text stringlengths 6 1.29k |
|---|
SPECIAL ARTICLE 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer Bryan R. Haugen,1,*Erik K. Alexander,2Keith C. Bible,3Gerard M. Do... |
guidelines, stakeholder input, and input of task force members. Task force panel members were educated onknowledge synthesis methods, including electronic database searching, review and selection of relevant cita- tions, and critical appraisal of selected studies. Published English language articles on adults were elig... |
regarding the initial management of thyroid cancer include those relating to screening forthyroid cancer, staging and risk assessment, surgical management, radioiodine remnant ablation and therapy,and thyrotropin suppression therapy using levothyroxine. Recommendations related to long-term management 1University of Col... |
Center, New York, New York. 16MedStar Washington Hospital Center, Washington, DC. *Chair.Authors are listed in alphabetical order and were appointed by ATA to independently formulate the content of this manuscript. None of the scientific or medical content of the manuscript was dictated by the ATA.THYROID Volume 26, Num... |
of differentiated thyroid cancer include those related to surveillance for recurrent disease using imaging and serum thyroglobulin, thyroid hormone therapy, management of recurrent and metastatic disease, considerationfor clinical trials and targeted therapy, as well as directions for future research.Conclusions: We ha... |
on age, sex, radiation exposure history, family history, and other factors (5,6). Differentiated thyroid cancer(DTC), which includes papillary and follicular cancer, com- prises the vast majority ( >90%) of all thyroid cancers (7). In the United States, approximately 63,000 new cases of thyroidcancer were predicted to ... |
the initial treatment and follow-up for many patients with thyroid cancer. A recent population-based study from Olmsted County re-ported the doubling of thyroid cancer incidence from 2000 to2012 compared to the prior decade as entirely attributable to clinically occult cancers detected incidentally on imaging or pathol... |
of thyroid neoplasia may be an important contributing factor to existing clinical uncertainties (12). Methodologic limitations or con-flicting findings of older studies present a significant chal- lenge to modern-day medical decision-making in many aspects of thyroid neoplasia. Although they are not a specificfocus of thes... |
potential harm from overtreatment in a majority of patients at low risk for disease-specific mortality and morbidity, while appropriatelytreating and monitoring those patients at higher risk. Theseguidelines should not be interpreted as a replacement for clinical judgement and should be used to complement in- formed, sh... |
our primary focus was review-ing the quality of evidence related to health outcomes and diagnostic testing, we decided a priori not to focus on eco- nomic resource implications in these guidelines. As part ofour review, we identified some knowledge gaps in the field, with associated future research priorities. Other grou... |
have recently revised guidelines on treatment of patients with thyroid tumors (23). Given the existing controversies in thefield, differences in critical appraisal approaches for existing evidence, and differences in clinical practice patterns across geographic regions and physician specialties, it should not besurprisi... |
was appointed. In order to have broad specialty and geographic representation, as wellas fresh perspectives, one-third of the task force is replaced for each iteration of the guidelines, per ATA policy. Upon discussion among the panel members and the Chair with otherChairs of other ATA guideline committees, the America... |
Different choices will be appropriate for different patients; the management decision should be consistent with patients’ preferences and circumstances. Policymakers: Policymaking will require careful consideration and stakeholder input. No recommendation Balance of benefits and risks cannot be determined.Decisions base... |
studiesBest action may differ based on circumstances or patients’ values Low-quality evidence Observational studies/case studies Other alternatives may be equally reasonable Insufficient Evidence is conflicting, of poor quality, or lackingInsufficient evidence to recommend for or against aThis description of supporting ev... |
