Randomized Prospective Evaluation of Frozen-Section Analysis for Follicular Neoplasms of the Thyroid

Abstract

ObjectiveTo evaluate the clinical utility of frozen section in patients with follicular neoplasms of the thyroid in a randomized prospective trial. Summary Background DataThe finding of a follicular neoplasm on fine-needle aspiration prompts many surgeons to perform intraoperative frozen section during thyroid lobectomy. However, the focal distribution of key diagnostic features of malignancy contributes to a high rate of noninformative frozen sections. MethodsThe series comprised 68 consecutive patients with a solitary thyroid nodule in whom fine-needle aspiration showed a follicular neoplasm. Patients were excluded for bilateral or nodal disease, extrathyroidal extension, or a definitive fine-needle aspiration diagnosis. Final pathologic findings were compared with frozen sections, and cost analyses were performed. ResultsSixty-one patients met the inclusion criteria. Twenty-nine were randomized to the frozen-section group and 32 to the nonfrozen-section group. In the non-frozen-section group, one patient was excluded when gross examination of the specimen was suggestive of malignancy and a directed frozen section was diagnostic of follicular carcinoma. Frozen-section analysis rendered a definitive diagnosis of malignancy in 1 of 29 (3.4%) patients, who then underwent a one-stage total thyroidectomy. In the remaining 28 patients, frozen section showed a "follicular or Hü rthle cell neoplasm." Permanent histology demonstrated well-differentiated thyroid cancer in 6 of these 28 patients (21%). Of the 31 patients in the non-frozensection group, 3 (10%) showed well-differentiated thyroid carcinoma on permanent histology. Complications were limited to one transient unilateral vocal cord dysfunction. All but one patient had a 1-day hospital stay. There were no significant differences between the groups in surgical time or total hospital charges; however, the charge per informative frozen section was approximately $12,470.

Hurthle Cell Lesions- A Retrospective Review of Final Surgical Pathology

“…In Dahl's series of 116 patients with Hurthle cell lesions, intraoperative frozen section was done on 111, and 9 of 49 (19%) patients with Hurthle cell carcinoma were diagnosed on frozen section [24]. In Udelsman's prospective study of follicular neoplasms, only 3.4% of the time did a frozen section diagnose malignancy [32]. Chen showed similar findings with a frozen section of a follicular neoplasm showing malignany only 5% of the time [33].…”

Dilemma in diagnosing thyroid adenoma – A case report

“…Thyroid lobectomy and isthmusectomy is the definite treatment for patients with a benign follicular adenoma and patients with minimally invasive follicular cancer whereas total thyroidectomy is necessary for invasive follicular carcinoma (5). Frozen section examination is not that helpful in intraoperative decision-making as it rarely distinguishes a follicular adenoma from a follicular carcinoma, which has been proven by various clinical trials (10). In such cases where FNA is insufficient there is a need for MIBI scintigraphy for the pre operative work up.…”

Diagnostic, therapeutic and health-care management protocol in thyroid surgery: a position statement of the Italian Association of Endocrine Surgery Units (U.E.C. CLUB)

“…Intraoperative consultation could be useful to confirm suspicious nodules ("Tir 4" on cytology, according to SIAPEC 2013 classification) [12] or node metastases. It is not useful for nodules with indeterminate follicular cytology (SIAPEC 2013 classification) [12], because it is generally non-diagnostic [63].…”