT (7%) compared to TL (3%) and cT (0%, p = 0.02). CONCLUSIONS At a high-volume center, the observed complication rates were equivalently low for TL, TT, and cT. SUMMARY Completion thyroidectomy is occasionally needed after lobectomy, but its procedure-specific risks are not well characterized. In a cohort study at a high-volume center, operative outcomes for patients undergoing thyroid lobectomy, total thyroidectomy, and completion thyroidectomy were compared and equivalently low complication rates were observed for all 3 procedures.
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Affiliation(s)
- Kristina J Nicholson
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh Medical Center, Kaufmann Building, Suite 101, 3471 Fifth Avenue, Pittsburgh, PA, 15213, United States.
| | - Cindy Y Teng
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh Medical Center, Kaufmann Building, Suite 101, 3471 Fifth Avenue, Pittsburgh, PA, 15213, United States.
| | - Kelly L McCoy
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh Medical Center, Kaufmann Building, Suite 101, 3471 Fifth Avenue, Pittsburgh, PA, 15213, United States.
| | - Sally E Carty
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh Medical Center, Kaufmann Building, Suite 101, 3471 Fifth Avenue, Pittsburgh, PA, 15213, United States.
| | - Linwah Yip
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh Medical Center, Kaufmann Building, Suite 101, 3471 Fifth Avenue, Pittsburgh, PA, 15213, United States.
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Acharya R, Dhir M, Bandi R, Yip L, Challinor S. Outcomes of Adrenal Venous Sampling in Patients with Bilateral Adrenal Masses and ACTH-Independent Cushing's Syndrome. World J Surg 2019; 43:527-533. [PMID: 30232569 DOI: 10.1007/s00268-018-4788-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Management of patients with bilateral adrenal masses and ACTH-independent Cushing's syndrome (AICS) is challenging, as bilateral adrenalectomy can lead to steroid dependence and lifelong risk of adrenal crisis. Adrenal venous sampling (AVS) has been previously reported to facilitate lateralization for guiding adrenalectomy. The aim of the current study was to investigate the utility of AVS using protocol from study by Young et al. in the management of patients with bilateral adrenal masses and AICS. METHODS AND DESIGN A retrospective review of all patients with bilateral adrenal masses and AICS who underwent AVS from 2008 to 2016 was performed. AVS for cortisol and epinephrine was performed with dexamethasone suppression. The adrenal vein to peripheral vein cortisol ratios and side-to-side cortisol lateralization ratios were calculated. RESULTS AVS was successful in 8 of 9 patients. All 8 patients had AVS results indicating bilateral cortisol hypersecretion. Six patients underwent adrenalectomy: 3 had unilateral adrenalectomy of the larger size mass, 2 had bilateral adrenalectomy (both sides >4 cm.) and 1 had stepwise bilateral adrenalectomy. Final pathology revealed macronodular adrenal hyperplasia in all 6 patients that underwent surgery. CONCLUSION AVS was useful in excluding a unilateral adenoma as the source of AICS in this study of patients with bilateral adrenal masses and AICS. However, adrenal mass size influenced surgical decision making more than AVS results. More data are needed before AVS can be advocated as essential for management of patients with bilateral adrenal masses and AICS.
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Affiliation(s)
- Runa Acharya
- Department of Medicine, Division of Endocrinology and Metabolism, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Mashaal Dhir
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Rupal Bandi
- Department of Radiology, Division of Interventional Radiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Linwah Yip
- Department of Surgery, Division of Endocrine Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sue Challinor
- Department of Medicine, Division of Endocrinology and Metabolism, University of Pittsburgh, Pittsburgh, PA, USA.
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Yip L, Barrett TH, Harries MJ. Folliculitis decalvans and lichen planopilaris phenotypic spectrum: a case series of biphasic clinical presentation and theories on pathogenesis. Clin Exp Dermatol 2019; 45:63-72. [DOI: 10.1111/ced.13989] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2019] [Indexed: 12/19/2022]
Affiliation(s)
- L. Yip
- Barton Specialist Centre Barton ACT Australia
| | - T. H. Barrett
- The Skin Hospital 7 Ashley Lane Westmead NSW Australia
| | - M. J. Harries
- The Dermatology Centre University of Manchester Salford Royal NHS Foundation Trust Salford Manchester UK
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Abstract
Cytologically indeterminate thyroid nodules are associated with a broad range (5%-75%) of malignant risk and accurately informing definitive management poses a challenge. Advancements in molecular testing of fine-needle aspiration biopsies have improved preoperative diagnostic accuracy and prognostication. For indeterminate nodules, such testing ideally will reduce the need for surgery for benign nodules and potentially guide appropriate extent of initial surgery for malignancy.
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Affiliation(s)
- Janeil Mitchell
- Fox Valley Surgical Associates, Endocrine Surgery, 1818 North Meade Street, Appleton, WI 54911, USA
| | - Linwah Yip
- Department of Surgery, Division of Endocrine Surgery, University of Pittsburgh School of Medicine, Kaufman Medical Building, 3471 Fifth Avenue, Suite 101, Pittsburgh, PA 15213, USA.
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