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Mahjabin F, Gonsalves C, Drew PA, Mukhtar F, Leon ME. Understanding and Overcoming the Pitfalls in Cytopathological Diagnosis of Hyalinizing Trabecular Tumor of Thyroid. Int J Surg Pathol 2024; 32:91-96. [PMID: 37050854 DOI: 10.1177/10668969231166295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
Hyalinizing trabecular tumor (HTT), a rare low-malignant-potential thyroid neoplasm, is usually treated with conservative surgery. However, cytomorphological diagnosis of HTT is challenging due to the significant overlap of nuclear features with more common malignancies such as papillary thyroid carcinoma (PTC), which usually requires more radical surgical intervention. To avoid unnecessary overtreatment, a precise diagnosis of HTT is therefore essential. Advances in molecular diagnostics provide the opportunity to overcome the limitations of cytological analysis. We present a case of HTT in a 71-year-old male who was initially suspected to be PTC based on cytopathology. However, further molecular analysis revealed PAX8::GLIS3 gene fusion, classifying the lesion as HTT and preventing surgical overtreatment. We discuss the diagnostic pitfall of cytopathology in HTT and suggest using emerging molecular genetic tools to avoid it.
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Affiliation(s)
- Fnu Mahjabin
- Department of Pathology, Immunology and Laboratory Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Catherine Gonsalves
- Department of Pathology, Immunology and Laboratory Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Peter A Drew
- Department of Pathology, Immunology and Laboratory Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Faisal Mukhtar
- Department of Pathology, Immunology and Laboratory Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Marino E Leon
- Department of Pathology, Immunology and Laboratory Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
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Brigante G, Craparo A, Pignatti E, Marino M, Monzani ML, De Vincentis S, Casarini L, Sperduti S, Boselli G, Margiotta G, Ippolito M, Rochira V, Simoni M. Real-life use of BRAF-V600E mutation analysis in thyroid nodule fine needle aspiration: consequences on clinical decision-making. Endocrine 2021; 73:625-632. [PMID: 33759074 DOI: 10.1007/s12020-021-02693-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 03/10/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE This study aimed to evaluate the real-life use of BRAF-V600E mutation analysis in washout liquid from thyroid nodule fine needle aspiration (FNA), and the consequences of genetic result on clinical decision-making. METHODS We retrospectively considered subjects tested for BRAF-V600E among those attending the Endocrinology Unit of Modena for FNA between 2014 and 2018. Washing fluid was collected together with cytological sample and stored at -20 °C. If the clinician deemed it necessary, the sample was thawed, DNA extracted, and genetic test performed by high-resolution melting technique. We collected data on cytology according to the Italian Consensus for the cytological classification of thyroid nodules, type of surgery (when performed), histology, and adverse events. RESULTS Out of 7112 subjects submitted to FNA, BRAF analysis was requested for 683 (9.6%). Overall, 896 nodules were analyzed: 74% were indeterminate at cytology, mainly TIR3A (low risk). Twenty-two nodules were mutant (BRAF+). Only 2% of indeterminate, mainly TIR3B, were BRAF+. Based on final histological diagnosis, BRAF test had high specificity (100%) but poor sensitivity (21%), also in indeterminate nodules. Mutant subjects underwent more extensive surgery compared to wild type (p = 0.000), with frequent prophylactic central lymph node dissection. One third had local metastases. Higher prevalence of hypoparathyroidism was found in BRAF+ compared to wild type (p = 0.018). CONCLUSIONS The analysis of BRAF-V600E outside of gene panels has low sensitivity, especially in indeterminate nodules, and a positive result could lead to more extensive surgery with greater risk of hypoparathyroidism and questionable clinical utility.
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Affiliation(s)
- Giulia Brigante
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy.
- Unit of Endocrinology, Department of Medical Specialties, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy.
| | - Andrea Craparo
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
- Unit of Endocrinology, Department of Medical Specialties, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
| | - Elisa Pignatti
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Marco Marino
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Maria Laura Monzani
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
- Unit of Endocrinology, Department of Medical Specialties, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
| | - Sara De Vincentis
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
- Unit of Endocrinology, Department of Medical Specialties, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
| | - Livio Casarini
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
- Center for Genomic Research, University of Modena and Reggio Emilia, Modena, Italy
| | - Samantha Sperduti
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
- Center for Genomic Research, University of Modena and Reggio Emilia, Modena, Italy
| | - Gisella Boselli
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
- Unit of Endocrinology, Department of Medical Specialties, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
| | - Gianluca Margiotta
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
- Unit of Endocrinology, Department of Medical Specialties, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
| | - Margherita Ippolito
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Vincenzo Rochira
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
- Unit of Endocrinology, Department of Medical Specialties, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
| | - Manuela Simoni
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
- Unit of Endocrinology, Department of Medical Specialties, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
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Hu MI, Waguespack SG, Dosiou C, Ladenson PW, Livhits MJ, Wirth LJ, Sadow PM, Krane JF, Stack BC, Zafereo ME, Ali SZ, Weitzman SP, Hao Y, Babiarz JE, Kennedy GC, Kloos RT. Afirma Genomic Sequencing Classifier and Xpression Atlas Molecular Findings in Consecutive Bethesda III-VI Thyroid Nodules. J Clin Endocrinol Metab 2021; 106:2198-2207. [PMID: 34009369 PMCID: PMC8277199 DOI: 10.1210/clinem/dgab304] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Indexed: 12/13/2022]
Abstract
CONTEXT Broad genomic analyses among thyroid histologies have been described from relatively small cohorts. OBJECTIVE Investigate the molecular findings across a large, real-world cohort of thyroid fine-needle aspiration (FNA) samples. DESIGN Retrospective analysis of RNA sequencing data files. SETTING Clinical Laboratory Improvement Amendments laboratory performing Afirma Genomic Sequencing Classifier (GSC) and Xpression Atlas (XA) testing. PARTICIPANTS A total of 50 644 consecutive Bethesda III-VI nodules. INTERVENTION None. MAIN OUTCOME MEASURES Molecular test results. RESULTS Of 48 952 Bethesda III/IV FNAs studied, 66% were benign by Afirma GSC. The prevalence of BRAF V600E was 2% among all Bethesda III/IV FNAs and 76% among Bethesda VI FNAs. Fusions involving NTRK, RET, BRAF, and ALK were most prevalent in Bethesda V (10%), and 130 different gene partners were identified. Among small consecutive Bethesda III/IV sample cohorts with one of these fusions and available surgical pathology excision data, the positive predictive value of an NTRK or RET fusion for carcinoma or noninvasive follicular thyroid neoplasm with papillary-like nuclear features was >95%, whereas for BRAF and ALK fusions it was 81% and 67%, respectively. At least 1 genomic alteration was identified by the expanded Afirma XA panel in 70% of medullary thyroid carcinoma classifier-positive FNAs, 44% of Bethesda III or IV Afirma GSC suspicious FNAs, 64% of Bethesda V FNAs, and 87% of Bethesda VI FNAs. CONCLUSIONS This large study demonstrates that almost one-half of Bethesda III/IV Afirma GSC suspicious and most Bethesda V/VI nodules had at least 1 genomic variant or fusion identified, which may optimize personalized treatment decisions.
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Affiliation(s)
- Mimi I Hu
- Department of Endocrine Neoplasia and Hormonal Disorders, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Correspondence: Mimi I. Hu, MD, Department of Endocrine Neoplasia and Hormonal Disorders, University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1461, Houston, TX 77030, USA.
| | - Steven G Waguespack
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Chrysoula Dosiou
- Department of Medicine, Division of Endocrinology, Gerontology, & Metabolism, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Paul W Ladenson
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Masha J Livhits
- Department of Surgery, Section of Endocrine Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Lori J Wirth
- Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Peter M Sadow
- Department of Pathology, Head and Neck Pathology Subspecialty, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Jeffrey F Krane
- Department of Pathology, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Brendan C Stack
- Department of Otolaryngology-Head and Neck Surgery, Southern Illinois University School of Medicine, Springfield, IL 62794, USA
| | - Mark E Zafereo
- Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Syed Z Ali
- Departments of Pathology and Radiology, The Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Steven P Weitzman
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Yangyang Hao
- Research and Development, Veracyte, South San Francisco, CA 94080, USA
| | - Joshua E Babiarz
- Research and Development, Veracyte, South San Francisco, CA 94080, USA
| | - Giulia C Kennedy
- Departments of Clinical Affairs, Medical Affairs, Research and Development, Veracyte, Inc., South San Francisco, CA 94080, USA
| | - Richard T Kloos
- Department of Medical Affairs, Veracyte, Inc., South San Francisco, CA 94080, USA
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Pinhas S, Tessler I, Bizer LP, Khalilia K, Warman M, Adi M, Halperin D, Cohen O. Validating the 'CUT score' risk stratification tool for indeterminate thyroid nodules using the Bethesda system for reporting thyroid cytopathology. Eur Arch Otorhinolaryngol 2021; 279:383-390. [PMID: 33844064 DOI: 10.1007/s00405-021-06783-9] [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] [Received: 01/09/2021] [Accepted: 03/23/2021] [Indexed: 01/21/2023]
Abstract
PURPOSE Managing intermediate thyroid nodules remains challenging. The CUT score is an Italian metanalysis-based cytologic (SIAPEC-IAP) scoring system, designed to assist clinicians. However, it was never evaluated against the Bethesda system for reporting thyroid cytopathology (BSRTC). This study aims to validate its utility for BSRTC III and IV nodules in a non-Italian population. METHODS We collected all BSRTC III and IV thyroid nodules with a documented final pathology between 2010 and 2020. We calculated the C + U components of the CUT score using retrospective clinical (C) data collection and reevaluation of preoperative sonography (U) examination. The cytology (T) component which originally referred to the five-tiered SIAPEC-IAP cytologic classification was replaced by the corresponding BSRTC categories. Optimal test performances were calculated using receiver operating characteristic (ROC) curve analysis. Data were analyzed twice with considering of NIFTP as benign and as malignant. RESULTS After exclusions, 62 nodules from 61 patients were included (50% BSRTC III, 50% BSRTC IV). Malignant nodules demonstrated a significantly higher C + U score compared with benign in both categories. The C + U cutoff value for BSRTC III was 5.25 (sensitivity and specificity of 69.23% and 66.67%, respectively, AUC = 0.72, p-value = 0.016), and 5.75 for BSRTC IV (sensitivity and specificity of 85.7% and 76.5%, respectively, AUC = 0.84, p-value < 0.001). CONCLUSION Our study suggests that the CUT score is applicable for both BSRTC III and IV nodules, and highlights the need for internal validations, since the cutoffs found were higher than previously reported.
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Affiliation(s)
- Sapir Pinhas
- Department of Otolaryngology, Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel.,Hadassah Medical School, Hebrew University, Jerusalem, Israel
| | - Idit Tessler
- Department of Otolaryngology, Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel. .,Hadassah Medical School, Hebrew University, Jerusalem, Israel.
| | - Luba Pasherstnik Bizer
- Hadassah Medical School, Hebrew University, Jerusalem, Israel.,Department of Radiology, Kaplan Medical Center, Rehovot, Israel
| | - Khaled Khalilia
- Hadassah Medical School, Hebrew University, Jerusalem, Israel.,Department of Radiology, Kaplan Medical Center, Rehovot, Israel
| | - Meir Warman
- Department of Otolaryngology, Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel.,Hadassah Medical School, Hebrew University, Jerusalem, Israel
| | - Meital Adi
- Hadassah Medical School, Hebrew University, Jerusalem, Israel.,Department of Radiology, Kaplan Medical Center, Rehovot, Israel
| | - Doron Halperin
- Department of Otolaryngology, Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel.,Hadassah Medical School, Hebrew University, Jerusalem, Israel
| | - Oded Cohen
- Department of Otolaryngology, Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel.,Hadassah Medical School, Hebrew University, Jerusalem, Israel
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Zhu CY, Donangelo I, Gupta D, Nguyen DT, Ochoa JE, Yeh MW, Livhits MJ. Outcomes of Indeterminate Thyroid Nodules Managed Nonoperatively after Molecular Testing. J Clin Endocrinol Metab 2021; 106:e1240-e1247. [PMID: 33394039 DOI: 10.1210/clinem/dgaa887] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Indexed: 01/27/2023]
Abstract
CONTEXT Molecular testing to refine the diagnosis of cytologically indeterminate thyroid nodules has become increasingly popular, but data on long-term durability of test results and the rate of delayed operation are limited. OBJECTIVE Determine the delayed rate of surgical resection in indeterminate nodules with benign/negative molecular testing and the risk of false-negative molecular test results. DESIGN Prospective follow-up of the Gene Expression Classifier vs Targeted Next-Generation Sequencing in the Management of Indeterminate Thyroid Nodules randomized controlled trial comparing the diagnostic test performance of Afirma Gene Expression Classifier and ThyroSeq v2. SETTING University of California, Los Angeles. PARTICIPANTS Patients who underwent thyroid biopsy with indeterminate (Bethesda III/IV) cytology (April 2016 to July 2017). INTERVENTION Ultrasound surveillance. MAIN OUTCOME MEASURE False-negative rate of molecular testing. RESULTS Of 95 indeterminate nodules with negative/benign molecular test results, 12 nodules underwent immediate resection (11 benign nodules, 1 noninvasive follicular thyroid neoplasm nodule with papillary-like nuclear features). Nonoperative management was pursued for 83 (87.4%) nodules. The median surveillance was 26.7 months. Ten nodules were resected during surveillance and malignancy was identified in 4 nodules (overall false-negative rate of 5.8%). In the 4 malignant nodules that underwent delayed operation, surgery was prompted by sonographic changes during surveillance. CONCLUSIONS The majority of indeterminate nodules with negative molecular testing have a stable clinical course over 3 years of follow-up, but our finding of a 6% false-negative rate highlights the importance of continuing sonographic surveillance. Long-term studies are needed to determine the optimal length of follow-up.
