Molecular diagnostics in the evaluation of thyroid nodules: Current use and prospective opportunities

Thyroid cancer is the most common endocrine malignancy with an estimated 43,800 new cases to be diagnosed in 2022 and representing the 7th most common cancer in women. While thyroid nodules are very common, being identified in over 60% of randomly selected adults, only 5-15% of thyroid nodules harbor thyroid malignancy. Therefore, it is incumbent upon physicians to detect and treat thyroid malignancies as is clinically appropriate and avoid unnecessary invasive procedures in patients with benign asymptomatic lesions. Over the last 15-20 years, rapid advances have been made in cytomolecular testing to aid in thyroid nodule management. Initially, indeterminate thyroid nodules, those with Bethesda III or IV cytology and approximately a 10-40% risk of malignancy, were studied to assess benignity or malignancy. More recently, next generation sequencing and micro-RNA technology platforms have refined the diagnostic capacity of thyroid nodule molecular testing and have introduced opportunities to glean prognostic information from both cytologically indeterminate and malignant thyroid nodules. Therefore, clinicians can move beyond determination of malignancy, and utilize contemporary molecular information to aid in decisions such as extent of surgery and post-therapy monitoring plans. Future opportunities include molecularly derived information about tumor behavior, neo-adjuvant treatment opportunities and response to thyroid cancer therapies.

Penetrating colon trauma-the effect of concomitant small bowel injury on outcome

INTRODUCTION

There is limited evidence to suggest that patients with penetrating colon injury have higher complication rates when there is concomitant small bowel (SB) injury.

AIM

We performed a retrospective study looking at outcomes of penetrating colonic trauma in patients with- and without concomitant SB injury.

METHODS

We interrogated our electronic registry over an eight-year period (2012-2020) for all patients over 18 years who had sustained penetrating colon injury and who had survived beyond 72 h. Demographic data, admission physiology, and Injury Severity Score (ISS) were recorded. Two groups of patients were observed: those with colonic injury (no SB injury) and those with combined colon and SB injury. Outcomes observed included leak rates, length of Intensive Care Unit (ICU) stay, length of hospital stay (LOS), morbidity and mortality.

RESULTS

A total of 450 patients were eligible for analysis, of which 257 had colon injury without SB injury and 193 had a combination of colon and SB injury. There was no difference in mechanism of injury between groups. Admission physiology was similar between groups but arterial blood gas values were worse in the combined group. Rates of damage control surgery and ICU admission were higher in the combined group. Primary repair was done in equal proportions between groups but anastomosis was more frequently performed in the combined group. There was no difference in complication rates, including gastro-intestinal complications and suture line leaks. Length of ICU stay, LOS, and mortality were similar between groups. Univariable analysis demonstrated that the presence of concomitant small bowel injury was not an independent risk factor for colonic suture line failure or death.

CONCLUSION

There is no evidence from this data that the presence of a combined penetrating colon and SB injury should change management priorities. Each injury should be treated on its own merit, in the context of the patient's physiology.

An audit of the outcomes of the College of Surgeons general surgery final examinations

BACKGROUND

An audit of the Fellowship of the College of Surgeons (FCS) of South Africa examination results has not been previously performed. The purpose of this study was to review and determine any predictors of outcome (pass or fail).

METHODS

The results of the FCS(SA) final examinations from October 2005 to and including October 2014, were retrieved from the College of Medicine of South Africa database. The current format of the examinations consists of two written essay question papers, an objectively structured clinical examination (OSCE), two clinical cases and two oral examinations. These were retrospectively reviewed and analysed. Predictors of failure or success were determined.

RESULTS

During the 10-year study period, 472 candidates attempted the examinations. A total of 388 (82%) candidates were successful in the written component of the examination and were subsequently invited to participate in the clinical component of the examinations. Overall, 296 (63%) candidates passed and 176 (37%) failed. There were 51 candidates who were invited to the oral examinations despite an average of less than 50% in the two papers, and 34 (67%) failed the overall examination. Similarly, 126 candidates were invited having failed one of the two papers of which 81 (64%) ultimately failed. A total of 49 candidates failed the OSCE, 82% of these candidates failed overall. There were strong correlations between the averages of the papers versus the orals (Spearman ρ = 0.51), the papers versus the cases (Spearman ρ = 0.50), and the papers versus the OSCE (Spearman ρ = 0.55).

