Preoperative evaluation and predictive value of fine-needle aspiration and frozen section of thyroid nodules

Frozen Section in Diagnosis of Thyroid Swelling: Does It Still Have Role?

Purpose The present study correlates the frozen section diagnosis of thyroid swelling with the histopathological diagnosis and assesses the expression of immunohistochemical markers in malignant thyroid tumours. Also, the study aims to analyse the accuracy and limitations of the frozen section as an intraoperative tool for the diagnosis of thyroid swellings. Method Fifty-three cases of thyroid swelling were included in the study. Frozen section reports were classified as benign, malignant and deferred. A correlation between frozen section and histopathology examination (HPE) reports has been evaluated. The malignant cases confirmed on HPE were subjected to Immunohistochemistry (IHC) with TTF-1, Thyroglobulin, and CK-7. Results Among the 53 patients, 45 (84.9%) were females, and the majority were younger than 40 years (60.37%). On frozen section majority, 42 (79.25%) were benign, while a definitive diagnosis of malignancy was made in six cases (11.32%). On the frozen section, there were no false-positive cases, six true-positive cases, one false-negative case and 46 true-negative cases, with a sensitivity of 85.71%, specificity of 100%, the positive predictive value of 100%, the negative predictive value of 97.87% and diagnostic accuracy of 98.11% respectively. All the six papillary carcinomas and one follicular carcinoma showed immunoreactivity of tumor cells to TTF 1, CK 7 and Thyroglobulin. Conclusion There was a strong correlation between the frozen section and histopathological diagnosis. Still, it is not recommended in routine use for intraoperative diagnosis of thyroid swelling because of various limitations and the high diagnostic accuracy of FNAC. Adequate histopathologic diagnosis of thyroid disease is based on extensive subsampling of the specimen, which is not possible during an intraoperative frozen section procedure. If the frozen section is used, its limitations must be recognized, preferably based on first-hand data.

Frozen section in thyroid gland follicular neoplasms: It's high time to abandon it!

Thyroid nodules are a very common clinical condition. The 2015 American Thyroid Association (ATA) guidelines recommend surgical excision for Bethesda IV nodules. The use of intraoperative frozen section (FS) has been recommended as a strategy to tailor the extent of the initial surgery. We critically evaluated the literature that discusses the utility and cost-effectiveness of FS to make an intraoperative decision in patients with thyroid nodules classified as follicular neoplasm. FS should not be recommended as a routine intraoperative test to assess for malignancy in thyroid follicular patterned lesions due to its low performance; the high number of deferred results; the inability to adequately assess histologically defining features; the improvements in risk stratification guiding total thyroidectomy; and the low cost-effectiveness of FS.

Utility of Routine Frozen Section of Thyroid Nodules Classified as Follicular Neoplasm

OBJECTIVES

To evaluate the diagnostic performance of frozen section in thyroid nodules classified as follicular neoplasm.

METHODS

A diagnostic test meta-analysis was designed. Studies that assessed frozen section in patients with thyroid nodules and a fine-needle aspiration biopsy result of Bethesda IV were selected. The outcomes measured were the number of false- and true-positive and -negative results. We used the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) instrument for methodological quality assessment and a bivariate mixed-effects regression framework and a likelihood-based estimation of the exact binomial approach.

RESULTS

Forty-six studies from 1991 to 2018 were included. Most studies had moderate methodological quality. The overall sensitivity and specificity were 43% (95% confidence internal [CI], 0.34-0.53) and 100% (95% CI, 0.99-1.00), respectively. The hierarchic summary receiver operating characteristic curve showed an area under the curve of 0.91 (95% CI, 0.80-0.97).

CONCLUSIONS

Frozen section demonstrates moderate diagnostic performance in patients with follicular neoplasm, and its utility for making intraoperative decisions is limited. Its routine use should be discouraged.

Is Frozen-Section Analysis During Thyroid Operation Useful in the Era of Molecular Testing?

BACKGROUND

With the increased use of molecular testing of thyroid fine-needle biopsies, the frequency and extent of thyroid resection for thyroid nodules has changed. Although the role of frozen-section analysis of the thyroid has been reduced markedly in recent years, many surgeons still routinely use it intraoperatively. We sought to determine the utility of frozen section during thyroidectomy in the era of molecular testing.

STUDY DESIGN

We reviewed 236 consecutive patients who had thyroidectomy with intraoperative frozen-section analysis at our institution between November 2015 and October 2017. We re-reviewed the preoperative diagnosis, frozen-section diagnosis, final pathology, and whether operative management changed from the initial plan based on frozen section.

RESULTS

Mean age of the patients was 55.6 ± 14.1 years, and 83% were female. Of the 236 patients, frozen section did not change the intraoperative management in 225 (95%). Of the 11 patients whose thyroid operation was modified, the operation was either too much or not enough in 6 patients. In only 5 (2.1%) patients, frozen-section analysis correctly changed the extent of thyroidectomy.

CONCLUSIONS

Thyroid frozen-section analysis adds cost and time to thyroid operations without notable benefit. In our cohort, only 2.1% of frozen sections accurately changed intraoperative management. We recommend against its routine use.

Diagnostic importance of CD56 with fine-needle aspiration cytology in suspected papillary thyroid carcinoma cases

Background

Palpable thyroid nodules can be found in 4%-7% of the adult population; however, <5% of thyroid nodules are malignant. Immunohistochemical markers, such as CD56, can be used to make a differential diagnosis between benign and malignant lesions. To increase the accuracy of the diagnosis and distinguish the malignant aspirates from the benign ones, chose to evaluate CD56, which is normally found in benign thyroid tissue.

Methods

A total of 53 fine-needle aspirate samples from patients diagnosed with suspected papillary thyroid carcinoma (PTC) were included prospectively. These aspirates were immunocytochemically stained for CD56.

Results

In histopathological examination, the fine-needle aspiration cytopathology specimens suspicious for PTC (after undergoing surgery) showed that 32 (60.4%) were benign and 21 (39.6%) were malignant. Thirty-one of the benign cases (96.87%) were CD56-positive, whereas the last case (3.13%) was CD56-negative. Staining was not seen in any of the malignant cases.

Conclusions

We believe that CD56 is an important marker in the definitive diagnosis of suspected PTC cases, with CD56-positivity being interpreted in favor of benignity.

Economic Impact of Frozen Section for Thyroid Nodules with "Suspicious for Malignancy" Cytology

Objective To perform a cost analysis of the routine use of intraoperative frozen section (iFS) among patients undergoing a thyroid lobectomy with "suspicious for malignancy" (SUSP) cytology in the context of the 2015 American Thyroid Association guidelines. Study Design Case series with chart review; cost minimization analysis. Setting Academic. Subjects and Methods Records were reviewed for patients with SUSP cytology who underwent thyroid surgery between 2010 and 2015 in which iFS was utilized. The diagnostic test performance of iFS and the frequency of indicated completion/total thyroidectomies based on the 2015 guidelines were calculated. A cost minimization analysis was performed comparing lobectomy, with and without iFS, and the need for completion thyroidectomy according to costs estimated from 2014 data from Medicare, the Bureau of Labor Statistics, and the Nationwide Inpatient Sample. Results Sixty-five patients met inclusion criteria. The malignancy rate was 61.5%, 45% of which was identified intraoperatively. The specificity and positive predictive value were 100%. The negative predictive value and sensitivity were 83% and 95%, respectively. Completion/total thyroidectomy was indicated for 9% of patients; 83% of these individuals had findings on iFS that would have changed management intraoperatively. Application of the new guidelines would have resulted in a significant reduction in the frequency of conversion to a total thyroidectomy when compared with the actual management (26.1% vs 7.7%, P = .005). Performing routine iFS was the less costly scenario, resulting in a savings of $474 per case. Conclusion For patients with SUSP cytology undergoing lobectomy, routine use of iFS would result in decreased health care utilization.

