Incidental Papillary Microcarcinoma Research Articles

8791 A Case of Hyperfunctioning Thyroid Nodules Evaluated for Thyroid Metastasis in the Setting of Oropharyngeal Squamous Cell Carcinoma

Abstract Disclosure: M. Alashoor: None. J. Gogineni: None. A. Bakar: None. Introduction: Identifying and evaluating hyperfunctioning thyroid nodules in the setting of metastatic head and neck cancers represents a diagnostic challenge that may result in inaccurate identification of perithyroidal lymph node metastasis as malignant or metastatic thyroid nodules with standard workup. Case presentation: A 72-year-old male with a history of stage IV metastatic oropharyngeal squamous cell carcinoma, metastasized to the lymph nodes, lungs, mediastinum, and bilateral iliac bones. He was diagnosed two years ago and received chemotherapy, maintenance immunotherapy with pembrolizumab, and targeted palliative radiation therapy, with good clinical response. Restaging PET-CT two years later revealed local progression. During his workup, he was noted to have persistently abnormal thyroid function test with low TSH (0.03​​µIU/mL, n 0.3-5.33), normal free T4 (0.97ng/dL, n 0.60 - 1.40), mildly elevated free T3 (3.91pg/mL, n 2.5-3.9), negative thyrotropin receptor antibodies levels, negative TSI, negative TPO antibody, noted evidence of subclinical hyperthyroidism consistent over the past year. Radioactive iodine uptake demonstrated multinodular gland, mildly elevated 24-hour uptake of 28% consistent with hyperthyroidism, with decreased activity in the left lobe. Thyroid ultrasound revealed multiple probable malignant thyroid nodules, a 1.8 cm TI-RADS 5 lesion of the deep margin of the lower pole of the right lobe, and a 1.6 cm TI-RADS 5 lesion of the upper pole on the right lobe. He was treated with methimazole 5 mg. Further workup with fine needle aspiration demonstrated the right upper lobe nodule sample was positive for squamous cell carcinoma, findings suspicious for metastasis. He subsequently proceeded with radical tonsillectomy, right neck dissection, and right hemithyroidectomy. Surgical pathology results noted, right neck metastatic HPV-associated squamous cell carcinoma involving the lymph nodes with extranodal extension, right oropharyngeal HPV-mediated squamous cell carcinoma. The thyroid gland biopsy was significant for incidental papillary microcarcinoma 2mm, thyroid follicular nodular disease, without evidence of squamous cell carcinoma or metastatic infiltration. Post-hemithyroidectomy, his thyroid function normalized, and methimazole was discontinued. Conclusion: Thyroid metastasis from head and neck cancers represent a rare entity. In patients with a history of malignancy, evaluation of new thyroid masses remains crucial. While FNA is a sensitive method for detecting thyroid metastases, inaccuracies may occur, impacting the identification of thyroid nodules in the presence of local metastatic lymphadenopathy. Identifying squamous cell carcinoma in the thyroid can significantly influence the treatment plan of patients with metastatic carcinomas, therefore careful consideration must be undertaken on evaluation. Presentation: 6/1/2024

Incidental Papillary Microcarcinoma and Papillary Thyroid Carcinoma in Multinodular Goiter.

This study aimed to examine the incidence of incidental papillary microcarcinoma (PMC) and papillary thyroid carcinoma (PTC) in patients with benign multinodular goiter (MNG) and to compare their relationship with some prognostic factors from a new perspective. Bilateral total thyroidectomy (BTT) was used to evaluate the data of 716 patients who underwent a surgery for MNG. The prognostic data for these tumors and the relationship between patients with bilateral and multifocal tumors were evaluated using statistical tests. Papillary carcinomas were detected in 201 patients, PMC in 134 of them, and PTCs in 67. Bilaterality was more common in patients with PTCs than in those with PMC. The incidence of bilaterality in male patients with PTC was statistically more common. The presence of intra-tumoral lymphocytes was higher in multifocal PTC cases than in unifocal PTC cases. The results revealed that the number of PMC s was high in incidental tumors, and patients with PTC with male sex, bilaterality, multifocality, and tumor capsule invasion were associated with poor prognosis.