CONCLUSION

The written papers are the main determinant of invitation to the second part of the examination. Candidates with marginal scores in the written component had an overall failure rate of 67%. Failing one paper and passing the other, resulted in an overall failure rate of 64%. Failing the OSCE resulted in an overall 82% failure rate. With the high failure rate of candidates with marginal scores and with the inter-examination variability of the papers, it might be prudent to revisit both the process of invitation selection and the decision to continue with the long-form of the written component.

Surgical resources in South Africa: an analysis of the inequalities between the public and private sector

BACKGROUND

The full extent of the global burden of surgical disease is largely unknown, however, the scope of the problem is thought to be large. Despite the substantial burden of surgical disease, surgical services are inaccessible to many of those who need them most. There are disparities between public and private sectors in South Africa, which compound inequitable access to surgical care. This study forms part of a series analysing surgical resources in South Africa.

METHOD

This study involved a descriptive analysis of surgical resources and included the total number of hospitals, of hospital beds, the number of surgical beds, the number of general surgeons (specialist and non-specialist), and the number of functional operating theatres in South Africa. A comparison was performed between the public and private sectors. Hospitals were contacted during the period from 1 October 2014 until 31 December 2014.

RESULTS

Surgical resources were concentrated in metropolitan areas of urban provinces. There were striking differences between the public and private sectors, where private resources were comparable to those available in high income countries (HICs).

CONCLUSION

Improving access to surgical services in lower middle income countries (LMICs) requires addressing gaps between the public and private sector regarding infrastructure, personnel, as well as equipment. These data identified disparities between geographic regions which may be contributing to ongoing inequity in South Africa, and by doing so allows for evidence-based planning towards improving surgical infrastructure and workforce.

Improving the adoption of thyroid cancer clinical practice guidelines

OBJECTIVES/HYPOTHESIS

To present an overview of the barriers to the implementation of clinical practice guidelines (CPGs) in thyroid cancer management and to introduce a computer-based clinical support system.

DATA SOURCES

PubMed.

REVIEW METHODS

A review of studies on adherence to CPGs was conducted.

RESULTS

Awareness and adoption of CPGs is low in thyroid cancer management. Barriers to implementation include unfamiliarity with the CPGs and financial concerns. Effective interventions to improve adherence are possible, especially when they are readily accessible at the point of care delivery. Computerized clinical support systems show particular promise. The authors introduce the clinical decision making modules (CDMMs) of the Thyroid Cancer Care Collaborative, a thyroid cancer-specific electronic health record. These computer-based modules can assist clinicians with implementation of these recommendations in clinical practice.

CONCLUSION

Computer-based support systems can help clinicians understand and adopt the thyroid cancer CPGs. By integrating patient characteristics and guidelines at the point of care delivery, the CDMMs can improve adherence to the guidelines and help clinicians provide high-quality, evidence-based, and individualized patient care in the management of differentiated thyroid cancer. Laryngoscope, 126:2640-2645, 2016.

Ultrasound-based clinical prediction rule model for detecting papillary thyroid cancer in cervical lymph nodes: A pilot study

PURPOSE

To identify sonographic features of cervical lymph nodes (LNs) that are associated with papillary thyroid cancer (PTC) and to develop a prediction model for classifying nodes as metastatic or benign.

METHODS

This retrospective study included the records of postthyroidectomy patients with PTC who had undergone cervical ultrasound and LN biopsy. LN location, size, shape, hilum, echopattern, Doppler flow, and microcalcifications were assessed. Model selection was used to identify features associated with malignant LNs and to build a predictive, binary-outcome, generalized linear mixed model. A cross-validated receiver operating characteristic analysis was conducted to assess the accuracy of the model for classifying metastatic nodes.

RESULTS

We analyzed records from 71 LNs (23 metastatic) in 44 patients (16 with PTC). The predictive model included a nonhomogeneous echopattern (odds ratio [OR], 5.73; 95% confidence interval [CI], 1.07-30.74; p = 0.04), microcalcifications (OR, 4.91; 95% CI, 0.91-26.54; p = 0.06), and volume (OR, 2.57; 95% CI, 0.66-9.99; p = 0.16) as predictors. The model had an area under the curve of 0.74 (95% CI, 0.60-0.85), sensitivity of 65% (95% CI, 50% to 78%), and specificity of 85% (95% CI, 73% to 94%) at the Youden optimal cut point of 0.38.