The futility of intraoperative frozen section in the evaluation of follicular thyroid lesions

OBJECTIVE

Investigate the utility of intraoperative frozen section (iFS) in patients with follicular thyroid lesions following publication of the 2015 American Thyroid Association (ATA) guidelines.

STUDY DESIGN

Retrospective chart review.

METHODS

Patient demographics, preoperative cytology, frozen pathology, and final pathology were reviewed on patients undergoing thyroid surgery at a tertiary care hospital in which iFS was utilized over a 5-year period. The test performance of iFS and the frequency of indicated completion/total thyroidectomies pre- and postpublication of the 2015 ATA guidelines were calculated.

RESULTS

One hundred and one patients met inclusion criteria: 54 patients with follicular lesions of undetermined significance (FLUS) and 47 patients with a cytologic diagnosis of suspicious for follicular neoplasm/follicular neoplasm. The malignancy rate was 36%, but only 14% of malignancies were identified on iFS. A definitive benign or malignant diagnosis was given on iFS in only 21% of cases, and operative management was altered in two cases as a result of iFS. There was a statistically significant reduction in the frequency of indicated total/completion thyroidectomies based on high-risk features as a result of the 2015 ATA guidelines compared to prior recommendations (20.8% vs. 5.0%, P = < 0.001). None of these patients had findings on iFS that would have altered management intraoperatively.

CONCLUSION

Intraoperative frozen section offers minimal diagnostic utility in the evaluation of follicular thyroid lesions. Updates in the 2015 ATA guidelines further diminish its potential to impact management intraoperatively. Significant improvements in its ability to identify malignancies would be needed to justify its use.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:1501-1505, 2018.

Thyroglobulin antibodies as a potential predictive marker of papillary thyroid carcinoma in patients with indeterminate cytology

BACKROUND

We investigated the efficacy of thyroglobulin antibodies (TgAb) in detecting malignancy in indeterminate thyroid nodules and evaluated the possible association between TgAb and autoimmunity in papillary thyroid carcinoma (PTC).

METHODS

This retrospective, nonrandomized study included 1,646 patients who had undergone preoperative fine-needle aspiration biopsy to evaluate their thyroid nodules, and then standard total thyroidectomy. Of 194 patients (11.8%) with indeterminate nodules, 61 (31.4%) had PTC and 133 (68.6%) had benign nodules at the final histologic examination.

RESULTS

Univariate analysis showed that multifocality (P = .002), bilaterality (P = .003), lymph-node metastasis (P = .030), and capsule penetration (P = .003) were significantly associated with positive TgAb in patients with indeterminate cytology and histopathologic diagnosis of PTC. The multivariate analysis showed that TgAb positivity (P < .001) and preoperative thyroid-stimulating hormone levels (P = .022) were independent predictive factor for PTC diagnosis in patients with indeterminate cytology.

CONCLUSIONS

Preoperative TgAb could be a marker for PTC in patients with indeterminate thyroid nodules, increasing diagnostic accuracy. TgAb positivity could also influence the clinical assessment and subsequent selection of total thyroidectomy.

Thyroglossal duct remnant carcinoma: beyond the Sistrunk procedure

Thyroglossal duct remnants (TGDRs) account for more than 70% of anterior neck masses in children and 7% in adults; however, cancer is identified in only 1-2% of the cases. The diagnosis of a TGDR is based on clinical manifestation of a painless, anterior neck swelling, which elevates with swallowing. Cytological evaluation with fine needle aspiration and biopsy (FNAB) may facilitate the pre-operative diagnosis of malignancy, as the majority of TGDR cancers are of papillary histotype. The recommended treatment for symptomatic TGDR without evidence of malignancy is a Sistrunk procedure, which entails en bloc resection of the remnant and the mid-portion of the hyoid bone. The optimal management of patients with diagnosed malignancy is controversial, and in the past, additional total thyroidectomy was recommended for all of these patients. The purpose of this study is to review the literature on TGDR carcinomas, present the evidence on the available diagnostic tools, identify the surgical and post-operative medical management strategies, discuss current controversies, and conclude with a management algorithm.

Better understanding in the differentiation of thyroid follicular adenoma, follicular carcinoma, and follicular variant of papillary carcinoma: a retrospective study

Background. To evaluate the role of ultrasonography (US), US-guided fine-needle aspiration (USFNA) and intraoperative frozen section (FS) in follicular neoplasm. Methods. US features, USFNA cytology, and FS results were compared based on the pathology results of patients with follicular adenoma (FA), follicular carcinoma (FC), and follicular variant of papillary thyroid carcinoma (FVPTC). Results. FC and FVPTC showed significantly higher rates of suspicious US features (P < 0.05) and positive findings on either US or cytology, 80.0% and 90.7%, compared to FA, 64.5% (P = 0.001). Intraoperative FS showed higher malignant rates in FVPTC and FC (81.8% and 75.0%, resp.), compared to FA (3.8%, P < 0.001). Conclusion. Suspicious US features were more significantly seen in FC and FVPTC compared to FA. Intraoperative FS is useful in the differential diagnosis of these lesions and supplements cytology results of USFNA.

High prevalence of papillary thyroid microcarcinoma in danish patients: a prospective study of 854 consecutive patients with a cold thyroid nodule undergoing fine-needle aspiration

We aimed to investigate the diagnostic accuracy of ultrasound (US)-guided fine-needle aspirates (FNAs) obtained from 854 consecutive Danish patients with a scintigraphically cold thyroid nodule in a borderline iodine-deficient area. Clinical, sonographic, and pathological findings in patients with a cold thyroid nodule undergoing US-guided FNA were prospectively registered. 408 patients underwent thyroid surgery, resulting in 50 cancers and in addition 37 patients had an incidental finding of papillary thyroid microcarcinomas. Based on the diagnostic FNA, we found sensitivity and specificity for malignancy of 73.9 and 99.2%, respectively. The positive and negative predictive values of a diagnostic FNA for malignancy were 89.5 and 97.7%. We identified 6 false-negative and 2 false-positive diagnoses. Solid versus cystic feature of the nodule, as well as >2 high-risk US features, were predictive for malignancy. Cancer incidence was 13% among females and 9% among males. The accuracy of a diagnostic set-up based on clinical examination, scintigraphy, US, and US-guided FNA was determined with a 48% rate of histopathological validation in the cohort. The overall thyroid cancer incidence has increased worldwide, but our results suggest that the most frequent occurring cancer is an incidental papillary thyroid microcarcinoma of which the clinical significance has yet to be established.

Reflex BRAF testing in thyroid fine-needle aspiration biopsy with equivocal and positive interpretation: a prospective study

BACKGROUND

The BRAF V600E mutation has been reported in 50%-80% of papillary thyroid carcinoma (PTC) cases and is highly specific for PTC. Reflex BRAF testing may improve the diagnostic accuracy of thyroid fine-needle aspiration (FNA) tests having equivocal cytologic interpretations and provide prognostic information that helps guide management in patients with PTC.