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Affiliation(s)
- Catherine Y Zhu
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Ines Donangelo
- Division of Endocrinology, Diabetes, and Metabolism, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Deepashree Gupta
- Division of Endocrinology, Diabetes, and Metabolism, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Dalena T Nguyen
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Joana E Ochoa
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Michael W Yeh
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Masha J Livhits
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
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Silaghi CA, Lozovanu V, Georgescu CE, Georgescu RD, Susman S, Năsui BA, Dobrean A, Silaghi H. Thyroseq v3, Afirma GSC, and microRNA Panels Versus Previous Molecular Tests in the Preoperative Diagnosis of Indeterminate Thyroid Nodules: A Systematic Review and Meta-Analysis. Front Endocrinol (Lausanne) 2021; 12:649522. [PMID: 34054725 PMCID: PMC8155618 DOI: 10.3389/fendo.2021.649522] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 04/13/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Molecular tests are being used increasingly as an auxiliary diagnostic tool so as to avoid a diagnostic surgery approach for cytologically indeterminate thyroid nodules (ITNs). Previous test versions, Thyroseq v2 and Afirma Gene Expression Classifier (GEC), have proven shortcomings in malignancy detection performance. OBJECTIVE This study aimed to evaluate the diagnostic performance of the established Thyroseq v3, Afirma Gene Sequencing Classifier (GSC), and microRNA-based assays versus prior iterations in ITNs, in light of "rule-in" and "rule-out" concepts. It further analyzed the impact of noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) reclassification and Bethesda cytological subtypes on the performance of molecular tests. METHODS Pubmed, Scopus, and Web of Science were the databases used for the present research, a process that lasted until September 2020. A random-effects bivariate model was used to estimate the summary sensitivity, specificity, positive (PLR) and negative likelihood ratios (NLR), and area under the curve (AUC) for each panel. The conducted sensitivity analyses addressed different Bethesda categories and NIFTP thresholds. RESULTS A total of 40 eligible studies were included with 7,831 ITNs from 7,565 patients. Thyroseq v3 showed the best overall performance (AUC 0.95; 95% confidence interval: 0.93-0.97), followed by Afirma GSC (AUC 0.90; 0.87-0.92) and Thyroseq v2 (AUC 0.88; 0.85-0.90). In terms of "rule-out" abilities Thyroseq v3 (NLR 0.02; 95%CI: 0.0-2.69) surpassed Afirma GEC (NLR 0.18; 95%CI: 0.10-0.33). Thyroseq v2 (PLR 3.5; 95%CI: 2.2-5.5) and Thyroseq v3 (PLR 2.8; 95%CI: 1.2-6.3) achieved superior "rule-in" properties compared to Afirma GSC (PLR 1.9; 95%CI: 1.3-2.8). Evidence for Thyroseq v3 seems to have higher quality, notwithstanding the paucity of studies. Both Afirma GEC and Thyroseq v2 performance have been affected by NIFTP reclassification. ThyGenNEXT/ThyraMIR and RosettaGX show prominent preliminary results. CONCLUSION The newly emerged tests, Thyroseq v3 and Afirma GSC, designed for a "rule-in" purpose, have been proved to outperform in abilities to rule out malignancy, thus surpassing previous tests no longer available, Thyroseq 2 and Afirma GEC. However, Thyroseq v2 still ranks as the best rule-in molecular test. SYSTEMATIC REVIEW REGISTRATION http://www.crd.york.ac.uk/PROSPERO, identifier CRD42020212531.
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Affiliation(s)
- Cristina Alina Silaghi
- Department of Endocrinology, “Iuliu Hatieganu” University of Medicine and Pharmacy Cluj-Napoca, Cluj-Napoca, Romania
| | - Vera Lozovanu
- Department of Endocrinology, “Iuliu Hatieganu” University of Medicine and Pharmacy Cluj-Napoca, Cluj-Napoca, Romania
- *Correspondence: Vera Lozovanu, ; Raluca Diana Georgescu,
| | - Carmen Emanuela Georgescu
- Department of Endocrinology, “Iuliu Hatieganu” University of Medicine and Pharmacy Cluj-Napoca, Cluj-Napoca, Romania
| | - Raluca Diana Georgescu
- International Institute for the Advanced Studies of Psychotherapy and Applied Mental Health, Babeş-Bolyai University, Cluj-Napoca, Romania
- *Correspondence: Vera Lozovanu, ; Raluca Diana Georgescu,
| | - Sergiu Susman
- Department of Morphological Sciences-Histology, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
- Department of Pathology, IMOGEN Research Center, Cluj-Napoca, Romania
| | - Bogdana Adriana Năsui
- Department of Community Health, “Iuliu Hatieganu” University of Medicine and Pharmacy Cluj-Napoca, Cluj-Napoca, Romania
| | - Anca Dobrean
- International Institute for the Advanced Studies of Psychotherapy and Applied Mental Health, Babeş-Bolyai University, Cluj-Napoca, Romania
- Department of Clinical Psychology and Psychotherapy, Babeş-Bolyai University, Cluj-Napoca, Romania
| | - Horatiu Silaghi
- Department of Surgery V, “Iuliu Hatieganu” University of Medicine and Pharmacy Cluj-Napoca, Cluj-Napoca, Romania
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Labourier E, Fahey TJ. Preoperative molecular testing in thyroid nodules with Bethesda VI cytology: Clinical experience and review of the literature. Diagn Cytopathol 2020; 49:E175-E180. [PMID: 33052631 PMCID: PMC7983887 DOI: 10.1002/dc.24637] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 09/29/2020] [Accepted: 10/05/2020] [Indexed: 02/05/2023]
Abstract
Risk assessment is critical to determine the timing of elective surgeries and preserve valuable resources in time of pandemic. This study was undertaken to better understand the potential value of molecular testing to risk‐stratify thyroid nodules with malignant cytology (Bethesda VI). Systematic review of the literature contributed 21 studies representing 2036 preoperative specimens. The BRAF p.V600E substitution was detected in 46% to 90% of cases with a pooled positivity rate of 70% (95% confidence intervals: 64%‐76%). None of the studies used comprehensive oncogene panels. Retrospective analysis of 531 clinical specimens evaluated with the next‐generation sequencing ThyGeNEXT Thyroid Oncogene Panel identified a total of 436 gene alterations. BRAF mutation rate was 64% in specimens tested as part of standard clinical care and 75% in specimens from cross‐sectional research studies (P = .022). Testing for additional actionable gene alterations such as TERT promoter mutations or RET and NTRK gene rearrangements further increased the diagnostic yield to 78%‐85% and up to 95% when including the ThyraMIR Thyroid miRNA Classifier. These data support the role of molecular cytopathology in surgical and therapeutic decision‐making and warrant additional studies.
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Affiliation(s)
| | - Thomas J Fahey
- Department of Surgery, New York Presbyterian Hospital, Weill Cornell Medicine, New York, New York, USA
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8
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Abstract
INTRODUCTION Fine-needle aspiration (FNA) is an important diagnostic tool for the evaluation of thyroid nodules. However, in almost ¼ of all nodules submitted to FNA cytology is indeterminate. Since the majority of genetic alterations in thyroid cancer have been identified, the use of molecular testing platforms has been endorsed by American Thyroid Association for management of indeterminate nodules. EVIDENCE ACQUISITION Several commercial tests were based on mRNA expression of FNA samples (Afirma®, Veracyte, South San Francisco, CA, USA) while others detect DNA alterations (ThyroSeq, UPMC, Pittsburgh, PA, USA). Noncommercial tests detect limited number of point mutations or re-arrangements (gene panels). Literature study included a Pubmed research for adult original studies from 2003 to 2020, focusing on terms such as "molecular tests," "nodules with indeterminate AUS/FLUS and FN/SFN cytology." EVIDENCE SYNTHESIS Gene expression profile tests serve as "rule out" tests due to their high negative predictive value and perform better in a setting of low cancer pretest probability. Genetic alteration platforms display high positive predictive value and serve as rather "rule in" tests but their diagnostic accuracy is hampered either because a small proportion of nodules does not harbor any of these alterations targeted (gene panels) or because commonly identified RAS mutations can also be found in benign nodules. CONCLUSIONS Next generation sequencing development and incorporation of other genetic markers such as miRNA can improve diagnostic accuracy of molecular tests.
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Affiliation(s)
- Olga Karapanou
- 401Hellenic Army General Military Hospital of Athens, Athens, Greece -
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9
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Muzza M, Colombo C, Pogliaghi G, Karapanou O, Fugazzola L. Molecular markers for the classification of cytologically indeterminate thyroid nodules. J Endocrinol Invest 2020; 43:703-716. [PMID: 31853887 DOI: 10.1007/s40618-019-01164-w] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 12/11/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND The diagnosis of indeterminate lesions of the thyroid is a challenge in cytopathology practice. Indeed, up to 30% of cases lack the morphological features needed to provide definitive classification. Molecular tests have been developed to assist in the diagnosis of these indeterminate cases. The first studies dealing with the preoperative molecular evaluation of FNA samples focused on the analysis of BRAFV600E or on the combined evaluation of two or three genetic alterations. The sensitivity of molecular testing was then improved through the introduction of gene panels, which became available for clinical use in the late 2000s. Two different categories of molecular tests have been developed, the 'rule-out' methods, which aim to reduce the avoidable treatment of benign nodules, and the 'rule-in' tests that have the purpose to optimize surgical management. The genetic evaluation of indeterminate thyroid nodules is predicted to improve patient care, particularly if molecular tests are used appropriately and with the awareness of their advantages and weaknesses. The main disadvantage of these tests is the cost, which makes them rarely used in Europe. To overcome this limitation, customized panels have been set up, which are able to detect the most frequent genetic alterations of thyroid cancer. CONCLUSIONS In the present review, the most recent available versions of commercial molecular tests and of custom, non-commercial panels are described. Their characteristics and accuracy in the differential diagnosis of indeterminate nodules, namely Bethesda classes III (Atypical follicular lesion of undetermined significance, AUS/FLUS) and IV (Suspicious for follicular neoplasm, FN/SFN) are fully analyzed and discussed.
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Affiliation(s)
- M Muzza
- Division of Endocrine and Metabolic Diseases, IRCCS IstitutoAuxologicoItaliano, 20149, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, P.le Brescia 20, 20149, Milano, Italy
| | - C Colombo
- Division of Endocrine and Metabolic Diseases, IRCCS IstitutoAuxologicoItaliano, 20149, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, P.le Brescia 20, 20149, Milano, Italy
| | - G Pogliaghi
- Division of Endocrine and Metabolic Diseases, IRCCS IstitutoAuxologicoItaliano, 20149, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, P.le Brescia 20, 20149, Milano, Italy
| | - O Karapanou
- Department of Endocrinology, 401 Military Hospital, 11525, Athens, Greece
| | - L Fugazzola
- Division of Endocrine and Metabolic Diseases, IRCCS IstitutoAuxologicoItaliano, 20149, Milan, Italy.
- Department of Pathophysiology and Transplantation, University of Milan, P.le Brescia 20, 20149, Milano, Italy.
