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Harahap AS, Subekti I, Panigoro SS, Asmarinah, Lisnawati, Werdhani RA, Agustina H, Khoirunnisa D, Mutmainnah M, Salinah, Siswoyo AD, Ham MF. Profile of BRAFV600E, BRAFK601E, NRAS, HRAS, and KRAS Mutational Status, and Clinicopathological Characteristics of Papillary Thyroid Carcinoma in Indonesian National Referral Hospital. Appl Clin Genet 2023; 16:99-110. [PMID: 37255533 PMCID: PMC10226481 DOI: 10.2147/tacg.s412364] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 05/19/2023] [Indexed: 10/29/2023] Open
Abstract
INTRODUCTION BRAFV600E and RAS mutations are the most common gene mutations in papillary thyroid carcinoma (PTC) that may be correlated with its biological behavior. There are still limited data about BRAFV600E and RAS mutations in Indonesia. This study aims to determine the prevalence of BRAFV600E and RAS mutations, and their association with clinicopathologic characteristics. METHODS Patients who had total thyroidectomy from 2019 to 2021 and those who met our study criteria underwent PCR and DNA sequencing analysis for BRAFV600E, BRAFK601E, exon 2 and 3 of NRAS, HRAS, and KRAS. Analyses were performed to determine the associations of BRAFV600E and RAS mutations with clinicopathologic characteristics. RESULTS Of 172 PTC patients, BRAFV600E mutation was observed in 37.8% of the patients and RAS mutations were found in 21.5%. One patient harbored BRAFK601E mutation. There was a significant association of BRAFV600E with a high-stage (p = 0.033, OR: 3.279; 95% CI: 1.048-10.259), tall-cell variants (p ≤0.001, OR: 41.143; 95% CI: 11.979-141.308), non-encapsulated (p = 0.001, OR: 4.176; 95% CI: 2.008-8.685), lymphovascular invasion (p = 0.043, OR: 1.912; 95% CI: 1.018-3.592), extrathyroidal extension (p = <0.001, OR: 3.983; 95% CI: 1.970-8.054), and lymph node metastasis (p = 0.009, OR: 2.301; 95% CI: 1.224-4.326). Follicular variant (p = 0.001, OR: 7.011; 95% CI: 2.690-18.268), encapsulated (p = 0.017, OR: 2.433; 95% CI: 1.161-5.100), and absent of extrathyroidal extension (p = 0.033, OR: 2.890; 95% CI: 1.052-7.940) were associated with RAS mutations. CONCLUSION A significant association between BRAFV600E mutation and high clinical stage, tall-cell variants, non-encapsulated morphology, lymphovascular invasion, extrathyroidal extension, and lymph node metastasis in PTC was observed. RAS mutations were associated with the follicular variant, encapsulated tumor, and no extrathyroidal extension. HRAS-mutated PTC frequently exhibited tumor multifocality.
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Affiliation(s)
- Agnes Stephanie Harahap
- Department of Anatomical Pathology, Faculty of Medicine Universitas Indonesia/Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia
- Human Cancer Research Center-Indonesian Medical Education and Research Institute, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
- Doctoral Program in Medical Sciences, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | - Imam Subekti
- Department of Internal Medicine, Faculty of Medicine Universitas Indonesia/Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Sonar Soni Panigoro
- Department of Surgery, Faculty of Medicine Universitas Indonesia/Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Asmarinah
- Department of Medical Biology, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | - Lisnawati
- Department of Anatomical Pathology, Faculty of Medicine Universitas Indonesia/Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Retno Asti Werdhani
- Department of Community Medicine, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | - Hasrayati Agustina
- Department of Anatomical Pathology, Faculty of Medicine Universitas Padjadjaran/Hasan Sadikin General Hospital, Bandung, Indonesia
| | - Dina Khoirunnisa
- Department of Anatomical Pathology, Faculty of Medicine Universitas Indonesia/Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Mutiah Mutmainnah
- Department of Anatomical Pathology, Faculty of Medicine Universitas Indonesia/Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Salinah
- Department of Anatomical Pathology, Faculty of Medicine Universitas Indonesia/Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Alvita Dewi Siswoyo
- Department of Radiology, Faculty of Medicine Universitas Indonesia/Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Maria Francisca Ham
- Department of Anatomical Pathology, Faculty of Medicine Universitas Indonesia/Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia
- Human Cancer Research Center-Indonesian Medical Education and Research Institute, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
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Halada S, Baran JA, Bauer AJ, Ricarte-Filho JC, Isaza A, Patel T, Franco AT, Mostoufi-Moab S, Adzick NS, Kazahaya K, Bhatti TR, Baloch Z, Surrey LF. Clinicopathologic Characteristics of Pediatric Follicular Variant of Papillary Thyroid Carcinoma Subtypes: A Retrospective Cohort Study. Thyroid 2022; 32:1353-1361. [PMID: 36103376 PMCID: PMC9700371 DOI: 10.1089/thy.2022.0239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Introduction: Follicular patterned thyroid nodules with nuclear features of papillary thyroid carcinoma (PTC) encompass a range of diagnostic categories with varying risks of metastatic behavior. Subtypes include the invasive encapsulated follicular variant of PTC (Ienc-fvPTC) and infiltrative fvPTC (inf-fvPTC), with tumors lacking invasive features classified as noninvasive follicular thyroid neoplasms with papillary-like features (NIFTPs). This study aimed to report the clinical and histological features of pediatric cases meeting criteria for these histological subtypes, with specific focus on Ienc-fvPTC and inf-fvPTC. Methods: In this retrospective cohort study, pediatric patients with thyroid neoplasms showing follicular patterned growth and nuclear features of PTC noted on surgical pathology between January 2010 and January 2021 were retrospectively reviewed and classified according to the recent 2022 World Health Organization (WHO) criteria. Clinical and histopathologic parameters were described for NIFTP, Ienc-fvPTC, and inf-fvPTC subtypes, with specific comparison of Ienc-fvPTC and inf-fvPTC cases. Results: The case cohort included 42 pediatric patients, with 6 (14%), 25 (60%), and 11 (26%) patients meeting criteria for NIFTP, Ienc-fvPTC, and inf-fvPTC, respectively. All cases were rereviewed, and 5 patients originally diagnosed with Ienc-fvPTC before 2017 were reappraised as having NIFTPs. The NIFTP cases were encapsulated tumors without invasive features, lymph node or distant metastasis, or disease recurrence. Ienc-fvPTC tumors demonstrated clearly demarcated tumor capsules and capsular/vascular invasion, while inf-fvPTC tumors displayed infiltrative growth lacking a capsule. inf-fvPTC cases had increased prevalence of malignant preoperative cytology, lymph node metastasis, and distant metastasis (p < 0.01). These cases were treated with total thyroidectomy, lymph node dissection, and subsequent radioactive iodine therapy. Preliminary genetic findings suggest a predominance of fusions in inf-fvPTC cases versus point mutations in Ienc-fvPTC (p = 0.02). Conclusions: Pediatric NIFTP and fvPTC subtypes appear to demonstrate alignment between clinical and histological risk stratification, with indolent behavior in Ienc-fvPTC and invasive features in inf-fvPTC tumors.
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Affiliation(s)
- Stephen Halada
- Division of Endocrinology and Diabetes, The Thyroid Center, Philadelphia, Pennsylvania, USA
| | - Julia A. Baran
- Division of Endocrinology and Diabetes, The Thyroid Center, Philadelphia, Pennsylvania, USA
| | - Andrew J. Bauer
- Division of Endocrinology and Diabetes, The Thyroid Center, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Julio C. Ricarte-Filho
- Division of Endocrinology and Diabetes, The Thyroid Center, Philadelphia, Pennsylvania, USA
| | - Amber Isaza
- Division of Endocrinology and Diabetes, The Thyroid Center, Philadelphia, Pennsylvania, USA
| | - Tasleema Patel
- Division of Endocrinology and Diabetes, The Thyroid Center, Philadelphia, Pennsylvania, USA
| | - Aime T. Franco
- Division of Endocrinology and Diabetes, The Thyroid Center, Philadelphia, Pennsylvania, USA
| | - Sogol Mostoufi-Moab
- Division of Endocrinology and Diabetes, The Thyroid Center, Philadelphia, Pennsylvania, USA
- Division of Pediatric Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - N. Scott Adzick
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Ken Kazahaya
- Department of Otorhinolaryngology: Head and Neck Surgery, Children's Hospital of Philadelphia; University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Pediatric Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Tricia R. Bhatti
- Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Zubair Baloch
- Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lea F. Surrey
- Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Al-Maghrabi H, Tashkandi M, Khayyat W, Alghamdi A, Alsalmi M, Alzahrani A, Al-Hakami H, Alqarni M. Non-invasive Follicular Thyroid Neoplasm with Papillary-Like Nuclear Features (NIFTP) lowers the risk of malignancy in the bethesda system for reporting thyroid cytopathology diagnostic categories. SAUDI JOURNAL OF MEDICINE AND MEDICAL SCIENCES 2022; 10:105-110. [PMID: 35602399 PMCID: PMC9121695 DOI: 10.4103/sjmms.sjmms_202_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 12/25/2021] [Accepted: 03/17/2022] [Indexed: 11/25/2022] Open
Abstract
Background: The introduction of non-invasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) has been shown to decrease the risk of malignancy (ROM) in The Bethesda System for Reporting Thyroid Cytopathology. This knowledge may alter the management of patients with thyroid nodules. Objectives: To correlate cytological diagnosis with histological diagnosis for establishing the ROM of all Bethesda system categories after the introduction of NIFTP. Methods: This was a retrospective cohort study. All consecutive fine-needle aspiration cytology (FNAC) specimens collected from January 1, 2013, to December 31, 2017, at King Abdullah Medical City, Jeddah, Saudi Arabia, were assessed, and patients who underwent surgical excision of thyroid nodules were further analyzed. The ROM and overall ROM for each Bethesda category were calculated with and without considering NIFTP as a malignant tumor. Results: Overall, 1066 FNAC specimens were collected, of which 281 had a surgical correlation. Our cases included 18 (6.4%) non-diagnostic (ND), 109 (38.8%) benign, 28 (9.9%) atypia/follicular lesion of undetermined significance (AUS/FLUS), 39 (13.8%) follicular neoplasm or suspicion for follicular neoplasm (FN/SFN), 20 (7.1%) suspicion for malignancy (SM), and 67 (23.8%) malignant (POM) cases. After considering NIFTP diagnosis on resection specimens, the ROM decreased as follows: ND, 38.8% to 27.7% (P = 0.2388); benign, 21.1% to 11.9% (P = 0.0343); AUS/FLUS, 50% to 39.2% (P = 0.2089); FN/SFN, 53.8% to 33.3% (P = 0.0336); SM, 85% to 75% (P = 0.2147); POM, 95.5% to 88% (P = 0.0582). Conclusion: The introduction of NIFTP would significantly decrease the ROM of thyroid FNAC in both benign and FN/SFN categories of the Bethesda system.
