Preoperative Fine-needle Aspiration Research Articles

The Potential Utility of RAS Q61R Immunohistochemistry as a Screening Tool in Pre-operative Fine Needle Aspirates of Medullary Thyroid Carcinoma.

Medullary thyroid carcinoma (MTC) can either be sporadic, often via mutually exclusive RET or RAS alterations, or inherited via a RET germline alteration. Germline testing is recommended for all patients diagnosed with MTC. RAS p.Q61R immunohistochemistry (RASQ61R-IHC) can identify a subset of RAS-mutated MTCs on resections, but whether this could be applied pre-operatively to cytology specimens remains unclear. Herein, we assessed RASQ61R-IHC in a tri-institutional cohort of cytologic and histologic MTC specimens with available molecular and germline data. Thirty-four fine needle aspirates with cell blocks were identified between three institutions from 2009 to 2024 with corresponding histology. Tumor sequencing and germline data were recorded, if available. RASQ61R-IHC was scored on staining intensity with documentation of membranous accentuation. Sensitivity, specificity, positive predictive (PPV), and negative predictive values (NPV) were calculated. Of the MTCs, 29% were germline-mutated, and 71% were sporadic. Among all sporadic MTCs (n = 22), 41% were RET-altered, 27% were RAS-altered, and 31.8% did not have available data. With any RASQ61R-IHC staining considered positive, sensitivity, specificity, PPV, and NPV for detecting RAS p.Q61R-mutated MTCs were 100%, 72.7%, 45.4%, and 100%, respectively. Requiring a stain score of > 1 and/or membranous accentuation for a true positive changed sensitivity, specificity, PPV, and NPV to 100%, 100%, 100%, and 100%, respectively. RASQ61R-IHC membranous staining was 100% predictive of RET-negative germline testing. RASQ61R-IHC, when requiring a score > 1 and/or membranous stain accentuation for true positive, had high sensitivity and specificity for RAS p.Q61R mutation in cytologic and surgical MTC specimens. Moreover, RASQ61R-IHC is a rapid and inexpensive modality that could potentially tailor which MTC patients undergo germline testing.

Correlation of Salivary Gland FNA Reporting Using the Modified Milan System for Reporting Salivary Gland Cytopathology (MSRSGC) and Intraoperative Frozen Section Evaluation with Final Histopathology Report for Major Salivary Gland Neoplasms.

Fine needle aspiration (FNA) is a commonly used investigation for salivary gland lesions. The modified MSRSGC was introduced to standardise the FNA reporting of major salivary gland lesions. A frozen section is also used intraoperatively for these lesions. In this retrospective study, we included all patients who were treated at our institute between January 2012 to December 2019. The FNA reports of all the patients were reclassified based on the modified MSRSGC, and the sensitivity, specificity, and positive and negative predictive values were calculated. We also assessed the indication for utilising the frozen section and correlated it with the preoperative FNA and the final histopathology report. A total of 325 patients satisfied the eligibility criteria and were included in this study. The sensitivity and specificity, positive predictive value, and negative predictive value of the modified MSRSGC were 64.18% and 91.94% and 92.27% and 63.11%, respectively. The frozen section (FS) was done in 131 patients, the commonest reason was for obtaining a primary diagnosis (n = 104,79.3%). When the FNA was type V and above the primary diagnosis was that of malignancy in the vast majority (p < 0.001, kappa 0.563). The values of the modified MSRSGC were comparable with available literature in all categories except categories I and II which were higher than what is reported in the literature. When the preoperative FNA was modified to MSRSGC V and above, the possibility of malignancy was high, and the use of FS for primary diagnosis may not add much value intraoperatively.

8760 Does an Increased Size of Thyroid Nodules Correlate with a Higher Probability of Intermediate or High-Risk Histopathological Features for Recurrence?