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10
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The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Thyroid Disease in Adults. Ann Surg 2020; 271:e21-e93. [PMID: 32079830 DOI: 10.1097/sla.0000000000003580] [Citation(s) in RCA: 222] [Impact Index Per Article: 55.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To develop evidence-based recommendations for safe, effective, and appropriate thyroidectomy. BACKGROUND Surgical management of thyroid disease has evolved considerably over several decades leading to variability in rendered care. Over 100,000 thyroid operations are performed annually in the US. METHODS The medical literature from 1/1/1985 to 11/9/2018 was reviewed by a panel of 19 experts in thyroid disorders representing multiple disciplines. The authors used the best available evidence to construct surgical management recommendations. Levels of evidence were determined using the American College of Physicians grading system, and management recommendations were discussed to consensus. Members of the American Association of Endocrine Surgeons reviewed and commented on preliminary drafts of the content. RESULTS These clinical guidelines analyze the indications for thyroidectomy as well as its definitions, technique, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Fine Needle Aspiration Biopsy Diagnosis, Molecular Testing, Indications, Extent and Outcomes of Surgery, Preoperative Care, Initial Thyroidectomy, Perioperative Tissue Diagnosis, Nodal Dissection, Concurrent Parathyroidectomy, Hyperthyroid Conditions, Goiter, Adjuncts and Approaches to Thyroidectomy, Laryngology, Familial Thyroid Cancer, Postoperative Care and Complications, Cancer Management, and Reoperation. CONCLUSIONS Evidence-based guidelines were created to assist clinicians in the optimal surgical management of thyroid disease.
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11
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Titov S, Demenkov PS, Lukyanov SA, Sergiyko SV, Katanyan GA, Veryaskina YA, Ivanov MK. Preoperative detection of malignancy in fine-needle aspiration cytology (FNAC) smears with indeterminate cytology (Bethesda III, IV) by a combined molecular classifier. J Clin Pathol 2020; 73:722-727. [PMID: 32213552 DOI: 10.1136/jclinpath-2020-206445] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 02/18/2020] [Accepted: 03/01/2020] [Indexed: 01/21/2023]
Abstract
AIMS Analysis of molecular markers in addition to cytological analysis of fine-needle aspiration (FNA) samples is a promising way to improve the preoperative diagnosis of thyroid nodules. Previously, we have developed an algorithm for the differential diagnosis of thyroid nodules by means of a small set of molecular markers. Here, we aimed to validate this approach using FNA cytology samples of Bethesda categories III and IV, in which preoperative detection of malignancy by cytological analysis is impossible. METHODS A total of 122 FNA smears from patients with indeterminate cytology (Bethesda III: 13 patients, Bethesda IV: 109 patients) were analysed by real-time PCR regarding the preselected set of molecular markers (the BRAF V600E mutation, normalised concentrations of HMGA2 mRNA, 3 microRNAs, and the mitochondrial/nuclear DNA ratio). The decision tree-based classifier was used to discriminate between benign and malignant tumours. RESULTS The molecular testing detected malignancy in FNA smears of indeterminate cytology with 89.2% sensitivity, 84.6% positive predictive value, 92.9% specificity and 95.2% negative predictive value; these characteristics are comparable with those of more complicated commercial tests. Residual risk of malignancy for the thyroid nodules that were shown to be benign by this molecular method did not exceed the reported risk of malignancy for Bethesda II histological diagnosis. Analytical-accuracy assessment revealed required nucleic-acid input of ≥5 ng. CONCLUSIONS The study shows feasibility of preoperative differential diagnosis of thyroid nodules of indeterminate cytology using a small panel of molecular markers of different types by a simple PCR-based method using stained FNA smears.
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Affiliation(s)
- Sergei Titov
- Department of the Structure and Function of Chromosomes, Institute of Molecular and Cellular Biology SB RAS, Novosibirsk, Russian Federation .,AO Vector-Best, Novosibirsk, Russian Federation
| | - Pavel S Demenkov
- Department of Systems Biology, Institute of Cytology and Genetics SB RAS, Novosibirsk, Russian Federation.,Department of Mathematics and Mechanics, Novosibirsk State University, Novosibirsk, Russian Federation
| | - Sergei A Lukyanov
- Department of General and Pediatric Surgery, South Ural State Medical University, Chelyabinsk, Russian Federation
| | - Sergei V Sergiyko
- Department of General and Pediatric Surgery, South Ural State Medical University, Chelyabinsk, Russian Federation
| | - Gevork A Katanyan
- Department of Surgery, Regional Clinical Hospital No. 2, Krasnodar, Russian Federation
| | - Yulia A Veryaskina
- Department of the Structure and Function of Chromosomes, Institute of Molecular and Cellular Biology SB RAS, Novosibirsk, Russian Federation.,Department of Systems Biology, Institute of Cytology and Genetics SB RAS, Novosibirsk, Russian Federation
| | - Mikhail K Ivanov
- Department of the Structure and Function of Chromosomes, Institute of Molecular and Cellular Biology SB RAS, Novosibirsk, Russian Federation.,AO Vector-Best, Novosibirsk, Russian Federation
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12
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McGill Thyroid Nodule Score in Differentiating Thyroid Nodules in Total Thyroidectomy Cases of Indeterminate Nodules. Indian J Surg Oncol 2020; 11:268-273. [PMID: 32523274 DOI: 10.1007/s13193-020-01053-2] [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] [Received: 08/06/2019] [Accepted: 02/20/2020] [Indexed: 10/24/2022] Open
Abstract
Fine-needle aspiration biopsy (FNAB) is the first-line modality in the evaluation of thyroid nodules. However, the results of indeterminate pathology place the thyroid surgeon in difficult management situations. This study evaluates McGill Thyroid Nodule Score (MTNS) to identify thyroid nodules that harbor malignancy in cases of indeterminate FNABs and to guide surgeon about the need and extent of surgery. We conducted a retrospective chart review of 344 patients who underwent total thyroidectomy between January 2013 and January 2018. Patients with FNAB of indeterminate nodules (Bethesda types III, IV, and V) and calculated MTNS were included in the study. Postoperative histopathology was divided into benign and malignant groups. The median and the mean MTNS, the malignancy rate, and the standard deviations were calculated for each subgroup. Of the 344 patient charts reviewed, 106 (30.8%) had an indeterminate FNA biopsy. Eighty-one (76.4%) patients were females and 25 (23.6%) were males. Final pathology revealed malignancy in 69 patients (65.1%). The mean MTNS of patients with malignant pathology (12.81 ± 3.55) was higher than the mean in the benign group (8.32 ± 2.32). 82.4% of thyroid nodules with median MTNS of less than 8 had a benign pathology, and 91.4% of thyroid nodules with median MTNS equal or more than 11 had a malignant pathology (p = 0.002). The rate of malignancy in our series of indeterminate FNABs was 65.1%. The MTNS can be of value to thyroid surgeons in preoperative decision-making when dealing with an indeterminate thyroid nodule.
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13
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Goldner WS, Angell TE, McAdoo SL, Babiarz J, Sadow PM, Nabhan FA, Nasr C, Kloos RT. Molecular Variants and Their Risks for Malignancy in Cytologically Indeterminate Thyroid Nodules. Thyroid 2019; 29:1594-1605. [PMID: 31469053 PMCID: PMC6864764 DOI: 10.1089/thy.2019.0278] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background: Gene panels are routinely used to assess predisposition to hereditary cancers by simultaneously testing multiple susceptibility genes and/or variants. More recently, genetic panels have been implemented as part of solid tumor malignancy testing assessing somatic alterations. One example is targeted variant panels for thyroid nodules that are not conclusively malignant or benign upon fine-needle aspiration (FNA). We systematically reviewed published studies from 2009 to 2018 that contained genetic data from preoperative FNA specimens on cytologically indeterminate thyroid nodules (ITNs) that subsequently underwent surgical resection. Pooled prevalence estimates per gene and variant, along with their respective positive predictive values (PPVs) for malignancy, were calculated. Summary: Our systematic search identified 540 studies that were supplemented by 18 studies from bibliographies or personal files. Sixty-one studies met all inclusion criteria and included >4600 ITNs. Overall, 26% of nodules contained at least 1 variant or fusion. However, half of them did not include details on the specific gene, variant, and/or complete fusion pair reported for inclusion toward PPV calculations. The PPVs of genomic alterations reported at least 10 times were limited to BRAFV600E (98%, 95% confidence interval [CI 96-99%]), PAX8/PPARG (55% [CI 34-78%]), HRASQ61R (45% [CI 22-72%]), BRAFK601E (42% [CI 19-68%]), and NRASQ61R (38% [CI 23-55%]). Excluding BRAFV600E, the pooled PPV for all other specified variants and fusions was 47%. Multiple variants within the same nodule were identified in ∼1% of ITN and carried a cumulative PPV of 77%. Conclusions: The chance that a genomic alteration predicts malignancy depends on the individual variant or fusion detected. Only five alterations were reported at least 10 times; BRAFV600E had a PPV of 98%, while the remaining four had individual PPVs ranging from 38% to 55%. The small sample size of most variants and fusion pairs found among ITNs, however, limits confidence in their individual PPV point estimates. Better specific reporting of genomic alterations with cytological category, histological subtype, and cancer staging would facilitate better understanding of cancer prediction, and the independent contribution of the genomic profile to prognosis.
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Affiliation(s)
- Whitney S. Goldner
- Division of Diabetes, Endocrinology, and Metabolism, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska
- Address correspondence to: Whitney S. Goldner, MD, Division of Diabetes, Endocrinology, and Metabolism, Department of Internal Medicine, University of Nebraska Medical Center, 984120 Nebraska Medical Center, Omaha, NE 68198-4120
| | - Trevor E. Angell
- Division of Endocrinology, Diabetes and Metabolism, Keck School of Medicine, University of Southern California, Los Angles, California
| | | | | | - Peter M. Sadow
- Pathology Service, Massachusetts General Hospital, Boston, Massachusetts
- Department of Pathology, Harvard Medical School, Boston, Massachusetts
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts
| | - Fadi A. Nabhan
- Division of Endocrinology, Diabetes, and Metabolism, The Ohio State University Wexner Medical Center and Arthur G. James Cancer Center, Columbus, Ohio
| | - Christian Nasr
- Endocrinology and Metabolism Institute, Cleveland Clinic Foundation, Cleveland, Ohio
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14
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Awad B, Al-Hakami H, Al-Garni M, Mufti N. Utilizing the McGill Thyroid Nodule Score to compare between hemithyroidectomy cases who required completion thyroidectomy and cases of hemithyroidectomy alone. Am J Otolaryngol 2019; 40:102277. [PMID: 31477365 DOI: 10.1016/j.amjoto.2019.102277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 08/15/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVES This study aims to evaluate whether the McGill Thyroid Nodule Score (MTNS) accurately helps to decide the extent of surgery (hemithyroidectomy versus total thyroidectomy) based on the malignancy risk and to assess whether its use lowers the rate of completion thyroidectomy in cases of indeterminate thyroid nodules. METHODS We performed a retrospective cohort study comparing MTNS results of patients undergoing hemithyroidectomy in King Abdulaziz Medical City, NGHA, Jeddah from the period of January 2013 to December 2017. We divided the cases into hemithyroidectomy who required completion and hemithyroidectomy who did not need completion surgery. The pre-operative indeterminate FNA biopsy subgroup comprised of Bethesda type III (atypia of undetermined significance/follicular lesion of undetermined significance) and Bethesda type IV (follicular neoplasm/suspicious for a follicular neoplasm/Hurthle cell neoplasm). Post-operative histopathology was divided into benign or malignant groups. RESULTS Of the 501 patient charts reviewed, 111 (22.2%) had an indeterminate FNA biopsy. 97 (87.4%) patients were females and 14 (12.6%) were males. In the hemithyroidectomy group, the pre-operative mean of the MTNS was 6.65, while in the completion thyroidectomy the mean was 11.47. The median MTNS was 7 (32% risk of malignancy) for the hemithyroidectomy group and 11 (63% risk of malignancy) for the completion thyroidectomy group (p < 0.001). CONCLUSIONS Based on the MTNS the risk of malignancy in cases of hemithyroidectomy who required completion surgery was significantly higher than those who underwent hemithyroidectomy only. The MTNS can be of value to thyroid surgeon in the pre-operative decision-making when dealing with an indeterminate thyroid nodule on FNA biopsy.
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Affiliation(s)
- Baraa Awad
- Department of Otolaryngology-Head & Neck Surgery, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, National Guard Health Affairs, Jeddah, Saudi Arabia
| | - Hadi Al-Hakami
- Department of Otolaryngology-Head & Neck Surgery, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, National Guard Health Affairs, Jeddah, Saudi Arabia.
| | - Mohammed Al-Garni
- Department of Otolaryngology-Head & Neck Surgery, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, National Guard Health Affairs, Jeddah, Saudi Arabia
| | - Nouri Mufti
- Department of Otolaryngology-Head & Neck Surgery, King Abdul-Aziz General Hospital, Makkah, Saudi Arabia
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15
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Abstract
The historical management approach for many patients with indeterminate thyroid nodule fine needle aspiration cytology is a diagnostic lobectomy or thyroidectomy. However, the majority of patients undergo surgery unnecessarily, because most are proven to have benign disease on histology. Molecular testing is a diagnostic tool that can be used to help guide the clinical management of thyroid nodules with indeterminate cytology results. Testing has evolved substantially over the last decade with significant advances in testing methodology and improvements in our understanding of the genetic basis of thyroid cancer.