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Xia R, Sun W, Yee J, Sheth S, Slywotzky C, Hodak S, Brandler TC. Do ACR TI-RADS scores demonstrate unique thyroid molecular profiles? Ultrasonography 2021; 41:480-492. [PMID: 35189676 PMCID: PMC9262667 DOI: 10.14366/usg.21130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 12/20/2021] [Indexed: 11/09/2022] Open
Abstract
Purpose The present study aimed to examine the molecular profiles of cytologically indeterminate thyroid nodules stratified by American College of Radiology Thyroid Imaging Reporting and Data System (TI-RADS) categories and to determine whether certain ultrasonographic features display particular molecular alterations. Methods A retrospective review was conducted of cases from January 1, 2016 to April 1, 2018. Cases with in-house ultrasonography, fine-needle aspiration Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) diagnoses, molecular testing, and surgery were included. All cases were diagnosed as TBSRTC indeterminate categories. The ultrasound studies were retrospectively reviewed and assigned TI-RADS scores (TR1-TR5) by board-certified radiologists. The final diagnoses were determined based on the surgical resection pathology. Binary logistic regression analysis was used to study whether demographic characteristics, TI-RADS levels, and TBSRTC diagnoses were associated with ThyroSeq molecular results. Results Eighty-one cases met the inclusion criteria. RAS mutations were the most common alteration across all TI-RADS categories (TR2 2/2; TR3 10/19, TR4 13/44, and TR5 8/16), and did not stratify with any particular TI-RADS category. Only TR4 and TR5 categories displayed more aggressive mutations such as BRAFV600E; and TERT. ThyroSeq results were positively correlated with thyroid malignancy when non-invasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) was categorized in the malignant category (odds ratio [OR], 6.859; P<0.01), but not when NIFTP was removed from the malignancy category. Echogenicity scores were found to be negatively correlated with ThyroSeq results in thyroid nodules (OR, 0.162; P<0.01). Conclusion Higher-risk molecular alterations tended to stratify with the higher TI-RADS categories.
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Affiliation(s)
- Rong Xia
- Department of Pathology, NYU Langone Health, New York, USA
| | - Wei Sun
- Department of Pathology, NYU Langone Health, New York, USA
| | - Joseph Yee
- Department of Radiology, NYU Langone Health, New York, USA
| | - Sheila Sheth
- Department of Radiology, NYU Langone Health, New York, USA
| | | | - Steven Hodak
- Department of Medicine, Division of Endocrinology, NYU Langone Health, New York, USA
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Marotta V, Bifulco M, Vitale M. Significance of RAS Mutations in Thyroid Benign Nodules and Non-Medullary Thyroid Cancer. Cancers (Basel) 2021; 13:cancers13153785. [PMID: 34359686 PMCID: PMC8345070 DOI: 10.3390/cancers13153785] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 07/21/2021] [Accepted: 07/23/2021] [Indexed: 12/17/2022] Open
Abstract
Simple Summary Only about 4% of thyroid nodules are carcinomas and require surgery. Fine-needle aspiration cytology is the most accurate tool to distinguish benign from malignant thyroid nodules, however it yields an indeterminate result in about 30% of the cases, posing diagnostic and prognostic dilemmas. Testing for genetic mutations, including those of RAS, has been proposed for indeterminate cytology to solve these dilemmas and support the clinician decision making process. A passionate debate is ongoing on the biological and clinical significance of RAS mutations, calling into question the utility of RAS as tumor marker. Recently, the description of a new entity of non-invasive follicular thyroid neoplasm and the accurate review of more recent analyses demonstrate that RAS mutations have limited utility in both the diagnostic and prognostic setting of thyroid nodular disease. Abstract Thyroid nodules are detected in up to 60% of people by ultrasound examination. Most of them are benign nodules requiring only follow up, while about 4% are carcinomas and require surgery. Malignant nodules can be diagnosed by the fine-needle aspiration cytology (FNAC), which however yields an indeterminate result in about 30% of the cases. Testing for RAS mutations has been proposed to refine indeterminate cytology. However, the new entity of non-invasive follicular thyroid neoplasm, considered as having a benign evolution and frequently carrying RAS mutations, is expected to lower the specificity of this mutation. The aggressive behavior of thyroid cancer with RAS mutations, initially reported, has been overturned by the recent finding of the cooperative role of TERT mutations. Although some animal models support the carcinogenic role of RAS mutations in the thyroid, evidence that adenomas harboring these mutations evolve in carcinomas is lacking. Their poor specificity and sensitivity make the clinical impact of RAS mutations on the management of thyroid nodules with indeterminate cytology unsatisfactory. Evidence suggests that RAS mutation-positive benign nodules demand a conservative treatment. To have a clinical impact, RAS mutations in thyroid malignancies need not to be considered alone but rather together with other genetic abnormalities in a more general context.
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Affiliation(s)
- Vincenzo Marotta
- UOC Clinica Endocrinologica e Diabetologica, AOU S. Giovanni di Dio e Ruggi D’Aragona, 84131 Salerno, Italy;
| | - Maurizio Bifulco
- Department of Molecular Medicine and Medical Biotechnology, University of Naples Federico II, 80100 Naples, Italy;
| | - Mario Vitale
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, Italy
- Correspondence: ; Tel.: +39-089-672-753
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Odate T, Oishi N, Vuong HG, Mochizuki K, Kondo T. Genetic differences in follicular thyroid carcinoma between Asian and Western countries: a systematic review. Gland Surg 2020; 9:1813-1826. [PMID: 33224857 DOI: 10.21037/gs-20-356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Thyroid cancer is the most common endocrine malignancy, and follicular thyroid carcinoma (FTC) is the second most common thyroid cancer following papillary thyroid carcinoma (PTC). RAS mutation and PAX8/PPARγ rearrangement are the two representative genetic alterations in FTC, and there are studies from various countries on their regional frequencies. In this study, we systematically reviewed all available literature aiming to create a complete global map showing the frequencies of these common oncogenic drivers in FTC and to highlight the trends in Asian and Western countries. We performed a search in two electronic databases and identified 71 studies that fit our criteria from 1,329 studies found with our database search terms. There were 54 articles with 1,143 FTC patients and 39 articles with 764 FTC patients available for calculating the frequency of RAS mutation and PAX8/PPARγ rearrangement, respectively. NRAS mutation was the most frequent RAS mutation in all regions, followed by HRAS and KRAS mutation. The frequency of RAS mutation in Asian countries was higher than Western countries (34% vs. 27%, P=0.006) when the mutation detection method was not taken into account. In contrast, this difference in RAS mutation incidence between Asian and Western countries (28% vs. 25%, P=0.47) did not show up in our subgroup analysis incorporating only studies using direct sequencing method. The reported difference of RAS mutation frequency in the previous literature might not be due to the true prevalence of RAS mutation. They could be attributed to the difference in the detection method. As to PAX8/PPARγ rearrangement, Western countries overall had a much higher prevalence than Asian countries (23% vs. 4%, P<0.001), but some European countries had a low incidence, implying regional heterogeneity of PAX8/PPARγ rearrangement. A substantial lack of mutation data in FTC was found in several regions of the world such as Central Asia, Middle East, Africa, and Central and South America. Our results provide the most comprehensive global status of representative genetic alterations in FTC and highlight the similarities and differences between Asian and Western countries.
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Affiliation(s)
- Toru Odate
- Department of Pathology, University of Yamanashi, Chuo, Yamanashi, Japan
| | - Naoki Oishi
- Department of Pathology, University of Yamanashi, Chuo, Yamanashi, Japan
| | - Huy Gia Vuong
- Department of Pathology, Oklahoma University Health Sciences Center, Oklahoma City, OK, USA
| | - Kunio Mochizuki
- Department of Pathology, University of Yamanashi, Chuo, Yamanashi, Japan
| | - Tetsuo Kondo
- Department of Pathology, University of Yamanashi, Chuo, Yamanashi, Japan
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Chu YH, Sadow PM. Noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP): Diagnostic updates and molecular advances. Semin Diagn Pathol 2020; 37:213-218. [PMID: 32646613 DOI: 10.1053/j.semdp.2020.06.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 05/31/2020] [Accepted: 06/08/2020] [Indexed: 12/30/2022]
Abstract
The noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) is a strictly defined thyroid lesion, reclassified in 2016, in order to more accurately reflect the biological behavior of the tumor and thus, modify the way the lesion is clinically approached and perceived both by practitioners and patients. Additionally, this newly specified designation also allows for more uniformity in reporting for general pathologists less comfortable to exclude overt malignancy with certain nuclear features. In recent years, increasing molecular analyses correlated with longitudinal clinical outcomes have fostered improved diagnostic and treatment paradigms. Important revisions made to the definition of NIFTP in 2018 include the prohibition of any true papillae formation and the exclusion of lesions harboring the BRAF V600E mutation and other high-risk genetic abnormalities. These changes reflect the imperfection of the current criteria in outcome prediction and the global efforts for improvement. NIFTP are lesions with a wide range of size and cytomorphology. Although not addressed in the original series, large (≥4 cm) and oncocytic NIFTP have recently been shown to incur no recurrence or metastatic risk. Molecularly, NIFTP have a similar mutational profile as other follicular thyroid neoplasms, with frequent RAS family mutations and PAX8-PPARɤ fusions. However, the transcriptomic landscape is highly heterogenous, adding difficulty to gene expression-based cytopathologic classification. This review summarizes the evolution of the NIFTP concept and important advances in recent literature.
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Affiliation(s)
- Ying-Hsia Chu
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Peter M Sadow
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
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Franco AT, Labourier E, Ablordeppey KK, Surrey LF, Mostoufi-Moab S, Isaza A, Adzick NS, Kazahaya K, Kumar G, Bauer AJ. miRNA expression can classify pediatric thyroid lesions and increases the diagnostic yield of mutation testing. Pediatr Blood Cancer 2020; 67:e28276. [PMID: 32196952 DOI: 10.1002/pbc.28276] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 02/27/2020] [Accepted: 02/28/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND Genetic alterations in multiple cell signaling pathways are involved in the molecular pathogenesis of thyroid cancer. Oncogene mutation testing and gene-expression profiling are routinely used for the preoperative risk management of adult thyroid nodules. In this study, we evaluated the potential value of miRNA biomarkers for the classification of pediatric thyroid lesions. PROCEDURE Double-blind case-control study with 113 resected pediatric lesions: 66 malignant and 47 benign. Quantitative and qualitative molecular data generated with a 10-miRNA expression panel (ThyraMIR) and a next-generation sequencing oncogene panel (ThyGeNEXT) were compared with clinicopathological parameters. RESULTS miRNAs were differentially expressed in benign versus malignant tumors with distinct expression patterns in different histopathology categories. The 10-miRNA classifier identified 39 (59%) malignant lesions with 100% specificity. A positive classifier score was associated with lymph node metastasis, extrathyroidal extension and intrathyroidal spread. Genetic alterations associated with increased risk for malignancy were detected in 35 (53%) malignant cases, 20 positive for point mutations in BRAF, HRAS, KRAS, NRAS, PIK3CA, or TERT and 15 positive for gene rearrangements involving ALK, NTRK3, PPARG, or RET. The 10-miRNA classifier correctly identified 11 mutation-negative malignant cases. The performance of the combined molecular test was 70% sensitivity and 96% specificity with an area under the curve of 0.924. CONCLUSIONS These data suggest that the regulatory miRNA pathways underlying thyroid tumorigenesis are similar in adults and children. miRNA expression can identify malignant lesions with high specificity, augment the diagnostic yield of mutation testing, and improve the molecular classification of pediatric thyroid nodules.
