Insufficient experience in thyroid fine-needle aspiration leads to misdiagnosis of thyroid cancer

Telecytology rapid onsite evaluation, with real-time communication between cytopathologist, cytotechnologist, and proceduralist, offers better adequacy rates for lymph node, but not thyroid, fine-needle aspirations

INTRODUCTION

Rapid onsite evaluation (ROSE) decreases rates of inadequate fine-needle aspirations (FNAs). Telecytology allows pathologists to perform ROSE without being physically "on site", thereby saving cytopathologists' travel time and allowing them to perform ROSE for multiple institutions. Little research exists comparing telecytology to non-telecytology ROSE for FNA inadequacy rates.

MATERIALS AND METHODS

Using previously obtained quality metrics, we compared inadequacy rates for lymph node and thyroid FNAs with and without ROSE and with non-telecytology ROSE compared with telecytology ROSE. Use of ROSE was determined by the proceduralist. Type of ROSE was location-based, as only certain locations at our institution have telecytology capabilities. Chi-squared testing was used to compare proportions of populations and P value was set to 0.05.

RESULTS

A total of 1168 lymph node and 1177 thyroid FNAs were included in our adequacy analysis. We found any ROSE decreased our inadequacy rate for both lymph node (20.4% to 12.7%, P = 0.002) and thyroid (34.7% to 4.8%, P = 7.4 × 10-18) FNAs. We found telecytology further decreased our inadequacy rate for lymph node (13.8% to 5.9%, P = 0.016), but not thyroid (3.3% to 5.0%, P = 0.34), FNAs.

CONCLUSIONS

At our institution, when using telecytology, slides are read in real time with the cytotechnologist and the proceduralist looking at slides together near the patient bedside, while the cytopathologist is on the phone looking at slides on the computer screen via Dameware. When non-telecytology ROSE is performed, the cytotechnologist evaluates a slide, brings it to the cytopathologist's office and then the cytopathologist calls the proceduralist to discuss the slide. We believe telecytology offers an opportunity for more inclusive communication thereby improving adequacy rates for more complex cases, like lymph nodes, without affecting adequacy rates for cases where assessment of adequacy is less complex, like thyroid. This research supports use of telecytology especially for complex cases.

The Role of MMP-9 and MMP-9 Inhibition in Different Types of Thyroid Carcinoma

Matrix metalloproteinase-9 (MMP-9), one of the most investigated and studied biomarkers of the MMPs family, is a zinc-dependent proteolytic metalloenzyme whose primary function is degrading the extracellular matrix (ECM). It has been proved that MMP-9 expression elevates in multiple pathological conditions, including thyroid carcinoma. MMP-9 has a detectable higher level in malignant or metastatic thyroid tumor tissues than in normal or benign tissues and acts as an additional marker to distinguish different tumor stages because of its close correlations with clinical features, such as lymph node metastasis, TNM stage, tumor size and so on. Natural and non-natural MMP-9 inhibitors suppress its expression, block the progression of diseases, and play a role in therapy consequently. MMP-9 inhibitory molecules also assist in treating thyroid tumors by suppressing the proliferation, invasion, migration, metastasis, viability, adhesion, motility, epithelial-mesenchymal transition (EMT), and other risk factors of different thyroid cancer cells. In a word, discovering and designing MMP-9 inhibitors provide great therapeutic effects and promising clinical values in various types of thyroid carcinoma.

THE LEARNING CURVE AND PERFORMANCE OF A NEWLY ESTABLISHED THYROID FINE-NEEDLE ASPIRATION CENTER

Context

Thyroid fine-needle aspiration (FNA) cytology is the best tool for preoperative diagnosis of thyroid carcinoma; however, its learning curve is poorly described. Our aim was to assess the learning curve of a new thyroid FNA center involving unexperienced operator and pathologist.

Methods

We retrieved from our tertiary endocrinology center database all thyroid FNA procedures done by a single operator (endocrinologist with no experience in FNA) between 2018 and 2021. Cytology was assessed by two pathologists with limited or no experience in thyroid cytology. We also got the corresponding sex, age, nodule diameter, EU-TIRADS score, Bethesda category and final pathology report.