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Affiliation(s)
- Sarah E Mayson
- Division of Endocrinology, Metabolism and Diabetes, University of Colorado School of Medicine, MS 8106, 12801 East 17th Avenue, Aurora, CO 80045, USA.
| | - Bryan R Haugen
- Division of Endocrinology, Metabolism and Diabetes, University of Colorado School of Medicine, MS 8106, 12801 East 17th Avenue, Aurora, CO 80045, USA
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16
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Hao Y, Choi Y, Babiarz JE, Kloos RT, Kennedy GC, Huang J, Walsh PS. Analytical Verification Performance of Afirma Genomic Sequencing Classifier in the Diagnosis of Cytologically Indeterminate Thyroid Nodules. Front Endocrinol (Lausanne) 2019; 10:438. [PMID: 31333584 PMCID: PMC6620518 DOI: 10.3389/fendo.2019.00438] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 06/18/2019] [Indexed: 01/21/2023] Open
Abstract
Background: Fine needle aspiration (FNA) cytology, a diagnostic test central to thyroid nodule management, may yield indeterminate results in up to 30% of cases. The Afirma® Genomic Sequencing Classifier (GSC) was developed and clinically validated to utilize genomic material obtained during the FNA to accurately identify benign nodules among those deemed cytologically indeterminate so that diagnostic surgery can be avoided. A key question for diagnostic tests is their robustness under different perturbations that may occur in the lab. Herein, we describe the analytical performance of the Afirma GSC. Results: We examined the analytical sensitivity of the Afirma GSC to varied input RNA amounts and the limit of detection of malignant signals with heterogenous samples mixed with adjacent normal or benign tissues. We also evaluated the analytical specificity from potential interfering substances such as blood and genomic DNA. Further, the inter-laboratory, intra-run, and inter-run reproducibility of the assay were examined. Analytical sensitivity analysis showed that Afirma GSC calls are tolerant to variation in RNA input amount (5-30 ng), and up to 75% dilution of malignant FNA material. Analytical specificity studies demonstrated Afirma GSC remains accurate in presence of up to 75% blood or 30% genomic DNA. The Afirma GSC results are highly reproducible across different operators, runs, reagent lots, and laboratories. Conclusion: The analytical robustness and reproducibility of the Afirma GSC test support its routine clinical use among thyroid nodules with indeterminant FNA cytology.
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Affiliation(s)
- Yangyang Hao
- Research and Development, Veracyte, South San Francisco, CA, United States
| | - Yoonha Choi
- Research and Development, Veracyte, South San Francisco, CA, United States
| | - Joshua E. Babiarz
- Research and Development, Veracyte, South San Francisco, CA, United States
| | - Richard T. Kloos
- Medical Affairs, Veracyte, South San Francisco, CA, United States
| | - Giulia C. Kennedy
- Research and Development, Veracyte, South San Francisco, CA, United States
- Medical Affairs, Veracyte, South San Francisco, CA, United States
- Department of Clinical Affairs, Veracyte, South San Francisco, CA, United States
| | - Jing Huang
- Research and Development, Veracyte, South San Francisco, CA, United States
| | - P. Sean Walsh
- Research and Development, Veracyte, South San Francisco, CA, United States
- *Correspondence: P. Sean Walsh
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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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de Koster EJ, de Geus-Oei LF, Dekkers OM, van Engen-van Grunsven I, Hamming J, Corssmit EPM, Morreau H, Schepers A, Smit J, Oyen WJG, Vriens D. Diagnostic Utility of Molecular and Imaging Biomarkers in Cytological Indeterminate Thyroid Nodules. Endocr Rev 2018; 39:154-191. [PMID: 29300866 DOI: 10.1210/er.2017-00133] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 12/27/2017] [Indexed: 12/21/2022]
Abstract
Indeterminate thyroid cytology (Bethesda III and IV) corresponds to follicular-patterned benign and malignant lesions, which are particularly difficult to differentiate on cytology alone. As ~25% of these nodules harbor malignancy, diagnostic hemithyroidectomy is still custom. However, advanced preoperative diagnostics are rapidly evolving.This review provides an overview of additional molecular and imaging diagnostics for indeterminate thyroid nodules in a preoperative clinical setting, including considerations regarding cost-effectiveness, availability, and feasibility of combining techniques. Addressed diagnostics include gene mutation analysis, microRNA, immunocytochemistry, ultrasonography, elastosonography, computed tomography, sestamibi scintigraphy, [18F]-2-fluoro-2-deoxy-d-glucose positron emission tomography (FDG-PET), and diffusion-weighted magnetic resonance imaging.The best rule-out tests for malignancy were the Afirma® gene expression classifier and FDG-PET. The most accurate rule-in test was sole BRAF mutation analysis. No diagnostic had both near-perfect sensitivity and specificity, and estimated cost-effectiveness. Molecular techniques are rapidly advancing. However, given the currently available techniques, a multimodality stepwise approach likely offers the most accurate diagnosis, sequentially applying one sensitive rule-out test and one specific rule-in test. Geographical variations in cytology (e.g., Hürthle cell neoplasms) and tumor genetics strongly influence local test performance and clinical utility. Multidisciplinary collaboration and implementation studies can aid the local decision for one or more eligible diagnostics.
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Affiliation(s)
- Elizabeth J de Koster
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Lioe-Fee de Geus-Oei
- Department of Radiology, Section of Nuclear Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Olaf M Dekkers
- Department of Endocrinology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Jaap Hamming
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Eleonora P M Corssmit
- Department of Endocrinology, Leiden University Medical Center, Leiden, the Netherlands
| | - Hans Morreau
- Department of Pathology, Leiden University Medical Center, Leiden, the Netherlands
| | - Abbey Schepers
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Jan Smit
- Department of Endocrinology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Wim J G Oyen
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, the Netherlands.,Division of Radiotherapy and Imaging, Institute of Cancer Research, and Department of Nuclear Medicine, Royal Marsden Hospital, London, United Kingdom
| | - Dennis Vriens
- Department of Radiology, Section of Nuclear Medicine, Leiden University Medical Center, Leiden, the Netherlands
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19
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Nishino M, Nikiforova M. Update on Molecular Testing for Cytologically Indeterminate Thyroid Nodules. Arch Pathol Lab Med 2018; 142:446-457. [PMID: 29336606 DOI: 10.5858/arpa.2017-0174-ra] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT - Approximately 15% to 30% of thyroid nodules that undergo fine-needle aspiration are classified as cytologically indeterminate, presenting management challenges for patients and clinicians alike. During the past several years, several molecular tests have been developed to reduce the diagnostic uncertainty of indeterminate thyroid fine-needle aspirations. OBJECTIVE - To review the methodology, clinical validation, and recent peer-reviewed literature for 4 molecular tests that are currently marketed for cytologically indeterminate thyroid fine-needle aspiration specimens: Afirma, ThyroSeq, ThyGenX/ThyraMIR, and RosettaGX Reveal. DATA SOURCES - Peer-reviewed literature retrieved from PubMed search, data provided by company websites and representatives, and authors' personal experiences. CONCLUSIONS - The 4 commercially available molecular tests for thyroid cytology offer unique approaches to improve the risk stratification of thyroid nodules. Familiarity with data from the validation studies as well as the emerging literature about test performance in the postvalidation setting can help users to select and interpret these tests in a clinically meaningful way.
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Affiliation(s)
| | - Marina Nikiforova
- From the Department of Pathology, Beth Israel Deaconess Medical Center, Boston, Massachusetts (Dr Nishino); and the Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania (Dr Nikiforova)
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20
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Baldini E, Sorrenti S, Tartaglia F, Catania A, Palmieri A, Pironi D, Filippini A, Ulisse S. New perspectives in the diagnosis of thyroid follicular lesions. Int J Surg 2018; 41 Suppl 1:S7-S12. [PMID: 28506417 DOI: 10.1016/j.ijsu.2017.03.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 03/06/2017] [Accepted: 03/08/2017] [Indexed: 12/27/2022]
Abstract
Thyroid nodules are very common, affecting 19%-67% of the adult population. However, about 10% of them harbor a malignant lesion. Consequently, the first aim in their clinical evaluation is to exclude malignancy. Fine-needle aspiration cytology (FNAC) represents the main diagnostic tool for the evaluation of thyroid nodules. However, FNAC has a main diagnostic limit, namely cellular atypias of indeterminate significance, which require surgical excision and histological examination to differentiate benign from malignant lesions. Histology reports show that approximately 80% of these patients harbor a benign lesion. Therefore, in order to reduce unnecessary thyroidectomy, over the last years, the cytological classification of thyroid nodules has been revised and a number of new instrumental and molecular approaches have been proposed. In the present article, we will attempt to summarize the most recent cytological, molecular and echographic strategies to enhance the diagnostic accuracy of preoperative thyroid follicular lesions. In particular, we will discuss the new cytological classifications from the Bethesda System for Reporting Thyroid Cytopathology (BSRTC), the British Thyroid Association-Royal College of Pathologists (PTA-RCPath) and the new Italian Society for Anatomic Pathology and Cytology (SIAPEC 2014. We will review molecular tests evaluated to ameliorate follicular lesion diagnosis as well as the clinical utility of the new echographic Thyroid Imaging Reporting and Data System (TI-RADS) score.
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Affiliation(s)
- Enke Baldini
- Department of Surgical Sciences, "Sapienza" University of Rome, Italy
| | | | | | - Antonio Catania
- Department of Surgical Sciences, "Sapienza" University of Rome, Italy
| | - Andrea Palmieri
- Department of Surgical Sciences, "Sapienza" University of Rome, Italy
| | - Daniele Pironi
- Department of Surgical Sciences, "Sapienza" University of Rome, Italy
| | - Angelo Filippini
- Department of Surgical Sciences, "Sapienza" University of Rome, Italy
| | - Salvatore Ulisse
- Department of Surgical Sciences, "Sapienza" University of Rome, Italy.
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21
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Roth MY, Witt RL, Steward DL. Molecular testing for thyroid nodules: Review and current state. Cancer 2017; 124:888-898. [DOI: 10.1002/cncr.30708] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 03/02/2017] [Accepted: 03/06/2017] [Indexed: 12/12/2022]
Affiliation(s)
- Mara Y. Roth
- Division of Metabolism, Endocrinology, and Nutrition, Department of Medicine; University of Washington; Seattle Washington
| | - Robert L. Witt
- Department of Otolaryngology; Thomas Jefferson University; Philadelphia Pennsylvania
- Multidisciplinary Head and Neck Clinic, Helen F. Graham Cancer Center; Newark Delaware
| | - David L. Steward
- Department of Otolaryngology; University of Cincinnati; Cincinnati Ohio
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22
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Comparative analysis of diagnostic performance, feasibility and cost of different test-methods for thyroid nodules with indeterminate cytology. Oncotarget 2017; 8:49421-49442. [PMID: 28472764 PMCID: PMC5564779 DOI: 10.18632/oncotarget.17220] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 03/22/2017] [Indexed: 01/07/2023] Open
Abstract
Since it is impossible to recognize malignancy at fine needle aspiration (FNA) cytology in indeterminate thyroid nodules, surgery is recommended for all of them. However, cancer rate at final histology is <30%. Many different test-methods have been proposed to increase diagnostic accuracy in such lesions, including Galectin-3-ICC (GAL-3-ICC), BRAF mutation analysis (BRAF), Gene Expression Classifier (GEC) alone and GEC+BRAF, mutation/fusion (M/F) panel, alone, M/F panel+miRNA GEC, and M/F panel by next generation sequencing (NGS), FDG-PET/CT, MIBI-Scan and TSHR mRNA blood assay.We performed systematic reviews and meta-analyses to compare their features, feasibility, diagnostic performance and cost. GEC, GEC+BRAF, M/F panel+miRNA GEC and M/F panel by NGS were the best in ruling-out malignancy (sensitivity = 90%, 89%, 89% and 90% respectively). BRAF and M/F panel alone and by NGS were the best in ruling-in malignancy (specificity = 100%, 93% and 93%). The M/F by NGS showed the highest accuracy (92%) and BRAF the highest diagnostic odds ratio (DOR) (247). GAL-3-ICC performed well as rule-out (sensitivity = 83%) and rule-in test (specificity = 85%), with good accuracy (84%) and high DOR (27) and is one of the cheapest (113 USD) and easiest one to be performed in different clinical settings.In conclusion, the more accurate molecular-based test-methods are still expensive and restricted to few, highly specialized and centralized laboratories. GAL-3-ICC, although limited by some false negatives, represents the most suitable screening test-method to be applied on a large-scale basis in the diagnostic algorithm of indeterminate thyroid lesions.