CONCLUSIONS

Nonhomogeneous echopattern, microcalcifications, and node volume were predictive of malignant LNs in patients with PTC. A larger sample is needed to validate this model.

ACTIVE SURVEILLANCE FOR PAPILLARY THYROID MICROCARCINOMA: NEW CHALLENGES AND OPPORTUNITIES FOR THE HEALTH CARE SYSTEM

OBJECTIVE

The dramatic increase in papillary thyroid carcinoma (PTC) is primarily a result of early diagnosis of small cancers. Active surveillance is a promising management strategy for papillary thyroid microcarcinomas (PTMCs). However, as this management strategy gains traction in the U.S., it is imperative that patients and clinicians be properly educated, patients be followed for life, and appropriate tools be identified to implement the strategy.

METHODS

We review previous active surveillance studies and the parameters used to identify patients who are good candidates for active surveillance. We also review some of the challenges to implementing active surveillance protocols in the U.S. and discuss how these might be addressed.

RESULTS

Trials of active surveillance support nonsurgical management as a viable and safe management strategy. However, numerous challenges exist, including the need for adherence to protocols, education of patients and physicians, and awareness of the impact of this strategy on patient psychology and quality of life. The Thyroid Cancer Care Collaborative (TCCC) is a portable record keeping system that can manage a mobile patient population undergoing active surveillance.

CONCLUSION

With proper patient selection, organization, and patient support, active surveillance has the potential to be a long-term management strategy for select patients with PTMC. In order to address the challenges and opportunities for this approach to be successfully implemented in the U.S., it will be necessary to consider psychological and quality of life, cultural differences, and the patient's clinical status.

Database and registry research in thyroid cancer: striving for a new and improved national thyroid cancer database

BACKGROUND

Health registries have become extremely powerful tools for cancer research. Unfortunately, certain details and the ability to adapt to new information are necessarily limited in current registries, and they cannot address many controversial issues in cancer management. This is of particular concern in differentiated thyroid cancer, which is rapidly increasing in incidence and has many unknowns related to optimal treatment and surveillance recommendations.

SUMMARY

In this study, we review different types of health registries used in cancer research in the United States, with a focus on their advantages and disadvantages as related to the study of thyroid cancer. This analysis includes population-based cancer registries, health systems-based cancer registries, and patient-based disease registries. It is important that clinicians understand the way data are collected in, as well as the composition of, these different registries in order to more critically interpret the clinical research that is conducted using that data. In an attempt to address shortcoming of current databases for thyroid cancer, we present the potential of an innovative web-based disease management tool for thyroid cancer called the Thyroid Cancer Care Collaborative (TCCC) to become a patient-based registry that can be used to evaluate and improve the quality of care delivered to patients with thyroid cancer as well as to answer questions that we have not been able to address with current databases and registries.

CONCLUSION

A cancer registry that follows a specific patient, is integrated into physician workflow, and collects data across different treatment sites and different payers does not exist in the current fragmented system of healthcare in the United States. The TCCC offers physicians who treat thyroid cancer numerous time-saving and quality improvement services, and could significantly improve patient care. With rapid adoption across the nation, the TCCC could become a new paradigm for database research in thyroid cancer to improve our understanding of thyroid cancer management.

What is the gold standard for comprehensive interinstitutional communication of perioperative information for thyroid cancer patients? A comparison of existing electronic health records with the current American Thyroid Association recommendations

BACKGROUND

Appropriate management of well-differentiated thyroid cancer requires treating clinicians to have access to critical elements of the patient's presentation, surgical management, postoperative course, and pathologic assessment. Electronic health records (EHRs) provide an effective method for the storage and transmission of patient information, although most commercially available EHRs are not intended to be disease-specific. In addition, there are significant challenges for the sharing of relevant clinical information when providers involved in the care of a patient with thyroid cancer are not connected by a common EHR. In 2012, the American Thyroid Association (ATA) defined the critical elements for optimal interclinician communication in a position paper entitled, "The Essential Elements of Interdisciplinary Communication of Perioperative Information for Patients Undergoing Thyroid Cancer Surgery."