Abstract Disclosure: R. Pishdad: None. N. Yousefzadeh: None. E. Gough: None. L. Rooper: None. J.S. Mammen: None. Does an increased size of thyroid nodules correlate with a higher probability of intermediate or high-risk histopathological features for recurrence? Background: The existing practice guidelines recommend total thyroidectomy for solitary nodules exceeding 4 cm regardless of other pre-operative findings. We hypothesize that through comprehensive pre-operative assessments, particularly including a thorough neck ultrasound, even nodules exceeding 4 cm that would otherwise meet ATA criteria for lobectomy (i.e., lacking extrathyroidal extension and suspicious lymphadenopathy) will not exhibit occult high-risk features at a higher rate compared to nodules measuring 1-4 cm. Consequently, these larger nodules would not necessitate a higher rate of completion thyroidectomy. Methods: Solitary thyroid nodules with a largest dimension ≥ 1 cm and operated on at a single institution between 2005 to 2023 were assessed to identify those that would have met ATA criteria for lobectomy. Surgical pathology reports were reviewed to perform risk stratification following ATA guidelines. Preoperative cytopathology, ultrasound characteristics, and patient demographics were considered as covariables. Statistical analyses were performed with R programming language. Simple logistic regression and multivariable logistic regression were performed to analyze the finding of occult intermediate or high-risk features based on size. Results: We identified 461 cases of solitary nodules without extrathyroidal extension or lymph node involvement (406 nodules 1-4 cm; 60 nodules ≥ 4 cm). Patients with larger nodules were more likely to be male than those with smaller nodules (52% versus 26%; P value &amp;lt;0.001). Interestingly, while the majority of smaller nodules meeting criteria for lobectomy were suspicious or malignant by cytopathology (Bethesda 5 and 6), only 20% of larger nodules that met criteria were malignant, with 68% either Bethesda 3 or 4 (p&amp;lt;0.001). There were no statistically significant associations between size or other variables such as age, race, sex, or positive family history and post-operatively assessed high/intermediate risk for recurrence. Conclusion: In this analysis of solitary nodules with larger sizes, the dimension itself did not emerge as a risk factor for occult intermediate or high-risk surgical pathology. Thus, the rates of completion thyroidectomy in appropriately screened patients would be acceptable even in patients with nodules greater than 4 cm. The majority of larger nodules that fulfill preoperative ATA criteria for lobectomy were assessed to be ACUS or a follicular neoplasm on pre-operative fine-needle aspiration. This suggests that the higher risk of more aggressive disease previously reported with larger nodules can be detected during preoperative assessment, emphasizing the essential role of neck US in the comprehensive evaluation of larger nodules. Presentation: 6/2/2024

6641 Observation in Lieu of Surgical Management in Hurthle Cell Neoplasm: Role of Thyroseq V3 Molecular Testing

Abstract Disclosure: R. Kaur: None. L. Kaur: None. T. Chaudhary: None. M. Shrivastava: None. N. Patel: None. The diagnostic utility of fine needle aspiration biopsy with cytology is often confounded in thyroid nodules with predominance of hurthle cells, often interpreted as an oncocytic/hurthle cell lesion with intermediate risk of malignancy, bethesda category (BC) III or IV. With the advent of molecular testing like thyroseq V3, it is helpful in ruling out substantial risk of cancer and considering observation in lieu of surgical management in such difficult cases. We present a case of a 75 year old woman with past medical history significant for type 2 diabetes mellitus and hypothyroidism who was found to have a left lobe complex nodule within a non-toxic multinodular goiter In 2022. Ultrasound of the neck showed a 1.6 x 1.8 x 2 cm intermediate nodule, followed by a fine needle aspiration biopsy which was non-diagnostic and reported as benign, showing only cystic contents and insignificant follicular cells, Bethesda class II. Follow up for the nodule was recommended in one year. Repeat Imaging one year later revealed left nodule without significant changes and repeat fine needle aspiration cytology was advised. The biopsy result was reported as an oncocytic/ Hurthle cell neoplasm, Bethesda class IV. The specimen was also submitted for thyroseq molecular testing and results were awaited. The patient was euthyroid with negative anti thyroid antibodies. There was no family history of thyroid cancer or radiation exposure. The patient denied any active symptoms like shortness of breath, neck pain or pressure, recent voice changes, dysphasia, loss of appetite or weight .On examination the patient was found to have a left thyroid nodule with no signs of tracheal deviation. CT scan of the neck demonstrated a left thyroid nodule with no compression. The patient was followed by both endocrinology and oncology and surgical options were discussed depending upon the biopsy results while awaiting molecular testing report. Molecular testing with thyrosec V3 revealed an absence of gene mutations and reported a low probability of cancer. Depending upon the results observation was considered in lieu of surgical management. Hence It was decided to keep the patient under observation considering the molecular test results in conjunction with all relevant imaging, clinical findings, symptoms, patients family history as well as patients preference. This case report demonstrates the crucial role of molecular Diagnostics specifically thyroseq V3 in the often difficult clinical management of hurthle cell thyroid nodules for ruling out surgical management. Thyroseq V3 shows reliable performance in Hurthle cell cancers with sensitivity of 93% and specificity of 69%. In times of patient guided decision making and ability to narrow down the need of surgery based on pre-operative fine needle aspiration cytology, molecular profiling of thyroid nodules has become increasingly utilized. Presentation: 6/1/2024

Kimura Disease of the Head and Neck Region.