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Gene Expression (mRNA) Markers for Differentiating between Malignant and Benign Follicular Thyroid Tumours. Int J Mol Sci 2017; 18:ijms18061184. [PMID: 28574441 PMCID: PMC5486007 DOI: 10.3390/ijms18061184] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 05/26/2017] [Accepted: 05/28/2017] [Indexed: 01/21/2023] Open
Abstract
Distinguishing between follicular thyroid cancer (FTC) and follicular thyroid adenoma (FTA) constitutes a long-standing diagnostic problem resulting in equivocal histopathological diagnoses. There is therefore a need for additional molecular markers. To identify molecular differences between FTC and FTA, we analyzed the gene expression microarray data of 52 follicular neoplasms. We also performed a meta-analysis involving 14 studies employing high throughput methods (365 follicular neoplasms analyzed). Based on these two analyses, we selected 18 genes differentially expressed between FTA and FTC. We validated them by quantitative real-time polymerase chain reaction (qRT-PCR) in an independent set of 71 follicular neoplasms from formaldehyde-fixed paraffin embedded (FFPE) tissue material. We confirmed differential expression for 7 genes (CPQ, PLVAP, TFF3, ACVRL1, ZFYVE21, FAM189A2, and CLEC3B). Finally, we created a classifier that distinguished between FTC and FTA with an accuracy of 78%, sensitivity of 76%, and specificity of 80%, based on the expression of 4 genes (CPQ, PLVAP, TFF3, ACVRL1). In our study, we have demonstrated that meta-analysis is a valuable method for selecting possible molecular markers. Based on our results, we conclude that there might exist a plausible limit of gene classifier accuracy of approximately 80%, when follicular tumors are discriminated based on formalin-fixed postoperative material.
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Sorrenti S, Baldini E, Tartaglia F, Catania A, Arcieri S, Pironi D, Calò PG, Filippini A, Ulisse S. Nodular thyroid disease in the elderly: novel molecular approaches for the diagnosis of malignancy. Aging Clin Exp Res 2017; 29:7-13. [PMID: 27832468 DOI: 10.1007/s40520-016-0654-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 10/12/2016] [Indexed: 12/14/2022]
Abstract
Epithelial thyroid cancers (TC) comprise two differentiated histotypes (DTC), the papillary (PTC) and the follicular (FTC) thyroid carcinomas which, following dedifferentiation, are assumed to give rise to the poorly differentiated thyroid carcinomas and the rare, but highly aggressive and invariably fatal, anaplastic thyroid carcinomas. Although thyroid cancer mortality has not been changed, its annual incidence has increased over the last two decades, mainly because of the improved ability to diagnose malignant transformation in small non-palpable thyroid nodules. Despite DTC patients have a favorable prognosis, aggressive disease is more frequently observed in the elderly showing a higher disease-specific mortality. Of relevance is the high prevalence of nodular thyroid disease in aged patients being higher than 90%, in women older than 60 year, and 60% in men older than 80 year. This implies a careful evaluation of thyroid nodules in this group of patients in order to exclude malignancy. In fact, despite the tremendous progress in the comprehension of the underlying molecular mechanisms deregulated in DTC progression, several aspects of their clinical management remain to be solved and novel diagnostic strategies are sorely needed. Here, we will attempt to review new molecular approaches, which are currently being exploited in order to ameliorate the diagnosis of thyroid nodules.
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Conzo G, Avenia N, Ansaldo GL, Calò P, De Palma M, Dobrinja C, Docimo G, Gambardella C, Grasso M, Lombardi CP, Pelizzo MR, Pezzolla A, Pezzullo L, Piccoli M, Rosato L, Siciliano G, Spiezia S, Tartaglia E, Tartaglia F, Testini M, Troncone G, Signoriello G. Surgical treatment of thyroid follicular neoplasms: results of a retrospective analysis of a large clinical series. Endocrine 2017; 55:530-538. [PMID: 27075721 DOI: 10.1007/s12020-016-0953-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Accepted: 04/05/2016] [Indexed: 02/06/2023]
Abstract
The most appropriate surgical management of "follicular neoplasm/suspicious for follicular neoplasm" lesions (FN), considering their low definitive malignancy rate and the limited predictive power of preoperative clinic-diagnostic factors, is still controversial. On behalf of the Italian Association of Endocrine Surgery Units (U.E.C. CLUB), we collected and analyzed the experience of 26 endocrine centers by computerized questionnaire. 1379 patients, surgically treated after a FN diagnosis from January 2012 and December 2103, were evaluated. Histological features, surgical complications, and medium-term outcomes were reported. Total thyroidectomy (TT) was performed in 1055/1379 patients (76.5 %), while hemithyroidectomy (HT) was carried out in 324/1379 cases (23.5 %). Malignancy rate was higher in TT than in HT groups (36.4 vs. 26.2 %), whereas the rates of transient and definitive hypoparathyroidism following TT were higher than after HT. Consensual thyroiditis (16.8 vs. 9.9 %) and patient age (50.9 vs. 47.9 %) also differed between groups. A cytological FN diagnosis was associated to a not negligible malignancy rate (469/1379 patients; 34 %), that was higher in TT than in HT groups. However, a lower morbidity rate was observed in HT, which should be considered the standard of care in solitary lesions in absence of specific risk factors. Malignancy could not be preoperatively assessed and clinical decision-making is still controversial. Further efforts should be spent to more accurately preoperatively classify FN thyroid nodules.
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Affiliation(s)
- Giovanni Conzo
- Division of General and Oncologic Surgery, Department of Anesthesiologic, Surgical and Emergency Sciences, Second University of Naples, Via Gen.G.Orsini 42, 80132, Naples, Italy.
| | - Nicola Avenia
- Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
- Unit of Endocrine Surgery, S. Maria University Hospital, Terni, Italy
| | - Gian Luca Ansaldo
- Dipartimento di Discipline Chirurgiche, Morfologiche e Metodologie Integrate, Cattedra di Chirurgia Generale, Università degli Studi di Genova, Genoa, Italy
| | - Piergiorgio Calò
- Chirurgia Generale A, Policlinico Universitario di Monserrato, AOU di Cagliari, Monserrato, Italy
| | - Maurizio De Palma
- General Surgery and Endocrine Surgical Unit, AORN A. Cardarelli, Naples, Italy
| | - Chiara Dobrinja
- UCO Chirurgia Generale, Cattinara Teaching Hospital, Strada di Fiume, 34100, Trieste, Italy
| | - Giovanni Docimo
- Division of General and Oncologic Surgery, Department of Anesthesiologic, Surgical and Emergency Sciences, Second University of Naples, Via Gen.G.Orsini 42, 80132, Naples, Italy
| | - Claudio Gambardella
- Division of General and Oncologic Surgery, Department of Anesthesiologic, Surgical and Emergency Sciences, Second University of Naples, Via Gen.G.Orsini 42, 80132, Naples, Italy
| | - Marica Grasso
- General Surgery and Endocrine Surgical Unit, AORN A. Cardarelli, Naples, Italy
| | - Celestino Pio Lombardi
- Division of Endocrine and Metabolic Surgery, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Maria Rosa Pelizzo
- Clinica Chirurgica 2, University School of Padova, Padova University, Padua, Italy
| | - Angela Pezzolla
- Department of Emergency and Oral Transplantation-DETO, Bari University Hospital Policlinico, Bari, Italy
| | - Luciano Pezzullo
- Thyroid and Parathyroid Surgery Unit, Istituto Nazionale Tumori, IRCCS Fondazione G. Pascale, Via Mariano Semmola, Naples, Italy
| | - Micaela Piccoli
- Chirurgia Generale d'Urgenza e Nuove Tecnologie - NOCSAE di Modena, Modena, Italy
| | | | - Giuseppe Siciliano
- Division of General and Oncologic Surgery, Department of Anesthesiologic, Surgical and Emergency Sciences, Second University of Naples, Via Gen.G.Orsini 42, 80132, Naples, Italy
| | - Stefano Spiezia
- Ultrasound Guided and Neck Pathologies Surgery Operative Unit, Department of Surgery, S. Maria del Popolo degli Incurabili ASLNA1 Hospital, Naples, Italy
| | - Ernesto Tartaglia
- Division of General and Oncologic Surgery, Department of Anesthesiologic, Surgical and Emergency Sciences, Second University of Naples, Via Gen.G.Orsini 42, 80132, Naples, Italy
| | | | - Mario Testini
- Unit of Endocrine, Digestive, and Emergency Surgery, Department of Biomedical Sciences and Human Oncology, Bari, Italy
| | - Giancarlo Troncone
- Department of Biomorphologic and Functional Sciences, "Federico II" University of Naples, Naples, Italy
| | - Giuseppe Signoriello
- Department of Mental Health and Preventive Medicine, Second University of Naples, Caserta, Italy
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Kloos RT. Molecular Profiling of Thyroid Nodules: Current Role for the Afirma Gene Expression Classifier on Clinical Decision Making. Mol Imaging Radionucl Ther 2017; 26:36-49. [PMID: 28117288 PMCID: PMC5283710 DOI: 10.4274/2017.26.suppl.05] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Thyroid fine-needle aspiration biopsy results are cytologically indeterminate in 15-30% of cases. When these nodules undergo diagnostic surgery, approximately three-quarters are histologically benign. These unnecessary surgeries diminish quality of life, generate complications, and increase healthcare costs. The Afirma gene expression classifier (GEC) is validated to pre-operatively identify cytologically indeterminate nodules likely to be truly benign so that surgery can be avoided. Its performance is supported by robust multicenter prospective and blinded clinical validation studies, and supported by extensive independent clinical utility publications which show a marked reduction in surgery among patients with benign Afirma GEC results. To rule-out cancer and avoid unnecessary diagnostic surgery, Afirma’s quality and depth of validation stand alone. The accuracy of a benign result is the negative predictive value (NPV). Afirma achieves an NPV ≥94% among cytologically indeterminate nodules (Bethesda III or IV). Thirteen clinical utility studies describing 1468 GEC benign patients demonstrate that few Afirma GEC benign nodules undergo surgery, including after 3 years of follow-up. With a specificity of 52%, over half of the truly benign nodules with indeterminate cytology receive a benign GEC result. High test sensitivity is critical to safely rule out cancer. The Afirma GEC’s 90% sensitivity means that regardless of the pre-test risk of malignancy, 90% of all malignant nodules are GEC suspicious. The Afirma GEC has transformed patient care. Where the majority of cytologically indeterminate patients were once operated to determine if the nodule was benign or malignant, now nearly half of these surgeries can be avoided.
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Affiliation(s)
- Richard T Kloos
- Veracyte, Inc., Department of Medical Affairs, Senior Medical Director-Endocrinology, California, USA, Phone: +1(650)243-6300, E-mail:
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BRAF V600E mutation as a predictor of thyroid malignancy in indeterminate nodules: A systematic review and meta-analysis. Eur J Surg Oncol 2016; 43:1219-1227. [PMID: 27923591 DOI: 10.1016/j.ejso.2016.11.003] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 10/17/2016] [Accepted: 11/01/2016] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Thyroid nodules are usually diagnosed using fine-needle aspiration (FNA). The sensitivity limitations of FNA result in 10-30% of nodules being classified as "indeterminate". The BRAFV600E mutation is associated with papillary thyroid carcinoma (PTC). We conducted a systemic review and meta-analysis to evaluate the diagnostic utility of the BRAFV600E mutation in indeterminate nodules. METHOD PUBMED and EMBASE were searched for studies testing for the BRAFV600E involving indeterminate nodules (Thy3a, Thy3f, Thy4) and containing information on final surgical histopathology. Thirty two studies involving 3150 indeterminate nodules were included in the analysis. RESULTS The overall sensitivity and specificity for BRAFV600E for the diagnosis of thyroid malignancy was 0.40 (95% CI: 0.32-0.48) and 1.00 (95% CI: 0.98-1.00) respectively. The diagnostic odds ratio (DOR) was 205.4 (95% CI: 40.1-1052). With a Fagan plot, the post-test probability of thyroid cancer, given a negative mutation was 6%, but this rose to 92% with a positive result. On subgroup analysis, for Thy3a nodules, the pooled sensitivity and specificity for thyroid malignancy was 0.21 (95% CI: 0.13-0.34) and 1.00 (95% CI: 0.98-1.00). For Thy3f nodules, the pooled sensitivity and specificity was 0.09 (95% CI: 0.03-0.20) and 1.00 (95% CI: 0.05-1.00) respectively. For Thy4 nodules, the corresponding sensitivity and specificity was 0.58 (95% CI: 0.5-0.64) and 0.99 (95% CI: 0.95-1.00) respectively. CONCLUSIONS Despite a high specificity for thyroid cancer, BRAFV600E mutation has a low overall sensitivity and therefore has a limited diagnostic value as a single screening test.
