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Sanjari M, Ordooei M, Amirkhosravi L, Naghibzadeh-Tahami A, Nazemi S. The effect of positive thyroglobulin antibodies on the prognosis and treatment response in patients with papillary thyroid carcinoma. Heliyon 2024; 10:e26092. [PMID: 38384522 PMCID: PMC10879018 DOI: 10.1016/j.heliyon.2024.e26092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 02/07/2024] [Accepted: 02/07/2024] [Indexed: 02/23/2024] Open
Abstract
Almost 15-30% of patients with papillary thyroid carcinoma (PTC) experience some degree of recurrence after treatment. Long-term follow-up and examination after thyroidectomy are very important in dealing with this issue. Serum thyroglobulin (Tg) level and neck ultrasound are the main part of follow-up for this purpose. The presence of thyroglobulin antibodies (TgAbs) leads to unreliable thyroglobulin (Tg) levels. The present study aims to evaluate the relationship between the simultaneous measurement of Tg and TgAb with long-term survival and response to treatment in these patients. This study was conducted by surveying available data from the medical records of 204 out of 600 patients over a 20-year period. In this research, 104 patients with positive TgAb were considered as the case group, and 100 patients with negative TgAb were selected as the control group. The relationship of TgAb titer was investigated with the staging, response to treatment (including the surgery number, number of radiotherapies, and dose of radioactive iodine), and recurrence in these patients. Also, the trend of TgAb changes was examined in the presence of high or low thyroglobulin levels during the follow-up period. Patients with high TgAb levels had more lymph node involvement, higher cumulative dose, a higher number of times received iodine, more surgical number, higher recurrence rate, and less excellent response (ER) to treatment during follow-ups. This effect of TgAb worsened in the presence of high Tg titer and remained up to 36 months. Overall, the baseline level of TgAb and its changes can be a suitable factor for predicting subsequent response to treatment and recurrence in patients with PTC. Accordingly, in cases with high TgAb and Tg levels, close follow-up should be considered up to Tg and TgAb normalization.
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Affiliation(s)
- Mojgan Sanjari
- Endocrinology and Metabolism Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Marzieh Ordooei
- Physiology Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran
| | - Ladan Amirkhosravi
- Endocrinology and Metabolism Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Ahmad Naghibzadeh-Tahami
- Modeling in Health Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Sarir Nazemi
- Department of Radiology, School of Medicine, Kerman University of Medical Sciences, Kerman, Iran
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Paparodis R, Livadas S, Karvounis E, Bantouna D, Zoupas I, Angelopoulos N, Imam S, Jaume JC. Elevated Preoperative TPO Ab Titers Decrease Risk for DTC in a Linear Fashion: A Retrospective Analysis of 1635 Cases. J Clin Endocrinol Metab 2023; 109:e347-e355. [PMID: 37440589 DOI: 10.1210/clinem/dgad408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 07/03/2023] [Accepted: 07/10/2023] [Indexed: 07/15/2023]
Abstract
CONTEXT For some, chronic lymphocytic thyroiditis (Hashimoto thyroiditis) is an important risk factor for differentiated thyroid cancer (DTC). Surgical cohort studies even suggested a potential role for thyroid peroxidase antibodies (TPO-Abs) on that risk. OBJECTIVE Our clinical observations argued against that possibility. We designed the present study to evaluate the relationship of TPO-Abs and DTC in a large patient population. METHODS We recruited individuals who underwent thyroidectomies at 4 different clinical sites (USA: 1 clinic, 2000-2013, and Greece: 3 clinics, 2007-2021). We gathered data on TPO-Abs titers measured with commercially available chemiluminescence immunoassays, and reviewed patients' data including surgical pathology. TPO-Abs of 34 IU/mL or greater was deemed positive (TPO+) and TPO-Abs less than 34 IU/mL was deemed negative (TPO-). Odds ratios (OR) for DTC were calculated with the Fisher exact test and P less than .05 was deemed significant. RESULTS We reviewed data from 8461 consecutive thyroid surgery cases. TPO-Abs titers were available for 1635 individuals: DTC n = 716 (43.8%), benign pathology n = 919 (56.2%), TPO+ n = 540 (33.0%), and TPO- n = 1095 (67.0%). DTC was found at a lower frequency in TPO+ (198/540, 36.7%) compared to TPO- (518/1095, 47.3%) patients, OR 0.64 (0.52-0.80; P < .0001). Rising TPO-Abs titers conferred protection against DTC in a linear fashion: TPO-Abs less than 10 IU/mL: 59.3%, TPO-Abs less than 34 IU/mL: 47.4%, TPO-Abs 34 to 100 IU/mL: 42.6%, TPO-Abs 100 to 500 IU/mL: 32.0%, TPO-Abs greater than 1000 IU/mL: 19.4%; P less than .0001. CONCLUSION Higher TPO-Ab titers appear protective against DTC in our large multicenter cohort of patients who underwent thyroidectomies. Rising preoperative TPO-Abs titers conferred linearly increasing protection against DTC.