for use in these guidelines, relating to critical appraisal and recommendations on therapeutic interventions (26) (Tables 1 and 2). An important component of these guidelines wasjudged to be critical appraisal of studies of diagnostic tests;however, the ACP Guideline Grading System is not designed for this purpose. We ... |
which benefits outweigh risks/burden, most would want the diagnostic to be offered (with appropriate counseling). A patient shouldrequest discussion of the test if it is not offered. In contrast,for a test in which risks and burden outweigh the benefits, most patients should not expe ct the test to be offered. Clinicians... |
test should, for the particular clinical situation, be explained. Policymakers: In the case of an accurate test for which benefits outweigh risks/burden, availability of thediagnostic test should be adopted in health policy. In contrast, for a test in which risks and burden outweigh the perceived benefits, some restricti... |
applicable), as well as the implications of the test result. The decision to perform the test should includeconsideration of the patients’ values, preferences, feasibility, and the specific circumstances. Counseling the patient on why the test may be helpful or not, inher/his specific circumstance, may be very valuable i... |
clinician, in reporting resultsin the medical record and communicating them to the patient (at the applicable time point in disease or follow-up trajectory), as opposed tooffering a specific choice of staging/risk stratification system to the patient.4 HAUGEN ET AL. |
methodologic elements: consecutive recruitment of patients representative of clinical practice, use of an appropriate ref- erence gold standard, directness of evidence (e.g., target population of interest, testing procedures representative ofclinical practice, and relevant outcomes), precision of diag- nostic accuracy ... |
(unless otherwise specified). Diagnostic tests or risk stratifi- cation systems used for estimation of prognosis were alsoappraised using the diagnostic test grading system. An im- portant limitation of our diagnostic test appraisal system is that it does not specifically examine the clinical utility of atest in improving... |
well-designed nonrandomized diagnostic accuracy studies (i.e., observational—cross-sectional or cohort) or systematic reviews/meta-analyses of suchobservational studies (with no concern aboutinternal validity or external generalizability of the results)Implies the test can be offered to most patients in most applicable... |
systematic reviews/meta-analyses of such ob-servational studies (with no concern about internal validity or external generalizability of the results)The degree to which the di- agnostic test is seriously considered may differ de-pending on circumstancesor patients’ or societal values. Moderate-quality evidence Evidence... |
uncertain and does not permit a reasonableconclusion to be made.Insufficient evidence exists to recommend for or againstroutinely offering the diag- nostic test.ATA THYROID NODULE/DTC GUIDELINES 5 |
studies could be considered high-quality evidence; yet, a therapeutic strategy incorporating the use of the diagnostic test would require one or more well-executed randomizedcontrolled trials (RCTs) to be considered high-quality evi-dence. In developing and applying our diagnostic test critical appraisal system, we con... |
another system, if it is superior andfeasible to execute by contributing physicians. Prior to initiating the reviews, all task force members were provided written and verbal group advice on conductingelectronic literature searches, critical appraisal of articles, and rationale for formulating strength of recommendation... |
draft manuscript and teleconfer- ences. The draft document continued to be revised until nofurther suggestions for further revisions were requested byany panel members. Thus, general consensus on acceptability of recommendations and manuscript text was achieved, with the fundamental understanding that not all recommend... |
2014. The guideline man-uscript was reviewed and approved by the ATA Board of Directors, then made available to the ATA membership for review and comments in September 2014. Substantivecomments were received from 33 members representing endocrinology, surgery, pathology, and nuclear medicine. Feedback and suggestions w... |