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Labourier E. Utility and cost-effectiveness of molecular testing in thyroid nodules with indeterminate cytology. Clin Endocrinol (Oxf) 2016; 85:624-31. [PMID: 27155136 DOI: 10.1111/cen.13096] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 03/29/2016] [Accepted: 05/05/2016] [Indexed: 11/27/2022]
Abstract
CONTEXT Molecular testing on biopsies from thyroid nodules with indeterminate cytology can improve patient management by preventing unnecessary surgeries on benign nodules. OBJECTIVE The aim of the study was to determine the health outcome benefits and cost-effectiveness of molecular testing in nodules with AUS/FLUS or FN/SFN cytology. DESIGN The initial diagnosis and treatment of a hypothetical cohort of adult U.S. patients with solitary thyroid nodules ≥1 cm was simulated by decision analytic modelling using Medicare cost estimates for three management strategies, standard of care without molecular testing (StC), gene expression classifier (GEC) and mutation and miRNA testing (MMT). RESULTS Gene expression classifier decreased the rate of unnecessary surgeries by 32% relative to StC, yielding incremental costs of $1008 per patient or $5070 per unnecessary surgery avoided. MMT decreased the surgery rate by 67%, yielding incremental savings of -$1384 per patient or -$3170 per unnecessary surgery avoided. Results remained robust in deterministic sensitivity analyses; MMT was dominant for every variable tested. Independent of cancer prevalence, MMT yielded 52% fewer unnecessary surgeries relative to GEC #bib70% fewer two-stage thyroidectomies and correctly identified 70% more benign nodules. Test specificity had to be >68% for molecular testing to be cost-effective and decrease by >50% the rate of unnecessary surgeries performed on benign nodules. CONCLUSIONS Molecular testing with high benign diagnostic yield can generate both positive health outcomes (less surgeries) and positive economic outputs (cost savings). These results are consistent with previously reported cost-utility data and provide valuable insights for informed decision-making by patients, physicians and payers.
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Zhang X. Value of Molecular Tests in Cytologically Indeterminate Lesions of Thyroid. Arch Pathol Lab Med 2016; 139:1484-90. [PMID: 26619020 DOI: 10.5858/arpa.2014-0245-ra] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT Fine-needle aspiration has been the initial step in the workup of thyroid nodular lesions and has successfully reduced the number of unnecessary surgeries and improved preoperative malignancy detection. However, up to one-third of cases fall in the diagnostically "indeterminate group," which poses a patient-management challenge. objective: To review the characteristics of molecular tests useful for stratifying the malignancy risk of indeterminate thyroid lesions, including their advantages and limitations. DATA SOURCES PubMed. CONCLUSIONS Molecular tests are useful for triage of indeterminate thyroid nodules initially diagnosed by using fine-needle aspiration. Immunocytochemistry is readily available with the shortest turnaround time among the molecular tests but suffers from poor reproducibility and low interpretation concordance. Gene mutation analysis is superior in detecting malignancies as a rule-in test, despite low specificity. Next-generation sequencing seems promising but needs more validations before widespread use. Gene expression profiling is more suitable for detecting benign lesions as a rule-out test to avoid unnecessary surgeries but is not reliable in excluding malignancies. MicroRNA profiling has great potential for both risk stratification and predicting prognosis but is limited by significant variations in sensitivity and specificity. Although many questions still need to be answered, taken together, molecular tests are a promising option for classifying cytologically indeterminate thyroid nodular lesions.
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Affiliation(s)
- Xinmin Zhang
- From the Department of Pathology and Laboratory Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania
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Abstract
Thyroid cancer is an increasingly common malignancy, with a rapidly rising prevalence worldwide. The social and economic ramifications of the increase in thyroid cancer are multiple. Though mortality from thyroid cancer is low, and most patients will do well, the risk of recurrence is not insignificant, up to 30%. Therefore, it is important to accurately identify those patients who are more or less likely to be burdened by their disease over years and tailor their treatment plan accordingly. The goal of risk stratification is to do just that. The risk stratification process generally starts postoperatively with histopathologic staging, based on the AJCC/UICC staging system as well as others designed to predict mortality. These do not, however, accurately assess the risk of recurrence/persistence. Patients initially considered to be at high risk may ultimately do very well yet be burdened by frequent unnecessary monitoring. Conversely, patients initially thought to be low risk, may not respond to their initial treatment as expected and, if left unmonitored, may have higher morbidity. The concept of risk-adaptive management has been adopted, with an understanding that risk stratification for differentiated thyroid cancer is dynamic and ongoing. A multitude of variables not included in AJCC/UICC staging are used initially to classify patients as low, intermediate, or high risk for recurrence. Over the course of time, a response-to-therapy variable is incorporated, and patients essentially undergo continuous risk stratification. Additional tools such as biochemical markers, genetic mutations, and molecular markers have been added to this complex risk stratification process such that this is essentially a continuum of risk. In recent years, additional considerations have been discussed with a suggestion of pre-operative risk stratification based on certain clinical and/or biologic characteristics. With the increasing prevalence of thyroid cancer but stable mortality, this risk stratification may identify those in whom the risk of conventional surgical treatment may outweigh the benefit. This review aims to outline the process of risk stratification and highlight the important concepts that are involved and those that are continuously evolving.
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Affiliation(s)
- Gal Omry-Orbach
- Department of Endocrinology, Diabetes and Metabolism, Virginia Mason Medical Center, Seattle, WA, USA
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31
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Pusztaszeri MP, Krane JF, Faquin WC. BRAF testing and thyroid FNA. Cancer Cytopathol 2015; 123:689-95. [PMID: 26335367 DOI: 10.1002/cncy.21614] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 08/18/2015] [Indexed: 12/17/2022]
Affiliation(s)
- Marc P Pusztaszeri
- Department of Pathology, Geneva University Hospital, Geneva, Switzerland
| | - Jeffrey F Krane
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - William C Faquin
- Harvard Medical School, Boston, Massachusetts.,Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
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Ferris RL, Baloch Z, Bernet V, Chen A, Fahey TJ, Ganly I, Hodak SP, Kebebew E, Patel KN, Shaha A, Steward DL, Tufano RP, Wiseman SM, Carty SE. American Thyroid Association Statement on Surgical Application of Molecular Profiling for Thyroid Nodules: Current Impact on Perioperative Decision Making. Thyroid 2015; 25:760-8. [PMID: 26058403 PMCID: PMC4519104 DOI: 10.1089/thy.2014.0502] [Citation(s) in RCA: 157] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Recent advances in research on thyroid carcinogenesis have yielded applications of diagnostic molecular biomarkers and profiling panels in the management of thyroid nodules. The specific utility of these novel, clinically available molecular tests is becoming widely appreciated, especially in perioperative decision making by the surgeon regarding the need for surgery and the extent of initial resection. METHODS A task force was convened by the Surgical Affairs Committee of the American Thyroid Association and was charged with writing this article. RESULTS/CONCLUSIONS This review covers the clinical scenarios by cytologic category for which the thyroid surgeon may find molecular profiling results useful, particularly for cases with indeterminate fine-needle aspiration cytology. Distinct strengths of each ancillary test are highlighted to convey the current status of this evolving field, which has already demonstrated the potential to streamline decision making and reduce unnecessary surgery, with the accompanying benefits. However, the performance of any diagnostic test, that is, its positive predictive value and negative predictive value, are exquisitely influenced by the prevalence of cancer in that cytologic category, which is known to vary widely at different medical centers. Thus, it is crucial for the clinician to know the prevalence of malignancy within each indeterminate cytologic category, at one's own institution. Without this information, the performance of the diagnostic tests discussed below may vary substantially.
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Affiliation(s)
- Robert L. Ferris
- Division of Head and Neck Surgery, Department of Otolaryngology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | - Zubair Baloch
- Department of Pathology, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania
| | - Victor Bernet
- Department of Endocrinology, Mayo Clinic, Jacksonville, Florida
| | - Amy Chen
- Department of Otolaryngology/Head and Neck Surgery, Emory University, Atlanta, Georgia
| | - Thomas J. Fahey
- Department of Surgery, New York Presbyterian Hospital, New York, New York
| | - Ian Ganly
- Head and Neck Service, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Steven P. Hodak
- Division of Endocrinology, New York University Medical Center, New York, New York
| | - Electron Kebebew
- Endocrine Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland
| | - Kepal N. Patel
- Division of Endocrine Surgery, New York University Medical Center, New York, New York
| | - Ashok Shaha
- Head and Neck Service, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - David L. Steward
- Department of Otolaryngology/Head and Neck Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Ralph P. Tufano
- Department of Otolaryngology/Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Sam M. Wiseman
- Department of Surgery, Division of General Surgery, St. Paul's Hospital and University of British Columbia, Vancouver, Canada
| | - Sally E. Carty
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Brauner E, Holmes BJ, Krane JF, Nishino M, Zurakowski D, Hennessey JV, Faquin WC, Parangi S. Performance of the Afirma Gene Expression Classifier in Hürthle Cell Thyroid Nodules Differs from Other Indeterminate Thyroid Nodules. Thyroid 2015; 25:789-96. [PMID: 25962906 DOI: 10.1089/thy.2015.0049] [Citation(s) in RCA: 98] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND The recently introduced Afirma gene expression classifier (AGEC) provides binary results (benign or suspicious) to guide management of cytologically indeterminate thyroid nodules. The AGEC is intended to reduce unnecessary surgeries for benign nodules, and management algorithms favor surgery for suspicious results. Limited data are available on the performance of this test for Hürthle cell nodules (HCNs). This study hypothesized that a predominance of Hürthle cells leads to an increased rate of suspicious AGEC results with a potential for overtreatment, despite a relatively low risk of malignancy. METHODS The pathology databases from three tertiary care facilities were queried from 2010 to 2014 for fine-needle aspirates (FNAs) diagnosed as suspicious for Hürthle cell neoplasm (SHCN) or atypia of undetermined significance/follicular lesion of undetermined significance concerning for Hürthle cell neoplasm (AFHCN). Cytology diagnoses were rendered internally prior to AGEC testing. The patient demographics, FNA diagnosis, AGEC result, surgical procedure, and pathologic outcomes were recorded. RESULTS The cohort consisted of 134 patients with HCNs. Prior to AGEC availability, 62 patients underwent surgery: 81% (50/62) of patients had surgery, and 34% (17/50) of the resected index nodules were malignant. After introduction of the AGEC, 72 patients underwent AGEC testing: 65% (47/72) of patients had surgery, and 13% (6/46) of the resected nodules were malignant. Thirty-two percent (23/72) of patients had a benign AGEC result and did not undergo surgery, and 4% (3/72) had surgery despite a benign AGEC result with benign final pathology, whereas 63% (45/72) of patients had suspicious AGEC results, with 96% of these patients (43/45) undergoing surgery, and 14% (6/43) of these index nodules were malignant. CONCLUSIONS While 32% of tested patients declined surgery based on a benign AGEC, 86% of patients with suspicious AGEC findings had unnecessary surgery, reflecting a substantially lower rate of malignancy from what was previously reported for all indeterminate nodules. Given the approximate pretest malignancy risk of 25-35% for an FNA diagnosis of SHCN or AFHCN, a suspicious AGEC diagnosis does not increase the probability of malignancy in an HCN, and patients should be counseled accordingly.
