Carcinoma of unknown primary in the head and neck: The evaluation of the effectiveness of 18F-FDG-PET/CT,own experience

AimThe aim of the present study was to estimate the clinical effectiveness of ¹⁸F-FDG-PET/CT in the detection of the primary tumor in patients with histologically proven squamous cell carcinoma cervical lymph nodes metastasis from an unknown primary.Background¹⁸F-fluorodeoxyglucose positron emission tomography combined with CT (¹⁸F-FDG-PET/CT) is believed to be very helpful in localization of primary tumor in CUP Syndrome patients.Material and method41 patients referred to Poznan Medical University Department of Head and Neck Surgery from January 2010 to December 2013 with CUP Syndrome were included in the study. All patients presented fine-needle biopsy proven squamous cell carcinoma metastasis of the upper-, or mid neck lymph nodes. The final results were obtained from the histopathologic reports of tissue samples from anatomical regions suspected for primary tumor, additional imaging exams as well as clinical follow-up data.ResultsThe ¹⁸F-FDG-PET/CT successfully detected primary tumor in 7 out of 41 patients (17%). In two more cases the primary tumor was indicated in the lung. 24 of 41 patients (58.5%) analyzed in our study remained without evidence of a primary tumor. In 4 cases (9.75%) we did not reveal any pathology within the localizations indicated by PET/CT on panendoscopy. In 4 cases we obtained histological confirmation of neoplasm on panendoscopy despite the negative results of PET/CT examinations.ConclusionWe may suppose a relatively high usefulness of ¹⁸F-FDG-PET/CT in the diagnosis process of CUP Syndrome patients. High NPV may indicate patients with no symptoms of primary tumor, which allows to avoid extensive resection or extra imaging.     

Thyroid carcinoma in children and adolescents: a retrospective review

ObjectiveTo describe clinical presentation, preoperative study, intervention, histology, surgical complications and follow-up characteristics, and survival in patients with thyroid carcinoma (TC) with less than 18 years at presentation.Material and methodsretrospective analysis of clinical data of all children and adolescents followed in S. João Hospital from January 1, 2000 to March 31, 2010 with histologic diagnosis of TC.ResultsTwenty-three patients were identified, 19 girls, and 4 boys. Median age at presentation was 17.0 years. Annual incidence was 2.3 cases/year. The main presenting symptom was a solitary thyroid nodule (60.8%). Three (13%) patients had risk factors for TC, 2 of the 3 had previous cervical irradiation. The other was a smoker. Total thyroidectomy was performed in 16 (69.6%), and 10 patients underwent a second surgical procedure. Four (17.4%) patients had postoperative complications. Histologic examination revealed differentiated TC in all, papillary thyroid carcinoma (PTC) in 86.9%, follicular carcinoma in the remaining. All patients received thyroxine suppressive therapy and 20 underwent therapeutic radioactive iodine (¹³¹I). During follow-up (7.1 years), 7 out of the 23 patients presented new metastases and needed new treatment. All patients are currently alive.ConclusionsTC is a reality in pediatric population, thyroid routine examination should take part in all clinical examination in children and adolescents.     

Management of Low-Risk Differentiated Thyroid Cancer

ObjectiveTo summarize the definitions of and management recommendations for low-risk thyroid cancer made by the American and European Thyroid Associations and synthesize this information with the recent literature, including systematic evaluations of tumor staging systems guiding therapy.MethodsThe American Thyroid Association and European Thyroid Association guidelines were compared and pertinent literature since 2005 was reviewed.ResultsOf papillary thyroid microcarcinomas (PTMC), up to 50% breach the thyroid capsule, 64% have lymph node metastases, up to 43% are multifocal, and as many as 2.8% have distant metastases. Locoregional and distant recurrences are, respectively, as high as 5.9% and 1.5%. As many as 1 in 4 patients with a papillary thyroid carcinoma 1.5 cm or smaller develop persistent disease. Cancer-related mortality rates are usually less than 1%, but are as high as 2% in some reports. Tumor staging systems are too inaccurate to guide therapy.ConclusionIt is unlikely that many patients will forgo treatment after understanding their risk, especially when total thyroidectomy and radioiodine (¹³¹I) therapy can reduce the PTMC recurrence or persistence disease rate to zero. Preoperatively diagnosed PTMC should be treated with total or near-total thyroidectomy, regardless of tumor size. For very low-risk patients with unifocal PTMC smaller than 1 cm that is removed by chance during surgery to treat benign thyroid disease, lobectomy alone without ¹³¹I therapy may be sufficient therapy if there are no concerning histologic features and no tumor extension beyond the thyroid, metastases, history of head and neck irradiation, or positive family history—any of which requires total or near-total thyroidectomy and remnant ablation with 30 mCi. (Endocr Pract. 2007;13:498-512)     