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Affiliation(s)
- Aime T Franco
- Division of Endocrinology and Diabetes, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | | | - Lea F Surrey
- Division of Anatomic Pathology and Genomic Diagnostics, Department of Pathology and Laboratory Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sogol Mostoufi-Moab
- Division of Endocrinology and Diabetes, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Division of Oncology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Amber Isaza
- Division of Endocrinology and Diabetes, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - N Scott Adzick
- Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ken Kazahaya
- Department of Otorhinolaryngology: Head and Neck Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Otorhinolaryngology/Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Andrew J Bauer
- Division of Endocrinology and Diabetes, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Wu D, Hu S, Hou Y, He Y, Liu S. Identification of potential novel biomarkers to differentiate malignant thyroid nodules with cytological indeterminate. BMC Cancer 2020; 20:199. [PMID: 32164602 PMCID: PMC7066786 DOI: 10.1186/s12885-020-6676-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 02/24/2020] [Indexed: 12/23/2022] Open
Abstract
Background The fine-needle aspiration (FNA) biopsy was broadly applied to clinical diagnostics evaluation for thyroid carcinomas nodule, while companioning with higher uncertainty rate (15~30%) to identify malignancy for cytological indeterminate cases. It is requirement to discover novel molecular biomarkers to differentiate malignant thyroid nodule more precise. Methods We employed weighted gene co-expression network analysis (WGCNA) to discover genes significantly associated with malignant histopathology for cytological indeterminate nodules. In addition, identified significantly genes were validated through another independently investigations of thyroid carcinomas patient’s samples via cBioportal and Geipa. The key function pathways of significant genes involving were blast through GenClip. Results Twenty-four signature genes were identified significantly related to thyroid nodules malignancy. Furthermore, five novel genes with missense mutation, FN1 (R534P), PROS1((K200I), (Q571K)), SCEL (T320S), SLC34A2(T688M) and TENM1 (S1131F), were highlighted as potential biomarkers to rule out nodules malignancy. It was identified that the key functional pathways involving in thyroid carcinomas. Conclusion These results will be helpful to better understand the mechanism of thyroid nodules malignant transformation and characterize the potentially biomarkers for thyroid carcinomas early diagnostics.
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Affiliation(s)
- Dandan Wu
- Institute of Life Sciences, Jiangsu University, 301 Xuefu Road, JinKou District, Zhenjiang, 212013, PR China
| | - Shudong Hu
- Department of Radiology, Affiliated Renmin Hospital of Jiangsu University, Zhenjiang, Jiangsu, PR China
| | - Yongzhong Hou
- Institute of Life Sciences, Jiangsu University, 301 Xuefu Road, JinKou District, Zhenjiang, 212013, PR China
| | - Yingying He
- Institute of Life Sciences, Jiangsu University, 301 Xuefu Road, JinKou District, Zhenjiang, 212013, PR China.
| | - Shubai Liu
- Institute of Life Sciences, Jiangsu University, 301 Xuefu Road, JinKou District, Zhenjiang, 212013, PR China.
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Sistrunk JW, Shifrin A, Frager M, Bardales RH, Thomas J, Fishman N, Goldberg P, Guttler R, Grant E. Clinical performance of multiplatform mutation panel and microRNA risk classifier in indeterminate thyroid nodules. J Am Soc Cytopathol 2020; 9:232-241. [PMID: 32247769 DOI: 10.1016/j.jasc.2020.02.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 02/11/2020] [Accepted: 02/18/2020] [Indexed: 12/12/2022]
Abstract
INTRODUCTION We evaluated the clinical performance of an expanded mutation panel in combination with microRNA classification (MPTX) for the management of indeterminate thyroid nodules. MATERIALS AND METHODS MPTX included testing of fine-needle aspirates from multiple centers with a combination of ThyGeNEXT mutation panel for strong and weak driver oncogenic changes and ThyraMIR microRNA risk classifier (both from Interpace Diagnostics; Pittsburgh, PA). MPTX test status (positive or negative) and MPTX clinical risk classifications (low, moderate, or high risk) were determined blind to patient outcomes. Surgical pathology and clinical follow-up records of patients from multiple centers were used to determine patient outcomes. MPTX performance was assessed by Kaplan Meier analysis for cancer-free survival of patients, with risk of malignancy determined by hazard ratio (HR). RESULTS Our study included 140 patients with AUS/FLUS or FN/SFN nodules, of which 13% had malignancy. MPTX negative test status and MPTX low risk results conferred a high probability (94%) that patients would remain cancer-free. MPTX positive test status (HR 11.2, P < 0.001) and MPTX moderate-risk results (HR 8.5, P = 0.001) were significant risk factors for malignancy, each conferring a 53% probability of malignancy. MPTX high-risk results elevated risk of malignancy even more so, conferring a 70% probability of malignancy (HR 38.5, P < 0.001). CONCLUSIONS MPTX test status accurately stratifies patients for risk of malignancy. Further classification using MPTX clinical risk categories enhances utility by accurately identifying patients at low, moderate, or high risk of malignancy at the low rate of malignancy encountered when clinically managing patients with indeterminate thyroid nodules.
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Affiliation(s)
| | - Alexander Shifrin
- Department of Surgery, Hackensack Meridian Health Jersey Shore University Medical Center, Neptune, New Jersey
| | - Marc Frager
- East Coast Medical Associates, Boca Raton, Florida
| | - Ricardo H Bardales
- Precision Pathology/Outpatient Pathology Associates, Sacramento, California
| | | | - Norman Fishman
- Diabetes & Endocrinology Specialists, Chesterfield, Missouri
| | | | | | - Edward Grant
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, California
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11
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Ablordeppey KK, Timmaraju VA, Song-Yang JW, Yaqoob S, Narick C, Mireskandari A, Finkelstein SD, Kumar G. Development and Analytical Validation of an Expanded Mutation Detection Panel for Next-Generation Sequencing of Thyroid Nodule Aspirates. J Mol Diagn 2020; 22:355-367. [DOI: 10.1016/j.jmoldx.2019.11.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 10/20/2019] [Accepted: 11/18/2019] [Indexed: 12/13/2022] Open
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12
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Baloch Z, LiVolsi VA. The Bethesda System for Reporting Thyroid Cytology (TBSRTC): From look-backs to look-ahead. Diagn Cytopathol 2020; 48:862-866. [PMID: 31999070 DOI: 10.1002/dc.24385] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 01/13/2020] [Indexed: 02/06/2023]
Abstract
The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) was formalized in October 2007 by experts in thyroidology at the National Institute of Health in Bethesda, Maryland. The first edition of the TBSRTC book was published in 2010 and the second edition in 2018. The TBSRTC is widely employed in cytology practices in the United States and has also served as a model for similar tiered classification schemes for reporting thyroid cytopathology specimens. The tremendous success of TBSRTC cannot be underscored, it has provided a diagnostic framework which is well aligned with the present and the future of thyroid nodule management.
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Affiliation(s)
- Zubair Baloch
- Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Virginia A LiVolsi
- Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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13
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Jackson S, Kumar G, Banizs AB, Toney N, Silverman JF, Narick CM, Finkelstein SD. Incremental utility of expanded mutation panel when used in combination with microRNA classification in indeterminate thyroid nodules. Diagn Cytopathol 2019; 48:43-52. [PMID: 31675178 PMCID: PMC6972518 DOI: 10.1002/dc.24328] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 10/03/2019] [Accepted: 10/08/2019] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Focused and expanded mutation panels were assessed for the incremental utility of using an expanded panel in combination with microRNA risk classification. METHODS Molecular results were reviewed for patients who underwent either a focused mutation panel (ThyGenX®) or an expanded mutation panel (ThyGeNEXT®) for strong and weak oncogenic driver mutations and fusions. microRNA results (ThyraMIR®) predictive of malignancy, including strong positive results highly specific for malignancy, were examined. RESULTS Results of 12 993 consecutive patients were reviewed (focused panel = 8619, expanded panel = 4374). The expanded panel increased detection of strong drivers by 8% (P < .001), with BRAFV600E and TERT promoters being the most common. Strong drivers were highly correlated with positive microRNA results of which 90% were strongly positive. The expanded panel increased detection of coexisting drivers by 4% (P < .001), with TERT being the most common partner often paired with RAS. It increased the detection of weak drivers, with RAS and GNAS being the most common. 49% of nodules with weak drivers had positive microRNA results of which 33% were strongly positive. The expanded panel also decreased the number of nodules lacking mutations and fusions by 15% (P < .001), with 8% of nodules having positive microRNA results of which 22% were strongly positive. CONCLUSIONS Using expanded mutation panels that include less common mutations and fusions can offer increased utility when used in combination with microRNA classification, which helps to identify high risk of malignancy in the cases where risk is otherwise uncertain due to the presence of only weak drivers or the absence of all drivers.