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MESH Headings
- Adenocarcinoma, Follicular/diagnosis
- Adenocarcinoma, Follicular/genetics
- Adenoma, Oxyphilic
- Adult
- Aged
- Biopsy, Fine-Needle
- Carcinoma/diagnosis
- Carcinoma/genetics
- Carcinoma, Neuroendocrine/diagnosis
- Carcinoma, Neuroendocrine/genetics
- Carcinoma, Papillary
- Cohort Studies
- Diagnosis, Differential
- Female
- Gene Expression Profiling
- Gene Expression Regulation, Neoplastic
- Humans
- Male
- Middle Aged
- Oxyphil Cells/metabolism
- Oxyphil Cells/pathology
- Retrospective Studies
- Thyroid Cancer, Papillary
- Thyroid Neoplasms/diagnosis
- Thyroid Neoplasms/genetics
- Thyroid Nodule/diagnosis
- Thyroid Nodule/genetics
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Affiliation(s)
- Eran Brauner
- 1 Department of Surgery, Massachusetts General Hospital , Boston, Massachusetts
| | - Brittany J Holmes
- 2 Department of Pathology, Massachusetts General Hospital , Boston, Massachusetts
| | - Jeffrey F Krane
- 3 Department of Pathology, Brigham and Women's Hospital , Boston, Massachusetts
| | - Michiya Nishino
- 4 Department of Pathology, Beth Israel Deaconess Medical Center , Boston, Massachusetts
| | - David Zurakowski
- 5 Departments of Surgery and Anesthesia, Boston Children's Hospital , Boston, Massachusetts
| | - James V Hennessey
- 6 Department of Medicine, Beth Israel Deaconess Medical Center , Boston, Massachusetts
| | - William C Faquin
- 2 Department of Pathology, Massachusetts General Hospital , Boston, Massachusetts
| | - Sareh Parangi
- 1 Department of Surgery, Massachusetts General Hospital , Boston, Massachusetts
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Hadjisavva IS, Dina R, Talias MA, Economides PA. Prevalence of Cancer in Patients with Thyroid Nodules in the Island of Cyprus: Predictive Value of Ultrasound Features and Thyroid Autoimmune Status. Eur Thyroid J 2015; 4:123-8. [PMID: 26279998 PMCID: PMC4521064 DOI: 10.1159/000430438] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 04/11/2015] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND The purpose of this study was to determine the prevalence of thyroid carcinoma in patients who underwent ultrasound-guided fine needle aspiration biopsy (USgFNA) of thyroid nodules in the island of Cyprus. Ultrasound features as well as the presence of autoimmune thyroid disease were evaluated as risk factors for malignancy. METHODS 322 consecutively examined patients (272 females/50 males, age 13-81) underwent USgFNA of thyroid nodules in a referral endocrine clinic between July 2007 and July 2009. The ultrasonographic characteristics examined were: echogenicity, margin irregularity, composition, calcifications, presence of increased vasculature and nodule size. The presence or absence of autoimmune thyroid disease was recorded. RESULTS From the 548 nodules examined, 74 (13.6%) were classified as THY3, 4 or 5. 75 patients (123 nodules) underwent surgical resection. 46 patients (64 nodules) proved to have thyroid carcinoma by histology. There was a significant correlation of suspicious/malignant cytology with solid composition, hypoechogenicity, irregular margins and the presence of calcifications. A significant association was also noted between the presence of positive antithyroglobulin antibodies (p < 0.05) and Graves' disease (p = 0.01) with suspicious/malignant cytology. CONCLUSION The overall prevalence of thyroid cancer was 14.3%. Ultrasound characteristics were highly predictive of thyroid malignancy. Thyroid autoimmunity should be considered as a risk factor.
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Affiliation(s)
- Irini S. Hadjisavva
- Economides Nicosia Endocrinology Center, Open University of Cyprus, Nicosia, Cyprus, London, UK
| | - Roberto Dina
- Department of Cellular Pathology, Hammersmith Hospital, Imperial College Healthcare Trust, London, UK
| | - Michael A. Talias
- Healthcare Management Postgraduate Program, Open University of Cyprus, Nicosia, Cyprus, London, UK
| | - Panayiotis A. Economides
- Economides Nicosia Endocrinology Center, Open University of Cyprus, Nicosia, Cyprus, London, UK
- *Dr. Panayiotis A. Economides, MD, PhD, FACE, Economides Nicosia Endocrinology Center, 9 Iona Nicolaou, Engomi 2406, Nicosia (Cyprus), E-Mail
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Burgos-Ojeda D, Wu R, McLean K, Chen YC, Talpaz M, Yoon E, Cho KR, Buckanovich RJ. CD24+ Ovarian Cancer Cells Are Enriched for Cancer-Initiating Cells and Dependent on JAK2 Signaling for Growth and Metastasis. Mol Cancer Ther 2015; 14:1717-27. [PMID: 25969154 DOI: 10.1158/1535-7163.mct-14-0607] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Accepted: 05/04/2015] [Indexed: 01/05/2023]
Abstract
Ovarian cancer is known to be composed of distinct populations of cancer cells, some of which demonstrate increased capacity for cancer initiation and/or metastasis. The study of human cancer cell populations is difficult due to long requirements for tumor growth, interpatient variability, and the need for tumor growth in immune-deficient mice. We therefore characterized the cancer initiation capacity of distinct cancer cell populations in a transgenic murine model of ovarian cancer. In this model, conditional deletion of Apc, Pten, and Trp53 in the ovarian surface epithelium (OSE) results in the generation of high-grade metastatic ovarian carcinomas. Cell lines derived from these murine tumors express numerous putative stem cell markers, including CD24, CD44, CD90, CD117, CD133, and ALDH. We show that CD24(+) and CD133(+) cells have increased tumor sphere-forming capacity. CD133(+) cells demonstrated a trend for increased tumor initiation while CD24(+) cells versus CD24(-) cells had significantly greater tumor initiation and tumor growth capacity. No preferential tumor-initiating or growth capacity was observed for CD44(+), CD90(+), CD117(+), or ALDH(+) versus their negative counterparts. We have found that CD24(+) cells, compared with CD24(-) cells, have increased phosphorylation of STAT3 and increased expression of STAT3 target Nanog and c-myc. JAK2 inhibition of STAT3 phosphorylation preferentially induced cytotoxicity in CD24(+) cells. In vivo JAK2 inhibitor therapy dramatically reduced tumor metastases, and prolonged overall survival. These findings indicate that CD24(+) cells play a role in tumor migration and metastasis and support JAK2 as a therapeutic target in ovarian cancer.
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Affiliation(s)
- Daniela Burgos-Ojeda
- Cellular and Molecular Biology Graduate Program, University of Michigan, Ann Arbor, Michigan. Department of Internal Medicine Division Hematology-Oncology, University of Michigan, Ann Arbor, Michigan
| | - Rong Wu
- Department of Pathology, Division of Gynecological Pathology, University of Michigan, Ann Arbor, Michigan
| | - Karen McLean
- Department of Obstetrics-Gynecology, Division of Gynecologic Oncology, University of Michigan, Ann Arbor, Michigan
| | - Yu-Chih Chen
- Department of Electrical Engineering and Computer Science, University of Michigan, Ann Arbor, Michigan
| | - Moshe Talpaz
- Department of Internal Medicine Division Hematology-Oncology, University of Michigan, Ann Arbor, Michigan
| | - Euisik Yoon
- Department of Electrical Engineering and Computer Science, University of Michigan, Ann Arbor, Michigan. Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan
| | - Kathleen R Cho
- Department of Pathology, Division of Gynecological Pathology, University of Michigan, Ann Arbor, Michigan
| | - Ronald J Buckanovich
- Cellular and Molecular Biology Graduate Program, University of Michigan, Ann Arbor, Michigan. Department of Internal Medicine Division Hematology-Oncology, University of Michigan, Ann Arbor, Michigan. Department of Obstetrics-Gynecology, Division of Gynecologic Oncology, University of Michigan, Ann Arbor, Michigan.
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Samir AE, Dhyani M, Anvari A, Prescott J, Halpern EF, Faquin WC, Stephen A. Shear-Wave Elastography for the Preoperative Risk Stratification of Follicular-patterned Lesions of the Thyroid: Diagnostic Accuracy and Optimal Measurement Plane. Radiology 2015; 277:565-73. [PMID: 25955578 DOI: 10.1148/radiol.2015141627] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
PURPOSE To evaluate the diagnostic accuracy of shear-wave elastography (SWE) for the diagnosis of malignancy in follicular lesions and to identify the optimal SWE measurement plane. MATERIALS AND METHODS The institutional review board approved this HIPAA-compliant, single-institution, prospective pilot study. Subjects scheduled for surgery after a previous fine-needle aspiration report of "atypia of undetermined significance" or "follicular lesion of undetermined significance," "suspicion for follicular neoplasm," or "suspicion for Hurthle cell neoplasm," were enrolled after obtaining informed consent. Subjects underwent conventional ultrasonography (US), Doppler evaluation, and SWE preoperatively, and their predictive value for thyroid malignancy was evaluated relative to the reference standard of surgical pathologic findings. RESULTS Thirty-five patients (12 men, 23 women) with a mean age of 55 years (range, 23-85 years) and a fine-needle aspiration diagnosis of atypia of undetermined significance or follicular lesion of undetermined significance (n = 16), suspicion for follicular neoplasm (n = 14), and suspicion for Hurthle cell neoplasm (n = 5) were enrolled in the study. Male sex was a statistically significant (P = .02) predictor of malignancy, but age was not. No sonographic morphologic parameter, including nodule size, microcalcification, macrocalcification, halo sign, taller than wide dimension, or hypoechogenicity, was associated with malignancy. Similarly, no Doppler feature, including intranodular vascularity, pulsatility index, resistive index, or peak-systolic velocity, was associated with malignancy. Higher median SWE tissue Young modulus estimates from the transverse insonation plane were associated with malignancy, yielding an area under the receiver operating characteristic curve of 0.81 (95% confidence interval: 0.62, 1.00) for differentiation of malignant from benign nodules. At a cutoff value of 22.3 kPa, sensitivity, specificity, positive predictive value, and negative predictive value of 82%, 88%, 75%, and 91%, respectively, were observed. CONCLUSION This prospective pilot study indicates that SWE may be a valuable tool in preoperative malignancy risk assessment of follicular-patterned thyroid nodules.
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Affiliation(s)
- Anthony E Samir
- From the Department of Radiology (A.E.S., M.D., A.A.), Institute for Technology Assessment (E.F.H.), Department of Pathology (W.C.F.), and Department of Surgery (A.S.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114; and Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Md (J.P.)
| | - Manish Dhyani
- From the Department of Radiology (A.E.S., M.D., A.A.), Institute for Technology Assessment (E.F.H.), Department of Pathology (W.C.F.), and Department of Surgery (A.S.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114; and Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Md (J.P.)
| | - Arash Anvari
- From the Department of Radiology (A.E.S., M.D., A.A.), Institute for Technology Assessment (E.F.H.), Department of Pathology (W.C.F.), and Department of Surgery (A.S.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114; and Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Md (J.P.)
| | - Jason Prescott
- From the Department of Radiology (A.E.S., M.D., A.A.), Institute for Technology Assessment (E.F.H.), Department of Pathology (W.C.F.), and Department of Surgery (A.S.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114; and Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Md (J.P.)
| | - Elkan F Halpern
- From the Department of Radiology (A.E.S., M.D., A.A.), Institute for Technology Assessment (E.F.H.), Department of Pathology (W.C.F.), and Department of Surgery (A.S.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114; and Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Md (J.P.)
| | - William C Faquin
- From the Department of Radiology (A.E.S., M.D., A.A.), Institute for Technology Assessment (E.F.H.), Department of Pathology (W.C.F.), and Department of Surgery (A.S.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114; and Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Md (J.P.)
| | - Antonia Stephen
- From the Department of Radiology (A.E.S., M.D., A.A.), Institute for Technology Assessment (E.F.H.), Department of Pathology (W.C.F.), and Department of Surgery (A.S.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114; and Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Md (J.P.)
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Varshney R, Forest VI, Mascarella MA, Zawawi F, Rochon L, Hier MP, Mlynarek A, Tamilia M, Payne RJ. The Mcgill thyroid nodule score - does it help with indeterminate thyroid nodules? J Otolaryngol Head Neck Surg 2015; 44:2. [PMID: 25645364 PMCID: PMC4323228 DOI: 10.1186/s40463-015-0058-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 01/16/2015] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Ultrasound guided fine-needle aspiration (USFNA) biopsy of thyroid nodules often gives a result of indeterminate pathology, placing thyroid specialists in difficult management situations. The aim of this study is to evaluate the incidence of malignancy in patients undergoing surgery and to correlate these results with the McGill Thyroid Nodule Score (MTNS). METHODS We performed a retrospective study comparing USFNA results, MTNS and histopathology of patients undergoing thyroid surgery between 2010 and 2012. Pre-operative USFNA results were divided into three subgroups: benign, indeterminate and suspicious for/malignant. The indeterminate USFNA subgroup comprised of Bethesda type III (atypia of undetermined significance) and Bethesda type IV (follicular neoplasms, including Hurthle cell neoplasms) lesions. Post-operative histopathology was divided into benign or malignant groups. RESULTS Of the 437 patient charts reviewed, 57.0% had an indeterminate USFNA biopsy. Within the indeterminate group, the malignancy rate was 39.8%. For indeterminate USFNA, the median MTNS was 7 (32% risk of malignancy) for benign nodules and 9 (63% risk of malignancy) for malignant nodules on post-operative histopathology (p < 0.05). CONCLUSION The rate of malignancy in operated patients with an indeterminate USFNA result was 39.8%. The MTNS can be of value to thyroid specialists in pre-operative decision-making when dealing with an indeterminate result of a thyroid nodule on USFNA.