Risk Factors for Nonremission and Progression-Free Survival after I-131 Therapy in Patients with Lung Metastasis from Differentiated Thyroid Cancer: A Single-Institute,Retrospective Analysis in Southern China

Objective: Prognostic factors related to progression-free survival (PFS) have not received much attention in the literature regarding iodine-131 (¹³¹I) therapy for patients with differentiated thyroid cancer and lung metastases. We sought to explore the factors associated with PFS and nonremission in a group of patients with differentiated thyroid cancer and pulmonary metastases at initial diagnosis and to investigate the impact of ¹³¹I therapy on pulmonary function and peripheral blood counts in the same cohort of patients.Methods: The medical records of 1,050 patients with differentiated thyroid cancer treated at the Zhujiang Hospital of Southern Medical University from January 2006 to January 2015 were retrospectively reviewed. Among them, 107 patients fulfilled the inclusion criteria.Results: Multivariate Cox regression analysis indicated that age ≥45 years and ¹³¹I nonavidity were independent risk factors for disease progression. Multivariate logistic regression analysis revealed that pulmonary nodule size ≥1 cm and ¹³¹I nonavidity were the strongest risk factors predicting nonremission. Varying cumulative ¹³¹I dosage had no association with posttreatment pulmonary function or peripheral blood cell counts.Conclusion: Similar to earlier studies, our results confirm that ¹³¹I nonavidity was associated with an increased risk of disease progression and greater odds of nonremission. In addition, patients with differentiated thyroid cancer and lung metastases with pulmonary nodules ≥1 cm had a reduced likelihood of achieving remission. Furthermore, special attention is needed when monitoring patients over 45 years at a higher risk of disease progression.Abbreviations:CI = confidence intervalDTC = differentiated thyroid cancer¹⁸F-FDG = fluoro-18 fluorodeoxyglucoseFEF = forced expiratory flowFTC = follicular thyroid cancerFVC = forced vital capacityGR = granulocytesHb = hemoglobinHR = hazard ratio¹³¹I = iodine-131LN = lymph nodeOR = odds ratioOS = overall survivalPET/CT = positive positron emission tomography/computed tomographyPFS = progression-free survivalPT = partial thyroidectomyPTC = papillary thyroid cancerRAI = radioactive iodineRBC = red blood cellTg = thyroglobulinTgAb = thyroglobulin antibodyTSH = thyroid-stimulating hormoneTT = total thyroidectomyWBC = white blood cellsWBS = whole body scan     

Assessing The Risk of False-Negative Fine-Needle Aspiration Cytology and of Incidental Cancer in Nodular Goiter

ObjectiveIn cases of multinodular goiter with negative cytologic result, reasonable management options include surgical treatment, simple follow-up, or more recently introduced conservative therapies such as laser or radiofrequency ablation, and recombinant human thyroid-stimulating hormone-augmented radioiodine. For patients who are eligible for follow-up or nonsurgical treatments, the possibility that they may have an undiagnosed malignancy (false-negative [FN]-fine-needle aspiration cytology [FNAC] result or incidental thyroid cancer [ITC]) should be considered. The aim of our study was to assess the risk of malignancy in patients known to have presumably benign thyroid disease.MethodsSurgical series of patients who underwent total thyroidectomy for benign disease between 2000 and 2010 at two Italian centers were reviewed. Patients with any preoperative suspicion of malignancy were excluded.ResultsHistologic examination revealed that 84 of 970 (8.6%) thyroidectomized patients had malignancy (5% ITC and 3.6% FN-FNAC), with 89.8% of ITCs having a diameter <10 mm, and 65.7% of FN-FNAC cancers having a diameter >30 mm. Sixty-seven thyroid malignancy patients (79.8%) had stage I disease (American Joint Committee on Cancer criteria). The risk of FN-FNAC increases with increasing size of the nodule, while the risk of ITC increases as nodule size decreases.ResultsThe risk of malignancy in presumably benign thyroid disease cannot be overlooked, but can be minimized through skillfully performed ultrasonography (US) examination and FNAC. Once a patient with multinodular goiter is referred for follow-up or nonsurgical therapy, careful US surveillance is mandatory. (Endocr Pract. 2013;19:444-450)     