Objective: We analyzed the clinical characteristics and treatment results in surgical patients with a final diagnosis of Kimura disease. Patients and Methods: A total of 8 patients with a final diagnosis of Kimura disease of the head and neck region after surgery from January 2007 to December 2022 were enrolled. Results: The most common symptom was a mass in the head and neck region (n = 7), followed by incidental detection (n = 1). Multiple head and neck lesions were observed except for 1 patient with Kimura disease in the buccal space. Kimura disease could not be diagnosed in 5 patients who underwent preoperative fine-needle aspiration cytology. All patients underwent surgical resection. No major complications after surgery occurred. Six patients received steroids after surgery, with 1 patient undergoing radiotherapy as a side effect of steroid treatment. During the follow-up period, 5 patients relapsed. Of the parameters assessed, only longer symptom duration was statistically significant with relapse of Kimura disease. Conclusion: Clinicians should suspect Kimura disease based on asymptomatic masses, peripheral blood eosinophilia, and imaging examinations and make a definitive diagnosis via surgery.

Utility of Intraoperative Frozen Section in Making the Decision of Lobectomy vs Total Thyroidectomy in Selected Cases of Solitary Thyroid Nodules

Abstract Background Intraoperative frozen section (IFS) had been, historically, the main tool to determine the initial histologic diagnosis of a thyroid nodule and therefore to guide the treatment strategy. Surgery could be limited to a hemi-thyroidectomy in case of a benign nodule, while a malignant IFS diagnosis indicates a total thyroidectomy. Since the advent of preoperative fine needle aspiration (FNA), and its establishment as a mainstay in the preoperative exploration of thyroid nodules, the role of IFS in this setting has been widely questioned. The introduction in 2007 of the Bethesda system for reporting thyroid cytopathology (BSRTC) has improved FNA reporting standards and became a standard of practice. Aim of the Work To determine accuracy and intertest agreement of preoperative fine-needle aspiration cytology (FNAC) and intraoperative frozen-section analysis (IFS) findings in thyroid surgery, and to assess the influence of intraoperative FS findings on decision making and the utility of IFS in solitary thyroid nodules. Patients and Methods This study is a retrospective and prospective cohort comparative clinical study. This study was conducted at (General surgery department), Ain Shams University Hospitals. Approval of the Ethical Committee and written informed consent from all participants was obtained. The period of the study between November 2020 and November 2023. Results The current study results Group A (n = 20) and Group B (n = 20) were assessed for demographic, baseline, hematological, biochemical, and preoperative characteristics to ensure equivalence prior to interventions. Results revealed no statistically significant differences in age distribution (p = 0.868) or gender composition (p = 0.327), indicating matched groups. Thyroid function tests (T3, T4, TSH) showed no significant variations (p = 0.820, p = 0.081, p = 0.567). Hematological and biochemical parameters (hemoglobin, creatinine, ALT, AST, INR) exhibited no significant disparities (p = 0.420, p = 0.811, p = 0.752, p = 0.571, p = 0.862). Preoperative characteristics (family history, TIRADS, nodule size, site) were well-balanced (p = 0.519, p = 0.752, p = 0.625, p = 0.321). Conclusion The comprehensive analysis of the clinical and pathological data comparing two groups reveals several key insights into the management and diagnostic evaluation of thyroid nodules. Firstly, there are no significant differences in baseline characteristics such as family history, TIRADS classification, nodule size, and site between the groups, ensuring a balanced comparison.

A Prospective Clinicopathological Study of Cervical Lymphadenopathy in a Head and Neck Unit of a Tertiary Referral Centre

Background and Aims: This study aims to investigate the clinicopathological profile of cervical lymphadenopathy in a tertiary referral centre. The findings will contribute to a deeper understanding of the disease spectrum, aid in accurate diagnosis, and help in improving patient treatment and outcomes. Methodology: This is a prospective study conducted in the Department of ENT, Head and Neck Surgery, Apollo Hospital, Chennai, between June 2022 and May 2023. The clinicopathological profile of all patients was analysed. The final histological diagnosis and the preoperative Fine Needle Aspiration Cytology (FNAC) were correlated. The primary tumour was identified in cases with metastatic secondary tumours in the neck. Results: Among the 80 patients in our study, 67% had a benign aetiology (most common was tuberculosis), and 33% had a malignant aetiology (most common was Hodgkin’s Lymphoma). Gender distribution was equal, with those between the ages of 35 and 60 more frequently affected. The nasopharynx (30%) was the most likely location of the occult primary, followed by the thyroid (20%) and larynx (20%). In detecting TB, FNAC had a sensitivity of 75.5% and a specificity of 98%; in detecting lymphomas, it was 64% and 100%; in detecting metastatic secondaries, it was 80% and 100%; and in detecting reactive lymphadenitis, it was 79% and 86%. Conclusion: Cervical lymphadenopathy is a common entity requiring careful evaluation and treatment. PET scans prove invaluable in detecting occult primary tumours. FNAC is an initial, cost-effective diagnostic tool. However, biopsy is indicated in specific conditions to obtain accurate diagnosis to enable prompt treatment.