and Differentiated Thyroid Cancer Page Location key Sections and subsections Itema 10 [A1] THYROID NODULE GUIDELINES 10 [A2] What is the role of thyroid cancer screening in people with familial follicular cell–derived DTC?bR1b 10 [A3] What is the appropriate laboratory and imaging evaluation for patients with clinicall... |
Table 5. (Continued ) Page Location key Sections and subsections Itema 19 [A16] What are the principles of the molecular testing of FNA samples?bR13–14 21 [A17] AUS/FLUS cytologycR15c 22 [A18] Follicular neoplasm/suspicious for follicular neoplasm cytologycR16c 23 [A19] Suspicious for malignancy cytologycR17c 23 [A20] ... |
the role of medical or surgical therapy for benign thyroid nodules?R25–29 27 [A28] How should thyroid nodules in pregnant women be managed? 27 [A29] FNA for thyroid nodules discovered during pregnancy R30 28 [A30] Approaches to pregnant patients with malignant or indeterminate cytologyR31 28 [B1] DIFFERENTIATED THYROID... |
[B14] Postoperative carebR44–45b 37 [B15] What are the basic principles of histopathologic evaluation of thyroidectomy samples?bR46b 40 [B16] What is the role of postoperative staging systems and risk stratification in the management of DTC? 40 [B17] Postoperative staging R47 40 [B18] AJCC/UICC TNM staging T10 41 [B19] ... |
GUIDELINES 7 |
Table 5. (Continued ) Page Location key Sections and subsections Itema implicationsb 47 [B27] Excellent response: no clinical, biochemical, or structural evidence of disease after initial therapy (remission, NED)bT13b 50 [B28] Biochemical incomplete response: abnormal Tg values in the absence of localizable diseasebT13... |
of RAI (including remnant ablation, adjuvant therapy, or therapy persistent disease) after thyroidectomy inthe primary management of differentiated thyroid cancer?R51 T14 58 [B37] What is the role of molecular marker status in therapeutic RAI decision-making?bR52b 58 [B38] How long does thyroid hormone need to be withd... |
beam radiation or chemotherapy? 65 [B46] External beam radiation R6065 [B47] Systemic adjuvant therapy R61 65 [C1] DTC: LONG-TERM MANAGEMENT AND ADVANCED CANCER MANAGEMENT GUIDELINES 65 [C2] What are the appropriate features of long-term management? 66 [C3] What are the criteria for absence of persistent tumor (excelle... |
(response to therapy) to guide disease long-term surveillance and therapeutic managementdecisionsb (continued )8 HAUGEN ET AL. |
Table 5. (Continued ) Page Location key Sections and subsections Itema 72 [C15] What is the role of TSH suppression during thyroid hormone therapy in the long-term follow-up of DTC?cR70c T15b 74 [C16] What is the most appropriate management of DTC patients with metastatic disease? 74 [C17] What is the optimal directed ... |
metastatic disease to various organs be treated? 78 [C29] Treatment of pulmonary metastases R77–7878 [C30] RAI treatment of bone metastases R7979 [C31] When should empiric RAI therapy be considered for Tg-positive, RAI diagnostic scan–negative patients?R80–82 79 [C32] What is the management of complications of RAI ther... |
systemic therapy (kinase inhibitors, other selective therapies, conventional chemotherapy, bisphosphonates) in treating metastatic DTC?c 85 [C42] Kinase inhibitorsbR96b, T16b 87 [C43] Patients for whom first-line kinase inhibitor therapy failsbR97b 87 [C44] Management of toxicities from kinase inhibitor therapybR98b, T1... |
significance/follicular lesion of undetermined significance; CT, computed tomography; DTC, differentiated thyroid cancer; FN, follicular neoplasm; FNA, fine-needle aspiration;18FDG-PET, [18F]fluorodeoxyglucose positron emission tomography; MRI, magnetic resonance imaging; NED, no evidence of disease; PET, positron emission... |
[A1] THYROID NODULE GUIDELINES A thyroid nodule is a discrete lesion within the thyroid gland that is radiologically distinct from the surrounding thyroid pa- renchyma. Some palpable lesions may not correspond to distinct radiologic abnormalities (32). Such abnormalities do not meetthe strict definition for thyroid nodu... |
highly un- likely, and given the unfavorable cost/benefit considerations,attempts to diagnose and treat all such small thyroid cancers in an effort to prevent exceedingly rare outcomes is deemed to cause more harm than good. In general, the guiding clinicalstrategy acknowledges that most thyroid nodules are low risk,and... |
at risk; (b) demonstration that screening allows the detection of the disease at an earlier sta ge; (c) early diagnosis has an impact on subsequent ou tcome, both recurrence and survival. Family members of patients with nonmedullary DTC may be considered at risk based on epidemiological evidence showingthat 5%–10% of D... |