Comparison of Ultrasound-Guided Fine-Needle Aspiration Biopsy with Core-Needle Biopsy in the Evaluation of Thyroid Nodules

ObjectiveTo compare the diagnostic rate of ultrasound-guided fine-needle aspiration biopsy (FNAB) with the diagnostic rate of combined FNAB and core-needle biopsy in the evaluation of nodular thyroid disease.MethodsWe performed a retrospective case-control study by reviewing charts of patients who underwent ultrasound-guided FNAB and core-needle biopsy of the thyroid at a tertiary referral center from January 1999 to December 2001. Results were classified as diagnostic (negative, suspicious, or positive for malignancy) or nondiagnostic. These findings were compared with an age- and sex-matched control group who underwent only FNAB. Complications between the groups were reviewed.ResultsThe patient group consisted of 320 patients who underwent 340 ultrasound-guided fine-needle aspiration and core-needle biopsies of the thyroid; the control group consisted of 311 patients who underwent 340 FNABs. There was no significant difference in the nondiagnostic rates between groups—12.9% in patients who had FNAB–only compared with 10.9% in patients who had both procedures (proportion difference, -2.1%; 95% confidence interval, -7.0% to 2.9%; P = .41). There was a trend towards an increased incidence of hematoma and infection in the core biopsy group. In the group that underwent FNAB and core-needle biopsies, 10 patients (3.1%) developed biopsy-specific complications (hematomas in 8 patients, biopsy site infections in 2 patients). In the FNAB only group, 3 patients (1.0%) developed hematomas; there was no incidence of infection.ConclusionsIn the evaluation of thyroid nodules, the addition of core-needle biopsies to FNAB confers little benefit in decreasing the nondiagnostic rates and may be associated with increased complications. Core-needle biopsies should not be routinely performed in the evaluation of thyroid nodules, but rather, patient selection for the more invasive core biopsy should be done judiciously. (Endocr Pract. 2008;14:426-431)     

Risk Factors for Central Lymph Node Metastases in Patients with Papillary Thyroid Microcarcinoma

Objectives: Papillary thyroid carcinoma with a maximum tumor diameter no more than 10 mm is defined as papillary thyroid microcarcinoma (PTMC). The proportion of newly diagnosed PTMCs has increased significantly in recent years. Different guidelines have different comments about optimal management of PTMC, especially on prophylactic central lymph node (CLN) dissection. The aim of the present study was to analyze the risk factors for CLN metastases in patients with PTMC.Methods: A total of 4,389 patients underwent thyroid surgery at our center from January 2017 to March 2018, and 2,129 patients with PTMC were selected and assessed retrospectively. The relationship between CLN metastases and clinicopathologic features of PTMC were analyzed by both univariate and multivariate analyses.Results: Of the 2,129 patients with PTMC, CLN metastases were confirmed by pathology in 923 patients. Univariate and multivariate analyses found several independent factors associated with CLN metastases. They were male gender (odds ratio [OR], 1.694; 95% confidence interval [CI], 1.386 to 2.071; P<.001), younger age (<45 years) (OR, 2.687; 95% CI, 2.196 to 3.288; P<.001), larger tumor size (>5 mm) (OR, 2.168; 95% CI, 1.782 to 2.636; P<.001), positive CLN metastases via ultrasound (OR, 4.939; 95% CI, 3.534 to 6.902; P<.001), and multifocality (OR, 1.424; 95% CI, 1.176 to 1.724; P<.001).Conclusion: CLN metastases are common in PTMC patients. Male gender, younger age (<45 years), larger tumor size (>5 mm), positive CLN metastases via ultrasound, and multifocality are independent risk factors for CLN metastases. Our data should be considered in the decision-making process related to performing CLN dissection.Abbreviations: CLN = central lymph node; PTC = papillary thyroid carcinoma; PTMC = papillary thyroid microcarcinoma     

Pre-Operative Ultrasound Identification of Thyroiditis Helps Predict the Need for Thyroid Hormone Replacement After Thyroid Lobectomy