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Affiliation(s)
- Rodis Paparodis
- Center for Diabetes and Endocrine Research, College of Medicine and Life Sciences (formerly Medical College of Ohio), University of Toledo, Toledo, OH 43606, USA
- Private Practice, Patras 26221, Greece
| | - Sarantis Livadas
- Division of Endocrinology, Diabetes and Metabolism, Athens Medical Center, Athens 11527, Greece
| | - Evangelos Karvounis
- Endocrine Surgery Center of Excellence, Euroclinic Hospital, Athens 11521, Greece
| | | | - Ioannis Zoupas
- University of Athens Medical School, Athens 10563, Greece
| | | | - Shahnawaz Imam
- Center for Diabetes and Endocrine Research, College of Medicine and Life Sciences (formerly Medical College of Ohio), University of Toledo, Toledo, OH 43606, USA
| | - Juan Carlos Jaume
- Center for Diabetes and Endocrine Research, College of Medicine and Life Sciences (formerly Medical College of Ohio), University of Toledo, Toledo, OH 43606, USA
- Department of Medicine, Edward Hines, Jr. VA Hospital/Loyola University Chicago, Hines, IL 60141, USA
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Cabibi D, Giannone AG, Bellavia S, Lo Coco R, Lo Bianco A, Formisano E, Scerrino G, Graceffa G. Serum Anti-Thyroglobulin Autoantibodies Are Specific in Predicting the Presence of Papillary-like Nuclear Features and Lymphocytic Infiltrate in the Thyroid Gland. Diagnostics (Basel) 2023; 13:2042. [PMID: 37370937 DOI: 10.3390/diagnostics13122042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 05/29/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023] Open
Abstract
(1) Background: Previous studies have reported a correlation between serum anti-Thyroglobulin-antibodies (TgAb) and papillary thyroid carcinoma. The aim of our study was to evaluate whether serum TgAb and anti-thyroid-peroxidase antibody (TPO) positivity was also related to pre-neoplastic histological changes such as papillary-like nuclear features (PLNF) and with the presence of lymphocytic infiltrate (LI) in thyroid surgical specimens. (2) Methods: The study was retrospectively carried out on 70 consecutively recruited patients who underwent thyroidectomy for benign process and whose TgAb and TPOAb values were retrieved from clinical records. Histological sections of thyroid surgical samples were revised, looking for PLNF and lymphocytic infiltrate. HBME1 expression was assessed by immunohistochemistry. (3) Results: Our results showed a significant association between TgAb, PLNF, and lymphocytic infiltrate. The presence of TgAb was highly specific, but less sensitive, in predicting the presence of PLNF (sensitivity = 0.6, specificity = 0.9; positive predictive value (PPV) = 0.88; negative predictive value (NPV) = 0.63). TgAb positivity showed a good association with the presence of lymphocytic infiltrate (sensitivity = 0.62, specificity = 0.9; PPV = 0.88 and NPV = 0.68). HBME1 immunoreactivity was observed in the colloid of follicles showing PLNF and/or closely associated with LI. (4) Conclusions: The presence of PLNF and LI is associated with serum TgAb positivity. The presence of TgAb and of LI could be triggered by an altered thyroglobulin contained in the HBME1-positive colloid, and could be a first defense mechanism against PLNF that probably represent early dysplastic changes in thyrocytes.