SUMMARY

We present a field-by-field comparison of the ATA's essential elements as applied to three contemporary electronic reporting systems: the Thyroid Surgery e-Form from Memorial Sloan-Kettering Cancer Center (MSKCC), the Alberta WebSMR from the University of Calgary, and the Thyroid Cancer Care Collaborative (TCCC). The MSKCC e-form fulfills 21 of 32 intraoperative fields and includes an additional 14 fields not specifically mentioned in the ATA's report. The Alberta WebSMR fulfills 45 of 82 preoperative and intraoperative fields outlined by the ATA and includes 13 additional fields. The TCCC fulfills 117 of 120 fields outlined by the ATA and includes 23 additional fields.

CONCLUSIONS

Effective management of thyroid cancer is a highly collaborative, multidisciplinary effort. The patient information that factors into clinical decisions about thyroid cancer is complex. For these reasons, EHRs are particularly favorable for the management of patients with thyroid cancer. The MSKCC Thyroid Surgery e-Form, the Alberta WebSMR, and the TCCC each meet all of the general recommendations for effective reporting of the specific domains that they cover in the management of thyroid cancer, as recommended by the ATA. However, the TCCC format is the most comprehensive. The TCCC is a new Web-based disease-specific database to enhance communication of patient information between clinicians in a Health Insurance Portability and Accountability Act (HIPAA)-compliant manner. We believe the easy-to-use TCCC format will enhance clinician communication while providing portability of thyroid cancer information for patients.

Improving the quality of thyroid cancer care: how does the Thyroid Cancer Care Collaborative cross the Institute of Medicine's Quality Chasm?

BACKGROUND

The current systems of healthcare delivery in the United States suffer from problems that often leave patients with inadequate quality of care. In their report entitled "Crossing the Quality Chasm," the Institute of Medicine (IOM) identified reasons for poor and/or inconsistent quality of healthcare delivery and provided recommendations to improve it. The purpose of this review is to describe features of an innovative web-based program called the Thyroid Cancer Care Collaborative (TCCC) and see how it addresses IOM recommendations to improve the quality of healthcare delivery.

SUMMARY

The TCCC addresses the three actionable IOM recommendations directed at healthcare organizations and clinicians to redesign the care process. It does so by exploiting information technology (IT) in ways suggested by the IOM, and it fits within a set of 10 rules provided by the IOM. Some features of the TCCC include: (i) automated disease staging based on three validated scoring systems; (ii) highly illustrated educational videos on all aspects of thyroid cancer care; (iii) personalized clinical decision-making modules for clinicians and physicians; (iv) portability of data to share among treating physicians; (v) virtual tumor boards, "ask the expert," and frequently asked questions modules; (vi) physician workflow integration; and (vii) data for comprehensive analysis to answer difficult questions in thyroid cancer management.

CONCLUSION

The TCCC has the potential to improve thyroid cancer care delivery and offers several benefits to patients, clinicians, and researchers. The TCCC is a valuable example of how IOM initiatives can improve the healthcare system.

Multicenter clinical experience with the Afirma gene expression classifier

BACKGROUND

Increasingly, patients with thyroid nodule cytology labeled atypical (or follicular lesion) of undetermined significance (AUS/FLUS) or follicular neoplasm (FN) undergo diagnostic analysis with the Afirma gene expression classifier (GEC). No long-term, multisite analysis of Afirma GEC performance has yet been performed.

METHODS

We analyzed all patients who had received Afirma GEC testing at five academic medical centers between 2010 and 2013. Nodule and patient characteristics, fine needle aspiration cytology, Afirma GEC results, and subsequent clinical or surgical follow-up were obtained for 339 patients. Results were analyzed for pooled test performance, impact on clinical care, and site-to-site variation.

RESULTS

Three hundred thirty-nine patients underwent Afirma GEC testing of cytologically indeterminate nodules (165 AUS/FLUS; 161 FN; 13 suspicious for malignancy) and 174 of 339 (51%) indeterminate nodules were GEC benign, whereas 148 GEC were suspicious (44%). GEC results significantly altered care recommendations, as 4 of 175 GEC benign were recommended for surgery in comparison to 141 of 149 GEC suspicious (P<.01). Of 121 Cyto Indeterminate/GEC Suspicious nodules surgically removed, 53 (44%) were malignant. Variability in site-to-site GEC performance was confirmed, as the proportion of GEC benign varied up to 29% (P=.58), whereas the malignancy rate in nodules cytologically indeterminate/GEC suspicious varied up to 47% (P=.11). Seventy-one of 174 GEC benign nodules had documented clinical follow-up for an average of 8.5 months, in which 1 of 71 nodules proved cancerous.