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Affiliation(s)
- Rickul Varshney
- McGill University, Otolaryngology-Head and Neck Surgery, Royal Victoria Hospital, 687 Pine Ave. West, E3-37, Montreal, QC, H3A 1A1, Canada.
| | - Veronique-Isabelle Forest
- McGill University, Otolaryngology-Head and Neck Surgery, Royal Victoria Hospital, 687 Pine Ave. West, E3-37, Montreal, QC, H3A 1A1, Canada.
| | - Marco A Mascarella
- McGill University, Otolaryngology-Head and Neck Surgery, Royal Victoria Hospital, 687 Pine Ave. West, E3-37, Montreal, QC, H3A 1A1, Canada.
| | - Faisal Zawawi
- McGill University, Otolaryngology-Head and Neck Surgery, Royal Victoria Hospital, 687 Pine Ave. West, E3-37, Montreal, QC, H3A 1A1, Canada. .,King Abdulaziz University, Jeddah, Saudi Arabia.
| | - Louise Rochon
- Department of Pathology, Jewish General Hospital, McGill University, 3755 Côte-Ste-Catherine Road, Montreal, QC, H3T 1E2, Canada.
| | - Michael P Hier
- McGill University, Otolaryngology-Head and Neck Surgery, Royal Victoria Hospital, 687 Pine Ave. West, E3-37, Montreal, QC, H3A 1A1, Canada.
| | - Alex Mlynarek
- McGill University, Otolaryngology-Head and Neck Surgery, Royal Victoria Hospital, 687 Pine Ave. West, E3-37, Montreal, QC, H3A 1A1, Canada.
| | - Michael Tamilia
- Department of Endocrinology and Metabolism, Jewish General Hospital, McGill University, 3755 Côte-Ste-Catherine Road, Montreal, Canada.
| | - Richard J Payne
- McGill University, Otolaryngology-Head and Neck Surgery, Royal Victoria Hospital, 687 Pine Ave. West, E3-37, Montreal, QC, H3A 1A1, Canada.
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Zeppa P. Liquid-based cytology: a 25-year bridge between the pap smear and molecular cytopathology. Acta Cytol 2014; 58:519-21. [PMID: 25428030 DOI: 10.1159/000369593] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Pio Zeppa
- Department of Medicine and Surgery, University of Salerno, Salerno, Italy
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Najafian A, Zeiger MA. Role of molecular diagnostic markers in the management of indeterminate and suspicious thyroid nodules. INTERNATIONAL JOURNAL OF ENDOCRINE ONCOLOGY 2014. [DOI: 10.2217/ije.13.4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Incidental thyroid nodules are commonly found during routine neck examination. Fine needle aspiration (FNA) followed by cytological examination is currently considered as the most reliable method for evaluation of thyroid nodules. However, 10–40% of FNA results are inconclusive, and are reported as indeterminate or suspicious. Approximately 20% of indeterminate or suspicious nodules are malignant. Therefore, there has been an increasing trend in use of molecular markers as an adjunctive measure for more accurate preoperative diagnosis of indeterminate or suspicious nodules. Molecular markers can be used alone or as a part of molecular panels. Although some investigations revealed promising findings regarding the potential use of molecular markers in the management of thyroid nodules, their true impact on management of patients with indeterminate nodules is still unclear.
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Affiliation(s)
- Alireza Najafian
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Martha A Zeiger
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
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Brace MD, Wang J, Petten M, Bullock MJ, Makki F, Trites J, Taylor SM, Hart RD. Differential expression of transforming growth factor-beta in benign vs. papillary thyroid cancer nodules; a potential diagnostic tool? J Otolaryngol Head Neck Surg 2014; 43:22. [PMID: 25927212 PMCID: PMC4115165 DOI: 10.1186/s40463-014-0022-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 06/27/2014] [Indexed: 01/05/2023] Open
Abstract
Background Thyroid nodules are common, but only 5% of nodules are found to be malignant. In North America, the incidence of thyroid cancer is increasing. Fine needle aspirate (FNA) biopsy is the diagnostic test of choice. Unfortunately, up to 20% of FNAs are non-diagnostic. A specific molecular marker for thyroid cancer is desirable. Evidence suggests that cell signaling through transforming growth factor beta (TGF- β) is important in the development of thyroid cancer. We sought to compare the expression of TGF- β in malignant and benign thyroid nodules. Methods From 2008-present, thyroid nodule tissue from thyroidectomy specimens was prospectively collected and stored at −80°C. RNA extraction and reverse transcription was performed on 47 samples (24 papillary thyroid cancer and 23 benign nodules). Quantitative PCR using SYBR green was performed to detect TGF-β-1 and −2. Resulting CT values were normalized against β-actin. Gene expression was calculated using the 2-ΔCT method. Results A significantly greater expression of TGF- β1 (p < 0.0001) was detected in the group of malignant thyroid nodules compared to benign nodules. There was no difference in the expression of TGF- β2 (p = 0.4735) between the two groups. Conclusions In this study, we demonstrated that expression of TGF- β1 but not TGF- β2 is significantly increased in papillary thyroid cancer compared to benign thyroid nodules. This may serve as a potential diagnostic marker for papillary thyroid cancer.
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Affiliation(s)
- Matthew D Brace
- Department of Otolaryngology - Head and Neck Surgery; 3rd Floor Dickson Building, Victoria General Site, QEII Health Sciences Centre, 5820 University Ave., Halifax, Nova Scotia, B3H 2Y9, Canada.
| | - Jun Wang
- Department of Microbiology & Immunology, Department of Pathology, Department of Pediatrics, Canadian Center for Vaccinology, IWK Health Centre, Dr. Richard B. Goldbloom Research and Clinical Care Pavilion, 3rd Floor West, 5850/5980 University Avenue, PO Box 9700, Halifax, Nova Scotia, NS B3K 6R8, Canada.
| | - Mark Petten
- Department of Microbiology & Immunology, Department of Pathology, Department of Pediatrics, Canadian Center for Vaccinology, IWK Health Centre, Dr. Richard B. Goldbloom Research and Clinical Care Pavilion, 3rd Floor West, 5850/5980 University Avenue, PO Box 9700, Halifax, Nova Scotia, NS B3K 6R8, Canada.
| | - Martin J Bullock
- Department of Pathology; Dr. D. J. Mackenzie Building, 5788 University Avenue, Halifax, Nova Scotia, B3H 2Y9, Canada.
| | - Fawaz Makki
- Department of Otolaryngology - Head and Neck Surgery; 3rd Floor Dickson Building, Victoria General Site, QEII Health Sciences Centre, 5820 University Ave., Halifax, Nova Scotia, B3H 2Y9, Canada.
| | - Jonathan Trites
- Department of Otolaryngology - Head and Neck Surgery; 3rd Floor Dickson Building, Victoria General Site, QEII Health Sciences Centre, 5820 University Ave., Halifax, Nova Scotia, B3H 2Y9, Canada.
| | - S Mark Taylor
- Department of Otolaryngology - Head and Neck Surgery; 3rd Floor Dickson Building, Victoria General Site, QEII Health Sciences Centre, 5820 University Ave., Halifax, Nova Scotia, B3H 2Y9, Canada.
| | - Robert D Hart
- Department of Otolaryngology - Head and Neck Surgery; 3rd Floor Dickson Building, Victoria General Site, QEII Health Sciences Centre, 5820 University Ave., Halifax, Nova Scotia, B3H 2Y9, Canada.
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Nardi F, Basolo F, Crescenzi A, Fadda G, Frasoldati A, Orlandi F, Palombini L, Papini E, Zini M, Pontecorvi A, Vitti P. Italian consensus for the classification and reporting of thyroid cytology. J Endocrinol Invest 2014; 37:593-9. [PMID: 24789536 DOI: 10.1007/s40618-014-0062-0] [Citation(s) in RCA: 270] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Accepted: 02/07/2014] [Indexed: 02/06/2023]
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Cheng SP, Hsu YC, Liu CL, Liu TP, Chien MN, Wang TY, Lee JJ. Significance of allelic percentage of BRAF c.1799T > A (V600E) mutation in papillary thyroid carcinoma. Ann Surg Oncol 2014; 21 Suppl 4:S619-26. [PMID: 24748129 DOI: 10.1245/s10434-014-3723-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Indexed: 01/07/2023]
Abstract
BACKGROUND Somatic BRAF mutation is frequently observed in papillary thyroid carcinoma (PTC). Recent evidence suggests that PTCs are heterogeneous tumors containing a subclonal or oligoclonal occurrence of BRAF mutation. Conflicting results have been reported concerning the prognostic significance of the mutant allele frequency. Our present aim was to investigate the association between the percentage of BRAF c.1799T > A (p.Val600Glu) alleles and clinicopathological parameters in PTC. METHODS Genomic DNA was extracted from fresh-frozen specimens obtained from 50 PTC patients undergoing total thyroidectomy. The BRAF mutation status was determined by Sanger sequencing. The percentage of mutant BRAF alleles was quantified by mass spectrometric genotyping, pyrosequencing, and competitive allele-specific TaqMan PCR (castPCR). RESULTS Positive rate of BRAF mutation was 72 % by Sanger sequencing, 82 % by mass spectrometric genotying, and 84 % by pyrosequencing or castPCR. The average percentage of mutant BRAF alleles was 22.5, 31, and 30.7 %, respectively. There was a good correlation among three quantification methods (Spearman's rho = 0.87-0.97; p < 0.0001). The mutant allele frequency was significantly correlated with tumor size (rho = 0.47-0.52; p < 0.01) and extrathyroidal invasion. The frequency showed no difference in pathological lymph node metastasis. CONCLUSIONS The percentage of mutant BRAF alleles is positively associated with tumor burden and extrathyroidal invasion in PTC. Relatively good correlations exist among mass spectrometric genotyping, pyrosequencing, and castPCR in quantification of mutant BRAF allele frequency.
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Affiliation(s)
- Shih-Ping Cheng
- Mackay Junior College of Medicine, Nursing, and Management, Taipei, Taiwan
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Ohori NP, Schoedel KE. Ancillary Studies in Thyroid Cytopathology. Surg Pathol Clin 2014; 7:47-60. [PMID: 26839268 DOI: 10.1016/j.path.2013.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Recent advances in thyroid imaging, clinical evaluation, cytopathology, surgical pathology, and molecular diagnostics have contributed toward greater understanding of thyroid nodules. In particular, the development of the Bethesda System for Reporting Thyroid Cytopathology (BSRTC) has brought standardization to the field and the system dovetails well with the implementation of immunohistochemistry and molecular testing to diagnostic practice. Among the molecular strategies available, the application of the molecular panel of common genetic alterations can stratify indeterminate BSRTC diagnoses into low-risk and high-risk groups. The molecular panel markers have a high positive predictive value and therefore, the panel is considered to be a "rule-in" test. In contrast, the Afirma gene expression classifier by Veracyte Corporation is a test that has been reported to have a high negative predictive value, and therefore, considered to be a "rule-out" test. With further advances, refinements are expected to be made. In particular, the application of next-generation sequencing technology holds promise in bringing thyroid cytopathology to the next level.
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Affiliation(s)
- N Paul Ohori
- Department of Pathology, University of Pittsburgh Medical Center-Presbyterian, A610, 200 Lothrop Street, Pittsburgh, PA 15213, USA.
| | - Karen E Schoedel
- Department of Pathology, University of Pittsburgh Medical Center-Presbyterian, A610, 200 Lothrop Street, Pittsburgh, PA 15213, USA
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Clinical advances in molecular biomarkers for cancer diagnosis and therapy. Int J Mol Sci 2013; 14:14771-84. [PMID: 23863689 PMCID: PMC3742272 DOI: 10.3390/ijms140714771] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Revised: 06/28/2013] [Accepted: 07/03/2013] [Indexed: 12/20/2022] Open
Abstract
Cancer diagnosis is currently undergoing a paradigm shift with the incorporation of molecular biomarkers as part of routine diagnostic panel. The molecular alteration ranges from those involving the DNA, RNA, microRNAs (miRNAs) and proteins. The miRNAs are recently discovered small non-coding endogenous single-stranded RNAs that critically regulates the development, invasion and metastasis of cancers. They are altered in cancers and have the potential to serve as diagnostic markers for cancer. Moreover, deregulating their activity offers novel cancer therapeutic approaches. The availability of high throughput techniques for the identification of altered cellular molecules allowed their use in cancer diagnosis. Their application to a variety of body specimens from blood to tissues has been helpful for appreciating their use in the clinical context. The development of innovative antibodies for immunohistochemical detection of proteins also assists in diagnosis and risk stratification. Overall, the novel cancer diagnostic tools have extended their application as prognostic risk factors and can be used as targets for personalized medicine.
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