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Affiliation(s)
- Daniela Cabibi
- Unit of Anatomic Pathology, Department of Health Promotion Mother and Child Care Internal Medicine and Medical Specialties (PROMISE), University Hospital AOU Policlinico "P. Giaccone", University of Palermo, 90127 Palermo, Italy
| | - Antonino Giulio Giannone
- Unit of Anatomic Pathology, Department of Health Promotion Mother and Child Care Internal Medicine and Medical Specialties (PROMISE), University Hospital AOU Policlinico "P. Giaccone", University of Palermo, 90127 Palermo, Italy
| | - Sandro Bellavia
- Unit of Anatomic Pathology, Department of Health Promotion Mother and Child Care Internal Medicine and Medical Specialties (PROMISE), University Hospital AOU Policlinico "P. Giaccone", University of Palermo, 90127 Palermo, Italy
| | - Roberta Lo Coco
- Unit of Anatomic Pathology, Department of Health Promotion Mother and Child Care Internal Medicine and Medical Specialties (PROMISE), University Hospital AOU Policlinico "P. Giaccone", University of Palermo, 90127 Palermo, Italy
| | - Anna Lo Bianco
- Unit of Anatomic Pathology, Department of Health Promotion Mother and Child Care Internal Medicine and Medical Specialties (PROMISE), University Hospital AOU Policlinico "P. Giaccone", University of Palermo, 90127 Palermo, Italy
| | - Eleonora Formisano
- Unit of Anatomic Pathology, Department of Health Promotion Mother and Child Care Internal Medicine and Medical Specialties (PROMISE), University Hospital AOU Policlinico "P. Giaccone", University of Palermo, 90127 Palermo, Italy
| | - Gregorio Scerrino
- Unit of General and Emergency Surgery, Department of Surgical Oncological and Stomatological Sciences (DICHIRONS), University Hospital AOU Policlinico "P. Giaccone", University of Palermo, 90127 Palermo, Italy
| | - Giuseppa Graceffa
- Unit of General and Oncological Surgery, Department of Surgical Oncological and Stomatological Sciences (DICHIRONS), University Hospital AOU Policlinico "P. Giaccone", University of Palermo, 90127 Palermo, Italy
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Januś D, Kujdowicz M, Wójcik M, Taczanowska-Niemczuk A, Kiszka-Wiłkojć A, Górecki W, Starzyk JB. Ultrasound evolution of parenchymal changes in the thyroid gland with autoimmune thyroiditis in children prior to the development of papillary thyroid carcinoma - a follow-up study. Front Endocrinol (Lausanne) 2023; 14:1172823. [PMID: 37124746 PMCID: PMC10130420 DOI: 10.3389/fendo.2023.1172823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 03/29/2023] [Indexed: 05/02/2023] Open
Abstract
Background Follicular cell-derived thyroid carcinoma represents the vast majority of paediatric thyroid cancers (TCs). Papillary thyroid carcinoma (PTC) accounts for over 90% of all childhood TC cases, and its incidence in paediatric patients is increasing. The objective of this follow-up study was to present the outcome of ultrasound (US) and laboratory monitoring of paediatric patients with autoimmune thyroiditis (AIT) prior to the development of PTC. Patients and methods This prospective study included 180 children and adolescents (132 females; 73.3%) with a suspicion of thyroid disorder referred to the Outpatient Endocrine Department. The patients were divided into four groups: 1) 28 patients with a mean age of 10.7 [standard deviation (SD), 3.1] y, in whom PTC was detected during the active surveillance of AIT [AIT(+), PTC(+) follow up (F)]; 2) 18 patients with a mean age of 12.8 (SD, 3.4) y, in whom PTC and AIT were detected upon admission (A) [AIT(+), PTC(+) A]; 3) 45 patients with a mean age of 13.0 (SD, 3.4) y, in whom PTC was detected upon admission and AIT was excluded [AIT(-), PTC(+) A]; and 4) an age- and sex-matched control group of 89 patients with AIT and with a mean age of 9.4 (SD, 3.0) y. The analysis included clinical, US, and laboratory assessment results of children on admission (groups 1-4) and during follow-up (groups 1 and 4) in the Paediatric Endocrine Outpatient Department. Results Upon admission of those in group 1, the US evaluation revealed a hypoechogenic thyroid gland in 12 and an irregular normoechogenic gland in 16 patients. US monitoring revealed an increase in thyroid echogenicity and an increased irregularity of the thyroid structure during the follow-up period of all of the patients from group 1. Such changes were not noticed in group 4. PTC was diagnosed at the mean time of 3.6 y (3 mo-9 y) since AIT confirmation in group 1. The mean maximum PTC diameter as per the US was significantly smaller in group 1 than in groups 2 and 3 [13.2 (10.8) mm vs. 22.2 (12.8) and 22.05 (15.4) mm]. Fewer patients in group 1 were referred to 131I than in groups 2 and 3 (71.4% vs. 94.4 and 93.3%). Interestingly, significant differences were observed in the thyroglobulin antibody (TgAb)/thyroid peroxidase antibody (TPOAb) ratio between groups 2 and 3, as opposed to group 4, at the beginning of observation [15.3 (27.6) and 3.5 (8.8] vs. 0.77 (1.9)]. In group 1, after the follow-up, an increase in the TgAb/TPOAb ratio was observed [1.2 (9.8) to 5.2 (13.5)]. There were no significant differences between groups 1-3 in labeling index Ki67, lymph nodes metastasis, extrathyroidal extension, and angioinvasion. There were no associations between thyroid-stimulating hormone, TgAb, and the extent of the disease. Conclusion The use of thyroid US focused on the search for developing tumours in the routine follow-up of patients with AIT may not only help in the early detection of thyroid malignancies that are not clinically apparent but may also influence the invasiveness of oncological therapy and reduce the future side effects of 131I therapy. We propose that the repeat evaluation of TPOAb and TgAb warrants further exploration as a strategy to determine TC susceptibility in paediatric patients with AIT in larger multicentre studies.