PATIENTS AND METHODS

Cases with equivocal thyroid FNA readings (indeterminate and suspicious for PTC) or a positive diagnosis for PTC and concomitant BRAF mutation analysis were included in this prospective study. BRAF mutation analysis was performed by polymerase chain reaction combined with single-strand conformation polymorphism gel electrophoresis using lavage fluid obtained from needle rinsing. The results of histopathologic follow-up were correlated with the cytologic interpretations and BRAF status.

RESULTS

One hundred fifty-seven FNAs with equivocal or positive cytologic interpretations were eligible for the study. All but one (99.4%) FNAs were found to have sufficient DNA quality and quantity for the assay. Based on the follow-up diagnosis of nodules after surgical resection, the sensitivity for diagnosing PTC was 63.3% with cytology alone and 80.0% with the combination of cytology and BRAF testing, respectively. No false positives were noted with either cytology or BRAF mutation analysis. All PTCs with extrathyroidal extension and of tall-cell variant were postive for BRAF mutation.

CONCLUSIONS

BRAF V600E mutation analysis can be easily performed on cytologic preparation using lavage fluids obtained from needle rinsing. By combining morphologic evaluation and BRAF testing, there is a substantial improvement in the preoperative identification of PTC when compared with cytology alone. Patients with equivocal cytologic diagnosis and BRAF V600E mutation are candidates for total thyroidectomy ± central lymph node dissection.

Operative Decision-Making for Follicular Thyroid Lesions: A Community Hospital System Experience

Follicular neoplasms of the thyroid are a frequent indication for surgery of the thyroid gland. We evaluated the use of frozen sections on intraoperative decision-making, possible avoidance of reoperative surgery, and histologic findings in a retrospective cohort. A database was created of all thyroid operations from 2001 to 2007. Data collected included age, gender, preoperative cytology, indication for surgery, surgeon, intraoperative decision-making, and histologic findings. Of the 723 thyroidectomies, 203 were performed for follicular neoplasms diagnosed by fine needle aspiration. Of these, 135 had cytology reports available within our electronic medical record; 44 per cent (59 of 135) of these patients had an intraoperative frozen section. Only two of 59 (3.4%) were positive for carcinoma, both of which were papillary carcinomas. One was interpreted as “suspicious” for carcinoma by the pathologist. In these three cases, the surgeon proceeded with total thyroidectomy at the time of initial surgery. The results of frozen section altered the operation in only three of 59 cases (5.1%). Intraoperative frozen section rarely impacts the conduct of thyroidectomy for follicular neoplasms.

Thyroid nodules; interpretation and importance of fine-needle aspiration (FNA) for the clinician - practical considerations

Thyroid nodules are very common lesions. Despite that the great majority is benign, in a significant percentage of them there is an underlying malignancy. Malignant thyroid nodules should be managed surgically, while the more common benign thyroid nodules may be managed conservatively. A systemic and careful diagnostic evaluation is needed to recognize nodules (overtly malignant or with malignant potential), and to avoid unnecessary surgery in a large percentage of patients with benign disease. Fine-needle aspiration (FNA) has a central role in the diagnostic investigation of the patient with thyroid nodules. FNA is a safe, useful, and cost-effective procedure. To increase accuracy, FNA can be performed under ultrasonographic guidance (if needed). Its results may be particularly helpful in determining the indication for surgery. In contrast, the role of FNA in selecting the extent of surgery is limited today. This is due to the fact that during the last decade there is a clear trend toward radical surgical management of thyroid nodular disease (both benign and malignant) by total/near-total thyroidectomy.

An Audit Study of the Sensitivity and Specificity of Ultrasound, Fine Needle Aspiration Cytology and Frozen Section in the Evaluation of Thyroid Malignancies in a Tertiary Institution

Introduction: The aim of this study was to conduct an audit of the sensitivity and specificity of ultrasound, fine needle aspiration cytology (FNAC) and frozen section in the evaluation of thyroid malignancies in our practice. Materials and Methods: The medical records of all the patients who underwent thyroid surgery in a tertiary institution’s General Surgery Department between January 2005 and December 2007 were retrospectively reviewed using a standardised data collection template. Results of the ultrasounds, FNACs and frozen sections were compared with the final histological diagnosis. Results: A total of 112 patients underwent thyroid surgery in the 3-year study period. Thyroid malignancy constituted 34 (30%) of all patients who underwent thyroid surgery. The most popular diagnostic tools used were ultrasound (81%), FNAC (69%) and frozen section (59%). The sensitivity of ultrasound, FNAC and frozen section were 41.4%, 86.4% and 68.8%, respectively. FNAC was shown to be a superior diagnostic test in detecting malignancy compared to ultrasound. FNAC was able to pick up 53% of thyroid cancers missed by ultrasound. Frozen section was able to pick up 33% of thyroid cancers that were missed by both ultrasound and FNAC. Conclusion: FNAC is the most reliable tool in detecting malignancies and ought to form the mainstay for investigation of thyroid nodules. The utilisation of ultrasonographic features in the evaluation of thyroid nodules might not necessary improve the detection rate of thyroid malignancy. Frozen section helps to improve the detection ate of thyroid malignancy but further studies into its cost-effectiveness ought to be performed. Key words: Investigations, Thyroid lesions

[Methodology for evaluation of malignancy screening in surgical thyroid gland disease]

INTRODUCTION

We review a methodology for detection of malignancy in thyroid gland surgery, comparing clinical exploration, ultrasonography, gammagraphy, fine-needle aspiration (FNA) and extemporaneous biopsy with the definitive pathological results.

MATERIAL AND METHODS

We carried out a retrospective study on a sample of 433 (N=433) patients who had been intervened due to thyroid gland disease at the same ENT centre between 1999 and 2004. We collected information focusing on the characteristics of cervical exploration, ultrasonography, gammagraphy, FNA, extemporaneous biopsy and definitive pathological results.

RESULTS

With N=433, the male/female ratio was approximately 1/9 (m/f 1/9), the average age was 45.5 years, with a range between 13 and 87 years, and with 20.3% of referred family history of thyroid gland disease; the cervical exploration, ultrasonography ang gammagraphy were not good tests for the screening of malignancy; FNA and extemporaneous biopsy offered 74% and 81% of sensitivity (Se), and 73% and 92% of specificity (Sp) in the detection of malignancy. The specific sensitivities towards papillary carcinoma of FNA and extemporaneous biopsy were 81% and 88%, whilst for follicular carcinoma they were 66% and 62.5%, respectively.

CONCLUSIONS

FNA has good sensitivity in clinical suspicion of thyroid papillary carcinoma, although it should be complemented by extemporaneous biopsy due to its better specificity. In the case of follicular carcinoma there is a tendency towards conservative treatment, without carrying out extemporaneous biopsy previously and with reintervention in case of definitive malignancy.

Clinical efficacy of fine-needle aspiration biopsy of thyroid nodules in males

BACKGROUND

It has recently been suggested that the use of fine-needle aspiration (FNA) biopsy of thyroid nodules in male patients is associated with an unacceptably high false-negative rate in the detection of thyroid malignancy. We hypothesize that FNA biopsy is an accurate preoperative tool for detecting thyroid cancer in men, and that false negative rates are significantly lower than recently reported.