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Affiliation(s)
- Sara Jackson
- Division of Research & Development, Interpace Diagnostics, Inc., Pittsburgh, Pennsylvania
| | - Gyanendra Kumar
- Division of Research & Development, Interpace Diagnostics, Inc., New Haven, Connecticut
| | - Anna B Banizs
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut
| | - Nicole Toney
- Division of Research & Development, Interpace Diagnostics, Inc., Pittsburgh, Pennsylvania
| | - Jan F Silverman
- Department of Pathology, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Christina M Narick
- Division of Pathology, Interpace Diagnostics, Inc., Pittsburgh, Pennsylvania
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14
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Borowczyk M, Szczepanek-Parulska E, Dębicki S, Budny B, Verburg FA, Filipowicz D, Więckowska B, Janicka-Jedyńska M, Gil L, Ziemnicka K, Ruchała M. Differences in Mutational Profile between Follicular Thyroid Carcinoma and Follicular Thyroid Adenoma Identified Using Next Generation Sequencing. Int J Mol Sci 2019; 20:ijms20133126. [PMID: 31248021 PMCID: PMC6651591 DOI: 10.3390/ijms20133126] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 06/18/2019] [Accepted: 06/24/2019] [Indexed: 02/06/2023] Open
Abstract
We aimed to identify differences in mutational status between follicular thyroid adenoma (FTA) and follicular thyroid cancer (FTC). The study included 35 patients with FTA and 35 with FTC. DNA was extracted from formalin-fixed paraffin-embedded (FFPE) samples from thyroidectomy. Next-generation sequencing (NGS) was performed with the 50-gene Ion AmpliSeq Cancer Hotspot Panel v2. Potentially pathogenic mutations were found in 14 (40%) FTA and 24 (69%) FTC patients (OR (95%CI) = 3.27 (1.22−8.75)). The number of mutations was higher in patients with FTC than FTA (p-value = 0.03). SMAD4 and STK11 mutations were present only in patients with FTA, while defects in FBXW7, JAK3, KIT, NRAS, PIK3CA, SMARCB1, and TP53 were detected exclusively in FTC patients. TP53 mutations increased the risk of FTC; OR (95%CI) = 29.24 (1.64–522.00); p-value = 0.001. FLT3-positivity was higher in FTC than in the FTA group (51.4% vs. 28.6%; p-value = 0.051). The presence of FLT3 and TP53 with no RET mutations increased FTC detectability by 17.1%, whereas the absence of FLT3 and TP53 with a presence of RET mutations increased FTA detectability by 5.7%. TP53 and FLT3 are candidate markers for detecting malignancy in follicular lesions. The best model to predict FTA and FTC may consist of FLT3, TP53, and RET mutations considered together.
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Affiliation(s)
- Martyna Borowczyk
- Department of Endocrinology, Metabolism and Internal Diseases, Poznan University of Medical Sciences, 60-355 Poznań, Poland.
| | - Ewelina Szczepanek-Parulska
- Department of Endocrinology, Metabolism and Internal Diseases, Poznan University of Medical Sciences, 60-355 Poznań, Poland
| | - Szymon Dębicki
- Department of Endocrinology, Metabolism and Internal Diseases, Poznan University of Medical Sciences, 60-355 Poznań, Poland
| | - Bartłomiej Budny
- Department of Endocrinology, Metabolism and Internal Diseases, Poznan University of Medical Sciences, 60-355 Poznań, Poland
| | - Frederik A Verburg
- Department of Nuclear Medicine, University Hospital Marburg, 35043 Marburg, Germany
| | - Dorota Filipowicz
- Department of Endocrinology, Metabolism and Internal Diseases, Poznan University of Medical Sciences, 60-355 Poznań, Poland
| | - Barbara Więckowska
- Department of Computer Science and Statistics, Poznan University of Medical Sciences, 60-806 Poznań, Poland
| | | | - Lidia Gil
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, 60-569 Poznań, Poland
| | - Katarzyna Ziemnicka
- Department of Endocrinology, Metabolism and Internal Diseases, Poznan University of Medical Sciences, 60-355 Poznań, Poland
| | - Marek Ruchała
- Department of Endocrinology, Metabolism and Internal Diseases, Poznan University of Medical Sciences, 60-355 Poznań, Poland
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15
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Abstract
Thyroid nodules are very common, and their frequency is four to five times higher in women than in men. Most of them are benign, with only a very little percentage revealing a malignant neoplasm. About 50% of thyroid nodules are detected by self-palpation of neck, whereas the other 50% are diagnosed by neck ultrasonography and following fine-needle aspiration. Management of thyroid nodules is very difficult, because benign nodules are prevalent, whereas thyroid carcinoma is uncommon, representing only 1% of all malignancies. A standard diagnostic approach is represented by 'first-level' exams, consisting in neck ultrasonography and serum thyroid-stimulating hormone measurement, followed, only for nodules that are suspicious of malignancy, by 'second-level' exams, consisting of fine-needle aspiration and mutational test, which does detect particular DNA mutations present only in malignant cells. In this review, we will analyze the genetics of thyroid cancer and its heterogeneity, and we will briefly describe the current available diagnostic and therapeutic approaches.
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16
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Abstract
Fine needle aspiration biopsy (FNAB) and ultrasonography are the most common modalities for the diagnosis and follow up of thyroid nodules. FNAB is able to distinguish benign from malignant nodules with high sensitivity and specificity; however, 20% to 30% of nodules are diagnosed as indeterminate with a risk of malignancy varying from 10% to 75% based on the 2017 revision of the Bethesda System for Reporting Thyroid Cytopathology. Molecular tests are being increasingly used to triage this group of nodules. Several molecular tests are commercially available and newer upgrades are being developed to either "rule in" or "rule out" malignancy with greater accuracy. The Afirma gene expression classifier and its recent upgrade (the Afirma gene sequencing classifier), Thryoseq v2, a next generation sequencing test and its recent upgrade (the v3), RosettaGX Reveal based on microRNA alterations, and ThyGenX/ThyraMIR, a combination test, are currently on the market. Familiarity with these tests, their performance, and postvalidation publications will enable appropriate test selection and improve triage of patients for appropriate therapy. The underlying rate of malignancy at different institutions and the interobserver variability in cytologic and histologic diagnosis of thyroid lesions are important factors that impact the performance of the various molecular tests.
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17
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Abstract
Genomic, clinical, and pathologic studies have prompted a more risk-stratified approach to the management of patients with thyroid nodules. The recent nomenclature change concerning noninvasive follicular thyroid neoplasm with papillary-like nuclear features reflects the clinical trend toward conservative treatment choices for carefully selected low-risk thyroid neoplasms. These developments have occurred in parallel with a growing array of molecular tests intended to improve clinical triage for patients with indeterminate fine needle aspiration diagnoses. This review discusses the implications of the nomenclature revision on the interpretation of thyroid fine needle aspiration and updates available ancillary molecular tests for thyroid fine needle aspirations.
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Affiliation(s)
- Michiya Nishino
- Department of Pathology, Harvard Medical School and Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA.
| | - Jeffrey F Krane
- Department of Pathology, Harvard Medical School and Brigham and Women's Hospital, 75 Francis Street, Amory 3, Boston, MA 02115, USA
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18
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Banizs AB, Silverman JF. The utility of combined mutation analysis and microRNA classification in reclassifying cancer risk of cytologically indeterminate thyroid nodules. Diagn Cytopathol 2018; 47:268-274. [DOI: 10.1002/dc.24087] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 08/15/2018] [Accepted: 09/10/2018] [Indexed: 01/11/2023]
Affiliation(s)
- Anna B. Banizs
- Department of Pathology; Allegheny General Hospital; Pittsburgh Pennsylvania
| | - Jan F. Silverman
- Department of Pathology; Allegheny General Hospital; Pittsburgh Pennsylvania
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19
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D'Cruz AK, Vaish R, Vaidya A, Nixon IJ, Williams MD, Vander Poorten V, López F, Angelos P, Shaha AR, Khafif A, Skalova A, Rinaldo A, Hunt JL, Ferlito A. Molecular markers in well-differentiated thyroid cancer. Eur Arch Otorhinolaryngol 2018; 275:1375-1384. [PMID: 29626249 DOI: 10.1007/s00405-018-4944-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 03/19/2018] [Indexed: 12/18/2022]
Abstract
PURPOSE Thyroid nodules are of common occurrence in the general population. About a fourth of these nodules are indeterminate on aspiration cytology placing many a patient at risk of unwanted surgery. The purpose of this review is to discuss various molecular markers described to date and place their role in proper perspective. This review covers the fundamental role of the signaling pathways and genetic changes involved in thyroid carcinogenesis. The current literature on the prognostic significance of these markers is also described. METHODS PubMed was used to search relevant articles. The key terms "thyroid nodules", "thyroid cancer papillary", "carcinoma papillary follicular", "carcinoma papillary", "adenocarcinoma follicular" were searched in MeSH, and "molecular markers", "molecular testing", mutation, BRAF, RAS, RET/PTC, PAX 8, miRNA, NIFTP in title and abstract fields. Multiple combinations were done and a group of experts in the subject from the International Head and Neck Scientific Group extracted the relevant articles and formulated the review. RESULTS There has been considerable progress in the understanding of thyroid carcinogenesis and the emergence of numerous molecular markers in the recent years with potential to be used in the diagnostic algorithm of these nodules. However, their precise role in routine clinical practice continues to be a contentious issue. Majority of the studies in this context are retrospective and impact of these mutations is not independent of other prognostic factors making the interpretation difficult. CONCLUSION The prevalence of these mutations in thyroid nodule is high and it is a continuously evolving field. Clinicians should stay informed as recommendation on the use of these markers is expected to evolve.
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Affiliation(s)
- Anil K D'Cruz
- Head Neck Services, Tata Memorial Hospital, Parel, Mumbai, 400012, India.
| | - Richa Vaish
- Head Neck Services, Tata Memorial Hospital, Parel, Mumbai, 400012, India
| | - Abhishek Vaidya
- National Cancer Institute, Nagpur, India
- NKPSIMS, Nagpur, India
| | - Iain J Nixon
- Departments of Surgery and Otolaryngology, Head and Neck Surgery, Edinburgh University, Edinburgh, UK
| | - Michelle D Williams
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Vincent Vander Poorten
- Otorhinolaryngology-Head and Neck Surgery and Department of Oncology, Section Head and Neck Oncology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Fernando López
- Department of Otolaryngology, Hospital Universitario Central de Asturias, IUOPA, University of Oviedo, CIBERONC, Oviedo, Spain
| | - Peter Angelos
- Department of Surgery and Surgical Ethics, The University of Chicago Medicine, Chicago, IL, USA
| | - Ashok R Shaha
- Head and Neck Service, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Avi Khafif
- Head and Neck Surgery and Oncology Unit, A.R.M. Center for Advanced Otolaryngology Head and Neck Surgery, Assuta Medical Center, Tel Aviv, Israel
| | - Alena Skalova
- Department of Pathology, Charles University, Faculty of Medicine in Plzen, Plzen, Czech Republic
| | | | - Jennifer L Hunt
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Alfio Ferlito
- International Head and Neck Scientific Group, Padua, Italy
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20
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He H, Li W, Liyanarachchi S, Wang Y, Yu L, Genutis LK, Maharry S, Phay JE, Shen R, Brock P, de la Chapelle A. The Role of NRG1 in the Predisposition to Papillary Thyroid Carcinoma. J Clin Endocrinol Metab 2018; 103:1369-1379. [PMID: 29121253 PMCID: PMC6018707 DOI: 10.1210/jc.2017-01798] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 11/01/2017] [Indexed: 02/06/2023]
Abstract
Context Previous genome-wide association studies have shown that single-nucleotide polymorphism (SNP) rs2439302 in chromosome 8p12 is significantly associated with papillary thyroid carcinoma (PTC) risk and dysregulated NRG1 expression. The underlying mechanisms remain to be discovered. Objective To evaluate the expression of NRG1 isoforms, candidate functional variants, and potential genes downstream of NRG1 in thyroid tissue. Methods Quantitative reverse transcription polymerase chain reaction was applied for gene expression analysis. SNaPshot assay, haplotype, and computer analyses were performed to evaluate candidate functional variants. Other functional assays [chromatin immunoprecipitation (ChIP) assay, luciferase assay, small interfering RNA knockdown, and RNA sequencing] were performed. Results Three NRG1 isoforms (NM_004495, NM_013958, and NM_001160008) tested were highly expressed in thyroid tissue. The expression levels of the three isoforms were significantly correlated with the genotypes of rs2439302. A DNA block of ~32 kb containing the risk G allele of rs2439302 was revealed, harboring multiple candidate functional variants. ChIP assay for active chromatin markers indicated at least nine regions in the DNA block showing strong H3Kme1 and H3K27Ac signals in thyroid tissue. Luciferase reporter assays revealed differential allelic activities associated with seven SNPs. Knocking down NRG1 in primary thyroid cells revealed downstream or interacting genes related to NRG1. Conclusions Our data suggest a role for transcriptional regulation of NRG1 in the predisposition to PTC.