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Affiliation(s)
- Dominika Januś
- Department of Pediatric and Adolescent Endocrinology, Chair of Pediatrics, Institute of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
- Department of Pediatric and Adolescent Endocrinology, University Children Hospital in Krakow, Krakow, Poland
| | - Monika Kujdowicz
- Department of Pathomorphology, Jagiellonian University Medical College, Krakow, Poland
- Department of Pathology, University Children Hospital in Krakow, Krakow, Poland
| | - Małgorzata Wójcik
- Department of Pediatric and Adolescent Endocrinology, Chair of Pediatrics, Institute of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
- Department of Pediatric and Adolescent Endocrinology, University Children Hospital in Krakow, Krakow, Poland
| | - Anna Taczanowska-Niemczuk
- Department of Pediatric Surgery, Institute of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
- Department of Pediatric Surgery, University Children Hospital in Krakow, Krakow, Poland
| | - Aleksandra Kiszka-Wiłkojć
- Department of Pediatric Surgery, Institute of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
- Department of Pediatric Surgery, University Children Hospital in Krakow, Krakow, Poland
| | - Wojciech Górecki
- Department of Pediatric Surgery, Institute of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
- Department of Pediatric Surgery, University Children Hospital in Krakow, Krakow, Poland
| | - Jerzy B. Starzyk
- Department of Pediatric and Adolescent Endocrinology, Chair of Pediatrics, Institute of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
- Department of Pediatric and Adolescent Endocrinology, University Children Hospital in Krakow, Krakow, Poland
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Huang D, Zhi J, Zhang J, Qin X, Zhao J, Zheng X, Gao M. Relationship Between Thyroid Autoantibodies and Recurrence of Papillary Thyroid Carcinoma in Children and Adolescents. Front Oncol 2022; 12:883591. [PMID: 35756669 PMCID: PMC9213685 DOI: 10.3389/fonc.2022.883591] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 05/04/2022] [Indexed: 11/13/2022] Open
Abstract
Background Numerous studies reported connection between papillary thyroid carcinoma (PTC) and thyroid autoantibody in adults, but few of them have investigated whether there is a similar link in children and adolescents. The purpose of this research was to explore the relationship between clinicopathological features, prognosis and preoperative thyroid peroxidase antibody (TPOAb) as well as thyroglobulin antibody (TgAb) status in children and adolescents with PTC. Methods This study retrospectively reviewed 179 patients of PTC who underwent a thyroidectomy from January 2000 to June 2021 at Tianjin Medical University Cancer Hospital. We compared preoperative TgAb and TPOAb status with the clinicopathological features and prognosis of children and adolescents with PTC in different age groups. Results Patients with positive preoperative TPOAb and TgAb had lower recurrence rate in the younger group (P = 0.006, 0.047, respectively). Patients with positive TPOAb preoperatively had normal level of preoperative Tg and less cervical LNM than patients with negative TPOAb in children and adolescents (P < 0.05). Positive TPOAb preoperatively of PTC patients had a longer median DFS (113.4 months) than negative TPOAb (64.9 months) (P = 0.009, log-rank). Univariate analyses showed age, maximal tumor size, T stage, multifocality, lateral LNM and N staging were predictors for cancer recurrence in children and adolescents (P<0.05). Cox regression analysis found younger age (HR 0.224, P < 0.001), lateral LNM (HR 0.137, P = 0.010), N stage (HR 30.356, P < 0.001) were independent risk factors for recurrence. Conclusions Our study found that presence of preoperative TPOAb and TgAb could serve as novel prognostic factors for predicting recurrence of PTC in children.
