Malignancy Analyses of Thyroid Nodules in Patients Subjected to Surgery with Cytological- and Ultrasound-Based Risk Stratification Systems

The fine needle aspiration (FNA) cytology is the gold standard for the preoperative diagnosis of thyroid cancer. However, up to 30% of FNA examinations yield nondiagnostic or indeterminate results and this complicates patient management. Clinical features and ultrasound (US) patterns, including US risk stratification systems, could be useful in the preoperative diagnostic workup and prediction of malignancy, but the evidences are not univocal. Methods: 400 consecutive patients subjected to thyroid surgery were retrospectively enrolled at our institution in Calabria, Southern Italy. Preoperative US and FNA cytological descriptions, formulated according to the “Italian consensus for reporting thyroid fine-needle aspiration cytology” (ICCRTC) classification and three US risk stratification systems (those developed by the American Association of Clinical Endocrinologists, American College of Endocrinology and Associazione Medici Endocrinologi (AACE/ACE/AME), American Thyroid Association (ATA), and American College of Radiology (ACR-TIRADS)), were collected, along with histological results. Results: 147 thyroid cancer cases, in large majority papillary carcinomas, were detected on final histological examination. Almost two-thirds of patients subjected to thyroid surgery for either benign or malignant lesions were female. Patient’s age ≤20 years and between 21–30 years were clinical features associated with increased risk of thyroid cancer in logistic regression analyses. US features associated with thyroid cancer included irregular margins, solid composition, microcalcifications, and marked hypoechogenicity. The AACE/ACE/AME, ATA, and ACR-TIRADS risk categories, corresponding to specific US patterns, were strong predictors of malignancy in both genders, but not in nodules with indeterminate cytology. A measured difference between the longitudinal (L) and the anteroposterior (AP) diameter >5 mm, a proxy for a parallel-oriented oval shape of a nodule, emerged as a robust protective factor against thyroid cancer (OR 0.288 (95%CI 0.817–0.443); p < 0.001), regardless of cytological risk. Conclusions: Some, but not all, well-established predictors of TC have been confirmed in this study. Controversy surrounds the diagnostic performance of US risk stratification systems for the detection of thyroid cancer in the subgroup of nodules with indeterminate cytology, suggesting their use only to set the thresholds for FNA. A measured difference between L and AP diameters >5 mm may represent an additional and practical tool for ruling out malignancy in thyroid nodules, with the potential to reduce unnecessary surgical procedures.

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Risk Stratification of Thyroid Nodules With Atypia of Undetermined Significance/Follicular Lesion of Undetermined Significance (AUS/FLUS) Cytology Using Ultrasonography Patterns Defined by the 2015 ATA Guidelines

Annals of Otology Rhinology & Laryngology ◽

10.1177/0003489417719472 ◽

2017 ◽

Vol 126 (9) ◽

pp. 625-633 ◽

Cited By ~ 16

Author(s):

Ji Hye Lee ◽

Kyunghwa Han ◽

Eun-Kyung Kim ◽

Hee Jung Moon ◽

Jung Hyun Yoon ◽

...

Keyword(s):

Risk Stratification ◽

Fine Needle Aspiration ◽

Clinical Characteristics ◽

Thyroid Nodules ◽

Needle Aspiration ◽

American Thyroid Association ◽

Fine Needle ◽

Malignancy Rate ◽

Undetermined Significance

Purpose: The purpose of this study was to evaluate the predictive value of ultrasonography (US) patterns based on the 2015 American Thyroid Association (ATA) guidelines for malignancy in atypia of undetermined significance or follicular lesion of undetermined significance (AUS/FLUS) nodules. Methods: From January 2014 to August 2015, 133 thyroid nodules that were initially diagnosed as AUS/FLUS on fine needle aspiration (FNA) were included in this study. Each nodule was assigned a category with US patterns defined by the ATA guidelines. Clinical characteristics and US patterns were compared between the benign and malignant nodules, and malignancy rates were calculated according to the ATA guidelines. Results: The malignancy rate in the very low suspicion group was 0.0% in AUS/FLUS nodules. When applying the ATA guidelines, significant differences existed for US patterns between the benign and malignant nodules in the AUS group ( P = .032) but not the FLUS group ( P = .168). Conclusions: Ultrasonography patterns by the 2015 ATA guidelines can provide risk stratification for nodules with AUS cytology but not for ones with FLUS cytology. For nodules with AUS/FLUS cytology with the very low suspicion pattern of the ATA guidelines, follow-up US might be recommended instead of repeat FNA.