Incidence and dynamic risk stratification in differentiated thyroid cancer in a high-resolution clinic, 2002–2017

ObjectiveWe evaluated the incidence, progression and the dynamic risk stratification in differentiated thyroid cancer (DTC) under follow-up in a high-resolution clinic (HRC). MethodsThis was a retrospective observational study on incident cases in the tumor registry from 2002 to 2017 and their evolution under follow-up in HRC. ResultsA total of 444 patients (78.5% women, 52.1±14.9 mean years old) were DTC diagnosed from 2002 to 2017. The incidence rate of DTC increased from 5.2 to 25.7×105 habitants/year in women and from 2.3 to 7.1×105 habitants/year in men (P<0.0001). This increased incidence was not associated with an increment in the incidental papillary microcarcinoma diagnosed (from 29.4% to 32%).In those patients undergoing follow-up at the HRC (84% papillary carcinomas), 65.7% were classified as being at a low risk of recurrence compared to 14.5% at high risk. Of those, 88.8% classified as making an excellent response at diagnosis remained disease-free at the final follow-up visit. However, those patients with an indeterminate or structurally incomplete response at diagnosis evolved to an excellent response in 55.8% and 42.9% of the cases, respectively, compared to 14.8% of those with a biochemically incomplete response (P<0.001) ConclusionsThe increased incidence of DTC is similar to results published previously in other countries. Dynamic risk stratification systems adequately classify DTC patients and assess diagnostic and treatment procedures, especially in low-risk subgroups.

Incidencia y estadificación dinámica del riesgo del carcinoma diferenciado de tiroides en una unidad de alta resolución. periodo 2002-2017

ObjectiveWe evaluated the incidence, progression and the dynamic risk stratification in differentiated thyroid cancer (DTC) under follow-up in a high-resolution clinic (HRC). MethodsThis was a retrospective observational study on incident cases in the tumor registry from 2002 to 2017 and their evolution under follow-up in HRC. ResultsA total of 444 patients (78.5% women, 52.1±14.9 mean years old) were DTC diagnosed from 2002 to 2017. The incidence rate of DTC increased from 5.2 to 25.7x105 habitants/year in women and from 2.3 to 7.1x105 habitants/year in men (P<0.0001). This increased incidence was not associated with an increment in the incidental papillary microcarcinoma diagnosed (from 29.4% to 32%).In those patients undergoing follow-up at the HRC (84% papillary carcinomas), 65.7% were classified as being at a low risk of recurrence compared to 14.5% at high risk. Of those, 88.8% classified as making an excellent response at diagnosis remained disease-free at the final follow-up visit. However, those patients with an indeterminate or structurally incomplete response at diagnosis evolved to an excellent response in 55.8% and 42.9% of the cases, respectively, compared to 14.8% of those with a biochemically incomplete response (P<0.001) ConclusionsThe increased incidence of DTC is similar to results published previously in other countries. Dynamic risk stratification systems adequately classify DTC patients and assess diagnostic and treatment procedures, especially in low-risk subgroups.

Diagnostic performance of the American Thyroid Association ultrasound risk assessment of thyroid nodules in endocrinology (the ETIEN 3 study)

IntroductionNo study has been published to date in Spain about the value of the American Thyroid Association (ATA) ultrasound risk assessment of thyroid nodules applied by endocrinologists. ObjectivesTo assess the diagnostic performance of ATA thyroid nodule risk classification applied by endocrinologists with respect to histological results. MethodsA retrospective, observational study of 317 patients (mean age, 51.7±13.7 years; 83.3% women) with thyroid nodules (maximum diameter: 3.2±1.4cm) who underwent US-guided FNA in endocrinology between October 2015 and December 2018, were classified based on the ATA ultrasound risk assessment. Surgery was performed in all of them. Quality criteria of the ultrasound classification were assessed as compared to histological results. ResultsOverall, 61.2% of nodules assessed were classified as benign (n=3) and very low (n=60) or low suspicion (n=131), 11.7% as intermediate suspicion (n=37), and 27.1% as high suspicion (n=86). Benign nodular disease was found in 260 patients, and thyroid cancer in 57 patients. There were 14 incidental papillary microcarcinomas. Classification of thyroid nodules as high suspicion showed a high diagnostic performance to identify malignant nodules (87.7% sensitivity, 86.2% specificity, negative predictive value 97.0%), improving sensitivity (93.0%) and reducing specificity (73.1%) when considering high and intermediate suspicion nodules as a risk for thyroid cancer. ConclusionsApplication by endocrinologists of the ATA ultrasound risk assessment of thyroid nodules shows a high diagnostic performance to identify malignant thyroid nodules before surgery.