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Affiliation(s)
- Huiling He
- Department of Cancer Biology and Genetics, The Ohio State University Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio
| | - Wei Li
- Department of Cancer Biology and Genetics, The Ohio State University Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio
| | - Sandya Liyanarachchi
- Department of Cancer Biology and Genetics, The Ohio State University Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio
| | - Yanqiang Wang
- Department of Cancer Biology and Genetics, The Ohio State University Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio
| | - Lianbo Yu
- Department of Biomedical Informatics, The Ohio State University Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio
| | - Luke K Genutis
- Department of Cancer Biology and Genetics, The Ohio State University Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio
| | - Sophia Maharry
- Department of Cancer Biology and Genetics, The Ohio State University Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio
| | - John E Phay
- Department of Surgery, The Ohio State University Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio
| | - Rulong Shen
- Department of Pathology, The Ohio State University Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio
| | - Pamela Brock
- Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio
| | - Albert de la Chapelle
- Department of Cancer Biology and Genetics, The Ohio State University Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio
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21
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Johnson DN, Furtado LV, Long BC, Zhen CJ, Wurst M, Mujacic I, Kadri S, Segal JP, Antic T, Cipriani NA. Noninvasive Follicular Thyroid Neoplasms With Papillary-like Nuclear Features Are Genetically and Biologically Similar to Adenomatous Nodules and Distinct From Papillary Thyroid Carcinomas With Extensive Follicular Growth. Arch Pathol Lab Med 2018; 142:838-850. [PMID: 29582677 DOI: 10.5858/arpa.2017-0118-oa] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT - Proposed noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTPs), formerly noninvasive encapsulated papillary carcinoma, follicular variant (PTC-FV), is an indolent tumor with follicular growth and frequent RAS mutations. OBJECTIVE - To detect histologic and molecular differences separating NIFTP from follicular adenomas (FAs) and invasive carcinomas, particularly papillary carcinomas with extensive follicular growth (PTC-EFGs) and invasive encapsulated PTC-FV (IE-PTC-FV). DESIGN - Sixty-one tumors were reviewed histologically and reclassified into 32 NIFTPs (52%), 4 IE-PTC-FVs (7%), 14 PTC-EFGs (23%), and 11 FAs (18%). Next-generation sequencing for mutations in 50 genes was performed. Clinical outcomes were recorded. RESULTS - The NIFTPs and FAs were well circumscribed and unencapsulated. The FAs had bland nuclei, whereas the NIFTPs showed at least 2 of 3 (67%; sufficient) nuclear features (enlargement, irregular contours, chromatin clearing). The IE-PTC-FVs had follicular growth, sufficient nuclear features, and extensive capsular invasion. The PTC-EFGs had a median of 5% papillae with intrathyroidal invasion (broad-based, sclerotic, or small follicle growth patterns); intranuclear pseudoinclusions were present only in PTC-EFGs (9 of 14; 64%). Mutations included RAS in 20 of the 32 NIFTPs (62%), 4 of the 11 FAs (36%), and 3 of the 4 IE-PTC-FVs (75%); BRAF K601E in 1 NIFTP (3%); BRAF V600E in 5 PTC-EFGs (36%). No NIFTPs or FAs recurred or metastasized. All 4 IE-PTC-FVs (100%) had hematogenous metastasis. Two PTC-EFGs (14%) had lymphatic metastasis. CONCLUSIONS - The morphologic similarity and RAS mutations in FAs, NIFTPs, and IE-PTC-FVs supports the genetic similarity of those follicular neoplasms in contrast to the unique presence of BRAF V600E mutations in PTC-EFGs. Using strict diagnostic criteria supported by molecular testing, tumors with extensive follicular growth can be classified into follicular type or RAS-like (FA, NIFTP, IE-PTC-FV) versus papillary type or BRAF V600E-like (PTC-EFG).
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Nicole A Cipriani
- From the Divisions of Anatomic Pathology (Drs Johnson, Antic, and Cipriani) and Molecular Pathology (Messrs Long, Zhen, and Mujacic; Ms Wurst; and Drs Kadri and Segal), Department of Pathology, University of Chicago, Chicago, Illinois; and the ARUP Laboratories, University of Utah, Salt Lake City (Dr Furtado)
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Raue F, Frank-Raue K. Thyroid Cancer: Risk-Stratified Management and Individualized Therapy. Clin Cancer Res 2018; 22:5012-5021. [PMID: 27742787 DOI: 10.1158/1078-0432.ccr-16-0484] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 08/24/2016] [Indexed: 11/16/2022]
Abstract
Thyroid cancer is the most common endocrine malignancy. Differentiated thyroid cancer (DTC) with the two subtypes, papillary thyroid cancer (PTC) and follicular thyroid cancer (FTC), is the most frequent subtype of thyroid cancer; more rare subtypes are medullary thyroid cancer (MTC) and anaplastic thyroid cancer (ATC). The incidence of DTC has increased rapidly in recent years due to the more frequent use of imaging methods such as ultrasound of the neck and fine-needle aspiration (FNA) of thyroid nodules. After total thyroidectomy and radioiodine treatment, DTC remains an indolent and curable disease in most patients, whereas the cure rate in MTC is lower and depends on early diagnosis. Most ATCs are incurable. In recent years, there has been great progress in identifying genetic changes in thyroid cancer, and genetic testing of FNA samples or blood samples provides useful information for clinical decision making. Tumor staging, either postoperatively or by imaging, and measuring the tumor markers thyroglobulin for DTC and calcitonin for MTC, allow for dynamic risk-adapted stratification for follow-up procedures. In advanced metastatic thyroid cancer, molecular targeted therapy using tyrosine kinase receptor inhibitors, including sorafenib, lenvantinib, vandetanib, and cabozantinib, helps control tumor progression and prolongs progression-free survival. Using a dynamic risk-stratified approach to manage thyroid cancer, the outcomes for most thyroid cancer patients are excellent compared with those for other cancers. The major challenge in the future is to identify high-risk patients and to treat and monitor them appropriately. Clin Cancer Res; 22(20); 5012-21. ©2016 AACR SEE ALL ARTICLES IN THIS CCR FOCUS SECTION, "ENDOCRINE CANCERS REVISING PARADIGMS".
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Affiliation(s)
- Friedhelm Raue
- Molecular Laboratory, Endocrine Practice, Heidelberg, Germany.
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Mostoufi-Moab S, Labourier E, Sullivan L, LiVolsi V, Li Y, Xiao R, Beaudenon-Huibregtse S, Kazahaya K, Adzick NS, Baloch Z, Bauer AJ. Molecular Testing for Oncogenic Gene Alterations in Pediatric Thyroid Lesions. Thyroid 2018; 28:60-67. [PMID: 29108474 PMCID: PMC5770125 DOI: 10.1089/thy.2017.0059] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Thyroid nodules are less common in pediatric patients (i.e., those ≤18 years) than they are in adults. The Bethesda System for Reporting Thyroid Cytopathology allows for individual risk stratification, but a significant number of nodules are indeterminate. Incorporating gene mutation panels and gene expression classifiers may aid in preoperative diagnosis. The overall aim of this study was to assess the prevalence of oncogene alterations in a representative pediatric population and across a broad-spectrum of thyroid tumor diagnoses. METHODS This was a retrospective cross-sectional evaluation of 115 archived samples, including: 47 benign (29 follicular adenoma, 11 diffuse hyperplasia, four thyroiditis, and three multinodular goiter), six follicular thyroid carcinomas (FTC), 24 follicular variant of papillary thyroid carcinomas (fvPTC), 27 classic variant of PTC (cPTC), eight diffuse sclerosing variant of PTC (dsvPTC), and three other PTC. Molecular testing was performed by multiplex qualitative polymerase chain reaction followed by bead array cytometry. Oncogene results were analyzed for association with age, sex, histology, lymph node metastasis, and intrathyroidal spread. RESULTS A mutation in one of the 17 molecular markers evaluated was found in: 2/6 (33%) FTC, 8/24 (33%) fvPTC, 17/27 (63%) cPTC, and 4/8 (50%) dsvPTC. Mutations in RAS or PAX8/PPARG were exclusive to FTC and fvPTC. BRAF was the most common mutation in cPTC (12/17; 71%), and RET/PTC was the only mutation associated with dsvPTC. Overall, a mutation was found in 32/68 (47%) malignant specimens, with a single follicular adenoma positive for PAX8/PPARG. The relative distribution of gene alterations in pediatric lesions was similar to adults. The presence of a BRAF mutation in pediatric cPTC did not predict a more invasive phenotype. CONCLUSIONS Of 33 nodules with genetic alterations, 32 were malignant. Mutations in RAS were most frequently associated with FTC, RET/PTC rearrangements with dsvPTC, and invasive fvPTC, and BRAF with cPTC. These results suggest a clinical role for mutational analysis of pediatric nodules to guide the surgical approach.