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GUIDELINE IMPLEMENTATION ON FINE-NEEDLE ASPIRATION FOR THYROID NODULES: FOCUSING ON MICRONODULES

Endocrine Practice ◽

10.4158/ep-2020-0163 ◽

2020 ◽

Vol 26 (9) ◽

pp. 1017-1025

Author(s):

Si Eun Lee ◽

Eun-Kyung Kim ◽

Hee Jung Moon ◽

Jung Hyun Yoon ◽

Vivian Youngjean Park ◽

...

Keyword(s):

Thyroid Nodule ◽

Fine Needle Aspiration ◽

Thyroid Surgery ◽

Thyroid Nodules ◽

Guideline Implementation ◽

Needle Aspiration ◽

Data System ◽

American Thyroid Association ◽

Fine Needle ◽

Thyroid Imaging

Objective: We investigated patients who were referred to our institution after fine-needle aspiration (FNA) was performed at outside clinics to evaluate how many nodules satisfied the FNA indications of the Korean Thyroid Imaging Reporting and Data System (K-TIRADS) and compare that to the number of thyroid nodules that satisfy the FNA indications of the American College of Radiology (ACR)-TIRADS and American Thyroid Association (ATA) guidelines. Methods: Between January 2018 and December 2018, 2,628 patients were included in our study. The included patients were those referred for thyroid surgery after having a suspicious thyroid nodule. We retrospectively applied the three guidelines to each thyroid nodule and determined whether each nodule satisfied the FNA indications. We compared the proportion of nodules satisfying the FNA indications of each guideline using a generalized linear model and generalized estimating equation. Results: The median size of the 2,628 thyroid nodules was 0.9 cm (range, 0.2 to 9.5 cm). We found that FNA was not indicated for 54.1%, 47.7%, and 19.1% of nodules and 87.3%, 99.0%, and 97.8% among them were micronodules (<1 cm) according to the ACR-TIRADS, ATA guideline, and K-TIRADS, respectively. The proportion of micronodules which satisfied the FNA indications was significantly higher for the K-TIRADS (65.1%) compared to the ACR TIRADS (12.1%) and ATA guideline (12.1%) ( P<.001). Conclusion: Among patients referred for thyroid surgery to our institutions, about 35% of the micronodules underwent FNA despite not being appropriate for indications by the K-TIRADS. Systematic training for physicians as well as modifications to increase the sensitivity of the guideline may be needed to reduce the overdiagnosis of thyroid cancers, especially for micronodules. Abbreviations: ACR = American College of Radiology; ATA = American Thyroid Association; FNA = fine-needle aspiration; K-TIRADS = Korean Thyroid Imaging Reporting and Data System; LN = lymph node; TIRADS = Thyroid Imaging Reporting and Data System; US = ultrasound

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The incidentaloma of the thyroid

Nuklearmedizin ◽

10.1055/s-0038-1625208 ◽

2005 ◽

Vol 44 (05) ◽

pp. 213-224

Author(s):

C. Kobe ◽

M. Schmidt ◽

H. Schicha ◽

M. Dietlein

Keyword(s):