Rendimiento diagnóstico del sistema de evaluación de riesgo ecográfico del nódulo tiroideo de la American Thyroid Association en endocrinología (estudio ETIEN 3)

IntroductionNo study has been published to date in Spain about the value of the American Thyroid Association (ATA) ultrasound risk assessment of thyroid nodules applied by endocrinologists. ObjectivesTo assess the diagnostic performance of ATA thyroid nodule risk classification applied by endocrinologists with respect to histological results. MethodsA retrospective, observational study of 317 patients (mean age, 51.7±13.7 years; 83.3% women) with thyroid nodules (maximum diameter: 3.2±1.4cm) who underwent US-guided FNA in endocrinology between October 2015 and December 2018, were classified based on the ATA ultrasound risk assessment. Surgery was performed in all of them. Quality criteria of the ultrasound classification were assessed as compared to histological results. ResultsOverall, 61.2% of nodules assessed were classified as benign (n=3) and very low (n=60) or low suspicion (n=131), 11.7% as intermediate suspicion (n=37), and 27.1% as high suspicion (n=86). Benign nodular disease was found in 260 patients, and thyroid cancer in 57 patients. There were 14 incidental papillary microcarcinomas. Classification of thyroid nodules as high suspicion showed a high diagnostic performance to identify malignant nodules (87.7% sensitivity, 86.2% specificity, negative predictive value 97.0%), improving sensitivity (93.0%) and reducing specificity (73.1%) when considering high and intermediate suspicion nodules as a risk for thyroid cancer. ConclusionsApplication by endocrinologists of the ATA ultrasound risk assessment of thyroid nodules shows a high diagnostic performance to identify malignant thyroid nodules before surgery.

Incidentally detected papillary microcarcinomas in thyroid surgeries for benign diseases

Background: Papillary microcarcinoma (PMC) is a papillary thyroid carcinoma (PTC) measuring 10 mm or less in dimension. Incidental papillary microcarcinomas (IPC) are those PMC that are detected only after thyroid surgeries for benign diseases.

The rate of incidental papillary microcarcinomas in total thyroidectomy specimens of patients with presumably benign thyroid disease: experience of a university hospital clinic

The rate of incidental papillary microcarcinomas in total thyroidectomy specimens of patients with presumably benign thyroid disease: experience of a university hospital clinic

Do all Thyroid Nodules >4 cm need to be Removed? An Evaluation of Thyroid Fine-Needle Aspiration Biopsy in Large Thyroid Nodules