MATERIALS AND METHODS

A retrospective database analysis was performed on all male patients who underwent thyroid surgery from May 1994 through January 2007 at a single institution. The results of preoperative FNA biopsies were compared with final surgical pathologic results. FNA biopsy results were reported as benign, malignant, inconclusive (i.e., follicular neoplasm), or nondiagnostic; final surgical pathology was reported as benign or malignant.

RESULTS

Of 1205 patients who underwent thyroidectomy, 273 (23%) were male. Preoperative FNA biopsy results were obtained in 60% of these male patients and were read as benign in 45/165 (27%) patients, malignant in 47/165 (28%) patients, inconclusive in 66/165 (40%) patients, and nondiagnostic in 7/165 (4%) patients. In male patients with cytology reported as benign, 3/45 (6.7%) FNAs were determined to be malignant on final pathology.

CONCLUSIONS

Our study determined that FNA biopsy of thyroid nodules in male patients has an acceptably low false-negative rate of 6.7% and is, therefore, an accurate and useful diagnostic tool. We recommend preoperative FNA biopsy for all male patients presenting with thyroid nodules as a standard of practice.

A meta-analysis of comparing fine-needle aspiration and frozen section for evaluating thyroid nodules

The literature on comparing fine-needle aspiration (FNA) and frozen section for evaluating thyroid nodules was reviewed. Publications on this subject were divided into three groups (follicular lesions, non-follicular lesions and thyroid lesions, not otherwise specified). A meta-analysis was done to compare sensitivity, specificity, and positive and negative predictive values between FNA and frozen section diagnoses. For follicular lesions, FNA was much more sensitive but less specific, with lower positive predictive value than frozen section. FNA and frozen section are virtually identical in all parameters of accuracy in evaluating thyroid nodules that are not follicular lesions. The third group of publications that did not separate/specify follicular lesions from non-follicular lesions was non-contributory.

A morpho-molecular diagnosis of papillary thyroid carcinoma: BRAF V600E detection as an important tool in preoperative evaluation of fine-needle aspirates

BACKGROUND

Although most thyroid nodule fine-needle aspiration (FNA) diagnoses are definitive or nearly definitive, about 30% of them are not read as definitively benign or malignant, the so-called indeterminate or suspicious FNA diagnosis. The prevalence of malignancy in FNA samples with these diagnoses varies from 10% to 52%. The first aim of this study was to determine if BRAF V600E analysis of thyroid FNA cytological smears could be performed with a relatively simple protocol. We also sought to determine if assessing the presence of BRAF gene mutations in preoperative FNA cytology slides would provide diagnostic information for FNA samples with a reading of indeterminate or suspicious thyroid lesions.

METHODS

DNA was extracted directly from FNA-stained smears of 111 patients with thyroid lesions having different cytological diagnoses. There was 1 cystic nodule, 20 microfollicular proliferations without atypia, 32 that were suspicious for papillary carcinoma, 56 papillary thyroid carcinomas (PTC), and 2 poorly differentiated carcinomas. The BRAF V600E mutational status was determined by sequencing analysis in all patients. The histopathological diagnosis was obtained in all cases.

RESULTS

We observed that 56/90 (62.3%) patients received a definitive diagnosis of PTC when only cytology was used. After molecular analysis, the BRAF V600E mutation was detected in 18/32 (56.2%) cases with a cytology of suspicious for papillary carcinoma and 41/56 (73.2%) with PTC. According to the morpho-molecular analysis (i.e., traditional cytology combined with BRAF V600E analysis) 74/90 (82.2%) patients could be assigned a definitive diagnosis of PTC. Therefore, the addition of molecular analysis yielded an increase of 20% in the sensitivity compared to cytology alone.

CONCLUSIONS

The method of molecular analysis of thyroid FNA smears described here can be easily performed after the FNA, thereby avoiding inconvenience and additional time during the FNA and permitting later analysis of samples having indeterminate cytology features. The increased sensitivity of this preoperative morpho-molecular analysis should provide information that is useful in deciding the extent of thyroid surgery for thyroid nodules that are indeterminate or suspicious on cytology.

The role of intraoperative frozen section if suspicious for papillary thyroid cancer

BACKGROUND

Optimal surgical intervention is straightforward when a fine-needle aspiration (FNA) is diagnostic for papillary thyroid cancer (PTC). However, if there are characteristics of an aspirate suspicious for PTC but not meeting criteria for diagnosis of PTC, the management is less clear.

METHODS

Of the 1,051 patients who underwent thyroid surgery at the University of Wisconsin between May 24, 1994, and October 21, 2004, 102 had preoperative FNA cytology that was diagnostic or suspicious for PTC. Within the subgroups of diagnostic for PTC and suspicious for PTC, we evaluated the accuracy of FNA, the utility of frozen section (FS), and the predictive value of demographic and pathologic variables.

RESULTS

When diagnostic for PTC, FNA was 97% accurate and FS did not alter management. However, if an FNA was interpreted as suspicious for PTC, there was a 57% (17/30) likelihood of PTC on permanent histology. In this subgroup, FS led to the optimal operative procedure in 96% (25/26) of cases. With the exception of size greater than 4 cm, demographic and pathologic variables did not predict malignancy or increase the likelihood of an FNA being diagnostic for PTC.

CONCLUSION

Intraoperative FS is a useful diagnostic tool when an FNA is suspicious for PTC.

An updated audit of fine needle aspiration cytology procedure of solitary thyroid nodule

This study was conducted to see the sensitivity, specificity, and accuracy of fine needle aspiration cytology (FNAC) for solitary thyroid nodules and to compare our experience with that of other regions of the world. It was a prospective cross sectional study conducted on 76 thyroid samples submitted and reported at the Department of Pathology, King Edward Medical University, Lahore. There were 65 (85.5%) females and 11 (14.5%) males. Male to female ratio was 1:5.9. Ages of the patients ranged from 10 to 60 year with mean age 35.37 +/- 12.17. Thirty-three (43.42%) samples were indeterminate. There were 30 cases (39.47%) of benign lesions, comprising of colloid goiter, follicular adenoma, and diffuse hyperplasia. The final reports of these cases were almost the same. On FNAC, 13 cases were declared as malignant (6 cases) or suggestive of malignancy (3 cases) or suspicious for malignancy [4 cases (5.26%)]. Only 9 cases (11.84%) were clearly committed as malignant lesions, comprising of papillary carcinoma, anaplastic carcinoma and suggestive of follicular carcinoma. Comparison of malignant cases on histopathology (14 cases) was close to that of FNAC (13 cases). After comparison of FNAC results with histopathology, overall sensitivity of FNAC was found to be 90%, specificity 87.5%, and accuracy 87%, while positive predictive value (PPV) was 93% and negative predictive value (NPV) was 79.5%. In conclusion, we recommend this procedure in the light of views of other experts as a primary investigation of thyroid lesions. We strongly recommend the suggestion that in a patient with one or more thyroid nodule, FNAC should be advised for every patient for exclusion of cancer. We will also encourage the clinicians to embrace this procedure in the initial management of patients. As FNAC is inexpensive, sensitive, specific, and an accurate procedure it should be adapted as an initial investigation of thyroid diseases in all tertiary hospitals in developing countries like Pakistan.