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Affiliation(s)
- Sogol Mostoufi-Moab
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Lisa Sullivan
- Division of Anatomic Pathology, Department of Pathology
| | - Virginia LiVolsi
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Yimei Li
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rui Xiao
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Ken Kazahaya
- Division of Pediatric Otolaryngology, Department of Pediatric Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Otorhinolaryngology—Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - N. Scott Adzick
- Division of General Surgery, Department of Pediatric Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Zubair Baloch
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrew J. Bauer
- Division of Endocrinology and Diabetes, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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García-Giménez JL, Seco-Cervera M, Tollefsbol TO, Romá-Mateo C, Peiró-Chova L, Lapunzina P, Pallardó FV. Epigenetic biomarkers: Current strategies and future challenges for their use in the clinical laboratory. Crit Rev Clin Lab Sci 2017; 54:529-550. [PMID: 29226748 DOI: 10.1080/10408363.2017.1410520] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Epigenetic modifications and regulators represent potential molecular elements which control relevant physiological and pathological features, thereby contributing to the natural history of human disease. These epigenetic modulators can be employed as disease biomarkers, since they show several advantages and provide information about gene function, thus explaining differences among patient endophenotypes. In addition, epigenetic biomarkers can incorporate information regarding the effects of the environment and lifestyle on health and disease, and monitor the effect of applied therapies. Technologies used to analyze these epigenetic biomarkers are constantly improving, becoming much easier to use. Laboratory professionals can easily acquire experience and techniques are becoming more affordable. A high number of epigenetic biomarker candidates are being continuously proposed, making now the moment to adopt epigenetics in the clinical laboratory and convert epigenetic marks into reliable biomarkers. In this review, we describe some current promising epigenetic biomarkers and technologies being applied in clinical practice. Furthermore, we will discuss some laboratory strategies and kits to accelerate the adoption of epigenetic biomarkers into clinical routine. The likelihood is that over time, better markers will be identified and will likely be incorporated into future multi-target assays that might help to optimize its application in a clinical laboratory. This will improve cost-effectiveness, and consequently encourage the development of theragnosis and the application of precision medicine.
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Affiliation(s)
- José Luis García-Giménez
- a Center for Biomedical Network Research on Rare Diseases (CIBERER) , Institute of Health Carlos III , Valencia , Spain.,b INCLIVA Biomedical Research Institute , Valencia , Spain.,c Department Physiology, School of Medicine and Dentistry , Universitat de València (UV) , Valencia , Spain.,d Epigenetics Research Platform (CIBERER/UV/INCLIVA) , Valencia , Spain.,e EpiDisease S.L. Spin-Off of CIBERER (ISCIII) , Valencia , Spain
| | - Marta Seco-Cervera
- a Center for Biomedical Network Research on Rare Diseases (CIBERER) , Institute of Health Carlos III , Valencia , Spain.,b INCLIVA Biomedical Research Institute , Valencia , Spain.,c Department Physiology, School of Medicine and Dentistry , Universitat de València (UV) , Valencia , Spain
| | - Trygve O Tollefsbol
- f Department of Biology , University of Alabama at Birmingham , Birmingham , AL , USA
| | - Carlos Romá-Mateo
- a Center for Biomedical Network Research on Rare Diseases (CIBERER) , Institute of Health Carlos III , Valencia , Spain.,b INCLIVA Biomedical Research Institute , Valencia , Spain.,c Department Physiology, School of Medicine and Dentistry , Universitat de València (UV) , Valencia , Spain.,d Epigenetics Research Platform (CIBERER/UV/INCLIVA) , Valencia , Spain
| | - Lorena Peiró-Chova
- b INCLIVA Biomedical Research Institute , Valencia , Spain.,g INCLIVA Biobank , Valencia , Spain
| | - Pablo Lapunzina
- a Center for Biomedical Network Research on Rare Diseases (CIBERER) , Institute of Health Carlos III , Valencia , Spain.,h Institute of Medical and Molecular Genetics (INGEMM) , IdiPAZ, Hospital Universitario La Paz, Universidad Autónoma de Madrid , Madrid , Spain
| | - Federico V Pallardó
- a Center for Biomedical Network Research on Rare Diseases (CIBERER) , Institute of Health Carlos III , Valencia , Spain.,b INCLIVA Biomedical Research Institute , Valencia , Spain.,c Department Physiology, School of Medicine and Dentistry , Universitat de València (UV) , Valencia , Spain.,d Epigenetics Research Platform (CIBERER/UV/INCLIVA) , Valencia , Spain
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Abstract
PURPOSE OF REVIEW Medullary thyroid carcinoma (MTC) comprises approximately 4% of all malignant thyroid neoplasms. Although the majority of patients have a good prognosis, a subgroup of patients develops progressive disease and requires systemic therapy. Here, we focused on the current MTC therapeutic approaches and discussed the advantages and disadvantages of molecular targeted therapies. RECENT FINDINGS Targeted molecular therapies that inhibit RET and other tyrosine kinase receptors involved in angiogenesis have been shown to improve progression-free survival in patients with advanced MTC. Two drugs, vandetanib and cabozantinib, have been approved for the treatment of progressive or symptomatic MTC, and several others have exhibited variable efficacy. No tyrosine kinase inhibitor has been shown to improve survival. Although no definitive recommendation can currently be made, cumulative data indicate that knowledge of the tumor mutational profile may facilitate improvements in targeted therapy for MTC. SUMMARY Tyrosine kinase inhibitors are effective therapeutic agents for the treatment of progressive MTC. Nevertheless, it is not clear who will benefit the most from therapy, and the decision regarding when and how to initiate the treatment should be made based on the patient's medical history and tumor behavior. Hopefully, in the near future, molecular profiling of MTC can be used to determine the most effective molecular therapeutic target.
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Morandi L, Righi A, Maletta F, Rucci P, Pagni F, Gallo M, Rossi S, Caporali L, Sapino A, Lloyd RV, Asioli S. Somatic mutation profiling of hobnail variant of papillary thyroid carcinoma. Endocr Relat Cancer 2017; 24:107-117. [PMID: 28062544 DOI: 10.1530/erc-16-0546] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Accepted: 01/06/2017] [Indexed: 02/06/2023]
Abstract
Hobnail variant of papillary thyroid carcinoma (HPTC) represents a recently described, aggressive and rare group of thyroid tumors with poorly understood pathogenesis. Molecular data about this group of cancers are few, and a more detailed molecular characterization of these tumors is needed. The main objective of the study is to define a comprehensive molecular typing of HPTC. Eighteen patients affected by HPTC, including eighteen primary tumors and four lymph node metastases, were screened for NRAS, KRAS, HRAS, BRAF, TP53, PIK3CA, hTERT, PTEN, CDKN2A, EGFR, AKT1, CTNNB1 and NOTCH1 gene mutations. Sequencing is conducted on the MiSEQ system, and molecular data are compared with clinical-pathologic data and follow-up. The patients include 14 women and 4 men. Ages range from 23 to 87 years. All 18 primary tumors of HPTC showed ≥30% hobnail features. BRAF and TP53 mutations are by far the most common genetic alterations in primary HPTC (72.2% and 55.6%, respectively), followed by hTERT (44.4%), PIK3CA (27.8%), CTNNB1 (16.7%), EGFR (11.1%), AKT1 (5.5%) and NOTCH1 (5.5%). The mutational pattern in primary tumors and metastasis was usually maintained. Univariate Cox regression analyses with bootstrap procedure indicated a significantly increased mortality risk in patients harboring BRAF mutation and BRAF mutation associated with TP53 and/or PIK3CA mutations. The detection of these multiple mutations appears to allow the identification of a subset of more aggressive tumors within the group and to bear information that should be useful for prognostic stratification of these patients including the planning of adjuvant therapy.
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Affiliation(s)
- Luca Morandi
- Department of Biomedical and Neuromotor SciencesSection of Anatomic Pathology 'M. Malpighi' at Bellaria Hospital, University of Bologna, Bologna, Italy
| | - Alberto Righi
- Department of PathologyRizzoli Institute, (IRCCS), Bologna, Italy
| | | | - Paola Rucci
- Section of Hygiene and BiostatisticsUniversity of Bologna, Bologna, Italy
| | - Fabio Pagni
- Department of PathologyUniversity of Milano Bicocca, Monza, Italy
| | - Marco Gallo
- Oncological Endocrinology UnitDepartment of Medical Sciences, AOU Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Sabrina Rossi
- Department of PathologyRegional Hospital, Treviso, Italy
| | - Leonardo Caporali
- Istituto delle Scienze Neurologiche di Bologna (IRCCS)Bellaria Hospital, Bologna, Italy
| | - Anna Sapino
- Institute for Cancer Research and Treatment (IRCCS)Candiolo, Italy
| | - Ricardo V Lloyd
- University of Wisconsin School of Medicine and Public HealthMadison, Wisconsin, USA
| | - Sofia Asioli
- Department of Biomedical and Neuromotor SciencesSection of Anatomic Pathology 'M. Malpighi' at Bellaria Hospital, University of Bologna, Bologna, Italy
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27
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Najafian A, Noureldine S, Azar F, Atallah C, Trinh G, Schneider EB, Tufano RP, Zeiger MA. RAS Mutations, and RET/PTC and PAX8/PPAR-gamma Chromosomal Rearrangements Are Also Prevalent in Benign Thyroid Lesions: Implications Thereof and A Systematic Review. Thyroid 2017; 27:39-48. [PMID: 27750019 DOI: 10.1089/thy.2016.0348] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Molecular markers associated with thyroid malignancy are increasingly being used as differential diagnostic tools for thyroid nodules. However, little has been reported recently regarding the prevalence of these markers in benign lesions. The literature was systematically reviewed to examine studies that reported on the prevalence of these markers in benign thyroid lesions. METHODS Appropriate studies published between January 1, 2000, and April 30, 2015, and cataloged in PubMed, Embase, Cochrane, Scopus, and Web of Science databases were searched for by combining different keywords for "thyroid tumor" with both general and specific keywords for "molecular marker" by using "AND" as the Boolean operator. All studies meeting criteria that reported the prevalence of RAS mutations, and RET/PTC and PAX8/PPAR-gamma chromosomal rearrangements in benign thyroid lesions were included for study. RESULTS A total of 64 articles (including 8162 patients, of whom 42.5% had benign lesions) that met all the study criteria were systematically reviewed and abstracted. Among 35 studies examining RAS mutations, the reported prevalence of RAS mutation in benign lesions ranged from 0% to 48%. In 38 studies examining RET/PTC rearrangements, the prevalence in benign lesions ranged from 0% to 68%. PAX8/PPAR-gamma rearrangements were examined in 27 studies, with the prevalence in benign lesions ranging from 0% to 55%. CONCLUSION The presence of these biomarkers and the tremendous variation in reports of their prevalence in benign lesions suggests the need for caution when including these markers in diagnostic decisions. Further understanding of the importance of these markers, as well as newly discovered markers of thyroid malignancy, may be required in order to avoid overtreatment of patients with benign thyroid tumors.