Results

There were 1872 FNA in 1618 patients. Proportion of Bethesda 1 nodules decreased significantly (p for trend=0.003) from 17% in the first 100 FNA procedures to 4% in the 401-500 group of procedures, and remained constant between 9% and 4% (p for trend=NS) for the rest of the study. Proportion of Bethesda 2 rose steady from 26% in the first 100 nodules to 80.1% in the last 241 nodules (p for trend<0.001). Indeterminate lesions (Bethesda 3 and 4) decreased significantly (p for trend=0.001) from 16% and 35% in the first 100 nodules to 2.5% and 5.8% in the last 241 lesions. Proportions of Bethesda 5+6 categories varied non-significantly over time. There were no time trends in the malignancy rate of surgically removed nodules.

Conclusions

At least 300 procedures are needed to reach the standard performance. A steadily state for the whole center is obtained after about 500 procedures.

Hashimoto's thyroiditis elicits decreased diagnostic efficacy of thyroid nodule ultrasound-guided fine needle aspiration

BACKGROUND

False negative (FN) or false positive (FP) results of thyroid ultrasound-guided fine needle aspiration (US-guided FNA) cause missed diagnosis of thyroid cancer or unnecessary thyroidectomy.

PURPOSE

To explore the impact of Hashimoto's thyroiditis (HT) on the diagnostic efficacy of US-guided FNA and to analyze the differences in diagnostic efficacy between US-guided FNA and thyroid ultrasonography (US) in patients with HT.

METHOD

Medical records were reviewed retrospectively. Patients with and without Hashimoto's thyroiditis (HT) were included in the exposure and non-exposure group, respectively.

RESULTS

HT was not an independent risk factor for thyroid cancer. The percentage of undetermined results of US-guided FNA (Bethesda I, III, IV) in the exposure group was significantly higher. The US-guided FNA's diagnostic sensitivity, specificity, and accuracy were significantly lower, and FP rate (FPR) and FN rate (FNR) were higher in the exposure group. In the exposure group, US tended to give higher diagnostic sensitivity, accuracy, PPV, NPV, and lower FPR and FNR. Receiver operating characteristic (ROC) curve analysis showed that, in the exposure group the diagnostic efficacy of thyroid US was significantly higher than of US-guided FNA.

CONCLUSION

HT tends to cause undetermined results and elicit lower diagnostic performance of US-guided FNA. In patients with HT, the diagnostic efficacy of thyroid US is, at least, not inferior to US-guided FNA.

Needle Biopsy Adequacy in the Era of Precision Medicine and Value-Based Health Care

CONTEXT.—

Needle biopsy of diseased tissue is an essential diagnostic tool that is becoming even more important as precision medicine develops. However, the capability of this modality to efficiently provide samples adequate for diagnostic and prognostic analysis remains quite limited relative to current diagnostic needs. For physicians and patients, inadequate biopsy frequently leads to diagnostic delay, procedure duplication, or insufficient information about tumor biology leading to delay in treatment; for health systems, this results in substantial incremental costs and inefficient use of scarce specialized diagnostic resources.

OBJECTIVE.—

To review current needle biopsy technology, devices, and practice with a perspective to identify current limitations and opportunities for improvement in the context of advancing precision medicine.

DATA SOURCES.—

PubMed searches of fine-needle aspiration and core needle biopsy devices and similar technologies were made generally, by tissue site, and by adequacy as well as by health economics of these technologies.

CONCLUSIONS.—

Needle biopsy adequacy can be improved by recognizing the importance of this diagnostic tool by promoting common criteria for needle biopsy adequacy; by optimizing needle biopsy procedural technique, technologies, clinical practice, professional education, and quality assurance; and by bundling biopsy procedure costs with downstream diagnostic modalities to provide better accountability and incentives to improve the diagnostic process.

The expression profile of integrin receptors and osteopontin in thyroid malignancies varies depending on the tumor progression rate and presence of BRAF V600E mutation

Thyroid cancer (TC) is one of the most common malignancy of the human endocrine system. BRAF V600E mutation is the most frequent genetic alteration of papillary carcinoma, the most frequent TC, which effects RAS-RAF-MEK intracellular signaling pathway. These alterations in RAS-RAF-MEK pathway lead to changes in expression levels of cell membrane integrin receptors and their ligand - extracellular matrix protein osteopontin, which in turn increases the metastatic potential of tumor cells. Thus, integrins and their ligand osteopontin can be considered as potential biomarkers of tumor progression and aggressive tumor phenotypes. The aim of the study was to evaluate the expression levels of integrin receptors ITGA2, ITGA3, ITGAV, ITGA6, ITGA9, ITGB1, ITGB3 and their ligands OPNa, OPNb in the thyroid cancer with different BRAF V600E mutation status.