Controversy exists regarding the ability of fine-needle aspiration (FNA) biopsy to rule out malignancy when thyroid nodules exceed 4 cm in diameter. The goal of this study was to provide data regarding FNA accuracy in a clinical setting for detecting/ruling out malignancy in large thyroid nodules (≥4 cm) and discuss FNA utility in guiding surgical decisions. All thyroid FNA cases performed at Marshfield Clinic from 1/1/2000 to 12/31/2010 followed by complete or partial thyroidectomy on nodules of at least 4 cm were identified. Demographics, medical history, nodule biopsy characteristics, surgical procedures, and diagnosis data were abstracted. FNA was compared to histologic evaluation of surgical specimens. A total of 198 patients with large thyroid nodules were identified. Most had a single large nodule, but ~40% were multinodular, and 206 total nodules were assessed. Females outnumbered males, and the mean age was ~50 years. After surgery, cancer was histologically identified in 49/206 (23.8%) nodules, including 9/123 nodules that had been categorized as benign by FNA, corresponding to a false-negative rate of 7.3%. Sensitivity/specificity for detecting malignancy by FNA was ~80%. The positive predictive value (PPV) was just below 60%, and the negative predictive value (NPV) was 93% but rose to 96% when papillary microcarcinomas were excluded. While FNA sensitivity in large nodules was relatively low, NPV was high, especially if incidental papillary microcarcinomas were excluded. When cancer prevalence and NPV are known, FNA can be a reliable "rule out" test in nodules ≥4 cm. This information is critical and can help guide the surgery decision, especially in high-risk patients. The decision for surgery should not be solely based on nodule size but should consider additional factors including cancer prevalence, clinical history, ultrasound features, surgical risk, and life expectancy. FNA = fine-needle aspiration NPV = negative predictive value PPV = positive predictive value.

Papillary thyroid cancer in childhood: is parental screening helpful?

Familial non-medullary thyroid cancer (FNMTC) mandates family screening with ultrasound; however, the need for screening paediatric thyroid cancer with no family history has not been addressed. This study conducted a retrospective cohort study in a tertiary hospital. The study group is composed of patients ≤18 years undergoing surgery for papillary thyroid cancer (PTC) from 2008 to 2014. During the study period, 15 paediatric patients had PTC. Only one patient had a prior family history of PTC involving two second-degree relatives. Of the 30 parents, four were lost to follow-up, with the remaining 26 undergoing screening thyroid ultrasound. Nodular thyroid disease was documented in eight ultrasounds performed. Subsequently, one has not undergone fine-needle biopsy, five were benign and two underwent surgical resection: one having a benign follicular adenoma and the other a papillary microcarcinoma with nodal micrometastasis. Routine ultrasound screening of parents of children presenting with PTC and no family history do not demonstrate an increased incidence of FNMTC. Screening of affected families is likely to demonstrate the expected background incidence of nodular thyroid disease and incidental papillary microcarcinoma. As such, it is unlikely to be useful.

Identification of high-risk patients with incidental papillary microcarcinomas of thyroid helps in deciding appropriate management

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Serum Thyroglobulin Improves the Sensitivity of the McGill Thyroid Nodule Score for Well-Differentiated Thyroid Cancer

The McGill Thyroid Nodule Score (MTNS) is a scoring system devised to help physicians to assess the preoperative risk that a thyroid nodule is malignant. It uses 22 different known risk factors for thyroid cancer (radiation exposure, microcalcifications on ultrasound, positive HBME-1 stain on biopsy, etc.) and attributes a percentage risk that the nodule is malignant. Recently, preoperative thyroglobulin (Tg) levels have been shown to correlate with the risk of malignancy. The aim of this study was to incorporate Tg levels into the already established MTNS. This is a retrospective analysis of 184 thyroidectomy patients at the McGill University Thyroid Cancer Center. Patients with preoperative Tg levels were included in the study, and patients with incidental papillary microcarcinoma without extrathyroidal extent on final pathology were excluded. MTNS scores were calculated for all patients. Preoperative Tg levels of 75 ng/mL added one point to the MTNS, and levels of 187.5 ng/mL added two points. The new system is named MTNS+. Malignancy rates were calculated for each MTNS+ score. Patients with a score of 0-1 were <5% at risk of malignancy. The malignancy rate for scores of 2-3 was 14.29%, followed by 28.95% for scores of 4-6, 32.65% for scores of 7-8, 64.86% for scores of 9-11, 71.43% for scores of 12-14, 78.57% for scores of 15-18, and 92.31% for scores of 19-22. All patients (five of five) with an MTNS+ score of 23 or more had a malignant final pathology result. Patients with scores greater than eight had a relative risk of 2.5 [CI 1.79-3.49] of malignancy compared to patients with lower scores. MTNS+ showed good specificity at higher scores, with 89%, 96%, and 100% at scores above 11, 14, and 20 respectively. Compared to MTNS, adding Tg levels did not improve positive predictive values (PPV) or specificity, but improved sensitivity by 7.89% for scores greater than eight, and by up to 10.48% for scores greater than seven. This study shows that adding Tg to the MTNS increases the sensitivity of this scoring system. Moreover, it suggests that a combined scoring system such as the MTNS+ can accurately stratify the risk of well-differentiated malignancy in patients with thyroid nodules.

