The thyroid fine-needle aspiration (FNA) diagnosis of "follicular neoplasm" does not differentiate between a benign and malignant tumor. Often cases diagnosed as "follicular or Hurthle-cell neoplasm" undergo surgical excision for further characterization. The aim of this study was to identify clinical features that may help in predicting malignancy in patients with an FNA diagnosis of follicular neoplasm. One hundred eighty-four cases in 167 patients were diagnosed as "follicular neoplasm" among 1,024 thyroid FNA evaluated with on-site interpretation from 1998-2000. The cases were evaluated for the following variables: histologic diagnosis, age, sex, and size of the nodule. One hundred thirty-nine patients were female, and 28 were male (age range, 23-80 yr). Among 122 patients (67%) undergoing surgical excision (lobectomy, 96; total thyroidectomy, 26), malignancy was identified in 37 cases (31%). Nonpapillary (follicular/Hurthle) carcinoma was diagnosed in 11 (9%), follicular variant of papillary carcinoma in 25, and medullary carcinoma in 1 case. The risk of malignancy was greater in males (47% vs. 29%, P < 0.0004) than females, in nodules measuring 3 cm or more (55% vs. 23%, P < 0.0001), than in nodules measuring less than 3 cm, and in patients 40 or more yr old (20% vs. 10%, P = 0.0001) than in patients younger than 40 years. The diagnosis "follicular neoplasm" is indeterminate, and the majority of cases (70% in the current study) are benign. However, clinical features, including gender, nodule size, and age, can be a part of the decision analysis in selecting patients for surgery.

Diagnosis of "follicular neoplasm": a gray zone in thyroid fine-needle aspiration cytology.

BACKGROUND

The American College of Surgeons Commission on Cancer (CoC) has conducted national Patient Care Evaluation (PCE) studies since 1976.



METHODS

Over 1500 hospitals with CoC-approved cancer programs were invited to participate in this prospective cohort study of U.S. thyroid carcinoma cases treated in 1996. Follow-up will be conducted through the National Cancer Data Base.



RESULTS

Of the 5584 cases of thyroid carcinoma, 81% were papillary, 10% follicular, 3.6% Hurthle cell, 0.5% familial medullary, 2.7% sporadic medullary, and 1.7% undifferentiated/anaplastic. Demographics and suspected risk factors were analyzed. Fine-needle aspiration of the thyroid gland (53%) or a neck lymph node (7%), thyroid nuclear scan (39%), and ultrasound (38%) constituted the most frequently utilized diagnostic modalities. The vast majority of patients with differentiated thyroid carcinoma presented with American Joint Committee on Cancer Stage I and II disease and relatively small tumors. For all histologies, near-total or total thyroidectomy constituted the dominant surgical treatment. No lymph nodes were examined in a substantial proportion of cases. Residual tumor after the surgical event could be documented in 11% of cases, hypocalcemia in 10% of cases, and recurrent laryngeal nerve injury in 1.3% of cases. Complications were most frequently associated with total thyroidectomy combined with lymph node dissection. Thirty-day mortality was 0.3%; when undifferentiated/anaplastic cancer cases were eliminated, it decreased to 0.2%. Adjuvant treatment, probably underreported in this study, consisted of hormonal suppression (50% overall) and radioiodine (50% overall).



CONCLUSIONS

In addition to offering information concerning risk factors and symptoms, the current PCE study compliments the survival information from previous NCDB reports and offers a surveillance snapshot of current management of thyroid carcinoma in the U.S. Identified opportunities for improvement of care include 1) more frequent use of fine-needle aspiration cytology in making a diagnosis; 2) more frequent use of laryngoscopy in evaluating patients preoperatively, especially those with voice change; and 3) improved lymph node resection and analysis to improve staging and, in some situations, outcomes. [See commentary on pages 1–4, this issue and communication on pages 192–201, this issue.] Cancer 2000;89:202–17. © 2000 American Cancer Society.