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Affiliation(s)
- Dongmei Huang
- Department of Thyroid and Neck Tumor, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin, China
| | - Jingtai Zhi
- Department of Thyroid and Neck Tumor, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin, China
| | - Jinming Zhang
- Department of Thyroid and Neck Tumor, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin, China
| | - Xuan Qin
- Department of Thyroid and Neck Tumor, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin, China
| | - Jingzhu Zhao
- Department of Thyroid and Neck Tumor, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin, China
| | - Xiangqian Zheng
- Department of Thyroid and Neck Tumor, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin, China
| | - Ming Gao
- Department of Thyroid and Neck Tumor, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin, China.,Department of Thyroid and Breast Surgery, Tianjin Union Medical Center, Tianjin, China.,Tianjin Key Laboratory of General Surgery Inconstruction, Tianjin Union Medical Center, Tianjin, China
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Alyousif H, Adam I, Alamin NA, Sid Ahmed MA, Al Saeed A, Hassoni AH, Musa IR. The prevalence and associated predictors for Bethesda III-VI for reporting thyroid cytopathology in Royal Commission Hospital, Kingdom of Saudi Arabia. Ther Adv Endocrinol Metab 2022; 13:20420188221122486. [PMID: 36111207 PMCID: PMC9469765 DOI: 10.1177/20420188221122486] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 08/04/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Thyroid cancer is increasing globally and is currently the most prevalent endocrine malignancy. Recent data show an increase in the incidence of thyroid cancer in the Kingdom of Saudi Arabia (KSA). Thyroid ultrasound and fine-needle aspiration cytology (FNAC) are the cornerstones in managing thyroid nodules. We conducted this study to evaluate the prevalence and the associated predictors for thyroid nodule Bethesda III-VI in eastern KSA. METHODS A retrospective study was conducted between January 2015 and 31 August 2021. The participants were recruited patients who received a thyroid ultrasound and ultrasound-guided thyroid FNAC, using the thyroid imaging reporting and data system (TI-RADS) and the Bethesda Classification, respectively. RESULT Three hundred and ten patients who underwent thyroid FNAC were enrolled in the study. The median (interquartile, IQR) age was 47.0 (20.0) years, and 266 (85.8%) of them were females. The median (IQR) body mass index was 30.2 (7.6) kg/m2. Out of these participants, 64.8% were euthyroid, 27.4% had hypothyroidism and 7.7% had hyperthyroidism. The ACR TI-RADS-3, 4 and 5 were 51.3%, 46.1% and 2.6%, respectively. The Bethesda outcome of thyroid FNAC I-VI was 5.2%, 63.9%, 15.5%, 5.8%, 3.5% and 6.1%, respectively. The risk for malignancy (Bethesda III-VI) was documented in 31.0% and atypia of undetermined significance was most prevalent (15.5%). A higher ACR TI-RADS score was associated with a higher risk of malignancy: ACR TI-RADS-3 (20.8%), ACR TI-RADS-4 (39.2%) and ACR TI-RADS-5 (87.5%). In a multivariate analysis, only the ACR TI-RADS score was significantly associated with the outcome of thyroid FNAC: ACR TI-RADS-4 [OR = 2.59 (95% CI = 1.54-4.36)] and ACR TI-RADS-5 [OR = 29.03 (95% CI = 3.44-245.07)]. CONCLUSION There was a high prevalence of Bethesda III-VI and atypia of undetermined significance was most prevalent. A thyroid ultrasound report for TI-RADS was significantly associated with the outcome of thyroid FNAC and is a reliable tool in the absence of molecular testing for thyroid cancer.
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Affiliation(s)
- Hussain Alyousif
- Royal Commission Hospital at AL Jubail Industrial City, Al Jubail, Kingdom of Saudi Arabia
| | - Ishag Adam
- Department of Obstetrics and Gynecology, Unaizah College of Medicine and Medical Sciences, Qassim University, Unaizah, Kingdom of Saudi Arabia
| | | | - Mona A. Sid Ahmed
- Royal Commission Hospital at AL Jubail Industrial City, Al Jubail, Kingdom of Saudi Arabia
| | - Ayat Al Saeed
- Royal Commission Hospital at AL Jubail Industrial City, Al Jubail, Kingdom of Saudi Arabia
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