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Affiliation(s)
- Alireza Najafian
- 1 Endocrine Surgery, Department of Surgery, The Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Salem Noureldine
- 2 Division of Head and Neck Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Faris Azar
- 1 Endocrine Surgery, Department of Surgery, The Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Chady Atallah
- 1 Endocrine Surgery, Department of Surgery, The Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Gina Trinh
- 2 Division of Head and Neck Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Eric B Schneider
- 1 Endocrine Surgery, Department of Surgery, The Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Ralph P Tufano
- 2 Division of Head and Neck Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Martha A Zeiger
- 1 Endocrine Surgery, Department of Surgery, The Johns Hopkins University School of Medicine , Baltimore, Maryland
- 3 Department of Oncology, The Johns Hopkins University School of Medicine , Baltimore, Maryland
- 4 Department of Cellular and Molecular Medicine, The Johns Hopkins University School of Medicine , Baltimore, Maryland
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Parangi S. Reclassification of Noninvasive Follicular Variant of Papillary Thyroid Carcinoma As a Benign Condition Will Reduce the Incidence of Malignancy in the Indeterminate FNA Categories. ACTA ACUST UNITED AC 2016. [DOI: 10.1089/ct.2016;28.167-170] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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29
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Viola D, Valerio L, Molinaro E, Agate L, Bottici V, Biagini A, Lorusso L, Cappagli V, Pieruzzi L, Giani C, Sabini E, Passannati P, Puleo L, Matrone A, Pontillo-Contillo B, Battaglia V, Mazzeo S, Vitti P, Elisei R. Treatment of advanced thyroid cancer with targeted therapies: ten years of experience. Endocr Relat Cancer 2016; 23:R185-205. [PMID: 27207700 DOI: 10.1530/erc-15-0555] [Citation(s) in RCA: 120] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 02/27/2016] [Indexed: 12/13/2022]
Abstract
Thyroid cancer is rare, but it is the most frequent endocrine malignancy. Its prognosis is generally favorable, especially in cases of well-differentiated thyroid cancers (DTCs), such as papillary and follicular cancers, which have survival rates of approximately 95% at 40 years. However, 15-20% of cases became radioiodine refractory (RAI-R), and until now, no other treatments have been effective. The same problems are found in cases of poorly differentiated (PDTC) and anaplastic (ATC) thyroid cancers and in at least 30% of medullary thyroid cancer (MTC) cases, which are very aggressive and not sensitive to radioiodine. Tyrosine kinase inhibitors (TKIs) represent a new approach to the treatment of advanced cases of RAI-R DTC, MTC, PDTC, and, possibly, ATC. In the past 10 years, several TKIs have been tested for the treatment of advanced, progressive, and RAI-R thyroid tumors, and some of them have been recently approved for use in clinical practice: sorafenib and lenvatinib for DTC and PDTC and vandetanib and cabozantinib for MTC. The objective of this review is to present the current status of the treatment of advanced thyroid cancer with the use of innovative targeted therapies by describing both the benefits and the limits of their use based on the experiences reported so far. A comprehensive analysis and description of the molecular basis of these therapies, as well as new therapeutic perspectives, are reported. Some practical suggestions are given for both the choice of patients to be treated and their management, with particular regard to the potential side effects.
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Affiliation(s)
- David Viola
- Department of Clinical and Experimental MedicineSection of Endocrinology, University of Pisa, Pisa, Italy
| | - Laura Valerio
- Department of Clinical and Experimental MedicineSection of Endocrinology, University of Pisa, Pisa, Italy
| | - Eleonora Molinaro
- Department of Clinical and Experimental MedicineSection of Endocrinology, University of Pisa, Pisa, Italy
| | - Laura Agate
- Department of Clinical and Experimental MedicineSection of Endocrinology, University of Pisa, Pisa, Italy
| | - Valeria Bottici
- Department of Clinical and Experimental MedicineSection of Endocrinology, University of Pisa, Pisa, Italy
| | - Agnese Biagini
- Department of Clinical and Experimental MedicineSection of Endocrinology, University of Pisa, Pisa, Italy
| | - Loredana Lorusso
- Department of Clinical and Experimental MedicineSection of Endocrinology, University of Pisa, Pisa, Italy
| | - Virginia Cappagli
- Department of Clinical and Experimental MedicineSection of Endocrinology, University of Pisa, Pisa, Italy
| | - Letizia Pieruzzi
- Department of Clinical and Experimental MedicineSection of Endocrinology, University of Pisa, Pisa, Italy
| | - Carlotta Giani
- Department of Clinical and Experimental MedicineSection of Endocrinology, University of Pisa, Pisa, Italy
| | - Elena Sabini
- Department of Clinical and Experimental MedicineSection of Endocrinology, University of Pisa, Pisa, Italy
| | - Paolo Passannati
- Department of Clinical and Experimental MedicineSection of Endocrinology, University of Pisa, Pisa, Italy
| | - Luciana Puleo
- Department of Clinical and Experimental MedicineSection of Endocrinology, University of Pisa, Pisa, Italy
| | - Antonio Matrone
- Department of Clinical and Experimental MedicineSection of Endocrinology, University of Pisa, Pisa, Italy
| | - Benedetta Pontillo-Contillo
- Diagnostic and Interventional RadiologyDepartment of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Valentina Battaglia
- Diagnostic and Interventional RadiologyDepartment of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Salvatore Mazzeo
- Diagnostic and Interventional RadiologyDepartment of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Paolo Vitti
- Department of Clinical and Experimental MedicineSection of Endocrinology, University of Pisa, Pisa, Italy
| | - Rossella Elisei
- Department of Clinical and Experimental MedicineSection of Endocrinology, University of Pisa, Pisa, Italy
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Wylie D, Beaudenon-Huibregtse S, Haynes BC, Giordano TJ, Labourier E. Molecular classification of thyroid lesions by combined testing for miRNA gene expression and somatic gene alterations. JOURNAL OF PATHOLOGY CLINICAL RESEARCH 2016; 2:93-103. [PMID: 27499919 PMCID: PMC4907059 DOI: 10.1002/cjp2.38] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Accepted: 12/31/2015] [Indexed: 12/20/2022]
Abstract
Multiple molecular markers contribute to the pathogenesis of thyroid cancer and can provide valuable information to improve disease diagnosis and patient management. We performed a comprehensive evaluation of miRNA gene expression in diverse thyroid lesions (n = 534) and developed predictive models for the classification of thyroid nodules, alone or in combination with genotyping. Expression profiling by reverse transcription-quantitative polymerase chain reaction in surgical specimens (n = 257) identified specific miRNAs differentially expressed in 17 histopathological categories. Eight supervised machine learning algorithms were trained to discriminate benign from malignant lesions and evaluated for accuracy and robustness. The selected models showed invariant area under the receiver operating characteristic curve (AUC) in cross-validation (0.89), optimal AUC (0.94) in an independent set of preoperative thyroid nodule aspirates (n = 235), and classified 92% of benign lesions as low risk/negative and 92% of malignant lesions as high risk/positive. Surgical and preoperative specimens were further tested for the presence of 17 validated oncogenic gene alterations in the BRAF, RAS, RET or PAX8 genes. The miRNA-based classifiers complemented and significantly improved the diagnostic performance of the 17-mutation panel (p < 0.001 for McNemar's tests). In a subset of resected tissues (n = 54) and in an independent set of thyroid nodules with indeterminate cytology (n = 42), the optimized ThyraMIR Thyroid miRNA Classifier increased diagnostic sensitivity by 30-39% and correctly classified 100% of benign nodules negative by the 17-mutation panel. In contrast, testing with broad targeted next-generation sequencing panels decreased diagnostic specificity by detecting additional mutations of unknown clinical significance in 19-39% of benign lesions. Our results demonstrate that, independent of mutational status, miRNA expression profiles are strongly associated with altered molecular pathways underlying thyroid tumorigenesis. Combined testing for miRNA gene expression and well-established somatic gene alterations is a novel diagnostic strategy that can improve the preoperative diagnosis and surgical management of patients with indeterminate thyroid nodules.
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Affiliation(s)
| | | | | | - Thomas J Giordano
- Department of Pathology University of Michigan Health System Ann Arbor Michigan USA
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31
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Pagan M, Kloos RT, Lin CF, Travers KJ, Matsuzaki H, Tom EY, Kim SY, Wong MG, Stewart AC, Huang J, Walsh PS, Monroe RJ, Kennedy GC. The diagnostic application of RNA sequencing in patients with thyroid cancer: an analysis of 851 variants and 133 fusions in 524 genes. BMC Bioinformatics 2016; 17 Suppl 1:6. [PMID: 26818556 PMCID: PMC4895782 DOI: 10.1186/s12859-015-0849-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Background Thyroid carcinomas are known to harbor oncogenic driver mutations and advances in sequencing technology now allow the detection of these in fine needle aspiration biopsies (FNA). Recent work by The Cancer Genome Atlas (TCGA) Research Network has expanded the number of genetic alterations detected in papillary thyroid carcinomas (PTC). We sought to investigate the prevalence of these and other genetic alterations in diverse subtypes of thyroid nodules beyond PTC, including a variety of samples with benign histopathology. This is the first clinical evaluation of a large panel of TCGA-reported genomic alterations in thyroid FNAs. Results In FNAs, genetic alterations were detected in 19/44 malignant samples (43 % sensitivity) and in 7/44 histopathology benign samples (84 % specificity). Overall, after adding a cohort of tissue samples, 38/76 (50 %) of histopathology malignant samples were found to harbor a genetic alteration, while 15/75 (20 %) of benign samples were also mutated. The most frequently mutated malignant subtypes were medullary thyroid carcinoma (9/12, 75 %) and PTC (14/30, 47 %). Additionally, follicular adenoma, a benign subtype of thyroid neoplasm, was also found to harbor mutations (12/29, 41 %). Frequently mutated genes in malignant samples included BRAF (20/76, 26 %) and RAS (9/76, 12 %). Of the TSHR variants detected, (6/7, 86 %) were in benign nodules. In a direct comparison of the same FNA also tested by an RNA-based gene expression classifier (GEC), the sensitivity of genetic alterations alone was 42 %, compared to the 91 % sensitivity achieved by the GEC. The specificity based only on genetic alterations was 84 %, compared to 77 % specificity with the GEC. Conclusions While the genomic landscape of all thyroid neoplasm subtypes will inevitably be elucidated, caution should be used in the early adoption of published mutations as the sole predictor of malignancy in thyroid. The largest set of such mutations known to date detects only a portion of thyroid carcinomas in preoperative FNAs in our cohort and thus is not sufficient to rule out cancer. Due to the finding that variants are also found in benign nodules, testing only GEC suspicious nodules may be helpful in avoiding false positives and altering the extent of treatment when selected mutations are found. Electronic supplementary material The online version of this article (doi:10.1186/s12859-015-0849-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | | | | | | | | | - Ed Y Tom
- Veracyte, Inc., South San Francisco, CA, USA
| | - Su Yeon Kim
- Veracyte, Inc., South San Francisco, CA, USA
| | - Mei G Wong
- Veracyte, Inc., South San Francisco, CA, USA
| | | | - Jing Huang
- Veracyte, Inc., South San Francisco, CA, USA
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32
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Nishino M. Molecular cytopathology for thyroid nodules: A review of methodology and test performance. Cancer Cytopathol 2016; 124:14-27. [PMID: 26348024 DOI: 10.1002/cncy.21612] [Citation(s) in RCA: 105] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 08/13/2015] [Accepted: 08/14/2015] [Indexed: 12/28/2022]
Abstract
Advances in the molecular characterization of thyroid cancers have fueled the development of genetic and gene expression-based tests for thyroid fine-needle aspirations. Collectively, these tests are designed to improve the diagnostic certainty of thyroid cytology. This review summarizes the early published experience with the commercially available versions of these tests: the Afirma Gene Expression Classifier, ThyGenX (formerly miRInform)/ThyraMIR, and ThyroSeq. Key differences in testing approaches and issues regarding test performance and interpretation are also discussed.