/pdf/initial-results-from-a-prospective-cohort-study-of-5583-v5s0mepp78.pdf

Initial results from a prospective cohort study of 5583 cases of thyroid carcinoma treated in the United States during 1996: An American college of surgeons commission on cancer patient care evaluation study

The incidence of cancer and rate of false-negative cytology in thyroid nodules greater than or equal to 4 cm in size.

Evaluation and management of the solid thyroid nodule

Hypothesis All thyroid nodules 4 cm or larger should be surgically removed regardless of fine-needle aspiration biopsy (FNAB) results because of an unacceptably high rate of false-negative preoperative biopsy results in these large nodules. Design Retrospective cohort study. Setting Single-institution, tertiary academic referral center. Patients A retrospective analysis was performed on all patients who underwent surgery for a thyroid nodule 4 cm or larger from May 1, 1994, through January 31, 2007. Main Outcome Measures Preoperative FNAB results were correlated with final surgical pathologic results. The FNAB results were reported as nondiagnostic, benign, inconclusive (follicular neoplasm), or malignant, whereas the final surgical pathologic data were reported as benign or malignant. Results Of 155 patients who underwent a thyroidectomy for a nodule 4 cm or larger, 21 patients (13.5%) had a clinically significant thyroid carcinoma within the nodule on final pathologic analysis. Preoperative cytologic testing of the mass was performed on 97 patients, and the results read as benign for 52, inconclusive for 23, nondiagnostic for 11, and malignant for 11. In lesions 4 cm or larger, 26 of 52 FNAB results reported as benign (50.0%) turned out to be either neoplastic (22) or malignant (4) on final pathologic analysis. Among patients with nondiagnostic FNAB results, the risk of malignant neoplasms was 27.3%. Conclusions In patients with thyroid nodules 4 cm or larger, the FNAB results are highly inaccurate, misclassifying half of all patients with reportedly benign lesions. Furthermore, those patients with a nondiagnostic FNAB result display a high risk of differentiated thyroid carcinoma. Therefore, we recommend that diagnostic lobectomy be strongly considered in patients with thyroid nodules 4 cm or larger regardless of FNAB cytologic test results.

https://jamanetwork.com/journals/jamasurgery/articlepdf/405147/sws90004_649_655.pdf

Accuracy of fine-needle aspiration biopsy for predicting neoplasm or carcinoma in thyroid nodules 4 cm or larger.

The utility of fine needle aspiration (FNA) and physical examination for selecting patients with palpable thyroid nodules for surgery was evaluated in 795 consecutive cases. Surgery was performed in 216 patients based upon the cytological diagnosis and clinical criteria. Excluding 42 patients who were lost to follow-up, the remaining 537 were regularly followed up (range, 2–10 years). Cytological findings were classified as malignant, histologic control recommended (suspicious), follicular tumor, benign, and unsatisfactory. Thirty-six aspiration biopsies were positive for malignancy and the diagnosis was confirmed histologically in 34 of them. In 65 patients with final histological diagnosis of malignancy, cytology was positive in 34, suspicious in 20, benign in 3 cases, and unsatisfactory in 8. All patients with cytological diagnosis of follicular tumor had a benign lesion at histology. There were two false positive and three false negative cytological results among the 216 histologically confirmed cases. Excluding unsatisfactory specimen sensitivity, specificity and the predictive value for a positive and a negative result were respectively 95%, 97.5%, 94.5%, and 97%. We conclude that FNA is a very reliable diagnostic test in the evaluation of thyroid nodules and is the best guidance in addition to clinical criteria for selecting patients to be submitted to surgery. © 1992 Wiley-Liss, Inc.

The role of fine needle aspiration in the diagnosis of thyroid nodules: analysis of 795 consecutive cases.

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The role of fine needle aspiration in the diagnosis of thyroid nodules: analysis of 795 consecutive cases.