family members are affected, the disease displays the features of ‘‘ge- netic anticipation’’ (occurrence of the disease at an earlier ageand with more aggressive presentation in the subsequent gener- ation compared with the first generation), which is considered good evidence for a distinct clinical entity possibly repr... |
al. (39) found that familial DTC patients had more aggressive disease compared with sporadic cases re- gardless of the number of family members affected. In contrast,Robenshtok et al. (40) found that staging at diagnosis and out- comes were not different in familial DTC patients compared with sporadic DTC patients. Syn... |
noted above (41). [A3] What is the appropriate laboratory and imaging evaluation for patients with clinically or incidentally discovered thyroid nodules? [A4] Serum thyrotropin measurement &RECOMMENDATION 2 (A) Serum thyrotropin (TSH) should be measured during the initial evaluation of a patient with a thyroid nodule. ... |
childhood or adolescence (43), familial thyroid carcinoma, or thyroid cancer syndrome (e.g., PTEN hamartoma tumor syndrome [Cowden’s dis-ease], FAP, Carney complex, Werner syndrome/progeria, or MEN 2, a risk for medullary thyroid cancer [MTC]) in a first- degree relative, rapid nodule growth, and/or hoarseness.10 HAUGEN... |
Pertinent physical findings suggesting possible malignancy include vocal cord paralysis, cervical lymphadenopathy, and fixation of the nodule to surrounding tissue. With the discovery of a thyroid nodule >1 cm in any di- ameter, a serum TSH level should be obtained. If the serum TSH is subnormal, a radionuclide thyroid s... |
as more advanced stage thyroid cancer (45,46). [A5] Serum thyroglobulin measurement &RECOMMENDATION 3 Routine measurement of serum thyroglobulin (Tg) forinitial evaluation of thyroid nodules is not recommended. (Strong recommendation, Moderate-quality evidence) Serum Tg levels can be elevated in most thyroid diseases a... |
unresolved issues of sensitivity,specificity, assay performance, cut-offs using calcium stim-ulation (55), and cost effectiveness. Two retrospective stud- ies have shown improved survival in patients diagnosed with MTC after routine calcitonin testing compared with historicalcontrols (53,56), but they were unable to sho... |
in the subgroup of patients in whom an elevated calcitonin may change the diagnostic or surgical approach(i.e., patients considered for less than total thyroidectomy, patients with suspicious cytology not consistent with PTC). If the unstimulated serum calcitonin determination has beenobtained and the level is greater ... |
further imaging or FNA. (Strong recommendation, Moderate-quality evidence) 18FDG-PET is increasingly performed during the evalua- tion of patients with both malignant and nonmalignant ill-ness. While18FDG-PET imaging is not recommended for the evaluation of patients with newly detected thyroid nodules or thyroidal illn... |
be monitored similarly to thyroid nodules with high-risk sonographic patterns that do not meet FNA criteria (see Rec- ommendation 24A). A recent meta-analysis confirmed thatapproximately one in three ( *35%)18FDG-PET positive thyroid nodules proved to be cancerous (60), with higher mean maximum standardized uptake value... |
of Hashimoto’s disease or other diffuse thyroidal illness. However, if detected, diffuse18FDG-PET uptake in the thyroid should also prompt sonographic examination to en-sure there is no evidence of clinically relevant nodularity.Most patients with diffuse 18FDG-PET uptake demonstrate diffuse heterogeneity on sonographi... |
How large is the nodule? What is the nodule’s pattern of US imaging characteristics? Is suspicious cervical lymphadenopathy present? Is the nodulegreater than 50% cystic? Is the nodule located posteriorly inthe thyroid gland? These last two features might decrease the accuracy of FNA biopsy performed with palpation (63... |
FNA decision-making (65,66) (see Recommendation 8). In the subset of patients with low serum TSH levels who have undergone radionuclide thyroid scintigraphy suggesting nodu- larity, US should also be performed to evaluate both the pres-ence of nodules concordant with the hyperfunctioning areas on the scan, which do not... |
