Comparison of Afirma GEC and GSC to Nodules Without Molecular Testing in Cytologically Indeterminate Thyroid Nodules

Background Analysis of cytologically indeterminate thyroid nodules with Afirma Gene Expression Classifier (GEC) and Genomic Sequencing Classifier (GSC) can reduce surgical rate and increase malignancy rate of surgically resected indeterminate nodules. Methods Retrospective cohort analysis of all adults with cytologically indeterminate thyroid nodules from January 2013 through December 2019. We compared surgical and malignancy rates of those without molecular testing to those with GEC or GSC, analyzed test performance between GEC and GSC, and identified variables associated with molecular testing. Results 468 indeterminate thyroid nodules were included. No molecular testing was performed in 273, 71 had GEC, and 124 had GSC testing. Surgical rate was 68% in the group without molecular testing, 59% in GEC, and 40% in GSC. Malignancy rate was 20% with no molecular testing, 22% in GEC, and 39% in GSC (p = 0.022). GEC benign call rate (BCR) was 46%, sensitivity 100%, specificity 61% and PPV 28%. GSC BCR was 60%, sensitivity 94%, specificity 76%, and PPV 41%. Those with no molecular testing had larger nodule size, pre-operative growth of nodules, and constrictive symptoms, and those who underwent surgery in the no molecular testing group had higher BMI, constrictive symptoms, higher TIRADS and Bethesda classification. Type of provider was also associated with the decision to undergo surgery. Conclusion Implementation of GEC showed no effect on surgical or malignancy rate, but GSC resulted in significantly lower surgical and higher malignancy rates. This study provides insight into the factors that affect the real- world use of these molecular markers preoperatively in indeterminate thyroid nodules.

Reevaluation of the Correlations between Ultrasound Features of Thyroid Nodules and Grades of Bethesda Classification

AIM: To reevaluate the correlations between ultrasound (US) features of thyroid nodules (THNs) and grades of Bethesda classification, to select correctly the patients who must undergo fine needle aspiration (FNAB). MATERIAL AND METHODS: In this study, we have included 260 cytologies of thyroid gland between the period of 2014–2018. The procedures are performed at radiology department of Hygeia Hospital. In our study are excluded the cases with a high risk of hemorrhage and the patients which did not accept the anesthetic procedure because of anxiety. The study includes only the first punctions with their respective Bethesda classification and not repeated FNAB cases. First using the z test, we compared the percentage occupied by the Bethesda categories that are indicative of surgery (BIV + BV + BVI) at US features that suspect malignancy (hypoechogenicity, microcalcifications, abnormal contours, central vascularization), with the percentage occupied by group (BIV + BV + BVI) at the US features which indicate benignity (hyperechoic, no microcalcifications, peripheral vascularization, cystic-solidocystic, spongiform, normal contours). Furthermore, We have evaluated utilizing the odds ratio if there was a correlation between TR4 and TR5 categories in ACR/TIRADS classification and the categories (BIV+BV+BVI) for any statistical significance. The significance of the dimensions of the nodule was tested as an indicator for surgical intervention. For this purpose, the percentage occupied by the nodules with a diameter larger than 1.5 cm at (BIV + BV + BVI) group was compared with the percentage occupied by nodules smaller than 1.5 cm at BIV + BV + BVI. In addition, we observed if there was a strong statistical connection between nodules larger than 1.5 cm and the Bethesda categories that suggested malignancy. There was no statistical test made for the features “taller than wide” and microcalcifications because of the small number of cases. It was also made a comparison of percentages (BIV + BV + BVI) even for three clinical features: Men versus women, solitary nodule versus multinodular goiter, left lobe versus right lobe. We compared the percentages occupied by the (BIV + BV + BVI) group of categories in patients over 45 years old with the percentages occupied by this group at patients younger than 45 years old. We also noted which of Bethesda categories is more frequent. CONCLUSIONS: The features that are more indicative for FNAB are hypoechogenicity, consistency, intranodal vascularization, and extralobar positioning. If a THN has one of the above features and has a dimension of more than 10 mm, it has an indication for FNAB. Indications for FNAB increase with the increasing of the abovementioned features of a THN. The combination of US features that suggest malignancy, TR4 and TR5, with BIII category is a strong indicator for surgical intervention. The results of this study are similar with the results of prior studies, and we could not distinguish any specific US feature that has an absolute indication for FNAB. The appropriate determination of the US features of a THN in correlation with the patient’s clinic information will determine the proper indication for a FNAB.

Adrenal metastasis as the initial diagnosis of synchronous papillary and follicular thyroid cancer

Background Differentiated thyroid cancer uncommonly presents with distant metastases. Adrenal metastasis from differentiated thyroid cancer presenting as the initial finding is even less common. Case Presentation A 71-year-old male was incidentally found on chest CT to have bilateral thyroid nodules, which were confirmed on ultrasound. Fine needle aspiration of the dominant right 3.3 cm nodule contained histologic features most consistent with Bethesda classification III, and repeat fine needle aspiration revealed pathology consistent with Bethesda classification II. Follow-up thyroid ultrasound showed 1% increase and 14% increase in nodule volume at one and two years, respectively, compared to baseline. Prior to the second annual thyroid ultrasound, the patient was incidentally found to have a 4.1 cm heterogeneously enhancing mass in the right adrenal gland on CT of the abdomen and pelvis. Biochemical evaluation was unremarkable with the exception of morning cortisol of 3.2 µg/dL after dexamethasone suppression. The patient then underwent laparoscopic right adrenal gland excision, which revealed metastatic follicular thyroid carcinoma. Total thyroidectomy was then performed, with pathology showing a 4.8 cm well-differentiated follicular thyroid carcinoma of the right lobe, a 0.5 cm noninvasive follicular thyroid neoplasm with papillary-like nuclear features of the left lobe, and a 0.1 cm papillary microcarcinoma of the left lobe. Thyrotropin-stimulated whole body scan showed normal physiologic uptake of the remnant thyroid tissue without evidence of other iodine avid disease. The patient then received radioactive iodine. At follow-up 14 months after total thyroidectomy, he remains free of recurrent disease. Conclusion Despite following the recommended protocol for evaluation and surveillance of thyroid nodules, thyroid cancer can be challenging to diagnose, and may not be diagnosed until distant metastases are identified.