Risk Stratification ◽

Fine Needle Aspiration ◽

Thyroid Nodules ◽

Outcome Measurement ◽

Needle Aspiration ◽

Epidemiological Studies ◽

Fine Needle ◽

Small Cancer ◽

The Family ◽

Wait And See

Summary:The incidentally detected thyroid nodule using sonography is described as incidentaloma; the most nodules have a diameter up to 1.5 cm. Sonography will detect thyroid nodules in more than 20% of the population in Germany. Epidemiological studies investigating the prevalence of malignancy in such incidentalomas are missing. The incidence of differentiated thyroid cancer is about 3 per 100,000 people and year. However, several monocentric studies have shown a prevalence of malignancy of up to 10% of the thyroid nodules in selected patients’ group. The histology did not found microcarcinomas only, but also small cancer with infiltration of the thyroid capsule, lymph node metastasis or multifocal spread. The studies were not designed for outcome measurement after early and incidental detection of small thyroid cancers. Hypoechogenity, ill defined borders, central hypervascularization or microcalcifications were used as combined criteria for risk stratification. The second method for risk stratification is scintigraphy and further tests are warranted for hypofunctioning nodule ≥1 cm. Additionally, the family history, patient’s age <20 years, former radiation of the neck, and measurement of calcitonin should be regarded. Without such a risk stratification selection for fine needle aspiration is impossible. Fine needle aspiration of non-palpable incidentalomas led to non-representative or unequivocal cytological findings in up to 40%. Because better outcome of incidentally detected small thyroid carcinomas is not proved and because sonography, scintigraphy and fine needle aspiration remain imprecise regarding dignity of incidentalomas, fine needle aspiration is not the standard for small, non-palpable thyroid nodules. Conclusion: For management of incidentaloma, sonographically unsuspicious, scintigraphically indifferent (nodules ≥1 cm) and without any risk factors in patients’ history, wait and see is justified when patient is informed about the problem.

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Molecular Diagnostics of Thyroid Tumors

Archives of Pathology & Laboratory Medicine ◽

10.5858/2010-0664-rair.1 ◽

2011 ◽

Vol 135 (5) ◽

pp. 569-577 ◽

Cited By ~ 2

Author(s):

Yuri E. Nikiforov

Keyword(s):

Thyroid Cancer ◽

Molecular Markers ◽

Fine Needle Aspiration ◽

Thyroid Nodules ◽

Needle Aspiration ◽

Genetic Alterations ◽

Braf V600e ◽

Fine Needle ◽

Molecular Alterations ◽

Diagnostic Use

Abstract Context.—Thyroid cancer is the most common type of endocrine malignancy and its incidence is steadily increasing. Papillary carcinoma and follicular carcinoma are the most common types of thyroid cancer and represent those tumor types for which use of molecular markers for diagnosis and prognostication is of high clinical significance. Objective.—To review the most common molecular alterations in thyroid cancer and their diagnostic and prognostic utility. Data Sources.—PubMed (US National Library of Medicine)–available review articles, peer-reviewed original articles, and experience of the author. Conclusions.—The most common molecular alterations in thyroid cancer include BRAF and RAS point mutations and RET/PTC and PAX8/PPARγ rearrangements. These nonoverlapping genetic alterations are found in more than 70% of papillary and follicular thyroid carcinomas. These molecular alterations can be detected in surgically resected samples and fine-needle aspiration samples from thyroid nodules and can be of significant diagnostic use. The diagnostic role of BRAF mutations has been studied most extensively, and recent studies also demonstrated a significant diagnostic utility of RAS, RET/PTC, and PAX8/PPARγ mutations, particularly in thyroid fine-needle aspiration samples with indeterminate cytology. In addition to the diagnostic use, BRAF V600E mutation can also be used for tumor prognostication, as this mutation is associated with higher rate of tumor recurrence and tumor-related mortality. The use of these and other emerging molecular markers is expected to improve significantly the accuracy of cancer diagnosis in thyroid nodules and allow more individualized surgical and postsurgical management of patients with thyroid cancer.

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NO BENEFIT OF DEDICATED THYROID NODULE SCREENING IN PATIENTS WITH ACROMEGALY

Endocrine Practice ◽

10.4158/ep-2019-0254 ◽

2020 ◽

Vol 26 (1) ◽

pp. 16-21 ◽

Cited By ~ 2

Author(s):

Ngan Betty Lai ◽

Dave Garg ◽

Anthony P. Heaney ◽

Marvin Bergsneider ◽

Angela M. Leung

Keyword(s):

