Gauging The Extent Of Thyroidectomy For Indeterminate Thyroid Nodules: An Oncologic Perspective

Stafford, Linda; Brys, Nicole; Greenberg, Caprice C.; Balentine, Courtney J.; Elfenbein, Dawn M.; Pitt, Susan C.

doi:10.4158/ep161540.or

Cited by 26 publications

(21 citation statements)

References 40 publications

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“…However, only 2 surgeons regularly used templated notes predominantly during the last 2 yeas this study. Because both of these authors (SCP and DFS) do decision-making research, their documentation of the decision-making process was extensive (15). Nonetheless, we may have missed other important factors in decision-making about the extent of surgery in patients with PTMC.…”

Section: Discussionmentioning

confidence: 99%

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Papillary thyroid microcarcinoma: decision-making, extent of surgery, and outcomes

Price

Randle

Sippel

et al. 2017

Journal of Surgical Research

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Background The optimal extent of surgery for patients with papillary thyroid microcarcinoma (PTMC), tumors ≤1 cm, is controversial, because survival is excellent regardless of approach. The objective of this study was to investigate patient and surgeon decision making about the extent of surgery for PTMC. Materials and Methods We conducted a retrospective review of thyroid cancer patients operated on at a single institution from 2008–2016. To examine decision-making about the extent of surgery, we performed a discourse analysis on all available documentation looking for patient or surgeon reasons. Results Of the 853 thyroid cancer patients, 125 (14.7%) had a PTMC as their largest tumor. Overall, 27.2% of the PTMC patients underwent a thyroid lobectomy (TL), while 72.8% had a total thyroidectomy (TT). Of those patients diagnosed with PTMC preoperatively (19/125), a significantly higher proportion underwent a TT (94.7% vs. 68.9%, p=0.02). In all cases, documentation indicated that these preoperatively diagnosed patients followed the surgeon’s recommendation regarding the extent of surgery. Reasons surgeons cited for recommending a TT included patient and disease factors (34.6%), belief that TT was the standard treatment (21.7%), ease of follow-up (8.7%), and referring provider preference (4.3%). Of the 19 patients diagnosed preoperatively, 4 (21.1%) patients had a complication, one (5.3%) of which was permanent and potentially avoidable with less extensive surgery. Conclusions These data suggest that surgeons drive decision making about the extent of thyroidectomy in patients with preoperatively diagnosed PTMC. With recent guidelines recommending TL, closer examination of decision-making is needed to ensure that patients make well-informed, preference-based decisions.

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Section: Discussionmentioning

confidence: 99%

“…Additional examples of how documentation was classified are included in the results. We previously utilized a similar technique to examine written language, called discourse analysis, for evaluating documentation in the EMR (15). …”

Section: Methodsmentioning

confidence: 99%

Papillary thyroid microcarcinoma: decision-making, extent of surgery, and outcomes

Price

Randle

Sippel

et al. 2017

Journal of Surgical Research

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“…Approximately three-quarters of these were benign on surgical pathology, indicating the unnecessary surgical removal of many benign nodules. At the same time, malignant nodules potentially underwent inadequate initial treatment (6). Given the need for an improved means of predicting cancer risk and guiding surgical management in such nodules, novel diagnostic approaches have arisen, including the evaluation of genomic variants and fusions.…”

Section: Introductionmentioning

confidence: 99%

Molecular Variants and Their Risks for Malignancy in Cytologically Indeterminate Thyroid Nodules

Goldner

Angell

McAdoo

et al. 2019

Thyroid

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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 BRAF V600E (98%, 95% confidence interval [CI 96-99%]), PAX8/ PPARG (55% [CI 34-78%]), HRAS Q61R (45% [CI 22-72%]), BRAF K601E (42% [CI 19-68%]), and NRAS Q61R (38% [CI 23-55%]). Excluding BRAF V600E , 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; BRAF V600E 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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“…There are three usual management options for patients with Bethesda III and IV nodules: (1) to repeat FNAB and/or (2) to perform molecular testing or (3) perform a diagnostic lobectomy. However, hemi-or totalthyroidectomy in a patient with benign nodules is an excessive treatment, whereas performing lobectomy in patients with malignant tumors characterized by higher risk features, such as extrathyroidal extension or lymph node metastases, can be seen as under-treatment (6).…”

Section: Introductionmentioning

confidence: 99%

Limited Utility of Circulating Cell-Free DNA Integrity as a Diagnostic Tool for Differentiating Between Malignant and Benign Thyroid Nodules With Indeterminate Cytology (Bethesda Category III)

et al. 2019

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Background: Analysis of plasma circulating cell-free DNA integrity (cfDI) has emerged as a promising tool in the diagnosis of malignant vs. benign tumors. There is limited data on the role of cfDI in thyroid cancer. The goal of this study was to analyze cfDI as a biomarker of malignancy in patients with cytologically indeterminate thyroid nodules. Methods: The cfDI was measured in the plasma of patients with cytologically indeterminate thyroid nodules. All patients underwent plasma collection within 24-72 h before surgical treatment for thyroid nodules. Additionally, samples were collected from seven patients via the vein draining the thyroid and peripheral vein during surgery. Quantitative real-time PCR was performed on the isolated cell-free DNA using two different primer sets (115 and 247 bp) to amplify consensus ALU sequences. The cfDI was calculated as the ratio of ALU247 to ALU115. Results: All data are given as median [25th−75th percentile]. The study group consisted of 67 patients with 100 nodules, 80.6% (54/67) women, aged 43 [33-60] years. There was no difference in cfDI between 29 patients with benign nodules (0.49 [0.41-0.59]) and 38 patients with malignant lesions (0.45 [0.36-0.57], p = 0.19). There was no difference in cfDI in the vein draining the thyroid (0.47 [0.24-1.05]) and peripheral vein (0.48 [0.36-0.56], p = 0.44). In comparison to thyroid cancer patients, patients with benign nodules were characterized by significantly higher concentrations of ALU115 (1,064 [529-2,960] vs. 411 [27-1,049] ng/ml; p = 0.002) and ALU247 (548 [276-1,894] vs. 170 [17-540] ng/ml; p = 0.0005), most likely because benign tumors were larger (3, [1.8-4.1 cm]) than Thakur et al. Liquid Biopsy and Indeterminate Thyroid Nodules malignant lesions (0.7 [0.23-1.45], p < 0.0001). Women had significantly lower cfDI (0.45 [0.27-0.54]) than men (0.56 [0.44-0.8], p = 0.011). Conclusion: The cfDI measured in the vein draining the thyroid is similar to the cfDI measured in the antecubital vein, validating cfDI measurements by peripheral liquid biopsy. Analysis of cfDI needs to be stratified by patients gender. In contrast to its diagnostic utility in aggressive cancers, cfDI has limited utility as a biomarker of malignancy in cytologically indeterminate thyroid nodules.

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Gauging The Extent Of Thyroidectomy For Indeterminate Thyroid Nodules: An Oncologic Perspective

Cited by 26 publications

References 40 publications

Papillary thyroid microcarcinoma: decision-making, extent of surgery, and outcomes

Papillary thyroid microcarcinoma: decision-making, extent of surgery, and outcomes

Molecular Variants and Their Risks for Malignancy in Cytologically Indeterminate Thyroid Nodules

Limited Utility of Circulating Cell-Free DNA Integrity as a Diagnostic Tool for Differentiating Between Malignant and Benign Thyroid Nodules With Indeterminate Cytology (Bethesda Category III)

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