ObjectiveTo evaluate whether pre-operative thyroiditis identified by ultrasound (US) could help predict the need for thyroid hormone replacement (THR) following thyroid lobectomy.MethodsData from patients who underwent thyroid lobectomy in 2006-2011, were not taking THR pre-operatively, and had >1 month of follow-up were reviewed retrospectively. THR was prescribed for relatively elevated thyroid-stimulating hormone (TSH) and hypothyroid symptoms. The Kaplan-Meier method was used to estimate the percentage of patients who required THR at 6, 12, 18, and 24 months postoperatively, and Cox proportional hazards regression models were used to evaluate prognostic factors for requiring post-thyroid lobectomy THR.ResultsDuring follow-up, 45 of 98 patients required THR. Median follow-up among patients not requiring THR was 11.6 months (range, 1.2 to 51.3 months). Six months after thyroid lobectomy, 22% of patients were taking THR (95% confidence interval [CI], 15-32%); the proportion increased to 46% at 12 months (95% CI, 36-57%) and 55% at 18 months (95% CI, 43-67%). On univariate analysis, significant prognostic factors for postoperative THR included a pre-operative TSH level >2.5 μ international units [IU]/mL (hazard ratio [HR], 2.8; 95% CI, 1.4-5.5; P = .004) and pathology-identified thyroiditis (HR, 2.4; 95% CI, 1.3-4.3; P = .005). Patients with both pre-operative TSH >2.5 μIU/mL and US-identified thyroiditis had a 5.8fold increased risk of requiring postoperative THR (95% CI, 2.4-13.9; P<.0001).ConclusionA pre-operative TSH level >2.5 μIU/mL significantly increases the risk of requiring THR after thyroid lobectomy. Thyroiditis can add to that prediction and guide pre-operative patient counseling and surgical decision making. US-identified thyroiditis should be reported and post-thyroid lobectomy patients followed long-term (≥18 months). (Endocr Pract. 2013;19:1015-1020)     

Transverse and Longitudinal Ultrasound Location of Thyroid Nodules and Risk of Thyroid Cancer

BackgroundThe high prevalence of thyroid nodules demands accurate assessment tools to avoid unnecessary biopsies. Prior studies demonstrated a correlation between the longitudinal location of thyroid nodules and the likelihood of malignancy. No study has evaluated the predictive value of transverse location on ultrasonography with malignancy.MethodsWe retrospectively reviewed the records of thyroid nodules that underwent fine-needle aspiration over 13 years, including demographics, risk factors, nodule sonographic features, location, and surgical pathology. Univariate and multivariable logistic regression models were used to evaluate the risk of malignancy.ResultsOf the 668 thyroid nodules, 604 were analyzed with a definitive diagnosis. Thirty-seven nodules were malignant, representing a prevalence of 6.1%. In the longitudinal plane, the upper pole nodules carried the highest incidence of malignancy (14.9%). In the transverse plane, the highest incidence of malignancy occurred in nodules located laterally (12.5%) and anterior-laterally (11.8%). Compared with the upper pole, the odds of malignancy were significantly lower for lower pole (odds ratio [OR] = 0.26, 95% confidence interval [CI]: 0.09-0.70) and midlobe nodules (OR = 0.31, 95% CI: 0.12-0.83). In the transverse plane, posteriorly situated nodules carried a significantly lower risk of malignancy (OR = 0.07, 95% CI: 0.01-0.69). Multiple logistic regression confirmed these associations after adjusting for age, sex, family history, radiation exposure, nodule size, and sonographic characteristics.ConclusionBoth the transverse and longitudinal planes were independent predictors of cancer in thyroid nodules. Lateral, anterior-lateral, and upper pole nodules carried the highest risk and posterior nodules had the lowest risk of malignancy.     