Risk Factors in Development of Incidental Papillary Thyroid Microcarcinoma: A Review of 2100 Patients

Objectives: Risk factor analysis of incidental papillary thyroid microcarcinoma in a cohort of 2100 patients undergoing thyroid surgery. Methods: Retrospective review of 2103 patients over a 10 year period (2000-2010) treated at Singapore General Hospital and Singapore National Cancer Centre. Outcome measurement Risk factors for developing incidental papillary thyroid microcarcinoma including sex (male vs female), age, size of thyroid nodule, fine needle aspiration cytology (FNAC) and ultrasound features at diagnosis. Results: Of the cohort of 2103 patients who underwent thyroid surgery for benign causes, 168 patients had incidental papillary microcarcinoma identified post-operatively. There was a preponderance of females (2:1), older age (&gt;45), larger nodule size (&gt;4cm). Ultrasound features that were commonly associated with this diagnosis included hypoechogenicity and increased vascularity of nodules, although these were noted to be benign on FNAC. Conclusions: Presence of the abovementioned risk factors in patients undergoing thyroid surgery for benign diseases may be included in the decision making process for advocating surgery in these patients.

The Clinical Implications of Non‐diagnostic Fine Needle Aspirates of the Thyroid Gland

Objective: Investigate the findings in repeat samples of patients with initial ultrasound-guided non-diagnostic fine needle aspirates (FNA) of thyroid tissue performed and interpreted over the most recent 10-year period at the University of Vermont. Method: Retrospective review of medical records for patients with nondiagnostic thyroid FNAs. Patients were identified using a pathology laboratory information system according to specific search parameters. Patients were excluded if ultrasound guidance was not used and if documentation in the medical records was limited. Results: A total of 239 patients met inclusion criteria. Of the 239, 145 have undergone follow-up FNA, surgical intervention, or both. There were 19 documented neoplasms after initial non-diagnostic FNA, including 2 incidental papillary microcarcinomas, 3 incidental follicular variant of papillary microcarcinomas, 1 follicular carcinoma, 7 papillary carcinomas, 2 follicular variant of papillary carcinomas, 1 non-Hodgkin DLBCL, 2 Hurthle cell neoplasms, and 1 follicular neoplasm. Excluding the 3 microcarcinomas, there were 13 significant neoplasms in the ipsilateral lobe (5%). For the 61 patients (25%) who were lost to follow-up before a definitive diagnosis was made, we cannot draw final conclusions regarding malignancy. Conclusion: Our study reveals significant potential for malignancy in patients with nondiagnostic FNAs. The IRB has granted permission to contact the 61 patients lost to follow-up before a definitive diagnosis was made. Delayed samples will be included as a separate analysis to profile this series of patients with nondiagnostic cytology.

Erratum to: Incidental Papillary Microcarcinoma of the Thyroid—Further Evidence of a Very Low Malignant Potential: A Retrospective Clinicopathological Study With Up to 30 Years of Follow-Up

Erratum to: Incidental Papillary Microcarcinoma of the Thyroid—Further Evidence of a Very Low Malignant Potential: A Retrospective Clinicopathological Study With Up to 30 Years of Follow-Up

Incidental Papillary Microcarcinoma of the Thyroid—Further Evidence of a Very Low Malignant Potential: A Retrospective Clinicopathologic Study with up to 30 Years of Follow-up

Incidental Papillary Microcarcinoma of the Thyroid—Further Evidence of a Very Low Malignant Potential: A Retrospective Clinicopathologic Study with up to 30 Years of Follow-up

Incidental Papillary Microcarcinoma of the Thyroid—Further Evidence of a Very Low Malignant Potential: A Retrospective Clinicopathological Study With Up to 30 Years of Follow-Up