CONCLUSIONS

These multicenter, clinical experience data confirm originally published Afirma GEC test performance and demonstrate its substantial impact on clinical care recommendations. Although nonsignificant site-to-site variation exists, such differences should be anticipated by the practicing clinician. Follow-up of GEC benign nodules thus far confirm the clinical utility of this diagnostic test.

The excretion of radiopharmaceuticals in human breast milk: additional data and dosimetry

The amount of radioactivity excreted in breast milk following administration of 11 different radiopharmaceuticals, including technetium-99m labelled microspheres, pyrophosphate, diisopropyl-iminodiacetic acid (DISIDA) and sestamibi, has been measured. This report summarises the data collected from 60 patients. An effective decay constant for the series of samples from each patient was calculated from exponential curves fitted by least squares to the data. It is difficult to compare values from individual patients, since times of expression, volumes of milk and the activity administered are not uniform. In order to formulate reliable guidelines, we therefore calculated the total activity theoretically excreted in milk until complete decay of the radionuclide, which is usually higher than that actually measured over the actual period of collection. Of the various 99mTc compounds, pertechnetate clearly reaches the highest concentrations in breast milk. The wide variability of data from different patients who received the same radiopharmaceutical despite identical methods of sample collection and data processing confirms the impression gained from literature that transfer of radionuclides into milk varies greatly between individuals. Although we have calculated average values for each compound, very large standard deviations were obtained, and we believe that for radiation protection purposes, a "worst case" approach is the most appropriate. With new data available and the revision of ICRP recommendations, the guidelines applicable when radiopharmaceuticals are administered to breast-feeding mothers are reviewed. The effective dose resulting from close contact between patient and infant was included in these calculations. Breast feeding need not be interrupted after administration of 99mTc-DISIDA, -sulphur colloid, -gluconate and -methoxyisobutylisonitrile (MIBI). However, after administration of 99mTc-MIBI, close contact should be restricted. 99mTc-pyrophosphate and -microspheres require interruption periods of several hours. High activities of 99mTc-pertechnetate may require interruption longer than 2 days. For pertechnetate and 99mTc-labelled red blood cells, interruption of breast feeding with measurement of activity in expressed milk samples is recommended. Breast feeding is contra-indicated after administration of 67Ga and 131I. General guidelines regarding breast feeding after administration of radiopharmaceuticals are summarised.

Excretion of gallium 67 in human breast milk and its inadvertent ingestion by a 9-month-old child

The concentration of radioactivity excreted in breast milk following the administration of gallium 67 to 3 patients was measured in milk samples obtained for several days after injection. Similar values were obtained from all 3 patients, with milk samples obtained approximately 120 h after administration containing 4.3-5.7 Bq/ml per MBq of 67Ga administered. These values are lower than those previously reported. The image of a child who had inadvertently been breast-fed for 48 h after administration of 67Ga to the mother showed activity in the intestines only. Our results seem to confirm recommendations by other authors that gallium scintigraphy should be avoided in nursing mothers. Should the administration of 67Ga be inevitable, breastfeeding should be discontinued, since interruption periods of approximately 2 weeks may be required to reduce the effective dose equivalent to the infant below 1 mSv. However, close contact between mother and child need not be avoided.

Excretion of technetium 99m hexakismethoxyisobutylisonitrile in milk

The amount of radioactivity excreted in breast milk following the administration of technetium 99m hexakismethoxyisobutylisonitrile (99mTc-MIBI) to a patient referred for cold spot myocardial scintigraphy was determined. During the first 24 h after administration, only 41.2 kBq 99mTc (0.0084% of the injected dose) was excreted in 448 ml milk with the highest concentration of 0.49 kBq/ml in the first sample. The images obtained show a high concentration of 99mTc-MIBI in the lactating breasts contrary to the very small percentage excreted in the milk. Comparison with various recommendations regarding nursing after administration of radiopharmaceuticals seems to indicate that the administration of 99mTc-MIBI does not necessitate an interruption of breast-feeding.

Excretion of radioiodine in human milk following a therapeutic dose of I-131

An investigation of 131I excretion into human milk after a therapeutic dose of 5142 MBq (139 mCi) 131I, in a patient who has had a thyroidectomy is presented. During the first 36 h, 17.4% of the administered dose was excreted into the milk. In addition to the known radiation risk, this may affect the quantity of 131I retained by the thyroid and metastases.