Imaging findings of gastric glomus tumors.

Sparse literature describes the imaging findings of gastric glomus tumors (GGT), focusing on benign tumors. We are not aware of prior radiology reports on malignant GGT. The aim of the study was to determine whether it is possible to differentiate between benign and malignant GGT on CT or MR. Institutional radiology and pathology databases were queried for the diagnosis of GGT between January 2010 to December 2023. Of 22 identified subjects, five were excluded due to non-availability of preoperative CT or MR images and three due to lack of pathological confirmation in our institution. The study cohort comprised of 14 patients (males = 6) with median age of 65 years (range 31 to 79 years). Two abdominal radiologists in consensus reviewed all relevant CT and MR images. There were 10 benign and 4 malignant GGT. Benign tumors were smaller than malignant GGT (median size of 2.0cm vs. 5.3cm, p = 0.03), more likely to exhibit homogeneous hyperenhancement (9/10 vs. 0/4, p < 0.01), and demonstrated intramural rather than exophytic growth. There was no substantial difference in T2 signal or diffusion restriction between benign and malignant GGT. On follow up, benign GGT were essentially stable in size, while malignant GGT grew. A biopsy proven GGT larger than 5cm or showing necrosis is likely to be malignant. This is important since preoperative endoscopic ultrasound-guided fine needle aspiration may be indeterminate for malignancy.

Predictive value of the single most suspicious ultrasound feature in subcentimeter thyroid nodules: a retrospective observational cohort study

PurposeProper management of subcentimeter thyroid nodules remains challenging for both clinicians and patients. Conducting extensive sonographic research using a safe and inexpensive tool for identifying thyroid nodules is necessary. The aim of this study was to identify whether having the highest-risk ultrasound (US) characteristic suggests that US-guided fine-needle aspiration (FNA) biopsy of subcentimeter nodules is more appropriate for the identification of malignancy than active surveillance (AS) or surgery.MethodsThe data of patients with highly suspicious subcentimeter thyroid nodules and US characteristic data who underwent surgery were retrospectively examined.ResultsAmong a total of 556 subcentimeter nodules, 223 (40.1%) were benign, and 333 (59.9%) were malignant, with a mean maximal nodule size of 8.1 mm. In addition to age younger than 45 years, several US features were significantly associated with malignancy: irregular margins, the presence of microcalcifications, and taller-than-wide shapes (P < 0.001). Multivariate analysis also revealed that a taller-than-wide shape (OR = 8.988, P = 0.0015) was an independent factor associated with malignancy in subcentimeter thyroid nodules. The diagnostic performance of preoperative FNA was classified as a malignancy, with a sensitivity of 98.4%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 76.9%.ConclusionsThis is one of the few reports based on actual data of the most suspicious US features in subcentimeter thyroid nodules. A taller-than-wide shape US feature is most significantly associated with malignancy. FNA is a simple, accurate, and reliable preoperative method for diagnosing malignant subcentimeter thyroid nodules with highly suspicious US characteristics. AS was less appropriate than FNA for subcentimeter nodules with a taller-than-wide shape, especially in patients ≤ 45 years of age.

The Combined Use of Fine-Needle Aspiration (FNA) and BRAF V600E Gene Testing: Can it Increase the Definitive Diagnosis Rate of Nodules Categorized as Bethesda III for Papillary Thyroid Carcinoma?

This study aimed to analyze the malignant probability of thyroid nodules diagnosed as indeterminate cytology, including atypia of undetermined significance or follicular lesion of undetermined significance (AUS/FLUS), and investigate the diagnostic value of combining BRAF V600E gene testing within this classification. We conducted a retrospective analysis of 126 patients who underwent fine-needle aspiration (FNA) examination of thyroid nodules and subsequent surgical treatment at Beijing Haidian Hospital between October 2021 and November 2022. Among them, there were 22 male and 104 female patients, aged between 18 and 75years old. Surgical pathology results were considered the gold standard for diagnosing the nature of thyroid nodules, evaluating the malignant incidence of cytological results categorized as AUS/FLUS. Fisher's exact test and diagnostic test evaluation methods were used to analyze the discriminatory diagnostic efficacy of preoperative FNA combined with BRAF V600E gene testing for papillary thyroid carcinoma (PTC). Statistical analysis was performed using SPSS 22.0 software. In PTC patients, the BRAF V600E gene mutation rate was 87.93% (102/116). Within the category of FNA results as AUS/FLUS, the proportion of PTC was 60.00% (15/25). The specificity, sensitivity, positive predictive value, and negative predictive value of the BRAF V600E gene mutation in diagnosing PTC within the AUS/FLUS category were 10/10, 6/15, 6/6, and 10/19, respectively. The BRAF V600E gene mutation significantly increased the detection rate of PTC in patients classified under this cytology (P = 0.028, <0.05). Preoperative FNA combined with BRAF V600E gene mutation testing significantly enhances the malignant detection rate of thyroid nodules diagnosed cytologically as AUS/FLUS. This combined approach provides a potent tool to improve diagnostic accuracy in this indeterminate classification.

