Paraganglioma is a neuroendocrine tumour derived from extra-adrenal cells of the neural crest paraganglia of the autonomic nervous system. These rare neoplasms comprise of around 0.012% of head and neck tumours. Paraganglioma arising in the thyroid gland is exceptionally uncommon and can present as a diagnostic challenge on fine-needle aspiration cytology (FNAC). We report a case of primary thyroid paraganglioma in a 19-year-old woman who presented with a solitary thyroid nodule without palpable cervical lymphadenopathy. FNAC from the lesion caused diagnostic dilemma by mimicking follicular neoplasm and C-cell-derived thyroid tumours; final diagnosis was established by histopathology and immunohistochemistry. The main purpose of this case report is to discuss the differential diagnosis and emphasise on the need of immune markers in the diagnosis of thyroid paraganglioma. In view of the uncertain malignant potential of these tumours, a long-term follow-up is recommended.

OBJECTIVES:

The authors analyse the predictive diagnostic accuracy of fine-needle aspiration cytology (FNAC) and frozen section examination in adult patients operated for thyroid nodules.

PATIENTS AND METHODS:

The same pathologist performed macroscopic and cytological examination, followed by frozen section examination on each operative specimen. FNAC results were classified into three groups: benign, malignant or suspicious of malignancy. Frozen section examination was also classified into three categories: benign, malignant or suspicious of malignancy when not all criteria of malignancy were present.

RESULTS:

One hundred and sixty-six (82%) of the 202 patients included in the study were females. Patients had a mean age of 51years. Thyroid carcinoma was diagnosed on final pathology in 22% of women and 25% of men. FNAC results were benign in 85% of cases, malignant in 9% of cases and atypical or suspicious in 6% of cases, with a specificity of more than 99% and a sensitivity, including and excluding microcarcinomas, of 36% and 48%, respectively. The diagnostic accuracy of FNAC was 84% and 89%, after excluding micro-carcinomas. Frozen section was benign in 85% of cases, malignant in 13% of cases and suspicious in 2% of cases, with a specificity of more than 99% and a sensitivity, including and excluding microcarcinomas, of 56% and 68%, respectively. The diagnostic accuracy of frozen section was 89% and 90%, after excluding microcarcinomas. The diagnostic accuracy of the combination of the two examinations was 94% after excluding microcarcinomas.

CONCLUSION:

FNAC and frozen section have a comparable predictive diagnostic accuracy. Frozen section is requested by the surgeon not only on the basis of preoperative FNAC, especially when it is suspicious, or even indeterminate, but also in the light of the macroscopic surgical findings.

Background Recommendation for subcentimeter thyroid nodules that need fine-needle aspiration biopsy is renewed in the revised American Thyroid Association (ATA) guidelines published in 2009. We applied these recommendations to analyze the diagnostic performance of the ATA guidelines and compared it to that of other modified guidelines. Methods We evaluated 1054 nodules with a size of 6 mm to 10 mm in 991 patients. A total of 713 nodules were included in the study population by excluding nodules with insufficient results for deciding whether they had a benign or malignant cytology. Frequencies of ultrasonographic features in benign and malignant nodules were compared, and odds ratios of suspicious ultrasonographic features were obtained with univariate and multivariate analysis. Seven modified guidelines were made based on the revised ATA guidelines and from multivariate analysis results. Diagnostic performances of the guidelines were compared by sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and the area under the receiver operating characteristic curve (Az) value. Results In addition to hypoechogenicity, infiltrative margin, microcalcification, and taller than wide shape that were suggested by the ATA guidelines, solid composition and macrocalcification were significantly associated with malignancy on multivariate analysis (p value = 0.001 and 0.003, respectively). Increased vascularity, however, was not significantly associated with malignant nodules (odds ratio 0.729, p value = 0.212). Among the eight guidelines, the ATA guidelines showed the lowest diagnostic performance (Az value = 0.616). Excluding increased vascularity and including solid composition with or without macrocalcification to the suspicious ultrasonographic features of the ATA guidelines improved sensitivity (96.6 % vs 97.0 %), specificity (26.6 % vs 42.9 %), PPV (48.3 % vs 54.7 %), and NPV (91.7 % vs 95.2 %), thereby resulting in the highest Az value (Az value = 0.699, p value < 0.001). Conclusions This study suggests that excluding increased vascularity and adding solid composition to the suspicious ultrasonographic features of the ATA guidelines would significantly improve the diagnostic performance in subcentimeter nodules for the identification of malignant lesions.