United States ◽

Growth Hormone ◽

Thyroid Cancer ◽

Growth Factor ◽

Thyroid Nodule ◽

Fine Needle Aspiration ◽

Thyroid Nodules ◽

Needle Aspiration ◽

Papillary Thyroid ◽

Fine Needle

Objective: Acromegaly results from the excessive production of growth hormone and insulin-like growth factor-1. While there is up to a 2-fold increased prevalence of thyroid nodules in patients with acromegaly, the incidence of thyroid cancer in this population varies from 1.6 to 10.6% in several European studies. The goal of our study was to determine the prevalence of thyroid nodules and thyroid cancer among patients with acromegaly at a large urban academic medical center in the United States (U.S.). Methods: A retrospective chart review was performed of all patients with acromegaly between 2006–2015 within the University of California, Los Angeles health system. Data were collected regarding patient demographics, thyroid ultrasounds, thyroid nodule fine needle aspiration (FNA) biopsy cytology, and thyroid surgical pathology. Results: In this cohort (n = 221, 49.3% women, mean age 53.8 ± 15.2 [SD] years, 55.2% Caucasian), 102 patients (46.2%) underwent a thyroid ultrasound, from which 71 patients (52.1% women, mean age 52.9 ± 15.2 [SD] years, 56.3% Caucasian) were found to have a thyroid nodule. Seventeen patients underwent a thyroid nodule FNA biopsy and the results revealed 12 benign biopsies, 1 follicular neoplasm, 3 suspicious for malignancy, and 1 papillary thyroid cancer (PTC), from which 6 underwent thyroidectomy; PTC was confirmed by surgical pathology for all cases (8.5% of all nodules observed). Conclusion: In this sample, the prevalence of thyroid cancer in patients with acromegaly and coexisting thyroid nodules is similar to that reported in the general U.S. population with thyroid nodules (7 to 15%). These findings suggest that there is no benefit of dedicated thyroid nodule screening in patients newly diagnosed with acromegaly. Abbreviations: AACE = American Association of Clinical Endocrinologists; ATA = American Thyroid Association; DTC = differentiated thyroid cancer; FNA = fine needle aspiration; GH = growth hormone; IGF-1 = insulin-like growth factor-1; PTC = papillary thyroid cancer; U.S. = United States

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Is it possible to eliminate the number of inappropriate thyroid surgeries combining scintigraphy and cytology?

Clinical Medical Reviews and Reports ◽

10.31579/2690-8794/076 ◽

2021 ◽

Vol 3 (5) ◽

pp. 01-03

Author(s):

Smaroula Divani

Keyword(s):

Fine Needle Aspiration ◽

Fine Needle Aspiration Cytology ◽

Thyroid Nodules ◽

Follicular Carcinoma ◽

Accurate Method ◽

Needle Aspiration ◽

Aspiration Cytology ◽

Fine Needle ◽

Needle Aspiration Cytology ◽

Indeterminate Cytology

Objective: Although fine needle aspiration cytology (FNAC) is the most reliable, safe and accurate method for the clinical management of abnormal thyroid nodules, 5%-15% of cases lead to indeterminate diagnoses and surgery is the recommended practice for them as they may be malignant. Nevertheless, the majority of cases with indeterminate cytology are benign, so the risk of unnecessary surgery is significant. In our study we combined FNAC and scintigraphy in order to reduce the number of inappropriate surgeries. Subjects and Methods: From 219 patients with thyroid fine needle aspiration cytology 33(9 males and 24 females) aged 18-73 years, had indeterminate FNAC diagnoses and were referred for scintigraphy. Surgery was performed in all cases. The results of FNAC, scintigraphy and histology were collected and compared. Results: From 33 cases with indeterminate cytology 32 had a benign histological diagnosis and only one was malignant (follicular Ca). That case had a positive scan. All cases with negative thyroid scans (29/33) were benign. False positive scans were 3, whereas one scan was true positive with final diagnosis follicular carcinoma. Conclusion: This study showed that combining the FNAC with the thyroid scintigraphy in cases of thyroid nodules with indeterminate cytology it is possible to reduce the number of inappropriate surgeries from 32 to 3.

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Managing Thyroid Nodules in Qatar During the COVID19 Pandemic

Journal of the Endocrine Society ◽

10.1210/jendso/bvab048.1717 ◽

2021 ◽

Vol 5 (Supplement_1) ◽

pp. A841-A842

Author(s):

Zaina Alamer ◽

Gowri Karuppasamy ◽

Arwa Alsaud ◽

Tania Jaber ◽

Hanan Farghaly ◽

...

Keyword(s):