Correlation Between BRAFV600E Positivity and Recurrence and Poor Prognosis in Preoperative Fine Needle Aspiration Biopsy of Papillary Thyroid Carcinoma

ÖZET Amaç: Tiroid maligniteleri epitelyal ve non-epitelyal olmak üzere iki ana gruptan oluşmaktadır. Epitelyal olanlar; papiller, folliküler ve anaplastik karsinomlardır. Non-epitelyal olan ise medüller karsinomlardır. Papiller tiroid kanseri (PTK) tüm tiroid maligniteleri içerisinde %80'lik bir kısmı oluşturmaktadır ve bu maligniteler içerisinde tedaviye en iyi yanıt alınanlardan birisidir. Papiller tiroid kanseri gelişiminde tümörogenezisin moleküler genetiğinde A-Raf, B-Raf (BRAFV600E) ve C-Raf olmak üzere 3 farklı Raf kinaz mevcuttur. Çalışmamızda papiller tiroid kanserlerinde cerrahi sonrası oluşan nükslerde BRAFV600E pozitifliğinin nüks açısından prognostik faktörlerle ilişkisini ortaya koymayı amaçladık. Gereç ve Yöntem: Papiller tiroid kanseri nedeni ile daha önce ameliyat edilmiş ve nüks gelişmiş olan hastaların ameliyat öncesi yapılan ince iğne aspirasyon biyopsi preparatları temin edildi. Bu preparatlar üzerinden kanserli bölge işaretlendi ve işaretli alanlardaki hücrelerden DNA izole edildi. İzole edilen DNA üzerinde pyrosequence dizi analizi yöntemi ile BRAFV600E mutasyonu varlığı araştırıldı. Hastaların papiller tiroid kanserinde nüks açısından diğer prognostik kriterleri de kayıt altına alınarak BRAFV600E mutasyonu ile ilişkileri istatistiksel olarak analiz edildi. Bulgular: Papiller tiroid kanserlerinde nüks nedeni ile ameliyat edilen hastalarda tüm çalışma grubunda BRAFV600E pozitifliği oranı %70,8 olarak bulunmuştur. Ayrıca kapsül invazyonu, yumuşak doku invazyonu, evresi, nüks zamanı ve lenf nodu metastazı ile BRAFV600E mutasyonu arasında pozitif korelasyon gösterilmiştir. Sonuç: BRAFV600E mutasyonu ile papiller tiroid kanserlerindeki bazı kötü prognostik kriterler arasında pozitif ilişki gösterilmiştir. Anahtar Kelimeler: Tiroid, İnce iğne biyopsi, Papiller, Kötü Prognoz, BRAFV600E, Sitoloji

Research progress of ectopic thyroid cancer in thyroglossal duct cyst: A case report and literature review.

Thyroglossal duct carcinoma, a rare clinical condition characterized by ectopic thyroid adenocarcinoma within thyroglossal duct cysts (TGDCs), typically confirmed through intraoperative rapid pathology, this condition generally has a favorable prognosis. Nevertheless, comprehensive treatment guidelines across all disease stages are lacking, the purpose of this study is to report 1 case of the disease and propose the treatment plan for each stage of the disease. A patient presented with thyroid swelling, classified as C-TIRADS 4A following a physical examination. Preoperative thyroid puncture identified papillary thyroid carcinoma, and genetic testing revealed a BRAF gene exon 15-point mutation. Ancillary tests showed a slightly decreased thyroid stimulating hormone (TSH) level (0.172) with no other significant abnormalities. Preoperative fine-needle aspiration cytology (FNAC) confirmed right-side thyroid cancer. Intraoperative exploration uncovered a TGDC and intraoperative rapid pathology confirmed thyroglossal duct carcinoma. A Sistrunk operation and ipsilateral thyroidectomy were performed. Postoperative recovery was satisfactory. Thyroglossal duct carcinoma is a rare disease affecting the neck. Due to limited clinical cases and the favorable prognosis associated with this condition, there is currently no established set of diagnostic and treatment guidelines. According to tumor size, lymph node metastasis, thyroid status and other factors, the corresponding treatment methods were established for each stage of thyroglossal duct cancer, which laid the foundation for the subsequent treatment development of this disease.