Introduction: Thyroid cancer is the most common endocrine cancer in the USA and its incidence is increasing worldwide. Thyroid fine-needle aspiration biopsy (FNA) and cytologic analysis is the most cost-effective approach to distinguish between malignant and benign thyroid nodules. However, up to 30% of thyroid FNA biopsy results are inconclusive. Areas covered: In this article, the authors provide an update on the current status and emerging approaches for improving thyroid cancer diagnosis. This review covers imaging, genetic and genomic approaches being used or in development to help distinguish between malignant and benign thyroid nodules. Expert opinion: There has been considerable progress in improving thyroid cancer diagnosis. The molecular markers analysis to avoid diagnostic surgeries seems to be promising. However, the clinical utility and accuracy of some markers reported in this review are not conclusive and need significant attention to be validated as clinical diagnostic tool.

OBJECTIVE.

The purpose of this article is to present, through systematic review of recent literature, a comparative effectiveness analysis of ultrasound elastography versus B-mode ultrasound features for differentiating thyroid nodules. MATERIALS AND

METHODS.

We conducted an extensive literature search of PubMed and other medical and general purpose databases from January 1966 through March 2012. Eligible studies were published in English, reported diagnostic performance of elastography (using elasticity score or strain ratio) with or without B-mode ultrasound in differentiation of thyroid nodules, and used histology or cytology as the reference standard. Summary diagnostic performance measures were assessed for each of the elasticity measuring methods and ultrasound features by means of a bivariate random effects model.

RESULTS.

Twenty-four studies provided relevant information on more than 2624 patients and 3531 thyroid nodules (927 malignant and 2604 benign). Six ultrasound features (echogenicity, calcifications, margins, halo sign, shape, and color Doppler flow pattern) were compared with elasticity score and strain ratio. The respective sensitivities and specificities were as follows: elasticity score, 82% and 82%; strain ratio, 89% and 82%; hypoechogenicity, 78% and 55%; microcalcifications, 50% and 80%; irregular margins, 66% and 81%; absent halo sign, 56% and 57%; nodule vertical development, 46% and 77%; and intranodular vascularization, 40% and 61%.

CONCLUSION.

Evaluation of thyroid nodules with ultrasound elastography appears to be both more sensitive and specific than each of the ultrasound features. The former is a safe and effective technique that warrants further rigorous investigation or use in the clinical diagnosis of thyroid nodules.

to describe two cases of familial papillary thyroid carcinoma.patients were investigated by fine needle biopsy, MRI imaging and tumor biopsy, (first case) and histological examination of colonic and thyroid tumors (first case) and histological examination of thyroid tumor (second case).case presentation: first case, 68 years old man had a colonic polyposis (attenuated form with only a few polyps) and a thyroid nodule. After hemicoleCtomy for a supposed colonic carcinoma with liver and lung metastases, histological examination revealed no malignant colonic disease. Two month later the diagnosis of invasive thyroid tumor with lymph node metastases was made, but only an open biopsy was done because tumor invasiveness demonstrated on MTI imaging. The biopsy identified a papillary thyroid carcinoma. Case 2: the son of the patient (30 years old) without known diseases was invited to be assessed for thyroid disease. Ultrasound examination discovered a large nodule with microcalcifications. Microscopic examination done after total thyroidectomy revealed a cribriform morular variant of papillary thyroid carcinoma, a variant that is known to be associated with FAP. Radioiodine ablation was made followed by suppressive thyroxine treatment. In the second case adenomatous polyposis was not found yet. In our knowledge these are the first cases of familial thyroid papillary carcinomas in our setting. Familial history allowed an earlier diagnosis and a good management of the disease in the second case.according to the literature and our first experience, screening for thyroid cancer must be done in all patients with FAP and in those with a FAP proband in the family.

Abstract

Background:

The utility and safety of level VI central compartment lymph node dissection (LND) for the early detection of lymph node (LN) involvement during diagnostic hemithyroidectomy, for the evaluation of suspicious thyroid nodules, has yet to be established in the literature.

Methods:

A retrospective review of all patients who underwent diagnostic hemithyroidectomy with level VI LND from a large head and neck oncology program from October 1, 2001, to May 10, 2009, was performed.

Results:

A consecutive series of 78 patients were reviewed. Twenty-six patients (29.8%) were diagnosed with malignant neoplasm. All patients with malignant LNs (n  =  5; 6.4%) were diagnosed with papillary carcinoma. On average, 4.8 LNs were found through neck dissection in patients with positive nodes compared to 2.4 LNs in those without lymph node involvement (p  =  .04). No postoperative adverse events in the patient group were attributed to the level VI neck dissection.

