Dorota Słowińska-Klencka

The usefulness of sonographic features in selection of thyroid nodules for biopsy in relation to the nodule's size.

OBJECTIVEnTo evaluate the efficacy of selected ultrasound (US) features of thyroid focal lesions useful for establishing indications for fine-needle aspiration biopsy (FNAB) with regard to the lesions size.nnnMETHODSnUS imaging features of 1141 thyroid nodules (shape, echogenicity, pattern of blood flow, presence of microcalcifications and the presence of other nodules in the thyroid) and their palpability were compared with the post-operative histopathological outcomes. The efficacy of the selected sets of the features was assessed for small nodules (SN)< or =15 mm and large nodules (LN)>15 mm, as well as separately for nodules< or =10 mm.nnnRESULTSnLogistic regression analysis showed that in SN hypoechogenicity (odds ratios, OR: 3.18), microcalcifications (OR: 19.12), solitary occurrence (OR: 3.29) and height-to-width ratio> or =1 (OR: 8.57) were independent risk factors for malignancy. The optimal set of small lesions that should be biopsied includes all lesions presenting at least one of the above-mentioned features (sensitivity 98%, specificity 44%). In the LN group, the selection criteria based on the shape of lesions and hypoechogenicity were less sensitive than in the SN group, but they allowed further reduction in the number of performed FNABs. Large nodules primarily selected for FNAB should be hypoechoic, more tall then wide or contain microcalcifications (sensitivity 84%, specificity 72%).nnnCONCLUSIONSnThe obtained results provide rationale for using features from the US examination in selecting both small and large nodules for FNAB. In the case of LN, the usefulness of sonographic features is less sensitive, but more specific than in the case of SN.

The fine-needle aspiration biopsy efficacy of small thyroid nodules in the area of recently normalized iodine supply

OBJECTIVEnTo evaluate the incidence of focal lesions in the thyroid in the area of recently normalized iodine supply as well as to compare the efficacy of fine-needle aspiration biopsy (FNAB) of small (infracentimetric) and large thyroid lesions in this area.nnnMETHODSnThe outcomes of 13,646 ultrasound (US) examinations, 13,437 US-guided FNABs of the thyroid and 1694 results of post-operative histopathological examinations were analysed.nnnRESULTSnInfracentimetric nodules (INs < or = 10 mm) were revealed by US examinations in 43.5% of patients; in the majority of the cases (82.2%) INs were multiple. The percentage of revealed carcinomas by aspiration of INs is similar to that observed when large nodules (LNs > 10 mm) are examined cytologically. However, the efficiency of preoperative diagnosis of INs is lower than LNs with respect to both US selection of lesions for FNAB and the percentage of false negative results of FNAB (29.8 vs 5.4%, P<0.001). In post-operative histopathological examination, extrathyroidal extension of thyroid cancers was observed in nearly 30% of microcarcinomas.nnnCONCLUSIONSnIn endemic or post-endemic areas, the efficiency of FNAB is lower in the case of small lesions than larger ones. In spite of this, the percentage of cytologically revealed carcinomas among small lesions is not lower than larger ones. Thus, it is particularly indicated to follow up small thyroid lesions with repeated US examinations in such areas.

Correlation between PCNA expression and AgNOR dots in pituitary adenomas.

Nucleolar organizer regions are segments of DNA associated with argyrophilic proteins (AgNORs). Our previous findings showed that the number, the area, and the intranuclear localization of AgNOR dots differ according to tumor aggressiveness and to the hormone-immunopositivity of pituitary adenomas. Proliferating cell nuclear antigen (PCNA) is a nuclear protein, whose expression is correlated with cell proliferation. The aim of the present paper was to examine PCNA-labeling indexes in pituitary adenomas and to correlate them with AgNOR dots in various immunohistochemical types of the tumors.Histological slides from 32 pituitary tumors and one normal pituitary were silver-stained and analyzed with a computerized system for microscopic image analysis. We found that the percentage of PCNA-positive cells did not differ significantly among examined groups of monohormonal adenomas. However, tumors immunopositive for α-subunit (α-SU) showed a significantly higher (p<0.05) PCNA index than adenomas immunonegative for that unit. PCNA index in recurrent tumors was significantly higher than in primary adenomas. There was a moderate positive correlation between the PCNA index and the mean area of AgNOR dots and a similar correlation between the PCNA index and the area of the biggest dot in the nucleus.The obtained results reveal that the PCNA indexes and estimated parameters of AgNOR dots differ according to tumor aggressiveness.