High Risk ◽

Early Detection ◽

Fine Needle Aspiration ◽

Medical Staff ◽

Thyroid Nodules ◽

Needle Aspiration ◽

Morbidity And Mortality ◽

American Thyroid Association ◽

Fine Needle ◽

Thyroid Fine Needle Aspiration

Abstract Background: The Coronavirus disease 2019 (COVID-19) pandemic impacted health care systems in all countries, including Qatar. Hamad Medical Corporation (HMC); In compliance with recommendations, suspended all non-urgent procedures, including thyroid fine needle aspiration biopsies (FNAB). Thyroid nodules are second most common cause of referral to HMC endocrine clinic. FNABs are gold standard to differentiate benign from malignant nodules.1- 2 Methods: Our approach includes a teleconsultation to obtain patient’s history and risk factors. Reviewing neck ultrasound (US), obtaining a calcitonin level if indicated, considering comorbidities associated with a high risk of COVID-19 morbidity and mortality.3 Results: We developed a pathway triaging thyroid (FNAB) to:1-Urgent: patients at higher risk of aggressive thyroid malignancy. Benefits of early detection and treatment outweigh the risk of COVID-19 exposure.4 FNAB should not be delayed.2-Semi-urgent: patients at low risk for COVID-19 and high suspicion thyroid nodules, but no evidence that early detection improves survival2, FNAB may be delayed up to 12 months.3-Non-urgent: patients with asymptomatic nodules that have low or intermediate suspicion US pattern.2 Also, includes nodules with ATA high suspicion US pattern in pregnant women and patients at high risk for COVID-19. The risks outweigh the benefits. FNAB should be delayed until outbreak is controlled.4 When urgent FNAB is indicated, safety of patients and medical staff needs to be addressed.5 We recommend testing patient for COVID-19 before FNAB, utilizing US guidance with rapid on-site adequacy evaluation in all cases. Cervical lymph node FNAB with TG washout should be done if indicated. The patient should wear a mask. All medical staff involved should wear personal protective equipment (PPE). The operator should wear N95 mask and face shield. The patient should be informed about cytopathology results via telemedicine. Conclusion: Triaging thyroid (FNAB) during the COVID-19 pandemic should be based on nodule characteristics and risk of COVID-19 morbidity and mortality. Our group recommends deferring FNAB for asymptomatic patients.4FNAB should not be delayed in selected patients who benefit from early detection and intervention. Table1: Triage of Thyroid fine needle aspiration biopsies (FNAB). ATA: American thyroid association. US: ultrasound.

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BRAF V600E as an accurate marker to complement fine needle aspiration (FNA) cytology in the guidance of thyroid surgery in the Chinese population: evidence from over 1000 consecutive FNAs with follow-up

Japanese Journal of Clinical Oncology ◽

10.1093/jjco/hyaa209 ◽

2020 ◽

Author(s):

Qunzi Zhao ◽

Yong Wang ◽

Qin Ye ◽

Ping Wang ◽

Jianyu Rao

Keyword(s):

Fine Needle Aspiration ◽

Thyroid Surgery ◽

Chinese Population ◽

Thyroid Nodules ◽

Needle Aspiration ◽

Braf V600e Mutation ◽

Braf V600e ◽

Histopathological Diagnosis ◽

Fine Needle ◽

Specificity And Sensitivity

Abstract Background Currently, several commercial molecular tests have been developed for reclassifying thyroid nodules with indeterminate fine needle aspiration cytology. These tests are quite expensive and not available in China. Previous studies demonstrated a very high prevalence of the BRAF V600E mutation in Asian people. A high incidence may result in a robust sensitivity. We conducted this study to determine the prevalence of BRAF V600E mutation and its ability to reclassify cytologically indeterminate thyroid nodules in the Chinese population. Methods Between January 2016 and October 2018, consecutive patients who underwent a fine needle aspiration procedure and agreed to provide materials for molecular analysis in our hospital were recruited in this study. All were followed up until they had a thyroidectomy and a final pathological diagnosis or until January 2019 (those did not have surgery). Results A total of 1960 patients were included in this study. Until January 2019, 1240 patients underwent surgery. Using histopathological diagnosis as a gold standard, the overall sensitivity and specificity of the BRAF V600E mutational analysis for the discrimination of benign nodules from cancer in thyroid fine needle aspiration samples were 83.3% (81.0–85.3%) and 96.0% (77.7–99.8%), respectively, with an area under the ROC curve of 0.90 (95% CI 0.85–0.95, P < 0.001). Among cases with indeterminate cytology, BRAF-positive cases were showing malignancy in the final pathology, and BRAF-negative cases were showing safer to be followed up. Conclusion The BRAF V600E mutation is highly prevalent in the Chinese population and can accurately complement cytopathology in the guidance of thyroid surgery. Mini-abstract: The BRAF V600E mutation has both high specificity and sensitivity to predict thyroid malignancy in the Chinese population. It can accurately complement cytopathology in the guidance of thyroid surgery.

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