Fine-needle aspiration may miss a third of all malignancy in palpable thyroid nodules: a comprehensive literature review

BACKGROUND

Fine-needle aspiration (FNA) is currently the primary diagnostic procedure in diagnosing thyroid malignancy and guides surgeons on patient selection for thyroidectomy for thyroid nodules. Diagnostic sensitivity is reported to be approximately 80%; however, patients with negative FNA results do not necessarily undergo surgery and are often not considered in statistical analysis. This may lead to bias in previous reported sensitivity of FNA. The aim of this study was to assess the diagnostic performance attributes of FNA based on a comprehensive review and summary of previous literature.

METHODS

A comprehensive review of published literature from 1966 to 2005 was performed, using structured selection and appraisal methods to include all studies that have assessed the sensitivity of FNA for detecting thyroid malignancy in palpable thyroid nodules. A statistical modeling study was designed to estimate the possible true sensitivity and specificity of FNA.

RESULTS

Twelve studies fulfilled inclusion criteria and were included in the review. Only 1 study had greater than 25% of patients with negative FNA results who proceeded to thyroidectomy. Statistical modeling indicated that the sensitivity of FNA is highly dependent on the risk of malignancy in the patients with negative FNA results who did not undergo thyroidectomy; in the "same risk" scenario, where the risk of malignancy in the whole group with negative FNA result was assumed to be the same as that in patients with negative FNA results who underwent surgical biopsy; sensitivity could be as low as 66% (confidence interval [CI]: 65-68%).

CONCLUSION

Based on existing reports, the true diagnostic attributes of FNA for thyroid malignancy in palpable nodules are uncertain and FNA could miss up to a third of all thyroid malignancy. Further research is required to investigate the incidence of malignancy in FNA negative cases and to determine the additive effect of clinical judgment.

Intraoperative pathologic examination: cost effectiveness and clinical value in patients with cytologic diagnosis of cellular follicular thyroid lesion

OBJECTIVE

Routine use of intraoperative pathologic examination (IOPE), including frozen section (FS) and scrape preparation cytology (SPC), during diagnostic thyroid lobectomy continues to be a source of controversy. We sought to better delineate the usefulness and cost-benefit ratio of IOPE in the context of cytologically diagnosed cellular follicular lesion (CFL) or follicular neoplasm (FN).

DESIGN

Records of 205 patients who underwent thyroidectomy for cytologically diagnosed FN or CFL between 1997 and 2005 were retrospectively reviewed. IOPE results, patient demographics, and tumor characteristics were correlated to final histopathologic diagnoses. Sensitivity, specificity, predictive values, accuracy, and costs of IOPE were calculated.

MAIN OUTCOME

IOPE correctly identified 3 of 16 follicular carcinomas and 9 of 36 papillary carcinomas. Sensitivity, specificity, and accuracy were 23%, 99%, and 78%, respectively. On univariate analysis, malignancy risk among follicular nodules did not correlate with age, gender, or nodule size. On multivariate analysis, nodule size was predictive of malignancy (p < 0.05). Over the entire patient series, routine IOPE resulted in a net cost savings of $74,304.33.

CONCLUSIONS

IOPE reduced costs and limited the number of completion thyroidectomies necessary. IOPE is specific, cost effective, and of minimal additional risk when performed routinely for patients with CFL or FN.

Surgical Treatment of Solitary Thyroid Nodules Via Fine-Needle Aspiration Biopsy and Frozen-Section Analysis

BACKGROUND

Fine-needle aspiration biopsy (FNAB) and frozen-section analysis of managing solitary thyroid nodules continue to generate considerable controversy.

METHODS

This study was a retrospective review of 619 patients with solitary thyroid nodules who underwent thyroidectomy.

RESULTS

Of 540 FNABs, 35 (6.5%) were positive for malignancy, 276 (51.1%) were benign, and 229 (42.4%) were suspicious. Only 5.1% were false negative, and 11.4% were false positive. Diagnostic FNAB sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy for malignancy were 86.1%, 59.7%, 33.0%, 94.9%, and 64.6%, respectively. Of 569 patients analyzed by frozen section, diagnosis was deferred in 86 (15.1%) patients, and results were positive for malignancy in 92 (16.2%) and benign in 391 (68.7%). No false-positive results were noted, but 2.3% (391) were false negative. Of 86 deferred frozen sections, 11 (12.8%) patients had malignant tumors confirmed by permanent section. Diagnostic frozen-section sensitivity, specificity, PPV, NPV, and accuracy for carcinoma were 82.1%, 100%, 100%, 95.8%, and 96.5%, respectively. Sensitivity, specificity, PPV, NPV, and accuracy for frozen-section analysis for diagnosis of carcinoma in patients with suspicious FNAB were 83.9%, 100%, 100%, 94.9%, and 96.0%, respectively.

CONCLUSIONS

FNAB is a sensitive diagnostic modality in selecting patients who require surgery. Routine use of frozen-section analysis is unwarranted for benign FNAB results. Frozen section is specific and cost-effective in determining the extent of surgery in patients with suspicious or malignant FNABs.

Fine-needle aspiration optimizes surgical management in patients with thyroid cancer

BACKGROUND

Fine-needle aspiration (FNA) is accurate in diagnosing papillary, medullary, and anaplastic thyroid cancer, as well as lymphoma. Although many surgeons routinely perform FNA before surgery, some question whether FNA influences operative management. Therefore, to determine whether FNA affects surgical management in patients with thyroid cancer, we reviewed our experience.

METHODS

A total of 442 consecutive patients underwent thyroid surgery at 1 academic center. Of these, 411 had surgery for an index nodule in the absence of previous radiation or familial thyroid cancer. FNA, operative, and permanent histology findings were reviewed.

RESULTS

The average patient age was 46 years, and 79% were female. A total of 211 patients (51%) had a preoperative FNA, and 71 (17%) had a final diagnosis of cancer. The sensitivity and specificity of FNA for thyroid cancer were 89% and 92%, respectively. In the FNA group, 1 (2.4%) of 41 patients with papillary thyroid cancer required completion thyroidectomy. In contrast, in the no-FNA group, 4 (40%) of 10 patients with papillary thyroid cancer required a second operation. No patient in the FNA group received thyroid resection for lymphoma, whereas three (100%) of three patients with lymphoma in the no-FNA group were treated surgically. A total of 98% of the FNA group, compared with 54% of the no-FNA group, received optimal surgical treatment for thyroid cancer.

CONCLUSIONS

FNA is a sensitive and specific test for the diagnosis of thyroid cancer, allowing definitive initial surgery and avoiding unnecessary procedures. Therefore, we recommend routine use of preoperative thyroid FNA, even in those patients in whom a resection is already planned.

Utility of BRAF V600E mutation detection in cytologically indeterminate thyroid nodules

Background

Fine needle aspiration (FNA) is widely utilized for evaluation of patients with thyroid nodules. However, approximately 30% are indeterminate for malignancy. Recently, a mutation in the BRAF gene has been reported to be the most common genetic event in papillary thyroid carcinoma (PTC). In this retrospective study, we assessed the utility of BRAF V600E mutation detection for refining indeterminate preoperative cytologic diagnoses in patients with PTC.