US-guided FNA is preferred. If the diagnostic US confirms the presence of a predominantlysolid nodule corresponding to what is palpated, the FNA may be performed using palpation or US guidance. [A10] Recommendations for diagnostic FNA of a thyroid nodule based on sonographic pattern Figure 1 provides an algorithm for ev... |
‡2 cm in greatest dimension with very low suspicion sonographic pattern (e.g., spongiform). Ob- servation without FNA is also a reasonable option. (Weak recommendation, Moderate-quality evidence) III. Thyroid nodule diagnostic FNA is not required for (Fig. 2, Table 6): (E) Nodules that do not meet the above criteria. (... |
microcalcifications, irregular margins, and tall shape,12 HAUGEN ET AL. |
although the sensitivities are significantly lower for any single feature (70–77). It is important to note that poorly definedmargins, meaning the sonographic interface between the nod-ule and the surrounding thyroid parenchyma is difficult to de- lineate, are not equivalent to irregular margins. An irregular margin indic... |
not consistently associated with thyroid cancer (78). Onthe other hand, a nodule that has interrupted peripheral calci- fications, in association with a soft tissue rim outside the cal- cification, is highly likely to be malignant, and the associatedpathology may demonstrate tumor invasion in the area of dis- rupted calc... |
PTC to have this same appearance as FTC (79). Distant metastases are rarely observed arising fromfollicular cancers <2 cm in diameter, which therefore justifies a higher size cutoff for hyperechoic nodules (83). The vast majority (82%–91%) of thyroid cancers are solid (70,73,75,77,84). Of 360 consecutively surgically re... |
pattern and FNA cytology. R, recommendation in text.ATA THYROID NODULE/DTC GUIDELINES 13 |
FIG. 2. ATA nodule sonographic patterns and risk of malignancy. Table 6.Sonographic Patterns, Estimated Risk of Malignancy, and Fine-Needle Aspiration Guidance for Thyroid Nodules Sonographic pattern US featuresEstimated risk of malignancy, %FNA size cutoff (largest dimension) High suspicion Solid hypoechoic nodule or ... |
in low, intermediate, or high suspicion patterns<3 Consider FNA at ‡2c m Observation without FNAis also a reasonable option Benign Purely cystic nodules (no solid component) <1 No biopsy b US-guided FNA is recommended for cervical lymph nodes that are sonographically suspicious for thyroid cancer (see Table 7). aThe es... |
solid component and cyst, and the presence of micro- calcifications consistently confer a higher risk of malignancy (85–87). Other findings such as lobulated margins or increasedvascularity of the solid portion are risk factors that are not asrobust (86,87). However, a spongiform appearance of mixed cystic solid nodules ... |
with a higher size cutoff. Lastly, pure cysts, although rare ( <2% of thyroid lesions), are highly likely to be benign (66,89,90). Given the nuances in sonographic appearances of different thyroid cancer histologies, as well as the challenges posed by partially cystic nodules, some authors have suggested riskstratificat... |
controlled studies (72), theuse of patterns exhibiting correlated sonographic features ismore robust. Two recent studies have reported substantial interobserver correlation for identification for nodule sono- graphic patterns (multirater kappa statistics >0.6) (92,93). High suspicion [malignancy risk >70%–90% (89,90,94)... |
micropapillary thyroid cancers ( <1 cm) often have an indolent course, but this may depend upon patient age (95). Although no distant metastases or deaths occurred in a recent observational series of 1235 Japanesepatients with biopsy-proven PTC, tumor growth and new appearance of lymph node metastases occurred more fre... |
than wide shape (Fig. 2, Table 6). Thisappearance has the highest sensitivity (60%–80%) for PTC, but a lower specificity than the preceding high suspicion pattern, and fine-needle biopsy should be considered for thesenodules ‡1 cm to refute malignancy. Low suspicion [malignancy risk 5%–10% (89,90,94)]. Isoechoic or hyper... |
featuresdescribed in the low, intermediate, or high suspicion patterns have a low risk of malignancy ( <3%). If FNA is performed, the nodule should be at least 2 cm. Observation without FNA mayalso be considered for nodules ‡2 cm (Fig. 2, Table 6). Benign [ £1% (89,90,94)]. Purely cystic nodules are very unlikely to be... |