Diagnostic Use of Ultrasonography in Patients with Nodular Thyroid Disease

ObjectiveTo review the published reports pertaining to the diagnostic utility of ultrasonography for evaluation of thyroid nodules.MethodsVarious roles for diagnostic thyroid ultrasonography and screening ultrasound studies of the thyroid are discussed, and ultrasound characteristics of thyroid nodules and their association with malignant potential are described.ResultsIn two studies that correlated ultrasound findings with physical examination findings in patients with a solitary thyroid nodule detected by palpation, 16% of such patients had no corresponding nodule evident on ultrasonography, and 45% of such patients had an additional nodule detected by ultrasonography. Similarly, approximately 18% of patients with a palpable multinodular thyroid had no nodules larger than 1 cm in diameter on ultrasound studies. Thyroid nodules larger than 1 cm have been found by ultrasonography to be present in from 2 to almost 5% of the population with normal findings on examination of the thyroid. Use of screening ultrasound study of the thyroid has been suggested for patients with a history of childhood irradiation to the head and neck or a family history of thyroid cancer. Numerous investigations that have evaluated ultrasound features of thyroid nodules have suggested five characteristics as suggestive of malignant potential—hypoechogenicity, microcalcifications. irregular or microlobulated border, absent or irregular thick halo, and increased intranodular vascularity.ConclusionCorrelation of ultrasound and palpation findings will provide a comprehensive evaluation of nodular thyroid disease. Moreover, real-time ultrasonography facilitates characterization of features associated with an increased risk of a malignant lesion. High-resolution thyroid ultrasonography is a dynamic tool for endocrinologists. (Endocr Pract. 2004;10:246-252)     

No Benefit of Dedicated Thyroid Nodule Screening in Patients with Acromegaly

Objective: Acromegaly results from the excessive production of growth hormone and insulin-like growth factor-1. While there is up to a 2-fold increased prevalence of thyroid nodules in patients with acromegaly, the incidence of thyroid cancer in this population varies from 1.6 to 10.6% in several European studies. The goal of our study was to determine the prevalence of thyroid nodules and thyroid cancer among patients with acromegaly at a large urban academic medical center in the United States (U.S.).Methods: A retrospective chart review was performed of all patients with acromegaly between 2006–2015 within the University of California, Los Angeles health system. Data were collected regarding patient demographics, thyroid ultrasounds, thyroid nodule fine needle aspiration (FNA) biopsy cytology, and thyroid surgical pathology.Results: In this cohort (n = 221, 49.3% women, mean age 53.8 ± 15.2 &lsqb;SD] years, 55.2% Caucasian), 102 patients (46.2%) underwent a thyroid ultrasound, from which 71 patients (52.1% women, mean age 52.9 ± 15.2 &lsqb;SD] years, 56.3% Caucasian) were found to have a thyroid nodule. Seventeen patients underwent a thyroid nodule FNA biopsy and the results revealed 12 benign biopsies, 1 follicular neoplasm, 3 suspicious for malignancy, and 1 papillary thyroid cancer (PTC), from which 6 underwent thyroidectomy; PTC was confirmed by surgical pathology for all cases (8.5% of all nodules observed).Conclusion: In this sample, the prevalence of thyroid cancer in patients with acromegaly and coexisting thyroid nodules is similar to that reported in the general U.S. population with thyroid nodules (7 to 15%). These findings suggest that there is no benefit of dedicated thyroid nodule screening in patients newly diagnosed with acromegaly.Abbreviations: AACE = American Association of Clinical Endocrinologists; ATA = American Thyroid Association; DTC = differentiated thyroid cancer; FNA = fine needle aspiration; GH = growth hormone; IGF-1 = insulin-like growth factor-1; PTC = papillary thyroid cancer; U.S. = United States     

Ultrasonographic Differentiation of Cervical Lymph Nodes in Patients with Papillary Thyroid Carcinoma After Thyroidectomy and Radioiodine Ablation: A Prospective Study

ObjectiveThe objective of the present study was to validate an ultrasound (US) classification of cervical lymph nodes (LNs) in patients with papillary thyroid cancer (PTC) after thyroidectomy and radioactive iodine (¹³¹I) ablation.MethodsWe performed a prospective study in which the patients were submitted to thyroidectomy and ¹³¹I ablation and then followed until neck US revealed LN(s) ≥ 5 mm. A total of 288 LNs from 112 patients with PTC were evaluated. Patient management was based on LN characteristics grouped according to the classification system studied here.ResultsThe presence of microcalcifications and/or cystic degeneration of cervical LNs were highly suggestive of a metastatic etiology (specificity of 99.4%). In contrast, the most sensitive finding for LNs affected by PTC was the absence of an echogenic hilum (sensitivity of 100%). In the absence of these findings (microcalcifications, cystic degeneration, echogenic hilum), a metastatic etiology was the most likely in the case of a round LN (specificity of 89%). The differentiation of a spindle-shaped LN without a visible hilum by Doppler analysis permitted us to dichotomize an initial probability of metastases of 13% in 25% (with peripheral vascularization) versus 3.3% (without peripheral vascularization).ConclusionsOur results confirm that the classification proposed for cervical LNs in patients with PTC is valid for determining patient management following initial therapy. (Endocr Pract. 2014;20:293-298)     