METHODS

Thyroid tumor samples of 70 patients obtained during surgical treatment were analyzed. Expression levels of the investigated genes were evaluated by real time RT-PCR. Fluorescent immunohistochemistry (IHC) was used to confirm the PCR results and to estimate the amount of protein levels. For IHC frozen sections were used. BRAF V600E mutation was determined using allele-specific amplification. Nonparametric criteria (Kruskal Wallis, Wilcoxon and Mann-Whitney tests) were used to evaluate group differences. P values of less than 0.05 were considered as statistically significant.

RESULTS

A higher gene expression level of ITGA2 (1.9-fold, p = 0.037), ITGA3 (21.1-fold, p = 0.041) and ITGA5 (2.08-fold, p = 0.048) was observed in papillary thyroid cancer (PTC) tissue in comparison with median expression level in control samples (conventionally normal tissue of thyroid gland). These changes were confirmed by IHC (significant changes for α2 integrin). ITGAV expression level was statistically significantly higher in follicular thyroid cancer (FTC) (2.0-fold, p = 0.040). Next, high gene expression levels in tissue samples of lymph node metastases were observed for ITGA5 (2.92-fold, p = 0.015), OPNb (4.36-fold, p = 0.037). For genes ITGA3 (37.48-fold, p = 0.017790), ITGA6 (18.76-fold, p = 0.028921) and ITGA9 (12.52-fold, p = 0.026710) higher expression level was detected in T_3-4 tumors (TNM) compared to tumors classified as T_1-2. Presence of BRAF V600E mutation was identified in 20 samples of PTC of 40 (50%). A significant increase of the expression level only of ITGA3 (3.1-fold, p = 0. 0422) was observed in BRAF V600E positive samples. Further, changes in expression levels of integrins and osteopontin were assessed in benign and malignant neoplasms. In PTC samples higher expression of ITGA2 (2.8-fold, p = 0.005), ITGA6 (2.11, p = 0.03) and ITGB1 (2.32-fold, p = 0.02) was detected. In FTC expression level of ITGA6 (2.67, p = 0.007) was higher than in benign thyroid nodules.

CONCLUSION

Identified changes in expression levels of the studied genes indicate that they could play an important role in tumor progression, and their expression could be affected by the product of mutant BRAF gene. Integrins and their ligand osteopontin might be considered as potential markers in determining prognosis and treatment of TC.

Usefulness of NRAS codon 61 mutation analysis and core needle biopsy for the diagnosis of thyroid nodules previously diagnosed as atypia of undetermined significance

A repeat fine needle aspiration (FNA) is recommended for thyroid nodules diagnosed as atypia of undetermined significance (AUS) in a previous cytology. We evaluated the utility of NRAS codon 61 (NRAS61) mutation analysis and core needle biopsy (CNB) for the diagnosis of thyroid nodules previously diagnosed as AUS. This study enrolled 236 patients who underwent both NRAS61 mutation analysis and CNB of thyroid nodules previously diagnosed as AUS at cytology. The NRAS61 mutation was detected in 36 nodules and was more frequently detected in the AUS and follicular neoplasm (FN)/suspicious for follicular neoplasm (SFN) categories, as determined by histological analysis of CNB, than in the benign group (p = 0.005). Sixty-one patients underwent surgery, and 29 nodules were finally diagnosed as malignant after surgery. Among 61 patients who underwent surgery, nodules with the NRAS61 mutation (42-65 %) had a significantly higher malignancy rate than nodules with wild-type NRAS61 (7-37 %, p = 0.038). The association between malignancy and the NRAS61 mutation was significant after adjusting for age, sex, nodule size, and histological diagnosis of CNB (p = 0.01). NRAS61 mutation analysis together with CNB could be helpful for arriving at a clinical decision in patients with thyroid nodules showing AUS in a previous cytology.

Carcinosarcoma of the thyroid gland

Introduction. Surgeon has significant role in the management of such rare and controversial clinical entities related to thyroid gland. In this case report we have presented an elderly patient with rapid enlargement in thyroid that was related to carcinosarcoma. Case Presentation. A 60-year-old lady was presented with rapid enlargement of the thyroid gland. A fine needle aspiration of the nodule in right lobe was performed several weeks before presentation to our clinic. End diagnosis was a papillary carcinoma of the thyroid with spindle cell component. Thus the nodule was recognized to be a carcinosarcoma. Conclusion. Thyroid surgery merits a multidisciplinary approach. Indeed the surgeon should make a conclusive decision in some controversial and rare clinical entities such as carcinosarcoma.