Evolution in the management of thyroid surgery over a period of 15 years in a Belgian center

BackgroundGuidelines for thyroid surgery have evolved to reflect advances in medical knowledge and decrease the overdiagnosis of low-risk thyroid cancer. Our goal was to analyze the change made in operative thyroid management and the impact on thyroid cancer diagnosis.BackgroundGuidelines for thyroid surgery have evolved to reflect advances in medical knowledge and decrease overdiagnosis of low risk thyroid cancer. Our goal was to study the evolution, over a long period, of pre- and postoperative management and the influence on histological cancer diagnosis and, more particularly, microcancer.MethodsIn this retrospective cohort study, we included 891 consecutive patients who underwent thyroid surgery between 2007 and 2020.ResultsRespectively 305, 290 and 266 patients underwent surgery over the 3 periods of 2007–2010, 2011–2015 and 2016–2020. In all three periods, women represented approximately 70% of the population, and the mean age was 54 years old (range: 67). Most surgeries (90%) involved total thyroidectomies. Over the study period, the proportion of preoperative fine needle aspiration (FNA) increased from 13 to 55%, p < 0,01. Cancer was found in a total of 116 patients: 35 (11%) patients between 2007 and 2010, 50 (17%) between 2011 and 2015 and 32 (12%) between 2016 and 2020 (p = 0.08). For all 3 periods, papillary thyroid cancer (PTC) was the most prevalent, at approximately 80%. The proportion of thyroid cancer > T1a increased significantly from 37% (2011–2015 period) to 81% (2016–2020 period), p = 0.001. Patients treated with radioiodine remained relatively stable (approximately 60%) but were more frequently treated with a low dose of radioiodine (p < 0.01) and recombinant human TSH (p < 0.01). Operative thyroid weight decreased over time in all but the low-risk T1a PTC cases.ConclusionsOver a period of 15 years and according to the evolution of recommendations, the care of patients who underwent thyroid surgery changed with the increased use of preoperative FNA. This change came with a decrease in low-risk T1a PTC.

Intraoperative ultrasound guided wire (IOUS-wire) localization biopsy with frozen section versus preoperative fine needle aspiration cytology (FNAC) for the evaluation of clinically positive nodes in patients with early breast cancer in China real-world clinical practice.

e12600 Background: Appropriate biopsy procedure for clinically positive (suspicious) lymph nodes (LN) plays a key role in accurate axillary staging of early breast cancer. Fine needle aspiration (FNA) is a recommended method for clinically suspicious nodes in the National Comprehensive Cancer Network (NCCN) guidelines. However, the false negative rate (FNR) of FNA remains too high. Therefore, it is valuable to explore an alternative and appropriate procedure in clinical practice. We conducted a retrospective review to compare the feasibility and diagnostic efficiency of using a novel procedure, the intraoperative ultrasound guided wire (IOUS-wire) localization biopsy with frozen section, to FNA for assessment of clinically positive nodes in patients with early breast cancer. Methods: Data on consecutive primary breast cancer patients with documented axillary ultrasound results who had clinically positive lymph nodes (cN1) between January 2015 and September 2023 either utilization of IOUS-wire localization or ultrasonography-guided fine-needle aspiration cytology (US-FNAC) for clinically positive lymph nodes were retrospectively analyzed. Sentinel lymph node biopsy (SLNB) was performed in patients with negative histopathological or cytological results. The false negative rate (FNR) of histopathology between two groups was calculated. Results: Eligible patients (n=198) referred to axillary biopsy by IOUS-wire localization biopsy(n=100) and US-FNAC(n=98) in this study. The FNR of clinically positive lymph nodes biopsy was 12.8 percent in the IOUS-wire localization group and 87.5 percent in the US-FNAC group.IOUS-wire failed in 5 patients. Among the remaining 32 successful identifications, 26 were IOUS-wire-node positive by intraoperative frozen section. 42 patients with additional lymph node metastases were found in FNAC-LN-negative patients by SLNB. The accuracy rate was respectively 95% and 57.1%. No significant difference was observed in complications and median number of SLNs harvested (5.3 versus 5.5; P=0.631) between the groups. Sufficient tissue samples can be obtained for intraoperative frozen pathology so the FNR is potentially reduced. In addition, the interval of waiting time for pathological results is reduced. Conclusions: Intraoperative US-guided wire localization biopsy is a feasible and alternative procedure compared to preoperative FNA for clinically node-positive patients with early breast cancer. This novel method is suitable for China's national conditions and should be further pursued as a potential biopsy method for evaluation of axillary node status in clinical practice.