Diagnostics and Treatment of Thyroid Carcinoma

Revised Guidelines of Polish National Societies Prepared on the initiative of the Polish Group for Endocrine Tumours approved in their final version between November 16th and 28th, 2015 by the Scientific Committee of the V Conference Thyroid Cancer and other malignancies of endocrine glands organised between November 14th and 17th, 2015 in Wisla, Poland; called by the following Societies: Polish Endocrine Society, Polish Society of Oncology, Polish Thyroid Association, Polish Society of Pathologists, Society of Polish Surgeons, Polish Society of Surgical Oncology, Polish Society of Clinical Oncology, Polish Society of Radiation Oncology, Polish Society of Nuclear Medicine, Polish Society of Paediatric Endocrinology, Polish Society of Paediatric Surgeons, Polish Society of Ultrasonography Gliwice-Wisła, 2015 DECLARATION: These recommendations are created by the group of delegates of the National Societies, which declare their willingness to participate in the preparation of the revised version of the Polish Guidelines. The members of the Working Group have been chosen from the specialists involved in medical care of patients with thyroid carcinoma. Directly before the preparation of the Polish national recommendations the American Thyroid Association (ATA) published its own guidelines together with a wide comment fulfilling evidence-based medicine (EBM) criteria. ATA Guidelines are consistent with National Comprehensive Cancer Network (NCCN) Recommendation. According to the members of the Working Group, it is necessary to adapt them to both the specific Polish epidemiological situation as well as to the rules referring to the Polish health system. Therefore, the Polish recommendations constitute a consensus of the experts group, based on ATA information. The experts analysed previous Polish Guidelines, published in 2010, and other available data, and after discussion summed up the results in the form of these guidelines. It should be added that Part II, which constitutes a pathological part, has been available at the website of the Polish Society of Pathologists for acceptance of the members of the Society, and no essential comments have been proposed. The Members of the Group decided that a subgroup elected from among them would update the Guidelines, according to EBM rules, every year. The Revised Guidelines should help physicians to make reasonable choices in their daily practice; however, the final decision concerning an individual patient should be made by the caring physician responsible for treatment, or optimally by a therapeutic tumour board together with the patient, and should take into consideration the patients health condition. It should be emphasised that the recommendations may not constitute a strict standard of clinical management imposed on medical staff. The data from clinical trials concerning numerous clinical situations are scarce. In such moments the opinion of the management may differ from the recommendations after considering possible benefits and disadvantages for the patient.

Usefulness of PTH measurements in FNAB washouts in the identification of pathological parathyroids — analysis of the factors that influence the effectiveness of this method