also warrants US- guided FNA of a subcentimeter nodule that is likely to rep- resent the primary tumor based upon sonographic features. Although there are several known clinical risk factors for thyroid cancer in patients with thyroid nodules including immobility with swallowing, pain, cough, voice change,growth, lymph... |
cancer risk. However, given the higher pretest likelihood of thyroid cancer associated with these clinical risk factors,FNA can be considered at lower size cutoffs for all of thesonographic appearances described above. Ultrasound elastography (USE) has similarly been investi- gated for its ability to modify thyroid can... |
(98). In this study, the positive predictive value (PPV) of USE was only 36%, comparable to that of micro- calcifications. The NPV of USE was 97% in a population with cancer prevalence of 9%. Thus, while USE holds promise as ameans by which to noninvasively assess cancer risk, its per- formance is highly variable and op... |
USE (when available) may prove to be ahelpful tool for preoperative risk assessment in those patients in whom accurate assessment can be performed. However, the committee cannot presently recommend its universal use orwidespread adoption. Importantly, the ability to perform (or not perform) USE should not modify the re... |
nodule FNA cytology should be reported using diagnostic groups outlined in the Bethesda System forReporting Thyroid Cytopathology. (Strong recommendation, Moderate-quality evidence) To address a significant variability in the reporting of cy- tological findings in thyroid FNA samples, the 2007 NationalCancer Institute Th... |
the Bethesda system, %aActual risk of malignancy in nodules surgically excised, % median (range)b Nondiagnostic or unsatisfactory 1–4 20 (9–32) Benign 0–3 2.5 (1–10) Atypia of undetermined significance or follicular lesion of undeterminedsignificance5–15 14 (6–48) Follicular neoplasm or suspicious for a follicular neopla... |
opinion (Fig. 1, Table 8). These categories are (i) nondiagnostic/ unsatisfactory; (ii) benign; (iii) atypia of undetermined signifi- cance/follicular lesion of undetermined significance (AUS/FLUS); (iv) follicular neoplasm/suspicious for follicular neo-plasm (FN/SFN), a category tha t also encompasses the diag- nosis of... |
Bethesda System, with the exception of the AUS/FLUS diagnosis, for which the risk of malignant outcome in some studies was sig-nificantly higher than predicted (Table 8) (103,105). Recently, a blinded prospective evaluatio n of inter-observer concordance using Bethesda classification was performed. These data con-firm an ... |
clinicians on risk estimates and help chooseappropriate molecular testing for patients with indeterminatecytology. [A12] Nondiagnostic cytology &RECOMMENDATION 10 (A) For a nodule with an initial nondiagnostic cytologyresult, FNA should be repeated with US guidance and, ifavailable, on-site cytologic evaluation (Strong... |
on a single slide) (99,108). Although an FNA speci-men found to have abundant colloid and few epithelial cells may be considered nondiagnostic by the above criteria, this is also likely a benign biopsy. After an initial nondiagnosticcytology result, repeat FNA with US guidance and, if avail- able, on-site cytologic eva... |
beappropriate. Repeat FNA with US guidance will yield a di- agnostic cytology specimen in 60%–80% of nodules, partic- ularly when the cystic component is <50% (64,112,117). Nodules with larger cystic portion have a higher chance to yield nondiagnostic samples on the initial and repeated FNA. Most nodules with a nondiag... |
only 4% lacking these features (118). In some studies, the use of thyroid core-needle biopsy (119) and molecular testing for BRAF (120,121) or a panel of muta- tions (122) helped to facilitate appropriate management of these patients, although the full clinical impact of these approachesfor nodules with nondiagnostic c... |
operator, FNA tech- nique, specimen preparation, and cytology interpretation.ATA THYROID NODULE/DTC GUIDELINES 17 |
Ultrasound-guided FNA with real-time visualization of needle placement in the target nodule decr eases the false-negative rate of a benign cytology diagnosis (68,69,126,128). Although pro-spective studies are lacking, malignancy rates of only 1%–2%have been reported in large retro spective series that analyzed the util... |
(137). This was a single-center study in which the practice is to offer thyroidectomy or lobectomy to all pa- tients with nodules ‡4 cm. The investigators identified thyroid cancer in 22% of 382 nodules. A subset of thyroid nodulesunderwent preoperative FNA, and of the 125 cytologically benign nodules, 10.4% were malign... |