Correlation of Findings from Iodine 123 Scan and Ultrasonography in the Recommendation for Thyroid Fine-Needle Aspiration Biopsy

ObjectiveTo assess the impact of correlating findings from iodine I 123 (¹²³I) radionuclide scans and thyroid ultrasonography on the decision to perform fine-needle aspiration (FNA) biopsy of thyroid nodules.MethodsIodine 123 scans and sonographic images of adult patients who had both examinations performed within 6 months of each other at our institution were retrospectively reviewed. The presence of 1 or more nodules satisfying imaging-specific criteria for recommending FNA biopsy was recorded. Iodine 123 scan and sonographic images were then directly compared to determine how frequently the FNA recommendation would be affected by discordant findings.ResultsThe study included 97 adult patients, with a total of 291 thyroid lobes (right thyroid lobe, left thyroid lobe, and isthmus). Recommendations for FNA biopsy were concordant in 231 of 291 lobes (79.4%), with both modalities recommending FNA biopsy in 55 lobes and not recommending FNA biopsy in 176 lobes. A discordant recommendation occurred in 60 of 291 lobes (20.6%). Using only ultrasonography findings, a recommendation for FNA biopsy was not indicated for 11 of the 291 lobes (3.8%) with functioning nodules. Using only ¹²³I findings, a recommendation for FNA biopsy was not indicated for 23 of the 291 lobes (7.9%); 13 had nodules, but none that fulfilled sonographic criteria, and 10 had no identifiable nodule on ultrasonography. Iodine 123 scan did not identify 26 lobes with nodules (8.9%) for which FNA biopsy was recommended based on ultrasonography findings.ConclusionRecommendations for FNA biopsy should not be based on the presence of hypofunctioning regions on ¹²³I scan without sonographic confirmation. (Endocr Pract. 2011;17:699-706)     

Recurrent Differentiated Thyroid Cancer

ObjectiveTo discuss the risk of recurrence in patients with differentiated thyroid cancer and emphasize the importance of risk-group stratification.MethodsCommon risk factors associated with recur rent thyroid cancer are outlined, and appropriate manage ment strategies are reviewed.ResultsThe overall prognosis in patients with dif ferentiated thyroid cancer is excellent. Factors associated with recurrent thyroid cancer include extrathyroidal exten sion of the primary tumor, bulky nodal metastatic lesions, macroscopic local invasion, and aggressive histologic subtypes. The locoregional recurrence and mortality are higher in patients with high-risk thyroid cancers. Patients initially presenting with locally aggressive and advanced thyroid cancer have a higher incidence of recurrent disease in the thyroid bed or nodal metastasis. These patients also have a high incidence of distant metastatic lesions. Locally recurrent thyroid cancer may be seen in more than 25% of patients with aggressive differentiated thyroid cancer. Recurrent disease in the thyroid bed can be a difficult prob lem to manage because of the proximity of the tumor to the recurrent laryngeal nerve, visceral structures in the central compartment, and occasional involvement of the trachea or larynx. External beam radiation therapy after surgical treatment may be important for better local control in the thyroid bed region, especially in patients with poorly dif ferentiated histologic features. The role of additional radio iodine therapy remains undefined at this stage.ConclusionManagement of patients with recur rent thyroid cancer necessitates a true multidisciplinary approach. These patients require close follow-up, with cross-sectional imaging and positron emission tomo graphic scanning in selected individuals. (Endocr Pract. 2012;18:600-603)     

Management of Sonographically Suspicious Thyroid Nodules 1 cm or Smaller and Candidacy for Active Surveillance: Experience of a Tertiary Center in China