INTRODUCTIONnThe aim of this investigation was to assess the usefulness of the measurement of PTH concentration in the material obtained during FNAB (PTH-FNAB) in the identification of pathological parathyroids in patients with frequently coexisting thyroid abnormalities (nodular goitre, chronic thyroiditis, previous thyroidectomy). Additionally, the influence of the size of goitre, parathyroid localisation and size on the results of PTH-FNAB measurement was examined.nnnMATERIAL AND METHODSnFifty patients with primary hyperparathyroidism and sonographically detected focal lesion that was suggestive of parathyroid gland were included in this study. PTH-FNAB results were correlated with the outcome of routine cytological examination and biochemical indices of hyperparathyroidism, SPECT-CT (33 patients) and histopathological examination (20 patients).nnnRESULTSnPositive PTH-FNAB was observed in 80% of patients, and in more than 70% of persons with non-diagnostic smears or smears contaminated with thyroid follicular cells. In the group of operated patients, sensitivity of PTH-FNAB (95.0%) was higher than SPECTCT (64.3%, p < 0.05). Presence of nodular goitre and/or chronic thyroiditis exerts a two times stronger negative effect on percentage of negative results of SPECT-CT than of PTH-FNAB. On the other hand, lower frequency of positive PTH-FNAB but not SPECT-CT was observed when the thickness of the thyroid was ≥ 20 mm (50% v. 87.5%, p < 0.05) and when the thickness of a lesion suspected of parathyroid pathology was ≤ 5 mm (66.7% v. 93.3%, p < 0.05).nnnCONCLUSIONSnIn patients with thyroid abnormalities, PTH-FNAB measurements show advantages over routine biopsy and SPECT-CT in the identification of typically located pathological parathyroids.

Low malignancy risk of thyroid follicular lesion of undetermined significance in patients from post-endemic areas

OBJECTIVEnNew classification of the thyroid fine-needle aspiration biopsy (FNAB) results tries to stratify the risk of malignancy of thyroid follicular lesions using follicular lesion of undetermined significance (FLUS) subcategory. Clinical significance of this category in the endemic (or post-endemic) areas has not been clearly established.nnnDESIGNnThe aim of the study was to determine the risk of malignancy for FLUS as well as to evaluate ultrasound (US) malignancy risk features (MRF) in such nodules in comparison with suspicious for neoplasm (SFN) and benign lesions (BL).nnnMETHODSnThe US images and cytological diagnoses of 589 thyroid follicular lesions were analysed from January 2010 to July 2012. Cytological follow-up was assessed in 110 cases and surgical one in 100 cases.nnnRESULTSnFLUS was diagnosed in 340 cases (3.8% of all cytological diagnoses and 57% of thyroid follicular lesions). Altogether, clinical and/or surgical follow-up revealed thyroid cancer in 3.2% patients with FLUS nodules. Repeat FNAB led to more specific diagnosis in 74.4% of FLUS (3.5%, papillary cancers or their suspicion; 2.3%, SFN; 68.6%, BL). The histopathological examination showed thyroid cancer in 6.4% cases of FLUS and 7.0% of SFN and follicular adenoma in 8.5% of FLUS and 11.6% of SFN (NS, FLUS vs SFN). FLUS showed MRF of intermediate values between BL and SFN; SFN more often than FLUS showed at least two MRF (53 vs 30%, P<0.0001).nnnCONCLUSIONSnThe risk of cancer in FLUS in areas with recently corrected iodine supply is low. In such areas, repeated biopsy leads to more precise cytological diagnosis in about 3/4 cases.

Diagnostics and treatment of differentiated thyroid carcinoma in children - Guidelines of Polish National Societies.

1Department of Paediatric Endocrinology and Rheumatology, Poznan University of Medical Sciences, Poznan, Poland 2Department of Nuclear Medicine and Endocrine Oncology, Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Gliwice Branch, Gliwice, Poland. 3Department of Paediatrics and Paediatric Endocrinology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland 4Department of Oncological and Reconstructive Surgery, Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Gliwice Branch, Gliwice, Poland 5Department of Oncological Endocrinology and Nuclear Medicine, Centre of Oncology – Maria Sklodowska-Curie Memorial Institute, Warsaw, Poland 6Department of Tumour Pathology, Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Gliwice Branch, Gliwice, Poland 7Department of Paediatrics and Endocrinology, Medical University, Warsaw, Poland 8Department of General and Oncological Surgery, Medical University of Lodz, Lodz, Poland 9Private practice, Katowice, Poland 10Department of Paediatric Surgery and Urology, Wroclaw Medical University, Wroclaw, Poland 11Department of Morphometry of Endocrine Glands, Chair of Endocrinology, Medical University of Lodz, Lodz, Poland 12Department of Dental Pathology, Medical University of Lodz, Lodz, Poland 13Department of Tumour Pathology, Poznan University of Medical Sciences, Poznan, Poland 14Department of Endocrinology, Metabolism and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland 15Department of Endocrinology and Metabolic Diseases, Polish Mother’s Memorial Hospital-Research Institute, Medical University of Lodz, Lodz, Poland