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Affiliation(s)
- Michiya Nishino
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Faquin WC, Wong LQ, Afrogheh AH, Ali SZ, Bishop JA, Bongiovanni M, Pusztaszeri MP, VandenBussche CJ, Gourmaud J, Vaickus LJ, Baloch ZW. Impact of reclassifying noninvasive follicular variant of papillary thyroid carcinoma on the risk of malignancy in The Bethesda System for Reporting Thyroid Cytopathology. Cancer Cytopathol 2015; 124:181-7. [PMID: 26457584 DOI: 10.1002/cncy.21631] [Citation(s) in RCA: 197] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2015] [Revised: 09/02/2015] [Accepted: 09/09/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Recent discussions have focused on redefining noninvasive follicular variant of papillary thyroid carcinoma (NI-FVPTC) as a neoplasm rather than a carcinoma. This study assesses the potential impact of such a reclassification on the implied risk of malignancy (ROM) for the diagnostic categories of The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC). METHODS The study consisted of consecutive fine-needle aspiration biopsy (FNAB) cases collected between January 1, 2013 and June 30, 2014 from 5 academic institutions. Demographic information, cytology diagnoses, and surgical pathology follow-up were recorded. The ROM was calculated with and without NI-FVPTC and was presented as a range: all cases (ie, overall risk of malignancy [OROM]) versus those with surgical follow-up only. RESULTS The FNAB cohort consisted of 6943 thyroid nodules representing 5179 women and 1409 men with an average age of 54 years (range, 9-94 years). The combined average ROM and OROM for the diagnostic categories of TBSRTC were as follows: nondiagnostic, 4.4% to 25.3%; benign, 0.9% to 9.3%; atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS), 12.1% to 31.2%; follicular neoplasm (FN), 21.8% to 33.2%; suspicious for malignancy (SM), 62.1% to 82.6%; and malignant, 75.9% to 99.1%. The impact of reclassifying NI-FVPTC on the ROM and OROM was most pronounced and statistically significant in the 3 indeterminate categories: the AUS/FLUS category had a decrease of 5.2% to 13.6%, the FN category had a decrease of 9.9% to 15.1%, and the SM category had a decrease of 17.6% to 23.4% (P < .05), whereas the benign and malignant categories had decreases of 0.3% to 3.5% and 2.5% to 3.3%, respectfully. The trend of the effect on the ROM and OROM was similar for all 5 institutions. CONCLUSIONS The results from this multi-institutional cohort indicate that the reclassification of NI-FVPTC will have a significant impact on the ROM for the 3 indeterminate categories of TBSRTC.
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Affiliation(s)
| | - Lawrence Q Wong
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Syed Z Ali
- Johns Hopkins Hospital, Baltimore, Maryland
| | | | | | | | | | - Jolanta Gourmaud
- Institute of Pathology, University Hospital, Lausanne, Switzerland
| | | | - Zubair W Baloch
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Labourier E, Shifrin A, Busseniers AE, Lupo MA, Manganelli ML, Andruss B, Wylie D, Beaudenon-Huibregtse S. Molecular Testing for miRNA, mRNA, and DNA on Fine-Needle Aspiration Improves the Preoperative Diagnosis of Thyroid Nodules With Indeterminate Cytology. J Clin Endocrinol Metab 2015; 100:2743-50. [PMID: 25965083 PMCID: PMC4490308 DOI: 10.1210/jc.2015-1158] [Citation(s) in RCA: 208] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
CONTEXT Molecular testing for oncogenic mutations or gene expression in fine-needle aspirations (FNAs) from thyroid nodules with indeterminate cytology identifies a subset of benign or malignant lesions with high predictive value. OBJECTIVE This study aimed to evaluate a novel diagnostic algorithm combining mutation detection and miRNA expression to improve the diagnostic yield of molecular cytology. SETTING Surgical specimens and preoperative FNAs (n = 638) were tested for 17 validated gene alterations using the miRInform Thyroid test and with a 10-miRNA gene expression classifier generating positive (malignant) or negative (benign) results. DESIGN Cross-sectional sampling of thyroid nodules with atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS) or follicular neoplasm/suspicious for a follicular neoplasm (FN/SFN) cytology (n = 109) was conducted at 12 endocrinology centers across the United States. Qualitative molecular results were compared with surgical histopathology to determine diagnostic performance and model clinical effect. RESULTS Mutations were detected in 69% of nodules with malignant outcome. Among mutation-negative specimens, miRNA testing correctly identified 64% of malignant cases and 98% of benign cases. The diagnostic sensitivity and specificity of the combined algorithm was 89% (95% confidence interval [CI], 73-97%) and 85% (95% CI, 75-92%), respectively. At 32% cancer prevalence, 61% of the molecular results were benign with a negative predictive value of 94% (95% CI, 85-98%). Independently of variations in cancer prevalence, the test increased the yield of true benign results by 65% relative to mRNA-based gene expression classification and decreased the rate of avoidable diagnostic surgeries by 69%. CONCLUSIONS Multiplatform testing for DNA, mRNA, and miRNA can accurately classify benign and malignant thyroid nodules, increase the diagnostic yield of molecular cytology, and further improve the preoperative risk-based management of benign nodules with AUS/FLUS or FN/SFN cytology.
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Affiliation(s)
- Emmanuel Labourier
- Asuragen, Inc (E.L., B.A., D.W., S.B.H.), Austin, Texas 78744; Jersey Shore University Medical Center (A.S.), Center for Thyroid, Parathyroid and Adrenal Diseases, Neptune, New Jersey 07753; Metropolitan Fine Needle Aspiration Service (A.E.B.), Washington, District of Columbia 20037 and Bethesda, Maryland 20814; Thyroid & Endocrine Center of Florida (M.A.L.), Sarasota, Florida 34231; and (M.L.M.) San Diego, California 92103
| | - Alexander Shifrin
- Asuragen, Inc (E.L., B.A., D.W., S.B.H.), Austin, Texas 78744; Jersey Shore University Medical Center (A.S.), Center for Thyroid, Parathyroid and Adrenal Diseases, Neptune, New Jersey 07753; Metropolitan Fine Needle Aspiration Service (A.E.B.), Washington, District of Columbia 20037 and Bethesda, Maryland 20814; Thyroid & Endocrine Center of Florida (M.A.L.), Sarasota, Florida 34231; and (M.L.M.) San Diego, California 92103
| | - Anne E Busseniers
- Asuragen, Inc (E.L., B.A., D.W., S.B.H.), Austin, Texas 78744; Jersey Shore University Medical Center (A.S.), Center for Thyroid, Parathyroid and Adrenal Diseases, Neptune, New Jersey 07753; Metropolitan Fine Needle Aspiration Service (A.E.B.), Washington, District of Columbia 20037 and Bethesda, Maryland 20814; Thyroid & Endocrine Center of Florida (M.A.L.), Sarasota, Florida 34231; and (M.L.M.) San Diego, California 92103
| | - Mark A Lupo
- Asuragen, Inc (E.L., B.A., D.W., S.B.H.), Austin, Texas 78744; Jersey Shore University Medical Center (A.S.), Center for Thyroid, Parathyroid and Adrenal Diseases, Neptune, New Jersey 07753; Metropolitan Fine Needle Aspiration Service (A.E.B.), Washington, District of Columbia 20037 and Bethesda, Maryland 20814; Thyroid & Endocrine Center of Florida (M.A.L.), Sarasota, Florida 34231; and (M.L.M.) San Diego, California 92103
| | - Monique L Manganelli
- Asuragen, Inc (E.L., B.A., D.W., S.B.H.), Austin, Texas 78744; Jersey Shore University Medical Center (A.S.), Center for Thyroid, Parathyroid and Adrenal Diseases, Neptune, New Jersey 07753; Metropolitan Fine Needle Aspiration Service (A.E.B.), Washington, District of Columbia 20037 and Bethesda, Maryland 20814; Thyroid & Endocrine Center of Florida (M.A.L.), Sarasota, Florida 34231; and (M.L.M.) San Diego, California 92103
| | - Bernard Andruss
- Asuragen, Inc (E.L., B.A., D.W., S.B.H.), Austin, Texas 78744; Jersey Shore University Medical Center (A.S.), Center for Thyroid, Parathyroid and Adrenal Diseases, Neptune, New Jersey 07753; Metropolitan Fine Needle Aspiration Service (A.E.B.), Washington, District of Columbia 20037 and Bethesda, Maryland 20814; Thyroid & Endocrine Center of Florida (M.A.L.), Sarasota, Florida 34231; and (M.L.M.) San Diego, California 92103
| | - Dennis Wylie
- Asuragen, Inc (E.L., B.A., D.W., S.B.H.), Austin, Texas 78744; Jersey Shore University Medical Center (A.S.), Center for Thyroid, Parathyroid and Adrenal Diseases, Neptune, New Jersey 07753; Metropolitan Fine Needle Aspiration Service (A.E.B.), Washington, District of Columbia 20037 and Bethesda, Maryland 20814; Thyroid & Endocrine Center of Florida (M.A.L.), Sarasota, Florida 34231; and (M.L.M.) San Diego, California 92103
| | - Sylvie Beaudenon-Huibregtse
- Asuragen, Inc (E.L., B.A., D.W., S.B.H.), Austin, Texas 78744; Jersey Shore University Medical Center (A.S.), Center for Thyroid, Parathyroid and Adrenal Diseases, Neptune, New Jersey 07753; Metropolitan Fine Needle Aspiration Service (A.E.B.), Washington, District of Columbia 20037 and Bethesda, Maryland 20814; Thyroid & Endocrine Center of Florida (M.A.L.), Sarasota, Florida 34231; and (M.L.M.) San Diego, California 92103
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