Conclusions:

In patients undergoing diagnostic hemithyroidectomies, routine level VI LND was able to identify LN metastases in 6.4% of patients. The number of LNs was a strong predictor of positive node disease. Minimal surgical risks are associated with this procedure, and surgeons may avoid the risks of level VI reexploration in subsequent completion thyroidectomy.

BACKGROUND:

This study was designed to evaluate the feasibility and the role of thyroid ultrasound (US) in predicting malignancy for Bethesda system III nodules and to suggest management guidelines for these nodules.

METHODS:

A total of 155 thyroid nodules with Bethesda system III cytology in 155 patients with surgery or follow-up repeat FNA were included in this study. On the basis of US features, final assessment for thyroid nodules were prospectively classified into one of three categories: (1) probably benign, (2) low suspicious for malignancy, and (3) suspicious for malignancy. The clinicopathologic characteristics of patients and US features of nodules were compared according to malignancy and benignity.

RESULTS:

Of the 155 Bethesda system III nodules, 69 (44.5 %) underwent surgery without repeat FNA and 86 (55.5 %) nodules underwent repeat FNA, and a malignancy rate of 55.5 % (86/155) was determined. Thyroid nodules with concurrent thyroid cancer were more likely to be malignant (P < 0.001). The malignancy rate of sonographically suspicious for malignancy was 100 %, higher than the 58 % of sonographically low suspicious for malignancy, and 7.7 % of sonographically probably benign nodules (P < 0.001).

CONCLUSIONS:

US assessment may help the clinician decide between surgery and repeat FNA for managing Bethesda system III nodules. When the US assessment for the thyroid nodules is suspicious for malignancy, repeat FNA may be unnecessary and surgery should be considered.

PURPOSE:

The main benefits of robot-assisted transaxillary thyroid surgery are to overcome the technical limitations of other endoscopic procedures for this surgical pathology and to avoid any cervical skin incision. This article describes the first experience of a Romanian team with the endoscopic robot-assisted thyroid surgery.

MATERIAL AND METHODS:

We used the da Vinci SI intuitive surgical system to carry out 50 thyroid operations: 33 unilateral total lobectomies with isthmectomy (TL), 8 unilateral total lobectomies, with contralateral subtotal lobectomy, and 9 total thyroidectomies. Preoperatively, the patients were diagnosed with nodular goiter in 42 cases, nodular autoimmune thyroiditis in 3 cases, Basedow disease in 2 cases, toxic thyroid adenoma in 2 cases, and diffuse goiter in 1 case. We analyzed the clinical characteristics, size and location of the nodules, surgery duration, postoperative complications, pain medication, histopathological findings and postoperative cosmetic results.

RESULTS:

All surgical procedures were carried out without major incidents. One case required conversion to open approach. The mean length of surgery was 159 ± 38.2 min and the average console time was 68 ± 39.9 min; postoperatively, we recorded one case of transient brachial plexus neurapraxia, one transient vocal cord paresis, one transient hypocalcemia, and four postoperative wound complications. The final histopathological examination revealed two cases of well-differentiated carcinoma.

CONCLUSIONS:

This paper reports the largest series to date in Southeast Europe about robot-assisted transaxillary thyroidectomy. On a group of selected Caucasian patients, postoperative results were similar to open cervicotomy in terms of postoperative complications. The major cosmetic advantage is the absence of scar in the anterior cervical region.

Background.

Although the value of surgeon-performed neck ultrasound (SPUS) for thyroid nodules has been validated, the utility of intraoperative ultrasound (US) in modified radical neck dissection (MRND) has not been reported in the literature. The aim of this study was to analyze the utility of intraoperative SPUS in assessing the completeness of MRND for thyroid cancer. Methods. Between 2007 and 2011, a total of 25 patients underwent MRND by 1 surgeon for thyroid cancer. All patients underwent intraoperative SPUS, which was repeated at the end of the neck dissection (completion US) to look for missed lymph nodes (LNs).

Results.

There were 10 male and 15 female patients. Pathology included 23 papillary and 2 medullary carcinomas. The number of LNs removed per case was 23 ± 2, and the number of positive was LNs 5 ± 1. In 4 (16%) cases, intraoperative US detected 7 residual LNs, which would have been missed, if completion US were not done. These missed LNs were located in low-level IV (3 nodes), high-level II (2 nodes), and posterior level V (2 nodes) and measured 1.4 ± 0.2 cm. At follow-up, recurrence was seen in 2 (8%) patients, including a superior mediastinal recurrence in a patient with tall cell cancer and a jugular LN recurrence at level II in another patient with papillary thyroid cancer.

Conclusion.

This pilot study shows that intraoperative SPUS can help assess the completeness of MRND. According to our results, intraoperative completion US identifies LNs missed by palpation 16% of the time.