E-cadherin expression is more associated with histopathological type of thyroid cancer than with the metastatic potential of tumors

The aim of this study was to evaluate the relationship between abnormal expression of E-cadherin (E-CAD) and the extracapsular extension of tumors, lymph node involvement and the presence of metastasis in various types of thyroid cancers. Histopathological specimens of 35 benign thyroid lesions and 122 malignant tumors (papillary, follicular, poorly differentiated and undifferentiated cancers) were analyzed. E-CAD immunostaining intensity, its subcellular localization, homogeneity within lesion, and the relation of staining intensity between tumor and surrounding thyroid parenchyma were evaluated. The obtained results show that the variants of differentiated cancers with a poorer prognosis (i.e. tall cell and follicular variants of papillary cancer and widely invasive follicular cancers) present reduced intensity of E-CAD expression, its abnormal localization or heterogeneity of staining more frequently than classical papillary cancers and minimally invasive follicular cancers. However, the assessment of E-CAD expression does not allow the prediction of extrathyroidal growth of thyroid cancers.

Detrimental Effects of Increasing Iodine Supply: Iodine-Induced Hyperthyroidism, Following Iodine Prophylaxis

This chapter discusses the epidemiology and etiology of iodine-induced hyperthyroidism (IIH), which follows normalization of iodine supply. The thyroid gland seems to be well adapted to incidents of iodine intake in very high amounts. Still, there is evidence showing that increased intake of iodine may induce clinically relevant problems in some susceptible subjects. These effects are optimally identifiable at population level, as individual responses vary depending on many other factors that are difficult to control. One of the main undesirable consequences of increased iodine intake in a population is a higher incidence of hyperthyroidism. The elevated incidence of IIH, which follows normalization of iodine supply, is transient. The greater the iodine deficiency, the more numerous and clinically more difficult are the cases of hyperthyroidism, which occur after correction of the iodine supply. In fact, IIH, which follows iodine supply normalization, can be viewed as an outcome of iodine deficiency. The deeper the iodine deficiency, the more numerous and more difficult are the IIH cases, which occur after the correction of iodine supply. Also, children form the group that benefits the most from iodine prophylaxis. Some effects of prolonged iodine deficiency, such as the presence of autonomous nodules in the thyroid, seem to be irreversible.

Non-diagnostic cytological outcome of thyroid biopsy and the risk of thyroid malignancy.

This study assessed the incidence of neoplasms, including malignant tumors, in lesions within the thyroid gland from which non-diagnostic biopsy aspirates were obtained. An auxiliary goal of the study was an evaluation of the diagnostic efficacy of repeated biopsy in cases when the first biopsy was non-diagnostic. Thus, results of 4603 fine-needle aspiration biopsies (FNABs) were submitted to histopathological verification. The verification revealed the rate of malignancy at 7.1% for non-diagnostic biopsies, i.e., significantly higher (p<0.001) than that in cases FNAB-diagnosed as benign lesions (2.1%). Repeated biopsy, performed when inadequate material has been collected, seems to be less effective than the first biopsy (non-diagnostic specimens; 14.4% vs 8.9%; p<0.01). The occurrence of neoplasms in the goiter was significantly higher (p < 0.0001) in patients with non-diagnostic first FNAB than in those with diagnostic one (50.7% vs 33.5%, p<0.001). And again, in patients with two non-diagnostic FNABs, the occurrence of neoplasms was higher than that in patients with the second diagnostic cytology (63% vs 41.2%, p<0.05). According to our data, patients with non-diagnostic FNAB results should be very carefully monitored, especially when the repeated biopsy is either non-diagnostic again or not performed at all.