Diagnostic value of FNAC combined with BRAFV600E mutation detection in Hashimoto's thyroiditis complicated with papillary thyroid carcinoma.

This study aimed to analyze the effect of preoperative fine needle aspiration cytology (FNAC) combined with BRAFV600E mutation detection as compared to that of fine needle aspiration cytology alone on the diagnostic performance of papillary thyroid carcinoma (PTC) combined with Hashimoto's thyroiditis (HT). Patients with thyroid nodules in Hashimoto's thyroiditis, who underwent fine-needle aspiration cytology examination and BRAFV600E mutation detection in the puncture eluate at the outpatient clinic, were selected. Finally, 122 patients received surgical treatment and were included in the study. We used postoperative pathological results as the gold standard. Accordingly, we compared the sensitivity, specificity and accuracy of preoperative FNAC alone and FNAC combined with BRAFV600E mutation detection in for the diagnosis of PTC combined with HT. For PTC patients with HT, the sensitivity of FNAC diagnosis was 93.69%, the specificity was 90.90% and the accuracy was 93.44%. However, the sensitivity, specificity and accuracy of FNAC combined with BRAFV600E mutation detection were 97.30%, 90.90% and 96.72%, respectively. Therefore, combined detection can improve the sensitivity and accuracy of diagnosis (p<0.05). FNAC combined with eluent BRAFV600E mutation detection can improve the sensitivity and accuracy of diagnosis of PTC in the background of HT.

Clinicopathologic Features and Cytologic Correlation of ALK-Rearranged Papillary Thyroid Carcinoma: A Series of Eight Cases

Anaplastic lymphoma kinase (ALK) gene fusions are rare in papillary thyroid carcinoma (PTC) but may serve as a therapeutic target. This study aims to evaluate the preoperative cytologic findings and clinicopathologic features of a series of eight ALK-rearranged PTCs from our pathology archives and consultations. All cases were confirmed by ALK D5F3 immunohistochemistry and six with additional targeted RNA-based next-generation sequencing (NGS). The original fine-needle aspiration (FNA) cytology diagnosis included the Bethesda System (TBS) category II in three (37.5%), TBS III in two (25%), TBS V in two (25%), and TBS VI in one (12.5%). Six cases had available FNA cytology and were reviewed. The cytologic features showed microfollicular architecture as well as limited or reduced nuclear elongation and chromatin alterations in all six. Nuclear grooves and pseudoinclusions were absent in two cases, rarely or focally noted in three, and frequently found in one. Two cases initially diagnosed as TBS II, showing microfollicular architecture without well-developed nuclear features, were revised to TBS III (with architectural atypia only). For histologic correlations, four were infiltrative follicular variant PTCs, three as classic subtype PTC with predominant follicular growth, and one as solid/trabecular subtype PTC. All eight cases demonstrated reduced PTC nuclear features with respect to nuclear elongation and chromatin alterations compared to those typically identified in “BRAF-like” PTCs. The NGS testing revealed EML4::ALK fusion in three, STRN::ALK fusion in two, and ITSN2::ALK fusion in one. In conclusion, although ALK-rearranged PTCs have been associated with neutral gene expression profile from a BRAF-RAS scoring perspective, the “RAS-like” nuclear features were more commonly identified in this series, resulting in frequent indeterminate diagnosis of preoperative FNA.

A RARE CASE OF TENOSYNOVIAL GIANT CELL TUMOR IN PALMAR ASPECT OF RING FINGER OF LEFT HAND

Introduction: Giant cell tumor of the tendon sheath (GCTTS) is an uncommon benign soft tissue tumor of unknown etiology. It is seen more commonly in hand than ankle and foot. It presents as a painless and palpable swelling. Its diagnosis is mostly established by histopathology after surgical resection, although pre-operative imaging and fine-needle aspiration cytology (FNAC) support its suspicion. Herein, a case of GCT of flexor tendon sheath of the right ring finger is reported due to its rarity. Case Report: A 30-year-old female presented with complaints of swelling over the front of the right ring finger for 6months.. The swelling was spontaneous, painless, and very slowly progressive. Examination revealed a 2 cm * 1.5 cm firm swelling situated on the palmar aspect of the right ring finger over proximal inter phalangeal joint. Swelling was well defined, having smooth surface, uniformly firm consistency and could be moved sideways easily. X-ray of the hand showed localized soft tissue shadow in the involved area without any bony involvement. Ultrasonography of the finger showed soft tissue mass.MRI revealed Moderate to intense heterogeneous enhancement suggesting giant cell tumor.. Excisional biopsy was done. Histopathology showed typical features of GCTTS. Conclusion: GCTTS should be kept as a differential diagnosis in soft tissue tumors of hand in adults. FNAC followed by excisional biopsy is diagnostic and curative, but the patient should be followed up for detecting and managing recurrences.