Methods

Archival indeterminate thyroid FNAs and corresponding formalin-fixed, paraffin-embedded (FFPE) surgical samples with PTC were identified in our patient files. DNA extracted from slide scape lysates and 5 μm FFPE sections were evaluated for the BRAF V600E mutation using LightCycler PCR and fluorescent melting curve analysis (LCPCR). Amplification products that showed deviation from the wild-type genomic DNA melting peak, discordant FNA and FFPE matched pairs, and all benign control samples, underwent direct DNA sequencing.

Results

A total of 19 indeterminate thyroid FNAs demonstrating PTC on FFPE surgical samples were included in the study. Using BRAF mutation analysis, the preoperative diagnosis of PTC was confirmed in 3/19 (15.8%) FNA samples that could not be conclusively diagnosed on cytology alone. However, 9/19 (47.4%) FFPE tissue samples were positive for the V600E mutation. Of the discordant pairs, 5/6 FNAs contained less than 50% tumor cells.

Conclusion

When used with indeterminate FNA samples, BRAF mutation analysis may be a useful adjunct technique for confirming the diagnosis of malignancy in an otherwise equivocal case. However, overall tumor cell content of some archival FNA smear slides is a limiting factor for mutation detection.

Prognostic factors for sporadic medullary thyroid carcinoma

INTRODUCTION

Medullary thyroid carcinoma (MTC) originates from the thyroid parafollicular cells and accounts for 3% to 10% of all thyroid malignancies. Approximately 84% of cases are sporadic. The aim of this study was to evaluate the outcomes of treatment for sporadic medullary thyroid carcinoma (SMTC) and define the prognostic factors for overall survival.

METHODS

The records of 32 SMTC patients treated at Ankara Oncology Education and Research Hospital between September 1993 and April 2003 were retrospectively evaluated. The effects of age, gender, tumor localization, extent of the primary surgical resection, tumor size, capsule invasion, lymph node metastasis, extranodal extension, tumor stage, local recurrence, and distant metastasis on the overall survival rate were evaluated by univariate and multivariate analyses.

RESULTS

There were 32 patients (19 females, 13 males) with a median age of 45 years (21-76 years). Altogether, 22 patients had undergone complete resection and 10 patients incomplete resection. The median follow-up was 48 months (9-111 months), and the overall 5-year survival rate was 51%. Based on the univariate analysis, the extent of primary surgical resection, pathologic tumor size, capsule invasion, lymph node invasion, extranodal extension, tumor stage, local recurrence, and distant metastasis were factors that significantly affected survival. In the multivariate analysis, however, only the extent of the primary surgical resection, capsule invasion, and distant metastasis were found to be statistically significant factors.

CONCLUSIONS

The extent of the primary surgical resection significantly influences the survival of patients with SMTC. Capsule invasion and distant metastasis were additional factors affecting the prognosis.

Utilidad de la biopsia intraoperatoria en el tratamiento quirúrgico del nódulo tiroideo

OBJECTIVE

To present our experience of the use of frozen section (FS) in the operative management of thyroid nodules and determine the utility of this procedure when deciding the extent of thyroidectomy.

PATIENTS AND METHOD

We performed a prospective and comparative study. The FS of patients who underwent surgery for thyroid nodules between 1995 and 2002 were evaluated. The results were compared with those of fine-needle aspiration cytology (FNA) and definitive biopsy. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy of both FNA and FS were calculated.

RESULTS

There were 469 thyroidectomies and 179 FS were performed. The results obtained for FNA and FS were, respectively: PPV: 100%/100%; NPV: 89%/90%; diagnostic accuracy: 89.5%/91%. When only "follicular hyperplasia" was included as the cytologic diagnosis, the PPV and NPV for FS were 100% and 86.7%, respectively.

CONCLUSION

The diagnostic accuracy of FNAC and FS is similar. In cases of follicular hyperplasia, the sensitivity of FS is too low to rule out malignancy.

Frozen section of thyroid and parathyroid specimens

CONTEXT

Preoperative fine-needle aspiration of thyroid lesions has greatly diminished the need for surgical evaluation. However, because thyroid nodules are common lesions, many still require surgical intervention and represent a substantial number of cases that the pathologist encounters in the frozen section laboratory.

OBJECTIVE

Comprehensive reviews of frozen section indications, as well as gross, cytologic, and histologic features of the most common and diagnostically important thyroid and parathyroid lesions, are presented to provide a guideline for proper triage and management of these cases in the frozen section laboratory. The most common pitfalls are discussed in an attempt to avoid discordant diagnoses.

DATA SOURCES

Thyroid lobectomy, subtotal or total thyroidectomy, and parathyroid biopsy or parathyroidectomy cases are included in this review.

CONCLUSIONS

The frozen section evaluation of thyroid and parathyroid lesions remains a highly accurate procedure with a low false-positive rate. Gross inspection, complemented by cytologic and histologic review, provides the surgeon with the rapid, reliable, cost-effective information necessary for optimum patient care.

Human telomerase reverse transcriptase gene expression and the surgical management of suspicious thyroid tumors

PURPOSE

Patients with a preoperative cytologic diagnosis of a suspicious thyroid nodule present a therapeutic dilemma because surgery differs for benign and malignant lesions. To address this issue, several molecular markers, including human telomerase reverse transcriptase (TERT), have been tested as markers of thyroid cancer. Because most studies select cases falling into well-defined categories to test new markers, they may overestimate their discriminatory power when applied to samples that are difficult to classify. Fine-needle aspirates (FNAs) of the thyroid with indeterminate cytology are an example of such cases.

EXPERIMENTAL DESIGN

We examined whether assessing TERT mRNA by reverse transcription-PCR could have improved the surgical management in a cohort of 100 patients undergoing thyroidectomy for indeterminate FNA results.

RESULTS

Ninety percent of 48 cancers were TERT positive, as were 35% of 52 benign lesions. When 10 cases with concomitant lymphocytic thyroiditis were excluded, the overall sensitivity of TERT was 91% (95% confidence interval, 80-98%) and specificity was 79% (64-90%). No clinical or tumor variable contributed to the predictive ability of TERT except for tumor size, which added only marginally. Basing the surgical approach on the TERT assay alone would have reduced lobectomies performed for malignant disease from 11 to 4 cases and reduced total thyroidectomies for benign lesions from to 15 to 9, an overall 50% reduction in suboptimal treatment.

CONCLUSIONS

The overall performance of preoperative differential diagnosis for thyroid tumors with indeterminate FNA results can be substantially improved by the inclusion of molecular markers such as TERT.

Reporting thyroid fine-needle aspiration: Literature review and a proposal

Reporting schemes for thyroid fine-needle aspirations in the literature were reviewed and classified according to the number of categories in the scheme and the significance of each category. The sensitivity, specificity, and positive predictive and negative values were determined for each scheme, if possible. A reporting scheme based on the probability of finding carcinoma on histology is proposed.

