SFE-AFCE-SFMN 2022 consensus on the management of thyroid nodules: Synthesis and algorithms

Summary and update on the management of differentiated thyroid cancer in 2023

The 6-fold increase in the incidence of differentiated thyroid cancer over the past 30 years in industrialized countries can be mainly attributed to improved detection. At the same time, in addition to the excellent prognosis for low-risk cancers, improved survival in metastatic forms has been also reported, likely due to the progress made recently in the treatment of aggressive forms, for which there is now an extensive therapeutic arsenal. Today, clinical management of differentiated thyroid cancer represents a paradigm of precision oncology, with personalized, risk-adapted therapeutic strategies. This has led to therapeutic de-escalation in those forms with a good prognosis, while targeted treatments play an increasingly important role in the management of radioiodine-refractory or advanced cancers. While endocrinologists will not always have the opportunity to prescribe these treatments, they will be called on to support and monitor patients during treatment. The aim of this article is to provide an overview of treatment options for differentiated thyroid cancer in 2023.

[Bethesda 2023: A new terminology for thyroid cytopathology]

A third update of The Bethesda System for Reporting Thyroid Cytopathology has been published in 2023 following the first (2010) and second (2017) versions. The main modifications are the following 1) a new co-Editor, 2) 4 associate editors, 3 of them from Europe, 3) the inclusion of 65 co-authors, 19 of them from Europe, 4) 2 new chapters: one dealing with pediatrics thyroid cytopathology and the other one describing molecular cytopathology profiling, 5) updated risks of malignancy (ROM), 6) a terminology in line with the 2022 WHO classification of thyroid tumors, 7) diagnostic categories now defined by a unique name, 8) 2 subtypes in the "Atypia of Undetermined Significance" category with corresponding ROM.

[SFE-AFCE-SFMN 2022 consensus on the management of thyroid nodules: Interest and place of thyroid cytology]

The SFE-AFCE-SFMN 2022 consensus deals with the management of thyroid nodules, a symptom that is a frequent reason for consultation in endocrinology. Thyroid nodules are very common and mostly benign. Thyroid ultrasound and thyroid fine-needle aspiration biopsy (FNAB) are the reference tests for the analysis of these nodules. The aim of this article is to describe for the cytopathologist the key points of the SFE-AFCE-SFMN 2022 consensus involving thyroid cytology: the indications for thyroid FNAB, the technique and analysis, and the management (treatment, follow-up) following this cytological screening examination, a key element in the management of the thyroid nodule.

Differentiating pathologic parathyroid glands from thyroid nodules on neck ultrasound: the PARATH-US cross-sectional study

Background

Neck ultrasound (US) is a widely used and accessible operator-dependent technique that helps characterize thyroid nodules and pathologic parathyroid glands (PPGs). However, thyroid nodules may sometimes be confused with PPGs. PARATH-US study aims at identifying US characteristics to differentiate PPGs from thyroid nodules, as there is no study, at present, which directly compares the US features of these two common neoplasms.

Methods

PARATH-US is a single-center study that was conducted at a tertiary referral center, including consecutive lesions from patients undergoing neck US examination from 2016 to 2022.

Findings

176 PPGs (158 patients: serum calcium levels 2.91 [IQR 2.74-3.05] mmol/L, PTH levels 173 [112-296] ng/L) were compared to 232 size- and volume-matched thyroid nodules (204 age- and sex-matched patients). The morphologic patterns, echoic content and vascular status were all different between PPGs and thyroid neoplasms (p < 0.01 for all comparisons). The combined parameters maximally discriminated PPGs from thyroid nodules (OR, 7.6; 95% CI: 3.4, 17.1, p < 0.0001). When applying risk stratification systems developed for thyroid malignancies, 58-63% of PPGs were classified as high-risk lesions. Parathyroid adenomas had larger sizes and volumes than hyperplasias (p = 0.013 and p = 0.029). Serum calcium and PTH levels were significantly correlated with PPG size and volume (p < 0.0001 for all comparisons).

Interpretation

We demonstrate the presence of distinct US characteristics in PPGs, which help differentiate them from thyroid nodules. When mistaken for thyroid nodules, PPGs bear high-risk US features. When dealing with high-risk cervical lesions detected on US, a PPG should be suspected, and an assessment of calcium levels recommended to avoid unnecessary invasive procedures.

Funding

CYTO-TRAIN, C2022DOSRH053, funded by the French Regional Health Agency.

Cytology and Histology of Thyroid Nodules: Exploring Novel Insights in the Molecular Era for Enhanced Patient Management

Significant advancements have been made over the past decade in our understanding of thyroid cancers, encompassing histomorphology, cytology, and ancillary techniques, particularly molecular tests. As a result, it is now feasible to put forth a comprehensive histo/cytomolecular approach to treating these tumors, thereby offering patients treatments that are precisely tailored to their unique circumstances.