Objective: To test whether a clinical algorithm using routine cytological molecular testing (MT) promotes initial total thyroidectomy (TT) for clinically significant thyroid cancer (sTC) and/or correctly limits surgery to lobectomy when appropriate.
Background: Either TT or lobectomy is often needed to diagnose differentiated thyroid cancer. Determining the correct extent of initial thyroidectomy is challenging.
Methods: After implementing an algorithm for prospective MT of in-house fine-needle aspiration biopsy specimens, we conducted a single-institution cohort study of all patients (N = 671) with nonmalignant cytology who had thyroidectomy between October 2010 and March 2012, cytological diagnosis using 2008 Bethesda criteria, and 1 or more indications for thyroidectomy by 2009 American Thyroid Association guidelines. sTC was defined by histological differentiated thyroid cancer of 1 cm or more and/or lymph node metastasis. Cohort 2 patients did not have MT or had unevaluable results. In cohort 1, MT for a multigene mutation panel was performed for nonbenign cytology, and positive MT results indicated initial TT.
Results: MT guidance was associated with a higher incidence of sTC after TT (P = 0.006) and a lower rate of sTC after lobectomy (P = 0.03). Without MT results, patients with indeterminate (follicular lesion of undetermined significance/follicular or oncocytic neoplasm) cytology who received initial lobectomy were 2.5 times more likely to require 2-stage surgery for histological sTC (P < 0.001). In the 501 patients with non-sTC for whom lobectomy was the appropriate extent of surgery, lobectomy was correctly performed more often with routine preoperative MT (P = 0.001).
Conclusions: Fine-needle aspiration biopsy MT for BRAF, RAS, PAX8-PPARγ, and RET-PTC expedites optimal initial surgery for differentiated thyroid cancer, facilitating succinct definitive management for patients with thyroid nodules.
Single-institution cohort study to determine whether prospective routine cytological molecular testing (MT) correctly guides the extent of initial thyroidectomy. MT guidance was associated with a higher incidence of initial total thyroidectomy for clinically significant thyroid cancer and limited surgery to lobectomy when indicated. Thus, MT optimizes surgery for patients with thyroid nodule.
Departments of *Surgery
‖Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA.
Reprints: Linwah Yip, MD, Division of Endocrine Surgery, University of Pittsburgh Medical Center, 3471 Fifth Ave, Kauffman Bldg, Ste 101, Pittsburgh, PA 15213. E-mail firstname.lastname@example.org.
Disclosure: L.Y. received a grant from the University of Pittsburgh Medical Center. N.P.O. received an honorarium for speaking at the 2013 Texas Society of Pathologists Annual Meeting. J.E.B. is a consultant for AVEO. S.P.H. received an honorarium for speaking at a 2012 Association for Molecular Pathology lecture. S.E.C. is a section editor for UptoDate, Inc. The remaining authors declare no conflicts of interest.