Role of Fine-needle Aspiration Biopsy and Frozen Section in the Management of Papillary Thyroid Carcinoma Subtypes

Since fine-needle aspiration biopsy (FNAB) was introduced, the value of frozen section (FS) has been questioned. This study compares FNAB and FS sensitivities among the usual form of papillary thyroid cancer (uPTC) and variants of PTC such as tall cell (tcPTC), follicular (fPTC), and Hurthle cell (HcPTC). A total of 257 patients who underwent preoperative FNAB, intraoperative FS, and thyroidectomy for PTC were, randomly selected from a database of a university teaching hospital in Toronto. There were 218 females (84.8%) and 39 males (15.2%), from 19 to 89 years of age (mean of 44 years), having uPTC (n = 212), fPTC (n = 24), HcPTC (n = 14), and tcPTC (n = 7). Data were analyzed using chi2 test. Sensitivities were calculated by division of true positives and by the sum of true positives and false negatives. True positives had to reflect a conclusive diagnosis of cancer. The FNAB sensitivities were uPTC (39.2%), fPTC (25%), HcPTC (42.9%), tcPTC (85.7%), similar to FS sensitivities (p = 0.497) for uPTC (44.3%), fPTC (16.7%), HcPTC (42.9%), and tcPTC (71.4%). Use of FS following FNAB increased sensitivities for uPTC to 56.1%, fPTC to 29.2%, and tcPTC to 100%. In addition, FS did not increase FNAB sensitivity in HcPTC. Combination FNAB plus FS failed in 43.9% of uPTC, 70.8% of fPTC, and 57.1% of HcPTC. We concluded that FNAB and FS sensitivity vary with PTC subtype and are still necessary for selection and treatment. The recognition of morphologic subtypes of PTC from the FNAB could optimize the selection of patients for intraoperative FS, enhance the preoperative assessment of prognosis, facilitate the surgical planning, and simplify the preparation of postoperative adjuvant therapy.

Factors Predicting Malignancy of H�rthle Cell Tumors of the Thyroid: Influence on Surgical Treatment

Controversy still exists about the ability to differentiate between malignant and benign Hürthle cell tumors (HCTs) before and during surgery. Diagnostic difficulties make surgical decisions debatable. The aim of this study was to evaluate factors predicting the malignancy of HCT and to plan its appropriate management. From January 1998 to May 2003 a series of 41 patients underwent thyroidectomy in our surgical department because of HCT. A cross-sectional study of 23 patients with carcinoma and 18 patients with adenoma was carried out: demographic data, tumor characteristics, diagnostic results of fine-needle aspiration cytology (FNAC), frozen section (FS), MIBI scan scintigraphy, surgical indications, and treatment were evaluated. The mean tumor size was significantly greater for carcinomas than adenomas (3.1 vs. 1.9 cm; p = 0.006). Threshold sizes of more than 3.0 cm and 4.0 cm, respectively, were significant for predicting malignancy ( p = 0.025 and p = 0.012). Conversely, 47.8% of carcinomas had a diameter smaller than 3.0 cm. FNAC and FS sensitivities for carcinoma detection were 23.8% and 33.3%, respectively. The positive uptake on MIBI scan imaging was likely to be similarly malignant or benign. Because of the lack of accuracy of all diagnostic studies for predicting malignancy, all oxyphilic cell nodules should be referred to surgery. Different tumor sizes cannot be the only factor on which to base a surgical decision. Therefore, because of diagnostic uncertainties, we believe that an experienced surgeon can safely perform total thyroidectomy in all patients with an HCT.

The utility of frozen section evaluation for follicular thyroid lesions

BACKGROUND

Because fine-needle aspiration cannot reliably discriminate between benign and malignant follicular thyroid lesions, some surgeons use intraoperative frozen section (FS) to guide operative management. To determine the utility of FS for these lesions, we reviewed our institutional experience.

METHODS

Between 1994 and 2001, 152 patients underwent surgical resection for follicular neoplasms.

RESULTS

The mean age of the patients was 47 years, and 76% were female. Forty-one (32%) FSs were reported as benign, 5 (4%) as malignant, and 3 (2%) as indeterminate, and in 80 (62%), the diagnosis was "follicular lesion, deferred to permanent histology." On paraffin section, all patients with malignant FSs had thyroid cancer, and all 41 patients with benign FSs had benign lesions. Thus, FS for diagnosis of follicular thyroid cancer had a sensitivity, specificity, positive predictive value, and accuracy of 67%, 100%, 100%, and 96%, respectively. In most cases (64%), FS rendered no additional information at the time of operation. Therefore, the cost per useful FS was $7800, which is higher than the charge of a completion thyroidectomy (approximately $6000).

CONCLUSIONS

FS analysis for follicular lesions seems to be highly specific and accurate. However, because of the low sensitivity, routine use of FS is not cost-effective in patients with follicular thyroid lesions.

Fine-needle aspiration cytology of thyroid nodules: how useful is it?

BACKGROUND

Thyroid nodules are common and the principal method of diagnosis is fine-needle aspiration cytology (FNAC).

METHODS

To determine the value of FNAC in the diagnosis of thyroid nodules, thyroid cytology of 253 patients with definitive histology after surgery was analyzed from 1992 to 2002. FNAC was correlated with histology and the sensitivity, specificity and likelihood ratios were calculated. The method of FNAC and number of non-diagnostic aspirates were noted. The frequency of thyroid cancer was investigated in male and females who presented with a solitary thyroid nodule.

RESULTS

The overall sensitivity of FNAC detecting thyroid neoplasia was 55.0%, specificity 73.7% and accuracy 67.2%. Likelihood ratios indicate that a 'malignant' or 'suspicious for malignancy' cytology dramatically increase the pretest probability of thyroid neoplasia. There were no false positive 'malignant' FNAC. Ultrasound guided FNAC had a significantly lower non-diagnostic rate compared to freehand FNAC (P < 0.02). Of 22 males, 22.7% who proceeded to surgery for their solitary nodule had thyroid carcinoma compared with 11.9% of 167 females (P = 0.02).

CONCLUSIONS

FNAC was essential to management in this series of patients. 'Malignant' or 'suspicious for malignancy' cytology are absolute indicators for thyroidectomy. FNAC should be undertaken with ultrasound guidance and if possible with a pathologist in attendance to assess sample adequacy. We recommend a high index of suspicion of thyroid cancer in the male patient who presents with a solitary nodule. If solitary nodules are to be observed, repeat FNAC should be undertaken because of the high false negative rate.

Evaluation of a thyroid nodule

Solitary thyroid nodules are common entities and the majority of these are benign. The main goal in evaluating these nodules is to identify the [figure: see text] nodules with malignant potentials. A multitude of diagnostic tests is available to the clinician. FNA biopsy is now considered the gold standard diagnostic test in the evaluation of a thyroid nodule. Ultrasound and nuclear scans are also useful tests, but are best used in conjunction with FNA. Clinical decisions are often based on the results of the FNA. A diagram of the clinical decision process based on FNA findings is presented in Fig. 1. Despite the clinical advantages that are provided by the FNA results, the clinician should not dismiss the importance of other clinical prognostic indicators to optimize timely treatment.

Well-differentiated carcinoma of the thyroid

Thyroid cancer will be diagnosed in more than 20,000 individuals in the United States in 2002. Approximately 16,000 of these patients will be women. During the same year, an estimated 1300 deaths from thyroid cancer are expected. The various types of thyroid cancer include papillary carcinoma, follicular carcinoma, Hurthle cell carcinoma, medullary carcinoma, anaplastic carcinoma, and thyroid lymphoma. Papillary, follicular, and Hurthle cell carcinoma are considered well-differentiated thyroid cancers and constitute the focus of this article.

Diagnostic value of frozen section examination in thyroid nodule--surgery at the Shariati Hospital (1997-2000)

INTRODUCTION

There is controversy regarding the use and accuracy of frozen section (FS) in managing thyroid nodules. We compared the diagnostic value of FS with that of permanent histopathology examination and fine needle aspiration (FNA).