Despite the frequent occurrence of papillary microcarcinoma (PMC) of the thyroid, no consensus on its malignant potential or its treatment exists. The objective of this study was to analyze the clinicopathological characteristics of a retrospective cohort of consecutive patients with PMC treated in a single institution during a 30-year period and to study the incidence rates of PMC in all patients operated on for thyroid diseases during this period. Demographic data, clinical characteristics, histological workup of the resected glands, histopathological features, treatment, and follow-up data were studied. Between 1975 and 2004, [corrected] 759 PMCs were detected in 28,197 patients who received thyroidal surgery. The detection rate of PMC was significantly determined by the accuracy of the histological examination. Only 5 patients with PMC presented with clinically apparent lymph node metastases and 754 were incidental PMCs. Mean follow-up was 88±2 (range, 11-639) months. Only three patients experienced recurrence in cervical lymph nodes, all of whom presented with clinically suspect cervical nodes. No patient died of disease. Clinically apparent lymph node metastases and stage pT3 were significantly associated with recurrence. Incidentally detected PMC, even when multifocal, is a biologically indolent tumor that seldom if ever progresses. In contrast, clinically occult PMC detected due to clinically suspected and histological confirmed lymph node metastases or extrathyroidal growth may show a more aggressive course with disease recurrence and an eventual poorer prognosis.

Approach to the Patient with Incidental Papillary Microcarcinoma

Approach to the Patient with Incidental Papillary Microcarcinoma

Follicular lesions of the thyroid: A retrospective study of 1,348 fine needle aspiration biopsies

Fine needle aspiration (FNA) has proven to be an effective tool in management of patients with thyroid nodules. However, the diagnosis of follicular patterned lesions can be challenging. The surgical and cytopathology computer database at a large referral medical center was searched for cases that had both cytologic and histologic thyroid accessions from January 2004 to November 2008. A total of 1,255 histologic thyroid specimens and 2,776 thyroid FNA biopsies were retrieved for review. Histologically, 272 overt malignancies were identified; 20 (7.4%) were follicular carcinomas. Cytologically, 1,348 cases were follicular-patterned lesions, comprising 1,044 cases of "benign follicular nodules" (BFN), 137 cases of "follicular lesions of undetermined significance" (FLUS), and 167 cases of "suspicious for follicular neoplasm" (SFN). Seventy-nine (7.5%) of BFN, 23 (16.8%) of FLUS, and 65 (38.9%) of SFN cases had histologic follow-up. Overt malignancy, a cystic papillary carcinoma, was identified histologically in only one case of BFN, for a negative predictive value of 98.7%. Overt malignancy was identified histologically in two cases of FLUS, both follicular variant of papillary carcinoma, for a positive predictive value of 8.7%. Overt malignancy was identified histologically in 14 cases of SFN, for a positive predictive value of 21.5%. Five follicular carcinomas were identified histologically in the SFN category, all minimally invasive. Incidental ("occult") papillary microcarcinoma were identified histologically in all three categories. In this study, the risk of overt malignancy increases from 1.3%, to 8.7%, to 21.5% for BFN, FLUS, and SFN, respectively. All follicular carcinomas identified histologically occurred in the SFN category and all were minimally invasive. Papillary microcarcinomas can occur in any of the three diagnostic categories.

Double thyroid ectopia (with incidental papillary thyroid microcarcinoma) (2010: 8b)

We present the case of a 45-year-old man with a long-standing history of a slow-growing left submandibular mass. Imaging was diagnostic as it disclosed an absent orthotopic thyroid gland and heterogeneous masses, with both solid and cystic components, as well as calcifications in the left sublingual/submandibular space and in the left paramedian aspect of the tongue base, consistent with double thyroid ectopia, originating from central and lateral thyroid anlages, respectively. Pathology confirmed an ectopic thyroid goiter in the left submandibular space with an incidental papillary microcarcinoma. Scintigraphy also demonstrated ectopic thyroid tissue in the left tongue base.