ObjectiveOur objective was to investigate the management of patients with asymptomatic suspicious thyroid nodules ≤1 cm.MethodsWe retrospectively reviewed medical records of patients with sonographically suspicious thyroid nodules ≤1 cm and without distant metastases, suspicious lymph node metastasis (LNM), or extrathyroidal extension (ETE).ResultsOf the 386 enrolled patients, 174 (45.1%) had immediate surgery (IS), while 212 (54.9%) underwent active surveillance (AS). In the IS group, 166 (95.4%) patients were confirmed as having papillary thyroid microcarcinoma. LNM and ETE were observed in 24.7% and 2.4% cases, respectively. In the AS group, nodule size increased by ≥3 mm in 11 (5.2%) patients and 39 (18.4%) had a >50% increase in nodule volume after a median follow-up of 12 months. Nodules with smaller volume at diagnosis were more likely to increase in volume later. Newly suspicious LNM was detected in 23 (10.8%) patients. Delayed surgery (DS) was performed in 101 patients, with 27 showing disease progression. ETE and LNM were detected in 3% and 36%, respectively, of patients with papillary thyroid microcarcinoma. Compared with IS, tumors in the DS group more frequently showed lateral LNM and capsular invasion (P < .05). No patient had recurrence or died of thyroid cancer during postoperative follow-up (median 26 [4-60] months).ConclusionsIS or DS of patients with asymptomatic suspicious thyroid nodules ≤1 cm was relatively high in China. The inertia of low-risk nodules and the effectiveness of DS for those that progressed make AS a feasible strategy.     

Syndromes paranéoplasiques : intérêt de la tomographie par émission de positons (TEP) au 18F-fluoro-déoxyglucose (FDG)

BackgroundWe evaluated the performance of ¹⁸F-fluorodeoxyglucose (¹⁸FDG) positon emission tomography (PET) in the diagnosis of underlying malignancy in cases of suspected paraneoplastic syndrome (PS).Methods¹⁸FDG-PET was performed in 31 patients, clinically suspected to have PS. The PS were 34, among which 12 neurological diseases, eight endocrine, seven rheumatological, one dermatological and six vascular. We compared computed tomography (CT), iodine-enhanced most of the time, and ¹⁸FDG-PET reports to clinicians definitive conclusion at the end of the work-up and a follow-up period of, at least, two months.ResultsWe obtained a histological diagnosis of cancer for ten patients, but could only identify the primary site of malignancy for nine of them. ¹⁸FDG-PET showed six primary sites among which three were not seen on CT. CT disclosed four primary sites, among which one was not seen on ¹⁸FDG-PET. In one case, ¹⁸FDG-PET disclosed regional lymph node metastases whereas these were not identified by CT. Eleven non-neoplasic causes were evidenced, among which ¹⁸FDG-PET played a major role in three cases. Ten causes were still undetermined at the end of the study.ConclusionWhole-body ¹⁸FDG-PET study plays an important role in the identification of underlying malignancy in clinically suspected paraneoplastic syndromes; either by identifying the primary tumor or by directing biopsy of metastases. Furthermore, it can identify non-neoplasic causes.     

Thyroid Cytology and Risk of Thyroid Cancer: Differences Among Indeterminate Specimens

ObjectiveTo assess the potential for stratification of indeterminate cytologic findings on fine-needle aspiration (FNA) of thyroid nodules in an effort to improve therapeutic strategies.MethodsWe attempted to determine the malignant risk associated with various indeterminate FNA cytologic patterns by correlation of specimens with the final histologic diagnosis. For this analysis, we identified 294 computerized medical records of surgically treated thyroid nodules during a 5-year period at our institution with the corresponding FNA cytology reports available.ResultsOf the 294 surgical cases, 162 with a positive or indeterminate cytologic report were selected, reviewed, and classified. Of 52 patients with positive cytologic findings on FNA, 51 (98%) had a final histologic report of a malignant thyroid nodule. Of 110 patients with indeterminate specimens, 30 (27%) had a final histologic diagnosis of thyroid carcinoma. The presence of nuclear atypia was predictive of thyroid carcinoma in 75% of patients, a Hürthle cell cytologic pattern was associated with a malignant thyroid nodule in 33%, and a hypercellular smear was suggestive of malignant involvement in 26% of cases. The lowest rate of malignant potential was associated with cytologic microfollicular and scant colloid alone subtype (6%).ConclusionThe results of this study show that indeterminate thyroid cytologic specimens can be subdivided into groups with different malignant risks. A microfollicular cytologic pattern in the absence of a hypercellular smear or nuclear atypia does not support a recommendation of surgical treatment. A malignant cytologic diagnosis has a high positive predictive value for detection of thyroid cancer. (Endocr Pract. 2004;10:330-334)     

The Usefulness of Standardized Uptake Value in Differentiation between Benign and Malignant Thyroid Lesions Detected Incidentally in 18F-FDG PET/CT Examination

Introduction

In the last decade, (18)F-fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography (PET and PET/CT) has become one of the major diagnostic tools used in oncology. A significant number of patients who undergo this procedure, due to non-thyroidal reasons, present incidental uptake of (¹⁸F-FDG) in the thyroid. The aim of the study was to compare the SUV_max (standardized uptake value) of thyroid focal lesions, which were incidentally found on PET/CT, in relation to the results of thyroid fine-needle aspiration biopsy (FNAB) and/or histopathological evaluation.

