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A Clinical Algorithm for Fine-Needle Aspiration Molecular Testing Effectively Guides the Appropriate Extent of Initial Thyroidectomy

Yip, Linwah MD*; Wharry, Laura I. MD*; Armstrong, Michaele J. PhD*; Silbermann, Ari BS*; McCoy, Kelly L. MD*; Stang, Michael T. MD*; Ohori, Nobuyuki P. MD; LeBeau, Shane O. MD; Coyne, Christopher MD; Nikiforova, Marina N. MD; Bauman, Julie E. MD§; Johnson, Jonas T. MD; Tublin, Mitch E. MD; Hodak, Steven P. MD; Nikiforov, Yuri E. MD, PhD; Carty, Sally E. MD*

Annals of Surgery:
doi: 10.1097/SLA.0000000000000215
Original Articles

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.

In Brief

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.

Author Information

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

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.

© 2014 by Lippincott Williams & Wilkins.