MATERIALS AND METHODS

Permanent, FS, and FNA sample reports were compared in 214 patients between 1997 and 2000. FS, FNA, and permanent pathology (gold standard) results were compared using McNemar's test.

RESULTS

160 women and 54 men (mean age: 42.3 +/- 5.4 yr) took part in the study; 163 patients (76%) had benign and 51 (24%) malignant lesions; 76% of our thyroid cancer cases were papillary, 13.5% follicular, 6% medullary carcinoma, 4% Hürthle cell carcinoma, and 0.5% anaplastic carcinoma. FNA yielded definite results in 150 patients (sensitivity 72%, specificity 96%, and precision 90%). In 64 patients with equivocal FNA, FS was performed (sensitivity 36%, specificity 73%, and precision 85%). The observed difference between FNA and FS was not statistically significant.

DISCUSSION

When FNA results are inconclusive, FS does not provide any further information. In suspected cases of papillary, undifferentiated, or medullary carcinomas, FS can confirm FNA findings and guide surgical therapy.

Use of fine-needle aspiration cytology and frozen section in the management of nodular goiters

BACKGROUND

This study evaluates the role of frozen section (FS) in surgical decisions for nodular thyroid disease when a preoperative fine-needle aspiration cytology (FNAC) is available.

MATERIAL AND METHOD

The charts of 113 patients who underwent thyroidectomy for nodular goiter were reviewed. Each patient underwent FNAC, FS, or both. Results were compared with the final pathologic examination to evaluate their effectiveness in predicting malignancy.

RESULTS

The sensitivity and specificity of FNAC alone (49 patients) were 73% and 93.5%, respectively, and of FS (111 patients) 68% and 99%, respectively. The result of fine-needle aspiration cytology was: benign (n = 8), malignant (n = 13), indeterminate (n = 25), and nondiagnostic (n = 3). All cases diagnosed as benign on FNAC were benign on final pathology, but of the six FS performed in these cases, four were benign and two were suspect. Of the 13 FNAC that were interpreted as malignant, 11 and 10 proved to be malignant on final pathology and FS, respectively. The 25 indeterminate cases on FNAC were on final pathology benign (n = 21) and malignant (n = 4) and on frozen section were benign (n = 12), malignant (n = 2), and suspect (n = 11).

CONCLUSION

When results of FNAC are interpreted as benign or malignant, FS is of little value, because it does not change the extension of thyroidectomy. FS proved useful in determining the extent of thyroidectomy only when results of the FNAC were suspect or atypical.

Is thyroid frozen section too much for too little?

BACKGROUND

The role of frozen section (FS) in thyroid disease is controversial. The goal of this study was to identify a cohort of patients who may or may not benefit from FS.

METHODS

Two hundred thirty-one patients who underwent thyroidectomy were evaluated in regard to fine-needle aspiration (FNA), FS, and the extent of surgery.

RESULTS

In all, 155 patients underwent FNA, 140 patients underwent FS, and 103 patients had both. A final diagnosis of malignancy was obtained in 47 of 231 patients. FNA had a sensitivity of 50% and a specificity of 99%, and FS had a sensitivity of 50% and a specificity of 100% for diagnosing malignancy. Accounting for the clinical findings and FNA results, FS results altered the extent of thyroidectomy in 1 of 103 patients.

CONCLUSIONS

The increased costs for the operative time and the pathologists needed to obtain routine FS are not supported with any substantial benefit in patient outcome.

Does frozen section have a role in the intraoperative management of thyroid nodules?

BACKGROUND

Frozen section in thyroid surgery is used to make an intraoperative pathological diagnosis of malignancy in a thyroid nodule at the time of hemithyroidectomy. A positive diagnosis allows completion of thyroidectomy, thus avoiding reoperation. However, the use of fine needle aspiration cytology in making a preoperative diagnosis of cancer has resulted in the lack of a defined role for frozen section. We examined the role of frozen section as an adjunct to fine needle aspiration cytology in determining which cytological subset will benefit from frozen section.

METHODS

All patients who underwent thyroidectomy between 1992 and 2000 by a single endocrine surgeon were reviewed.

RESULTS

Two hundred and nine frozen sections were performed, of which 144 underwent preoperative fine needle aspiration cytology. Frozen sections reported 135 benign nodules, 59 follicular neoplasms, five specimens with suspicious histology and 10 cancers. Ten out of 20 thyroid cancers were correctly identified by frozen section (sensitivity: 50%; specificity: 100%), eight cancers were reported on frozen section as indeterminate and two benign. Of 144 fine needle aspiration cytological procedures, frozen section on seven suspicious aspirates identified two cancers, and frozen section on 70 follicular aspirates identified four cancers, allowing intraoperative conversions to total thyroidectomy. Frozen section on seven malignant aspirates confirmed four cancers but resulted in reoperation for three because of the indeterminate frozen section reports. There were no cancers found on 135 benign aspirates.

CONCLUSIONS

Frozen section on benign aspirates is unhelpful in the management of thyroid nodules. It need not be performed for cytologically proven malignant thyroid nodules. Selective use of frozen section complements fine needle aspiration cytology findings of suspicious or follicular lesions, especially in the subset with papillary cancer, allowing one-stage total thyroidectomy.

The spectrum of thyroid diseases in childhood and its evolution during transition to adulthood: natural history, diagnosis, differential diagnosis and management

In this contribution, we review current knowledge on the pathogenesis, diagnosis and differential diagnosis of thyroid disorders in childhood and adolescence, as well as present an update on therapy methods and management guidelines for these disorders. This overview is conceptually divided into two parts, one focusing on thyroid functional disorders, i.e. conditions leading to hyper- and hypothyroidism, and another one pertinent to structural abnormalities of the thyroid gland, i.e. nodular disorders and thyroid cancer. Currently, congenital hypothyroidism is diagnosed in a much more timely fashion rather than in the past, rendering hypothyroidism-related mental retardation and developmental deficits very rare in newborns and children and, hence, diminishing significantly its public health impact. At the same time, considerable advances have occurred in our understanding of the molecular basis of several genetic conditions affecting the thyroid gland in childhood, such as familial non-autoimmune hyperthyroidism, as well as of the pathways leading to thyroid neoplasia.

Diagnostic accuracy of fine-needle aspiration and frozen section in nodular thyroid disease

OBJECTIVE

To assess the diagnostic accuracy of fine-needle aspiration (FNA) and frozen section (FS) in nodular thyroid disease.

SETTING

Tertiary care academic medical center.

STUDY DESIGN

Retrospective review of 139 consecutive patients undergoing surgery for nodular thyroid disease. FNA and FS sensitivity, specificity, and accuracy were calculated with respect to permanent section histology.

RESULTS

Among 63 patients with an FNA interpreted as either benign (n = 38) or malignant (n = 25), FNA was accurate (sensitivity 89%, specificity 97%, accuracy 94%). FS identified only one case of carcinoma missed by FNA. Among 76 patients with a "suspicious" FNA, FS was reasonably accurate (sensitivity 67%, specificity 100%, accuracy 89%), but was deferred in 50% of cases.

CONCLUSION

Given high FNA accuracy, more selective use of FS is suggested.

SIGNIFICANCE

The study results will assist with intra-institutional patient counseling and intraoperative decision-making with respect to FNA and FS results in patients with nodular thyroid disease.