8.5 years 18 false- negative malignancies were detected. However, no deaths attributable to thyroid cancer were identified in this cohort.These data confirm that an initially benign FNA confersnegligible mortality risk during long-term follow-up despite a low but real risk of false negatives in this cytologic cate- gory ... |
immediate surgery in (A) patients with very low risk tumors (e.g., papillary microcarcinomas without clinically evident metasta- ses or local invasion, and no convincing cytologicevidence of aggressive disease),(B) patients at high surgical risk because of comorbid conditions, (C) patients expected to have a relatively... |
outcomes in 1465 patients with biopsy-proven PTMC that were not sur- gically removed and were followed for up to 15 years (av-erage 5–6 years, range 1–17 years) (95,143). In the study by Itoet al. (95), observation was offered to 1235 patients with PTMC that did not have (i) location adjacent to the trachea oron the do... |
tumor enlargement and new lymph node metastases. These patients have been followed an average of 75 months (range1–246 months) after the surgical intervention. Only one of the patients treated with surgery after observation developed tumor recurrence. In the study by Sugitani et al. (143), 230 patients with asymptomati... |
younger pa- tients ( <40 years old) had an 8.9% rate of clinical progres- sion, while those 40–60 years old had a 3.5% rate ofprogression and those >60 years old had the lowest rate of clinical progression (1.6%). Despite the evidence that cautious observation is a safe and effective alternative to immediate surgical r... |
of PTMC patients destined to develop clinically significant progression from the larger population of people that harbor indolent PTMCs that will not cause significant disease. Similarly, well-known thyroid cancer oncogenes, such as BRAF , when taken in isolation, are not able to specifically identify the microcarcinomas ... |
suggest that specific molecular profiles, such as the coexistence of BRAF with other oncogenic mutations (such as PIK3CA ,AKT1 ),TERT promoter, or TP53 mutations may serve as more specific markers of less favorable outcome of PTC. Therefore, it is likely that finding of one of these genetic profiles in a small tumor would s... |
molecular markers involves the identification of patientsubgroups in which a therapeutic intervention is proven to be either beneficial or harmful, with intended implications for appropriate clinical stratification of therapies (158). Validationstudies of molecular marker tests may include examination of (a) analytic vali... |
is diagnostic (ruling out or in the presence of thyroid malignancy),with the implication of a companion use to informdecision-making on primary surgical treatment (i.e., the decision to perform surgery and if so, the extent of surgery). However, the focus of this section is restrictedto the clinical validity of molecul... |
ATA Surgical Affairs Committee, use o fm o l e c u l a rm a r k e rt e s t i n go ni n d e t e r m i n a t eF N As p e c - imens should not be intended to replace other sources ofinformation or clinical judgment (159,160). The pretest probability of malignancy (based on clinical risk factors, cytology, US findings), fea... |
a PPV for histopathologically proven ma-lignancy similar to a malignant cytologic diagnosis (98.6%),and an ideal ‘‘rule-out’’ test would have a NPV similar to a benign cytologic diagnosis (96.3%) (predictive value esti- mates based on a recent meta-analysis of performance of theBethesda system) (103), and these would h... |
blinding of outcome assessment(162–164). Mutational testing has been proposed for use as a rule-in test because of relatively high reported specificity (86%–100%)*The final draft for the sections (A15–A19) and recommenda- tions (13–17) were revised and approved by a subgroup of seven members of the task force with no per... |
and PPV (84%–100%) (105,122,162,165–168). Although BRAFV600Esingle mutation testing has been estimated to have a specificity of approximately 99% (pooled data from 1117nodules with histopathologic confirmation from multiplestudies), the sensitivity has been deemed to be too low to reliably rule out the presence of malign... |
End of preview. Expand in Data Studio
- Downloads last month
- 27