Incidental but Not Insignificant: Thyroid Cancer in Patients with Graves Disease.

Graves disease is the most common cause of hyperthyroidism in the US. Treatment with antithyroid drugs and radioactive iodine is more commonly used than surgical management with total thyroidectomy (TTx). However, incidentally discovered thyroid cancer (TC) has been described on surgical pathology from patients who underwent surgical treatment of Graves disease, which would be missed with these other treatment strategies. We sought to determine the incidence rate of TC among patients with surgically treated Graves disease. We retrospectively reviewed patients with Graves disease who underwent TTx at a single institution from 2011 to 2023. Pathology reports were reviewed for TC. Patient demographics, preoperative laboratory and radiological evaluations, preoperative medical management, and surgical outcomes were compared between patients with and without incidental TC. There were 934 patients, of whom 60 (6.4%) patients had incidentally discovered TC on pathology. The majority (58.3%) of patients had papillary thyroid carcinoma, followed by 33.3% with papillary microcarcinoma. Preoperative ultrasound (US) was obtained in 564 (60.4%) of patients, with 44.3% with nodules, but only 34 (13.7%) of those with nodules had TC on final pathology. Preoperative fine needle aspiration was obtained in 15 patients with TC, and 8 patients (53.3%) were reported as benign lesions, which ultimately had TC on final pathology. There was no difference in sex, race or ethnicity, preoperative medical management, and postoperative outcomes between the 2 groups. Incidental TC was found on surgical pathology in 6.4% of patients undergoing TTx for Graves disease. Preoperative imaging with US and fine needle aspiration were often unreliable at predicting TC. The incidence of TC should not be underestimated when counseling patients on definitive management for Graves disease.

Diagnostic Difficulties of Plunging Ranula: A Review of 18 Cases.

Despite advancements in imaging techniques and cytological analysis, plunging ranula remains a challenging surgical, radiologic, and pathologic phenomenon. Of the 18 patients we evaluated at our institution, we highlight three cases that illustrate the high rate of misleading imaging and cytological results when assessing plunging ranula. Imaging results, biopsy findings, operative techniques, and pathological reports were reviewed from patients who had either a preoperative or postoperative diagnosis of ranula and underwent surgery by a single head and neck surgeon at a tertiary care center. Of the 18 identified patients, computed tomography was correct on preoperative imaging 73% of the time and magnetic resonance imaging was correct on preoperative imaging 71% of the time. Two patients underwent preoperative ultrasound and their ultrasound reports did not accurately diagnose the presence of a ranula. Two patients underwent preoperative fine needle aspiration biopsy due to inconclusive preoperative imaging, in which results suggested either a ranula or epidermal cyst. Both ultimately did not match the final pathology. Three of eighteen patients (17%) underwent an inappropriate initial surgery due to incorrect imaging diagnoses and/or biopsy findings. Despite use of preoperative modalities to distinguish plunging ranula from other cystic floor of mouth lesions, surgeons must be aware that no workup modality is fully precise. The potential for revision surgery must be included in all preoperative discussions for presumed plunging ranula. 4 Laryngoscope, 134:2689-2696, 2024.

Histologic Alterations in Salivary Glands Post Fine Needle Aspiration Cytology – A Diagnostic Challenge

Fine-needle aspiration (FNA) is used widely in the initial workup and diagnosis of both palpable and deep-seated masses. Salivary glands are among the most commonly aspirated locations in the head and neck area. Fine-needle aspiration cytology (FNAC) is a simple, safe and non-invasive ancillary diagnostic method that is relatively atraumatic. However, it can lead to histologic changes that may obscure the underlying pathology or mislead the unwary to render an erroneous diagnosis of malignancy. The tissue changes after FNAC include haemorrhage, squamous cell metaplasia, infarction and necrosis and needle track tumour seeding. Although tissue changes induced by FNAC are rare and account for only 7% and 10 % cases, awareness of these alterations will prevent the pathologist from overestimating the diagnosis. The aim of this review is to emphasize the importance of recognizing the histologic changes induced by FNAC and of obtaining the clinical history of a preoperative FNA procedure to avoid potential misdiagnosis.