Materials and Methods

Patients referred for PET/CT examination, due to non-thyroidal illness, presented focal ¹⁸F-FDG uptake in the thyroid and were advised to undergo ultrasonography (US), hormonal evaluation, FNAB and/or total thyroidectomy at our institution.

Results

6614 PET/CT examinations performed in 5520 patients were analyzed. Of the 122 patients with focal thyroid ¹⁸F-FDG activity, 82 patients (67.2%) underwent further thyroid evaluation using FNAB. Benign lesions were diagnosed in 46 patients, malignant - in 19 patients (confirmed by post-surgical histopathology), while 17 patients had inconclusive results of cytological assessment. Mean SUV_max of benign lesions was 3.2±2.8 (median = 2.4), while the mean SUV_max value for malignant lesions was 7.1±8.2 (median = 3.5). The risk of malignancy was 16.7% for lesions with a SUV_max under 3, 43.8% for lesions with a SUV_max between 3 and 6, and 54.6% for lesions with a SUV_max over 6. In the group of malignant lesions, a positive correlation between the lesion’s diameter and SUV_max was observed (p = 0.03, r = 0.57).

Conclusions

Subjects with incidental focal uptake of ¹⁸F-FDG in thyroid are at a high risk of thyroid malignancy. A high value of SUV_max further increases the risk of malignancy, indicating the necessity for further cytological or histological evaluation. However, as SUV_max correlated with the diameter of malignant lesions, small lesions with focal uptake of ¹⁸F-FDG should be interpreted cautiously.     

Comparison of the Efficacy and Safety of Ultrasound-Guided Core Needle Biopsy Versus Fine-Needle Aspiration for Evaluating Thyroid Nodules

ObjectiveUltrasound-guided core needle biopsy (UG-CNB) is a procedure that is often performed either after repeated inadequate or nondiagnostic ultrasound-guided fine-needle aspiration (UG-FNA) or in combination with UG-FNA in the evaluation of thyroid nodules. The purpose of this study was to compare the efficacy and safety of UG-CNB and UG-FNA for evaluating thyroid nodules.MethodsThis was a retrospective study of 350 consecutive patients who had thyroid nodules biopsied by UG-CNB or UG-FNA from January 2007 until November 2011 at our institution. Biopsy results were compared to the surgical specimen pathology reports for the 105 patients who subsequently underwent hemi- or total thyroidectomy in order to determine whether UG-CNB has advantages over UG-FNA for diagnosing thyroid malignancy and neoplasia.ResultsOut of 461 thyroid nodules biopsied from 350 patients, 365 (79%) involved UG-CNB and 96 (21%) involved UG-FNA. The UG-FNA biopsy group had a significantly higher rate of inadequate sampling than the UG-CNB group (P < .0001; Fisher’s exact test). Out of 365 UG-CNB samples, 6 (2%) were deemed inadequate for histologic diagnosis, whereas 26 (27%) of the 96 UG-FNA samples were considered inadequate for cellularity. Comparison of biopsy results with the surgical specimen pathology reports revealed that the diagnostic accuracy of UG-CNB and UG-FNA for detecting malignancy was similar, at 89 and 94%, respectively (not significant by Fisher’s exact test). However, the UG-CNB group had a higher detection rate for benign follicular lesions compared to the UG-FNA group (65% versus 48% for UG-FNA; P = .002). Although UG-FNA detected neoplasia with high sensitivity (100%), the specificity was poor (30%). Neither biopsy group had any significant immediate or delayed procedure-related complications.ConclusionOur study demonstrated that UG-CNB is safe and is less likely to result in a nondiagnostic biopsy. The accuracy of the UG-CNB technique is similar to that of UG-FNA for detecting thyroid malignancy. (Endocr Pract. 2015;21:128-135)